key: cord- - e xn kj authors: falcón-lezama, jorge abelardo; santos-luna, rené; román-pérez, susana; martínez-vega, ruth aralí; herrera-valdez, marco arieli; kuri-morales, Ángel fernando; adams, ben; kuri-morales, pablo antonio; lópez-cervantes, malaquías; ramos-castañeda, josé title: analysis of spatial mobility in subjects from a dengue endemic urban locality in morelos state, mexico date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: e xn kj introduction: mathematical models and field data suggest that human mobility is an important driver for dengue virus transmission. nonetheless little is known on this matter due the lack of instruments for precise mobility quantification and study design difficulties. materials and methods: we carried out a cohort-nested, case-control study with individuals ( cases, intradomestic controls and population controls) with the goal of describing human mobility patterns of recently dengue virus-infected subjects, and comparing them with those of non-infected subjects living in an urban endemic locality. mobility was quantified using a gps-data logger registering waypoints at -second intervals for a minimum of natural days. results: although absolute displacement was highly biased towards the intradomestic and peridomestic areas, occasional displacements exceeding a -km radius from the center of the studied locality were recorded for all three study groups and individual displacements were recorded traveling across six states from central mexico. additionally, cases had a larger number of visits out of the municipality´s administrative limits when compared to intradomestic controls (cases: . versus intradomestic controls: . , p = . ). we were able to identify extradomestic places within and out of the locality that were independently visited by apparently non-related infected subjects, consistent with houses, working and leisure places. conclusions: results of this study show that human mobility in a small urban setting exceeded that considered by local health authority’s administrative limits, and was different between recently infected and non-infected subjects living in the same household. these observations provide important insights about the role that human mobility may have in dengue virus transmission and persistence across endemic geographic areas that need to be taken into account when planning preventive and control measures. finally, these results are a valuable reference when setting the parameters for future mathematical modeling studies. a a a a a dengue fever (df) is the most important arthropod-borne viral disease in the world. it is caused by infection with any of the four dengue virus (denv) serotypes. nearly half of the human population inhabits areas with denv transmission. in mexico dengue incidence and severe cases have been increasing in the last decade. to date, there is no specific treatment or vaccine for df and vector control stands as the cornerstone for df prevention [ , ] . df is an important public health problem, especially in urban areas [ ] , where it usually presents in large outbreak. the costs of treatment and management during a df outbreak are a serious burden for health systems, especially when there is a risk for saturation of health facilities [ ] . the actors that are necessary for denv transmission are fairly well understood. nonetheless, some of the dynamical features about these actors still need to be elucidated in order to understand how they impact on transmission. human mobility has been studied in relation to other infectious diseases, where its role as an important driver for disease transmission has been proven [ , ] . mathematical models have suggested that local scale human mobility may play a role in denv transmission, outbreak persistence, and control efficiency [ , ] . however, little information is available on detailed human mobility patterns in geographic areas where df is endemic or on confirmed cases during an outbreak. recently, gps-based technologies have been tested and shown to be a reliable and acceptable tool for quantifying human mobility [ , ] . human mobility has been described in relatively recent reports by using indirect measures [ , ] . for these reasons, we studied the micro and macromobility of dengue virus-infected subjects in an endemic locality. here we present the results of a cohort-nested case-control study on a dengue endemic urban locality in mexico. the protocol of the project was reviewed and approved by the comité de etica y de prevención de conflictos de interes (institutional review board) ci no and departamento de investigación (external review) servicios de salud de morelos, mexico dei/cei/ / . cohort-nested, case-control study. sample: individuals ( cases, intradomestic controls and population controls) with age older than , and residents in axochiapan, morelos state, méxico, were selected from the cohort "peridomestic infection as determinant for dengue virus transmission" [ ] . they were assigned into three study groups: a. cases were individuals with laboratory evidence of recent, symptomatic or asymptomatic, denv infection, and identified as the only persons infected within their households during the study. b. intradomestic controls, were individuals with a negative serological result for recent denv infection, living in the same household with a case; c. population controls were individuals with a negative serological result for recent denv infection, randomly selected from the same locality. all controls tested negative for denv during the same period and using the same validated techniques than cases (igm or igg capture elisa) as reported in the cohort study [ ] . partici-pant´s selection was performed as follows: cases were approached first, if accepted participation an intradomestic control was randomly assigned from the pool of subjects living in the same house that had both baseline and final negative elisa results. for each pair of in-house participants, a randomly selected population control was then assigned (fig ) . given the limited number of available gps loggers and the three-month time frame for the follow-up, the recruitment was limited to a maximum of cases with their respective intradomestic and population controls. between may and september, , with prior signed informed consent, all participants were provided with a portable gps (gps data-logger, transystems mod. a+), programmed for recording its position at -second intervals (variables date, time, latitude, longitude, altitude and speed), during hours a day, for a minimum period of days. participants were instructed to carry their gps at all times whenever they left their homes and to recharge the equipment's battery daily during their in-home resting times. this follow up was performed in cases identified during the immediate previous season, on average one year after diagnosis confirmation, in order to match the activities performed during the high transmission season, and under the assumption that their mobility patterns remained unchanged after disease, and constant through time. a web-based interface was developed to import the text files from gps equipment to a main database. variables were homogenized, waypoints in the initial and final days of each individual gps track (comprising incomplete days) were eliminated in order to standardize the period of time to be analyzed starting at : : hours on the second day of follow up and ending at : : on the last to final day of follow up. data were converted into a feature dataset and projected from the geographic coordinate system to a lambert coordinate system (from hexadecimal to metric units) with the purpose of performing arithmetic operations for distance calculations. origin or routinely residence sites were identified by means of an iterative algorithm (mean center) employing waypoints from : : to : : hours, monday to friday. routine residence coordinates were added to the database. distance to home variable (dhome) was calculated for each extradomestic waypoint using sql applying the following formula: where; x = xhome (x coordinate from home), x = xccl (x coordinate from each waypoint), y = yhome (y coordinate from home) y, y = yccl (y coordinate from each waypoint). waypoints within the peridomestic area (dhome < m) were identified. distance, speed, altitude and time differentials were created: where: xccl = (x coordinate from previous waypoint), xccl = (x coordinate from current waypoint), yccl = (y coordinate from previous waypoint) and, yccl = (y coordinate from current point) displacement and spatial permanency variables for each subject with complete data were generated. visit sites were defined as those areas out of the individual's home with a m radius in which each participant remained static for a period enough to allow a potential effective interaction with local vectors. these sites were identified by generating an algorithm through which visit clusters were formed using the following criteria: stops lasting minutes or longer, a distance from home of m or farther, distance of the current waypoint from previous waypoint < m, and speed for the current waypoint of km / h or less. for each cluster (visit site) a centroid was calculated. common visit sites for cases were identified as hexagonal cells with m radius [ ] which were visited by at least two different cases at a given time, and where the proportion of different visiting cases was at least two thirds of the total visiting population for that cell. common visit sites for controls were identified as hexagonal cells with m radius which were visited by at least two members from each control population and not visited by any of the cases. the geographic universe in the study was divided in five areas ( .-inside the house, .-out of the house but in the locality, .-out of the locality but in the municipality, .-out of the municipality but in the state, .-out of the state), limited by four buffers. a circular buffer with m radius around each participant's home limited the first area and three additional polygonal buffers were drawn according to the administrative limits for the locality, municipality and state. arcgis arcinfo was used for processing and analyzing spatial data, sql server was used to create a geodatabase, arc sde was used as interpreter between entre sql and arcgis. statistical analyses were performed using stata . fifty randomly selected cases were asked to participate in the study from which ( %) accepted participation. all approached controls agreed to participate. in total individuals ( cases, intradomestic controls and population controls) were recruited. our drop-out rate was lower than % ( / ) since one participant (intradomestic control) did not finish the follow-up due to the loss of the assigned gps logger. table describes the main characteristics of the subjects in each group. no statistically significant differences were observed in most of variables except in age, since cases were significantly younger than the intradomestic or population controls (cases mean: . , sd: . ; intradomestic controls mean: . sd: . ; population controls mean: . sd: . . p = . ). of participants, ( . %) participants completed their follow up since one gps used by an intradomestic control went missing. the final database contains , , waypoints from these participants, and all participants were followed by a mean of . continuous days. as for the number of days of follow-up for each group no differences were recorded. as expected, most of the waypoints in the population fell within the intradomestic area (< m radius from home centroid). as distance from home (absolute displacement) increased, we observed a marked decrease in the proportion of waypoints. all three groups presented a small peak when the distance reached the m radius. from this point the proportion of waypoints quickly decayed (fig ) . no differences were noticed for absolute displacement among the groups. the hourly distribution of recorded waypoints out of the participant's homes is shown in fig . as expected, participants usually left their homes early in the morning and returned by the end of the day. although we recorded waypoints out of the participants' homes in every hour of the day, the period comprised between : pm and : pm registered the peak in the number of waypoints recorded out of the homes, and this number decreased steadily as the day progresses. the pattern during weekdays ( fig a) suggests that cases leave their homes and return to them slightly earlier than control groups. as for the weekends (fig b) , both control groups show a similar pattern to that observed for weekdays, nonetheless, cases seem to remain in their homes more often and return earlier. table shows values for different mobility variables. no significant differences were recorded among groups for the following variables: mean distance from home at all times, maximum recorded distance at any given time, and mean time spent in each geographic area at any speed or at static speed. nonetheless, when comparing the number of visits per geographic area, the cases had fewer recorded visits in the area out of the locality but in the municipality ( . vs . , p = . ), and more visits in the area out of the municipality ( . vs . , p = . ), both compared to intradomestic controls. these differences were statistically significant. consistent with this behavior, although non-statistically significant, cases visited more states, municipalities, and regions with high dengue incidence through their follow up, in comparison to both control groups. we next examined the proportion of waypoints recorded by the comparison groups in each area stratified by age (fig ) . there is a notorious difference in the proportion of waypoints among the cases, observing an increase of nearly percentile points in the intradomestic waypoints, recording the highest frequency in cases under age (fig a. however the difference not statistically significant (cases < : median . %, interquartile-range . - . ; cases ! : % iqr - . ; p = . ). we also observed a difference in the area out of the municipality but in the state, where the group of cases aged and older spent the highest proportion of time (age < : % iqr - %; age ! : . % iqr - . ; p = . ). there was no significant difference between cases and population controls, regardless of age. when comparing cases versus intradomestic controls, we observed a statistically significant difference in time spent in area out of the municipality but in the state (cases: . % iqr - . ; ic: % iqr: - . ; p = . ). we found differences in mobility patterns when analyzing data by gender ( fig b) . women had a higher proportion of waypoints within the intradomestic area than men. these differences were statistically significant for intradomestic area (male: . % iqr: . - . ; female: . % iqr . - . ; p = . ), out of their homes but in the locality (male: . % iqr . - ; female: . % iqr . - . ; p = . ) and the area out of the locality but in the municipality (male: . % iqr: . - . ; female: . % iqr: - . ; p< . ). nonetheless, linear mean (p = . ) and maximum (p = . ) distances were not. a) cases vs. intradomestic controls. a conditional logistic regression analysis was performed, including variables identified in the bivariate analysis as having a p value < . , and by data mining techniques using all variables as reported previously [ ] . for bivariate analysis variables were age (continuous and dichotomic [under or and older]) gender, occupation (intra or extradomestic), education (dichotomic), and the proportion of time spent in each geographic area. for the data mining we considered the whole data base. the final model included age (or: . ic % . - . ; p = . ) and the area out of the municipality but in the state (or . ic % . - . ; p = . ). we observed a protective effect in the and older group, and a risk effect when the proportion of time spent in the area out of the municipality but in the state is increased. b) cases vs. population controls. a multiple logistic regression analysis was performed including variables identified with p value < . in the bivariate analysis and data mining techniques using all variables as reported previously [ ] . for bivariate analysis, only the variables age (continuous and dichotomic [under or and older]), gender, occupation (intra and extradomestic), education (dichotomic), proportion of time spent in each area and linear distance were taken into consideration. for the data mining we considered the whole database. the final model included: occupation (or . ic % . - . ; p = . ), proportion of time in the area out of the municipality but in the state ( . ic % . - . ; p = . ), proportion of time in the area out of the locality but in the municipality (or . ic % . - . ; p = . ), and age (or . ic % . - . , p = . ). next we analyzed the geographic distribution of the recorded waypoints for each group, both locally and regionally (fig ) . all three groups recorded waypoints exceeding a km radius from their homes (fig a, b and c ). as expected, most of recorded waypoints were located within the locality. nonetheless, all three groups recorded waypoints exceeding the locality, municipality and state limits. these trajectories were headed mainly to the east, north and west of the locality, and were consistent with the location of the main cities in the area, including cuernavaca (population , ) and cuautla (population , ), the capital city and the second most important city in the state of morelos, respectively. the geographic distribution of the visits performed by cases and df cumulative incidence for the central mexico region, during year , is shown in fig . as seen, this group performed visits to locations with and without df transmission. the number of states, municipalities and regions with high dengue incidence is shown in table . within the locality of axochiapan the most visited areas were identified by dividing the locality in m-radius hexagonal cells (fig a) . the most visited cells were those located in the locality's central area, which correspond to the location of the main market, road junctions and main administrative and / or service offices. the location of the cells considered as common visit sites for cases are shown in fig b. unlike in fig a, the geographical distribution of these cells tends to be peripheral with respect to the locality. using google earth™ we identified the geographic features of each of the cells that was classified as a common visit site for cases. fourteen out of fifteen cells were geographically located within the locality of axochiapan, morelos, and the last one was in the central area of a neighboring small locality (town of tzicatlán) in the state of puebla. as for their typology, xix out of cells clearly corresponded to residential areas (including that in the neighboring state), one cell was a residential area adjacent to a local large business, four cells included small processing plants, a warehouse and a local business, three peripheral cells were crop fields and one cell was clearly a soccer field. previous works have used gps tools for measuring exposure to infectious diseases [ ] [ ] [ ] . in df, recent works in the endemic area of iquitos, peru, have elegantly described human population mobility [ , ] . however, few data are available for infected cases so far. our work builds upon our knowledge of the role played by mobility in denv transmission documenting spatial mobility of subjects from an endemic region that had, or had not been recently infected by denv. our data show that the people from axochiapan stay within their houses or surrounding areas most of the time. this is consistent with previous observations in iquitos, where population rarely moves more than km away from their homes [ ] , however, some individuals recorded movements to very distant locations through the relatively short follow-up period. these movements were present in all three study groups and exceeded a -km radius from the center of the study, covering the neighboring states of morelos, state of mexico, puebla, mexico city, tlaxcala and hidalgo. all of these states are located in the mexican central plateau, which is also the best connected region in the country and therefore it is not difficult to reach those destinations by commute travel [ ] . surprisingly, spatial mobility in humans was not geographically symmetrical in our study, since no movements were recorded to state of guerrero, which is a coastal, highly endemic area for dengue and also a popular destination for leisure activities. as for the reason why the mobility of the individuals is biased towards central plains in mexico and practically absent towards the southern regions, it was a surprising finding also for us, but we think that it has to do with two factors: first the economic activities in axochiapan are mainly related to agriculture, trade and services which are strongly influenced by the needs of mexico city and its metropolitan area, comprised also by the states of morelos, puebla, méxico and hidalgo. the main cities of these states were those that were visited by the cases and in a lesser extent by the controls. secondly, we did not perform any follow-up during summer and christmas holidays, which in mexico are specific periods for leisure. these activities are usually performed in places that might be different that those observed in our study, including the beaches in the southern coast. it is possible that had we performed our follow-up in vacation periods the observed mobility might have been different, and also leave us with a very interesting research question for the future. the large size of the area covered by these few individuals from a small locality (axochiapan has roughly , inhabitants) is of capital importance, given the fact that in mexico, and probably in many other places, epidemiological surveillance, prevention and control activities for df are mainly planned, supported and executed by local health authorities, who rely on the information generated by a number of systems, most of them automated [ ] , but that are usually restricted to their local administrative limits, namely municipality, sanitary jurisdiction or state at best. thus when df outbreaks overcome those limits and a wider coordination is needed, it is probably that the outbreaks are already established and the window of time for effectively applying control measures has been lost. our data show that the cases group had the largest difference on the time spent in the home area with strong age dependence. older cases spent less time in their homes compared to younger cases. as far as the number of visits is concerned, subjects in the cases group, especially those aged over , performed many and more distant visits, than subjects in the intradomestic control group. this difference with the population control group was less marked. this scenario suggests that the population aged over might play an important role in denv persistence and dispersion perhaps working as geographic spreaders. our group previously determined dengue incidence for this age group and proposed a dynamic model which seems to be corroborated by the results presented here [ ] . infected individuals, both symptomatic but also asymptomatic [ ] , may facilitate the infection of extradomestic mosquito populations in a local scale as models have suggested [ ] , or at a regional scale introducing or exporting the virus. given the fact that we performed an uninterrupted -hour follow up, we were capable to register the time when individuals left their homes for whatever activity they performed. to our surprise, we recorded waypoints out of the participant's homes virtually at any hour of the day. although the majority of records show that people in axochiapan have a day-light pattern of activities, we recorded waypoints from cases, between : and : am, which were consistent with participants' declared jobs, which were related to nocturnal activities such as bakers and workers from the local stone processing plant. the dispersion patterns described above, both in space and time, might be of importance in the results obtained in the control of denv transmission in this and similar small localities. the usual schedule considered by local health authorities for applying preventive measures, which favors early hours for insecticide spraying and the visits by entomological control brigades, in a geographically focalized strategy might hinder the efficacy of the actions by the mere fact that people moves from their homes and remain away during the time these actions are normally applied. in our data, the hourly pattern for activity suggests that cases might leave earlier their homes during weekdays, and thus their homes might have a higher probability to remain closed by the time health authorities apply preventive or control measures. it is important to notice the high mean age of the cases in axochiapan, in both the participants in the study and those recorded historically in the state of morelos, in comparison to other endemic areas from mexico and the americas. this is however, consistent with a previous work in the area [ ] , and is probably due to the fact that most ( out of members of the cases group) of the cases that we studied were asymptomatic, also, although not statistically significant, the mean age of the asymptomatic individuals was higher than that from symptomatic individuals (mean age asymptomatic: . vs mean age symptomatic: . , t test p = . ). thus, suggesting a possible stronger role of asymptomatic population with age above as spreaders for denv transmission. previous studies have described that visiting other cases' households is a risk factor for denv dispersion [ ] ; working sites have also been suggested as possible transmission sources outside of cases' households [ ] . models have shown that sites outside homes can play a role in denv transmission and infection [ ] , and a recently published work showed positive correlations in thailand between the aedes spp. house index and specific landscape features [ ] . our findings are consistent with these data since cases coincided in houses different to their own in at least five different geographical locations. additionally we found cases that coincided in four potential working places, and a soccer field. as far as we know, this is the first time that leisure sites have been documented as possible areas for denv transmission. the lack of study of such sites has previously been pointed out as a weakness in the study of human mobility [ ] . as for the common visit sites for controls, we identified cells that were visited only by individuals from both control groups but not by cases. these cells included only one potential working site; whereas the cells commonly visited by cases included several likely workplaces. the identification and study of the extradomestic sites where people coincide is relevant: a recent simulation model has concluded that the selection of areas for df control out of the cases' homes is important not only in terms of the time the subjects spend in them, but also because of the local vector:host ratio, and the other habitual destinations of people that visit the same area [ ] . it is possible that much of the movement in a given society is driven by specific population needs and the possibility to fulfill them within or outside from their own locality. axochiapan is a fairly small and well connected locality to other small cities, all of them endemic for df. it is not unrealistic to think that some of the population needs can be readily fulfilled within the same locality whereas other cannot, compelling the population to move away in a permanent or transitory fashion. if a specific population such as that with age older than becomes infected and effectively play a role as spreaders, then perhaps small and peripheral localities to larger cities might have a key importance in sustaining denv transmission across large geographic areas. the assessment of such situations requires a critical review of existing data and the generation of specific studies that may help us to recast current models and more importantly, to completely understand urban denv transmission [ ] . we have identified some weaknesses in our study. the most relevant is our small sample size which might have hindered our capability to identify clear patterns in the mobility from this mexican community. there is a possibility that any individual belonging to either control group might have get infected during the follow up; thus making her/him eligible to become a case, therefore disqualifying him/her for being a suitable control and consequently introducing an information bias; nonetheless, we believe that, although a possibility, this was negligible due to two reasons: first, the follow-up of days was very short for this event to occur, and secondly because while recovering each gps, we asked all individuals whether they had experienced fever or any other symptom suggesting dengue infection during the follow-up. none of the participants reported any change in their health status. although we understand that a more robust argument to ensure the infected/uninfected status might be performing an elisa to each control after finishing their follow-up in order to be certain about their exposure, financial constrains made impossible this procedure. possible future improvements in our study are: increase the limited sample size, the inclusion of adequate representation for the population under the age of , which probably is a relevant group for transmission during the initial and focalized phases of a df outbreak. although no schools could not be identified in our study as a common site visited by cases, this observation needs to be taken cautiously since our study did not consider the follow-up of children usually studying elementary education. thus, we cannot rule out any role of these sites in dengue transmission at younger ages. additionally, extending the duration of the follow up might improve the chances of successful identification of patterns whose frequencies are longer than a week, such as wage collection, bill payments, and communitarian meetings, among others. this last topic is essential; nonetheless it is limited by technical issues that might be addressed as technology for massive and continuous long-lasting follow up becomes available. finally, the main reasons for which the participants move were not deeply explored in our study, thus we cannot be certain whether the recorded movements indeed depend on non-satisfied needs or on leisure activities. we can only assume that at least those movements performed during the mornings and afternoons between monday and friday correspond to real needs such as employment, education, and supply acquisition, and those performed during weekends are related to leisure. some causes for loss of gps information in field studies have been recently described [ ] . although some of these causes might be present in our study, we believe they did not represent significant sources of bias or information loss, since we took some specific measures. for example, people were prevented of accidentally turning the gps off by strapping a tape in the controls. in order to diminish the probability that the participants could forget their gps units at home we performed a weekly phone call reminding them the importance of the usage attachment according the protocol during each individual follow-up. barriers to signal were not important in the studied area since it is located in a plateau with few elevations, and buildings taller than -stories are practically absent. finally, the gps equipment used in the study had battery autonomy of up to straight hours and enough memory for recording up to five times the mean number of waypoints programmed to collect in each subject. based on our own data and that from recently published works we conclude that gpsbased technology is a solid tool for the study of detailed human mobility in denv transmission or other infectious diseases, which can and must be adopted in public health and epidemiology as a basic instrument. the important geographic dispersion in our results demonstrates the necessity for studying the potential role that human mobility has in denv transmission and outbreak duration and also a strong argument to study and clarify the role that asymptomatic cases might have in dengue virus dispersion. furthermore our data strongly suggest that the size of the areas considered for prevention and control of df outbreaks needs to be revised and that it is necessary to integrate this knowledge into the planning of preventive and control measures, which usually are prone to using basic shapes such as circles or squares as geographic references in order to define limits, ranges, trajectories and points of origin. it is clear that human populations move normally across geographical areas and not only during holidays or vacations. according to our data, the magnitude of these displacements is larger than that considered as an administrative responsibility for local health services providers. this is relevant for denv transmission if a large fraction of that mobile commuting population is also asymptomatic but viremic, facilitating with their movements the exposure of local uninfected mosquito populations with the virus, which might result in an increased geographical dispersion and persistence of the outbreaks due a continuous process of spreading and reintroduction of the virus to susceptible populations. finally, we believe that the data here reported should be valuable for parameterization of mathematical models exploring specific issues in dengue epidemiology such as geographical dispersion of human activities, contact rate among humans in intermediate spots, optimal range for vector control coverage, optimal target places for health promotion activities, impact of coordinated regional collaboration, and transmission dynamics among satellite and large cities. all essential topics that are still to be understood and weighed as drivers in the transmission of this and other mosquito-transmitted diseases. dengue and dengue heamorrhagic fever world health organization. dengue guidelines for diagnosis treatment, prevention and control urbanisation and infectious diseases in a globalised world the global economic burden of dengue: a systematic analysis travel implications of emerging coronaviruses: sars and mers-cov effect of travel on influenza epidemiology man bites mosquito: understanding the contribution of human movement to vector-borne disease dynamics day-to-day population movement and the management of dengue epidemics assessing and maximizing the acceptability of global positioning system device use for studying the role of human movement in dengue virus transmission in iquitos, peru using gps technology to quantify human mobility, dynamic contacts and infectious disease dynamics in a resource-poor urban environment understanding individual human mobility patterns the scaling laws of human travel peridomestic infection as a determining factor of dengue transmission nation-wide, web-based, geographic information system for the integrated surveillance and control of dengue fever in mexico a search space reduction methodology for data mining in large databases the use of a vest equipped with a global positioning system to assess water-contact patterns associated with schistosomiasis distribution and interspecies contact of feral swine and cattle on rangeland in south texas: implications for disease transmission health &demographic surveillance system profile: the kombewa health and demographic surveillance system (kombewa hdss) multiple outbreaks for the same pandemic: local transportation and social distancing explain the different "waves" of a-h n pdm cases observed in méxico during asymptomatic humans transmit dengue virus to mosquitoes house-to-house human movement drives denguevirus transmission epidemiology of dengue and dengue haemorrhagic fever in a cohort of adults living in bandung analyzing the spatio-temporal relationship between dengue vector larval density and land-use using factor analysis and spatial ring mapping population movement and vector-borne disease transmission: differentiating spatial-temporal diffusion patterns of commuting and noncommuting dengue cases recasting the theory of mosquito-borne pathogen transmission dynamics and control strengths and weaknesses of global positioning system (gps) data-loggers and semi-structured interviews for capturing fine-scale human mobility: findings from iquitos authors wish to thank to servicios de salud de morelos for its support to this project. the authors have declare that no competing interests exist. key: cord- -ge qt authors: torner, núria; martínez, ana; basile, luca; mosquera, mmar; antón, andrés; rius, cristina; sala, m. rosa; minguell, sofia; plasencia, elsa; carol, mónica; godoy, pere; follia, núria; barrabeig, irene; marcos, m. angeles; pumarola, tomàs; jané, mireia title: descriptive study of severe hospitalized cases of laboratory-confirmed influenza during five epidemic seasons ( – ) date: - - journal: bmc res notes doi: . /s - - -y sha: doc_id: cord_uid: ge qt objective: the plan of information on acute respiratory infections in catalonia (pidirac) included the surveillance of severe hospitalized cases of laboratory-confirmed influenza (shclci) in . the objective of this study was to determine the clinical, epidemiological and virological features of shclci recorded in sentinel hospitals during five influenza seasons. results: from a sample of shclci recorded during the influenza epidemics seasons from – to – , cases were confirmed by pcr and/or viral isolation in cell cultures from respiratory samples. a total of shclci were recorded, % required icu admission and % died. the median age of cases was years (range – years); . % were unvaccinated; . % received antiviral treatment (in . and % of cases within h after hospital admission and the onset of symptoms, respectively); influenza virus a [ . % a (h n )pdm , . % a (h n )] was identified in . % of cases. surveillance of shclci provides an estimate of the severity of seasonal influenza epidemics and the identification and characterization of at-risk groups in order to facilitate preventive measures such as vaccination and early antiviral treatment. electronic supplementary material: the online version of this article ( . /s - - -y) contains supplementary material, which is available to authorized users. influenza is an infectious disease affecting mainly upper respiratory tract worldwide. influenza virus causes between three and five million severe cases and an estimated , - , deaths annually. in the european union, there are between , and , annual deaths attributable to influenza. however, mortality is only the tip of the iceberg in terms of the disease burden, since influenza also causes a decrease in functional status and increased dependency in the elderly [ ] . estimating the burden of disease caused by influenza is difficult because many cases do not require medical care, or no confirmatory laboratory tests are widely performed to all influenza like illness' cases [ , ] . in catalonia, influenza surveillance is conducted through the plan of information on acute respiratory infections in catalonia (pidirac) based on the network of sentinel physicians, who provide information on patients with influenza symptoms [ ] . given the situation generated by the pandemic caused by the new influenza a (h n ) pdm virus, the pidirac sentinel network included surveillance of severe hospitalized cases of laboratory-confirmed influenza (shclci) to assess severity. the pidirac sentinel surveillance network has a primary care sentinel network made up by gps and pediatricians who inform on a daily basis of all ili attended and perform sampling of respiratory swabs for confirmation. this information allows to plot weekly ili incidence and sentinel hospital facilities who notify on a weekly basis all influenza confirmed cases that meet the ecdc definition for severe influenza [ , ] . this surveillance allows the clinical and epidemiological characteristics and risk factors associated with greater severity to be determined, and the emergence of influenza virus strains with clinical characteristics and behaviours outside the normal range to be detected, in order to correctly prioritize and direct preventive and control measures during the influenza season [ ] . the aims of shclci surveillance are to provide an estimate of the severity of seasonal influenza epidemics to identify and characterize the risk groups that may present serious complications as a result of infection by circulating influenza viruses or their association with some underlying diseases and to identify the virological characteristics of viruses associated with these severe cases, such as genetic changes and/or antigenic changes that lead to increased virulence. the aim of this study was to describe the clinical, epidemiological and virological characteristics of shclci based on data collected in five influenza seasons in catalonia. epidemiological surveillance of severe cases of influenza in catalonia during five epidemic influenza seasons ( - ), beginning on week of the season until week of the following year, with the recording by twelve hospitals (covering , % of the population) from the pidirac sentinel network of shclci reported to the epidemiological surveillance units corresponding to each hospital [ , ] . shclci cases were cases with previous influenza like illness symptoms (sudden onset of symptoms and/ or fever; malaise; headache; muscle pain; and/or cough; sore throat; shortness of breath) who presented to a hospital facility and complyed with shclci case definition. shlcic was defined as a severe case of laboratory-confirmed influenza due to the influenza virus (a, a (h n )pdm , b, c) that required hospitalization because of pneumonia, septic shock, multiorgan failure or any other severe condition, including icu admission or who developed clinical signs during hospitalization for other reasons. influenza diagnosis was confirmed by polymerase chain reaction (pcr) and/or culture of nasopharyngeal swabs. respiratory tract samples were processed within h of receipt at the laboratory. a μl aliquot was taken for total nucleic acids extraction and eluted in μl of rnase-free elution buffer using the automatic qiasymphony system (qiagen, hilden, germany) according to the manufacturer's instructions. subsequently, two specific one-step multiplex real-time pcr was carried out using the stratagene mx p qpcr systems (agilent technologies, santa clara, ca, usa), were used for typing a/b influenza virus and subtyping influenza a virus [ , ] . for each reported case, an epidemiological survey was made to collect anonymized demographic variables (age and sex); risk factors; icu admission; day of onset of symptoms, of hospital admission and discharge; vaccination history; influenza virus type and subtype; and outcome at hospital discharge. epidemiological survey was conducted by preventive medicine physician from data in medical history registry and public health epidemiologist in charge. we studied all data on shclci from five influenza seasons in pidirac sentinel network hospitals and made a comparative analysis of viral types and subtypes. the strain identified in > % of cases in each season was considered the predominant strain. duration of hospital stay was divided into two categories < days and days or more. the statistical analysis was made using the chi square test and student's t test with % confidence intervals (ci) for continuous variables and the anova test for categorical variables. during the - seasons cases of shclci were recorded, ( %) required icu admission and ( %) died: ( . %) were male. the median age was years (range - years-mean . (sd . years). the most-affected age group was the ≥ years age group with cases ( . %) ( table ). the median age of the ≥ years age group was years (range - ) and the mean age was . years (sd . years): ( %) were aged ≥ years. of deaths, ( . %) occurred in patients aged ≥ years and ( . %) in patients aged > years ( table ) . the distribution by type of influenza virus was: . % ( ) influenza virus a, ( . %) of which corresponded to the a (h n )pdm subtype and ( . %) to a (h n ), and . % to influenza a that remained unsubtyped: ( . %) of cases were influenza b (additional file ). there were significant differences in the mean age of cases according to the virus type, with a higher prevalence of virus a (h n ) in older patients and virus a (h n )pdm in younger patients with mean age of cases . and . years (p < . ) and those with death as outcome . and . years, respectively (p < . ) ( table ) . in ( . %) of shclci there was a known risk factor. the most prevalent risk factors were cardiovascular disease, chronic obstructive pulmonary disease and diabetes ( . , . and . %, respectively). the most prevalent complication was pneumonia in ( . %) cases, of these ( . %) presented bacterial superinfection. for cases with known immunization for influenza, / ( . %) of cases were not vaccinated for the current season included in the study (missing data on vaccination status: ( %). the age group with highest vaccine coverage was the older than age group ( %) and cases with at least one risk factor had low vaccination coverage ( . %). vaccine proved effective in reducing intensive care unit (icu) admission [or = . ( % ci . - . ) p = . ] ( table ) . of the pregnant women hospitalized as shclci, all were unvaccinated, ( . %) required icu admission, ( . %) received antiviral treatment and none of them had any underlying disease or risk factor other than pregnancy. the mean hospital stay was . days (sd . ) with a median of days (range - days). the mean stay by age group was: - years . a total cases ( . %) had information on antiviral treatment, ( %) received oseltamivir and ( %) zanamivir. of these cases ( . %) received treatment in the first h after admission. antiviral treatment administered before h on admission was associated with a shorter length of stay (los) (or . : ci . - . , p < , ) nosocomial cases ( ) were excluded from the analysis (table ). after the influenza virus a(h n )pdm pandemic, among the lessons learned was the need to expand surveillance of seasonal influenza to include severe cases in order to determine the characteristics of shclci caused by seasonal influenza viruses circulating during each season. the results obtained by the pidirac sentinel surveillance system during five post-pandemic seasons underscore the importance of prevention by vaccination in order to avoid serious complications such as ards and icu admission of the most vulnerable persons, while showing the need for increased vaccination coverages in groups such as pregnant women, in whom the proportion of icu admission is . % while vaccination is zero [ , ] . in our study no significant differences between influenza a and b virus infections among hospitalized cases was observed, except for younger age for a (h n ) pdm cases; similar results also found by other studies in the united states and australia [ ] [ ] [ ] . although the number of hospitalizations associated with influenza a virus infections was greater than the number with influenza b virus infections this fact can be explained by greater prevalence of influenza a viruses circulating in the community during the seasons included in the study. the delay in the administration of antiviral drugs at symptom onset in people with an identified risk of complications, such as the elderly or people with medical conditions that worsen the prognosis of influenza or make a longer hospital stay likely, also demonstrates the need to confirm influenza in primary healthcare and administer treatment within - h for it to be effective. influenza remains an important global public health problem in spite of scientific evidence which support immunization to protect those at high risk for complications, such as the elderly [ ] . predominant influenza type/subtype circulating each season, influenza vaccination policies and coverage, influenza vaccine strain match/mismatch and vaccine effectiveness significantly influence the % of hospitalised influenza cases and cfrs in all age groups, including older age groups. however, the high percentage of hospitalizations ( . %) and mortality ( . %) in the ≥ years age group, especially in people aged > years, where mortality is higher ( . %), reflect the consequences of increased life expectancy. early administration of antiviral treatment has proven to diminish length of stay. healthcare providers should start antiviral treatment as soon as possible, before h from onset of symptoms is the recommendation, [ ] unfortunately this is not feasible. yet if treated as soon as patient is admitted to the hospital facility and influenza is confirmed, shorter length of stay and prompt recovery can be attained [ , ] . this makes it necessary to deepen our knowledge of the effect of aging and its interaction with the most prevalent chronic diseases in the elderly and the immune response in order to implement preventive measures to provide better protection of this population group [ ] . it is necessary to improve some surveillance aspects, especially with regard to data collection, in order to avoid a loss of information that makes some variables impossible to assess, such as risk factors such as smoking, which was not recorded in % of cases as well as lack of information on the vaccination status, which was more than % [ , ] . a limitation to this study is that only shclci cases were recorded during the study period. this unables global hospitalization burden estimates caused by seasonal influenza nor the estimation of seasonal differences in vaccine effectiveness to prevent severity and death. the system identifies the epidemiological and virological characteristics of severe forms of influenza that show changes in their virulence, but comparison between severe and non-severe cases is not feasible. the proportion of shclci cases admitted to icu and cfrs are potentially higher than other surveillance systems that monitor all hospitalised cases of confirmed influenza. this is particularly evident with regard to pregnant women because of the small number of cases. yet, in all shclci surveillance provides an estimate of the severity of seasonal influenza epidemics, and provides ad hoc information to identify and characterize the groups at risk of complications and take appropriate preventive measures. abbreviations ards: acute respiratory distress; icu: intensive care unit; cfr: case fatality rate; ci: confidence interval; ecdc: european center for disease control; ili: influenza like illness; los: length of stay; or: odds ratio; pcr: polymerase chain reaction; pidirac: plan of information on acute respiratory infections in catalonia; sd: standard deviation; shclci: severe hospitalized cases of laboratoryconfirmed influenza. • fast, convenient online submission ready to submit your research ? choose bmc and benefit from: vaccine effectiveness in older individuals: what has been learned from the influenzavaccine experience influenza illness and hospitalizations averted by influenza vaccination in the united states predicting clinical severity based on substitutions near epitope a of influenza a/h n public health agency of catalonia. department of health. pla d'informació de les infeccions respiratòries agudes a catalunya (pidirac) estratègia de vigilància dels casos greus de grip hospitalitzats vigilancia de casos graves hospitalizados confirmados de virus de la gripe the global influenza hospital surveillance network (gihsn): a new platform to describe the epidemiology of severe influenza global burden of respiratory infections due to seasonal influenza in young children: a systematic review and meta-analysis virological surveillance of influenza and other respiratory viruses during six consecutive seasons from severe influenza in us hospitals, - : complications and risk factors for death in patients early administration of oral oseltamivir increases the benefits of influenza treatment effectiveness of antiviral treatment in preventing death in hospitalized cases of severe influenza over six influenza seasons increased antiviral treatment among hospitalized children and adults with laboratory-confirmed influenza estimating the burden of seasonal influenza in spain from surveillance of mild and severe influenza disease estimated influenza illnesses, medical visits, hospitalizations, and deaths averted by vaccination in the united states seasonal influenza (flu) cdc. centers for disease control and prevention, national center for immunization and respiratory diseases (ncird) the members of the pidirac working group for the surveillance of severe nt conceived and wrote the manuscript, am and mj reviewed the manuscript and cr, ib, nf, pg, ep, sm, ms, mc, mm , mm , aa and tp were involved in case management. all authors read and approved the manuscript. the authors declare that they have no competing interests. the raw data supporting this study are publicly available as additional file. not applicable. ethical approval was not necessary as the study uses routinely collected, anonymous surveillance data. the study was partially funded by agaur (agència de gestió d' ajuts universitaris i de recerca) grant and ciber epidemiologia y salud pública ciberesp and by fondo de investigación sanitaria pi / and recercaixa acuo_ i of the catalan association of public universities (acup). springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -leedutqo authors: nawaz, sameena; allen, david j.; aladin, farah; gallimore, christopher; iturriza-gómara, miren title: human bocaviruses are not significantly associated with gastroenteritis: results of retesting archive dna from a case control study in the uk date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: leedutqo gastroenteritis is a common illness causing considerable morbidity and mortality worldwide. despite improvements in detection methods, a significant diagnostic gap still remains. human bocavirus (hbov)s, which are associated with respiratory infections, have also frequently been detected in stool samples in cases of gastroenteritis, and a tentative association between hbovs, and in particular type- hbovs, and gastroenteritis has previously been made. the aim of this study was to determine the role of hbovs in gastroenteritis, using archived dna samples from the case-control infectious intestinal disease study (iid). dna extracted from stool samples from , cases and , controls were tested for the presence of hbov dna. all samples were screened in a real time pcr pan-hbov assay, and positive samples were then tested in genotype to -specific assays. hbov was detected in . % but no significantly different prevalence was observed between cases and controls. in the genotype-specific assays of the hbov-positive samples were genotyped, with hbov- predominantly found in controls whilst hbov- was more frequently associated with cases of gastroenteritis (p< . ). a significant proportion of hbov positives could not be typed using the type specific assays, % of the total positives, and this was most likely due to low viral loads being present in the samples. however, the distribution of the untyped hbov strains was no different between cases and controls. in conclusion, hbovs, including hbov- do not appear to be a significant cause of gastroenteritis in the uk population. in a novel parvovirus was discovered in respiratory secretions of young children and was termed human bocavirus (hbov- ) [ ] . other important members of the parvoviridae family include b which causes fith disease and human parvovirus (parv ) which has not yet been associated with a disease [ ] . parvoviruses in animals are generally associated with systemic disease but also with respiratory and enteric symptoms [ , ] . since the discovery of hbov- three other hbov genotypes have been described, hbov- , hbov- and hbov- . the association between hbov- and respiratory disease has previously been well established [ , , , , , , , , , , , , , , ] . although all hbovs have also been detected in stool samples with prevalences ranging from , % to %, only hbov- has been reported to be associated with symptoms of gastroenteritis [ ] . nevertheless, the role of hbov as an aetiological agent of gastroenteritis has not been clearly confirmed, furthermore, to date, no clear association between the presence of hbov- and hbov- and disease has been established [ , ] . recent seroepidemiological studies indicate that exposure to hbovs occurs early in life and % of the population are seropositive by the age of , although differences were reported in the seroprevalence of type-specific antibodies to the different hbovs, which suggested that hbov- infections are more prevalent [ ] . the infectious intestinal disease study (iid study) was a large case control study of gastroenteritis carried out in the uk between - [ ] with the aim to determine the burden and aetiology of sporadic cases iid in the uk population. initially, the use of classical microbiology diagnostic methods and electron microscopy (for virus detection) failed to detect a potential aetiological agent or toxin in % of the cases [ ] . retesting of the archived samples from this study using molecular methods for the detection of enteric viruses, bacteria and protozoa revealed viruses to be the most common aetiological agents of gastroenteritis,the diagnostic gap for iid was reduced to % from % [ ] . the aim of the present study was to evaluate the role of hbovs in iid in the uk population, using archived dna samples from the matched case-control iid- study [ ] . in addition, the presence specifically of hbov- , or was investigated in order to determine any possible associations between specific hbov genotypes and iid. a total of , archived dna from the iid study [ , ] were tested for the presence of hbov dna. this archive comprised dna extracted from stool samples from , cases and , controls. the qpcr assay targeted the ns gene (ratcliff et al., unpublished method, personal communication) and was performed using an abi taqman . oligonucleotide primer and probe sequences and positions are described in table . the reaction consisted of . m ddt (invitrogen), x platinum quantitative pcr supermix-udg (invitrogen), pan-hbov-f and pan-hbov-r primers each at a concentration of mm, pan-hbov-ns probe at mm concentration, rox mm (invitrogen) . ml of template dna and rnase free water to a final reaction volume of ml. the amplification consisted of an initial denaturation at uc for min, followed by cycles with denaturation at uc for sec, annealing at uc for sec and extension at uc for sec. hbov- , and -specific primer pair and probes were designed in house through alignment of sequence data available in genbank. the reaction conditions are as follows; x platinum quantitative pcr supermix-udg (invitrogen), hbov-ns - f, hbov- r, hbov -r and hbov r primers each at a concentration of mm, the hbov , and probe at mm concentration, rox mm (invitrogen), . ml of template and rnase free water was added to a final reaction volume of ml. the amplification conditions for the typing assay are the same as those described in the hbov ns detection assay above. plasmids containing a bp and a bp region of the ns encoding gene of hbov- and hbov- respectively were used for assay optimisation and as controls. control material was kindly provided by r. ratcliff, adelaide, australia. the controls were also used in order to generate a standard curve for use with the pan-hbov assay in order to allow for normalisation of the data generated including the comparison of relative sensitivities of the different assays and for quantitation of dna present in each of the positive samples. the standard curve was generated using the plasmid containing a genome segment of the hbov- and consisted of a series of fold dilution containing from , copies/ml down to copies/ml. inter-and intraassay reproducibility was analysed by performing replicate testing of the standards in a single run (x ) and repeated runs (x ), and the standard curve was also included in each assay run for quality control and normalisation of results. a subset of samples positive in the pan-hbov assay but which failed to amplify in the type-specific assays were confirmed using an alternative method published elsewhere [ , ] , and were further confirmed though direct sequencing of the amplicons obtained after purification either from solution or agarose gels using agencourt ampure (beckman coulter, usa) and geneclean spin kit (qbiogene), respectively, following manufactures protocols. the chi-squared test was used in order to evaluate the significance of differences observed between groups. for comparison of median values (analysis of ct values) the mann witney utest was used. prevalence odds ratio (por = pcases/( -pcases)/ pcontrols/( -pcontrols)) was calculated in the total cohorts and by age group. table . hbov-specific oligonucleotide primers and probes (all located at the ns gene). sequence ( a total of . % of the samples tested were positive for hbov. no statistically significant differences were seen in the prevalence of hbov between cases and asymptomatic controls, por = . (table ) . peak hbov infection was observed in children under the age of , both in cases and controls, with significantly higher hbov incidence in children between and in asymptomatic controls than in the cases of gastroenteritis (por = . ; p, . ). the number of hbov positives in older age groups was too small for meaningful statistical analysis. the average ct values were . and . , and the median ct values were . and . in cases and controls respectively (see distribution in figure ). the majority of hbov-positives in both cases and controls had copy numbers ranging between and copies/reaction (or between . and . copies/ml of feaces). the distribution of hbov viral loads between cases and controls was comparable and the median ct values between cases and controls were not significantly different (u-test; z = . , p. . ). hbov dna was found in ( %) samples in the absence of other co-pathogens (table ) . no statistically significant differences were observed in the proportion of cases or controls in which hbov was found as a single organism or in the presence of one or more pathogens in the cohort as a whole, however in the - years of age group, hbov in the absence of any other enteric pathogens was found in % of the cases, but in % of the controls (p, . ). hbov infections were detected year round although a peak was observed in the spring/early summer months, between april and june (figure ). hbov dna was found in . % and . % of female cases and controls, respectively. the distribution of hbov among females and males was not significantly different from the distribution of females and males in the entire cohort which was % and %, respectively. a total of ( . %) hbov positives were genotyped, whilst ( . %) remained untyped after testing in the hbov types , or specific assays (table ). hbov- detection was found predominantly in controls, (p, . ) and hbov- was predominantly associated with cases (p, . ). the prevalence of hbov- was not significantly different between cases and controls. hbov- and - were predominantly found in children (table ) . hbov- in the absence of any other pathogen was detected in ( . %) of the cases, compared to ( . %) of the controls. in cases, hbov- was found across the age groups, although more frequently in children , , whereas in controls they were found predominantly in children , with only example in an adult ( table ). the prevalence of hbov- in children , years old was however not significantly different between cases and controls, . % and . %, respectively. a subset of hbov that were negative in the type , or specific assays were confirmed in an alternative pan-hbov pcr, and sequencing of a small number confirmed them as types , or . the majority of the untyped samples ( %) had a ct value of . in the screening pan-hbov pcr, indicative of low viral loads being present in the samples. this represents the largest study to date investigating the role and distribution of hbovs infections in community acquired sporadic gastroenteritis and in asymptomatic controls. the prevalence of hbov infection in the uk population was found to be . % across all ages, with a higher percentage of the infections occurring in children , years of age ( %). however, the prevalence of hbov infections was comparable in cases of gastroenteritis and in age-matched asymptomatic controls. although the presence of enteric pathogens, eg norovirus or rotavirus, in asymptomatic individuals is well documented, a significantly higher prevalence of the pathogen is seen in cases than in the controls [ ] . therefore, our data suggests that hbov are not causally associated with gastrointestinal disease in the uk population as a whole, nor in children. the prevalence of detection of hbov in stool samples in previous studies varies widely (see summary in table ), but most coincide in reporting the highest prevalence in children. hbov infections were detected all year round in the uk although a tentative peak was observed in the spring/early summer months in (between april and june). different seasonal patterns in the peak prevalence of hbov have been reported in different countries (see table ), of the hbov positive samples, ( . %) were genotyped in the type-specific assays. hbov- was found predominantly in controls (p, . ) and the prevalence of hbov- was similar in cases and controls. both hbov- and - were predominantly found in children. hbov- was predominantly associated with gastroenteritis cases (p, . ). the overall prevalence in cases was . % and . % in controls, however, in children , year of age, the prevalence in cases and controls was similar, . % and . %, respectively. the prevalence of hbov- in children in the uk was significantly lower than that reported in a study in australia, in which hbov- was detected in . % and . % of the cases and controls, respectively [ ] . the findings of the study in australia lead to the proposal of hbov- as an important aetiological agent of infantile gastroenteritis. it is noteworthy however, that in the australian study, the association of hbov- with gastroenteritis was only significant when cases with a bacterial co-pathogen were included in the analysis. although in the present study hbov- in the absence of other enteric pathogens was found more frequently in cases than in controls, the small numbers found in such large study suggest that the role of these viruses in iid, if any, is likely to be small. a lack of correlation between hbovs or hbov- and paediatric gastroenteritis was also reported in several smaller studies published elsewhere [ , , ] . a total of % of the hbov-positive samples could not be genotyped using the genotype-specific pcr assays. the majority of these untyped samples ( %) had ct values . . this suggests that failure to type may be associated with low viral loads and differences in the relative sensitivities of the genotyping assays compared to the detection assay. although under experimental conditions and using plasmid controls the sensitivities of all assays were comparable, it is likely that when applied to true clinical samples the sensitivity of the type-specific assays was inferior, possibly due to as yet not identified strain variability within genotypes. also, a hbov type -specific assay was not included in this study, therefore, any possible hbov infections would not have been typed. of the panel of samples that were tested in an alternative pan-hbov pcr, the strains typed through sequencing were hbov- ( samples), hbov- ( sample) and hbov- ( samples). furthermore, the distribution of untyped hbovs was not significantly different in cases and controls. hbovs in the absence of other enteric pathogens were seen in % of the hbov-positive samples, and more frequently in the controls, . % vs . % in cases. no significant difference in hbov load was observed between cases and controls, or between the samples positive for hbov alone or in the presence of other pathogens. previous studies have investigated the relationships between viral load and disease severity [ , , , , ] . in respiratory infections significantly higher hbov loads were seen in samples collected from children positive for hbov alone than in those from children with co-infections. in respiratory infections also, viral loads . were associated with disease, whereas loads , were associated with asymptomatic children [ , ] . this lead to the suggestion that higher viral loads are indicative of a causative role of hbov in respiratory infections [ , ] . however, brieu et al [ ] found no significant correlation between viral load and clinical symptoms or disease severity. in conclusion, the results obtained from investigating for the presence of hbov dna in archived dna samples from a large and previously well described case-control study of iid suggest that hbov, including hbov- ,do not appear to be a significant cause of gastroenteritis in the uk population, and particularly in the paediatric population. although hbovs are relatively frequent across all ages, and in particular in preschool age children, they are found just as frequently among children and adults without symptoms of gastroenteritis. cloning of a human parvovirus by molecular screening of respiratory tract samples new dna viruses identified in patients with acute viral infection syndrome epidemiological studies of parvovirus infections in calves on endemically infected properties minute virus of canines (mvc, canine parvovirus type- ): pathogenicity for pups and seroprevalence estimate frequent detection of human rhinoviruses, paramyxoviruses, coronaviruses, and bocavirus during acute respiratory tract infections human bocavirus: prevalence and clinical spectrum at a children's hospital detection of human bocavirus in canadian children in a -year study complete coding sequences and phylogenetic analysis of human bocavirus (hbov) the association of newly identified respiratory viruses with lower respiratory tract infections in korean children human bocavirus: a novel parvovirus epidemiologically associated with pneumonia requiring hospitalization in thailand human bocavirus quantitative dna detection in french children hospitalized for acute bronchiolitis human bocavirus infection in young children in the united states: molecular epidemiological profile and clinical characteristics of a newly emerging respiratory virus clinical features and complete genome characterization of a distinct human rhinovirus (hrv) genetic cluster, probably representing a previously undetected hrv species, hrv-c, associated with acute respiratory illness in children detection of human bocavirus in japanese children with lower respiratory tract infections epidemiological profile and clinical associations of human bocavirus and other human parvoviruses human bocavirus in iranian children with acute respiratory infections human bocavirus infection, people's republic of china human bocavirus in hospitalized children frequent detection of bocavirus dna in german children with respiratory tract infections a newly identified bocavirus species in human stool human bocaviruses are highly diverse, dispersed, recombination prone, and prevalent in enteric infections a novel bocavirus associated with acute gastroenteritis in australian children seroepidemiology of human bocaviruses - a report of the study of infectious intestinal disease in england.: food standard agency. the stationery office a study of infectious intestinal disease in england: microbiological findings in cases and controls detection by pcr of eight groups of enteric pathogens in , faecal samples: re-examination of the english case-control infectious intestinal disease study ( - ) detection of viral, bacterial, and parasitological rna or dna of nine intestinal pathogens in fecal samples archived as part of the english infectious intestinal disease study: assessment of the stability of target nucleic acid human bocavirus in children hospitalized for acute gastroenteritis: a case-control study evidence of human coronavirus hku and human bocavirus in australian children human bocavirus in children detection of human bocavirus- in children with acute gastroenteritis in south korea high prevalence of human bocavirus and its role in childhood acute gastroenteritis in china human bocavirus and acute wheezing in children human respiratory syncytial virus (hrsv) rna quantification in nasopharyngeal secretions identifies the hrsv etiologic role in acute respiratory tract infections of hospitalized infants quantitation of group a rotavirus by real-time reverse-transcription-polymerase chain reaction: correlation with clinical severity in children in south india diagnosing rotavirus a associated iid: using elisa to identify a cut-off for real time rt-pcr diagnosing norovirus-associated infectious intestinal disease using viral load human bocavirus infection in children with respiratory tract disease this study was conducted using existing material and data form the iid- study, which was funded by the food standards agency. we would like to thank the iid study executive committee for their support in approving the use of the archive dna material for this study. key: cord- -gl cjmno authors: pang, xinghuo; yang, peng; li, shuang; zhang, li; tian, lili; li, yang; liu, bo; zhang, yi; liu, baiwei; huang, ruogang; li, xinyu; wang, quanyi title: pandemic (h n ) among quarantined close contacts, beijing, people’s republic of china date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: gl cjmno we estimated the attack rate of pandemic (h n ) and assessed risk factors for infection among close contacts quarantined in beijing, people’s republic of china. the first confirmed cases detected between may and september , , were investigated; , close contacts were located and quarantined. the attack rate of confirmed infection in close contacts was . % overall, ranging from . % among aircraft passengers to > % among household members. risk factors for infection among close contacts were younger age, being a household member of an index case-patient, exposure during the index case-patient’s symptomatic phase, and longer exposure. among close contacts with positive test results at the start of quarantine, . % had subclinical infection. having contact with a household member and younger age were the major risk factors for acquiring pandemic (h n ) influenza virus infection. one person in with confirmed pandemic (h n ) was asymptomatic. i n early april , human cases of infection with a novel infl uenza virus of swine origin, pandemic (h n ) virus, were identifi ed in the united states and mexico, and this virus spread rapidly across the world ( - ). on june , , the world health organization raised the pandemic level to , the highest level for pandemic alert ( ) . estimating attack rates is a major task in characterizing pandemic (h n ) . some studies have reported attack rates of pandemic (h n ) among household members and aircraft passengers ( ) ( ) ( ) . these studies suggested that the transmissibility of pandemic (h n ) virus was low. these studies were conducted in outbreak settings, and attack rates were calculated on the basis of clinical diseases that included infl uenza-like illness (ili) or acute respiratory illness (ari) of close contacts rather than confi rmed infection with pandemic (h n ) virus. in addition, in these studies only symptomatic index and secondary cases were included. although most infections of pandemic (h n ) infl uenza virus produce ili or ari symptoms ( ) ( ) ( ) ( ) ( ) , subclinical infection can occur and can change the estimate of attack rate. in addition, the infectivity of asymptomatic case-patients has not been clearly defi ned ( ) . because of the high rates of illness and death among the initial case-patients with pandemic (h n ) ( ) , the chinese government decided to prevent and contain the rapid spread of disease through tracing and quarantine of persons who had close contact with persons with confi rmed cases of pandemic (h n ) . beijing, the capital of the people's republic of china, took strict containment and control measures through october . the beijing municipal government implemented border entry screening, ili screening in hospitals, health follow-up of travelers from overseas, and quarantine and testing of close contacts to identify new introduction of cases and local transmission. public health workers conducted epidemiologic investigation of all index case-patients (including those with subclinical infections) and traced and quarantined close contacts whose residence was within the jurisdiction of beijing. we estimated the attack rate of pandemic (h n ) virus infection and assessed risk factors or correlates for infection among different types of close contacts, including household members and aircraft passengers. in , under the guidance of the beijing center for disease prevention and control (beijing cdc), a network of collaborating laboratories was established to perform reverse transcription pcr testing to confi rm cases of pandemic (h n ) ( ) . the confi rmed cases included symptomatic and asymptomatic cases, and these cases were detected mainly by border entry screening, ili screening in hospitals, health follow-up of travelers from overseas, and quarantine and testing of close contacts. once confi rmed, index case-patients were immediately quarantined in designated hospitals to receive treatment while in isolation. all the confi rmed cases were required by law to be reported to beijing and local cdcs. from may through october , a detailed epidemiologic investigation was conducted for each confi rmed case of pandemic (h n ) (including symptomatic and asymptomatic cases) by beijing and local cdcs within hours after confi rmation of infection. patients with confi rmed cases were interviewed about demographic characteristics, course of illness, travel and contact history, and information about close contacts. patients with confi rmed cases were categorized as having imported cases (travelers) and locally acquired cases (no travel history) on the basis of where the infection was acquired. close contacts were defi ned as anyone who ever came within meters of an index case-patient without the use of effective personal protective equipment (ppe) (including masks and gloves, with or without gowns or goggles) during the presumed infectious period. trained staff from local cdcs made the determinations on the basis of fi eld investigation. the relationships of close contacts to index case-patients were categorized as ) spouses, ) other household members, ) nonrelated roommates, ) contacts at workplace or school, ) nonhousehold relatives, ) passengers on the same fl ight, ) friends, and ) service persons met at public places. a close contact on an aircraft was defi ned as a passenger sitting within rows in front and rows behind the index case-patient. all close contacts were traced and quarantined for days after the most recent exposure to the index casepatient. all index case-patients detected between may (the fi rst case, the date of confi rmation) and september , (before widespread transmission in beijing), and their close contacts were included in this study. we excluded cluster or outbreak cases for which close contacts could not be determined clearly by epidemiologic investigation (the transmission chain was obscure). for each close contact, before quarantine, a pharyngeal swab specimen was collected for reverse transcription pcr testing, regardless of symptoms. a second pharyngeal swab specimen was collected for testing for pandemic (h n ) virus if any of the following symptoms developed in a close contact during quarantine: axillary temperature > . °c, cough, sore throat, nasal congestion, or rhinorrhea. data were analyzed by using spss version . (spss inc., chicago, il, usa). median and range values were calculated for continuous variables, and percentages were calculated for categorical variables. differences in attack rates were compared between subgroups of close contacts by using the χ test. for the signifi cant difference found in multiple subgroups, this test does not enable identifi cation of which multiple subgroups are signifi cantly different, only that across all the subgroups there are differences. the variables with p< . in χ test were included in multivariate analysis. multivariate unconditional logistic regression analysis was conducted to determine risk factors associated with infection in close contacts. backward logistic regression was conducted by removing variables with p> . . odds ratios (ors) and % confi dence intervals were calculated for potential risk factors of infection. the hosmer-lemeshow goodness-of-fi t test was used to assess the model fi t for logistic regression. all statistical tests were -sided, and signifi cance was defi ned as p< . . a total of eligible index case-patients, detected from may through september , , were included in this study. through fi eld epidemiologic investigations, , close contacts were traced and quarantined in beijing. the median number of close contacts per index case per day was . persons (range . - . persons); the median number for an imported index case was . persons (range . - . persons) and for a locally acquired index case was . persons (range . - . persons). for the symptomatic index case-patients, the median interval between illness onset and sample collection was . days (range − . to . days). among close contacts with symptomatic infection, the median interval between illness onset and sample collection was . days. more than % of close contacts were quarantined within hours after interview of the index case-patients. the median interval between fi rst exposure and quarantine was . days for the close contacts, and it was shorter, on average, for fl ight passenger contacts than nonpassenger contacts ( . days vs. . days). for symptomatic close contacts infected with pandemic (h n ) , the median of generation time (i.e., the time from illness onset in an index case to illness onset in a secondary case) were . days; it was shorter for fl ight passenger contacts than nonpassenger contacts ( . days vs. . days) ( table ) . approximately % of the index case-patients were women; the median age was years, and % likely contracted pandemic (h n ) virus locally because they had not traveled recently. among the index casepatientss, % had subclinical infection. only % of index case-patients had close contacts with confi rmed pandemic (h n ) (table ) , and the total number of close contacts who were infected by the virus from index case-patients was . fifty percent ( , of , ) of close contacts were women, and the median age was years. approximately % of close contacts were household member of index case-patients (spouse or other household member), and aircraft passengers accounted for % of close contacts. approximately % of close contacts were exposed to symptomatic index case-patients during their symptomatic phase. about % were quarantined in a quarantine station ( table ). the overall attack rate for infection among close contacts (positive test result) was . % ( of , ), indicating that index case-patient transmitted infection to . close contacts ( of ) on average (reproduction number = . ). among those close contacts with a positive test result, . % ( of ) had subclinical infection; among the close contacts with positive test results at the start of quarantine, . % ( of ) had subclinical infection. attack rates did not differ by index case-patient's sex (p = . ). however, attack rates differed signifi cantly by index case-patient's age (p = . ), and the lower attack rate was found for older index case-patients. there was no signifi cant difference in attack rates between close contacts of patients with imported cases and those with locally acquired cases (p = . ). no infection was found in close contacts exposed to index case-patients with subclinical infection, and the attack rate observed in close contacts exposed to symptomatic index case-patients during their symptomatic phase was higher (p< . ). almost identical attack rates were found among male and female close contacts (p = . ). however, attack rates were signifi cantly different among different age groups of close contacts (p< . ), and the lowest attack rate was found for those > years of age. the attack rates were signifi cantly different across contact types (p< . ). the attack rate was . % among spouses and . % among other family members in the household, and was lower among other types of close contacts ( table ).the attack rate among passengers on the same fl ight was low, . % overall, and index case-patient transmitted infection to . close contacts on a fl ight on average ( of ), and the attack rate was higher among the passengers with longer fl ight times (> hours, p = . ). the attack rate among close contacts of service persons at public places was . %, and index case-patient transmitted infection to . close contacts of service persons on average ( of ). nonpassenger close contacts with longer exposure duration (> hours), compared with those with shorter duration (> hours), recorded the higher attack rate (p< . ) ( table ) . by multivariate analysis, age and type of contact were the major predictors of infection ( (or . ; p = . ) and - years of age (or . ; p< . ) were at higher risk for infection. other signifi cant independent risk factors associated with infection included being a household member of a person with an index case (or . ; p< . ), being exposed to index case-patients during their symptomatic phase (or . ; p = . ), and exposure duration > hours (or . ; p = . ). similar risk factors were observed among aircraft passengers. we estimated that pandemic (h n ) virus was transmitted by % of index case-patients to their close contacts and that . % ( of , ) of close contacts we traced were infected. our data indicate that pandemic (h n ) virus has low transmissibility in nonoutbreak settings. we found that index case-patient transmitted infection to . close contacts on average, i.e., reproduction number = . . this fi nding suggests that among those quarantined index case-patients, the number of persons with secondary cases who could be traced through rigorous fi eld investigation was small and far less than the number needed for the sustainable transmission of infectious disease in the population (reproduction number > ). however, the fact that the pandemic eventually spread in beijing indicates that contact and case tracing were far from complete, especially later in the summer and early fall of . the strict control measures may have worked to some extent at the beginning but were outpaced by local transmission ( ) ; the percentage of locally acquired infections ranged from < % in june to > % in september (data not shown). in this study, the median number of close contacts per index case-patient per day was . persons. although locating and quarantining these close contacts was done quickly, and stringent quarantine measures were used, which hindered implementation of control measures, the real number of close contacts was unknown and probably exceeded this number. many close contacts were persons met in public places, including public transportation, theaters or cinemas, and shopping malls, and it is nearly impossible to trace all of the contacts. in addition, some persons who had worn ppe during contact with index casepatients were excluded from close contacts management (i.e., they were not quarantined), but because wearing ppe might not protect (or fully protect) against infection, some persons excluded might have become infected. in addition, many persons with mild and asymptomatic cases cannot be detected, but they may transmit the virus. furthermore, the short generation time of pandemic (h n ) shown in this study and in a previous study ( ) could lead to the rapid accumulation of infection sources and close contacts. this rapid compounding could overwhelm response capacity and would have resulted in compromised effectiveness of containment measures. it should also be mentioned that we did not include persons with cluster or outbreak cases for whom close contacts could not be determined clearly by epidemiologic investigation to examine the basic feature of pandemic (h n ) (e.g., generation time), and the reproduction number obtained from our data is an underestimate. attack rates of infection differed signifi cantly by contact type. among household members of index casepatients, the attack rate was the highest, as shown in the multivariate analysis after controlling for age and other factors. the most likely reason for this fi nding is that household members are more likely to have come into closer contact with index case-patients for a longer period with shorter distance and longer duration. another possible reason is that household members may have some certain linkage with index cases in genetic susceptibility or living habits that would cause higher predisposition in household members than in other close contacts. this fi nding is similar to fi ndings in other investigations of respiratory infectious disease ( ) . close contacts on fl ights accounted for the highest proportion of all the close contacts, in part because of how the index cases were detected and the broad defi nition we used for close contacts. however, the attack rate was much lower than that for other close contacts; index case infected only . close contacts on fl ights on average. this fi nding indicated that the possibility of transmission of pandemic (h n ) virus on fl ights was low, and the yield of tracing and quarantining of close contacts on fl ights was limited. tracing contacts of service persons at public places was more diffi cult than tracing other categories of contacts, and the lowest attack rate ( . %) was recorded in this category. despite extensive measures, on average, only . infected close contacts per index case-patient were identifi ed among service persons. tracing the contacts of service persons at public places seems far less cost-effective. criteria for close contacts on fl ights and those of service persons should be refi ned with respect to exposure duration and age of those exposed. exposure to index case-patients for > hours was a signifi cant independent risk factor for infection in fl ight passenger contacts. this fi nding suggests that limiting the time of contact with persons with ili on aircraft can reduce risk for transmission, and a long duration of exposure may be necessary for transmission to occur on aircraft. younger close contacts were at higher risk for infection than older ones. the possible reason was that younger persons had much closer contact with index case-patients than did older persons; another reason may be that younger persons were more susceptible to infection with pandemic (h n ) virus ( ) . this fi nding was consistent with fi ndings reported in other studies ( , ) . no secondary cases were found among close contacts exposed to index case-patients with subclinical infection. the attack rate among close contacts who were exposed to symptomatic index case-patients during their symptomatic phase was much higher than that among those exposed to these case-patients before their illness onset. exposure to index case-patients during the symptomatic phase was a signifi cant independent risk factor for infection among close contacts. these fi ndings indicate that the infectivity of pandemic (h n ) virus was higher after illness onset, and that the infectivity of symptomatic pandemic (h n ) case-patients before illness onset was higher than that of persons with subclinical cases, although persons in each group were asymptomatic when in contact with other persons. in general, the earliest infectious time for pandemic (h n ) was considered as day before illness onset ( ) . we found that index case-patients and infected close contacts shed pandemic (h n ) virus < day before illness onset, which suggests that the infectious period of symptomatic persons with pandemic (h n ) might be < day before illness onset. among close contacts with pandemic (h n ) , ≈ . % were asymptomatic. it is noteworthy that specimens from some close contacts tested negative for pandemic (h n ) virus before quarantine, but those persons could shed the virus during quarantine without symptoms. such infection could not be detected, and the proportion of subclinical infection was underestimated. therefore, we calculated the proportion of subclinical infection by cross-sectional analysis of the subclinical infection of close contacts before quarantine, and we found that ≈ % of case-patients with pandemic (h n ) were asymptomatic. this study has several limitations. we could not fi nd all close contacts of persons with pandemic (h n ) and did not know their infection status, so the infection parameters of pandemic (h n ) that we found in this study might not be precise, especially for reproduction number, which may be underestimated to some extent. furthermore, we could not exclude the possibility that the infected close contacts had been infected from another unknown source before quarantine started, which might infl uence our conclusion to some extent. in summary, the attack rate among close contacts was low, even among household contacts. household member and younger age were the major risk factors for infection with pandemic (h n ) virus among close contacts. approximately % of cases of pandemic (h n ) were asymptomatic. table were included in multivariate unconditional logistic regression analysis. hosmer-lemeshow goodness-of-fit test was used to assess the model fit for logistic regression. or, odd ratio; ci, confidence interval; na, not available, indicating not included in the final model. †one dependent variable (infection with pandemic [h n ] virus) and independent variables (age of index case-patient, type of exposure to index case-patients, age of close contacts, relationships to index case-patients, and exposure duration of close contacts) were included in multivariate analysis. one independent variable (age of index case-patient) was removed in the stepwise regression equation. the goodness-of-fit test suggested that the logistic regression model fitted well (p = . ). ‡one dependent variable (infection with pandemic [h n ] virus) and independent variables (age of index case-patient, type of exposure to index case-patient, age of close contacts, and exposure duration of close contacts) were included in multivariate analysis. two independent variables (age of index case-patient and type of exposure to index case-patient) were removed in the stepwise regression equation. the goodness-of-fit test suggested that the logistic regression model fitted well (p = . ). §one dependent variable (infection with pandemic [h n ] virus) and independent variables (age of index case-patient, type of exposure to index case-patient, age of close contacts, relationships to index case-patient, and exposure duration of close contacts) were included in multivariate analysis. two independent variables (age of index case-patient and exposure duration of close contacts) were removed in the stepwise regression equation. the goodness-of-fit test suggested the logistic regression model fitted well (p = . ). ¶exposed to symptomatic index case-patients before their illness onset or exposed to index case-patients who had subclinical infections. pneumonia and respiratory failure from swine-origin infl uenza a (h n ) in mexico swine infl uenza a (h n ) infection in two children-southern california pandemic potential of a strain of infl uenza a (h n ): early fi ndings world health organization. world now at the start of infl uenza pandemic household transmission of infl uenza a (h n ) virus after a school-based outbreak household transmission of pandemic infl uenza a (h n ) virus in the united states transmission of pandemic a/h n infl uenza on passenger aircraft: retrospective cohort study novel swine-origin infl uenza a (h n ) virus investigation team emergence of a novel swine-origin infl uenza a (h n ) virus in humans clinical features of the initial cases of pandemic infl uenza a (h n ) virus infection in china subclinical infection with the novel infl uenza a (h n ) virus shedding and transmission of novel infl uenza virus a/ h n infection in households-germany clinical and epidemiologic characteristics of early cases of infl uenza a pandemic (h n ) virus infection, people's republic of china european centre for disease prevention and control. ecdc risk assessment: pandemic h n outbreak of swineorigin infl uenza a (h n ) virus infection-mexico severe, critical and fatal cases of h n infl uenza in china alternative epidemic of different types of infl uenza in - infl uenza season, china evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in beijing incidence of pandemic infl uenza a h n infection in england: a cross-sectional serological study interim guidance for emergency medical services (ems) systems and - - public safety answering points (psaps) for management of patients with confi rmed or suspected swine origin infl uenza a (h n ) infection we thank fujie xu for her suggestions and comments. all material published in emerging infectious diseases is in the public domain and may be used and reprinted without special permission; proper citation, however, is required. key: cord- -u u k hj authors: ding, hua; chen, yin; yu, zhao; horby, peter w; wang, fenjuan; hu, jingfeng; yang, xuhui; mao, haiyan; qin, shuwen; chai, chengliang; liu, shelan; chen, enfu; yu, hongjie title: a family cluster of three confirmed cases infected with avian influenza a (h n ) virus in zhejiang province of china date: - - journal: bmc infect dis doi: . /s - - - sha: doc_id: cord_uid: u u k hj background: a total of laboratory-confirmed cases infected with avian influenza a (h n ) virus (including deaths) have been reported till october , , of which . % ( / ) of the cases were identified from zhejiang province. we describe the largest reported cluster of virologically confirmed h n cases, comprised by a fatal index case and two mild secondary cases. methods: a retrospective investigation was conducted in january of . three confirmed cases, their close contacts, and relevant environments samples were tested by real-time reverse transcriptase-polymerase chain reaction (rt-pcr), viral culture, and sequencing. serum samples were tested by haemagglutination inhibition (hi) assay. results: the index case, a -year-old farmer with type ii diabetes, who lived with his daughter (case , aged ) and wife (case , aged ) and his son-in-law (h n negative). the index case and case worked daily in a live bird market. onset of illness in index case occurred in january , and subsequently, he died of multi-organ failure on january . case presented with mild symptoms on january following frequent unprotected bed-side care of the index case between january to , and exposed to live bird market on january . case became unwell on january after providing bedside care to the index case on january to , and following the contact with case during january to at the funeral of the index case. the two secondary cases were discharged on february and separately after early treatment with antiviral medication. four virus strains were isolated and genome analyses showed . ~ % genetic homology, with two amino mutations (v i in ns and v a in np). % ( / ) of environmental samples collected in january were h n positive. twenty-five close contacts remained well and were negative for h n infection by rt-pcr and hi assay. conclusions: in the present study, the index case was infected from a live bird market while the two secondary cases were infected by the index case during unprotected exposure. this family cluster is, therefore, compatible with non-sustained person-to-person transmission of avian influenza a/h n . electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. human infection with avian influenza a/h n virus was first identified in march of , in china, a total of confirmed cases were found in the world up to date [ ] . the seasonal epidemiology is characterized to occur from november through april in china, coinciding well with both seasonal human influenza and h n in birds [ ] . almost all cases were hospitalized, and / of cases died. the fatality is much higher than that for seasonal influenza in the china ( . %), but it is lower than for cases of h n ( %) [ , ] . current evidence suggests that human infection appears to be associated with exposure to infected live poultry or contaminated environments, including markets where live poultry are sold [ ] [ ] [ ] . in the light of this opinion, the closure of live bird markets (lbm) has been associated with a reduction in the incidence of human infections [ ] . despite the fact that h n remains to be a zoonotic infection of avian origin, there are concerns that the virus show genotypic and phenotypic evidence of partial adaptation to mammals [ ] . compared to other subtypes of avian influenza virus, h n virus show increased binding affinity to mammalian-type receptors, and their amount grow up rapidly at the temperatures that are close to the normal body temperature in mammals (although it is lower than that of birds). in addition, they possess pb gene mutations that are associated with adaptation to mammals [ ] [ ] [ ] . whilst sequence analyses had shown that the haemagglutinin (ha) and neuraminidase (na) genes of h n virus detected in china show very high homology, whereas the genes for coding internal proteins are diversified [ ] . ferret and mouse models confirm that strains isolated from humans could replicate efficiently in both mammalian and human airway cells, with efficient transmissibility by direct contact and modest transmissibility by respiratory droplets [ , ] . given these signatures of partial adaptation to mammals, it is imperative to closely monitor and investigate all clusters of human h n virus to determine the transmissibility and severity of virus infection, as well as its potential host and pathogen determinants. a few of family clusters of h n infections (in shanghai, jiangsu, shandong, guangdong and beijing) have been described involving two family members. it was concluded that limited person-to-person transmission may occur following close, prolonged, and unprotected contact with the symptomatic index case, while sustained transmission was not found [ ] [ ] [ ] . here we describe an additional cluster, comprised of three laboratory-confirmed cases of human infection with h n virus reported in zhejiang province in january . this is the largest reported cluster of virological confirmed h n cases, and the full genome data of the virus were isolated from all cases and associated with clinical and epidemiological data and their close contacts. all three h n confirmed cases and adult contacts and surveillance cases had provided written consent for the participation in this study and the publication of their individual details. data collection for h n cases was determined by the national for h n cases was determined y f man of china, as a part of the continuing public health outbreak investigation; therefore, it was exempt from assessment by institutional review board. the protocol for collecting epidemiological data and conducting serological test of close contacts were approved by the institutional review board of the china cdc. suspected cases of human infection with h n virus are identified through the chinese surveillance systems for influenza-like illness, severe acute respiratory illness (sari), pneumonia of unexplained origin, and clinical diagnostics of cases of pneumonia. based on the chinese guidance, an individual could be considered as a confirmed case of h n virus infection if the presence of the h n virus is verified by real-time reverse transcriptase polymerase chain reaction assay (rt-pcr), virus isolation, or serologic testing [ ] . epidemiological and clinical data were collected through interviews and reviews of medical records between january and , . all three cases and their relatives were interviewed by public health staff to record their exposure history during the two weeks before the onset of symptoms, to validate the timeline of events and to identify close contacts. respiratory tract samples were collected from the index case, case , and case , on january , , and , respectively. environmental samples were collected from the lbm (a market) and the secondary wholesale markets (b , c , and d markets) and from a neighboring household where several chickens were bred. all samples were placed in sterile viral transport medium and shipped within hours to the laboratory of zhejiang cdc at °c for h n testing. viral rna was extracted using qiagen rneasy mini kit. real-time rt-pcr was used to detect influenza type a, subtype h and n using the protocol, specific primer and probe sets provided by china cdc [ ] . specimens were also tested by rt-pcr for the presence of seasonal influenza virus (h , h , and b) and h n virus. complete genomic fragments of the h n virus were amplified directly from clinical samples, and sequencing was performed using an abi xl automatic dna analyzer. the nucleotide sequences were determined by dideoxy sequencing using an abi prism bigdye terminator cycle sequencing kit as previously described [ ] . nucleotide sequences were analyzed with the dnastar package (lasergene, madison, wi, usa). phylogenetic analysis was done by neighbor-joining method with mega (version . ). close contacts were placed under daily active surveillance for fever and respiratory symptoms, which was last for seven days after their last exposure to the h n infected case. close contacts were defined as individuals who had close contact (< meter) with any case without the use of personal protective equipment at any time before illnesses onset to the time of isolation of the case in hospital. antiviral chemoprophylaxis was neither recommended nor provided to contacts. following written informed consent, a structured questionnaire was used to gather demographic information and data on use of personal protective equipment, antiviral chemoprophylaxis, symptoms, and potential risk factors for h n infection during the two weeks starting from their last exposure to h n -infected cases. respiratory specimens for h n testing were taken from close contacts with a febrile respiratory illness occurred during the -day observation period. contacts were asked to provide a single convalescent serum collected ≥ - weeks after their last exposure to a case with h n . h n serological testing was done by hi assay using a modified horse red-blood-cell assay, recommended by the who. the antigen used for the hi assays was the a/zhejiang/ / (h n ) strain. a hi titer ≥ : in single serum sample and a four-fold or greater rise in titer in paired sera was defined as seropositive. the index case, a -year-old farmer with type ii diabetes, taking antidiabetic drugs for one year, had been unwell since january , , with fever ( . °c) and flank pain. after consulting a health care clinic (a clinic) on january and , he was treated as an outpatient with ciprofloxacin and intravenous amoxicillin/ clavulanate potassium. on january , he made a further consultation at a local hospital (b hospital) owing to persistent fever. chest radiography showed a leftlower-lobe pneumonia; meanwhile, treatment with ciprofloxacin was continued. peripheral blood cell count was normal. on january , index case's condition was worsened and again medical advice was sought; therefore, index case was admitted to a different hospital (hospital c ). upon admission in hospital c , he had severe leucopenia, lymphopenia and thrombocytopenia (table ) . he was diagnosed with community acquired pneumonia with a left pleural effusion. on january , he consulted at hospital d (a more advanced hospital) where a sputum sample was collected and sent to zhejiang cdc for microbiologic testing. on january , h n virus-specific rna was detected by rt-pcr (ct value ) in the sputum sample. once the h n virus infection was confirmed, the patient was transferred from hospital c to d immediately. at hospital d , he was isolated in a single room, where he was intubated, mechanically ventilated and commenced on oseltamivir ( mg, twice daily by nasogastric tube) and peramivir ( mg, once daily, intravenously). on january , the patient died of acute respiratory distress syndrome (ards) and multi-organ failure (table , figure , figure , and additional : figure s ). case (index case's daughter, figure ), a -year-old female with no underlying diseases, developed a throat sore and cough on january , the day her father died. she initially consulted the healthcare clinic in hospital a due to constant fever on january , where she was treated with antibiotics (amoxicillin) and then transferred to hospital d for further examination, where sputum and throat swab samples were taken. rt-pcr was conducted on the samples of sputum and throat swabs on the january , and the influenza a/h n specific rna (ct value ) was positive. afterwards, case was admitted directly to an isolation room at the hospital d and commenced on oral oseltamivir ( mg, twice daily), and intravenous peramivir ( mg, once daily). on admission her peripheral blood count, serum blood biochemistry, and chest ct scan were normal (table ) . she was given supplemental oxygen via nasal cannula with a flow rate of - l/min, whereas her oxygen saturation was %. her condition remained stable, and symptoms were improved during hospitalization. later, she was completely recovered and was discharged on february after sputum samples tested negative for h n rna by rt-pcr on january and february (table , figure ). case (index case's wife and case 's mother), a year-old female farmer, with no underlying diseases, developed an acute cough with expectoration on january . she attended the hospital d where a throat swab was collected and an rt-pcr assessment was conducted on the throat swab sample, which was positive for h n (ct value of ). she was admitted to the hospital d on january . although chest radiography was normal, she was treated empirically with oral oseltamivir ( mg, twice daily) and intravenous peramivir ( mg, once daily). results of peripheral blood cell count, serum electrolytes, renal and liver function, and coagulation profiles were normal. arterial blood gas results were normal while the patient was breathing room air. the case remained stable during her admission and then she was discharged on february after sputum tested h n negative by rt-pcr on february (table , figure ). the husband of case , who had been in close contact with the index case and case , had no respiratory symptoms, and throat swabs and paired serum samples were negative ( figure ). rt-pcr-positive throats swabs or sputum samples were obtained on days, days and day of illness for the index case, case , and case , respectively. from these samples, four complete full genome sequences were amplified. sequence analyses indicated that the four isolates were highly homologous the other h n strains previously identified in shanghai, jiangsu, anhui province, and with candidate vaccine strains (sharing . % identity in amino acid sequences of all segments). the four sequences from the three confirmed h n case shared . ~ . % homology with the animal isolates (a/chicken/zhejiang/sd / ), and phylogenetic analysis showed that the four isolates were almost genetically identical to other h n virus isolated from the other provinces and chickens. furthermore, amino acid analyses showed that the ha gene of all four strains possessed the mutation l, indicating high affinity to human receptor alpha - sialic acid receptors. it showed that the four isolates were entirely of human origin, and na protein possessed amino acid sequences associated with susceptibility to neuraminidase inhibitor antiviral drugs (h and e and h in na). the fragments isolated from the index case, and two secondary cases were identical except for three non-synonymous amino substitutions identified in the index case. these were g a nucleic acid substitution (aa mutation v i) in the ns gene, g a nucleic acid substitution in the pb gene (nonsense amino mutation) and c t nucleic acid substitution (v a) in the np gene. (figure , additional file : figure s , table and table ). the index case, his daughter (case ), his wife (case ), and his son-in-law (the husband of case ) lived in separate rooms of one large house with three floors. there were no domestic animals and birds within the home or in the immediate vicinity of the home. however, two neighboring families located meters and meters respectively from the cases' homebred ducks and chickens, and there were a several free-range domestic poultry in the village. the index case and case worked in the lbm (a market), selling vegetables and bird eggs between am and pm during the two weeks prior to the illness onset in the index case. furthermore, two weeks before the illness onset, the index case had visited a wholesale lbm (d market) to buy vegetables twice per week (each time he stayed there for hours). the last known exposure date of the index case in a market was january ( hours), and the last exposure date of case to a market was on january for around three hours. in total. case had been exposed to the live bird market on three occasions for a total of hours from january - as follows: case visited d market for a total of three hours between january - and she worked in a market for , and, hours on january , , and , respectively. the index case became ill on january and was admitted to hospital on january . between january and , cases and lived together with the index case in one house. furthermore, case and index case had very close contact between january and , sleeping together in one room. case had three hours faceto-face contact with the index case on january . on january , case provided bedside care in the hospital for the index case for approximately hours. between january and , cases and provided bedside care to the index case in hospital without any personal protective equipment for approximately hours and hours, respectively, including washing, cleaning his body, change his clothes and disposing urine and feces of the index case. during this period, the index case had high fevers ( . °c), frequent coughing, and extensive sputum production. after the index case had been confirmed h n infection on january , he moved to icu for treatment and isolation. cases and visited the index case for four hours on january , wearing facemasks. case had frequent close contact with case during the funeral ceremony of the index case on january - . case visited case on the january when case was hospitalized with mild symptoms; case wore a facemask during this visit. a summary of the cases' exposure to each other was shown in table . the results of rt-pcr assay of environment samples were listed as follows: swabs of chicken and duck eggs from the index case working site (a market) were h n negative; of environmental samples from secondary live wet market (b market, a wholesale for a market) were positive for h n ; of sewage samples from c market (located nearby b market) were positive for h n ; of environmental samples taken from d market through routine avian influenza surveillance were h n positive; environmental samples from the area where neighbors were breeding poultry were all h n negative; of environmental samples from different live birds markets under routine surveillance in xiaoshan district were h n positive during january (source: unpublished data from the zhejiang avian surveillance system, additional file : figure s ). none of the close contacts developed acute respiratory symptoms during the seven days surveillance period. throat swabs collected from all twenty-five close contacts on january were negative for influenza a/ h n virus by rrt-pcr, and all serum samples tested negative for h n antibodies (titer < : ) by microneutralization and horse red-blood-cell hi assays (see table ). no close contacts were reported taking oseltamivir chemoprophylaxis. here we describe a family cluster of three confirmed cases of h n virus infection, involving a fatal index case, his wife and daughter (both survived). the index case presented with severe pneumonia and died of ards and multi-organ failure. the presence of chronic diseases has been associated with an increased risk of hospitalization with h n virus infection [ ] , and the index case had pre-existing diabetes, which requires oral anti-diabetic medication. another factor that may have played a role in the severity of disease was the late diagnosis of h n virus infection and the late commencement of anti-viral therapy. the efficacy of neuraminidase inhibitors (nais) in reducing the risk of mild influenza infection progressed to severe illness has not been fully assessed in randomized controlled trials; however, observational data suggest that early treatment with nais of hospitalized patients with influenza infection is associated with better outcomes [ ] . the other two cases i v i i i v i i i i i t k t t t t t t t t t single letters refer to the amino acid (aa) found in the noted protein at a specific site. *the numbering starts with the first condon of methionine for these proteins. were previously reported healthy, and presented with lower viral loads and mild symptoms that did not progress. both patients received early antiviral treatment, but it is not possible to determine whether the lack of clinical progression was result from antiviral treatment or as a consequence of a naturally indolent course [ ] [ ] [ ] . since there were no functionally important differences in the genotype of the virus infecting the three cases, viral virulence is not likely to contribute the differential severity. who evaluates all clusters of human cases of nonseasonal influenza virus to determine whether humanto-human transmission or common exposure to infected animals or contaminated environments may have occurred [ ] . the homology of all eight gene segments was between . ~ %, suggesting it was either a common source exposure or a person-to-person transmission. whilst all three individuals were exposed to potentially contaminated market environments within a putative maximum incubation period of days, case and case had extensive unprotected exposure to the index cases when he was ill. we believe that most likely explanation for this family cluster is that the index case was infected from the live bird market, and the virus was transmitted directly from the index case to his daughter and his wife. several reasons could explain for this conclusion, as follows: ( ) days prior to illness onset in the index case, he had not been in contact with any people with a febrile illness and other confirmed cases, but was frequently exposed to the a live bird market for hours daily and to the d secondary live bird market. although the a market was h n negative based on the environments samples collected on january , , the samples from wholesale market b that supplied a market were h n positive. furthermore, . % ( / ) of environments samples from different live bird markets under routine surveillance in xiaoshan district during the same period were h n positive (source: unpublished data from the zhejiang avian surveillance system); ( ) case stayed with the index case and provided beside bed medical care frequently on the january , , and - . she had close unprotected contact with the index case for cleaning and washing his body on january without any personal protection when the index case had severe symptoms such as high fever and cough. although case had visited the a live bird market for three hours in three days prior to her illness onset, she reported no direct contact with live birds or poultry products. ( ) there were multiple potential sources of infection for case , including the index case, the live market a , and case . however, the index case and case shared the same room every day and worked closely together after the illness onset in the index case. most importantly, case provided beside bed care to the index case including washing his body, dealing with his secretions, and changing his clothes for him, without any personal protective equipment. the day numbers between the onset of illness in the index case and the onset of illness in the secondary cases (the serial interval) was and days, [ , ] . furthermore, sequence analysis showed that four strains isolated from the three cases were genetically similar to each other. all four isolates possessing amino acids q l and g s in the ha segment were associated with increased affinity for human receptors (α- , linked sialo-saccharides) [ ] . virus from all three cases possessed p s in ns and e k and d n in pb (which were associated with increased virulence in mice) and i v and h y in pb (which was associated with aerosol transmission of avian virus between ferrets) [ , ] . there were only two amino differences (v i in ns and v a in np) between the virus infecting the index case and the secondary cases. those two mutations are not associated with any known functional change. therefore, field investigation and h n full genomics analyses supported the secondary cases acquired infection most likely from the index case. person-toperson transmission of h n has been reported [ , ] . previous animal experiments (ferrets, mice, and pigs) also indicate that h n virus possess the capability to bind to both avian and human receptors and it might be transmissible by respiratory droplets under certain conditions [ , ] . our findings indicate that the virus has not gained the ability for efficient sustained transmission from person to person [ ] . in this study, four close contacts and frequent contacts were negative for h n infection by hi testing and rt-pcr. although the husband of case had close contact with the index case, case , and case without any personal protective equipment, he showed no evidence of infection with the h n virus. there were several limitations in this paper. firstly, h n positive samples in environmental or bird samples were not found from a live bird market where the index case and case were working. secondly, the full genetic sequence of h n virus detected in the environment and live birds could not obtained. thus it is not able to compare human, avian, and environmental strains. on the basis of experiences of controlling of h n and h n virus, continued risk assessment, surveillance, and vigilance are required. a high degree of clinical awareness is necessary for people with possibility of h n infection, especially for health workers who are occupationally exposed to poultry and for people with respiratory illness following recent contact with live poultry or live bird markets [ , ] . here we report a largest size of the family cluster with confirmed h n in china, in which the index case was fatal while the secondary cases were mild. in the term of an infectious source, the index case was infected from a live bird market while the index case infected the two secondary cases during unprotected frequent exposure. this family cluster supported that the transmission of avian influenza a/h n was limited and not sustained. all of h n referred isolates in additional materinals were download from genbank (http://www.ncbi.nlm.nih. gov/nuccore/?term=h n ++and+china) and the global initiative on sharing all influenza data (gisaid) (http://platform.gisaid.org/epi /frontend# dda ). additional file : figure s . family pedigree showing three h n affected individuals and their close contacts. figure s . phylogenetic analysis of six segments (mp, np, ns, pa, pb , and pb ) from the four h n isolates in three confirmed cases of a family cluster in hangzhou, zhejiang province, china, in january of . figure s . all authors have declared: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. authors' contributions hd, yc, zy, pwh, ec, and hy designed the study. fw, jh, and xy conducted the field investigation and analyses. hm, sq and cc collected and tested the samples, performed and sequence analyses. sl and pwh wrote the first draft and all authors contributed to review and revision of the report. ec and hy are guarantors. all authors read and approved the final manuscript. human infections with avian influenza a(h n ) virus h n : preparing for the unexpected in influenza writing committee of the second world health organization consultation on clinical aspects of human infection with avian influenza av pandemic characteristics and controlling experiences of influenza h n virus year after the inception in hangzhou amino acid substitutions in polymerase basic protein gene contribute to the pathogenicity of the novel a/h n influenza virus in mammalian hosts dynamic reassortments and genetic heterogeneity of the human-infecting influenza a (h n ) virus human infection with avian influenza a(h n ) virus re-emerges in china in winter live-animal markets and influenza a (h n ) virus infection pathogenesis and transmission of avian influenza a (h n ) virus in ferrets and mice limited airborne transmission of h n influenza a virus between ferrets novel avian-origin human influenza a(h n ) can be transmitted between ferrets via respiratory droplets the k r substitution in viral protein pb enhances the effects of e k on influenza virus replication environmental connections of novel avian-origin h n influenza virus infection and virus adaptation to the human epidemiology of human infections with avian influenza a(h n ) virus in china family outbreak of severe pneumonia induced by h n infection surveillance of the first case of human avian influenza a (h n ) virus in beijing probable person to person transmission of novel avian influenza a (h n ) virus in eastern china, : epidemiological investigation one family cluster of avian influenza a(h n ) virus infection in characterization of h n influenza a viruses isolated from humans infectivity, transmission, and pathology of human-isolated h n influenza virus in ferrets and pigs human infection with a novel avian-origin influenza a (h n ) virus comparison of patients hospitalized with influenza a subtypes h n , h n , and pandemic h n determinants of antiviral effectiveness in influenza virus a subtype h n risk assessment on the epidemics of human infection with a novel avian influenza a (h n ) virus in jiangsu province global concerns regarding novel influenza a (h n ) virus infections analysis of the clinical characteristics and treatment of two patients with avian influenza virus (h n ) comparative epidemiology of human infections with avian influenza a h n and h n viruses in china: a population-based study of laboratory-confirmed cases probable longer incubation period for human infection with avian influenza a(h n ) virus in jiangsu province receptor binding by an h n influenza virus from humans probable person-to-person transmission of avian influenza a (h n ) three indonesian clusters of h n virus infection in genomic signature and protein sequence analysis of a novel influenza a (h n ) virus that causes an outbreak in humans in china human infection with avian influenza a h n virus: an assessment of clinical severity we thank all of staff at zhejiang provincial and hangzhou municipal cdc, xiaoshan district cdc, for their help in field investigation and collection of environmental samples. the views expressed are those of the authors and do not necessarily represent the policy of the china cdc. note: data are median (iqr) or n (%). *including direct contact (touching), preparation, cooking, and consumption of well-appearing poultry. key: cord- -wccmeaep authors: orcutt, connie j. title: emergency and critical care of ferrets date: - - journal: vet clin north am exot anim pract doi: . /s - ( ) - sha: doc_id: cord_uid: wccmeaep ferrets are becoming increasingly popular as pets in the united states. emergency situations involving ferrets are most often caused by gastrointestinal disease, neoplasia, cardiac disease, or endocrinopathy. hospitalization and supportive care of the critically ill ferret, emergency treatment techniques, and diagnostic procedures are discussed. diseases most commonly involved in critical presentations are reviewed along with treatment protocols. localities mandate euthanasia of the animal for rabies testing? if the ferret is active yet tractable, support the body vertically under the forelimbs for examination. with more energetic ferrets or those prone to biting, scruffing and holding the patient vertically elicits relaxation and a yawning reflex. distraction is afforded by offering nutri-cal (evsco pharmaceuticals, buena, nj) or ferretone ( -in-l pet products, hauppauge, ny), but avoid sugary treats in ferrets suspected of insulinoma. fractious ferrets can be scruffed in lateral or sternal recumbency with one hand while placing the other hand cranial to the pelvis and stretching the body slightly? awareness of specific anatomic, physiologic, and behavioral characteristics of the ferret is important for accurate clinical assessment. modify the extent of the physical examination based on the ferret's status. dyspneic animals may tolerate only brief periods of handling without oxygen supplementation. bruxism, ptyalism, or pawing at the mouth most often indicates gastrointestinal discomfort or nausea resulting from hypoglycemia or other causes. hypoglycemic ferrets may also appear dazed. posterior paresis in the ferret can be a manifestation of hypoglycemia, neurologic disease, or weakness of any cause. the ferret's normal body temperature is ° to ° f. testing the hydration status of a ferret by tenting the skin can be inaccurate, and evaluating mucus membrane capillary refill time is generally a more reliable method. the normal heart rate of to beats / min often varies greatly due to the ferret's normal respiratory sinus arrhythmiay the thorax is long relative to the total body length of a ferret, and the entire area must be ausculted for murmurs or abnormal arrhythmias. splenomegaly is a common finding in many ferrets, but pronounced splenomegaly or abnormal splenic texture may indicate pathology. most pet ferrets in the united states originate from large breeding facilities in which kits are neutered at to weeks of age, and a tattoo is placed inside the right pinna. although this makes disease involving the reproductive tract less likely, it does not preclude the presence of a reproductive remnant. a swollen vulva in a female ferret may indicate adrenal disease (most commonly, especially in middle-to older-aged animals), an intact female in estrus, or the presence of an ovarian or uterine remnant. male ferrets have an os penis, and the prepuce is located on the ventral abdomen. the critically ill ferret is optimally hospitalized in a quiet area separate from dogs and cats. isolation areas must be available for pa-tients suspected of having infectious disease (for example, canine distemper virus or epizootic catarrhal enteritis). hospital personnel with influenza should avoid contact with ferrets. the ferret requiring supplemental oxygen or heat can be hospitalized in the same type of oxygen cage or incubator used for a dog or cat. alternatively, ferrets can be placed in acrylic intensive care cages designed for birds. monitor ferrets in incubators carefully to prevent hyperthermia. the normothermic, eupneic ferret hospitalized in a wellventilated cage must also be monitored closely to prevent hypothermia. placing a towel or disposable diaper in the cage discourages the ferret from expending energy while attempting to burrow under cage paper. anorectic ferrets are at risk of developing hepatic lipidosis or hypoglycemia. enteral feeding is recommended whenever possible. debilitated ferrets refusing their regular food often accept syringe feeding or soft foods offered on a tongue depressor. aid diet (hills pet products, topeka, ks) provides an easily digestible diet accepted by most ferrets. syringe feeding is dosed at - ml three to four times daily. supplements such as nutri-cal or deliver . (mead johnson, evansville, il) provide additional calories when added to syringe-fed foods, but these sources are not nutritionally complete for ferrets and should not be fed as their sole diet for extended periods. nutri-cal and other sugarcontaining formulations can cause rebound hypoglycemia in ferrets that have insulinoma and should be avoided in those animals. raw meat or eggs that may contain bacterial pathogens are also not recommended. pharyngostomy tube placement in ferrets has been described? the technique is identical to that described for cats and utilizes an to fr pediatric feeding tube. in cases of protracted diarrhea or vomiting, gastrointestinal ulceration, or resistance to syringe feeding, a total nutrient admixture (tna) has been used successfully to provide parenteral nutrition (pn) to more than ferrets in the author's clinical practice. if a veterinary practice does not have the capability to compound parenteral solutions, some human hospitals mix pn solutions in their own pharmacies and will formulate a bag of tna for a veterinarian when provided with a prescription (table ) . a mixture of lipid and dextrose provides the ferret's resting energy requirement (rebecca remillard, phd, dvm, acvn, angell memorial animal hospital, boston, ma, personal communication, november ). this mixture is supplemented with amino acids, electrolytes, water-soluble vitamins, and minerals, and fluid is added so the total solution meets daily fluid volume requirements. such all-in-one solutions can be refrigerated for at least days. a silicone elastomer or polyurethane jugular catheter (cook veterinary products, bloomington, il) is recommended for delivery of the solution by infusion pump. hospitalized ferrets eating voluntarily and without special dietary requirements are optimally provided with their regular diet. otherwise, offer a premium-quality dry cat, kitten, or ferret food . ferrets have high fat and animal protein requirements and metabolize fat more efficiently for energy than carbohydrates. if a ferret requires fasting before surgery for the evaluation of blood glucose or for radiographic examination of the gastrointestinal tract, do not withhold food for more than hours. ferrets with insulinoma are especially at risk for developing profound hypoglycemia during extended periods of fasting. the critically ill ferret should be stabilized before pursuing extensive diagnostics. however, even severely compromised ferrets usually toler-ate the sampling of a small volume of blood from a peripheral vein for estimated blood glucose (bg), total protein (tp), packed cell volume (pcv), and blood urea nitrogen (bun) measurements. use an insulin syringe with a -gauge needle for collecting small volumes of blood « . ml) from either the lateral saphenous or cephalic vein. visualization of peripheral veins is facilitated by using a / -in. penrose drain as a tourniquet. for larger volumes of blood, the jugular vein or anterior vena cava are preferred sites of venipuncture. a healthy ferret's blood volume is approximately % to % of its body weight? as much as % of the blood volume can be safely withdrawn in a healthy ferret?- determine the ferret's initial pcv and level of hydration before withdrawing substantial volumes of blood. for jugular venipuncture, use a -gauge needle on a tuberculin or -ml syringe. hold the ferret at a table's edge or in lateral recumbency as for a cat, or alternatively, wrap the ferret in a towel and restrain in dorsal recumbency? the ferret's jugular vein lies more lateral than that in a dog or cat?- venipuncture of the anterior vena cava for ferrets has been described. this procedure can be performed without sedation in a debilitated ferret. however, if the patient resists restraint or the practitioner is inexperienced with this technique, anesthesia may be required. restrain the ferret in dorsal recumbency while one assistant extends the forelimbs caudally and a second assistant stretches the body with gentle traction applied cranial to the pelvis (fig. ) . palpate a slight depression at the thoracic inlet lateral to either side of the manubrium and cranial to the first rib. approach the site at a ° angle to the skin while aiming toward the opposite hip. insert a -gauge needle attached to a -ml syringe up to the needle hub. apply negative pressure, and slowly withdraw the needle until blood begins to fill the syringe. withdraw the needle if the ferret struggles. it is not necessary to apply pressure to the venipuncture site after the sample is collected. a method for obtaining volumes of as much as . to . ml of blood from the ventral tail artery of ferrets has been described? this procedure is painful to perform in the unanesthetized patient. restrain the ferret in dorsal recumbency. insert a -gauge needle attached to a syringe along the ventral midline of the tail, to cm distal to the tail base. direct the needle at a shallow angle toward the body while gently aspirating. peripheral catheterization can be performed in the awake debilitated ferret, but more active ferrets often require anesthesia. use a -or gauge peripheral catheter for placement in the lateral saphenous or cephalic vein. to facilitate intravenous (iv) catheter placement, first puncture the skin overlying or adjacent to the vein with a -or gauge needle while being careful to avoid the vein. secure the catheter with sterile tissue glue or a tape butterfly sutured to the skin before bandaging the leg. for jugular catheterization, the author most often uses a -gauge, -in. through-the-needle catheter on a - auge needle (intracath, becton dickinson vascular access, sandy, ut). a cutdown procedure may be necessary to access the vein. ferrets often act depressed with a jugular catheter and neck bandaging in place. access to the vascular system for more than several days can be achieved with a subcutaneously placed vascular access system (vascular-access-port, access technologies, skokie, il). an intraosseous ( ) catheter can be placed in the humerus, femur, or tibia, with the femur being the site least likely to impede the ferret's movement, , use a -or -gauge, . -in. spinal needle or a -or gauge hypodermic needle with a sterile surgical wire inserted into the lumen as a stylet to prevent occlusion of the needle with a plug of bone. , placement of the catheter is done with the ferret under anesthesia unless the animal is very debilitated. alternatively, the soft tissues and the periosteum can be blocked with local anesthetic. the technique for catheter placement is the same as that described for a cat. catheters can be left in place for several days during which time prophylactic use of parenteral antibiotics is recommended? maintenance fluid requirement for the ferret is estimated at ml/kg / h ? calculate additional fluid requirements for correction of dehydration and compensation for ongoing losses following protocols used for small animals. iv or fluid delivery is recommended in severely debilitated ferrets requiring dextrose supplementation. continuous delivery of fluids using an infusion pump is recommended. alternatively, a buretrol device (baxter healthcare, deerfield, il) can be used to deliver small fluid volumes. monitor the ferret carefully for overhydration, which may first be evident by auscultation of harsh lung sounds or a heart murmur. ferrets with cardiac disease are especially at risk of overhydration. debilitated, anorectic animals may require fluids supplemented with dextrose, vitamin b, and potassium following the protocols used for small animals. in cases of protracted anorexia, a tna delivered iv can be substituted for this fluid mix. use only small volumes of heparinized saline when flushing any catheter in the ferret to prevent heparin overdosage. antibiotics and most other medications are administered at dosages used with cats on a per kilogram basis. when an indwelling catheter is not in place, use a -gauge butterfly catheter for iv medications. most medications given intravenously, with the exception of some chemotherapeutic drugs, can alternatively be administered via an catheter? limit the use of intramuscular ( m) medications in ferrets owing to their reduced muscle mass. this author prefers the quadriceps for m injections because of its increased mass and the reduced risk of iatrogenic nerve damage at this site compared with the caudal thigh. administer subcutaneous injections as for a dog or cat. oral medications are best administered in liquid form, because pill administration is difficult in ferrets. most tablets can be crushed and compounded into a suspension with a vehicle such as ora-plus (paddock laboratories, inc., minneapolis, mn), flavoring, and water in a : : ratio. refrigerate the medication and shake well before using. there is no guarantee of stability. transfusion in the ferret has been recommended when the pcv drops below % to %, depending on whether the anemia is acute or has developed gradually. blood groups have not been demonstrated in ferrets, and there is little risk of a transfusion reaction even without crossmatching and after using a variety of donors?' , estimation of the blood volume required by the recipient can be calculated as for a cat. d . . rcv desired -fcv of recipient anticoagulated blood volume (ml) = body welght (kg) x x fcv f d . . i o onor ill anhcoagu ant place a -gauge jugular catheter or a -gauge catheter for transfusion delivery. the author treats the recipient minutes before transfusion with a slow iv bolus of a short-acting corticosteroid (prednisolone sodium succinate at mg/kg or dexamethasone sodium phosphate at -to -mg/kg)y choose a clinically normal ferret (pc v at least %) as a donor. the author collects a maximum blood volume (milliliter) equivalent to . % of the donor's body weight. use a -gauge butterfly catheter on a -to -ml syringe for blood collection. an acid-citrate-dextrose (acd) solution is used as an anticoagulant. flush the needle, tubing, and syringe with acd before collection, and use . ml acd per . ml whole blood collected from the anesthetized donor ferret. whole blood can be transfused immediately with a slow bolus or with a syringe pump?' , sedation is recommended for cystocentesis in all but very debilitated ferrets, because the bladder wall is thin and can be easily lacerated if the patient struggles? use a -or -gauge needle for cystocentesis. urethral catheterization requires anesthesia even with depressed patients. most cases of urethral obstruction involve male ferrets and are the result of cystic calculi or hyperplastic prostatic-like tissue at the neck of the bladder? catheterization of the male is complicated by the jshaped os penis as well as the very small diameter of the penile urethra. place the male in dorsal recumbency, and aseptically prepare the prepuce. if the prepuce or tip of the penis is swollen, a small incision can be made in the preputial opening to exteriorize the penis. the tissue covering the os penis is very thin. a surgicalloupe aids visualization of the small penile urethral opening lying on the ventral surface of the penis several millimeters proximal to the tip of the os. a -gauge pediatric catheter with the stylet removed can be used to localize the urethral orifice (fig. ) . flush the catheter with sterile saline if resistance is met while catheterizing the urethra. in some cases, a . -fr rubber feeding tube can be used as an indwelling catheter, but this will be too large in many ferrets. the author most often uses a -or -gauge, -in. jugular catheter with the stylet removed (see the section on iv catheterization). the stylet can be left in place with the end retracted to provide support around the pelvic flexure, but exercise extreme caution to avoid perforation of the urethra. suture the catheter to the skin using tape butterflies, and tape the administration port of the catheter to a tongue depressor to prevent kinking. place a padded bandage taped to the skin, and attach the catheter to a closed urinary collection system. monitor the ferret carefully, because many animals attempt to remove the bandage and catheter. the ferret with an indwelling urinary catheter should be treated empirically with a broad spectrum antibiotic (see the section on cystitis). for catheterization of the female ferret, place the anesthetized patient in ventral recumbency, elevate the hindquarters, and aseptically prepare the vulva and perivulvar area. use a small vaginal speculum or otoscope cone to locate the urethral opening on the ventral floor of the vaginal vestivule, approximately to . cm cranial to the clitoral fossa?' use a catheter as described above for the male ferret. in some instances of pneumothorax or pleural effusion, placement of a chest tube may be required. the author has performed this technique as described for a cat by using, as a chest tube, an -fr rubber feeding tube with a kirschner wire stylet. once sutured in place, the tube is capped for intermittent suction. the author has successfully used continuous suction at to cm h -negative pressure in one case of a ferret with a continuous spontaneous pneumothorax. isoflurane provides the safest means of anesthesia in the critically ill ferret. avoid the use of injectable agents in debilitated animals. ideally, a ferret should be fasted for to hours before induction. an induction chamber is recommended, because ferrets often violently resist induction by face mask. many ferrets hypersalivate during isoflurane induction, but because this is usually a transient behavior, atropine is generally not necessary? ferrets are not prone to laryngospasm, and intubation is relatively easy with a . to . mm endotracheal tube. , deliver anesthesia via a nonrebreathing circuit. to prevent hypothermia, place the ferret on a circulating warm water heating pad for any procedure lasting more than a few minutes. administer iv fluids to debilitated patients, taking care to avoid overhydration, especially in patients suspected of having cardiac disease, administer . % to % dextrose-containing fluids to hypoglycemic ferrets during prolonged surgical procedures?' monitor anesthesia with a pulse oximeter or a doppler ultrasound blood pressure monitor. a rectal probe may increase the usefulness of the pulse oximeter in small animals , clinical signs of pain in ferrets include lethargy, anorexia, vocalization, stiff movements, reluctance to curl up in a sleeping position, and squinting? buprenorphine ( , to . mg/kg iv, m, or sc q to h) or butorphanol ( . to . mg/kg m or sc q h) is well-tolerated by ferrets ?' monitor carefully for signs of significant depression, hypothermia, or hyperthermia. if necessary, naloxone ( . mg/kg iv, m, or sc) can be administered as a reversal agent? the pcv of ferrets is high relative to that of other species, and normal values have been reported to range from % to %. the normal leukocyte range of . to x , with clinically normal ferrets often having white blood cell counts of to x , is generally lower than that of other species, there is no evidence that ferrets demonstrate a leukocytosis with stress? the ferret's normal differential parallels that of the cat. isoflurane administered for minutes has been shown to result in significant decreases in hematocrit, hemoglobin, and plasma protein as well as red and white blood cell counts. coagulation profiles have not been standardized for ferrets, but the normal mean prothrombin time has been reported to be . to seconds, in contrast to the cat and the dog, bun values in the ferret appear to be more sensitive than creatinine in the evaluation of renal status. in cases of renal failure, bun levels are often drastically elevated compared with relatively less significant increases in creatinine. , however, an elevated bun is not specific for a renal disorder. other significant clinicopathologic findings with renal disease in the ferret include hyperphosphatemia, hypocalcemia, hyperkalemia, and acidosis. the cardiac silhouette of a normal ferret may appear slightly elevated from the sternum on lateral radiographs as a result of fat accumulation surrounding the ligament extending from the heart to the sternum, and this finding alone should not be interpreted as a pneumothorax. normal ferrets should have only a small amount of gas in the gastrointestinal tract. variations from this norm may indicate an obstructive pattern or ileus. the spleen is often pronounced in radiographs of even clinically normal ferrets. cardiopulmonary resuscitation in the ferret is based on protocols published for cats. establish an airway by intubation with a . to . mm endotracheal tube, and ventilate the ferret at a rate of to breaths/min taking care not to overinflate the lungs. evaluate the cardiac rhythm with an electrocardiogram. in cases of asystole, place the ferret in lateral recumbency, and gently perform cardiac massage at a rate of /min. evaluate the femoral pulse frequently. if external massage alone does not stimulate a heart beat, administer epinephrine ( . to . mg/kg diluted with sterile water delivered intratracheally, or . mg/ kg via an intracardiac, iv, or route). establish an iv line, and administer fluids at a rate of ml/kg/h. if mechanical systole returns but the ferret is bradycardic, administer atropine at a dose of . mg/ kg intravenously or . mg/kg intratracheally. continue to monitor the electrocardiogram for treatment of specific arrhythmias. differential diagnoses for the ferret in respiratory distress include pleural effusion (cardiac disease, neoplasia, infection, heartworm disease, hypoproteinemia, metabolic disease); pulmonary edema (cardiac disease, hypoproteinemia, metabolic disease, electrical cord bite); anterior mediastinal mass; pneumonia; pneumothorax; diaphragmatic hernia; tracheal obstruction; metabolic disease (acidosis); and profound weakness (circulatory collapse, hypoglycemia, anemia). , hyperthermia or pain may also manifest as dyspnea in ferrets. the dyspneic ferret often requires oxygen supplementation before pursuing extensive diagnostics. evaluate the initial pcv, bg, tp, and bun if the ferret is insufficiently stable to collect blood for an initial complete blood count (cbq and serum chemistry. if cardiac disease is suspected, administer furosemide (see the section on cardiac disease). obtain whole body radiographs as soon as the animal tolerates further handling. perform thoracocentesis in cases of pronounced pleural effusion or pneumothorax, and submit fluid collected for cytology and a gram's stain as well as culture and sensitivity if indicated. cardiac disease is seen most frequently in middle-to older-aged ferrets. the most common form of cardiac disease in the ferret is dilated cardiomyopathy (dcm), with hypertrophic cardiomyopathy occurring less frequently. historical abnormalities include lethargy, anorexia, weight loss, exercise intolerance, and periods of dyspnea, tachypnea, or coughing. tachycardia, murmurs, irregular arrhythmias, moist rales, muffled heart and lung sounds, rear limb weakness, and hypothermia are possible physical examination findings. radiographs may reveal an enlarged cardiac silhouette, pleural effusion, pulmonary edema, ascites, hepatomegaly, or splenomegaly. electrocardiography is recommended if abnormal arrhythmias are ausculted. isoflurane anesthesia is usually needed to obtain an electrocardiogram (ecg). the ferret ecg normally contains small p waves but large r waves. echocardiography is ultimately the most informative aspect of the cardiac workup in the ferret and should be performed as soon as possible. use feline dosages on a per kilogram basis for cardiac drugs when uncertain of specific dosing in the ferreu furosemide for treatment of pulmonary edema is dosed at to mg/kg iv, sc, m, or po q to hy, although the iv route is most direct in cases of fulminant heart failure, the ferret in severe respiratory distress may only tolerate m injection. digoxin is used as a positive inotrope in cases of dcm or to depress av nodal conduction of supraventricular tachyarrhythmias at a dose of . mg/kg po q h dosed on lean body weight (estimating a normal % body fat). balanced vasodilators used to decrease afterload in cases of dcm include enalapril ( . mg/kg po q h) or captopril ( / of a . -mg tablet/ferret po q h),b, monitor the ferret closely for hypotension, decreasing the frequency of dosing to once every third day if the ferret becomes lethargic. alternatively, during the initial management of heart failure, one can use a venous vasodilator such as % nitroglycerin ointment ( / in. applied to the skin or inner pinna q to h). monitor the patient for signs of hypotension. beta-adrenergic blockers (atenolol, . mg/ferret po q h) or calcium channel antagonists (diltiazem, . to . mg/ferret po q h) are most commonly used to relax the myocardium and to improve diastolic filling in cases of hypertrophic cardiomyopathy.l , administer fluid therapy judiciously in ferrets with cardiac disease to avoid fluid overload and subsequent development of pulmonary edema. prednisone and diazoxide, medications often used to treat insulinoma, can also increase preload on the heart. lymphosarcoma (lsa) is one of the most common forms of neoplasia reported in the ferreu dyspnea can result from an anterior mediastinal mass, pleural effusion, pulmonary metastasis, or profound weakness. mediastinal masses and pleural effusion are most common in ferrets less than year of agey in young animals, acute onset of clinical signs or sudden death are typical with the rapidly progressive mediastinal form of lsa. . other clinical signs may include anorexia, weight loss, vomiting, depression, dehydration, or signs associated with secondary infections. accompanying physical examination findings may be referable to any body system but most commonly include hepatomegaly, splenomegaly, and lymphadenopathy. lo diagnosis of mediastinal lymphoma is generally made by cytologic examination of pleural fluid. ultrasound-guided aspiration of an anterior mediastinal mass can be used to collect samples for cytology.j ferrets that have mediastinal lsa have been reported by some authors to respond favorably to chemotherapeutic protocols described in the references. . . infection with the canine heartworm (dirofilaria immitis) is uncommon in ferrets, but the risk increases in heartworm endemic areas and when the ferret is housed outside. signs include lethargy, coughing, dyspnea, ascites, heart murmur, pulmonary congestion, or sudden death. . the presence of even one adult worm in the small heart of a ferret can be fatal, peripheral microfilaremia is uncommon in ferrets with dirofilariasis, so testing for the dirofilaria antigen may be inconclusive. • . antibody tests used for feline patients are species specific and are not applicable to ferrets (karen rosenthal, ms, dvm, abvp-avian, personal communication, october ). radiographic changes with dirofilariasis include cardiomegaly, pulmonary congestion, pleural effusion, and ascitesy· a peripheral eosinophilia may be evident on the cbc. the test of choice for diagnosing dirofilariasis in ferrets is echo cardiography, which images the parasite in the heart (karen rosenthal, ms, dvm, abvp-avian, personal communication, october ). in some cases, angiography has been used to confirm the presence of adult worms. treatment protocols have been reported, but results are inconsistent. • pneumothorax pneumothorax can occur as a result of trauma, primary pulmonary disease, or esophageal perforation. the author has treated two ferrets with spontaneous pneumothorax. thoracocentesis is performed using protocols described for other small animals. if pleural air continues to accumulate, perform a tube thoracostomy. in uncommon cases of severe pneumothorax, resolution can be rapid when managed by continuous underwater suction if pressure is carefully monitored. o perform diagnostics as indicated to reveal the primary pathology, and treat as indicated. pneumonia is uncommon in ferrets and is most commonly associated with severe influenza virus or canine distemper virus (cdv) infections. coughing is not as prominent a sign of pneumonia in ferrets as in dogs. clinical signs of influenza include sneezing, epiphora, serous ocular discharge, rhinitis, anorexia, lethargy, and pyrexia. , o influenza is usually mild and self-limiting in adult ferrets but can be fatal in neonates. because ferrets are susceptible to human influenza viruses, affected caretakers should avoid contact with ferrets. ferrets with cdv may initially present with clinical signs similar to influenza but go on to develop a severe crusting dermatitis on the face and other areas of the body as well as marked hyperkeratosis of the footpads. ferrets that have advanced cdv infection may also present with neurologic signs. bacterial pneumonia is occasionally seen in ferrets. pulmonary mycosis is uncommonly reported. , radiographs and a cbc are often the most helpful initial diagnostic tests in cases of pneumonia. a neutrophilic leukocytosis with a left shift may be pronounced. , o radiographs demonstrate an interstitial pattern progressing to an alveolar pattern if the pneumonia worsens. aspiration pneumonia primarily involves the dependent lung lobes. if the ferret is stable, a tracheal wash to collect samples for cytology as well as bacterial and fungal cultures is important in guiding treatment. diagnosis of cdv is generally made on the basis of clinical signs, but viral inclusion bodies may be visualized or fluorescent antibody tests performed on conjunctival or mucus membrane scrapings. treatment for influenza consists of supportive care. antihistamines used to control sneezing or to improve appetite include chlorpheniramine ( to mg / kg po q to h) or diphenhydramine ( . to . mg/ kg po q to h). , use antibiotics only if a secondary bacterial infection is suspected. euthanasia is recommended for ferrets with cdy' , antibiotic treatment of bacterial pneumonia is based on culture and sensitivity results. empirical broad-spectrum antibiotics to consider while awaiting culture results include trimethoprim / sulfonamide ( mg/kg of combined drug po qi h), cephalexin ( mg / kg po qi h), or amoxicillin / clavulanate ( mg/kg po q h). , , parenteral antibiotics used with cats more rapidly achieve therapeutic blood levels in severe cases. nebulization with gentocin may be useful in young animals. clinical signs of gastrointestinal (gi) discomfort in ferrets are often not specific: collapse; lethargy; anorexia; dehydration; nausea evident by bruxism, ptyalism, pawing at the mouth, or frequent swallowing; retching or gagging; diarrhea; or vomiting. a number of the gi diseases affecting ferrets can have similar clinical presentations. profuse diarrhea can rapidly produce severe dehydration in the ferret. in contrast to the canine patient, diarrhea in the ferret is difficult to classify as being small intestinal or large intestinal in character. differential diagnoses for diarrhea include gi foreign body or trichobezoar, dietary indiscretion, helicobacter mustelae gastritis, eosinophilic gastroenteritis or other inflammatory bowel disease, neoplasia, metabolic disease (i.e., hepatopathy), clostridial overgrowth subsequent to prolonged antibiotic administration, influenza, rotavirus (usually in very young, unweaned ferrets), edv (generally accompanied by respiratory signs and a crusting dermatitis), epizootic catarrhal enteritis ("green slime disease"), gi parasitism (i.e., coccidiosis, giardiasis), and proliferative bowel disease. , , less common entities associated with diarrhea in pet ferrets include salmonellosis, aleutian disease, and mycobacteriosis. , , frank blood in the stool may be evident with proliferative bowel disease, salmonellosis, or clostridial overgrowth. , differential diagnoses for melena in the ferret include h. mustelae gastritis, toxin ingestion, gi foreign body or trichobezoar, hemorrhaging gi polyps, neoplasia, uremic ulceration, iatrogenic causes (i.e., nonsteroidal inflammatory drug induced), and aleutian disease (uncommon in pet ferrets). , . vomiting is not as common in ferrets as in dogs or cats and must be distinguished from regurgitation. the most common differential diagnoses for true vomiting in . ferrets include gi foreign body, h. mustelae gastritis, or inflammatory gastroenteritis (including eosinophilic gastroenteritis). vomiting is not commonly seen with metabolic disease (i.e., azotemia or hepatic disease) in ferrets. regurgitation or gagging may be caused by esophageal foreign body or megaesophagus. initial treatment of dehydration and electrolyte imbalances is critical while pursuing diagnostics. evaluate the pev, bg, tp, and bun before treatment, and submit a ebe and serum chemistry. obtain initial survey radiographs. additional imaging diagnostics may include ultrasonography, endoscopy, or colonoscopy. evaluate a fecal sample wet mount and flotation as well as a fecal gram's stain. in cases of hematochezia or if the ferret is febrile, culture the stool for campylobacter jejuni or salmonella spp. rubber, latex, or cloth objects are the most common gi foreign bodies in ferrets under to years of age, whereas trichobezoars are more common in older ferrets. , , in contrast to cats, linear foreign bodies are uncommonly ingested by ferrets. , clinical signs of gi foreign bodies vary greatly. in cases of total gastric or intestinal obstruction, the ferret may present recumbent, dehydrated, and in circulatory collapse. in general, vomiting is an infrequent finding with gi foreign bodies in ferrets. , , diarrhea or melena may be a part of the history with trichobezoars or other foreign bodies. in some cases, gastric foreign bodies may not be totally obstructive and instead act as chronic ball valves, causing intermittent nausea, vomiting, melena, gagging, anorexia, and weight loss. esophageal foreign bodies, though uncommon, can elicit regurgitation, gagging, or pawing at the mouth. on physical examination, the ferret may be dehydrated with tacky mucus membranes and a delayed capillary refill time. ferrets often resist abdominal palpation or grind their teeth as a sign of gi pain, especially with small intestinal foreign bodies. a gas-or fluid-dilated stomach or bowel may be palpable, and in some cases, the foreign body may be localized as well. radiographs are often diagnostic with abnormal findings including segmental ileus, gaseous distension of the stomach, and occasionally a visible object or trichobezoar. the ferret's normal gi transit time is to hours? include the esophagus in the film for evaluation. barium studies are rarely needed to confirm the diagnosis of a gi foreign body. obtain a pcv, tp, bg, and bun as a minimum database on admission, and submit blood for a cbc and serum chemistry. with ferrets in circulatory collapse, begin fluid therapy immediately via an iv or catheter. administer a broad-spectrum antibiotic with severely compromised animals or those with melena. consider removal of a gi foreign body a surgical emergency when accompanied with signs of obstruction. an esophageal foreign body, if devoid of sharp edges, may be removable with a small diameter endoscope, or alternatively, can be pushed into the stomach where it can be retrieved by way of gastrotomy.l if surgery is not an option in cases of suspected obstruction, fluid therapy and administration of a cat hairball remedy may facilitate passage of small objects. h. mustelae naturally colonizes the stomach and the pyloric duodenum of many ferrets and may be clinically silent or can cause mild to severe gastritis, gastric and duodenal ulceration, and gastric adenocarcinoma. , , , , pathology may be exacerbated by environmental stress owing to environment or additional disease. , clinical signs include bruxism, ptyalism, abdominal pain, chronic vomiting, anorexia, weight loss, and melena, which can cause significant anemia. while clinical disease is reported to be most common in ferrets to weeks of age, this author has seen ferrets of all ages affected. assessment of the initial pcv and tp is especially important in cases of severe melena. a cbc, serum chemistry, and radiographs are part of the initial database. once the patient is stabilized, definitive diagnosis includes biopsy of the gastric mucosa via an endoscopic or surgical approach. administer fluids to correct hydration. supportive care includes parenteral nutrition in cases of severe ulcerative gastroenteritis. treatment for h. mustelae gastritis has centered on a three-drug combination: amoxicillin ( mg/kg po q h), metronidazole ( mg/kg po q h), and bismuth subsalicylate ( ml/kg po q h) administered for to weeks. , a combination of omeprazole (a proton-pump inhibitor), amoxicillin, and clarithromycin has shown a notable success rate in the eradication of helicobacter pyloru however, omeprazole capsules supplied in timed-release form should not be opened before administration, therefore dosing is difficult in the ferret. epizootic catarrhal enteritis (ece) is a highly infectious diarrheal disease that affects ferrets and that can rapidly cause severe dehydration. this syndrome has been called /i green slime disease" by the lay community because of the profuse green diarrhea that is its most pronounced clinical manifestation. however, green mucoid diarrhea can be seen in a variety of malabsorptive syndromes affecting ferrets and is not pathognomonic for ece. although the etiology of ece has not been identified, histologic findings appear to be similar to those caused by rotavirus or corona virus. ferrets most commonly affected are those recently exposed to new ferrets, that is, at fairs, pet stores, or as recent additions to the household. incubation appears to be only several days before the onset of clinical signs that may include a brief period of vomiting followed by anorexia, profuse diarrhea that often lasts from days to weeks, and subsequent pronounced dehydration. morbidity is high, but mortality is low with the most severely affected individuals being those having underlying disease. diagnosis is presumptive based on the ferret's history and clinical signs. the pcv and tp may be drastically elevated due to dehydration. profound leukopenia is generally not evident. radiographs may demonstrate segmental ileus, which can be confused with an obstructive pattern. hospitalized ferrets must be isolated from other ferrets, and personnel should be made aware of possible viral transmission by fomites. treatment consists of aggressive supportive care aimed at correcting dehydration and providing nutritional support. antibiotic use appears to be of little use unless indicated with accompanying disease. the author has noted significant improvement in persistent cases after administration of prednisone at anti-inflammatory doses. eosinophilic gastroenteritis (ege) is an uncommon disease of ferrets generally seen in animals older than months. the cause is unknown, but some authors suggest an allergic or immunologic response to foods or parasites as an initiating factor. clinical signs include vomiting, diarrhea, anorexia, melena, lethargy, and weight loss. thickened abdominalloops or enlarged mesenteric lymph nodes may be evident on palpation. ege is suspected when clinical signs are accompanied by a peripheral eosinophilia (equal to or greater than /mm ); however, not all cases demonstrate an abnormal differentia . histopathologic demonstration of an eosinophilic infiltration of intestine, lymph node, or other tissues provides the definitive diagnosisy, initiate supportive care with fluids and nutritional supplementation. although this author has successfully treated the majority of diagnosed cases with prednisone, treatment may be unreliable because the underlying cause is unknown. adjust the dose of prednisone ( . to . mg/ kg sq or po ql h) to control clinical signs. resolution of signs is most often evident within days, but treatment is recommended for an additional month before tapering the dose of corticosteroid. in some cases, treatment may be lifelong. lymphoplasmacytic gastroenteritis is a similar clinical syndrome. histopathology provides the definitive diagnosis, and treatment is similar to that for ege. primary neoplasia of the gi tract is uncommon in ferrets. lsa can affect any area of the ferret's digestive tract. o , pyloric adenocarcinoma has been associated with chronic h. mustelae-associated gastritis in the ferreu affected animals may have clinical signs similar to those seen with a gi foreign body. palpation and radiographs may demonstrate a fluid-distended stomach. lo , , definitive diagnosis is made on biopsy, but abdominal ultrasonography may aid localization of pathology. critical care is supportive until the animal is stable for abdominal exploratory. surgical resection of the pyloric mass in a ferret followed by a bilroth i gastroduodenostomy was reported to be successful in one case of gastric adenocarcinoma. lsa involving the intestine or liver typically responds poorly to chemotherapy. , , hepatopathies can present as acute or chronic conditions in the ferret. differential diagnoses include hepatic lipidosis, toxin ingestion, primary or metastatic neoplasia, bacterial infection, and inflammatory disease. other than neoplasia, primary hepatopathies appear to be rare in ferrets. hepatic lipidosis is a common result of chronic anorexia. steroid hepatopathies are very rare, and to date, vascular shunts have not been reported in the ferret. clinical signs of hepatic disease include lethargy, anorexia, weight loss, diarrhea, vomiting, melena, anemia, and icterus (in advanced stages). . the most consistent diagnostic abnormality with hepatic disease is an often drastic elevation of alanine aminotransferase (alt). . alkaline phosphatase may be elevated as well, and in severe cases, total bilirubin levels may increase. abdominal ultrasound is recommended, but this author does not encourage ultrasound-guided liver biopsy, because coagulation panels, useful to assess risk of hemorrhage, have not been standardized for ferrets. definitive diagnosis requires biopsy of the liver. although bacterial hepatitis is not commonly reported for the ferret, in cases of persistent elevation of liver enzymes, submission of tissue for culture and sensitivity is recommended. institute supportive care while determining the definitive diagnosis of hepatopathy. nutritional supplementation is important in the treatment of hepatic lipidosis. once anorexia has resolved, hepatic lipidosis commonly requires no further treatment in the ferret. in cases of suspected bacterial hepatitis, empirical antibiotic choices pending culture and sensitivity include enrofloxacin ( mg/kg po ql h) or amoxicillin ( mg/kg po ql h) in combination with metronidazole ( mg/kg po qi h). administer vitamin k at the feline dosage on a per kilogram basis in cases of suspected coagulopathy. lactulose ( . to . mg/ kg po q - h) is indicated with hepatic encephalopathy. definitive treatment of hepatic neoplasia is unrewarding unless a small portion of the liver is involved and can be resected. although acquired megaesophagus is a chronic condition in the ferret, complications of the disease can lead to a critical situation. the cause of megaesophagus in the ferret is unknown. clinical signs include lethargy, anorexia, dysphagia, regurgitation, coughing or gagging, and weight ss. aspiration pneumonia is a common complication. diagnosis relies on history, clinical signs, and radiographic evidence of a dilated esophagus. aerophagia or aspiration pneumonia may also be apparent on radiographs. an esophagram may delineate esophageal abnormalities, and fluoroscopy can illustrate abnormal esophageal motility. management of megaesophagus is generally less successful in fer-rets than in dogs, and the prognosis is very poor. motility modifiers (metoclopramide at a dose of . to mg/kg po or sc q to h, or cisapride at a dose of . mg/kg po q to h) may be useful. treat aspiration pneumonia with protocols described in the section on cardiorespiratory emergencies. rectal prolapse is not common in ferrets but can occur in some cases of proliferative bowel disease (pbd), coccidiosis, or neoplasia. , , , pbd, uncommonly seen in the author's practice, generally affects ferrets less than months of age. , clinical signs, in addition to rectal prolapse, include chronic liquid or mucoid diarrhea sometimes with frank blood, tenesmus, anorexia, and cachexia, pbd may be exacerbated by environmental stress, and affected ferrets may be more susceptible to other diseases, an affected ferret may be moderately to severely dehydrated with thickened bowel loops evident on abdominal palpation. initial diagnostics include a fecal direct wet mount and flotation, radiographs, a cbc, and serum chemistry. definitive diagnosis is made on biopsy of intestinal mucosa, rectal prolapse can initially be repaired with a pursestring suture. chloramphenicol ( mg/kg m, sc, or po q h for to days) is the treatment of choice for pbd. , resolution of the prolapse may occur spontaneously as the colon heals. coccidiosis is treated with feline protocols, urethral obstruction most commonly affects male ferrets, clinical signs include stranguria, lethargy, and anorexia. male ferrets may have a palpable mass caudodorsal to the bladder. ferrets with accompanying adrenal disease may also be pruritic with bilaterally symmetrical or diffuse alopecia. in the author's experience, the most common differential diagnoses for urinary obstruction include prostatic enlargement associated with adrenocortical disease in males, urolithiasis, and cystitis. less frequently, bladder neoplasia has also been reported as a cause of dysuria. initial treatment for urinary obstruction is urethral catheterization. place an indwelling catheter while determining the origin of the obstruction. if a urinary catheter cannot be passed, a -or -gauge needle can be used to perform cystocentesis as an emergency measure. submit urine collected for urinalysis and culture and sensitivity. a cystostomy allows catheterization of the bladder directly from the body wall if passage of a catheter via the urethra is obstructed. submit blood for a cbc and serum chemistry. place an iv catheter and begin fluid diuresis concentrating on correction of dehydration and electrolyte imbalances. empirical broad-spectrum antibiotic therapy is recommended once a urine culture has been submitted and a urinary catheter placed (refer to the section on cystitis). further diagnostics to determine the cause of the obstruction include radiographs and abdominal ultrasound. along with ultrasonographic evaluation of the bladder, areas of special interest include the urethra, periurethral region, and adrenal glands. partial or complete urethral obstruction by hypertrophied prostatic tissue accompanies some cases of adrenocortical disease in male ferrets, and prostatic disease may be the most common cause of stranguria in male ferrets over years of age. s , , androgens of adrenal gland origin are hypothesized to cause hyperplasia or cystic changes of prostatic tissue, which subsequently presses on the urethra. , in some cases, prostatic tissue may become abscessed with a resultant thick purulent discharge from the prepuce. abdominal ultrasound may reveal unilateral or bilateral adrenomegaly, but not all cases of adrenal disease can be reliably diagnosed with this method. although studies of adrenal gland ultrasonography in ferrets have been published, diagnosis of adrenomegaly may be difficult for the ultrasonographer with little experience imaging ferrets. elevated plasma androgen and estrogen levels have been shown to be useful in diagnosing adrenal disease in ferrets, s, but test results are often not available soon enough to be useful in an acute situation. removal of the diseased adrenal gland generally results in rapid dissipation of prostatic hypertrophy. , cystotomy may be necessary to remove accumulation of purulent material,b and if a prostatic abscess is involved, surgical resection of the involved tissue is recommended after a sample has been retrieved for culture and sensitivity. this author maintains an indwelling urethral catheter for at least to days after surgery. persistent obstruction by prostatic tissue may be a result of infection or neoplastic changes or may be stimulated by remaining abnormal adrenal tissue. s , the prognosis with prostatic abscessation may be poor because it is difficult to remove all affected tissue, and response to antibiotics is uncertain.s, magnesium ammonium phosphate (struvite) uroliths are the most common type of calculi reported in ferrets. the incidence of struvite urolithiasis in ferrets has been less frequent with the introduction of higher-quality, animal protein-based diets that produce a more acidic urine than do plant protein-based foods. s , diagnosis and treatment are similar to procedures used with cats and dogs. the practitioner can treat cases of severe or persistent urolithiasis with prescrotal urethrostomy using a technique similar to that described for the dog. although primary cystitis is reported to be rare in the ferret, , purulent material in the bladder can be thick enough to cause a complete urethral obstructiony what appears to be cystitis in some male ferrets may actually be discharge from a prostatic abscess. submit a urinalysis and a urinary culture and sensitivity obtained by cystocentesis. in cases of urethral obstruction, place a urinary catheter and stabilize the ferret. obtain radiographs and an abdominal ultrasound to evaluate the bladder, urethra, and adrenal glands. while awaiting culture and sensitivity results, begin treatment with a broad-spectrum antibiotic: trimethoprim/sulfonamide ( mg/kg of combined drug po q h), amoxicillin ( mg/kg po q h), or amoxicillin/ clavulanate ( mg/kg po q h). severe cases of cystitis may require treatment for months or longer. clinical signs of renal failure may be nonspecific and include collapse, depression, lethargy, dehydration, anorexia, weight loss, rear limb weakness, polydipsia or polyuria, anemia, melena, oral ulcerations, or an azotemic odor to the breathy, differential diagnoses for renal failure in the ferret include chronic interstitial nephritis, pyelonephritis, neoplasia, toxins, and glomerulonephropathy secondary to other causes such as aleutian disease (rarely seen in the clinical setting with pet ferrets). diagnostics include a cbc, serum chemistries, urinalysis, urine culture and sensitivity, and radiographs. abdominal ultrasound is helpful in evaluating renal cysts, urinary tract calculi, or abnormal renal parenchyma. an ultrasound-guided renal aspirate may yield diagnostic information. initial treatment consists of iv fluid support geared toward correction of dehydration and electrolyte imbalances. an active urinary sediment indicates the need for a broad-spectrum antibiotic while awaiting results of a urine culture. the most common cause of hypoglycemia in pet ferrets in the united states is insulinoma (pancreatic islet cell neoplasia). additional differential diagnoses for hypoglycemia include anorexia or starvation, sepsis, neoplasia, hepatopathy, and other metabolic disease. insulinoma affects ferrets ranging in age from to yearsy initial signs may be insidious and attributed by the owner to geriatric changes in their ferret. the history may include episodes of collapse with hypersalivation or extreme weakness lasting from minutes to hours that typically resolve after administration of sugar-containing solutions. other common clinical signs include depression, rear limb weakness (which may be apparent as posterior paresis or ataxia), gagging, pawing at the mouth, or a dazed appearance. occasionally severely hypoglycemic ferrets appear dyspneic. signs are often intermittent and may not be apparent on clinical presentation. although hypoglycemic seizures are the most common clinical sign of insulinoma in the dog, they are rare in ferretsy when a ferret over the age of years presents collapsed or exhibiting any of the clinical signs described, immediately evaluate the bg level. initial evaluation can be performed with glucose measurement strips or a digital glucometer. for more accurate evaluation of bg levels, submit blood in a sodium fluoride (gray top) tube. a bg glucose level less than mg/ dl with accompanying clinical signs is suspicious for insulinoma, and ferrets presenting collapsed or comatose often have bg levels lower than mg/dl. , an elevated serum insulin concentration (using an assay that has been validated for ferrets) concurrent with hypoglycemia is diagnostic for insulinoma, in cases of hypoglycemic collapse, administer a slow iv bolus of % dextrose ( . to ml) to response, the goal of treatment is stabilization and not the complete reversal of hypoglycemia. if dextrose is administered too rapidly, the tumor will be stimulated to release large amounts of insulin, resulting in rebound hypoglycemia, place an iv catheter and begin infusion of fluids supplemented with % dextrose, control rare persistent seizures with diazepam (refer to the section on seizures). administer prednisone ( . to mg/kg sq) to inhibit peripheral tissue uptake of glucose and stimulate gluconeogenesis. begin with the lowest dose needed to maintain adequate bg levels (i,e" > mg/ dl), continue to monitor clinical signs along with bg concentrations q h, and increase dextrose supplementation if necessary. once the ferret is stable, administer prednisone orally. in cases of persistent hypoglycemia, concurrently administer diazoxide, which acts to inhibit insulin release from pancreatic beta cells, beginning at the low end of the dose range ( to mg/kg po q h). once clinical signs have resolved, gradually discontinue dextrose supplementation while monitoring the bg level, and adjust medications accordingly, prednisone doses can often be lowered with concurrent administration of diazoxide. offer a meatbased, high-protein ferret or feline diet while avoiding foods high in sugar or carbohydrate. in a minority of cases, hypoglycemic seizures or collapse may recur in spite of medications once iv dextrose supplementation is discontinued, these ferrets, once stabilized, may require surgical debulking of the tumors to allow further management. ongoing medical and surgical management of insulinoma is well described in the references. , , spontaneous diabetes mellitus (dm) is uncommon in ferrets. most cases of hyperglycemia develop secondary to surgery for insulinoma. clinical signs are similar to those seen in other small animals with dm. dm is suspected when the bg concentration is consistently greater than mg/ dl in conjunction with glycosuria. in cases of ketoacidosis, ketones are detected in the urine. a low insulin concentration concurrent with hyperglycemia confirms the diagnosis of dm. for the initial treatment of ketoacidotic dm, follow protocols used with cats to stabilize metabolic derangements. tight regulation of bg levels in ferrets with dm can be difficult. one protocol suggests initiation of treatment with insulin when the bg level is consistently greater than mg/ dl. neutral protamine hagedorn (nph) insulin is administered at an empirical dose of . unit per ferret twice daily with serial bg concentrations to dictate dosagey once the ferret is stabilized with a bg concentration less than mg / dl, treatment is continued with either nph or ultralente insulin (which only requires once daily dosing). the owner is instructed to use dipsticks to check for the presence of glucose and ketones in the ferret's urine. the same dose of insulin is administered if only trace amounts of glucose are present in the urine. if no glucose is detected, insulin is not administered, and if the glucose concentration is elevated, the insulin dose is increasedy in cases of transient dm secondary to debulking of pancreatic tumors, hyperglycemia usually resolves within several days to weeks after surgery. , ferrets with ongoing hyperglycemia are often very difficult to regulate. the differential diagnoses for anemia are broadly divided on the basis of regenerative versus nonregenerative processes. differentials for regenerative anemia in ferrets include blood loss (i.e. gi bleeding, trauma, flea infestation) and hemolytic anemia potentially caused by heavy metal toxicosis or immune-mediated disease. causes of nonregenerative anemia include estrogen toxicosis of the bone marrow secondary to persistent estrus in an intact female, ovarian remnant(s), or adrenocortical disease; neoplastic infiltration of the bone marrow; or anemia of chronic disease. immune-mediated hemolytic anemia has not been identified in ferrets owing to the lack of reagents specific for ferret antibodies. aleutian disease, an immune-mediated disease caused by a parvovirus is uncommon in pet ferrets. although estrogen-induced bone marrow suppression was once a serious and common cause of nonregenerative anemia involving intact female ferrets, this form of pancytopenia is rarely seen owing to the current practice of spaying females at to weeks of age. rarely, an ovarian remnant may secrete estrogen with similar results. increased levels of estrogen may infrequently be associated with adrenocortical disease either as a result of estradiol secretion from an adrenocortical tumor or subsequent to conversion of tumor-secreted androgens to estrogen in peripheral tissues. , resultant pancytopenia has been reported, but this syndrome is uncommon in spite of markedly increased serum estrogen concentrations in some ferrets with adrenocortical disease. clinical signs observed with pancytopenia of any cause include petechiation, ecchymosis, gi bleeding, infection, and sepsis. obtain an initial pcv from the critically anemic ferret before collecting a larger volume of blood for a cbc, platelet count, reticulocyte count, and serum chemistries. avoid anterior vena cava venipuncture in cases of suspected pancytopenia. normal mean reticulocyte counts for female and male albino ferrets have been reported as . % and %, respectively. pursue further diagnostics as indicated. if the pcv is less than %, transfuse whole blood. if an catheter is used, obtain a bone marrow sample before transfusion. if an ovarian remnant is suspected, administer human chorionic gonadotropin (hcg) ( iu per ferret) to stimulate ovulation. administration of hcg has no effect on hyperestrogenism secondary to adrenocortical disease. if the pcv remains below %, the prognosis is poor, and multiple transfusions along with b complex vitamins, an anabolic steroid (stanazolol, . mg/kg po, sc q h),b iron supplementation, fluid therapy, and nutritional support may be required. , pursue surgical treatment for adrenocortical disease, a retained ovary, or bleeding gi masses once the patient is stabilized. anecdotal reports of reactions following canine distemper vaccination in ferrets describe clinical signs ranging from diarrhea, gagging, vomiting, fever, or erythematous skin to circulatory collapsey although many of these reactions happen within minutes after vaccination, less severe signs can be noted up to several hours later. in cases of postvaccination collapse, administer diphenydramine hydrochloride ( . to . mg/kg iv or im), epinephrine ( j-lg/kg iv, m, sc, or intratracheally), and a slow iv bolus of a short-acting corticosteroid ( mg/kg of prednisolone sodium succinate or to mg/kg of dexamethasone sodium phosphate).b administer iv fluids, and provide supportive care following treatment protocols for small animals. seizures are uncommon in ferrets with the most common cause arguably being insulinoma-induced hypoglycemia. l additional differential diagnoses include hypoglycemia from other causes; trauma; toxin ingestion; ens infection (including rabies or canine distemper), inflammation, or neoplasia; renal failure; hepatopathy; or other metabolic derangements. evaluate the bg level on presentation, and treat hypoglycemia as described above (refer to the section on hypoglycemia). administer diazepam ( to mg iv to effect), and treat supportively using protocols applied to other small animals. pursue diagnostics as indicated. lumbar cerebrospinal fluid tap has been described in the ferret. l gastrointestinal disease, neoplasia, cardiac disease, and endocrinopathy are among the most common syndromes affecting the ferret that presents in an emergency situation. knowledge of these and other disease processes, indicated diagnostic testing, and immediate treatment protocols are critical to provide efficient and effective care to the ferret in crisis. musculoskeletal and neurologic diseases a cluster of cases of juvenile mediastinal lymphoma in a ferret colony helicobacter muste/ae gastritis, proliferative bowel disease, and eosinophilic gastroenteritis intraosseous catheters in small mammals biology and medicine of the ferret ferrets: basic anatomy, physiology, and husbandry (of the ferret) clinical techniques in domestic ferrets stranguria in a castrated male ferret a practitioner's guide to rabbits and ferrets ferrets, rabbits, and rodents: clinical medicine and surgery. philadelphia, wb saunders medical and surgical management of esophageal foreign body in a ferret diagnosis and treatment of insulin-secreting pancreatic islet cell tumors in ferrets: cases ( - ) exotic animal formulary s. pet ownership and pet populations chemotherapeutical remission of multicentric lymphosarcoma in a ferret (mustela putorius juro) cardiac emergencies clinical and pathologic findings in ferrets with lymphoma: cases ( - ) helicobacter mustelae-associated gastric adenocarcinoma in ferrets (mustela putorius jura) gastric colonization of the ferret with helicobacter species: natural and experimental infections cystic ovarian remnant in a ferret critical care of ferrets, rabbits, and rodents ferrets, rabbits, and rodents gastrointestinal diseases of ferrets (mustela putorius juro! urogenital diseases cardiac disease in ferrets gastrointestinal diseases gastrointestinal diseases of ferrets helicobacter infection normal parameters and laboratory interpretation of disease states in the domestic ferret blood transfusions multisystemic eosinophilic complex in a ferret (mustela putorius juro) estradiol- j -secreting adrenocortical tumor in a ferret lack of detectable blood groups in domestic ferrets: implications for transfusion effect of isoflurane on hematologic variables in ferrets anesthesia, analgesia, and sedation for small mammals differential diagnoses for common clinical problems in ferrets soft tissue surgery gastrointestinal foreign body in ferrets: cases ultrasonography of adrenal glands in normal ferrets pleura and pleural space helicobacter mustelae-associated hypergastrinemia in ferrets (mustela putorius jura) basic approach to veterinary care endocrine diseases: insulinoma use of a vascular access system for administration of chemotherapeutic agents to a ferret with lymphoma pyloric adenocarcinoma in a ferret the collapsed ferret endocrine diseases: adrenal gland disease, d iabetes mellitus, and thyroid disease evaluation of plasma androgen and estrogen concentrations in ferrets with hyperadrenocorticism proceedings of the north american veterinary conference ferret respiratory disease diagnosis new therapeutics in small mammals respiratory diseases stranguria in a castrated male ferret cardiovascular diseases: cardiac disease small mammal radiology radiographic and angiographic evaluations of ferrets experimentally infected with dirofilaria immitis estrogen induced bone marrow depression in a ferret (mus tela putorius juro) with adrenal gland tumors key: cord- - tpj vb authors: dass hazarika, rashna; deka, nayan mani; khyriem, a. b.; lyngdoh, w. v.; barman, himesh; duwarah, sourabh gohain; jain, pankaj; borthakur, dibakar title: invasive meningococcal infection: analysis of cases from a tertiary care centre in north east india date: - - journal: indian j pediatr doi: . /s - - - sha: doc_id: cord_uid: tpj vb objectives: to report an outbreak of invasive meningococcal disease from meghalaya, in the north east india, from january through june . methods: retrospective review of case sheets was done. one hundred ten patients with invasive meningococcal disease were included for the study. results: of the total patients, . % were boys and . % were girls (boy to girl ratio = . : ). the average age of presentation was . ± . y. meningococcal meningitis was seen in . % of cases, meningococcemia in % and . % had both. fever was the most common manifestation ( %) followed by meningeal signs ( . %), headache ( . %), vomiting ( . %), shock ( . %), low glasgow coma scale (gcs) ( . %), purpura and rashes ( . %), seizures ( . %), abdominal symptoms ( . %), irritability and excessive crying ( . %) and bulging anterior fontanalle ( %) in those below mo of age. raised intracranial pressure (icp) was the most common complication ( . %) followed by coagulopathy ( . %), hepatopathy ( %), herpes labialis ( . %), syndrome of inappropriate adh secretion (siadh) ( %), pneumonia ( %), arthritis ( %), purpura fulminans, respiratory failure, sixth nerve palsy and diabetes insipidus in . % each, subdural empyema, optic neuritis, ards and arf in . % each, cerebral salt wasting syndrome, third nerve palsy, cerebritis and hearing impairment in . % each. culture was positive in . %. patients were treated initially with ceftriaxone and dexamethasone but later on with chloramphenicol due to clinical drug resistance. mortality was . %. conclusions: this is the first epidemic report of invasive meningococcal disease from the north east india. chloramphenicol acts well in areas with penicillin or cephalosporin resistance. mortality reduces significantly with early diagnosis and prompt intervention. meningococcal disease is a global problem. it has a rapid onset with varied presentations and wide regional variation in disease pattern. the endemic disease is rare but epidemic form occurs commonly in many regions of the world especially described in the 'meningitis belt' in sub-saharan africa, parts of asia and also in india. meningococcal disease mostly affects children in the school going age and adults working in close contact such as in military barracks. the disease requires early and prompt antibiotic treatment and supportive therapy. the outcome of the disease depends on the time required to seek medical help i.e., the 'house to hospital time' and also on the rapidity of administration of the first antibiotic dose i.e., the 'door to needle time'. meghalaya situated at an altitude of , m above sea level has a predominantly rural tribal population. an epidemic of meningococcal disease occurred in this region during [ ] [ ] . the present study documents the occurrence of the disease in this part of the world, and also highlights the various clinical manifestations, laboratory findings and management outcome. this descriptive retrospective study over the period of the epidemic, january through june is being reported from the department of pediatric disciplines, nei-grihms, shillong. one hundred ten children diagnosed as either 'meningococcemia' or 'meningococcal meningitis' or 'meningococcemia with meningitis' during the study period were identified from discharge summaries and inpatient records. their charts were retrieved and reviewed thoroughly. at admission, blood and cerebrospinal fluid (csf) were sent to the laboratory immediately for culture and sensitivity testing, cytology and gram staining. complete blood count (cbc) and peripheral blood smear for malarial parasite, random blood sugar (rbs), liver function test (lft), coagulation profile, renal function test (rft), serum electrolytes and chest x-ray (cxr) were done on the day of admission in all patients and repeated periodically if necessary. mri brain was done when clinically indicated. the cases of meningococcal meningitis and meningococcemia in the present case series were labelled as probable meningococcal meningitis, confirmed meningococcal meningitis, probable meningococcaemia and confirmed meningococcaemia as per standard guidelines [ ] . patients were treated for the first mo with injection ceftriaxone but later with parenteral chloramphenicol due to observation of clinical drug resistance in the form of delayed or no response to ceftriaxone in - h. antibiotics were administered for a minimum of d in all patients along with supportive care and monitoring. injection dexamethasone was used in all cases with meningitis for d. shock was treated with normal saline and inotropes (dopamine and dobutamine), whenever indicated and hydrocortisone. a total of children were diagnosed as having either 'meningococcemia' or 'meningococcal meningitis' or 'meningococcemia with meningitis'. the demographic profile and clinical presentations are outlined in table . among these cases, . % were boys and . % were girls (boys:girls . : ). the mean age of presentation was . ± . y ( mo- y). fever was the most common symptom ( %) followed by headache ( . %), vomiting ( . %), altered sensorium ( . %), purpura and rashes ( . %), seizures ( . %), abdominal symptoms ( . %), irritability and excessive crying ( . %). meningeal signs were present in cases ( . %) and bulging anterior fontanalle in out of cases ( %) below the age of mo. shock was seen in cases ( . %) ( compensated and decompensated). the average number of isotonic saline boluses required was ml/kg (range: ml/kg to ml/kg). fifteen cases ( . %) required inotropic support and hydrocortisone singly or in combination. the average duration of inotropic support was - h. the laboratory investigations of all the cases are summarized in table . culture (either blood or csf) was positive in cases ( . %) (csf: , blood: ). in three cases ( . %), growth was seen both in the blood and csf. gram negative diplococci in csf was seen in cases; of which cases were culture negative. all cases were identified as serogroup a and were susceptible to ceftriaxone and chloramphenicol by in-vitro antimicrobial testing. the mean blood leukocyte count was , ± /cumm. the csf cell count ranged from to , /cu mm and hypoglycorrhacia were seen in . % of the cases. ten percent of the cases had deranged lft and . % had coagulopathy. majority of the cases were seen in the months of december and january to march (fig. ) . sixty nine percent of the cases were seen in children above y of age (fig. ) . meningococcal meningitis and meningococcemia were diagnosed in cases ( . %) and cases ( %) respectively with a corresponding mortality of . % ( / ) and . % ( / ). twenty children ( . %) presented with both meningococcemia and meningitis with death. there was no difference in mortality or morbidity between the culture positive or culture negative cases. of the children with meningococcal meningitis, had probable meningitis while were confirmed. of the children with meningococcemia, had probable meningococcemia while were confirmed. of the children with meningococcemia and meningitis, were probable while were confirmed (fig. ) . the important complications have been summarized in table . raised icp was the most common ( . %) and was diagnosed clinically by the presence of bulging anterior fontanelle, bradycardia/tachycardia, papilledema and hypertension. herpes labialis was observed in . % of cases. three important metabolic complications of meningococcal infection observed in the present case series were siadh ( cases, . %), diabetes insipidus ( cases, . %) and cerebral salt wasting syndrome ( case, . %). all the cases with diabetes insipidus and cerebral salt wasting syndrome expired. meningococcal purpura fulminans were seen in cases ( . %) whereas cases ( . %) developed arthritis, and cases each had subdural empyema and optic neuritis. mortality was . %. epidemic meningococcal disease was first described by vieusseaux in from switzerland [ ] . meningococcal infections are commonly found in developing countries such as in the african meningitis belt and occasionally in developed countries like the united states. serogroup a is more prevalent in developing countries whereas, in the developed countries the disease is mostly caused by serogroup b and c [ ] . in india, meningococcal disease is endemic in delhi with sporadic cases reported in the past [ ] . isolated cases of meningococcal meningitis were also reported from several states of india involving haryana, uttar pradesh, rajasthan, sikkim, gujarat, jammu & kashmir, west bengal, chandigarh, kerala and orissa in [ ] . most of these outbreaks have been caused by serogroup a [ ] . n. meningitidis was the dominant pathogen isolated in surat between and [ ] . in early , spurt of cases of neiserria meningococcemia and meningitis due to serogroup a have been reported from delhi and adjoining areas [ ] . no previous reports exist from north east india. approximately % were above y of age. maximum cases reported were below - y of age from usa for endemic disease [ ] . in epidemic outbreaks a shift to higher age occurs [ ] . in sudan, % were above y in a group a -n. meningitidis outbreak [ ] . in ghana however the peak incidence was found in - y old children [ ] . neonatal meningococcal meningitis is rare and there was no case of neonatal meningitis in the present study. meningococcal infection is characteristically fulminant presenting with fever, severe headache, vomiting, neck stiffness, positive meningeal signs, photophobia, drowsiness and confusion. deterioration and death can occur in hours. the disease spectrum usually ranges from meningococcal meningitis to meningococcemia. meningitis may or may not be present with rash. seizures occur in % of cases. meningococcemia is more abrupt presenting with chills, nausea, vomiting, myalgias and the classical purpuric or petechial rash with or without bullae formation. absence of meningitis is a poor prognostic factor. septicaemia was found in % cases. urmila et al. from delhi reported that % children had meningococcal meningitis, % had meningococcemia and % had both with mortality of . %, % and %, respectively [ ] . this is similar to findings in the present study. shock was the presenting symptom in % of the index cases. of these, % had compensated and % had decompensated shock compared to % in other reports [ ] . shock is endotoxin mediated and due to factors such as widespread capillary leak, loss of vasomotor tone and maldistribution of intravascular volume, impaired myocardial function and impaired cellular function. early recognition of shock is crucial for early intervention and improved outcome [ ] . tachycardia may be the only sign present in the early phase of the disease and is enough to mandate fluid resuscitation. circulatory management aims to maintain tissue perfusion and oxygenation. repeated fluid boluses with ml/kg of isotonic saline are to be given initially till shock resolves. in case shock persists after ml/kg of fluid, central venous pressure (cvp) line is inserted and fluid resuscitation continued with addition of dopamine and/or dobutamine. some children require as high as - ml/kg of fluid resuscitation but such patients also require mechanical ventilation. about . % of the index cases required inotropic support either alone or in combination for an average duration of - h. some studies have shown that . % albumin is more useful as a resuscitating fluid [ ] . albumin is routinely used in the uk with significant reduction in mortality in the last y (decrease up to %) in patients with meningococcal disease and albumin use may play a role along with other factors [ ] . the authors do not have any personal experience of using albumin. survival rate reaches % when shock is reversed within min of presentation [ ] . rash was observed in . %, while this sign ranged from . % to % in other studies [ , ] . meningococcal purpura fulminans is a hemorrhagic condition associated with meningococcal septicemia with features of hypotension, disseminated intravascular coagulation (dic), and purpura leading to tissue necrosis and small vessel thrombosis. in the present study, cases ( . %) presented with purpura fulminans and of them died. schaad ub [ ] has described arthritis in % of patients with meningococcal disease. in the present study, . % presented with arthritis involving big joints. arthritis may occur early in the disease due to direct bacterial seeding of the joints or in the sub-acute or convalescent phase of the illness secondary to immune-complex reactions. treatment of bacterial arthritis consists of analgesics, antibiotics and drainage of joint fluid if needed. immune complex reactions are usually treated with non-steroidal anti-inflammatory drugs or steroids. some may require intravenous immunoglobin [ ] . reactivation of latent herpes simplex virus infections (primarily herpes labialis) is common during meningococcal infection as observed in the present study with good response to local acyclovir. coagulopathy is frequent and multifactorial, and was seen in . % of the present cases. mild clotting abnormalities are well tolerated. in severe cases fresh frozen plasma (ffp) is recommended. the authors have used intravenous vitamin k and if required ffp with good results. currently the best treatment for meningococcal related coagulopathy is the optimal management of shock. dodge and swartz [ ] reported seizures in % in the acute stage of the disease, focal cerebral signs in %, and of patients had cranial nerve involvement early in the course of disease. in the present study, . % of the cases presented with seizures in the acute stage and cranial nerve involvement was present in . % cases. siadh was detected in of patients by dodge and swartz [ ] . in the present study, siadh was found in cases ( . %) and was managed with fluid restriction and low dose diuretic (furosemide) therapy. five cases ( . %) had diabetes insipidus (di), requiring aggressive management with hypotonic fluids, vasopressin and mechanical ventilation and one had cerebral salt wasting (csw). all the index patients with di and csw had % mortality. although pollard rb [ ] has reported that deafness has not been a common complication of meningococcal meningitis in the antibiotic era, there was one case with bilateral sensorineural hearing defect in the present study. pneumonia, epiglotitis and otitis media can occur. pneumonia is seen in to % of invasive meningococcal disease cases, particularly with serogroups y and w- [ ] . in the present study, pneumonia was present in . % cases. recovery may be complicated by ards, anuria and multi organ failure. in some cases ards develops within a few hours after admission and in the present study cases each developed ards and arf. in a study from punjab (ludhiana), . % were culture positive and all isolates were sensitive to most of the common antibiotics [ ] . urmila j et al reported positive cultures ( / blood cultures and / csf cultures) [ ] . low rate of culture positivity in the present study ( . %) may be due to prior use of antibiotics outside or delay in transporting the specimen. antibiotic therapy remains the cornerstone of therapy in meningococcal disease. three factors that influence the success of antibiotic therapy are timing of the antibiotic, tissue penetration and antibiotic resistance. broad spectrum antibiotics like penicillin g, ceftriaxone and cefotaxime remain widely used. increasing resistance to penicillin is being reported and ceftriaxone remains the recommended first line therapy in the present scenario. however in the authors' experience they had patients with good response to ceftriaxone in the beginning of the epidemic. after about mo of the epidemic, there was poor clinical response to ceftriaxone and the unit antibiotic policy was revised to intravenous chloramphenicol for d with good response. they now routinely use parenteral chloramphenicol as the first line therapy in meningococcal disease. there are other reports of ciprofloxacin as well as ceftriaxone resistance from india [ , ] . the second line therapy consists of vancomycin and azithromycin. the nice guidelines recommend dexamethasone therapy for suspected or confirmed bacterial meningitis above mo of age [ ] . the authors used injection dexamethasone in all meningococcal meningitis cases for d. steroids are not indicated in meningococcal shock unless there is suspicion of hypoadrenalism. overall fatality rate of invasive meningococcal infection is - %, although these rates are difficult to assess as some studies only take into account meningococcal meningitis, while others reflect overall fatality from meningococcal disease [ , ] . reported mortality from meningococcemia ranges from % to % [ ] . for overall invasive meningococcal infection, the fatality rate in the present study was low ( . %). for meningococcemia, fatality rate in the present study was . % which is similar to other studies [ ] . low mortality in the present study can be explained by the fact that patients reached the hospital fast due to good information, education and communication activities by the local health authorities, combined with a low threshold for diagnosis and aggressive management of shock, rapidity of administration of the first antibiotic dose (door to needle time) and continuous monitoring in a well equipped pediatric intensive care unit. this is the first epidemic report of invasive meningococcal disease from north east india. although the majority of patients had meningitis, the full range of manifestations were also seen. this study highlights that clinical resistance to commonly used antibiotics such as ceftriaxone can be seen where chloramphenicol is an alternative effective choice. mortality reduces significantly with early diagnosis and prompt interventions like early shock management, antibiotic therapy and frequent monitoring in an intensive care set up. although invasive meningococcal infection did not have much impact on the morbidity and mortality of children from this region compared to other parts of the world, it remains one of the major causes of life threatening infections requiring continuous vigilance. contributions rd conceived the idea of the study and approved the final manuscript and will act as guarantee of the paper; nmd, hb, sgd, pj and db were involved in data retrieval, analysis and writing of the paper; abk and wvl were involved in the laboratory diagnosis and analysis of the microbiological data. meningococcal disease, need to remain alert. cd alert mémoire sur la maladie qui a regné a genêve au printemps de meningococcal meningitis outbreak control strategies meningococcal meningitis in delhi and other areas group b meningococcal meningitis in india meningococcal meningitis in an industrial area adjoining surat citysome clinic-epidemiological aspects meningococcal disease: history, epidemiology, pathogenesis, clinical manifestations, diagnosis, antimicrobial susceptibility and prevention multicenter surveillance of invasive meningococcal infections in children update on meningococcal disease with emphasis on pathogenesis and clinical management clinical features and complications of epidemic group a meningococcal disease in sudanese children meningococcal meningitis in northern ghana: epidemiology and control measures clinical profile of group a meningococcal outbreak in delhi early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome albumin: saint or sinner treatment of meningococcal infection meningococcal disease among children who live in large metropolitan area review of management of purpura fulminans and two case reports arthritis in disease due to neisseria meningitides immune complex reaction after successful treatment of meningococcal disease: an excellent response to ivig bacterial meningitis-a review of selected aspects. ii. special neurologic problems, post meningitic complications and clinicopathological correlations early bilateral eight nerve involvement in meningoccal meningitis connecticut, and selected areas meningococcal meningitis in ludhiana emergence of non-ceftriaxonesusceptible neisseria meningitidis in india ciprofloxacin-resistant neisseria meningitidis management of bacterial meningitis and meningococcal septicaemia in children and young people: summary of nice guidance epidemiology of bacterial meningitis meningococcal infection in children: a review of cases prognostic factors in acute meningococcaemia role of funding source none. key: cord- -ndmf ekp authors: akins, paul taylor; belko, john; uyeki, timothy m.; axelrod, yekaterina; lee, kenneth k.; silverthorn, james title: h n encephalitis with malignant edema and review of neurologic complications from influenza date: - - journal: neurocrit care doi: . /s - - - sha: doc_id: cord_uid: ndmf ekp background: influenza virus infection of the respiratory tract is associated with a range of neurologic complications. the emergence of pandemic influenza a (h n ) virus has been linked to neurological complications, including encephalopathy and encephalitis. methods: case report and literature review. results: we reviewed case management of a -year old hispanic male who developed febrile upper respiratory tract signs and symptoms followed by a confusional state. he had rapid neurologic decline and his clinical course was complicated by refractory seizures and malignant brain edema. he was managed with oseltamavir and peramavir, corticosteroids, intravenous gamma globulin treatment, anticonvulsants, intracranial pressure management with external ventricular drain placement, hyperosmolar therapy, sedation, and mechanical ventilation. reverse transcriptase polymerase chain reaction analysis of nasal secretions confirmed h n virus infection; cerebrospinal fluid (csf) was negative for h n viral rna. follow-up imaging demonstrated improvement in brain edema but restricted diffusion in the basal ganglia. we provide a review of the clinical spectrum of neurologic complications of seasonal influenza and h n , and current approaches towards managing these complications. conclusions: h n -associated acute encephalitis and encephalopathy appear to be variable in severity, including a subset of patients with a malignant clinical course complicated by high morbidity and mortality. since the h n influenza virus has not been detected in the csf or brain tissue in patients with this diagnosis, the emerging view is that the host immune response plays a key role in pathogenesis. the current pandemic of influenza a (h n ) ( h n ) virus has presented challenges for clinicians the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the centers for disease control and prevention. worldwide. neurologic complications of seasonal influenza are likely under-recognized by neurologists and the frequency of acute or post-infectious neurologic complications with h n virus infection is unknown. it is worth noting the historical relationship between h n and neurology. following the - h n pandemic, an increase was observed in encephalitis lethargica cases [ ] . what have neurologists learned about complications of h n virus infections worldwide? we present a case report of h n -associated encephalopathy and review neurologic complications associated with seasonal influenza and h n virus infection. the kaiser permanente inpatient neurosurgery service maintains ongoing institutional review board approval for a prospective database registry for clinical research purposes. we identified a case of acute encephalopathy associated with h n virus infection of the upper respiratory tract referred from an outside kaiser community hospital for management. we conducted a detailed review of the electronic medical records. we also conducted a literature review using pubmed. mesh search terms included influenza, encephalitis, encephalopathy, h n , acute necrotizing encephalopathy, and meningitis. a previously healthy -year old male college student had days of non-productive cough, rhinorrhea, myalgias, and fever but no headaches or neck stiffness. on the th illness day, he presented to the emergency department of a community hospital with lethargy and confusion. he was electively intubated for airway protection. his chest x-ray (cxr) was normal. routine admission laboratory tests including hepatic transaminases were within normal range. a non-contrast head computed tomography (ct) did not reveal any abnormalities (fig. , top row) , and he underwent lumbar puncture. cerebrospinal fluid (csf) analysis showed wbc/ll with % lymphocytes, rbc/ll, protein mg/dl, and glucose mg/dl. he was diagnosed with meningoencephalitis and started on vancomycin, ceftriaxone, acyclovir, and oseltamivir ( mg twice daily per nasogastric tube). on the morning of the third-day of hospitalization, he experienced tonic-clonic seizures and remained comatose with extensor posturing afterwards. repeat head ct (fig. , bottom row) demonstrated diffuse brain edema and effaced basal cisterns. he received fosphenytoin, mannitol, and propofol. the treating physicians contacted the neuro-intensive care unit at kaiser sacramento for additional assistance. he was emergently transferred to the kaiser permanente sacramento neuro-intensive care facility (nicu). on arrival, his initial examination demonstrated a glasgow coma scale of (e v m ). his repeat cxr did not demonstrate on the bottom row, the small arrow points to effacement of basal cisterns (left) and subcortical brain edema (larger arrows, bottom row, left and right). this subcortical edema is confirmed on mr imaging (fig. ) any infiltrates or signs of acute respiratory distress syndrome (ards). an external ventricular drain was placed by the neurosurgeon at the bedside. he reported that the csf pressure noted at the time of initial catheter placement was elevated. the first recorded intracranial pressure (icp) was mm hg, and this reading was taken after the expected loss of csf during the procedure. on the second day of nicu hospitalization, his glasgow coma scale (gcs) score was (e v m ) and average icp was mm hg. throughout the remainder of the hospitalization, the recorded icp remained below mm hg. initial icp was maintained with external ventricular drainage at cm relative to the external auditory canal and a midazolam infusion ( mg/h). electroencephalogram (eeg) monitoring demonstrated diffuse, severe slowing in the delta range and no electrographic seizures. on hospital day , mri of the brain was obtained (see fig. ). he received days of dual neuraminidase inhibitor treatment (oseltamivir mg twice daily per nasogastric tube, peramavir mg iv daily); intravenous gamma globulin ( gm/ kg days); dexamethasone ( mg iv load, mg iv every h with taper over weeks); icp monitoring and management; ventilator support; and anticonvulsants (fosphenytoin, levetiracetam). his weekly glasgow scale scores showed delayed improvement ( , e v m , admission): (e v m , week ), (e v m , week ), (e v m , week ), (e v m , week ). the midazolam infusion was discontinued on hospital day , after clinical observation and eeg confirmation that he was not having electrographic seizures. thereafter he received intermittent doses of lorazepam as needed for sedation while on the ventilator. over weeks, neuroimaging demonstrated improvement in his brain edema with restoration of his basal cisterns, and the external ventricular drain was successfully weaned and removed. more rapid weaning of his external ventricular drain was not attempted due to severe neurologic impairments with gcs less than eight and radiographic appearance of diffuse brain edema and effaced basal cisterns. his nicu course was complicated by ventilatorassociated klebsiella pneumoniae and spontaneous pneumomediastinum on day of intensive care. chest ct demonstrated subcutaneous emphysema, mediastinal emphysema, bilateral lower lobe atelectasis, and no pulmonary interstitial emphysema, or pneumothorax. he did not develop adult respiratory distress syndrome or suffer periods of hypoxemia. rt-pcr of an admission nasopharyngeal swab was positive for h n virus at the california department of public health virology laboratory. rt-pcr analysis of csf samples was negative for influenza a and b viruses, herpes virus type , , and , varicella, enterovirus, and epstein barr virus. nasopharyngeal samples were negative for enterovirus and mycoplasma pcr. bacterial and viral cultures of csf were negative. test results from clinical specimens (blood, endotracheal aspirate, serum, and csf) sent to the california encephalitis project did not reveal an alternative cause. follow-up mri brain imaging (fig. b, d) was repeated at month. after weeks, he transitioned to acute rehabilitation, and month later returned home. because he had improved upper extremity use without recovery in his legs, the physiatry staff performed spine mr imaging and no specific cause was identified. at the time of this case report, the patient has returned home with his family. he is talking and interacting with his family normally. he has not returned to college. his gastromy tube has been removed. he has generalized rigidity without tremor or dyskinesia. he is ambulatory but requires a walker due to reduced endurance and leg weakness. fig. magnetic resonance imaging was done at the time of patient transfer a, c to the neuro-intensive care center and at month of treatment b, d with influenza-specific antiviral therapy, corticosteroids, and intravenous gamma globulin therapy. a coronal flair image shows diffuse brain edema with sulcal effacement and symmetric hyperintensities selectively affecting the white matter and sparing cortex and subcortical nuclei such as basal ganglia and thalami. b coronal flair image at month shows resolution of sulcal effacement, marked reduction in white matter hyperintensity, and relative brain atrophy ( year old patient). c diffusion-weighted imaging on admission showed some increased signal in the periventricular zones that were also bright on t and flair sequences consistent with t shine-through. d diffusionweighted imaging at month revealed hyperintensity in the caudate and putamen with corresponding decreased signal in adc map and lack of hyperintensities on t and flair sequences (see fig b) we present a case of a patient with acute encephalitis associated with febrile upper respiratory tract illness due to h n complicated by seizures and malignant cerebral edema. few adult cases of h n influenzaassociated acute encephalitis or encephalopathy have been reported to date. descriptions of h n -associated neurologic complications are limited to case reports and small case series, and have been more commonly reported among young children. given the current influenza pandemic, we provide an overview of neurologic complications associated with seasonal influenza and h n (fig. ) and review clinical management and rationale. influenza virus infections can cause human respiratory disease and have been associated with a variety of central nervous system disorders [ ] . influenza virus has been rarely detected in csf of patients that developed acute encephalitis/encephalopathy [ ] [ ] [ ] . the systemic inflammatory response syndrome (sirs) to influenza virus infection of the upper respiratory tract is hypothesized to play a prominent role in the more severe stages leading to cytokine dysregulation (''cytokine storm'') in influenzaassociated encephalopathy or encephalitis (iae) patients [ ] . elevated cytokines in serum and csf have been reported in patients with seasonal influenza-associated encephalopathy [ , [ ] [ ] [ ] [ ] . elevated csf to plasma ratios suggest activation of cytokine production within the cns may have occurred along with the respiratory tract and systemic cytokines [ , , ] . microglia and astrocytes are capable of producing cytokines in the cns [ , ] . it is known that influenza virus infects and replicates at the nasopharyngeal epithelium leading to extensive damage during infection. below the mucosa, the free nerve endings of the olfactory nerves may also become infected. as seen with herpes simplex viruses, some postulate that influenza virus could penetrate and replicate at the olfactory mucosa and the free nerve endings with resultant axonal transport of virions to the olfactory bulbs, to the olfactory tract, and finally to the brain [ ] . there is some literature to support this mechanism when one looks at h n , or avian influenza, where mice inoculated intranasally with h n developed cns lesions in the pons, medulla oblongata, and cerebellar nuclei. astrocytes and glial cells were positive for viral antigen but viral replication ceased before days [ , ] . further study is needed to elucidate the pathogenesis of cns disease complicating influenza a infection. neurologic symptoms associated with influenza can arise at different intervals after the initial influenza illness (fig. , table ). when assessing patients clinically, it is important to determine if the patient has active or recent symptoms (within days) of influenza or if the neurologic symptoms have appeared in a subacute manner. we will first discuss neurologic complications in the setting of recent influenza virus infection and then proceed to complications that present in a delayed manner the development of a confusional state in the setting of influenza illness symptoms and fever raises the possibility of influenza-associated encephalitis or encephalopathy. the degree of encephalopathy varies from a confusional state to obtundation. it is important to recognize that a small portion of cases can rapidly deteriorate to coma and subsequent brain death due to diffuse, malignant cerebral edema. focal and generalized seizures often occur and can be present with either mild or severe cases. the presence of fever and altered mental state should prompt clinicians to pursue csf analysis unless neuroimaging or laboratory studies reveal a contraindication. influenza illness may include upper respiratory symptoms, pneumonia, or diarrhea (more commonly in young children with seasonal influenza). a thorough medical assessment to exclude other causes such as sepsis, metabolic or toxic disorders, structural cns diseases, and other cns infections is warranted. we define encephalitis by the presence of inflammation in the csf or demonstration of viral infection in brain biopsy or autopsy specimens. we define encephalopathy when csf is acellular and brain biopsy or autopsy specimens have failed to demonstrate viral infection. in some cases, this distinction is arbitrary and the case has borderline csf pleocytosis or csf analysis was not performed due to malignant brain edema. a consistent observation is that patients with seasonal influenza-associated encephalopathy rarely ever have evidence of influenza viral rna in csf based on rt-pcr analysis of csf. furthermore, there is no evidence of seasonal influenza virus infection of brain specimens. in one case series, only one out of patients with acute seasonal influenza-associated encephalitis had influenza viral rna detected [ ] . terminology for post-infectious encephalitis can be confusing. for example, the international pediatric multiple chronic condition * sometimes classified as adem [ ] sclerosis study group [ ] listed ten terms that have been used to describe acute disseminated encephalomyelitis (adem). some terms focus on the triggering event, such as post-infectious encephalomyelitis; others on pathologic or pathophysiologic features such as acute demyelinating encephalomyelitis or hyperergic encephalomyelitis. these authors also classify acute hemorrhagic leukoencephalitis, acute necrotizing hemorrhagic leucoencephalitis (also known as acute necrotizing encephalitis, (ane)), and acute hemorrhagic encephalomyelitis as hyperacute forms of adem. these diagnostic terms are of great historical interest. they generally preceded modern neuroimaging and relied more on the clinical and pathologic details. the study group also lumps a diversity of neuroimaging findings under the diagnosis of adem including: ring-enhancing lesions; diffuse and multi-focal regions of t hyperintensity with and without associated hemorrhage; multi-focal lesions with associated mass effect (tumefactive lesions); and images with symmetric, bithalamic edema. while we prefer one term (adem) rather than ten terms to describe post-infectious encephalitis, we are concerned that the pathophysiology and outcome of a process leading to the formation of ring-enhancing lesions (demyelinating, for example, acute demyelinating encephalomyelitis) must be radically different than that causing bithalamic edema (necrotizing, for example, ane). in reality, iae presents along a spectrum ranging from milder cases with normal neuroimaging to more malignant cases with abnormal neuroimaging and less favorable outcomes. for the sake of discussion and literature review, we present a simplified classification scheme based on clinical and imaging findings. the iae benign variant can present with fever, confusional state, and seizures but neuroimaging with ct brain or mri brain does not demonstrate any acute abnormalities. csf analysis is within normal limits or has borderline findings. rt-pcr testing for h n influenza viral rna is positive in upper respiratory secretions but negative when csf is tested [ ] [ ] [ ] . these patients typically recover within week, and most cases have received oseltamavir and anticonvulsants. the initial reports of pediatric cases of h n encephalopathy in the us were not severe [ ] . similarly, other reported adult cases of h n iae without ards have not been severe with complete recovery [ , ] . a more recent pediatric case series of h n iae reported that / patients had imaging abnormalities and neurologic sequelae [ ] , so the treating physicians need to be aware that full recovery is not a certainty. the iae with splenial sign presents with acute febrile respiratory illness and additional neurologic symptoms with a characteristic mri abnormality. we found case reports associated with seasonal influenza but not with h n . it has been reported in children, but rarely in adults [ ] [ ] [ ] [ ] [ ] [ ] . encephalopathy is always present and can be severe. seizures are often present. mri imaging demonstrates increased t and flair signal and restricted diffusion in the splenium of the corpus callosum. this finding is reversible. the mri finding is not specific and has been reported with other infections, high-altitude brain edema, and certain metabolic states such as hypernatremia [ ] . csf analysis is unremarkable. these patients have been treated with oseltamavir and anticonvulsants, and typically recover within month. the iae with posterior reversible leucoencephalopathy syndrome (pres) presents as moderate to severe febrile encephalopathy. this subtype has been reported with seasonal influenza but not specifically with h n . the mri imaging appears radiographically identical to pres caused by more typical causes such as pregnancy or malignant hypertension [ , ] . vascular caliber changes have been observed in these cases; this is non-specific and can be related to infectious vasculitis or pres. given the diverse causes of pres including malignant hypertension, pregnancy, metabolic disorders, and certain medications such as chemotherapeutics and immunosuppressants; it is often difficult to distinguish the pathophysiology of iae in this clinical setting. therapy is focused upon antiviral treatment, corticosteroid administration, and supportive care. iae with malignant brain edema is one of the most challenging subtypes to diagnose and treat. both seasonal influenza and h n can be complicated by severe forms of acute encephalopathy and malignant brain edema [ ] [ ] [ ] [ ] . survival in some cases has been achieved with aggressive neuro-intensive case management with other therapies, including administration of antivirals, corticosteroids, immunoglobulin ( gm/kg in adult patients), hyperosmolar therapy, plasmapheresis, and hypothermia in some cases. one of the goals of treatment is to reduce viral expression with early antiviral treatment and thereby to reduce stimulation of the host inflammatory response. our case presentation illustrates the rapid time course for this complication (see fig. ) and neurocritical care treatment approaches. because of diffuse brain edema, a broad treatment approach using hyperosmolar therapy, intubation, fever control, and sedation were important. to the best of our knowledge, this is the only case description of iae in which an external ventricular drain was utilized, probably because it is difficult to place a catheter into the small, compressed ventricles of patients with diffuse brain edema associated with influenza. another adult case of h n encephalitis has been reported with radiographic findings similar to ours. fugate et al. [ ] described an adult with h n influenza-associated acute hemorrhagic leukoencephalitis. like our patient, their case also showed confluent areas of increased t signal in the periventricular white matter and centrum semiovale. because of the additional finding of microhemorrhages demonstrated on gradient echo mri sequences, they diagnosed acute hemorrhagic leukoencephalitis or hurst disease. their patient also had restricted diffusion in the basal ganglia (see fig. ). because their patient had severe adult respiratory distress syndrome (ards) with oxygen saturation readings in the range of - %, the authors attributed the basal ganglia findings to hypoxic brain injury. our patient did not have advanced pulmonary disease, hypoxia, or hypotension. care should be taken to distinguish iae with malignant edema from reyes' syndrome in which patients may present with lethargy, confusion, seizures, or coma accompanied by brain edema. reyes' syndrome most commonly occurs in children but has been reported in adults following influenza and aspirin ingestion [ ] . it can be distinguished based on the accompanying hepatic abnormalities, hyperammonemia, and hypoglycemia. caution should be taken with any neurosurgical procedures in reyes' syndrome due to increased risk of perioperative bleeding. one of the most devastating complications of seasonal and pandemic influenza is ane [ ] [ ] [ ] . patients develop rapid neurologic deterioration to coma. seizures are often present. initial brain ct may show decreased density in the thalami, and mri of brain demonstrates the characteristic bilateral thalami lesions. this finding may be initially mistaken for ischemic strokes (top-of-basilar syndrome) or venous infarction secondary to thrombosed internal cerebral veins, vein of galen, or straight sinus. it is interesting that there have been case reports for recurrent ane and also familial ane. this suggests that there may be a genetic susceptibility and a gene associated with familial seasonal influenza ane cases has been reported (nuclear pore gene, ranbp ; [ ] ). this condition is often fatal or accompanied by permanent neurologic sequelae in surviving cases. it is intriguing that the neuroanatomical changes found in the thalami, midbrain, and cerebellum on neuroimaging correlated with the clinical symptoms reported for encephalitis lethargica, specifically ''sleeping sickness'', ophthalmoparesis, quadriparesis, and delayed parkinsonism (see below). it is conceivable that survivors with less fulminant involvement could manifest a clinical syndrome with symptoms and signs that localize to brainstem structures. a pediatric case of h n -associated ane with bilateral thalamic imaging findings without associated malignant brain edema has been published [ ] , but detailed clinical follow-up was not reported. during the subacute period, additional classic neurologic syndromes associated with influenza have been described. post-influenzal cerebellitis is quite uncommon and has been reported rarely in adults [ ] [ ] [ ] . this syndrome was diagnosed in a -year old woman who developed ataxia, dysarthria, and truncal titubation month after influenza b virus infection, with neurologic symptoms that resolved gradually after an additional month. ct and mri brain imaging were unrevealing. csf studies detected evidence of the persistence of the np gene of influenza b virus in the csf from samples taken and weeks after the onset of initial influenza illness. a -year old woman gradually developed gait and speech problems after influenza a illness that was treated with oseltamavir. csf showed pleocytosis. the cerebellar cortex had increased t signal which resolved over an day period. she received pulse intravenous corticosteroid therapy. her symptoms resolved [ ] . plasmapheresis [ ] and ivig [ ] have also been used for this condition. some cases of cerebellitis following viral and mycoplasma illness have developed fulminant cerebellar swelling with secondary brainstem compression, obstructive hydrocephalus, with fatal outcome [ ] . interventions with posterior fossa decompression and external ventricular drain placement may lead to a favorable outcome in a child with this severe condition. antibodies to the glutamate receptor have been reported in patients with post-infectious influenza viral cerebellitis [ ] . guillain-barre syndrome (gbs) is a subacute, immunemediated disease predominantly affecting the peripheral nervous system. the diagnosis and treatment are wellknown to most neurologists and this condition has been extensively described and reviewed. gbs has been rarely reported in association with seasonal influenza virus infection [ ] , but it should be noted that influenza testing is rarely pursued in gbs cases and may be unrevealing. treatment for influenza-related gbs is identical to treatment for other gbs due to other associated causes. monitoring for respiratory compromise due to neuromuscular weakness with timely respiratory support if needed is critical. plasmapheresis or gammaglobulin treatments are also helpful. the precise pathophysiology is uncertain, but molecular mimicry of the infectious agent is presumed to stimulate autoimmune responses. this has been demonstrated to occur in campylobacter jejuni-associated gbs [ ] . influenza-associated myositis has been reported with seasonal influenza [ ] and h n variant [ ] . myalgias are a common symptom of influenza, but some patients develop frank weakness and have elevated serum levels of creatine phosphokinase (cpk). it is more common in children but has been seen in all age groups. the calf muscles are most suspectible, and patients may walk with a stiff gait or toe walk. onset is usually within the first week of infection and spontaneous improvement typically occurs within weeks in most cases. rarely, severe cases can result in myoglobinuria-associated renal failure and compartment syndromes requiring fasciotomies. influenza can also selectively attack specific muscle groups such as the heart (myocarditis). muscle biopsy shows necrosis, regenerating fibers, and occasionally inflammation. post-viral parkinsonism has been reported after an assortment of infections including influenza virus [ ] . an outbreak of these cases was temporally noted following the great influenza (h n ) pandemic of - [ ] . patients with this condition respond poorly to medical therapy, and it has an unfavorable prognosis. encephalitis lethargica is also known as von economo encephalitis and sleeping sickness [ ] . a wave of such cases was reported following the - influenza a (h n ) virus pandemic. the cardinal features of this condition are altered consciousness with prolonged somnolence and ophthalmoplegia. after intervals of months to years, survivors are at risk of developing parkinsonism. pathological findings include nerve cell destruction primarily in the midbrain, subthalamus, and hypothalamus [ , ] . using modern laboratory techniques, formalin-preserved autopsy brain specimens of encephalitis lethargica cases analysed for influenza viral rna were negative [ ] . scientists have proposed a ''hit-and-run'' model of early viral-mediated injury with late sequelae [ ] . the neurologist oliver sacks [ ] drew attention to this mysterious disorder and the discovery of l-dopa, in his book, awakenings later converted to a feature-length movie. the delayed appearance of restricted diffusion in the basal ganglia in our patient and others [ ] is concerning for this condition (fig. ) . we do not know if this indicates that our patient with h n is at risk of developing postviral parkinsonism, but long-term clinical follow-up will be important. a delayed diffusion neuroimaging abnormality was also reported in the dentate nucleus of a patient with seasonal influenza encephalopathy/splenial sign [ ] . we present a case of acute encephalitis associated with pandemic influenza a (h n ) virus infection, complicated by malignant brain edema. the emerging hypothesis about acute neurologic complications of seasonal influenza is that the immune response triggered by influenza virus infection of the respiratory tract plays a prominent role in the pathogenesis of neurological manifestations. this hypothesis regarding the development of acute encephalopathy and brain edema is analogous to current theories about the role of the immune system and cytokines in the development of ards with h n virus infection. we have also provided an overview of the spectrum of acute and post-infectious neurologic complications reported in association with seasonal and pandemic influenza virus infection of the upper respiratory tract. neurologists should be aware of the potential for a wide range of neurologic complications in association with the current h n pandemic and seasonal influenza. influenza, encephalitis lethargica, parkinsonism neuropathogenesis of influenza virus infection in mice pcr on cerebrospinal fluid to show influenza associated acute encephalopathy or encephalitis detection of influenza virus rna by reverse-transcription-pcr and proinflammatory cytokines in influenza-associated encephalopathy acute encephalopathy associated with influenza a virus infection th and th hypercytokinemia as early host response signature in severe pandemic influenza acute encephalopathy associated with influenza a infection in adults systemic cytokine responses in patients with influenza-associated encephalopathy cytokine profiles induced by the novel swine origin influenza a/h n virus: implications for treatment strategies tumor necrosis factor-a, interleukin- b, and interleukin- in cerebrospinal fluid from children with prolonged febrile seizures. comparison with acute encephalitis/encephalopathy sepsis causes neuroinflammation and concomitant decrease of cerebral metabolism microglia in health and disease microglia in diseases of the central nervous system astrocytes are active players in cerebral innate immunity hypothetical pathophysiology of acute encephalopathy and encephalitis related to influenza virus infection and hypothermia therapy highly pathogenic h n influneza virus can enter the cns and induce neuroinflammation and neurodegeneration encephalitis in mice inoculated intranasally with an influenza virus strain originated from a water bird for the international pediatric ms study group. acute disseminated encephalomyelitis neurologic complications associated with novel influenza a (h n ) virus infection in children novel influenza a (h n ) presenting as an acute febrile encephalopathy in a mother and daughter surveillance of h n -related neurological complications neurological sequelae of influenza a (h n ) in children: a case series observed during a pandemic influenza-associated encephalitis-encephalopathy with a reversible lesion in the splenium of the corpus callosum: case report and literature review influenzaassocaited encephalitis/encephalopathy with a reversible lesion in the splenium of the corpus callosum: a case report and literature review transient splenial lesion of the corpus callosum in clinically mild influenza-associated encephalitis/encephalopathy reversible splenial lesionin influenza virus encephalopathy a reversible lesion of the corpus callosum with adult influenza-associated encephalitis/encephalopathy: a case report mild influenza-associated encephalopathy/encephalitis with a reversible splenial lesion in a caucasian child with additional cerebellar features isolated and reversible lesions of the corpus callosum: a distinct entity posterior reversible encephalopathy syndrome and cerebral vasculopathy associated with influenza a infection: report of a case and review of the literature influenza a encephalopathy, cerebral vasculopathy, and posterior reversible encephalopathy syndrome: combined occurrence in a year-old child case of adult influenza type a virus-associated encephalopathy successfully treated with primary multidisciplinary treatments elderly autopsy case of influenza-associated encephalopathy an adult autopsy case of acute encephalopathy associated with influenza a virus acute hemorrhagic leukoencephalitis and hypoxic brain injury associated with h n influenza influenza a virus and reye's syndrome in adults acute necrotizing encephalopathy in a child with h n influenza infection acute necrotizing encephalopathy in a child during the influenza a (h n ) pandemia: mr imaging in diagnosis and follow-up infection-triggered familial or recurrent cases of acute necrotizing encephalopathy caused by mutations in a component of the nuclear pore, ran-bp mr imaging in novel influenza a (h n )-associated meningoencephalitis an adult case of acute cerebellitis after influenza a infection with a cerebellar cortical lesion on mri probable post-influenza cerebellitis acute cerebellar ataxia and consecutive cerebellitis produced by glutamate receptor delta autoantibody plasmapheresis improves outcome in postinfectious cerebellitis induced by epstein-barr virus brain spect imaging and treatment with ivig in acute post-infectious cerebellar ataxia: case report acute near-fatal parainfectious cerebellar swelling with favourable outcome guillain barre syndrome and influenza virus infection carbohydrate mimicry between human ganglioside gm and campylobacter jejuni lipooligosaccharide causes guillain-barre syndrome benign acute childhood myositis: laboratory and clinical features melting muscles: novel h n influenza a associated rhabdomyolysis viral parkinsonism lack of detection of influenza genes in archived formalin-fixed, paraffin waxembedded brain samples of encephalitis lethargica patients from to new york: random house, inc key: cord- - x nnsc authors: javelle, emilie; lesueur, alexandre; pommier de santi, vincent; de laval, franck; lefebvre, thibault; holweck, guillaume; durand, guillaume andré; leparc-goffart, isabelle; texier, gaëtan; simon, fabrice title: the challenging management of rift valley fever in humans: literature review of the clinical disease and algorithm proposal date: - - journal: ann clin microbiol antimicrob doi: . /s - - - sha: doc_id: cord_uid: x nnsc rift valley fever (rvf) is an emerging zoonotic arbovirus with a complex cycle of transmission that makes difficult the prediction of its expansion. recent outbreaks outside africa have led to rediscover the human disease but it remains poorly known. the wide spectrum of acute and delayed manifestations with potential unfavorable outcome much complicate the management of suspected cases and prediction of morbidity and mortality during an outbreak. we reviewed literature data on bio-clinical characteristics and treatments of rvf human illness. we identified gaps in the field and provided a practical algorithm to assist clinicians in the cases assessment, determination of setting of care and prolonged follow-up. rift valley fever virus (rvfv) is an arbovirus, mainly transmitted by mosquitoes, responsible for a zoonosis disease that affects cattle, sheep, camels and goats. it was first identified in during an investigation into an epidemic among sheep on a farm in the rift valley of kenya [ ] . the virus infects also humans through inoculation after contact with infected animals or through ingestion of unpasteurized or uncooked by-products of infected animals, or also through inhalation of aerosols produced during the slaughter of infected animals. however, human infections occurred also from the bites of infected mosquitoes, mainly aedes and culex but also anopheles or mansonia, and other blood-feeding vectors such as flies and ticks have been identified [ ] [ ] [ ] . to date, no human-to-human transmission of rvfv has been documented. rvfv belongs to the phenuiviridae family (formerly bunyaviridae), member of the phlebovirus genus. the enveloped virion contains a tripartite, predominantly negative-sense, single-stranded rna genome, which codes for structural and non-structural proteins the virus needs to replicate both in mammalian hosts and insect vectors. rvfv attach to cells via the interaction between the viral structural proteins gn and gc and c-type lectins, dc-sign and i-sign [ ] . cells become infected with rvfv by receptor-mediated endocytosis, followed by ph-mediated fusion of virus-endosomal membranes to release nucleocapsids into the cell cytoplasm. transcription, translation, and genome replication occur in the cytoplasm. the non-structural protein nss is known to be a major virulence factor allowing the virus to escape host innate immune response. only one serotype is recognized but strains exist of variable virulence. moreover, rvfv is classified as a risk group agent, and biosafety page of javelle et al. ann clin microbiol antimicrob ( ) : level (bsl)- containment requirements are needed to work with the virus in the laboratory [ ] . as other arboviral infections including dengue, chikungunya and zika, rvf is emerging worldwide, due to the globalization of arthropod vectors, mainly mosquitoes, which efficiently transmit an increasing number of old, unrecognized and new viruses. arboviruses pose a major threat of introduction to several continents, including europe and north america, with the possibility of cocirculation [ ] . the widespread presence of competent vectors, the high viral load in infected animals, trade and global travel, all increase the likelihood of rvfv exportation and establishment outside endemic regions [ ] [ ] [ ] . cases have already been imported to europe and asia [ , , ] and concerns have raised about its potential to extend to other parts of asia, europe [ ] and united states [ , ] . such an introduction would cause significant losses to the livestock industry and substantial human morbidity and mortality [ ] . clinicians need to consider rvf in the differential diagnosis for febrile illnesses in a suitable context, however manifestations of rvfv in humans are varied and unspecific including hepatitis, encephalitis, hemorrhagic disease, and retinitis with potential dramatic consequences. the overall case fatality rate is estimated from . to % [ , ] , but higher mortality rates were recorded, as for example % by the saudi health ministry in [ ] , around % in east africa, west africa, south africa and madagascar from to [ ] , and % in tanzania in [ ] . in rvfv emerged in mayotte, a french overseas department and region and gave growth to this work [ ] . strategies of rvfv control appeared us challenging because of its complex biological cycle and its multiple routes of transmission to humans [ ] . besides, the wide clinical spectrum over a long-period of time made very difficult the establishment of standard definitions of human cases and recommendations for their management. we conducted a literature review on the rvf clinical disease and treatments in humans. we identified the state and frontiers of knowledge. lacking guidelines on the rvf human disease, we proposed an algorithm to assist physicians on the field in the evaluation of cases. this algorithm could help and be improved during next epidemics. we based on preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines to conduct this clinical review and build the flow diagram ( fig. ) [ ] . we did a literature search for english and french language studies published in electronic databases for an unlimited period until december, : pubmed central, embase, medline and scopus. we used the keywords "rift valley fever" and "human". along with this, we conducted targeted search within the online archives of journals of tropical medicine, which published the first clinical reports of rvf in humans since s, i.e. "south african medical journal" and "transaction of the royal society of tropical medicine and hygiene". we contacted editorial office of other journals to get relevant articles published between s and s. if available, we reviewed citations in pubmed of these first articles in literature. besides, we consulted the databases, datasets and official reports of the world health organization (who) and the centre for disease control (cdc) on their official websites and the mentioned references. we removed duplicates and screened titles and abstracts of all these records to include manuscripts reporting clinical descriptions and/or treatments of rvf in humans (case reports and case series). animal models for rvfv pathogenicity studies published during the last years were also considered. serological surveys, works on vaccines, immunology, biology, veterinary science and entomology were excluded. totally, articles resulting from these searches with full-text available were assessed for eligibility. among them, with uncertain rvf diagnosis or without significant content or input were removed. relevant references cited in the eligible articles were reviewed and other records were manually searched and added for specific purposes of our article using the following terms "rift valley fever" and "severity", "severe", "prognosis", "death", "fatal", "risk factors" and "scores". at the end, articles were referenced in the final review ( fig. ) . we used data on rvf human cases reported by the who in the rubric "disease outbreak news" [ ] and the cdc outbreak summaries [ ] to build an epidemiological overview and we used the software adobe illustrator . and macrovector official freepik for figures. human cases have been reported from many african countries following the virus introduction via infected livestock trade [ ] . since the end of s, the virus has extended outside the african continent to indian ocean islands: madagascar [ ] , comoros, and mayotte [ ] [ ] [ ] [ , ] , but methods used to calculate this basic reproductive ratio have some limits [ ] . infection with rvfv is mostly pauci-symptomatic in humans. general signs may occur in to % of infected cases after an incubation period of to days. the typical presentation includes headache, fever, backache and generalized aches in muscles and joints, lasting to days [ , , , ] also reported [ , ] . rvf differs from influenza, dengue and chikungunya as to whether cough, skin involvement (i.e. rash or pruritus) and arthritis are respectively uncommon signs. a slight meningism at the acute stage is not rare, however its prognosis value has never been evaluated [ ] . basically, retro-orbital pains and neck stiffness are features hard to classify because both of them were commonly reported in uncomplicated rvf cases [ ] , but were also associated with the occurrence of complications [ , ] . incidences of complications are uncertain because rvfv infection can go unrecognized or be misdiagnosed considering the unspecific symptoms of suspected cases, which overlap with many other co-circulating pathogens [ ] . no standard definition of suspected cases exists. rates of complications measured in studies depend on the definitions and methods of recruitment. indeed, the use of clinical or biological criteria specific to rvf complications to define suspected cases could lead to underestimate the mild forms [ ] [ ] [ ] . globally, since the first description of the spectrum of rvf in humans by laughlin et al. during the major outbreak in egypt in , it is considered that less than % of symptomatic cases will present complications including ocular, neurologic and hemorrhagic symptoms, while favorable outcome will occur within week for the others [ ] . in this historical series, the different known complications occurred in equal proportions ( - %), but hepatic or renal failures were not identified. during the kenyan outbreak, kahlon et al. described a clinical syndrome suggestive of severe rvf, characterized by fever, large-joint arthralgia, and gastrointestinal complaints, later followed by jaundice, right upper-quadrant pain, and delirium, often coinciding with hemorrhagic manifestations [ ] . complicated forms could have represented up to % of symptomatic cases during recent epidemics [ ] . morbidity, as well as mortality, varied from one to another outbreak. for example, in south africa in [ ] and in tanzania in [ ] most of rvf severe cases presented with encephalopathy (respectively % and %), whereas hemorrhagic manifestations predominated in mauritania in ( %) [ ] and madagascar in ( %) [ ] . in saudi arabia in , hepatic insufficiency ( %) and renal failures ( %) were the most frequent complications [ ] . moreover, during the epidemic in madagascar, highly fatal associations of two or more complications were highlighted. these occurred in / ( %) severe cases, of whom ( %) had encephalitis with hemorrhagic symptoms which were lethal in / ( %), representing half of the deaths ( / ) [ ] . variations in the rvfv tropism and virulence are hypothesized according to the lineage involved and the possible accumulation of genetic mutations or genomic reassortments [ , [ ] [ ] [ ] , despite a low overall genomic diversity (∼ %) at the nucleotide level [ ] . genetic, ethnic or epidemiologic factors in the population exposed to the virus, as well as access to care also play a role [ , ] . manifestations of rvf in humans are represented in fig. . alternative diagnoses concern a broad array of conditions which may be worldwide distributed or restricted to endemic areas. characteristics and differential diagnoses of rvf manifestations are summed-up in table . determinants for severe rvf outcome are poorly known. a number of retrospective studies suggest that touching, handling, living close to, and consuming animal products are factors associated with increased likelihood of rvf virus infection and possibly more severe outcomes [ , ] . this is probably linked with a significant exposure to the virus that results in higher inoculation rate. indeed viremic loads have been reported correlated with severe rvf diseases [ ] . single nucleotide polymorphisms (tlr , tlr , tlr , myd , trif, mavs, and rig-i) were also associated with severe symptomatology [ ] . acute malaria co-occurrence was observed in severe forms and hiv-positive status was associated with a % case fatality rate in tanzania in [ ] . schistosomal liver co-involvement and bacterial or fungal co-infections were also documented in fatal cases [ ] . liver is the primary site of rvfv replication, so that it is frequently early involved during rvfv acute infection [ , ] . a severe acute hepatotropic disease may occur with liver failure and jaundice within the first weeks of the disease [ ] . tenderness, palpable enlargement and more than threefold elevation in transaminases are criteria of severity [ , ] . jaundice was proved to be independently associated with a high mortality rate [ ] . acute hepatitis may complicate with prolonged blood coagulation times and may occur together with or precede fatal hemorrhages or neurologic complications. autopsy studies and pathogenesis characterization in mouse model found evidence of liver necrosis with rvf viral antigens identified within hepatocytes and küpffer cells, arguing for a direct virus-induced cellular necrosis [ , , , , , ] . a rvf case with a co-existing condition of cirrhosis after hepatitis b infection died as a result of gastrointestinal bleeding and hepatic encephalitis in mayotte [ ] , and / ( %) severe cases described during the epidemic in mauritania in had chronic hepatitis b [ ] , suggesting that patients with chronic hepatic acute or delayed encephalitis day vision disorders day [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] disorders-mainly hepatitis b chronic infection-could be at higher risk of unfavorable outcome. soon after the onset of flu-like illness or acute hepatitis, patients may present bleeding from the nose or gums (gingivorrhagia being a key early warning sign) [ ] , hematemesis or melaena, petechial/purpuric rash or ecchymoses, menorrhagia, hematuria, or bleeding from venipuncture sites [ , ] . yellow fever-like expression were also reported with a first improvement at day followed by a rebound of fever [ ] . epistaxis is not considered a reliable sign of how serious the illness is [ , ] . thrombocytopenia is invariably present. hepato-renal failure with jaundice, disseminated intravascular coagulation and encephalitis can be associated [ , ] . overall prevalence is estimated %, but prevalence was rather % in hospital cohorts [ , ] . a population-based survey during the outbreak in kenya even reported % of hemorrhagic rvf disease with a mortality of % in this group of cases [ ] . indeed, the mortality rate associated with bleeding manifestations is the highest, up to % [ , ] . viral load could play an important role in the hemorrhagic expression. in humans studies, it exhibited positive correlation with markers of inflammation (ip- , crp, eotaxin, mcp- and granzyme b), markers of fibrinolysis (tpa and d-dimer), and markers of endothelial function (sicam- ), but a negative correlation with p-selectin, adamts , and fibrinogen, which are associated with coagulation pathways occurring on the endothelial surface [ ] . the onset of meningoencephalitis usually occurs to weeks after the first symptoms (which may be very mild or subclinical), and in some cases neurological complications can manifest beyond days after the initial symptoms of rvf. clinical features may include intense headache, neurological deficit, rigor, neck rigidity, hyperreflexia, hypersalivation, choreiform movements, loss of memory, hallucinations, confusion, disorientation, vertigo, convulsions, ataxia, lethargy, decerebrate posturing, locked-in syndrome and coma [ , , , [ ] [ ] [ ] [ ] . in a human outbreak in mauritania in , up to % of observed infections had encephalitis [ ] . two types of pure encephalitis were described: acute febrile forms with short duration and possibility of death, and subacute forms with a longer duration, a lower fatality rate but frequent sequelae [ ] . pulmonary complications may occur [ , ] , and malaria can worsen the severity of neurologic symptoms [ ] . lethality may be as high as % in this form [ ] . from mauritania in , clear a cellular csf were documented in all cases with encephalitis [ ] . in a -year old woman treated for chronic myeloid leukemia with acute rvfv encephalitis acquired in saudi arabia, csf was documented predominantly with polynuclear leukocytes. magnetic resonance imaging (mri) showed high signal intensity on t -weighted images in frontoparietal and thalamic regions, with multiple bilateral asymmetrical cortical hyperintense areas consistent with inflammation or ischemia in axial diffusion, while changes in ct-scan of her brain appeared much later [ ] . in delayed meningoencephalitis normal glucose and protein concentrations will lymphocytic pleocytosis were found in csf [ ] . in a kidney transplant recipient with cured hepatitis b, presenting acute hepatitis followed by delayed pachymeningitis, specific rvf-igm were detected in lymphocytic csf at day , while igg were positive in blood at the first screening at day [ ] , which was consistent with the first neurologic description in literature [ ] . in a mouse model of rvf infection, survivors to primarily hepatitis cleared the virus from liver and blood, but exhibited neuro-invasion and fatal encephalitis [ ] . active viral replication in brain leading to necrotizing encephalitis was documented in several animal models [ , ] . the route of transmission and prompt robust immune response could be a determining factor of the rvf neurologic disease course [ ] . indeed, whatever the routes of inoculation, rvfv rna was detected in the brain of infected rats confirming the virus neurotropism [ ] , but aerosol exposure to rvfv caused earlier and more severe neuropathology in the murine model and fatal encephalitis in primates [ , ] . in aerosol-infected rats with lethal encephalitis, neutrophils and macrophages were the major cell types infiltrating the cns, and this was concomitant with microglia activation and extensive cytokine inflammation [ ] . differences in the peripheral blood biomarkers during the course of the neurological disease in african green monkeys were measured with defect in early t-cells, proinflammatory and antiviral responses in lethal encephalitis [ ] . other immune disorders and alteration in vascular permeability in the brain could be more involved in delayed forms [ ] . during rvfv infection, elevated urea and creatinine levels may be secondary to hypovolemia, multipleorgan dysfunction, or hepatorenal syndrome [ , ] . acute hepatonephritis, possibly related to direct rvfv injury, characterized by proteinuria and oliguria were also reported with a bad prognosis [ ] . in mauritania in , creatininemia was meanly more than fourfold upper the reference range in severe cases [ ] . in saudi arabia in , renal impairment concerned up to % of rvf inpatients and dialysis was needed in % of them [ ] . the mortality rate was % in patients with acute renal failure, % in those with hepatorenal syndrome, and % in patients with primary hepatic involvement and mild renal impairment [ ] . progression to chronic renal failure was not seen [ , , ] . in in mayotte, an acute pericarditis with symptoms of right-sided heart failure, relapsing at month, was documented in a -year old farmer diagnosed with rvfv infection [ ] . in historical post-mortem examinations, fragmentation in myocardial muscle was found in two cases and rvfv was isolated from one pericardial fluid [ , ] . macular exudates with potential permanent loss of central visual acuity were firstly described in among , estimated cases (< . %) during the - outbreak in south africa [ , ] . the prevalence of ocular manifestations has been estimated to % during epidemic outbreaks in egypt in , and up to % both in patients with mild and severe rvf disease during the outbreak in southwest saudi arabia [ ] . unilateral or bilateral symptoms generally occur to days after the rvfv infection, but can be more delayed, and may include decreased visual acuity, scotoma, acute hemorrhagic conjunctivitis and retro-orbital pain [ ] . the most frequent and most specific ocular lesion is a macular or paramacular retinitis [ , ] . the funduscopy by indirect ophthalmoscopy usually shows a single well demarcated necrotic lesion with ill-defined creamy-white patchy lesions of macular retinitis with hemorrhages [ ] . the other retinal signs include arterial occlusions, vasculitis (mostly phlebitis and sometimes arteritis) [ ] , sheathing of the vessels, which are best explored using fluorescein angiography. in series, vitreous reaction with vitreal haze or vitritis occurred in less than one third of patients, optic-nerve head edema or palor were described in % of cases with retinal involvement, and no infectious optic neuropathy was reported [ , ] . anterior uveitis was associated with a posterior uveitis, defining a panuveitis with aqueous flare and fine non-granulomatous keratic precipitates [ , ] . fluorescein angiography performed during the active phase of the disease may show early hypofluorescence with delayed filling of the arterioles and venules, associated with late staining of the lesions [ ] . it also helps for the diagnosis of vasculitis, showing vessels sheathing and staining, and vascular occlusions when present. follow-up fluorescein angiography performed several months after rvf diagnosis have revealed window defect in the area of the retinitis, vascular occlusions and obliterated macular vessels [ ] . however, ophthalmoscopic and angiographic features of the rvfv associated retinitis are not specific and can be encountered in several viral or bacterial infections (table ) [ , [ ] [ ] [ ] . ocular active lesions resolve spontaneously in to weeks. macular or paramacular scarring, vascular occlusions and post-infectious optic atrophy associated to the central scarring lead to poor visual acuity outcomes. retinal complications may cause - % of permanent vision loss, and up to % of the affected eyes reached the criteria for legal blindness [ , , ] . no chronic anterior uveitis, posterior synechiae, iris nodules, uveitic glaucoma nor cataract were described [ , , ] . it is not known if the ocular manifestations of the rvf result from direct toxicity of the virus or from an immune response to the infection. post-mortem examination suggested the presence of focal areas of retinal necrosis and retinal pigment epithelium (rpe) degeneration with round cell inflammatory infiltration and perivascular cuffing but the presence of the virus in the ocular tissues has not been proved. most of animal models for rvf do not show any ocular disease [ , ] . in a sheep model quantitative rt-pcr (qrt-pcr) was positive on eye tissues after the viremic phase [ ] , but retinal complications of rvf could also be caused by antibodyrelated auto-immune reactions [ ] . in a seroprevalence study, mothers experiencing fetal death or miscarriage had the same rvfv antibody prevalence as those with normal deliveries [ ] . a retrospective study in egypt in found no increase in the risk of abortion in humans [ ] . however a recent cross sectional study has demonstrated an association between infection with rvfv and miscarriage in sudanese pregnant women ( % versus % of risk in non-infected pregnant women with p < . and or . with % ci [ . - . ] in multiple logistic regression analysis) [ ] . the teratogenic potential of the rvfv is unknown. occasional vertical transmission has been reported, sometimes with fatal outcome in the newborn [ , ] . few symptomatic infections were described in pregnant women [ ] and children under the age of years old [ , ] . the question is remaining whether it is the result of a lack of exposure to infected mosquitoes and infected animals, or if there are differences in susceptibility between animals and humans [ ] . importantly, hemorrhagic complications require high cautious infection control measures, following the cdc guidance on infection control precautions for hemorrhagic viral fevers (hvfs), while waiting for the exclusion of other hvfs such as ebola virus disease or crimean-congo hemorrhagic fever [ , ] . standard precautions with personal protective equipment (ppe) were reported sufficient to prevent from nosocomial transmission of rvfv during the outbreak in arabian peninsula [ ] , and must be implemented according the who checklist [ ] , to care any suspected case regarding the theoretic risk of rvfv transmission through contact with infected blood, tissues, or other body fluids, secretions and excretions. considering rvf is also mosquito-borne disease [ ] , we recommend for all-day preventive measures against vectors using physical (long clothing and bed nets), chemical (topical repellents and insecticide impregnations) barriers in the environment of viremic patients. considering the mean length of the viremia, these measures could be reasonably stopped week after the illness onset, but there is no evidence-based cut-off time to allow donation of blood and removal of tissue or organs for transplantation from a rvfv-infected patient. samples of suspected cases must be collected with ppe and safe handled adhering to bsl- precautions. specimens must be labelled, packaged in accordance with the guidelines for the transport of dangerous biological goods (triple packaging), stored at °c and addressed to a reference center. if necessary, whole-blood specimens can be dried on blotting paper, stored - days and transported without refrigeration for retrospective diagnosis confirmation [ ] . according to who a confirmed rvf infection relies on (i) detection of rvfv rna by reverse transcriptasepolymerase chain reaction (rt-pcr) on sera or plasma; (ii) igm and igg detection by enzyme-linked immunosorbent assay (elisa). viral isolation is also an assay for laboratory confirmation of rvfv infection but this assay needs to be done on bsl and is less sensitive than detection of viral rna by rt-pcr. interestingly, rt-pcr for rvfv was reported positive for a prolonged period in urines, semen [ ] and whole blood [ ] . the rvfv rna load in blood usually decreases between days to and may be detectable until day after the onset of symptoms [ ] . prolonged and intense viremias were reported during acute encephalitis and hemorrhagic fever. thus, testing of serial patient specimens collected to h apart may have prognostic value in determining patient outcome. the decrease in viral loads coincides with a rise in rvfv specific igm and igg antibodies that may be testing using elisa. the presence of igm antibodies appears as an early transient response (day to ) and protective igg antibodies persist for several years [ ] . a second convalescent blood sample collected - days after the first is necessary to confirm the seroconversion making a definitive diagnosis of a recent rvf infection. in case of delayed-onset of encephalitis or ocular complications, imputation to rvfv may be difficult if only igg are identified in blood at this stage. in human cases with encephalitis, specific igm and igg can be detected in csf [ , ] . no positive rvfv cultures or rt-pcr have been reported in csf, or on aqueous or vitreous samples and should be further tested. management of rvf human cases comprises ipc measure implementation and general supportive therapy. no specific treatment is currently available. iatrogenic use of medications such as hepatotoxic analgesics (acetaminophen), aspirin or non-steroid anti-inflammatory drugs, which enhance the risk of hemorrhagic complications, must be avoided in the early stage. co-infections or alternative diagnosis with parasitic, bacterial, fungal or viral pathogens must be considered and treated as early as possible to improve the outcome. severe patients should be treated empirically with broad spectrum antibacterial drugs and antimalarial molecules according to the local epidemiology. in , the saudi arabian ministry of health evaluated the feasibility of a randomized, placebo-controlled trial using intravenous ribavirin in patients with suspected severe rvf, but no official result was published. in a who report of the emerging and dangerous pathogens laboratory network in , it was briefly mentioned that ribavirin was used without efficacy in saudi arabia [ ] . evidence suggests ribavirin efficacy in animal models [ , ] , but it failed to prevent from neuropathology in mice infected by rvfv by aerosol exposure [ ] . ribavirin is recommended for the treatment and the prophylaxis of hemorrhagic fever due to arenaviruses and bunyaviruses [ ] and was successfully used to cure and prevent from lassa fever [ ] . to date, its use is not indicated when rvf diagnosis is confirmed [ , ] . antiviral drugs are under development including favipiravir t- , ′-fluoro- ′-deoxycytidine ( ′-fdc), and benzavir- [ ] [ ] [ ] [ ] . molecules targeting viral components, host cellular components or pathways, such as the ubiquitin proteasome system, autophagy system, kinases and oxidative stress responses, have demonstrated in vitro efficacy against rvfv [ ] . the use of polyclonal immunoglobulins or serum of recovered patients has not been reported. specific monoclonal neutralizing antibodies could be developed in the coming years [ ] . to date, liver transplantation has never been attempted in rvfv fulminant hepatitis. in case reports of encephalitis, the use of amantadine, rifampicin, and dexamethasone [ ] , doubled prednisone doses with a stop in immunosuppressive drugs [ ] , and phenytoin [ ] were reported but not evaluated precisely. early renal substitution therapy in patients with severe acute renal failure improve the prognosis and survival [ , , ] . for eye involvement, artificial tear preparations may maintain corneal lubrication and provide temporary comfort for ocular irritation. topical ophthalmic steroids were used in the rvfv anterior segment manifestations [ ] . aciclovir was used in eyes lesions of other mosquito-transmitted viral disease notably chikungunya, dengue and west nile (table ) [ ] . other antiviral drugs (e.g. ganciclovir, foscarnet) could be administrated through intravitreal routes. in case of elevated intraocular pressure, antiglaucoma medications could be useful. ocular surgery including cataract removal, retinal hole and detachment repair, vitrectomy, and laser ablation for neovascularization could be additional therapeutics to be evaluated. based on the clinical and biological scoring system for the prognosis of rvf established by adam et al. [ ] , the cdc definitions of suspected severe rvf cases during the major epidemic in saudi arabia in [ ] , the updated guidelines for health workers [ ] , and clinical series in literature [ , , , , , , ] , we propose an algorithm to help clinicians at the bedside in the classification and referral of patients during a rvf outbreak (fig. ) . using the dengue model for case management, we identified clinical and biological warning signs defining complicated cases at risk of severe illness and requiring hospitalization for medical supervision, as we already proposed for chikungunya [ ] . severe illness included hemorrhagic fever, neurological disorders or hepatic/ renal failures requiring intensive cares. ocular signs were classified as complications. ophthalmologic examination should be prospectively performed in all confirmed cases to detect early asymptomatic rvfv ocular signs and evaluate their potential ability to predict the occurrence of neuro-ophthalmologic complications. this should at least include visual acuity determination, intra-ocular pressure measurement, slit-lamp biomicroscopy and funduscopy by indirect ophthalmoscopy. in case of rvf signs, a fluorescein angiography should be performed as well as fundus photography if available. indocyanine green angiography has not been evaluated yet in fvr ocular manifestation but could possibly bring arguments for a choroidal involvement since a delayed peripapillary choroidal filling in the arteriovenous phase of fluorescein angiography has been described [ , ] . optic coherence tomography (oct) is a recent technique that is yet to be evaluated in the retinal complications of rvf. oct could be helpful to describe the retinal lesions and their evolution through time, and could help elucidate the nature of the macular exudate-like lesions described before [ ] . we recommend to follow-up rvf patients for at least month after the onset of symptoms to monitor for possible delayed neurological and/or ocular complications. in the lack of adequate medical support, considering the diversity and time course of rvf complications, medical evacuation of confirmed cases may be considered, except if hemorrhages because this presentation is a highly contagious vital emergency. rift valley fever has emerged and extended outside africa in the s, leading to the re-description of the human disease. there is a global concern about the risk of rvfv exportation in areas where competent vectors are present including europe and north america. economic losses, human morbidity and mortality may be significant during epidemics. infection with rvf has a wide clinical spectrum and may result in delayed complications. there are no commercially licensed vaccines nor antiviral treatment for humans. human cases are often detected when the virus has already spread among livestock and people, hence outbreak control is challenging. thus, human case surveillance systems for early detection and correct management are essential to reduce global morbidity and mortality. we proposed a tool for physician guidance on the field. this algorithm should be evaluated during ongoing and coming outbreaks, and could help neighboring places in the detection of cases. we identified frontiers of knowledge and remaining uncertainties concerning rvf which deserves more interest. in particular, therapeutic trials on specific supportive care, antiviral molecules or immunotherapies, should be anticipated to be implemented at the start of future epidemics. enzootic hepatitis or rift valley fever. an undescribed virus disease of sheep cattle and man from east africa a review of mosquitoes associated with rift valley fever virus in madagascar rift valley fever in namibia rift valley fever rift valley fever: biology and epidemiology biosafety in microbiological and biomedical laboratories (bmbl), th edn. cdc laboratory portal mosquitoes of north-western europe as potential vectors of arboviruses: a review rift valley fever virus (bunyaviridae: phlebovirus): an update on pathogenesis, molecular epidemiology, vectors, diagnostics and prevention tracking rift valley fever: from mali to europe and other countries relevance of rift valley fever to public health in the european union the first imported case of rift valley fever in china reveals a genetic reassortment of different viral lineages emerging rift valley fever in china: what should be known? competence of mosquitoes native to the united kingdom to support replication and transmission of rift valley fever virus national center for foreign animal and zoonotic disease defense advisory group on rift valley fever. potential effects of rift valley fever in the united states entomological risk factors for potential transmission of rift valley fever virus around concentrations of livestock in colorado rift valley fever and a new paradigm of research and development for zoonotic disease control epidemic rift valley fever in egypt: observations of the spectrum of human illness more deaths from rift valley fever in saudi arabia and yemen epidemiologic and clinical aspects of a rift valley fever outbreak in humans in tanzania rift valley fever: new outbreak in mayotte recent outbreaks of rift valley fever in east africa and the middle east. front public health preferred reporting items for systematic review and meta-analysis protocols (prisma-p) world health organization (who) outbreak summaries rift valley fever a systematic review of rift valley fever epidemiology - rift valley fever on the east coast of madagascar the epidemiology of rift valley fever in mayotte: insights and perspectives from years of data rift valley fever, mayotte rift valley fever in humans and animals in mayotte, an endemic situation? fièvre de la vallée du rift: cas humains signalés à mayotte an epidemiological model of rift valley fever an epidemiological model of rift valley fever with spatial dynamics the failure of r the pathogenesis of rift valley fever avec la participation de la cire réunion-mayotte et l'institut de veille sanitaire (invs). rift valley fever rift valley fever virus infections in egypt: pathological and virological findings in man rift valley fever ocular manifestations: observations during the epidemic in egypt rift valley fever epidemic in saudi arabia: epidemiological, clinical, and laboratory characteristics rift valley fever outbreak-kenya update: outbreak of rift valley fever saudi arabia severe rift valley fever may present with a characteristic clinical syndrome rift valley fever affecting humans in south africa: a clinicopathological study severe hemorrhagic form of rift valley fever in mauritania severe presentations of rift valley fever in madagascar epidemic rift valley fever in saudi arabia: a clinical study of severe illness in humans sequential rift valley fever outbreaks in eastern africa caused by multiple lineages of the virus has rift valley fever virus evolved with increasing severity in human populations in east africa? rapid accumulation of virulent rift valley fever virus in mice from an attenuated virus carrying a single nucleotide substitution in the m rna complete genome analysis of ecologically and biologically diverse rift valley fever virus strains reveals widespread virus movement and low genetic diversity due to recent common ancestry rift valley fever virus: unanswered questions factors associated with severe human rift valley fever in sangailu using a field quantitative real-time pcr test to rapidly identify highly viremic rift valley fever cases association of symptoms and severity of rift valley fever with genetic polymorphisms in human innate immune pathways rift valley fever the pathogenesis of rift valley fever virus in the mouse model liver involvement in patients with moderately severe rift valley fever ultrastructural pathology of human liver in rift valley fever pathologic studies on suspect animal and human cases of rift valley fever from an outbreak in eastern africa severe human illness caused by rift valley fever virus in mauritania hemorrhagic forms of rift valley fever in mauritania clinical studies on rift valley fever, part i: acute febrile and hemorrhagic-like diseases development of a clinical and biological scoring system for the prognosis of rift valley fever mild clinical forms of rift valley fever during the epidemic in mauritania rift valley fever hepatitis complicated by disseminated intravascular coagulation and hepatorenal syndrome risk factors for severe rift valley fever infection in kenya severe hemorrhagic forms of rift valley fever: about cases rift valley fever viral load correlates with the human inflammatory response and coagulation pathway abnormalities in humans with hemorrhagic manifestations rift valley fever encephalitis neurologic and neurosensory forms of rift valley fever in mauritania rift valley fever encephalitis. a description of a case clinical studies on rift valley fever. part : ophthalmologic and central nervous system complications rift valley fever in kidney transplant recipient returning from mali with viral rna detected in semen up to four months from symptom onset, france, autumn . eurosurveillance aerosol exposure to rift valley fever virus causes earlier and more severe neuropathology in the murine model, which has important implications for therapeutic development aerosolized rift valley fever virus causes fatal encephalitis in african green monkeys and common marmosets emerging infections of cns: avian influenza a virus, rift valley fever virus and human parechovirus neutrophil and macrophage influx into the central nervous system are inflammatory components of lethal rift valley fever encephalitis in rats peripheral blood biomarkers of disease outcome in a monkey model of rift valley fever encephalitis vascular permeability in the brain is a late pathogenic event during rift valley fever virus encephalitis in rats acute renal failure associated with the rift valley fever: a single center study rift valley fever in man, complicated by retinal changes and loss of vision macular changes in rift valley fever ocular complications of rift valley fever outbreak in saudi arabia systemic viral infections and their retinal and choroidal manifestations potential for autoimmune pathogenesis of rift valley fever virus retinitis ocular pathology: role of emerging viruses in the asia-pacific region-a review posterior segment manifestations of rickettsia conorii infection new infectious etiologies for posterior uveitis lymphoplasmacytic endotheliitis and anterior uveitis in sheep infected experimentally with rift valley fever virus rift valley fever: a sero-epidemiological survey among pregnant women in mozambique rift valley fever as a possible cause of human abortions association of rift valley fever virus infection with miscarriage in sudanese women: a cross-sectional study case report: rift valley fever with vertical transmission in a pregnant sudanese woman vertical transmission of fatal rift valley fever in a newborn an outbreak of rift valley fever in northeastern kenya, - rift valley fever among children and adolescents in southwestern saudi arabia isolation precautions. guidelines library. infection control the risk of nosocomial transmission of rift valley fever standard precautions in health care fièvre de la vallée du rift en afrique: aspects cliniques chez l'homme enhanced efficacy of liposome-encapsulated ribavirin against rift valley fever virus infection in mice prospects for treatment of viral hemorrhagic fevers with ribavirin, a broad-spectrum antiviral drug bichat guidelines for the clinical management of haemorrhagic fever viruses and bioterrorism-related haemorrhagic fever viruses review of the literature and proposed guidelines for the use of oral ribavirin as postexposure prophylaxis for lassa fever anti-rift valley fever virus activity in vitro, pre-clinical pharmacokinetics and oral bioavailability of benzavir- , a broad-acting antiviral compound t- ) protects against peracute rift valley fever virus infection and reduces delayed-onset neurologic disease observed with ribavirin treatment ′-fluoro- ′-deoxycytidine is a broad-spectrum inhibitor of bunyaviruses in vitro and in phleboviral disease mouse models lethal mutagenesis of rift valley fever virus induced by favipiravir recent advances in the development of antiviral therapeutics for rift valley fever virus infection a protective monoclonal antibody targets a site : • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research: over ready to submit your research ? choose bmc and benefit from: of vulnerability on the surface of rift valley fever virus ocular manifestations of mosquitotransmitted diseases french guidelines for the management of chikungunya (acute and persistent presentations) the role of optical coherence tomography angiography in the management of uveitis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors are very thankful to julien ripamonti for his precious help in figures.marseille, france. authors' contributions ej made the literature review and wrote the first draft. al made literature review and wrote the draft on ocular diseases and built table . gh reviewed and corrected the ophthalmological part of the draft. vps, fl, gt are the epidemiologists involved in the response to rvf cases in soldiers in mayotte, they provided epidemiological data, asked for questions to clinicians and reviewed the draft. tl was the french military physicians deployed in mayotte who was at the origin of this work. gd and ilg from the french national reference center for arboviruses, confirmed cases in mayotte and helped in the discussion and the draft for the biological part. fs is national referent in infectious diseases for the french armed forces; he managed the working group, helped in the selection of references and the algorithm development. he reviewed and corrected the draft. all authors read and approved the final manuscript. authors did not receive any funding for this work. not applicable. not applicable. not applicable. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential competing interests. key: cord- -t w cdr authors: nan title: royal academy of medicine in ireland date: - - journal: ir j med sci doi: . /s - - - sha: doc_id: cord_uid: t w cdr nan the tuberculin-skin-test is the most commonly used test to screen for tuberculosis worldwide. in most cases it is administered by the most junior member of the medical team. there is some anecdotal evidence to suggest that junior doctors have limited knowledge of how to administer and interpret this test correctly. the aim of this audit was to assess the proficiency of interns and senior-house-officers in st. vincent's university hospital at performing the tuberculin-skin-test and improve standards. a multiple choice questionaire was used to assess doctors' knowledge of tuberculin-skin-test administration, interpretation, alternatives and the availability and awareness of information regarding the tuberculin-skin-test within the hospital. interns and senior-house-officers were assessed. of those questioned . % correctly identified intradermal as the method of administration. . % knew to correctly assess the induration at - h, but only % knew that the induration should be measured across the forearm. only . % were aware of the information leaflet within the hospital. . % of senior-house-officers correctly identified intradermal injection as the method of administration. it is apparent that the tuberculin-skin-test is often administered and/or interpreeted incorrectly. we recommend formal teaching for junior doctors in this area, coupled with improved availability of the information leaflet. mucinous tubular and spindle cell carcinoma (mtscc) is an extremely rare type of kidney tumour that has only recently been described, with less than eighty cases in the literature. this was only recognized as a specific entity in the world health organization classification of renal cell carcinoma (rcc). mtsccs are polymorphic renal neoplasms characterized by small, elongated tubules lined by cuboidal cells with cords of spindled cells separated by pale mucinous stroma. we report the case of a -year old lady who had an incidental finding of a mass in her right kidney. the radiological features were consistent with a rcc and following a multidisciplinary team discussion she underwent a laparoscopic radical nephrectomy. macroscopic examination revealed a well circumscribed . . right lower pole mass. histologically it was composed of elongated tubules, small tubules and papillary structures with a necrotic centre. the cells demonstrated cuboidal and spindle cell morphology. histological grade was fuhrman grade . subsequent ct thorax abdomen and pelvis staged the tumour as pt b. the majority of mtsccs are indolent, and there is only one report of a distant metastasis which responded favourably to adjuvant sunitinib. to date there is no international consensus on long term surveillance of these patients. due of the favourable prognosis with this type of tumour, mtscc must be differentiated from papillary renal cell carcinoma to avoid administration of excessive adjuvant treatment to patients. this is the first recorded case of this recently classified, rare tumour in ireland. this incidental finding of solid pseudopapillary neoplasm (spn) was discovered when a -year-old female underwent a chest x-ray to investigate a wheeze. a subsequent ct abdomen revealed a cm well circumscribed mass adjacent to the tail of the pancreas. this neoplasm had reached a significant size of cm appreciable on radiological imaging and yet was asymptomatic and not palpable on physical examination. laparatomy revealed a highly haemorrhagic and calcified mass emanating from the pancreas. this was adherent to the omentum, distal pancreas and splenic vessels. distal pancreatectomy was performed with en bloc resection of the mass. repeated ct scans at , and months failed to demonstrate recurrence. solid pseudopapillary neoplasms are rare entities accounting for between . and . percent of pancreatic tumours. this neoplasm has a predilection for females under the age of . these tumours are indolent and usually reach a large size before detection. diagnosis is confirmed on histology and complete surgical excision of localised tumours is curative. we aimed to assess the prevalence of smoking among patients with vascular disease and the role of the health care profession in encouraging smoking cessation. patients who attended the vascular outpatient department were surveyed over a month period in . patients gave verbal consent to partake in the audit and the surveyor entered the responses into a standardised questionnaire response sheet. % of patients were current smokers, % ex-smokers and % had no history of smoking. % smoke over cigarettes per day and % had a smoking history spanning over years. just % of smokers who are under the care of the vascular service have been advised to give up smoking in the past by a healthcare professional. smoking has long been established as a major modifiable risk factor for the development of atherosclerosis however % of patients attending the vascular service continue to smoke. just half of patients who were offered smoking cessation advice found it was effective. therefore a system needs to be put in place where all vascular patients are advised of the benefits of smoking cessation and the manner in which information is dispensed needs to be revised. to investigate the optimum location for the teaching of procedural skills to medical students english n, o'flynn s introduction: procedural skill training is a vital component of medical education. traditionally it has been teaching hospital based however general practice rotations may provide greater opportunities than previously thought. aims: this study aimed to ascertain whether a general practice setting or a teaching hospital setting provided a better environment for acquiring procedural skills in terms of opportunity to practice and the variety of skills performed. the correlation between end of year osce results and the amount of procedural skill exposure was also looked at. methods: a cross-sectional quantitative study which included all rd year medical students at ucc was conducted. a log book listing procedural skills was made available to all students before beginning both general practice and teaching hospital rotations. students were instructed to indicate on the log when they performed any of these skills and in which location. logs were returned to medical school. data was obtained and analysis performed using spss . results: a response rate of % was achieved. . % of students performed more skills at the gp setting. . % (n = ) did not perform any skills while in a teaching hospital . skills were performed significantly more frequently in a gp setting while were performed more frequently in a teaching hospital. students who performed a high number of skills in one location were no more likely to perform a high number in the other. conclusions: students were able to take greater advantage of procedural skills opportunities in a gp setting. as this was the students first clinical year it is likely that the one-to-one teaching scenario provided them with a more suitable location to practice skills for the first time. this study also highlighted the diverse nature of procedural skills which a general practice setting can provide. accuracy of sentinel node biopsy in determining the requirement for second axillary surgeries in t -t breast cancer with retrospective application of z criteria background: lymph node status is the most important prognostic marker in breast cancer management. in tandem with breast conser-vative surgery, surgical approaches to the axilla have also become less invasive thus decreasing the morbidity associated with axillary clearance. the acosog z trial reported no difference in survival in patients undergoing sentinel lymph node biopsy (slnb) alone versus axillary lymph node dissection (alnd) in t -t tumours. our aims were to establish whether sentinel lymph node biopsy was a true representative of axillary burden. we also analysed whether retrospective application of criteria from z trial would have prevented patients undergoing second axillary surgery. methods: all patients with t -t tumours undergoing sentinel node biopsy were included in our study (n = ). analysis of our prospectively updated breast cancer database was performed. minitab version . was used to carry out statistical analysis of the data results: slnb procedures for t & t tumours were performed over a year period. patients were reported as histologically negative and were positive. of the lymph node positive group, patients progressed to axillary clearance. staging of patients remained unchanged with only patients having [ axillary lymph nodes reported as positive. patients from the slnb negative group also had an axillary clearance. of these patients had further axillary disease with patient being upstaged having [ axillary lymph nodes positive. with retrospective application of z criteria % of patients would have avoided second axillary surgery. conclusions: sentinel node biopsy is a strong indicator of axillary tumour burden. this study highlights the accuracy of sentinel lymph node biopsy in staging disease and representing overall tumour burden. flaherty ra, kelly bd, coyle d, quinlan mr, d'arcy ft, rogers e, jaffry sq we report the first case of a spontaneous right nephrocutaneous fistula (ncf) with an accompanying fistula limb communicating with the right ureter. a -year-old man presented with a groin mass, which was initially diagnosed as a hernia. he was scheduled for an inguinal hernia repair. upon incision there was extravasation of urine from the wound and the procedure was abandoned. a ct urogram identified a ncf running from the right lower pole calyx, anterior to the psoas muscle and emerging on the right groin skin with an accompanying fistula limb communicating with the right ureter. during the course of investigation it was discovered that the patient was suffering from chronic indolent calculus pyelonephritis which led to the formation of both aberrant pathways from the kidney and the ureter and that both had calculi located at their origins. the patient was first treated with a nephrostomy and ureteric stenting to relieve urinary obstruction and after this failed to resolve the fistula, was successfully treated with percutaneous nephrolithotomy for removal of the calculi and fibrin glue injection into the fistula. this case is one of only a few reported cases of spontaneous nephrocutaneous fistula and the anatomy of the fistulous tract in this case is very unusual and posed a particular challenge for surgical management. this case report further advocates the use of fibrin glue in the management of complicated ncf. this is a retrospective case study. there were six cases of ocular tuberculosis over the year period, one annually, four of whom are women, with ages ranging from to years old. two were foreign-born. all patients presented with reduced visual acuity. four developed posterior uveitis, one anterior uveitis and one panuveitis. this was also complicated by vitritis, retinal detachment and retinal vasculitis in four. the median duration of symptoms until commencement of treatment was months. all cases had a positive mantoux and one case had evidence of pulmonary tuberculosis on chest x-ray. tuberculosis was isolated in two cases. the intended duration of anti-tuberculous therapy for all patients was months. vision improved in all cases. ocular tuberculosis is rare in developed countries, with prevalence ranging from \ to %. however, it is important to be considered in all cases of uveitis. despite the use of pcr, most cases are presumptive. this leads to delayed commencement of therapy causing further complications. a high index of suspicion is required. we describe the case of a -year-old gentleman who presented to our emergency department (ed) with a very unusual complication of central venous catheterisation. this resulted in spontaneous extrusion of a retained intravenous guide wire from the base of the occiput. this has been described only once previously in the literature, but not at such a delayed time interval from insertion [ ] . this -year-old gentleman presented to the ed reporting that he felt the point of a sharp object irritate his finger in his midline occipital area. he had successfully retrieved approximately cm of a thin metal wire. he had a history of rheumatic fever and had undergone an elective aortic valve replacement years previously, necessitating central venous cannulation. he had remained asymptomatic up to this time. plain radiography of his neck revealed a short segment of wire in the posterior spinal musculature. this segment of wire (approximately cm) was removed manually with minimal force and minor manipulation. the procedure was uncomplicated and the patient was discharged shortly afterwards. retained foreign bodies may migrate slowly over many years eventually extruding from the body, without any serious complications. events such as retained or lost guide-wires are rare. this phenomenon may become more frequent with increasing complexity of medical care and with increasing use of cv catheters in the treatment of sepsis and other emergent critical conditions. physicians should be aware of the possibility of retained foreign bodies and should be somewhat re-assured by reports of simple uncomplicated removal. we present the case of a -year-old gentleman who was recently admitted with symptomatic right heart failure and new onset atrial fibrillation. our patient had been treated in the community for symptoms suggestive of ccf but had not previously been investigated. of note, he has no history of a chronic inflammatory condition and no symptoms suggestive of an underlying neoplastic process. on presentation he was also noted to have evidence of an arthropathy affecting his knees and ankles and bipedal oedema. renal function was abnormal with a urea of . and a creatinine of . urinalysis was positive for protein and h urine collection for protein is ongoing. liver enzymes were also elevated and revealed a cholestatic picture. echocardiogram showed a reduced ejection fraction of % and findings consistent with amyloidosis. biopsy of abdominal fat pad at time of writing is pending. amyloidosis refers to an uncommon group of disorders characterised by extracellular tissue deposition of a variety of proteins in an abnormal fibrillar pattern which are resistant to degradation. it can occur alone (primary) or can complicate many chronic inflammatory conditions (secondary). the major sites for clinically reported amyloid deposition are the kidneys, heart and liver. clinically patients present more often with right heart failure; pulmonary oedema is rare. amyloid infiltration results in increased echogenicity on echocardiogram and gives a ''sparkling'' appearance to the myocardium. biopsy is diagnostic. this was achieved using a retrospective review of all children receiving gh therapy (n = ) over a -year period (october -october ). of patients on gh therapy had ghd. of these, had ighd ( male) and had cphd ( male). all had appropriate work-up and follow-up. age at presentation to endocrinology was older in the ighd group (mean . years) than in those with cphd (mean . years). / children with ighd presented with short stature, compared to only with cphd; the remainder presenting with clinical features of other pituitary hormone deficiencies. the mean height centile at diagnosis was lower in the ighd group ( . th) versus the cphd group ( th). mri brain/pituitary was abnormal in the majority of patients ( / ) with cphd, compared with / with ighd. both groups responded well to treatment and height increased by one centile on average at months. all patients diagnosed with ghd at temple st had appropriate work-up and follow-up. children with ighd presented later than those with cphd, and had shorter height centiles at diagnosis. there was a strong male predominance in children presenting with ighd, which may reflect psychosocial factors. structural pituitary abnormalities were more common in those with cphd, and their clinical presentation was more varied. response to therapy was similar in both groups. background: out of hospital cardiac arrests have poor survival rates approx - %. improving outcomes in ireland have been seen in the past decade. better outcomes are seen if arrest is witnessed and when bystander basic life support was initiated. worse prognosis is seen in a rural setting due to delay in paramedic response times and in administration of advanced cardiac life support. case report: a -year-old donegal male experienced chest pain in his rural home and subsequently cardiac arrested. his spouse, whom months prior had trained in basic life support as part of a fas course contacted the 'out of hours' gp and ambulance service and commenced cpr. the gp failed to reach the house and the first ambulance broke down. on arrival of second ambulance, one person cpr had been administered for [ min. paramedics delivered dc shocks and intubated the patient. in the regional hospital pc was admitted to the intensive care unit for days being managed with acute respiratory distress syndrome (ards). transoesophageal echocardiogram on day of admission showed ef %. ct brain carried out showed no acute pathology. once stable, angiography was carried out showing multivessel disease. discussion at st james's hospital (sjh) cardio-thoracic conference resulted in plan for transfer and pci. in sjh pressure wire study of left anterior descending (lad) coronary artery was positive and stenting (drug-eluting) commenced. lad stents, left circumflex stents and right coronary artery (rca) stents. patient is currently well with no overt signs of hypoxic brain injury and is enrolled in cardiac rehabilitation programme. discussion: this is an incredible case of an out of hospital cardiac arrest. elapsed time in the chain of survival events would predict a negative outcome. however, adequate cpr was administered preventing long term brain injury and certain death. this highlights the need for a greater community-based cpr skill base. recently citalopram and escitalopram have been reported to cause dose dependent qtc prolongation. prescribing guidelines have since changed including contraindication of co-prescription with other qtc prolonging agents. domperidone is a dopamine antagonist widely used as an anti emetic. qtc prolongation and ventricular arrhythmias have also recently been highlighted with domperidone and, since november , caution advised when prescribing domperidone, particularly in patients [ years of age, or at doses [ mg/day. in this audit, we aimed to study whether information on qtc prolongation affects prescribing practice by looking at the prescription of a commonly used medical drug, with recently highlighted qtc effects, and its co-prescription with psychotropics. a list of drugs with substantial evidence for qtc prolonging effects was obtained. a kardex review was completed from acute medical and surgical; long stay and rehabilitation wards. kardexes with domperidone were reviewed for dose, age, gender and co-prescription of other qtc prolonging agents. of surveyed kardexes, % (n = ) were prescribed domperidone. % were[ years. % were on[ mg/day. coprescription with another qtc prolonging agent seen in % of cases; of these % were psychotropics, most commonly citalopram (n = ). four patients were co-prescribed [ qtc prolonging agent. qtc prolonging agents were commonly co-prescribed with domperidone, which continues to be used even in at-risk groups. psychotropics were the most likely class to be concurrently prescribed. further work in this area is necessary to inform clinical psychiatric practice and encourage responsiveness to new evidence regarding cardiac risk. the development of a mathematical model to predict the time to osteoporosis (tto) using dexa scanning background: dual-energy x-ray absorptiometry (dexa) is the gold standard used for measuring bone mineral density and such readings are currently used to predict osteoporosis and osteoporotic fractures. however, no similar prediction model has been developed to identify the time it will take to become osteoporotic based on dexa scanning. objective: the aim of this study was to develop a mathematical model to determine the tto based on two or more dexa scans with tto defined as the age at which the patient will enter the osteoporotic t-score range. methods: fifty patients who had previously undertaken five dexa scans were identified from the dexa database. t-scores were graphed against patient age using graphpad prism software. straight line curves for the most recent scans and cumulative scans were generated with the age at which the curve intersects t = - . being classed as tto. results: the mathematical model developed successfully predicted the time to osteoporosis for each patient, as well as creating a cumulative osteoporotic trend based on total dexa scans performed. additionally, if the patient was classified as osteoporotic following dexa scanning, the model also successfully predicted the time out of osteoporosis. implication: the tto provides a simple and informative parameter of dexa scanning that a patient can immediately comprehend and understand, while also providing a more simple measure to monitor response to therapy. based on the results presented tto can be incorporated into future dexa scans result summaries. further research will involve validation of this tool. an audit of clinical outcomes in transcervical resection of the endometrium compared to outpatient balloon thermablation anglim bc, von bunau g department of gynaecology, adelaide and meath children's hospital, tallaght, dublin thermablation was introduced to the coombe in november and thus far it has provided a quick and effective means of treating women with menorrhagia refractive to medical treatment. a retrospective audit was carried out over a year period in tallaght hospital from november to october . the aim of the study was to compare the efficacy of balloon thermablation compared to transcervical resection of the endometrium (tcre) with or without mirena coil insertion, in the treatment of menorrhagia. patients in total were studied, of which underwent a tcre, and of which underwent balloon thermablation. out of those who underwent a tcre had successful treatment of the menorrhagia and and weekly follow up, had continued menorrhagia which may require a future hysterectomy, however one of which was due to a large fibroid, and one patient described a reduction in menorrhagia however an increase in dysmenorrheoa. out of those who underwent thermablation were treated successfully, had continued menorrhagia to be considered for hysterectomy, had reduced bleeding but increased dysmenorrhoea and one patients symptoms had resolved however she then developed idiopathic thrombocytopenia purpura which led to a recommencement of symptoms. one can therefore conclude that there are both pros and cons to both procedures, tcre being less expensive, however it requires general anaesthesia and may require mirena insertion. thermablation is more expensive however it is a quick outpatient procedure ( min, s) and is done under local anaesthetic. akinmoluwa s, tormey s department of breast surgery, mid-western regional hospital, limerick breast pain is a common problem especially among women of reproductive age. it accounts for a great percentage of gp visits by young women. it represents a huge proportion of gp referrals to the breast clinic. the palpable effects of this include, among others, an increase in waiting time, increase in healthcare cost, stress on the limited resources and ultimately a decrease in quality of care. in this era of unfavorable economic climate, it is prudent to sanitise our healthcare systems by way of identifying and eliminating practices that have not been proven to alter the course of care. in this study, i reviewed the number of breast pain cases referred to ms tormey's breast clinic in the month of march. the objective of this study is to determine whether or not all breast pain complaints should be referred for specialist review. to achieve this objective, i reviewed all the cases of breast pain referred to the breast clinic in march. the table represents my findings. it is evident from the study that hormonal mastalgia accounts for majority of breast pain complaints in women of reproductive age while a few other cases are attributed to musculoskeletal and other benign disorders. these women, with no risk factors, only need reassurance and pain relief. they do not require specialist intervention. alrashed d introduction: anaemia is a common finding in the elderly population. it may be a sign of chronic disease, underlying malignancy, nutritional status, or blood loss. depending on the classification of anaemia, further investigations such as haematinics and endoscopy may be warranted, as replacing the haemoglobin deficit is never a definitive treatment. objective: to determine the prevalence of anaemia in a population of elderly in-patients and whether further screening was performed. methods: this was a cross-sectional review of all patients years and older under a gastroenterology, a rheumatology, and three geriatrics services at a large teaching hospital. patients' full blood counts were reviewed during their current admission. anaemic patients were then categorised based on anaemia subtype and whether haematinics were investigated. results: out of patients under the five teams, were years and older. out of of these elderly patients were anaemic. none of these subjects had microcytic anaemia during their current admission. out of of these patients had normocytic anaemia. out of of anaemic patients had macrocytic anaemia. haematinics were investigated in out of , including out of patients with normocytic anaemia and out of patients with macrocytic anaemia. one patient had abnormal haematinics after being investigated for macrocytic anaemia. conclusion: anaemia was very prevalent in the patients selected for this audit, with the normocytic subtype being the commonest. haematinics were investigated in half those patients. anglim b, murphy c aims: to determine the nature of surgical management of ovarian cysts in the adolescent and paediatric population over a year period. methods: a retrospective audit was carried out over a year period in tallaght hospital from january to december . this audit reviewed cases of ovarian cystectomy, oopherectomy and salpingooopherectomy using both a hospital online database and records of theatre procedures to identify these patients. results: a total of cases were identified. the commonest presentation was due to pelvic pain. there was a total of ovarian cystectomies, fimbrial cystectomies, oopherectomies, bilateral oopherectomy, and salpingo-oopherectomies. a total of appendicectomies were performed in conjunction with these. histology varied from functional and non functional cysts to dermoids and cystadenomas. there were a total of functional cysts, of which were hemorrhagic. there were follicular cysts, fimbrial cysts, paratubal cysts, dermoid cysts, endometrial cysts, cystadenomas, ovarian torsions and fimbrial torsions. of the total amount of procedures performed were done by a paediatric surgeon, and by a gynaecologist. notably there were fewer cases of benign histology in those procedure performed by gynaecologists. conclusions: adnexal surgery is commonly performed in adolescents and children. pathology is frequently benign. there may be a role for more conservative management. we suggest that imaging of the pelvis and tumour markers should be used more frequently in the pre-operative period. protocols may be developed for future implementation. anglim bc, crowley p day surgery is an efficient way of using hospital beds, provided patients are discharged as planned on the day of surgery. unplanned overnight stay following day surgery places an extra burden on a hospital with the busiest accident and emergency department in ireland. a retrospective audit was carried out of one years day case admissions to determine the incidence and causes of unintended or unplanned overnight stay. women were admitted as day cases over the period of st july to june th . a total of diagnostic laparoscopies, operative laparoscopies, diagnostic hysteroscopies, ninety-three operative hysteroscopies, tension free vaginal tapes (tvt) and miscellaneous minor procedure were carried out during this time period. women ( . %) were retained overnight. the main reason for overnight stay was excessive post-operative pain. additional reasons included voiding difficulties, reactions to spinal anaesthetic, asymptomatic tachycardia and the need for intravenous antibiotics. there was no evidence of inappropriate selection amongst the laparoscopies and hysteroscopies, however % of the patients undergoing tvt required admission. one can conclude from this study that most patients were appropriately selected for day case admission. patients undergoing tvt surgery should be scheduled for a h hospital stay. a vulval clinic is an ideal and efficient way of detecting patients with vulval cancer. once potential patients have been flagged by general practice clinicians or other specialities within the hospital, immediate steps can be taken to rule out malignancy. a retrospective audit was carried over a month period on a new vulval clinic which commenced in tallaght hospital on / / . the aim of the study was to determine the need for a specialised vulval clinic for detection of vulval cancer. a total of patients were referred to the four clinics which took place over this time frame. the majority of referrals were from general practice, other referrals were from dermatology, gynaecology and colposcopy clinics. the main reason for referral was vulval pruritis and pain. nine patients were referred with suspicious lesions on clinical examination. a total of biopsies were taken, two of which showed vulval intraepithelial neoplasia (vin). amongst the other biopsies were cases of lichen sclerosis and the remaining biopsies showed non specific dermatitis. one can conclude from this study that a combined dermatological-gynaecological clinic would be of benefit. in addition a . % detection rate of vin was achieved and therefore highlights the necessity of this clinic. the prevalence of renal disease in patients aged above with normal serum creatinine balasubramanian i, peters c, lyons d and o'connor m department of ageing and therapeutics, mid-western regional hospital, limerick background: the prevalence of chronic kidney disease (ckd) increases with age. older patients have lower lean muscle mass and therefore using serum creatinine alone as marker of renal function can lead to underdiagnosis of ckd. objective: the aim of this study was to review the prevalence of ckd amongst a cohort of elderly patients with normal serum creatinine. methods: doctot application on the smartphone was used to calculate egfr in a cohort of patients over years with a normal serum creatinine on admission. patients were included. this application is based on the mdrd formula (includes age, sex, ethnicity and serum creatinine). patients were then classed into the various stages of ckd. results: of the patients reviewed, had renal disease. interestingly, only had a diagnosis of renal impairment recorded in the medical notes. of the patients had stage ckd and the other had stage ckd. of the patients with renal impairment especially stage , were found to be frail females over years. this group also had a number of co-morbidities including diabetes and hypertension. conclusion: egfr is better than serum creatinine alone for assessment of renal function in the elderly. it is important not only for diagnosis but also for appropriate medical investigation and drug prescribing. as the mdrd formula excludes bmi, further research is warranted to compare measurement of egfr using mdrd formula with the cockcroft and gault equation in this older population. chronic obstructive pulmonary disease (copd) is increasingly prevalent worldwide and the main responsibility for it's prevention and management lies with general practitioners. the aim of this audit was to analyse current standards of care of copd patients in a suburbanrural general practice by examining icgp criteria and comparing results with best practice guidelines. the existing coded population of active patients with copd were telephoned and consent was obtained to ask a set of questions designed to examine certain criteria chosen from the icgp copd quick reference guide [ ] . . of the patients included in the audit (n = ), % of patients were male, the mean age was years (sd = . ) and % were general medical service (gms) patients. there was poor recording of smoking status, high uptake of influenza vaccines compared to international figures, a lower uptake of pneumococcal vaccinations and an increased need for osteoporosis prophylaxis. vaccination reminders, smoking cessation advice and information leaflets have been posted to these patients. development of protocols for coding and management have been implemented. in conclusion, general practitioners must focus on ensuring optimum managment of copd in the community. clinical audit is a useful tool to initiate change. we assessed the accuracy of continuous non-invasive haemoglobin measurement using the sphb pulse co-oximeter Ò when compared to traditional laboratory haemoglobin assessment in an outpatient antenatal population. a total of women were recruited. traditional laboratory haemoglobin samples were taken and quantified in the hospital laboratory. the sphb pulse co-oximeter Ò was calibrated and the mean of three non-invasive measurements of haemoglobin were recorded prior to venipuncture. bland-altman plots were used to determine acceptability of the new non-invasive test as a replacement for invasive testing in a clinical setting. the mean gestation at haemoglobin estimation was . ( . ) weeks. laboratory haemoglobin values ranged from . to . g/dl with a mean of . ( . ) g/dl. the range for the sphb pulse co-oximeter Ò assessment was . to . g/dl with a mean of . ( . ) g/dl. non-invasive haemoglobin measurement provides a clinically acceptable accuracy compared to traditional haemoglobin testing. pressure wound therapy (npwt). in this review we examine the role of npwt in wound healing, compare the products available to clinicians in irish hospitals and explore cost implications today. we achieved this through review of online data, peer reviewed articles regarding efficacy, collection and assessment of data from suppliers of npwt and examining the use and cost of npwt in the mater misericordiae university hospital. we summarise the mechanism of action of npwt, patient selection and indications for its use. the products available on the irish market are compared. through examination of these elements we clarify a role of npwt in management of complex wounds and identify flaws in the management of this service that are both wasteful of money and hospital services and create barriers to discharge. potential strategies to correct the issues identified are detailed, for example, funding of the product by the treating hospital rather than by local authorities in the community or selection of less costly devices in negotiation with suppliers by local health authorities. the solutions we outline will potentially have a financial benefit to the hospital, will lead to the more efficacious running of the hospital system and as such will benefit the patient. we conclude that this is a fundamental service and that there are alternative approaches to implementing use of the product in a more efficacious manner. poster q fever: questions to be answered? brandon l, bannon c, fleming c department of infectious diseases, university hospital galway q fever, an aptly named condition, describes infection with gramnegative bacteria coxiella burnetti. q denotes a question, and there are many to be answered in this rare, but not unknown, condition. take mr. m.c, a -year-old farm worker, who had an aortic valve replacement in , for congenital aortic valvular disease. he next presented to medical services in , with fevers, sweats, fatigue and weight loss. investigations at the time diagnosed autoimmune hepatitis, following liver biopsy. he commenced prednisolone and azathioprine. in , again symptomatic, he had another aortic valve replacement. post-operatively, he required weeks of antibiotics for a culture negative valvular infection. in , still on immunosuppression, he developed culture negative meningitis, requiring weeks of antibiotics. azathioprine was discontinued. a renal biopsy revealed proliferative glomerular nephritis in , carried out for macroscopic haematuria. he commenced high dose prednisolone and cyclophosphamide. throughout this time, he regularly presented to medical personnel with high fevers, up to c, present since . they responded to steroids but relapsed on doses below mg. in , the fevers were investigated with a toe, and vegetations seen on the aortic graft. he was diagnosed with culture negative bacterial endocarditis, and subsequently tested positive for q fever. this case highlights the q behind q fever, and raises important issues for medical personnel. when should we remember it? when should we test for it? and what can we do to ensure high risk populations dont slip through the cracks, as this gentleman did? previous point prevalence studies of antimicrobial use in sch have consistently produced the same conclusions and recommendations pertaining to prescribing habits, highlighting doctors' failure to meet ideal standards of antimicrobial prescription. the aim of this study was to assess antimicrobial prescribing habits from the doctors' point of view, to compare this to available prescription data and to raise awareness of the principles of prudent antimicrobial prescribing. a multiple choice questionnaire was used to examine antimicrobial prescribing habits with regard to documentation of indication, documentation of a stop/review date, awareness of local empiric guidelines and other principles of prudent antimicrobial prescribing. trainee and consultant doctors were surveyed. of those questioned, % claimed they always ensure that an indication for commencing antimicrobial treatment is documented in the patient's healthcare record. only % always document a stop/ review date when prescribing antimicrobials, while % indicated that they had failed to do this at least once in the preceding month. % of those surveyed sometimes or never consult local guidelines. when switching patients from intravenous to oral therapy, % believed oral bioavailability to be an important factor, with only % citing cost as being relevant. identifying doctors self-reporting of their deficits allows us to target appropriate interventions to these deficits. our survey identifies areas where awareness of diverted resources and safety issues could be used as a fulcrum for changing prescribing practices. we recommend formal teaching for doctors in this area, with particular emphasis on prudent prescribing and the correct use of empiric guidelines. venous thromboembolism (vte) is a cause of inpatient morbidity and mortality which may be reduced by appropriate thromboprophylaxis. it is well established that vte risk assessment and thromboprophylaxis prescribing may often be inadequate. recently it has been estimated that as many as , deaths per year due to hospital-acquired vte in england may have been prevented with appropriate prophylaxis [ ] . in the current study, a cross section of inpatients was examined to establish concordance with current evidence-based guidelines for vte prophylaxis. data was collected from inpatient charts and drug kardexes relating to patients on three medical wards. laboratory data was also obtained from the hospital it system. data relating to patient mobility was obtained from medical charts, nursing staff, observation, and the patient themselves. sixty-three medical patients and surgical patients (including one patient under obstetrics and gynaecology) were included in the study. ( . %) out of at-risk medical patients who were suitable candidates for thromboprophylaxis had sub-cutaneous heparin prescribed, whereas out of of the suitable at-risk surgical patients were prescribed thromboprophylaxis. medical patients ( . %) and surgical patients ( %) were prescribed anti-embolism compression stockings. prescribing of thromboprophylaxis is relatively thorough in this patient population although it remains less than optimal. there exists some evidence of disagreement amongst clinicians regarding the optimum vte prophylaxis strategy [ ] . implementation of hospitalspecific guidelines regarding thromboprophylaxis is recommended in keeping with recognised guidelines [ ] . ali sheikh a, chandra r, gardezi a, o'hare j mid-western regional hospital, limerick background: good documentation represents good medical practice. objectives: to assess our current standard of documentation of allergy in admission notes, synchronicity with risk alert bands, information given by the patient, documentation on the front allergy alert section of medical notes and drug kardex. methodology: we assessed five parameters i.e. drug kardex, alert band, medical and admission notes and gathered information from each patient staying in medical and surgical services. there were patients in hospital. results: % of the patients admitted under medical and surgical teams had allergy or allergies to different drugs. % had single allergy, whereas % had multiple allergies. penicillin allergy was the commonest . % followed by opioids . %. furthermore, it is found that recording of allergies was under par as % was on front page and % appeared in medical notes. more than half of allergy information was found on drug kardex %, patient knowledge % and allergy bands %. it is well documented that use of elastic compression stockings (ecs) prevents post thrombotic syndrome in patients with prior deep venous thrombosis (dvt). a % reduction in these complications has been noted, with year duration of therapy suggested [ ] . the advice given to patients, their understanding of the benefits of this therapy and adherence issues has not been documented at sligo general hospital (sgh), this research aimed to address this. a short patient questionnaire was undertaken. this consisted of demographic information, and questions regarding the advice and use of ecs. the population consisted of patients with prior dvt attending the warfarin clinic at sgh. this data collection took place from october -february . the questionnaires were collated and results identified using microsoft excel with simple statistical analysis. eleven patients were included in the study, % were not advised to wear ecs, and only % wore the ecs daily. reasons for nonadherence include; difficulty fitting, discomfort and no benefit noted. improvement in adherence could be achieved if advice was given promoting use, the benefits explained, optimal frequency/duration of use advised and correct measurement. as research strongly supports use of ecs, it is essential adherence is encouraged to reduce the risk of post-thrombotic syndrome and future dvt. opiate injecting drug use is a well-established phenomenon in inner city dublin. the complications arising from this practice affect a predominantly young cohort of patients, who under different circumstances would be expected to enjoy good health. acute infections, acute vascular issues such as pseudoaneurysm, and chronic medical conditions such as hepatitis c and hiv are well recognised and frequently encountered by medical physicians who care for these patients. we present the case of a lady in her thirties with a long history of opiate injecting drug use. approximately months prior to presentation, she underwent left sided pseudoaneurysm repair. she presented to the emergency department in a drowsy opiate induced state. on waking, she stated that she had lost some needles while injecting into her groins. plain radiology of pelvis revealed the two ''lost'' needles ( fig. ) . on closer questioning she admitted to significant manipulation of the needle injecting path and angle in the weeks prior to presentation. she had attributed this to her previous surgery and the duration of her injecting drug use. follow-up duplex sonography revealed bilateral intact femoral arteries. further surgical management was non-operative with the focus on addiction counselling and further attempts at facilitating cessation of heroin use. bilateral ''lost'' needles is an unusual complication of injecting drug use and certainly would not rank as one of the protean manifestations of such practices. the aim of the study was to investigate patients' recall of their surgery and influencing factors. a questionnaire was given to patients at outpatient follow up and surgical details were recorded. patients completed the questionnaire. the median age was years (range - ) and the median follow up was months (range - ). the extent of surgery did influence patients' recall with those having an alnd (n = , %) having significantly more accurate recall of their surgery as opposed to those who had slnb (n = , %), p = . . the presence of ongoing postoperative symptoms also significantly improved recall, p = . . almost half the patients who had slnb ( . %) could not accurately remember the extent of the surgery they had but . % were more careful of their arm or would not allow cannulation. the patient's consent process influenced patient accuracy. patients who filled the consent at both the outpatient consultation and in the hospital were significantly more accurate than those who had signed the consent at the clinic or hospital alone, p = . . patients who have minimally invasive surgery, such as slnb are not accurate at recalling their surgery. this misinformation results in confusion over the subsequent vigilance of their upper limb. the consent process may have a role in improving patient recall. introduction: waiting times can exceed days for general surgical clinics and can reach up to months in different surgical specialities. many outpatient slots are lost by patients who do not attend (dna) to their scheduled appointment. we sought to ascertain whether a reminder text message (rtm) could decrease the number of patients who dna to surgical outpatients. methods: a single text message was sent to patients days before their scheduled appointment, reminding them of the date and time of their upcoming surgical outpatient visit. this incentive was initiated in january . outpatient appointment scheduling and attendances for a single surgical team were analysed over a year period, encompassing two month periods before and after implementation of the rtm service. data was exported to spss v for statistical analysis with p \ . considered statistically significant. results: over the month period there were , scheduled outpatient appointments for the surgical service, with attending prior to the implementation of the reminder text message service and the remaining attending in the months following its implementation. the percentage of dna patients did not differ significantly ( . classically, focussed assessment with sonography in trauma (fast) addresses a yes/no binary question as to whether fluid is present in the context of trauma. fast generally concentrates on four areas: perihepatic, peri-splenic, pelvic and a sub-xiphoid view of the pericardium. we report on two patients who were the victims of trauma. both patients had normal haemodynamic parameters. in both patients, the initial fast ultrasound scan was technically negative but it exhibited other signs of intraperitoneal injury. in the first case, a young gentleman sustained a penetrating injury to his right upper quadrant area. morison's pouch (the interface between the liver and the right kidney) did not exhibit any fluid. there was, however, a thin anechoic strip around the gallbladder. ct confirmed the suspicion of peri-cholecystic fluid and this patient required urgent laparotomy and repair of his hepatobiliary injury. in the second case, a gentleman in his thirties sustained a blunt injury to his left upper quadrant. ultrasonography exhibited heterogeneous echogenicity of the spleen. this patient proceeded to have urgent laparotomy and splenectomy for this shatter-type injury. as experience with fast techniques grows, the binary question of whether intra-peritoneal fluid is present becomes more nuanced. the objective of this audit was to review the hospitals compliance with hospital guidelines, to get an overview of how fluids are being prescribed in the hospital and to produce quality improvement plans. thirty drug kardexs were chosen randomly from wards around the hospital, both medical and surgical. if a kardex was found to have no fluid prescription, an alternative kardex was chosen in its place. note was taken on whether the prescription had the patient name and hospital number, the date, name, dosage and strength of the prescription, the route of administration and the frequency and rate of administration. the main areas of non-compliance were found to be: name: only ( . %)orders out of had the name on the order medical record number: only ( . %)orders out of had the mrn on the order, and the route of administration was not present on any of the orders checked. in conclusion, this audit would suggest that there is a lack of compliance with detailing the patients name and mrn on fluid orders, that the route of administration was not written on any kardex, however the back page of each is exclusively dedicated to iv fluid prescription and also that non-approved abbreviations are being used when prescribing fluid orders. spontaneous hip fractures, or fractures without a fall have been described in up to % ( , ) of cases of hip fracture. an upsurge in such cases was recently observed in our emergency department. we present these in the form of a retrospective case series. patient is a -year-old ex intravenous drug user who presented with non-traumatic right-sided hip pain over a period of weeks. initial plain films did not reveal fracture. over week her symptoms deteriorated to the extent that she became unable to weight-bear. patient is a -year-old gentleman with increasing left sided hip pain following a seemingly innocuous fall months prior to index presentation. again initial radiographs did not reveal an abnormality. patient is an -year-old bed-bound nursing home resident with end-stage alzheimer's disease. she was noted by nursing staff to have bilateral hip symptoms post seizure. the patient was unable to mobilise independently and had not fallen out of bed at any stage. patient is a -year-old lady who presented with unilateral sacroiliac pain following a recent intensive exercise program including kickboxing week previously. in each of these cases, subsequent review and plain films demonstrated fracture and in one case bilateral fractures secondary to seizure were demonstrated. our cases highlight the need for diagnostic vigilance and a structured approach in dealing with possible radiologically occult hip fractures, even in patients with no proximate antecedent history of trauma. delerium, or acute confusional state, is a common presentation to our emergency departments, and occurs in up to % of hospitalised patients. we describe the case of acute deterioration in mental status, on a background of alzheimer's disease, with an interesting aetiology. mr k's family sought emergency medical review of days deterioration; withdrawal, somnolence and general disorientation. he is a -year old with moderate alzheimer's disease. history and initial investigations were unremarkable. he was mildly dehydrated and physical exam showed only mild truncal ataxia. further investigations to elucidate cause included lumbar puncture, mri brain and immunological and vasculitic parameters. serology revealed human immunodeficiency virus (hiv) infection with acute seroconversion pattern. a history obtained with help of his family identified several casual heterosexual partners within past year. this included a contact who may be an intravenous drug user, with involvement in commercial sex work. symptoms abated within a week of admission, following pattern of hiv viral load. he has subsequently commenced antiretroviral therapy. this case highlights several areas of interest. sexual history is often overlooked in the older patient, which can be deleterious to outcomes. trends of hiv infection in ireland include primary infection in the older person, in addition to greater longevity of people infected in earlier adult life. we would advocate opt-out testing within the emergency department, and this is currently under study in our tertiary emergency department. comparison of comorbidities in patients with pre-diabetes to those with diabetes mellitus type the management of type diabetes and its complications are well researched. the prevalence of these complications in pre-diabetes has not been researched to the same extent. there has been no research comparing the prevalence of complications in pre-diabetes and type diabetes in ireland. a cross sectional study performed on pre-diabetes and type diabetes patients, selected from the diabetes interest group database (a database of the diabetic patients in general practices in cork region) using stratified sampling for age and gender. a questionnaire was designed and completed in each practice assessing the presence of diabetes related complications in pre-diabetes and type diabetes patients. data was analyzed on spss. the prevalence of complications was determined and the chi square test performed to see is there a statistically significant difference in the prevalence of these complications between pre-diabetic and type diabetic patients. the prevalence of ischaemic heart disease and autonomic neuropathy is actually higher in pre-diabetes but the prevalence of renal disease and cerebrovascular disease is higher in type diabetes. none of these differences in prevalence are statistically significant. the prevalence of peripheral vascular disease, eye disease and peripheral neuropathy is higher in type diabetes, this difference being statistically significant. the prevalence of many of the complications in pre-diabetes is as high as in type diabetes which may have implications for the screening and management of these conditions and the related comorbidities. the both groups were evenly matched. the median age was and median homocysteine level was (range - . ). results: in group b, immediate clinical improvement was equivalent between the normal homocysteine group and treated hyhc group. median time to binary restenosis in hyhc was months and in normal homocysteine was months. p = . . secondary endpoints and all cause survival showed no significant difference. pre-treatment multivariate logistic regression for group a; depicts that hyhc is the main culprit of graft occlusion and limb loss p \ . . multivariate logistic regression for treatment group reports that corrected hyhc is no longer a significant factor of operative outcome. conclusion: patients with treated hyhc have similar outcomes compared to those with normal homocysteine. it is therefore crucial to measure homocysteine in all patients with cli and correct aggressively prior to intervention to improve outcomes. the efficacy of clinical guidelines in promoting co-prescription of bone protection with glucocorticoids among hospital doctors treating inpatients background: therapeutic glucocorticoids (gc) rapidly decrease bone mineral density, inducing a catabolic shift by promoting osteoclast differentiation and activation and by inhibiting osteocytes. current guidelines ( ) direct that bisphosphonates (bp's) and calcium carbonate , mg (ca ++ co -) with vitamin d (vit. d ) should be given at initiation of gc therapy as it is known that bone catabolism occurs early with steroid usage. we circulated these guidelines within our hospital after auditing the existing practice of the hospitals doctors and year later we sought to measure the efficacy of our intervention by completing an audit loop. methods: a cross sectional audit was performed of all adult medical and surgical inpatients in a tertiary referral centre teaching hospital. it was noted if inpatients had been prescribed gc and if concurrent anti osteoporotic medication had been prescribed. subsequent to the initial audit, guidelines promoting the use of bp's, ca ++ co and vit. d when prescribing gc's were advertised on hospital notice boards, in hospital bulletins, hospital prescribing guidelines and on the hospital website. one year after publishing the new guidelines the audit loop was completed by performing a similar cross sectional audit. results: all inpatient medical records (n = ) were reviewed in jan of whom % were female and % were older than . / ( %) inpatients were prescribed gc's. ca ++ co with vit. d was prescribed for % of patients on gc's with % also receiving bp therapy. % of patients were also receiving-post menopausal hormone replacement therapy. in nov year after guideline publication all inpatient medical records (n = ) were reviewed of whom % were female and % were older than . / ( %) inpatients were prescribed gc's. ca ++ co with vit. d was prescribed for % of patients on systemic steroids with % also receiving bp therapy. creation and circulation of hospital guidelines resulted in an improvement in the co-prescription of ca ++ co and vit. d and bp's with gc's by the order of . and respectively. however % of patients on systemic steroids received no bone protection and % received suboptimal bone protection from steroid induced osteoporosis. conclusion: publication and advertisement of current bone protection guidelines when prescribing systemic steroids resulted in a substantial but suboptimal improvement by hospital doctors in our hospital in the co-prescription of bone protecting drugs to prevent steroid induced osteoporosis. in this audit it appears that the majority of prescribers do recognise the necessity to protect bone health when a patient requires steroids. however a substantial number of patients did not receive any bone protection. it is our perception that most physicians are not aware that short courses of steroids reduce bone mineral density and therefore greater efforts must be made to enhance doctor awareness of the necessity for bone protection to be prescribed at initiation of systemic steroids. there is a trend towards longer total survival for jetflow tcvcs. these results suggest a potential advantage from using this line type, however, further study and formal cost analysis needs to be undertaken prior to changing our practice. with increasing resource restrictions, appropriate ordering of blood tests is vital for medical economic viability. this study evaluated the pattern and cost of thyroid function test (tft) requests and aimed to determine if tsh alone identifies thyroid abnormalities. a retrospective review of tfts performed on in-and-out-patients at a -bedded regional hospital was undertaken in january , evaluating the number, results and costs of tsh, t and t levels. tsh, t and t were ordered. / patients ( . %) were euthyroid. tsh abnormalities occurred in / ( . %) ( table ) only / ( . %) patients had a normal tsh despite an abnormal t or t level. / ( . %) of these patients had known thyroid disease, undergoing treatment with thyroxine or thyroidblocking medications. / ( . %) had t levels \ nmol/l outside the normal range and asymptomatic so were considered to be euthyroid. / ( . %) had a variety of diagnoses, for example, pituitary disease. tft reagents alone cost € , . ir j med sci ( ) (suppl ):s -s this study has identified that non-selective requests for t and t add little diagnostic value, except in certain circumstances like treatment of thyroid disease, in pregnancy or if pituitary disease is suspected. optimising tfts requests could save in the region of € , /per annum. tsh alone would appear to be adequate for the majority of patients. case study: neurodegenerative disorders we present a case with an unusual combination of neurodegenerative disorders. a fit and healthy -year-old man, with no history of medical or psychiatric illness deteriorated progressively over a year span, presenting initially with speech and language difficulties, followed by development of extra-pyramidal signs non responsive to levodopa. neurological permacol Ò mesh is an acellular porcine-derived dermal collagen surgical implant used in a wide variety of surgical reconstructions and repairs. we describe two cases where permacol Ò mesh was used to anchor the contents of the femoral triangle in patients undergoing radical block nodal dissection as part of the surgical management for metastatic penile squamous cell carcinoma, one of whom had an atrophied sartorius muscle due to previous infection with poliomyelitis. both patients underwent successful inguinal node dissections and femoral triangle repairs, with permacol Ò proving to be an effective means of protecting the femoral vessels in both patients despite complications related to wound healing secondary to a fixed flexion deformity in one patient. a -year-old gentleman, with a past history of vestibular schwannoma requiring a ventriculoperitoneal shunt (vps) was admitted with acute diverticulitis. his condition worsened and required a laparotomy for bowel perforation and faecal peritonitis. this case reports the successful perioperative management of the patient with a vps in situ in the setting of an emergency abdominal surgery. vps placement is an effective treatment of hydrocephalus, diverting cerebrospinal fluid (csf) into the peritoneal cavity. unfortunately, the shunt devices have a high incidence of malfunction mainly due to catheter obstruction or infection and are associated with various complications, % of which are abdominal [ ] . incidental pathology unrelated to the vp shunt can also occur such as appendicitis [ ] , endometriosis [ ] and diverticulitis as in this case. no standard current set of guidelines for perioperative management of vps exists for patients undergoing general gastrointestinal or urologic procedures with varying degrees of contamination [ ] . this case reports successful and conservative management of a patient with a vp shunt that underwent contaminated abdominal surgery. there is no consensus on the management of vps in patients undergoing elective or emergent abdominal surgery and further studies are required in this area. the use of antithrombotic therapy on management of atrial fibrillation in an irish general practice malomo k , breen n , dunne l , farrell g , bryne p ucd (university college dublin), ireland, now intern, mid-western regional hospital, limerick; general practice, dublin, ireland; pottersway medical centre, bunclody, ireland background and objective: atrial fibrillation (af) is a common cardiac arrhythmia associated with increased risk of stroke events [ ] . to assess the use of antithrombotic therapy in patients with known af attending an irish general practice (igp) and use of stratification schemes to assess their suitability for oral anticoagulant therapy. methods and subject: permission to carry out the study was sort from university-college-dublin ethics committee. there were patients with af attending the igp identified using the computerized disease coding system who international classification of disease (icd- ). thirty patients were diagnosed between / / and / / and their data from the computerized medical notes was used to calculate chads , cha ds -vasc, has-bled scores and identify antithrombotic therapy they were using. results: there were af patients. sixty-three percent (n = ) were males and % (n = ) were females (ratio . : ). twentythree percent (n = ) of patients were aged \ years, % (n = ) - years inclusive and % (n = ) =/[ years. two patients with chads score zero were on warfarin although one of them had cha ds vasc score of one. sixty-percent (n = ) were on warfarin alone, % (n = ) aspirin alone, % (n = ) warfarin plus aspirin, % (n = ) aspirin plus clopidogrel and % (n = ) on warfarin plus clopidogrel. seven patients were not on warfarin for various reasons. the has-bled score revealed patients at low risk, moderate risk and at high risk of bleeding. implications: ninety-three percent of patients were correctly managed and two patients were on warfarin with chads scores of zero. the use of evidence based management guidelines is necessary to manage patients. keywords: atrial fibrillation, chads score, cha ds vasc score, has-bled score meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. only % of meckel's diverticulum are symptomatic [ ] . it can cause complications such as ulceration, obstruction, intussusception, haemorrhage and perforation and these complications are more common in the paediatric age group. a -year-old has a lifetime risk of . of developing a complication, this falls to zero over time [ ] . adults most commonly present with bleeding [ ] . we have a case of a -year-old male who presented with a day history of abdominal pain, constipation and anorexia. on examination he had rif tenderness, but no signs of peritonism. a provisional diagnosis of appendicitis was made. the patient was taken to theatre the next morning for laparoscopy and appendicectomy. the appendix was normal and surgery proceeded to laparotomy. an inflamed and perforated meckel's diverticulum was found. a terminal ileum resection with side to side anastomosis was performed. the patient made an uneventful recovery and was discharged to opd follow up. this case illustrates the importance of further evaluation following normal laparoscopy in the case of the ill patient. references: neonatal graves disease is a rare condition, caused by transplacental transfer of thyroid stimulating antibodies from mother to fetus. . % of pregnant women have graves disease and . % of their offspring will have overt hyperthyroidism. a further % will have biochemical thyrotoxicosis without symptoms. this is the case of a baby girl with neonatal graves disease. her antenatal course was uncomplicated until weeks gestation. at this point, her mother became clinically thyrotoxic. maternal blood tests showed an elevated free thyroxine level ( pmol/l) and positive thyroid receptor antibodies. a diagnosis of graves disease was made. she was commenced on treatment but remained thyrotoxic at the time of delivery. the baby was healthy at birth. however, thyroid function tests on day of life showed an elevated free thyroxine ( pmol/l) and thyroid receptor antibodies were positive. clinically, she remained asymptomatic and examination was normal. treatment with carbimazole was commenced and the dose titrated to maintain her euthyroid. most neonates affected by neonatal graves disease will have biochemical thyrotoxicosis but are clinically asymptomatic. the minority will be severely affected with goitre, eye signs, weight loss, tachycardia, arrhythmias and heart failure. it is a transient disorder, limited by clearance of maternal thyroid receptor antibodies and is usually self-limiting over - weeks. mortality rates of up to % are reported in untreated cases, usually from arrhythmias and heart failure. this case emphasises the importance of close monitoring of pregnant women with a history of thyroid disorders, before and during their pregnancy, as well as monitoring their babies in the neonatal period. fibreoptic bronchoscopy is considered a safe diagnostic tool [ ] . it is suggested however that post-bronchoscopy complication rate increases with age [ ] . we decided to study the complication rate and the outcomes of bronchoscopy in patients over the age of years in our institution. a retrospective review of the case notes of patients aged greater than years who underwent bronchoscopy between september and november was carried out. data on complications experienced during and after bronchoscopy and the influence of the results on subsequent management of patients were collated and analysed. ninety-six patients were included. the mean age was . years (sd . ). thirty subjects ( . %) had a documented lung disease. fifty-nine patients ( . %) were current or ex-smokers. indications for bronchoscopy were; to evaluate for malignancy ( . %) and to evaluate for tb ( . %). post bronchoscopy complications were noted in eight ( . %) cases including hypoxia ( . %), infection ( . %), tachycardia ( %) haemoptysis ( %) and pneumothorax ( %). six patients required treatment including nebulised bronchodilators ( . %), antibiotics ( . %), and oxygen therapy ( . %). malignancy was diagnosed in twenty cases ( . %). clinically significant pathogens were detected in six cases ( . %). as a result of bronchoscopy fourteen patients ( . %) had alterations to their drug therapy, three ( . %) received lung cancer treatment with curative intent, eighteen ( . %) had palliative care input, seventeen ( . %) were referred for further investigation and thirty-seven ( . %) had no change to their management. in conclusion, bronchoscopy is relatively safe and has good diagnostic utility in patients aged more than years. patient records were identified from a database of patients who underwent a spinal mri to investigate spinal metastatic disease between november and april . an analysis of the management of those diagnosed with mscc, specifically radiotherapy and/or surgical intervention was performed. three hundred and sixtyone patient records were identified with one hundred and seventy-one patients having metastatic spinal column disease. of these, thirty-four had mri evidence of metastatic spinal cord compression. radiotherapy alone was the most common therapy employed for patients with mscc. a multidisciplinary team approach was not taken in the majority of cases. a surgical opinion was sought in the minority of cases. this is not congruous with nice guidelines as a management protocol. the complexity of management decisions for metastatic spinal cord compression demands a multi-disciplinary approach. current practise in this major supra-regional cancer centre does not routinely employ this approach. a surgical opinion is sought in the minority of cases. this reflects the national trend with some centres having no spinal surgeons as staff. we recommend the establishment of a care pathway in order to comply with best evidence based practise as outlined by the nice guidelines. pet ct as a staging modality in primary cervical cancer; to establish the correlation between histological subtype and fdg- avidity of the primary lesion purpose: pet ct has become one of the mainstays of diagnostic imaging both in staging and prognosis of cervical cancer. we wanted to establish the link between fdg- uptake in the primary lesion and correlation with specific histological subtypes of cervical cancer including squamous cell carcinoma, adenocarcinoma and other rarer subtypes such as clear cell and adeno-squamous carcinoma. methods and materials: the main audit involved working out the fdg uptake in the primary lesions from the cervical cancer database of patients. the patient list was derived from a database of patients collated by the gynaecological services at sjh of all patients who received workup and treatment for cervical cancer from - . the computer system at sjh was employed for analysing pet-ct reports and histology reports. microsoft excel was used to store this information parameters and complete statistics on the data. results: the results of this study are to follow. conclusion: there is a correlation between fdg avidity and histological subtype of cervical cancer and this provides valuable information on the reliability of pet-ct findings in a specific cohort of patients with cervical cancer. we present the case of a -year-old male with a primary piriform fossa squamous cell carcinoma (scc) who attended for staging positron emission tomography/computerised tomography (pet/ ct) scan. distant to the primary lesion, focused f fluorodeoxyglucose (fdg) uptake was noted in the left iliac bone, without underlying abnormality on the accompanying ct scan. low grade uptake was also noted in subcentimetre upper mediastinal nodes, without any underlying lung parenchymal abnormality. these nodes were felt to be inflammatory or reactive in origin. though an unusual pattern for metastatic head and neck scc, the left iliac bone lesion was concerning for malignancy. thus, a percutaneous biopsy of this region was performed under image guidance. histology revealed non caseating epithelioid granulomata consistent with sarcoidosis. the patient was subsequently able to have potentially curative treatment of his head and neck primary. discussion: sarcoidosis is a chronic inflammatory multisystem condition characterised by the presence of non-caseating granulomas in affected organ tissues. it commonly affects young and middle aged adults with a slightly higher prevalence in women. the disease shows a predilection for adults under , peaking between and , with a second peak in women over [ ] . despite its unknown aetiology, it is felt that t lymphocytes play a central role in the development of sarcoidosis, as they likely propagate an excessive cellular immune reaction. it has been shown that abnormalities with the cd /cd ratio and production of t helper and (th /th ) cytokines such as interferon and tumour necrosis factor (tnf) are found in sites of disease activity [ ] . the importance of tnf in sarcoidosis is demonstrated by the efficacy of anti-tnf medications such as pentoxifylline and infliximab [ ] . it is estimated that bone lesions occur in - % of sarcoidosis patients [ ] . these figures are however based on radiographic data and are likely an underestimate as the majority of bone lesions would be asymptomatic [ ] . varying osseous manifestations of sarcoid have been described; punched out lytic lesions, lace-like destruction and subperiosteal resorption mimicking hyperparathyroidism. commonly, the small bones of the hands and feet (predominantly the middle and distal phalanges) are involved often bilaterally and symmetrically. while pulmonary involvement occurs in % of patients with sarcoidosis [ ] , bony involvement is rare without other clinical manifestations of the disorder [ ] . indeed our patient had low grade subcentimetre mediastinal nodes. the fdg avidity of sarcoid is a well documented phenomenon. indistinguishable from metastatic disease on f fdg pet scan alone it can lead to false-positive appearance of metastatic disease on pet/ ct. furthermore one-third of pet/ct positive sarcoidosis have osseous abnormalities on pet/ct the majority of which will not be evident on low dose ct [ ] . this case serves to remind us of the diagnostic limitations of f fdg pet in the differentiation of inflammatory and metastatic processes. in a patient with an unusual pattern of 'metastatic' disease tissue diagnosis is a necessity. distinct islet auto antibodies against antigens insulin, gad , ia and znt have been identified. the presence of autoantibodies has been shown to be predictive of reduced beta cell mass. international data suggests that - % of patients with newly diagnosed t dm are positive for at least one of the above antibodies. our aim is to study the prevalence of autoantibody positivity in our population of children with newly diagnosed t dm over a year period ( ) ( ) ( ) ( ) ( ) . details of all children newly diagnosed with t dm were collected using the endocrinology department database and chart review was undertaken. children diagnosed elsewhere whose care was transferred to our centre and children who had non type diabetes were excluded. one hundred and thirty-six children were diagnosed with t dm in our centre, of which ( %) presented in diabetic ketoacidosis. age at diagnosis ranged between months and . years. the male to female ratio was : . other autoimmune conditions (coeliac disease, hypothyroidism, addison's) were present in %. ninety-six percent (n = ) were tested for one of the three antibodies. % were positive for at least one antibody, % positive for two, % positive for all three antibodies. the most common antibody found was anti gad ( %). positive autoantibodies are helpful in confirming the presence of t dm and their absence in raising the possibility of monogenic diabetes. the absence of pancreatic islet autoantibodies at diagnosis can be predictive for maintained beta cell function during the years after diagnosis. maternal obesity, based on a body mass index (bmi)[ . kg/m , is associated with increased pregnancy complications. moderate exercise during pregnancy is associated with decreased complications such as pre-eclampsia [ ] and gestational diabetes mellitus [ ] and has a beneficial effect on mood with those who exercise experiencing fewer symptoms of depression and anxiety both during and after pregnancy [ ] . the purpose of this study was to determine if obese women exercise less during pregnancy. we recruited women at their convenience after a routine scan confirmed an early ongoing pregnancy. maternal height and weight were measured accurately and bmi calculated. women completed the international physical activity questionnaire. of the studied in early pregnancy, . % took no exercise, . % walked only, . % undertook moderate exercise and . % undertook vigorous exercise. of the obese women (n = ), only % reported moderate-vigorous exercise in early pregnancy compared with . % in women from the normal bmi category (n = ). also % of the obese group reported doing no exercise compared with % of those with a normal bmi. women with a bmi of or more were found to sit for an average of min per day whereas those with a normal bmi sit for min per day on average. although bmi increases with age and parity, these variables were not found to influence exercise levels in early pregnancy. exercise may be physically challenging in obese women, particularly if morbidly obese, but due to its beneficial effects it should be encouraged antenatally in all pregnant women irrespective of their bmi category. references: angiogram showed an absence of coronary artery disease and echocardiogram ruled out structural abnormality. exercise stress test showed short runs of vt in recovery. further tests included ajmaline and adrenaline challenges. cardiac mri showed right ventricular outflow tract scarring consistent with either a primary diagnosis of arvc or secondary with that of myocarditis. sarcoidosis was outruled by further laboratory and radiological means. non-sustained runs of vt on telemetry were noted and a dual chamber implantable cardiac defibrillator was placed. on discharge, medication included atenolol mg daily and patient will undergo genetic screening. follow up for the siblings included phenotyping and mri. discussion: history, presentation and pathology uncovered are consistent with a diagnosis of arvc. suspected paternal inheritance of an autosomal dominant genetic defect predisposed to the ventricular arrhythmias which at first, manifested as self-limiting palpitations however, later caused a near fatal event. long term management may include cardiac transplantation. prevalence of diagnosed atrial fibrillation in adults: national implications of rhythm management and stroke prevention: the anticoagulation and risk factors in atrial fibrillation (atria) study complications of fiberoptic bronchoscopy at a university hospital the relationship between age and process of care and patient tolerance of bronchoscopy central skeletal sarcoidosis mimicking metastatic disease sarcoidosis is a th /th multisystem disorder osseous sarcoidosis treated with tumour necrosis factor-inhibitors: case report and review of literature. spine (phila pa ) musculoskeletal manifestations of sarcoidosis multiple atypical bone involvement in sarcoidosis imaging in sarcoidosis. semin respir crit carre med f- fdg pet/ct for detecting bane and bone marrow involvement in sarcoidosis patients poster diaphragmatic rupture: delayed diagnosis and its consequences-a case report diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs the introduction: lymphoscintigraphy has been shown to be accurate in identifying sites of potential nodal metastases in melanoma patients. recent guidelines published by the eortc-eanm have defined specific criteria with relation to performing lymphoscintigraphy in melanoma patients. methods: the aim of this study was to audit all patients with malignant melanoma who underwent sentinel lymph node biopsy (slnbx) and lymphoscintigraphy in university college hospital galway between - . results were compared with eortc-eanm recommendations. results: melanoma patients underwent slnbx during the study period. patients had preoperative lymphoscintigraphy using intradermal injections of technetium m. sentinel nodes were identified in of patients ( . %) on lymphoscintigraphy. . % of lymphoscintigrams were reported on the same day as the procedure, . % after day and . % greater than day postop. obligatory imaging, as defined in the eortc-eanm guidelines, was obtained in % of all patients undergoing lymphoscintigraphy. no nodal uptake was reported in patients, of whom received imaging in accordance with the guidelines. the location of those melanomas with no nodal uptake was . % on the head and neck, and . % on the trunk. the overall rate of false-negative lymphatic mapping and sentinel node biopsy was . %. in patients receiving lymphoscintigraphy the false negative rate was . versus . % in patients who did not have lymphoscintigraphy. conclusion: preoperative lymphoscintigraphy is an essential adjunct in identifying the sentinel lymph node in clinically node negative melanoma patients and should adhere to eortc-eanm guidelines. conflict of interest: none. on examination, she was alert, hr , bp / . she was tachypnoeic, but reported this to be her baseline. there was a palpable, non-reducible mass in the left upper quadrant. a chest x-ray showed loops of bowel above the diaphragm. ultrasound showed an abscess in the rectus sheath, which drained mucopurulent fluid.mb opted not to have the diaphragm repaired, despite medical advice. she was readmitted weeks later with a recurrence of the abscess. her clinical condition deteriorated, with severe abdominal pain, and oxygen saturations of %. an emergency laparotomy was performed, which showed an obstructing lesion in the descending colon, with large and small bowel above the diaphragm. she had an extended right hemicolectomy, with restoration of bowel to the abdominal cavity and mesh repair of the diaphragm. histology showed an descending colon adenocarcinoma, t n m .traumatic diaphragmatic rupture is a rare problem, occurring in - % of blunt and penetrating traumas. ( ) plain films and ct scans are not always diagnostic in the acute phase, due to concomitant injuries. ( ) repair is essential once diagnosis has been reached to avoid herniation of abdominal viscera. patients with ongoing dyspnoea after blunt trauma may benefit from a repeat chest x-ray. a -year-old retired veterinary surgeon was referred to tertiary referral with a months history of a painless enlarging neck mass. clinical examination showed a right side neck mass approximately cm cm in size which extended through both anterior and posterior triangles. cervical lymphadenopathy was not appreciated and the patient was clinically euthyroid. patient was admitted under the care of the maxillofacial service, where he underwent a needle core biopsy of the neck mass. this was returned showing poorly differentiated spindle cell tumour with large pleomorphic nuclei and abundant abnormal mitoses. the immunoprofile was consistent with metastatic poorly differentiated sarcomatoid carcinoma and the differential diagnosis included origin fro the kidney, lung or thyroid.the case was discussed at the head and neck mdm and a consensus was reached that the patient as developed a sarcoma of the neck, with a level neck dissection the most appropriated intervention.intraoperatively, following the removal of the neck mass it was noted that the right lobe of the thyroid was enlarged. an intra-op fna was performed on the mass in the right lobe of the thyroid. the fna was returned showing bizarre giant cells, suggestive of malignancy. ultimately the patient underwent a total thyroidectomy but, despite surgery the patient died weeks post-operatively. using feedback from the pilot study and analysis of the preexamination consultant and registrar-led teaching schedule for students a further 'intern-led' tutorial timetable was structured. it allowed for a weekly maximum of h of teaching dependent on demand and intern availability. programme duration was weeks, january to march . group sizes were a maximum of students. tutorials were all at the patient bedside. feedback forms were distributed at the end of the programme.sixty-four tutorials were given in total. seventy feedback forms were returned. mean number of tutorials attended per student was . . students rated statements - ( -strongly disagree, -disagree, -neutral, -agree, -strongly agree). median scores were used. scoring showed improvements were made from last year in terms of level of intern preparation for tutorials and importantly, the students own subjective view of their level of preparation for forthcoming examinations. most importantly, students agreed that tutorials improved their history taking skills and strongly agreed that their examination skills improved. matching feedback from the pilot study, students strongly agreed that intern-led teaching is an appropriate adjunct to the final year programme.of the intern working in st james's hospital, participated. seventeen of these had received tutorials on the pilot programme. of the that did not participate, many had never received formal intern teaching.the feedback obtained from the pilot study was invaluable in organising and delivering this teaching programme. ongoing improvements will be made for next year based on this audit. this also highlights that the intern-teaching tool is extremely beneficial, yet largely underused. key: cord- -oswgjaxz authors: nan title: abstracts: (th) european congress of trauma and emergency surgery may – , brussels, belgium date: journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: oswgjaxz nan introduction: frequently fractures of modern sport disciplines are fractures of the clavicle. most of them are uncomplicated and still treated without operation. therefore there is a lack of bigger studies about the treatment of clavicle fractures by elastic stable intramedullary nailing (esin). nevertheless this method becomes more and more popular, especially for young and active people. intention of this investigation was to analyze risks and results of this method to check the indication for operative treatment of simple fractures in this group of patients. material and methods: this study is a retrospective analysis of patients whose fractures of the clavicle were treated by intramedullary nailing. crucial for the decision for operation was the individual request of the patient after information of the relative indication. included were patients with fractures of the middle third, fractures of the lateral third and fractures with concomitant shoulder injuries from to . the duration of operation, intraoperative radioactive loading and complications were analyzed from the medical file. the functional outcome was measured by the constant-score. the anatomical reduction was proved by measuring the difference of the length of both clavicles ( - month after operation). results: the average duration for the middle third was min ( - ), for the lateral third ( - ) minutes and for fractures with concomitant injuries min . the mean radioactive surface dose was , cgy/cm . four complications ( %) cause revision operations: one secondary dislocation which leads to pseudarthrosis and two imminent penetrations of the medial end of the nail. one patient had developed a painful pseudobursa due to lateral penetration of the nail. additional there were two prematurely nail extractions because of medial irritation of the soft tissue. altogether we documented complications in % of the operations. overall an open reduction was necessary in %. after healing there has been no significant shortening of the fractured clavicle in comparison of both sides. the constant-score showed good postoperative results (average: , median: , lowest / ). conclusion: esin with titan nails is an alternative method of treatment with good results. nevertheless we documented complications in %. in the literature complication rates from - % has been described. the complication rate of esin seems to be comparable to the conservative treatment. in our opinion the relevant intraoperative radioactive dose is an often underestimated factor. the operation time is often longer than thought before starting and often an open reduction is necessary. because of these reasons the conservative therapy should still be the standard. esin can be an alternative especially for young athletic ambitious patients after a detailed information about the risks. disclosure: no significant relationships. introduction: the optimal management of clavicle fractures is still controversial, although the nonoperative treatment remains the standard in most fractures. recent studies have reported a higher nonunion rate and unsatisfactory functional results after nonoperative treatment. therefore, there is an increasing interest in the primary operative management of displaced midshaft fractures. however, no treatment-consensus exists at this moment. the goal of the present study was to compare plate fixation with nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of weeks follow-up. material and methods: in a multi-center prospective clinical trial patients with a fully displaced midshaft clavicle fracture were included within one week after the injury. after a standard information procedure, patients were asked if they wanted to have a operative or a nonoperative treatment. outcome analysis included standard clinical follow-up, the constant shoulder score, the disability of the arm, shoulder and hand (dash) score and complication rate at and weeks after the injury. results: between january and october a total of patients were included: patients were treated operatively ( . % men, mean age . years) and patients were treated nonoperatively ( . % men, mean age . years). constant and dash scores were significantly higher in the operative group compared with the nonoperative group at weeks ( vs and . vs . ). there was no significant difference at weeks ( vs and . vs . ). in both groups two patients developed pseudartrosis, all four required surgery. in the nonoperative group symptomatic malunion was more frequent: twelve patients at weeks ( . %) versus none in the operative group. other complications in the operative group were mostly hardware related: pain and irritation requiring plate removal after consolidation in four patients ( . %), two broken plates due to the earlier mentioned pseudartrosis ( . %), one early outbreak of the plate ( . %) and one woundinfection ( . %). furthermore, patients with heavy professional work activities returned to their jobs at an average of three weeks after injury in the operative group compared with seven weeks in the conservative group. at weeks after the injury, the patients in the operative group were more satisfied compared to those in the nonoperative group ( % vs %). conclusion: operative fixation of a displaced midshaft clavicle fracture results in improved functional outcome at weeks after injury and in a higher satisfaction rate at weeks. this study shows that patients with heavy jobs restarted their professional activities sooner if they were treated operatively. furthermore, higher satisfaction with the appearance of the shoulder may be a reason for surgery. introduction: the unstable shoulder girdle with a fracture of the clavicle (floating shoulder, ipsilateral serial rib fractures) is a classical indication for a plate osteosynthesis of the clavicle. despite a relatively high complication rate ( - %), such as implant failure, non-union and refracture after implant removal, open reduction and internal plate fixation (orif) has been the gold standard for many years. this open procedure with direct reduction maneuvres might be blamed for at least some of the complications due to iatrogenic damage of the blood supply of the fracture fragments. our hypothesis is that a closed method with indirect reduction might reduce some of the complications. the goal of our study was to test the practicability of the mipotechnique in clavicle fractures in unstable shoulder girdles. material and methods: between and we included, out of internally fixed shaft fractures in total ( x plate, x elastic nail), patients with either a floating shoulder (n = ) or a clavicle fracture in combination with ipsilateral serial rib fractures (n = ), in this study. operative technique: a locking compression plate (lcp) . with - holes was anatomically shaped to the anterior (-caudal) contour of the contralateral clavicle and then inserted percutaneously from lateral to medial using a short incision at the anterior border of the lateral end of the clavicle. using mainly indirect maneuvres, the fracture was reduced and then fixed in a pure bridging technique never using interfragmentary lag screws. free unloaded rom was allowed immediately after the operation with full loading - weeks later. follow-up examination was performed to years later with clinical (dash-score, shoulder function, length measurement) and radiological (fracture healing, length measurement) examination. results: / fractures healed without complications. clinical and radiological length measurement showed no significant differences to the contralateral side (range: + mm to - mm). in all patients a very good functional result was achieved with an average dash score of . ( - ). one implant failure occured two years after the initial trauma in a road workman. at reoperation only a partial consolidation of the original fracture was observed. restabilization and bone grafting led to an uneventful healing. conclusion: the mipo technique is feasible even in clavicle fractures and can lead to good functional and cosmetic results. the advantage might be its low invasiveness which better preserves the vascular supply of the fracture fragments. however it is technically demanding mainly due to the small size of the fractured bone. therefore in our opinion it requires a surgeon experienced in the mipo technique of treating fractures of larger bones as tibia and femur. introduction: there are some reports on the difficulties of removing the locking compression plate in clavicle fractures, due to problems of removing the self tapping locking screws. we retrospectively investigated if this was also the case in our institution in removal of lcp plate of the clavicle and if this was incidential or becoming a trend. material and methods: from october till october , we have removed locking compression plates after claviclefracture stabilization. all of the locking screws were inserted by trauma surgeons with the use of the torque limiting srewdriver according to the manufacturer's recommendations. a total of screws where removed. they consisted of fifty-one . mm self tapping cortical screws and hundred and twenty . mm self tapping locking screws. results: from the locking compression plates that where removed after claviclefracture stabilization, in eleven patients ( %) a problem with removal of the plate arised. this was caused by a total of self tapping locking screws. in all cases jamming of the screwheads in the plate was found to be the reason. there was ''cold welding'' between the threaded head of the locking screw and the locking plate. for removal four different strategies were used. in two screws the head was drilled off and the plate removed and subsequent the rest off the screw removed with forceps. five times the plate was bend around the screw and by rotating the plate (helicopter) both were taken out. in eight screws the recess of the head of the screws were enlarged and a conical extraction screwbit . was used to remove the screws. two times a combination of cutting the plate and helicopter tecnique was used succesfull. in comparison the fifty-one . mm selftapping cortical screws were removed without any problem. conclusion: the locking compression plate is a usefull attribute in fracture treatment of the clavicle. however in one-third of the patients removal of locking compression plates and especially the . mm self tapping locking screws from the clavicle, becomes an increasingly challenging procedure. we find this an unacceptably high percentage. number of mri studies it was possible to describe the intraarticular disc. until now there was no in vivo verifying of one of these mri protocols. the introduction of a high resolution mri protocol using a superficial coil ( d wats and t ffe) that has been developped in an ex-vivo model allows the visualisation of the intra-articular structures. the aim of this study is to ascertain the significance of the mentioned mri protocol and the applicability in the clinical practice in a limited patients cohort with instability of the ac-joint. the mri findings are compared to the arthroscopic findings. material and methods: in a one year period patients with chronic acromioclavicular-joint dislocation rockwood type ii and iii were seen in the outpatient clinic the major symptom was pain followed by loss of power. inclusion criteria where a history of more than three month the exclusion of subacromial pathologies, age over and the indication for arthroscopic revision of the ac-joint. the radiological examiner was blinded to the clinical findings. the mri-scan was performed on both sides. at the time of the operation the surgeon was blinded to the mri reading. the surgical procedure was performed by arthroscopy in beach chair position. the surgical findings have been documented by video and also in a descriptive manner. the examination was performed on a . t mri-system . results: throughout the radiological examination, in / patients a rupture of the intra-articular disc was suspected. in / cases degenerative alterations were described. in one case the reading was negative (e.g. ,,no rupture of the intra-articular disc''). during the surgical examination / patients showed ruptures of the intraarticular disc. in one patient no signs of macroscopical disintegration of the disc could be detected. in the case with negative radiologiocal reading, the disc was verified as intact during surgery. in all other cases the disc was disintegrated, including those with the radiological reading ''alterations without clear signs of rupture''. the significance of the described mri protocol was %. introduction: cancer of the colon is a common disease. the choice of treatment after diagnosis is surgery, in an elective setting, to remove the tumor. however, a large number of patients present with colonic obstruction requiring acute surgery before the diagnosis is known, or before the set date for elective surgery. previous studies have shown a worse outcome for patients who undergo surgery in the acute setting compared to patients in scheduled care. the aim was to establish characteristics and prognosis in patients with acute obstructing colon cancer compared to patients who underwent elective colon cancer surgery. material and methods: all patients diagnosed with colon cancer during - in the linkoping area were identified through the swedish colorectal cancer register (n = ). a retrospective analysis of patients with colonic obstruction (n = ) was done using various criteria from the medical records. exclusion criteria were acute surgery due to reason other than obstruction (n = ), non-surgical treatment (n = ), other diagnosis (n = ), or missing medical records (n = conclusion: acute surgery due to colonic obstruction of colon cancer is common. tumor stage seems to be more advanced in patients with obstructing disease than in patients scheduled for elective surgery and consequently the rate of complications is higher and the outcome is worse. however, when stratified for different tnm-stages, the worse outcome in -year survival for patients with acute obstructing colonic cancer still remains. the explanation for this difference is to be elucidated in further studies. disclosure: no significant relationships. introduction: acute colonic obstruction due to malignancies is often a surgical emergency. hartmann's procedures or one stageresection with primarary anastomosis (with or without ileostomy) have been the treatment of choice. however these procedures are associated with a significant morbidity and mortality rate. self expanding metallic stents (sems) have shown their efficiency as palliative treatment in colonic cancer. colonic stenting has been advocated as a''bridge'' towards surgical procedures in potentially resectable diseases. the aim of this study is to evaluate the efficacy of colonic stenting in the emergency treatment of large bowel occlusion either for palliation or to enable to planned surgical procedure. s. tamulis, e. v. gaidamonis surgical, vilnius unuversity emergency care hospital, vilnius, lithuania introduction: to evaluate the results of the treatment of patients with the small bowel obstruction due to intestinal adhesions. material and methods: medical records for the patients treated with small bowel obstruction due to adhesions from to were reviewed. the patient's age, gender, previous abdominal operations, method of the treatment and outcomes were analyzed. results: there were patients admitted to the vilnius university emergency hospital during years period. appendectomy as a previous operation was recorded in % of cases. surgery was required in of the cases ( . %). strangulated small bowel was found in patients ( , %). in cases ( , %) the surgical procedure was limited to adhesiolysis, whereas in cases ( , %) an intestinal resection was performed. enterodecompresion tube was used in cases ( , %). the operative mortality was , % ( cases). mortality after the treatment due to strangulation was , % ( cases). conclusion: there were % of surgicaly treated patients. main reasons of adhesions formation was previous performed apendectomy and midline lower laparotomy. the criteria of uneffective conservative treatment were absent of the positive results of the physical, laboratory, rentgenological and ultrasound examination. mortality after the strangulated small bowel resection was higher. operative enterodekompresios reduces the risc of the postoperative complications and mortality. disclosure: no significant relationships. introduction: hartmann's procedure (hp) still remains the most frequent performed procedure in diffuse peritonitis due to perforated diverticulitis. [ ] [ ] [ ] nevertheless it is associated with high morbidityand mortality . the aim of this study was to assess feasibility, morbidity and mortality of resection with primary anastomosis (pa) with or without diverting loop ileostomy versus hp in case of diverticular peritonitis. , . material and methods: we retrospectively reviewed our prospectively collected database from / to / of patients who were operated in the emergency department of bellvitge university hospital. only patients operated on generalized diverticular peritonitis (hinchey iii-iv) were included. data on patients' demographics, asa classification, hinchey score, peritonitis severity score (pss), surgical procedure, post-operative morbidity, mortality and post-operative hospital stay were studied. results: a total of patients [median age ( - ) years], female . % were included. sixty ( %) had undergone hp and ( %) pa. only in patients ( . %) a diverting ileostomy was performed. overall post-operative morbidity was . %, most frequent complications were wound infection . %, respiratory complications . % and sepsis . %. overall mortality was . % ( pt). these patients had a mean pss of . while the survival group . . there was an overall reintervention rate of . %, after pa . % and after hp . %. significant differences were found in the hp versus pa group in asa score (asa i-ii: % v %, asa iii-iv: % v %) and the median pss ( versus ) . % ( / pt) with pss £ underwent pa, but none ( / ) with pss ‡ . the post-operative morbidity was significantly higher for hp ( . %) compared to pa ( . %). focusing on hospital stay there was a significant difference between pa (mean . days) versus hp (mean . days). in the stratified analysis considering patients with hinchey iii peritonitis we found a mortality of . % ( / pt) in the hp group versus . % ( / pt) of the pa group. the mortality rate stratified for asa and surgical procedure shows no difference in asa i-ii, but in asa iii-iv a lower postoperative mortality for hp ( . %) versus pa ( . %). including only patients with pss less than ( patients) there is a significantly lower morbidity in pa ( . %) versus hp ( . %). conclusion: our data show that pa can be performed safely with lower morbidity and mortality for diverticular peritonitis in patients with asa i-ii, hinchey iii peritonitis grade or pss less than respectively to hp. these findings are supported by a shorter hospital stay in favor to pa. y. arlettaz orthopaedics and trauma, chcvs hô pital du valais, sion, switzerland introduction: one of the most demanding steps of intramedullary nailing is the distal locking. most of young surgeon are ''affraid'' to treat a long bone fracture by a nail because of the distal locking. the aim of this study is to evaluate a new frendly radiation free targeting device on cadavers. material and methods: the study was conducted on fixed cadavers. femurs were available. the method consists of the following steps: determining the zero position of the device; opening the tip of the great trochanter; introducing the nail (sirus nailÒ x (zimmer inc.)); introducing an emitter inside the nail to be positioned in the distal holes; adaptation of the guide on the standard handle with a receptor; moving the receptor to be aligned to the emitter; changing the receptor for the sleeve and performing the drilling and the locking. for the second or even third screw, the targeting device needs a little adjustment. results: on the distal locking procedures ( screws), we observed only one failure due to the breakage of the prototype. this translates as a % success rate for two screws with a mean time of . min. two surgeons conduct this study. not only the inventor but also a inexperimented surgeon tested the new device with the same succes. conclusion: this new device has the advantage to be fully mechanical, to be solidly linked to the patient and to be totally radiation free. it can be used in any hospital, by any surgeon. the procedure is easy to learn and reproducible. it could be adapted to any nail system and does not need external power supply. introduction: anterior knee pain is one of the most frequent complication of tibial nailing. its aetiology remains unclear, potentially being a multifactorial event. the aim of this prospective study was to evaluate if anterior knee pain has any negative influence on: bone healing(the hypothesis is if the patient has anterior knee pain he or she will not put weight on the affected leg and this will not stimulate the bone healing), ability to return to work and quality of live. material and methods: european level trauma center was involved in this study. methods: between januari and december , patients with a tibia fracture was admitted to the trauma departments we used a standard t tibia nail(stryker) with the possibility of proximal and distal fixation with screws the approach was trans or parapatellar. results: at - weeks, months, months follow-up we had , , patients with anterior knee painthe vas decreased from , to , , bone healing was % and for % of patients it was possible to do their previous full time job after months. the quality of life (walking up and down stairs normally without any help, putting on shoes and socks, sitting/standing from a chair, total weight bearing,) was improving. conclusion: we conclude that anterior knee pain in this study is mild, that the two different method of patellar tendon approach(trans or paratendinous approach) have no relevance and it does not have a negative influence on bone healing, ability to return to work and the quality of live. introduction: the aim of this study was to see if there is any difference between manual traction and fracture was applied in one step. twenty-seven femurs and thirthy-three tibias were treated. the mean distraction rate was . mm (range . - . mm) for the femur and . mm (range . - . mm) for the tibia. the necessary pressure to advance the distraction in the tibia was average of bar (range - bar), to distract the femur, bar (range - bar). results: bone healing index for tibia . and femur . months/cm distraction. implant failure five cases; infections three cases. nonunion of the distraction site or docking site four cases. we did not encounter major stiffness of the adjacent joints. conclusion: although the presented technique is a semi-closed distraction procedure, we find this system appealing because of it simplicity in use, low cost and the ability to immediate weight bearing. introduction: bone transport for treatment of segmental bone defects as a salvage procedure is related to a high complication rate. posttraumatic soft tissue problems and callus insufficiency are to be dealed with especially in posttraumatic conditions. the ilizarov ringfixator allows a stable external bone fixation enabling full weight bearing. in bone defect reconstruction bone transport is commonly used. a major problem is the skin cutting wires for bone fixation. a new method of the cable transport with intramedullary cable passing avoids skin cutting thus reducing skin problems. material and methods: patients with a metaphyseal and diaphyseal bone defect of the tibia after open trauma and posttraumatic infection were treated with debridement, bone resection and soft tissue coverage by local and free flaps. after soft tissue healing the monolateral external fixation was replaced in each patient by a four ring ilizarov fixator with a proximal percutaneous tibia osteotomy. for bone transport a flexible cable was placed around the distal part of the segment and passed intramedullarly through the distal segment out of the tibia and onto the ilizarov fixator and the transport clickers. the bone segment was transported after a delay of days anterograd by the intramedullar placed cable one mm per day. results: in all patients the bone defect was closed by the bone transport. in one patient early consolidation of the regenerate occurred and a rupture of the cable. two patients had an insufficiency of the callus. the distal docking site was augmented in all patients after the segment transport with iliac bone graft for consolidation. the one patient with early consolidation was treated by a second osteotomy; the two patients with insufficiency were augmented during the docking operation with iliac bone graft. conclusion: the intramedullar cable transport is a new modification of the bone transport with the ilizarov ringfixator. the main advantage is the soft tissue spearing and protecting transport mechanism enabling bone transports after free flap soft tissue coverage with micro vascular anastomosis. therapeutical course before and after amputation (number of operations before and after amputation) in relationship to co-morbidities and bacteria which caused the infection. results: hospital data from ( female, male) patients were available for septic amputations in the lower extremities on account of non-manageable infections. the average age was . years ( to years). the first age peak lies with , the second with years. in cases infected endoprostheses were found ( total hip arthroplasties, total knee arthroplasties) in cases osteomyelitis was diagnosed. before amputation the patients underwent an average of . interventions (between and ) in oder to control the infection. the average treatment period before the amputation was . days (from to days). post amputationem an average . interventions were necessary (from to ). the average period of treatment was about . days (from to days). the analysis of the co-morbidities showed that hypertension was the most frequent, cases ( . %), followed by diabetes in cases ( . %), coronary desease in cases ( . %), obesity in cases ( . %) and copd in cases ( . %). conclusion: a statistical relevant risk-assesment based on these data (correlation of microbiological findings co-morbidities and risk of amputation) cannot be carried out due to the relatively small number of patients. however, a trend may be estemated: combination of mrsa, diabetes and cardial disease in combination with a great number of operations leads to an increased amputation-risk independent to the individuals age. introduction: maggot debridement therapy (mdt) as an ancient method is succesfully used for the treatment of acute and chronic wound infections in trauma surgery . the underlying mechanisms of action of mdt are unknown, but could provide information for a novel treatment modality against infection, which is important in these times of increasing antibiotic resistance. therefore, in this research the effect of living maggots on planktonic cells was investigated. furthermore, the influence of maggot excretions on planktonic cells and on bacterial biofilms was tested. material and methods: sterile tubes were filled with living maggots in a bacterial suspension and every two hours samples were cultured and compared with controls. a turbidimetric assay was performed to test the susceptibility of six bacterial species to maggot excretions. bacterial biofilms were formed in vitro on polyethylene, stainless steel and titanium and maggot excretions were added to test their influence. results: the results show that living maggots as well as their excretions stimulate the bacterial growth of s. aureus, e. faecalis, cns, s. pyogenes and k. oxytoca (all p-values £ . ). only p. aeruginosa had a decrease of bacterial growth (p = . ). the strongest biofilms in vitro were formed by s. aureus, s. epidermidis and p. aeruginosa in contrast to the weak and inconsistent formed biofilms by e. faecalis, e. cloacae and k. oxytoca. for p. aeruginosa, stainless steel was the best biomaterial with respect to biofilm formation and for s. aureus and s. epidermidis, the best biomaterial was titanium. maggot excretions were added to the strongest biofilms, named above, and reduced these on all biomaterials. the maximal biofilm inhibition by maggot excretions was seen on polyethylene: % for p. aeruginosa (p < . ), % for s. aureus (p < . ) and % for s. epidermidis (p < . ). conclusion: this study shows that nor living maggots, neither maggot excretions have direct antibacterial properties. however, maggot excretions do reduce biofilms formed by different bacterial species on commonly used biomaterials. future research will focuss on the exact mechanism and the substance(s) that cause biofilm reduction. furthermore, possible indirect antibacterial activity will be investigated and the potential role herein of the immune system. introduction: tetanus is an acute disease caused by a neurotoxin produced by the bacterium clostridium tetani, characterised by generalised rigidity, muscle spasm and fatality. open orthopaedic injuries are at particular risk of developing infection from tetanus spores found in the environment. the uk department of health has established guidelines for the prevention of tetanus infection. we assessed the adherence of these guidelines on the initial pre-operative management of tetanus prone open orthopaedic injuries in trauma patients admitted for surgery. material and methods: a retrospective case note review was conducted on patients admitted to the orthopaedic department for intervention with a tetanus prone wound between february and june . tetanus prone injuries included open fractures, soft tissue injury requiring surgical intervention that is delayed for > h, wounds with significant devitalised tissue, wounds in contact with soil and open injuries containing foreign bodies. we assessed to what extent these patients had their immunisation status ascertained, application of wound irrigation and appropriate dressing, correct tetanus prophylactic cover (tetanus toxoid booster versus human tetanus immunoglobulin) and appropriate administration of antibiotics. results: of the patients included in the study, ( %) of patients were considered to have a 'high risk' tetanus prone injury and ( %) patients were deemed as having a 'low risk' clean wound based on the nature and extent of injury. performance within the high risk category showed that % of patients had their tetanus immunisation status ascertained, % correctly received wound irrigation and betadine dressing, % of patients were appropriately given prophylactic antibiotics. only % of patients with a high risk tetanus prone wound received tetanus immunoglobulin and % of patients were given a tetanus toxoid booster as a method for prophylaxis. conclusion: our study showed that a large proportion of patients correctly received supportive wound care and antibiotics. we also demonstrated that patients with open tetanus prone orthopaedic injuries are not adequately receiving correct tetanus immunoglobulin as the indicated prophylaxis. a large number of patients were given tetanus toxoid instead, which does not protect immunity early enough to cover the acute injury period, thus posing a major risk of developing a devastating and largely preventable infection. the orthopaedic and trauma doctor attending these patients must adhere closely to the correct initiation of simple measures in the management of tetanus prone orthopaedic wounds. all patients were irrigated and debrided, before the application of vac system. required debridements were maintained during vac therapy. time elapse between the injury time and vac application time was days on the average (min , max ). when the granulation tissue became sufficient to cover the bone, these wounds have been closed secondarily with several methods. time elapse between the start of vac and wound closure or formation of sufficient granulation tissue for grafting was days on the average (min , max ). results: distribution mean postinjury time for the osteosynthesis was , hours. three of these wounds were closed spontaneously without any need for other wound closure procedures. split thickness grafting is applied in patients, free flap to patients, full thickness grafting to patients, secondary suturing was applied in wound to close it. there was no infection in any extremities that we had osteosynthesed by internal or external methods. conclusion: wound care is as much important as osteosynthesis in open fractures. even if osteosynthesis is successful, failures in wound care may result in loss of extremity. vac alone does not suffice for wound closure. expectation in this therapy is to obtain ideal granulation tissue and to prevent infection development via appropriate wound care. the greatest disadvantage of vac therapy at the time being is its high economic cost. introduction: surgical haemostasis in trauma patients can be difficult and hazardous. commercial products are promoted to accomplish this task at a reasonable cost. in this study we compared the effectiveness of two topical gelatin-based haemostatic agents, flosealÒ and surgifloÒ in a porcine liver trauma model. material and methods: we compared the activity of flosealÒ (with human or bovine thrombin), surgifloÒ and surgifloÒ with added bovine thrombin in two porcine models. one anesthetised piglet mimicked ''normal'' conditions, while the other was kept in a status of hypotension, hypothermia and haemodilution, necessitating inotropic support (''critically ill''). laparotomy was performed, after which we inflicted five identical stab wounds on each liver lobe. each wound was treated with one of the four agents, while one wound was kept as a control. haemostasis was evaluated clinically. after euthanizing the piglets, the pathologist performed a macroscopic, microscopic and electron microscopic evaluation, blinded for which agent was used in which wound. results: clinically, surgifloÒ was able to produce a clot in some of its applications in the healthy piglet (''normal'' conditions), which was not the case in the critically ill animal, not even with the added thrombin. flosealÒ induced clotting in every wound. both microscopic (hematoxylin and eosin and mallory stain) and electron microscopic examination of the stab wounds confirmed that flosealÒ created a stable and dense agglomerate of gelatin and fibrin, firmly attached to the adjacent liver tissue, whereas with surgifloÒ, the gelatin contained more air bubbles, there was a lot less fibrin included in the clot and the clot was not strongly adherent to liver tissue. conclusion: it would seem that flosealÒ is a superior haemostatic agent, creating a dense and stable blood clot, even in a critically ill animal, hence ensuring haemostasis. disclosure: no significant relationships. introduction: bleedings stemming from splenic traumas are still among important causes of morbidity and mortality. aim of this study is comparison of fibrin glue with hemostasis effectiveness of ankaferd blood stopper lower lob resections on spleen of rats. material and methods: the study was performed at the animal laboratory of istanbul university after obtaining an approval from the ethics committee. twenty-four rats were randomly divided into three groups, namely, fibrin glue group (n = ), abs group (n = ) and control group (n = ). a wedge resection was performed on the lower lobe of the spleen. in fibrin glue group, spleen was hemostasis with fibrin glue (tisseel), while abs was administrated on the lower lobe surface in abs group. chronometric measurements were made to determine bleeding times. blood samples from the tail and vena cava were used for whole blood count and blood chemistry. histopathological scores were measured postoperatively on day th. results: in abs group, chronometric bleeding period is , s. whereas in fibrin glue group it takes , secods (p > , ). it was noted that the hemogramme test results, hemoglobin and hematocrit levels on the th days of abs and fibrin glue groups did not show sensible differences from one another ( . vs . ) p = . ( , vs , ) p = , . conclusion: there are no differences between the hemostasis speed and effectiveness of ankaferd blood stopper and fibrin glue as an applied material in bleeding stemming from experimental partial lower lob resections on spleen of rats. of the hemoperitoneum in right iliac fossa was performed and days after trauma, resulting in drainage of and cc of blood. patients were discharged month later and follow up was successful. conclusion: in selected hemodynamically unstable patients and upon availability of appropriate facilities, nom can be safely challenged over the usual limits. the indicators of tissue perfusion such as ph and be seems to be more reliable and sensitive prognostic parameter than hemodynamic instability evaluated by blood pressure and heart rate, in selecting the patients needing surgical control of hemorrhage. a moderate iah in young patients able to tolerate an increased intra-abdominal pressure, can allow a mechanical compression of the injured parenchyma achieving the arrest of hemorrhage, and extend the indications for nom in selected hemodynamically unstable patients, without signs of severe tissue hypoperfusion. material and methods: our case describes a year old male who fell m and landed on the right side of his torso dislocating a rib through the diaphragm, causing a transecting grade liver injury to liver lobes iv and vii, the right hepatic artery and a lesion of the retrohepatic vena cava (vc). the patient presented alert, hemodynamically stable with normal breath sounds. ct scan showed right sided hemothorax and a grade liver injury. a right sided chest tube drained ml of blood. the patient became unstable and was transferred to the or. profuse haemorrhage from the liver was encountered and massive blood transfusion protocol was initiated. the right hepatic artery showed to be injured and was ligated. pringles manoeuvre and packing of the liver were not enough to control the bleeding. an injury to the retrohepatic vc was suspected and manual compression was not sufficient to gain control. endovascular assistance was called for and using a bilateral femoral vein approach two occlusive balloons were placed and inflated under x-ray and open view in the vc to gain proximal and distal control. the patient stabilized and the injury to the vc could be sutured and covered with a topical haemostatic agent. the balloons were deflated but were left in place as a security measure. the liver was then again packed. the pringle manoeuvre had intermittently been used for approximately h in total. two vessel loops were left tension free around the hepatodoudenal ligament and brought out through the midline incision as a security measure. units of rbcs, units of ffps and units of platelets were given. angioembolization of the right hepatic artery was performed after the first surgery. during the second operation, the haemostats, vessel loops and occlusion balloons could safely be removed. days after the injury the patient showed increasing signs of liver failure. the patient was accepted for liver transplantation days after the injury; this procedure was carried out successfully. the combined open and endovascular approach in this case was crucial. the nature of the injury, the pringle manoeuvre, packing of the liver and arterial embolization caused permanent damage to the liver which had to be managed with liver transplantation which was successful. the use of endovascular occlusive balloons might also have had a role in the permanent damage of the liver, but had great benefit in saving the patients life. introduction: the incidence of pulmonary failure in multiple trauma patients is postulated to be influenced by several factors such as thoracic trauma and liver injury. the incidence of pulmonary failure increases in patients with an abbreviated injury scale thorax ‡ (ais) and they are more likely to face poor outcome. thus, the aim of the present study was to test the hypothesis that patients sustaining significant thoracic trauma (ais thorax ‡ ) in combination with a relevant liver injury (ais liver ‡ ) are more likely to develop pulmonary failure when compared to patients which sustained thoracic trauma without additional liver injury. material and methods: records of multiple trauma patients documented in the trauma registry of the german society for trauma surgery were analyzed using uni-and multivariate analyses. patients were subdivided into four groups according to their liver and thoracic injury: group (ais thorax < ; ais liver < ); group (ais thorax ‡ ; ais liver < ), group (ais thorax < ; ais liver ‡ ) and group (ais thorax ‡ ; ais liver ‡ ). potential relevant variables were subjected to univariate analysis between groups using the chi square test to predict the probability for pulmonary failure rate. subsequently, multivariate logistic regression analysis was performed, employing pulmonary failure as the dependent variable. differences at the level of p < . were considered statistically significant. results: , patients with a mean age of . ± . years and a mean iss of . ± . points fulfilled the inclusion criteria and were enrolled in this study. the overall rate of pulmonary failure was ± %. % of the patients in group , % in group and % in group developed pulmonary failure. the largest proportion of patients ( %) who developed pulmonary failure was found in group . those factors which proved to show a significant correlation with the incidence of pulmonary failure were included in a subsequent multivariate analysis. however, the presence of relevant lung injury, male gender, pre-existing medical conditions (pmcs), transfusion of more than packed red blood cells (prbcs) as well as iss and age played a significant role. in contrast to our hypothesis, liver injury did not proof to be associated with the incidence of pulmonary failure. conclusion: pulmonary contusion and significant liver injury seem to have a synergistic effect on the incidence of pulmonary failure. however, multivariate analysis with adjustment of further relevant factors reveal, that liver injury is not a predictive factor for the incidence of pulmonary failure. rather male gender and reported pmcs together with relevant lung injuries are more likely to develop pulmonary failure following multiple trauma. nethertheless, patients with combined pulmonary and liver injury are at higher risk for pulmonary failure with critical outcome. disclosure: no significant relationships. introduction: thoracic trauma is the leading death cause in % of politraumatised patients and contributes to the death of another % of these fatalities. identifying the determining causes, assessing their severity, early and qualified intervention in a multidisciplinary team may improve outcome of these patients. the goal of this paperwork is to assess the effects of thoracic trauma on clinical management, morbidity, mortality and outcome. material and methods: retrospective study of politraumatised patients admitted in the emergency department of st. pantelimon hospital between jan and jun . the followed parameters were most common injuries, severity, mortality, survival rate correlated with iss and rts, using data from emergency charts, hospital charts and anatomopathologic exams. results: out of patients, associated thoracic trauma, with a survival rate of , %. patients had blunt trauma. injuries that claimed early surgical intervention and had the highest death rate were: massive haemothorax patients ( % mortality rate), aortic and great vessels injuries patients ( % mortality rate), open pneumothorax patient ( % mortality rate), tension pneumothorax patients ( % mortality rate), flail chest patients ( % mortality rate). conclusion: thoracic trauma is often associated to politrauma and may increase significantly the mortality rate of these patients. lifesaving surgical procedures must be immediately performed, on patient arrival. it is important to adopt intervention protocols for multiple trauma, with a leading role of the emergency department medical staff. disclosure: no significant relationships. introduction: to evaluate treatment modalities of penetrating and/or contusive hemothorax, we reviewed our experience with patients admitted for traumatic hemothorax to our center for thoracic surgery. material and methods: from january to we treated consecutive patients (mean age, + sd years; m/f, / ) presenting traumatic hemothorax: patients had contusive hemothorax (cont) following car accident ( %), fall ( %), motorbike accident ( %), crushing trauma ( %), bike accident ( %); patients had penetrating trauma (pen) following stab wound ( . %), gunshot ( %) and impalement ( . %). we recorded demographic data, injury severity score (iss) at admission, endo-and extrathoracic injuries, method of treatment and outcome. results: there were no statistically significative differences between cont group and pen group regarding mean age ( vs years), gender (m/f = / vs / ), mean iss ( vs ) and icu admission rate ( % vs %). the cont group however presented a higher rate of extrathoracic lesions (bone, visceral, cns) than the pen group ( . % vs %: p < . ). in all patients a chest tube was immediately inserted, as the definitive treatment in % of cont pts and in % of pen pts (p < . ). surgical introduction: evaluation of penetrating injuries to the chest presented at a level traumacenter. the main study question was to see whether there was an increase in incidence in time. material and methods: in this retrospective study fifty-nine consecutive patients were included with penetrating injuries of the chest during the period of june until june . the penetrating injury had to be caused by gunshot or stab incident. statistical analyses of the data was performed using spss . . results: the study group consisted of fifty-nine patients. ninety percent were male with a mean age of years (range - ). the mechanism of injury were stab ( , %) and gunshot wounds ( , %). sixteen patients required a thoracotomy. in four other cases a laparotomy was performed. twenty-two ( , %) patients were admitted to the icu. the number of patients treated in the first year of the study period ( of the patients with a shotwound % died of their injuries and mortality rate of the patients with a stabwound was . %. in the last year of the study period the mortality of gunschot wounds was . %. conclusion: there is an increase in incidence of penetrating injury of the thorax for both stabwounds and gunshot wounds. the increase of gunshot wounds was especially large in the period july -june . the risk of suffering a gunshot or stabwound to the chest in our traumaregion is gender related. with the increase in the number of gunshot wounds, and thus experience, the mortality seems to decrease. introduction: rib fractures and more specific the flail chest are currently treated conservative. in our level one trauma centre we have on average patients with rib fractures and flail chests/yr. until recently we mainly treated the patients conservative. according to the literature the morbidity and mortality increases twofold with or more ipsilateral rib fractures and an age > yrs old. , some studies have also shown that operative fixation of rib fractures may reduce the morbididity significantly with this data and the recent development of specific dedicated osteosynthesis material for rib fractures we devised a pilot study in order to analyse the efficacy of this new matrixÒ rib fixation system (synthesÒ) and the effect on the morbidity/mortality of the patient. material and methods: during a month period we included all patients with the before mentioned criteria( rib fractures, > yr) or with a flail chest. we analysed operation details, lenght of icu stay, hospital stay and recorded complications. the results were compaired with a matched control group from . results: patients were included with an average age of yrs and a m:f distribution of : . patients had a flail chest and patients had or more rib fractures. on average all patients were operated within days ( - ). on average ( - ) rib were stabilized with an operating time of min ( - ). no implant failures were seen. patients had an average icu stay of days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . total hospital stay for the whole group was days ( - ), specific for flail chest it was days and for the ipsilateral rib fractures it was days. one patient sustained an extra rib fracture due to the procedure and one patient sustained an iatrogenic pneumothorax. one patient died due to neurologic complications. one patient had a superficial wound infection. no deep infections, pneumonia or chest related mortality occurred. compared to a matched control group of , the overall length of stay was not significant different. vs days. the length of stay for the ipsilateral fractures was not significantly shorter, vs . however the length of stay for the flail chest was significantly shorter in the study group vs (p < . ) the control group had significant more pneumonia, vs (p < , ). conclusion: the new matrixÒ system is easy and safe to work with. the system has good stabilizing capabilities. operative treatment reduces pneumonia and length of stay with flail chest. these results warrant a randomised study, comparing operative treatment vs conservative treatment. introduction: severe thoracic wall injuries can result in long time icu stay with ventilatory support substantial morbidity and even death. if the patient recovers persistent thoracic wall pain, restricted respiratory capacity and/or non union of the rib fractures can be the consequence. in a systematic review of literature we demonstrated that there is some evidence that early internal fixation can shorten the on-ventilator time, the icu stay and lower the short time morbidity. long term pulmonary function is not altered by internam fixation, however the rate of rib nonunion and chest wall pain is decreased. however high quality evidence is lacking. in order to evaluate the feasability of rib osteosynthesis with a new plating system: the synthes matrix system a preliminary study is performed and its results presented. this study preceeds a randomised controled trial comparing plate ad screw osteosynthesis and conservative treatment. material and methods: consecutive patients with flail chest and or serial rib fractures involving at least five ribs necessitating measures other than analgetics to maintain pulmonary function are included and prospectively documented. exlusion criteria: *hemodynamic instability necessitating a damage controle approach *intrathoracic injuries necessitating surgery *normal pulmonary function *patient refusing surgical treatment *patient not available for follow-up all patients are operated upon with use of the matrixrib system. postoperative icu stay, on-respirator time, pain at defined moments of follow-up, healing of the rib fractures and complications are recorded prospectively. patients grade their rate of satisfaction (functional and esthetical) on a scae of to . the results in these patients concerning on-ventilator time, icu stay and morbidity are compared to a historical series of patients with comparable iss. prospective case series with historical control group.(level iii) results: preliminary data indicate: *a shorter time on ventilator than anticipated (based on comparisson to historical data) * a shorter time on icu * less pneumoniae * no intra-operative complications * good healing results of the rib fractures * no implant failures * acceptable pain scores * good overal satisfaction * acceptable cosmetic results conclusion: internal fixation of rib fractures (flair chest or multiple sequential fractures with pulmonary function compromise) results in a earlier recuperation of pulmonary function with shortened icu stay. the overal satisfaction of the patient after operative treatment is good, with acceptable cosmetic results. there were no implant related complications. these results form the basis for a randomised control trial comparing operative fixation with the matrix rib system to conservative treatment. disclosure: no significant relationships. a. e. elsherif , m. fawzy , n. badr , m. marashda surgery, tawam hospital/johns hopkins international, abu dhabi, uae, surgery, tawam hospital, abu dhabi, uae, surgery, tawam hospital/johns hopkins international, abu dhabi, uae introduction: acute airway emergencies result from a wide variety of malignant and benign diseases. for both the patient and the clinician, the presentation can be frightening, and advanced interventional pulmonary/endobronchial techniques are required to achieve prompt relief of symptoms. general anesthesia is sometimes prohibited in these situations with complete loss of airway. we report our initial experience with these patients in a tertiary referral center. material and methods: three patients (two males) with acute proximal airway emergencies were included. two patients presented with acute stridor. the third presented with massive bronchial air leak and purulent drainage after an acute traumatic event. all patients were treated emergently with bronchoscopy and placement of an ultraflex bronchial stent under local anesthesia. all patients were followed up after discharge. results: there was no perioperative mortality or morbidity. the median age was . one patient had anaplastic thyroid cancer obstructing the trachea and was denied treatment elsewhere. the second patient had a malignant tracheoesophageal fistula. the third patient had an acute bronchopleural fistula following pneumonectomy for a gunshot wound. complete symptom relief was obtained after stenting under local anesthesia in all patients. median length of stay was days for the patients with malignancy. on a median follow up of months; two patients were symptom free, one patient died from malignant disease progression. conclusion: stenting under local anesthesia is feasible with acute airway emergency. obstruction of the central airways by malignant tumor is associated with poor prognosis.the alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life the primary goal rather than cure. introduction: on april th an earthquake measuring . on the richter scale stuck a large area of the abruzzo region in central italy. the first notice suggested a lot of injured people and destroyed structures, incuded the main hospital of the area, the san salvatore hospital. material and methods: the national civil protection immediately send the field hospital (fh) of the marche regional government, the neighbouring region, together with a large amount of medical staff and personnel by the non governmental organization ares (regional association sanitary emergencies). this association, already involved during other national and international disaster situations and relief efforts, sent professionals volunteers (md and nurses) whit disaster knowledge and specific medical specializations. the international literature demonstrated that a fh is a complex structure and often the time required to be completely functionally is very long, indeed longer than the affected people needs. results: from april th , june th when the mission ended, the fh provided medical treated to almost patients, and the ares personnel ( ) where backed by the sanitary personnel of the san salvatore hospital. conclusion: a well planned medical response is very important to provide health assistance during a disaster, yet it is very hard to substitute a damaged hospital in the hearth of the disaster area. a modular sanitary structure, very light at the beginning, with specific and restricted medical supplies, with a little number of specialists in disaster medicine and disaster logistics, could improve the already good results obtained in the l'aquila abruzzo mission. disclosure: no significant relationships. around , people died, twice as many were injured, and almost million people were made homeless. in any situation of disaster, both natural and complex, may be produced a large number of victims that defeat the ability of local health resources to provide adequate health care. on one hand, the system may be overwhelmed with a high number of casualties. on the other hand, hospitals and other health care facilities generally may be compromised heavily: buildings may be destroyed or damaged and the supply of water, electricity, medical gasses, etc. may be limited. the transportation infrastructures may be severely damaged, creating problems for both people and equipment arriving at the hospital. damage to the health care infrastructure will further compromise the delivery of health services. material and methods: italian government responded immediately to this emergency after the official request for international relief efforts from the president of pakistan. two days after the impact, the first italian evaluation emergency team was already arrived in pakistan and the initial field structure was already fully operative, offering medical care, especially advanced trauma care and life support intervention, provided by specialists. later, when the structure had been completed and became larger provided also hospitalization, and surgical abilities, appropriate treatments and essential drugs. all the medical activities of the responding italian mission team field hospital in manshera were recorded and evaluated. results: a total of , patient contacts occurred at the field hospital during the days it operated, patients were admitted in the field hospital with a total number of nursing days with a average length of stay per admission of , days and with the occupancy rate of , %. a total number of major operations were performed. introduction: mass casualty incident's (mci) management is a present problem which is now more frequent because of iraki, afghan wars and terrorists actions. numerous new plans are evolved in each emergency association or military organization. nato as built a ''masscal'' plan to help teams in role ii in afghanistan to take care mci. through two experiences of mci in french role ii in afghanistan (kaboul) and through the litterature, we discuss the different ways of taking in charge mci. material and methods: the french role ii is located in kaboul near helicopter area. there are surgical teams ( pax, nationalities), emergencies boxes, icu beds and operating theatres. we have a pool of blood units, an echograph, a first generation ct-scan and all materials for traumatologic surgery. for mci, we use nato triage classification. each trauma undergoes ressucitation room, has needing x-ray exams, fast echography and intensive care if necessary. patient who needs urgent surgery runs immediately to operating theatre. iss score is calculated. the first mci concerns patients involved in a suicid bomber's explosion near the role ii. all were taken in charge min later. the second concerns an attack against a french coy occured km in the east of kaboul. there were casualties and soldiers died. they were taken in charge belatedly between to h later. results: fisrt mci : surgical interventions, one %burned, and a blast injury. second mci : surgical interventions, injuries with no surgery, blast injuries. we organize for these second mci a stratevac in france for casualties in less than h. mean iss score is for alive injuries and for the died soldiers. through these mci, we analyse the litterature and discuss about presents concepts in mci management. conclusion: the contemporary history of war, especially in iraqi and afghanistan constrains military surgical teams to improve their way of management of mci. training is necessary. first of all we have to define clearly each place of each actor, the conditions of triage, wich priority for which surgery and the possibility of modern communications and fast and efficient transports. the lower extremity ( %). % suffered multiple severe injuries, % upper extremity injury, % upper extremity and head/neck injury, % back injury, % head/neck injury, % upper and lower extremity injury, % abdominal injury and % miscellaneous. patients ( %) underwent an primary amputation of one or more extremities. ( %) patients underwent secondary amputation. all primary amputated limbs were shortened later. patient ( %)died one day after arrival in the cmh because of multiple severe injuries. conclusion: this single-center, and therefore complete dataset of the repatriated military personnel demonstrates the impact of participating in a nato mission for a small european country. it puts a high and challenging burden on the shoulders of the medical personnel in our hospital. further it shows, in contrast to studies from owens and dougherty, a higher prevalence of lower extremity injuries than upper extremity injuries. data regarding admission time, infection rate, disposition and quality of life will be presented. a lot of medical-ethical decisions had to be made about continuation of medical threatment or to decide whith patient will be treated and with patient will not be treated. as war surgeon you have to do operation for which you were not educated. because there is no other surgeon you have to the operation or the patient will die. it gives the opportunity to learn and gives a lot of surgical experience. this can be useful in civilian circumstances also. conclusion: the period as war surgeon in afghanistan has been of a forse impact. i had to take a lot of medical-ethical decisions and to do operations in which i was not trained. but i have learned a lot about war surgery and on human aspects also. introduction: there are a lot of unique challenges for the medical personnel which are assigned to the combat environment in afghanistan. especially the medical groups are in contact with patients from different nationalities and with different characteristics under special and difficult war circumstances. this article evaluates the effectiveness of the co-operation between a german and a greek surgical team during a -month period in a role ii hospital in north afghanistan. material and methods: from st july through th september , patients were admitted. there were male ( %) and female ( %). we reviewed the type of diseases, mechanism and location of injuries, management, type of surgical procedures performed, blood supply and outcome. results: . % of the patients were international security assistance force (isaf) personnel. most of the patients were men in a percentage of %. four children were included among the local patients. . % of the patients had surgical diseases while the rest . % were of orthopaedic interest patients. ( . %) patients underwent a surgical operation; ( . %) of them were operated immediately. gunshots were the main mechanism of injury for local patients whereas isaf personnel were usually presented with burns after improvised explosive devices (ieds) and rocket attacks. conclusion: the co-operation between medical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in order to manage war casualties. introduction: in the emergency caused by natural and social disasters there are evident deficits between the health needs of affected population and the local health system capacity. the causes of disasters are various and not predictable, usually the health structures can not face up to the population needs. knowing that disaster medicine has different protocols and materials from ordinary medicine structures and that improvisation during the disaster's acute phases is not a good practice, it has been created an emergency operating health group, the non-profit ares association. (regional association sanitary emergencies) material and methods: the ares, whose members are about , all over the nation, is configured as an extraordinary health resource, activated by the national civil defence operations centre, in according with the regional centre of marche, in disater situations results: the main objectives of ares are training and organization of medical staff and structures and its growth crosses several missions including: ae earthquake in molise, introduction: cephalomedullary nails rely on a large lag screw that provides fixation into the femoral head. there is an option to statically lock the lag screw (static mode) or to allow the lag screw to move within the nail to compress the intertrochanteric fracture (dynamic mode). the purpose of this study was to compare the biomechanical stiffness of static and dynamic modes for a cephalomedullary nail used to fix an unstable peritrochanteric fracture. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was then inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and the cephalomedullary nail was reinserted. mechanical tests were conducted for axial, lateral, and torsional stiffness with the lag screws in: ) static and ) dynamic modes. a paired student's t-test was used to compare the two modes. results: the axial stiffness of the cephalomedullary nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than in the dynamic mode ( . ± . n/mm) (fig a) . similarly, the lateral bending stiffness of the nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than the dynamic mode ( . ± . n/mm). the torsional stiffness of the nail was significantly greater (p = . ) in the dynamic mode ( . ± . n/mm) than in the static mode ( . ± . n/mm). a post hoc power analysis with a = . and ß = . revealed that the paired t-test on samples was sufficiently powered to determine a difference in mean axial stiffness of . n/mm ( . % of static stiffness), a difference in mean lateral bending stiffness of . n/mm ( . % of static stiffness) and a difference in mean torsional stiffness of . n/mm ( . % of static stiffness). conclusion: our results show that there is a n/mm reduction in axial stiffness of the cephalomedullary nail when the lag screw is changed from static to dynamic mode. this represents a . % reduction in axial stiffness with a change from axial to dynamic modes which may be clinically significant. the differences in lateral ( . n/mm, . %) and torsional ( . n/mm, . %) are small enough that they are likely not clinically significant. we felt that a difference of greater than % in axial stiffness and a difference of greater than % in lateral or torsional stiffness would be clinically significant. our study was adequately powered to detect these differences. given the significant reduction in axial stiffness with dynamization of the cephalomedullary nail construct, we recommend use of the static mode when treating unstable peritrochanteric fractures with a cephalomedullary nail. disclosure: no significant relationships. introduction: minimizing tip-apex distance has been shown to reduce clinical failure of sliding hip screws used to fix peritrochanteric fractures. the purpose of this study was to determine if such a relationship exists for the position of the lag screw in the femoral head using a cephalomedullary device. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and repaired using one of lag screw placements in the femoral head: ) superior (n = ), ) inferior (n = ), ) anterior (n = ), ) posterior (n = ), ) central (n = ). mechanical tests were repeated for axial, lateral and torsional stiffness. all specimens were radiographed in the anterioposterior and lateral planes and tip-apex (tad) distance was calculated. a calcar referenced tip-apex distance (caltad) was also calculated. anova was used to compare means of the five treatment groups. linear regression analysis was used to compare axial, lateral and torsional stiffness (dependent variables) to both tad and caltad (independent variables). results: anova testing proved that the mean axial (p < . ) and torsional stiffness (p < . ) between the five groups was significantly different, but lateral stiffness was not statistically different (p = . ). post hoc analysis showed that the inferior lag screw position provided significantly higher mean axial stiffness ( . ± . n/mm) than superior ( . ± . n/mm; p < . ), anterior ( . ± . n/mm; p = . ) and posterior ( . ± . n/mm; p = . ) lag screw positions. there as no significant difference in mean axial stiffness between inferior ( . ± . n/mm) and central ( . ± . n/ mm) lag screw positions (p = . ). post hoc analysis revealed significantly less mean torsional stiffness for the superior lag screw position compared to other lag screw positions (p < . all pairings). there were no significant correlations between tad and axial (r = - . , p = . ), lateral (r = - . ,p = . ) or torsional (r = . , p = . ) stiffness. there were significant correlations between caltad and axial (r = - . , p < . ), lateral (r = - . , p = . ) and torsional (r = - . , p = . ) stiffness. conclusion: our results suggest that placement of the lag screw inferiorly in the femoral head when using a cephalomedullary nail to treat an unstable peritrochanteric fracture results in the stiffnest construct in axial and torsional biomechanical testing. a simple radiographic measurement, caltad, provides an intraoperative method of determining optimal cephalomedullary nail lag screw position to achieve greatest construct stiffness. introduction: a potential of polymethylmethacrylate (pmma) augmentation to increase the purchase of cephalic implants in the treatment of intertrochanteric hip fractures has been proven in sev-eral biomechanical studies [ ] [ ] [ ] [ ] . the aim of this study is to compare the cut-out ratio of pmma augmented helical blades to not augmented ones in human cadaveric femoral heads. material and methods: six pairs of osteoporotic cadaveric femoral heads were instrumented with a proximal femoral nail antirotational (pfna) blade in a standardized manner. within each pair, one blade was augmented using ml of pmma cement. cyclic loading was performed at hz. starting at n, the load was monotonically increasing by . n/cycle until failure of the construct. x-rays were taken at cycle increments to monitor the movement of the blade with respect to the head. paired nonparametric test statistics were used to identify differences between groups. results: a significant higher number of cycles to cut-out was found for the augmented group (p = . ). a significant correlation was observed between bone mineral density and cycles to cut-out for the non-augmented specimens (p < . , r = . ), whereas no correlation was found for the augmented group (p = . introduction: when treating distal tibial deformities or fractures with the ilizarov external fixator the ankle joint and foot is often transfixed within the ring construction. for some patients full weight bearing can only be achieved in assembling a walking device on the distal ring. the biomechanical effect of the indirect loading on the fixator stiffness, the osteotomy and the wire tension is still unkown. material and methods: on the basis of a standarized ilizarov external fixator ( rings, mm diameter) with two , mm wires per ring applied in anatomical position on composite tibiae ( rd generation sawbones) direct and indirect loading was analyzed using a universal testing machine (model , uts germany). a middiaphyseal osteotomy of , mm was performed. the following parameters were recorded: micromotion at the osteotomy, relative movement between bone and rings, compressive forces at the osteotomy and strain of the wires. each experimental setup was tested ten times with kg maximal axial loading. results: the osteotomy gap closure occurred at n at direct loading and at an average of n at indirect loading. the compressive forces at the osteotomy were almost double as high at direct loading. regarding the relative motions between rings and bone the amplitude of motion was higher at indirect loading. the stress on the wires was up to four times higher when the walking device was applied on the distal ring for indirect loading. conclusion: the indirect loading using a walking device has a substantial influence on the mechanical characteristics of the ilizarov fixator which determine the biomechanical environment of the osteotomy/fracture. the results showed a higher mechanical load while achieving less compressive forces at the osteotomy. in the need of the walking device we suggest to apply additional half-pins at least in the distal fragment. ) . three randomized groups of pairs were formed. after the osteosynthesis with the implants was done the fracture (a . ) was made with a jigsaw. for further destabilsation the troch. minor was removed. the femura were fixed in the testing machine and tested under dynamic condition with a physiologic load for normal walking ( . x bodyweight) under cycles. we measured the load on the implant, the migration and rotation of the bone around the implant. the data was dokumented with lab view, results: the intramedulare implants showed significant lower migration rates (mean . mm) of the head compared to the extramedular implants (mean . mm). the rotation of the head around the lag screw startet earlier within the dhs an showed higher rates (mean °) followed by the gamma (mean °) until the end of the cycle. the best stabilisation against rotation was documented for the pfn a (mean °). the post x-rays showed a significant migration and sintering process of the femoral head with lateralisation and fracture of the lateral wall. this was even higher in probes with a low bmd. introduction: excising part of an implant through the femoral head is a rare but severe complication of osteosynthesis of proximal femoral fractures. there is little evidence in the literature about incidence and management of this complication. according to opinion leaders in an recent international user meeting most cases end up in total hip arthroplasty (tha). the value of re-osteosynthesis remains unclear. most patients that suffer an excision are geriatric and multimorbid patients, rather suitable to less invasive revision surgery. to assess the incidence and management of cutting out of the pfna blade (proximal femoral nail antirotation by synthes gmbh international) was the aim of this multicenter study. material and methods: the incidence and management of excision of the pfna blade in trochanteric femoral fractures was assessed retrospectively in cases in participating hospitals all over europe in a time period between and . all implantations were screened for this complication. the preoperative, follow up x-rays and patients' medical records including the surgical reports were collected and analysed with a special focus on revision surgery until union or tha. results: the incidence of excision of the implant was . % ( / ). the mean age of patients was years. % of mostly female ( %) patients sustained an unstable a fracture according to the ao classification. final revision surgery was performed with tha in cases ( %). in cases re-osteosynthesis led to union ( %). reosteosynthesis was either exchange of blade with or without cement augmentation alone or re-nailing. in % of tha revisions additional revision was necessary. in % of revisions with exchange of blade additional revision was required (all tha). % ( / )of revision cases with cement augmented blades healed. in % of revision with re-nailing, additional surgery was inevitable. on average . operative procedures were performed after excision of the pfna blade. conclusion: cutting out of the blade of the pfna is a rare complication. nevertheless the management after removal is challenging as indicated by the high number of surgical revisions. revision with total hip arthroplasty showed a lower rate of reoperations compared to re-osteosynthesis. nevertheless % of all revision cases were managed successfully with a minimally invasive osteosynthesis. this gives a rationale for osteosynthesis in managing this complication in geriatric multimorbid patients with a high risk for operation. references: . simmermacher, r. k., j. ljungqvist, et al. ( ) . ''the new proximal femoral nail antirotation (pfna) in daily practice: results of a multicentre clinical study.'' injury ( ) in a prospective series of subtrochanteric fractures with or without involvement of the pertrochanteric region and in revision procedures of this area the pf lcp was applied. in out of patients a fixation failure was observed. this paper reports on these fixation failures. material and methods: all patients with a multifragmented subtrochanteric fracture with or without involving the trochanteric or the femoral neck region which where judged to present a compromised nail entry point from may until may were stabilized using the pf lcp. the plates were applied in a minimally invasive manner through soft tissue windows (mipo). intrinsic stability of the fixation was increased by excentric drilling or applying the tensioning device. all patients were followed up to fracture healing. intraoperative and postoperative complications were noticed. intraoperative and postoperative x-rays were analysed using the ccd angle and the gardens alignment index. results: we report out of patients who sustained a fixation failure with secondary varus collapse requiring revision surgeries until healing. revision consisted in a reosteosynthesis in one, a plate exchange to a o blade plate in the second and a dhs in the third patient. in all our reported cases of implant failure the posteromedial buttress was missing [two ao a and two seinsheimer type v], and all patients were not able to restrict wheight bearing due to different reasons like, noncompliance (alcohol abuse, limited force, advanced age) leading to increased axial bending forces and finally to breakage of the femoral neck screws with varus collapse of the fracture. conclusion: in conclusion the pf lcp proximal femoral plate . / . due to its guide wire technique allows for straightforward plate application and reduction also in very complex fractures of the trochanteric region, including fractures with extension into the greater trochanter or reverse oblique intertrochanteric fractures. however in fracture patterns with missing posteromedial support and limited ability to restricted weight bearing (e.g.: advanced age, additional handicap or mal-compliance) an alternative fixation device should be considered, e.g. the hook plate extension of the lcp proximal femoral plate to apply higher intrinsic stability of the fixation when using the tensioning device. further clinical and biomechanical studies are needed to evaluate the potentiality and limitation of this device for the treatment of these challenging fractures of the trochanteric region. the majority of the the former fixation was replaced by a blade plate. in % we performed a total hip prosthesis. in these cases we saw an overproportional tend to prosthesis-luxations. conclusion: we conclude that mechanical complications like cut out are a little more frequent after dhs-implantation and should be treated by change to a blade-plate-osteosynthesis. this allows a fracture consolidation in that the minor trochanter becomes that stable, that a regular total hip replacement becomes possible. this seems to be the best prevention of mechanical complications after posttraumatic hip replacement like luxations. disclosure: no significant relationships. introduction: hip fractures often concern elderly patients with a high degree of co-morbidity and therefore susceptible for the associated postoperative morbidity and mortality. according to the literature, several factors have an influence on the amount and severity of postoperative complications after hip fractures. low preoperative haemoglobin levels (hb) in elderly patients seem to be associated with increased short-term morbidity and even mortality after surgery. the aim of this study was therefore to establish the impact of anaemia and blood transfusion on postoperative recovery of hip fracture patients. results: there were women and men with medium age of , years ( - years) and with medium follow-up of years ( - years). the lesions occur in sports, % of the fractures occur while practicing soccer. the fractures were bimalleolar (n = ), medial malleolus (n = ), lateral malleolus (n = ), with sindesmotic lesion (n = ) and trimalleolar (n = ). months after surgery % of the patients returned to sports activity ant at months %. at months the younger patients (p = , ) and men (p = , ) returned earlier to sports activity. at one year % of the amateur and % of the professional athletes, had returned to sports practice. fractures of the lateral malleolus returned earlier in , weeks than medial malleolus fracture in , weeks. the smfa and aofas scores were high in all types of fracture. conclusion: correct treatment of instable ankle fractures in athletes, with anatomic reduction and preservation of the integrity of the articular surface, is crucial to the return to sports practice. the fractures that influence an earlier return were younger age, male sex and less severe fracture, and negative predictors were older age and female sex. athletes submitted to open reduction and internal fixation with adequate and precocious programme of physical rehabilitation, can return to the same level of sports practice, despite the seriousness of the fracture without pain and functional limitation( ). results: in all cases anatomic reduction could be achieved. no secondary dislocation was observed and all fractures healed uneventfully. conclusion: indirect reduction of the volkmann triangle from anterior makes an image intensifier mandatory and has potential of not achieving anatomic reduction due intercalated tissue. in larger fragments the fixation with a lag crew from anterior, the buttressing effect might not be sufficient to avoid secondary displacement. with the use a postero-lateral approach and dorsal plate for fixation of the volkmann triangle, it is possible to reliably obtain an anatomical reduction of the dorsal articular surface of the tibia, thus potentially minimizing the risk of posttraumatic osteoarthtitis. introduction: after ankle-and hindfoot fractures, edema often delays surgery and postoperative mobilisation. therefore effective treatment of edema is of great importance. the aim of this study was to evaluate the efficacy of the continuous lymphological multi-layer compression therapy and of the av-intermittent impulse compression (avi) in reducing ankle-and hindfoot edema. material and methods: randomized, controlled, single-blinded, clinical trial. patients ( ± years, m, f) with unilateral fractures of the ankle or hindfoot pre-or postoperatively were randomized into a) the control group (elevation and cold packs), b) the continuous multi-layer compression therapy group (cct) or c) the av-impulse compression group (avi). primary outcome was the pre-respectively postoperative reduction of edema as measured with the figure-of-eight methode . results: pre-and postoperatively the continuous lymphological multi-layer compression therapy (cct) showed a significant better edema reduction when compared to the control group. after three days of intervention the mean preoperative edema reduction in the control group was - . ± . mm ( . %) figure-of-eight methode vs. - . ± . mm ( . %) in the cct group (p < . ) and vs. - . ± . mm ( . %) in the avi group. three days postoperatively the mean edema reduction was - . ± . mm ( . %) in the control group vs. - . ± . mm ( . %) in the cct group (p < . ) and - . mm ± . ( . %) in the avi group. pre-and postoperatively the cct group shows moderate effect sizes after two days of intervention and large effect sizes after three days. avi is more effective when combined with elevation during off-session periods. conclusion: continuous lymphological multi-layer compression therapy leads to a clinical relevant and significant better reduction of ankle-and hindfoot edema as compared to the standard treatment with elevation and cold packs. av-intermittent impulse compression shows a tendency towards a better edema reduction compared to the standard treatment. continuous lymphological multi-layer compression therapy reasonably can be applied when edema delays operation or postoperative mobilisation. considering the avi application we strongly recommend to elevate the leg during off-session periods. introduction: the objective of the study is to define the global hospital costs of a group of patients that suffered from severe trauma. additionally we identify the distribution of the expenses between the different services and the different procedures fulfilled to the patient. ( ), season ( ), moon phases ( ), times on duty ( ) and weather condition ( ) . the observed mortality was adjusted with the risc based prognosis and the smr calculated. results: the selected collective had an average age of . years and % of the patients were males. the mean iss was . and the mean hospital mortality was of . %. for the time of day the highest rate of admission was between : and : p.m., with the highest numbers on saturdays. in the times of on-call duty (weekend, public holiday, weekday between : p.m. and : a.m.) twice as much trauma patients were delivered to trauma centers as within the regularly working hours. in summer, the admission rate was highest ( . %) and lowest in winter ( . %), with more victims of car accidents in autumn and winter as in the warm season and more victims of motor-and bicycle accidents in spring and summer as in the cold season. but none of the mentioned factors showed an effect on survival (smr between . and . ). the moon phases had no influence either on frequency of accidents nor on outcome. the effects of temperature was similar to this of the seasons: with warm temperatures/month less car accidents and more bike accidents occurred (and the opposite for cold temperatures). in the subgroup with temperatures under zero degree the mortality was % higher ( . %) than in the subgroups with temperatures above zero ( , to , , even though a similar iss ( , vs. , to , ) . in a second step a multivariat analysis was done in order to improve the predictive power, but none of the external factors could improve the prognosis. conclusion: there are large variations in the incidence of severe accidents due to time of day, day of week and time of year. but there is no effect of patient's outcome in regard to medical care in german trauma centers. the quality of medical trauma care is consistent around the day, the week and throughout the year. additionally, we observed an increasing difference between mortality rate and risc prediction rate from - , % to - , %, means less deceased polytraumatized patients than predicted. within the late secondary transferring patients with spinal cord injuries were leading ( %), followed by patients with pelvic injuries ( %), infections ( %) and complex extremity injuries ( %). conclusion: with this investigation, we tried to characterize the influence of the new mapping of germany on patient data using the example of the regional trauma network ''saar-(lor)-lux-west-rhineland-palatinate''. although, knowing a lot of interferences, we noticed an abrupt rise of primary admittances of trauma patients in our level- hospital since starting networking. among the load rejection for smaller hospitals this fact leads to a distinct concentration of the treatment of polytraumatized patients in specialized trauma centers. the improved routine by increased quantity could be responsible for the improvement of process and outcome quality in the treatment of severely injured patients. but, the enormous quantity of emergency patients also reflects a future challenge in dealing with emergency operations besides routine operations as well as seldom icu-beds in these trauma hospitals. the role of the nlfc is to work in parallel to doctor led clinics, assessing and treating uncomplicated musculoskeletal injuries with a favourable natural history. since its inception, throughput in this clinic has increased and with greater clinical exposure and training, the spectrum of referred injuries has also broadened. the aim of the present study was to determine patient satisfaction with the nlfc using a validated questionnaire with a specific emphasis on how patients viewed being seen by a nurse rather than a doctor material and methods: consecutive patients were prospectively recruited in the nlfc in january . patients were referred by their resepective consultants after reviewing the presenting history, examination findings and radiographs. after their consultation with the nurse, each patient was asked to fill in a item questionnaire consisting of different domains related to patient satisfaction based on a validated patient satisafction questionnaire adapted for use in the fracture clinic setting. results: there were respondents, men and women, with a mean age of years (range - years). questionnaires were completed by parents, by carers and the remainder by the patients themselves. the most common treated injuries were distal radial, metatarsal and metacarpal fractures. % of patients felt they received the best care from the staff working in the clinic with greater than eighty percent of patients registering satisfaction with the nurse's assessment of their injury, their bedside manner and the treatment and information given. only % of patients felt that they would rather be seen by a doctor for their injury. the highest rates of dissatisfaction related to the building and seating comfort. conclusion: generally, over % of patients were satisfied with their clinic visit with the vast majority of patients not having any objection to seeing a nurse rather than a doctor. patient satisfaction with treatment remains the ultimate outcome measure by which healthcare interventions should be assessed. the results of this study demonstrate the nlfc to be an effective method of managing selected patients in a clinic setting thus reducing the workload of patients which would traditionally be reviewed by the doctor. this has significant implications for improving opportunities for doctors training as well as reducing clinic waiting times. [ ] [ ] [ ] [ ] . the aim of this study is to evaluate the anatomical correlation between the lateral end of the clavicle and the attachment area of the supraspinatus tendon. material and methods: using a mathematical model based upon ct-scan data performed on healthy individuals, the dimensional correlation between the lateral and of the clavicle and the rotator cuff is analyzed. each individual is examined in supine position, using different positions of the arm (maximum external rotation, maximum internal rotation and maximum abduction and external rotation (''aber position''), respectively). for every position the contact area of the lateral end of the clavicle and the spupraspinatus tendon is calculated. results: six healthy individuals ( shoulders) could be included into the study. the average contact area between the lateral end of the clavicle and the supraspinatus tendon (%) is . % for maximum external rotation, . % for maximum internal rotation, respectively. in the aber position only / shoulders showed a contact area > % (av. . %). conclusion: according to these morphological findings the contact area between the lateral clavicle and the supraspinatus tendon is less than %. this contact zone is located in the dorsal aspect of the clavicle. therefore the additional resection of an osteophyte, especially at the anterior part of the lateral clavicle should not have a significant influence on the outcome after subacromial decompression. and good to moderate outcome in the cs (mean ), one patient had a moderate dash score of with a poor cs of . irrespective of treatment strategy the majority of the patients regained normal range of motion and grip strength in the affected shoulder. the most common complication was impingement of the shoulder, which occurred three times in the conservatively and four times in operatively treated patients. all but one conservatively treated patient with a non-union healed without complications. conclusion: minor ( £ mm) and moderate ( - mm) displaced greater tuberosity fractures can successfully be treated conservatively with good to excellent long-term rehabilitation of function with a low risk of complications. whereas there is no doubt that major displaced fractures (> mm) should be treated operatively, special attention must be paid to moderate ( - mm) displaced fractures, as the degree of displacement may be misinterpreted on plain standard radiographs. disclosure: no significant relationships. introduction: a recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. we studied impairment and disability an average of twenty-one years after injury in a cohort of dutch patient, with the hypotheses that ) objective measurements of impairment correlate with disability, ) depression and misinterpretation of nociception correlate with disability; and ) patients injured when skeletally mature and immature have comparable impairment and disability. material and methods: seventy-one patients were evaluated an average of years after injury. the majority of the skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the skeletally mature patients were treated with plate and screw fixation. objective evaluation included radiographs and measurements of range of motion and grip strength. questionnaires were used to measure arm-specific disability (disabilities of the arm, shoulder and hand: dash), misinterpretation or over interpretation of pain (pain catastrophizing scale-pcs-), and depression (ces-d). multivariable analysis of variance and multiple linear regression were used to analyse the ability of the independent variables to account for variation in the dash-score. (spss . , spss inc., chicago). results: there were men and women with a an average age of forty-one at time of follow-up (range, to ). fractures were classified as ao/ota-type a in patients (simple), b in (including wedge fragment) and c fractures in patients (comminuted). the average dash score was points ( to ) and % reported no pain. both rotation and wrist flexion/extension were % of the uninjured side; grip strength was %. there were small, but significant differences in rotation ( versus degrees, p = . ) and wrist flexion/extension ( versus degrees, p = . ), but not disability between skeletally mature and immature patients. the best predictors of dash score were pain catastrophizing, pain, ipsilateral injury and grip strength, explaining % of the variation in dash scores. pain alone accounted for % of variation in dash scores. conclusion: twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over % motion and grip strength) and disability after non operative and operative treatment respectively. patients that were skeletally immature at the time of injury had better motion, but comparable disability. disability correlated with pain and pain catastrophizing rather than motion. results: the mesenteric injuries vizualized on initial ct-scan were mesenteric vascular beading or extravasation in cases, and mesenteric infiltration or hematoma in cases. associated abnormalities of the gastrointestinal tract (thickening, abnormal enhancement, perforation) were present in / cases ( %). nine patients underwent surgery ( %), patients in the early hours, and others after a delay of more than h. indication for surgery was hemodynamic instability in cases and suspicion of bowel perforation in cases. in total, intestinal perforations were found in patients. three patients ( . %) died of associated injuries. no false positive scan has led to unnecessary surgery. however, the negative predictive value of initial ct was % for intestinal associated lesions. conclusion: the mesenteric injuries in blunt polytrauma patients are uncommon but serious. the whole body scanner is a powerful tool for the diagnosis of these mesenteric lesions. conservative treatment is feasible but a clinical and paraclinical reassessment is essential for early detection of intestinal lesions initially undiagnosed, or aggravation of initial lesions. disclosure: no significant relationships. introduction: drug smuggling by gastrointestinal concealment, body-packers, is an increasing problem in developed countries. although conservative treatment is usually successful in most cases, some of these patients suffer complications such as obstruction, gastrointestinal perforation or massive drug intoxication due to a leaking package. despite an urgent surgery and a careful management in the icu, morbidity and mortality remain high. our aim was to assess the outcomes of conservative and surgical management of these patients in our hospital, the referral centre for this entity in madrid. ( ) ( ) pre-hospital fatalities were more frequent (although not statistically significant), which may reflect improvement of trauma organization in recent years ( ) ( ) ( ) ( ) . domestic (may related to delay due to victim's solitude) and urban environment (inexperienced personnel, delay due to referral to another hospital) incidents lead more frequently in pre-hospital death. age and iss as indicators of physiologic reserve and severity of injury were independent predictors of fatality before the victim reaches hospital. introduction: the triad of the elbow is a complex traumatic injury. these injuries have traditionally been considered a poor prognosis for the consequences that arise as a secondary instability, stiffness and loss of functional ability. the objective of this free paper is to review from a clinical and radiological perspective our experience with cases. material and methods: we retrospectively reviewed patients with this type of injury. in patients was not carried out a comprehensive treatment of all existing lesions. the coronoid process was not addressed specifically and fractured radial head was removed or and an osteosynthesis was performed. in the remaining were treated by a treatment protocol trying to repair all the damaged structures (coronoid synthesis, radial head arthroplasty/orif and ligament repair, at least in the external lateral ligament complex). the median followup was months ( - ).the results were evaluated by the scale of may elbow performance score (meps), range of mobility, radiographic parameters and complications during follow up. results: patients treated according to protocol in a systematic manner trying to repair all damaged structures had better outcomes in both the radiological point of view as functional, as well as a lower rate of complications. meps in these patients the average was points (vs. the other group), the arc of º flexoextensió n (vs. º) and the arc pronosupinació n º (vs º). conclusion: despite being an injury traditionally associated with poor results, which have been established treatment protocols that try to treat all manner of injured structures involved in the injury outcomes have improved significantly. we think it must be performed a radial head artroplasty/orif (not resection), anchorage/ osteosynthesis coronoid process and a ligament repair at least of the external lateral ligament complex. if residual instabilty results it may be repaired the medial colateral ligament complex and a temporal external fixator may be used. disclosure: no significant relationships. tion. patients received a secondary implantation including chronic luxations, nonunions, failed osteosynthesis and reimplantation after deep prosthetic infection. the mean follow up was ± months. the functional outcome was measured by using the mayo elbow performance score. results: we had female and male patients with a mean age of ± years. all patients achieved very good results based on the ,,mayo elbow performance score'' with a postoperative mean of points (range between and points) with a maximum performance of points. the mean range of motion concerning extension and flexion was degrees ( to degrees), concerning pronation and supination degrees ( to degrees). the mean flexion deformity was degrees ( to degrees), the mean maximum flexion was degrees ( to degrees). we had two partial ruptures of the triceps tendon, one treated by operative refixation and one conservative, one temporary lesion of the ulnar nerve with complete recovery and one postoperative hematoma which needed surgical treatment. one patient needed revision surgery and resection arthroplasty due to a deep infection, but received a new prosthesis after two months. we recorded no radiographic loosening or other mechanical problems so far. conclusion: according to the used ''mayo elbow performace score'' all patients achieved a very good functional outcome. eventhough they all had severe injuries of the elbow. with modern types of elbow prosthesis the rate of complications and revision surgery is quite low. Ô ur findings indicate that total elbow arthroplasty should be considered as an additional treatment alternative. patients with a lower functional demand and of higher age benefit most from a prosthesis. for younger patients preservation of the joint should be achieved as far as possible. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. however secondary overload of the lateral facet of the humero-ulnar joint (with consequent arthritis), instability (especially in the presence of medial collateral ligament injury), painfull anteroposterior instability of the radial stump, and radial shortening (in essex-lopresti lesions) with wrist pain can be the result. radial head arthroplasty widely is proposed as prevention of these complication. however as we demonstrated in a systematic review of the litterature, radial head arthroplasty has equally high secondary arthritis rates as radial head resection. the complex anatomy of the radial head, articulating both with the capitellum and the proximal ulna is not reproduced by most contemporary radial head prostheses. material and methods: we describe the complex radial head anatomy based upon an analysis of mriâ e tm s of the elbow performed in healthy volunteers under standardised situations. we describe the next variables: â e¢radial head shape and diameter at the most proximal part of the pruj (proximal radio-ulnar joint) â e¢radial head shape and diameter at the midpoint of the pruj â e¢radial head height medial and lateral â e¢depth of the radial head through â e¢offset of the radial headâ e tm s through relative to the center of the radial head â e¢offset of the radial headâ e tm s through relative to the axis of the radius â e¢offset of the radial head relative to the axis of the radius â e¢angulation of the radial neck to the axis of the radius we compare these parameters to the available radial head prostheses. results: there is a high variability of the different parameters and no relation between all of the parameters could be determined. the existing radial head prostheses do only reproduce the anatomy to a limited extend. conclusion: the high rates of post arthroplasty arthritis can be related to the non-anatomical shape of the existing designs. as the proximal radius articulates both with the capitellum and the proximal ulna, a precise reconstruction of both joints is a necessity to avoid maltracking and/or edge contact in both joints. given the high variability this only can be realised using a theoretic modular prosthesis that allows for reconstruction of the synchronisation between both joints. we found no significant differences (p > . ) in the deficit of the range of motion. flexion: screws ± °, prosthesis ± °, plate ± °e xtension: screws ± °, prosthesis ± °, plates ± °p ronation: screws ± °, prosthesis ± °, plates ± °s uppination: screws ± °, prosthesis ± °, plates ± °a ccording to elbow functional evaluation criteria by broberg and morrey, we found excellent and good results in % of all patients treated with screws, in % of all patients treated with prosthesis and in % of all patients treated with plates (p > . ) the average dash score of patients treated with screws was ± points, of patients treated with prosthesis ± points and of patients treated with plates was ± points (no significant differences, p > . ). the physical and mental component of the sf- score was at the time of follow-up within the normal range at all patients (physical component: screws ± . , prosthesis ± . , plate ± . ; mental component: screws ± . , prosthesis ± . , plate ± . ). in the subcategory of physical functioning, screws performed better than prosthesis (p < . ). no other items of sf- were significantly different (p > . ). conclusion: according to our results osteosynthesis with only screws seem to be the best of the three studied methods. radial head prosthesis replacement yields better functional results than treatment with plates. it must be considered that prosthesis replacement of the radial head has the long-term risk of loosening, especially in young and active patients. plates showed worse clinical results especially in rotation of the forearm even after removing the plate in patients. disclosure: no significant relationships. s is angular stable osteosynthesis of the olecranon more economical than traditional treatment? n. spaepen , k. govaerts , s. nijs , p. broos trauma surgery, uz leuven, leuven, belgium, department of traumatology, university hospitals leuven, leuven, belgium, traumatology, university hospitals leuven, leuven, belgium introduction: although tension band wiring is considered as the gold standard in the treatment of simple olecranon fractures and olecranon osteotomies, the complication rate is high (delayed healing in up to % of cases, hardware migration %). in an historical series using anatomical preshaped lcp plates, we could lower the rate of healing disturbances, but the volume of the implant did make hardware removal necessary in the majority of patients. the lcp , mm hook plate is a low volume angular stable compression plate, designed for the treatment of simple fractures and osteotomies of the olecranon. in this study we want to evaluate the early results of using this new device for the treatment of acute fractures and osteotomies at a level trauma centre. material and methods: we prospectively include all patients treated by lcp , mm hook plate between and. months results considering range of motion (as measued by), meps (mayo elbow performance score), complications and radiographic results are presented. we perform a cost analysis of primary operation using the different implants available, length of stay and time off work. we also perform a cost analysis for reoperation because of delay in union results: we included patients. average age is , years (range - ). there were female and male patients. at months average extension deficit was °, the average flexion °. there was no substantial loss of pro-supination. all factures but one united anatomical (early loss of reduction, but patient refused reoperation). there were complications: early loss of reduction (treated conservatively), crps (complex regional pain syndrome) and arthrofibrosis necessitating implant removal). because of symptomatic hardware two additional hardware removals have been performed. according to the mayo elbow performance score all but patient scored good to based upon the cost analysis the predicted average cost per patient is significantly lower in the hook plate group as compared to the tension band and anatomical preshaped plate group. conclusion: although still a limited series, the early results of this implant are very promising. we document ranges of motion witch are comparable to those described previously in tension band wiring or anatomical plating, but at lower complication and reoperation rates. based upon an analysis of the cost of treatment and of reoperation we advocate the routine use of the olecranon hook plate in the treatment of simple olecranon fractures and osteotomies. disclosure: no significant relationships. material and methods: dutch surgeons (n = ) were asked to draw two incisions for an olac on embalmed human specimen (n = ). they also filled out a questionnaire of their experience. all incisions were photographed and digital measurements were taken. each incision was compared to the gold standard on criteria. incisions should not be closer than two-thirds of the distance between: ) distal tip of the lateral malleolus and the achilles tendon. there was no correlation between number of mistakes and number of procedures per year or years of experience (spearman correlation: . and - . respectively) the median of the mistakes for l-shaped incisions was (iqr = ) and (iqr = ) for j-shaped incisions (p = . , mann-whitney). the spearman correlation between the mistakes for the two incisions drawn by each surgeon was . . conclusion: conclusions: inter-surgeon variation of incision lines was high and since the number of mistakes per incision was not correlated to the surgeon's experience, casam can be useful in two ways: ) pre-operative planning using casam, might assist the surgeon in determining a 'tailor made' safe zone in each patient. ) for educational purposes casam is able to compare a student's incision with the gold standard or the computed location of the sural nerve, thus providing personal feedback. introduction: a precise sustentaculum tali screw placement is crucial for the fixation strength of operatively treated calcaneus fractures, as shown in biomechanical studies. due to the complex anatomic shape of the calcaneus and the limited visualization of the sustentaculum tali fragment via the common lateral approach, the exact screw positioning is demanding and a bright knowledge of the surgeon is mandatory. with the introduction of navigation procedures an increased precision of implant positioning could be achieved for different applications, as reported for pedicle-and iliosacral screw placement. the aim of this study was the evaluation of different navigation procedures compared to the conventional technique for the placement of the sustentaculum tali screw. material and methods: sustentaculum tali screws were placed via a standard lateral approach in artificial calcanei with a prefabricated soft tissue envelope. we used different navigation techniques: group i: d-based fluoroscopic navigation group ii: d-based fluoroscopic navigation group iii: fluoro-free navigation compared to the standard procedure without navigation (group iv). for each screw the time of procedure and time of fluoroscopy was measured. the precision was evaluated in postoperative ct scans. results: no x-ray exposure was necessary for the standard procedure and the fluoro free navigation, whereas ± . and . ± . s of fluoroscopy time were needed for the d-and d-based fluoroscopic navigation. significant differences were observed for the mean procedure time: . ± . (group iv), . ± . (group iii), . ± . (group i) and . ± . min (group ii). no significant differences were seen for the precision with one mal-placed screw in each group. whereas for the image based navigation procedures wide experience in computer assisted surgery was necessary, the fluoro free navigation procedure could easly used without that experience, due to a simplified and self-explanatory workflow. conclusion: all three navigation procedures increase the intraoperative orientation for the placement of the sustentaculum-tali screw, but significant differences of precision compared to the standard technique could not be observed in our experimental set up. potential reasons are a visual and tactile memory effect, despite a randomized order of drillings and a better visualization of the osseous structures in the used artificial model. in clinical situations a lack of surgical routine for this rare injuries and a limited display of anatomic landmarks exist, making all of the evaluated navigation procedures to a helpful tool. if the fracture reduction is controlled intraoperatively by an d fluoroscopic scan, we recommend the d navigation, otherwise we use the fluoro free navigation. disclosure: no significant relationships. overall satisfaction of functional status was measured using a visual analogue scale (vas; range zero to ten). results: four-hundred metatarsal fractures were identified in patients. the distribution of fractured metatarsals was: first metatarsal %, second %, third %, fourth %, and fifth %. multiple metatarsal fractures were seen in . %. most fractures were caused by an inversion injury or fall from height ( %). more than eighty percent of fractures were undisplaced or minimally displaced, and most fracture patterns were transverse or oblique/spiral. a total of patients ( . %) returned the questionnaire with a median follow-up of months. responders were female in % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). in the univariate analysis the aofas and vas score were inversely dependent of the body mass index (r s = - . and - . ; p < . ). patients with known diabetes reported lower vas (p = . ) and aofas scores (p = . ). female patients reported a lower aofas (p = . ). an increase in dislocation (> mm) resulted in a decrease in vas (p = . ). no correlations were identified with outcome and which metatarsal was affected, number of fractured metatarsals, fracture type and location, articular involvement, and smoking habits. in the multivariate analysis the bmi correlated with the aofas (p < . ) and vas (p = . ) and the dislocation with the vas (p = . ). conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at months. outcome is dependent of bmi, diabetes, gender, and dislocation at the fracturesite. disclosure: no significant relationships. introduction: incidence of fracture non-union is increased after severe trauma. the systemic inflammatory response syndrome (sirs) resulting from major trauma appears to play a role in this healing impairment. especially the cellular reaction associated with sirs influences the inflammatory response, which is of vital importance in fracture healing. we hypothesize that systemic inflammation may impair healing through an altered interaction between neutrophils and stem-or osteoprogenitor cells within the fracture hematoma. we therefore investigated the effect of neutrophils on differentiation of mesenchymal stem cells (mscs). material and methods: osteogenic differentiation of mscs was assessed using an alkaline phosphatase colorimetric assay on the adhered cell lysate after culturing mscs for days in the presence of different quantities of neutrophils. chondrogenic differentiation of mscs was assessed within the same samples using a glycosaminoglycan colorimetric assay in the cell medium. proliferation was measured within the same samples using a picogreen(r) dsdna fluorescent assay. to assess whether any effect was mediated through release of soluble factors or through direct cell-cell contact, supernatants of stimulated neutrophils were used. stimulation of neutrophils was achieved during h with tnf-alfa. tnf-alfa in the supernatant was subsequently blocked with humira prior to interaction with mscs. results: low neutrophil concentrations resulted in increased alkaline phosphatase concentrations compared to control levels. high concentrations of neutrophils resulted in increased glycosaminoglycan concentrations and decreased alkaline phosphatase concentrations. introduction: angiogenesis is a cue element in the early wound healing and is considered most important for tissue regeneration. in addition to aiding research in understanding the regulatory mechanisms of angiogenesis and vasculogenesis, the concept of co-cultures has helped to better understand the mechanisms of interactions between osteoblasts and endothelial cells focusing on new therapeutic approaches for critical size bone defects. here, we describe in detail the cellular and molecular interaction between human osteoblasts (hob) and human endothelial progenitor cells (epc) in a complex d-environment. material and methods: we investigated endothelial differentiation and morphological organization of human epc in cocultures with hob using methylcellulose sphaeroids as well as collagen biomatrices. cocultures of human umbilical vein endothelial cells (huvec)/ hob were used as controls. epc were tracked with cell tracker red, whereas hob were transduced using a lentiviral egfp-vector to allow direct cell visualization using confocal laser microscopy and analysis of cell-specific gene expression. we studied the survival of both cell types and formation of vessel-like sprouts as a criterion of endothelial activity of epc. expression of several relevant angiogenic and osteogenic markers, as well as different extracellular matrix proteins was investigated using quantitative rt-pcr. results: using the hybrid coculture technology we could clearly show that hob regulate the survival, proliferation, and spouting of epcs. concordantly, expression of endothelial cell markers cd and vwf was significantly up-regulated by cocultivation with hob. by contrast, epcs did neither proliferate nor did they form any apparent vessel-like structures when cultured in a monoculture. using the lentiviral egfp-reporter transduction method the expression of osteoblast marker genes was also estimated accurately. we could clearly show that epcs inhibit the terminal differentiation of hob by interfering with expression of specific transcription factors runx and sp . in contrast, cell proliferation and expression of the early osteoblastic differentiation marker alp were induced in cocultures. conclusion: in the present study we demonstrate that human endothelial progenitor cells interact with human osteoblasts on the cellular level. we have identified a complex regulatory mechanism which accounts for endothelial cell survival and cell differentiation of both cell types. this study provides new insight into regulatory mechanisms of bone regeneration and may unveil potential applications in bone tissue engineering and fracture healing. introduction: failure of fixation is more common in osteoporotic than in other fractures. early treatment of osteoporosis as well as early stimulation of the fracture healing may improve the later clinical outcome. bisphosphonates are effective in osteoporosis treatment, and bone morphogenetic proteins (bmps) stimulate fracture healing, although several studies show less effect in estrogen deficient models. in order to determine the effect on early fracture healing of bisphosphonates and bmps in osteoporotic fractures, these treatment modalities were applied in estrogen deficient rats. material and methods: fourty rats underwent an ovariectomy (ovx), followed by low calcium diet during six weeks. ten rats underwent a sham operation, followed by normal diet. after six weeks, a closed femoral fracture was induced in all animals. the ovx animals were then assigned to four different groups: ovx alone, injection of bisphophonate, injection of bmp- in the fracture gap, or the combination of these. all animals received a normal diet after the fracture. after sacrifice at two weeks, fracture healing was evaluated using radiographs and four-point bending stiffness andstrength. results: radiographs showed a higher score in the bmp- treated animals, with or without the bisphosphonates (p = . , kruskal-wallis test). no delay in healing was seen in estrogen deficiency as compared to the sham group. bending stiffness was higher in the bmp- treated groups compared to the others (p = . , kruskal-wallis), as was the strength (p = . , kruskal-wallis). no significant improvement was found by the injection of bisphosphonates conclusion: early fracture healing is significantly stimulated by injection of bmp- in the fracture gap in estrogen deficient rats. early treatment with bisphosphonates showed no effect on fracture healing. introduction: traumatic brain injury (tbi) is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly due to humoral factors. however, the pathophysiological mechanism of heterotopic ossification after tbi is still not fully understood. this study investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with tbi. material and methods: blood was collected from patients with severe tbi as well as ten control subjects. primary skeletal muscle cell cultures were isolated from orthopedic surgery patients and characterized using immunohistochemical techniques. proliferation and osteoblastic differentiation were assessed using commercial cell assays, western blotting (for osterix protein) and the villanueva bone stain. results: all serum-treated cell populations expressed osterix after one week. cells treated with serum from both study groups in mineralization medium had increased alp activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks. serum from patients with tbi induced a significant increase in the rate of proliferation of these cells compared to the controls (p < . ). introduction: the current gold standard to establish the diagnosis of osteoporosis and to follow the pharmacological treatment is the measurement of the bone mineral density (bmd). with a growing number of predicted fractures due to osteoporosis the expenses for bmd-measurement will increase. it was therefore the objective of this study to determine parameters that possibly allow a laboratory follow-up of these patients. material and methods: since we operated patients (Ø . y, % female) with an osteoporotic fracture (group ). all of them were more than years old and underwent a laboratory screening including the serum levels of vit-d -oh, vit-d . -oh, calcium (s-ca), phosphate (s-pho), p np, b-cross-laps, intact pth, osteocalcin, tsh and sex hormones as far as the urine concentration of calcium (u-ca) and phosphate (u-pho). in vit d -oh insufficient patients without treatment a therapy with alandronat lg once a week and daily calcium and vitamin d substitution was started. patients (Ø . y, % female) of the orthopedic department underwent the same screening and served as a control (group ). these patients did not sustain a fracture or relevant surgery within at least months. in a second part we checked the evolution of group -patients laboratory screening at a , and -months postoperative interval. results: group and displayed significant differences with regard to s-ca, u-ca, u-pho (p < . ), osteocalcin (p < . ) and vit-d -oh level (p < . ). after separating male and female patients significant serum concentration differences of testosteron (p < . ) in the male patients and of fsh (p < . ) and oestradiol (p < . ) in the female patients could be observed. during the follow up at , and months we could demonstrate a significant elevation of s-ca (p < . ), s-pho (p < . ), osteocalcin (p < . ) and vit-d -oh (p < . ) concentration. further we found a significant elevation of fsh-(p < . ), lh-(p < . ) and testosteron (p < . ) concentration as well as a significant decrease of the oestradiol (p < . ) concentration. as former studies showed we confirmed by comparing group and a deficiency of vit-d -oh, s-ca and an elevation of u-ca in patients with osteoporotic fractures. we could also show a significant difference of the concentration of osteocalcin. by following these blood parameters during treatment we found an improvement or normalization of these differences as a result of the treatment. therefore we believe that vit-d -oh, s-ca, u-ca and osteocalcin could serve as follow-up parameters in the treatment of osteoporosis. further our preliminary results suggest that under the treatment there is a decrease of the testosterone level in male patients and a decrease of the fh-and increase of the oestradiol-concentration in female patients which has not been reported in the literature yet. in consecutive cycli an alternating traction of newton was exerted on the subscapularis and infraspinatus, while a continuous force was applied for the supraspinatus. the motion of the tuberosities and the shaft were recorded by high-speed cameras. the following parameters were investigated: failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. results: group : cable fixation was significantly more stable for intertuberosity motion and tuberosity-shaft motion. furthermore we found failures for the lesser tuberosity in the suture group. we found no significat difference for the metaphysis-shaft motion. group : the greater tuberosity-shaft motion was significantly lower using two cables. all other parameters showed no significant difference. we found no failures. group : since the tuberosity-shaft motion and the intertuberosity motion were significant higher using fibre-wire, this series was abandoned after / pairs. conclusion: cable fixation is significantly more stable than suture fixation for tuberosities in shoulder arthroplasty. double-cable fixation does not improve intertuberosity stability. we found tendencies for an enlarged tuberosity-shaft stability. introduction: the results following prosthetic treatment of primary humeral head fractures present great variability. dissolving of tuberosities leading to dysfunction of the rotator cuff with limited motion, pain and instability are often reported. the short term results on inverse prosthesis on the one hand are promising, whereas scapular notching turns out to be a major problem leading to a high failure rate in the long run. high complication rates are also reported. material and methods: in an ongoing prospective and consecutive multicentre study until today, cases with an inverse shoulder prosthesis system are documented. in this series we analyse the results of the cases treated for primary fracture as indication. in all cases the affinis Ò fracture inverse prosthesis has been used. this implant was specially designed as a reversed treatment option for selected fracture cases. mechanical and biological notching should be reduced due to the special design features of the prosthesis. patients were asked to describe pain and satisfaction for the injured shoulder one week before the trauma and also to fill in the ases score. the constant score for the healthy shoulder was measured whenever possible. postoperatively constant and the ases score were assessed. the x-rays were evaluated for notching and the healing of the tuberosities. results: from february until today a total of n = cases ( females and males) were treated for primary fracture with the fracture prosthesis. mean age at operation was . years (range . - . ). according to the neer classification we treated patients with a -part fracture, with a -part fracture and cases with a head split fracture. after a mean of months (range - ) the cs reached . points. active forward elevation was . °and passive . °. the active lateral elevation (abduction) was . °for the active movement and . °passive. the ases score was . points at the latest follow-up and the value for pain and satisfaction were . and . respectively. we found no notching in this series and the tuberosities were judged as anatomically healed in % of the cases. we found no difference in the clinical outcome between patients with healed tuberosities compared to the group with non visible tuberosities. postoperatively two complications occurred one fracture of the clavicula and one fracture of the acromion. so far we did not have any luxations or implant disconnections. introduction: the purpose of this study is to evaluate the survival and function of splenic autotransplants using spleen imaging with tc m labeled heat-damaged erythrocytes. material and methods: patients with splenic rupture underwent spleen imaging with tc m labeled heat-damaged erythrocytes at to months after splenic autotransplantation (early scans); also, of them underwent the same imaging technique at to months after operation (follow-up scans). results: on early scans, splenic autotransplants were faintly and the intensity of radioactivity in autotransplants was lower than in liver. the increase of intensity of tracer accumulation in autotransplants was significant higher on follow-up scans. one week after operation the levels of cd , cd and cd /cd ratio were significantly lower than those of controls and returned to normal months later. conclusion: the spleen imaging with tc m labeled heat-damaged erythrocytes is a valuable and effective method for evaluation of the survival and function of splenic autotransplants. , respectively / in the group ''skiers''( %) and / in the group ''snowboarders''( %). the aast grade of injury was: aast case; aast cases; aast cases; aast cases; aast case. of the ''skiers''( %) and of the ''snowboarders''( %) showed a high grade (aast > ) splenic injury. patients has an injury severity score > ( / skiers and / snowboarders): cases of severe brain injury, case of associated liver injuries, cases of associated left renal injuries. patient had associated colonic and pancreatic injury. four patients were not stables at admission and had immediate laparotomy with splenectomies. patients were elected for nonoperative management. results: splenectomies was performed with a splenic salvage rate of. %. there was no mortality and morbidity was %. for thr three patients who had immediate splenectomy the recovery was uneventfull. in te group nonoperative management three patients had angioembolization and four had delayed laparotomy ( for delayed splenic rupture at post injury , and resectively; for sirs). in the patients with availables data, mean hospital stay was days ( - ), . days ( - ) for the group skiers and - days ( - ) for the group snowboarders. patients( %) were recovered less than days. patients were admitted initially in icu ward(from h to days). conclusion: ski accidents are in cause for more the one-third of all splenic injuries admitted to grenoble university hospital. the mean age is lower and male incidence is higher than splenic injuries admitted for others causes (road traffic accident, falls, other mountain accidents). an high number of snowboarder's' accidents was observed and pattern of injury is poor in these patients. the incident of polytrauma cases was the same in two groups and this observation confirm that snowboard practice is at higher risk than skiing for severe splenic injuries. in france, if number of raod traffic accidents is decreasing, the number of sport accidents is imcreasing in the last years. a better comprehension of mechanism, epidemiology and hystological findings of splenic injuries resulting from skiing and snowboarding is necessary to improve trauma preventiin programs. introduction: management of splenic injuries has evolved over the past three decades. prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of the concern about ongoing hemorrhage and/or missed intraabdominal injuries. in children the nonoperative management (nom) of splenic injuries rapidly gained interest because of the significant incidence of post-splenectomy sepsis as well as the complications associated with non-therapeutic laparotomies. the last decade has witnessed a proliferation of reports of nom in adults with injuries to the spleen. inclusion criteria for nom in adults, which have been a source of controversy, continue to evolve. moreover we noted that most publications focused on isolated splenic injury and not on patients with multiple injuries. this study was conducted to summarize the indications for the nom of blunt splenic injury with special attention to the multiply injured patient. material and methods: we conducted a medline search. the search was designed to identify english language citations between and : using the keywords: blunt splenic injury, conservative management, multiply injured patients and blunt abdominal trauma. the bibliographies of the selected references were examined to identify relevant articles not identified by computerised search. one hundred articles were identified. a cohort of three trauma surgeons selected articles for review and analysis. we used the methodology developed by the agency for health care policy and research of the united states department of health and human services to group the references into three classes. reviewing all data showed that the nom of blunt splenic injury is a save treatment modality in isolated cases but also the multiply injured patient. conclusion: currently the non-operative management of blunt injury to the spleen is the treatment modality of choice. important is a haemodynamically stable patient, with no signs of peritonitis on physical examination. patients who only maintain their blood pressure by the constant infusion of crystalloid or blood products are not haemodynamically stable and need surgical intervention. ct scan findings and grade of injury are not, in themselves, criteria for laparotomy. these criteria are applied to isolated injuries to the spleen but can also be applied to the multiply injured patient. age itself is not a contraindication. the general condition of an individual patient needs to be decisive. and finally hospitals with a low trauma incidence can safely use these guidelines in their management protocol. introduction: the treatment of trauma patients with solid organ injury has changed over the last years towards a less invasive treatment. still our algorithms especially in dealing with trauma patients with ongoing internal abdominal haemorrhages is still based on fast control en stopping of the bleeding by any means. the use of ct-abdomen and subsequent performing angiography and embolization takes time. we analyzed the time path involved in angiographic control of the bleeding spleen. material and methods: a retrospective study. the study group consisted of ten patients presenting at our institution with a traumatic spleen injury in the period november till november . all patients were managed according to the principles of atls. data were analyzed using spssÒ . . results: the study group consisted of seven men and three women. average age was years (range till ). the iss was on average (range - ). all patients in the study group received an angiography after ct-abdomen which showed an active bleeding focus in the spleen. organ injury score were eight grade and two grade spleen injuries. average time from admission to angiography was min. time to control of bleeding by embolization took average min. time loss between ct and angiography was on average min. conclusion: the time paths involved in managing this group of trauma patients with spleen injuries by embolization are much longer than expected. the time involved after diagnoses to actual control of the bleeding spleen injury is much longer than anticipated. logistic changes to limit the time loss in interpretation of data from the ct-a, transfer of the patient, preparation of the angio-suite and less time consuming technique to actual embolization are needed. articles were eligible if they reported the failure rate of nom with or without angio-embolization (ae) in pediatric patients with splenic and/or liver injuries with a contrast blush on ct and included two or more trauma patients. two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. interrater differences were resolved by discussion. results: nine studies were included describing pediatric patients. the median sample size was five (range - ). seven studies (including patients) reported a total of patients with failure after nom without ae. failure rates across these studies ranged from . to %; the pooled percentage was . % ( % ci: . %- . %). the failure percentages after nom with or without ae ranged from to %; the pooled percentage was % ( % ci: . %- . %. two studies (including patients) reported a total of patients with failure after nom with primary ae: a percentage of . %. conclusion: despite the current low level of evidence on failure rate of nom when a contrast blush is present on ct we emphasize that there is a significant amount of patients in whom nom fails. we therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiological response but also when a contrast blush is present on ct. results: primary blast injury: this form of injury results from the deleterious effects of the blast wave passing through the body. these waves have little or no effect on solid organs but have their major destructive potential in air containing organs, especially lungs. secondary blast injury refers to the impact on a patient's body of projectiles usually inert. the addiction of destructive metal fragment, nails and other such objects to bombs increase the severity of injury and lethality. tertiary blast injury refers to the deceleration and impact with the ground, wall or other inanimate object of the patient whose body is displaced by the blast. quaternary blast injury refers to the miscellaneous forms of injury by-products of explosions, burns, inhalation of dust, contamination in case of ''dirty bombs'' or penetration of allogenic body parts shrapnel. this last one asks the question of contamination by hepatitis or hiv and modalities of surveillance and treatment. conclusion: blast injuries are complex and require the expertise of surgeons for their evaluation, treatment and longterm recovery. the victims of this form of terrorism sustain unusually severe and complex multidimensional forms of trauma not typically encountered in routine surgical practice. surgeons must be leaders and active participants in disaster planning and management; they are uniquely qualified to manage the physical trauma that results from most forms of mass casualty events, including blasts. disclosure: no significant relationships. a. s. dogjani general surgery, military university central hospital, tirana, albania introduction: as the risk of terrorist attacks increases in the world, disaster response personnel must understand the unique pathophysiology of injuries associated with explosions and must be prepared to assess and treat the people injured by them. the explosions at the army depot in gerdec village, some km north of tirana, were heard more than km ( miles) away. introduction: during the last decades there is a debate concerning the fact if the facial fracture can cause further damage or somehow to protect the brain parenchyma from a more severe injury. the aim of our study is to analyze the effects of facial trauma exerted upon brain parenchyma. material and methods: a series of patients with craniofacial fractures was studied. the injuries were separated into five grades of severity based on neurological examination including cranial ct. the injuries was also grouped into three categories based of facial regional involvement ct -facial reconstruction results: the control group included patients with head trauma but without any facial fracture or brain injury. in group a included ( , %) patients with both facial fracture and brain damage.among them diagnosed with temporal-mandibular fractures accounting for , %, patients( , %) had lower mandibular fracture, patients ( , %) diagnosed with nasal fractures and patients ( , %) had orbital fractures. in group b were categorized patients with only brain damage accounting for %. conclusion: the data demonstrated that patients with upper facial fractures were at greatest risk for serious closed head injury (chi).injuries to both the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild chi with a modest likelihood of no neurological deficits. trauma to only the mandibular region or to only the midfacial region was least likely to involve chi disclosure: no significant relationships. introduction: post-traumatic stress disorder (ptsd) is a psychiatric disorder that results from exposure to a traumatic event. the individual may develop symptoms of three distinctive types: intrusive and unwanted recollections, avoidance followed by emotional withdrawal, and heightened physiological arousal. people who are exposed to traumatic events may also have somatic symptoms and physical illnesses, particularly hypertension, asthma and chronic pain syndromes. hospitalized victims of suicide terror attacks are unique due to the circumstances and severity of their injuries which could have possibly affected the occurrence of ptsd and delayed the recognition of ptsd development. our objectives were to evaluate the prevalence and severity of ptsd among hospitalized victims of suicide bombing attacks and to assess variables of physical injury as risk factors for the development of ptsd. material and methods: forty-six hospitalized victims of suicide bombing attacks were evaluated for ptsd using the pss-sr questionnaire by phone. demographic and medical data considering the severity of injury, type of injury and medical treatment were collected from the medical files. injury severity scale (iss) was used to assess severity of physical injury. results: the prevalence of ptsd among hospitalized victims of suicide bombing attacks was . %. presence of blast lung injury was significantly higher in the ptsd group compared with the non-ptsd group ( . % vs. . % respectively, p < . ). there was no significant difference in iss values between ptsd and non-ptsd groups. blast lung injury and intracranial injury were found to be predictors of ptsd (odds ratio and , respectively). no correlation was found between length of hospital stay, length of icu stay or severity of physical injuries to the severity of ptsd. conclusion: hospitalized victims of suicide bombing attacks are considerably vulnerable to develop ptsd. they should be evaluated with a high level of suspicion in order to identify ptsd symptoms and treated as soon as possible in conjunction with physical treatment. blast lung injury and intra cranial injury are predictors of ptsd. victims suffering from these conditions should be monitored closely and treated in conjunction with their physical treatment. conclusion: from the use of the smart adopted for the evaluation of the code of entrance in emergency department, we have deduced and confirmed the facility and the speed of use of this new model of triage. the triage smart typically holds not only besides in consideration the traumatic pathologies but also internists that, it is an usable advanced triage both on the territory and in the hospital. we can classify the model smart triage as a valid system in case of a disaster as is reliability and sensibility of assessment of patients result to be more appropriates in comparison to the other models of triage taken in examination. conclusion: we showed that alcohol, massive bleeding needed blood transfusion and age were risk factor of trauma and japanese emergency medical technician attendance was effective for trauma care. we suggested the reason of detachment by the injury form was that japanese penetrating wound include many stub wound not gun shot wound. introduction: rapid aging of japanese population is causing numbers of emerging problems in trauma patients care which consists of trauma in elderly people and increased pre-existing co-morbidities such as cardiovascular diseases, neoplasms and organ failures. nevertheless, little is known about the relationship between co-morbidities and trauma. the aim of the study was to clarify the influences of co-morbidities on the trauma mortality, using data from the japan trauma data bank (jtdb), a multicenter, nationwide and prospectively recruited trauma registry in japan. material and methods: we selected the records from jtdb which fulfilled the requirements to estimate trauma injury severity score (triss) system. logistic regression analysis after adjustment for baseline trauma severity based on triss system assessed the risk of in-hospital trauma death for following co-morbidities: hypertension (ht), diabetes (dm), psychotic disorders (pd), dementia (de), stroke (st), chronic obstructive lung diseases (cold), bronchial asthma (ba), coronary diseases (chd), congestive heart failure (chf), liver cirrhosis (lc), chronic hepatitis (ch), chronic renal failure on dialysis (crf) and active cancer (acn). we conducted a couple of analysis which were adjusted or unadjusted by age in consideration for confounding between co-morbidities and elderly in age. introduction: monitoring the quality of trauma care is frequently done by analyzing the preventability of trauma deaths and errors during trauma care. in the academic medical center traumatic deaths are discussed during a monthly morbidity and mortality meeting. in this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a dutch level- trauma center for (potential) preventability. material and methods: all patients who died during or after presentation in the trauma resuscitation room in a two year period were eligible for review. all information on trauma evaluation and management was summarized by an independent physician. an external multidisciplinary panel individually evaluated the cases for preventability of death. disagreements in classification were resolved during two consensus meetings. potential errors or mismanagements during the admission were classified for type, phase and domain. overall agreement on (potential) preventability was compared between the panel and the amc consensus. results: of the evaluated trauma deaths one was judged preventable and were judged as potentially preventable by the review panel. overall agreement on preventability between the review panel and the amc consensus was moderate (kappa . ). the classification of the panel was more favourable than the amc consensus. the interobserver agreement between the review panel members was also moderate (kappa . ). the panel judged errors to have occurred in the (potential) preventable death group and errors in the non-preventable death group. most frequently mentioned errors were related to choice or order of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. conclusion: the preventable death rate in the present study was comparable to the available literature. external review does not seem necessary to improve our current internal reviewing system. however, multidisciplinary reviewing of our trauma deaths provided us potential insights to optimize trauma care. disclosure: no significant relationships. arab emirates (uae). the aim of this paper is to report on the long term effects of our early analysis of this registry. material and methods: data in the early stages of this trauma registry were collected for patients during a period of months in . data was collected on a paper form and then entered into the trauma registry using a self-developed access database. descriptive analysis was performed. results: most were males ( %), the mean age (sd) was . ( . ). uae citizens formed . %. road traffic collisions caused an overwhelming . % of injuries with . % of those involving uae citizens while work-related injuries were . %. the early analysis of this registry had two major impacts. firstly, the alarmingly high rate of uae nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. second, the equally alarming high rate of work-related injuries led to collaboration with a preventive medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention. conclusion: analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention. disclosure: no significant relationships. as a result of injuries related to skating on natural ice. we analysed epidemiological aspects, diagnostically examinations, prevalence of injuries per anatomical location as well as the necessary therapeutic interventions and costs for national health services. results: injuries related to skating on natural ice accounted for % of all attendances. the mean age for man and women did not significantly differ ( , and , years resp.; p < . ), but adults aged - years are more prone to injuries. women were affected in %. radiological examinations were requested in % ( % xrays; % ct-scans). the upper extremity was affected in %, with the wrist accounting for % of those injuries. fractures accounted for % of all ice-skating related attendances. an operative therapy was indicated in %. the mean costs for national health services were e per patient. conclusion: fractures, especially those of the upper extremity, were the predominate type of injury as a consequence of collectively performed skating on natural ice. this incidence is > times higher compared to fractures occured during skating on artificial ice-rinks [ ] . wearing wrist guards is an effective tool in protecting skaters against injuries. we recommend wearing wrist guards during skating on natural ice [ , ] . especially (employed) adults aged - years are very prone to injuries resulting in a high loss of work days [ ] . in contrast to children, adults might be more accessible for wearing protectors [ ] . in future it seems reasonable for national health services to provide steps to increase public awareness on the benefits of prophylactic safety measures. this might result in a substantial reduction of costs for health care and society. introduction: liver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. we therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients. material and methods: using the multi-center population-based trauma registry of the german society for trauma surgery, we retrospectively compared outcome in patients (iss > = , > = ) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis means were compared using student's t-test and analysis of variance (anova) and categorical variables using chi (p < . = significant). results: overall , patients met the inclusion criteria and were, thus, analyzed. ( . %) patients had a documented alcohol abuse and ( . %) suffered from liver cirrhosis. patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. more specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted ( % vs. predicted %) and increased single-and multi organ failure rates. while alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality. of note, alcohol abuse significantly decreased -hour mortality. conclusion: patients suffering from liver cirrhosis are at maximised risk for impaired outcome after multiple injuries. pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile. introduction: early in-hospital treatment of severely injured patients has been internationally standardized by the implementation of algorithms such as the atls Ò -concept. however, due to lack of time, the instability of the patients and the complexity of injuries, there is a risk that some lesions will be missed at this stage. the purpose of our study was to evaluate the incidence and significance of these missed injuries. material and methods: retrospective chart analysis (in-hospital and follow-up as outpatient) of data prospectively collected via an accessÒ-based documentation system was performed. missed injuries were determined as injuries not found during primary and secondary survey. introduction: complication registration is important for monitoring the quality of health care. aim of this article was to describe the incidence, type and impact of complications occurring within months after the initial trauma in multitrauma patients. second, we assessed potential risk factors for the occurrence of complications. material and methods: during a -year period all trauma patients presented to the academic medical center and having an injury severity score of ‡ were included. patients who were directly transferred to other hospitals were excluded. we used the prospective dutch national surgical complication registry of the amc, a level- trauma center, to assess complications within months after the initial trauma. for verification we additionally performed a chart review and searched the decubitus specialists-and icu registration. complications were graded (no real health loss) to (lethal). identification of risk factors associated with an increased risk of complications was performed by univariate analysis. we also analyzed an autopsy findings of these patients and found that of ( . %) had a difference between clinical and autopsy iss. the most frequent missed injury were rib fractures. six of these patients were hospitalized in a period when we did not use msct routinely in multiple injured patients. conclusion: triss is not a clinical prognostic tool but is used retrospectively for clinical and epidemiological research, performance evaluation, and resource allocation. it is required as a basis for quality assessment and improvement. in combination with autopsy findings, triss methodology can be an valuable tool for recognition of unexpected trauma deaths and further analyze of possible treatment errors. patients had to be operated , times and were treated days in the icu and stayed days in hospital. mortality rate was % and rate of multi-organ failure %. % demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. % recovered well or at least moderately. out of survivors answered the polochart. a personal interview was performed with patients. the state of health was at least moderate in % of patients. in % interpersonal problems and in % severe pain was observed. in % problems in working ability concerning duration, as well as quantitative and qualitative performance were observed. symptoms of post-traumatic stress disorder were found in %. the more distal the lesions were located (foot/ankle) the more functional disability affected daily life. in only %, working ability was not impaired. out of interviewed patients demonstrated complete work disability. conclusion: even severely injured patients after polytraumatization have a good prognosis. the iss is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. introduction: one of the most common cause of preventable deaths in severe trauma is represented by delay in diagnosis and treatment of injuries, therefore a good teamwork aimed to reduce time consumption and errors is essential. there is in fact good evidence that the outcome of trauma care depends on effective trauma team performance (ttp). critical points during trauma management are represented by lack of leadership, information sharing, difficult communication and decision making. to improve ttp, advanced simulators with full scale realistic patients ( ) and trauma crew resource management (crm) educational programmes are increasingly being used. material and methods: we made a survey among health care professionals (hcp) from different level i and level ii trauma centers in the milan area that confirmed that difficulties in communication and conflictual behavior during trauma action is perceived as a barrier to ideal management. after a focus group interview to establish the need to improve performance we tested in our hospital a tailored trauma teamwork course using an advanced human patient simulator. the peculiarity of this course is the recreation of the same location of the trauma bay using same trauma team components and teamwork laboratory conducted by a professional coach as facilitator for the teamwork. this role is particular important since with this facilitation hcp can reach the awareness of wrong attitudes that lead to errors and bad performance. in particular, the tasks of the facilitator were the following: to help people understand their common goals to assists the trauma team to plan to achieve common goals to assist the group in achieving a consensus of any disagreements that preexist or emerge in the meeting so that it has a strong basis for future action a second survey few months after the course was made among hcp of our institute to evaluate the possible improvement of the ttp. results: the second survey confirmed a perceived benefit among hcp who started to work in a proactive manner. in particular % of hcp reported the feeling of a better ttp and % suggested regular practice with advanced simulation. conclusion: integration of a tailored advanced simulation and a facilitator assisted teamwork could be a powerful method to improve quality of treatment in trauma patients. a score index to evaluate the improvement of the ttp during the course and in reality is although needed and is under evaluation. introduction: our university hospital is one of the only two national university hospitals in tokyo and our emergency medial center is one of the busiest emergency center in japan that receives to ambulances per day. japan has a quite unique emergency medical system in the world. in japan, emergency patients are stratified into tiers, minor-primary, moderate-secondary, severe-tertiary. japanese emergency doctor, that is not same as the emergency physician in the usa, take care only for the most severe emergency cases, tertiary level emergency patients. and if they find out the patient who needed an emergency operation, then they do the surgery by themselves. if the patients need to admit to icu, they take care the patient in icu by themselves. this unique system was installed in mid- s. japanese emergency doctors do not only trauma cases, but also nontrauma severe emergency cases. for talking about trauma, they do not only the initial management of trauma patients but also do emergency surgery and trauma critical care. the mou came into effect with the signatures of the appropriate representatives, acknowledging that four courses had been run in portugal prior to its signature and that all future courses would be conducted in accordance with the essential requirements established by iatsic. in practical terms, the first two courses run after signing the mou must be of the form and nature as laid down by iatsic. thereafter, variations as determined by the nsc may be allowed. the slide material will be provided ''locked''. after the two initial courses, the ''unlock'' code will be provided. details of all modifications must be lodged with the iatsic. nsc will be responsible for ensuring the maintenance of high standards in the conduct of all courses and the selection of participants, ensuring that they meet the minimum standards as laid down by iatsic. nsc is entitled to appoint two representatives at international subcommittee meetings. introduction: clinical skills must be to the fore of medical occupation, especially in surgery, where the mastery of basic skills is of great importance for the young learner. the acquisition of basic clinical skills during surgery clerkships has been shown to be inadequate. this work presents an analysis of different teaching methods in a standardized training program for basic clinical skills in surgery. material and methods: the program is part of a four week surgical rotation for th year medical students, consisting of the one-week training program in basic surgical skills and a three-week clerkship on surgical ward. during the skills training, a maximum of students per group rotate through modules. in a randomized study, the effects of different teaching modalities as skills lab, simulation and role play, as well as different teaching methods as four-step-approach, short-lecture, video were tested on their effect on theoretical and practical skills acquisition. results: a total of students participated on a voluntary basis. the theoretical and practical examinations revealed significant differences in the acquired skills comparing the different teaching modalities and methods. the use of video as part of the -step approach was effective for training the basic skills such us suturing and wound care. least effective for all skills were short-lectures. conclusion: the choice of teaching modality and method has a significant impact on students' skills acquisition and its long term retention. disclosure: no significant relationships. training in trauma center: where to pay attention to? l. handolin traumatology, helsinki university hospital, helsinki, finland introduction: systematic trauma team simulation training was started in helsinki university hospital in . in terms of getting the optimal advantage of training and maintaining the justification of resource allocation, an advantageous balance in various team training principles has to be applied. the aim of the present study was to analyze the standardized written feedback given by trainees after training sessions. material and methods: the study period was three years ( ) ( ) ( ) . the collected data consisted of a subjective self-assessment on the level of knowledge, skills, and team work in traumaresuscitation. also a selfassessment on the effect of training on decision making, communication, skills, team work, and leadership, as well as a general rating of training session were collected. self-assessment was done using five step scoring system from one to five. results are presented as means. conclusion: the actual evaluated interspinous devices led to a significant reduction of rom during flexion-extension, but to a significant increase of rom for the whole specimen (l -l ) during lateral bending and rotation, which increases the risk of adjacent level degeneration. therefore the decision for the optimal individual treatment should be made on the knowledge of the biomechanical effect of each device and the underlying disease of the patient's symptoms. introduction: gait analysis is a powerful tool to monitor the degree of convalescence in fracture care after fracture fixation and during bone healing. because of the availability of a large array of monoclonal antibodies and gene-targeted animals, the mouse has become the preferred species for molecular studies on fracture healing. of interest, gait analysis after fracture fixation and during the bone healing process has not been performed in mice yet. we present a novel technique for dynamic gait analysis in mice and report the change of motion pattern after femur fracture and fixation. materials and methods: all animal procedures were performed according to the national institute of health guidelines for the use of experimental animals and were approved by the german legislation on the protection of animals. ten cd- mice were divided into two groups: fracture group (n = ) and control group (n = ). all mice were anesthetized by an i.p. injection of xylazine ( mg/bw) and ketamine ( mg/bw). a standardized closed midshaft fracture according to ao-classification a -a was stabilized by a common pin. the non-fractured tibia was additionally marked with a pin, allowing a measurement of the tibio-femoral angle by a digital videoradiography system recording images/s. for the control group, one pin was inserted into the femur and one into the tibia without producing a femoral fracture. dynamic gait analysis was performed at day fourteen after surgery in a x-ray compatible running wheel and the following gait parameters were determined: the minimum and maximum tibio-femoral angle, the stride frequency, the stride time, the stride length and the stride velocity. eighteen representative strides per mouse were analyzed. all measurements were done using osirix imaging software and the open source program imagej. all data are given as means ± standard error of the mean (sem introduction: single distal locking screw insertion had been accepted as an option in clinical practice of femoral nailing. however, effect of number and location of the screw on rotational stability of the construct was still doubtful. therefore, this experimental study was conducted to compare rotational stability of the femoral nail construct among three different conditions (two distal screws, single distal screw in different locations). materials and methods: eight right femoral sawbones were selected for this study. each of which was implanted with gk femoral interlocking nail ( · mm) and a static proximal locking screw follow by single distal screw insertion in the most distal screw hole. then, transverse osteotomy was performed at the mid-shaft to simulate simple fracture. after the femur was stabilized on the custom holding jig, rotational force was applied to the femoral condyle by using a torque wrench connecting to the distal part of the jig starting from to nm in nm increment. total rotational angle in each situation was measured by modification of navigation system. thereafter, testing protocol was repeated to the same specimen but two distal locking screws and single distal locking screw in the most proximal screw hole, sequentially. different angle in each testing condition was compared among the different constructs by using paired t-test. results: rotational stability was significantly better in the group of two distal locking screws in every testing condition (p < . ). single distal screw in the most proximal screw hole provided more rotational stability than that in the distal screw hole at nm (p = . ). conclusion: this study demonstrated that two distal locking screws provide more rotational stability than single screw in the case of simple mid-shaft femoral fracture stabilized with interlocking nail. if single distal screw was considered, insertion in the most proximal hole would be a better option in term of rotational stability than that in the most distal hole. introduction: the exothermal reaction of pmma leads to an extensive interaction between the bone cement and the plastics of the application system. this chemical reaction changes the structure of the bone cement and especially makes air pockets. it is necessary to develop application systems with a special composition of the plastics so that there is no interaction between the cement and the application system. in this study a new application system is presented for the first time which does not interact with the bone cement. materials and methods: two different application systems for bone cement were tested in this study. one popular and frequently used system made of polyethylene and a new system made of polypropylene. a special testing unit, in which the application systems were mounted, was used. the testing unit worked with a certain pressure so that a defined amount of bone cement was injected. the resistence data and the time were digitally collected and statistically evaluated. in all procedures were carried out. after the injection all application systems and the injected bone cement were microscopically analyzed. results: two groups, old versus new application systems, were divided. both groups showed significant differences. when using the old application systems made of polyethylene the time frame for injection of the cement was min while the time frame with new system made of polypropylene was min. microscopically there is a significant interaction between the plastics and the cement in the old systems with massive air pockets. in contrast there is no interaction, no air pockets and a homogeneous pattern of the cement when using the new systems. conclusion: the new application system made of polypropylene showed a significant longer time frame for application of the cement as well as no interaction with the plastics. it is possible to treat more than one localization with one application system which makes it financially rewarding. additionally there are no air pockets reducing the danger of infection und increasing the structural stability of the bone cement. introduction: femoral neck fractures are common fractures. despite the frequency of this fracture and the consequences associated with it, little is known about the functional changes that can be expected during and after rehabilitation. the aim of this study was to identify prognostic factors for functional outcome, using a modified harris hip score, after a femoral neck fracture treated with an arthroplasty. materials and methods: we included patients who sustained a displaced femoral neck fracture treated with an arthroplasty. functional outcome after surgery was assessed using a modified harris hip score, and was evaluated after (hhs ) and (hhs ) years. we analyzed the following prognostic factors for functional outcome of patients after treatment of femoral neck fractures with an arthroplasty: age, pre-operative co-morbidity, asa-score, type of arthroplasty (hemi-or total hip replacement), surgeon experience (resident or attending surgeon), interval between trauma and operation, blood loss, direct (associated with the arthroplasty) peri-and post operative in-hospital complications related to the arthroplasty and general post operative in-hospital complications. to challenge the outcome of the analyses we used the cronbach's alpha coefficients for testing the internal consistency. results: after one year the existence of co-morbidities ( ‡ ) was a significant predictor for a poor functional outcome. with and without co-morbidities the mean hhs was . and . , respectively. after years all potential prognostic factors did not have significant influence on the functional outcome. to further analyse this outcome, internal consistency of the hhs was assessed. when pain and function of the hhs were analysed together the internal consistency was poor (hhs : . and hhs : . ). the internal consistency of the harris hip score solely in function (without pain) improved to . (hhs ) and . (hhs ). when the potential prognostic factors were analysed with only the functional aspect, age and the existence of co-morbidities could be defined as a predictors for the functional outcome of femoral neck fractures after and years (r and % resp). conclusion: pain has such a dominant position in the harris hip score that even immobile patients without pain can obtain a reasonable hhs score. the hhs, with the omittance of pain, is therefore a more reliable score to estimate the functional outcome. after using the hhs in this modification, age and the existence of preoperative co-morbidities appeared to be predictors of the functional outcome after and years. many studies have shown that delay to theatre beyond h has an associated increased risk of morbidity and mortality in this cohort. our data revealed that there is certainly room for improvement regarding treated more patients within the h guideline however, there will always be a group of patients whom medical input is required prior to surgical management. lack of theatre time appears to be a significant administrative reason for delay. this is an area of potential improvement however it must be noted that any system of this nature will carry an intrinsic delay in processing. . x-rays and post-op data were analyzed on displacement, postoperative reduction, loss of reduction, and avascular necrosis (avn) and revision rates. high volume surgeons were defined as surgeons who performed > fixation procedures for proximal femoral fractures annually. results: mean age ( vs. years) and percentage of fracture displacement ( vs. %) were equal in both groups. re-operations following loss of reduction or infection was seen in ( %) patients. less frequent complications were avn ( %), coxarthrosis ( %) and pain due to screws bulging out ( %) led to a total conversion rate to arthroplasty in %. displaced fractures show a higher rate in loss of reduction ( %, p < . ) and revision ( %, p = . ) than non-displaced fractures ( . %; . %). patients > years showed % loss of reduction, % avn and taking the reoperations due to coxarthrosis and pain into account, a total revision rate of % was seen compaired to , , and % in younger patients. radiological analyses revealed that the lack of medial support lead to revisions in % of the cases, dorsal angulation in %. low volume surgeons did not perform worse than high volume surgeons. the latter group showed % loss of reduction, % avn and total revision rate %, compared to , and % in the low volume group. we found no differences in the outcome of treating displaced fractures. conclusion: the outcome of fixation of femoral neck fractures is poor. especially displaced fractures, inadequate fracture reduction and high age were associated with poor outcome. therefore, arthroplasty should be considered in patients older than years with displaced fractures that cannot be reduced anatomically. we could not demonstrate that high volume surgeons performed better in this group but we are convinced that further specialization of care is mandatory to improve results of this unsolved fracture. ( ) ( ) ( ) ( ) . internal fixation has shown to provide minor results. the majority of these patients are therefore treated by a hemiarthroplasty of the hip. since the primary goal is to regain the pretraumatic level of mobility as soon as possible( ; ), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss ( ), postoperative pain( ; ) and thus postoperative mobility ( ) . material and methods: in a randomised controlled trial, patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within hours after trauma( ). apart from parameters like age, asa-score or body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. all data collected were compared between groups to detect statistical significant differences. additionally the same parameters were checked for significant differences comparing patients with or without complications within their group. results: a significant difference between groups was found for postoperative pain within the first hours and for operation time, both to the disadvantage of the minimal invasive approach group. within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at hours was rated higher in patients with complications in the lateral approach group. these results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up. conclusion: despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. still, the operation time was significantly linked to postoperative complications. in this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results. of the patients, ( . %) received a formal assessment for antiresorptive therapy. the outcomes of this assessment is as follows: . % did not require any antiresorptive therapy, . % awaiting bone clinic assessment on discharge, . % awaiting a dexa scan, . % of patients were started on antiresorptive therapy and % were continued on antiresorptive therapy from pre-admission. conclusion: our study highlighted that in our trust only . % received this assessment formally. we can conclude that when this assessment occurs the guidelines and hence subsequent fragility fracture secondary prevention is addressed. we have then presented this data locally and amended our integrated neck of femur documentation pathway to include a section on antiresorptive therapy assessement. to follow this up we plan to re-audit from st january to st january . in the upper thoracic spine / ( %) could be placed with navigation, / ( %) were controlled intraoperatively. occasionally, scan-setup was problematic, in addition, we experienced technical problems. correct placement was seen for each screw, thus correlating well with theintraoperative findings. conclusion: the application of the combination of intraoperative d-imaging and navigation for posterior instrumentation of the cervical and the upper thoracic spine is technically feasible and reliable in clinical use. user-and software-dependant sources of error could be solved during the first course of the series. image-quality at the cervical spine is depending on individual bone density, and possible metal artifacts. with undisturbed visibility of the vertebral body, the reliability of d-based navigation at the cervical spine is comparable to that of ct-based procedures. additionally, it has the advantage of skipping preoperative acquisition of data as well as thematching-process. furthermore, exposure to radiation is reduced due to the possibility of sparing pre-and postoperative ct. disclosure: no significant relationships. the average lka measurements in order were: . °, . °, . °( p < . ), and for aca: . °, . °, . °(p < . ). while a significant difference between the averages of lka, e/f of group and group (p < . ), no statistical difference was found comparing the average aca angle (p = , ). while there was no significant change in e for all groups (p > . ), the increase in f after surgery was considered significant (p < . ), and no difference was observed between the averages of group and group (p > . ). vas was . ( - ). conclusion: at the end of an average year follow up period of posterior tl fractures no difference was found between the early and late period measurements of aca and anterior height although lka showed a statistical loss in height the correction degree achieved in the late period was found to be significantly higher than preop. ( cases), crushing without skeletal injuries ( cases) in all these cases, pulse was present at the first evaluation, and the onset of acute post-traumatic ischaemia was at - hrs after trauma . tha diagnosis, based on clinical suspicion, became definite after doppler evaluation and arteriography. the anatomical base of ischaemia was late thrombosis ( cases) and compressive hematoma ( cases). thrombosis was due to obstruction of the big arteries ( cases) and microcirculation, due to overrun compartment syndrome- cases.vascular restoration and fasciotomy was performed whenever muscles were viable, but amputation was necessary in cases results: the patients were analysed from the point of view of the corelation between the moment of onset of the ischaemia, the type of injury, the status of the muscular structures, the algorithm of diagnosis, the type of the treatment, and the clinical outcome. the study revealed that the clinical outcome was better when the time between trauma and ischamia onset was less, since the muscular ischaemic had less time to develop. in the same time, there were cases in which clinical symptomes were not corresponding to the imagistic evaluation. conclusion: high energy trauma affect all the structures of the limbs. clinical suspicion has particular importance especially when trauma affects one of the regions which is known as establishing a dangerous environment between the arteries and the bones / joints. in all the cases that authors analyse, complete and early diagnosis and treatment of acute post-traumatic ischaemia, based on the close monitoring of the patient and '' clinical alarm signs '' seemd to be the conditions for the favourable outcome of the patients. introduction: the aim of presentation is to demonstrate the surgical treatment and postoperative period of a patient who was caught on a fence-pole and suffered severe injuries of perineal region and lower extremity. material and methods: after a long time of technical rescue the patient arrived to our department with a one meter long portion of fence in his perineal region. after the urgent extraction of metal fence we performed an intraoperative rectoscopy. during the debridement and exploration of deep perineal injuries we realised a heavy swelling around the punctated wound of the left leg. we made a femoral incision and exploration and recognised the several injury of the femoral vein and artery. we provided the cm long injuries with stitches. results: in the postoperative period we made a second-look and debridement because of lymhphatic retention and small skin necrosis around the incision. no real vascular or circular lesions were recognised during the control period of the patient. injuries were totally improved. conclusion: the edification of this case is that it's never sure that the major wound makes the biger trouble to the patient or to the surgeon. in our presentation we plan to demonstrate the intra -and postoperative pictures and the results of controll period. results: the incidence of various types of trauma were blunt in patients ( %), gunshot wounds in patients ( %), and stab wounds in patients ( %). only ( %) patients were hemodynamicaly stable. isolated abdominal vascular trauma was detected in patients ( %). vessels injured included aorta ( , %), inferior vena cava ( , %), named visceral arteries ( %), named visceral veins ( %), iliac arteries ( , %), and iliac veins ( , %), epigastric, hypogastric, intercostal arteries ( , %), epigastric, hypogastric, intercostal veins ( %), gonadal vessels ( %), renal veins ( %), non-named mesenteric vessels with segmental bowels necrosis ( , %). two or more vascular injuries were found in ( , %) patients. according to organ injury scaling, st grade injuries were found in ( %), nd -in ( %), rd -in ( %), th -in ( %), and th -in ( , %) patients. the most frequent associated injuries were small bowel - , liver - , colon - , stomach , duodenum - , diaphragm - , pancreas - , spleen - , with an incidence of %, %, %, , %, , %, %, % and , % respectively. all injuries were managed according to injury score. infrarenal v. cava ligation was performed in all cases of hemodynamic instability. minor named abdominal vessels were ligated in all cases. segmental intestinal resection was performed in all patents with th grade of intestinal injuries due to devascularisation. overall mortality rate was %. the vessels with the highest mortality rates were inferior vena cava ( % - / ). there were no mortalities in isolated abdominal vascular trauma patients and in cases of st grade of injury. mortality rate in accordance to ois was: nd - patients ( %), rd - patients ( , %), th - patients ( %), th - patient ( %). no differences in mortality rate were found according to type of trauma (blunt or penetrating). the associated injuries with the highest mortality rates were pancreas ( / - %), diaphragm ( / - , %), liver ( ( ), a rupture of the heart ( ) or a aneurysma dissecans with a rupture of the aorta ( ). in addidtion to the detailed forensic examination and autopsy, we took the anthropometrical measurement of all corpses in dimensions, so that we were able to create a biomechanical simulation of the accidents with ''finite element models''. there the shear forces affecting the aorta can be calculated. as three forces (frontal impact, side impact and deceleration) are the most important, we will present three comprehensible example accidents. the reason of death is always the ''aortic rupture'', but every time the biomechanical way of application of the force was completely different. in detail they are a car accident (frontal collision of a small car with a wall); a downfall from the height of meters in suicidal purpose and a compression of the thorax of a eight year old boy with a shovel of an excavator. results: although all three accidents have completely different course of crash, we were able to see the same reason for death: a rupture of the aorta at the onset of the ligamentum arteriosum botalli. by using the numerical simulation, it can be shown that three main directions of force are important in an accident: the frontal impact, the side impact and the deceleration. in all these examples, it was able to simulate the reaction of the aorta in relation to the development of the force. the simulation will be presented as well as all clinical treatement made by the medical stuff. conclusion: although the rupture of the thoracic aorta is a frequent cause of death, the injury mechanism has not been comletely known. a database with several victims of aortic ruture was created and special accident types will be presented and simulated. introduction: overlooked compartment syndrome represents a catastrophic complication for patients and orthopedic surgeons. invasive compartment pressure measurement continues to be the gold standard. however, repeated measurements in uncertain cases can be difficult to achieve. we, therefore, developed a model for a noninvasive technique to assess tissue pressure by ultrasound based elastography. material and methods: a perforated plastic tube filled with saline was surrounded by a silicone sealed plastic cover, mimicking the shape of the tibial compartment. a pressure transducer inside the compartment was installed. a second pressure transducer was installed on the ultrasound probe to allow simultaneous monitoring of the pressure inside the compartment and the tissue deformity. for calibration, ultrasound images were generated at and mmhg. the plastic cover to tube distance was measured before and after compression (delta d). subsequently, increments of mmhg pressure increases were used to generate a standard curve ( - mmhg), thus mimicking rising compartment pressures. the intra-observer reliability was tested by using subsequent measurements. a correlation was determined between the skin to bone distance (delta d) and the pressure measurement (p). the pearson correlation coefficient was calculated, and a regression analysis was performed. ( ), better antibiotics and computed tomography-guided percutaneous drainage ( ). however, when everything else has failed, the burder of decision making the choice of a 'last resort' operation will be shifted again to the surgeon. we here described our recent experience with such cases treated by abbreviated laparotomy using the bogota bag technique ( ). results: for the seven first patients, we performed colon resection with colostomy. after extensive debridement, lavage and drainage, the peritoneal cavity was closed with a sterile gastric bag sutured on the rectus aponeurosis according to the so-called bogota-bag procedure ( ). the mean operative time was minutes. a second look laparotomy was planned after hours: one patient required one reexploration, four patients required two and two required three. the decision of re-exploration was based on the visual aspect of the peritoneal content, the clinical evolution and the bacteriologic results. for the last three cases, we elected perform colon resection without colostomy followed by anastomosis in two patients in the second look laparotomy and colostomy in one because of two relaparotomies. none of the ten patients required further percutaneous drainage. two patients died in multiple organs failure (one with perforated diverticulitis and one with ischemic colon after aneurysm repair). conclusion: abbreviated laparotomy with temporary closure of the abdominal wall associated with planned re-exploration of the peritoneal cavity is a simple and effective way to treat patients with severe abdominal sepsis. introduction: pelvic fractures usually are the result of high energy trauma and such patients often have many associated injuries. long term outcome data of pelvic injury patients is sparse, we present our information with special emphasis on poly-trauma patients, with consideration for the combined involvement of associated injuries on functional outcome. material and methods: general functional outcome and clinical outcome were determined with an examination by a physician and patient assessment at a minimum of years after the injury. pelvic fracture patients that had suffered poly-trauma were categorized by fracture location: acetabular, pelvic ring, or a combination. results: the long term outcome in the patients with pelvic ring fractures (exclusive of acetabular fracture) was the worst clinically, as evidenced by evaluation of pain( . %), increased use of special medical aids( . %), a poor merle d'aubigne score( . %), and worse sf- and haspoc scores. patients with acetabular fracture had poorer general functional outcomes than those with combined pelvic acetabular fractures and were noted to have higher incidence of associated injuries such as type iv pipkin fractures. further subcategorization of pelvic ring fractures into anterior, posterior or combination showed specifically those patients with combined anterior posterior pelvic ring fractures had the worst long term outcome. conclusion: a combined anterior posterior pelvic ring injury accounts for the worst long term outcome of pelvic injury poly-trauma patients. we found that bilateral pelvic injury and particular associated injuries greatly influence long term functional outcome. disclosure: no significant relationships. material and methods: canulated screws were placed in human semi-cadaver models and plastic pelvis models in d navigated, d navigated and conventional matta technique. aim of this study was to evaluate intraoperative time, intraoperative radiation dose (fluoroscopy time, area dose product and images per screw) and accuracy (amount of exactly placed screws, mean deviation of tip placement and misplaced screws per group). results: the accuracy of d navigated procedures is significantly higher (p < , ) than in the conventional technique. there is a significant lower radiation dose in the navigated procedures (p < , ) for the operation team. the intraoperative radiation dose is increasing significantly from conventional method to d navigated to d navigated procedures for the patient (p < , ). there is a significant higher time per screw necessary for navigated procedures (p < , ). conclusion: the usage of flatpannel technology seems promising in d navigation. our data shows a benefit from using navigated procedures in transilliosacral screw placement. the higher precision and lower radiation exposure for the operation team show that d navigation is superior to d navigated procedures. the higher accuracy of the d navigated procedures renders a postoperative routine ct scan obsolete thus lessening the total radiation exposition of the patient. introduction: the purpose of this biomechanical study was to determine whether locking screws or smooth locking pegs optimize fixation of ao a distal radius fractures. material and methods: pairs of fresh-frozen human distal radii were used. ao a extra-articular distal radius fractures were created by removal of a -cm-wide dorsal wedge of corticocancellous bone centered cm from the articular margin of the distal radius and were fixed using palmar locking plates. the radii were divided into matched-paired groups for comparison. the side order, the fixation order and the testing order were randomized. the distal fragment in group i was stabilized with angular stable screws. the distal fragment in group ii was fixed with locking pegs. the proximal fragment in both groups was fixed with screws. the probes were tested with . nm for torsion and with n axial load for cycles each. stiffness was measured from the first cycles regarding torsion and axial load. then the differences of the stiffness were recorded during the remaining cycles. the wilcoxon test was performed, a value of p £ . was considered statistically significant. results: there were no statistically significant differences in the first load cycles within the eight matched pairs. after cycles the constructs with locking screws (group i) showed statistically higher stiffness values (p = . ) compared to the constructs with smooth locking pegs (group ii introduction: plate fixation of the odontoid process without c -c arthrodesis appears to a practicable option for the management of odontoid fractures that are not suitable for conventional screw fixation. although previous biomechanical works have evaluated the effectiveness of different odontoid screw fixation techniques, no study has quantified the mechanical stability of odontoid fixation by a plate device. the purpose of this study was to measure the mechanical stability of odontoid plate fixation using a specially designed plate construct, and to compare the results to those after odontoid single-and double screw fixation. material and methods: the second cervical vertebra was removed from fifteen fresh human spinal columns. the specimens were fixed to the experimental apparatus, with the load cell at the articular surface of the odontoid process. in a first test series, stiffness and failure load of the intact odontoid were measured. type ii odontoid fractures were created by °oblique extension loading at the articular surface of the odontoid process. afterwards, the specimens were randomly assigned to one of the following three groups: in group i (n = ) the fractures were stabilized using a specially designed plate construct, in group ii the fractures were fixed using two . mm cortical screws, and in group iii we used one regular . mm cortical screw. in a second test series, stiffness and failure load of the stabilized odontoid fractures were assessed for comparison and statistical analysis. results: group i (plate device) showed a significantly higher mean failure load than group ii and group iii. the mean failure load of group i after fixation of the odontoid fracture was % of the mean failure load that was necessary to create a type ii odontoid fracture, initially. comparing group ii (double screw technique) and group iii (single screw technique), there was no significant difference regarding the mean failure load. in both groups the mean failure load after odontoid fixation was approximately % of the mean failure load of the intact odontoid. statistical analysis also revealed a significantly higher stiffness of the stabilized odontoid after plate fixation, than after single or double screw fixation. conclusion: plate fixation of the odontoid process as an alternative procedure in certain fracture patterns provided a significantly higher biomechanical stability than the technique of odontoid screw fixation. using a specially designed plate construct fixed with two cancellous screws into the body of c and an additional cortical screw inserted in the odontoid process, % of the original stability of the intact odontoid was restored. single or double screw fixation of the odontoid only restored approximately % of the original strength. results: extension and flexion were not influenced of all implants significantly. all dynamic implants and also the rigid implant led to a significant increase of the mobility during side bending and rotation in the area of the adjacent segments. conurrently the cephaled adjacent segment (l /l ) showed a significantly higher mobility than the caudal adjacent segment (l /l ). conclusion: dynamic implants such as the interspinous spacer enlarge the mobility of the adjacent segments during side bending and rotation in a comparable size as the rigid implant. to this extent is to be assumed that reinforced adjacent degeneration cannot be prevented by the use of the interspinous spacer substantially. introduction: osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and disrupted microarchitecture of bone tissue. the most severe consequence of osteoporosis are osteoporotic fractures. these are mainly low-energy fractures, which anamnestically, clinically and radiologically differ from fractures in healthy bone. we tried to find the answer to a queston, whether it is possible, that osteoporotic compression fractures are single events, or if they represent a gradual, progressive vertebral collapse in patients with osteoporosis. we evaluated the forces, necessary for vertebral fractures, regarding the bone mineral density. material and methods: cadaver vertebrae were isolated with the approval of ethics committee. we mesured their bone mineral density and then subjected them to the stress-test. we used the computer-controlled hydraulic press and stress vertebrae to the fracture point and beyond, monitoring the deformation and the load. a sigma-epsilon diagram was constructed from the data. results: with the loading of vertebrae the pressure grew exponentially as a function of deformation to the breakage point. then we observe a plateau of saw-like shape, which corresponded to the progressive vertebral collapse. further deformation led to gradual compacting of vertebrae and we observed once again an exponential increase in pressure. this bone compaction is therefore the first mechanisms of fracture repair. the saw-like plateau form suggests progressive collapse of vertical trabeculae and their jaming into the horizontal, which then with the increasing deformation and load also fail. a similar phenomenon can be observed in the collapse of buildings during the demolition. (the - phenomenon). conclusion: unlike a high energy vertebral fractures, the osteoporotic fractures are presented as a gradual vertebral collapse. they take place parallel with the processes of bone reparation and remodelation. from this standpoint, osteoporotic fracture is unique. vertebral collapse increases the bone mineral density in the broken vertebrae, what is observed radiologically and densitometrically. repair of medium to large, but reparable, rotator cuff defects, augmented with a restore patch or not. patients have been randomly assigned to receive standard repair augmented with the restore implant or to receive non-augmented standard repair as the repair procedure is exactly the same in both patient groups, and the implantation of the restore implant does not necessitate any additional incision or measures, neither the patient nor the assessors are aware of the fact an implant has been used. the ethical committee of the university hospitals leuven has approved the study. all patients get full information and are enrolled in the screening program after written consent only. clinical evaluation, both pre-operatively and at months post-operative is performed by the same, independent physiotherapist trained in shoulder evaluation using the constant score structural evaluation is performed by ultrasonography, performed by a radiologist specialised in musculoskeletal radiology and sonography. unpaired two-tailed t tests, performed with prism software for mac osx, were used to compare the results of the scores in the control group with those in the xenograft group. fisher exact tests were used to evaluate the significance of differences in the proportions of retears in the patients for whom a sonography was obtained. results are expressed as the mean and standard error and significance was set at p < . . results: we included patients. there were female and male patients. in the non-augmented group there were females and males. in the restore group there were female and male patients. the average age of patients was years of age. in the non-augmented group the average age is , y (+/- , ) years of age, in the restore group , y (+/- , ). the mean pre-operative constant score of the non-augmented group was , +/- , points whereas it was +/- , points for the restore augmented group. post-operative the functional outcome months after surgery again was scored using the constant score. the mean score in the non-augmented group was +/- , points; in the restore group it was , +/- , points in the non-augmented group we documented a retear in / patients, in the restore group we had a retear in / patients ( small tears, massive tear). introduction: it has been estimated that up to % of adults suffer from rotator cuff tears [ ] , which can impair their ability to work or perform household tasks [ ] . management of rotator cuff tears is difficult as a large proportion of technically correct surgical repairs re-rupture, estimated between - % [ ] . it has been estimated that thousands of extracellular matrix repair grafts are used annually [ ] to augment surgical repair of rotator cuff tears and act as temporary scaffolds to support tendon healing. the only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus [ ] . as the shoulder is subject to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. we used dynamic shear analysis (dsa), which is a form of rheology and allows the study of flow and material deformation. material and methods: the shear properties of four different commercially available rotator cuff repair grafts were measured (restore, graftjacket, zimmer collagen repair and sportsmesh). mm punch biopsies were taken from the grafts and subjected to oscillatory deformation under compression. the bulk storage modulus (g') was calculated [ ] and used as an indicator of mechanical integrity. to assess how well the repair grafts were matched to torn and normal rotator cuff tendons, the storage modulus was calculated for human rotator cuff specimens obtained from the edge of rotator cuff tears during surgery, from patients aged between and years. age and sex matched normal controls were also obtained during shoulder hemiarthoplasties and stabilisations. results: we report a significant difference in the shear moduli of all four rotator cuff repair grafts (p < . , way anova). of the repair grafts (restore and graftjacket) had a significantly lower storage modulus when compared to human rotator cuff tendons (p < . , dunn's multiple comparison test). only the zimmer collagen repair and sportmesh had a storage modulus which was comparable to that of normal rotator cuff tendons (p > . ), and thus were most closely matched. conclusion: with increasing numbers of repairs of rotator cuff tears, and augmentation of these repairs, there is a need to understand the mechanical and biological properties of the both repair grafts and the tendons they are designed to augment. there is no clear definition of the ideal mechanobiological properties. current rotator cuff repair grafts display a wide variation in their shear mechanical properties, and how closely they are matched to the mechanical properties of human rotator cuff tendons. it is hoped that this study, in conjunction with others, will help to guide surgeons in deciding on the most appropriate repair graft. three-dimensional computed tomography reconstructions also improved the average intraobserver reliability for all fracture characteristics, from j d = . (substantial agreement) to j d = . (substantial agreement). the addition of three-dimensional images had limited influence on the average interobserver reliability for the recognition of specific fracture characteristics (j d = . versus j d = . , both moderate agreement). three-dimensional computed tomography images improved interobserver reliability for the recognition of coronal plane fractures from fair (j d = . ) to moderate (j d = . ) but this difference was not statistically significant. conclusion: three-dimensional computed tomography is helpful for; ) individual orthopaedic surgeons for preoperative planning (improves intraobserver reliability for the recognition of fracture characteristics), and for ) comparison of clinical outcomes in the orthopaedic literature (improves interobserver reliability of classification systems). disclosure: no significant relationships. introduction: in recent years, d fluoroscope has used increasingly in orthopaedic surgery because it offers some advantages such as generation d data without anatomic registration requirement. previous studies have focused on the clinical use of d fluoroscope in surgical procedures such as calcaneus or acetabular fracture reduction, or placement of screws in spinal surgery. there are no reported data on radiation exposure of d flu to orthopaedic theater staff. we want to correlate radiation exposure and distance concerning the patients and members of surgical team during using three-dimensional fluoroscope and study how far is enough until radiation exposure can not be measured. material and methods: an isocentric c-arm fluoroscope (siremobile isoc d) was used for the study. human cadaveric extremity was used for target. digital dosimeters (mydose mini pdm- , aloka) were used to measure radiation exposure at specific distances. dosimeters were systematically exposed by the following protocol. represented positions were direct contact and every -cm. radius from the center of the beam. the distances were increasing until the dosimeters could not detect the radiation. each radius distances were designed to record different positions; top, bottom, left and right side. dosimeters were exposed and removed ( dosimeter positions at a time from each radius). first we used low resolution scan technique to obtain the images. after all radiation exposure records were collected, we changed to use high resolution scan technique and repeated the protocol. each technique was repeated in times to obtain the mode of data. results: radiation dose at ground zero is lsv in high resolution and lsv in low resolution. radiation in high resolution technique can not be measured beyond meter from the center of the beam at the top, bottom, and right direction and . meters at the left direction. in low resolution, radiation cannot be detected farther than cm. in the top, bottom and right direction and . meters at left direction. conclusion: radiation dose measurements in each direction are decreased during increasing distance and dose in left direction is higher and farther than others. beyond . meters is safe from radiation in knee application. high resolution gives higher radiation and farther than low resolution. introduction: tibial plateau fractures with impression are often associated with poor outcomes and a high rate of complications. the current guidelines advocate anatomic reduction, re-establishment of tibial alignment, stable fixation, and filling of the sub-articular defect. we hypothesized that fixed-angle liss-plates provide adequate stabilization with less need for void filling, minimal complications and good radiological outcome. material and methods: retrospective evaluation study. in the period - , we operated patients with an intra-articular tibial plateau fracture. forty were treated with a liss-plate. mean age was years, were male. all fractures were classified as ao type b or c; were schatzer type ii, type iv, type v, and type vi. five patients were initially treated with external fixation. mean time until definitive surgery was days (range, - days). in fractures, the subchondral void was filled with either hydroxy or bone graft, in the other cases no graft was used. demographic data and fracture classification were equal in both groups. articular impression was measured by independent evaluators pre-operatively, post-operatively and months after surgery on plain x-rays. results: mean pre-operative impression was . mm (with void filling . mm, without . mm, ns). thirty-four fractures were additionally stabilized with k-wires or screws. the post-operative impression was on average . mm. evaluation criteria included the lysholm and tegner activity score. all fractures were stabilized post primarily. the surgical main approach was strictly medial. exposure of the entire medial condyle fracture was first performed anteromedial following the fracture line to the articular border. the posterolateral impaction was addressed directly through the main fracture gap. small fragments were removed, larger reduced and preliminarily fixed with separate kwire(s). the posteromedial part of the condyle was then prepared for main reduction and application of a buttress t-plate in a posteromedial position, preserving the pes anserinus and medial collateral ligament. in addition a parapatellar medial mini-arthrotomy through the same main approach was performed for reduction and pds-suture-fixation of the anterior eminence (acl and anterior horn of lateral meniscus). results: we treated patients with fractures. median age was years ( - ). we could evaluate patients ( %), patients were lost to follow-up due to foreign residency. the fractures were treated post primarily at an average of days, of them in a twostaged procedure with initial knee-spanning external fixator. all fractures healed without secondary displacement or infection. patients showed none to moderate osteoarthritis after a median of years. one patient showed a severe osteoarthritis after years. all patients judge the result as good to excellent. the lysholm score reached ( - ) and the tegner activity score ( - ). all patients have achieved a minimum flexion of °. conclusion: in our view it is crucial to recognize this increasingly observed type of knee injury in winter sport areas. with our strategy we achieved good results in nearly all patients. the described larger medial approach allows addressing most of the injured parts of the tibial head (medial condyle with posteromedial buttressing, tibial spine, posterolateral impaction). material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator (sif). there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to metaphyseal fractures of distal femur and proximal and distal tibia. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. for opened fracture it has been used high mobile external fixation system as temporarily ( fractures) or definitive ( fracture) method. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the . - months. it has been allowed to patients early full weight bearing, if fractures not intraarticular. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). when used external fixation system, axial dynamisation has been regularly activated. conclusion: according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site if no intraarticular dislocation. it can be used as primary method or soon after external fixation if damaging control concept used. introduction: disaster, is the disproportion between the need for medical care and the means available in the community. this discrepancy of needs /means is the major problem in every step of the rescue chain, when a disaster situation is present. this is more obvious at the end of the chain, which is the hospital and especially, the bottleneck of the entire disaster's management system, the emergency department. material and methods: in greece, the most common and frequent disaster situation is the earthquake. and so, the most expected pathology of the victims is trauma. because of the lack of . special organization of emergency medicine and . independent modern emergency departments in greek hospitals, their directors did not give the appropriate attention to organize a disaster plan (internal or external introduction: accurate response to major incidents requires accurate decisions on all levels, from command level to the care of the individual patient. development, evaluation and training of the process of decision-making requires standardized models providing complete and accurate information as a base for the decisions; a decision based on incomplete or incorrect data can not be properly evaluated. the aim of the present project was to design a simulation model that could be used both for evaluation of different methods in the response to major incidents and for training and evaluation of skills in making correct decisions. material and methods: a system was created providing the information required for this process in the whole chain of management and performance: scene, transport, hospital response, co-ordination and command. input data were based on real scenarios and real resources. for evaluation of methodology, all parameters except the one studied, in this study triage, were standardized. the results from (a) physiological and (b) anatomical triage, performed by staff on different levels of competence and experience, serving as their own controls, were compared. for training, the system was used in courses in medical response to major incidents with training of the whole chain of management and performance, from prehospital patient management to over all co-ordination and command. results: the methodological evaluation showed differences in priority and outcome between anatomical and physiological triage related to the level of experience and to the position in the chain of response, providing a base for choice of method related to those factors. the results from training with the use of the system, so far only evaluated by the participants own ranking, showed high percepted improvement of relevant skills. conclusion: a methodology for simulation of major incident response designed for scientific evaluation of methodology also provides a very good educational tool, since correct and complete data as a base for decision making also gives an effective and realistic training. disclosure: one of the authors, sl, has the copyright to the mac-sim system, a non-commercial system intended mainly for scientific use. equipment for training can be produced by users, but also purchased for production costs. introduction: interhospital referral of traumapatients for reasons of special (most neuro-)surgical competencies to a specific level traumacenter, is common practice in the netherlands. these traumapatients are sometimes admitted directly through specialized intensive care units and therefore do not enter the emergency department (ed). therewith the standard assessment according to the atls guidelines is bypassed in these cases. this withholds the risk of an incomplete assessment. we therefore consistently coordinate the assessment of all transferred traumapatients. in this study we analysed the number of newly found injuries in referred polytraumatized patients and the clinical consequences in terms of extra treatment, permanent damage or death to the patient. we also analysed possible risk factors for missing injuries. introduction: synchronous admission of large numbers of patients into the hospital requires a perfect coordination of activities of designated teams in the process of reclassification at the entry to the hospital and subsequent continuous provision of medical care for the patient in the course of examination and treatment, up to his hospitalisation at the target department, in accordance with the characteristics of the injury and seriousness of his medical condition. this process cannot be accomplished through improvisation but only with creating a uniform organisational scheme, defining the recommended structure of medical teams and their activities during a multiple admission of casualties into the hospital. in this article, we present a proposal of such consensual organisational scheme, partially verified in practice. the organisational scheme is defined in the following areas: -space arrangements -places of admission and organisation of work -creation of mini trauma teams (anaesthesiologist, traumatologist and surgeon or another traumatologist take over the most serious patients, the teams are accompanied by consulting specialists of relevant specialities (neurologist, neurosurgeon, radiologist), the whole teams or at least parts of them, accompany the patients for the whole period up to the definite treatment at operating theatre, or his placement at a destination department -the continuity of care is secured in this way, without the need to pass on any findings and information -placement of patients into individual hospital departments (follows certain rules, it is necessary to direct all the admitted patients into as few departments as possible (one or two), and thus keep the best possible view over the priorities during their treatment -entry corridors -,,green corridor'' -patients are immediately transported through this area by transport teams into the ''green'' designated area, the ''red'' and ''yellow'' entry area does not have to be extremely large, however it requires an adequate equipment from the material and technical point of view results: multiple admission of patients must be well-organised and managed, most often by a head-physician of the ua department, or another authorised specialist (in hospitals without the ua department). the idea of the traumanetwork d dgu is to built up regional networks of various trauma centers with the objective to standardise and optimise the treatment of severely injured patients -with the additional involvement of rescue services, physicians and competent facilities and centres for the treatment of specific injuries as severe burn or spinal cord injuries etc. to assure that all participating hospitals meet the criteria needed for the treatment of trauma patients, a certification firm (diocert) was assigned to accomplish the audits and to control the process of certification. thus, every hospital has to pay a sum of nearly eur for audit, certification, benchmarking, yearly quality reports and the use of special it-tools which were designed for the traumanetwork d dgu. material and methods: coordination of traumanetwork implementation coordination of audit and certification process results: since the beginning in the year actually hospitals are participating the traumanetwork d dgu. these hospitals are organized in regional traumanetworks. % of the hospitals are preliminary categorized as local trauma centers, % as regional trauma centers and % as over-regional traumacenters (the highest category). % still aren¢t categorized. hospitals have already signed the contract with the german trauma society and paid the participation fee. hospitals meet the criteria for audit and hospitals are already audited by the firm. in october the first regional trauma network (trauma network east bavaria / tno) was certificated with a total of participating hospitals. conclusion: in the past years the number of participating hospitals increased year by year. the nationwide acceptance and the high level of participation in the traumanetwork d dgu in germany show that the treatment of severely injured patients is one of the main topics and exercises for trauma surgeons in germany. if the expected improvement in treatment quality and the decline in trauma mortality is only wish and fiction or reality and fact has to be proven by studies in the next years. therefore a working group with focus on quality improvement, changes in mortality, improvement in rehablitation results etc. was founded. introduction: one of the challenges in trauma care is diagnosing all injuries. any delay in treatment can lead to increased morbidity, prolonged length of hospital stay, costs, and even mortality. despite the use of standardized guidelines for initial evaluation such as atls, the incidence of missed injuries in the literature is considerable. the aim of this study was to assess the rate of missed injuries in trauma patients evaluated in two dutch level- trauma centers and to determine potential factors that contribute to injuries being missed. we assessed all radiological reports during initial admission and operation records of the patients included in the prospective randomized react trial. this study was part of a randomized trial conducted in two dutch level- trauma centers investigating the role of ct scanning in the trauma room. missed injuries were defined as not diagnosed during initial radiological evaluation in the trauma room. we assessed all missed injuries and the phase in which these injuries were diagnosed. second, we assessed potential contributing factors by univariate analysis. results: there were a total of total calls performed with real patients and test calls. of the actual calls, ( %) were performed while moving and ( %) were done from a stationary position. initial video quality in was rated good in cases ( %) and initial audio quality was rated good in ( %) cases with actual patients. of the actual calls ( %) experienced some sort of temporary video drop during the entirety of the call and calls ( %) experience some sort of temporary audio drop. these drops were a result of the setup of mesh wifi and the need to jump from router to router. users in the hospital found the program to be a very useful trauma and emergency medicine tool, but adjustments need to be made to improve the network. conclusion: the use of telemedicine in a pre-hospital setting may play a significant role in the management and treatment of trauma and critically ill patients as hospital medical staff can intervene in real time during transport. patients can be evaluated in real time which allows the necessary staff and resources to be available on arrival. initial user feedback has been encouraging with users acknowledging its usefulness as a pre-hospital tool. ( ) in the elective setting it is logical that a lower egfr reflects poor renal function and low overall physiological reserve. the same is not obviously true for emergency patients who may have an ''artificially'' low egfr merely as a reflection of acutely altered fluid balance. change in egfr from admission to hospital to itu admission was also significantly different between survivors and nonsurvivors. this would suggest that egfr reflects a response to treatment as well as renal function. this study supports the use of egfr in the decision making process when trying to predict outcome in emergency general surgery patients. introduction: the surgical medium care (smc) in our hospital is a bed ward with monitoring facilities, and is used critical ill patients from the trauma and other surgical wards. over the last years there has been an increase in the number and severity of trauma patients admitted to out hospital, as well as there has been an increase in patients undergoing major elective surgery. the aim of this study was to verify if these trends are reflected in an increase in patient-and workload on our smc. in this study we describe the patient-and workload on the smc between and using the tiss- . the modified therapeutic intervention scoring system (tiss- ) is a validated score of therapeutic activities and an alternative approach to evaluate outcome of critically ill patients ( ) ( ) ( ) . material and methods: a prospective cohort study of all consecutive patients admitted to the smc between / / and / / was performed, using the tiss- database. of all admitted patients a daily tiss-score was performed. besides the tiss data, patients demographics, referring ward, discharge destination, length of stay, and hospital mortality were retrieved from the database. results: there were a total of admissions of patients in the study period. % of patients were male, % were female. the median length of stay was days ( - ). the overall hospital mortality rate was , %, with no significant differences over the years. % of the patients admitted to the smc came from the icu, % came from the emergency department, , % came from home, , % came from the recovery ward, and % came from the trauma and surgical ward. these percentages did not change over time. the average tiss score during the study period was and did not significantly differ during the study period. there was, as expected, no significant difference in tiss score between patients who survived and the non survivors. introduction: the demands placed on systems and organisations that protect the general population are constantly growing. the reasons for this include, among other things, circumstances altered by the threat of inter-national terrorism and the increasing frequency and magnitude of mass public events and natural catastrophes. crisis situations such as these present unique, often completely unprecedented chal-lenges to those affected and to all actors with responsibility for crisis management and the protec-tion and rescue of people.with regard to effective interdisciplinary crisis management, both germany's security and rescue forces and its general population suffer from widely acknowledged and scientifically proven deficits. impact on people and the society. in this context, all natural and man-made threats will be considered (''all hazards approach''). elearning and virtual reality modules based on these scenarios will be offered to target groups via the internet on an individualised basis. results: the aim of this project is to develop a platform to prepare security and rescue forces, doctors, caregiv-ers and the general population for terrorist attacks, crises and disasters. an online platform with a modular structure (employing teaching methods such as e learning, blended learning etc) will offer innovative and specialised instruction and advanced training to all users. conclusion: experts agree that the modern teaching methods and computer-based simulations mentioned here (such as virtual reality methods) are excellent tools to help train people efficiently to respond to events that cannot be planned, such as terrorist attacks and other catastrophes. the use of these innovative methods and com-pletely novel, userfriendly, web-based instruction and information modules is designed to address -to a heretofore unprecedented degree -all security and rescue forces concerned as well as the general population in particular. ultimately this will signifi-cantly improve security and rescue operations in the event of terrorist attacks, crises and disasters. conclusion: in a proper setting, laparoscopic emergency is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients. the diagnostic and therapeutic versatility afforded by the laparoscopic approach avoids extensive preoperative studies, averts delay in operative intervention and minimize morbidity and shorten the postoperative hospitalization. we do think that laparoscopy should be incorporated into general surgeon's armamentarium for the management of patients with acute abdomen as just as another tool to be used selectively when indicated. laparoscopy, however, must not be used as an alternative to good clinical judgment. about our algorithm in patients with acute abdomen: if there aren't any contraindications to laparoscopy, obtained an informed consensus, in presence of a well trained surgical team in minimally-invasive surgery, excluded any major gynaecological diseases (about which we and our gynaecological colleagues haven't a skilled experience with a laparoscopic approach), we always approach laparoscopically. introduction: stable patients with thoracoabdominal penetrating or blunt injuries resulting in diaphragmatic injuries represent a difficult and challenging management dilemma. although laparoscopy and thoracoscopy have now emerged as the most reliable and efficient diagnostic and treatment modality of these injuries, a conversion to laparotomy for mere evidence of peritoneal penetration and or diaphragmatic injuries is common for most trauma surgeons. we hypothesized that laparoscopically-assisted mini-thoracotomy for repair of diaphragmatic injuries will be as effective as open laparotomy or thoracotomy and will prevent the morbidity associated with open technique and should be used in hemodynamically stable trauma patients. we designed a minimally invasive technique that combines laparoscopic exploration of the intraperitoneal cavity and existing injury site as an entrance to the injured site or organ. open hassan technique, using vertical midline incision is used to create the pneumoperitoneum. additional two to three or mm ports are placed to enable thorough examination of the peritoneum, running the small bowel and examining other abdominal viscera. diaphragmatic lacerations are repaired by extending ( - cm) the existing thoracic stab or gunshot wound. the diaphragm is grasped with two graspers and brought to the operative field. continuous or interrupted suture are used for repair. we applied this technique to hemodynamically stable trauma patients (la group) treated over a year period at the university level i trauma center and compared to trauma patients requiring laparotomy (og) for isolated diaphragmatic injury repair . all laparoscopically assisted procedures were performed by the senior author (rl). length of stay, morbidities and complications were studied in both groups. both groups were matched for iss, age, and gender and mechanism of injuries. results: there were patients (five with stab, two with gunshot wound and one with blunt trauma and chronic diaphragmatic injury) in the la group. introduction: acute small bowel obstruction is mostly due to adhesions ( %), while internal hernia can cause acute small bowel obstruction in % of cases. this clinical condition has been considered for many years a relative contraindication for laparoscopic surgical treatment. with the introduction of ct-scan in the diagnosis of this clinical situation and the experience in laparoscopic techniques, more surgeons are now attempting laparoscopic management for this indication. the advantages of laparoscopy in abdominal surgery are now well defined, such as a shorter intestinal function recovery, a shorter hospital stay and less post-operative pain complained by the patients. in our presentation we want to analyse the importance of laparoscopy in the diagnosis and the treatment of acute small bowel obstruction, in order to underline advantages and limits of this technique. material and methods: in san raffaele hospital milan (italy) a total of patients underwent a surgical intervention for small bowel obstruction from january to december . % of the obstructions was due to adhesions, % to internial hernias. all the patiens underwent preoperative abdominal x-ray and ct-scan. results: of the total of patients, have been operated on with a laparoscopic approach, with a conversion rate of . %. postoperative morbidity was % in the laparoscopic group and . % in the traditional surgical approach, with a shorter hospital staying in the first group. conclusion: the analysis of our data suggests us that the selection of patients that can benefit from a laparoscopic approach to acute small bowel obstruction has to be made accurately, better with the use of ct-scan, in order to limit the percentage or useless laparoscopy and to diminish the conversion rate and to give the patient the better curative option. introduction: intestinal obstruction has remained one of the most common surgical emergencies. the aim of our study is to evaluate the feasibility, safety and palliative role of laparoscopic bowel surgery in the management of large bowel obstruction. material and methods: in a period of years, patients were subjected to loop sigmoidostomy. in patients the diagnosis was bowel obstruction due to rectal cancer. in patients the obstruction was attributed to ovarian cancer. from those patients with rectal cancer, patients had contominant liver and lung metastases and had an unresectable liver lession. in that period lapassisted ileo-transverse anastomosis were performed due to obstruction from cecum carcinoma together with mlitple liver and lung metastases. single surgeon-performed pocus in the evaluation of acute appendicitis led to a correct diagnosis in , % ( / ). surgeons trained in us ordered a ct scan in , % of cases and ratio of negative appendectomy was , %. surgeons not trained in us ordered a ct scan in , % and their ratio of negative appendectomy was , % (including pts that underwentent surgery on clinical investigation basis only). conclusion: surgeon-performed pocus has a high sensitivity in the assessment of acute appendicitis and it is a powerful tool that minimize the use of ct scan and ratio of negative appendectomy with reduction of hospital and social costs; furthermore an advantage for the patients in terms of radiation exposure can be achieved. moreover, to reduce additional costs, laparoscopic approach should be indicated only when the appendix cannot be perfectly visualized and localized. introduction: severe bleeding is, besides head injury, the most important predictive factor in severe trauma. therapy of hemorrhagic shock starts already at the scene of accident. however, the best strategy regarding preclinical volume therapy is controversially discussed. the traumaregister of the german society for trauma surgery (tr-dgu) observes the routine management of severely injured patients since many years. this registry will be used to describe the behaviour of preclinical volume administration as well as the consequences in early hospital care and its changes during the last ten years. material and methods: the tr-sdgu is a voluntary anonymous documentation of severely injured patients for the purpose of quality management. data collection started in . about parameters are collected per patient. for the present investigation only adult patients (age >= ) admitted directly from the scene to one of the participating hospitals during the past ten years ( - ) were considered. a minimum injury severity of iss > = and available data for volume administration and blood transfusion were required. means and prevalence rates were analyzed on a yearly basis. results: a total of , patients injured between and were analyzed. mean age was . years, and % of patients were males. in % of cases there was a blunt trauma mechanism, and % of cases were unconscious at the scene (gcs £ years that required presentation in one of the two level- trauma centers (amc or vumc) were eligible. in the amc the ct scanner was located in the trauma room (intervention group) and in the vumc the scanner was located in the radiology department (control group). randomization was performed prehospitally at the time of dispatch from the scene. primary outcome measure was the number of non-institutionalized days within the first year following trauma. secondary outcomes were mortality, length of initial admission and transfusion requirements. preplanned subgroup analyses consisted of multitrauma patients and severe traumatic brain injury (tbi) patients. results: in total, patients were included for analysis of which were multitrauma patients and had severe traumatic brain injury (tbi). demographic data were comparable between both groups except that there were more multitrauma patients evaluated in the amc. introduction: the effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of common injury patterns, incidence, mortality, and consequences. the needed inital radiological imaging remains controversial and should be adapted to the expected injury pattern. material and methods: in this retrospective study, the injury patterns of polytraumatized paediatric patients (age £ years) in the period from december to may were evaluated. all children were initially diagnosed with a whole body ct scan. the cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. the ais (abbreviated injury scale) and iss (injury severity score) were used to classify the severity of injuries in different body regions. moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated. results: the mean score of the iss was ± in boys and girls with a mean age of ten years. the lethality was % and only % in the first hours. the most severe and most frequent injury was craniocerebral trauma in % with an ais ‡ in %. surgical intervention of the head was done in %. thorax injuries were found in % with % with an ais ‡ and in % a thoracic drainage was needed. abdomial trauma was found in % (surgery %) with an ais ‡ in %. fractures of the spine occured in % (surgery %) with an ais ‡ in % and pelvic injuries were diagnosed in % (surgery %) with an ais ‡ in %. injuries of the upper extremity were found in % (surgery %) with an ais ‡ in % and of the lower extremity in % (surgery %) with an ais ‡ in %. conclusion: especially because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery the authors recommend a whole body ct scan in children who are potentially polytraumatized. not only in adults but especially in children the authors suggest the initial use the quickest imaging with a high sensitivity-the whole body ct scan. introduction: patients who suffer physical injuries following a traumatic event are at risk for developing posttraumatic distress. care workers in hospitals treating polytrauma patients are in an optimal position to screen and identify patients developing posttraumatic stress disorder (ptsd). to start early intervention procedures and possibly lower the prevalence, a screening instrument to identify patients at a higher risk is needed. aims of this study were to determine if the severity of injury is related to the prevalence of ptsd and to review the personality traits of patients with ptsd. with these results a screening instrument might be developed. to simulate an unstable extraarticular distal radius fracture, an osteotomy with a mm gap was made. axial loads of - to - n and torque loads of - , to , nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. after that, cycles of dynamic torque load alterations of , to , nm (or - , to - , nm convenient to side) at , hz with a preload of - n were performed. in the specimens that were still intact after cycles, loading in torque was continued until failure occurred. axial and torque stiffnesses of the osteosynthesis system were calculated. results: with a median of , n/mm axial stiffness of xscrewÒfixed specimens was higher than of dnpÒ-fixed specimens with a median of , n/mm but did not reach statistical significance. with a median of , nm/°torque stiffness of xscrewÒ-fixed specimens was significant higher than of dnpÒ-fixed specimens with a median of , nm/°. the xscrewÒ-group reached % of the axial stiffness and % of the torque stiffness and the dnpÒ-group reached % of the axial stiffness and % of the torque stiffness of the intact radii. conclusion: fixation of unstable extraarticular distal radius fractures with a xscrewÒ provide biomechanically more stability than a fixation with a dnpÒ. disclosure: no significant relationships. after distal radius fractures occur in % to % of fracture cases. the resulting deformity resembles madelungs deformity and is also called pseudo-madelungs deformity. this deformity leads to ulnocarpal impaction and dorsal dislocation of the distal radioulnar joint (druj). several treatment options such as lengthening of the radius and shortening of the ulna or epiphysiodesis of the distal ulna have been described. the taylor spatial frame (tsf) is a hexapod based external ring fixator, which is widely used to perform six-axis deformity corrections of the lower limb. tsf-planning is web based (www.spatialframe.com) but its use is only available for lower extremities. the purpose of this study was to apply the tsf to the upper extremities to correct pseudo-madelung deformities. material and methods: defining the nomenclature to correct bony deformities with the tsf, one must determine the deformity parameters, the frame parameters, and mounting parameters for the web based planning program. the six deformity parameters and the four mounting parameters use the anatomic nomenclature for the lower extremities. to use the tsf on the forearm, one must transfer the nomenclature of the deformity parameters and the mounting parameters to the nomenclature of the forearm with the transferred nomenclature, one can correct forearm deformities with the correction mode long bone of the planning program for the lower limb. patients two boys (patient , years, patient , years old) and two girls (patient , years, patient , years) were seen in our clinic with progressive pseudo-madelung deformities after an epiphysial fracture of the distal radius at age in the boys and in the girls. skeletal maturity (rus, tw method) was equivalent to the patientâ e tm s age. results: in the four patients, the multiplanar deformitiy of the distal radius could be corrected anatomically with the tsf. there were no frame changes or frame modifications necessary for deformity correction. patient was slightly overcorrected because of some growth in the distal ulnar growth plate. during the distraction, each patient had two low-dose ct scans for better visualization of the radiocarpal and radioulnar joint. the web-based planning program was adjusted twice until total deformity correction was achieved. no further immobilization after frame removal was required. the one-year follow-up showed an anatomic aligned forearm/hand relation with increased pronation and supination compared to the preoperative range of motion in all patients. the wrist and especially the druj were stable and reduced at the one-year follow-up examination. the patients did not complain about any pain or functional deficits in the hand. conclusion: in conclusion, the power of the tsf with the ability to move two fragments precisely can be transferred to the forearm. this allows for the correction of multiplanar radial deformities simultaneously without the need for frame modifications of rotational and translational deformities, as is necessary with the standard ilizarov system. material and methods: thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent ct and mri within ten days after trauma. ct-reconstructions were made in planes defined by the long axis of the scaphoid. the reference standard for a true fracture of the scaphoid was -week follow-up radiographs in four views, based on current available evidence in the literature. a panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. we calculated sensitivity, specificity and accuracy as well as positive (ppv) and negative predictive values (npv) for both imaging modalities. results: according to the reference standard there were six true fractures of the scaphoid (prevalence % both mri and ct are better at ruling fractures out than in ruling them in and both were subject to false positive and false negative interpretations. the best reference standard for a true fracture is debatable, but for now it is not clear when bone edema on mri and small unicortical lines on ct represent a true fracture. we advice ct because costs are lower and overall availability is higher. introduction: the scaphoid bone is the carpal bone most commonly fractured in wrist trauma. traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. conversely, displaced fractures are recognised as unstable, with a significant risk of non-union if not treated surgically. there is a current trend in orthopaedic practice, however, to treat non-or minimal displaced fractures also with early open reduction and internal fixation. this trend is not evidence based. in this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarise the best available evidence. material and methods: fourty fresh frozen cadaver scaphoid bones have been sampled at our disposal for testing of screws. the bone density measurement of all specimens has been performed using a qct scan. a transverse osteotomy will be performed at the waist of each scaphoid simulating a b fracture according to the herbert classification. a load cell will be interposed, in an already established method, between the proximal and distal pole of the bone to measure compression force while introducing the screw. the screws will be applied as recommended by the manufacturer using original instruments. the intrascaphoid compression will be recorded at the peak during insertion of the screw, and after and seconds, , , and minutes. results: preliminary results determined that a greater compression can be sustained over a time by headless compression screws with significant differences between those screws. the tests will be finished at the end of january and we will present the final results. conclusion: in more than % of our cases a fracture was missed with the initial radiograph. bone scintigraphy is still a good choice to detect an occult fracture around the wrist. introduction: operations in trauma patients represent a second insult and the extent of the surgical procedures influences the extent of the inflammatory response. the aim of this study was to evaluate the operative burden related to femoral intramedullary nailing. our hypothesis was that a reamer-irrigator-aspirator (ria) system would cause lesser inflammatory response than traditional reaming (tr) due to a lesser intramedullary pressure increase and thereby reduced intravasation of bone marrow content. material and methods: coagulation, fibrinolysis and cytokine responses were studied in norwegian landrace pigs during and after intramedullary reaming and nailing with the two different reaming system; the tr (n = ) and the ria (n = ) reaming system, and compared to a control group (n = ). the animals were followed for hours. simultaneously arterial, mixed venous and femoral vein blood were withdrawn peroperatively and until two hours after the nail was inserted for demonstration of pulmonary, systemic and local activation. results: significantly procedure-related increased levels were found for tat, t-pa and il- in the tr group and tat in the ria group. the local and the pulmonary activation of coagulation, fibrinolysis and cytokine response was more pronounced in the tr than in the ria group, but the difference did only reach significance for il- (femoral vein) and pai- (arterial). the arterial levels of il- and tat exceeded the mixed venous levels indicating an additional pulmonary activation. these differences, however, did not reach significance. two animals in the tr group, who died prior to planned study end point, demonstrated higher inflammatory response compared to rest of the tr group. conclusion: the inflammatory response to the reaming and nailing procedure was modest, and the response was lesser in the ria group than in the tr group. introduction: approximately . million joint arthroplastic operations are performed annually worldwide. implant failure due to massive bone loss and aseptic prosthesis loosening, however, is a major complication of joint replacement. it is generally accepted that small particles (''wear debris'') and activated macrophages play a key role in aseptic loosening. but also the prosthesis loosening fibroblast (plf) plays an important role. material and methods: between and abg- -hip arthroplasties were implantated. after a year analysis % had to be removed because of massive wear of polyethylene (pe) and consecutive acetabular osteolysis. we analysed the influence of patient and surgeon, the implantdesign incl. pe-thickness, anchorage coupler, material roughness i.e. and the material i. medtronic) the application of the cements was done according to the specifications of the manufacturer. after extrapedicular kyphoplasty on cadaveric lower thoracic spine vertebrae (th - ), the intervertebral distribution pattern was investigated by microtomography ( lct). besides creating high resolution d and d reconstructions, the mathematic calculation of the porosity of the vertebra, the bone substitute material and the relative part within the different compartments was performed. of special interest were the characterization of the bone substitute material -spongiosa -interface and the penetration of the calcium phosphate cement into the adjacent spongiosa. the following parameters were investigated: . trabecular structure, porosity and hydroxylapatite concentration of the native vertebrae . structure (homogeneity, distribution of pores) of the bony substitute material . characterization of the bone-bone substitute-interface a. central located, filled kyphoplasty defect b. transition zone with spongiosa and bone substitute material c. solitary spongious bone results: the investigation of the native spongiosa yielded a comparable trabecular structure, porosity and hydroxylapatite concentration in the intra-individual comparison of the vertebrae of the lower thoracic spine. between the cements differences in the solitary structure as well as distribution pattern during kyphoplasty were observed. especially the analysis of the ability to penetrate into the spongiosa adjacent to the centrally located kyphoplasty defect yielded significant differences. the main influencing factor of the ability to penetrate into the spongiosa is the different viscosity of the -according to manufacturer specification -used calcium phosphate cements. the cements differ in their native structure as well as in their distribution pattern during kyphoplasty. the differences in micro-morphology of the calcium phophate cements have a high probability to influence the degradation of the sedimentation products and later osseointegration. disclosure: this research was funded by a grant of ao germany. introduction: it is difficult to predict the long-term clinical outcome in the early period following an acetabular fracture. introduction: the tremendous increase of acetabular fractures in the elderly provides new challenges for the surgical treatment of acetabular fractures. surgical reduction of the acetabular joint represents the most reliable possibility to prevent the development of premature arthrosis even in the elderly. biomechanical studies showed, that plates with periarticular long screws result in an increased stability of the osteosynthesis, it has to be considered that the insertion of these screws always bears the risk of penetrating the joint the aim of this study was to evaluate the biomechanical properties of these standard plates and newly developed minimal invasive osteosynthesis techniques for stabilization of an anterior column combined with posterior hemitransverse fracture type (acphtf), which represents a typical acetabular fracture in the elderly. material and methods: using a single-leg stance model we analyzed different implant systems for the stabilization of acphtfs in synthetic pelvises (standard reconstruction plate, new developed prototype and definitive repofix Ò (adi -ao foundation, switzerland). applying an increasing axial load in a biomechanical testing machine, fracture dislocation was analyzed with a multidirectional ultrasonic measuring system (zebris, germany). differences in change of center of gravity are statistical analysed by man-whitney-u -test. results: analog to a long bow, the repofix Ò supports the quadrilateral surface sufficiently and reconstructs the surface of the pelvic brim from the inner side of the pelvis. in synthetic pelvises, the new repofix Ò is associated with a significantly less pronounced dislocation (center of gravity) of the fractured quadrilateral surface when compared to prototype and the standard reconstruction plate. the biomechanical results could be seen at a measuring point at the quadrilateral surface and in the rotation around the x -axis (angle y results: we collected data on acetabular fractures. a conventional image intensifier was used in cases (group a), d-navigation was used in cases (group b). in group a the kocher-langenbeck-approach was used in most of the cases ( %), followed by the maryland-approach ( %). in group b, the kocher-langenbeck-approach and the ilio-inguional-approach were used in an almost equal number of patients ( % / %), but extended approaches were only used twice. in % of the cases in group b fractures were stabilised by navigated placement of percutaneous lag screws. when we excluded the percutaneous operations in group b (n = ), the difference in or-time between navigated (n = , ± min) and conventional treatment (n = , ± minutes) was significant (p < , ). in group a we detected relevant postoperative complications in % of patients. the complication rate was significantly lower in group b ( %, p < , ). the postoperative radiological analysis revealed a better qualitiy of reduction in group b (n = ) with an average post-op fracture gap of , mm vs , mm in group a (p < , ). conclusion: by using a navigation system and a d image intensifier we found a significant increase in the or-time in the navigated group. however, in the postoperative radiological analysis, we detected a better quality of fracture reduction in the navigated group. navigation in combination with the -dimentional pictures of the iso-c d led to a better visualisation of the acetabulum, therefore the need for extended approaches was reduced. to our opinion, this explains the significant reduction of postoperative complications in group b. we conclude that navigation and a d image intensifier should always be used for orif of acetabular fractures. disclosure: no significant relationships. introduction: the traumatism is the first cause of the mortality in patients under . it means a serious incapacity in of trauma patients. the initial management in trauma patients is essential to improve these results material and methods: this is a prospective and multicentric study with the participation of hospitals in catalunya (spain). the objectives are to improve the evaluation and the initial management of trauma patients, and to improve the knowledge of the frequency, the magnitude and the approach of these trauma patients. we defined points to improve which are: to intubate patients with glasgow < ( ); to not remove the cervical collar without clinical or radiologic cervical exploration ( ); to move trauma patients monitorized ( ); to not move haemodinamically instable trauma patients ( ); to use two thick intravenous cannulations ( ); to take thorax and pelvic simple radiographies in the trauma box ( ); to fix pelvis fracture with a grassland before moving the patient ( ) we took more thorax and pelvic radiographies in the trauma box (from . % and % in the first period to . % and . % in the second period, p < . ). and we also fixed more pelvis fracture with a grassland before moving the patient, from % in the first period to . % in the second period. conclusion: the registration of the information about trauma patients allows the identification of the points to improve. we improved the evaluation and the initial management of the trauma patients, especially in the monitorization of trauma patients and in the management of the thoracic and pelvic traumatism introduction: there is wide evidence about the importance of having good protocols for assisting trauma patients and a teaching system for the personnel involved in this assistance is needed. it is also well known that the formation for assisting trauma patients in spain is not very much spread in general. material and methods: we describe how we have arranged the care for this type of patients in a level ii center and a teaching system for our staff and we prospectively analyze the impact of this specific formation by means of a questionnaire and analyzing how correctly the trauma team is activated. results: from november through october ( months), editions of our course have taken place and people have participated ( , % of the staff for whom the course is aimed to). we found a clear improvement on the results of the test (prior and after the course: % of improvement for physicians and % for nurses, p < . ) and the qualification of the final exam was superior. the incidence of rightly activated trauma team improved as the staff was completing the course. conclusion: we conclude by enhancing the importance of having adequate protocols for treating these patients and the correct means for teaching the personnel because they can improve the care of these patients. (tonk) score. this system is specialty specific and tries to eradicate the weaknesses in a previously published scoring system, which was generic. material and methods: a total score of is assigned to each firm from the beginning and marks are deducted for missed documentation. sets of notes are randomly selected from discharged patients for each firm, one from trauma and one from elective surgery, each having at least entries. each case note is given marks and the total deduction for both case notes are then subtracted from the total score of to give the resultant score. the tonk score has four major parts comprising initial clerking, subsequent entries, discharge letter and legibility. an objective system of scoring the legibility of medical notes is part of the tonk score. this scoring system is easily reproducible and it's been validated using the kappa statistic. introduction: despite the increasing mechanization in medicine, clinical skills must be to the fore of medical occupation and consequently must have a main focus in medical training. especially in surgery, the mastery of basic clinical skills is of great importance for the young learner as it besides the knowledge of elementary principles substantially contributes to the understanding of the subject, the development on the wards, the operation theatre and the ambulance. in order to assure a standardized training using reliable, effective modern teaching methods, a ''train-the-teacher''-course was developed. material and methods: in an -hour training, the important teaching modalities and methods for surgical skills as skills lab, simulation, role play, -step approach are presented and trained in small groups with a maximum of participants per group. furthermore, the training focuses on ,,giving adequate feedback'' and examining practical skills. the training is evaluated using a standardised evaluation form. furthermore, the teachers are evaluated by their students after each of their teaching sessions before and after the training. results: a total of surgeons participated in the training program ( chief physicians, senior physicians). overall, the training was rated to be very good ( %) or good ( %). in students' evaluation, there was a significant increase in positive ratings for teachers' didactical compentencies as well as for their overall training after the participation in the training program. introduction: sports injury risk management and prevention is a very complex challenge that must be addressed . one of the basic tasks is to perform epidemiological studies to estimate the risk in different types of sport. up to now many studies were conducted on injury rates in specific organised sports . just a few taking into account any physical activity (pa) . therefore only for specific sports data about the influence of higher sport skills on injury risk can be found . the goal of our study was to investigate the relevance of motor skills and sport education on injury risk, including the total pa and the occurrence of any injury in any type of sport. material and methods: in two austrian secondary schools (gymnasien) fifty-five of classes were asked to fill out a two sided questionnaire regarding pa and sports injuries within the last year. demographic data and information about the types of sport, the intensity and the occurrence of injuries was collected. pupils, from a ''normal'' school (ng) and from a ''sports-school'' (sg) filled out the questionnaire. in the sg every child has to pass an entrance exam containing basic coordinative and motor tasks as well as complex motion sequences in different types of ballgames. in the educational program of this school a strong emphasis is placed on sports. in the ng just the basic sport lectures are held. results: the total physical activity (pa) containing organised, unorganised sports and leisure time activities was significant higher in the sports-school (sg), . hours per week vs. . h/w (p < . ). the most performed types of sport were similar: in the sg soccer (n = , %), riding bike (n = , %) and running (n = , %); in the normal school (ng) riding bike (n = , %), soccer (n = , %), snowboarding (n = , %) and running (n = , %). proportionally there were more boys than girls in both schools: % boys, % girls vs % boys, % girls. boys ( . h/w, . h/w) were more active than girls ( . h/w, . h/w) in both schools. the rate of injury was statistically significant higher in boys ( . ) than in girls ( . ) (p < . ). the mean age was higher in the normal school . vs . years. the proportion on injured children was at the same highest level ( %) in and , and , and in and year-olds. the ratio of injury per pupil is statistically significant higher in the sg ( . ) than in the ng ( . ) (p < . ). but including the extension of activity the injury risk is a little bit lower in the sg: . injuries in hours of pa vs . . conclusion: it seems that better motor skills and intense sport education have no effect on the population risk . the individual risk has to be investigated more extensively in future studies. references: fuller, spinks, spinks, schwebel disclosure: no significant relationships. introduction: pain is one of the main complaints of trauma patients in emergency medical care ( ). in the netherlands, a third of all prehospital emergency medical systems (ems) rides concern trauma patients and yearly . patients are treated in the accident & emergency department (ed) due to an injury. significant deficiencies in pain management in emergency medicine have been identified ( ) . as a consequence, patients unnecessarily suffer from pain, and also recovery and healing are delayed. furthermore, chronic pain is reported one year after trauma ( ). there is no appropriate systematic approach to acute pain management in the chain of care for trauma patients in prehospital ems and the ed. aim: the aim of the research project is the development of a national evidence-based guideline for the management of acute pain in adult trauma patients in prehospital ems and the ed. during the open reduction we applied a incision allowing to remove soft tissues and to set fragments of fractured bone correctly. in patients we performed close reduction of the fracture without the fixation because of a patient's age. results: xr month after surgical procedure was done and in all cases we achieved consolidation of the ulnar fracture and good of radial head reduction. complication after the treatment was the paresis of the median nerve, neurosurgical procedure needed. the nails were remove , month after procedure ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . after obtaining the union of the fracture and rehabilitation of the limb we removed the nails ( - month after procedure). conclusion: featured way of the operative treatment doesn't claim wide opening region of the fracture and reduces possibility of complications. dislocated radial head after close reduction and immobilization period shows full stability. years. data and x-rays were retrospectively gathered and analyzed. all fractures were scored according to the ao-pediatric classification. patients were treated with solely closed reduction and cast immobilisation and patients were additionally treated with k-wire fixation. spss version . was used for all statistical analysis. results: incidence of recurrent dislocation was significantly higher in patients treated solely with closed reduction ( %) compared to patients treated with additional k-wire fixation ( %) (p . ). the proportion of patients requiring a second surgical intervention was also higher in patients treated with closed reduction: % versus % of patients treated with additional k-wire fixation (p . ). additional k-wire fixation results in a relative risk reduction of % and % for recurrent dislocation and secondary surgical interventions respectively. complications of k-wire fixation comprised local infection (n = ) and k-wire migration (n = ). conclusion: additional k-wire fixation might reduce the incidence of recurrent dislocation and secondary surgical interventions after closed reduction of displaced distal forearm fractures in children. larger and randomized studies will have to be obtained to confirm the results from our data. radiographic controls were planned after one and six month and until the removal of the intramedullary nailing. we documented all peri-and postoperative morbidity, further operative procedures, the radiographic findings as classified by capanna and the time till removal of the nails. results: a cohort of children (four girls, six boys) was recruited. mean patient age was , years ( - y). the bone defects included eight juvenile and two aneurysmatic bone cysts. four patient suffered earlier unsuccessful treatment after pathologic fracture. the other six presented with acute pathologic fractures (five humeral, one femoral). no postoperative complications occurred after the treatment combination of elastic intramedullary nailing, curettage, artificial bone substitute and autologous platelet rich plasma (gps Ò-system). the radiographic findings showed at six month a total resolution of the cysts in eight cases (capanna typ i), in two cases a tiny residual cyst remained (capanna typ ii). the removal of the nails was possible after six to nine month. one fourteen year old boy (typ ii capanna) wished a further gps application to reach a total resolution. all patients showed very good functional results and no refracture occurred. conclusion: the gpsÒ-system enhances the treatment of bone cysts in children. it is a save method without additional perioperative complications. by this, total treatment time can be shortened and secondary procedures as difficult changes of the elastic nails will be lessened. technically the decisive factor is the debridement of the . albumin values were significantly lower in patients with two or three complications than those with zero complications (zero and two complications p = . , zero and three complications p = . ). no significant difference in levels was found between one and zero complication (p = . ). admission albumin was not significantly lower in patients with wound infection than those without ( . ± . g/l versus . ± . g/l, p = . ). patients with a dry and intact wound had a higher mean albumin value than those with wound healing complications (mean albumin ± . g/l versus ± . g/l, p = . ). conclusion: our study findings support the hypothesis that lower preoperative albumin levels are associated with a more adverse inpatient post-operative recovery. these patients can be identified and optimised early in preparation for adverse events likely to occur in the post-operative period. material and methods: the targon fn is a new kind of side plate with six locking screw ports. the two distal holes are used to fix the plate to the lateral cortex of the femur with angle stable . mm cortical screws. the proximal holes allow the implementation of up to four ''telescrews'' which cross the fracture site. these . mm screws are dynamic and allow therewith the collapse of the fracture at the femoral neck. we present a prospective study on patients with a comparative patients case control with a total hip cementless arthroplasty for the same indication at the same period. results: this new device show a lower incidence of complications on the first weeks than with the total hip group. wereas the month control show no difference between the two groups. there are an x rays neck collapse one year folow up in osté oporotic patients with singh an stade with no significant consequences on the functional score. conclusion: targon fn is a good alternative for older and multimorbid patients with less surgical burden and reduced early access morbidity in comparison to the prosthesis group. conclusion: the number of re-interventions and the mortality within one year after hip fracture surgery is sizable. nonetheless, our numbers are not unfavourable in comparison with international literature. the percentage of re-interventions in the cannulated hip screw group is significantly higher than in the other subgroups. on the contrary, the mortality in this group is low. this is undoubtedly an expression of our attempts to preserve the femoral head in vital, active patients. possibly, the combination of the two standardsnamely the re-intervention and mortality-is a new accurate performance indicator. informed. the operative treatment with lcp and tension bandages shows small morbidity regardless the comorbidities and the geriatric cohort. it remains standard procedure for periprosthetic fractures of the femur at our institution. we are expecting the number of periprosthetic fractures to be increasing rapidly. introduction: periprosthetic femoral fractures are rare but severe complications following total hip-or knee-arthroplasty. the incidence for of these fractures are increasing, caused by a raising frequency of total arthroplasty for both younger and elderly patients as well as by a higher life expectation. so far there are very little long-term results regarding this issue. material and methods: patients ( female, male) with a mean age of years ( - ) were clinically and radiologically examined on average months after surgery. we investigated the prosthesis (total hip arthroplasty vs. total knee arthroplasty) and compared the treatment (revision arthroplasty vs. osteosynthesis) in this study. for the clinical examination we used the harris-hip-score (hhs), oxford-hip-score (ohs), the oxford-knee-score (oks), the sf- and the funktionsfragebogen hannover (ffh) which measured the functionality of patients in his daily routine in his environment. results: tha + osteosynthesis (n = ) % of the patients had fair or better results with an average hhs of . % of this group had a good or excellent result with an average ohs of and % had a ffh score of ‡ %. % of the patients had a possible hip flexion of ‡ °and ( % ‡ °). the average sf- score for this group was . tha + revision arthroplasty (n = ) % of the patients had fair or better results an average hhs of . % of this group had a good or excellent result with an average ohs of and % a mean ffh score of ‡ %. % had a possible hip flexion of ‡ °( % ‡ ° the results of the scores are mainly caused by the high age, the common multimorbidity and the low overall functionality of the patients and confirm the severity and importance of these kinds of fractures. most authors suggest a treatment of these fractures according to the classification by using osteosynthesis to treat stable fractures and revision for unstable fractures. however we see a slightly better outcome of the revision arthroplasty compared to the patients that were treated with osteosynthesis. we suggest more studies with a higher number of patients regarding this issue. introduction: fracture dislocation of the proximal humerus is a rare but challenging situation for the orthopaedic surgeon. if a closed attempt to reduce the dislocation fails, a demanding surgical procedure is required and the emergency setting is not always the best situation to face difficult cases. as a matter of fact a proper approach to this fractures involve an experienced surgeon, more than one assistant and a variety of instrumentation that often lack in emergency. fracture dislocation of the humeral head is related with a significant increase of the risk of the humeral head necrosis and it is widely accepted that these lesions are best treated in emergency, but there are no reports on the influence of the dislocation time on the results of the surgical procedure. with this study we wanted to determine if a delayed procedure could affect the outcome of these lesions and if there is a rationale in postponing the procedure to allow a better organisation of the surgical time. material and methods: we retrospectively analysed the clinical and radiological records of patients admitted at out institute for fdhh between jan and jan . ten out of them were operated in emergency while with a minimum delay of hours. all the patients underwent open reduction and fracture fixation with locking plates. results: the results of the two groups were similar and influenced mainly by the bone quality and age of the patient. it seems that a delay in the procedure do not alter the result in terms of rate of necrosis of the humeral head or influence a worse clinical outcome conclusion: on the basis of these results we do not consider these fractures as emergencies anymore: our preference is still an immediate operation provided the presence of an experienced surgeon, assistant and nurse and the availability of the proper instrumentation, conversely we believe that the risks of an immediate procedure overwhelm its benefits. introduction: minimal invasive plate osteosynthesis (mipo) should belong nowadays to the armentarium of each trauma surgeon. applied correctly, mipo not only meets the criteria of a ''biological'' osteosynthesis by minimizing invasivity as well as iatrogenic soft tissue damage caused by the operation, but can also provide adequate reduction and stability for fracture healing and early functional aftertreatment. up to date, only few publications report on mipo of humeral shaft fractures mainly using the antero-lateral deltopectoral approach for plate insertion - . material and methods: in this present study, we evaluated patients (mean age years, range - ) with displaced metadiaphyseal fractures of the proximal humerus treated in mipo technique using an angular stable long philos Ò -plate. a lateral deltoid-split approach was used proximally and a brachialis/ brachioradialis intermuscular approach with exposure of the radial nerve was used distally. there were acute fractures including two periprosthetic as well as one pathological fracture. three patients were operated after failed conservative treatment, one for delayed-union and two cases were revision surgeries. results: there were no infections and no iatrogenic injuries to the axillary and radial nerve, respectively. all the patients were immediately allowed active shoulder and elbow movement. one patient had to be reoperated ten weeks postoperatively for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. this patient was successfully operated using the same method and implant. whereas one patient refused follow-up, patients showed entirely healed fractures and satisfactory shoulder and elbow function after a mean follow-up of months (range - months). conclusion: minimal invasive long philos Ò -plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe and viable procedure for the treatment of metadiayphyseal fractures of the proximal humerus with low morbidity and good functional outcome. introduction: plating for reduction and stabilization of proximal humerus fractures is a common orthopaedic procedure. however, angular and rotational malalignment is not an infrequent result, and extensive use of fluoroscopy is commonly involved. we checked the accuracy of a computerized navigation system(vector vision trauma navigation system, brain lab) to enhance multiplanar fracture reduction and to decrease the requirement for fluoroscopy. material and methods: men and women aged to (mean, ) years underwent philos plate fixation for proximal humeral fractures. all fractures were closed with no associated injuries and classified as -a (n = ), -b (n = ), and -b (n = ), according to the ao classification. the cases were assessed operation time, radiation time. and accuracy measurements were taken. results: patients were followed up for to (mean, ) months. all the fractures united and occured no avascular necrosis. the mean operation time and radiation time were minutes (range, - ) and . minutes (range, - ). the mean distance between fluoroscopy and navigation of reduction accuracy at the fracture site were . mm (range, - ). conclusion: the fluoroscopic operation using pilos plate was troublesome, but navigated operation was easy to reduce the fracture because of the direction visualization at the same time. and computerized navigation has the potential for increasing precision in fracture reduction while minimizing fluoroscopic requirements at proximal humerus fractures. introduction: the proximal humerus fracture is a frequent fracture in the elderly people. the lower density of the bone with increasing age is one of the main reasons for implant failure after osteosynthesis with a range of - %. the options of therapy are including the screw-, platelet-or nail-osteosynthesis or the endoprosthesis.belonging to failure rates and the demand for early activity there is a tendency to be seen for early and strong stabilisation. material and methods: since august proximal humerus fractures were operated with the retron-humerus-shortnail. the average of age was , +- , ( - ) years. the demographic data, bone quality and fracture classification were documented including procedure of reposition, details of the implants, complications and postoperative course. results: there were , % a fractures, , % c , , % c and , % c fractures (ao-classification). the reposition was done in a closed mannor with a direct percutaneous assistance respectively. intraoperatively secondary dislocations and corticalis brake was to be seen. there have been insufficient nailing procedures. screws had to be exchanged. the gymnastic began immediately after operation or with a delay of - weeks depending on the fracture classification. the evaluation of the constant score is on the way. the results show a good stability of the nail especially in osteoporosis. comparing with platelets or antegrade nailing it is a minimal invasive procedure. the exraarticular access avoids any damage to the shoulder structures, especially to the rotator muscles. therefore early gymnystic of the shoulder is possible. shoulder impingement, screw dislocation and problems with the shoulder are avoided principally. the learning curve is short. shoulder score was used to evaluate functional outcomes. anova was used for statistical analysis, with significance set at p < . . results: files were available on patients. failure rate was . % at mean follow-up of . years and a mean ases-score of . . there was a reoperation rate of . %. mean age at operation was . years. mean operative delay was days (range - ). delay did not influence outcome. young age at operation was associated with better results. when evaluating fracture characteristics significant better outcomes were evaluated with ao type aand b-fractures, valgus or neutral fracture type, the presence of impaction and less displaced fractures. quality of reduction and fixation of the fracture was evaluated with significant better results with anatomic reduction of the medial cortical border, less residual displacement and a ccd-angle that was corrected or in residual valgus. osteosynthesis failed significantly more in c-type fractures, in fractures with an avascular head fragment, in varus displaced fractures and in fractures where an anatomical reposition was not obtained. introduction: fractures of the proximal humerus are responsible for - % of all fractures.the most extensive used operative treatments are the plate osteosynthesis and the intra-medullarry nail fixation with proximal locking nailsscrews. especially the latter technique can give iatrogenic injury of the axillary nerve. in this study, we define a safe-zone by using radiological parameters material and methods: the following procedure was performed in ten shoulders of embalmed specimen. first, the deltoid muscle was dissected from the clavicle. then the axillary nerve was identified together with its branches and was marked with clips and radioopaque wires. the muscle was then re-attached to its anatomical position.standard ap radiographs were made with the forearm in neutral (anatomical) position and exorotation. on these radiographs, the distance between the cranial side of the humeral head and the axillary nerve and its branches was measured. results: the median distance from the head of the humerus to the axillary nerve is mm (sd = . mm, range - mm) measured on the ap radiograph in degrees exorotation. the mean number of branches to the deltoid muscle is three. the distances vary from to mm. the median distance from the first proximal branch measured from to the humeral head is mm (n = , range - mm), to the second branch mm (n = , range - mm), to the third branch mm (n = , range - mm) and to the fourth branch mm (n = , range - mm). conclusion: there is a great variation in the course of the axillary nerve and its branches. with the insertion of an intra-medullar nail from the proximal side or by placing locking-screws nails the surgeon has to reckon with the course of this clinically important nerve. it is unsafe to place the locking-screws nail in the zone between mm and mm from the humeral head with the arm in exorotation. the greatest risk to damage the main branch of the axillary nerve is in the zone between and mm. this study provides distances to avoid damage to the axillary nerve. in contrast to the existing literature these distances are measured from the humeral head. there are several reasons to use the humeral head instead of the acromion are: first, the distance between the humerus and the acromion can vary due to the preceding trauma, relaxation of the deltoid muscle or by manipulation of the arm. second, from an anatomical perspective, the position of the axillary nerve is determined by the position of the humerus due to the connection to the deltoid muscle. results: emg/eng records were without pathologic variances of the axillary nerve. of them pre-operatively showed pathologic variances. of these continued to show variances months after the operation, which indicates a chronic lesion. just one patient showed a pathologic eng after surgery which was not seen before. the constant score was as expected. introduction: patella recurrent dislocation and patellofemoral pain syndrome is a common cause of instability in young patients and especially athletes. in the present study we present the results of the extension mechanism realigment throughout the fulkerson oblique osteotomy of the tibial tubercle and soft tissue balancing. material and methods: during the last two years patients ( men, women, mean age . / range - ) were treated operatively for recurrent dislocation of the patella using the fulkerson procedure. all our patients had as onset a traumatic dislocation of the patella that developed to recurrent. all patients were underwent knee arthroscopy for the treatment of potential chondral trauma or loose bodies removal and lateral retinaculum release. after that, we performed oblique osteotomy of the tibial tubercle, medialization and internal fixation with two cortical screws. this oblique osteotomy provides additionally to the medialization, anteriorization of the tibial tuberosity as we move it medially. moreover we perform medial plication. all patiens used functional brace locked in  º immediately after the operation and gradual rom increase untill the th p.o. week. results: the patients had no initial or long term complication. during their last follow up examination had a painless knee with full rom and marked improvement of the patella tracking. the mean lysholm score was improved from . to . . no patella dislocation was referred. conclusion: our findings show that fulkerson procedure of the tibial tubercle osteotomy and anteriomedialization, with additional intervention on the lateral and medial patella retinaculum is an excellent option for the treatment of recurrent patella instability and relief of patellofemoral pain. disclosure: no significant relationships. introduction: injuries to the knee involving the anterior cruciate ligament (acl) are very common related to sports especially in soccer and skiing. more than % of those with acl injury will develop radiographic osteoarthritis (roa) within years of injury although it is not known if return to sports is a risk factor for longitudinal roa development. in this retrospective study, we evaluated the long term radiographic and clinical results of acl reconstruction by comparing the injured knee with the contralateral knee in athletes returning to pre-injury sports. material and methods: twenty-eight patients ( men and women, mean age years at the time of acl surgery, bmi . ± . kg/ m ) were studied. patients returning to previous sports and without meniscal injury at baseline were selected. acl reconstruction was performed using patella tendon or hamstrings tendon graft. radiological assessments using x-ray and a -t mri of both legs were obtained at a mean follow up of years after acl reconstruction. roa was determined according to the classification of bohndorf. the ikdc score and tegner activity index were used for clinical evaluation and the knee injury and osteoarthritis outcome score (koos) for evaluating self-reported knee function. results: the -t mri revealed positive signs of roa on the operated knee in % and on the non-operated knee in %. these changes were however limited to small localized areas of the knees. the statistical difference of morphological and clinical outcome of acl reconstructed patients weeks after injury vs. replacement after this period showed no significance (p = , - . ). the total ikdc score was . ± . points and the total koos was . ± . . the median pre-injury tegner score was (range - ) corresponding to (range - ) at follow up. in % of the patients the tegner score was unchanged from pre-injury to follow up. according to the ikdc score % had type a symptoms, % type b, % type c, and none type d. conclusion: eight years after acl reconstruction in athletes returning to pre-injury sports, the risk of developing knee roa in the injured knee was not higher than the risk of developing roa in the contra lateral knee. disclosure: no significant relationships. radiographs and a mri of the knee were available for all patients. all patients were followed prospectively and lysholm, tegner and ikdc score were surveyed before treatment and after at least months. after diagnosis, a brace immobilization with tibial supporter with full extension of the knee was applied for weeks followed by another to weeks of pcl brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. all patients received concomitant physiotherapy. after at least weeks, stress radiographs were taken for evaluation of the pcl. the further treatment depended on the harner classification based on the stress radiographs. in cases of grade a or asymptomatic grade b injuries, conservative treatment was continued. in cases of symptomatic grade b, grade c or d injuries, operative treatment with arthroscopic transtibial pcl reconstruction using single bundle hamstring tendons was performed. results: patients were treated conservatively (group i), patients had an arthroscopic pcl reconstruction (group ii). mean patient age was . years (range - years). the mean tegner score in group i raised from . before treatment to at follow up, in the operative group from . to . . the mean lysholm score ascended in the conservative group from to , in group ii from . introduction: the virtual reality (vr) d arthroscopy surgical simulator provides arthroscopy training on knees in a controlled, stressfree, and virtual-reality environment. it is unknown whether better visomotoric three-dimensional ( d) condition will facilitate arthroscopic training. therefore, our objective was to evaluate the visomotoric condition to novice individuals and assess whether visomotoric abilities ameliorates arthroscopic performance within a d surgical environment. material and methods: medical students without any knee arthroscopic experience were investigated. both groups received a fixed protocol of simulator based arthroscopic skills training and a visomotoric skills test. this consisted of an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator. . their learning curve was assessed objectively using motion analysis. time taken, path length and roughness for probe and camera were recorded. results: motion analysis demonstrated objective improvement in performance during simulator training, if visomotoric skills performed better. conclusion: better condition of visomotoric skills lead to subsequent improvement at an arthroscopic vr skills training simulator. this may assume that visomotoric skills training before arthroscopic vr skills training is a useful tool. however further studies are necessary to find preliminary practice exercises to get a better performance at an arthroscopic vr skills training simulator. -ii and c-iii after tscherne § open fractures o-ii and o-iii after gustilo o urgent operative treatment § first stabilisation with miniosteosynthesis and external fixation § soft tissue debridement and their temporary closure o second look after - hours, next looks after the soft tissue condition o delate treatmentdefinitive stabilisation -osteosynthesis conversion in - days after injury. o type of osteosynthesis § orif with lcp distal tibia platesmedial or anterolateral § imterlocked intrtamedullary nail § external fixation -in cases of serious soft tissue defects we prefer fracture stabilisation ae serious soft tissue defects closing with rotation or microsurgery stem lobs. introduction: fractures of the distal tibial metaphysis account for . % of fractures over the distal end of the tibia. many of them are high-energy injuries causing extensive articular damage and compromise the soft tissues. managing these fractures continues to challenge most orthopaedic surgeons, as soft tissue injury could be further compromised by unjudicious surgical technique. aim of the treatment is to restore physiological alignment of the distal tibia and stabilize the fracture with minimal damage to soft tissues. material and methods: we designed an implant for the stabilization of distal tibial metaphyseal fractures, and gave the name ''angle stable''. the features of the implant are: precontoured plate with holes above the distal metaphysis providing positioning of screws with angular stable characteristics. the screws are self tapping and self cutting at the threaded part (far end) and have a cylindrical shape with a rim at the near end, that tightly fits into the holes at a special angle, guided by a targeting device. the distal screws penetrate the opposite cortex, and when they are tightened, compression is achieved. the plate is introduced through a small incision and guided onto the surface of distal tibia. screws can be inserted distally, proximal screws are inserted through stab wounds. biomechanical tests of this system were performed on cadaver bones. since the ''angle stable'' system has been used in patients in cases as a primary stabilization, and in cases as conversion of external fixation. follow-up time was months. outcome was assessed with regard to function, pain and alignment. introduction: the fracture of the distal lower limb with or without participation of the ankle joint remains a challenge to the surgeon. due to the high energy released at the time of fracture, these injuries are usually accompanied by a severe soft-tissue damage. the success of the surgical therapy of tibial pilon fractures depends largely on the extent of the soft tissue damage as well as the quality of reconstruction of the tibial joint surface. a problem of the minute anatomical reconstruction is an increase in soft tissue problems and bone infection. aim of this study was to investigate the results gained by a primary stabilization by external fixator followed by a multidirectional locked plate osteosynthesis after soft tissue consolidation. material and methods: setting is a level trauma centre, the design a consecutive series with a retrospective data evaluation. between and , patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: . the fracture was stabilized with an external fixator immobilizing the ankle joint. . after stabilization of the soft tissue situation (mean . days) internal fixation with a locked-screw plate was performed. the implant used was a multi-directional locking internal plate fixator (tifix, litos, hamburg/germany), made of pure titanium with locking holes for titanium screws which can be fixed in different angles and is available in seven different lengths ( - holes in the diaphyseal area). the mean follow-up time was . months. all follow-up examinations were supervised by a specialized orthopedic trauma surgeon. the examination consisted of a set of standardized questions, clinical evaluation, the aofas score and radiographs. results: superficial wound-necrosis was noted times, conservative treatment led to complete wound healing. dvt of the injured leg occurred in cases. in cases autologous bone graft was necessary after and months. deep wound infection or postoperative osteomyelitis was not observed. the definitive treatment was performed after an average of . days. in cases an autologous bone graft was used. in a further cases a later autologous bone graft was performed for delayed union at and weeks after orif. full weight bearing was reached after an average of . weeks. bony union was achieved in all cases after an average of . months as determined by conventional radiographs. in cases range of motion (rom) of the ankle did not show any restriction compared to the opposite side. in cases the range of motion was reduced by less than / compared to the opposite side, of up to / in patients and restriction of > / was not noted in cases. the mean aofas score was . . conclusion: a twostage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result. disclosure: no significant relationships. introduction: the internal fixation for complex distal tibial fractures is sometimes challenging. nowadays, successful outcome were reported about osteosynthesis through medial and anterior approaches including minimally invasive plate osteosynthesis (mipo). however, there are cases in which such methods are not indicated because of their soft tissue problems or their fracture pattern. in this presentation, the new posterior plating procedure using the mipo technique is reported. material and methods: this procedure was indicated only when no other internal fixation methods were present, which includes intramedullary nailing or medial/anterior plating, were found. so the indication for this procedure was extremely rare. from to , cases of ao classification -a and c type fractures were treated operatively in our institution. cases met the criteria. both of them were female and aged and . the follow up period was and months. the procedure was as follows; before the operation, the spanning external fixator was applied and the alignment was reduced as properly as possible. the patient was in the supine position and the knee was flexed at about degrees. the distal window for mipo was positioned between the distal fibula and achilles tendon, which is called a ''posterolateral approach.'' blunt dissection was performed, and exposed the edge of the flexor hallucis longs muscle (fhl). the tunnel over the periosteum at the posterior surface of the distal tibia was made and the plate was inserted. then an incision was made at the posteromedial border of the tibial shaft and exposed the proximal part of the plate (proximal window). the plate was placed properly under the image intensifier and fixed with screws. the wounds were irrigated and sutured in layers. postoperative rehabilitation included a range of motion exercise and non-weight bearing gait and use of crutches immediately begun. full weight bear was permitted around twelve weeks post operatively. time to union, complication and final ambulatory ability were evaluated. results: bony union was uneventfully completed within three months in both cases. there were no complications such as infection, skin problems, or plate irritation/impingement. free gait was achieved within four months in both cases. conclusion: posterior plating using the mipo procedure for complex distal tibial fractures can be a good option, although our experience is very limited. however, this procedure should be indicated only when no other osteosynthetic methods are found because irritation/ impingement of the fhl or the achilles tendon or some other complications may arise, which has already been reported in open reduction and internal fixation through posterolateral approach. references: hayes ag, nadkarni jb. extensile posterior approach to the ankle. j bone joint surg ; b: - . disclosure: no significant relationships. introduction: even the most modern technology has failed to induce satisfactory functional regeneration of traumatically severed peripheral nerves. delayed neural regeneration and in consequence slower neural conduction seriously limit muscle function in the area supplied by the injured nerve. this inferiority study aimed to compare a new nerve coaptation system involving an innovative prosthesis with the classical clinical method of sutured nerve coaptation. besides the time and degree of nerve regeneration, the influence of electrostimulation was also tested. material and methods: the ischiatic nerve was severed in female gö ttinger minipigs with an average weight of approx. - kg. the animals were randomized electronically to four groups: group i: nerve prosthesis without stimulation; group ii: nerve prosthesis with stimulation; group iii: microsurgical coaptation without stimulation; group iv: microsurgical coaptation with stimulation. in groups iii and iv, the nerve was sutured microsurgically, while the animals in groups i and ii received the new nerve prosthesis. postoperative monitoring and the stimulation schedule covered a period of months, during which axonal budding was evaluated monthly. results: preliminary data indicate that results with the nerve prosthesis are comparable to those with conventional coaptation. the results of this pilot study indicate that implantation of the nerve prosthesis allows good and effective neural regeneration. this new and simple treatment option for peripheral nerve injuries can be performed in any hospital with surgical facilities as it does not involve the demanding microsurgical suture technique that can only be performed in specialized centers. disclosure: no significant relationships. in mean there were , previous operations. in cases a change of osteosynthesis was neccessary. in cases bmp was used alone. in cases bmp was expanded by autologeous bone grafting. in cases the bmp was extended by autografts or ceramic scaffolds. results: divided in a healing group and a not healing group we found in the healing group a excellent clinical result by . points (able for sports) for the atrophic non unions and a good result of . points (walking long distances) for the post infected non unions. the radiological score is as high . / . ( cortices healed and bridging callus). in the non healing group the clinical rate was . / . (walking with splint) and the radiological rate was . / . (two cortices healed) the overall healing rate was %. divided in several groups the healing rate increases from % (infected non unions not tibia) to % (atrophic aseptic non union tibia). overal the secondary intervention rate was %. the healing time is . months in the middle. we see only mild side effects in %, like swelling. the most serious complication was the bony reinfection in %. there were amputations. conclusion: compared to the literature the healing rate of non unions could be increased using a strong concept in the treatment. as a part of the treatment the bmp treatened group increases the healing rate from % (friedlä nder) to %. the results are similar to the papers from kanakaris or zimmermann. there were no significant side effects noticed. material and methods: methods: at our level i trauma institute, from july, to september, each patient who presented with a clavicle fracture that was deemed operative received plate fixation alone or supplemented with bioresorbable calcium phosphate cement or autogenous bone grafting. patient records and radiographs were retrospectively reviewed. follow-up included standard radiographs to evaluate union at a minimum of months. all complications were also reviewed. results: results: two different clavicle plating systems, smith and nephew (smith and nephew, memphis, usa) ( clavicles) and implant technology systems (i.t.s., lassnitzhohe, austria) ( clavicles), were used with orif alone ( ), autogenous bone graft ( patients), or bioabsorbable calcium phosphate ( clavicles). of patients treated with open reduction internal fixation, complications have occurred at a minimum of month follow-up. three prominent hardware occurrences necessitated plate removal. one nonunion, one distal screw cut-out and one hardware breakage have been treated successfully with revision plating. using fisherâ e tm s exact test, no statistical significance was seen between the orif alone, autogenous bone grafting ( ) and bioabsorbable calcium phosphate ( ) in regard to overall failure incidence (p = . ). complications necessitating revision orif with bioabsorbable calcium phosphate ( ) and bone graft ( ) were not statistically significant either (p = . ). conclusion: there appears to be no statistically significant difference between union and complication rates between orif alone, or orif augmented with bioresorbable calcium phosphate cement or autogenous bone graft in this retrospective study. introduction: the purpose of the present study was to determine the effect of two anti-osteoporotic treatments on fracture healing in osteoporotic ovx rats, days after fracture occurrence. pth which has been proven to influence fracture healing in ovx rats, was taken as a control treatment. strontium ranelate is acting on both resorption and formation. we combined the rat model of a closed, standardised diaphyseal fracture of the femur with the model of a post-ovariectomy osteopenic rat, mimicking post-menopausal bone loss. material and methods: forty-five animals were ovariectomised at the age of weeks and a further were sham operated. at the age of weeks, osteopenia in the ovx rats was diagnosed. then, in all animals, a standardised mid-diaphyseal fracture was induced. at the time of fracture, the animals were divided into four groups. group was the sham control group, groups , and were the ovx treatment groups. groups and were treated with nacl . % s.c. daily, group was treated with mg/kg/d strontium ranelate p.o. daily and group received lg pth - x/ week s.c. the animals were killed after days and the fractured femur removed. the samples were scanned using microct by scanco medical, zurich, switzerland. the evaluation of the data focused on outer callus contour, cortical contour and marrow contour as well as cortical thickness. torsion testing on the bones was carried out using the axial-torsional system by instron (darmstadt, germany). results: treatment with strontium ranelate significantly improved the mechanical properties of the callus when compared to the ovx control group, while the improvement induced by the treatment with pth - did not reach significance. pth - and strontium ranelate both showed a significant increase in bone volume of the callus when compared to ovx control rats with no significant difference between the two treatments. as for the callus tissue volume, the increase induced by strontium ranelate was significant compared to ovx whereas pth induced no change and the difference between both drugs was significant . in both the pth - -and strontium ranelate-administered animals bv/tv was significantly increased compared to the ovx control rats . the bv/tv of the pth-treated rats was even higher than in the sham rats. conclusion: this is the first report on the enhancement of fracture healing with strontium ranelate. the callus in strontium ranelatetreated animals is even more resistant to torsion in comparison to ovx and sham-untreated animals and even to those treated with pth - . pth did not significantly enhance the resistance of the callus versus ovx, despite a significant increase in bv/tv within the callus. the superior results obtained with strontium ranelate compared to pth could be the consequence of a better quality of the new bone formed within the callus. introduction: recent clinical and animal studies suggest an elevated homocysteine serum concentration to be a risk factor for osteoporosis and fragility fractures ( ) . in vitro studies showed that increasing homocysteine concentrations stimulate the activity of human osteoclasts ( ). however, there is no data demonstrating that circulating homocysteine is related to structural and biomechanical properties of human bones. this study aimed to investigate the relation between morphological as well as biomechanical bone properties and homocysteine serum concentrations in humans. material and methods: fasting blood samples and femoral heads were obtained from males and females who underwent hip arthroplasty. bones were assessed by dual energy x-ray absorptiometry (dxa), biomechanical testing (indentation method), and histomorphometry. blood was sampled to measure homocysteine, folate, vitamin b , and vitamin b . according to their homocysteine serum concentration, subjects were classified as hyperhomocysteinemic (> lmol/l, n = ) and normohomocysteinemic (< lmol/l, n = ). results: folate and vitamin b , but not vitamin b , were significantly lower in hyperhomocysteinemic subjects when compared to controls. however, dxa, biomechanical testing, and histomorphometry did not reveal significant differences in bone quality between hyperhomocysteinemic subjects and controls. the results of the present study do not indicate a significant relation between circulating homocysteine and morphological as wells as biomechanical bone properties. introduction: sometimes fractured bones heal poorly with standard treatment and sometimes a bone defect is a major problem. although the bone grafting technique is considered a standard, there is a need for enhancement of this procedure. healing of the cancellous bone is a complex process in which many inflammatory and signaling molecules take part. to improve the outcome of the healing process, one can influence it by applying platelet rich plasma gel locally, thereby releasing cytokines and growth factors ( ). cancellous bone is rich with mesenchymal stem cells that produce new bone when stimulated. material and methods: we enlisted patients with hard to heal fractures and fractures that demonstrated poor healing in the study. five of the patients had osteomyelitis in the fracture and all fractures resulted in a bony defect as a serious complication after treatment. we designed a protocol for the preparation of allogeneic platelet rich plasma gel with suspended autologous cancellous bone, based on laboratory experiments in vitro ( ) . cancellous bone was harvested from iliac bone crest. we used standard ab and rhd identical, leukocyte depleted and irradiated platelets from a blood bank. activation of the platelet gel was achieved by using a cacl and thrombin mixture. we accepted patients after fulfilling the inclusion criteria and they were operated on in a standardized manner by their elected surgeons under technical supervision. in their follow-up, the ingrowths of bone grafts were measured by using x-ray analysis ( ). results: in patients the transplant was sufficiently incorporated in the fracture to give a limb full function. there were no major complications related to the platelet rich plasma additives. in one patient a nerve paresis was observed, which resolved spontaneously. in patients bone graft was not sufficiently incorporated, once because of poor compliance and the other time because of complex nature of distal tibia fracture. the clinical outcome of the operated patients ( %) is satisfactory and encouraging. conclusion: the preliminary clinical results show that using platelet rich plasma and cancellous bone in the treatment of large bone defects has a promising therapeutic potential. ( ) marx re. platelet-rich plasma: evidence to support its use. time from injury to reduction and to surgical intervention was noted. apoptosis was verified by microscopy with tunel, hematoxilin and eosine stained specimens after decalcification of the samples, a time consuming process. the number of live, apoptotic and necrotic chondrocytes were counted. the patients are followed with harris hip score, merle de aubigne score and radiographs for two years. results: patients were admitted directly to our hospital, the rest transferred from other hospitals. patients had their hip reduced after a mean time of minutes. had femoral traction applied and patients were not reduced. mean time from trauma to operation was ± . days. three patients received total hip arthroplasty. the results of will be presented at the congress. conclusion: the conclusions will be given at the presentation. introduction: distal inter-locking using free-hand technique in intramedullary nailing is always a time consuming procedure. the use of xray amplifier is mandatory and the exposure to radiation is rarely modest. if we use navigation devices we rarely trust the device completely and that is why we check the position with x-ray amplifier more than we need to. that is why we did laboratory testing of the new system using the electromagnetic navigation with the use of micro sensors for free-hand interlocking technique in laboratory without the use of x-ray amplifier to ensure the use of system in the operating theatre. material and methods: three residents with little experience in distal interlocking and no experience with this device were testing the electromagnetic navigation system with the use of micro sensors for free-hand interlocking technique. interlocking holes were drilled by the use of guiding star platform in lidis module, ekliptik, slovenia. the system producer had minutes of introduction time, afterwards drilling was done. distal locking was done on utn synhes nail and instead of bone, cannulated hard wood rods were used. we measured time needed for calibration and time needed for reaming and weather we were successful or not. introduction: percutaneous catheter drainage (pcd) is a useful method to manage pericardial effusion. however, pcd is not always effective in a case of hemopericardium due to clot. to perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method following finger dissection by subxiphoid approach, which was preliminary reported in . we present the final data to report the usefulness of blind subxiphoid pericardiotomy (bsp) for emergency cases with acute hemopericardium. material and methods: we designed a study to determine a favorable management for cardiac tamponade due to hemopericardium. emergency patients with acute hemopericardium secondary to trauma (n= ), acute aortic disease (n= ) and cardiac rupture following acute myocardial infarction (n= ), were the subjects. board certified surgeons performed bsp (n= ) and other emergency physicians performed pcd (n= ) for patients with cardiopulmonary arrest (cpa) or near cpa due to cardiac tamponade from to . since , bsp (n= ) or pcd (n= ) has been performed at the physicians' discretion. results: bsp was effective to relieve cardiac tamponade in all cases but pcd was ineffective in cases ( . %, p=. ) because of clot in pericardium (n= ) or right ventricular puncture (n= ). in addition to ineffective drainage, acute occlusion of percutaneous drainage tube (n= ) were observed and resulted in deaths in the pcd group. procedure-related complication rates of bsp and pcd and survival rates of bsp and pcd were % and . % (p=. ), . % and . %, respectively (p=. ). sixteen patients (bsp, ; pcd, ) could discharge following emergency surgery (n= ) or conservative treatment (n= ). conclusion: blind subxiphoid pericardiotomy was safe and could be performed quickly in an emergency situation. percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clot in pericardium in some cases. disclosure: no significant relationships. introduction and objectives: heart trauma, mostly penetrating, is not common in our community, but carries a significant morbidity. its clinical presentation can be variable. our objective was to asses the incidence, clinical presentation, associated injuries and mortality of our patient population with trauma to the heart. material and methods: observational, descriptive, retrospective analysis of patient with heart trauma included in our trauma registry between and . we reviewed demographic characteristics, mechanism of injury, associated injuries, injury severity score (iss) and new injury severity score (niss), mortality, triss probability of survival (ps), and hospital length of stay. results: we found ( . %) patients with cardiac traumatism out of . patients included in our registry, ( %) with associated injuries and ( %) isolated; ( . %) were from penetrating trauma, and only ( . %) were from blunt trauma. mean iss and niss were of (+/- ) and (+/- ), respectively. three patients presented ''in extremis'' (agonal status), nine presented with hemodynamic ''stability'' (sbp> mmhg) ( % of them with a hr> bpm), and five patients presented with hemodynamic instability. only % of the patients presented with cardiac tamponade, without hemothorax. two pericardiocentesis ( %), pericardial windows ( %), and emergency room thoracotomies were done ( . %). the most frequent location was in the left ventricle, followed by right atrium and right ventricle. the most frequent associated injuries were in the lungs ( %), followed by the abdomen and vascular injuries ( . %). fifty-nine percent required icu admission, with a median length of stay of days. ten patients died ( %), and three of them ( . %) were dead on arrival. two patients ( . %) died with a ps > . . conclusion: heart trauma is not frequent in our community, and displays great variability in its clinical presentation, with a high mortality. over half of the patients presented with hemodynamic ''stability''. disclosure: no significant relationships. approach of two cases of secondary aortoesophageal fistula results: the st patient was a -y-old man in which fistula was secondary to a fish-bone ingestion, days before the admission. in the nd cause, a -y-old man, fistula was secondary to rupture in oesophagus of a known thoracic aortic aneurysm. diagnosis was made by a contrast-enhanced ct scan; a gastrografin x-ray in the st and an endoscopy in the nd case completed the examination. in both cases the lesion consisted of a few-mm-diameter defect of the oesophageal wall. in the i case an emergent endovascular repair of thoracic aorta by bolton relay · mm stent graft was per-formed; in the ii case, endovascular repair of thoracic aorta (by bolton relay x mm) was associated to an endoprosthesis placement for primary treatment of a preexisting infrarenal abdominal aortic aneurysm. postoperatively tpn was administered. definitive treatment of fistula was performed in both cases by an explorative right thoracotomy (in v and vii post-operative day respectively): oesopagus was primarily repaired and reinforced by a pedicled intercostal muscle flap and a nutritional jejunostomy was associated. subsequent post-operative course consisted in ne administration, prolonged nasogastric suction, resuscitation with fluids, antibiotics. hemorrhagic complications or infections were excluded by repeated ct scan. oral feeding was in th and th postoperative day, after exclusion of a persistent fistula at a gastrografin x-ray of oesophagus. hospital stay was of days in both cases. no late complications were registered at follow-up. conclusion: when an aortoesophageal fistula occurs (if consists of a small oesophageal lesion), emergent treatment of endovascular aortic repair can be successfully associated to a second-step primary repair using a pedicled intercostal muscle flap via a right thoracotomy. results: case : a -year-old male is taken to our hospital after a car crash. on ct scan there was a periaortic hematoma from isthmus to diaphragm, multiple rib (flail chest) fractures, and a pelvic fracture. the aorta was repaired with an endograft with good immediate results. case : a -year-old male, injured in a frontal car crash. on ct scan a mediastinal periaortic hematoma was seen, with a pseudoaneurysm at the origin of the descendent thoracic aorta, distal to the sublavian artery. the aorta was repaired with an endograft, which was replaced at day th because of a leak. on follow-up he is doing very well. case : a -year-old male, injured in a car crash. ct scan findings were as follows: a left diaphragamatic herniation, bilateral lung contusion, traumatic laceration of the descending aorta, pelvic fracture and spleen laceration. he underwent an emergency laparotomy with splenectomy and diaphragmatic repair. on the nd postop. day an endograft was placed at the descending thoracic aorta, without complications. case : a -year-old male, injured in a frontal car crash. on ct scan there was a thoracic aortic laceration, distal to the isthmus, and an aortic endovascular repair was undertaken at day th , after complete hemodynamic normalization. the patient died at day th from multiple organ failure. conclusion: traumatic thoracic aortic injuries are frequently associated to severe thoracic, abdominal and orthopaedic injuries. traditional early surgical aortic repair through thoracotomy, with single lung ventilation and, occasionally, extracorporeal circulation carries a high morbidity and mortality. that is the reason why aortic repair has classically been delayed, but this carries an additional mortality rate of between % and %. endovascular treatment allows for an early management in severely traumatized patients who otherwise wouldn't stand such a risky surgery. it has also revealed lower rates of paraplegia after years of follow-up. introduction: injuries in zone i of the neck are rare and difficult to manage particularly in environment of war. this area gathers aerodigestive, vascular, lymphatic and nervous elements. all the difficulties lie in diagnosis of the lesions, in the decision of a surgical exploration and in the way of repair if necessary. in that situation, fistula between carotid artery and jugular vein is very uncommon, accounting for % of all arterial injuries. through one case, which has occurred in afghanistan, we discuss the various possible solutions to repair such a lesion. material and methods: we report one case of a french soldier, yo, who was wounded by a rocket splinter on left side of the area i of the neck. he was transported immediately in french role ii in kaboul. respiratory tracks are not injured, there's no neurologic lesions. he had a huge haematoma of the area with a tracheal back pushing (xray exam). during an effort of cough, a haemorrhage through the wound occurred requiring an oro-tracheal intubation and a surgical exploration by a cervicotomy. no obvious vascular lesions were found but just a thrill at the base of the neck. the patient was hemodynamically stable. he was transferred by medevac to france in the night. an angioscanner showed a fistula between carotid and jugular vein ( photos). results: he was re-operated h after. the fistula was just behind the first rib requiring an enlarging by sternotomy to control the origine of left carotid. there was a section of left pneumogastric nerve. after exclusion of the fistula and the vein, we interposed an allograft on carotid artery ( photos). the patient discharged from the hospital one week later without lateral damage except a bitonal voice with no need of re-education. conclusion: arterio-veinous fistula is an uncommon consequence of carotid injury. the taking in charge of this patient and the decision of the kinds of repair are difficult. stenting has also been used to repair distal internal carotid injuries that are not easily approached surgically. the favorable outcome of this case illustrates that surgery is a reasonable alternative when an endovascular approach is not feasible in patients with trauma-acquired arteriovenous fistulae. allograft or vein graft, if possible, is also a good solution for this kind of injuries. introduction: we report cases of subclavian artery injury caused by traffic accidents. in all cases, surgical vascular reconstruction was undertaken. in of the cases, the subclavian artery was obstructed by intimal dissection caused by falling down from a motorcycle. in the remaining case, subclavian artery aneurysm caused by seat belt injury occurred. material and methods: case : -year-old male while driving a large motorcycle, the patient collided with a car and the left side of his body was trapped in the car. this resulted in traumatic pneumothorax and severe ischemia of his left upper limb, and he was transported to our level trauma center for surgical treatment. bypass surgery using a mm diameter ptfe was performed. postoperative arteriography showed good patency of the graft and the patient was discharged. recovery from the motor dysfunction caused by brachial plexus injury took months. case : -year-old male for this case, the patient ran into a wall while driving a cc motorcycle. bypass surgery and clavicular orif were undertaken simultaneously for right clavicular fracture and ischemia of the right upper limb. postoperative arteriography showed good patency of the graft and the ischemia improved. however, rehabilitation was needed for the motor dysfunction caused by brachial plexus injury. case : -yearold female the patient ran into a tree while driving a car resulting in hemorrhagic shock caused by bilateral femoral and humeral fractures. she was transported to our center by helicopter. a scar from seat belt injury was found in the right cervical area. she presented with an expanding mass around the subclavian artery with accompanying pulsating pain. arteriography detected a cm-diameter pseudoaneurysm and aneurysmectomy was undertaken. postoperative computed tomography confirmed the disappearance of aneurysm and she was discharged. results: these cases showed favorable outcomes with surgical vascular reconstruction. conclusion: traumatic subclavian artery stenosis is caused by crushinduced local dissection and is frequently complicated with brachial plexus injury. subclavian artery aneurysm caused by seat belt injury occurred. disclosure: no significant relationships. results: case description: years old male patient who was brought in after receiving a large stab wound below the mid-portion of the left clavicle. severe external bleeding was prevented by manual compression in transit to the hospital. three foley catheters introduced through the wound at the ed failed to temporarily control the bleeding due to its large size, and he was rushed to the or. an emergency left antero-lateral thoracotomy allowed for the blind manual compression of the bleeding vessel from within the thoracic cavity, and was very successful in stopping the external bleeding. a long supra-and infra-clavicular incision was done, and the clavicle was divided. this failed to expose the bleeding vessel, due to the large muscle mass of the patient. a decision was taken to split the sternum in a ''trap-door'' approach, which nicely exposed a large laceration of the subclavian vein. this was suture-ligated, and the incision closed, in a surgical field with profused oozing from coagulopathy. he was taken to the icu, and then back to the or two hours later because of persistent bleeding through the chest drains. the ''trap-door'' incision was reopened and careful haemostasis was performed. the patient had a protracted course in the icu but eventually recovered. as a striking and very uncommon sequel he developed severe blindness from bilateral ischemic optic neuropathy attributed to hypotension and use of vasopressors. he is free of pain at the incision and with good cosmetic results conclusion: ''trap-door'' incisions are very infrequently used nowadays, but should be kept in mind in the armamentarium of trauma surgeons. disclosure: no significant relationships. conclusion: mortality in patients with ivc injuries can be well predicted by hemodynamic parameters on arrival and intra-operative findings .hemodynamic instability and intraoperarive findings of expanding hematomas and active intra-peritoneal bleeding are associated with high mortality. introduction: vascular complications due to intravenous drug abuse pose significant challenges to vascular surgeons and no standardized surgical management of the resultant infected pseudoaneurysm was established. material and methods: we present our successful management of a case of an expanding retroperitoneal haemathoma due to external iliac artery pseudoaneurysm caused by self inflicted trauma (heroin administration). mri showed an external iliac artery pseudoaneurysm surrounding by an infected old haemathoma, venous thrombosis (external illiac and femoural) and multiple muscular abscesses of the left thigh. a self-expandable stent-graft was deployed across the pseudoaneurysm after crossing the lession with an exchange glide wire through the left brachial artery route. post-stenting angiography showed complete exclusion of the pseudoaneurysm with no residual stenosis. we decided local surgical debridement; after haemathoma evacuation we identified external illiac artery presenting a stent graft and reinforced it by double layer of tissue sealing surgical patch. results: postoperative course was favorable under complex general and local therapy. conclusion: endovascular treatment of arterial pseudoaneurysms has become feasible as natural extension of the endovascular techniques. ct, mri, sonography and angiography may all be valuable in the imaging working of pseudoaneurysms. prompt diagnosis and treatment are necessary to avoid the morbidity and mortality secondary to hemorrhage and rupture. although endovascular stent-grafting is not considered a standard therapy for infected aneurysms, our case suggest that stent-graft deployment, secondary surgical debridement and major antimicrobial therapy may be the most favorable treatment option for patients unfit for major surgery. introduction: the incidence of traumatic vascular injuries (tvi) has increased significantly in the last decades, with penetrating trauma as the most frequent mechanism. our aim was to estimate the incidence, management by interventional radiology, and the preventable death rate in our patient population. material and methods: a retrospective observational study based on our trauma registry covering a -year period (july to july ) . we have assessed the demographics, severity, diagnostic and therapeutic approaches, outcome, and triss probability of survival (ps). results: patients ( % males, with a mean age of years) suffered a tvi located at the head ( ), neck ( ), thorax ( ), abdomen ( ), upper extremities ( ) and lower extremities ( ), respectively. ( . %) were caused by a blunt mechanism, and ( . %) by an open one. the average time spent before being taken to hospital was minutes. upon arrival to hospital, were in shock, required orotracheal intubation, and a cardiac massage. the diagnostic methods used were a ct scans in , dpl in , fast in , angiography in , echocardiogram in and duplex-doppler in . ( . %) patients underwent emergency surgery and ( . %) were treated with interventional radiology ( of them associated with surgery). only ( . %) were treated conservatively. overall mortality was of patients ( . %) ( of them died upon their arrival to hospital or in the operating room, all of them with an aortic injury), out of which ( . %) had a triss ps > . . the incidence of tvi increased from cases in the - period to in - , remaining stable in - ( ) . however, the mortality rate has shown a steady decline over the years (from % in - , to % in - ) . conclusion: the incidence of traumatic vascular injuries has increased considerably during the last years in our hospital. these injuries are most commonly located in the lower extremities, followed by the thorax. % of patients could be managed by interventional radiology techniques. introduction: the tip apex distance (tad) is a simple measurement that predicts screw cut out in the femoral head in peritrochanteric fractures treated with a fixed angle sliding hip screw device. we wanted to assess whether the tad measurements in our centre were comparable to previously published results, how reproducible these measurements were between observers and how accurate we were at reducing the fractures. material and methods: a retrospective review was conducted of consecutively treated peritrochanteric fractures over a month period. patients were excluded because they did not sustain a peritrochanteric fracture, had treatment of a pathological fracture or because of incomplete radiographic data. three observers used a standardised method to measure the tad (from orthogonal projections with a correction for magnification). the stability of the fracture patterns and the accuracy of reduction were measured according to criteria from the original baumgaertner paper introduction: distal locking screw insertion of the short gamma nail is normally performed by using a targeting device attached firmly to the proximal part of the nail. generally, the accuracy of targeting device should be promising. however, missing the target in the process of drilling might be a potential risk. we report cases of such condition in term of early radiographic finding, method of solving and the result of treatment. material and methods: the patient records, operative notes and intraoperative c-arm images of the patients underwent short gamma nailing for unstable pertrochanteric fractures during october to october have been reviewed in order to identify an error of distal locking screw insertion via a targeting device. the intraoperative radiographic finding, solving procedure and the outcome has been analyzed. results: there were cases of short gamma nailing over the past one year in our institute. five of which had an error during distal screw insertion even using the targeting device. an error occurred in the drilling process in all cases. intraoperative images showed that the drillbit missed its target posteriorly after perforating the near cortex of the femur. all has been corrected by using a free-hand technique under c-arm guidance. no any serious complication afterword and all fractures healed in an appropriated time. conclusion: distal screw insertion during gamma nailing can be missed even though using the targeting device. therefore, radiographic confirmation on the lateral view after perforation the near cortex is recommend in all cases in order to obtain early detection prior to bicortical perforation. freehand technique can be carried out in order to correct the error. . systemic antibiotics were used in patients ( %). ten different types of antibiotics were used after wound exploration for a period between and weeks. in-hospital mortality was %. sixty-nine percent (n= ) was finally discharged from follow-up. conclusion: we conclude that our infection rate was higher than reported in literature and the infections classified initially as superficial required a prolonged treatment as well. moreover, the treatment of this disastrous complication showed no uniformity whatsoever and should be the topic of further research, resulting in a clear protocol to increase survival and decrease morbidity. introduction: allograft meniscal transplantation is known as a possible procedure to solve pain and loss of function in the knee of patients with a history of subtotal or total meniscectomy. medium-term and long-term results after meniscal allograft transplantation in the knee are scarce. in this study patients who received an arthroscopically assisted meniscal allograft transplantation with a follow-up between and years were evaluated using subjective questionnaires, a clinical and a radiographical evaluation. material and methods: demographic data of all patients were collected and pre-operative results, using the koos (knee injury and osteoarthritis outcome score), the lysholm score, the tegner score, the sf and the vas (visual analogue scale) for pain were compared with actual results of those questionnaires to evaluate the therapeutic effects of allograft meniscal transplantation in the knee during medium-term follow-up. patients were evaluated with a standardized clinical examination of the knee to objectivate knee related symptoms. standard weight bearing radiographs and a full leg standing radiograph were performed to evaluate the evolution of osteoarthritis and malalignment. results: for all questionnaires (vas, koos, lysholm, sf ) there is a significant (p< , ) and clinically relevant increase in postoperative score. this improvement stays consistent during the followup period. the more severe the osteoarthritis, the lower the improvement. despite the meniscal transplantation, there is still a significant (p= , ) increase in osteoarthritis. an increase in osteoarthritis grade was seen in % of the patients, as scored following the kellgren-lawrence classification. when strictly respecting the indications, there is no significant correlation between preoperative cartilage damage, pre-operative osteoarthritis, alignment deviation, gender and body mass index on the one hand and outcome scores or improvement on the other hand. conclusion: meniscal allograft transplantation results in important pain relief and functional improvement in patients with a history of (sub)total meniscectomy and pain localized in the affected compartment. strictly following the indications, meniscal transplantation can give good and predictable results. introduction: intramedullary nailing of the tibia has become the conventional therapy for tibial shaft fractures. one of the most common complaints associated with this procedure is chronic knee pain. incidence rates between % and % have been reported and a significant number of patients have problems in kneeling, affecting professional and recreational activities. surgical damage to the infrapatellar nerve is one possible causative factor for post-nailing knee pain. the infrapatellar nerve is exclusively sensory and runs subcutaneously almost perpendicular to the patellar tendon just below the patella. the purpose of this study was to determine the prevalence of chronic knee pain in our institute and its relation with sensory disturbances in the knee area. material and methods: a chart review was conducted. all patients between and years with healed traumatic tibial shaft fractures treated with an intramedullary nail between and were included. exclusion criteria were: fracture lines extending into the knee or ankle joint, any other fracture in the affected leg, lacerations in the knee area, pre-operatively existing knee pain and loss of follow-up. chronic knee pain was defined as persisting pain in the knee area months after tibial nailing. sensory disturbances were defined as hyperesthesia or anesthesia at the nail entry site. introduction: femoral nailing causes an influx of fat in the circulation. in the multiply injured patient, especially in the patient with concomitant lung or brain contusion, this can lead to ards, fat embolism syndrome and multiple organ failure. the timing and kind of fixation of femoral fractures in patients with multiple injuries is controversially. the advantage of damage control orthopaedics (external fixation) would be less fat embolisation but some authors report more problems of infection and delayed healing. the aim of our study was to investigate the effect of external fixation on healing and infection rates of femoral shaft fractures in the multiply injured patient. material and methods: between january and januari , we treated femoral shaft fractures. in this group there where polytrauma patients with a total of fractures. we compared the rate of infection and delayed union in the group treated by damage control external fixation to the group primarily treated by intramedullary nailing. results: no significant difference in infection or union rates could be demonstrated between the damage control external fixation and the primary nailing group. we also noted that there's a correlation between the complexity of the fracture and the percentage of prolonged healing. and although not statistical significant there seems a tendency of less healing problems with the reamed femoral nail in comparison with the unreamed femoral nail. introduction: the diagnostic information power of a level one emergency room has risen excessively within the last years. the need for quality control, judicial regulations, insurance claims and forensic reasons still lead to a high number of autopsies being performed in patients not surviving the first h after admission to the er. however, the number of autopsy clarification featured in a level one trauma centre after trauma related deaths considerably vary and also the rate of deathly diagnoses missed within er assessment of early stage deceased patients differ in the literature. the aim of this study was to assess the value and necessity of autopsy after modern er assessment with a multi-slice ct-scan as an integrated part of the diagnostic algorithm. material and methods: prospectively reviewing our emergency database, case histories, laboratory values and radiological findings compared to findings in autopsy between jan and sep , we charged for missed deathly diagnoses in early stage deceased trauma patients (< h). patients were classified into two groups: group : patients with limited diagnostic assessment (conventional xray, sonography). group : patients with full er assessment (msct). all patients in group could not be sufficiently stabilised in terms of circulation patterns and therefore did not receive full assessment. non-trauma patients and patients reaching the er under cpr were excluded. results: the autopsy rate of all included patients was %. the overall incidence of missed deathly diagnoses was . %. in terms of missed deathly diagnoses, groups varied significantly (group : . %;group : . %).the iss after autopsy increased significantly in group from to . . in group there was no difference of iss between status emergency room and after autopsy. the most concerned region of missed deathly injuries was thorax with . % of all patients with autopsies followed by pelvic ( %) and spine injuries ( . %). conclusion: in spite of complete and nearly ideal conditions within a modern emergency room assessment nowadays, detecting all diag-noses is still challenging. overall, our findings show that almost every tenth early stage deceased patient showed at least one missed potential deathly diagnose in a level one trauma centre. regarding the insufficient assessment performance in group , the relative high rate of missed diagnoses seem explicable. nevertheless, even having acquired full assessment power (group ), still . % deathly diagnoses were missed. for this reason, autopsy is still the most powerful and indispensable tool in finding the ''whole'' diagnosis. completeness of autopsies after trauma related death therefore is essential referring a continuous gain of quality. introduction: in a physiological environment metallic biomaterials undergo corrosion through a variety of mechanisms. this study investigated whether, beside the well recognized electrochemical aspect of corrosion, human osteoclasts are able to directly corrode titanium alloys, uptake and finally release corresponding metal ions into their environment. the released ions are believed to cause inflammatory reactions and activate osteoclastic differentiation and activity, which most likely play a role in the pathophysiological mechanisms of aseptic loosening [ ] . material and methods: human monocytes and in vitro generated osteoclasts were seeded onto titanium and aluminum (positive control) foils. after days scanning electron microscopy analysis was performed in order to assess whether monocytes were able to grow and differentiate on the metals. in order to visualize uptake and distribution of intracellular metal ions, a novel protocol using confocal microscopy analyses with newport greentm dcf diacetate ester staining was developed [ ] . additionally, the concentrations of metal ions released into the culture supernatant were measured using atomic emission spectrometry. ). nine bre-gfp mice were used. mice were allowed unrestricted activity. a mini-external fixator fixed to the proximal and distal tibia was applied under general anesthesia on day . the animals were permitted full weight baring and unrestricted activity after awakening from anaesthesia. the gfp signal of tibia and fibula in bilateral limbs was measured on days , , , and after application of the external fixator. results: baseline measurements of the gfp-signal ranged from . x e photons to . x e photons between individual mice. after application of the external fixator, the gfp signal of the unloaded tibia and fibula decreased in all mice to on average % of baseline on day (sd ± %, p = . ), % on day (sd ± %, p < . ), % on day (sd ± %, p < . ), % on day (sd ± %, p = . ) and % on day (sd ± %, p < . ). in the contra-lateral non-operated limb, the gpf signal increased to an average % on day (sd ± %, p = . ), % on day (sd ± % p < . ), % on day (sd ± %, p = . ), % on day (sd ± %, p < . ) and % on day (sd ± %, p < . ). introduction: the aim of the present study was to assess the effect of antibiotic loaded fresh-frozen allografts and compare it with antibiotic loaded acrylic bone cement in staphylococcal tibia osteomyelitis and to combine the effects of bone repair and eradication of infection in one stage surgery. material and methods: a unicortical . -mm-diameter defect was created in the proximal tibial metaphysis of thirty-six new zeland albino rabbits. after contamining the wounds with x colony forming units of staphylococcus aureus, we divided the animals into four groups. the negative control group received no treatment, the positive control group received teicoplanin-impregnated polymethylmethacrylate beads, the allograft group received fresh-frozen allografts and the experimental group received teicoplanin-impregnated fresh-frozen allografts. histopathological evaluation with light microscope were made and intraosseous tissue cultures were performed on postoperative day . clinical evaluation in a daily-routine were made. results: the cultures showed no evidence of intramedullary infection in the experimental or the positive control group in eight of the nine rabbits, but they were positive for staphylococcus aureus in one of the nine rabbits in the experimental group, one of the nine rabbits in the positive control group and all of the rabbits in the negative control and allograft groups. the experimental group and the positive control group has similar effects in eradication of the infection. conclusion: teicoplanin-impregnated allografts was effective in preventing intramedullary staphylococcus aureus infection in a staphylococcal tibia osteomyelitis model. this combination therapy could potentially eliminate the need for surgical removal of cement beads. using an antibiotic-graft compound, eradication of pathogens and grafting of bony defects may be carried out in a one stage procedure. introduction: we first report a case of an infection in humans by streptococcus pluranimalium, a new streptococcal species that has been isolated in the genital tract and tonsils of cattle, tonsils of a goat and a cat, and from the crop and the respiratory tract of canaries. according our knowledge there are a few reports in the literature reporting infections by this strain of streptococcus in animals, but never since now in humans. a year old farmer, fit and well, nonimmunocompromised has been treated in our department, for a close tibial plateau fracture (schatzker vi), with a circular external fixator. postoperatively, i.v antibiotics -cefuroxime mg every h was administrated for hours. radiological and clinical healing of the fracture achieved successfully within weeks of the fracture. the frame removed and the patient was followed up as an outpatient. six days after the removal of the frame, the patient turned up to the a&e department, systematically unwell, complaining for a swollen painful knee, and a discharging abscess in one of the proximal pin sites near by the joint line.fluid samples from the abscess and the knee aspiration, obtained and revealed streptococcus pluranimalium in all samples. debridement of the abscess and an arthroscopic wash out was performed twice, followed by i.v antibiotics according to the sensitivity test (levofloxacin ( mgx ) ceftriaxone ( grx )) for six weeks, and p.o antibiotics (clarithromycin mg every h and levofloxacin mg every ) for another two weeks. results: symptoms were settled and the patient is free of infection for the last months. conclusion: we hypothesized that the bacterium was settled on the wires of the circular fixator and was inoculated in the patient during the removal of the frame. according our knowledge, it is the first case of infection in a human individual by this specific strain of streptococcus. disclosure: no significant relationships. introduction: post traumatic knee joint contracture is the most difficult complication of the lower limbs traumas, considerably limits the functional abilities and make the patients invalids. besides, the frequent consequence of knee joint injure is gonarthrosis, and kinesitherapy is one of the element of the complex treatment. the basis of the procedure is the joint relief, leading to adjoining muscles tonus lessening, and paraarticular tissues general tense lessening and infrajoint hydrostatic pressure, joint tissues nourishing improvement. the introduction: ilizarov frames are still removed in the operating theatre in a lot of centers. this is due to a variety of reasons, the main one being that it is a painful procedure. we decided to evaluate patient satisfaction and pain experienced on removal of ilizarov frames in an outpatient setting, using oral analgesia and entonox. material and methods: seventy consecutive patients, who had their frames removed in the out patients department, had their level of pain scored using a visual analogue score (vas) and a simple questionnaire. results: the mean score for frame removal was . on the vas. there was no difference between male and female scores. the age of the patient does make a difference in the pain score, the pain score decreases with the age of the patient. pain increases when there are or more olive wires to be removed conclusion: removal of ilizarov frames in the outpatient department is a moderately painful but well tolerated procedure. introduction: the proximal metaphyseal tibial fractures are difficult to treat due to their frequent association with tibial plateau fracture and due to their aspect, which is often comminuted and has a significant impact on the function of the knee. surgery has to restore local anatomy and to allow early rehabilitation, meaning proper evaluation and stabilization of the fracture. material and methods: cases, operated between . . - . . (mean age - yrs) with proximal metaphyseal tibial fractures, were analysed. pre-operative planning using ct scan was used. the fractures were complicated with compartment syndrome ( cases) which needed additional fasciotomy.the fractures were stabilized with : plates and screws ( cases) or external fixation ( cases) depending on the soft tissue status. bone graft was used in cases. the patients were monitorised at , , , and months postoperative, concerning: bone healing, restoring of the axis of the knee, joint mobility, septic complications. results: the axis of the knee were completely restored in all the cases. bone healing appeared in all the patients (starting from months- cases, at months in the rest of the fracture) depending on the initial aspect of the fracture. flexion of the knee was limited in cases ( % of the pactients) and extension was affected in patients, depending, also, on the initial characteristics of the fracture. the frequency of the complications depended on the initial aspect of the fracture, initial stabilization, time from intial stabilization to final fixation. conclusion: results after surgery for tibial plateau fractures depend on the initial aspect of the fracture, but also on the results of surgery . the method proposed by the authors, which allows the suspension of the articular surphace, is valuable especially when the fracture is cominuted and has small fragments. the double plate fixation (medial and lateral) with single anterior incision is the best, effective and simple procedure in treatment of complex proximal tibial fractures (type v and vi of schautzker classification). introduction: compartment syndrome is one of the most frequent complications after proximal metaphyseal tibial fractures, due to the anatomical characteristics of this area. the importance of the problem is that the compartment syndrome radically changes the local and general and especially the type of fixation of the fracture. the purpose of this study is to evaluate the impact of the compartment syndrome on the outcome of the patients with this type of fracture, when recognized and treated early and complete. material and methods: the authors analyse cases of proximal metaphyseal tibial fractures treated in the emergency hospital, bucharest, between . . - . . . from these, in cases, compartment syndrome was diagnosed. in all these cases, the patients were operated and the fracture stabilized (with plates and screws in cases and external fixation in cases). decompressive fasciotomy was performed in all the cases with installed compartment syndrome and intra-compartimental pressure was monitored post-operative in all the other cases. frome these, in cases secondary compartment syndrome developed and fascitomy was necessary - hours after surgery the patients are analysed concerning: the moment of surgical treatment, and the characteristics of the patient in that moment, post-operative treatment, the postoperative local and general outcome, local and general complications. results: the incidence of the complications was influenced by the time between trauma and complete surgery. there were cases of superficial infection and case of deep infection, without needing implant removal. all the fractures healed, the interval proved to be longer when external fixation was first used. there were no systemic definitive complications after these trauma. conclusion: compartment syndrome is frequent after proximal metaphyseal tibial fractures and the incidence of this complication was significant in the group of patients we studied, and the outcome was good when the treatment was early and complete . the compartment syndrome influenced the local and general prognosis, due to the importance of microcirculation in healing after trauma. results: a ct pulmonary angiogram illustrated a metallic density, which appeared to lie in the lumen of the main pulmonary artery just proximal to the pulmonary valve. conclusion: in this case, the respiratory symptoms and signs were due to a metallic pulmonary embolus rather than fat or thrombus. formal anticoagulation was initiated and the patient's clinical condition consistently improved without the need for cardiothoracic surgery, although this is described in the literature with retained catheter fragments. eight months after the injury, the fracture has consolidated with the patient returning to work. toid is often necessary to obtain adequate exposure. as an alternative to this we promote the minimal invasive transdeltoid approach. material and methods: the operative technique of the minimal invasive transdeltoid approach is explained in a first section. this approach has the advantage of direct access to the fracture site with more opportunities for adequate reduction and good plate placement without extensive distraction of the muscles. an important step in the procedure is the palpation of the axillary nerve. in a second section the results of a prospective cohort of the first patients treated with this technique will be presented. the neer criteria were used as guidelines for operative treatment. fractures were classified according to the ao-classification. the ases shoulder score was used to evaluate functional outcomes. preoperative xrays were used to evaluate displacement, vascularity of the humeral head (according to the hertel criteria) and ao fracture type. postoperative x-rays were analyzed for quality of reduction of the ccd angle, reconstruction of the medial hinge and reposition of the tuberosities. follow-up x-rays were evaluated for healing, avascular necrosis, loss of reduction and implant related failures of osteosynthesis. the -year-old male patient was taken to hospital after a traffic accident. he was a pedestrian hit by a car. he suffered comminuted proximal humeral fracture on the dominant right side. the fracture was closed. the glenoid cavity was damaged and acromion was broken. the fractures of the v-vi th ribs were found without complication. otherwise the patient's condition was good. he had only a controlled hypertension. for preoperative planning ct scan was performed. as pieces of the humeral metaphysis wedged into the glenoid cavity insertion of glenoid component seemed uncertain. an early shoulder replacement was done on the th day. the denudated fragments were removed. the tubercles with the muscle attachments were preserved. as a long bone defect remained in the metaphyseal zone normal stem would have been insufficient. a cm long stem used in tumor cases was implanted. the length of the arm and size of the humeral head were compared to the intact side. the tubercles were attached to the prosthesis by non absorbable sutures. after the operation long bone defect remained which was filled up by heterotopic bone visible on x-ray. the postoperative period was complication free. fever, severe pain, hematoma did not occur. the arm was in rest for weeks, only controlled pendulum exercises were done from the second week. active physiotherapy was started on the th week. after months the patient finished the follow up treatment. he was pain free and self-sufficient. conclusion: for three-or four-part displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment/ , /. in trauma cases short prosthesis stem is usually sufficient but in comminuted fractures involving the metaphyseal zone long stem has to be used for certain bone-prosthesis contact. introduction: there is a trend to apply plate and screw fixation directly medial and lateral (so-called parallel plating), and many implants designed specifically for the distal humerus extend more laterally to improve fixation. this may risk injury to the origins of the common extensor and flexion musculature and the collateral ligaments either via operative dissection or by damage to the blood supply. internal plate and screw fixation is often accomplished with subperiosteal elevation of muscle attachments and tight apposition of the plate to the bone, but this should not be done over the epicondyles. plates applied to the medial and lateral aspects of the lateral and medial epicondyles should be placed directly over the soft tissues without elevating or disturbing them. damage to the collateral ligaments could cause elbow instability. material and methods: in order to emphasize these important technical aspects, we report three patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle led to post-operative instability after open reduction and internal fixation of a fracture of the distal humerus. results: while the cases are very complex and the exact cause of elbow instability by necessity somewhat speculative, our concern is that the operative dissection performed to apply implants to the lateral side of the elbow contributed to the ulnohumeral instability. injury to the lcl is the most common cause of recurrent elbow dislocation. attempts to place a direct lateral implant directly on the bone by elevating soft tissues will put the origin of the lcl at risk. it is preferable to place implants directly over the soft tissues, although there is a risk of interfering with blood supply leading to soft tissue insufficiency. it seems safe to assume that the operative treatment contributed in some way to the instability in each patient. patient one in particular had osteoporotic bone noted intraoperatively, so that one would expect failure to occur through bone with any subsequent trauma. the failure through the ligamentous structures seems to implicate the operative technique. conclusion: in any case, these three patients establish that instability of the ulnohumeral joint is an uncommon complication or sequel of the operative treatment of a bicolumnar fracture of the distal humerus. our intention in reporting these cases is to increase awareness of these potential complications and we encourage others to report any similar cases so that we can learn enough to limit the risk of this complication. introduction: orif of comminuted distal humerus fractures carries a high risk of complications such as secondray loss of reduction, pseudarthrosis and heterotopic ossifications. especially elderly patients with osteoporotic bone quality are struck by these complications. therefore total elbow arthroplasty (tea) is gaining more and more in importance as it has proven to achieve good results in elderly patients with poor bone quality. the latitude total elbow system (tornier inc., stafford, usa) is a modular, convertible implant that allows not only linked and unlinked tea with or without radial head replacement but also hemiarthroplasty. the aim of this system is to reproduce the patient's anatomy to reconstitue the elbow's physiologic kinematics. therefore the latitude prosthesis is offered in four different sizes, respecting the flexion-extension axis and three different humeral offsets based on anatomical findings. the purpose of our study was to evaluate the short-term results after elbow arthroplasty with the latitude system. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. other authors propose radial head arthroplasty as an alternative to radial head resection to avoid the complications of radial head resection. different concepts of radial head prostheses are available: silicon prosthesis, monopolar prosthesis (loose fit and cemented/thight fit) and bipolar prostheses. evidence is lacking on the exact place for arthroplasty as opposed to radial head resection. to answer this question we performed a systematic review of litterature. material and methods: inclusion criteria are clinical studies reporting on radial head resection or radial head arthroplasty, published between and today in english, french, german or dutch language. a search has been performed using the pubmed and embase databank. a secondary search has been performed based upon the reference list of the included publications. exclusion criteria are: â e¢cadaver or animal studies â e¢biomechanic studies â e¢clinical studies with a follow up of less than years â e¢clinical studies with less than patients data extraction â e¢elbow function â e¢complication rate â e¢arthritis rate data are reported according to the moose guidelines. results: only low evidence studies are available. we did not find any randomised controlled trial comparing resection to radial head arthroplasty. there is evidence that radial head resection results in high complication rates (including arthritis) and poor function in case of elbow instability and/or essex-lopresti lesions. the rate of complications in these indications is higher than for radial head arthroplasty. in cases without instability or essex-lopresti lesion there is a trend to better function in radial head resection. complication rate is higher in the prosthesis patients. the rate of post-traumatic arthritis is not significantly differing between the resection and the arthroplasty group, and remains very high (+/_ %). conclusion: complex radial head fractures remain difficult to treat. based upon the findings of this systematic review we suggest: â e¢that adequate level of evidence studies are a necessity â e¢that in case of fracture without evident instability or essex lopresti lesion resection results in better function and less complications than arthroplasty â e¢that in case of fracture with evident instability or essex lopresti lesion resection results in worse function and higher complication rates than arthroplasty â e¢as secondary arthritis rate remains %, further therapeutic optimisation is a must. often, mortality. a new pelvic stabilizer (t-pod Ò ) provides secure and effective simultaneous circumferential compression of the pelvis. material and methods: in this study we have managed fifteen patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the t-pod Ò . before and minutes after applying the t-pod Ò , heart rate and blood pressure were measured. an x-ray before and after applying the t-podÒ was made to measure the effect on reduction in symphyseal diastasis. results: application of the t-pod Ò reduced the symphyseal diastasis with % (n= ; p= . ). the mean arterial pressure (map) increased significant from . to . mmhg (n= ; p= . ) and the heart rate declined from beats per minute to (n= ; p= . ). in ten patients of whom circulatory response before and after the t-pod Ò was recorded, there were seven good responders, one transient and two poor responders. conclusion: in the acute setting, the t-pod Ò device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. the t-pod Ò is therefore an easy to use and effective way of (temporarily) stabilizing the pelvic ring in an acute setting. introduction: thoracolumbar and lumbar fractures treated with surgical methods aim to decompress the spinal cord and correct the deformity. we aimed to compare the effects of anterior, posterior and anterior-posterior surgery on the local kyphosis angle in thoracolumbar and lumbar vertebral fractures. material and methods: thoracolumbar and lumbar, burst or compression fractured and surgically treated patients were evaluated retrospectively. preoperative, postoperative and follow-up local kyphosis angles were measured on the x-rays and changes in these angles were compared according to the applied surgical treatment methods. results: early application of surgical treatment following trauma decreases the correction loss suffered after surgery. the increase in correction loss continues after removal of the hardware. it is observed that laminectomy applied in the course of posterior surgical interventions has no effect on the correction loss. the length of the implantation, fusion and the addition of a hook to the lamina of the vertebra which is located one segment lower than the transpedicular screw applied vertebra do not affect the loss of correction. conclusion: in the surgical treatment of thoracolumbar and lumbar vertebral fractures, different degrees of correction loss are observed after each surgical treatment modality. considering the corrective effect of combined anterior-posterior surgery on the correction of kyphotic derformity due to trauma and the preoperative local kyphosis angle, follow-up correction achievement is higher when compared with anterior and posterior surgical approaches. domain questionnaire (eq- d), the point self-rated back pain (vas) and device and/or procedure related adverse events. the ethic committee of the hospital did not accept a randomized study because of the results in this proof of concept, they accepted the study with a minimum of patients (based on the results of a previous proof of concept). the incidence of missed injuries without the application of the tertiary survey was % and this incidence has been reduced to % with the application of the tertiary survey (it means a reduction of the . % in the incidence of missed injuries). the incidence of clinically significant missed injuries without the application of the tertiary survey was % and it has been reduced to % with the application of the tertiary survey (it means a reduction of the % in the incidence of missed injuries). the tertiary survey is an essential task in the management of the trauma patients to reduce the incidence of missed injuries and clinically significant missed injuries. introduction: knee-arthroscopy is a complex surgical ability. it is a combination of factors like anatomical knowledge, hand-eye coordination, three-dimensional mental activity and operating experience. surgeons as well as students were not able to train knee arthroscopy before. parts of these abilities were trained by playing video games. former studies indicated a correlation between a better performance in virtual reality (vr) laparoscopy simulation and video game experience. the aim of this study is to show that experienced video gamer perform better in a virtual arthroscopy simulation. material and methods: medical students did an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator (the insight arthro vr Ò gmv, madrid, spain). the students completed a questionnaire asking for their game experience: none (n = ), monthly (n = ) weekly (n = ) daily (n = ) before they did the arthroscopy. the simulator assessed different parameters: time, distance moved and roughness both for probe and camera and a global score (combination of all metrics). results: students with game experience (n = ) performed significantly (p <= , ) better than not experienced students (n = ). there is a tendency that the performances get better with more game experience. conclusion: gamer performed better in a vr knee arthroscopy than not gamer. these result correlates to the laparoscopic simulator training. there is a tendency of achieving a better performance in vr arthroscopy simulation due to a higher frequency of playing games. extensive training on the simulator improves the abilities of nongamers with respect to their arthroscopy skills. we will evaluate these dates in the future. ) and mostly injuries of tendons (n = ) and/or vessels / nerves (n = ). buzzsaws of different manufacturers and different price ranges were used. the work conditions were well in all cases, the saws were placed firmly on the ground and the lighting was sufficient. most injuries appeared on the week-end (friday n = , saturday n = ). a break or a meal, taken shortly before the accident, had no influence on the injury risk. all patients had a several years lasting experience in dealing with buzzsaws, half of the patients even for at least years. the safety device of the saw was folded back in most cases (n = ), only few patients (n = ) had correctly put on the saw safety device at the accident time, patients provided moreover no information. the accident had entered in cases shortly before working end, mostly with the last cut. in cases a wooden piece had become stuck in the saw and the patient had tried to solve it. conclusion: a many years' routine in dealing with buzzsaws can lead to the fact that necessary safeguarding measures are not followed any more and so cause an increased injury risk. in particular shortly before working end the attention decreases and the injury risk rises. an especially injury-laden situation is becoming stuck of wooden parts in the saw. the attempt to solve these parts without switching off the saw before bears a high injury risk. the patients showed predominantly heavy injuries. this might be the result of our clinic as a university clinic. patients with less severe injuries are concerned to be treated in smaller clinics next to their residence . ethibond was then used to anatomically oppose the ends of the sleeve fracture. the construct was reinforced with a circlage wire with the wire twisted so that it could be retrieved later through a small lateral incision post operatively the legs were immobilised in lightweight casting material for a period of weeks followed by an unlicked hinged knee brace for weeks. the circlage wires were removed at months. the child now has full, pain free range of motion. the knee is stable and he has no functional problems. conclusion: we report a rare case and emphasize the timing of diagnosis as being crucial in outcome. early operative intervention with accurate open reduction will yield good results. this publication serves to educate and refresh those who deal with general and paediatric lower limb trauma. introduction: the purpose of this study was to evaluate the effect of electromagnetic fields in healing progression of delayed union of long bones in the lower extremities. we defined delayed union, as failure of expected healing progression and nonunion when a minimum of nine months has elapsed since injury and failure or halting of healing progression was observed in three successive monthly radiographs (infection ruled out results: an average of . x-rays were performed on each patient from the time of diagnosis to discharge from clinic. none of these fractures displaced on follow up x-rays. conclusion: stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources. ( ). we aim to describe the rate of postoperative complications after calcaneal plate osteosynthesis in relation to the hospital fracture load as a means to increase insight into the clinical audit data. material and methods: a search was performed using the disease code for intra-articular calcaneal fractures and operative code for orif for the period - . the medical records of all included patients were obtained. as postoperative complications we included superficial and deep wound infection, mobilisation problems with need for orthopaedic shoes or walking aid and secondary arthrodesis. current complication rate of deep infection and arthrodesis rate from the clinical audit were compared with the mean logarithmic correlation coefficient relating complication rates with the institutional fracture load data, reported earlier in the literature ( ) . results: over a period of months a total of intra-articular calcaneal fractures were reconstructed with a calcaneal plate using orif (mean institutional fracture load = . fractures per month). eight patients had a wound infection, six of them were treated with antibiotics and two of them needed surgical debridement. thirteen patients have mobilisation problems, patients suffered from pain when walking, patients used orthopaedic shoes and one patient mobilised using a wheelchair. two patients had an secondary arthrodesis (n = , . %). in seven patients the osteosynthesis was removed due to pain. both deep infection rate and arthrodesis rates related to the institutional fracture load were below the % ci reported in the literature. the outcome of open reduction and internal fixation of intra-articular calcaneal fractures is known to be determined not only by factors related to patient and the fracture, but also to the institutional fracture load ( ) . the complication rate regarding deep wound infection and arthrodesis is below the data reported in the literature, related to the institutional fracture load. clinical audits studying the complication rate should take the institutional fracture load into account. introduction: toe fractures are the most common fracture of the foot. there is little data on demographics and no studies on functional outcome of toe fractures. material and methods: the initial radiographs of all consecutive patients with toe fractures treated between january and september at the reinier de graaf groep in delft, the netherlands were re-evaluated; patient and fracture characteristics were collected. all patients in aged to ( patients) were sent a questionnaire concerning pain, activity and functional limitations, footwear, walking distance, and gait (aofas midfoot score). overall satisfaction was measured using a visual analogue scale (range zero to ten). results: a total of patients with digital and phalangeal fractures of the foot were identified. the distribution of fractured toes was: first %, second %, third %, fourth %, and fifth %. multiple digital fractures were seen in . %. most fractures were caused by stubbing the toe or a crush injury ( . %). more than % of the fractures were undisplaced or minimally displaced and most fracture patterns were transverse or oblique/spiral. a total of patients ( %) returned the questionnaire with a median follow-up of months. responders were female in . % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). no correlations were identified with outcome and which toe or phalangeal bone was affected, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and diabetes. in the univariate analysis a trend was found for dislocation and aofas score (p = . ). in the multivariate analysis the vas was dependent of age (p = . ) and gender (p = . ). the aofas midfoot score was not influenced by any of the parameters. conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome. almost all toe fractures were healed without complaints at months. patient satisfaction is slightly less in younger female patients. the appendix has been one of the most common site of carsinoid tumors( ). carsinoid tm is seen incidental in appendectomised cases( , - , ) and frequently in female( , ). mean diagnosis age is between - in literature, whereas in our serise it is ( ). postoperative living prognosis is good in incidental carsinoid tumors of appendix ( ) .in our cases, additional surgical procedure was not applied because tumor is less than cm, mesoappendix is healthy, and vascular invasion was not seen in hystopathologic examination. introduction: for clinical importance, two cases are presented who were operated with diagnosis of acute apppendicitis. intraoperatively,appendixes were normal, for this reason meckel's diverticulas were explored and diverticulitis were seen. material and methods: two cases are explored retrospectively results: case :the case is years old male patient.he admitted to emergency department with abdominal pain for days.there were defans and rebaund on the right inferior quadrant of the abdomen. leucocytosis( , x /mm ), aperistaltic intestinal ans in ultrasonografic examination were seen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen case :the case is years old male. he admitted to emergency departmant with abdominal pain for days because his pain increased last days. he has nausia, vomiting, fever( , °c), leucocytosis( , x /mm ), defans and rebaund on the right inferior abdomen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen. conclusion: meckel's diverticula is the most congenital anomalies of the gastrointestinal anomalies and it was found % in autopsy ser-ies. ( ) .it is asymptomatic generally. risk of complication is - %( ). preoperative diagnosis may not be done frequently, so to delay of operation may be serious complication.( )in our clinic, we explore meckel's diverticula, over(in female) and duodenum, if we do not see pü rü lant material on the appendix. results: patients with abdominal tb were diagnosed by laparoscopy and peritoneal biopsy in cases and by laparotomy in cases. from these patients we observed peritoneal tb in cases, intestinal tb in cases, mesenteric lymph nodes tb in case. at admission patients presented complications: cases with perforations and peritonitis, case with intestinal obstruction and cases presented as ileo-cecal ''tumors'' (solved by right colectomy); other surgical procedure performed was enterectomy with either entero-entero-anastomosis, either ileo-colic anastomosis. in abdominal tuberculosis ascites was present in cases. other common findings were weight loss ( cases), weakness ( cases), abdominal pain ( cases), anorexia ( cases) and night sweat ( cases). only patients had chest radiography suggestive of a new tb lesion. in those patients with peritoneal tuberculosis subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white ''miliary nodules'' or plaques, enlarged lymph nodes, ascites, ''violin string'' fibrinous strands, and omental thickening. biopsy specimens revealed granulomas, while ascitic fluid showed numerous lymphocytes. postoperative management was applied by the tb medical system. all patients were treated for months by specific drug therapy, with favorable evolution. pcr of ascitic fluid was positive for mycobacterium tuberculosis (m. tuberculosis) in all cases. introduction: abdominal trauma represents an important cause of morbidity and mortality in children. conservative management is preferred in blunt trauma with hemodynamic stability although there is a risk of intestinal damage when free fluid without solid organ injury is found in image studies. early laparotomy may be unnecessary in most cases but a delay in diagnosis of bowel perforation could lead to increased rate of complications. on the other hand the presence of a penetrating abdominal trauma is considered an absolute indication of laparotomy. we present five cases of abdominal trauma treated in our department in which laparoscopy proved to be an optimal diagnostic and therapeutic tool. material and methods: chart review of our cases and literature review results: three cases of blunt abdominal trauma underwent laparoscopy. we found a small bowel perforation in one case that was repaired by externalization of the jejuna loop by one of the ports. in the other two cases we found intestinal and mesenteric contusions that were treated by peritoneal drainage. two cases of penetrating trauma underwent laparoscopy. one of them presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. conclusion: in our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure in blunt abdominal trauma in stable children with abnormal abdominal examination and moderate free fluid and no solid organ injury in image studies, and it could be a first and sometimes definitive approach to minimal penetrating abdominal trauma. %) patients, biliary tract injury in ( . %) patients, multiple stones in the abdomen due to perforation in ( . %) patients, inadequate technical equipment in ( . %) patients, liver injury in ( . %) patient, intraoperatively detected umbilical hernia in ( . %) patient, uncontrollable bleeding in trocar entry site in ( . %) patient, insufficient insufflation in ( . %) patient, and unstoppable bleeding of arteria cystica in ( . %) patient, respectively. conclusion: although laparoscopic cholecystectomy is the golden standard of treatment in cholecystectomy, it involves the risk of conversion to open surgery. the rate of conversion to open surgery has been reported to be between - % in many series and is considered to be % on average. in our study, we found it as . %, a rate which is close to the rate reported in the literature. chief reasons for conversion from laparoscopic to open cholecystectomy include the difficult dissection of callot's triangle due to obscured anatomy and adhesions, gallbladder perforation, bleeding, the failure to produce pneumoperitoneum, gallbladder cancer, and injury in main biliary tracts and neighboring organs. the presence of pericholecystic adhesion and liquid in acute cholecytitis cases and the presence of edema in the tissue affect regional anatomy and complicate dissection, which increases the risk of gallbladder perforation. in our study, changes due to acute cholecytitis and difficulties in the preparation of callot's triangle ranked first among the indications for open cholecystectomy with a rate of . % ( / introduction: the most difficult decision in the management of the patients with severe necrotizing pancreatitis is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. recently a great deal of data has emerged suggesting that a pulsating irrigation stream delivered at high pressure and with a high flow effectively decreases bacteria, foreign bodies, and necrotic crushed tissue in wounds and decreases the incidence of resultant wound infection. this study evaluates the effect of inter pulse jet irrigation, used for the first time in open abdominal surgery. material and methods: twelve patients presenting proven infected/ non-infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological or laparoscopic drainage were prospectively offered necrosectomy using itner pulse jet irrigation. open necrosectomy and subsequent jet irrigation were performed using a midline laparotomy. in all patients, to tube drainages were placed during necrosectomy for continuous closed lavage. temporary abdominal closure using modified mesh-foil laparostomy was applied for relief of abdominal compartment syndrome. results: no intraoperative complications were recorded with a median operative time of +/- minutes. in cases two sessions of necrosectomy were sufficient to completely clear the necrotic tissues. another patients with extended retroperitoneal necrosis required irrigation procedures. necrosectomy using inter pulse jet irrigation was successful in all patients, and none required complementary surgical or radiological treatment. introduction: intra-abdominal hypertension (iah) and abdominal compartment syndrome (acs), have been described often in patients with abdominal trauma or after emergency abdominal surgical operations. we present patients with vomiting, meteorism, acute abdomen and acute respiratory insufficiency provoked by phytobezoars. aetiopathogenesis, symptoms and differential diagnosis are analyzed and a brief report of the literature is discussed. material and methods: three patients, were admitted to the emergency department of our hospital during the last year. all patients were presented with acute respiratory failure, abdominal pain, discomfort, meteorism and vomiting. the first patient, a years old man, alcoholic was admitted with meteorism, acute abdominal pain and discomfort. a fr nasogastric tube was introduced and the symptoms were remitted after gastric evacuation. the second patient suffered from bowel obstruction after closure of colostomy as a result of traumatic injury of sigmoid colon. a laparotomy was performed and a phytobezoar was revealed at the level of anastomosis. the last patient was presented with meteorism, vomiting and dyspepsia, as a result of enlarged gastric mass, revealed after endoscopy. results: gastric evacuation in the first patient revealed lt of fluid mixed with a smelly gas under pressure (iap = cmh o after evacuation) followed by washouts. laparotomy was performed in the second patient revealing a large phytobezoar at the level of anastomosis. mini laparotomy and gastrotomy in the third patient (after two unsuccessful gastroscopies) revealed large phytobezoars. introduction: the objective was the substantiation of using dcs tactics in wounded with ctmi. material and methods: in case of cranial injuries dcs tactics implied treating superficial wounds of skin, arrest of exterior bleeding and subsequent evacuation of the wounded within the first hours after getting trauma. in case of extremity injuries, dcs tactics implied first of all the operations on the occasion of gunshot injuries, including the arrest of bleeding, application of the external fixation apparatuses, application of temporary shunts for injured vessels. the burn wounds treating were carried out after helping the patient out of shock. in case of the wounded with chest injury in the presence of hemo-and pneumothorax, drainage of pleural cavity of silicone tubes with active air aspiration was fulfilled. in case of abdomen injuries after laparotomy abdominal cavity was cleaned and inspected including examination of the most probable sources of bleeding: liver, spleen, magistral vessels. on the background of unstable hemodynamics the abdominal cavity tamponage along the right and left side canals, supraliver and underliver space and small pelvis. results: thus, in accordance with dcs principles in case of ctmi, operations regarding gunshot injuries were made in the first turn, and operations connected with burns -in the second turn. the first were urgent operations. then, intensive therapy in the conditions of resuscitation unit. conclusion: the repeated operation of the second stage -final removal of lesions -was carried out after the condition of the wounded had been stabilized. introduction: the aa highlight the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. material and methods: man, age , rd pod after total gastrectomy with precolic reconstruction for gastric cancer (t n mxr ) in another institution. no significant past diseases. mechanically ventilated, in septic shock, with purulent drainage from right hemithorax and blue drainage from right abdominal upper quadrant, after ''methilene blue'' swallow. distended abdomen. relaparotomy with median frenotomy (pinotti) and damage control procedures for oesophagojejunal and cardiophrenic pleural sinus perforation by an esophagojejunal tube, with right pleural empyema, mediastinitis and peritonitis: primary closure of the perforation, washing and drainage of the pleura, mediastinum and peritoneum, delayed abdominal closure (dac, rotondo and schwab) and intensive care unit (icu). on th pod, revision of the mediastinum and peritoneum, no evidence of fistula: internal pleural drain retired, fibrin glue and collagen placed to protect the anastomosis, dac and icu. on th pod, anastomotic leak: a ttube (kehr) has been placed as a minimal drainage procedure; dac and icu. on th pod, descendent feeding jejunostomy and abdominal closure. on th pod, subfrenic abscess on ct scan: surgical drainage through the upper third of the previous closed laparotomy. on nd pod, intestinal suboclusion: drainage jejunostomy above the feeding one. on st pod, right pleural drainage: oesophagoscopy, t-tube removed and expansible silicon covered oesophageal prosthesis inserted, covering the anastomotic fistula. on nd pod, patient left the icu. results: on th pod, patient sent back to the institution where he has been operated first. on th pod, endoscopical removal of the prosthesis with baritated swallow control, with patient sent back home. conclusion: this case highlights the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. disclosure: no significant relationships. y. el-ashaal , a. hefny , y. saadeldinn , f. m. abu-zidan al-ain hospital, department of surgery, al-ain, united arab emirates, al-ain hospital, department of radiology, al-ain, united arab emirates, surgery, department of surgery, uae university, al-ain, united arab emirates introduction: acute gastric dilatation due to superior mesenteric artery syndrome in healthy subjects is extremely rare. herein we report its sonographic findings and highlight the value of point of care bedside ultrasound in such a case. material and methods: a -year old female was admitted to al-ain hospital complaining of epigastric pain of two days duration following excessive eating. she was nauseated but could not vomit. succussion splash was positive. bedside ultrasound has shown a hyperactive duodenum, a distended stomach compressing on the ivc, and a narrowed angle between the superior mesenteric artery and the aorta. these findings were confirmed by abdominal ct scan. the angle between the aorta and superior mesenteric artery was only â -p p . gastrographin follow through has shown complete obstruction of the third part of the duodenum. nasogastric tube immediately drained ml of yellowish fluid. results: five days later gastrographin follow through has shown free passage of the dye to the small intestine with significant reduction in the stomach size. the patient was discharged home in a good condition. conclusion: bedside ultrasound has proven extremely useful for both the diagnosis and management of this rare case. introduction: a rare and potentially lethal complication during right hemicolectomy material and methods: a year-old male, underwent a right hemicolectomy due to malignancy in the cecal region. during the operation the relatively constant venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas was injured, resulting in excessive haemorrhage. in the effort to manage the bleeding, the superior mesenteric vein (smv) was torn, and after multiple unsuccessful efforts to repair the vein, we finally had to ligate the smv. the operation was completed by typical right hemicolectomy and the abdomen was closed. five hours later the patient showed acute distention of the abdomen together with respiratory distress. due to increased abdominal pressure (> cm h o), the patient was taken back to the or. the small bowel was edematous, bluish but viable. the abdomen left open and was closed by using the vac. the patient was taken to the icu. six days later the small bowel returned to normal colour and thickness, but the generalized edema made the closure of the abdomen impossible. by day ten the patient was on full enteral feeding, and was taken to the or, where free partial thickness skin grafts were used to close the abdomen. results: the patient was extubated by day sixteen and was taken to the rehabilitation center. conclusion: accidental injury of the venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas, may prove a potentially life threatening condition. we present this case in order to point out this rare complication of right hemicolectomy. aimed to explore the influence of different surgical diagnosis groups on long term health status and to make comparisons with general population norms. material and methods: qol was measured in all surviving surgical icu patients admitted to a dutch teaching hospital between and . patient-reported data on qol were collected with the euroqol- d + after a mean follow up of (range - ) years. patient characteristics, surgical diagnosis group, length of icu stay and survival were prospectively registered. eq-utility scores (eq-us), eq visual analoge scales (vas) and prevalences of domain-specific health problems were calculated. the effect of surgical diagnosis group on eq-us/eq-vas was assessed by multivariable generalized linear regression analysis. logistic regression was used to explore the influence of surgical diagnosis group on domain specific health problems. long term quality of life of surgical icu patients was compared to an age-and sex-matched general dutch population using the t-test analysis. results: patients survived the icu and were available for follow up. in ( %) patients the health-related qol was measured. for all surgical groups combined, after - years nearly half of all patients still suffered from problems in the dimensions mobility ( %), usual activity ( %), pain ( %) and cognition ( %). compared to the age-and sex matched general dutch population hrqol was worse with a difference of . on the eq utilities score (range - ). oncological surgery patient had the best (eq-us . ) and vascular patients had the worst (eq-us . ) hrqol. trauma (odds ratio between . - . ) and vascular surgery ( . - . ) showed significantly increased prevalences of problems in mobility, self-care, usual activities and cognition. conclusion: more than years after a surgical icu admission, quality of life of this patient population is largely reduced. many patients still suffer from a variety of health problems, including decreased cognitive functioning. treatment advances should be made to reduce the current health deficit of surgical icu survivors compared to the general population. disclosure: no significant relationships. u. sekmen , g. altaca , s. aktas kalayci , g. moray general surgery, baskent university, ankara, turkey, general surgery, baskent university, ankara, turkey, internal medicine and division of gastroenterology, baskent university, ankara, turkey introduction: predicting the prognosis in severe acute pancreatitis is cruciate in order to constitute effective treatment strategies. material and methods: thirteen consecutive patients admitted with the diagnosis of severe acute pancreatitis according to glasgow or ranson criteria were evaulated. we searched the prognostic values of age, gender, etiology of pancreatitis, comorbidity and labarotory values and their affects on complications and length of hospital stay. results: mean age was , years (range: - yrs). etiology was biliary in patients ( after ercp). acute cholecystitis was also present in patients. patients had diabetes mellitus. two patients had percutaneous cholecystestostomy. five patients had ercp at a mean of , days after admission. cholecystectomy was performed in patients, either at the first admission (n: ) or after - weeks. mean wbc, alt, ast, and ldh values on admission and mean highest hscrp levels and mean lowest serum calcium (ca) levels in the first hours were /mm , u/l, u/l, u/l, and mg/l and mg/dl, respectively. pancreatic necrosis ( , %) was diagnosed by computerised tomography in patients ( / in diabetics, / in nondiabetics); a total of patients ( %) had systemic complications. mean ldh ( u/l vs u/l) and lipase levels ( u/l vs u/l) were higher in patients who developed necrosis, though not statistically significant. other parameters were similar in patients with or without necrosis. two patients who had pancreatitis due to ercp underwent pancreatic necrosectomy. median hospital stay was days (range: - days). all patients survived. mean highest hscrp and lowest ca levels in the first hours correlated significantly with the hospital stay (r: . p: . for hscrp, and r: - . p: . for ca). conclusion: although we have a limited number of patients, we may conclude that high levels of ldh, lipase, hscrp and low levels of ca can be used as predictive factors for severe pancreatitis. pancreatitis seen after ercp and in diabetic patients tend to be more severe. abdomen. abdominal imaging reveals persistent bleeding and multiple bone lesions compatible with bone hemangioma with low blood platelets count -kasabach-meritt syndrome. patient is transferred to a central hospital for arterial embolization of the right hepatic artery that is not effective. the authors describe surgical control of the bleeding without liver resection. second look surgery was undertaken with removal of hepatic packing and pringle's manoeuvre with temporary control of the haemorrhage with haemostasis and ligation of the right hepatic artery. it was needed several surgery's more with additional packing, haemostatic mesh and haemostatic products in order to control the bleeding. the patient was proposed for liver transplant during the process but was not accepted. introduction: management of splenic injury has evolved over the past years. nonoperative management has gained currency, first in children and after in adults. material and methods: we present a case of a years-old man who falled for m, haemodinamically stable, presenting pain on the left part of thorax and upper abdomen. results: the patient fall for m hours before the arrive in our er; he was haemodinamically stable (bp= / mmhg, av= bpm) and presented pain on the left thorax and left hypocondrium. laboratory showed , g/dl haemoglobin. radiologic test: laterally th left rib fracture. ct scan revealed iv grade spleen injury and perisplenic hemoperitoneum. we choosed non-operative managementafter days ct scan showed reduced dimensions of dilacerated spleen injury and no hemoperitoneum. the patient status was stable during the days hospitalisation. imagistic control after month: homogenous spleen structure. conclusion: the haemodinamic status of the patient is the most reliable criteria for non-operative management, not ct aspect of the injury. years old) submitted to upper partial splenectomy for blunt trauma. residual spleen after surgery was / and / respectively. ceus was preceded by standard b-mode us with color flow mapping in all cases; videoclips of each exam were stored for forensic medicine issue too. mean time for ceus exam was - minutes. results: ceus allowed to recognize regular perfusion of the residual spleen in both patients. conspicuity of ceus imaging was high and impressive. homogeneous complete distribution of the contrast medium in the parenchyma was observed on day in both pts. ceus follow-up on day and did not add any supplementary information. pts were discharged on day and day respectively, without indications for vaccinations or antibiotic prophylaxis. conclusion: ceus is an effective method for assessing perfusion of the residual spleen after partial splenectomy. ceus can be performed bedside by the surgeon in the early po period or on an outpatient basis. imaging interpretation is immediate and distribution of the contrast medium assure about viability of the splenic tissue. ceus imaging allowed us to omit prophylactic vaccinations. it is the first description of the use of ceus in this particular setting. introduction: injuries to the abdominal visceral vessels are uncommon but devastating entities that incur extremely high rates of mortality.the rarity of these injuries prevents many trauma centers and trauma surgeons from developing a significant knowledgement learning curve. the authors describe a case with abdominal visceral vascular abdominal blunt trauma, presented with laceration in the confluence of inferior mesenteric vein and splenic vein, laceration of the hepatic artery associated with hepatic hematoma, periduodenal and peripancreatic hematoma. the routine principles of vascular surgery were applied to the management of these visceral blood vessels injuries :adequate exposure, proximal and distal control, dé bridement of the vessel wall,meticulous arteriorraphy and venorraphy with fine monofilament vascular sutures and early instituition of damage control resulting a successfull repair. material and methods: the authors made a review of several large series in the literature wich are also consistent with a low incidence of visceral vessel injuries. vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment a broad spectrum of surgical specialities are involved in the ressuscitative phase of trauma care including general, trauma, thoracic and vascular surgery . despite a relatively low incidence of vascular trauma in portugal, the results are satisfactory because of active and early management by surgeons on call, weather with vascular training or not, treating all kinds of vascular surgical emergencies. a trauma and emergency surgical speciality is a challenge. results: little information describing the first repair or ligation of any visceral vessel injuries can be found in the literature. visceral vascular injuries carry a significant mortality rate. vascular injury poses a small but significant challenge in portugal trauma care. opportunities such as better practise guidelines and minimum standars will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. training in the management of vascular trauma surgery with integration of vascular and general surgeryin trauma care should optimize outcomes. conclusion: from reviews of large series dealing with the management of abdominal vascular injuries, the incidence can be estimated to be between . % to . %of all vascular injuries. few data are available describing the mortality rate for patients with portal veins injuries. te author's vision is that all vascular and general surgery trainees would eventually undertake the definitive surgical trauma care course and improve outcomes and reduce mortality. introduction: high rates of intra-abdominal pressure, has been proved to increased mortality, especially in multi-trauma patients followed laparotomy. multiple organ failure syndrome (mofs), derived by intra-abdominal hypertension, has been called abdominal compartment syndrome (acs), the epidemiology and the characteristics of which, have not been thoroughly determined. introduction: intercostal pulmonary hernias are rare and mostly resulting from complications related to the chest trauma.the authors report a case of traumatic intercostal pulmonary hernia in a -yearold man. he was admitted to the hospital as a traumatic patient after a motor-cycle accident . material and methods: beside multiple polytraumatic injuries the patient had a blunt injury to the left chest.physical examination revealed a bulge on palpation of the left chest wall.computed tomography (ct) scan of the chest revealed the protrusion of lung tissue outside the intercostal space.size of hernia, incarceration and respiratory insufficiency mandate immediate surgical intervention.postoperative course was uneventful, and there has been no sign of recurrence of hernia. results: post -traumatic lung herniation through a defect in chest wall is an uncommon injury .various methods of tratement and repair have been described, including both purely thoracoscopic to full open techniques.the authors repaired a case using a minithoracotomy. conclusion: lung hernia is an uncommon entity defined as the protrusion of pulmonary tissue and pleural membranes through defects of the thoracic wall.chest trauma is the most common cause.timely surgical intervention is critical to favorable patient outcomes.effective management, surgical approaches and repair of thoracic injuries are discussed and the available literature. of the hernia from the outside, dé bridement and closure layer-bylayer with maxon- was performed. the postoperative course was uneventful. conclusion: a tawh after blunt trauma is a rare entity. the reported incidence of acute hernia ranges from ,%- , % . in our case the tawh was already diagnosed in the trauma room. mahajna et al. reported the case of herniation of the right colon with vessel strangulation, which wasn't seen in the primary survey. a right hemicolectomy had to be performed on the nd posttraumatic day. in our case we decided intraoperatively to perform a primary reconstruction of the abdominal wall without mesh repair. the potential advantage of a mesh implantation lies in the augmentation of the abdominal wall, thereby potentially lowering the risk of incisional hernia. however, the benefits of such augmentation should be cautiously weighed against the risk of foreign body contamination when resecting bowel during the same operation. introduction: impalement is an uncommon and spectacular injury, which combines aspects of both blunt and penetrating trauma. impalement injuries from falls are rarely seen, because most of the patients die at the scene of injury. we present an unusual case in which a patient survived a perineal impalement after a fall.with reference to our latest case and discuss the initial management and the operative treatment of this rare injury according to a literature review. material and methods: a young man was working on a construction site when he suddenly lost his footing and fell m off a scaffold. he orientated such that he landed in a sitting position on a vertical aluminium u-tube, which penetrated his perineal region and stucked. upon arrival at the emergency room he was in stable condition, intubated. after the initial treatment and diagnosis according to atls a ct of the abdomen was performed; it showed a penetrating tube perianal left, from caudal into the cavity of the pelvis, the point of the tube stucked in the sacrum -in the hole of neuroforamina s . there was no intraabdominal or laceration. the patient was taken to the operating room in stable condition. the laparotomy was performed. there was no laceration detected, explorating the praesacral cavity brought out a profuse bleeding of the main pelvic vein. after the active bleeding was stopped the tube was removed from the outside. after lavage and positioning of drains, a protective loopileostoma was placed to avoid further contamination. the perineal wound was carefully debrided, drains were inserted and the wound was not completely closed by adapting stitches. a wash-out of the colon was performed, he received antibiotics and the perineal wound was rinsed daily. he was dismissed days post-trauma. results: impalement injuries result when a solid object pierces a body cavity or extremity. the object often remains fixed within the body. this case report showed a positive outcome. impalement injuries are impressive but also rare, so it is important to show an algorithm in management of such injuries. the object should be in situ during transport. in large or immoveable objects, the impaling device should be cut just above the skin. the management of the injuries depend on the particular body region of penetrating. perineal impalement often appear quite complex. these injuries may need the assistance of gynecology and urology surgery praesacral drainage and distal rectal washout is recommended. wound care is essential in the care of impalement injuries. the skin should generally left open. even uncomplicated wounds have to be treated with antibiotics. conclusion: impalement injuries are rare and treating is a challenge for the surgeon. the degree of the injury determines the functional result. strict adherence to the transportation and management principles outlined in this paper are necessary to decrease morbidity and mortility disclosure: no significant relationships. introduction: the insertion of foreign objects into the anus and rectum is a well-known phenomenon. rectal foreign bodies can present a difficult diagnostic and management dilemma. . a foreign body may be inserted by a doctor for diagnosis or treatment like rectal thermometer, enema tubes or anal packs, by the patient for self eroticism or by a third party as a result of assault or sexual activity, but the most common cause for insertion of a foreign body is sexual stimulation. , , . anorectal foreign bodies are more common in men than in women . they can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, rectal bleeding and can be associated with perforation or delayed injury. material and methods: in this study, in the ten years from to , we used the medical records of patients with foreign bodies in the rectum have been diagnosed and treated,at izmir teaching and research hospital,izmir. results: all patients were men.they ranged in age from to (mean age ).two of these patients had impulse body spray, two patients had bottle, one patient had eggplant,one patient had brush and one patient had wishbone (after oral ingestion) in the rectum. five objects were removal transanally extracted by anal dilatation under general anesthesia.two patients required laparotomy.one patient of these the object was high lying in the rectosigmoid and performed laparotomy.the object was removal transanally extracted by abdominal manuplation.one patient had a intraperitoneal rectosigmoidal perforation.the perforation was treated by primer suture, proximal colostomy and appropriate antibiotic therapy. routine rectosigmoidoscopic examination is performed after removal.one patient had perforation of the rectosigmoid and had lacerations of the mucosa. no patient had a mortality. conclusion: foreign bodies in rectum should be managed in a wellorganized manner. the diagnosis is confirmed by means of plain abdominal radiographs and rectal examination. manual extraction without anaesthesia is usually only possible for very low lying objects. patients with high lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction.open surgery should be reserved only for those patients with perforation, peritonitis and impaction of the foreign body. results: definitive pathological examination confirmed the diagnosis of pancreatic pseudocyst. the patient postoperative outcome was unremarkable and was discharged from the hospital at the seventh postoperative day. conclusion: retroperitoneal and ''well protected'' location implies that a high energy traumatism is needed to injury the pancreas. the fact that in this case a non-classical injury mechanism has occurred, makes the diagnosis more difficult to reach. pancreatic pseudocyst is the most frequent complications in this type of traumatisms. effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch uncomplicated mason type-ii and iii fractures of the radial head and neck in adults. a long-term follow-up study surgical treatment of intra-articular fractures of the distal part of the humerus. functional outcome after twelve to thirty years disclosure: one or more of the authors received funding from the small bone innovations (dr) fractures of the neck of the talus. long-term evaluation of seventy-one cases tuberosity malposition and migration: reasons for poor outcome after hemiarthroplasty for displaced fractures of the proximal humerus tuberosity osteosynthesis and hemiarthroplasty for four part fractures of the proximal humerus abdominal -mdct for suspected appendicitis: the use of oral and iv contrast material versus iv contrast material only socioeconomic factors, medicolegal issues, and trauma patient transfer trends: is there a connection? are patients being transferred to level-i trauma centers for reasons other than medical necessity? the delaware trauma system: impact of level iii trauma centers improving outcomes in a regional trauma system: impact of a level iii trauma center jupiter -metaanalysis: nondisplaced scaphoid fractures. operative vs. nonoperative management(update to nov dodds -minimally invasive management of scaphoid nonunions chess -a biomechanical analysis of intrascaphoid compression using the herbert scaphoid screw system. an vitro cadaveric study is the mortality rate for septic shock really decreasing? systemic inflammation after trauma in vivo effects of a synthetic -kilodalton macrophage-activating lipopeptide of mycoplasma fermentans after pulmonary application alveolar macrophages from septic mice promote polymorphonuclear leukocyte transendothelial migration via an endothelial cell src kinase/nadph oxidase pathway macrophage inflammatory protein- alpha mediates lung leukocyte recruitment, lung capillary leak, and early mortality in murine endotoxemia fracture-dislocation of the hip joint. the nature of the traumatic lesion, treatment, late complications, and end results cervical spine trauma in the pediatric patient spinal injuries in children and adolescents long-term clinical and radiographic outcomes after open reduction for missed monteggia fracture-dislocations in children elastic stable intramedullary nailing as alternative therapy for pediatric monteggia fractures unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing delayed radial paralysis after monteggia fracture-a case report, unfallchirurg a simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures a fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation an analysis of different types of surgical fixation for avulsion fractures of the anterior tibial spine modified arthroscopic suture fixation of a displaced tibial eminence fracture tibial spine fractures in children fractures of the tibial spine in children seventeen-year follow-up of a reattachment of a nonunited anterior tibial spine avulsion fracture arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method the mechanism of clavicular fracture: a clinical and biomechanical analysis functional outcome following clavicle fractures in polytrauma patients evidence-based orthopaedic trauma working group. treatment of midshaft clavicle farctures: systemic review of fracturese: on behalf of the evidence-based orthopaedic working group harnroongroj t, vanadurongwan v. biomechanical aspects of plating osteosynthesis of transverse clavicular fracture with and without inferior cortical defect autologous bone versus calcium-phosphate ceramics in treatment of experimental bone defects iliac crest autogenous bone grafting: donor site complications clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation augmented with iliac crest aspiration literature review of current techniques for the insertion of distal screws into intramedullary locking nails a new fluoroscopy-free navigation device for distal interlocking screw placement disclosure: we all are surgeons at gregorio marañ ó n hospital, madrid. dr. turegano is the chief of the emergency surgery department. references: -nandapalan and al factors related to mortality in inferior vena cava injuries: a year experience disclosure: we certify that all our affiliations with or financial involvement (employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending) with any organization or entity with a financial interest. references: . blaisdell, f.w. the pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. references: robinson cm evaluation of consecutive patients with the extended data set of the standardised audit for hip fractures in meniscus allograft transplantation: a current concepts review homologous meniscus transplantation: experimental and clinical results cell survival after transplantation of fresch meniscal allografts: dna probe analysis in a goat model freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale meniscus replacement with bone anchors: a surgical technique meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations clinical evaluation of arthroscopic-assisted allograft meniscal transplantation knee joint biomechanics following arthroscopic partial meniscectomy an evaluation of a shockroom located ct scanner: a randomized study of early assessment by ct scanning in trauma patients in the bi-located trauma center north-west netherlands (react trial) overlooked spine injuries associated with lumbar transverse process fractures frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal ct in patients with trauma traumatic lumbosacral dislocation: report of two cases references: prevalence of suicide ideation and suicide attempts in nine countries uptake and intracellular distribution of various metal ions in human monocyte-derived dendritic cells detected by newport green dcf diacetate ester biomechanical analysis of bicondylar tibial plateau fixation:how does lateral locking plate fixation compare to dual plate fixation? operative treatment of tibial plateau fractures.:five to years follow-up results treatment of high energy tibial plateau fractures with half ring external fixation combined with minimal internal fixation. nan fang yi ke da xue xue bao disclosure: no significant relationships de smet l, debeer p, degreef i. fixation of a periprosthetic humeral fracture with ccg-cable system results of non-operative and operative treatment of humeral shaft fractures. a series of cases complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. surgical technique the anteromedial facet of the coronoid process of the ulna ring d, doornberg jn. fracture of the anteromedial facet of the coronoid process. surgical technique broberg ma, morrey bf. results of treatment of fracture-dislocations of the elbow disclosure: one or more of the authors received funding from the small bone innovations (dr perilunate and axial carpal dislocations and fracture dislocations evaluation of the spanish versió n of the dash and carpal tú nel síndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability philadelphia: w. b. saunders company; . p. - . . meyer pr. complications of treatment of fractures and dislocations of the dorsolumbar spine no significant relationships. references: . general medical council. consent: patients and doctors making decisions together is informed consent effective in trauma patients is informed consent in trauma a lost cause? a prospective evaluation of acutely injured patients' ability to give consent factors affecting the quality of informed consent the impact of objective assessment and constructive feedback on improvement of labrascopic performance in the operating room united arab emirates, medical education at the main trauma hospital. results: patients were studied ( . % males) having a mean age of . years. % of patients were from the indian subcontinent and % were uae nationals. % of patients presented immediately following injury. ambulances brought only % of the patients. % of trauma took place in the street or highway, % in work places and % at home. the mechanisms of injury were road traffic collision in % and falls in %. % of injuries were to extremities, % to head, face and neck, and % to chest. the mean iss was . . the mean (range) hospital stay was . ( - ) days; ( %) patients needed icu admission of whom ( . %) died. the mean icu stay was . days (range - ). overall mortality was ( . %). conclusion: road traffic collisions and falls are the main cause of trauma admissions in al ain city. extremities, head, neck, face and chest are the main body regions sustaining injuries. disclosure: no significant relationships hip fractures in the elderly: a world-wide projection disclosure: no significant relationships. references: d. ring et al.: predictors of acute carpal tunnel syndrome associated with fracture of the distal radius pm non-surgical treatment of the distal radial fracture. is there an advantage in immobilization in degrees dorsiflexion compared to immobilization in a neutral position? janzing , l. horta emergency department, viecuir medical centre the netherlands introduction: according to the literature immobilization of collespoints where radiological (dorsal dislocation, radial inclination), functional, the necessity for surgical intervention a comparison of methods of plastic cast fixation in treatment of loco classico radius fracture. a prospective, randomized study, unfallchirurg pm buzzsaw injuries: mechanisms of damages and predisposing factors r. ziegler , w. knopp woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools references: beasley ls, vidal af. traumatic patellar dislocation in children and adolescents: treatment update and literature review long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum -year follow-up mri of traumatic patellar dislocation in children reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children injuries to the inferior pole of the patella in children disclosure: no significant relationships pm results of electromagnetic fields in healing progression of delayed union in the lower extremities the effect of low-frequency electrical fields on osteogenesis references: complex trauma of the limbs with vascular injuries-olivera lupescu, mihail nagea carcinoid tumour of the appendix:an analysis of consecutive emergency appendectomies tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy. dig. liver dis at perforated ulcer treatment, suture of the place of prefotation was used at ( , %) people, billroth ii stomach resection at six ( , %), suture of the place of prefotation with psv at three ( , %), and billroth i stomach resection at one ( , %) patient. postoperative complications were noticed at ( , %) people. we had postoperative mortality at four ( , %) patients. recidive ulcer was registred at ( , %) patients who were surgically treated for perfored ulcer before. conclusion: ulcer perforation is an acute complication of the ulcer disease that appears most frequently after bleeding and which usually requires surgical treatment. references: . behçet disease complicated by a perforated ileal ulcer presenting as an acute abdominal emergency gastro-duodenal ulcers with perforation caused by short-term acetylsalicylic acid ingestion: case report culafiÄ à d, matejiÄ à o perforated gastroduodenal stress ulcer melinte c, dragomir c pubmed -indexed for medline] spontaneous rupture of the spleen as immediate complication in autologous transplantation for primary systemic amyloidosis delayed splenic rupture as a cause of haemoperitoneum in a capd patient with amyloidosis boluda garcà a f, calvo català ¡ j, campos fernà ¡ndez c, parra rà denas jv, gonzà ¡lez cruz mi laparoscopic cholecystectomy for acute cholecystitis disclosure: no significant relationships. references: . pokorný j. et al. urgentní medicína, . st edition: praha, galé n . stetina et al. medicína katastrof a hromadný ch neštÄ >stí pt perforation of oesophagojejunal anastomosis by venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in cadavers pt validation of fournier's gangrene severity index score (fgsis) general surgery dobrzanska l, newell r. readmissions: a primary care examination of reasons for readmissions of older people and possible readmission risk factors pt spontaneous rupture of giant cavernous hemangioma of the liver in a patient with systemic hemangiomatosys and kasabach-meritt syndrome. an interactive and multidiscipline case b general surgery general surgery portugal introduction: hemangiomas are frequent benign tumors of the liver nonoperative management of blunt splenic and liver injury is ct grading of splenic injury useful in the nonsurgical management of blunt trauma? management of blunt splenic trauma: ct contrast blush predicts failure of nonoperative management references: . ochsner mg. factors of failure for nonoperative management of splenic injuries associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management introduction: aim. to establish the diagnostics and management trauma, ( , %) -head trauma, ( . %) -limbs injuries, and ( %) -severe shock. in cases the splenic injury was initially manifested - ( . %), and in ( , %) cases the clinical signs developed later (p < . ) practice management guidelines for the evaluation of blunt abdominal trauma: the east practice management guidelines work group diagnostic accuracy of surgeonperformed focused abdominal sonography (fast) in blunt paediatric trauma surgeon-performed bedside organ assessment with sonography after trauma (boast): a pilot study from the wta multicenter group disclosure: no significant relationships. pt incidence of abdominal compartment syndrome in patients with multiple injuries. a single institution experience koulas , o. mousafiri hatzikosta general hospital, ioannina, greece, intensive care unit, g. hatzikosta general hospital intensive care unit, g hatzikosta general hospital delayed presentation of traumatic parasternal lung hernia management of retained colorectal foreign bodies:predictors of operative intervention disclosure: no significant relationships. treatment. disclosure: no significant relationships. references: .demetriades d, velmahos g. technology-driven triage of abdominal trauma: the emerging era of nonoperative management management of high grade renal trauma: -year experience at a pediatric level i trauma center pt blunt abdominal trauma. year experience in our department greece ( , %), without spinal fractures. resection/anastomosis was permorbidity. in first group, there were deaths ( , %), cases due to intestinal injuries. the second group (without seatbelt sign) had deaths ( , %), none due to intestinal injuries but related with multiple thoracic and cranial lesions. conclusion: in this study we found a consistent evidence that ''seatbelt sign small-bowel and mesentery injuries in blunt trauma mortality reduction with air bag and seat belt use in head-on passenger car collisions disclosure: no significant relationships. references: management strategies in isolated pancreatic trauma disclosure: no significant relationships. references: enterocutaneous fistula complicating trauma laparotomy: a major resource burden the american surgeon staged management of giant abdominal wall defects injured patients -documentation of black spots j. heinzmann , u. culemann , t. pohlemann universitä tsklinik des saarlandes, klinik fü r unfall-, hand-und wiederherstellungschirurgie, homburg, saar, germany, trauma-, hand and reconstructive surgery, university of saarland, homburg, saar, germany, klinik fü r unfall-, hand-und wiederherstellungschirurgie, universitä tsklinikum des saarlandes, homburg, saar, germanyintroduction: nonunions of the tibia represent a complex problem, particularly if they occur at the distal third of the tibia. the aim of the study was to evaluate a standardized treatment concept to manage different types of nonunions of the tibia with regard to their location within the tibia. material and methods: prospective, non randomised study ( / - / ); nonunions of the diaphyseal and metaphyseal tibia (ao type / ); standardized treatment concept: diaphysis: reamed intramedullary nailing; dia-metaphyseal junction and pilon: lcp with a minimal invasive approach or an open approach plus bone grafting from the iliac crest; infected nonunions: external fixator. analysis parameters: demographic data, fracture type (ao classification), primary surgery, healing process, time to union (radiographic), complications. results: forty-eight patients ( m, f; mean age , y) with hypertrophic (primary surgery: x nail, x external fixator) and atrophic nonunions of the tibia (primary surgery: x nail, x plate, x screws and x external fixator) were included in the study. fifteen tibial nonunions had been primary treated in our department, patients had been admitted from other hospitals. seventy-three% of all nonunions were located at the distal third of the tibia ( % at the diaphyseal-metaphyseal junction, ao-classification type ; % at the pilon, ao-classification type ). seventy-five% of the dia-metaphyseal fractures and % of the pilon fractures were primary treated with an intramedullary nail. the mean time between injury and nonunion-surgery was , ( - ) months. follow up: / patients ( %) for an average time period of , months; union-rate: / (hypertrophic nonunions / ; atrophic nonunions / : re-nonunions each). complications: death by lung embolism, re-nonunion (united after second surgery), implant (plate) loosening with the need of reosteosynthesis, x varus malalignment, x valgus malalignment, x peroneal nerve lesion. conclusion: especially the distal third of the tibia still represents a high risk area for nonunions. impaired perfusion, thin soft tissue coverage, as well as the rising number of nailing even of distal tibial fractures are some of the causes. we think that the herein introduced treatment concept is effective to manage tibial nonunions. thus, the union-rate in this study population was % , . an adequate primary osteosynthesis as well as the prevention of extensive soft tissue damage during surgery are mandatory to improve the outcome of tibial fractures. besides, new therapy options as e.g. the application of growth factors and ultrasound have to be considered also for the treatment of tibial nonunions. g. heinrichs , a. p. schulz , e. wilde , r. oheim , c. jü rgens trauma&orthopedics, university lü beck, lü beck, germany, trauma&orthopaedics, university lü beck, lü beck, germany, trauma + orthopaedics, university lü beck, lü beck, germany, trauma&orthopedics, university lü beck, hamburg, germanyintroduction: high energy tibial head fractures with bicondylar involvement have a much poorer outcome compared to the other forms of tibial head fracture. soft tissues are almost allways compromised. bilateral plating carries the risk of soft tissue and bone infections. due to loss of reduction, steps or gaps might remain in the joint surfaces. aim of this study was to evaluate the clinical and radiological outcome of schatzker , and six type fractures treated with locked osteosynthesis plating. material and methods: between january und january we treated patients suffering from a tibial head fracture. in cases osteosynthesis was performed with the use of an angular stable implant, this group forms the study population. indication for locked screw plates were bicondylar fractures treated unilateral to avoid bilateral approach with double-plate osteosynthesis and tibial head fractures with a shaft involvement (schatzker ). follow-up was performed after an average of . months after surgery. we treated male and female patients with an average of . years of age ( to years). there were no patients with open fractures or primary nerve injury included in this study. operative treatment was performed after an average of . days after trauma. we used an angular stable plate fixator made from pure titanium (tifixÒ, litos, hamburg/ germany). the plate is consisting of the softer titanium grade ; the screws are made from harder titanium grade .results: there was one case of a postoperative peroneal nerve lesion with spontaneous regression after two weeks. no postoperative wound necrosis or infection occured. all patients showed bony consolidation after a mean of . weeks as judged by radiographs. additional autologous bone transplantation was not necessary. we did not observe any secondary loss of reduction or loosening of the internal plate fixator when comparing direct postoperative radiographs to those at follow up. rom of the knee did not show any restriction compared to the opposite side in patients. cases showed mild and cases a remarkable restriction of rom compared to the not injured side.applying the rasmussen score, cases achieved a good and very good result. patients had to be judged as moderate and as poor conclusion: unilateral plate fixation for the treatment of bicondylar tibial head fractures seems to offer advantages in particular concerning infection rate and implant failure in the treatment of tibial head fractures. results: the adjacent level th-l fracture was found in . % ( / patients) in kyphoplasty group and in % ( / patients) in vertebroplasty group. we did not found any serious complication but established postoperative bmd loss. we did not found any intradiscal cement leakage in cases with adjacent level fractures. intraoperative correction of kyphosis was better achieved in kyphoplasty group; pain relief was similar in both groups.conclusion: natural process of further bone loss seems to be the most influent factor for future compression fractures in elderly patients. trauma patients represent a challenge in terms of obtaining informed consent as they are often in significant pain and maybe under the influence of strong medication at the time of the consent process. we designed a prospective, randomised un-blinded control study to test the hypothesis that there would be no difference in the ability of trauma patients to recall details of the consent process whether the patients were given verbal compared with verbal and written information.material and methods: a consecutive cohort of trauma patients presenting to a major teaching hospital were recruited and randomised into two groups. group a received structured verbal information only. group b received structured verbal information and written information about the proposed procedure. all patients were interviewed within the first post operative week (mean . days) and scored on their ability to recall key facts given in the original consent interview. results were analysed using the mann-whitney u test.results: patients have been recruited. information recall was significantly improved in the group receiving written information (mean questionnaire score % vs % for verbal information alone, p= . ). patient satisfaction with the consent process was also significantly improved in the group receiving written and verbal information, with . % of patients reporting they understood the risks of surgery when they signed the consent form, compared to . % who received verbal information alone (p= . ).conclusion: written information improves patient recall of the consent process. it is a simple, cost-effective intervention with high patient acceptability. introduction: survivorship of second hip fracture patients is worse than initial hip fracture patients. however, previous studies included in-hospital mortality. the actual survivorship of initial hip fracture patients with subsequent second hip or major long bone of extremity or vertebral body fracture by exclusion of in-hospital mortality patients have not been studied. we aim to compare the actual survival of initial hip fracture patients with and without second hip or subsequent major fracture. in addition, risk factors, mortality causes, and hazards ratio of each fracture groups were studied. material and methods: in - , after exclusion of in-hospital mortality patients, initial hip fracture patients were reviewed and divided into four groups. group i, ii, iii, and iv were initial hip fracture patients with second hip, subsequent major long bone of extremity, vertebral body fracture, and without any subsequent fractures, respectively. we set group i, ii, and iii as study groups comparing the data with group iv (control group). age, gender, mobility-status, co-morbidity, causes of death, and survival years after hospitalization of last fracture treatment of each group were recorded. actual survival rate and risk factors difference between initial hip fracture with and without subsequent fracture were analyzed by chi-square test. hazards ratio differences among the groups were analyzed by cox regression models.results: there were ( . %), ( . %), ( . %), and ( . %) subjects in group i, ii, iii, and iv respectively. at one-year and one-to-five year mortality of group i were . % and . %, group ii were . % and . %, group iii were . % and . %, and group iv were . % and . % respectively. statistical analysis by using chi square test of one-year mortality and one-to-five year mortality rate showed no significant difference among four groups (p > . ). but from cox regression analysis, second hip fracture produced significant hazards ratio as . (p = . ). the actual survivorship of initial hip fracture patients with second hip or other subsequent fracture were not different from patients who have only one hip fracture. however, special care should be focused in patients with second hip fracture which produced significantly highest hazards ratio for mortality.reduction or redislocation after one week of treatment. due to the lack of sufficient patient data a statistical analysis was not carried out. it was obvious that the dorsal dislocation after reduction was worse in the dorsiflexion group. there was no obvious difference in radial inclination or functional outcome between the two groups. conclusion: mainly the dorsal inclination was worse in the degrees dorsiflexion group. a possible explanation for these results is the technique used when modeling the plaster cast. in our hands immobilization in dorsiflexion yielded poorer results then immobilization in a neutral position. due to the poor results the study was terminated prematurely. the traumatic patellar luxation in adult patients is operatively treated with medial reefing and lateral release. the value for the treatment of adolescents is still discussed controversially in literature. the aim of the present study was to evaluate the efficacy of the minimal-invasive treatment of traumatic patellar luxation in adolescents. , that was treated with acute angular shortening using a monolateral ao fixator followed by gradual correction using the taylor spatial frame (tsf). the conversion in the tsf was achieved in exchanging only two half-pins. results: the deformity was anatomically corrected without any soft tissue complications. the fixator was worn for weeks under full weight bearing while the actual correction took only days. we did not see any typical external fixator complications like pin trac infection. conclusion: acute angular shortening can lead to direct soft tissue closure without any additional plastic surgery. the accuracy the the fixator allows the gradual anatomical reduction of the fracture and simplifies the correction of the mostly multiplanar deformities. when the surgeon is familiar with the tsf even a primary treatment of such fractures could be recommended. the image control (plain x-rays, ct) revealed and definitively determined whether a two-part or three part triplane fracture in the distal tibial physis were present, the amount of the displacement, and the co-existed fracture of the fibula. the principal goal must be the anatomical reduction of the fracture initially closed and in failure opened. an open reduction and fixation with steinmann via anterior approach followed. a long-leg cast worn for initial weeks, followed by a short-leg cast for weeks. results: at a minimum of fourteen months of clinical follow -up all patients lacked complaints and had full range of motion in ankle.conclusion: these injuries occur in the adolescent age group generally slightly younger than the child with a tillaux fracture, needed good image control (ct) and must reduced anatomically and fixed. disclosure: no significant relationships. it is necessary in - % of patients. to provide dynamisation using conventional methods, it is necessary to perform one additional surgery. in this presentation it is shown one new method of selfdynamisation. material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept (in % of patients), which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - the severity of injury was measured by the injury severity score (iss). the outcomes for categorical variables were tested using v test and a significance level at p < . was maintained. delayed complications were defined as any complication directly attributable to the splenic injury that occurred more than hours after injury. the following data was retained: age, sex, mechanism of injury, iss, number of icu days, overall length of stay, number of blood units transfused, day of operation and discharge status. results: our study found , % incidence of delayed complications after nom. these complications include delayed hemorrhage ( cases), splenic artery pseudoaneurysm ( ) and splenic abscess ( case). the need for operation due to ongoing bleeding was retained in following situations: more than u of blood to maintain a hb higher than g/dl, systolic pressure to less than mm hg despite resuscitation and evidence of peritoneal signs. of the patients failing nom, % failed between days and and % in the first week. in all cases a splenectomy is performed with no mortality rate. the results of this study indicate independent risk factors of failure of nom: a high ct grade of splenic injury (grade iii and above) and a transfusion with more than u of blood. results: results : out of the patients suffering of liver injuries patients had grade , and grade liver injuries and were treated conservatively. patients had grade and liver injuries and were operated. patient who was initially managed conservatively was operated due to inability to control the blood loss. out of the patients suffering injuries of the spleen, were grade and grade and were successfully operated and were grade and and were treated conservatively. all patients suffering of injuries of the retroperitoneal space, unilateral kidney injuries and injuries of the hypogastrium were managed conservatively. conclusion: blunt abdominal injuries can be managed successfully and safely by conservative treatment whenever it is allowed by the circumstances. the ct scan is a very sensitive diagnostic scanning, capable of diagnosing intrabdominal haemorrhages retroperitoneal lesions as well as the extent of the organ injury and is a necessary tool for the physician in order to diagnose accurately any abdominal injury. disclosure: no significant relationships. introduction: more and more hepatic injuries are treated non operatively if the hemodinamic's and lesion's stability is confirmed. the count and the scaling of lesions doesn't directly influence surgical indications. we report about cases of blunt trauma with serious hepatic and renal lesions treated successfully with a non operative management material and methods: we treated liver and renal injury associated in a period from to . patients were admitted to tor vergata -roma and hospital universitario clínico san carlos-madrid. data collected were: age, sex, comorbidities, sequence of events, type and number of associated lesions, management, morbidity and mortality. all liver and renal organ's injuries were evaluated by abdominal ct scan with contrast and classified according to ct-based scale results: middle age was ± sd years. patient were male in ( , %) of cases. ct scale of liver lesion was °for ( , %) patient and °for two ( . %) patients. renal lesions were i°category in cases ( , %) and ii°category in patient. no ureteral or major vessels rupture were founded. all patients have been treated non operatively. a ct based follow up of lesions was planned (at admittance, after hours, after a week and after a month). the mean length of hospitalization was ± sd days. during hospitalization, patients were monitored by clinic and labs daily. all patients were dismissed in good conditions and are in in health on a months follow up. at ct follow up, one patient presented an intra-hepatic biloma, that was successfully treated with ct-guided drainage conclusion: this work support the hypothesis that the association of liver and renal lesions in a blunt abdominal trauma, doesn't necessarily influences indications for an explorative laparotomy. if an ureteral rupture is suspected, a more aggressive treatment is necessary, in order to prevent peritonitisintroduction: the aim of this study is to analyze the most frequent mechanisms of injury, the evaluation in the emergency department and the period of increase of the blunt abdominal trauma incidence. material and methods: during the last years ( - ) patients were admitted to our department for blunt abdominal trauma.the most frequent mechanisms of injury were: traffic accidents (automobile crashes and motor vehicle collisions) ( , %) work accidents ( , %) . others (fall from high altitude, beating) ( , %) we analyzed the most frequent injuries observed, the final treatment for these patients and the period of increase of blunt abdominal trauma.results: the peak incidence occurs in persons aged - years. the male/female ratio was : . the most frequent abdominal injuries regarded: spleen ( , %), liver ( , %), large bowel ( , %), small bowel ( %), pancreas ( , %). patients underwent surgical treatment ( , %). the incidence of missed injuries is quite low, one case with pancreatic injury and one with small bowel injury. during summer period a significant increase in blunt abdominal trauma incidence occurs because of the increase of population due to tourism. the initial physical examination, after appropriate primary survey and initial resuscitation with the help of diagnostic studies such as ultrasonography, abdominal ct scan, is essential for the final treatment for these patients, operative or not operative. abdomino-throcal injuries were found in ( %) patients.abdominal organ injuries were found in decreasing frequencies in small bowel( %),liver ( %),large bowel ( %), spleen ( %), major vasculer, stomach and others. thoracal injuries were found in lung and heart in and cases.one organ injury was found in ( %) patients,mostly small bowel,and these group had a good haemodynamic status.thirty-two( %) patients had two organ injuries which of them associated with lung injury.three, and < organ injuries were found in , and patients. haemodynamic unstability at presentation,and shock was found in five patients( , and organ injury in , and cases). the overall mortality was found in ( %) patients.mortality from gun injury was % from major vascular injury ,lung,pancreas and large bowel ,lung and large bowel one.mortality from penetrating trauma was % from lung and multipl abdominal organ injury ,heart ,lung,spleen and stomach injury and major vasculer injury from blunt trauma in one ( %) patient. five patients who remain haemodynamically unstable after resuscitation died intraopreoperative period.these group was not received some resuscitation, and they referred to our hospital later than hours of injury. introduction: retroperitoneal location of the pancreas makes the diagnostic of any traumatism to be difficult, especially when this is not suspected. we report on a case of blunt pancreatic trauma with months delayed diagnosis, after injury due to maneuvers in a difficult birth. material and methods: we report on a case of a twenty-nine year-old female who consulted at the emergency department for constant right upper quadrant pain that didn't ease with any analgesic prescribed by the general practitioner. these symptoms started after a birth six months before and loss of kg of weight was associated. after reviewing the previous history of the patient, the birth had been difficult and forceps, suction pad and repeated abdominal pressure maneuvers were needed. abdominal examination showed a painful non-pulsatile mass located at epigastrium and both right and left upper quadrants. abdominal ultrasonography and enhanced ctscan were performed and demonstrated the presence of multicystic x x cm mass located between the stomach, spleen and left kidney. the high density content seemed to be blood. the mass was pushing the stomach anteriorly and no communication between both of them was shown. the splenic vein was pushed superiorly and thinned and plenty collateral circulation was evidenced. the tail and the body of the pancreas were not identified in any of the studies. the first choice diagnosis was posttraumatic complicated (with bleeding) pancreatic pseudocyst. the patient underwent emergency operation and a big cystic pancreatic mass was encountered, with plenty of collateral circulation. intraoperative biopsy confirmed that it was a pseudocyst and therefore, the majority of the cyst was removed and roux-en-y pancreatojejunostomy was performed. cholecistectomy was also done. introduction: unnoticed traumatic injuries produce avoidable morbidity, mortality and a higher medical cost. we present a special case of the reconstruction of a catastrophic abdomen with several intestinal fistulae and giant abdominal wall defect. material and methods: we present the case of a year old woman with blunt thoraco-abdominal trauma secondary to a road traffic accident. several lower left rib fractures, a fast echo with free fluid without solid organ injury and fractures of l and l were seen in the initial assessment. on the third day surgery was required due to septic shock with diffuse peritonitis due to a jejunal laceration and section of the body-tail of the pancreas. simple suture of the jejunal laceration, distal pancreatectomy, and abdominal packing without closure of the abdomen was performed. she developed several intestinal and colonic fistulae. over surgical procedures were performed on her and she was discharged months later with night parenteral nutrition, a closed abdomen by secondary intention and intestinal fistulae. she was readmitted a year later for reconstruction. we performed monoblock resection of the abdominal wall and the fistulized loops, subtotal colectomy and bowel transit reconstruction with three enteroenteric and an ileosigmoid anastomosis, leaving , m of small bowel. abdominal plastia with permacol mesh was also performed. results: surgical time was of minutes and oral tolerance was initiated on the th postoperative day. she was discharged on the th day postop. the only complication was a fever secondary to infection a central venous catheter on the rd day. key: cord- -lye qjw authors: song, r.; pang, x.; yang, p.; shu, y.; zhang, y.; wang, q.; chen, z.; liu, j.; cheng, j.; jiao, y.; jiang, r.; lu, l.; chen, l.; ma, j.; li, c.; zeng, h.; peng, x.; huang, l.; zheng, y.; deng, y.; li, x. title: surveillance of the first case of human avian influenza a (h n ) virus in beijing, china date: - - journal: infection doi: . /s - - - sha: doc_id: cord_uid: lye qjw purpose: human infections with avian influenza a (h n ) virus manifested in china in march . the first case infected with h n virus in beijing involved a family member of a chicken dealer and was reported in april . the clinical and epidemiological characteristics of this case and her parents were examined to illustrate some key traits regarding this novel h n virus. methods: the index case was subjected to intensive clinical examination in order to observed the clinical process. real-time pcr was used to confirm cases infected with h n virus. the index case was administered oseltamivir ( mg, twice daily) at the early stage of the infection. sera were collected from the index case and her parents from the onset of illness onwards. the subjects were followed for weeks. results: the sera were confirmed by neutralizing antibody tests. the index case’s clinical manifestation progressed quickly. the pharyngeal swab tested positive for influenza a based on the detection of influenza a antigen (rapid influenza diagnostic test) h after the onset of fever and was positive for h n virus. the patient’s temperature dropped to . °c h after treatment by oseltamivir ( h after fever). cough and other symptoms alleviated rapidly. a number of specimens from the environment of this cluster and from the feces specimens tested positive for viral rna of the h n virus on the fourth day following onset of the index case’s illness. pharyngeal swabs of the mother tested positive for h n virus twice, but she showed no clinical symptoms. four weeks after disease onset, the family did not present any clinical symptoms, and the results of the physical examination and blood tests were normal. the mother and the case’s sera had a fourfold increased neutralizing antibody titer. conclusion: early diagnosis and early initiation of the treatment of confirmed infections is the most effective strategy for managing h n virus infection. human beings exposed to h n virus may develop asymptomatic infection. the sera were confirmed by neutralizing antibody tests. the index case's clinical manifestation progressed quickly. the pharyngeal swab tested positive for influenza a based on the detection of influenza a antigen (rapid influenza diagnostic test) h after the onset of fever and was positive for h n virus. the patient's temperature dropped to . °c h after treatment by oseltamivir ( h after fever). cough and other symptoms alleviated rapidly. a number of specimens from the environment of this cluster and from the feces specimens tested positive for viral rna of the h n virus on the fourth day following onset of the index case's illness. pharyngeal swabs of the mother tested positive for h n virus twice, but she showed no clinical symptoms. four weeks after disease onset, the family did not present any clinical symptoms, and the results of the physical examination and blood tests were normal. the mother and the case's sera had a fourfold increased neutralizing antibody titer. in march , patients infected with a novel avian-origin influenza a (h n ) virus were identified in the yangtze river delta of south eastern china. influenza a h n is a triple reassortant virus [ ] . in contrast to the common clinical features of patients infected with other h subtype viruses, those infected with h n rapidly develop lower respiratory tract illness [ ] [ ] [ ] [ ] . in many cases of h n influenza, the health status of the patients can rapidly deteriorate into severe acute respiratory distress syndrome (ards) or multiple organ failure, ultimately progressing to death. the spectrum of h n infections remains unclear as epidemiological data are still limited. prior may , cases had been diagnosed worldwide, with a casefatality rate (cfr) of up to . % ( / ) [ ] . an efficient treatment strategy to reduce the cfr is therefore urgently sought in china. following notification of the first three confirmed cases of h n infection in the yangtze river delta, a hospitalbased h n surveillance program was initiated throughout china. all patients presenting with pneumonia caused by an unknown pathogen [definitions: fever (axillary temperature c °c); radiological characteristics of pneumonia; normal white cell count or leucopenia or lymphopenia; infection of unknown origin] were screened for h n virus [ ] . in addition, close contacts were traced and submitted to medical observation. on april , a -year-old girl was confirmed to have been infected with h n virus in beijing. her family members were exposed to the same environment. the index case had pneumonia and the mother had an asymptomatic infection. in this report we describe the clinical and epidemiological characteristics of the index case and her family to illustrate a number of key traits regarding this novel h n virus. the index case was a -year-old girl who was from a family of chicken dealers. she presented with fever, cough and discomfort on april at : a.m. she was admitted to beijing ditan hospital, captial medical university with a temperature of . °c. after admission, she underwent radiological and blood tests. chest radiography showed patchy opacities and edge effusion on bilateral lungs (fig. a) . after admission, this patient developed fever (maximum temperature . °c) which could not be brought under control with the administration of acetaminophen ( ml orally). by h after the fever began, her respiratory rate had risen to breaths per minute and finger oxygen saturation had dropped to - %. the breath sounds of her right lung became weak, and fine moist rales could be heard, with the intensity of the right lung's breath sound decreasing. chest ct scan showed right lower lobe consolidation (fig. b) . the pharyngeal swab was positive for influenza a using a rapid influenza diagnostic test based on the presence of influenza a antigens. subsequently, oseltamivir ( mg twice daily) was prescribed to the patient. the specimens sent to the beijing center for disease control and prevention (cdc) and the chinese national influenza center (cnic) tested positive for h n virus. the patient's temperature dropped to . °c h after the initiation of treatment with oseltamivir. cough and other symptoms alleviated rapidly. the chest ct scan showed improvement days after disease onset (fig. c) . five hours after the fever began, blood tests showed that the peripheral white blood cell count (wbc) was normal ( . /l), although neutrophil ( . /l) and lymphocyte counts were depressed ( . /l). on the second day after disease onset lymphocyte ( . /l), cd ? t cell ( cell/ll) and cd ? t cell ( cell/ll) counts were significantly depressed. on the third day the lymphocyte count ( . /l) began to increase (fig. ) , and on the fourth day wbc ( . /l) and neutrophil ( . /l) counts sunk to their lowest respective level. the patient's platelet count and red blood cell count remained normal during the hospitalization period. the parameters of cardiac enzymes, liver function and arterial blood gas analysis remained normal. the wbc, neutrophil and lymphocyte counts returned to normal days after onset of symptoms. the index case's parents, who earned their livelihood by purchasing and selling live chickens, had no clinical symptoms, and examinations of their blood were normal. samples of the patient's pharyngeal swab, which tested positive for influenza a (see above), were sent to the beijing cdc and the cnic for further testing. rna was extracted from all specimens using the qiaamp viral rna mini kit (qiagen, venlo, the netherlands) following the manufacturer's instructions. realtime reverse-transcriptase-pcr (rt-pcr) assays were performed to detect the h n virus, relying on specific primers and probes, as described by cnic. viral isolation, genome sequencing and phylogenetic analysis of h n viruses were carried out at cnic [ ] . fifteen hours after the fever began, the pharyngeal swab collected from the index case tested positive for the h n virus by rt-time pcr. about h after the initiation of treatment with oseltamivir, the pharyngeal swab tested positive for influenza a and negative for both h and n . thirty hours after the initiation of treatment with oseltamivir, all of the pharyngeal swab specimens tested negative for influenza a, h and n . the fecal specimen was available only on the fourth day of the onset of symptoms, and it tested positive for h n virus. pharyngeal swabs collected from the index case's mother tested positive for the h n virus on april and april and were negative after april. at weeks after admission of the index case to the hospital, the father's pharyngeal swabs tested negative. the influenza virus a/beijing/ / (h n ) was isolated from the index case, but the virus could not be isolated from her mother's specimens or from specimens taken from the patient's environments. phylogenetic analysis showed that a/beijing/ / (h n ) was highly homologous with a/shanghai/ / (h n ) and a/anhui/ / (h n ), a/shanghai/ / (h n ) and a/anhui/ / (h n ) in all eight gene segments (fig. a, b) . we conducted a seroepidemiologic investigation from april to may. written informed consent was obtained surveillance of the first case began at admission to hospital and continued for weeks. we collected serum on the day of admission to hospital (first day of illness onset), then on post-admission days , , and . the parents of the index case were also tested at the given time-points. the presence of h n neutralizing antibodies within the sera was tested using the microneutralization assay and confirmatory immunoblot assay. knowledge of the strain of virus and cells used for the neutralization assay would be useful information, as would details of the immunoblot (i.e. antibodies and antigen used). serological evidence of h n virus infection was defined as an h n neutralizing antibody titer of c with confirmatory findings from the immunoblot assay. the index case and mother's sera specimens all possessed a fourfold increased neutralizing antibody titer. the parents of the index case were identified as close contacts, and her mother was subsequently diagnosed with asymptomatic infection. all of her father's specimens that were collected during the period of medical observation tested negative for h , n and influenza a, and he did not develop any influenza-like symptoms during this period. the index case was discharged on post-admission day . two weeks after the illness onset ( week after discharge), the index case and her parents were followed-up. they did not present any clinical symptoms, and the results of physical examination and blood tests were normal. this report provides a new insight into the characteristics of h n infection, including the strategy of treatment, spectrum of this disease, viral shedding, and the source of transmission. the gene sequences of the virus isolated from the index case had a high homology with those from the cases of h n infection detected in south east china (fig. ) , suggesting that this virus would have a similar virulence as those viruses leading to severe symptoms and death in patients reported previously [ ] . the time-frame of patient treatment these cases was upon admission (index case in beijing) and h and - days after onset of symptoms (index cases in south east china); antiviral agents were administered to the cases at h and - days after symptom onset, respectively. within h onset of symptoms, the index case developed pneumonia, persistent high fever, local lobe consolidation and remarkable lymphopenia. given the rapid progression of the illness in the previously reported h n infected patients [ ] , ards was expected to occur if the causative agent and appropriate cause of treatment were not identified rapidly. a rapid influenza a antigen test was performed h after the fever began, and the positive result precipitated early application of oseltamivir. maximal plasma concentrations of oseltamivir carboxylate (oc), the active metabolite of oselatamivir, occur approximately - h after administration. the plasma half-life of oc is - h, which enables a twice-daily dosing regimen [ , ] . our index case recovered rapidly and did not develop ards, an outcome which may be attributed to the early administration of oseltamivir ( h after onset of fever). the pharyngeal swab collected from the index case tested negative h after treatment with oseltamivir. the specimen of feces from the index case tested positive for h n viral rna days after the onset of symptoms, indicating that this virus was able to cause enteric infection, such as h n virus [ ] [ ] [ ] . this finding suggests that the prevention and control of enteric transmission should be pursued in the treatment and management of patients infected with the h n virus. among the family of individuals infected with the h n virus in beijing, one asymptomatic infection was observed, which was the first reported case of asymptomatic infection in china since this virus was identified. we report here the first documented study on asymptomatic infection with avian influenza virus that was identified by the detection of viral rna rather than on the results of retrospective assays of antibodies against avian influenza virus [ ] [ ] [ ] [ ] . although the family members of the index case were all exposed to asymptomatic chickens infected with h n virus, they presented with distinct outcomes. the daughter developed pneumonia, the mother remained asymptomatic, and the father remained free of infection. in addition, the presence of q l in the ha protein and the substitution of e k in the pb protein found in the h n virus reported by gao et al. indicates that this virus may have an increased ability to infect mammals [ , [ ] [ ] [ ] . taken together, these results suggest that humans may have a higher susceptibility to h n viruses, which poses a serious public health concern. our experience with the index case suggests that early diagnosis and treatment is the most effective strategy to limit h n virus infection. this is first report to document the different clinical presentations within a family of infected and exposed individuals. conflict of interest none. af _a/england/ / (h n )_united_kingdom gu _a/england/av / (h n )_united_kingdom a/chicken/karachi/narc- / (h n )_pakistan a/duck/hong_kong/ / (h n )_hong_kong a/turkey/oregon/ (h n )_usa a/pheasant/minnesota/ / (h n )_usa a/turkey/va/ / (h n )_usa a/ruddy_turnstone/delaware_bay/ / (h n )_usa a/duck/guangdong/ / (h n )_china a/turkey/new_york/sg- / (h n )_usa a/quail/pa/ / (h n )_usa a/northern_shoverl/mississippi/ os / (h n )_usa cy _a/mexico/indre / (h n )_mexico a/chicken/jalisco/cpa / (h n )_mexico cy _a/canada/rv / (h n )_canada a/chicken/victoria/ (h n )_australia a/duck/tasmania/ / (h n )_australia a/chicken/new_south_wales/ / (h n )_australia a/chicken/brescia/ (h n )_italy a/northern_shoveler/california/ / (h n )_usa a/turkey/minnesota/ / (h n )_usa a/black_duck/ohio/ / (h n )_usa a/ruddy_turnstone/delaware/ / (h n )_usa a/redhead_duck/alberta/ / (h n )_canada a/gull/maryland/ / (h n )_usa a/goose/zambia/ / (h n )_zambia eurasian a/emu/ny/ / (h n )_usa (h n )_australia a/duck/hong_kong/ / (h n )_hong_kong a/shoveler/netherlands/ / (h n )_netherlands a/chicken/italy/ a/ (h n )_italy human infection with a novel avianorigin influenza a (h n ) virus avian influenza a virus (h n ) associated with human conjunctivitis and a fatal case of acute respiratory distress syndrome transmission of h n avian influenza a virus to human beings during a large outbreak in commercial poultry farms in the netherlands avian influenza virus isolated from a woman with conjunctivitis avian influenza a/(h n ) outbreak in the united kingdom world health organization/global influenza program. cumulative number of confirmed human cases for avian influenza a(h n ) reported to who guideline on prevention and control of avian influenza a (h n ) oseltamivir in seasonal, pandemic, and avian influenza: a comprehensive review of -years clinical experience clinical course of avian influenza a (h n ) in patients at the persahabatan hospital influenza a/h n virus infection in humans in cambodia influenza a h n replication sites in humans fatal avian influenza a (h n ) in a child presenting with diarrhea followed by coma risk factors associated with subclinical human infection with avian influenza a (h n ) virus-cambodia prevalence of antibodies against avian influenza a (h n ) virus among cullers and poultry workers in ho chi minh city measurement of antibodies to avian influenza virus a(h n ) in humans by hemagglutination inhibition test serosurvey against h and h avian influenza viruses in italian poultry workers airborne transmission of influenza a/h n virus between ferrets experimental adaptation of an influenza h ha confers respiratory droplet transmission to a reassortant h ha/h n virus in ferrets hostrange determinants on the pb protein of influenza a viruses control the interaction between the viral polymerase and nucleoprotein in human cells key: cord- - ybxuy authors: everett, tom; douglas, jenny; may, shoshanna; horne, simon; marquis, peter; cunningham, richard; tang, julian w title: poor transmission of seasonal cold viruses in a british antarctic survey base date: - - journal: j infect doi: . /j.jinf. . . sha: doc_id: cord_uid: ybxuy nan recently, it is reported in journal of infection that h n and h n subtype avian influenza virus may have an increased pathogenicity to humans.the h n subtype influenza virus has emerged in china. not only the h n ( %) subtype but also several h n ( %) subtype influenza viruses have been detected in samples. according to chinese national influenza data ( http: //ivdc.chinacdc.cn/ ), the h n subtype influenza virus was prevalent from the end of to the beginning of . the h n and h n subtypes of influenza virus are resistant to adamantanes (amantadine and rimantadine), and a small number of h n strains have been found to be less sensitive to na inhibitors (nais; oseltamivir, zanamivir, and peramivir). in this study, we briefly evaluated the evolution patterns of the h n influenza virus and the h n influenza virus. we collected non-repeat h n and h n subtype influenza virus sequences isolated in china over the course of nearly years from the global initiative on sharing avian influenza data (gisaid) database ( www.gisaid.org ) and national center for biotechnology information (ncbi) ( www.ncbi.nlm.nih.gov/genomes/flu ). the haplotype network map shows that the h n strain has a node in common with the / h n strain ( fig. ) , and h n and h n often co-infect the same patients. when multiple strains of influenza infect the same host, they may undergo recombination and reassortment of the gene fragment, which greatly changes the pathogenicity and epidemiological characteristics of the virus. currently, the h n subtype influenza virus is widespread in the population, and the number of children with neurological symptoms increased significantly this year. the influenza virus has shown some variation, and whether this variation occurs along h n and h n lines remains to be seen. when multiple viruses co-infection occurs, it becomes possible for the viruses to undergo genetic communication, which may change the direction of viral evolution and so deserves our attention. we calculated the average gene evolution rate (nucleotide replacement rate) of the h n influenza virus and the h n influenza virus between different years from to . it can be seen that the genetic evolution rate of the h n influenza virus and the h n influenza virus is . e − - . e − and . e − - . e − ( table ) , respectively, in the same year and there are up and down fluctuations that may be related to the subtypes that were prevalent that year. additionally, we calculated the evolution rate of the h n influenza virus from the end of to the beginning of ( . e − ). a large increase in the rate of advancement indicates a rapid change in the virus in the short term, triggering changes in the replication, resistance, and transmission of the virus. the type a influenza virus emerges periodically every year,influenza undergoes continuous evolution, and different lineages have appeared. at the same time, under the action of vaccines and drugs, the antigenicity and antigenic site of the virus are transformed and resistant. however, medical science has also improved. it is necessary to determine the frequency of gene exchange between different subtypes and be alert to possible variations in gene communication between different subtypes. pu et al. and shi et al. reported that duck-derived virus h nx and recombination of h n can produce new h n that can cause disease death in waterfowl. this recombination event may have occurred in or earlier, but the recombinant virus has a distinct evolutionary advantage given the use of a vaccine. exchange between h n and h n may allow them to give each other different viral characteristics, hence, ongoing surveillance of h n and h n subtypes of influenza is warranted. the authors declare not conflict of interest. recent studies in this journal revealed that some h n viruses reassorted with duck aivs, and then attained the ability to efficiently infect ducks. , h n aivs have been endemic in chicken since their emergence in china in february . after its emergence, h n viruses have evolved substantially, and have frequently reassorted, acquiring internal genes from other chicken h n viruses, increasing the genetic diversity of h n viruses. this raises the concern that whether h n can attain internal genes from other aivs. thus, we collected all available h n sequences to detect potential novel reassortments of the h n aivs, and found evidences that three human-isolated h n isolates attained internal genes from duck and human aivs. all available sequences of h n aivs were downloaded from the ncbi ( https://www.ncbi.nlm.nih.gov ), gisaid ( https://www.gisaid.org ) and fludb ( https://www.fludb.org ) public databases. then, phylogenetic trees for ha, mp, np, ns, pa, pb , pb and na genes were reconstructed, respectively, using raxml v. . . with gtrgamma model, and bootstrap tests. phylogenetic analyses revealed that five genes (np, ns, pa, pb , and pb ) of a/fujian/ / (h n ), mp gene of a/gd- / /h n / - - , and two genes (pb and pb ) of a/zhejiang/ / (h n ) did not clustered with chicken h n aivs, respectively ( fig. and supplementary fig. ). further, blastn ( https://blast.ncbi.nlm.nih.gov/blast.cgi ) was used to search the homology sequences of these three abnormal strains ( while domestic ducks act as an interface between the natural gene pool and terrestrial poultry in the influenza virus ecosystem. the h n viruses cannot replicate efficiently in ducks in the first four waves. however, studies have indicates that the highly pathogenic h n virus has extended its host range by acquiring genes from duck influenza viruses and has now adapted to ducks. , , the reassortments between h n and duck aivs would further raise the diversity and spread of the h n . in addition to our finding of the reassortments between duck aivs and the human-isolated h n viruses suggest that surveillance and control of duck aivs is critical for the control of h n viruses, which was almost ignored previously. it's surprising that the pb and pb genes of a/zhejiang/ / (h n ) showed the most closed relationship with human h n viruses ( % and % identity respectively, table ). reassortments between human and avian aivs can make the reassortant viruses replicate efficiently in mammalian hosts. it's very possible that the reassortment between h n and human h n , may make the reassortant virus more adaptive to human, even attain the ability to efficiently transmit between humans, and thus raise great thread to the public health. historically, several pandemic human influenza viruses were derived from reassortant virus between avian and human influenza viruses. for example, the h n /pdm virus, which was a swine reassortant virus that attained the pb from human h n , was rapidly transmitted between humans and then, globally circulates as a seasonal virus, posing a substantial risk to human. h n aivs have the genetic makeup associated with human infections, in addition to our finding that the reassortant human-isolated h n virus attained the pb and pb from human h n , possibility like the h n /pdm virus, the reassortant virus would become more invasive to humans, and thus pose serious pandemic threat to humans. h n is a novel reassortant aiv subtype, which has surpassed h n in laboratory-confirmed human infections despite its limited dissemination outside of china. thus, whether this subtype could acquire the ability to efficiently human-to-human transmission, and become a new influenza pandemic raise great attention. although a h /h vaccination in chicken has successfully decreased the prevalence of the h n viruses in chicken, our findings that h n viruses attained internal genes from human and duck aivs raise concerns about the potential ability of the viruses to increase their diversity and spread, and especially the possibility to develop better ability to infect human, and eventually attain efficient human-human infections. we note with interest these previous studies into household and hospital influenza outbreaks. , such community and hospitalbased respiratory virus transmission and outbreak investigations often suffer from the potential confounding arising from possible exposures to undiagnosed index cases outside of the outbreak cohort, leading to an overestimate of virus transmissibility, and potentially unnecessary costly and restrictive infection control interventions. to avoid such confounding, we performed a small pilot study in a closed population of adult research scientists ( n = out of a possible ). all participants signed informed consent forms, following ethical approval from plymouth university ethics committee. these scientists were confined to a british antarctic survey base for month (march ), during which no personnel entered nor left the base. therefore any detectable human respiratory viruses could only have been brought into the base by personnel at the beginning of this 'closed period'. participants were given anonymous codes to maintain confidentiality. each agreed to give nasal swabs (collected in virus transport medium, virocult, medical wire and equipment ltd, corsham, wiltshire, england) upon entry (day , / / ), then at days ( / / ), ( / / ) and ( / / ) post-entry. all viral swabs were stored at − °c until they could be shipped back to the uk and tested at the leicester royal infirmary. this was performed using a respiratory multiplex pcr assay ( -well, ausdiagnostics uk ltd., chesham, uk) that could detect any of: influenza a, b, respiratory syncytial virus (rsv), parainfluenza (piv) types - , human metapneumo (hmpv)-, entero-/rhino-, corona-( e, oc , nl , hku ) and adeno-viruses. no specific instructions about infection control were given to the participants. they were left to act as they would normally behave throughout the period of the study. any participants who developed any of , self-assessed, influenza-like symptoms (fever, cough, stuffy nose and/or sinuses, headache, sore throat, myalgia, fatigue, shortness of breath, nausea or vomiting) would complete a tick-box questionnaire (on a scale of -'very mild' to -'very severe') to describe the relative severity of their symptoms. this same questionnaire also requested the contact intensity (i.e. number, nature and frequency) of their daily contacts with other participants as a self-assessed, linear graded score (from -'sharing just one meal together' to -'spending the majority of the day and evening with the other person'), depending on the frequency of contact whilst working, eating meals and socialising together. the daily location of all personnel in any of the four station zones at , , , and h was also recorded routinely for safety and security, using a 'tagboard' system. out of the participants who consented, later declined to have any viral swabs taken, and of the resulting (i.e. × swabbing time-points) possible swabs, were successfully collected and stored for testing. testing the incubation period of human coronaviruses is around - days, which can be used to link symptomatic cases together, epidemiologically, with viral shedding being reported for up to days post-symptom onset. so the symptoms and positive nl and oc results for participants and , respectively, could have been acquired from participants and , who may have been the original index cases (sources) for these viruses. although no respiratory virus was detected in their samples, participants , and all reported similar symptoms to those of and during the study period, which were typical common cold symptoms. note that the participants' self-reported contact intensities were not entirely robust, e.g. both participants and list participant as a contact, so could both have been index cases for him/her. however, did not list either or as a contact (such contacts should be reciprocal). this may have just been a simple oversight, but it makes the contact link less reliable. similarly, participant could have served as the index case for participant , but neither lists the other as a contact. regardless of the contact intensities reported in the questionnaires, there were no secondary cases of either nl or oc coronaviruses detected in any of the other study participants' weekly swabs. one possible explanation for this may have been an insufficient sensitivity of the assay to detect low levels of these respiratory viruses. the limit of detection (lod) for the ausdiagnostics assay varies significantly with each virus (as given in the kit insert, all in copies/ml): influenza a ( - ), b ( ), rsv ( - ), piv types - ( - ), hmpv ( - ), entero-/rhino-( - ), corona-( e, oc , nl , hku ) ( - ) and adeno-( ) viruses. however, in the acute infection stage respiratory viruses are generally present in relatively high copy numbers, with median values of mostly - log (i.e. , - , , copies/ml) for adeno-, corona-, hmpv, influenza, piv and rsv, as reported in one comprehensive paediatric study. although children generally shed higher viral loads than adults, it is likely that the coronavirus loads in acutely infected adults would still be mostly detectable on this assay, which is approved (i.e. ce-marked) for routine diagnostic testing. yet, it is still possible for viruses that are infecting individuals at the lowest loads within these ranges, to fail to be detected by this assay. given the results that are currently available from this study, one of the key questions is: from where did the nl and oc coronaviruses arise? in addition, the lack of any secondary nl or oc coronaviruses cases (symptomatic or asymptomatic) arising from the known positive sources (participants and ), suggests that the transmissibility of these common cold viruses may be limited. this seems unexpected, given the potential stress on the body immune system whilst living and working in such an extreme environment. however, such relatively poor transmission of respiratory viruses has been previously described in antarctic base personnel for rhinovirus and adenovirus, , for reasons that are still unclear. another potential confounding factor is the unknown status of the individuals who were also present at the base (mostly base personnel) but who declined to participate in the study. it is possible that one or more of these non-participants could have been the original sources (i.e. index cases) of the nl and oc coronaviruses at the start of the study. whilst there are some limitations to this study, there are plans to repeat this on a larger scale, over a longer 'closed' period, with the use of real-time, point-of-care testing (poct) to detect such respiratory viruses. although previous respiratory virus outbreaks have been described in remote research bases, , these were unable to utilise the greater sensitivity and spectrum of respiratory viral targets provided by modern, molecular, diagnostic tools. , thus, some positive cases in these earlier studies may have been missed, leading to an underestimate of the transmissibility of these respiratory viruses in these populations. respiratory infections in research personnel can impact significantly on their productivity, an important consideration when their time at such remote research bases is limited. this and future studies will enable medical teams to enhance the healthcare of research base personnel to optimise their precious research time spent there. none of the authors have any conflicts of interests to declare. we thank the following for their support of this study: uk clinical virology network (cvn), for general funding support; medical wire & equipment ltd., for donating some of the sampling swabs; ausdiagnostics uk ltd., for donating the respiratory multiplex pcr tests. none of these companies were involved in the writing of this article. we read with interest, the article by poller et al. , in this journal, entitled "a unified personal protective equipment….". we understand the importance of proper personal protective equipment(ppe) as an integral component of healthcare workers(hcw) protection in outbreak situations of infections with possible high consequence. but at times, such an outbreak occurs in an unsuspected region, when initial cases present in early course of illness before the development of ominous clinical features. medical staff, particularly in busy rural set ups of resource-poor developing countries may discover that they have been exposed to a high consequence infectious disease after the event of exposure, particularly if these centres are unaware, reluctant or unequipped regarding routine use of ppe. a similar situation occurred in a rural healthcare setting of kerala, india, during the may- outbreak of nipah virus (niv), killing out of reported cases. a -year-old male ( index case of the outbreak report ) from kerala's perambra town died undiagnosed with fever, en-cephalitis and respiratory distress in government medical college kozhikode(gmck), after being transferred from taluk hospital, perambra(thp). another -year-old male patient ( case- ) was admitted in thp for an acute febrile illness and recovered while the unsuspected index case was being treated there in the adjacent bed. two weeks later, case- presented to taluk hospital, balussery(thb) (the setting of our intervention), with complaints of fever, headache and vomiting of days duration. he was treated there as inpatient for about h after which he was referred to gmck, owing to clinical deterioration. the next day he developed altered sensorium, respiratory distress and expired. till then, there was no suspicion about the niv outbreak situation, as kerala is at least km away from the last known outbreak in the indian subcontinent in , . in the meanwhile, the brother, father and aunt of the index case , and a nurse, who cared for him at thp, developed similar clinical features of acute encephalitis with respiratory distress and got admitted. all of their samples, along with that of case- , were tested positive for niv from the reference laboratory. the state public health authorities swiftly declared the outbreak and ensured containment and protective measures. however, by this time, out of confirmed niv cases were already infected and fell ill, being epidemiologically related as contacts of the index case in family, during transit to healthcare facilities or in hospital . here, we report our experience with eight hcw including two doctors (authors aps and mb of this correspondence) and six nurses working in thb, who had unsuspected, inadvertent, yet significant exposure to case- when he was admitted there, without any ppe. both the doctors had closely clinically examined case- and the six nursing-staff had repeated bare-hand, unmasked contacts with him ( table ). all of them were extremely panicked once the outbreak notification was out and beseeched aps and mb for an immediate solution. aps and mb contacted the other authors for advice regarding any possible post-exposure prophylaxis(pep). considering the possibility of human-to-human (airborne / contact) transmission of niv, , in-vitro and in-vivo effects of ribavirin on niv, evidence of safety and efficacy of short-course high-dose ribavirin pep(rpep) used for lassa fever and unavailability and inexperience of any other alternatives (favipiravir or monoclonal antibody m . ), were discussed by vkmn, sb, ms, nw and ab, and a consensus opinion of rpep as the only available and reasonably safe option was placed before aps and mb. the importance of psychological factors in the hcws were also considered seriously. the suggested dose was mg thrice daily for days(cumulative , mg) in congruence to the lassa fever recommendation. all the contacts started rpep within h of exposure. the mean cumulative dose of rpep taken by the contacts was , mg( , - , mg) and the mean duration was . days( - days, table ). their clinical and laboratory parameters were monitored for the next months. mean age of the hcws was . years( - years). two were males and rest females; none were pregnant ( table ) . most of them experienced minor side effects like fatigue, headache, nausea, dry mouth and palpitations. there was a mean drop of . g/dl of haemoglobin, predominantly between days and after starting rpep, which started rising in all within a week of stopping rpep. bilirubin levels rose by a mean of . (range: . - . ) mg/dl in of the hcw ( fig. ) . none of them ultimately contracted niv disease. interestingly, one -year-old male patient ( case - of the outbreak report ), was admitted at an adjacent bed in thb with dysentery, while case- was admitted. he was present within a distance of metre for more than h. there was apparently no direct contact between them, except that same hcw served both of them sharing non-critical medical devices. after recovery, case - was discharged from thb, to return after a week to gmck with high grade fever, developing encephalopathy and respiratory distress, diagnosed to have niv infection and succumbed to it. in the current outbreak, family members, one staff nurse, one trainee nurse, one radiology assistant who took care of the index case and hospital contacts contracted the infection, proving human-to-human transmission. respiratory aerosols and fomites cause human-to-human spread. the mortality rate, in all recent niv outbreaks in the indian subcontinent is - % with the bangladeshi strain (niv-b) and its close relative in the recent kerala outbreak, has been consistently almost double compared to ebola. further that case - getting infected from case- in the same premises of thb, makes our case for rpep stronger. the survivors out of infected patients in this outbreak have also received ribavirin. given the recent findings of widespread presence of niv among pteropus bats in india, another outbreak might be just a matter of time. our field notes from emergency, voluntary, off-label rpep among hcw provides evidence, albeit low-quality, of its safety and probable efficacy, strongly suggesting a pre-planned trial for pep to be started immediately once such an explosive outbreak of niv is notified. none. we note the previous report describing a decreasing incidence of eosinophilia in returning travellers by barrett and colleagues. in contrast, another type of hazard reported by returning travellers -monkey bites -appears to be increasing. this makes it necessary for our frontline medical staff to be aware of the potential risks from rabies and simian herpes b virus (shbv or cercopithecine herpesvirus -cehv- ) associated with this type of exposure. although infections are rare as a consequence of bites, , both viruses can result in very high ( - %) mortality if the appropriate post-exposure prophylaxis is not initiated promptly. in view of these serious consequences, post-exposure protocols have been developed to reduce likelihood of infection. , - while this is agreed for rabies, , post-exposure prophylaxis is not uniformly recommended for shbv, as cases have only been reported with captive monkeys, , despite numerous monkey bite exposures in regions where animals are thought to be infected. assessing risks versus benefits obviously needs to be done judiciously in each case, and national public health specialists can be consulted to support decision making. , the main risk is primarily from monkey bites from macaque monkeys (genus macaca ), which are now encountered relatively frequently in various tourist areas in southeast asia (e.g. philippines, indonesia, malaysia, cambodia, vietnam, thailand). after a monkey bite, the patient should perform immediate wound cleansing: irrigation with soap and water, or other skincleansing detergent, or sterile water alone, for at least min. later, when the patient presents to the emergency department (ed), all medical staff need to be aware of both the rabies and shbv post-exposure protocols (peps) associated with such bites. whilst most ed teams will likely know of the rabies pep protocol, fewer will be aware of the guidelines for shbv pep. along with the wound cleansing and post-exposure rabies immunoglobulin (rig) and vaccination, any risk of shbv requires that high dose acyclovir (preferably valaciclovir g tds po; or acyclovir mg times daily po, for adults) pep for at least days should be considered. immediate pcr and later serological testing for signs of shbv infection are possible. however, recommendations for such testing are somewhat variable, with some advising testing in symptomatic cases only, whilst others will test all potentially exposed cases, regardless of symptoms. , symptoms of possible shbv disease include vesicular lesions, pain and itching near the bite site, local lymphadenopathy, flulike illness (fever, headache, myalgia, fatigue), and any focal or progressive neurological symptoms, including dyspnoea. outcomes are generally fatal ( % mortality without any treatment), once there is central nervous system involvement. , however, with antiviral prophylaxis and treatment, such fatal outcomes are rarer. bacterial infections (e.g. staphylococcus and streptococcus spp.) can also arise from the bite itself, especially in children, for which systemic antibiotics can be given, and tetanus vaccination. to highlight this issue, we present three cases of returning travellers with monkey bites. case : a -year old male was admitted with headache, lethargy and myalgia following a trip to indonesia (monkey forest, ubud, bali), where he sustained a penetrating bite to his right shoulder from a macaque monkey. there were no immediate post-bite complications. however, days later, he developed paresthesia and neuropathic pain in his right thigh. after seeing a local physician, oral aciclovir mg times daily for days was prescribed, as prophylaxis for possible shbv. one day later he developed a vesicular rash on his right thigh, which subsequently resolved on the antiviral therapy. on return to the uk, given this history, he was admitted and started rabies post-exposure immunisation, without rabies immunoglobulin (rig). he was then extensively investigated for possible shbv infection. he had five days of intravenous aciclovir and a further nine days of oral valaciclovir, whilst awaiting investigation results. diagnostic testing performed at the department of viroscience, erasmus medical centre (m/c), rotterdam, the netherlands on cerebrospinal fluid (csf), blood, lesion swab and saliva by shbv pcr showed no evidence of infection at that time. at outpatient review, two months later, there had been no further history of any rash or neurological symptoms, though the patient did mention several recurring episodes of genital herpes, for which he was given a -day course of oral valaciclovir mg bd po. by this time, the risk of latent shbv was considered negligible and he was discharged from clinic. case : a -year old male was seen in clinic who gave a history of receiving an unprovoked, penetrating bite on his right upper arm from a vervet monkey ( chlorocebus pygerythrus , previously classified as cercopithecus aethiops ), one week earlier whilst on holiday in barbados. after immediate wound care, he was seen in a local clinic and received tetanus vaccine and oral antibiotics. no aciclovir shbv pep was commenced at this time. the bite wounds healed without complication. after returning to the uk a week later, an outpatient review revealed that he was still asymptomatic for any clinical features of shbv, rabies or other travel-associated illnesses. however, as a precaution, valaciclovir g tds po, for days was prescribed as shbv prophylaxis, due to the possibility of an incubating shbv infection. blood and saliva samples were sent to viroscience for pcr testing to check for any residual shbv, dengue, chikungunya or zika virus infections. all tests were negative. the patient continued to remain asymptomatic, so was eventually discharged from outpatient follow-up. case : a -year old female was seen in clinic upon return from southeast asia, with a history of receiving a penetrating bite to her right upper arm from a macaque monkey, whilst visiting monkey island, vietnam, days previously. she received her first dose of rabies vaccination (without rig) at a local clinic within four hours of the bite. a week later, whilst still in vietnam, she received a second dose of rabies vaccine from a different clinic, which also started her on acyclovir post-exposure prophylaxis for shbv. the bite wounds healed without sequelae. at her -day clinic review once back in the uk, she was still asymptomatic. baseline saliva and blood samples were taken and stored but not tested for shbv. she continued both the shbv and rabies pep whilst continuing her travels a week later, and remained asymptomatic six weeks post-exposure. this small case series demonstrates a diversity of presentations and follow-up management for these patients, notably: case likely presented with genital herpes; case sustained a bite from a vervet, not a macque, monkey; case did not have any shbv testing. to our knowledge, all of these cases remain well. as there are no consensus guidelines available for managing such monkey bites, we suggest a precautionary approach and that to be safe, assume that both rabies and shbv are potential risks, regardless of monkey species. therefore, in the event of a monkey bite, where, after discussion with the patient (based on their individual clinical assessment), a decision is made to give prophylaxis: (i) immediately cleanse the wound for mins with clean water + / − soap or detergent. consider appropriate antibiotic therapy to prevent skin infection (e.g. co-amoxiclav or amoxicillin), and tetanus vaccination. (ii) seek competent clinical help and obtain the first dose (day ) of rabies vaccine + / − rig, depending on the risk assessment (in the uk, public health england tel: , - pm mon-fri). complete post-exposure rabies vaccination with further doses on days , and , post-exposure. (iii) start acyclovir ( g valacyclovir tds po or mg acyclovir times daily po -depending on local availability, for adults. adjust the dose as appropriate for children) as soon as possible after the bite, for at least days, as post-exposure prophylaxis against shbv. (iv) if symptoms compatible with shbv develop within the next - weeks (e.g. vesicular lesions, pain, itching around the bite, local lymphadenopathy, flu-like illness, focal or progressive neurological symptoms), continue the acyclovir and seek further expert advice. (v) baseline samples (serum, saliva, wound swabs) can be taken and stored for comparison. if acute illness develops, repeat samples (including cerebrospinal fluid -csf) should be taken for diagnostic testing (by pcr) to check for shbv dna, and serology for shbv antibodies -if such testing is available. recent article in this journal has reported dengue patients were associated with a higher risk of autoimmune diseases than nondengue patients . dengue has been a serious public health prob-lem in the world, the number of dengue epidemics has been on the rise worldwide. before , only nine countries had experienced severe dengue epidemics; however, currently more than countries have been severely affected by dengue . after the first dengue-fever epidemic in china, which occurred in may in foshan, guangdong province, there have been regional outbreaks of dengue every year and the number of cases has increased. guangdong province is the area most seriously affected by dengue in china. the number of cases in guangdong accounts for more than % of the total number of cases in china , . however, the epidemic characteristics of dengue fever in guangdong province have not been reported since . a dengue epidemic is closely related to various factors, such as environmental conditions, imported cases, and migration; thus, its epidemic characteristics and patterns change rapidly. especially after the outbreak of dengue in guangdong province in , the epidemic patterns have changed greatly. therefore, exploring the changing patterns of dengue outbreaks and epidemics in guangdong is of great significance to the prevention and control of dengue. this study aimed to investigate the changing patterns of the epidemic characteristics of dengue in guangdong province and to propose prevention and control measures. we collected dengue cases from to from the web-based disease reporting information system of the chinese national center for disease control and prevention. a total of , cases were reported for this period. population data were obtained from the statistics bureau of guangdong province ( http://www.gdstats.gov.cn/ ). a chi-square test was used to determine spatial differences in cities. this study was approved by center for disease control and prevention of pla review board. in terms of temporal distribution ( fig. ) , dengue cases showed an increasing trend from to in guangdong province, and a decreasing trend from to ( cases in , , cases in , and cases in ). the dengue outbreak in , with , cases and deaths, was the largest dengue outbreak in china in the past years. before the outbreak in , an average of people was infected with dengue annually. following the outbreak, an average of people were infected with dengue annually-nearly twice the number of cases per year compared to that before . dengue fever had typical characteristics in population distribution. adults aged - years accounted for . % of patients, and children aged - years only accounted for . % of patients. in terms of distribution across occupations, housekeepers and the unemployed ( . %), retired individuals ( . %), those involved in commercial services ( . %), industrial worker ( . %), and students ( . %) formed the majority of patients with dengue fever. these five groups accounted for . % of the total number of cases. the number of male patients was comparable to that of the number of female patients (male: female = : . ), and the mortality rate of dengue was low at only . ‰ . monitoring data of the past years showed that although the number of cases increased greatly after the outbreak in , the population distribution did not change significantly. the key population for the prevention and control of dengue fever were adults over the age of years. although cases have been reported in various regions, there are significant differences ( p < . ) in the distribution of dengue among the different cities in the guangdong province ( fig. ) . incident cases were mainly concentrated in guangzhou city and foshan city. guangzhou city had a total of , cases during - , which accounted for . % of cases among the different cities. foshan city had a total of cases, which accounted for . % of cases. however, according to annual data trends, was the turning point in spatial distribution patterns for dengue fever. from - , the incidence of dengue was concentrated in foshan city, guangzhou city, jiangmen city, and zhongshan city ( . % of cases). however, by , except for meizhou city, there were case reports from all cities in the province. among them, there were cities with more than cases each. after , dengue fever was prevalent throughout the province. even in zhanjiang city, zhaoqing city and jieyang city, which are distant from guangzhou city, and the number of cases in remote areas increased significantly. this paper is the first to analyze the characteristics of the change in dengue epidemics in guangdong province in the past years. in general, the incidence of dengue fever has typical spatial differences. the cases were mainly concentrated in urban areas with large populations and developed economies, such as guangzhou city and foshan city. theinflux of many migrants, especially those from southeast asia, could have caused the higher incidence of dengue fever in these areas. studies have shown that dengue epidemics in china were initiated by imported cases and then became prevalent in the local areas . however, attention should be given to the large number of dengue epidemics in remote areas, which appeared after . a possible reason for this could be global climate warming, which has caused the natural environments in some remote areas to become suitable for mosquito breeding. moreover, rapid development in tourism and trade has also led to an increase in local and imported cases. in summary, after , the epidemic characteristics of dengue fever in guangdong province have undergone major changes. the key areas for prevention and control are no longer confined to traditional epidemic areas, such as guangzhou city and foshan city. instead, dengue prevention and control should be conducted throughout the province. in addition, according to the national dengue surveillance in , dengue fever has shown a trend of "moving up north" in the country . therefore, the changing characteristics of this epidemic warrant high attention of relevant departments. the authors declare that they have no competing interests. this work was supported by national key r&d program of china ( yfc ), beijing nova program ( z ) and military medical innovation project ( cxz ) and pla youth training project for medical science ( qnp ). the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. pathogenicity and transmissibility of three avian influenza a (h n ) viruses isolated from wild birds evolving ha and pb genes of influenza a (h n ) viruses in the fifth wave -increasing threat to both birds and humans? genetic and antigenic characterization of a(h n )pdm in yantai, china, during the - influenza season neurologic manifestations of influenza a(h n ) infection in children during the distinct molecular evolution of influenza h n strains in the / season and its implications for vaccine effectiveness rapid evolving h n avian influenza a viruses pose new challenge rapid evolution of h n highly pathogenic viruses that emerged in china in hemagglutinin characteristics, changes in pathogenicity, and antigenic variation of highly pathogenic h n avian influenza viruses in china two novel reassortant high pathogenic h n viruses isolated in southern china in fifth wave shows internal genomic diversity and high virulence in chickens and ducks human infection with a novel avian-origin influenza a (h n ) virus evolutionary dynamics of avian influenza a h n virus across five waves in mainland china evolution and ecology of influenza a viruses rapid evolution of h n highly pathogenic viruses that emerged in china in deciphering the sharp decrease in h n human infections h n hybrid viruses bearing /h n virus genes transmit in guinea pigs by respiratory droplet origins and evolutionary genomics of the swine-origin h n influenza a epidemic potential pandemic of h n avian influenza a virus in human case-ascertained study of household transmission of seasonal influenza -south africa haemagglutinin and neuraminidase sequencing delineate nosocomial influenza outbreaks with accuracy equivalent to whole genome sequencing incubation periods of acute respiratory viral infections: a systematic review identifying the probable timing and setting of respiratory virus infections human coronaviruses and other respiratory infections in young adults on a university campus: prevalence, symptoms, and shedding. influenza other respir viruses is higher viral load in the upper respiratory tract associated with severe pneumonia? findings from the perch study rhinovirus infections in an isolated antarctic station. transmission of the viruses and susceptibility of the population adenovirus infection in an isolated antarctic station: transmission of the virus and susceptibility of the population a unified personal protective equipment ensemble for clinical response to possible high consequence infectious diseases: a consensus document on behalf of the hcid programme outbreak investigation of nipah virus disease in kerala, india nipah virus-associated encephalitis outbreak nipah virus contamination of hospital surfaces during outbreaks characteristics of nipah virus and hendra virus replication in different cell lines and their suitability for antiviral screening treatment of acute nipah encephalitis with ribavirin review of the literature and proposed guidelines for the use of oral ribavirin as postexposure prophylaxis for lassa fever post-exposure prophylaxis in ebola virus disease: don't forget the psychological factors adaptive immune responses in humans during nipah virus acute and convalescent phases of infection a spatial association between a nipah virus outbreak in kozhikode, kerala, india and nipah virus infection in pteropus bats the changing aetiology of eosinophilia in migrants and returning travellers in the hospital for tropical diseases expert review of evidence bases for managing monkey bites in travelers understanding primate herpesviruses rabies in nonhuman primates and potential for transmission to humans: a literature review and examination of selected french national data immunisation against infectious diseases virus working group recommendations for prevention of and therapy for exposure to b virus (cercopithecine herpesvirus ) monkey bites in travelers: should we think of herpes b virus rabies and immunoglobulins service follow-up of monkey bites. phe publications gateway number keep children away from macaque monkeys! increased risk of autoimmune diseases in dengue patients: a population-based cohort study developing a time series predictive model for dengue in zhongshan, china based on weather and guangzhou dengue surveillance data the changing epidemiology of dengue in china, -kk : a descriptive analysis of years of nationwide surveillance data spatial and temporal patterns of dengue in guangdong province of china clinical and epidemiological features of the large-scale dengue outbreak in guangzhou city center for disease control and prevention of chinese people's liberation army, dongdajie street xinying du center for disease control and prevention of chinese people's liberation army, dongdajie street beijing , china hongbin song * center for disease control and prevention of chinese people's liberation army the authors declare not conflict of interest. supplementary material associated with this article can be found, in the online version, at doi: . /j.jinf. . . . we thank the following for their support of this study: uk clinical virology network (cvn), for general funding support; medical wire & equipment ltd., for donating some of the sampling swabs; ausdiagnostics uk ltd., for donating the respiratory multiplex pcr tests. none of the authors have any conflicts of interest to declare. key: cord- - lclcf x authors: tibary, a.; rodriguez, j.; sandoval, s. title: reproductive emergencies in camelids date: - - journal: theriogenology doi: . /j.theriogenology. . . sha: doc_id: cord_uid: lclcf x emergencies in theriogenology practice go beyond just saving the life of the patient, but also preserving its reproductive abilities. camelid emergency medicine is a relatively new field. this paper discusses the most common reproductive emergencies, their diagnosis, treatment, and prognosis in male and female camelids. the conclusions drawn are based primarily on clinical observations by the authors over the last years. special consideration is given to peculiarities of the species, particularly in the choice of obstetrical manipulations and therapies. in theriogenology practice, emergencies are defined not only in terms of concerns for the welfare of the patient, but also for its future reproductive life. the challenge often faced with reproductive emergencies is how to preserve the life of the patient and maximize the chance to maintain reproductive ability. in camelids, this is even more important, as assisted reproductive technologies have either not yet been perfected (semen preservation, in vitro embryo production, nuclear transfer) or are not allowed (embryo transfer) by some breed registries. in the case of pregnant females, which constitute the majority of reproductive emergencies, the life and welfare of the neonate must also be considered. the objective of the present paper is to review the most common reproductive emergencies in male, female, and neonatal camelids. this review draws primarily on the clinical experience of the authors, as there are very limited controlled studies regarding clinical reproduction and emergency care in camelids. although many disease processes that present as emergencies may have some severe repercussions on the reproductive process in the male, our review will be limited to diseases and accidents with sudden onset that are directly linked to the urogenital system. reproductive emergencies in the male camelid are primarily due to sudden onset of visible abnormalities in the external genitalia. these abnormalities can be summarized as acute scrotal or preputial swelling, preputial prolapse or paraphymosis, and post-surgical emergencies [ ] [ ] [ ] . in camels, preputial swelling is also a primary clinical sign of acute trypanosomiasis, a disease with high morbidity and mortality in many countries where camel breeding is important [ ] . www.theriojournal.com . . general approach to examination of the male for reproductive emergency as with any other emergency, accurate body weight, body condition score, physical examination, degree of dehydration, baseline complete blood count (cbc), blood biochemistry, and urinalysis should be part of the initial evaluation. immediate placement of an intravenous catheter is indicated in severely compromised or recumbent animals. ultrasonography of the urogenital organs should also be conducted. testicular thermoregulation is very important for normal spermatogenesis in camelids. therefore, compromised testicular thermoregulation in these animals should considered serious, as the effect on spermatogenesis can be long lasting or permanent. acute scrotal swelling is generally due to heat stress, trauma, or a local or systemic infectious process. testicular torsion and scrotal hernia are commonly considered as differential diagnoses in other large animal species, but have never been encountered in camelids in our practice [ ] . scrotal and preputial edema and development of severe hydrocele are features of heat stress in the male llama and alpaca [ ] . this syndrome is relatively common in the usa. factors predisposing to heat stress include prolonged high ambient temperature and humidity, inadequate shade, long fleece, dark coat color, and obesity. the risk for heat stress is exacerbated by stresses such as transportation, exercise, fighting, and breeding [ , ] . hyperthermia results from impaired evaporative cooling, particularly under hot and humid conditions [ ] . scrotal edema may be the first clinical sign in the male. the exact pathophysiology of the scrotal and ventral abdominal edema is not well understood. contributing factors may include inability of the pampiniform plexus and testicular artery to cope with the fluid turnover, or vascular thermal injury resulting in impaired wall permeability and extravasation of intravascular proteins, electrolytes, and fluid into the interstitium. many cases may resolve spontaneously, but leave the male infertile for various intervals, usually lasting from months to years [ ] . spermatogenesis (sperm production and semen quality) was severely impaired in llamas housed at an ambient temperature of c for weeks [ ] . these temperatures, relatively common in summer months in many countries outside the native range of south american camelids, can result in infertility due to decreased sperm numbers, decreased motility, and increased abnormalities. the heat index (ambient temperature  humidity) would cause even more severe changes in hot and humid summers [ ] . in advanced cases, other clinical signs appear and include hyperthermia, increased salivation, anorexia, depression, ataxia, muscular weakness, dehydration, ketosis/hepatic lipidosis, and dyspnea/hyperpnea [ , ] . these animals generally display an inflammatory or stress leukogram. anemia may be secondary to hemolysis. serum biochemical abnormalities may include hypophosphatemia, hypocalcaemia, hypomagnesaemia, hyponatremia, hypochloridemia, hypo-or hyperkalemia, hyperglycemia, and elevated serum ast and cpk concentrations. serum glucose concentration > mg/dl has been associated with a poor prognosis. severe electrolyte imbalances and damage to the thermoregulatory center in the hypothalamus will be the end point of the disease progress in nontreated animals, leading to multi-organ damage or failure and increased mortality [ , ] . stabilization of the heat-stressed animal should include urgent cooling of the core body temperature to the normal range (shearing, spraying the ventral abdomen with cold water, fan), and fluid therapy to rehydrate the animal and correct metabolic abnormalities. intravenous isotonic sodium bicarbonate solution may be required to treat metabolic acidosis. maintenance fluid rates are - and - ml/kg/day in adults and crias, respectively. pulmonary edema is a serious risk if fluids are administered too fast (> ml/ kg/h). palliative therapies against other complications should include nasal oxygen insufflation in hypoxemic patients, nonsteroidal anti-inflammatory drugs (nsaids; e.g. flunixin meglumine), antioxidants (vitamin e and selenium), and broad-spectrum antibiotics. steroids such as dexamethasone may be indicated in advanced cases, but should not be used in females in the second half of pregnancy. therapeutic diuresis with furosemide is indicated in animals with respiratory distress due to pulmonary edema. heat stress is best prevented by timely shearing, adequate hydration (clean, cool water) and providing shade and cooling mechanisms such as sprinklers, a pond, or wading pool. prevention of obesity and reduction of stresses of long transportation, handling and breeding during the hottest part of the day also reduce the risk for heat stress. the primary indicator of heat stress risk is not only the ambient temperature, but also the humidity. the heat stress index (hsi), expressed as the ambient temperature ( f) + humidity (%), is considered too high when it reaches or surpasses (e.g. combination of f and % humidity). traumatic injuries to the scrotal area are relatively common in the male camelid and are usually inflicted by other males; they occur when new, mature males are added to a paddock, particularly when competing for breeding. severe traumatic fighting injuries are more common in camels during the rutting season [ , ] . scrotal traumatic injuries are relatively rare in wild camelids, probably because of their strict social organization. traumatic injuries are often due to bites and can range from a superficial scrotal laceration to severe testicular rupture and hemorrhage. testicular hemorrhage may occur without external lacerations, but requires ultrasonographic evaluation of scrotal contents [ ] . treatment protocols should focus on reducing local swelling, preventing infectious complications, and providing a tetanus toxoid booster. unilateral castration is the treatment method of choice for severe unilateral testicular trauma involving the tunica vaginalis and testis [ ] . testicular and epididymal inflammation may present as an emergency in the male camelid. the most common complaint is a sudden onset of lameness or reluctance to breed and visible swelling of the scrotum. various infectious agents have been reported in cases of orchitis that are spread by hematogenous routes, such as brucella abortus, brucella meletensis and streptococcus equi zooepidemicus, or the agent may ascend from scrotal wounds [ , ] . treatment with systemic antimicrobials is often unrewarding. therefore, for unilateral orchitis, unilateral orchidectomy is the best option for the welfare of the male and salvage of reproductive ability [ , ] . . . acute penile/preputial swelling acute penile or preputial swelling may be due to complications from urolithiasis or traumatic injuries. the etiology of urinary calculi in the camelid is not well understood, but is suggested to be similar to that in other domestic ruminants [ ] [ ] [ ] [ ] [ ] [ ] [ ] . early clinical signs of urethral obstruction often go undetected. some males may show increased straining to defecate, odontoprisis, inappetence and ileus, followed by anorexia, frequent unsuccessful attempts at micturition or dribbling blood tinged urine, and signs of abdominal discomfort [ ] [ ] [ ] [ ] . complications of urethral obstruction include urethral or urinary bladder rupture. this may happen within days of the first clinical signs. in emergency cases, the animal presents with anorexia, inability to pass urine, and signs of depression. physical examination often reveals tachycardia, tachypnea, and elevated rectal temperature. complete blood count may reveal an elevated white cell count and neutrophilia with a left shift, increases in fibrinogen, increased creatinine kinase and aspartate aminotransferase activity, hyperglycemia, hypercreatininemia and increased urea nitrogen. serum electrolyte abnormalities included hyponatraemia, hypochloraemia, and hyperkalaemia. fluid obtained by abdominocentesis or from the preputial swelling has increased creatinine concentration [ ] [ ] [ ] [ ] [ ] . increased serum urea nitrogen and creatinine concentrations suggest uroperitoneum [ ] . transcutaneous ultrasonography of the ventral abdomen may enable visualization of subcutaneous free fluid and tissue edema in the case of urethral rupture and a large volume of free fluid in the abdominal cavity in the case of urinary bladder rupture. with the latter, it may not be possible to visualize the urinary bladder. transrectal ultrasonography may reveal dilation of the pelvic urethra if the bladder is intact. the prognosis is grave if there is hydroureter and hydronephrosis [ ] . uroliths are often located in the distal penile urethra, approximately - cm from the penile orifice, but are occasionally immediately proximal to the sigmoid flexure. camelids, like domestic ruminants, have a urethral recess at the ischial arch, making catheterization of the urinary bladder exceedingly difficult. management techniques for obstructive urolithiais is similar to those reported in ruminants and include repair of the ruptured urinary bladder and relief of the obstruction via retrograde flushing and urethrotomy. however, these techniques do not salvage the reproductive career of the animal. flushing, followed by tube cystotomy, may be the only option to try to salvage the reproductive life of the animal [ ] . postsurgical management should include multiple therapies, including antimicrobial (procaine penicillin, , iu/kg im, twice daily; and gentamicin sulphate, . mg/kg iv, once daily), anti-inflammatory (flunixin meglumine, mg/kg iv, twice daily) and intravenous fluids. prognosis for life is fair, but prognosis for return to breeding is usually guarded [ ] . preputial lacerations are relatively common in breeding males. they are usually a consequence of masturbation (breeding the ground or objects) or complications from foreign objects within the prepuce. hair-ring lacerations of the penis are common in llamas and suri alpacas. males may present because the owner has observed an abnormal protrusion of the prepuce, or discomfort during urination or mating. however, bloody or purulent discharge may be the only clinical sign. preputial and penile lacerations can quickly become complicated and jeopardize the reproductive life of the male due to development of severe inflammation and adhesions. injured males may continue to attempt breeding, further exacerbating the lesions [ ] . evaluation of penile and preputial injuries is best performed under heavy sedation or general anesthesia. the penis should be completely exteriorized and inspected for lesions. early management of preputial and penile injuries should center on providing adequate protection of the traumatized tissue and prevention of infection and complication with urine scalding. the initial treatment is to replace viable prolapsed preputial mucosa and maintain it in place with a purse string suture. daily cleaning of the sheath with saline, and application of local anti-inflammatory and antimicrobial ointment (petercillin) for - days will reduce the chance of further complications. sutures may be removed after - days. excessive preputial prolapse with slight necrosis requires circumferential resection and anastomosis of the prepuce. prognosis for return to normal breeding activity is poor if adhesions or abscesses develop at the base of the prepuce [ , ] . the most common post-surgical complication in the male camelid is post-castration hemorrhage, often secondary to inadequate time to insure hemostasis of the testicular cord. management of these conditions is not different from other species and includes placing the male in a calm environment and packing the bursa for - h. several commercial hemostatic agents are available and may be helpful [ ] . exteriorization of the soft palate (dulla) is a characteristic rutting behavior in the dromedary camel [ ] . furthermore, permanent exteriorization of the soft palate during the rut season is a common in the dromedary. this usually starts with an impaction of the diverticulum with food or a foreign body [ , ] . part of the impacted soft palate becomes trapped under the molars and is traumatized during mastication. traumatic lesions of the soft palate range in severity from superficial cuts and bruises to severe lacerations accompanied by hemorrhage; these lesions are rapidly complicated by infection and development of severe inflammation and edema. formation of large abscesses is not uncommon. in most cases, the inflamed organ is permanently hanging from the side of the mouth and becomes progressively necrotic [ ] [ ] [ ] . in a few cases, the soft palate is swollen, but not exteriorized, and blocks air exchange, which may lead to asphyxiation. if the condition is not treated, the animals become emaciated due to dysphagia and impairment of mastication and deglutition. management of these cases requires surgical ablation of the soft palate [ ] . surgical excision of the soft palate can be performed under heavy sedation and a local block. large vessels are ligated with resorbable suture material. laser ablation is the best approach. postsurgical management includes administration of nsaids, antimicrobials, and tetanus prophylaxis. animals should be on soft feed for at least - days after surgery. urethral rupture and subcutaneous infiltration of urine is relatively common in draught camels and is due to a tight strap. advanced stages are managed surgically by complete urethrostomy. animals present with varying degrees of ventral swelling and prolapse of mucocutaneous junction of the penis and prepuce. tissue necrosis is common, and may include the penis due to pressure ischemia. surgical debridement [ ] , phalectomy, or both, may be required [ ] . reproductive emergencies in female camelidae can be divided into emergencies occurring in the nonpregnant female, severe pregnancy complications, obstetrical emergencies, and postpartum emergencies. emergencies requiring intervention during parturition and the immediate postpartum phase must concurrently take into account emergencies pertaining to the neonate. the most common reproductive emergencies in nonpregnant females are traumatic injuries during breeding or iatrogenic injuries during reproductive examinations. although rare, breeding trauma may occur during an unsupervised paddock mating. in camels, traumatic injuries are not always restricted to the reproductive tract, and include bite wounds and fractures of the pelvis and/or dislocations. these traumatic injuries are seen in multiple-sire breeding systems. in south american camelids, breeding trauma may occur by heavy llama males trying to breed alpacas. discussion of these types of traumatic injuries are beyond the scope of this paper, but should be considered in downer syndrome in females with a history of recent (< h) mating. iatrogenic traumatic injuries are by far the most common emergency in camelid practice; they include perforation of the rectum, colon, vagina, or uterus. anal sphincter bleeding due to excessive stretching and rectal prolapse can occur secondary to transrectal palpation, particularly when there is already a predisposing factor for excessive straining (e.g. pelvic mass, urinary bladder disease). however, these are not life threatening and can be managed successfully with sedation, a caudal epidural, and protection of the prolapsed tissue. rectal and colonic injuries have been reported in llamas and alpacas, and are a common reason for malpractice suits. rectal or colonic injuries may happen during breeding, but they more commonly are due to excessive manipulation during transrectal palpation or ultrasonography [ , ] . the examiner will usually recognize that an injury has occurred when palpating llamas and camels. however, in alpacas, when the ultrasound transducer is mounted on an extension for reproductive examination, the practitioner may not detect evidence of perforation until it is too late. the amount of blood retrieved with the palpating hand is variable; it is the sensation of rupture or tear that is most indicative of the seriousness of the injury. since the distance between the anus and the peritoneal reflection is very short ( - cm in alpacas, cm in llamas, and - cm in camel), complete rectal tears in camelids are rapidly complicated by peritonitis. often the only clinical sign is reluctance to stand, lethargy and progressive dehydration a few hours after a reproductive examination. severe toxic shock and death follows within - h if no medical action is taken. all suspected rectal or colonic injuries should be immediately referred to a surgical facility. the animal should be sedated and started on intravenous antimicrobial and anti-inflammatory therapy for transport. further evaluation at the referral facility includes cbc, blood chemistry, transabdominal ultrasonography, and abdominocentesis. animals with evidence of peritonitis should be immediately prepared for surgical correction by celiotomy or celiotomy and pubic symphysiotomy to allow peritoneal lavage. stable patients without alarming changes in their blood and peritoneal fluid characteristics may be further evaluated under epidural anesthesia to decide if a transanal repair is possible. evaluation of the injury can be performed under general anesthesia. the anal sphincter is dilated using stay sutures on the mucocutaneous junction. gentle evacuation of the rectal cavity may be attempted by low-power vacuum aspiration until the lesions can be visualized. use of a flexible videoendoscope can facilitate this evaluation. in llamas and camels, lacerations due to transrectal palpation are usually located in the ventral aspect of the rectum, - cm anterior to the anus. however, in alpacas, particularly when the perforation has occurred with a transducer mounted on an extension, the lesion can be dorsal. also, in these cases, the presence of more than one perforation is possible, perhaps due to faulty alignment between the extremity of the transducer and the extension rod. transanal repair is successful if the laceration is not deep [ ] . celiotomy with pubic symphysiotomy is the only option for caudal injuries and in particular for alpacas. successful repair of rectal and colonic injuries by celiotomy or celiotomy/pubic symphysiotomy has been reported in a few llamas [ ] . preventive measures for colonic rectal injuries include use of caution when choosing the candidate for transrectal palpation, ample lubrication, and cautious use of an extension rod, particularly in maiden or agitated females. sedation of the female or relaxation of the rectum and rectal sphincter may be obtained by epidural anesthesia or instillation of % lidocaine into the rectal cavity before examination. most cases of uterine perforations seen in our practice are iatrogenic, due to aggressive placement of foley catheters, infusion pipettes, and biopsy forceps. these are more common in alpacas than in llamas and camels. they become an emergency if a major blood vessel is damaged, or if an irritating substance (e.g. iodine) is infused into the abdominal cavity. females with these injuries may present with colicky signs consistent with peritonitis or hemoperitoneum. anemia is a feature if there is sufficient blood loss; for example, one animal had a pcv of % following an endometrial biopsy. suspicion is based on a history of recent gynecological examination and the feel of a ''pop'' during manipulation. the patient should be worked up as for any case of colic of abdominal origin [ ] . supportive therapy includes nsaid's and antimicrobials. blood transfusion and surgical intervention may be indicated if the pcv is < %. vaginal perforation with severe bleeding may be controlled by vaginal compression packs. any clinical syndrome occurring during pregnancy may have a serious effect on the fetus. therefore, monitoring fetal well-being should be part of any protocol for medical management of the pregnant female and particularly in the case of emergencies. camelids rely exclusively on the cl for progesterone secretion and maintenance of pregnancy. therefore, severe illness associated with an inflammatory or extreme stress response may rapidly lead to luteolysis and abortion (with all its complications). pregnant females may present with a variety of emergency clinical syndromes, ranging from severe colic, downer (lateral or sternal continuous recumbency), anorexia, diarrhea, depression, neurologic conditions, excessive straining, vaginal discharge, premature lactation, vulvar dilation, or vaginal prolapse. some of these presentations may have a genital origin. the cardinal rules in handling emergencies in the pregnant females are a thorough physical evaluation of the dam, evaluation of the fetus, and ruling in or out the genital origin of the presenting complaint after stabilization of the dam. the main emergencies of genital origin in the pregnant female are uterine torsion, vaginal prolapse, impending abortion, and uterine rupture. the main complication of any emergency in late pregnant females is hepatic lipidosis. pregnancy can also exacerbate clinical diseases. for example, in a recent outbreak of respiratory diseases in alpacas and llamas in north america, morbidity and mortality was highest in females in their last trimester of pregnancy. an important principle in our practice is that any suspicion by an owner that ''something is wrong'' with a pregnant female is taken seriously. behavioral assessment may be conducted while taking history, unless the female is obviously depressed or painful. a detailed history should be obtained and include breeding dates, time and methods used for pregnancy diagnosis, history of previous illness of reproductive disorders, onset and duration of the clinical problem, and recent treatments. if the female is obviously in severe distress, blood samples should be taken immediately and the female stabilized before further examination. oxygen therapy may be indicated for severely compromised females. a jugular catheter should be placed immediately to allow fluid therapy and emergency anesthesia if needed. sedation may be needed for some females in order to complete evaluation. choices of drugs and dosage for sedation should take into account their effect on the fetus. butorphanol tartrate ( . - . mg/kg) provides good sedation and has minimal effect on the cardiovascular system. however, there is a mild decrease in systemic vascular resistance that can be relevant if uterine blood flow is already compromised [ ] . transabdominal ultrasonography should be used to determine fetal well-being, and the integrity of the uterus and placenta. in addition to the reproductive organs, abdominal viscera and the peritoneal cavity should be assessed [ ] . in advanced pregnancy, imaging of abdominal viscera becomes very difficult in the absence of severe displacement. for complete imaging of abdominal contents, the lower abdomen should be clipped and cleaned with alcohol from the xyphoid region to the base of the mammary gland. the area to be examined may need to be extended dorsally to the flank in order to visualize the dorsal aspect of the abdomen and the kidneys. cranially, the projection area of the liver may also need to be prepared for examination. for transabdominal ultrasonography, a mhz linear-array transducer may be sufficient for mid-pregnancy and in small patients, whereas in the last trimester, the use of a . - . mhz sector transducer provides better penetration and imaging of the abdomen. transabdomimal ultrasonography may also be used to locate distinct pockets of free peritoneal fluid and to perform abdominocentesis. other imaging techniques such as radiography, mri or ct scanning may be indicated in the case of downer females, but they are not routine procedures and are only a possibility in referral centers. following transabdominal ultrasonography, transrectal palpation and ultrasonography should be performed, albeit, cautiously, as this may cause additional stress. administration of an epidural and infusion of a mixture of lidocaine and lubricant in the rectal cavity may reduce straining, provide some relaxation, and facilitate the examination in llamas and alpacas. the primary objective of transrectal palpation is to determine the location and direction of the broad ligaments and evaluate the caudal abdomen for any masses or abnormalities of the pelvic area, kidneys, and urinary bladder. transrectal palpation in the female sitting in a sternal position may offer some challenges for the inexperienced practitioner. the quantity and quality of fecal material in the rectal cavity should be evaluated. severely stressed camelids often have profuse diarrhea, whereas an absence of fecal material and/or the presence of scant mucoid feces may be due to intestinal transit disorders or tenesmus. vaginal examination should be performed with a speculum after thoroughly cleaning the perineal area. the speculum should be advanced slowly, while concurrently examining the vagina for any abnormalities. the cervix is evaluated for the degree of relaxation and opening. the cervix of the llama and alpaca is often difficult to visualize during late pregnancy, but it should be obvious if it is patent. manual examination of the vagina and cervix may be indicated in some cases, but this procedure is often limited by the size of the examiner's hands. assessment of fetal well-being is an important component in the evaluation of medical crises. unfortunately, there is a paucity of information regarding fetal biophysical characteristics in camelids. however, based on clinical experience in the authors' laboratory, the two main indicators for fetal distress are fetal heart rate and rhythm. normal fetal heart rate in mid-to late-pregnancy range from . to . times that of the dam. in that regard, fetal heart rate is usually - bpm in the last trimester of pregnancy, but decreases to bpm a few days before parturition. fetal heart rates that are consistently > or < bpm suggest fetal distress. the fetal heart rhythm should be regular and respond to phase of activity by a - % increase in rate. fetal activity is maximal in the first half of pregnancy, but substantially reduced in the last months. the entire fetus should be examined to determine fetal position and number. normal fetal positioning for parturition appears to occur a few hours before parturition. it is not uncommon to image the fetus low in the abdomen with the dorsum against the diaphragm and all limbs pointing to the pelvic area. transverse position of the fetus in the abdomen does not mean a transverse position inside the horn, but rather reflects the position of the entire pregnant horn. that the fetus is entirely in the left horn and the special arrangement of the pregnant horn vis-à-vis the abdominal viscera may contribute to signs of discomfort in some females in late pregnancy. late in pregnancy, the presence of twins is best confirmed by abdominal radiography [ ] . fetal biometrics may provide data regarding fetal growth and stage of pregnancy, but in our experience, most measurements are not very accurate and cannot be used for physical bioprofiling [ , ] . fetal fluids are difficult to assess, due to the low volume of amniotic and allantoic fluid in camelids. uteroplacental thickness should be evaluated in the horn containing the fetus (left horn) only, as the placenta may appear thicker in the nonpregnant horn. the combined uteroplacental thickness should be < mm in the last trimester. excessive edema of the uterine horn or premature placental detachment are relatively easy to detect and require immediate intervention if the female is at term. a minimum baseline evaluation of a severely depressed or colicky pregnant female should include complete blood count (cbc), blood chemistry, and fibrinogen. evaluation of peritoneal fluid (abdominocentesis), fecal evaluation, and urinalysis should be considered in select cases. although a stress leukogram is often present in many females, neutrophil count, immature neutrophil count, neutrophil morphology, packed cell volume, and fibrinogen concentration are very valuable in evaluating inflammatory and toxic states. anemia may be due to blood loss, or the onset of other problems such as mycoplasma hemolamae. blood chemistry will determine electrolyte imbalances and risk for hepatic lipidosis, a major concern in anorectic, stressed pregnant females. hypoprotenemia is often present in old pregnant females and may predispose to metabolic complications. in some cases, the serum may be grossly hyperlipemic (white). however, lipemia and ketonemia are not always present in hepatic lipidosis. elevated concentrations of nonesterified fatty acid (nefa; > mmol/l) and b-hydroxybutyrate (bhb) are important indicators of stress and liver compromise. liver compromise is also indicated by elevated bile acids, gamma-glutamyl transferase, aspartate transaminase, and sorbitol dehydrogenase [ , ] . furthermore, arginal calcium and magnesium concentrations or hypocalcemia may be present in late-pregnant females and require correction and monitoring. progesterone is the major hormone evaluated routinely during pregnancy [ , ] . determining baseline progesterone concentration is a good practice if an assay is readily available. the cl is the primary source of progesterone throughout pregnancy in camelids; pregnancy cannot be maintained if blood progesterone concentrations are < ng/ml [ ] . progesterone concentrations may be substantially altered by level of hydration and weight and body condition score of the female. progesterone supplementation is still a subject of debate. estrone sulfate concentrations in plasma increase after days of pregnancy, reaching a peak immediately before parturition. determination of relaxin concentration may be helpful in the evaluation of placental function, but this assay is not widely used [ ] . there are no studies on the effect of a compromised liver (typically due to hepatic lipidosis) on steroid metabolism and blood steroid concentrations. supportive therapy in pregnant females depends on the symptoms and degree of compromise. it may include oxygen therapy, fluid therapy, antimicrobials, and nsaid's. compromised pregnant females should be placed immediately on broad spectrum systemic antimicrobials. our primary choices of antimicrobials have been ceftiofur in alpacas and llamas and longacting tetracycline in camels. uterine torsion remains the main genital cause of colic or depression in pregnant new world camelids. there are no detailed studies regarding the epidemiology of this disorder. it is noteworthy that uterine torsion is not common in camels (a. tibary, unpublished observations), nor is it common in llamas and alpacas in south america (j. sumar, personal communication). perhaps this apparent difference is due to nutrition or body size. in our experience, there are two common stages of pregnancy at presentation: - months and at parturition. clinical signs of uterine torsion are quite variable, ranging from mild discomfort to severe colic, diarrhea, and anorexia. we have had cases present simply as ''quieter than usual'' and ''decreased appetite'' or ''just a little off her normal routine'' [ ] . the female may display signs of pain, circling, kicking at the belly, lateral recumbency, and excessive vocalization. tachypnea and tachycardia are very common. the cbc and blood chemistry are consistent with a stress leukogram, with various metabolic changes (hepatic lipidosis) depending on the duration and severity of the problem [ ] . diagnosis is based on transrectal palpation of the broad ligaments, as described in other large animal species [ , ] . clockwise torsion is indicated if the left broad ligament is stretched across midline to the right and over the uterus, whereas the right ligament is shorter and pulled ventrally and medially under the uterus. palpation of the broad ligament may elicit a severe painful reaction. difficulties encountered in transrectal evaluation for uterine torsion include physical limitations, particularly in alpacas (tight anal sphincter, narrow pelvis and size of the examiner's hand and arm), as well as a lack of experience palpating late-pregnant camelids in a sternal position. although diagnosis by vaginal palpation has been reported by practitioners, in our experience, it is not reliable unless the torsion includes the cervix. with a severe colic, a definitive diagnosis may not be possible until exploratory laparotomy. alternatively, the female could be palpated under general anesthesia, which provides greater relaxation of the anal sphincter and perineal area [ ] . transrectal ultrasonography may sometimes reveal increased dilation of the blood vessels. although it was reported that the majority (> %) of camelid uterine torsions are clockwise [ ] , this has not been our experience; therefore, direction of the torsion needs to be ascertained before attempting nonsurgical correction. correction of uterine torsion can be accomplished nonsurgically by rolling or surgically after coeliotomy. both techniques are very efficient. rolling should be considered only if the uterus and its vasculature are not compromised. rolling may be performed done under general anesthesia, sedation, or without sedation. the female is placed on lateral recumbency on the side of the direction of the torsion and rolled while the fetus is maintained in position with a small plank or with the fists [ , ] . the pain usually disappears immediately after correction of the torsion and females may return to normal activity immediately. however, if they have been anorexic, correction of metabolic disorders should included in post-surgical management. surgical correction may be performed following flank or midline laparotomy. midline laparotomy is the preferred method in late pregnancy [ ] [ ] [ ] [ ] . the success rate of both rolling and surgical correction is very high, as is survival of the fetus. no special management is needed if the torsion has been diagnosed and corrected early. however, anorexia and pain may cause hepatic lipidosis, in which case the patient should be placed on broad spectrum antimicrobial therapy [ ] . monitoring blood progesterone is useful, particularly if an assay is readily available. the need for progesterone supplementation after correction of a torsion remains controversial. complications of uterine torsion include abortion, uterine rupture/hemorrhage, endotoxemia, and death of the dam [ , ] . splenic torsion concurrent with uterine torsion has been described in one case, with persistent pain following correction of the uterine torsion [ ] . uterine rupture is often secondary to severe or inadequate clinical management of a uterine torsion. females usually present in an advanced stage of shock, in lateral recumbency. abdominocentesis may reveal large amount of serosanguinous or bloody fluid. severe pain with presence of serosanguinous peritoneal fluid may also be due to splenic torsion [ ] . the only option is surgical intervention to remove the fetus and salvage the uterus. complete hysterectomy should be considered if the uterus is severely compromised. vaginal prolapse has been described during the first half of pregnancy, but the condition is more common during the last months of pregnancy [ , [ ] [ ] [ ] . it is likely due to softening of tissues due to increased estrogen concentration during the last part of pregnancy. predisposing factors include age (older females), parity, and body condition (obese and very thin females) [ , ] . the prolapse tissue may be limited to - cm, and visible only in the recumbent female. however, with increased inflammation and edema of the tissues, the degree of prolapse increases and becomes permanently exteriorized. prolapse of the entire vagina and exteriorisation of the cervix is rare, but possible. prolonged periods of prolapse increase inflammation and can cause severe necrosis of the vaginal mucosa, potentially resulting in ascending infectious placentitis. increased tenesmus with risk of abortion and/or rectal prolapse occurs in chronic cases. furthermore, rectal and vaginal prolapse may be the only indications of dystocia or abortion [ ] . the prognosis for the life of the fetus and dam is relatively good if the condition is treated early. in camels, the vaginal tissue is maintained in place with a bühner suture around the vulva. in the alpaca and llama, a shoelace suture pattern is sufficient. more advanced cases of prolapsed vagina with increased tenesmus may require epidural anesthesia [ ] . the animal should be monitored regularly and the suture removed if signs of impending parturition are observed [ ] . other complications of pregnancy in camelids include ventral abdomen herniation, prepartum downer syndrome, metabolic diseases, and premature lactation/ placentitis. hydrops of fetal fluid is extremely rare in camelids. ventral herniation during pregnancy is often a complication of previous abdominal surgeries, including cesarean section. in addition to determining the primary cause of these disorders and assessing the chances for survival of the female, determination of fetal well-being and the possibility of induction of abortion or parturition should be contemplated. abortion can be induced with the prostaglandin f a analogue, cloprostenol ( mg in llamas and alpacas, and mg in camels). the same dose is sufficient for induction of parturition, with good neonatal survival at > days of pregnancy and sufficient mammary gland development and colostrum production. abortion or parturition occurs approximately - h after prostaglandin treatment. in a few situations, a second treatment with a prostaglandin f a analogue is necessary [ ] [ ] [ ] . giving llamas or alpacas > mg of pgf a (dinoprost thrometamine) has been associated with severe respiratory distress. most neonatal deaths occur during birth or shortly thereafter. adequate obstetrical management and monitoring for early signs of distress are closely linked with the chances of survival of the cria and the reproductive future of the dam. proper procedures, immediate neonatal care, and close of observation of the newborn, are the best means of reducing neonatal losses. normal parturition and proper obstetrical techniques have been reviewed in detail elsewhere and are not very different from the approach used in other large animal species (especially horses) [ ] . it is estimated that approximately % of all camelid births will require some assistance and $ % will require advanced obstetrical expertise. obstetrical problems are an emergency in camelids, due to the relatively explosive and short duration of stages of parturition (similar to the mare). all normal births are in an anterior longitudinal presentation. dystocia of maternal origin include uterine inertia, uterine rupture, and failure of appropriate dilation of the cervix or vestibulum [ , , ] . uterine torsion and failure of cervical dilation require delivery by cesarean section. however, it is important to confirm that the dam is at term and to first rule-out uterine torsion [ , ] . dystocia of fetal origin occur most commonly as a result of malpositioning or malposture, and to a lesser degree, presence of malformations, twins, and large fetuses. the most common fetal causes of dystocia are carpal or shoulder flexure or head deviations (lateral and ventral). breech and transverse presentations are possible and are common reasons for cesarean section [ , ] . fetal abnormalities causing dystocia include schistosoma reflexus, contracted tendons, and ankylosis of the hind limbs or neck [ ] . other anomalies that may complicate delivery include fetal anasarca and an emphysematous fetus resulting from fetal death and gas production during decomposition [ ] . although twining is rare in camelids, a few twin births have been reported. delivery of twins may be complicated by both fetuses in the birth canal at the same time. in our experience, all dystocias due to twins required a cesarean section to preserve the integrity of the female reproductive tract [ ] . regarding obstetrical procedures, there are three major differences between camelids and ruminants: ( ) the pelvic inlet is narrower; ( ) the cervix and vaginal are more prone to laceration and severe inflammation (often leading to adhesions); ( ) risks for neonatal hypoxia and death are increased by the forceful uterine and abdominal contractions and the rapid detachment of the microcotyledonary placenta. consequently, ( ) early recognition of dystocia is paramount, ( ) obstetrical decisions and manipulations should be rapid, and ( ) supportive care should be provided to the dam and fetus (if alive) before and during manipulation. dystocia is recognized by prolongation of the first or second stage of labor. assessment of the health of the female and viability of the fetus is the first step in managing obstetrical cases. providing analgesia (epidural and administration of butorphanol) may facilitate examination of the parturient alpaca. prolongation of the first stage of parturition is primarily due to failure of cervical relaxation and uterine torsion [ ] . examination of the parturient female is continued by vaginal palpation to judge cervical dilation, determine the presentation, posture and position of the fetus and its viability, and to formulate a course of action based on the findings. abdominal radiography may be helpful in determining position, posture and number of fetuses in alpacas [ , ] . fetal manipulations are similar to other species, but need to be restricted to a maximum of - min. a different approach should be attempted if fetal position, presentation, and posture suggest that manipulation is not possible, or if manipulations are not fruitful after min. we consider that fetotomy is not an option in alpacas and most llamas and camels. surgical relief of dystocia (cesarean section) remains the best approach if controlled vaginal delivery cannot be achieved in < min. techniques for cesarean delivery in camelids are well described [ , ] . we recommend a flank approach in camels and any severely compromised dam. this technique does not require deep general anesthesia and can be performed under sedation and a regional block, which is a good choice under field conditions. a midline celiotomy approach is ideal if the uterus is compromised or needs to be completely exteriorized [ , ] . regardless of the type of obstetrical intervention, adequate oxygen delivery to the uterus is essential for a healthy neonate. reducing uterine blood flow or oxygen-carrying capacity of the blood is liable to harm the fetus and may increase fetal or neonatal mortality. in most species, uterine blood flow is reduced when the dam is exposed to pain or stressful conditions. sedatives, analgesics, and anesthetics may all supress cardiac output and therefore decrease blood flow to the fetus. in addition, certain drugs or drug combinations may further decrease uteroplacental perfusion, due to their tonic effect on the myometrium. unfortunately, there are no studies on the effects of anesthetics on the uterus and fetus in camelid. xylazine, a drug of choice for sedation of camelids in the field, markedly reduced blood flow (by as much as %) and availability of oxygen to the uterus. furthermore, min after xylazine treatment, uterine artery resistance increased by %. xylazine has also been associated with increased myometrial contraction in ruminants and could cause increase fetal morbidity and mortality, at least in these species [ , ] . this effect was not significant in mares. there are no studies on the effect of xylazine on uterine perfusion in camelids. in sheep, the fetus responds to hypoxia, hypotension and hypovolumia with increased concentrations of acth, vasopressin and cortisol, via activation of the hypothalamic-pituitary axis, mediated by changes in afferent neural activity of arterial baroreceptors and chemoreceptors; it has been suggested that the fetal response is primarily mediated through chemoreceptors [ ] . ketamine, a dissociative anesthetic and known noncompetitive inhibitor of glutamatergic n-methyl-daspartate (nmda) receptors, blocks the fetal reflex bradycardic response to maternal ventilatory hypoxia and may not be a good choice for anesthesia. this corroborates our observations in camelids where use of ketamine as a preanesthesic has been associated with severely depressed neonates. propofol ( , -di-isopylphenol compound) is a small molecule that is rapidly metabolized; its advantages are rapid onset and offset of action and redistribution from the central nervous system. even with continuous propofol anesthesia, maternal and fetal heart rate and blood pressure were not affected in pregnant ewes [ ] . this makes the drug ideal for induction of anesthesia for cesarean section or for surgical management of uterine torsion. propofol decreased myometrial activity in the gravid ovine uterus in vivo [ ] and in uterine muscle from gravid humans in vitro [ ] . in vivo, there is no effect on placental perfusion. it can induce a transient tachycardia and decrease in po and ph in the dam, but these effects have minimal repercussions on fetal heart rate and blood pressure. because propofol is primarily metabolized by the liver, it should be used with caution in females with hepatic lipidosis. maintenance of general anesthesia with isoflurane or sevoflurane are ideal, because these inhalation anesthetics are rapidly eliminated [ ] . the combination propofol/isoflurane has been used successfully by our group in emergency cesarean section in camelids; a similar combination was also very good for cesarean section in the bitch [ , ] . it is noteworthy that the effects of these anesthetics may be exacerbated by pre-existing conditions in the fetus (e.g. hypoxia) [ , , ] . postpartum emergencies are often due to complications of obstetrical situations. however, females may present for emergency critical care with a history of what appears to have been an uncomplicated parturition. in addition to the primary genital problems that may alarm the owner (i.e. traumatic injuries, bleeding, uterine prolapse, and retained placenta) some of these cases present with ataxia, prolonged recumbency, and varying degrees of anorexia or depression as primary complaint. evaluation of the postpartum female should include a complete history and a detailed account of the obstetrical situation, including delivery of the placenta. the female should be assessed by complete physical examination, cbc, blood chemistry, transabdominal and transrectal ultrasonography, and vaginal examination. excessive fluid in the abdomen would warrant abdominocentesis. due to their small perineal body and powerful expulsive efforts, rectal-vaginal tear is common following overt obstetrical manipulations in camelids. a common cause of these tears is rapid vaginal delivery of the fetus without sufficient preparation of the vulva and vestibular area. episiotomy should be considered in females with insufficient dilation of the vulva, particularly maidens. cases seen in our practice are often a complication of fetotomy. rectal-vaginal tears may be repaired immediately, or a few weeks later, after second-intention healing [ ] . postpartum uterine tears are not as dramatic as in the mare, unless there is involvement of a large vessel or severe contamination of the uterus and peritonitis. uterine bruising is often seen following excessive obstetrical manipulation (particularly fetotomy). uterine involution is very rapid in the camelid and small, dorsal uterine tears may heal spontaneously; the only sequela may be infertility due to peri-uterine adhesions. complications from uterine tears are often due to severe contamination, either during obstetrical manipulation or following partial or total retention of the placenta [ ] . these females may initially appear comfortable, then slowly develop a fulminating peritonitis. clinical signs of toxemia may appear within the first h, but it may take as long as - days for the clinical picture to become recognizable. it is important that these cases be stabilized, with antimicrobial and anti-inflammatory therapy initiated at the first sign of compromise. uterine lavage should be considered only after verification of the integrity of the uterine wall and should be monitored by transabdominal ultrasonography to visualize remnants of the placenta. a case of complete passage of the placenta into the abdominal cavity was described in a llama with progressive deterioration of health, which eventually succumbed to peritonitis days after dystocia [ ] . it is not clear how uterine tears occur in camelids; although most are associated with obstetrical manipulation, we have seen cases following spontaneous and apparently uneventful parturition. therefore, every female should be monitored to ensure delivery of the placenta, followed by inspection of the placenta to ensure that it is complete. the camelid placenta is epitheliochorial, mircocotytledonary and is rarely retained more than h, even after dystocia. if a uterine tear is detected in the early postpartum period by direct vaginal palpation, an attempt could be made to induce uterine prolapse after treatment with epinephrine and epidural anesthesia. alternately, the uterine tear can be repaired after celiotomy. if the placenta is still present, it should be pealed from the endometrium around the tear before suturing. in cases of unexplained fever, abdominal pain or anorexia in the postpartum female, exploratory celiotomy or laparoscopy should be considered. adjunctive therapy for peritonitis is indicated and should include abdominal lavage and systemic broad-spectrum antimicrobial and anti-inflammatory therapy, along with intravenous fluid therapy for cardiovascular support. postpartum hemorrhage from the uterine arteries is less common in camelids than mares. most of the postpartum hemorrhage cases diagnosed by our group consist of rupture or laceration of the vaginal uterine artery. this artery is easily recognized by palpation per vaginum during obstetrical manipulation and is peculiarly large in camelids. excessive manipulation, and in particular fetotomy, may cause erosion of the mucosa and laceration of the artery. unfortunately, many of these hemorrhages are missed, as no outward signs are apparent until it is too late. typically, blood accumulates within the uterus for a few hours, followed by cardiovascular collapse. in one case, the female was found dead in her stall h after delivery. ruptured vaginal arteries may be sutured and blood transfusion should be considered in females with a pcv < %. packing of the vaginal with compresses, i.e. a device similar to the ''umbrella pack'' used in humans, may be helpful. partial or total uterine prolapse occur secondary to dystocia, manual removal of a retained placenta, and excessive use of oxytocin (dose and frequency). uterine prolapse is far more common in camels than in llamas and alpacas, and is often associated with hypocalcemia, selenium deficiencies, and retained placenta [ , ] . dairy camels seem to be more prone to uterine prolapse [ ] [ ] [ ] [ ] [ ] [ ] [ ] . uterine prolapse occurs generally immediately (first min) after parturition or abortion [ ] . techniques for replacement are similar to those reported in cattle and small ruminants, and are usually done under sedation and epidural analgesia. the placenta is often easily peeled off and should be removed if possible before replacement of the uterus. the female is positioned in sternal recumbency, with the hind quarters slightly elevated. the uterus should be inspected for any lacerations or hemorrhage. the area of major risk for hemorrhage is located near the cervix where the uterine artery may be exposed. the uterus is cleaned with warm dilute povidone iodine solution before replacement. a bühner suture is used in camels and a shoelace pattern can be used around the vulvar lips in alpacas and llamas. uterine prolapse tends to reoccur if the uterine horns are not fully extended. hysterectomy should be considered if the uterine tissue has sustained severe damage [ , , ] . rectal prolapse has been reported in llamas and camels. pregnant females with tenesmus and diarrhea are predisposed. rectal prolapse can be intermittent. in a case of a dromedary female near term, rectal prolapse was noticed intermittently, without vaginal prolapse. treatment of the underlying cause and surgical repair have been successful [ , ] . emergency postpartum complications in camelids include a vast array of conditions which often manifest themselves as lethargy, depression and progress towards a downer female syndrome. the approach to diagnosis of the causes of downer syndrome is similar to that used in cattle [ ] . predisposing factors include septic metritis, necrotic vaginitis, retained placenta, hypocalcemia, dystocia, pelvic injuries, hemorrhage, and presence of compressive lesions. a milk fever syndrome (hypocalcemia), similar to the condition in dairy cattle, is also observed in dairy camels. toxic mastitis has been described in dairy camels, but not in south american camelids [ ] . in addition to physical evaluation, cbc and blood biochemistry, the evaluation of the downer postpartum camelid should include transrectal and transabdominal ultrasonography and potentially collection and evaluation of cerebrospinal fluid. more advanced imaging techniques may be required in some cases in order to detect neoplastic masses. although, retained placenta is not usually an emergency in camelids, failure of delivery of the placenta following a cesarean section may lead to severe complications. severe swelling of the vulva and vagina are painful conditions associated with overt obstetrical manipulation. females experiencing these complications may have persistent straining and abandon their neonate. untreated vaginal and cervical inflammation may lead to adhesions and development of pyometra. females with severe inflammation of the birth canal should be treated with systemic and local anti-inflammatory drugs. daily application of cold compresses and treatment with ointments with anti-inflammatory and antimicrobial properties may reduce inflammation and adhesions. in an epidemiological study in the united kingdom, - % of deaths amongst llamas and - % of deaths in alpacas occur during the first months of life. a high proportion of these deaths occur within the first week of life [ , ] . in camels, neonatal mortality can reach % of the calf crop in the first days of life [ ] . newborn morbidity and mortality is very high in the immediate neonatal (< week old) period following obstetrical manipulations, cesarean section, prematurity, or dysmaturity [ ] . these losses are often due to complications from hypoxia, failure of passive transfer, and intrapartum infection. the clinical signs are often nonspecific and vague, resulting in an individual that is slow to adapt to extrauterine life, or that dies suddenly within the first few days of life. infections may be acquired in utero or intrapartum, and should be suspected if the newborn has elevated plasma fibrinogen concentrations in the first - h of life, the placenta appears abnormal, or the dam exhibited uterine discharge peripartum [ ] . therefore, immediate identification and care of the newborn camelid at high risk for sepsis is an important part of reproductive emergencies. the newborn should be evaluated within the first hours of life to detect any abnormalities of development or maladjustment to extra-uterine life. physical and behavioral parameters of the normal newborn are shown ( table ). assessment of the newborn cria should include evaluation of the epidermal membrane and placenta, respiration, cardiac function, and the presence of obvious congenital abnormalities. the epidermal membrane, which is normally translucent, may become yellow or brownish due to meconium staining in case of fetal stress due to dystocia. many congenital abnormalities have been described in camelids, some of which can be lethal. amongst the most important are: cleft palate, choanal atresia, atresia ani, and heart defects. the initial examination of the cria should establish if any of these abnormalities are present (table ) , so they can be corrected early or a decision made to humanely euthanize the cria. neonatal cases are presented with a wide variety of nonspecific complaints based on deviations from the normal appearance and behavior presented above. the minimum database used to evaluate the cria include: evaluation of maternal transfer of immunogobulins, cbc (including differential count and determination of plasma fibrinogen concentration), arterial blood gas analysis, serum chemistry, and aerobic and anaerobic blood cultures. contrast radiographs of the nasopharyngeal area may be indicated if choanal atresia is suspected as a cause of dyspnea [ ] . any cria delivered before day of pregnancy should be considered premature. premature birth may be a consequence of a stressful illness during pregnancy or due to a decision to induce parturition because of severe compromise to the dam. recently, the authors have seen a high rate of premature births following an outbreak of respiratory diseases. premature birth may also be secondary to uterine pathology (i.e. placentitis or placental insufficiency) [ ] . premature crias display specific phenotypic characteristics, including a birth weight significantly (> %) lower that that the average for the farm, and a thick epidermal membrane firmly attached to the foot pads and the mucocutaenous junctions. a ''floppy'' syndrome, often seen in premature camelids, includes inability to rise, to hold the head up, or to maintain sternal recumbency and floppy ears (new world camelids), due to immaturity of the cartilage. the coat appears silky and the limbs are overextended at the carpus and fetlock, due to laxity of the tendon and poor muscle tone. the incisors are not erupted and the suckling reflex is absent or weak. premature neonates adapt to extrauterine life very slowly. due to the normal elevated fetal cortisol concentrations, they may appear healthy initially, but become comprised a few hours later due to developing metabolic problems. these problems are often due to hypoxemia, acidosis, hypoglycemia, and limited body reserves or poor thermogenic ability. premature neonates are exposed to a wide range of respiratory and intestinal compromise due to immaturity of these systems. respiratory distress may be notice by labored or even open-mouth breathing. this syndrome is likely due to lack of surfactants required for normal air sac expansions and inefficient oxygen absorption. mortality rate is very high is these crias if they do not receive immediate attention [ , ] . intestinal immaturity in premature crias predisposes them to failure of passive transfer, even if colostrum is ingested orally in the first hours of life (failure of absorption). they also tend to be more at risk for bloating and meconium retention due to poor gut motility. dysmature or hypoxic neonates are often the result of induction of parturition, severe illness during pregnancy, or prolonged gestation. they usually present with similar biophysical characteristics as the premature neonates, except that they may have normal body development. mature compromised crias are usually the result of lengthy obstetrical manipulation or delivery via cesarean section. the degree of compromise depends on several factors. there is a complete lack of evidence-based medicine in emergency critical care of newborn camelids; most of the available information is anecdotal and based on clinical experience with other species. premature or stressed neonates require intensive care in the first few hours of life. they should be placed immediately in a warm environment. baseline cbc and blood biochemistry are indicated to determination status of hydration and electrolytes, blood glucose concentration, total protein and igg at - h. at-risk patients should receive an intravenous plasma transfusion. if the suckling reflex is absent, tube feeding is necessary and should be restricted to small volumes every - h, to reach - % of body weight by h of life. oxygen supplementation may be required if respiratory distress is pronounced. lung function should be monitored by blood gas analysis. aminophylline, an adenosine a ( a)-receptor antagonist like caffeine, has been given for days to stimulate the central nervous system and regulate breathing and to stimulate the type ii pneumocytes to produce components for the surfactant production [ , ] . intraoperational administration of aminophylline to the dam may be advantageous if a cesarean section is planned [ , ] . doxapram is routinely used to stimulate the central nervous system and relieve neonatal apnea following dystocia or cesarean section [ , ] . we general administer a small dose sublingual ( mg in llama and alpaca crias and mg in camels) initially after a cesarean section or dystocia. in neonates with severely depressed respiration, this dose, or up to twice this dose, should be given iv or iv. the neonate should be monitored closely for convulsions or hyperventilation. sepsis is a major concern in all compromised neonates. in one study, the median age at presentation of [ , , ] . both gram + and gram À organisms have been isolated from neonates with septicemia. based on common isolates, the antibiotics of choice for camelids at high risk of sepsis include the following combinations (enrofloxacin and ppg, enrofloxacin and ceftiofur, ceftiofur and gentamicin) [ , , ] . gentamicin should be used with care, as it can be extremely nephrotoxic to severely dehydrated newborn camelids, or if there is already evidence of renal dysfunction. blood cultures may be submitted, but broad-spectrum antimicrobial treatment should be started without delay. supportive treatment should include nsaids (ketoprofen mg/kg sid) to control pain and toxemia and antiulcer medication (omeprazol, given orally, mg/kg daily) to offset the effect of stress and nsaid. intravenous fluid therapy is indicated in all dehydrated, hypoglycemic newborns, however caution should be exercised regarding the rate of fluid replacement, as camelids are prone to pulmonary edema. severely dehydrated crias require fluid therapy. the type of fluid should be determined based on glucose, electrolyte and blood gas evaluation. generally, a balanced isotonic solution with % dextrose and bicarbonate to correct metabolic acidosis are sufficient. dextrose concentration may be increased to % in hypoglycemic crias. rate of administration should aim to correct half of the deficit over the first hour, and the other half over the next h. total or partial parenteral nutrition should be considered in severely depressed crias that are unable to nurse [ ] . prognosis for life and normal growth depends primarily on the interval between birth and providing emergency care. diseases in the first h of life are usually associated with congenital abnormalities, digestive (meconium retention), urinary problems (urine retention), exposure or malnutrition. the most common lethal congenital abnormalities that affect the camelid neonate are: choanal atresia, atresia ani or coli, and heart defects. most commonly, affected animals will suffer from severe respiratory, circulatory or metabolic complications. heart defects can be very severe and lead to death of the cria within a few hours, but most will survive for a few days to months, with the only abnormality being failure to thrive. syncope or fainting were observed in crias with severe heart defects. choanal atresia is the lack of opening of the nasal air passages, resulting from the presence at the level of the choanae of a membranous or osseous separation between the nasal and pharyngeal cavities [ , ] . diagnosis can be confirmed by mouth to nose artificial breathing or by contrast radiographs of the head after injection of a radio-opaque substance in the nasal cavity. maxillofacial agenesis or dysgenesis ''wry face'' is a head deformity characterized by varying degrees of deviation of the maxilla. this abnormality may be associated with choanal atresia. there is no treatment for this condition and the cria should be euthanized. respiratory distress associated with congenital goiter has been described in camels [ ] . atresia ani and atresia coli are, respectively, the lack of opening of the anal sphincter and lack of connection between the colon and the rectal cavity. these abnormalities results in the blockage of the intestinal transit and accumulation of fluid in the gastrointestinal tract. the cria becomes progressively bloated and depressed. ultrasonographic and radiologic examination of the abdominal cavity allows confirmation of the diagnosis. atresia coli may be mistaken for meconium retention. in the female cria, these abnormalities may involve the genital tract. surgical correction of the atresia ani has described [ ] . congenital blindness associated with different ocular defects has also been reported and will impact neonate behavior and wellness [ ] [ ] [ ] . it is important that the practitioner established the diagnosis of congenital abnormalities with certainty, because some of these may be hereditary [ , ] . meconium is the amniotic fluid ingested by the fetus during pregnancy. meconium is usually passed within - h after birth as dark pasty or stringy feces. clinical signs of meconium retention include straining, squatting, tail wagging, anorexia, and signs of abdominal discomfort. initial treatment consists of one or two warm soapy water enemas ( - ml). if after two enemas, the meconium has not passed, intravenous fluids may be indicated, as multiple soapy water enemas may irritate the rectal mucosa, resulting in severe straining and rectal prolapse [ ] . crias that have retained meconium may have other abnormalities and should be examined closely. routine administration of enemas to every newborn cria should be discouraged. urine retention may be associated with congenital abnormalities of the urinary and genital tracts [ ] . in males, urethral blockage (aplasia) results in bladder rupture. in females, vulvar agenesis or atresia vulvi present with an obvious bulging of the perineum and often symptoms of pain, due to the large quantity of urine in the uterus and abdominal distension [ , ] . accidents to the umbilical stump are not uncommon. the simplest form is persistent bleeding, which can be treated with hemostasis provided by a hemostat or sutures. persistent urachus is not as common as in other species. umblical hernia and rupture of the abdominal wall with eventration has been seen by the author following dystocia due to uterine torsion and may be due to wrapping of the cord around the fetus. these are easily replaced surgically. failure of passive transfer is a major cause of neonatal mortality in camelids [ ] . assessment of igg concentrations can be performed h after birth [ ] [ ] [ ] . serum total protein concentrations < mg/ dl are also very indicative of failure of passive transfer. in these cases, hyperimmune plasma should be given iv or ip ( - ml/kg). commercial products are now available (triple j farm, kent laboratories, jorgensen place, bellingham, wa , usa). this product is collected from llamas regularly immunized with clostridium perfringens type c, escherichia coli bacterin-toxoid, clostridium chauvoeisepticum, clostridium haemolyticum, clostridium novyi, clostridium tetani and clostridium perfringens types c and d bacterin-toxoid, killed equine herpes virus- , bovine rota-coronavirus modified live virus, j- e. coli bacterin, imrad killed rabies vaccine, and inactivated cultures of leptospira canicola, leptospira grippotyphosa, leptospira hardjo, leptospira ichterohaemorrhagiae and leptospira pomona. reproductive emergencies involve not only saving the health but also the reproductive future of the patient. emergencies in the pregnant female present an additional challenge, in that the fetus has to be considered regarding response to treatment and viability. at times, it is important to make a decision as to which of the two (dam or fetus) has more economic or sentimental value, or chances to survive. one of the main challenges in emergency care in camelids is the lack of evidence-based scientific data on treatment and outcome assessment. although extrapolation from other species has been possible, it is important to remember species peculiarities, especially with regard to fluid therapy. handling of obstetrical situations is particularly important, as many female camelids loose their ability to reproduce due to iatrogenic vaginal adhesions and cervical trauma from prolonged manipulation. in the male, hyperthermia (environmental or pathologic) is the leading cause of reproductive loss and client education regarding its prevention and early recognition is paramount for successful preservation of fertility. veterinarians involved in camelid practice, of which reproductive services (including reproductive emergencies and neonatology) represents over % of the complaints, should have a very good understanding regarding anatomical, physiological and medical peculiarities of camelids, and utilize their experience in other species. this makes an excellent point for the importance of comparative approach to training theriogenologists and large animal veterinarians. emergency drugs and protocols (table ) should be in place to ensure timely delivery of critical care and improved outcomes. uro-genital defects, renal agenesis, atresia vulvi preputial prolapse in an alpaca reproductive physiology and infertility in male south american camelids: a review and clinical observations pathology and surgery of the reproductive tract and associated organs in the male camelidae heat stress in a llama (lama glama): a case report and review of the syndrome hyperthermia in llamas and alpacas changes in testicular histology and sperm quality in llamas (lama glama), following exposure to high ambient temperature theriogenology in camelidae: anatomy, physiology, bse, pathology and artificial breeding. actes ed., institut agronomique et veterinaire hassan ii reproductive disorders in the male camelid infectious causes of reproductive loss in camelids septic orchitis in an alpaca common surgical procedures in camelids gastrointestinal causes of colic in new world camelids surgical management of a ruptured bladder secondary to a urethral obstruction in an alpaca silica urolithiasis in the dromedary camel in a subtropical climate urinary retention in two male dromedaries due to silica uroliths silica urolithiasis in a male llama nutritional diseases of south american camelids the complete alpaca book active and mechanical hemostatic agents ablation of the soft palate in a male dromedary impaction of the distensible part of the soft palate (dulaa) in the arabian camel soft palate gangrene in camels (camelus dromedarius) impactation of the dulaa, palatine diverticulum in the dromedary facial paralysis, glossoplegia and injured soft palate in a camel urethral and subcutaneous infiltration of urine in camels (camelus dromedarius) surgical disorders of the male urogenital system in the dromedary camel perforation of the rectum in a llama mare caused by rectal palpation (vet expert opinion) rectal and colonic injury in the llama: anatomic considerations and surgical-management in llamas effects of intravenous butorphanol on cardiopulmonary function in isoflurane-anesthetized alpacas transabdominal ultrasonographic appearance of the gastrointestinal viscera of healthy llamas and alpacas obstetrics and neonatology prediction of gestational age by ultrasonic fetometry in llamas (lama glama) and alpacas (lama pacos) real-time ultrasonic biparietal diameter measurement for the prediction of gestational-age in llamas hepatic lipidosis in llamas and alpacas hormonal indicators of pregnancy in llamas and alpacas plasma concentrations of -ketodihydro-pgf( alpha), progesterone, oestrone sulphate, oestradiol- beta and cortisol during late gestation, parturition and the early postpartum period in llamas and alpacas reproduction in female south american camelids: a review and clinical observations surgical and nonsurgical correction of uterine torsion in new world camelids: cases ( - ) splenic torsion in an alpaca surgical treatment of uterine torsion in a llama (lama glama) surgery of the reproductive tract in camelids surgical correction of an acquired vaginal stricture in a llama, using a carbon-dioxide laser vaginal prolapse in a camel simple management of vaginal prolapse in the camel (camelus dromedarius) institut agronomique et veterinaire hassan ii use of cloprostenol as an abortifacient in the llama (lama glama) induction of parturition in alpacas and subsequent survival of neonates obstetrics, neonatal care, and congenital conditions ventral midline caesarean section for dystocia secondary to failure to dilate the cervix in three alpacas recent advances in camelid reproduction. ithaca: international vet information service recent advances in camelid reproduction. ithaca: international vet information service cardiopulmonary effects of xylazine and acepromazine in pregnant cows in late gestation the effects of xylazine on intrauterine pressure, uterine blood flow, maternal and fetal cardiovascular and pulmonary function in pregnant goats ketamine inhibits fetal acth responses to cerebral hypoperfusion a comparison of the haemodynamic effects of propofol and isofluronae in pregnant ewes effects of propofol-sevoflurane anesthesia on the maternal and fetal hemodynamics blood gases, and uterine activity in pregnant goats the effect of propofol on isolated human pregnant uterine muscle maternal and fetal effects of propofol anaesthesia in the pregnant ewe transplacental transfer of propofol in pregnant ewes use of propofol-isoflurane as an anesthetic regimen for cesarean section in dogs periparturient and neonatal anesthesia peritonitis associated with passage of the placenta into the adbominal cavity in a llama diseases and causes of mortality in a camel (camelus dromedarius) dairy farm in saudi arabia an outbreak of nutritional muscular dystrophy in dromedary camels uterine prolapse in a camel (camelus dromedarius) rectal prolapse caused by a fibroma in a she camel-a case report uterine prolapse in a camel uterine prolapse in the dromedary camel uterine prolapse in a camel (camelus dromedarius) reproductive disorders of the female camelidae rectal prolapse, surgery and radiology of the dromedary camel al ahsa. saudi arabia: ramadan, r.o. king faisal university a review of the causes, prevention, and welfare of nonambulatory cattle lactation and udder diseases south american camelids in the united kingdom: population statistics, mortality rates and causes of death gram-negative bacterial-infection in neonatal new-world camelids- cases ( - ) neonatal care of camelids: a review and case reports body condition and blood metabolite characterization of alpaca (lama pacos) three months prepartum and offspring three months postpartum adenosine a( a)-receptor blockade abolishes the roll-off respiratory response to hypoxia in awake lambs the combined maternal administration of magnesium sulfate and aminophylline reduces intraventricular hemorrhage in very preterm neonates surfactant administration to the human fetus in utero: a new approach to prevention of neonatal respiratory distress syndrome (rds) a new look at the respiratory stimulant doxapram oral pharmacokinetics of doxapram in preterm infants culturepositive sepsis in neonatal camelids: cases practical fluid therapy in llamas and alpacas complete choanal atresia in a llama what is your diagnosis? [complete bilateral choanal atresia in a llama surgical correction of anorectal atresia and rectovaginal fistula in an alpaca cria congenital glaucoma in a llama (lama glama) congenital cataracts and persistent hyaloid vasculature in a llama (lama glama) congenital coloboma in a llama congenital abnormalties an overview of camelid congenital/genetic conditions perinatal and neonatal care of south-american camelids urinary obstruction in a hermaphroditic llama failure of passive immunoglobulin transfer: a major determinant of mortality in newborn alpacas (lama pacos) a note on colostral immunoglobulin g concentrations versus subsequent serum concentrations in naturally suckled llama (lama glama) and alpaca (lama pacos) crias evaluation of assays for determination of passive transfer status in neonatal llamas and alpacas passive transfer of colostral immunoglobulin g in neonatal llamas and alpacas congenital defects in the llama medicine and surgery of south american camelids: llama, alpaca, vicuna, guanaco renal agenesis in an alpaca cria anderson kl. bilateral renal agenesis in an alpaca cria atresia vulvi in camels (case reports) a case of atresia ani with rectovestibular fistulae in an alpaca (l. pacos) surgical repair of a cleft soft palate in an alpaca surgical repair of a bilateral choanal atresia in a llama surgical treatment of a congenital flexural deformity of the tarsal joint in a llama management of bilateral flexural deformity of the metacarpophalangeal joints in three alpaca crias surgical correction of carpal valgus deformity in three alpacas multiple non-lethal congenital anomalies in a llama diaphragmatic hernia in a llama key: cord- - i kf j authors: nan title: abstracts from uscap : pulmonary, mediastinum, pleura, and peritoneum pathology ( - ) date: - - journal: lab invest doi: . /s - - - sha: doc_id: cord_uid: i kf j nan conclusions: a panel of immunostains including bap , mtap, cd , cd and tdt can be useful in the distinction between thymomas and thymic carcinomas with only a minority of cases being inconclusive. feasible markers of cellular senescence on paraffin but the expression of p protein and a low ki are surrogate markers of that cellular stage. sclerosing pneumocytoma (sp) is a benign tumor with a combination of patterns and a characteristic dual population of surface cells and round cells. the first express ttf and ck and the last only ttf . no driver mutations have been described in this lesion. we reviewed the histological characteristics and immunohistochemical findings of ba from patients and compared it to sp and adk (from the patient with ba). the antibodies used were: ttf (ventana, clone g g ), ki (ventana, , p (cintec, e h ) and p (ventana, bc ) . we also performed next-generation sequencing (ngs) (thermofisher, panel oncomine solid tumor) for all the ba and the adk. results: all ba displays high expression of p protein in over % cells and a proliferative index below %. one of the ba contained round cells ck-and ttf +, similar to round cells in sp. sp, sp-like cells and adk did not show a significant p expression. see we have identified a sp-like component that has not been described in classic ba. ba may represent another kind of benign tumor with senescent features and oncogenic alterations, similarly to nevus or pylocitic astrocytomas. these findings can be relevant in the differential diagnosis with adenocarcinomas as well as in the understanding of the malignant transformation in lung tumors. further research in a larger number of cases is needed. conclusions: in summary this study of selected images suggests that the distinction between stas and artifacts is achievable and reproducible. further work on reproducibility is needed using glass slides and frozen sections. these data suggest that these originally proposed criteria to make the distinction between artifacts and stas are readily applicable. this likely has helped the many independent investigators who have performed studies demonstrating the clinical significance of stas. design: a retrospective multi-center retrieve was performed for a ten-year period. ninety cases of mm, cases of non-small cell lung adenocarcinoma (nscla) and cases of breast carcinoma (bc) were retrieved from the pathology archives. all slides were reviewed and reclassified by expert pathologists. a tissue microarray (tma) was built from three sections of each case, resulting in cores. immunofluorescence (if) was performed with a col (v) in-house clone (described by atayde et al, plos ) . images were captured through a microscope camera and the percentage of the positive area was accessed by threshold properties in the imagej software. patterns of deposition were defined as fibrillar (a linear pattern in fine bundles of intercellular deposition), surrounding (a membrane pattern, surrounding and isolating each cell) and mixed. for the mm tma, a double col (v) d - stain was also performed to enhance mesothelial cell specificity. statistical analysis was performed using spss by anova followed by spearman's test. a p-value of less than . was considered significant. the analysis was possible in spots ( % of total): nscla ( %), bc ( %), mm ( %). the fibrillar type was expressed in ( %) of nscla, ( %) of bc and ( . %) of all spots of mm. the surrounding pattern was expressed in ( %) of mm spots (p-value < . ). the mixed pattern was expressed in ( . %) and ( . %) of nscla and bc spots, and when present, fibrillar dominated. average col (v) expression was: . % (nscla), . % (bc), and . % (mm). lung expressed significantly less than the other groups (p< . ). than that of patients with zeb -negative tumors ( days and days, respectively; p = . ). among epithelioid tumors, median survival of patients with zeb -high tumors was significantly shorter than that of patients with zeb -low tumors ( days and days, respectively; p = . ). conclusions: as expected, biphasic morphology was associated with zeb staining and poorer survival. zeb -positive epithelioid tumors had shorter median survival. furthermore, strong and diffuse positive staining in epithelioid mesotheliomas was associated with worse prognosis. use of this immunohistochemical stain may help to risk-stratify patients with epithelioid mesotheliomas, even in the absence of sarcomatoid morphology. results: using the above criteria, we identified cases, of which were diagnosed as lam on histology. all cases were females, ranging from - years, with an average age of years (table ). . the vegf-d levels ranged from to pg/dl. no case was above the present diagnostic cut-off of pg/ml. all cases with vegf-d levels > pg/ml were diagnosed as lam on histology. out of cases with vegf-d levels < pg/ml did not have lam. (ppv= %, npv= . %) . all positive cases had a typical radiological findings of multiple, diffuse, bilateral small cysts, usually < cm. radiological findings in cases not diagnosed as lam were variable, including predilection for lower lobes, coexisting nodular lesion, varying size cysts, etc. . cases where the radiology was characteristic but histologically not proven to be lam, were noted to have vegf-d levels of < pg/ml age sex vegf-d (pg/ml) radiological findings histopathology it is important to correlate radiological findings and vegf-d levels when considering the need for a surgical lung biopsy, as those cases with non-characteristic radiological findings and vegf-d < pg/ml were unlikely to be diagnosed as lam on histology. considering that all patients with biopsy proven lam had a vegf-d levels of greater than pg/ml, we speculate that this level might be used as new cut-off for triaging patients with cystic lung disease for a biopsy, in an appropriate clinical setting. lorelle brownlee , robert bentham , nicholas mcgranahan , charles swanton , david moore , mariam jamal-hanjani , tracerx consortium results: patients were identified. on fu (mean months) cases ( . %) had a final diagnosis of malignancy ( adenocarcinomas, squamous cell carcinoma, malt lymphoma, dlbcl, nsclc). of these, were diagnosed on repeat cnb, on wedge resection after repeat benign cnb and on fu fna. other cases ( . %) with repeat biopsy and cases ( . %) with fu resection were benign ( wedge resection and lobectomy, both nodular lymphoid hyperplasia). all nodules were solid ( . %) or part-solid on ct. most benign and all malignant cases had spiculated ( . %) or irregular margins ( . %). initial biopsies in malignant cases had either inflammatory ( / ) or lymphoma-like pattern ( / ). all cases with scar-like pattern ( / , . %) were benign. shorter solid lesional component on cnb correlated with final benign diagnosis (p= . ; solid component of all malignant cases measuring ≤ mm). cases with final malignant diagnosis also had cnb with shorter lesional tissue and higher suvmax, which approached statistical significance despite low number. conclusions: combined radiological-pathological approach may improve the diagnostic accuracy of patients with focal lung lesions and non-specific inflammation on initial cnb. good representation of the solid component of the lesions is associated with final benign diagnosis and should be considered when sampling and making management decisions. matthew cecchini , tara tarmey background: many forms of interstitial lung disease (ild) are diseases of aging secondary to repetitive injury or exposures that causes an abnormal cellular senescence. a subset of ild occurs in patients with short telomeres who can also have premature greying of hair, liver fibrosis and bone marrow failure. cells with critically shortened telomeres can enter into a cellular senescence mediated in part by upregulation of the cdk inhibitor p . despite our increasing understanding of the underlying pathogenetic mechanisms, histopathologic and radiologic features of ilds in patients with confirmed short telomeres have not been well characterized. design: cases diagnosed as positive for short telomeres ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were identified by testing of peripheral blood granulocytes and/or lymphocytes with th percentile of telomeres or less. lung explants or wedge biopsies from the patients with short telomeres were reviewed independently by pathologists using defined morphologic parameters. discordant cases were reviewed by a third pathologist. high resolution ct scans were reviewed by radiologists independently. immunohistochemistry for p (clone e h ) was performed on a section of each case showing the most areas of active fibrosis with abundant interfaces between fibrotic and architecturally preserved lung parenchyma. all foci showing p positivity in both epithelial cells and associated fibroblasts were counted. cases without short telomeres were used as controls. the morphologic and radiologic features of cases with short telomeres (n= ) as compared to those without short telomeres (n= ) are outlined in table . among cases with short telomeres that were tested for mutation, ( . %) cases had a germline mutation in a gene related to telomere maintenance (naf , tert, rtel , terc). the cases in the short telomere group often demonstrated features atypical for usual interstitial pneumonia (uip) on both histopathologic and radiologic examination. nine of ( %) cases with short telomeres were classified as non-uip, while of ( %) without short telomeres were diagnosed as uip. the average number of p -positive foci was higher in the cases with short telomeres though not statistically significant (p= . ) ( table ) . the majority of ilds in patients with short telomeres showed morphologic and radiologic features atypical for uip and were often diagnosed as chp or unclassifiable ild. both groups with and without short telomeres demonstrated p -positive foci. we have recently reported on the utility of comprehensive next-generation sequencing (ngs) for distinguishing separate primary lung carcinomas (splc) from intrapulmonary metastases (ipm) in clinical practice. here, we report on detailed review of histologic challenges in determining the relationships between multifocal adenocarcinomas using ngs as a gold standard. design: a total of surgically-resected adenocarcinoma pairs underwent molecular profiling using - gene hybridization-capture based ngs assay. comparative genomic profiles were used to stratify tumor pairs into clonally-unrelated (splc) and clonally-related (ipm). relationship of tumor pairs predicted by prospective histopathologic assessment was compared with ngs-based classification. histopathologic features contributing to challenges in distinguishing tumor relationships were assessed retrospectively. of adenocarcinoma pairs, ngs classified as splcs and as ipms. prospective histologic prediction was discordant with ngs in cases ( %), with significantly higher histologic misclassification rate for ngs-confirmed ipms than splcs ( % vs %, p= . ). the discordance rate was significantly higher when histologic prediction was regarded as potentially equivocal by a pathologist and confirmation by ngs was suggested (p= . ). retrospective review highlighted several specific factors contributing to misinterpretation of ngs-defined ipms as morphologically unrelated tumors, including ) morphologic progression leading to higher proportion of solid and micropapillary patterns in secondary tumors (n= ), and ) presence of significant amounts of non-predominant lepidic pattern in both primary and secondary tumors (n= ). ngs-defined splcs that were initially misinterpreted as morphologically related tumors (n= ) showed closely overlapping architectural or cytologic features. comprehensive histopathologic assessment is adequate for distinguishing splcs from ipms in most cases, but has notable limitations in the recognition of a subset of cases, particularly ipms. our results support the adoption of molecular testing to supplement histologic assessment for robust discrimination of clonal relationships of multifocal adenocarcinomas in clinical practice, and we propose an algorithm incorporating specific histopathologic scenarios where molecular profiling may be most helpful. background: malignant mesothelioma (mm) is rare but lethal; some affected individuals develop mm in the setting of predisposing inherited mutations. our group found a % prevalence of pathogenic or likely pathogenic variants in prospectively tested mm patients. these patients showed longer survival after platinum therapy, suggesting distinct biology. germline mutated bap mm, the most prevalent mutated gene in mm, appears to be more indolent than wild-type. this study aims to compare the morphology of epithelioid (e-) mms with germline mutations to those without. design: eligible patients with pathologically confirmed mm underwent panel-based hereditary cancer susceptibility germline genetic testing. there were two control groups with no germline mutation matched by mm histologic subtype, age at diagnosis, and sex; patients had retained bap and had loss of bap on ihc. in e-mm, nuclear grade ( -tiers comprised of mitotic count and nuclear grade), presence of necrosis (yes/no), and patterns were compared using graphpad prism via fisher's exact tests. results: of mms tested, had germline mutations; an additional cases were from other institutions (n= ). pathology was unavailable in . of the left (table ) , there were e-mm and biphasic mm with gene variants. bap was most common (n= ). among all mms with a nuclear grade of (n= ), ( %) had a germline mutation. the e-mms had a lower nuclear grade than those without (p= . ). the mitotic count was a significant contributor to lower grade (p= . ). by site, there was a trend in lower grade for peritoneal mms (n= ) between germline mutated and non-mutated cases (p= . ); that difference was not observed for pleural mms (n= , p= . ). when focusing on bap , lower nuclear grade was also present when comparing bap mutated mms to sporadic bap ihc loss mms (p= . ) and bap ihc retained mms (p= . ). there was a trend of lower mitotic count in the bap germline mutated cases compared to the bap ihc loss and the retained cases (p= . , p= . ). there was a trend of less necrosis in bap germline mutated mms vs mms with retained bap (p= . ). solid and trabecular patterns were most frequently observed in both study cases and controls. background: lung cancer has been the most prevalent and the most deadly malignant cancer globally, which is still incurable disease in essence. immunotherapy targeting pd- /pd-l represents a breakthrough in the treatment of lung cancer. nevertheless, the response rate of anti-pd- /pd-l immunotherapy remains unsatisfactory, due to tumor resistance and complexity of immune microenvironment. to enable more patients to benefit from immunotherapy, a thorough understanding of the regulatory mechanisms of pd-l expression will be pivotal for novel combinational immunotherapies. pyruvate kinase m (pkm ) is a critical player of glycolysis, conducing to tumor progression and immune response. however, the correlation and clinical significance of pkm and pd-l expression in human lung adenocarcinoma (luad) remain not entirely explored. design: expression of pkm and pd-l were detected by immunohistochemistry in cases of luad and the corresponding noncancerous tissues. simultaneously, multiplex immunofluorescence was used to detect pkm , pd-l , cd , cd , cd and pan-ck by using the opal -color ihc kit, combined with multi-spectral imaging system and inform software. we measured expression patterns and co-localization of these targets, evaluating their correlation with clinicopathological features and overall survival. validation of findings was conducted using mrna expression data from the cancer genome atlas (tcga) of lung adenocarcinoma cases. results: co-expression of pkm and ck, cd , cd were found. pd-l protein expression was detected in the tumor cells and immune cells including t cells and tumor associated macrophages (cd +cd +). high expression of pkm in tumor cells (tcs) was significantly related to lymph node metastasis and tnm stage. moreover, pkm expression in tcs was positively correlated with pd-l expression in tcs. high expression of pkm , pd-l , as well as both pkm and pd-l in tcs and immune cells predicted high mortality rate and worse survival, respectively. additionally, multivariate cox regression models indicated that high expression of pkm in tcs was an independent prognostic factor. based on tcga genomic data, high pkm mrna expression was significantly associated with poorer survival. background: immunotherapeutic agents have revolutionized the standard of care in patients with advanced non-small cell lung cancer (nsclc) and have emerged as novel treatment strategies as they have demonstrated promising treatment advantage over traditional chemotherapeutic agents. immunohistochemical (ihc) detection of pd-l expression in nsclc cases is considered to be a clinical decision-making tool to support the use of checkpoint inhibitors in nsclc patients. fda-approved assays and other antibodies are commercially available. this validation study is designed to compare a commercially available assay ( - ) with another clone (cal ), and to also determine the distribution patterns of expression of pd-l and pd in the tumor and tumor-associated environment. design: consecutively diagnosed nsclcs with available whole tissue sections were evaluated for the study, which includes testing with the fda-approved pd-l assay - (clone - ; agilent/dako), pd-l clone cal (biocare medical) and pd clone (nat ). whole sections were chosen over tissue microarrays to adequately assess intra-tumor heterogeneity. deparaffinized tissue sections were pretreated using either online (for the two non-fda approved tests) or offline (for - ), followed by antibody incubation, polymer detection and dab visualization. for the pd-l assays, the -revised fda tps scoring criterion of ≥ % was employed. for the pd assay, immunoe cell score was employed. results: % of tumors (n = ) showed tps positive expression of ≥ % using - as a gold standard assay for pd-l . agreement between - and cal was %, with a consistently higher tps score observed with cal compared to - . immune cell score of nat anti-pd antibody was positive in % of tumors (n = ). when comparing the distribution of pd-l and pd expression on the same tumor, out of the pd positive cases, showed positive pd-l expression, and showed a mutually exclusive expression with only pd positive expression. the validation study shows that pd and pd-l expression on the same tumors in nsclc is uncommon, a phenomenon that can be exploited to expand targeted therapy treatment strategies in this setting, and could possibly be expanded into other oncology settings. it also demonstrates the slightly higher sensitivity of detection achieved by clone cal compared to - using the tumor proportion score, which warrants an expanded evaluation. swi/snf complex, sensitizes smarca -mutant lung tumors to chemotherapy (fillmore, nature ). however, the expression of ezh in smarca -mutant lung tumors is unknown. we reviewed a cohort of thoracic specimens sampled between - that previously underwent next generation sequencing (ngs) of over cancer-associated genes as part of routine clinical care. smarca frameshift, nonsense and splice site mutations were defined as loss of function (lof). ezh immunohistochemistry (ihc) was performed and expression was quantitatively assessed on tumor cells based on the extent of staining as follows: loss ( ), weak ( +), moderate ( +) and strong ( +). a cohort of lung carcinomas without smarca -mutations were also stained as controls. we identified patients (mean age , range to years, % male) with smarca -mutant lung cancers (incidence . %). lof mutations were present in ( %) cases and included nonsense, frame shift and splice site variants. two additional cases had smarca duplications. all but two cases ( %) were lung adenocarcinomas, with poorly differentiated non-small cell carcinoma and sarcomatoid carcinoma. all cases with lof mutations exhibited a solid growth pattern and % presented as distant metastatic disease. tumor tissue was available for cases; ezh was expressed in % of cases with confirmed smarca -mutations (mean . intensity). of smarca non-mutated tumors, only tumor demonstrated ezh expression (mean . intensity, p< . ) conclusions: ezh is overexpressed in smarca -mutant lung cancers and may serve as a potential prognostic and predictive factor for those treated with epigenetic inhibitor therapy. this is the first study to assess ezh expression in this subset of tumors that are known to be resistant to conventional chemotherapy. results: oncogenic rearrangements were found in / samples ( %) with contributive analyses. the most frequent event was a kif b-ret translocation ( patients). we also found ros cases (cd and ezr), nrg (slc a and flywh ), egfr (vopp ), alk (eml ) and ntrk (egfr). moreover, patients had met exon skipping confirmed by the identification of a splice mutation. all but egfr-vopp fusions were targetable ( / , %). ret fish was negative or equivocal in / cases, ros fish was negative in / positive case. alk ( a ) and ntrk ihc were negative in both positive cases. patients with fusions were younger than usually described and the sex ratio was close to . the proportion of smockers was higher in the group without oncogenic events (p = . ). patients without an oncogenic event were more likely to express pd-l (p < . ). five patients were treated, with partial response. the clinicoradiologic presentation of these four cases are similar to those recently reported in the literature. our small series suggest that vapi is characterized by organizing acute lung injury and should be considered in the differential diagnosis of diffuse alveolar damage of unknown etiology, particularly in younger patients. while foamy macrophages were found in cases, the characteristic features of lipoid pneumonia were not evident on histologic examination. as such, the significance of lipid-laden macrophages on bal requires further investigation. background: congenital pulmonary airway malformations (cpams) are rare developmental malformations of airway branching in the lung, typically diagnosed antenatally. they are classified into subtypes (type , type , type , and type ) based on their histologic appearance. their origin, natural history, and genetics remain poorly understood as does their malignant potential. a subset of type cpams are thought to possess malignant potential and eventually go on to develop into invasive mucinous adenocarcinoma. these lesions are characterized by areas of mucinous epithelium that can often represent a very small fraction of the total type cpam. it remains to be determined if type cpam lesions with mucinous epithelium are molecularly distinct from type cpams that lack mucinous epithelium. design: a total of type cpams and type cpams with available slides and tissue blocks were identified. each type cpam was assessed for the presence or absence of mucinous epithelium. four cases of type cpam had microscopic evidence of mucinous epithelium and these areas were separately micro-dissected from areas without mucinous epithelium. genomic dna was extracted and used for molecular testing. capture-based next generation sequencing was performed at the ucsf clinical cancer genomics laboratory, using an assay (ucsf panel) that targets the coding regions of cancer-related genes, select introns from approximately genes, and the tert promoter with a total sequencing footprint of . mb results: among the four type cpams that contained mucinous epithelium, a pathogenic hotspot mutation in kras codon was detected in all four cases. this pathogenic mutation was detected in both the mucinous and non-mucinous epithelium at roughly similar mutant allele frequency. none of the remaining cases of type cpams that lacked mucinous epithelium or the type cpams contained a kras mutation. results: biopsies with dsa had a statistically significant difference versus nabs with regards to ali (p= . ), presence of capillary neutrophilic inflammation (p= < . ), and the presence of asw (p= . ). similar to earlier reports, we found a positive correlation between the capillary neutrophils, ali, and dsas. frequent asw was noted in our patients with dsas and was an easily recognized feature at low-power magnification. endothelialitis was not appreciated in any of our cases, likely due to a small sample size. complement d (c d) was available in . % of specimens and showed only focal staining (< %). c d, acute cellular rejection, and airway inflammation did not reveal any significant statistical association with dsa status. conclusions: ali, capillary neutrophilic inflammation, and asw were morphological features found to be statistically significant in this small sample size study. these are not pathognomonic, and currently, the triple test (clinical allograft dysfunction, dsas, pathologic findings) is the best approach for the diagnosis of amr. further research investigating asw, exploring its likelihood to be included among conventional histopathologic patterns prompting clinical and serologic evaluation is needed. figure) , storiform pattern, myofibroblastic proliferation, granulation tissue, maximum nuclear length (defined in relation to lymphocyte size, right figure), nuclear atypia (grades - ), mitotic score of ( - / mm ), ( - / mm ) or (≥ / mm ) and infiltrating inflammatory cells (%). overall survival (os) was determined by kaplan-meier method and compared between groups using log-rank test. results: invasion, bland necrosis, proliferation nodules, nuclear atypia (grade > ), mitotic score (> ), nodular growth and storiform pattern showed % specificity (all p< . ) but variable sensitivity ( %, %, %, %, %, % and %, respectively) for mm. nuclear length was significantly greater in mm than in cfp (median . vs . x size of lymphocyte, respectively; p< . ). myofibroblastic proliferation and granulation tissue were more frequently observed in cfp ( % and %, respectively) than in mm (both %) (p= . and p< . , respectively). percentage of infiltrating inflammatory cells was not significantly different (p= . ) between mm and cfp (median % and %, respectively). there were no significant differences in gender (p= . ), age (p= . ), stage (p= ) and os (p= . ) between patients with sarcomatoid mm (n= ) and dmm (n= , defined as > % desmoplastic component by who). conclusions: in the distinction from cfp, several features appear specific for mm, among which nuclear atypia, mitotic score, nodular growth and storiform pattern are most sensitive. myofibroblastic proliferation and granulation tissue, while not exclusive to cfp, may be a reliable indicator of benignity in absence of features specific for mm. based on this limited cohort, there appear to be no significant survival differences in patients whose tumors meet who criteria for dmm compared to those with mm showing < % desmoplastic component. mona farahi , alain borczuk , kartik viswanathan , michael kluger , hanina hibshoosh background: well-differentiated papillary mesothelioma (wdpm) is a rare indolent mesothelial tumor that is usually found incidentally in the peritoneal cavity. there is controversy about the prognosis of the disease with few reported cases of invasive and malignant behaving wdpm. thus, some consider it a tumor of uncertain malignant potential. in contrast, diffuse malignant peritoneal mesothelioma (dmpm) is an aggressive tumor associated with asbestos exposure with a poor prognosis. the distinction between these two entities relies heavily on histopathological findings. prior studies identified traf and cdc (mutually exclusive) somatic mutations in wdpm. l cell adhesion molecule (l cam) an nf-kb activated gene was overexpressed in wdpm. the goal of the present study is to assess the diagnostic utility of l cam in a larger cohort of peritoneal mesotheliomas. design: immunohistochemistry utilizing mouse monoclonal anti-l cam antibody (clone uj . , sigma, l , : dilution) was performed on formalin-fixed, paraffin-embedded tissue sections in total cases consisting of: cases of biphasic/sarcomatoid dmpm, cases of wdpm, cases of benign multicystic mesothelioma (bcm), and cases of epithelioid dmpm. the staining was scored as either positive or negative but since % was the minimum percentage to show complete and intense membranous staining among the wdpm, this was chosen as the true positive cutoff. background: adenosquamous lung carcinoma (asc) is a rare yet aggressive malignancy thought to potentially arise from a bipotential undifferentiated precursor cell. a topic of controversy until coined a distinct entity in the th edition of the who classification of lung cancer, asc is defined as a tumor with two separate malignant populations (> % glandular and squamous components). the coexistence of glandular and squamous differentiation within the same tumor cells has also previously been reported (pelosi, journal of thoracic oncology ) and termed "asc immunophenotype" due to its amphicrine phenotypic nature. the single case report showed dual ttf- and p immunohistochemical (ihc) expression, along with specific electron microscopy and molecular findings. we report here for the first time a case series with dual differentiation and further characterize the findings with molecular analysis. design: from primary lung ascs diagnosed between and at our institution, we identified patients (mean age . years) with dual glandular and squamous differentiation within the same population of malignant tumor cells. ihc stains for ck / , ck , ttf- , p , and p were performed. the ion ampliseq tm cancer hotspot panel v (chp ) and variantplex myeloid kit (archerdx) next generation sequencing (ngs) assays targeting oncogenes were performed on two cases. fluorescence in-situ hybridization (fish) was also performed on the two sequenced cases. ascs with dual differentiation occurred predominantly in women ( . %, age range to years) with variable smoking history. all cases were poorly differentiated with a solid growth pattern and % ( / ) presented with distant metastasis. the following ihc stains were positive in the tumor population: ck / ( / , %), ck ( / , %), ttf- ( / , %), p ( / , %), and p ( / , %). ngs revealed cdkn a and tp mutations in both cases; one cdkn a variant is known to disrupt p ink a-and p arf-dependent regulation of cdk / and p . loss of function atrx, bcorl and notch mutations were also identified. fish revealed cdkn a mutations and relative loss of p in one case, and chromosome monosomy in the other. we report for the first time a case series of these rare lung ascs with dual differentiation and show an association with cdkna mutations and corresponding p overexpression. background: there is considerable interobserver variability in the pathological diagnosis of uip and other ild. the variability in finding "ground truth" presents a difficult problem during the development of deep learning platforms designed to diagnose ild using ai. we describe the use of a smartphone application that allows for the collection of multiple opinions from sixteen pulmonary pathologists from nine countries as a novel method for finding "ground truth" for uip diagnoses. design: whole slide images from consecutive interstitial lung disease cases were scanned by aperio cs at x objective and sliced into multiple individual x mm images, resulting in jpeg image patches. these individual images were randomized and shown over the internet to expert pathologists from countries using the novel smartphone application, bonbon system. expert lung pathologists were asked to classify each image into one of categories: uip/ipf; ctd/uip; chp/uip; uip/other cause; non-uip; "not sure"; "normal"; and "exclude". images classified as "exclude" by any of the experts were deleted from analysis. all individual diagnostic classes selected for individual images were grouped by case, and the predominant class for each case, was used as "diagnosis". all diagnoses were analyzed using clustering analysis and kaplan meier statistics using jmp. interobserver agreement was calculated by fleiss kappa coefficient using r. the diagnosis of each of the cases by each of the pathologists showed that interobserver agreement using the categories was poor (k= . ) . none of the cases were classified as chp-uip or uip/others by a majority of pathologists. in order to simplify the diagnoses into more clinically relevant classes, the categories uip/ipf, chp-uip, and uip/others were grouped into uip and non-uip and ctd-uip into non-uip as shown in figure . clustering analysis stratified the diagnoses of each case into clusters as shown in figure a (k= . , . , and . , respectively), validating cluster a and b were meaningful. log rank test showed significant survival difference between uip and non-uip groups only for cases in cluster a (p= . ) ( fig b) but not for cases in cluster b (fig c) . eventually, h&e images with high agreement of uip and non-uip group were selected as "ground truth" for ai training. conclusions: classification of image patches from wsi over app offers a useful method to standardize uip diagnosis and to develop diagnostic ai. results: precision, reproducibilty and lod were assessed using hd in triplicate by operators on instruments. the ffpe and hd were used for accuracy. idylla™ results were in complete agreement with those obtained by ngs for egfr mutations targeted by idylla™ except for one sample. these include l r ( ), g a ( ), g c ( ), l q ( ), s i ( ), l q ( ), t m ( ), exon deletions ( ) and exon insertion ( ). the discrepant sample had an exon deletion identified by ngs but was wild-type by idylla™. upon review of ngs data, an egfr synonymous snv was present downstream of the deletion which might impair the probe binding, leading to false negative results. lod of % vaf and tumor content of % were confirmed. no egfr mutations were detected by idylla tm in the samples determined by ngs as having wild-type egfr. the fully automated idylla™ system offers rapid (turnaround time of approximately . hours) and reliable testing of clinically actionable mutations in egfr directly from ffpe tissue sections. in our center, it will complement ngs testing by providing rapid egfr results within - days of diagnosis. background: identification of patients with synchronous lung adenocarcinomas has crucial implications for their staging and clinical management. these tumors are thought to represent independent primary neoplasms, but their oncogenesis is still poorly characterized. a few studies based on the analysis of limited panel of genes suggest that synchronous tumors have a high level of genetic heterogeneity. we sought to investigate the genetic mutations in a well-defined cohort of synchronous adenocarcinomas using whole-exome sequencing (wes). design: a retrospective cohort of caucasian patients that underwent surgical resections for synchronous lung adenocarcinomas between and in our center was selected. all slides were reviewed by a thoracic pathologist to confirm the diagnosis based on a comprehensive histologic assessment. clinical characteristics and outcome were extracted from the electronic medical files. for each patient, three formalin-fixed paraffin embedded blocks were selected: one from two synchronous tumors and one from normal lung tissue. dna was extracted and samples were submitted to wes on an illumina hiseq platform (agilent sureselect xt). data processing was made according to gatk best practices and somatic variants (single nucleotide variants and insertion-deletions) were called using strelka and mutect. the cohort comprised . % men with a mean age of . years, . % had a stage i or ii disease and . % were smokers or ex-smokers. mean follow-up was of . months with an . % overall and . % progression-free survival rates. wes showed an average of called somatic variants per tumor. variants were identified in known driver genes at the following prevalences: kras . %, egfr . %, braf . %, ros . %, alk . %, met . %, ret . %. synchronous tumors from the same patients showed a high level of heterogeneity, as pairs shared to ( % to . %) variants. all shared variants were likely passenger mutations, but one pair of tumors shared three variants including one in a driver gene, a kras p.g c mutation. we showed a high level of genomic heterogeneity between two synchronous adenocarcinomas from the same patient using wes, supporting independent primary tumors. one pair of tumors had an identical kras mutation with a high level of genomic heterogeneity, emphasizing the fact that synchronous tumors can share a mutation in a frequent driver gene randomly. andréanne gagné to improve their recognition, the international association for the study of lung cancer (iaslc) recently proposed a classification based on clinicopathologic criteria. it divides msla in three categories: second primary, multiple ground glass opacities (ggo) and pneumonic type. however, the prevalence of these three subgroups remains poorly described and their clinical characteristics have been mostly described in asian cohorts. we aimed to establish the prevalence, clinicopathologic characteristics and prognosis of patients with msla in a caucasian population according to the iaslc criteria. we selected a retrospective cohort of consecutive patients, including surgical patients, with a diagnosis of lung adenocarcinoma in our center between and . the cohort was divided according to the iaslc classification: a group of sporadic tumors, comprising patients with one tumor and those with intrapulmonary metastasis (ipm), and a msla group further divided in second primary, multiple ggo and pneumonic type. prevalence of each group was calculated in the whole cohort. chi-square and t-tests were used to evaluate the associations between clinicopathological characteristics and the iaslc groups in surgical patients. overall survival of surgical patients was compared using a cox proportional model. : patients ( . %) with msla were identified, including ( . %) second primary, ( . %) multiple ggo and ( . %) pneumonic type. age (p= . ), gender (p= . ) and smoking status (p= . ) were not associated with msla. msla patients had significantly more metachronous lung tumors (p= . ), atypical adenomatous hyperplasia foci (p< . ) and tumors with lepidic and acinary predominant patterns (p= . ). there were no significant differences between the msla groups. compared with patients with a single tumor, the multiple ggo group tended to have the best prognosis (hr= . , p= . ) and the second primary (hr= . , p= . ) and pneumonic type (hr= . , p= . ) had worse survival when using a multivariate model. to our knowledge, this is the first report to assess msla prevalence using the ialsc criteria to define patients with multiple adenocarcinomas. even though there were no differences in the clinicopathological variables between the msla groups, their survival disparity supports the iaslc classification. design: histologic slides of pulmonary lobectomies for high grade necs from the - period were reviewed. high grade was characterized by a mitotic count > per mm². necrosis was subtyped as massive or punctuate. carcinoid morphology was identified according to the who morphological criteria. tumors with diffuse architecture, nuclear polymorphism and marked nucleoli were classified as "classic" lcnec. proliferation was also assessed with immunodetection of ki . results: ten cases were available, were classic lcnec, had carcinoid-like features. clinical and pathological data are listed in table . there were no differences between the groups for clinical data. carcinoid-like subgroup had lower mitotic count (mean vs ), ki index (mean % vs %) and better survival ( vs months) than classic lcnec respectively. no reliable statistical analysis was allowed due to the small size of our cohort. classic lcnec (n = ) carcinoid-like lcnec (n = ) age mean ( conclusions: lcnecs with carcinoid features form a homogeneous subtype with precise morphological criterias. it is rare ( . % of resected lung tumors in our center), nevertheless its real incidence is probably underestimated. indeed, for sampling reasons, we chose to report a series including only surgical specimens but we have already identified this tumor-type on biopsies from on resectable mediastinal lesions. proliferation markers are lower in carcinoid-like lcnecs than in classic lcnecs. nevertheless, results differ depending on the method of assessment. there is no overlap between the mitotic count values in both subgroups whereas ki index overlaps with no upper limit value in carcinoid-like group. these results rise two questions : / the choice of the method of evaluation of proliferation between mitotic count or ki , / the place of carcinoid-like lcnec within pulmonary nets classification: an intermediate group between atypical carcinoids and classic lcnecs or a high grade well differentiated net equivalent to that described in the digestive tract. however, the interests of individualizing the carcinoid-like lcnec subgroup are : diagnostic (must be distinguished from atypical carcinoid), prognostic (better than classic lcnec) and probably therapeutic (therapeutic response) jonathon gralewski background: lung cancer is a leading cause of cancer death worldwide. however, the introduction of targeted therapies in recent years has led to improved overall prognosis and survival. current guidelines for lung adenocarcinoma require epidermal growth factor receptor (egfr) exons - mutational testing. furthermore, it outlines molecular methods, such as next generation sequencing (ngs) with an acceptable turnaround time (tat) up to two weeks. this prolonged tat delays treatment decisions and increases healthcare costs. recently, a fully-automated, cartridge-based platform has been introduced with an ultra-rapid (i.e. < hours) sample-to-result tat that does not require traditional sample preparation, such as dna extraction, library preparation, and pcr amplification. design: twenty-one archived formalin-fixed paraffin embedded lung adenocarcinoma including cytology and surgical samples with previously characterized exon - egfr mutations were selected for this study. a single unstained section of the selected paraffin blocks was macrodissected, placed between filter papers, and subsequently placed into the cartridge and run for egfr variant mutational analysis as per the manufacturer instructions. results were generated in < hours without the need for complex bioinformatics analysis and interpretation. results: of previously characterized egfr mutations in analyzed samples, egfr variants were successfully detected by fully integrated ultra-rapid platform ( % concordance). the automated platform failed to identify an egfr g c variant with allelic frequency of % that had been detected using conventional ngs platform. an additional egfr l r variant was only seen by the cartridge based pcr platform. this variant was re-interrogated on the ngs-based platform and deemed likely a false positive result. conclusions: the cartridge-based fully integrated platform with ultra-rapid tat demonstrated high concordance with the conventional ngs-based platform. the fully-automated and integrated platform has minimized the need for significant molecular expertise and laboratory infrastructure. however, this platform does have its limitations, such as only detecting the most common egfr mutations. overall, this fully automated platform provides an ultra-rapid, and reliable cost-effective method in detecting the most common egfr variants, as outlined in the current guidelines with a detection sensitivity comparable with the conventional ngs platform. nancy greenland background: lung transplant recipients undergo bronchoalveolar lavage (bal) and biopsies to detect rejection and infection that may be antecedents of chronic lung allograft dysfunction (clad), the major limitation to long term survival. bal cytology is routinely performed but recently some centers have advocated abandoning this practice because of the low diagnostic yield. we hypothesized that inflammation observed on bal cytology would predict clad risk. we grouped diagnostic findings on bal cytology between and . bronchoscopy indication, infection treatment, bal and biopsy results, and clad-free survival were abstracted from medical records. cytology associations with clinical characteristics were compared using generalized-estimating equation-adjusted logistic regression. the association between bal inflammation and clad or death were determined using time-dependent cox proportional hazards models adjusted for age, gender, diagnosis, lung allocation score, and transplant type. we evaluated , cytology reports from subjects. inflammation was the most common finding ( . %), followed by fungi ( . % of which . % were likely pathogenic). there were cases of malignancy and cases of cmv. inflammation on bal cytology was more common in procedures performed for symptoms ( %) versus surveillance ( %, p< . ), associated with antimicrobial initiation (a proxy for clinically significant infection, % vs %, p< . ), associated with acute cellular rejection (p= . ), and linked to increased bal neutrophil and lymphocyte concentrations (p< . ). inflammation on bal cytology was present for % of subjects on at least one sample, was more frequent around the time of clad onset, and was associated a . -fold hazard ratio (ci . - . ) for clad or death ( figure ). however, this association was not significant after adjusting for bal cell counts and acute cellular rejection (p= . ). the presence of inflammation on bal cytology specimens is clinically significant, suggesting acute rejection or infection and increased risk of clad or death. however, other indicators of allograft inflammation can substitute for some of the information provided by bal cytology. hongxing gui background: primary pulmonary myxoid sarcoma (ppms) is an exceedingly rare low-grade lung neoplasm characterized by reticular/lacelike growth of spindle to epithelioid cells embedded in an abundant myxoid matrix. it overlaps with myxoid variant of angiomatoid fibrous histiocytoma (afh) morphologically. in terms of molecular genetics, they both have ewsr gene rearrangements, with ewsr -creb fusion in ppms and either ewsr -atf or ewsr -creb fusion in afh. it is unclear whether they are distinctive entities or the same entity with a spectrum of histomorphologies. we evaluated two cases of low-grade myxoid spindle cell tumor of the lung by histomorphology, immunohistochemistry and fish studies. results: case was a -year-old man with a . cm right lower lobe mass extending into bronchus. sections of the mass revealed proliferation of spindle cells in cords, strands and reticular patterns within an abundant myxoid stroma ( figure ). the tumor cells were positive for ema and negative for desmin, ae / , cam . , ck , ck , ttf- , c-kit, vimentin, cd a, p , and s . case was a year-old man with left main bronchial mass. the periphery of the mass was partially encapsulated with a lymphoid cuff. the central portion contained juxtaposed myxoid and nodular components. the former was composed of spindle cells in myxoid matrix and the latter consisted of histiocytic and spindle cells in whorled and storiform patterns ( figure ). the tumor cells from both areas were diffusely positive for desmin and negative for ema, panck, ae / , s , sma, cd and alk . fish analysis demonstrated positive ewsr gene rearrangements in both cases, showing ewsr -atf fusion gene in case and ewsr -creb fusion in case . we reported for the first time a case of ppms with a novel ewsr -atf translocation, which is usually common in afh. the second case represented a hybrid of jaxtaposed ppms and afh components. these findings provide new evidence supporting that ppms and myxoid afh may represent a continuum with overlapping histologic, immunohistochemical and genetic features. sarika gupta , sagar vishal , anthony snow , andrew bellizzi university of iowa hospitals and clinics, iowa city, ia, coralville, ia, north liberty, ia disclosures: sarika gupta: none; sagar vishal: none; anthony snow: none; andrew bellizzi: none background: the differential diagnosis for epithelial tumors in the mediastinum includes carcinomas (ca) of the lung and thymus and thymoma. cd and kit are often used to distinguish thymic (+) from lung (-) ca, but these markers are rarely positive in thymoma. prior studies demonstrated frequent polyclonal pax -positivity in thymoma (≥ %) and thymic ca ( %). we recently switched to monoclonal pax , which has been shown to be negative in thymic tumors. given prior experience, we hypothesized that polyclonal pax -positivity in the thymus represents cross-reactivity with another pax-family transcription factor. pax is normally expressed during thymic development, and a high-quality monoclonal antibody recently became commercially available. design: pax immunohistochemistry (ihc) (clone a ) was performed on tissue microarrays of thymomas, thymic cas, and other cas with an emphasis on differential considerations and pax -positive tumors: squamous cell cas ( lung); urothelial cas; lung adenocas; renal cell, serous, endometrioid, and papillary and follicular thyroid, breast, colon, esophagus, poorly differentiated neuroendocrine, and prostate ca. intensity ( - +) and extent ( - %) of expression was evaluated, and an h-score was calculated. fisher's exact and mann whitney tests were used with p< . considered significant. results: pax was expressed by % of thymic tumors, including % of thymomas (mean/median h-score / ) and % of thymic cas (mean/median h-score / ). the differences in frequency (p= . ) and h-score (p= . ) were not significant. pax -positivity was noted in only . % of non-thymic cas at a mean (median) h-score of ( ) (both p< . compared to thymic tumors); these included thyroid cas ( %), sccs ( %) [including lung ( %)], urothelial cas ( %), and ( %) breast ca. two of the pax negative thymic cas were kit-positive; all were cd -negative. detailed pax expression data by thymoma type are presented in the table; pax was very frequently, strongly expressed across types. conclusions: pax ihc using a novel monoclonal antibody is sensitive and specific for thymic epithelial neoplasms. occasional weak positivity in thyroid tumors may represent low-level cross-reactivity with pax . this study exemplifies "next-generation ihc," which seeks to apply knowledge from developmental biology and molecular genetics to "intelligently design" novel ihc markers. background: tumor spread through the air space (stas) is an invasive pattern of lung cancer recently described. but there are some debates on its definition, quantification and clinical impact. in this study, we investigated the association between stas grade and clinicopathological characteristics, as well prognostic impact in resected lung cancers. design: stas has been prospectively described from and it was graded according to the distance from the edge of tumor margin as -tier system, i or ii from . correlations between stas grade and clinicopathologic characteristics and prognostic significance were analyzed in surgically resected lung cancers. conclusions: stas was more frequently found in nets and mp-predominant adcs. it was associated with well-known aggressive features, and stas-gr ii tumors more frequently showed these features than gr i tumors in adcs. in stage ia non-mucinous adc, multivariate analysis revealed that stas grade was independent prognostic factor for rfs regardless of the extent of surgery. moreover, comparable rfs rates were observed in patients with stage ia/stas-gr ii and those with stage ib. % ( ) % ( ) % ( ) tps=tumor proportion score. note that pdl high cases are also counted in the pdl positive category. *tumors with one of the following: alk fusion, nrg fusion, met exon skipping, egfr mutation, or mutation in erbb , braf, ret, pik ca, or idh / our data indicate that at least half of ras-driven nsclc have high pdl expression, an important consideration for frontline therapy selection. the majority of genomically-actionable tumors have at least low-positive expression of pdl , highlighting the potential importance of immune checkpoint therapy in the resistant-progression setting. less than one third of genomically-negative cases have high pdl expression, and a significant percent are completely negative; additional innovations are needed to better tailor therapy for this patient subset. background: identification of ros rearrangements in advanced lung cancer carries therapeutic implications, given the available ros targeted therapy, but can be technically challenging. immunohistochemistry (ihc) for ros show expression in ros -rearranged tumors, but staining may be weak in some cases and seen in reactive pneumocytes. fluorescence in situ hybridization (fish) using break-apart probes may be difficult to interpret in cases with subtle intrachromosomal rearrangements. next-generation sequencing (ngs) can be useful but requires sufficient tissue and a turnaround time of at least - weeks. given that these current methods may have drawbacks, this study explores the utility of rna in situ hybridization (rna-ish) in detecting ros rearrangements in lung adenocarcinomas. results: using the ros rna-ish, all seven ( %) genetically-confirmed ros -rearranged lung adenocarcinomas showed positivity; whereas none of the controls ( %) was positive. the fraction of cells in ros -rearranged lung adenocarcinoma showing positivity ranged - % (median %). the average number of ish signal dots was far higher in confirmed ros -rearranged lung adenocarcinomas than controls (average: . per cell vs. . per cell). background lung showed minimal ish signal (average: . per cell). also, the positive ish signals were easily observed and could be seen using x objective in all cases or with a x objective in of cases. the automated ros rna-ish assay appears sensitive and specific in identifying ros rearrangements in lung adenocarcinoma, with ease of use for minimally-trained eyes. ros rna-ish may be a quick orthogonal tool in confirming ros rearrangements in clinically problematic cases. nonetheless, systematic comparison on its performance with that of ros ihc and fish may be warranted. on univariate analysis of all mpems, shorter os was significantly associated with year of diagnosis, asbestos exposure, poorer performance status, lymph node metastasis, higher peritoneal disease burden, absence of cytoreduction and hyperthermic intraperitoneal chemotherapy, biphasic or sarcomatoid histotype, and tumor necrosis. on univariate analysis of epithelioid mpem only, shorter os was additionally associated with nuclear pleomorphism, higher mitotic rate, higher composite nuclear grade, and non-tubulopapillary architecture. on multivariate analysis, sarcomatoid and biphasic histotypes predicted shorter os when adjusted for sex, asbestos exposure, and year of diagnosis. on multivariate analysis of epithelioid mpem only, nuclear grade and non-tubulopapillary growth were independently predictive of shorter os when adjusted for sex, year of diagnosis, and tumor necrosis. among patients with epithelioid mpem, shorter pfs after cytoreduction was associated with lymph node metastasis, tumor necrosis, nuclear pleomorphism, higher mitotic rate, higher composite nuclear grade, and solid growth. on multivariate analysis, nuclear grade and solid growth were independently predictive of shorter pfs when adjusted for year of diagnosis, sex, and necrosis. background: there is emerging evidence that vaping can result in significant lung injury, the severity of which can be variable with few cases resulting in the patient's death also been reported. there is limited data on the pathologic findings in vaping-induced lung injury. here, we report histologic and cytologic findings of four patients who developed lung disease following vaping. design: review of pathologic material and clinical information of four patients with a history of vaping ( specimens, male and female patient, age - years old). we have identified patients with a history of vaping who presented to the hospital with severe respiratory dysfunction. three of the patients are teenagers, while one is a younger adult and all of them required admission to the icu. the three younger patients had bronchoscopy with bronchoalveolar lavage (bal) with transbronchial biopsy in two. bal showed lipid laden macrophages in all three with acute inflammation in one. transbronchial biopsy showed intraalveolar fibrin with acute inflammation and organization in one of the biopsies. the adult patient is a known chronic alcohol and drug abuser who presented to the ed with dry cough and had subsequent wedge resection showing organizing pneumonia and chronic interstitial changes with the organizing pneumonia attributed to vaping. background: lymphangioleiyomomatosis (lam) is a rare low-grade neoplasm associated with widespread interstitial infiltration of spindle cells and subsequent cystic changes of the lesions. lam is also uniformly distributed in the lungs. target therapies such as mtor inhibitor have been to manage lam but there are no curative therapies at this juncture. lam cells are known to produce vegf-c and vegf-d with their receptor, vegfr , which promote proliferation of lam cells also present in tumor cells. however, roles of other angiogenic factors have remained unclear. therefore, in this study, we examined the expression of angiogenic factors such as vegfr family and vasohibin (vash) and examined the correlations between these angiogenic factors and histological and clinical findings. design: lam cases were obtained from patients who underwent lung transplantation in tohoku university hospital from to . we performed hierarchical clustering analysis to classify the cases based on the results of vegfr , vegfr , vegfr , vash- , and vash- immunoreactivity in lam cells. we also immunolocalized vash- / , cd , and d - in microvessels of the lesions. one of these clusters harbored higher vegfr / and lower vegfr and vash- / , and the patients in this cluster clinically manifested symptom much older and higher p/f ratio was detected at the time of lung transplantation than those in the cluster with higher expression of all of the factors above. the cluster with higher vegfr / / expression and lower vash- /- expression also demonstrated significantly higher vash- /cd and vash- /cd ratios in microvessels than the cluster with lower expression of all these factors above. however, there were no significant differences of lymphatic vessel strength or other histological characteristics detected in our present clustering analysis. conclusions: angiogenic factors such as vegfr and vash- /- influenced on an early onset and progression of the clinical symptoms of lam. in addition, lam cells expressing vegfr / / promoted angiogenesis. therefore, not only vegf-c/d-vegfr axis but also other angiogenic factors may also enhance lam progression. background: micro-computed tomography (micro-ct), is a non-invasive method which allows -dimensional morphometric analysis of tissues in formalin fixed paraffin-embedded (ffpe) tissue blocks without any sectioning or loss of sample. lung adenocarcinoma has a major five tissue patterns according to the who classification (lepidic, acinar, papillary, solid and micropapillary). each tissue pattern has different prognostic indicators and outcomes. in practice, pathologists have to diagnose a predominant tissue pattern and measure each percentage of tissue pattern. the aim of this study is to analyze the structure of lung adenocarcinoma tissue patterns using micro-ct images from ffpe tissue blocks. the ffpe blocks were then sectioned, stained with hematoxylin-eosin (h&e) and scanned to create whole slide images for comparison. design: ffpe tissue blocks from five lung adenocarcinoma cases were scanned using a custom-built micro-ct scanner (nikon metrology) and digitally re-constructed for visualization and analysis using a digital image system. all h&e slides were scanned with . um/pixel by nanozoomer s (hamamatsu photonics, japan) whole slide imaging scanner. we then investigated features of each tissue pattern and correlate between micro-ct images and whole slide images as well as histology d. results: micro-ct of ffpe blocks highlighted the structure of lung adenocarcinoma ( figure. ) and normal lung tissue ( figure. ) in d images. we can detect lung adenocarcinoma in a micro-ct image, and detect the tissue pattern, such as lepidic, acinar, papillary, solid, and micropapillary pattern as well as spread through air spaces (stas) (figure ). we could detect the co-relation of normal lung tissue (bronchus, alveolar wall, pulmonary vessels, and visceral pleura) on h&e slides and micro-ct images ( figure ). conclusions: whole block imaging by micro-ct allows for the identification of lung adenocarcinoma tissue patterns in ffpe blocks in a non-invasive and non-destructive manner. correlation between micro-ct images of ffpe blocks and h&e histology images suggests that there is potential for ( ) detecting pathologic features without sectioning and staining of the tissue and ( ) to measure the volume of each adenocarcinoma tissue pattern including the invasive component in a block accurately. metastasis, respectively, and more frequently associated with recurrence and death ( . % vs. . %, p< . and . % vs. . %, p= . ) compared with mp/s-group. survival analysis indicated that mp/s+ and mp/s < % were associated with shorter recurrence free survival compare with mp/s-(hr= . , % ci= . - . , p< . ; and hr= . , % ci= . - . , p< . , respectively). mp/s+ and mp/s< % were more powerful predictor of recurrence than t or n stage in multivariate analyses. even very small proportion of mp/s subtype component was a significant predictive factor for recurrence in surgically resected lung adenocarcinoma. further investigation on the underlying biological mechanism of poor prognostic effect of mp/s subtype is warranted. results: patients' characteristics of cases were as following; median age was years old (range - ); male and ten female; / / / of clinical stage i/ii/ii/vi; chemotherapy, chemoradiation and radiotherapy; adenocarcinomas, squamous cell carcinomas and seven other types of histology. mpr was observed in ( %), and pcr in ( %). the concordance rate of mpr and pcr assessment among two pathologists was high ( % and %). inter-observer agreement was high in mpr (kappa . , p< . ) and pcr (kappa . , p< . ). the discrepancy of mpr/pcr was due to the different judgment of tumor bed area and atypical cells whether they are benign or malignant. pathological findings of discrepancy cases had temporal and spatially heterogeneity of fibrosis, active inflammation with reactive stromal and epithelial cell changes. survival analysis will be updated at the time of presentation. our results revealed high reproducibility of mpr, and higher incidence compared to pcr, indicating mpr as a useful method for pathological therapeutic response. background: interstitial lung disease (ild) encompasses a spectrum of conditions with distinct clinical and pathologic features. a subset of ild has been linked to abnormal cellular senescence which can induce a pro-fibrotic senescence associated secretory phenotype that results in progressive pulmonary fibrosis. the senescence is mediated in part by activation of the cdk inhibitor p which can arrest the cell cycle and can be used to mark senescent cells. we aim to demonstrate that a distinct subset of ild associated with a senescent phenotype can be identified by expression of p . design: cases of ild diagnosed with surgical lung biopsy were identified between and at a large tertiary-care level hospital ( figure ). additional p staining (clone e h , roche) was performed on representative sections with the most active fibrosis. p positive senescent foci were defined as a loose collection of p -positive fibroblasts with an overlying p -positive epithelium and scored as p -low ( - foci/slide) or p -high (≥ foci/slide). the diagnosis was verified with the original pathology report and outcome data by time of biopsy to time of death or lung transplant. the presence of any p -positive senescent foci was highly specific ( %) for the diagnosis of usual interstitial pneumonia (uip). in the uip group there was variable expression of p with a range of senescent foci between and per slide with ( %) cases expressing some level of p and ( %) cases expressing high levels of p . comparing cases with high levels of p to cases with low to absent p , there was a reduced survival (hr . ; % ci, . to . ; p = . ) in the p high group that was an independent predictor of lung transplant-free survival (figure ) . in a sub-group analysis of only cases with a diagnosis of uip, p status trended towards significance (hr . ; ci, . to . )( table ) . conclusions: increased levels of p positive foci are highly specific for the diagnosis of uip and identify a subset of cases with a significantly worse transplant-free survival. these cases may represent an important subset of ild that may be most effectively treated with emerging classes of drugs that target senescent cells. design: cases of nsclc patients who received ici were identified from departmental surgical archive and response was retrieved from the electronic medical records, including cases of responders and cases of non-responders. responders were defined as achieving a progression free response for more than months. immunohistochemistry (ihc) studies for pd-l , cd , cd , cd , cd , cd , cd , cd , foxp , and mmr proteins (mmrp mlh /msh , pms /pms ) were performed. for cd / / ihc, the lymphocytic density (%) as well as the location (peripheral vs infiltrating) of positive t-cells were evaluated. results: all responders displayed a high pd-l expression (avg. of . %, range % to %). the cd / / positive t-cells heavily infiltrated the tumor (avg. of . %, range % to %). for non-responders, only out of cases displayed a lesser pd-l expression (avg. of . %, range % to %). the cd / / positive t-cells were much less dense and infiltrative (< %), and tended to concentrate at the periphery. the ihc results for cd , foxp , cd were negative. cd and cd had a similar pattern in both responders and non-responders. mmrp showed intact mlh , msh , pms , and pms except for one non-responder. in addition to high pd-l expression, the percentage and pattern of cd / / positive t-cells appear to be more predictive of ici response in nsclc than pd-l alone and may easily be implemented in routine testing. the tumor microenvironment may also play an important role in facilitating immunotherapy response. however, nk-cells (cd ), tumor-associated macrophages (cd ), regulatory tcells (foxp ), and mmrp were not predictive of ici response in our pilot study. additional studies are needed to further investigate our preliminary findings. background: high-grade fetal adenocarcinoma (hfa) and enteric adenocarcinoma (ea) are both rare histopathological subtypes of lung adenocarcinoma. hfa and ea are occasionally combined with conventional-type lung adenocarcinoma, but pure types of both malignancies exist. the fact that the lungs and colon develop from the primitive striatum led us to speculate that these subtypes might share a common pathogenesis. design: among the cases of primary lung adenocarcinomas reported in our hospital, we identified and pure (p) hfas ( . %) and eas ( . %), respectively. all phfa tumors were high-grade adenocarcinomas with fetal lung morphology, necrosis, and immunopositivity for at least one of the following markers in addition to lacking morule formation: α-fetoprotein, sall- , or glypican- . all pea cases involved tumor cells that resembled colonic adenocarcinoma with no history of colorectal cancer. we evaluated the clinicopathological and molecular characteristics of these phfa and pea tumors. next-generation sequencing was performed using the ion-torrent personal genome machine platform and the ion ampliseq cancer hotspot panel v . results: both phfa and pea were associated with several characteristic clinicopathological features such as smoking exposure, high incidence of lymphovascular invasion, and frequent expression of cdx and hnf α. furthermore, nuclear accumulation of β-catenin was observed in cases of phfa ( %) and cases of pea ( %), which indicate activation of wnt signaling. the most frequently mutated gene was tp ( peas), and other mutated genes that lead to the activation of wnt signaling were ctnnb ( phfa) and apc ( pea). an analysis of copy number variations revealed that smad deletion was the most frequently detected mutation, regardless of wnt activation ( phfas; peas). additionally, amplifications of fgfr were detected in cases ( ea; phfas), which tend to be mutually exclusive with wnt activation. common mitogenic mutations in lung adenocarcinoma, such as egfr and kras, were not detected. conclusions: phfa and pea have similar clinicopathological features and oncogenic alterations which included frequent association with the activation of wnt signaling, amplifications of fgfr , and smad deletion. recognition of these genetic subsets may help distinguish between lung adenocarcinoma with fetal and enteric morphology. background: gnas hotspot mutations have been described in indolent and slow-growing mucinous epithelial neoplasms in several organs, such as the pancreas and appendix. large genomic databases show that a subset of mucinous and non-mucinous lung adenocarcinomas harbor gnas mutations. however, the clinicopathological impact of gnas mutations on invasive mucinous adenocarcinoma of the lungs (ima) is not fully determined. we evaluated the clinicopathological and molecular characteristics of imas with gnas mutations in comparison with gnas wildtype cases. we examined egfr, kras, gnas, and tp mutations by pcr-direct sequencing in imas. subsequently, a nanostringbased screen for tyrosine kinase fusions was performed for all imas with wild type egfr and kras. next-generation sequencing using the ion-torrent personal genome machine platform and ion ampliseq cancer hotspot panel v or rna sequence were performed to confirm gnas mutations and tyrosine kinase fusions. mucin core proteins (muc , muc , muc , muc ac, and muc ) and differentiation transcription factors, particularly differentiating on the basis of the cellular lineage (ttf- , cdx- , and hnf α) were detected by immunohistochemical staining. results: three of imas ( . %) harbored gnas mutations ( r h and r c). other mitogenic alterations including kras mutations ( cases, . %), tp mutations ( cases, . %), cd -nrg fusions ( cases, . %), and met exon skipping ( case, . %) were detected. among cases of kras mutations, g v was the most frequent ( %), followed by g d ( %) and g c ( %). neither egfr mutations nor rearranged alk, ros , ret, and ntrk were detected. all cases of gnas mutations were found in women who were never or light smokers with wild-type tp . furthermore, gnas r h mutations cooccurred with kras g d mutations in two cases. in comparison with gnas wild-type cases, gnas-mutated cases were significantly associated with the female sex (p< . ) and immunopositivity for muc (p< . ). however, no significant differences were observed in other clinicopathological and immunohistochemical features, and progression-free and overall survival among both groups. conclusions: gnas-mutated imas are rare, but frequently co-occur with kras g d mutations and immunopositivity for muc , and are predominantly found in never-or light-smoking women; however, the prognostic impact of gnas mutations in imas is unclear. background: lung cancer is classified into small cell lung cancer (sclc) and non-small cell lung cancer (nsclc), which mainly contains adenocarcinoma (ac) and squamous cell carcinoma (sq). lung cancer subtyping plays an important role in choosing therapeutic schemes. sputum is a kind of noninvasively accessible biologic fluids containing exfoliated airway epithelial cells. although cytopathological examination of sputum is now available, its positive-rate of malignant cells is very low. it is hard to classify subtype via classic cytology on sputum specimens. we had reported that microrna panels could accurately discriminate between three subtypes of lung cancer in bronchial brushing specimens. the diagnostic value of micrornas in sputum specimens is need to be explored. in this study, sputum specimens ( ac, sq, and sclc) were investigated. reverse-transcriptase quantitative polymerase chain reaction (rt-qpcr) was performed to evaluate expression of candidate micrornas discovered via microarrays previously. two logistic regression models constructed before was validated in the cohort of sputum specimens. the area under the receiver operating characteristic curve (auc) was used to assess the diagnostic accuracy of microrna panels. the diagnostic performance was compared between microrna panels and cytology. results: panel a, consisting of mir- a and mir- , was built to discriminate sclc from nsclc. in the cohort of sputum specimens, the auc value was . with sensitivity of . % and specificity of . %. similarly, panel b, consisting of mir- a and mir- , was used to discriminate sq from ac. in the cohort of sputum specimens, the auc value was . with sensitivity of . % and specificity of . %. compared with cytology, microrna panels or the combination of microrna panels and cytology were of higher sensitivity and specificity in diagnosis of ac, sq and sclc. conclusions: in sputum specimens, those two microrna panels for lung cancer subtype discrimination could achieve high sensitivity and specificity. moreover, the combination of microrna panels and cytology could improve the diagnostic accuracy in further. these findings could be helpful in therapy of lung cancer. (table) . on image analysis, median total diagnostic area was . mm and the median size of the largest fragment was . mm (n= ). the largest fragment size was obtained for a case of diffuse large b-cell lymphoma (total area : . mm , figure ). there was no significant correlation between lpd diagnostic category and total fragment size (p= . ) or largest fragment size (p= . ). preliminary data on surgical specimens obtained by mediastinoscopy show a total diagnostic area ranging from . mm to . mm , with largest fragment size varying from . to . mm (n= ). we report here a series of lymphoma cases diagnosed by ebus/eus, ranging across several diagnostic categories, based primarily on small size fragments. quantification of endoscopic diagnostic tissue provides insight on tissue yield, on its relationship with lymphoma subtype, and supports ebus/eus as an acceptable procedure for lymphoma diagnosis. background: light chain deposition disease (lcdd) is characterized by amorphous "glassy" deposits of immunoglobulin light chains in organs such as kidneys, heart, and liver. since these amyloid-like deposits lack the secondary structure consisting of beta-pleated sheets, they don't stain salmon-pink with congo red. additionally, a negative congo red may be attributed to suboptimal staining, especially when the deposits primarily involve organs where lcdd is rarely encountered. moreover, congo red stains are compromised when the available sections are micron thick. we noticed in a case of primary lcdd of the lung that the light chain deposits stained bright red with masson trichrome and pink with sulfated alcian blue (sab) stains. in the current study, we tested whether these two stains can distinguish between amyloidosis and lcdd. we reviewed lung cases with eosinophilic deposits and immune infiltrates with negative congo red stain. we assessed trichrome and sab staining on cases of lcdd and control case of amyloidosis involving the lung. results: cases were identified ( table ). the age of the patients ranged from to years and % were females. imaging studies of cases showed nodular deposits and the remaining cases showed cystic lesions and/or nodular lesions. underlying hematologic abnormalities were detected in lcdd patients which included malt lymphomas (n = ) and plasma cell neoplasm (n = ). systemic involvement was absent in cases with available information. hematoxylin and eosin stained slides of all cases showed "glassy" eosinophilic amyloid-like deposits predominantly around airways and vasculature. congo red staining was negative in all lcdd cases, while it showed salmon-pink staining of amyloid deposits in the control case. for all lcdd cases tested, trichrome stained the deposits as bright red and the sab stained the deposits as pink (figure ). in contrast, amyloid deposits in the control case stained greyish blue with trichrome and bright green with sab stains, as expected. figure - conclusions: when congo red fails to stain "glassy" amorphous eosinophilic material salmon-pink, trichrome and sab stains might indicate the non-amyloid, light chain nature of lcdd deposits when red and pink staining is seen, respectively. these screening studies can inform downstream testing such as immunofluorescence staining for light chains, transmission electron microscopy, and typing of light chains by mass spectrometry. background: pulmonary pleomorphic carcinoma (ppc) is known for its aggressiveness and poor prognosis than other subtypes of nonsmall cell carcinoma. to better understand the molecular characteristics of ppc, we analyzed genetic alterations of ppcs and their metastatic lesions by whole exome sequencing. we included ppc patients who underwent surgical resection for both primary lung cancer and metastatic lesions at seoul national university bundang hospital. carcinomatous and sarcomatous components of each primary ppc along with the metastatic lesions were microdissected. somatic mutation profiles were generated by whole exome sequencing. the majority of ppc patients were male ( of , . %) and smokers ( of , . %). carcinoma components of ppc consisted of adenocarcinoma ( of , . %), squamous cell carcinoma ( of , . %) or adenosquamous carcinoma ( of , . %). tp ( %) was the most frequently recurrent genetic alteration, followed by wdfy ( %), otog, pxdnl, and slitrk ( %). kras mutation was found in cases ( . %) and egfr mutation in one ( . %). in addition, mutations discovered to be richer in either carcinomatous, sarcomatous or metastasis included various genes known to be associated with tumor progression and poor prognosis (flnc, nrxn , csmd , znf , auts ). gene alterations associated with somatic hypermutation (pole, pold ) and epithelial-mesenchymal transition (notch , cdh , fn ) were also found. four cases ( . %) had high tumor mutation burden (tmb). of the altered genes investigated in depth in this study, roughly half (n= ) were shared by carcinomatous, sarcomatous and metastasis in at least one case. significant overlap of the mutation profiles between metastasis and either carcinomatous or sarcomatous component was not found. conclusions: this is the first study to analyze the molecular profile of ppc in both metastatic lesions and primary carcinomatous and sarcomatous components. sporadic genetic alterations appeared to occur among carcinomatous, sarcomatous components and metastatic lesions of ppc. various genes associated with tumor progression were altered in both primary and metastatic lesions. christin lepus , julia rotow , pasi janne , lynette sholl background: histologic transformation of egfr-mutant non-small cell lung carcinoma (nsclc) to small cell lung carcinoma (sclc) is a mechanism of acquired resistance to egfr-tyrosine kinase inhibitors (tkis) that occurs in approximately % of egfr-mutant nsclcs. however, the natural history/histologic progression of sclc transformation from nsclc is poorly understood. a retrospective analysis was conducted to characterize the morphologic variation during transformation of egfr-mutant nsclc to sclc. we identified patients with egfr-mutant nsclc that transformed to sclc during treatment with egfr-targeted tyrosine kinase inhibitor therapy. histologic evaluation of longitudinal specimens (n= - per patient) from both lung and distant metastases was performed to characterize the morphologic spectrum of lesions obtained from the initial diagnosis of nsclc to sclc transformation. results: all patients had lung adenocarcinoma harboring egfr mutations at initial diagnosis (exon deletion, . %; l r, . %) and had been treated with at least one egfr tki prior to development of sclc. most patients ( of ; . %) were on secondline osimertinib at the time of transformation. when transformation was first documented, four patients ( . %) were reported to have combined adenocarcinoma and sclc or poorly differentiated carcinoma with mixed adenocarcinoma and sclc morphologic features; the remaining patients ( . %) were reported to have sclc. retrospective review of this latter group demonstrated focal nsclc-like morphology (mildly increased cytoplasm, variably prominent nucleoli, and rare gland formation) in patients ( . %). conversely, of patients who had post-treatment, pre-transformation biopsies reported as adenocarcinoma showed classic adenocarcinoma architecture with superimposed small cell carcinoma-like cytomorphology, including increased nuclear-to-cytoplasmic ratio, nuclear hyperchromasia, and finely granular chromatin. overall, a hybrid/transitional phenotype was captured in of patients ( . %). among patients who had tumor genotyping upon sclc transformation, all maintained the sensitizing egfr mutation and showed acquired rb loss. recognition of these transitional morphologies may facilitate earlier detection of sclc-driven resistance to egfr-targeted therapy and inform timely selection of alternate treatment regimens. yuan li background: random forest model is a recently developed machine-learning algorithm, and superior to other machine learning and regression models for its classification function and better accuracy. but it is rarely used for predicting causes of death in cancer patients. on the other hand, specific causes of death in lung cancer patients are poorly classified or predicted, largely due to its categorical nature (versus binary death/survival). we therefore tuned and employed a random forest algorithm (stata, version ) to classify and predict specific causes of death in lung cancer patients, using the surveillance, epidemiology and end results- and several clinicopathological factors. the lung cancer diagnosed during were included for the completeness in their follow-up and death causes. the patients were randomly divided into training and validation sets ( : match). we also compared the accuracies of the final random forest and multinomial regression models. we identified and randomly selected , lung cancers for the analyses, including , cases for either set. the causes of death were, in descending ranking order, were lung cancer ( . %), other causes or alive ( . %), non-lung cancer ( . %), cardiovascular disease ( . %), infection ( . %), and. we found more iterations and the variables produced the best prediction, whose best accuracy was . % (error-rate . %, figure ). the final random forest model with iteration and variables reached an accuracy higher than that of multinomial regression model ( . % vs . %). the top- most important factors in the random-forest model were sex, chemotherapy status, age, radiotherapy status and nodal status (figure ). we optimized a random forest model of machine learning to predict the specific cause of death in lung cancer patients using a population database. the model also appears more accurate than multinomial regression model. background: primary pulmonary hematolymphoid neoplasms (phlns) are rare, and the incidence is increasing with modern diagnostic advances and treatments. flow cytometry (fc) is a proven powerful tool in the diagnosis of hematolymphoid disease, however its role in phln is not well represented. in the current study, we aim to assess the utility of fc in diagnosis of patients with phlns. we retrospectively reviewed the fc analyses of pulmonary specimens from our institutional database between - . the specimens are comprised of pleural fluid, bronchoalveolar lavages, bronchoscopy or ct guided fnas, and vats or surgical biopsies of lung mass. phlns were detected by -color panel fc by identification of clonal or immunophenotypical aberrant hematolymphoid populations. primary neoplasms are classified if no extrapulmonary lesions were detected by clinical radiological work up at the time of diagnosis or within three months of diagnosis. lung involvement is also a frequent site in involvement of lymphoproliferative diseases and are referred to as secondary involvement of the lung. we retrieved pulmonary specimens submitted for fc. we identified cases that were positive for phlns. median age was years with m:f ratio= . / specimens aided in the diagnosis of a hematolymphoid disease. distribution are as follows: pleural fluids, tissue biopsies, bronchoalveolar lavages. cases were classified as either primary ( / ( %)) or secondary ( / ( %)), and categorized as myeloid neoplasms, b-cell neoplasm, t-cell neoplasm, primary effusion lymphoma (pel), post-transplant lymphoproliferative disorder (ptld); and plasma cell neoplasms (table ) . of the phlns, diffuse large b-cell lymphoma (dlbcl) was the most common diagnosis ( / ( %)). immunosuppression were notable in patients. the remaining / cases represent followups of known lymphoproliferative diseases where fc analysis of lung specimen played a role in assessment of disease status. all fc positive cases were confirmed by tissue examination with positive predictive value (ppv) of %. conclusions: fc demonstrates a clear utility for immunophenotyping in the diagnosis of phln, with a perfect ppv. appreciating the spectrum of phln is helpful in disease detection. in addition, fc provides the ability to monitor residual disease and response to therapy; especially in immunosuppressed patients where expedited treatment can impact prognosis. background: piwi-interacting rnas (pirnas) are small non-coding rnas ( - nt) that play an essential role in maintaining genome integrity trough regulation of transposable elements. their expression was tough to be limited to germinal cells and early embryogenesis but recently an implication of pirnas in cancer biology has been reported. the aim of this study was to explore the expression of pir- pirna, which was identified by small rnaseq, in resected nonsmall cell lung cancer (nsclc) patients, and to analyze the correlation with the clinic-pathological features. we have analyzed resected nsclc samples from patients who underwent surgery in hospital clínic between and . pir- pirna was quantified using custom taqman non-coding rna assays in tumor and normal tissue. in vitro studies using sirnas to inhibit pirna expression were performed in two lung adenocarcinoma cell lines: hcc and a . results: pir- was overexpressed in tumor tissue compared to normal tissue (p< . ). it also appeared to have higher expression in squamous cell carcinoma compared to adenocarcinoma histological subtype. expression of pir- had prognosis impact in the group of early stage (i-ii) adenocarcinoma patients. higher pir- levels were associated with shorter disease-free survival (p= . ). in vitro analysis showed that the silencing of pir- was associated with decreased cell migration in a cell line (p< . ) and increased apoptosis in hcc cell line (p= . ). in conclusion, pir- may have an important role in carcinogenesis in nsclc, promoting cell migration and regulating apoptosis and may be a potential new prognostic biomarker for nsclc. lucas massoth lcdd rarely involves the lungs in a nodular or diffuse pattern. we present herein a large series of pulmonary nodular lcdd. in an institutional review from > patients in - , we identified specimens from patients with pulmonary nodular lcdd. we reviewed clinicopathologic features and performed electron microscopy in all cases. of patients ( women, men; age - [median ] years), were smokers, had a history of autoimmune disease, but none had a history or evidence of a systemic lymphoproliferative/plasma cell disorder. clinical presentations were most often incidental. of patients with radiology available, showed a solitary nodule each; showed multiple nodules (including with associated cystic changes). each nodule ranged . - . (median . ) cm. by light microscopy on hematoxylin-eosin staining, each nodule appeared as amorphous eosinophilic deposits; all cases showed multinucleated giant cells engulfing the deposits and prominent plasma cell infiltrates. while the morphology was reminiscent of amyloidoma, staining for congo red was negative for amyloid in all cases. pas was positive in all cases tested, and trichrome was distinctly bright red in of cases tested. of cases with plasma cell cytoplasmic light chain expression tested by immunohistochemistry and/or in-situ hybridization, were kappa-predominant, lambda-predominant and polytypic. immunofluorescence studies in cases confirmed kappa and lambda light chain restriction in case each. ultrastructurally, all cases showed extracellular electron-dense granular deposits, variably admixed with entrapped collagen fibers, often appearing perivascular, and lacking non-branching fibril formation characteristic of amyloid. of patients with > years of follow-up (median . years), were alive (the single death was unrelated to lcdd). pulmonary nodular lcdd appears clinically indolent, radiologically solitary or multifocal, and mimics amyloidoma by light microscopy. yet, special stains (negative congo red, bright red trichrome) and ultrastructural features (granular deposits with variable entrapped collagen) aid the diagnosis of lcdd and its distinction from amyloidoma. the high rate of autoimmune disease in this cohort may suggest a role of chronic immunologic stimulation in the pathogenesis of pulmonary nodular lcdd. background: molecular targeted therapies against egfr and alk have improved the quality of life of lung adenocarcinoma patients. however, targetable driver mutations are mainly found in ttf- /nkx - -positive terminal respiratory unit (tru) types and rarely in non-tru types. design: to elucidate the molecular characteristics of the major subtypes of non-tru-type adenocarcinomas, we analyzed lung adenocarcinoma cell lines ( tru types and non-tru types). a characteristic of non-tru-type cell lines was the strong expression of tff- (trefoil factor- ), a gastric mucosal protective factor. by immunohistochemistry, we examined tff- , ttf- /nkx - , hnf -alpha, and muc ac expressions using primary lung adenocarcinomas resected at jichi medical university hospital. we also examined the correlation between tff- expression and clinico-pathological factors and genetic abnormalities. results: an immunohistochemical analysis of revealed that tff- was positive in cases ( %). tff- expression was frequently detected in invasive mucinous ( / ( %)), enteric ( / ( %)), and colloid ( / ( %)) adenocarcinomas, less frequent in acinar ( / ( %)), papillary ( / ( %)), and solid adenocarcinomas ( / ( %)), and negative in micropapillary ( / ( %)), lepidic ( / ( %)), and microinvasive adenocarcinomas or adenocarcinoma in situ ( / ( %)). tff- expression correlated with the expression of hnf alpha and muc ac (p< . , p< . , respectively) and inversely correlated with that of ttf- /nkx - (p< . ). these results indicate that tff- is characteristically expressed in non-tru-type adenocarcinomas with gastrointestinal features. tff- -positive cases harbored kras mutations at a high frequency, but no egfr or alk mutations. tff- expression correlated with a poor prognosis in advanced stages. moreover, the knockdown of tff- inhibited cell proliferation and induced apoptosis in a tff- -positive and kras-mutated lung adenocarcinoma cell line. these results indicate that tff- is not only a biomarker, but also a potential molecular target for non-tru-type lung adenocarcinomas. background: accurate and timely biomarker results are essential for the modern-day treatment of non-small cell lung cancer (nsclc). nonetheless, many institutions around the world, particularly those without in-house testing capabilities, are faced with prolonged turnaround time. this study investigates the clinical impact of implementing a rapid biomarker testing strategy. design: rapid in-house biomarker testing was implemented utilizing immunohistochemical assays for pd-l , alk, ros, and braf v e, as well as qpcr for egfr using the biocartis idylla technology. after a -month period, we performed a retrospective chart review of nsclc patients presenting pre-and post-implementation of rapid biomarker testing at our facility. results: patients were included in the study ( underwent rapid biomarker testing and underwent traditional testing). the median (iqr) turnaround time for biomarker reports decreased from . ( - ) to ( - ) days (p < . ), with turnaround time defined as the total number of days between the diagnosis and biomarker result appearing on the medical record. the mean time to initiation of systemic therapy for advanced-stage patients decreased from . days to . days (p < . ) the proportion of patients who had a complete biomarker report at the time of their first consult with a medical oncologist increased from . % to . %. similarly, the proportion of patients who had a complete biomarker report at the time of initiation of systemic therapy increased from . % to . %. timely biomarker results are essential for the delivery of targeted therapy and immunotherapy to nsclc patients. many centres experience delays in biomarker results for a number of reasons. in this study, we demonstrate that a small panel of rapidlyreported biomarkers can significantly reduce delays in the initiation of systemic therapy, ultimately leading to superior patient outcomes. mitra mehrad background: primary sarcomas of the thorax (heart, lung, pleura, thymus, mediastinum) are rare and little information is available on predictors of their prognosis. the national cancer institute's seer (surveillance, epidemiology, and end results) database contains abundant information on the natural history of soft tissue sarcomas. therefore, we investigated the clinical outcomes of primary thoracic sarcomas (ts) utilizing the seer database. the seer database was queried for ts entered between and . ts was compared to sarcomas arising in soft tissues of the extremities and trunk. staging was performed based on the ajcc th edition. multivariable cox regression was used to identify prognostic factors. kaplan-meier curves were plotted to assess cancer-specific survival (css). patients < years of age and those without confirmed surgical resection were excluded. results: a total of ts and soft tissue sarcomas were available for analysis. most ts arose in the lung ( ; . %) followed by mediastinum ( ; . %), heart ( ; . %), pleura ( ; . %) and thymus ( ; . %). the most common ts were malignant solitary fibrous tumor (sft) ( ; . %), leiomyosarcoma (lms) ( ; . %), synovial sarcoma ( ; . %), undifferentiated pleomorphic sarcoma (ups) ( ; . %), and angiosarcoma ( ; . %), whereas in the soft tissue were ups ( ; . %), lms ( ; . %), myxoid liposarcoma (lps) ( ; . %), well-differentiated lps ( ; . %), and myxofibrosarcoma ( ; . %). comparing the two groups by multivariate analysis, the ts were larger and more frequent in males (p< . ). they were also of higher histologic grade and stage and were less likely to receive adjuvant therapy (p< . ). among the ts, tumors of heart origin (p< . ), greater than cm, stage iii-iv, and histologic grade had worse css (p< . ). the more common ts tumors including malignant sft, lms, synovial sarcoma, and angiosarcoma still had worse css compared to their soft tissue counterparts even when adjusting for stage, size and treatment. conclusions: primary thoracic sarcomas show worse clinical outcome compared to soft tissue sarcomas. a thoracic specific sarcoma staging system may be more predictive of css. background: primary pulmonary mucinous adenocarcinoma (pma) may be difficult or impossible to distinguish from colorectal adenocarcinoma (crc) due to considerable morphologic and immunohistochemical (ihc) overlap. since the lung is a common site of metastasis, the need to distinguish pma from crc in the lung is a routine challenge. commonly used lineage-specific ihc markers like cdx , ttf- , and napsin a are helpful to distinguish non-mucinous lesions but are either insensitive or nonspecific when applied to mucinous lesions. satb is a relatively new ihc marker that distinguishes crc from upper gastrointestinal and pancreaticobiliary tumors. its ability to distinguish crc from pma is not yet completely elucidated. design: three tissue microarrays of lung resections containing primary pulmonary mucinous adenocarcinomas (pmas), metastatic colorectal carcinomas (crcs), and primary pulmonary non-mucinous adenocarcinomas (pnmas) were stained with ck , ck , satb , cdx , villin, ttf- , and napsin a. two pathologists evaluated the number of positive neoplastic cells semiquantitatively, regardless of intensity: (no staining), + (< %), + ( - %), + (> %). results: thirty-one pmas, crcs, and pnmas were assessed (table ) . thirty ( %) of pmas and ( %) of pnmas were positive ( +) for ck , while all crcs were negative for ck . twenty-seven ( %) of crcs and ( %) of pmas were positive ( +) for satb , and ( %) of crcs and ( %) of pmas were positive ( +) for cdx . both pmas and crcs had high rates of villin positivity, with ( %) and ( %) positive ( +), respectively. only ( %) and ( %) of pmas were positive ( +) for ttf- and napsin a, respectively. no crcs were positive for ttf- or napsin a. in deciding pma vs. crc, ck was % sensitive and % specific for pma. satb was superior to cdx and villin but was only % sensitive and % specific for crc. conclusions: although the lineage-specific markers satb and cdx were fairly specific for crcs, a few pmas were also positive. in contrast, all crcs were negative for ck while almost all of the pmas were positive. lineage-specific markers ttf- and napsin a had a low sensitivity for pmas. villin showed a low specificity with the majority of crcs and pmas staining positively. our results suggest that a ck -positive tumor in the lung, whether mucinous or non-mucinous, is unlikely to be of colorectal origin. lineage-specific markers such as satb are of questionable value when evaluating mucinous lesions in the lung. massimo milione , patrick maisonneuve , federica grillo , alessandro mangogna , giovanni centonze , giovanna garzone , laura cattaneo , ketevani kankava , adele busico , paola spaggiari , alessandro del gobbo , luisa bercich , luigi rolli , elisa roca , natalie prinzi , giancarlo pruneri , alfredo berruti , ugo pastorino , carlo capella fondazione irccs istituto nazionale tumori milano, milano, italy, ieo, milan, italy, university of genova, genova, italy, university of trieste, trieste, friuli venezia giulia, italy, fondazione irccs istituto nazionale tumori milano, milan, italy, irccs foundation, istituto nazionale dei tumori, milan, italy, irccs foundation, istituto nazionale dei tumori, milano, italy, teaching, scientific and diagnostic pathology laboratory, tbilisi state medical university, tbilisi, georgia, istituti clinic humanitas, rozzano, milano, italy, fondazione irccs ca granda ospedale maggiore policlinico, milan, italy, university of brescia at brescia, italy, irccs foundation national cancer institute, milan, italy, with regards to molecular analyses, cases ( , %) of the co-lcnec group were studied (see table ). no single next-generation sequencing marker was statistically associated with os. the identification and morphologic characterization of combined features in lcnecs as well as the application of ki- cut off at % contribute in predicting clinical outcome of pure-lcnec and co-lnec patients. background: ctnnb encodes for β-catenin, which is a member in the wnt signal transduction pathway required for proliferation, survival and differentiation of different epithelial cells. mutation of ctnnb causes constitutional changes in the β-catenin protein that impedes its degradation, leading to an uncontrolled proliferation of the mutated cell. ctnnb exon hot-spot mutations are described in various tumor types and, for instance, in endometrial cancer, are associated with high risk of disease recurrence. the role of ctnnb , frequency and type of co-mutations has not been well characterized in non-small cell lung carcinomas (nsclc). design: between - , lung cancer samples from patients were sequenced on the ion torrent pgm with the gene ampliseq cancer hotspot panel v . our in-house sequencing database was searched to identify patients with ctnnb mutations; co-mutations in genes commonly altered in nsclc were also recorded. results: thirteen patients ( . %) with ctnnb mutations (p.s f ( ) (one also with p.d y), p.s c ( ), and p.s c, p.d h, p.g e, p.d v, p.d n, in one patient each) were identified. all tumors were adenocarcinoma histology. five patients underwent lobectomy and the predominant histologic patterns were solid ( ), papillary ( ) and micropapillary ( ) . the patients' age ranged from - , at the time of diagnosis, and eight were female ( . %). all patients were current ( ) or former ( ) smokers. five patients presented with stage iv disease, two with stage iii, two with stage ii, and four with stage i disease. six are deceased and seven are alive with disease. co-mutations were identified in all but one case and consisted of: braf ( -v e), egfr ( -ex deletions), kras ( ), pik ca ( ), and tp ( ). in two patients, egfr, pik ca and ctnnb mutations were co-occurring. we identified ctnnb mutations in . % of lung adenocarcinomas, which, in our population, were associated with frequent co-mutations. additional clinicopathologic data will be aggregated from our internal patients and available databases (cbioportal) to better understand the clinical implications of ctnnb mutations in nsclc. co-mutation with egfr may be a mechanism of primary resistance to egfr tkis. in addition, ctnnb mutations make patients eligible for newer small-molecule tkis (e.g. ttki). mohammad mohammad . samples from normal tissue included pancreas (n= ), rectum/appendix/colon (n= ) and ilium/duodenum/stomach (n= ). nuclear expression for otp was interpreted as negative (< % tumor cells stained), + (< %), + ( - %), + ( - %), and + (> %). results: six of ( %) pcs were diffusely positive for otp. one of ( %) pancreatic nets, of ( %) bladder sccs, and metastatic net in the liver (negative for ttf and no lung mass identified) were positive for otp. all other tumors and normal tissues were negative. representative cases are shown in figure . conclusions: our data demonstrated that otp expression was only rarely identified in non-pulmonary neuroendocrine tumors/carcinomas, which further validated the previous report of otp to be a highly specific marker for diagnosing pcs. the diagnostic sensitivity for pcs in this study appears to be lower than the previous report, which is probably due to the small number of cases included. caution should be taken because rare pancreatic nets and bladder sccs can be positive for otp. background: quantification of pd-l /pd- expression in non-small cell lung cancer (nsclc) is not always predictive of efficacy of immune checkpoint inhibitor therapy, and response to these agents remains limited to a minority of patients. human leukocyte antigen (hla- ) participates in presentation of aberrant peptide antigens, enabling cytotoxic t cells to recognize and destroy tumor cells. correspondingly, loss of hla- expression precludes immune recognition, and this loss is one proposed mechanism of treatment failure of immunotherapy. we hereby examine the expression of pd-l and hla- in a large cohort of nsclcs to determine the patterns and frequency of expression of these two markers. design: nsclc resection specimens from - classified as adenocarcinoma (ac) or squamous cell carcinoma (scc) were identified. tumor microarrays with . mm diameter cores were constructed, with sections of neoplastic tissue and section of uninvolved lung for each case. immunohistochemistry for pd-l ( c ) and hla- was performed. membranous tumoral pd-l staining was semi-quantitatively scored as < %, - %, and > %. hla- was scored as intact, partial (clonal) loss, or complete loss with total absence of staining. conclusions: hla- loss is common in nsclc and can readily be assessed by immunohistochemical methods. in this study, there is no association between pd-l expression and hla- expression. given that hla- expression may be a determinant of response to immunotherapeutic agents targeting the pd- /pd-l axis, it may be considered as an adjunct immunohistochemical marker prior to initiation of immune checkpoint therapy or in instances of treatment failure. background: short telomere syndromes (sts) are multisystem accelerated aging syndromes caused by inheritable gene mutations in telomere maintenance genes; frequent manifestations include bone marrow failure and interstitial lung disease (ild). insufficient information is available about histologic findings and patterns of ild in individuals with sts and whether these vary by specific inherited sts gene. our study aims to describe the morphology of lung disease in patients with sts. design: probands enrolled in the inherited hematologic disorders registry at our hospital with a personal or familial history of pulmonary fibrosis underwent genetic testing via targeted genomic capture and next-generation sequencing (ngs) of sts genes. available specimens(n- ), including wedge resections(n- ) and lung explants (n- ), were analyzed for histopathological features (table ) . eight patients with known sts with ild had available histology (m= , f= average age at diagnosis . years). pathognomonic findings of usual interstitial pneumonia (uip) were seen in all patients. one patient with two different mutations in the telomere-associated genes showed features of both uip and non-specific interstitial pneumonia (nsip). there was associated lymphoplasmacytic infiltration which was mild in % and extensive in the remainder. other histologic findings were variable, e.g. nonnecrotizing granulomas and upper lobe predominance are noted in % of the patients. pulmonary hypertension was seen in all of the patients except one who had a very early disease. conclusions: sts associated lung disease frequently shows uip with additional findings including inflammatory (lymphoplasmacytic infiltrate) and hypersensitivity pneumonia-like (granulomas and upper lobe predominance) features. consideration should be given to testing for sts in patients with uip with these histologic findings. it is important to identify this cohort of patients because these patients may have a more rapid progression of their ild and an increased toxicity from immunosuppressive drugs especially in post-transplant setting. if a pathogenic gene mutation is identified, first-degree family members (especially siblings) should be informed about disease monitoring options and knowing the risks of future health issues. background: genetic polymorphisms in key genes encoding enzymes involved in the bio-activation (cytochrome p (cyp)) or detoxification (glutathione s-transferase (gst)) of environmental carcinogens including tobacco specific nitrosamines are potential lung cancer risk factors. the frequencies of these variants and consequently their effects vary across ethnicities. the interactive effects with cyp-gst combination along with smoking have not been documented. five single nucleotide variants and two homologous deletion variants associated with cyp and gst genes and their interactive effects with smoking in non-small cell lung cancer (nsclc) were investigated design: the case control study comprised cases of histologically diagnosed nsclc and healthy controls. iec approval and informed consent were obtained. mean age of cases was . ± . + sd, male: female ratio was . , were non-smokers and smokers subdivided into ( . %), - ( . %) and ( . %) in pack-years. histological subtypes included adenocarcinoma (adc), squamous cell carcinoma (scc) and adeno-squamous cases. majority were diagnosed in late stages with only in stage ii, . % had lymph-node metastasis and cases had distant metastasis. dna was isolated from whole blood and genetic polymorphism analyses were determined by polymerase chain reaction coupled with restriction fragment length polymorphism followed by agarose and poly acrylamide gel electrophoresis for genetic variants. all the statistical analyses were performed with graph pad instat version . and spss version (chicago, usa). significantly high risk of nsclc and subtype adc was associated with variant cyp a , gstt and gstm ( conclusions: functionally relevant polymorphisms in cyp and gst genes with gene-gene and gene-environment interactions play a significant role in modifying the susceptibility to nsclc in population of indian ethnicity. design: thirty consecutive surgically resected lung-nens comprising tc, ac and six lcnec, all with long-term follow-up, were immunohistochemically stained for ki- and scanned at x (nanozoomer xr, hamamatsu, japan). a tailored algorithm was constructed to recognize all ki- -stained tumor cells and the obtained patterns were described using spatial statistics, graph modeling, fractality and shannon entropy parameters. a support vector machine classifier with polynomial kernel was then trained, employing the parameters that resulted most informative out of the initially computed, to distinguish dead (true positive) from alive (true negative) patients. over repetitions of -fold cross-validation, the model averaged . % diagnostic accuracy in the prediction of ultimate clinical outcome (dead vs alive) in the lung-nen patients under evaluation, which resulted to be independent of who classification. the corresponding values of sensitivity, specificity, ppv and npv were . %, . %, . %, and . %, respectively. the intratumor heterogeneity of ki- is a powerful and histology-independent resource to unravel clinical outcome of lung-nens by using machine learning algorithms. roshan raza background: cytologic diagnosis of mm is challenging since atypia in mesothelial cells is not specific for malignancy and there is no architecture to assess for invasion. loss of bap expression by icc and homozygous deletion of p /cdkn a by fish are specific but not sensitive for mm. co-deletion of mtap occurs in most mm with p /cdkn a deletions and can be detected by icc, which has advantages over fish. recently, -hmc has been reported to show % sensitivity and % specificity for distinguishing mm from benign mesothelial proliferations. to our knowledge, these markers have not yet been studied in combination in cytology. herein, we determine the sensitivities and specificities of bap , mtap and -hmc icc for the diagnosis of mm in cytology. design: icc with mtap, -hmc and bap was performed on all available mm cytology specimens from -present and benign specimens with reactive mesothelial cells on cell block. icc was scored as nuclear loss of bap expression, loss or marked reduction of cytoplasmic mtap expression, loss of nuclear expression of -hmc in at least % of tumor cells or non-contributory (nc) in cases without internal positive control. all available clinical next generation sequencing (ngs) data were collected. results: cytology specimens ( fluids, fna, touch preparation) from patients with diagnosis of mm confirmed by histology ( epithelioid, biphasic) contained adequate tumor cellularity on formalin-fixed cell blocks for study inclusion. all cases with benign mesothelial cells showed retained bap and mtap expression and retained or < % loss of -hmc expression. mm in , and patients showed bap loss, mtap loss and/or > % loss of -hmc expression (sensitivities of , and %), respectively. bap icc was nc in one mm specimen. while sensitivity of mtap was low, mtap loss was seen in mm with retained bap and either retained or < % loss of -hmc expression. combined sensitivity of all markers was %. cdkn a deletions were detected by ngs in all mm with mtap loss by icc. mtap icc was retained in mm with cdkn a deletions detected by ngs. the status of the intratumoral immune microenvironment is important to guarantee the effect of immune checkpoint (ic) blockade therapy, which has been broadly used in patients with non-small cell lung carcinoma (nsclc). glucocorticoid (gc) is a hormone well-known to act strongly on the immune system. therefore, we examined the correlation between intratumorally synthesized gc through β hydroxysteroid dehydrogenase (hsd) and the immune microenvironment in nsclc. we evaluated surgical specimens from patients with nsclc ( adenocarcinoma and squamous cell carcinoma), assessing mainly the immunoreactivity for βhsd and βhsd and the levels of tumor-infiltrating lymphocytes (tils) and cd -or cd -positive t cells. furthermore, we examined the correlations between βhsd immunoreactivity and the therapeutic efficacy of ic blockade therapy using nine biopsy specimens from patients with nsclc. subsequently, we explored the mechanisms of gc effects on the intratumoral immune microenvironment, focusing on cytokines. results: βhsd immunoreactivity was significantly inversely correlated with the numbers of intratumoral tils, cd -positive t cells, and cd -positive positive t cells. additionally, we found βhsd immunoreactivity tended to be inversely correlated with the efficacy of the ic blockade therapy. according to the in vitro study, gc reduced the expression of cytokines such as il- and il- , resulting in an inhibition of monocytes migration. furthermore, production of cortisol, active gc, was confirmed in the cell lines expressing βhsd . conclusions: this is the first study demonstrating the significant inhibitory effects of intratumorally synthesized gc through βhsd on tissue immune microenvironment in nsclc, and the possible correlation of intratumoral βhsd status with the efficacy of ic blockade therapy. our results provided new insights into the therapeutic strategies and the efficacy prediction of ic blockade therapy. these prognostic factors may be useful to the treating physician in crafting treatment plans. this study seeks to compare these parameters between metastatic and primary sites in mm. design: paired cases of pleural mm with metastatic and primary sites were identified from the pathology archives at the participating institutions with review of h&e stained sections. histologic subtype was noted in all cases. for epithelioid mm, ng ( , , or , as previously described in the literature by kadota et. al.) and necrosis were determined. results: paired cases were identified with the primary site subtype comprised of epithelioid, biphasic, and sarcomatoid cases. of ( %) metastases showed epithelioid morphology; ( %) metastases were biphasic. the positive predictive value of epithelioid subtype at metastatic site was %, sensitivity %, and specificity %. ng and the presence or absence of necrosis at metastatic sites were not correlative with primary site histologic subtype (p= . and p= . , respectively). thirty-three pairs of metastases and primaries with epithelioid morphology were graded; metastases were too small to grade. pairs were more likely to show a higher ng at primary rather than metastatic sites (p< . ) with of ( %) metastatic sites with ng showing ng at primary site, and of ( %) metastatic sites with ng showing ng at primary site. all metastases with ng had ng at primary site. there were no pairs with lower ng at primary site than metastatic site. the presence or absence of necrosis at metastatic site was not predictive of the presence or absence of necrosis at primary site (p= . ). the application of pathologic parameters to metastatic mm may not accurately predict the parameters at primary site. while sensitive, epithelioid morphology at metastatic site is not specific. metastatic sites may underestimate nuclear grade at the primary site. the presence of necrosis in a metastatic site may not be predictive of necrosis at the primary site. biopsy of the primary site may be required to more accurately classify the tumor. background: immunotherapy has dramatically changed the treatment landscape of various malignancies including lung adenocarcinomas. the nccn guidelines initially recommended single agent immunotherapy as a first line treatment option for advanced lung adenocarcinoma with pd-l expression levels of % or greater. however, given the recent data suggest that pd-l monotherapy is less effective in patients with egfr or alk gene alterations, the nccn panel recently deleted the recommendation for subsequent immunotherapy in these patients. we retrospectively analyzed cases of lung adenocarcinoma with pd-l expression (> % expression) using pd-l ihc c pharmdx test and correlated pd-l expression with the presence of egfr mutations or alk gene rearrangement in the cases where all tests were performed. pd-l expression levels were subcategorized as low expression level ( %- % of the tumor cells express pd-l ) and high expression level ( %- % of the tumor cells express pd-l ). results: high expression levels of pd-l ( %- %) were observed in % ( / ) of the cases. among the ( %) tumors that harbored alk gene rearrangement, showed high pd-l expression. among the ( %) tumors with detected egfr mutations, only showed high pd-l expression. these two alterations were mutually exclusive. results are summarized in the table . conclusions: in our study cohort % ( / ) of lung adenocarcinomas with pd-l expression showed high ( %- %) expression levels. % of these high pd-l expressors were positive for either egfr or alk alterations: % ( / ) harbored alk gene rearrangement and % ( / ) showed egfr mutations. we corroborated the previously reported association of alk gene rearrangement with high expression levels, and egfr mutations with low expression levels of pd-l in lung adenocarcinomas that express pd-l . our study showed a substantial number ( %) of lung adenocarcinomas that express (> %) pdl- have egfr mutations or alk gene rearrangement, suggesting that it is important to consider the results of these tests simultaneously in order to be able to stratify patients according to current nccn therapeutic guidelines. background: pd-l is a predictive marker of anti-pd- /pd-l therapies for non-small cell lung cancer (nsclc). heterogeneous pd-l expression may cause dilemmas in anti-pd- /pd-l therapies when faced with discrepant biomarker results. our aim was to comprehensively analyze the heterogeneity of pd-l expression defined as intratumoral area, paired samples and clones of anti-pd-l antibody to optimize tumor sampling and improve its accuracy. we selected nsclc surgically resected specimens, cell block and biopsy specimens. we analyzed the associations of pd-l expression with histopathological characteristics, assessed the heterogeneity between paired cell block and biopsy samples (n= ), paired biopsy and resected samples (n= ), paired two blocks of the same resected sample (n= ), paired primary and metastatic lesions (n= ), and compared the consistency of clones of pd-l antibody ( c and sp , n= ). background: recently, we identified two young adults with idiopathic acute respiratory distress syndrome (ards) histologically characterized by diffuse alveolar injury with marked alveolar denudation, a novel pattern termed daide. both patients were exposed to trimethoprim-sulfamethoxazole (tmp-smx). here, we report four additional patients with daide following tmp-smx exposure and detail the features of all six patients. the original patients were identified through routine surgical pathology, and an additional patients were identified in the consultation archives. daide was identified on surgical biopsy (n= ), autopsy (n= ), or both (n= ). six patients with dad on surgical biopsy were used for comparison. clinical information was obtained from the medical record. h&e and ihc for ae . /cam . , cd , and ck / were reviewed. six otherwise healthy patients (m:f= : , median age: years; age range: - years) initially presented with uri symptoms that rapidly progressed to ards; extensive infectious and rheumatologic workups were negative. no patients had a history of vaping. all patients were intubated and placed on ecmo for a median of days (range: to days). surgical biopsy was performed in patients ( days before to days after intubation), and autopsy was performed in patients ( and days after intubation). all surgical biopsies showed marked alveolar denudation with histiocytes replacing alveolar lining and nested peribronchiolar metaplasia, consistent with daide. hyaline membranes were rare when present (n= ). the autopsies showed patchy alveolar-filling fibrosis and reepithelialization of most alveoli, with focal areas of alveolar denudation and histiocytic lining, suggestive of partially resolving daide. in comparison, control surgical dad cases showed prominent hyaline membranes, only focal alveolar denudation, and no significant histiocytic lining. on follow-up, daide patients underwent bilateral lung transplant (n= ); overall, patients are deceased (n= ). conclusions: daide appears to be a novel variant of dad with a rapid and severe clinical course involving previously healthy patients and is characterized by extensive alveolar denudation with a lining replaced by histiocytes and a paucity of hyaline membranes. although our patients share a history of tmp-smx exposure, the role of tmp-smx in daide is currently unclear. nonetheless, patients with daide appear to have a poor prognosis. lynette sholl , adrian dubuc , jason hornick , david chapel brigham and women's hospital, boston, ma, brigham and women's hospital, harvard medical school, boston background: the entity diffuse idiopathic neuroendocrine hyperplasia (dipnech) is a clinical syndrome defined by the who as a generalized proliferation of neuroendocrine cells either confined to the bronchial mucosa or resulting in formation of carcinoid tumorlets or tumors. when thus defined, dipnech is a diagnostic entity seen in clinically symptomatic patients presenting with histologic alterations of neuroendocrine proliferations combined with radiological features of airtrapping and multiple bilateral nodules. the significance of incidentally discovered neuroendocrine cell hyperplasia in surgically resected specimens and its correlation to radiological and clinical features is not known. this study aims to characterize the clinicopathological and radiological patterns identified in patients with histologically identified diffuse neuroendocrine cell hyperplasia (nech). we searched the pathology database starting jan, till sept, . for the for the combination of the following keywords "diffuse" and "neuroendocrine cell hyperplasia (nech)'' and "lung" and identified ten cases that met the search criteria. the radiological data was reviewed by one thoracic radiologist in a blinded fashion. clinical, radiological and pathological features of these patients are depicted in table . there was female predominance in our study ( / ) and all patients were above the age of years. % ( / ) of the nech cases were diagnosed incidentally during imaging workup or postoperative surveillance for other malignancies. the remaining cases were biopsied for presentation of respiratory symptoms and or radiological finding of interstitial lung disease. radiologically, bilateral involvement of lung was seen in out of cases with air trapping in cases. the radiological diagnosis of dipnech could be made only in three cases, one of which was incidentally discovered (case ). nine cases showed presence of carcinoid tumor or tumorlet along with nech and cases showed granulomas along with nech. in conclusion, in this study, vast majority of patients with nech were incidentally discovered during surveillance and follow up imaging for an unrelated malignancy or nodules. none of these incidentally discovered patients were clinically symptomatic. the criteria for evaluation of nech in incidentally discovered asymptomatic patients is not well defined and necessitates further investigation and appropriate follow-up for an evolving interstitial lung disease. elisabeth tabb background: recent studies have implicated local microbiota in activating gamma-delta t-lymphocytes (gdtl) and subsequently inducing neutrophilic infiltration to promote oncogenesis in murine models of kras-mutant lung adenocarcinoma. this study aimed to examine the translational relevance of these preclinical findings by evaluating gdtl and tumor-associated neutrophils (tan) in human lung adenocarcinomas, including those with and without kras mutations. we quantified the numbers of gdtl and tan using immunohistochemistry for t cell receptor-gamma chain and myeloperoxidase, respectively, from high-power fields (hpf; each . mm ) of viable tumor areas on tissue microarray (duplicate of -mm core) sections of human lung adenocarcinomas resected in - . high and low gdtl or tan were defined as above or below the respective median. data were correlated with demographics, histologic features (ajcc th edition), immune parameters (tumoral pd-l expression, cd + tumor-infiltrating lymphocytes [til]), molecular alterations (using a multiplex-pcr based assay), and outcome via chi-square or logrank tests as appropriate (significance: p< . ). results: gdtl ranged - (median . ) per hpf (in tumors with evaluable data); whereas tan ranged - (median . ) per hpf (in tumors with evaluable data). the numbers of gdtl and tan correlated with each other (p< . ). both high gdtl and high tan were associated with smoking history (p< . ; p< . ), solid/high-grade acinar histologic patterns (p< . ; p< . ), the presence of tumor necrosis (p< . ; p< . ), and elevated cd + til (p< . ; p< . ). high tan -but not high gdtl -was also associated with greater total tumor size (p< . ), invasive size (p< . ), advanced stages - (p< . ), and worse progression-free survival (p< . ), with a trend toward worse overall survival (p= . ). however, gdtl and tan were not associated with tumoral pd-l expression or molecular alterations including kras or egfr. in human lung adenocarcinomas, we identified correlations of gdtl and tan with smoking history, aggressive histology, and elevated cd + til, but no associations with mutation status. tan also appeared to be associated with worse patient outcome. increased gdtl and tan may reflect aggressive tumor biology; our data also suggests that their effects may be more general and not restricted to kras-mutant tumors. background: pd-l expression in non-small cell lung cancer (nsclc) is used as a biomarker to treat patients with pd blockade therapy. pd-l expression may be related to tumor stromal interactions guided by underlying genotypic/phenotypic characteristics of a tumor and tumor antigenicity. increasing evidence has shown that c-met pathway activation in coordination with interferon gamma can lead to pd-l upregulation. in order to determine whether the underlying genomic characteristics of a tumor, including c-met status is associated with pd-l status, we analyzed lung nsclc that had been genomically characterized and correlated with pd-l status. design: immunohistochemical staining for pd-l was performed with clone c on a dako autostainer and scored as no expression (< %), low expression ( - %) or high expression ( % or greater). flourescent in situ hybridization was performed for alk, ret and ros (break apart probes) and c-met amplification/polysomy. mutations were detected by next generation sequencing of a gene panel (cmp , based on illumina tst ) or multiplex hotspot mutation assay (snapshot, gene panel). we evaluated lung nsclc ( adenocarcinomas/favor adenocarcinoma, squamous cell carcinomas, not otherwise specified, adenosquamous and combined large cell neuroendocrine carcinoma with adenocarcinoma). no pd-l expression was seen in % (n= ) while pd-l expression was seen in % (n= ) with low expression in % (n= ) and high expression in % (n= ). among the no expression cohort there was a slight increase in egfr mutated patients as compared to pd-l expression cohort ( % vs. %) while similar frequencies in kras mutations were seen in both cohorts (no expression %; pd-l expression %). c-met alterations in the form of amplification, high polysomy and mutations (exon skip mutations and juxtamembrane mutations) were associated with pd-l positive status (no pd-l expression % (n= ) vs expression % (n= )), p= . ), especially when there is high pd-l expression ( % (n= ); p= . ). only in the no pd-l expression category was concurrent egfr mutation and c-met amplification/polysomy observed ( of ). higher pd-l expression is associated with c-met amplification, polysomy and mutations. these results indicate that patients with abnormalities in c-met may benefit from combined inhibition of pd- pathway and c-met pathway. background: differentiating malignant pleural mesothelioma from reactive mesothelial processes can be quite challenging. ancillary tests such as bap immunohistochemisry (ihc) and p fluorescence in situ hybridization (fish) are very helpful tools to aid in this distinction. ihc for mtap has recently been proposed as an effective surrogate marker for p fish, and it is an attractive alternative test due to shorter turn-around time. there is little data regarding the specificity of mtap ihc for mesothelioma, or whether it may be useful to distinguish mesothelioma from other entities in the differential diagnosis. while there are many reliable markers to distinguish epithelioid mesothelioma from adenocarcinoma, this is not true of sarcomatoid mesothelioma, which can be very difficult to distinguish from sarcomatoid carcinoma. the goal of this study was to determine if mtap loss is present in pulmonary sarcomatoid carcinoma or only in sarcomatoid mesothelioma. design: well-characterized cases of sarcomatoid carcinoma (n= ) and sarcomatoid mesothelioma (n= ) were included; diagnoses were confirmed by two thoracic pathologists with incorporation of immunophenotype, clinical and radiographic features. each case was stained for mtap (clone g ) and bap (clone c- ). successful staining was confirmed by presence of internal positive control for both stains. results: loss of mtap expression by ihc was observed in of pulmonary sarcomatoid carcinomas ( %); of these cases also had successful bap staining performed, which was retained in all cases. mtap expression was lost in of sarcomatoid mesotheliomas ( %); bap was successful in all cases, and showed loss in ( %). in the cases of sarcomatoid mesothelioma with bap loss, also had loss of mtap, while mtap expression was retained in case. conclusions: loss of mtap expression by ihc is common in pulmonary sarcomatoid carcinoma, present in half of cases. this may reflect homozygous p deletion, which has been described in a few cases of sarcomatoid carcinoma studied by fish analysis. this rate is similar to what is observed in sarcomatoid mesothelioma ( %). therefore, mtap loss is not specific for mesothelioma, and this stain is not useful to distinguish between these two malignancies. mtap loss is more common than bap loss in the setting of sarcomatoid mesothelioma ( % vs %, respectively). basile background: metexon skipping (metex ) mutations present in % of lung adenocarcinoma is now becoming an important alteration to test for targeted therapy, similarly to alk. the only commercially available way to test for metex mutations is through next generation sequencing. there is a need for a faster and more available method to be used for the detection and validation of metex mutations but traditional animal base monoclonal antibody (mabs) techniques are slow and difficult to scale. a newer, faster and animal-free approach using instead b-cells cloning to generate in vitrorecombinant antibodies (rabs) is increasingly popular. here we compare a novel rabs technique to the more traditional mabs generation approach in developing a mutation-specific monoclonal immunohistochemistry (ihc) to metex mutation. design: using the same amino acid sequence overlapping the fusion of metexon and , we generated a total of antibody clones: rabs and rabbit-based mabs. the clones were validated by enzyme-linked immunosorbent assay (elisa) and ihc using a combination of synthetic peptides, metex mutated cell line (h ) and archival lung adenocarcinoma tissue with metex mutation. of the rabs screened for affinity by elisa, were retained for ihc validation along with all mabs. using the metex mutated cell line, strong ( / staining intensity) diffuse ( % tumor cells staining) membranous staining was achieved in of the rabs. seven other rabs had weak-to-intermediate ( - / staining intensity) non-diffuse ( - % tumor cell staining) membranous staining and the remaining rabs showed no membranous staining. the best mabs clone only showed focal ( %) weak-to-intermediate staining with substantial background staining and the other mabs were completely negative. the rabs technique was an effective approach to generate metex mutation-specific ihc clones. it can be scaled up more readily as opposed to the traditional animal-based hybridoma technique, and as a result, it increases its rate of success and decreases cost. this technique might allow for easier transition of mutation-based biomarkers to ihc and improve turnaround time and access for predictive tests in oncology. the top rabs are currently being tested on an extended cohort of lung carcinoma tissue. ( ) and weak staining ( +) were classified as negative; focal moderate staining ( +) as equivocal; patchy and diffuse moderate staining ( +) and strong staining ( +) as positive. (figure ) results: among cases, insm was positive in cases ( . %) and equivocal in cases ( . %). of adenocarcinomas, insm was positive in cases ( . %) and equivocal in cases ( . %). the positive adc cases included case with focal + nuclear staining, cases with diffuse + staining, and cases with patchy + staining. of squamous carcinomas, insm was positive in cases ( . %) and equivocal in cases ( . %). the positive sqcc cases included case with patchy + staining, cases with diffuse + staining and cases with patchy + staining. focal + nuclear staining was seen in of other nsclc cases. (table ) other non-small cell carcinoma conclusions: our study demonstrates that insm is expressed in a subset of nsclcs and suggest that caution must be exercised in interpreting insm staining, especially with limited sample such as biopsy and cell block sections. although insm is useful for the diagnosis of neuroendocrine tumors, it should not be used as a stand-alone marker in differentiating primary lung tumors. background: egfr tyrosine kinase inhibitors (tkis) therapy is a validated approach in the treatment of egfr-mutated non-small cell lung carcinoma (nsclc), but resistance universally develops and it has become a major obstacle in prolonging the survival of patients. more novel molecular biomarkers are still urgently required to elucidate the underlying mechanisms of resistance. this study aimed to investigate the role of linc in the acquired resistance of nsclc to egfr-tkis. design: gene expression profiles from geo dataset were analyzed to identify the genes associated with egfr-tkis resistance. egfrmutated nsclc cell line pc was cultured with gefitinib for more than months to acquire gefitinib-resistance, which was designated as pc r. the expression patterns of linc were characterized using reverse transcription quantitative polymerase chain reaction (rt-qpcr), and lentiviral vectors were used to infect cells to regulate the expression. cytotoxicity of egfr-tkis on infected cells was determined by cell counting kit- (cck- ). survival follow-up time of nsclc samples from tcga dataset were enrolled in this study. in addition, statistical analysis was mainly performed by r programming language and graphpad prism . (graphpad). results: linc is highly expressed in gefitinib-resistant cell line pc r relative to pc (p< . ). inhibiting linc with lentivirus vectors induces apoptosis in pc r. linc could promote cell proliferation and induce resistance. statistics from tcga dataset demonstrate there is no significant difference in linc expression between luad tissues ( ) and normal tissues ( ), but the expression level in lusc tissues ( ) conclusions: linc is involved in acquired resistance of egfr-tkis in nsclc. it may serve as a predictor and a potential therapeutic target for egfr-tkis resistance. ilyas yambayev background: lung cancer is the most common cause of cancer death worldwide. screening by ldct is expected to increase the frequency of early-stage nsclc of which lung adenocarcinoma (luad) is the most common subtype. although the assignment of predominant histologic subtypes is now recommended, there remains no widely accepted prognostically relevant grading system. several grading systems have been proposed however there has been no direct comparison of these grading systems in an independent cohort. here we compare several previously published architecturally based grading systems in a large cohort of stage i luad. design: h&e slides were reviewed from stage i luad resection specimens form a multi-institutional cohort of patients diagnosed between - . the staging was reassigned using ajcc th edition after determining the invasive size and assessing for pleural invasion. comprehensive histologic subtyping in % increments was performed along with mitotic figure counts and assessment for angiolymphatic invasion. this data was applied to compare recurrence-free survival rates using published grading systems. the demographic, smoking status and stage characteristics are summarized in table . results: figure shows the kaplan meier curves for published grading systems. predominant architectural pattern assignment alone was prognostically significant in stratifying patients into low ( - conclusions: predominant architectural pattern assignment alone is a valuable grading system. the addition of mitotic grade and angiolymphatic invasion allows for further refinement to identify higher proportions of low-risk and a small but significant subset of very high-risk luad which might aid in the precision clinical management of early-stage luad. harbored egfr mutations. lung cancers with atm p.v g were identified, with generally higher vafs ( - %). / cases with atm p.v g also harbored the egfr p.l r variant, while cases also harbored kras codon mutations. interestingly, the two kras/atm-mutated cases were from a single patient, with different kras mutations. conclusions: disease-associated brca / variants are rare in lung carcinomas, and many cases were associated with kras hotspot variants, suggesting that brca / mutations may be somatic in origin, likely in the setting of significant smoking history. in contrast, while atm p.v g is equally rare, the genomic context and vafs of the atm variants suggest possible germline events. assessment of other genes in the hr pathway is currently underway. jingping yuan , huihua he , lin xiong , li xu background: pulmonary enteric adenocarcinoma (pea) is a rare histologic type of lung adenocarcinoma. pea is composed mainly of tall columnar cells arranged in an irregular acinar or cribriform pattern with extensive central necrosis, closely resembling the appearance of intestinal epithelial and colorectal carcinomas under the microscope. immunohistochemically, pea is usually positive for ck . however, some cases lack ck expression and are positive for intestinal differentiation markers, such as cdx , villin, and ck . for these reasons, it is difficult to distinguish between pea and pulmonary metastases of colorectal carcinoma (mcrc), so new identification methods need to be explored. satb expression is tissue-specific, and the only epithelial cells expressing this protein in adult tissue are the glandular cells lining the lower gastrointestinal (gi) tract. the sensitivity of satb in colorectal adenocarcinoma reaches %- %, and their low expression in primary pulmonary tumors. therefore, this study investigated differential diagnostic values of satb in pea and mcrc. design: according to the who primary pea diagnostic criteria, the cases of lung adenocarcinoma were collected from patients being treated at the renmin hospital of wuhan university from . - . were screened. the specimens were independently reviewed by two pathologists, and immunohistochemical staining of lung adenocarcinoma markers (ck , ttf- , and napsina) and intestinal cancer markers (ck , cdx , and villin) was performed to aid identification. finally, after excluding possible colorectal cancer metastasis by carefully analyzing the clinical histories and imaging examinations, we recruited primary pea specimens and mcrc specimens for study. the sensitivity and specificity of immunomarkers satb , ck , ttf- , napsina, ck , cdx and villin for distinguishing pea from mcrc are evaluated. the expression rates of satb in pea and mcrc were . % ( / ) and . % ( / ), respectively. the sensitivity of satb -, ck +, ttf- +, napsina+, ck -, cdx -and villin-for distinguishing pea from mcrc were . %, . %, . %, . %, . %, . %, . %, respectively. the specificity of satb -, ck +, ttf- +, napsina+, ck -, cdx -and villin-for distinguishing pea from mcrc were . %, . %, . %, . %, . %, . %, . %, respectively. conclusions: our study shows that the sensitivity and specificity of satb , which can all reach %, is much higher than those of common lung adenocarcinoma immunomarkers (ttf- , napsina) and intestinal cancer immunomarkers (ck , cdx and villin). satb can be viewed as the best immunomarkers for distinguishing pea from mcrc. the diagnostic value of ck is slightly inferior to satb , the results of ck can be used as a reference for differential diagnosis of satb . lisi yuan results: of nsclcs tested between - / , met ex variants were present in ( . %). a recurring vus not expected to impact exon splicing seen in cases (c. c>t (p.thr ile) was excluded from analysis. in positive cases, median age was ( % men; % women), and . % were fna specimens. of variants were met exon skipping (previously reported and/or involve the canonical recognition site), while the other mutations were significant missense ( ) or vus ( ). of vus, were adjacent to the canonical splice site and likely to impact splicing, and were missense variants. average allele fraction was . . four cases had concomitant mutations ( =kras, =egfr). of cases with known clinical staging, stage - = ( %), stage = ( %), and stage = ( %). of resected nsclss, histological types and growth pattern included lepidic predominant, acinar predominant, micropapillary predominant, solid predominant, sarcomatoid, and adenosquamous. pd-l expression in cases is shown in table . stage pd-l < % pd-l > % pd-l < % pd-l > % cases ( %) cases ( %) cases ( %) cases ( %) figure - conclusions: most met variants identified in our cohort ( %) are met ex skipping. another % likely result in exon skipping, while the other % are missense variants presumably unrelated to splicing. the prevalence of met ex variants is lower than previously reported ( . % vs %), and a large percentage of tumors has lower clinical stage and less aggressive pathologic features, both possibly reflecting sampling differences attributed to universal testing of nsclc at our institution rather than testing of only advanced disease. background: the who classification of lung tumors provided the first specialized classification for small biopsies. this article aimed to apply the newest classification to reclassify a group of small lung biopsies and analyze their status of the main driver mutations. design: cases of small lung biopsies (bronchoscopic, needle, or core biopsies) were selected, which ranged from to . we applied the newest classification to reclassify them and analyzed the relationship between the diagnostic subtypes of these biopsy specimens and the mutation rates of egfr and alk. the numbers of small lung biopsies each year during - were respectively , , and . there were men and women, ranging in age from to years (median years). the most common diagnosis was primary lung cancer ( , figure - - figure - conclusions: this study gave an panoramic view on pd-l expression and clinicopathological profiles based on the largest chinese nsclc cohort. the discrepancy of pd-l expression between surgically resected specimens and biopsy specimens and metastatic lesions may result from inter/intra-tumoral heterogeneity. background: accurate assessment of pd-l expression is critical for selection of patients of non-small cell lung cancer (nsclc) for immunotherapy with pd-l /pd- inhibitors. however, only limited reports of pd-l expression in population of nsclc in north america are available. this study reports pd-l expression level in a large patient population of nsclc in canada. design: pd-l testing of nsclc was performed for patients from the whole province of british columbia, canada in a centralized provincial pathology laboratory at bc cancer, vancouver centre. the test used dako pd-l ihc c pharmdx and dako autostainer link immunostainer, as it was fda approved companion diagnostic test for pembrolizumab. pd-l protein expression is determined by using tumor proportion score (tps), which is the percentage of viable tumor cells showing partial or complete membrane staining at any intensity. results: from january to march , , nsclc was tested, which included , ( . %) adenocarcinoma, ( . %) squamous cell carcinoma and ( . %) nsclc, nos. pd-l expression level in adenocarcinoma was similar to that in squamous cell carcinoma (p> . ), but was significantly higher than in nsclc, nos (p< . , table ). the overall percentage of high pd-l expression (tps³ %) was %. the high pd-l expression (tps³ %) was found in % distant metastases, % mediastinal lymph nodes, and % lung primary tumors. the differences in the distribution of high pd-l expression among distant metastatic sites, mediastinal lymph nodes metastases and primary sites had statistical significance (c = . , p< . ). conclusions: using fda approved dako pd-l ihc c phamadx assay, we found that adenocarcinoma had a similar pd-l expression level to squamous cell carcinoma but significant higher expression than nsclc, nos. the percentage of high pd-l expression (tps³ %) was significantly higher in mediastinal lymph nodes and distant metastatic sites than in primary sites, which suggests that pd-l testing of metastatic nsclc could identify more patients eligible for immunotherapy. figure - - figure - conclusions: the correlations among fs, fsc, and rt are low. fs stas+ cases remain stas+ only in % of fsc and % of rt. stas shows higher correlation with grade on rt than it does on fs. these results show a lack of reliability in the assessment of stas on fs, and do not support the proposal of reporting stas in fs to make intraoperative clinical decisions, as doing so may subject patients to unnecessarily aggressive surgery. ki % when classes were used (log-rank p= . and p= . , respectively) or when classes were used with either % ki % (logrank p= . and p= . ) or % ki % (log-rank p= . and p= . ) as cut-point conclusions: our findings do not support the use of % as the minimum ki % in lcnec as suggested by who or the use of % as the minimum ki % for lcnec as described for diagnosing entero-pancreatic neuroendocrine carcinoma expression of insulinoma-associated (insm ) in non-small cell lung cancers: a diagnostic pitfall for neuroendocrine tumors none background: insulinoma-associated (insm ) has recently been reported as a highly sensitive and specific marker of pulmonary neuroendocrine tumors. it has also been noticed that insm expression can be seen, although uncommonly, in non-neuroendocrine tumors. the aim of this study was to evaluate the expression of insm in non-small cell cancers (nsclcs) to avoid diagnostic pitfall uv genomic signature classifies lung melanomas of unknown primary as metastases from occult cutaneous melanomas grant or research support bristol myers squibb; advisory board member, immunocore; consultant, castle biosciences; marc ladanyi: none none alterations were identified for a total of - shared alterations per pair (mean of shared alterations). the probability of chance co among the primary lung cancer, the dominant type was adenocarcinoma ( , . %), followed by nscc, favor adenocarcinoma ( , . %), squamous cell carcinoma ( , . %), and nscc, favor squamous cell carcinoma ( , . %). the tests of the main driver mutations using arms-pcr technology demonstrated that egfr was positive in . %( / , in adenocarcinoma and nscc, favor adenocarcinoma) %, / ) and p.s _d dup ( . %, / ) were most frequent. . % ( / ) of erbb insertions were found in adenocarcinoma, among which surgical samples were more common than small biopsies ( . % vs . %, p= . ). among adenocarcinoma, female have higher frequencies of erbb insertions than male ( . % vs . %, p< . ). the median age of egfr insertion carrier, erbb insertion carrier and non-erbb insertion carrier was -, -and -year old respectively (p< . ). compared with invasive adenocarcinoma (ia) ( . %), adenocarcinoma in situ (ais) ( . %) and minimally invasive adenocarcinoma (mia) ( . %) were more likely to harbor an erbb insertion (p< . ). the pleural invasion frequency of egfr insertion carrier, erbb insertion carrier and non-erbb conclusions: the insertion mutations in kinase domain of egfr and erbb were more common in younger, female and adenocarcinoma patients. ais and mia were more frequent to harbor an erbb insertion than ia, which suggest erbb insertion may be related to the evolution of adenocarcinoma. erbb insertion carrier tend to have a lower pleural invasion rate while a higher lymph node metastasis rate correlation between pd-l expression and clinicopathological and molecular characteristics of non-small cell lung cancer: a large scale multi-centric real-world study of chinese cohort the first affiliated hospital of none background: programmed cell death ligand- (pd-l ) is a predictive marker of anti-pd- /pd-l immune therapies for non-small cell lung cancer (nsclc).the definite relationship between pd-l expression and clinicopathological, molecular profiles of nsclc design: a total of nsclc specimens were enrolled from centers in china. we analyzed pd-l ( c ) expression by immunohistochemistry on dako autostainer link platform. the status of egfr was defined by rt-pcr or ngs in samples and alk was tested by ihc, fish or ngs in samples pd-l high expression was more frequent in egfr-wild type than in mutant type ( . % vs. . %, p < . ). furthermore, pd-l high expression was more prevalent in rare egfr mutant types than in common mutations ( . % vs. . %, p= . ). besides, pd-l high expression was more frequently identified in alk fusion cases ( . % vs. . %, p= . ). a total of small biopsy cases included primary specimens and metastatic specimens. the prevalence of pd-l high expression in surgical samples was much lower than in primary biopsy samples. among of them, pd-l high expression was also prevalent in egfr-wild type than in mutant type ( we found that high pd-l expression was more prevalent in metastatic specimens than in primary biopsy specimens ( . % vs. . %). in metastatic adc specimens, the rate of high pd-l expression was greater than in primary adc navneet narula , mari mino-kenudson , andre moreira nyu school of medicine none background: spread through air spaces (stas) has been reported to be associated with a worse prognosis in adenocarcinoma of lung. recently it has been proposed that stas be reported on frozen sections (fs) as an indication for more aggressive surgery (lobectomy vs sublobar resection). we undertook this study to evaluate the reliability of stas assessment on fs compared to fs controls (fsc) design: cases of adenocarcinoma that had fs of the tumor were identified retrospectively from two institutions. for each case, the following was recorded: presence(+)/absence(-) of stas on fs, fsc, and rt; and % of tumor patterns: lepidic(l) cross-tabulations and spearman's correlations (rs) were performed in spss (see table) of which / ( %) had stas+ on fsc (rs= . ) and / ( %) had stas+ on rt (rs= . ) ( tumor was only present on fs/fsc). of the stas+ cases on rt, / ( %) did not have stas (stas-) on fs (rs= . ). / of cases were stas-on fs; of these of the g cases with stas+ on fs, had % to < % high grade pattern (m/s) we performed a retrospective review of patients with imas who had genomic analysis performed on tumors in different lobes. molecular assays included dna-based targeted next-generation sequencing (ngs) for - cancer genes combined with rna-based ngs fusion assay (archer) and non-ngs panels for a subset of cases. tumor clonal relationships were assessed by comparing somatic alterations between the separate tumor sites.results: twenty-one patients with genomically-profiled imas involving contralateral (n= ) or ipsilateral different lobes (n= ) were identified. in most patients (n= ), tumors had discrete nodular presentation. second ima presented metachronously in patients with a mean latency of . years. notably, in patients, contralateral spread manifested ≥ years (up to years) after initial tumor resection. genomic analysis was performed on separate imas in patients and separate imas in patients, resulting in a total of genotyped tumors. comparative genomic analysis revealed that tumors in all patients shared matching driver alterations including kras (n= ), nrg (n= ), erbb (n= ) and braf (n= ). in addition, in tumor pairs profiled by ngs and archer, other shared we have encountered a group of patients with melanomas involving the lung in the absence of a clinically known primary melanoma elsewhere. a subset of patients presented with solitary large tumors. while primary pulmonary melanomas (ppm) is a category included in the thoracic who classification, given the absence of normal melanocytes in the lung its existence has been questioned. herein we investigate genomic profiles of melanomas of unknown primary origin involving the lung. in particular, we sought to determine whether uv genomic signature -a characteristic feature of most cutaneous melanomas -is present in such tumors.design: cases of melanomas involving the lung with no known primary elsewhere were identified retrospectively. the clinicopathologic characteristics of each case were annotated. all cases included in the study underwent targeted dna next-generation sequencing (ngs) interrogating up to cancer genes. genomic signatures were analyzed based on a method described by alexandrov lb et al. (nature ; : - ) .results: ten ngs-profiled melanomas involving the lung were identified. five patients had solitary lung lesions with the median size of . cm (range . to . cm). of those, tumors were endo/peri-bronchial, thus meeting the suggested criteria for ppm. hilar nodes were involved in patients, and tumors had epithelioid morphology resembling non-small cell carcinoma. no evidence of primary melanomas was found for any patients on clinical follow-up (median months; range to months). genomic testing revealed the following driver mutations commonly found in melanomas: braf (n= ), nras (n= ) and kit (n= ). genomic signature analysis was feasible for cases harboring > mutations required for reliable analysis, including patients with solitary masses. this revealed the presence of a dominant uv signature in all cases. in contrast, none of the primary lung carcinomas tested by the same method (n = ) had a uv signature. the consistent presence of a uv signature provides strong support for an occult or regressed cutaneous origin of melanomas involving the lung, and argues against the concept of ppm. clinical presentation as solitary large (reaching > cm) masses occasionally with hilar adenopathy and epithelioid morphology may closely mimic primary lung carcinomas both clinicoradiologically and pathologically, representing a major potential diagnostic pitfall. background: pulmonary invasive mucinous adenocarcinoma (ima) commonly presents as a multifocal disease. it is widely recognized that diffuse 'pneumonic-type' ima represents aerogenous spread of a single tumor. however, imas may also present as discrete nodules in different lobes, raising the possibility of separate primary tumors. here, we explored the clonal relationship of imas involving different lobes using comparative molecular profiling.conclusions: molecular profiling supports that multifocal imas involving different lobes represent intrapulmonary spread of a single tumor rather than separate primary tumors, including tumors presenting contralaterally after a remarkably long latency (> years). overall, these findings reinforce the unique biology and clinical behavior of imas, and draw a sharp distinction with multifocal non-mucinous lung adenocarcinomas, which recent molecular studies confirm to represent predominantly separate primary tumors. we addressed these issues in human non-small cell lung cancer (nsclc). design: pd-l and b -h expression in tumor cells were evaluated using immunohistochemistry. composition of tumor-infiltrating immune cells, including lymphoid cells, macrophages and dendritic cells, was analyzed using flow cytometry for fresh tissues from a prospective cohort of patients with nsclc and was compared according to pd-l and b -h expression status. ju-yoon yoon , jason rosenbaum we examined the local cohort of patients with the referral diagnosis of "lung cancer", sequenced by the in-house gene massively parallel sequencing (mps, also known as next-generation sequencing or ngs) assay. all alterations were filtered and reviewed for disease-associated variants. for atm, our assessment was limited to p.v g, a variant with the highest penetrance among the atm variants, associated with increased breast cancer risks at levels comparable to disease-associated brca / variants.results: , cases were successfully sequenced by the in-house solid mps assay, among which patients ( . %) were found to harbor disease-associated brca ( / ) or brca ( / ) alterations, with variant allele fractions (vafs) ranging - %. these cancers were mostly adenocarcinomas ( / , with carcinoma nos and scc). / harbored kras hotspot mutations, and no cases the criteria for small lung biopsies proposed by the classification of lung tumors should be applied to pathologists' daily work. it can improve the diagnostic efficiency and quality of small lung biopsies and assist oncologists in accurately understanding the pathologic diagnosis. in this way, accurate treatment and improved prognosis are more available to the patients. zhihong zhang background: to study the differential diagnosis of multi-focal lung cancer and lung cancer with pulmonary metastasis by detecting the different lesions of the same patient. to explore the differences in prognosis between mplc and im, and to explore the factors affecting the prognosis of multi-focal lung cancer and the tumor heterogeneity of multi-focal lung cancer in combination with histopathology and molecular biology.design: fifty patients with multi-focal lung cancer were screened, and the relevant clinical information was noted; the patients were diagnosed by accp standard. mutations of the lesions were detected by arms-pcr, and the detected genes included egfr, alk, ros , met, kras, ret, her- , braf, nras and pik ca. the results of genetic testing were compared with those of accp standard diagnosis. we analyzed a total of tumors from patients. classification based on gene testing contradicted the clinicopathologic diagnosis in ( %) of the comparisons, identifying independent primaries in cases diagnosed as metastasis and metastases in cases diagnosed as independent primaries. another ( %) tumor pairings were assigned an "equivocal" result based on gene testing. the results of gene testing of the remaining ( %) tumor pairings were consistent with the clinicopathologic diagnosis. the mutant heat map indicated that im patients have a higher rate of mutation consistency than mplc patients. the difference of prognosis between patients with mutations and those with wild-type genes patients was statistically significant (p= . ). the difference of prognosis between patients with lymph node metastasis and those with no metastasis of lymph nodes was statistically significant (p= . ). the difference of prognosis between patients with mplc and those with im was statistically significant (p= . ). the difference of prognosis between patients who had different condition was statistically significant (p= . ). multi-gene detection of multi-focal lung cancer has a certain auxiliary effect on the differential diagnosis of multiple primary lung cancer and lung cancer with pulmonary metastasis, which can complement the clinical standards, but also has some limitations. key: cord- - px s c authors: hopkins, richard s.; magnuson, j. a. title: informatics in disease prevention and epidemiology date: - - journal: public health informatics and information systems doi: . / - - - - _ sha: doc_id: cord_uid: px s c this chapter provides a description of the components of disease prevention and control programs, and then focuses on information systems designed to support public health surveillance, epidemiologic investigation of cases and outbreaks, and case management. for each such system, we describe sources used to acquire necessary data for use by public health agencies, and the technology used to clean, manage, organize, and display the information. we discuss challenges and successes in sharing information among these various systems, and opportunities presented by emerging technologies. systems to support public health surveillance may support traditional passive case-reporting, as enhanced by electronic laboratory reporting and (emerging) direct reporting from electronic health records, and also a wide variety of different surveillance systems. we address syndromic surveillance and other novel approaches including registries for reporting and follow-up of cases of cancer, birth defects, lead poisoning, hepatitis b, etc., and population-based surveys (such as brfss or prams). systems to support epidemiologic investigation of outbreaks and clusters include generic tools such as excel, sas, spss, and r, and specialized tool-kits for epidemiologic analysis such as epi-info. in addition to supporting outbreak investigation, agencies also need systems to collect and manage summary information about outbreaks, investigations, and responses. systems to support case management, contact tracing, and case-based disease control interventions are often integrated to some degree with surveillance systems. we focus on opportunities and choices in the design and implementation of these systems. systems to support case management, contact tracing, and case-based disease control interventions are often integrated to some degree with surveillance systems. we focus on opportunities and choices in the design and implementation of these systems. public health programs to prevent disease typically have been designed and implemented one disease at a time. each disease has its own patterns of distribution in populations, risk factors, and optimal and practical intervention strategies that are effective in controlling, preventing, or even eliminating cases of the disease. for example, an important strategy to prevent measles is vaccination, the main strategy to prevent gonorrhea is antibiotic treatment of case contacts before they become ill themselves, an important strategy to prevent cervical cancer is screening with pap smears and treatment of preclinical disease, and the main strategy for prevention of neural tube defects is folic acid supplementation of selected foods. still, each disease prevention program's components are drawn from a relatively short list: • planning and evaluation • public health surveillance • outbreak or cluster recognition and response • policy and guidance development • clinical services -screening -immunization -prophylaxis -treatment • laboratory services • case-contact identifi cation and interventions • education and training for clinicians • public education • regulation (for example, of food services, drinking water, child-care centers, hospitals, etc.) • administration and fi nancial management ideally, program managers choose the most effective combination of these program components to prevent or control the disease or diseases they are charged with addressing. however, as this must be done within the constraints imposed by the available funds, cost-effectiveness is the usual criterion for choosing the preferred combination of program components. public health agencies typically are organized both by disease and by function. for example, each disease-specifi c program usually does not have its own laboratory, and a single public health clinical facility and its staff may provide varied services such as immunizations for well children, treatment of people with tuberculosis (tb) and their contacts, and pap smear services. to variable degrees, they may even combine activities in a single patient encounter, for example, testing women for gonorrhea and chlamydia trachomatis infections at the same visit where they get a pap smear, or offering hepatitis b vaccination during a visit for sexually transmitted diseases (std) treatment. as information technology has become more widely used in public health and replaced paper-based systems, it has typically been implemented program area by program area, as resources became available. this has led to the creation of information 'silos.' for example, laboratory information systems usually have developed in isolation from those to support clinical care or public health surveillance. information systems to support clinical operations of public health departments (for example, clinical services for stds, childhood immunizations, hiv/aids, tb, or family planning services) have characteristics similar to those of other electronic health record systems in ambulatory care. however, in some health departments, clinical information systems have been separated by disease or clinic. if one were to design information systems from scratch for a set of disease prevention programs, there would be potential savings and effi ciencies from identifying the ways that one program component depends on information from another, or can serve multiple programs, and then designing the system to provide that information seamlessly. one can identify potential effi ciencies from two perspectives: in reality, it is rare to have an opportunity to design such extensive information systems as a single project. one is dealing with numerous legacy systems that were designed to support program-specifi c workfl ows. so a key challenge for the public health informaticist is to help their agency make decisions about where information system 'integration' will yield substantial benefi ts and where it will not. for example, if it is desired to know (one time) how many people in the jurisdiction have been reported during a particular time interval with both syphilis and hepatitis b, one could do an ad hoc match of information in two independent surveillance information systems. this task might take an analyst a few days or weeks to accomplish -which is almost certainly inexpensive compared to the cost of building a new information system that could do this task almost immediately. for many purposes, it may be useful and suffi cient to be able to display multiple streams of surveillance or programmatic data in the same environment, on the same screen or even in the same chart. in florida, de-identifi ed reportable disease case information and death certifi cate information are imported into the essence analytic environment that was originally designed for syndromic surveillance [ ] , so that trends for similar conditions by age, sex, and geographic area in the two data streams can be easily compared. on the other hand, if it is desired to have real-time information available to the std clinic staff about past diagnoses of hepatitis b, or about past receipt of hepatitis b vaccine, then information systems need to be designed to support this kind of look-up; the usual solution is a shared person index between the two systems. alternatively, a common data repository can be designed in which all information about each person is permanently linked. as mentioned earlier, there are a number of components common to disease control and prevention programs. in this chapter, we will address information systems designed to support the following: • public health surveillance • outbreak or cluster recognition and response • acquisition of laboratory information • case-contact identifi cation and intervention cdc defi nes public health surveillance as "the ongoing, systematic collection, analysis, and interpretation of health data, essential to the planning, implementation, and evaluation of public health practice, closely integrated with the dissemination of these data to those who need to know and linked to prevention and control" [ ] . each word of this defi nition is carefully chosen, and has implications for the design of surveillance information systems. a one-time data collection activity is not surveillance. data collection for research purposes is not surveillance. surveillance data are collected to support public health action, and analyses and recommendations based on these data must be shared with those who provided the data and with others who need to know. objectives of surveillance systems differ at the local, state, and federal levels [ ] . at the local level, immediate response to individual cases is relatively more important, while at the federal level the analysis of larger-scale patterns is the most important function of surveillance. for state health departments, both uses of surveillance data may be important, depending on the disease and the size of the state. public health surveillance systems may be based on data capture from a variety of sources, including case reports, population-based surveys, sentinel providers, electronic health records (including laboratory information management systems for elr and emergency department records for syndromic surveillance), or administrative data (like hospital or physician claims for reimbursement). for some noninfectious diseases, surveillance is carried out through registries (see below). information systems to support reportable disease surveillance contain records representing case reports that currently are, for the most part, entered manually into an application by public health staff, based on information received from doctors, infection control practitioners, hospitals, and laboratories. increasingly, the laboratory information in these records comes from electronic records transmitted by the public health laboratory, hospital laboratories, and commercial laboratories, when there is a positive result meeting certain reporting criteria (like a positive igm antibody test for hepatitis a). these records typically contain a combination of clinical, laboratory, and epidemiologic information about each case. in future, increasing proportions of these case reports will be entered directly into a website by the practitioner creating the case report, or be transmitted electronically from the practitioner's electronic health record (ehr) system. currently almost half the states in the us use the cdc-provided nedss base system (nbs) as their platform for managing case reports. the remainder use either a system developed in-house or one of several commercially-available solutions [ ] . in case-based surveillance practice, there is usually a relatively short list of required elements in the initial case report. for some diseases this is the only information received on all cases. for other diseases, usually of more importance and with lower case numbers, an additional data collection form is initiated by the receiving health department, which gathers information as appropriate from the ill person, the treating physician, and health records. the optimum amount of information to collect in the initial case report, as opposed to the disease-specifi c case report form, is a matter of judgment and may change as technology changes. in a largely manual system, health departments typically desire to minimize barriers to reporting of cases, so the incentive is to keep the initial case report form short. if much of the information desired for the disease-specifi c case report form can in fact be extracted from an electronic medical record with no additional effort by the person making an electronic case report, then the balance changes. careful decisions are needed: for which cases of which diseases are follow-up interviews necessary [ ] ? until very recently, virtually all of the case-based surveillance information used at the federal level was collected initially at the local (or sometimes state) level, where it was used in the fi rst instance for local response. as the case report information passes from the local to the state to the federal level, it is subjected to validation and cleaning: cases not meeting the surveillance case defi nition have been removed from the data submitted to the federal level, missing data have been fi lled in to the extent possible, and cases have been classifi ed as to whether they are confi rmed, probable, or suspected using standard national surveillance case defi nitions (these case defi nitions are developed by the council of state and territorial epidemiologists in consultation with cdc) [ ] . more recently, advances in technology have allowed case reports, and the information on which they are based, to move almost instantaneously from electronic health record systems, maintained by doctors, hospitals, and laboratories, to public health authorities. there are no technical barriers to these data being available at the federal level essentially as early as they are at the local and state levels. this ready availability of unfi ltered clinical information may allow more rapid awareness by public health offi cials at all levels of individual cases of high-priority diseases (like botulism or hemorrhagic fevers like ebola virus infection), and thus lead to more rapid detection and characterization of likely outbreaks. the simultaneous availability of raw data to multiple agencies at different levels of government also presents certain challenges. the user at the local level will have ready access to information from many sources about local conditions and events, and can use this information to interpret local observations. they will be in a position to understand when an apparent anomaly in their surveillance data is due to an artifact or to local conditions that are not a cause for alarm. they will also know whether a problem is already under investigation. a user at a state or federal level will be able to see patterns over a larger area, and thus may be able to identify multijurisdictional outbreaks, patterns, or trends that are not evident at a local level. the fact that several users may be examining the same raw data at the same time requires that these multiple users be in frequent communication about what they are seeing in their data and which apparent anomalies are already explained or need further investigation. there is a danger that users at a higher level may prematurely disseminate or act on information that, while based on facts, is incomplete or misleading. similarly, users at a local level may not realize that what they are seeing is part of a larger phenomenon. in the syndromic surveillance domain, the biosense . governance group [ ] has adopted a set of etiquette principles which participating jurisdictions will be required to agree to, that spell out the mutual obligations of analysts at each level of the system (scott gordon , association of state and territorial health offi cials, , personal communication). from an information management perspective, an important question is where to put human review of case reports in this information fl ow. for example, it is becoming technically possible for likely cases of reportable diseases to be recognized automatically in health care electronic record systems. some of these could be passed on to public health authorities without human review, in the same way that reportable laboratory results are already passed on in electronic laboratory reporting (elr). for which constellations of fi ndings in the electronic health record would this be appropriate? should some electronic case reports generated by electronic health record systems be passed to state or even federal public health offi cials before they are reviewed and validated at the local or state levels? if so, which ones? as always, there is a tension between the speed of information fl ow and its quality and completeness. there is a need for research to determine which constellations of fi ndings in electronic health records have adequate specifi city and sensitivity to warrant automated identifi cation of a person as being likely to have a case of a reportable disease. the acceptable sensitivity and specifi city will vary by disease. in , cdc published the updated guidelines for evaluating public health surveillance systems [ ] . this document identifi es a set of key attributes of surveillance systems to be assessed during a surveillance system evaluation, including simplicity, fl exibility, data quality, acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability. these are also useful attributes to consider when designing a surveillance information system [ ] . the relative importance of these attributes will vary depending on the condition under surveillance and the main purposes for surveillance. for example, a surveillance system to detect cases of botulism for immediate public health response puts a high premium on timeliness, and its operators are likely to be willing to accept a modest number of false-positive reports (a lower positive predictive value ) in order to assure that reports are received very quickly. on the other hand, surveillance to support planning of cancer prevention programs and treatment services is less time-sensitive, given the quite long incubation periods for most cancers, and therefore more concerned with diagnostic accuracy of every case report than with speed of reporting. timeliness, positive predictive value, and sensitivity of a public health surveillance system are always in tension with each other; increasing two of these always compromises the third. in systems based on case-reporting from doctors, hospitals, and laboratories, and receipt of electronic health records from these same organizations, records for an individual can in principle be linked with records for that same individual in numerous public health information systems, including those supporting clinical service, immunization registries, case investigation, partner or contact identifi cation, partner or contact notifi cation, and provision of interventions to partners or contacts. sometimes this will be done best by automated messaging of structured data from one system to another, sometimes by supporting real-time look-up capabilities, and sometimes by development of a master person index to underlie some or all of these applications. one key decision is which application to consider as the hub for this information sharing, for example, the surveillance application itself or a clinical application. surveillance systems that are based on sample surveys (such as the behavioral risk factor surveillance system, brfss [ ] ), on sentinel practices (such as ili-net for surveillance of infl uenza-like illness [ ] ) or on syndromic surveillance do not have individual patient identifi ers, and so intrinsically cannot be linked at the individual level to information systems supporting other disease control program components. their data are typically managed in systems built on standard statistical software packages, or other independent systems. syndromic surveillance systems are based on rapid acquisition of unfi ltered, real-time, electronic records without individual identifi ers from hospital emergency rooms [ ] and urgent care centers, and also, increasingly, from outpatient physicians' offi ces and from hospital admissions [ ] . the primary purpose of these systems is to support detection and characterization of community disease outbreaks, as they are refl ected in care received at emergency departments, physicians' offi ces, or hospitals. each visit to an emergency department is assigned to a category or syndrome , based on words and strings contained in the patient's chief complaint and/or the triage nurse's notes. as the records received by the health department do not have individual identifi ers, they cannot be linked to records in other information systems. however, records received by the syndromic surveillance system should contain unique identifi ers that could allow the epidemiologist analyzing the data to work back through the sending facility to an identifi ed clinical record. this traceback might become necessary if the person appeared to have a case of a reportable disease or to be part of a signifi cant outbreak. adding outpatient visits and hospital admissions to the scope of syndromic surveillance is opening up additional uses for this technology, especially in the areas of real-time non-infectious disease surveillance. surveillance for cancers [ ] , stroke [ ] , birth defects [ ] , and some other chronic diseases like amyotrophic lateral sclerosis (als) is carried out through registries. registries are usually established by specifi c legislation, and typically relate to a single topic -for example a registry of records for a disease, or of immunization records. registries may be restricted to a geographic region. a distinctive feature of registries is that individual case reports are kept open for long periods of time, up to several or many years, allowing additional information about treatment, hospitalization, and death or other outcomes to be added. registries thus serve as systems to monitor type, duration, and outcome of treatment for these diseases, in addition to the occurrence of new cases of disease (disease incidence ). they may also support outreach efforts to patients or their families, as a way to document that appropriate steps have been taken to link patients to needed types and sources of care. most cases recorded in state-level cancer registries are acquired from hospitallevel registries, using an electronic case report in a standardized format [ ] . some case abstracts are obtained directly by registry personnel or contractors, when hospitals do not have suitable registries of their own. case reports require extensive review and abstraction of medical records by trained workers. birth defect registries may also be built by active search for cases in hospital and other medical records, and abstraction of those records to make case reports. they also may be built by electronically linking records from vital statistics (birth and death records), centralized hospital discharge record systems, and clinical service providers for children with birth defects (such as state programs for children with special medical needs) [ ] . the latter are much less expensive to develop but cannot be assumed to have captured all cases of the disease under surveillance, or captured them correctly [ ] . a disease outbreak is defi ned as a number of cases greater than the number expected during a particular time interval in a geographic area or population. this term usually is used for events due to infectious diseases, and sometimes for those of toxic origin. a similar increase above expected numbers for a non-infectious disease, such as birth defects or cancer, is usually called a cluster . outbreaks and clusters may be due to diseases for which individual cases are reportable (like shigellosis or breast cancer), or diseases for which they are not (like food poisoning due to staphylococcal or clostridium perfringens toxins in most states, sars when it was new, or multiple sclerosis). surveillance systems are designed to facilitate recognition of outbreaks or clusters by frequent examination of the most current information available. the design of the user interface is particularly important. the interface should allow users to: fl exibly display line lists, bar charts by date of event (epidemic curves), and maps of location of cases; fl exibly select subsets of cases for display; apply appropriate statistical tests to detect improbable increases in case counts; and display multiple streams of data on the same chart. for example, users may want to display the epidemic curve of an infl uenza outbreak for several different regions of a state or for several different age groups, or to display counts of positive infl uenza tests and emergency department visits for infl uenza-like illness on the same graph with different scales for each. syndromic surveillance systems have been leaders in developing and evaluating statistical algorithms for automated detection of anomalies which may, on investigation, turn out to be outbreaks. such algorithms have less frequently been applied for automated detection of possible outbreaks or clusters in reportable disease data streams. most outbreaks and clusters are in fact not recognized by examination of regularly-collected surveillance system data. instead, they are recognized by private citizens (such as the organizer of a social event, a teacher or school nurse, the manager of a child care center, the manager of a food service facility, an employer, or the ill people themselves) or by practicing doctors, and brought to public health attention via a phone call or e-mail or entry on a web site established for the purpose [ ] . public health workers assess the information and make the decision whether or not to do a formal investigation of the outbreak. one part of such an assessment is to look at available streams of surveillance data and determine whether there is information supporting the occurrence of an outbreak. for example, a report of a possible infl uenza outbreak in a high school might prompt closer examination of syndromic surveillance data from nearby hospital emergency departments to determine whether there is a more general increase in visits for infl uenza-like illness. a report of a neighborhood cluster of brain cancers would prompt closer examination of available cancer registry information, which might or might not support an interim conclusion that such a cluster is real and statistically signifi cant. in order to be accountable for the effectiveness of their work, local and state health departments need to track the occurrence of outbreaks and the public health response to those outbreaks. since outbreaks can be due to reportable or nonreportable diseases, this cannot be done only by actions such as identifying some cases in the reportable disease data system as being part of an outbreak. systems to track the occurrence of outbreaks need to document the following: • time and date the fi rst and last cases occurred • total (estimated or counted) number of cases • population group most affected (by age, sex, location) • setting of the outbreak (school, workplace, restaurant, wedding, etc.) • suspected or confi rmed agent • most common clinical presentation • suspected or confi rmed source and mode of spread • methods used to investigate agent, source and mode of spread • control measures recommended • control measures implemented • lessons learned for prevention of future outbreaks and improved investigation and response in future events this information about outbreaks should be stored for ready retrieval, and to serve as a basis for quality improvement efforts. for quality improvement purposes, it is also helpful to document the content of the summary report written about each outbreak. when the outbreak is due to a reportable disease, individual cases in the reportable disease surveillance information system can be linked to the outbreak, for example by having an outbreak identifi er attached to their records. if preliminary information about outbreaks in a jurisdiction is entered into the outbreak information system in real time, as the investigation is proceeding, and if the outbreak database is readily searchable by all communicable disease investigators in the jurisdiction, then local investigators can use the outbreak database to help them with investigations of new illness or outbreak complaints [ ] . for example, if they receive a complaint that illness has occurred in people who consumed a particular food product, they can look in the database and determine whether other recent or current complaints or outbreaks mention the same food product. if they receive a report about a gastroenteritis outbreak in a childcare center, they can determine what agents have been found to be responsible for recent or current similar outbreaks in nearby communities; this can help focus their laboratory testing and initial control strategies. some us states have had long-standing systems to document all outbreaks investigated by local or state personnel, but others have not. a major variable in the design of such systems is the state-local division of responsibilities in each state, including the degree of state oversight of 'routine' local outbreak investigations. the actual investigation of an outbreak or cluster may involve enhanced "active" case-fi nding, use of case-report forms, group surveys, and formal epidemiologic studies. active case-fi nding involves regular solicitation of case reports from doctors, hospitals, and laboratories. managing the reports of possible, probable, and confi rmed cases that are part of the outbreak is an important task. for a reportable disease, the jurisdiction's reportable disease surveillance system may be adequate to manage reported cases. it may be necessary, however, to create a continuouslyupdated line list of possible cases and their current status, which is outside the scope of the standard reportable disease application. outbreak investigation surveys will typically involve interviewing everyone with a possible exposure (like all attendees of a wedding reception), whether they were ill or not. formal studies may involve interviewing selected non-ill people, for example, as part of a case-control study. the investigation may also involve obtaining and sending to a laboratory a large number of specimens from ill persons, and sometimes from exposed non-ill persons and from environmental sources (food, water, air, soil, etc.). managing these disparate types of information is a challenge, especially in a large outbreak or one involving multiple jurisdictions. there is currently no one widely-accepted and satisfactory way to manage data in such settings. each investigation team typically uses the tools it is most familiar with, including some combination of data management tools like ms excel, ms access, or epiinfo [ ] , and standard statistical packages. many health departments maintain libraries of standard questionnaires with associated empty data bases, for use during outbreak investigations. when cdc is involved in a multistate outbreak, the investigation team at the local or state level needs to be able to produce and transmit timely case report and other information in the format desired by cdc. the services of an experienced public health informaticist can be extremely helpful to the investigation team when outbreaks are large and multifocal. an ongoing challenge for cdc and the states is how to make the transition from specialized case reporting during an outbreak of a new disease, such as west nile virus encephalitis or sars, to routine case-based surveillance. if this transition is not well-managed, it is likely to result in the creation of a permanent stand-alone surveillance information system (or silo) for that disease. if the new disease is of national importance, cases should be made nationally notifi able and its surveillance should be incorporated into existing systems. laboratory information is a critical component of disease surveillance and prevention. laboratory data form the foundation of many surveillance systems. there are different types of laboratories involved in the public health data stream. laboratories providing data to public health fall into the general categories of commercial or private industry, hospital or clinical, and public health laboratories. public health laboratory information systems (lis) contain information about test results on specimens submitted for primary diagnosis, for confi rmation of a commercial or hospital laboratory's results, for identifi cation of unusual organisms, or for further characterization of organisms into subgroupings (like serotypes) that are of epidemiologic importance. in some states, all clinical laboratories must submit all isolates of certain organisms to the public health laboratory. many of the results obtained in a public health laboratory turn out to be for diseases that are not reportable and not targets of specifi c prevention programs. some of those results may, however, be for cases of non-reportable diseases that are historically rare in the jurisdiction but of great public health importance, or are new or newly-recognized. the main business of clinical laboratories (located both inside and outside hospitals) is to test specimens for pathogens or groups of pathogens specifi ed by the ordering physician, and return the results to the person who ordered the test. public health agencies have, since the early s, asked or required such laboratories to also identify results meeting certain criteria (indicating the presence of a case of a reportable disease) and send a copy of the results to the public health agency for public health surveillance. initially, case reporting by laboratories was accomplished on paper forms, which were mailed or faxed to public health departments. some laboratories very soon moved to mailing printouts of relevant laboratory results, then to sending diskettes, then to transferring computerized fi les containing laboratory results by direct modem-to-modem transfer, and eventually to transferring such fi les via the internet using standard formats and vocabularies. in some states, public clinics (for example, std clinics) have used contract laboratories for their testing needs. in this situation, the outside laboratory supplies both positive and negative results to the public health agency, increasingly by transfer of electronic results in standard formats. laboratories provide data on reportable conditions to their local or state public health authority. reportable diseases are determined by each state; clinicians, hospitals, and/or laboratories must report to public health when these conditions are identifi ed. some reportable conditions are also nationally notifi able. deidentifi ed cases of these are voluntarily notifi ed by states and territories to cdc, which, in collaboration with the council of state and territorial epidemiologists, maintains a listing of nationally notifi able conditions that includes both infectious (e.g., rabies, tb) and non-infectious (e.g., blood lead, cancer) conditions [ ] . the public health partnership with laboratories has led to the very successful and still increasing implementation of electronic laboratory reporting (elr) in the us. elr refers to the secure, electronic, standards-based reporting of laboratory data to public health. elr implementation has been steadily escalating since its inception around the year , replacing previous reporting systems that relied on slower, more labor-intensive paper reporting. the elr national working group conducted annual surveys from to [ ] which gathered data from all states as well as from several territories and large metropolitan areas. these data were supplemented with data for years - , retroactively gathered in the survey. the tracked growth of elr (fig. . ) illustrates its rapid rise in the us, from the start of early stage planning to fully operational elr [ ] . the expected benefi ts of elr include more rapid reporting of reportable cases to public health departments, allowing faster recognition of priority cases and outbreaks for investigation and response, and thus more effective prevention and control [ ] . elr also is expected to reduce the number of missed cases, as automated systems do not require laboratory staff to actively remember to make case reports, and to improve the item-level completeness and quality of case reports. although experience shows that the expected improvements in timeliness, sensitivity, completeness, and accuracy are generally being realized [ ] , timeliness may not be improved substantially for those diseases where clinicians routinely report based on clinical suspicion without waiting for laboratory confi rmation (for example, meningococcal disease) [ ] . in addition, laboratories (especially referral laboratories) often do not have access in their own information systems to home addresses for people whose specimens they are testing, and have struggled with providing complete demographic information to public health agencies. implementation of an operational elr system is not a trivial undertaking. laboratories must confi gure data into an acceptable message format, most commonly health level seven (hl ® ) [ ] . laboratory tests and results should be reported with correlated vocabulary or content codes. two of the most common code systems used for laboratory tests and their associated results are logical observations identifi ers names and codes (loinc ® ) [ ] and systematized nomenclature of medicine (snomed ct ® ) [ ] . neither of these systems is suffi cient by itself to encode all the information needed for public health surveillance. public health jurisdictions have introduced elr to their partner laboratories using one or more of the following approaches: • the "charm" approach -relies on establishing goodwill and collaboration with laboratory partners. while this collegial approach is very appealing, it may be unable to overcome signifi cant barriers such as lack of laboratory funding or resources, and some facilities will supply data only in methods specifi cally required by law. • the incentive approach -involves offering either fi nancial or technical assistance to laboratory partners, assisting them in the startup process of elr. while this approach may be preferred by many laboratories, relatively few jurisdictions have the discretionary funds (or are able to receive federal assistance funds) to implement the approach. • the enforcement or legislative approach -requires reporting rules or legislation that requires laboratories to participate in elr. the most successful enforcement approach will include low-cost options for smaller laboratories, such as web data entry, so that they may benefi t from an elr -"lite" implementation [ ] . the mainstreaming of elr systems in the us has pioneered a clear path forward for public health to begin maximizing its presence in the domain of electronic data interchange. at a local level, case reports for communicable diseases prompt action. although the specifi c action varies by disease, the general approach is the same. it starts with an interview of the ill person (or that person's parents or other surrogates) to determine who or what the person was in contact with in ways that facilitate transmission, both to determine a likely source of infection and to identify other people who may be at risk from exposure to this person. information systems to support contact tracing, partner notifi cation, and postexposure prophylaxis (for stds or tb, for example) contain records about all elicited contacts (exposed persons) for each reported case of the disease in question. these records contain information about each contact, such as whether they were located, whether they received post-exposure prophylaxis, and the results of any additional partner-elicitation interviews or clinical testing that were completed. information systems to support surveillance for other reportable diseases also increasingly contain information about what disease-appropriate action was taken in response to each case; such actions may include identifi cation of contacts, education of household members, vaccination or antibiotic prophylaxis of contacts, isolation of the case (including staying home from work or school), or quarantine of exposed people. std and tb information systems typically capture full locating information for contacts, and can be used both to support fi eld work and to generate statistics on effectiveness of partner notifi cation activities worker by worker and in the aggregate. systems for other reportable diseases may capture only the fact that various interventions were done, and the date that these were initiated. information about the timeliness of initiation of recommended control measures is now required as a performance measure for selected diseases by cdc's public health emergency preparedness cooperative agreement [ ] . in the investigation of a case of meningococcal disease, contacts are people who had very close contact with the original person, for example a household member, boyfriend, or regular playmate. health department staff determines who the close contacts are. each will then be offered specifi c antibiotic treatment to prevent illness. for syphilis, contacts are people who have had sex with the original case. contacts will be examined by a clinician and assessed serologically to see if they are already infected, and offered appropriate prophylactic or curative antibiotic treatment. for measles, contacts may include anyone who spent even a few minutes in the same room as a case. contacts whose exposure was recent enough, and who are not fully immunized already, will receive a dose of measles-containing vaccine, and all contacts will be asked to self-isolate immediately if they develop symptoms of measles. in investigating a common-source outbreak of legionellosis, histoplasmosis, or anthrax, the local health department may want to locate everyone who had a specifi ed exposure to the apparent source of the infection. these exposed people may need antibiotic prophylaxis or may be advised to seek medical care promptly if they become ill. information systems to support this type of work typically have three purposes: . serve as a place for workers to record and look up information about people who are or may be contacts, and to track which contacts have and have not yet received needed interventions. . serve as a source of information for calculating indices of program or worker timeliness and performance, such as the average number of sexual contacts elicited per syphilis patient interviewed, or the percentage of measles contacts who were identifi ed in a timely way and who received post-exposure measles vaccine prophylaxis. . document the workload and effort put in by epidemiology and disease control fi eld staff it seems logical that the surveillance information system should serve as the basis for a system to support fi eld investigation, and this is often the case. the fact that the recommended interventions vary by disease makes designing a single system more complex. existing systems that track fi eld worker activities in detail are much more common for std and tb programs than for others. for general communicable disease fi eldwork, it is currently more common that the system simply documents which interventions were done and when, rather than use the application to track specifi c named contacts or exposed people. the public health informatics institute has published a detailed analysis [ ] of the typical workfl ow involved in surveillance, investigation, and intervention for reportable diseases, and the corresponding information system requirements. the work group that phii convened had representatives of nine different state and local health departments, who were able to identify a large number of processes that were common to all nine jurisdictions, such as case-fi nding, case investigation, data analysis and visualization, monitoring and reporting, case/contact specifi c intervention, and others. these common processes can then serve as a basis for designing information systems to support case-reporting, surveillance, and case-based intervention work that are useable in multiple jurisdictions. consider existing or planned surveillance systems for multiple diseases and conditions. broadly, there are three functions in each of these systems -acquiring the raw data, cleaning and managing the data, and making the data available to users. each of these functions potentially can be integrated, to varying degrees. for example, multiple surveillance systems may benefi t from receiving electronic laboratory reports with a result indicating the presence of a case of a reportable disease. laboratories appreciate having a single set of instructions and a single destination for all their required reports, as this simplifi es their work. the laboratories then benefi t from the ability of the recipient health department to route the reports internally to the right surveillance information system. at the other end of the data pathway, users appreciate having a single interface with which to examine data about multiple conditions or diseases, using the same commands and defi nitions. the users do not have to understand how different surveillance information systems may internally code the same concept in different ways. they also appreciate being able to directly compare information that originally was submitted for the use of different program areas -for example, hepatitis b and gonorrhea in the same chart or table. in the short to medium term, it is not necessary to build a single integrated data repository or a master person index to achieve these goals, even if that is what one would have designed if one were starting from the beginning. however, if one wants to be able to see information about the same person that originates and is stored in multiple systems -for example, so that tb clinicians can see hiv data on their patients and vice versa -then an integrated data repository, or a master person index, or a query system that is extremely accurate in fi nding data on the right person, is needed. modifying existing systems to be able to carry out these functions is time consuming and expensive, so the business case and requirements need to be especially clear. florida's essence system: from syndromic surveillance to routine epidemiologic analysis across syndromic and nonsyndromic data sources (abstract) history of public health surveillance blueprint for a national public health surveillance system for the st century status of state electronic disease surveillance systems -united states prioritizing investigations of reported cases of selected enteric infections. paper presented at council of state and territorial epidemiologists nationally notifi able disease surveillance system case defi nitions association of state and territorial health offi cers. biosense . governance updated guidelines for evaluating public health surveillance systems, recommendations from the guidelines working group design and operation of local and state infectious disease surveillance systems oxford handbook of public health practice behavioral risk factor surveillance system overview of infl uenza surveillance in the united states international society for disease surveillance meaningful use workgroup. final recommendation: core processes and ehr requirements for public health syndromic surveillance electronic syndromic surveillance using hospital in patient and ambulatory clinical care electronic health record data national program of cancer registries coverdell national acute stroke registry surveillance -four states atlanta congenital defects program (macdp) north american association of central cancer registries, inc. (naaccr). implementation guidelines and recommendations report on birth defects in florida a comparison of two surveillance strategies for selected birth defects in florida online food and waterborne illness complaint form biosurveillance plan for human health, version . . atlanta national notifi able diseases surveillance system (nndss), cdc. accessed at http:// wwwn.cdc.gov/nndss/ on available from www.coast coastin-formatics.com national electronic laboratory reporting (elr) snapshot survey. available from www.coast coastinformatics.com . cited statewide system of electronic notifi able disease reporting from clinical laboratories: comparing automated reporting with conventional methods a comparison of the completeness and timeliness of automated electronic laboratory reporting and spontaneous reporting of notifi able conditions potential effects of electronic laboratory reporting on improving timeliness of infectious disease notifi cation -florida health level seven (hl ® ) homepage. available at logical observation identifi ers names and codes (loinc ® ) systematized nomenclature of medicine-clinical terms (snomed ct ® ) see for example section d- . ( ) of the florida administrative code: notifi cation by laboratories public health emergency preparedness cooperative agreement, budget period , performance measures specifi cation and implementation guidance, at-a-glance summary redesigning public health surveillance in an ehealth world on . what are some of the methods for surveillance besides case-reporting? . how are registries different from other surveillance information systems? . what are the advantages and disadvantages of building a master person index across surveillance information systems for multiple diseases? . what are the expected benefi ts of electronic laboratory reporting as a method to enhance surveillance? . what are the advantages and disadvantages of building a system to manage information about case contacts as part of the surveillance information system? . who determines for which diseases cases are nationally notifi able? key: cord- -kc thr authors: bradt, david a.; drummond, christina m. title: technical annexes date: - - journal: pocket field guide for disaster health professionals doi: . / - - - - _ sha: doc_id: cord_uid: kc thr . humanitarian programs ; . security sector ; . health sector : core disciplines in disaster health . primary health care programs . disease prevention . clinical facilities . reproductive health . water and sanitation . food and nutrition . chemical weapons . epi methods ; . tropical medicine : tropical infectious diseases—vector-borne and zoonotic . tropical infectious diseases—non-vector-borne ; . epidemic preparedness and response ; . communicable disease control : diarrhea . influenza . malaria . measles . meningitis . viral hemorrhagic fever ; . diagnostic laboratory : indications, laboratory tests, and expected availability . specimen handling ; . acronyms ; this section provides guidance on technical issues in the health sector. the annexes contain compilations of frequently used reference information. • humanitarian programs-contains conceptual frameworks on global clusters, relief programs, humanitarian financing, and early recovery. • security sector-contains key definitions from the rome statute of the international criminal court • health sector-contains a broad range of core health technical information including environmental classification of water and excreta-related diseases, disease prevention measures, water treatment end points, anthropometric classifications, micronutrient deficiency states, management of chemical weapon exposures, and epi methods. • tropical medicine-contains clinical summaries of tropical infectious diseases with details on disease vector and host, clinical presentation, diagnostic lab tests, clinical epidemiology, and therapy. • epidemic preparedness and response-contains core principles of epidemic preparedness and response. • communicable disease control-contains an overview of selected communicable diseases of epidemic potential including diarrhea, influenza, malaria, measles, meningitis, and viral hemorrhagic fever. • diagnostic laboratory-contains guidance on lab specimen handling and testing. • acronyms-contains acronyms commonly used in disaster management and humanitarian assistance. a. in-kind donations (eg food, seeds, tools, fishing nets, etc) b. types of community projects in food-for-assets programs ( ) natural resources development (a) water harvesting (b) soil conservation ( ) restoration of agri(aqua)culture potential (a) irrigation systems (b) seed systems ( ) infrastructure rehabilitation (a) schools (b) market places (c) community granaries (d) warehouses (e) roads (f) bridges ( ) diversification of livelihoods (a) training and experience sharing . increase individual purchasing power a. cash distribution b. cash for work (cash for assets) c. vouchers d. micro-credit e. job fairs f . artisanal production g. livelihoods/income generation . support market resumption a. market rehabilitation b. infrastructure rehabilitation c. micro-finance institutions goals-protect what's left ( month), restore the system ( months), improve the system ( . promote transformational development support far-reaching, fundamental changes in relatively stable developing countries, with emphasis on improvements in governance and institutions, human capacity, and economic structure, so that countries can sustain further economic and social progress without depending on foreign aid. focus on those countries with significant need for assistance and with adequate (or better) commitment to ruling justly, promoting economic freedom, and investing in people. reduce fragility and establish the foundation for development progress by supporting stabilization, reform, and capacity development in fragile states when and where u.s. assistance can make a significant difference. . support strategic states help achieve major u.s. foreign policy goals in specific countries of high priority from a strategic standpoint. . international cooperation to protect lives and health . timely and sustained high-level political leadership to the disease . transparency in reporting of cases of disease in humans and in animals caused by strains that have pandemic potential to increase understanding, enhance preparedness, and ensure rapid and timely response to potential outbreaks . immediate sharing of epidemiological data and clinical samples with the world health organization (who) and the international community to characterize the nature and evolution of any outbreaks as quickly as possible . prevention and containment of an incipient epidemic through capacity building and in-country collaboration with international partners . rapid response to the first signs of accelerated disease transmission . work in a manner supportive of key multilateral organizations (who, fao, oie) . timely coordination of bilateral and multilateral resource allocations; dedication of domestic resources (human and financial); improvements in public awareness; and development of economic and trade contingency plans . increased coordination and harmonization of preparedness, prevention, response and containment activities among nations . actions based on the best available science . genocide (article )-acts committed with intent to destroy, in whole or in part, a national, ethnic, racial, or religious group a. killing members of the group b. causing serious bodily or mental harm to members of the group c. inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part d. imposing measures intended to prevent births within the group e. forcibly transferring children of the group to another group . crimes against humanity (article )-acts committed as part of a widespread or systematic attack against any civilian population, with knowledge of the attack a. murder b. extermination c. enslavement d. deportation e. imprisonment in violation of international law f. torture g. rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or other comparable form of sexual violence h. persecution on political, racial, national, ethnic, cultural, religious, gender, or other grounds universally recognized as impermissible under international law i. enforced disappearance j. apartheid k. other inhumane acts intentionally causing great suffering or serious injury to body or to mental or physical health . war crimes (article ) a. grave breaches of the geneva conventions of aug ( ) willful killing ( ) torture or inhumane treatment including biological experiments ( ) willfully causing great suffering ( ) extensive destruction and appropriation of property ( ) compelling a pow to serve in the armed forces of a hostile power ( ) willfully depriving a pow of the right to a fair trial ( ) unlawful deportation ( ) taking of hostages b. serious violations of laws and customs applicable in international armed conflict ( ) intentionally directing attacks against the civilian population or against civilians not taking direct part in hostilities ( ) intentionally directing attacks against civilian objects ( ) intentionally directing attacks against personnel, installations, material, units, or vehicles involved in humanitarian assistance or peacekeeping mission ( ) intentionally launching an attack in the knowledge that it will cause incidental civilian loss of life or severe damage to the natural environment ( ) attacking undefended towns, villages, dwellings, or buildings which are not military targets ( ) killing or wounding a combatant who has surrendered ( ) improper use of a flag of truce, flag or insignia or uniform of the enemy or of the un, or emblems of the geneva conventions resulting in death or serious personal injury ( ) transfer by the occupying power of parts of its own civilian population into the territory it occupies, or the deportation or transfer of all or parts of the population of the occupied territory within or outside the territory ( ) intentionally directing attacks against buildings dedicated to religion, education, art, science, charitable purposes, historic monuments, hospitals, and places where sick are collected, provided they are not military objectives ( ) subjecting persons to physical mutilation or to medical or scientific experiments which are not justified by the medical treatment nor carried out in his/her interest ( ) killing or wounding treacherously individuals belonging to the hostile nation or army ( ) declaring that no quarter will be given ( ) destroying or seizing the enemy's property unless such be imperatively demanded by the necessities of war ( ) declaring abolished, suspended, or inadmissible in a court of law the rights and actions of the nationals of the hostile party ( ) compelling the nationals of the hostile party to take part in the operations of war directed against their own country ( ) pillaging a town or place, even when taken by assault ( ) a range of generic prevention measures should be considered for its impact on diseases in a biological "all-hazards" environment. overall, excreta disposal, water quantity, personal hygiene, and food hygiene commonly contribute more to environmental health than do other listed measures. epidemic threats will oblige heightened consideration of disease-specific strategies for prevention and control. c. water treatment (bold text of particular relevance in clinical facilities) ppm = mg/kg (solids) = mg/l (liquids) = ug/ml (liquids) = basic unit of measure for chloroscopes : , ppm = % • sam = whz < − , muac < . cm, or bilateral pitting edema (who). whm not in definition. • sam prevalence worldwide ≈ , , . • sam mortality ≈ x mortality of normally nourished child and its cfr can be - %. • gam = mam + sam • gam = moderate wasting cases, severe wasting cases, or bilateral pitting edema cases (where due to malnutrition) • underweight is not used for screening or surveys in nutritional emergencies. it reflects past (chronic) and present (acute) undernutrition and is unable to distinguish between them. it encompasses children who are wasted and/or stunted. however, weight gain over time can be a sensitive indicator of growth faltering which is easily tracked on road to health charts. • stunting generally occurs before age . it is irreversible. • stunting prevalence worldwide ≈ , , . • stunting is not a good predictor of mortality, but the cfr from ids in cases of severe stunting ≈ x the cfr from ids in cases without stunting. reference standards can be absolute muac, centile, % of median reference, or z scores: • muac easy to understand. an excellent predictor of mortality. permits comparisons between age groups insofar as the low growth velocity of muac in the u age group makes data roughly comparable. may be used alone in "quick-and-dirty" convenience samples to estimate local prevalence of wasting. however, not used alone in authoritative anthropometric surveys, and is commonly part of a two stage screening process to determine eligibility for feeding programs. • overall whz gives higher prevalence of malnutrition than whm for the same population. this is most marked where there is low baseline prevalence of disease, and especially for adolescents (who get subsequently over-referred). whz is more statistically valid, but whm is better predictor of mortality and is used for admission to tfcs. weight-for-age is influenced by weight-for-height and height-for-age. it can be difficult to interpret. b. adults and adolescents (o ) anthropometrics: bmi = weight (kg) / height (m) . death rates-calculated incidence of death expressed per , p/d or per p/mo; data collected by retrospective surveys (eg month period) to gauge severity of public health emergency particularly where sudden events lead to spike in mortality a. cdr-crude death rate b. asdr-age-specific death rate (eg u dr or death rate of children - yr) during a studied time interval (written as . mortality rates-calculated probability of dying before a specified age expressed per live births; data collected by national health authorities in periodic (annual) demographic surveys to reflect ongoing health status a. cmr-calculated probability of mortality in given population for specific time b. imr-calculated probability of a live borne child dying before yr c. u mr-calculated probability of a live borne child dying before yr nb mr ≠ dr. eg cmr ≠ cdr, u mr ≠ u dr. different rates measure different things and are not directly comparable. however, mrs may be converted into drs by the following: cdr or u dr (deaths/ , /d) = − ln( −p/ ) × . where p = cmr or u mr (deaths/ live births). however, this has little field utility. nb mmr-maternal mortality ratio has different units in numerators (maternal deaths) and denominators (live births), thus is a ratio, not a rate the application of study findings to an entire population from which the sample was drawn. if the survey was well-conducted, the results may be considered representative of the entire population. this is scientifically justified. however a confidence interval should accompany any parameter estimate of that population. extrapolation the extension of study findings to a population or period which was not represented in the sample. it works by association-if populations appear to be experiencing similar conditions, the morbidity/mortality experience of one may be imputed to the other. this is not scientifically justified, but is often done where data are insufficient or impossible to collect. s/sx think differential diagnosis (below). . severe muscle pain may be a symptom of sepsis even without fever. . elderly patients with sepsis may be afebrile. in elderly patients, fever is rarely caused by a viral infection. . septic patients who are hypothermic have a worse prognosis than those with high fever. treat as a medical emergency. . fever in a postoperative patient is usually related to the surgical procedure (eg pneumonia, uti, wound, or deep infection). . fever with jaundice is rarely due to viral hepatitis. think liver abscess, cholangitis, etc. . the rash of early meningococcal infection may resemble a viral rash. . generalized rashes involving the palms and soles may be due to drugs, viral infections, rickettsial infections, or syphilis. . all febrile travelers in or returned from a malaria infected area must have malaria excluded. . disseminated tb must be suspected in all elderly patients with fever and multisystem disease who have been in an area with endemic tb. . septic arthritis may be present even in a joint which is mobile. . back pain with fever may be caused by vertebral osteomyelitis or an epidural abscess. . a patient may have more than one infection requiring treatment (eg malaria and typhoid), especially if they are elderly, immunosuppressed, or have travelled. . always remember common infections, not just opportunistic infections, in aids patients with a fever. understand morbidity multipliers-measles, malnutrition, and tb/hiv. understand occult co-morbidities. for any undifferentiated illness, even in infants, think of hiv, tb, syphilis, and sarcoid. for any child, think of malaria, hookworm, and anemia. malarial anemia usually in pedes < year-old; hookworm anemia usually in pedes > year-old. for any icp, think of tb, vl, histoplasmosis, and strongyloides. must treat early. watch for clinical mimics-malaria presenting as pneumonia or diarrhea in pedes; vl presenting as malaria in adults; lepto presenting as mild df (esp in df endemic areas where the pt has mild onset of illness, worsening course, and no rash but jaundice). tx do basic things well, use equipment you understand, teach others, delegate. this annex profiles selected communicable diseases of epidemic potential whose incidence, management complexity, or mortality obliges particular attention. • if (+) agglutination to o antisera, then the strain is further tested for agglutination to antiserum of ogawa and inaba serotypes. • if (+) agglutination to o antisera, then the strain is not further subdivided (except as producer or non-producer of ct as noted below). • if (−) agglutination to o and o antisera, then the strain is known as non-o , non-o v. cholerae. a strain is further identified as a producer or non-producer of cholera toxin (ct). ct production is a major determinant of disease development. strains lacking ct do not produce epidemics even if from the o or o serogroup. • serogroup o exists as main biotypes-classical and el tor-though hybrids also exist. each biotype occurs as two serotypes-ogawa and inaba. classic biotype caused the th and th pandemics but little epidemic disease since the s though it still causes cases in india. el tor biotype caused the th (current) pandemic and almost all recent outbreaks. el tor was first isolated in in el tor, egypt after importation by indonesian pilgrims travelling to mecca. it survives longer in the environment and produces ct similar to the classical biotype. presumably because of ct pathogenicity, the % of cholera patients with severe disease has doubled over the past yrs. these patients tend to require iv fluid therapy. • serogroup o may have evolved from strains of o el tor as they share many properties though not agglutination. in spring of in dhaka, o cases exceeded o el tor cases for the first time, and it was postulated that o may become the cause of an th pandemic. however, since then, o has again become dominant. infective dose depends on individual susceptibility. relevant host factors include immunity produced by prior infection with serogroup o as well as stomach acidity. id may be , orgs, so personal hygiene plays a lesser role than in shigellosis where the id is much lower. shigella has species. • s. dysenteriae type (sd or shiga bacillus) causes the severest disease of all shigella sp because of its neurotoxin (shiga toxin), longer duration of illness, higher abx resistance, higher cfr thru invasive complications, and great epidemic potential. • s. flexneri is the most common, and is generally endemic, in developing countries • s. sonnei is the most common in industrial countries • s. boydii and s. sonnei give mild disease. some kinds of e. coli produce a shiga toxin. shiga toxin genes reside in a bacteriophage genome integrated into the bacterial chromosome. some abx, eg fluoroquinolones, induce expression of phage genes. the bacteria that make these toxins are variously called "shiga toxin-producing e. coli" (stec), "enterohemorrhagic e. coli" (ehec), or "verocytotoxic e. coli" (vtec). all terms refer to the same group of bacteria. • e. coli o :h (often called "e. coli o " or "o ") is the most commonly identified stec in north america, and it causes most e. coli outbreaks. approximately - % of ehec infections result in hus. • non-o stec serogroups also cause disease. in the usa, serogroups o , o , and o are the most commonly identified e. coli pathogens overall. weather (esp weeks - in apr-may) creating increased biological activity; post-monsoon (esp weeks - in aug-sep) with contamination of water sources. pre-monsoon epidemics are generally worse than postmonsoon ones. dysentery has low level year-round incidence, but epidemics occur roughly each decade. epidemic strains display new, additive antibiotic resistance which probably triggers the epidemic. once resistant strains have become endemic, antibiotic susceptibility rarely reappears. sd acquires resistance quickly. sf acquires it more slowly, and that resistance may wane with decreasing abx pressure. at icddr, annual proportional incidence approximates the following: clean water and waste management especially for cholera. personal hygiene (hand washing with soap and clean towels) especially for shigella. water safe drinking water (boiled, chlorinated) nb sphere standards are not enough-you need increased quantities of chlorinated water at household level. san clean latrines for safe disposal of excreta hand washing with soap food safe food (cooked, stored) breast feeding fomites safe disposal of dead bodies with disinfection of clothing nb after outbreak of a fecal-oral pathogen, food hygiene and funereal practices may influence human-to-human transmission more than water quality. health education to affected population wash hands with soap: after using toilets/latrines. after disposing of children's feces. before preparing food. before eating. before feeding children. dukoral has been the main vaccine considered for use in high-risk populations. • morc-vax and shanchol-similar to dukoral except they do not contain the rbs, hence do not require a buffer, and are / the cost to produce. morc-vax, produced in vietnam, is derived from a vaccine administered to millions of people since , but is not who pre-qualified, and is not expected to have international distribution. • shanchol, produced in india, has international distribution (eg used in the haiti cholera vaccination campaign of ), and is now the agent of choice for who. it confers immunity d p nd dose, effectiveness > % at mo, and protection > % at yr. also confers short-term protection vs etec. dose: . cc vaccine followed by water ingestion but no fasting needed; doses, wks apart; cold chain required except for day of use. • orochol-bivalent formulation as in dukoral without rbs of ct. dose: single dose. no longer manufactured. who recommendations: "vaccination should not disrupt the provision of other high-priority health interventions to control or prevent cholera outbreaks. vaccines provide a short-term effect that can be implemented to bring about an immediate response while the longer term interventions of improving water and sanitation, which involve large investments, are put into place." [ ] icddr recommendations: "because of limitations in terms of transport, formulation, and cost of the current dukoral vaccine, the cots program does not require the utilization of the vaccine during an outbreak; it is not necessary to vaccinate to overcome an outbreak. however, if dukoral is readily available and staff are properly trained in its use according to the guidelines that come with the vaccine, the cots program permits dukoral's use (ideally before an outbreak) in the following high-risk populations: refugee populations in which cholera is present, health care workers managing cholera cases, and communities in which the incidence rate is greater than in annually." [ ] epidemiological surveillance (specific to cholera) epidemiological assumptions (who, cots): estimated attack rates: - % extremely vulnerable hosts and poor environmental health (who) % (refugee camps with malnutrition) (cots) % (rural communities of < p) (cots) % (severe epidemic-good estimate of ultimate disease burden) (who) . % (endemic areas with bad sanitation) (cots) . % (endemic areas in open settings-suitable for initial calculations of early resource requirements) nb overall, % of cases are mild and difficult to distinguish from other types of d. nb asymptomatic carriers are very common ( x # of cases). referral rates for ivs % of cases (much higher- % at icddr as it shortens recovery time) case fatality ratios % (with good care) the following catchment populations will yield acute pts of whom will be severely dehydrated: refugee camp of people (ar of % = pts) open settings in endemic area with , people (ar . % = pts) a population of , infected individuals in an epidemic area will yield the following (who): population infected , clinical cases , ( % of infected population) cases needing early resources ( % of cases) cases needing iv therapy ( % of cases) anticipated deaths ( % cfr) nb in non-endemic areas, ar adults > ar pedes because adults have higher exposure risks. in endemic areas, ar pedes > ar adults because adults have been exposed since childhood delivery of health services shigella are fragile and difficult to recover if transport time > d. - isolates initially to confirm outbreak - isolates initially to create abx use policy (bacterial resistance renders cotrimoxazole, amp/amox, nalidixic acid, and tetracycline unusable) - isolates monthly from ipd and opd before abx therapy to assess evolving abx resistance - isolates periodically to reference laboratory to confirm abx resistance patterns and undertake molecular studies isolates at end of the outbreak to confirm that new diarrheas are not epidemic pathogens nb systematic sampling is most representative-eg every th pt or all pts q weeks adjusted as needed to collect the necessary specs. sensitivity > > important than specificity in rdt screening during an epidemic. pts from one geographic area are more likely to constitute a cluster involving a new pathogen. an area may be considered cholera-free after incubation periods (total of d) have passed without cholera disease. however, hospital monitoring should continue for a year due to tendency of enteric pathogens to re-emerge long after they are declared gone. cholera may be viable but nonculturable from the environment; environmental monitoring has many false negatives. consider improvements to existing diagnostic labs • hotline set up for reporting of rumor this often translates into a hastily conceived vaccination campaign that distracts from core principles of cholera management. for every symptomatic pt, there may be asymptomatic carriers. in an established epidemic, the affected community is already extensively infected. cholera vaccination, under these circumstances, has little public health benefit for the resource investment. if undertaken, the following will apply: • vaccination campaign requires numerous staff. community mobilizers are key. clinical staff should not be poached from their clinical duties. supervisors must be free to move at will. • logistics is key-if the st day goes badly, the campaign goes badly. • mark the domiciles which are done. • hold after-action meetings each day. • last day, use mobilizers with mobile broadcasting to attract those who missed out. • second phase vaccination should include chws with multi-purpose messages on water and sanitation. avoid: press exaggeration abx prophylaxis reliance on ivf and insufficient ors lab investigation of cases once epidemic etiology is ascertained prolonged hospitalization hospital discharge criteria requiring multiple negative stool cultures enthusiasm for ocv during epidemic exaggerated water purification objectives concentration of technical competencies in moh at expense of districts failure to share information with stakeholders influenza viruses comprise genera-influenza types a, b, and c-each with species. • influenza type a is divided into subtypes based upon serological response to hemagglutinin (ha) and neuraminidase (na) glycoproteins. there are different ha subtypes and different na subtypes. h n , h n , and h n are responsible for the major human pandemics in the last century. h n virus circulated between and but currently does not. only influenza a subtypes infect birds, and all subtypes can do so. bird flu viruses do not usually infect humans. but, in , an outbreak of h n avian influenza in poultry in hong kong marked the first known direct human transmission of avian influenza virus from birds to humans. since then, h , h , and h avian influenza subtypes have been shown to infect humans. • influenza type b is morphologically similar to a and also creates seasonal and epidemic disease. • influenza type c is rare but can cause local epidemics. seasonal human influenza vaccine currently has strains-h n /h n /b. influenza disease in humans has a short incubation period ( - d). early symptoms are non-specific. it is highly infectious, especially early in the course of the disease, with a large # of asymptomatic carriers. transmission potential (r ) is a function of infectivity, period of contagiousness, daily contact rate, and host immunity. in general, the faster the transmission, the less feasible is interrupting transmission thru usual disease control tools of case finding, isolation, contact tracing, and ring vaccination. • specific groups of exposed or at risk in the community-most likely to work when there is limited disease transmission in the area, most cases can be traced to a specific contact or setting, and intervention is considered likely to slow the spread of disease eg quarantine of groups of people at known common source exposure (airplane, school, workplace, hospital, public gathering; ensure delivery of medical care, food, and social services to persons in quarantine with special attention to vulnerable groups) (useless once there is community-based spread) eg containment measures at specific sites or buildings of disease exposure (focused measures to > social distance) cancel public events (concerts, sports, movies) close buildings (recreational facilities, youth clubs) restrict access to certain sites or buildings • community-wide measures (affecting exposed and non-exposed)most likely to work where there is moderate to extensive disease transmission in the area, many cases cannot be traced, cases are increasing, and there is delay between sx onset and case isolation. infection control measures ari etiquette-cover nose/mouth during cough or sneeze, use tissues, wash hands avoidance of public gatherings by persons at high risk of complications nb use of masks by well persons is not recommended "snow" (stay-at-home) days and self-shielding (reverse quarantine) for initial d period of community outbreak-may reduce transmission without explicit activity restrictions closure of schools, offices, large group gatherings, public transport (pedes more likely to transmit disease than adults) nb community quarantine (cordon sanitaire)-restriction of travel in and out of an area is unlikely to prevent introduction or spread of disease anopheles vector biology egg becomes adult mosquito in d adult mosquito becomes infective in d after bite on infected host susceptible human host becomes infective in d after bite from infected mosquito :. earliest human clinical disease in d after eggs are laid follow the -d rule: dusk and dawn stay indoors as much as possible with window screens in good repair dress in light colored long sleeve shirts and long pants when outside identify cause of the outbreak undertake vaccination campaign strengthen routine immunization and surveillance meningitis is a disease with significant mortality. meningococcus (neisseria meningitides) is renown for its rapid onset, rapid progression (death sometimes within hours), and high mortality ( % untreated). there are serogroups of neisseria meningitides but only (a, b, c, w, x, y) are known to cause epidemics. the bacteria spread from person to person via respiratory and nasal secretions. polysaccharide vaccines are available with serotypes (a and c), serotypes (a, c, and w) or serotypes (a, c, w, and y). duration of immunity is approximately years. meningococcal protein conjugate vaccines confer longer immunity but at higher cost than polysaccharide vaccines. monovalent conjugate vaccine against group c dates from , and tetravalent (a, c, w, and y) conjugate vaccine dates from . group b vaccine made from bacterial proteins has been licensed since but is not readily available. meningococcal vaccines have a very low incidence of side effects. regular disease surveillance is necessary to detect outbreaks. the epidemic threshold is suspected cases/ , population in any given week. two suspected cases of meningitis in the same settlement should trigger an outbreak investigation. nasopharyngeal carriage rates do not predict epidemics. - % of meningococcal disease presents with meningitis. % of cases occur in patients < y/o. peak incidence in meningitis belt is ages - yrs. diagnosis is straightforward when patient presents with signs of meningitis-fever, headache, vomiting, changes in mental status. however, most patients have non-specific illness - days before onset of meningitis. cfr of untreated meningococcal meningitis can be %. cfr of properly treated meningococcal meningitis is < %. - % of meningococcal disease presents with septicemia unaccompanied by meningitis or other focal features. it is a dramatic illness which affects previously healthy children and young adults. it presents with acute fever leading to purpura fulminans (hemorrhagic or purpuric rash), shock, and waterhouse-friderichsen syndrome (acute adrenal failure). etiologic diagnosis can be easily missed. cfr of meningococcal septicemia is % and may be % even with proper treatment. diagnosis may be confirmed by agglutination tests, polymerase chain reaction, culture and sensitivity testing of spinal fluid and blood. in many situations, these tests are not available. throat swabs may be helpful on occasions. do not delay treatment for tests or test results. minutes count. it is more important to have a live patient without a confirmed diagnosis than a dead one with a diagnosis. differential diagnosis in a tropical patient with fever and altered mental status, but without purpura or shock, includes cerebral malaria. co-infection may occur. standardized case management of bacterial meningitis in developed countries involves - days of parenteral antibiotic therapy. drug of choice in adults and older children is ceftriaxone which also rapidly eliminates the carrier state. alternate drugs include ampicillin and benzylpenicillin which do not eliminate the carrier state. in developing countries, days of parenteral antibiotic therapy are empirically shown to be effective. in large epidemics in resource-poor settings, a single im dose of chloramphenicol in oil is the drug of choice. for patients who do not improve in hours, a repeat dose may be given. viral meningitis is rarely serious and requires only supportive care, recovery is usually complete. patient isolation and disinfection of the room, clothing, or bedding are not necessary. respiratory precautions are advised particularly early in the course of treatment. chemoprophylaxis of contacts is available in some settings but rarely in the disaster setting. vigilance and education of close contacts is mandatory. epidemic preparedness and early detection of outbreaks are key. vaccines against n. meningitides serogroups a, c, y and w are very effective in controlling epidemics. in epidemic settings, children - are the priority target with serogroups a and c typically the priority antigens. rapid mass vaccination campaigns can contain outbreaks in - weeks. for immunocompetent patients over years, vaccine efficacy rate is % one week after injection. however, duration of immunity may be as little as years in younger children. in some countries, vaccine may also be used with close contacts of sporadic disease cases to prevent secondary cases. chemoprophylaxis of contacts is not recommended in epidemics, but community education and ready access to health care are essential. preventive medicine [ ] source control/reduction/elimination undertake quarantine and culling of sick reservoir animals and known disease carrier species. avoid unnecessary contact with or consumption of dead reservoir animals or known disease carrier species. avoid unnecessary contact with suspected reservoir animals and known disease carrier species (eg primates). avoid direct or close contact with symptomatic patients. establish appropriate communicable disease controls for burial of the dead. administrative controls (improve people's work practices) environmental and engineering controls (isolate people from the hazard) avoid needle stick exposure to blood specimens thru automated machine handling. ppe (protect people with ppe) use standard precautions-gloves, masks, and protective clothing-if handling infected animals or patients. wash hands after visiting sick patients. active surveillance and contact tracing (enhanced surveillance) through community-based mobile teams active case finding (screening and triage) and contact tracing dedicated isolation facility food provision to isolated patients so they are not dependent on family case definition treatment protocols emphasizing supportive care and treatment of complications essential drugs referral guidelines secondary prevention barrier nursing strictly enforced family and community education ministerial task force to address policy local health authority task force to address procedures national level task forces to comprise if a lab is not available, then you need a sampling strategy that addresses specimen acquisition, preparation, and transportation in compliance with international regulations on the transport of infectious substances. guidance note on using the cluster approach to strengthen humanitarian response international conference on primary health care selective primary health care-an interim strategy for disease control in developing countries water and excreta-related diseases: unitary environmental classification infections related to water and excreta: the health dimension of the decade world health organization. cholera vaccines: who position paper available from: international centre for diarrhoeal disease research history and epidemiology of global smallpox eradication available from: us department of health and human services communicable disease control in emergencies-a field manual. geneva: world health organization ebola: technical guidance documents for medical staff world health organization. manual for the care and management of patients in ebola care units/community care centers-interim emergency guidance. who/ evd/manual/ecu/ . . geneva: world health organization what tests does it perform? is there transport to and from the laboratory? who prepares transport media? who provides specimen collection material and supplies? how can these supplies be obtained? who provides cool packs, transport boxes, car, driver …? • refrigerate other vials for cytology, chemistry ( °c) leak-proof specimen container wrapped with enough absorbent material to absorb the entire content of the st container . leak-proof secondary container usually plastic or metal . outer shipping container whose smallest dimension is mm diagnostic specimens use iata packing instruction without biohazard label. infectious materials use iata packing instruction with biohazard label. what to send with the sample? lab request form with: • sender's name and contact info • patient name, age, sex • sample date, time • suspected clinical diagnosis with main signs and symptoms • sample macroscopic description • context-outbreak confirmation, ongoing verification, outbreak end, etc • epidemiological or demographic data where to send the sample? • reference lab • contact person what and when to expect results? source: world health organization world health organization department of communicable disease surveillance and response. highlights of specimen collection in emergency situations. undated . designate a lead official in the lcc. . anticipate roles for partner agencies (eg inter-agency and team coordination, disease surveillance, field epidemiological investigation, laboratory identification, case management guideline development, outbreak logistics, public information, and social mobilization). . identify sources of funds. . intensify disease surveillance. . identify reference lab(s) for communicable diseases of epidemic potential. . ensure mechanism for specimen transport. a. initial response to suspected outbreak . form an emergency team to investigate and manage the outbreak a. identify key roles on the outbreak investigation team(s) ( ) epidemiology and surveillance ( ) case management ( ) water and sanitation ( ) laboratory services ( ) communication b. staff those roles ( ) epidemiologist-to monitor proper data collection and surveillance procedures ( ) physician-to confirm clinical s/sx and train health workers in case management ( ) water and sanitation expert-to develop a plan for reducing sources of contamination ( ) microbiologist-to take environmental/biological samples for laboratory confirmation, train health workers in proper sampling techniques, and confirm use of appropriate methods in the diagnostic laboratory ( ) key: cord- -nkr x authors: yokomichi, hiroshi; tanaka-taya, keiko; koshida, rie; nakano, takashi; yasui, yoshinori; mori, masaaki; ando, yuka; morino, saeko; okuno, hideo; satoh, hiroshi; arai, satoru; mochizuki, mie; yamagata, zentaro title: immune thrombocytopenic purpura risk by live, inactivated and simultaneous vaccinations among japanese adults, children and infants: a matched case–control study date: - - journal: int j hematol doi: . /s - - - sha: doc_id: cord_uid: nkr x this case–control study investigated immune thrombocytopenic purpura (itp) risk following live, inactivated, and simultaneous vaccination, with a focus on infants aged < years. we matched case patients with itp to one or two control patients with other diseases by institution, hospital visit timing, sex, and age. we calculated mcnemar’s pairwise odds ratios (ors [ % confidence interval]) with case–control pairs. the case group had ( %) males and ( %) infants, and the control group included ( %) males and ( %) infants. for all age groups, the mcnemar’s or for itp occurrence was . ( . – . , p = . ) for all vaccines. among infants, these were . ( . – . , p = . ) for all vaccines, . ( . – . , p = . ) for live vaccines, and . ( . – . , p = . ) for inactivated vaccines. sex-adjusted common ors for simultaneous vaccination were . ( . – . , p = . ) for all vaccines, . ( . – . , p = . ) for inactivated vaccines only, and . ( . – . , p = . ) for mixed live and inactivated vaccines. in infants, these were . ( . – . , p = . ), . ( . – . , p = . ) and . ( . – . , p = . ), respectively. these limited data suggest no significant itp risk following vaccinations or simultaneous vaccination in any age group, including infants. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. immune thrombocytopenic purpura (itp) is a haemorrhagic disorder characterised by thrombocytopenia, a purpuric rash, normal bone marrow and the absence of signs of other identifiable causes of thrombocytopenia [ ] [ ] [ ] [ ] [ ] . previous studies have shown that itp risk increases after measles, rubella, chickenpox and influenza infection [ , [ ] [ ] [ ] . recently, live measles-mumps-rubella (mmr) [ ] [ ] [ ] [ ] and varicella [ ] vaccines have been reported to potentially increase the risk for itp. studies have also suggested that inactivated hepatitis b [ ] and diphtheria-tetanus-acellular pertussis (dtap) [ ] vaccines may increase itp risk. evidence suggests that itp risk after vaccination increases through the same mechanism as that by which microbial infections induce antiplatelet autoantibodies [ ] . because vaccines are designed to induce protective immunity by mimicking infections in the human body, both live and inactivated vaccinations can theoretically trigger the development of itp [ ] . researchers have investigated associations between multiple vaccinations and itp risk, but findings regarding inactivated vaccinations were inconsistent [ ] [ ] [ ] [ ] [ ] . however, because many vaccines are administered to children in infancy, an epidemiological study for vaccine safety conducted some time after a single vaccine dose is difficult to design. therefore, more studies are needed to clarify the itp risk associated with live and inactivated vaccines. a combined vaccine is defined as a single product in which equivalent component vaccines are administered as a single vaccine to prevent more than one disease or to protect against multiple strains of infectious microbes [ ] . for example, mmr, diphtheria-pertussis-tetanus and multivalent pneumococcal conjugate vaccines have been licensed for large-scale supply. the nature of combined vaccines means it is difficult to separately measure the adverse reaction rate of each component. simultaneous vaccination, which is commonly conducted for children in europe [ ] , north america [ , ] and asia [ ] , is defined as administering more than one vaccine at different anatomic sites during the same clinic visit, without combining these vaccines in the same syringe [ ] . early research reported that parents were concerned about the efficacy of simultaneous immunisation [ ] . however, experimental and clinical epidemiological studies provided a scientific basis for the efficacy of this practice [ ] . recently, the focus of interest in simultaneous vaccination has moved from questions of efficacy to questions of safety [ ] [ ] [ ] . if a vaccination has adverse reaction risks, these risks may accumulate in simultaneous vaccination [ ] . however, no research has compared the risks when administering vaccines simultaneously versus separately in the same population. studies conducted in the s indicated rates of adverse reactions were similar between simultaneous and separate vaccine administration [ ] [ ] [ ] . correspondingly, the centers for disease control and prevention issued a guideline recommending that parents use simultaneous vaccination for children younger than years to avoid missing the appropriate vaccination timing [ ] . however, some studies suggested that rates of several adverse reactions may increase with simultaneous vaccination [ , ] . therefore, the risk associated with simultaneous vaccine administration needs to be investigated more comprehensively. in this case-control study, we aimed to determine the itp risk after live, inactivated and simultaneous vaccination in japan. we also examined the risk associated with simultaneous vaccination among subjects aged < years, referred to in this study as infants [ ] , because this age group are frequently immunised using this method. we requested physicians from paediatrics and internal medicine departments at seven university hospitals and regional centre hospitals in japan to recruit inpatients and outpatients for this study. recruitment occurred from october to march . during this period, participating physicians enrolled in all new cases with itp that attended their hospital and met the inclusion criteria for this study. these physicians filled in the study questionnaire with the requested data for the case and control patients. we defined exposure as vaccination within days before the onset of itp. to measure this exposure, participating physicians who treated case (itp) and control (other diseases) patients completed questionnaires covering retrospective information on vaccination history and other characteristics. in japan, vaccination history for infants and preschool children is recorded in the maternal and child health handbook, which is provided by the municipality. vaccination history for other children and adults was captured in a medical interview conducted by physicians or obtained from medical records. additional information was obtained from hospital medical records. in japan, the immunization law defines itp as an adverse event following immunisation that occurs within days after vaccine administration [ ] . based on this law, we considered ≤ days after administration as the duration in which vaccinated people could potentially develop itp as a result of vaccination. the live vaccines investigated were the bacillus calmette-guérin (bcg), rotavirus, varicella, mumps and measles-rubella (mr) vaccines (in japan, mr and mumps vaccines are administered separately). inactivated vaccines were the influenza, diphtheria-pertussis-tetanus-polio (dpt-ipv), hepatitis b, following japanese and american guidelines [ ] [ ] [ ] [ ] , cases with itp were identified when patients met all of the following conditions. ( ) peripheral blood platelet count ≤ , /µl [ ] [ ] [ ] . ( ) without anaemia unless the patient was bleeding as a result of itp. ( ) without deformation of red or white blood cells. ( ) without aplastic anaemia, myelodysplastic syndrome, leukaemia, malignant lymphoma, paroxysmal nocturnal haemoglobinuria, systemic lupus erythematosus, disseminated intravascular coagulation, bone marrow metastasis, myelofibrosis, thrombotic thrombocytopenic purpura, haemolytic uraemic syndrome, liver cirrhosis, hypersplenism and megaloblastic anaemia. ( ) without bernard-soulier, wiskott-aldrich, may-hegglin and kasabach-merrit syndromes. ( ) condition was not pseudo-thrombocytopenia due to ethylenediaminetetraacetic acid. ( ) condition was not thrombocytopenia caused by pharmacological agents, radiation or measles. because this study included patients with new onset itp, all itp cases were considered to be as acute [ ] . each patient with itp (case) was matched with one or two control patients [ , ] . participating physicians matched controls with case patients by the institution, timing of hospital visit (within a -month difference), sex and age. in the matched study design, we permitted overlapping use of case patient datum to be paired with two different control patient data; within an institution, one control datum was paired with two different case patient data. we requested that participating physicians reduced the difference in timing of hospital visit between case and control patients to within weeks where possible. age was matched as age in months for case patients aged under year, and within years for case patients aged - years. for case patients aged ≥ years, age was matched within years where possible, with a maximum difference of years. all participating patients were of asian ethnicity. sex, age at hospital visit and consulted department were measured; height and body weight were not measured. to exploit the matched study design, we calculated mcnemar's odds ratios (ors) and their % confidence intervals (cis) [ ] for the primary outcome. mcnemar's or is suitable for matched case-control design. briefly, in this calculation method, vaccination histories for case-control pairs were grouped into four profiles: ( ) vaccination ( +) for a patient with immune thrombocytopenic purpura (case) and vaccination ( +) for a patient with other diseases (control); ( ) vaccination ( +) for case and vaccination ( −) for control; ( ) vaccination ( −) for case and vaccination ( +) for control; and ( ) vaccination ( −) for case and vaccination ( −) for control. in calculating mcnemar's ors, only two of these profiles ( and ) were used based on an assumption of the binary distribution. for example, if the number of the case-control vaccination profile equalled that of profile , mcnemar's or = (null hypothesis) [ ] . if the former number of profile doubled the latter number of profile , mcnemar's or = . this calculation method originated when mcnemar's or was developed to evaluate the results of a matched case-control study. subsequently, conditional logistic regression was developed to further adjust for covariates. we also calculated mcnemar's ors stratified by age group. because vaccination for measles, rubella and varicella are known risk factors for itp onset [ ] [ ] [ ] [ ] [ ] , we calculated those ors as the reference values. tests for p values were based on a binary distribution with the null hypothesis being the same pair of numbers between the two vaccination history profiles, which is usually used in calculating ncnemar's or [ ] . we also calculated common ors to exploit all available data for unmatched case and control patients. data for those patients whose paired partner was excluded from the matched data analysis were included in the unmatched analysis. common ors were the secondary outcome. we aimed to measure confounders of history of infection with helicobacter pylori [ , ] , other viruses and bacteria, but only obtained these data for a subset of patients. therefore, in estimating common ors, we only adjusted for sex [ , , ] , and calculated ors stratified by age group. the age groups were < , - , - and ≥ years, based on the vaccination schedule for children, adults and older adults recommended by the japan pediatric society and the infectious disease surveillance center (english versions) [ , ] . because the risk associated with simultaneous vaccination could not be assessed in the matched analysis because of the small sample size, this risk was only assessed in the unmatched analysis. we calculated sex-adjusted common ors for itp occurrence in the simultaneous administration of two or more vaccines. we performed all statistical analyses using sas version . (sas institute, cary, nc, usa). all reported p values were two-sided, and p < . was considered significant. in total, pairs were included in the matched analyses, and patients in the unmatched analyses. most patients with itp were enrolled from paediatrics departments. in the itp case and control groups, varied infectious diseases were reported month before the hospital visit. there were no underlying diseases involving an immunocompromised status, but there was an epilepsy case in the itp case group and an asthma case in the control group. table shows the characteristics of the matched case and control patients. in total, participants ( . %) were under years of age, ( . %) were aged - years and ( . %) were male. for the cases on whom data was provided by their physicians, the mean (standard deviation) of duration from vaccination to itp onset was . ( . ) days. among case patients, there were cases of purpuras, three of bleeding in the oral cavity and difficulty stopping bleeding, three of hypermenorrhoea and one of haematochezia. diagnoses recorded for hospital visits among control patients included respiratory tract infections, nine digestive tract infections, three urinary tract infections, nine allergic diseases and four malignant neoplasms. there were positive results for any helicobacter pylori test in the case group, but no positive results in the control group. figure presents a histogram of the ages of case patients. most case patients with itp were aged < - years. for simultaneous vaccination, we investigated children aged months to years: six children had two vaccines, four had three vaccines, two had four vaccines and one had five vaccines. table shows the sex-adjusted common ors for itp occurrence in the simultaneous administration of two or more vaccines. the mcnemar's and common ors for itp occurrence for all, live and inactivated vaccines ranged from almost null to more than among people of all ages, children aged < years and children aged < years, but these results were not statistically significant. the common ors for simultaneous administration of two or more vaccines were greater than for all, live and inactivated vaccines; these results were not statistically significant. previous research suggests that people may develop itp as an immune reaction to vaccination in combination with a genetic predisposition [ , [ ] [ ] [ ] [ ] [ ] . because vaccines are designed to mimic real infections and trigger immune reactions, clinicians have been concerned that vaccinationparticularly the administration of live vaccines-may cause autoimmune disease [ ] . mmr-associated acute itp has been frequently investigated in studies on this topic [ , [ ] [ ] [ ] . in , the united states institute of medicine acknowledged that evidence had established a causal relationship between mmr vaccination and thrombocytopenia [ ] . in our study, the common or for mr vaccination was . , although this result was not statistically significant (supplementary table ). in summary, the present study did not find many significant effects, but the mcnemar's and common ors estimated for live vaccination ranged from null to high across age groups. itp risk associated with inactivated vaccination has not been sufficiently investigated in previous studies. a postlicensure retrospective study in the united states did not find any itp cases among -month-old infants vaccinated with the dtap-ipv/hib or other dtap-containing vaccine from october to july [ ] . a canadian surveillance study ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) identified eight itp cases after dtp or dtap ± ipv ± hib vaccinations, three after hepatitis b vaccination and two after influenza vaccination in paediatric hospitals [ ] . an italian post-licensure prospective study involving a large number of older adults conducted from to reported cases of itp after seasonal influenza vaccinations [ ] . a study using a taiwanese national database found an incidence rate ratio for itp of . ( % ci . - . ) following pandemic influenza (h n ) monovalent vaccination without adjuvant versus non-vaccination among people aged - years, and of . ( % ci . - . ) among children [ ] . the united states vaccine adverse event reporting system database reported that from to , influenza vaccination had a proportional reporting ratio (an index of identifying unexpectedly frequent reports) for thrombocytopenia occurrence of . ( cases, lower bound of % ci of the empirical bayesian geometric mean < . ) [ ] . however, there is a lack of consistent evidence about the itp risk associated with inactivated vaccines. in our study, the estimated mcnemar's ors for inactivated vaccines varied from under to over , and were not statistically significant in the examined age groups. calculation of mcnemar's ors used discordant case-control pairs in terms of vaccination history; therefore, calculating mcnemar's ors required a much larger sample size than would have been required to calculate common ors [ ]. because of insufficient power, we were unable to clarify whether itp risk accompanied inactivated vaccination. care should be taken in the interpretation of the ors reported for inactivated vaccines in this study. in the context of japan, many inactivated vaccinations are scheduled for children aged < year [ ] , meaning that infants of this age have a high chance of being immunised with inactivated vaccines. previous research suggests that among japanese children, the peak age of itp onset is < years [ ] . the ors for inactivated vaccination could, therefore, be overestimated in this study because most data used for their estimation included data for infants aged < year, who frequently receive inactivated vaccines and have a relatively high incidence of itp. therefore, we interpreted the mcnemar's or of . (table ) and common or of . (table ) among children aged < years as indicating that this study did not detect itp risk in inactivated vaccination. vaccination is frequently criticised in the media [ , ] . however, vaccination has three types of benefits: direct effects (immunity of the vaccinated person), indirect effects (herd protection of non-vaccinated people) and reduction in the risk for developing itp caused by infection with viruses or bacteria. the third type of benefit could be rephrased as the observation that the incidence of itp following vaccination is lower than the incidence of itp after infection with wild viruses [ ] . the incidence of itp development in children immunised with mmr is reportedly around one in , , whereas it is approximately one in following natural rubella infection and approximately one in following measles infection. another report suggested that the incidence of itp caused by mmr vaccination is - times lower than the incidence of itp following natural infection [ ] . as is inherent with a single outcome (in this case, the development of itp), the present findings of ors greater than do not consider the third type of vaccination benefit. in other words, it is difficult to investigate the long-term effect of vaccination on preventing itp development from the perspective of the third type of benefit-if it exists-in cohort or case-control studies. the present study is notable for investigating itp risk following simultaneous vaccination. although we did not find statistically significant results, the sex-adjusted ors were relatively high (or . among children aged < years and . among children aged < years; table ). the point estimate of the or was larger than that of single vaccination ( . among children aged < years and . among children aged < years; table ) in children of each age group. few studies have investigated the risks associated with simultaneous vaccination. a randomised controlled trial involving people receiving simultaneous influenza vaccination reported increased haemagglutinin inhibition titre, seroconversion and seropositivity rates, suggesting that the immune response was boosted [ ] . because vaccine efficacy and immune-related adverse reactions have the same origin [ ] , the rate of itp development may increase depending on the administration method. table suggests that there is potential for a relatively higher risk for itp with simultaneous vaccination compared with separate vaccination. however, further analyses using large databases are needed to confirm this finding. there are several limitations inherent to this study. first, the sample size meant the study was underpowered because we adopted a matched design to adjust for several confounders between cases and controls. this sample size also made it difficult to estimate ors separately by age group. to compensate for this limitation and present additional results, we calculated common ors using all available data, although adjustment for confounders might have been insufficient for this analysis. second, we could not adjust for infection history as a confounder. although we aimed to measure infection history in the questionnaire, we did not obtain sufficient data. third, because the investigation depended on the voluntary replies of physicians by post, reporting bias might have occurred. physicians who were interested in potential adverse events might have been more likely to participate in this study, which could have led to an overestimation of the ors. a national surveillance system of adverse events following vaccinations in japan is needed in an era when people are concerned about drug-induced diseases. fourth, each case was matched to one or two controls. this method might have resulted in an imbalance in the weight of samples for the primary outcome. because several matching factors may restrict selecting potential control patients, we chose a design to counter this limitation. in terms of study strengths, the detection of itp cases by physicians was a main advantage of the present study. the use of physician-registered cases enhanced the internal validity of this investigation. this validity would not be possible in a large database study. second, the data were gathered from hospitals across japan. the reported itp risks, therefore, reflect a broad area, suggesting relatively high external validity. third, the analyses included detailed results stratified by age group and type of vaccine. this information will be informative for researchers and clinicians seeking to assess the potential risks for adverse events for their patients. based on the limited data available in this study, high itp risk was not found following inactivated or simultaneous vaccination. future investigations of itp risk should include analyses using large databases. idiopathic thrombocytopenic purpura recurrent immune thrombocytopenia after influenza vaccination: a case report prediction of response to first-line therapy with itp by flow cytometric analysis of bone marrow lymphocyte phenotypes diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (ttp) in japan glucocorticoids promote response to thrombopoietin-receptor agonists in refractory itp: a case series the itp syndrome: pathogenic and clinical diversity virus-associated immune thrombocytopenic purpura in childhood association between drug and vaccine use and acute immune thrombocytopenia in childhood vaccine administration and the development of immune thrombocytopenic purpura in children risk of immune thrombocytopenic purpura after measles-mumps-rubella immunization in children mmr vaccine and idiopathic thrombocytopaenic purpura immune thrombocytopaenic purpura: an autoimmune cross-link between infections and vaccines thrombocytopenia reported in association with hepatitis b and a vaccines consequence or coincidence?: the occurrence, pathogenesis and significance of autoimmune manifestations after viral vaccines immune thrombocytopenic purpura (itp) associated with vaccinations: a review of reported cases thrombocytopenia after vaccination: case reports to the us vaccine adverse event reporting system safety of dtap-ipv/hib vaccine administered routinely to infants and toddlers thrombocytopenia after immunization of canadian children safety of mf -adjuvanted influenza vaccination in the elderly: results of a comparative study of mf -adjuvanted vaccine versus nonadjuvanted influenza vaccine in northern italy safety of pandemic (h n ) monovalent vaccines in taiwan: a self-controlled case series study best practices guidance of the advisory committee on immunization practices (acip) vaccination schedules for individual european countries and specific age groups advisory committee on immunization practices recommended immunization schedule for children and adolescents aged years or younger-united states canada's provincial and territorial routine (and catch-up) vaccination routine schedule programs for infants and children. . public health agency of canada vaccination schedule recommended by the japan pediatric society addressing parents' concerns: do multiple vaccines overwhelm or weaken the infant's immune system? simultaneous administration of childhood vaccines: an important public health policy that is safe and efficacious children who have received no vaccines: who are they and where do they live? the pandemic influenza a (h n ) vaccine does not increase the mortality rate of idiopathic interstitial pneumonia: a matched case-control study safety of the influenza a (h n ) vaccine in chronic obstructive pulmonary disease: a matched case-control study additive, multiplicative, and other models for disease risks simultaneous administration of measles-mumpsrubella vaccine with booster doses of diphtheria-tetanus-pertussis and poliovirus vaccines safety, tolerability, and immunogenicity of concurrent administration of haemophilus influenzae type b conjugate vaccine (meningococcal protein conjugate) with either measles-mumps-rubella vaccine or diphtheriatetanus-pertussis and oral poliovirus vaccines in -to -monthold infants immune response to simultaneous administration of a recombinant dna hepatitis b vaccine and multiple compulsory vaccines in infancy reactions following administration of influenza vaccine alone or with pneumococcal vaccine to the elderly centers for disease control and prevention ministry of health, labour and welfare consensus guideline for diagnosis and treatment of childhood idiopathic thrombocytopenic purpura epidemiology of primary immune thrombocytopenia in children and adults in japan: a population-based study and literature review standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group chinese guidelines for treatment of adult primary immune thrombocytopenia reference guide for management of adult immune thrombocytopenia in japan: revision thromboembolism in patients with immune thrombocytopenia (itp): a meta-analysis of observational studies : the analysis of case-control studies the mcnemar test for binary matched-pairs data: mid-p and asymptotic are better than exact conditional high-dose dexamethasone therapy as the initial treatment for idiopathic thrombocytopenic purpura risk of immune thrombocytopenic purpura after measles-mumps-rubella immunization in children. child care health dev a nationwide survey of newly diagnosed childhood idiopathic thrombocytopenic purpura in japan routine/voluntary immunization schedule in japan vaccination and autoimmune disease: what is the evidence? idiopathic thrombocytopenic purpura and mmr vaccine recurrent thrombocytopenic purpura after repeated measles-mumps-rubella vaccination effect of live measles vaccine on the platelet count persistent changes in circulating white blood cell populations after splenectomy adverse events associated with childhood vaccines other than pertussis and rubella: summary of a report from the institute of medicine on the sample size for studies based upon mcnemar's test safety and immunogenicity of a pandemic influenza a h n vaccine when administered alone or simultaneously with the seasonal influenza vaccine for the - influenza season: a multicentre, randomised controlled trial publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to express our deep gratitude to the participating patients. for their cooperation as physicians in this study, we would also like to thank dr. katsuko maeda, yamagata city hospital saiseikan; dr. yuya sato, dokkyo medical university hospital; dr. noritaka furuya, saitama citizens medical centre; dr. yoshinori kobayashi, national hospital organization yokohama medical centre; conflict of interest tn received honoraria from daiichi sankyo co., sanofi k.k. and mitsubishi tanabe pharma corporation. mmochizuki received honoraria from pfizer inc. mmori's department received unrestricted research grants from abbvie gk; ayumi pharmaceutical corporation; chugai pharmaceutical co., ltd.; csl behring k.k.; japan blood products organization; nippon kayaku co., ltd.; ucb japan co., ltd.; and asahikasei pharmaceutical corporation. the other authors have no conflicts of interest to declare. the study protocol was reviewed and approved by the ethics committee of the national institute of infectious diseases (the principal institution of this project) in accordance with the ethical guidelines and regulations of the declaration of helsinki (approval number: h - ).informed consent physicians in hospitals explained the study to their patients and obtained written informed consent from the parent(s) or legal guardian(s) of each child and/or assent by the child (when applicable) before initiating medical interview and record review. hiroshi yokomichi · keiko tanaka-taya · rie koshida · takashi nakano · yoshinori yasui · masaaki mori · yuka ando · saeko morino · hideo okuno · hiroshi satoh · satoru arai · mie mochizuki key: cord- -o mh wz authors: olano, juan p.; peters, c.j.; walker, david h. title: distinguishing tropical infectious diseases from bioterrorism date: - - journal: tropical infectious diseases doi: . /b - - - - . - sha: doc_id: cord_uid: o mh wz nan bioterrorism can be defined as the intentional use of infectious agents or microbial toxins with the purpose of causing illness and death leading to fear in human populations. the dissemination of infectious agents with the purpose of attacking livestock and agricultural resources has similar motives. many of the agents that could potentially be used in bioterror (bt) attacks are also responsible for naturally occurring infectious diseases in the tropics. as such, naturally occurring outbreaks must be differentiated from bt attacks for public health, forensic, and security reasons. if a bt attack occurs in tropical underdeveloped countries, owing to their weak public health infrastructure, the public health implications would be even more dramatic than in developed countries. an outbreak of smallpox due to a bt attack would probably require vaccination and mandatory quarantine of millions of people in order to control the outbreak and quell global public unrest. this chapter will concentrate on selected infectious agents that have the potential to be used as bioterror agents in human populations. the first step in managing the damage from a covert biological dissemination is recognition of the attack and the organism(s). as in most emerging infections, we predict that in bioterrorist attacks the etiological diagnosis will be made by a clinician or pathologist and the recognition of a bioterrorist event will be through geographical and epidemiological anomalies. we have very limited environmental detection capability at this time, and there are no comprehensive pointof-care diagnostics for most of the high-impact bt agents. some diseases such as inhalational anthrax or smallpox may be relatively readily recognized by an alert clinician because of their very distinctive presentation in many cases. however, the leading edge of a bt epidemic may arrive on a pathologist' s doorstep without prior suspicion. for example, individual cases of pneumonic plague as the earliest harbingers of an attack will presumably present as community-acquired pneumonia and probably die without clinical diagnosis. given the short window available for successful treatment, the recognition of these earliest cases is paramount. sartwell has demonstrated empirically that incubation periods follow a log-normal distribution, which results in "front-loading" of cases ( fig. - ). delay in recognizing the epidemic through reliance on syndromic surveillance or other surrogates will likely result in most of the cases of diseases such as plague and tularemia being well into their disease course and perhaps unsalvageable. bioterrorist events will enlarge our knowledge of tropical diseases. for example, inhalational anthrax and several viral hemorrhagic fevers (vhf) thought to be transmitted mainly by aerosol are under-represented in naturally occurring case series, and a bt attack would provide an opportunity to answer questions about the underlying host factors and pathogenesis. indeed, the extension of the risk population to include children, the elderly, and the immunosuppressed is likely to provide considerable insight into these oftenunderstudied groups. it is also likely that our lack of information about them will challenge our current diagnostic algorithms. in october , anthrax spores were distributed covertly in the u.s. postal service, leading to cases of human anthrax and billions of dollars spent on controlling the potentially devastating effects of a small inhalational anthrax epidemic. , this attack was by no means the first intentional attempt to use infectious agents as weapons of terror. ever since the times of the ancient greeks and romans, humans have tried to inflict damage by the use of contagion on other populations. , less than % of the people or groups responsible for terrorist attacks on human populations take responsibility for their actions. therefore, the use of biological weapons is ideal to conduct covert attacks. in addition, it has been estimated that to kill the same number of human beings with biological weapons as compared to chemical or nuclear weapons, the cost is far less with biological weapons ($ /human casualty) compared with chemical ($ / human casualty) and nuclear ($ , , /human casualty) weapons. hypothetical bt attacks would range from an overt attack of a large city with a bomb containing several kilograms of an agent (weaponized bacteria, viruses, or toxins) to discrete or covert intentional release of the infectious agent through a delivery system, such as spray devices, postal service, ventilation ducts, water supplies, and food supply. based on transmissibility, severity of morbidity and mortality, and likelihood of use (availability, stability, weaponization), potential bt agents are divided into three categories (table - ) . this chapter will concentrate on selected agents from categories a and b and on the diagnostic challenges posed by illnesses caused by such agents. table - are capable of producing illness under natural circumstances. therefore, the first challenge is to identify the infectious agent responsible for a certain disease correctly, followed by a thorough epidemiologic and microbiologic analysis of the epidemic or outbreak. in some circumstances, the identification of a bt attack would be obvious. a case of smallpox in any human population is an international emergency that would trigger a massive response of the public health systems around the world. sophisticated epidemiological investigations would follow in order to characterize the outbreak, identify the source, and possibly label it "intentional." in other cases, the identification of the outbreak as secondary to intentional dissemination of an infectious agent will require the use of sophisticated epidemiological and molecular tools, especially for diseases endemic to the area where the outbreak occurs. the need to use genetic sequences as markers has spawned a new discipline referred to as microbial forensics, sister to phylogenetics and "molecular epidemiology." differentiation between natural infections and a biological warfare attack rests firstly on disease patterns given by several epidemiological clues. they include presence of disease outbreaks of the same illness in noncontiguous areas, disease outbreaks with zoonotic impact, different attack rates in different environments (indoor versus outdoor), presence of large epidemics in small populations, increased number of unexplained deaths, unusually high severity of a disease for a particular pathogen, unusual clinical manifestations owing to route of transmission for a given pathogen, presence of a disease (vector-borne or not) in an area not endemic for that particular disease, multiple epidemics with different diseases in the same population, a case of a disease by an uncommon agent (smallpox, viral hemorrhagic fevers, inhalational anthrax), unusual strains of microorganisms when compared to conventional strains circulating in the same affected areas, and genetically homogenous organisms isolated from different locations. , these are a few guidelines that could prove helpful when investigating an outbreak, but it has to be kept in mind that the deduction will not be based on any single finding but rather the pattern seen in its totality. first and foremost, the possibility of an attack must be ever in mind, or differentiation of a covert bt attack and a natural outbreak of an infectious disease may not be made. in fact, the outbreak of salmonellosis in oregon in was due to a covert attack planned by the rajneeshee leadership and accompanied by distinctive epidemiological clues. it was not labeled as intentional until somebody came forward with the information leading to the responsible group; as in most of medicine, the unsuspected diagnosis is the easiest to miss. an increasing number of public health departments are now acquiring the technology necessary to perform syndromic surveillance. this new method of surveillance is based on syndromic disease rates such as respiratory, gastrointestinal, and neurological syndromes or analysis of other health-related activities such as laboratory test requests and results, purchasing rates for certain pharmaceutical agents, unexplained death rates, and veterinary surveillance. , , the purpose of syndromic surveillance is to detect a bt attack as early as possible by analyzing the previously mentioned variables by extracting and analyzing data through computer networks. the rationale behind syndromic surveillance is the nonspecific nature of early signs and symptoms of many of the illnesses caused by bt agents. examples of proposed syndromes are as follows: gastroenteritis of any apparent infectious etiology, pneumonia with the sudden death of a previously healthy adult, widened mediastinum in a febrile patient, acute neurologic illness with fever, and advancing cranial nerve impairment with weakness. a key component factors affecting syndromic surveillance include selection of data sources, definition of syndrome categories, selection of statistical detection thresholds, availability of resources for follow-up, recent experiences with false alarms, and criteria for initiating investigations. it must be emphasized that these systems are experimental and not yet of proven value in managing bt attacks. they are expensive, require follow-up confirmation, have unproven sensitivity and specificity, and ultimately depend on the clinician. they may prove to be more useful in managing an event than in expeditiously detecting one. conventional epidemiological investigations are by no means obsolete with the availability of more sophisticated methods to study possible bt attacks. they include the confirmation of an outbreak once it is suspected. confirmation is based in many cases on laboratory analysis of patients' samples or autopsy material. a case definition is constructed to increase objectivity of the data analyzed and to enable determination of the attack rate. other variables are included in the analysis, such as time and place, and an epidemiological curve can be constructed. epidemiological curves are an important tool to analyze epidemics and suggest the mode of transmission and propagation. a point source epidemic curve is classically log-normal in distribution and would suggest a common exposure of a population to an infectious agent. of course, there can be variations depending on the presence of susceptible subpopulations (e.g., children, immunosuppressed, aged) and on varying doses of the agent. propagative curves are more characteristic of highly communicable agents such as smallpox. a short description of selected category a and b agents follows. all these pathogens are addressed as naturally occurring disease agents in other chapters of this book. bacillus anthracis (anthrax) b. anthracis (see chapter ) is without a doubt the microorganism that has received the most attention as a bt agent due to its high lethality (inhalational form), ease of propagation, and high environmental stability. fortunately, the disease is not transmitted from person to person. however, the first three characteristics make it one of the ideal bioweapons. anthrax presents in humans as four different clinical syndromes, depending on the portal of entry: cutaneous (the most common form of the disease resulting from contact with infectious animal products), gastrointestinal and oral/oropharyngeal (both secondary to ingestion of contaminated meat), and inhalational (woolsorter' s disease), secondary to inhalation of spores from the environment. in the event of a bioterror attack, either overt or covert, the clinical presentation of the patients affected by the attack would be that of inhalational anthrax. this form of anthrax is so rare that a single case of inhalational anthrax should raise immediate suspicion, as dramatically demonstrated during the bt attacks in the fall of . [ ] [ ] [ ] during those attacks, % of cases were cutaneous anthrax thought to be secondary to handling of anthraxlaced mail envelopes or environmental surface contamination in the presence of minor cutaneous lesions, providing a portal of entry for the spores. an outbreak of inhalational anthrax also took place in sverdlovsk (former soviet union) as a result of an accidental release into the air of b. anthracis spores from a facility producing anthrax for the bioweapons program in the ussr. , [ ] [ ] [ ] inhalational anthrax should be suspected clinically in any individual presenting with fever and a widened mediastinum on chest radiograph (due to hemorrhagic mediastinitis). , the incubation period is normally to days, but in some cases it can be as short as days and as long as days depending on inoculum and the time of germination of the spore. based on research performed on rhesus monkeys, the ld is estimated to be to , spores. [ ] [ ] [ ] however, as few as to spores may be capable of producing a fatal outcome in approximately % of those exposed to these quantities. the initial symptoms are nonspecific and consist of fever, malaise, anorexia, fatigue, and dry cough. these symptoms are followed in to days by an abrupt onset of respiratory insufficiency, stridor, diaphoresis, and cyanosis. the subsequent clinical course is rapid, and patients usually die within to hours after clinical deterioration. mortality is % without antibiotic therapy. , [ ] [ ] [ ] early diagnosis, aggressive treatment with antimicrobial agents to which the bacteria are susceptible, and aggressive supportive therapy decreased the mortality to % in the attacks. pathologic studies performed on the sverdlovsk victims confirmed some of the findings in animal models of inhalational anthrax, such as hemorrhagic lymphadenitis and mediastinitis. however, many patients also developed hematogenous hemorrhagic pneumonia. pleural effusions were usually large and frequently led to severe lung atelectasis. in about half of cases, hemorrhagic meningitis developed, leading rapidly to central nervous system (cns) manifestations terminating in coma and death. , , yersinia pestis (plague) y. pestis (see chapter ) is a gram-negative, aerobic, nonsporulating coccobacillus, member of the enterobacteriaceae with a wide host range, including rodents, felines, and humans. the most important reservoirs are urban rats, and its main vector is the rat flea. in rural epizootics, reservoirs include prairie dogs and squirrels in the united states. y. pestis has been responsible for some of the most devastating pandemics in human history in the preantibiotic era ( th, th, and th centuries). public health measures have made this disease a rarity in the united states (around cases/year) and around the world, although approximately cases are reported to the world health organization (who) every year (countries reporting plague include madagascar, tanzania, and peru, among others). clinical presentation in naturally acquired infections takes five forms, namely bubonic, septicemic, pneumonic, cutaneous, and meningeal. the pneumonic form is the most likely presentation in a case of plague due to a bt attack. it is worth mentioning that plague has already been used as a bt agent when japan dropped thousands of y. pestis-infected fleas over china leading to small outbreaks of bubonic plague in continental china during world war ii. , the incubation period for pneumonic plague is short, ranging from to days. it is the rarest form in natural infections ( % or less) but has the highest mortality, reaching % in untreated patients. the initial presentation is nonspecific and consists of cough, fever, and dyspnea. cough may be productive (bloody, purulent, or watery in the initial phases). this is followed by a rapid clinical course leading to respiratory failure and the patient' s demise if not treated with antibiotics early in the course of the disease. , , the factors that led to the severe manchurian pneumonic plague outbreaks in the early th century are unknown, but weather, hygiene, and crowding were important factors. more recent outbreaks worldwide and particularly in the united states have been much smaller and readily controlled. pneumonic cases are common in the united states, but secondary transmission has been rare in the last years. modeling of pneumonic transmission using eight small outbreaks to derive the parameters find average of secondary cases per primary case (ro) to be approximately . prior to any control measures. this is one of the most scientifically neglected microorganisms with bt potential. tularemia is a zoonotic infection caused by a strictly aerobic, gram-negative, nonsporulating small coccobacillus. two subspecies are recognized, namely f. tularensis subspecies holarctica (jellison type b) and f. tularensis subspecies tularensis (jellison type a). type a is by far the more virulent and is present only in north america. of the bacteria with potential as bt agents, f. tularensis has by far the widest host range, including wild and domestic animals, humans, fish, reptiles, and birds. vectors are also numerous and include ticks, fleas, mosquitoes, and biting flies. , this is an impressive range for any human pathogen. in contrast to other diseases described in this chapter, tularemia does not have the remarkable history that some of the other pathogens have. in europe, tularemia was first described in ; in the united states, it was first described in in california in the aftermath of the san francisco earthquake. in natural infections, the most common source of infection is a tick bite and manipulation of infected animals such as wild rabbits. six different clinical syndromes have been described as follows: ulceroglandular, glandular, oculoglandular, pharyngeal, pneumonic, and typhoidal. marked overlap exists among all these forms, and for practical purposes two syndromes (ulceroglandular and typhoidal) have been proposed. [ ] [ ] [ ] as a bt agent, f. tularensis will most likely cause a disease with a primary pulmonary component with secondary dissemination (typhoidal/systemic). in natural infections, both ulceroglandular and typhoidal forms can have a hematogenous pulmonary component, although it is more common in typhoidal forms. pulmonary features include cough, pleural effusions, and multifocal bronchopneumonic infiltrates. if not treated promptly, patients usually develop adult respiratory distress syndrome leading to respiratory insufficiency and the patient' s demise. case-fatality rate approaches % if not treated with appropriate antibiotics. smallpox eradication remains the single most important victory in the war against infectious diseases. smallpox (see chapter ) is the only disease so far eradicated from the face of the earth due to human intervention. the who declared smallpox eradicated in after the last case of natural disease was diagnosed in somalia in , and vaccination ceased around the world, rendering humankind vulnerable to reintroduction of the virus. [ ] [ ] [ ] a laboratory accident was responsible for two more cases in in england. this accident prompted the who to restrict the frozen virus to two places in the world: the cdc in atlanta, georgia, and the institute for polyomyelitis and viral encephalitides in moscow, later moved to npo vector, novosibirisk, russia. however, it is suspected that secret military repositories exist after the fragmentation of the soviet union and the subsequent exodus of scientists involved in its bioweapons program (biopreparat). , the agent responsible for this disease is an orthopox virus with no known animal reservoir, but high aerosol infectivity, stability, and mortality. although not a category a agent, monkeypox is responsible for outbreaks in africa and is the only other member of the orthopox genus capable of producing systemic disease in humans. the clinical disease is potentially indistinguishable from smallpox, where mortality rates in tropical africa are around % to %. in may and june , an outbreak of monkeypox occurred in the united states. thirty-seven infections were laboratory-documented and involved humans exposed to infected prairie dogs that had become infected because of contact with infected gambian rats and dormice, two animal species shipped from africa earlier that year. infected humans included veterinarians, exotic pet dealers, and pet owners. the clinical spectrum in this outbreak ranged from asymptomatic seroconversions to febrile illness with papulovesicular rash. no deaths were associated with this outbreak. however, phylogenetic analysis of the virus placed it in the west africa clade as opposed to the central africa clade which carries the previously mentioned case-fatality rate of % to %. a single case of smallpox would trigger a massive public health response in order to contain the outbreak. an outbreak in germany in resulted in cases with , people vaccinated to contain the infection. in , yugoslavia underwent an epidemic with a total of cases ( deaths) and a vaccination program that included million people in order to contain the outbreak and obtain international confidence. vaccination with the vaccinia virus (a related orthopox virus) is the most effective way to prevent the disease and can be administered up to days after contact with ill patients. strict quarantine with respiratory isolation for days is also mandatory. the newer generation of antivirals that have been developed after the disease was eradicated has never been tested in human populations, but in vitro data and experiments in animal models of poxvirus disease suggest some antiviral activity for the acyclic nucleoside phosphonates such as cidofovir. the only vaccine available in the united states is dryvax, and sufficient doses have been manufactured to cover the entire u.s. population. however, newer vaccines that may have fewer side effects are being developed. the clinical presentation is characteristic. the incubation period ranges from to days. the initial phase is nonspecific, common to other viral syndromes, and is characterized by abrupt onset of fever, fatigue, malaise, and headaches. during this prodromal phase in % of patients with fair complexion, a discrete erythematous rash appears on the face, forearms, and hands. the typical smallpox rash has a centrifugal distribution (that is, more abundant on the face and extremities than on the trunk and abdomen). an enanthem also develops with presence of oral ulcerations by the time the exanthem appears. systemic manisfestations begin to subside once the rash appears and can reappear with superinfection of skin lesions or superimposed bacterial bronchopneumonia. progression of the lesions is synchronous (maculopapules, vesicles, pustules). after pustules rupture, scabs form and detach in to weeks, leaving depigmented, scarred areas. this form of the disease, called variola major, is fatal in up to % of unvaccinated patients and % of vaccinated individuals. various hemorrhagic forms exist. in some cases, the rash progresses very slowly and hemorrhage develops into the base of the lesions, which remain flat and soft instead of tense, carrying a bad prognosis. in some other cases, the disease is hemorrhagic from the beginning, leading to death to days after the initial symptoms appear (case-fatality rate: %). finally, in some cases, a severe and overwhelming illness is followed by dusky skin lesions; these patients have a large quantity of virus and are extremely dangerous epidemiologically. previously vaccinated individuals usually develop a milder disease that consists of a mild pre-eruptive phase followed by few skin lesions that appear more superficial, evolve more rapidly, and are not as synchronous as the classical type. viral hemorrhagic fever (vhf; see chapter ) is caused by a heterogenous group of rna viruses that belong to several different families. the cdc identified filoviruses (ebola and marburg viruses), arenaviruses (lassa, junin, machupo, guanarito, and sabia), and bunyaviruses (crimean-congo hemorrhagic fever [cchf] and rift valley fever [rvf]). [ ] [ ] [ ] the common denominator in these infections is the increased vascular permeability in the microcirculation leading to hemorrhagic diathesis and systemic manifestations such as pulmonary edema and cerebral edema related to leaky capillaries. these viruses usually have a very narrow geographic range determined by their natural reservoirs and vectors. humans are accidental hosts. these diseases have caught great public attention due to their high mortality. this, combined with their aerosol infectivity, has led to the use of biosafety level laboratories in their study. clinical presentation is usually nonspecific and consists of fever and malaise, followed by signs of increased vascular permeability and circulatory compromise. vhf usually terminates in shock, generalized mucocutaneous hemorrhages, and multiorgan failure. differences exist among the clinical details and pathogenesis of the different viruses (see chapter for an overview and the individual chapters for details). for example, vhf due to filoviruses usually have prominent hemorrhagic manifestations and disseminated intravascular coagulation (dic) as a terminal event. rvf virus leads to liver damage, dic, and hemorrhagic manifestations in approximately % of patients with severe disease. cchf also behaves like the filoviral infections with prominent hemorrhagic manifestations. lassa fever has few neurologic or hemorrhagic manifestations. the south american arenaviral hemorrhagic fevers usually have hemorrhagic and neurologic components. toxins in the context of bt agents are substances of biologic origin that are capable of producing human illness. toxins are usually proteins synthesized by living bacteria, fungi, or plants. toxins are generally less dangerous than infectious agents. the most potent biological toxin is that from clostridium botulinum and it is -fold or more less lethal than anthrax on a weight basis. other toxins such as ricin are more than a -fold less toxic than botulinum toxin and sarin is -fold less toxic than ricin. there are seven similar toxins produced by seven different serotypes of c. botulinum (a to g), all leading to the same clinical manifestations and with the same lethality. the toxins have a molecular weight of approximately kda and block neurotransmission at the presynaptic level in cholinergic neurons including the neuromuscular junction, leading to progressive palsies of cranial nerves and skeletal muscle. botulinal toxins are among the most lethal substances known to mankind with ld of . μg/g of body weight when administered parenterally. , , the aerosol route decreases its lethality to times. both aerosol attacks and contamination of food supplies are potential bt scenarios. clinical manifestations consist of progressive bulbar and skeletal paralysis in the absence of fever, including diplopia, dysphagia, blurred vision, ptosis, dysarthria, dysphonia, mydriasis, dry mucosae, and descending paralysis. , the cause of death in lethal cases is respiratory insufficiency due to paralysis of respiratory muscles. onset of symptoms is variable and depends on the inoculum, ranging from hours to several days after exposure. most cases of naturally occurring intoxication are related to consumption of improperly sterilized canned food or ingestion of preserved fish. rare cases of inhalational botulism were documented in germany in the early s due to accidental laboratory exposure. the rapid absorption through the respiratory tract may offer a different pathogenesis and it is not known if antitoxin is useful in therapy, although animal models show efficacy in prophylaxis. all the agents in category a are generally recognized as serious threats for causing extensive casualties. categories b and c are much more heterogeneous. they were considered to provide significant threat potential but there are continuing reassessments. these conditions are caused by the genus alphavirus, family togaviridae (eastern, western, and venezuelan equine encephalitis [vee] viruses; see chapter ). natural infections are usually transmitted by mosquitoes, but aerosol transmission is the notorious cause of numerous laboratory infections and is the basis of its historic weaponization. , most of these viruses cause systemic illness characterized by fever, myalgias, and prostration. clinically apparent involvement of the central nervous system is present in some cases and varies among the different viruses. eastern equine encephalitis (eee) is by far the most virulent, leading to case-fatality rates of % to %, and survivors usually have severe neurologic sequelae. , vee, in contrast, leads to cns manifestations in no more than % of cases and almost all vee infections are symptomatic even in the absence of cns involvement. [ ] [ ] [ ] rickettsia prowazekii (epidemic typhus) and r. rickettsii (rocky mountain spotted fever) typhus (see chapter ) is another disease that has played a historic role in human populations. [ ] [ ] [ ] [ ] millions of people perished in world war i and world war ii due to epidemic, louse-borne typhus. large outbreaks of the disease still occur in tropical regions around the world in areas stricken by war, famine, and poverty. rocky mountain spotted fever (rmsf), on the other hand, is transmitted by tick bites and occurs endemically in south and central america as well as north america. rickettsiae target the microvascular endothelium leading to leaky capillaries systemically. the main causes of morbidity and mortality are noncardiogenic pulmonary edema and cerebral edema leading to diffuse alveolar damage and meningoencephalitis. clinical manifestations are nonspecific and include fever, malaise, headache, myalgias/arthralgias, cough, nausea, vomiting, confusion, stupor, and coma in severe cases. skin rash ranges from maculopapular to petechial, depending on the severity, and is observed in around % of patients with rmsf and % to % of cases of epidemic typhus, depending on the darkness of cutaneous pigmentation. rickettsiae are remarkably underestimated biothreats as they are highly infectious by low-dose aerosol exposure, possess a stable extracellular form, and are resistant to most empirically administered antibiotics, including β-lactams, aminoglycosides, and macrolides, and are exacerbated by sulfonamides. case-fatality rates can be as high as % to % without antibiotic therapy and % to % with adequate antibiotic coverage. lethal cases are usually due to delayed diagnosis. , , these rickettsiae are highly infectious by aerosol and are potent bt agents. they are often discounted because of their susceptibility to tetracycline and chloramphenicol. however, the severity of the illness, the exhaustion of antibiotics in the face of a mass attack, and the existence of antibiotic-resistant organisms suggest they are still formidable players. this gram-negative, obligately intracellular bacterium has a high degree of infectivity (one organism is capable of causing infection by inhalation) and low lethality. [ ] [ ] [ ] [ ] the distribution of q fever is worldwide and results from exposure to animals such as sheep, cattle, goats, cats, rabbits, and others. c. burnetii has spore-like characteristics that can withstand harsh environmental conditions and be transported by wind to other places. in natural infections, % of cases are asymptomatic and are diagnosed by seroconversion. in symptomatic cases, the presentation is nonspecific and includes malaise, fever, myalgias, cough, chills, headaches, anorexia, weight loss, and in some cases pleuritic chest pain. hepatomegaly and splenomegaly are sometimes observed, although not frequently. transmission occurs by exposure to infected animal products (meat, milk). less common routes of infection are inhalational and cutaneous. the clinical presentation of brucellosis is highly variable, even after inhalational exposure. the clinical spectrum ranges from asymptomatic seroconversion to severe acute systemic disease. intermediate forms include undulant fever or chronic disease, characterized by presence of brucella in virtually any organ. acute systemic disease is highly incapacitating with high fever, headache, nausea, vomiting, chills, severe sweating, and, in very severe cases, delirium, coma, and death. undulant fever is characterized by relapses of fever, weakness, generalized aching, and headache. chronic infections may have manifestations related to several organ systems such as the gastrointestinal and genitourinary tracts, cns, joints, and bones. [ ] [ ] [ ] developing countries with insufficient water treatment and food security are more vulnerable to enteric bt attack. these agents include shigella dysenteriae, salmonella spp., enterohemorrhagic e. coli, vibrio cholerae, and cryptosporidium parvum. shigella and salmonella have in fact already been used as agents of biorevenge or biopolitics in small-scale attacks: one (shigella) in an office setting by a disgruntled employee and one in oregon by a religious sect that led to nearly cases of salmonella-related gastroenteritis. , these agents are indeed ideal for small-scale attacks since large-scale attacks would require contamination of large water supplies which, because of enormous dilution factors and susceptibility of all these agents (except for c. parvum) to standard chlorinating procedures, would decrease the number of bacteria to below that required to infect large numbers of people. occasional outbreaks of nontyphoidal salmonella and shigella infections occur in the united states. shigella is a highly infectious organism that requires very low numbers ( - organisms) to provoke clinical disease. the illness caused by shigella and enterohemorrhagic e. coli is explosive and starts with fever, vomiting, severe abdominal cramping, bloody diarrhea, and systemic manifestations such as hypotension, and circulatory collapse if not treated rapidly. both microorganisms produce an exotoxin responsible for most of the systemic manifestations associated. a distinct complication, hemolytic uremic syndrome, occurs in a small percentage of cases, being more common in children younger than years of age, leading to renal failure and hemolysis. salmonella is less infectious and less explosive than shigella, and leads to fever, vomiting, diarrhea, abdominal cramping, and in some cases to typhoidal manifestations. imported cases of v. cholerae have been diagnosed in the united states in the past. however, the disease occurs in southern asia and latin america as large outbreaks. the clinical illness is characterized by explosive watery diarrhea that leads to rapid dehydration and circulatory collapse. c. parvum infections are characterized by watery diarrhea and abdominal cramping for to weeks. the disease is self-limited except in patients with acquired immunodeficiency syndrome (aids) or other conditions of compromise, in whom illness can last for months or years if immune function is not restored. c. parvum is resistant to standard chlorine concentrations in water supplies. the largest outbreak in this country occurred in milwaukee in the early s and was responsible for thousands of cases and increased mortality among those with aids. , , this section addresses other toxins considered of potential bt use, such as staphylococcal enterotoxin b (seb) and ricin toxin (derived from castor beans, which in turn are the fruit of the ricinus communis plant). the ricin toxin is composed of two glycoproteins of approximately , kda. the toxin inhibits protein synthesis by blocking elongation factor (ef ) at the ribosomal level. ricin toxin is not a weapon of mass destruction since its lethal dose in humans is much higher than previously believed. however, the use of the toxin in small bt attacks is possible in the tropics because of its ready availability and relatively easy extraction from the beans. clinical presentation depends on the route of administration as does the ld . in cases where large amounts of the toxin are ingested, the manifestations include nausea, vomiting, severe abdominal cramping, rectal hemorrhage, and diarrhea. as the clinical course progresses, anuria, mydriasis, severe headaches, and shock supervene leading to the patient' s demise in to days. clinical manifestations usually appear within hours after ingestion of the toxin. inhalational exposure leads to prominent pulmonary manifestations to hours after exposure and fever, dyspnea, progressive cough, cyanosis, and death. histologically, there is widespread necrosis of pulmonary parenchyma and pulmonary edema. a single case of parenteral intoxication was documented. a defector from bulgaria was injected with a pellet containing ricin from a weapon disguised in an umbrella, resulting in local necrosis, regional lymphadenopathy, gastrointestinal hemorrhage, liver necrosis, nephritis, and dic. staphylococcus aureus enterotoxin b (seb) is a -kda, heatstable exotoxin produced by certain strains of s. aureus and is responsible for food poisoning after ingestion of the preformed exotoxin in improperly handled food. in bt scenarios, exposure can occur either by inhalation or ingestion leading to seb food poisoning or seb respiratory syndrome. the toxin is highly incapacitating and not very lethal. the dose that causes symptoms in half of exposed persons and ld differ by a magnitude of log scales for inhalational exposure. thus, it is thought of as an incapacitating agent. incubation time after ingestion is short ( - hours) followed by explosive vomiting that persists for several hours. weaponization of the toxin as an aerosol is possible due to its high stability. manifestations after inhalation of the seb are related to the respiratory system and consist of fever, cough, chills, myalgias, chest pain, and pulmonary insufficiency due to alveolar edema. general symptoms and signs are universal and consist of multiorgan failure secondary to a cytokine storm. these toxins are superantigens due to their ability to bind to major histocompatibility complex (mhc) class ii molecules on large numbers of lymphocytes and macrophages, leading to a hyperactivation of the immune system and massive cytokine release including interferon-gamma (ifn-γ), tumor necrosis factor-alpha (tnf-α), interleukin (il- ), and other mediators such as leukotrienes and histamine. the role of the clinical laboratory in the diagnosis of possible cases related to a bt attack is of utmost importance. , on the one hand, standard clinical microbiology laboratories will be receiving specimens for diagnostic purposes, and communication with clinicians regarding their suspicions is critical. certain isolates in the laboratory are not pursued further (bacillus spp. is a classic example) unless specifically requested due to the frequent isolation of contaminants with similar characteristics. in addition, handling of certain specimens will require added biosafety level requirements due to their infectivity (table - ) . certain samples will have to be shipped to highly specialized laboratories for initial or further work-up. environmental testing is challenging due to the complexity of the samples to be analyzed. , this type of testing takes place in highly specialized laboratories and is not undertaken by the standard clinical microbiology laboratory. the bacterial diseases caused by the bt agents outlined in this chapter, with the exception of c. burnetii and rickettsia spp., can be diagnosed by standard isolation techniques in clinical microbiology laboratories. isolation of rickettsiae and the bt viruses requires specialized laboratories with bsl- or bsl- biocontainment. serological assays are available for detection of antibodies against all bt agents. however, for many organisms serological assays require the presence of rising antibody titers, and therefore the serologic diagnosis is usually retrospective in nature. for some viral diseases, a reliable diagnosis can be established based on elevation of immunoglobulin m (igm) titers in the acute phase of the disease. with the advent of molecular techniques, rapid and sensitive diagnostic tests are becoming available for bt agents during the acute phase of the disease. [ ] [ ] [ ] this is of utmost importance in a bt event since identification of the first cases would be critical for a rapid and effective public health response. in addition, treatment and prophylactic measures can also be initiated as quickly as possible. molecular diagnostic techniques can be applied to potential bt agents in an additional setting: as part of the epidemiological and forensic investigations that a bt attack would immediately trigger. postmortem diagnosis is also possible by analysis of frozen or paraffin-embedded tissues by immunohistology or nucleic acid-based amplification techniques. rapid diagnosis of the initial case (cases) in a bt event requires a high degree of clinical suspicion from the physicians having contact with such patients in the emergency room or outpatient setting. the clinical laboratories would then play a critical role in detecting the suspected agent and/or referring the appropriate specimens to higher level laboratories for specialized testing (table - ) . , , several of the agents discussed in this chapter are zoonotic diseases. therefore, diagnosis of certain zoonotic diseases in animals may be important in identifying some bt attacks. in such situations, animals could be seen as either direct victims of the attack or as sentinel events in a human outbreak. there are currently efforts to establish a network of laboratories dedicated to diagnosis of veterinary agents. bsl- suitable for work involving well-characterized agents not known to cause disease in healthy bacillus subtilis adult humans and of minimal potential hazard to laboratory personnel and the environment. naegleria gruberi canine hepatitis virus bsl- suitable for work involving agents of moderate potential hazard to personnel and the measles virus environment. laboratory personnel have specific training in handling pathogenic agents salmonella spp. and are directed by competent scientists; access to the laboratory is limited when work toxoplasma spp. is being conducted; extreme precautions are taken with contaminated sharp items; and hepatitis b virus certain procedures in which infectious aerosols or splashes may be created are conducted in biological safety cabinets or other physical containment equipment. bsl- suitable for work with infectious agents which may cause serious or potentially lethal coxiella burnetii disease as a result of exposure by the inhalation route. in addition to the requirements rickettsia spp. described for work in bsl- environment, all procedures are conducted within biological m. tuberculosis safety cabinets, or other physical containment devices, and by personnel wearing alphaviruses appropriate personal protective clothing and equipment. laboratory should be located in a separate building or an isolated zone within a building. laboratories are equipped with double door entry, directional inward flow, and single-pass air. bsl- required for work with dangerous and exotic agents that pose a high individual risk of filoviruses aerosol-transmitted laboratory infections and life-threatening disease. members of the arenaviruses laboratory staff have specific and thorough training in handling extremely hazardous infectious agents. they are supervised by competent scientists who are trained and experienced in working with these agents. access to the laboratory is strictly controlled by the laboratory director. the facility is either in a separate building or in a controlled area within a building, which is completely isolated from all other areas of the building. all activities are confined to class iii biological safety cabinets, or class ii biological safety cabinets used with one-piece positive pressure personnel suits ventilated by a life support system. the biosafety level laboratory has special engineering and design features to prevent microorganisms from being disseminated into the environment. the diagnosis of inhalational anthrax is based on isolation and identification of b. anthracis from a clinical specimen collected from an ill patient. in cases of inhalational anthrax, samples of sputum, blood, or cerebrospinal fluid (csf) may yield growth of the agent. demonstration of b. anthracis from nasal swabs has more epidemiological and prophylactic implications than clinical importance. standard diagnostic techniques are based on visualization and isolation in the clinical microbiology laboratory and serological demonstration of antibodies against b. anthracis. [ ] [ ] [ ] [ ] [ ] visualization of b. anthracis from clinical specimens (blood cultures, csf, and cutaneous lesions) by gram stains is not difficult. b. anthracis appears as large gram-positive, spore-forming rods with a bamboo appearance. isolation is achieved by inoculating standard sheep blood agar plates, and colonies appear as small, gray-white, nonhemolytic colonies. a selective medium (polymyxin-lysozyme-edta-thallous acetate agar) is available mostly for environmental samples and inhibits the growth of other bacillus spp., such as b. cereus. growth is rapid ( - hours) . confirmatory tests include γ-phage lysis, detection of specific cell wall and capsular antigens, and polymerase chain reaction (pcr) amplification of dna followed by sequencing. serological tests available for clinical diagnosis are based on detection of antibodies directed against protective antigen (pa). cross-reactive antibodies decrease the specificity of this test. assays based on toxin detection are available in specialized centers and are based on capture of anthrax toxins by using antibodies. antibody-coated immunomagnetic beads are then analyzed by electrochemiluminescence technology. the analytical sensitivity of this technique for detection of anthrax toxin is at the picogram to femtogram level ( − to − ). , immunoliposomal technology combined with real-time pcr (for a dna reporter sequence) is also in the early stages of development for several toxins (ricin, cholera, and botulinum) and appears promising with analytical sensitivity in the attomolar to zeptomolar ( − to − ) range for cholera toxin. the specificity of this assay is given by the toxin-capturing antibody. nucleic acid amplification techniques (pcr) are also available both in standard format and real-time format. extraction of dna from spores is challenging and requires modification of dna extraction protocols in order to facilitate release of dna from spores or induction of germination prior to dna extraction. real-time pcr tests have been developed by applied biosystems (taqman ' nuclease assay) and roche applied science (lightcycler). [ ] [ ] [ ] the analytical sensitivity of both techniques is extremely high, and testing times have been decreased to to hours. portable pcr instruments are being developed for rapid deployment to the field. examples include the rugged advanced pathogen identification device (rapid), the smartcycler (cepheid, ca), and the miniature analytical thermal cycler instrument (matci) developed by the department of energy' s lawrence livermore national laboratory. this instrument later evolved into the advanced nucleic acid analyzer (anaa) and handheld advanced nucleic acid analyzer (hanaa). molecular subtyping of b. anthracis is also possible by using the s ribosomal rna (rrna) subunit gene, multiplelocus vari-able number tandem repeat analysis of eight genetic loci, and amplified fragment length polymorphism (aflp) techniques. , environmental testing also plays a role in the investigation of a bt event. in this setting, detection of b. anthracis relies heavily on molecular techniques for confirmation of potentially contaminated samples (e.g., surfaces, air). , postmortem diagnosis is also possible by using gram stains on paraffin-based tissues or immunohistochemical procedures using polyclonal or monoclonal antibodies against various anthrax antigens. diagnosis of y. pestis is based on demonstration of the bacillus in blood or sputa from patients. standard diagnostic techniques in the laboratory include visualization of gramnegative coccobacilli, which by giemsa, wright, or wayson stains reveal a "safety pin" appearance. isolation is performed in blood and mcconkey agar plates on which colonies appear as nonlactose fermentors. the organisms are identified preliminarily by direct immunofluorescent assay with y. pestisspecific antibodies, with final identification based on biochemical profiles in clinical microbiology laboratories. molecular diagnostic techniques based on real-time pcr have become available in recent years and involve detection of y. pestis genes such as plasminogen activator (pla), genes coding for the yop proteins and the capsular f antigen, and the s rrna gene, which allows distinction from other yersinia spp. [ ] [ ] [ ] assays have been developed to detect resistance to particular antibiotics. the importance of these diagnostic techniques in a disease such as plague is evident. the log-normal epidemic curve with a narrow dispersion of the incubation periods (see fig. - ) and the short interval for successful antibiotic therapy mandate recognition of the earliest cases if the bulk of the exposed are to be saved. molecular subtyping of y. pestis is also possible by analyzing polymorphic sites in order to identify the origin of strains in the event of a bt attack. diagnosis is made in the clinical laboratory by demonstration of the microorganisms in secretions (sputa, exudates) by direct immunofluorescence or immunohistochemically in biopsy specimens. isolation in the clinical laboratory may be achieved by using regular blood agar plates, posing a risk to laboratory personnel not employing bsl- facilities and procedures. the procedure for isolation of f. tularensis in the laboratory is very similar to that described for y. pestis. final identification in the clinical laboratory is based on the biochemical profile. molecular diagnostic techniques are based on pcr detection of f. tularensis by using primers for different genes such as outer membrane protein (fop) or tul and real-time detection systems. , , smallpox virus diagnosis of variola major is suggested by its clinical presentation and the visualization of guarnieri bodies in skin biopsy samples. preliminary confirmation requires visualization of the typical brick-shaped orthopox virus by electron microscopy, followed by isolation from clinical specimens and accurate molecular identification to differentiate it from the morphologically (and sometimes clinically) similar monkeypox virus. confirmation of this diagnosis is performed only under bsl- containment facilities at the cdc. molecular techniques are based on pcr amplification using real-time or standard technology followed by sequencing or use of restriction fragment length polymorphism (rflp) for accurate identification. technologies so far developed for smallpox molecular testing include taqmanand lightcycler-based assays with primers designed for the hemagglutinin gene and a-type inclusion body proteins. [ ] [ ] [ ] [ ] sequencing of the smallpox genome has been completed for some asian strains of variola major and one of variola minor. other strains are being sequenced and will provide more information for probe design and treatment targets. diagnosis of these diseases is performed in highly specialized centers in the united states because special isolation procedures and highly contained laboratories are required. initial diagnosis of these diseases is suspected on clinical and epidemiologic grounds. laboratory diagnosis involves isolation, electron microscopy, and serological assays. immunohistochemical detection of hemorrhagic fever viral antigens in paraffin-embedded tissues is also performed in highly specialized centers such as the cdc. [ ] [ ] [ ] [ ] [ ] molecular diagnostic techniques have also improved dramatically during the last few years. serum or blood is the most common specimen used for reverse transcriptase-pcr amplification of viral nucleic acids. both standard and realtime techniques are available. design of primers for this heterogenous group of rna viruses that are highly variable is one of the limitations. therefore, multiplex pcr techniques are required to detect as many targets as possible in a single assay. , real-time pcr based on detection of the target sequence using fluorescent probes therefore limits the number of targets that can be identified because of the limited wavelength range for fluorescent applications (usually only four different wavelengths can be detected at the same time). [ ] [ ] [ ] the use of microchips containing several thousands of oligonucleotides from all viruses known to be pathogenic to humans is an encouraging development. in fact, the rapid identification and characterization of the novel human coronavirus responsible for the sars outbreak in is an excellent example of the power of hybridization-based microchips. the creation of an automated and easily deployable instrument capable of detecting all possible potential bt agents based on highly sensitive techniques such as electrochemoluminescence (ecl) or pcr would be ideal. the nonspecific nature of presenting symptoms is a major problem with several of the agents. the rapid recruitment of cases into the infected cohort requires that an early diagnosis of the epidemic be established, particularly for organisms such as y. pestis in which there is only a short window for successful treatment. in fact, such projects are already in the making. an example of this system is the automated biological agent testing system (abats) that combines the techniques mentioned previously. the system is the result of integrating several commercially available technologies into a single automated and robotized instrument for detection of viruses, bacteria, and parasites considered potential bt agents. the technologies incorporated into this "super system" include automated specimen preparation (both nucleic acid-based and protein-based such as immunodiagnostics), thermocyclers for pcr detection, chemiluminescent detectors for immunobased assays, sequencers, and software programs for sequence analysis. rickettsia prowazekii (epidemic typhus) and r. rickettsii (rocky mountain spotted fever) diagnosis of these infections in the clinical microbiology laboratory currently rests on the identification of antibodies in serum during the acute and convalescent period in order to demonstrate seroconversion or rising titers. the diagnosis is therefore retrospective. , detection of rickettsial dna from blood or skin samples during the acute phase of the disease is possible via pcr assays. however, these assays are not standardized and are not commercially available. primers have been designed for amplification of several rickettsial genes including citrate synthase, -kda protein gene, ompa, and ompb. [ ] [ ] [ ] [ ] [ ] the clinical sensitivity and specificity of standard or real-time pcr techniques have not been determined. most likely real-time pcr is superior due to the higher analytical sensitivity of this technique and low risk of sample contamination with dna amplicons when compared to standard pcr amplification methods. isolation of rickettsiae from clinical specimens is performed in very few specialized laboratories in the nation and requires the use of cell monolayers, embryonated eggs, or animals. detection of rickettsial antigens or whole bacteria in blood specimens is theoretically possible by using ultrasensitive methods, but such assays are currently only in the early phases of development. immunohistochemical detection of rickettsiae in paraffin-embedded tissue has also been applied to tissue samples obtained pre-or postmortem. [ ] [ ] [ ] salmonella spp., shigella dysenteriae, vibrio cholerae, and cryptosporidium parvum (acute enteric syndromes) diagnosis of salmonella, shigella, and vibrio infections is based on isolation of the offending agent on standard microbiological media in the clinical laboratory, followed by specialized confirmatory tests to identify the specific serotype involved. diagnosis of c. parvum is based on visual identification of the protozoan in fecal specimens by using modified trichrome stain. the diagnosis rests on serological demonstration of antibodies by immunofluorescent assay (ifa) or enzyme-linked immunosorbent assay (elisa). antibodies remain elevated for years after the acute infection, and therefore a fourfold rise in titers is the gold standard for diagnosis. pcr detection of c. burnetii dna from blood or tissues also yields a diagnosis of q fever. brucella spp. diagnosis of brucellosis requires a high degree of clinical suspicion due to the protean manifestations related to this disease. laboratory diagnosis is based on isolation of the microorganism from blood, bone marrow, or other tissue samples. isolation is not easy due to the slow-growth of brucella spp. colonies usually appear after to weeks, and therefore communication with the clinical laboratory is important so that appropriate media will be used and the cultures will be held long enough for colonies to be detected. serologic assays for demonstration of rising antibody titers are available, although the diagnosis is retrospective. pcr detection is promising, but it is not standardized. [ ] [ ] [ ] alphaviruses (encephalitic syndromes: venezuelan, eastern, and western equine encephalomyelitis) diagnosis is based on isolation of the virus from serum or brain (postmortem specimens) in a bsl- environment. pcr detection of viral sequences is also possible. serologic diagnosis is based on demonstration of antibodies in acute and convalescent sera. [ ] [ ] [ ] botulinum toxins the diagnosis of botulism relies heavily on clinical parameters. an afebrile patient with signs and symptoms of progressive bulbar palsies and descending neuromuscular paralysis is highly suspected of having botulism. demonstration of the toxin in cases of botulism due to ingestion of contaminated food is made from gastric samples, feces, blood, and urine. however, detection of minute amounts of toxin (and contacts with samples from cases may prove fatal due to the toxin' s potency) would be difficult by current immunoassay systems such as elisa platforms. detection techniques based on electrochemiluminescence and immunoliposomes are currently under development. , pcr assays can be performed in cases of ingestion of contaminated food in order to detect the genetic material present in c. botulinum. if weaponized toxin is used in the absence of c. botulinum organisms, detection of the genetic material would be difficult and would rely on the presence of residual dna after toxin purification procedures. if inhalational botulism is suspected, respiratory secretions and nasal swabs should be obtained as early as possible. postmortem samples of liver and spleen can be used for detection of botulinum toxins. diagnosis is also based on clinical presentation and requires a high index of suspicion due to the nonspecific nature of the signs and symptoms. laboratory diagnosis rests on detection of the toxin in body fluids by immunoassays (capture elisa and igg elisa). a new generation of tests using more sensitive detection methods is under development (see preceding discussion). diagnosis is also suspected on clinical grounds and confirmed by demonstration of the toxin in nasal swabs early in the disease process, feces, and, in fatal cases, from kidney and lung tissue. serum can be analyzed by elisa, and pcr can be performed for detection of toxin genes of s. aureus if present. the distribution and incubation periods of infectious diseases syndromic surveillance and bioterrorism-related epidemics viral hemorrhagic fevers anthrax bioterrorism: lessons learned and future directions investigation of bioterrorism-related anthrax history of the development and use of biological weapons biological warfare. a historical perspective [see comment laboratory aspects of biowarfare. philadelphia, wb saunders mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions a large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars a systems overview of the electronic surveillance system for the early notification of community-based epidemics (essence ii) epidemiologic response to anthrax outbreaks: field investigations bioterrorism-related inhalational anthrax: the first cases reported in the united states first case of bioterrorism-related inhalational anthrax in the united states quantitative pathology of inhalational anthrax i: quantitative microscopic findings the sverdlovsk anthrax outbreak of death at sverdlovsk: what have we learned? anthrax as a biological weapon: medical and public health management. working group on civilian biodefense updated recommendations for management pathology of experimental inhalation anthrax in the rhesus monkey the pathology of experimental anthrax in rabbits exposed by inhalation and subcutaneous inoculation pathology of inhalation anthrax in cynomolgus monkeys (macaca fascicularis) fatal inhalational anthrax in a -year-old connecticut woman [see comment clinical recognition and management of patients exposed to biological warfare agents clinical presentation of inhalational anthrax following bioterrorism exposure: report of surviving patients [see comment recognition and treatment of anthrax pathology of inhalational anthrax in cases from the sverdlovsk outbreak of pathology and pathogenesis of bioterrorism-related inhalational anthrax yersinia species, including plague yersinia infections: centennial of the discovery of the plague bacillus the bubonic plague factories of death clinical recognition and management of patients exposed to biological warfare agents plague as a biological weapon: medical and public health management. working group on civilian biodefense [see comment epidemiologic determinants for modeling pneumonic plague outbreaks manual of clinical microbiology clinicopathologic aspects of bacterial agents tularemia as a biological weapon: medical and public health management [see comment francisella tularensis tularemia: a -year experience with cases the world' s last endemic case of smallpox: surveillance and containment measures virological evidence for the success of the smallpox eradication programme eradication of infectious diseases: its concept, then and now smallpox and its eradication. geneva, world health organization smallpox: an attack scenario smallpox as a biological weapon: medical and public health management. working group on civilian biodefense monkeypox transmission and pathogenesis in prairie dogs potential antiviral therapeutics for smallpox, monkeypox, and other orthopox virus infections viral hemorrhagic fevers including hantavirus pulmonary syndrome in the americas viral agents as biological weapons and agents of bioterrorism hemorrhagic fever viruses as biological weapons: medical and public health management [see comment role of the endothelium in viral hemorrhagic fevers the action of botulinum toxin at the neuromuscular junction botulinum toxins venezuelan equine encephalitis an outbreak of eastern equine encephalomyelitis in jamaica, west indies. i: description of human cases eastern and western equine encephalitis an outbreak of venezuelan equine encephalomeylitis in central america. evidence for exogenous source of a virulent virus subtype an epidemiologic study of venezuelan equine encephalomyelitis in costa rica venezuelan equine encephalitis zinsser h: rats, lice and history rickettsial infections. in lack ee rocky mountain spotted fever and other rickettsioses typhus and its control in russia rickettsia conorii infection of c h/hen mice. a model of endothelial-target rickettsiosis rickettsioses as paradigms of new or emerging infectious diseases threats in bioterrorism ii: cdc category b and c agents q fever - . clinical and epidemiologic features of , infections epidemiologic features and clinical presentation of acute q fever in hospitalized patients: french cases human brucellosis an overview of human brucellosis medical aspects of chemical and biological warfare an outbreak of shigella dysenteriae type among laboratory workers due to intentional food contamination viability of cryptosporidium parvum oocysts in natural waters surveillance for waterborne-disease outbreaks-united states cryptosporidiosis in children during a massive waterborne outbreak in milwaukee, wisconsin: clinical, laboratory and epidemiologic findings medical aspects of chemical and biological warfare georgi markor--death in a pellet staphylococcal enterotoxin b and related pyrogenic toxins bioterrorism: implications for the clinical microbiologist the role of the clinical laboratory in managing chemical or biological terrorism diagnostic analyses of biological agent-caused syndromes: laboratory and technical assistance automated biological agent testing systems department of health and human services applying molecular biological techniques to detecting biological agents current laboratory methods for biological threat agent identification molecular diagnostic techniques for use in response to bioterrorism a national laboratory network for bioterrorism: evolution from a prototype network of laboratories performing routine surveillance definitive identification of bacillus anthracis-a review pc bacillus and other aerobic endospore-forming bacteria mabs to bacillus anthracis capsular antigen for immunoprotection in anthrax and detection of antigenemia specific, sensitive, and quantitative enzyme-linked immunosorbent assay for human immunoglobulin g antibodies to anthrax toxin protective antigen comparison of a multiplexed fluorescent covalent microsphere immunoassay and an enzyme-linked immunosorbent assay for measurement of human immunoglobulin g antibodies to anthrax toxins an enzymatic electrochemiluminescence assay for the lethal factor of anthrax comparative studies of magnetic particle-based solid phase fluorogenic and electrochemiluminescent immunoassay high-sensitivity detection of biological toxins a field investigation of bacillus anthracis contamination of u.s. department of agriculture and other washington, dc, buildings during the anthrax attack of sensitive and rapid identification of biological threat agents detection of bacillus anthracis dna by lightcycler pcr a handheld real time thermal cycler for bacterial pathogen detection real-time microchip pcr for detecting single-base differences in viral and human dna rapid pathogen detection using a microchip pcr array instrument genetic sleuths rush to identify anthrax strains in mail attacks sequencing of s rrna gene: a rapid tool for identification of bacillus anthracis environmental sampling for spores of bacillus anthracis bacillus anthracis contamination and inhalational anthrax in a mail processing and distribution center manual of clinical microbiology development of rrnatargeted pcr and in situ hybridization with fluorescently labelled oligonucleotides for detection of yersinia species ' nuclease pcr assay to detect yersinia pestis yersinia pestis-etiologic agent of plague francisella and brucella detection of francisella tularensis in infected mammals and vectors using a probe-based polymerase chain reaction detection of francisella tularensis within infected mouse tissues by using a hand-held pcr thermocycler pcr strategy for identification and differentiation of small pox and other orthopoxviruses real-time pcr system for detection of orthopoxviruses and simultaneous identification of smallpox virus gene for a-type inclusion body protein is useful for a polymerase chain reaction assay to differentiate orthopoxviruses the potential of ′ nuclease pcr for detecting a single-base polymorphism in orthopoxvirus detection of smallpox virus dna by lightcycler pcr comparative pathology of the diseases caused by hendra and nipah viruses a novel immunohistochemical assay for the detection of ebola virus in skin: implications for diagnosis, spread, and surveillance of ebola hemorrhagic fever. commission de lutte contre les epidemies a kikwit immunohistochemical and in situ localization of crimean-congo hemorrhagic fever (cchf) virus in human tissues and implications for cchf pathogenesis retrospective diagnosis of hantavirus pulmonary syndrome, - : implications for emerging infectious diseases hantavirus pulmonary syndrome. pathogenesis of an emerging infectious disease molecular diagnostics of viral hemorrhagic fevers rapid detection and quantification of rna of ebola and marburg viruses, lassa virus, crimean-congo hemorrhagic fever virus, rift valley fever virus, dengue virus, and yellow fever virus by real-time reverse transcription-pcr quantitative real-time pcr detection of rift valley fever virus and its application to evaluation of antiviral compounds development and evaluation of a fluorogenic ' nuclease assay to detect and differentiate between ebola virus subtypes zaire and sudan rickettsioses as paradigms of new or emerging infectious diseases laboratory diagnosis of rickettsioses: current approaches to diagnosis of old and new rickettsial diseases citrate synthase gene comparison, a new tool for phylogenetic analysis, and its application for the rickettsiae diagnosis of mediterranean spotted fever by cultivation of rickettsia conorii from blood and skin samples using the centrifugation-shell vial technique and by detection of r. conorii in circulating endothelial cells: a -year follow-up differentiation of spotted fever group rickettsiae by sequencing and analysis of restriction fragment length polymorphism of pcr-amplified dna of the gene encoding the protein rompa differentiation among spotted fever group rickettsiae species by analysis of restriction fragment length polymorphism of pcr-amplified dna diagnostic tests for rocky mountain spotted fever and other rickettsial diseases immunohistochemical diagnosis of typhus rickettsioses using an anti-lipopolysaccharide monoclonal antibody monoclonal antibody-based immunohistochemical diagnosis of rickettsialpox: the macrophage is the principal target investigation of foodborne and waterborne disease outbreaks rapid laboratory confirmation of human brucellosis by pcr analysis of a target sequence on the -kilodalton brucella antigen dna the -kda cytoplasmic protein of brucella species-an antigen useful for diagnosis-is a lumazine synthase characterization of an -kilodalton brucella cytoplasmic protein which appears to be a serological marker of active infection of both human and bovine brucellosis genus-specific detection of alphaviruses by a semi-nested reverse transcription-polymerase chain reaction standardization of immunoglobulin m capture enzyme-linked immunosorbent assays for routine diagnosis of arboviral infections toxins as weapons of mass destruction: a comparison and contrast with biological warfare and chemical warfare agents sensitive detection of biotoxoids and bacterial spores using an immunomagnetic electrochemiluminescence sensor key: cord- -oatjcmy authors: arata, andrew a. title: old and new pestilences date: journal: understanding the global dimensions of health doi: . / - - - _ sha: doc_id: cord_uid: oatjcmy a. “any fatal epidemic disease, affecting man or beast, and destroying many victims.” the oxford universal dictionary, (rd) edition, , oxford press, pp. b. “a contagious or infectious epidemic disease that is virulent and devastating.” webster’s seventh new collegiate dictionary, . g. & c. merriam co., springfield, mass., pp. accordingly, a pestilence should be an infectious disease, devastating (killing) a large number of people (or animals). there has been much popular interest in, as well as technical concern over, newly emerging diseases, and there is a fear that heretofore unknown virulent pathogens will create new, global epidemics. at the time of this writing, two such pathogens are active, warranting such concern: a) cases of sars (severe acute respiratory syndrome, caused by a coronavirus) appeared in china in november, , and has spread to western and central europe and north america; b) a strain of avian influenza virus (n h ), first identified in hong kong in , reemerged in in southeast asia. other avian flu strains found simultaneously in poultry in north america have underscored the concern of local and international health authorities. both sars and avian flu demonstrate high mortality rates, but, to date, the number of cases has been only in the hundreds. so, are these pestilences? what constitutes a pestilence? is the term synonymous with newly emerging diseases? two definitions of pestilence have near unanimity, but are not very specific: a) "any fatal epidemic disease, affecting man or beast, and destroying many victims." the oxford universal dictionary, rd edition, , oxford press, pp. b) "a contagious or infectious epidemic disease that is virulent and devastating." webster' s seventh new collegiate dictionary, . g. & c. merriam co., springfield, mass., pp. accordingly, a pestilence should be an infectious disease, devastating (killing) a large number of people (or animals). the truly epidemic diseases are usually of viral or bacterial origin (although we will make a case for some other types of pestilences). the classification of that may have been bubonic plague continuing until a.d. ). the "black death" of the fourteenth century, which continued to appear in chronic pockets of europe and the middle and near east for centuries thereafter, is by far the best-known plague, and the one that produced the greatest mortality and social impact on the affected populations. consider that as a conservative estimate, − % of the european population died, and maybe more. this death rate reduced the available work force so that, for the first time, peasants and landless people could sell their labor, which introduced freedom of movement and resulted in economic changes that eventually contributed to the decline of the feudal system. the rd pandemic of plague began in the s and continues to this date, although reduced in more recent years. a major characteristic of this epidemic has been the dissemination of plague from its traditional homes in africa and asia into areas previously plague free, especially north and south america, by the inadvertent transport of rats and their fleas by boat. the infection is now well established in africa (gerbils); central asia (gerbils, ground squirrels or "susliks," and marmots); southeast asia (various rattus species); north america (ground squirrels and some native field mice); and south america (introduced rattus). the last major urban outbreak was in surat, india in : more than , cases and deaths were reported. however, the impact of this outbreak was also seen in the number of people who fled the plague zone, and the over two billion dollar loss that ensued. only a few outbreaks are reported to who each year. indochina and burma frequently report, as well as sites in africa (ovamboland on the frontier between namibia and angola); the united states has a vast infected area in the west of the country, but only - cases per year are reported, with - deaths on average every years. many other sites of infection are known and should be monitored, as some rodent species are highly susceptible to serving as effective amplifying reservoirs, whereas others maintain low-level infections for long periods of time, allowing much time to pass between outbreaks. environmental measures (rat-proofing, rodent and flea control, etc.,) are the first measures of control. surveillance, prompt diagnosis, and treatment with antibiotics (e.g., streptomycin and tetracycline) are recommended. yellow fever is the best known of the arboviral (arthropod-borne virus) diseases. there are some known arboviruses, of which about , produce disease in man. both the yellow fever virus and the primary mosquito vector, aedes aegypt, are of african origin -the species name, 'aegypti,' refers to classical africa in general, not, specifically, modern egypt. most cases in africa occur east to west along the transition zone (ecotone) between the savannas and the rain forests inhabited by numerous aedine vectors as well as a. aegypti. the disease has two cycles: a 'jungle' cycle involving various tree dwelling mosquitoes and nonhuman primates as reservoirs, and an 'urban' cycle, with a. aegypti as the vector and humans as reservoirs. the last reported major african outbreak vectored by a. aegypti occurred in nigeria and involved some , cases and over , deaths between and . yellow fever was introduced into the americas one or more times most likely during the age of sail: the virus can be transmitted vertically (transovarian passage) in a. aegypti. the mosquito' s eggs can easily be laid in water barrels and withstand desiccation for months, only to hatch and develop when submersed at a later date. epidemics of yf raged throughout the caribbean and tropical america until the end of the s, when the transmission cycle was elucidated by the team led by walter reed, confirming the role of a. aegypti which had been proposed by, but not confirmed by, carlos finlay. epidemics occurred as far north as philadelphia in the united states and the last epidemic in north america occurred in new orleans as late as , with over , deaths. cases (with - %) mortality continue to occur sporadically in brazil and in the foothills of several andean countries (bolivia, peru, ecuador, and colombia) . often the victims are young, indigenous males from the highlands who were temporarily working in the coca processing plants in the forests. these infected areas are only kilometers from large cities (with populations of more than million people) such as santa cruz, bolivia, which are accessible by public transportation and are heavily infested with a. aegypti. although the yf vaccine is one of the oldest, safest, and most effective available, and immunological protection is rated for at least years, vaccination coverage in many of the affected areas of africa and south america is low. the cholera pathogen, vibrio cholera, originally described by robert koch, was one of the first human pathogens (along with anthrax and tuberculosis) to be identified, in the late s, shortly after pasteur' s publication of the "germ theory." koch and his students studied material they collected in alexandria, egypt, during an outbreak. it was difficult to determine the origin of cholera and/or to distinguish it historically from other diarrhetic diseases except by the severity and rapidity of onset. health historians such as mcneill suggest an origin on the indian sub-continent, associated with dense populations, poor hygiene, and certain religious practices such as communal bathing; thus the term "asiatic cholera," by which the disease became known in europe in the s. the disease' s appearance in europe and the americas (london and new york in , and again in ) were clearly associated with intercontinental traffic. it was during the epidemic in london that a physician, john snow, noted the clustering of cases and deaths in people using the same water source, and proposed what turned out to be the correct action to stop the epidemic ("take the handle off the broad street pump!!"), although he had no idea of the actual cause of the disease. however, it was such observations, along with structural, hygienic, and administrative changes in major cities, particularly in europe and north america, that established the public health measures that we tend to take for granted in this early part of the st century. cholera is still with us: various serotypes of the vibrio have spread since the early s, affecting over countries in asia, in the americas, and into the west pacific. in , approximately , cases and , deaths from cholera were reported. in , the el tor strain of cholera was reported in lima, peru; by , almost a million cases had been reported in the western hemisphere. measles is one of the oldest known and most widespread infections of man: epidemics ascribed to measles appear in the oldest literature, although they are often confused with smallpox. however, in a.d., ad ahrun, a christian priest living in alexandria, egypt, described the pox lesion, and in a.d. the arab physician al-razi distinguished between the two diseases. prior to widespread immunization, measles was common in childhood-more than % of people were infected by age . although endemic in large communities, measles became epidemic every several years, with the severity of infection decreasing with the frequency of the epidemics. in his study of the history of plagues, mcneill makes mention of the importance of animal husbandry and zoonotic diseases in the area. measles, he claims is probably related to both rinderpest (in hoofed-mammals) and canine distemper. because dogs, sheep, and goats have been domesticated for at least , years, measles may have been among the first viral diseases to have "jumped the species barrier." as we will see, most, if not all, of the new pestilences are, or may be, derived from animal wild or domesticated reservoirs. measles was responsible for (or contributed to, along with smallpox) the decimation of the indigenous amerindian populations, first in central and south america at the time of the spanish conquest ( s), and later ( s and s), in north america. amerindian populations lacked immunological protection from these and other imported infectious diseases. some attribute this immunological naïveté to the comparatively small number of domesticated animal species-dogs, ducks and turkeys, guinea pigs, and cameloids (llamas and relatives) in the andes, and few, if any, in large number prior to the european invasion. in any case, the attack and mortality rates were staggering. by one estimate, a pre-conquest amerindian population of perhaps thirty million by was reduced by %, down to only million. this catastrophe occurred in less than years after the spanish entered the american mainland. influenza is another viral disease that has many unstable varieties infecting a host of mammalian and avian species, both wild (sylvatic) and domestic. epidemics with symptoms similar to modern influenza were noted by hippocrates as early as b.c., and later, in rome, by livy. various medieval and renaissance writings describe influenza-like illnesses. robert johnson of philadelphia is credited with the first "modern" description of an influenza epidemic, which occurred in that city in . his description was applied to subsequent epidemics in , , , - , and . antigenic shifts in the structure of the influenza virus may change the virulence of the strains, increasing the likelihood of epidemics. the most severe flu epidemic ever recorded ( ) ( ) -also known as the spanish flu (although it did not originate there)-first struck world war i troops of all combatant nations while in northern france, and it continued on to become a global pandemic. conservative estimates of mortality range between twenty and forty million persons, and other estimates more than double these figures. the ease with which the various influenza strains infect domestic mammals, pigs, and poultry (chickens and ducks) producing huge reservoirs of potentially infectious material, often proximate to human habitations, is a major public health concern. especially worrisome are the conditions under which millions of such animals are raised and brought to market. the 'old' diseases examined above are only a few of those which might be used as examples of the old pestilences: others might prefer to include schistosomiasis, typhus (murine and/or louse-borne), and several of the classic childhood diseases (diptheria, pertussis, tetanus, rubella), as well as leprosy, yaws, the leishmaniases, and, certainly, smallpox. fortunately many of those mentioned here (schisto and others) are being controlled rather well in some areas by vaccines, specific drugs, and/or antibiotics when applicable, at least in the more developed countries. even polio, which had been a major epidemic threat for centuries, has been virtually eliminated as a threat in areas where the politics and health infrastructure allow the efficient application of this very effective vaccine. much of the fear engendered by specific diseases depends on the time, place, and severity of the local outbreaks, as well as the knowledge and perception of the community. for example, i was raised in new orleans, in the southeast of the united states, during the s. although i and my brothers were normal, well nourished children, our parents were fearful of dogs (rabies), cuts on unshod feet (tetanus), and any summer colds or stiffness/weakness of the extremities (polio), and they preached cleanliness as a means to prevent anything bad happening. these diseases are old, but at present each has developed certain new characteristics that make their modern expression different from their historic ones, and decreases our ability to control them. in the last years, malaria parasites have developed resistance to chloroquine, the most common, globally used anti-malarial drug; at the same time, the anopheline mosquito vectors of malaria have progressively developed a parallel resistance to the insecticides used to control them. dengue, and dengue hemorrhagic fever (dhf), have spread globally, infecting vast new areas, especially urban areas where the human living conditions are substandard, but readily suited for vector breeding. finally, tuberculosis, whose incidence was slowly reduced in the late s and early s by improved public health, housing conditions, and nutrition, has again surfaced as a secondary infection to immuno-compromised persons, especially those suffering from hiv infections. at the same time, the causative agent, mycobacterium tuberculosis, continues to develop resistance to the most economic and readily available antibiotics. malaria is caused by blood parasites of the genus plasmodium and vectored by anopheline mosquitoes. there are four species of human malaria parasites: p. falciparum, p. malariae, p. vivax, and p. ovale, as well as a number of related species infecting other mammals (non-human primates, rodents, etc.). historians note that malaria-like symptoms were discussed in the chinese canon of medicine ( b.c.) and malaria-like illnesses were described in th -century b.c. cuneiform literature from nineveh (now part of iraq). hippocrates made a connection between stagnant water and fevers in the local population. it is estimated that there are still several hundred million unreported cases each year resulting in - million deaths per annum, mostly children. although malaria is still endemic in asia, latin america, and africa, % of the cases are found in africa, where p. falciparum is the most common malaria parasite. such huge figures mask the focal, and sometimes epidemic, nature of malaria, which may be brought about by natural or man-made environmental conditions. some of the human activities that may enhance malaria transmission may be development projects for agriculture (e.g., irrigation schemes), other water and land use projects (as in the amazon basin, converting forest areas through resource extraction such as mining and logging) into marginal livestock and farming areas. often such environmental changes bring about changes in malaria transmission from 'stable' (endemic) to 'unstable' (epidemic). in highly endemic areas, severe malaria and death is concentrated in the younger age groups, whereas in the areas of unstable (epidemic) transmission, severe malaria and death is more evenly distributed throughout all age groups. needless to say, prevention and /or case control strategies must be different for each transmission type. in many parts of the world the anopheline vectors of malaria have developed resistance to the insecticides used for their control. frequently, this is due to the use, often excessive, of the same or similar insecticides for control of agricultural pests in the same geographic areas. such resistance not only hinders control operations directly, but also indirectly, by increasing the need for greater quantities and/or more costly insecticides. broadscale usage of insecticides has also become limited on environmental grounds, because some donors have reduced funding insecticide purchases. by far the most serious setback to malaria control in recent decades has been the emergence and spread of chloroquine-resistant strains of p. falciparum, the causative agent of the most severe form of malaria, and the most common in africa. emerging in the s in southeast asia and south america, resistance spread rapidly from these focal points. it was not noted in africa until - but spread rapidly in the ensuing ten-fifteen years. chloroquine-resistant strains of p. vivax have been identified in some areas of southeast asia, new guinea, and indonesia. efforts to produce a malaria vaccine(s) have been under way for over years. a number of candidate vaccines have been produced, but none are operational in humans as yet. like yellow fever, described earlier, dengue and dengue hemorrhagic fever are vector-borne diseases transmitted (primarily but not exclusively) by the mosquito aedes aegypti. "classical" dengue is caused by infection with one of the four serotypes of the dengue virus. dhf may occur following a subsequent infection with a different serotype. the following quotation is from an article written by the author in (r. lennox and a. arata, dengue fever: an environmental plague for the new millennium. capsule report, environmental health project/usaid. pp.): with . billion people at risk and estimated cases in the tens of milllions, dengue is considered by many to be the second most important vector-borne disease in the world (surpassed only by malaria). classical dengue and its more lethal form, dengue hemorrhagic fever (dhf), now circle the world with endemic illness and continuing threats of epidemics. dengue is very much an environmental disease, affecting urban and periurban settlements in more than countries. it is characterized by seasonal outbreaks of illness carried by mosquitoes that thrive in household containers which collect water (such as flowerpots and washtubs) and in the detritus of human consumption, such as bottles, tin cans, and old bottles. children, specially in asia, are most frequently and seriously affected by the severe form of the infection, dhf. mosquito control is the only effective approach to prevention, although effective case management will reduce mortality. insecticides targeted at larval mosquitoes are effective, but resistance of mosquitoes to affordable and environmentally safe chemicals as well as declining will and infrastructure have all but eliminated this approach in most countries. vaccines are in the pipeline, but a system which could deliver them to half the world' s population is probably at least a decade away. community action-to protect containers from becoming havens for mosquito breeding and to dispose of empty containers and trash, along with surveillance and personal protection-is the best hope for transmission risk reduction. tuberculosis is another ancient disease that has bridged the old to new definition: the tb bacillus, mycobacterium tuberculosis, was among the first to be scientifically identified and described (by robert koch, in ). the disease is transmitted by airborne droplets from people with pulmonary or laryngeal tuberculosis. this mode of transmission is most effective in dense populations, and hence tb became widespread with the development of urban centers in the middle ages (europe), and was very common from the th century until recently in europe. with improvements in housing and nutrition tb rates continued to decline (except for periods of war) until the first half of the th century. at that time, two conditions emerged: the development of multiple drug resistant tb (mdrtb) and the emergence and spread of acquired immune deficiency syndrome (aids) upon which tb is an opportunistic infection. prior to , about % of tb bacilli isolated from patients in the u.s. were resistant to even one antibacterial drug: in , % were resistant to at least one drug, and % were resistant to more than one drug. in the u.s. the cost of treatment of ten cases of mdrtb in texas in was us$ , . who lists tb as one of the major causes of mortality in the world. a new major funding effort (who and world bank and various bilateral donor groups) is focusing on hiv/aids, tb, and malaria as the most serious, and intractable, causes of death. other forms of tb, including non-pulmonary cases and those associated with other species of mycobacterium sp. (e.g. m. bovis), are sporadic, but suggest the possible very early animal origin of the pathogen group. diseases such as chagas disease and schistosomiasis are examples of diseases that do not easily fit the epidemic definitions of a pestilence mentioned earlier in this chapter, but they do heavily impact the affected populations, not only through mortality rates, but especially through morbidity/disability. there are several forms of schistosomiasis caused by different species of schistosoma, a blood fluke (trematode)-this is an ancient illness, known from egyptian antiquity. infections occur in fresh water where people work and/or wash and children play. larval worms, known as cercaria, developed in a snail intermediate host, pass through the skin and penetrate diverse organs according to species. the most important effects are those that arise from chronic, and cumulative, infection. chagas disease has a very different etiology, mode of transmission, and pathology than does schistosomiasis. by definition it could be new because it was first described in by the brazilian carlos chagas, who subsequently described the pathogen, a flagellate protozoan, trypanosoma cruzi, and the vectors, bloodfeeding triatomine bugs. the disease is also know as american trypanosomiasis, and occurs only in the western hemisphere, from mexico to argentina-a few cases have been reported in north america. this form is very different from african trypanosomiasis (sleeping sickness). the initial (acute) phase of the disease usually occurs in children; there is then a long latent phase (∼ years or more), culminating later in life in a chronic phase which may include irreversible cardiac and/or intestinal manifestations and shortened life spans in the victims. paho and who consider chagas disease to be the most serious parasitic disease in latin america and the main cause of heart disease in the region. there is no adequate medical intervention. the infection can be transmitted by vectors, congenitally, or by transfusion of blood or blood products. an estimated million persons in the region are at risk, and in some countries (e.g., bolivia) % of the million inhabitants have been shown to be seropositive. in addition, in bolivia, one study demonstrated that the burden of chagas disease, in terms of disability adjusted life years (dalys), was million dalys, or estimated loss of million bolivianos: equal to more than million us dollars at the time of the report ( ). the purpose of this brief segment is to emphasize that pestilences need not carry with them only high mortality. very high morbidity and sustained disability with all the concurrent social and economic implications can be a tremendous burden on a population-or a nation. puerperal fever, a forgotten pestilence, is caused by a streptococcal infection and is an iatrogenic disease (induced by a physician) that was once the scourge of pregnant women, before physicians learned to wash their hands before examining pregnant women and/or assisting at childbirth. improved hygiene in hospitals was concurrent with the development of the germ theory and mortality rates dropped quickly. this disease, also called childbirth fever, was never reported as one of the great pestilences, however a few figures reveal the state of scientific knowledge regarding any infectious diseases, both endemic and epidemic. it is frightening that not only was the incidence of puerperal fever higher in the hospitals, but so was the associated mortality: % of the patients died if the disease occurred after a home delivery, but - % died if the disease was contracted in a hospital. although we have no crystal ball to predict what, if any, new pestilences are in store for mankind in the future, several groups of zoonotic viruses include likely candidates (table ) . also included is hiv/aids, truly a new pestilence that already, in a relatively brief period, has taken its place among the worst pestilences ever known to man. as mentioned above, there are over arboviruses isolated and characterized-about are capable of infecting humans, from nonapparent infections to very severe ones. two of these have already been mentioned above (dengue and dhf and yellow fever), but the arboviruses as a group represent the source of many potentially new diseases-or, put more correctly, existing zoonotic diseases that emerge when humans accidentally become involved in their cycles. a good example is the recent outbreak of west nile encephilitis in the u.s. in and , the virus was isolated from/around new york city from large numbers of dead birds (especially crows and jays): human cases and two deaths were confirmed. by , the disease moved west toward the mississippi river, infecting people and killing nine. in , there were over , cases ( fatal); by , the virus, and human cases, were found in all contiguous states (excepting alaska and hawaii). the virus has been found in mammals, birds, and mosquitoes throughout the u.s. but is this a new disease, or just a disease new to us? west nile virus has been found in over countries since its discovery in in uganda, and has been most of the above are mosquito-borne, and the major mosquito vector genera, culex, aedes, and anopheles, have global representatives from which a competent vector might be found. the same is true of ticks, sandflies, and other potential vectors. rodents, or other local vertebrates, may serve as reservoir hosts while infected migratory birds may provide distribution of the infection. although many arboviral infections have broadly similar transmission cycles, the ecology and dynamics of each may differ widely. arboviruses do not belong to a single viral family, but rather, to several,which increases their diversification. although the potential for increased arboviral epizootics or epidemics is high, the most recent episodes have not been high on the pestilence scale; rather, the most severe arboviral epidemics have been yf and dengue/dhf, the oldest of the group. the arenaviruses were thought for years to be monotypic, a single species, lymphocytic choriomeningitis (lcm), occurring primarily in the house mouse/ laboratory mouse, mus musculus. the virus (first described in ) has been isolated in numerous locations, but human disease is known only from europe and the americas. a second arenavirus was isolated from a phyllostomatid (fruit-eating) bat from trinidad, but there was no associated human disease. severe hemorrhagic cases in argentina and later in bolivia in the s and s resulted in the discovery of new viruses and diseases in these countries-junin virus/argentine hemorrhagic fever (ahf) and machupo virus/bolivian hemorrhagic fever (bhf). more recently, additional arenaviruses found in brazil (sabia virus) and venezuela (guanarito virus) produce similar hemorrhagic symptoms. ahf is the most common, - , recorded annually between and -the others are only sporadic, but mortality rates are high in all these diseases. in each of these, transmission is by contact with infected rodent excreta, dust, and other substances associated with grain harvesting and storage. there are another five arenaviruses in the americas that are not known to cause any illness in humans or their rodent hosts. all of the rodents associated with these viruses belong to only one of the rodent families currently inhabiting south america. these rodent genera (calomys, sigmodon, oryzomys, et al) , are very closely related, and share a common ancestry. paleontological evidence indicates that the isthmus of panama was a bridge connecting north and south america more than - million years ago, allowing a faunal interchange. the sigmodont rodent progenitors entered south america at that time, and rapidly evolved into the modern genera and species. presumably the "ancestor virus" tagged along, co-evolving into the situation that now exists. by far the most important arenaviral disease is lassa fever: discovered in nigeria in , it is known from african countries, mostly in west and central africa, but also zimbabwe and mozambique. the natural host of lassa virus is the multi-mammate rat, mastomys natalensis, one of the most common and widely distributed african field rats. like their south american counterparts, the ahf and bhf hosts, mastomys, is basically a grassland species, easily adapting to the man-made grasslands of maize, sorghum, millet, sugarcane, and other cultivated grasses. cases of lassa are generally associated with agricultural activities and food storage: transmission is by contact with excreta of infected rodents. without laboratory facilities for confirmation, it is difficult to distinguish lassa fever from ebola, yf, or even severe cases of malaria. there are an estimated , cases a year, with more than % mortality rate in hospitalized cases. the disease is more severe in pregnancy, with fetal mortality reported at more than %. in the early s (and before ebola outbreaks occurred), lassa caused great consternation in europe and the americas over the possibility of introduction of this disease. these concerns still exist and have been heightened after the appearance of these other groups of viral hemorrhagic diseases. the hantaviruses are comprised of two large groups of viruses, all transmitted by rodents and producing a range of hemorrhagic, renal, and/or pulmonary complications. the old world hantaviruses are comprised of over different viruses, several known for some time under a different classification (e.g., hanta virus is the cause of korean hemorrhagic fever with renal syndrome, an important military disease in the s). most cases still occur in agrarian and military populations and occur in over countries in asia, africa, and europe: each year approximately , cases occcur in eurasia, with more than % of these reported in china. case fatalities range from . % to . % depending on the virus. the or so new world hantaviruses produce a pulmonary, rather than a renal, syndrome. since being described as a group in , approximately , cases have been reported in the americas, with a high case fatality rate ( - %). the natural hosts/reservoirs for the hantavirus groups are mostly muroid rodents (old world group), and cricetid rodents (new world group). this is not surprising, as these two are amongst the largest and most widely distributed mammalian families. however, the manner and zones of transmission are similarrodent contamination of grain crops in the field and storage where people come in contact with rodent excreta. the two closely related filoviruses (marburg and ebola) are among the most virulent viruses yet described with an overall fatality rate of more than %, and higher in several outbreaks (possibly augmented by use of dirty syringes and needles to give injectable chloroquine (an anti-malarial drug) to the patient' s friends who carried him/her to the hospital. marburg virus was first described ( ) among monkeys sent from east africa to european laboratories, there killing laboratory technicians. subsequent outbreaks have occurred in africa. ebola virus appeared in in simultaneous outbreaks in zaire (democratic republic of congo). (barry, ) one ebola strain was implicated in an outbreak in an animal holding facility in reston, virginia, u.s.a. several humans seroconverted but showed no disease symptoms. the repeated outbreaks of ebola and marburg virus, mostly in central africa, have been described as commencing with "rapidity and devastation." during an epidemic, transmission is generally by contact with contaminated blood or other tissues from infected persons. most outbreaks have been in rather remote areas with poor health care facilities, so that patients are seen only with advanced symptoms. we have not been able to find reservoir organisms (there have been subsequent, better equipped expeditions than the one described in the footnote, but none have been successful), nor do we know the mechanism(s) of transmission in the wild. one distinct ebola virus strain from ivory coast was isolated from a chimpanzee: primates are hunted and eaten by humans in parts of africa and this may serve as the 'link' at which the virus(es) are able to "cross the species barrier" and enter the human population. (barry, ) the government of sudan requested who assistance, and the government of zaire requested the same from the u.s. government (cdc). representatives of who and cdc met in the next few days at the london school of hygiene and tropical medicine to work out details and coordination (who was represented by dr. paul bres and the author, and cdc by dr. karl johnson). we had all thought of lassa and marburg viral fevers, and were surprised when dr. johnson said it was neither: he then showed us electron photomicrographs of tissue taken from an early case-the stringlike " and " figures were just like marburg. but, he explained, this one was serologically distinct from marburg, and they proposed to name it after a river in the area, the 'ebola'. we agreed that i (aaa) and a virologist (dr. bruce johnson) from the lshtm would go to the site in sudan to sample potential reservoirs and/or vectors. bruce would bring the supplies needed for taking tissue samples and the liquid nitrogen containers needed to return the samples to the uk. i was to gather the animal collecting materials. who had no such equipment in geneva, of course, so i borrowed 'mist' nets for collecting bats from the british musum (natural history) and the museé d' histoire naturelle in geneva and borrowed sample rodent traps from the swiss agricultural research station in nyon, near geneva. we had the traps made in nzara, one of the sites of the outbreak in sudan. to autoclave the dissecting instruments we purchased two household 'pressure cookers' at the local super market (migros) in geneva. placed on stones over an open fire, they served well. an experimental ebola vaccine has been reported to be successful in trials with non-human primates. human trials will be conducted soon. two previously unknown and unrelated human viral infections, severe acute respiratory syndrome (sars) and an asian avian influenza (strain h n ), originating in southeast asia, have received a great deal of popular attention and public health concern. in november , cases of a respiratory illness, subsequently labeled sars, appeared in china. a delay in timely reporting of the initial cases allowed it to spread to other southeast asian countries, australia, the americas, and at least european countries. reports of the actual number of persons infected varied, but cases numbered in the thousands, and mortality rates of up to % were indicated. surveys of wild animals captured for human consumption quickly showed that ferrets, civets (related to mongooses), and raccoon dogs (shaggy fox-like carnivores) were positive for harboring the virus, but it is not known if any of these are the true reservoir in nature. the who has reported that the chain of transmission may have been broken (no new cases reported in a period of time equal to two consecutive day incubation periods). this is clearly a case of a virus "species jumping". in the world' s largest, most densely populated country this could spell disaster, especially if the reporting network is compromised. the asian avian influenza strain initially appeared in poultry in hong kong in , when it jumped the species barrier and killed out of infected persons. this recent outbreak spread to korea (december, ) , then japan and vietnam (january ). hong kong reportedly slaughtered . million chickens and ducks, and as many as three million slaughtered through the southeast asia region, but other reports indicate that there are nonspecific wild variants of this strain in wild birds that serve as natural reservoirs. of major concern is that outbreaks of highly pathogenic avian influenza are increasing in frequency and severity. reportedly, in the years from to , there were only outbreaks, but in the past six years, from to , there have been six, not including the most recent incidents. if bubonic plague was the quintessential pestilence of the ancient and medieval worlds, acquired immunodeficiency syndrome, caused by the human immunodeficiency virus (aids/hiv) is the chief pestilence of the modern world; and it is still growing, not receding. there is also a vast literature that will not be reviewed here, but the following data points describe the severity of the pandemic pestilence: r aids is gaining a firmer foothold in the large populations of india and china; r world wide, million people are infected with hiv; r - million of these infected people live in sub-saharan africa; r million persons became infected this year, , are children; r million persons died of aids this year, , of them less than years old; r existence of simian immunodeficiency virus (siv) suggests animal origin. the social damage accompanying this pandemic is not reflected in the bare figures given above; especially the orphaned children, destroyed family structures, and so forth. it has been estimated that billion dollars us, per annum, is required to provide the prevention and treatment facilities and services needed: to date, less than one-half ($ . billion per annum) has been made available. some of the old category diseases are still strongly with us (e.g., malaria, tb, influenza), and, by adapting traits such as drug-resistance and crossing or jumping species, they expand their reservoir-host base. as such, they could be considered new. some other old diseases are rather well controlled in the developed countries where the surveillance systems are efficient and vaccination and other preventive services are readily available and properly used. these would include smallpox (eradicated), polio (eradicated in some areas), and childhood illnesses such as pertussis, diptheria, tetanus, measles, and so on. even bubonic plague could be characterized as being under control-it is widespread, but also well understood, and with vector control and appropriate antibiotics, outbreaks are not severe and mortality is low. on the other hand, some of the new (most recently discovered) diseases like ebola and hiv/aids are hard to handle. we know little about the natural history of ebola, lassa, or the south american hemorrhagic fevers, and our knowledge of hiv/aids in the laboratory probably exceeds our understanding of the socioeconomic impacts it is having on whole cultures. when lassa virus "jumped" from the field rat, mastomys, to humans it was dreadfully virulent, and it seemed to come from nowhere. but, after a few years, we know that (with one exception from a bat) all arenaviruses are well adapted to particular rodent groups; most rodents are grass eaters, and lots of crops are grasses (wheat, maize, sugarcane, rice, etc.); therefore, the arenaviral fevers are seen primarily in agricultural settings and with stored grain. yet, for the more recently known hantavirus group, or even less with the multiferous arboviruses, we do not have good data on ecological determinents, or even host-reservoir relationships. at the same time, people are modifying environmental conditions rapidly and extensively, and we have little information indicating whether such changes will eliminate potential disease cycles or exacerbate them. this may be even more important for diseases like influenza. if they have obligate or opportunistic vertebrate hosts and these are coincidentily reduced in number or eliminated, what selection pressures are set in action on the virus population to select new hosts? and when it comes to modifying environments, man has no equal. yet we know that this microbial evolution is going on at a rapid pace-just look at how fast drug-resistance develops and spreads! in reading articles and researching references for this document, i was amazed to discover again how many human illnesses have their direct animal (zoonotic) counterparts, or were vectored/hosted by arthropods, rodents, or snails, and how an avian influenza can become a mammalian influenza very quickly, and how a bat or an oppossum can do the same for the chagas disease trypanosome. it is in this context that i feel that we know very little of the natural history or the ecological dynamics of the disease transmission cycles we teach. especially disturbing is to read of a new strain of asian avian influenza and the necessity, around the world, to kill millions of birds. if one was to dream up a model pathogen incubator and dissemination engine, the perfect model would be a modern chicken farm of , birds, defecating as birds do, and that at a constant temperature and with residues of organic chicken feed all about. and we wonder why new diseases emerge? any farmer worth his/her salt knows that monoculture breeds pests. this is a good place to bring up one other difficult subject-bioterrorism. it is difficult for one dedicated to public health principles to imagine why anyone would even consider using infectious diseases as a weapon, but it is being done, and we need to be able to distinguish between a natural epidemic and one orchestrated by man. again, knowledge of the natural history of the organisms, their natural hosts and reservoirs, will help. already the u.s.a. is stockpiling smallpox and anthrax vaccines in large quantities. one final point; most people concerned with new versus old pestilences work as epidemiologists, infectious disease specialists, hospital officials, and so forth. but public health work is broader than the study and treatment of infectious diseases, and the study the global burden of disease, sponsored by the who, world bank, and harvard university, based on measuring dalys, predicts that fewer infectious disease will be as important in the future as they are at present. for example, "the next two decades will see dramatic changes in the health needs of the world' s populations, and non-communicable diseases such as depression and heart disease . . . are replacing the traditional enemies, such as infectious diseases and malnutrition." maybe toxic smog and non-communicable diseases will replace pestilences, both old and new! the great influenza control of communicable diseases manual exotic viral diseases death by migration plague: an ancient disease in the twentieth century (rev emerging infections plagues and people the global burden of disease the doctor's plague viruses, plagues, and history emerging infectious diseases (vol. - ). www.cdc.gov/eid or hard copy from cdc key: cord- -dbdtpojs authors: thompson, mark g.; sokolow, leslie z.; almendares, olivia; openo, kyle; farley, monica m.; meek, james; ray, julie; kirley, pamala daily; reingold, arthur; aragon, deborah; hancock, emily; baumbach, joan; schaffner, william; lynfield, ruth; ryan, pat; monroe, maya; cheng, po-yung; fry, alicia m.; shay, david k. title: effectiveness of nonadjuvanted monovalent influenza a(h n )pdm vaccines for preventing reverse transcription polymerase chain reaction–confirmed pandemic influenza hospitalizations: case-control study of children and adults at us influenza surveillance network sites date: - - journal: clin infect dis doi: . /cid/cit sha: doc_id: cord_uid: dbdtpojs during – , we examined patients hospitalized with laboratory-confirmed pandemic influenza in influenza hospitalization surveillance network sites and age- and community-matched controls and found that a single dose of monovalent nonadjuvanted influenza a(h n )pdm vaccine was % ( % confidence interval, %– %) effective in preventing hospitalization associated with a(h n )pdm virus infection. during - , we examined patients hospitalized with laboratory-confirmed pandemic influenza in influenza hospitalization surveillance network sites and ageand community-matched controls and found that a single dose of monovalent nonadjuvanted influenza a(h n )pdm vaccine was % ( % confidence interval, %- %) effective in preventing hospitalization associated with a(h n ) pdm virus infection. keywords. influenza; influenza vaccines; vaccine effectiveness; hospitalization; pandemic/prevention & control. the influenza a(h n ) pandemic, which began in and continued into , resulted in increased hospitalizations in the united states and globally [ , ] . a recent review reported that monovalent a(h n )pdm vaccines were % effective in preventing medically attended influenza during the pandemic [ ] . studies focused specifically on hospitalization have reported estimates of vaccine effectiveness (ve) that ranged from % to % [ ] [ ] [ ] [ ] ; however, to date, no estimate of ve against these outcomes in the united states has been published. we identified patients with community-acquired, laboratoryconfirmed a(h n )pdm infections through the influenza hospitalization surveillance network (flusurv-net) within the centers for disease control and prevention's (cdc) emerging infections program. flusurv-net conducts populationbased surveillance of influenza-associated hospitalizations among children and adults from select counties in states (california, colorado, connecticut, georgia, maryland, minnesota, new mexico, oregon, tennessee) that represent approximately . % of the us population [ , ] . although a(h n ) pdm vaccine was initially only available to priority groups [ ] , enrollment for this study started after vaccine became available to the general population and at least % of the local population was estimated to be vaccinated (november-december ; supplementary figure) . cases were patients aged > months residing in a flusurv-net catchment area who tested positive for a(h n )pdm influenza by reverse transcription polymerase chain reaction (rt-pcr) assay from respiratory specimens collected shortly before ( %) or upon ( %) admission to the hospital for an acute respiratory illness; % of specimens were collected within days of illness onset. patients in longterm care facilities and those with nosocomial infections were not enrolled. for each rt-pcr-confirmed hospitalized influenza case, community controls matched by age group and county of residence were enrolled. persons who had not been hospitalized for a respiratory illness from october until the hospital admission date of a corresponding case were eligible for enrollment. control children were matched on differing age bands depending on age (children aged - months were matched ± weeks of the case's birth; those aged - months were matched ± months of the case's birth; children aged - years were matched in -or -year age bands, ie, - years, - years, - years, and - years; and adults were matched in -year age bands, with the exception of a single - years age band). controls were recruited from individuals identified through birth certificate registries (for children aged < years) or lists of random landline telephone numbers (for those aged ≥ years). structured telephone interviews (forms available upon request) were conducted with cases after hospital discharge and their matched controls; guardians were interviewed for participants aged < years. participant characteristics, vaccination status and date, and the presence of medical conditions associated with increased risk of influenza complications [ ] were collected from telephone interviews, from reviews of medical records at primary care providers, and through review of hospital records for hospitalized cases. receipt of at least dose of vaccine was documented by medical record or by self-report (if date and location of vaccination could be provided). high-risk conditions and vaccination status were documented by self-report only for the % of cases and % of controls for whom medical records were unavailable. immunization was defined as receipt of any monovalent a (h n )pdm vaccine ≥ days before illness onset for the case; for matched controls, the illness onset date of their corresponding case was used. ve was estimated as % × ( odds ratio [ratio of odds of being immunized among the cases to the odds of being immunized among the controls]) using conditional logistic regression models. the following covariates in our adjusted models were similar to those used in other recent pandemic ve studies [ , , ] : age, race, ethnicity, region, highrisk medical condition, and month of index-case illness onset. other covariates were considered for inclusion in the model as confounders if they were related to both vaccination and influenza status or if they affected the ve point estimate by > %. we estimated that cases were needed to achieve % power (α = . ) to detect a ve of % with controls per case and a vaccination rate of % among controls. each participating site submitted a protocol for evaluation by their state institutional review board (irb), and irb approval was obtained if required. april , a total of hospitalized patients with rt-pcr-confirmed a(h n )pdm infection were identified as potential study cases; pediatric and adult patients were excluded either because they did not give consent (n = ) or because vaccination status could not be confirmed (n = ). enrolled cases were similar to all eligible cases with respect to age and onset month (data not shown). only matched control was enrolled for % of the cases ( of ). compared with community controls, hospitalized influenza cases were more likely to be non-white, hispanic, and unmarried; have less education and lower incomes; lack private healthcare insurance; be obese; and have high-risk medical conditions (table ) . among cases, the proportion immunized differed by age; among controls, hispanics and those with a high-risk medical condition were more likely to be immunized; no other significant association between participant characteristics and immunization status was observed. among hospitalized influenza cases, % were immunized compared to % immunized among community controls. the crude ve against a(h n )pdm for prevention of hospitalization was % ( % confidence interval [ci], %- %) for all ages. the ve adjusted for age, race, ethnicity, region, high-risk respiratory condition, and month of index case illness onset was % ( %- %). potential confounding was observed for education, insurance status, and presence of a nonpulmonary high-risk medical condition. adding these to the multivariate model resulted in a fully adjusted ve of % ( % ci, %- %). hispanic ethnicity, lower education, lack of healthcare insurance, and pulmonary and nonpulmonary high-risk medical conditions were all statistically significant contributors in the final multivariate model (data not shown). in secondary stratified analyses, the adjusted ve for those with or more high-risk medical condition was % ( % ci, %- %), and the ve point estimate for those without a high-risk condition was similar at % ( % ci, − % to %), although confidence intervals were wide given the small number of cases without a high-risk condition. in sensitivity analyses, ve estimates were unchanged when those vaccinated - days prior to the illness onset of the index case were considered immunized. we estimated that during the winter wave of the influenza a(h n )pdm pandemic in the united states, a single dose of monovalent nonadjuvanted a(h n )pdm vaccine was % ( % ci, %- %) effective in preventing hospitalization associated with a(h n )pdm virus infection. this finding is similar to the adjusted ve of % ( %- %) against medically attended a(h n )pdm influenza reported by a us study with the same vaccine options in which % of the cases were hospitalized [ ] . our ve point estimate of % was consistent with ve estimates in an australian study of hospitalization and unadjuvanted pandemic vaccine that used a test-negative control design (ve = %; % ci, %- %) [ ] , but was substantially lower than the inpatient ve reported by a european study of adjuvanted pandemic vaccine that used a test-negative control design (ve = %; % ci, %- %) [ ] . the strengths of this study include case ascertainment through population-based surveillance and confirmation of abbreviations: bmi, body mass index; ca, california; co, colorado; ct, connecticut; ga, georgia; md, maryland; mn, minnesota; nm, new mexico; ns, not statistically significant (p > . ); or, oregon; tn, tennessee. a two controls who had not been hospitalized for a respiratory illness since october were recruited matched by age and community. for cases aged - months, controls were within plus or minus (±) weeks of the case's age at illness onset; for cases aged - months, controls were ± months of the case's age. potential controls for cases aged < years were selected at random from birth certificate registries and matched to the case's zip code. for cases aged > years, controls were within ± years of the case's age, resided in the case's county, and were contacted from a telephone sampling list generated by survey sampling international (shelton, connecticut). b pearson χ test was used to assess differences between cases and controls in the distribution of participant characteristics. c pearson χ test was used to assess differences between participant characteristic groups (rows) in the percentage vaccinated; differences in vaccination by participant characteristics were tested separately with cases and then controls. d characteristic describes interviewed parent/caregiver when participant is aged < years. e high-risk respiratory conditions included lung disease and asthma as indicated by self-report of physician diagnosis and/or a medical encounter with international classification of disease (icd- ) codes available upon request. other high-risk medical conditions were indicated by self-report of physician diagnosis and/or or more medical visits for a condition associated with increased risk of influenza complications, including cancer, diabetes, and neurological disorders as well as heart, immune, and kidney disease (icd codes available upon request). medical conditions were determined by self-report for % of cases and % of controls with missing or unavailable medical records. f vaccination is defined as receipt of at least dose of vaccine documented by medical record or self-report (if date and location were also provided); immunization is defined as receipt of any a(h n )pdm vaccine ≥ days before illness onset of the case or index case if a matched control. the difference between the number vaccinated and the number immunized reflects the fact that cases and controls were vaccinated after the illness onset date (of the index case) and cases and controls were vaccinated - days before the illness onset date. vaccination status and dates were determined by self-report for % of cases and % of controls with missing or unavailable medical records. influenza by rt-pcr. the study addresses a gap in knowledge regarding ve against serious influenza complications during the pandemic and the ve of nonadjuvanted vaccines, which may have fewer local and systemic reactions but can be less immunogenic in some populations [ ] . our study also has limitations. first, cases and matched controls differed on multiple characteristics. although adjusting for potential confounders increased the ve point estimate from % to %, residual or unmeasured confounding may have biased our results in unknown ways. second, our limited sample size resulted in ve estimates with wide confidence intervals and precluded stratification by age or consideration of site differences in a mixed-effects model. third, our findings may have been influenced by information and selection biases, as only residents with telephone landlines could be enrolled as controls (for those aged ≥ years) and medical history was incomplete for one-third of cases and controls. because the proportion with missing information was similar for cases and controls, we do not expect this was a significant source of bias, but bias could have been introduced if the likelihood of recalling vaccination differed for cases vs controls with only selfreport data. fourth, information on vaccine type (inactivated vs live attenuated) and on receipt of a second recommended dose (among children aged < years) was not available for every subject, which likely resulted in underestimation of ve, as other studies found that ve improved after accounting for these differences [ ] . finally, similar to other ve estimates [ , , ] , we lacked information on medical utilization or possible infections during earlier waves of the pandemic. natural immunity acquired from infection prior to the availability of vaccine would lead to over-or underestimating ve if those immune were more or less likely to be vaccinated, respectively. in conclusion, our results suggest that a single dose of monovalent nonadjuvanted a(h n )pdm vaccine prevented onehalf of the potential hospitalizations associated with a(h n ) pdm virus infection. this finding from the flusurv-net, which serves geographically and economically diverse communities across the united states, confirms previous reports of the preventive benefit of the vaccine [ , ] and adds to the evidence indicating that influenza vaccines have the potential to prevent a substantial proportion of influenza-associated hospitalizations [ ] . increase in rates of hospitalization due to laboratory-confirmed influenza among children and adults during the - influenza pandemic epidemiology of pandemic influenza a (h n ) in the united states efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis estimating the effect of influenza vaccines and pandemic vaccines, to prevent influenza hospitalizations during the autumn influenza pandemic wave in castellon, spain. a test-negative, hospital-based, case-control study effectiveness of h n / monovalent and trivalent influenza vaccines against hospitalization with laboratory-confirmed h n / influenza in australia: a test-negative case control study adult hospitalizations for laboratory-positive influenza during the effectiveness of non-adjuvanted pandemic influenza a vaccines for preventing pandemic influenza acute respiratory illness visits in u.s. communities prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices (acip) immunogenicity and safety of as -adjuvanted influenza a h n vaccine in children - months effectiveness of dose of influenza a (h n ) monovalent vaccines in preventing reverse-transcription polymerase chain reaction-confirmed h n infection among school-aged children in maine effectiveness of seasonal vaccine in preventing confirmed influenza-associated hospitalizations in community dwelling older adults disclaimer. the findings and conclusions in this report are those of the authors and do not necessarily represent the views of the cdc.potential conflicts of interest. w. s. serves as a consultant for pfizer, inc, and dynavax technologies; has received an honorarium from sanofi pasteur; and is a member of the advisory board for the data safety monitoring board for merck & co, inc. r. l. has received royalties from a book chapter published by blackwell-wiley and travel expenses partially paid by the global pertussis initiative (parexel international). all other authors report no potential conflicts.all authors have submitted the icmje form for disclosure of potential conflicts of interest. conflicts that the editors consider relevant to the content of the manuscript have been disclosed. key: cord- -r tl kq authors: nan title: dublin pathology . th joint meeting of the british division of the international academy of pathology and the pathological society of great britain & ireland date: - - journal: j pathol doi: . /path. sha: doc_id: cord_uid: r tl kq nan the christie nhs foundation trust, manchester, uk one controversy in preparing the rcpath "dataset for tumours of the urinary collecting system [ nd edition])", april was which who grading scheme ( or ) to use for urothelial carcinoma. since there is a split within grade ( ) between low grade & high grade, use of both schemes in parallel was recommended. this has the advantage of better indicating where a particular patient lies in the grading continuum & minimises the consequences of 'grading error' for cases close to the threshold between low & high grade in the scheme, (a critical distinction for management if who grading is used in isolation). the nice guidance on bladder cancer (http://www.nice.org.uk/guidance/ ng ) incorporates risk stratification tables for ta/t bladder cancer utilizing this parallel who grading recommendation in a multiparameter formula that also considers tumour size, pt classification and the presence/absence of cis or aggressive subtype(s). amongst the more aggressive bladder cancer subtypes is invasive micropapillary urothelial carcinoma and the nested variant. a bladder origin can be difficult to recognise at metastatic sites, especially for micropapillary and discohesive/plasmacytoid subtypes. uroplakin ii has recently become available, is more sensitive than uroplakin iii & may assist within a panel. spindle cell lesions of the bladder are often difficult & loss of cytokeratin expression is common in sarcomatoid carcinoma. there is potential to mistake inflammatory myofibroblastic tumour for a malignant tumour. two molecular pathways for bladder cancer are recognised. fgfr at p is the most frequently mutated oncogene in bladder cancer & is prevalent in low grade papillary tumours. p loss of function mutations and loss of rb are prevalent in cis. no prognostic molecular test is currently validated for clinical use in bladder cancer, though some (e.g. fish) are in use as an adjunct in diagnosis. indiana university school of medicine, indianapolis, usa some dogmas in testicular pathology do not hold up to scrutiny. the belief that all pure, postpubertal teratomas are malignant is invalid. within this group there is a small subset that is benign; these may be divided into dermoid and non-dermoid types that, however, share features that distinguish them from the usual teratoma of adults. these include absence of: atypia, regressive parenchymal changes, intratubular germ cell neoplasia, and i( p). also they usually show organoid arrangements, and prominence of ciliated epithelium, squamous cysts and smooth muscle. patients do not need further intervention beyond excision sufficient to establish the diagnosis. cases often interpreted as isolated testicular polyarteritis nodosa because of the presence of fibrinoid vascular necrosis are mostly attributable to chronic, intermittent torsion. they usually present as pain-associated, palpable or ultrasound-detected masses, with the "mass" corresponding to infarct and/or hemorrhage. there are associated chronic vascular changes, with frequent marked intimal hyperplasia of arteries, mural fibrosis of veins, dilated venules and arteriolar hyalinization, consistent with torsion-induced venous outflow obstruction and secondary arterial hypertension. these patients do not develop systemic vasculitis on follow-up. many "sarcomas" in patients with germ cell tumours, especially after chemotherapy, are more correctly regarded as sarcomatoid yolk sac tumours. they are reactive for cytokeratin and glypican . they often show characteristic features: nodular growth, myxoid and fibrous stroma, spindled and epithelioid cells, abrupt changes in cellularity, and tumor "ringlets." most are high grade and aggressive. most regressed germ cell tumours can be recognized through a combination of findings, although the only diagnostic ones are a scar with coarse intratubular calcifications or with intratubular germ cell neoplasia. alcohol consumption has doubled in ireland and the uk in the last years. the causes of this increase include increased affordability of alcohol and its widespread availability. as a consequence, the health harms associated with alcohol have dramatically increased. binge drinking and alcohol consumption among by women have risen especially dramatically. for example, the mortality from cirrhosis has doubled in the last years in both men and women. in response to this, the medical profession on both islands have led informal and later formal campaigns to encourage policy change regarding alcohol at a national level. in ireland, this was driven by rcpi. the involvement of the medical profession has had a powerful influence, as doctors do not have a conflict of interest in this matter, in contrast to the alcohol industry. the policy changes advocated include particularly minimum unit pricing (mup), which has been shown to be effective in reducing alcohol consumption, alcohol-related admission to hospital and crime in canada. modelling of the data suggests it would have similar benefits in uk and ireland. this is regarded as the single most important first step. other steps which will help include actions around alcohol labelling, availability and breaking the link between alcohol and sports and leisure promotion. turning off the tap of cheap alcohol will hopefully soon reduce alcohol health harms in uk and ireland  barrett's oesophagus: an evolving challenge for the gastroenterologist p dot o'toole cost-effective surveillance programmes for barrett's oesophagus (bo) needs to be focused at risk groups. it is not only a question of identifying more individuals with bo (initial screening) but screening and subsequent surveillance has to identify at-risk individuals with bo who can benefit most from surveillance or therapy. advances in endoscopic imaging (high resolution endoscopy ([hre] with dye-based chromoendoscopy, electronic chromoendoscopy, and autofluorescence,...) certainly prove beneficial in better detecting dysplasia within known bo and can guide sampling and subsequent therapy. dysplasia can be patchy and easily missed during routine biopsy sampling of bo and adequate training with high resolution instruments is needed to increase detection rates. once dysplasia is detected, endoscopic ablation is recommended. until recently, the standard treatment for hgd was oesophagectomy but endoscopic resection and ablation techniques are now available to eradicate dysplasia and mucosal adenocarcinomas. resecting visible lesions (using endoscopic mucosal resection [emr] or endoscopic submucosal dissection techniques) allows full pathological t staging. when invasive cancer is eliminated at multidisciplinary review (i.e., purely mucosal neoplasia confirmed with a nodal risk < %), further endotherapy to ablate residual metaplasia in bo can be performed using radiofrequency ablation (raf). in a tertiary centre use of staging emr is frequently necessary (> %) in patients referred for endotherapy and expert endoscopy is required to ensure safe and complete oncological resection. conversely pt submucosal cancers detected following emr are confidently triaged for oesophagectomy. combination of emr and rfa in expert groups exceeds > % for eradication of neoplasia and metaplasia. adverse events are quite low (stricture form healing, %; self-limited haemorrhage, very rare perforations ...) and recurrence of bo is also low (< % at years). careful follow-up endoscopies is necessary at to months initially; intervals theerafter probably yearly.  the pathologist's role in the diagnosis and management of neoplasia in barrett's oesophagus p c muldoon st. james's hospital, dublin, ireland the last decade has seen a revolution in the management of neoplasia in barrett's oesophagus. more detailed biopsy protocols, along with the advent of sophisticated local resection and ablation techniques, have radically altered the management of this expanding cohort of patients. these new treatment modalities, coupled with a massive increase in the numbers of cases of barrett's being diagnosed, have significantly altered the demands placed upon pathologists involved in this area. these changes have presented pathologists with an opportunity to challenge our existing practices, to improve the reproducibility of our analysis and to increase the clinical relevance of the way in which we report neoplasia in this setting, where the pathologist plays a critical role in the multidisciplinary management approach. this talk aims to outline a practical approach to the handling of these specimens and to provide clear guidelines as to how to report them in the most clinically useful way.  modern management in ibd p mwr vieth ; h neumann klinikum bayreuth, pathology, bayreuth, germany; university hospital erlangen, medical clinic i, erlangen, germany ulcerative colitis and crohn's make a distinct histological picture. around % of an ibd diagnosis is the clinical information and about % derives from histology, only. for routine purposes it is recommendable in case of a first manifestation of an ibd to make a diagnosis such as: "picture of ulcerative colitis or picture of crohn's disease" and to recommend a follow-up endoscopy with biopsies not prior to weeks after the first endoscopy and than confirm the diagnosis later to exclude mimickers of ibd. in crohn's disease it is helpful to take biopsies from the upper gi-tract to get further hints of crohn's disease. in case of neoplasia, the guidelines leave some room for local endoscopic treatment of low grade dysplasia whereas high grade dysplasia is still seen as an indication for operation since there is a high probability of detecting a carcinoma in the operation specimen afterwards. operation means on normal complete proctocolectomy. this has been indivdually questioned in the last time. there are exceptions for discussing the indication of an operation in ibd: cases with numerous pseudopolyps that cannot be searched for neoplasia, low grade lesions that cannot be completely removed, multiple neoplastic lesions and unresponsiveness to medical treatment.operation and endoscopic specimen in ibd need a subtile search for neoplastic lesions. a microscope with reverse light may help to identify suspicous lesions and may help to decide where exactely to cut a specimen. in conclusion a tight cooperation between clinical and histopathological partners is recommended to reach a high standard for patient care. second opinions may help to achieve and fuel the own learning process esp. in an institution with a lower number of ibd patients during the year. colorectal or bowel cancer screening (bcs) is commonplace and organised national screening programmes have been developed in many countries, most notably in western europe. traditionally, faecal occult blood (fob) detection has been the screening method of choice, those testing positive being selected for subsequent colonoscopy, but this is changing, with alternative or additional screening tests gaining favour. most of the problems in bcs pathology practice are particularly related to fob-based screening programmes, as these are enriched for large, bleeding sigmoid adenomas, in comparison to programmes utilising endoscopy as the primary screening modality. experience within the closely related uk bcs programmes to date has yielded several recurring problems: the diagnosis of stage pt or 'polyp' cancers, in particular distinguishing common epithelial misplacement from 'true' invasion; the management of stage pt cancers, in relation to indications for surgical intervention after such a diagnosis; and the minimum criteria for a biopsy diagnosis of colorectal adenocarcinoma. these issues will be discussed with illustrative examples, along with the somewhat more mundane but highly important practical issue of measuring various parameters related to bcs pathology. the importance of quality assurance measures to ensure high standards within bcs pathology is emphasised. with the introduction of colorectal cancer screening in various countries of the eu there is a sharp increase in the incidence of early colorectal cancer. a significant part of these early tumours presents in a pedunculated polyp. in most cases, these carcinomas are already completely removed by polypectomy. classic risk factors that suggest a high risk for lymph node metastases include haggitt level , positive resection margins, poor differentiation and lymphatic or vascular invasion. however, the evidence is rather thin. most pt studies are performed on sessile polyps. risk factors are more firmly established and include differentiation grade, lymphatic invasion, kikuchi level sm or the presence of budding. however, for a clinical useful decision model, we will need an integrated approach, and both specificity and sensitivity of the various factors should be taken into account. radical surgery seems overtreatment for a large number of polyp cancers. leeds university, leeds, uk minimum datasets have changed cancer reporting. this talk will explain the decision making processes behind the latest datasets both for cancer reporting and bowel cancer screening. it will also look at where we may be going in the future for staging and molecular reporting. the intestines play host to a broad spectrum of infective organisms ranging from viruses, through bacteria , fungi and unicellular parasites to worms. the spectrum of infections seen varies with geographical location, due to socioeconomic factors and due to changes in human behaviour. immunocompromisation due to infections (in particular hiv), malignancy (especially haematological tumours) and the use of immunosuppressive drugs also has an important role in determining the infections commonly seen in the gi tract. the typical pathological features of intestinal infections will be discussed together with suggestions on how to optimise the diagnosis of such pathologies. erasme university hospital, brussels, belgium pathologists are confronted with different types of colitis, most commonly infectious colitis and inflammatory bowel disease (ibd) followed by microscopic colitis and ischaemic colitis. several other forms of colitis, however, exist and might be underrecognised; these diseases include segmental colitis associated with diverticulosis, diversion colitis, eosinophilic colitis and behcet's colitis. clinical presentations of these rare types of colitis vary, and laboratory data are often non-specific; mucosal biopsy is essential in establishing the diagnosis. segmental colitis associated with diverticulosis (scad) is mainly characterised by the involvement of the sigmoid colon with sparing of the rectum and proximal colon. scad often mimics ibd at endoscopic and histological examination; since scad has a self-limited course that resolves without further recurrence or need for treatment, the implications of an inaccurate diagnosis are obvious. diversion colitis is a non-specific colonic inflammation following surgical diversion of the faecal stream. is is characterised by a chronic lymphoplasmacytic infiltrate, and the existence of lymphoid follicular hyperplasia is considered to be a hallmark feature. the development of diversion colitis is attributed to a lack of short chain fatty acids. eosinophilic colitis is etiologically obscure and can be associated with involvement of other sections of the gastrointestinal tract. an infiltrate of eosinophilic granulocytes is found to varying degrees in all wall layers. a history of food intolerance or allergy is present in most of the patients, and peripheral eosinophilia is present in % of cases. gastrointestinal involvement has been reported in up to % of patients with behcet's disease. in cases with ileocolonic involvement, it is often difficult to distinguish behcet's disease from other inflammatory bowel diseases. the diagnosis, therefore, often depends on clinical manifestations and intestinal ulcerative lesions. s·  how to write a paper and get it published p cs herrington ; p dm berney university of edinburgh, edinburgh, uk; barts health nhs trust, london, uk scientific papers have a predetermined structure, and writing in this way requires practice. most journals accept only a small fraction of submitted papers and it is important that any paper has something specific to say; and says it in a clear and concise way that can be understood by editors, reviewers and readers, all of whom play a role in assessment of its contribution. editors look for novelty and significance in the context of the aims and scope of their journal; and scientific rigour, which expert reviewers help them to assess. writing a paper and having it assessed by a journal is an iterative process. during the writing phase, the scientific rigour of the argument can be refined; and following submission and peer review, reviewers and editors often make constructive comments that help to improve it still further. the peer review process therefore acts not only as a quality filter but also as a mechanism for quality improvement. writing papers and submitting them for publication is therefore generally a positive experience, particularly if one remembers that the process is iterative and (inevitably) not all papers will be accepted for publication by the first journal that they are sent to.  large-scale routine diagnostics using whole-slide imaging in sweden -the linköping experience p c lundström cmiv, linköping university, linköping, sweden this presentation will describe the large-scale routine usage of wsi at linköping university hospital, sweden. since all histology slides are scanned, amounting to more than half a million slides to date. to a significant extent the digital images are used for primary review. the initial implementation led to several of the benefits foreseen with digital pathology, but it could also be concluded that further development was needed to unlock the full potential, in particular within the it solutions. therefore, a consortium led by cmiv, linköping university was formed in to create innovations for a new generation of digital pathology. this triple helix consortium also includes industry and more than half of sweden's health care providers, an engagement that reflects the dominating view in swedish pathology that large-scale adoption of wsi practice is possible and desirable. this talk covers the experiences made during the initial digitization, including laboratory process adjustments, and the later additions to the digital pathology toolbox accomplished by the ongoing innovation project. apart from obvious targets such as the pathologists' workstation, the developments also touch upon other areas including grossing and enterprise image management.  digital pathology -are we there yet? p sm hewitt national cancer institute, bethesda, maryland, usa the implementation of whole slide imaging for diagnostic histopathology is far more complex than connecting an instrument to a server, and placing a computer on a pathologist's desk. the technology is additive to the histology workflow, with additional cost beyond the current practice of review with a microscope. the adoption of digital pathology for histomorphologic diagnosis requires the restructuring of the workflow, additional technology advances beyond the imaging instrument, and development of new tools to assist the pathologist. the end goal is to improve pathologist's productivity and provide additional diagnostic information. digital pathology, to succeed must become a value-added proposition. the adoption of digital pathology requires: )improvements in scanner performance as measured by defined quality metrics. )advancement in server and networks to distribute images to the desktop efficiently. )software to facilitate review and diagnosis, beyond presenting only and image of the slide. evolution of the current technologies is required to provide an economic impetus for widespread adoption and use of digital pathology in the diagnostic setting. to a significant extent, the distinction between melanocytic naevi and malignant melanomas is based on tissue architecture. amongst the best known architectural features pointing to malignancy are absence of lesional symmetry and maturation, and presence of melanocyte ascent. however, each of these three features has significant pitfalls. as a rule, naevi are 'roughly symmetrical' and melanomas are not, but there are asymmetrical naevi (traumatized naevi, most larger congenital naevi; some combined naevi; some large acral and genital naevi) and symmetrical melanomas (including many small melanomas, especially small nodular melanomas; some spitzoid melanomas). in addition, it is not always clear whether a lesion should be considered 'roughly symmetrical' or not. i suspect that not uncommonly, a diagnosis is reached first, and the verdict regarding symmetry is adjusted according to that diagnosis. similar caveats relate to absence of maturation as an indicator of malignancy. it is seen in blue naevi and all its variants; deep penetrating naevi; some bap naevi. melanomas not uncommonly feature smaller cells in their deeper parts, or there may be an underlying naevus remnant with smaller cells. naevi with ascent include many spitz naevi; reed naevi; some naevi in early infancy; traumatized naevi; naevi of acral skin. over-interpretation of ascent may result from inexperience with melan-a and some other immune stains. melanomas devoid of ascending melanoma cells comprise a wide variety of subtypes including, desmoplastic melanomas and, vexingly, some spitzoid melanomas. these architectural features must, therefore, be evaluated in the context of all other findings, and with a 'splitter's' mind set, taking into account the individual characteristics of the specific naevus and melanoma variants that are of relevance to the case under study. most melanomas are fairly easy to diagnose on histological grounds. however, melanoma is a tumour that can histologically mimic almost any other tumour including epithelial and mesenchymal neoplasms. pathologists need to familiarize with the wide histological appearances of melanoma to avoid serious misdiagnoses. of crucial importance is the knowledge that a number of melanomas can closely mimic benign naevi. some variants of melanoma represent distinctive clinicopathological entities and these include desmoplastic melanoma, "malignant" blue naevus, pigment synthethizing melanoma, naevoid melanoma, spitzoid melanoma and epidermotropic metastatic melanoma. tumoral melanosis refers to complete regression of a melanoma, a diagnosis that it is often missed because of the absence of tumour cells within the regressed area. a small percentage of melanomas display focal or extensive histological changes that closely mimic other neoplasms and often a combination of histological features with immunohistochemistry is necessary to arrive to the correct diagnosis. microscopic variants of melanoma include adenoid (pseudoglandular), angiotropic and angiomatoid, signet ring cell, balloon cell, clear cell, rhabdoid and follicular (with exclusive involvement of hair follicles). some melanomas display heterologous differentiation also known as transdifferentiation. the latter should not be confused with the so-called collision tumour in which a melanoma co-exists with a neoplasm of different lineage. a wide variety of heterologous differentiation has been described in melanoma including osteosarcomatous and chondrosarcomatous (mainly seen in acral melanomas), meiomysarcomatous, rhabdomyosarcomatous, neuroendocrine, ganglioneuromatous and even epithelial. except for desmoplastic and pigment synthetizing melanoma, all other variants of the tumour have the same behaviour as ordinary melanomas. melanocytic tumours with spitzoid features represent one of the most challenging and controversial areas in dermatopathology. what is currently known as spitz naevus was initially reported as "juvenile melanoma" by sophie spitz on . she recognized the relatively indolent but somewhat unpredictable behaviour of these distinctive melanocytic lesions that are particularly common in young children. over the years, the histological spectrum of these tumours was expanded, and it has become clear that classical spitz naevi follow an entirely indolent disease course. the prognosis of tumours with atypical histological features remains somewhat unpredictable. this presentation will give an overview of the morphological spectrum of spitzoid melanocytic tumours, their behaviour and recent advances of their molecular characteristics. optimisation is a core tenet in radiography and involves the radiographer ensuring that images of diagnostic quality are produced with minimum radiation dose burden to patient and staff [ , ] . in paediatric practice this is particularly important due to the more radiosensitive nature of the child [ ] . in alignment with the isrrt world radiography day theme 'radiographers optimise dose', radiography students in an institution submitted clinical case study coursework that focused on paediatric radiation dose optimisation. the purpose of the current study was to analyse these case studies as examples of prevailing radiographic practice and to compare students' perception of optimisation with the evidence within each case. the evidence of optimisation was established through independent and objective image analysis along with thematic analysis of the case commentaries. the case study evidence demonstrated that optimised techniques were generally well implemented. the exception was collimation, which was sub-optimal in % (n= ) of the examinations, and on average irradiating an area % larger than necessary. students were generally able to correctly identify techniques as optimal or not. however, when appraising exposure, positioning and collimation, between % and % of students were inaccurate in their assessment of what is optimal. overall the study reflects positively on current irish paediatric radiography with regard to dose optimisation, although more accurate collimation needs to be practised. similarly student perceptions show good understanding of optimal techniques, although appreciation of exposure, positioning and collimation errors could be improved. the aim of this project was to design and prototype immobilisation devices for children who are unable to independently maintain upright sitting posture during radiographic investigations. while current market devices exist, they are seldom used by radiographers -particularly in europe as their methods of restraint have been deemed 'culturally unacceptable' with some claiming that they are in violation of the human rights of the child [ ] . the design challenge was to create devices that were functional (fit for purpose [ ], radio-lucent, compliant with infection control and easy to use) while minimising discomfort and intimidation. a search of the literature, prior art, patent landscape and current market devices was performed in order to identify product requirements. triz methodologies -a problem solving, analysis and forecasting tool derived from the study of patterns of invention in the global patent literature were used to identify the physical contradictions underlying the design challenge and generate potential solutions. eight unique concept designs were identified from these methods. these were then evaluated using pugh criteria -a ranking system of the relative merits of each concept based on design requirements identified. four of the eight concepts were chosen to be prototyped: a -d printed seat, a swing based template, an acrylic-based support and an adaptable wheelchair. the prototypes were made in collaboration with the ucd school of engineering and tested using paediatric phantoms in ucd radiography department. the final prototypes will be trialled in crumlin children's hospital with a view to future use and development. thrombotic microangiopathy (tma) is a pathology that results in thrombosis of capillaries and arterioles due to endothelial injury. it is usually characterized by an atypical haemolytic syndrome (ahus) or thrombotic thrombocytopaenic purpura (ttp). tma is considered to be caused by infections, drugs, autoimmunity, tumours, pregnancy, transplants and inherited abnormalities involving the alternate complement pathway. this presentation describes the pathology of tma. it includes a retrospective year study ( - ) of all renal biopsies reported by one pathologist. all renal biopsy request forms and reports, where cases included light (lm), fluorescence(fm) and electron microscopy(em), were reviewed. cases without all modalities (lm, fm, and em) were excluded. biopsies were reported in the study period ( in ( in to in . were transplant biopsies. biopsies were insufficient (lm, fm and em all not possible. this resulted in native renal biopsies as the study group. following review of the reports cases were reported as tma. were associated with thin membrane nephropathy, with minimal change disease and with plasma cell dyscrasia/ b cell malignancy. this resulted in cases with tma as the only pathology reported which represents % of all adequate native medical renal biopsies. clinical indications included proteinuria in %, nephrotic syndrome in %, increased creatinine in %, increased blood pressure in % and haematuria in % of the cases. acute renal failure was described in % and hus in just % of the cases. pathological changes were predominently arteriolar sclerosis and glomerular double contours on lm with chronic subendothelial injury on em. the conclusions of this presentation are . tma is overwhelmingly a chronic lesion as seen in renal biopsy pathology. . it is a very common pattern of injury. . it is not usually associated with clinical hus or ttp features at presentation. the era of targeted cancer therapeutics has brought forth new challenges for molecular diagnostic laboratories. the list of genes, and indeed specific mutations, that predict drug responses keeps growing, and with it grows the demand for molecular sub-classification of tumors. in colorectal carcinoma, for example, recent studies support expanding testing beyond kras to include nras and braf in predicting resistance to egfr-targeted therapies. similarly, in non-small cell lung carcinoma standard screening for egfr mutations and alk gene fusions may be insufficient when actionable alterations involving ros , ret, her , met, braf and other genes are being targeted (successfully) in ongoing clinical trials. fortunately, the introduction of next-generation sequencing (ngs) into the clinical laboratory is meeting the demand. due to its quantitative output, ngs not only provides precise mutant allele ratios, but it can also be used to detect gene gains and losses. furthermore, when applied to rna, ngs supports the detection of gene fusions and serves in assessing gene expression levels. while ngs is a powerful tool for molecularly characterizing solid tumors, the quality of the results in large part rests on the selection of appropriate input material; therefore, review by a pathologist prior to testing remains a cornerstone to success. other growing uses of ngs include monitoring minimal residual disease in the setting of hematologic malignancies, and in the detection of targetable mutations in cell-free dna within the plasma. the advent of next generation sequencing has ushered in an era of tremendous potential for identifying the molecular causation of simple and complex disorders, both rare and common. the successes of next generation sequencing reflect the combined interpretive skills of geneticists, bioinformaticians and clinicians working in close collaboration. in the realm of muscle disease, we have witnessed both the strengths and the weaknesses of next generation sequencing technologies. the use of exome sequencing in patients with rare muscle disease who have been carefully phenotyped has proven to be a successful strategy for identifying causative variants in new genes as well as in known genes. in fact, exome sequencing has significantly expanded both the clinical and the histological phenotypic spectra of muscle conditions associated with causative variants in known genes. in the absence of careful phenotyping or large genetic reference data sets for identifying variants of interest, causative variants may be missed, however. the use of rna sequencing-using rna extracted from muscle biopsy specimens-has proven to be a powerful tool for finding causative variants affecting gene splicing or expression, which may be missed with next generation sequencing. muscle pathology plays an essential role in complementing next generation sequencing. the deep phenotyping of patients with muscle disease relies heavily on muscle histological and immunohistochemical findings in combination with muscle imaging, clinical history and neuromuscular examination findings. examples of how next generation sequencing coupled with careful clinical and histological phenotyping has uncovered causative variants in new genes as well as in known genes will be discussed in this talk. medicine, diagnostic pathology, technology, and diagnostic tests are evolving at an extremely rapid pace. drug developers and diagnostic developers each face unique challenges. companion diagnostic development is a key component of pharma drug development strategy. we will discuss the importance of companion diagnostics in the success of personalized medicine, the fda position on companion diagnostics, and the role, advantages and disadvantages of tissue based companion diagnostics. other technologies, such as next gen sequencing, will increasingly be utilized in a complementary fashion along with traditional slide based immunohistochemical and in situ hybridization. the scope and limitations of available technologies will be reviewed. diagnostic technologies of all types will complement each other to provide the most accurate diagnostic information for clinicians and patients. following the who classification of haematological malignancies there has been a greater emphasis on the integration of molecular information with clinical and morphological data not just for diagnostic purposes but also to help convey both prognostic and therapeutic information. this talk will concentrate on routine testing in the work-up of common haematological malignancies focusing specifically on clonality and translocation analysis in lymphoproliferations and mutational testing in bcr-abl negative myeloproliferative neoplasms. using case studies to illustrate common indications for testing this talk will also highlight some of the practical points and pitfalls in the interpretation of these tests. beaumont hospital, dublin, ireland "should i keep the brain?" is one of the most frequent questions addressed to neuropathologists by surgical pathology colleagues. fears relating to inappropriate organ retention coupled with decreasing availability of expert neuropathology opinion and the widely held belief that advances in neuroimaging have replaced the brain autopsy, have all contributed to a decline in the post mortem study of human brain tissue. leaving aside the critical relevance of neuropathology to forensic medicine, the vital role played by careful examination of the post mortem brain extends far beyond pathology and has contributed greatly to science and medicine. in general, prolonged retention of entire brains may be avoided. in hospital practice it is uncommon for a patient to die without brain imaging. access to pre-mortem brain imaging will guide the surgical pathologist in careful and appropriate sampling of calvarial, dural, meningeal, vascular and parenchymal central nervous system components. spinal cord examination requires prior experience in spinal cord removal but most post mortem technologists are expert in cord extraction. sampling and appropriate processing of nerve and muscle requires prior experience or neuropathology advice. high quality photography obtained at all phases of post mortem brain examination including the coronally sectioned individual cerebral hemispheres, with retention of blocks from each of the brain lobes together with cerebellum, brain stem, vessels and dura -meninges will ensure that in the event of a neuropathology opinion benign required -that opinion will not be compromised. specific issues which will be addressed will include the death of patients with epilepsy, dementia, stroke and undiagnosed neurological disease. the key learning objective will be to ensure that pathology trainees approach post mortem examination of the nervous system with interest and excitement. following several high profile misdiagnoses in ireland a national quality assurance (qa) programme for cellular pathology in was initiated with a vision of establishing a patientcentred pathologist-led framework that would enhance the quality of patient care with timely, accurate and complete pathological diagnoses and reporting. national qa guidelines were developed based on key quality activities generating a total of key quality indicators (kqi). examples of the quality activities include turnaround time, monitoring of amended reports, frozen section correlation and various elements of peer review. all cellular pathology departments in the public state-funded hospitals participate in the programme in addition to laboratories within privately-run hospitals. each laboratory enters codes on individual cases designed to capture the relevant kqi and the anonymised encrypted qa data is then electronically extracted from the laboratory information system to a national database. this national central database is managed by a novel information technology system, the national quality assurance intelligence system (nqais)-histopathology, that was designed to process and display the qa data so that each individual laboratory can analyse their own data and also compare their performance to the national average for each kqi. since complete national data has been inputted into the nqais system and in initial qa targets were agreed for turnaround time, frozen section correlation and rate of intra-departmental consultation (idc). in additional targets for autopsy icd, frozen section deferral rate and turnaround time have been added. to our knowledge this programme has enabled ireland to be the first country to publically report national metrics on the quality of their pathology services.  the politics of eqa: the nhs england qa review and its consequences p de hughes in , a review of external quality assessment processes was carried out on behalf of nhs england. the main recommendations of this review related to the strengthening of governance of eqa, both nationally and within pathology provider organisations. recommendations specifically affecting cellular pathology were: (i) professional bodies, led by rcpath, should develop methodologies for assessing the performance of individuals in eqa schemes. (ii) all pathologists reporting pathology results and providing clinical advice should be participate in eqa schemes relevant to their practice, should achieve levels of performance determined by the professional bodies and this performance should be noted at annual appraisal. (iii) where a need to improve performance is identified, additional remedial training should be carried out, or practice in the area of concern should be stopped until appropriate retraining has been undertaken and revalidation achieved. this process should supported and resourced by the employing organisation, as should eqa scheme participation. (iv) interpretative eqa schemes are designed to assess and improve individual performance, and attempts at collusion are considered matters of professional probity. the professional response to these recommendations is expected to be led by the rcpath under the guidance of a newly-established national oversight group working on behalf of nhs england and should be more clear at the time of the pathsoc conference. a key part of this response will be to separately consider the implications of this review for technical schemes, affecting laboratories, and interpretative schemes, affecting individual practitioners. roche tissue diagnostics, tucson, arizona, usa tumour samples to guide treatment decisions have become of increasing significance. most importantly the results of companion diagnostic testing directly influences the management of individual patients as more drugs are approved for treatment of specific molecular distinct subgroups. reporting suboptimal quality test results may be harmful to the patient and cause the mismanagement of a prescribed companion drug. the consequences of unsatisfactory performance and measures for improvement are the responsibility of the laboratory. presently, there are number of eqa schemes for molecular testing available in europe however, their results clearly indicate the need for eqa since %- % of laboratories do not carry out according to the standard set by the eqa provider or utilize standardized procedures. continual improvement programs, internal quality control and validation program assist laboratories however; by using standardized quality practices such as iso and the use of external quality assurance schemes can provide essential feedback to the laboratory to assure accurate molecular testing results.  how to run a histopathology eqa in the digital age p nj mayer ;p jd oxley cork university hospital, cork, ireland; southmead hospital, bristol, uk interpretative eqa schemes in histopathology were first introduced in the uk in the mid- s, well before the advent of the internet and high resolution digital images. in this lecture we will outline key developments, as eqa schemes have evolved into the digital era, with particular emphasis on the national urological eqa scheme, which we have run since . we will outline the main practical issues involved in running an eqa scheme and share our personal experience of the development and introduction of the web-based eqalite software, which is being utilised by increasing numbers of schemes. we will address the pros and cons of traditional glass slide-based circulations versus virtual circulations using scanned digital images and show how the digital archive generated from old eqa circulations has become a valuable educational and teaching resource. we will also briefly explore, from an organiser's perspective, the major issues facing eqa schemes in the future, as eqa performance becomes more embedded into revalidation and fitness to practice.  molecular pathology: the future? p cs herrington molecular pathology is already central to stratified medicine. and the ability of pathologists to understand disease phenotype is essential for interpretation of the current explosion in '-omics' data. moreover, the future of stratified medicine will require integration of information from different sources, in the context of disease phenotype, to inform patient management: pathologists are ideally placed to lead this integration. this applies not only to data derived from ex vivo cells and tissues but also to molecular imaging data, which require accurate correlation with cell and tissue phenotype for accurate interpretation. molecular pathology is key to the future of pathology; and this future extends beyond the traditional light microscope the following plenary, oral and poster abstracts have been subjected to peer review. hypothesis: suppressor of cytokine signalling (socs) family members play a vital role in the activation of the jak/stat signalling pathway via a negative feedback loop and have been implicated in the development of cancers. in breast cancer (bc), socs mrna has been correlated with oestrogen receptor (er) positive tumours favouring a good prognosis (bmc cancer , : ) . this study aimed to determine whether socs at the protein level correlates with tumour morphology and low grade in bc. methods: differential expression analysis between tubular and grade matched nsts were undertaken in the metabric cohort. primary breast cancer tissue microarrays (n= ) were immuno-stained for socs and expression patterns correlated with clinico-pathological and molecular variables including outcome. results: differential gene expression analysis on the metabric data identified socs as the top gene with a significant overexpression in the tubular type as compared to low grade nsts (adjusted p value= . ). immunohistochemistry on the tenovus series showed positive nuclear socs expression to correlate with tumours of low grade (p< . ), low proliferation (ki p< . ), er/pr positive (p< . ) phenotype and tubular morphology (p< . ); as well as negative her status (p= . ) and non-triple negative status (p< . ). survival analysis revealed significant associations with long term breast cancer specific survival (p= . ). positive socs correlations were also observed with the expression of androgen receptor (ar) (p< . ) and stat (p= . ), further indicating its role in these two signalling pathways. conclusions: results from this study suggest socs to be a marker of favourable prognosis: identifying low grade, er positive breast tumours with particular correlations to the tubular histological tumour type. background: ovarian cancer is the fifth leading cause of cancer in women and has poor long-term survival, in part, due to chemoresistance. tumour hypoxia is associated with chemoresistance in ovarian cancer. however, relatively little is known about the genes activated in ovarian cancer which cause chemoresistance due to hypoxia. this study aimed to firstly identify genes whose expression is associated with hypoxia-induced chemoresistance, and secondly select hypoxia-associated biomarkers and evaluate their expression in ovarian tumours. methods: cisplatin-sensitive (a ) and cisplatin-resistant (a cis) ovarian cancer cell lines were exposed to combinations of hypoxia and/or cisplatin as part of a matrix designed to reflect clinically relevant scenarios. rna was extracted and interrogated on affymetrix human gene arrays. differential gene expression was analysed for cells exposed to hypoxia and/or treated with cisplatin. potential markers of chemoresistance were selected for evaluation in a cohort of ovarian tumour samples by rt-pcr. results: a wide range of genes associated with chemoresistance were differentially expressed in cells exposed to hypoxia and/or cisplatin. selected genes [angptl , her and hif- α] were chosen for further validation in a cohort of ovarian tumour samples, n= . high expression of angptl trended towards reduced progression-free and overall survival. high expression of her trended to increased progression-free but reduced overall survival, while high expression of hif- α trended towards reduced progression-free and increased overall survival. conclusion: this study has further characterized the relationship between hypoxia and chemoresistance in an ovarian cancer model. we have also identified many potential biomarkers of hypoxia and platinum resistance and provide initial validation of a subset of these markers in ovarian cancer tissues. methods: analysis of affymetrix™ human exon . st microarray data revealed differentially expressed genes (degs) between a bc group and a control non-bc group. ingenuity pathway analysis (ipa; bioinformatics software) was used to identify networks of the degs. the expression of a micro-network was validated using immunohistochemistry. double immunofluorescence was undertaken to identify the lineage of cells expressing components of the network. results: we identified a network of interacting genes that were upregulated in fcdiib compared to normally formed cortex or fcd without balloon cells (fcdiia). some components of this network were expressed in bcs but others were expressed in novel cell populations. double immunofluorescence identified a cell with the phenotype of a glial progenitor that was only present in fcdiib but not in normally formed cortex. conclusions: we have identified a novel population of glial progenitors found frequently adjacent to bcs in fcdiib. paracrine signaling between bcs and the novel chi l positive cells is likely to be involved in the pathogenesis in fcdiib. further investigations into the role of these cells would give us a better understanding of the molecular abnormalities underlying fcd and possibly provide novel therapeutic targets. excellent anatomical knowledge of the anal sphincter complex (asc) is essential for the treatment and understanding of low rectal and anal pathology. some of the current descriptions of the asc are contradictory. in this study, the three-dimensional ( d) anatomy of the asc is described with relevance to low rectal and anal surgical pathology. six human adult cadaveric specimens (three males, three females) were obtained from the leeds gift research tissue programme. paraffin embedded mega-blocks containing the asc were serially sectioned at µm intervals. sections were stained with haematoxylin & eosin, masson's trichrome and millers' elastin, from which d reconstructions were developed. the asc is a complex structure, varying between individuals in the size and distribution of its layers with intermingling of fibres and inconsistency of the longitudinal smooth muscle affecting the creation of the surgical intersphincteric plane. longitudinal fibres penetrate the internal and external anal sphincter to anchor in the submucosa and ischiorectal fossa. striated muscle fibres from the external sphincter were identified in the submucosa in four of six specimens. the asc is highly complex due to the degree of variation in its structure and intermingling of smooth and striated muscle fibres and their penetration of major structures. this creates potential tissue planes for the spread of infection, fistula extension and tumour spread. the complex anatomy of the asc also impacts on the staging of low rectal cancers in this region, which requires further investigation. p h thorpe; a asiri; m akhlaq; d jackson; m ilyas cten is upregulated in a number of tumour types and in colorectal cancer expression is associated with advanced dukes stage, poor prognosis and distant metastasis. cten is localised at focal adhesions and regulates cell motility but knowledge of underlying signalling mechanisms is sparse. epithelial to mesenchymal transition (emt) is a process whereby cells acquire an invasive phenotype to aid cell migration and is found to occur in a number of biological processes including cancer metastasis. we investigated whether cten increases cell migration through emt pathways in colorectal cancer. cten was forcibly expressed in colorectal cell lines and snail expression determined by qpcr and western blot. the cycloheximide pulse chase assay was used to assess any changes in snail protein stability. further to this, the transwell migration assay was performed to investigate changes in cell motility. forced expression of cten was shown to increase snail protein expression in hct and caco cell lines. there was no change in the level of snail mrna suggesting that cten regulates snail at a post transcriptional level. inhibition of protein synthesis confirmed this and showed that cten regulates the stability of snail protein. simultaneous forced expression of cten and knockdown of snail demonstrated that this relationship was functionally active. forced expression of cten increased cell migration (p< . ) which was subsequently lost when snail was knocked down (p< . ). we are the first to identify snail as a downstream target of cten signalling. this finding advances the understanding of cancer cell motility regulatory networks and further highlights cten as a potential therapeutic target in colorectal cancer. work supported by a pathological society grant. treatment strategies for patients with advanced colorectal cancer p sd richman ; gj hemmings ; p chambers ; m taylor ; hm wood ; e tinkler-hundal ; k southward ; jm foster ; a ouime ; kg spink ; p quirke leeds institute of cancer and pathology, leeds, uk; affymetrix, high wycombe, uk treatment for advanced colorectal cancer is moving to combination therapies, targeting multiple signalling pathways. indeed, mrc focus has been designed to assess this. we determined pten protein expression, and assessed this in relation to other biomarkers associated with signalling downstream of the epidermal growth factor receptor. tissue microarrays were constructed from advanced colorectal cancer (acrc) clinical trials (focus and piccolo) for immunohistochemistry (ihc). mutation status of kras, nras, pik ca and braf was assessed by pyrosequencing. copy number variation was assessed on oncoscan® ffpe assay kit (affymetrix inc.). pten protein expression was correlated with mutation status, mmr status, primary tumour location and copy number. pten protein expression for patients showed complete loss of expression in / ( . %) -focus and / ( . %) -piccolo. braf mutation status was significantly different between the pten negative and pten positive populations (p< . ), with significantly more pten negative tumours having the braf v e mutation. loss of pten expression correlated with genomic deletions involving the pten gene. / ( %) of pten negative tumours exhibited loss of the pten region ( q), half of which were focal deletions. only / ( . %) pten positive tumours showed deletions of this region, and none were focal events. there was no significant difference in either primary tumour site or mmr status (p= . ) between the pten negative and pten positive populations. signalling pathways do not stand in isolation; they are interlinked in a complex signalling network. current treatment interventions must target the correct pathway combinations if patients are to benefit from targeted therapy. our data suggests a subset of patients may require dual akt and mek pathway inhibition, in addition to anti-egfr monoclonal antibody therapy and inhibition of braf. zonal differences in pd expression in centre of tumour versus periphery in microsatellite stable and unstable colorectal cancer p gm o'kane ; m lynch ; j aird ; s hooper ; c muldoon ; n mulligan ; c loscher ; dj gallagher st. james's hospital, dublin, ireland; dublin city university, dublin, ireland; mater misericordiae university hospital, dublin, ireland colorectal cancers (crc) that show evidence of microsatellite instability (msi-h) are marked by a high tumour infiltrating lymphocyte (til) population which is thought to be prognostic. programmed cell death (pd- ) is a negative regulator of the immune system and targeting the interaction with its ligand pd-l offers a potential therapeutic target. we aimed to characterize cd and pd- expression in both the tumour centre (ct) and tumour periphery (pt) of microsatellite stable (mss) and unstable crc. methods: paraffin-embedded tumour blocks were cut at um, prepared and stained using specific antibodies for cd and pd- . the pt was defined as the area within a x high power field (hpf) from the outline of the tumor. the ct was defined as the area at least one x hpf apart from the tumor outline toward centre of the tumor. images were taken at x, x, x and x. positive cells were averaged across high power fields and classified as high or low positivity. results: forty-two specimens have been analysed to date including msi-h and mss tumours. sixty-eight percent of msi-h were stage ii and % of mss were stage iii. in the msi-h group, a high cd count in the ct and pt correlated with and earlier tumour size and stage. pd- positivity was seen in % of msi-h ct compared to % positivity in the ct of mss tumours. the periphery of both mss and msi-h specimens showed significant pd- expression with % and % of samples showing positivity respectively. there was no association between high or low densities of staining and stage. conclusions: zonal differences exist in the expression of cd and pd- in microsatellite stable and unstable tumours. a high proportion of msi-h tumours show pd- activity in the centre of the tumour despite an improved prognosis. further profiling of other t cell populations may help to further understand this expression which may act as a biomarker or provide a therapeutic target biomarkers that are able to distinguish stage ii and iii colon cancer patients at high risk of developing disease recurrence, who may benefit from adjuvant chemotherapy, are still lacking. genome-wide profiling of somatic aberrations, including gene point mutations, dna copy number aberrations (cna) and structural variants (sv), is expected to provide better insight into the molecular pathology of tumour progression and clinical outcome. genome-wide analysis of cnas was performed using high-resolution comparative genomic hybridization for microsatellite stable (mss) stage ii and iii primary colon cancer samples (n= ). in addition, the prevalence of genes suffering from cna-associated chromosomal breaks, indicative for svs, was determined. the mutation status of commonly affected apc, tp , kras, pik ca, fbxw , smad , braf and nras genes was examined for samples using targeted massive parallel sequencing. associations of genomic aberrations with disease-free survival (dfs) rates were explored by log-rank tests using , permutations. disease recurrence and dfs rates differed significantly for several cna-regions (p< . ). a total of genes were recurrently affected by cna-associated chromosomal breaks (fdr< . ), among which genes ( %) that were also identified in a previously analysed cohort of metastatic colorectal cancers. gene point mutation frequencies were in concordance with literature. in a univariate analysis, none of the individual mutated genes appeared to be significantly associated with dfs. in summary, several associations are found between highly prevalent genomic cnas and disease recurrence in this cohort of mss stage ii and iii colon cancers. further in-depth analysis is required to unravel underlying biology that contributes to disease recurrence. km sutton ; d bottomley ; d morton ; p quirke ; p np west accurate and reliable methods for assessing the molecular profile of clinical tumour samples are important for the delivery of personalised medicine. when adopting a targeted amplicon sequencing method in combination with next generation sequencing (ngs), it is ideal to call mutations against a control sample to enable artefacts to be removed from the analysis. blood is considered the gold standard control but may not always be available. we compared the use of histologically normal mucosa to blood as a control in colon cancer. we examined mutations in colon cancers from the ncri foxtrot trial using the fluidigm access array for ngs library preparation. we assessed the use of both blood and normal colonic mucosa as a control for assessing mutations in genes. all samples were tested in duplicate. the work was partly funded by a pathsoc career development fellowship and is presented on behalf of the foxtrot collaborative group. mutation calls made using normal mucosa as a control compared to blood were in good agreement; a mathew's correlation coefficient above . was seen for all of the genes where agreement could be assessed. we found that false positive mutations were due to poorer amplification of the normal mucosa samples and false negatives were due to mutation calls in the normal mucosa. overall we found that when assessing mutations in hotspot oncogenes, testing in duplicate and the use of a normal control tissue is not required to make mutation calls. however, where a normal control is required, normal mucosa from the resection margin is a suitable alternative to blood where it is not available. we report a series of four unusual ovarian or extraovarian neoplasms composed of an admixture of adenosarcoma and a predominant component comprising a sex cord tumour. the neoplasms occurred in women aged to . three cases arose within the ovary and one was extraovarian (pelvis and abdomen) in location. in all four cases, there were minor areas with morphological features of adenosarcoma with a phyllodes-like architecture and periglandular increased cellularity with mitotic figures. in two cases, the stromal component was morphologically in keeping with a juvenile granulosa cell tumour. in one case, the stromal component had some features of both adult granulosa cell tumour and sertoli cell tumour within a fibromatous background. the fourth case morphologically could not be categorised as any of the usual types of ovarian sex cord tumour and was categorised as an unclassifiable sex cord tumour. in all four cases, there was immunohistochemical evidence of sex cord differentiation. in each case, we propose that the sex cord tumour arose from a pre-existing adenosarcoma thus representing an unusual form of sarcomatous overgrowth of sex cord elements which can occur within adenosarcomas. this phenomenon is not well described in the literature. background: human epididymis protein (he ) is a secreted protein that is overexpressed in some cancers. he is emerging as a useful biomarker in diagnosis and follow-up of endometrial cancers. the aim of this study was to evaluate the potential role of serum he in the diagnosis and management of endometrial cancer. methods: patients undergoing surgery for endometrial disease were recruited into this study and had pre-operative serum samples taken, n= . demographic, clinical, radiological and laboratory data were reviewed. he and ca serum levels were analysed using the fujirebio diagnostic elisa kits and results correlated with clinicopathological details. standard cut-off points of pmol/l for he and u/ml for ca were used. results: he showed a sensitivity of % and specificity of . % for detection of endometrial cancer. ca had a very low sensitivity of % for endometrial cancer diagnosis. he was elevated in all stages of endometrial cancer and demonstrated the ability to distinguish between benign and malignant groups. he also provided information about myometrial space invasion. conclusion: he has a role in endometrial cancer diagnosis and prognosis and has the potential to be used in a screening setting or as a triage marker in the primary care setting. for women diagnosed with endometrial cancer, he has the potential to stratify them into treatment regimens where the most appropriate treatment can be delivered resulting in improved quality of life and outcome for endometrial cancer patients. platelets drive metastatic changes in ovarian cancer cells p cd spillane ; nm cooke ; s o'toole ; d kenny ; o sheils ; jj o'leary histopathology department, trinity college dublin, dublin, ireland; department of molecular and cellular therapeutics, rcsi, dublin, ireland; department of obstetrics and gynaecology, trinity college dublin, dublin, ireland background: ovarian cancer is the th leading cause of cancer related deaths in women. previously we described a dynamic interaction between ovarian cancer cells and platelets in vitro, involving platelet adhesion, activation and induction of pro-survival and pro-angiogenic signals in the cancer cells. this study looked to further investigate this phenomenon in ovarian cancer cells by assessing the molecular changes it induced. methods: cell lines m and skov were used as in vitro models of metastatic ovarian cancer. platelet cloaking of cells was quantified by flow cytometry. cells co-cultured with/ without platelets for hrs were examined by rt-pcr for emt related changes and by affymetrix gene . st arrays for whole transcriptome changes. results: significantly more platelets adhered to skov cells than m cells. while there were different rates of adhesion, the platelets induced similar changes in emt related genes in both. there was a significant loss in expression of epithelial genes and an increase in mesenchymal genes, indicating the induction of emt. whole transcriptome analysis showed that there were a greater number of gene expression changes occurring in skov cells compared to m cells, correlating with the adhesion data. a gene panel of commonly affected genes in both cell lines was identified, many of which form part of an interlinking pathway that is regulated by tgfβ and associated with cell adhesion/ecm remodelling. though only genes overlapped, the biological processes affected in both cell lines were very similar, with of the processes enriched in the m data set also seen in the skov data set. conclusion: this study shows that platelets can enhance the metastatic potential of ovarian cancer cells through the induction of emt and ecm changes. in addition, it has identified a set of genes that hold potential to be in vivo markers of this interaction. background: during the metastatic cascade, circulating tumour cells rapidly and efficiently adopt a platelet cloak. platelet cloaking of tumour cells promotes metastatic disease by promoting cellular proliferation, angiogenesis and emt while inhibiting autophagy and apoptosis. the aim of this study is to examine whether the platelet cloak contributes to tumour cell evasion of nk cell mediated immune surveillance. methods: freshly isolated pbmcs were harvested from healthy donors and stimulated for hours with il- ( u/ml). pbmcs were co-incubated with ovarian ( m and skov ), melanoma (sk-mel- ) and cml (k ) cell lines that were either uncloaked, or cloaked with washed platelets from healthy donors. the nk-tumour cell receptor ligand systems, nkg d-mica/micb and cd /cd -cd were examined using nk cell cd a expression and interferon-gamma production to quantify nk cell mediated recognition and 'killing' of cancer cells. results: we first demonstrated that ovarian and melanoma cancer cell lines when cloaked with washed platelets strongly inhibited nk cell antitumor reactivity. platelet cloaking induced down-regulation of the stress ligands mica and micb on the tumour cell coupled with their release into the microenvironment, a known nk cell immune decoy strategy. in addition, platelets significantly down-regulated both cd (nk cell) and cd (tumour cell), inhibiting nk cell activity. both mechanisms occur in tandem to comprehensively incapacitate nk cells and promote tumour immune evasion. conclusions: ovarian and melanoma tumour cells are efficiently cloaked by platelets, which facilitates immune evasion by actively suppressing nk cell cytotoxicity and cytokine production. purpose of the study: glioblastomas (gbm) are the most common and most aggressive primary malignant brain tumours in adults. one of their histopathological hallmarks is the microvascular proliferation; these tumours are among the most angiogenic of malignancies by displaying the highest degree of microvascular proliferation. igfiir/man- -p is a receptor that belongs to the insulin-like growth factor (igf) system. the involvement of igf-iir/man- -p in the process of angiogenesis has been postulated in rare earlier studies. to our knowledge, the role of igf-iir/man- -p in the neovascularisation of human gbm has never been studied. methods: igf-iir/man- -p expression was evaluated in the vascular compartment from human gbm and from normal adult brain samples by means of quantitative immunohistochemistry on tissue microarray sections. in vitro cell line experiments were carried out in order to characterise the igfiir/man- -p role in angiogenesis. summary of results: igf-iir/man- -p was strongly expressed in the cytoplasm of endothelial cells in hyperplastic vessels and exhibited a dot-staining pattern. we found a higher expression of igf-iir/man- -p in gbm vessels compared to normal brain vessels (p= . ). furthermore, preliminary in vitro experiments suggest a role of igf-iir/man- -p in tube formation but not in growth of the ea.hy endothelial cell line. conclusions: this work shows a possible role of igfiir/man- -p in the process of neovascularisation of gbm angiogenesis. additional investigations are required to confirm the role of this receptor as a direct actor of angiogenesis in gbm. purpose of the study: vasa vasorum (vv) are microvessels which supply vessels that cannot be nourished by diffusion from their own lumina. vv are believed to be a key element in the pathogenesis of vascular diseases. a number of different imaging methods have been used to study the vv but there is still no definitive consensus on their structure. the aim was to describe the normal microvessel anatomy of temporal arteries. methods: human temporal artery, obtained following routine biopsy with ethical approval and patient consent. samples were embedded into paraffin blocks and serially sectioned at micron intervals. alternate sections were stained with h&e and scanned to create virtual slides. the slides were aligned, vv were segmented (annotated) and iso-surfaced to generate d reconstructions. summary of results: the reconstruction shows the structural arrangement of the vv as a complex plexus. no connection to the vascular lumen was visualised. in this segment a hierarchical branching structure was not observed. vv were almost exclusively restricted to the adventitia of the vessel wall. mean ± sd area of the vv (n = ) is . µm (± . ). the mean ± sd number of vessels per slide is . (± . ). these metrics are based on one arterial specimen. conclusion: this method allows us to study the three-dimensional spatial relationships of microvessels within arterial specimens. furthermore, metric data generated in the process can support the d images to study the microvasculature. this method will be applied to diseased arteries in future to generate novel hypotheses about the inflammatory process. acknowledgements: this research was supported by a pathsoc intercalated studentship. purpose of the study: it is controversial whether mesothelioma can be diagnosed with confidence in effusion cytology and therefore an ancillary marker of malignant mesothelial cells would be clinically valuable. brca- associated protein (bap ) is a tumour suppressor gene which shows biallelic inactivation in approximately half of all mesotheliomas. bap expression is commonly lost in mesothelioma. we investigated whether loss of bap expression can be used to support a diagnosis of mesothelioma in effusion cytology. methods: immunohistochemistry (ihc) for bap was performed on cell blocks from effusions associated with confirmed mesothelioma cases, effusions containing mesothelial cell atypia, benign effusions, and effusions from patients with lung adenocarcinoma. results: ihc for bap was performed on cases of confirmed mesothelioma. ( . %) showed negative staining in the presence of an internal positive control. in effusions considered to have atypical mesothelial cells in the absence of definitive diagnosis of mesothelioma, cases demonstrated negative staining for bap . on follow up, of these patients received a definitive diagnosis of mesothelioma in the subsequent months ( were lost to follow up immediately). only of consecutive benign effusions were interpreted as bap negative. patients with confirmed adenocarcinoma demonstrated positive staining for bap . conclusion: we conclude that loss of bap expression in effusion cytology is quite specific for mesothelioma. whilst it is not definitive, it can be used to support the diagnosis of mesothelioma in atypical effusions. we caution that interpretation of bap ihc on cell block may be difficult and that convincing positive staining in non-neoplastic cells is required before atypical cells are considered negative. we also note that bap loss is not a sensitive test and cannot be used to exclude mesothelioma. the south-east of scotland experience on the molecular detection of egfr, kras and alk mutations in lung adenocarcinomas p y kheng ; l williams ; k walsh ; j fairley ; s camus ; l gilroy ; k gilmour ; d stirling ; w wallace ; d harrison ; a oniscu royal infirmary of edinburgh, edinburgh, uk; the university of edinburgh, edinburgh, uk the approval of novel targeted treatments for egfr-positive and alk-positive non-small cell lung cancer (nsclc) has led to the increased requirement for mutation testing services in south east of scotland. egfr mutations are typically found in females, asians and never smokers whereas kras mutations are associated with smoking. alk rearrangements are commonly found in younger patients and never smokers. this study aimed to determine the prevalence of egfr, kras and alk mutations in south east of scotland and to evaluate our experience in testing of alk with ihc and fish. data of all patients tested were collected retrospectively from clinical records. from january to may , we reported mutation rates of egfr, kras and alk to be . % ( / ), . % ( / ) and . % ( / ) respectively. in our cohort, an increase in one pack years of smoking resulted in a decrease in the odds ratio of egfr-positivity (or . , % ci . - . , p< . ). kras-positivity was associated with a history of smoking, with rates in both former (or . , % ci . - . , p= . ) and current smokers (or . , % ci . - . , p= . ) significantly higher than in non-smokers. the number of smoking pack years had no influence on the rates of kras-positivity. alk-rearrangements were found to be associated with never smokers (p< . ) and younger patients (≤ years old) (p< . ). to date, no false positives were reported for parallel testing of alk with ihc and fish. we observed % sensitivity ( ihc+/ fish+) and . % specificity ( ihc-/ fish-) when comparing ihc with fish. in conclusion, the prevalence of egfr mutation in south east of scotland has reflected mutation rates reported in west of scotland. our findings further support the use of alk-ihc as a diagnostic screening tool. purpose of the study: the molecular mechanisms of metastasis and progression of penile squamous cell carcinoma (pscc) are unclear. nobody, to our knowledge, has investigated the expression of cell-cycle proteins in advanced or metastatic pscc. we aimed to determine the extent of hpv infection in patients with advanced pscc and its effect on the expression of the key cell-cycle proteins p , p ink a and retinoblastoma (rb). methods: archival paraffin embedded blocks were obtained from primary penile cancers, all patients having developed locally-advanced or metastatic disease. all patients were treated in the phase ii trial of docetaxel, cisplatin & -fluorouracil (tpf) chemotherapy cruk/ / (nicholson et al. bjc ; : - ) . samples were analysed immunohistochemically for p ink a, p and rb protein expression on a tissue microarray. all tumours were hpv typed using pcr. summary of results: hpv dna was detected in / ( %) with hpv present in / ( %). cases were not suitable for analysis. no association was found between hpv and expression of either p ink a (p= . ), p (p= . ) or rb (p= ) using fisher's exact test. conclusions: hpv dna is detected in less than half of progressive pscc, suggesting either the loss of hpv in advanced disease or that non-hpv related cancers progress more commonly. the lack of correlation between hpv and these cell-cycle proteins suggests that they may undergo somatic mutation that is not driven by hpv, leading to increased growth and invasiveness. treatment strategies may be hampered by this genetic diversity, which requires further investigation. prostate cancer is the second most common form of cancer in males, and the incidence of this disease is predicted to double globally by . more than . million new cases of prostate cancer are diagnosed each year and two thirds of these patients are from the western world. current diagnostic tests for prostate cancer are limited in both sensitivity and accuracy, and a method for accurate prognosis in these patients is yet to be developed; therefore, there is a need for a sensitive and specific prostate cancer test to implement early and appropriate therapy. the recent discovery of altered endosomal-lysosomal biogenesis in prostate cancer cells has identified a fundamental change in the cell biology of this cancer that holds great promise for the identification of novel biomarkers that can predict disease outcomes. investigation of the endosome compartment and endosome biogenesis revealed elevated gene and expression of critical machinery components that are required for endosome biogenesis and endocytosis. here we demonstrate significantly altered expression of endosomal and lysosomal genes in mrna microarrays of prostate cancer tissue compared to non-malignant tissue, and that specific endosomal and lysosomal genes are predictive of patient outcomes. two endosomal tri-gene signatures were identified that had a significant capacity to stratify patient outcomes. changes in the expression of these genes was further ascertained by qpcr in fresh-frozen prostate tissue specimens, which further implicated altered endosome biology during disease progression, with significant changes in expression observed between aggressive prostate cancer and indolent disease or normal prostate tissue. these findings support the initiation of a retrospective trial to determine if these new biomarkers can accurately predict clinical progression in prostate cancer patients. m craze; c joseph; c nolan; a green; ea rakha; io ellis; p a mukherjee university of nottingham, nottingham, uk introduction: lymphovascular invasion (lvi) is an important step in the metastatic cascade. identification of a molecular signature for the lvi positive phenotype will help identify relevant drivers and pathways. this study aimed to investigate determinants of lvi from a biomarker database. methods: biomarkers (n > ) from a well annotated series (n= ) were analysed for correlations with lvi [clinical/ihc (d - ) supplemented]. proteins with significant associations with lvi were interrogated for pathway enrichment analysis [corrected for false discovery rate (fdr)], using the string . platform incorporating gene ontology (go), kegg and nci. results: biomarker analysis related to both clinical/ihc determined lvi identified positively associated markers, in both clinical and ihc categories (e.g. ada , cd , foxp , kpna ). a further markers were negatively associated, in both categories (e.g. bcl , brca , mage and sox ). significant pathways (p< . ) unifying the positively associated proteins include metabolism, immune responses (t-cell regulation and differentiation), cell activation and transcription [go] ; t-cell receptor signalling pathways and pathways in cancer and haematopoietic cell lineages [kegg] . for negatively associated proteins, the following were significant: ubiquitination processes, regulation of the mitosis [go]; p pathways [kegg] and apoptotic and cell cycle pathways [go & kegg] . on cross-validating a subset included in the metabric cohort, there were overlapping enrichments for immune response regulation (go) and haematopoietic cell lineages (kegg). conclusions: these preliminary findings are the first to unify biomarkers for lvi pathway analysis in bc, using protein based data. within the constraints of selection bias, data mining from immunohistochemistry of multiple biomarkers in relation to biological processes hold promise. *am supported by the nihr and the academy of medical sciences abstracts s· assessment of her status on needle core biopsy of breast cancer: impact of histopathological concordance p m pigera; ahs lee; io ellis; ea rakha; z hodi nottingham city hospital, nottingham, uk one of the key recommendations introduced in the asco/cap update guideline recommendation on her testing is the novel concept of "histopathological concordance." it is proposed that certain tumour morphological features such as histologic type and grade should trigger repeating a molecular test in cases of "discordance". in this study we have we have reviewed breast cancer cases consecutively reported in routine practice in nottingham in the last years. data on her status was collected and cases with her assessed on resection specimens (rs) were analysed in details. results: of all cases, patients ( %) had her status assessed on core biopsy and the corresponding tumour rs. the main reasons for a repeat were tumour multifocality and morphologically different or heterogeneous tumours. a few cases were repeated because of borderline negative fish results or neoadjuvant therapy. cases were repeated due to insufficient tumour in the core biopsy. in this study the her status of the index tumour was changed in cases and both were in the borderline result category. her testing of different tumour foci of multifocal or morphological heterogeneous tumours was consistent with that of the index tumour assessed on the core biopsy apart from two cases; one positive and one negative. tumours were upgraded from grade on core to grade on excision and her status did not change. no contribution of hormone receptor or tumour type was identified. conclusion: there is excellent agreement between her assessed in core biopsy and rs. histopathological discordance seems to play a minor role which does not justify test repeat in routine practice. tamoxifen prevents breast cancer in a sub-set of high-risk women in a mechanism that appears to be dependent on reduction of md. animal model studies suggest that tamoxifen remodels the mammary stroma to a tumour-inhibitory phenotype. this study aims to analyse the effect of tamoxifen on breast fibroblast function and identify potential protumourigenic pathways contributing to density-associated risk. methods: primary human breast fibroblasts were treated with hydroxytamoxifen ( nm- µm). fibroblast function was analysed by measuring: proliferation; expression of stromal proteins fibronectin (fn), lox and collagen ; effects on tgf-β signalling via smad phosphorylation and upregulation of the myofibroblast marker sma. genome wide analysis was performed using rna-seq. summary of results: fibroblasts from patients were treated with tamoxifen. all patients showed reduced proliferation with treatment. in % of patients tamoxifen treatment resulted in reduced expression of fn. tgf-β-mediated upregulation of sma and fn were consistently inhibited by tamoxifen, as was fibroblast contraction of collagen gels. rna-seq analysis revealed modulation of a number of metabolic pathways by tamoxifen, including significant upregulation of dhcr , part of the microsomal antioestrogen binding site (aebs). conclusions:these data indicate that tamoxifen can directly remodel the stromal microenvironment, generating a less 'reactive' stroma. modulation of aebs activity has been proposed to be anti-tumourigenic, and also is implicated as a suppressor of hedgehog signalling. thus, tamoxifen impacts on multiple pathways to create a tumour inhibitory phenotype. this work was supported by the pathsoc small grant scheme. purpose of the study: the phenotypic features of basal like (bl) breast cancer (bc) resemble those occurring in brca -germline mutation carriers. several lines of evidence suggesting the overall tendency of basal-like/triple negative bc to spread through vascular rather than lymphatic routes. the latter has recently been attributed to the activation of cadherin switch, an emt-like phenomenon, in blbc. this study aims at studying the cadherin switch expression profile tgfb , a key emt-trigger, expression in brca mutated compared to sporadic bc. the expression of e-cadherin, n-cadherin and tgfb were studied in a subset of germline brca mutated bc (n= ) compared to non-selected cohorts of non-lobular sporadic invasive blbc (n= ) and non-basal bc (n= ) using ihc and tma. summary of results: compared to sporadic bc, brca mutated cases were of younger age, more grade , with more medullary-like tumours, and more lvi positive. e-cad was significantly less expressed in brca cases than in the sporadic non-basal and in the blbc. however, n-cad was not significantly expressed in brca , non-basal, and blbc. tgfb was significantly less expressed in sporadic bc, both non-basal blbc than brca mutated bc. e-cad/n-cad combinatorial expression phenotypes were significantly different between brca mutated and non-basal and blbc. higher proportions e-cad-/n-cad+ were significantly observed blbc than non-basal bc. brca mutated cases displayed the least e-cad+ expression and the highest e-cad-/n-cad+ in the studied series. conclusions: despite the known similarities between brca mutated and blbc, results of this study demonstrate the more occurrence of cadherin switch in brca mutated breast cancer. e-cad repression appears to contribute more than n-cad gain in blbc than non-basal bc. exploring molecular mechanisms underlying lymphovascular invasion in breast cancer p sn sonbul ; a mukherjee ; r russell ; om rueda ; m aleskandarany ; ar green ; e provenzano ; c caldas ; io ellis ; ea rakha the development of tamoxifen resistance (tr) in oestrogen-dependent breast cancer (bc) is a therapeutic challenge. insulin-like growth factor binding proteins (igfbps) may play a role in this process. we have investigated the role of igfbp proteins in tr bc. igf axis genes were evaluated in mcf- (wt) cells and tamoxifen-resistant (tamr) variants using qrt-pcr and confirmed by elisa, western, and ligand blotting. igfbp- & - were knocked down by shrna transfection, and subsequent sensitivity to -hydroxytamoxifen ( -ht) was determined via wst- . cell migration was investigated by using the incucyte system. igfbp- expression was evaluated in bc cases by tma immunohistochemistry. five out of genes of the igf axis (igf-ir, igf- r, igfbp- , - and - ) had the highest expression levels by both parental wt and tamr cells. igfbp- was down-regulated by ~ -fold while igfbp- was up-regulated by ~ -fold in tamr versus wt cells (mrna and protein levels). significantly, a knockdown of igfbp- in tamr cells restored sensitivity to ( -ht), reduced erα expression to ± . % and enhanced cell migration. expression of igfbp- was significantly (p< . ) associated with survival advantage in tr patients. igfbp- and igfpb- are reciprocally regulated in the acquisition of tr by mcf- cells. igfbp- may play a role in the development of tr in vitro and its high levels in clinical samples may predict tr. purpose of the study: several lines of evidence are currently suggesting that the morphologic heterogeneity of breast cancer is mirrored at the genetic level. understanding the molecular genetic evolution of bc would contribute further insights into the molecular derangements driving disease progression. moreover, varied clinical outcome and response to similar therapeutic regimen is attributed, at least in-part to intratumoural heterogeneity. ngs can reliably study the genetic events using miniscule amounts of genomic dna. methods: gdna was extracted from ffpe tissue sections from a case of invasive duct carcinoma ( primary tumour samples and samples from positive axillary lymph node metastases). sample preparation and exome enrichment was performed using nextera rapid capture exome kits (illumina, fc- - ). exome sequencing was performed using illumina miseq with x depth of coverage (following adapter/barcode trimming). exploratory analyses and data mining were executed regarding variant (s) concordance/ discordance between primary tumour samples and their respective metastatic variants. summary of results: initial findings revealed candidate indels common to all three axillary lymph node samples yet absent from the three primary tumour samples. several genes have been identified as having frameshift mutations caused by indels. molecular players previously linked to anti-angiogenesis are amongst the genes affected by indel mutations in their coding sequences that may lead to potential abrogation of protein function. conclusions: these initial findings provide the framework for detailed molecular analyses for assessing molecular evolutionary events in primary breast cancer and their corresponding metastases. c-myc is amplified in approximately % of breast cancers (bc) and is associated with poor outcome. c-myc protein is multi-faceted and participates in many aspects of cellular function and is linked with therapeutic response in bc. we hypothesised that the functional role of c-myc differs between molecular subtypes of bc. we therefore investigated the correlation between c-myc protein expression and other proteins involved in cell cycle control, proliferation, apoptosis and dna damage together with clinicopathological parameters, outcome and treatments in early invasive primary bc (n= , ) using immunuohistochemistry. the metabric bc cohort (n= , ) was evaluated for c-myc mrna expression. in whole series, there was significant association between c-myc protein expression with higher tumour grade, lymph node(ln) positivity and medullary-like tumours. c-myc showed differential association with other proteins in the molecular classes. in luminal a tumours, c-myc was associated with atm (p= . ), cyclin b (p= . ), pik ca (p= . ) and ki (p< . ). in contrast, in basal-like tumours, c-myc showed positive associated with cyclin e (p= . ) and p (p= . ) expression. c-myc was an independent predictor of a shorter distant metastases free survival in luminal a ln+ tumours treated with endocrine therapy (et; p= . ). c-myc expression did not predict patient outcome in the other molecular subtypes with respect to adjuvant treatment. high c-myc mrna expression was associated with higher grade and basal phenotype (p< . ). in luminal tumours treated with et, c-myc mrna expression was associated with bc specific survival (p= . ). c-myc function is associated with specific molecular subtypes of bc and confers resistance to et. the diverse mechanisms of c-myc function, particularly in luminal a bc, warrants further investigation. metasin axillary predictive score (maps): a measure of axillary nodal disease prediction to provide an informed choice for breast cancer patients and surgeons p pp gopinath ; d george ; p sai-giridhar ; s jader ; e arkoumani ; s holt ; g francis ; c yiangou ; s al ramadhani ; s el sheikh ; n agrawal ; v sundaresan purpose of study: intra-operative sentinel lymph node sampling and molecular analysis empowers the surgeon to carry out axillary clearance as a one-step process. we have recently completed the clinical validation of metasin, an intraoperative molecular assay for sentinel lymph node analysis in breast cancer patients ( cases). method: the assay uses positive predictive markers and is quantitative, enabling the prediction of tumour volume using markers ck and mammaglobin. in this study group, patients had positive sentinel nodes and cases underwent axillary clearance. of the axillary clearance cases, % contained positive lymph nodes. % were sentinel node (snb) macrometastases, % were snb micrometastases and % were snb negative or contained isolated tumour cells. informative data was available for sentinel nodes from positive cases. results: using the qpcr values (from metasin assays using standardised pre-mixes) and clinical axillary clearance data, the cases have been stratified on the basis of the involvement of other axillary nodes. we have shown a three-tiered predictive grouping exists: group a includes low tumour volume disease with a nodal positivity of % within the axilla (n= ): group b with a % positivity of other nodal involvement (n= ) and group c with positivity of % of axillary clearances (n= ). the clustering of the metasin data is dependent on the qpcr results and shows that the cases can be sub-grouped to provide a probability basis for prediction of axillary nodal involvement; dependent on the qpcr cut offs. this gives the patient and surgeon a statistical basis for determining the likelihood of other axillary nodal disease. sequencing of the brca and brca genes has long been used in genetics laboratories to identify cases of familial breast and ovarian cancer. however, the advent of chemotherapy for ovarian cancer based on parp inhibitors, which requires the presence of a brca or brca mutation, is turning this specialist test into a commonly-applied companion diagnostic. at the same time, the introduction of new dna sequencing technologies is posing challenges even for experienced genetics laboratories. emqn has been providing eqa of brca and brca gene sequencing world-wide for years. the rate of serious diagnostic errors has varied from year to year, but the mean has hovered stubbornly around %. in eqa, just samples per year are sent out, and the quality and experience of participating laboratories varies greatly. we recently carried out a collaborative study to measure the quality of brca gene sequencing by traditional and new methods in experienced, expert laboratories from countries. ten dna samples ( with pathogenic mutations, with normal dna sequence) were sent to each laboratory. ten labs used next-generation sequencing (ngs) alone, used sanger sequencing alone, and the others used combinations of sanger sequencing, ngs, mlpa and other technologies. seventeen ( %) of labs identified all clinically-significant variants on all samples. four false negative results were reported by labs. two were due to deficiencies in the bioinformatics pipeline of the ngs process, while were attributed to a sample swap, and incorrect interpretation of a melting profile. no significant trend was identified with respect to the genotyping accuracy of the different methodologies used. the observed error rate of % amongst expert laboratories indicates the complex and challenging nature of this kind of testing. caution will be required when applying these technologies to sub-optimal ffpe samples in pathology laboratories. p n wolstenholme ; sj patton ; z deans ; s abbs ; j coxhead ; k brugger ; p westwood ; k thomson ; h scheffer next generation sequencing (ngs) is increasingly being introduced into clinical diagnostic laboratories worldwide. the huge amount of data generated by ngs cannot be duplicated by alternative methods for laboratories to internally validate all results, therefore external assessment of data is required. the uk national external quality assessment scheme (ukneqas) for molecular genetics and the european molecular genetics quality network (emqn) have developed a joint eqa scheme for ngs, with the aims to: (a) assess and improve quality; (b) enable laboratories to benchmark their ngs service against others and against best practice; (c) work towards consistency of reporting clinical results generated by ngs; and (d) contribute towards best practice. emqn and ukneqas offer numerous disease-specific, molecular pathology and technical eqa schemes. the objectives for developing ngs eqa were to make it generic (independent of genes, diseases, platforms, and testing context (e.g,. somatic, germline etc)) and applicable all users. two pilot eqas have been run and labs from countries participated. these labs were sent a genomic dna sample and asked to sequence either their smallest gene panel or largest single gene which the lab tested, submit technical details, and genotypes at known snps. the results were compared against a "consensus eqa genome" established by multiple validations of the dna. different genes were tested. most labs are using small panel of - genes. % of all variants were detected by every lab which tested for them. a detailed summary of the key findings will be presented. both pilots have proved to be challenging to meet our objectives, however the results have enabled clinical diagnostic labs to start to address the quality of their ngs testing. tumours invade the vasculature, which transports circulating tumour cells (ctcs) to distant sites enabling growth of secondary tumours. ctcs hold the potential to monitor: therapeutic response, emergent mutations and act as a screening tool for the early detection of cancer. there are numerous methods to isolate ctcs. once isolated, epcam and/or panck positivity and cd negativity are used to verify ctc status. however, due to the metastasis associated process of epithelial-mesenchymal transition, epithelial markers may be ineffective at identifying all ctcs. to overcome such protein marker based limitations, we have developed a novel staining pipeline (ctc- ) that combines histochemical staining (giemsa) with immunofluorescene (dapi, epcam/panck, her and cd ) staining and whole slide imaging for robust identification, enumeration and characterisation of ctcs from cancer patients. ctcs are isolated from whole blood using screencell cyto devices. cyto devices are then slide mounted, giemsa stained and digitised. giemsa staining is washed out and slides are immunofluorescently stained for epcam/panck, cd , her and counter stained with dapi. fluorescently stained slides are digitised. giemsa stained and four colour immunofluorescent digital slides are processed in silico generating a single z-stacked digital slide for pathological assessment. the ctc- staining pipeline has been experimentally validated via ctc characterisation of peripheral blood from lung, breast and ovarian cancer patients, with respect to healthy donor and spiked-in controls. the ctc- pipeline overcomes recognised weaknesses in ctc characterisation. histochemical staining is added to the current gold standard of epcam/panck and cd staining, while also preserving a fluorescent channel for assessment of biomarker status (e.g. her , apoptosis or platelet cloaking). such advancements enable robust pathological assessment of ctcs in the clinic. thorough interrogation of diseased tissue requires the use of multiple biomarkers in order to investigate biological pathways. unless fluorescent technology is used, multiple sections are required from each tissue block as each section can only be tested for a limited number of markers. histogenic molecular mapping (hmm) is a technique which used digitized images to evaluate multiple biomarkers. although each section cut from a block is slightly different from the immediately preceding section, the similarity is sufficient to allow non-linear registration of images of successive sections. if the order is known, multiple sections can be mapped onto each other by registering each with the immediately preceding section. this allows several biomarkers to be mapped into a single "composite" section thereby giving a representation of the pathways activated/expressed in the tissue. we used hmm to investigate the mismatch repair pathway in colorectal cancer. sequential tissue sections were stained for mlh , pms , msh and msh and then scanned. bespoke computational algorithms were used for image registration and composite images were binned as either "mismatch repair proficient" or "mismatch repair deficient". validation of each category could be obtained by quantification of pixels in binarized images or pixel distribution using stereology. our data show that hmm can be used for interrogating biological pathways in tissue sections and, ultimately, automated diagnosis of disease states. personalising whilst pre-operative radiotherapy is the standard of care in locally advanced rectal cancer (larc), only half of patients respond. individualised treatment based on a predictive test could avoid unnecessary radiation exposure in poor responders. macrophages in the tumour microenvironment with tumoricidal m and tumour protective m phenotypes could be modulating this response. this study investigated the possible predictive value of m and m subpopulations in identifying the response to short-course radiotherapy (scrt). pre-treatment biopsies and post-treatment resection samples were taken from patients with larc given scrt. dual-staining immunohistochemistry was performed with cd , hla-dr (m marker), and cd (m marker). samples were scored for hot-and-random spots by nuance software (version . . ) and compared with tumour response measured by reduction in tumour-cell density. the work was partly funded by a pathsoc career development fellowship. samples showing a low score for hla-dr positive m macrophages exhibited a better response to scrt with a median % reduction in tumour cell density (iqr to ). those with a high score exhibited a poor response with only a % reduction (iqr to , p= · ). no such trends were observed for cd + m macrophages. the ratio of hla-dr+ to cd + macrophages for biopsy and resection samples was significantly different showing a drop in the hla-dr positive macrophages in the resection samples (biopsy median · , iqr . to . ; resection median · , iqr . to . ; p= · ). assessment of macrophage subpopulations in pre-treatment biopsies appears to predict the degree of response to scrt in larc. further investigation to validate these findings is now required prior to developing a predictive test for use in routine clinical practice. patients with a poor predicted response could avoid toxic and costly radiotherapy and undergo alternative strategies including chemotherapy. next-generation sequencing technologies (e.g. s profiling) are increasingly used to investigate complex bacterial communities. they have advantages over classical methods, as a significant proportion of bacteria are 'non-culturable'. however, they do not distinguish 'viable' and 'non-viable' populations, which may skew results, particularly following antibiotic exposure. here we report culture and s data from a clinically reflective human gut model, describing changes in the gut microbiota following exposure to multiple antibiotics. a triple-stage chemostat model was inoculated with pooled human faeces from healthy volunteers to establish gut microbiota populations. the model was sequentially exposed to clindamycin ( . mg/l, qds, days), vancomycin ( mg/l, qds, days) and fidaxomicin ( mg/l, bd, days). specific bacterial populations were enumerated daily on selective agars. periodically, s profiling of gut model samples was performed; dna was extracted on a qiaxtractor, s v pcr products were sequenced on an illumina miseq, and resulting data were analysed using qiime. both culture and s profiling demonstrated marked alterations in gut microbiota populations following antibiotic exposure. for many populations, notably bifidobacteria and enterobacteria, changes seen by culture correlated with s profiling. however, as culture describes numerical changes in populations, and s profiling describes proportional changes, results are not always directly comparable. s profiling greatly increased microbiome coverage, particularly for clostridia. population diversity (number of observed species and shannon index) decreased with sequential antibiotic exposure. use of culture and molecular methods in tandem can greatly increase understanding of changes occurring in complex microbial populations. barrett's oesophagus is the erosive replacement of the normal squamous oesophageal lining with a glandular epithelium and is the major precursor of oesophageal adenocarcinoma. barrett's patients are enrolled into active surveillance programmes in order to detect and treat oesophageal cancer at an early stage. surveillance however is costly and burdening to patients. to improve screening efficacy there is an acute need for accurate biomarkers of cancer progression risk in barrett's patients. understanding the pattern and pace of clonal evolution that occurs within the barrett's segment is a key step towards achieving this goal. opinion is divided over whether goblet cells (intestinal metaplasia) on oesophageal biopsy are required for a diagnosis of barrett's oesophagus. this is based on the unproven assumption that goblet cell differentiation marks increased cancer risk in barrett's oesophagus patients. we have investigated the clonal structure of non-dysplastic and neoplastic barrett's oesophagus by combining state-of-the-art d modeling and genetic lineage tracing. by tracing the clonal origin of an early oesophageal adenocarcinoma through whole-exome sequencing and mitochondrial dna sequencing, we find that this cancer developed from non-goblet columnar epithelium, whereas the adjacent goblet-bearing mucosa was free of oncogenic mutations. our results have important implications for the harmonization of the clinical diagnosis of barrett's oesophagus. long-course chemoradiotherapy (crt) is used to down-stage locally-advanced rectal cancer (larc) prior to resection. an interval period prior to surgery allows for tumour shrinkage to facilitate surgical removal. the optimal time interval remains unclear, with little high-quality evidence to guide clinical decisions about when to operate. this study explores the pathological outcomes from a pilot randomised controlled trial comparing an interval of weeks versus weeks between crt and surgery. thirty one patients were recruited from seven uk centres between june and may . photographs were taken of the specimens and assessed by a blinded histopathologist for the quality of the mesorectal dissection. rates of pathological complete response (pcr), down-staging, and circumferential resection margin (crm) involvement were determined. response was also assessed using novel tumour cell density (tcd) assessment where the slides from the resected specimen and baseline biopsy were scanned at x magnification, the tumour area selected and to data-points analysed by a blinded expert to describe the percentage of different tissue components. the work was partly funded by a pathsoc career development fellowship and is presented on behalf of the starrcat trial investigators. twenty three patients underwent surgery ( from the -week arm and from the -week arm). the mesorectal fascial plane was intact in specimens from the -week arm ( %) and from the -week arm ( %). three patients at -weeks and two patients at -weeks showed a pcr. only one patient (from the -week arm) had an involved crm. tcd was . % for the -week arm and . % for the week arm (p= . ). in this small randomised trial, rates of mesorectal quality, crm status, pcr and tcd were similar following either a or week interval after crt. further studies are now needed to clarify whether a longer interval does facilitate on going down-staging. the role of tissue factor pathway inhibitor (tfpi) in liver injury p g petts ; h kudo ; a dorling ; m thursz ; r goldin imperial college london, london, uk; kings college london, london, uk introduction: studies have demonstrated that inhibition of the coagulant cascade is associated with less advanced liver fibrosis and better outcome in acute liver injury. tfpi is a serine protease inhibitor that acts as a homeostatic inhibitor of the coagulation cascade and may be a target to modify outcome in liver disease. methods: transgenic mice carrying a genetic modification that allows cells expressing a-smooth muscle actin (asma; e.g. activated hepatic stellate cells) to simultaneously express tfpi were used in models of chronic liver injury (carbon tetrachloride, ccl ) or acute liver injury (paracetamol) and culled at set time points after dosing. results:chronic liver injury: at hours after the last dose of ccl the transgenic mice had significantly decreased asma expression and tissue inhibitor of metalloproteinase (timp) - gene expression but no difference in matrix metalloproteinase (mmp) - and - gene expression compared to wild types. this suggested a microenvironment that would promote fibrosis resolution. however after hours this difference was lost. at all time points there was no significant difference between fibrosis in transgenic and wild type mice as demonstrated by sirius red staining, hydroxyproline assay and collagen a gene expression. acute liver injury: in paracetamol induced liver injury there was a significant difference in parenchymal necrosis in transgenic mice compared to wild types at and hours after dosing ( hours: mean necrosis % vs. % respectively, mann-whitney test p= . . hours: mean necrosis % vs. % respectively, mann-whitney test p= . ). conclusion: these results suggest that tfpi is an unlikely therapeutic target in chronic liver injury. however in acute paracetamol induced liver injury tfpi appears to rescue the injured liver in a sustained manner from hours after the initial insult and suggests a role for tfpi in managing acute liver injury. (research funded by the pathological society). analysis of adenocarcinoma and non-small cell lung cancer (nos) for egfr mutations now forms part of the royal college of pathologists' lung cancer dataset. identification of patients harbouring these mutations facilitates delivery of targeted therapies with superior efficacy. testing of these tumours for alk has also been introduced in our centre. we assessed our compliance with the college guidelines in this area for and . in those tumours positive for egfr or alk mutations, we examined the original sections to assess any correlation between mutation status and morphological subtype. of the appropriate cases ( %) diagnosed histologically in were sent for egfr mutation analysis, increasing to / ( %) in . of the cases over this time ( %) were positive for an egfr mutation. of these, showed an acinar growth pattern, were solid, lepidic, papillary and micropapillary. it was not possible to characterise the growth pattern in two of the cases analysed as cell blocks. the most common mutation, a missense mutation at codon of exon , was most frequently associated with an acinar growth pattern. of the cases, ( %) were sent for alk mutation analysis, compared with ( %) in . both of the two cases with an alk translocation ( p rearrangement) showed an acinar growth pattern. our compliance with college guidelines in sending appropriate lung specimens for mutation analysis is improving. the correlations between mutation status and morphological subtype add to, and are in keeping with, the current body of evidence in this area. primary synovial sarcoma of the heart -an interesting case report and review of literature p s venkatesan ; p sloan ; s kendall ; m giles royal victoria infirmary, newcastle, uk; james cook university hospital, middlesbrough, uk seventy five percent of primary cardiac tumours are reported to be benign atrial myxomas. the remaining are malignant tumours with most of them being sarcoma, particularly angiosarcoma and malignant fibrous histiocytoma. synovial sarcoma of the heart is a very rare malignancy accounting for less than % of all primary cardiac tumours. most of them arise from the pericardium and the right side of the heart and is considered to be highly aggressive with reduced survival rates. diagnosis in these rare locations is also challenging. we report a -year-old gentleman who presented to us with productive cough, chest pain and paroxysmal nocturnal dyspnea. echocardiography revealed a calcified left atrial mass arising from the posterior leaflet of the mitral valve and radiologically was thought to be a benign atrial myxoma. excision was planned with histology showing a malignant biphasic spindle cell tumour exhibiting marked cellular atypia and numerous mitoses. on immunohistochemistry, the glandular component expressed diffuse positive staining for bcl- and ema with focal positive staining for pancytokeratins. the spindle cell component expressed cd and ema and was found to be negative for cd , s , desmin, melan-a and hmb- . cytogenetic testing revealed ss -ssx / gene fusion with ss rearrangement confirming the diagnosis of synovial sarcoma in this rare location. a postoperative computed tomography was performed which showed no evidence of metastasis or primary lesions elsewhere. there was excellent postoperative surgical recovery and adjuvant chemotherapy was considered in the multi disciplinary meeting. primary cardiac synovial sarcoma is an extremely rare malignancy especially when arising from the left atrium posing diagnostic difficulty mimicking atrial myxoma. in contrast to the poor prognosis mentioned in the literatures, there was excellent recovery in this gentleman. swyer-james-macleod syndrome (sjmls) is a rare lung condition that manifests radiologically as unilateral hemithorax lucency as a result of post-infectious obliterative bronchiolitis, leading to small airways obstruction and secondary emphysema. the histological features of sjmls are poorly and infrequently described. we present three cases of the syndrome that underwent lobectomies in our institution from to , in three women, aged, , and years, presenting with recurrent lower respiratory tract infection, shortness of breath and pleuritic chest pain. two underwent left upper lobectomies, one left lower lobectomy. the first case demonstrated hyperlucency of the affected lobe with markedly reduced blood vessel attenuation. the radiological findings of the second case were of extensive bronchiectasis, hyperlucency, mucus plugging and hypervascularity. the radiological findings of the third case were of an apical bulla and upper lobe cavitating lesion with lobar hypolucency and hypoperfusion. the main histological findings were bronchiolar changes with bronchiolectasis, mucus plugging, constrictive / obliterative bronchiolitis and various degree of peribronchiolar inflammation. emphysema was mild and diagnosed as loss of attachment of alveolar walls. in addition, case had dystrophic, hypoplastic or absent branches of the pulmonary arteries. case showed prominent bronchial arterioles and abnormal tortuous dilated pulmonary arteries and veins. case had established bronchiolar scars in the bronchovascular bundles, pleural arteries showed medial hypertrophy and the interlobular septa contained dilated prominent veins, as well as cystically dilated inflamed peripheral bronchus. these cases highlight the importance of vascular changes in sjmls, likely secondary to the bronchiolar inflammation and destruction leading to capillary bed destruction from secondary emphysema and reactive pulmonary and arterial changes. mediastinal nodal staging with ebus is recommended for patients with resectable non-small cell lung cancer and has emerged as a safe tool to establish granulomatous pathology in suspected sarcoidosis. we conducted a retrospective analysis of the outcomes of ebus performed in a large teaching university hospital with a rapid access lung clinic over a month period and correlation with endobronchial and ct guided biopsies, and surgical resections, when available, and compared the adequacy of ebus when performed with and without rapid on-site evaluation (rose background and aims: in interstitial lung disease (ild), when an aetiological factor appears absent and clinical-radiological correlation is non-contributory, histology is required. the traditional surgical lung biopsy (slb) is not without risks. cryotechnically obtained specimens contain more alveolated lung tissue and less crush artefact than conventional transbronchial biopsies and may offer an alternative to slb in selected cases. we aimed at studying the complications of cryoprobe transbronchial lung biopsy (cpbx) and the quality and pathological characteristics of the tissue obtained. methods: this is a prospective study of patients who were selected for cpbx including cases of possible/probable idiopathic pulmonary fibrosis (ipf). complications of the procedure as well as the quality and pathological characteristics of the tissue are studied. results: twenty-seven procedures were performed in patients, of which were radiologically ipf. a total of biopsies were obtained (average . biopsies per procedure). only one was inadequate initially. fibroblast foci and features consistent with usual interstitial pneumonia (uip) pattern were present in biopsies from patients ( . % of total; % of suspected ipf cases). granulomas were identified in patients ( . %), of which were radiologically suspected ipf ( % of suspected ipf cases). two patients ( . %) had organizing pneumonia; both were inconsistent with ipf radiologically. the findings in the remaining patients were nonspecific; two of these were radiologically ipf ( % of ipf cases). seven patients ( . % of procedures) developed pneumothorax, only of them ( . %) required chest tube drainage. five patients ( . %) developed bleeding (moderate in ( . %) and mild in ( . %)). conclusion: cpbx was useful in this cohort at potentially identifying features not typical of ipf and displayed an acceptable complication rate. cardiomyopathy zj van der klooster ; s sepehrkhouy ; m harakalova ; r goldschmeding ; n de jonge ; ajh suurmeijer ; ra de weger ; f asselbergs ; p a vink introduction: genetic dilated cardiomyopathy is a heterogenous group of diseases caused by mutations in various genes. several types of cardiomyocyte cell death have been implicated in dilated cardiomyopathy: (macro)autophagy-related cell death, apoptosis, necroptosis and oncosis. one plausible mechanism of genetic cardiomyopathy is proteotoxicity of accumulated protein aggregates. we investigated the association of such aggregates as sign of autophagy-related cardiomyocyte cell death with specific pathogenic mutations. methods: hearts from patients with a genetic dilated cardiomyopathy or a combined phenotype of dilated and arrhythmogenic cardiomyopathy were included. microscopic slices from regions were immunohistochemically stained for p , a marker for aggregated proteins destined for autophagy. results: sporadic p positive cells were seen in control hearts ( . % of cardiomyocytes, range . - . %). troponin mutations (tnnt and tnni ; . %, range . - . %, n= ) showed hardly any increase in p . titin ( . %, range . - . % ,n= ) and lamin a/c ( . %, range . - . %, n= ) mutations showed a threefold increase in p staining. a tenfold positive staining was found in desmosomal mutations (pkp and dsp; . %, range . - . %, n= ) and myosin mutations (myh and mybpc ; , % range . - . %, n= ). phospholamban mutations ( . %, range . - %, n= ) and desminopathies (desmin and alpha-b crystallin; % of cardiomyocytes, range . - %, n= ) showed the highest number of p positive cells. conclusion: accumulation of p positive protein aggregates is associated with the type of mutation underlying the dilated cardiomyopathy. titin, lamin a/c and troponin mutations revealed little protein aggregation, whereas desminopathies, phospholamban, desmosomal and myosin mutations show abundant aggregates. this suggests that the type of mutation plays an important role in determining distinct mechanisms of cardiomyocyte cell death. major trauma centre status and its impact on the department of cellular and anatomical pathology in a large tertiary referral centre p ra hadden background: major trauma has been centralised into major trauma centres which act as the focus of major trauma networks. in april , derriford hospital in plymouth, devon became operational as the regional major trauma centre for the south west peninsula. as a result, there was potential for an increased number of trauma-related deaths to be referred to the local coroner, as well as surgical specimens, potentially increasing the work load on pathologists. the case mix could include post-operative cases, neurosurgical cases, polytrauma cases and forensic cases. methods: on admission, all eligible trauma patients are recorded onto the trauma audit & research network (tarn) database. the tarn data was retrospectively analysed and cross referenced with the department of cellular and anatomical pathologies database to determine how many patients had died, how many had post-mortem examinations were performed and how many surgical specimens were sent, on patients from outside the region or transferred from smaller major trauma units. results: over the first two years, there was a small increase in workload from patients who, prior to trauma centre status would have gone to other centres. conclusions: in recieveing patients from elsewhere in the region, there was an increase in workload for both autopsy and non-autopsy work. this excluded some neurosurgical cases, which traditionally would have been referred (as derriford is the neurosurgical centre). there are several areas for implication including, apt time, mortuary space and non-autopsy surgical work. although the workload increase is small, at a time when services are being stretched it is important to ensure any increase in work will not be the "straw that broke the camels back" and can be dealt with accordingly. derriford hospital, plymouth, uk to attempt to streamline general pathologist's approach to the investigation of potentially asbestos-related deaths methods turnaround times, tissue sampling protocol and frequency with which samples were sent for formal fibre counts was investigated for consecutive coronial autopsies at the author's institution. colleagues at other institutions were questioned about their own practice when investigating cases of potential asbestosis, lung cancer or mesothelioma. the author found no consensus in opinion on methods of sampling of the lungs in potential asbestosis, lung cancer or mesothelioma. the most common indication for samples to be sent for asbestos fibre counts was for malignant mesothelioma. sending tissue for fibre counts led to considerable delays in the authorisation of postmortem reports and to significant cost implications. the author presents a pragmatic algorithmic guide to approaching potentially asbestosis-related deaths with suggestions for sampling the lungs and tumour in all cases. in general terms, malignant mesothelioma previously confirmed premortem with histology and immunohistochemistry should not require extensive postmortem histological sampling. lung cancer and asbestosis require widespread sampling of lung tissue to determine amphibole count according to helsinki criteria in the former, and in the latter, assessment of the distribution and degree of fibrosis in addition to fibre count. one or more of these tissue blocks can be sent for formal counts in equivocal cases after following the algorithmic approach. conclusions although predominantly intended as a pragmatic approach to assist the busy practicing autopsy pathologist, the author believes that the algorithm presented will help departments streamline their approach to these cases and help the relative of the deceased gain access to compensation when appropriate in a more timely fashion. purpose of the study: this is a case report of a three year old girl who died suddenly at home. an autopsy was performed in order to determine the cause of death. method: an autopsy was conducted which showed no gross abnormalities. microscopy of the main organs and microbiological samples were taken for further assessment. results: histological assessment of the heart showed multiple small foci of lymphocytes around vessels and within the interstitum of the epicardium, myocardium and subendocardium. these lymphoid aggregates consisted of - lymphocytes up to larger numbers of lymphocytes collectively. several foci were present within virtually all of the sections taken in both right and left ventricles. there was no evidence of myocyte necrosis. immunohistochemistry confirmed they were of t lymphocyte cell origin admixed with smaller numbers of macrophages. histology from the respiratory system showed a diffuse subepithelial lymphocytic infiltrate in the larynx and trachea, and the nasopharyngeal samples detected coronavirus, adenovirus and two types of parainfluenza virus. however, viral polymerase chain reaction (pcr) from the cardiac tissue was negative. conclusion: an unequivocal diagnosis of a myocarditis could not be made in this case due to the lack of myocyte necrosis and the absence of viral dna within the cardiac tissue. genetic testing was strongly advised as splenic material had been taken at autopsy and following molecular genetic techniques a mutation was detected in the sodium channel indicating an inherited ion channelopathy. further genetic counselling and testing of the remaining siblings and family members is being performed. varicose veins affect a third of the uk population. isolated case reports and small series of fatalities resulting from varicose vein haemorrhage appear in the literature infrequently. some of the earliest reports of fatality we have found appear in british medical journal ( ) and the lancet ( ), more recently they have appeared in journals of forensic pathology. our purpose is to establish and bring attention to the rarity of fatality resulting from varicose vein haemorrhage and the importance of the scene of death and autopsy findings. a literature review was undertaken, we obtained relevant office of national statistics (ons) mortality data for the years - , and reviewed our own post-mortem records for demographic, clinical and scene of death information in cases we have encountered. our findings confirm that fatality resulting from varicose veins remains a rare cause of death. some of these deaths are preventable and in nice (national institute of health and care excellence, uk) issued guidelines in which haemorrhage from varicose veins constitute a vascular emergency. importantly emphasis on first aid is required, simply elevating the limb stops bleeding and is life saving, whereas direct pressure and tourniquets do not. pathologists should be aware of potential findings at autopsy in these cases. in particular, awareness that even obscure minor injury to a varicose vein could have resulted in significant blood loss leading to death. blood lost at the scene will not be apparent at autopsy, and details of blood loss could be variably recorded on the scene of death information provided, therefore vigilance is required. histopathologists practice in an era of ever advancing medical treatments for a wide variety of oncological, neurological, haematological and rheumatological diseases. immune modulating therapies are taking a more prominent place in clinical practice. however, with such great advances in therapy comes great risk, with the potential of life threatening opportunistic infections in our patients. we present a series of immunosuppressed patients who acquired such infections and in whom the diagnoses were made by histopathological examination. the spectrum of these pathogens ranges from viral (cmv, ebv, herpes), parasitic (strongyloides) to fungal (p. jirovecii, cryptococcus), and the range of infections is diverse. our series includes males and females, with an age range of - (mean age = years). unsuspected infectious diagnoses were made at post mortem in of the cases. organs affected included lung (n = ), brain (n = ) and haematological system (n = ). in one case both colon and lung were affected (n= ) and in a further case both liver and lung were affected (n= ). immunohistochemistry and/or histochemistry was invaluable in making the diagnoses and was used in all cases (n= ). treatments leading to immunosuppression included chemotherapeutic agents, monoclonal antibodies, steroids and methotrexate. we believe that with the ever increasing use of immunosuppressive therapies (both new and old) for a wider number of disorders, vigilance should be paid to their potential to cause life threatening side effects. histopathologists play a pivotal role in the recognition of this risk and in the diagnosis of these diseases. audit of hospital-based adult autopsy practice in a university hospital from july - p d abu-sinn; f macsweeney the contribution of hospital-based autopsy practice to improvements in patient care is substantial; however, there remains a void in the processes of audit and raising quality of standards in autopsy services. we aim to assess the current autopsy practice compared to rcpath guidelines and identify areas for achieving a high quality autopsy service. all adult autopsy cases performed at a university hospital mortuary between july and were reviewed. a total of adult autopsies were performed by consultant histopathologists. ninety nine percent were coroners' cases. the median turnaround time was . days, with a range of - days, excluding outlier cases (complex timeconsuming cases). there was considerable variation in turnaround times in complex cases and between the various reporting pathologists. eighty five percent of cases were compliant with rcpath minimum dataset for autopsy practice. the remainder were lacking clinical information only. histology and toxicology contributed to cause of death in . % and . % respectively. no organs were retained. further review of the cases not compliant with rcpath guidelines ( %), identified that the possible reasons were the inaccuracy, and sometimes irrelevance to the cause of death, of the information received by the pathologists. in many instances, the clinical information given to the pathologist may be controversial, and a certain degree of caution needs to be implemented to avoid including misleading information in the autopsy report. the turnaround times could be improved if a preliminary report is issued within a set time frame, to be followed by the complete report when the histology and toxicology results are available. however, this practice is not acceptable to some coroners who prefer one complete final report. variations in autopsy practice are to be expected as each autopsy involves substantial case-specific information to which a case-specific answer to the cause of death is expected. prostate cancer is the second most common form of cancer in males, and the incidence of this disease is predicted to double globally by . more than . million new cases of prostate cancer are diagnosed each year and two thirds of these patients are from the western world. the current psa-based test for the diagnosis of prostate cancer lacks specificity, results in missed-diagnoses, over-diagnosis and unnecessary biopsies/treatment. there is an urgent need for a method that enables early accurate detection of prostate cancer. endosomes and lysosomes are cellular compartments that degrade and turnover macromolecules in order to maintain cellular homeostasis. these organelles are directly involved in the critical processes of energy metabolism, cell division, and intracellular signalling, which are all hallmarks of cancer pathogenesis. endosomes have a critical role in controlling the secretion of proteins into extracellular fluids, making them an ideal system to identify new biomarkers that are released from cancer cells. we have discovered that endosome biogenesis (formation and function of endosomes) is altered in prostate cancer. there were significant changes in the gene and protein expression for endosomal proteins and differential distribution of endosome subsets in prostate cancer cell lines. there were also changes to the endosomal traffic and signalling of the transferrin receptor in prostate cancer cells. these fundamental changes in the cell biology of prostate cancer have allowed us to identify a specific set of endosomal proteins that have diagnostic potential. we are developing elisa's to quantify these endosomal proteins in patient samples and antibodies for immune histology applications. the objective for this project is to develop an effective method for the early and specific diagnosis of prostate cancer, which is important as this will have a major impact on patient outcome and survival. the incidence of malignant melanoma has rapidly increased in recent times and melanoma currently represents the second most common cancer diagnosed in young adults. diagnosis is based predominantly on histological assessment; however, due to the wide spectrum of morphological characteristics and lack of firm diagnostic criteria, accurate diagnosis can be challenging. some atypical melanocytic lesions do not display clear-cut morphological features to allow distinction of benign from malignant tumours, making diagnosis and treatment difficult. among these atypical melanocytic lesions blue nevi, spitz nevi and dysplastic lesions are common. from histological features alone, it can be difficult to exclude a diagnosis of melanoma and therefore aggressive surgical strategies may be employed in cases were they are unnecessary, highlighting the need for improved diagnostic techniques. both mrna and mirna profiling have been shown to be able to distinguish benign nevi and primary melanoma tumours. studying mirna expression levels is an attractive strategy as mirnas are highly resistant to degradation and can be easily analysed in ffpe samples. we have studied mirna expression levels in a cohort of benign, blue, spitz and dysplastic nevi versus primary melanoma tumours and their derived metastases. expression levels of key melanoma mirnas, including mirna , mirna , mirna and mirna c can be used to distinguish between nevi and malignant melanomas. we propose an easy to implement, simple and robust molecular method based on mirna expression ratio that, in combination with histological assessment, allows diagnosis of difficult to classify atypical melanocytic lesions. background: diagnosis of lynch syndrome (ls) traditionally relies on clinical criteria to guide diagnostic genetic testing. mmr status of the patient's tumour can help detect lynch syndrome families as well as having other recognised applications for the patient's management including prognostic and predictive significance. as such, the 'dataset for colorectal cancer histopathology report' recommendations from the royal college of pathologists were updated in july to include screening of colorectal cancer patients under the age of and molecular testing for abnormalities in the mismatch repair genes. in south-east of scotland we introduced molecular testing to identify individuals at risk of ls. to widen our screening in line with revised guidelines set by european experts, we expanded our cohort criteria to include those between the age of and . methods: molecular analysis was carried out on individuals: via 'reflex testing' (newly diagnosed colorectal carcinoma ≤ yrs, or clinical/ pathological features associated with mmr defects, such as pre-menopausal endometrial carcinoma, multiple tumours and medullary-type carcinomas) and via 'request testing' (clinical criteria and referral dependent). 'molecular-positive' profiles for ls were identified for genetic pre-testing counselling/diagnostic testing. results: patients with potential ls were identified, ( . %) underwent genetic counselling/testing and cases were confirmed ls with germline pathogenic mutations in the mmr genes. eight of these were identified using reflex testing. conclusion: this is the first uk study to show that screening for ls in patients with colorectal cancer under the age of is effective at identifying families with ls. the testing protocol is in line with the recent recommendations. the human microbiome is rich and diverse, especially in the oral cavity and gastro-intestinal tract, where it has been shown to be more stable in adults, although various factors such as diet and antibiotics mays influence its composition. this pilot study aimed to examine and compare the oral and gut microbial composition in four individuals using a culture-independent approach. methods: saliva and faecal samples were collected from volunteers within the same day on two separate occasions. the v region of the s rrna gene was amplified in all samples and pcr products sequenced on an illumina miseq. unique barcodes were used to sequence multiplexed libraries together. the data were analysed using the quantitative insights into microbial ecology (qiime) software. a second series of samples of faeces from individuals were run to investigate consistency over time. operational taxonomic units (otus) were assessed and showed major phyla represented in the saliva samples: firmicutes, proteobacteria, bacteroidetes, fusobacteria and actinobacteria. similar phyla except forfusobacteria, were found in the stool samples. the weighted unifrac pcoa analysis displayed a clear separation of the sample groups, and also showed a more disperse bacterial profile for the saliva samples, based on population sizes, whereas rarefaction curves and unweighted analysis indicated higher bacterial diversity in the stool samples. each individual could be distinguished either by oral or faecal microbiome. one volunteer who had had previous radiotherapy to the mouth displayed a particularly distinct oral microbiota. the microbial community profiles of saliva and faecal samples of four individuals were found to be distinct from each other, despite sharing similar phyla. analysis of multiple samples from each volunteer clearly separated each sample by volunteer and by sample type. are current automated approaches for determining the phylogeny of multiple deposits capable of interpreting the complexity of cancer evolution? p tg palmer; hm wood; m taylor; w fateen; im carr; p quirke tumour heterogeneity is central to chemotherapy resistance and disease progression in advanced malignancy. this heterogeneity arises due to the evolution of clones within the tumour cell population; the advent of high throughput sequencing has allowed the detection of different tumour cell clones within and between primary tumours and their metastases, potentially allowing mapping of tumour evolution. several, automated bioinformatic approaches have been devised for determining tumour phylogeny from changes in genomic copy number (cn); either by the overall similarity of genomic changes between tumour deposits or by examining the occurrence of shared breakpoints. we have compared these automated approaches with a manual determination of phylogeny based upon shared breakpoints identified from four cases of metastatic colorectal cancer consisting of between and deposits. we illustrate several recurrent issues identified with the use of automated systems for the determination of tumour phylogeny associated with an inability to correctly identify and interpret changes in ploidy, an inability to identify heterogeneity within tumour deposits, the masking of smaller events by larger ones, overinterpretation of convergent, but unrelated events, over calling sequencing artefacts as changes in cn, and non-calling of genuine cn changes due to low tumour cell content or low sequencing depth. we conclude that manual interpretation of bioinformatics data is still required to determine the phylogeny of metastatic cancer within an individual. results: levels of agreement between each sample size and the 'gold standard' were evaluated using bland-altman plots. separate pairwise comparisons were performed. some small sample sizes were shown to have small mean difference and narrow limit of agreement. the ki- pis were then translated into grades and similar comparisons were performed by calculating the kappa score for categorical variables. additionally, the interobserver variation between the two independent researchers were calculated. conclusion: smaller sample sizes (below ) tend to overestimate the ki- pis, possibly due to the effect of concentric counting starting from the center of the hotspot. however, the ki- pis do start to stabilise closer to (e.g. ). the interpretation of whether a lower sample size can replace the current standard would be a subjective decision, but the kappa score gives a rough idea of how much it affects the clinical grading. updated data will be presented. purpose of the study: targeting the stem cell properties of tumor-initiating cells is an avenue through which cancer treatment may be improved. before this can be achieved, so-called cancer stem cell (csc) models must be developed and characterized in specific malignancies. methods: in this study, holoclone formation assays were used to characterize stem-like molecular signatures for prostate cancer (pca) cells. summary of results: lncap and pc parent cells were capable of responding to stem cell differentiation morphogen retinoic acid (ra), suggesting the presence of inherent stemlike properties. lncap cells, which represent early, androgen-responsive disease, formed holoclones after twenty six days. pc cells, which represent advanced, metastatic, castrationresistant disease, formed holoclones after only six days. holoclones displayed decreased expression of ra-genes, suggesting a more immature, less differentiated phenotype. gene and mircorna arrays demonstrated that holoclones downregulated a number of stem cell differentiation regulators while displaying enhanced regulation of g to m transition and the mitotic spindle checkpoint components of the cell cycle. pc holoclones displayed pronounced downregulation of known regulators of osteoblast differentiation from mesenchymal stem cells and epithelial mesenchymal transition. conclusion: our results suggest that some pca cells retain the ability to transition to a more immature state in which differentiation and metastatic mechanisms are changed. the highlighting of osteoblast differentiation regulators in this mechanism is particularly notable, considering the propensity of pca to metastasize to bone. we examined by flow cytometetry the interaction in vitro between platelets and human cancer cell lines of different origin and metastatic potential. the emt profile of cells hr post platelet exposure was assessed by morphology and gene expression analysis (rt-pcr). here we showed that platelet cloaking of cancer cells is universal, occurring across all tumour types examined. however, it is heterogeneous with adhesion rates varying both across and within tumour types, from % (pc -metastatic prostate cancer) to % (skmes -metastatic lung cancer). changes indicative of emt were seen in all cell lines. however, again they were heterogeneous in nature; with morphology changes akin to emt observed at varying degrees across the cancer types. also, there was no consistent pattern to the emt-like gene expression changes seen, with one exception a significant increase in the expression of plasminogen activator inhibitor (pai- )was observed in % of the cell lines examined. in this study we describe the universal nature of platelet cloaking and that even though the interaction is not inducing precisely the same molecular changes in all the cancer cells; overall it is driving these cells into a mesenchymal phenotype. giant cell tumours of bone (gct) are primary locally aggressive bone tumours with a recurrence rate of up to ~ %. the tumour is characterised by numerous osteoclasts and neoplastic stromal cells. making a diagnosis can be challenging because the differential diagnosis incudes an array of benign osteoclast-rich tumours but also osteoclast-rich osteosarcoma. recently the occurrence of h f a p.gly try (g w) and g l mutations was reported in % of gct, the latter occurring rarely. these mutations occur in less than % of > other benign and malignant bone tumours. it has been emphasised that a diagnosis of gct should be made with caution in the absence of detection of g w substitution. given the diagnostic importance of g w mutation in gct, we have developed a simple, quick and cost-efficient diagnostic test to detect this recurrent alteration in ffpe dna using droplet digital pcr (ddpcr). the ddpcr data from dna of > gct have been compared with previous 'genotype' data generated using sanger sequencing, and a number of next generation sequencing approaches (whole exome, whole genome and targeted panels). the g w and g l can both be detected in a single assay. we have demonstrated the sensitivity, specificity, repeatability and robustness of the test to be very high with a turnaround time of no more than working days. as ~ % of gct recur locally following curettage a blood test would be valuable to monitor patients. to this end the ddpcr test also shows that the mutation can be detected in plasma. typically resistant to chemotherapy and radiotherapy, high grade disease has been treated by surgery for more than years. it has recently been shown that idh and idh mutations are present ab initio in ~ % of chondrosarcoma cases and that these are retained throughout disease progression. this has opened up a number of new potential diagnostic, biomarker and therapeutic options. digital pcr is currently the most sensitive and accurate method for detecting and quantifying mutant dna molecules. the biorad qx digital pcr platform is also both cost effective and scalable. using the qx platform, we have developed assays for the common idh mutations and the common idh mutation. we have developed the idh assays both in singleplex and multiplex. we have optimised and validated all assays in tissue samples demonstrating both high sensitivity and specificity when compared to previously genotypes samples. we have demonstrated that the assays are quantitative over orders of magnitude and in high quality dna we can detect idh mutations at below mutant molecule in , wild type molecules. in a pilot study, we have used digital pcr to analyse circulating tumour dna levels in plasma taken pre-surgery from patients whose chondrosarcoma harbour an idh mutation. it was possible to detect idh mutant molecules in plasma of all grade iii samples, % of grade ii and none of the grade i samples. in of these cases where the ctdna was also measured post-operatively, the levels of ctdna dropped dramatically. tumour necrosis factor receptor, cd , gene functions as an oncogene and promotes cell proliferation in colorectal cancer cell lines p haa almasmoum; h thorpe; m ilyas introduction: cd is a tumour necrosis factor (tnf) receptor which regulates a range of cellular responses. cd is activated by its ligand cd l and may promote tumourigenesis in haematological cancers. however, cd functions as a tumour suppressor in solid cancers. cd maps to chromosome q , a region which is amplified in - % of colorectal cancer (crc). the functional activities of cd were tested in crc cell lines for cell proliferation and motility. methods: expression of cd was screened in crc cell lines by western blot. to define the role of cd in human crc, we knocked down cd using small interfering rna (sirna) and the knockdown was confirmed by qpcr and western blot. the prestoblue assay was used to study proliferation in colorectal cell lines, and flow cytometry to study the cell cycle. transwell migration and wound healing assays were performed to investigate the effect of cd on cell motility in crc. result: cd was expressed in crc cell lines hct , rko, dld and ht , and not expressed in sw and sw cell lines. knockdown of cd reduced cellular proliferation in hct (p= . ) and dld (p= . ) cell lines. knockdown of cd showed a higher number of cells in the sub g phase (dead cells) in the cell cycle analysis compared to the control. however, knockdown of cd in hct did not have an effect on cell motility in both the transwell migration (hct = p= . ) and wound healing assays. discussion: cd exhibited oncogenic activity in crc cell lines. cd enhanced cell proliferation but not cell motility in crc cell lines. the expression of cd (common leucocyte antigen) and cytokeratin is thought to be mutually exclusive with cd expression largely restricted to haematological malignancies and cytokeratin expression largely restricted to carcinomas. we report two clinically relevant cases. the first case is a urinary bladder biopsy showing a high grade malignant tumour with cells that had scanty cytoplasm, hyperchromatic stippled nuclei and high mitotic activity. nuclear molding was present. the tumour cells showed focal strong positivity for ck and diffuse positivity for cd and synaptophysin. focal positivity for cd was present and confirmed on repeat staining. the morphology and immunoprofile was consistent with a small cell carcinoma showing aberrant cd expression. the second case is a maxillary tumour biopsy composed of medium/large atypical lymphoid cells with hyperchromatic nuclei, small nucleoli and scanty cytoplasm. mitoses and apoptotic cells were noted. immunohistochemistry showed the atypical cells to express cd , cd a, bcl and mum but not cd , cd , cd , cyclin d , cd , tdt, alk , cd , cd , neuroendocrine or melanocytic markers. a high ki proliferation fraction was present. the appearances were consistent with a diffuse large b-cell lymphoma. the above cases highlight the possibility of aberrant expression as well as loss of expression of immunohistochemical markers by neoplastic cells in undifferentiated malignancies. attention to tumour morphology may provide diagnostic clues. interpretation of immunohistochemistry in the context of tumour morphology as well as awareness of aberrant expression/loss of expression can help avoid diagnostic error. accurate, timely diagnosis is the ultimate aim in surgical pathology. numerous histological pitfalls and lesional mimics exist, with the need to maintain an awareness of such entities vital if potentially serious misdiagnoses are to be avoided. this case report describes two distinct lesions within the same lymph node, both of which are potential mimics of each other. a year old female presented with a three week history of a left breast lump. she had no known previous breast disease or any associated risk factors. a needle core biopsy of this clinically and radiologically suspicious mass yielded a diagnosis of grade invasive lobular carcinoma. left axillary sentinel node biopsy was thus undertaken. two hot and blue sentinel lymph nodes were excised. one was free of neoplasia, the second contained benign naevus cell inclusions within the capsule together with a micrometastasis. immunocytochemistry confirmed the presence of two distinct cell populations; the benign naevus inclusion cells stained positively for s but not for ae / , the reverse pattern was observed in the invasive lobular carcinoma cells. heterotrophic benign inclusions within lymph nodes are an infrequent yet well recognised entity. ridolfi et al reviewed the lymph nodes from axillary surgery patients and found . % of lymph nodes contained benign naevus cell inclusions. small benign naevus cells within the capsule of a lymph node can resemble the 'indian file' pattern of classic invasive lobular carcinoma. this case is unusual in that both metastatic carcinoma and benign naevus inclusion cells were present within the same lymph node, enabling a clear comparison of the cytomorphology and immunoprofile of these two distinct lesions. an awareness of benign inclusions within lymph nodes helps to avoid the potential for misdiagnosis. the judicious use of immunocytochemistry can be useful in distinguishing benign inclusions from carcinoma. recently there has been increasing recognition of distinct breast cancer phenotypes. of these, basal phenotype breast cancer (bbc) has attracted particular interest since the majority are triple negative (tn); have an aggressive natural history and can be associated with brca germline mutation. this area is mired in difficulty, as a precise unifying definition of bbc remains elusive. several morphological features more prevalent in bbc have been identified. in our practise we noticed variable use of 'basal' in reports. given this, whilst no specific therapies to bbc currently exist, we felt it necessary to understand how accurate our designations have been and whether this is a worthwhile practise. method: the diagnostic database was searched for all malignant tn breast resections or reports containing the word 'basal' within -months. tn was defined as allred score er - / , pr - / and her , + or + negative on fish. for completeness, we considered including all breast cancers, but pragmatically this was not possible. we carried out ck and ck staining on all cases where not performed. results: of the invasive breast cancers, cases ( %) were identified, of which % were tn and % were designated bbc in the report. % were both tn and bbc. where a diagnosis of bbc was made, % of cases had additional markers requested. preliminary results showed % were ck + and ck +. this is higher than other studies, implying specificity but not sensitivity in suspecting bbc amongst reporting pathologists. discussion: a limitation of this review is that it cannot identify the rare non-tn bbc not diagnosed as such. it also represents current practise in a single institute and may not reflect national practise. we identified patchy use of the designation bbc, with overall under-reporting of this subtype. we recommend that if it becomes necessary to distinguish bbc lesions, additional markers studies, such as ck and be consistently performed. purpose: neoadjuvant chemotherapy (nact) is increasingly used for the management of large but operable, inflammatory, and locally advanced breast cancer (labc). little is known about predictors of response/survival following nact. the topoisomerase iiα (top a ) gene, a key regulator of dna repair and modelling, is thought to be target for anthracyclin and other chemotherapeutic agents. the aim of this study is to assess the role of top a as marker for response/resistance to nact and patient outcome. methods: patients who underwent nact, predominantly anthracyclin, for primary and operable invasive carcinoma or labc in the period between to at a single large tertiary referral breast unit were identified. comprehensive data on chemotherapy regimen, surgical treatment, pathological response and survival were collected. pre-treatment tumour samples were stained for standard predictive and prognostic markers and top a. results were correlated with pathological response (pr) and patient survival. results: patients fulfilled inclusion criteria. mean age was . ys. complete pr was achieved in . %. the mean expression level of top a in pre-treatment core biopsies was . %, range - %. there was significantly higher expression in high grade tumours (p= . ) and positive correlation with ki expression (r= . , p< . ). there was no correlation with nodal status, pr or her expression. cases with high expression (> %), had significantly worse overall survival (mean vs months, p= . ). this was also identified in the endocrine non responsive group (er allred score≤ ), mean vs months, p= . . on multivariate analysis, top a was not an independent factor for overall survival. conclusions: top a protein is expressed in high grade breast carcinoma with high ki proliferation index. its expression in pre-treatment biopsies predicted patient outcome in the neoadjuvant setting. this strong adverse effect on survival warrents further prospective investigation as a marker of outcome in nact patients. the risk of circumferential resection margin (crm) involvement is confined to tumours of the rectum with the risk of peritoneal involvement increasing the further a tumour is located above the peritoneal reflection. there is no internationally accepted definition of the upper limit of the rectum, and the term 'rectosigmoid' is frequently applied to tumours in this area leading to confusion around the risks and whether radiotherapy can be given. the photographs from abdominoperineal excision specimens were available for quantitation using aperio imagescope. both fresh and fixed specimen images were included where available. the position of the anal verge, top of the sphincters, anterior peritoneal reflection, mesorectal apex (defining the limit of the mesorectum) and high vascular tie were identified and the distances between each point measured. the work was supported by a pathsoc bursary. there was wide variation in the length of the mesorectum in both fresh (median mm, iqr to mm) and fixed ( mm, to mm) specimens. the length of the anal canal also showed variation (fresh mm, to mm; fixed mm, to mm). the height of the anterior peritoneal reflection was lower in females compared to males (fresh vs. mm, p= . ; fixed vs. mm, p= . ). there is marked variability in the anatomy of the rectum between individuals and genders. this potentially affects the risk of either crm or peritoneal involvement and whether radiotherapy could be offered. a fixed definition of the upper limit of the rectum for all patients is not helpful. this should be determined for individual patients on the basis of the mri findings. the term 'rectosigmoid' should be abolished and more accurate definitions based on the position of the mesorectal apex and commencement of the sigmoid mesentery should be used to define the boundaries of the rectum and sigmoid colon and determine subsequent risks to the patient. pre-operative chemoradiotherapy (crt) with anti-egfr antibodies may change the status of egfr pathway mutations. we assessed the mutational status of a number of egfr pathway genes before and after crt in the nwcog excite trial. patients with mri-threatened surgical margins were given pelvic radiotherapy ( gy) with capecitabine, irinotecan and cetuximab followed by surgery after weeks. dna was retrospectively extracted from the pre-treatment biopsy and resection specimen by macrodissecting areas of greatest residual tumour. the mutational status of kras (codons / / / ), nras ( / / ), pik ca ( / / / ) and braf (v e hotspot) were determined by pyrosequencing. the work is presented on behalf of the nwcog excite trial investigators and was part-funded by a pathsoc fellowship. patients commenced treatment and underwent surgery with pathological complete response in ( %) and near-complete in ( %). pre-treatment testing (n= ) detected mutations in kras (n= ), braf (n= ), nras (n= ) and pik ca (n= ). any egfr pathway mutation was detected in %. following crt, cases with residual tumour able to be tested (n= ) showed mutations in patients ( %). there was a discrepancy compared to pre-treatment biopsy in cases ( %): from wild-type (wt) to mutant (mut) in , from mut to different mut in and from mut to wt in . one patient changed in codons (mut to wt in kras /pik ca and wt to mut in kras ). in patients ( %) this changed their overall egfr pathway status ( x wt to mut and x mut to wt). intratumour heterogeneity may explain some of the differences in egfr pathway mutations reported between biopsies and resections presenting a challenge to personalised medicine. however, cetuximab may also drive the growth of undetectable mutant clones to detectable levels on pyrosequencing. further assessment using more sensitive sequencing technologies is currently being employed to investigate these differences. there is a vast amount of historical ffpe material held in archives, but due to variations in fixation and processing this presents several challenges when applying newer genomic technologies to it. in this study we compared the genomic information obtained with the oncoscan® ffpe assay kit (oncoscan) and next generation sequencing (ngs). samples from patients were obtained from centres taking part in the mrc cr trial of short course radiotherapy versus selective long course chemoradiotherapy in rectal cancer. dna was prepared using agilent sureselect kits and sequenced using illumina platforms in parallel to analysis using the oncoscan assay. for both methods, quality control (qc) data was generated and the sample classified as a 'pass' if it fell within the pre-defined qc boundaries. for the oncoscan assay, copy number (cn) and somatic mutation (sm) data was further investigated. this study was part funded by a pathsoc fellowship. in total, cases ( %) passed the ngs qc and ( %) passed the oncoscan qc. a total of ( %) passed qc on both platforms with marked variability in sample pass rates between the centres for the ngs (range % to %) and oncoscan (ranges % to %). when assessed manually, the oncoscan sm data was considered acceptable for cases ( %), which included initially classified as 'failed' by the qc data. similarly, the oncoscan cnv data was interpretable for the majority of cases. this study has shown that whilst historical dna held in the ffpe blocks of archival clinical trials like mrc cr can present challenges when using new genomic technologies, a large proportion of samples can still yield valuable genomic data. marked variation exists in the quality of genomic material between centres confirming that differences in specimen handling affect dna quality. prospective trials must address this by standardising fixation and processing protocols. the plane of colon cancer resection has recently been shown to predict survival. complete mesocolic excision (cme) with central vascular ligation (cvl) produces an oncologically superior specimen and appears to be related to optimal outcomes. we aimed to assess whether a regional educational programme in cme with cvl led to an improvement in the quality of colon cancer specimens. following a regional educational programme in cme with cvl in the capital and zealand areas of denmark, cases of primary colon cancer resected across six hospitals were assessed by grading the plane of surgery and undertaking tissue morphometry. these were compared to specimens resected prior to the educational programme. this work was partly supported by a pathsoc undergraduate bursary. across the region, the mesocolic plane resection rate improved from % to % (p< . ). hillerød hospital had implemented cme with cvl as standard prior to the educational programme and continued to produce optimal specimens. three of the other hospitals showed a significant improvement in the plane of surgical resection. hillerød specimens continued to be more radical with a greater distance between the tumour and the high tie, area of mesentery and lymph node yield compared to the other five hospitals. a multidisciplinary regional educational programme in cme with cvl has improved the oncological quality of colon cancer specimens as assessed by mesocolic planes, however, there has been no significant effect on the amount of tissue resected. surgeons at hillerød continue to produce more radical specimens suggesting that such educational programmes are not alone sufficient to increase the amount of tissue resected around the tumour. hillerød have recently published their long term outcomes with survivals being % higher when compared to other hospitals across the region. further engagement is now necessary to ensure that optimal outcomes are achieved across the region. investigating the faecal microbiome in formalin fixed paraffin embedded (ffpe) material p itr jobling ; m taylor ; c young ; hm wood ; p quirke university of leeds, leeds, uk; leeds institute of cancer and pathology, leeds, uk purpose: research into the faecal microbiome has shown a diverse population with a high level of variability between individuals. altered faecal microbiomes are present in a range of diseases but work remains to understand their role in gastrointestinal disease. current research into the microbiome makes use of fresh or frozen faecal samples. this restricts researchers to predominantly prospective study designs. one potential method for rapidly increasing and diversifying research is the retrospective study of ffpe material. we aimed to investigate the feasibility of typing the microbiome in ffpe faecal samples using next generation sequencing (ngs) technology. methods: material from six faecal samples was divided and stored as frozen or fixed and paraffin embedded creating two matched sub-groups. to assess assay sensitivity one sample was diluted to eight different concentrations before fixing and embedding. the v and v regions of the s rrna gene were amplified. primer pairs created approximately bp and bp targets in e.coli respectively. pcr products were multiplexed and sequenced on an illumina miseq. qiime software was used for analysis. results: analysis of alpha (within sample) diversity showed a significant difference between sub-groups when targeting v (p= . ) but not v . analysis of beta (between sample) diversity showed a significant difference between sub-groups when targeting v (p= . ) while the v region showed a reduced, but still significant (p= . ) difference. the sensitivity assay showed comparable results down to . % concentration levels. conclusion: to our knowledge this is the first feasibility study generating ngs data on the microbiome from ffpe faecal material. variation between matched frozen and ffpe faecal material was less when targeting v compared to v . we hypothesise this may be due to the shorter amplicon undergoing less dna fragmentation in ffpe material. there are several platforms available for dna mutation detection in formalin-fixed paraffin-embedded (ffpe) material, all with their relative strengths and weaknesses. we investigated the oncoscan® ffpe assay kit (oncoscan) in comparison to pyrosequencing in patients with operable colon cancer recruited to the phase ii component of the ncri foxtrot trial of pre-operative vs. post-operative chemotherapy. ffpe samples of tumour from the resection specimens of cases were tested for kras / / and braf v e mutations using pyrosequencing. the oncoscan assay allows for the interrogation of mutations across nine genes. pre-extracted dna was analysed on the oncoscan assay and quality control (qc) scores generated, indicating confidence in mutation calling results. the mutational status of all samples was automatically assessed in the affymetrix sm viewer, and then manually confirmed. this work is presented on behalf of the foxtrot collaborative and was part funded by a pathsoc fellowship. out of samples, failed oncoscan qc thresholds, however, only of these were deemed inconclusive by manual interrogation. samples were interpretable by pyrosequencing. of the samples that produced conclusive results on both platforms, the concordance rate was very high at . % when calling a mutated versus non-mutated kras/braf status. mutations were 'missed' by pyrosequencing in only case ( . %) and by oncoscan in cases ( . %). in addition, the oncoscan assay provides mutational data in additional genes along with copy number (cn) and loss of heterozygosity (loh) information. in patients with colon cancer recruited to the ncri foxtrot trial, the oncoscan ffpe assay shows good correlation with pyrosequencing when determining the mutational status of kras/braf. although pyrosequencing has a slightly lower failure rate, the oncoscan has the added advantage of targeting more mutations, producing genome wide cn, and loh information in one assay. excellent anatomical knowledge of the rectum and surrounding structures is essential for total mesorectal excision (tme). denonvilliers' fascia (dvf) has been frequently studied, though the optimal anterior plane in tme is still disputed. the relationship of the lateral edge of dvf to the autonomic nerves is also unclear. we studied whole-mount microscopic sections of en-bloc cadaveric pelvic exenteration specimens and describe implications for tme. four human adult cadaveric specimens (two males, two females) were obtained from the leeds gift research tissue programme. paraffin-embedded mega-blocks were produced and serially sectioned at and µm intervals. sections were stained with haematoxylin & eosin, masson's trichrome and millers' elastin. additionally, a developmental series of eleven human fetal pelvic specimens (embryonic age of - weeks) were studied. dvf consisted of multiple fascial condensations of collagen and smooth muscle fibres and was indistinguishable from the anterior mesorectal fascia and the capsule of the prostate or posterior vaginal wall. the lateral edges of dvf appeared fan-shaped, and the most posterior part was continuous with the mesorectal fascia. peri-rectal fasciae were not identified in fetal specimens. dvf is adherent to and continuous with the mesorectal fascia. optimal surgical dissection during tme should be carried out anterior to dvf to ensure radical removal, particularly for anterior tumours. autonomic nerves are at risk, but can be preserved by following the mesorectal fascia along the anterolateral mesorectum. the lack of evident fasciae in fetal specimens suggests that these might be formed in later developmental stages. the perineal body (pb) is poorly understood. in abdominoperineal excision (ape), there is no natural dissection plane through the pb. knowledge of the pb is essential to avoid straying in to incorrect planes leading to tumour perforation and unnecessary urogenital and anorectal injuries. this study describes the anatomy of the pb and the implications for ape. six human adult cadaveric specimens (three males, three females) were obtained from the leeds gift research tissue programme. paraffin-embedded mega-blocks containing the pb were produced and serially sectioned at and µm intervals. sections were stained to reveal collagen and elastin, and with an antibody against α-smooth muscle actin. the pb is formed of a fibromuscular mass, which was thicker and wider in female specimens compared to males, extending from the external anal sphincter to the rectogenital septum. muscles from the urogenital diaphragm and anterior rectal wall anchored into the pb. the longitudinal muscle (lm) of the rectal muscularis propria extended in anterolateral directions and intertwined with the somatic pelvic floor muscles to create strong fixation of the anorectum. the lm plays a dominant role in the formation of the pb. surgeons should be aware of the complex course of the lm through the pb to prevent injuries to the urogenital organs and perforation of the anterior rectal wall. the perineal phase of an ape starts with excellent exposure followed by proper tension on the pb to allow safe dissection through the densely-packed fibromuscular mass. introduction: ki is a proliferation marker that is exclusively present in dividing cells and absent in resting cells. its expression has already been studied in different cancers and used to understand the cellular organisation of barrett's epithelium (lavery ). however, very little is known about the cellular organisation based on ki expression patterns in upper gi sequence. this study aims to examine the cellular organisation as defined by ki expression patterns in upper gi cancer sequence. methods: ki expression within barrett's crypts was assessed in cases (nbde , lgd , hgd ) . the barrett's crypts were divided into three equal regions: crypt base (bottom third), middle region and the surface (upper third), respectively. ki was scored using the allred system and analysed using one-way anova with bonferroni post-hoc analysis. results: one-way anova showed significant difference across the three groups (p < . ). bonferroni post-hoc analysis showed significant difference in the surface architecture between nbde and hgd (p < . ) and lgd and hgd (p < . ). for the middle region, although there was no statistical significance between the groups, nbde and lgd and lgd and hgd showed statistical trends (p = . and p = . respectively). for the basal compartment there was significant difference between nbde and lgd (p = . ). this study showed for the first time a significant difference in the ki expression between nbde, lgd and hgd in the basal and surface regions. middle compartments showed trends but additional ndbe, lgd and hgd groups need to be analysed to increase the statistical power. the results warrant further molecular analysis between the various groups and show a clear role for proliferation in the maintenance of the cellular architecture and organisation across the upper gi groups which might help in the understanding of the origin and development of oac. • frequency of serosal involvement in rectal cancers (suggested contributing factors for this include effect of pre-operative therapy, tumour regression and recent changes in surgical practice). • turnaround times: suggested contributing factors include increased departmental workload, retirements and reduced reporting capacity. the following action plan was implemented to improve compliance with standards: • ensure all pathologists are aware of results via presentation/dissemination of audit report • identify issues affecting turn-around times and improvement strategies • support recruitment to increase reporting capacity. • maintain awareness of the need to recognise serosal involvement in rectal excisions. • re-audit in year. the design and maintenance of a pilot online digital archive of archetype colorectal polyps and gastrointestinal (gi) teaching cases for the national bowl screening programme (bowelscreen) in the republic of ireland. methods: suitable internal and referral cases were identified by bowelscreen consultants at saint vincent's university hospital. these cases were subject to both internal and external review, by the mater misericordiae university hospital, and represented typical examples of lesions seen in a national bowel cancer screening programmes (e.g adenomas, ssls, adenomas with misplacement, tsas). representative slides, including immunohistochemistry, were anonymised and digitised using the hamamatsu nanozoomer digital pathology (ndp) whole slide scanner platform and associated software packages (ndp scan and view). whole slide images (wsi) were uploaded to secure cloud storage using a generic file transfer protocol program. wsi were collated into cases and accessible via the pathxl gateway (pathxl.co.uk) by approved users via an online case referral and reporting system. users were notified of pending cases via email and the viewing of wsi occurred within the user's web browser utilising an online version of ndp view program and did not require local use of propriety software. each case was referred across the two participating sites and scored in four areas; diagnosis concordance, quality of wsi, web interface and the online referral and reporting system. conclusion: with the maturation of technology involved in digital microscopy a digital archive program is now a feasible approach to the standardisation of diagnosis and a useful adjunct to traditional optical microscopy in education within the national bowel screening programme. conclusions: a committed and conscientious bms can learn how to report histopathology cases. however, if this is to be achieved, the department in which he or she works must also be committed and supportive. carcinoid tumour of the appendix: a case report p aae shalaby; p aae shalaby a case of a years male operated on for acute appendicitis and an incidental finding of a carcinoid tumour at the tip is reported. the tumour was less than cm in greatest dimension but it infiltrates through the wall of the appendix into the surrounding fat. it stains positive for the neuroendocrine markers. carcinoid tumour of the appendix is unusual, but it has to be looked for during examination of appendectomy specimens done for appendicitis ( . %). women are more frequently affected than men ( : ) and the tumour is usually small less than cm in diameter and frequently located at the tip. it is usually diagnosed incidentally after an operation for acute appendicitis and sometimes during other procedures (colectomy, cholecystectomy and others). the tumour rarely metastasis to the liver and this is usually related to the tumour diameter) and can cause a "carcinoid syndrome": flush, diarrhea bronchoconstriction, cardiac valve disease. diagnosis is made by the pathologist and staging by conventional radiologic procedures (tac, us), dosage of neuroendocrine mediators such as hours urinary -hiaa. simple appendectomy is adequate treatment for appendicular carcinoids less than cm in diameter. adequate treatment for tumours greater than cm is right hemicolectomy. the mangement of tumours to cm range is controverisal, but generally, appendectomy alone is sufficient except when meso-appendix is invaded. carcinoid tumour of the appendix has a good prognosis with a -year-survival rate, of - %. the prevalence of epithelial changes in helicobacter pylori-associated gastritis in oman: a retrospective study p aae shalaby; a al saadi there is strong association between h. pylori gastric infection and epithelial changes and progression to cancer. it has been shown that h pylori infection is strongly associated with high proliferative activity and it could be a risk of initial step of gastric carcinogenesis. the aim of this study was to examine the association between epithelial changes in the gastric mucosa and gastric h pylori infection in oman by retrospective examination of the gastric biopsies for patients presented to sultan qaboos university hospital (squh) in . a total of biopsies were studied with a prevalence of h pylori infection in % with about % showing epithelial changes, mainly intestinal metaplasia in % out of the h pylori positive cases, a few cases with low grade dysplasia and reactive atypia. in cocnlusion intestinal metaplasia was the main epithelial change that was related to h pylori infection. further studues are required to investigate the relation between h pylori infection and the progression to gastric carcinoma. purpose of the study: low rectal carcinoma may require abdomino-perineal excision of the rectum (aper), which has been associated with higher rates of tumour perforation and circumferential margin (crm) involvement than anterior resection. this increases the risk of local recurrence and may necessitate adjuvant treatment. the extralevator abdominoperineal excision of rectum (elape) in the prone position has been found to improve these outcomes and has been encouraged by the low rectal cancer national development programme (lorec). we aimed to assess the effect of increasing the practice of elape on the histological and oncological outcomes in these cases in the mid-yorkshire nhs trust, a large district general hospital. in the number of surgeons routinely performing aper was reduced and all those performing the procedure had been trained in the cylindrical resection technique. joint operating and laparoscopic procedures were encouraged. a retrospective review of case notes and histological reports between and was performed (before and after sub-specialisation). patient demographics, histological findings and complications including local recurrence were recorded. summary of results: between and , apers were performed, with tumour perforation in ( %) and crm involvement in ( %) of cases. after sub-specialisation, were performed. none were perforated and cases ( %) showed margin involvement. local recurrence occurred in two cases before specialisation and none after at the time of follow-up. joint operating and subspecialisation increased the number of cases performed by each surgeon, and the number performed laparoscopically. conclusions: elape in conjunction with departmental restructuring significantly improves immediate oncological outcomes in a dgh setting, with no effect on day mortality. the technique may reduce local recurrence, although longer follow-up would be required. background: systems biology uses computational and simulation approaches to interrogate gene expression datasets and explore biological pathways. by employing systems biology and data mining tools we can identify new biomarkers. our objective was to ascertain the utility of a novel panel of systems biology derived biomarkers in cervical pre-cancer for more accurate grading and stratification of cin disease. methods: this project is conducted within the framework of an fp funded programme "systemcerv". gene pathways were analysed using matlab and sirene. along with accessing keggs online database for gene prediction and david for gene functional classification, we identified a novel panel of biomarkers. gephi software was used to visualise communities of genes related to cervical pre-cancer and cancer progression. clinical validation was performed by immunohistochemistry on a range of cervical lletz specimens (normal, cin , cin and cin ). all patients gave written informed consent. in parallel, p ihc was performed on all specimens as a benchmark stain. the mortality associated with cervical cancer can be reduced if the disease is detected at the early stages of development or at the pre-malignant stage. the pap smear is the current screening method, but is highly subjective and can often exhibit low specificity and sensitivity. for this reason, either a replacement or supportive technique is necessary to improve the quality of cervical cancer screening. raman spectroscopy is a powerful tool that can generate a biochemical fingerprint of a sample in a rapid and non-destructive manner. in this study, raman spectroscopy has been applied to the investigation of cervical cells from preservcyt specimens. raman measurements were taken from the nuclei of cervical cells from normal, cin , and cin samples. these spectra were processed, analysed and used to define a spectral signature for each grade of cervical disease. principal component analysis (pca) was used to discriminate between the two data sets. distinct raman spectral differences were detected between normal, cin and cin cells. notably, it was possible to observe spectral peak shifts representing fluctuations in guanine (dna/rna), ch deformation in proteins and carbohydrates, carbon-carbon double bonds in phenylalanine, tyrosine and tryptophan, and amide i. the pca showed an excellent discrimination between the data sets. this study has shown that raman spectroscopy can detect subtle changes between cervical cells, and may be a powerful tool for improved diagnosis of cervical dysplasia. background: myd and mad are two potential prognostic biomarkers that have been investigated in ovarian cancer. high myd and low mad ihc staining is associated with reduced pfs, both markers are also linked to paclitaxel chemoresistance. the main objective of this study was to assess the in vitro relationship between mad and myd , through alteration of mad , myd or its receptor tlr in two ovarian cancer cell lines using sirna targeting mad , tlr or myd and a myd overexpression plasmid vector. following overexpression/sirna knockdown procedures, myd , tlr and mad expression was assessed through qpcr and western blot analysis. mir- , mir- and mir- a gene expression was also assessed by qpcr. furthermore the effect of tlr / myd knockdown on chemoresponse was assessed in skov- cells using the cck- assay. results/discussion: it was found that knockdown or overexpression of myd in skov- or a cells respectively or knockdown of tlr in skov- cells had no effect on mad expression or the expression of mir- , mir- and mir- a. interestingly however knockdown of mad in both cell lines induced a fold increase in tlr expression, furthermore knockdown of tlr in skov- cells was shown to restore chemosensitivity to paclitaxel. the results demonstrate a potential in vitro link between tlr and mad and support a role for tlr in paclitaxel chemoresistance. background: the prognosis of epithelial ovarian cancer is poor in part due to the high frequency of chemoresistance. recent evidence points to the toll-like receptor- (tlr ), and particularly its adaptor protein myd , as one potential mediator of this resistance. downregulation of mad , a key component of the spindle assembly checkpoint complex, has also been linked with paclitaxel resistance . both markers have individually been shown to be associated with poor outcome in ovarian cancer. high myd and low mad immunohistochemical staining is associated with reduced progression free survival. the main objective of this study was to assess the combined utility of mad and myd in predicting patient prognosis. methods: two tissue microarrays composed of cores from high grade serous epithelial ovarian cancers patients were constructed and stained for mad and myd . staining was scored based on previously derived scoring schemes for myd or mad staining. the mean overall score from triplicate cores was then used to classify patients into high and low staining categories. results: a trend towards reduced progression free and overall survival was observed in patients with high myd and low mad expression. the results demonstrate the combined utility of mad and myd as predictors of prognosis in ovarian cancer. purpose: ovarian cancer is characterised by high rates of terminal, chemoresistant recurrence. although chemoresistance is known to be a property of cancer stem cells (cscs), the mechanism is poorly understood. we have previously identified a novel four-member csc stem-progenitor cell hierarchy for ovarian cancer. the aim of this study was to characterise the contribution of each member of the ovarian csc hierarchy to chemoresistance. methods: the csc hierarchy was assessed for tolerance to chemotherapy drug cisplatin (mtt assay) both as components of the parent population (a cell line) and as isolated cell types. the hierarchy was additionally assessed in the long-term cisplatin-adapted 'a cis' cell line. cell types were analysed and isolated via flow cytometry and assessed for stem cell characteristic via single-cell asymmetric division and murine xenograft tumourigenicity assays, and molecularly characterised (whole transcriptome arrays). results: cisplain dose-response assays from a -derived csc sub-populations indicated that only one of the four populations within the hierarchy had a high cisplatin-tolerance (ic = um) compared to the other populations (ic = um). this was notable as the relative cisplatin ic s for the a and a cis parent cell lines are um and um respectively. treatment of the parent a cell line with the ic ( hours) resulted in a proportional % loss in each of the four cell types, suggesting that this specific csc subpopulation adapts to cisplatin over a longer period of time. conclusion: although cscs are known to be chemoresistant, the mechanism though which this is achieved is poorly understood. our data indicates that only some members of a csc hierarchy are responsible for chemoresistance. notably, this sub-population appears to possess inherent chemoresistance in pre-treatmentcells. as such, it should be possible to target these cscs in the primary malignancy to prevent chemoresistant recurrence. mixed sex cord-stromal tumours of the ovary are very rare. we report a case of mixed sex cord -stromal tumour (also referred to as gynandroblastoma) containing both sertoli-leydig cell tumour and adult granulosa cell tumour in a female years old who presented with postmenopausal bleeding. on histology, the majority of the tumour represented an unsual form of well differentiated sertoli-leydig cell tumour with a pseudoendometrioid appearance. minor foci of classic adult granulosa cell tumour were present. on immunohistochemistry, the tumour was diffusely positive for inhibin and sf and focally for calretinin, er and cd . ema, pax and ck were negative. as far as we are aware, this is the first report of an ovarian mixed sex cord-stromal tumour containing a component of pseudoendometrioid sertoli-leydig cell tumour. a year old female patient presented with bilateral painful warty lesions on the labia majora. the patient had had hiv for a long time and was on highly active antiretroviral therapy. she also suffered chronic renal failure requiring haemodialysis three times weekly. clinically, the lesions were highly suspicious of vulval cancer. the lesions increased significantly in size over a short period of time ( months) requiring surgical resection under general anaesthesia. histological examinations revealed polypoid lesions with prominent pseudoepitheliomatous hyperplasia and dense inflammatory infiltrate, composed mainly of lymphocytes and plasma cells, extending to the hypodermis. numerous abscesses with large numbers of eosinophils were present withinin the hyperplastic epithelium. the typical intranuclear inclusions of herpes simplex virus (hsv) were identified. hsv immunohistochemistry was positive. this is a rare case of vulval hsv warts mimicking cancer. oral acyclovir was administered following surgery and resulted in good control. literature review shows only previously described cases of verrucous hsv, types and , simulating neoplasia in patients with aids on antiretroviral therapy. primary mucinous eccrine adenocarcinoma of the skin is a rare adnexal neoplasm, typically involving the head and neck region in the elderly population. here we present a case of primary mucinous eccrine adenocarcinoma of the vulva; occurrence at this site is extremely rare, with only five cases published in english literature. a year old female presented with a mm vulval lesion, clinically suspected to be an inclusion cyst. the lesion was removed and sent for histopathological assessment. histological examination revealed a well circumscribed, partly encapsulated tumour composed of rounded and irregular nests of polygonal epithelial cells with scattered lumina, suspended in pools of extracellular mucin. the epithelial cell nuclei displayed a uniform chromatin pattern with small distinct nucleoli. the mucin pools stained positive for alcian blue and dpas. immunohistochemical staining demonstrated positivity for cea, ck , gcdfp, oestrogen receptor, progesterone receptor, synaptophysin and chromogranin. immunostaining was negative for ck , cdx , ca- , ttf- , ch / , ck , her- , wt- , cd and s . ki- proliferation fraction was approximately %. overall, the findings were those of a mucinous eccrine adenocarcinoma with neuroendocrine differentiation. following multidisciplinary discussion, and negative imaging of the breasts and gastrointestinal tract, a diagnosis of primary mucinous eccrine adenocarcinoma of the vulva was reached. only a handful of cases of primary mucinous eccrine adenocarcinoma of the vulva have been reported. metastatic disease, particularly from breast and colon, must be excluded. follow up data from patients with primary mucinous eccrine adenocarcinoma of the skin suggests a high local recurrence rate ( . %), necessitating close follow-up. however, risk of metastasis is low ( . %). royal shrewsbury hospital, shrewsbury, uk introduction: primary extraskeletal myxoid chondrosaroma (emc) of the vulva is a rare mesenchymal neoplasm. the myxoid tumour differential diagnosis on a core biopsy can be quite challinging. to date, few cases have been reported in the literature. case report: a -year old woman noticed a swelling on the right side of the labia, thought to be a bartholin's cyst in . she was managed conservatively. she had drainage and marsupialization under general anaesthesia. this resulted in extreme bruising of the vulva. this was managed with antibiotics and non-steroidal anti-inflammatory medication, and it resolved after weeks. six months later, the patient presented again with a persistent vulval mass. a biopsy was obtained under general anaesthesia, and it showed a myxoid tumour with differential diagnosis of low grade chondroid tumour. an mri was performed to assess the extent of the disease. the tumour was excised. at surgery, a x cm lobulated, extremely vascular vulval tumour was found. the tumour was inseparable from the inferior pubic ramus of the pelvic bone. a complete macroscopic resection was obtained. histology confirmed low grade myxoid chondrosarcoma. conculsion: vulval lesions with unusual characteristics or insidious evolution in the labia majora or bartholin's glands area should be carefully and promptly investigated. differential diagnosis of myxoid tumours in the vulva should include myxoid chondrosarcoma amongst other diagnoses. (fish) showed the presence of a bcl rearrangement in a proportion of cells. therefore this case is best regarded as a composite lymphoma of diffuse large b cell lymphoma with hairy cell leukemia rather than blastic transformation of hairy cell leukemia. to the best of our knowledge, simultaneous occurrence of diffuse large b cell lymphoma and hairy cell leukemia in a lymph node has not yet been reported in the literature. bone marrow examination by aspirate and trephine biopsy is an important haematological investigation. ideally, aspirate findings should inform examination of the trephine biopsy, but if the two modalities are separate the aspirate report can be delayed and histopathologists may assess the trephine biopsy without being aware of the aspirate findings. we audited the availability of aspirate results to the histopathologist examining trephine biopsies, over the period in which our department implemented an integrated haematopathology reporting system. the effects on diagnostic concordance, turnaround times and immunohistochemistry requesting were also assessed. the setting was a regional specialist haematopathology centre. prior to integration, a prospective audit of consecutive trephine biopsies received by a senior haematopathologist was carried out, against standards set by the international committee for standardisation in haematology. data were collected from hospital computer systems. the move to integrated reporting involved the installation of new software (hilis) to specifically handle integrated haematopathology data. ten months later, a retrospective analysis of a further cases was performed using hilis data. prior to integration, % of aspirates were reported within days, and access to the aspirate report was available at time of examination for % of trephine biopsies. after integration, % of aspirates were reported within days, and reports were available at time of examination for % of trephine biopsies. diagnostic concordance was % initially, and % after integration. the mean number of immunostains requested per case was unchanged ( . vs . ). our findings show integrated reporting has markedly increased the availability of aspirate reports to the histopathologist, and improved diagnostic concordance. this new model benefits the haematologist, histopathologist and patient. introduction: clonality studies are carried out when the diagnosis of lymphoma is particularly challenging. the detection of clonality in lymphoproliferative lesions suspicious for lymphoma can be a valuable supplementary tool as it has a high positive predictive value. clonal studies can also help to distinguish recurrent or residual disease from reactive inflammation. however false positive and negatives are common and can be attributable to several factors, including poor dna quality. methods: cases reported over a six month period (jun-nov ) were retrospectively reviewed, % of which were referral cases. we investigated various aspects of clonality studies; including dna quality, fixation method, clinical information provided and correlation between the morphological/immunophenotypical findings and clonality results using euroclonality/biomed- primers (igh, igk, tcr-Β and gamma-delta). results: ( %) had adequate dna quality, ( %) poor dna and ( %) had inadequate dna quality. external cases had better dna quality in the majority of cases. clinical information was provided in % of local cases and % of external cases. in % of cases clonality results supported the initial histological report. cases showed clonal expansion despite a benign process on histology. suspected cases lymphoma ( b-nhl and t-nhl) showed no clonality, of which yielded poor dna quality. skin cases although had good dna quality, usually had low number of neoplastic cells resulting in poor pcr products. conclusions: dna quality is very variable and clinical information is often not provided precluding adequate assessment of clonality findings. dna was worse locally (decalcified marrow trephines using formic acid and peloris system with high temperatures that can cause dna degradation). standardisation of fixation methods and interpretation of peaks/ bands in the clinical context of the patient is essential for clonality to be informative. kikuchi-fujimoto disease: a novel diagnosis by transbronchial biopsy of mediastinal lymphadenopathy p pm ellery; n archard; a ramsay ucl hospitals nhs foundation trust, london, uk objectives: kikuchi-fujimoto disease (kfd) is a rare, self-limiting form of necrotising lymphadenitis that most commonly affects young asian women, and classically presents with fever, malaise and lymphadenopathy. the cervical lymph nodes are involved in around % of cases, with other sites rarely involved. we report an unusual case in which an unexpected diagnosis of kfd was made via transbronchial biopsy of mediastinal lymph nodes. a year old boy of pakistani origin presented with a month history of lethargy, neck stiffness and weight loss, with fever (up to °c) and night sweats. chest x-ray, mantoux test, blood cultures and viral pcr were negative. lumbar puncture was normal, with no acid fast-bacilli. ct showed enlargement of the deep cervical lymph nodes (petpositive on further imaging), and mediastinal lymphadenopathy. he was transferred to our hospital for further management, with a differential diagnosis of tb, lymphoma, rare infection or autoimmune disease. he underwent transbronchial biopsy of the mediastinal lymph nodes. results: his biopsy showed blood clot and cores of lymph node, with focal collections of crescentic macrophages, admixed lymphocytes and prominent apoptotic debris. immunohistochemistry demonstrated a population of cd -positive plasmacytoid dendritic cells and granular mpo positivity in macrophage cytoplasm. the background lymphocytes were mainly cd -positive t-cells. the features were those of kfd. conclusion: involvement of deep lymph nodes is unusual in kfd, and to our knowledge, this is the first case diagnosed via transbronchial biopsy. such biopsies often produce scanty diagnostic material, and here the detection of the characteristic immunoprofile of kfd helped confirm the diagnosis. this case highlights that kfd should be considered at sites other than the cervical lymph nodes, and demonstrates the value of immunohistochemistry in reaching a definitive diagnosis. we describe a benign intravascular proliferation of atypical polytypic cd positive t cells, co-expressing follicular t helper cell lineage markers coincidental to local sepsis of the buttock. a year old female presented with a x cm buttock abscess at the site of a longstanding palpable lump. peripheral blood showed only a neutrophilic leucocytosis. immunohistological examination showed large aggregates of atypical cd positive, alk negative lymphoid cells expressing a pan t helper phenotype with cd partially downregulated. podoplanin proved that the atypical t cells were primarily, but not exclusively, localised within lymphatic channels. a t cell receptor clone was not detected using pcr. to find intravascular concentrations of atypical lymphoid cells is uncommon in skin biopsies and raises the possibility of leukaemia or intravascular lymphoma. intravascular lymphoma is a rare variant of non hodgkin lymphoma with a minority possessing t or nk cell lineage but frequently involving skin. cd is a transmembrane glycoprotein and a member of the tnf superfamily involved in regulating proliferation. it is considered a reliable marker of lymphoma. primary cutaneous cd positive tlpds encompass a spectrum of biological aggressiveness and include primary cutaneous anaplastic large-cell lymphoma and lymphomatoid papulosis (lyp). cd can also be up regulated in activated b and t cells and it has been proposed that cd positive ivtlpds are equivalent to an intravascular form of lyp. intravascular proliferations of atypical cd positive t cells have been linked with chronic inflammation and abscess formation. furthermore atypical cd positive tlpd expressing a cd positive t helper phenotype and exhibiting an indolent clinical course have been reported in the arm, trunk, neck and prepuce. ultimately ivtlpd may require follow up based upon clinical features and natural progression due to overlapping diagnostic features. p g laing; s craig; l moss; c crichton; p johnston the investigation of lymphoid neoplasia requires multiple sections, in our practice consisting of twelve antibodies and thirteen single stained slides. by selecting particular antibodies for double staining, spatial relationships between cell types and overall tissue organisation can be more easily visualised. this pilot study aimed to optimise the staining intensity and specificity to provide accurate diagnostic information, reduce slide number, material and consumables costs, preparation time in the laboratory and storage space to enhance costbenefit. twelve antibodies were chosen and paired: kappa/lambda, cd /cd , mum- /cd , cyclin d /cd , bcl- /cd and cd /pax- . firstly, these combinations were applied to normal tissue and then known tumours to optimise technique. once the staining protocols were finalised they were run on eleven consecutive cases with conventionally stained non-hodgkin lymphoma (nhl) panel requests. the slides were then reviewed by the lymphoma team for quality and diagnostic accuracy compared to the standard single stained slides. the results demonstrate that double staining is possible in the diagnosis of nhl. the combinations chosen have proved successful and have provided interpretable results; for example, the relationship of light chain staining in plasma cells, mum- and cd positive cells in diffuse large b-cell lymphoma proves positive. we feel time will be saved cutting sections to improve efficiency in lymphoma investigation and reduce panel storage space by around %. in conclusion the outcomes from this pilot study have been positive for medical and scientific staff, has shown that double staining in the diagnosis of nhl is possible and that optimising this protocol with a view to live diagnosis is worthwhile. in an age in which novel therapies are not necessarily defined by their ability to kill malignant cells, understanding the biology of malignant cells after treatment is extremely important. this is particularly true of ibrutinib (pcl- ) therapy in chronic lymphocytic leukaemia which is characterised by lymphocytosis. imagej/fiji image analysis software could therefore be used to analyse cell shape and grouping characteristics. we used a novel assay in which chronic lymphocytic leukaemia cells, cultured for days, were seeded onto fibronectin coated glass coverslips and then had their b cell receptors ligated with goat anti human igm. they were compared with cells simultaneously inhibited with ibrutinib. we tested multiple staining techniques and found that using either rose bengal or texas red phalloidin staining produced the most reproducibly analysable data when using imagej/ fiji. we demonstrated, using the assumption that the outline of interacting cells would be larger than cells which were alone that homotypic interactions were increased after b cell receptor cross linking ( groups larger than cells against group larger than cells per nm x nm field (p= . )). nuclei were also significantly larger when cross linked. (mean . (+- . ) pixels without cross linking and . (+- . ) (p=≤ . )) suggesting increased nuclear spreading. these effects were reversed by the addition of ibrutinib with groups larger than cells per the same field(p= . compared with cross linked sells) and nuclear size mean being . (p≤ . compared with cross linked cells). this study demonstrates a novel, easily reproducible assay to assess a variety of cellular responses to ibrutinib therapy and suggests a method of quantifying activity both when stimulated and inhibited. this technique could easily be scaled up to further investigate cellular behaviour following ibrutinib therapy. purpose: gliomas represent % of all solid intracranial tumours and are associated with a poor prognosis. recent studies indicated that the human cytosolic branched chain aminotransferase protein (hbcatc), which metabolises the branched chain amino acids (bcaa), was significantly upregulated in idh / wild type (wt) glioblastomas, correlated with methylation patterns in the bcat promoter and is associated with a worse prognosis compared with idh mutant gliomas. the diagnostic and prognostic significance of markers of bcaa metabolism is currently under investigation. methods: glioma tumour samples were compared for hbcatc, hbcatm and bckdc expression using western blotting and immunohistochemistry. dna was extracted from fresh frozen tissue. sanger sequencing of the p.arg region of idh and p.arg region of idh was undertaken using a dna analyser (applied bio-systems). summary: in idh wt tumours, like hbcatc (p= . ), the expression of the mitochondrial isoform (hbcatm) is significantly (p= . ) expressed relative to idh mutant gliomas. hbcatm additionally shows a more significant correlation with patient survival than hbcatc on kaplan-meier analysis. in idh wt tumours, low hbcatm expression is a positive prognostic factor (p = . ). hbcatm expression additionally correlated with who grade. although previous reports indicate that increased hbcatc occurs exclusively in idh-wt tumours, our studies demonstrate that % of idh mutant tumours express comparable levels of hbcatc. although hbcatc alone has been suggested as a putative therapeutic target, it is important to evaluate the expression of hbcatm in glioblastomas as its expression may impact the efficacy of new treatments targeting hbcatc. conclusions: idh wt high grade gliomas traditionally have a poor prognosis. however we demonstrate for the first time that relatively low hbcatm may select for a better performing clinical cohort and may be a possible candidate target for drug therapy. a year old female presented with an occipital mass, presumed to be a lymph node and underwent fine needle aspiration of the lesion. fna yielded two air dried slides, upon which a diagnosis of mesenchymal neoplasm was made. the patient underwent a subsequent incisional biopsy allowing a formal histological diagnosis of myxoinflammatory fibroblastic sarcoma to be made. myxoinflammatory fibroblastic sarcoma is a low-grade neoplasm usually occuring on the distal extremities and only rarely presents as a head and neck neoplasm. fna is a useful tool in the diagnosis and subsequent management of head and neck neoplasia and we describe here the cytological features and subsequent histological diagnosis of myxoinflammatory fibroblastic sarcoma occuring in the occipital scalp. objective: presentation of giant cell fibroblastoma (gcf). because of it has a dilemma of microscopic appearances; it is mandatory to differentiating it from atypical dermatofibroma (adf), fibrous hamartoma of infancy (fhi) and vascular lesions. methods: eighteen month-male egyptian child presented with painless slowly expanding subcutaneous back swelling at the left scapular area. results: histologically, the lesion is poorly circumscribed and range from cellular to myxoid in a dense to loose collagenous stroma. the tumours composed of mixture of spindle shaped or stellate cells admixed with multinucleated giant cells with occasional pleomorphism and very low mitotic index (< per high-power fields). these cells infiltrate around adnexal structures and through subcutaneous fat. a distinctive finding is cracking artifact of the stroma simulating angiectoid spaces. these pseudovascular spaces are lacking a true endothelial lining and lined by discontinuous layer of enlarged multinucleated giant cells. immunostains, including factor viii, cd , cd a, sma, s and cd were negative. ki labeling index is very low. all the cellular components show positive immunoreactivity for cd . conclusions: first case of gcf reported in egypt. we recommend a wide scaled study to categorize this tumour with molecularly similar lesions. the royal county sussex hospital, brighton, uk a year old man being investigated for obstructive hydronephrosis was incidentally found to have a . cm splenic mass on computed tomography (ct). no lymphadenopathy was present and the mass remained stable on sequential ct and ultrasound scans. on positron emission tomography (pet) the lesion had a low signal with moderate uptake. all haematological investigations were within normal limits including a negative epstein barr virus (ebv) test. his past medical history included previous immunosuppressive therapy for inflammatory bowel disease. a core biopsy under ct guidance was performed. the cores showed a paucicellular spindle cell lesion with bland, blunt ended nuclei, no cytological atypia and a sparse chronic inflammatory infiltrate. there was no necrosis. the spindle cells stained positive for smooth muscle actin (sma) and h-caldesmon indicating this to be a splenic leiomyoma. splenic lesions are uncommon and within their differential include, lymphoma, inflammatory pseudotumour, harmatomas and leiomyomas. ( ) a splenic leiomyoma is an unusual and rare benign smooth muscle tumour with an unknown pathogenesis. they are thought to arise from the capsule and blood vessel walls of organs. ( ) they have been documented in immunosuppressed states (constitutional or acquired), in those with ebv infection and in children with ataxia-telangiectasia. ( ) leiomyomas within the spleen are rarely reported in the literature, especially in those patients over the age of eighteen. in this case there was historical immunosuppression, however leiomyomas should be considered in the differential diagnosis of well-defined solitary splenic lesions purpose of the study: the zucker diabetic fatty (zdf) rat is extensively used as a model of diabetic kidney disease (dkd) associated with obesity and progressive insulin resistance ('diabesity'). this study aimed to validate qualitative ultrastructural parameters of glomerular injury in the zdf animal model and apply these criteria to an interventional study investigating the effects of roux-en-y gastric bypass (rygb) on dkd. methods: superficial renal cortices were immersion-fixed in . % glutaraldehyde, post-fixed in % osmium tetroxide, processed and embedded in epoxy resin prior viewing under a technai transmission electron microscope. glomerular basement membrane (gbm) thickness, podocyte foot process diameter (pfpd) and podocyte foot process frequency (pfpf) per unit length of gbm were determined for each group (sham and rygb operated zdf fa/fa diabetic animals vs non-operated non-diabetic zdf fa/+ lean controls). statistical analysis was performed using a mann whitney u test and an unpaired t-test where appropriate. summary of results: selected tem parameters (gbm thickness, pfpd and pfpf) demonstrated significant differences between specified sham-operated zdf fa/fa vs fa/+ samples, p= . . analysis of rygb interventional study samples still in progress. early post-operative glucose measurements showed a significant improvement in glucose homeostasis in the rygb group (rygb vs sham, p= . ) occurring independently of weight loss. urinary albumin:creatinine ratios were lower in the rygb group vs sham operated positive controls (p= . ) and were comparable with age-matched lean control fa/+ samples. conclusions: preliminary findings support a beneficial role for rygb in an animal model of 'diabesity'. validated ultrastructural parameters should assist in elucidating changes in podocyte activation and differentiation as mediators of the observed remission of albuminuria following rygb surgery. nottingham university hospital, nottingham, uk spitz naevus is a benign melanocytic lesion that shares many histological features with malignant melanoma. although the morphological criteria differentiating the two entities are well established however, some cases can be challenging. many isolated markers have been proposed to help in differentiating spitz naevus from melanoma, albeit none has been shown to be definitive. aim: this is a preliminary study looking at the immunohistochemical expression of markers that are known to have important role in cell cycle regulation, proliferation and melanocytic differentiation (p , ki , and hmb ). the aim is provide to a combination of proteins that can help in differentiating spitz naevus from malignant melanoma. the study included cases of spitz naevi, benign compound naevi and cases of malignant melanoma. immunohistochemical expression of p , ki , and hmb has been accessed and compared with the morphological features of these lesions. results: it is noted the mean p expression is higher in compound and spitz naevi than melanoma ( , , and respectively). proliferation activity as measured by ki index is higher in melanoma in comparison with compound and spitz naevi ( . , . , and . respectively). hmb shows only junctional positivity in out of cases of spitz naevi while in the other two it shows week dermal component. hmb is constantly positive at the deep dermal component of melanoma, albeit the staining intensity is variable. the immunoprofile of spitz naevus is different from that of a malignant melanoma. a combination of biological markers as (p , ki , and hmb ), can provide a potential tool to differentiate between the two entities. nevertheless, expanding the biomarker repertoire on a large number of cases is necessary to further establish a reliable panel to differentiate among difficult cases. direct immunofluorescence in a tertiary referral centre: an audit of local guidelines and usage p lj lumsden; l motta; r green salford royal hospital, salford, uk direct immunofluorescence (dif) forms an important and costly adjunct to conventional haematoxylin and eosin (h&e) histology in dermatopathology, particularly in bullous diseases and other immune-mediated diseases. we aim to assess the usage and diagnostic yield of dif in our dermatopathology department. requests for dif on skin biopsies received over a month period met the inclusion criteria. each individual report was assessed with regard to the indication for dif, whether dif was deemed to be indicated or not indicated on assessment of the clinical history supplied on the request card, the results of dif and whether dif was contributory to the final diagnosis. we also collected data on the usage of dif over the last years to assess changes in practice. all requests for dif were granted in line with current departmental policy. the indication categories were divided as follows: bullous , alopecia , lupus , vasculitis , dermatitis herpetiformis (dh) and 'other' . all requests for dif were deemed to be indicated in both the bullous and dh categories by our panel, but indicated requests varied from . % to % in the remaining categories. in . % ( out of ) of cases dif was deemed to be contributory to the final diagnosis. our analysis also showed that usage of dif in our department is escalating, with a . % increase in requests from to . our departmental policy with regard to dif is inclusive and operates solely on the basis of clinician request. with the increasing usage of dif, established departmental guidelines and/or a protocol for dif usage should be mutually agreed with dermatology colleagues in order to ensure effective use of this expensive test. overview of merkel cell carcinoma in an irish population p a cooper ; j thorne royal college of surgeons in ireland, dublin, ireland; beaumont hospital, dublin, ireland purpose of study: merkel cell carcinoma (mcc) is an uncommon but highly aggressive primary cutaneous malignancy of neuroendocrine cells with a propensity for regional and distal metastases. due to it's rarity, information relating to it's epidemiology in an irish population is limited, mainly owing to difficulty in gathering large patient series. our aim was to identify all cases of mcc in our institution in a defined year period and review the patient demographics compared to internationally available data. a search was carried out on the hospital laboratory system to identify all cases of mcc from / / to / / . all histology reports were reviewed and any information pertaining to patient demographics was recorded in an excel spreadsheet. a literature review was performed relating to the patient profile of mcc internationally and the results were compared. results: a total of reports pertaining to individual patients were recovered. all patients were of caucasian irish ethnicity. the incidence of mcc was higher in men ( % of cases, n= ) than women. the median age at diagnosis was years (range - ). men presented at an earlier age (median years) than women (median years). regarding the anatomic site of the tumours, % (n= ) were on the head or face, % (n= ) were on the lower limb and % (n= ) were on the upper limb. all were on sun-exposed sites. of note, the majority of tumours in the male population were on the head ( . %, n= ), while the female population showed an equal distribution between the head and the lower limbs ( %, n= for each sub-site). the subset of patients we identified show demographics consistent with published literature for us, australian and other european cohorts. merkel cell carcinoma is a disease of the elderly affecting sun-exposed sites. we note some variation in the dominant anatomic sites between genders and conclude this is due to differing environmental exposure. background: a novel cell-dispensing instrument referred to as a single cell manipulator (scm) device was developed with the following features: i) rapid optical and fluorescent detection of single cells ii) generation of picoliter sized droplets encapsulating the isolated single cell and iii) printing of the single cell in an "ink-jet" like manner onto a chosen substrate. this technology was used to isolate cells of interest from i) heterogeneous mixed populations of cells, ii) co-cultures of cells and iii) clinical patient samples for subsequent downstream biological analysis. methods: cells were injected into a reusable silicon dispenser chip that was coupled to a live cell camera for image capture and display of cells approaching the chip's exit nozzle. an optical detection mechanism determined the presence of single, fluorescent cells within the selected region of interest close to the chip exit nozzle. a sorting algorithm ensured that only droplets containing the single cells of interest were selected for printing to the prescribed location and user-chosen substrate. results: fluorescently labelled hpv caski cervical cells were spiked into a cervical liquid based cytology sample and printed onto a glass slide using the scm. undifferentiated ntera human embryonal cancer stem cells were isolated from a mixture of differentiated and undifferentiated cells based on fluorescent tagging of the cell surface receptor, stagespecific embryonal antigen (ssea ). the thyroid stimulating hormone receptor (tshr) was expressed in anaplastic v e mutated thyroid cancer cell lines that were treated with the mek inhibitor pd . treated cells were isolated using the scm. the scm pasca technology allows isolation of single cells from heterogeneous populations of cells and clinical samples for downstream analysis at a single cell level. this study aims at quantifying immunohistochemistry (ihc) stained human cell lines for protein biomarkers by manual pathologist review. staining analyses are used to calibrate tissue microarrays of tumour cores, against quantitative protein concentration allowing a systems-based data analysis. as a proof of concept, ffpe human cell line pellets (n= ) were ihc stained for smac protein and analysed using aperio image analysis software. staining quantification manually performed by pathologists provided parameters including average staining intensity, percent total cell positivity and h-score. these data were enriched by qualitative parameters pointing out possible histological artefacts. a calibration curve was plotted using h-score data and protein concentrations, previously determined by western blotting. the panel of cell lines provided a range of strong and weak/absent ihc staining using a highly specific smac antibody. the calibration curve showed a strong correlation between absolute protein concentrations and manual h-scores. expression amounts in cell lines correlate with ihc staining intensities determined by pathologist review. the linear correlation between manual h-score and absolute protein values provides an avenue to indirectly determine protein expression. further analysis will be performed on additional antigens and analysis outcomes will be then compared to digital results. this data will provide the basis for deterministic systems-biological data analysis approaches. purpose of the study: 'lean' is a management framework for maximising value and minimising waste. it originated in the automotive manufacturing industry and has been utilised successfully in non-manufacturing processes. one such application in our department was the 'leaning' of the molecular test requesting process using a smart-phone app. this study will look at the potential utility of this application within the national health service (nhs), wherein approximately twenty different molecular test request forms are currently in use. a mobile application to facilitate molecular test requesting was developed using xcode and the objective c programming language. the application was built around an email based system. patient anonymity was paramount in the design; nhs numbers are used as identifiers. the application generates a molecular test request form and can also generate a national cancer drugs fund application form for each request. administrative staff use colour coded flags to represent the progress of each email request through the workflow process to facilitate tracking. the app reduced the administrative staff workload by reducing the number of steps and paperwork involved in the molecular test requesting process. a threefold reduction in time taken by clinicians to request molecular tests was noted. a survey of staff involved with molecular test requesting revealed a % reduction in 'lost requests' after the introduction of the application. we present a 'lean' method for requesting molecular tests using a smart-phone app. this application can be used to standardise molecular test request forms within the nhs along with automatic generation of a national cancer drugs fund application form for each request. purpose of study: automated approaches for quantitative digital image analysis (dia) of tissues are becoming increasingly popular in pathology due to advances in whole slide scanning hardware and digital imaging technology. it is essential that dia is standardised to ensure accuracy and reproducibility of results. very limited published data exists on the effect of scanner hardware variations on the accuracy and reproducibility of dia results.the aim of this study was to test the following variables: variation in light source intensity during the day; presnap calibration & white balance of scanned images; variation in dia due to debris on peripheral parts of the section or coverslip edges. methods: immunohistochemistry stained sections from patient samples were scanned on the same aperio cs scanner, hourly, for consecutive days to generate scanned images of each sample, representing images in total. all scanned images were run through aperio software using a macro to quantify positive cell counts. for a subset of images, a region of interest was drawn around the tissue to exclude any debris/coverslip edges from peripheral parts of the slide in the subsequent dia. statistical analysis was performed to calculate the coefficient of variation between dia results from scans on different days. results: variation in light source intensity accounted for . % to . % variation in cell counts between repeat scans of the same slide. exclusion of debris/coverslip edges accounted for - % variation in cell counts between repeat scans of the same slide. subjective analysis revealed no significant difference in appearance of different scans of the same slide. conclusion: variation in light source intensity, presnap calibration and overall white balance, plus debris in peripheral areas of the section account for minimal variation in resultant dia results. technical advances in scanner hardware have reduced variability in scanning operations. further investigations are ongoing. the complexity of ovarian cancer resistance mechanisms: a novel, clinically relevant, in-vitro investigation p s busschots g blackshields ; bt hennessy novel carboplatin and taxol resistant cell lines were developed from upn oc cells in a clinically relevant selection strategy to better understand resistant mechanisms in oc. upn - c models carboplatin resistance and upn - t models taxol resistance. upn - calt and upn - talt were exposed to alternating treatments of both agents during development. affymetrix arrays were used to characterise gene/mirna signatures linked with the development of chemoresistance in oc cell lines upn - c and upn - t. bioconductor software, david v . and mirna-target interactions (mtis) analysis was carried out to identify de-regulated genes/mirnas, gene pathways and gene/mirna interactions involved in resistance. upn sublines developed using taxol were significantly resistant to taxol, vinblastine and olaparib (p-gp substrates), and reversible with elacridar (p-gp inhibitor) treatment. significant up-regulation abcb was seen in upn - t which was reflected at the protein level. srpx was highly up-regulated in upn - t. gli and ccl were up/down-regulated respectively in upn - c. gli had a validated interaction with mir- down-regulated in upn - c. lin b was highly deregulated in upn - c and upn - t and had a validated interaction with let- i, down-regulated in upn - c. p-gp over-expression is a dominant mechanism for taxol resistance in our cell lines. mechanisms for carboplatin resistance are more complicated. the top deregulated genes are involved in numerous pathways including apoptosis, cellular transformation, signal transduction, and cell migration cervical glandular neoplasia: the influence of excision procedure on margin status although cold knife cones (ckc) have been traditionally advocated for treatment of adenocarcinoma in situ (ais), large loop excisions of the transformation zone (lletz) are increasingly used. we analysed excisions from patients where ais was confirmed prior to procedure over years to assess the influence of excision procedure on final margin status. we tabulated whether margins were involved, close (lesional tissue less than mm from margin) or excised. results: lletzs were performed in % ( of patients), ckc excision in % ( of ). women who had lletzs were younger than those having ckc excision ( . years versus . years). positive margins were present in % ( of ) and close margins in % ( of ) lletz cases. for ckc, margins were positive in % of cases ( of ) and close in % ( of ) conclusion: although complete excision is more frequently observed when ckc is performed, compared to lletz, for the treatment of ais %) patients, discordant low-grade lymphoma was identified in the bone marrow during staging investigations. were classified as follicular lymphoma, marginal zone lymphoma, chronic lymphocytic lymphoma, lymphoplasmacytic lymphoma, non cll -like monoclonal b-cell lymphocytosis. five had an accompanying a low-grade component that could not be classified. none of the transformed high-grade lymphoma cases were ebv positive. in our cohort, we did not observe statistically significant difference in survival between the transformed and non-transformed cases. an equal proportion of cases transformed from follicular lymphoma and marginal zone lymphoma. . % of transformed patients had a previous history of another cancer, compared to . % of non-transformed cases. age, gender and a history of autoimmune disease were not associated with transformation. transformed chronic lymphocytic lymphoma an investigation into the presentation and nature of diffuse large b cell lymphoma within a large patient cohort p hr freer t cell/histoiocyte-rich large b cell lymphoma ( . %) was the next most common subtype, followed by primary dlbcl of the cns ( . %). a modified r-ipi (the patient performance score was unknown) was used to stratify the patients into four risk groups and was found to be predictive of patient outcome. the average ldh level was . iu/l, well above , the upper limit of the normal range. of the cohort of patients, . % achieved remission, . % were alive with disease at the end of the study and . % are now deceased. the majority of patients that did die did so within a year of diagnosis. in addition, bcl- negative patients were identified, with a mean age at diagnosis of . years. of these patients were female and male. the mean ldh level was some researchers included additional clinical features that were common when there was malignancy in the asymmetrical tonsils. in this study we aim to evaluate the cancer detection rate in this setting including those who possess high risk clinical features such as age (> ), pain and history of smoking. methodology: in total, consecutive tonsillectomy cases, clinically labelled as asymmetrical tonsils were analysed. out of these, cases (group ) were additionally labelled with investigation for unknown primary, obvious lesion or suspicious ulcer seen. the remaining cases with a sole clinical indication of asymmetry were stratified as group . results: in the first group, cases had a histological confirmation of tonsillar primary ( %). while, in the second group, the histological analysis showed cases with benign reactive pathology ( %) while, one case was diagnosed as malignant lymphoma ( %), cases with mild dysplasia ( %) conclusion: our results do correlate with the considerable agreement amongst otolaryngologists that the appearance of an asymmetrically enlarged tonsil in the presence of associated risk factors is considered an indication for tonsillectomy and histological examination given the significant rate of tonsillar malignancies in this group. anatomical difference in the depth of tonsillar fossa and asymmetry of the anterior tonsillar pillar may give a false impression of a clinically asymmetrical or unilateral enlarged tonsil metastatic adenoid cystic carcinoma to the lung and kidney: a single case report p rm doyle the tumour has three prognostically significant subtypes which form the basis for tumour grading; cribriform, most frequent, tubular and solid, associated with a more aggressive clinical course and metastasis. in the majority of cases ( %) the tumour has an insidious onset and patients have locally invasive disease at first presentation, which coupled with adjacent, important anatomical structures means a complete primary surgical resection is often not feasible. distant metastases are frequent and predominately involve the lung and bone with renal metastasis a rare occurrence. an optimal treatment regime for acc has yet to be established and while local management with combination surgery and adjuvant radiotherapy is currently favoured there is conflicting evidence regarding the use of radiotherapy and no formal surveillance guidance for local and regional recurrence or distant metastasis exists. we report a single case of a year old male who presented in with an asymptomatic right neck mass and underwent right radical neck dissection and adjuvant radiotherapy for acc. the patient represented in with aspiration pneumonia on a seven month history of dysphagia and dyspnea. xray and subsequent computed tomography (ct) imaging identified large, multiple right sided lung lesions, maximum cm, and a . cm left renal upper pole mass. ct guided biopsy of the right lung lesion and ultrasound guided biopsy of the renal mass were reported as metastatic adenoid cystic carcinoma regan ; cm martin ; cv timon cytokeratin (ck ) is a junctional biomarker with a seqika fragment which stabilises hpv- e transcripts. we assessed the expression pattern of ck protein in tumour specimens from patients diagnosed with oropharyngeal squamous cell carcinoma (scc) presenting at two major irish head and neck centres, within the last years. methods: archived tumour specimens together with epidemiological data were collected from patients presenting with new primary oropharyngeal scc at two main head and neck centres in ireland, within the last years. briefly, dna was extracted from tissue blocks and hpv testing carried out using spf hpv pcr immunohistochemical staining for ck [clone sp , ventana] was performed on tissue blocks following optimisation on the ventana benchmark ultra immunostainer. slides were analysed by light microscopy and scored using the h scoring system with % of these identified as hpv- subtype. ck expression was observed in the tonsillar crypt epithelium of both normal tonsils and tumour specimens. % of cases were positive for ck , with % of cases demonstrating h score of > . ck expression in the tumour cells was significantly linked to hpv status and our results suggest that the expression of ck in normal tonsillar crypt epithelial cells provides a selective advantage to hpv-related carcinogenesis at this site, possible due to the unique propensity of ck to bind and stabilise hpv- e transcripts regan ; cm martin ; cv timon methods: archived hpv-positive tumour specimens and epidemiological data were collected from patients presenting with new primary oropharyngeal scc at two head and neck centres in ireland over a one year period. briefly, dna was extracted from tissue blocks and hpv testing carried out using spf hpv pcr. the inno-lipa hpv genotyping extra test [fujirebio] was used to determine genotype. immunohistochemical staining for ck , gda, mmp- , agr- , pd- and pd-l was performed following optimisation. slides were analysed by light microscopy and scored using the h scoring system (junctional biomarkers) frozen section reporting of necrotising granuloma of the liver following percutaneous instrumentation of the biliary tree: a case series eh hadjimichael; p df fielding; mi ilyas; az zaitoun; dl lobo; pk kaye nottingham university hospital, nottingham, uk percutaneous transhepatic cholangiography (ptc) is an interventional radiological technique for both diagnostic imaging and therapeutic decompression of the proximal biliary tract in malignant distal obstruction when retrograde techniques fail. recognised complications of ptc include sepsis, haemorrhage and pneumothorax. we describe four cases where necrotising granuloma, apparently secondary to previous ptc, has resulted in frozen section examination at the time of subsequent planned cancer resection, to exclude tumour metastasis. four cases of necrotising granuloma in the liver have been identified between january and february . all cases were planned whipple's procedures for pancreatic cancer where initial intraoperative evaluation revealed solitary subcapsular liver lesions. biopsy and intraoperative frozen section examination were performed to exclude metastatic disease. all frozen sections except one were reported as showing benign necrotizing granuloma formation. the first case was initially reported as malignant and the operation was abandoned. a benign diagnosis was confirmed on paraffin sections in all four cases with the first patient undergoing successful surgical resection at a later date. to the best of our knowledge these are the first reported cases of necrotising granuloma in the liver secondary to prior instrumentation of the liver and leading to intraoperative histological assessment. we highlight this as a potential pitfall in frozen section interpretation undertaken ahead of planned potentially curative surgery which can lead to overstaging of otherwise resectable disease or to the interpretation of a potential diagnosis of tuberculosis. these risks can be reduced with greater surgical and pathological awareness of this entity. inclusion body fibromatosis, also known as infantile digital fibroma, is a benign, predominantly myofibroblastic tumour primarily found on the digits of infants. clinically, these lesions present as asymptomatic cutaneous nodules, rarely larger than cm in size, classically on the dorsal or dorsolateral aspect of the second, third and forth digits. they have a high recurrence rate, reported as between and %, although this can be reduced by undertaking complete wide local excision. we report a case of inclusion body fibromatosis in an month-old boy, presenting with an enlarging, firm lesion on his left second toe. following surgical excision, the lesion showed classical histological features of inclusion body fibromatosis -spindle cells arranged in interlacing fascicles in collagenous stroma and numerous pink intracytoplasmic inclusions. the lesion appeared incompletely excised and the patient will be kept under review on account of the high risk of recurrence.decreased expression of the mitochondrial bcat protein correlates with improved patient survival in idh wild-type gliomas me conway ; j hull ; m el hindy ; sc taylor ; f el amraoui ; c paton-thomas ; p white ; m williams ; p hr haynes ; sm hutson ; km kurian key: cord- -twwa djm authors: tomashefski, joseph f.; dail, david h. title: aspiration, bronchial obstruction, bronchiectasis, and related disorders date: journal: dail and hammar&#x ;s pulmonary pathology doi: . / - - - - _ sha: doc_id: cord_uid: twwa djm the conducting airways play a pivotal role in the spectrum of pulmonary pathology, not only as conduits for injurious agents to enter the lung, but also as an anatomic compartment that is affected by a diverse array of primary or secondary bronchocentric diseases. this chapter discusses aspiration and bronchial obstruction in detail, with emphasis on the aspiration of toxic, infective, or particulate matter. lung abscess, a frequent complication of obstruction or aspiration, is also reviewed. both aspiration and lung abscess are reconsidered within the context of pulmonary infectious disease mainly in chapter on bacterial infections, and to some extent in the chapters on mycobacterial (chapter ), fungal (chapter ), and parasitic diseases (chapter ). the conducting airways playa pivotal role in the spectrum of pulmonary pathology, not only as conduits for injurious agents to enter the lung, but also as an anatomic compartment that is affected by a diverse array of primary or secondary bronchocentric diseases. this chapter discusses aspiration and bronchial obstruction in detail, with emphasis on the aspiration of toxic, infective, or particulate matter. lung abscess, a frequent complication of obstruction or aspiration, is also reviewed. both aspiration and lung abscess are reconsidered within the context of pulmonary infectious disease mainly in chapter on bacterial infections, and to some extent in the chapters on mycobacterial (chapter ), fungal (chapter ), and parasitic diseases (chapter ) . bronchiectasis, which is frequently grouped with other forms of obstructive lung disease (see chapter ) , is discussed in this chapter as a major pathway of airway remodeling that may be of inflammatory, postobstructive, or congenital etiology, and is, itself, an important sequela of aspiration. the topic of bronchiectasis cannot be considered without reference to inflammatory lesions of the small airways, which may follow or precede the development of bronchiectasis (see chapter ) . the present chapter also discusses a variety of pulmonary disorders that may simulate, initiate, or complicate bronchiectasis. involvement of the large airways in systemic diseases such as amyloidosis (chapter ), sarcoidosis (chapter ), collagen vascular diseases, including relapsing polychondritis (chapter ), connective tissue disorders such as marfan's syndrome (chapter ), or as a complication of environmental dust exposures (chapter ) is reviewed in each of their respective chapters. an excellent review of bronchiectasis in systemic diseases is that by cohen and sahn.l a discussion of asthma and its related conditions of mucoid impaction, bronchocentric granulomatosis, and allergic bronchopulmonary aspergillosis can be found in chapter . unique congenital lesions of the airways in addition to the enigmatic intralobar sequestration are discussed respectively in chapters and on pediatric lung pathology. a variety of degenerative or so-called metabolic disorders that affect the large airways, such as tracheobronchopathia osteoplastica, are reviewed in chapter . finally, bronchial tumors are extensively covered throughout volume , which is devoted to pulmonary neoplasia. aspiration is the inhalation of liquid or solid materials into the lower respiratory tract, usually from the oral or nasal cavities, oropharynx, esophagus, or stomach. logically, the course of aspiration is determined by such laws of physics as inertia and gravity. larger, more solid materials, and finer more liquid materials, all follow the straightest and most dependent course after they enter the trachea. as explained in chapter , the right mainstem bronchus continues on a more direct course than the left ( to degrees compared to to degrees for the left mainstem bronchus); the wider angle of the left bronchus allows it to extend around the heart. larger, more solid objects that pass the larynx often lodge in the right mainstem bronchus, while smaller solid objects most frequently continue into the right lower lobe bronchus. this has been well demonstrated in the aspiration of foreign objects by children, generally in the age group of to years. , during this age range, children examine almost everything by placing items into their mouths. in both children and adults, larger objects are sometimes stopped at the larynx and may be expelled by strong coughing. in adults, sudden death due to laryngeal obstruction by aspirated food (most frequently meat) has been termed the cafe coronary.s more than % of aspirated foreign bodies occur in children, and among all age groups only % are spontaneously expectorated. , sharper objects may perforate a bronchus and cause bleeding, or even penetrate the pleural cavity and cause pneumothorax. a foreign body may migrate within the bronchi and cause wandering infiltra tes. young children most frequently aspirate peanuts, beads, and other fragments of wooden or plastic toys. peanuts and sunflower seeds lead the list in western countries, whereas in arabic countries children most often aspirate melon seeds. older children may inhale flowering grass fragments, which wedge themselves into more distal bronchi and resist expectoration. in any age group, teeth, fragments of bone ( fig. . ) , food, blood clots, tissue fragments, nasal pack components, lipids from oily nose drops or orally administered cathartics, bacterial fragments, and gastric content most commonly enter the lung. noguchi et a . reported a subacute reaction to mud aspiration in a victim of near-drowning, while aspiration of sand in children has been reported to cause a radiographic "sand bronchogram.,, drowning, often thought of as occurring in fresh or salt water, has also occurred in large vats of beer, wine, liquid chocolate, and other interesting concoctions. a literary example of this is shakespeare's richard iii, in which the duke of clarence is finally dispatched in a large vat of wine (the "malmsey butt,,). brock . in , beautifully illustrated the mechanics of aspiration with abscess formation, which most often followed the dependent course described. once within the lung, finer and more fluid ingredients flow into the first dependent orifices that are encountered. in the supine position, these are most often the posterior segment of the upper lobe and superior segment of the lower lobe ( fig. . ). in the more upright position, material flows preferentially into the basilar segments of the lower lobes. the basilar segments divide rather evenly, and localization within these segments is not as discrete as in other areas of the lung. when a person is in the lateral decubitus position, the axillary branches of the subsegments of apical and posterior upper lobe bronchi are favored. the more anterior portions of the lung are usually spared the effects of aspiration, unless aspiration occurs in the prone position, as in near-drowning. aspiration need not only be from external sources. rupture of large fluid-filled abscess cavities, tuberculous cavities, or other cysts might be followed by intrabronchial aspiration of infective or other types of material into dependent zones (see fig. . in chapter ). the most common conditions predisposing to aspiration include impaired consciousness, most frequently from alcohol, drugs, or anesthesia, followed by central nervous system disorders (e.g., epilepsy, stroke, dementia) or neuromuscular diseases. next in frequency is aspiration secondary to obstructing masses or other functional defects of the esophagus or stomach. episodes of aspiration are eventually confirmed in about % of children, but in only about % of adults. ,ls the difference in documentation is probably related to the altered level of consciousness in adults causing temporary amnesia. the common clinical manifestations of an aspirated foreign body constitute a triad of cough, wheezing or rhonchi, and decreased air entry. the wheezing that is sometimes associated with aspirated foreign bodies in children may be ameliorated with theophylline, leading to diagnostic confusion with asthma. early experimental animal studies showed that aspiration of material into the lungs regularly occurs when materials are placed in the nares or accessory sinuses during anesthesia. , myerson found blood immediately postoperatively in the tracheobronchial tree in % to % of humans who underwent tonsillectomy, including those under general or local anesthesia. several experimental studies have also proven that normal adults aspirate with some regularity. quinn and meyer in introduced lipiodal (iodinated poppy seed oil) into the noses of sleeping subjects and found the material often entered the lungs. amberson in reported placing barium in the mouths of normal subjects during sleep, with similar results. radiologists sometimes observe aspiration while performing upper gastrointestinal tract barium studies (see below). as reviewed by bartlett, various markers placed in the stomach the night prior to surgery have been identified in lungs sampled during surgery the next day in % to % of patients. • huxley and associates s refined these techniques by placing indium-ll chloride in the posterior nasopharynx periodically during sleep. on lung scanning, this tracer was found in the lungs of % of normal individuals and in % of those with some alteration of the central nervous system. those in the normal group who did not aspirate were fitful sleepers who tended not to enter deep sleep. the implication is that most normal people who enter deep sleep, aspirate. nasogastric and oropharyngeal tubes, including endoscopes and tracheostomy tubes, increase the risk of aspiration. normal individuals tend to clear such occult aspirations without difficulty or sequelae. an acute cough reflex is most important, but also valuable are intact mucociliary activity and alveolar macrophage response (see chapter ) . the pathologic effects of aspiration are dependent on the character, volume, and frequency of the aspirated components. in this chapter, food and medicinals, gastric acid, lighter hydrocarbons, and heavier oils are separately considered. aspirated bacteria are covered in the section on abscess formation. retained squamous if. tomashefski, jr. , and d.h. dail cells from meconium in newborns are a sign of in utero distress. squamous cells in the lungs of adults are an indicator of oral, oropharyngeal, or esophageal aspiration ( fig. . ). in the absence of other evidence of aspiration, finding mixed bacteria in lung tissue is very suggestive of aspiration of oral content. lung injury following aspiration has been subdivided by marik into aspiration pneumonitis and aspiration pneumonia. aspiration pneumonitis refers to acute chemical lung injury due to inhaled gastric acid with or without injury due to aspirated particulate matter, whereas aspiration pneumonia is an infectious process resulting from the inhalation of oropharyngeal secretions colonized by pathogenic bacteriay aspiration of gastric acid, a major cause of acute respiratory distress syndrome (ards), has been well studied in humans and in experimental animals. in experimental models, it has been suggested that a ph of . or lower and a significant quantity of acid (estimated to be to ml in an adult human or to mllkg in an experimental animal) are necessary to induce a chemical pneumonitis. when gastric acid with methylene blue was put into anesthetized dog tracheas, dye was visible on the pleural surface to seconds later. atelectasis oflung tissue was noted in minutes. human studies date from the classic study of mendelson in , and acute gastric acid aspiration is sometimes called the mendelson syndrome. mendelson studied cases of massive gastric aspiration in obstetric patients ( . % incidence) under ether anesthesia. respiratory distress occurred soon after aspiration, with accompanying cyanosis, tachypnea, and tachycardia. bronchospasm occurred in most of his patients. chest radiographs initially showed rather widespread mottled densities, most of which cleared by to days. only eight of patients became infected. this study was conducted before antibiotics were readily available, but other studies in humans with or without antibiotics or steroids have confirmed his findings. in general, later studies have found a lower incidence (about %) of bronchospasm, more frequent early temperature elevation, and increased mortality (in the range of % to %) despite therapy. hypotension and hypoxemia occurred more commonly than in mendelson's series. the combination of acid and particulate aspiration exacerbates alveolar capillary injury. bynum and pierce ! studied patients with welldocumented gastric acid aspiration. in their series, all these events followed altered consciousness, most often by a sedative drug overdose or a general anesthesia. as in mendelson's experience, respiratory symptoms developed rapidly and were very similar in all patients despite eventual outcome. three clinical outcomes were described: % died shortly after aspiration; % had rapid clinical and radiographic clearing on the average of . days; and % had rapid improvement followed by deterioration relating to bacterial infection. of this latter group % died, whereas % of the whole group died; death occurred between day and , averaging . days. these authors found initial steroid or antibiotic therapy did not affect eventual outcome. in both humans and animals, edema, congestion, hemorrhage, and degeneration of bronchiolar lining cells and alveolar type i and ii cells follows early in the course (fig. . ) . after hours alveoli are filled with polymorphonuclear neutrophils (pmns) and fibrin. hyaline membranes are formed by hours, providing a histologic picture of diffuse alveolar damage (dad) (see chapter ) . resolution begins at about hours and may either lead to figure . . gastric acid aspiration. acute effects show hemorrhagic necrosis of lung parenchyma. complete restoration of alveoli or leave some residual scarring. of course repeated aspiration may lead to combined acute, subacute, and chronic appearances. in his review, bartlett referred to this rapid and irreversible type of injury as comparable to a "flash burn," and noted that little can be done to prevent injury once acid has made contact with the lung (fig. . ). the reactions just described plus fluid extravasation help to dilute the acid, as do buffering components from serum and cell breakdown products, but these only occur after injury. more recent studies have indicated that the mechanism of lung injury following acid aspiration extends beyond the direct chemical effects of acid to involve various inflammatory mediators including tumor necrosis factora (tnf-a), interleukin- (il- ), adhesion molecules, and cyclooxygenase and lipoxygenase products. - the role of reactive oxygen species, and the adverse effect of oxygen administration after an episode of aspiration were demonstrated experimentally by nader-djalal et al. a primary role is currently placed on neutrophils and complement in mediating lung injury in this setting. , , . thus, aspiration pneumonitis represents a biphasic response composed of early-onset direct pulmonary injury due to acid, followed by delayed injury due to acute inflammation. , low-grade chronic aspiration of gastric content may escape easy detection. these occult aspirations may lead to interstitial fibrosis, and perhaps account for the % to % incidence of associated and unexplained pulmonary fibrosis in patients with esophageal abnormalities, most commonly hiatal hernia or simple reflux, , the role of reflux in asthma, chronic bronchitis, chronic cough, recurrent pneumonia, cystic fibrosis, and sudden infant death syndrome has been reviewed by allen et al. [see also section on cholesterol (endogenous lipid) pneumonia in this chapter]. children, particularly those aged to years, are likely to ingest various lighter hydrocarbons, mostly lighter volatile petroleum distillates. these products include kerosene, turpentine, and other paint thinners; furniture or shoe polish; lighter fluid; gasoline; dry cleaning fluids; and some insecticides. the toxicity is greater with those products that disperse most easily, specifically those that cause the greatest decrease in surface tension, or have the least viscosity or the highest volatility. although ingestion precedes aspiration, eade and associates nicely reviewed the reasons that aspiration is the most important toxic pathway of injury. symptoms develop rapidly and radiographs often show localized pulmonary infiltrates, often in the aspiration zones mentioned earlier. experimentally, the lethal dose by figure . . lentil bean. a. at top is thick outer coat; below, cotyledon compartments with starch cells. b. cellulose framework of legume cotyledon compartments is birefringent under ingestion alone is much higher than that usually ingested by persons who subsequently aspirate. sizable doses of distillates have been placed in the stomachs of experimental animals whose esophagi were ligated, and these animals did not suffer pulmonary toxicity. the pulmonary changes, almost identical to those of gastric acid aspiration, include diffuse congestion, hemorrhage, edema, hyaline membrane formation, and bronchopneumonia. atelectasis occurs early, apparently by direct toxic effect of these light hydrocarbons on s urfactan t. about % of affected children have abnormal chest radiographs, but only % to % have pulmonary signs or symptoms. , in the past, death has been reported in about % to % of cases, but in two large series death occurred in . % and %, respectively. a death usually occurs within hours of exposure. most survivors experience few sequelae. various food particles, such as skeletal muscle, fat tissue, or fragments of bone, may be aspirated and identified histologically in lung tissue. cooking or digestion may result in poorly defined particles that appear foreign but defy further definition. as was well demonstrated by knoblich and others, - portions of legume seeds are one of the better markers of food aspiration. the legumes most commonly eaten are various peas, beans, and peanuts; because they are relatively inexpensive and nutritious, they occur in many products. (the word lentil is sometimes used in these references, but it is also j.f. tomashefski, jr., and d.h. dail polarized light. c. degenerated aspirated vegetable material retains compartmental structure and stains strongly with gomori methenamine silver. the name of a specific type of bean). the legume seed ( fig. . ) consists of a thick cellulose outer coat, the cellulose walls of the inner food storage compartments, and the starch cells contained within these food compartments. cooking softens the outer shell and cell walls of the beans or peas and allows easy disruption of the content, with a resultant jelling effect of the starch particles (called "thickening" in cooking). the cellulose walls of the outer coat and starch compartments are more difficult to totally disrupt or digest, and therefore act as both a chronic irritant and a good marker of aspiration. aspiration of these fragments in both experimental animals and humans produces an acute exudative response within hours (fig. . ), followed by a foreignbody giant cell reaction ( fig. . ) . these cell wall fragments are gomori methenamine silver (gms) positive, and usually birefringent under polarized light (fig. . ). the glycogen compartments, when intact, are vividly periodic acid-schiff (pas) positive ( fig. . a) . starch cells may be mistaken histologically for parasite larvae (fig. . b ). at about days (experimentally) an organized granulomatous reaction occurs around the aspirated particles, and eventually the starch cells disappear, leaving only the cellulose fragments. the walls of carrots, onions, and most nonlegumes digest more readily and do not give rise to as much exuberant chronic reactions as seen with legumes. they do, however, undergo the same type of early changes if aspirated, and initiate acute and subacute pneumonia during digestion of the starch cells. some of the most offensive aspirated food fragments have undergone alterations in preparation, and some of the worst combinations are cooking oils and salts, as, for example, an aspirated potato chip ( fig. . b). eventually these areas become small fibrotic or fibrocalcific nodules, which may appear almost as degenerated parasites or as sclerosed blood vessels ( fig. . ). they may appear as small hyalinized granulomas or possibly as entrapped calcospherites, usually within a fibrous stroma. at times the conditions for aspiration are chronic, and recurrent aspiration leads to the acute and chronic changes together or in close proximity in the same specimen. respiratory bronchioles exhibit marked remodeling associated with proliferative bronchiolitis obliterans, foreign-body granulomas, and entrapped food particles. the macroscopic appearance is that of scattered yellow miliary nodules that are reminiscent of miliary figure . . chronic reaction from aspirated lentil beans. two hyalinized starch cells may be mistaken for fibrosed, obliterated blood vessels. matsuse and colleagues have designated this condition as diffuse aspiration bronchiolitis, which they observed in of consecutive autopsies ( . %). the mean age of patients with this condition was . years. affected individuals frequently were bed-ridden or had dysphagia due to underlying neurologic disorders. high-resolution computed tomography (hrct) may show a striking pattern of centrilobular miliary opacities. in chronically ill or hospitalized patients, aspirated medicinal products, such as intact or partially digested pharmaceutical tablets, may be associated with aspiration pneumonitis. inert tablet components such as microcrystalline cellulose, talc, and crospovidone may be identified histologically in conjunction with aspirated food, pneumonia, and foreign-body reaction (see chapter ) microcrystalline cellulose, like legume components, is brightly birefringent on polarization, and also positive with gms stain. it can be distinguished from vegetable particles, however, by its fiber-like, or "matchstick-like" appearance. aspirated tablet filler components, which reside within alveoli and bronchioles, usually can be discriminated from identical particles introduced by illicit intravenous injection of aqueous tablet suspensions, which localize within small pulmonary arteries or in a perivascular, interstitial distribution (see chapter ) . aspirated sodium (or calcium) polystyrene sulfonate (kayexalate), a potassium-binding cation exchange resin, has a distinctive histologic appearance characterized by large dark eosinophilic or basophilic, angulated, "glassy" particles, that sometimes appear striated ( fig. . ). [ ] [ ] [ ] [ ] duct. b. angulated, "glassy" kayexalate particles have elicited a foreign-body giant cell reaction. kayexalate particles are weakly birefringent, and positive with pas, acid-fast, and gram stains, but negative with von kossa stain. kayexalate has also been identified in tissue sections by infrared microspectrophotometry. l in humans and experimental animals, kayexalate has been shown to produce a necrotizing or organizing pneumonia. l , more frequently, kayexalate is a cause of mucosal ulcers of the gastrointestinal tract. , kayexalate histologically closely resembles the less frequently encountered material cholestyramine. cholestyramine, however, is more opaque and pink rather than red on acid-fast staining. the aspiration of an intact ferrous sulfate tablet may induce severe, potentially fatal, bronchial mucosal ulceration and hemoptysis. - the endoscopic appearance of the ulcerated bronchus typically is of a golden-brown discoloration ( fig. . a ). histologically, ulceration, necrosis, foreign-body reaction, and brown or yellow pigment that stains blue with prussian blue stain may be seen ( fig. . b ). the pathogenesis of this syndrome, colorfully termed "iron lung," is thought to be a chemical burn induced by oxidation of iron from the ferrous to the ferric form. the radiographic contrast material barium sulfate (bas ) is also readily visualized by chest x-ray in patients who aspirate this material. barium is a fairly inert white powder that tends to produce minimal functional lung impairment. grossly, following barium aspiration, lung parenchyma is chalky, tan-gray, and slightly indurated ( fig. . a ). histologically, fine, golden-tan, refractile, weakly birefringent particles of barium sulfate are present within the cytoplasm of alveolar macrophages. with chronicity, or upon repeated aspiration, barium-laden macrophages migrate into the interstitium (fig. . b ). inhalation of barium in the industrial setting (barytosis) is discussed in chapter . activated charcoal is sometimes given therapeutically for oral drug overdose. however, if the airway is not protected, charcoal may be aspirated in copious amounts, causing "charcoal lung," in which coarse black carbon particles obstruct small airways. oils that may be aspirated include mineral oils such as used in nose drops and cathartics, vegetable oils used in cooking, and animal oils such as cod liver oil or fat-soluble vitamin preparations. mineral oil, derived from petroleum products, is the most common agent of exogenous lipid pneumonia. oil aspiration was first described by laughlen in in a child who received oily oral and pharyngeal preparations for diphtheria; it was confirmed by him experimentally. the role of oil-based contrast media used for bronchoscopy was well reviewed by spencer. animal oils cause a more severe inflammatory reaction than mineral or vegetable oils, and this difference appears related to the number of free fatty acids and increased viscosity of animal oi . , . mineral oils are fairly inert, as they have no fatty acids, and are rapidly emulsified and consumed by pulmonary macrophages. vegetable oil droplets may remain in alveoli for months without eliciting significant reaction, but eventually, due to low-grade chronic irritation, they cause scarring. animal and mineral oils, but only rarely vegetable oils, may be seen in regional lymph nodes. aspiration of oils commonly occurs in older individuals, who may take oily nose drops or cathartics at bedtime. aspiration most frequently gravitates to the basilar segments of the lower lobes suggesting these patients usually sleep in a more upright position or experience aspiration before reclining. because of its weakly irritative nature, mineral oil can enter the tracheobronchial tree without stimulating glottic closure or cough reflex. only two of cases documenting exogenous lipid pneumonia at autopsy had reported significant clinical symptoms during life. because these oils float in the stomach, it is possible they also are aspirated via reflux from the stomach,z . in unselected autopsy series, oil aspiration has been documented in . % to . % of adults. . other oily products that have been incriminated as being aspirated in the lung include fragments of lip balm, burning fats (an occupational exposure), a rapid drying agent in spray enamel paint, oils applied to tobacco products (blackfat tobacco), and possibly hair spray. - children may aspirate oily medications if they are force-fed these while resisting and crying violently. atypical mycobacteria, particularly rapid growers such as mycobacterium jortuitum or m. chelonae, have been reported associated with oil aspiration pneumonia (see chapter ) . [ ] [ ] [ ] [ ] [ ] symptoms of lipid aspiration include fever ( % of patients), weight loss ( %), cough ( %), and dyspnea ( %), although in one large study lipid pneumonia was an incidental finding, without associated symptoms, in % of patients. lung function tests may indicate either obstructive or restrictive changes. computed tomography (ct) scans usually show alveolar consolidation or groundglass opacities in the lower lobes. subfissural clear zones may be interposed between densities, creating a "sandwich effect" on ct scan. grossly, lungs affected by oil aspiration are often gray to yellow and rather solid (fig. . a ). dense localized fibrotic lesions (paraffinomas) may grossly mimic cancer or complicated pneumoconiosis. , occasionally oily droplets exude from the cut surface. microscopically the lipid droplets are often dissolved by tissue processing. one exception is cod liver oil, which remains as salmoncolored droplets on hematoxylin and eosin stain after tissue processing. fats may be seen with rapid watersoluble or oil red stains on frozen section ( fig. . d); variably sized fat droplets and varying numbers of multinucleate giant cells are present ( fig. . a-c). when only a small amount of fat has been aspirated, the reaction may be contained in alveolar macrophages. this is most commonly seen in mild degrees of aspiration with a diluted fatty substance, as might be seen with milk aspiration. when larger doses of thicker and more toxic oils are aspirated or when oil aspiration is repeated, the areas become densely fibrotic with reduction of the background lung architecture ( fig. . a ). occasionally, cor pulmonale results, . transbronchial biopsies may provide enough tissue to make this diagnosis. precise identification of specific lipids can be determined by infrared spectrophotometry. in the differential diagnosis is artifactual collapse of lung around remnant air bubbles (see fig. . c in chapter ). exogenous lipid pneumonia can usually be distinguished histologically from endogenous lipid chronically ingested mineral oil as a laxative. note yellow oil layered on the surface of fluid. (cholesterol) pneumonia by subdivisions within fat droplets, coarse cytoplasmic vacuoles in macrophages, multinucleated foreign-body giant cell response, and, in more chronic cases, a greater degree of chronic inflammation and fibrosis with destruction of background lung parenchyma in exogenous lipid pneumonia ( fig. . ). at times some lipid is incorporated/entrapped in the interstitium ( fig. . c ), resembling a similar appearance in diffuse pan bronchiolitis and xanthomatous bronchiolitis obliterans (see below and chapter ). diffuse panbronchiolitis is centered more on terminalrespiratory bronchioles and is composed mostly of finely vacuolated fat. sputum cytology or cytologic aspiration specimens have been used to confirm lipid pneumonia. on bronchoalveolar lavage an oily layer is sometimes present on the surface of the collection tube ( fig. . b ). in , losner et al., using oil stains, found lipid-rich macrophages in of suspected cases in contrast to two of control patients. more recently, corwin and irwin restudied this situation using bronchoalveolar lavage in various lung diseases including aspiration, hemoptysis, cancer in the lung (either primary or secondary), bronchiectasis, interstitial fibrosis, and sarcoidosis. when compared to normal lungs, samples from diseased lungs in general contained increased fat-filled macrophages. these authors warned that the simple presence of fatty macrophages in cytology preparations is not diagnostic of lipid pneumonia; however, the quantity of lipid was more abundant in aspirators than in these other groups. their figure . . oil aspiration. a. subacute effects of oil aspiration show varyingly sized fat droplets, inflammation, lymphoid aggregates, and fibrosis. most of the lung architecture has been obliterated. b. higher power view shows foamy lipid-filled macrophages and multinucleate foreign-body cells. c. in the chronic state, oil droplets are still seen within the interstitium with "aspirator" group consisted mainly of patients with a history of upper gastrointestinal tract disease, including reflux in most. in young children the presence of numerous (> ) oil red o-positive lipid-laden macrophages on tracheal aspirate is highly specific for aspiration. corwin and irwin emphasized that the size of the fat droplets in lavage fluid cannot be used to distinguish endogenous from exogenous lipid pneumonia. wherever it occurs, an abscess is a localized accumulation of inflammatory cells, initially having abundant neutrophils, that is usually accompanied by tissue destruction. in the lungs, "cross-country" necrosis occurs during the formation of an abscess (figs. . bronchi, and arteries. in contrast, cavities that are more chronic and more slowly formed, such as tuberculous cavities, often leave remnants of fibrotic bronchopulmonary rays coursing through the cavity itself (see chapter ) . some more slowly forming nontuberculous abscesses can do this, but most of the abscesses in the lung have an acute initial phase that destroys most of the tissue in the area ( fig. . b ). bronchi frequently connect with abscess cavities, allowing drainage of the necrotic material, leaving an empty or partially empty cavity with or without an air/fluid level on chest radiograph (figs. . and . ). occasionally, inflammation seals off all such bronchial connections, resulting in a solid mass that may be suspected of being a tumor. adjacent organization in acute and subacute abscesses often accounts for an enlarged surrounding radiographic density (figs. . and . ). there are many etiologies for cavity formation in the lung, and abscess formation is but one of them. other pulmonary abscess formation, which were already well known by , were summarized in this review. by , a total of cases had been published. aspiration is the most common cause of lung abscess. other instigators of this type of damage include b. gross specimen. note cavity is mostly drained, with freshappearing, thin lining without fibrous wall. note also persistence of some trabeculae, presumed bronchopulmonary rays, and variable but narrow surrounding inflammatory reaction. penetrating trauma, postoperative states, obstruction, hemorrhage or infarction, necrotizing pneumonia, infected emboli, infection of a preexistent cyst or bulla, or extension from nearby infected areas in the mediastinum, chest wall, diaphragm, or infradiaphragmatic loca- tions. nonaspiration types of pulmonary abscesses of course do not follow the aspiration patterns of distribution, but occur as their coexistent factors dictate. for example, if there is an infarct or an obstructing tumor, infection would occur in the affected areas. septic emboli are hematogenously spread, and resultant abscesses are often multiple, small, and peripherally distributed (see fig. . in chapter ). as aspiration is the principal cause of pulmonary abscess formation, it is reasonable that conditions that favor abscess formation are identical to those favoring aspiration. the locations are similar; men are more frequently affected than women; and the right lung is involved twice as often as the left. - the posterior segments of the right upper lobe and superior segments of the right lower lobe are involved most frequently, followed by the corresponding segments on the left side. the single most commonly associated event is an alteration of consciousness; the second most frequent association is poor dental hygiene; and the third is an immunodeficient status. poor dental hygiene was noted in cases without other apparent causes of pulmonary abscess in the early studies between and . - the spectrum of bacteria involved in abscess formation is almost identical to that of endogenous oral flora. - moreover children and edentulous older people do not often develop lung abscesses.ll in children cases caused by aspiration must be separated from other cases of cavitary necrosis, such as pneumatoceles in primary staphylococcal pneumonia. - l anaerobic bacteria are the only organisms cultured in about one half to two thirds of lung abscesses; in the remaining cases either aerobic or facultative aerobic bacteria are isolated, or no bacteria are culturedys the anaerobic bacteria most frequently found are peptostreptococci (i.e., gram-positive anaerobic cocci), pigmented gram-negative bacilli (including bacteroides), and the fusobacteria. . l . spirochetes were described morphologically in earlier studies and seemed to be significant, as they were present in the growing rims of necrosis; however, they have not been mentioned much recently, perhaps because they are difficult to culture.los. about half of cultures with anaerobes also contained aerobic bacteria capable of necrosis, specifically staphylococcus, streptococcus, haemophilus, pseudomonas, klebsiella, and escherichia spp. patients with predominantly anaerobic pulmonary abscesses often present with indolent symptoms, in contrast to those with necrotizing aerobic abscesses. the latter may be more common in nosocomial-acquired lung abscess. s - immunocompromised patients often acquire gram-negative necrotizing pneumonias and vasoinvasive necrotizing fungal pneumonias, both of which may lead to cavitation. one clue to aspirated bacteria in lung abscesses is finding mixed-type organisms on smear gram stain, tissue gram stain, or culture. the oral cavity abounds with mixed bacteria and is estimated to contain some different types of organisms. this is one reason sputum cultures are notoriously difficult to interpret, and why even oral contamination of a bronchoscope interferes with most lung cultures. transtracheal and transthoracic needle aspirations, however, correlate well with blood culture results. i . the third most frequent factor in abscess formation is host response. factors that compromise normal host defenses include alcohol ingestion, diabetes mellitus, renal failure, malnutrition, malignancy, and other debilitations, along with treatment with immunosuppressive agents for any reason. patients with these factors do more poorly with pulmonary abscesses (and most other insults) than those without. [ ] [ ] [ ] pathologically, acute cavities have only a thin transition zone into the reactive adjacent lung parenchyma (see numbers of neutrophils and macrophages, along with tissue necrosis. the nearby lung parenchyma has variable findings depending on the rapidity of spread. rapidly growing cavities necrose nearby lung parenchyma, destroying any early attempts at organization. there may be adjacent hemorrhage, exudate, and fibrin extravasation. in those that are slightly more stable, beginning organization occurs in the surrounding lung parenchyma, sometimes chronic cavities heal with a thin fibrous border and may retain a coagulum of necrotic debris in their lumen. this apparently indicates that the nearby bronchi have been sealed off. chronic cavities may resolve by collapse and fibrosis, or may remain open. in the open variety they may become reepithelialized, first with a squamous lining and then with ciliated respiratory lining. in the latter case, the distinction from bronchiectasis or bronchocele may be somewhat confusing, but multiple bronchial connections in a chronic abscess cavity distinguish these entities. spontaneous healing may occur, but healing is greatly aided by appropriate antibiotic dosage. weiss l noted in appropriately treated and monitored cavities that % of cavities disappeared by weeks of therapy, % by weeks, % by weeks, and % by months. surgery is sometimes indicated for nonhealing cavities or when complications develop, such as hemoptysis, persistent sepsis, bronchopleural fistulas, or empyema. the incidence of abscess formation has greatly decreased during the past years, partly because antibiotics are available and frequently used early in pulmonary infections, and partly because factors leading to of fibrin ( ) resting on cellular granulation tissue ( ). b. wall of chronic abscess cavity composed of dense, fibrotic, mature granulation tissue. abscess formation are better understood; for example, surgery is avoided with the patient in the upright position or on patients with food in the stomach. in the pre antibiotic era approximately % of the patients treated either conservatively or by surgery died, and another one third had chronic residual lung disease. more recently the prognosis is much better, but the mortality associated with established abscess formation remains in the range of % ? although the term gangrene of the lung has been applied to necrotizing, sometimes putrid, pneumonia in any location, it has more recently been used more specifically to indicate massive necrosis and sloughing of lung associated with severe infection. this entity almost always involves the upper lobes, usually on the right side, and radiographically evolves through typical changes of diffuse infiltrate into multiple cystic spaces that become confluent, leaving a crescent of lung density compressed medially, or occasionally laterally, with a final walled-off area of pus and necrotic lung in an otherwise empty structureless space. curry and colleagues l and penner et a . attribute the first description of pulmonary gangrene to laennec in the s. phillips and rao,l l who reported four cases, refer to sir william osler's description of diseased lung "converted into a horribly offensive greenish, black mass, torn and ragged in the centre" (fig. . ) . the patients may cough up large pieces of necrotic lung, which in one case was therapeutic. these fragments histologically show ghosts of lung parenchyma and thrombosed vessels. vasculitis has been described in some reports. , assorted microorganisms cultured from these cases include klebsiella pneumoniae, pseudomonas aeruginosa, haemophilus injluenzae, staphylococcus aureus, streptococcus pneumoniae, and mucor species, anaerobic bacteria probably also playa significant role. in their reviews, phillips and rao l l and penner and colleagues note that similar predisposing factors as those with community-acquired pneumonia, such as aspiration and abscess formation, pertain to this entity, but the location helps distinguish it from the other typical sites of aspiration, when in the upper lobes, it appears to progress through necrotizing pneumonia with thrombosis of arteries (pulmonary and bronchial) and veins, [ ] [ ] [ ] although not strictly abiding by the foregoing definition (of localization in upper lobe), in one case total unilateral lung gangrene was attributed to hilar vessel involvement following treatment of a massive hilar recurrence of hodgkin's disease. pulmonary gangrene is life threatening, and surgical removal of necrotic lung tissue if. tomashefski, jr. , and d.h. dail figu re . . pulmonary gangrene, lung parenchyma is greenish-black, necrotic, and cavitated in this specimen from a patient with central bronchogenic carcinoma, bronchial obstruction, pulmonary artery invasion, and thrombotic occlusion. note hyperemic rim between necrotic lung and apical lung parenchyma. proteus, e coli, and enterococcus cultured, is often indicated since only a few patients survive with antibiotic therapy alone, an entire lung, or even one lobe, may rotate around the hilar structures and cause congestion, hemorrhage, or infarction, cases of torsion involving only single lobes most commonly occur postoperatively when a portion of ipsilateral lung has been removed, , torsion is an infrequent event. a review of the literature in by schamaun documented cases of postoperative torsion, five posttraumatic occurrences, and four spontaneous events. in a poll of british thoracic surgeons, however, of responders ( % ) had encountered at least one instance of torsion, torsion has also been documented to occur in transplanted lungs or as a result of pneumothorax or mass lesions. , due to the simultaneous compromise of pulmonary and bronchial arteries and the pulmonary vein, fatal gangrene may occur (see above), the entity of obstructive, golden, or endogenous lipid pneumonia is most commonly seen secondary to tumor obstruction of large airways, but any of the causes of obstruction can lead to obstructive pneumonia. the obstructive effect accounts for a much larger infiltrate on the usual chest radiograph than is caused by tumor alone. the involved area is primarily supplied by the affected bronchus, and the larger the obstructed bronchus, the greater the area involved. however, even when obstruction occurs in the smallest bronchioles, there may be secondary effects in the centriacinar regions. cholesterol pneumonia may also spread into the adjacent nonobstructed segment, and occasionally throughout the lobe. the latter pattern of disseminated spread is often associated with more poorly differentiated or cavitated carcinomas. the involved lung is reduced in size, but not to the extent expected in simple atelectasis. the difference is due to the infiltration by abundant inflammatory cells. the microscopic hallmark of obstructive pneumonia is flooding of air spaces initially by edema followed by fat-filled, finely vacuolated, so-called foamy alveolar macrophages (fig. . a golden-yellow color, hence the term golden pneumonia. obstructed secretions, increased cell breakdown products, and possibly leakage from vessels and interstitium, may give rise to the fat seen in this characteristic reaction. as these products are derived from the lung, this is called endogenous lipid pneumonia. early in its course the alveolar outlines are well defined though distended with foamy macrophages. if the pneumonia is rapidly reversed, lung function may return. gradually, permanent damage ensues, including fibrosis and vascular sclerosis, and it is then difficult to restore lung function even though the obstruction may eventually be reversed. some degree of intraalveolar organization may also be present in approximately % of cases. l features of superimposed infection, such as acute inflammation, necrosis, or abscesses are seen in a minority of cases. in contrast to exogenous (aspiration) lipid pneumonia, endogenous lipid pneumonia is characterized by finely vacuolated fat, absence of a foreign-body response, and minimal inflammation and fibrosis of the underlying lung architecture (figs. . and . b,c). sometimes there are changes that suggest pulmonary alveolar lipoproteinosis (see below). . at times parenchymal changes very similar to those just described may be present, although no obstruction of bronchus can be identified, so-called idiopathic cholesterol pneumonia. , in , robbins and sniffen described cases of chronic nonobstructive cholesterol pneumonia, of which ( %) occurred in men aged to years, the only female being a -year-old girl. in extent, five of their cases involved most of the lobe and six cases included a portion of one or more segments, often with pleural adhesions; some had small abscess cavities. the involved areas were wedge-shaped with their bases on the pleura and were described as bright yellow; they were accounted for histologically by abundant, finely vacuolated foamy macrophages, but otherwise these areas presented as mass effects. mucoid or mucopurulent exudate filled some bronchioles and bronchi, but no other cause of obstruction was present. bronchiectasis was absent, although focal necrotizing bronchitis was noted. the lobar distribution was not documented. these authors argued against aspiration as they noted the usual aspiration to be more diffuse, often multifocal, and more often seen in lower lobes. lawler able foreign material in ( %) and strongly suspected aspiration in another six for a total of % in this series. all except two cases ( %) of confirmed aspiration were solitary lesions. it seems reasonable that at least some of both chronic organizing pneumonia and idiopathic cholesterol pneumonia, even when not so confirmed, may be the result of aspiration, usually involving ingredients other than exogenous lipid. secondary chronic organizing pneumonia, involving large portions of a lobe or presenting as a mass lesion, is not to be confused with the distinctive form of interstitial lung disease termed cryptogenic organizing pneumonia (bronchiolitis obliteransorganizing pneumonia), which is further discussed in chapter . fisher et al. have described a series of patients (six children [< years of age] and two adults) with progressive diffuse interstitial lung disease having a combination of histologic features including endogenous lipid pneumonia, interstitial cholesterol granulomas, and patchy alveolar proteinosis (fig. . ). three patients in this study had severe combined immunodeficiency, two had pulmonary hypertension, and one each had cystic fibrosis (cf), trisomy q, and ventricular septal defect (vsd), or lysin uric protein intolerance. all patients exhibited delayed growth, five had digital clubbing, six had depressed appetite or anorexia, five were anemic, and three experienced hemoptysis. six of eight patients also had evidence of gastroesophageal reflux, which the authors suggest is important in the pathogenesis of this condition. pulmonary function tests in four patients showed either restrictive or mixed restrictive and obstructive physiology. chest x-rays predominantly showed nodular pulmonary opacities, while bronchiectasis and perihilar or mild hazy parenchymal infiltrates occurred in one patient each. the mechanism whereby gastroesophageal reflux might elicit this interesting triad of histologic findings is through recurrent micro aspiration of gastric content with associated bronchospasm (see discussion of alveolar proteinosis in chapter ). the differential diagnosis of cholesterol pneumonia also includes drug reactions, notably reactions to amiodarone. the clinical history and documentation of amiodarone therapy should facilitate the correct diagnosis (see chapter and fig. . ) . while the foamy macrophages in both of these disorders resemble each other histologically, electron microscopy demonstrates more abundant osmiophilic dense bodies and giant lamellar bodies in many different cell types in amiodarone toxicity compared to similar but smaller inclusions within macrophages in endogenous lipid pneumonia. . ~ compared to endogenous lipid pneumonia, amiodarone toxicity also encompasses a prominent inflammatory response that may include fibrosis, organizing pneumonia and diffuse alveolar damage (see chapter ) . other drugs that have been implicated as a cause of endogenous lipid cholesterol granulomas not only are associated with endogenous lipid pneumonia and pulmonary alveolar proteinosis, but also have been attributed to pulmonary hypertension, organizing hemorrhage, and a unique case of excessive consumption of apples. - kay and colleagues suggest that cholesterol granulomas in patients with pulmonary hypertension are more likely due to other concomitant processes characterized by type ii pneumocyte hyperplasia and degeneration. atelectasis is the collapse of aerated lung. most often it is caused by internal bronchial obstruction of the air flow (absorption atelectasis) (see fig. . in chapter ), but it may result from external compression of the lung, such as by empyema, mesothelioma, constrictive pleural fibrosis, or tumors, or by internal compression, secondary to a bulla, tumor, or other space-occupying lesions (compressive atelectasis). pneumothorax is an important cause of atelectasis in the ipsilateral lung. atelectasis may also be caused by a change in metabolism or surface-wetting balance such as with hyaline membrane disease, ards, infection, or gastric acid or other aspiration with loss of pulmonary surfactant. it may also have vascular causes as with embolism, postoperative splinting, obesity (e.g., pickwickian syndrome), or secondary to nerve or muscle dysfunction of diaphragm or chest wall. following complete airway obstruction, atelectasis occurs when alveolar oxygen and nitrogen are absorbed. atelectasis is also commonly seen around chronic inflammatory reactions such as bronchiectasis, and may be part of the sequence of events leading to bronchiectasis (see below). pathologists must be cautious, however, because most often, when observed histologically, atelectasis is artifactual. upon the release of negative pressure, air escapes from the lung when the thorax is opened or when lung tissue is excised, and this collapse may cause confusion with preexisting atelectasis (see fig. when bronchial obstruction is partial, it may easily lead to air trapping, as discussed in chapter (see asthma). obstruction of segmental bronchi usually does not cause atelectasis because of preserved collateral ventilation. a collapsed lung may be an isolated cause of fever, but is also a frequent site for superinfections, such as in postoperative patients. chronic atelectasis may lead to irreversible scarring. the special situation of rounded atelectasis is discussed in chapter on asbestos-related pathology. bronchiectasis simply defined refers to dilatation of bronchi. included in this broad definition are conditions such as traction bronchiectasis secondary to parenchymal scarring; airway dilatation accompanying parenchymal loss as in emphysema; or reversible dilatation, which may be seen radiographically in atelectasis or pneumonia. - a more selective definition of bronchiectasis, and the type usually understood by pathologists, is irreversible fixed airway dilatation associated with inflammation and destruction of bronchial matrix components. • bronchiectasis can be further categorized as localized or diffuse/multifocal. causes of localized bronchiectasis, the most important of which is airway obstruction, are listed in table . . localized bronchiectasis may also have an infectious etiology, most notably pulmonary tuberculosis (see fig. . in chapter ). obstructive bronchiectasis is most commonly seen beyond endobronchial tumors (fig. . ), but foreign bodies, concretions such as broncholiths, secretions such as inspissated mucus in mucoid impaction and allergic bronchopulmonary aspergillosis (see chapter ), strictures, or compression as by tumor or enlarged nodes may play a role. rarely, lack of cartilaginous support with airway collapse, bronchial atresia, or mucosal webs may be associated with bronchiectasis. obstructive bronchiectasis occurs anywhere obstruction occurs, but there are some localizing factors in a few of these conditions: the upper lobe in allergic aspergillosis or with primary epithelial tumors, which are more common in this site; the middle lobe with its tendency toward airway compression (middle lobe syndrome); and localized bronchiectasis governed by the usual routes of aspiration (covered earlier in this chapter). there are many exceptions, and bronchoscopy is usually indicated in both children and adults to diagnose the type of obstruction. localized bronchiectasis is often successfully treated by surgical resection or elimination of the cause of bronchial obstruction. diffuse or multi focal bronchiectasis is usually of the nonobstructive type, the major causes of which are listed in table . . it is this type that is more frequently a cause of significant chronic obstructive pulmonary disease (copd) and respiratory failure. nonobstructive bronchiectasis occurs most frequently in the basal segments of the lower lobes, often sparing the superior segment and the anterior basal segment. it is found more than twice as frequently in the left lower lobe as in the right. s -j next in frequency are the right middle lobe and its counterpart, the lingula. these areas of the lung may have the poorest drainage. the upper lobes may be involved but are usually not solely involved by nonobstructive bronchiectasis. tuberculosis more selectively causes bronchiectasis in the upper lobes, and cystic fibrosis should be considered in cases of upper lobe involvement without a definitive etiology. about one third of the cases of nonobstructive bronchiectasis have bilateral involvement. . , macroscopically bronchiectasis typically involves the second to the eighth order of segmental bronchi, sparing the larger, more proximal airways, which are protected by a firmly supporting cartilaginous network. - more distal airways are often obliterated or effaced as the number of bronchial divisions is reduced (fig. . ). , within a bronchopulmonary segment there may be patchy involvement (see fig. . in chapter ). there is also apparent loss of more distal lung parenchyma as the dilated airways approach the visceral pleura ( fig. . ) . , bronchiectasis has been divided into many different patterns grossly and radiographically. the most widely applied classification is that suggested by reid l : ( ) saccular (cystic), ( ) cylindrical (fusiform or tubular), and ( ) varicose. in the saccular form, the distal extensions of the bronchi are more dilated than proximal portions, described by reid as "globular ballooning." usually, the second-to fourth-order bronchi are involved. cylindrical bronchiectasis consists of evenly enlarged tubular dilatation of bronchi, usually involving the sixth-to eighthorder bronchi. is i on bronchograms dilated bronchi come to an abrupt, square-ended termination thought to be caused by impacted endobronchial secretion. the varicose type describes focal dilatation separated by more narrow areas (see fig. . in chapter ). these various gross patterns were previously best visualized by bronchography, and are not specific for any given etiology, although certain clinical-pathologic correlations have been made (see below). whitwell integrated histologic features into his classification of follicular, saccular, and atelectatic bronchiectasis. follicular bronchiectasis most frequently begins in childhood as the sequela of viral infections, most notably adenovirus. saccular bronchiectasis, in whitwell's series, was often found to be postinfective or idiopathic. the pathogenesis of atelectatic bronchiectasis was linked to lobar bronchial obstruction, often by enlarged lymph nodes. congenital bronchiectasis, purportedly due to cartilage deficiency in the bronchial walls, is a controversial entity discussed elsewhere in this chapter under the williams-campbell syndrome. , s , not to be confused with congenital bronchiectasis are those hereditary conditions, such as cystic fibrosis or primary ciliary dyskinesia, that predispose to the subsequent development of progressi ve bronchiectasis (see below). , patients with bronchiectasis typically present clinically with forceful cough, purulent sputum production, wheezing, and recurrent pneumonia in the bronchiectatic zones. wet bronchiectasis refers to abundant inflammation and mucus hypersecretion, whereas dry bronchiectasis refers to minimal sputum production. dry bronchiectasis is most common in the upper lobes, is often of the cylindrical type, and probably relates to better drainage in this zone. hemoptysis commonly presents as blood-streaked sputum, but may be massive and life-threatening. frequently purulent sinusitis accompanies bronchiectasis and may contribute to its development. the chest radiograph is usually abnormal in bronchiectasis, including specific features of ring-like shadows due to dilated airways seen on end, or of tram lines when the airways are visualized longitudinally. iss high-resolution ct scan is the best current modality for diagnosing bronchiectasis, revealing airways that are dilated relative to the adjacent blood vessels, lack of airway tapering, constrictions along the path of the airway, and terminal balloon-like cysts. is ,is pulmonary function tests show obstructive changes with reduced forced expiratory volume in second (fev )/ forced vital capacity (fvc) and frequently airway hyperresponsiveness. various theories have been proposed to explain nonobstructive bronchiectasis. inflammation seems to best account for the changes that are observed, including the fact that the involved zones of lung are those most difficult to drain. it was known even in the s and confirmed in subsequent decades that respiratory infection often preceded bronchiectasis. , , - usually older children and young adults have the well-developed disease pattern, but also have a history of infections before the age of or years, with recurrent respiratory problems dating from this time. many patients may appear stable and do well for some time, and then develop a progressive course of recurrent infections and systemic toxicity. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in approximately % of cases of bronchiectasis, however, a specific inciting factor is not identified-so-called idiopathic bronchiectasis . in these patients, childhood respiratory infections especially those likely to have produced bronchiolitis obliterans, are presumed to have initiated the process of bronchiectasis. , , viral infections may be important in many cases. , , - glauser and associates noted in an extensive review that measles and pertussis immunizations probably have played a significant role in decreasing the incidence of bronchiectasis. bacteria also playa significant role, both in primary infections (see following) and in superinfections or reinfections in areas of previous injury. aggressive treatment of pediatric pulmonary infections with antibiotics has helped to make bronchiectasis a disappearing disease. historically, the impact of immunizations and antibiotics on the declining incidence of bronchiectasis occurred at about the same time, and it is difficult to differentiate their effects; nonetheless, this association supports the role of early infection in initiating bronchiectasis. excluding cases of kartagener's syndrome, the concurrence of sinusitis and bronchiectasis is greater than expected. as early as , quinn and meyer noted a % incidence of chronic sinusitis in cases of bronchiectasis. aspiration of infective material from the sinuses may playa role. however, another study noted a % incidence of sinusitis in cases with less than years of symptoms of bronchiectasis compared to the % incidence in all cases of bronchiectasis. h. infiuenzae, a common pathogen of the upper respiratory tract, is also found with some regularity in lung cultures from patients with bronchiectasis. anaerobic bacteria, reflecting endogenous oral flora , may also be cultured from bronchial secretions. long-term antimicrobial treatment may be required for complete eradication of these organisms. the role of recurrent infection in perpetuating and aggravating bronchiectasis cannot be overemphasized. this has been documented in children and adults. the dilatations of the bronchial contours, their irregularities, their relative stenosis at the proximal end, altered secretions and exudate, surface mucosal ulcerations, and metaplasia all playa role in hampering adequate drainage. a vicious cycle ensues as the injured area perpetuates further injury, leading to increased damage and progressive bronchiectasis. necrotizing inflammation involves bronchial walls and adjacent parenchyma (fig. . ) . some scarring probably takes place in healing, with retraction of surrounding tissue. retraction occurs circumferentially, and bronchial dilatation results. as noted, the more distal bronchi and bronchioles are often destroyed. there is also general lung contracture due to atelectasis of involved zones, while nonaffected lobes may undergo compensatory hyperinflation (fig. . ) . the basic principles of fibrosis and contraction also apply to traction bronchiectasis seen in interstitial fibrosis and honeycombing. traction bronchiectasis is usually not as marked as primary bronchiectasis, and is localized and most severe in the peripheral subpleural zones where fibrosis is often most prominent (see chapter ) . grossly, the involved lung tissue is usually atelectatic, gray-blue, shrunken, and rubbery. there may be zones of golden or obstructive pneumonia, and sometimes these zones form layers around the dilated bronchial tubes. it may be difficult or impossible to adequately inflate such a chronically contracted specimen. the involved bronchi are dilated instead of following their smoothly contoured courses as they extend peripherally. these dilated bronchi almost reach the pleural surface and run in a somewhat parallel or radial fashion without interbronchial connections (figs. . and . ). partially or totally circumferential thin folds in the mucosa extend internally from the wall and are seen as transverse infolded pleats on the bronchial cast (see fig. . in chapter ). these give the appearance of webs or bands of mucosa. there are variably sized outpouchings, larger ones between the remnant bronchial cartilages, and dilated smaller pits that appear to be dilated submucosal glands. grossly, elastic fibers can be seen still running through the wall, but these are more widely separated than is normal because of the stretched diameter of the bronchus. in wet bronchiectasis there is thickening of the wall, and mucinous, granular, semisolid material accumulates within the lumen (fig. . ). occasionally this material hardens and even calcifies (see broncholithiasis, below). in dry bronchiectasis the wall is thin, almost translucent, and gray-pink without mural thickening. microscopically the respiratory mucosa may be intact, show squamous metaplasia, or be ulcerated or inflamed (fig. . ). the bronchial walls are usually chronically inflamed. submucosal glands and surface goblet cells are not prominent and may decrease, although they may occasionally increase. elastic tissue is preserved except in areas of necrosis (fig. . ). smooth muscle is usually present and often shows some degree of hypertrophy; occasionally this is atrophic. cartilage seems less obvious and occasionally is eroded, but most often appears normal histologically. in advanced saccular bronchiectasis cartilage is markedly reduced or absent. , , neutrophils, macrophages, and desquamated and mucinous debris are present in the bronchial lumen in wet bronchiectasis. acute inflammatory cells may infiltrate the bronchial wall or the adjacent lung parenchyma depending on the status of inflammation and active infection at the time of lung removal. as these patients are subject to recurrent infections, acute pneumonia may also be present. lymphocytes and plasma cells usually predominate in bronchial wall and surrounding lung tissue. in follicular bronchiectasis, hyperplastic lymphoid follicles may appear to constrict the bronchial lumens (fig. . ). there may be a degree of obstructive pneumonia correlating with the gross yellow color. small granulomas are present in a few cases, apparently as a reaction to inspissated material within the bronchi. if granulomas are extensive or present in the adjacent lung parenchyma, in more normally contoured segmental and subsegmental bronchi, or in lymph nodes, one must consider fungal or mycobacterial infections. if granulomas are confined to the injured areas, one must also consider aspiration. bronchioles are often constricted or obliterated beyond the dilated bronchi (fig. . ). other small airways may be dilated and sometimes mucus-filled probably because of their obstruction at the junction with the larger bronchi. foci of carcinoid atypical proliferation (tumorlets) occur with some frequency in bronchiectasis (see chapter ) . bronchial arteries respond to sustained inflammation, and may exceed mm in diameter. ulceration of these systemic arteries accounts for the bright-red appearance of hemoptysis. the right middle lobe and occasionally its left-sided counterpart the lingula, have lobar bronchi that branch from their parent supply at a more acute angle than most other dividing bronchi (see chapter ) . the middle lobe bronchus is relatively narrow, and there are frequently moderately prominent nodes in the angle of bifurcation that may compress and further constrict the bronchus. the subcarinal node may even approach this angle. several authors have also suggested there is less effective collateral ventilation in the middle, compared to the adjacent upper lobe. . because of these anatomic characteristics there is a greater tendency toward middle lobe and lingular atelectasis, inflammation, nonspecific scarring, broncholith formation, and bronchiectasis-collectively termed middle lobe syndrome (mls) . io in addition to peribronchial lymphadenopathy, mls can result from numerous disorders including asthma, tuberculosis, foreign bodies, cf, broncholiths, endobronchial silicosis, cardiovascular and of bronchiolar wall. white arrow indicates cross section of separate, obliterated airway (patient with cf) (elastic van gieson stain). bronchopulmonary malformations, and allergic bronchopulmonary aspergillosis. - the pathologic findings in resected lung specimens of patients with middle lobe syndrome have been comprehensively described most recently by kwon and colleagues, and are delineated in table . . although the histologic findings are nonspecific, a combination of bronchiectasis, bronchiolitis, and atelectasis is typical. in this series, a mechanical obstruction (broncholith) was identified in only one patient. as early as , culiner also recognized bronchial patency in most cases of middle lobe syndrome. the current understanding suggests that mls is due to recurrent infection related to poor lung drainage, possibly associated with intermittent obstruction of the precariously situated bronchi in the setting of reduced collateral ventilation of the middle lobe. . broncholiths represent calcified material in the airways. - they most commonly are calcified lymph nodes that compress bronchi and either partially or completely erode through the bronchial walls (fig. . ). . they then may be expectorated (lithopytsis) (fig. . ) calculus (scale equals cm). c. rare yeast-like organisms, consistent with histoplasma, were identified in the necrotic center of the broncholith (gomori methenamine silver stain). or aspirated and cause hemorrhage or obstructive changes, including cough, atelectasis, pneumonia, abscess formation, bronchiectasis, or air trapping. broncholiths form less often from chronic reaction to retained aspirated material or eroded fragments of calcified or ossified bronchial cartilage. o they may also occur with retained mucus as in bronchiectasis. historically, "spitting stones" dates back to descriptions by aretaeus, galen, and aristotle. although usually less than cm in diameter, a record-sized calculus of g c/ ib) occurred in a patient who also had produced multiple sand-like or melon-seed-sized calcified particles. the pathognomonic finding of lithoptysis is fairly rare and was seen in only two of ( %) cases by faber et al. and six of ( %) cases by schmidt et au the regional nodes usually calcify from old granulomatous disease, and tuberculosis is the most common etiology worldwide while histoplasmosis is the most common etiology in the united states. other infectious agents include coccidioides, cryptococcus, actinomyces, or no cardia. , o, , the latter two organisms probably represent superinfections of necrotic debris. silicotic lymph nodes may also cause a similar reaction. , men and women are about equally affected, and although calcified nodes may occur at any junction of the bronchial tree, they are to . times as common on the right side, and favor the anterior superior segment of the upper lobe and the bronchus intermedius, along with the right middle lobe bronchus, where they may produce the middle lobe syndrome. , , the superior segment of the lower lobe is also a site of occurrence. occasionally, erosive calcified nodes may cause bronchopleural fistulas and are the most common cause of bronchoesophageal fistulas, [ ] [ ] [ ] retraction diverticula of the esophagus may also occur secondary to peribronchial fibrosis and calcified mediastinallymph nodes associated with broncholiths. , calcified nodes have also been studied with ct scans. in the retrospective series by conces et al., of patients with ct-proven broncholiths, ( % ) had juxtabronchial calcified nodes identified on chest radiographs. calcified intraparenchymal nodules were seen radiographically in only four ( %) patients. bronchoscopy is less accurate in detecting calcifications, ranging from % to % of cases. rarely, calcifying tumors such as an ossifying bronchial carcinoid or endobronchial hamartoma can cause confusion (see chapters and ) . , histologically broncholiths appear similar to calcified fibrocaseous lymph node lesions. the outer surface of the often sharp-edged calculus may be coated with inflammatory exudate or, in cases of actinomyces superinfection, eosinophilic rays (splendore-hoeppli phenomenon). , the gms stain may disclose histoplasma yeast forms in the centrally necrotic area of the calculus (fig. . b) . , , the airway in which the calculus is lodged is typically stenotic, with mural fibrosis and chronic inflammation. within the chest, fistulas may be bronchopleural, bronchocutaneous, bronchomediastinal, or bronchoesophageal in their connections. an aortobronchial fistula is a rare (and often fatal) complication of previous aortic or cardiac surgery, bronchopleural fistulas are the most common form and often are secondary to surgery, such as from a leaking postoperative bronchial stump. other causes include necrotizing pneumonia or abscess, penetrating wounds, eroding granulomatous disease, penetrating broncholiths, or malignancies. see chapter for congenital causes. extrathoracic bronchial fistulas include connections with bile ducts, pancreas, and other assorted sites. bronchocele means one or more dilated bronchi filled with fluid, which may be mucinous (bronchomucele) or purulent (bronchopyocele ). this condition is caused by stenosis or occlusion of the proximal end of dilated sac(s), and therefore differs from bronchiectasis and mucoid impaction, in which proximal ends are generally still patent. it may be either congenital, or early or late acquired, usually of postinflammatory nature but sometimes of malignant nature. localized emphysema, which occurs around the bronchocele, may be caused either by inflammation early in lung growth with continued traction-type effects on nearby lung, or by sustained air-trapping due to airway obstruction. , . o many cases are reported as bronchial atresia. - bronchocele/ atresia may present in adults or children and typically affects the left upper lobe. a characteristic ct appearance is that of a branching mass surrounded by hyperlucency. an irregularly cylindrical (sometimes branched) thin-walled cyst (fig. , a) grossly and histologically resembles a bronchocele lined by respiratory or squamous epithelium. , o, occasionally a scar or intrabronchial web proximal to the lesion represents the remnant atretic or occluded bronchus. the adjacent bronchial arteries may appear hypertrophic, especially if there have been recurrent infections (fig. . b) , bronchocele may be a relative of saccular bronchiectasis and may be the etiology for some so-called intraparenchymal bronchogenic cysts (see below and chapter ). mucoid impaction may also be related to an allergic effect, often to noninvasive aspergillus (see chapter ), usually does not have proximal bronchial stenosisocclusion, and has more eosinophils and cellular debris in the mucus, in addition to intraluminal hyphae. bronchocele/atresia is distinguished from intralobar seques- bronchogenic cysts are closed sacs lined by respiratory mucosa, usually with bronchial glands, smooth muscle, and cartilage in their walls. they often represent congenital fragments that drop off or are remnants of the original budding of the lungs from the primitive endodermal canal. they are most common in the middle mediastinum where they account for % to % of all primary mediastinal masses but can be seen as isolated masse es) in the lung. within the lung, some may form as bronchoceles as discussed previously. a series of cases of bronchogenic cyst, with ( %) in the mediastinum and ( %) in the lung, was presented by st. georges et al. from montreal. a similar distribution was recorded in adult patients by patel and colleagues. of interest, % to % of those in the lung were symptomatic at the time of operation, most often because of infection or bronchial obstruction,z , although suspected, a preoperative diagnosis was not correctly made in any case in the large montreal series. the presence of bronchial epithelial cells on trans bronchial fine-needle aspiration (fna) was found not to be specific for the diagnosis of bronchogenic cyst. most occur in the lower lobes, but all lobes may be affected. -z the ct appearance is that of a well-defined hypertrophic bronchial arteries (ba). lumen of cyst is at top (movat stain). ovoid lesion, with surrounding mosaic and band-like linear attenuation consistent with emphysema and bronchiolar metaplasia/fibrosis. a bronchioloalveolar cell carcinoma arising in a bronchogenic cyst in a -year-old woman has been reported as a rare association. bronchogenic cysts are uncommon in adults and are further discussed in children in chapter . bronchorrhea is arbitrarily defined as production of more than ml of sputum per day. although it is a clinical symptom, pathologists may ponder the differential diagnosis if faced with this history on a specimen request card. bronchorrhea may be idiopathic, or secondary to chronic bronchitis, bronchiectasis, scleroderma, asthma, mucinous bronchioloalveolar carcinoma, metastatic mucinous adenocarcinoma, tuberculosis, or relapsing polychondritis. - cytology exams, cultures, or trans bronchial biopsies may help evaluate at least some of these possibilities. cystic fibrosis is a prototypic example of bronchocentric inflammation and bronchiectasis and the most common lethal genetic disease among caucasians, having a frequency of approximately in live births. - the molecular defect of this autosomal recessive disorder was discovered in to involve mutations in a amino acid polypeptide, the cystic fibrosis transmembrane conductance regulator (cftr), encoded by a gene on the long arm of chromosome . , over different mutations of the cftr gene have so far been identified, but the most frequent mutation worldwide and the most severe genetic lesion, is the deletion of phenylalanine at position of cftr (af ), accounting for over % of affected patients. o , cystic fibrosis transmembrane conductance regulator functions as a cell membrane-associated, cyclic adenosine monophosphate (camp)-regulated chloride channel, which also has regulatory activity on the absorption of sodium through a separate epithelial channel (enac). - the structure of cftr is schematically depicted in figure . . mutations in cftr have been grouped into six major types, each of which may present phenotypically as cf: ( ) lack of synthesis of cftr; ( ) defective processing of cftr such that it does not reach the cell membrane; ( ) aberrant regulation of ion transport due to dysfunctional cftr; ( ) abnormal conductance of chloride ions; ( ) partly defective production and processing; or ( ) accelerated turnover at the cell surface ( fig. . ) . , , , the af mutation is a type defect in which abnormal cftr is sequestered within cellular organelles leading to reduced insertion into the cell membrane, markedly limiting the ability of chloride to cross the membrane. in epithelial cells of bronchi, biliary tract, and intestine, impaired transport of intracellular chloride and its accompanying water molecules leads to dehydration of ductal and lumen secretions. o in bronchial epithelium there is also enhanced intracellular absorption of sodium ions, which further dehydrates secretions within the airway lumen. o , , in contrast, the uptake of extracellular chloride is inhibited in sweat ducts, causing an elevation of sweat chloride concentration, a key diagnostic indicator of cf. , the manifestations of cf are protean, involving nearly every organ system either directly or secondarily. the correlation between genotype and phenotypic expression is best exhibited for pancreatic function and is relatively poor for pulmonary manifestations. , , however, certain mutations such as a e or the ivs t allele are associated with relatively mild lung disease that may initially present in adults.m- a unifying feature of the pathophysiology of cf is impaction of viscid secretions in exocrine gland ducts leading to cardinal manifestations such as intestinal obstruction (e.g., meconium ileus); pancreatic acinar atrophy and fibrosis with consequent metabolic insufficiency (due to intestinal malabsorption); organ maldevelopment (e.g., congenital bilateral absence of the vas deferens); hepatic fibrosis (focal biliary cirrhosis); and infection associated with mucus stasis (e.g., infective bronchitis). o, pulmonary involvement is usually the lungs in cf are structurally normal at birth. dilatation of mucous gland ducts followed by intrabronchial mucus stasis are the earliest pulmonary lesions seen in infants. , , o it has long been recognized that patients with cf are predisposed to lung infection. . current hypotheses suggest that susceptibility to infection may be related not only to entrapment of bacteria in thick bronchial secretions, but also possibly to abnormal binding and reduced uptake of bacteria by epithelial cells, or impaired epithelial antimicrobial protection provided by defensins (natural antibiotics of the innate immunity system). . - even in infants without apparent infection, however, bronchoalveolar lavage studies document ongoing bronchial inflammation associated with increased levels of endobronchial il- , a potent cytokine that recruits neutrophils into the inflammatory response, and relatively decreased levels of il-lo, an inhibitor of proinflammatory cytokines. g- it is as yet undetermined whether or not intrinsically exaggerated inflammatory responses are the direct result of mutations in cftr. infection and inflammation stimulate bronchial mucus secretion leading to a vicious cycle of worsening airway infection and obstruction, progressing to chronic bronchitis, bronchiolitis obliterans, and bronchiectasis. the chronic pulmonary complications of cf evolve from the airway disease. hyperinflation or collapse is the direct result of bronchial obstruction. air trapping and postinflammatory cystic lesions underlie an increased susceptibility to recurrent pneumothorax. pulmonary hypertension and cor pulmonale derive from sustained hypoxia, while hemoptysis is a direct effect of bronchiectasis and bronchial artery hypertrophy. endobronchial infection tends to occur in sequential fashion, initiated by s. aureus, followed by h. injluenzae, and finally by p. aeruginosa (mucoid strains). . submucosal glands are enlarged and chronically inflamed behind ducts that are obstructed by dense, inspissated, eosinophilic secretion (a characteristic, but not pathognomonic feature of cf) (fig. . ). - although bronchial smooth muscle in individual patients may appear hypertrophic, its mean volume density is within the normal range. in patients with cf-associated lung disease, saccular bronchiectasis is usually present beyond months of age. r although all bronchopulmonary segments may be affected, bronchiectasis tends to be more severe in the upper lobes (fig. . ). . . blind-ended ectatic airways, devoid of cartilage, are surrounded by atelectatic, chronically inflamed, and fibrotic parenchyma (see fig. . ). bronchial mucosa is frequently denuded or ulcerated leaving the bronchial surface lined by highly vascular granulation tissue that is rich in histiocytes (see fig. . ). in severe disease, bronchi terminate in large, juxtapleural, thin-walled cavities that present radiographically as contiguous, bubble-like cysts. intrapleural blebs or emphysematous bullae are less common forms of cystic lesions, which contribute to an increased incidence of pneumothorax. . extensive acute and chronic bronchiolitis and bronchiolar mucoid impaction impart a finely nodular texture to the parenchymal surface and account for a micronodular radiographic appearance ( fig. . ). bronchiolitis obliterans, predominantly of the constrictive type, contributes importantly to airway obstruction, and likely precedes the development of bronchiectasis (see fig. . ). . occasionally, occlusion of respiratory bronchioles by polypoidal protrusions of fibroblastic tissue accompanies interstitial and organizing pneumonia? small airway density decreases with age and is most significantly reduced in patients with hypercapnia. . the lung parenchyma is grossly indurated by multifocal, bronchocentric chronic pneumonia and fibrosis, with features of both organizing pneumonia and endogenous lipid (cholesterol) pneumonia. a variable degree of acute bronchopneumonia may also be seen at autopsy. some patients who are colonized by burkholderia cepacia undergo an accelerated decline due to acute necrotizing pneumonia (see figs. . and . in chapter ). other patients colonized by burkholderia follow a more protracted course, similar to those colonized by p aeruginosa. [ ] [ ] [ ] fungi and nontuberculous mycobacteria may also colonize cf airways and contribute to lung destruction. , , bhargava and colleagues identified fungal organisms histologically in % of cf patients retrospectively studied at autopsy. the dilated, obstructed airways of cf patients are predisposed to fungal colonization, accounting for an increased prevalence of allergic bronchopulmonary aspergillosis (abpa) of approximately . %. infrequently the pathologic features of abpa, including bronchocentric granulomatosis, are superimposed on chronic cf-associated airways disease (see fig. . in chapter ). in cf patients with non tuberculous mycobacterial infections (often due to mycobacterium avium or rapidly growing strains like m. chelonae or m. abscessus), necrotizing fibrocaseous granulomas may be present. , , , pulmonary lesions are most likely to be found in patients with repeatedly positive sputum cultures for mycobacteria (see chapter ) . the pulmonary vascular changes of cf-associated lung disease are usually pronounced, chronic hypoxia and inflammatory changes contribute to pulmonary artery medial hypertrophy and intimal fibrosis of muscular pulmonary arteries and medial myxoid degeneration of elastic arteries. - postmortem arteriograms often show abnormally tapered arteries with a reduced background haze (see fig. . in chapter ). morphometric studies provide evidence of a decreased density of arteries, which correlates inversely with the degree of right ventricular cardiac hypertrophy, the dropout of arteries may be related to impaired postnatal growth or to vascular destruction secondary to chronic hypoxia or sustained inflammation. right ventricular cardiac hypertrophy, seen at autopsy in approximately % of cf patients older than years of age, is a direct consequence of pulmonary artery remodeling and associated pulmonary hypertension. bronchial arteries also undergo significant hypertrophy as a response to sustained bronchial inflammation, bronchiectasis, and bronchocentric abscesses (fig. . ). - the source of hemoptysis in cf patients is most frequently the delicate capillaries within airway granulation tissue (see fig. . ), , occasionally, mucosal ulcers erode into hypertrophied bronchial vessels leading to life-threatening massive hemoptysis (fig. . ). interventional bronchial artery embolization of metal coils, polyvinyl alcohol (ivalon), or gelfoam particles is undertaken to induce thrombosis and control bronchial artery bleeding. , degenerated remnants of embolized polyvinyl alcohol may surround stenotic or occluded bronchial arteries in patients who have undergone this procedure. bronchopulmonary arterial anastomoses may further allow the paradoxical entry of small embolized particles into the pulmonary arterial circuit (see fig. . in chapter ). other less frequently reported complications of cystic fibrosis include systemic amyloidosis, intralobar sequestration, and anaerobic lung abscess. - emphysema is usually a minor feature, localized to bronchiolocentric scars or as paraseptal emphysema in the upper lung zonesys, s, cystic fibrosis patients with indwelling venous access devices may surreptitiously inject aqueous suspensions of psychoactive pharmaceutical tablets leading to pulmonary artery obstruction due to embolized tablet filler materials (see chapter ). primary ciliary dyskinesia (pcd) is an autosomal recessive disorder, occurring in approximately of , to , persons, characterized by the absence or dysregulation of ciliary movement mainly due to ultrastructural defects in the ciliary axoneme. (see chapter )? - cilia on the respiratory epithelial surface play an important role in propelling mucus, bacteria, and inhaled particulate debris out of the lung (see chapter ). as a result of impaired clearance due to ciliary malfunction, patients with pcd are predisposed to chronic sinusitis, serous otitis, and recurrent bronchopulmonary infections beginning in early childhood. , primary ciliary dyskinesia has also been implicated as a cause of neonatal respiratory distress syndrome. , male patients are usually infertile due to poor flagellar motility of sperm. approximately % of patients with pcd also have situs inversus secondary to abnormal rotation of embryonic epithelia consequent to the lack of ciliary movement. the syndromic triad of situs inversus, sinusitis and bronchiectasis was first proposed by kartagener in , and is now designated kartagener's syndrome (fig. . ). . while pcd is an important cause of bronchiectasis, the prognosis is generally more favorable than that of cf. in afzelius and pedersen and mygind were among the first to recognize that ultrastructural abnormalities of ciliary dyne in arms were associated with kartagener's syndrome. originally termed immotile cilia syndrome by afzelius, it is now recognized that there are numerous structural variations that may contribute to if. tomashefski, jr., and d.h. dail pcd, and that cilia are not always immotile? when compared to normal (fig. . a) , the most commonly observed ultrastructural defects are the complete absence of dyne in arms or the selective absence of either inner or outer arms (fig. . b ). other derangements of the axoneme contributing to pcd include defective or absent radial spokes (fig. . d ), transposition of microtubules (fig. . c ) (well seen in longitudinal sections of cilia), central microtubular agenesis, absence of nexin links, agenesis of cilia, or rarely, bizarre cystic dilatation of ciliary shafts. - nonspecific findings such as ciliary blebs, megacilia, compound cilia, and displaced microtubules may accompany the more specific defects, but are also frequently present in inflammatory airway disease of diverse causes including infectious bronchitis, cf, or air pollution. - some patients with structurally normal cilia and a normal ciliary beat frequency may develop the clinical manifestations of pcd due to ciliary disorientation, resulting in uncoordinated ciliary motion (fig. . e ). , ciliary disorientation has also been described in individuals with infectious bronchitis (including cf), but the degree of disorientation is usually not as great as in those in whom the defect is primary, and the disorientation secondary to infection typically resolves after effective antibiotic treatment. the diagnosis of pcd is established by ultrastructural analysis of respiratory epithelium in conjunction with typical clinical manifestations, exclusion of other causes of chronic airway inflammation, and documentation of abnormal ciliary motion by phase contrast microscopy. . , mucosal samples obtained by endoscopic biopsy or brushing are examined by transmission electron microscopy. in patients with pcd, nasal mucosal samples are reflective of bronchial changes when most cilia are abnormal. when only few cilia are structurally abnormal in a patient in whom the diagnosis of pcd is highly suspected, a bronchial sample is required. abnormalities in sperm flagella may differ in type and quantity from those of respiratory cilia within the same patient, suggesting separate genetic control of axone mal structures at differing loci? the lung pathology in pcd is postinfective in appearance. both saccular and cylindrical bronchiectasis may be present with the predominant histologic pattern of follicular bronchiectasis. , , neither bronchial mucus stasis nor squamous metaplasia is prominent chronic interstitial pneumonitis, peribronchial fibrosis, and atelectasis accompany the bronchiectatic changes. , , studies to date suggest that pcd is a genetically heterogeneous disorder. the molecular basis of pcd has been localized in a few instances to mutations in the human dyne in axonemal heavy chain (dnah ) located on chromosome , or in the intermediate dynein chain gene (dnail) on chromosome , - a mutation in the dyne in axonemal heavy chain type (dnahll) has been associated with pcd and situs inversus, without evident ultrastructural ciliary changes, ongoing studies on genetically engineered knockout mice may uncover other genetic defects associated with pcn, , in donald young, a urologist, reported a series of patients with obstructive azoospermia, % of whom had associated respiratory conditions including bronchitis and bronchiectasis, this condition was initially designated as berry-perkins-young syndrome and later shortened to young's syndrome. patients, nearly all had chronic cough, sputum production, and recurrent pulmonary infections. bronchiectasis and chronic sinusitis were each present in about two thirds of patients. in one study it was estimated that young's syndrome accounted for approximately % of all patients who presented with bronchiectasis of unknown etiology (equivalent to the prevalence of cf and slightly greater than that of pcd). azoospermia in young's syndrome is the result of retention of semen in an enlarged epididymal head. motility studies have demonstrated impaired upper airway mucociliary transport; however, ciliary beat frequency and ultrastructure are normal. , , , in patients with young's syndrome, sweat chloride concentration and the electrical potential difference across the nasal epithelium are normal. the respiratory symptoms in young's syndrome have been suggested to be the result of altered viscoelastic properties of airway secretions, but the basic molecular defect is unknown. an association with mercury toxicity has been hypothesized. friedman and colleagues evaluated mutations of cftr in a cohort of patients with young's syndrome and found that the prevalence of mutations did not differ significantly from the expected carrier frequency in the general population. pulmonary involvement is generally less severe than in cf. bronchiectasis tends to occur at an early age and predominantly involves the lower lobes. pulmonary function tests indicate mild obstruction with decreased fev and increased residual volume, although a number of patients have undergone lung resections for bronchiectasis, the pathologic features of bronchiectasis in young's syndrome have not been well described, and it is uncertain if there are any distinctive histopathologic changes. from a diagnostic standpoint it is important to exclude cf and pcd, each of which may be clinically misclassified as young's syndrome? , the distinguishing characteristics among these three conditions are presented in table sa . williams-campbell syndrome is a rare disorder in which extensive loss of bronchial cartilage is associated with diffuse cystic bronchiectasis without other recognized predisposing factors. , the clinical presentation that commences in infancy may include cough, dyspnea on exertion, cyanosis, and clubbing. on chest radiograph large thin-walled cysts reside in hyperinflated lungs. highresolution ct scan characteristically shows central, cystic, thin-walled airways that collapse upon expiration. . the clinical course is one of recurrent pulmonary infections leading to respiratory failure. patients may survive into adulthood and require lung transplantation. as described in the original report by williams and campbell and substantiated in subsequent morphologic studies, the lungs grossly exhibit extreme saccular and cystic bronchiectasis (fig. . a ). - microscopically, dilated airways have very thin walls with minimal inflammation (fig. . b ). cartilage is absent or markedly deficient from the fourth to the eighth divisions of subsegmental bronchi. first-and second-order bronchi usually have a normal cartilage investment. pan acinar emphysema or emphysema localized to the peribronchial zone is usually also present. . bronchiolitis obliterans has also been reported. . the williams-campbell syndrome has been considered to be the result of a congenital absence of cartilage in the subsegmental airways. morphologic studies documenting absent cartilage and insignificant inflammation, and rare reports of familial occurrence have been used to support this view. . . however, given the propensity for cartilage loss in acquired saccular bronchiectasis of diverse etiologies, the williams-campbell syndrome remains a controversial entity, and its congenital origins have yet to be proven beyond question. . . . the williams-campbell syndrome has not been associated, nor is it to be confused, with congenital lobar emphysema, in which cartilage is focally deficient, usually in upper lobe bronchi, leading to bronchial collapse and air trapping (see also chapter ). tracheobronchomegaly (tbm) is a condition of marked dilatation of the trachea and major bronchi, often associated with recurrent respiratory infections. tbm can be congenital, or at least evident in early life, in which it is termed mounier-kuhn syndrome (see chapter ) . it has occurred in several cases of ehlers-danlos syndrome, suggesting it may be related to poor elastic support, or perhaps to loss of other matrix components as in chondromalacia. tracheobronchomegaly occurs in adults, mostly in men in their fourth and fifth decades, and can be an acquired condition secondary to sustained inflammation affecting the trachea, such as in chronic tracheo- bronchitis secondary to tobacco abuse, cystic fibrosis, trauma, emphysema, or pulmonary fibrosis. , a comprehensive review and an intriguing study of various pulmonary fibrotic reactions associated with this entity was reported by woodring et al. these investigators evaluated the tracheal diameter on plain chest radiography in a series of cases of fibrotic lung reactions, and found enlargement of the trachea in ( %). the associated lung diseases were idiopathic pulmonary fibrosis and sarcoidosis in four patients each, and progressive histoplasmosis in two patients. in seven of these patients as well as in nine of patients ( %) who did not meet initial radiographic criteria for tracheal dilatation, tracheomegaly developed or progressed over time, tracheobronchomegaly was usually associated with moderate-to-severe restrictive pulmonary defects, and it was proposed that shrinkage of the lung tissue retracts all adjacent spaces including the trachea in a manner similar to traction bronchiectasis. regardless of the cause oftbm, airway dilatation may extend distally, bronchomegaly simulates bronchiectasis, probably impairs lung clearance, and promotes recurrent bronchopulmonary infection, which paradoxically may induce secondary bronchiectasis. roditi and weir identified tracheobronchomegaly in % of patients with evidence of bronchiectasis on ct scan, thereby emphasizing the frequent association and possible causal connections between these two conditions. tracheobronchomegaly is predominantly a radiologic diagnosis, and its pathologic features have not been well characterized. associated radiographic features include marked tracheal wall thinning, scalloping due to mural infolding, bronchial diverticula, and collapse on expiration. . the diagnostic criteria of tbm by ct scan are a tracheal diameter of greater than cm (measured cm above the aortic arch) and diameters of . and . cm for the right and left main bronchi, respectively. al? tracheobronchomegaly must be distinguished from saber-sheath trachea, seen in some patients with emphysema, in which there is a decrease in tracheal coronal diameter and increased sagittal diameter. . patients with immune deficiency, especially hypogammaglobulinemia due to x-linked agammaglobulinemia or common variable immunodeficiency (cvid), are predisposed to develop bronchiectasis secondary to recurrent pulmonary infections. - chronic pulmonary disease is the most common long-term complication in patients with hypogammaglobulinemia. common variable immunodeficiency, a heterogeneous immunodeficiency syndrome characterized by depressed levels of serum immunoglobulin g (igg) and defective antibody response to antigen challenge, is associated with sinusitis, recurrent pneumonia, and chronic sputum production in up to % of patients. patients with cvid also have an increased incidence of autoimmune diseases, and as with other primary immunodeficiency syndromes, a tendency toward lymphoproliferative disorders (see chapter ) . , in this population there is a spectrum of lung abnormalities including interstitial fibrosis (> % of patients), pneumonia, lymphoid interstitial pneumonia (lip), sarcoidosis-like granulomatous disease ( %), lung abscess, and bronchiectasis. , bronchiectasis is the most common radiologic finding and may be identified in over % of patients by chest x-ray, and in up to % of patients by hrct. , by hrct bronchiectasis may be either focal or multilobar, and is of the cylindrical or rarely cystic type. , the lower and middle lobes tend to be predominantly involved. . although mucociliary clearance is impaired in these patients, ciliary ultrastructure is normal. there is little information on the histopathology of bronchiectasis in cvid. . hill and colleagues noted severe bronchiectasis, emphysema, fibrosis, and granulomas in the lung explant of a -year-old man with cvid. no unique features of bronchiectasis were described. patients with cvid are treated with immunoglobulin replacement therapy, which reduces the severity and frequency of respiratory infections. symptomatic bronchiectasis, identified by hrct scan, has also been reported in patients with hiv disease in whom it is associated with rapidly progressive airways obstruction. o , king and colleagues correlated airway dilatation on ct scan with increased neutrophils on bronchoalveolar lavage. a single report of a transbronchial biopsy showed only nonspecific lymphocytic peribronchiolitis. the pathogenesis of bronchiectasis in hiv patients is likely consequent to bronchial damage from recurrent pneumonia and bacterial bronchitis in this immunosuppressed population. . frequently cultured microorganisms include h. injluenzae, p. aeruginosa, and s. pneumoniae. , bronchiectasis also occurs as a complication of lung transplant-associated immunosuppression and bronchiolitis obliterans and is further discussed in chapter . . rheumatoid arthritis symptomatic bronchiectasis is estimated to occur in % to % of patients with rheumatoid arthritis (ra), although with hrct scan, up to % of patients with ra can be shown to have cylindrical bronchiectasis. . , early autopsy studies of patients with ra provided a prevalence of bronchiectasis of % to %. [ ] [ ] [ ] [ ] in some studies bronchiectasis typically preceded the development of arthritis, leading to the interesting hypothesis that chronic suppurative airway disease is involved in the pathogenesis of ra. - shadick and colleagues, however, reported patients with bronchiectasis and ra, of whom developed bronchiectasis as a late complication of severe ra. bronchiectasis may also be more frequent in patients with ra-associated sjogren's syndrome. a bronchiectasis associated with ra cannot be adequately ascribed to either traction bronchiectasis or therapeutic immunosuppression. , the morphologic features of ra-associated bronchiectasis are not well documented. by ct scan, cylindrical bronchiectasis primarily involves the middle and lower lung zones. a , bronchiectasis is part of the spectrum of lung involvement in patients with inflammatory bowel disease (ibd), ulcerative colitis more so than crohn's disease (see also chapter ) . , suppurative bronchiectasis may also develop after proctocolectomy for either of these conditions. , in the literature review of camus et al., bronchiectasis was identified in six patients with ulcerative colitis out of patients ( %) with ibd-associated lung disease histologically a dense cuff of lymphocytes typically occupies the submucosa, and squamous metaplasia replaces the overlying epithelium (fig. . ). the chronic inflammatory infiltrate involves bronchial glands and ducts; however, lymphoid germinal centers are usually absent, distinguishing ulcerative colitis-associated bronchiectasis from the usual pattern of follicular bronchiectasis (fig. . b). , neutrophils infiltrating the mucosa and spilling into the dilated bronchial lumen impart a suppurative appearance in some cases. -- direct immunofluorescence staining of bronchial biopsies in three patients with ulcerative colitis showed deposits of immunoglobulin and complement in bronchial structures. lung biopsy in patients with crohn's disease and bronchiectasis may show features of either granulomatous bronchiolitis or suppurative-appearing acute bronchiolitis (see fig. . in chapter ). inhaled steroids were of durable benefit in patients with ibd-associated chronic bronchitis, but less so in patients with bronchiectasis. speculations on the pathogenesis of bronchiectasis in ibd are presented in a provocative editorial by stockley. bronchiectasis is reported as a late sequela of heroinassociated pulmonary edema. the bronchographic features include diffuse or localized cylindrical and varicose bronchiectasis. itis are etiologic factors in some patients, and bronchial ulceration and foreign-body giant cells have been observed at autopsy. other cases of diffuse bronchiectasis in heroin users appear to be unrelated to aspiration. see chapter for other pathologic features of heroin toxicity. in adults, severe direct chemical injury such as ammonia gas inhalation or aspiration can cause bronchiectasis. - delayed-onset bronchiectasis has also been described starting years after smoke inhalation. bronchiectasis in systemic diseases foreign body inhalation foreign body in the airway: a review of cases quinn ceo aspiration emergencies the cafe coronary: sudden deaths in restaurants thoracic and cardiovascular surgery with related pathology inhaled foreign bodies migratory pulmonary infiltrates secondary to aspirated foreign body muddy lung idowu . sand aspiration: a case report shakespeare, the complete works. fort worth: harcourt brace observations on the anatomy of the bronchial tree, with special reference to the surgery of lung abscess. guy's bronchial embolism and posture in relation to lung abscess. guy's aspirated foreign bodies in the tracheobronchial tree: report of cases bronchial foreign body vs. asthma studies on the lymph drainage of the accessory nasal sinuses the pulmonary aspiration of particulate matter pulmonary aspects of tonsillectomy under general anesthesia the relationship of sinusitis and bronchiectasis aspiration pneumonia silent" regurgitation and aspiration during anesthesia aspiration of food and vomit pharyngeal aspiration in normal adults and patients with depressed consciousness aspiration pneumonia. recognizing and managing a potentially growing disorder aspiration pneumonitis and aspiration pneumonia bosomworth pp aspiration pneumonitis the aspiration of stomach contents into the lungs during obstetrical anesthesia pulmonary aspiration of gastric contents in anaesthesia pulmonary aspiration of gastric contents acid aspiration-induced lung injury in rabbits is mediated by interleukin- -dependent mechanisms synergism between leukotriene b and thromboxane a in mediating acid-aspiration injury tumor necrosis factor-alpha mediates acid aspiration-induced systemic organ injury intercellular adhesion molecule- mediates acid aspiration-induced lung injury reactive oxygen species contribute to oxygen-related lung injury after acid aspiration acid aspiration induced lung injury. new insights and therapeutic options experimental murine acid aspiration injury is mediated by neutrophils and the alternative complement pathway incompetency of the gastric cardia without radiologic evidence of hiatus hernia: the diagnosis and management of cases pulmonary fibrosis associated with tracheobronchial aspiration: a study of the frequency of hiatal hernia and gastroesophageal reflux in interstitial pulmonary fibrosis of obscure etiology gastroesophageal reflux and chronic respiratory disease hydrocarbon pneumonitis effects of furniture polish on pulmonary surfactant roentgenographic changes in the lungs of children with kerosene poisoning pulmonary granulomatosis caused by vegetable particles: so-called lentil pulse pneumonia foreign body reaction to inhalation of lentil soup: giant cell pneumonia pulmonary nodular granulomatosis caused by inhaled vegetable particles diffuse miliary granulomatosis of the lungs due to aspirated vegetable cells case records of the massachusetts general hospital. case - zuzarte , tomashefski if lr. the histologic spectrum of aspiration bronchiolitis obliterans (abo). an autopsy study importance of diffuse aspiration bronchiolitis caused by chronic occult aspiration in the elderly miliary pulmonary nodules due to aspirated vegetable particles. pediatr lentil aspiration pneumonia: radiographic and ct findings the pulmonary pathology of illicit drug and substance abuse the microscopic appearance of a sodiumpotassium exchange resin in histologic sections calcium polystyrene sulfonate: an unusual cause of inhalation pneumonia chaplin al histologic occurrence of polystyrene sulfonates kayexalate (sodium polystyrene sulfonate) aspiration necrosis of the gastrointestinal tract in uremic patients as a result of sodium polystyrene sulfonate (kayexalate) in sorbitol sodium polystyrene sulfonate (kayexalate) aspiration. histologic appearance and infrared micro spectrophotometry analysis of two cases sodium polystyrene sulfonate pneumonitis upper gastrointestinal tract injury in patients receiving kayexalate (sodium polystyrene sulfonate) in sorbitol. clinical, endoscopic, and histopathologic findings iron lung": distinctive bronchoscopic features of acute iron tablet aspiration bronchial necrosis and granuloma induced by the aspiration of a tablet of ferrous sulphate syndrome of iron pill aspiration charcoal lung. bronchiolitis obliterans after aspiration of activated charcoal exogenous lipid pneumonia: a retrospective multicentre study of cases in france pneumonia following nasopharyngeal injections of oil pathology of the lung the reaction to oils and fats in the lungs toxicological studies on hydrocarbon: ix. the aspiration hazard and toxicity of hydrocarbons and hydrocarbon mixtures lipoid pneumonia exogenous lipoid pneumonia lipoid pneumonia in a veterans' hospital incidence of lipoid pneumonia in a survey of chronically ill patients lipid pneumonia: a new etiology inhalation lipoid pneumonia from burning fats. a newly recognized industrial hazard acute lipoid pneumonitis due to aspiration of pressurized paint droplets the lipoid pneumonia of blackfat tobacco smokers in guyana lung disease due to abuse of hair spray lipoid pneumonia: review of the literature with a case report infection of lungs by "saprophytic" mycobacteria in achalasia of cardia, with report of fatal cases showing lipoid pneumonia due to milk stergus . death due to mycobacterium fortuitum group iv atypical mycobacterium infection occurring in association with mineral oil granuloma of lung atypical mycobacterial infection complicating mineral oil pneumonia aspiration and occult esophageal disorders paraffinoma confirmed by infrared spectrophotometry case records of the massachusetts general hospital. case - lipoid (mineral oil) pneumonia and cor pulmonale due to cardiospasm chronic cor pulmonale associated with lipoid pneumonia diagnosis of lipoid pneumonia by examination of the sputum the lipid-laden alveolar macrophage as a marker of aspiration in parenchymal lung disease the cytologic evaluation of lipid-laden alveolar macrophages as an indicator of aspiration pneumonia in young children thoracic and cardiovascular surgery with related pathology abscess of the lung treatment of lung abscess with report of consecutive cases lung abscess: pathogenesis, diagnosis and treatment lung abscess revisited: a survey of cases primary lung abscess lung abscess: a study of the results of treatment based on consecutive cases lung abscess: an analysis of the massachusetts general hospital cases from through lung abscess experimental aspiration abscess fuso-spirochaetal diseases of the lungs putrid abscess of the lung following dental operations etiologic factors in the pathogenesis of putrid abscess of the lung the symptomatology of putrid abscess of the lung the microbiota of the gingival crevice area of man-ii: the predominant cultivable organisms the micro biota of the gingival crevice area in man-i: total microscopic and viable counts and counts of specific organisms anaerobic bacteria: role in disease. springfield: charles c thomas microorganisms indigenous to man bacteriology and treatment of primary lung abscess bacteriologic flora of aspiration-induced pulmonary infections a clinical consideration of abscesses and cavities of the lung lung abscess in childhood primary lung abscess in childhood anaerobic (putrid) lung abscess in adolescence anaerobic bacterial infections of the lung anaerobic infections lung abscess should fiberoptic bronchoscopy aspirates be cultured? diagnostic accuracy of transtracheal aspiration bacteriologic studies aspiration pneumonia, necrotizing pneumonia, and lung abscess clinical classification and analysis of cases of lung abscess lung abscess: a changing pattern of disease the lining of healed but persistent abscess cavities in the lung with epithelium of the ciliated columnar type cavity behavior in acute, primary nonspecific lung abscess pulmonary gangrene: radiologic and pathologic correlation pulmonary gangrene. a complication of bacterial pneumonia gangrene of the lung gangrene of the lung total unilateral lung gangrene in hodgkin's disease: treatment by thoracostomy gangrene of the lung: successful medical management of three patients lung lobe torsion following lobectomy lung torsion: survival of a patient whose hemorrhagic infarcted lung remained in situ after detorsion postoperative pulmonary torsion: report of a case and survey of the literature including spontaneous and posttraumatic torsion lung torsion after lung transplantation: evaluation with helical ct an unusual case of lung torsion obstructive pneumonitis of neoplastic origin. an interpretation of one form of so-called atelectasis and its correlation according to presence or absence of sputum lipoid pneumonia in lung cancer: radiographic and pathological features obstructive pneumonitis: a pathologic and pathogenetic reappraisal xanthomatous bronchiolitis obliterans with cholesterol pneumonia organizing pneumonia adjacent to lung cancer. frequency and clinico-pathologic features pulmonary phospholipid accumulation distal to an obstructed bronchus endogenous lipid pneumonia and alveolar proteinosis-type changes in the vicinity of non-small cell lung cancer: histopathologic, immunohistochemical, and ultrastructural evaluation cholesterol pneumonitis correlation between the roentgenologic and pathologic findings in chronic pneumonitis of the cholesterol type idiopathic cholesterol pneumonitis localized organizing pneumonia: its resemblance to carcinoma. a review of its clinical, roentgenographic and pathologic features organization of pneumonic exudates aetiology of unresolved pneumonia coexisting endogenous lipoid pneumonia, cholesterol granulomas, and pulmonary alveolar proteinosis in a pediatric population: a clinical, radiographic, and pathologic correlation in vitro studies of the foamy macrophage of postobstructive endogenous lipoid pneumonia in man electron microscopic demonstration of lysosomal inclusion bodies in lung, liver, lymph nodes, and blood leukocytes of patients amiodarone lung toxicity: a human and experimental study pulmonary histiocytosis simulating desquamative interstitial pneumonia in rats receiving oral iprindole effects of chlorphentermine on the rat lung electron microscopy of chlorphentermine lung pulmonary parenchymal cholesterol-ester granulomas in patients with pulmonary hypertension pulmonary lipogranulomatosis due to excessive consumption of apples diffuse storage of vegetal wax hydrocarbons of dietary origin aetiology of pulmonary cholesterol-ester granulomas bacteriological studies in pulmonary atelectasis reexpansion of atelectatic lower lobe and disappearance of bronchiectasis pseudo bronchiectasis the pathologic anatomy of influenza. based chiefly on american and british sources bronchiectasis: a bronchographic study of cases of pneumonia the reversal of advanced bronchiectasis reversible bronchiectasis reversible bronchial dilatation: report of a case traction bronchiectasis in end-stage pulmonary fibrosis pathology of pulmonary disease. philadelphia: lippincott textbook of pulmonary diseases whitwell e study of pathology and pathogenesis of bronchiectasis the natural history of bronchiectasis. a clinical, roentgenologic and pathologic study bronchiectasis: a study of prognosis based on a follow-up of cases surgical diseases of the chest. philadelphia: lea and febiger bronchial obstruction, bronchiectasis, and related disorders pathology of the lung chronic airflow obstruction reduction in bronchial subdivision in bronchiectasis latent adenoviral infection in follicular bronchiectasis generalized bronchiectasis associated with deficiency of cartilage in the bronchial tree bronchiectasis in children pathology of bronchiectasis bronchiectasis: study of pathology of surgical lobectomies for bronchiectasis factors causing bronchiectasis: their clinical application to diagnosis and treatment bronchiectasis: a neglected disease long-term follow-up of bronchiectasis if. bronchiectasis: update of an orphan disease an investigation into causative factors in patients with bronchiectasis bronchiolitis obliterans, bronchiectasis and other sequelae of adenovirus type infection in young children pneumonia following influenza (at camp pike, ark) crofton . respiratory tract disease. diagnosis and treatment of bronchiectasis. i. diagnosis crofton . respiratory tract disease. bronchiectasis. ii. treatment and prevention non-tuberculous juvenile bronchiectasis: a viral disease? bronchiectasies secondaires a une adenovirose: etude radiologique, virologique et anatomique d'une observation chronic lung damage caused by adenovirus type : a ten-year follow-up study bronchiectasis: a review of cases in children with follow-up pulmonary function studies in the cartilage of the intrapulmonary bronchi in normal lungs, in bronchiectasis, and in massive collapse destruction and loss of bronchial cartilage in cystic fibrosis enlargement of the bronchial arteries and their anastomoses with the pulmonary arteries in bronchiectasis the right middle lobe syndrome, a nonobstructive complex collateral ventilation and the middle lobe syndrome middle lobe syndrome the middle lobe syndrome and its quasi variants middle lobe syndrome. a clinicopathological study of patients right middle lobe atelectasis associated with endobronchial silicotic lesions lloyd . broncholiths. with report of four cases the surgical implication of broncholithiases current concepts of an ancient disease bronchiolithasis: bronchoscopic vs. surgical management a review of twentyseven cases etiology of bronchiolithiasis case records of the massachusetts general hospital. case - bronchiolithiasis due to histoplasma capsulatum subsequently infected by actinomyces letter: broncholithiasis in silicosis tracheobronchial obstruction due to silicosis bronchiolithiasis: ct features in patients egg-shell silicotic calcification causing bronchoesophageal fistula broncholithiasis: a neglected cause of bronchoesophageal fistula acquired bronchoesophageal fistula of benign origin traction diverticula of the esophagus in the middle lobe syndrome broncholithiasis: review of the causes with radiologic-pathologic correlation ct demonstration of an ossifying bronchial carcinoid simulating broncholithiasis schwarz . broncholithiasis. produced by histoplasmosis complications of the arrested primary histoplasmic complex postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management bronchocele and blocked bronchiectasis the syndrome of bronchial mucocele and regional hyperinflation of the lung developmental origin of cystic, bronchiectatic and emphysematous changes in lungs. a new concept the syndrome of bronchial mucocele and regional hyperinflation of lung: report of four cases atresia of the bronchus to the apical posterior segment of the left upper lobe congenital bronchial atresia. a report of cases and a review of the literature bronchial atresia of the left upper lobe atresia of an apical bronchus of the left upper lobe-report of three cases bronchial atresia computer tomography in bronchial atresia clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult presentation and management of bronchogenic cysts in the adult intrapulmonary bronchogenic cyst: ct and pathologic findings in five adult patients bronchioloalveolar carcinoma arising in a bronchogenic cyst biochemistry and rheology of sputum in asthma a case of pituitous catarrh crofton , douglas a. respiratory diseases bronchorrhea in a case of alveolar cell carcinoma bronchorrhea-a presenting feature of active endobronchial tuberculosis pang . relapsing polychondritis presenting with bronchorrhea cystic fibrosis cystic fibrosis identification of the cystic fibrosis gene: cloning and characterization of complimentary dna identification of the cystic fibrosis gene: chromosome walking and jumping ion channels-basic science and clinical disease macromolecular interactions and ion transport in cystic fibrosis cystic fibrosis transmembrane conductance regulator. structure and function of an epithelial chloride channel a clinical perspective of cystic fibrosis and new genetic findings: relationship of cftr mutations to genotype-phenotype manifestations new approaches to cystic fibrosis cystic fibrosis f del patients have apically localized cftr in a reduced number of airway cells laboratory tests for the diagnosis of cystic fibrosis fibrosis genotype-phenotype consortium. correlation between genotype and phenotype in patients with cystic fibrosis cftr expression and organ damage in cystic fibrosis a cystic fibrosis mutation associated with mild lung disease a mild variant of cystic fibrosis mutations in the cystic fibrosis gene in patients with congenital absence of the vas deferens lung disease associated with the ivs t allele of the cftr gene the pathology of cystic fibrosis the lung in cystic fibrosis. a quantitative study including prevalence of pathologic findings among different age groups quantitative evaluation of the development of tracheal submucosal glands in infants with cystic fibrosis and control infants the pathogenesis of fibrocystic disease of the pancreas. a study of cases with special reference to the pulmonary lesions the bronchial mucous glands-their hypertrophy and change in intracellular mucus similarity of the tracheobronchial mucous glands and epithelium in infants with and without cystic fibrosis the innate immune system in cystic fibrosis lung disease the genesis of cystic fibrosis lung disease pathogenesis of bacterial bronchitis in cystic fibrosis current understanding of the inflammatory process in cystic fibrosis: onset and etiology how mutant cftr may contribute to pseudomonas aeruginosa infection in cystic fibrosis lung infections associated with cystic fibrosis bacterial infections and inflammation in the lungs of cystic fibrosis patients bronchoalveolar lavage findings in cystic fibrosis patients with stable, clinically mild lung disease suggest ongoing infection and inflammation cystic fibrosis lung inflammation: early, sustained and severe inflammatory cytokines in cystic fibrosis lungs normal bronchial epithelial cells constitutively produce the antiinflammatory cytokine interleukin-lo, which is downregulated in cystic fibrosis early pulmonary inflammation in infants with cystic fibrosis cytokine secretion by cystic fibrosis airway epithelial cells immunohistopathologic localization of pseudomonas aeruginosa in lungs from patients with cystic fibrosis. implications for the pathogenesis of progressive lung deterioration basal-like cells constitute the proliferating cell population in cystic fibrosis airways ultrastructural features of respiratory cilia in cystic fibrosis ciliary disorientation in patients with chronic upper respiratory tract inflammation a morphometric study of bronchial and bronchiolar walls in children quantitative aspects of lung pathology in cystic fibrosis the central bronchial glands in cystic fibrosis, a morphometric, clinicopathologic study regional distribution of macroscopic lung disease in cystic fibrosis pulmonary cystic fibrosis in the adult: early and late radiologic findings with pathologic correlation pulmonary air cysts in cystic fibrosis: relation of pathologic features to radiologic findings and history of pneumothorax pneumothorax in cystic fibrosis cystic fibrosis: state of the art cystic fibrosis of the pancreas: structural changes in peripheral airways the pathologic characteristics of interstitial pneumonia in cystic fibrosis. a retrospective autopsy study clinical findings and lung pathology in children with cystic fibrosis age as a factor in the distribution of lower-airway conductance and in the pathologic anatomy of obstructive lung disease pseudomonas cepacia colonization among patients with cystic fibrosis. a new opportunist pseudomonas cepacia associated pneumonia in cystic fibrosis. relation of clinical features to histopathologic patterns of pneumonia burkholderia cepacia complex infection in patients with cystic fibrosis nontuberculous mycobacteria in cystic fibrosis isolation of rapidly growing mycobacteria in patients with cystic fibrosis the pathology of fungal infection and colonization in patients with cystic fibrosis allergic bronchopulmonary aspergillosis in cystic fibrosis-state of the art: cystic fibrosis foundation consensus conference mycobacterium abscessus infection in cystic fibrosis. colonization or infection? nontuberculous mycobacteria in cystic fibrosis. an autopsy study the pulmonary circulation in cystic fibrosis pulmonary hypertension in cystic fibrosis. a description and morphometric analysis of the pulmonary vasculature cor pulmonale in cystic fibrosis. a morphometric analysis new findings in pulmonary arteries of rats with hypoxia-induced pulmonary hypertension pulmonary hypertension and cor pulmonale in cystic fibrosis of the pancreas medial mucoid lesions of the pulmonary artery in cystic fibrosis, pulmonary hypertension, and other disorders the bronchial arteries in cystic fibrosis selective bronchial arteriography in patients with cystic fibrosis and massive hemoptysis cystic fibrosis in adults. an autopsy study pulmonary changes and cor pulmonale in mucoviscidosis bronchial artery embolization in cystic fibrosis: technique and long-term results a pathological study following bronchial artery embolization for haemoptysis in cystic fibrosis longterm histopathologic follow-up of bronchial arteries after therapeutic embolization with polyvinyl alcohol (ivalon) in patients with cystic fibrosis intrapulmonary shunts in cystic fibrosis secondary (aa) amyloidosis in cystic fibrosis. a report of three cases systemic amyloidosis complicating cystic fibrosis pulmonary intralobar sequestration in a patient with cystic fibrosis lung abscess in cystic fibrosis recreational use of psychoactive drugs by patients with cystic fibrosis a human syndrome caused by immotile cilia absence of axone mal arms in nasal mucosa cilia in kartagener's syndrome the immotile-cilia syndrome. a congenital ciliary abnormality as an etiologic factor in chronic airway infections and male sterility immotile cilia primary ciliary dyskinesia-diagnostic and phenotypic features evidence for congenitally nonfunctioning cilia in the tracheobronchial tract in two subjects immotile cilia syndrome in persons with and without kartagener's syndrome kartagener syndrome: an uncommon cause of neonatal respiratory distress? immotile cilia syndrome: a new cause of neonatal respiratory distress zur pathogenese der bronchiektasien: bronchiektasien bei situs viscerum inversus bronchiectasis with situs inversus primary ciliary dyskinesia cilia with defective radial spokes. a cause of human respiratory disease transposition of ciliary microtubules. another cause of impaired ciliary motility absence of nexin links as a possible cause of primary ciliary dyskinesia severe bronchiectasis in patients with "cystlike" structures within the ciliary shafts central microtubular agenesis causing primary ciliary dyskinesia nasal ciliary ultrastructure and function in patients with primary ciliary dyskinesia compared with that in normal subjects and in subjects with various respiratory diseases ultrastructural nasal pathology in children chronically and sequentially exposed to air pollutants ciliary defects in healthy subjects, bronchiectasis, and primary ciliary dyskinesia ultrastructural ciliary defects in children with recurrent infections of the lower respiratory tract atypical bronchial cilia in children with recurrent respiratory tract infections. a comparative ultrastructural study random ciliary orientation. a cause of respiratory tract disease ciliary disorientation alone as a cause of primary ciliary dyskinesia syndrome clinico-pathological evaluation of ciliary dyskinesia: diagnostic role of electron microscopy computer-assisted analysis of radial symmetry in human airway epithelial cilia: assessment of congenital ciliary defects in primary ciliary dyskinesia do nasal ciliary changes reflect bronchial changes? an ultrastructural study kartagener's syndrome with motile cilia and immotile spermatozoa: axone mal ultrastructure and function dissimilar expression of axone mal anomalies in respiratory cilia and sperm flagella in infertile men fertility in men with primary ciliary dyskinesia presenting with respiratory infection a reappraisal of kartagener's syndrome report of a family with two cases of kartagener's triad and two additional cases of bronchiectasis among six siblings genetic regulation of cilia assembly and the relationship to human disease homozygosity mapping of a gene locus for primary ciliary dyskinesia on chromosome p and identification of the heavy dynein chain dnah as a candidate gene germline mutations in an intermediate chain dynein cause primary ciliary dyskinesia investigation of the possible role of a novel gene, dpcd, in primary ciliary dyskinesia surgical treatment of male infertility lung mucociliary clearance in patients with young's syndrome obstructive azoospermia: respiratory function tests, electron microscopy and the results of surgery young's syndrome. obstructive azoospermia and chronic sinopulmonary infections screening young syndrome patients for cftr mutations respiratory tract disease and obstructive azoospermia ciliary function in young's syndrome rutland i mucociliary function, ciliary ultrastructure, and ciliary orientation in young's syndrome measurement of nasal potential difference in adult cystic fibrosis, young's syndrome and bronchiectasis viscoelastic properties of sputum from patients with young's syndrome was young's syndrome caused by exposure to mercury in childhood? cystic fibrosis, young's syndrome, and normal sweat chloride young's syndrome (a case report) alpha-i-antitrypsin deficiency presenting as bronchiectasis alpha-i-antitrypsin deficiency presenting as bronchiectasis lieberman i bronchiectasis and homozygous alpha- antitrypsin deficiency distribution of alpha-l antitrypsin alleles in patients with bronchiectasis bronchiectasis in patients with alpha-l antitrypsin deficiency. a rare occurrence? pathological findings in alpha-l antitrypsin deficiency alpha- antitrypsin deficiency: evaluation of bronchiectasis with ct for the alpha i-antitrypsin deficiency registry study group. the bronchopulmonary pathology of alpha- antitrypsin (aat) deficiency: findings of the death review committee of the national registry for individuals with severe deficiency of alpha- antitrypsin selective iga deficiency and pi zz-antitrypsin deficiency: association with recurrent sinopulmonary infections, emphysema and bronchiectasis chronic airflow obstruction chronic obstructive lung disease. a comparison between clinical, roentgenologic, functional and morphologic criteria in chronic bronchitis, emphysema, asthma and bronchiectasis an assessment of the anatomical factor in cor pulmonale in emphysema the non-respiratory bronchioles in pulmonary emphysema familial bronchiectasis generalized bronchiectasis due to extensive deficiency of bronchial cartilage erasmus i case : williams-campbell syndrome congenital bronchiectasis in an adult lung transplantation for williams-campbell syndrome congenital bronchiectasis due to deficiency of bronchial cartilage (williams-campbell syndrome) mortality following adenotonsillectomy in a patient with williams-campbell syndrome familial congenital bronchiectasis: williams-campbell syndrome probable familial congenital bronchiectasis due to cartilage deficiency (williams-campbell syndrome) congenital lobar emphysema acquired tracheomegaly in adults as a complication of diffuse pulmonary fibrosis radiologic and pathologic abnormalities of the trachea in older patients with cystic fibrosis weir . the association of tracheomegaly and bronchiectasis using ct to diagnose nonneoplastic tracheal abnormalities: appearance of the tracheal wall a -year-old man with tracheomegaly, tracheal diverticulosis, and bronchiectasis mounier-kuhn syndrome): ct diagnosis sabre-sheath" trachea: relation to chronic obstructive pulmonary disease recurrent respiratory infections in a family with immunoglobulin a deficiency bronchiectasis in hypogammaglobulinaemia-a computed tomography assessment igg subclass deficiencies associated with bronchiectasis common variable immune deficiency: respiratory manifestations, pulmonary function and high-resolution ct scan findings pulmonary manifestations of hypogammaglobulinaemia respiratory disorders in common variable immunodeficiency pulmonary abnormalities in patients with primary hypogammaglobulinemia radiologic findings of adult primary immunodeficiency disorders. contribution of ct mucociliary clearance in patients with immunoglobulin deficiency respiratory dysfunction in patients with common variable hypogammaglobulinemia heart lung transplantation in a patient with end stage lung disease due to common variable immunodeficiency bronchiectasis in hiv disease accelerated obstructive pulmonary disease in hiv infected patients with bronchiectasis bronchial dilatation in patients with hiv infection: ct assessment and correlation with pulmonary function tests and findings at bronchoalveolar lavage bacterial bronchitis and bronchiectasis in human immunodeficiency virus infection pathologic pulmonary alterations in long-term human heart-lung transplantation postmortem findings in lung transplant recipients use of high resolution computed tomography of the lungs in patients with rheumatoid arthritis airways involvement in rheumatoid arthritis. clinical, functional, and hrct findings visceral lesions associated with chronic infectious (rheumatoid) arthritis lung lesions in rheumatoid arthritis pulmonary disease associated with rheumatoid arthritis convalescent care in chronic arthritis bronchiectasis and rheumatoid arthritis: a clinical study pulmonary lesions and rheumatoid arthritis bronchiectasis. a late feature of severe rheumatoid arthritis high resolution computer tomography of the lung in lifelong nonsmoking patients with rheumatoid arthritis the lung in inflammatory bowel disease bronchiectasis following colectomy for crohn's disease chronic bronchial suppuration and inflammatory bowel disease unexplained bronchopulmonary disease with inflammatory bowel disease noninfectious lung pathology in patients with crohn's disease commentary: bronchiectasis and inflammatory bowel disease the impact of substance abuse on the respiratory system bronchiectasis: a cause of pulmonary symptoms in heroin addicts pulmonary complication of heroin intoxication. aspiration pneumonia and diffuse bronchiectasis bronchiectasis following ammonia burns of the respiratory tract: a review of two cases fatal anhydrous ammonia inhalation bronchiectasis following pulmonary ammonia burn said sl bronchiectasis and progressive respiratory failure following smoke inhalation acknowledgments. the authors are deeply appreciative to diane gillihan for expert secretarial assistance, vince messina for photography, and the staff of the brittingham memorial library for bibliographic support. key: cord- -l k authors: finke, jürgen; bertz, hartmut; kaskel, anna-katharina; heinz, jürgen; thomas, a.k.; berger, dietmar p.; engelhardt, rupert; schmah, oliver title: hematology and hemostasis date: journal: concise manual of hematology and oncology doi: . / - - - - _ sha: doc_id: cord_uid: l k nan destruction / suppression of hematopoietic stem cells or progenitor cells caused by various factors is of central importance: • activation of the immune system with primary or secondary (immunologically induced) bone marrow aplasia with activated cytotoxic t-cells, which cause destruction of cd -positive progenitor cells via: -direct t-cell-mediated cytotoxicity -production of ifnγ and tnfβ -induction of fas receptor and antigen → apoptosis induction • direct dna damage (e.g., irradiation) • cellular membrane damage and interference with the cellular metabolism (e.g., viral infection) • drug-induced: direct toxicity or hapten-mediated autoimmune reaction • secondary clonal expansion of hematopoiesis • nk cells ↓ (as with other autoimmune diseases) • fanconi's anemia: chromosomal instability based on multiple genetic defects (fanconi anemia genes fanc a-l). characteristics are: progressive bone marrow aplasia, increased incidence of malignancy, and abnormalities in skin, musculature, skeletal system, and urogenital system. in > % of cases, manifestation is during infancy. • increased incidence of aplastic anemia in the presence of hla a , dr , dr , and dpw . • pnh association ( chap. . • antibiotics (particularly sulfonamides, chloramphenicol), antimalarial drugs • thyreostatics, antidiabetics • antirheumatics, nsaids (e.g., phenylbutazone, gold) • diuretics (furosemide), ticlopidine, nifedipine • antiepileptics (e.g., carbamazepine, phenytoin) • cytotoxic compounds (e.g., busulfan) • aromatic solvents (e.g., benzene) • insecticides (lindane, ddt, etc.) • parvovirus b (isolated erythropoietic aplasia, "pure red cell anemia") • hepatitis (non-a-b-c-g hepatitis, poor prognosis, mostly young men) • ebv (infectious mononucleosis, rare) • hiv • complete blood count: bi-or trilineage cytopenia, generally without pathological morphology, increased granulation, neutropenia, monocytopenia, and eosinopenia; reticulocytes ↓; in cases of thrombocytopenia: small platelets • ferritin, haptoglobin, coombs' test, blood group, coagulation parameters • esr, total protein, electrophoresis, immunoglobulins, immunofixation, cold agglutinins, rheumatoid factor, ana • pnh exclusion (ham's test, sugar water test, gpi-linked proteins, cd , cd ) • vitamin b , folic acid (exclusion of megaloblastic anemia) • liver function (exclude past history of hepatitis) • serology (ebv, cmv, hav, hbv, hcv, hiv, hsv, parvovirus b ) • hypocellular (cellularity < %) with predominance of fat cells • lymphocytes, macrophages, and plasma cells present • cd -positive progenitor cells ↓; in bone marrow cultures, reduced colony formation (cfu-gm, colony-forming units -granulocytes / macrophages) and ltcic (long-term culture-initiating cells). improved growth pattern in t-cell-depleted cultures (→ t-cell-mediated reaction?) • chest x-ray, abdominal sonography • hla typing (in cases of potential transplantation) • cytogenetics, chromosome analysis (exclusion of mds, fanconi's anemia) • increased serum levels of hematopoietic growth factors: g-csf (granulocyte colony-stimulating factor), tpo (thrombopoietin), m-csf, and erythropoietin; scf (stem cell factor) not increased • myelodysplasia with hypoplastic bone marrow ( chap. . ) • primary myelofibrosis (pm) ( chap. . . ) • vitamin b deficiency, folic acid deficiency ( chap. . . ) • paroxysmal nocturnal hemoglobinuria (pnh) ( chap. . . ) • leukemias, lymphomas, solid tumors with bone marrow infiltration • development of pnh in % of cases ( chap. . . ) • transformation into mds or acute leukemia in - % of cases ( chaps. . . , . . , . ) indications for treatment hematology and hemostasis • infection prophylaxis, antibiotics, amphotericin b prophylaxis • oral hygiene • prophylaxis / therapy of hemosiderosis (desferrioxamine mesylate) • granulocyte transfusions ( chap. . ) • suppress menses, avoid platelet aggregation inhibitors • blood products (cmv negative, irradiated); erythrocyte transfusions according to symptoms, platelet transfusions for counts below , - , /µl • growth factors: granulocyte colony-stimulating factor (g-csf), erythropoietic factors attention: use blood products as sparingly as possible until decision on bmt / pbsct is made (danger of alloimmunization). do not use blood products from relatives. transplantation types ( chaps. . , . ) • in patients under years of age, allogeneic hematopoietic stem cell transplantation (hsct) from hla-identical related (family) donors in conjunction with fludarabine / cyclophosphamide-containing protocols • matched unrelated donor (mud) transplantation recommended only in patients under years of age • most common form: drug-induced toxic suppression of granulopoiesis or direct neutrophilic damage ("delayed onset neutropenia, " e.g., after radio-or chemotherapy), usually with simultaneous thrombocytopenia ( chap. . ) • drug-induced allergic reactions with destruction of neutrophils, often caused by metabolites • usually, rapid granulocyte decrease within week after exposure; in case of re-exposure, within hours. destruction of mature granulocytes ("abrupt onset neutropenia"), acute onset with fever and chills (dd: infection). causative agent: e.g. phenylbutazone • in rare cases, slow decrease, between and months after the beginning of treatment, due to destruction of hematopoietic progenitor cells. causative agent: e.g., clozapine, in patients with hla phenotype b and alleles dr and dqw • autoimmune diseases: t-cell-mediated inhibition of granulopoiesis (felty's syndrome, rheumatoid arthritis) or as a result of clonal t-cell expansion in patients with t-γ-lymphoproliferative disease ("t-γ-disease") • complement activation (e.g., with hemodialysis, sepsis): expression of adhesion molecules on the surface of neutrophils → neutrophilic aggregation, capillary occlusion (esp. pulmonary capillaries) • pseudoneutropenia ("shift neutropenia"): neutrophilic redistribution (shift) from the peripheral blood into the tissues, e.g., with infections • congenital dysgenesis with familial pancytopenia • reticular dysgenesis with congenital aleukocytosis: agranulocytosis + lymphoid hypoplasia + thymic aplasia; unknown etiology • periodic neutropenia: stem cell regulation defect; neutropenic phases in -to -day intervals, compensatory monocytosis; autosomal dominant inheritance • kostmann's syndrome: severe agranulocytosis in children (abnormal differentiation in the promyelocytic stage), reversible by administration of g-csf (attention: possibly higher risk of mds / aml development); autosomal dominant or recessive inheritance • x-linked agammaglobulinemia • schwachman-diamond-oski syndrome: neutropenia + pancreatic insufficiency + metaphyseal dysplasia; unknown etiology; autosomal recessive inheritance • neutropenia with bi-/ tetraploid leukocytes: abnormal phagocytosis and chemotaxis as well as bi-and tetraploid granulocytes • chédiak-higashi syndrome: albinism + neurological disorders + leukocytic granulation abnormalities; unknown etiology • dyskeratosis congenita: neutropenia, skin abnormalities; x-linked inheritance • lazy leukocyte syndrome: chemotaxis defect (actin defect); unknown etiology • cytostatic treatment, immunosuppressives, azidothymidine (azt), benzenes, ionizing radiation • idiosyncratic drug reactions (individual sensitivity) in % of cases: antibiotics (penicillin, chloramphenicol, cephalosporins, sulfonamides) , sulfasalazine, nonsteroidal antirheumatics (ibuprofen, indomethacin, phenylbutazone), phenothiazine, thyreostatics, quinidine, procainamide, propafenone, ticlopidine, antihistamines, anticonvulsives, nifedipine, levamisole, tamoxifen, allopurinol, tranquilizers, neuroleptics (clozapine), gold, captopril + interferon • bone marrow aspiration, biopsy and culture (cfu) • abdominal sonography (spleen), chest x-ray (exclusion of infection) • leukemia ( chaps. . . , . . ) • myelodysplasia ( chap. . ) • primary myelofibrosis ( chap. . . ) • aplastic anemia ( chap. . ) • susceptibility to infections, fever ( chap. . ) • mucositis, gastroenteritis ("neutropenic enterocolitis") • hygiene, anti-infectious environment, isolation • mucositis prophylaxis • selective intestinal decontamination • oral antimycosis (e.g., fluconazole mg/day p.o.) • signs of infection: blood cultures, urine and stool cultures, swabs, immediate start of empirical antibiotic treatment ( chap. . ) • with severe infections: granulocyte transfusion ( chap. . ) • discontinue all drugs administered within weeks of onset of symptoms • g-csf (filgrastim, lenograstim) - µg/kg daily s.c. treatment according to the assumed pathogenic causes, e.g.: • in patients with clinically relevant recurrent infections, g-csf may be used as long-term treatment • use of other hematopoietic growth factors in clinical studies: gm-csf, il- , stem cell factor (scf) • in cases of autoimmune neutropenia: -prednisolone mg/kg daily p.o. (maximum weeks) -cyclosporin a (serum level target: - ng/ml): initial treatment over at least weeks; if successful, continue for at least months -azathioprine - mg/kg daily • with hypersplenism: consider splenectomy (only after pneumococcus vaccination) • in cases of congenital neutropenia: consider allogeneic transplantation ( chap. web: web: . neutropenia and agranulocytosis decreased platelet count (< , /µl), most common cause of hemorrhagic diatheses. • thrombopoiesis: megakaryoblasts → megakaryocytes → platelets; regulated by thrombopoietin and other cytokines (e.g., il- , il- , il- ) • directly after being released by the bone marrow, approximately one third of platelets are reversibly stored in the spleen ("pool") • two thirds of platelets circulate in the blood, life span - days, biological half-life - days; % of these platelets are spent daily to maintain hemostasis splenomegaly (portal hypertension, splenic infiltration with hematological neoplasia). • heart valve and vascular prostheses • extracorporeal circulation (surface activation) • immune thrombocytopenia (itp) ( chap. . . ) • microangiopathic disorders: hemolytic-uremic syndrome (hus) , thrombotic-thrombocytopenic purpura (ttp) ( chap. . . ) • disseminated intravascular coagulation (dic) ( chap. . . ) • disturbances in platelet and coagulation factor interaction: von willebrand's disease type iib, heparin-induced thrombocytopenia (hit) ( chap. . bone marrow aspiration and biopsy: megakaryocytes ↓ in case of dysfunctional thrombopoiesis, megakaryocytes normal or ↑ in cases of peripheral platelet loss. attention: if platelet count < , /µl: risk of hemorrhage → iliac crest biopsy (no sternal puncture), apply careful pressure imaging chest x-ray (lymphomas, infections), abdominal sonography (lymphomas, spleen) note: if plasmatic coagulation and blood vessels are normal, there is only a low risk of hemorrhage with a platelet count of > , - , /µl. "pseudothrombocytopenia": formation of platelet aggregates in edta blood: . - % of blood samples; cause: autoagglutinating igg antibodies → in vitro platelet aggregation in the presence of the anticoagulant agent edta → false low count by automatic platelet counter → repeat platelet count with citrated or heparinized blood • therapeutic: at signs of bleeding or acute hemorrhage (e.g., petechiae, hemorrhage of mucous membranes or epistaxis) with proven thrombocytopenia or thrombocyte dysfunction. • prophylactic: platelet count < , - , /µl. with concomitant diseases (especially acute leukemia, fever, sepsis, splenomegaly) risk of hemorrhage with higher platelet counts ( , - , /µl). with invasive interventions (e.g., catheter installation, punctures) the platelet count target is > , - , /µl. to avoid alloimmunization, transfusions should be avoided in patients scheduled for allogeneic hematopoietic stem cell transplantation. acquired thrombocytopenia, platelet count < , /µl. classic definition: itp = idiopathic thrombocytopenic purpura. diagnosis by exclusion; acquired thrombocytopenia of unknown etiology with normal to increased megakaryocyte count in the bone marrow. alternative definition: itp = immune thrombocytopenic purpura. acquired thrombocytopenia caused by antithrombocytic antibodies. incidence: - cases / , population / year. distribution male:female = : . igg-mediated immune reaction (rarely igm) against platelet membrane antigens, e.g., gpiib / gpiiia (fibrinogen receptor), gpib / ix (von willebrand receptor), and gpia / iia (collagen receptor). • specific platelet antibodies detectable in approximately - % of cases • macrophage binding via fcγ i, ii, and iii receptors (in itp patients: receptor polymorphism with altered binding affinity for igg) • complement activation • complement-mediated lysis and enhancement of phagocytosis → res phagocytosis of igg-coated platelets, esp. in spleen → biological half-life of platelets ↓↓ to a few hours • decreased thrombocytopoiesis (antibodies against megakaryocytes and thrombopoietic progenitor cells) • possibly t-cell-mediated process (in vitro, cd + t-cells can be activated by platelets) • without known causative disease ("primary itp") • in conjunction with an underlying disease ("secondary itp"): lymphoproliferative diseases, autoimmune diseases (systemic lupus erythematosus, etc.), viral diseases (e.g., hcv, hiv), bacterial infections (esp. in children), after bone marrow transplantation • children: in > % of cases, "acute" course: severe thrombocytopenia, usually spontaneous remission within months • adults: in > % of cases, "chronic" course (thrombocytopenia > months): < % risk of fatal hemorrhages (esp. intracranial), rarely spontaneous remission ( %), persists for more than months despite adequate treatment in % of patients thrombocytopenia with normal differential and morphology. normal or reactively increased megakaryocyte count, increased number of immature megakaryocytes. otherwise, normal bone marrow, no abnormal cells. • rare with platelet count > , /µl . itp • petechial type of hemorrhage (skin, mucous membranes), with hematomas / bruising / epistaxis • complication: intracerebral hemorrhage (rare), organ bleeding, retinal bleeding, gastrointestinal bleeds the diagnosis of itp is a diagnosis of exclusion. therefore, the diagnostic strategies are aimed at identifying potential underlying causes of secondary thrombocytopenia. • medical history, family history, drug exposure, occupational hazards • physical examination (petechiae, bruising, mucosal bleeds) • full blood count with differential • virology: hcv / hiv serology in patients at risk • screening for platelet antibodies ( % positive) bone marrow biopsy and smear in accordance with recommendations of ash (american society of hematology) and bcsh (british committee for standards in hematology): • patients over years of age • laboratory abnormalities (neutropenia, anemia) • prior to splenectomy • poor response to primary treatment. differential diagnosis of thrombocytopenia chap. . only a small number of randomized studies have been conducted in itp. the life expectancy of itp patients with a platelet count > , /µl is equal to that of the normal population. with higher platelet counts ( , /µl), treatment is therefore only indicated if blood loss is expected (perioperatively, before delivery) or in the case of active hemorrhage. • initial response rate > %, long-term effect in % of patients, low-dose maintenance treatment is required in most cases • prednisolone - mg/kg daily, duration of treatment depending on response, or dexamethasone mg/d for days • with durable platelet response: dose reduction of prednisolone over - weeks, monitoring of platelet counts • if no increment to > , /µl within - weeks or required steroid dose markedly above the threshold dose for cushing's disease → change treatment to immunoglobulins or alternative immunosuppressive drugs • initial response rate %, normalization of the platelet count in % of patients; however, only transient (up to weeks) • standard dose: . g/kg daily i.v. days - or g/kg daily i.v. day + • alternative: anti-d igg in rh-positive patients, µg/kg body weight over - days. disadvantage: i.v. product not available in all countries, high costs in cases of severe or life-threatening hemorrhage: combined administration of methylprednisolone g daily i.v. over days and immunoglobulins . - g/kg daily over - days, platelet transfusion. due to the short platelet half-life in itp, the expected platelet need is approximately - times higher than in other forms of thrombocytopenia. in patients with uncomplicated itp, platelet transfusions are, generally not indicated. thrombopoietic agent, binds to tpo receptor and stimulates platelet production of the bone marrow. in phase iii studies in itp, platelet responses in - % of cases. starting dose µg/kg once weekly s.c., dose adjustment according to platelet counts. • immunoapheresis • rituximab (cd antibody) . itp acquired heparin-induced thrombocytopenia d . incidence of hit type ii (see below) with intravenous use of unfractioned heparin (ufh): - %, with use of low-molecular-weight heparin (lmwh): < . %. • dose-dependent mild early-onset thrombocytopenia (platelet count , - , /µl) in the initial - days of heparin treatment (ufh / lmwh) • caused by minor heparin-induced platelet aggregation, no immunological genesis • usually self-limiting (after - days) while heparin administration is ongoing • frequency of up to % • dose-independent late-onset thrombocytopenia, - days after start of heparin treatment (ufh / lmwh). in patients previously exposed to heparin (< days), reoccurrence within hours • severe thrombocytopenia (platelets < , /µl), median platelet count approximately , /µl, rarely < , /µl or decreased to < % of the initial count; worsening of thrombocytopenia if heparin treatment is continued • thromboembolic complications up to days after heparin administration • igg antibodies mostly against the platelet factor (pf )-heparin complex → immune complex formation → platelet activation due to binding of the immune complex to the fc receptor (fcγ riia), pf release → platelet aggregation, endothelial cell damage, thrombin activation → thromboembolic complications ("white clot syndrome") clinical relevance: hit type ii: • main symptom: thrombophilia, not hemorrhage • warning signs: exanthema or necrosis at injection site • high incidence (up to %) of venous and arterial thrombosis, renal dysfunction, pulmonary embolism, infarction (complications may occur weeks after discontinuation of heparin) • exclusion of other causes of thrombocytopenia ( chap. . ). • combination of a functional test (e.g., heparin-induced platelet activation, hipa) with elisa (detection of pf -heparin complexes). • attention: if hit ii is clinically suspected, discontinue heparin immediately and use alternatives, even without positive test. the diagnosis of hit is based on clinical findings. tests serve as confirmatory tools only. exclude other causes of thrombocytopenia ( chap. . ) therapeutic intervention (with hit type ii): • discontinue heparin treatment (ufh / lmwh). attention: exclude exposure to "hidden" heparin, e.g., coagulation factor products, "heparin lock" of central catheters • anticoagulation must be continued for at least weeks, using: − danaparoid sodium: heparin-free heparinoid, atiii-mediated inhibition of factor xa, half-life h, renal elimination, monitoring via factor xa levels, no antidote available − hirudin derivatives, e.g., lepirudin: bivalent direct thrombin inhibitor, half-life . h, renal elimination, monitoring via ptt, no antidote available . hit thrombocytopenic thrombotic microangiopathies with hemolytic anemia (microangiopathic hemolytic anemia, maha). subtypes: • thrombotic-thrombocytopenic purpura (ttp, moschcowitz disease): main symptoms are microangiopathic hemolytic anemia, thrombocytopenia, and neurological symptoms; renal dysfunction in % of cases • hemolytic-uremic syndrome (hus, gasser's disease): main symptoms are acute renal failure (renal microangiopathy, glomeruli are particularly affected) and hemolytic anemia; thrombocytopenia and neurological symptoms are less pronounced than in ttp • toxic microangiopathic hemolytic anemia (toxic maha): after treatment with mitomycin c or high-dose chemotherapy it is not yet clear whether ttp and hus are separate diseases or whether they are different manifestations of one syndrome. due to the frequently overlapping symptoms, the more commonly used term is ttp-hus (in adult patients). exception: hus in children after e. coli infection. ttp: age peak - years, distribution male:female = : hus: incidence - cases/ , children/year, age peak - years, distribution male:female = : • acquired or congenital (total) dysfunction of the vwf-cleaving protease (= adamts ; a disintegrin and metalloprotease with thrombospondin type- motifs; cleaves vwf between the amino acids and ), with unusually large von willebrand factor multimers (ul-vwf-m), particularly in chronically recurrent ttp • acquired ttp: autoimmune disease with anti-vwf protease autoantibodies • associated with infections (hiv), pregnancy, postpartum, after allogeneic bone marrow transplantation, drugs (mitomycin c, cyclosporine, ticlopidine, clopidogrel, quinine), autoimmune diseases (sle) • normal vwf protease activity. • commonly associated with gastrointestinal infections caused by shiga toxin or verotoxin-producing escherichia coli (serotypes oh, particularly o :h , o :hu, o :h ), rarely shigella (shigella dysenteriae serotype i). • in the absence of gastrointestinal infections, hus is probably complement-mediated and occurs in connection with autosomal recessively inherited factor h mutations. in sporadic forms, factor h autoantibodies are thought to be involved. in this case, association with glomerulonephritis type ii and involvement of autoantibodies against c convertase. under physiological conditions, vwf multimers are excreted by endothelial cells and deposited subendothelially. in the case of endothelial damage → complex formation of vwf multimers with thrombocytes → thrombocyte aggregation due to binding to platelet glycoproteins ib, ix, and v as well as activated gp iib/iiia. in cases of thrombotic microangiopathies, platelet aggregates or microthrombi are formed in capillaries and small vessels causing infarction, particularly in cns and kidney. • thrombocytopenia due to peripheral destruction • anemia due to mechanical destruction of erythrocytes in partially thrombosed small vessels (fragmentocytes, ldh ↑, haptoglobin ↓↓). . ttp-hus thrombotic microangiopathies constitute a hematological emergency → immediate specific treatment is of vital importance. without adequate treatment, the mortality rate is %. • plasma exchange via pheresis with fresh frozen plasma (ffp) initially ml/kg daily • aim: depletion of vwf multimers and autoantibodies, substitution of vwf protease (t½ > h) through ffp or as cryoprecipitate • success parameters: normalization of ldh and platelets, regression of neurological symptoms; once laboratory parameters have normalized, lengthening of pheresis intervals • if symptoms persist: increase pheresis frequency to twice daily or raise volume to ml/kg (in individual cases, as much as ml/kg/day may be indicated → however, twice daily pheresis seems to be more effective); in addition, prednisone ( mg/kg/day) or methylprednisolone ( mg i.v. twice daily) and possibly vincristine or immunoglobulins • pheresis is often accompanied by moderate citrate toxicity (muscle cramps, tetany) → calcium replacement • even with adequate treatment, full reconstitution of renal function may be delayed • with suspected acquired ttp: prednisolone × mg/day i.v. or p.o. over week, withdraw gradually over a period of at least weeks • patients with acquired antibody-mediated ttp who respond insufficiently to plasmapheresis or have relapsed: additional immunosuppressive treatment, e.g., splenectomy, immunoadsorption via protein a column, possibly azathioprine or other immunosuppressives (e.g., anti-cd antibody rituximab ± cyclophosphamide, cyclosporine). • congenital vwf protease deficiency: treatment according to symptoms: replacement of vwf protease ± plasmapheresis, prophylactic platelet aggregation inhibitors may be required with platelet recovery. platelet transfusion only after careful benefit-risk assessment (e.g., life-threatening hemorrhage) → possible deterioration of symptoms (increased intravascular thrombus formation). . ttp-hus reduced hemoglobin concentration and hematocrit. red blood cell (rbc) number below normal level. substitution of packed red blood cells: restrictive indication ( chap. . . ). • individual assessment of transfusion indication for each patient. • in acute blood loss, consider indication when hemoglobin < . g/dl. • with chronic anemia lower levels of hemoglobin ( - g/dl) are generally tolerated. • patients with coronary heart disease or risk of cerebral ischemia: transfusion indication at hemoglobin < g/dl. • specific conditions (surgery, thalassemia major, etc.) may require rbc transfusion support. the indication for transfusion is based on clinical symptoms. asymptomatic blood loss does not constitute an indication for transfusion. anemias with decreased corpuscular hemoglobin (mch < pg) and decreased corpuscular hemoglobin concentration (mchc < %): • iron deficiency anemia (> % of hypochromic anemias) • anemia of chronic disease (inflammation-/ infection-/ tumor anemia) • thalassemia ( chap. . . ) • rare causes: vitamin b deficiency, lead intoxication iron deficiency anemia most frequent form of anemia. proportion male:female = : . about - % of women in childbearing age demonstrate latent iron deficiency. daily iron resorption required: men mg, women and adolescents - mg, pregnant women - mg. about - % of body iron store bound in hemoglobin, additional % in myoglobin. g hemoglobin contains . mg of iron. in iron deficiency the iron need is greater than the available iron supply, resulting in hemoglobin synthesis disorders → microcytic, hypochromic erythrocytes. • ferritin serum : correlates with total iron (↓ in iron deficiency) • transferrin serum : correlates with circulating iron and need (↑ in iron deficiency) most important cause: loss of iron due to chronic bleeding → in manifest iron deficiency evaluation of underlying cause is of central importance. microcytic, hypochromic erythrocytes, poikilocytosis, anisocytosis, anulocytes. iron stain (prussian blue stain): storage iron not detectable (ferritin, hemosiderin). • skin and nail changes: skin atrophy, spoon-shaped nails (koilonychia) • oral rhagades, impairment of mucous membranes, in extreme cases painful mucous membrane atrophy of tongue, pharynx, and esophagus with dysphagia (plummer-vinson syndrome) • history, esp. infections, drugs, bleeding, nutritional habits • physical examination: including skin, mucous membranes, lymph node status, spleen / liver, heart (tachycardia, particularly systolic murmur), rectal examination with fecal blood test, urine dipstick • gynecological examination • endoscopy: esophago-gastro-duodenoscopy, colonoscopy, rectoscopy • hematology: blood count, mcv ↓, mch ↓, reticulocytes, differential blood count • clinical chemistry: routine tests with bilirubin, renal function parameters, iron status (iron ↓, ferritin ↓, transferrin-binding capacity ↑) • blood group (if red cell substitution necessary) • iron resorption test (if resorption deficiency is suspected) in inconclusive cases eventually bone marrow aspiration / biopsy, including iron staining, to exclude other causes of anemia. • anemia of chronic disease (iron ↓, ferritin normal or elevated, transferrin-binding capacity ↓) • thalassemia (mcv ↓↓, iron, ferritin, and transferrin-binding capacity normal) • hemolytic anemia (bilirubin, ldh, haptoglobin, coombs' test) treatment of anemia with iron deficiency always requires a combined approach: . treatment of the underlying cause of iron deficiency (e.g., chronic blood loss) . iron substitution • application of ferrous ii preparation, e.g., fe(ii) sulfate, fumarate, gluconate, or succinate, - mg/day p.o., for - months. • pkin: oral bioavailability, depending on preparation, - %, better bioavailability when taken prior to food. • se: gastrointestinal tract symptoms (nausea, vomiting,), dark discoloration of stool (atten-tion misdiagnosis: upper gastrointestinal bleeding). • treatment monitoring: after - days reticulocytes ↑, hemoglobin ↑. most frequent cause of a treatment failure is lack of compliance, followed by combined anemia (e.g., coexisting iron deficiency and lack of vitamin b ). • parenteral application of iron should be limited to individual cases (e.g., in malabsorption syndrome), due to severity of side effects. • strictly intravenous application of ferrous(iii) preparations, consider premedication with steroids and antihistaminics. • se: thrombophlebitis, headache, flush, nausea, vomiting, fever, allergic reactions up to anaphylaxis. with paravenous injection local pain and visible iron deposits in tissue. application of packed red blood cells is generally not indicated in iron deficiency anemia. exceptions exist in patients with additional blood loss and clinical symptoms. second most common form of anemia (after iron deficiency anemia). multifactorial anemia with chronic underlying disease (malignancy, inflammation, infection, collagen diseases). pathogenetic factors: • cytokine-mediated (tnfα, interleukin- , interferon γ) → erythrocyte-survival time ↓, interference with iron mobilization from reticuloendothelial iron stores (macrophages), iron uptake / utilization in normoblasts ↓, erythropoietin secretion and effect ↓, inhibition of erythroid progenitor cells, etc. • treatment-associated (drugs, radiation therapy, etc.) • consequence of underlying disease normochromic, normocytic or hypochromic, microcytic red blood cells, poikilocytosis, anisocytosis. • pallor of skin and mucous membranes, nail beds, conjunctivae • weakness, tiredness, reduced performance, exertional dyspnea • lack of concentration, headache depending on disease, generally with • tiredness, weakness, reduced performance • fever, weight loss, night sweats (b symptoms) • loss of appetite, myalgia, arthralgia, etc. in inconclusive cases consider bone marrow aspiration / biopsy, including iron staining, to exclude other causes of anemia. anemia with increased erythrocyte volume (mcv > fl), usually caused by lack of vitamin b (cobalamin) and/or folic acid. incidence - cases/ , population/year, distribution male:female = : , age peak years the reference nutrient intake (rni) for vitamin b is µg, with maximum daily absorption in the terminal ileum of - µg. "intrinsic factor" (glycoprotein) is a prerequisite for vitamin b resorption. • cofactor in the synthesis of succinyl coa, methionine, and tetrahydrofolic acid • in case of vitamin b deficiency: → dna synthesis and fatty acid metabolism impaired → delayed nuclear maturation, normal cytoplasmic development → ineffective myelopoiesis, large cells with altered nucleus: plasma ratio • most frequent cause: pernicious anemia ( % of cases): autoimmune atrophic gastritis with antibodies against gastric parietal cells ( % of cases) and/or antibodies against intrinsic factor ( % of cases) → achlorhydria, intrinsic factor deficiency → decreased vitamin b resorption in the terminal ileum • insufficient vitamin b uptake (strict vegetarians, alcoholics) • postoperatively (gastrectomy, resection of the terminal ileum, blind loop syndrome) • vitamin b malabsorption, rare (crohn's disease, scleroderma, amyloidosis) • infections / parasites (fish tapeworm, bacterial gastrointestinal infections) macrocytic hyperchromic erythrocytes, poikilocytosis, anisocytosis, hypersegmented granulocytes (right shift); in severe cases, granulocytopenia and thrombocytopenia. megaloblastic changes: ineffective left-shifted erythro-, thrombo-, and granulopoiesis, pronounced erythropoiesis with increased numbers of immature erythroid precursors (erythropoietic hyperplasia with megaloblastic erythroblasts), giant band forms, immature megakaryocytes. • pale skin and mucous membranes, icterus (due to intramedullary hemolysis) • weakness, fatigue, reduced performance, dyspnea on exertion • difficulty concentrating, headache in advanced cases: funicular myelosis: neuropathy caused by symmetrical damage of the posterior columns of the spinal cord, the corticospinal tract and peripheral nerves; motor abnormalities mainly affecting the lower extremities; staggering gait, ataxia, spastic paresis, impaired vision, psychological disorders. • type a gastritis • trophic disorders of the skin and mucous membranes: hunter's glossitis, etc. • sterility (gonad dysfunction), reversible • medical history: infections, drugs, hemorrhage, nutritional habits • physical examination: skin, mucous membranes, lymph node status, spleen / liver, heart (tachycardia, in some cases: systolic cardiac murmur), rectal examination and test for fecal blood, neurological examination • hematology: blood count with mcv (↑), mch (↑), reticulocytes (↓), differential blood count • clinical chemistry: liver and renal function tests, total protein, hemolysis parameters (bilirubin ↑, ldh ↑↑, haptoglobin ↓ due to intramedullary hemolysis) • antibodies against gastric parietal cells and/or against intrinsic factor • vitamin b serum level (normal: - pg/ml), folic acid serum level • vitamin b absorption test (schilling's test): oral administration of radioactive b ± intrinsic factor, determination of urinary vitamin b , comparison of vitamin b absorption / excretion with and without intrinsic factor • blood group (if red cell transfusion is necessary) • gastroscopy: detection of chronic atrophic gastritis, exclusion of gastric carcinoma (incidence times higher with chronic atrophic gastritis) • bone marrow aspiration / biopsy to confirm megaloblastic abnormalities • alcoholism (most common cause of a macrocytic blood count) • hepatic disorders, severe hypothyroidism • reticulocytosis, myelodysplasia ( chap. hydroxycobalamin mg i.m. → initially: injections within - weeks (to replenish vitamin b stores), then: one injection every months. additionally: application of ferrous ii preparation and folic acid to cover increased erythropoesis during substitution phase. attention: close monitoring during the first days of treatment: critical increase in reticulocytes and platelets possible → increased risk of thrombosis, potassium and iron deficiency. gastroscopy at regular intervals due to increased risk of gastric cancer. reference nutrient intake (rni) for folic acid: - µg, during pregnancy µg. • folic acid is a cofactor of thymidylate synthesis (c transfer), i.e., dna synthesis • in case of folic acid deficiency: → disorder of dna synthesis → delayed nuclear maturation with normal cytoplasmic development → ineffective myelopoiesis, giant cells with an abnormal nucleus: plasma ratio • insufficient folic acid intake: nutritional deficiency, alcoholism, anorexia nervosa • malabsorption: gluten-induced enteropathy, tropical sprue, crohn's disease, scleroderma, amyloidosis, postoperatively (small bowel resection, gastrectomy) • increased demand: pregnancy, chronic hemolytic anemia, chronic inflammatory disease, or malignancies • loss of folic acid: hemodialysis • drug-induced (with folic acid antagonists): methotrexate, trimethoprim, pyrimethamine, phenytoin, triamterene see vitamin b deficiency anemia • pale skin and mucous membranes, icterus (due to intramedullary hemolysis) • weakness, fatigue, reduced performance, dyspnea on exertion • difficulty concentrating, headache • folic acid deficiency during pregnancy: increased incidence of neural tube defects (spina bifida, anencephaly) • sterility (gonadal dysfunction), reversible • hematology: blood count with mcv (↑), mch (↑), reticulocytes (↓), differential blood count • clinical chemistry: liver and renal function tests, total protein, hemolysis parameters (bilirubin ↑, ldh ↑, haptoglobin ↓ due to intramedullary hemolysis) • vitamin b level, folic acid level (normal: - ng/ml) • blood group (if red cell transfusion is necessary) • esophago-gastro-duodenoscopy: exclusion of gluten-sensitive enteropathy (sprue) • bone marrow aspiration / biopsy to confirm megaloblastic abnormalities see vitamin b deficiency anemia anemia caused by erythrocyte destruction characterized by decreased erythrocyte survival (< days) in the bone marrow, × erythrocytes are produced per day; median erythrocyte survival: days; erythrocyte destruction in spleen and liver (reticuloendothelial system, res). generally, normochromic normocytic anemia with normal leukocytes and platelets; characteristic changes in cases of hereditary membrane defects (spherocytes, elliptocytes, etc.); anisocytosis, poikilocytosis, and, in some cases, fragmentocytes. . hemolytic anemia erythropoietic hyperplasia, increase in erythroblasts. consider bone marrow aspiration / biopsy, including iron stain, to exclude other causes of anemia. therapeutic options depend on the anemia subtype. treatment components are: • supportive treatment: red cell transfusion (only in individual cases with symptomatic anemia, controversial in cases of autoimmune hemolytic anemia) • treatment of underlying disease • immunosuppression (in cases of autoimmune hemolytic anemia) • splenectomy → removal of the sequestration filter for damaged erythrocytes attention splenectomy • splenectomy can correct the decrease in erythrocyte survival, but it is not a causal therapy in the sense of a correction of the triggering hemolytic defect. • prior to splenectomy, mandatory vaccination against streptococcus pneumoniae, neisseria meningitidis, and haemophilus influenzae because of the sepsis risk. • after splenectomy, prevention of thromboembolic events (platelets ↑) → low-dose heparin. most common hereditary hemolytic disease; prevalence . %; in most cases hereditary disease (autosomal dominant), spontaneous mutation is rare. rare, higher incidence in mediterranean countries / africa (increased malaria resistance of elliptocytes) heterogenic disease group with > % of elliptic erythrocytes; protein defects of the erythrocytic cytoskeleton (spectrin, protein . r) usually asymptomatic; only - % of patients have varying degrees of anemia, icterus or hemolytic crises • positive family history • blood smear with > % elliptocytes in symptomatic patients: splenectomy acquired clonal disorder of myeloid stem cells (i.e., of the erythrocytic, granulocytic, and thrombocytic line) with somatic mutations of phosphatidylinositol-glycan a (pig a) → defect of the "phosphatidylinositol-glycan anchor" (pig anchor) the pig anchor fixes various proteins to the cell membrane, including three complement-regulating proteins: cd (membrane inhibitor of reactive lysis; mirl), cd (decay accelerating factor; daf), and "c binding protein" (cbp). → changes in the pig anchor lead to a decrease in the respective proteins in the cell membrane → reduced resistance against activated complement factors → complement-mediated lysis ↑, incidence of thromboembolic events ↑ • chronic hemolytic anemia • different severity levels of nocturnal hemolysis (even nocturnal hemolytic crises), with morning hemoglobinuria • recurrent thrombosis, particularly portal vein, liver veins (budd-chiari syndrome), cerebral vessels, splenic vein, skin veins (skin necrosis) • iron deficiency anemia due to chronic loss of iron (renal) • medical history: circadian occurrence of symptoms • physical examination: anemia signs and symptoms, urinary discoloration • normochromic normocytic anemia, in some cases with granulocytopenia and thrombocytopenia • hemolysis parameters (ldh ↑, haptoglobin ↓, indirect bilirubin ↑, hemoglobinuria) • acid hemolysis test (ham's test) and sugar water test (sucrose test), pathological: complementmediated lysis after addition of sugar water or acid to the blood sample • molecular genetic proof of the pig defect in rare cases development of aplastic anemia, myelodysplasia, or aml • prophylactic anticoagulant therapy: phenprocoumon. attention: avoid heparin → possible complement activation • iron and folic acid supplementation • in cases of hemolytic crisis: corticosteroids (prednisolone - mg i.v.), supportive treatment • blood transfusion: only washed erythrocytes to avoid administration of additional complement • eculizumab, antibody against complement c , inhibits complement-mediated lysis of pnh erythrocytes allogeneic stem cell transplantation ( chap. . ): only in severe cases with repeated hemolytic crises or complications (thromboembolic events, etc.) hereditary disease, genetic modification of the glucose- -phosphate dehydrogenase (> mutants worldwide) one of the most common hereditary diseases worldwide, regional differences in incidence and prevalence. in africa, asia, and the mediterranean region, as much as - % of the population may be affected (patients are more resistant to malaria plasmodia). x-chromosomal recessive inheritance → mainly males affected. heterozygotics have two different populations of erythrocytes and usually have less pronounced symptoms. hereditary defect of the enzyme pyruvate kinase, i.e., the erythrocytic glycolysis. most common hereditary glycolytic defect (embden-meyerhof pathway), autosomal recessive inheritance. heterozygotic individuals are usually asymptomatic. homozygosis (rare) leads to hemolytic anemia. pyruvate kinase deficiency results in abnormal glycolysis: → atp deficiency → abnormal na + / k + -atpase activity in the erythrocyte membrane → membrane instability, hemolysis usually asymptomatic. in homozygotic individuals, hemolytic crises may occur. • blood smear with acanthocytes, anisocytosis, poikilocytosis • hemolysis parameters, reduced erythrocytic pyruvate kinase activity symptomatic patients: splenectomy; in cases of iron overload: venesection therapy and administration of desferrioxamine. hemoglobin s (hbs): point mutation in the β-globin locus (chromosome ) of the hemoglobin molecule in position : replacement of glutamic acid by valine (β glu → val). hbs precipitates when deoxygenated (risk factors: lack of oxygen, dehydration, fever, increased serum osmolality, stasis): → sickle-shaped erythrocytes with reduced elasticity → hemolysis, disturbed microcirculation, capillary occlusion heterozygotic individuals (hbas) are usually asymptomatic. in homozygotic cases (hbss): • hemolytic anemia and hemolytic crisis • vaso-occlusive crises: organ infarction (particularly spleen, kidney, cns), bone infarction, pulmonary hypertension • abdominal pain, bone pain, cerebral disorders, in some cases with fever, tachycardia, leucocytosis • hepatosplenomegaly, recurrent splenic infarction → "autosplenectomy, " functional asplenia • osteoporosis, growth defects due to recurrent bone infarction • pure red cell aplasia / aplastic crisis with parvovirus b infections • proliferative retinopathy → impaired vision • bilirubin gall stones • immunodeficiency (due to recurrent splenic infarction) • medical history (family history), clinical examination • hemoglobin electrophoresis • sickle cell test: erythrocytes show sickle shape after addition of sodium sulfide • molecular genetic screening (pcr) other hemoglobinopathies: more than hemoglobinopathies have been described. hb c, e, and d are the most common. sickle cell anemia is treated supportively: • fluid replacement, at least , ml/day • oxygen (via nasal tube, - l/min) • treatment of infections, analgesia • red cell transfusion, in case of severe complications: exchange transfusion • in cases of splenic infarction / hemorrhage / rupture: splenectomy • prophylactic pneumococcus vaccination • hydroxyurea prevention of lack of oxygen, dehydration, and infections. quantitative disturbance of hemoglobin synthesis due to a genetic defect in globin chain formation. subtypes: • β-thalassemia: abnormal β-chain synthesis • α-thalassemia: abnormal α-chain synthesis (rare) regional differences in incidence: β-thalassemia in mediterranean regions, africa, and asia; αthalassemia in south east asia and africa. abnormal synthesis of the hemoglobin β-chain, i.e., no formation of normal adult hba (αα/ββ). → compensatory formation of γ-or δ-chains (hbf = αα/γγ and hba = αα/δδ) → ineffective erythropoiesis (free α-globin is toxic for erythroblasts) with intramedullary hemolysis → hypochromic microcytic anemia, signs of hemolysis . hemolytic anemia hematology and hemostasis usually, no clinical symptoms; in some cases minor chronic hemolysis, anemia, and splenomegaly. • chronic hemolysis, icterus • hepatosplenomegaly • cardiac insufficiency • infections • microcytic hypochromic anemia (hb ↓, hct ↓, mcv ↓, mch ↓) • iron serum ↑, ferritin ↑, transferrin iron-binding capacity ↓ • blood smear: microcytic hypochromic erythrocytes, target cells, polychromasia, isolated normoblasts • chronic erythropoietic bone marrow hyperplasia → expanded marrow, detectable in bone marrow scan or skull x-ray ("hair-on-end" sign) • hemoglobin electrophoresis: increase in hbf (αα/γγ) and hba (αα/δδ) • molecular genetic detection of the defective globin gene (via pcr) iron deficiency anemia ( chap. . . ) . • rbc transfusion • hemosiderosis treatment: desferrioxamine , iu/day s.c. in homozygotic cases / severe hemolysis: allogeneic stem cell transplantation during infancy. autoimmune hemolytic anemia caused by igg incomplete "warm" autoantibodies (incomplete antibodies: antigen-antibody binding, but no lysis or agglutination). seventy-five percent of all autoimmune hemolytic anemias. • in non-hodgkin's lymphoma, particularly in low-malignant nhl (cll) • with autoimmune diseases, e.g., systemic lupus erythematosus (sle) • following infections (viral infections, rarely bacterial infections) • drug-induced hemolysis (various mechanisms): antibiotics, α-methyldopa, l-dopa, quinine, quinidine, x-ray contrast agents, procainamide, diclofenac • idiopathic ( % of cases) • binding of incomplete antibodies to erythrocytes • destruction of antibody-coated erythrocytes in spleen and liver (extravascular non-complement-mediated lysis by cells of the reticuloendothelial system) • hemolysis and hemolytic crises, with icterus, hemoglobinuria, fever, etc. • anemia symptoms (fatigue, weakness, reduced performance, pallor, headache, etc.) • case history including medication • physical examination including signs and symptoms of anemia treatment of underlying disease or discontinuation of causative drugs. • corticosteroids (prednisolone - mg/day i.v.), slowly taper dose after hemolysis parameters have normalized • in cases of chronic hemolysis and poor response to corticosteroids: use alternative immunosuppressive agents, e.g., azathioprine mg/m /day, cyclophosphamide mg/m /day p.o. • splenectomy: in cases of treatment-refractory chronic hemolysis or refractory acute hemolytic crisis • transfusion of packed red cells only in cases of symptomatic anemia (e.g., cardiovascular symptoms, dyspnea, cerebral ischemia) autoimmune hemolytic anemia caused by igm complete "cold" autoantibodies, usually targeting the i-antigen of the erythrocyte membrane (complete antibodies: capable of agglutination and lysis induction after antigen-antibody binding). fifteen percent of all autoimmune hemolytic anemias. • in low-malignant non-hodgkin's lymphoma or hodgkin's disease • after infection (viral infections, mononucleosis / ebv infection, mycoplasma pneumoniae) → cold agglutinin titer up to : , rare congenital disease → cold agglutinin titer up to : , when the intravascular temperature drops to < - °c: antigen-antibody binding, agglutination and complement-mediated intravascular hemolysis. • exposure to cold leads to hemolysis and hemolytic crisis (with icterus, hemoglobinuria, fever, etc.) • anemia symptoms (fatigue, weakness, reduced performance, pallor, headache, etc.) • acrocyanosis: painful / malperfused extremities (fingers / toes / nose) • splenomegaly . hemolytic anemia hematology and hemostasis • medical history, physical examination • diagnostic clues: erythrocyte agglutination when blood is drawn and during laboratory analysis • anemia (hb ↓, hct ↓), signs of hemolysis (ldh ↑, indirect bilirubin ↑, haptoglobin ↓), detection of cold autoantibodies • exclusion of potential underlying diseases • blood group treatment of the underlying disease. • protection against cold • with severe acute hemolysis: plasmapheresis (objective: removal of autoantibodies), often technically difficult (due to agglutination within the plasmapheresis system) • with chronic hemolysis: immunosuppressive drugs, e.g., azathioprine, cyclophosphamide, or chlorambucil • with symptomatic anemia (cardiovascular symptoms, dyspnea, cerebral malperfusion, etc.): transfusion of washed packed red cells (avoid complement administration in cases of complement-mediated hemolysis) • corticosteroids and splenectomy are usually ineffective anemia with normal corpuscular hemoglobin (mch - pg) and normal corpuscular hemoglobin concentration (mchc - g/dl). • hemolytic anemia ( chap. . . ) • aplastic anemia ( chap. . ) • acute posthemorrhagic anemia • renal anemia normochromic normocytic hyporegenerative anemia as a result of chronic renal failure. incidence: - cases/ , per year. • complex pathogenesis based on renal insufficiency • renal erythropoietin synthesis ↓, the degree of anemia correlates with the severity of the underlying disease • myelosuppresion and intramedullary hemolysis due to accumulation of uremic toxins • concurrent chronic blood loss due to hemodialysis • pale skin and mucous membranes • weakness, fatigue, reduced performance, dyspnea on exertion • difficulty concentrating, headache • uremic fetor • "café au lait" complexion due to urochrome deposits and concurrent anemia, pruritus • weakness, headache • medical history: signs of chronic renal insufficiency • physical examination: skin, mucous membranes, lymph node status, spleen / liver, heart (tachycardia, systolic heart murmur), rectal examination and testing for fecal occult blood • hematology: blood count including mcv (normal), mch (normal), reticulocytes (↓), differential blood count • clinical chemistry: hepatic and renal function tests, total protein, hemolysis parameters (bilirubin, ldh, normal haptoglobin, low-grade hemolysis due to uremic toxins) • vitamin b level, folic acid level • serum iron, ferritin, transferrin; in cases of chronic blood loss due to hemodialysis, iron deficiency may occur • erythropoietin ↓ / normal (i.e., inadequate increase given the degree of anemia) • blood group (if red cell transfusion is required) • erythropoiesis stimulation with darbepoetin . µg/kg body weight once weekly s.c. or i.v., adjust dose according to hemoglobin response • alternatively, recombinant erythropoietin, iu/kg body weight three times weekly s.c. or i.v., adjust dose according to hemoglobin response . normochromic anemia • target hemoglobin - g/dl • attention: blood pressure may rise as hematocrit increases, especially in cases of pre-existing hypertension • hemodialysis • additional iron supplementation with signs of iron deficiency ( chap . . ) causal treatment • vasoconstriction • platelet adhesion to endothelial lesion, aggregation, clot formation (primary hemostasis) • coagulation cascade, fibrinogenesis (secondary hemostasis) • fibrinolysis coagulation and fibrinolysis are physiologically balanced and are regulated by activators and inhibitors. the distinction of an extrinsic and intrinsic system is artificial and not relevant for the physiological situation (in vivo). however, it helps to understand in vitro phenomena and clotting laboratory tests (quick's value, ptt). . coagulation disorders • antithrombin (at): prevention of excessive thrombin activation by formation of thrombin-at complex, inhibition of iia, ixa, xa, xia, xiia; important physiological coagulation inhibitor; at deficiency constitutes an increased risk of thrombosis (thrombophilia, chap. . ) • protein c: thrombin-induced conversion into active protein c (apc); apc inhibits fva and fviiia and induces the release of tpa (plasminogenic activator); protein c deficiency constitutes an increased risk of thrombosis ( chap. . ) • protein s: cofactor of protein c • heparin: activation of physiological at → inhibition of thrombin generation; ineffective in cases of at deficiency. unfractionated (ufh) and low molecular weight (lmwh) heparins • hirudin: direct thrombin inactivation, effective in cases of at deficiency • coumarin: vitamin k antagonists; inhibition of the hepatic synthesis of the factors ii, vii, ix, and x as well as the proteins c and s • acetylsalicylic acid: irreversible cyclooxygenase inhibition • ticlopidine: inhibition of fibrinogen binding by interaction with gpiib/iiia • tirofiban hydrochloride: gpiib/iiia receptor antagonist • dipyridamole: increases the level of cellular cyclic amp (camp) • clopidogrel: selective inhibition of adp binding, inhibition of adp-mediated activation of the gpiib/iiia receptor complex vitamin k deficiency or abnormal synthesis of vitamin k-dependent clotting factors ( chap. . . ) • severe liver damage • antibiotic treatment, malabsorption syndrome, abnormal fat absorption, alcoholism coagulopathies which may occur spontaneously or as a result of an underlying disease which is not primarily related to the hemostatic system. in contrast to primary disorders, several components of the hemostatic system are usually affected. impaired synthesis and metabolic defects can be distinguished. the liver is the primary site of formation and elimination of coagulation factors and their inhibitors as well as filtration → hepatic dysfunction can lead to complex hemostatic disorders: • impaired synthesis of clotting factors → factor deficiency (esp. factor ii, v, vii, ix, x, xiii, fibrinogen, plasminogen, α -antiplasmin, antithrombin, protein c, protein s) • impaired elimination of clotting factors → factor excess (e.g., viii, von willebrand-factor) • impaired thrombopoiesis / platelet function (hypersplenism, bone marrow defect due to toxic effects of alcohol, vitamin b / folic acid deficiency, thrombopoietin deficiency) • hyperfibrinolysis • ascites → loss of coagulation factors (loss of coagulation factors via ascites) • signs of hepatic failure • bleeding signs and symptoms: hematomas, mucous membrane hemorrhage, epistaxis • esophageal variceal bleeding (life-threatening) • quick's test ↓ (earliest indication of hepatic coagulation defects: includes factor vii which is the first to decrease due to its short half life of h); suitable parameter for monitoring hepatic disorders • aptt: may be normal or increased in advanced hepatic disorders • platelets ↓, fibrinogen ↓, factor v ↓, protein c ↓, protein s ↓, antithrombin ↓ (may be increased in case of cholestasis), d-dimers ↑ • determination of separate factors usually not required • initial treatment with fresh frozen plasma (ffp) ml/kg. • if insufficient: antithrombin supplementation, fibrinogen supplementation (for levels below . g/l), administration of cryoprecipitate. • administration of platelet concentrates, desmopressin (ddavp; . µg/kg) and antifibrinolytics (e.g., aprotinin , iu in min, million iu/day i.v.) may be considered. atten-tion: dic ( chap. . . ) . • if factor xiii concentration < % and ffp is without effect: administration of factor xiii concentrate. • if initial values are unknown / emergency situations: empirical treatment with antithrombin iu/kg, fibrinogen g, and ppsb iu/kg. in cases of severe hemorrhage, treatment with activated factor viia may be considered. administration of antifibrinolytics (e.g., tranexamic acid g three times daily), vitamin k antibodies to clotting factors, occurring as primary (spontaneous) or secondary (due to underlying disease) antibodies: • autoantibodies − inhibitors to individual clotting factors (most commonly to factor viii, antigen-induced hemophilia) − antiphospholipid antibodies ( chap. . ) − monoclonal immunoglobulins, heparin-like antibodies • alloantibodies (inhibitors in hemophilia a / b replacement therapy) incidence of factor viii inhibitors : , , acquired factor viii inhibitors: % of cases occur spontaneously, secondary inhibitors in conjunction with: asparaginase therapy of acute leukemias • impaired synthesis of clotting factors (esp. fibrinogen, antithrombin, protein c and s, factors ii, ix, and xiii) • potential complication: dic ( chap. . . ) hemorrhages of all degrees and in all locations (hematomas, mucous membrane hemorrhage, postoperative bleeding) levels of fibrinogen, antithrombin, d-dimers . acquired coagulation disorders hereditary bleeding disorder caused by deficiency ( % of cases) or inactivity ( %) of coagulation factor viii (fviii, ahg-a, antihemophilic globulin a). most common hereditary coagulopathy, incidence case/ , men/year. women are heterozygotic carriers of the gene. clinically apparent hemophilia in women is rare. ratio between hemophilia a and b approximately : . • factor viii coding gene located on the x chromosome → mainly men are affected, x-linked recessive inheritance ( % of cases) or spontaneous mutations ( %) • synthesis in liver, kda protein, no vitamin k dependence; half-life: - h • factor viii circulates in the plasma bound to von willebrand factor (vwf) → protection from proteolytic degradation attention: treatment must be provided as early as possible and must be sufficient with respect to dosage and treatment period. ddavp, nasal spray, or intravenous administration ( . - . µg/kg in ml saline over min, every - h); effect occurs within - min: transient fviii increase by factor - for up to days; may also be given prior to minor surgery (e.g., tooth extraction), possibly with antifibrinolytics. administration of recombinant factor viii or plasma factor viii. administration of recombinant factor products excludes the risk of viral contamination (hbv, hcv, hiv, hsv, ebv, cmv, etc. (feiba) - iu/kg body weight every - h. in emergency situations: plasmapheresis or immunoadsorption normal life expectancy • early detection of signs of bleeding • controlled exercise and sports program to prevent bleeding into joints and to maintain mobility • avoid platelet aggregation inhibitors (ass, etc.), no intramuscular injections • caries prophylaxis, meticulous local hemostasis during surgical procedures; no surgery without prophylactic administration of fviii • hepatitis a/b vaccination is recommended • x-linked inheritance → examine coagulation status of patient's relatives bleeding-related arthropathy often goes unnoticed → close monitoring, permanent fviii treatment in cases of severe hemophilia: - iu/kg - times weekly → rate of complications / arthroplasty significantly decreased. • severe bleeding / planned operation: increase factor ix for days to > % , then keep at > % for days • in cases of emergency, fresh frozen plasma (ffp) may be used, if recombinant fix concentrate is not available • aptt monitoring is not sufficient, plasma factor ix should be determined (shortly after replacement and before administration of the next dose) • - % of patients develop antibodies against infused factor, with treatment resistance → monitoring via fvii inhibitor assay normal life expectancy patient information and instruction ( chap. . . ) bleeding-related arthropathy often goes unnoticed → close monitoring, prophylactic factor ix treatment in cases of severe hemophilia in children: - iu/kg times weekly → significant decrease of complication / arthropathy rate. hereditary coagulopathy due to qualitative or quantitative deficiencies of the von willebrand factor (vwf). d . most common hereditary coagulopathy, heterozygotic gene carriers : to : , ; incidence of symptomatic cases: cases/ , , population. von willebrand factor is a heterogenic multimeric plasma glycoprotein (normal serum level: mg/l). the vwf precursor is synthesized as a monomer in the endothelium and megakaryocytes. active forms (vwf multimers) are found in the endothelium, platelets, and plasma. functions: • mediation of platelet adhesion to vascular wall (collagen) via high-molecular vwf multimers and binding to platelet glycoprotein ib (gpib) • factor viii carrier in plasma hereditary defect caused by mutation in the vwf gene (chromosome ); autosomal-dominant (subtype and ) or autosomal-recessive (subtype and ) inheritance. consequences: • impaired platelet adhesion • reduced fviii activity rare: acquired cases due to vwf antibodies in connection with autoimmune diseases, lymphoproliferative diseases, or after multiple transfusions ("von willebrand syndrome, " vws). defects in the vwf-binding glycoprotein gpib can mimic von willebrand's disease ("pseudo-vwd"). frequency definition • type : mild form, bleeding time ↑, discrete tendency to bleed, epistaxis, gum bleeding, increased menstruation, bleeding after minor surgery • type : different characteristics depending on subtype; increased soft tissue bleeding, mucous membrane bleeding, gastrointestinal bleeding, hematuria; bleeding into joints less common than with hemophilia; rarely intracerebral bleeding • type : most severe form with pronounced bleeding (soft tissue bleeding, bleeding into joints, and petechial type bleeding) • attention: in all types life-threatening bleeding may occur up to days after surgery. • medical history (including family history) • physical examination including type of bleeding systemic consumption coagulopathy due to release of coagulation activators, with intracapillary coagulation, microthrombus formation, subsequent ischemic organ damage (kidney, liver, lung) and organ failure. diffuse tendency to bleed due to collapsed hemostasis with secondary hyperfibrinolysis. acute dic is a severe life-threatening disease. chronic dic with continuous coagulation may occur in patients with malignant diseases. • infections: sepsis (gram-negative / gram-positive), malaria, rickettsia, chlamydia, mycobacteria, meningococcus (waterhouse-friderichsen syndrome: consumption coagulopathy with adrenocortical bleeding), viral infections • solid tumors: carcinomas of the lung, pancreas, stomach, colon, prostate, kasabach-merritt syndrome (hemangiomas) • hematological neoplasia: acute promyelocytic leukemia (fab m ) • obstetric complications: placenta abruptio, amniotic fluid embolism, septic abortion, eclampsia, postpartal hemolytic-uremic syndrome • hypoxia and shock: traumatic, hemorrhagic, cardiac, septic • hemolysis: transfusion errors, toxins, paroxysmal nocturnal hemoglobinuria • operations on organs with a high thrombokinase content (prostate, pancreas, lung), extracorporeal circulation (contact activation of the endogenous coagulation system) • trauma: head injury, soft tissue damage, fat embolism • others: snake bites, heat stroke (endothelial damage), abdominal aortic aneurysms excessive thrombin synthesis leads to fibrin formation and subsequent intravascular coagulation with consumption of platelets and clotting factors. inhibitory mechanisms (e.g., inhibition of fva and fviiia via thrombomodulin-activated protein c) cannot compensate the thrombin formation. . dic initially (phase i and ii), pathological laboratory parameters only. only with severe consumption coagulopathy (phase iii) clinically detectable symptoms: • hemorrhagic diathesis with ubiquitous bleeding, % of cases: skin / mucous membrane bleeding, hematomas, secondary bleeding after venipuncture / from puncture sites, pulmonary hemorrhage, gastrointestinal bleeding, renal bleeding, hematuria, adrenal bleeding / insufficiency, intracerebral bleeding • multiple microthromboses with impaired organ function, %: acute renal failure, impaired liver function, acute respiratory insufficiency (ards, "acute respiratory distress syndrome"), intradermal microvascular thrombosis → "purpura fulminans" (skin bleeding with central necrosis), cerebral small vessel ischemia (coma, epileptic seizures) • shock: tachycardia, decrease in blood pressure, edemas, organ failure • chronic course: coagulation factor synthesis ↑, thrombosis ↑ → malperfusion of larger blood vessels (embolisms, cerebral ischemia, etc.) • case history including risk factors • physical examination i activation rapid decrease of platelets, platelet count n / ↓, antithrombin n / ↓, fv n / ↓, fviii n / ↓, coagulation products ↑ (soluble fibrin, prothrombin fragment f + , thrombin-antithrombin complex tat) ii early consumption platelets ↓, antithrombin ↓, quick ↓, coagulation factors (fibrinogen, fv) ↓, ptt ↑, tat ↑, protein c ↓ iii late consumption platelets ↓↓ (< , /µl), antithrombin ↓↓, quick ↓↓, coagulation factors ↓↓ (fibrinogen, fv, and fviii), ptt ↑↑, thrombin time ↑↑, fibrinogen degrading products / fibrin monomers +, d-dimers +++, detectable fragmentocytes iv recovery decrease in coagulation products (soluble fibrin, prothrombin fragment f + , tat), increase of clotting factors (fibrinogen, fv, fviii), normalization of global clotting tests n normal, f factor, tat thrombin-antithrombin complex, ptt partial thromboplastin time • basic diagnosis: platelets (platelet decrease often first symptom), antithrombin, d-dimers, fibrinogen, quick's test, ptt • advanced diagnosis: fibrin monomers (soluble fibrin), prothrombin fragments f + , thrombin-antithrombin complex (tat), plasmin-plasmin inhibitor complex, factor v, protein c, possibly protein s (in cases of purpura fulminans) basic screening test score a score ≥ indicates ongoing dic; with scores < diagnostics should be repeated every - h depending on the individual clinical condition. • with tumors / infections / pregnancy, the platelet count is often increased ("reactive thrombocytosis") → normal platelet counts may already indicate dic. • fibrinogen is an acute-phase protein → "normal" fibrinogen levels may already be pathologically decreased (e.g., with infections). • with dic, frequent monitoring is required to determine the dynamics and course of disease. • primary hyperfibrinolysis: normal platelet count, normal atiii, no fibrin monomers basic therapy • antithrombin (at) replacement if at level < % (initially , iu, then iu every h), check level (target: - %) • heparin: - iu/kg/day (not with aml type m or patients with high bleeding risk), depending on platelet count organ dysfunction, bleeding • fresh frozen plasma (ffp, ml/kg) • antithrombin (at), - iu every h • fibrinogen replacement with fibrinogen levels of < mg/dl • platelet transfusion (target: > , /μl) • red cell transfusion according to hemoglobin level, compensation of acidosis • heparin is contraindicated, no intramuscular injections • patients should be treated in intensive care unit • severe uncontrollable bleeding: administration of activated fviia. attention: potential risk of thromboembolic complications attention: administration of coagulation factors can increase dic and should be avoided. for replacement therapy, use fresh frozen plasma (ffp). • severe sepsis: activated protein c (drotrecogin) µg/kg/h over h → decreases mortality from % to %. attention: with thrombocytopenia higher risk of hemorrhagic complications. contraindicated after brain hemorrhage, epidural catheter, etc. • in dic, avoid fibrinolysis inhibitiors: → in cases of uncontrollable bleeding: use aprotinin (e.g., , units in the first half hour, followed by million units/day), platelets, fibrinogen, and ppsb. in cases of life-threatening bleeding or lack of success: administer recombinant fviia. • fibrinolysis inhibitors (antifibrinolytics, e.g., tranexamic acid) may be indicated with hyperfibrinolytic conditions (prostate carcinoma, aml m ) in phase i of a dic only. • low-dose heparinization is indicated in cases of: purpura fulminans, acral ischemia, venous thrombosis. for phase i, some studies favor low-molecular weight heparin ( - units/kg/ day). • clinical monitoring: close monitoring of neurological, cardiovascular, respiratory and renal parameters • monitoring of bleeding: tachycardia, hemoglobin decrease, retroperitoneal bleeding (→ sonography), neurology • laboratory tests: coagulation parameters, blood count, hepatic and renal function parameters, electrolytes dd: dd: th: th: . dic platelet aggregation inhibitors (acetyl salicylic acid, ticlopidine, clopidogrel) new therapies for itp guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and pregnancy amg , a thrombopoiesis stimulating protein, for chronic itp management of adult idiopathic thrombocytopenic purpura idiopathic thrombocytopenic purpura: a guideline for diagnosis and management of children and adults long-term outcomes in adults with chronic itp after splenectomy failure morbidity and mortality in adults with idiopathic thrombocytopenic purpura long-term observation of adults with chronic idiopathic thrombocyto--argatroban: direct thrombin inhibitor, interacts with the active site of thrombin. half-live min., monitored by ptt. no dose adjustment in renal failure • in cases of existing thrombosis: coumarin overlapping with danaparoid or hirudin. • avoid using lmwh how i treat heparin-induced thrombopenia and thrombosis heparin-induced thrombocytopenia british committee for standards in haematology. the management of heparin-induced thrombocytopenia heparin-induced thrombocytopenia: new evidence for the dynamic binding of purified anti-pf -heparin antibodies to platelets and the resultant platelet activation delayed-onset heparin-induced thrombocytopenia cancer-related anemia: pathogenesis, prevalence and treatment eortc guidelines for the use of erythropoietic proteins in anaemic patients with cancer guidelines for the clinical use of red cell transfusion the impact of hemoglobin levels on treatment outcomes in patients with cancer red cells i: inherited anaemias red cells ii: acquired anemias and polycythaemia ash/asco clinical practice guideline update on the use of epoetin and darbepoetin modern treatment of thalassaemia intermedia british committee for standards in haematology. guidelines for the diagnosis and management of hereditary spherocytosis hereditary elliptocytosis: spectrin and protein . r management of cold haemolytic syndrome the complement inhibitor eculizumab in pnh treatment of autoimmune hemolytic anemia glucose- -phosphate dehydrogenase deficiency sickle-cell disease recessively inherited coagulation disorders mechanisms of disease: the impact of antithrombotic therapy in cancer patients coagulation disorders • ffp ml/kg (coagulation factor increase by • antithrombin concentrate: iu/kg → increase by approximately blood coagulation and its regulation by anticoagulant pathways: genetic pathogenesis of bleeding and thrombotic diseases acquired haemophilia: review and meta-analysis focused on therapy and prognostic factors the antiphospholipid syndrome identification of the gene for vitamin k epoxide reductase rituximab in the treatment of acquired factor viii inhibitors treatment of acquired hemophilia by the bonn-malmö protocol immune tolerance induction: recombinant vs. human-derived product haemophilia : emerging risks of treatment haemophilia a: from mutation analysis to new therapies recombinant activated factor vii in patients at high risk of bleeding dose and response in haemophilia: optimization of factor replacement therapy comparing outcomes of different treatment regimens for severe haemophilia consensus perspectives on prophylactic therapy for haemophilia: summary statement inhibitor development in haemophilia b recombinant activated factor vii in patients at high risk of bleeding dose and response in haemophilia: optimization of factor replacement therapy clotting factor concentrates given to prevent bleeding and bleeding-related complications in people with hemophilia a or b prg: prg: px: px: ref: ref: web: web ref: web: web: in cases of manifest severe dic: - % mortality administration of heparin efficacy and safety of recombinant human activated protein c for severe sepsis the prothrombotic state in cancer: pathogenetic mechanisms update on the treatment of disseminated intravascular coagulation disseminated intravascular coagulation: what's new? dic : a review of disseminated intravascular coagulation high dose antithrombin iii in severe sepsis dic in acute leukemia: clinical and laboratory features at presentation thrombosis: localized intravascular aggregation of blood components → thrombus (clot) formation with consecutive vascular occlusion embolism: migration of detached thrombus (clot) elements in the blood stream with consecutive vascular occlusion. triggers: thrombotic material, tumor particles or leukemic cell thrombi, sclerotic material, fat droplets, amniotic fluid, air. thrombophilia: increased risk of occurrence of thromboembolic events thrombosis incidence: cases/ , population/year; location: > % in inferior vena cava or leg / pelvic veins; male:female = : ; particularly in patients > years of age idiopathic" deep vein thrombosis or pulmonary embolism in clinically "healthy" adults is due to an underlying malignancy in - % of cases pulmonary embolisms or venous thromboses are found in up to % of cancer patients at autopsy virchow triad: major pathomechanisms of thrombogenesis • • • endothelial alterations: vascular sclerosis, inflammation, trauma, etc. circulation disorders: intravascular stasis, vortex formation endothelial alterations (esp. with arterial thrombosis) phlebitis circulation disorders • immobilization, bed rest • intravascular stasis due to vascular constriction or compression: e.g., after extended periods of travel ("economy class syndrome"), varicosis, obesity, pregnancy, solid tumors, or lymphomas • altered blood flow due to cardiac disorders hypercoagulability thrombocytosis e.g., myeloproliferative syndromes ( chap. . ) def: def: icd- : icd- : ep: ep: pg: pg: . thromboembolism and thrombophilia apc (activated protein c) resistance: most common cause of thrombophilia; in % of cases due to factor v mutations → abnormal apc binding site (mainly point mutations in the factor v gene, g a, "factor v leiden") → insufficient inactivation of factor v by mutated apc. prevalence: heterozygotic carriers - % of normal population, - % among patients with thrombosis. relative thrombosis risk in heterozygotic cases approximately -to -fold, in homozygotic cases -to -fold increased. other causes (< %) for apc resistance: antiphospholipid antibodies, oral contraceptives, pregnancy. factor ii mutation: prothrombin mutation g a, often associated with increased prothrombin levels. prevalence: heterozygotic carriers - % of normal population; among patients with thrombosis - %. relative risk of thromboembolisms: -to -fold increased. factor viii increase: % of thrombosis patients show persistent fviii increase of unknown etiology antithrombin / protein c / protein s defects: rare hereditary disorders; at deficiency especially is associated with a high risk of thrombosis. dd: hepatic diseases. hyperhomocysteinemia: hereditary defect of cystathionine β synthetase; or acquired due to vitamin b , b , or folic acid deficiency. antiphospholipid syndrome: most common acquired form of thrombophilia; occurs as primary or secondary (as a result of systemic lupus erythematosus sle, collagenosis, malignancy, medication, infections) subtype − rapid onset of the anticoagulation effect; minimal laboratory monitoring required (platelet count during first weeks, antifactor xa levels in patients with renal failure, cachectic, or overweight patients) hemorrhagic complications, osteoporosis, and heparin iu bolus > kg; then continuous intravenous treatment: , iu/ h, maximum , iu/ h; dosage according to ptt: target ptt > - s, first ptt test after h, then every h; once stable, it is sufficient to check ptt once daily • alternatively, subcutaneous administration: , - , iu s.c. times daily; studies have shown that with identical ptts, intravenous and subcutaneous administration are equally effective • side effects: hemorrhage (in up to % of patients), hypersensitivity (urticaria, bronchospasm, fever, even shock), alopecia (rare), vasospasm (rare), osteoporosis (with long-term use), heparin-induced thrombocytopenia • arterial occlusion (extremity arteries, acute myocardial infarction discontinuation of heparin treatment • adoption of coumarin: discontinuation of heparin treatment once target inr is reached (usually after days); exception: in cases of extensive thrombosis (calf to pelvis), continue heparin treatment for - days • absence of contraindications and patient compliance provided, lmwh treatment may be possible in an outpatient setting effect vitamin k antagonism → inhibition of the hepatic synthesis of coagulation factors f ii, vii, ix, x of age, hemorrhagic diathesis, sepsis • uncompensated hypertension, liver or renal insufficiency • surgery within last - days, arterial puncture, intramuscular injections • cns surgery within the last months, cerebral bleeding, cerebral sclerosis, csf puncture within the last days • pancreatitis, endocarditis lenta, diabetic retinopathy, nephrolithiasis • pulmonary / gastrointestinal diseases with high risk of bleeding recommendations from the british committee for standards in haematology and national patient safety agency british committee for standards in haematology (bcsh). guideline. investigation and management of heritable thrombophilia prophylaxis for thromboembolism in hospitalized medical patients the effect of low molecular weight heparin on survival in patients with advanced malignancy deep vein thrombosis randomized comparison of low molecular weight heparin and coumarin derivatives on the survival of patients with cancer and venous thromboembolism deep venous thrombosis asco guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer hereditary coagulopathy due to deficiency or inactivity of coagulation factor ix (fix, christmas factor, antihemophilic globulin b, ahg-b). rare hereditary coagulopathy, incidence case/ - , men/year. women are heterozygotic carriers of the gene.• factor ix coding gene is located on the x chromosome → mainly men are affected, x-linked recessive inheritance; hereditary forms ( % of cases) and spontaneous mutations ( %) • hepatic synthesis, kda protein, vitamin k-dependent, half-life h • mild bleeding: vasopressin analog desmopressin (ddavp), nasal spray or intravenously, e.g., every - h . µg/kg body weight i.v. in ml saline . % over min → release of vwf in endothelium, increase of the vwf level by factor - . response within - min in > % of patients; duration of effect - h. since not all patients respond, conduct provocation test prior to treatment; treatment must be interrupted after - days due to depletion of endogenous vwf stores. • with menstruation, single doses of ddavp prior to menstruation are usually sufficient; supportive estrogen therapy with subtype . • severe bleeding: similar strategy to type b, n, and . • administration of high-vwf plasma products (e.g., - u/kg - times daily or - u/kg/ h per infusor) until ristocetin cofactor activity > % for at least h. attention: recombinant fviii products contain no vwf and are ineffective in von willebrand's disease → use special high-vwf plasma or fviii products. • platelet concentrates • if surgery is planned: vwf antigen as well as ristocetin cofactor activity should be %, pre-as well as postoperatively. • attention: with subtype b, ddavp did not demonstrate a clear benefit (risk of thrombocytopenia). with subtype iii, it is ineffective. • monitoring of vwf antigen, fviii function (fviii:c), ristocetin cofactor (ricof) according to disease subtype.th: th:. von willebrand's disease• development of vwf alloantibodies in - % of cases, risk of anaphylactic reactions with repeated exposure. with neutralizing antibodies and bleeding complications factor viia may be given. • if ddavp has proven to be effective, give min prior to surgery • high risk of hemorrhage (e.g., tonsillectomy): raise vwf antigen and ristocetin cofactor activity up to %; administer high-vwf fviii concentrate • intraoperative use of fibrin glue and fibrinolysis inhibitors (e.g., tranexamic acid mouthwash with dental surgery) • during pregnancy, hormone-induced increase in vwf and fviii:c → with subtype and no further treatment required • peripartum: keep vwf antigen and ristocetin cofactor activity above %; with cesarean section, aim for % pre-and postoperatively • vessel wall defects: endothelial alterations due to intravascular catheters / lines, antineoplastic treatment, direct invasion of tumor tissue; cytokine-mediated activation of the endothelium → enhanced expression of tissue factor / adhesion molecules / pai and decreased endothelial thrombomodulin expression → thrombophilic surface • changes in blood flow: immobilization, tumor-related vascular compression, stasis, hyperviscosity • changes in coagulation system: fibrinogen ↑, factor v ↑, fviii ↑, von willebrand factor ↑, fxii ↑, at ↓ • release of procoagulating substances ("cancer coagulants, " e.g.,tissue factor = tf, fx activators) with activation of the extrinsic system via factor vii or direct fx activation; high levels of tf in promyelocytes of acute leukemia type fab m • decrease in coagulation inhibitors (antithrombin, protein c and s) due to chemotherapy (asparaginase) • swelling of the arm, hyperthermia, livid discoloration, tightness • pain in forearm, upper arm and/or shoulder, fever veins, mesenteric veins); thromboembolic event despite effective anticoagulation; thrombosis during pregnancy and tendency to miscarriage and stillbirth − analysis of: fibrinogen, antithrombin, protein c, protein s, prothrombin (fii), fviii, apc resistance, factor ii mutation, antiphospholipid antibodies (lupus anticoagulants, anticardiolipin antibodies), plasminogen deficiency − extended diagnostics: homocysteine, methyltetrahydrofolate reductase (mthfr) mutation g t, fix, and fxii − in most cases, repeated tests are required. with suspected thrombophilia, patients should be referred to specialized hematology centers. • venous thrombi → pulmonary embolism (in > % of cases due to phlebothrombosis, approximately % of patients with phlebothrombosis develop pulmonary embolism) • arterial / cardiac thrombi → cerebral malperfusion, renal infarction, extremities • post-thrombotic syndrome (after - years, in - % of conventionally treated patients) • chronic leg ulcer (in % of patients) • effect: factor xa inhibition, half-life: - min • dosage: enoxaparin mg/kg twice daily s.c., dalteparin iu/kg twice daily, or tinzaparin iu/kg once daily • advantages of treatment with lmwh compared to ufh: according to inr ("international normalized ratio"). in normal weight patients (≈ kg), the following rule of thumb applies: current quick value divided by is the number of coumarin tablets to be given in the first days. on day , give tablets, on days and give (or ) tablets (slow initiation to reduce the risk of coumarin necrosis). the inr should be checked on day . the result determines the dosage of subsequent treatment. heparin treatment may be discontinued once the target inr has been reached (usually after - days). the duration of anticoagulation treatment has to be determined individually for each patient, based on thrombosis type, location, risk factors and comorbidities. guideline: patients with contraindications against coumarin may receive low molecular weight heparin as secondary prophylaxis on a long-term basis. half the therapeutic lmwh dose is usually recommended (comparable to an inr of - ); start after - days of "full dose" therapeutic lmwh treatment. cancer patients in particular benefit from treatment with low molecular weight heparin. due to frequent occurrence of hemorrhagic complications ( - %), increased mortality ( - %) and limited long-term benefit (no reduction in occurrence of post-thrombotic syndrome), fibrinolysis now only plays a secondary role. an indication for treatment with fibronolytics (e.g., streptokinase, urokinase) may exist in young patients with extensive fresh thrombosis. surgical thrombectomy allows immediate perfusion of the blood vessel. however, endothelial injury and incomplete thrombus removal often lead to rapid reformation of thrombi. indications: • phlegmasia cerulea dolens • fresh isolated descending pelvic vein thrombosis (not older than - days) • acute arterial occlusion placement of a filter in the v. cava reduces the risk of severe pulmonary embolism in patients with recurrent thromboses. indications are:• recurrent pulmonary embolism despite effective anticoagulation • contraindication against anticoagulants • immobilization: studies did not confirm a role for immobilization in the prevention of pulmonary embolisms. • in patients with severe pain or edema: elevation and immobilization of the leg for a limited number of days. • compression therapy: compression dressings with bandages or compression stockings; contraindicated with peripheral arterial occlusive disease and phlegmasia cerulea dolens. compression stockings should be worn for at least years as secondary prophylaxis after dvt of the lower extremity. in most cases, calf compression stockings on the affected leg are sufficient.• anticoagulants • platelet aggregation inhibitors, acetylsalicylic acid mg daily p.o. (protective effect in particular with arterial occlusion and coronary heart disease) • elimination of risk factors (see above), early postoperative mobilization, physiotherapy, compression stockings key: cord- -oqwbmyft authors: ammon, andrea; sasse, julia; riedmann, klaus title: early disease management strategies in case of a smallpox outbreak date: journal: poxviruses doi: . / - - - - _ sha: doc_id: cord_uid: oqwbmyft as a consequence of the threat of smallpox being potentially used as a means of bioterrorism, many countries have developed preparedness plans for smallpox in the past few years. this chapter summarizes some of the most important issues for the management of smallpox. usually, the strategy for the management of clinical cases of poxviruses includes the early detection of cases, rapid laboratory diagnosis, an assessment of the risk of further spread and containment measures. for the early detection, different systems are being tested to identify suspected cases before a diagnosis is confirmed (e.g., syndromic surveillance). also it is necessary to provide special training on the disease pattern, including differential diagnosis, to clinicians and practitioners. if a suspected case has been identified, rapid diagnostic tests are required. in addition to the national and international notifications based on given case definitions, certain measures are necessary to allow an initial risk assessment of the epidemic development. for a rapid risk assessment, the investigations should follow the algorithms of epidemiological outbreak investigation such as the tracing and identification of exposed contacts and the sources of infection. further decisions have to be taken on the basis of a continuous risk assessment. countermeasures can be divided into medical and non-medical ones. the choice of an adequate vaccination strategy as a medical countermeasure for the case of a re-emergence of smallpox very much depends on the epidemic scenario, and the general availability and quality of a vaccine. logistic aspects of the vaccination strategies have to be considered in preparedness planning (e.g., resources necessary for the implementation of mass vaccinations), and also the prioritization of groups to be vaccinated. in addition non-medical measures to prevent the spread of infection, such as the isolation of cases and quarantining of exposed persons (e.g., contact persons of confirmed cases) have to be foreseen. the effectiveness of other measures like prohibition of mass gatherings or closure of institutions is often assessed in the light of historical events. however, they have to be considered within today’s ethical and societal context, taking into account, in particular, the increased number of people who are immunocompromised. since our knowledge of how the virus would behave today is limited to extrapolations from historical data and is therefore imperfect, these measures are still under discussion. all relevant groups should be involved in exercises to assure the effective operation of the plan mainly regarding communication and cooperation. after the eradication of smallpox, it was possible to cease the most successful strategy against smallpox, namely vaccination. apart from rare events like the outbreaks of monkeypox in the democratic republic of congo or in the usa [ , ] , there has been no need to think about the management of this disease anymore. however, the threat of smallpox being used as a means of bioterrorism has forced reconsideration of the need for smallpox vaccinations and other measures to manage potential cases or outbreaks of smallpox. in the past few years, many countries have developed preparedness plans for smallpox. in the following chapter we have tried to summarize some of the most important issues for the management of smallpox. a full description of all the necessary parts of the preparedness plans would go beyond the space available here. the strategy for the management of clinical cases of poxviruses (occurring sporadically or in outbreaks) usually includes the early detection of cases, rapid laboratory diagnosis, an assessment of the risk of further spread and containment measures. early detection of a first smallpox case will be crucial for a successful management of any new outbreak. the earlier anti-epidemic countermeasures are initiated, the more likely the epidemic can be controlled or prevented in time and casualties can be limited. conventional surveillance systems like epidemiological surveillance of a well-defined set of clinically suspected diseases or laboratory confirmed agents are important to monitor and control the occurrence of infectious diseases. yet, these systems usually detect outbreaks or unusual epidemic developments only with a certain time delay. therefore, planning considerations include concepts that identify an attack as early as possible [ ] . among such systems are for example strategies to monitor the number of emergency department visits, over-the-counter medication sales or school absenteeism. also, environmental monitoring systems like air samplers, which permanently test the air for threat agents to detect a biological agent before it causes symptoms, have been suggested. since they only cover selected areas and have to be analyzed against a background noise, they do not necessarily guarantee a timely recognition of a biological threat [ ] . after th september , various models of syndromic surveillance have been established and tested in the united states for different syndromes (e.g., [ ] ), but they also still need to prove their value in detecting a bioterrorist attack in a timely manner. most likely a deliberate release of smallpox would not be detected unless one or more human cases with clinical symptoms of the disease occurred. the early clinical detection of a smallpox case requires familiarity with the disease pattern. the number of the actually practicing physicians who have clinical experience with smallpox patients is decreasing, and it is therefore necessary to provide special training on the disease pattern, including differential diagnosis to clinicians and practitioners. the emergence of highly contagious diseases with high mortality and morbidity rates pose an immediate threat to public health and ask for a real time detection of the onset. as a separate chapter in this book describes poxvirus diagnostics, we will not go into specific diagnostic techniques. a very important issue is the necessity to confirm any suspicion of smallpox as fast as possible to avoid false alarms with far-reaching consequences. to ensure the safety of staff involved in taking samples and performing the diagnostics, good cooperation and agreed procedures between health authorities, clinicians and laboratory staff are required. electron microscopy and nucleic acid detection are the fastest methods and can give results within h. for culturing the virus, biosafety level facilities are required. an initial suspected smallpox case triggers various notifications according to the requirements of national and international health legislation and regulations. furthermore, if a deliberate release of the virus seems possible, an actual threat to the affected state has to be presumed. in this case, disaster management and law enforcement agencies will assist the responsible health authorities to guarantee a comprehensive management in case of a confirmation and the likely spread of the disease. epidemiological and criminal investigation should be coordinated. in addition to the national and international notifications based on given case definitions, certain measures are necessary to allow an initial risk assessment of the epidemic development. these measures should follow the algorithms of epidemiological outbreak investigation, such as the tracing and identification of exposed contacts and the sources of infection. further decisions have to be taken on the basis of a continuous risk assessment. immediate anti-epidemic measures are of considerable importance. a permanent monitoring of the epidemic is necessary to guarantee that the effectiveness of the measures taken can be accurately evaluated, which in turn can lead to new measures or to a modification of the actual strategy. the following target groups for intervention measures can be distinguished: smallpox patients must be transferred immediately to a hospital with an isolation unit for further treatment. if no adequate infrastructure is available, isolation standards should be followed as well as possible (for requirements for isolation and isolation facilities see tab. ). most important is the vaccination of the contact persons as soon as possible within the first days after exposure and their isolation and observation either at home or in hospital. contraindications, e.g., history of severe eczema or immunodeficiency have to be weighed against the risk of disease. the treatment of complications resulting from vaccination must be also taken into account. even after a deliberate release, it is rather unlikely that a major epidemic or pandemic will occur if the appropriate countermeasures are taken in time. in the event of a smallpox outbreak the population can be protected by the prompt implementation of a vaccination campaign adapted to the epidemic realities. due to the historical experience, a second eradication of the smallpox disease is possible on the basis of the known eradication measures. the bigger challenge will be the identification and elimination of the sources of the intentional release. furthermore, the spread of a smallpox epidemic can be counteracted by limiting access to public facilities and events and by restricting freedom of movement. in addition, recommending appropriate protective measures and risk avoidance behavior to the population will be helpful. it is most important that all the measures taken are communicated to the public according to best practice of a consistent risk communication. the general public has to be given consistent information adapted to target groups and the situation via the available media. information of general relevance can be broadcast nationwide by television, for example, whereas information of regional or local relevance can be transmitted via other media (radio, local newspapers, cars with loudspeakers, leaflets, etc.). the information to be disseminated will include recommendations for protective measures as well as the announcement of restrictions on entry to events and facilities. the protection of the non-infected population will necessitate quarantine measures for suspect cases. as viruses do not recognize national borders, international cooperation is also of decisive importance. this may include technical and personnel support as well as the exchange and coordination of information but also coordinated action. in the revised international health regulations adopted by the world health assembly in , smallpox is one of the four diseases (the other three are poliomyelitis due to wild-type poliovirus; human influenza caused by a new subtype; severe acute respiratory syndrome, sars) for which just a single case case is considered unusual or unexpected with potentially serious public health impact, and thus must be notified (http://www.who.int/csr/ ihr/wha _ -en.pdf, accessed th may ). who member states have years to implement the necessary systems for surveillance and response including national focal points, which have to be accessible at all times for communication with the who focal points. the choice of an adequate vaccination strategy for the case of a re-emergence of smallpox in a country very much depends on the epidemic scenario one has in mind and the general availability and quality of a vaccine. at the same time, logistic aspects of the vaccination strategies have to be considered in preparedness planning, i.e., the facility and personnel resources necessary for the implementation of mass vaccinations have to be determined and identified. with the exception of the very unlikely situations of an accidental release or a natural re-emergence [caused, for example, by mutants of orthopoxviruses (camel-or monkeypox)], the only realistic scenario for a re-emergence of smallpox is a deliberate release of the agent, which does not necessarily have to follow historic patterns of epidemic spread. simultaneous and multilocal outbreaks are possible and have to be included as possible scenarios for a comprehensive preparedness planning. predictive modeling of the epidemic spread has to rely entirely on historic data and is of limited value. the availability and quality of a vaccine has the most significant influence on the strategy, as there is no evidence of an effective therapy with antiviral drugs against a smallpox infection in humans. the chosen strategy will be determined by the particular epidemiological situation and consideration of the threat of further releases and the risk of secondary infections compared with the well-known adverse effects of the currently available vaccines. unlike during a natural outbreak, the threat of additional intentional releases has to be considered for a vaccination policy. various models have been developed to assist in identifying the best use of the available vaccines (e.g., [ ] [ ] [ ] [ ] ), as well as other control measures like case isolation and contact tracing or combinations thereof [ , ] . since all these models have different assumptions for important parameters (like r ), the conclusions also vary. following historical data from the last natural, in this case imported, smallpox cases in europe in the decades before and during the eradication, the first step will be -after the immediate isolation measures have been initiated -the vaccination of contacts and simultaneous ring vaccinations. there are efforts to predict the best anti-epidemic measures on the base of mathematic modeling [ , , [ ] [ ] [ ] [ ] [ ] . such models are fitted in such a way that they can reproduce historical outbreaks very well and try to predict the effects of different anti-epidemic measures on the basis of historical data. the quality and predictive value are limited and depend very much on the inclusion of a sufficient number of necessary and correct parameters. a slight change in a parameter can lead to exaggerated effects that do not follow the common sense experience. a lot of the decisive factors can only be roughly estimated, like transmission rate, population immunity or the effectiveness of a post-exposure vaccination. furthermore, as the re-emergence of smallpox is most likely to result from a deliberate release and multiple geographically unlinked outbreaks may be possible, this historically based vaccination strategy might seem idealistic. public and political pressure and security considerations may quickly lead to the ultimate step, the mandatory vaccination of the entire population. nevertheless, this should be done after a careful risk-benefit-calculation considering the serious adverse effects of the available vaccines. vaccination priorities: first responders, other priority groups no matter which strategy is chosen the availability of vaccine is a key issue. most industrialized countries have acquired a certain stockpile of first or second generation vaccine. the sizes of the stockpiles vary from country to country. some countries have sufficient stockpiles to cover the whole population, some do not. therefore, priority population groups have to be identified for vaccination -in accordance with epidemiological, political, ethical and societal necessities and based on a public consensus. as long as there are no smallpox cases worldwide, obligatory prophylactic vaccinations especially of entire populations are not necessary. the re-emergence of smallpox has a limited likelihood, whereas the certainty of serious adverse effects due to vaccination is a proven fact. nevertheless, it can be necessary if there is an increased likelihood of occupational expo-sure. prophylactic vaccination may seem useful for the staff of special isolation units, which are most likely to treat the first smallpox cases or of those laboratories designated for confirmatory diagnostics. in this phase also members of infectious disease task forces (interdisciplinary teams on any administrative level for the initial risk assessment and subsequent investigations) may be offered vaccination on a voluntary basis. as soon as a first smallpox case is confirmed worldwide, and a real threat and exposure seem more likely, the offer of voluntary vaccination to all professional groups who are required to keep the necessary public services running during a smallpox epidemic has to be considered. these groups include mainly medical staff, fire brigades and disaster relief organizations, red cross etc., but also people working in critical infrastructures (power and water supply, public transportation and communication) or for public security and order or on the administration or political level, i.e. those population groups who are relevant for the maintenance of public life. once a smallpox case is confirmed, vaccination strategies should focus on the necessities of an anti-epidemic management. first of all the population being affected or at risk must be vaccinated. if the epidemic spread cannot be controlled, mandatory mass vaccinations will be necessary. smallpox can be spread by droplets and by direct or indirect contact with the pustules on the skin. this assumes that all primary contact persons of a confirmed smallpox case (see tab. ) may be infected and must be identified as soon as possible. the risk of infection for persons with an extended contact time or a close contact distance is much higher than for persons with a short contact time. according to historical data, the highest risk of infection exists for household members or hospital contacts. the european outbreaks between and showed that % of the infected persons contracted smallpox at a hospital, % in the family, % at their working place or school and % of the infected persons were working in a laundry, while % were unidentified contacts. none of the smallpox cases in europe since the second world war contracted it on an airplane, a train or a bus [ ] . yet, under special conditions, an airborne transmission may be possible. in a hospital in meschede, germany, patients and nurses from the two floors above the floor where a smallpox patient was treated were infected by air circulation [ , ] . based on publications on smallpox transmissions, table describes the risks of infection. it might be impossible to control an outbreak of smallpox using only vaccination, therefore isolation of cases and monitoring of the contacts may be necessary in addition [ , ] . quarantine in an isolation ward for all persons who were exposed seems to be the safest way, but it has some limitations, like the quantity of qualified isolation wards, the supply of the population with food, drinking water etc. and the cooperation of the population. therefore, it will be helpful to adjust the anti-epidemic measures to the likelihood of developing the disease (tab. ) [ ] . the isolation concept should be adapted to the epidemic situation, the requirements on effective isolation and the expected number of contact persons. the personnel in all hospitals/facilities must be vaccinated and trained, personal protective equipment (including gloves, masks, goggles, gowns) and means to follow the hygiene measures must be available. if pri- high risk -persons who are living in the same household with the patient and persons with a similar risk of infection (members of the family and household contacts, etc.) -persons who have had "face-to-face-contact" with a sick person, which includes all persons, who have been so close to the patient that they could be infected by droplets, or who have touched the efflorescence of the skin [e.g., friends or neighbors who have taken care of the patient, physicians who have been consulted before the hospital, hospital staff (medical doctors, nurses, cleaning staff), persons in a public traffic system with direct contact, i.e., less than ca. m to the infectious case of smallpox, etc.] -persons who have been longer in the same (confined) room with a patient (e.g., work colleagues, transport staff of the ambulance, etc.) -persons who have direct contact with the dead body of a smallpox patient (e.g., undertaker, pathologist, priest, etc.) -persons who have worked with infectious samples of a smallpox patient without appropriate protection -persons who have touched scabs of a smallpox patients without appropriate protection -persons who have had direct, non-protected contact with the personal clothes, bed linen or other personal belongings, materials that a smallpox patient wore or used after the onset of fever medium risk -persons who are in the same building as a smallpox case, if this building has a ventilation system, air conditioning or comparable installation systems that circulate the air between different rooms in the building -persons who have traveled in the same compartment of a public transportation system or airplane with a ventilation system, air conditioning or comparable installation systems to circulate the air low risk -persons with a short and/or not close contact to an infectious smallpox case (e.g., a short stay in the same room, or a longer stay in the same building without ventilation system, air conditioning or comparable installation systems to circulate the air; sharing the same public transportation system without ventilation system, air conditioning or comparable installation to circulate the air; distance to the index case > m) -medical staff, if they have used appropriate personal protection equipment mary contacts develop fever and other typical symptoms of smallpox, their transfer to a hospital with isolation ward is immediately necessary. for contact persons with a low risk of infection and a timely, successful vaccination, segregation at home seems to be appropriate as long as they have not developed fever, all household contacts have been vaccinated and the local health authority has the capacity to observe them daily. nevertheless, it must be kept in mind that a vaccination, even when administered in time, does not yield % protection. according to historical data, the risk of infection for vaccinated household contacts of a smallpox patient in the past was . % [ ] , in comparison to % of unvaccinated household contacts. these data did not give any information about when the contact persons had had their last vaccination. vaccination should also be offered to secondary contact persons. they must be registered because they will become primary contacts themselves if the originally primary contact develops the disease. since transmission of smallpox is favored by close distance between persons, so-called "social distancing" measures are considered as further intervention measures to stop the spread. whereas the isolation of cases or segregation of exposed persons (contacts) is not under debate, the effectiveness of other measures like prohibition of mass gatherings, closure of institutions or even curfews are often assessed in the light of historical events. however, they should be considered within today's ethical and societal context, taking into account differences in the society, in travel behavior, and the increased recognition of contraindications to vaccination [ ] . also, the number of people who are immunocompromised (due to hiv, chemotherapy, transplantations etc.) has increased [ ] . these measures are still under discussion, since we have limited knowledge of how the virus would behave today. according to the vaccination strategy described above, the majority of vaccinations would be carried out in the case of the real event. therefore, elaborate preparations have to be implemented in the pre-event phase. smallpox vaccine and bifurcated needles have to be procured and stockpiled. some governments have a national stockpile of smallpox vaccines, but not all of them have a stockpile covering the need of their entire population. therefore, multi-lateral support in the case of an event has to be assured in time. within the european union, a task force on bioterrorism was set up in may with the main objective of implementing the health security program [ ] . the world health organization (who) has to convince some states to contribute to an international stockpile at who level. for national stockpiles, the logistics for storage, transport and distribution have to be determined in advance as well. to allow immediate mass vaccinations, the required infrastructure, such as facilities or personnel, has to be identified and the latter informed and trained in time. the entire process should be tested and practiced in simulation exercises. when choosing vaccination facilities important aspects have to be considered to enable the vaccination of a large number of people in a very short time, such as: -number and size of vaccination facilities according to population density -transport connections -easy access, also for handicapped people -water and energy supply -toilets -possibility of separate treatment of suspected cases -availability of rooms for personnel, first aid, treatment -phone -furniture material for documentation of the vaccinations and checking of contraindications (questionnaires, vaccination list/card) as well as information for the public has to be produced in advance and distributed to the authorities. they take care of the implementation of preparedness measures on the regional and local level. other tasks have to be achieved or initiated in the pre-event phase as well: vaccination of the vaccinators, training of the necessary staff and provision of the material needed at the vaccination facilities. a survey of over million vaccinations in the usa in showed that per million vaccinations there were serious adverse effects, including death [ ] . some of the known adverse effects that may arise from smallpox vaccination are post-vaccination encephalitis, progressive vaccinia, eczema vaccinatum or generalized vaccinia. therefore, the production of modern and more compliant vaccines is under consideration. a way to minimize the adverse events of smallpox vaccination might be the use of modified vaccinia virus ankara (mva), which was developed in the s by more than passages in chicken embryo fibroblasts [ ] . however, smallpox had been eradicated before the efficiency of the protective effect of mva could be tested. experiments with animals indi-cate that there may be fewer complications after vaccination with mva [ ] [ ] [ ] , and show also that mva provokes a high antibody titer and a high concentration of ifn--positive cells. some data show that mva-vaccinated animals are protected against smallpox infection [ , ] , but other results allow the interpretation that a mva-vaccination alone can not guarantee a full protection against infection [ ] . mva might be a good candidate for a pre-immunization [ ] or for persons with strong contraindications [ , ] . other replication-deficient vacv strains have also been developed for immunization [ , [ ] [ ] [ ] . some mva strains currently under development require a higher virus titer as they do not replicate in the human body. vacv strains have the potential to inducing post vaccination encephalitis. derived from historical data with - cases per million, the vaccination of the entire population of a country like germany would lead to - cases of severest adverse effects. finally, a lot of research is being performed to develop new vaccines. experiments on a dna basis are very promising, even if these vaccines do not fully protect from infection yet [ , ] . all the vaccines under development are still in the pre-clinical state. usually, vaccination strategies are chosen on the basis of scientific evidence and national health legislation. for the special case of smallpox, the only vaccine which has proven its efficiency decades ago is known to produce serious side effects. therefore, legal regulations for the financial compensation of vaccination damages have to be agreed upon and guaranteed before the implementation of vaccinations, no matter if they are being recommended for occupational safety reasons in the pre-event phase or as antiepidemic measure in the case of an event. more than years after the eradication of smallpox only very few health professionals have practical experience with the management of this disease. therefore, all relevant professions involved in the management of a smallpox outbreak or epidemic have to be trained on the disease pattern and its specific consequences on their professional tasks. training must include the professional implementation of sampling techniques as well as safe transport, which have to be arranged in advance to avoid any unnecessary delay or hazard from improper handling or packaging. the laboratories selected for smallpox diagnostics have to guarantee that this can be done both rapidly and with assured quality. these labora-tories have to immediately report a suspected or confirmed laboratory diagnosis to the appropriate authorities. public health officers, clinicians and practitioners for example have to update their knowledge on the clinical picture to guarantee an early recognition of the disease and also get familiar with the treatment and therapy of smallpox cases. laboratory personnel have to be trained in the diagnostics of smallpox on the basis of the standard operating procedures. the validity of the diagnosis is improved by regular participation in a quality assurance system. in general, if preparedness plans exist, they have to be evaluated among all the relevant groups by exercises to assure the effective operation of the plan mainly in the field of communication and cooperation. public health services might test the implementation of mass vaccinations or the reporting systems for a smallpox alert; clinicians might check the clinics' preparedness plans for cases of highly contagious diseases, ambulance services might train for the transport of highly contagious patients and all together they might check the interaction between the relevant actors aiming at a harmonization of the preparedness planning. outbreak of human monkeypox update: multistate outbreak of monkeypox -illinois advances in detecting and responding to threats from bioterrorism and emerging infectious diseases syndromic surveillance in public health practice ring vaccination and smallpox control modelling responses to a smallpox epidemic taking into account uncertainty a model for a smallpox-vaccination policy effectiveness of a postexposure vaccination for the prevention of smallpox: results of a delphi analysis a first smallpox case or first smallpox cases would need "official" confirmation in one of the two laboratories designated by who (cdc and vector) case isolation and contact tracing can prevent the spread of smallpox surveillance and control measures during smallpox outbreaks towards a containment strategy for smallpox bioterror: an individual-based computational approach containing bioterrorist smallpox transmission potential of smallpox in contemporary populations modeling a safer smallpox vaccination regimen, for human immunodeficiency virus type -infected patients. in: immunocompromised macaques modeling potential responses to smallpox as a bioterrorist weapon smallpox in europe, - a different view of smallpox and vaccination an airborne outbreak of smallpox in a german hospital and its significance with respect to other recent outbreaks in europe the recent outbreak of smallpox in meschede, west germany begriffsbestimmungen seuchenhygienisch relevanter maßnahmen und bezeichnungen smallpox and its eradication the european commission's task force on bioterrorism complications of smallpox vaccination, /national surveillance in the united states der pockenimpfstamm mva: marker, genetische struktur, erfahrungen mit der parenteralen schutzimpfung und verhalten im abwehrgeschwächten organismus [the smallpox vaccinnation strain mva: marker, genetic structure, experience gained with the parenteral vaccination and immunogenicity of a highly attenuated mva smallpox vaccine and protection against monkeypox highly attenuated smallpox vaccine protects mice with and without immune deficiencies against pathogenic vaccinia virus challenge modified vaccinia virus ankara protects macaques against respiratory challenge with monkeypox virus shared modes of protection against poxvirus infection by attenuated and conventional smallpox vaccine viruses modified vaccinia ankara; potential as an alternative smallpox vaccine immunogenicity and safety of defective vaccinia virus lister: comparison with modified vaccinia virus ankara induction of potent humoral and cell-mediated immune responses by attenuated vaccinia virus vectors with deleted serpin genes genetically stable and fully effective smallpox vaccine strain constructed from highly attenuated vaccinia lc m smallpox vaccines: looking beyond the next generation smallpox dna vaccine protects nonhuman primates against lethal monkeypox key: cord- - p efxo authors: daniels, norman title: resource allocation and priority setting date: - - journal: public health ethics: cases spanning the globe doi: . / - - - - _ sha: doc_id: cord_uid: p efxo there has been much discussion of resource allocation in medical systems, in the united states and elsewhere. in large part, the discussion is driven by rising costs and the resulting budget pressures felt by publicly funded systems and by both public and private components of mixed health systems. in some publicly funded systems, resource allocation is a pressing issue because resources expended on one disease or person cannot be spent on another disease or person. some of the same concern arises in mixed medical systems with multiple funding sources. risks matters, not just the aggregate impact. resource allocation in public health thus focuses on deciding what risks to reduce-which depends in part on their seriousness as population factors and who faces them-and how to reduce risks. the cases in this chapter that discuss resource allocation force us to contemplate decisions about priorities in public health as opposed to the more frequently discussed medical issues about health care priorities. later we suggest that making decisions about these issues should be part of a deliberative process that emphasizes transparency, stakeholder participation , and clear, relevant reasoning. collectively, these resource allocation cases bring out several important points. separately, they raise other central issues. it is worth noting these general issues before commenting on the more specifi c problems raised by each case. the fi rst point the cases collectively make is that effi ciency has ethical and not just economic importance (daniels et al. ) . if one health system is more effi cient than another, it can meet more health needs per dollar spent than the less effi cient one. if we want systems to meet more health needs, and we should, then we prefer more effi cient health systems. specifi cally, if we think we have obligations to meet more health needs, or if we think meeting more "does more good," and we ought to do as much good as we can with the resources we have, then we have an ethical basis for seeking more effi cient health systems. the economic pursuit of effi ciency should not, then, be dismissed as something that has no ethical rationale. a second point the cases collectively make is that effi ciency is not the only goal of health policy , for we have concerns about how health benefi ts are distributed as well as how they add up. health policy is not only concerned with improving population health as a whole, but also with aiming to distribute that health fairly (daniels ) . that means many resource allocation decisions involve competing health policy goals. the point about competing goals is illustrated by a problem often encountered in policy decisions: should we always favor getting the best outcome from the use of a resource, or should we give people "fair" chances to get a benefi t if it is at least signifi cant (brock ) ? for example, during an i nfl uenza pandemic, should we allocate ventilators to those with the best chance of survival, or should we give signifi cant but lesser chances to a broader group? reasonable people often disagree about when the difference in expected benefi ts means we should favor best outcomes over fair chances, or even about what counts as a fair chance. hence, a third point emerges from the cases taken collectively: reasonable people often disagree about the choice, and it is not possible to simply dismiss one side as irrational or insensitive to evidence and argument (daniels and sabin ) . indeed, reasonable people will disagree about how much priority to give to the sickest (or worst off) patients. they may think we have to weigh the seriousness of an illness against the potential benefi t that we know how to deliver, they may disagree about how to trade off those considerations, or they may disagree about when modest benefi ts to larger numbers of people outweigh greater benefi ts delivered to fewer people. together these "unsolved rationing" problems-the best outcome versus fair chances problem (when to prefer best outcomes to fair chances), the priorities problem (how much priority to give to those who are worst off), and the aggregation problem (when do modest benefi ts to more people outweigh significant benefi ts to fewer people)-mean that there is pervasive ethical disagreement underlying many resou rce allocation problems (daniels ) . there are other common sources of disagreement. one of the most common sources of controversy in resource allocation decisions arises when a particular intervention is seen as the last chance to extend life by some-a necessity if we are to act compassionately-and when it is seen primarily as an unproven intervention by others that we have no obligation to provide it. denials of such interventions in last-chance cases have been considered the "third rail" of resource allocation decisions (daniels and sabin ) . here we have two competing public value s-compassion and stewardship-and most public offi cials would prefer to be seen by the public as committed to saving lives rather than as ha rd-nosed stewards of collective resources. the cases taken collectively bring out one fi nal point: our main analytic tools for aiding resource allocation decision making are limited in several ways, particularly by insensitivity to various ethical issues, especially issues of distribution. in short, these tools may take the fi rst point, about the importance of effi ciency , seriously, yet fail to help us with the second and third lessons the cases collectively bring out, that we are also interested in distributing effi ciently produced health fairly, and that reasonable people disagree about how to do that. to see this, consider two widely used tools: comparative effectiveness research (cer) , which has been given prominence as a r esearch focus in the patient protection and affordable care act of , and cost-effectiveness analysis (cea) . both help to answer policy-making questions. for example, a typical use of cer compares the effectiveness of two interventions (drugs, procedures, or even two methods of delivery), and policy makers may want to know if a new technology is more effective than older technologies. of course, they may also want to know if the new technology provides additional effectiveness at a reasonable cost , which points to a shortcoming of much cer in the united state s, where considerations of cost are generally avoided. similarly, if there is only one effective treatment for a condition, cer tells us nothing useful. it also tells us nothing about whether a more effective intervention is worth its extra cost. and, cer cannot help us compare intervention outcomes across different disease conditions, since it uses no measure of health that permits a comparison of effectiveness. indeed, decision makers face many resource allocation questions that cannot be answered by cer, even if cer can help avoid wasteful investments in interventions that do not work or that offer no improvement ov er others. in germany, however, cer is combined with an economic analysis that takes cost into account and that allows the calculation of " effi ciency frontiers " for different classes of drugs (caro et al. ) . presumably, this method could be extended to different classes of public health interventions if they are grouped appropriately. to calculate an effi ciency frontier, the effect of each drug in a class in producing some health outcome is plotted against its cost , and the curve is the effi ciency frontier for that class of drugs. it is then possible to calculate if a new intervention in that drug class improves effectiveness at a price more or less effi cient than what is projected from the existing efficiency frontier. this use of cer allows german decision makers to negotiate the price of treatments with manufacturers, rejecting payments that yield ineffi cient improvements. german policy makers can then cover every effective intervention sold at a price that makes it reasonably effi cient. still, because german use of cer cannot make comparisons across diseases, it allows vast differences in effi ciency across conditions. cea aims for greater scope than cer. it deploys a common unit for measuring health outcomes , either a disability-adjusted life year (daly) or a quality-adjusted life year (qaly) . this unit purports to combine duration with quality, permitting us to compare health states across a range of disease conditions. with this measure of health effects, we can construct a ratio (the incremental cost-effectiveness ratio, or ic er) of the change in costs that results from the new intervention with the change in health effects (as measured by qalys or dalys). we can then calculate the cost per qaly (or dal y) and arrive at an effi ciency measure for a range of interventions that apply to different condi tions. critics have noted p roblematic ethical assumptions in the construction of the health-adjusted life-year measures and in the use of cea (nord ; brock ) . to see some of these problems, consider the following table: rationing problem cea fairness priorities no priority to worst off some priority to worst off aggregation any agg regation is ok some aggregations ok best outcomes/fair ch ances best outcome s fair chances cea systematically departs from judgments many people will make about what is fair. the priorities problem asks how much priority we should give to people who are worse off. by constructing a unit of health effectiveness , such as the qaly, cea assumes this unit has the same value , regardless of who gets it or wherever it goes in a life ("a qaly is a qaly" is the slogan). but intuitively, many people think that a unit of health is worth more if someone who is relatively worse off (sicker) gets it rather than someone who is better off (less sick) (brock ) . at the same time, people generally do not think we should give complete priority to those who are worse off. we may be able to do little for them, so giving them priority means we would have to forego doing more good for others. few would defend creating a bottomless pit out of those unfortunate enough to be the worst off. similarly, cea assumes that we should aggregate even small benefi ts. then, if enough people get small benefi ts, it outweighs giving large benefi ts to a few. but intuitively, most people think some benefi ts are trivial goods that should not be aggregated to outweigh larger benefi ts to a few (kamm ) . curing many people's colds, for example, does not outwei gh saving a single life. finally, cea favors putting resources where we get a best outcome, whereas people intuitively favor giving people a fair (if not equal) chance at a benefi t. locating an hiv/aids treatment clinic in an urban area may save more lives than placing a clinic in a rural area, but in doing so, we may deny many people a fair chance at a signifi cant benefi t (daniels ) . in all three of these examples of rationing problems, cea favors a maximizing strategy, whereas people making judgments about fairness are generally willing to sacrifi ce some aggregate population health to treat people fairly. in each example, whether it is giving some priority to those who are worse off, viewing some benefi ts as not worth aggregating, or giving people fair chances at some benefi t, fairness deviates from the health maximization that cea favors. yet we lack agreement on principle s that tell us how to trade off goals of maximization and fairness in these cases. people disagree about what trades they are willing to make, and this ethical disagreement is pervasive. determining priorities primarily by seeing whether an intervention achieves some cost/qaly standard is adopting a health maximization approach. this approach departs from widely held judgments about fairness, even where people differ in these judgments. thus, the national institute of clinical and health excellence (nice) in the united kingdom has had to modify its more rigid practice of approving new interventions only if they met a cost/ qaly standard in the face of recommendations from its citizens council. this council, intended to refl ect representative social and ethical judgments among british citizens, has proposed relaxing nice's threshold in various cases where judgments about fairness differed from concerns about health maximization. the judgments of the citizens council in this regard agree with what the social science literature suggests are widely held views in a range of cultures and contexts (dolan et al. ; menzel et al. ; nord ; ubel et al. ubel et al. , . there are, of course, those who criticize departures from the nice threshold of the sort that the citizens council recommended. compromising the maximization of health that cea promotes may be seen as a moral error, perhaps the result of elevating the rescue of an "identifi ed" victim (say, a cancer patient whose life might be extended modestly by a new drug) ove r benefi ts to "statistical" lives (using the resources to provide greater benefi ts to others). the reasonable disagreement about how to proceed suggests that we should view cea as an input into a discussion about reso urce allocation, not as an algorithm for making decisions. this "aid to decision making" role was proposed by the public health service in its recommendations about the use of cea (gold et al. ) . in short, controversial ethical positions are embedded in cea, and using cea uncritically commits one to these views, even though many disagree with them. we have already noted that the effi ciency of a health system has ethical consequences. but what should we count as effi ciency ? should we use our resources to generate more revenues for a unit of the health system-say, a hospital? doing so would defi ne effi ciency the way most businesses do: other things being equal, an allocation that produces a greater return on investment is a more effi cient use of stockholder or owner resources. alternatively, we might narrow the range of effects to health effects on the covered population . then we have greater effi ciency when an allocation produces more positive health effects in that population than an alternative allocation. the case guzmán brings from colombia raises this issue forcefully. should hospitals, or a specifi c health plan, allocate resources favoring services (certain treatment s) that raise more revenues than an alternative allocation (certain preventive measures)? perhaps the gains from the treatments will involve fewer population health gains over time than those obtained by the preventive or health promotional measures, even if they show their improvement more quickly and so look better sooner. which plan should the policy maker adopt? this issue examines our purpose in designing a health system. is it to meet the health needs of a population or is it to provide a good return on investment for those who invest in health services? we might think that this question is easier to answer in a system where health care delivery is seen largely as a public undertaking aimed at improving population health. in such a system, it might seem that there is only one purpose behind the health care system. return on investment for the taxpayer funding such a system should be measured by how effi ciently the system improves population health. in systems where resources are owned privately (and there are many of these), however, it seems we must consider at least two goals. even if the private sector must in part seek to improve population health , which may be a requirement of state-imposed health care regulation or, in some people's opinions, a social responsibility of corporations, private health-care organizations still must deliver a reasonable return on investment for owners. thus, policy makers within private health-care organizations have a dual task. balancing return on investment with improvement in populatio n health thus becomes the central issue in the colombian case study. the chilean case written by gómez and luco raises a similar issue, but this case focuses on measurable differences in the cost effectiveness of certain services and in the severity of two conditions. if we consider only cost effectiveness, we view effi ciency in one way-the best health outcomes in the aggregate for the population for an investment in health. if we take severity of condition into account, we might view this as an equity demand-in which case, we have an effi ciency-equity confl ict and must make a trade-off. or, we might think of effi ciency as a ranking of needs by severity of condition. in the latter, the resource allocation case turns on how we defi ne effi ciency. specifi cally, the chilean category of guaranteed health interventions could include cataract surgery (the leading cause of blindness in the chilean population), but not multiple sclerosis (ms) treatment s, which might be viewed as maximizing effi ciency in a standard sense. or, the guaranteed health interventions scheme could include the less cost-effective treatment of ms but not cataract surgery, since ms is viewed as a more severe condition (because it can be life threatening and lead to premature death), even if it is far less prevalent than cataracts. if this were the case, the more effi cient system, in this nonstandard view, would rank treating more severe conditions as more effi cient than treating less severe conditions. if budget limitations mean only one should be included in the guaranteed health interventions program, either m s or cataract surgery, which should it be? the cataract surgery intervention delivers a signifi cant benefi t in terms of qalys to a larger part of the population than does the intervention package for ms, but the greater severity of premature death seems to be an important reason for favoring ms. if this reason is given priority over cost effectiveness and over the standard view of effi ciency , then are less effective treatments for more severe conditions supposed to have priority over more effective and cost-effective treatments for less severe conditions? if so, what kind of a health system does that produce if all needs can not be met given resource limits? alternatively, do we want a system that always we ighs cost effectiveness more highly than the severity of a condition that some people have? that too seems problem atic. suppose we think improving population health is a worthwhile and defensible goal of a health system, we favor improving population health over increasing revenues for the private sector (in the guzmán case), and we also favor giving priority to cost effectiveness over severity of a condition (in the gómez and luco case). a confl ict still remains between health maximization in the aggregate and concerns about equity , as illustrated in the blacksher and goold case (and arguably in the case about triage in pand emics by smith and viens). in the case that blacksher and goold describe, the task is to decide whether to reallocate resources from a program focused on maternal-child health and reduction of b lack-white in fant mortality dis parities to a program that may get more health per dollar spent through other interventions. infant mortality among blacks and whites has declined rapidly in the united state s; and in absolute terms, the decline has been more rapid for blacks. still, the ratio of black infant mortality to white infant mortality has increased. because the public health department is in a highly segregated city, this shift in program focus might seem to require viewing the remaining bl ackwhite health d isparities as morally a cceptable (especially given the high rate of improvement that past programs gave to black infant mortality rates). when should we view health disparities as morally acceptable? when should we weigh reducing health disparities as more important than some aggregate gains in health that we know how to produce in a population ? if public health has two goals-improving population health and distributing that health fairly-how should we weigh the goals when they confl ict? one important feature of the blacksher and goold case, namely the opinions within the community whose inequalities are at issue, is really a feature to which nearly all cases warrant attending. people affected by a policy ought to have some infl uence in determining that policy. some people might believe this is what democracy requires. a diffi culty this view of democracy faces, however, is that those who speak for the community may not appropriately represent the community affected by the decision. nevertheless, the opinions of a broader range of stakeh olders may improve deliberation (depending on how those opinions are managed). it may also improve the acceptance of the decisions, which arguably enhances the legitimacy of the decision-making process . resistance to including a broader range of stakeholder s in decision making about health priorities may come from a concern that they bring with them "partiality." this resistance may come from the view that greater impartiality leads to better deliberation. arguably, this concern about partiality ignores the positive gains that partiality often brings to deliberation, especially if we know how to manage such deliberation so that we minimize the risk s that partiality sometimes brings. we need such management skills in any case since partiality is unavoidable in most contexts. rather than banning what cannot be eliminated, managing partiality in deliberations is the best way to improve decision making in contexts of reasonable disagreement. the confl ict between improving population health and treating people fairly can arise in other contexts. arguably, the problem raised by smith and viens about the principle that should govern triage in pande mics can be viewed as a confl ict between health maximization, in this case, saving the most lives, versus recognizing the claims that the sickest people have on us for assistance. ordinarily, health systems give some priority to those who are sickest, but should that priority disappear in favor of saving lives when scarce resources, such as ventilators, are allocated in pandemic conditions? if we allocate our ventilators to the sickest patients, we may save fewer lives than if we allocate them to those whose lives we can better expect to save. even if we think we should give priority to those worst off, do we ordinarily think that concern for them should govern triage policy in pandemics? if we believe saving the most lives trumps concerns about helping those who are sickest in pandemics, can we justify why the priority we give to the sickest should be revised in pandemics? suppose we have an acceptable way of measuring the burden of disease in a population , and according to this measure, mental illness is not given the priority it ought to have. that is, it contributes more to the burden of disease than is normally recognized in standard health systems, which provide too few services to meet mental health needs. this is the problem upon which rentmeester et al.'s case focuses. specifi cally, some mental health conditions require signifi cant resources for what medicaid terms as "behavioral management," which is seen as a social support service not a medical treatment . as a result, these services, to the extent they are provided, fall to state-funded social service budgets. the services place a burden on state fi nances that would be diminished if they were instead included in medicaid bud gets ( % of which are fi nanced by each state). arguably, the stigma that attaches to mental health issues is one important reason for this underprovision of social supports for people with mental health issues. in nebraska, the political opposition to expanded medicaid coverage through the affordable care act ad ds to the burden on state budgets and the potential under-servicing of these mental-health induced needs. it takes resources to meet public health needs. suppose we can increase the resources to meet some of those needs by accepting a pu blic-private partnership that improves a compromised private partner's image? should we meet health n eeds at this price? that is the issue posed by the hernández-aguado case from spain . specifi cally, should public health authorities put their stamp of approval, in the form of their logo, on fl u epidemic notices printed on soft drink labels? the inclusion of the logo is a requirement of the private entities that are willing to donate space on the labels of their products. obviously, this provides a form of public support for soft drinks that arguably contribute to obesity in a population and thus to the prevalence of noncommunicable diseases associated with obesity. but in view of the low budgets available for fl u warnings, is this a price worth paying? what would the decision maker have to know about the effects of such labels to decide this case, or is the decision something that can be made independently of the specifi c payoffs of implementing the warning system? is there a way to consider the cost and assess whether the outcome of the warning is worth this price? is this simply an effi ciency calculation about the cost effectiveness of reducing a disease burden in this way? one fi nal crosscutting issue lurks behind all the cases in the resource allocation chapter (perhaps all the cases in the volume)-namely, the nature of the decisionmaking process that addresses the issues they raise. public health decisions about resource allocation-judging from the cases on that topic in this volume-face reasonable ethical disagreement. that is because the tradeoffs involved in the two main goals of public health policy -improving population health and distributing health fairly-are trade-offs about which people often reasonably disagree. how can public health decisions be made in real time, given these ethical disagreements, in ways that enhance their legitimacy and are arguably fair to all parties? one approach to the problem is to construct a fair process for making those decisions and to rely on the outcomes of such a process. people will judge the outcomes of a fair process to be fair (daniels and sabin ) . what conditions should such a decisionmaking process meet if it is to be considered fair? four conditions are arguably necessary (even if some may think they are not suffi cient and want to add others): ( ) the decisions and the rationales for them should be made public. ( ) they should be based on reasons all think are relevant. ( ) they should be revisable in light of new evidence and arguments. and ( ) , these conditions should be enforced so that the public can see that they obtain. some explanation is needed for these conditions. the publicity condition is widely embraced, even if it is fairly strong. it calls for the grounds for decisions-not just the content of the decisions-to be transparent. people have a right to know why decisions that affect their health are made the way they are. moreover, making the reasoning for such decisions public is a way of exposing them to scrutiny so errors in reasoning or evidence can be detected and decisions improved. even though we may not be able to be explicit in advance about all criteria we use to decide such cases, that is, we may work out our reasons through deliberation, we can explain on what we base our decisions. and that gives people affected by our decisions the knowledge they have a right to possess. the search for reasons that all consider relevant to making a reasonable public health decision about resource allocation can narrow disagreement considerably. even if people can agree on what reasons they think are relevant-in the spirit of fi nding mutually justifi able grounds for their decisions-they may not agree about the weight they give these reasons. one way to test the relevance of such reasons is to subject them to scrutiny by an appropriate range of stakeholder s. what counts as appropriate may vary with the case. who should be heard in deliberations is itself worthy of deliberation. stakeholders raise different arguments that should be heard, and including their voices improves buy-in to decisions. since stakeholders may not in many instances be elected representatives, we may be skeptical about whether the democratic process is improved by including them, but, if the deliberation is well managed, the quality of the discussion may improve greatly. the revisability condition , requiring that decisions be modifi able in light of new evidence and argument, is also widely embraced and not considered controversial. decisions are made on the basis of evidence and arguments, and better evidence and arguments may emerge that require revisiting some decisions. some decisions can then be modifi ed, though it may be too late for others, and our consolation is that we made the best choices we could, given the evidence and arguments. the intent of the enforcement condition is to ensure that the other, more substantive, conditions are met. sometimes enforcement is a matter of state regulation . sometimes it can be the result of vol untary conformance with a process. since ethical disagreements abound in resource allocation decisions , we need a process that enhances legitimacy. but can we claim that a decision-making process that is fair yields fair outcomes? one view is that we may ultimately become persuaded by a good argument that fairness requires a different decision than one that emerged from a fair process. we can in this way defeat the fairness we might ordinarily attribute to the outcome of a fair process. does the prospect of defeating the fairness of a decision emerging from a fair process mean that we should not attribute fairness to the outcomes? alternatively, we can admit that the fai rness that comes from a deliberation is only "defeasible" fairness, but it is the fairest conclusion we ca n reach at the time. during the s, many latin american countries began reforming their health systems according to a neoliberal development model that emphasizes free markets (homedes and ugalde ; stocker et al. ) . approved in , health reform in colombia was supposed to overcome problems such as low coverage, inequality in access and use of health care services, and ineffi ciency in the allocation and distribution of resources. but the reform also hoped to encourage more focus on illness prevention and health promotion and more community participation in health decision-making processes. the reformers advocated predominantly for neoliberal value s like effi ciency, free choice, universality, and quality. although they were also committed to the communitarian values of solidarity , equity , and social participation . the colombian health reform was one of the fi rst examples of implementing managed competition in the developing world (plaza et al. ) . to stimulate competition among insurers and health service providers, both public and private, health reformers applied the theory of managed competition (enthoven ) . according to this theory, competition achieves effi ciency and reduces cost , making health care services responsive to consumer needs (londoño and frenk ) . hospitals become responsive when they are able to sell services and become fi nancially sustainable. to achieve sustainability, supply subsidies (direct transfers from the state to hospitals) had to replace demand subsidies (transfers directed to the poor through a subsided s ecurity plan). the colombian reform established a general social security system in health that featured two insurance plans: ( ) the contributory plan, fi nanced by mandatory contributions (formal employees and employers from the public and private sectors). ( ) the subsidized plan, funded by resources from the contributory plan and from taxes and other sources, which covered people unable to pay (vargas et al. ) . the actors of the system are the insurance companies, the health service providers, and the state regulatory organizations. insurance companies contract with health service providers, and the regulatory organizations control compliance with the defi ned basic health packages. to optimize resources, the reform placed controls on medical practitioners and established explicit priority criteria based on clinical guidelines that defi ned benefi t packages. from , some adjustments to the reform have been introduced, such as the creation, in , of the institute for health technology assessment to provide a n evidence base for health decisions. the institute recommends which medical technologies should be paid with public resources on the basis of which technologies optimally improve the quality and cost effectiveness of medical care. to determine these technologies, it conducts health outcomes research that guides technology development, evaluation, and use (giedion et al. ) . nevertheless, years later, the promise of reform lies unfulfi lled and many patients still experience high out-of-pocket costs, long wait times, or denial of services. to access health services, frustrated citizens are turning to the legal system as a last resort and, by so doing, congesting the courts (defensoría del pueblo ). physicians are responding to economic incentives and penalties by restricting hospitalization time and decreasing the use of expensive diagnostic tests and specialist referrals (abadía and oviedo ) . to further reduce labor costs, service providers have increased the workload of health profession als and the number of patients seen per day, whi le reducing the time spent with each patient (defensoría del pueblo ). insurance companies often take a long time to pay health service providers, and they also contract their own service network (a process known as vertical integration), so many public hospitals are in serious fi nancial diffi culties. meanwhile, hospital workers frequently disrupt the normal operation of hospitals as they strike to improve work conditions and have their paychecks issued more promptly. should hospitals fail- % of the public hospitals in colombia are classifi ed as being at medium or high fi nancial risk -nearly ten million people could be left without health service (ministerio de salud y protección social ; quintana ) . add to that, the reforms have increased inequity, as more affl uent patients can more easily access quality health care services than can low-income patients (vargas et al. ) . the described problems refl ect a complex situation that requires profound structural reform . as one way to address the immediate problems of effi ciency and quality, colombia in instituted public hospital accreditation. accreditation requires hospital directors to reach goals in service delivery related to fi nancial viability, quality, and effi ciency. hospital boards can now fi re directors who fail to meet these g oals within a specifi ed period (rodríguez ) . given the imbalances between budgets, service demands, and ongoing costs, hospital directors face enormous challenges and ethical dilemmas in formulating and executing their mana gem ent plans. you are a director of a public hospital that focuses on health promotion and prevention activities, such as general practice, dentistry, clinical laboratory, hospitalization, and emergency care. in developing your management plan, you must make decisions about which services to prioritize . if you prioritize services that represent higher revenues and lower costs as a way of conserving resources, you may have to reduce priority for some services. to guide your decision making, you conducted a retrospective study of service billing in the past years and learned that the clinical laboratory and external medical consultation yielded higher incomes. the lowest yielding programs in the short term-vaccination , educational programs to improve lifestyles , and provision of micronutrient supplements to children and pregnant women-were associated with the best long-term health results. taking seriously your fi duciary responsibilities, you try to guarantee fi nancial sustainability by containing labor costs, restricting consultation times, and shortening hospital stays. your challenge is to do these things without diminishing the quality of patient care. but because you compete with other institutions, you must also assure suffi cient reserves to maintain and update medical equipment that will improve the "sale of services." knowing that every management decision you make will affect the population you serve, you begin to refl ect on the factors affecting your h ospital man agement plan. . who are the major stakeholder s in this case and what are their interests, value s, and moral claims? between which of them are there ethical confl ict s or tensions? . which of these interests, values, and moral claims should be prioritized? how would you justify your priorities? . would you prioritize programs that in the short term brought in needed revenues or those programs that had highest impact long term? . how can tensions between the goals of effi ciency, fi nancial viability, and quality be resolved? what weight should be assigned to each goal by the hospital board when evaluating your performance? . at least in the short run, the new reforms seem to be prioritizing effi ciency, viability, and quality over equity . should a health system attain the former goals before tackling the problem of equity, or should it insist on equity from the start? . can equity in health care be achieved without doing something about wealth inequity and other social determinants of health? . should you justify your decisions by emphasizing solidarity with other hospital directors and seeking community support? . how could collaborations between public health, communities and the health care system begin to address neoliberal concern s with effi ciency, viability, and quality? the global burden of disease (gbd) compares disease burdens based on epidemiological measures of prevalence, mortality, disability, and associated cost s. the gbd for mental illness amounts to % of the world's total disease burden (world health organization ). i n the united state s alone, every fi fth child suffers from a mental disorder (perou et al. ) . although mental illness clearly causes disabilities (prince et al. ), underservice to those with mental illness is commonplace. lack of access to mental health services counts as the fi rst of many hurdles facing families who have a child with a mental illness. stigma and the lack of parity in health coverage for physical and mental illness are other hurdles for these families. not surprisingly, these hurdles can critically affect the development of children with mental illness. lack of access to mental and behavioral health services for children years and younger especially threatens their development. rapid brain growth occurs in the fi rst years of life, which lays the foundation for cognitive, emotional, and moral development. exposure to chronic stress can prompt the release of hormones in the brain that can have enduring consequences for how the adult brain is organized and how it functions (shonkoff and phillips ) . because poor health can show up in children as developmental delay, access to mental and behavioral health services is critical. longitudinal studies demonstrate positive and long-acting effects of early childhood interventions, such as environmental enrichment programs, on a range of cognitive and noncognitive skills, social behaviors, academic achievement, and adult job performance (heckman ) . the esti mated annual rate of return on investment from targeted early childhood development programs is %, and early intervention reduces the predictable need for higher, more costly levels of care in later life (heckman et al. ) . in the united state s, medicaid is a government-funded program that provides health coverage to people with certain disabilities and to low-income adults and their children. the federal medicaid act (fma) requires states participating in medicaid programs to provide medically necessary treatment to eligible children. under federal medicaid law , states must provide "early and periodic screening , diagnostics, and treatment," also known as epsdt services, to eligible medicaid recipients under age (u.s.c. § d(a)( )(b)). the defi nition of epsdt includes necessary health care , diagnostic services, treatment, and other measures described in the medical assistance subchapter for the united states code ( u.s.c. § d (a)) ( ) that correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, regardless of whether such services are covered under the state plan ( u.s.c. § d (r)( )) ( ). the medical necessity standard , which is based on clinical standards of care, refers to interventions that may be justifi ed as reasonable, necessary, or appropriate. states must comply with the fma standard to cover all treatments for a medicaideligible child's physical or mental condition, even if service coverage is optional for adults covered by medicaid. fma also bars states from arbitrarily denying or reducing the amount, duration, or scope of a required service to an otherwise eligible recipient solely because of the diagnosis, illness, or condition (nebraska legislature ). despite the provisions of fma, the u.s. department of health and human services, which oversees the medicaid program, excludes certain behavioral health treatments for children with developmental disabilities and autism (national health law program ; autism society of nebraska ). in addition, some states' medicaid contracts allow insurers more freedom than other states to deny payment for services. states also vary in who-the claimant or the insurer-must prove whether coverage provisions are adequate or fall short of federal medicaid legal standards (rosenbaum and teitelbaum ) . differences among states in approval of payment for specifi c treatments, including mental and behavioral health treatment, illustrate the need for more consistency in medicaid coverage provisions and the lack of parity between mental and physical health coverage. mental health benefi ts must be offered at parity with medical services to newly eligible recipients as part of the patient protection and affordable care act (aca), and medicaid expansion controversy is clear evidence that parity is a work in progress (mental health america ; u.s. department of labor ). because of inadequate coverage for mental and behavioral health services for medicaid-eligible children , some parents have no option other than to surrender their child to the child welfare system so that the child will receive full coverage for necessary mental and behavioral health care services. this results in signifi cant cost-shifting from medicaid to the state's child welfare system. that is, when a state provides federally mandated services to medicaid-eligible children, it receives a fi nancial match from the federal government to pay the cost s. when a state denies federally mandated medicaid services and a family surrenders a child to state custody so the child can receive care, the state pays the expense of the previously denied medicaid costs plus the expense of entitlements the child acquires as a ward of the state. the aca medicaid expansion offers a window of opportunity to increase coverage for behavioral health treatment for children with mental illnesses. although the federal government will bear the primary fi nancial burden of medicaid expansion, some states have elected, for political reasons, not to participate in this expansion. for participating states, aca medicaid expansion will replace state and local mental health services funds with federal medicaid money that will cover a wider range of home and community-based services for mental illness treatment (bazelon center for mental health law ). public health agencies and leaders often provide input for the medicaid system, helping to develop protocols, criteria, and rules about which treatments are defi ned as medically necessary . such decisions about medical necessity affect clinicians, patients, and families because they determine which treatments get recommended at the clinical level and infl uence which treatments insurers cover. you are the medicaid director of a state with the country's highest percentage of children in the child welfare system. twenty-fi ve percent of children in the state's foster care system are there not because of abuse or neglect, but because of behavioral problems and mental illnesses. as a state offi cial, you are aware that this results in signifi cant cost-shifting from medicaid to the state's child welfare system. recently, the case of -year-old sam has come to your attention. sam's family cannot afford mental and behavioral health care for sam, although he is medicaideligible and insured through magiscare (a private company with a state contract to administer medicaid for mental and behavioral health services). sam's parent s are considering surrendering their boy to become a state ward to get him the mental health services he needs. sam, you learn, eats random objects and dirt, throws tantrums, bangs his head on the ground, hits and bites himself and others, and often runs away. recently diagnosed by his physician as having autism, sam was referred to a psychologist who recommended outpatient behavioral therapy. both the physician and the psychologist expect this therapy to be covered through the family's magiscare plan. magiscare denied the psychologist's requests for payment on the grounds that, for children of sam's age, behavioral management is not covered under state law because it is not "medically necessary." magiscare substantiated their denial of payment because sam's behaviors primarily refl ect developmental disabilities related to autism, which are not covered under their contract with the state. when you ask the magiscare executive director about this case, she suggests that sam's parent s could attend therapy sessions to help them cope with their son's behaviors, but she reasserts that behavioral management is not covered for children as young as sam under state law because it is not medically necessary. members of the state legislature and child mental health advocacy groups are trying to expand access to home-based and community-based mental health services. they have asked you to support their efforts. you also consider that your governor, who is your boss, has publically stated his fi rm opposition to aca medicaid expansion, thus denying the state the opportunity to expand coverage for children's mental and behavioral health treatment through the aca. at present, you know that your state is offering limited mental and behavioral health service s and that narrow defi nitions of medical necessity are used to limit access to those services. as the state medicaid director, which steps should you take? . who are the main stakeholder s in this case, and what are their primary interests? . "passing" the expense of coverage denied by medicaid to other components of public service, such as the child welfare system, has fi scal and social implications. (a) what are some of these implications? (b) how should prevalence, mortality, disability, and cost be factored into thinking about ways to balance short-and long-term risk s and benefi ts to individuals and to the public in this case? . suppose a policy advisor warns that expanding behavioral health care for children will strain the medicaid budget and require cuts in services for adults or reduce their eligibility. (a) how should you respond? (b) which considerations or priorities would guide your funding allocations? . what role should ethical principle s such as stewardship , public health leadership , and moral courage play in this case? . medical necessity implies an acute care model of health service delivery and refl ects a clinical perspective. how well does this idea apply to a public health prevention model of health service delivery? are there better alternatives? . parity in insurance coverage for mental health is federally mandated for private insurers, which covers most citizens, but has proven to be an elusive goal for people who do not have private insurance or do not have enough coverage. medicaid is a public ( government funded) insurance program, not a private one. although medicaid benefi ciaries receive coverage for medically necessary mental health services, e ach state defi nes medical necessity uniquely. (a) should a federal mandate defi ne medical necessity for mental and behavioral services? (b) what fi nancial implications would such a mandate have from a state perspective and from an overall perspective? . the term principle-policy gap can be used to characterize situations in which most people support health coverage in principle ; but in practice, they are unable to pay for coverage or unwilling to take the political , social, cultural, or fi scal risk s necessary to enable such coverage. what do such gaps tell us about which value s the majority favors, and how might the term principle-policy gap help us understand the dynamics in this case? what roles should public health leaders play in responding to principle-policy gaps? public health systems are usually underfunded in comparison with health care systems. in fact, the organisation for economic co-operation and development (oecd) countries allocate on average only % of their health spending to pub lic health and prevention activities (oecd ) . this low funding of public health programs hinders the capacity to implement effective public health policies (robert wood johnson foundation ). population health challenges, such as infl uenza pandemics, are increasingly complex, and tackling them involves urgently executing a wide array of public health measures to prevent disease transmission. in the case of infl uenza pandemics, measures can vary from border quarantine, social distancing, provision of antivirals and vaccine s, and personal hygiene strategies. recommendations often need to be made quickly even when knowledge about the seriousness and potential health and social effects are incomplete. the target for preventive interventions is the entire population. however, resources for intense and sustained health campaigns through mass communications are expensive. in addition, the social determinants of the disease must be understood and considered (crowcroft and rosella ) . this typically involves the need for policies that engage the health and non-health sectors, such as educational policies and social or economic factors (savoia et al. ). this complexity, together with decreasing funds and other factors, has contributed to increasing private sector involvement in health care. according to the world health organization (who), a public-private partnership gathers a set of actors for the common goal of improving population health through agreed roles and principle s. this may also be described as public sector programs with private sector participation (who ). who has described several types of partnerships, including philanthropic, transactional, and transformational. sponsorship is a form of a public-private partnership defi ned as "any form of monetary or in-kind payment or contribution to an event, activity, or individual that directly or indirectly promotes a company's name, brand, products, or services" (kraak et al. ) . in this sense, sponsorship is a commercial transaction, not type of philanthropy. public-private partnerships have become increasingly common for public health campaigns. some transnational companies and their corporate foundations collaborate with public institutions, such as united nation s agencies and government s, to tackle complex public health problems, such as treatment of diarrhea in developing countries (torjesen ) , tuberculosis , and malaria (ridley et al. ) . these collaboration s have been encouraged by international institutions and experts as a way to mobilize resources and expertise, which could complement the public sector. who has also encouraged using public-private partnerships to deliver health services for a range of health problems, including hiv infection, malaria , tuberculosis , trachoma, and vaccine-preventable diseases (buse and walt a , b ) . however, corporations' increasing role in public health has been criticized as jeopardizing the mission of public health and its commitment to population health (hastings ; ludwig and nestle ) . some corporations have used tactics that discredit public health actions, such as distorting scientifi c information and using fi nancial tactics and political infl uence to avoid unfavorable regulations (wiist ) . public health profession als, public health agencies, and governments often must decide whether to collaborate with the private sector to improve population health. these decisions are increasingly frequent as health department budgets shrink and public-private partnerships are seen as a way to secure funds for core public health programs. ethical considerations can help us decide whether and when to form such partnerships. however, the available public health ethics frameworks (e.g., public health leadership society ; nuffi eld council on bioethics ; kass ) do not specifi cally discuss public-private partnerships. only the public health leadership society provides guidance for such collaborations. principle proposes that, "public health institutions and their employees should engage in collaborations and affi liations in ways that build the public's trust and the institution's effectiveness." continued discussion about the ethical implications of private-public partnerships is needed. top health offi cials in an industrialized country have declared a public health emergency due to an infl uenza pandemic. the head of the country's health department receives a call from the president of a multinational company that produces sugary, high-calorie drinks. the company president expresses his concern about the pandemic and wants to collaborate with the government to prevent the spread of fl u. the company offers the health department a considerable amount of space, onethird of each can, on its star product (a soft drink) free of charge, to include messages on fl u prevention . the company insists that the health department logo be included on the can along with the preventive messages. for them, the association between the health department (through the logo) and their product is essential for the collaboration as it would be an acknowledgement by the health department of the company's social responsibility. the head of the health department arranges a meeting with several health authorities and offi cials to consider the offer. on one side, some members of the group support the proposal because of the need to carry out far-reaching public health campaigns to limit the impact of pandemic fl u. at that stage, the incidence of pandemic fl u is increasing quickly and the number of new outbreaks in schools is worrying the health authorities and the population . there have been recent budget cuts to the health department, and some offi cials argue the company's contribution may be the best option to ensure a far-reaching campaign on prevention measures to benefi t the population. they see sponsorship as a form of social responsibility because the company does not have any apparent economic interest in fl u-related activities. they also note that there are no other companies offering a similar collaboration. but other offi cials say the company's soft drink products contribute to the obesity and diabetes epidemic and that the company's use of the health department logo would label it a pro-health industry with the backing of the highest health authority in the country. they also raise concerns about risking the independence of the health department in future regulatory action on sugar-rich beverages. as the hea d of the health department, you must decide if you should collaborate with the company. . what considerations should the health department director weigh when deciding whether to collaborate with the beverage company? . who are the major stakeholder s the health department should consider, and what value s might each of these stakeholders bring to this decision? . in making your decision, what values should be prioritized? . what positive or negative impacts would displaying the health department logo on the soft drink cans have on health department operations? . how might sponsorship by a company that produces sugary beverages affect public trust in the health department and the institution's effectiveness? . would the decision be different if the company produced healthy foods and the department's logo was placed on a healthy product? . would community involvement facilitate decision making and the consideration of the ethical questions? what ethical criteria or guidance should be established to accept or reject a future donations or sponsorship of a public health program by a company? preterm births, the leading cause of infant mortality, are increasing annually worldwide (world health organization ). the united state s shares company with nigeria, india, and brazil among the top ten countri es with the highest numbers of preterm births and ranks st among organisation for economic co-operation and development ( in , about infants died per live births. by , that number fell to . . during the last half of the twentieth century, the rate of black infant mortality dropped dramatically. in , black infant mortality was . deaths per live births compared with . deaths per live births among whites (mechanic ) . but by black infant mortality fell to . deaths per live births compared with . deaths per live births among whites. as these numbers show, both groups made signifi cant absolute gains, with blacks gaining more in absolute terms-a reduction of . for blacks and . for whites. yet, black infant mortality still remained about twice that of whites. these disparities have persisted in the twenty-fi rst century. in , non-hispanic black women experienced the highest rate of infant mortality, with . infant deaths per live births, while non-hispanic white women had a considerably lower rate, with . infant deaths per live births. citing a report from the national healthy start association, macdorman and mathews ( ) report that programmatic efforts to reduce disparities in black-white infant mortality have had some successes at local levels, but eliminating the disparities is diffi cult. the u.s. centers for disease control and prevention and the u.s. department of health and human services have prioritized both the elimination of health disparities and improvement in overall population health. these twin goals-one distributive, the other aggregative-are separate and sometimes confl ict (anand ) . increases in health disparities often accompany advances in aggregate gains in population health (mechanic ) . although this case is specifi c to the united state s, the dilemma is not. data show that signifi cant progress on child mortality has been made in many countries but that this overall success is often coupled with increased inequalities between advantaged and disadvantaged groups (chopra et al. ) . in china and india, for example, disparities in mortality persist between boys and girls younger than years, a function of entrenched gender discrimination (you et al. ) . these examples raise challenging questions about how ethically to assess such cases and set priorities for the allocation of scarce public health resources. you serve as the director for the local health department in a racially segregated urban city in the midwest with one of the greatest concentrations of african americans in the united states. the city has a long history of civil rights activism that led to protests and marches that ultimately empowered and mobilized black communities and organizations. your health department has a history of prioritizing maternal-child health and the elimination of black-white disparities in infant mortality in its programs, an investment of resources affi rmed by the city residents through the department's community outreach program and planning processes. chronic underfunding of public health, made worse by the economic downturn, has resulted in drastic and unprecedented reductions in the public health budget. in consultation with your staff and community board of health, you have raised the possibility of redirecting resources from maternal-child health into other programs based on a number of practical and ethical considerations. as with national statistics, the city has seen signifi cant declines in black infant mortality, even as blackwhite disparities remain. you note that although the maternal-child health programs are cost-effective, their impact on reducing black-white disparities seems to have stalled. other programs appear to meet targets more consistently. to help support these other programs, you note that allocating resources to more effective programs provides more "health" per dollar, thus meeting the utilitarian demand to maximize overall health, which many view as the primary goal of public health and health policy (powers and faden ) . in addition, although black-white disparities in infant mortality persist, blacks have made signifi cant gains, declining more than whites in some decades. you note that remaining inequalities could be deemed ethically acceptable by some standard s of equity , such as the "maximin" principle . although this distributive principle is subject to interpretation (van parijs ) , it is generally understood to require that social and economic inequalities work to benefi t society's least advantaged groups. thus, inequalities (even signifi cant ones) are morally acceptable as long as the least advantaged have signifi cantly benefi ted (powers and faden ) . the director of community outreach proposes that the health department not make this decision unilaterally, but instead listen to community opinions on these questions of priorities and fairness. he suggests that the health department collaborate with community partners to host a series of public forums. he insists that a topic of such historic and contemporary concern to the community must be subject to public deliberation. despite having a history of supporting community discussions, you are concerned about the cost of community forums, noting that they will drain resources from an already slim budget. the chilean sy stem of guarantees in health-created by law in -aims to establish guaranteed health care interventions in health promotion, disease and injury prevention , diagnosis and treatment , rehabilitation and palliative care (ministerio de salud ) . the law mandates that public and private insurers provide the resources needed to protect the public against excessive health-related spending and guarantee timely and universal access to authorized interventions based on standard s of care. national health objectives, established by the ministry of health, determine the list of guaranteed interventions. this list, however, is reviewed every years and amended as new scientifi c and health information emerges. as of , the system o f guarantees in health included interventions for health-related conditions (ministerio de salud ), accounting for almost % of the chilean burden of disease. the system of guarantees in health is a priority system based on acknowledged criteria, namely scientifi c evidence and socially shared value s. for the system to be effective, the criteria must be transparent, publicly accepted, and open to review and modifi cation. the law that created the system of guarantees in health also mandated a procedure for selecting the guaranteed interventions (ministerio de salud ) . the procedure factors in public opinion research to identify social consensus on health priorities, studies to identify effective interventions that prolong and improve quality of life, and assessments of interventions' cost effectiveness (burrows ). the procedure determines priorities with an algorithm that includes these factors and information on disease burden and health system capacity (missoni and solimano ) . after choosing the health interventions, the health ministry elaborates on a package of interventions related to specifi c health conditions and develops clinical guide lines for such interventions. you direct a team within the ministry of health that is responsible for recommending priorities for guaranteed health interventions. the priority ranking system emphasizes the selection of cost-effective interventions for conditions with the greatest burden. however, the health ministry also has authorized including expensive interventions that are less effective or treating health conditions with low prevalence, if that condition or those interventions signifi cantly impact health. because of budget reductions, a number of interventions are under review. your team has been asked to recommend funding interventions for two health conditions-cataract (a common condition with highly effective treatment ) and multiple sclerosis (a less prevalent condition but one with signifi cant health and social impact). cataract, the main cause of blindness, primarily affects people over . this health problem has a high impact as measured by quality-adjusted life years (qalys) (ministerio de salud ) . its surgical treatment is effective for - % of patients. the package of guaranteed interventions includes diagnostic confi rmation within days after suspected diagnosis and surgical treatment days after confi rmation. in , it was expected that , cataract surgeries would be performed in chilean public hospitals and in private institutions. multiple sclerosis , an autoimmune infl ammatory disease leading to demyelination in the central nervous system, produces a progressive deterioration of health and quality of life. it represents a minimal disease burden at the population level, mainly due to premature death. in chile, it is estimated that patients are treated for multiple sclerosis each year. the package of guaranteed interventions includes diagnostic confi rmation within days; confi rmed cases must receive treatment within days. treatment includes pharmacological therapy and p hysiotherapy. contingency arrangements. to make the best use of resources and personnel (even in the absence of a pandemic), patients are triaged-evaluated to determine the type and priority of care to be received. while medical information informs the development of triage criteria, ethical considerations about triage goals-whether explicit or implicit-also play a role. for public health emergencies that overwhelm capacity, some propose adjusting critical care triage criteria to emphasize certain public health goals, like saving the most lives possible (christian et al. ; silva et al. ) . some contend that utilitarian reasoning should predominate in critical care triage, based on the intuition that, when resources are scarce, allocation decisions should produce the greatest good for the greatest number (charlesworth ; childress ) . critics of utilitariani sm reply that it requires coercion or covertness to succeed, because the public will not voluntarily sacrifi ce their lives or their loved ones for the greater good (baker and strosberg ). utilitarian triage may be unpalatable to the public on the further ground that it quantifi es and judges the value of one life over another, which could disproportionally impact particular population groups (hoffman ). others therefore would base triage decisions on egalitarian considerations, for instance, by giving everyone an equal chance at obtaining a scarce good, an approach for which historical precedent exists (baker and strosberg ) . whatever approach is adopted, prior arrangements between policy makers, practitioners, and the public based on thoughtful, transparent deliberation about the most ethical approach to ccu triage usually will improve the legitimacy of d ecisions. those who promote an approach based on fairness and equity need to consider that, during public health emergencies, the goal of saving lives may force a retreat to utilitarian ethics (kirkwood ; veatch ) . while not necessarily unethical in itself, a retreat that overturns prior arrangements lays itself open to charges of illegitimacy. variability in the frameworks used to allocate public health resources illustrates the importance of refl ecting upon the value s that undergird policy decisions and individual practices, like critical care triage. appealing spontaneously in the heat of the moment to values that have not been adequately refl ected upon or discussed in a transparent and deliberative manner may lead to undesirable outcomes and accusations of unethical practices. while discussions of ccu triage criteria ultimately concern institutional clinical policy and practice, they refl ect a larger discussion about the overarching public health goals in the face of large-scale, widespread public health emergencies, like pandemics. an outbreak of a novel infl uenza virus has progressed to the point that the world health organization has declared a pandemic. in the pandemic's fi rst wave, hospital capacities were suffi cient to handle the infl ux of pandemic infl uenza patients, whose morbidity and mortality rates mirrored rates for seasonal infl uenza. however, despite a vaccination campaign and other measures, such as ensuring surge capacity, rates of morbidity and mortality associated with the virus have increased drastically during the pandemic's second wave. the resulting increased number of patients needing hospital beds has overwhelmed even the surge capacity of the ccus of a metropolitan city's tertiary care hospitals. to meet this challenge, a teleconference has been scheduled between several members of the hospitals' administration, the ccu directors from each hospital, and public health offi cials involved in leading the jurisdiction's pandemic response. as a public health offi cial who played a central role in developing the pandemic plan for your jurisdiction, you have been included on the call to provide guidance for the pandemic response. during the meeting, a number of ccu directors report that their physicians and nurses are concerned about the type of patients bein g admitted into the ccu. some of the directors see a trend that they suggest is ultimately undermining the effi ciency of the pandemic response. they argue that, as the severity of the pandemic continues to increase, their triage criteria should be modifi ed so as to use ccu resources to save the most lives possible. they worry that admitting those who present with the most need is preventing treatment of those who will benefi t most from ccu admission. "so long as our triage scheme saves the most lives, it is ethically justifiable" a number of them declare. the group takes up the proposal of a ccu director to triage according to sequential organ failure assessment (sofa) scores-which are derived using a tool that determines a patient's organ function and failure rate to predict outcomes (vincent et al. ) . were the pandemic's severity to increase, the group suggests that, in addition to the ccu director's proposal to use sofa criteria, even more inclusion, exclusion, and priority criteria could be added with the goal of saving as many lives as possible. they've proposed exclusion criteria for ccu admittance that include patients with a poor prognosis, patients with other known health issues, and some mention of age cut-offs, to name a few. others involved in the teleconference question whether this is the right approach to take. they argue that, by aiming to save the most lives possible, those who may benefi t less from ccu admission, like older adults or individuals with disabilities, will be unfairly affected. they say, "we should not just aim to save lives, but rather save lives fairly ." as you and your public health colleagues are leading the pandemic response, the hospital administrators and ccu di rectors look to you for a recommendation or decision about how to proceed. . ensuring that the ccu has surge capacity is a common strategy to accommodate an infl ux of patients who have been infected with pandemic infl uenza. (a) does surge capability require alternative critical care triage criteria? (b) if the population's health needs exceed contingency arrangements, should alternative critical care triage criteria be used? (c) how should these decisions be made? (d) what principles, value s, or processes should infl uence these decisions? . what considerations might exist during a pandemic that do not exist in everyday critical care and critical care triage that do or do not support the modifi cation of triage criteria? if pandemic critical care triage requires a unique conceptual framework, what principles ought to be valued in such a framework (e.g. need, equality, utility, effi ciency)? . would the severity of a pandemic ever warrant the use of a utilitarian scheme for critical care triage, given that the public generally fi nds it unpalatable and carrying out such a plan could require coercion? how could an adverse public reaction to coercive or covert measures be mitigated? . in a pandemic, the most seriously ill patients with the lowest probability of being saved might be left untreated because their care would require too many resources with little prospect of recovery. this illustrates a confl ict between the common good and the best interests of individual patients. what other confl icts might arise when triaging in a pandemic? . triage can be used to maximize the number of lives saved with available resources. should we aim to maximize the number of lives or, alternatively, the number of life years saved? this can also give rise to questions about the quality of those lives and years lived. is it ever appropriate to make allocation decisions based on quality of life or life years? ethical issues in recipient selection for organ transplantation priority to the worst off in health care resource prioritization ethical issues in the use of cost effectiveness analysis for the prioritization of health care resources the effi ciency frontier approach to economic evaluation of health-care interventions rationing fairly: programmatic considerations how to achieve fair distribution of arts in " by ": fair process and legitimacy in patient selection just health: meeting health needs fairly setting limits fairly: learning to share resources for health benchmarks of fairness for health care reform qaly maximization and people's preferences: a methodological review of the literature cost-effectiveness in health and medicine morality, mortality: death and whom to save from it toward a broader view of values in cost-effectiveness analysis in health care cost value analysis in health care: making sense out of qlays bureaucratic itineraries in colombia: a theoretical and methodological tool to assess managed-care health care systems autonomía médica y su relación con la prestación de los servicios ?option=com_content&view=article&id= :la-tutela-y-el-derecho-a-la-salud- &cat id= :libros&itemid= . accessed the history and principles of managed competition serie de notas técnicas sobre procesos de priorización de salud: introducción a la serie de priorización explicita en salud why neoliberal health reforms have failed in latin america structured pluralism: towards an innovative model for health system reform in latin america ministerio de salud y protección social, colombia managed competition for the poor or poorly managed competition? lessons from the colombian health reform experience los actores e intermediarios del sistema de salud en colombia gerentes de hospitales públicos y acreditación en salud the exportation of managed care to latin america barriers of access to care in a managed competition model: lessons from colombia nebraska appleseed-cases of denial of behavioral health coverage for children are needed take advantage of new opportunities to expand medicaid under the affordable care act: a guide to improving health coverage and mental health services for low-income people, following the supreme court ruling on the affordable care act schools, skills, and synapses the rate of return to the high/scope perry preschool program medicaid expansion fact sheet lawsuit fi led to protect the rights of nebraska children with autism and development disability nebraska legislature. . floor debate on lb mental health surveillance among children -united states no health without mental health coverage decision-making in medicaid managed care: key issues in developing managed care contracts phillips, and committee on integrating the science of early childhood development; board on children, youth, and families; institute of medicine; division of behavioral and social sciences and education title : public health and welfare. u.s.c.a § d(a)( )(b) (west ) and u.s.c. § d (r)( ) the mental health parity and addiction equity act of mental health: facing the challenges, building solutions global public-private partnerships: part i-a new development in health? global public-private partnerships: part ii-what are the health issues for global governance? the potential effect of temporary immunity as a result of bias associated with healthy users and social determinants on observations of infl uenza vaccine effectiveness; could unmeasured confounding explain observed links between seasonal infl uenza vaccine and pandemic h n infection? why corporate power is a public health priority an ethics framework for public health balancing the benefi ts and risks of public-private partnerships to address the global double burden of malnutrition can the food industry play a constructive role in the obesity epidemic public health: ethical issues principles of the ethical practice of public health. http:// phls.org/cmsuploads/principles-of-the-ethical-practice-of-ph-version- . - a role for public-private partnerships in controlling neglected diseases? investing in america's health: a state-by-state look at public health funding and key health facts predictors of knowledge of h n infection and transmission in the u.s. population coca-cola supply chain helps bring diarrhoea treatments to developing world the corporate play book, health and democracy: the snack food and the beverage industry's tactics in context about cdc's offi ce of minority health & health equity (omhhe) understanding the determinants of the complex interplay between cost-effectiveness and equitable impact in maternal and child mortality reduction infant deaths-united states the challenge of infant mortality: have we reached a plateau? disadvantage, inequality, and social policy population health: challenges for science and society oecd health data: infant mortality social justice: the moral foundations of public health and health policy hhs action plan to reduce racial and ethnic health disparities difference principles born too soon: the global action report on preterm birth levels and trends in child mortality priority setting in healt h care: ethical issues m. inés gómez and lorna luco centro de bioética, facultad de medicina clínica alemana-universidad del desarrollo what are some of the ethical, scientifi c, and social considerations that should be weighed in deciding if interventions for both cataract and multiple sclerosis should be covered by the system of guarantees in health? is there an obligation for health systems to cover all health problems affecting a population? are there limits? how should health problems be prioritized and who should have the authority to make these decisions? which criteria should receive the most weight in ranking priorities? how should resources be distributed among health conditions affecting many people versus health conditions affecting few people? how should resources be distributed among procedures that are preventive versus treatments for existing conditions? how does taking a public health perspective versus a clinical medicine perspective affect your thinking about including these two conditions in the system of guarantees in health? what role should transparency play in the selection procedure? references burrows establece un régimen general de garantías en salud estudio carga enfermedad y carga atribuible decreto supremo no. . aprueba garantías explícitas en salud del régimen general de garantías en salud towards universal health coverage: the chilean experience , background paper case : critical care triage in pandemics smith dalla lana school of public health and the triage and equality: an historical reassessment of utilitarian analyses of triage. kennedy institute of bioethics in a liberal society disaster triage development of a triage protocol for critical care during an infl uenza pandemic allocating ventilators during largescale disasters-problem, planning, and process preparing for disaster: protecting the most vulnerable in emergencies in the name of the greater good? pandemic triage: the ethical challenge mechanical ventilators in us acute care hospitals contextualizing ethics: ventilators, h n and marginalized populations department of health and human services priority setting for pandemic infl uenza: an analysis of national preparedness plans disaster preparedness and triage: justice and the common good scoring systems for assessing organ dysfunction and survival addressing ethical issues in pandemic infl uenza planning: discussion papers the authors thank student chelsea williams for her assistance in assembling the facts of the case. we also thank creighton university's center for health policy & ethics. acknowledgements we thank mr. jonathan whitehead for language editing. open access this chapter is distributed under the terms of the creative commons attribution-noncommercial . license ( http://creativecommons.org/licenses/by-nc/ . / ) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. the images or other third party material in this chapter are included in the work's creative commons license, unless indicated otherwise in the credit line; if such material is not included in the work's creative commons license and the respective action is not permitted by statutory regulation, users will need to obtain permission from the license holder to duplicate, adapt or reproduce the material. this case is presented for instructional purposes only. the ideas and opinions expressed are the authors' own. the case is not meant to refl ect the offi cial position, views, or policies of the editors, the editors' host institutions, or the authors' host institutions. infectious diseases such as pandemic infl uenza and severe acute respiratory syndrome (sars) have attuned the attention of policy makers and health practitioners to the importance of protecting and promoting the public's health in the face of increased care needs and extreme resource scarcity. in particular, acute care needs for the critically ill and discussions of treatment priorities have been the subject of much debate in pandemic planning (hick et al. ; melnychuk and kenny ; uscher-pines et al. ). this is not surprising, as it has been estimated that more than , americans may require mechanical ventilation during a pandemic, far outnumbering available ventilators (rubinson et al. ; u.s. department of health and human services ) . additionally, shortages of hospital beds, personnel, and other equipment can be expected during a pandemic, which may limit the ability to meet an expected increase in patient volu me (world health organization ).prudentially planning for the public's increased care needs during a pandemic requires assessing surge capacity, especially in critical care units (ccu). however, as pandemics increase in severity, they can overwhelm critical care capacity and key: cord- -mcw v c authors: arnold, andreas; arnold, wolfgang; bovo, roberto; ganzer, uwe; hamann, karl-friedrich; iurato, salvatore; kiefer, jan; lamm, kerstin; livi, walter; martini, alessandro; o’donoghue, gerard m. title: inner ear date: journal: otorhinolaryngology, head and neck surgery doi: . / - - - - _ sha: doc_id: cord_uid: mcw v c herpes zoster oticus, herpes zoster cephalicus, ramsay hunt syndrome. caused by reactivation of the varicella zoster virus at the level of the ganglion cells of cranial nerves vii and viii, herpes zoster oticus accounts for approximately - % of acute facial palsy cases. one or days of general malaise with fever. • burning earache followed by a vesicular eruption in-• volving the aperture of the external auditory canal and the auricle. the bluish-red vesicles eventually form crusts within a few days. facial palsy. • sensorineural hearing loss and vertigo (lesion of cra-• nial nerve viii). pain in the pharynx (lesion of cranial nerves ix and • x). facial pain due to involvement of cranial nerve v. • headache, neck stiffness, photophobia. • persistent complete hearing loss, persistent vertigo, postherpetic pain, persistent facial paralysis. inspection: varicella zoster vesicles • on the lateral surface of the auricle, concha and entrance of the auditory canal ( fig. . . ). vesicles may occur over the face and neck and may involve the buccal mucosa. warning: the vesicles may be small or may resolve before the patient is evaluated (pay attention to encrusted areas). otomicroscopy: vesicles or vesicle remnants in the • external auditory canal and on the tympanic membrane. audiometric evaluation: sensorineural hearing loss. • vestibular tests: spontaneous nystagmus towards the • affected side (at the beginning), later towards the opposite direction. serological confirmation: rarely utilized. • local treatment • of the vesicles with drying agents (e. g. % alcohol) and acyclovir cream. antiviral treatment with acyclovir ( mg five times a • day orally). alternatively, brivudin or famciclovir may be given. prednisolone, mg/day for - days together with • proton pumps blockers. alternatively, prednisone, mg/kg of body weight daily orally for - days with tapering to zero over the following days. in cases of persistent facial paralysis, gold weight implant in the upper eyelid, hypoglossal-facial anastomosis. the prognosis for recovery of the facial function is • less favourable than that of bell's palsy. incomplete recovery is frequent (only less than % of the patients recover satisfactorily). prognosis is worse in elderly patients. often persistent neuralgia (years). complete hearing loss and complete vestibular areflex-• ia are irreversible. the route of infection may be otogenic, meningogenic or haematogenic. the symptoms are: • during the course of a viral infection of the upper respiratory tract including the middle ear (picornavirus, influenza virus, parainfluenza virus, respiratory syncytial virus, coronavirus, adenovirus). serous effusion of the middle ear, vestibular disturbances, combined or pure sensorineural hearing loss, tinnitus. no earache. • during the course of mumps, measles or parainfluenza meningitis. route of infection are the internal auditory canal and the cochlear aqueduct. protein deposits can be seen in the perilymphatic spaces ( fig. . . ) . clinical signs of meningitis are fatigue, vomiting, headache, stiff neck, fever, and unilateral or bilateral deafness. purulent (suppurative) bacterial labyrinthitis may be secondary to acute otitis media or purulent meningitis. in acute otitis media, bacteria may enter the inner ear through the oval and round windows ( fig. . purulent labyrinthitis is frequently followed by meningitis as the microorganisms gain access to the subarachnoid space through the cochlea aqueduct or internal auditory canal. bacterial labyrinthitis can be a complication of cholesteatoma, spontaneous or acquired labyrinth fistula or may occur in malformations of the cochlea with enlarged perilymphatic spaces (mondini dysplasia). glucocorticoids, initially mg intravenously for • days followed by oral administration of prednisolone starting with mg per day, then reducing the dosage by mg per day treatment of the rhinogenic infection (nasal spray, • mucolytica) vestibular suppressant medications and antiemetics • antibiotics intravenously to avoid bacterial super-• infection (cephalosporine, aminopenicillin with or without a β-lactamase-inhibitor) high doses of antibiotics, e. g. cephalosporines (third • generation), chloramphenicole and aminoglycosides, according to the smear culture results vestibular suppressant medications and antiemetics • in lues iii, penicillin g or tetracycline • in tuberculosis, tuberculostatic therapy • in mucormycosis, amphotericine b, control of diabe-• tes infusions with electrolytes; antipyretica • each otogenic labyrinthitis caused by bacteria needs surgical intervention. myringotomy, insertion of ventilating tubes ( the most frequent bacteria causing meningogenic labyrinthitis are meningococci, pneumococci and hemophilus influenzae type b. : severe vertigo with nystagmus, vomiting, high fever. it invariably results in complete hearing loss and is often followed by facial paralysis. meningogenic labyrinthitis: • classic symptoms of meningitis, severe vertigo with nystagmus, vomiting, unilateral or bilateral, often fluctuating hearing loss or complete deafness. postinflammatory rapid ossification of the cochlear fluid spaces. meningitis, encephalitis, brain abscess, complete deafness, lethal outcome. : congenital or acquired syphilis (third stage). fluctuating hearing loss, endolymphatic hydrops, dizziness. hennebert sign positive. if untreated, it results in complete hearing loss. : formation of tuberculous granuloma along vascular spaces which spread into the labyrinth spaces. progressive sensorineural hearing loss. in most cases it is associated with a systemic haematogenic spreading of tuberculosis. • systemic, in many cases fatal mycotic sepsis (caused by, e. g., rhizopus, absidia) in immunodepressed patients (aids, leukaemia, diabetes): high temperature, meningitis, deafness, facial palsy, vertigo, purulent sinusitis. otoscopy or ear microscopy: serous or purulent otitis • media, pulsating tympanic membrane, cholesteatoma, bone fracture hearing examination: tuning fork, audiogram (mixed • or pure sensorineural hearing loss, deafness) frenzel glasses: at the beginning nystagmus in the • direc tion of the affected ear, later in the opposite direction high-resolution "emergency ct" • early onset of therapy (antibiotics, antimycotics) is • obligatory in this life-threatening infection of the temporal bone. deafness and long-lasting dizziness. lethal outcome • in most cases of generalized mucormycosis. in cases of bilateral complete deafness following bacte-• rial meningitis, early cochlear implantation is recommended before ossification of the cochlea occurs (see sect . . ). concussion of the labyrinth. microinjuries of the vestibulocochlear organ (bleeding, membrane ruptures, microfractures) caused by a blunt concussion of the skull, with or without fracture of the skull base or contusio cerebri. sensorineural hearing loss affecting all frequencies or mainly the frequencies above khz. in lateral (parietal) trauma, mainly the opposite ear is affected (contrecoup); when the blunt forces act from behind (occipital trauma) then both labyrinths can be damaged. vertigo and tinnitus are accompanying symptoms. luxation of the ossicles (e. g. incus), perilymphatic • fistula, slowly progressive sensorineural hearing loss, deafness, long-lasting vertigo, subdural bleeding, posttraumatic endolymphatic hydrops. postconcussion disequilibrium syndrome: patho-• mechanisms and symtoms are identical with those of benigne paroxysmal vertigo (see sect. . . ) and cupolithiasis [ ] . detailed history (of forensic importance) • inspection of the skull, searching for skin injuries, • haematoma inspection of the oral, nasal and nasopharyngeal cavi-• ties otoscopy or ear microscopy, searching for fracture • signs, haemotympanum, rupture of the tympanic membrane hearing examination: tuning forks, audiogram, tym-• panogram, stapedius reflexes frenzel glasses: to exclude vestibular irritation or loss • of function of one vestibular organ schüller-x-ray, high-resolution ct: to exclude frac-• tures examination of the vestibular function (electronystag-• mography, video-oculography) examination of the sense of smell to exclude rupture • of the fila olfactoria the recommended european standard is use of antioedematous principles (see sect. . . ). if there is an additional conductive hearing loss caused by trauma of the middle ear structures, reconstruction of the ossicular chain is recommended some weeks following the injury. csf leak: e. g. complication of vestibular schwannoma surgery, middle and posterior fossa surgery, surgery for chronic ear disease (less frequently) a watery pulsating secretion when there is a tympanic membrane perforation or rupture. when the tympanic membrane is intact, there is clear fluid behind the tympanic membrane simulating a serous otitis media ( fig. . . ) . outflow of watery fluid from the nose (otorhinoliquorrhoea). coughing at night. a sensation of salty fluid in the mouth. recurrent meningitis, meningoencephalitis. the prognosis is uncertain: in many cases complete restoration of the cochleovestibular deficit is possible; in some cases progressive hearing loss and/or long-lasting vertigo are possible. sudden deafness, sudden idiopathic sensorineural hearing loss. sudden sensorineural hearing loss is characterized by an acute in the majority of cases unilateral hearing loss originating in the inner ear of unknown pathogenesis and origin. hearing loss may be slight, moderate, profound or complete and concerns the high, middle, deep or all frequencies. the disease is accompanied by tinnitus in about % of cases and dizziness in about % of cases. the incidence ranges between cases per , residents per year in austria and germany, eight to cases per , residents per year in japan and about cases per , residents per year in the usa. women are equally affected as men, most frequently at the age of ± years. however, there is an increasing incidence in younger people, whereas children are rarely concerned. the cause is still unknown. the following pathomechanisms are currently discussed: impairment of cochlear blood flow due to vasomotor according to the affected frequencies and severity the following types of sudden idiopathic sensorineural hearing loss can be distinguished ( fig. . . ): high-frequency idiopathic sensorineural hearing • loss, which may be due to cellular malfunction of outer (below db hl) and inner (beyond db hl) hair cells (fig. . . a). low-frequency idiopathic sensorineural hearing • loss, which may be due to endolymphatic waterelectrolyte imbalance or even endolymphatic hydrops as a possible result of impaired blood flow within the vascular stria and subsequent hypoxic cellular damage ( fig. . . b). middle-frequency idiopathic sensorineural hearing • loss, which may be due to impaired blood flow within the spiral lamina and subsequent hypoxic cellular damage of the organ of corti or, alternatively may be due to genetic defects ( fig. . . c). all-frequency idiopathic sensorineural hearing • loss, which may be due to blood flow impairment in the spiral modiolar artery and/or upstream arteries resulting in hypoxic damage of cochlear tissues ( fig. . . d). profound idiopathic sensorineural hearing loss and • deafness, which may be due to thrombotic or embolic blood flow obstruction in the arteria cochlearis communis or spiral modiolar artery resulting in hypoxic damage of cochlear tissues. perilymphatic fistula due to rupture of the round window membrane or lesion of the oval window which may result in acute profound hearing loss or even deafness is a disorder of a distinct origin and, therefore, cannot be referred to as idiopathic sensorineural hearing loss by definition ( fig. . . e). , such as fluctuating hearing thresholds, progressive hearing loss in spite of current therapy etc. patients complain about symptoms in the following descending order of incidence: acute • unilateral subjective hearing loss, although this symptom may be not perceived in cases of slight hearing loss restricted to a few frequencies another complication may concern psychoemotional and psychosocial problems in cases of persistent hearing loss and/or tinnitus (see sect. . . ). recommended european standard tus was not taken into consideration. patients would not regard themselves as fully recovered when their tinnitus is still persistent. however, in well-informed patients presenting with a slight hearing loss without previous ipsilateral or contralateral hearing loss and without tinnitus and/or dizziness, one may await spontaneous recovery for a few days. basic therapeutic interventions comprise normalization of systemic blood pressure, heart rate and haematocrit level (below ). for patients complaining of moderate to severe psychoemotional ailments such as anxiety, fear, distress, restlessness, agitation, resignation and sense of guilt, a psychotherapist should be included. according to the aforementioned cause and pathogenesis possibly involved, therapeutic recommendations differentiate between the various types of sudden idiopathic sensorineural hearing loss. high-frequency idiopathic sensorineural hearing • loss. a daily dose of - mg prednisolone intravenously on three consecutive days is recommended. in the case of partial or no remission, prednisolone treatment should be continued orally for days, starting with , , , , , , and . mg each dosage for two days. prednisolone therapy should be accompanied by gastric proton pump inhibitors ( mg omeprazole per day or mg ranitidine per day or others). prednisolone is a synthetic analogue of endogenous corticosteroid hormones classified as glucocorticoids. besides anti-inflammatory effects, prednisolone possesses multiple other cellular effects. the rationale for administration of prednisolone is based on the consideration that inflammatory tissue alterations are also elicited by tissue ischaemia and hypoxia. in addition, prednisolone mobilizes amino acids for gluconeogenesis, alters glucose utilization and influences protein metabolism. finally, prednisolone binds with equal affinity to both glucocorticoid and mineralocorticoid receptors widely distributed in cochlear tissues, thereby contributing to restoration of cellular osmolarity, electrochemical gradients, transmembrane ion flux and neuronal conduction. in patients presenting with contraindications (e. g. diabetes, severe chronic gastritis, gastric or duodenal ulcera) for the treatment with prednisolone, intravenous infusion of a hyperoncotic hydrophilic haemodilutive plasma-expanding agent, such as hydroxyethyl starch or others ( - ml/day for - days) is a good alternative option. sudden idiopathic sensorineural hearing loss must be managed with care and as soon as possible concerning the diagnostic procedures and the mode and beginning of therapy. according to the categories of the oxford centre for evidence-based medicine (http://www.cebm.net), the evidence level of most clinical trials on therapy of sudden deafness is relatively low. in addition, the clinical trials considered in the cochrane international register of controlled clinical trials, e. g. prospective, randomized, placebo-controlled and double-blind conducted studies, are of relatively high level of evidence; however, the underlying study protocols vary tremendously. therefore, universally valid therapeutic options based on reproducible results are not available. instead, thera peutic recommendations are merely formed empirically. spontaneous recovery rates range from to %; however, these data were revealed from retrospective, non-randomized and mostly non-controlled trials on a few patients only. furthermore, the term "recovery" was not exactly defined, e. g. partial remission was not distinguished from complete remission, and a persistent tinni-however, contraindications (e. g. arterial hypertension) should be noted, and potential side effects (e. g. temporary pruritus) should be considered. in the case of contraindications for haemodilution, another haemorheological active drug such as pentoxifylline ( mg, equivalent to ml/day dissolved in ml . % isotonic saline) may be intravenously infused for - days. additional administration of scavangers of toxic free oxygen radicals such α-lipoic acid ( mg/day orally) during haemodilutive or haemorheological infusion therapy may be reasonable to prevent reperfusion injury within the cochlea. low-frequency and middle-frequency idiopathic • sensorineural hearing loss. a daily dose of - mg prednisolone intravenously on three consecutive days is recommended. in the case of partial or no remission, prednisolone treatment should be continued orally for days together with gastric proton pump inhibitors as described above. additional osmotic infusion therapy using mannitol ( g in ml solution) and acetazolamide ( mg) intravenously on three consecutive days may be administered. acetazolamide ( mg/day) may be continued orally for days. in patients presenting with contraindications (e. g. diabetes, severe chronic gastritis, gastric or duodenal ulcer) for the treatment with prednisolone, initial osmotic therapy is recommended. all-frequency idiopathic sensorineural hearing • loss. a daily dose of - mg prednisolone intravenously on three consecutive days is recommended. in the case of partial or no remission, prednisolone treatment should be continued orally for days together with gastric proton pump inhibitors and additional haemodilutive/haemorheological infusion therapy together with α-lipoic acid should be administered as described for high-frequency idiopathic sensorineural hearing loss. in patients suffering from an elevated fibrinogen level (above mg/dl) fibrinogen and low density lipoprotein apheresis may be a good alternative to haemodilutive or haemorheological infusion therapy. however, the expense is relatively high and the long-term outcome on hearing gain was proved to be equally effective as with conventional therapy as described above. profound idiopathic sensorineural hearing loss and • deafness. a daily dose of mg prednisolone intravenously on three consecutive days together with haemodilutive/haemorheological infusion therapy and α-lipoic acid should be administered as described for high-frequency idiopathic sensorineural hearing loss. prednisolone treatment should be continued orally for days together with gastric proton pump inhibitors as described, and haemodilutive/haemorheological infusion therapy and α-lipoic acid should be continued for another seven consecutive days. in patients suffering from an elevated fibrinogen level (above mg/dl) fibrinogen and low density lipoprotein apheresis may be additionally tried (but see the comments for all-frequency idiopathic sensorineural hearing loss). in the case of minor or no remission at all, perilympatic fistula due to rupture of the round window membrane or lesion of the oval window may be considered and tympanoscopy should be performed preferably within - days after onset of hearing loss. if initial therapy with prednisolone and/or haemodilutive or alternative haemorheological agents is only partially or not effective at all, and this is the case in over % of patients, hyperbaric oxygenation therapy (ten to sessions on ten to consecutive days) should be started as soon as possible, preferably within - weeks after the onset of idiopathic sensorineural hearing loss. in the case of progressive hearing loss in spite of current therapeutic intervention or in the case of minor or no remission of profound hearing loss, tympanoscopy should be performed to exclude or seal a rupture of the round window membrane or a lesion of the oval window (see sect. . . . ). sudden sensorineural hearing loss may also be attributable to the following diseases: perilymphatic fistula • . perilymphatic fistulae of the oval or round window are rare clinical findings. they the prognosis is most favourable in low-frequency and middle-frequency idiopathic sensorineural hearing loss without previous hearing loss. however, recurrence rates of such hearing losses range up to %. patients with slight to moderate threshold shifts recover better than patients presenting with moderate to profound hearing loss. a relatively worse prognosis is expected in profound hearing loss or even sudden deafness. ménière's syndrome, idiopathic endolymphatic hydrops, morbus ménière. the syndrome is characterized by: recurrent spontenous attacks of vertigo, fluctuating hearing loss (at the early beginning mainly affecting low frequencies) tinnitus and aural fullness. according to the american academy of otolaryngology-head and neck surgery at least two attacks of objective rotational vertigo, each of -min duration or longer must occur to confirm the diagnosis of ménière's disease. unilateral sensorineural hearing loss may occur during skull trauma, following stapes surgery, middle ear surgery, after lifting heavy weights or spontaneously. perilymphatic fistulae in the area of the annular ligament of the stapes footplate cause sensorineural hearing loss and dizziness of different extent. they can occur after stapes surgery with insufficient sealing of the prosthesis. congenital perilymphatic fistulae of the stapes footplate occur in cases of malformation of the stapes and cause recurrent meningitis. they are usually detected during exploration of the oval window. perilymphatic fistulae of the round window membrane are rare findings in cases of sudden hearing loss. there are no clear clinical symptoms characteristic for round window membrane rupture. in some cases the history reveals strong physical exertion (explosion trauma after goodhill). all diagnosed perilymphatic fistulae should be completely sealed with connective tissue and fibrin glue to avoid labyrinthitis and/or meningitis. surgical sealing of the ruptured round window membrane or annular ligament with connective tissue sometimes results in partial or complete, but not predictable, restoration of hearing. haematological diseases (e. g. polycythaemia, poly-• globulia, leukaemia, exsicosis psychogenic hearing loss. • must be documented audiometrically on at least one occasion. the diagnosis "ménière's disease" always is a diagnosis "per exclusionem" since other diseases of the cochleovestibular system can mimic ménière's symptoms. temporal bone histopathology from ménière's patients are usually showing dilatations (hydrops), distortions and/or ruptures ( fig. . . ) of the delicate membranes separating the endolymphatic from the perilymphatic fluid compartements. hydrops can develop simultaneously as well in the cochlear as in the vestibular compartments, but also isolated in only one of the compartments (this may explain why in ménière the symptoms can only consist of attacks of vertigo or hearing loss with tinnitus). a malfunctioning spiral ligament and /or endolymphatic sac (disturbed resorption of the endolymph, immunologic factors causing "saccitis") seem to be involved in the pathophysiology of endolymphatic hydrops. recently the homing of herpes type i viruses has been demonstrated as well within the endolymphatic sac as in ganglion cells of scarpa's ganglion. reactivation of these viruses seems to be triggered by (immunologic) stress factors clinically causing the typical symptoms of the disease. there are many known causes of endolymphatic hydrops: viral labyrinthitis, autoimmune inner ear disease (e. g. cogan's syndrome), otosclerosis, leukaemia, otosyphilis, surgical trauma to the inner ear, temporal bone trauma, etc. when the cause cannot be identified, the term "ménière's disease" is used. the incidence is one in , individuals per year in europe. approximately % of patients will develop contralateral involvement over time ( % at -year follow-up). classic symptoms are: recurrent attacks of rotational vertigo (the most dis-• abling symptom for the patients) which last from several minutes to hours. vertigo is often associated with nausea and vomiting. fluctuating, unilateral low-frequency hearing loss of • the sensorineural type (upsloping audiometric pattern). in the late stages of the disease, there is flat or downsloping non-fluctuating sensorineural hearing loss (hearing threshold of - db, speech discrimination of - %). during the attacks, subjective tinnitus and aural full-• ness/pressure are present. between attacks patients are not dizzy but aural fullness and tinnitus may persist. vertigo attacks can vary in frequency, intensity and duration. generally the attacks increase in severity and frequency with progression of the disease. the frequency and intensity of the vertigo attacks decrease after approximately - years. clinical history: extremely important. physical examination: normal findings. between the • attacks patients usually display horizontal, spontaneous nystagmus beating away from the affected ear (paretic nystagmus). electrocochleography • : a significant enhancement of the summating potential to action potential amplitude ratio (more than %) occurs in % of patients with ménière's disease. auditory brainstem response. • mri with contrast medium plays an important role in • excluding a retrocochlear lesion (vestibular schwannoma) in any patient with unilateral neurotologic symptoms! blood sedimentation rate, antinuclear antibody test • for autoimmune ear disorders (see sect. . . ); fluorescent treponemal antibody absorption test to rule out syphilis. glucose tolerance and thyroid function tests are rec-• ommended as hypothyroidism and diabetes may be associated with the disease. lipid profile. caloric tests (with electronystagmography): reduced • caloric response on the affected side. intratympanic application of ganciclovir mg/ml per • days through a ventilating tube or a microwick inserted into the tympanic membrane [ ] . endolymphatic glycerol test ( . - . ml/kg body weight of glycerol • mixed with lemon juice): frequently used in the past, but much less nowadays because of its side effects (headache, nausea, vomiting). note: the diagnosis is often by exclusion. vestibular schwannoma • sudden sensorineural hearing loss • autoimmune hearing loss • migraine • . . . therapy . in acute attacks bed rest, vestibular suppressant medication (diazepam) and antiemetics (transdermal scopolamine, thiethylperazine, prochlorperazine) are recommended . to prevent attacks, decrease the amount of fluid in the inner ear by diet and diuretics − diet: low salt intake (less than g per day) and reduced water intake − diuretics: acetazolamide, chlortalidone, hydrochlorothiazide, furosemide. replace potassium if needed . in addition − vasoactive drugs (betahistidine) to improve blood flow in the inner ear − steroids to suppress inflammatory and/or allergic tissue reactions within the inner ear (endolymphatic sac) . avoidance of caffeine, alcohol, tobacco . antiviral approach [ ] : oral acyclovir ( mg times a day) for weeks; if the patient feels better, reduce the dose to mg times a day for month and then to mg daily for another month before ending the treatment. insertion of a • transtympanic ventilating tube (montandon) ( fig. autoimmune hearing loss, immune-mediated inner ear disease. an underlying genetic predisposition results in auto-• immune disease expression following immunoregulatory defects in immune response to unknown environmental pathogens. today there is substantial evidence of autoimmune • mechanisms in relapsing polychondritis ( fig. . . c), cochlear vasculitis (e. g. cogan's syndrome), progressive sensorineural hearing loss of both sides and some types of sudden deafness. with regards to ménière's disease, around % of bi-• lateral cases and % of monolateral cases may be due to immune dysfunction. autoimmune inner ear disease • represents less than % of all cases of hearing impairment or dizziness; nevertheless, the diagnosis might be overlooked because of the lack of a specific diagnostic test. the disease seems to be more common in females than in males; the first onset of symptoms generally occurs between and years of age. sympathetic cochleopathy: sudden sensorineural hear-• ing loss in the last hearing ear (similar to sympathetic ophthalmopathy). hearing loss: a rapidly progressive, often fluctuating, • bilateral sensorineural hearing loss over a period of weeks to months. the progression of hearing loss is too rapid to be diagnosed as idiopathic progressive sensorineural hearing loss or presbyacusis and too slow to conclude a diagnosis of sudden sensorineural hearing loss. tinnitus: - % of patients also have tinnitus (ring-• ing, hissing, roaring) and aural fullness, which can fluctuate. vertigo and/or imbalance: generalized imbalance, • ataxia, motion intolerance, positional vertigo and episodic vertigo may be present in up to % of patients. occasionally only one ear is affected initially, but bilat-• eral hearing loss occurs in most patients ( %), with symmetric or asymmetric audiometric thresholds. currently, the diagnosis of autoimmune inner ear dis-• ease is based either on clinical criteria or on a positive response to steroids. there is seldom convincing evidence from broader laboratory tests indicating autoimmunity. detailed history: endocrine diseases? recurrent fe-• ver? otoscopy findings are usually normal; nevertheless external ear skin and/or cartilage inflammation and/or facial palsy may rarely occur (e. g. relapsing polychondritis), as well as tissue destruction at the level of the tympanic membrane, middle ear and mastoid (e. g. wegener's granulomatosis). there are no antigen-specific tests (migration inhibition test, lymphocyte transformation test and western blot analysis) that are commercially available and proven to be useful for the diagnosis of systemic autoimmune diseases. in clinical practice next to the indispensable blood sedimentation rate (bsr) a non-specific antigen screening test may be useful for evidence of systemic immunologic dysfunction; yet it does not strictly correlate with a diagnosis of immune-mediated inner ear disease. recommended tests are: blood tests for autoimmune disorders: levels of cir-• culating immune complexes, bsr, antinuclear antibodies, rheumatoid factor, complement c q, smooth muscle antibody, tsh and antimicrosomal antibodies, antigliadin antibodies (for celiac disease), hla testing. blood tests for conditions that resemble autoimmune • disorders: fluorescent treponemal antibody absorption test (for syphilis), lyme titre, hba c (for diabetes, which is often also autoimmune-mediated), hiv (hiv is associated with auditory neuropathy). note that a commercially available test, called "anti- kd (hsp- ) western blot" (otoblot tm ) was reported to de- autoimmune inner ear disease is analogous to rapidly progressive glomerulonephritis. if not treated, the inner ear inflammation progresses to severe irreversible damage within months of onset (and often much more quickly). on the other hand, steroid responsiveness is high and with prompt treatment the hearing loss may be reversible. nevertheless, several patients become steroiddependent. ringing in the ears (from latin tinnire meaning "ringing"). it is important to distinguish between objective and subjective tinnitus: patients affected by an • objective tinnitus notice a real existent endogenous acoustic source originating in the middle ear, eustachian tube, soft palate or extracranial or intracranial vessels. such acoustic phenomena may also be perceived by the non-affected fellow human being using a stethoscope; however, the incidence of this kind of tinnitus is relatively seldom. depending on the underlying disease, the patients notice intermittent clicks or crackles due to spasm of the middle tect a local autoimmune inner ear process in the absence of any systemic autoimmune process and to be correlated with steroid responsiveness. the test uses purified hsp- kda antigen from a bovine kidney cell line and is based on the assumption that the -kda protein is heat shock protein (hsp- ). unfortunately, this assumption has now been refuted: in fact, there is mounting evidence that the target antigen of the -kda antibody is not hsp- (as was believed over the last years), but the human choline transporter-like protein (ctl ). furthermore, the sensitivity and specificity of this test are very low. large vestibular aqueduct syndrome • endocranic hypertension • prednisolone, mg/kg per day for weeks followed by • a gradual tapering over several weeks to a maintenance dose of - mg per day or every other day. shorterterm or lower-dose long-term therapy either has been ineffective or appears to increase the risk of relapse. patients often learn the necessary maintenance dose to preserve their hearing, as the disease activity often waxes and vanishes. if hearing suddenly worsens or tinnitus reappears in one or both ears during the tapering period, repetition of the initial high-dose treatment is indicated. oral as well as systemic steroid treatment over long • period of time should always be accompanied by proton pump inhibitors to avoid a gastric ulcer. in patients with no response to steroids within • - weeks, methotrexate and cyclophosphamide have been used over the long term. these agents are associated with considerable toxicity and the decision regarding when and how to use them should always be multidisciplinary. the normal oral dose of methotrexate is . - mg weekly with folic acid. cyclophosphamide in addition to steroids has been used with the following regimen: cyclophosphamide mg/kg per day intravenously for weeks, followed by a rest period of weeks, and then a final period of infusions for weeks. ear muscles or myoclonus of soft palate muscles, respiratory noise and breath, respectively, due to an abnormally wide eustachian tube, or a pulsatile noise due to intracranial hypertension, glomus tumour, angioma, aneurysm, arteriovenous fistula, stenosis or thrombosis of extracranial or intracranial vessels as well as due to systemic rheological diseases such as hyperglobulinaemia or anaemia. in contrast, a • subjective tinnitus is exclusively perceived by the affected patient. in most cases it consists in an intermittent or continuous whistling or fizzling, in broadband or narrowband noise, hum, ping or ringing, or even in pure tones of various frequency, intensity and duration. such auditory perceptions emerge from deficient neuronal plasticity within the central auditory system triggered by an auditory input failure. in this respect, a subjective tinnitus is a symptom of any disease of the peripheral and/or central auditory system associated with malfunction of hearing. in this particular context it should be emphasized that tinnitus is not a symptom of an organic or functional disease of the cervical spine, temporomandibular joint or any other orthopaedic or dental distress; likewise tinnitus is not caused by emotional, mental or physical distress, although the intensity and annoyance of tinnitus may be amplified by such problems. there are no epidemiological data available concerning the incidence and prevalence of an objective tinnitus. a transient subjective tinnitus is perceived by about - % of the population of industrial nations at least once in their life; - % have perceived tinnitus over a longer period in their life, with an annual incidence of . % in germany. the point-prevalence of a constant chronic tinnitus (perceived as longer than months up to years) averages about % of the population of industrial nations, of which about . - % regard themselves as severely psychoemotionally affected. of those patients who perceive tinnitus over a longer period in their life, - % notice the tinnitus in a silent environment only (grade i); - % perceive their tinnitus permanently, however it may be masked by moderate environmental noise (grade ii). in only - % of cases is tinnitus perceived even in a relatively loud environment (grade iii). according to a recent evaluation of about , members of the german tinnitus support group (deutsche tinnitus-liga, http://www.tinnitus-liga.de) who perceived tinnitus for more than months up to years, % localized their tinnitus in both ears, while a further % localized their tinnitus perception in the middle of the head. of the unilaterally affected, % perceived tinnitus in the left ear and % in the right ear. the high incidence of bilateral tinnitus averaging about % and the slight preference of the left ear is also known from former evaluations among non-selected populations. the prevalence of tinnitus is only somewhat higher (by - %) in females than in males. respecting the age distribution, manifestation of tinnitus is most common between and years of age; however, there is an increasing incidence of noise-induced tinnitus in younger people owing to exposure to leisure noise such as noisy toys, amplified music, motorcycling and other loud recreational activities. data from long-term studies concerning the incidence and prevalence of a chronic tinnitus (for more than months up to years) in this population are not available so far. concerning an objective tinnitus, there are no data available regarding the incidence of the underlying diseases, as mentioned already in sect. . . . . the subjective tinnitus is a symptom of any diseases of the peripheral and/or central auditory system associated with malfunction of hearing in the following descending order of incidence: in % tinnitus is being caused by noise-induced damage of the inner ear due to single or repetitive exposure to industrial or leisure noise; in % by acute acoustic trauma of the inner ear due to single or repetitive sound impulses from pistols, revolvers, military rifles, sport guns, firecrackers, fireworks and others; in - % by idiopathic sensorineural hearing loss (sudden deafness); in % by ménière's disease (morbus ménière); in % by age-related sensorineural hearing loss (presbyacusis); in % by toxic labyrinthitis due to an acute serous or purulent otitis media; in % by chronic otitis media inclusive of cholesteatoma; in - % by otosclerosis; and in % by a vestibular schwannoma (acoustic neurinoma). in the remaining - % tinnitus may be caused by obliteration of the outer ear canal with wax, exostosis or others; myringitis, rupture or perforation of the ear drum; dysfunction of the eustachian tube due to acute or chronic infections of the upper respiratory tract; barotrauma of the middle ear; tympanosclerosis; luxation of the incudomalleal or incudostapedial articulation; rupture of the round window membrane; perilymphatic fistula of the round or oval window; labyrinthine contusion or fracture of the temporal bone due to head trauma; meningitis or encephalitis; ototoxic medication (aminoglycosides, cisplatin, etc.); intoxication by alcohol or drugs; peridural in summary, there are almost diseases of the peripheral and/or central auditory system which may cause tinnitus. in this respect, an accurate otoneurological diagnostic procedure is of prime importance. subjective tinnitus cannot be treated directly. in fact, treatment is targeted to the underlying disease of the peripheral and/or central auditory system to achieve elimination of auditory input failure, thereby correcting pathological neuronal plasticity within the central auditory system. it is important to explain these issues to the patient in the acute stage, e. g. first tinnitus counselling. . acute stage (less than months' duration). acute tinnitus due to noise-induced damage or acoustic trauma of the inner ear, idiopathic sensorineural hearing loss (sudden deafness), acute attack of ménière's disease, toxic labyrinthitis, rupture of the round window, perilymphatic fistula of the round or oval window, labyrinthine contusion or fractures of the temporal bone due to head trauma should be treated with a daily dose of - mg prednisolone intravenously on three consecutive days. in the case of partial or no remission, prednisolone treatment should be continued orally for days, starting with , , , , , , and . mg each on two consecutive days. prednisolone therapy should be accompanied by gastric proton pump inhibitors ( mg omeprazole per day or mg ranitidine per day or others). in patients presenting with contraindications (e. g. diabetes, severe chronic gastritis, gastric or duodenal ulcer) for the treatment with corticosteroids classified as glucocorticoids such as prednisolone, infusion therapy as described below may be a good alternative option. in cases of severe hearing loss, additional intravenous infusion therapy using a hyperosmotic hydrophilic haemodilutive plasma-expanding agent, such as hydroxyethyl starch or others ( - ml/day for - days), would be reasonable to improve microcirculation. however, contraindications (e. g. arterial hypertension) should be noted, and potential side effects (e. g. temporary pruritus) should be considered. in the case of contraindications for haemodilution, another haemorheological active drug such as pentoxiphylline ( mg, equivalent to ml/day dissolved in ml . % isotonic saline) may be intravenously infused for - days. if this initial therapy with prednisolone and/or haemodilutive or alternative haemorheological agents is only partially effective or not effective at all, and this is the case in over % of patients, hyperbaric oxygenation therapy should be started as soon as possible (ten to sessions on ten to consecutive days). however, according to clinical trials therapeutic results on tinnitus are only available from patients suffering from acoustic trauma, noise-induced hearing loss and idiopathic sensory-neural hearing loss (sudden deafness); therefore, hyperbaric oxygenation therapy should be restricted to these three indications. for additional treatment of tinnitus due to an acute attack of ménière's disease, toxic labyrinthitis, rupture of the round window, perilymphatic fistula of the round or oval window, labyrinthine contusion or fractures of the temporal bone due to head trauma, see the specific sections. likewise, for treatment of all other diseases of the peripheral and/or central auditory system which may cause a subjective tinnitus, such as chronic otitis media, cholesteatoma, mastoiditis, otosclerosis and vestibular schwannoma (acoustic neurinoma), see the specific sections. . subacute stage (duration of more than months up to year) and chronic stage (duration of more than year). in both, the subacute and the chronic stage a − patients presenting with tinnitus-associated and/ or other complaints, such as sleep disturbance, concentration and attention problems, psychoemotional and psychosocial problems, should be admitted to a cognitive tinnitus coping therapy including a multimodal behavioural treatment in a specialized psychotherapeutic-psychosomatic outpatient department, or in selected cases to a psychotherapeutic-psychosomatic inpatient clinic. − a promising novel therapeutic innovation is neurofeedback training, which has been shown to effectively relieve stress-associated symptoms and thereby annoyance of tinnitus. the outcome is dependent on the quality of the initial and the following medical attendance, e. second tinnitus counselling should be performed as follows: − tinnitus is an auditory phantom perception which emerges from deficient neuronal plasticity within the central auditory system triggered by an auditory input failure due to any disease of the peripheral and/or central auditory system. − it is ensured that all aforementioned initial therapies and/or other causal treatment of the underlying disease of the peripheral and/or central auditory system have failed to ameliorate or eliminate tinnitus at the latest by the end of the subacute stage. − the patient should be briefed that the following pharmaceuticals, natural remedies and other therapeutic strategies have been proven to have no persistent effect on subacute and/or chronic tinnitus in placebo-controlled clinical trials: intratympanal application of glucocorticoids, lidocaine, glutamate-receptor agonists or antagonists; systemic administration of antiarrhythmics such as lidocaine, anticonvulsive drugs such as lamotrigine or carbamazepine, antidepressives such as trimipramine, nortriptyline or amitriptyline, benzodiazepines such as diazepam or alprazolam, vasodilative drugs such as pentoxifylline, cyclandelate, prostaglandin e , analogues of histamine such as betahistine, antagonists of histamine receptors such as cinnarizine, calcium antagonists such as flunarizine or trimetazidine, gaba agonists such as baclofen, antiphlogistic drugs such as azapropazone, diuretics such as dyazide, melatonin, zinc, vitamins, ginkgo biloba, laser therapy of any kind with or without ginkgo biloba, acupuncture of any kind, ultrasonic therapy and electromagnetic stimulation of any kind. − therefore, in the chronic stage correction of pathological neuronal plasticity within the central auditory system cannot be achieved directly by pharmaceuticals, natural remedies or other treatment strategies already mentioned, but can be achieved indirectly by compensation of the remaining hearing loss using hearing aids as soon as possible. however, in cases where hearing loss is less than db hl at three or fewer frequencies ( khz included), a broadband noise generator (formerly tinnitus masking device) may be helpful to defocus on tinnitus. − in addition, active listening to music of someone's own choice and/or to audiobooks are reasonable therapeutic auditory training strategies which may be helpful to direct the patient's attention to external auditory stimuli again. . . noise-induced hearing loss . . noise-induced hearing loss the disorder is defined as hearing loss caused by acute or chronic exposure to high-intensity sound. impulse sound exposure with an intensity above db(a) spl peak equivalent with a peak sound pressure duration greater than ms. explosion traumas are seen in explosives fabrication and the processing industry, in the military, in the gas, tyre and chemical industry as well as in motor vehicle accidents. additionally, they can occur from a physical injury to the ear, such as a blow to the side of the head, diving head first into water or deployment of an airbag. an explosion trauma of the ear generally leads to inner ear damage concomitant with a rupture of the eardrum and, most often, a disruption of the ossicular chain ( fig. . . b) . this leads to a unilateral or bilateral, moderate to severe combined (conductive and sensorineural) hearing loss with otalgia, tinnitus and, frequently, vestibular symptoms. at the time of examination, a serous otitis media has commonly developed. complete hearing loss and tinnitus are feared. further complications are long-lasting vertigo and rupture of the round window membrane. detailed patient history-important in the case of a video-oculography (vog) or electronystagmography • (eng). an eventual caloric testing must be performed with cold and warm air insufflation in the case of ear drum injury. tinnitus analysis with subjective loudness assessment • and testing of masking possibility ( fig. . . ). as in sudden hearing loss (see sect. . . ) • initiate hyperbaric oxygen therapy as soon as pos-• sible! in the case of complete hearing loss and suspicion of as in sudden hearing loss (see sect. . . ). with more severe inner ear damage, initiate additional • hyperbaric oxygen therapy as soon as possible. in the case of complete hearing loss and suspicion of • rupture of a cochlear window: tympanotomy and closure of a perilymphatic fistula (see sect. . . ). minor high-frequency sensorineural hearing loss and a more or less disturbing tinnitus can persist in spite of rapid and correct therapy. the chances of spontaneous recovery without therapy • is low. sometimes untreated post-traumatic hearing loss is progressive. myringoplasty (see sect. . . ) • tympanoplasty (see sect. . . ) • with occupational explosion trauma, special compensation insurance must be addressed (berufsgenossenschaft in germany, suva in switzerland, inail in italy). shooting trauma, muzzle blast trauma. impulse sound exposure with an intensity above db(a) spl peak equivalent with a peak sound pressure duration shorter than ms (normally . - . ms). the main cause of shooting trauma is inappropriate use of a handgun, e. g. in the military, by police or by hunters. however, also guns firing blanks and toy guns produce sound pressures greater db(a)! additionally, fireworks and airbags ( fig. . . ) can cause muzzle blast trauma. otomicroscopy shows no abnormalities. in audiometric testing, there is an acute, most often unilateral mild to moderate sensorineural hearing loss of around khz (c notch) and a positive recruitment. tinnitus in the damaged ear is common. sometimes otalgia or vestibular disturbance is present. in the case of repeated muzzle blast trauma in a short period of time (toy gun), a steep highfrequency hearing loss above khz develops. persistent tinnitus. complete deafness or persistent vestibular vertigo is very rare. the surgical treatment is no replacement for conserva-• tive therapy. if needed, it is carried out additionally. derived from patient history, the event of accident and clinical findings any of the following other possible diagnoses should be considered: cochlear window rupture • contusio labyrinthi • distortion of the cervical spine (whiplash injury) • an initial good recovery of the high-frequency hear-• ing loss occurs in approximately half of the cases. after some weeks, a remaining hearing loss or a persisting tinnitus must be considered as permanent damage. a post-traumatic increase of hearing loss above khz is possible. a spontaneous recovery of a high-frequency tinnitus is rare. if high-dose glucocorticoid, rheologic therapy and • hyperbaric oxygen therapy is administered as soon as possible, recovery to normal hearing is frequently achievable. with occupational blast trauma any special compensation insurance must be addressed (berufsgenossenschaft in germany, suva in switzerland, inail in italy). broadband sound exposure with an intensity above db(a) spl peak equivalent for minutes to hours. exposure to non-impulse permanent sound causes metabolic as well as mechanical ultrastructurally visible damage at the level of the organ of corti (outer hair cells, stereocilia). excessive demand for oxygen and subsequent progressive ischaemia of the cochlea lead to production of free radicals, depletion of endogenous cellular antioxidants and, finally, apoptotic cell death. discotheques: averaged over min, a music sound • pressure level of - db(a) with sound pressure peaks of up to - db(a) spl can be measured. acute, most often bilateral, mild to moderate high-frequency sensorineural hearing loss (c notch) with positive recruitment. tinnitus is frequent, as is a temporary threshold shift. otalgias or vestibular symptoms occur rarely. permanent hearing loss and/or tinnitus. detailed patient history-important in the case of a • later lawsuit and for expert reports. complete ent examination. by definition, noise-induced hearing loss is an effect of working in noise and therefore occurs most frequently in metalworkers, mineworkers, airport workers, radio operators, disc jockeys and military personnel as well as construction workers and orchestra musicians, etc. because of extensive recruitment, this progressive binaural hearing loss leads to an important communication problem in noisy environments (conversation of multiple persons, theatre, restaurant). a pronounced hyperacusis is common. tinnitus is found in % of patients. social isolation following hearing loss, psychiatric impairment secondary to the tinnitus. detailed patient history, including professional and the prognosis is unfavourable despite correct therapy; progress is possible. bilateral, mostly symmetric sensorineural hearing loss following intermittent exposure to broadband and/or impulse sound with an intensity above - db(a) and a daily exposure of - h (work shift) over many years. therefore, it is a matter of chronic noise damage. chronic noise exposure causes metabolic as well as mechanic ultrastructural visible damage at the level of the organ of corti, initially causing a loss of outer hair cells, leading finally to neuronal degeneration. typically, hearing loss initially occurs as a sensorineural high-frequency notch, normally at khz (c notch). the middle frequencies, e. g. the main speech frequencies, are affected considerably later. the recruitment is always positive. in approximately % of cases, a bilateral tonal tinnitus exists. the extent and the progress of the hearing loss depend on the intensity, duration of exposure and frequency composition of the sound as well as the duration of recovery phases and the individual noise susceptibility. an individual noise susceptibility is suspected in genetically predamaged inner ears, after sudden hearing loss, after treatment with ototoxic medication and trauma. moreover, humans with blond hair, fair complexion and lightly coloured eyes seem to be especially endangered owing to a lack of melanin. in most cases, the hearing loss can be compensated for • with hearing aids. in selected cases, a tinnitus masker can be helpful. by avoidance of noise or use of effective ear protection when working in a noisy environment, the progress of the chronic noise induced hearing loss can be prevented. presbyacusis (see sect. . . ), progressive idiopathic • hearing loss, hereditary sensorineural hearing loss. drug-induced or toxic sensorineural hearing loss. post-traumatic sensorineural hearing loss following • contusio or commotio labyrinthi, craniocerebral injury, distortion of cervical spine (whiplash injury). if evident asymmetry of hearing thresholds and/or • pathologic findings in vestibular testing or bera are present, the diagnosis of noise-induced hearing loss is unlikely and a search for a retrocochlear cause of hearing loss (tumour of the cerebellopontine angle, multiple sclerosis, etc.) is necessary. after cessation of activity in a noisy environment, • noise-induced hearing loss is not progressive anymore. this is the reason why routine use of noise protectors or a change to a less noisy work environment can stop the progression of hearing loss. if a sensorineural hearing loss shows progression de-• spite cessation of noise exposure, other or additional causes must be sought. adverse effect to the cochlear or vestibular portion of the inner ear caused by pharmaceutical agents. the most ototoxic compounds in clinical practice are aminoglycoside antibiotics (streptomycin, dihydrostreptomycin, neomycin-all routes of administration, kanamycin, gentamicin), loop diuretics, quinines and chemiotherapy agents (cisplatin) (table . . ). the incidence of ototoxicity has not been accurately determined. risk factors are a decreased renal function, increased daily doses, extended duration, concomitant administration with more than one ototoxic drug and prematurity. the following symptoms may be temporary or permanent: high-pitched tinnitus (earliest sign of cochlear damage), hearing loss (with or without vertigo), nausea, dizziness. initially the loss of hearing affects the high frequencies. as damage progresses, the lower frequencies become involved. uwe ganzer and andreas arnold age-related hearing loss. presbyacusis describes the progressive sensorineural hearing loss nearly every human experiences starting in the fifth decade of life. it is more or less symmetric and begins in the higher-frequency range with or without tinnitus. degeneration of hair cells, cochlear neurons, stria vascularis, cochlear nerve and components of the central auditory pathway, e. g. cochlear nuclei. baseline of db or more at both and khz, either unilaterally or bilaterally as assessed - weeks after beginning of the treatment. monitoring of the status of the cochlea with the acous-• tic emissions and high-frequency audiometry. discontinue or change the medication (if it is pos-• sible). antioxidant therapy (iron chelators, vitamin e, ascor-• bic acid). prophylactic treatment (aspirin). in a patient who has decreased renal function, dose • schedules should be adjusted. if the hearing is still serviceable, amplification with a hearing aid may be used. through a perforation of the tympanic membrane otic drops may enter into the round window niche, diffuse across the round window membrane and reach the membranous labyrinth. ototoxic preparations include alcohol, povidone iodide, gentamicin, neomycin, polymixin b, chloramphenicol and hydrocortisone. non-ototoxic preparations include amphotericin b, sulphacetamide, ciprofloxacin, triamcinolone and dexamethasone. the hearing loss is caused, on one hand, by the physi-• ologic processes of aging based on individual genetic predisposition and, on the other hand, by exogenous degeneration of parts of the inner ear (supporting cells, basilar membrane, outer hair cells) and central auditory pathway components. the exogenous degeneration is essentially the consequence of environmental influences, nutritional habits, toxicity of legal drugs, professional and recreational noise exposure, ototoxic medications, medical and neurological problems, etc. a hereditary component of presbyacusis has been demonstrated. worldwide, million humans are affected. in the • uk % of persons older than years show a hearing loss of more than db. in denmark, the percentage of hearing loss per decade is db up to the age of years and db for persons older than years. progressive hearing loss with the greatest threshold shift in the high frequencies ( fig. . . ). speech comprehension is reduced, mainly in ambient noise (party effect), loss of discrimination. discomfort in noisy environments, during phone calls. decline of directional hearing. tinnitus is common. psychosocial isolation und suspiciousness of the environment are caused by the loss of ability to communicate, secondary to the hearing loss. depressive crisis can be triggered by the tinnitus. detailed patient history, including professional and • recreational sound exposure as well as family history. complete ent examination. • otomicroscopy: without pathological findings. • hearing test battery: tuning fork, audiogram, speech • audiogram, tympanogram and stapedial reflex audiometry. symmetric sensorineural hearing loss limited to the higher frequencies, pantonal or gently declining from khz. poor discrimination in the speech audiogram. mostly, a positive recruitment is seen. with pancochlear sensorineural hearing loss, recruitment can also be negative. tinnitus analysis with subjective loudness assessment • and testing of masking possibility (fig. . . ). basic vestibular testing with frenzel glasses: exclusion • of spontaneous and provoked nystagmus, positional childhood deafness. hearing impairment in childhood • refers to any hearing loss, occurring from birth to late childhood, e. g. around the age of years. it may be unilateral or bilateral. it may be present at birth, e. g. • congenital, or acquired after birth, either during the perinatal period of life or later during lifetime. as hearing impairment affects the acquisition of speech, its occurrence is also classified in relation to the stages of speech development as prelingual ( - years of age), perilingual ( - years) and postlingual (more than years). it can be classified into four categories of severity: • mild (average hearing levels ranging from to db), moderate (average hearing levels from to db), severe (average levels ranging from to db) and profound (hearing loss that has average hearing levels greater than db). in principle, hearing loss can be • conductive (due to malfunction of the outer ear or the middle ear) or sensorineural (due to malfunction of the inner ear or the auditory nerve), or mixed. its course may be temporarily, fluctuating, progressive • or permanent (permanent childhood hearing impairment, or pchi). normally, unavoidably slowly progressive hearing loss. the diagnosis of "presbyacusis" requires the exclusion of all other possible causes. not every hearing loss in the elderly is a presbyacusis! further causes of congenital hearing loss are: − infections during pregnancy (rubella, cytomegalovirus, toxoplasmosis). − inner ear malformations due to developmental arrest in embryonic stages such as mondini malformation or common cavity malformation. they may be related to syndromes that are associated with other symptoms or occur in isolated forms. . acquired hearing impairment: hearing loss may be acquired in the perinatal period owing to hypoxaemia, severe infections, prolonged newborn icterus and others. following the perinatal period, the commonest cause of acquired inner ear hearing loss in early childhood is bacterial meningitis, with permanent hearing loss complicating up to % of affected children, mostly mild or unilateral. however, about % of children affected by meningitis develop a bilateral permanent and profound hearing loss. vaccination against haemophilus influenzae type b and early vaccination against streptococcus pneumoniae reduce the risk of developing meningitis as well as the risk for acquired deafness due to meningitis. other causes include infections (e. g. measles, mumps, varicella), trauma, middle ear diseases and administration of ototoxic drugs. . progressive hearing impairment: progressive inner ear hearing loss during childhood can be associated with genetic mutations causing syndromes such as pendred syndrome (fig. . . ) and the genetically associated syndrome of a large vestibular aqueduct ( fig. . . ) , usher syndrome (retinitis pigmentosa and progressive hearing loss) and alport syndrome. other forms of genetically caused hearing loss occur as progressive hearing loss starting during adolescence. frequently, the cause of progressive hearing loss remains unknown. the most important symptoms of pchi are the absence of adequate reactions to environmental sounds and speech as well as the delay or absence of normal speech development, depending on the severity of the hearing impairment. additional symptoms may be poor general communication skills and behavioural difficulties out of frustration in communicational attempts. however, it is important to understand that these symptoms are not easy to recognize, even for professional child carers, and that diagnosis even of severe hearing impairments is often considerably delayed, even up to the age of - years, if based only on the recognition of these symptoms. in many cases, the parents' concern precedes professional diagnosis and should therefore be taken for serious and prompt further hearing assessments for the child. risk factors that are associated with pchi such as a family history of hearing impairment, infections during pregnancy (e. g. rubella, toxoplasmosis, cytomegalovirus), prematurity, low birth weight, necessity of admission to intensive care unit, prolonged newborn icterus, administration of ototoxic drugs (e. g. aminoglycosides), craniofacial abnormalities and hereditary syndromes should draw attention to possible hearing impairment. deficits in speech development include receptive skills of speech understanding as well as speech production. affected areas range from basic skills such as segmentation and analysis of phonemic structure, short-term auditory memory as well as vocabulary to higher levels of speech such as syntax and grammar. it is important to monitor the speech development of children, since some children may have progressive hearing loss occurring during childhood. the early auditory system is particularly receptive to • sounds and speech. sufficient auditory input is necessary to induce the maturation of the auditory system. failure to stimulate the auditory system during this period (referred to as the critical period) can have lifelong detrimental effects on the acquisition of spoken language. untreated hearing loss can also compromise a − reactions to sound and speech: does the child startle at loud sounds, does it react to voice when the speaker is not visible, e. g. calming or smiling? − language development: does the child vocalize, does it imitate (mama, papa), what is the range of vocabulary, are there articulation problems, are there problems with syntax or grammar? − behavioural abnormalities: e. g. aggression, low tolerance to frustration, communicative strategies. . inspection − general physical examination should pay attention to any signs of hereditary syndromes. − look at the facial features of the child and its parents: craniofacial abnormalities, e. g. outer canthi of the eyelid slant downwards in treacher collins syndrome or upwards in the branchio-oculo-facial syndrome. − ear anomalies such as hypoplasia or aplasia of the pinna, preauricular appendages and atresic ear canal draw attention to possible conductive hearing loss or associated inner ear malformations. − the neck should be evaluated for any branchial remnants (found in the branchio-oto-renal syndrome) or an enlarged thyroid gland (pendred syndrome and associated enlarged vestibular aqueduct). − blue sclerae are associated with osteogenesis imperfecta. − a white forelock and pigmental anomalies of the iris may indicate waardenburg syndrome. . otoscopy: note anomalies of the pinna and external auditory ear canal, check for the presence of a normal tympanic membrane, possible anomalies of the handle of the malleus, signs of ome (retraction, fluid behind the eardrum) or chronic otitis media. rarely, a whitish mass behind the eardrum may indicate congenital cholesteatoma ( fig. . . ). note that in sensorineural hearing losses, the tympanic membrane is normal. . rhinoscopy: to exclude nasal stenosis, choanal atresia, nasal infections. . pharyngoscopy: to exclude hyperplastic or infected adenoids or tonsils. we distinguish between subjective and objective auditory tests. subjective tests require some form of reaction of the subjects tested, whereas objective tests can be carried out without active feedback. even in small children and babies, age-adequate subjective tests are possible (e. g. behavioural response audiometry, conditioned response audiometry); however, they require special expertise. objective tests such as oae and bera can be performed at child's reading ability and educational attainment. this may limit access to further education, may restrict employment opportunity and lead to greater dependence on social services later in life. thus, permanent untreated hearing impairment can have far-reaching consequences for the child, its family and for the wider community. evidence suggests that early identification and treatment may significantly reduce the impact of pchi. fitting of hearing aids or cochlear implantation after the critical period of language development (from to - years) will not be able to fully recover these effects. after meningitis • , labyrinthitis may develop to fibrosis and/or neo-ossification of the cochlear duct, making cochlear implantation difficult and less successful. early diagnosis via mri or ct after meningitis ( fig. . . ) is recommended to detect possible early signs and proceed to implantation. recommended (european consensus conference ) since diagnosis of hearing impairment is often delayed and early intervention is of great importance. all newborns should be screened during their first days of life. screening methods should have high sensitivity and specificity, and should be objective as well as time-and cost-efficient. the following methods are available: − automated measurements of otoacoustic emissions (oae), such as transitory evoked oae (teoae) and distortion products of oae (dpoae) − automated brainstem evoked response audiometry (bera) − automated measurements of amplitude modulation following response (amfr) . if the child fails to pass the screening for hearing impairment, follow-up with eventual rescreening and more extensive auditory testing to confirm or exclude hearing loss is necessary. . risk factors that are associated with pchi such as a family history of hearing impairment, infections during pregnancy, prematurity, low birth weight, necessity of admission to an intensive care unit, prolonged newborn icterus and administration of ototoxic drugs should be investigated. . ask about: any age, sometimes requiring sedation. diagnosis should only be based on the combination of subjective and objective tests, and should be reevaluated at subsequent developmental stages of the child to reach a higher degree of exactitude, to distinguish between transitory, permanent or progressive problems and to account for maturation and developmental processes. subjective tests are: behavioural response audiometry • (age range - years): spontaneous responses to sounds such as calming, blinking and startling are watched for by experienced examiners. in visual reinforcement audiometry, reactions of the child such as head turning are reinforced by attractive visual stimuli. bilateral freefield testing is possible; thresholds found are generally - db above real auditory thresholds. performance test and play audiometry • (age range - years): this test requires that a child can be actively involved in a task. it uses a conditioned response (e. g. stacking cubes) to evaluate auditory thresholds in bilateral free-field conditions. pure tone audiometry • (age range from . - years upwards): testing side specific pure tone thresholds (see sect. . . . ). the child must be able to wear headphones and cooperate in the task. : various speech tests with ageappropriate language material are available. results are influenced by auditory thresholds, capacity of auditory speech analysis as well as general speech development. tests for • central auditory processing disorders: special tests such as the dichotic listening test or hearing in noise are used to diagnose central auditory processing dis orders such as in auditory attention deficit syndrome. screening tests • : they are designed to detect hearing losses greater than - db, in general without giving detailed thresholds. tympanometry • : to detect middle ear problems (e. g. ome). stapedial reflex measurements are useful to estimate thresholds (see sect. . . . ). oae • : oae reflect the normal activity of outer hair cells. they are generally present when hearing loss does not exceed - db. however, they do not reflect the function of inner hair cells and the auditory nerve; therefore, they might be present in cases of auditory neuropathy or neural hearing loss. teoae are click-evoked and have a broad response spectrum over the whole frequency range. dpoae are evoked by continuous two tones and are frequency-specific. by determining growth functions of dpoae, one can obtain an approximation of auditory thresholds. : the synchronized neural activity of the auditory pathway (spiral ganglion and cochlear nerve, cochlear nucleus, lateral lemniscus, superior olive and inferior colliculus) is recorded in response to click stimuli (broad frequency response) or tone bursts (limited frequency specificity). auditory thresholds can be approximated. the method may require sedation in children. : like for auditory brainstem response, the synchronized neural activity is measured but is elicited by sine waves that are amplitude-modulated. higher frequency specificity can be achieved. as one of the main symptom of pchi is delayed speech and language development, it is important to include assessment of speech and language development by psychologists, speech and language therapists or teachers of the deaf in a multidisciplinary approach. many children with pchi have additional neurological and vision deficits. neurological examination and vision screening should be carried out if indicated. high-resolution, thin-section ct is the modality of • choice to visualize the bony structures of the outer ear, the middle ear, the mastoid, the inner ear and the internal acoustic meatus (figs. . . , . . ). soft tissue masses or fluid in the middle ear or mastoid can also be detected. special attention has to be paid to detect possible malformations of the ossicles, of the inner ear, e. g. mondini malformation ( fig. . . ), common cavity, labyrinthine malformations, enlarged vestibular aqueduct ( fig. . . ) , or in postmeningitis cases, neo-ossifications of the scala tympani, media or the labyrinth ( fig. . . ). mri is indicated to visualize the fluid content of the • inner ear, the auditory and vestibular and facial nerves in the inner acoustic meatus, and to detect central nervous system abnormalities. it is of special importance to detect early signs of fibrosis and neo-ossification of the cochlea after meningitis. genetic testing may be useful in syndromic as well as non-syndromic hearing loss for diagnostic purposes and counselling of patients and parents. specific genes associated with syndromes such as waardenburg, pendred and usher have been identified. in non-syndromic hearing hearing aids are possible surgical options (see sect. cochlear implants replace the function of the inner ear in transferring acoustic sounds into neural excitation patterns. unlike hearing aids, which amplify sounds acoustically, cochlear implants convert the sounds into electrical stimulation patterns, which electrically stimulate fibres of the cochlear nerve and thus elicit hearing sensations ( fig. . . ) . a cochlear implant system consists of two parts: the external speech processor and the implant itself ( fig. . . ). the speech processor picks up external sounds, analyses them for frequency and time content and generates instructions for stimulation. together with the necessary energy, the information is sent to the implant via a short high-frequency radio connection. the sender is centred over the implant with a magnetic link. the implant receives the instructions and generates electric pulses. these are delivered by the intracochlear electrodes (currently between and ) that follow the tonotopic organization of the cochlea. electrodes at the base (near the round window) elicit high-pitched auditory sensations; electrodes near the apex elicit low pitches. for profoundly deaf children (typically those with • hearing losses greater than db) and those chil-loss, the gjb gene encodes for the connexin molecule. it can be tested in many centres and may account for approximately % of cases of presumed non-syndromic genetic deafness. however, the number of gene mutations associated with deafness continues to increase; more then mutations have been described. therefore, negative findings in genetic testing do not preclude the genetic origin of a hearing loss. early intervention • is a key factor to prevent sequelae of hearing impairment. even children as young as - months can be fitted with hearing aids; however, special expertise is needed to fit very small children. : the first step in therapy of pchi is providing adequate amplification by means of hearing aids. they should be fitted on the basis of subjective and objective measures, and bilaterally, if the hearing loss is bilateral. hearing aids have to be maintained and ear moulds have to be adjusted regularly to fit the ear canals, which typically enlarge with age. in conductive hearing loss, e. g. in ear malformations, that is not ready to be corrected surgically, bone-conduction hearing aids are the treatment of choice ( fig. . . ) . reactions to sound and speech as well as speech and language development of children fitted with hearing aids have to be monitored by the children's parents, paedaudiologists, teachers and therapists to make sure that amplification is adequate and optimal benefits are obtained. training of communicative skills and counselling of parents is of great importance and should start as soon as possible. : if hearing capacities as well as speech and language development remain insufficient in patients with severe or profound hearing impairment, despite optimally fitted hearing aids, a cochlear implantation has to be considered. : reconstruction of the outer ear canal and ossicular chain, implantation of active middle ear implants and placement of bone-anchored fig. . . cochlear implant dren with severe to profound hearing loss, who do not obtain sufficient benefit from powerful hearing aids to develop their speech and language skills, cochlear implants are extremely valuable in providing access to speech signal and sounds. cochlear implantation can be performed as early as • - months if indicated. early intervention, e. g. implantation before the age of years, is best to make use of critical periods in hearing as well as speech and language development. therefore, early diagnosis and hearing aid trial periods are of importance. bilateral implantation is possible and beneficial in • adults and in children, allowing for better speech understanding under difficult listening conditions and partial development of spatial and directional hearing. children with multiple handicaps in addition to pro-• found hearing loss will obtain significant profit from cochlear implantation in most cases, even if receptive and expressive language development may not be expected owing to, e. g., intellectual handicaps. for malformations of the inner ear or neo-ossifications • after meningitis, special surgical techniques have been developed. cochlear implantation is not possible if the auditory • nerve is absent. in these cases, brainstem implants may be an alternative approach. cochlear implantation is contraindicated if sufficient • rehabilitational and/or technical support for maintenance of the device function cannot be ensured. additional speech and language therapy is necessary • in most patients with severe and profound hearing impairment. general support, careful choice of educational settings • and counselling of parents is of importance. children with a cochlear implant require regular pro-• gramming and control of the speech processor, which is best ensured in multidisciplinary cochlear implant rehabilitation programmes. differential diagnosis between conductive and sen-• sorineural hearing loss is an essential prerequisite. pchi has to be differentiated from central auditory • processing disorders that may be mistaken for peripheral hearing loss. non-organic hearing loss (psychogenic) should not be • missed, occurring most often in teenage children. unilateral hearing loss is often overlooked in child-• hood. progressive loss may pass unrecognized; the same is • true for hearing loss affecting only part of the frequency range as the findings of the initial objective hearing screening can be normal. walter livi a hearing aid is a miniature electronic instrument that detects, amplifies, elaborates and transmits sound to the hearing impaired patient's ear. its basic components are the microphone (input), the amplifier (elaborator) and the receiver (output). hearing aids can be classified into three groups depending on the technology used: . analogue: the microphone converts sound waves to a continuous electrical signal that is similar to the stimulus in intensity, frequency and time. the amplifier then amplifies the electrical signal, which can be modified by manual controls (trimmers), and then transmitted to the receiver that reconverts the elaborated electrical signal to a sound wave. . digitally programmable analogue: they represent an evolution of analogue hearing aids that differ only in the phase of amplification. the amplified electrical signal is not modified by a manual trimmer but is amplified electronically by the computer. the elaboration of the signal remains an analogue process. the microphone converts sound waves into an analogue electrical signal. the analogue-todigital converter transforms the continuous electrical signal into a series of binary numbers ( - ). the digital sound processor digitally elaborates the numerical signal according to algorithms contained in the program. the analogue-to-digital converter transforms . . . prognosis evidence confirms that early identification and treatment, coupled with sustained, appropriate habilitation and educational support can achieve excellent outcomes. development of spoken language can proceed at rates similar to that for normal-hearing children even in profoundly deaf children, provided that early identification and cochlear implantation are achieved. they can achieve impressive competence with oral communication, and can often attend mainstream schools (with varying degrees of assistance), achieving their full educational potential. negative prognostic factors include late age at diagnosis, the presence of other cognitive disabilities, inappropriate communication strategies, inadequate educational and rehabilitational support and poor socioeconomic status. fig. . . ) . the series of numbers into an electrical signal. the receiver then reconverts the electrical signal into sound waves. types of hearing aids are shown in fig. . . . depending on the place in which they are worn, hearing aids can be classified in the following way: behind the ear (bte), in the ear (ite), body aid, and eyeglass aid (spectacles). the choice is influenced by the type and entity of the hearing impairment and by the needs of each patient: . bte hearing aids − can be used for all types of hearing impairments. − are composed of a plastic shell that contains the microphone, amplifier, receiver, volume control (or other manual controls or switches) and battery. − they are quite small and are placed bte (pinna). − they are connected to the flexible tube of the ear mould by a plastic hook or by a fine wire to a receiver positioned directly in the ear canal (receiver in the ear, rite) ( fig. . . ). the ear mould is composed of biocompatible material that is made to measure for the ear canal of the patient. . ite hearing aids − they can be placed completely inside the canal (cic) or mainly in the external ear canal (ite) or in the concha of the external ear canal (itc) (fig. . . ). − they are made of biocompatible material and are well accepted by patients because they are small and practical. − they are not a good choice in cases of severe to profound hearing loss because they do not provide sufficient amplification. − they are not often prescribed to children, because of the limited size of the child's ear canal and its continuous change in size. . body worn pocket aids: the plastic case of the aid contains all components except for the receiver, which is placed in the ear canal. they are no longer in use because they are not very practical. . eyeglasses/spectacles: all components of the hearing aid are in the arm of the glasses. they can transmit sounds by: − air conduction: air-conduction spectacles are practically obsolete. − bone conduction: bone-conduction spectacles contain the vibrator at the end of the arm and transmit the vibrations to the mastoid. they may be prescribed in cases of mild to moderate conductive loss and of mixed loss up to db. note that a much better type of bone-conduction aid is the bone-anchored-hearing aid. . implantable hearing devices: a conventional hearing aid takes sound and makes it louder. the amplified sound is conducted to the ear canal either via an ear mould or directly via the hearing aid. − a device that is semi-implantable (retrox) has been classified by the fda as a transcutaneous airconduction hearing aid system (tachas). this is a conventional hearing aid, where the sound-transmitting silicon tube is placed from behind through the skin and cartilage of the auricle to direct the sound into the outer ear canal. − in the vibrant soundbridge implantable hearing system a tiny magnet (floating mass transducer, fmt) is directly attached to the ossicular chain (during surgery) and amplifies the natural vibrations of the ossicles. many patients report that "direct" coupling leads to improved hearing quality and improved speech understanding. the system consists of external and internal parts. the external part, called the audio processor, is worn underneath the hair and held in place with a magnet. it contains a microphone, a battery and electronics. the audio processor converts environmental sounds into signals that are transmitted to the implanted internal coil of the soundbridge. the implanted part consists of the internal coil, magnet, conductor link and the fmt. the signal from the audio processor is transmitted across the skin to the internal coil, which relays the signal down the conductor link to the fmt. the fmt is attached either to the incus or to the round window membrane (fig. . . ). the fmt converts the signal into vibrations that directly drive and move the ossicles or via the round window the peri- fig. . . the application of modern design to advanced electronic technology. a hearing aid that implements the receiver in the ear (rite) solution fit binaurally to guarantee the best result for speech discrimination (interpersonal communication). the patient must be motivated to correctly use both hearing aids. three phases should be respected for an optimal result in fitting a hearing aid: . prescription: in this phase the medical specialist is involved and he/she must carry out the testing necessary and an otomicroscopic objective examination. the testing includes subjective and objective tests; that is pure tone audiometry using earphones and free field. impedance testing with particular attention to the stapedial reflex and in some cases, especially with children, the study of evoked potentials (auditory evoked brainstem responses). : this is carried out by the audiologist/dispenser on the basis of the results from the testing and diagnosis. in this phase the hearing aid is chosen along with any assistive listening devices (if necessary) to satisfy the individual needs of the patient. to obtain the maximum benefit from hearing aids it is necessary that the patient and audiologist/ dispenser work together closely. after approximately months, the plastic processes are completed. in this phase the medical and paramedical competences (audiologist/dispenser, ent specialist, speech therapist, psychologist) converge to obtain the best result. although hearing aids from a technological point of view rely on extremely sophisticated technologies, they are "obsolete" from the cosmetic point of view and this is usually the reason why many patients refuse hearing aids. for this reason hearing aids today have been restyled and special attention is given to their "design". if a hearing aid is to be accepted it should be perceived as a modern assistive device for communication, an extension of the patient's body, eliminating the sense of shame that the patient feels by wearing a hearing aid. there is a kind of tabu that is linked to dentures, hearing aids, cosmetics for men and in the past to eyeglasses. but today these negative connotations are decreasing and that changes the perception of the abovementioned items. they are no longer disturbing; they may become a part of fashion trends! according to the audiological classification of hearing loss there is a distinction on the basis of the average tone threshold into mild (threshold between and db), moderate ( - db), severe ( - db) and profound ( - db) hearing loss. the choice of the hearing aid with respect to the above classification takes into account the audiometric curve (flat, symmetrical, asymmetrical, lymph and amplify their natural movement. these vibrations then conduct the sound to the basilar membrane and the organ of corti. this system is designed for mild to severe sensorineural hearing loss (fmt attached to the incus) or for moderate or severe mixed hearing loss (fmt attached to the round window), e. g. cochlear otosclerosis, malformations of the ear. another middle ear implant is the middle ear transducer, an implantable hearing device where the sound is transmitted by a similar vibrating driving system attached to the head of the malleus. − a bone-anchored-hearing aid is a hearing aid fixed to a bone-anchored titanium screw, in which bone conduction is used to transmit sound directly via the skull into the cochlea (fig. . . ) . − in deaf patients cochlear implants are used (see sect. . . ). sound is transformed by the so-called speech processor to electric signals which are sent to a retroauricular subcutaneously implanted receiver. the receiver is connected with a stimulating electrode which is inserted into the cochlea. it is well known that hearing impairment can negatively influence interpersonal relations and create difficulties in everyday tasks. the fitting of a hearing aid is necessary for patients who cannot benefit from pharmacological therapy and/or surgical procedures, and in some cases may be of support to the latter. patients with a bilateral hearing loss with a loss in the better ear of at least db for at least one of the frequencies examined (from . - . khz) and when the speech discrimination for monosyllabic words in the better ear is %. in cases of monolateral hearing loss, the loss should be db or more at . khz or at two frequencies between . and . khz. make certain that the patient can properly use the hearing aids after a period of training with the hearing healthcare professional. the patient must also be motivated to use the hearing aid all the time. when deciding on hearing aids, the professional and the patient must evaluate subjective, social, cognitive and lifestyle aspects. stereophonic hearing is necessary for good speech discrimination, especially in noisy surroundings. if both ears can benefit from amplification, the rule today is to tests. a vestibular schwannoma, which in very rare cases is mimicked by the same symptoms, can be excluded by mri. treatment is exclusively conservative. in the early stage of the disease sedating drugs such as h antagonists ( mg dimenhydrinate - times a day) are recommended, but only for a short time, not longer than days. as soon as possible vestibular habituation training should be started to induce a rapid vestibular compensation. corticosteroid treatment is recommended during the first days (start with mg intravenously with decreasing doses to mg within days). to accelerate vestibular compensation active movements (sports), stimulating agents such as caffeine and avoidance of calming procedures such as bed rest seem useful therapeutic options. differential diagnosis of vestibular neuritis is simple, because the duration of vertigo for some days is very characteristic; therefore, benign paroxysmal positioning vertigo, vestibular paroxysmia, ménière's disease or vestibular migraine can be excluded by a careful questionnaire. the fact that vestibular neuritis is monosymptomatic facilitates the differential diagnosis in patients with additional hearing problems. although vestibular schwannoma only very seldom becomes apparent by vertigo complaints, mri allows a clear differential diagnosis. the prognosis is generally favourable. if there are additional factors which can inhibit vestibular compensation, such as sedating drugs, old age or additional abnormalities in the cns, the complaints can continue for a long time. acute unilateral, partial or complete loss of peripheral vestibular function, caused probably by a viral inflammation. current findings point to a viral origin (herpes simplex virus) similar to facial palsy. owing to immunologic deficiencies, herpes simplex viruses, which were already present in the patient as a result of an earlier infection, are reactivated and destroy vestibular sensory fibres. vestibular neuritis is one of the most frequent peripheral vestibular disorders (about % of vertigo patients seen in an ent vertigo unit suffer from this disease). the symptoms are marked by the acute appearance of severe vertigo, mostly purely rotatory, sometimes accompanied by vomiting, nausea and ataxia. in the acute state a violent horizontal-rotatory nystagmus, beating towards the intact side, is always present. hearing impairment or tinnitus do not belong to vestibular neuritis. in the acute state a tendency to fall is obvious, so a prevention against falls is necessary, to avoid orthopaedic sequelae. not seldom benign paroxysmal positioning vertigo follows a vestibular neuritis within a short delay, this is named "lindsay-hemenway syndrome". a careful questionnaire reveals the sudden onset of the vertiginous complaints, which decrease within a period of some days. the only objective sign is a strong horizontal-rotatory nystagmus, beating to the intact side. the caloric test proves the hypofunction of the lesioned side, which is in the beginning not compensated in the rotatory test. vestibular spinal tests show a marked deviation and a tendency to falls directed to the lesioned side. a lesion in the auditory system, which does not belong to the vestibular neuritis, can be excluded by audiological karl-friedrich hamann benign paroxysmal positional vertigo. benign paroxysmal positioning vertigo (bppv) is a mechanically induced vertigo caused by a canalolithiasis or a cupulolithiasis. normally otoliths are fixed in the otolithic membrane. by head traumatism, in old age or idiopathically, otoliths can be loosened and travel in one or some of the semicircular canals. bppv is one of the most frequent kinds of vertigo, mainly in the elderly. the different semicircular canals are not affected equally. in % of cases the posterior vertical canal is concerned, the horizontal canal in % of cases and the anterior vertical semicircular canal only in % of cases. the vertigo attacks have a short duration, only a few seconds, typically triggered by certain head movements, for example by head turning in the morning for a look at the alarm clock. bppv never occurs when the head is not moved. complications in the real sense of the word do not exist. as for all forms of vertigo, falls can occur. the questionnaire reveals that vertigo appears only during head movements and lasts only for some seconds. apart from the characteristic complaints, the diagnosis is made by nystagmus observation under frenzel's glasses. by specific positioning of the head in the plane of one of the semicircular canals (hallpike manoeuvre), one can prove a bppv if a typical nystagmus appears. the involved semicircular canal can be identified by analysis of the nystagmus, because the pattern of eye movements for each semicircular canal is known. other neurotological tests such as caloric or rotatory tests do not show pathological findings; the auditory system is not involved as well. additional diagnostic procedures are not necessary. imaging techniques are only suitable for exclusion of possible central abnormalities. owing to the mechanical pathophysiologic nature of bppv only a mechanical treatment is reasonable. the goal of a rational treatment of bppv is to liberate the semicircular canals from the dislocated otoliths. this can be carried out by liberatory manoeuvres of semont [ ] (fig. . . ) or epley [ ] (fig. . . ). both have principally the same intention, namely to bring the dislocated otoliths by specific movements of the head to a "neutral point" in the vestibular apparatus nearby the utriculus. for the treatment of a canalolithiasis or a cupulolithiasis of the horizontal canal, a barbecue rotation or brandt-daroff exercises can be recommended as for a prophylaxis of bppv. only in extremely rare cases (less than %) surgical treatment can be indicated. two procedures exist: ( ) neurectomy of the posterior canal nerve, ( ) plugging of the affected canal. because of the typical clinical signs (vertigo only in combination with head movements, duration of vertigo never more than s, provocation of typical nystagmus by specific positioning), normally the differential diagnosis does not present a problem. one of the rare differential- motion sickness is a special kind of physiological vertigo, induced by an unusual stimulation of the multisensory system, which normally guarantees adequate orientation in space. diagnostic possibilities is the vestibular paroxysmia, which is characterized by vertigo attacks of a few seconds. but these attacks are not correlated typically with certain head movements which trigger the bppv. another differential diagnosis, but less frequent, is the possibility of a vestibular migraine, which, in contrast to bppv, should be accompanied by headaches. the prognosis of bppv is very favourable. after one liberatory manoeuvre about % of patients no longer have complaints. in the remaining %, repetitive liberatory manoeuvres lead to a complete cure. if necessary, brandt-daroff exercises must be continued. the rate of recurrences is relatively high. in a period of years after a liberatory manoeuvre, about % of patients complain about vertigo again; in a period of years, the rate of recurrences reaches %. only in extremely rare cases does a surgical treatment become necessary (see sect. . . . ). fig. . . a first movement of a liberatory manoeuvre (semont) for treatment of a canalolithiasis of the left posterior canal: starting from a sitting position the patient is positioned to the left side, the head turned ° to the unaffected right side. b second movement of the liberatory manoeuvre (semont): the head and trunk of the patient were thrown from the left side to the right side without changing the position of the head relative to the body it is generally accepted that motion sickness develops when a sensory conflict between the different sensory systems, responsible for the orientation in space, occurs. both intrasensory mismatch (within the vestibular system) and intersensory mismatch (between the vestibular and visual system for example) can trigger the symptoms of motion sickness. the crucial condition is that different sensory receptors give different signals about the passive motion of an individual in space. so the perceived pieces of information do not correspond amongst themselves nor to the expected perception pattern, previously adapted by experience. principally in all people with an intact sensory system motion, sickness can be induced, if certain conditions which can create a sensory conflict are fulfilled. fig. . . a-e epleys manoeuvre. a first step: the patient is sitting in the upright position, the head is ° turned to the concerned side. b second step: the patient is in the lying position, the head still turned to the concerned side. c third step: the head is turned ° to the contralateral side. d fourth step: the head and trunk of the patient are turned ° to the contralateral side. e fifth step: the patient is returned in the upright position. intervals between each step of - min increases. the medical treatment consists in the uptake of an h histamine antagonist such as dimenhydrinate or meclozine. it must be pointed out that all h antagonists have sedative side effects. interestingly, ginger root, given in a pulverized form, has significantly favourable effects on motion sickness symptoms. a differential diagnosis of motion sickness does not exist. the only exception is that a real vestibular disease can be triggered also by a specific movement or a sensory conflict. the prognosis of motion sickness is very favourable. at the latest in the moment when the inducing motion ceases, a rapid decrease of the uncomfortable symptoms begins. after some hours, the symptoms of motion sickness disappear. motion sickness is clinically characterized by nausea, pallor, yawing, vomiting and mainly by a feeling of severe discomfort. these symptoms last not only for the time of conflict stimulation but also for a certain period afterwards, when motion stimulation had stopped. complications in the real sense of the word do not exist. falls and aspiration caused by vomiting are sequelae of the symptoms themselves. motion sickness is diagnosed very simply, because the coincidence of the inducing motion and the typical symptoms is pathognomonic. further diagnostic procedures are not necessary. a prophylactic therapy can be useful if it is predictable that a motion sickness inducing sensory conflict will occur. the best prevention consists in a vestibular habituation training with the intention to prepare the orientation system for a conflict stimulation. as a medical prophylactic treatment, scopolamine used in the form of a transdermal skin patch can be recommended. when the symptoms of motion sickness appear, one can try to break free from the sensory conflict situation. in the case of seasickness the suffering person has to leave the cabin and should go on the ship's deck. then he/she should fixate on an object not too far away. in this way there the correspondence between visual and vestibular information deafness and vertigo from head injury evidence for a viral neuropathy in recurrent vertigo intratympanic application of an antiviral agent for the treatment of ménière's disease suggested reading checkliste: hals-nasen-ohren-heilkunde. thieme herpes simplex virus antibodies in the perilymph of patients with ménière's disease peripheral vestibular disorders guidelines for the diagnosis and evaluation of therapy in menière's disease menière's disease: a review herpes simplex virus and ménière's disease schuknecht: presbyacusis. laryngoscope a new semiimplantable hearing system device-retrox l'adattamento degli apparecchi acustici. oticon, rd edn. arti grafiche reggiani totally implantable hearing aids: the effects of skin thickness on microphone function hearing aids. boomerang current status in the development of implantable middle ear hearing aids vestibular neuropathy, "vestibular neuronitis" (wrong term, because one neuron cannot be inflamed). . . benign paroxysmal positioning vertigo vertigo-its multisensory syndromes training gegen schwindel vestibular exercises improve central vestibulo-spinal compensation after vestibular neuritis suggested reading benign positional vertigo. clinical and oculographic features in cases vertigo-its multisensory syndromes a positional manoeuvre for treatment of horizontal canal benign positional vertigo eye movements from single utricular nerve stimulation in the cat the canalith repositioning procedure: for treatment of benign paroxysmal positioning vertigo curing the bppv with a liberatory manoeuvre drug effectiveness on experimental optokinetic and vestibular motion sickness vertigo-its multisensory syndromes postural behaviour in motion sickness the prevention and treatment of motion sickness motion sickness, ginger, and psychophysics after tympanoplasty open or closed, radical cavity − implantable bone-conduction aids (bone-anchored hearing aids) in adults in some cases and in children (over the age of years). − bone-conduction vibrators mounted on a headband for a child. − bone-conduction spectacles for adults. . prelingual profound hearing loss in adults who have never used hearing aids. all hearing aids, including cochlear implants give unsatisfactory results. . prelingual profound hearing loss in adults who have always used analogue hearing aids. in many cases digital hearing aids with custom-made ear moulds can be recommended and when possible cochlear implants.the most frequent complaints that arise from patients using traditional hearing aids are the hearing aid whistles (feedback), loud sounds are uncomfortable, unsatisfactory speech discrimination in noisy surroundings and the perception of the person's own voice altered owing to the occlusion effect of the external auditory canal. to solve these problems today there are digital ite and bte hearing aids with artificial intelligence that use technologies capable of improving speech discrimination in noise, eliminating feedback and with the "open fitting" system the problems connected to the occlusion effect are resolved. fitting hearing aids in children is difficult both for the diagnosis and in the actual fitting. it is essential that children are fitted with hearing aids at a very early stage (within - months). to obtain the best results, the family must be actively involved in the process, the child must be placed in an adequate scholastic and social environment and followed closely by a speech therapist. to evaluate the results of the fitting, objective audiometric testing (impedance testing, auditory evoked brainstem response, electrocochleography, otoacoustic emissions) is essential. the testing and the evaluation of the hearing aid fitting must be carried out in a medical environment with the cooperation of the audiologist/dispenser. when the child is in kindergarten it is important to use a personal fm system to eliminate any interference from background noise present in classrooms. most hearing-impaired children suffer from moderate hearing loss and in those cases a hearing aid is an adequate solution. in cases of profound hearing impairment, after approximately months of hearing aid use and an accurate evaluation of the entity of the hearing loss and after a careful psychological evaluation and speech evaluation, the possibility of a cochlear implant may be considered and must be carried out before the child is months old. key: cord- -n mlxe p authors: nan title: cis annual meeting: immune deficiency & dysregulation north american conference date: - - journal: j clin immunol doi: . /s - - - sha: doc_id: cord_uid: n mlxe p nan a y.o. female was referred to our clinic with a history of multilineage cytopenias/evans syndrome, a history of idiopathic thrombocytopenic purpura, hemolytic anemia, chronic neutropenia, lymphopenia, and hypogammaglobulinemia treated with ivig. our patient was healthy until she was years old; at that time, she developed joint pain, rash, and bruising. she was found to have evans syndrome with idiopathic thrombocytopenic purpura (itp), neutropenia, and lymphopenia. she was initially diagnosed with lupus and was given steroids. her bone marrow biopsy did not conclude myelokathesis. when she was years old, she remained thrombopenic and was started on high dose of immunoglobulin replacement therapy. in ( years old), she developed polyarthritis in her upper and lower extremities. in ( years old), she had a severe nosebleed, for which she was admitted and treated with amicar twice; her platelets were found to be , k/ul. she received rituximab weekly for weeks resulting in an increase of platelet count to - k/ul. she recently (march ) had a splenectomy to remove her large spleen, and since then, her platelets have rebounded to - k/ul. in , she was placed on long-term immunoglobulin replacement therapy after being hospitalized for bilateral pneumonia for nights requiring iv antibiotics for treatment. in , she developed and was treated for another pneumonia. her family history is characterized by multiple members with autoimmune multilineage cytopenia as well as autoimmune diseases such as multiple sclerosis (mother), thyroiditis and enteropathy. on physical examination, she did not present with any warts and the remainder of her physical examination being unremarkable, except for her scar from her splenectomy and a cervical lymphadenopathy. immunologic evaluations showed igg mg/dl, iga < mg/dl, and igm mg/dl. cbc with differential and lymphocyte screen were as follows (cell/mm ): wbc . x , hemoglobin . g/dl, platelets x ; % neutrophils (anc: ), % lymphocytes, % monocytes, % eosinophils; absolute total t-cell number was ( - cells/mcl), cd + t-cells ( - cells/mcl), cd + t-cells ( - cells/mcl), natural killer cells ( - cells/ mcl), and absolute number of b cells was ( - cells/ mcl). she came to our clinic with her sister, who also had multilineage cytopenia and hypogammaglobulinemia, treated with monthly ivig; and her nephew whom had neutropenia. based on this family presentation all three underwent whole exome sequencing (wes). the patient, the patients sister and the patients nephew were all found to have a variant on cxcr (frameshift mutation on chromosome , p.val fs; refnt: tca; altnt: t). as an important note, the patient had a bone marrow biopsy, which did not conclude myelokathesis. in summary, our patient with trilineage cytopenia and hypogammaglobulinemia, without any warts or myelokathexis, had whim syndrome (warts, hypogammaglobulinemia, immunodeficiency, and myelokathexis), which was discovered by studying her wes. with the identification of her specific diagnosis, this allowed us to discuss the potential future indication of plerifaxor (antagonist of the alpha chemokine receptor cxcr ). and equally important, we discussed family planning and future pregnancies given that the mutation is autosomal-dominant. ( ) submission id# taha al-shaikhly, mbchb , kathleen mohan, arnp , matthew basiaga, do, msce introduction: complement component- (c ) is shared by the classical, lectin and alternative complement activation pathways. c , a major opsonin, facilitates phagocytosis of encapsulated microorganisms. inherited c deficiency is rare and is associated with increased risk of bacterial infections. subjects with connective tissue diseases (ctd) and c nephritic factors can have low and occasionally undetectable c levels, yet they are at an underappreciated infectious risk. we hypothesize that excessive c consumption in secondary complement deficiency disorders (scd) is associated with higher risk of bacterial infections similar to primary complement deficiency disorders (pcd). objectives: to compare the rate of bacterial infections between pcd and scd patients and evaluate the association between c level and bacterial infection risk. methods: we performed a retrospective cohort study. subjects with an undetectable complement activity (ch ) or any of the complement components measured at seattle childrens hospital from - were included in our study. we recorded the number of infections, observation periods, diagnosis (pcd, scd and its underlying etiology), lowest complement component levels, and the immunosuppressive agents used. the date of birth, and date of lowest c level were considered as start points to calculate the observation periods for pcd and scd subjects respectively. infections requiring hospitalization or parenteral antibiotics were categorized as serious bacterial infections (sbis). descriptive analyses were performed to determine medians and ranges for continuous variables. differences in rates of bacterial infection were assessed using the chi-square and kruskal-wallis tests when appropriate. among subjects with ctds, we treated every c measurement as a single observation (n= , ) and studied the association between c concentration and the -day odds of having a sbi. multivariable logistic regression was performed to determine infection risk based on c level while controlling for contributing factors. results: we identified subjects with pcd, and subjects with scd. scd consisted of three subgroups (ctd-related (n= ), nephritic factor-related (n= ), and infection-related (n= )). collectively, ctd subjects had a lower median rate of sbi compared to pcd subjects (p = . ). subjects with ctd and c level < have higher rate of bacterial infection (of any severity) (p = . ) and of sbi (p = . ) when compared to ctd subjects with c >= at the beginning of observation period ( figure ). while controlling for immunosuppression level pediatric resident, baystate medical center faculty advisor, baystate medical center introduction: zap codes for a -amino acid enzyme, zap , a member of the syk-protein tyrosine kinase family that plays an important role in t cell development and activation. zap is phosphorylated at tyrosine kinase residues upon t cell receptor (tcr) stimulation resulting in tcr-mediated signal transduction with src family kinases. zap deficiency results in a rare t+b+ nk+ severe combined immunodeficiency (scid). we report a novel compound heterozygous mutation in zap leading to presumed absent zap function in an infant with a normal trec newborn screen and scid. case description: the patient is a term, fully immunized female, born to non-consanguineous parents who was hospitalized for rsv bronchiolitis at mo. at mo she developed an erythematous, papular rash on her face and extremities, nonresponsive to topical antifungal therapy. at mo she was re-hospitalized with rsv bronchiolitis and subsequently treated with multiple courses of antibiotics for presumed bacterial pneumonia followed by albuterol and oral steroids for possible reactive airways disease. during this course of treatment, her rash resolved. at mo she presented with failure to thrive (wt < . % for age), multifocal pneumonia and respiratory failure requiring intubation. bronchial alveolar lavage confirmed pneumocystis jiroveci pneumonia prompting an immune evaluation. total immunoglobulins were normal for age, however antibody titers to tetanus, diphtheria and streptococcus pneumoniae were absent. lymphocyte enumeration revealed elevated cd t cells and markedly diminished cd t cells, normal b and nk cells. t cell proliferation to mitogens (pha, pwm) and antigens (candida, tetanus) was absent, however t cells proliferated normally to stimulation with pma and ionomycin. trec number was normal by newborn screening, but was std deviations below the mean and would have resulted in a positive screen upon repeat. invitae gene scid panel revealed two variants of unknown significance, c. c>g (p.arg gly) leading to substitution of arg with gly and c. _ dupgcat (p.ile metfs* ) resulting in a premature translational stop signal expected to disrupt the last amino acids of zap protein. parental sequencing revealed these variants to be on opposite chromosomes. the patient was successfully treated for pjp pneumonia and has since successfully engrafted a / matched unrelated donor stem cell transplant. discussion: we report a novel compound heterozygous mutation in zap which we presume led to t+ b+ nk+ scid. our patients clinical presentation of failure to thrive, recurrent lower respiratory tract infections, dermatologic findings and pjp pneumonia are consistent with previously reported cases of zap scid. her paucity of cd t cells, abundance of cd t cells and absent proliferation to mitogens are also consistent with previously described cases of zap . normal proliferation of t cells when bypassing the tcr by stimulating cells with ionomycin and pma confirms a defect in the tcr. we believe this is the second documented case of missed scid by newborn screen in ma since the implementation of trec screening in . pediatric resident (pgy iii), goryeb children's hospital attending physician, pediatric and adult asthma, allergy and immunology, llc introduction: acute otitis media (aom) is one of the most common reasons for antibiotic use in early childhood. we explored the challenges when aom fails traditional therapies and immunologic evaluation does not identify a commonly described immunodeficiency. case description: an eighteen-month-old male presented with episodes of aom and recurrent purulent otorrhea requiring intravenous antibiotics. laboratory evaluation revealed a normal cbc, normal immunoglobulins (igg , iga , igm , ige ) and igg subclasses. lymphocyte subset panel was normal. initial responses to dtap and prevnar boosters were normal, however, there was rapid decline to tetanus and pneumococcal antibody titers. a sub optimal response to haemophilus influenza type b vaccine was noted. although vaccinated twice for mmr, he never mounted mumps specific igg. mitogen response to pha was normal with decreased responses to cona and pokeweed and no detectable tetanus nor candida responses. further investigation revealed decreased non-class and class switched memory b-cells. the patient was recently vaccinated to pcv and at the present time has protective titers. discussion: it has been previously suggested that decreased memory b cells may contribute to decreased antibody responses to select vaccine antigens resulting in recurrent aom in children. our case supports the need to investigate beyond typical immunologic screening for immunodeficiencies. introduction: dna mismatch repair (mmr) system corrects replication errors in newly synthesized dna, and prevent recombination between dna sequences when they were not identical ( ) . msh is a part of mmr genes, ( ) ( ) ( ) . case: a ten-year-old girl presented with fever, brown spots on her skin, hair loss, recurrent pulmonary infections, arthritis on the left hand and right ankle. she has also been followed up with nf ( figure ). there was a first-degree cousin marriage between her parents. physical examination revealed findings of pneumonia and nf. anti-nuclear antibody, anti-ndna, anti-dsdna, anti-histone, anti ro and anti-nucleosome antibodies were positive. in her immunologic assessment showed low igg and iga levels associated with high igm level ( table ). the coexistence of nf, hyper igm syndrome, sle, were considered in the patient. intravenous ig ( mg/kg, every weeks) treatment was started due to hypogammaglobinemia. the frame shift mutation in exon of the msh gene was detected in the boztug's laboratory. in the follow up period, she admitted at years old with back pain. a mass in the left paravertebral area, related to the spinal canal and neural foramina, was detected at the l -l levels in spinal mri. the lymphadenopathy around the liver and hilum and the left parietal bone lesions were developed within two months despite surgical excision of primary mass ( figure ). as a result of pet examination; suvmax was found to be around . in the mass lesion in the paravertebral region and suvmax values did not exceed . in other lymphadenopathy and masses. atypical cellular infiltration suggesting neoplastic events, which were including small-medium size atypical pleomorphic mononuclear cells and t cells. since all these formations did not indicate definite cancer, chemotherapy was not started. interestingly, although chemotherapy was not given, progression stopped, and partial spontaneous regression was observed. discussion: the effect of msh mutations on patients may significantly vary with the inheritance pattern ( ) . leukemias or lymphomas are not common in heterozygote mmr gene defects ( , ) . however, homozygote mutations in mmr genes show a different pattern. wimmer and etzler proposed the new term constitutional mismatch repair-deficiency syndrome (cmmr-d) for patients who have a homozygous mutation in mmr ( ) . cmmr-d characterized by development of childhood cancers, mainly hematological malignancies and/or brain tumors, as well as early-onset colorectal cancers, and neurofibromatosis type ( ) . bi-allelic germline mutations in any of the mmr genes in which msh is involved increases hematological malignancies by % ( , ) . msh mutation has been associated with many cancers since its identification. leukemia, lymphoma, colorectal cancer, endometrial cancer, brain tumors are some of these cancer types ( ) ( ) ( ) ) . msh deficiency is an important disease that can affect different systems at the same time. there is a high risk of malignancy in the cases and therefore they must be closely monitored. this case has also shown that atypical lymphoproliferation may occur in msh homozygous mutant cases. (normal rage: - ) background: advances in inborn errors of human immunity have supported the discovery of new syndromes that are marked by striking features of autoimmunity and immune dysregulation often associated with cytopenias, lymphoproliferation, and a predisposition to reticuloendothelial malignancies leading to evaluation with hematologists/oncologists. moreover, hematologists/oncologists have also seen an increasing use of effector cell-based therapies, checkpoint inhibitors, immunomodulatory and targeted therapies resulting in autoimmunity and hyperinflammatory complications. a working knowledge of clinical immunology could help practicing hematologists/oncologists in the identification and management of these conditions. objectives: to support the advancement of aspho members and the field by facilitating education regarding the best practices in diagnosis and management of immunological disorders. to create a platform for the development of collaborative clinical research in patients with hematological/oncological manifestations of immunological disorders or those requiring hematopoietic stem cell transplantation for a underlying immunological disorder. design/methods the aspho clinical immunology sig was initiated based on collaboration with the clinical immunology society (cis). aspho members who are pediatric hematology/ oncology clinicians, clinical researchers, and trainees are eligible to participate. we have established a steering committee with representatives from across the united states and canada with diverse clinical and research expertise. through regular teleconferences and annual in-person meetings, we have developed a platform to provide our members with a network of immunology resources to ensure a strong foundation of knowledge and tools to conduct clinical care and research pertaining to the diagnosis, evaluation, and treatment of patients with immunological disorders. results we currently support over members within our online community. several educational initiatives have been successfully launched. we have submitted an invited review to pediatric blood and cancer which provides a case-based review of primary immune regulatory disorders. we hosted the first immunology for hematology oncology practice (i-hop) cased-based webinar series. this series features case-based discussions of patients with primary immunodeficiency disorders presented by fellow trainees and mentored by senior clinicians. we will also be hosting an aspho webinar focusing on the laboratory evaluation of primary immunodeficiencies and immune dysregulation syndromes. we have also begun the process of laying the groundwork for clinical research initiatives. conclusion: the aspho clinical immunology sig seeks to serve as a collaborative resource for pediatric hematology/oncology clinicians and researchers. through the development of educational and research initiatives, we envision improving the care of patients with immunological disorders that are often managed by pediatric hematologists/oncologists. moreover, we hope to broaden our understanding and application of clinical immunology within pediatric hematology/oncology. we hope that this successful initiative will serve as a blueprint for the development of future collaborations with other specialty societies and patient groups. autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (apeced) is a rare autosomal recessive disease caused by aire gene mutations. clinical diagnosis is established by the presence of at least two components of the classic triad of chronic mucocutaneous candidiasis, hypoparathyroidism, and addisons disease. in europe, the classic presentation is widely recognized and nonendocrine autoimmune manifestations are rarely reported. a recent study of american apeced patients demonstrated a more heterologous presentation, with many nonendocrine manifestations including urticarial eruption, hepatitis, gastritis, intestinal dysfunction, pneumonitis and sjogrens-like syndrome, all uncommon in european reports. within the american cohort, % of patients developed a mean of three non-triad manifestations before reaching the classic triad. finding of aire mutations and high-titer antiifn-autoantibodies is seen in both european and american cohorts. we present the case of two siblings, who demonstrate an apeced-like phenotype with both classical and atypical features. they share the same heterozygous c + _ + delinsct aire mutation. the older, an eight-year-old boy, with history of prematurity, bronchopulmonary dysplasia and onychomadesis in infancy, came to medical attention at months of age due to failure to thrive (ftt), in addition to fevers and urticarial rash lasting months after his mmr vaccine. the fevers resolved with anakinra, which was discontinued two years later due to pneumonia. from age - he developed an alps negative lymphadenopathy which self-resolved. lung issues include chronic cough, initially treated as asthma but with poor bronchodilator response, and frequent lung infections, including - pneumonias per year. at age five evaluation for ftt revealed growth hormone deficiency. two years later he was diagnosed with primary addisons disease. chronic abdominal discomfort, bloating, cyclical constipation/diarrhea, recurrent rashes, dystrophic nails, and sicca symptoms are also present. his sister, age five, shows ftt, but no growth hormone deficiency. at age one, she too developed a fever and rash syndrome lasting months. severe gerd and constipation started in infancy and are ongoing. at age three she developed a transaminitis, initially diagnosed as ebv, but later thought to be autoimmune hepatitis. she has frequent viral respiratory infections, and pneumonia at age two. she has had a chronic cough, with poor bronchodilator response, for most of her life. evaluation of seizure at age three showed normal brain activity. brain mri revealed partial agenesis of the corpus callosum and microgyria. her brother has similar mri findings. both children have had developmental motor delay and poor tone. brain dysgenesis and neurodevelopmental delay has not previously been described in apeced. although there were both typical and atypical symptoms, the history in combination with genetic findings led to further investigation of an apeced-like syndrome. autoantibody testing confirmed high-titer antiifn-autoantibody typical of apeced in both children and hightiter bpifb autoantibodies found almost exclusively in apeced pneumonitis in the brother. whole exome sequencing and copy number variation analyses are underway to further evaluate the patients condition. this case demonstrates the importance of clinical presentation in the evaluation of genetic results and in the guidance of therapeutic management. ( ) submission id# rationale: infants with low t cell receptor excision circles (trec) born in queens, nassau, and suffolk counties are referred to our center for further evaluation. this study elucidates the demographic and laboratory characteristics of referred infants with transient or persistent idiopathic t cell lymphopenia (tcl) without clearly identified genetic or acquired etiology. methods: a retrospective analysis was performed from september (when trec screening started) through the end of december . descriptive statistics were calculated for demographic and laboratory characteristics. t-test or mann-whitney tests were used to compare laboratory variables. pearson or spearman tests were used to determine correlation between initial trec levels and t cell counts. by definition, the cd +, cd +, and cd + populations of transient tcl patients normalize by age year. results: eighteen infants with transient and with persistent tcl were identified. males comprised . % of the transient and . % of the persistent tcl cohorts. whites comprised . % of the transient and . % of the persistent tcl cohorts. the mean initial trec levels did not differ between the transient and persistent cohorts ( . vs. . trecs/l of blood, p = . ). mean initial absolute counts of cd + ( vs. cells/l, p < . ), cd + ( vs. cells/l, p < . ), and median initial absolute counts of cd + ( vs. cells/l, p = . ), were higher for transient vs persistent cohorts. initial trec level did not correlate with initial cd +, cd +, or cd + absolute counts. the median age of resolution for the transient cohort was . days (range - ). the absolute cd +, cd +, or cd + counts rarely exceeded the reported median values for age, and remained closer or below the th percentile for age up to days of life. the majority of both transient and persistent tcl patients demonstrated unremarkable lymphocyte proliferation to mitogens. conclusion: our centers transient tcl cohort appears to be predominantly male and non-white, whereas the persistent tcl cohort is more evenly distributed by sex but still predominantly non-white. the transient cohort had lower initial trec levels, but higher initial t cell counts. both cohorts appear to have relatively intact in vitro function. introduction: primary immune deficiency disease (pidd) is typically considered a pediatric illness, although advances in treatment and diagnosis are changing this paradigm. currently, data on pidd in older patients are very limited. objectives: to characterize the prevalence of pidd among older individuals using a patient database maintained by the consortium of independent immunology clinics (ciic), comprised of specialty immunology outpatient practices in the us. methods: patients with pidd were identified in the ciic database using icd- codes d , d. . , d . , d . , d . , d . , d . , d . , d . , and d . . a total of records from geographically-diverse clinics were identified and characterized by age, gender, and pidd diagnosis. results: of the pidd patients in the ciic registry, ( %) were between - years of age (see figure) . within this age group, most patients were female (n= , %). the most common diagnoses among patients > years of age included common variable immunodeficiency with predominant abnormalities of b-cell numbers and function (d . ; n= , %) and antibody deficiency with near normal immunoglobulins (d . ; n= , %) . in comparison, the registry included ( %) patients aged - years; this age group was predominantly male (n= ; %). the most common icd- codes within the younger cohort were relatively evenly distributed between hereditary hypogammaglobulinemia (d . ), antibody deficiency with near normal immunoglobulins (d . ) , and common variable immunodeficiency with predominant abnormalities of b-cell numbers and function (d . ). conclusions: our data suggest that pidd in patients over age may be more prevalent than previously reported. additional research is needed to corroborate these findings, further characterize the nature of pidd in this population, and determine whether there are unique diagnostic and treatment considerations within this demographic. introduction/background: increased susceptibility to invasive infections with neisseria has been well documented in patients with deficiency of terminal complement proteins. the molecular attack complex is constructed with complement components c to c . a deficiency in complement c has been described previously in both african american and south african populations. complement c deficiency is inherited in a co-dominant pattern, with multiple known mutations. we present a case of a -year-old, previously healthy male, who presented with invasive n. meningitides infection. he was found to have a novel mutation noted on genetic sequencing of the complement c gene. objective: we present the case of a -year-old, previously healthy male, who presented with invasive n. meningitides infection. on genetic sequencing, he was found to have three mutations of the complement c gene. two of which have been described previously, and a third novel mutation. methods: a -year-old male with no known history presented to us with a -hour history of emesis. he was found to be febrile, and quickly decompensated, developing septic shock. blood cultures were drawn, and within hours grew n. meningitides. he was treated with broad spectrum antibiotics upon arrival, and subsequently narrowed to ceftriaxone. his hospital course was complicated by disseminated intravascular coagulation, as well as acute tubular necrosis, leading to endstage renal disease for which he is listed for kidney transplant. results: on immunodeficiency evaluation, he was noted to have an undetectable ch (< , reference range - ). complement levels returned with c of . (reference range - ) and c r of . % (reference range - %). complement c function screen returned at % (reference range . - %). all other complement levels were within normal limits. genetic sequencing showed the patient to be compound heterozygous for two of known four variants which have been reported to recur in african patients with complement c deficiency. this included c. del and c. del, which are predicted to result in frameshift and premature protein termination. he was also found to be heterozygous for sequence c g>a, which results in amino acid substitution p.arg lys. this variant is rare, with one large database reporting it in of alleles, and not in a homozygous state. it has not been reported in a case of c complement deficiency previously. conclusions: we present the case of a previously healthy -year-old male with invasive meningococcal disease. he is compound heterozygous for two mutations that have been associated with total complement c deficiency; however, he was found to have subtotal c deficiency. furthermore, he has a third novel mutation of the complement c gene. further investigation is warranted on the significance of this finding and impact on relevance to possible kidney transplant. background: measuring the function of the classical pathway of complement activation is useful in several disease states, including complement deficiency, autoimmune conditions such as systemic lupus erythematosus and certain forms of nephritis. the original method for assessing classical pathway activity was the haemolytic ch method, but this assay can be time consuming and has reagent stability issues due to the use of sheep red blood cells. there can also be high lab-to-lab variability due to differences in the protocols used. here we report the assay characteristics of an automated, commercial, liposome-based assay to measure ch activity. we also compare the results obtained using the traditional haemolytic method with the automated, liposome-based method used on the spaplus turbidimetric analyser. methods: a linearity study was performed based on clsi guideline ep -a. the linear range of the spaplus ch liposome assay was established by analysis of a series of sample dilutions and evaluation of results against pre-defined goals for recovery and %cv. precision was assessed based on clsi guideline ep -a over days. samples with different ch activities ( . - . u/ml) were run in duplicate, with two runs per day using reagent lots and different analysers. interference analysis was performed by spiking haemoglobin, bilirubin, chyle, ascorbic acid or saline (as a control) into samples before measuring the ch activity. for the assay comparison study, sera from routine patient samples were used. samples were collected from chulalongkorn hospital, faculty of medicine, chulalongkorn university, thailand. ch classical pathway activity was assessed using a haemolytic method and also using the liposome based ch assay for use on the spaplus turbidimetric analyser (the binding site ltd., birmingham, uk). c protein concentrations were also available for of these samples. results: the liposome ch assay gives a linear response over the range . - . u/ml, covering the measuring range of the assay ( . - . u/ml) at the standard analyser dilution (neat). the within run, between run and between day %cvs were all . %. the total %cv was . % in all samples. minimal interference was observed with the four common interferents tested. a significant correlation was observed between the two ch methods (p< . , r= . , y= . x± . ), with . % agreement between the methods in determining whether patients were above or below the lower limit of the assay normal range. the individuals in disagreement had normal ch results using the haemolytic method, and low ch values in the liposome assay. of these, c values were available for / , and had c concentrations below the lower limit of the assay normal range. conclusion: the liposome ch assay for use on the spaplus analyser has passed assay development guidelines based on those set out by the clsi for linearity, precision and interference, and there is a strong correlation between this automated assay and the haemolytic ch method used here. five additional patients with low c concentrations were defined as having a low ch using the spaplus liposome method compared to the haemolytic method. ( ) submission id# background/aims: rotavirus vaccine is a live viral vaccine that is part of the routine u.s. childhood immunization schedule. live viral vaccines administered to infants of mothers who received biologic medications during pregnancy can potentially cause vaccine-associated disease. infant death from disseminated mycobacterial infection after vaccination with bacille calmette-guerin (bcg) in infants whose mothers received infliximab during pregnancy has been reported. it is currently recommended that infants born to women who received biologic therapy during pregnancy not receive live viral vaccines, however there is a paucity of information regarding adverse events from live viral vaccines. we report two infants, born to mothers receiving infliximab during pregnancy, who tolerated the complete series of rotavirus vaccine. methods: two infants who received rotavirus vaccine and whose mothers received infliximab (monoclonal antibody against tumor necrosis factor alpha which blocks the inflammatory response) during pregnancy were identified and their charts were reviewed. each mothers chart was assessed for timing of the biologic doses during pregnancy and concurrent immunosuppressant therapy. results: the mother of the first infant had crohn's disease and received infliximab every weeks throughout her pregnancy (final infusion at approximately weeks estimated gestational age [ega] ). she did not take additional immunosuppressive drugs throughout her pregnancy. the infant was born at weeks ega. the infant received rotavirus vaccine at , , and months of age. the infant did not have coexisting medical conditions or recorded hospitalizations during the first year of life. there were no side effects from rotavirus vaccine documented during well child examinations. the childs growth was normal during the first year of life. the mother of the second infant also had crohn's disease and received infliximab infusions every six weeks during pregnancy until weeks ega. additionally, she took mesalamine (anti-inflammatory) daily. the infant was born at weeks ega. the baby had a brief and uncomplicated neonatal intensive care unit stay. she did not have medical conditions diagnosed at the time of birth, or in the first year of life. the child received rotavirus vaccination at , , and months of chronological age, and the infant did not experience documented adverse reactions. the child presented to the emergency department twice in the first year of life: once for thrush at months of age and once for viral gastroenteritis at months of age. the childs growth curve was unremarkable. conclusions: we report two infants, whose mothers received infliximab during pregnancy, who safely tolerated the -dose series of rotavirus vaccination. neither infant in this case series suffered from minor or severe adverse events as a direct consequence of receiving rotavirus vaccine. this suggests that administration of rotavirus vaccine may be safe in infants whose mothers received biologic therapy. introduction: combined immunodeficiencies (cids) can arise from partial loss of function variants in recognized scid genes, which can lead to relative lymphopenia with poorly functioning and oligoclonal t cells. cids have been most commonly associated with variants of the rag genes, but other genes are also implicated. clinical symptoms may be less severe, and the onset generally is delayed, compared to typical scid presentations. case report: a -year-old female presented with a history of recurrent and progressively worsening infections involving multiple microorganisms and organs, starting in infancy and requiring frequent hospitalizations. bacterial or viral infections included rhinosinusitis, otitis media, herpetic stomatitis, dental abscesses, pneumonias, pulmonary mycobacterial abscesses, cmv hepatitis, urinary tract infections, dermal abscesses, and groin hidradenitis. fungal and yeast infections included cryptococcal meningitis, oral thrush, dermatophytosis of the face, osteomyelitis of a finger, and onychomycosis. laboratory tests in showed: mildly low t cell counts ( /ul) with a reversed ratio of cd /cd t cells ( . ); almost absent b cells ( /ul) ; and low nk cell counts ( /ul). cd + t cells were mostly of the memory phenotype ( %). t cell development showed low counts of th cells. t-cell stimulation tests demonstrated poor proliferation responses (< %) to concanavalin a, tetanus toxoid, and candida albicans, with near-normal responses to pokeweed (> %) and pha (> %). she had low ig levels (iga , igm , ige < ), except for igg ( mg /ml; due to replacement since early childhood). limited genetic evaluation at age showed a heterozygous variant in the rag gene (g. t>c, c. t>c, p.met thr; nm_ . ). discussion: loss of function variants in rag or rag genes are known to cause a t-b-nk+ type scid. more than missense variants have been reported for rag , with disease-associated variants predominantly in zinc binding regions. the rag missense variant in our patient also lies within the zinc binding region (amino acids - ). the variant is rare (mean allele frequency . in gnomad) and has been identified in at least one other individual with scid (t-, b cell-, nk+). although classified as a variant of unknown significance, occurrence in at least two individuals with deficiencies of t and b cells-within a functionally important rag domainsupports an interpretation that the variant may be pathogenic. most patients with cid with rag variants are either homozygous for a poorly functional allele or have one nonunfucitonal and a second, poorly functional allele. we detected only a single potentially pathogenic allele. our patient has decreased nk cells in addition to t and b cell defects. further genetic studies including whole exome sequencing, are planned to identify further variants in rag or other relevant genes. rationale: infants with low t cell receptor excision circles (trec) born in queens, nassau, and suffolk counties in new york were referred to northwell health for further evaluation after abnormal newborn screens. the demographic and immune parameters of infants with transient t cell lymphopenia (ttcl) without clearly identified genetic or acquired etiology are described. tcl is considered transient if the lymphopenia resolves by months of age. similar data from the following infants with low lymphocytes (fill) program of the united states immunodeficiency network (usidnet) are presented. methods: a retrospective analysis of two separate patient cohorts with ttcl are described. cohorts include patients referred to a single center, northwell health, in ny from september to december and at usidnet using data tracked by fill from june to july . results: out of , referrals at northwell, infants with ttcl were identified. infants were predominantly male ( . %) and non-caucasian ( . %). out of fill participants, infants with ttcl were identified. infants were predominantly male ( . %) and non-caucasian ( . %). initial laboratory parameters for the northwell versus fill cohorts are summarized: a) median trec levels: . vs. . trec/l of blood; b) median absolute cd + count: vs. cells/l; c) median cd + count: vs. . cells/l; d) median absolute cd + count: . vs. . cells/l. initial naïve cd + t cell information was available for northwell and fill infants (median %). mitogen proliferation studies were performed in ( . %) northwell and ( . %) fill infants with % of these northwell and % of these fill infants demonstrating normal proliferation. genetic testing, such as targeted genetic panels or chromosomal microarrays (cma), was performed in northwell and fill infants. no genetic or chromosomal aberrations were identified. whole exome sequencing (wes) was not performed in either cohort. of ( . %) northwell and of ( . %) fill infants did not receive the initial rotavirus vaccine. no fill infants were vaccinated but no adverse effects were reported in of ( . %) northwell infants who received the first rotavirus dose. of these, of ( . %) had normal mitogen proliferation while ( . %) had decreased proliferation to phytohemagglutinin. conclusions: identifying biomarkers for ttcl and developing evidencebased guidelines for the diagnosis and management of ttcl are important knowledge gaps. this descriptive study is limited by small sample size and the constraints of registry-based research. although there appear to be differences between these cohorts, our findings suggest that ttcl may disproportionately affect different segments of the population. ttcl infants with normal mitogen proliferation may be able to tolerate rotavirus vaccination. thus, routinely checking proliferation studies in all ttcl infants may help risk stratify these patients and minimize vaccinerelated adverse events. currently, there is insufficient evidence to recommend more extensive genetic testing such as genetic panels, cma, or wes. systematically collecting information about patient characteristics and outcomes, as well as encouraging increased participation in registries such as fill, may help address these shortcomings. background: systemic lupus erythematosus (sle) is a chronic, inflammatory disease that affects multiple organs. the measurement of anti-dsdna antibodies (abs) is a gold standard serological test used in the diagnosis and monitoring of sle, with higher serum levels associated with worse prognosis. however, not all anti-dsdna abs are pathogenic, and some patients have consistently high levels with low disease activity. one mechanism suggested for the pathogenicity of these antibodies is complement activation. here we describe an assay to measure the c q binding activities of anti-dsdna abs in sle patients. materials & methods: the concentration of anti-dsdna abs was determined using the quantalite dsdna elisa kit (inova) as per the manufacturers instructions. in order to determine the c q binding capacity of bound abs, samples were added to the pre-coated plate and incubated. bound anti-dsdna ab/c q complexes were then detected using a biotinylated anti-c q antibody ( ng/ml) and streptavidin peroxidase ( mg/ml). normal reference ranges were developed in serum samples from healthy controls, and upper limits of these normal ranges were used as cut-offs. the dsdna abs and c q binding capacity of bound abs was then assessed in sle patients, and compared to other markers and the sle disease activity index (sledai) score. results are displayed as absorbance at nm (au). results and conclusions: the th percentile ranges for anti-dsdna abs ( . - . au) and c q binding activities ( . - . au) were developed from the measurements generated in healthy serum samples. sle patients with an increased anti dsdna ab concentration (> . au) were then separated into those with low (< . au) and high (> . au) c q binding activities. patients whose dsdna abs had high c q binding activity were found to have significantly higher sledai scores (mean . vs . ) . serum c q concentration, serum dsdna abs (measured by another method) and serum c and c concentrations were not significantly different between the two groups. this assay suggests that dsdna abs from sle patients differ in their ability to bind complement, and that high complement binding activity of these antibodies may be linked to a more active form of disease. x-linked lymphoproliferative (xlp) is a primary immunodeficiency, caused by signaling lymphocyte activation molecule (slam)-associated protein (sap) deficiency. patients with xlp have severe immune dysregulation, usually triggered by ebv infection, leading to fulminant infectious mononucleosis, dysgammaglobulinemia and lymphoproliferation. without hematopoietic stem cell transplant (hsct) fatality is reportedly % by age . we report the natural history of xlp in a patient, and describe the lessons learned. our patient was healthy and developed normally until -years of age, when he developed progressive respiratory symptoms. lung biopsy revealed mature lymphoplasmacytic infiltrate in the alveolar septa, consistent with lymphoid interstitial pneumonia (lip). he received corticosteroids and cyclophosphamide with significant improvement. at age , he developed severe infectious mononucleosis (fever, hepatosplenomegaly, lymphadenopathy, lymphocytosis). he had a protracted clinical course, but eventually recovered and seroconverted to a typical convalescent pattern. he subsequently developed hypogammaglobulinemia, and was started on intravenous immunoglobulin (ivig). during the same year, his -year-old brother developed lip, and subsequently hemophagocytic lymphohistocytosis (hlh) and died within months from overwhelming candidiasis. unfortunately, his youngest brother (age ) then developed lip and died months later from a massive gastrointestinal bleed. both siblings were treated with corticosteroids and cyclophosphamide; they did not have detectable ebv infection. at age years, our patient experienced recurrent strokes and was found to have biopsy-proven cns vasculitis. he was treated with interferon-and recovered with residual left sided weakness, but was lost to follow-up. he continued on ivig, with no other immunomodulatory agents for several decades. he had progressive lung disease and recurrent seizures controlled with anti-epileptics. at age , he developed sudden vision change, headache and right-sided weakness, followed by a seizure. mri of the brain revealed small bilateral areas of acute infarction suggestive of a central embolic event, however, no primary thrombus was identified. he did not receive any immunosuppression but was anti-coagulated. eventually he was discharged home with resolution of weakness to his baseline. the patient was referred to our clinic after discharge and we re-evaluated him after years. immune profiles at the time showed therapeutic igg troughs, low/undetectable igm/a/e, normal t/b/nk-cell counts, normal spontaneous, but decreased antibody-dependent nk cytotoxicity, % sap protein expression (on cd +cd +, cd -cd + and cd + cd + cells), and deletion on the x chromosome encompassing the sh d a gene which encodes sap. his mother was a carrier of the same deletion. his functional status excluded the option of hsct. a year later, he had rapid deterioration with recurrent lung infections, liver failure, and thrombocytopenia. bone marrow biopsy revealed hodgkins lymphoma. he declined chemotherapy and died few days after diagnosis. our case represents a rare patient with xlp surviving to the fifth decade without hsct, particularly having experienced mononucleosis and non-ebv related cns vasculitis. our patient survived decades longer than his brothers (who most likely shared the same genetic defect) without evidence of somatic reversion ( % sap expression in cd +cd +) to explain his milder clinical phenotype. this case may help in understanding the natural history of xlp, and confirms that prognosis remains poor without hsct. haematology and oncology, chu de québec ctla- is a major negative regulator of immune responses, and ctla- haploinsufficiency has been identified as a monogenic cause of primary immunodeficiency in patients presenting with a common variable immunodeficiency (cvid) phenotype with autoimmunity. here we present the case of pb, a -year-old man who had been followed by the immunology service of our center for years. a diagnosis of cvid had first been made when the patient presented with atypical transverse myelitis, low immunoglobulin levels, and lymphopenia. over the years, his clinical picture was dominated by various forms of autoimmunity, namely inflammatory demyelinating disorder of the central nervous system, autoimmune haemolytic anemia, immune thrombocytopenia, cryptogenic organizing pneumonia, rheumatoidlike polyarthritis, chronic liver transaminitis with biopsy-proven moderate fibrosis, and lymphocytic colitis with malabsorption. immunoglobulin replacement therapy was started at diagnosis, and autoimmunity was sequentially treated with methotrexate, interferon beta -a, cyclophosphamide, mycophenolate mofetil, rituximab, and finally a combination of low-dose prednisone and sirolimus, with stabilization of his neurological condition, the most debilitating complication of his immune dysregulation syndrome. bone marrow transplant had been offered, but declined by the patient due to perceived good quality of life compared to transplant-associated risks. the patient was later referred to our hematology ward in july of for septic shock complicating febrile neutropenia, which was part of a twomonth, gradual-onset pancytopenia. the diagnosis of immune-mediated aplastic anemia soon became apparent, as demonstrated by a bone marrow biopsy performed in a peripheral center two days prior to admission. the underlying pneumonia and thereafter biopsy-induced staphylococcus aureus iliac osteomyelitis and soft-tissue abscess were treated with broad-spectrum antibiotics as well as multiple surgical interventions. the patient was started on eltrombopag, high-dose corticosteroids and cyclosporin a, the latter promptly switched to tacrolimus due to liver enzymes disturbances, all of which resulted in no significant hematologic response despite over seven weeks of treatment (with concurrent treatment of complicating infection, upper gastrointestinal bleeding, and intensive-care-unite myopathy). during that time, genetic confirmation of ctla- haploinsufficiency was received, and the patient was thereafter started on abatacept on day of current hospitalization. administration of equine anti-thymocyte was initially foregone because of perceived infectious risk in the setting of poor iliac wound healing and superimposed adenovirus viremia; however, given the lack of response, it was given on days through of hospitalization. haematologic response began on day of hospitalization with a steady rise in alllineage myelopoiesis up to a complete neutrophil response, platelet near-complete response as well as resolution of transfusion needs by day . while waiting for a well-matched bone marrow donor, isolated platelet decrease was observed and attributed to multiple factors, including low-grade thrombotic microangiopathy, inflammatory consumption and drug-related thrombocytopenia, but the patient remained well. to our knowledge, our patients presentation is one of the most severe manifestation of ctla- haploinsufficiency to have responded to targeted therapy with abatacept, as a bridge to hematopoietic stem cell transplantation, with resolution of both immune and infectious complications, showing that genetic diagnosis is helpful in optimizing the management of presumed cvid patients. hospital de octubre health research institute (i+ ), madrid, spain, dept. of immunology, university hospital octubre. madrid. spain background: xlf/cernnunos deficiency is a rare primary immunodeficiency classified within the dna repair defects. these patients present severe growth retardation, microcephaly, lymphopenia and increased cellular sensitivity to ionizing radiation. here, we describe two unrelated cases with the same nonsense mutation in the nhej gene showing significant differences in clinical presentation and immunological profile but a similar dna repair defect. methods: missense nhej mutation was identified by targeted next-generation sequencing with an in-house designed panel of genes. for foci experiments, primary skin fibroblasts were irradiated with ionizing irradiation ( cs) or treated with mm etoposide for hour. after irradiation, the cells were seeded at a density of x cells/ml in t flasks in triplicate. to evaluate cell sensitivity to gamma-ir ( and gy),adherent cells were trypsinized and counted days later. pbmcs from patient and healthy controls were irradiated with gy, fixed and stained for cd , cd and phospho-histone h ax. mean fluorescence intensities (mfi) of gamma-h ax were evaluated on gated cd + lymphocytes. results:we report two patients harboring the same homozygous mutation in cernunnos/xlf/nhej gene. strikingly, their clinical phenotype ranges from severe combined immunodeficiency to isolated thrombocytopenia followed until escolar age (table ) . they harbour the same c. c>t mutation in nhej gene but different immunologic features (table ) . p presented with mild t lymphopenia, hypersensitivity and nhej repair defect, typical for patients with xlf/nhej defects. on the other hand, p presented a more severe phenotype (t-b-) , however hypersensitivity and nhej repair defect was similar to p .of note, p has survived into the first decade of live. both patients are alive and well after hsct. discussion: usually the repair defect in these disorders is assessed by immunofluorescence assays of irradiation-induced gamma-h ax foci using skin fibroblasts. a high throughput, sensitive and reliable assay to quantify gamma-h ax foci in pbmcs isolated from blood samples would be a valuable tool to diagnose these patients and perform hsct early. flow cytometry (fc) can be applied as a rapid diagnostic tool for dna repair disorders. patients with the same homozygous mutation (p.r x) in nhej gene have been previously reported. two patients died at . and years while another of the patients is already years old and is alive (without hsct). however,none of these patients presented severe t lymphopenia as it has been observed in our first patient. conclusions: the assignment of a timely and accurate diagnosis is of paramount importance in the management of patients with defects in dna repair. in the era of nbs an abnormal trec assay should be followed by ngs approach as cernunnos deficiency may present early in life as scid,as other rs-scid defects. since genetic diagnosis takes time,functional radiosensitivity assays in peripheral blood may lead to the correct diagnosis and avoid exposure to alkylating agents during the conditioning regimen prior to genetic diagnosis. it would also be helpful in cancer patients to individualize and to guide the dosing of ionizing radiation (ir) and/or genotoxic agents to avoid accumulation of cells with genomic instability that could accelerate cancer development. figure ). her skin lesions also significantly improved after starting the medication ( figure ). her hospitalizations were complicated by fluid overload and hypertension. both fluid overload and hypertension resolved prior to discharge. she remains on mg prednisone daily, cetirizine, ranitidine, cromolyn and benadryl and hydroxyzine prn. to our knowledge, this is the youngest patient successfully treated with midostaurin and she is doing very well on therapy with no apparent side effects. she has had resolution of many of her systemic mastocytosis symptoms including skin lesions, axillary mass and improvement in her diarrhea and growth as well as objective improvements in her tryptase levels. case report: a two-year-old male presented to the hospital with a painful, non-pruritic facial and groin rash. the rash started one week prior to presentation. he had no associated fevers. his history was remarkable for failure to thrive (ftt) and chronic bilateral leg pain with antalgic gait. over the preceding months, he had been diagnosed with hand-foot-mouth disease and varicella. he had also had recurrent cervical lymphadenopathy (lad) for greater than one year requiring incision and drainage. gram stain and gomori methenamine-silver nitrate stain (gms) were negative and pathology showed only acute and chronic inflammation with areas of necrosis. his family history was negative for autoimmune disease or immunodeficiency. infectious exposure history was significant for an incarcerated father with unknown tuberculosis status and history of living in a shelter. on physical examination, the patient was well appearing with multiple erythematous papules, with superficial erosions and scabbing on the face (figure ), lower abdomen, genital area, buttocks and proximal lower extremities. he had large, firm, non-tender submandibular lymph nodes. he also had small palpable axillary and inguinal lymph nodes bilaterally. his laboratory workup revealed normal white blood cell and platelet counts, but microcytic anemia, an erythrocyte sedimentation rate of mm/hr, and c-reactive protein of . mg/dl. full body magnetic resonance imaging (mri) revealed bilateral cervical, supraclavicular, right hilar and inguinal lymphadenopathy and a patchy right upper lobe consolidation with at least one small area of cavitation ( figure ) and an adjacent smaller area of ring enhancement. it also revealed three small nonspecific hypodense foci within the right lobe of the liver and borderline splenomegaly. given these findings, there was concern for granulomatous diseases. the patient underwent a liver biopsy ( figure ) which showed non-specific evidence of necrotizing granulomatous disease. microbiological cultures and stains for bacteria, acid-fast bacilli and fungi were negative. his infectious work-up was negative for hsv, tuberculosis, hiv, syphilis, histoplasmosis, and toxoplasmosis. superficial bacterial cultures from the face and groin grew mixed gram positive and negative organisms, including methicillin-susceptible staphylococcus aureus (mssa). his immunologic workup revealed borderline elevated iga and igg with normal igm, normal t,b, nk-cell counts and pneumococcal and tetanus titers. a dihydrorhodamine (dhr) flow cytometric test was positive, consistent with a diagnosis of chronic granulomatous disease (cgd). genetic testing confirmed x-linked disease. he was treated with acyclovir and ceftriaxone with resolution of his rash. conclusion: we present a case of a two-year-old male with newly diagnosed x-linked cgd. though he had been seen by multiple healthcare providers for recurrent lymphadenopathy over the preceding year, he had no other history of recurrent viral or bacterial infections or significant family history that might implicate a primary immunodeficiency. at time of presentation, he had diffuse rash which could have caused his palpable lymphadenopathy on exam. a high index of suspicion for cgd in the setting of recurrent lad and ftt prompted sending the dhr, which led to the diagnosis. chronic granulomatous disease (cgd) is an inherited primary immunodeficiency (pid) which results in both inflammatory response dysregulation and an increase in susceptibility to certain bacterial and fungal infections. without curative treatment such as a bone marrow transplant, it remains a chronic disease with daily medication management, intermittent treatment and life-long surveillance. in general, chronic disease involves physical, psychological and social effects which can affect the patients quality of life. although some research has been done on how pid affects quality of life, there is little research in the united states about how cgd affects patients quality of life. to examine the effect of cgd on patients quality of life, as a part of a voluntary research protocol examining the natural history of immune deficiencies, we administered the who qol-bref instrument to adult cgd patients enrolled on a nih irb approved protocol and seen in the infectious disease clinic at the national institutes of health (nih) over a five-month period. the who qol-bref is comprised of items, which measure the following broad domains: physical health, psychological health, social relationships and environment. each item is rated on point likert scale. it has been validated cross culturally and has been widely field tested. the survey was interview administered to patients ( males, females) with genetically confirmed cgd. the age range was - years old (mean age . years) with a distribution of % x-linked cgd and % autosomal recessive cgd. results have been obtained and will be presented. rationale: common variable immunodeficiency (cvid) is the most common primary immunodeficiency with an estimated prevalence of : , . we aimed to analyze the clinical presentations and their associated comorbidities amongst cvid patients in usa. methods: data on , cvid patients reported in the united states immunodeficiency network (usidnet) from to were analyzed based on clinical, immunological and genetic factors. univariate analysis with spearman rank coefficients was done to analyze correlations between disease outcomes. observed survival was estimated using the kaplan-meier method. results: among the patients, ( . %) were female and ( . %) were male. median age at diagnosis was years [mean (sd), . ( . ); range, - ; iqr, - ] with median age of onset of years (mean (sd), . ( . ) ; range, - ; iqr, . females showed a longer delay in diagnosis ( . vs. . years, p= . ). higher body mass index (bmi) linearly correlated with the age of diagnosis (r= . ). in survival analysis, a -year delay in age at diagnosis increased the risk of death by . % (hr: . , % ci: . - . , p= . ). conclusions: our study suggests a longer delay in diagnosis in female subjects and a strong association with diagnosis of cvid in patients with higher bmi. females may have a longer period without symptoms leading to a diagnostic delay. gender-based and disparities-based inquiry into these trends may need additional study. the physical well-being of those with primary immunodeficiency (pi) and the physical maladies of those with pi are well-documented. since the s, advances in identification and treatment of pi has for many led to lives where the physical infections of these groups of diseases are manageable. however, not as well understood are the emotional and mental health aspects of living with pi. as part of a larger survey project the idf national patient survey, this study aims to quantify any potential mental health issues or challenges faced by adults with pi. our hypothesis-those with pi, suffer from statistically higher rates of depression when compared to the u.s. general population. the idf national patient survey was a nationally distributed, unincentivized, mail-based survey of , persons in the idf patient database identified as being either adults with pi or the parent/caretaker of a child with pi. the questionnaire comprised approximately main questions about pi as well as the validated sf- v , brief fatigue inventory and the patient health questionnaire- (phq- ) instruments. additional questions asked about current use of prescription medications for anxiety, depression, stress and pain. for the purpose of this study, only adult respondents with pi are included as the basis for analysis. the two-item patient health questionnaire (phq- ) meets the criteria for general screening of depression suggested by the u.s. preventive services task force. scored on a scale of - , a score of three or higher is suggested as the cut-point for depressive screening. according to a ahrq study that utilized meps data, , of the , ( %) respondents scored three or greater. in our survey of the ( %) adults scored three or greater ( <. .) overall, those in our survey scored lower on the sf- v mcs scale when compared to the u.s. population ( . v. . , p<. ) . further, adults with pi who scored three or higher on the phq- had an average mcs of . . those who met the phq threshold in our survey were also more likely to report moderate to severe limitations in normal activities as a result of emotional problems than those that fell below the threshold ( % versus %, p <. ). not surprisingly, those that met the phq threshold reported much higher use of prescription medications for anxiety, depression, stress ( % versus % below threshold, p <. ) as well as a higher reported use of prescription pain medications ( % versus % below threshold, p <. ). though moderate to severe fatigue was reported by % of those below threshold, % of those with phq scores at threshold reported experiencing moderate to severe fatigue (p <. ). health care providers should consider including the phq- in the overall health assessments of their patients with pi. those scoring three or higher should be referred to the appropriate professional for further evaluation. (lek et al., ) . the w l is a semi-conservative amino acid substitution, which may impact secondary protein structure. in-silico analyses supported a deleterious effect, located within the sh domain, which is a critical functional domain (chandesris et al., ; koskela et al., ) . it was thus determined that this variant is likely pathogenic. the patients prophylactic treatment was optimized with tmp-smx ( mg- mg) twice daily for prevention of infections. she was also started on hibiclens (chlorhexidine) baths once per week. she was referred to pulmonology for optimization of pulmonary health in the setting of bronchiectasis and mild decline in dlco. she was advised to followup on a yearly basis to the primary immunodeficiency clinic to assess for recurrent infections and for changes in pulmonary health. finally, targeted testing and clinical evaluation of both of the patients parents was recommended to determine if w l was inherited or arose de novo. the pathogenic role of the w l missense change would be further supported if it had occurred de novo or if it segregates with the disease in the family. uploaded file(s) uploads pulmonary function testing results.pdf j clin immunol ( ) (suppl ):s -s s introduction: lipopolysaccharide-responsive and beige-like anchor protein (lrba) deficiency is a rare autosomal recessive disease of the immune systems characterized by hypogammaglobulinemia and decreased ctla expression on t regulatory cell (t regs) due to defective intracellular trafficking of ctla . previous in vitro study has shown a significant increase of ctla expression on lrba deficient t cells after overnight culture with chloroquine, an older anti-malarial agent. this effect is likely due to increasing lysosomal ph. however, there is no evidence of such effect in human subjects after administration of weight appropriate doses anti-malarial agents. we are presenting a set of siblings with lrba deficiency who had ctla expression measured before and four weeks after starting hydroxychloroquine. case reports: case is a -year-old east-indian boy with autoimmune thyroiditis, type diabetes mellitus (dm), short stature, autoimmune cytopenias, and lymphadenopathy. he was referred to immunology clinic at years of age for suspicion of autoimmune lymphoproliferative disorder. primary immunodeficiency genetic panel was sent which revealed a homozygous mutation in lrba gene (c. _ del). this novel variant resulted in a frameshift and created a premature stop codon amino acids downstream from this location which may lead to absent or abnormal protein. lung ct scan showed interstitial lung disease. lung biopsy showed interstitial nodular and diffuse lymphoid proliferation. this diagnosis led to the testing of his sister (case ) given her history of autoimmune illnesses and the family history of consanguinity. case is a now -year-old girl with type dm, autoimmune thyroiditis, lymphadenopathy, psoriatic arthritis, and seizures. her lung imaging showed pulmonary nodules without interstitial lung disease. both cases received hydroxychloroquine while waiting for insurance approval of abatacept. ctla expression on tregs was measured prior to and four weeks after starting hydroxychloroquine treatment. at baseline, . % of case s cd cells were treg (foxp +ve, cd hi) and . % of them expressed ctla- (in contrast to . % tregs in the healthy control) with mean fluorescence intensity (mfi) of . this ratio and mfi did not change after weeks of hydroxychloroquine treatment ( mg/kg/day). soluble interleukin- receptor levels were measured: case had a baseline level of pg/ml, which decreased to pg/ml after weeks of hydroxychloroquine treatment. for case : . % of her cd + t cells were found to be foxp +cd hi and . % of these tregs expressed ctla- . this ratio increased by % after one month of hydroxychloroquine. increase in mfi was also noted from to . case had a drop in soluble interleukin- receptor level from pg/ml to pg/ml after treatment. conclusion: in contrast to the previous in vitro assays, we did not find a significant increase in ctla expression on t regulatory cells in vivo after weeks of mg/kg/day hydroxychloroquine. interestingly, soluble il- receptor levels improved dramatically with hydroxychloroquine. ( ) submission id# human nf-kappab defect results in defective intrinsic b-cell differentiation, function and class switching introduction/background: autosomal dominant heterozygous mutations in nfkb (encoding for the protein nf-kb ) have been identified in the etiology of a form of primary immunodeficiency disorder that presents with hypogammaglobulinemia, defects in b-cell maturation, endocrinopathy, and autoimmune manifestations. in humans, the effects of altered nf-kb and mechanisms of immune system impairment have not been fully delineated. objectives: to understand the mechanism of the antibody deficiency in patients with hypomorphic mutations in nfkb (c. dela; p.lys serfs* ) by evaluating b-lymphocyte proliferation, differentiation, function, and gene expression. methods: immunophenotyping of primary b-cells from subjects with mutant nfkb was completed by flow cytometry. proliferation of b-cells was assessed by cfse stimulation of primary cd + b-cells from healthy and nfkb mutant subjects. differentiation of healthy and affected naïve b-cells (cd -cd -) into plasmablasts (cd +cd +) following stimulation was assessed by flow cytometry. the supernatant from these cells were assayed for iga, igg and igm production by elisa. to study the defect in class-switch recombination, naïve b-cells and ebvtransformed b-cells from affected and healthy individuals were stimulated and expression of the aicda gene was quantified by qpcr. in parallel experiments, ebv b-cells from wildtype and nfnb mutant individuals were stimulated and aid (activationinduced cytidine deaminase) protein levels were determined by western blot. results: patients with hypomorphic mutations in nfkb (c. dela) had low memory b-cell (cd + cd + igd-igm+) and class-switched memory b-cell (cd + cd + igd-igm-) numbers. in vitro, primary bcells from these patients demonstrated a % reduction in proliferation and cell division in response to cd l and il- (p = . ). compared to healthy naïve b-cells, mutant naïve b-cells had a significant reduction in plasmablast differentiation (p = . ) and secreted significantly lower levels of immunoglobulins in response to cd l and il- stimulation. mutant naïve b-cells and mutant ebv b-cells failed to increase aicda expression and aid protein levels in response to cd l and il- stimulation. conclusions: our studies demonstrate that a hypomorphic nfkb mutation in humans affects intrinsic b-cell proliferation and differentiation. the mutation impairs transcription of the aicda gene that encodes aid, a key protein involved in b-cell class-switch recombination. the nfkb gene defect also impairs immunoglobulin production, as seen in common variable immunodeficiency-like cases. these studies provide unique translational insights into physiological activities of nf-kb in downstream immunologic outputs in humans, expanding those suggested by experimental observations in mice. background: few studies have evaluated the quality of life (qol) and patient reported outcomes of primary immunodeficiency disease (pidd) patients, and no studies have assessed medical provider perceptions of their pidd patients qol, neurocognition, physical well-being and psychosocial health. understanding provider beliefs regarding patient reported outcomes is essential to improving clinical management of pidds. here we report our pidd medical provider survey results. methods: providers were contacted via email with the assistance of the clinical immunology society. participants completed adult and/or pediatric-based likert scale survey questions via a secure online survey service. in addition to demographic information, survey questions assessed provider perceptions of patients overall qol and their impression of the impact of disease or its associated treatment on mental health, physical well-being, neurocognition, social relationships and school/work performance. clinicians were expected to make their assessments based on their pidd patient cohort as a whole rather than on specific diagnoses or patients. given the small sample size, a p-value < . was considered statistically significant; repeated measures anova and paired t-test analyses were used. results: study participants (n= ) were primarily from the united states ( %), born between - ( %) , and trained in allergy/ immunology ( %). % of survey takers practiced within an academic center, % were female and % cared for children with % of providers concurrently caring for adults. there was a statistically significant difference (p= . ) in the perceived overall qol of pediatric versus adult pidd patients with % of providers feeling as though their pediatric patients had a good qol while only % believed their adult patients had a good qol. clinicians believed adult pidd individuals had more difficulties related to associated co-morbidities rather than their actual pidd compared to pediatric pidd patients (p= . ). providers felt that the neurocognition and school performance of children were more often negatively affected by a pidd than the neurocognition and work performance of immunodeficient adults (p= . ). clinicians believe children with pidd more frequently had difficulties related to their concentration than memory (p< . ). % of those who care for pidd adults believe their patients work performance or daily mental functioning is at times negatively impacted. anxiety symptoms and social relationships were viewed as being more negatively impacted by a pidd diagnosis or treatment than anger or depressive symptoms in both children and adults (p< . ). % of pediatric clinicians feel their pidd patients experience anxiety symptoms often or almost always. of physical health parameters, energy, rather than mobility or pain, was deemed to be more deleteriously influenced by an immunodeficiency in adult and pediatric patients (p< . ). conclusions: our results show that medical providers perceive the overall qol of pediatric pidd patients to be superior to that of adults with pidd, but most clinicians feel a diagnosis or associated treatment regimen for pidd can negatively impact the physical well-being, psychosocial health, school/work performance and neurocognition of both children and adults. [cbm] complex is a critical signalling adaptor that regulates lymphocyte activation, proliferation, survival, and metabolism. primary immunodeficiencies affecting each component (termed cbmopathies) result in broad clinical manifestations ranging from severe combined immunodeficiency (scid) to lymphoproliferation. we present the laboratory and clinical findings of two canadian first nations patients found to be homozygous for the same novel card mutation (c. c>t; p.r *). results: we have identified an -month-old boy who presented with a severe case of entero/rhinovirus bronchiolitis with interstitial lung disease and a -year-old boy with a history of severe pulmonary infections (including pjp), chronic sinusitis, candidiasis, invasive bacteremia, and severe ileo-colitis and oral ulceration requiring total colectomy. both patients possessed absent tregs, absent memory b cells, and hypogammaglobulinemia. however, only the -month-old had poor t cell proliferation to pha, cona, and cd . both patients were found to be homozygous for the same novel variant of card (c. c>t; p.r *). the mutation rendered card protein expression unstable and it was undetectable by immunoblot. to confirm card deficiency, we stimulated patient b cells with phorbol -myristate acetate (pma) and ionomycin across a time-course and immunoblotted for various signalling proteins in both the nf-b (ikk/, ib, p ) and mapk (mek / , mkk , jnk / , erk / ) pathways as well as various cleavage substrates of the malt paracaspase (relb, cyld, bcl , hoil ). nf-b and jnk activation were completely absent and malt paracapase activity was lost, but surprisingly, mkk (which acts upstream of jnk) was intact. furthermore, co-immunoprecipitation experiments revealed that card was required for optimal malt association with bcl in response to stimulation. conclusions: these two cases highlight the crucial role of card in regulating lymphocyte development, function, and humoral responses. in addition, we have identified the oldest known living individual with card deficiency and he presented uniquely with inflammatory gastrointestinal disease in addition to scid, further adding to the spectrum of phenotypes associated with card -related primary immunodeficiencies. abstract: the usidnet registry began in with an niaid contract with the immune deficiency foundation, which continues today. it aims to provide a resource for clinical and lab research through enrollment of known immunodeficiency patients into a national registry, the usidnet. nih is a major national and international referral center for clinical trials on inborn errors of immunity, or primary immunodeficiency diseases. it is a mechanism for depositing nih data into usidnet. a registry of patient information may help us understand how many people have each disease. the information may improve how we diagnose and treat these conditions. the patient registry is designed to obtain longitudinal data on a large number of patients with primary immunodeficiency diseases who come to nih to participate in research. the data is collected from the nih electronic medical record system, cris and is deposited into a secure registry with restricted and monitored access. all medical information is anonymized for patient privacy. department of biochemistry, emory university, atlanta, ga oas is an intracellular sensor for dsrna that generates the second messenger '- '-oligoadenylate to activate rnase-l as a means of antiviral defense. we describe four patients with a complex early-onset autoinflammatory and immunodeficiency disease caused by heterozygous de novo oas mutations. patients presented early in life with lung inflammation including pulmonary alveolar proteinosis and interstitial lung disease. they had febrile flares with dermatitis specifically with macular, pustule and bullous features often progressing to ulceration. infants had episodes of bloody diarrhea in patients (assoc. with villous blunting and cryptitis in two patients and oesophagitis in one patient). immunoglobulin igm, igg, and iga levels were low while t cell, b cell, and nk cell numbers were generally in the normal range. exome sequencing identified de novo heterozygous oas missense mutations in all patients. one patient had a heterozygous de novo oas mutation p.ala val, with mutant oas protein being expressed in ex vivo generated t cell blasts. in sorted primary patient monocytes and b cells, oas p.ala val was associated with spontaneous rna degradation and apoptosis as determined by rna chip technology and flow cytometry, respectively, while t cells were not affected. monocytes displayed disturbed terminal differentiation and functioning as indicated by reduced gm-csf-r expression and signaling. b-cells display reduced class-switch-recombination. proliferation of allogeneic t-cells was reduced in response to sorted oas mutated monocytes and b-cells. activation of interferon response genes in pbmcs was detected. two further unrelated patients had a heterozygous de novo oas mutation p.cys tyr, which appeared to compromise protein stability in transformed patient fibroblasts and when transfected. cells transfected with this mutant protein had reduced - oligoadenylate synthesis compared to wild type transfected cells. immortalized fibroblast lines demonstrated higher levels of inflammatory cytokines and spontaneous cleavage of rnas. a th patient with the clinical phenotype had a heterozygous de novo oas variant p.val gly, but has yet to have formal validation of the variant. three patients underwent hematopoietic stem cell transplants in an effort to control their diarrhea and skin inflammation. one patient died with ongoing chronic graft versus host disease, while the two others (p.ala val, cys tyr) are alive and reasonably well with a followup of . - years. the untransplanted patient died as a result of respiratory failure. in summary, patients with de novo heterozygous oas mutations have chronic ongoing inflammation of multiple organs. this is at least in part due to spontaneous rna cleavage, apoptosis and production of inflammatory cytokines and type i interferons. this defines a new category of autoinflammatory disorder. introduction: increased susceptibility to infections is the most common complication of chronic granulomatous disease (cgd). hemophagocytic lymphohistiocytosis (hlh) is a severe disorder resulting from hyperinflammation and hypercytokinemia that can lead to multi-organ system dysfunction ( ) characterized by certain criteria: fever, splenomegaly, cytopenias, hypofibrinogenemia or hypertriglyceridemia, hyperferritinemia, increased soluble cd /il- ra, evidence of hemophagocytosis, or decreased/absent nk cell cytotoxicity ( ) . secondary hlh occurs infrequently but often is preceded by smoldering infection in cgd ( , , ) . we present a case of hlh in a -day old male, the youngest reported case with cgd. case: a -day old male with previously diagnosed x-linked cgd, due to known family history, presented with fevers. initial evaluation was unrevealing including chest x-ray, urinalysis, and blood and csf cultures. he was admitted and treated empirically with cefepime. ct demonstrated multiple multifocal nodules of the lungs and spleen. after lung nodule biopsy was performed, antimicrobial therapy was broadened to iv meropenem, voriconazole, and micafungin. despite this, he continued to have fever and developed new onset tachycardia, respiratory distress, and lactic acidosis. further decompensation with vasoactive refractory shock was treated with vasopressors and stress dose hydrocortisone. additional laboratory evaluation revealed rising liver enzymes (ast u/l, alt u/l), cytopenias (hemoglobin g/dl, anc /ul, platelets , /ul), and coagulopathy (fibrinogen - mg/dl). splenomegaly was present on abdominal ultrasound. a diagnosis of evolving hlh was considered and dexamethasone was administered. within hours of clinical decompensation, the patient died of multiorgan failure. subsequent blood cultures returned with gram-negative rods (and ultimately burkholderia cepacia). autopsy confirmed hemophagocytosis within the bone marrow. no mutations were found in genes associated with primary hlh. discussion: patients with cgd are susceptible to infectious complications and auto-inflammation most commonly involving the lungs, gi, and gu systems ( , ) . patients with cgd can be at increased risk of hyperinflammatory syndromes secondary to infections and chronic inflammation. as shown in the included case, hlh can present in infancy and can be deadly. early consideration and directed treatment of hlh is imperative, even in the setting of sepsis malignant proliferation of gamma-delta t cells include hepatosplenic t-cell lymphoma (hstl), primary cutaneous t-cell lymphoma and t-cell large granular lymphocytic leukemia (t-lgl). the former two have often been associated with splenomegaly and cytopenias. however, reactive proliferation of gamma-delta t cells in spleen mimicking malignancy has only been reported once and has a significant risk of misdiagnosis. a -year-old female presented with two years of unintentional weight loss, persistent leukopenia and thrombocytopenia, with leucocytes around - x ^ /l and platelets around x ^ / l. she also had associated macrocytic anemia (hemoglobin= - g/dl) with laboratory evidence of dat (direct anti-globin test) negative hemolysis. physical examination and computed tomography (ct) imaging showed splenomegaly. there was no hepatomegaly or lymphadenopathy. serum liver function test, auto-immune studies, hemolysis and hereditary diseases workup, viral and bacterial serologies were all normal or negative, except for mild hyperbilirubinemia and ldh elevation. bone marrow examination performed four months prior to the splenectomy revealed mildly hypocellular marrow ( %) with trilineage hematopoiesis. flow cytometric analysis and cytogenetics of the bone marrow aspirate and peripheral blood were normal except for small population of large granular lymphocyte and mild low absolute b cell counts in peripheral blood. a laparoscopic splenectomy was performed for diagnostic and therapeutic purposes due to patients worsening luq pain. there was no other treatment given prior to surgery. hours postsplenectomy her leucocytes increased to . and platelets to . her three-month post-splenectomy wbc count and platelet count was . and , respectively. hemoglobin also improved to . . pathology showed red pulp expansion by small lymphocytes (fig. ) and subsequent ihc (immunohistochemistry) was positive for cd ( fig. ) , cd , cd , tia- and negative for cd , cd and cd . cd was difficult to interpret. eber was negative. flow cytometry ( fig. ) showed increased gamma-delta t-cell population ( %) with positive cd , cd and cd and negative cd , cd and cd . molecular studies by pcr didnt reveal any t-cell receptor gamma or beta gene rearrangement. cytogenetics was negative for isochromosome q or any other abnormalities. she was symptom free at months from her splenectomy. the morphology and immuno-phenotype of these gamma-delta t cells show significant overlap with the malignant cells seen in hstl and t-lgl, such as loss or downregulation of cd , cd and cd . awareness of this reactive condition is necessary to prevent making a wrong diagnosis of a malignant disease with a potentially benign, spontaneously resolving disease. additional studies of similar cases is needed in order to establish more definitive criterion to separate benign from malignant processes and delineate the role of gamma-delta t cells. uploaded file(s) uploads fig . flow cytomtery.pptx background: sex steroids in the human thymic environment influence aire expression as well as interactions with its partners, i.e. genes coding for aire interactors. here we investigated the effects of sex steroids on these interactions during minipuberty the surge of sex hormones that occur along the first six months of life -and up to months of life. we employed a network-based approach for investigating aire-interactors gene-gene relationships and how abundantly co-expressed thymic mirnas covariate with those genes. aire-interactors networks allowed the measuring of gender-related differences in gene-gene expression correlation disclosing relevant differences between minipuberty groups. methods: total rna was extracted from thymic surgical explants obtained from male (m) and female (f) infants -aged - months (groups mm and mf, for minipuberty) and - months (group nm and nf, for nonpuberty) and used in dna microarray assays. gene coexpression network (gcn) analyses were performed for aire and its interactors and for mirna-gene coexpression analysis. the set of genes coding for the aire-targeted proteins was previously identified in tecs by abramson et al. (cell : - , ) . aire-interactors networks were obtained for all groups (link strength cut-off for gene-gene > | . | and for mirnagene < - . ). aire expression in mtecs was quantified by immunohistochemistry. these methodologies are described in moreira-filho et al. (sci rep : , ) . results: the mm x mf networks comparison showed that abundantly expressed mirnas are interacting with the different aire interactor genes in both networks. it is interesting to note that network topology were more similar between nm and nf groups, although aire interacts with only one distinct mirna in each network (mir- - p in the nm group or mir- in the nf group). conversely, in the non-puberty networks the sets of mirnas and their interacting genes are distinct for each network. immunohistochemistry analysis revealed a higher percentage of mtec aire positive cells in the minipuberty groups: i.e. there is a significant difference between mm x nm (p = . ) and between mf x nf (p = . ). conclusions minipuberty and genomic mechanisms shape thymic sexual dimorphism along the first months of life. this process does not involve changes in aire expression between genders, but differences in the interactions of aire with its partners that persist throughout the non-puberty period, probably regulated by mirnas and also by genetic and epigenetic factors. introduction: neutrophils are presumed to defend against aspergillus species by releasing reactive oxygen species (ros) and neutrophil extracellular traps (nets) to degrade fungal hyphae. triazole antifungals synergistically enhance neutrophil mediated hyphal degradation. patients with cgd are particularly susceptible to aspergillus species likely due to their inability to create ros and nets, and in severe cases may not be amenable to antifungal therapy alone. objective: we present a case of severe disseminated aspergillosis in a patient with cgd in whom gt served as an important adjunct to antifungal therapy and bridge to transplant. results: a -year-old boy with known cgd, lost to follow up and nonadherent to prophylaxis, presented acutely with right-sided hemiparesis. neuroimaging revealed an embolic left middle cerebral artery infarction and cardiac magnetic resonance imaging showed extensive vegetations involving both right and left ventricles and atria, with an ejection fraction of %. the patient was admitted to intensive care, started on liposomal amphotericin b, meropenem and vancomycin, and underwent debulking of the intracardiac masses on post admission day (pad) . operative findings showed severe constrictive pericarditis with multiple abscesses and intracardiac vegetations. thorough debridement of the vegetations was undertaken, however some deep seated abscesses in the myocardium were not amenable. operative cultures were positive for aspergillus fumigatus. clinical status remained precarious, with ongoing requirement for inotropic and ventilator support. antimicrobial therapy was refined to voriconazole, with amphotericin b remaining on board until therapeutic levels of voriconazole were achieved. as effective neutrophils are integral in the immune response against aspergillus, the decision was made to start granulocyte transfusions to aid in clinical stabilization prior to hsct. interferon gamma infusions were not administered because of the risks of adverse effects and potentially increasing transplant rejection. gts were started on pad , at a dose of approximately x ^ granulocytes, three times a week. the patient tolerated the infusions well, with no allergic or inflammatory response. neutrophil oxidative burst measured one hour post infusion showed . % mean fluorescent intensity, compared to a baseline of % ( figure ). clinical improvement was seen, with inotrope cessation on pad and extubation to bipap on pad . human leukocyte antigen (hla) allosensitizaton was tested on pad , days after the first gt, with no evidence of hla antibodies. a total of gts were given over months, prior to proceeding to a / hla matched related donor transplant (pad ), with two transfusions given before neutrophil engraftment (anc ) on day + . the patient is now stable months post transplant, with no evidence of graft rejection. he remains on chronic suppressive antifungal therapy, to continue until full lymphoid reconstitution. conclusion: gt may be a useful adjunct to antifungal therapy in patients with impaired neutrophil function with severe invasive aspergillosis, and potentially provide a life sustaining bridge to hsct. methods: subjects were enrolled in irb protocol for rvt- . rvt- was implanted into the quadriceps with immunosuppression. results: subject was normal at q . but had hypocalcemia, an asd, pda, and abnormal ears. the subject received a cord blood transplant mismatched at hla-b and hla-c alleles at age months. subsequently mild graft-versus-host disease (gvhd) developed and was treated with antithymocyte globulin, steroids and cyclosporine. donor t cells developed in low numbers. twelve years later, the subject developed epstein barr virus lymphoma and suffered two relapses. while in remission, subject received unmatched rvt- . two weeks after rvt- implantation, the subject developed an adenovirus infection resulting in skin and gut gvhd, presumably from activation of the cord blood t cells. subject was treated with corticosteroids, cyclosporine, cidofovir and infliximab. four years post rvt- , subject is healthy with genetically recipient t cells/mm and % naïve cd t cells. subject was normal at q . but had an asd, pda, hypoparathyroidism, and no t cells at birth. his genetic defect is unknown. subject was treated with a ric myeloablative, allogenic, unrelated, / cord blood transplant, and a subsequent myeloablative, unrelated / cord blood transplant. hematopoietic chimerism was established without t cell development. rvt- expressed the one allele in the recipient that was not expressed by the second cord donor. the post-thymic transplant course included immune thrombocytopenia requiring rituximab and splenectomy and generalized adenopathy for years but no gvhd. he failed weaning of immunoglobulin replacement. three years post rvt- , he has cd , cd , and cd t cells/mm . he is active in school. subject had absent trecs on newborn screening with cd + t cells/ mm. a single mutation in foxn was identified; she has sparse scalp hair. subject received a / matched unrelated umbilical cord transplant. the post-transplant course was complicated by significant morbidity, and no naïve t cell development. rvt- expressed the one allele in the recipient that was not in the cord blood donor. the subject did not develop gvhd, is healthy and at months has naïve cd + t cells. she had resolution of longstanding norovirus and sapovirus gastroenteritis. conclusion: rvt- can improve t cell immunity after poor or failed correction with allogeneic hematopoietic transplants. in subject , gvhd post rvt- was related to an acute viral infection; cord t cells attacked hla mismatches in the recipient. subjects and were given rvt- matched to recipient alleles that were not expressed in the hematopoietic donor. we hypothesize that thymocytes developing in rvt- , if strongly reactive to the recipient-mismatched allele, are deleted by the bonemarrow-donor dendritic cells (that acquire recipient mhc from the recipient-allele-matched thymic epithelial cells) thereby preventing gvhd. rationale: ctla haploinsufficiency is an autosomal dominant immune dysregulation syndrome characterized by variable phenotypes. here we present a young woman diagnosed with evans syndrome and lymphoproliferation as a child, found to have a novel ctla variant as a young adult, and who developed hypogammaglobulinemia and a bacterial endocarditis while stabilized on ctla- replacement therapy. methods: sequencing of genes, including ctla , in primary immunodeficiency panel. results: our patient was diagnosed with evans syndrome at age with manifestations of anemia and thrombocytopenia recalcitrant to treatment over many years with steroids, cyclosporine, and vincristine. bone marrow biopsy reportedly showed normal trilineage maturation and her symptoms responded for a short time to splenectomy at age . symptoms recurred at age when she was also found to have pulmonary reticular opacities, prominent lymph nodes, and elevated b cells. repeat bone marrow and lymph node biopsies at that time were unrevealing. minor responses to treatment with ivig, rituximab, mycophenolate mofetil and gcsf were noted. at age , she developed varicella-related encephalitis shortly after vaccination. with a strong suspicion of an immune dysregulation syndrome, immune evaluation revealed normal immunoglobulins with good vaccine responses, elevated b cell numbers, normal t cell numbers, and normal mitogen proliferation. ctla sequencing revealed a mutation in exon [c. c>a, p.tyr *] causing a premature translational stop signal, which was consistent with previously reported cases of ctla haploinsufficiency. she was started on rapamycin initially for her cytopenias but was then transitioned successfully to abatacept with almost complete resolution of her anemia, neutropenia, and pulmonary opacities. after months of stable control, she developed a precipitous drop in her platelets and was eventually diagnosed with streptococcus viridans endocarditis of her native mitral valve. this responded to antimicrobial therapy, but eventually needed surgical intervention due to ongoing insufficiency. around this time, she was also found to be newly hypogammaglobulinemic, necessitating ongoing igg supplementation therapy. during successful replacement of her mitral valve with a biosynthetic prosthesis, it was noted that her aortic valve also had evidence of previous disease, implicating a prior endocarditis as part of her clinical syndrome as well. conclusions: in this patient, the presentation of recalcitrant cytopenias, lymphadenopathy, elevated b cells, vaccine-induced viral infections and lung findings precipitated concern for immune dysregulation syndromes and allowed for identification of a novel deleterious ctla mutation. in addition to previously reported clinical findings, our patient presents with the first reported case of repeated endocarditis in the setting of ctla insufficiency disease. given the finding in this patient of prior (unrecognized) disease, regularly screening patients with ctla insufficiency for evidence of cardiac affectation may be prudent. clinical research nurse, johns hopkins university background: the relationship between elevated serum alpha fetoprotein (afp) concentration and age, mortality, genotype and neurologic outcome in ataxia telangiectasia (a-t) patients has remained inconclusive over the past decades, leaving afp as a useful marker for disease diagnosis without further clinical significance. objective: to examine the relationship between afp levels and age, mortality, genotype and neurologic outcome using a data set larger than any prior study. methods: we retrospectively collected data on a-t patients at johns hopkins medical center ( - years of age) with both classical (predicted protein null) and variant a-t. this included serum afp measurements ( serial levels in a-t patients, max observations per patient). mixed model compound symmetry covariance was used for statistical analysis to examine the effect of age at visit on afp levels. subgroup analysis by mutation type, mortality, feeding/swallowing scores as a surrogate for neurologic function, x-ray induced in vitro chromosomal breakage and serum transaminase levels were similarly analyzed. results: significant association between age and afp level was found such that for every year increase in age, afp level increases ng/ml (p< . ). subgroup analysis by mutation type found that the patients with missense mutations showed a negative linear relationship be-tween log afp levels and age (r= - . , p= . ). we found greater afp levels in patients who subsequently died, after controlling for age (least square mean afp level in log scale . greater in deceased patients versus living patients, p= . ). we found a significant decline in feeding score by . units (score range - ) per ng/ml afp increase (p= . ) after adjusting for age. there was no significant relationship between afp levels and serum transaminase levels. conclusion: afp increases with age in a-t patients, though this may not apply to patients with missense mutations. there is a statistically significant increase in mortality and worsened swallowing scores with increasing afp levels, but this remains to be proven clinically significant. here we present a pediatric hae patient who had recurrent abdominal attacks in which constipation, secondary to the adhd medication dexmethylphenidate (focalin), appears to be a trigger. of importance, this is the first pediatric patient with hae to be described as having safely undergone a capsule endoscopy for direct visualization of the gastrointestinal tract. this was done to decrease the risks associated with the more invasive procedure of traditional endoscopy and colonoscopy. case presentation: the patient was an -year-old male with hereditary angioedema who presented with day history of diffuse abdominal pain and nausea. in the ed, patient was in no acute distress. abdominal ultrasound showed severe circumferential thickening of the wall of multiple bowel loops and a large amount of simple ascites. x-ray revealed stool in the colon. he was admitted for pain control and hydration. in the next year, he visited the ed five more times for exacerbations of angioedema of his hand, penis, and bowel. each time, he presented he had underlying abdominal pain and constipation. he was seen by gastroenterology and had a workup that was negative for helicobacter pylori, parasites, and other gastrointestinal infections. to further evaluate his abdominal pain, capsule endoscopy was performed and well tolerated. during an admission in january he received a full inpatient bowel cleanout, after which, his angioedema finally improved. of note, he was diagnosed with adhd and started on dexmethylphenidate (focalin) just prior to this period of recurrent angioedema attacks, and he did not have attacks during the summer months when he was off the medication. discussion: abdominal pain is a common complaint in pediatric hospitals, and further workup consists of endoscopy and colonoscopy. this may be easily accomplished in the general population, however, in patients with hae, these procedures carry greater risk and may be avoided, leading to delayed diagnosis and treatment ( , ) . a newer and less commonly used alternative for direct visualization of the gastrointestinal tract is capsule endoscopy. some benefits are that it does not require sedation, is less invasive, and is less likely to be irritating to the mucosa ( ). additionally, since psychological stress may be a trigger for angioedema attacks, the decreased stress associated with a noninvasive procedure such as capsule endoscopy, makes it safer to use ( ) . limitations of capsule endoscopy include dependence on battery life and its inability to biopsy or administer therapy if needed ( ) . hereditary angioedema treatment consists primarily of avoiding triggers and managing acute episodes. in this first case of hae in a pediatric patient where capsule endoscopy was used, the procedure was well tolerated without any complications. recognizing constipation as a trigger and capsule endoscopy as a safe method of direct visualization of the gastrointestinal tract will help others to control and decrease the severity of their hae attacks as well. a year old male with past medical history of common variable immune deficiency (cvid) and related autoimmune complications, including granulomatous-lymphocytic interstitial lung disease (glild), hepatosplenomegaly, leukopenia, and thrombocytopenia tolerated monthly subcutaneous immunoglobulin replacement as outpatient for several years with infrequent infectious complications. four months ago, he was found to have elevated liver enzymes on routine chemistry. a liver biopsy two months later showed pathology consistent with nodular regenerative hyperplasia (nrh) without overt cirrhosis. a hepatic venous pressure gradient (hvpg) of mmhg was found, consistent with portal hypertension. his hepatitis viral markers were negative, he did not drink, and portal venogram was negative for thrombosis. in early october, the patient was admitted to the hospital with anasarca and tense ascites. he underwent a diagnostic and therapeutic large volume paracentesis and was also found to have spontaneous bacterial peritonitis (sbp) and bacteremia with group b streptococcus. the patients course was complicated by polymicrobial peritonitis, vre bacteremia, fungemia, variceal hemorrhage, hepatic encephalopathy, and hepatorenal syndrome. his hepatic complications from portal hypertension were out of proportion to his liver parenchymal disease. transjugular intrahepatic portosystemic shunt (tips) was considered to alleviate portal hypertension but was not feasible due to his degree of encephalopathy. immunosuppressants such as high dose steroids were given while in the hospital with plans to start rituximab to treat patients glild after he had recovered from the acute infections. unfortunately, after two months in the hospital, the patient succumbed to sepsis and progressive liver failure. this case emphasizes the importance of systematic screening and continued vigilance for hepatic complications in patients of cvid as studies have shown that nrh of the liver is present in more than % of cvid patients who undergo a liver biopsy (pmid: ). a cross-sectional study of patients with primary hypogammaglobulinemia and hepatic dysfunction found that histological findings of nrh were present in % of cvid patients and was associated with portal hypertension in % of cases (pmid: ). another study estimated the minimal prevalence of nrh in cvid patients as % (pmid: ), stating that this was likely a gross underestimate as nrh may also be present in patients with normal liver function tests that are not routinely biopsied. therefore, liver enzyme levels may not anticipate the severity of liver involvement. there is currently no treatment for cvid-related liver disease. other causes of non-cirrhotic portal hypertension, including hepatic veno-occlusive disease and budd-chiari syndrome should be ruled out or treated in cvid patients presenting with hepatic disease. in the case of hepatic nrh in cvid patients, early detection could lead to earlier interventions (such as tips prior to hepatic encephalopathy), to mitigate complications. we describe the application of epigenetic quantification of t regulatory (treg) cells in addition to cd +, cd +, cd + t cells, b cells, nk cells, monocytes and neutrophils from as little as μl of fresh, frozen or dried blood. the method yields identical results to flow cytometry from fresh blood samples of a healthy donor cohort, with the advantage of being more sensitive and precise with limited amount of blood and minimal sample preparation (sci transl med ). we have used this method ) to immunophenotype patients with early onset immune regulatory disorders (pird) and primary immune deficiency (pid), and ) to evaluate cell subsets reconstitution early after hematopoietic stem cell transplantation (hsct). patients with immune dysregulation, polyendocrinopathy, enteropathy, x-linked (ipex) and ipex-like pird were evaluated by analyzing the treg-specific demethylated region (tsdr) of the foxp locus in the total of cd + t-cells. despite the dysfunctional foxp mutated protein, ipex patients exhibited elevated treg/cd + cell ratios which seemed to correlate with disease severity. in contrast, most of the patients with ipex-like symptoms without foxp mutations exhibited decreased treg/cd + cell ratios -in line with the possible central pathogenic role of treg function and number in pird. using epigenetic quantification of cd +/b-and nk cells, out of confirmed scid and xla cases were correctly identified within a cohort of newborn dried blood spot (dbs) samples ( % sensitivity, % specificity). the method identified one delayed onset scid as well as a xla case that were missed by combined trec/krec testing. epigenetic immune cell quantification missed one scid case with maternal engraftment that was identified by combined trec/krec testing. abnormally elevated treg/cd + ratio was also detected in a dbs from a newborn who was subsequently confirmed to be affected with ipex syndrome. when applied to serial blood samples during engraftment and reconstitution post-hsct, the epigenetic method allowed identification of the different blood cell subsets, including treg cells, at earlier time points than flow cytometry according to current clinical practice. this opens the way to a better understanding of the correlation between early immune reconstitution events and graft vs. host disease or viral reactivation, earlier than with the current methods, in different types of hsct. these studies underscore the suitability of epigenetic immune cell quantification for accurately measuring multiple immune cell types from limited blood sample sources. we propose this method as uniquely suitable for novel molecular diagnostic applications in settings with limited fresh blood sample or limited cell number, at the point of care as well as for newborn screening. we evaluated a -year-old male with hyperpyrexia, hypertrichosis, conical hypodontia, and a history of illnesses concerning for nemodeficiency syndrome. starting at six months of age, he suffered recurrent episodes of acute otitis media (non-typeable hib and actinobacter iwolffli), pneumonia, and rsv bronchiolitis. whole exome sequencing demonstrated a de novo heterozygous c. g>a (p.r q) mutation in the eda-receptor (edar) gene not present in the parental dna. his physical exam findings and mutation were consistent with hypohidrotic ectodermal dysplasia (hed), a rare genetic condition characterized by abnormal development of skin, teeth, hair, and sweat glands. hed is caused by defects in the ectodysplasin-a (eda)-nfkb signaling pathway but is not typically associated with immune deficiency. consistent with this, immunophenotyping showed normal sub-populations of t-, b-, and nk-cells. immunoglobulin and complement levels were quantitatively appropriate. he had normal mitogen-induced lymphocyte proliferation and normal antibody response to pneumococcal vaccination. nk-cell studies demonstrated robust cytotoxicity. however, nasal mucosa biopsy showed diffuse squamous metaplasia and the absence of ciliated epithelial cells. we hypothesize that recurrent infections in our patient arose from impaired mucociliary clearance due to a ciliary defect. this case raises the possible association between edar variants and ciliary dysfunction. it also underscores the importance of evaluating the immune status of hed patients with recurrent infections which could mimic nemo-deficiency and have broad implications about clinical management. the rapid pace of new gene discovery and phenotype expansion for primary immunodeficiency diseases (pidds) creates challenges for genetic testing and variant interpretation. whereas well-described clinical case reports in published literature have traditionally served as the source of phenotypic data used for variant interpretation, for pidds the causal variants are often private to the patients family and thus the sole source of phenotypic information for a novel genetic variant is frequently the history provided by the clinician on the test requisition form. taking into account such heterogeneous information during variant interpretation requires establishing objective criteria for its inclusion as part of the variant interpretation process. to this end, we adapted our laboratorys preexisting, evidence-based variant classification framework, called sherloc, by developing point-based criteria for the inclusion of clinical information such as a patients phenotype, familial segregation patterns, and whether the variant is inherited or de novo in the patient. as part of this process, we defined clinical criteria for pidd genes. here, we illustrate the application of this method and the importance of integrating clinical information into variant interpretation. between april and october , our commercial diagnostic laboratory performed immunological genetic tests, and information about the patients clinical history was provided in ( %) of these orders. restricting our analysis to just the genes for which case report information is currently used in variant interpretation, these tests revealed variants, ( %) of which were classified as pathogenic or likely pathogenic (p/lp). information from case report descriptions, segregation patterns, and de novo status were applied for %, % and % of p/lp variants, respectively. in ( %) cases, the clinical information provided by the clinician on the test requisition form was used as evidence in the classification of the patients variant as p/lp. ten variants were initially classified as being of uncertain significance and reclassified following receipt of further clinical information or testing of additional relatives. in addition, suspicious variants of uncertain significance were identified in which one or two additional patient case reports would allow for reclassification from uncertain significance to p/lp. these data illustrate the importance of providing good quality clinical information to the genetic testing laboratory both at the time of sample submission and following the receipt of genetic test results. background: cartilage-hair hypoplasia (chh) is a skeletal dysplasia with combined immunodeficiency, variable clinical course and increased risk of malignancy, mostly non-hodgkin lymphoma and basal cell carcinoma. there is a paucity of long-term follow-up data, as well as knowledge on prognostic factors in chh. objective: we conducted a prospective cohort study in finnish patients with chh to describe clinical course and analyze risk factors for adverse outcomes. methods: we recruited finnish patients with chh in - and performed clinical follow-up in - . we obtained health information from finnish national medical databases (covering time period of - ), the finnish cancer registry and the cause-of-death registry of the statistics finland and analyzed all patients' health records. standardized mortality ratios (smrs) were calculated based on the population data. primary outcomes included immunodeficiencyrelated death (from infections, respiratory diseases or malignancies), the development of lymphoma and the development of skin cancer. results: the study cohort included males and females. median age at recruitment was . yrs (range weeks - . yrs) and median duration of follow-up for the surviving patients was . yrs (range . - . yrs). half of the patients ( / , %) had no symptoms of immunodeficiency, while ( %) and ( %) patients manifested symptoms of humoral or combined immunodeficiency respectively, including six cases of late-onset immunodeficiency. in a significant proportion of patients ( / , %), clinical features of immunodeficiency progressed over time. of the patients with non-skin cancer, eight had no preceding symptoms of immunodeficiency. altogether patients had deceased (smr= . , % confidence interval (ci)= . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] including deaths due to pneumonia (n= ), malignancy (n= , smr= , %ci= . - ) and lung disease (n= , smr= , %ci= . . malignancy was diagnosed in / ( %) patients, mostly lymphoma (n= ) and skin cancer (n= ). severe short stature at birth (compared to normal, smr/smr ratio= . , , symptoms of combined immunodeficiency (compared to asymptomatic, smr= ( %ci= . - ) vs smr= . ( %ci= . - . ), hirschsprung disease (odds ratio (or) . , %ci= . - ), pneumonia in the first year of life or recurrently in adulthood (or= . / , , and autoimmunity (or= , %ci= . - ) in adulthood associated with early mortality. in addition, recurrent pneumonia in childhood was associated with the development of lymphoma, while warts and actinic keratosis were associated with the development of skin cancer. birth length standard deviation score correlated significantly with the age at the diagnosis of first malignancy (p= . ), lymphoma (p= . ) and skin cancer (p= . ), demonstrating that patients with shorter birth length developed malignancies at an earlier age. conclusions: patients with chh have high mortality due to infections and malignancies, but also from lung disease. some subjects present with late-onset immunodeficiency or malignancy without preceding symptoms of immune defect, warranting careful follow-up and screening for cancer even in asymptomatic patients. we provide clinicians with the risk factors for adverse outcomes to assist in management decisions. autoimmune lymphoproliferative syndromes (alps and related disorders) are characterized by insufficient apoptosis due to defects in the fas apoptosis pathway. fadd deficiency (omim ) is an autosomal recessive disorder resulting from a mutation in fas-associated protein with death domain (fadd), the adaptor protein involved in fas signaling to caspases and . we present a case of fadd deficiency identified by whole exome sequencing with a novel genetic mutation we describe two brothers with recurrent febrile episodes accompanied by seizures and respiratory compromise. the older sibling initially presented with status epilepticus following the measles mumps rubella vaccination later experiencing similar episodes until his demise at months of age. the younger sibling, who is unvaccinated, presented at months with fever, rash, vomiting, and diarrhea. he developed status epilepticus with respiratory depression that required intubation. he also had enlarged cervical lymph nodes that regressed with antibiotics and steroids. he recovered from that episode but subsequently had a series of similar illnesses with fevers, altered mental status and seizures. with the exception of elevated hhv igg, extensive infectious workup up in all instances was negative. previously described fadd deficiency patients demonstrate an alps like phenotype with increased circulating double negative t cells, lymphocyte apoptosis defects, elevated fas ligand and il , encephalopathy, functional asplenism but no splenomegaly or lymphadenopathy. our patients clinical and laboratory findings were similar. he had normal igg and iga, decreased igm, and lack of isohemagglutinins. absolute cd + count is elevated, with elevated percent of cd + tcr+ cd -cd -. normal mitogen and antigen t lymphocyte stimulation, but with defect in pokeweed induced b cell proliferation. fas ligand and il level are increased (see table ). no hepatosplenomegaly, but howell jolly bodies were detected in peripheral blood indicating functional hyposplenism. whole-exome sequencing revealed two different genetic alterations in the fadd gene: a maternally inherited nonsense mutation predicted to severely truncate the protein and a paternally inherited missense mutation in codon . although this paternal mutation has not been described as pathogenic, a different variant in same nucleotide of fadd has been associated with fadd deficiency (reference ). there are very few cases in the literature of fadd deficiency patients and the overall prognosis is poor compared to classical alps patients, as these patients are at significant risk of deadly sepsis from encapsulated organisms or death from neurologic complications. of the fadd deficiency patients described in the literature, several died prior to years old. while pneumococcal prophylaxis may reduce the risk of sepsis, hematopoietic stem cell transplant has been reported for patients with fadd deficiency (reference ), and is being considered for our patient. rationale: hcuvp is a patient product-introduction program that provides cuvitru® (immune globulin subcutaneous [human], % solution [ig gly]) free of charge for the first infusions to eligible patients with primary immunodeficiency disease (pid). using patient data from this ongoing program, our analysis described the clinical characteristics and infusion parameters of pediatric and adolescent patients who were initiated on ig gly through hcuvp. methods: hcuvp eligibility criteria were: patients aged years old, with a primary icd- -cm code verifying diagnosis of pid, and no current or prior use of ig gly at program initiation. data from patients who received the first ig gly infusion between january , , and september , were included. data from patients receiving infusions after october , were censored. descriptive statistics were calculated for patients demographic and clinical characteristics and prescribed and actual infusion characteristics by age group (< years and years). results: in total, patients who completed all infusions were included in the analysis, of whom were aged < years. among those who previously received immunoglobulin (ig) therapy, a greater percentage of patients aged < years were treated with intravenous ig therapy (n= ; %) compared with adult patients (n= ; %) before initiating ig gly. nine patients aged < years were treatment naïve. the mean infusion volume per site was lower among patients aged < years ( years: . ml; years: . ml; and years: . ml) than among patients aged years ( years: . ml and years: . ml). however, the mean infusion rate per site was similar between patients aged < years ( xmen disease (x-linked immunodeficency with magnesium defect, epstein-barr virus infection and neoplasia) is a primary immune deficiency caused by mutations in magt and characterized by chronic infection with epstein-barr virus (ebv), ebv-driven lymphoma, cd t-cell lymphopenia, and dysgammaglobulinemia. magt gene codifies to magt protein, a mg +-selective transporter, expressed in the human immune system, specifically in the spleen and the thymus. functional studies have established the key role of magt in t cells and natural killer (nk) cell activation. upon cd + t-cell receptor stimulation, magt mediates a transient mg + influx that is necessary for phospholipase c gamma (plcy ) activation, which drives ca + rise and downstream signaling. this mg + influx also regulates cytotoxic functions of nk and cd t cells through nkgd , reason why these patients have impaired cytolytic responses against ebv. eleven male xmen patients have been described. we present the case of a -year old hispanic infant with a pathogenic variant in magt gene that clinically manifested with early pneumocystis jirovecii and cytomegalovirus (cmv) interstitial pneumonia, and ebv chronic infection with good response to intravenous immunoglobulins supplementation without hematopoietic stem cell transplantation or gene therapy. laboratory study highlights low levels of nkg d ligands. the objective of this case report is to broaden the spectrum of clinical presentation of xmen disease, that manifests initially as a combined immune deficiency (cid) and evolved with a favorable course of the disease with intravenous immunoglobulins supplementation therapy and chemoprophylaxis with trimethoprim-sulfamethoxazole. introduction: lysinuric protein intolerance (lpi) is a recessively inherited disorder of the cationic amino acids transporter subunit y+lat caused by variants in the slc a gene. the disease is characterized by protein-rich food intolerance has a heterogeneous presentation. the clinical findings are a result of depletion of lysine, ornithine, and arginine. symptoms can include hyperammonemia, failure to thrive, protein aversion, neurologic disease, and lung disease. there is also evidence that inflammatory manifestations are mediated through upregulation of nfb, il , and tnf that occur independent of intracellular arginine levels and can lead to lifethreatening episodes of hemophagocytic lymphohistiocytosis (hlh). case presentation: a -year-old male presented with history of anxiety, depression, eating disorder, delayed puberty and complex partial seizures. due to poor nutrition and failure to thrive, a gastrostomy tube was placed. following commencement of enteral feeds, he presented with altered mental status, bilateral mydriasis, hyperreflexia, and agitation which lead to a picu admission. ammonia peaked as high as μmol/l and episodes ceased with cessation of enteral feedings. prior to enteral feeds, he had been self-restricting protein in his diet. biochemical testing was consistent with lpi and illumina next-generation sequencing revealed compound heterozygous variants in slc a (p.s lfs* and p.e dfs* ). hyperammonemia resolved quickly with cessation of protein intake and high rate dextrose infusion without the need for ammonia scavenging agents. he was subsequently started on proteinrestricted enteral feeds. at diagnosis he did not have any respiratory symptoms, ct scan of chest showed patchy areas of groundglass opacification that was suggestive of early pulmonary alveolar proteinosis (pap). bronchoalveolar lavage demonstrated foamy, cloudy pink fluid and elevated bronchioalveolar macrophages on cell differential. his clinical course and slc a genotype led to suspicion for smoldering hlh. the findings of elevated ferritin, hypertriglyceridemia, decreased fibrinogen, splenomegaly, elevated il- receptor, decreased nk cell function, along with hemophagocytosis on bone marrow biopsy confirmed the diagnosis. because of his pap and hlh, in addition to dietary modifications, a trial of il- beta inhibition (anakinra) at mg/kg/day was initiated. follow up ct scan of chest months after initiation of anakinra showed complete resolution of pulmonary groundglass opacifications and pap. bone marrow evaluation showed continued hemophagocytosis in spite of the normalization in ferritin, soluble il- receptor, nk function, and triglycerides levels. overall, he is significantly improved on daily anakinra and no longer meets criteria for hlh or pap. discussion: recent data has shown in y+lat models that thp- macrophages and a airway epithelial cells upregulate il and tnf regardless of intracellular arginine content. this suggests that inflammatory manifestations may continue independent of dietary modifications. we present a year old patient with newly diagnosed lpi who was treated dietary modification and anti-il therapy resulting in resolution of hlh and pap. more research is needed to see if long-term il blockade that can consistently control both the immunologic and pulmonary manifestations of lpi and positively impact morbidity and mortality. learning objective: recognize that symptoms of bartonella endocarditis and associated complications can share features of certain immunocompromising conditions. case description: an -year-old caucasian boy with history of repaired pulmonary atresia and aortic root dilation was diagnosed with pancytopenia and splenomegaly during a brief hospitalization for atypical pneumonia. pancytopenia persisted, splenomegaly worsened, and five months after presentation, he developed hypertension and renal insufficiency. he was diagnosed with hypocomplementemic, diffuse sclerosing and crescentic glomerulonephritis and was started on mycophenolate mofetil with improvement in kidney function and stabilization of cytopenias. as part of a comprehensive immune work-up, alps (autoimmune lymphoproliferative syndrome) panel was sent and demonstrated elevated double-negative t (dnt) cells with out of positive immunologic criteria for alps. neither targeted sequencing for alps and alpslike disorders nor whole exome sequencing revealed pathogenic mutations. by age , the patient remained on mycophenolate, but developed failure to thrive, with weight dropping from th percentile to less than rd percentile. he was hospitalized again for low-grade fever, increased work of breathing, left shoulder pain and fatigue and was found to have right lower lobe pneumonia. pancytopenia worsened, and he was started on cefepime and azithromycin without improvement in symptoms. echocardiogram revealed vegetations in his pulmonary conduit and bilateral branch pulmonary arteries, but multiple blood cultures were negative. upon further history, the patient reported contact with kittens. bartonella henselae titers and polymerase chain reaction (pcr) from blood were sent and were both positive. he completed a -week course of gentamicin, -month course of ceftriaxone, and was transitioned to doxycycline and rifabutin. after initiating antimicrobial therapy, his weight and energy significantly improved, his blood bartonella pcr became negative, and his splenomegaly resolved. approximately one year later, the patient underwent pulmonary artery conduit replacement and bartonella pcr testing of the tissue specimen was positive. he has had sustained weight increase, resolution of hypocomplementemia and splenomegaly, decrease in dnt cell frequency from > % to . %, and improvement though not resolution of cytopenias. he currently remains on doxycycline and rifabutin and continues treatment with mycophenolate. discussion: alps is characterized by defective lymphocyte apoptosis and clinical features such as lymphadenopathy, splenomegaly, hepatomegaly, cytopenias, and glomerulonephritis. the hallmark laboratory finding is expansion of dnts. our patient met criteria for a probable alps diagnosis based on the presence of both required criteria (chronic splenomegaly and elevated dnt cells) and secondary additional criteria (typical immunologic findings noted on alps panel). pediatric cases of bartonella henselae endocarditis have been associated with splenomegaly, cytopenias, and glomerulonephritis which mimic many features of monogenic immune dysregulatory disorders. the diagnosis of bartonella endocarditis in our patient therefore raises the question of whether his immunosuppression predisposed him to infection or if his entire clinical presentation can be explained by bartonella endocarditis. physicians taking care of patients with immune dysregulatory disorders should consider bartonella endocarditis in the differential diagnosis of onset or exacerbations of immune dysregulation. rationale: while fever is considered a sign of infection, many individuals with primary immunodeficiency (pi) anecdotally report a lower than normal average body temperature. on immune deficiency foundation (idf) friends and idf pi connect research forum online, pi patients report a diminished fever response even when other signs of infection are present. there is limited knowledge about the average body temperature in persons with pi. however, the implications of missing an infection in those with pi is well established. methods: study investigators partnered with patient investigators to design a prospective cohort study to determine whether body temperature differed between persons living with and without pi. three hundred fifty adults with pi were recruited from idf and one adult household member without pi was also recruited. mckesson digital oral thermometers (model - bgm) were provided and used to record temperatures in all participants three times a day for five consecutive days. descriptive statistics were calculated. median body temperatures were compared between the two cohorts at each time point using mann-whitney test. results: data from households were used for analysis ( . % participation rate). the pi population was largely female ( . %) with a median age of years and largely caucasian population ( . %). the non-pi population was largely male ( . %) with a median age of years and largely caucasian population ( . %). pi diagnoses included cvid ( . %), hypogammaglobulinemia ( . %), igg subclass deficiency ( . %), selective iga deficiency ( . %), specific antibody deficiency ( . %), agammaglobulinemia ( . %), chronic granulomatous disease ( . %), combined immunodeficiency ( . %), and complement deficiency ( . %). a total of individuals with pi ( . %) reported a lower than normal non-sick body temperature, while individuals with pi ( . %) reported a normal (between °f - °f) non-sick body temperature. a total of individuals with pi ( . %) reported absence of fever with infection, while individuals ( . %) reported a normal fever response with infection. the median body temperature was significantly higher for the pi patients in the morning, but not evening or bedtime, reading in of the days (monday: pi = . °f vs. non-pi = . °f, p = . ; tuesday: pi = . °f vs. non-pi = . °f, p = . ; wednesday: pi = . °f vs. non-pi = . °f, p = . ; thursday: pi = . °f vs. non-pi = . °f, p = . ; friday: pi = . °f vs. non-pi = . °f, p= . ). conclusions: despite the limitations of this non-clinical study, individuals with pi are knowledgeable about their conditions and can offer unique insights and direction to researchers. this study demonstrates that collaboration with patient advocacy groups may facilitate patient-centered and patient-driven research with high participation among the target population. introduction: familial mediterranean fever (fmf) is a hereditary condition characterized by recurrent episodes of painful inflammation caused by mutations in the pyrin (mefv) gene. alterations in the mefv gene affect pyrin production leading to recurrent fevers and painful inflammation in the peritoneum, synovium, and pleura. amyloidosis may also develop as a complication. arabic, turkish, armenian, and sephardic jewish populations are most commonly affected. homozygosity for mefv mutations are associated with a more severe course. there is a paucity of information regarding pediatric fmf in the literature. case: we present a case of a -year-old male with minor speech delay diagnosed with compound heterozygous fmf. patient was initially referred due to recurrent fevers and infections. at months of age, he was hospitalized with septic shock requiring intubation secondary to adenovirus. at months of age, the patient began to have recurrent fevers every to weeks, leading to multiple blood draws and courses of antibiotics prior to referral. at , , and months of age, he developed three separate episodes of febrile seizures. a total of - lifetime episodes of acute otitis media occurred prior to bilateral myringotomy tube placement. four episodes of streptococcus pyogenes pharyngitis confirmed by throat culture preceded tonsillectomy. no oral ulcers, joint pain, or abdominal pain were reported. no other infections such as pneumonia, sinusitis, uti, non-viral gastroenteritis, fungal infections, or skin infections were reported. both parents are ashkenazi jewish and a maternal history of early miscarriage was noted. family history was negative for immunodeficiency, malignancy, and autoimmunity. the patients vital signs and physical exam were unremarkable. serology indicated leukocytosis of . k/l with elevated monocytes of cells/l, elevated eosinophils of cells/l, and slightly elevated cd t cell count of cells/l. neutrophil, cd t cell, b cell, nk cell enumeration, and immunoglobulin panel were normal for age. tetanus, diphtheria, rubella, streptococcus pneumoniae, and haemophilus influenzae b titers were protective. genetic analysis identified that the patient was compound heterozygous for the e q and v mutations in the mefv gene. family was instructed to keep a fever diary. colchicine . mg once a day was given initially, then increased to . mg once a day for inadequate response. loose stools were observed while patient was maintaining a lactose free diet so he was switched to colchicine . mg bid with resolution of loose stools. apart from two occasions when his colchicine dose was missed, the patient remained afebrile at his follow up visits. conclusion: we present a pediatric case of compound heterozygous fmf (e q and v mefv mutations) in an otherwise healthy -year-old male of ashkenazi jewish background, initially symptomatic at months of age. individuals who are compound heterozygous for the e q and a second mevf mutation are generally symptomatic, although severity cannot be predicted. additional pediatric research on symptomatic heterozygous and compound heterozygous fmf is recommended. natural killer (nk) cells are innate lymphocytes that play a key role in defense against virally-infected cells and in tumor surveillance. nk cells can be divided in two subsets. the majority of nk cells in peripheral blood expressed intermediate levels of cd and are referred to as cd (dim). these nk cells are responsible for nk cell cytotoxicity. a minor population of nk cells express very high expression of cd and are referred to as cd (bright). these nk cells are responsible for cytokine production and are precursors to cd (dim) nk cells. a few immunodeficiencies have been described in which there are abnormal nk cell subsets, such as autosomal dominant gata deficiency where cd (bright) nk cells are absent and irf where there is a paucity of cd (dim) nk cells and relative expansion of cd (bright) nk cells. here we present a patient with an absence in cd (bright) nk cells secondary to cd deficiency. our patient is a -year-old african american female born to non-consanguineous parents. the patients past medical history is significant for chronic lung disease secondary to prematurity, recurrent acute otitis media, failure to thrive and congenital hypothyroidism. family history is significant for an older sister that presented at age with ebv-associated hodgkin lymphoma whose treatment was complicated by chronic activated ebv infection and who ultimately underwent hematopoietic stem cell transplantation (hsct). our patient presented with pancytopenia, fever, lymphadenopathy and splenomegaly. she was found to have ebv viremia with greater than , copies in whole blood by pcr. she was treated with two doses of rituximab followed by etoposide and dexamethasone as a bridge to hsct. whole exome sequencing demonstrated a homozygous mutation in cd . cd is a member of the tumor necrosis factor receptor family and influences the function of t cells, b cells and nk cells. in nk cells, cd is primarily expressed in cd (bright) nk cells. cd deficiency is an autosomal recessive disorder associated with persistent symptomatic ebv viremia, including ebv-driven hemophagocytosis and lymphoma, hypogammaglobulonemia and specific antibody deficiency. our patients immune evaluation prior to initiation of chemotherapy and immunosuppression was notable for very elevated igg, iga and igm. despite hypergammaglobulonemia patient had only out of protective titers against streptococcus pneumoniae. the patient had pan-lymphopenia with appropriate percentages of lymphocyte subsets. assessment of her b cell subsets showed a slight increase in the percentage of transitional b cells/plasmablast and a nearly complete absence of cd -expressing b cells. her nk cell phenotyping demonstrated a complete loss of cd (bright) nk cells with reduced nk cell cytotoxicity, comparable to what has been previously reported in patients with gata deficiency. previous reports of patients with cd deficiency denote normal nk cell numbers with normal to moderately reduced nk cell cytotoxicity, however, cd deficiency causing a specific loss of the cd (bright) nk cell subset has not been previously reported. cd deficiency should be consider in patients with ebv driven disease and abnormal nk cell studies. introduction/background: the transcription factor ikaros is encoded by the ikzf gene and plays a crucial role in lymphopoiesis. somatic, and more recently also germline mutations of ikzf are associated with a hematologic malignancies, most notably b-cell precursor acute lymphoblastic leukemia. germline mutation in ikzf was first reported as a monogenic cause of human disease characterized by marrow failure and immune deficiency in a single neonate in . subsequently, mutations leading to haploinsufficiency were discovered to underlie a proportion of patients with cvid and low b cell numbers, and dominant-negative mutations have been observed to cause more severe combined immune deficiency phenotypes. at this time, there is very little known regarding allogeneic hematopoietic cell transplantation (hct) outcomes for patients with severe dominant-negative ikzf mutations. concerningly, ikaros deficiency has been observed to have a negative impact on graft versus host disease in mouse models. objective: to describe allogeneic stem cell transplant outcomes in patients with the dominant-negative ikaros mutation. methods: we collected transplant data from patients who underwent allogeneic hct at transplant centers around the world. results: patients underwent allogeneic hct using a variety of conditioning regimens. patients received bone marrow (n= ) or cord blood (n= ) grafts from an hla-matched sibling donor (n= ) or single allele hlamismatched unrelated donor (n= ). neutrophil engraftment occurred between day + and + post-transplant. platelet engraftment occurred between day + and + except in one patient who did not have return of normal platelet counts due to underlying liver dysfunction. all patients were documented to have greater than % whole blood donor chimerism at a median of days (range - days) following transplant and maintained > % donor chimerism until last follow-up. only one patient developed grade ii acute gvhd. no patients developed chronic gvhd. one patient died approximately year post transplant related to cryptosporidium cholangitis which existed prior to hct. at the most recent follow up of the surviving patients (range: . - . y), ivig had been discontinued, antimicrobial prophylaxis had been stopped, and patients had received routine vaccinations. they all had excellent performance status. conclusions: allogeneic hct may be a safe option to consider for patients with dominant-negative ikaros mutation as there does not appear to be an increased risk of death or gvhd. moreover, -out-of- of the transplanted patients are alive and well and show no features of the disease. however, because of the limited number of patients evaluated and the retrospective nature of this analysis, our data do not allow firm conclusions to be made, and further studies will be needed to evaluate outcomes in larger cohorts. introduction: when evaluating patients with t-cell lymphopenia, we often are concerned about defects in lymphocyte production and function, especially in the setting of frequent infections. here we outline a case demonstrating t-cell lymphopenia due to increased loss, which should be considered in the differential diagnosis. case report: we report a -year-old male who initially presented with recurrent, right-sided pneumonias requiring frequent hospital admissions including severe episodes necessitating intensive care unit admission. his work up for the pneumonias included a bronchoscopy revealing normal anatomy with minimal inflammation, and a chest ct with mild peribronchial wall thickening. as his pulmonary disease progressed, he developed a persistent, productive cough with expectorated mucous plugs that were plastic-like in appearance. while his pulmonary symptoms responded to steroids, his mucous plug production persisted. sputum cultures were intermittently positive, isolating cryptococcus neoformans and aspergillus niger. he underwent vats and wedge biopsy, concerning for recurrent aspiration. an immunologic evaluation initially demonstrated normal t-and b-cell counts, but serial evaluation of his lymphocyte population demonstrated low cd + cells (ranging - cells/cumm), and low normal cd cells (ranging - cells/cumm) with normal b-and nk-cell numbers. further t-cell evaluation revealed normal ratios of naive and memory p o p u l a t i o n s ( c d c d r a + % , c d c d r o + % , cd cd ra+ %, cd cd ro %), normal trec ( copies per ^ cd cells) and normal thymic emigrants (cd cd cd ra+ : , normal - ), indicative of sufficient thymopoiesis. mitogen and antigen stimulation assays demonstrated normal responses to phytohemagglutin, concanavalin a, and pokeweed mitogen, with a low lymphocyte response to candida. he had normal quantitative immunologlobulins, normal diphtheria, tetanus and streptococcus pneumonia titers. his dihydrorhodamine flow cytometry and fish for chromosome q . deletion were negative. given normal function and thymic output, his immunologic profile was concerning for t-cell loss. our patient was registered with the undiagnosed disease network, and had a second review of his lung biopsy, concerning for plastic bronchitis. subsequent lymphatic imaging demonstrated abnormal lymphatics within the bilateral clavicular space, right greater than left, with questionable partial thoracic duct, explaining his unilateral symptoms. he was diagnosed with plastic bronchitis secondary to abnormal lymphatic drainage, with lymphatic fluid filling his airways and secondary t-cell loss. discussion: plastic bronchitis is a rare and potentially fatal disorder, seen commonly after the fontan procedure for congenital heart disease. this process has resulted in t-cell loss into the airway and subsequent t-cell lymphopenia. in patients with fontan-related protein losing enteropathy, multiple immune abnormalities have been described including reduced immunoglobulins, lymphopenia, and selective cd lymphocyte deficiency. similar findings have been reported in patients with lymphatic malformations. although the impact of t-cell loss on adaptive immunity is not entirely known, there is no indication of increased risk for atypical infections. given his normal mitogen assay, our patient did not start prophylactic antibiotics. he continues to have symptomatic episodes with lymphopenia, but has had no opportunistic infections, and remains stable with an aggressive pulmonary regimen. we conclude by reiterating the importance of considering t-cell loss in patients presenting with lymphopenia, particularly with evidence of normal thymopoeisis and t-cell function. introduction: granulomatous disease (gd) has been described with a variable incidence ( . - . %) in patients with common variable immunodeficiency (cvid). an increase in malignancies has been reported in cvid patient cohorts, particularly for lymphoma, reported in . - . % of the cvid patients depending on the cohorts. prior analysis of a cohort of cvid patients included patients with gd (gd+). in these, there was a suggestion of more cases of lymphoma ( . %) when compared to cases without (gd-) ( . %) although the difference was not statistically significant (p=. ). objectives: compare the frequency of lymphoma in gd+ and gd-patients in the cvid patient cohort from the usidnet registry. methods: we submitted a query to the usidnet registry requesting deidentified data for patients with the diagnosis of cvid, through august . statistical analysis was performed on spss, with comparisons done with pearson chi-square or fisher's exact test, depending on the sample sizes, using an alpha level of . . results: a cohort of cvid patients from the usidnet registry was analyzed. ninety-one patients ( . %) were gd+. overall, patients ( . %) had a malignancy diagnosis, of these ( . %) with lymphoma. lymphoma was present in / gd+ patients ( . %) versus / gdpatients ( . %) (p=. ). overall malignancy was present in / gd+ ( . %) versus / ( . %) (p=. ). discussion: in the cohort of cvid patients from the usidnet registry, we found a frequency of lymphoma of . %, which is in the range of previously described cohorts. the frequency of lymphoma was . % in patients with gd, higher than the . % frequency for gd-patients, but these differences were not statistically significant. our identified frequency of lymphoma in gd+ patients was lower than the one previously identified in the cvid patient cohort, but with similar proportional differences between gd+ and gd-patients. despite no statistical significance, the frequency of lymphoma, as shown here and elsewhere, was higher in cvid patients gd+ than gd-in both studies, with no full understanding of this increased risk of lymphoma. expanding this analysis to larger groups of cvid patients may help to confirm, or deny a more robust association, which may have a meaningful impact in the outcomes of this particular population. introduction: patients with refractory pericarditis have been treated with intravenous immunoglobulin (ivig) or interleukin receptor antagonist (anakinra) with limited and transient benefit. separate or combined therapy with subcutaneous immunoglobulin (scig) and interleukin (il) inhibitor (rilonacept) for refractory pericarditis in a cohort of patients has not been previously described. case descriptions: patients were referred for recurrent pericarditis refractory to traditional therapies at ages ranging from to years. they all had multiple serious sequelae of their pericarditis and abnormal immune parameters including hypogammaglobulinemia, poor responses to vaccines, poor mitogen induced lymphocyte proliferation, and/or b cell lymphopenia. the patients had varied past medical histories and associated conditions. patients were started on ig, with some initiated on ivig, though all were transitioned to hyaluronidase-facilitated scig (hyqvia). patients were then started on either anakinra or rilonacept with patients continuing on rilonacept and remaining on anakinra. all patients had complete or near complete resolution of their pericarditis on dual therapy for greater than year. the markedly elevated il prior to therapy seen in all of the patients normalized post-therapy. some patients had elevated il prior to therapy that also improved post-therapy. patient who has also been diagnosed with familial mediterranean fever (fmf) has stopped both therapies for greater than year with no further episodes of her pericarditis. discussion: patients with recurrent refractory pericarditis and signs of immunodeficiency and autoinflammatory disease on laboratory testing responded to dual therapy with hyqvia and rilonacept or anakinra resulting in resolution of pericarditis. inflammasome and immune abnormalities may be implicated or associated with recurrent pericarditis and may respond to targeted therapies. chief, laboratory of clinical immunology and microbiology, idgs, dir, niaid, nih, bethesda, md, usa hypomorphic recombination activating gene (rag ) mutations result in residual t-and b-cell development in both humans and mice and have been found in patients presenting with delayed-onset combined immune deficiency with granulomas and/or autoimmunity (cid-g/ai). recent studies have shed light on how hypomorphic rag mutations alter the primary repertoire of t and b cells, but less is known about their effect on immune dysregulation in targeted organs. in order to investigate the role of these mutations in determining intestinal disease, we set out to evaluate gut immunity and microbiota interplay in rag mutant hypomorphic mice. we evaluated two mouse models carrying homozygous rag mutations (r q and r w), corresponding to human mutations (r q and r w, respectively) described in patients with cid-g/ai. both mutations fall in the coding flanksensitive region of the rag c-terminal domain. on the basis of aminoacid properties and in vitro studies, the r q mutation has demonstrated a moderate effect on rag protein stability while the r w mutation resulted highly disruptive. analysis of intestinal pathology in rag mutant mice (niaid animal protocol lcim e) revealed different degrees of spontaneous colitis, with the most severe inflammatory infiltrate observed in mice carrying the most disruptive mutation, r w. colonic inflammation was characterized by crypt elongation, epithelial hyperplasia, and an abundant inflammatory infiltrate extending to the colonic lamina propria, with occasional crypt abscesses. a significant increase in activated cd hicd lcd + t cells expressing the gut homing receptor was observed in mesenteric lymph nodes (mlns) of both mutant strains, and was especially prominent in r w mutant mice. additionally, the proportion of mln cd + t regulatory (treg) cells was increased in both mouse models. finally, mln of mutant mice contained a high number of myeloid cells (cd b+ ) along with a decreased number of b + b cells, and these abnormalities were also more prominent in r w than in r q mice. in summary, we have shown that rag mutant hypomorphic mice present with different degrees of inflammatory bowel disease, with the mouse model carrying the most disruptive mutation presenting with the most severe phenotype. we are currently performing studies to evaluate the impact of rag mutations on microbiome composition and diversity in these mouse models of cid-g/ai. background: hypogammaglobulinemia or low serum immunoglobulin g (igg) levels either inherited (primary) or acquired (secondary) is associa t e d w i t h i n c r e a s e d i n f e c t i o n r a t e s . p r i m a r y ( °) hypogammaglobluinemia can be caused by many primary immune deficiencies (pid) including combined variable immune deficiency (cvid), while secondary ( °) hypogammaglobluinemia can be caused by many acquired conditions such as lymphomas, leukemias, or chemotherapies and other immunosuppressive drugs. immunoglobulin replacement therapy (irt) has been the mainstay of treatment in patients with hypogammaglobulinemia by reducing infection through replenishing the quantitative igg. there are other applications of ig therapy such as in autoimmune diseases, where the mechanism of action is thought to be ig mediated immunomodulation. innate immune cells have shown to be involved in such mechanism, but whether irt modulates adaptive immune cells in patients with hypogammaglobulinemia is not well known. hypothesis: irt has an immunomodulatory effect on t-cell function and proliferation in patients with hypogammaglobulinemia. methods: blood from thirty patients with °(n= ) or °(n= ) hypogammaglobulinemia recruited from the immunodeficiency clinic at the ottawa hospital was drawn for peripheral blood mononuclear cell (pbmc) isolation, before starting irt and minimum weeks after starting irt. data regarding igg level, number and type of infections after receiving irt was collected. pbmcs were analyzed using flow cytometry for quantitation of t-cell subset. cultured and anti-cd /cd stimulated pbmc were also analyzed for extracellular and intracellular cytokine production, measured by e l i s a a n d f l o w c y t o m e t r y, r e s p e c t i v e l y. c o m b i n e d cytomegalovirus, epstein-barr virus and influenza virus (cef) peptides were used to study specific t-cell responses. anti-cd / cd stimulated pbmc were used for celltrace t-cell proliferation a s s a y s . d a t a w a s g r o u p e d b a s e d o n n a t u r e o f hypogammaglobulinemia i.e. °or °. results were compared between before and after irt using wilcoxon matched-pairs signed rank test. results: irt was not found to significantly alter proportion of treg, cd +, or cd + t-cell populations or activation state as measured by cd ra/r expression. however, irt was found to significantly increase expression of intracellular ifn-y in cd + and cd + t-cells post-cd /cd stimulation in °(p = . ), but not in °h ypogammaglobulinemia patients. there was no change in extracellular il- and il- cytokine production in both groups. in contrast, cd + tcells in °hypogammaglobulinemia patients showed significantly higher expression of intracellular ifn-y and tnf-a post-cef viral peptide stimulation (p = . ). cd + and cd + t-cell proliferation after cd /cd stimulation was found to be decreased after irt for both groups (p = . & p = . ). conclusions: our results suggest that irt can alter cd + and cd + t-cell function with differential effect in patients with °o r °hypogammaglobulinemia in addition to replenishing serum igg level. more experiments assessing cytotoxicity of t-cells will be conducted to further study t-cell subset function as well as bcell function. these laboratory results will be analyzed for association with clinical outcomes. uploaded file(s) uploads background: severe congenital neutropenia (scn) is a rare immunodeficiency disorder characterised by the extremely low absolute neutrophils count (anc) less than . x /l. the clinical feature of scn is recurrent bacterial infections and the patients the risk of leukemia development. the incidence of scn is estimated to be in individuals. mutations in more than genes have been described causing scn and it is either recessive, dominant or x-linked inheritance. case presentation: we described an years old malaysian girl who presented with recurrent abscesses over the whole part of the body, recurrent oral candidiasis, growth failure and recurrent pneumonias since months old. she also had history of a few episodes of acute tonsillitis, chronic suppurative otitis media and herpes zoster infections. throughout her age, she had persistent neutropenia less than . x /l but in few occasions, her anc elevated up to more than . x /l . she was treated as autoimmune neutropenia, respectively due to few positive results of autoimmunity workout such as antinuclear antibodies (ana) and double stranded dna (dsdna) but eventually later to be negative. later at the age years old, whole exome sequencing was performed and confirmed by sanger s e q u e n c i n g , f o u n d a h e t e r o z y g o u s v a r i a n t i n e l a n e gene(c. g>t; p.gly ter), an autosomal dominant which was described to cause scn. both parents do not carry this mutation, hence, it is a de novo mutation. currently, she had few on and off recurrent infections. despite that, she is relatively well and on prophylaxis antibiotic. conclusion: to our knowledge, we report for the first time a malaysian girl with scn, with confirmed mutational analysis of the elane gene. the delayed diagnosis might be due to the insufficient awareness of the phenotypic presentation of this rare disease. moreover, the genetic analysis is not available in malaysia and need to be done outside of the country. this case demonstrates the importance of the genetic analysis which may help in improving the diagnosis and management of the patient. ( ) submission id# professor of paediatrics and immunology, university college london; great ormond street hospital nhs trust; orchard therapeutics, london, uk background: ada-scid is a rare genetic disorder which causes severe combined immunodeficiency. historically, ada-scid has been treated using enzyme replacement therapy (ert) followed by allogeneic hematopoietic stem cell (hsc) transplant (hsct) from a matched related donor (mrd) or, if none is identified, a non-mrd (matched/mismatched unrelated or mismatched related donor). we developed a self-inactivating lentiviral vector (lv), in which a codon optimized human ada cdna is driven by the short form of the elongation factor- alpha (efs) promoter (efs-ada lv). the drug product (otl- ), composed of autologous hscs transduced ex vivo with the efs-ada lv, was evaluated in a prospective, historically-controlled phase i/ii clinical trial in ada-scid pediatric subjects. we report safety and efficacy at months in ada-scid subjects treated with lentiviral gene therapy (gt) compared to a historical cohort of ada-scid patients treated with hsct. methods: twenty subjects ( male, female; mo . yrs) were treated with gt. autologous cd + hscs were isolated from bone marrow and pre-stimulated with cytokines before transduction with efs-ada lv. busulfan was administered at a single dose ( mg/kg) prior to infusion of otl- . the control group included patients ( . mo . yrs) treated with allogeneic hsct (mrds n= , non-mrds n= ) at great ormond street hospital, uk (n= ) or duke university childrens hospital, usa (n= ) between . results: at months, overall survival (os) and event-free survival (evfs), defined as survival in the absence of ert reinstitution or rescue allogeneic hsct) were statistically significantly higher in the gt group compared with the hsct group (table) . successful engraftment of genetically modified hsc was observed in all gt subjects at months, which persisted over months, based on vector gene marking in granulocytes (median . copies/cell [range . - . ] at months) and peripheral blood mononuclear cells (median . copies/cell [range . - . ] at months), and was associated with increased red blood cell ada enzyme activity and metabolic detoxification from deoxyadenosine nucleotides. over months, none of the gt subjects required peg-ada ert reinstitution and % were able to stop receiving immunoglobin replacement therapy (igrt), whereas % hsct patients required rescue hsct or reinstitution of peg-ada ert, and % were able to stop receiving igrt (table) . nine subjects in the gt group experienced a serious adverse event (sae), most frequently infections and gastrointestinal events; only one was considered treatment-related. in the gt group, there were no events of autoimmunity during the study. due to the autologous nature of the product, there was no incidence of graft vs host disease (gvhd) in the gt group; whereas patients in the hsct group experienced acute gvhd and experienced chronic gvhd events, one of whom died. conclusions: treatment with lentiviral gt for ada-scid is well tolerated and has a favorable benefit-risk profile at months based on sustained gene correction and restoration of immune function, as well as improved os and evfs compared with hsct (mrd or non-mrd) at months. background: ada-scid is a rare genetic disorder that causes severe combined immunodeficiency, with minimal or absent b cell function. prior to, and often after, treatment with allogeneic hematopoietic stem cell (hsc) transplant (hsct) or autologous ex vivo hsc gene therapy (gt), patients are managed with enzyme replacement therapy (ert) and immunoglobulin (ig) replacement therapy (igrt). we evaluated a gt treatment with autologous hscs transduced ex vivo with a self-inactivating lentiviral vector (lv), in which a codon optimized human ada cdna is driven by an internal short form of the elongation factor- alpha (efs) promoter ("efs-ada lv"). at months follow-up, pediatric ada-scid subjects treated with gt were compared to a historical cohort of ada-scid patients treated with hsct. here, we report on b cell reconstitution in these cohorts. methods: twenty subjects ( male, female) aged mo - . yrs received gt. autologous cd + hscs were isolated from bone marrow and pre-stimulated with cytokines before transduction with efs-ada lv. genetically modified cells were administered after conditioning with single dose busulfan ( mg/ kg). the control group included patients aged . mo to . yrs treated with hsct at great ormond street hospital (uk) (n= ) or duke university children's hospital (us) (n= ) between - . the hsct patients received an allogeneic transplant from matched related donors (mrds) (n= ) or non-mrds (n= ). subjects continued to receive igrt post-gt until a clinical decision was made to stop, factoring in b cell reconstitution, general medical condition and seasonal infections. results: by month , in the gt group, % had stopped treatment with igrt compared to % in the hsct group overall. by months and , higher proportions of gt-treated subjects had stopped igrt ( % and %, respectively) compared with mrd hsct patients ( % and %, respectively) and non-mrd hsct patients ( % at both timepoints) (table) . in the gt group, vector gene marking was detectable in peripheral blood mononuclear cells within months and persisted at months post-infusion (median . copies/cell [range . - . ]), suggesting successful gene modification. as evidence of b cell reconstitution, iga and igm levels in peripheral blood sera more than doubled by months, from . mg/dl (range to ) to . mg/dl (range to ) and . mg/dl (range to ) to . mg/dl (range to ), respectively. additionally, antibody response following tetanus vaccination, was evaluated in subjects. all subjects mounted a protective response to the vaccine (median antibody response . iu/ml [range . to . ]), based on a normal threshold of . iu/ml (hammarlund clin infect dis ) and a laboratory reference range ( . to . iu/ml). conclusions: gt with autologous hscs transduced ex vivo with efs-ada lv resulted in b cell reconstitution, as evidenced by doubled iga and igm production at months, cessation of igrt in % of patients by months, and protective specific antibody responses to tetanus vaccine in patients that were evaluated. background: x-linked chronic granulomatous disease (xcgd) results from mutations in cybb encoding the gp phox subunit of phagocyte nadph-oxidase. attempts to treat xcgd with gene therapy (gt) using transduced autologous hematopoietic stem cells (hsc) transduced ex vivo with a gammaretroviral vector have met with limited efficacy due to transient engraftment of gene corrected hscs, gene silencing, and vector insertion-mediated activation of oncogenes leading to myelodysplasia. we developed a novel self-inactivating (sin) lentiviral vector (g xcgd lv) with a chimeric cathepsin g/cfes myeloid-specific promoter driving gp phox expression from a codon optimized cdna. following transplant of g xcgd lv ex vivo transduced autologous hscs into busulfanconditioned xcgd patients, there was long-term restoration of oxidase activity in peripheral blood polymorphonuclear neutrophils (pmn) at months in of severely affected xcgd patients without evidence of genotoxicity. here we present data about the multiple assays used to assess quality and quantity of restoration of pmn oxidase activity. methods: similar trials of gt with g xcgd lv were initiated in the uk (n= , plus compassionate use patient) and usa (n= ). all patients had histories of inflammatory disease and severe, persistent infections (some non-responsive to conventional therapy at time of gt). g-csf plus plerixafor-mobilized cd + hscs were transduced with ex vivo g xcgdlv. subjects received myeloablative conditioning with singleagent busulfan, targeted to net area-under-the-curve of , ng/ml*hr. freshly prepared or cryopreserved quality-tested genetically-modified hsc, manufactured on-site, were administered intravenously. pmn oxidase activity post-gt was assessed by p-nitroblue tetrazolium (nbt) reduction, dihydrorhodamine (dhr) flow cytometry assay, and quantitative ferricytochrome c assay (ferric) measurement of superoxide generation. results: we report results for patients (aged - years) with - . years of follow-up; two additional patients were treated but died within three months of gt from complications deemed related to pre-existing diseaserelated co-morbidities (severe pulmonary disease and anti-platelet antibodies). within month post-gt, oxidase (+) pmn were present in peripheral blood based on nbt testing and dhr flow cytometry. expression of the corrective transgene was confirmed by flow cytometry using antibody detection of gp phox. quantitative biochemical measurements of oxidase activity were also confirmed in some samples using the ferric assay, demonstrating quantitative levels of superoxide production per corrected cell that were within the normal range. functional testing of oxidase burst activity using dhr fluorescent assays was applied serially to follow levels of corrected pmn where oxidase activity per corrected cell also were in the normal range. all patients had > % pmn dhr+ within one month, which remained stable for most patients over the follow-up period ( figure) . follow-up demonstrated sustained stable persistence of - % oxidase burst positive neutrophils in of surviving subjects at months, with restoration to clinically beneficial levels (defined as % of pmn being dhr+) in these patients as of december . conclusion: these results demonstrate corrected pmn function within month in x-cgd patients treated with autologous gt. pmn oxidase activity was sustained at levels which restore biochemical function and provide clinically beneficial levels of immunity for months in / patients. the formulation for igsc % was developed based on the knowledge acquired from the formulation of grifols currently licensed % immune globulin (human), gamunex®-c; however, the protein concentration was increased from % to % to facilitate efficient subcutaneous administration. gamunex-c has an extensive record of safety and tolerability when administered intravenously and subcutaneously for greater than years in diverse patient populations. the igsc % manufacturing process employs the same purification steps as gamunex-c and was demonstrated to be robust and to provide an igg product with the required potency, purity, and quality. the formulation excipient characteristics and compatibility with the drug product have been well established. glycine has been an excipient of intramuscular immune globulin (human) for fifty years and intravenous immune globulin (igiv) for over twenty years. the igsc % formulation has low buffering capacity, and a low ph was selected to achieve a product with low aggregates, low fragments and viscosity suitable for subcutaneous administration. to improve visual clarity, the igsc % formulation contains a small amount of polysorbate (ps ), which is widely used in biopharmaceutical products. subcutaneous administration of the igsc % formulation has been well tolerated in clinical studies. objectives: the goal was to provide the pid population with a new % immunoglobulin liquid product for subcutaneous administration (igsc %). methods: igsc % is manufactured using the current manufacturing process for gamunex-c, followed by an additional concentration step so that the product can be formulated at a higher protein concentration. igsc % and gamunex-c batches were produced at full industrial scale and then subjected to a series of analytical testing including assessment of purity, composition and neutralizing activity. results: the igsc % and gamunex-c manufacturing processes and formulations have preserved the igg integrity, molecular characteristics and potency. the manufacturing processes have eliminated lipids, alcohols, and acetate and coagulation factor impurities, including fxia, which were undetectable by either specific or global methods. the igsc % and gamunex-c batches were % gamma globulin by agarose membrane electrophoresis, and have a subclass distribution similar to normal plasma and acceptable specific antibody content. igsc % was shown to be primarily monomer plus dimer igg ( ± %) with minimal aggregate or fragment, which confirms that appropriately gentle processing conditions were used during the concentration of % igg solutions to % igg. conclusions: igsc % is a highly concentrated igg solution with characteristics comparable to gamunex-c, but with twice the igg concentration in order to facilitate subcutaneous administration with reduced volumes and shorter infusion times. analytical testing demonstrates suitable potency, purity, and neutralizing activity for a number of specific antigens. funding: this study was funded and conducted by grifols, a manufacturer of % immunoglobulin for subcutaneous administration. disclosure: all authors are employees of grifols. frequent respiratory tract infections and seizures cause recurrent hospitalizations in these children and are typically considered a result of neurological impairment and poor airway clearance. evaluation of these patients for immunodeficiency is not a common clinical practice. here we report combined immune deficiency in patients with mds and recurrent respiratory tract infections. case presentation case : a boy with mds was initially referred at age months for an abnormal newborn screen with low t cell receptor excision circles (trec) for severe combined immunodeficiency (scid). initial evaluation revealed moderate cd + and cd + t cell lymphopenia (figure ). initial immunoglobulins levels were normal. he was placed on antiseizure medications. he later developed recurrent and severe respiratory tract infections starting in infancy. at months of age, he developed hypogammaglobulinemia ( figure ). in addition, t cell counts progressively decreased and stayed around cells/ul. immunoglobulin replacement therapy started at months of age. hospitalizations due to respiratory tract infections significantly decreased. case : a -year-old boy with mds had recurrent bacterial and viral respiratory infections which required numerous hospitalizations including intensive care unit stays. newborn screening for scid was negative. he had been on anti-seizure medications. immunologic evaluation at years of age revealed low total cd + cells and cd + t cells (cd +: cells/ul[normal range - cells/ul], cd +: cells/ ul[normal range - cells/ul]), hypogammaglobinemia (igg: mg/dl[normal range - mg/dl]), and non-protective igg levels to tetanus, varicella and pneumococcus serotypes. immunoglobulin replacement therapy started at years of age which resulted in reduced frequency and severity of respiratory infections, and improved quality of life. discussions: t cell lymphopenia and hypogammaglobulinemia were seen in both our cases of miller-dieker syndrome. to our knowledge, immune deficiency has never been reported in mds. one of our cases suggests that low t cell counts may start as early as at birth and may be detected by newborn screening. hypogammaglobulinemia may be primary or secondary due to antiepileptics. both children had reduced frequency and severity of respiratory infections and improved quality of life after immunoglobulin replacement highlighting the importance of screening and early management of immunodeficiency. conclusion: miller-dieker syndrome is likely another syndromic primary immune deficiency disorder. a high index of suspicion with early screening and management of immunodeficiency may be beneficial for children with miller-dieker syndrome. uploaded file(s) uploads this prospective, multi-center, open-label study assessed the pharmacokinetic (pk), safety, and tolerability of immune globulin subcutaneous (human), % caprylate/chromatography purified (igsc %) in subjects with primary immunodeficiency (pi). the objectives were to determine a weekly subcutaneous (sc) dose of igsc % that is noninferior to the intravenous (iv) dose of immune globulin injection (human), % caprylate/chromatography purified (igiv-c %) and to determine the steady state trough igg levels after igsc % and igiv-c % infusions. there were possible phases. if not on a qualifying igg regimen at enrollment, subjects (n= ) were required to enter the run-in phase, receiving igiv-c % to achieve steady-state before entering the iv phase to determine steady-state area-under-the-curve (auc) of iv infusions. subjects with a qualifying igiv-c % regimen ( - mg/kg) (n= ) directly entered the iv phase for steady-state iv pk assessments. upon completion of the iv pk assessments subjects entered the sc phase, receiving weekly doses of igsc % for up to weeks, with steady-state auc determined at the th dose. igsc % was not associated with any reports of serious local infusion site reactions (isrs). the majority of local isrs were mild-to-moderate. igsc % (at a dose conversion factor of . ) provided equivalent exposure to igiv-c % as assessed by steady-state auc - days, with % higher mean igg trough values, lower fluctuations in igg concentrations and the flexibility of at home administration. igsc % was well tolerated with a safety profile comparable to igiv-c %. clinicaltrials.gov identifier: nct disclosure: kecia courtney, elsa mondou, and jiang lin are employees of grifols, a manufacturer of igsc %. grifols is the sponsor of this study. background: in two reports described the deficiency of adenosine deaminase (dada ) as early-onset lacunar strokes, intermittent fevers, livedoid rash, and early onset polyarteritis nodosa (pan). since these first reports, the clinical spectrum has dramatically expanded to include antibody deficiency, liver disease, vasculopathy, pure red cell aplasia, cytopenias, and lymphoproliferative disease. methods: forty-two patients were enrolled in an irb approved study at the nih. sequencing of ada , the gene encoding adenosine deaminase (ada ), was performed in all patients. information was obtained by chart review of all clinical, serologic, and radiographic testing. results: all patients had germline biallelic loss of function mutations in ada , leading to absent or significantly decreased protein expression and function of ada . the cohort comprises females ( %) and males ( %). there were sibling pairs and families with affected individuals. twenty-seven patients had a history of at least one ischemic stroke and experienced a hemorrhagic stroke. the average age at the time of first stroke is . years (range months - years), and the average number of strokes is (range - ). no new strokes have occurred in patients on anti-tnf therapy. skin manifestations occurred in % of patients and include livedo ( %), cutaneous vasculitis resembling pan ( %), and raynauds ( %). hepatomegaly ( %) and splenomegaly ( %) were also notable. portal hypertension was observed in ( %) patients, with patient requiring a spleno-renal shunt for a massive variceal bleed. abdominal mra revealed arteritis and aneurysm in / patients evaluated; patients developed bowel necrosis. peripheral vasculopathy was seen in patients, with one requiring amputation of gangrenous digits. the most common immune abnormality seen in this cohort is hypogammaglobulinemia ( %); patients have low igg, patients have low igm, and patients have low iga. ten of these patients are on immunoglobulin replacement. specific antibody responses to vaccines were inadequate in / patients challenged. lymphocyte phenotyping revealed decreased class-switched memory b cells in / patients ( %) tested. however, there was no relationship between absolute number of class switched memory b cells and hypogammaglobulinemia or infection frequency. hematologic abnormalities include transfusion depended anemia ( %), neutropenia ( %), lymphopenia ( %), and thrombocytopenia ( %). seven patients developed pancytopenia, presented with pure red cell aplasia, and developed aplastic anemia. three patients have undergone bone marrow transplant, with two of those patients requiring a second transplant for graft failure. conclusions: the spectrum of dada has expanded from strokes, intermittent fever, and cutaneous manifestations to include portal and systemic hypertension, immune deficiency, cytopenias, vascular abnormalities, and bone marrow failure. while initiation of anti-tnf therapy improves inflammatory markers, and no new strokes have occurred while on therapy, cytopenias do not seem to improve. bone marrow transplantation should be considered in patients with findings of bone marrow failure, although transplant of our patients has been complicated by immune mediated neutropenia. disease manifestations are heterogenous, making a comprehensive evaluation critical to our understanding of this disease. given the increase in neonatal diagnosis of athymia, clinical care is provided by the referring medical centers prior to rvt- implantation and patients return to the referring centers earlier after rvt- . this creates the need for clear, concise guidelines for the care of these patients. primary goals of pre-transplantation clinical care are ( ) management of pre-existing medical needs such as feeding difficulties, airway obstruction, congenital cardiac defects and developmental disabilities; ( ) management of symptoms related to oligoclonal recipient t cell expansion (autologous gvhd/atypical complete digeorge anomaly) and ( ) prevention of infections. most deaths in the pre and early post-transplantation period are secondary to pre-existing infections. necessary surgical and medical procedures (ie cardiac surgery, hearing aids) should not be delayed. for the first to months after rvt , patients have profoundly low naïve t cell numbers and may require immunosuppression to prevent rejection of rvt- by oligoclonal recipient t cells. immunosuppression needs to be closely monitored and titrated for desired effect while minimizing side effects such as renal toxicity, electrolyte abnormalities and hypertension. t cell counts should be performed every months and are used to guide weaning of immunosuppression. most patients with successful transplants develop greater than /mm naïve t cells by months post rvt- . infection prevention, clinical stability and optimal nutrition are critical for lasting engraftment. clinical guidelines have been developed to address immunosuppression, management of autologous gvhd symptoms (gut, skin and liver), preservation of renal function, and developmental considerations. after the development of naïve t cells, patients should continue to be monitored regularly by an immunologist. patients may develop autoimmune complications such as thyroid disease and transient cytopenias. while risk of complications related to viral infections is greatly decreased after development of naïve t cells, patients with comorbidities (central venous access device dependence, tracheostomy, chronic lung disease) continue to require complex care from multidisciplinary teams. medical conditions associated with athymia but not alleviated by thymus transplantation, such as hypoparathyroidism or cardiac defects, may require lifelong medical care. lastly, patients must be evaluated for readiness for killed and live vaccines. transplant outcomes are influenced by the clinical condition at the time of rvt- implantation and optimization of immunosuppression, nutrition and clinical stability in the first months following rvt- . clinical care that maintains a well-nourished, clinically stable, infection free patient yields the best chance for successful t cell development. guidance documents supporting these goals ensure patients are best prepared to receive rvt- and develop long lasting thymic function. hemophagocytic lymphohistiocytosis (hlh) is a life-threatening disease of immune dysregulation characterized by unchecked inflammatory responses leading to end-organ dysfunction. primary hlh results from inherited mutations that impair capacity for immune regulation whereas secondary hlh arises from inappropriate response to an immune stimulus such as infection, malignancy or autoimmunity. we report a -monthold male who presented with symptoms of hlh as an initial manifestation of congenital disorder of glycosylation (cdg) due to mutations in the gene component of oligomeric golgi complex (cog ) resulting in cog -cdg (cdg-iij). a -month-old male with history of mild motor delay presented with days of fever, vomiting, and diarrhea. initial evaluation identified highly elevated ferritin and triglycerides, transaminitis, coagulopathy, and hyperammonemia. he subsequently developed generalized seizures. liver and bone marrow biopsies demonstrated erythrophagocytosis consistent with hlh. immunologic evaluation was notable for mild hypogammaglobulinemia, neutropenia, thrombocytopenia, and anemia. serum cd levels and nk functional studies were later found to be normal. the patient was initially treated with ammonia-scavenger therapy and fresh frozen plasma (ffp) for coagulopathy with subsequent intravenous immunoglobulin and dexamethasone several days later. within hours after starting ffp, the patients ferritin level declined sharply. hyperammonemia and transaminitis also resolved, and his fever curve improved. additional immunosuppression was considered, but not initiated due to the patients ongoing clinical improvement. over the next months, the patient experienced two further acute episodes of fever, liver dysfunction, coagulopathy, and sepsis physiology. the second episode was successfully treated with ffp, though no clear infectious trigger was identified. the third episode occurred days after routine vaccinations. the patient had prolonged hypotension requiring ionotropic support that resolved after receiving daily ffp, and hypoxia with pleural effusions that resolved after a single treatment with protein c concentrate. as the patient had met / clinical diagnostic criteria for hlh, but also had a history of hyperammonemia, he underwent concurrent biochemical and genetic evaluation for both primary hlh and inborn errors of metabolism. whole exome sequencing identified compound heterozygous mutations in cog , part of an oligomeric protein complex involved in golgi apparatus structure and function. cog mutations have previously been reported in two patients with autosomal recessive cog -cdg (cdg-iij), who were described to have similar clinical symptoms of hypotonia, seizures, coagulopathy, and liver dysfunction, as well as recurrent infections. subsequent immune phenotyping while the patient was healthy was notable for slightly low numbers of nk cells, but normal cd a mobilization and perforin/granzyme b expression in vitro. our patient represents a novel presentation of cdg due to cog defect with associated immune dysfunction manifesting as recurrent episodes of inflammatory crisis with features of hlh. cdg and inborn errors of metabolism should be considered during diagnostic evaluation for patients with hlh symptoms, as cdg patients may develop acute episodes of severe inflammation, in the absence of cellular regulatory defects, for which ffp and protein c concentrate may have therapeutic value. of the deaths with identifiable causes, ( %) were related to infections. the rate of death per person-year was . . the most common autoimmunity-related complication was sweets syndrome, seen in patients ( %) with anti-ifn-g autoantibodies. sixteen of those patients ( %) had recurring sweets syndrome. additionally, patients ( %) developed lymphatic obstruction, which continued to recur in patients ( %). seven patients ( %) in this study did not have anti-ifn-g autoantibodies. the median [iqr] age of autoantibody-negative patients was [ , ] years and patients ( %) were female. none of the autoantibody-negative patients developed new infections during follow-up. at the end of the follow-up period, none of the patients had active/progressive disease and patients ( %) had died. conclusions: ninety-one percent of hiv uninfected thai patients with disseminated ntm infection with or without other opportunistic infections had detectable anti-ifn-g autoantibodies. about one third of patients with autoantibodies to ifn-g had recurrent infections during follow-up. after approximately years of follow-up, % of patients with anti-ifn-g autoantibodies had inactive disease following multi-drug antibiotic therapy while % had active/progressive disease and % had died. patients with anti-ifn-g autoantibodies are at risk for recurrent infections and autoimmunity-related complications. therefore, longterm follow-up is recommended. life-long secondary antibiotic prophylaxis may be required to prevent recurrence of infection in the setting of persistent anti-ifn-g autoantibodies. the study of early t cell development in patients with severe t cell immunodeficiencies is challenging because of the rarity of these diseases, the difficulty to obtain hematopoietic stem cells (hscs), and limitations in the assays to assess in vitro differentiation of hscs to mature t cells. we recently developed a serum-free system that allows faithful analysis of sequential steps of t cell differentiation. in this system, artificial thymic organoids (atos) are generated, based on the d aggregation and culture of a delta-like canonical notch ligand (dll )-expressing stromal cell line (ms -dll ) with cd + cells isolated from bone marrow (bm) samples of normal donors (nd). in this project, we set out to evaluate the possibility of using the ato system to study t cell differentiation in patients carrying t cell defects, in order to define the exact steps of t cell development affected by different genetic defects. using the ato system, we studied in vitro t cell differentiation from cd + cells obtained from patients carrying defects that are intrinsic to hematopoietic cells (rag , rag , ak , il rg) or that affect thymus development (digeorge syndrome, dgs). the ak -deficient patient showed a markedly decreased viability in cd + cells and a very early defect in t cell development, already at the pro-t cell stage. this defect was very similar to that observed in a patient carrying a null il rg mutation who was reported to show autologous reconstitution after unconditioned haploidentical hsc transplantation. in contrast, cd + cells from a patient carrying a missense il rg mutation and with a leaky scid phenotype were capable of differentiating into mature t cells in vitro, although with -fold decreased efficiency as compared to normal donors (nd). interestingly, in the patient carrying the null il rg mutation, we noticed very few cells that could reach full maturation, with an absolute number of cd + tcrab+ cells around -times less than in nd. at variance with pro-t cells (that failed to express the gc protein), these mature t cells did express normal levels of gc, suggesting that they may have derived from residual cd + cells from the bm donor. in addition, cd + cells from the patients carrying rag and rag hypomorphic mutations were able to differentiate to cd +cd + double positive cells, but not to cd +tcrab+ cells. finally, the dgs patient showed a completely normal in vitro t cell differentiation, confirming that t cell deficiency reflected thymic abnormalities. in summary, our data show that the ato system could be extremely useful in determining whether the lack of t cells in patients with unknown gene defects reflect hematopoietic or thymic intrinsic problems, and may therefore provide critical evidence in deciding whether hsc or thymus transplantation is warranted, even without knowing the actual gene defect. introduction: ataxia-telangiectasia (at) is an autosomal recessive disorder caused by mutations in the ataxia telangiectasia mutated (atm) gene, which aids in detection and repair of dna damage. at is characterized by progressive cerebellar ataxia, oculomotor apraxia, choreoathetosis, conjunctival telangiectasias, variable degrees of t-cell lymphopenia (tcl) and immune compromise. patients are at an increased risk for malignancy, particularly leukemia and lymphoma, and are unusually sensitive to ionizing radiation. with the advent of trecbased newborn screening (nbs) for scid, at patients are being recognized with asymptomatic tcl in early infancy. objectives: we present an older child with at and chronic granulomatous lesions and discuss how this may be avoided in individuals with at diagnosed following abnormal nbs. case report: a y/o male was born at term following an uncomplicated twin pregnancy and delivery, prior to institution of scid nbs. he demonstrated mild gross motor and speech delay as an infant and was diagnosed with at at age . he had received all routine immunizations, including live vaccinations. he developed granulomatous skin lesions at age , initially small papules on his cheeks and ears, which subsequently formed large disfiguring plaques on sun-exposed areascheeks, arms and hands (fig ) . following an extensive workup, his lesions were found to be secondary to a mutated vaccine-strain rubella (ra / ) based on bp genotyping, previously described in other immunocompromised individuals [perelygina/sullivan et al. jaci ] . his lesions have been refractory to multiple treatments including nitazoxanide. he is currently on daily oral and topical steroids, tmp/smx and ivig. retrieval of his nbs for trec determination revealed that he would have screened positive [mallot/puck et al. j clin immunol ] . when first measured at age , cd t-cells were low, /ul, with cd /ul and cd /ul. b and nk cell numbers were normal. since april , cases of at were seen at ucsf in infants with non-scid tcl on nbs. these males and female were all born at term and discharged from well-infant nurseries. at was diagnosed at - months of age. their initial trecs ranged from - /ul (normal with perkinelmer enlite kit > ), and all had low t-cells on initial flow cytometry ( - cd /ul, ref range> ) with decreased cd ( - /ul) and cd ( - /ul) t-cells; however naïve t-cells were present, ruling out typical scid and raising concern for non-scid tcl. three infants also demonstrated low b-cells (< - /ul), while nk cells were normal in all. two are currently receiving ivig, one of whom is also on tmp/smx. all have avoided not only rotavirus but also mmr and varicella live vaccinations. conclusions: at is now often diagnosed in infants with low trecs on scid nbs, prior to neurologic manifestations. benefits of early diagnosis include avoidance of live vaccines, including mmr, which led to the debilitating granulomas in our older patient. additionally, patients receive prompt immunologic monitoring and treatment, avoidance of unnecessary radiation, specialty referrals and family genetic counseling. while there is no cure for at, ongoing research may bring neuroprotective treatments in the future. introduction: subcutaneous immune globulin %, ig gly, was well tolerated in the phase / north american study in patients with primary immunodeficiency diseases (pidd). here we assess comorbidities, use of concomitant medications, infusion parameters, and tolerability in advanced age patients ( y) treated with ig gly in the north american study. methods: patients aged years with pidd received weekly ig gly infusions at volumes ml/site and rates ml/h/site for~ . years in the north american study (nct ). the medical history at baseline, medical conditions that were ongoing (defined as comorbid events), use of concomitant medications, adverse events (aes), tolerability, and infusion parameters were assessed by age: in advanced age patients ( y; n= ), adult ( < y; n= ), and pediatric/adolescent patients (< y; n= ). results: the mean number of medical history events at baseline was higher in advanced age patients ( . events/patient; events in patients) versus adult ( . events/patient; events in patients), and pediatric/adolescent patients ( . events/patient; events in patients). of these, the medical conditions that were ongoing at baseline (comorbid events) were also higher in the advanced age patients ( . events/patient; events in patients) versus adult ( . events/ patient; events in patients), and pediatric/adolescent patients ( . events/patient; events in patients). in the advanced age patients, neurological comorbidities ( events) were the most common, followed by those related to eyes, ears, nose, and throat ( events), gastrointestinal ( events), and musculoskeletal comorbidities ( events). concomitant medications were given to treat a preexisting condition in all patients in the advanced age group ( medications in patients). despite the higher mean number of comorbid conditions, infusion parameters in the advanced age patients were comparable to those in the adult age group. median maximum infusion rates and infusion volumes/site were comparable in the advanced age patients ( ml/h/site; . ml/site) and adults ( ml/h/site; ml/site); lower infusion rates and volumes/site were reported in the pediatric/adolescent patients ( . larger infusion volumes and faster infusion rates were not associated with increases in causally related local aes in the advanced age group, consistent with the trends seen in the pediatric/ adolescent and adult patients. conclusions: despite the higher mean number of comorbidities in advanced age patients with pidd, ig gly was infused at relatively high rates and volumes and was well tolerated. introduction: hyqvia (ighy; immunoglobulin infusion % with recombinant human hyaluronidase [rhuph ]) is an immunoglobulin (ig) replacement therapy approved for patients with primary immunodeficiency diseases (pidd) that allows larger infusion volumes, up to ml/site, and has improved ig bioavailability compared with conventional subcutaneous ig products. a post-authorization safety study is being conducted in the united states to acquire long-term safety data on ighy and to assess prescribed administration regimens in routine clinical practice. infusion characteristics and treatment-related adverse events from an interim analysis are reported here. methods: patients aged years with pidd receiving ighy were included in this ongoing, prospective, non-interventional, open-label, uncontrolled, multicenter study. as a part of routine clinical practice, patients are treated with ighy according to standard medical care and their treatment regimen is at the discretion of the treating physician. adverse events (aes) are collected from enrollment to study completion/discontinuation using a subject diary and assessed at every study visit (every months or standard practice). aes are assessed based on seriousness, severity, and causal relatedness to ighy. the presence of anti-rhuph antibody is evaluated on a voluntary basis. treatment preferences for various attributes of ig therapy were assessed annually using a treatment preference questionnaire. results: a total of patients were enrolled at us study sites (data cutoff date: august , ). infusions were self-administered at home ( %) or at the clinical site ( %) most commonly using -week infusion intervals ( . %). the mean maximum ig infusion rate was . ml/h and the mean ig dose was mg/kg bodyweight/ weeks. the mean number of infusion sites used for administration was . and mean infusion duration was . hours. most infusions ( . %) were administered without a rate reduction, interruption, or discontinuation due to aes. there were no serious aes (saes) related to ighy. sixteen patients experienced a causally related non-serious local ae ( . %; . events/patient-year, . events per infusion) and patients experienced a causally related non-serious systemic ae ( . %, . events/patient year, . events per infusion). seven of patients who were tested for anti-rhuph antibody had positive binding antibody test to rhuph (titer : ; maximum titer : at enrollment, : during the study); no neutralizing rhuph antibodies were detected. of the patients who responded to the treatment preference questionnaire at the end of year , the majority ( / [ . %]) preferred to receive their ig therapy at home; . % ( / ) preferred the doctors office; patients preferred treatment at the hospital, had no preference, or indicated other. almost all patients ( / [ . %]) indicated a preference to continue treatment with ighy. conclusion: this interim analysis of patients with pidd treated with ighy in routine clinical practice supports previous observations that ighy is a well-tolerated and preferred therapy with no reports of treatment-related saes or neutralizing anti-rhuph antibodies. background: cartilage hair hypoplasia (chh) is an autosomal recessive chondrodysplasia associated with variable immunodeficiency. pathogenic defects in rmrp, encoding the untranslated rna subunit of ribonucleoprotein endoribonuclease complex (rmrp), result in reduced mrna and rrna cleavage. rmrp c. a>g is the most common variant, increased in finnish and amish populations. while cellular immunodeficiency is associated with increased morbidity and mortality, there is no established correlation between clinical and immunological phenotype. lymphocyte radiosensitivity has not been described. case: a full-term amish female infant had low trec copies on newborn scid screen. flow cytometry at months-old demonstrated severe t and b cell lymphopenia (cd +t-cells cells/mcl, range: , - , cells/mcl; cd +b-cells cells/mcl, range: - , cells/mcl) with normal nk quantitation (cd / + cells/mcl, range: - , cells/mcl) and cd + memory t-cell expansion ( . %) relative to the naïve subset ( . %). t-cell functional mitogen responses were normal. she was diagnosed with chh with homozygous rmrp c. a>g mutation. lymphocyte subset (t, b and nk cells) radiosensitivity was evaluated by flow cytometric analysis of phosphorylated (p) atm, smc and gamma-h ax after low-dose ( gy) irradiation. an increase in gamma-h ax level was observed in a subset of non-irradiated t cells ( . % v. . % gamma-h ax+) and nk cells ( . % v. . % gamma-h ax+) in the patient, suggestive of a constitutive defect in dna repair. the relative distribution of t, b and nk cells expressing patm, psmc and gamma-h ax at hour postirradiation (ir) was not significantly different from the experimental healthy control (ehc) or pediatric reference range (prr). however, the kinetics of dephosphorylation at hours post-ir was altered with residual gamma-h ax expression in a subset of the patients t cells (delta . %, mode ratio mean fluorescence intensity (mfi)= . ; ehc: delta . %, mode ratio mfi= . ; prr: delta . %, mode ratio mfi= . ). a similar finding was observed in a subset of patient b-cells for gamma-h ax (delta . %, mode ratio mfi= . ; ehc: delta . %, mode ratio mfi= . ; prr: delta . %, mode ratio mfi= . ). the frequency of the patient's lymphocytes with residual gamma-h ax persistence at h post-ir was prominent, with . % t-cells demonstrating persistence of gamma-h ax (compared to . % in the ehc, and . % in the prr), and . % b-cells gamma-h ax+ (compared to . % in the ehc, and . % in the prr). there has been lack of follow-up, but verbal report suggests no significant immunological or infectious concerns at year of age. discussion: lymphocyte radiosensitivity is a novel finding in chh with t and b cell lymphopenia. the ability of rmrp to associate with telomerase reverse transcriptase (tert) and function as an rna-dependent rna polymerase, yielding distinct silencing rna sequences, may underlie radiosensitivity in rmrp mutants. systematic characterization of lymphocyte radiosensitivity and immunological phenotype could provide useful information on whether this could serve as a biomarker for the magnitude or complexity of immunodeficiency. assessment of radiosensitivity has implications in conditioning regimen selection for patients requiring allogeneic hematopoietic cell transplantation. we recommend lymphocyte radiosensitivity assessment in chh infants identified by nbs scid and chh patients with significant immunodeficiency and/or malignancy. novel primary immunodeficiency with lymphoproliferative disease due to biallelic defects in nckap l background: three children from non-consanguineous families and different ethnic backgrounds developed lymphoproliferative disease by years of age. they also had recurrent infections, including pneumonia and bronchiectasis, otitis media, and skin pustules. immune phenotyping revealed low cd + t cell percentages, an accumulation of memory-like cd + t cells, impaired t cell proliferation, and low total nk cell numbers. methods: the affected individuals, unaffected parents, and other unaffected family members underwent exome sequencing. results: all affected cases had rare and bioinformatically damaging biallelic variants, with appropriate familial segregation, in nckap l, which encodes hem . hem is an essential component of the wave regulatory complex (wrc). immunoblotting confirmed destabilization of the wrc in all patients. immunofluorescence microscopy demonstrated defective f-actin and wave localization to immune synapses in nk cells. significant abnormalities were identified in patient lymphocyte and neutrophil migration and morphology, consistent with altered wrc-mediated cytoskeletal dynamics. all patients exhibited impaired inside-out integrin activation. knockdown of hem produced deficient proliferative responses and mtorc -mediated akt activation in control t cells. conclusions: the immunologic and clinical phenotype in the affected individuals recapitulates the phenotype observed in hem -deficient mice. biallelic defects in nckap l therefore result in a novel human primary immunodeficiency disease characterized by lymphoproliferation and susceptibility to infections. background: concurrent existence/significance of immunodeficiency with new onset lymphoproliferative disease remains understudied. just two studies to date have evaluated the prevalence of hypogammaglobulinemia in chronic lymphocytic leukemia (cll) and neither studied prevalence and impact of ige deficiency on outcomes in cll [ , ] . therefore, the objective of this study was to examine the prevalence of hypogammaglobulinemia, examining all isotypes, in newly diagnosed cll patients and to test the hypothesis that patients with hypogammaglobulinemia have a distinct clinical profile and outcome. methods: using the banked sera of newly diagnosed, treatmentnaïve, cll adult patients from the lymphoma molecular epidemiology resource (l-mer), ig (igg, iga, igm and ige) levels were measured. the l-mer was initiated as an observational cohort study of prospectively enrolled newly diagnosed lymphoma patients evaluated at the mayo clinic (rochester, mn) and the university of iowa (iowa city, ia) [ ] . igg/a/m levels were measured using immunoturbidimetric assay whereas the ige level was determined using electrochemiluminescence immunoassay. the associations between ig deficiencies and clinical factors were evaluated with wilcoxon rank sum and chi-squared (fishers exact, where appropriate) tests. cox regression models were used to assess the effects of clinical variables on overall survival (os). time was calculated from biopsy to death due to any cause; patients still alive were censored at last contact. all tests were two-sided and assessed for significance at the % level using sas v . (sas institute, cary, nc). results: the mean age (sd) of the selected cll cohort was . ( . ) years with a male predominance ( . %). . % of the patients were white. with a median follow-up of five years, there were deaths. hypogammaglobulinemia in newly diagnosed, treatmentnaïve cll was common in our cohort with ( . %) patients having a measurable isotype deficiency. the most common ig deficiency was igm ( . %, % ci . - . %), followed by igg ( . %, % ci . - . %), ige ( . %, % ci . - . %) and iga ( . %, % ci . - . %). multiple deficiencies in the same patient were common ( figure ). iga and ige deficiency were associated with higher rai stages (grading system for cll) at presentation (p< . and . respectively) as well as with higher white blood cell counts at presentation (p= . and . respectively). a higher proportion of iga deficient patients needed second treatment during follow-up ( % compared to %, p= . ). when comparing predictors of overall survival, higher rai stage [ - vs , hazard ratio (hr) . , % ci . - . , p= . ] and age (hr . , % ci . - . , p< . ) correlated with worse overall survival. individual immunoglobulin deficiencies did not correlate with overall survival. conclusions: a significant proportion of treatment-naïve patients with cll have underlying ig deficiencies-both in isolation and a combination of different isotypes. a deficiency of iga or ige was associated with severe disease at presentation. the underlying relationship between these two immunologic disorders deserves further study. background: patients with primary immunodeficiency (pid) have an increased risk of developing autoimmune diseases, including rheumatoid arthritis (ra). management of these patients is challenging as immunomodulators can further increase their risk for infections. additionally, patients with ra that undergo therapy with drug modifying antirheumatic drugs (dmards) may develop a secondary immunodeficiency. there are few studies reviewing the characteristics of patients with a pid who later develop ra, and no studies have been reported comparing these patients to those who develop an immunodeficiency after starting dmard therapy for ra. methods: patients were identified as having inflammatory arthritis and a concomitant immunodeficiency (id) at our institution between / / - / / using icd- and codes. manual chart review was performed to confirm and identify the timing of diagnosis of these disorders. patients were excluded if either there was no definitive diagnosis of id or ra (clinically diagnosed by a practicing allergist/immunologist and meeting acr criteria for ra with a score of or higher, respectively), or rituximab was administered prior to diagnosis of id . clinical symptoms, treatment, and laboratory data were extracted. fishers exact test was used to compare the categorical variables between the groups; ttest was used to compare the continuous variables. results: patients met the inclusion criteria. patients were diagnosed with an id and developed ra later in life (group ), and patients were diagnosed with ra and subsequently developed a clinically significant id (group ). the mean ages of diagnosis of id and ra in group patients were . years (sd ± . ) and . years (sd ± . ), respectively. in group , the mean age of diagnosis of ra was . (sd ± . ), compared to . years (sd ± . ) for the diagnosis of id. most patients in both groups were female ( % in group and % in group ). all patients in both groups had a humoral id, including common variable immunodeficiency (cvid) ( % of group patients), specific antibody deficiency (sad) ( % of group and % of group patients), and hypogammaglobulinemia ( % of group and % of group patients). all patients in group were seropositive for rheumatoid factor (rf) or anti-cyclic citrullinated peptide (anti-ccp), whereas only % of patients in group were positive for rf or anti-ccp (table ). most patients in both groups were treated with immunoglobulin replacement therapy. treatment of ra in both groups was similar, but combination dmard therapy was not used in group patients in contrast to group patients. conclusions: our study indicates that even though clinical characteristics and management are similar in patients with coexisting id and ra, rf and anti-ccp are usually negative in patients who develop ra after id, possibly due to impaired antibody production in immunodeficient patients. assistant professor of allergy and immunology, arkansas children's hospital, university of arkansas medical sciences introduction/background: complement deficiencies are relatively rare, comprising less than % of primary immunodeficiencies. they are associated with increased risk for infections with encapsulated organisms and autoimmunity. of all complement deficiencies, the rarest are defects in the alternative complement pathway. properdin deficiency is the most commonly described alternative pathway deficiency, with factor b and factor d deficiency more rarely described. fewer than patients with factor d deficiency have been reported with all reported cases being children of consanguineous parents who succumbed to meningococcal sepsis. objectives: to describe a case of factor d deficiency associated with recurrent respiratory infections with streptococcus pneumoniae pneumonia with associated lung abscess and empyema. methods: retrospective chart review was conducted. laboratory investigations included lymphocyte immunophenotyping by flow cytometry, lymphocyte proliferation to mitogen, quantitative serum immunoglobulins, vaccine titers, complement assays and functional evaluation, and genetic evaluation by next generation sequencing. results: a year old marshallese male was transferred from an outside hospital to our facility for further evaluation of worsening pneumonia and was found to have right-sided pleural effusion and pulmonary abscess in the right lower lobe. the abscess was drained and was found to be positive for streptococcus pneumoniae via polymerase chain reaction. he improved after chest tube placement and treatment with intravenous antibiotics. his medical history was significant for recurrent acute otitis media and prior hospitalization out-of-state for pneumonia with empyema secondary to streptococcus pneumoniae, which required chest tube placement and admission to the pediatric intensive care unit at months of age. immunologic work up revealed age-appropriate lymphocyte subpopulations, lymphocyte proliferative responses to mitogens, quantitative immunoglobulin levels, pneumococcal/tetanus/diphtheria titers, and ch complement assay. ah complement assay was decreased to units/ml. complement testing was repeated -with normal ch and ah of units/ml. further evaluation revealed normal levels of factors b, h, i and properdin. factor d level was . mcg/ml, and factor d function was decreased to units/ml, indicating a diagnosis of factor d deficiency. sequencing of the cfd gene revealed a previously undescribed homozygous deletion (c. _ del and p.lys del). the parents were not agreeable to personally undergoing genetic evaluation to determine if this was a de novo mutation. the patient was managed with pneumococcal and meningococcal immunizations, prophylactic amoxicillin and intravenous gamma globulin (ivig) without any further infections. unfortunately, after two ivig infusions, he was lost to follow up. conclusion: factor d deficiency is an extremely rare alternative complement pathway deficiency, described in less than patients. all infections described thus far have been secondary to neisseria meningitidis. this case represents not only a novel mutation in the cfd gene leading to factor d deficiency, but also the first description of a patient with factor d deficiency developing invasive infection secondary to streptococcus pneumoniae. background: viral infections are a significant cause of morbidity and mortality in patients with primary immunodeficiency disorders and following hematopoietic stem cell transplantation. adoptive immunotherapy using virus specific t-cells (vsts) has been shown to prevent and treat viral infections in immunocompromised hosts. human parainfluenza virus- (hpiv ) is a common cause of severe respiratory illness in immunocompromised patients and has no approved antiviral therapies and has not previously been used as a target for t cell therapeutics. introduction: we previously reported that fatigue is increased in common variable immunodeficiency (cvid). however, in previous studies, fatigue was not defined using validated tools. our aim from this study is to identify the prevalence of patient-reported fatigue, using validated questionnaires, and determine the factors predisposing to fatigue in cvid methods: data from cvid who responded to the idf patient national survey a were analyzed. fatigue was measured using the brief fatigue inventory (bfi) questionnaire, which includes seven items to identify fatigue, and measure fatigue severity. a total of patients with cvid and responses to bfi were enrolled. demographics, co-morbidities, immunoglobulin replacement therapy (iggrt) route and dose, co-morbidities, infections, depression, quality of life (qol) (using the sf- v ) and disability were compared between fatigued and non-fatigued. logistic regression was used to identify the significant variables. ebv reactivation without ptld, treated with rituximab. alive and well. j clin immunol ( ) (suppl ):s -s s granulomas are the most significant day-to-day problem for cvid patient management. currently, there are limited options for their treatment and the optimal therapy is unknown. in case reports and small series, infliximab has been reported effective while others found it useless. we here describe a yo white male referred for monthly ivig in august . at age , he developed large areas of erythematous polymorphic plaques in his cheeks, arms and legs. a skin biopsy showed tuberculoid granulomas negative for bacteria, baar and fungi, with infiltrating cd + lymphocytes. a prolonged course of steroids did not improve his skin. he also had multiple pneumonias and bronchiectasis, and oral candidiasis. he received all vaccines, including bcg with no complications. with low immunoglobulins and a poor response to pneumococcal polysaccharides and tetanus toxoid he was diagnosed as cvid and placed on ivig at yo with excellent infectious control since then. at age , his skin lesions persisted and deepened to the bone on his left leg. broad spectrum antibiotics for months were unsuccessful. at yo to yo, skin grafts were performed on his arms, legs and both cheeks. two ulcers persisted on his left leg until august that increased in size, deepened and became erythematous and extremely painful (fig. ) . in september, two new ulcers appeared on his right cheek and right gluteus, respectively. one week later a third ulcer was found on his left calf. on september th, infliximab mg/kg ( mg) was administered. on the second infliximab dose, october th, the pain was completely gone and all ulcers were shrinking, and those ones in the cheek, gluteus and calf almost completely resolved. by the third dose, on november rd the ulcers in his right leg were almost closed (fig. ) . infliximab mg treatment continues every weeks. lab test remained unchanged from till , when his wounds got worsened. (table ) granulomatous disease in cvid is a challenge. both b and t cell directed therapies are encouraged. we add a new case of an infliximab responsive patient to others already reported. over genes have been reported to cause monogenic cvid. a year old girl presented with recurrent pneumonias and a diagnosis of cvid. the parents sought a second opinion. born at weeks gestational age, she was "always smaller and sicker than her friends," and in the prior months she had episodes of pneumonia with fever to f requiring emergency department treatment. two of these were associated with rsv and metapneumovirus, respectively. laboratory evaluation confirmed low levels of igg ( mg/dl) iga ( ) and igm ( ) congenital tuberculosis (ctb) is a rare disease most often associated with maternal genitourinary (gu) tuberculosis (tb) or disseminated tb. due to infertility caused by gu tb, ctb is rarely reported even in endemic countries. infants can acquire tb hematogenously via the placenta or umbilical vein or by fetal aspiration of infected amniotic fluid. presenting symptoms include respiratory distress, fever, hepatosplenomegaly, poor feeding, lethargy, and low birth weight. we report a premature female infant conceived via in vitro fertilization (ivf), who was born to indian immigrant parents at weeks of gestation due to preterm premature rupture of membranes. maternal history was significant for pulmonary tb at years of age. she denied abdominal or gu symptoms. infants nicu course was complicated by opacifications in the right lung and leukocytosis with neutrophil predominance, identified during evaluation of frequent apnea and bradycardia episodes at month of age. clinical improvement was noted after treatment with vancomycin, amikacin and piperacillin-tazobactam; however, leukocytosis of unknown etiology persisted. at . months of age she was discharged to inpatient rehabilitation. at months of age, she was readmitted for fever and respiratory distress. during this admission, an immune evaluation was undertaken due to persistence of symptoms along with unresolved leukocytosis with a peak of , cells/l with neutrophilia to , cells/l, and chest ct evidence of progressive multifocal lung disease worse in the right upper lobe despite empiric treatment with broadspectrum antibiotics. infectious work-up was negative, including acid-fast bacilli testing from bronchoalveolar lavage. due to the pronounced and persistent leukocytosis and neutrophilia, a primary immune defect was suspected. immune evaluation included: normal immunoglobulins (ig) g, a, and e, elevated igm, vaccine-specific antibody titers protective to diphtheria and of streptococcus pneumonia strains, mildly elevated t and b cells, a normal flow cytometry for dihydrorhodamine, myeloperoxidase stain and glucose- -phosphate dehydrogenase level, as well as a peripheral smear with no giant azurophilic granules. her primary immunodeficiency genetic panel was unrevealing. she underwent lung biopsy via video-assisted thoracoscopic surgery, which showed noncaseating granulomas and eventual growth of multi-drug-resistant mycobacterium tuberculosis (mtb). upon treatment with an appropriately adjusted anti-tuberculosis regimen, she showed rapid clinical and laboratory improvement. endometrial samples obtained from mother showed gu tb, confirming the diagnosis of ctb. the slow-growing nature of mtb that resulted in delayed diagnosis, along with the presence of non-caseating granulomas and persistent neutrophilia, prompted an immune work up that was completely normal. this case demonstrates the importance of considering ctb in the differential diagnosis of an infant presenting with severe lung infection, persistent neutrophilia, suboptimal response to broad-spectrum antibiotics and relevant epidemiologic risk factors. furthermore, in the setting of appropriate parental exposures and infertility prompting the use of ivf, maintaining a high level of suspicion of ctb can aid in earlier diagnosis of affected neonates. -year-old caucasian male who initially presented with recurrent otitis media, persistent hsm, lad, and hypogammaglobinemia (igg < mg/dl) at years of age. he was diagnosed with common variable immunodeficiency (cvid) and chronic arthritis when he was and years of age, respectively. subsequently, he developed hepatitis and recurrent pneumonia with mycobacterium avium complex (mac). his arthritis partially responded to anti-tumor necrosis factor (tnf) agents and tofacitinib, but did not respond to anti-interleukin- treatment. a combination of anti-tnf inhibitor, tofacitinib, and low dose prednisone was required to control his arthritis. hypogammaglobulinemia (igg < mg/dl), recurrent otitis media, pneumonia, crohn's disease, celiac disease, lad and failure to thrive at years of age with more recent development of hsm. he required only immunoglobulin replacement therapy. case# is a -year-old caucasian male, the half-brother of case# , who initially presented with recurrent pleural effusion and bilateral pulmonary infiltrates, hsm, lad, abdominal distension and ascites at years of age. a transbronchial lung biopsy revealed chronic eosinophilic pneumonitis. liver biopsy showed increased eosinophils in the sinusoids with diffuse enlargement of hepatocytes, but without hepatitis. colon biopsy revealed minimal colonic eo-sinophilia. his pulmonary infiltrates and pleural effusion responded to prednisone, and he has not required additional treatment for past . years. conclusions: the clinical manifestations of the same genetic variant may be variable and unpredictable even in the same family. stat gof syndrome should be considered in children with multisystem autoimmune diseases, lad, hsm and low switched memory b cells regardless of presence of hypogammaglobulinemia or history of recurrent infections. background: patients with primary immune deficiencies characterized by severe t lymphopenia and/or poor t cell function and patients posthematopoietic cell transplantation are at high risk of severe viral infections. antiviral medications are expensive, not always effective and associated with significant toxicity and/or long-term side effects. as such, there has been increasing interest in the use of donor-derived or thirdparty virus-specific t cells (vsts), and several studies have demonstrated efficacy of vsts generated using various manufacture strategies. however, in depth immunologic and metabolic characterization of vsts has not been reported, limiting correlative investigations into efficacy. methods: ebv-vsts were generated from apheresis t cells collected from healthy donors using three methods: ( ) stimulation and expansion with hla-matched ebv-lymphoblastoid cell lines (lcls) purchased from astarte biologics or sigma-aldrich over a period of weeks, ( ) stimulation with ebv peptivator from miltenyi followed by expansion over - days with different cytokines, and ( ) stimulation with ebv peptivator followed by isolation of activated cells using the ifn-gamma capture system from miltenyi. immunophenotyping by flow cytometry was performed using the miltneyi macsquant analyzer. the nanostring ncounter system was used to measure gene expression for metabolic pathway analysis, and the agilent seahorse xf cell mito stress test system was used to measure mitochondrial respiration. results: ebv-vsts generated using lcls or peptivator plus il- both resulted in a high percentage of cd t cells skewed to the effector memory and terminal effector memory phenotype with high expression of the exhaustion markers pd- , tim- , and lag- . conversely, ebv-vsts generated using peptivator plus il- and il- and the ifn-gamma capture system resulted in a mixed cd and cd t cell population with a high number of central memory t cells and lower percentage of cells positive for pd- , tim- , and lag- . stimulation with peptivator followed by expansion with il- resulted in an intermediate immunophenotype. nanostring results demonstrated upregulation of the glycolytic pathway in ebv-vsts stimulated with peptivator followed by expansion with il- or il- compared to ebv-vsts generated using the other manufacture approaches. the seahorse mito stress test demonstrated that the peptivator plus il- ebv-vsts had a significantly lower spare respiratory capacity than other ebv-vsts and a low extracellular acidification rate despite upregulation of the glycolytic pathway. the peptivator plus il- and il- ebv-vsts had the highest basal oxygen consumption rate, atp-linked respiration, and extracellular acidification rate. conclusions: manufacture of ebv-vsts using the various approaches currently employed clinically results in t cell pools with different immunophenotypes and different metabolic profiles. ebv-vsts stimulated with peptivator followed by expansion in il- and il- and ebv-vsts isolated using the ifn-gamma capture system have immunophenotypes and metabolic phenotypes suggestive of potential greater in vivo persistence, whereas ebv-vsts expanded in il- and il- have characteristics correlated with increased effector function. however, these vsts are more likely to be short-lived and to have impaired metabolic fitness. these phenotypes will enable better correlation with clinical results and suggest combinatorial approaches depending on clinical indication. introduction: majority of patients with primary immunodeficiencies (pid) require life-long replacement therapy with immunoglobulins (ig) to prevent severe infections and irreversible complications. in addition to safety and efficacy, tolerability and convenience of administration of ig products are essential factors for patients. a new . % ig preparation octanorm (octapharma, lachen; tradename cutaquig® in north america) has been developed for subcutaneous administration (scig) derived from the established manufacturing process of octapharmas intravenous ig (ivig) brand octagam®. objectives: primary outcome was assessment of the efficacy of octanorm in preventing serious bacterial infections. main secondary endpoints included (among others) evaluation of tolerability and safety of octanorm, the number and rate of other infections, number of days missed at work, and use of antibiotics. methods: a prospective, open-label, non-controlled, single-arm phase study involving adult patients with pid was conducted at russian centers. patients treated with at least infusions of ivig prior to enrollment and with igg trough levels . g/l underwent an -week wash-in/wash-out period followed by a week efficacy period. during the study, patients received weekly administrations of octanorm at the same monthly dose as during previous ivig treatment (monthly ivig dose divided by for weekly dose). in total, each patient received scig infusions. results: twenty-four patients completed the study. one patient terminated early (after infusion , during wash-in/wash-out phase; personal reasons). mean age was . years (range - years). fifteen patients ( %) were female and patients ( %) male. no serious bacterial infections were recorded. during the efficacy period a total of non-serious infections was observed in patients. seventeen infections in patients were of mild and infections in patients of moderate intensity. the infection rate per person-year was . . in total patients received infusions of study drug. the average dose of cutaquig® was . g/kg/week. during the entire study, systemic adverse events were reported (including infections). three of these systemic adverse events were rated as related to study drug, all were non-serious. there was no serious or significant adverse event nor was there an adverse event leading to withdrawal. infusion site reactions were reported for % of infusions. serum igg trough levels were nearly constant during the efficacy period. median igg trough levels were . g/l at screening, . g/l at the end of wash-in/wash-out period and . g/l at the termination visit. one patient had a trough level g/l at visits during the efficacy period and the dosing was subsequently adjusted for this patient. during the primary treatment period patients ( . %) used antibiotics in treatment episodes (total of treatment days; range - days) and patients had absences from work or school due to infections (total of days of absence). conclusion: this study demonstrated that the new subcutaneous human normal immunoglobulin . % is well tolerated, safe and effective in adult patients with pid. background: children with chronic granulomatous disease (cgd) are at high risk for fungal infections (especially with aspergillus species) and these infections usually have contiguous site involvement. most patients have pulmonary presentation. infective endocarditis and fungal osteomyelitis of skull are distinctly unusual. we report one such case. case: a -year-old boy, born out of a non-consanguineous marriage, presented with soft tissue swellings of skull for months. his past history was significant with an episode of pneumonia at year and recurrent soft tissue swellings all over the body since ½ years of age. on examination he was wasted, had signs of micronutrient deficiency, rickets, pallor, cervical lymphadenopathy and two abscesses, x cm on right temporo-parietal region and x cm over left frontal region. he was also found to have hyperdynamic precordium with an ejection systolic murmur. investigations revealed hemoglobin g/l; platelet count . x /l; total leukocyte count x /l(n /l /m /e ); elevated c-reactive protein( mg/l) and a raised erythrocyte sedimentation rate( mm sthr). chest x ray revealed cardiomegaly (cardiothoracic ratio %) and d echocardiography showed vegetation of x mm over the anterior mitral leaflet suggestive of infective endocarditis. blood and urine cultures were sterile. culture from pus over the temporo-parietal abscess showed growth of aspergillus fumigatus. human immunodeficiency virus serology was non-reactive. immunoglobulin profile revealed elevated igg . g/l ( . - . g/l) and iga . g/l( . - . g/l); igm was . g/l( . - . g/l). in view of strong suspicion of cgd, nitroblue tetrazolium dye reduction test (nbt) was carried out-it revealed no reduction and dihydrorhodamine (dhr) assay showed a low stimulation index ( . ). flow cytometry for gp phox and gp phox was normal and dhr of mother did not reveal x linked carrier state. contrast enhanced computerized tomography (cect) of head showed osteomyelitis of the calvarial bones. contrast enhanced magnetic resonance imaging (cemri) brain showed heterogeneously enchancing soft tissue lesion in the scalp at right fronto-parietal region and left frontal region with underlying bony destruction suggestive of osteomyelitis. he was given intravenous antimicrobials (ceftriaxone, gentamycin, cloxacillin, voriconazole). after weeks of therapy, he showed resolution of findings on mri brain and a repeat d echocardiography showed significant decrease in size of mitral leaflet vegetation. conclusion: this case highlights a rare presentation of cgd with infective endocarditis and skull osteomyelitis due to aspergillus fumigatus. to the best of our knowledge, this has not been reported previously. background: genetic defect in il r affect cellular immunity, underlie mendelian susceptibility to mycobacterial disease (msmd) and inflammatory bowel disease (ibd) through different pathways. we present for the first time a patient with il- r deficiency from a consanguine family with two different phenotypes. initially diagnosed as crohn's disease prior to the msmd diagnosis. method and material:patient was referred to the clinical immunology and allergy clinic at the at alzahra university hospital for immunological and genetic evaluation . blood samples from patient, his family and healthy donor controls were collected upon informed consent. in this study, we investigated effect of il r mutation in il- /ifnaxis by evaluation of patients whole blood cell response to il- and ifn-, il- r expression in pbmcs and t cell blasts. also wholeexome sequencing has been performed. result and discussion: a years old male from consanguine family , with history of right sub-axillary bcg lymphadenitis, recurrent mouth ulcers , chronic diarrhea in childhood and appendectomy at age of was investigated. based on his clinical presentation abdominal pain, significant weight loss, chronic and bloody diarrhea , endoscopic and pathological findings treatment for crohn's disease (cd) was started at the age of seven . unfortunately, protracted patient's symptoms ends up to resection of his colon and colostomy two years later. he was presented with multi focal osteomyelitis at the age of . although no bacteria was detected in pcr and tissue culture of the bone biopsy and the patient was not responded to antibacterials , he had a dramatic response to empirical anti mycobacterial treatment and his severe bone pain and lesions were healed. even though the bone manifestations were completely controlled, he continuously was under treatment for his gastrointestinal symptoms. genetic analysis was confirmed segregation of homozygous mutation in splice site of exon in il- r . expression of gene was completely abolished in pbmcs of patient and the surface expression of il rb was not detectable in t cell derived pbmcs of the patient compared to healthy control. furthermore, did not response to il stimulation since we could not detect increase of inf-after stimulation with il and bcg. our patient received bcg vaccination at birth and had bcg lymphadenitis as an infant, cd and mycobacterial multifocal osteomyelitis as a child. furthermore there are some evidences which indicate the role of atypical mycobacterial infections as a trigger for cd. conclusion: we reported for the first time contemporary msmd and ibd in years old patient, who had impaired il- signaling and abolished il r expression in pbmcs and t cell blast. however, mycobacterial osteomyelitis is a typical phenotype of msmd patients with deficiency in ifn-r or stat, there were no mycobacterial osteomyelitis reported in il- r deficient patients. background: advanced genetic studies help explain the occurrence of many undiagnosed, rare conditions. recently, nbas variants were identified as a causative basis of recurrent liver failure in infants (infantile liver failure syndrome , ilfs ). the nbas (neuroblastoma amplified sequence) gene encodes a protein involved in golgi to er retrograde transport. nbas functions seem to be broad and loss of function variants in nbas have been associated with multisystem manifestations. case report: a y m old chilean male presented to the er with a three day history of vomiting, diarrhea and one day of fever ( . °f). on examination he was pale, lethargic, and tachycardic. a chemistry profile revealed markedly elevated liver enzymes, increased bilirubin, and coagulopathy, consistent with the acute hepatic failure (alt , ast > , total bilirubin . ( . db), ggt , and inr of . ). he was hospitalized, given vitamin k, and kept on intravenous fluids, ursodiol, and antipyretics. his liver function improved significantly within days of admission (alt was down to , ast , total bilirubin . ). work-up of possible etiologies including autoimmunity and infectious hepatitis was negative. liver sonogram was normal, but liver biopsy was consistent with acute hepatitis with some necrosis. urine organic acid and plasma amino acid screens were not consistent with any inherited metabolic disorders. his parents recalled two previous episodes of liver failure at ages and years. both were preceded with a mild febrile illness and non-specific symptoms including fever, coughing, vomiting, diarrhea, lethargy, and decreased po intake. these subsequently were followed by jaundice and marked elevation of liver enzymes. flu a and adenovirus were identified as causes of febrile illnesses of the two previous episodes. for this admission, adenovirus was found in the respiratory secretions and a mild ebv viremia was also detected. genetic evaluation in chile was reportedly normal. after a literature review we obtained sequencing of nbas which revealed two variants: c. g>t,p.glu * and nbas c. t>g, p.iie ser. both variants have been previously reported in patients with an infantile onset, recurrent liver failure syndrome. his other clinical features include developmental and speech delays, failure to thrive, and facial dysmorphism. he also has a history of recurrent ear infections and has had sets of tympanostomy tubes. further testing was limited due to the lack of insurance coverage. conclusion: nbas deficiency is a newly described syndrome of recurrent acute liver failure that occurs early in life. once individuals have survived to adulthood they do not seem to develop liver failure with illness. typically, liver crisis is triggered by a common childhood febrile illness. the mechanism of disease is thought to be thermal instability of hepatocytes which improves over time in most cases. however, although spontaneous recovery can occur following the crises, each episode can be fatal or result in permanent liver damage required liver transplantation. increased awareness of this disease will lead to the early establishment of the diagnosis. appropriate and timely management of fever at the onset of illness can significantly improve outcome in this potentially fatal disease. associate prof., infectious diseases and tropical medicine research center, isfahan university of medical sciences, isfahan, iran background: pre-eclampsia, a pregnancy-specific complication, has been shown to be associated with cytomegalovirus (cmv) infection. cmv specific t-cell response plays the major role in cmv infection or disease .we explored whether a change in cmv-specific cell-mediated immunity (cmi) is related to the development of preeclampsia. method: cmv-specific cmi was assessed using cmv-quantiferon (qf-cmv) assay in serum from women with pre-eclampsia as well as normal pregnancy controls retrospectively. participants were matched for gestational age individually. proportion of reactive results, mean value of interferon-level produced in mitogen and antigen tubes were compared between the cases and controls via chi-square, wilcoxon rank-sum tests, respectively. odds ratio (or) and confidence interval (ci) were calculated as well. result: no significant differences observed between demographic characteristics of the case and control groups. the qf-cmv assay turned reactive (qf-cmv [+]) in of of patients ( %) vs. of controls ( . %) (p = . ). women with pre-eclampsia had lower mean ifn-levels in antigen tube ( . ± . ) compared with normal pregnancy controls ( . ± . ) (p = . ). there was no statistically significant differences in this value of mitogen tube between cases ( . ± . ) and controls ( . ± . ) (p = . ). women with suppressed cmv-cmi were . times more likely to manifest pre-eclampsia (or= . , % ci: . - . ). this result even strengthened after adjustment for age, gestational age and gravidity (or = . , % ci: . - . ). conclusion: our finding support an association between suppressed cmv specific cmi and pre-eclampsia. introduction: the triad of susceptibility to infections, auto-inflammation, and cancer in a patients personal and family history are always suggestive of an underlying primary immunodeficiency; however, in some cases the diagnosis might be delayed for years. furthermore, the results of immunological and inflammatory evaluation can also be affected by ongoing immunomodulatory therapy initiated by different specialists upon clinical diagnosis. objective: to describe a unique presentation of auto-inflammatory disease with combined immunodeficiency in an adult patient. case presentation: we report here the case of a year old male, who had a long history of infections including recurrent sino-pulmonary bacterial infections starting during childhood, osteomyelitis at years of age, recurrent tonsillitis requiring tonsillectomy at years of age, recurrent cellulitis, an episode of prostatitis with septicaemia, as well as recurrent varicella zoster and warts. the patient was also diagnosed with sclerosing mesentheritis, and reynauds phenomenon, recurrent oral ulcers, arthritis, uveitis, autoimmune thyroiditis, lung fibrosis and suffered repeated episodes of abdominal pain. furthermore, there is a family history of early childhood death, multiple soft tissue cancers, crohns disease, and autoimmune thyroiditis. upon physical examination, the patient had multiple telangiectasia, baseline erythroderma, and flushing. immunological evaluation showed lymphopenia with significant reduction in both circulating b and t cells, however, assessment of humoral immunity revealed low igg and decreased igm with normal iga levels. at the time of the evaluation he had been on low dose daily prednisone ( . mg), colchicine, and methotrexate as immuno-modifying therapy. genetic evaluation revealed a heterozygous mutation in nod as well as compound heterozygous mutations in the mefv gene. discussion: mutations in nod have been described in association with blau syndrome a multisystem auto-inflammatory syndrome which may explain many of the features experienced by our patient. to our surprise next generation sequencing revealed a second aberration in the mefv gene which causes familiar mediterranean fever, another multisystem auto-inflammatory disease, which might lead to the phenotype observed in the patient. conclusion: this is the first report of genetic lesions in two different genes leading to a severe course of auto inflammation. monogenic autoinflammatory syndromes (mais) are a diverse group of disorders characterized by primary over-activation of the innate immune system. induction of the inflammasome complex by innate immune sensors and increased production of il- b are implicated in the pathogenesis of mais. macrophage activation syndrome (mas) is a life-threatening illness defined by acute hyper-inflammation and unopposed cytokine release. it is considered an acquired condition secondary to infection, rheumatoid disease or malignancy. the early therapeutic use of il- b inhibition has profoundly improved the prognosis mas. it has recently been shown that increased free il- levels in the blood are causatively linked to the development of mas. significant overlap in clinical presentation and laboratory markers between patients with mais and mas led us to explore the role of free il- and therapeutic use of il- b inhibition in a patient with cdc mutation. here, we report the case of an months-old female who presented with hydrops fetalis in utero, and later developed failure-to-thrive, splenomegaly, anemia, thrombocytopenia, arthralgias, rashes, frequent febrile episodes and mild facial dysmorphism along with massive increase in crp, esr and ferritin. whole exome sequencing (wes) identified a heterogenous likely pathogenic de novo variant in cell division control protein homolog (cdc ) c. g>a (p.c y). cdc encodes a small rho family gtpase that regulates multiple signaling pathways controlling cell polarity, migration, endocytosis and cell cycle progression. single allele mutations in the cdc gene were recently reported to cause takenouchi-kosaki syndrome manifesting with growth retardation, developmental delay, facial dysmorphism, and thrombocytopenia however systemic autoinflammation has not been described. cdc closely interacts with the wiskott-aldrich syndrome protein but little is known about the mechanism underlying immune abnormalities associated with cdc mutations. our patient had an inflammamosopathy-like syndrome. because of significant clinical overlap to mas, we measured il- , il- , free il- and il- binding protein, all of which were significantly increased. this increase in free il- heightened her risk of developing mas. her il b level was normal, but an increase in il- b is hardly ever detectable in the serum despite playing a critical role in this type of inflammation. indeed, chronic il- b excess in the tissues promotes systemic inflammation and is associated with chronically elevated crp and esr. with this rationale we started the il- receptor antagonist anakinra. within hours from starting anakinra, the parents observed an increase in appetite, resolution of arthralgias and improved mobility. over the course of the following weeks, fever, anemia, thrombocytopenia and rash disappeared, the spleen massively decreased in size and the patient started to meet developmental milestones. crp, esr eventually normalized while ferritin and free il- are still trending down. conclusions: significant increase in free il- and extremely encouraging clinical response to therapy with anakinra in a patient with novel cdc mutation suggests a link between mas and defects in cdc . elucidating the mechanism of inflammasome activation and the drivers of il- increase in mas and mais more broadly may shed light on novel therapeutic targets like the use of human recombinant il- binding protein. j clin immunol ( ) (suppl ):s -s s maintenance; smarcal is enriched in cells that maintain telomeres via the alternative lengthening of telomeres pathway and smarcal decifient cells demonstrate telomere instability with replication fork collapse and increased telomere-associated dna damage. [ , ] telomere analysis of siod patients, including one patient who received a hematopoietic stem cell transplant (hsct) years prior, as well as heterozygous family members revealed significantly shorter telomeres in siod patients compared to heterozygous family members and compared to agematched, healthy controls. methods: peripheral blood mononuclear cells were isolated using a ficoll-hypaque density gradient, cryopreserved, then sent to repeat diagnostics in north vancouver, bc. telomere length measurements were performed at a single-cell level using flow-fluorescence in situ hybridization as previously described. [ ] telomere length was measured in total lymphocytes, naive and memory enriched t cells, b cells, and nk cells and compared to reference samples from age-matched, healthy individuals. results: compared to age-matched healthy controls, three siod individuals had mean telomere lengths (mtls) less than the st percentile for age across all lymphocyte subsets (total lymphocytes, b cells, nk cells, naïve and memory t cells). in comparison, three unaffected family members had normal mtls ( th percentile< x < th percentile) across all subsets, and two unaffected family members had low mtls ( st< x < th percentile) in some subsets. the siod individual who received a matched-sibling hsct years prior, had normal mtl in nk cells ( th < x < th percentile) but low mtls ( st< x < th percentile) for all other subsets. conclusions: these data show that siod patients have significantly impaired telomere lengths across multiple lymphocyte lineages and support a limiting role for smarcal deficiency in telomere maintenance. in comparison, unaffected family members, heterozygous for smarcal mutations, have mean telomere lengths that are normal or slightly low for age. this suggests that abnormally short telomeres are seen in individuals with homozygous but not heterozygous smarcal mutations. for the individual who received a hsct, we do not have pre and post-hsct telomere data, but these results support obtaining pre and post-hsct telomere length analysis in future cases. abnormally short telomeres have been linked to widespread perturbation of gene expression. [ ] we hypothesize that smarcal deficiency, by the effect of stalled forks and shortened telomeres, leads to perturbation in the transcriptome of affected tissues. shortened telomeres may explain the reduced hematopoietic bone marrow production in siod, as bone marrow failure is a cardinal feature of dyskeratosis congenita, a disorder of impaired telomere maintenance. future studies to investigate the role of telomere maintenance in siod include measurement of telomerase activity in polyclonally activated t cells and transcriptome analysis using rna-seq background: yellow fever is a potentially fatal disease for which only supportive treatment is available. vaccination is the primary strategy for prevention of this disease and the vaccine is extremely effective, but there are a few specific populations where it is contraindicated. regarding iga deficiency (the most frequent primary immunodeficiency), current recommendations in the literature are controversial. there are no specific studies in this disease, so case series addressing the safety or possible adverse events after vaccination are essential for decisionmaking during epidemic scenarios, as experienced in brazil in the last years. in this context, this study aimed to describe adverse events after the use of the yellow fever vaccine in iga deficient patients. method: a retrospective cross-sectional study was conducted including iga deficient patients followed at a specialized pediatric outpatient clinic between and . all patients had at least one year of follow-up. immunoglobulin levels, antibody response to vaccines and lymphocyte subset count were evaluated to exclude other immunodeficiencies or the presence of abnormalities that could contraindicate vaccination. demographic data, the presence of infections and comorbidities, use of immunosuppressive medication and adverse events after vaccine administration of the vaccine were described. results: thirty-eight patients with iga deficiency were included in the study and received the vaccine. vaccinated patients had a mean age at the time of the study of . years (sd ± . y). six out of the presented comorbidities: thyroiditis (n= ), type diabetes mellitus (n= ), celiac disease (n= ) and juvenile rheumatoid arthritis (n= ). all patients were atopic and only one had recurrent infections in the last year despite the use of antibiotic prophylaxis. all patients had normal igg and igm levels for their age, positive vaccine responses for measles, rubella and mumps, and age-appropriate lymphocyte subset count. after months of observation, no immediate or late adverse events were reported. among the non-vaccinated patients, only one had a formal contraindication (systemic erythematosus lupus using immunosuppressive therapy). five out of the non-vaccinated patients reported being afraid of receiving the vaccine, still intended to receive it and for other patients data regarding vaccination was unavailable. conclusion: despite the small number of patients, the absence of adverse events in this case series suggests that immunization with yellow fever vaccine may be safe in iga deficient patients, excluded other contraindications. more studies are essential to confirm the safety and help the decision-making process regarding the vaccine administration for iga deficient patients, especially in this yellow fever outbreak scenario. introduction/backround: immunodeficiency, centromeric instability, and facial anomalies syndrome (icf) is a rare group of autosomal recessive disorders involving the triad of hypogammaglobulinemia, centromeric instability, and facial anomalies. the majority of patients have hypo-or agammaglobulinemia, but t cell defects have also been reported. we present the case of a child with icf- who presented with nk deficiency and ultimately developed an ebv-driven malignancy and was successfully treated with bone marrow transplant. methods: whole exome sequencing and nk cell function via -cr cytotoxicity assay and phenotyping via flow cytometry were performed at baylor college of medicine and texas childrens hospital. centromeric banding studies were performed at university of pittsburgh medical center. results: the female patient presented at months of age with cmv pneumonitis and persistent cmv viremia requiring treatment followed by prophylaxis with valgancyclovir. she initially had hypogammaglobulinemia and low t, b, and nk cells; she had normal trecs, lymphocyte mitogen proliferation responses and zap , mhci and mhcii expression. the hypogammaglobulinemia and t-and b-cell lymphopenia resolved within months after initial presentation as she clinically improved from her cmv infection. she was found to have nk cell deficiency on three separate commercially tested samples. whole exome sequencing revealed a homozygous variant in zbtb indicative of icf- syndrome that was confirmed with sanger sequencing (c. _ del, p.q vfs). repeat nk cell studies confirmed impaired function, and phenotyping showed an increase in cd -bright and a decrease in cd -positive cells, suggesting either impaired transition from immature to mature nk cells or impaired survival of mature cells. her karyotype and centromeric banding studies were normal, as were centromeric instability studies. she later developed a memory b-cell defect and presented at months of age with persistent fever, respiratory distress, loss of vaccine titers, hypogammaglobulinemia and low b and t cells. she was found to have ebv viremia and an eber-positive diffuse large b-cell lymphoma in her right lung. due to tenuous clinical status, she received rituximab for treatment of ebv prior to definitive lymphoma diagnosis. she was treated with chemotherapy per protocol anhl , group b (pre-phase with cop, courses and with copadm, and courses and with cym) and her course was complicated by seizures attributed to methotrexate toxicity. she ultimately underwent reduced intensity conditioning with hydroxyurea, alemtuzumab, fludarabine, mephalan, and thiotepa followed by a cd- selected, hla-matched, unrelated donor peripheral blood stem cell transplant. her early post-transplant course was complicated by adeno-, ebv, and cmv viremia, all successfully treated with antivirals and a donor lymphocyte infusion. she is now greater than months posttransplant, off immunosuppression with % donor engraftment, no evidence of organ toxicity or gvhd, and with excellent immune reconstitution. conclusions: this is the first reported case of impaired nk cell function and phenotype and ebv-driven malignancy in a patient with icf- . this case expands the phenotype of icf- and suggests that early bone marrow transplant should be considered in these children. it also demonstrates a novel requirement for zbtb in human nk cell maturation and function. rationale: common variable immunodeficiency (cvid) is a disorder that affects the production of immunoglobulins and is associated with development of autoimmunity. multiple mutations have been described that are associated with cvid, but plcg mutations have only been described in patients with phospholipase c gamma (plc ) associated antibody deficiency and immune dysregulation (plaid) and autoinflammatory plc associated antibody deficiency and immune dysregulation (aplaid). we present a case of a y/o male cvid patient with recurrent upper respiratory tract infections, steroid-dependent autoimmune thrombocytopenia, low b cell count, hepatosplenomegaly, and restrictive lung disease. he was found with a variant of unknown significance at the plcg gene. in contrast to plaid our patient does not exhibit cold urticaria. method: case presentation of a cvid patient followed in our clinics. patients chart and previous laboratories were reviewed. sequence analysis and deletion/duplication cvid panel testing was performed using invitae© discussion: genetic testing has revolutionized the diagnosis of immune deficiencies, but variants of unknown significance are being increasingly reported. in this case, a variant of uncertain significance was identified which replaces threonine for alanine at codon of the plcg protein. this codon is located at the sh domain, which is part of a region that provides auto-inhibitory enzymatic functions. plaid mutations have been identified in sh domain, but it has been known that both sh and sh domains facilitate plcg association with other proteins. studies with deletion of plcg gene have shown functional abnormalities in b cells, natural killer cells and mast cells. to our knowledge, there has not been any previous report of a cvid patient with a variant mutation at the sh domain of the plcg gene without being diagnosed as plaid or aplaid. our patient has immunodeficiency, recurrent upper respiratory tract infections, steroid-dependent recurrent autoimmune thrombocytopenia, rheumatoid arthritis, hepatosplenomegaly, early-osteoporosis and restrictive lung disease. he does not have cold urticaria as seen in plaid, but exhibits autoimmunity not observed in aplaid. conclusion: conclusion: plcg is an important protein in the pathway of b cell development. a novel mutation in the sh domain of the plcg gene may be associated with the cvid phenotype of low b cells and autoimmunity. this could lead to a gain-of-function mutation as seen in plaid but without early-onset cold urticaria. functional studies are required to confirm the significance of this mutation. primary (or familial) hemophagocytic lymphohistiocytosis (hlh) is a rare, life-threatening hyper-inflammatory disease affecting mainly young children. it is caused by mutations in genes involved in the granule-dependent cytotoxic pathway, and is characterized by extreme inflammation and massive tissue infiltration by activated t cells and macrophages. to this day, hematopoietic stem cell transplantation is the only available curative treatment with a transplantrelated mortality of %. thus, the development of new, more efficient anti-inflammatory treatments would be a significant advancement in the treatment of hlh. here, we hypothesize that combination therapies targeting both jak-dependent and independent cytokines will be more effective than either one alone to reduce the lifethreatening symptoms induced by this pathology. using a perforin-deficient mouse model of hlh, we first compared the effect of targeting individual cytokines with blocking antibodies on the progression of the disease. we show that blocking ifng and il- , but not il- , significantly reduces the severity of hlh. targeting the jak-stat signalling pathway with ruxolitinib, a specific inhibitor of jak and jak , downstream of ifng and il- , but not il- , is similarly beneficial. more importantly, combination therapies using ruxolitinib and blocking antibodies to either ifng or il- show synergistic effects, further mitigating the progression of the disease. these results suggest that jak-dependent and independent cytokines drive the pathogenicity of hlh in perforin-deficient mice. it further supports that ruxolitinib, although effective in reducing the symptoms of hlh, should be used in combination with anti-ifng and/or anti-il- antibodies to prevent hlh progression. this is particular relevant since the former were recently approved for the treatment of hlh while the latter (il- binding proteins) are in clinical trials for il- -dependent macrophage activation syndromes. despite the increased risk of opportunistic lung infection in patients with severe t cell dysfunction (e.g. cd l deficiency) and/or severe cd t cell lymphopenia, we are not aware of any reports of disseminated pneumocystis jiroveci infection in non-human immunodeficiency virus (hiv) patients with primary immunodeficiency (pid). we report the first case, to our knowledge, of disseminated pjp in a patient with cvid like/ctla haploinsufficiency. he had been diagnosed with common variable immunodeficiency (cvid) in , approximately eight years prior to being referred to us, and was on intravenous immunoglobulin (ivig). he was also diagnosed with multilineage evans syndrome in . his medical history was also significant for potential granulomatous lymphocytic interstitial lung disease (glild) (lung biopsy in the remote past with interstitial disease), significant splenomegaly ( . cm), severe portal hypertension, nodular liver disease (likely nodular regenerative hyperplasia) complicated by anasarca, history of chronic diarrhea (potential enteropathy), lymphadenopathy s/p biopsy with nodular lymphoid hyperplasia, and a history of multiple pneumonias. in , he had developed disseminated pjp with lung, liver, and bone involvement. the t vertebra pjp invasion was confirmed with a bone biopsy; gomori methenamine silver staining and pcr were performed and concluded pjp. he was treated with trimethoprim sulfamethoxazole (tmp-smx) and steroids, then was continued on tmp-smx prophylaxis. due to his liver damage and his chronic neutropenia, tmp-smx was replaced by atovaquone as a secondary prophylaxis for pjp. his laboratory studies were significant for an absolute neutrophil count of . k/ul, absolute lymphocyte count of . k/ul, hemoglobin of . g/dl, platelets of k/ul, total bilirubin of . t-cell receptor beta chain repertoire analysis showed an oligoclonal distribution. severe combined immunodeficiency panel through ambry genetic testing was negative as was genetic testing for cd l deficiency. given his complex clinical history, whole exome sequencing was obtained and detected an autosomal dominant heterozygous missense mutation (c. g>a) implicated in ctla- haploinsufficiency and previously reported by schwab et al. our patient is currently undergoing therapy with abatacept (ctla- fusion protein), which has been reported to improve glild, splenomegaly and enteropathy in patients with ctla- haploinsufficiency. he is improving on this regimen. he has met with the stem cell transplant team, but at this point of time, due to his abnormal lung function, his liver damage and his significant splenomegaly, he is not a good candidate. defects in the nf-b signaling pathway are implicated in the pathogenesis of several primary immune deficiencies in humans. the clinical features of these conditions vary significantly, reflecting the complexity of the pathway, and its broad role in innate and adaptive immune responses, and the development and differentiation of lymphoid organs. here we report the first case of a human pid caused by a homozygous mutation in nfkbid in a year-old male. he was the second child of consanguineous parents, and was diagnosed with possible cvid at the age of , after recurrent episodes of pneumococcal pneumonia. however the clinical features have evolved over time; he developed severe ebv infection at age , causing hepatitis and pancreatitis. at the age of , he presented with an anca-negative systemic vasculitis, manifesting as pulmonary haemorrhage, and acute necrotizing pauci-immune glomerulonephritis. pulsed methylprednisolone and cyclophosphamide induced an initial remission, however, relapse a year later led to end-stage renal failure. he is now dialysis-dependent, and due to the underlying pid, and chronic cmv viraemia, is not a candidate for renal transplantation. genomic dna was subjected to whole-exome sequencing. variants were filtered using a model of autosomal-recessive inheritance and functional analysis of primary cells was performed. we identified a novel, homozygous, single-base deletion resulting in a frame-shift, and premature stop in nfkbid. nfkbid encodes ibns, a non-classical inhibitor of nf-b signaling. at diagnosis the patient had reduced levels of igg , iga and igm, elevated ige, with absent humoral immune responses to pneumococcal polysaccharide vaccine, and an intact response to tetanus. lymphocyte numbers were initially within normal reference ranges, albeit with an increased proportion of cd +:cd + t cells. however, over time there has been a significant reduction in b cells and cd + t cells. cd + t cells demonstrated a skewing towards a central memory phenotype (cd ro+/ccr +), and cd t cell proliferative responses to pha were comparable to a healthy control. functional analysis of primary cells from the proband revealed a complete absence of bns protein expression, dysregulated nf-b signaling, and elevated pro-inflammatory cytokine production. the patient is currently receiving a trial of targeted therapy to modulate the aberrant immune responses. this novel pid highlights the importance of regulation of nf-b signalling, in orchestrating an appropriate immune response, maintenance of self-tolerance, and protection against viral pathogens. primary immunodeficiency diseases (pid) are a heterogeneous group of conditions with variable clinical features that are frequently associated with significant diagnostic delay. accurate diagnosis has significant therapeutic benefit and may lead to personalized therapies. we established the immunology flagship of melbourne genomics health alliance in australia to determine the clinical utility of genomic sequencing for diagnosis and management of individuals with suspected and confirmed cases of pid. adults and children with suspected or confirmed pid (n= ), autoinflammatory disease (n= ) and hereditary angioedema (hae, n= ) were recruited to the melbourne genomics immunology flagship. whole-exome sequencing (wes) was performed, with targeted gene analysis. variant curation and reporting was performed according to the american council of medical genetics guidelines. overall, wes was diagnostic in % ( / ), confirming a preexisting diagnosis in % ( / ), and offering a new or more specific diagnosis in % ( / ). variants of uncertain significance were identified in a further patients ( %) in genes known to be associated with their clinical diagnosis, that warrant further functional validation. in the hae group, diagnosis was confirmed in only patients ( %), suggesting that wes may not be the appropriate technique for genetic diagnosis in this condition. a higher diagnostic rate was observed for autoinflammatory disorders ( %; / ) compared to pid ( %; / ). of those who received a diagnosis, immediate changes to patient management and treatment occurred for / patients ( %), including hsct for and specific targeted therapy for ( %) individuals. we have demonstrated the utility of wes for accurate diagnosis of complex immune diseases, with the potential to change diagnoses, guide therapeutic intervention and provide opportunities for genetic counseling. further longitudinal analysis will determine clinical outcomes and health economic implications of genomic sequencing for diagnosis and management of immunological conditions in australia. at birth he had neonatal asphyxia and cerebral palsy. at years old he had presented involuntary movements, left paresis, bilateral horizontal nystagmus. at years of age, he had a right nasal obstruction. it was resected by otorhinolist and informed by biopsy: inflammatory polyp and chronic sinusitis. he has had pneumonias, sinusitis and diarrhea. at the age of years, the ataxia telangiectasia was confirmed by sequencing with pcr ( exons, bp) of the atm gene: transition g> a, nucleotide position , codon , affecting splicing. alpha fetoprotein - . u/ml. brain mri, say cerebellar atrophy. he had igg mg / dl - mg / dl, iga . mg / dl, < mg / dl, igm mg / dl - mg / dl, ige . -< iu / ml. subclasses of igg: igg : . g / dl, igg : . gr/dl, low. igg anti hepatitis b , . no seroconversion. hiv negative tcd + lymphocytes: , %, = cells / mm , ltcd +: , % = , cel / mm , ltcd +: , % = , cells / mm , cd / cd : . . for all of the above, common variable immunodeficiency was diagnosed. he receives human immunoglobulin. at , i arrived at this hospital due to fever, respiratory distress and lymphadenopathy in the neck. ct showed ganglionic conglomerate on right side neck. lymph node biopsy: strong tumors with cd and bcl , weak and moderate diffuse pax- ; negativity with cd , cd and cd , and a cell proliferation index with ki of %, diagnosis: diffuse large b cell lymphoma. treated with rituximab and chemotherapy. lymphoma completely remitted. conclusion: the association ataxia telangiectasia and lymphoma is frequent. by contrast, cvid and ataxia telangiectasia are extraordinarily rare. introduction: chronic granulomatous disease (cgd) is a primary immunodeficiency wherein affected patients are susceptible recurrent infections caused by specific bacteria and fungi as a result of defective nadph activity. additionally, inflammatory complications involving the bowel and lungs can cause significant morbidity. currently the only proven permanent cure to cgd remains hematopoietic stem cell transplant. case: a -year-old patient was diagnosed in infancy with x-linked cgd. at age yrs he received a nonmyeloablative peripheral blood stem cell transplant from his / non-carrier sister as previously reported (nejm : , ) . conditioning was cyclophosphamide ( mg/kg) on d- and d- ; daily fludarabine ( mg/m ) on d- through d- ; antithymocyte globulin at mg/kg on d- through d- . posttransplant immunosuppression consisted of cyclosporine on d- through d+ . he received . x cd + peripheral blood stem cells which were t-cell depleted with x add back of cd + cells on day . after days of neutropenia (anc < ) there were signs of engraftment. per protocol, he received donor peripheral-blood lymphocytes containing . x cd + cells/kg on d+ after transplantation. since donor t cells constituted less than percent of his circulating cd + t cells and he had no graft versus-host disease, he received . ¬ cd + cells/kg on d+ . after the discontinuation of cyclosporine, he received a total of three donor-lymphocyte infusions ( . ¬ cd + cells/kg) at -day intervals achieving % t cell and myeloid engraftment at months post-transplant with no acute nor chronic gvhd. at last follow-up years post-transplant ( ) he had % and % lymphoid and myeloid peripheral chimerisms, respectively. the patient and family declined further periodic followup. then, in october he presented with malaise, cough and fevers. he eventually was found to have a large consolidation and a bal grew burkholderia cepacia. his dhr showed % activity and peripheral blood myeloid and lymphoid chimerisms were % and %, respectively. discussion: this late graft failure following peripheral blood transplant occurred following a conditioning regimen which is not the current standard for transplant in cgd. in the case series in which this patients transplant is reported (nejm ), another patients myeloid chimerism fell to % by years post-transplant, remaining stable at that level of chimerism without any serious infections over regular periodic follow up to the present time. current regimens typically include busulfan to enhance engraftment and prevent graft failure. this case reinforces the need for prolonged monitoring of primary immune deficiency patients after transplantation. introduction: with the introduction of severe combined immunodeficiency (scid) newborn screen (nbs) in the state of kansas in , a case of complete digeorge syndrome (dgs) was discovered in an infant born to a diabetic mother with atypical features. this is the first dgs case diagnosed after adding the scid nbs, which emphasizes the need to establish scid nbs in all states. case presentation: the female infant was born via spontaneous vaginal delivery at / weeks to a year old g now p mother. maternal history was significant for chronic hypertension, obesity, insulin dependent type diabetes, anxiety, depression, and scoliosis. the infant was noted to have a left sided abdominal wall defect and hernia, imaging identifying left renal agenesis, and was initially suspicious for vater syndrome. fortunately, the infant's scid nbs revealed low t cell receptor excision circles (trecs). her initial white blood cell count was . with an absolute lymphocyte count of . k/ul. ebv pcr, cmv pcr, and hiv studies were negative. chest imaging discovered absent thymus, abnormal vertebrae with only ribs on the right and ribs on the left, and abnormally formed thoracic vertebrae (t ). echocardiogram detected an atrial septal defect measuring . cm, possible pfo versus secundum asd. endocrinology was consulted for management of labile calcium and phosphorus levels. fish was negative for q . deletion. microarray r evealed a variant of unknown signif icance arr[grch ] p . ( _ )x . sequence analysis of combined and severe immune deficiency genes showed a variant of uncertain significance c. c>a (p.leu met). management and outcome: additional evaluation included: cd ul ( - ul), cd ul ( - ul), cd ul ( - ul), cd ra cells/ul ( - cells/ul), normal cd , and cd / , normal immunoglobulin g level, and normal dihydrorhodamine assay. skeletal survey, ct abdomen and chest, and hla typing were performed in preparation for thymic transplant. discussion: patients with complete dgs, a form of scid found in less than percent of patients with qds, have absent thymus and a t cell count < standard deviations below normal for age (typically < naïve cd + t cells/mm ). in a large series of patients with complete dgs, only percent had an identifiable q . deletion [ ] . infants of a diabetic mother have various genetic and syndromic associations including diabetic embryopathy. [ ] despite the importance of immunological aspects in pregnancy, few studies have reported on the cellular immune modifications of diabetic embryopathy. diabetes during pregnancy may affect the development of the thymus and thus maturation of the immune system in the offspring. [ ] the recent addition of a trec assay to newborn screening can identify such a subset of infants with atypical presentations. scid nbs uses an assay for trecs, a biomarker of t cell development. [ ] [ ] [ ] this initial presentation now places the immunologist in the role of "first responder" with regard to diagnosis and management of these patients, who may present with atypical features. newer genetic and molecular techniques now allow for earlier identification of immune defects in such disorders with life-long clinical concerns. [ ] references: introduction/background: goods syndrome is a rare cause of combined b-and t-cell immunodeficiency occurring in association with a thymoma. affected patents are susceptible to bacterial, fungal, viral, and opportunistic infections. an association with autoimmunity has also been reported. current knowledge of goods syndrome is primarily limited to case reports and small series. objectives: to examine the spectrum of clinical and laboratory features of a major cohort of goods syndrome patients in the us. methods: we conducted a retrospective analysis of patients with goods syndrome in the usidnet registry and the mount sinai hospital (msh) cohort. r e s u l t s : we i d e n t i f i e d p a t i e n t s w i t h t h y m o m a a n d hypogammaglobulinemia (usidnet, n= ; msh, n= ; median age: years; female: %), representing data from patient years. the median age at diagnosis of thymoma and hypogammaglobulinemia were years (range - ), and . years (range - ), respectively. two patients were deceased (at age and years, cause unspecified). all patients had low igg (median mg/dl, range - ). iga and igm were reduced in % and % of patients, respectively. low cd + b cells (median . /mm^ , range - ) were reported in all available records. the absence of cd + b cells was observed up to years postthymectomy. a wide range of additional laboratory abnormalities were identified: low cd + t cells (n= ), low cd + t cells (n= ), low cd / cd ratio (n= ), low nk cells (n= ), and absent peripheral eosinophils (n= ). the most common sites of infections were lower respiratory ( %), upper respiratory ( %), and gastrointestinal ( %). in addition, sepsis ( %), meningoencephalitis ( %), osteomyelitis ( %), and urinary tract infection ( %) were also observed. identifiable infectious agents included: bacteria ( %), virus ( %), fungus ( %), parasites ( %), and protozoa ( %), with opportunistic infections recorded in % of patients. opportunistic infections were significantly associated with absolute cd lymphopenia (p= . , fishers exact test). enterovirus was identified as a previously unreported cause of meningoencephalitis in this population. autoimmune manifestations were reported in % of patients, with a higher prevalence of inflammatory colitis ( %) than previously reported. hashimoto thyroiditis, fibromyositis, and bronchiolitis obliterans organizing pneumonia (n= each) were identified as previously unreported autoimmune/inflammatory conditions in this population. a case of alopecia areata was also observed. additionally, bronchiectasis was recorded in % of patients. all patients were initiated on immunoglobulin replacement, with antibiotics prophylaxis in %, and immunosuppressive medications employed in % of patients post diagnosis of immunodeficiency. conclusion: goods syndrome is a combined immunodeficiency, with a wide range of autoimmunity in a subset of patients. we expanded upon the spectrum of associated infectious and inflammatory complications through a major us cohort. persistent immune dysregulation was observed up to decades post-thymectomy. introduction: primary immunodeficiencies (pids) constitute a large group of rare disorders that affect the immune systems function. some pid patients develop autoimmunity in addition to having increased susceptibility to infections due to their impaired immunity [ ] . ( ) case presentation/ management: a year old caucasian female with history of bipolar disorder, factor v leiden deficiency, anti thrombin deficiency, pulmonary embolism, endometriosis, and seasonal allergies was evaluated for chronic granulomatous disease (cgd) in . the main symptoms were inflammatory breast lesions necessitating surgeries on the right breast, and back, facial, genital, ocular, mouth, and scalp sores. biopsy with cultures of the wounds was positive for corynebacterium, coagulase-negative staphylococcus, enterococcus, bacteroides species, and provatella. neutrophil oxidative burst was ordered by the infectious disease specialist and showed normal and abnormal neutrophil populations, a finding consistent with cgd carrier. patient was started on interferon gamma- b after failing multiple courses of antibiotics. her symptoms were well controlled on interferon gamma- b mcg/ . ml sq every other day, trimethoprim mg tab ( tabs in am and tab in pm), cefixime mg once daily, and topical mupirocin as needed except for her recurrent genital ulcers. cgd can be rarely associated with oral ulcers however there is a limited literature describing associated genital ulcers. according to the international study group diagnostic criteria published in ( ), the patient was diagnosed by a rheumatologist as having behcets disease (bd). there are no pathognomonic laboratory tests in bd; as a result, the diagnosis is made clinically. patient failed a trial of colchicine and was later started on cyclosporine, which resulted in decrease of her mouth and genital ulcers. discussion: bd is a rare disease mostly seen along the silk road. the prevalence has been reported as . (usa) to (in a single village, northern turkey) for inhabitants. ( ) cgd is a primary immunodeficiency caused by defects in any of the five subunits of the nadph oxidase complex responsible for the respiratory burst in phagocytic leukocytes. patients with cgd are at increased risk of life-threatening infections with catalase-positive bacteria and fungi, and inflammatory complications such as cgd colitis. ( ) reports of cgd female carriers with discoid lupus erythematosus, photosensitivity rashes, and other autoimmune phenomena have been published [ , ] ( ) . to the best of our knowledge, this is the first case to report bd in an affected cgd carrier. the treatment of inflammatory disease in patients with cgd poses a difficult balance between therapeutic immunosuppression and the increased risk of severe infection. ( ) . high dose intravenous immunoglobulin, and targeted therapies such as ctla -ig for t cell mediated pathologies, rituximab for b-cell mediated pathologies, and anti-tnf for ibd, may be preferable over the broad immunosuppressive activity of glucocorticoids. in addition, emerging evidence suggests that hematopoietic stem cell transplantation has indication for cases that have been difficult to control using immunosuppression. ( ) given all that, our case emphasizes the need to maintain suspicion for autoimmune disorders / immune dysregulation in patients with pid. introduction: cd -ligand deficiency is an x-linked combined immunodeficiency, characterized by susceptibility to infection, often with associated neutropenia, malignancy, and autoimmunity. central nervous system (cns) manifestations are less commonly reported than respiratory or gastrointestinal complications, but are most often attributed to infection. herein we describe a challenging case of gradual onset episodic memory loss, confusion, and unilateral hemiplegia in a young male with cd ligand deficiency. case presentation: the patient is a -year-old male with cd -ligand deficiency on immunoglobulin replacement therapy presenting with recurrent, episodic altered mental status (ams) and gradual neurocognitive decline. initial neurologic symptoms began at age years, and included fever, nausea, and eyelid fluttering. initial comprehensive infectious workup at this time, including blood and urine cultures, lyme antibody, serum pcr for hsv, cmv, ebv, respiratory viral pcr including atypical viruses, csf studies including culture, lyme eia, pcrs for enterov i r u s , v z v, e b v, c m v, h s v / w e r e u n r e v e a l i n g . electroencephalogram (eeg) and mri displayed generalized slowing and global atrophy, respectively. definitive diagnosis was not made. the patient continued to decline with worsening developmental delay and memory loss. one year later, at age years, he had a recurrent episode of ams with repeat negative infectious workup including blood and urine cultures, respiratory virus pcr including atypical viruses, csf culture including acid fast bacillus and fungi, cryptococcal antigen, viral encephalitis panel by pcr, and serum pcr for ebv and hhv- . eeg at this time showed left hemispheric epileptogenic potential, consistent with seizure activity. his presentation, at age years, was notable for right-sided hemiplegia with facial numbness, dysarthria, nausea, and fever. he was found to have anello virus on pcr of csf, abnormal left temporal region on eeg, and global atrophy with stable, diffuse generalized volume loss on mri. he was diagnosed with occult anello virus-induced encephalitis with hemiplegic migraine and discharged on valproate. discussion: here we present the first reported case of anello virus detected by pcr in a cd -ligand deficient male with neurocognitive manifestations, attributed primarily to hemiplegic migraine. given the anello virus prevalence and relatively avirulent character, it is presumed to be unlikely culprit for encephalitis; however, the significance of this finding is as yet unknown. this case highlights diagnostic challenges in immunodeficiency: infection may go undetected by standard diagnostic techniques; however, the significance of infections identified with advanced techniques may not yet be understood. background: henoch-shönlein purpura (hsp) is an iga-mediated small vessel vasculitis that presents with a tetrad of abdominal pain, arthritis, glomerulonephritis, and purpura. hsp is typically a selflimiting disease of childhood following a viral illness. there is no universal treatment for patients with chronic or recurrent hsp. we report a chronic refractory case of hsp that was successfully treated with a tumor necrosis factor inhibitor (tnfi), etanercept. etanercept functions as recombinant protein that consists of a tnf-alpha receptor ligand-binding region that links to the fc portion of human igg. it is currently approved for use in diseases: juvenile rheumatoid arthritis, rheumatoid arthritis, ankylosing spondylitis, plaque psoriasis, psoriatic arthritis. tnfi are categorized into two broad categories, recombinant receptors (etanercept) and neutralizing antibodies (ex. infliximab and adalimumab). there have been prior case reports of hsp associated with tnfi agents during the treatment of other autoimmune conditions in the adult population. to our knowledge, there have been prior etanercept related hsp reports, one report associated with adalimumab, and one with infliximab. however, there has been no prior report of etanercept use successfully treating chronic refractory hsp. case presentation: a -year-old native american male with year history of chronic hsp, hla-b positive, and enthesitis related arthritis who was initially treated with steroids, sulfasalazine and methotrexate for symptoms of joint pain and purpura. his iga level was mg/dl prior to therapy. despite treatment for one month of steroids, eight months of sulfasalazine exclusively and eight months of methotrexate and sulfasalazine, he continued to have persistent purpura on bilateral extremities without improvement. he was subsequently initiated on etanercept mg weekly and methotrexate was discontinued. approximately one month later, his rash significantly improved. his rash and joint pain recurs when he misses a dose of etanercept. punch biopsies were taken months after initiation of etanercept. the biopsies of a lesion from his left arm showed early leukocytoclastic vasculitis and from his left leg showed weak granular deposition of iga, igm and c within vessel walls. there is controversy whether this is a true iga vasculitis. however, we believe that his clinical presentation and the deposition of iga and c within blood vessel walls seen on biopsy correlates with chronic henoch-shönlein purpura. conclusion: there is no standard treatment of chronic hsp, but there are reports of benefit with nsaid and corticosteroids. per our literature review, there are no prior reports of etanercept use in the treatment of chronic hsp. tnf inhibitor, etanercept should be considered as a treatment for chronic refractory hsp in the pediatric population as it has showed rapid resolution of purpura in this case report. further studies of etanercept in the treatment of chronic hsp should be conducted given the controversial literature of anti-tnf ab induced hsp during the treatment of other autoimmune diseases. although clinical manifestations of iron overload appear to be quite uncommon in patients who are heterozygous carriers of hfa mutation, we present cases that appear to suggest an increased risk non allergic rhino-sinusitis. case report: we present a year old gentleman with perennial colored rhinorrhea, with facial pressure and tenderness, constant post nasal drip, dry cough and bilateral congestion that had been going on for the past several years. he also had a frequent urge to clear his throat and had frequent episodes of sore throat despite having no history of gerd or lpr. he reported to have multiple sinus infections every year that would progress to pneumonia and eventually require long courses of oral antibiotics. all started in his s intensified in the recent past. he had other siblings; one died in his s due to liver complications of hh and had a carrier sister and brother with a hx of sino nasal problems exactly similar to the patients. his exam was remarkable for bilateral narrowed nasal passages and moderate edema of the mucosa. his rhinolaryngoscopy showed significant edema and purulent drainage, most notably from bilateral middle meati. his skin test was negative. his cbc showed a wbc count of . /ml with % eosinophils and his immunoglobulin panel showed an iga of mg/dl, igg of mg/dl and ige of mg/dl. patient was placed on alkalol sinus rinses and azelastine nasal spray, which he reported to work pretty well. he left for costa rica and is expected to return back with his siblings to a&i clinic in the coming months. discussion: hh is one of the most common inherited disorders in people of northern european descent with an incidence of : and carrier rate of : .. most affected hh patients are homozygous for the mutation designated c y at the hfe gene located at the th chromosome. unlike hereditary hemochromatosis, clinical manifestations of iron overload appear to be quite uncommon in patients who are heterozygous carriers. hh patients are at risk for a number of infections with bacteria whose virulence is increased in the presence of excess tissue iron. hh is also a risk factor for acute fulminant frs . here the mechanism is postulated to be due to quantitative or qualitative neutrophil defects as this condition is mostly seen in patients with dm, aplastic anemia, and can happen in patients undergoing antineoplastic chemotherapy. no known increased susceptibility for infections through either mechanism is postulated for patients with the heterozygous carrier state. here we present hh carrier patients who present with recurrent rhinosinusitis with no allergen sensitizations and normal ige levels. since most fungal immunity is at the tissue level and is cytokine driven, it can be speculated that increased tissue levels of iron might interfere with mechanisms of innate immunity. chief, human immunological diseases section, laboratory of clinical immunology and microbiology, niaid, nih, bethesda, md background: dedicator of cytokinesis (dock ) mutations are associated with a combined immunodeficiency disorder marked by atopic features, infectious susceptibility with a striking preponderance of cutaneous viral disease, and a risk for the development of malignancy including lymphoma. almost all cases can be diagnosed by documentation of the loss of dock protein expression. methods: we describe a -year-old male with a diagnosis of pre-b cell acute lymphoblastic leukemia (all) followed by epstein-barr virus (ebv) associated diffuse large b cell lymphoma (dlbcl). compound heterozygous mutations in dock were documented following the completion of whole exome sequencing (wes). the pathogenicity of the variants was assessed. flow cytometric quantification of intracellular dock protein was completed. dock protein function was assessed by evaluating the morphology of patient lymphocytes when migrating in a d collagen matrix. results: a concern for a primary immunodeficiency was raised due to a history of recurrent otitis media which began at months of age. by years of age, numerous warts were noted on his fingers; however, they were transient for a duration of only years. no atopic features were appreciated. at years of age, a diagnosis of pre-b cell all was made. during all therapy, infectious complications were severe including an intestinal perforation, osteomyelitis, and sepsis. at years of age, still in an ongoing remission from his all, an incidental finding of a lung nodule led to a diagnosis of ebv-associated dlbcl. during therapy, however, infectious complications were again severe including a soft tissue infection and sepsis. wes was performed and compound heterozygous mutations in dock (c. _ del and c. - g>c) were documented. flow cytometric quantification of intracellular dock protein was normal when compared to a normal control. nevertheless, additional functional assessment of dock protein was completed. when migrating through a d collagen matrix, % of the patient lymphocytes studied demonstrated abnormal elongation (stretch ratio > defined by length/width) compared with % of lymphocytes from a normal control. he is being evaluated for hematopoietic stem cell transplant. conclusion: autosomal recessive mutations in dock are a rare cause of a combined immunodeficiency marked by atopic features, infectious susceptibility with a striking preponderance of cutaneous viral disease, and a risk for the development of malignancy including lymphoma. here, pre-b cell all followed by the development of a subsequent malignant neoplasm (ebv-associated dlbcl) led to the discovery of dock deficiency. hence, as our case underscores, for rare instances of high clinical suspicion despite normal dock protein expression, additional functional testing is crucial to make a definitive diagnosis and plan treatment. understanding the spectrum of dock mutants and their phenotypes will improve our understanding of dock deficiency. background: autosomal dominant hyperimmunoglobulin e syndrome (ad-hies) is a rare primary immunodeficiency caused by heterozygous loss-of-function mutations in the signal transducer and activator of transcription (stat ) gene. ad-hies classically characterized by recurrent cold staphylococcal abscesses, pneumonia, eczema, and an elevation of ige level. other additional clinical manifestations of hies have been recognized including skeletal dysplasia (scoliosis, pathologic fractures, delayed dental deciduation), pneumatoceles, coronary-artery aneurysms, brain lesions, and chiari malformations. objective: to describe a unique case of abdominal abscesses in a patient with ad-hies. method: a -year-old female with known ad-hies (c. c>t (p.arg trp)) and a complicated history of early pneumococcal pneumonia and meningococcemia resulting in bilateral amputation below the knees along with loss of several digits, presented for evaluation of skin infection. she had a history of recurrent staphylococcal skin abscesses and presented with inability to use her prostheses due to pain from inflammation around her amputation sites. she underwent imaging and was found to have bilateral extremity abscesses with an associated osteomyelitis of her l tibia (which was found to be mrsa after incision and drainage). while receiving intravenous antibiotics for her osteomyelitis, she developed intractable abdominal pain. imaging showed a thick-walled, multi-septated, paranephric abscess as well as several smaller abscesses scattered throughout her abdomen. she underwent multiple drain placements and drainage of retroperitoneal fluid collections via interventional radiology (ir). purulent fluid from the abdominal abscess drainage grew mrsa. the patient continued to have re-accumulation of abscesses despite multiple drainages. repeat imaging noted increased paranephric abscesses which were not communicating with drains. given lack of response to several ir-placed abdominal drains and to weeks of intravenous antibiotics, she had an open surgical washout with minimal improvement. hospital course was further complicated by development of a left lower lung lobe consolidation and sub-segmental pulmonary embolism necessitating treatment with heparin. finally, after several weeks of escalating antimicrobial therapy and with additional drain placements, the retroperitoneal abscesses started to recede. repeat abdominal imaging several months later while asymptomatic revealed slow but continuing resolution of the abscesses. conclusion: the present case raises awareness of an unusual location for infection in a patient with ad-hies. although the majority of complications of ad-hies are sinopulmonary and skin infections, recalcitrant intra-abdominal abscesses should be considered in the differential of infections in hies. introduction/background: the recent epidemiologic studies have revealed that primary immunodeficiencies (pids) are more common than previously thought. however, there are very few data on epidemiology of pids in korea. objectives: we attempted to estimate the pid epidemiology and disease burden in korea and provide the background information for pid registry for future. methods: to review the previously reported scientific studies, pubmed, koreanmed, google scholar were searched. any studies on pids reported in scientific journal (korean or international) from january to november were searched. both korean and english reports were searched. diagnosis for pid was categorized from group i to group xi according to iuis phenotypic classification. study period was divided into two periods: period from to and period from to , because there was a multicenter study to estimate pid epidemiology from to . in addition, the number of pid patients and the cost for care were estimated among patients who requested reimbursement to health insurance review and assessment service (hira) korea for one year in . results: a total of pid patients were identified in reports. one hundred and ninety-nine patients ( reports) and patients ( reports) were found in period and period , respectively. the pids were reported in patients for immunodeficiencies affecting cellular and humoral immunity, patients for combined immunodeficiency with associated or syndromic features, patients for predominantly antibody deficiencies, patients for diseases of immune dysregulation, patients for congenital defects of phagocyte, patient for defects in intrinsic and innate immunity, patients for auto-inflammatory disorders, patients for complement deficiencies, and none for phenocopies of pid. from hira reimbursement data, the number of pid patients were for combined immunodeficiency, for predominantly antibody deficiency, for common variable immunodeficiency, for functional defect of neutrophils, for immunodeficiency associated with other major defects, for other immunodeficiencies. a total of , pid patients were treated for , days and $ , , was reimbursed in . conclusions: we performed a systematic review on published studies for pid in medical journals and national open data system of hira to estimate the pid disease burden for the first time in korea. to obtain more information on true pid epidemiology and disease burden in korea, a national multicenter study for pid registry is required in the future. micro-thrombocytopenia is one of the most serious challenges for wiskott-aldrich syndrome (was) and x-linked thrombocytopenia (xlt) patients. thrombocytopenia leads to severe, potentially life-threatening, bleeding episodes, which require frequent transfusions and account for % of deaths in patients experiencing was mutations. the gold standard treatment for was patients is hematopoietic stem cell transplantation (hsct) from an hla-identical donor but more recently a number of gene therapy (gt) trials in europe and usa showed promising results. in particular, it has been shown that was patients receiving lentiviral mediated gt, consisting of autologous cd + cells transduced with lentiviral vector encoding the human was gene under the control of the endogenous promoter, in combination with a reduced intensity conditioning regimen, have a significant increase in platelet (plt) counts. even though plt counts do not reach normal levels, treated patients decreased the severity and frequency of bleedings. here, in a cohort of xlt and was patients, fifteen treated with gt, the plt phenotype and function were analyzed by electron microscopy, flow cytometry and proteomic profile. the aim of the project is to assess the presence of plt defects in was untreated patients and the impact of gt treatment on the correction of plt behavior. we demonstrate that plts of untreated was patients have reduced size and abnormal ultrastructure along with hyperactivated phenotype at steady state, showing increased expression of cd p, activated iib integrin and cd l; conversely, activation response to agonist and aggregation capacity are both decreased. analyzing plt samples isolated from treated patients, we found that gt restores plt size and ultrastructure very early after treatment and reduces the hyperactivated phenotype proportionally to was protein (wasp) expression and follow-up length. plts isolated from gt treated patients showed a normal activation response to agonists and restored aggregation capacity in out of analysed patients. by proteomics, various protein pathways were found downregulated in untreated plt samples, mainly involving cytoskeletal-rearrangement proteins, integrins, signal transduction molecules, vesicles-transport proteins; additionally, decreased metabolic capacity were observed. these results are in line with the functional defects observed in plts in terms of activation and aggregation. conversely, the expression of protein-pathways found downregulated in untreated patients is comparable to healthy controls in gt-treated plt samples, reflecting the amelioration of plt phenotype and function. overall, our study highlights the coexistence of multiple defects in the activation and aggregation responses occurring in was patient plts in absence of wasp. gt was able to normalize the plt proteomic profile followed by consequent restoration of plt ultrastructure and phenotype, suggesting gt is responsible for the observed reduction of bleeding episodes in treated patients. introduction: pik cd is an autosomal dominant genetic disorder of the immune system that results in persistent activation of pi k. signaling through pi k is essential for immune cell regulation of metabolism, migration, proliferation and differentiation, leading patient to present with lymphadenopathy, immunodeficiency and senescent t cells. the mutated protein causes t cells to over activate and mature too quickly leading to their death, this over activation also blocks the maturation of b cells. case presentation: a -year-old female with a childhood history of failure to thrive, asthma, chronic rhinitis and common variable immunodeficiency on intravenous immunoglobulin replacement, was seen in immunology clinic to establish care. she reported frequent episodes of pneumonia and bronchitis in her childhood. her family history was significant for family members with leukopenia, but no diagnosed immunodeficiency. patient had son who did not report symptoms concerning for immunodeficiency. physical exam was within normal limits with no lymphadenopathy. laboratory examinations exhibited normal iga ( mg/dl), igg ( mg/dl), and igm ( mg/dl). while flow cytometry showed normal absolute cd ( - cells/ul), cd ( cells/ul), nk cells ( cells/ul), cd ( cells/ul), cd ra ( cells/ul), cd ro ( cells/ul), cd ( cells/ul), and hla-dr ( cells/ul), nonswitched memory cells ( cell/ul) and class-switched memory cells: ( cells/ul). ( - cells/ul). vaccine response was not pursued as patient had been on ivig. genetic testing was pursued, and revealed a mutation in pik cd gene, specifically a mutation in the c. g>a; p.val met variant (rs ). this mutation though seen in databases, is not currently reported in medical literature as associated with this condition. based on these, ct chest was ordered to screen for bronchiectasis, adenopathy and lymphoma. ct showed no cardiopulmonary disease or adenopathy, but did show an incidental adrenal mass which is now being worked up. while the pattern of inheritance of this mutation is autosomal dominant, her son is asymptomatic and testing of her son has not been pursued, though it was advised for her cousins given history of leukopenia. patient has continued on igg replacement therapy. conclusion: recent publication by the clinical immunology society suggests consideration for next generation sequencing when it can affect future family planning or it has treatment and prognostic implications. this case highlights all aspects of the importance of genetic testing as part of the diagnosis of cvid, since it can affect progeny, it offers the possibility of treatment with immune modulating agents and has implications on screening, since patients are at increased risk for malignancies. background: abnormal v(d) j recombination activity in patients with mutations in the recombination-activating genes and (rag / ) results in markedly reduced usage of distal vand j genes at the t cell receptor alpha (tra) locus. mucosa-associated invariant t (mait) cells express a semi-invariant t cell receptor containing the distal trav - gene. mait cells can be identified by flow cytometry using a mab directed against valpha . , which recognizes the product of the trav - gene. by performing high throughput sequencing (hts) of tra rearrangements and flow cytometry, we have confirmed lack of t cells using distal valpha genes in patients with known rag mutations. we now report that flow cytometry with mab against valpha . successfully identified rag deficiency in two patients with an atypical presentation. methods: tra rearrangements were analyzed by hts using gdna from sorted t cell subsets from rag-mutated patients and healthy donors. distal valpha usage was measured in whole blood by flow cytometric analysis with an anti-valpha . antibody. rag mutations were detected by sanger sequencing. patients were enrolled in niaid protocol -i- . results: hts of tra rearrangements revealed lack of distal trav and traj gene usage in patients with rag / mutations. the presence of circulating mait cells in controls and patients with known rag / mutations and various clinical phenotypes was analyzed by flow cytometry using mab against valpha . . we found a virtual lack of valpha . expression in rag mutated patients (< . %) compared to controls ( - %) . we used the valpha . assay to test two patients with unknown immunodeficiency manifesting as skin granulomas and autoimmune cytopenia, and found nearly absent expression ( . % and . %). targeted sequencing of rag / revealed that both patients were compound heterozygous for rag mutations: p.r h/p.c y and p.r w/p.r q, respectively. conclusions: patients with mutations in rag / demonstrate a skewing of their tcralpha repertoire. the reduction in recombinase activity in these patients does not allow for rearrangements of the most distal valpha segments. rapid identification of patients lacking valpha . + t cells by flow cytometry may prompt sanger sequencing and identification of rag / mutations in a matter of days. this assay represents a simple but powerful tool to reduce the cost and time associated with other analysis methods. acknowledgements: supported by dir/niaid/nih. director, centro de inmunología clínica dra.bezrodnik y equipo introduction: the fate of effector t cells is strongly dependent on the expression of bcl- or blimp- , which are inhibited reciprocally through a complex signaling pathway. several studies have shown that bcl- is a key transcription factor for differentiation towards the follicular helper t cells (tfh) lineage able to collaborate with b lymphocytes (bl). on the contrary, the transcription factor blimp- is highly expressed in t lymphocytes th , th and treg, thus regulating the differentiation towards tfh. materials and methods: whole fresh blood and peripheral mononuclear cells from a patient with homozygous mutation in stat b were analysed by flow cytometry. analysis of ctfh (cd +cd ra-cxcr +), ctfh (cxcr +), ctfh (ccr +), ctfh (cxcr -ccr -), naïve bl (lb igm+igd+cd -), memory (mbl) (lb igm+ igd-cd +), switched (mbl-sw) (igd-igm-) and plasmablast (pbc) (cd +cd ++) cells was performed. immunoglobulins were measured in serum. results: the patient with stat b deficiency showed increased values of ctfh ( %) (healthy donors p -p : , - , %) that presented an activated phenotype (icos+ and pd- +) with a skewed to a th profile (ccr +), consistent with her hipergammaglobulinemia and the marked and sustained increase in the switched mbl and pbc subpopulations in peripheral blood over the years. discusion: this immunological phenotype described in the patient with stat b deficiency could explain in part the pathophysiology of the autoimmune disorders. this patient (as well as the other two patients with mutations in stat b previously described by our group), have had chronic hypergammaglobulinemia, autoantibodies and consequently autoimmune processes (psoriasis, hypothyroidism, eczema, alopecia and celiac disease, among others). we believe that the link between this clinical symptomatology and the molecular defect relies in the fact that the absence of stat b promotes a greater expression of bcl- , which generates a bias towards the production of ctfh cells, that give rise to a greater activation of lb, generation of lbm and plasma cells (dysregulation in the cg), events that manifest as hypergammaglobulinemia and autoimmunity. in summary, we provide promising evidence of the mechanisms that lead to autoimmunity in this type of patients that could also be a consequence of the defect in the regulation of gc, highlighting the crucial role of stat b in the humoral immune response and maintenance of the tolerance of the immune system. background/introduction: the term primary immunodeficiencies (pid) encompasses a phenotypically and genetically diverse group of conditions. genetic testing for these conditions can guide treatment, reduce morbidity and mortality, allow for genetic counseling, and identification of additional at-risk family members. however, this testing can be complicated by a number of factors, including pseudogenes, high homology, methodology limitations, and the heterogeneous nature of pids. methods: mayo clinic laboratories launched their first set of nine pid next generation sequencing (ngs) tests approximately one year ago. these tests include one single gene assay for gata deficiency and eight targeted next generation sequencing panels for: atypical hemolytic uremic syndrome (ahus), autoinflammatory disorders, b-cell disorders, monogenic irritable bowel disease (ibd), phagocytic defects, severe combined immunodeficiencies (scid), and severe or cyclic neutropenia. herein we summarize our first year of experience with these ngs tests, with a focus on the eight targeted panel tests. results: from march through november we performed testing for cases. our highest volume of tests was for the ahus panel ( / cases, %). a variant was reported in / cases ( . %). these variants included variants of uncertain significance, likely pathogenic variants and pathogenic variants. the indication with the highest percentage of cases where a variant was reported was scid ( / cases, . %). the number of cases that were considered solved, where the genotype likely explains the patients phenotype, varied widely by indication. twenty cases were found to have a pathogenic or likely pathogenic variant or variants; however / cases were heterozygotes for an autosomal recessive condition and were not considered solved cases. the panel with the highest percentage of solved cases is our scid panel ( / cases, . %). conversely, we have yet to solve an autoinflammatory, irritable bowel disease, or telomere defects case; however % of cases in each of those three panels have had a variant of uncertain significance reported. we hypothesize that one of the reasons for the low detection rate for these three panels is inappropriate test orders. we are also actively looking for ways to update all panels to increase detection rates and clinical utility, for example expanding the gene list of our ibd panel, including large deletion/duplication detection, and including ncf , a difficult gene to capture by ngs, on the phagocytic panel. finally, we present the molecular findings from a number of interesting cases that were solved using our targeted ngs panels. conclusions: the launch of our pid ngs tests in march of has allowed us to aid patients by confirming diagnoses and providing molecular diagnoses that will enable more accurate genetic counseling and risk assessment. we have also uncovered areas for improvement, both on the clinical side: provider education is important to enable better identification of patients who can benefit from molecular genetic testing for pids, and on the laboratory side: introduction of more expanded panels and additional methodologies. the progressive decrease of red blood cells, platelets or neutrophils via a self-directed immune process is jointly termed as autoimmune cytopenias. while autoimmune cytopenias, including autoimmune hemolytic anemia (aiha), immune thrombocytopenic purpura (itp), and autoimmune neutropenia (an), are a common presentation of autoimmunity in the general population, they are particularly frequent and can appear as the first sign in patients with primary immunodeficiencies (pids). possible causes of cytopenia in pids comprise mainly immune dysregulation, bone marrow failure (bmf) and myelodysplasia. our goal is to investigate possible immune mediated mechanisms underlying chronic cytopenia in children in order to achieve an early diagnosis and consequently offer timely and appropriate therapy. we selected patients affected by chronic cytopenia, evaluated with immunophenotyping by flow-cytometry; data were subjected to multivariate analysis by principal component analysis (pca). next generation sequencing (ngs) analysis of genes frequently implicated in pids was performed. among the patients, were affected by bone marrow failure, of which were diagnosed with fanconi anemia and severe congenital neutropenia; were affected by immune-mediated cytopenia and by idiopathic cytopenia. the immunephenotyping showed a typical pattern of cd t cell subpopulations expression in patients compared with healthy donors with an increase of naïve t cells and a reduction of central memory (cm) and effector memory (em) t cells levels. we observed a decrease in total b cells, b switched and b memory cells and an increase in cd low cells. pca showed an overlap between groups, however it revealed a peculiar trend of some single patient, suggesting the pathway involved in immune defect. preliminary results from ngs studies revealed genetic variations in genes previously associated with pids in out of patients investigated. in particular we identify one patient with a mutation in fas, one with a mutation in aire and one with a mutation in ikaros. concerning the remaining patients further studies are ongoing to validate the pathogenicity of the genetic variations. pca is a very effective tool to analyze several parameters at the same time, highlighting patients whose phenotype shows the main peculiarities. the presence of specific lymphocyte subpopulation patterns can be important indicators of immune-mediated cytopenias and helpful signs of specific pids that should promptly be investigated with genetic analysis. the rapid of discovery of novel, monogenic primary immunodeficiencies has been made possible by the broad availability of clinical whole exome sequencing (wes). however, clinical wes has major shortcomings that should be understood by practicing immunologists. focusing on the iuis list of~ monogenic primary immunodeficiency genes, we show here limitations in coverage that could significantly impact clinical interpretation. on the agilent whole exome capture kit, the most common wes platform, there are a number of genes with exons that are poorly covered. specifically, there are at least genes with less than % exonic coverage, with less than % coverage and with less than % coverage (e.g. ikbkb, ncf , taci, unc b and tbx ). beyond this challenging technical issue, there are more subtle issues as well. these include the presence of pseudogenes in at least of our genes (e.g. ak , c qbp, cd , cftr, cr , msn, ncf , ncstn, ikbkg, nhp , pms , pten, rnaseh c, rps, sbds and was), which can make accurate sequencing very challenging. finally, there are many known causative intronic (e.g. btk, ctla- , wasp) and copy number variant mutations (e.g. rag and xiap) as well as large deletions (e.g. dock ) that we cannot expect to be optimally covered using wes. this list of genes requires consideration even with a negative exome and may require additional approaches including whole genome sequencing, sanger sequencing, cnv arrays and/or long-read ngs sequencing. wes is a powerful genomic diagnostic tool, but to avoid missing key diagnostic insights using these alternative approaches may be critical when certain genes are in the differential diagnosis. going forward, as pid phenotypes continue to broaden, these issues remain fundamentally important even if these genes are not obviously implicated in a given clinical phenotype. more physicians are utilizing targeted genetic panels to reach a definitive diagnosis for their patients with immunodeficiency. however, this increase in testing also has led to the discovery of many more variants of uncertain significance (vus) in the genes tested. these findings can often leave the patient and the physician with more questions than answers. we present a patient with recurrent infections found to have multiple variants of uncertain significance in several genes associated with primary immunodeficiency. a -year-old female who was diagnosed with crohns disease at age after intestinal perforation and jejunal resection experienced two discrete episodes of epstein barr virus (ebv) meningoencephalitis and septic shock. the first episode was diagnosed when patient had fever and altered mental status and occurred prior to her crohns disease diagnosis and the second episode was complicated with altered mental status, disseminated intravascular coagulation (dic) and hypotension requiring picu admission. aside from these two major infections, the family denied any other infections requiring antibiotics in the last years and reported a remote history of repeated streptococcal pharyngitis that have not recurred. immunology was consulted at the time of the second episode of meningoencephalitis and work up was mainly unremarkable with normal immunoglobulins, adequate vaccine response to hib, tetanus, diphtheria, rubella, measles and pneumococcus ( out of protective titers). she had normal t cell numbers with slightly decreased natural killer numbers for age. neutrophil studies showed normal dihydrorhodamine (dhr) analysis, glucose- -phosphate dehydrogenase levels and myeloperoxidase (mpo) stain. commercial testing of her toll like receptors ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) showed normal function. invitae primary immunodeficiency panel demonstrated a heterozygous variant in nod (c . c>t; p.arg trp) as well as heterozygous variants of uncertain significance in il r (c. g>t; p.ser ile) and tlr (c. c>g; p.leu val). the patients nod variant is known to be associated with an increased risk for crohns disease. even with our patients presentation with recurrent severe viral infections and ibd, it is not immediately clear how these genetic results explain the pathology. innate immune defects probably contribute to her presentation and it is currently unclear if and how the combination of multiple genetic variants has left her immunologically vulnerable. we use this case to demonstrate that even when genetic testing does not elucidate a clearcut diagnosis of primary immunodeficiency, it can still provide helpful insight into a patients underlying immune phenotype. introduction: xiap deficiency is a rare primary immune deficiency characterized by hemophagocytic lymphohistiocytosis, recurrent fever and inflammatory syndromes, inflammatory bowel disease, hypogammaglobulinemia, recurrent infections, and other manifestations. loss of xiap results in abnormal tnf receptor signaling and nlrp inflammasome actvity which leads to dysregulated production of il- beta and il- . we hypothesized that suppressing the nlrp inflammasome with either targeted deletion or pharmacologic inhibition would suppress abnormal production and secretion of inflammatory il- beta and il- . methods: bone marrow derived macrophages (bmdms) from control, xiap-deficient, and xiap and nlrp double knock-out mice were derived with week of culture in l -cell conditioned media. bmdms were stimulated with a variety of tlr agonists or tnf-alpha, with or without a variety of inhibitors including the nlrp inhibitor mcc , the cathepsin b inhibitor ca- , and quercetin, which is a natural flavonoid (antioxidant) found in many fruits and vegetables, and available as a nutritional supplement. il- beta, il- , and tnf-alpha were measured in supernatants by elisa, and cell death was evaluated by flow cytometry using pi exclusion. results: as expected, bmdms from xiap deficient mice had markedly increased tlr-agonist-or tnf-alpha-induced il- beta production compared to normal bmdms. genetic deletion of nlrp and the pretreatment of cells with the nlrp inhibitor mcc greatly reduced abnormal il- beta production; residual production of il- beta could be inhibited by caspase- inhibition. pre-treatment of cells with the cathepsin b inhibitor ca- also decreased cytokine production but was toxic at higher concentrations. quercetin reliably abrogated il- beta, and also il- . quercetin was found to inhibit priming of the nlrp inflammasome (decreased upregulation of pro-il beta and nlrp ) and also decreased tnf-alpha secretion following tlr agonist stimulation. conclusion: quercetin suppresses the nlrp inflammasome and may be a promising therapeutic option for patients with xiap deficiency. it prevents il- beta and il- secretion. it is a particularly appealing option given that it is a naturally occurring antioxidant, has a great safety profile, and is readily available as a nutritional supplement. human studies are needed. recently, single cell rna sequencing (scrnaseq) analysis in mice has disclosed an unexpected complexity of thymic stromal cells, and medullary thymic epithelial cells (mtecs) in particular. however, the developmental origin, hierarchy, and function of these subpopulations remain ill-defined. moreover, although cortical tecs (ctecs) are thought to represent a more homogeneous population, their characterization has been largely restricted to the adult thymus. we have previously shown that impaired lymphostromal cross-talk in the thymus of patients with combined immunodeficiency (and of corresponding mouse models) is associated with abnormalities of thymic architecture and tec maturation. here, we sought to compare tec distribution and gene expression in wild-type (wt) and in mice carrying rag hypomorphic mutations observed in patients with combined immune deficiency and immune dysregulation. methods: multi-color flow cytometry and scrnaseq were used to analyze composition and distribution of ctec and mtec subpopulations in wt and rag mutant mice at various weeks of age (niaid animal protocol: lcim- e). results: we observed that rag mutant mice have an excess of ctecs, and that their mtec compartment is predominantly represented by cells with high levels of mhc class ii (mhc-ii) expression, recapitulating the phenotype of neonatal wt thymi. while mhc-iihi mtecs are thought to represent a minor fraction of mtecs in adult wt mice and include mature aire+ cells, a relative abundance of mhc-iihi mtecs is observed also at neonatal age, where they are thought to represent immature mtecs. to define more precisely tec maturation, we performed scrnaseq on sorted cd -epcam+ cells, and identified and distinct clusters of tecs in wt and rag mutant mice, respectively. a large proportion of cells in rag mutant mice could be ascribed to the ctec compartment, confirming our previous flow cytometry and histopathology results. furthermore, scrnaseq analysis also disclosed a different distribution of mtec subsets in wt and rag mutant mice. to address the hypothesis that this difference in ctec and mtec abundance and subset distribution may reflect different maturation stages in tec development in wt and rag mutant mice, we will perform lineage tracing and transplantation experiments, and we will also extend tec scrnaseq analysis to wt and mutant mice of embryonic and neonatal age. in parallel, to evaluate the contribution of thymocyte maturation in shaping the stromal populations, scrnaseq will be performed on thymocytes. conclusions: we have further refined the complexity of tecs, and shown that impaired development of t cells in combined immune deficiency (as exemplified by rag mutant mice) has profound effects on the composition and maturation of tecs and may thus contribute to abnormalities of immune tolerance that are often associated with these conditions. the advent of next-generation sequencing (ngs), with the development of whole-exome sequencing (wes) in particular, has allowed the identification of unknown genetic lesions for many diseases and the implementation of specific therapeutic strategies. primary immunodeficiencies (pids) are a group of rare diseases which have benefited from ngs, with the discovery and molecular characterization of previously genetically undefined diseases and the identification of novel molecules involved in the regulation of the immune system. pids are often associated with autoimmune disease due to the dysregulation of the immune system as a whole. the clinical phenotypes are heterogeneous and often overlapping. while a monogenic cause of disease has been identified in a most subsets of patients, the recent application of whole-genome sequencing has found that a polygenic cause is likely. our aim is to investigate the genetic background of patients with immunedysregulations and autoimmunity and to evaluate the possible pathogenicity of the identified gene variants through extensive functional studies. we select patients with sign of immunedysregulation and autoimmunity, extended immunophenotyping and next-generation sequencing (ngs) analysis of genes frequently implicated in pids was performed. in six of them we identify a single gene as responsible of the clinical feature. in particular, we identify two patients with gain of function mutation in stat , one patient with a mutation in ctla , one patient with an activating pik cd mutation, one with a rag mutation and one with a fas mutation. in most of them variants in multiple genes have been detected. interestingly, we find that some genes are recurrently mutated in more then one patient such as was, dock , casp , casp , nfatc and fcgr a. further studies are ongoing to validate the effect of the variations identified. our results strongly suggest that the old hypothesis, based on a single gene mutation as a cause of illness, should be revised in favor of the concept that "is the sum that causes the effect" and that a different point of view on pids now seems inevitable. physician, omni allergy, immunology, and asthma introduction/background: immunoglobulin replacement therapy (igrt) may be optimized to reduce the severity and incidence of infections and potentially delay or abrogate the development of pulmonary complications of primary immune deficiencies. pulmonary complications including bronchiectasis are common in common variable immune deficiency (cvid) and contribute significantly to morbidity and mortality in these patients. it remains unclear whether continued obstructive bronchial changes are a result of repeated respiratory infections, associated inflammation and immune dysregulation, or simply lung-damage that is irreversible by the time therapy is initiated. it has also been suggested that under-treatment in addition to the diagnostic delay may contribute to the development of bronchiectasis in patients with pid. lower serum igg levels with any given dose of immunoglobulin replacement therapy have been demonstrated in patients with bronchiectasis compared to those pid patients without this complication. in addition, earlier studies have shown that greater doses of ig ( mg/kg/ month) may reduce the frequency and duration of infections and help prevent or slow progression of chronic lung disease. objective: to evaluate the prevalence of bronchiectasis in a cohort of patients with a diagnosis of cvid and identify associated ig dosing patterns and clinical outcomes. methods: data were analyzed from the ideal (immunoglobulin, diagnosis, evaluation, and key learnings) patient registry. this is a prospective, longitudinal registry study of patients receiving ig replacement therapy in the home or ambulatory infusion suite with one national home infusion provider. nursing and pharmacy standard of care forms were collected, and dose, infection rate, and prevalence of bronchiectasis were evaluated in patients with a diagnosis of cvid (icd- codes: d . , d . ) results: there were patients in the registry with cvid, ( . %) of which bronchiectasis was also observed. seventy-nine percent (n= ) of the study population was female, and % (n= ) of the cases of bronchiectasis were observed in females. the mean age of the patients with concurrent bronchiectasis was ± . at start of care compared to ± . in those without this observed bronchial obstruction. most bronchiectasis patients (n= ) received igrt subcutaneously every week with a mean dose of . ± . mg/kg/wk. the mean dose of ig in the remaining patients receiving ig intravenously was . ± . mg/kg/month. the average annual rate of infection in ivig and scig patients with bronchiectasis was . ± . and . ± . , respectively, however many were serious bacterial infections. at time of analysis, of the bronchiectasis patients remained active in the registry and had withdrawn. reasons for withdrawal included stopping igrt due to the following: patient decision (n= ), physician decision (n= ) insurance change (n= ), and patient expired (n= ). conclusions: there were documented cases of bronchiectasis in our cohort of cvid registry patients, and dosing patterns aligned with standard doses despite the presence of bronchial obstruction. further studies are necessary to assess evolution of lung damage with respect to ig dosing in patients with cvid. background: activated phosphoinositide -kinase syndrome type (apds ) is a combined immunodeficiency resulting from gain-offunction (gof) mutations in pik cd, the gene encoding the catalytic subunit of phosphoinositide -kinase (pi k). this form of pid is characterized by recurrent respiratory tract infections, susceptibility to herpes virus infections, impaired antibody responses, lymphoproliferation and autoimmunity. previous studies showed that patients with apds have b cell defects that contribute to the clinical phenotype. furthermore, these patients display t cell abnormalities, including increased numbers of memory t cells and t follicular helper cells (tfh), reduction of naïve t cells and impaired t regulatory cell (treg) function. whether these t cell abnormalities are also associated with perturbations of t cell repertoire in unknown. objective: we aimed to investigate the effects of increased pi k signaling on the t-cell repertoire of patients with apds. methods: high throughput sequencing was used to study composition and diversity of t-cell receptor (tra) and t-cell receptor (trb) repertoire in sorted treg, tfh, conventional cd + (tconv), and cd + t cells from patients with pik cd gof mutations and healthy controls. results: treg cells of patients with apds show restriction of tra and trb repertoire diversity, and increased clonality. no repertoire restriction was detected in tfh, tconv, and cd + t cells from the same patients. however, the trb repertoire of treg and cd + cells was enriched for the presence of hydrophobic amino acids in position and of the cdr , a biomarker of self-reactivity. conclusion: these data demonstrate that the t-cell repertoire of patients with apds is characterized by a molecular signature that may contribute to the increased rate of autoimmunity associated with this condition. furthermore, our result support the notion that the pi k pathway is a key regulator of treg cell development and homeostasis in humans. j clin immunol ( ) (suppl ):s -s s ( ), iii. predominantly antibody deficiencies ( ), i. immunodeficiencies affecting cellular and humoral immunity ( ), vii. auto-inflammatory disorders ( ), ix. phenocopies of pid ( ) . two non related cases of ataxia-telangiectasia and one case of schimke syndrome (smarcal compound heterozygous mutation) were diagnosed in the last year. we observed a wide range of age (we evaluate adult and pediatric population) with a male:female ratio close to : immunodeficiency, immune dysregulation, and systemic autoimmunity. clinical diagnosis of these disorders is complicated by overlapping phenotypes. in april , a -gene next generation sequencing (ngs) panel inclusive of copy number variation analysis was launched by a commercial laboratory to facilitate clinical diagnosis of primary immunodeficiency (pid), monogenic autoimmunity and autoinflammatory disorders. we assessed the outcomes of genetic testing utilizing this panel on a cohort of pediatric patients with immunohematologic phenotypes evaluated at our tertiary care center during an -month period ( / / - / / ). eligible subjects were evaluated by at least two of three providers from a multidisciplinary pediatric hematology-immunology team, including a hematology physician, immunology physician and a geneticist or genetic counselor. twenty-three patients met inclusion criteria; ( %) were caucasian, ( %) were male with an average age of . years. the two most common phenotypic diagnoses included cytopenias, single-or multilineage (leukopenia, neutropenia, anemia, thrombocytopenia) primarily attributed to autoimmune causes or hypogammaglobulinemia. five ( %) were given a definitive genetic diagnosis as a result of panel testing, though in two of these cases, the causative mutations were listed as variants of uncertain significance (vus). diagnoses included common variable immunodeficiency due to a pathogenic variant in nfkb , stat multiorgan autoimmunity due to gain-of-function mutation, and familial cold autoinflammatory syndrome due to a pathogenic mutation in nlrp . biallelic dnmt b vus were found in a patient whose phenotype and further laboratory studies (including karyotype) were consistent with immunodeficiency-centromeric instability, facial anomalies syndrome. further, a stat vus was identified in a patient with multiorgan autoimmunity and his father with hypothyroidism; studies from an outside research laboratory were consistent with gain-of-function with this variant (private communication). an additional three patients had vus identified that were suspected to be related to their phenotype, prompting eligibility for research studies. four ( %) patients had increased risk alleles in nod , conferring an increased risk of crohns disease. three ( %) patients had pathogenic or likely pathogenic carrier findings warranting genetic counseling. in addition, vus (an average of per patient) thought to be unrelated to phenotype were identified, necessitating further investigation and counseling. the use of an ngs panel in a cohort of pediatric patients with immunohematologic disorders led to a definitive diagnosis in % of previously undiagnosed patients and prompted further research investigation in several more. genetic testing also led to the identification of clinically significant carrier findings, risk alleles and vus unrelated to phenotype, necessitating genetic counseling. our experience illustrates the value of genetic testing for diagnosis of immunohematologic disorders, and the importance of multidisciplinary care, including genetic counseling, for the proper evaluation and management of these patients. background: allogeneic hematopoietic cell transplantation (allohct) is curative for primary immune deficiencies (pid). however, many patients lack a fully-matched unaffected sibling, or may have an unknown underlying genetic defect, rendering it undesirable to use related donors. many pid patients have significant comorbidities at the time they are referred to allohct, precluding the use of myeloablative conditioning. the use of alternative donors with reduced-intensity conditioning (ric) has historically led to increased rates of graft failure, graft-versus-host disease (gvhd), and transplant-related mortality (trm). posttransplantation cyclophosphamide (ptcy) as gvhd prophylaxis immunomodulates the graft through the preferential sparing of regulatory t cells and hematopoietic stem cells from its cytotoxic effects, thus allowing for robust donor engraftment that overcomes the hla barrier while effectively preventing severe acute and chronic gvhd. we report the outcomes of two institutions using a ric allohct regimen with alternative donors and ptcy in patients with pid. design: we transplanted pid patients (table ) using alternative donors and ric, either serotherapy-free (n= ) or alemtuzumab-based (n= ). all patients received ptcy for gvhd prophylaxis on days + and + , either alone (n= ), or combined with mycophenolate mofetil and either sirolimus (n= ) or tacrolimus (n= ). donors included haploidentical family members (n= ), matched unrelated (n= ), and mismatched unrelated (n= ). stem cell source was t cell-replete bone marrow (n= ) or peripheral blood stem cells (n= ). results: the median follow-up is months (range . - years). at months, overall survival is %, and event-free survival (defined as alive without graft failure) is %. the median days of neutrophil and platelet engraftment are (range - ) and (range - ), respectively. there were patients who developed acute gvhd, grade (n= ) or grade (n= ), and there were no cases of grade or agvhd. seven of eight patients treated with systemic corticosteroids responded, and one was corticosteroid-dependent, then responded to second-line therapy. one patient developed skin-only chronic gvhd, which responded to corticosteroids and puva light therapy. five patients developed graft failure, either primary (n= ) or secondary (n= ), and four were successfully re-transplanted and remain engrafted. one patient with secondary graft failure had autologous recovery and has not required a second allohct given some durable infection control gained during initial engraftment. there were three deaths prior to day due to infection, and one death at . years secondary to presumed overdose. in ongoing follow-up of engrafted survivors (n= ), evidence of phenotype reversal has been demonstrated in all patients, with complete or ongoing resolution of some or all of their underlying disease manifestations, including infection, transfusion-dependence, autoimmunity, malignancy, and/or immune dysregulation. discussion: we have observed high rates of engraftment, low rates and severity of acute and chronic gvhd, and low trm in patients with pid transplanted using alternative donors, ric, and ptcy-based gvhd prophylaxis. ric allohct with ptcy shows promise for curing pid, and its use minimizes toxicity and widely expands the donor pool, thus allowing us to offer this curative therapy to many more patients with pid. chronic granulomatous disease (cgd) is a primary immune disorder that involves mutations in the nicotinamide adenine dinucleotides (nadph) oxidase complex (deffert, cachat, & krause, ) . two-third of cgd cases are caused by loss-of-function mutations in the cybb gene that encodes the gp pox subunit of the nadph. the increased in patients' life expectancy thanks to progress in diagnosis and management has underlined the burden of inflammatory manifestations occurring independently of infectious agents (dunogue et al., ; marciano et al., ) . cgd patients develop inflammatory granulomatous disorders, notably colitis, as a consequence of a dysregulated inflammasome activation. the treatment of inflammatory manifestations remains challenging, as it can be associated with an increased risk of infections. thus, understanding the pathophysiological mechanism of auto-inflammation in cgd could help improve the therapeutic arsenal for the management of these manifestations. to reveal the precise pathophysiological mechanism of auto-inflammation in cgd, we have developed a cellular model that reproduces the cgd phenotype in phagocytic cell. through crispr-cas gene-editing we generated a thp- c e l l l i n e h a r b o r i n g t h e p r e v i o u s l y d e s c r i b e d mu t a t i o n c. _ delccginsggt (p.tyr ter) in the cybb gene responsible for gp phox knock-out by early termination of translation. this cell line recapitulates the phenotype of cgd phagocytes: (i) decreased h o production (ii) and enhanced inflammatory responses after pma stimulation as evidenced by increased il- , il- and tnfa secretion levels (kuijpers & lutter, ) . these features were rescued by complementation through lentiviral transduction of a wild type cybb gene. this new model will help us to investigate the auto-inflammation reported in cgd patients and also to propose new therapeutic targets of inflammatory manifestations in this disorder. interleukin- (il- ) driven responses. children with irak- deficiency are predisposed to recurrent and invasive infections secondary to streptococcus pneumoniae, staphylococcus aureus and other pyogenic bacteria with high mortality rates in early childhood. the frequency and severity of infections is thought to decrease with age due to the acquisition of humoral immunity and immunologic memory, however due to the rarity of the disease, the natural history of this condition beyond early childhood is not well described. objectives: we present three unrelated irak- deficient patients with persistent chronic rhinosinusitis with nasal polyposis that developed in childhood. cases: patient is a y/o male with compound heterozygous mutations in irak (p.g afs* /c. - g>t) with a history of recurrent s. pneumoniae osteomyelitis (left hip at age and left knee at age ) and c. septicum sepsis at age following acute bowel perforation. additionally, he experienced recurrent aom during infancy and recurrent uti since age . despite prophylactic antibiotics and ivig, he has had recurrent polymicrobial (mrsa, s. pneumoniae, h. influenzae, p. aeruginosa, a. fumigatus) rhinosinusitis with nasal polyposis since age refractory to medical management requiring surgical intervention and prolonged courses of iv antibiotics. patient is an y/o female with homozygous deletions (exons - ) in irak with a history of ruptured appendicitis complicated by pseudomonas abscess and bacteremia at age , culturenegative sepsis with septic arthritis and osteomyelitis of the right leg at age , and septic shock secondary to mssa bacteremia complicated by rhabdomyolysis and dic at age . she has a history of chronic rhinosinusitis, and despite ivig and prophylactic antibiotics, she developed polymicrobial (h. influenzae, b. fragilis) rhinosinusitis with associated nasal polyposis pending surgical management. patient is a y/o female with homozygous mutations in irak (q x/q x on exon ) with a history of s. pneumoniae meningitis at months, m. catarrhalis epiglottitis and neck cellulitis at months, rsv bronchiolitis at months, enterococcus bacteremia at months, s. pneumoniae sepsis at age and streptococcus lymphadenitis at age . despite ivig and prophylactic antibiotics, she developed recurrent polymicrobial (h. influenzae, b. fragilis, mssa, v. cholera, p. aeruginosa, a. fumigatus) rhinosinusitis refractory to medical management requiring surgical intervention and iv antibiotics. conclusions: in our centers experience, irak- deficient patients continue to suffer from infectious complications, most prominently recurrent polymicrobial sinus infections beyond early childhood. the consistent presence of sinonasal polyps in these children is unusual, as it is not typically found in uncomplicated pediatric chronic rhinosinusitis. these infections have occurred despite antimicrobial prophylaxis and ivig, highlighting the role of irak- in sinopulmonary epithelium. additionally, the infectious organisms identified in our patient cohort are not commonly associated with irak- deficiency. further study of chronic rhinosinusitis and nasal polyposis in a larger cohort of irak- deficient patients and other innate immunodeficiencies may help identify pathways for targeted treatment of these patients. introduction: chronic granulomatous disease (cgd) is an inherited phagocytic defect associated with inability to clear catalase positive organisms. infections in patients with cgd are severe and recalcitrant. commonest infections are pulmonary followed by soft tissue infections and suppurative lymphadenitis. osteomyelitis is an uncommon infection in patients with cgd. it poses several diagnostic and therapeutic challenge. we herein report our experience of osteomyelitis in cgd over the last years. material and methods: review of records was carried out to describe the profile of osteomyelitis in cohort of patients with cgd at pediatric immunodeficiency clinic, advanced pediatrics centre, postgraduate institute of medical education and research, chandigarh, india. the diagnosis of cgd was based on nitroblue tetrazolium dye reduction test (nbt) and dihydrorhodamine reduction (dhr) assay. results: of the patients with cgd, ( . %) had osteomyelitis ( males and females; age range - years). most patients had their first episode of serious infection in early childhood (mean age: . years). stimulation index (si) of dhr assay ranged from to . . mutational analysis was done in / patients ( x-linked; autosomal recessive). site of involvement was variable ribs- ; vertebrae- ; radius- ; skull- ; tibia- . aspergillus fumigatus was the most common isolate ( %; / ); others had aspergillus flavus, aspergillus terreus and serratia marcescens each. all patients with rib osteomyelitis had concurrent pneumonia, and fungus was isolated in all of them (aspergillus fumigatus- , aspergillus flavus- , zygomyces spp.- ). antifungals (intravenous amphotericin b) were given for a duration of - weeks and were followed by oral voriconazole in therapeutic doses for to months in majority of them. debridement and resection of ribs was required in one patient, while other patients were managed conservatively. out of patients, ( %) succumbed to pneumonia and respiratory failure. conclusion: osteomyelitis in the context of cgd is usually caused by aspergillus spp. involvement of ribs and vertebra usually occurs with the contiguous spread of infection from the lungs. therapy often requires prolonged duration of anti-microbials, and may require surgical debridement in addition to it. a -year-old woman with history of hypogammaglobulinemia and acute liver failure a -year-old woman with a -month history of nausea, vomiting, and abdominal pain was admitted to an outside hospital with new onset of jaundice and anasarca. liver biopsy was thought most consistent with alcoholic steatohepatitis, and she was discharged with counseling on alcohol cessation and medical management of liver disease. she presented to our facility for a second opinion. over the following days, she developed further rise in direct hyperbilirubinemia up to . mg/dl, new coagulopathy with an inr . and hypoalbuminemia to . mg/ dl in the absence of ongoing alcohol consumption. liver sonography revealed course echotexture and patent vessels. pcrs directed against multiple hepatotropic viruses were negative and copper studies were normal. due to a history of moderate alcohol consumption, she was started on high-dose corticosteroids due to a presumptive diagnosis of alcoholic hepatitis. additional history raised concern for a possible primary immunodeficiency, including idiopathic thrombocytopenic purpura at years of age, multiple episodes of sinusitis treated with antibiotics and sinus surgery, one episode of suspected bacterial pneumonia, and one hospitalization for influenza a during which she developed neutropenia. in her s, she developed refractory genital warts, prompting infectious diseases evaluation. initial immune evaluation had revealed low immunoglobulins (iga < mg/dl, igg mg/dl, igm mg/dl) with very low responses to tetanus and diphtheria, despite a recent booster dose, and b and t cell lymphopenia (cd + cells/μl, cd + cells/μl, cd + v, cd + cells/μl, cd / + cells/μl); antigen and mitogen proliferation were not assessed. intravenous immunoglobulin replacement was initiated but discontinued by the patient due to infusion-related adverse effects, and she was lost to follow up until she presented with liver failure. both parents were deceased from cardiovascular disease in their s and she had no siblings. she had limited knowledge of family history but no known immune diseases. due to suspicion for genetic etiology of immune disorder and liver disease, we performed next-generation sequencing of a panel of over genes implicated in primary immune deficiencies. patient was heterozygous for a nucleotide substation (c. + g>a) within a splice site at the exon /intron boundary of the nfkb gene. during the hospitalization, immunoglobulin replacement and trimethoprim-sulfamethoxazole prophylaxis were initiated. an attempt was made to refer the patient for additional immunological evaluation and transplantation evaluation but unfortunately, she developed worsening liver failure and multiple complications, including extended-spectrum beta-lactamase (esbl)-producing e. coli bacteremia, hypotension requiring vasopressors and extensive bowel ischemia, and died in the hospital. in summary, this case highlights both the risk of diagnostic delay in adult patients presenting with a primary immune deficiency and potential for genetic testing to clarify the diagnosis. while the particular genetic change has not been described, other splice site and predicted loss-offunction mutations have been reported as pathogenic in this gene, which have been implicated in autosomal dominant common variable immunodeficiency. this case further expands on the genetic causes and spectrum of disease associated with changes in the nfkb gene. introduction: malnutrition and micronutrient deficiency are underrecognized causes of acquired immunodeficiency in adults, and may occur even in patients with high body mass index (bmi). methods: a -year-old woman with a medical history significant for one remote urinary tract infection presented to the emergency department after sudden onset of severe right flank pain. the pain was accompanied by urinary frequency and not relieved by ibuprofen; she denied fevers or chills. she was diagnosed with pyelonephritis and discharged on ciprofloxacin, which was later changed to trimethoprim-sulfamethoxazole after her culture grew resistant e. coli. her pain continued despite treatment, prompting her to return to the hospital three days later. upon presentation, she was afebrile with blood pressure of / mmhg and heart rate of bpm. her body mass index was . kg/m^ . her physical exam was otherwise notable for right costovertebral angle tenderness. laboratory studies revealed a leukocyte count of , /ul with % neutrophils; alkaline phosphatase of units/l and albumin of . g/dl, but otherwise normal liver function tests; normal lactic acid; and urinalysis with , wbc/hpf, rbc/hpf, moderate bacteria, and the presence of wbc clumps. ct scan of the abdomen and pelvis demonstrated an obstructing mm right renal stone with hydronephrosis and a right renal abscess contiguous with a right-sided hepatic abscess measuring . x . x . cm. she was treated with ceftriaxone and metronidazole, and underwent imaging-guided drainage of the abscesses. abscess cultures again grew resistant e. coli. she was discharged from the hospital with drains in place and a plan to continue trimethoprim-sulfamethoxazole until definitive management of her nephrolithiasis with ureteroscopy and lithotripsy. discussion: there remained the question of how an ostensibly immunocompetent patient had developed such severe intraabdominal infection with little systemic inflammatory response (e.g. no fever and only mild leukocytosis). a hiv antibody screen was negative. on further interview, she described a lb intentional weight loss over the preceding years, accomplished by dietary restriction to less than calories per day. nutritional assays revealed prealbumin, vitamin c, and vitamin b levels below the threshold of detection. she had low-normal b and b . out of concern for an acquired immunodeficiency resulting from malnutrition with micronutrient deficiency, balanced nutrition was discussed with the patient who agreed to liberalize her diet. background: the past decade has brought dozens of new mendelian disorders of immunity. yet, the genetic contribution(s) to diverse disorders of the immune system remain largely unelucidated. the majority of research participants referred to the national institute of allergy and infectious diseases (niaid) for what may be a mendelian disorder evade molecular diagnosis. making progress in this area requires a coordinated, systematic, and transparent approach to clinical genomics research which leverages the unique environment at the national institutes of health clinical center (nih cc). methods/design: this study is designed to systematically apply exome sequencing and related technologies with clinical grade interpretation and reporting to niaid research participants at the nih cc under a single protocol in order to facilitate research and clinical genetics care across niaid. we are recruiting approximately participants per year from approximately intramural clinical investigators. we generate genomic data, collect standardized phenotyping and report clinical interpretation in the medical record, all while providing linked genetic counseling. results: to date, we consented participants, we sent out samples for exome sequencing and samples underwent copy number variant analysis. we have completed analysis for families ( individuals) and finalized and resulted cases. here we present a case series illustrating some of our findings. case : a year-old female was referred to niaid for neonatal onset multisystem inflammatory disease (nomid). developmental delay and mild intellectual disability were appreciated on clinical evaluation. exome sequencing detected a mosaic novel likely pathogenic variant in nlrp . chromosomal microarray analysis (cma) showed ã mb interstitial deletion of chromosome previously associated with developmental delay and intellectual disability. case : a year-old ukrainian male was referred to niaid for the clinical diagnosis of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (apeced). exome sequencing and cma did not detect pathogenic variants in aire, but did find a de novo variant in fam b. defects in fam b are associated with poikiloderma with tendon contractures, myopathy, and pulmonary fibrosis (poiktmp). the clinical features of the patient were consistent with poikmp. case : a -year-old man had a history of brain, liver and kidney nocardiosis, disseminated mac infection, prostate cancer and lymphoma. family history was significant for prostate cancer. exome sequencing showed a heterozygous pathogenic variant in brca , associated with susceptibility to breast-ovarian, male breast, pancreatic and prostate cancer. conclusion: this case series illustrates that multiple diagnoses, unexpected diagnoses, secondary genomic findings, and data sharing helped identify variants in candidate genes. process standardization supports data integrity and efficiency while accommodating the need for investigator flexibility and providing tailored patient care. rationale: activated pi kinase delta syndrome (apds) is a primary immunodeficiency caused by dominant mutations that increase activity of phosphoinositide- -kinase (pi k). the catalytic subunit p is mainly expressed in cells of the hematopoietic system, primarily lymphocytes and myeloid cells, and mutations affect both b-and t-cells. we sought to further evaluate the role of the t-cell receptor (tcr) repertoire in immune dysregulation and the pathogenesis of autoimmunity and lymphoproliferation in patients with apds. methods: we evaluated the tcr repertoire in the peripheral blood in patients with pik cd mutations and compared these to the peripheral tcr repertoire in patients with common variable immunodeficiency (cvid) and healthy controls to investigate the role of the tcr in disease. the tcr repertoire in affected tissue of patients with pik cd mutations was also evaluated (tissue included lymph nodes for both patients, in addition to gastrointestinal tract and lung tissue in one patient). a fixed number of tcrs were subsampled ( , for blood and , for tissue) and diversity was calculated using the gini and shannon indexes. results: using the shannon and gini diversity indexes, the tcr repertoire in patients with pik cd mutations had less diversity/ increased clonality as compared to healthy controls and those with cvid ( figure ). for the two apds patients with biopsy tissue available for analysis, the diversity of the tcrs in tissue was increased as compared to the peripheral blood tcr repertoire ( figure ). conclusions: pi k plays an important role in the development and function of both b-and t-cells. patients with apds were found to have decreased tcr repertoire diversity in the circulating t-cell compartment compared to healthy controls and other cvid patients. the increased tcr diversity in the affected tissues compared to peripheral blood implicates the pi k/akt signaling pathway with t-cell trafficking and tissue immune homeostasis, and suggests this pathway may play a role in the development of inflammatory and lymphoproliferative complications in these patients. gain-of-function mutations in pi kd result in a human primary immunodeficiency, named apds (activated pi k-delta syndrome), characterized by lymphopenia, lymphoproliferation, respiratory infections and inefficient responses to vaccination. however, what promotes these immune disturbances at the cellular and molecular level remains unknown. we have recently published a mouse model that recapitulates major features of this disease and used this model and patient samples to probe how hyperactive pi kd fosters aberrant humoral immunity. we found that mutant pi kd alters the intrinsic function of t and b cells, leading to icos-independent increases in t follicular helper (tfh) and germinal center (gc) b cells, disorganized gcs, and poor class-switched antigen-specific responses to immunization. these phenotypes were associated with increased phosphorylation of akt and s in t and b cells, and lower threshold of activation, with altered regulation of foxo and bcl family members. moreover, b cells showed enhanced responsiveness and proliferation to both antigens and innate stimuli, accompanied by reduced cell death. strikingly, aberrant responses were accompanied by increased reactivity to gut bacteria, and a broad increase in autoantibodies that were dependent on commensal microbial stimulation, as demonstrated by striking reduction of self-reactivity upon antibiotic treatment in mutant mice. we now have further examined b cell function in these mice and demonstrate that altered foxo plays a major role in disruption of both b and t cell function. we further provide evidence for altered activation of metabolic pathways in b cells, compared to wt cells, that may contribute to the dysregulated b cell reactivity. our findings suggest that proper pi kd regulation is critical for ensuring optimal host-protective humoral immunity despite tonic stimulation from the commensal microbiome. this research was supported in part by the intramural research program of the nih, nhgri and niaid. autoimmune cytopenias are seen in a significant proportion of patients with immunodeficiencies affecting antibody production. previous b-cell maturation studies using fluorescence-activated cell sorting (facs) have associated various phenotypes of primary immunodeficiency diseases affecting antibody production with differing levels of b-cell differentiation. in this study we analyzed the peripheral b-cell compartment of patients with a hypogammaglobulinemia and > % b-cells with and without a history of autoimmune cytopenias. b-cells were isolated from peripheral blood using monoclonal anti-cd and these cells were gated to identify the proportion of memory b cell (cd +cd + ), igm+ memory b (cd +igm+), marginal zone b-cells (igm+ igd+), isotype-switched memory b-cells (cd +igm-igd-) and transitional cells (igmhicd hi). pid patients with a history of aic had decreased proportions of total cd + b-cell ( . % vs . %; p= . ) and igm memory b cells ( . % vs . %; p = . ). conversely, the proportion of marginal zone b-cells was increased in this group ( . % vs . %; p = . ). consistent with previous reporting, the proportion of isotype-switched memory b-cells was significantly lower in the aic group ( . % vs . %; p = . ). statistically significant inter-group difference was not seen within the transitional b-cell subset. our data suggest that maturation arrest of marginal zone (cd +igm+ igd+) b-cells may be implicated in the development of autoimmune cytopenias in humoral immunodeficiency. ( ) submission id# taissa de matos. kasahara , sudhir gupta, md phd student, state university of rio de janeiro and university of californis irvine professor, university of california at irvine, irvine, ca, usa introduction/background: common variable immunodeficiency (cvid) is the most frequent form of primary hypogammaglobulinemia with decreased serum igg and iga levels and variable levels of igm in adults. in addition to decreased serum immunoglobulins, - % of cvid patients present autoimmune manifestations. the mechanisms that lead to a breakdown of selftolerance in cvid are not completely understood. however some differences in b and t cells subsets and autoreactive b and t cells can be detected. elevated expression of surface igd and downregulation of igm receptor are hallmarks of anergic naïve b cells that contain autoreactive receptors in human peripheral blood. moreover, memory b cells that have class switched to igd and present an igd+igm-phenotype are also highly reactive to self-antigens in healthy individuals. the role of these autoreactive naïve and memory b cells in the immunopathogenesis of cvid has not been evaluated. here we investigated the frequency of cd -and cd + b cells expressing igd and igm in peripheral blood of cvid patients. methods: peripheral blood mononuclear cells (pbmc) from cvid patients (n= ) and health subjects (n= ) were separated by ficollhypaque and incubated with anti-human cd -percp, cd -fitc, igd-bv and igm-apc to identify different subsets of b cells by flow cytometry. cd +cd -igd+igm-and cd +cd -igd+ igm+ b cells were sorted, loaded with cfse and cultured with cpg and ant-cd for days to evaluate the proliferation. results: among the compartment of cd -b cells, cvid patients showed an increased frequency of igd+igm+ cells and a lower frequency of igd-igm-cells as compared to control group. no differences were observed in the frequency of igd+igm-cells in cd -b cells between cvid patients and controls. in contrast, in the compartment of cd + b cells, cvid patients showed an increased frequency of igd+igm-, igd+ igm+ and igd-igm+ cells and a lower frequency of igd-igm-cells when compared to health subjects. when the patients were divided in two groups based on autoimmune manifestations, the group with autoimmune disease showed an increased frequency of igd+igm+ and igd-igm+ cells in cd -b cells when compared to the control groups. both patient groups showed an increased frequency of igd+igm-, igd+igm+ and igd-igm+ cells and a lower frequency of igd-igm-cells when compared to health subjects. regarding the proliferation, naïve b cells from cvid patients showed a reduced proliferative capacity in response to in vitro stimulation as compared with naïve b cells from health subjects. conclusion: our results suggest that the increase of cd +igd+igm-b cells can be related to the susceptibility of autoimmunity in cvid patients. introduction: immunoglobulin g -related disease (igg -rd) is a group of immune-mediated conditions where tissues are affected with dense lymphoplasmacytic infiltrations with a predominance of igg -positive plasma cells and storiform fibrosis, usually in the setting of elevated serum concentrations of igg . common presentations include autoimmune pancreatitis, sclerosing cholangitis, retroperitoneal fibrosis, salivary gland disease, and orbital disease, among others. symptoms of asthma or allergy are present in approximately percent of patients and they typically exhibit a good initial therapeutic response to glucocorticoids. case presentation: a -year-old female with a history of gastroparesis, cutaneous lupus erythematosus and suspected autoimmune pancreatitis was referred to allergy/immunology clinic for evaluation of elevated igg . she reported a -year history of recurrent abdominal pain attributed to recurrent pancreatitis based on previous mild lipase elevations. prior endoscopic ultrasound (eus) of the pancreas revealed edema. there was concern for gallstone pancreatitis but ercp followed by cholecystectomy, biliary and pancreatic sphincterotomy had no change in her symptoms. in , she was noted to have a positive ana and high serum igg , per patient (values from osh records could not be obtained). symptoms improved with a course of steroids, hence suspicion for autoimmune pancreatitis. in she developed a rash on her arms and face. biopsies of the affected areas revealed cutaneous lupus erythematosus on the arms and a basal cell carcinoma on the face, which was excised. ana was only : at that time. at the visit, she complained of severe allergic rhinitis, joint pains, as well as a malar rash, which responded to intermittent courses of prednisone by prior providers. laboratories obtained at initial visit were significant for thrombocytopenia ( thou/cu mm), positive lupus anticoagulant ( sec) and elevated igg ( mg/dl; normal range - mg/dl). c , c , c q, ana, anti-double stranded dna, anti-smith antibodies, antiphospholipid panel, upep and spep were all unremarkable. ct chest and abdomen were also normal. given the patient's history of cutaneous lupus erythematosus, plaquenil was started as a steroid sparing agent. eus of the pancreas with possible biopsy was ordered in an attempt to obtain a histopathologic diagnosis of igg -rd. conclusion: this case exhibits the association between elevated igg , pancreatitis of unknown origin, allergic rhinitis, and cutaneous lupus erythematosus, highlighting the value of identifying a pathologic connection between seemingly unrelated disorders in patients with elevated igg , as they may be manifestations of igg -rd. in order to make the diagnosis, histopathologic findings showcasing lymphoplasmacytic tissue infiltration consisting mainly of igg -positive plasma cells and small lymphocytes is essential. the majority of patients respond to glucocorticoids, and while the duration of response is variable, most patients flare during or after glucocorticoids are tapered, as noted in this patient. rituximab has been shown to be effective in some patients and will be considered in this patient if symptoms persist. ( ) submission id# rationale: pnp deficiency is an autosomal recessive disorder due to defective purine metabolism leading to severe combined immunodeficiency (scid) and neurological deterioration. newborn screening utilizing t-cell receptor excision circle (trec) assay can detect affected patients before complications arise. herein, we describe an infant initially identified by newborn screening with pnp deficiency and congenital cmv, a previously unreported presentation. methods: cmv quantitative pcr (qpcr) was performed by nebraska medicine, pnp enzyme activity by duke and genetic sequencing by invitae. results: a small for gestational age (sga) male infant was reported to have an abnormal trec assay on day of life (dol) . he was hospitalized for further evaluation. initial studies revealed profound lymphopenia, normal lymphocyte proliferation to mitogens and no evidence of maternal engraftment. additionally on dol , he had cmv viremia and viruria; thus with sga, failed unilateral hearing screen and head ultrasound with bilateral parenchymal calcifications, congenital cmv was suspected. pnp enzyme activity was abnormal. cmv treatment was initiated with ganciclovir on dol . foscarnet was added on dol . cmv qpcr levels decreased below the limit of detection by dol . genetic testing found a pathogenic homozygous mutation in pnp (c. - g>a). the infant has a / hla-matched, unaffected, cmv positive sibling and will proceed to hematopoietic stem cell transplantation. conclusions: to our knowledge, this is the first reported case of pnp deficiency identified through newborn screening. this novel case of congenital cmv and pnp deficiency highlights the importance of cmv screening and need for treatment strategies for congenital cmv in scid. despite a dramatic increase in the use of next generation sequencing over the last decade, the majority of the more than million identified human genomic variants do not have well-established clinical implications. progress is being made on this complex challenge through multiple approaches, including data sharing. to maximize our understanding of genomic data, platforms that enable effective and responsible data-sharing are essential. this means that genotypic and phenotypic data must be findable, accessible, interoperable, and reusable under conditions that are ethical and transparent. to highlight innovations in data-sharing and their potential to advance discovery, we present three data-sharing mechanisms. for each platform, we will present a case highlighting its key functionality and discuss opportunities and challenges that may arise as each platform is scaled up. ( .) genomic research integration system (gris) is a collaborationengendering web application that facilitates the identification of genetic variants associated with rare immunological disorders. users can access integrated and standardized phenotypic and genomic data that is analyzable within the platform. gris enables systematic and automated capturing, and links patient data from disconnected systems and paperbased records. standardized annotations allow for the comparison of data from different clinical studies. the main goal of this tool is discoverability of other affected individuals enrolled in separate protocols within the niaid intramural research program. this internal database was used to find a second family with a rare variant in a candidate gene. ( .) the genomic ascertainment cohort (tgac) is a resource that aims to improve our understanding of the phenotypic consequence of genetic variation by providing access to aggregate, de-identified genomic data from large nih intramural and related cohorts. participants have provided informed consent to be re-contacted for additional phenotyping in the future. the main goal of this tool is to enable further study of the clinical consequence of variants in a large, unbiased cohort of patients ascertained for many indications. this database was used to investigate findings in participants with previously published pathogenic variants in genes associated with primary immune deficiency based on medical record review. ( .) clingen is dedicated to building an authoritative central resource that defines the clinical relevance of genes and variants for precision medicine and research. through the sharing of genetic and health data, clingen seeks to answer whether a given gene is associated with a disease (clinical validity)?; whether a given variant is causative (pathogenicity)?; and whether the information is actionable (clinical utility)? this resource is meant to convene disease-and gene-specific expert groups to curate the medical literature on mendelian disease to better define gene-disease and variant-disease relationships using many lines of evidence. this resource was used to clarify clinical validity of disease-gene assertions. together these efforts help create a clinical research ecosystem that maximizes the value of clinical research data and ultimately improves patient care. this research was supported by the intramural research program of the nih, niaid. introduction: according to the population reference bureau, the number of elderly americans, defined as age and older, is projected to more than double from million to million by , rising from % to % of the total population. the impact of immunodeficiency in this important segment of the population remains understudied. methods: the usidnet registry was queried to obtain demographic, clinical data of elderly patients defined as age and older. descriptive analyses were performed on the data. results: participants ( . %) were eligible out of total registry participants. the median age of the cohort was years and predominantly female ( . %) and white ( . %) with a median bmi of . ± . .the majority ( . %) of subjects were living. humoral deficiencies comprised the majority of diagnoses ( . %), with common variable immune deficiency being the most frequent ( . %). of the remaining non-humoral diagnoses, immune dysregulation ( . %) and immunodeficiency with myelodysplasia ( . %) were the most frequent. the majority ( . %) of subjects reported having received immunoglobulin replacement therapy (igrt) at some point, with . % reporting via iv route. of the infections that occurred in this cohort, sinopulmonary infections were the most commonly reported, specifically sinusitis ( . %), pneumonia ( . %), upper respiratory infection ( . %), and otitis media ( . %). in this cohort, autoimmune, cardiovascular, and granulomatous complications were reported . the number of patients with malignancy was , with some patients diagnosed with multiple malignant disorders. of the reported malignancies, the majority ( . %) were solid tumors. conclusions: compared to the age-matched non-immunodeficiency united states population, this cohort had more females . % (usidnet) versus . % (us population) and fewer whites . % (usidnet) vs . % (us population. humoral immunodeficiencies, specifically cvid, were most common diagnoses, similar to other age groups of immunodeficiency patients. majority of these patients have received igrt, with approximately half via iv route. this cohort reported living with a variety of non-infectious complications, including autoimmunity and malignancies. more research which specifically focuses on elderly patients with immunodeficiency is needed. clinical microbiologist and infectious disease physician, university of calgary x-linked agammaglobulinemia (xla) is a primary immunodeficiency caused by mutations in the bruton tyrosine kinase gene which leads to b cell maturation failure and defective antibody production. this puts patients at risk of recurrent sinopulmonary infections, gastrointestinal infections, and recurrent skin infections including infections caused by helicobacter sp. helicobacter sp are gram negative bacilli commonly found in the gastrointestinal tract of various animals. helicobacter sp. have been linked with gastritis most notably helicobacter pylori causing gastric ulcers in humans. helicobacter sp. has been found in rare cases to cause disseminated infections including pyodermic gangrenosum and cellulitis notably in patients with agammaglobulinemia. infections caused by helicobacter bilis are challenging to diagnosis due to difficulties with culturing the pathogen as well as poor guidelines for antimicrobial management. case report: the patient was diagnosed with x-linked agammaglobulinemia at the age of months with a history of recurrent sinusitis and was started on ivig q weeks. despite regular ivig, he developed bronchiectasis. at years of age in , he developed a chronic rash around his left knee resembling erythema nodosum. by , he had developed a left knee effusion associated with left sided calf pain. his knee pain was found to improve during courses of ciprofloxacin to treat recurrent lung infections. given case report data of h. pylori causing erythema nodosum in patients with agammaglobulinemia, he was treated empirically for an h. pylori infections with no improvement. in he was found to have progressive cellulitis with pyomyositis of the left leg. a skin biopsy of a calf nodule was found to be culture negative but s pcr was positive for h. bilis. he was started on treatment with ertapenem and levofloxacin with subsequent resolution of his rash. his left ankle pain progressed and by late and was found to have possible osteomyelitis of the left ankle on mri. in he was found to be bacteremic with h bilis. due to progressive symptoms with significant impact on function and rising inflammatory markers despite months of antimicrobial treatment, doxycycline and flagyl were added leading to clinical improvement and normalization of his inflammatory markers. he was continued on oral doxycycline and flagyl for months for a chronic osteomyelitis. discussion: h. bilis is a slow growing pathogen which is challenging to culture in the laboratory often requiring special agar plates and prolonged incubation. in patients with agammaglobulinemia and associated chronic skin infections or erythema nodosuma, h bilis should be suspected as a possible pathogen. due to challenges with culturing, s pcr or amplification of the s ribosomal subunit should be considered to try to identify the pathogen. there are poorly delineated clinical antimicrobial breakpoints to help guide therapy with minimal evidence. case reports suggest prolonged therapy with aminoglycosides and penicillin. other studies have successfully treated patients with a carbapenem, azithromycin and levofloxacin. in the absence of sensitivity data, prolonged treatment ( months) should be considered with a combination of antimicrobials. patients should be followed closely as recurrent infections are not uncommon. chief, human immunological diseases section, laboratory of clinical immunology and microbiology, niaid, nih, bethesda, md introduction: dock deficiency is a combined immunodeficiency characterized by eczema, recurrent sinopulmonary infections, viral skin infections, malignancy and early mortality. in recent years, liver disease and vasculopathy have been increasingly recognized as a complication of dock deficiency. we clinically characterized our cohort of dock deficient patients, with a specific focus on these newly identified areas of disease involvement. methods: chart reviews were performed on patients seen at nih with genetic and clinical diagnosis of dock deficiency. patients were all enrolled on irb approved niaid protocols. results: we identified patients from families with dock deficiency in our nih cohort, ranging in age from - years. of the families, had homozygous mutations. of the patients, food allergy was diagnosed in ( %), eczema in ( %), and asthma in ( %). chronic or recurrent viral skin infections were seen in / ( %). chronic ebv viremia by pcr positivity was seen in / patients ( %); only patients were known to be ebv immune without viremia. cmv viremia was infrequent. sinopulmonary infections were common, with bronchiectasis occurring in / ( %) with available imaging. liver disease was diagnosed in ( %), with having biliary tract abnormalities on imaging and stool positive for cryptosporidia; most patients with cryptosporidia were without diarrhea. the incidence of cryptosporidia is likely under-represented due to more recent availability of sensitive assays for cryptosporidia detection. other liver abnormalities included fatty liver, metastatic disease from malignancy and medication related hepatitis. vasculopathy, predominantly of the aorta and cerebral arteries, was diagnosed in , with patients in the last years being prospectively imaged. autoimmunity was rare ( %) including autoimmune cytopenias and hypothyroidism. of with follow-up are alive ( %) with age range - years. of the living patients, ( %) have had a hsct. causes of deaths include malignancy ( ), infection ( ) , and hsct complications ( ) . long-term follow-up of patients with hsct (up to years) has revealed resolution of the infection susceptibility and eczema, no new cancers, and stabilization of vasculopathy. conclusions: in addition to the well described manifestations of dock deficiency including eczema, allergy, recurrent sinopulmonary infections, skin viral infections and malignancy, our cohort revealed a relatively high incidence of liver disease, frequently associated with stool positivity for cryptosporidia, as well as vasculopathy. both of these clinical manifestations should be considered during preparation for hsct as they may affect management through transplant. autoimmunity has likely been over-estimated in prior descriptions of dock deficiency. long-term follow-up after hsct is needed to determine the prognosis from the vasculopathy, liver disease, and malignancy risk. ( ) submission id# yasuhiro yamazaki , stefano volpi , luigi d. notarangelo introduction/background: extl (exostosin like glycosyltransferase ) is an exostosin family member which initiates heparan sulfate (hs) chain biosynthesis and elongation. we have reported homozygous extl hypomorphic mutation (r w) as a cause of immunoosseous-dysplasia syndrome. fourteen patients who have extl homozygous mutation were reported so far. eight of them manifested t cell lymphopenia, and presented with severe combined immunodeficiency (scid) or omenn syndrome. using patient-derived induced pluripotent stem cells (ipscs) as a model, we have previously reported that extl mutations affect differentiation to thymic epithelial progenitor cells as well as expansion of hematopoietic progenitor cells. consistent with the latter, previous studies have suggested that mutations in other genes involved in hs biosynthesis affect hematopoietic stem cell (hsc) differentiation. however, the exact mechanisms by which extl mutations affect hematopoiesis are not known. objectives: we tried to clarify gene expression difference in hscs derived from wild-type, extl hypomorphic and extl knock-out (ko) human ipscs. methods: the control bj ipsc line was engineered by crispr/cas gene targeting. extl ko ipscs were obtained which carried compound heterozygous extl mutations (c. _ inst; c. _ insgatattt). hsc differentiation was induced using the stemdiff hematopoietic kit (stemcell technologies). bulk rna from each ips cells and each differentiated cd +cd +cd + was analyzed by rna sequencing. results: as compared to control ipscs, patient-derived cells showed slightly lower capacity to generate cd +cd +cd + cells. on the other hand, extl ko cells showed no differentiation into cd + cd +cd + cells. gene set enrichment analysis showed enriched expression of genes involved in hematopoietic progenitor cell differentiation, regulation of hemopoiesis, and positive regulation of hemopoiesis in both control and patient-derived cd +cd +cd + cells compared to parental ipscs. moreover, these gene sets were more abundantly enriched in control than in patient-derived cd +cd +cd + cells. the gene set of response to type i interferon was significantly enriched in control versus patient-derived cd +cd +cd + cells. conclusions: these results confirm that extl plays an important role for hsc homeostasis in human cells. because type interferons play a role in hsc proliferation, the decreased type i interferon signature may account for the reduced number of hscs that we have previously reported upon in vitro differentiation of extl -mutated versus control-derived ipscs. this study was supported by the division of intramural research, niaid, nih, under protocol -i-n . a case of autoinflammatory syndrome with osteoporosis and specific antibody deficiency autoinflammatory syndromes are inherited disorders with an exaggerated inflammatory response with no specific trigger. the clinical phenotypes of variants of autoinflammatory syndromes may overlap. we report a case of a year old male with prior diagnosis of specific antibody deficiency, periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis (pfapa) syndrome, arthralgia and moderate atopic dermatitis. he was diagnosed at years of age with specific antibody deficiency based on persistently low pneumococcal titers against repeat immunizations. due to recurrent infections, he was placed on immunoglobulin replacement therapy (igrt) at years of age. igrt was discontinued at years of age due to full resolution in infections and patient demonstrated robust response to immunizations. patient had lifelong history of recurrent fevers (every weeks) associated with pharyngitis and aphthous ulcers consistent with diagnosis of pfapa. as he became older these episodes became less frequent. last episode of fever was over a year ago. the father had similar symptoms of recurrent fevers and oral ulcers as a child but currently remains asymptomatic. paternal grandfather died of kidney disease. patient has been generally in good health until recent year with intermittent abdominal pain, arthralgia and several long bone fractures with no history of prior trauma. a bone density scan revealed osteopenia and osteoporosis with a z score of - . of lumbar spine, - . of left femoral neck, - . of left hip. given history of familial autoinflammatory disease, and antibody deficiency genetic testing was obtained which identified a pathogenic heterozygous variant of taci and mefv c. g>a (p.met lle). taci mutation has been linked to antibody deficiency syndromes. genetic study for family members is pending. the mefv gene is associated with autosomal recessive familial mediterranean fever (fmf) and has been reported in autosomal dominant fmf as well. fmf is characterized by recurrent episodes of fever associated with serositis, arthralgia, and arthritis. patients with fmf have elevation in acute phase reactants during attacks with most returning to normal levels during the episode-free periods. multiple studies have shown that patient with fmf have lower bone mineral density and zscores than the general population. inflammation in fmf is thought to be mediated by several different cytokines (il- , il- , il- , il- , il- , il- , il- and tnf-). these same cytokines play a role in osteoclast activity and bone resorption. it has been suggested chronic inflammation during acute attacks and subclinical inflammation during the disease-free period lead to bone loss and osteoporosis. regular use of colchicine, the main treatment for fmf, may slow down osteoporosis. beside careful monitoring of clinical and laboratory phenotype, genetic evaluation is an important step in distinguishing between overlapping entities and can prevent complication and promote targeted intervention. a year old previously healthy boy was referred for periodic fever/ pfapa and mosquito bite hypersensitivity. eight weeks earlier he developed fever to f, mouth sores and exudative tonsillitis; a rapid strep screen was negative. one week later he developed moderate cervical lymphadenopathy and had a positive ebv early antigen antibody.. one month later he had several severe local reactions to mosquito bites. each manifested - cm of erythema and induration with a + cm bullae which left an ulcer after rupture and healed with a hypopigmented scar. the bites were accompanied by fever to f for days. one febrile episode was treated with low dose prednisolone for presumed pfapa, and the fever resolved within hours. his past history was positive for nasal allergy and mild asthma. his parents are not related: mom is of european-indonesian and dad european-african (creole ancestry. testing prior to this visit showed normal igg, iga and igm, elevated ige ( , u/l) and normal cbc. lymphocyte subsets revealed cd + % ( /mcl), cd + % ( /mcl), cd + % ( / mcl), cd + % ( /mcl), nk cells % ( /mcl). on examination he appeared well with height at th%ile and weight at th%ile. there was no lymphadenopathy, hepatosplenomegaly or inflammed skin lesions; there was a cm round scar on the right plantar surface at the site of a prior mosquito bite. laboratory studies confirmed nk lymphocytosis % ( /mcl) and elevated ige ( , u/l). lymphoproliferation to mitogens, cd /cd , cmvand hsv were normal, but absent to tetanus and candida antigens. ebv antibodies reflected past infection (vca-igg+, vca-igm-, ebna+); quantitative ebv pcr was > , , copies/ml whole blood. nk cytotoxicity and cd a expression were decreased. bone marrow nk analysis suggested conality. the patient was diagnosed with "hypersensitivity to mosquito bites with ebv-associated t-/ nk lymphoproliferation." this disorder represents a subset of chronic active ebv (caebv) that is rarely seen outside of east asia. the lack of organomegaly or lymphadenopathy with hyper-ige and nk lymphocytosis and decreased nk function support the likelihood that nk cells are the target of ebv infection in this patient. this diagnosis may be a precursor to hemophagocytosis, liver necrosis or lymphoma/leukemia, and the only curative treatment is bone marrow transplantation. the patient's sister is a / hla match. she is seropositive for past ebv infection, and she has no history of extreme reactions to mosquito bites. genetic mutations that cause familial hemophagocytic lymphohistiocytosis have not been reported in caebv, and to the best of our knowledge familial cases of this disorder have not been identified. the response to bmt in this patient is pending. introduction/background: a number of case reports have described symptomatic hypogammaglobulinemia following administration of anti-epileptic drugs (aeds), specifically lamotrigine, carbamazepine, and levetiracetam. the mechanism by which symptomatic hypogammaglobulinemia develops is unclear. we evaluated the prevalence and the clinical significance of hypogammaglobulinemia associated with use of these aeds. objectives: our aim was to characterize the prevalence of aed-induced hypogammaglobulinemia, identify specific aeds associated with hypogammaglobulinemia, and characterize the timeline to development of hypogammaglobulinemia after initiation of therapy. methods: a retrospective, multicenter, electronic medical record review spanning years identified patients with hypogammaglobulinemia who were on aed therapy (lamotrigine, carbamazepine, or levetiracetam). patients were excluded if they had a pre-existing primary immunodeficiency (pid), malignancy, protein-losing enteropathy, or significant proteinuria. patients on chronic immunosuppressive therapy, those without laboratory criteria for hypogammaglobulinemia, or those on one of the aeds for less than one month were also excluded. results: of the cases reviewed, patients met our inclusion criteria. the median age was ; % were adults, % were female, and % were white. lamotrigine was implicated in / of the cases, carbamazepine in / , and levetiracetam in / . tetanus and pneumococcal titers were available for / patients. of those patients, / had protective titers to both per report with responses to > % of the serotypes. only one patient reported severe, recurrent infections while the remaining four had little to no symptoms. interestingly, the patient with severe infections did have protective titers. of the five laboratory proven hypogammaglobulinemia patients, one died of an infection, two have continued on the medication due to refractory seizures responsive only to these medications, and two are currently being tapered off of their aed. conclusion: while it appears that aed-induced hypogammaglobulinemia is quite rare, it should be considered in a patient without other secondary causes of hypogammaglobulinemia on aed therapy. many antiepileptics downregulate nfkb signaling suggestive that patients who develop symptomatic hypogammaglobulinemia may have hypomorphic mutations in the nfkb signaling pathway. ( ) submission id# autoimmune lymphoproliferative syndrome (alps) results from defective apoptosis of lymphocytes mediated through the fas/fas ligand (fasl) pathway. the hallmark lab finding is an expansion of t cells that express the alpha/beta t cell receptor, but lack both cd and cd (double negative t cells) in the setting of normal or elevated lymphocyte counts. patients present with chronic, nonmalignant, noninfectious lymphadenopathy or splenomegaly. for definitive diagnosis, patients need to have ( ) a pathogenic mutation in fas, fas ligand or caspase or ( ) a defective fas-induced lymphocyte apoptosis. we describe a probable case of alps with heterozygous mutation in fas c. a>g(p.his arg), a variant that has not been previously reported (his lymphocyte apoptosis assay is pending). unique to this case is the patients castleman disease-like features on pathology. a year-old male referred from hematology clinic presented with an year history of chronic lymphadenopathy, splenomegaly, anemia, and no underlying diagnosis. malignancy had previously been excluded by bone marrow aspirate and biopsy years prior. however, he had a right sided lymph node that had increased in size for the past months. he was otherwise asymptomatic. a lymph node biopsy years prior was reportedly normal. his exam demonstrated significant bilateral lymphadenopathy, greater on right, with an approximately x cm mobile right neck mass. he had splenomegaly palpated cm down and across to midline. he was therefore admitted for excisional lymph node biopsy to evaluate for possible malignancy and labs were sent to evaluate for alps. labs were supportive of alps. he had elevated t cell receptor alpha beta double negative t cells (tcr a/b dntcs) in blood ( . %). b level was elevated (> pg/ml). plasma soluble fasl level was elevated ( pg/ml). interleukin- (il- ) and il- levels were elevated ( and pg/ml respectively). he had multilineage cytopenias: anemia with hgb of . g/dl and neutropenia (absolute neutrophil count of k/ul). he had hypergammaglobulinemia with an igg level of mg/dl. broad infectious work-up was negative, including hiv, quantiferon, cocci, bartonella, toxoplasma, coxiella burnetii, ebv pcr and, cmv igm. lymph node biopsy showed no evidence of malignancy. immunostains and flow cytometry showed the presence of expanded tcr a/b dntcs in the lymph node, consistent with alps. interestingly, lymph node histology showed morphologic features typical of plasma cell variant castleman disease. numerous castlemanlike follicles showed typical regressive changes with onion-skinning morphology. paracortical hyperplasia with sheets of plasma cells was noted. there was negative staining for hhv (a well-known cause of plasma cell variant castleman disease). the diagnosis of idiopathic multicentric hhv -negative castleman disease was excluded by definition in the setting of alps, per evidence-based consensus criteria published in . in addition, our patient did not show any symptoms typically associated with it, such as fever, night sweats, weight loss, weakness or fatigue. should his fas-induced lymphocyte apoptosis be defective (in separate assays), this would confirm his alps-fas diagnosis and we would start the patient on sirolimus. head of immunology unit, children' s hospital ricardo gutierrez introduction: slc a gene encodes the proto-couple folate transporter (pcft), which supports intestinal folate uptake, and participates in folate transport into the central nervous system. slc a mutations cause pcft defects, resulting in low folate levels in serum and cerebrospinal fluid. hereditary folate malabsorption (hfm) is a rare, autosomal recessive disorder with pcft deficiency resulting in cerebral folate deficiency. most of the patients present megaloblastic anaemia, moderate pancytopenia in the first few months of life, failure to thrive, diarrhoea and/or later onset neurological symptoms including seizures and developmental delay. i m m u n o d e f i c i e n c y i n h f m c a n m a n i f e s t i t s e l f w i t h hypogammaglobulinemia with normal t-cell function. b-cell precursor compartment seems to be particularly vulnerable to folate deficiency in some hfm patients. this immunodeficiency can be restored with specific treatment with folic acid. aim: to describe a female patient with a homozygous pathological variation in the slc a gene. results: a months old girl, born of non-consanguineous parents. she started at months old with diarrhoea due to rotavirus, low weight and bicytopenia with normal bone marrow aspiration. she presented low levels of folic acid . ng/ml (nv . - . ng/ml) at first thought due to secondary to malnutrition. treatment with folic acid supplementation was administrated, improving platelets counts. at months old she presented steatorrhea with severe perianal panniculitis which required surgical treatment. no germs were rescued after a skin biopsy. moreover, she suffered from a respiratory infection due to picornavirus with two episodes of pneumothorax which required intensive care. at that moment ivig treatment was administered due to hypogammaglobulinemia and clinical severity. chronic diarrhoea worsened with bloody depositions. three rectal ulcers were found in the gut biopsy. bowel inflammatory disease was suspected and mesalazine administration was started with weight improvement. furthermore, at months old she presented status epilepticus, with pathological eeg and normal mri; one of them related to a cmv infection, successfully treated. in the immunological evaluation igg and iga were low with normal igm and igd. the protein-antibody response was not evaluated. she presented normal lymphocyte and t cells extended populations, t cells proliferation assay, dhr, treg cells, complement, cd a expression, alpha-fetoprotein, without autoantibodies a molecular panel testing was done by ngs and a homozygous variant in slc a gene was found, causing impaired intestinal folate absorption. conclusion: hfm should be considered in the diagnosis of patients with cytopenias and hypogammaglobulinemia in order to provide specific treatment. hfm has wide clinical manifestations, not only with megaloblastic anaemia and neurological impairment but also with gastrointestinal and skin manifestations. with folate treatment, clinical and immunological defects can be normalized. introduction: multifocal epithelial hyperplasia (meh), or hecks disease, is a rare, benign infection of the mucosa caused by human papilloma virus (hpv). clinically, meh manifests as numerous painless, soft, sessile papules or plaques, and typically occurs in the labial, lingual, and buccal mucosa. meh lesions are usually associated with hpv types and , and seen more commonly in patients of caribbean or central/south american descent. prior studies in adults have shown that tumor necrosis factor alpha (tnf) promotes hpv, and may influence duration of hpv infection. case: we present a five-year-old full term male of haitian descent referred for assessment of multiple flesh colored, papular lesions on the buccal and labial mucosa that had persisted and quantitatively increased over one year, although some lesions regressed. he had no pain or difficulty eating. medical history significant for one seizure; negative for infection. no family history of infection, immunodeficiency, consanguinity, or miscarriage. head and neck examination failed to reveal cervical lymphadenopathy, masses, or hypertrophy in the salivary glands. intraoral examination revealed multiple papular nodules, mostly flat although some were corrugated. the greatest concentration was noted on the lower left labial surface extending to the mucosal vermillion interface, not involving the vermillion or commissure region. lesions extended into the mandibular vestibule and the left buccal mucosa. no other lesions were noted on extremities, genitalia, or any other visualized mucosal surface. based on history and exam, he was diagnosed with meh. white blood cell count, neutrophils, lymphocytes, cd and cd t cell, b cell, nk cell enumeration, and immunoglobulin panel were normal for age. tetanus and streptococcus pneumoniae titers were protective. cytomegalovirus igg and igm were negative. epstein-barr virus igg was positive, igm and early antigen ab negative. serology was significant for elevated tnf ( pg/ml; reference range < pg/ml) while interferon gamma and interleukins , , , , , , , , , and were normal, as was il- receptor cd . one month after the initial visit, lesions were stable and unchanged. nine-valent hpv vaccination was considered, but not administered. conclusions: meh is a rare but benign disease caused by hpv. awareness of the disease and its course is important to prevent unnecessary expanded immunodeficiency work-up and possible procedures to eliminate lesions. although mucosal immunity can be site specific, especially with hpv, our understanding of t-cell cytokine and chemokine responses to hpv in cervical and laryngeal lesions may be instructive. the mechanism which allows hpv persistence in meh is not characterized, but it likely is due to increased viral persistence and an inability for the host immune response to successfully induce viral latency and successful containment. elevated tnf levels, with normal levels of il- , il- , il- , il- , may correlate with decreased clearance of hpv and prolonged duration of meh. it remains unclear if viral persistence is the cause of, or the sequela of, increased tnf. longitudinal monitoring of cytokine (tnf, il- , il- , il- , il- ) and chemokine (ccl , ccl , ccl , ccl , ccl , and ccl ) serum concentrations may be useful biomarkers for disease resolution. introduction: autosomal dominant hyper ige (jobs) syndrome is a rare primary immunodeficiency characterized by eczema and sinopulmonary infections as well as musculoskeletal and vascular complications. as in all chronic illnesses, patient education is an ongoing need. in the rare disease population, patient education is especially important as patients must be able to explain their unique healthcare concerns in a variety of medical settings. we focused on ad-hies, due to our relatively large cohort of patients, the frequent lack of classic signs of illness often impairing diagnosis of severe infection, and the diverse nonimmunologic clinical features of this disease. objectives: we aimed to increase understanding of the clinical manifestations of ad-hies to promote earlier recognition of symptoms and to increase self-efficacy for symptom management in the adult hies population. methods: adult patients were asked to participate in a patient education project. demographic information was collected from participants. they also completed a -item multiple choice test about symptom recognition in ad-hies and promis self-efficacy for managing symptoms, an item validated survey. then, patient education handouts that focused on pulmonary symptoms, eczema, bone health, and cardiovascular complications were reviewed with the participant. six weeks later, participants were asked to repeat the -item test and the self-efficacy survey. the demographic information, test, and self-efficacy were collected anonymously. results: participants provided demographic information, completed the test and the self-efficacy survey. of the participants, were male and were female. participants ranged in age from to years. / ( %) reported looking for information about ad-hies using search engines and most patients ( %) report that they have been given information about ad-hies from a doctor. / ( %) participants identified pulmonary symptoms as the symptom that concerns them most and / ( %) participants identified more than one symptom of concern. participants returned the second test and second survey. the mean test score increased from . to . with / participants achieving a score of / or higher. the self-efficacy scores were unchanged with a mean score of . before reviewing the patient education handouts and . after. conclusions: participant feedback to this project was generally positive. ad-hies patients are seeking information and an educational intervention can improve their understanding of disease. self-efficacy results were mixed and unchanged overall, but suggest that ad-hies patients manage symptoms as well as other patients with chronic illnesses. patient education should continue at each encounter. this project can be expanded to include more topics, pediatric patients, and other rare disease populations. funded by the nci contract no. introduction: bcl b plays an important role in the development and maintenance of the immune system and the central nervous system. expression of bcl b represses nk and myeloid factors while inducing t cell lineage genes in thymocytes at the dn stage. conditional loss of bcl b expression in murine thymocytes leads to t cell deficiency while complete knockout of bcl b was fatal within a few days of birth. recently, specific heterozygous bcl b mutations have been reported in individuals with global development delay. however, only of these cases, both carrying heterozygous missense variants, had low trec values with other cases having frequent infections. little is known regarding the impact of bcl b on human nk and t cell function. methods: we identified a novel heterozygous truncating mutation in bcl b in an infant who was first detected by trec newborn screening. she subsequently developed severe autoimmune hemolytic anemia at the age of months. we used standard immunoblotting and flow cytometry methods to assess protein expression and the impact of this bcl b mutant on t cell and nk cell development and function. results: the patient has a novel single base-pair deletion in the bcl b gene, which is predicted to produce a truncated protein with the loss of of zinc finger domains in bcl b. immunoblotting of t cell blast lysates revealed a reduced bcl b expression in the patient consistent with the heterozygous defect in bcl b but also generated a novel band with a smaller molecular weight that we postulate represents the truncated protein product. while mitogen responses to cona and pha were normal, both cd + and cd + t cell counts were decreased, especially cd + naïve and cd +cd + naïve t cells, suggesting reduced thymic output. the function of th cells was skewed with reduced il- production but increased ifn levels after pma and ionomycin stimulation. moreover, t regulatory cell counts were below normal range. nk cell counts were normal but these were mostly cd bright nk cells. of the few cd dim nk cells that presented, approximately half did not express cd , the fc receptor for adcc. perforin was only present in cd expressing nk cells. as such, anti-cd stimulation understandably led to low but not defective nk cell degranulation. function after stimulation with k cells was normal when controlled for nk cell counts. conclusion: we report a novel bcl b truncating mutation with a leaky scid phenotype that manifested with t-cell lymphopenia and autoimmunity. lowered thymic-derived naïve t and regulatory t cells, skewed th cytokine response, and incomplete nk cell development suggests that bcl b is important for the development and differentiation of multiple lymphocyte lineages. introduction: chronic diarrhea is one of the most common gastrointestinal complaints in patients with common variable immune deficiency (cvid) and can lead to life-threatening complications such as malabsorption and malnutrition. chronic diarrhea in cvid could be caused by infections, an inflammatory bowel disease-like picture, as well as malignancy. giardia lamblia is one of the most common parasites causing diarrhea in cvid (up to %), and can be refractory in these patients, leading to villous atrophy, weight loss, and failure to thrive. case report: a -year-old female with a history of cvid presents with chronic diarrhea and significant weight loss. her cvid was diagnosed by hypogammaglobulinemia (low levels of igg, igm, and iga), inadequate responses to protein and polysaccharide-based vaccines, decreased memory b cells (cd +cd + . %), and recurrent sinopulmonary infections. she was started on immune globulin replacement therapy and had significant improvement in her rate of infections. four years before her presentation to our center, she developed chronic, severe diarrhea. work up revealed giardia lamblia infection on endoscopy and colonoscopy. biopsy showed intraepithelial lymphocytes, villous blunting, and atrophic gastritis with rare plasma cells concerning for non-infectious enteropathy related to her cvid, in addition to the high burden of giardia organisms. she was initially treated with metronidazole for several weeks. however, her diarrhea did not improve, and she developed significant peripheral neuropathy leading to lower extremity weakness and limited mobility. her diarrhea persisted and was associated with approximately a -pound weight loss. repeat endoscopy and colonoscopy two years later showed persistent high burden giardiasis of the small intestine, as well as reactive lymphocytic infiltrates and atrophic gastritis. she was treated with nitazoxanide but continued to have diarrhea, and her stool continued to show trophozoites. given the significant inflammation and the lack of response to multiple antiparasitic agents, she was referred to our center for further evaluation. she was started on oral budesonide ( mg daily) and oral immune globulin ( grams weekly for weeks). with this regimen, she had significant improvement in her diarrhea with a -pound weight gain. repeat colonoscopy showed considerable improvement in inflammation and resolution of her giardia infection, though her stool antigen continues to be positive. conclusions: persistent diarrhea in our patient is most likely due to a combination of cvid enteropathy and giardiasis. a prolonged course of metronidazole and later nitazoxanide did not control her diarrhea and led to significant side effects. switching to an immunomodulatory approach significantly decreased the inflammation in her bowel and may even have helped to reduce the burden of giardia in the gut. targeting both underlying bowel inflammation as well as active infection in cvid patients with chronic diarrhea might be needed to control symptoms. introduction: sphingosine- -phosphate (s p) is a lipid chemoattractant that is critical for lymphocyte egress from lymphoid organs. following a s p concentration gradient maintained by s p lyase ubiquitously expressed in tissues, lymphocytes within lymphoid organs are drawn to efferent lymph and blood unless their s p receptor is internalized or downregulated. owing to diminished degradation of not only s p, but also other sphingoid bases, deleterious mutations in sgpl (encoding s p lyase) perturb sphingolipid catabolism in numerous tissues. correspondingly, human s p lyase deficiency results in multiorgan dysfunction including kidney, skin, endocrine gland, and neurologic impairment alongside expected lymphopenia. although severe t cell lymphopenia (< cells/microliter) rivaling that of severe combined immunodeficiency (scid) can be seen in patients with s p lyase deficiency, no such patients have been identified by newborn screening of t cell receptor excision circle (trec) counts, which are a surrogate measure of effective t cell production. herein, we describe an infant boy with an undetectable trec count at birth who was found to have two novel, biallelic sgpl mutations resulting in s p lyase deficiency. case description: a -day-old boy with a preceding history of fetal hydrops is born at a gestational age of weeks and presents with renal failure, anasarca, and respiratory failure. trec analysis of a dried blood spot obtained at hours of life reveals zero copies/microliter. subsequent peripheral blood studies show profound lymphopenia, with diminished cd + t ( /microliter; cd +, cd +), cd + b ( /microliter), and cd / + natural killer ( /microliter) cell counts. recent thymic emigrants are reduced ( . % of cd + t cells are cd ra+cd +), as is the ratio of naïve-to-memory cd + t cells ( % cd ra+, % cd ro+). expedited whole genome sequencing identifies two novel variants in sgpl a paternally inherited splice site variant (c. + t>c) predicted to impact a canonical splice donor site, and a maternally inherited missense change (c. g>a; p.cys tyr) located in a well-established functional domain of s p. in addition to nephrotic syndrome and lymphopenia, the patient displays evidence of adrenal insufficiency and has increased plasma levels of sphingoid bases and ceramides. before further analyses could be pursued, the infant dies at days of age due to ongoing complications of renal failure and eventual cardiorespiratory failure. summary: we report the first case of s p lyase deficiency identified by newborn trec screening for scid. as sgpl is not included in most commercially-available, scid-tailored gene panels, s p lyase deficiency would be missed by conventional genetic testing. therefore, analysis for variants in sgpl should be considered in neonates with low-to-undetectable trec counts, nephrotic syndrome, and other suggestive sequelae. w a r t s , hypogammaglobulinemia, recurrent infections, and myelokathexis) is a rare autosomal dominant primary immunodeficiency. it is caused by a defect in the gene encoding the chemokine receptor cxcr . this receptor, along with the associated ligand cxcl , regulates leukocyte migration. we present the case of a -year-old female, who presented after she self-identified the signature signs of whim syndrome in herself and multiple family members. objectives: we present the case of a -year-old female who presented with a history of recurrent warts, leukopenia of unknown cause, and recurrent infections as a child. as a child, she experienced multiple ear and sinus infections, along recurrent warts on her upper and lower extremities that have persisted to this day. furthermore, during a routine examination when she was -years-old, she had a complete blood count drawn significant for leukopenia. no further workup was undertaken at that time. when continued leukopenia was noted at the age of , referral to a hematologist and a bone marrow biopsy was completed. bone marrow was significant for myelokathexis with borderline hypercellular marrow for patient age ( % cellularity), and normal cell line quantity. a trial of neupoegen was undertaken, without significant improvement. her family history is significant for father and brother with both leukopenia and recurrent warts. results: genetic analysis showed a heterozygous pathogenic variant in the cxcr gene, c. _ dup (p.ser phe fs* ). recent complete blood count was significant for a total wbc count of . k/ul, with a differential consisting of % neutrophils and % lymphocytes. lymphocyte subsets were significant for quantitatively low cd +, cd + and cd + subsets, with normal numbers of cd + and nk cells. immunoglobulin levels revealed an igg of mg/dl, iga of mg/ dl, and igm of mg/dl; igg anti-diphtheria and tetanus titers were protective, however, none of the s. pneumoniae serotype titers were > . ug/ml. mitogen (pha, cona and pwm) and antigen (candida and tetanus) stimulation of lymphocytes were normal for all stimuli. conclusions: we present the case of a -year-old female with a history of recurrent infections, warts, and myelokathexis. on genetic analysis, she is noted to have a pathogenic mutation of the cxcr gene. the substitution of a phenylalanine for a serine decreases one of the seven serine phosphorylation sites in the carboxy tail of the molecule that occurs upon binding to its ligand, cxcl (sdf ). additionally, the variation generates a premature stop condon terminating the remainder of the carboxy terminal amino acids including ser - , known to have a role in carboxy terminial beta-arrestin binding. failure to generate adequate beta-arrestin binding sites leads to prolonged cxcr cxcl interaction resulting in myelokathexis. background: lacking protective antibodies, patients with primary antibody deficiencies (pad) suffer from frequent respiratory infections leading to chronic pulmonary damage. macrolides prophylaxis has been proven effective to successfully manage chronic lung diseases as cystic fibrosis, bronchiectasis, copd. we conducted a trial to evaluate the efficacy and safety of orally low-dose azithromycin prophylaxis when added to the usual care in pad patients. methods: a -year, phase ii, prospective, multicenter, randomized, double-blind, placebo-controlled trial on pad patients (age - years) with chronic infection-related pulmonary disease. patients received azithromycin mg or placebo once daily three-times a week for months. the primary outcome was the decrease of annual episodes of respiratory exacerbations. secondary endpoints included: time to the first exacerbation, number of hospitalizations, additional doses of antibiotics, health related quality of life measures, and safety. results: forty-four patients received azithromycin and patients received placebo. the mean number of exacerbations was · per patientyear ( %ci · - · ) in the azithromycin arm, and · ( %ci · - · ) in the placebo arm (p= · ). in the azithromycin group the hr for having an acute exacerbation was · ( %ci , - · , p= , ) and the hr for hospitalization was . ( %ci , - · ) (p= · ). the rate of additional antibiotic treatment per patient-year was · ( %ci · - · ) in the intervention and · ( %ci · - · ) in placebo groups (p= · ). improvement in hrqofl was observed in intervention group. azithromycins safety prole was comparable with placebo. conclusion: in pad with respiratory exacerbation, azithromycin prophylaxis led to reduction of exacerbation episodes, of additional courses of antibiotics, and of risk of hospitalization. given the deleterious effects of respiratory diseases adding azithromycin to pad treatment should be considered as a valuable option. background: the autosomal-dominant hyper-ige syndrome (hies), is a primary immunodeficiency caused by mutations in signal transducer and activator of transcription (stat ) that leads to defective th immunity. adverse reactions following -valent pneumococcal polysaccharide vaccine (ppsv ) have been reported in % of stat -hies patients, including severe local reactions that appear to be specific to this vaccine. case report: we present the case of a six-year-old girl, second child of nonconsanguineous healthy parents, that developed an extensive inflammatory skin reaction at the vaccination site following a single dose of ppsv . the vaccine was prescribed due to history of recurrent respiratory tract infections and an incomplete vaccine calendar with no previously administered pneumococcal vaccines. the reaction began after hours with local erythema and edema at vaccination site, expanding in hours to a phlyctenular lesion with no well-defined borders. within the first weeks, it progressively evolved to a deep necrotic lesion that required surgical debridement. the subsequent skin defect required surgical repair with a split-thickness skin graft from her right thigh as the donor site. the complete wound healing process took about months, leaving a large scar ( figure) . the patient had a longstanding history of recurrent infections with multiple hospitalizations including severe neonatal pneumonia that required respiratory support, a colon perforation with secondary peritonitis and septic shock that required a hemicolectomy at months of age, recurrent oral candidiasis, recurrent pneumonias of different lobes, recurrent acute otitis media, a cervical phlegmon, three episodes of dental abscess and multiple kidney abscesses due to gram-negative bacteria treated with intravenous antibiotics and surgical drainage. family history is notable for an older sibling that died due to sudden infant death syndrome. the patients mother has large and wide nose suggestive of stat -hies phenotype, but no history of infections. immunological work up showed mild eosinophilia ( cells/ mm ), elevated ige ( mg/dl), normal igg, iga, igm and lymphocyte subsets (cd , cd , cd , cd , cd ). peripheral th cells were markedly decreased ( . % vs. . % of normal control). specific pneumococcal antibodies evaluated month after psv revealed / serotypes in protective levels. high resolution thorax ct showed multilobar bronchiectasis. echocardiogram and total spine x-rays were normal. stat -hies was suspected with a national institutes of health score of . a novel heterozygous missense variant in stat affecting the src homology (sh ) domain (p.lys glu) was found by next-generation panel sequencing. a variant in the same position (p.lys met) has been previously reported in a hies patient (clinvar). currently, she is on monthly ivig and prophylactic antibiotics (cotrimoxazole, azithromycin and fluconazole). conclusions: the case presented raises awareness on the risk of severe local adverse reactions to ppsv in stat -hies patients. the etiology of such reactions is unclear and warrants further study. the benefits and risks of immunizing stat -hies patients with ppsv should be weighed carefully by medical providers. abstract (max words) introduction: dock deficiency is a rare primary immunodeficiency characterized by susceptibility to viral infections, atopic eczema, defective t-cell activation and th differentiation, impaired eosinophil homeostasis and dysregulation of ige. to date, there are no reported cases from malaysia. objective: we aimed to describe the clinical, immunological profile and mutational analysis of three siblings of consanguineous parents, presented with hyper-ige and lymphopenia between the years and , which were solved by mutational analysis of the second and third siblings. methods: clinical data and investigation results were collated from the medical record. scoring of the symptoms and physical examination findings using nih score was performed. t, b, nk lymphocyte subsets and serum igg, iga, igm, total ige quantification, lymphocyte proliferation test and pneumococcal specific antibody response were performed. mutational analyses were performed in freiburg, germany. result: three siblings presented at different time points over a -year span with raised ige levels, recurrent infections, eczema, hypereosinophilia and bronchiectasis. the nih scores for hyper-ige syndrome (hies) ranged from . we also documented two serious infections in the siblings, which were disseminated cryptococcus neoformans and salmonella sp. immunological results showed t-cell lymphopenia, defective t-cell proliferation, decreased igm, raised ige, hyper-eosinophilia and defective pneumococcal antibody responses present but not in all siblings. we identified a large deletion in dock starting from exon - in of the siblings from mutational analysis performed. we will proceed with next generation sequencing and dock protein assay in malaysia to further characterize the defect. conclusion: our on-going study is the first description of dock in a family from malaysia. the diagnosis of dock should be suspected in cases with raised ige levels, recurrent infections and lymphopenia, despite no warts infection in the history. this study emphasized the importance of international research collaboration and networking in solving complicated cases. the index patient presented at the age of years with increased susceptibility to lower airway and gastrointestinal infections (hospital admissions x/year until puberty). she suffered from mumps and varicella disease despite immunization, as well as from recurrent local, partially destructive hsv infections. she was diagnosed with common variable immunodeficiency (cvid) at age and started on immunoglobulin replacement therapy. following a hypoglycemic seizure at age , the patient was diagnosed with isolated acth insufficiency with secondary adrenal insufficiency requiring hormone substitution. during and following her first pregnancy at age , she suffered from recurrent bronchopneumonias including pneumocystis jirovecii infection, resulting in bronchiectases documented on chest ct at age . currently, chronic lung disease is severely limiting her quality of life (table ) . her daughter was noticed to be hypogammaglobulinemic soon after birth and failed to develop antibody responses to inactivated vaccines. she was started on immunoglobulin replacement therapy. she has not suffered from severe lower airway infections, but developed alopecia totalis at age and nail dystrophy. w h o l e e x o m e s e q u e n c i n g r e v e a l e d a h e t e r o z y g o u s c. _ insacccgag (p.lys profster , nm_ ) mutation in exon of nfkb in both mother and daughter. this monoallelic loss-of function frameshift mutation was not found in gnomad, gvs washington or clinvar databases. as previously published, a monoallelic mutation in this c-terminal domain leads to impaired phosphorylation and subsequent reduced nuclear translocation of the nfkb /p active form. pediatricians and internal specialists need to be aware of the combination of hypogammaglobulinemia, acth deficiency, immune dysregulation and ectodermal dysplasia which is unusual for cvid -possibly indicating nfkb deficiency. this clinical syndrome may overlap with symptoms and signs found in both apeced/ aire (ar) and eda-id/nfkbia (ad) deficiencies. besides ig and hormone replacement therapy, curative treatment with hematopoietic stem cell transplantation is a therapeutic option for patients with nfkb deficiency, although the experience is limited. table introduction: the modes of immunoglobulin (ig) administration for primary immunodeficiency diseases (pidd) differ in pharmacokinetics, infusion parameters, and tolerability. during consecutive clinical studies, a cohort of patients with pidd experienced all modes of administration with the same ig % product in sequence from intravenous (iv) to subcutaneous (sc), then to hyaluronidase-facilitated sc (ighy), providing a unique opportunity to assess each administration modality within the same patient cohort treated and observed at the same sites. here we report the rates of infections stratified by igg trough levels, and the rates of adverse events (aes) with the modes of ig administration (ivig, scig, ighy) within this patient cohort. design and methods: this analysis included patients with pidd aged years who participated in clinical studies: in study (nct ) patients received ivig % every weeks followed by weekly scig %; in study (nct ), patients were treated with ighy every weeks; in study (nct ; extension of study ), patients continued with the same ighy dose. to assess a potential association between the administration route at comparable igg trough levels and the infection rate, igg trough levels were categorized as < mg/ dl, < mg/dl, < mg/dl, < mg/dl, < mg/dl and mg/dl. periods where patients had trough levels within these strata were assessed, and the infection frequency was calculated. the time periods for this analysis were months for ivig and months each for ighy and scig % ( . years) treatments. in order to account for differences in the frequency of administration, rates of systemic and local aes were assessed as aes/patient-year for each mode of therapy. results: for igg trough levels of < mg/dl, the associated annual infection rates were lower or similar for ighy than scig ( the treatment involves the control of infections and immune dysregulation with chemotherapeutic regimens followed by definitive treatment with hematopoietic stem cell transplant (hsct). aim: to describe a female patient with a pathogenic variation in stx with normal cd a expression. results: she was a years old female, the th daughter of nonconsanguineous parents, without relevant personal or family records. she was admitted due to a prolonged febrile syndrome, lymphoproliferation, pancytopenia and hepatitis, with hhv rescued in bone marrow and blood. gancyclovir treatment started with good response. she was admitted one month later with similar clinical symptoms with relapsed hhv infection. furthermore, hemophagocytosis was found in the bone marrow and evaluation of nk cell cytotoxicity demonstrated slightly reduced cytotoxic activity. functional studies for primary fhl were performed: perforin expression and cd a surface expression were normal. she fulfilled criteria of fhl, and treatment with gancyclovir and steroids was administered. despite this treatment, she persisted with activated macrophagic parameters, and started with hlh treatment protocol. she improved the clinical symptoms and laboratory parameters, but persisted with hhv low viremia. three months later, when immunosupression was decreased, she was readmitted with similar clinical manifestations and added neurological symptoms (facial paralysis, abnormal movements and sleep tendency). cerebral spinal fluid was pathological with hhv positive rescue. immunosupresive treatment was adjusted, but hhv copies in blood increased markedly. foscarnet treatment was administered and immunosupression was suspended for days in order to control viral infection. unfortunately the patient died days later. although specific functional tests were normal, sequencing of stx gene by ngs revealed a homozygous variation in c. _ deltgcc, which is a previously reported mutation responsible for fhl. conclusion: despite the fact that cd a was normal, the strong clinical and laboratory results must keep the fhl diagnosis in mind and intensive treatment should be early administered; in order to give the patient the opportunity to achieve the curative treatment. objectives: to report and characterize the clinical course of a patient with apeced and specific antibody deficiency. methods: retrospective chart review was performed. the patient was enrolled in niaid irb-approved protocol -i- . results: the patient is a year-old-girl with apeced caused by homozygous aire c. _ del , who manifested cmc, hypoparathyroidism, adrenal insufficiency, sjogrens-like syndrome, autoimmune hepatitis, intestinal dysfunction and autoimmune pneumonitis. she suffered from recurrent sinusitis and severe pneumonias requiring hospitalization and administration of intravenous antibiotics several times per year. at age , she presented to our institution with fever and cough, a computed tomography (ct) of the chest revealed bilateral pulmonary infiltrates and bronchiectasis. bronchoscopy showed mucopurulent secretions in the bilateral lower lobes with culture of the bronchoalveolar lavage fluid growing streptococcus pneumoniae. further evaluation for an underlying disorder such as primary ciliary dyskinesia and cystic fibrosis including exome sequencing and sweat chloride testing was unrevealing. quantitative immunoglobulins were normal. despite prior vaccination, specific antibody testing showed negative rubeola igg and protective levels (> . mcg/ml) to only of pneumococcal serotypes. lymphocyte enumeration showed normal b cell subsets. as approximately % of apeced patients may experience asplenia, splenic ultrasound was performed confirming the presence of a cm spleen and peripheral blood smear did not reveal howell-jolly bodies. serotyping of the s. pneumoniae isolate confirmed serotype f, which is part of the -valent vaccine. follow up vaccine challenge with the valent pneumococcal polysaccharide vaccine showed an inadequate response. hence, she was started on monthly immunoglobulin replacement and over the following years she has experienced a single methicillin sensitive staphylococcus aureus pneumonia. she has missed very few school days and other parameters including linear growth have improved, she is now along the fifth percentile for height and along the tenth percentile for weight. although she continues to experience intermittent cough she remains active participating in sports without limitation. conclusions: we report the evaluation, treatment and outcome of a patient with apeced complicated by autoimmune pneumonitis and specific antibody deficiency. as infectious susceptibility of apeced classically pertains to the signature infectious disease, cmc, patients with invasive or recurrent infections should be evaluated for underlying immune deficiency. investigation should include assessment for asplenia, quantitative immunoglobulins and specific antibodies with response to antigens. in patients with predominate respiratory symptoms, autoimmune pneumonitis should be evaluated given the near % prevalence of pneumonitis observed in american apeced patients. acknowledgements: supported by dir/niaid/nih introduction: autoinflammatory diseases are genetically heterogeneous disorders of innate immunity characterized by recurrent fever, rash, and/ or serositis, which generally are considered distinct from autoimmune diseases. we report a case of a patient with lupus-like disease and a mutation of nucleotide-binding oligomerization domain-containing protein (nod r w, yao syndrome) suggestive of an overlap between autoinflammatory and autoimmunity processes. case presentation: a -year-old man was evaluated for recurrent pleural effusions, morning stiffness, erythematous rashes, and fever up to °c. history was notable for hashimotos thyroiditis and multiple admissions for presumed pneumonia with recurrent bilateral lung infiltrates and pleural effusions. transbronchial biopsy showed nonspecific pneumonitis and organizing pneumonia. antinuclear and anti-dsdna antibodies were positive. he received prednisone for presumed lupus pneumonitis leading to improvement. prednisone was tapered and hydroxychloroquine was started, but his fevers, pleuritic pain and pleural effusion reoccurred. genetic testing revealed a nod sequent variant (r w) associated with autoinflammatory disease. hydroxychloroquine was stopped and colchicine was added to his regimen, allowing prednisone to be tapered without recurrence of symptoms. further immunological testing revealed increased signaling through the type i interferon receptor (interferon signature). conclusion: although this patient had several clinical (serositis, arthralgia) and immunological (antinuclear and anti-dsdna antibodies, interferon signature) manifestations of lupus, his clinical presentation also was consistent with yao syndrome. in retrospect, he had been having recurrent inflammatory symptoms for many years. recent studies in both mice and humans suggest that inflammasome activation and il- production are involved in the pathogenesis of lupus. this case provides further support for the idea that lupus and hashimotos thyroiditis, prototypical autoimmune diseases, may have overlapping autoinflammatory features. background: the implementation of severe combined immunodeficiency (scid) newborn screening by trec assay has played a pivotal role in identifying these patients early in life. the screen has also led to the identification of infants with other immunologic abnormalities, of which the clinical implications have been unclear and there are limited data on their outcomes. objective: to review immunologic and genetic outcomes of infants referred to an immunology service of a tertiary care center with abnormal newborn scid screens. methods: we retrospectively reviewed charts of infants with positive scid screen from july to november . we excluded patients who had positive screen at < weeks corrected gestational age. we classified outcomes into groups including scid, non-scid t-cell lymphopenia (nscid-tcl) and normal t-cell count. idiopathic t-cell lymphopenia was defined as nscid-tcl (cd + < , cells/mcl) with negative chromosome microarray and negative whole exome sequencing/or genetic panel (either genedx® scid panel or invitae® primary immunodeficiency panel). results: of infants, % were male, % were caucasian, and % were african-american. fifty-four % and % of infants were identified by illinois and missouri screens, respectively. the mean age at initial evaluation was days ( - days). % of infants had a normal tcell count (n= ) or normal repeat newborn screen (n= ), % had nscid-tcl, including mild (cd + , - , cells/mcl, n= ) and moderate (cd + - , cells/mcl, n= ) tcl, and % had scid (n= ), leaky scid (n= ) or complete digeorge (n= ). genetic etiologies of nscid-tcl included q deletion (n= ), trisomy (n= ), and mutations of tbx (n= ), foxn (n= ), and cd e (n= ). three of these infants had novel variants at the time of diagnosis. secondary causes of tcl were identified in infant (thoracic infantile fibrosarcoma). one infant had idiopathic tcl. eighteen infants with nscid-tcl were followed clinically without complete genetic testing performed. for scid, mutations were found in jak (n= ), ada (n= ), il rg (n= ), and rag (n= ). the patient with leaky scid had negative whole exome sequencing. all patients with scid and leaky scid underwent hematopoietic stem cell transplantation at a median age of weeks ( weeks - months), with successful engraftment in all but patient. of idiopathic and nscid-tcl cases followed clinically, had at least one follow-up visit at median age months ( . months . years) and the majority had improved or stable lymphocyte count without serious infections requiring intravenous antibiotics, though had a hospitalization for rsv infection. the mysm patient died after cord blood transplant from unclear etiology. our study had limitations. half of infants with nscid-tcl did not have a complete genetic workup, and only a fifth of patients with nscid-tcl were inpatients, potentially explaining the relatively low number of infants with secondary lymphopenia. conclusions: in our cohort, one-fourth of infants with abnormal scid screen had nscid-tcl. although the majority of nscid-tcl did well, approximately one-third of them had underlying genetic abnormalities associated with their t-cell lymphopenia. ( ) submission id# introduction: accumulation of intracellular adenosine and deoxyadenosine nucleotides (daxp) due to adenosine deaminase deficiency results in profound lymphopenia and severe combined immunodeficiency. left untreated this form of scid is uniformly fatal. while allogeneic hematopoietic cell transplant (hct) and autologous gene corrected stem cell therapy (gt) are potential cures for ada-scid , initiating enzyme replacement therapy (ert) immediately upon diagnosis regardless of definitive treatment is standard of care. hct and gt are not therapeutic options for all ada-scid patients and ert offers immediate therapeutic intervention for these patients leading to partial immune reconstitution, and durable survival in most patients treated. adagen (pegademase), approved by the fda in in the usa, is a pegylated bovine ada (nada) with the enzyme harvested from bovine intestines. this unsustainable production process led to the development of a recombinant enzyme source based on the bovine protein sequence and an improved pegylated linker by using succinimidyl carbamate (revcovitm-(elapegademase-lvlr). methods: a phase ii/iii clinical trial was performed at us sites under institutional irb approval. eligible ada-scid subjects were stable on adagen and without complicating underlying conditions. demographics, medical history, lymphocyte counts, immunoglobulin levels, trough plasma ada activity and rbc daxp measurements were collected. patients were treated with adagen as a single, weekly im dose adjusted to achieve a trough plasma ada activity of > mmol/hr/l and rbc daxp < . mmol/l (protocol target levels). once patients had achieved this level ( - weeks), a seven-day pk on adagen was done and the patients were transitioned to revcovi based on the formula for enzyme equivalent activity of mg revcovi = units adagen. after weeks on revcovi, trough ada and daxp were assessed and a seven-day pharmacokinetic study was conducted at week . patients were assessed periodically for clinical and laboratory values and evaluation of the study endpoints was done at week . subjects subsequently continued on revcovi and were assessed periodically. results: six patients, ages - entered the trial with initial adagen dosing at . - . u/kg/wk (see table ). adagen dosing was adjusted to target endpoints of ada trough activity (> mmol/hr/l) and rbc daxp (< . mml/l). patients transitioned to weekly revcovi using the aforementioned conversion formula at doses of . - . mg/kg/wk. the spectrum of clinical manifestations range from infections to autoimmunity and inflammation among patients with hypomorphic recombination gene and (rag / ) pathogenic variants. auto-antibodies targeting cytokines ifn-alpha, ifn-omega and il- were reported in a large proportion of these patients and their occurrence often coincides with viral infections. we report the time of emergence and relative frequency of anti-cytokine antibodies in children and adults, and their persistence among patients with hypomorphic rag deficiency. antibodies were measured from plasma samples of patients by enzyme linked immunoassay (elisa). our rag cohort includes patients with rag (n= , %) and rag deficiency (n= , %). antibodies targeting ifn-alpha ( %) were most common followed by il- and ifn-omega ( % each). two asymptomatic patients who were detected by newborn screening for scid and received hematopoietic stem cell transplantation had no detectable anti-cytokine antibodies. in the cohort of young children (ages mo- years, n= ), all patients had detectable antibodies to ifn-alpha, prior history of severe viral infection and subsequently developed autoimmune cytopenias. other anti-cytokine antibodies were less common (ifn-omega %, il- %). similarly, children between - yo age (n= ) also had high fraction of anti-ifn-alpha antibodies ( %) with prior history of infections ( %) and continued to have other anticytokine antibodies less commonly (ifn-omega %, il- %). in the adult cohort (n= , ages - years) the frequency of anti-ifnalpha anti-cytokine antibodies were lower ( %,) and il- and ifnomega ( % each) continued to persist. three adult patients had anticytokine (ifn-alpha, ifn-omega and il- ) antibodies tested at multiple timepoints and elevated titers persisted up to years. our data demonstrates that anti-cytokine antibodies, especially those targeting ifn are frequent and emerge early in life in association with viral infections in patients with rag deficiency. a lower fraction of adult patients have detectable anti-cytokine antibodies, and maintain these over several years. anti-ifn-alpha may serve as a useful biomarker for identifying partial rag deficiency among young and adult patients with history of viral infections and autoimmune cytopenias. the role of these antibodies to cytokines is yet to be determined but a specific signature of these antibodies may help to identify an underlying immunodeficiency and initiate early definitive treatment with bone marrow transplantation. anti-cytokine antibodies appear to be a novel tool in evaluation of autoimmune diseases including rag deficiency. introduction: norovirus is one of the most common pathogens causing gastroenteritis in immunocompromised patients, often leading to chronic infection, causing villous atrophy, malabsorption, weight loss, organ failure, need for parenteral nutrition, and death. norovirus treatment in immunocompromised patients is challenging. oral immunoglobulin (poig) has been used to treat norovirus gastroenteritis with variable success. our aim in this study was to determine the outcomes of treating norovirus gastroenteritis in immunocompromised patients methods: electronic medical records were reviewed for patients with norovirus infection confirmed by rt-pcr since january . our initial cohort was focused on patients with primary immunodeficiency (pid), lung, and liver transplant. data on demographics, immunological phenotype, treatment with poig, the number of bowel movements (bm), and virus clearance were collected. descriptive statistical methods were used to describe treatment outcomes. further analysis of patients immunophenotype, immunosuppression medications, and co-morbid illnesses is underway. results: twenty-six immunocompromised patients ( norovirus infection episodes, as one patient had reinfection) were analyzed twelve females, age range months- years. twelve patients had pid diagnosis ( common variable immunodeficiency, severe combined immunodeficiency, x-linked agammaglobulinemia, wiskott-aldrich syndrome, digeorge syndrome, hyper-igm, stat gain-of-function, nemo and lymphopenia in a patient with trisomy ), patients were status-post liver transplant, and two patients were status-post lung transplant. of patients were on ig replacement therapy at the time of the norovirus infection. the average number of bm/day in all patients was . (range - ) . eight patients received poig ( - mg/kg) weekly for a duration from - weeks. three of those received additional nitazoxanide and received ribavirin. / patients in the poig group were receiving total parenteral nutrition (tpn), and / on no treatment group received tpn. the average number of bm/day in poig before treatment was . (range - ), and . (range - ) in those who did not receive any treatment. of ( %) on poig vs. of ( %) in the no treatment group cleared the virus. the average number of weeks to return to baseline bm was . (range - ) in the poig group vs. . (range days- weeks) in the no treatment group. of on poig continued to have chronic diarrhea that is still ongoing. conclusion: despite anecdotal reports suggesting successful use of poig in immunocompromised patients, our data did not show a significant decrease in stool output in patients treated with poig, compared to no treatment. however, poig led to a higher rate of virus clearance. a study with larger sample size might be warranted to identify the patients who benefit from poig in the context of norovirus infection and ensure the appropriate use of ig products, especially given the concerns for the national shortage of ig products. chief medical officer, novimmune sa primary hemophagocytic lymphohistiocytosis (phlh) is a life-threatening, immune regulatory disorder characterized by immune hyperactivation that is driven by high production of interferon (ifn)-. patients with hlh typically develop fever, splenomegaly, cytopenias and coagulopathy. until recently, there have been no fda approved treatments for hlh, and standard dexamethasone/etoposide-based treatment has not evolved significantly in + years. emapalumab-lzsg (ni- ) is a fully human, anti-ifn-monoclonal antibody that neutralizes ifn-and which was recently approved (november ) by the fda for the treatment of adult and pediatric (newborn and older) patients with phlh with refractory, recurrent, or progressive disease or intolerance with conventional hlh therapy. results of the pivotal trial supporting this approval are presented herein. methods: this open-label pivotal study (nct ) includes patients years with a diagnosis of phlh and active disease. data presented were from patients, of whom had failed conventional hlh therapy prior to study entry. the initial emapalumab-lzsg dose was mg/kg given intravenously every - days. subsequent doses could be increased up to mg/kg based on the evolution of response parameters. dexamethasone was administered concomitantly at to mg/m /day and could be tapered during the study. treatment duration was weeks, with possible shortening to a minimum of weeks, or extension up to the time of allogeneic hematopoietic stem cell transplantation (hsct). the primary efficacy endpoint was the overall response rate (orr) at end of treatment, assessed by pre-defined objective parameters, including normalization or at least % improvement from baseline of fever, splenomegaly, cytopenias, hyperferritinemia, fibrinogen, d-dimer, central nervous system (cns) abnormalities, and with no sustained worsening of scd serum levels. the primary analysis used an exact binomial test to evaluate the null hypothesis that orr be % at a one-sided . significance level. patients were eligible to enter an extension phase for follow-up after completing the main study (nct ). the data cut-off applied is july . results: patient characteristics are summarized in table and efficacy is summarized in table . disease at study entry was consistent with the broad spectrum of phlh abnormalities. over % of patients had signs and/or symptoms of cns disease. orr was significantly higher than the pre-specified null hypothesis of %, meeting the primary endpoint. the response rate based on investigators clinical judgement was . %. emapalumab-lzsg infusions were in general well tolerated, with mild to moderate infusion-related reactions reported in % of patients. the observed safety events (pre-hsct conditioning) mostly included hlh manifestations, infections or toxicities due to other administered drugs. infections caused by pathogens potentially favored by ifn-neutralization occurred in patient during emapalumab-lzsg treatment (disseminated histoplasmosis), and resolved with appropriate treatment. no off-target effects were observed. conclusions: treatment with emapalumab-lzsg was able to control hlh activity with a favorable safety and tolerability profile in a very fragile population. the majority of patients proceeded to hsct with favorable outcomes. our results indicate that emapalumab-lzsg should be considered as a new therapeutic option in phlh thanks to its targeted mode of action. results: a total of genes were differentially expressed between t cells of qds patients (n= ) and healthy controls (n= ) (log fold change range (- . , . )).when these genes were tested for pathway enrichment, the top pathways in t lymphocytes based on their p value included communication between innate and adaptive immune cells, cross talk between dendritic cells and natural killer cells, allograft rejection signaling, dendritic cell maturation, and b cell receptor signaling. the top biological processes with differential expression included immune response, inflammatory response, apoptotic process, interferon gamma mediated signaling pathway, nucleosome assembly, defense response to virus, lipopolysaccharide mediated signaling pathway, positive regulation of nf-kappa b import into nucleus, type i interferon signaling pathway, and neutrophil chemotaxis genes. we compared gene expression between qds participants with low t cell counts (n= ) and qds participants with normal t cell counts (n= ) and found genes that were differentially expressed (q< . ) (log fold change range (- . , . ) patient began experiencing recurrent high fevers and developed splenomegaly. elevated transaminases and concern for lymphoproliferative disease prompted a splenectomy and liver biopsy. both the spleen and liver biopsy were positive for ebv but were negative for malignancy. bone marrow biopsy was unrevealing. genetic testing identified a pathogenic variant in xiap/ birc ( c>t), and the patient was treated with high dose oral steroids resulting in an improvement in symptoms. subsequently, therapy with anakinra was started and steroids were tapered. during the steroid taper, he noticed a change in the vision of his left eye consistent with naion, as well as worsening of his colitis. there was loss of the inferior visual field and fundoscopic exam was significant for left optic disc swelling. oct noted superior retinal nerve fiber layer thinning. oral steroids were restarted with improvement in optic disc swelling, but without improvement or change in vision. as of his most recent exam, the patient has persistent bilateral inferior visual field defects with segmental optic nerve atrophy typical of naion. he has continued therapy with anakinra, and subsequently tapered off of prednisone; though he remains on a physiologic dose of hydrocortisone. conclusions: this case demonstrates an unreported ocular manifestation in a patient with xiap deficiency, which clinically appeared sensitive to immunomodulation. our patient is an unusual candidate for naion due to his young age, the average age of onset being the mid to late s, and lack of vascular risk factors. we hypothesize that his hyper-inflammatory condition contributed to irreversible vascular damage in the optic nerve head, resulting in naion. therefore, it may be useful to consider the involvement of systemic inflammatory and immune dysregulatory conditions when treating patients with atypical naion. additionally, naion should be considered in patients with xiap deficiency and sudden unilateral vision loss. the importance of de novo mutations in causing severe sporadic immune disease is well described, yet significance of such a variation in less severe and later onset of immune disease is poorly investigated. whole exome sequencing has been a powerful tool to resolve and explain the genetic basis of novel syndromes in immune related diseases. however, proving causation can be complicated due to low number of the affected individuals. we performed whole exome sequencing in a cohort of patients with noncongenital immune defects, along with detailed cellular biochemical phenotyping. we report and describe a novel non-congenital combined immune deficiency arising from a de novo gain-offunction mutation in ikbkb(c. g>a). this gene encodes ikk , and activates canonical nfkb signalling. cellular and biochemical studies of the proband revealed that ikk v i results in enhanced nf-kb signaling, as well as t and b cell functional defects. ikk v is a highly-conserved residue, and to prove causation, we generated a crispr/cas mouse model that carry the precise orthologous missense mutation. we show that mice and humans carrying this missense mutation exhibits remarkably similar cellular and biochemical phenotypes. dysregulation in patients. total rna isolated from cryopreserved peripheral blood mononuclear cells was reverse transcribed to generate cdna. we selected four known gata transcriptional targets, gata , gata , tal and zfpm (encoding fog ) and used droplet digital pcr to quantify transcript levels normalized to the low-expressing gene tbp . we used samples from individuals with wild-type gata (wt), known gata mutation patients (mut) and two individuals suspected of gata deficiency but without identified mutation or allelic imbalance (unk , unk ). transcript analysis revealed significantly decreased transcript levels of gata , gata and tal in mut pbmcs compared to wt. most wt samples had higher zfpm transcripts than gata mutated patients however it did not reach statistical significance. strikingly, we were able to use this analysis for two individuals suspected of gata deficiency. in the first case (unk ) a yr old female with primary lymphedema, hypogammaglobulinemia, recurrent infections and possible family history of leukemia was referred for gata testing. no mutation was identified however it was noted that she was homozygous across the gene preventing allelic evaluation. the second patient (unk ), a yr old female, had erethemya nodosa on legs, mycobacteria kansasii and cytopenias. in each of the targets analyzed, transcript levels from unk were lower than the wt samples and in a similar range as the gata mutation samples while unk had a profile consistent with the wt samples. we propose the use of gata targets as surrogate markers in cases where a mutation is not identified and allelic expression analysis is uninformative. are often under-reported and under-recognized. we sought to further understand and evaluate the prevalence, type, and association with serum immunoglobulin e (ige) for cvid patients with atopic manifestations. methods: we performed a retrospective analysis of cvid patients with atopic manifestations in the partners healthcare cvid cohort. we evaluated baseline patient characteristics, atopic diagnoses, and serum ige levels. results: in the partners cvid cohort, the average age was years old (± ) and % female. / ( . %) of patients had a diagnosis of asthma, with the majority of these diagnosed by an allergist ( %) or pulmonologist ( %). eczema/atopic dermatitis was diagnosed in / patients ( %), by either an allergist ( %) or a dermatologist ( %). allergic rhinitis was diagnosed in / ( . %) with positive skin prick testing in % of these patients. food allergy was diagnosed in patients ( . %). the median cohort serum ige was . iu/ml. the median serum ige was higher in patients with or more atopic complications compared to those with one or less atopic condition ( vs. iu/ml), which was statistically significant (p= . ). conclusions: we report higher rates of atopy than previously described in other cvid cohorts. consistent with previous reports, we find a low median cohort serum ige level in cvid patients compared to the general population. however, we identify a subset of patients with a predisposition towards atopy and higher ige levels within the broader characterization of cvid, and these patients may have a more specific molecular diagnosis that leads to elevated ige and atopic conditions. whole exome sequencing is underway to further evaluate this hypothesis. whim (warts, hypogammaglobulinemia, infections, and myelokathexis) syndrome is a primary immunodeficiency with autosomal dominant inheritance. in most patients, the genetic cause of the disease is a gain-offunction variant in c-x-c chemokine receptor type (cxcr ) that results in arrest of neutrophil migration from the bone marrow. most patients develop hypogammaglobulinemia and early waning of antibody response with vaccination. however, the exact origin of aberrant humoral immunity in whim syndrome patients is yet to be clarified. here we describe a -year-old iraqi female with a heterozygous cxcr p.ser ter variant, which is presented with haemophilus influenzae meningitis, history of tetralogy of fallot, early onset intermittent neutropenia, lymphopenia, recurrent bacterial and viral infections. immunologic evaluation revealed hypogammaglobulinemia, elevated igm level and a lack of protective vaccine titers after tetanus and prevnar vaccinations. a bone marrow biopsy was consistent with myelokathexis. immune phenotyping, functional studies and apoptosis assays were performed on peripheral blood cells by flow cytometry in our whim patient and controls. although we found that all lymphocyte compartments were reduced, naïve cd t helper cells and switched memory b cells were predominantly affected. spontaneous apoptosis was most pronounced in b rather than t cell compartments in whim patients. in addition, naïve b cells easily activated and died upon activation in vitro. cxcl , a ligand of cxcr , induced elevated t helper cell migration and increased actin polymerization in p.ser ter mutant cells. we conclude that intrinsic b cell abnormalities, such as increased rate of apoptosis and altered activation, might be responsible for defective antibody response in whim patients. although most individuals effectively control herpesvirus infections, some suffer from unusually severe and/or recurrent infections requiring anti-viral prophylaxis. a subset of these patients possesses defects in nk cells, innate lymphocytes which recognize and lyse herpesvirus-infected cells; however, the exact genetic etiologies are rarely diagnosed. plcg encodes a signaling protein in nk cell and b cell receptor-mediated signaling. dominant-negative or gain-of-function mutations in plcg cause cold urticaria, antibody deficiency, or autoinflammation. however, loss-of-function mutations and plcg haploinsufficiency have never been reported in human disease. we examined families with autosomal dominant nk cell immunodeficiency with mass cytometry and whole-exome sequencing to identify the cause of disease. we identified two novel heterozygous loss-of-function mutations inplcg that impaired nk cell function, including calcium flux, granule movement, and target killing. although expression of mutant plcg protein in vitro was normal, phosphorylation of both mutants was diminished. in contrast to plaid and aplaid, b cell function remained intact. plcg +/-mice, as well as targeted crispr knock-in mice, also displayed impaired nk cell function with preserved b cell function, phenocopying human plcg haploinsufficiency. we report the first known cases of plcg haploinsufficiency, a clinically and mechanistically distinct syndrome from previously reported mutations. therefore, these families represent a novel disease, highlighting a role for plcg haploinsufficiency in herpesvirus-susceptible patients and expanding the spectrum of plcg -related disease. we pursued genetic diagnosis, which identified bi-allelic frameshift mutations in the rag gene which had not been previously described: c. delg (p.v sfsx ) and c. _ del insaaaagagtg (p.v kfsx ). taken together, his presentation suggested significant immune dysfunction had evolved since transplant leading to extensive pulmonary nontuberculous mycobacterial infection and possible bronchiolitis obliterans. he therefore will undergo a subsequent unconditioned cd + stem cell boost from his sister, the original donor, once he completes mycobacterium abscessus treatment. this case highlights the potential long-term immune dysfunction which may evolve after unconditioned allogeneic stem cell transplant for scid, in which full engraftment in all myeloid and lymphoid compartments is not expected. it also highlights the importance of guideline-driven follow-up of these patients to monitor for said dysfunction, to prevent serious infection and long-term sequelae. somatic hypermutation (shm) in the b cell receptor (bcr) heavy (igh) and light chain genes promotes affinity maturation and also mutation away from self-reactivity, therefore serves as an important peripheral tolerance checkpoint. as an example, unmutated bcr ighv - genes give rise to antibodies that bind to i/i antigen on red blood cells (rbc) and may elicit cold agglutinin disease (cad), a variant of autoimmune hemolytic anemia (aiha). in case of healthy individuals, frequent shms in the i/i binding site of bcr ighv - genes decrease rbc reactivity and cad. patients with primary immunodeficiencies (pid) paradoxically develop autoimmune diseases, including autoimmune cytopenias, especially aiha. it is unclear if impaired shm of bcr, in particular mutation away from i/i binding, is relevant in the development of rbc reactivity and consequently aiha in a pid background. our studies focus on pid patients with hypomorphic recombination activating gene (rag and ), combined immunodeficiency phenotype and history of autoimmunity, in particular aiha (rag cid/ai). we detected increased frequency of unmutated ighv - bcr in memory b cell repertoires of rag-cid/ai patients as well as elevated titer of unmutated ighv - antibodies in the patients' plasma. lower level of shm likely reflect abnormal germinal center (gc) reaction. as rag and heterotetramer primarily shapes the pre-immune t and b cell repertoire, we studied the interaction of follicular helper t cells (tfh) and naive b cells via in vitro co-culture experiment. interestingly, tfh cells from rag cid/ai patients exhibited highly activated phenotype with increased expression of cd l and il- compared to healthy controls and were able to initiate exaggerated response (class switching and shm) of healthy donor naive b cells. on the contrary, in vitro activated naive b cells from rag cid/ai patients showed impaired proliferation, class switching and decreased level of shm with diminished induction of genes involved t cell co-stimulation (cd , il- r) and shm (aicda, repair enzymes) compared to healthy donor naive b cells indicating intrinsic defect in patient b cells. furthermore, b cells from rag cid/ai patients also showed increased apoptosis and accumulation of gamma-h ax foci at steady state indicating reduced cellular fitness. these findings suggest that the development of aiha is a multifactorial process in partial rag deficiency. our studies highlight that impaired germinal center reaction is an important tolerance checkpoint with the inability of patient's b cells to respond to hyperactive tfh cells and introduce proper level of shm. hence, we propose that b cell fitness is compromised which impairs proper gc interaction, shm, including mutation away from self and sustains rbc reactivity in hypomorphic rag deficiency. introduction/background: the forkhead box n (foxn ) transcription factor is an essential regulator of t cell development, affecting the differentiation and expansion of thymic epithelial cells (tecs). autosomal recessive mutations in foxn cause a t-b+nk+ lymphocyte phenotype due to a thymic aplasia in conjunction with alopecia universalis and nail plate dystrophy resulting from keratinocyte dysregulation. this is a classic nude/scid (omim # ) phenotype. we report on the identification of two independent patients, identified through newborn screening with absent trecs and with a t-nk+b+ scid phenotype who presented with a t cell lymphopenia who had compound heterozygous mutations in foxn . notably, these individuals had normal hair and nail beds. objectives: to determine whether distinct compound heterozygous mutations in foxn cause a novel t-nk+b+ phenotype in the absence of a classic nude presentation. neutralizing autoantibodies (autoabs) against cytokines increase the susceptibility for selected infections (e.g. anti-ifn-autoabs for nontuberculous mycobacteria and non-typhoid salmonella, anti-il- -autoabs for mucocutaneous candidiasis and anti-gm-csf-auotabs for infections by cryptococcus, nocardiae and aspergillus spp). however, the role of anti-il- -autoabs is less clear. il- is a key mediator of the acute-phase response and released early in bacterial infections. patients with impaired signaling or affected production of il- are at increased risk for severe bacterial infections. only three patients with high-titer and neutralizing anti-il- -autoabs who suffered from severe infections caused by s. aureus, s. intermedius and e. coli have been described so far. to investigate the prevalence of anti-il- -autoabs in patients with bacterial infections, we investigated a cohort of patients and identified three further patients, all previously healthy, with neutralizing auotabs against il- who hardly developed an acute-phase response. the first patient suffered from life-threatening pneumonia caused by s. pneumonia, the second patient developed a submandibular abscess and septic arthritis caused by s. pyogenes and the third patient suffered from life-threatening pneumonia caused by s. aureus. we also discovered neutralizing anti-il- -autoabs in two adults among a cohort of patients with autoimmune diseases (n = ), in one adolescent among a cohort of obese individuals (n = ) as well as in three mothers of neonates with impaired il- signaling. so far none of the later individuals developed a severe bacterial infection. this suggests that naturally occurring and neutralizing anti-il- -autoabs are a risk factor for severe bacterial infections yet with incomplete penetrance. ( ) submission id# persistent transaminitis in copa syndrome researcher, immunodeficiencies research unit, national institute of pediatrics, mexico city social service intern, immunodeficiencies research unit, national institute of pediatrics pediatrics resident, pediatrics hospital, st century national medical center, mexican institute of social security researcher, data science department, mexican autonomous institute of technology researcher, department of research methodology, national institute of pediatrics background: inborn errors of immunity constitute a heterogeneous group of over individually rare congenital diseases that involve genes coding for proteins of the immune system, and which result in increased susceptibility to infection, inflammation, autoimmunity, allergy and cancer. the complexity of the diagnostic task, and the intrinsic biases and limitations of the human mind, can be aided by computational tools. among the available machine learning approaches, decision tree algorithms select the best node to split based on entropy and information gain; random forests build hundreds or thousands of decision trees randomly (bootstrapping), to improve accuracy and reduce overfitting. aim: to implement a machine learning-assisted clinical decision support system for the diagnosis of inborn errors of immunity (iei). methods: with a local database of patients with suspected iei, we built a decision tree using c . dtc, and a random forest on python (jupyter notebook, scikit, mathplotlib, pandas, numpy). the database was obtained by conducting an electronic search on medsys of patients with the term immunodeficiency in their electronic medical records, and then hand-picking cases in which an iei had been confirmed or ruled out. it consisted of patients, of which had been diagnosed with iei. we first split the dataset randomly into training ( %) and testing ( %) sets. the decision tree was tasked with classifying correctly pid or not. after running the algorithm in the training set, we evaluated in the testing set. the random forest classified all cases by majority vote into nine groups ( to ), according to the iuis pid group. next, we repeated the process on a larger scale with a dataset of , patients from usidnet. accuracy was assessed by out-of-bag (oob) error estimates. results: accuracy was greater than % for the local dataset (pid/ not, groups), and for the usidnet dataset ( groups). we provide a list of decision nodes and a diagnostic route with those questions that achieved a greater information gain and less entropy. this might help clinicians direct their interrogation and diagnostic approach of suspected iei patients. discussion: we built two classification models. decision trees lend themselves more easily to learning and deriving rules of thumb from their sequences. random forests are more robust and better suited for categoric (as opposed to binary) classification. we next want to develop a chatbot that will ask relevant questions in optimal sequence, and extract undiagnosed patients with suspected iei, based on statistical red flags. researcher, immunodeficiencies research unit, national institute of pediatrics, mexico city dna repair defects are inborn errors of immunity that result in increased apoptosis and oncogenesis. dna ligase -deficient patients suffer from a wide range of clinical manifestations since early in life, including: microcephaly, dysmorphic facial features, growth failure, developmental delay, mental retardation; hip dysplasia, and other skeletal malformations; as well as a severe combined immunodeficiency, radiosensitivity and progressive bone marrow failure; or, they may present later in life with hematological neoplasias that respond catastrophically to chemo-and radiotherapy; or, they could be asymptomatic. we describe the clinical, laboratory and genetic features of five mexican patients with lig deficiency, together with a review of other patients available in pubmed medline. four out of five of our patients are dead from lymphoma or bone marrow failure, with severe infection and massive bleeding; the fifth patient is asymptomatic despite a persistent cd + lymphopenia. most patients reported in the literature are microcephalic females with growth failure, sinopulmonary infections, hypogammaglobulinemia, very low b-cells, and radiosensitivity; while bone marrow failure and malignancy may develop at a later age. dysmorphic facial features, congenital hip dysplasia, chronic liver disease, gradual pancytopenia, lymphoma or leukemia, thrombocytopenia and gastrointestinal bleeding have been reported as well. most mutations are compound heterozygous, and all of them are hypomorphic, with two common truncating mutations accounting for the majority of patients. stem-cell transplantation after reduced intensity conditioning regimes may be curative. department of laboratory medicine, clinical centre immunology, allergy and rheumatology division, department of pediatrics, baylor college of medicine, texas children's hospital, houston,texas, usa laboratory of clinical immunology and microbiology, fungal pathogenesis section, national institute of allergy and infectious diseases, department of intramural research, national institute of allergy and infectious diseases (niaid), national institute of health, bethesda maryland, usa card deficiency is an autosomal recessive primary immunodeficiency known to underlay increased fungal infection susceptibility mostly presenting as invasive cns candida infections (in infancy or adulthood) and dermatophyte infections. more recently, a rare card variant (c. + g>c, leading to exon skipping, card del ) showed a significant protective association towards inflammatory bowel disease (ibd) when present in heterozygosity. at the nih we studied an -year-old male patient (p ) born to a non-consanguineous marriage who presented as an infant with recurrent/severe thrush, candida esophagitis, and an episode of tinea pedis; p also has mild hypogammaglobinemia (igg mg/dl at age y). p s gdna was tested by whole exome sequencing and showed a card c. + g>c mutation in homozygous state. segregation analysis and sanger confirmation determined that both parents and p s elder brother carried the same variant in heterozygosity, while his asymptomatic younger brother (p ) was also homozygous. as previously described, this variant caused card exon deletion as determined in p and p s pbmcs by cdna sequencing and by a lower molecular weight card protein by immunoblot evaluation. p and p s pbmcs, as well as the heterozygous parents cells, showed a defective cytokine generation (tnf-, il- , il- and gm-csf) in response to heat killed candida (hkc), but not to lps. while patients pbmcs failed to induce phospho-erk and phospho-p- upon hkc-stimulation but presented an intact response to pma+ionomycin; the parents cells responded normally to both stimuli. moreover, t-cell activation and proliferation was affected in response to hkc but not to pha in both patients, whereas the parents exhibited normal results under the same conditions. when hek cells were transiently transfected with wt or card del vectors together with a trim plasmid (e -ubiquitin ligase, naturally associated to card ), we confirmed that card del failed to bind trim by immunoprecipitation. furthermore, malt , bcl and trim were only co-precipitated by wt card , but no by card del , strongly suggesting trim is an integral part of the card /bcl /malt -cbm-complex. in summary, herein we demonstrate that the card del allele fails to bind trim , and in turn is unable to conform a complete/functional cbm complex. our data also show that card del acts in a dominant negative fashion in terms of cytokine generation (previously reported), but one wt allele seems sufficient to generate normal levels of hkcinduced p-erk and p-p- , as well as t-cell proliferation. while decreased cytokine generation associated with card del in heterozygosity has been described to be sufficient to protect towards ibd, other defective pathways are affected in homozygosity and likely necessary to confer increased susceptibility to fungal infections. altogether these results suggest that card del acts through a gene dosage mechanism that can dissect pathways that associate ibd protection and fungal infection susceptibility. further work is warranted to explore card del role, if any, in b-cell and t-cell biology. professor, endocrinology, university of michigan medical school background: acquired generalized lipodystrophy (agl) syndromes are a heterogeneous group of diseases characterized by selective dysfunction and loss of adipose tissue after birth. this causes ectopic lipid deposition and deficiency of the adipokine leptin, which promotes metabolic dysfunction through impaired glucose handling resulting in insulin-resistant diabetes mellitus, dyslipidemia and steatohepatitis. while the metabolic effects of altered adipokine secretion are known, the molecular mechanism is less clear. many agl cases are suspected to have an autoimmune etiology. effector and regulatory t cells, dendritic cells and macrophages reside in normal adipose tissue. t cells within adipose tissue highly express pd- and regulatory t cells express ctla , which limits immune activation in the adipose tissue under normal circumstances. thus, inhibition of these immune checkpoints may hypothetically cause immune activation, leading to adipocyte dysfunction and autoimmune destruction. we have encountered two cases that raise clinical concern for this process. patient cases: patient is a -year-old female who presented with failure to thrive at months. she was diagnosed with insulin-resistant type diabetes and hypertriglyceridemia at ages and years with progressive subcutaneous fat loss and low leptin levels culminating in a diagnosis of agl. her childhood clinical course was complicated by hypertrophic cardiomyopathy, hepatomegaly, autoimmune hemolytic anemia with massive splenomegaly and severe chronic diarrhea secondary to autoimmune enteropathy. she presented at years with acute liver failure, thrombotic microangiopathy, nephrotic syndrome and progressive kidney insufficiency. evaluation for her multi-faceted autoimmune presentation identified a familial heterozygous pathogenic variant in the ctla gene (c. _ insgttgg,p.ala glyfster ). despite aggressive immune therapies, including ctla -ig (abatacept), her kidney disease and enteropathy have progressed. patient is a -year-old male diagnosed with localized malignant melanoma of the right neck in july . he underwent excisional biopsy and regional lymph node dissection with negative margins. he relapsed in november and underwent a modified radical neck dissection with lymph node positive for disease and received external beam radiation from january-february . additionally, he was started on anti-pd- therapy with the humanized antibody drug pembrolizumab in april but discontinued the drug in february in the setting of toxicities including hypothyroidism. subsequently, he developed up to . % weight loss with progressive loss of subcutaneous fat first in his face, then generalized to the rest of his body. in the ensuing months, imaging with pet-ct demonstrated loss of subcutaneous fat concurrent with elevations in alt and triglyceride levels plus a low leptin level consistent with agl. conclusion: these cases raise concern that inhibition of the immune checkpoints ctla and pd- may facilitate the development of agl. we hypothesize that these defects significantly increase t cell autoimmune activity in the adipose tissue and/or alter t cell metabolism resulting in agl. disorders of immune dysregulation should be considered in the etiology of agl. similarly, patients with either genetic or pharmacologic inhibition of immune checkpoints should be monitored for the development of agl with careful physical exam and periodic monitoring of glucose and triglyceride levels. background: rosai-dorfman disease (rdd; also known as sinus histiocytosis with massive lymphadenopathy) is a rare non-langerhans cell histiocytosis. it is characterized by proliferation and accumulation of activated histiocytes in affected tissues. classically, rdd presents with bilateral, non-tender, and often markedly enlarged cervical lymphadenopathy. case presentation: a -year-old female presented with a -week history of asymptomatic, persistent and bilaterally enlarged cervical lymph nodes. she was otherwise healthy with no significant past medical history. operative excision biopsy of the largest lymph node confirmed the diagnosis of rdd. three months following diagnosis, routine bloodwork revealed that she had developed lymphopenia (lymphocyte count . x /l). between -year and -and-a-half-years post-diagnosis, the patient was hospitalized and treated with intravenous antibiotics for presumed episodes of osteomyelitis and presumed episodes of lymphadenitis. given the recurrent presumed infections and persistent lymphopenia, the patient was referred to immunology for evaluation. she received a full immunologic work-up. lymphocyte immunophenotyping revealed low cd ( cells/mm ) and low cd ( cells/mm ) counts. the rest of her immunologic work-up was within normal limits. approximately -and-a-half-years post-diagnosis, the decision was made to initiate treatment for rdd. she was started on a -week tapering course of prednisone therapy. within -weeks of starting corticosteroid therapy, the lymphadenopathy had diminished, and by -weeks, the lymphopenia completely resolved. at her most recent clinic visit, she had been free of serious infections for more than -years, and her lymphocyte counts had remained stable and within normal limits for over one year. discussion: in the literature, immune system dysfunction has been reported in rdd, with both auto-antibodies and cellular immunodeficiency implicated. in this patient, the persistent lymphopenia and recurrent episodes of presumed infections appeared consistent with an immunodeficiency. given the known association of rdd with immunologic dysfunction, this was certainly a reasonable assumption; however, when these issues resolved following corticosteroid therapy, we questioned whether her clinical presentation could instead represent a manifestation of her underlying rdd. this case highlights the diagnostic challenge of differentiating between an infection and an rdd exacerbation. the episodes of presumed infections were considered probable but not confirmed with microbiologic or histopathologic specimens. the mechanism underlying lymphopenia in rdd is not clear but may involve decreased production, increased destruction, or sequestration of lymphocytes. to our knowledge, this has not been specifically studied in rdd in the past, however lymphopenia has been linked to lymphocyte maldistribution in other diseases. for example, studies have shown that experimentally altering either the surface of the lymphocyte or the environment through which the lymphocyte travels through can cause sequestration of lymphocytes in various lymphoid organs including lymph nodes. conclusion: we describe the case patient with rdd that developed persistent lymphopenia, and multiple episodes of presumed infections resulting in hospitalization and intravenous antibiotic therapy. her lymphopenia resolved and she had sustained remission of rdd following treatment with corticosteroids. we hypothesize that lymphocyte sequestration in enlarged lymph nodes may have resulted in lymphopenia. this, combined with recurrent rdd exacerbations that clinically resemble infections created a presentation that mimicked an immunodeficiency. background: there is an expanding spectrum of immunodeficiency phenotypes linked to dna repair defects, and some patients may not be diagnosed until adulthood. the most well recognized genetic defect linked to dna repair is in the gene, ataxia telangiectasia mutated (atm), which causes ataxia telangiectasia, characterized by combined immunodeficiency, neurodegeneration, radiation sensitivity, and ocular telangiectasias. however, there are several other dna repair defects associated with immunodeficiency, including some syndromic and severe combined immunodeficiency (scid) disorders. objective: we present the case of an adult patient with prolonged history of recurrent infections, facial abnormalities, and autoimmunity who was found to have radiosensitivity suggestive of a dna repair defect. methods: retrospective chart review, immunodeficiency evaluation, flow-based radiosensitivity assay, gene sequencing. results: a -year-old female was referred to our clinic due to a complex history of recurrent infections and immune dysregulation. the patient had a lifelong history of sinopulmonary infections and panhypogammaglobulinemia with low vaccine responses, leading to a diagnosis of common variable immunodeficiency (cvid), necessitating treatment with immunoglobulin replacement. clinical features were also notable for congenital dysmorphia (strabismus, thin and angular face, high arched palate, nasal septal defect, small mouth, missing dentition, clinodactyly, severe equinovarus, and scoliosis). she was subsequently diagnosed with autoimmune features of vasculitides requiring trial of cyclophosphamide, azathioprine, rituximab and belimumab, which was later discontinued due to neutropenia and worsening sinopulmonary and skin infections despite immunoglobulin replacement. in the course of our evaluation she was revealed to have severe b cell lymphopenia ( %), cd naïve t cell lymphopenia, persistent iga and igm deficiency one-year post rituximab therapy, and elevated alpha fetoprotein (afp). radiosensitivity assay revealed decreased atm phosphorylation and elevated levels of h ax -hours after low-dose ( gy) radiation in her lymphocyte subsets (t, b and nk cells) . due to the evidence of radiosensitivity and elevated afp levels, there was concern for an atm or other genetic defects in a dna repair pathway. therefore, a targeted (primary immunodeficiency genes) panel was pursued for genetic testing ( genes, invitae, san francisco). the evaluation did not identify a variant in the atm gene but rather a variant of uncertain significance was identified in the chd gene, in exon , c. g>a (p.gly arg), which may be mosaic. this variant has not been reported in population databases. chd is typically associated with charge syndrome, and while this patient has some dysmorphic features, she is not typical for charge syndrome. currently, studies on copy number variation (cnv) and deep intronic variants in atm are pending. conclusion: dna repair defects may occur in adult patients with a primary diagnosis of cvid. our patient exhibits some phenotypic features of both a chd variant, and atm leading to possible abnormal dna damage responses (ddr). the exact cause of the immune deficiency in our case remains presently unsolved. this case highlights the relevance of both functional studies and genetic evaluation of complex cases of immune dysregulation, for improving our understanding of the phenotypic variability in these immunological disorders. background: womens health issues in patients with immunodeficiency are largely underrepresented in the literature. there are no studies assessing for fertility issues in patients with antibody deficiencies, and there are few sizable studies examining pregnancy and outcomes on progeny in the same cohort. the two largest studies of pregnancy in antibody deficiency, an idf survey and a study of the czech population, provide conflicting data about the safety of pregnancy for these patients. immunoglobulin replacement has been shown to be safe and beneficial in pregnancy for patients with cvid, however, dosing strategies are unguided. we sought to further understand these and other issues associated with fertility and pregnancy in a large cohort of patients with antibody deficiencies. methods: we performed a retrospective chart review of over patients with icd and/or icd codes of cvid or another antibody deficiency from january to december . inclusion criteria also comprised of having reached at least years of age, the beginning of child bearing years. data collected included disease characteristics, comorbidities, laboratory values, and outcomes. this was followed by a phone survey to elucidate data regarding fertility, pregnancy, delivery complications, and outcomes of children. this study was irb approved. results: the current age of women included ranged from to years of age, currently being in childbearing years to being post-menopausal. forty percent of the women had been pregnant, delivering an average of babies per woman who had been pregnant. fertility issues were not a prominent factor for women who never became pregnant. a majority of women who had babies ( %) did not receive a diagnosis of antibody deficiency until after their child bearing years. recurrent upper respiratory tract infections, bacterial sinusitis, and urinary tract infections during pregnancy were common even in those not yet diagnosed with antibody deficiency. immunoglobulin levels and dosing of intravenous and/or subcutaneous replacement were recorded for a subset of patients with recent pregnancies. the data re-enforced that increases in dosing are needed in the third trimester. cord blood igg levels were also recorded for baby and were the same or higher than the mothers most recent igg prior to delivery. it was rare for children of our patients to be diagnosed with antibody deficiency or a related condition, although cvid, hypogammaglobulinemia, combined immunodeficiency, lymphoma, rheumatoid arthritis, and other diagnoses were found. conclusion: this is the largest report of outcomes before, during, and after pregnancy for patients with antibody deficiencies in the united states. this report highlights the importance of closely monitoring women during pregnancy for recurrent infections regardless of whether a diagnosis of antibody deficiency is present. it also highlights that close monitoring of igg levels during pregnancy is necessary for women with antibody deficiencies. backgrounds: autoinflammatory diseases (aids) are a group of disorders with an inborn error of innate immunity, characterized by recurrent episodes of fever and inflammatory attacks. the spectrum of aids is expanding, but no data on clinical presentation and symptom variability exist for the iranian population for timely precise diagnosis. this study aims at establishing the first autoinflammatory registry of an iranian population focusing on the clinical and laboratory features that may help clinicians toward a better understanding and diagnosis of these disorders. methods: clinical and laboratory characteristics of patients who clinically and or genetically diagnosed with aids collected. we used the updated version of classification criteria from the eurofever registry for the clinical diagnosis. results: in our retrospective study, clinical and laboratory characteristics of the participants collected. mean age of disease onset, disease course manifestation, the mean duration of episodes, atypical symptoms, laboratory and imaging studies as well as complications, and response to treatment also reviewed. data resulted in patients of whom were male. their age ranged from to years. out of were genetically diagnosed. familial mediterranean fever (fmf) was the most common clinically and genetically approved diagnosis. there were also patients suspected of nlrp and nod mutations. age at disease onset differed variably and ranged from the neonatal period to adulthood. fever was present in all the participants and the duration of episodes was - days. the frequency of attacks was between to more than per year. some of the common clinical manifestations were as follows: myalgia or fatigue ( %), arthralgia and arthritis ( %), abdominal pain ( %), aphthous stomatitis ( %), chest pain ( %), chronic gastrointestinal symptoms ( %), skin lesion ranging from urticarial rash and severe nodular acne to pyoderma gangrenosum ( %), exudative and or erythematous pharyngitis ( %), consanguineous parents ( %), symptoms of a type of allergy ( %), lymphadenopathy ( %), splenomegaly ( %), increased acute phase reactant ( %), elevated liver function test ( %) . out of of the individuals reported positive family history and in one of the cases, a patient carrying the homozygous mutation in the mefv gene has shown no clinical manifestation. conclusion: this study highlights the most common manifestations of aids in the population of iranian origin and can be used as evidencebased clinical criteria for their diagnosis. background: the term benign ethnic neutropenia (ben) is used to describe patients of african/arabic descent with absolute neutrophil counts (ancs) less than cells/ul in the absence of other causes. historically, race has been used to support the diagnosis of ben, but self-reported race is notoriously imprecise. the duffy null phenotype (fya -/fyb-) is a known molecular cause of ben and may be a more reliable marker of ben than self-reported race. in addition, although the anc is known to be lower in patients with ben, the lower limit of ancs is poorly described. it is important to differentiate patients with ben from primary immunodeficiency diseases (pidd) and to recognize their expected anc values. methods: eligible subjects included patients less than years seen at the university of michigan between january -july . duffy null (fya -/fyb-) patients were identified using electronic medical record search engine (emerse) software and search terms duffy and fyab. potential subjects were identified; patients met inclusion criteria including duffy null status and the absence of other conditions or medications, potentially impacting ancs. unique healthy anc values were recorded from the duffy null patients. age and sex matched controls were identified using emerse software with search terms tonsillectomy, department of anesthesiology and absolute neutrophil count. subjects with conditions or medications that might impact the anc or of african/arabic descent were excluded from the control group. asian and caucasian patients included as controls were presumed to be duffy null given that < % of these populations are expected to be duffy null. control subjects were identified; met inclusion and exclusion criteria. statistical analysis was performed using two-sided two-sample t-test, anova and onesample t-test. results: the median age of the duffy null cases was . years (iqr: . - . ) with . % (n= ) male and all of african or arabic descent. mean anc for duffy null patients was cells/ul (n= , sd= ) while mean anc for controls was cells/ul (n= ; sd= ) with a mean difference between controls and duffy null cases of cells/ul ( % ci: - ; p= . ). the anc levels between duffy null individuals and controls were evaluated by five age categories (p= . for all age categories). however, there was no difference in anc levels between duffy null cases at different age categories (anova, p= . ). ( . %) duffy null cbcs had anc levels in the nonneutropenic range (> cells/ul), ( . %) cbcs had mild neutropenia ( - cells/ul), ( . %) cbcs had moderate neutropenia ( - cells/ul), and ( . %) cbcs had severe neutropenia (< cells/ul). conclusions: although neutropenia can be associated with pidds and is often a sign of a compromised immune system, duffy null patients have a wide range of values that are often much lower than previously appreciated. the degree of neutropenia related to duffy null phenotype appears to persists throughout childhood and young adulthood. in the context of patients of african/arabic descent presenting with asymptomatic neutropenia, duffy null status should be assessed, and ben should be considered in the differential. complications, hypogammaglobulinemia and a unique characteristic of decreased susceptibility to enveloped viral infections. objective: to investigate the role of impaired host n-linked glycosylation on viral susceptibility to ebola virus. methods: to mimic the condition observed on cdg-iib patients, we tested in vitro three proprietary iminosugars (emergentbiosolutions©), uv b, uv , and uv , which act as competitive inhibitors of -glucosidase i and ii. their ability to inhibit the trimming of n-glycans was compared to known n-glycans modifiers as castanospermine, tunicamycin, as well as the bacterial enzyme peptide-nglycosidase f (pngase-f). ebola virus envelope protein gp was chosen as a prototype glycoprotein, as it is heavily glycosylated with nglycosylation sites. hek t cells were seeded at x ^ cells/well in well plate. after h, cells were transfected with pflag-ebolavirus gp by coupling with effectene®. after h, cells were treated with the inhibitors and harvested h after treatment. trimming of n-glycans was evaluated via molecular weight assessment by western-blot. results: all three inhibitors had comparable effectiveness in inhibiting trimming of nglycans from ebola gp glycoprotein compared to castanospermine. a greater molecular weight shift was seen with tunicamycin and pngase f as expected. conclusions: chemical inhibition of the n-linked glycosylation pathway was successfully achieved using three new mogs inhibitors. this approach merits further investigation on potential applications on antiviral therapies. investigator, laboratory of human genetics of infectious diseases, necker branch, inserm u , necker enfants malades hospital, paris, france head, immunodeficiencies research unit, national institute of pediatrics stat gof mutations are associated with infections, autoimmunity and inflammatory manifestations; the rosacea is one of the manifestations described in this disease, however, the etiology rosacea is not clearly established. the characteristics of rosacea are not described in stat gof in the different clinical series. we describe the different characteristics of rosacea in a family with affected members with stat gof. a family with eight members with stat gof mutation were diagnosed through a first affected member affected with tuberculosis and onychomycosis. seven members more had a clinical history of mycobacterial, viral and fungus infections and autoimmunity disease, in all the seven, was documented the same mutation stat gof. in six of these adults patients, we documented rosacea, it started after adolescence, it was localized in the face and/or eyes, was progressive and not ameliorated with medical treatment and caused nose deformity. rosacea has been described previously as a unique manifestation, and the etiology is not clear, an autoimmune hypothesis has been proposed. the fact that is present in patients with stat gof could suggest that have effectively an autoimmune component. physicians face the patients with rosacea must look for other manifestation presents in stat gof mutations. genetic studies in rosacea patients could evidence an new gene defect. introduction: homozygous mutations causing loss of function of the transcription factor forkhead-box n (foxn ) underlie autosomal recessive severe combined immunodeficiency with congenital alopecia and nail dystrophy (nude scid). affected humans, like the scid mouse, have small or absent thymus, absent or severely diminished t cells, alopecia, and nail dystrophy. infants with nude scid have had neonatal lymphopenia and severe, life-threatening infections. studies of heterozygous carriers of foxn mutations are limited, some having been reported with no phenotype or mild disease manifestations, such as nail dystrophy without lymphopenia or recurrent infections. objective: we describe six infants, including two brothers, with t-cell lymphopenia (tcl) following abnormal california newborn screens (nbs) for scid. each had a single heterozygous variant in foxn . case reports: six infants ( female, male) were referred for evaluation after abnormal california nbs for scid (table ) , with t-cell receptor excision circle (trec) counts from undetectable to (normal > ). all infants were well at the time of initial evaluation. five infants with absolute cd t cell counts > cells/ul and cd t cell counts > cells/ul began evaluation as outpatients on home isolation. patient , with undetectable trecs, cd t cell count , and cd t cell count was urgently admitted for inpatient evaluation and management and immediately started on antimicrobial prophylaxis. patient further evaluation was significant for lymphocyte proliferation to mitogens that was initially normal but waned with time, prompting treatment with a paternal haploidentical hematopoietic cell transplant at months of age. patients and developed neutropenia within weeks of birth treated with granulocyte colony stimulating factor (gcsf). patient remains well on gcsf but has had persistent growth failure under continued evaluation. patients , , and remain stable off antimicrobial prophylaxis, but with persistent moderate tcl. as part of an immune evaluation, patients and - had gene panel testing revealing heterozygous variants in foxn . only the variant of patient (presumed shared by patient , his brother) was predicted to be pathogenic; patient had dystrophic nails and sparse hair most evident after years of age, features shared by his mother and his brother, patient . the other patients lack the clinical features of the previously described phenotype of nude scid. their heterozygous foxn variants are of unknown significance; the functional role of these variants in the patients clinical phenotype is unknown. conclusion: six infants with abnormal nbs for scid had lymphopenia and heterozygous variants in foxn . for these infants, variation exists in level of tcl and presence of hair and nail findings. heterozygous variants of unknown significance in foxn have been uncovered in others, including infants with abnormal nbs for scid, highlighting the need for functional studies to address the possible role of each heterozygous foxn variant in congenital lymphopenia and neutropenia. more work is needed before attributing tcl to a novel foxn variant of unknown significance in the absence of family history, abnormal hair or nails, or functional evidence. remains poorly understood. we characterized the intestinal microbiome and metabolome in patients with cgd to determine if intestinal microbiome and metabolomic signatures could distinguish subpopulations of patients with cgd while using the metabolome to add a functional dimension to observed microbiome signatures. methods: clinical metadata and fecal samples were collected crosssectionally from healthy volunteers (hv; n= ) and patients with cgd (n= ). metabolomic profiling and s rrna (v ) sequencing was performed on fecal samples (total samples: ; reads/sample: , to , ; median: , ) . results: samples from patients with cgd had distinct intestinal microbiome signatures and metabolomic profiles depending on genotype, presence of cgd-ibd and specific interventions (e.g. treatment with an elemental diet). notably, samples from patients with active cgd-ibd (compared to samples from patients without a history of cgd-ibd) had significantly different alpha-and betadiversities, and were enriched for enterococcus spp. signal transducer and activator of transcription gain of function (stat -gof) is a primary immunodeysregulatory disease in which a subset of patients have features of autoimmunity and autoinflammation. enteropathy with growth failure and nutrient wasting is a more common feature of immunodysregulation. ruxolitinib is a janus kinase-stat inhibitor that has been shown effective for the treatment of immunodysregulatory features in stat -gof. our patient is a year old male with stat -gof (c. a>g p.h r) with severe total parenteral dependent enteropathy that led to growth failure (weight . kg). treatment with ruxolitinib led to resolution of diarrhea, return of normal diet, and catch up growth. a dose of . mg twice daily was initially started but was decreased to . mg every morning and mg every evening due to elevated transaminases and thrombocytopenia. over the following year the patient thrived gaining . kg with normal every other day stools. despite weight gain, he remained stable on the same dose of ruxolitinib. as he outgrew his dose, he developed an increased frequency of upper respiratory infections (parainfluenza, coronavirus, rhinovirus). one year after initiation of ruxolitinib, he again developed profuse watery diarrhea that was norovirus positive (weight kg, bsa . ). he was placed on bowel rest and ruxolitinib was dose escalated with a goal of mg/m /day. when he reached mg twice daily, enteropathy completely resolved but liver function tests began to rise. he gained weight and began thriving after weeks of therapy. six months later, enteropathy is controlled, and transaminases have remained elevated (alt iu/l, ast iu/ml) but stable. the appropriate dose and pharmacokinetics for ruxolitinib for the treatment of immunodysregulatory symptoms in pediatric patients has not been thoroughly studied. the dose used was extrapolated from data on the use of ruxolitinib in pediatric myelofibrosis. a dose of mg/m /day appears to provide the most benefit with tolerable adverse effects. this dose should be maintained in order to prevent recurrence of disease related manifestations. abstract clathrin-mediated endocytosis (cme) is the major endocytic pathway by which eukaryotic cells internalize cell-surface cargo proteins and extracellular molecules, thereby allowing for a broad range of biological processes, including cell signaling, nutrient and growth factor uptake, and cell fate and differentiation . the fbar domain only proteins and (fcho /fcho ) are involved in the initiation of clathrin coat pit formation. whether fcho and fcho are functionally redundant or have distinct functions is unclear. we report here the first cases of a severe immunodeficiency due to a genetic defect affecting cme. by using whole exome sequencing and genomic analysis of a targeted pid gene panel, we have identified biallelic loss-of-function fcho mutations in five patients from unrelated families of italian (p ), turkish (p , p , and p ) and algerian (p ) origin with severe t cell lymphopenia manifesting as recurrent and severe infections of bacterial, mycobacterial, viral and fungal origin. p developed ebv-associated diffuse large b cell lymphoma. three patients (p -p ) died in childhood, whereas p and p are alive with full donor chimerism at and . years after allogeneic hematopoietic stem cell transplantation, respectively and have cleared pre-transplant infections. patients p , p , and p carried homozygous frameshift mutations predicted to cause premature termination. western-blotting analysis of ha-or flag-tagged fcho constructs showed expression of truncated products in p and p , whereas no protein was detected in p , presumably due to mrna decay. p and p carried homozygous splice-site mutations at the invariant - and + positions, respectively, leading to skipping of exon in p 's fcho cdna. qpcr analysis demonstrated differential expression of the fcho and fcho genes, with the former being predominantly expressed in lymphoid cells, whereas fcho was more abundantly expressed in fibroblasts and k cells. analysis of t cell activation in p (the only patient for whom pre-transplant pbmc were available) revealed reduced t cell proliferation. while tcr internalization in response to cd cross-linking was normal (consistent with recent evidence that tcr internalization occurs through a clathrin-independent pathway), chase experiments demonstrated that transferrin internalization was abolished in activated t cells from p . we had previously reported that a missense mutation in tfrc, encoding transferrin receptor , impairs transferrin internalization and intracellular iron delivery, causing a combined immunodeficiency with defective t cell proliferation. our data identify the first form of severe immunodeficiency due to defects of clathrin-mediated endocytosis, and provide additional evidence in support of the critical role played by iron cellular metabolism in t cell function and homeostasis. natural history of anti-interferon-gamma autoantibody-associated immunodeficiency syndrome in thailand submission id# centralized sequencing initiative at niaid: year therefore, we set out to investigate the pneumococcal-specific responses of igg, igg , iga and igm to prevnar ® in igg subclass deficient (iggscd) patients in this study. pneumococcal responses were measured using the vacczyme pneumococcal capsular polysaccharide igg, igg , iga and igm elisas (the binding site group, birmingham, uk) in control (n= , median age years, range - ) and iggscd patients (n= , median age years, range - ) recruited from the immunodeficiency unit at the karolinska university hospital iga and igm antibodies in response to pcv vaccination was observed weeks post vaccination in iggscd patients (median, . th and . th percentile these median concentrations were lower than those observed in control patients (median, . th and pcv igg mg/l, - however, percentage changes between pre to post vaccination concentrations of igg, igg and iga in response to pcv in iggscd patients were not significantly different to the control patients u/ml vs . u/ml, respectively) iga u/ml and pcv igm u/ml) responders and non-responders of pcv igg iga and igm in response to pcv in iggscd patients were generally lower compared to the control population. these results support the fact that in addition to igg and igg , measurement of iga and igm could also provide useful information for the clinician gain-of-function ikbkb mutation causes human combined immune deficiency submission id# neutralizing anti-il- -autoantibodies are a risk factor for pyogenic bacterial infections national institutes of health, national institutes of allergy and infectious diseases service of immunology and rheumatology, garrahan national pediatric hospital copa mutations impair er-golgi transport and cause hereditary autoimmune-mediated lung disease and arthritis copa syndrome: a novel autosomal dominant immune dysregulatory disease analysis of pulmonary features and treatment approaches in the copa syndrome expanding the phenotype of copa syndrome: a kindred with typical and atypical features the forest and the trees: machine learning to classify cases of suspected inborn errors of immunity using decision tree and random forest algorithms submission id# card Δ gene dosage: from mono-allelic protection to ibd, to bi-allelic increased fungal infection susceptibility yamanaka d , walkiewicz m , lionakis m and rosenzweig s stim mutation associated with a syndrome of immunodeficiency and autoimmunity a novel hypomorphic mutation in stim results in a late-onset immunodeficiency clinical, histological and genetic characterisation of patients with tubular aggregate myopathy caused by mutations in stim gain-of-function mutation in stim (p.r w) is associated with stormorken syndrome gain-of-function mutations in stim and orai causing tubular aggregate myopathy and stormorken syndrome stormorken syndrome caused by a p.r w stim mutation: the first italian patient and a review of the literature by studying ecs-pre and ecs-post patients we were able to describe the bona-fide effect of gcs on the immune system in general, and t lymphocytes in particular. decreased lymphocyte/thymic output, as well as increased apoptotic tcell death underlies lymphopenia in ecs/chronic gcs-exposed patients. under such conditions, il- was significantly decreased in plasma and our in-vitro studies showed that il- replenishment was able to increase bcl (anti-apoptotic molecule) and bcl expression, and efficiently counteract the apoptotic effects of gcs. recombinant il- has been explored as a co-adjuvant treatment for multiple human cancers and may offer a treatment option for lymphopenia and its genetic counselor, co-director of personalized medicine, division of hematology/oncology/bmt and the institute for genomic medicine, nationwide childrens hospital genetic counselor, division of hematology/oncology/bmt, nationwide children's hospital acknowledgments. genetic sequencing was kindly provided by drs. raif geha and janet chou at the division of immunology, allergy, rheumatology and dermatology, boston children's hospital, harvard medical school. the following grants are acknowledged: . rui . /cippt/ (usm) . bmbf eo (freiburg) the authors would like to thank the director general of health of malaysia for permission to publish this scientific presentation. while severe viral infections may also be an initial presentation of primary immunodeficiency, an immune evaluation is not always obtained in this scenario. patients with xla have an increased susceptibility to severe enterovirus infections, manifesting as chronic meningoencephalitis, which can be fatal. the following case describes a patient with newly diagnosed xla presenting as suspected coxsackievirus and confirmed hhv- meningitis, pseudomonas meningitis and bacteremia. this may be the first reported new diagnosis of xla presenting with both severe bacterial and viral coinfection. case description: a year old, partially vaccinated, hispanic male with a history of febrile seizures presented to the emergency room with fever, oliguria, watery diarrhea, lethargy, meningismus, ecthyma gangrenosum and lower abdominal pain. eight days prior to presentation, he was seen by his pediatrician for facial rash and low grade temperature, and was diagnosed with hand-foot-and mouth disease. he worsened on empiric antibiotics. he had no history of sinopulmonary infections. he did not attend daycare. his vaccines were delayed due to parental choice, and he had not received live vaccines (rotavirus, mmr or vzv). full sepsis evaluation was performed. csf demonstrated pleocytosis, and he was started on empiric antibiotics and transferred to picu. due to worsening abdominal pain, ct of the abdomen was performed, which was consistent with ruptured appendicitis and septic emboli at the lung bases. csf pcr panel was positive for hhv- and he was started on gancyclovir. csf and blood cultures subsequently grew pseudomonas aeruginosa. immune evaluation was performed. serum immunoglobulins were undetectable. in addition to iv antibiotics, he received mg/kg ivig and lymphocyte subsets revealed profound b cell lymphopenia ( . %, cells/ul). btk protein analysis revealed hemizygous btk pathogenic variant confirming the diagnosis of x-linked agammaglobulinemia. the hospital course was further complicated by brain abscesses and pyoventriculitis. he was treated with additional doses of mg/kg ivig and iv antibiotics. repeat mri of the brain nearly weeks after admission demonstrated significant improvement. there was significant clinical recovery. he was discharged home at baseline neurological status. his igg level upon discharge home was mg/dl with the plan to increase dose to mg/kg per month with close monitoring. conclusion: both severe opportunistic bacterial infections and severe viral infections as the initial presentation of xla have been well reported in the literature. this case describes the first reported severe pseudomonas aeruginosa and hhv- co-infection in a newly diagnosed xla patient. this case further highlights the necessity for an increased index of suspicion of primary immunodeficiency in a patient who presents with a severe first infection, despite lack of recurrent infections. we present two patients with dock deficiency due to compound heterozygous variants including a copy number loss at chromosome band p . spanning approximately . mb with partial deletion of the dock gene and a novel c. c>t (p.ser leu) missense variant [chr : (grch ) nm_ ] in dock . functional data is presented to support the pathogenicity of the missense change, along with a review of the literature on dock variants. the proband is a -year-old female with elevated serum ige, severe atopic dermatitis, mild persistent asthma, food allergies, and seasonal allergic rhinitis. she is currently healthy following haploidentical bone marrow transplant in june . she has a -year-old brother with dock deficiency with the same compound heterozygous variants. the brother had later onset of symptoms and a milder presentation of intermittent asthma and seasonal allergic rhinitis. each of the parents is heterozygous for one of the two variants. we evaluated the pathogenicity of the c. c>t missense variant with western blots of dock protein expression, intracellular flow cytometry, and dock stretch assays. flow cytometry showed decreased dock protein expression and stretch assays revealed t cells that were stretched in collagen gels. notably, dock is a large gene containing exons spanning kb and it is relatively common to be a carrier of a rare missense change. in fact, gnomad has approximately individuals with rare (< . frequency) missense alleles in dock . therefore, it is important to demonstrate the potential pathogenicity of any given rare missense change, since few pathogenic missense variants in dock have been reported. of the published dock variants listed in the human gene mutation database (hgmd) only are missense. the majority are gross deletions, of which were reported in hgmd. the remaining reported dock variants include nonsense, splicing, small deletions (all frameshifting), small insertions (all frameshifting), small indels, and gross insertions/duplications. this case demonstrates the relatively infrequent but important contribution of missense changes to pathogenic dock alleles. functional validation of missense alleles is critical in the complex evaluation of dock deficiency. background: hsct is the only known curative option currently for cd l deficiency, an x-linked disorder. in cd l deficiency and other x-linked immune deficiencies, there is an ongoing debate regarding the use of a carrier female sibling or mother as hsct donor. skewed lyonization despite complete donor chimerism has raised concerns for incomplete disease control post-hsct. no data exist regarding the efficacy of related female carrier as hsct donor for cd l deficiency. we herein report outcomes of three patients with cd l deficiency who underwent hsct using a related female carrier donor. method: retrospective review of patients who received hsct from carrier female related donor at three separate institutions. results: three patients with cd l deficiency underwent hsct between - . patient had recurrent episodes of pneumocystis jiroveci pneumonia (pjp) despite being on bactrim and immunoglobulin replacement. patient presented with pjp and severe neutropenia. patient presented with acute respiratory failure from severe respiratory viral infections, cmvand had severe neutropenia requiring g-csf treatment. age at the time of hsct ranged from . - yrs. all three underwent reduced toxicity hsct with busulfan and fludarabine-based preparatory regimens. two of them received matched sibling bone marrow hsct and one received tcr and cd depleted mobilized maternal pbsc haploidentical hsct. donor cd l expression varied from % - % on activated cd cells. immunoglobulin profile and lymphocyte subset were done in two of donors, they were within normal range for age, and none had significant infection history. no history of intermittent neutropenia or oral ulcers noted in donor and the absolute neutrophil count of the donor varied between /l. donor age ranged from . yrs years. cd dose ranged from . x - . x cells/kg and cd dose ranged from x . x cd + cells/kg. gvhd prophylaxis consisted of csa/mmf (n= ) and tcr-a/b depletion and no csa (n= ). neutrophil engraftment ranged from - days and platelet engraftment ranged from days. none of the patients developed acute or chronic gvhd. all three patients maintain full donor myeloid chimerism at the latest testing ( months months); t cell chimerism was % in one and mixed in two patients ( % at nine months, % at months). all three patients had excellent t cell immune reconstitution; two patients came off immunoglobulin replacement - months post hsct, whereas the rd patient is ivig dependent, though iga level was mg/dl at nine months post-transplantation. latest evaluation, months post-hsct, revealed % - % cd l expressing activated cd t cells, which correlated with donor cd l expression and t-cell chimerism. conclusion: our data suggest that hsct utilizing x-linked carrier appears to be safe and results in durable engraftment with excellent humoral and cellular immune reconstitution in patients with cd l deficiency. longer follow-up and data from a larger cohort is needed to make a definitive determination of safety and efficacy of utilizing female carrier as hsct donors in this disease. chief, immunology service, department of laboratory medicine, nih clinical center, bethesda, md, usa background: ikaros belongs to a hematopoietic-specific zinc-finger (zf) family of transcription factors. after dimerizing and dna binding to pericentric-heterochromatin (pc-hc) regions, ikaros is described as a central regulator of lymphocyte differentiation. somatic mutations/ deletions affecting ikaros n-terminal zf have been identified in b-acute lymphoblastic leukemia (all) patients, and germline n-terminal mutations were reported in cvid patients with progressive lack of b cells, hypogammaglobinemia, autoimmune diseases and b-all. methods: we performed targeted sequencing panel for known inborn errors of immunity disease-causing genes in a previously healthy male pediatric patient with burkitt lymphoma, followed by benign lymphoproliferation, thrombocytopenia and neutropenia. b-cells and immunoglobulin levels were normal. ikaros dna-binding, nuclear localization and protein binding were evaluated by emsa, fluorescence microscopy and immunoprecipitation. protein modeling was also performed. results: a novel heterozygous germline mutation in ikaros c-terminal zf dimerization domain (p.r l) was detected in this patient. this mutant showed normal pc-hc localization but dna-binding was markedly reduced in terms of ikaros dimerization and multimerization. moreover, reduced wt-mutant binding was also detected. mutant/wt cotransfection experiments suggest a haploinsufficient defect. geometry based docking of wildtype ikaros predicted that r is within the homodimer interface and may abolish cation-pi interactions and destabilize the ikaros-zf dimerization domain. conclusion: a novel germline ikaros c-terminal mutation affecting homodimerization/multimerization and resulting in reduced dna binding to its dna consensus site was detected in a patient with burkitt lymphoma, benign lymphoproliferation and cytopenias. further studies are warranted to formally establish the casual connection between this genotype and phenotype.( ) submission id# patricia pichilingue-reto, md , prithvi raj, phd , igor dozmorov, phd , quan-zhen li, md, phd , edward wakeland, phd , nancy kelly, md , maria teresa de la morena, md , nicolai s. van oers, phd methods: mice were generated by crispr/cas technology to genocopy the foxn compound heterozygous mutations identified in one of the human patients. thymopoiesis and hair follicle extrusion was analyzed in the various heterozygous and homozygous mutant mice. gene expression analyses of the hypoplastic and normal-sized thymii and the developing skin were performed. in addition, a structure-function analysis was performed with luciferase reporter assays using distinct and previously unreported foxn mutations uncovered in patients who presented with low trecs. results: mice harboring compound heterozygous mutations in foxn that match the human patient phenocopy the t-b+nk+ scid phenotype with normal hair and nails. a functional characterization of the diverse foxn mutations suggests that the severity of the block in thymopoiesis depends on whether the mutations affect the dna binding or transactivation domains of foxn . a -amino acid segment at the end of the dna binding domain appears to be essential for tec development. however, this segment is not required for normal keratinocyte functions in the skin and nail plate. gene expression comparisons are revealing key targets of foxn that suggest a dichotomy in its function in the thymus versus the skin. conclusions: novel compound heterozygous mutations in foxn are causal to a t-nk+b+ phenotype with normal hair shaft extrusion and nail plate extension. this differs from the classic nude/scid (omim # ) reported for individuals with autosomal recessive mutations in foxn . assistant professor of medicine and pediatrics, department of allergy and immunology, uva introduction: copa syndrome is a recently described monogenic immunodysregulatory syndrome. the cop protein, encoded for by the copa gene, is expressed in all cell types and is involved in trafficking from the golgi complex to the endoplasmic reticulum ( ) . the most common clinical features of copa syndrome are interstitial lung disease, pulmonary cysts or follicular bronchiolitis, pulmonary hemorrhage, arthritis, glomerular disease, and autoantibody development ( , ) . atypical features of copa syndrome identified thus far include: extrapulmonary cysts in the liver and kidney, renal and neuroendocrine malignancies, autoimmune neurological disorders such as neuromyelitis optica, and infections, such as meningitis ( ) . clinical case: we present a case of a year-old male with copa syndrome (de novo heterozygous mutation in exon , c. g>c; p.ala pro) manifesting as lymphocytic interstitial pneumonitis, peripheral blood b-cell lymphocytosis, mediastinal lymphadenopathy and persistent transaminitis (alt and ast - u/l, nl ast< u/l, alt < u/l) with normal bilirubin, alkaline phosphatase and pt/inr. the transaminitis was noted prior to diagnosis of copa syndrome, and has persisted despite seven months of therapy with pulse dose steroids, two cycles of rituximab and maintenance therapy with hydroxychloroquine and prednisone. he has had a normal ck and aldolase excluding muscle injury as a source of his transaminitis. a congenital cholestasis panel was normal. markers of autoimmune liver disease including ana, anti-liver kidney microsomal antibody and anti-smooth muscle were negative. serum ceruloplasmin and alpha- -antitrypsin level were normal and celiac serologies, were negative. liver ultrasound was normal. a liver biopsy did not demonstrate inflammatory changes, hepatocyte necrosis, mononuclear cell infiltrates or fibrosis. nonspecific biopsy findings included occasional intraparenchymal neutrophils. it is unclear if these scattered neutrophils and the transaminitis are due to an early as yet unidentified autoimmune process, perhaps in response to hepatocellular stress exacerbated by the copa mutation. discussion: liver involvement has not been reported in copa syndrome. we describe a child with copa syndrome who has had chronic transaminitis with no clear alternative cause. if the phenotypic spectrum of copa syndrome involves the liver, it may limit immunomodulatory options for the treatment of this disease. background: in humans, biallelic stat lost-of-function (lof) mutations lead to a very low or complete absence of the wild-type (wt) protein. whereas, heterozygous mutations can lead to partial loss of function. these patients are susceptible to mycobacteria and herpes virus infections. on other hand, heterozygous gain-of-function (gof) mutations in the stat gene result in a hyperphosphorylated state where patients develop recurrent or persistent chronic mucocutaneous candidiasis (cmc), other cutaneous mycosis, bacterial infections, disseminated dimorphic fungal infections, viral infections and autoimmune disease. methods: in this study, we evaluated novel stat mutations, three gof and one lof. in vitro, pbmcs from these patients were stimulated with ifn-and ifn-for , , and minutes and levels of phospho-stat were measured by flow cytometry. the stat phosphorylation and activity (firefly and renilla luciferase activities) were evaluated in u a-stat deficient cells transfected with a reporter plasmid (for luciferase), wt or mutant-stat plasmids. results: we observed higher levels of stat phosphorylation after two hours of stimulation from three gof mutations compared to wt. however, a lof mutation showed absent stat activation at baseline and in response to ifn-and ifn-. luciferase reporter assay confirmed gain of function and loss of function stat activity observed by flow cytometry. conclusions: using flow cytometry followed by a luciferase assay, we confirmed four novel stat mutations. measuring phosphorylation of stat by flow cytometry is sufficient to determine whether the stat mutation is disease causing. this assay can be translated to a clinically accessible test for stat related disease. background: variants in recombination-activating genes (rag) are common genetic causes of autosomal recessive forms combined immunodeficiencies (cid) ranging from severe combined immunodeficiency (scid), omenn syndrome (os), atypical scid (as) and cid with granulomas and/or autoimmunity (cid-g/ai). the clinical and immunological presentation is broad, ranging from severe infections secondary to near absence of t and b lymphocytes and hypogammaglobulinemia to the occurrence of autoimmunity with late manifestations with partly preserved immune subsets and near normal immunoglobulin levels and broad spectrum of autoantibodies. objective: we aim to estimate the incidence, clinical presentation, genetic variability and treatment outcome with geographic distribution of patients with the rag defects in populations inhabiting south, west and east slavic countries. due to shared ancestry, we also investigated our cohort for founder variants in rag and rag genes. methods: demographic, clinical and laboratory data were collected from rag deficient patients of slavic origin via chart review, retrospectively. results. based on the clinical and immunologic phenotype, our cohort of patients from families represented a wide spectrum of rag deficiencies, including scid (n= ), os (n= ), as (n= ) and cid-g/ai (n= ). sixty-six ( . %) patients carried rag and patients ( . %) carried rag biallelic variants. we estimate that the minimal annual incidence of rag deficiency in slavic countries varies between in , , live birth and it may vary secondary to health care disparities in these regions. in our cohort, % of the patients carried rag p.k vfs* (c. _ delaa), either in homozygous (n= , %) or compound heterozygous (n= , %) form. the majority ( %) of patients with homozygous rag p.k vfs* originated from vistula watershed area in central and eastern poland, and compound heterozygote cases distributed among all slavic countries except bulgaria. clinical and immunological presentation of homozygous rag p.k vfs* cases was highly diverse suggestive of strong influence of other genetic and/or epigenetic factors in shaping the final phenotype. survival of rag deficient patients without hematopoietic stem cell transplant (hsct) (n= , . %) is poor and dramatically improved in the last decade with access to hsct and tailored conditioning regimens. conclusion: we propose that rag p.k vfs* is a founder variant originating from the vistula watershed region in poland, which may explain a high proportion of homozygous cases from central and eastern poland and the presence of the variant in all slavs. our studies in cases with rag founder variants confirm that clinical and immunological phenotype only partially depend on the underlying genetic defect. hsct is becoming available for rag deficient patients in eastern europe with improving outcome. clinical immunologist, centre hospitalier universitaire de montréal (chum) background: acute gvhd following solid organ transplantation is a rare complication. intestinal and liver transplantation have the greatest risk of gvhd among solid organs due to high number of donor lymphocytes in these organs. prevalence of acute gvhd after liver transplantation is estimated to be around , - % and has a poor prognosis ( ) . chronic neurological gvhd is a rare form of gvhd with three subtypes described: cerebral vasculitis, demyelinating disease and immune mediated encephalitis. acute neurological gvhd has no clear definition and is still considered a controversial entity. case presentation: a year-old male underwent cadaveric liver transplantation for alcoholic cirrhosis and hepatocellular carcinoma. the donor was a year-old man who died from anoxic brain injury. the receiver was induced with basiliximab and then put on prednisone, azathioprine and tacrolimus. he was readmitted weeks later for myalgia, headache, fever and neutropenia. clinical state initially improved with empiric antibiotics. he then developed a skin eruption, colitis and dic. the latter was thought to be tacrolimus-induced. he was switched to cyclosporine. skin and rectosigmoid biopsies were compatible with acute gvhd. he received basiliximab and ivig and developed a refractory convulsive state. csf analysis showed elevated proteins and slight pleocytosis. cerebral mri showed non-specific white matter lesions and conventional angiography was normal. chimerism on peripheral blood was % but was % donor on csf. with the presence of chimerism on csf, evidence of cutaneous and digestive gvhd and no infectious cause, neurological gvhd was considered the most likely diagnosis. brain biopsy showed non specific change including neuropil spongiosis, microglial activation and reactive gliosis; but no signs of vasculitis or demyelinating disease. he was treated with atg, highdose systemic corticosteroids, cyclosporine, ivig and intrathecal methotrexate and corticosteroids. csf pleocytosis, proteins and chimerism improved with treatment ( % to % donor). no improvement was noted regarding his neurological state and he developed pancytopenia. he was then transfer to palliative care and died shortly after ( month and a half after liver transplant). discussion: to our knowledge, there is only one prior case published of neurological gvhd following liver transplantation ( ) . both patients were old, had hepatocellular carcinoma and had at least one hla match. age > year, hepatocellular carcinoma and shared hla antigen are known risk factors for gvhd following liver transplantation ( ). our patient had only one hla match with the donor. this case is intriguing as there was a great discrepancy between blood and csf chimerism. acute neurological gvhd following transplantation is a real complication. it must be taken into consideration in patients with neurological involvement after transplant, even solid organ transplantations. introduction: hyper-igm syndrome are rare. although no data are available on the frequency of activation-induced cytidine deaminase (aid) deficiency, this disorder is estimated to affect less than : , , individuals. by the year , cases worldwide ( ) with such mutation have been described. we describe a patient with hyper igm by mutation in the aicda gene. case report: mvv, -year-old boy, born to consanguineous parents, was referred with recurrent pneumonia, which started shortly after discontinuation of breastfeeding at months old. repetitive otitis evolved with bilateral tympanic and partial hearing loss. he was submitted to adenoidectomy without improvement. immunological evaluation showed normal numbers of b and t cells with cd + ( /mm , %), cd + ( /mm , %), and cd + ( /mm , %). immunoglobulin concentrations were: igg = mg/dl (p ). treatment with intravenous immunoglobulin and prophylactic antibiotic was initiated and he had no infections during the follow up except for one episode of sinusitis. at years of age, molecular evaluation was performed and a mutation in homozygosity in the aicda gene (omim * ) at position chr : . . was found, confirming the clinical suspicion. conclusion: the role of aid in the immunoglobulin class-switch recombination (csr) and somatic hypermutation (shm) have not been fully elucidated. summarizing within the shm and csr processes, aicda mutation can induce dna lesions in directed sequences in the s and v regions required for dna cleavage. recurrent infections and consanguinity raised the suspicion of inborn errors of immunity in this patient. the literature described late diagnosis as in the second or even the third decade of life. it was suggested that high levels of igm antibodies may provide effective defense, at least, against some infectious agents. it is important to emphasize that the impossibility to obtain genetic diagnosis did not prevent to introduce therapy. * aicda: activation induced cytidine deaminase gene patients with chronic granulomatous disease (cgd) are at risk for recurring infections and non-infectious inflammation, reduced quality of life and life expectancy. conventional treatment with life-long anti-bacterial and antifungal prophylaxis prolongs lifespan but does not eliminate the lifelong risk of infection and inflammation. allogenic stem cell transplantation is currently the only curative option for this disease. although sct with reduced intensity conditioning has improved treatment-related mortality and efficacy, it remains a matter of debate whether all patients with cgd benefit from sct, whether pre-existing infections and non-infectious inflammation are risk factors and at what age sct should be performed. we compared patients with cgd on conventional treatment with those after stem cell transplantation for their prognosis and evaluated potential risk factors for stem cell transplantation outcome followed up in six european centers. frequency of infections, inflammatory complications, hospitalizations, operations and immunomodulative/immunosuppressive therapy, height and weight were compared in patients on conventional treatment /before stem cell transplantation versus patients after sct. correlation between transplantation outcome and patient characteristics or medical history was tested. patients were recruited, on ct, after stem cell transplantation. before/without transplantation % of patients suffered from at least one infection, , % from inflammatory complications. patients on conventional treatment developed infection/inflammation/ hospitalization/surgery at a median of , (range [ , - , ] , iqr , ) per year, versus (range , iqr , ) in the first year after stem cell transplantation but (range [ - ], iqr , ) after the first year post stem cell transplantation. there was a significant decrease of all complications after stem cell transplantation (p < . ). growth improved significantly after stem cell transplantation (z-score weight - , versus - , (p. ), z-score height - , versus - , (p. )). nevertheless, complications post stem cell transplantation are frequent: % of patients had at least one infection, % had severe acute gvhd, % chronic gvhd, % had graft rejection, % died. preexisting active mold infection increased the risk for complications after stem cell transplantation. in summary infections and non-infectious inflammation are common in patients with cgd on conventional treatment, their growth is significantly impaired. stem cell transplantation, if successful, significantly reduces the risk for infections and non-infectious inflammation. however, treatment related mortality of stem cell transplantation in patients with cgd remains considerable. introduction: development of a diverse t cell repertoire is essential for full immune recovery following definitive treatment for severe combined immunodeficiency (scid), whether by allogeneic hematopoietic cell transplantation (hct); autologous gene therapy (gt); or, in the case of adenosine deaminase deficiency, enzyme replacement therapy (ert). however, the time course and depth of diversity of t cell receptor rearrangements have been difficult to measure directly, necessitating estimates from total and naïve t cell counts and from spectratyping, in which t cell receptor (tcr) beta chain diversity is estimated by the length distributions of cdna amplicons between a series of tcr beta chain variable (v-beta) segments that have productively recombined with the tcr beta-chain constant region. analysis of the actual sequences of rearranged tcrs could indicate more precisely the status of the t cell compartment of these patients, and might reveal oligoclonal expansion of dysregulated t cells, t cell insufficiency, or t cell exhaustion. objectives: we wished to ascertain whether deep sequencing of individual tcr v-beta rearrangements in peripheral blood could be performed sequentially following diagnosis and treatment of scid to differentiate satisfactory immune reconstitution from incomplete or skewed repertoire development that might require further cellular therapies. methods: equal amounts of total rna were obtained from peripheral blood of controls and scid patients pre-hct and at d, and mo, and yearly post-treatment(s). cdna was used as template to semi-quantitatively amplify rearrangements at the tcr-beta locus (trb). raw sequences were filtered to remove pcr errors, and resulting fastq files were converted into fasta format (seqtk software, github, inc), filtered for productive rearrangement, and analyzed for v, d, and j gene composition and length (imgt highv-quest software). the vdj statistics file (past program) was used to calculate a shannon entropy (h) index to measure repertoire diversity, taking into account both abundance and richness of the overall repertoire; and a gini-simpson index of unevenness, measuring inequality in the relative representation of species in a given sample. graphical representations of repertoire diversity were generated by hierarchical tree maps of the trb repertoires (irepertoire software): each dot represents a unique sequence and the dot size corresponds to frequency of that sequence in the total sample. results: tcr v-beta sequence analysis of scid patients (image) showed (top) baseline poor diversity due to pre-treatment ada deficiency followed by improvement to normal complexity (shannon h > . ) after receiving peg-ada and autologous lentivirus gene therapy at age m; (middle) increasing diversity in xscid after maternal t-depleted unconditioned hct, although b cells did not recover; and (bottom) failure of initial unconditioned maternal t-depleted hct in another xscid patient at m, followed by autologous lentivirus gene therapy with subsequent improvement (shannon h increasing from . to ) months later. conclusions: tcr v-beta diversity sequence analysis provided a detailed assessment of repertoire diversity in response to cellular therapies for scid. this method could become a useful predictive tool to measure successful t cell immune reconstitution, both as early as d and in the years following treatment. background: the stim (stromal interaction molecule ) protein, encoded by the stim gene, is involved in calcium regulation in the endoplasmic and sarcoplasmic reticulum. pathogenic variants in this gene are associated with three different disorders. homozygous loss-of-function (lof) pathogenic variants in stim have been reported to cause autoimmune cytopenias, lymphoproliferation, enamel defects, anhydrosis, and iris hypoplasia. the first described cases had frequent mortality in early childhood due to recurrent life-threatening infections and development of kaposi sarcoma ( ), while recently discovered cases have had more prolonged survival, though still with recurrent serious infections ( ) . heterozygous gain-of-function (gof) pathogenic variants in stim have been associated with both tubular aggregate myopathy (tam) and stormorken syndrome. tam is a clinically heterogeneous progressive muscle disorder with a variable age of onset. muscle biopsy characteristically demonstrates tubular aggregates, with type ii muscle fiber atrophy ( ) . stormorken syndrome has a phenotype that includes miosis, thrombocytopenia, intellectual disability, mild hypocalcemia, muscle fatigue, asplenia, and ichthyosis ( ) . the thrombocytopenia has not been reported to be immune-mediated; rather it is due to abnormal platelet calcium regulation ( ). we report a patient with stim pathogenic variant presenting with tam and immune-mediated thrombocytopenia, along with lymphoproliferative features, arthritis, and a mild immune deficiency. case: the patient is a -year-old with a history of congenital thrombocytopenia (platelets ranging , - , ) who presented with acute arthritis of bilateral hand joints after exposure to cold temperatures, which resolved with naproxen. he had back pain without muscle weakness, and preceding sore throat and general fatigue. labs were significant for leukocytosis and elevations in his inflammatory markers and creatine kinase. mri of his lower extremities was negative for inflammatory myositis, but did demonstrate bilateral hip and knee effusions, and significant inguinal lymphadenopathy and hyperintense linear signal changes in the mid-and distal femurs with patchy red marrow signal. abdominal ultrasound could not identify a definite spleen. bone marrow biopsy was negative for malignancy but significant for toxic granulation of neutrophils, evident of inflammation. alpha-beta double negative t cells were not elevated. interferon-gamma was mildly elevated. flow cytometry demonstrated normal t, b, and nk cell absolute counts. circulating antibodies against platelets (both igg and iga) were detected. on lymphocyte antigen and mitogen proliferation testing, he did not exhibit any proliferation when stimulated with tetanus toxoid even though he had been fully vaccinated against tetanus. muscle biopsy demonstrated large vacuoles consistent with tam on both light and electron microscopies. invitaes primary immunodeficiency panel identified a pathogenic variant in stim (c. c>t; p.arg trp), consistent with a diagnosis of autosomal dominant stim -related conditions, including stormorken syndrome ( ) . conclusion: this patient expands the phenotypic spectrum of stim related disease. based on previous evidence, gof pathogenic variants in stim are associated with tam and stormorken syndrome, while lof pathogenic variants in stim are associated with immune deficiency. however, our patient with a stim gof pathogenic variant has features of lymphoproliferation and immune dysregulation in addition to tam. stim gof pathogenic variants should be considered in the differential of patients with immune thrombocytopenia and lymphoproliferation. references: introduction / background: card is critical for protein binding upstream of nf-kb (nuclear factor kappa b) and mtorc (mammalian target of rapamycin complex ) the signaling pathway involved in t-cell activation and inflammatory response. prior testing of card mutations demonstrated variable t-cell dysfunction. in vitro studies have demonstrated reduced interferon gamma cytokine production, interference of t-cell receptor (tcr) signaling, and th phenotype skew in t-cells with card defects. while homozygous mutation causes severe combined immunodeficiency deficiency, heterozygous card defect is associated with atopy by way of inappropriate th skewing. heterozygote atopy is characterized by eosinophilia, elevated ige, and severe dermatitis. despite multiple studies demonstrating in vivo consequences of card on t-cell function, little is known of the clinical significance. moreover, few studies have demonstrated the impact of card mutations on b-cell maturation and development, despite the recognized tcr and interleukin signaling deficits. objectives: this case demonstrates a card defect that evolved from atopy to combined immunodeficiency requiring intravenous immunoglobulin therapy. it highlights the poorly understood effect of card mutation on t-cell function, and the downstream impact on b-cell quality. methods: -year-old male, with past medical history of t-cell lymphoma and no evidence of disease status post autologous stem cell transplant, was found to have card e d missense mutation by genetic testing. consistent with previous literature regarding heterozygous card defects, the patient suffered from frequent asthma exacerbations, aeroallergen sensitivity, and eczema. lab work was consistently positive for elevated ige and eosinophilia. family history was positive for a son born with congenital molluscum, and multiple other children with recurrent infections. one child was also identified with card mutation. the patient had flow cytometry demonstrating % of circulating cells with atypical immunophenotyped cd + t-cells, and positive gene rearrangement studies. his qualitative immunoglobulin levels were significant for consistently low igm, but normal quantity igg. in the patients adulthood, he had recurrent bronchitis and pneumonia requiring hospitalization and intravenous antibiotics. given his recurrent infections, the patient underwent immunodeficiency evaluation. despite previous infection with herpes zoster, the patient did not have protective titers. additionally, the patient had received the pneumococcal conjugate vaccine once, and the pneumococcal polysaccharide vaccine four times. the most recent vaccination was one year prior to evaluation. despite repeated vaccinations, titers were unprotective. consequently, the patient was diagnosed with combined immunodeficiency, and initiated on intravenous immunoglobulin therapy. results: in summary, card defect is a cause of atopy, observed to become less severe with age. studies of card heterozygote mutations have demonstrated in vitro deficiencies in t-cell activation, likely secondary to skewed or decreased inflammatory cytokine production and tcr activation. our patient demonstrates that the variable t-cell dysfunction seen in vitro can have significant clinical implications evidenced by his inadequate vaccine response, and recurrent infections. his combined immunodeficiency poses a connection between card defects and, not only t-cell, but also b-cell function. conclusions: further studies are needed to determine deficits in t-cell and b-cell function in the setting of card defect, as this case suggests the clinical implications span further than atopy. genetic variants in the scaffold gene card cause disorders of the immune system. the clinical course and treatment depends on whether the card variant causes gain-or loss-of-function. however, lymphocyte immunophenotyping and proliferation assays in cells expressing card variants don't easily distinguish between gain-and loss-of-function. to address this challenge in variant interpretation, we used multiplexed genome editing in a lymphoma b cell line (tmd ) to generate cell populations expressing all possible singlenucleotide variants in the n-terminal amino acids of card . to assess function in each variant, we tracked its relative abundance over multiple conditions using dna sequencing. since card is required for survival of tmd lymphoma b-cells, cells expressing clinically identified gain-of-function variants grew faster relative to cells expressing other variants, even in the presence of upstream pathway inhibitors. upon evaluation of the relative abundance of each variant in genomic dna and mrna, we found that clinically identified loss-of-function variants were depleted in mrna, which could be attributed to alterations in splicing or to nonsensemediated decay. to address the impact of splicing, we modeled a newly-identified splice donor mutation (c. + g>a) found in two patients from one family diagnosed with combined immune deficiency, autoimmunity and atopy that was also observed in our screen. we show that the variant causes deletion of exon four and that card missing exon four exerts a dominant-negative effect leading to decreased nf-kb signaling and cell growth. these experiments demonstrate the utility of multiplexed functional assays for determining variant effect in clinically-relevant genes, which will improve diagnosis and treatment in patients. mutations in the rag and rag genes in humans cause a wide spectrum of phenotypes, ranging from severe combined immunodeficiency (scid) with lack of t and b cells to omenn syndrome (os), atypical scid (as) and combined immunodeficiency with granulomas and/or autoimmunity (cid-g/ai). here, we sought to investigate the molecular basis for phenotypic diversity presented in patients with various rag mutations. methods: we have recently described a novel flow-cytometrybased assay in which mouse rag -/-pro-b cells containing an inverted gfp cassette flanked by recombination signal sequences (rss) are transduced with a retroviral vector expressing either wild-type or mutant human rag (hrag ). the green fluorescent protein expression directly relates to the activity of rag proteins, representing a quick and powerful tool to correlate between defective activity of hrag mutant and severity of the clinical phenotype. the genetic variants of hrag analyzed in this study were affecting the various domains of the protein: ring, zinc finger ring type domain (amino acids - ); nbr (amino acids - ); hbr (amino acids - ) and the core domain (amino acids - ). using this sensitive assay, we tested the recombination activity of human rag variants that have been reported in patients. results: we have demonstrated correlation between the recombination activity of the mutants and the in vivo clinical phenotype of patients. in particular, similarly low levels of recombination activity were observed in patients with scid and os, whereas patients with as and especially those with cid-g/ai carried mutations that retained significant residual levels of activity. conclusions: these data provide a framework to better understand the phenotypic heterogeneity of rag deficiency. here we report a case of a child with b. cepacia lymphadenitis, ultimately diagnosed with takayasu arteritis. takayasu arteritis is a large vessel vasculitis which may have a nonspecific clinical presentation in childhood possibly leading to difficulty in diagnosis. case: a -month-old female presented with two weeks of fever, respiratory distress, and lymphadenopathy, and was treated with ivig for presumed atypical kawasaki disease. imaging studies performed due to worsening respiratory distress revealed retropharyngeal abscess with bilateral cervical lymphadenopathy, culture-positive for prevotella oralis and melaninogenica, with improvement following incision and drainage and antibiotic therapy. recurrence of fever and respiratory distress prompted ct imaging of her neck significant for worsening lymphadenopathy. cultures from lymph node biopsy grew b. cepacia. following treatment, she was readmitted with respiratory distress requiring chronic steroid treatment and found to have candida albicans on bronchoalveloar lavage and necrotizing granulomatous inflammation on lung biopsy. an immunologic evaluation was notable for two normal dhr assays. cgd genetic panel was negative for pathogenic variants in cybb (p ), ncf (p ), cyba (p ), ncf (p ). testing was also notably negative for hiv pcr, bartonella pcr, cryptococcal antigen, histoplasma antigen, bal afb stain and mycobacterial cultures, cmv pcr, ebv pcr, anca, serial blood cultures, and sweat test. lymphocyte subsets were normal for age. mitogen stimulation test, myeloperoxidase antibody igg, serine protease igg, c level, lad panel, and cytokine panel were normal. autoimmune lymphoproliferative disorders (alps) panel was negative. whole exome sequencing demonstrated heterozygous mutations in cfi and jak , not considered to be clinically relevant given the patients clinical picture and laboratory evaluation. the patient was then lost to follow-up for over a year. at the age of years, the patient presented with fever and back pain. imaging revealed severe large vessel vasculitis involving the aorta and subclavian, vertebral, mesenteric, and renal arteries. she also had evidence of cardio-embolic strokes on brain mri. she had had no significant interval infections, and her immunologic evaluation remained unrevealing. in the context of her new vasculitis, evaluation for deficiency of ada (dada ) was negative. she was ultimately diagnosed with takayasu arteritis and has begun therapy with systemic corticosteroids, aspirin, and etanercept. conclusions: we describe a case of b. cepacia infection in a child without identified immunodeficiency, ultimately diagnosed with a large vessel vasculitis. the presence of b. cepacia infection warrants a thorough investigation. burkholderia has been previously associated with giant cell arteritis, another type of large vessel vasculitis, though causation has not been established. to our knowledge b. cepacia infection has not been associated with takayasu arteritis. christopher santaralas, valentine jadoul, jacqueline squire, john cannon, jessica trotter, susan aja, neil goldenberg, david graham, jennifer leiding background: chronic granulomatous disease (cgd) is a primary phagocytic immunodeficiency secondary to mutations in any of the components of nadph oxidase. in addition to infection susceptibility, patients with cgd can develop auto-inflammatory disease that is difficult to manage. metabolomics is the systematic study of small molecule biomarkers of the clinical phenotype of disease. we sought to investigate plasma metabolic profiles in cgd as we hypothesized that unique signatures may differentiate patients with cgd. methods: plasma collected from subjects with cgd ( x-linked, p phox-deficient, p phox-deficient) and x-linked cgd carriers was analyzed using a targeted multiplex assay by liquid chromatography mass spectrometry (lc-ms) and simultaneously a profiling assay by lcms. sufficient signal was present for metabolites. x-linked cgd and p phox-deficient groups were sufficiently sized for multivariate and univariate analyses in metaboanalyst. twelve patients had a single time point of plasma metabolomics analysis and three had multiple time points, including one in whom both pre-and post-hematopoetic cell transplantation time points were assessed. post-hoc comparisons were also performed for those with, versus without, clinical comorbidities of autoinflammation. results: plasma from patients with x-linked and p phox deficient cgd had a differential metabolomic signature at baseline. many metabolites as measured by ion intensity were present at high levels, particularly homocysteine, kyneurine, tryptophan, citric acid, carnitine, methionine, and adenosine. increased values of metabolites reduced to that of normal (compared to post hct). homocysteine levels were elevated among patients with (mean . x ), versus without (mean . x ), clinical comorbidities of auto-inflammation (i.e., colitis, lupus). baseline samples showed elevated kynurenine among all cgd patients, relative to historical normal controls (unmatched, separate analysis). patients with colitis had elevated citric acid levels that were higher among patients with (mean . x ), versus without (mean . x ), colitis irrespective of genotype. conclusions: preliminary data with a small patient subset suggest that patients with cgd have metabolomic signature distinguishable by phenotype. citric acid cycle metabolites are elevated in crohns disease and ulcerative colitis. based on our data, citric acid may too act as a biomarker for inflammatory bowel disease in cgd. analyzing a larger number of samples, across time points, will likely describe a metabolomics profile for cgd and identify biomarkers for auto-inflammation in cgd. no significant medical history in mother; paternal history is unknown and unavailable.no significant medical history in mother or father. rationale: ataxia telangiectasia is a disorder with variable phenotypes characterized by cerebellar degeneration, immunodeficiency, chromosomal instability, radiosensitivity, and cancer predisposition which may correspond to the degree of atm protein expression and/or radiosensitivity. we used in vitro cytometric assessment of atm, smc and h ax phosphorylation to assess dna damage in response to radiation and found that two siblings with the same copy number gain in atm have variable clinical neurologic and immunologic phenotypes. methods: chart review and radiosensitivity assays using cytometric assessment of patm, psmc , and h ax expression after irradiation with gy. results: patient a is a month old male identified after having low trecs on newborn screening, then found to have lymphopenia and elevated igm. he has diffuse café au lait macules and no neurologic symptoms. his year old sister, patient b, was being followed by neurology for several years for ataxia. she has selective iga deficiency, normal lymphocyte counts, lymphocyte proliferative responses, gammaglobulins, and vaccine specific antibodies. both patients have a copy number gains in atm (exons - ). mother and father both have copy number gains in atm and are healthy without neurologic symptoms or recurrent infections. both patient a and b have normal atm protein expression. phosphorylated atm, smc , and h ax was assessed in lymphocyte subsets (t, b, and nk cells) after low-dose irradiation to induce dna double-stranded breaks (dsbs). these parameters were assessed at hour post-irradiation when they are expected to be maximal and at hour post-irradiation, when under conditions of normal and effective dna repair, the phosphorylation state returns to baseline. patient a had abnormal patm and psmc but normal h ax expression hour and hours after irradiation of t, b, and nk cells. patient b had normal patm, psmc , and h ax expression in t cells but abnormal patm and psmc expression in b and nk cells hour after irradiation. patient b, however, had abnormal atm phosphorylation at hours after irradiation of t, b, and nk cells.conclusions: our results indicate that a unique copy number gain in atm within a family can correspond to different clinical and immunologic phenotypes as well as variable degree of radiosensitivity. the persistence of h ax at hours post-irradiation and impaired phosphorylation of atm and smc at hour post-irradiation demonstrates defects in dna dsb repair, and this is variably altered in different lymphocyte subsets. correlation between atm phosphorylation in lymphocytes with outcomes may be an area for future studies and particularly important in counseling patients regarding outcomes. antibodies have been implicated in both protection and pathology of dengue virus infections. however, much of this data is gathered from serum/plasma responses that is a cumulative of historical and ongoing infection. to precisely understand the role of antibodies with respect to the ongoing dengue virus infection, we employed the cutting edge approach of generating of human monoclonal antibodies from individual plasmablasts from peripheral blood of dengue patients that allows us to probe for answers at a single cell level. this method involves ex vivo single cell sorting of plasmablasts from peripheral blood of well-characterized dengue infected patient followed by single cell molecular cloning of immunoglobulin heavy-and light-variable regions into expression vectors containing the defined constant region followed by transient cotransfection of hek a cells with the heavy and light chain expression vectors made from genes arising from the same cell. thus far, using this powerful technology, for the first time in india, we have made number of human monoclonals, of which are specific to dengue and neutralize dengue virus at various concentrations. all the neutralizing antibodies are dengue-envelope specific and bind the highly conserved fusion loop of the dengue virus envelope. together, with the ongoing comprehensive analysis of the b cell repertoire and somatic hypermutations, these studies provide a detailed understanding of the dengue-specific plasmablast cell response at a single cell level and create a platform for testing these antibodies for basic research, diagnostic, prophylatic and as well as therapeutic applications. surviving. six of the ( . %) surviving patients remain dependent on ig replacement despite robust donor chimerism of - % and no active gvhd. all but two received rituximab pre-hsct. of the patients who are independent of ig replacement, only one ( . %) received rituximab post-hsct, whereas / of the ig dependent patients received rituximab post-hsct. t cell immune profiling revealed that the absolute numbers of lymphocyte subsets, cd + naïve t cells, and cd + recent thymic emigrants were not statistically different between ig independent and dependent patients ( figure ). however, there was a marked decrease in the number of total b cells, the percentage of memory b cells (cd + b cells), and classswitched memory b cells (cd + igd-igm-cells) in ig dependent patients ( figure ). t follicular helper (tfh) cell populations (cd +cd ra-cxcr +pd +) were evaluated in four patients and the frequency was similar to healthy controls ( . +/- . vs. . +/- . %). the ability of the patients naïve b cells to class-switch was assessed following exposure to il- , anti-cd antibody, and anti-human igm, and revealed normal b cell class-switching and differentiation to plasmablasts ( figure ) . additionally, t cell ability to provide b cell help was assessed by coincubating naïve b cells with activated cd + t cells. this revealed comparable b cell class switching to that of healthy controls. conclusion: the high incidence of poor long-term functional b cell reconstitution following allogeneic hsct for xlp- could be related to the use of rituximab in the post-hsct setting rather than pre-hsct. normal tfh numbers and function, and ability of b-cells to class-switch in-vitro suggest that persistent hypogammaglobulinemia is these patients is unlikely from a b or t-cell intrinsic defect. the possibility of rituximab induced acquired lymph nodal stromal defect in these patients is being explored. further studies are needed to understand the biology of persistent hypogammaglobulinemia in xlp- . additionally, due to the high incidence of persistent hypogammaglobulinemia, exposure of rituximab should be limited post-hsct. background: tandem mass spectrometry (ms/ms) has emerged as a primary platform for many clinical and newborn screening laboratories. the application of ms/ms mainly focuses on the quantification of accumulated small metabolites in plasma resulting from various metabolic defects. however, many disorders do not yield such metabolic markers and would benefit from the direct quantification of intracellular target proteins. unfortunately, the extremely low (e.g., pmol/l range) protein concentrations in blood cells limit their detection via ms/ms. in recent years, peptide immunoaffinity enrichment coupled to selected reaction monitoring (immuno-srm) has emerged as a promising technique for the quantification of low abundance proteins in complex matrices, including dried blood spots (dbs). our lab has demonstrated that immuno-srm methods are able to reliably distinguish affected patients from the normal controls for wilson disease (wd), wiskott-aldrich syndrome (was), severe combined immunodeficiency (scid), and x-linked agammaglobulinemia (xla) (j. proteome res., and front. immunol., in press). these results demonstrate the utilization of immuno-srm as a sensitive platform for multiplexed quantification of signature peptides in the low pmol/l range. methods: several candidate peptides for each protein were selected based on uniqueness using in silico blast tools and lc-ms/ms response. monoclonal antibodies (mabs) were then generated for peptide enrichment from dbs. blood from normal controls, wd, xla, scid, and was patients was spotted onto filter paper, dried, and stored at - °c until use. proteins were extracted from dbs, digested with trypsin, and enriched using mabs bound to magnetic beads. the enriched peptides were then eluted and analyzed using srm mode with a waters xevo tq-xs. results/conclusions: to date, immuno-srm methods have been generated for wd, was, scid, xla, and cystinosis. preliminary data shows immuno-srm methods are able to reliably quantify target proteins using signature peptides and accurately distinguish affected patients from normal controls. analysis of signature peptides found statistically significant reduction or absence of peptide levels in affected patients compared to control groups in each case (was and btk: p = . , scid: p = . ). intra and inter-assay precision ranged from - % and - %, respectively, and the multiplexed assay showed a broad linear range ( . fmol peptide) . in a blinded sample set of pidd patients and normal controls, immuno-srm-predicted diagnoses showed excellent agreement with clinical or genetic diagnoses. every molecularly-confirmed case of was and btk was also diagnosed by immuno-srm analysis. in addition, randomly selected samples provided by the nbs laboratory of washington state were tested and peptide concentrations were found to be within normal ranges. efforts are underway to validate and incorporate peptide biomarkers for adenosine deaminase deficiency, dock deficiency, and ataxia telangiectasia, as well as general markers for nk cells and platelets into a single multiplexed assay. in addition, scid, was and xla samples continue to be run while we focus on reducing assay costs, time, and necessary sample input. our data herein provides proof of concept for the immuno-srm workflow to be extended to various other genetic diseases as potential multiplexed newborn screening methods.( ) submission id# the background: the long-term effects of glucocorticoids (gcs) on the immune system have been extensively studied in patients with different underlying conditions (e.g, malignancies or autoimmune conditions), as well as in healthy volunteers receiving short-term courses of these drugs. although these approaches provided highly relevant data, neither of them answered the unbiased/bona-fide effect of long-term gcs use on the immune system. endogenous cushing syndrome (ecs) may be caused by pituitary or ectopic acth-producing adenomas, or by tumors or hyperplasia of the adrenal cortex. patients with ecs present with different gcsdependent manifestations, including those affecting the immune system as neutrophilia and lymphopenia. when tumors are removed, most of the effects of gcs tend to progressively regress. methods: paired samples from patients with ecs due to acth-producing adenomas (age range - y, females) were studied before (ecs-pre) and - months after tumor removal (ecs-post). extended lymphocyte phenotypes and apoptosis in different cell subsets were evaluated by flow cytometry. cytokine production (elisa) and responses, as well as their effects on cell proliferation and viability, were evaluated using cell trace violet and annexin-v staining. results: among multiple immunophenotypic changes, ecs-pre patients showed significantly reduced naïve t cells and recent thymic emigrants (rte) as well as increased apoptosis in t cells when compared to themselves (ecs-post) or age matched healthy controls. moreover, significantly increased exhausted cd t cells were observed in ecs-pre patients. interestingly, ecs-post patients showed full cellularity recovery of t cells and rte with increased proliferation and reduced apoptosis, in addition to correction of most of the other changes evidenced. significantly lower il- plasma levels were also detected in ecs-pre when compared to ecspost patients. to determine the role of il- in an ecs-resembling condition, healthy control pbmcs were treated with gcs in-vitro and the effect of il- and other cytokines was tested. a significant reduction in apoptosis was observed in the il- -treated cells that almost completely countered the pro-apoptotic effects of gcs; il- was also significantly more efficient than il- , il- , ifn-alpha and ifn-gamma in rescuing cells from apoptosis. il- -specific upregulation of bcl and bcl expression was evidenced in these cells.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -f mzwhrt authors: aggrawal, anil title: agrochemical poisoning date: journal: forensic pathology reviews doi: . / - - - - _ sha: doc_id: cord_uid: f mzwhrt a general increase in the use of chemicals in agriculture has brought about a concomitant increase in the incidence of agrochemical poisoning. organophosphates are the most common agrochemical poisons followed closely by herbicides. many agricultural poisons, such as parathion and paraquat are now mixed with a coloring agent such as indigocarmine to prevent their use criminally. in addition, paraquat is fortified with a “stenching” agent. organo-chlorines have an entirely different mechanism of action. whereas organophosphates have an anticholinesterase activity, organochlorines act on nerve cells interfering with the transmission of impulses through them. a kerosene-like smell also emanates from death due to organochlorines. the diagnosis lies in the chemical identification of organochlorines in the stomach contents or viscera. organochlorines also resist putrefaction and can be detected long after death. paraquat has been involved in suicidal, accidental, and homicidal poisonings. it is mildly corrosive and ulceration around lips and mouth is common in this poisoning. however, the hallmark of paraquat poisoning, especially when the victim has survived a few days, are the profound changes in lungs. other agrochemicals such as algicides, aphicides, herbicide safeneres, fertilizers, and so on, are less commonly encountered. governments in most countries have passed legislations to prevent accidental poisonings with these agents. the us government passed the federal insecticide, fungicide and rodenticide act (fifra) in and the indian government passed the insecticides act in . among other things, these acts require manufacturers to use signal words on the labels of insecticides, so the public is warned of their toxicity and accompanying danger. a general increase in the use of chemicals in agriculture has brought about a concomitant increase in the incidence of agrochemical poisoning. organophosphates are the most common agrochemical poisons followed closely by herbicides. many agricultural poisons, such as parathion and paraquat are now mixed with a coloring agent such as indigocarmine to prevent their use criminally. in addition, paraquat is fortified with a "stenching" agent. organochlorines have an entirely different mechanism of action. whereas organophosphates have an anticholinesterase activity, organochlorines act on nerve cells interfering with the transmission of impulses through them. a early humans are believed to have started agriculture around bce. as the knowledge of chemistry grew, so did the use of chemicals in agriculture. today, chemicals are used in agriculture for three main purposes: to increase farm production (fertilizers and related chemicals), to kill pests (pesticides), and to preserve farm products (preservatives). unfortunately, all three classes of chemicals can cause serious poisoning in humans, mainly through improper labeling, storage, or use. most poisonings with agrochemicals occur in predominantly agricultural economies where a lack of hygiene, information, or adequate control creates unsafe and dangerous working conditions. cases of such poisonings also occur in small factories where pesticides are manufactured or formulated with little respect for safety requirements. accidental poisonings may also take place at home when pesticides are mistaken for soft drinks or food products, and often the victims are curious children who can easily reach pesticides if they are not kept safely away from them. then, there are the intentional poisonings, where compounds, such as phosphorus, arsenic, paraquat, organophosphates, and strychnine, are used as agents for suicidal or even homicidal purposes. this may happen because these chemicals are easily available, relatively cheap, and almost certainly cause death. poisoning occurring as a result of improper use of chemicals used in agriculture has been termed "agrochemical poisoning." agrochemical poisoning can be classified as shown in table . agrochemical poisoning remains one of the major causes of morbidity and mortality around the world today ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , and a review of this relatively untouched subject seems to be justified. experience has shown that above the wide range of chemicals a vast majority of poisonings occur because of pesticides only. the annual report of the american association of poison control center's (aapcc) toxic exposure surveillance system listed a total of , , human exposures to poisons occurring in the united states during the year alone ( ) . out of these, there were , exposures to pesticides ( % of all exposures) and , exposures to fertilizers ( . % of all exposures); a total of fatalities caused by pesticides and one caused by fertilizers were reported. the break-up for pesticide exposure is shown in table , and the fatalities caused by pesticides are given in table . two categories in which deaths were not reported at all were fungicides and repellants. most deaths (n = ) were to the result of insecticides. herbicides and rodenticides accounted for five deaths each, and one death was caused by fumigants. a comparison of poisoning data for the years to ( ) ( ) ( ) ( ) indicates that, although the absolute number of pesticide exposure has been increasing, it is more or less stable at around % of all exposures to poisons; fatalities owing to pesticide poisoning amount to . to % of all fatalities resulting from poisons (table ). in the following sections, those agrochemical poisons that are important from a medicolegal and pathological point of view will be discussed. organophosphorus insecticides are derivatives of phosphoric acid (h po ) or phosphonic acid (h po ) in which all h atoms have been replaced by organic moieties (figs. - ) . l represents the so-called "leaving moiety" and is the most reactive and most variable substituent. it is called so because this moiety "leaves" the organophosphate molecule after it is attached to the esteratic site of the acetylcholinesterase (ache, also known as true cholinesterase type che). r and r are less reactive moieties. most commonly they are poisonous plants (used as green manure, e.g., ricinus communis). . chemicals used to kill pests (pesticides) (i) acaricides (used to kills mites and ticks, also known as miticides, e.g., avermectins, azobenzene, benzoximate, bromopropylate, dofenapyn, nikkomycins, tetranactin). (ii) algicides used to control growth of algae in lakes, canals, and water stored for agricultural purposes (e.g., cybutryne, hydrated lime [component of bordeaux mixture]). (iii) aphicides (used to kill aphids, e.g., triazamate, dimethoate, and mevinphos). (iv) avicides (used to kill birds harmful to agriculture, e.g., -aminopyridine, -chloro-p-toluidine hydrochloride). bactericides (e.g., bronopol, nitrapyrin, oxolinic acid, oxytetracycline). (vi) fumigants (gas or vapor intended to destroy insects, fungi, bacteria, or rodents, used to disinfect interiors of buildings, as well as soil, before planting, e.g., carbon disulfide, sulfuryl fluoride, methyl bromide). (vii) fungicides (e.g., sodium azide, various compounds of copper and mercury, thiocarbamates, captan, captafol). (viii) herbicide safeners (e.g., benoxacor, cloquintocet, cyometrinil, dichlormid, dicyclonon). these compounds basically protect crops from herbicide injury by increasing the activity of herbicide detoxification enzymes, such as glutathione-s-transferases and cytochrome p- . (ix) herbicides/weed killers (e.g, paraquat, diquat, - dichlorophenoxyacetic acid, mecoprop). (x) insecticides (e.g., organophosphorus compounds, organochlorine compounds, carbamates). (xi) microbial pesticides (those pesticides whose active ingredient is a bacterium, virus, fungus, or some other microorganism or product of such an organism, e.g., bti which is made from the bacterium bacillus thuringiensis var. israelensis and used to control mosquito and black fly larvae, bacillus sphaericus and laegenidium giganteum, a fungal parasite of mosquitoes). (xii) molluscicides (used to kill molluscs, such as snails and slugs, e.g., metaldehyde). (xiii) nematicides (used to kill nematodes that feed on plant roots, e.g., , dichloropropene, , -dibromoethane, ethylene dibromide, diamidafos, fosthiazate, isamidofos). (xiv) ovicides (used to kill eggs of insects and mites). (xv) pesticide synergists (e.g., piperonyl butoxide, n-octyl bicycloheptene dicarbozimide, piprotal, propyl isome, sesamex, sesamolin). (xvi) rodenticides (used to kill rodent pests, e.g., strychnine, vacor, antu, cholecalciferol, anticoagulants and red squill). (xvii) virucides (e.g., ribavirin, imanin). (xviii) miscellaneous chemical classes including contaminants and adjuvants of some pesticides which are toxic on their own (e.g., dioxins, present as contaminants of some herbicides produce toxicity of their own). . chemicals used to disturb the feeding/growth/mating behavior etc. of pests, or used for other miscellaneous agricultural purposes (i) bird repellents (e.g., anthraquinone, chloralose, copper oxychloride). (ii) chemosterilants (e.g., , -dibromo- -chloropropane, apholate, bisazir, busulfan, dimatif, tepa). (iii) desiccants (chemicals which promote drying of living tissues such as unwanted plant tops or insects). (iv) defoliants (chemicals which cause leaves or foliage to drop from a plant, usually to facilitate harvest). feeding deterrents or antifeedants (chemicals having tastes and odors that inhibit feeding behavior, e.g., pymetrozine, azadirachtin a). (vi) insect attractants (substances that attract or lure an insect to a trap, e.g. brevicomin, codlelure, cue-lure, dominicalure, siglure). (vii) insect growth regulators (chemicals which disrupt the action of insect hormones controlling molting, maturity from pupal stage to adult, or other life processes, e.g., hexaflumuron, teflubenzuron and pyriproxyfen). (viii) insect repellents (e.g., butopyronoxyl, dibutyl phthalate, diethyltoluamide). (ix) mammal repellents (e.g., copper naphthenate, trimethacarb, zinc naphthenate, ziram). mating disrupters (e.g., disparlure, gossyplure, grandlure). (xi) plant activators (a new class of compounds that protect plants by activating their defense mechanisms, e.g., acibenzolar, probenazole). (xii) plant growth regulators (substances [excluding fertilizers or other plant nutrients] that alter the expected growth, flowering, or reproduction rate of plants through hormonal rather than physical action). . chemicals used for preservation of grains (i) aluminum phosphide. (ii) nitric oxide. available as dusts, granules, or liquids, organophosphorus insecticides are among the most popular and widely used insecticides throughout the world. they began to be synthesized first around with the esterification of alcohols to phosphoric acid. the earliest synthesis of an organophosphate, tetraethyl pyrophosphate, was reported by phillipe de clermont at a meeting of the french academy of sciences in ( ) . many different organophosphorus compounds were synthesized in the early s, but their toxicity was first recognized by lange in . lange stated that inhalation of the vapor of dimethyl or diethyl phosphofluoridate produced a choking sensation and dimness of vision. as nations started looking for lethal gases with the start of world war ii in , interest in these compounds was rekindled. by , schrader in germany and saunders in england and their study groups had synthesized a number of highly toxic organophosphates for possible use in warfare. most notable among these were soman, sarin, and tabun. currently, about organophosphorus compounds are in use as insecticides worldwide. of these, parathion is the most effective for insecticidal use. tetraethyl pyrophosphate enjoys two distinctions among organophosphates: it was the first organophosphate to be synthesized in and is the organophosphorus insecticides are basically ache inhibitors allowing the accumulation of excess acetylcholine at various nicotinic and muscarinic receptors throughout the body including the central nervous system (cns). this essentially results in acetylcholine toxicity. the main symptoms can be remembered by either of the two acronyms sludge (salivation, lacrimation, urination, defecation, gastrointestinal distress, emesis) or dumbels (diarrhea, urination, miosis, bronchospasm and bradycardia, emesis, lacrimation, salivation). rarely, there is chromolachryorrhoea (shedding of red or bloody tears) ( ) because of a disturbance in porphyrin metabolism and its accumulation in lacrimal glands. ld (lethal dose; the amount of a material, given all at once, which causes the death of % of a group of test animals) of these compounds varies from to mg/kg (extreme toxicity) to more than mg/kg (slight toxicity). compounds that are extremely toxic are chlorfenvinphos, diazinon, and methyl parathion, whereas those that are slightly toxic are malathion, acephate, and trichlorphon ( ) . most patients who have ingested a fatal dose will die within hours of ingestion. organophosphorus toxicity has recently been reviewed extensively by rousseau and co-workers ( ). signs of asphyxia are commonly found in fatal intoxications with organophosphorus insecticides. there is congestion of the face and cyanosis of the lips, nose, fingers, and acral parts of the extremities. one of the most remarkable findings is the characteristic odor emanating from the corpse: it has been described as garlic-or kerosene-like and is due to the fact that organophosphates are dissolved on a kerosene base. there is often frothy, bloody staining at the mouth and nostrils, and the pupils may be constricted. a coloring agent, indigocarmine, is added to parathion (e ® ) to prevent its accidental ingestion or criminal use as a poison. this gives rise to a bluishgreenish discoloration of the lips and oral mucosa. the addition of indigocarmine, however, is not a general practice worldwide. for instance, in india and several other asian countries, this practice is not followed. an interesting sign to be observed (albeit only in somewhat less modern mortuaries) is the death of bluebottles and others insects and flies dying immediately after they alight on an opened cadaver at autopsy ( ). the gastric mucosa is congested and may appear hemorrhagic (fig. ) and the stomach contents often contain an oily, greenish scum. the mucosa of the respiratory tract is congested and the airway passages contain frothy hemorrhagic exudate. the lungs show congestion, hemorrhagic pulmonary edema, and subpleural petechiae. the brain is swollen and there is generalized visceral congestion. parathion (e ) has been studied most extensively for histopathological lesions and these are considered to be representative of other organophosphorus insecticides, too ( ) . in the kidneys, there is epithelial necrosis in the straight sections of the renal tubules. in the epithelia of the remaining renal cortical sections, there is pronounced plasma granulation, nuclear wall hyperchromatosis, and clumping and reduction in the chromatin and marginal nucleoli. epithelia in loops of henle and collecting tubules appear swollen. the liver is more resistant to the effects of organophosphates, partly because of its ability to manufacture serum cholinesterase on its own. hepa- tocytes show opaque swelling and glycogen depletion; there are destructive changes in the liver cell strands, detached hepatocytes, and perivascular edema. myocardium, medulla oblongata, and vagal nuclei of the brain show fine, maculate perivascular hemorrhages. limaye has described a type of toxic myocarditis that he had observed in autopsy cases ( ) . kiss and fazekas described focal myocardial damage with pericapillary hemorrhage, micronecrosis, and patchy fibrosis in victims of organophophorus poisoning ( ) . pimentel and da costa ( ) have described the following myocardial ultrastructural changes in fatal poisonings with organophosphorus: multiple circumscribed necroses are found in the skeletal musculature. the oolemma is damaged and sometimes even necrotic. the glomus caroticum shows an increase in the number of dark-cell nuclei, perhaps as a consequence of increased nuclear metabolism owing to augmented demand. ache and butyrylcholinesterase (bche, also known as pseudocholinesterase or type che) levels are depressed in deaths owing to organophosphorus insecticides. the measurement of their levels can assist in the determination of the cause of death ( ) . ache is found mostly in red blood cells, motor endplates, and gray matter, whereas bche is found mostly in plasma, white matter, liver, heart, and pancreas. the physiological function of bche is unknown ( ) , but it is established that bche hydrolyzes suxamethonium (succinylcholine), and for this reason it is of interest to anesthesiologists as well. postulated functions of bche include its role in transmission of slow nerve impulses, lipid metabolism, choline homeostasis, permeability of membranes, protection of the fetus from toxic compounds, and degradation of acetylcholine and in tumorneogenesis ( ) . the plasma cholinesterase (pseudocholinesterase) is more sensitive and levels fall more rapidly than those of the red blood-cell cholinesterase. red blood-cell cholinesterase levels are more satisfactory for the diagnosis of organophosphorus poisoning because they represent the true cholinesterase levels. sample collection and storage (time and temperature) are critical to the catalytic stability of che and thus influence the quality and interpretation of results of the toxicological analysis. fluids and tissues that should be collected at autopsy are blood, cerebrospinal fluid (csf), semen, muscle, brain, liver, heart, and pancreas. the recommended procedures for collection and storage of biological fluids are as follows: . blood must be collected in heparinized tubes. . the samples must be collected and stored in glass rather than plastic containers to avoid contamination by leachates from plastic. . sample contamination with acid or alkali must be avoided. . samples must be immediately refrigerated because che catalytic activity is temperature dependent. . fluid and cellular components of blood, csf, and semen have to be separated. . determine enzyme activity as soon as possible. if enzyme activity is not determined immediately, samples can be stored for several days at °c. if tissues are intended to be stored for longer periods, the storage temperature should be - °c or below. . tissue should be homogenized at ph . to . using a sonicator or nonmetallic homogenizer and then should be stored as indicated above. che activity in blood, serum, and tissues can be measured by a number of methods. one of the most popular is the ph method by michael ( ), whereby a change in ph is measured when che acts on acetylcholine. the principle is that cholinesterase hydrolyzes acetylcholine, thus producing acetic acid, which in turn decreases the ph of the reaction mixture. electrometric determination of the change in ph from . for a definite period of time (e.g., hour) at a specific temperature (e.g., °c) represents the enzyme activity. normal values of che activity as measured by this method (in Δph/hour/ . ml red blood cells or plasma at °c, mean ± standard deviation) are given in table ( ) . in deaths owing to organophosphorus insecticides, the values will be much lower. a % or greater depression of the red blood-cell che level is a true indicator of poisoning. death occurs when levels have decreased by more than %. blood and urine should be preserved for toxicological analysis of che levels. samples from lung, liver, kidney, skeletal muscle, brain, and spinal cord, as well as gastric contents, must similarly be preserved for toxicological analysis of cholinesterase levels ( ) according to the precautions detailed in steps - in section . . . . paranitrophenol is a metabolite of many organophosphates. it is excreted in urine and its presence in urine is characteristic of organophosphorus poisoning. organophosphates usually resist putrefaction and can be detected in the viscera for quite some time after death. wehr ( ) studied five exhumations where the decedents were suspected having been poisoned with parathion. he could detect the degradation products of parathion (aminoparathion and p-nitrophenol) up to years after burial, but after years, neither parathion nor any of its degradation products were detectable. pohlmann and schwerd found evidence of parathion in a corpse exhumed after months ( ) . more recently, karger and co-workers ( ) described a case where they detected paraoxon, the main conversion product of parathion, from the abdominal cavity of a -month-old boy, months after his death. his mother had poisoned him with parathion; her deed was detected when, several months later, her second child-a -year-old girl-also suffered the same fate and parathion was detected in her blood. carbamates (fig. ) are derivatives of carbamic acid. their structure is similar to that of organophosphates (fig. ) . the first recognized anti-che was in fact a carbamate, physostigmine (also called eserine), obtained in pure form in by jobst and hesse from the calabar bean ( ) . some common carbamates used as insecticides today are aldicarb, carbaryl, γ-benzene hexachloride, triallate, propoxur, methomyl, carbofuran, and carbendazim. like organophosphates, carbamates are inhibitors of ache, but instead of phosphorylating, they carbamoylate the serine moiety at the active site. this is a reversible type of binding, and therefore, their toxicity is less severe and of lesser duration ( ) . because they do not penetrate the cns to any great extent, the cns toxicity of carbamates is relatively low. signs and symptoms are the same as those seen in poisoning with organophosphates/organophosphorus insecticides but they are milder in nature. convulsions are not seen in carbamate poisoning. postmortem findings in carbamate poisonings are mostly similar to those found in organophosphates. a bluish discoloration of the mucosa of the mouth and stomach is not seen because the blue green dye indigocarmine is usually not mixed with carbamates. determination of cholinesterase levels is not of much help because these are restored very rapidly in carbamate poisoning. organochlorine pesticides are nonselective insecticides. they are cyclic in nature, have molecular weights between and d, are cns stimulants, and have limited volatility. they are poorly soluble in water but readily soluble in organic solvents and fats, which is the way how they accumulate in the human body. they are very stable, both in the environment and in the body tissues, and can be demonstrated in the bodies of most people born since . based on their chemical structures, organochlorines can be divided into four categories ( fig. ) ( ): (a) dichlorodiphenyltrichloroethane (ddt) and related analogs, such as methoxychlor, (b) hexachlorocyclohexane or lindane, (c) cyclodienes and related compounds (e.g., aldrin, dieldrin, endrin, endosulfan, chlordane, chlordecone, heptachlor, mirex, isobenzan), and (d) toxaphene and related compounds. the best known organochlorine, ddt, was synthesized by the german chemist othmar zeidler in , but he failed to realize its value as an insecticide. it was the swiss paul hermann müller ( - ) who recognized its potential as an effective insecticide. in , ddt was tested successfully against the colorado potato-beetle by the swiss government. the united states department of agriculture used it successfully in . in january , ddt was used to quash an outbreak of typhus carried by lice in naples, italy; this was the first time a winter typhus epidemic could be stopped. so revolutionary was his work that müller was awarded with the nobel prize in medicine in . it is ironic that just years later, in , ddt was banned in the united states. it is perhaps a unique example in the history of science that a nobel prize-winning work was banned within such a short period of time. the main driving force behind this ban was the ecologists' concerns about the persistence of ddt in the environment and its resulting harm to the habitat-humans are equally affected by persistent ddt in the environment. it was rachel carson's book silent spring, published in , which brought the problem to everyone's notice. endrin, one of the cyclodienes, is chiefly used against insect pests of cotton, paddy, sugarcane, and tobacco. it is active against a wide variety of insect pests, and hence is commonly known as plant penicillin. it has been banned in most western countries, but unfortunately continues to be used in several agrarian economies. the mechanism of action of organochlorines is entirely different from that of organophosphates and carbamates. organochlorines act on axonal membranes affecting the sodium channels and sodium conductance across the neuronal membranes. organochlorines also alter the metabolism of acetylcholine, noradrenaline, and serotonin. lindane and cyclodienes appear to inhibit the γaminobutyric acid-mediated chloride channels in the cns. therefore, not very surprisingly, the main symptoms induced by poisoning with organochlorines are cns-related and include vertigo, confusion, weakness, agitation, hyperesthesia or paresthesia of the mouth and face, myoclonus, rapid and dysrhythmic eye movements, and mydriasis (in contrast to organophosphates and carbamates, where miosis is found). other symptoms include nausea, vomiting, fever, aspiration pneumonitis, and renal failure. the fatal dose of ddt and lindane is to g, whereas that of aldrin, dieldrin, and endrin is to g ( ). the conjunctivae are congested and the pupils are dilated. there may be a kerosene-like smell emanating from the mouth and nostrils. this is because most organochlorines are poorly soluble in water and are dispensed as solutions in organic solvents that may have a kerosene-like smell. fine white froth, which may or may not appear hemorrhagic, can be seen around the mouth and nostrils; this is a general effect of pulmonary edema coupled with respiratory distress and therefore, signs of cyanosis are seen on the face, ears, nail beds, etc. the mucosa of the respiratory tract appears congested and the respiratory passages contain frothy mucus which may or may not be tinged with blood. subpleural and subpericardial petechial hemorrhages are common. the lungs appear large and bulky, showing pulmonary edema. the mucosa of the esophagus, stomach, and bowel is congested owing to the irritating effect of organochlorines on the gastrointestinal tract. the stomach contents smell kerosene-like. the visceral organs are congested. hepatic necrosis may be found on cut sections of the liver. in animals killed by ddt, vacuolization around large nerve cells of the cns, fatty change of the myocardium, and renal tubular degeneration can be detected histologically ( ). feces, urine, and subcuatenous adipose tissue (placed in a glass-stoppered vial or a vial with a teflon-lined cap [ ] ) should be collected for toxicological analysis. samples must be frozen before onward transmission to the toxicology laboratoy. nicotine salts, such as nicotine sulfate, were very popular pesticides in the s and s. these compounds generally contained % nicotine (fig. ). now, because most countries have banned nicotine-based insecticides, less than % of home garden insecticides are nicotine-based. these are usually available in powder form. main among these is black leaf- (manufactured by black leaf products company, elgin, il). when nicotine-based insecticides come in contact with moist skin, fatal doses of nicotine may be absorbed through the skin ( ) . apart from occupational exposure to nicotine spray, other methods of fatal exposure include careless storage and inadvertent mixing with foodstuffs, fruits, and vegetables. these insecticides have also been used successfully with suicidal or homicidal intention. brownish froth around the mouth and nostrils is a frequent finding in nicotine poisoning. there is a characteristic odor of stale tobacco emanating from the gastric contents. the esophageal and gastric mucosa is intensely congested, showing a brownish discoloration. liver and kidneys show considerable acute congestion ( ). the liver shows plaque-like granulations in the cytoplasm of centrilobular and intermediary hepatocytes. intrapulmonary hemorrhages and pulmonary edema are typical and there often is detachment of the alveolar epithelium. in the kidneys, there is necrosis and detachment of the epithelia in the straight and convoluted renal tubules. a variety of arterial wall lesions, including lacerations of the elastic interna, are seen that have been connected with extreme fluctuations in blood pressure from the effects of nicotine ( ). an estimated % of all plant species are weeds, with a total of some , species. chemicals, such as common salt, have been used for centuries for weed control. the era of chemical weed control is generally recognized as starting in . bonnet in france found that the bordeaux mixture, already being used on vines to control powdery mildew, also provided control of specific weeds. by the s, farmers were still using simple chemicals for this purpose; for example, copper sulfate (blue vitriol), which was first used for weed control in , was still in use at this time. in the early th century, scientists in europe started using the salts of heavy metals to control weeds but when this was attempted in the united states, the low humidity in the western states prevented these chemicals from being absorbed by the weeds. other chemicals were tried, but most of them had drawbacks. for instance, carbon bisulfide used to control thistles and bindweeds smelled like rotten eggs and was, therefore, quite understandably unpopular. most chemical weed killers of those times (such as sodium arsenate, arsenic trioxide, and sulfuric acid) were highly toxic to humans and had to be used in large quantities (several kilograms per hectare), which was another serious drawback. the first synthetic organic chemical for selective weed control was introduced in . its chemical name was -methyl- , -dinitrophenol, and it could control some broadleaf weeds and grasses in large seeded crops, such as beans. more modern herbicides are now available. these have to be sprinkled in very low doses (grams per hectare) in order to kill weeds and the crop is spared. herbicides are categorized as selective when they are used to kill weeds without harming the crop and as nonselective when the purpose is to kill all vegetation. killing of all vegetation is generally not intended in an agricultural setting. it is required more often in places such as recreational areas, railroad embankments, irrigation canals, fence lines, industrial sites, roadsides, and ditches. both selective and nonselective herbicides can be applied to weed foliage or to soil containing weed seeds and seedlings depending on the mode of action. the term true selectivity refers to the capacity of an herbicide, when applied at the proper dosage and time, to be active only against certain species of plants but not against others. selectivity can also be achieved by placement, such as when a nonselective herbicide is applied in such a way that it reaches only the weeds but not the crop. herbicides can also be classified as contact or translocated. contact herbicides kill the plant parts to which the chemical is applied. translocated herbicides are absorbed either by the roots or the above-ground parts of plants and are then circulated within the plant system to distant parts. timing of herbicide application regarding the stage of crop or weed development forms another basis of classification. a preplanting herbicide is sprinkled on the farm before the planting of the crop. a preemergence herbicide is sprinkled after planting but before emergence of the crop or weeds. finally, a postemergence herbicide is used after the emergence of the crop or weed. herbicides can be applied to weeds in a number of ways. a band application treats a continuous strip, such as along or in a crop row. broadcast application covers the entire area, including the crop. spot treatments are confined to small areas of weeds. directed sprays are applied to selected weeds or to the soil to avoid contact with the crop. in the more recent overthe-top-application, herbicides are applied "over the top" of the crop and weeds shortly after germination. the crops in these instances are naturally tolerant to the specific herbicide or have been genetically engineered to be tolerant to the herbicide used. from a toxicological point of view, the following herbicides are the most important. dipyridyl weed killers include paraquat, piquat, and morfamquat ( fig. ). paraquat is the most important of these three. paraquat ( , ′dimethyl- - ′bipyridylium dichloride) is an important agricultural chemical from a toxicological viewpoint. out of the deaths caused by pesticides reported by the aapcc annual report ( ) , two were the result of paraquat poisoning. paraquat was first synthesized in , but its herbicide activity was discovered very late. its use as an herbicide was first reported in , and paraquat was introduced commercially as a nonselective herbicide in . the introduction of paraquat caused an agricultural revolution because it has some unique properties. it can be sprayed from the ground level or the air and is totally denatured when it comes in contact with the earth. thus, it cannot harm the seeds or young plants that will be placed in the same ground a short time later. indeed, the crop can be planted within days, if not hours, after herbicidal treatment with paraquat. an additional advantage is that plowing is unnecessary aggrawal in many cases with much less soil erosion. paraquat is therefore of immense value in an economic sense ( ) . in countries like sri lanka, its use has resulted in three crops, instead of two, per year being taken off the same field ( ) . paraquat is highly soluble in water and is marketed most commonly as a concentrate containing g paraquat dichloride per liter ( % wt/vol); this is an odorless brown liquid. a "stenching" agent (a pyridine derivative) is added to prevent accidental or criminal poisoning; a bluish-greenish dye is also added for the same reason, and an emetic may be added as well. paraquat is sometimes sold in combination as a mixture with diquat and other herbicides. the liquid concentrate is known as gramoxone (not to be confused with gammexane, which is the trade name for lindane); a weaker, granulated preparation for horticultural use, known as weedol, is also available ( % wt/vol). the solution may be decanted in soda bottles and left unlabelled. because it looks like a cola drink, accidental ingestion may occur. it may be mistaken for vinegar as well; one patient is reported to have sprinkled it on his french fries. wesseling and co-workers ( ) reported that paraquat is the pesticide most frequently associated with injuries among banana workers in costa rica; the injuries involve mostly the skin and eyes. although most fatalities caused by paraquat occur from ingestion, absorption through the skin can also cause fatalities. wohlfahrt ( ) reviewed paraquat poisoning in papua new guinea from to and found that out of fatalities caused by paraquat, six were the result of transdermal absorption. diquat ( , ′-ethylene- , ′-dipyridylium dibromide) is less commonly used than paraquat. it has the same indications and mode of action as paraquat. diquat is, however, used additionally for the control of aquatic weeds. jones and vale ( ) compiled all cases of diquat poisoning published between the years and and found that only cases were reported in detail in the literature, of which ( %) were fatal. conning et al. showed that out of the three dipyridyl weed killers, it was only diquat that produced bilateral cataracts ( ) . diquat was introduced in as a fast-knockdown, contact herbicide and plant desiccant. diquat-only formulations manufactured by syngenta (formerly imperial chemical industries) or its subsidiaries do not contain the dye, "stenching" agent, or emetic added to paraquat ( ). the symptoms include intense pain in the mouth and pharynx, with inflammation and even ulceration of the oral mucosa. esophageal ulceration may lead to perforation with all its attendant risks. renal and hepatic failure develop within to days. the most important effect is on the lungs (pneumotropism), where massive, irreversible pulmonary fibrosis is seen. pulmonary fibrosis is thought to be the result of an increase in the pulmonary concentrations of prolyl hydroxylase, an enzyme which promotes collagen formation. paraquat is one of the few poisons that may produce necrosis of the adrenal glands, possibly leading to hypotension. the fatal dose is to g (about a mouthful of gramoxone). subcutaneous injection of just ml of gramoxone has shown to be fatal ( ) , with death occuring after to weeks as a result of respiratory failure caused by pulmonary fibrosis; greater doses can kill a human within hours. why does paraquat show such remarkable pneumotropism? it has been postulated that inside the pneumocytes, the paraquat dication pq + accepts one electron from reduced nicotinamide adenine dinucleotide and becomes the monocation pq + . (pyridinyl-free radical) (fig. ). the monocation pq + . is unable to cause any injury on its own, but in the presence of molecular oxygen (o ) in the lungs, it is oxidized once again to its dication form (pq + ). in this process, it passes on its electron to the molecular oxygen (o ), which, in turn, becomes the superoxide anion radical (o -. ). this process, known as redox cycling, is sustained by oxygen in the lungs. the superoxide anion radical o -. (reactive oxygen species) generated as a result of this cycle is responsible for cell death. this also explains why oxygen enhances the toxicity of paraquat and should never be administered during paraquat intoxication; by administering oxygen, one is supplying the "raw material" for the formation of the damaging superoxide radical. formation of free radicals is implicated in injuries caused by at least two other poisons-myocardial injury caused by doxorubicin and liver injury by carbon tetrachloride. the related bipyridylium compounds, such as diquat and morfamquat, do not affect the lung as seriously, but rather cause liver damage ( ). there is ulceration around lips and mouth, although it is not as bad as is seen after ingestion of inorganic acids, such as nitric or sulfuric acids. the oral and esophageal mucosa is reddened and desquamated. a unique feature of paraquat ingestion is the formation of pseudomembranes in the pharynx resembling to that seen in diphtheria ( ). patchy hemorrhages in the stomach mucosa are a frequent finding. the liver is pale, showing fatty changes. the kidneys may exhibit pallor of the cortex. the most striking findings are found in the lungs. both type and type alveolar epithelial cells accumulate paraquat and are thereby destroyed. this destruction is followed by inflammatory cell infiltration and hemorrhages; fibroblast proliferation then leads to fibrosis and impaired gas exchange. the lungs are congested, appear stiffened, and retain their shape during evisceration. each lung is typically approx g or more in weight. teare ( ) reported a case of paraquat poisoning (a -year-old man dying of suicidal ingestion of paraquat after days of illness), with the left lung weighing g and the right lung weighing g. blood-stained pleural effusions and fibrinous pleurisy are other typical autopsy findings. cut surfaces of the lungs reveal edema and fibrosis. subendocardial hemorrhages may accompany the aforementioned pathological findings. the pathological features of paraquat poisoning have been reviewed in detail by vadnay and haraszti ( ) . at the beginning of the toxic process, severe degenerative changes appear in the pneumonocytes with fatty infiltration, desquamation, necrosis, and detachment ( ) . later, there is splintering of the basement membranes, fragmentation, aneurysma formation, and multiple ruptures. fibrinous edematous fluid is seen in the interstitium and within alveoli and hyaline membranes can be observed. there is a large-scale dissolution of the pulmonary structure. there may be active proliferation of the bronchial epithelium, forming small adenomata within the pulmonary parenchyma. marked proliferation of fibroblasts with an increase in macrophages in the alveoli (these two mechanisms obliterate the alveolar spaces) can be seen. acute tubular necrosis is a frequent finding in the kidneys. extensive renal cortical necrosis is also seen at times. in the liver, centrilobular hepatic necrosis, cholestasis, and giant mitochondria with paracrystalline inclusion bodies can be detected ( ) . in the myocardium, there is edematous disaggregation of the sarcoplasm and sporadic fragmentation of the myofibrils. paraquat-type herbicides in aqueous solutions have traditionally been determined by colorimetric methods. these involve measurement of the complex formed with some chemical (α-dipicrylamine hexanitrodiphenylmethane). plasma paraquat levels can be assayed by spectroscopy, high-performance liquid chromatography ( ) or radioimmunoassays; levels greater than . μg/ml confirm death by paraquat intoxication. urine paraquat levels can be deter-mined using spectrophotometry, too; levels greater than μg/ml confirm death by paraquat intoxication ( ) . berry and grove introduced an ion exchange and colorimetric method in for the determination of paraquat in urine ( ) . diquat (reglone) is selectively concentrated in the kidneys and causes marked renal tubular damage. in a case of fatal diquat poisoning, mccarthy et al. found esophagitis, tracheitis, gastritis, and ileitis ( ) . autopsy findings and toxicokinetic data in diquat poisoning have been described in detail by hantson et al. ( ) . morfamquat is used far less commonly than the other two bipyridyls, paraquat and diquat. conning et al. have shown that rats that fed on morfamquat developed renal damage ( ). chlorophenoxy herbicides (fig. ) are growth regulators or auxins. they cause abnormal plant growth, thereby ultimately destroying the plant. chlorophenoxy herbicides are commonly used for control of broadleaf weeds in cereal crops and pastures ( ). - dichlorophenoxyacetic acid ( , -d; trimec) has been and continues to be one of the most useful herbicides developed; it is frequently applied to lawns to control broadleaf weeds and is often found in fertilizer products along with other phenoxy herbicides, such as dicamba, mecoprop, and ( -chloro- -methylphenoxy)acetic acid. , -d is easily absorbed through the skin and lungs ( ). on ingestion, , -d causes peripheral neuropathy, muscle weakness, cheyne-stokes respirations, hyperthermia, acidemia, and coma ( ) . the patient is hypotonic, hyporeflexive, hypotensive, and comatose ( ) , and nasogastric aspirate may be guaiac-positive ( ). , -d earned a notorious reputation during the vietnam war as an ingredient of agent orange sprinkled by united states troops over vietnam (see subheading . ). suicidal ingestions of , -d are occasionally reported ( , ) . postmortem findings in deaths caused by chlorophenoxy herbicides are nonspecific. the gastrointestinal mucosa may be intensely congested and/or hemorrhagic. all internal organs are usually congested. confirmatory tests of suspected poisonings with chlorophenoxy herbicides are the demonstration of these herbicides in plasma and urine,which can be detected by radioimmunoassay ( ) and gas liquid chromatography ( ). this category comprises mainly dinitrophenol (dnp), dinitro-orthocresol (dnoc), and pentachlorophenol ( ) . these substances are used in agriculture mainly as selective weed killers for cereal crops. the effects of dnp in stimulating metabolism have been known since , and dnp was used at one time for "slimming." dnp (fig. ) is a potent "uncoupler" of oxidative phosphorylation, causing the energy obtained from the oxidation of nicotinamide adenine dinucleotide and reduction of o to be released as heat. it has been demonstrated that these compounds are dangerous to humans and thus, they are no longer used for medicinal purposes. the principal risk of poisoning is in the agricultural use of concentrated solutions for spraying crops aggrawal (as weed killers). dinitrophenol (dnp) is also used in agriculture for the control of mites and aphids ( ) . absorption occurs by inhalation and thus, breathing apparatus are a must for those who are exposed to this poison. absorption also occurs by ingestion and through the skin. excretion of dnp is extremely slow, so the poison accumulates in the body gradually. the symptoms are fatigue, insomnia, restlessness, excessive sweating, weight loss, and thirst. clinical signs include tachycardia, increase in the rate and depth of respiration, rise in temperature (up to °c and higher) and some yellow discoloration of the sclera. in severe cases, body temperature may keep rising and just before death, it may reach °c. when death occurs, the onset of rigor mortis is rapid. sodium chlorate is a nonselective herbicide. it acts as a soil sterilant at rates of lbs/acre. it is also used as a foliar spray at lbs/acre as a cotton defoliant. it was once avidly advocated as a weed killer, not only because it is effective, but also because it was considered safe. this fallacy was so prevalent that containers of sodium chlorate used to be marked as "nonpoisonous." however, chlorates cause methemoglobinemia. severe hemolysis is a constant clinical feature in sodium chlorate poisoning, with presence of heinz bodies in the red blood cells. acute renal failure and anuria sets in later. anuria occurs because of (a) a direct damaging action of chlorates on the renal tubular epithelium, and (b) mechanical obstruction of the renal tubules by the hemoglobin set free by hemolysis. the fatal dose of sodium chlorate is to g with death occuring within to days. poisoning with sodium chlorate can occur accidentally, suicidally, or even homicidally. accidental poisoning is probably the most common. a -year-old gardner was severely poisoned in a curious way. he was using a concentrated solution of sodium chlorate in an atomizer while a strong wind was blowing. consequently, spray was blown onto his face and he inhaled and ingested some of the solution. symptoms of poisoning started the same evening. he was saved with some heroic effort on the part of the doctors, yet he could only return to full-time work after about year ( ). the skin has a distinctive chocolate-brown color. blood smears may show evidence of hemolysis and heinz bodies. the kidneys are enlarged and their principal change is a brown streaking of the cortex; microscopical examination reveals acute renal tubular degeneration with blockage of tubules by broken red blood cells and brown pigment granules (released hemoglobin owing to hemolysis). glyphosate is an important agricultural chemical from the toxicological viewpoint. out of the deaths caused by pesticides reported by the aapcc annual report ( ) , one was caused by glyphosate. glyphosate is a broad-spectrum, nonselective, systemic herbicide used for control of annual and perennial plants including grasses, sedges, broad-leaved weeds, and woody plants. it can be used on non-cropland as well as on a great variety of crops. although glyphosate itself is relatively harmless, its chemical formulations (e.g., roundup ® , rodeo ® , touchdown ® , gallup ® , landmaster ® , pondmaster ® , ranger ® ) have been used successfully for committing suicide. this is because glyphosate invariably is formulated in a surfactant (polyethoxylated tallow amine), which is quite toxic ( , ) . glyphosate is generally distributed as water-soluble concentrates and powders. mild poisoning results only in gastrointestinal symptoms, such as vomiting, abdominal pain, diarrhea, and nausea, which usually resolve within a day or two. severe poisoning results in intestinal hemorrhage and ulceration, acid base disturbances, renal failure, hypotension, cardiac arrest, pulmonary dysfunction, convulsions, coma, and death. postmortem findings are nonspecific. glyphosate and the concomitant surfactant are demonstrated by toxicological analysis in the gastric contents and other visceral organs. glyphosate levels of mg/ml or more can be detected postmortem in blood, liver, and urine in less than a minute by using p nuclear magnetic resonance ( ). among the several arsenical herbicides available are cacodylic acid, calcium hydrogen methylarsonate, disodium methylarsonate, hexaflurate (asf k), methylarsonic acid, monoammonium methylarsonate, monosodium methylarsonate, potassium arsenite, and sodium arsenite. cacodylic acid (fig. ) is also known as dimethylarsinic acid. cacodylic acid is a white crystalline substance, readily soluble in water and alcohol, and is still used as an herbicide. when it unites with metals and organic substances, it forms salts known as cacodylates. cacodylic acid contains . % of arsenic. fungicides, or antimycotics, are toxic substances used to kill or inhibit the growth of fungi that cause economic damage to crop or ornamental plants. most fungicides are applied as sprays or dusts. seed fungicides are applied as a protective covering before germination. systemic fungicides, or chemotherapeutants, are applied to plants, where they become distributed throughout the tissue and act to eradicate existing disease or to protect against possible disease. bordeaux mixture (cuso cu[oh] caso ) was one of the earliest fungicides to be used ( ) . bordeaux mixture is a liquid composed of hydrated (slaked) lime, copper sulfate, and water. it was accidentally discovered in in the modoc region of france, where farmers, tired of schoolboys pilfering their grapes, sprayed their grapevines with a poisonous-looking mixture of lime and copper sulphate; it was a desperate idea meant just to deter schoolboys from stealing their grapes. however, in , pma millardet from the university of bordeaux observed that the very same mixture effectively controlled the downy mildew of grapes as well. burgundy mixture is a mixture of copper sulfate and disodium carbonate. both bordeaux mixture and burgundy mixture are still widely used to treat orchard trees. copper compounds and sulfur have been used on plants separately and together. synthetic organic compounds are now more widely used because they give protection and control over many types of fungi. cadmium chloride and cadmium succinate are used to control turfgrass diseases. mercury(ii)chloride, or corrosive sublimate, is used as a dip to treat bulbs and tubers. mercury salts used as fungicides include mercurous chloride, mercuric chloride, mercuric oxide, phenylmercury nitrate (fig. ) , tolylmercury acetate, and ethylmercury bromide. organophosphorus fungicides include ampropylfos, ditalimfos, edifenphos, and fosetyl (fig. ) . carbamate fungicides include benthiavalicarb, furophanate, iprovalicarb, and propamocarb (fig. ) ; the toxicity of organophosphates and carbamates has been dealt with earlier. among the most important inorganic fungicides are potassium azide, potassium thiocyanate, sodium azide, and sulfur. other substances occasionally used to kill fungi include chloropicrin, methyl bromide, and formaldehyde. many antifungal substances occur naturally in plant tissues. creosote, obtained from wood tar or coal tar, is used to prevent dry rot in wood. the most important fungicides-from the toxicological viewpoint-aside from organophosphorus and carbamates, are sodium azide and compounds of copper and mercury. copper compounds are also especially important because they are used in agriculture as insecticides and algicides. somerville discussed the metabolism of several fungicides including maneb, mancozeb, zineb, captan, chlorothalonil, benomyl, triadimefon, triadimenol, and cymoxanil ( ). sodium azide is important because it is a potential intentional or accidental poison. aside from being used in agriculture, sodium azide is also used widely in hospitals where it is used as a component chemical in the fluid used to dilute blood samples. sodium azide, like dnp, is an "uncoupler" of oxidative phosphorylation; it also inhibits the enzymes catalase and cytochrome oxidase. ingestion of sodium azide results in nausea, vomiting, diarrhoea, hypotension, and cns symptoms, such as headache, hyporeflexia, seizures, and coma. postmortem findings include edema of the brain and lungs. edema of the myocardium with myocardial necrosis has also been reported ( ) . fig. . fosetyl, an organophosphate fungicide. salts of copper, although mostly used as fungicides, are used for a large number of other purposes in agriculture as well. copper acetate, copper carbonate, cupric -quinolinoxide, copper silicate, and copper zinc chromate are used as fungicidal agents only; copper arsenate is used as insecticide and copper sulfate as algicide, fungicide, herbicide, and molluscicide; copper acetoarsenite is employed as insecticide and molluscicide; copper hydroxide is used as bactericide and fungicide; copper naphthenate is used as fungicide and mammal repellent; copper oleate as fungicide and insecticide; and copper oxychloride as bird repellent and fungicide. chronic exposure to bordeaux mixture in vineyard sprayers causes the socalled "vineyard sprayer's lung." observed mainly in portugal, the disorder includes pulmonary fibrosis ( ) and may lead to lung cancer ( , ) . bordeaux mixture is the only other significant pesticide aside from paraquat that induces significant pulmonary fibrosis with organophosphates coming in a distant third ( ) . the radiological picture in vineyard sprayer's lung resembles that of silicosis with micronodular features in the early stages of the disease ( ) . only in later stages does a picture of massive fibrosis emerge with continuing development of respiratory insufficiency. plamenac et al. ( ) examined the sputum of rural workers engaged for years in spraying of vines. sputum specimens were tested for copper by rubeanic acid. macrophages containing copper granules in their cytoplasm were found in % of the workers engaged in vine spraying compared with none in a control group. other abnormalities, such as eosinophils, respiratory spirals, respiratory cell atypia, and squamous metaplasia, were also found in the sputum. atypical squamous metaplasia was observed in % of vineyard workers who were also smokers ( ). eckert et al. ( ) exposed mice to copper sulfate aerosol for a longer period of time and were able to replicate these changes in the animals' lungs. the authors concluded that the changes seen in vineyard sprayer's lung are a result of copper sulfate toxicity. pimentel and menezes studied the liver of vineyard sprayers by percutaneous biopsy and also at autopsy ( ) . they found histiocytic and noncaseating granulomas containing inclusions of copper as identified by histochemical techniques. they also found that the affected individuals were prone to liver fibrosis, cirrhosis, angiosarcoma, and portal hypertension ( ) . copper sulfate is a popular suicidal poison in india ( ) and copper sulfate was once a very popular homicidal poison ( ) . although no reports of suicide and homicide with bordeaux mixture exist, this is certainly possible. quite possibly such cases did, and still do, occur but have never been reported. mercury is widely used as a fungicide in agriculture. both inorganic and organic salts are used. inorganic mercury fungicides being used as fungicides include mercuric chloride, mercuric oxide, and mercurous chloride. organomercury fungicides include ( -ethoxypropyl)mercury bromide, ethylmercury acetate, ethylmercury bromide, ethylmercury chloride, ethylmercury , -dihydroxypropyl mercaptide, ethylmercury phosphate, n-(ethylmercury)-ptoluenesulphonanilide (fig. ) , hydrargaphen, -methoxyethylmercury chloride, methylmercury benzoate, methylmercury dicyandiamide, methylmercury pentachlorophenoxide, -phenylmercurioxyquinoline, phenylmercuriurea, phenylmercury acetate, phenylmercury chloride, phenylmercury derivative of pyrocatechol (fig. ) , phenylmercury nitrate, phenylmercury salicylate, thiomersal (fig. ) , and tolylmercury acetate. the ingestion of wheat and barley seed treated with methyl mercury fungicides for sowing by a largely illiterate population in iraq led to a major poisoning with mercury in to with a high fatality rate ( ) . the seed-about , tons of it-was intended for spring planting; there had been ample warning that the seed was unfit for consumption, but this warning was disregarded. there was a latent period of several weeks after which pares- thesias began to appear in several victims. paresthesias involved lips, nose, and distal extremities. more serious cases progressed to ataxia, hyperreflexia, hearing disturbances, movement disorders, salivation, dementia, dysarthria, visual field constriction, and blindness. in the most severe cases, individuals remained in a mute rigid posture altered only by spontaneous crying, primitive reflexive movements, or feeding efforts. there were victims with deaths ( ) ( ) ( ) ( ) . seven children remained permanently incapacitated both physically and mentally. this was the second major mercury disaster after the minamata bay disaster in japan occurring between and , when about people were poisoned and died ( ) . phenylmercury acetate has been found to be embryotoxic and teratogenic ( ). in deaths caused by acute mercury poisoning, the mucosa of the mouth, throat, esophagus and stomach is greyish in color showing superficial hemorrhagic erosions; a softened appearance of the stomach wall is characteristic. in cases where the patient survived a few days, the large bowel may show ulcerations. the kidneys appear pale and swollen owing to edema of the renal cortex. microscopically, the kidneys usually demonstrate necrosis of the renal tubules ( ). sperhake et al. ( ) reported the case of a -year-old chemist who died of mercury poisoning. an autopsy carried out hours postmortem revealed unspecific signs of intoxication including severe edema of the lungs and brain, dilatation of the bowel, and marked congestion of the parenchymatous organs. the stomach contained ml of a reddish fluid. between the gastric folds, the mucosa appeared highly preserved with a brownish discoloration, but streaklike erosions in the exposed parts. the mucosal surface of the oral cavity and esophagus also appeared brownish and discolored. histologically, the pre-served areas of the gastric mucosa were totally unaffected by autolysis with an intact epithelial layer, whereas the eroded areas showed loss of mucosal lining with infiltrates of polymorphonuclear granulocytes and lymphocytes. mercury was detected in the epithelial layer of the gastric mucosa in situ using , diphenylcarbazone staining ( . % in % ethanol). tubular necrosis was present in the kidneys. a case of chronic arsenic poisoning in a -year-old man has been described; the man used a sodium arsenite-based fungicide for cultivating his vine yard ( ). methyl bromide (ch br), also known as bromomethane, monobromomethane, embafume, or iscobrome, is mainly used as a gas soil fumigant against insects, termites, rodents, weeds, nematodes, and soil-borne diseases ( , ) . it has been used to fumigate agricultural commodities, mills, grain elevators, ships, furniture, clothes, and greenhouses. its main advantages are its effective penetrating power and absence of danger of fire or explosion hazards. methyl bromide acts rapidly, controlling insects in less than hours in space fumigations, and it has a wide spectrum of activity, controlling not only insects but also nematodes and plant-pathogenic microbes ( ) . about % of methyl bromide produced in the united states goes into pesticidal formulations. pure methyl bromide is a colorless gas that is heavier than air. odorless and tasteless in low concentrations, it has a musty, acrid smell in high concentrations. occupational exposure to methyl bromide also occurs frequently. it is estimated that about , american workers are occupationally exposed to this gas annually. its toxicity is severe and, despite safeguards, cases of acute and chronic intoxication occur, mainly in the fruit and tobacco industries. the maximum allowable concentration of methyl bromide is ppm. concentrations of ppm or less are considered safe. death has been reported to occur at ppm ( ) . methyl bromide can enter homes through open sewage connections, thus causing fatalities. lagard et al. ( ) reported an interesting case of methyl bromide poisoning where methyl bromide caused toxicity in this manner. the sewage pipes serving two houses (one house was fumigated and in the other the poisoning occurred) had been sucked empty only to hours prior to the start of fumigation. because it depletes ozone into the atmosphere ( ) , methyl bromide has been banned in several industrialized countries, except for exceptional quarantine purposes. phosphine, sulfuryl fluoride (see subheading . .) , and carbonyl sulfide are considered viable alternatives. the mucosa of trachea and bronchi is congested and shows petechial hemorrhages. the lungs show subpleural hemorrhages and pulmonary edema. bilateral bronchopneumonia may also be present. the brain is edematous with necrosis of cortical cells, especially in the frontal and parietal lobes. multiple perivascular hemorrhages may be detected throughout the brain and small subarachnoid hemorrhages may be seen in some cases. circumscribed hemorrhages may also be present in stomach, duodenum, myocardium, spleen, and retina. the kidneys are acutely congested and show tubular necrosis on the micromorphological level; the proximal tubules are most commonly affected. in severe cases, the loops of henle and the distal tubules are also affected. the liver is also congested, but liver cell necrosis is not a common feature ( ) . methyl bromide can be detected and quantitatively determined in various biological samples by headspace gas chromatography ( ). sulfuryl fluoride (f o s) is an important agricultural fumigant. according to the annual report of the aapcc ( ), the only death that occurred as a result of fumigants was caused by sulfuryl fluoride (fig. ) . it is an inorganic gas fumigant used in structures, vehicles, and wood products for control of drywood termites, wood-infesting beetles, and certain other insects and rodents. it is also used as a gas fumigant for postharvest use in dry fruits, tree nuts, and cereal grains. it is available under the trade name vikane™ gas fumigant. because methyl bromide has now been graded as an ozone-depleting substance and is being gradually phased out, sulfuryl fluoride is taking its place. because sulfuryl fluoride is an inorganic material, as opposed to the organic methyl bromide, it does not bind onto items being protected and therefore, less quantities of gas are required for the same insecticidal effect. sulfuryl fluoride is a colorless and odorless gas. it does not cause tears or immediately noticeable eye irritation and lacks any other warning property. chloropicrin is added to products containing sulfuryl fluoride to serve as a warning indicator; chloropicrin is a gas that causes eye and respiratory irritation and vomiting. sulfuryl fluoride acts as a cns depressant. symptoms of poisoning include itching, numbness, depression, slowed gait, slurred speech, nausea, vomiting, stomach pain, drunkenness, twitching, and seizures. inhalation of high concentrations may cause respiratory tract irritation and respiratory failure. skin contact with sulfuryl fluoride normally poses no hazard, but contact with liquid sulfuryl fluoride can cause pain and frostbite-like lesions owing to rapid vaporization. occupational sulfuryl fluoride exposure may be associated with subclinical effects on the cns, including effects on olfactory and some cognitive functions ( ) . the oral ld for sulfuryl fluoride in rats and guinea pigs is mg/kg. scheuerman has reported two cases of suicide by sulfuryl fluoride ( ). according to scheuerman, toxicological analysis should include a plasma and urine fluoride level because the toxic effects of sulfuryl fluoride are probably related to this ion. concentrations of fluoride in his cases were and . mg/l, respectively. however, all values have to be interpreted in the light of all information available (kind and length of exposure, symptoms, autopsy findings, etc.) in a given case. aluminum phosphide (alp) is an ideal grain preservative for a number of reasons. it is highly toxic to almost all stages of insects with remarkable penetration power. alp dissolves well in water, oil, and fat. it is considered an ideal seed fumigant since the seeds' viability is not affected and is practically free from residual toxic hazards-provided the seeds have less than % water content. alp is minimally absorbed and easily desorbed from the treated commod- ity, such as wheat grains. it is inflammable at the prescribed dosage and devoid of tainting on fumigated stock. it has a distinct odor, which has been described as a fishy odor. because of this and also because of delays in evolving, phoshine provides considerable safety in handling this fumigant. safety in handling is due to both these reasons. because it has an odor, it is difficult for handlers to accidently ingest it. because the tablet generates the predetermined weight of gas, it is very convenient to administer the exact dose. cost of fumigation is low and its effects on the fumigated stock last longer. alp is easy to transport and handle. unfortunately, no specific antidote to alp is known. alp is used very extensively throughout agrarian economies like india. on exposure to moisture it releases the poisonous phosphine, which percolates through the grain: alp+h _ al(oh) +ph . as long as the grain is stored in airtight godowns, the liberated phosphine remains in the environment, repelling all pests. when the grain is to be used, it is brought out and aerated. this releases phosphine, leaving behind virtually no or only nontoxic residues. alp is generally available as tablets (alphos ® , celphos ® , fumigran ® ), which are dark brown or grayish in color, g in weight, and measuring mm in diameter and mm in thickness. they come in an aluminum container containing ten tablets. alp is also available as . -g pellets. the tablets are composed of pure alp (the active ingredient) and ammonium carbamate/carbonate (the inert ingredient). the ratio of the active and inert ingredient is generally about : . on contact with moisture, each -g tablet evolves about g of phosphine along with carbon dioxide and ammonia, which prevents self-ignition of phosphine gas. this is why it is also called a "protective gas." carbon dioxide and ammonia are liberated by combination of water with other inert ingredients in the tablets. the main function of the inert ingredients is to produce these gases, so phosphine may not ignite easily. the phosphine gas, once liberated, spreads quickly and kills insects and rodents almost in all stages of their development. after complete decomposition of the tablet, alp is left behind as a harmless and nontoxic grayish white residue, which is less than % of the original tablet weight. alp is the leading cause of accidental and suicidal deaths in india ( ) ( ) ( ) ( ) ( ) . it has been implicated in several homicides including dowry deaths (deaths of newlywed brides occurring in relation to dowry and covered under section b of the indian penal code). the mortality rate for poisoning with alp is almost % ( ) . there is an intense garlic-like odor emanating from the mouth and after opening of the stomach at autopsy. all internal organs are congested and show petechial hem-orrhages. pericarditis may be present ( ) . the stomach contents are hemorrhagic and the mucosa shows detachment. residues of alp may be demonstrable in the stomach contents, but rarely can alp itself be detected because it readily reacts with acid and water within the stomach. misra et al. ( ) described eight cases of alp poisoning after ingestion of alp tablets for attempting suicide; the mean age of the patients was years (age range - years). six of the patients died; the mean hospital stay was hours (range - hours). an autopsy was carried out in two patients, revealing pulmonary edema, congestion of the gastrointestinal mucosa, and petechial hemorrhages on the surface of liver and brain. anger and co-workers ( ) reported the case of a -year-old man who committed suicide by ingestion of alp. autopsy revealed signs of asphyxia with marked visceral congestion. the authors also toxicologically analyzed peripheral blood, urine, liver, kidney, adrenal, brain, and cardiac blood. phosphine gas was absent in peripheral blood and urine but present in the brain ( ml/g), the liver ( ml/g), and the kidneys ( ml/g). high levels of phosphorus were found in the blood ( . mg/l) and liver ( . mg/g). aluminum concentrations were highly elevated in peripheral blood ( . mg/l), brain ( μg/g), and liver ( μg/g) compared with the reference values. histopathological findings in alp poisoning have been described in detail by chugh et al. ( ) . various viscera show congestion, edema, and inflammatory cell infiltration. in the myocardium, there are patchy areas of necrosis, whereas the liver shows fatty changes and the lung parenchyma displays gray/red hepatization. the adrenal cortex shows complete lipid depletion, hemorrhage, and necrosis. chugh et al. assumed that the changes in the adrenal cortex could be both a sequel of shock and/or a cellular toxic effect of phosphine. in out of the patients studied by chugh and associates, there was a significant rise in the plasma cortisol level (> nmol/l). in the remaining patients, the adrenal cortex was critically involved and the cortisol level failed to rise beyond normal levels (< nmol/l). pillay ( ) noted that in alp poisoning the heart shows features of toxic myocarditis, necrosis may be seen histologically in both liver and kidneys, and the lungs may demonstrate evidence of adult respiratory distress syndrome (ards). ards has also been reported by chugh et al. ( ) . the dose of the intoxicant in chugh's cases varied from two g) to three tablets (corresponding to and g, respectively). all patients were in shock at admission and developed ards within hours after ingestion of alp. according to these authors, the exhalation of phosphine (which they detected by a positive silver nitrate paper test) was the possible noxious triggering factor in developing ards. in misra at al.'s series ( ) , histopathological changes included pulmonary edema, desquamation of the lining epithelium of the bronchioles, vacuolar degeneration of hepatocytes, dilatation and engorgement of hepatic central veins and sinusoids, as well as hepatocytes showing nuclear fragmentation. in anger's single case ( ) , microscopic examination revealed congestion of inner organs and pulmonary lesions that were attributed to asphyxia. silo filler's disease is another disorder associated with agrochemical poisoning during preservation. corn used for silage is usually grown under conditions of heavy sunlight and drought and its nitrate content is usually very high. when this silage is stored in a silo, the nitrates are fermented into nitrites, which in turn combine with organic acids to form nitrous acid. nitrous acid decomposes into water and a mixture of nitrogen oxides. these are nitric oxide (no), nitrogen dioxide, and dinitrogen tetroxide. the decomposition starts within approx hours of putting the crops into the silo and continues for about days. when entering these silos (which virtually turn into a kind of gas chamber), farm workers may suffer acute poisoning from these gases, and many such deaths have occurred. this type of death in a silo was first described in , but at that time it was wrongly attributed to asphyxia ( ). nos, being relatively poor soluble in water, can reach the terminal bronchioles and even alveoli. within the lungs, the nos react with water to form nitrous and nitric acids, which cause extensive lung damage, resulting in chemical pneumonitis and profuse pulmonary edema. nos trigger histamine release, which causes bronchoconstriction resulting in increased airway resistance. douglas and colleagues ( ) examined patients of silo filler's disease between and . all exposures had occurred in conventional top-unloading silos. acute lung injury occurred in patients, one of whom died. in the fatal case, autopsy findings included early diffuse alveolar damage with hyaline membranes, hemorrhagic pulmonary edema, and acute edema of the airway walls. poisoning with and fatalities owing to fertilizers are rarely encountered but do occur. the annual report of the aapcc toxic exposure surveillance system reported one death caused by fertilizers ( ) ( table ). used as a fertilizer, anhydrous ammonia is a respiratory irritant, which, in high doses, causes pulmonary edema ( ) . exposure most often occurs during transfer operations. ammonia reacts with water to form the strong alkali ammonium hydroxide, which causes severe tracheobronchial and pulmonary inflammation with bronchiolitis obliterans. normally, the peculiar odor of ammonia warns the potential victim. during world war ii, in london, a brewery cellar having ammonia-carrying condenser pipes was temporarily converted into a bomb shelter. during a bombing, a bomb fragment pierced one such pipe resulting in a mortality rate of the affected individuals as high as % ( ) . saito et al. ( ) described the case of a -year-old male who presumably consumed water contaminated with a nitrate fertilizer. on admission to hospital, the man showed drowsiness, deep cyanosis, and dyspnea; the patient died hours later. at autopsy, no particular morphological changes were noted except for the blood being a chocolate-brown color. postmortem toxicology of the blood revealed a methemoglobin concentration of % and the concentrations of nitrate and nitrite were . and . μg/ml, respectively. in deaths caused by nitrate fertilizers, methemoglobinemia and the presence of appreciable quantities of nitrites and nitrates may be demonstrated in cardiac blood and gastric contents (stored at - °c until toxicological analysis) ( ) . capillary gas chromatography-mass spectrometry and capillary gas chromatography with a nitrogen-phosphorus detector can be used to detect nitrates and nitrites in blood. sato and colleagues ( ) described the case of an -year-old woman who supposedly consumed agricultural fertilizer containing ammonium sulfate. she was found lying dead on the ground outside her house. a thorough autopsy could not determine the cause of her death. a beer can was found next to her, and when it was examined, it was found to contain ammonium sulfate. subsequently, ammonium and sulfate ions were detected in her serum samples and gastric contents. the cause of her death was determined as poisoning by ammonium sulfate. in order to further confirm that this death was indeed a result of an ammonium sulfate fertilizer, the authors administered a total dose of mg/kg of ammonium sulfate to three rabbits. the animals developed mydriasis, irregular respiratory rhythms, and local and general convulsions until they came into respiratory failure with cardiac arrest. electroencephalogram showed slow, suppressive waves and a high-amplitude with a slow wave pattern that is generally observed clinically in hyperammonemia in humans and animals. there was a remarkable increase in the concentration of ammonium ions and inorganic sulfate ions in the animals' serum and blood gas analysis showed severe metabolic acidosis. the authors suggested that when the cause of death can not be clearly determined and the previous history is suggestive of ammonium sulfate intake, measurement of ammonium ions, inorganic ions, and electrolytes in blood, as well as in stomach contents, are a prerequisite for the diagnosis. villar and co-workers reported poisoning and death in animals who drank fertilizer-contaminated water ( ) . the water had been hauled in tanks previously contaminated with a nitrogen-based fertilizer. in udaipur, india, chronic fluorotic lesions in cattle and buffalo have been described following consumption of fodder and water contaminated by the fumes and dusts emitting from superphosphate fertilizer plants ( ) . similar lesions have been reported from australia where the main source of fluoride appeared to have been gypsum that was included in a feed supplement and also ingested from fertilizer dumps on paddocks ( ) . gypsum fertilizers have caused several deaths in animals ( ) . similar morbidity and mortality may be seen in humans who drink contaminated water either intentionally or out of ignorance as well. the latter situation is quite possible among the uneducated farmers of agrarian economies. adrian ( ) drew attention to a very unique situation of poisoning related to fertilizers. in several countries, sewage sludges are used on farms as fertilizers because they do contain these materials. however the sewage-not surprisingly-also contains industrial wastes, such as chromium, lead, zinc, cadmium, and mercury. when this sewage is used as fertilizing material, plants tend to concentrate these heavy metals, especially chromium. ingestion of such farm produce may lead to heavy metal poisoning. several other cases of fertilizer poisoning, especially among animals, have been reported, too ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . in several countries, poisonous plants, such as castor, are used as green manure which can cause poisoning of both humans and animals. soto-blanco and colleagues from the university of sao paulo, brazil, described a case of canine poisoning where castor bean (ricinus communis) cake was used as a fertilizer ( ) . the authors stressed that these cakes may be accidentally ingested by humans as well, and recommended that cake production should include heat treatment to denature the poisonous proteins. nematicides can cause poisoning in banana plantations. wesseling and co-workers, studying pesticide-related illness and injuries among banana workers in costa rica, reported that workers at highest risk per time unit of exposure were nematicide applicators ( ) . slugs are major pests of oilseed rape that are poorly controlled by conventional bait pellets. therefore, compounds, such as metaldehyde and methiocarb, are used as seed dressings to control slugs ( ) . metaldehyde is a popular molluscicide that can cause fatal poisoning; the aapcc annual report ( ) mentions as many as cases of exposure to this agent. kiyota ( ) reported the case of a -year-old mentally retarded man suffering from pica, who ingested about . g of metaldehyde. despite medical treatment, he developed acute lung injury and died after days; he was found to have ascites and splenomegaly. high-performance liquid chromatography revealed . μg/ml metaldehyde in the serum. jones et al. ( ) developed a method to detect metaldehyde in samples of stomach contents by gas chromatography-ion trap mass spectrometry for forensic toxicology investigations. a suicide attempt using metaldehyde was reported by hancock and co-workers ( ) . a case of homicide using metaldehyde has been described by ludin ( ) . detailed overviews of metaldehyde toxicity have been provided earlier by booze and oehme ( ) and longstreth and pierson ( ) . avermectins used as acaricides (avermectin acaricides), insecticides (avermectin insecticides), and nematicides have been used for suicidal poisoning. chung and co-workers ( ) from taiwan studied the clinical spectrum of avermectin poisoning reported to a poison center from september to december . eighteen patients with abamectin (agri-mek; % wt/wt abamectin) exposure and one with ivermectin (ivomec; % wt/vol ivermectin) ingestion were identified ( males, females; age range - years). fourteen out of the patients had been exposed as a result of attempted suicide; one patient died days later as a result of multiple organ failure. algicides have not been reported to cause fatal poisoning in humans; minor ailments owing to algicide exposure include, e.g., contact dermatitis ( ) . aphicides are known to persist in crops ( ) ; their toxicity in house sparrows has been described in detail by tarrant and co-workers ( ) . bird repellants are trigeminally mediated avian irritants ( ) . toxic effects to humans have apparently not been reported so far. chemosterilants are chemicals that aim at destroying the fertility of pests. , -dibromo- -chloropropane is used to induce infertility in rats ( ) . the chemosterilant bisazir is extremely hazardous. ciereszko and co-workers ( ) have recommended that special safety measures are necessary when handling this chemical. however, toxic effects to humans have not been reported in the medical literature so far. antifeedants are chemicals having tastes and odors that inhibit feeding behavior. several chemicals, such as silphinene sesquiterpenes ( ), , , oxadiazoles ( ) , and ryanoid diterpenes ( ) , are used as antifeedants; again, toxic effects to humans have not been reported so far. herbicide safeners are compounds protecting crops from herbicide injury by increasing the activity of herbicide detoxification enzymes such as glutathione-s-transferases ( ) ( ) ( ) and cytochrome p- s. several herbicide safeners are used in agriculture such as benoxacor ( ) and dichloroacetamide ( , ) ; there toxicity in humans has not been reported so far. insect attractants attract or lure an insect to a trap. several of them are available, such as boll weevil attract and control tubes ® (plato industries, houston, tx) ( ), imidacloprid ( ) , and gf- fruit fly bait ( ) . their toxicity has been studied in detail by beroza et al. ( ) . the secondary effects of conventional insecticides on the environment, vertebrates, and beneficial organisms have caused a move to the use of more target-specific chemicals, such as insect growth regulators (igrs) ( ) . igrs are chemicals disrupting the action of insect hormones controlling molting, maturity from pupal stage to adult, or other insect life processes. several igrs are known, such as halofenozide ( ), s-methoprene ( , ) , buprofezin ( ) , tebufenozide ( ) , the chitin synthesis inhibitors teflubenzuron, diflubenzuron ( ) , and hexaflumuron, as well as the juvenile hormone mimic pyriproxyfen ( ) . halofenozide (rh- ) is a novel nonsteroidal ecdysteroid agonist that induces a precocious and incomplete molt in several insect orders ( ) . the antifeedant , , -oxadiazoles also show a considerable amount of igr activity ( ) . the toxicity of these antifeedants to animals has been studied by wright ( ) . pesticide synergists are chemicals that, although they do not possess inherent pesticidal activity, they nonetheless promote or enhance the effectiveness of other pesticides when used combined (synergism). synergists usually increase the toxicity of a pesticide so that a smaller amount is needed to bring about the desired effect. this may reduce the cost of application. an example of a synergist is piperonyl butoxide, often used with pyrethrin, pyrethroid insecticides, rotenone, and carbamate-containing pesticides. piperonyl butoxide is a liver toxicant and a possible human carcinogen ( , ) ; it also inhibits t-cell activation and function ( ) . -chloro-p-toluidine hydrochloride (cpth) is an aniline derivative registered as a selective, low-volume-use (< kg/yr) avicide. rice baits are treated with cpth to cause poisoning in birds harmful to crops ( ) . cpth may be mutagenic. stankowski et al. ( ) conducted three in vitro mutagenicity tests of cpth according to methods recommended by the united states environmental protection agency, e.g., the ames/salmonella assay, the chinese hamster ovary (cho)/hypoxanthine-guanine phosphoribosyl-transferase mammalian cell forward gene mutation assay, and the cho chromosome aberration assay. they found that cpth did not display mutagenic activity using the ames/salmonella or cho/hypoxanthine-guanine phosphoribosyl-transferase assays. however, cpth induced statistically significant, concentration-dependent, metabolically activated increases in the proportion of aberrant cells. the authors concluded that the results were suggestive of minimal mutagenicity effects associated with exposure to cpth ( ) . stahl and co-workers draw attention to the consumption of cpth treated rice baits by nontargeted bird species, such as pigeon (columbia livia) and house sparrow (passer domesticus). cpth can persist in the breast muscle tissues of both targeted and nontargeted birds which may be a potential secondary hazard to scavengers and predators ( ) . toxicity of cpth both in humans and animals has been discussed by several other authors as well ( ) ( ) ( ) ( ) ( ) . if a particular agrochemical poison has been banned in a country, it is not necessarily that poisoning with this agent will not be seen in that particular country. for example, in japan, production of azomite emulsion (an acaricide) has been stopped since . however, moriya et al. in ( ) described a recent azomite-related fatality. poisoning with azomite was confirmed when aramite and azoxybenzene, two effective components of azomite emulsion, were detected in the patient's serum when qualitatively analyzed with gas chromatography-mass spectrometry. the authors concluded that even if an agrochemical poison is banned, the pathologist must still keep the possibility of its ingestion in mind. many times, it is not the active agricultural chemical that is responsible for poisoning but impurities (such as dioxin), surfactants (e.g., polyethoxylated tallow amine used with glyphosate) and adjuvants used along with the chemical. these adjuvants, or "inert" ingredients, could be solvents, stabilizers, preservatives, sticking or spreading agents, or defoamers ( ) and may constitute petrochemical solvents, such as acetone, fuel oil, toluene, and other benzene-like chemicals. these could sometimes be more toxic than the active ingredient. rubbiani drew attention to several of these adjuvants and clinical syndromes produced by them ( ) . according to harry ( ) , toxicity is often due to solvents or surfactants included in the composition of a formula used as an agricultural chemical. when the obligatory declaration on the label about identity and concentration of some of these substances is not provided by the actual legislation in a particular country, the problem becomes more acute. it is also often difficult to determine if the cause of the poisoning is the actual agricultural chemical itself or its adjuvants. metabolites are breakdown products that form when a pesticide is exposed to air, water, soil, sunlight, or living organisms and often the metabolite is more hazardous than the parent compound. an estimated three million cases of agrochemical poisoning are reported from around the world every year, making it one of most serious toxicological problems of the present times. an overwhelming majority of these-more than %-are reported from developing countries, such as india, presumably because these are predominantly agrarian economies. in the united kingdom, pesticides are responsible for only about % of deaths ( ) , whereas in united states, as seen in table , the figure varies between and %. the equivalent figures in india have been reported to be as high as % ( ) . figure shows some common pesticides used in india. accidental poisoning may occur in a number of ways. accidental poisoning can occur if the insecticide is stored inadvertently with foodstuffs ( ) . one of the most shocking cases of mass agrochemical poisonings occurred in the indian state of kerala in (known popularly as the "kerala food poisoning case of ") when bags of foodstuffs, such as wheat and sugar, were inadvertently stored together with those of folidol (parathion) in the same cabin on a ship ( ) . the insecticide leaked and contaminated the foodstuffs; more than people were accidentally poisoned when they consumed these contaminated foodstuffs. out of these, more than people died. mixing of pesticides with foodstuffs may be intentional, albeit entirely because of ignorance and without any criminal intent. such a case came to notice in the late s in lakhmipur in kheri district, in the indian state of uttar pradesh. farmers in this state were found to be preserving food grains with benzene hexachloride. a severe convulsive epidemic broke out among several hundred people because of this ignorance and more than people died. in , improper use and application of benzene hexachloride in the town sunser in the indian state of madhya pradesh resulted in many people falling ill. fortunately, no human died, but there were reports of several bird casualties. in march , a case of agricultural poisoning from india was reported where an entire family was poisoned owing to leakage of pesticides into cereal (sorghum/jowar) stored in the same room ( ) . the indian state of kerala is a major cashew growing region. there have been attempts at aerial spraying of this cash crop with endosulphan. because these areas are close to local residential areas, deleterious effects occurring in humans have caused a major controversy in recent times ( ) . pillay ( ) suggests that accidental poisoning due to pesticides can occur in four different scenarios: (a) occupational exposure among agriculturists and those engaged in the task of pesticide spraying, (b) contamination of foodstuffs on account of negligence, (c) inadvertent ingestion by children, and (d) reusing pesticide containers for storing food or drink (the latter is very common among third-world countries). instances of fatalities among agricultural workers due to accidental exposures have been reported from time to time ( ) . accidental poisoning owing to some pesticides, such as paraquat, occurs in a number of scenarios, e.g., when the mouthpiece of fumigation equipment is sucked by the operator while cleaning and it is suddenly cleared of obstruction, confusion under the influence of alcohol, consumption of contaminated water or foods, accidental ingestion by children, and accidental cutaneous exposure or oral topical application for toothaches by ignorant persons ( ) . robert g. book of bloemfontein, south africa, reported a unique case of accidental poisoning with paraquat: a young woman tried to "achieve a high" by spiking her coca-cola with paraquat. she died after a few days of hospitalization. at the time of her admission she had told the doctor that her husband had maliciously put paraquat in her drink a few days before; however, only days later she changed her version as just mentioned ( ) . it is noteworthy that in india it is very common for married women at the time of their death to shield their murderous husbands by making such statements. whether the woman's first or second statement was correct is anybody's guess. according to harry ( ) , accidental pesticide intoxications are mainly caused by ingestions of diluted fertilizers, low-concentration antivitamin k rodenticides, ant-killing products, or granules of molluscicides containing % metaldehyde, whereas voluntary intoxications are mostly by chloralose, strychnine, organophosphorus or organochlorine insecticides, concentrated antivitamin k products, and herbicides, such as paraquat, chlorophenoxy compounds, glyphosate, and chlorates. suicidal poisoning with agrochemicals, especially organophosphates and alp, is very common in countries like india. one of the main reasons is the easy availability of these agrochemicals. many companies now add an emetic to dangerous agrochemicals, such as paraquat and alp. addition of a "stenching" agent to paraquat has apparently not deterred suicidals from consuming this poison. homicidal poisoning with organophosphorus compounds is possible and from time to time, one gets to hear or read about cases of a homicide commit-ted with these substances. svraka and colleagues have described four cases of homicide with organophosphorus compounds ( ) . however, homicidal poisonings with organophosphorus compounds are rare because of the unpleasant taste of most agrochemicals, especially of organochlorines, such as endrin, but they have been mixed with alcohol, especially toddy (a strong liquor that is very popular in india), which masks its smell and has been used with organophosphorus compounds for homicidal purposes in this way. homicidal poisoning with parathion is much easier ( ) ( ) ( ) ( ) . to prevent this, a coloring agent, such as indigocarmine, is added to parathion. this is, however, not a universal practice. in india for instance, addition of indigocarmine to parathion is not practiced. the commonly used herbicide paraquat is odorless and gives rise to symptoms mimicking viral pneumonitis. these two properties-classically hailed as the properties of an ideal homicidal poison-make it very attractive as a homicidal poison. paraquat is supposed to have a burning taste, but this can be masked in hot liquids or spicy foods ( ) . several homicide cases with paraquat undoubtedly must have gone unnoticed. teare and teare and brown ( , ) described five cases of paraquat poisoning, of which, two were homicidal in nature. the first is a well-documented case (reg vs kenyon and roberts) in which a -year-old man, keith william kenyon, was killed by his wife jennifer kenyon and her friend, david roberts, a consultant on the effects of agricultural chemicals. she purchased gramoxone along with her friend olive hemming (who turned out to be the chief prosecution witness) from a farm shop, and most likely administered it to her husband in repeated small doses. kenyon was taken ill on november , and died days later, on december . during his illness, he displayed all the classical symptoms and signs of paraquat poisoning. postmortem examination confirmed death by paraquat intoxication. mrs. kenyon was convicted of murder, whereas david roberts was acquitted because of lack of evidence against him ( ) . the second case occurred only month later. after christmas , on the falkland islands, four local agricultural workers had been having a boxing day party when some gramoxone was slipped for some unknown reason into one of their beers. the man died after displaying typical symptoms of paraquat poisoning. autopsy confirmed poisoning by paraquat. criminal charges against the other three laborers were contemplated, but eventually it was decided to drop them. paul ( ) described the case of a -year-old woman who killed her husband by mixing paraquat in his steak-and-kidney pie twice. when he developed a sore throat and was prescribed medicine for treatment, she mixed paraquat in the medicine as well. the husband died on june , after suffering a day illness. the cause of death was attributed to cardiac arrest in combination with renal failure and bilateral pneumonia and it was only by a curious chain of circumstances that paraquat was detected in the young man's tissues preserved in the mortuary in a bucket, months after the man's death. his wife and her paramour were found guilty and sentenced. stephens and moormeister from the medical examiner's office of san francisco, ca, reported four cases of homicidal poisoning by paraquat ( ) . of these, the first three murders were perpetrated by one man against members of his immediate family, and the fourth case was equivocal-it could either have been suicide or homicide. the first three murders were committed by a man who had been married five times. his first three wives were alive and healthy. when the fourth wife threatened to divorce him, she found herself ill and died days after the onset of her illness ( days after hospitalization). eight years later, when his fifth wife threatened divorce, she suffered the same fate, and a few months later, his -year-old mother also died. all three showed typical symptoms of paraquat poisoning. the postmortem findings seemed to suggest natural disease of the lungs. although a suggestion of paraquat poisoning was made in all three cases, the concerned pathologist was reluctant to sign death certificates as paraquat poisoning. toxicological analysis in the second and third cases revealed the presence of paraquat in the victims' tissues and this resulted in conviction of the murderer. it was found that the defendant worked as a mechanic on a large agricultural ranch and had easy access to paraquat; his thumb print was found on one of the opened paraquat containers, although he had earlier denied having to do anything with those containers. the fourth case involved a -year-old man, a registered herbicide and pesticide user, who had marital difficulties with his aggressive, "shrew-like" wife who also stood to benefit from a large insurance policy upon his death. while in hospital, the victim denied suicidal ingestion; he died days after the start of his illness. no testing of toxic effects from the compounds he worked with was ever performed, nor was any consideration given to this possibility. the case did not result in court charges for anyone. stephens and moormeister concluded that the reason why such cases will often go unnoticed is because of the reluctance on the part of both clinicians and forensic pathologists to even think in the direction of paraquat poisoning when they see such a clear and typical picture of "viral pneumonia." in their opinion, the clinician should suspect paraquat ingestion in all cases in which there is progressive pulmonary involvement with no features of viral infection ( ) . the pathologist conducting the postmortem would do well to go through the clinical history, if available, in detail to rule out the possibility of paraquat poisoning. in all doubtful cases, a full toxicological analysis should be done and the tissues should be particularly analyzed for paraquat. daisley and simmons from the university of the west indies in trinidad reported two cases of homicide by paraquat poisoning ( ) . both cases occurred in children and the common clinical presentations were gastrointestinal ulceration and acute respiratory distress with pneumomediastinitis. at autopsy, the most prominent finding was bullous lung emphysema. the authors stress that pathologists should be aware of this finding because they feel that if this autopsy finding is seen combined with the typical clinical presentation mentioned in sections . . . and . . ., it is almost diagnostic of acute paraquat poisoning. da costa et al. have dealt with the medicolegal aspects related to paraquat poisoning in detail ( ) . another weed killer that has been used commonly for homicidal purposes is sodium chlorate. in reg vs hargreaves, hampshire (winchester) assizes, april , a -year-old woman was charged with the murder of a -year-old man whom she had known for the last years as an uncle. in august , he made his last will, written out by the accused in her favor. on january , the accused bought the weed killer sodium chlorate apparently for a friend who was a gardener. on january , , the old man died and the postmortem examination showed signs of death from sodium chlorate poisoning. the victim had consumed beer and the remaining beer in the mug contained some mg of sodium chlorate. the jury found the woman guilty of manslaughter and sentenced her to months of imprisonment ( ) . one of the biggest and most well-known medicolegal controversies in connection with herbicides has been that of agent orange. agent orange is the name given to a mixture of herbicides that united states military forces sprayed in vietnam from to during the vietnam war for the dual purpose of destroying crops that might feed the enemy and defoliating forest areas that might conceal viet cong and north vietnamese forces. the defoliant consisted of approximately equal amounts of the unpurified butyl esters of , -d and , , -trichlorophenoxyacetic acid ( , , -t). agent orange also contained small, variable proportions of , , , -tetrachlorodibenzo-p-dioxin-commonly known as dioxin-which is a byproduct of the manufacture of , , -t and is toxic even in minute quantities; dioxin is considered one of the most toxic compounds synthesized by humans. agent orange was delivered in -gallon drums with an orange stripe to distinguish the drums visually from those containing other chemical agents (hence the name). about million liters of agent orange were sprayed over vietnam from low-flying aircrafts. among the vietnamese, it is considered to be the cause of an abnormally high incidence of miscarriages, skin diseases, cancers, birth defects, and congenital malformations (often extreme and grotesque). alterations in manufacturing procedures had reduced the dioxin content in agent orange later to minimal levels. today, , , -t registrations have been cancelled and agent orange was voluntarily removed by the manufacturers in . many united states, australian, and new zealand servicemen who suffered long exposure to agent orange in vietnam later developed cancer and other health disorders. a class-action lawsuit was brought against seven herbicide makers that produced agent orange for the united states military. the suit was settled out of court with the establishment of a $ , , fund to compensate some , claimants and their families. separately, the united states department of veterans affairs awarded compensation to about veterans. agent orange has now been replaced by agent white, a mixture of , -d and picloram, which is longer lasting and more effective. in the united states, the federal insecticide, fungicide and rodenticide act (fifra) was passed in (amended in , , and [ ] ). this act divides all pesticides in four broad classes depending on their toxicity. the label of each pesticide has to contain a signal word depending on its toxicity. the criteria established by the fifra are given in table . according to the fifra, toxic category i pesticides must have the signal words danger and poison (in red letters) and a skull and crossbones prominently displayed on the package label. the spanish equivalent for danger, peligro, must also appear on the labels of highly toxic chemicals. toxic category ii pesticides must have the signal word warning (aviso in spanish) displayed on the product label. toxic category iii pesticides are required to have the signal word caution on the pesticide label. toxic category iv pesticide products shall bear on the front panel the signal word caution on the pesticide label. pesticides formulated in petroleum solvents or other combustible liquids must also include the precautionary word flammable on the product label. this was obviously done to prevent cases of accidental poisoning, and similar acts exist in almost all countries. in india, a predominantly agricultural country, handling of insecticides is governed by the insecticides act and the insecticide rules, (amended in ) ( ) . section of the insecticide rules, classifies insecticides on a similar basis. section also insists on affixing a label to the insecticide container in such a manner that it cannot be ordinarily removed. among other things, it must contain a square, occupying not less than onesixteenth of the total area of the face of the label, set at an angle of °(diamond shape). this square is to be divided into two equal triangles, the upper portion of which shall contain the signal word, and the lower portion the specified color. the classification of insecticides, signal words to be used, and the color of the identification band on the label according to the insecticide rules, of india are given in table . if a pesticide is misused in any way, the person who bought and stored the pesticide may be legally responsible. in the united states, the food quality protection act was passed in as a complementary set of regulations, which, among other important features, specifically recognizes the special situations and usages of pesticides for public health. these laws regulate the registration, manufacture, transportation, distribution, and use of pesticides. the regulations are administered by the environmental protection agency. more than , bright green ld : lethal dose in % of the exposed subjects intoxications caused by plant protection chemicals in forensic toxicology in urban south africa patterns and problems of deliberate self-poisoning in the developing world pesticide poisoning agricultural and horticultural chemical poisonings: mortality and morbidity in the united states effects of chemical factors on health of the population in various regions of russia green revolution agriculture and chemical hazards human poisoning caused by agents for plant protection in human poisoning caused by chemicals for plant protection in an epidemic of pesticide poisoning in nicaragua: implications for prevention in developing countries agrichemical hazards in the south african farming sector chemical hazards to agricultural workers acute pesticide poisoning: a major global health problem agrochemical poisoning in sri lanka annual report of the american association of poison control centers toxic exposure surveillance system annual report of the american association of poison control centers toxic exposure surveillance system annual report of the american association of poison control centers toxic exposure surveillance system annual report of the american association of poison control centers toxic exposure surveillance system annual report of the american association of poison control centers toxic exposure surveillance system goodman & gilman's pharmacological basis of therapeutics clinical and experimental toxicology of organophosphates and carbamates carbamate insecticides acute neurotoxic organophosphate poisoning: insecticides and chemical weapons knight's forensic pathology forensic histopathology acute organophosphorus compound poisoning organophosphate poisoning and complete heart block clinical and experimental toxicology of organophosphates and carbamates biochemical determination of cholinesterase activity in biological fluids and tissues pseudocholinesterase deficiency and anticholinesterase toxicity biochemical and toxicological investigations related to op compounds an electrometric method for the determination of red blood cell and plasma cholinesterase activity handbook of pesticide toxicology ( vols.) handbook of autopsy practice detection of e several years after burial concerning evidence of parathion (e ) in an exhumed corpse after months analysis of consecutive forensic exhumations with emphasis on undetected homicides clinical and experimental toxicology of organophosphates and carbamates pocketbook of pesticide poisoning for physicians. cbs publishers and distributors goldfrank's toxicologic emergencies modern medical toxicology dreisbach's handbook of poisoning-prevention acute nicotine poisoning the bipyridylium herbicides poisoning by paraquat pesticide-related illness and injuries among banana workers in costa rica: a comparison between and paraquat poisoning in papua new guinea mechanisms of toxicity, clinical features, and management of diquat poisoning: a review paraquat and related bipyridyls death from paraquat after subcutaneous injection reduction of paraquat and related bipyridylium compounds to free radical metabolites by rat hepatocytes morphologic lesions in paraquat poisoning simultaneous determination of paraquat and diquat in human tissues by high-performance liquid chromatography the determination of paraquat ( , ′dimethyl- - ′bipyridylium cation) in urine diquat intoxication a case of fatal diquat poisoning: toxicokinetic data and autopsy findings pesticides studied in man extoxnet pesticide information profile: , -d fatal suicidal poisoning due to , -d fatal human ingestion of , -d, a common herbicide radioimmunoassay for , -dichlorophenoxyacetic acid simultaneous gas chromatographic determination of , -d and dicamba in human blood and urine classes of toxic chemicals clinical management of poisoning and drug overdose sodium chlorate poisoning complicated by acute renal failure acute poisoning with a glyphosatesurfactant herbicide safety evaluation and risk assessment of the herbicide roundup and its active ingredient, glyphosate, for humans rapid determination of glyphosate in postmortem specimens using p nmr bordeaux mixture the metabolism of fungicides three fatal sodium azide poisonings vineyard sprayer's lung": a new occupational disease vineyard sprayer's lung vineyard sprayer's lung-a rare occupational disease pesticide-induced pulmonary fibrosis cytologic changes of the respiratory tract in vineyard spraying workers lung changes induced by copper sulfate. an experimental contribution to the so-called "vineyard sprayer's lung liver granulomas containing copper in vineyard sprayer's lung. a new etiology of hepatic granulomatosis liver disease in vineyard sprayers acute copper sulfate poisoning history of toxicology mercury exposure and early effects: an overview methylmercury poisoning in iraq methylmercury poisoning in iraqi children: clinical observations over two years an outbreak of methylmercury poisoning due to consumption of contaminated grain methyl mercury poisoning in iraq. a neurological study minamata disease embryotoxic and teratogenic action of the organomercury fungicide falizan on chick embryos perimortem fixation of the gastric and duodenal mucosa: a diagnostic indication for oral poisoning chronic arsenicism death and injury caused by methyl bromide, an insecticide fumigant a fatal case of acute methyl bromide poisoning alternatives to methyl bromide treatments for storedproduct and quarantine insects halogenated hydrocarbons fatal accident resulting from methyl bromide poisoning after fumigation of a neighbouring house; leakage through sewage pipes death following intentional methyl bromide poisoning: toxicological data and literature review health effects associated with sulfuryl fluoride and methyl bromide exposure among structural fumigation workers suicide by exposure to sulfuryl fluoride cardiovascular manifestations of aluminium phosphide intoxication aluminium phosphide: worse than bhopal epidemic aluminium phosphide poisoning in northern india lal-mm ( ) occupational phosphine exposure in indian workers aluminium phosphide poisoning adrenocortical involvement in aluminium phosphide poisoning acute pericarditis in aluminium phosphide poisoning acute phosphine poisoning following ingestion of aluminium phosphide fatal aluminum phosphide poisoning adult respiratory distress syndrome following aluminium phosphide ingestion. report of cases four cases of sudden death in a silo silo filler's disease chemical hazards to agricultural workers ammonia gas poisoning. forty-seven cases in a london shelter a case of fatal methemoglobinemia of unknown origin but presumably due to ingestion of nitrate a case of fatal intoxication with ammonium sulfate and a toxicological study using rabbits acute poisoning of cattle by fertilizer-contaminated water industrial fluorosis in cattle and buffalo around udaipur chronic gypsum fertiliser ingestion as a significant contributor to a multifactorial cattle mortality sheep deaths after accidental ingestion of gypsum fertiliser contribution of the incidence of urban sewage spreading to dietary chromium hyperkalemia after house plant fertilizer poisoning accidental superphosphate fertilizer poisoning in pregnant ewes urea poisoning in suckler cows acute, fatal illness in cattle exposed to boron fertilizer suspected superphosphate poisoning in calves forensic pathological studies on autopsy of a patient who died after ingesting the liquid fertilizer hyponex nitrite poisoning in herring gulls (larus argentatus) and ringbilled gulls (larus delawarensis) accidental ammonia exposure to county fair show livestock due to contaminated drinking water ricinus communis cake poisoning in a dog seed dressings to control slug damage in oilseed rape case report-fatal snail bait (metaldehyde) overdose presenting aspiration pneumonia determination of metaldehyde in suspected cases of animal poisoning using gas chromatography-ion trap mass spectrometry attempted suicide with a pesticide mixture murder by metaldehyde poisoning metaldehyde toxicity: a review metaldehyde poisoning from slug bait ingestion agricultural avermectins: an uncommon but potentially fatal cause of pesticide poisoning -chloro- , -dinitrobenzene as an algicide. report of four cases of contact dermatitis aphicide persistence on spinach and mustard greens biochemical and histological effects of the aphicide demeton-s-methyl on house sparrows (passer domesticus) under field conditions bird repellents: interaction of chemical agents in mixtures (dbcp)-induced infertility in male rats mediated by a post-testicular effect efficacy of animal anti-fertility compounds against sea lamprey (petromyzon marinus) spermatozoa silphinene sesquiterpenes as model insect antifeedants the toxic and anti-feedant activity of h-pyridazin- -one-substituted , , -oxadiazoles against the armyworm pseudaletia separata (walker) and other insects and mites selective insect antifeedant and toxic action of ryanoid diterpenes tissue-specific expression and localization of safener-induced glutathione s-transferase proteins in triticum tauschii structure of a tau class glutathione s-transferase from wheat active in herbicide detoxification partial characterization of glutathione s-transferases from wheat (triticum spp.) and purification of a safenerinduced glutathione s-transferase from triticum tauschii partial characterization of glutathione stransferase isozymes induced by the herbicide safener benoxacor in maize herbicide safener-binding protein of maize. purification, cloning, and expression of an encoding cdna specific binding of a dichloroacetamide herbicide safener in maize at a site that also binds thiocarbamate and chloroacetanilide herbicides boll weevil (coleoptera: curculionidae) bait sticks: toxicity and malathion content laboratory and field performance of an imidacloprid gel bait against german cockroaches (dictyoptera: blattellidae) effectiveness of gf- fruit fly bait spray applied to border area plants for control of melon flies (diptera: tephritidae) acute toxicity studies with insect attractants insecticidal activity of a nonsteroidal moulting hormone agonist on mosquito larvae and effects on ecdysteroid amounts laboratory evaluation of selective pesticides against the storage mite tyrophagus putrescentiae (acari: acaridae) pulse-exposure effects of selected insecticides to juvenile australian crimson-spotted rainbowfish (melanotaenia duboulayi) laboratory evaluation of selected larvicides and insect growth regulators against field-collected culex quinquefasciatus larvae from urban dhaka inter-regional differences in baseline toxicity of bemisia argentifolii (homoptera: aleyrodidae) to the two insect growth regulators, buprofezin and pyriproxyfen significance of penetration, excretion, and transovarial uptake to toxicity of three insect growth regulators in predatory lacewing adults cytotoxic effects of two antimolting insecticides in mammalian cho-k cells persistence and residual activity of an organophosphate, pirimiphosmethyl, and three igrs, hexaflumuron, teflubenzuron and pyriproxyfen, against the cowpea weevil, callosobruchus maculatus (coleoptera: bruchidae) environmental and toxicological aspects of insect growth regulators mechanistic study on liver tumor promoting effects of piperonyl butoxide in rats piperonyl butoxide technical fact sheet cuprizone and piperonyl butoxide, proposed inhibitors of t-cell function, attenuate experimental allergic encephalomyelitis in sjl mice poisoning with -aminopyridine: report of three cases -aminopyridine poisoning of crows in the chicago area stabilization of the avicide -chloro-ptoluidine as the beta-cyclodextrin adduct -chloro-p-toluidine hydrochloride: in vitro mutagenicity studies for human health hazards determinations improved method for quantifying the avicide -chloro-p-toluidine hydrochloride in bird tissues using a deuterated surrogate/gc/ms method toxicity of the avicide -chloro- -acetotoluidide in rats: a comparison with its nonacetylated form -chloro-p-toluidine the role of renal aromatic n-deacetylase in selective toxicity of avicide -chloro-p-toluidine in birds effects of an acutely toxic dose of the avicide -chloro-p-toluidine in chickens toxicologic studies on the avicide -chloro-p-toluidine tissue distribution and binding of radioactivity in mouse after intravenous administration of [ c] -chloro-p-toluidine a case of suicide suspected of poisoning from taking some agricultural chemicals label review manual chapter : ingredient statement. office of pesticide programs the problem of the presence of dangerous adjuvants in pesticide preparations used in agriculture or households textbook of forensic medicine and toxicology foodborne outbreak of organophosphorus compound poisoning food poisoning due to organophosphorus compounds investigation of a fatality among parathion applicators in california paraquat poisoning in children: survival of three cases homicidal poisoning by paraquat four cases of murder with organophosphorous compound a case of homicidal parathion poisoning six homicides by means of e- committed by a minor criminal poisoning by means of administration of parathion mixed with a medicinal substance a case of murder by parathion (e ) which nearly escaped detection homicidal poisoning by paraquat poisoning by paraquat murder under the microscope-the story of scotland yard's forensic science laboratory homicide by paraquat poisoning the forensic medical aspects of paraquat poisonings sodium and potassium compounds fifra- , glp, and qa: pesticide registration the insecticides act, with the insecticide rules, , as amended by the insecticide (amendment) rules, . delhi law house acknowledgment i wish to thank my wife marygold gupta, a chemist, and my son tarun aggrawal for their whole-hearted support during the writing of this chapter. marygold was especially helpful in making me comprehend the chemical structures of several pesticides. tarun drew several chemical structures and figures on his computer. key: cord- -vm d mj authors: bradt, david a.; drummond, christina m. title: technical annexes date: - - journal: reference manual for humanitarian health professionals doi: . / - - - - _ sha: doc_id: cord_uid: vm d mj this chapter provides guidance on technical issues in the health sector. the annexes contain selective compilations of frequently used reference information. material ( ) financial f. identification of deliverables and timetables g. consolidated reporting and dissemination ( ) group terms of reference ( ) meeting minutes ( ) epidemiology updates ( ) health sitreps ( ) component analysis ( ) field documentation (toolkit) for new arrivals . capacity building of host authorities . civil society partnership and support a. organize community leaders b. encourage gender mainstreaming c. encourage privatization d. discourage entitlements . advocacy . transition to early recovery d. strategy for livelihood/economic relief . restore productive assets (supply side interventions) a. in-kind donations (e.g. food, seeds, tools, fishing nets, etc.) b. types of community projects in food-for-assets programs ( ) natural resources development (a) water harvesting (b) soil conservation ( ) restoration of agri(aqua)culture potential (a) irrigation systems (b) seed systems ( ) infrastructure rehabilitation (a) schools (b) market places (c) community granaries (d) warehouses (e) roads (f) bridges ( ) diversification of livelihoods (a) training and experience sharing . increase individual purchasing power a. cash distribution b. cash for work (cash for assets) c. vouchers d. micro-credit e. job fairs f. artisanal production g. livelihoods/income generation . support market resumption a. market rehabilitation b. infrastructure rehabilitation c. micro-finance institutions e. goals-protect what's left ( month), restore the system ( months), improve the system ( ( ) non-food items c. financial assistance ( ) cash grants ( ) cash for work ( ) microfinance (loans) ( ) livelihood/income generation . ensure responsible resource management a. human resources management ( ) incident management command and control ( ) team structure and function ( ) staff selection (a) internationals (b) homologues ( ) field activities (a) briefing (b) meetings and reports (c) debriefing ( ) operations support (a) comms (b) transport (c) office (d) food and lodging ( ) personal health maintenance and morale b. material resources management c. financial resources management d. supervision e. monitoring and evaluation . scale up coverage of priority health interventions . address bottlenecks of the disrupted health system (otherwise temporary solutions become permanent) . protect essential public health infrastructures . build capacity of local authorities with focus on sustainable systems a. technical oversight-hiring of local experts b. material assistance-production of key commodities c. financial assistance . provide incentives for host government . support host country non-beneficiary population . find new partners in the development community . use health sustainable development goals as targets for recovery activities . seek opportunities and develop mechanisms for transition and phase out f. . programmatic constraints a. staff ( ) western trained ( ) hospital-based ( ) resource intensive ( ) technology dependent ( ) procedurally oriented ( ) invasive ( ) monolingual ( ) hazard naïve b. supervision ( ) limited responsibility ( ) limited authority ( ) limited accountability c. projects ( ) acute ( ) curative ( ) short-term ( ) intermittent d. systems ( ) inadequate security ( ) weak rule of law ( ) limited accountability framework ( ) uncoordinated . international cooperation to protect lives and health . timely and sustained high-level political leadership to the disease . transparency in reporting of cases of disease in humans and in animals caused by strains that have pandemic potential to increase understanding, enhance preparedness, and ensure rapid and timely response to potential outbreaks . immediate sharing of epidemiological data and clinical samples with the world health organization (who) and the international community to characterize the nature and evolution of any outbreaks as quickly as possible . prevention and containment of an incipient epidemic through capacity building and in-country collaboration with international partners . rapid response to the first signs of accelerated disease transmission . work in a manner supportive of key multilateral organizations (who, fao, oie) . timely coordination of bilateral and multilateral resource allocations; dedication of domestic resources (human and financial); improvements in public awareness; and development of economic and trade contingency plans . increased coordination and harmonization of preparedness, prevention, response and containment activities among nations . actions based on the best available science d. program innovations at community level . genocide (article )-acts committed with intent to destroy, in whole or in part, a national, ethnic, racial, or religious group a. killing members of the group b. causing serious bodily or mental harm to members of the group c. inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part d. imposing measures intended to prevent births within the group e. forcibly transferring children of the group to another group . crimes against humanity (article )-acts committed as part of a widespread or systematic attack against any civilian population, with knowledge of the attack a. murder b. extermination c. enslavement d. deportation e. imprisonment in violation of international law f. torture g. rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or other comparable form of sexual violence h. persecution on political, racial, national, ethnic, cultural, religious, gender, or other grounds universally recognized as impermissible under international law i. enforced disappearance j. apartheid k. other inhumane acts intentionally causing great suffering or serious injury to body or to mental or physical health . war crimes (article ) a. grave breaches of the geneva conventions of aug ( ) willful killing ( ) torture or inhumane treatment including biological experiments ( ) willfully causing great suffering ( ) extensive destruction and appropriation of property ( ) compelling a pow to serve in the armed forces of a hostile power ( ) willfully depriving a pow of the right to a fair trial ( ) unlawful deportation ( ) taking of hostages b. serious violations of laws and customs applicable in international armed conflict ( ) intentionally directing attacks against the civilian population or against civilians not taking direct part in hostilities ( ) intentionally directing attacks against civilian objects ( ) intentionally directing attacks against personnel, installations, material, units, or vehicles involved in humanitarian assistance or peacekeeping mission ( ) intentionally launching an attack in the knowledge that it will cause incidental civilian loss of life or severe damage to the natural environment ( ) attacking undefended towns, villages, dwellings, or buildings which are not military targets ( ) killing or wounding a combatant who has surrendered ( ) improper use of a flag of truce, flag or insignia or uniform of the enemy or of the un, or emblems of the geneva conventions resulting in death or serious personal injury ( ) transfer by the occupying power of parts of its own civilian population into the territory it occupies, or the deportation or transfer of all or parts of the population of the occupied territory within or outside the territory ( ) intentionally directing attacks against buildings dedicated to religion, education, art, science, charitable purposes, historic monuments, hospitals, and places where sick are collected, provided they are not military objectives ( ) subjecting persons to physical mutilation or to medical or scientific experiments which are not justified by the medical treatment nor carried out in his/her interest ( ) killing or wounding treacherously individuals belonging to the hostile nation or army ( ) declaring that no quarter will be given ( ) destroying or seizing the enemy's property unless such be imperatively demanded by the necessities of war ( ) declaring abolished, suspended, or inadmissible in a court of law the rights and actions of the nationals of the hostile party ( ) compelling the nationals of the hostile party to take part in the operations of war directed against their own country ( ) pillaging a town or place, even when taken by assault ( ) employing poison or poison weapons ( ) employing asphyxiating, poisonous or other gases, and all analogous liquids, materials, or devices ( ) employing bullets which expand or flatten easily in the human body ( ) employing weapons, projectiles, material and methods of warfare which cause superfluous injury or unnecessary suffering ( ) committing outrages upon personal dignity, in particular humiliating and degrading treatment ( ) committing rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or other comparable form of sexual violence ( ) utilizing a civilian or other protected person to render certain areas or military forces immune from military operations ( ) intentionally directing attacks against buildings, material, medical units, transport, and personnel using the emblems of the geneva conventions in conformity with international law ( ) conscripting or enlisting children under the age of years c. serious violations of common article applicable in non-international armed conflict, i.e. acts vs. persons taking no active part in the hostilities, including armed forces placed hors de combat by sickness, wounds, detention, or other cause ( ) violence to life and person ( ) outrages upon personal dignity ( ) taking of hostages ( ) passing of sentences and carrying out of executions d. non-applicability of c (above) to internal disturbances (riots, sporadic violence, etc.) e. other serious violations of laws and customs applicable in non-international armed conflict c. degradation of health system a. ppm = mg/kg (solids) = mg/l (liquids) = μg/ml (liquids) = basic unit of measure for chloroscopes :. , ppm = % a range of generic prevention measures should be considered for its impact on diseases in a biological "all-hazards" environment. overall, excreta disposal, water quantity, personal hygiene, and food hygiene commonly contribute more to environmental health than do other listed measures. epidemic threats will oblige heightened consideration of disease-specific strategies for prevention and control. note: in u , length is the preferred term over height . . this last includes kwashiorkor and marasmatic kwashiorkor in the wellcome classification. • sam = severe wasting cases or bilateral pitting edema cases (where due to malnutrition) • sam = whz < − , muac < . cm, or bilateral pitting edema (who). whm not in definition. • sam prevalence worldwide ≈ , , . • sam mortality ≈ × mortality of normally nourished child and its cfr can be - %. • gam = mam + sam • gam = moderate wasting cases, severe wasting cases, or bilateral pitting edema cases (where due to malnutrition) underweight • underweight is not used for screening or surveys in nutritional emergencies. it reflects past (chronic) and present (acute) undernutrition and is unable to distinguish between them. it encompasses children who are wasted and/or stunted. however, weight gain over time can be a sensitive indicator of growth faltering which is easily tracked on road to health charts. • stunting generally occurs before age . it is irreversible. • stunting prevalence worldwide ≈ , , . • stunting is not a good predictor of mortality, but the cfr from ids in cases of severe stunting ≈ × the cfr from ids in cases without stunting. reference standards can be absolute muac, centile, % of median reference, or z scores: • muac • easy to understand. an excellent predictor of mortality. permits comparisons between age groups insofar as the low growth velocity of muac in the u age group makes data roughly comparable. may be used alone in "quick-and-dirty" convenience samples to estimate local prevalence of wasting. however, not used alone in authoritative anthropometric surveys, and is commonly part of a two stage screening process to determine eligibility for feeding programs. easy to understand. permits comparisons between age groups and outliers. however, data are not convenient to convert. e.g. z - . = . nd percentile • % of median of reference population whm is the preferred indicator to determine eligibility for feeding programs (sphere). calculations are easy and are used in the who road to health charts. however, median reference data are not comparable between ages. eg % wt-for-age = severe malnutrition in infants = moderate malnutrition in school age kids moreover, median reference data are not comparable between indicators. eg % wt-for-age = severe malnutrition in infants % wt-for-ht = death • z scores preferred indicator (sphere, who) for reporting anthropometry survey results because it permits comparisons between age groups and nutritional indices. however, data may be difficult to understand. eg z score wt-for-age for y/o: . . kg kg -= − sd below median for his age overall: whz gives higher prevalence of malnutrition than whm for the same population. this is most marked where there is low baseline prevalence of disease, and especially for adolescents (who get subsequently over-referred). whz is more statistically valid, but whm is better predictor of mortality and is used for admission to tfcs. weight-for-age is influenced by weight-for-height and height-for-age. it can be difficult to interpret. blanket-all hh in geographically targeted catchment area (e.g. where ipc + and gam > % or - % with aggravating factors) targeted-some hh in catchment area (e.g. where gam - % or - % with aggravating factors); u and pregnant or lactating women vs. u alone vs. u alone depending on resources available and challenges with case finding) overall programmatic target- % coverage for sam in rural areas (sphere); % coverage for mam in rural areas admission criteria: pedes: age - mo, muac < . cm, with appetite, discharged from otp, no severe medical complications pregnant & lactating: muac < . cm, and nd- rd trimester or with infant < mo treatment: rusf as dry rations e.g. plumpy'sup ® , csb, csb + (supercereal), csb ++ (supercereal +) nb csb may also be cooked on-site as in emergency school feeding. discharge criteria (pedes): weight gain, muac > . cm, time in program > months community outreach with mobile brigades admission criteria for u : sam (whz < − , muac < . cm, or bilateral pitting edema) discharge criteria for u : whz >− . , no edema, and clinically well (generally takes - weeks) treatment protocol (who, icddr) shock severe dehydration: rl + d , ½ strength darrow's + d , or ½ ns + d dose: cc/kg iv death (~ % sam will die with good care, and % will die with mediocre care) c. measures of association quantify the strength or magnitude of the association between the exposure and the health problem of interest. they are independent of the size of the study and may be thought of as best guess of the true degree of association in the source population. however, they give no indication of the association's reliability. • cohort study-relative risk (rr) = riskexposed/riskunexposed • in acute outbreaks, risk is represented by the attack rate (ar) • case-control study-odds ratio (or) • no denominator with which to calculate an attack rate • cross-sectional-prevalence ratio or prevalence odds ratio c. survey designs (see r magnani [ ] , and f checchi [ ] ) . census-complete enumeration of the entire population . sample a. probability sampling ( ) simple random sampling (srs) it requires a complete enumeration of population n-names and locations of all persons or households (hh)-and sample size n nb much effort is necessary to conform to requirements of random sampling. it is easier to sample less often but take more specimens as a cluster. unfortunately, it is recognized that individuals from a cluster often share characteristics which < the precision of the method. ( ) systematic random sampling it requires a complete enumeration of population n, and sample size n, to calculate the skip interval k = n/n. ( ) stratified random sampling it requires a population size n divided into groups or strata l, then srs within each stratum. the method ensures over-sampling in under-represented groups. it yields separate estimates for each stratum at less cost. however, it requires extra info and has complicated analysis. ( ) cluster sampling, cluster sample survey (css) it is used when you don't have a complete enumeration n of all people in the area, and thus can't do random sampling; or when the area is too big to cover, and thus can't do systematic random sampling. • what should be done to compensate for the bias induced when one samples clusters rather than individuals? use n. empiric data on association within clusters in smallpox immunization suggests doubling n. if n = , n = . • what is the minimum number of clusters that can be selected and still fulfill requirements of the theory on which binomial sampling is based? . statistical theory demonstrates that > clusters help ensure cluster means have a normal distribution. the larger the number of clusters, the smaller the design effect (i.e. study efficiency improves, and the total number of study subjects needed will decrease). e.g. × (n = ) will prove more accurate and efficient than × (n = ). clusters × households will be more precise, but clusters × households may be more logistically feasible. choice of cluster should be driven by what one team can complete in a day. × css leaves . min/hh/team, but × css leaves min/hh/team. if a team can only measure kids/day (which is common), then it's best to increase the number of smaller clusters. • to permit an equal number of children to be selected from each of clusters, children would not achieve the necessary n. therefore, children are selected per cluster ( × = ). b. non-probability sampling ( ) convenience ( ) purposeful/judgment (most affected area, hhs, etc.) ( ) quota bias (see r magnani [ ] , f checchi [ ] , and smart [ ] ) systematic, non-sampling error which lowers accuracy of findings. it is usually not appreciated by the survey team. it is usually not apparent from the survey results. it cannot be arithmetically calculated or corrected. its extent cannot be judged by readers of the report. methods and materials must be explicit. report authors must discuss possible sources of bias as limitations to their study. accuracy depends on validity of findings. it is more important than precision (section e), and bias should be prevented at all costs. awareness of sources of bias is the first step in minimizing its impact on any study. as sample size increases, it is more difficult to control quality. more teams to train and supervise create higher risk of bias. it is better to have smaller sample size with less attendant precision but much less risk of bias. . selection bias-respondents are not representative of the population a. project bias-assessors work where a project may be conceptually familiar to them b. spatial/access bias-assessors work where access is easiest (roadside or "windshield" bias) c. refusal or non-response bias (self-selection) bias-subject nonparticipation may undermine representativeness of the sample d. survivor bias-assessments are conducted where households have disappeared due to family death or migration. mortality rate is thereby underestimated. this bias is most likely where hh size is low, recall period is long, mortality is high, and clustering is present. e. class/ethnic bias-different social classes or ethnic groups are inadequately included if not excluded from the assessment. local assessors may have ethnic bias, or the key informants may be drawn from one particular social class or ethnic group. f. season bias-assessments are conducted during harvest season or periods of weather when segments of the population may be under-represented g. time of day/schedule bias-assessments are conducted at a time of day when segments of the population may be under-represented nb items - below may also be grouped as information/measurement bias. . interview bias a. interviewer bias ( ) cultural bias-assessors cultural norms lead to incorrect assumptions about the interview subjects ( ) mandate or specialty bias-assessors mandate or specialty blinds them to needs outside of that mandate or specialty. e.g., a shelter specialist may only assess shelter needs while neglecting livelihood or nutrition needs. gender bias-assessors interview only one gender ( ) language bias-assessors may have a limited spectrum of people with whom they can communicate ( ) key informant bias-assessors may be partial to key informants who appear credible in ways meaningful to the assessors ( ) information/political bias-assessors focus on information that confirms preconceived notions rather than pursue evidence of alternate beliefs ( ) mistranslation ( ) interviewer error-assessors write down answers incorrectly b. subject (response) bias ( ) event recall bias-retrospective surveys only, esp. with recall periods > yr (a) informants underreport remote events (e.g. neonatal deaths) (b) calendar bias-informants over report events within the recall period ( ) event reporting bias (a) taboos-informants underreport taboo subjects (e.g. neonatal deaths) (b) lies-informants misinterpret surveys as registration activities and over report family members or underreport deaths to maintain assistance (c) political bias-informants present information that conforms to their political agenda ( ) age heaping/digit preference-informants exhibit digit preference . instrument/measurement bias-errors in design or use of instrument (e.g. questionnaire, lab equipment, etc.) a. random errors in measurement random errors in weight measurement, even if yielding equal numbers of high and low measurements, widen the distribution curve without altering the mean. hence, the prevalence of malnutrition is overestimated. the effect is greater for severe malnutrition than for moderate malnutrition, and greater when prevalence is low than when it is high. the data distribution should be checked for normal distribution with an sd between . and . z scores. improving the data quality thus appears to reduce the prevalence of malnutrition. b. systematic errors in measurement systematic errors in weight measurement, even if small (e.g. g error in presence of clothing), may alter the mean, but also widen the distribution curve. hence, the prevalence of malnutrition is overestimated. systematic errors in height measurement, such as erroneous lengthboard, may alter the mean without altering the sd. if the measurement is too short, there will be > stunting, albeit < wasting. if the measurement is too long, there will be < stunting, albeit > wasting. a standardization test is routine before undertaking anthropometric surveys. nb some scholars prefers terms "counted" and "calculated" to "measured" and "derived" . data entry bias . analytic bias a. anchoring bias-focusing on one major piece of information b. confirmation bias-favoring data which confirm underlying beliefs c. familiarity bias-weighing familiar/understandable events and spokespersons more than unfamiliar ones d. recency bias-weighing recent events more than remote ones e. salience bias-weighing vivid events more than mundane ones f. "time will tell" bias-collecting more data or letting time pass instead of making a hard decision e. imprecision (see r magnani [ ] , f checchi [ ] , and smart [ ] ) sampling, non-systematic error which lowers precision of findings and affects the level of certainty in extrapolating sampling estimates to the population's true value. it is always present, unavoidable, and a function of chance. its magnitude depends on sample size, sampling statistics, prevalence of condition, and length of recall period. precision refers to consistency of results obtained from repeated measurements. what is the sample size n of a random sample of binomial variables needed to yield a result of specified accuracy and precision? n = [(z pq)/d ] × design effect e.g. n = first estimate of sample size z = confidence limits (accuracy), or normal deviate. usually set at % :. z "score" = . p = proportion of the target population with attribute p q = proportion of the population without attribute p = -p. usually set at . to maximize the n of a study having a result of specified accuracy and precision. if you knew p and q, you would not need to do a survey. d = confidence interval (precision). usually set at +/− % :. d = . design effect (see e below) . . . once n is calculated, compare it to the size of the target population (n). if n < % of n, then use n as final sample size. if n > % of n, then recalculate the final sample size (n f ) by the following correction (a smaller sample size may be used). n n n n f = + / n f = / . n f = nb n to calculate the mean weight may be much smaller than n to calculate the prevalence of malnourished outliers ( vs. ). . sampling statistics and error measurement a. malnutrition prevalence or death rate the higher the prevalence (or death rate), the lesser the precision (higher d) available through a fixed sample size. (this is a consequence of the formula.) % gam is a common trigger for intervention. but, smart discourages use of this because high survey precision is needed (narrow ci). :. choose highest expected prevalence or rate-tends to > n. nb at levels of malnutrition and mortality generally found in emergencies, precision has much greater effect on sample size than suspected prevalence of malnutrition or death rate. n is related to d . e.g., if the malnutrition rate estimate is %, and assuming a design effect of : • survey statistic with a ci of +/− % requires n = • survey statistic with a ci of +/− % requires n = as rule of thumb, prevalence (%)/ approximates the range of appropriate ci. e.g. malnutrition prevalence of % calls for a precision of +/− % (range of %). it's generally unfeasible to achieve precision greater than +/− %. b. standard deviation (sd, σ). the degree to which individuals within the sample differ from the sample mean (μ); unaffected by sample size c. standard error (se = sd/√n) standard deviation of the sampling distribution of a statistic; decreases with larger sample sizes as estimate of the population mean improves, thus a lower se is more precise ( ) standard error of the mean (sem) is standard deviation of a sample mean's estimate of a population's true mean; an estimate of how close to the population's true mean the sample mean appears to be. ( ) relative standard error (rse)-sem/μ expressed as % • se of g on weight mean of kg = rse of % • se of g on weight mean of kg = rse of % d. confidence interval (ci = μ + z (se)) the margin of error around a point estimate. for normally distributed data, the ci yields the range in which a parameter is % likely to be found. a convention for reporting such data would be: "the most probable estimate of the parameter is x, and we are % confident the parameter lies somewhere between y and z [bounds of the ci]" (paraphrased from checchi, ) . nb in general, the lower the prevalence (or death rate), the greater the precision (lower d) needed to detect it and any subsequent changes in it. (this is intuitive.) overall, there is no benchmark for precision. increasing precision (decreasing d) slightly can dramatically increase n. +/− . deaths/ , /d is a practical limit in precision of mortality surveys. :. choose widest acceptable ci-tends to < n. e. design effect (d eff = variance study design /variance simple random sample ) a measure of the (in)efficiency of a cluster sample survey compared to that of a simple random sample. if d eff > , but the analysis treats it as a srs, then the confidence interval is inappropriately narrowed, and a test for differences is more likely to produce a positive result (type error). • if each child in a cluster had an unrelated probability of immunization, the precision of the sample estimate would match that of a simple random sample in which children were chosen. d eff = . however, this is generally not the case. • if each child in a cluster had an identical probability of immunization, the precision of the sample estimate would match that of a simple random sample in which children were chosen. d eff = cluster size of . nb focal phenomena create clustering of findings which increase the d eff . :. choose largest d eff -tends to > n. . length of recall period a. the shorter the recall period, the more accurate the mortality estimate (more distant events are more likely to be forgotten). b. the longer the recall period, the more precise the mortality estimate for a fixed sample size. the "sample" is effectively the number of person-days. for a fixed level of precision, the length of the recall period is inversely related to number of study subjects needed. if you cannot increase the sample size, you must increase the recall period. confounders are extraneous variables that correlate with both dependent and independent variables of interest (e.g. both the exposure of interest and the outcome of interest), are unevenly distributed across the levels of exposure, but are not causally linked to exposure and outcome. age and sex are the most common confounders. hence, the importance of matching in intervention and control groups. g. validity . study validity a. internal-capacity of the study to yield sound conclusions for the study population after considering bias, imprecision, and confounding (see d-f above) b. external-generalizability beyond the study population (ill-advised) . measurement validity a. criterion validity ( ) concurrent-sensitivity/specificity or correlation with a gold standard ( ) predictive-ability to predict an event b. face validity-common sense c. content validity-all relevant elements of a composite variable are included d. construct validity (usually for a new measure)-extent to which the measure corresponds to theoretical concepts (constructs) e. consensual validity-extent to which experts agree the measure is valid :. strength of evidence: face validity, criterion validity > content, construct, consensual validity. in absence of validity, a measurement may be embraced for its reliability (below). . death rates-calculated incidence of death expressed per , p/d or per p/mo; data collected by retrospective surveys (e.g. month period) to gauge severity of public health emergency particularly where sudden events lead to spike in mortality a. cdr-crude death rate b. asdr-age-specific death rate (e.g. u dr or death rate of children - yr) during a studied time interval (written as m or - dr); age of study cohort, e.g. - yr, should not be confused with study time intervals . mortality rates-calculated probability of dying before a specified age expressed per live births; data collected by national health authorities in periodic (annual) demographic surveys to reflect ongoing health status a. cmr-calculated probability of mortality in given population for specific time b. imr-calculated probability of a live borne child dying before yr c. u mr-calculated probability of a live borne child dying before yr nb mr ≠ dr. e.g. cmr ≠ cdr, u mr ≠ u dr. different rates measure different things and are not directly comparable. however, mrs may be converted into drs by the following: cdr or u dr (deaths/ , /d) = -ln( -p/ ) × . where p = cmr or u mr (deaths/ live births). however, this has little field utility. nb mmr-maternal mortality ratio has different units in numerators (maternal deaths) and denominators (live births), thus is a ratio, not a rate i. . stability-inter/intra-observer variation a. discrete variables-kappa coefficient b. continuous variables-correlation coefficient . internal consistency-correlation among all items in the measure . tests of reliability-cronbach's alpha, kuder-richardson, split halves j. conclusions the application of study findings to an entire population from which the sample was drawn. if the survey was well-conducted, the results may be considered representative of the entire population. this is scientifically justified. however a ci should accompany any parameter estimate of that population. the extension of study findings to a population or period which was not represented in the sample. it works by association-if populations appear to be experiencing similar conditions, the morbidity/mortality experience of one may be imputed to the other. this is not scientifically justified, but is often done where data are insufficient or impossible to collect. .k. • holo-endemic areas (e.g. congo) have an intense level of malaria transmission year-round. epidemics don't occur unless displacement brings in nonimmune populations. infection may be asymptomatic. effective partial immunity develops in adults which enables clinical tolerance of infection and protects against serious episodes. mortality is highest in pedes u and pregnant women. • hyper-endemic areas (e.g. w. africa) have an intense but unstable level of transmission in seasonal peaks when the climatic conditions are favorable. epidemics occur. infection is generally symptomatic. partial immunity fails to develop. mortality occurs across all age groups. • hypo-endemic areas (e.g. thai-burmese border) have a low level of transmission year-round. epidemics occur. infection is generally symptomatic. partial immunity fails to develop. mortality occurs across all age groups. think differential diagnosis (below). know the golden rules of infectious diseases (abstracted from a yung [ ] and used with permission). rigors are always important-serious bacterial infections are the most likely cause. severe muscle pain may be a symptom of sepsis even without fever. elderly patients with sepsis may be afebrile. in elderly patients, fever is rarely caused by a viral infection. septic patients who are hypothermic have a worse prognosis than those with high fever. treat as a medical emergency. fever in a postoperative patient is usually related to the surgical procedure (e.g. pneumonia, uti, wound, or deep infection). fever with jaundice is rarely due to viral hepatitis. think liver abscess, cholangitis, etc. the rash of early meningococcal infection may resemble a viral rash. generalized rashes involving the palms and soles may be due to drugs, viral infections, rickettsial infections, or syphilis. all febrile travelers in or returned from a malaria infected area must have malaria excluded. . disseminated tb must be suspected in all elderly patients with fever and multisystem disease who have been in an area with endemic tb. . septic arthritis may be present even in a joint which is mobile. ddx failure to thrive without f in infants is worked up like f without localizing signs. watch for clinical mimics-malaria presenting as pneumonia or diarrhea in pedes; vl presenting as malaria in adults; lepto presenting as mild df (esp in df endemic areas where the pt has mild onset of illness, worsening course, and no rash but jaundice after a week). do basic things well, use equipment you understand, teach others, delegate. h. count the number of fresh graves or bodies at health facilities and inquire as to cause. . orient the descriptive data-person, place, and time. a. tabulate data on affected patients. b. make a spot map. ( ) when and where was/were the first reported case(s) seen indicating an outbreak? c. plot an epidemic curve. ( ) what is the present # of patients/day or week? ( ) what is the usual # of patients/day or week? ( ) is this an increase? ( ) what is the present # of deaths/week or month? ( ) what is the usual # of deaths/week or month? ( ) is this an increase? d. calculate attack rates and case fatality ratios for total patients, u , o , and gender. . develop hypothesis. a. postulate sources of disease and mechanism of spread. b. estimate the population at risk of contracting disease and of dying from it. consider especially: those with limited access to health services pregnant and lactating ( ) infants not breast fed, children unvaccinated ( ) elderly . initiate control measures considering agent, host, and environment. a. what action has the community taken? b. identify local response capacity. ( ) what number and type of staff are locally available? ( ) what drugs and supplies are locally available? c. determine immediate unmet needs. ( ) specimen collection and lab diagnosis ( ) logistics ( ) support for clinical care-staff, drugs, and supplies ( ) support for environmental health d. undertake further necessary actions. ( ) case management with secondary prevention ( ) patient isolation ( ) health education ( ) agent and reservoir identification ( ) environmental decontamination ( ) primary prevention ( ) public information . inform authorities with investigation report. . initiate ongoing disease surveillance. during epidemic there is no clinical difference between them. other serogroups may cause disease in individuals, but not epidemics. when a suspected cholera serotype (strain) is isolated in the lab, one of the first tests performed is bacterial agglutination with o and o antisera. strains are thereby identified as v. cholerae o , o , or non-o /non-o . • if (+) agglutination to o antisera, then the strain is further tested for agglutination to antiserum of ogawa and inaba serotypes. • if (+) agglutination to o antisera, then the strain is not further subdivided (except as producer or nonproducer of ct as noted below). • if (−) agglutination to o and o antisera, then the strain is known as non-o , non-o v. cholerae. a strain is further identified as a producer or non-producer of cholera toxin (ct). ct production is a major determinant of disease development. strains lacking ct do not produce epidemics even if from the o or o serogroup. • serogroup o exists as main biotypes-classical and el tor-though hybrids also exist. each biotype occurs as two serotypes-ogawa and inaba. classic biotype caused the th and th pandemics but little epidemic disease since the s though it still causes cases in india. el tor biotype caused the th (current) pandemic and almost all recent outbreaks. el tor was first isolated in in el tor, egypt after importation by indonesian pilgrims travelling to mecca. it survives longer in the environment and produces ct similar to the classical biotype. presumably because of ct pathogenicity, the % of cholera patients with severe disease has doubled over the past yrs. these patients tend to require iv fluid therapy. • serogroup o may have evolved from strains of o el tor as they share many properties though not agglutination. in spring of in dhaka, o cases exceeded o el tor cases for the first time, and it was postulated that o may become the cause of an th pandemic. however, since then, o has again become dominant. infective dose depends on individual susceptibility. relevant host factors include immunity produced by prior infection with serogroup o as well as stomach acidity. id may be , orgs, so personal hygiene plays a lesser role than in shigellosis where the id is much lower. shigella has species. • s. dysenteriae type (sd or shiga bacillus) causes the severest disease of all shigella sp because of its neurotoxin (shiga toxin), longer duration of illness, higher abx resistance, higher cfr thru invasive complications, and great epidemic potential. • s. flexneri is the most common, and is generally endemic, in developing countries • s. sonnei is the most common in industrial countries • s. boydii and s. sonnei give mild disease. id may be orgs, so personal hygiene plays a greater role than in cholera. some kinds of e. coli produce a shiga toxin. shiga toxin genes reside in bacteriophage genome integrated into the bacterial chromosome. some abx, e.g. fluoroquinolones, induce expression of phage genes. the bacteria that make these toxins are variously called "shiga toxin-producing e. coli" (stec), "enterohemorrhagic e. coli" (ehec), or "verocytotoxic e. coli" (vtec). all terms refer to the same group of bacteria. • e. coli o :h (often called "e. coli o " or "o ") is the most commonly identified stec in north america, and it causes most e. coli outbreaks. approximately - % of ehec infections result in hus. • non-o stec serogroups also cause disease. in the usa, serogroups o , o , and o are the most commonly identified e. coli pathogens overall. diarrhea epidemiology is seasonally dependent. environmental temperature directly influences biologic activity-∆ °c is proportional to × risk of disease • temperate climates: bacterial diarrhea in warmer, humid season; rotavirus diarrhea in cooler, dry season • tropical climates: bacterial diarrhea in rainy season; rotavirus diarrhea year round with increased incidence in cooler season • most common pathogens for watery diarrhea-rotavirus, etec, v. cholerae; most important pathogen for epidemic watery diarrhea-v. cholerae • most common pathogens for dysentery-shigella species, salmonella species, campylobacter jejuni, clostridium difficile, eiec, ehec, e. coli o :h , entamoeba histolytica, yersinia enterocolitica; most important pathogens for epidemic dysentery-s. dysenteriae serotype (developing countries), e. coli o :h (developed countries) bangladesh has two seasonal cholera peaks: pre-monsoon with hot, humid weather (esp weeks - in apr-may) creating increased biological activity; post-monsoon (esp weeks - in aug-sep) with contamination of water sources. premonsoon epidemics are generally worse than post-monsoon ones. dysentery has low level year-round incidence, but epidemics occur roughly each decade. epidemic strains display new, additive antibiotic resistance which probably triggers the epidemic. once resistant strains have become endemic, antibiotic susceptibility rarely reappears. sd acquires resistance quickly. sf acquires it more slowly, and that resistance may wane with decreasing abx pressure. at icddr, annual proportional incidence approximates the following: • e. coli overall = % of cases, but etec = %. • e. coli tends to dominate before monsoon season and flooding. • cholera tends to dominate after monsoon season and flooding. • overall, - % of diarrhea cases may be vaccine-preventable. • % of pts have no pathogen identified. clean water and waste management for cholera. personal hygiene (hand washing with soap and clean towels) for shigella. water safe drinking water (boiled, chlorinated) nb sphere standards are not enough-you need increased quantities of chlorinated water at household level. san clean latrines for safe disposal of excreta hand washing with soap food safe food (cooked, stored) breast feeding fomites safe disposal of dead bodies with disinfection of clothing nb after outbreak of a fecal-oral pathogen, food hygiene and funereal practices may influence human-tohuman transmission more then water quality. health education to affected population wash hands with soap: after using toilets/latrines. after disposing of children's feces. before preparing food. before eating. before feeding children. is identical for all patients, and thus can't be given to pedes < yr because of volume loading. dukoral has been the main vaccine considered for use in high-risk populations. • morc-vax and shanchol-similar to dukoral except they do not contain the rbs, hence do not require a buffer, and are / the cost to produce. morc-vax, produced in vietnam, is derived from a vaccine administered to millions of people since , but is not who pre-qualified, and is not expected to have international distribution. shanchol, produced in india, has international distribution (e.g. used in the haiti cholera vaccination campaign of ), and is now the agent of choice for who. it confers immunity d p nd dose, effectiveness > % at mo, and protection > % at yr. also confers short-term protection vs etec. dose: . cc vaccine followed by water ingestion but no fasting needed; doses, wks apart; cold chain required except for day of use. orochol-bivalent formulation as in dukoral without rbs of ct. dose: single dose. no longer manufactured. who recommendations: "vaccination should not disrupt the provision of other high-priority health interventions to control or prevent cholera outbreaks. vaccines provide a short-term effect that can be implemented to bring about an immediate response while the longer term interventions of improving water and sanitation, which involve large investments, are put into place" [ ] . icddr recommendations: "because of limitations in terms of transport, formulation, and cost of the current dukoral vaccine, the cots program does not require the utilization of the vaccine during an outbreak; it is not necessary to vaccinate to overcome an outbreak. however, if dukoral is readily available and staff are properly trained in its use according to the guidelines that come with the vaccine, the cots program permits dukoral's use (ideally before an outbreak) in the following high-risk populations: refugee populations in which cholera is present, health care workers managing cholera cases, and communities in which the incidence rate is greater than in annually" [ ] . if undertaken, the following will apply: vaccination campaign requires numerous staff. community mobilizers are key. clinical staff should not be poached from their clinical duties. supervisors must be free to move at will. logistics is key-if the st day goes bad, the campaign goes bad. mark the domiciles which are done. hold after-action meetings each day. last day, use mobilizers with mobile broadcasting to find those missed. second phase vaccination should include chws with multi-purpose messages on water and sanitation. key lessons in epidemic response avoid: press exaggeration abx prophylaxis reliance on ivf and insufficient ors lab investigation of cases once epidemic etiology is ascertained prolonged hospitalization hospital discharge criteria requiring multiple negative stool cultures enthusiasm for ocv during epidemic exaggerated water purification objectives concentration of technical competencies in moh at expense of districts failure to share information with district stakeholders influenza viruses comprise genera-influenza types a, b, and c-each with species. • influenza type a is divided into subtypes based upon serological response to hemagglutinin (ha) and neuraminidase (na) glycoproteins. there are different ha subtypes and different na subtypes. h n , h n , and h n are responsible for the major human pandemics in the last century. h n virus circulated between and but currently does not. only influenza a subtypes infect birds, and all subtypes can do so. bird flu viruses do not usually infect humans. but, in , an outbreak of h n avian influenza in poultry in hong kong marked the first known direct human transmission of avian influenza virus from birds to humans. since then, h , h , and h avian influenza subtypes have been shown to infect humans. • influenza type b is morphologically similar to a and also creates seasonal and epidemic disease. • influenza type c is rare but can cause local epidemics. seasonal human influenza vaccine currently has strains-h n /h n /b. influenza disease in humans has a short incubation period ( - d) . early symptoms are non-specific. it is highly infectious, especially early in the course of the disease, with a large # of asymptomatic carriers. transmission potential (r ) is a function of infectivity, period of contagiousness, daily contact rate, and host immunity. in general, the faster the transmission, the less feasible is interrupting transmission thru usual disease control tools of case finding, isolation, contact tracing, and ring vaccination. case definitions may change and become more specific as epidemic evolves case management guidelines for communicable diseases with epidemic potential outbreak management protocol rapid response teams to investigate case reports epidemic investigation kits to mobilize specimens to collect labs to verify diagnosis and share specimens with peer labs pts to identify, isolate, and treat (ipd and opd settings) contacts to trace and ? quarantine hotline use and rumor investigation secondary prevention specific groups of exposed or at risk in the community-most likely to work when there is limited disease transmission in the area, most cases can be traced to a specific contact or setting, and intervention is considered likely to slow the spread of disease eg quara ntine of groups of people at known common source exposure (e.g. airplane, school, workplace, hospital, public gathering; ensure delivery of medical care, food, and social services to persons in quarantine with special attention to vulnerable groups) (useless once there is community-based spread) eg containment measures at specific sites or buildings of disease exposure (focused measures to > social distance) cancel public events (concerts, sports, movies) close buildings (recreational facilities, youth clubs) restrict access to certain sites or buildings community-wide measures (affecting exposed and non-exposed)-most likely to work where there is moderate to extensive disease transmission in the area, many cases cannot be traced, cases are increasing, and there is delay between sx onset and case isolation. eg infection control measures ari etiquette-cover nose/mouth during cough or sneeze, use tissues, wash hands avoidance of public gatherings by persons at high risk of complications nb use of masks by well persons is not recommended eg "snow" (stay-at-home) days and self-shielding (reverse quarantine) for initial d period of community outbreak-may reduce transmission without explicit activity restrictions eg closure of schools, offices, large group gatherings, public transport (pedes more likely to transmit disease than adults) nb community quarantine (cordon sanitaire)-restriction of travel in and out of an area is unlikely to prevent introduction or spread of disease international travel nb travel advisories to restrict international travel are generally useless in slowing epidemic spread nb health screening for fever and respiratory sx at ports of entry is also generally useless in slowing epidemic spread meningitis is a disease with significant mortality. meningococcus (neisseria meningitides) is renown for its rapid onset, rapid progression (death sometimes within hours), and high mortality ( % untreated). there are serogroups of neisseria meningitides but only (a, b, c, w, x, y) are known to cause epidemics. the bacteria spread from person to person via respiratory and nasal secretions. kissing, sharing eating and drinking utensils, cigarettes, coughing, and sneezing are recognized methods of transmission. close contacts over a period of time, as between household or dormitory residents, are most commonly affected. population movements (e.g. pilgrimages, displacement, military recruitment), poor living conditions, and overcrowding are epidemic risk factors. large, recurring epidemics of meningitis occur in the "meningitis belt" of sub-saharan africa where over million people live. this belt encompasses countries from senegal in the west to ethiopia in the east and as far south as tanzania and the democratic republic of congo. sub-saharan arica has epidemic seasonality. dry seasons and droughts favor epidemics. rains stop them. large regional epidemics, as well as epidemics in displaced populations and refugee camps, have mainly been due to meningococcus serogroup a. since , extensive use of meningococcal type a conjugate vaccine in the meningitis belt has reduced the incidence and case load of type a epidemics by nearly %. in , the most common lab confirmed meningitis isolate was streptococcus pneumoniae. in non-epidemic settings, neisseria.meningitidis, streptococcus pneumoniae, and haemophilus influenzae account for % of all cases of bacterial meningitis. prior to the availability of conjugate vaccines, h. influenza type b (hib) was the most common cause of childhood bacterial meningitis outside of epidemics. where hib vaccines are in the routine infant immunization schedule, hib meningitis has nearly disappeared. polysaccharide vaccines are available with serotypes (a and c), serotypes (a, c and w) or serotypes (a,c, w, and y). duration of immunity is approximately years. meningococcal protein conjugate vaccines confer longer immunity but at higher cost than polysaccharide vaccines. monovalent conjugate vaccine against group c dates from , and tetravalent (a, c, w and y) conjugate vaccine dates from . a group b vaccine made from bacterial proteins has been licensed since but is not readily available. meningococcal vaccines have a very low incidence of side effects. regular disease surveillance is necessary to detect outbreaks. the epidemic threshold is suspected cases/ , population in any given week. two suspected cases of meningitis in the same settlement should trigger an outbreak investigation. nasopharyngeal carriage rates do not predict epidemics. - % of meningococcal disease presents with meningitis. % of cases occur in patients < y/o. peak incidence in meningitis belt is ages - yrs. diagnosis is straightforward when patient presents with signs of meningitis-fever, headache, vomiting, changes in mental status. however, most patients have non-specific illness - days before onset of meningitis. cfr of untreated meningococcal meningitis can be %. cfr of properly treated meningococcal meningitis is < %. - % of meningococcal disease presents with septicemia unaccompanied by meningitis or other focal features. it is a dramatic illness which affects previously healthy children and young adults. it presents with acute fever leading to purpura fulminans (hemorrhagic or purpuric rash), shock, and waterhouse-friderichsen syndrome (acute adrenal failure). etiologic diagnosis can be easily missed. cfr of meningococcal septicemia is % and may be % even with proper treatment. diagnosis may be confirmed by agglutination tests, polymerase chain reaction, culture and sensitivity testing of spinal fluid and blood. in many situations, these tests are not available. throat swabs may be helpful on occasions. do not delay treatment for tests or test results. minutes count. it is more important to have a live patient without a confirmed diagnosis than a dead one with a diagnosis. differential diagnosis in a tropical patient with fever and altered mental status, but without purpura or shock, includes cerebral malaria. co-infection may occur. standardized case management of bacterial meningitis in developed countries involves - days of parenteral antibiotic therapy. drug of choice in adults and older children is ceftriaxone which also rapidly eliminates the carrier state. alternate drugs include ampicillin and benzylpenicillin which do not eliminate the carrier state. in developing countries, days of parenteral antibiotic therapy are empirically shown to be effective. in large epidemics in resource-poor settings, a single im dose of chloramphenicol in oil is the drug of choice. for patients who do not improve in h, a repeat dose may be given. viral meningitis is rarely serious and requires only supportive care, recovery is usually complete. patient isolation and disinfection of the room, clothing, or bedding are not necessary. respiratory precautions are advised particularly early in the course of treatment. chemoprophylaxis of contacts is available in some settings but rarely in the disaster setting. vigilance and education of close contacts is mandatory. epidemic preparedness and early detection of outbreaks are key. vaccines against n. meningitides serogroups a, c, y and w are very effective in controlling epidemics. in epidemic settings, children - are the priority target with serogroups a and c typically the priority antigens. rapid mass vaccination campaigns can contain outbreaks in - weeks. for immunocompetent patients over years, vaccine efficacy rate is % one week after injection. however, duration of immunity may be as little as years in younger children. in some countries, vaccine may also be used with close contacts of sporadic disease cases to prevent secondary cases. chemoprophylaxis of contacts is not recommended in epidemics, but community education and ready access to health care are essential. source control/reduction/elimination avoid unnecessary contact with suspected reservoir animals and known disease carrier species (e.g. primates). avoid direct or close contact with symptomatic patients. undertake quarantine and culling of sick reservoir animals and known disease carrier species. avoid unnecessary contact with or consumption of dead reservoir animals or known disease carrier species. establish appropriate communicable disease controls for burial of the dead. administrative controls environmental and engineering controls avoid needle stick exposure to blood specimens thru automated machine handling ppe use standard precautions-gloves, masks, and protective clothing-if handling infected animals or patients. wash hands after visiting sick patients. active surveillance and contact tracing (enhanced surveillance) through community-based mobile teams active case finding (screening and triage) and contact tracing dedicated isolation facility food provision to isolated patients so they are not dependent on family case definition treatment protocols emphasizing supportive care and treatment of complications essential drugs referral guidelines secondary prevention barrier nursing strictly enforced family and community education ministerial task force to address policy local health authority task force to address procedures national level task forces to comprise guidance note on using the cluster approach to strengthen humanitarian response panel on humanitarian financing report to the united nations secretary-general. too important to fail-addressing the humanitarian financing gap belgian development corporation, government of bulgaria, government of canada, et al. the grand bargain-a shared commitment to better serve people in need available from usaid's development experience clearinghouse gender equality and female empowerment policy national strategy for pandemic influenza selective primary health care-an interim strategy for disease control in developing countries ten great public health achievements-united states ten great public health achievements-united states water and excreta-related diseases: unitary environmental classification infections related to water and excreta: the health dimension of the decade addendum to ipc technical manual version . . tools and procedures for classification of acute malnutrition. rome: ipc global partnership integrated food security phase classification technical manual version . . evidence and standards for better food security decisions nbc domestic preparedness training hospital provider course. undated. curriculum available from the center for domestic preparedness sampling guide interpreting and using mortality data in humanitarian emergencies-a primer for non-epidemiologists. humanitarian practice network, network paper no . london: overseas development institute measuring mortality, nutritional status, and food security in crisis situations: smart methodology. v infectious diseases-a clinical approach cholera vaccines: who position paper cholera outbreak training and shigellosis (cots) program [cd-rom version . , undated history and epidemiology of global smallpox eradication retrieved from us department of health and human services geneva: world health organization. laboratory available? . what tests does it perform? . is there transport to and from the laboratory? . who prepares transport media? . who provides specimen collection material and supplies? . how can these supplies be obtained? . who provides cool packs, transport boxes, car, driver …? . what forms/information must be sent with the specimens? how does the epidemiologist obtain results? if a lab is not available, then you need a sampling strategy that addresses specimen acquisition, preparation, and transportation in compliance with international regulations on the transport of infetious substances. reference . world health organization department of communicable disease surveillance and response. highlights of specimen collection in emergency situations. undated. available from who laboratory and epidemiology capacity strengthening office regulation ) . leak-proof specimen container wrapped with enough absorbent material to absorb the entire content of the st container . leak-proof secondary container usually plastic or metal . outer shipping container whose smallest dimension is mm diagnostic specimens use iata packing instruction without biohazard label. infectious materials use iata packing instruction with biohazard label. what to send with the sample? lab request form with: • sender's name and contact info • patient name, age, sex • sample date, time • suspected clinical diagnosis with main signs and symptoms • sample macroscopic description • context-outbreak confirmation, ongoing verification, outbreak end, etc. • epidemiological or demographic data where to send the sample? a. prior to seasonal epidemic . establish a national coordinating committee (ncc). . designate a lead agency and lead official in the ncc. . establish a local coordinating committee (lcc). . designate a lead official in the lcc. . anticipate roles for partner agencies (e.g. inter-agency and team coordination, disease surveillance, field epidemiological investigation, laboratory identification, case management guideline development, outbreak logistics, public information, and social mobilization). . identify sources of funds. . intensify disease surveillance. . identify reference lab(s) for communicable diseases of epidemic potential. . ensure mechanism for specimen transport. initial response to suspected outbreak . form an emergency team to investigate and manage the outbreak a. identify key roles on the outbreak investigation team(s) ( ) epidemiology and surveillance ( ) case management ( ) water and sanitation ( ) laboratory services ( ) communication b. staff those roles ( ) epidemiologist-to monitor proper data collection and surveillance procedures ( ) physician-to confirm clinical s/sx and train health workers in case management ( ) water and sanitation expert-to develop a plan for reducing sources of contamination ( ) microbiologist-to take environmental/biological samples for laboratory confirmation, train health workers in proper sampling techniques, and confirm use of appropriate methods in the diagnostic laboratory ( ) behavior change communication (bcc) specialist-to assess the population's reaction to the outbreak, create, and disseminate appropriate health messages outbreak investigation protocol in place rapid response teams to investigate case reports epidemic investigation kits to mobilize specimens to collect labs to confirm dx of v. cholerae, s. dysenteriae, other shigella, and e. coli o :h dipstick identification on representative sample of specs is useful for cholera, but c&s is essential because dipsticks are not available for shigella, etec. vibrio are hardy if kept moist and cool. they can survive a week in cary blair media. shigella are fragile and difficult to recover if transport time > d. - isolates initially to confirm outbreak - isolates initially to create abx use policy (bacterial resistance renders cotrimoxazole, amp/amox, nalidixic acid, and tetracycline unusable) - isolates monthly from ipd and opd before abx therapy to assess evolving abx resistance - isolates periodically to reference laboratory to confirm abx resistance patterns and undertake molecular studies isolates at end of the outbreak to confirm that new diarrheas are not epidemic pathogens nb systematic sampling is most representative-e.g. every th pt or all pts q weeks adjusted as needed to collect the necessary specs. sensitivity >> important than specificity in rdt screening during an epidemic. pts from one geographic area are more likely to constitute a cluster involving a new pathogen. an area may be considered cholera-free after incubation periods (total of d) have passed without cholera disease. however, hospital monitoring should continue for a year due to tendency of enteric pathogens to re-emerge long after they are declared gone. cholera may be viable but nonculturable from the environment; environmental monitoring has many false negatives. consider improvements to existing diagnostic labs hotlines set up for reporting of rumor health reference and educational materials in place case definitions case management and referral guidelines for communicable diseases with epidemic potential pt, provider, and community educational materials specimen handling protocols epidemic command & control center established under local health authorities using principles and practices of incident mgmt unified command of multi-disciplinary specialists information channel to government and stakeholders support by government for technical actions coordination with technical sectors-particularly wash (cfr is a function of case mgmt, but ar overall is a function of wash) water supply, purification, and distribution systems bucket chlorination is low tech but reasonable way to reach individual hh or small communities water treatment units need ca hypochlorite, chlorimetric, and colimetric monitoring devices chlorinators worth considering at water sources of high public demand and epidemic activity hygiene promoters with environmental health assessors to address hand and food hygiene in communities around the outbreak area (think ring vaccination with knowledge) safe disposal of medical waste and infectious sludge from treatment facilities medical logistics-resource prepositioning and stockpiles cots (take one and have carpenter make copies) plastic sheets with defecation hole or sleeve buckets ( white color for stool-enables recognition of diarrhea color; different color for emesis; different color for domestic waste) ivf, iv sets, iv poles or suspension cords (cholera kits) key: cord- - z ykb authors: healing, tim title: surveillance and control of communicable disease in conflicts and disasters date: journal: conflict and catastrophe medicine doi: . / - - - - _ sha: doc_id: cord_uid: z ykb nan tim healing • to describe the principles of health surveillance in conflict and disaster situations • to assist in organizing a health surveillance system in conflict and disaster situations • to describe the principles of control of communicable diseases in conflict and disaster situations • to assist in organizing a response to outbreaks and epidemics • to introduce the challenges associated with health surveillance and communicable diseases in conflict and disaster situations there are five fundamental principles for the control of communicable disease in emergencies: • rapid assessment -identify and quantify the main disease threats to the population and determine the population's health status • prevention -provision of basic health care, shelter, food, water, and sanitation • surveillance -monitor disease trends and detect outbreaks • outbreak control -control outbreaks of disease. involves proper preparedness and rapid response (confirmation, investigation, implementation of controls) • disease management -prompt diagnosis and effective treatment rapid assessment has been dealt with elsewhere in this book as have the prevention aspects of disease control (adequate shelter, clean water, sanitation, and food, together with basic individual health care). this chapter therefore covers surveillance, outbreak/epidemic control, and public health aspects of disease management. the topics are dealt with in general terms. more details can be found in references. disasters, particularly conflicts, by damaging or destroying the infrastructures of societies (health, sanitation, food supply) and by causing displacement of populations, generally lead to increased rates of disease. outbreaks and epidemics are not inevitable in these situations and are relatively rare after rapid-onset natural disasters, but there is a severe increase in the risk of epidemics during and after complex emergencies involving conflict, large-scale population displacement with many persons in camps and food shortages. in most wars more people die from illness than from trauma. preventing such problems, or at least limiting their effects, falls on those responsible for the health care of the population affected by the emergency. they must be able to • assess the health status of the population affected and identify the main health priorities • monitor the development and determine the severity of any health emergency that develops (including monitoring the incidence of and case fatality rates from diseases, receiving early warning of epidemics and monitoring responses) at first sight, undertaking public health activities in emergencies, especially in conflicts, may seem to be difficult or impossible. the destructive nature of warfare may prevent or inhibit the provision of adequate food and shelter, of clean water and sanitation and vaccination programs. despite the difficulties that warfare imposes, it is generally possible to undertake at least limited public health programs, including disease surveillance and control activities. in other types of disaster public health activities may be expected to be less affected by the security situation than in a war (although aid workers may be at risk if populations are severely deprived of resources such as food, shelter, water, or cash), and with limited access and damage to communication systems and other parts of the infrastructure assessment, surveillance and control activities can be severely restricted. for example, following the pakistan earthquake late in access was severely restricted for some time and the urgent need to treat the injured and provide food and shelter meant that the limited transport available was heavily committed. the surveillance and control of communicable disease require data which can be collected in one of three ways: . surveillance systems -covering all or at least a significant proportion of the population . surveys -in which data are collected from a small sample of the affected population considered to be representative of the whole . outbreak investigations -in-depth investigations designed to identify the cause of deaths or diseases and identify control measures although the latter two can provide valuable information for disease control and form part of the surveillance process, proper control of disease requires regular monitoring of the overall disease situation, which in turn requires the establishment of a properly designed health surveillance system. it is important therefore that responsibility for surveillance activities is defined at the beginning of planning for an aid mission. generally speaking, a team will be required, including a team leader (often an aid agency health coordinator), who should ideally have surveillance experience, clinical workers, a water and sanitation specialist, and representatives of the local health services and communities. the team may also need clerical, logistic, information technology and communications specialists. the world health organization defines health surveillance as "the ongoing systematic collection, analysis and interpretation of data in order to plan, implement and evaluate public health interventions." data for surveillance must be accurate, timely, relevant, representative, and easily analyzed, and the results must be disseminated in a timely manner to all who need to receive them. in addition the data collected, the methods used for collection and the output must be acceptable to those surveyed (health-care professionals and the population). in emergencies the time that can be given to surveillance by medical personnel is likely to be limited and surveillance activities will be far from the minds of most of those involved. therefore the methods used need to be rapid, practical, and consistent, and while the greatest possible accuracy must be achieved, "the best must not be the enemy of the good." it is necessary to strike a balance between collecting large amounts of information ("what we would like to know") and collecting too little which can lead to an ineffective response. those responsible for establishing surveillance programs must therefore try to determine what is really needed ("what we need to know"). it is better to err on the side of too much than of too little. ideally any existing surveillance system should be used. there is no point in establishing a system if one already exists, unless the existing one is inadequate or inappropriate or has broken down irretrievably. surveillance systems for use in conflict and disaster situations should therefore adhere as far as possible to the criteria given in table . . notes on these criteria: complexity and inflexibility are incompatible with surveillance systems generally and particularly when operating in emergencies where collection of data may be difficult and where situations can change very fast. defining what you "need to know" will allow you to set up the appropriate data collection methods (questionnaires, sites, etc.) and to design the system so that it can obtain and handle the information required. information that is accurate but out of date is useless for immediate disease control purposes and of little value for forward planning. communications therefore form an integral part of any surveillance system. do not try to overreach when setting up a system. for example, expatriate staff may best be used to recruit local staff for the system and in supervisory activities rather than in collecting data. this criterion is certainly a goal to aim for as sustainability must be the target for all aid work. however, there may be situations where an emergency system is needed rapidly and where it cannot readily be integrated into existing systems or be developed as a new long-term system. . based on standardized sampling methods the sampling system must use the same data collection methods throughout if data are to be comparable. ideally this should be methods that are internationally agreed and approved. agreement should be sought for the methods from the other agencies on the ground to ensure consistency. without case definitions that are agreed by all parties the likelihood of success of a surveillance system is very low. this is especially so when laboratory support is minimal or absent since clinical case definitions have to be drawn very tightly if different diseases are not to be confused. routine surveillance requires more than material from ad hoc sources. sites such as medical centers (in towns, villages, or refugee camps), hospitals, and/or public health units should be recruited. the more comprehensive the coverage of the system, the more likely is it that the data will be accurate and complete and that problems will not be missed. such coverage can be problematic. the coverage of the different systems that can be used is discussed below. the data collected and the methods used should ideally fit in with systems that are operating or have previously operated in the area. following from criterion , if systems are already in existence or in abeyance but revivable then this should be done so as to ensure compliance by local health-care services and continuity of data collection and analysis. existing records are of considerable value for predictive purposes. knowledge of past problems makes it possible to anticipate future trends and problems and allows for early planning decisions. if several health agencies are operating it is essential to ensure collaboration among them in surveillance activities to avoid confusion and duplication of effort. . involve collaboration with local services so as to avoid duplication as above, early involvement of local health and surveillance services will reduce workloads and avoid duplication of effort. if those from whom the data are collected, those who are collecting the data, and those who will receive the results are unhappy with the system, the system is unlikely to operate effectively. these criteria can be used to evaluate a plan for a surveillance system and also, with some additions, to evaluate an existing system. however, failure to fulfil all these criteria need not rule out a system. in many emergencies it can be difficult to meet such a wide range of "best case" criteria, and the question that must be asked is whether the proposed system is capable of fulfilling its purposecan it provide sufficiently accurate essential information to those who need it when they need it? the emphasis of an emergency surveillance program may need to be altered as the situation changes especially if a particular item emerges as being of key importance. those running the surveillance program should use the data gathered and a continuous assessment of the general running of the system, to alter the program as required (preferably after consultation with relevant stakeholders). when designing health surveillance systems, it is essential to do the following: the population under surveillance may be relatively small and well defined (such as the population of a refugee camp) or a much less defined group such as mobile groups of refugees or idps or the population of a village, town, or region, the size of whose population may be unknown or may be fluctuating because of a disaster. establishment of denominators may therefore be difficult. even refugees or idp camps may present a challenge as, while the size of the population may appear to be (or actually be) stable, its makeup may vary over time because of movements in and out. if the age or sex makeup of the camp alters, the pattern of disease may also alter. both the number of cases detected and the rate of factors such as morbidity or mortality per unit of population are important values needed to inform emergency programs. those responsible for all aspects of health care need to know what numbers of cases are involved so as to ensure adequate provision of services (amounts of medicines, numbers of hospital beds, etc.). however, simple numbers are of little value in assessing trends and patterns since increases or decreases in numbers of cases (or numbers of deaths) may reflect changes in population size (resulting, for example, from population displacement) rather than a trend due to (for example) a particular disease. in addition, several rates (such as the crude mortality rate) are key indicators in defining health emergencies (see below). knowing the demography of the affected population is therefore important and all agencies working in an emergency should agree on and use the same population figures. the essential demographic data needed include the following: • total population size • population structure -overall sex ratio and the sex ratio in defined age groups -population under years old, with age breakdown ( - years) -this group has special needs and is usually a key factor in planning the emergency response -age pyramid -ethnic composition and place of origin -number of vulnerable persons (e.g., pregnant and lactating women, members of female-headed households, unaccompanied children, destitute elderly, disabled and wounded persons) at the outset it is therefore important to establish methods to obtain demographic data. often the best that can be managed initially is a rough estimate, but this can usually be refined later. it is helpful to use several methods and cross-check the figures to obtain the best estimate. surrogates of the whole population (such as those attending a clinic) may be the best that can be achieved early on. the ease with which such data can be obtained usually depends on the size and scale of the population under consideration. the demography of a well-run refugee camp is quite easy to obtain but that of a larger area may be much more difficult. a lack of knowledge of the size of a displaced group can be confounded by a lack of knowledge of the size of the resident population. in many countries with poor infrastructures, accurate census data are not available. in some instances tax records may be helpful if these can be obtained. it should be noted that demographic data, especially if they involve refugees and idps, can be politically sensitive and interested parties may place undue weight on any figures that are given. ideally, communicable disease surveillance should be nationwide (or at least "affected area wide"), drawing information from a range of health-care centers that cover a sufficient proportion of the population to ensure that the great majority of cases (preferably all) of the relevant conditions are reported. a surveillance system in a refugee or idp camp is effectively a miniature comprehensive system as it is possible to cover the whole population. there are situations where comprehensive surveillance is not possible and these often arise in disasters. damaged access and communications and staff shortages frequently mean that only limited numbers of reporting sites (sentinel sites) can be used. as far as possible these should be chosen to ensure a wide coverage of the area and also to maximize the proportion of the population that is covered. sentinel surveillance systems are inherently less satisfactory than comprehensive systems largely because they provide a much less complete coverage. the calculation of rates can sometimes be difficult or impossible; such systems can be very labour intensive, and important events may be missed. both types of system may rely on notification of cases based solely on clinical evidence (and this is the most likely situation in conflicts and disasters at least in the early stages), or may include laboratory verification of some or (preferably) all diagnoses. if there is more than one center involved in establishing the diagnosis (for example, a clinical department, a hospital laboratory, and a reference laboratory) the channels of reporting must be very carefully set up so as to avoid duplicate reporting. surveillance must provide information on key health indicators, which should include the following: the selection of information sought in these categories must be done carefully. it is neither possible nor desirable to monitor everything, especially in the early stages of a disaster response. at that stage (the acute phase) the priority of surveillance is the detection of factors that can have the greatest and most rapid effect on the population. in terms of communicable disease this means diseases that affect large numbers of people and have epidemic potential. in most instances this also means diseases for which effective rapid control measures exist. while gathering data on other largescale disease problems should not be excluded, the main surveillance and control efforts should be aimed where they can do the most immediate good. in the very early stages, only clinical information may be available since laboratory diagnostic services will probably be damaged or simply unavailable. however, this need not be a problem if the medical response is also geared to a syndromic approach. as the situation stabilizes, laboratory support becomes available, and longer term control measures can be supported, the surveillance can become more refined and additional diseases (for example, those which can cause severe morbidity and mortality in the longer term -such as tuberculosis, hiv or aids, and stds) can be added to the list. the main morbidity figures that are routinely sought are as follows: • incidence -the number of new cases of a particular disease reported over a defined period • attack rate (used in outbreaks -usually expressed as percentage) (also called incidence proportion or cumulative incidence) -number of new cases within a specified time period/size of the population initially at risk (× ). (e.g., if per , persons develop a condition over weeks, the ar/ip/ci is / , [ . %]) • incidence rate -number of new cases per unit of person-time at risk. in the above example, the ir is / , person-weeks. (this statistic is useful where the amount of observation time differs between people, or when the population at risk varies with time) • prevalence -the total number of cases of a particular disease recorded in a population at a given time (also called "point prevalence") (nb: prevalence "rate" is the number of cases of a disease at a particular time/population at risk) there are a number of ways of estimating morbidity. health information systems based on health center attendance are the most common but are passive and rely on who presents to the services. other ways of gathering morbidity data include the following: • surveys -in which data are collected from a small sample of the emergencyaffected population deemed to be representative of the whole (or from a particular group for a specific purpose) • outbreak investigations -which entail in-depth investigations designed to identify the cause of deaths or diseases and identify control measures as with disease, changes in numbers of deaths may reflect changes in population size. determination of rates is needed because mortality rate is an important surveillance indicator in an emergency. often the first indication that a problem is developing is an increase in death rate, especially in particular vulnerable groups. all deaths occurring in the community must therefore be recorded. the following indicators can provide the essential information to define the health situation in a population: • crude mortality rate (cmr) is the most important indicator as it indicates the severity of the problem, and changes in cmr show how a medical emergency is developing. cmr is usually expressed as number of deaths per , persons per day. if the cmr rises above / , per day (> / , per day for young children) an acute emergency is developing and the emergency phase lasts until the daily cmr falls to / , per day or below. • age-specific mortality rate (number of deaths in individuals of a specific age due to a specific cause/defined number of individuals of that age/day). in children this is usually given as the number of deaths in children younger and older than years/ , children of each age/day). nb: if population data for the under s are not available, an estimate of % of the total population may be used. • maternal mortality rate. maternal mortality is a sensitive indicator of the effectiveness of health-care systems. a maternal death is usually defined as the death of a woman while pregnant or within days of the termination of the pregnancy (for whatever cause) from any cause related to or aggravated by the pregnancy or its management. the -day cut-off is recommended by who but some authorities use a time of up to a year. maternal mortality rate = (number of deaths from puerperal causes in a specified area in a year/number of live births in the area during the same year) × , (or × , ) • cause-specific death rates (case fatality rates -usually given as a percentage). proportion of cases of a specified condition which are fatal within a specified time. case fatality rate = (no. of deaths from given disease in a given period/no. of diagnosed cases of that disease in the same period) × the following indicators must be measured: • prevalence of global acute malnutrition (includes moderate and severe malnutrition) in children - months of age (or - cm in height) (percentage of children with weight for height under two standard deviations below the median value in a reference population and/or edema) • prevalence of severe acute malnutrition in children - months of age (or - cm in height) (percentage of children with weight for height under three standard deviations below the median value in a reference population and/or edema) • • estimate number of children needing to be cared for in selective feeding programs • estimate number of additional calories per day provided by selective feeding programs immunization programs are a vital part of the public health measures undertaken following disasters. for example, measles vaccination is one of the most important health activities in such situations. the need for campaigns may be assessed on the basis of national vaccination records if they exist. in the absence of such records questioning of mothers may provide the information required, or children or their parents may have written vaccination histories with them (rare). the effectiveness of the programs undertaken can be assessed in defined populations by recording the percentage of children vaccinated. in less well defined populations an assessment of coverage may be made using the numbers of children attending clinics as a surrogate for the population as a whole. items such as water, sanitation, food, and shelter are essential to maintain a healthy population and prevent communicable diseases. depending on the circumstances it may be necessary to monitor these elements in the affected population. indicators such as number of consultations per day, number of vaccinations, number of admissions to hospitals, number of children in feeding programs are typically reported. other factors such as effectiveness of the supply chain, maintenance of the cold chain, and laboratory activities may also be surveyed. activities in related sectors such as water and sanitation, shelter and security may also be included. the major sources of health data will be hospitals and clinics (both national and those established by aid agencies), individual medical practitioners, and other health-care workers. specialized agencies should be able to provide data on particular needs (e.g., food, water, sanitation, and shelter). case definitions are an essential part of surveillance. if the diseases (or syndromes) that are to be covered by the system are not clearly defined, and if the definitions are not adhered to, the results become meaningless -changes from week to week are as likely to be due to changes of definition as to real changes in numbers of cases. this is especially important when laboratory confirmation is not possible. it is therefore important that all agencies working in an emergency agree to and use the same case definitions so that there is consistency in reporting. case definitions must be prepared for each health event or disease or syndrome. if available, the case definitions used by the host country's moh should be used to ensure continuity of data. several different sets of case definitions already exist, either in generalized form (for example, those produced by the centers for disease control in atlanta) or sets prepared for specific emergencies (e.g., the who communicable disease toolkit for the iraq crisis in ). standard case definitions may have to be adapted according to the local situation. it should be noted that such case definitions are designed for the purposes of surveillance, not for use in the management of patients, nor are they an indication of intention to treat the patients. when case definitions based purely on clinical observations are used, each case can only be reported as suspected, not confirmed (see table . ). although lacking precision, such definitions can make it possible to establish the occurrence of an outbreak. samples can subsequently be sent to a referral laboratory for confirmation. once samples have been examined and the causative organism has been identified, a more specific case definition can be developed to detect further cases. visits to surveillance sites and discussions with staff involved will help define the recording and data transmission systems required. the great advances in information technology that have been made in recent years have greatly facilitated the collection, recording, transmission, and analysis of surveillance data, but care must be taken that the systems put in place are appropriate. in areas where electricity supplies are problematical and communications poor it may be better to use a paper recording system and verbal data transmission by radio than a computerized system. data verification is essential for the credibility of a surveillance system. those responsible for surveillance systems must ensure good adherence to case definitions if a symptom-based system is in operation and that laboratory quality control systems operate where appropriate. regular assessments of record keeping and the accuracy of data transfer are required. triangulation of results from several sources can sometimes help to detect anomalies. frequency of reporting will usually depend on the severity of the health situation. in general, daily reporting during the acute phase of an emergency will be needed, although in an acute medical emergency (such as a severe cholera outbreak) even more frequent reporting may be necessary, especially if the situation is fluctuating rapidly. the frequency may reduce to (say) weekly as the situation resolves. who is to analyze the data and how it is to be analyzed must be established at the outset. in a relatively defined area such as a camp, a data analysis session may be the last of the daily activities of the person responsible for surveillance. if record keeping and analysis protocols have been carefully worked out initially this task is not necessarily a large additional burden. surveillance systems that cover larger areas and bigger and more diffuse populations usually rely on a central data collection point where designated staff analyze the data. use of such a system requires good data transmission systems. output is as important as input. collecting data without dissemination of results is a sterile exercise and tends rapidly to demotivate those who are collecting the data. there are some important points to consider: • the results of surveillance must be presented in a readily comprehensible form. • surveillance reports should be produced regularly and widely distributed to aid agencies, and to national and international governments and organizations. this will help those involved to understand the overall picture, rather than just that in the area where they are working, and will allow them to take informed decisions about future actions. surveillance systems should be evaluated constantly to ensure that they are working properly, that the data are representative, analysis is appropriate and accurate, and that results are being disseminated to where they are needed. the public health aspects of communicable disease control can be broadly divided into preventive activities (such as vector control and vaccination programs) and the investigation and control of outbreaks and epidemics. experience from many emergencies and disasters has made it possible to identify a number of syndromes or diseases that are most likely to occur in such situations (table . ). this makes it possible to plan activities and interventions on the basis of likely occurrences, even before those involved are present at the scene of the disaster, and to make initial purchases and establish stockpiles of appropriate medicines and equipment. "prevention is better than cure" and proper attention to preventive measures from the earliest stage of the response to the disaster will greatly reduce the risks to the health of the population from infectious disease. a key method of preventing communicable disease is the provision of shelter, adequate amounts of clean water, sufficient safe food, and proper sanitation (latrines and facilities for personal hygiene, clothes washing, and drying). arthropod vectors (mosquitoes, ticks) can be controlled by appropriate spraying programs and also by habitat management (e.g., the removal of places where water can accumulate and mosquitoes breed). provision of bed nets, particularly nets impregnated with insecticide, is effective for reducing infection with agents such as malaria and leishmania. control of rodents, by proper control of rubbish, by rodent proofing food stores, by attention to domestic hygiene and by use of rodenticides, will reduce the risks of transmission of rodent-borne diseases such as plague and lassa fever. medical waste includes laboratory samples, needles and syringes, body tissues, and materials stained with body fluids. this requires careful handling, especially the sharps, as infectious agents such as those causing hepatitis b and c, hiv and aids, and viral hemorrhagic fevers can be transmitted by these materials. used sharps should be disposed of into suitable containers (proper sharps boxes are ideal but old metal containers such as coffee or milk powder tins are adequate). medical waste should ideally be burned in an incinerator. this should be close to the clinic or hospital but downwind of the prevailing wind. a -l oil drum can be used for this purpose with a metal grate half way up and a hole at the bottom to allow in air and for the removal of ash. larger-scale and more permanent incinerators can be constructed if necessary. burning pits can be used in emergency. if burning is not possible items should be buried at least . m deep. this is more suitable than burning for large items of human tissue such as amputated legs. ensure there is no risk of groundwater contamination. a few others, such as malaria and other vector-borne diseases (e.g., typhus and leishmaniasis), are also likely to occur but are region specific. tb and hiv or aids can also cause major problems in the longer term this is a complex process involving not just considerations of infection risk but also legal, sociocultural, and psychological factors. there are a number of specialist publications which can be of help. after almost every natural disaster, fear of disease has encouraged authorities to dispose rapidly of the bodies of the dead, often without identifying them, and this sometimes seems almost to take precedence over dealing with the living. however, in sudden impact disasters (such as the indian ocean tsunami in ), the pattern and incidence of disease found in the dead will generally reflect those in the living. the situation is much the same in wars and other long drawn out disasters, although these may affect disease patterns and create vulnerable groups. in fact dead bodies pose little risk to health (with some exceptions listed below) since few pathogenic microorganisms survive long after the death of their host. the diseased living are far more dangerous. the decay of cadavers is due mainly to organisms they already contain and these are not pathogenic. those most at risk are those handling the deceased, not the community. the most likely risks to them are as follows: mortuary facilities may need to be provided where the dead can be preserved until appropriate legal proceedings have been undertaken and where relatives, etc., may easily attend to identify and claim the deceased. cold stores and refrigerated vehicles can be used as temporary mass mortuary facilities. alternatively such facilities can be provided in buildings, huts, or tented structures, but refrigeration will be needed. the dead must always be treated with dignity and respect. as far as possible the appropriate customs of the local population or the group to which the deceased belonged should be observed. if the dead have to be buried in mass graves then the layout of the cemetery must be carefully mapped to facilitate exhumation if needed. when an individual may have died of a particularly dangerous infection, then body bags should be used (and also for damaged cadavers). in general, bodies should be buried rather than cremated (as exhumation for purposes of identification may be needed). bodies should be buried at least . m deep or, if more shallowly, should have earth piled at least m above the ground level and . m to each side of the grave (to prevent access by scavengers and burrowing insects). disinfectants such as chloride of lime should not be used. new burial sites should be at least m from drinking water sources and at least . m above the saturated zone. vaccination programs are an essential part of disease prevention. information about existing vaccination programs must be obtained during the assessment process and this should include information from external assessors (e.g., who, unicef, ngos) as to the effectiveness of the vaccination programs that have been undertaken in the past. it cannot be assumed that simply because children have received vaccines that these vaccines were effective. measles kills large number of children in developing countries and is one of the greatest causes of morbidity and mortality in children in refugee and idp camps. mass vaccination of children between the ages of months and years should be an absolute priority during the first week of activity in humanitarian situations and can be conducted with the distribution of vitamin a. a system for maintaining measles immunization must be established once the target population has been covered adequately in the initial campaign. this is necessary to ensure that children who may have been missed in the original campaign, children reaching the age of months, and children first vaccinated at the age of - months who must receive a second dose at months of age are all covered. some of the children vaccinated during such a mass campaign may have been vaccinated before. this does not matter and a second dose will have no adverse effect. it is essential to ensure full coverage against measles in the population. other epi vaccinations for children are not generally included in the emergency phase because they can only prevent a minor proportion of the overall morbidity and mortality at that stage. however, should specific outbreaks occur then the appropriate vaccine should be considered as a control measure. vaccination programs require the following: • appropriate types of vaccines. • appropriate amounts of these vaccines. • equipment (needles, syringes, sterilization equipment, sharps disposal). emergency immunization kits, including cold chain equipment, are available from a number of sources, including unicef and some ngos (e.g. msf). • logistics (transport, cold chain). • staff: a vaccination team may be quite large. it must include the following personnel: -a supervisor. -logistics staff. -staff to prepare and administer vaccines. -record keepers. -security staff (to maintain order and control crowds) may also be needed. maintenance of the cold chain is particularly important. this is the system of transporting and storing vaccines within a suitable temperature range from the point of manufacture to the point of administration. the effectiveness of vaccines can be reduced or lost if they are allowed to get too cold, too hot, or are exposed to direct sunlight or fluorescent light. careful note should be taken of the conditions needed to transport different vaccines because these can vary. the essential cold chain equipment needed to transport and store vaccines within a consistent safe temperature range includes the following: • dedicated refrigerators for storing vaccines and freezers for ice packs (fridges and freezers powered by gas or kerosene are available as alternatives to electric machines, and solar-powered fridge/freezer combinations specially designed for vaccine storage are also available) • a suitable thermometer and a chart for recording daily temperature readings if possible, vaccines should be stored in their original packaging because removing the packaging exposes them to room temperature and light. check the temperature to ensure the vaccines have not been exposed to temperatures outside the normal storage ranges for those vaccines (see table . ). max. storage time at the different levels: primary, months; region, months; district, month; health center, month; health post, daily usemax. month diluents must never be frozen. freeze-dried vaccines supplied packed with diluent must be stored between + and + °c. diluents supplied separately should be kept between + and + °c vaccines must be kept at the correct temperature since all are sensitive to heat and cold to some extent. all freeze-dried vaccines become much more heat-sensitive after they have been reconstituted. vaccines sensitive to cold will lose potency if exposed to temperatures lower than optimal for their storage, particularly if they are frozen. some vaccines (bcg, measles, mr, mmr, and rubella vaccines) are also sensitive to strong light and must always be protected against sunlight or fluorescent (neon) light. these vaccines are usually supplied in dark brown glass vials, which give them some protection against light damage, but they must still be covered and protected from strong light at all times. only vaccine stocks that are fit for use should be kept in the vaccine cold chain. expired or heat-damaged vials should be removed from cold storage. if unusable vaccines need to be kept for a period before disposal (e.g., until completion of accounting or auditing procedures) they should be kept outside the cold chain, separated from all usable stocks and carefully labelled to avoid mistaken use. diluents for vaccines are less sensitive to storage temperatures than are the vaccines with which they are used (although they must be kept cool), but may be kept in the cold chain between + and + °c if space permits. however, diluent vials must never be frozen (kept in a freezer or in contact with any frozen surface) as the vial may crack and become contaminated. when vaccines are reconstituted, the diluent should be at same temperature as the vaccine, so sufficient diluent for daily needs should be kept in the cold chain at the point of vaccine use (health center or vaccination post). at other levels of the cold chain (central, provincial, or district stores) it is only necessary to keep any diluent in the cold chain if it is planned to use it within the next h. freeze-dried vaccines and their diluents should always be distributed together in matching quantities. although the diluents do not need to be kept in the cold chain (unless needed for reconstituting vaccines within the next h), they must travel with the vaccine at all times, and must always be of the correct type, and from the same manufacturer as the vaccine that they are accompanying. each vaccine requires a specific diluent, and therefore, diluents are not interchangeable (for example, diluent made for measles vaccine must not be used for reconstituting bcg, yellow fever, or any other type of vaccine). likewise, diluent made by one manufacturer for use with a certain vaccine cannot be used for reconstituting the same type of vaccine produced by another manufacturer. some combination vaccines comprise a freeze-dried component (such as hib) which is designed to be reconstituted by a liquid vaccine (such as dtp or dtp-hepb liquid vaccine) instead of a normal diluent. for such combination vaccines, it is again vital that only vaccines manufactured and licensed for this purpose are combined. note also that for combination vaccines where the diluent is itself a vaccine, all components must now be kept in the cold chain between + and + °c at all times. as for all other freeze-dried vaccines, it is also essential that the "diluent" travels with the vaccine at all times. the effectiveness of a vaccination program will need to be assessed. the program can be evaluated both by routinely collected data and, if necessary, by a survey of vaccination coverage. routine data on coverage is obtained by comparing the numbers vaccinated with the estimated size of the target population (and clearly depends on accurate assessment of the latter). a coverage survey requires the use of a statistical technique called a two-stage cluster survey details of which can be found in the appropriate who/epi documents. information about the effectiveness of the campaign should be obtained from routine surveillance of communicable disease. if, for example, large number of measles cases continue to occur, or there is an outbreak, then data on coverage should be reexamined. if this is shown to be good (over %) then the efficacy of the vaccine must be suspected. if the field efficacy is below the theoretical value % (for measles vaccine -data on efficacy of other vaccines can be obtained online) then possible causes of a breakdown in the vaccination program must be investigated (failure of the cold chain, poorly respected vaccination schedule). methods for measuring vaccine efficacy can be found in the who/epi literature. mass chemoprophylaxis for bacterial infections such as cholera and meningitis is not usually recommended except on a small scale (for example, the use of rifampicin may be considered to prevent the spread of meningococcal meningitis among immediate contacts of a case), but the difficulties of overseeing such activities and the risks of the development of antibiotic resistance outweigh any benefits that might be gained. the use of chemoprophylaxis for malaria must be undertaken with care. it may be indicated for vulnerable groups of refugees/idps (for example, children and pregnant women) arriving in an endemic area, particularly if they come from a nonmalarious area, but care must be taken to provide drugs to which the local strains of malaria are sensitive. the spread of resistance means that many of the standard drugs are ineffective and the replacements are both costly and may have unwanted side effects. public health education and information activities play a vital role in disease prevention. vaccination programs will not work unless there is acceptance by the public of the necessity for such programs. individuals must be informed as to why these programs are necessary and also where and when they need to take their children for vaccination. such activities are also essential to inform people about particular health programs (for example, feeding programs or vector control programs) and about the steps they can take to protect their health and that of their families (e.g., good hygiene). information can be propagated in many ways: staff who are trained in this type of activity therefore play a key role in disease prevention. heath education also requires transport and equipment (such as video or film projectors, screens, generators, blackboards, etc.). details of the treatment of individuals for various infectious diseases and the facilities needed are covered elsewhere in this book and in many textbooks covering disasters and disease response. in terms of the population aspects of the treatment of disease, important requirements are to ensure that there are • appropriate laboratories (microbiological, parasitological, hematological, biochemical) available to confirm diagnoses and monitor treatment. • adequate supplies of appropriate antimicrobial agents available and the facilities to transport these, store, and distribute them under appropriate conditions (e.g., controlled temperature), together with relevant instruction for use. the provision of laboratory facilities in emergencies is usually limited to basic tests such as those for malaria. more advanced tests, including identification of microorganisms and the determination of antimicrobial sensitivities, require more sophisticated facilities. these may be available in the affected country but are unlikely to be operating in the disaster-affected area. it is more likely that specimens will have to be transported to laboratories abroad. collection of specimens requires appropriate equipment. this will include items such as swabs, transport media, needles, syringes, or vacum sampling systems for blood sampling, different blood collection bottles (with and without anticoagulants) and other sterile specimen tubes, and containers for faeces and urine. transporting specimens must be done safely, and packing specimens for shipment requiring specially trained personnel. treatment of disease requires good supplies of appropriate antimicrobial agents. it is important to ensure that the agents chosen are suitable for use in the area. it is common for doctors in affected areas to ask for the latest therapeutic agents. however, these agents, although effective, are often expensive and not part of the normal treatment programs in the region. the local doctors may not therefore be familiar with the use of these agents, nor may laboratories be capable of monitoring their use. it is better to use funds, which are often limited, to supply larger amounts of older (generic) agents. one caveat is the possibility that regular use may have allowed resistance to certain agents to develop in a country. data on this may be available from local surveillance records. antimicrobials should always be supplied with relevant guidelines in a language that can be understood locally. if local laboratories are unable to test microbes for resistance to antimicrobials, isolates or specimens should be sent as soon as possible to appropriate reference laboratories for testing. outbreaks of communicable disease may occur before preventive measures can take effect or because the measures are in some way inadequate or fail. an epidemic is generally defined as the occurrence in a population or region of a number of cases of a given disease in excess of normal expectancy. an outbreak is an epidemic limited to a small area (a town, village, or camp). the term alert threshold is used to define the point at which the possibility of an epidemic or outbreak needs to be considered and preparedness checked. the areas where vaccination campaigns are a priority need to be identified and campaigns started. the term epidemic (outbreak) threshold is used to define the point at which an urgent response is required. this will vary depending upon the disease involved (infectiousness, local endemicity, transmission mechanisms) and can be as low as a single case. infections where a single case represents a potential outbreak include the following: infections where the threshold is set higher, usually based on long-term collection of data, and will vary from location to location, include the following: • human african trypanosomiasis • visceral leishmaniasis a surveillance system that is functioning well should pick up the signs that an outbreak or epidemic is developing and should therefore allow time for measures to be introduced that will prevent or limit the scale of the event. however, this may not always work and it is essential therefore that plans are made to combat outbreaks or epidemics. in addition to the establishment of surveillance, outbreak preparation involves the following: • preparing an epidemic/outbreak response plan for different diseases covering the resources needed, the types of staff and their skills that may be needed and defining specific control measures. • ensuring that standard treatment protocols are available to all health facilities and health workers and that staff are properly trained. • stockpiling essential supplies. this includes supplies for treatment, for taking and shipping samples, other items to restock existing health facilities and the means to provide emergency health facilities if required. • identifying appropriate laboratories to confirm cases and support patient management, make arrangements for these laboratories to accept and test specimens in an emergency, and set up a system to ship specimens to the laboratory. • identifying emergency sources of vaccines for vaccine-preventable diseases and make arrangements for emergency purchase and shipment. ensure that vaccination supplies (needles, syringes, etc.) are adequate. make sure the cold chain can be maintained. • identifying sources for other supplies, including antimicrobials, and make arrangements for emergency purchase and shipment. if the number of reported cases is rising, is this in excess of the expected number? ideally work with rates rather than numbers (see above) because (for example) the number of cases in a refugee camp could increase if the number of people in the camp increases without an outbreak occurring. verify the diagnosis (laboratory confirmation) and search for links between cases (time and place). laboratory confirmation requires the collection of appropriate specimens and their transport to an appropriate laboratory. in the case of a limited outbreak this team should be set up by the lead agency with membership from other relevant organizations, including moh, who, other un organizations, ngos, etc. in the case of an epidemic the moh will probably take the lead or may ask who or another un agency to do so. the team will need to include a coordinator, and specialists from the various disciplines needed to control the outbreak. this may include health workers, laboratory staff, water and sanitation, vector control, and health education specialists, representatives of the moh or other local health authorities, representatives of local utilities (e.g., water supply), representatives of the police and/or military, and representatives of the local community. this team should meet at least once a day to review the situation and define the necessary responses. it has additional responsibilities, including implementing the response plan, overseeing the daily activities of the responders, ensuring that treatment protocols are followed, identifying resources (both material and human) to manage the outbreak and obtaining these as necessary, and coordinating with local, national, and international authorities as required. the team should also act as the point of contact for the media. a media liaison officer should be appointed and all media contact should be through this individual. this will allow team members to refer media representatives to a central point and reduce interference with their activities. it will also ensure that a consistent message based on the most complete data is given to the media. the appropriate national authorities should be informed of the outbreak. in addition to their responsibilities to their own population and to any refugees within their borders, they have a responsibility under the revised international health regulations ( ) to report outbreaks of certain diseases. these include four diseases regarded as public-health emergencies of international concern: • smallpox • polio (wild-type) in some cases, member states must report outbreaks of additional diseases: cholera, pneumonic plague, yellow fever, viral hemorrhagic fever, and west nile fever, and other diseases that are of special national or regional concern (e.g., dengue fever, rift valley fever, and meningococcal disease). once the diagnosis has been confirmed and the causative organism identified, then there are a number of steps that must be taken in addition to continuing to treat those affected: • produce a case definition for the outbreak. this is primarily a surveillance tool that will reduce the inclusion of cases that are not part of the outbreak and prevent dilution of the focus and activities of the main control effort. • collect and analyze descriptive data by time, person, and place (time and date of onset, individual characteristics of those affected -age, sex, occupation, etc., location of cases). plot the distribution of the cases on a map (can help locate source(s) of an outbreak and determine spread) and plot outbreak curves (which will help estimates of how the outbreak is evolving). • determine the population that is at risk. • determine the number of cases and the size of the affected population. calculate the attack rate. • formulate hypotheses for the pathogen about the possible source and routes of transmission. • conduct detailed epidemiological investigations to identify modes of transmission, vectors/carriers, risk factors). • report results and make recommendations for action. the two main statistical tools used to investigate outbreaks are as follows: • case-control studies in which the frequency of an attribute of the disease in individuals with the disease is compared to the same attribute in individuals without the disease matched in terms of age, sex, and location (the control group) • cohort studies in which the frequency of attributes of a disease is compared in members of a group (for example, those using a particular feeding center) who do or do not show symptoms however the design and methods involved in such studies are often too complex for the austere environment of conflict and disaster. • implement prevention and control measures specific to the disease organism (e.g., clean water, personal hygiene for diarrheal disease) • prevent infection (e.g., by vaccination programs) • prevent exposure (e.g., isolate cases or at the least provide a special treatment ward or wards) • evaluate the outbreak detection and response -were they appropriate, timely, and effective? • change/modify policies and preparedness to deal with outbreaks if required • what activities are needed to prevent similar outbreaks in the future (e.g., improved vaccination programs, new water treatment facilities, public health education, etc.)? • produce and disseminate an outbreak report. the report should include details of the outbreak, including the following: -cause -duration, location, and persons involved -cumulative attack rate (number of cases/exposed population) -incidence rate -case fatality rate -vaccine efficacy (if relevant) (no. of unvaccinated ill − no. of vaccinated ill/no. of unvaccinated ill) -proportion of vaccine-preventable cases (no. of vaccine-preventable cases/no. of cases) -recommendations this is an easy-to-use tool which is of great value for handling epidemiological data and for organizing study designs and results, which can be downloaded free of charge from the internet. it is produced by the centers for disease control (atlanta) and is a series of microcomputer programs which can be used both for surveillance and for outbreak investigation and includes features used by epidemiologists in statistical programs, such as sas or spss, and database programs such as dbase. public health action in emergencies caused by epidemics. geneva: who, . cdc atlanta. case definitions for infectious conditions under public health surveillance updated guidelines for evaluating public health surveillance systems epidemiology for the uninitiated communicable disease control in emergencies -a field manual last jm (ed). dictionary of epidemiology medicins sans frontieres. refugee health -an approach to emergency situations geneva: international committee of the red cross sphere project. humanitarian charter and minimum standards in disaster response. geneva: the sphere project key: cord- -kgyl w authors: oommen, seema title: emerging respiratory pandemics date: - - journal: clinical pathways in emergency medicine doi: . / - - - - _ sha: doc_id: cord_uid: kgyl w since the identity of the respiratory pathogen is not known at the time of admission, emergency department personnel and intensive care staff are at the highest risk of exposure while handling such patients. swine fl u is the popular name of the relatively new strain of infl uenza a/ / h n that caused a pandemic which began in mexico and spread rapidly from there across the world in - . more than , laboratory-confi rmed cases were reported from more than countries worldwide as of march with a total of , deaths as reported by the world health organization (who) in august [ ] . this is considered an under-representation of the actual numbers as many deaths were never tested or recognized as infl uenza related [ ] . meanwhile new cases of h n are being diagnosed worldwide including india in . the who estimates a total of laboratory-confi rmed human cases of avian fl u (h n ) infection and related deaths in countries from to [ ] . avian infl uenza viruses are divided into the high pathogenicity h n virus with % mortality in the poultry and low pathogenicity h n viruses not associated with severe disease in poultry. cases of h n are reported mainly from the people's republic of china. the most recent respiratory illness was fi rst reported in saudi arabia in and is of a new strain of coronavirus called the middle east respiratory syndrome coronavirus (mers-cov) that shares a genetic relatedness to a similar virus found in camels. by june there were around laboratory-confi rmed infections with deaths [ ] . the majority of these cases were from the middle east countries with few cases in the usa, europe, malaysia and the philippines in asia. thus the crude case fatality rate of h n is highest at %, followed by mers-cov ( %), sars-cov ( %) and the least h n ( . %), the latter being most likely under-represented [ - ] . adaptation of the viruses by mutation or reassortment leading to an ability to cross the species barrier into humans, the capability to become established in humans and a sustained ability to pass from one human to the other are the three features needed to cause an infectious disease of epidemic proportions. combine this with the increased mobility of individuals across the world; transfer of these infections from one part of the globe to the other can take place in a relatively short period of time. direct lysis of the host cells is one of the mechanisms of host tissue damage. more important are the indirect consequences of the host immune response which get disrupted, tipping the balance from being favourable to an exaggerated and destructive host immune response leading to an outpouring of pro-infl ammatory chemokines and cytokines termed as 'the cytokine storm' [ ] . cytokines like tumour necrosis factor alpha (tnf α), interleukin (il- ), il- β and il- play a major role in tissue damage [ ] . of this il- β has been found to be the main cytokine in the broncho-alveolar lavage (bal) fl uids of patient with lung injury [ ] . the net result is local diffuse damage to the alveoli (acute lung injury -ali) due to increased arrival of leucocytes, dilatation of blood vessels and tissue oedema and can swiftly progress to the more severe acute respiratory distress syndrome (ards). spillover of these cytokines into the systemic circulation leads to multisystem organ failure and fi nally death. there is a considerable overlap in the clinical presentation by the common respiratory viruses and other atypical causes of community-acquired pneumonia making arousal of suspicion in the treating physician of an emerging epidemic virus unlikely. hence suitable samples may not be collected at the appropriate time leading to misdiagnosis and a delay initiation of therapy. • the common clinical presentation [ , , ] of most respiratory pandemic viruses is that of an 'infl uenza-like illness (ili)': an acute respiratory infection with sudden onset of fever (temperature of > °c or > . °f), chills, myalgia and a non-productive cough. sore throat and rhinorrhoea may also be present. many cases are associated with gastrointestinal symptoms like abdominal pain and diarrhoea. • a history of contact, in the preceding days of symptom onset with poultry or with a known case in the countries detected to have human avian infl uenza cases, has to be elicited. likewise, history of travel to the middle east countries should arouse suspicion of a mers-cov infection. • cases may range from a mild ili to a fulminant viral pneumonia. rapid clinical deterioration may occur with diffuse viral pneumonitis with hypoxaemia, acute respiratory distress syndrome (ards), septic shock, multisystem organ failure and death occurring within a week of onset of illness [ ] . • secondary bacterial pneumonia especially due to staphylococcus aureus, s. pyogenes and s. pneumoniae is a common complication with infl uenza [ ] . • extremes of age; pregnancy; obesity; presence of pulmonary, cardiac, hepatic, renal or metabolic co-morbidities; and underlying neurological conditions are the common risk factors for severe disease [ , ] . • case fatality of h n is much higher than seasonal infl uenza viruses with rapid clinical deterioration mainly due to early involvement of the lower respiratory tract. considering the rapid spread of virus in the past within hospitals and community, methods to rapidly identify infected cases are of utmost importance. • the real-time-based polymerase chain reaction (rt-pcr)-based assay is one such means which has proven its worth both during the sars-cov and the h n outbreak. the only caveat is that appropriate clinical samples need to be collected at the appropriate time during the disease and should be transported to the laboratory in cold chain in a viral transport medium so as to maintain the viability of the nucleic acid. • multiplex pcr can detect simultaneously other viruses causing a similar clinical picture like the seasonal infl uenza a and b, respiratory syncytial virus (rsv) and human metapneumovirus. • the most preferred specimen is a nasopharyngeal aspirate or a swab preferably within - days of onset of disease [ ] . cotton swabs are not recommended due to presence of inhibitors; rayon-or nylon-fl ocked swabs are used instead. broncho-alveolar lavage, tracheal aspirates and sputum which contains the highest viral loads are the ideal specimens especially later in the course of illness [ ] . • rt-pcr tests may be carried out on serum specimens. • in case of suspicion of mers-cov or sars-cov, stool specimens may also be sent to the laboratory. • many a times these newer molecular assays may not be available even in established diagnostic molecular laboratories and the specimen may have to be shipped under strict biohazard protocols to the national or a regional reference centre for testing. • rapid diagnostic tests available for the diagnosis of infl uenza have high specifi city but low sensitivity and hence a negative result should be interpreted with care [ ] . • though viral cultures don't play a signifi cant role in rapidly diagnosing cases, it is important in confi rmation of emerging and re-emerging cases of viral infection, epidemiological typing of isolates and research into vaccines and newer drugs. • clinical signs on examination are minimal when compared to the radiological fi ndings of the chest. chest x-rays typically show diffuse interstitial infi ltrates, unilateral or more commonly bilateral ground-glass opacities to focal consolidation that is seen early in the disease [ , , ] . these opacities are usually seen in the lower lungs fi rst and may become widespread affecting larger areas as the disease progresses. high-resolution computed tomography may be required in ambiguous cases. • tests done to rule out other infectious aetiology include blood cultures, gram's stain and culture of the sputum and urinary antigen detection for legionella and pneumococci. acute and convalescent serum samples may be collected for antibody detection of various pathogens. healthcare personnel should be on high alert in the present global climate for any clustering of similar cases. picking up a probable epidemic early in its course may limit the spread of the infection within the hospital and the community. treatment is largely supportive for uncomplicated cases, also bed rest and maintenance of hydration, in addition to analgesics and antipyretics. severe cases require supportive measures including ventilation and antibiotics for secondary bacterial infections. • oseltamivir and zanamivir [ , ] are neuraminidase inhibitors that decrease the release of infl uenza viruses from infected cells, thus limiting its spread. it has been used extensively in the h n pandemic. resistance to oseltamivir has been documented [ ] . best results were obtained when treatment was started within h of symptom onset even before the availability of laboratory results. • the dosage of oseltamivir for persons above years of age and > kg weight is mg twice daily for duration of days. • for children < kg, the dose of oseltamivir is mg twice a day, - kg is mg twice a day and > - kg is mg twice daily. • zanamivir is advised for persons above years of age at a dose of mg (two inhalations) twice a day. oseltamivir is the drug of choice to treat human cases of avian infl uenza. • unlike infl uenza there is no specifi c antiviral or vaccine available for the coronaviruses. a combination of ribavarin and interferon α shows synergistic action in vivo and has been used to treat mers-cov and sars-cov infections but limited data is available on their effectiveness to combat the disease and clinical trials are needed to demonstrate their effectiveness [ ] . • steroids were used during the sars outbreak to limit the cytokine-mediated lung injury in conjunction with ribavirin but the actual role of steroids has to be elucidated with further studies. steroids are contraindicated in cases of infl uenza pneumonia as it may further predispose to secondary bacterial infection. • the incubation period for most infl uenza viruses including h n is - days [ ] , whereas the incubation period for h n is slightly longer ranging from to days. • patients with infl uenza are most infectious in the fi rst days of the onset of illness averaging from a day before the onset of symptoms to - days after the onset of illness. • the incubation period of coronaviruses like sars-cov and mers-cov is around - days. in contrast to infl uenza cases, they transmit the virus usually after the fi fth day of the onset of disease when viral load maximizes in the nasopharyngeal secretions [ ] . . immunoprophylaxis [ ] : exists currently only for infl uenza. it is advised by the advisory committee on immunization practices (acip) that all persons over months of age be vaccinated annually against the predicted infl uenza strains which are most likely to cause infections in the next infl uenza season based on surveillance data. it is available as an annual infl uenza vaccine incorporating three or four live attenuated or inactivated infl uenza strains. it is available for administration as nasal sprays (live attenuated vaccine) and the intramuscular or intradermal route (killed vaccine). . chemoprophylaxis [ ] : • oseltamivir and zanamivir (neuraminidase inhibitors) are active against both infl uenza a and b viruses. it is indicated in exposed unvaccinated immunocompromised persons or people with co-morbid conditions who are at a high risk of developing infl uenza. • oseltamivir should be given within day after exposure at a dose of mg once daily for persons years and above of age for a minimum of days after exposure to a recent contact with a known case of infl uenza. • zanamivir is prescribed at two inhalations once daily for people above years of age. if the exposed person develops respiratory symptoms, he should be given treatment doses of the drug. • in case of h n , close contacts of strongly suspected cases of human avian infl uenza and personnel handling infected poultry are advised oseltamivir as chemoprophylaxis [ ] . . standard contact , droplet and airborne precautions [ ] : oftentimes, emergence of an infection of pandemic potential is not routinely expected by physicians and staff in their regular days' work. but going by the past experience especially in case of sars-cov, healthcare personnel were the ones at high risk of infection given the close proximity to the patient. hence it is important that all staff follow the standard contact and droplet precautions for any case suspected to have a respiratory infection. • contact and droplet precautions include wearing of personnel protective equipment (ppe) such as gloves, gowns, eye and face shields. • there is special emphasis on hand hygiene which must be diligently performed before and after contact with the patient, the potentially infectious material generated by him, before wearing and after removing ppe. • airborne precautions include placement of patients in an airborne infection isolation room (aiir) and wearing of n or greater respirators and masks. airborne transmission is especially possible while suctioning a ventilated patient, bronchoscopy, sputum induction, intubation and extubation and cardiopulmonary resuscitation. • pending placement of patient in the aiir a face mask must be placed on the patient and the patient isolated in a single room to prevent spread of infection. • environment infection control must be followed per hospital infection control policy using a suitable disinfectant for disinfection and collection, transport and treatment of all infectious waste generated. patient presenting with 'influenza like illness' and chest radiograph showing signs of pneumonia necessitating hospitalization inform district heath authorities. always maintain personnel protection: contact, droplet and airborne precautions to be practised. elicit travel history to middle eastern countries for mers-cov and or history of contact with poultry for h n . physicians and staff to be alert on clustering of similar cases in the recent past collect appropriate specimens to confirm diagnosis and to rule out alternate diagnosis. severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection infl uenza at the human-animal interface. summary and assessment as of middle east respiratory syndrome coronavirus (mers-cov) summary and literature updateas of into the eye of the cytokine storm two years after pandemic infl uenza a/ / h n : what have we learned? writing committee of the who consultation on clinical aspects of pandemic (h n ) clinical aspects of pandemic infl uenza a (h n ) virus infection antiviral agents for the treatment and chemoprophylaxis of infl uenza. recommendations from the advisory committee on immunization practices (acip) prevention and control of seasonal infl uenza with vaccines who rapid advice guidelines on pharmacological management of humans infected with avian infl uenza a(h n ) virus. available at guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings key: cord- - pika authors: merck, melinda d. title: clinical management of large-scale cruelty cases date: - - journal: august's consultations in feline internal medicine, volume doi: . /b - - - - . - sha: doc_id: cord_uid: pika nan large-scale feline cruelty cases typically arise from investigations involving individual hoarders, rescue organizations, sanctuaries, or breeders. these cases involve the crime scene, animal processing at the scene and temporary shelter, animal removal and transport, sheltering, and final animal disposition. the veterinarian plays a role in the planning of the operation, at the crime scene, the temporary shelter, and the hospital receiving cats for more advanced treatment. the clinical management of these cases is different from traditional shelter medicine or feline practice. to act and respond appropriately, the veterinarian must have an understanding of all aspects of the operation. these are legal cases requiring certain types of documentation and procedures. the organization of the entire operation should be conducted similar to disaster response using the incident command systemwhere the medical management on scene and at the temporary shelter is incorporated into this reporting structure with direct communication to the lead investigator. extensive planning is needed, anticipating the number of cats, age ranges, known or likely medical issues, and socialization status. decisions must be made considering practicality, stress on the animals, costs, resources, future animal placement, and any legal impact. the goal is a successful outcome for the individual cat and the criminal case. supplies needed for on-scene and shelter medical operations need to be planned very early in the investigation. all team leaders should be involved in this planning, including those from the medical, forensic evidence, and shelter branches, with a supply list compiled for each branch (table - ) . arrangements should be made to obtain supplies during the case response for items that were not anticipated or depleted due to use. the use of color codes is important for large-scale cases to implement a visual system of communication at the scene, from scene to the shelter, within the shelter, and for forensic examinations. the colors are used to designate triage categories, initial cat temperament, and other conditions that determine placement and housing within the shelter. in addition, this system serves to establish the examination sequence. the assignment of color categories may vary with each case based on the availability of the color devices used (table - ) . colored duct tape is easily used and readily purchased at home improvement, hardware, office supply, and general merchandise stores. colored flagging tape may also be used but poses a risk of animal ingestion and can be difficult to remove from transport carriers or cages. a piece of the appropriate colored duct tape is placed on the animal identification (id) label located on the transport carrier or cage; some animals may have more than one color assigned (figure - ) . the primary use of the color system is at the scene, but some colors may continue to be used within the sheltering system. the color system and their assigned categories should be posted at the scene, within each forensic examination area, and at multiple areas within the shelter. the purpose of the critical triage team, comprised of veterinarians with or without veterinary technicians, is to identify any animals in need of urgent care. the critical triage team assesses animals after the initial scene walk-through is complete and as the physical evidence, animal id, and animal removal teams begin their work. any critically ill or injured animals should have priority for id assignment and removal from the scene. provisions for an on-site critical examination area should be made, such as a mobile veterinary clinic, trailer, tent, or one of the buildings within the scene itself. cats requiring more extensive diagnostics or treatment should be transported to a local veterinary hospital. the forensic examination teams are responsible for examination of all the animals. these teams are comprised of a veterinarian, scribe, and animal handler. it is important that all animals are examined in a timely fashion, within hours, to ensure the examination evidence is representative of the the effect of stress on cats has been well documented. in large-scale cases, stress can come from crowding, prolonged confinement, isolation, lack of environmental enrichment, an unsanitary environment, poor food and water resources, and untreated medical conditions. every consideration should be made to minimize stress during removal, transport, sheltering, and examination of the cats. physical handling of the cats and change of environment are additional but necessary stressors in these cases that carry a risk of exacerbating any pre-existing medical conditions. it is not unusual for these large groups of cats to be subclinical disease carriers that have reached a state of homeostasis that when disrupted results in new outbreaks. in addition, many of these cases involve animals that lack proper socialization and/or have been under severe emotional stress. they may exhibit aggression (due to fear or pain), or they may be completely unable to interact. some cats may exhibit subtle behavioral clues of extreme distress. it is the initial handling at the scene that can set the animal up for success or failure more so than any setbacks that may occur during examination or sheltering. resistance to handling and restraint is almost always the result of fear, anxiety, or pain, which is compounded when force is used. if possible, it is preferable to take several hours to remove a cat from the scene rather than forcefully remove it, which can reinforce the animal's fear and behavioral response. it is important to recognize that these cats may have reactions to novel stimuli different from those raised as pets in private homes. therefore, any negative behavioral designations assigned at the scene should be considered temporary and only for the purpose of cautionary handling. the key to successful handling of animals involves the accurate appraisal of behavior, an adequate number of staff, and the appropriate equipment; proper training in each of these areas being the most important aspect. transportation of cats from the scene to the sheltering site should be done in such a manner to minimize stress on the animals and to maintain compliance with applicable laws and regulations. considerations should be given to the environmental conditions and the time required to load the vehicle (which directly affects the first animals loaded). the spacing of the animal transport carriers within the transport unit should be planned to provide adequate ventilation for the cats inside. individual transport carriers should be of sturdy construction, put together properly to prevent animal escape or injury, have adequate ventilation, and consist of a design that allows stacking of carriers. special areas may need to be animal's condition at the original scene and any health issues are addressed as quickly as possible. the examination and treatment process should be complete and efficient. these teams usually work best when the scribe, who must be familiar with medical terminology, fills out the examination form as the veterinarian dictates the findings. the creation of special laboratory and treatment teams can improve efficiency and free the veterinarian to focus on examination and documentation. it is preferable to have one team designated to examine the more severe medical cases and animals that may require sedation to handle. this team should have ample medical supplies, controlled drugs, and the most secure examination area. there are several assessments that must be made at the crime scene that directly impact handling of the cats throughout the operation and have important legal ramifications. these evaluations may be conducted by veterinarians along with case investigators. it is critical that the veterinary teams, offsite hospitals, and sheltering operations take this into consideration. the assessment should include information about the cats and current housing conditions along with medications and supplies present. the most important consideration, and most overlooked, is the evaluation and continuous monitoring of stressors on the cats. it is important to document any obvious medical, husbandry, or behavioral care needs at the scene. this includes the presence of neonates, nursing queens, chronic medical conditions, infectious diseases, and potential zoonotic diseases. any records present should be assessed for pertinent information, including intake date, medical history, and individual cat names. any medications, supplies, and supplements should be documented, noting any prescriptions for individual cats, the date prescribed, expiration dates, the original amount and quantity remaining, and the prescribing veterinarian's information. the medications and supplies should be assessed for indicators of current or past medical issues. the general housing of the cats should be assessed and documented with photography and mapping. this assessment is an important consideration for housing decisions at the sheltering site. special note should be taken of the number of cats in a room or cage and natural groupings or obvious social bonds. the flow of people and animals within and between housing areas should be documented, with special focus on the potential for fomite transmission of pathogens. the type and brand of food offered should be recorded as well as the number of feeding stations and the number of cats that have access to each one. the availability and potability of water sources should be assessed. the litter boxes should be evaluated, including the type of litter, the amount of urine and feces, the type of litter box, and the number of cats with access to each litter box. samples of diarrhea should be taken for individual cats and representative samples for group population medicine whenever possible, the same persons should care for the same cats to help reduce stress, enhance opportunities for socialization, and decrease risk for injuries. assessments and monitoring may be improved when performed by personnel familiar with individual cats. creating separate sections in housing areas should be carefully considered, because they can create more stress on the cats and complicate management of the shelter. these separations are often based on infectious diseases, zoonotic diseases, critical medical observation, bite quarantine, reproductive status, and special needs (such as those cats that are difficult to handle, pregnant, neonates, or nursing). decisions for separate housing areas must be done with consideration of the crime scene assessment. most of these cases involve cats that have previously been exposed to each other either through housing design or fomite transmission; therefore, separation based on infectious disease is neither necessary nor recommended. in large open shelters, separate areas can be created by hanging tarps or clear plastic sheets that are open at the ceiling for airflow. other considerations for housing of cats include lighting, number of separate rooms, secure areas, and airflow. cats are more stressed when at ground level, so every effort should be made to elevate the housing. in the planning stages, it is important to develop medical protocols, including those for examinations, diagnostic testing, and all treatments. planning should include what tests will be conducted at the shelter and what outside laboratories will be used. because this is a legal case, the use of standard examination forms that are developed specifically for these types of cases is recommended (box - ) . these forms should be structured to prompt and guide the veterinarian through a complete examination. photographic id of the cat can be performed by one of the forensic examination team members, or a separate floating photographer may support multiple examination teams. the photographs should begin with the case information, including the case number, date, and animal id written on a card or dry erase board. this first picture with the case and animal information may be taken with or without the animal in the photo, and all photographs following this initial picture should only be of that animal. general photos should be taken showing the entire body of the cat: right and left sides, front (facial), hind (rear), dorsal, and ventral (if possible or appropriate) views. photographs, with and without a photo scale, should be taken of any obvious lesions, abnormal physical findings, and any evidence found on the body. it is important that each veterinarian use the same examination form (see box - ). it is the responsibility of the scribe to ensure that the entire form is complete, and it is the veterinarian's responsibility to review it for accuracy. in designated at the offloading area for animals requiring immediate veterinary care or assessment upon arrival to the shelter, especially neonates. planning for animal carrier placement based on infectious disease status is difficult and usually unnecessary as in most cases there has been ongoing exposure among animals due to their living conditions. for large-scale cat cruelty cases, there is rarely an existing animal shelter that can house all of the animals at one location. this requires creating a temporary shelter, which follows the same principles used for animal disaster sheltering, with the primary difference that the animals are evidence in a criminal case. protocols must be in place for monitoring, treatment, daily assessment, and progress documentation, including change of medical or behavioral status. there should be a shelter mapping system to identify and track the location of every animal, including when animals are moved. it is important to have the veterinarian's input on the initial design and any adjustments made based on the crime scene assessment or forensic examinations. the shelter should be designed to be flexible based on changing medical or behavioral conditions of the animals. shelter design should take into account the number of cats, special housing needs, ease of handling, infectious disease, temperature control, airflow, foot traffic, noise levels, animal stress, and environmental enrichment. continued assessment and reassessment of cat behavior and temperament should be conducted, with changes made to address any issues noted. any final behavior or temperament designations should only be assigned after the cats have had time to adjust to their new environment and recover from all stressors, which may take several days to weeks. consideration should be given to the original housing, grouping, and social bonds of the cats at the scene. often these cases involve group housing or free-roaming shelter settings, and the temporary shelter results in isolation of cats into individual cages. although this can be another stressor on the cats, it can be offset (at least for the short term) by the positive change to a sanitary environment and the elimination of competition for resources of space, litter, food, and water. cats should be paired or group-housed whenever possible and practical to reduce stress. shy or feral cats are often less stressed when paired with another cat. wire cages are especially amenable to alteration, creating a "double-wide" space for this purpose. environmental enrichment is important to incorporate into the sheltering design and protocols. this includes soft bedding, boxes, or small carriers to hide in, toys, treats, and catnip. it is critical to offer canned food, especially for cats with upper respiratory or dental disease, to assess and stimulate appetite, and for further enrichment. it is important to minimize changing of bedding and other items within the cages, which can create additional stress. the use of synthetic pheromones (e.g., feliway, ceva animal health) may be effective in stress reduction when sprayed on bedding and through the use of plug-in diffusers. addition, the veterinary teams should use consistent terminology and abbreviations, which may be posted in the exam areas. breed descriptions should be done carefully. unless the breed is known, it is often best to use "breed-type" or predominant "breed-mix." the body condition score (bcs) to be used should be posted in each examination area so that the veterinarians can refer to it. the age or estimated age of a cat should only be documented if supported by examination findings, such as dentition or ocular changes. it is preferable to use designations of neonatal, juvenile, adult, or geriatric with documentation of the basis for the determination. after the examination is complete, a check mark should be placed on the animal's id marker to create a visual indication that the animal has been examined. any color-coded markers should be assessed and removed or changed based on the examination; those that may impact shelter operations should be communicated to the shelter manager. the standard medical protocols enacted depend on the known existing conditions and diseases within the population, the expected length of stay in the temporary shelter, and the expected disposition of the cats; however, a variety of infectious diseases (including respiratory, enteric, and dermatologic pathogens) should be expected. depending on the legal process, the cats may be adopted directly from the shelter, placed at another animal facility within or outside the area, placed in foster homes, or euthanized. these potential scenarios and outcomes may be fluid and will dictate what protocols are most appropriate for the cats at any given time. the medical protocols should be implemented during the forensic examination process. standard vaccination protocols should follow the american association of feline practitioners (aafp) recommendations for shelter-housed cats. vaccinations should be given at the time of intake to the temporary shelter and should include feline herpesvirus type , feline calicivirus, feline panleukopenia, and rabies. vaccination for feline leukemia virus (felv) may be considered based on viral test results and group housing. a majority of intensively housed cats will harbor at least one enteropathogen, often of zoonotic significance; the presence of such pathogens is not limited to cats with clinical population medicine euthanasia protocols for euthanasia, necropsy examinations, and the storage of deceased animals should also be determined in advance. because the animals are evidence and also to remain sensitive to the case responders and public sentiment, the criteria and parameters for euthanasia decisions should be discussed with the lead investigator and prosecutor prior to the day of seizure. the decision for euthanasia should first be agreed upon by the examining veterinarian and the case lead veterinarian. the lead veterinarian should obtain permission from the lead investigator to perform euthanasia according to the agreed upon parameters. another factor to address in the planning phase is the use and storage of controlled drugs, including euthanasia solution and sedatives. a controlled drug log must be maintained according to applicable laws. many of the cats may have obvious medical needs. regardless of the presence or absence of clinical signs, it should be expected that most of the cats are likely carrying multiple different pathogens. these may or may not become clinically relevant, depending on the individual cat and the stressors placed on it. the most common medical finding is upper respiratory tract disease (urtd). this may vary from mild to severe with secondary pneumonia, ulcerations of the nasal or oral area, nasopharyngeal polyps, and ocular involvement ( figure - ) . mild cases may not need to be treated while being closely monitored for disease progression; most cases will resolve within to days. the more severe cases typically involve secondary bacterial infection, regardless of the primary pathogen, which should be treated aggressively. considerations for choices of medication should include the availability of personnel and their ability to administer signs of illness. therefore, routine deworming for roundworms, hookworms, and tapeworms should be part of the standard medical protocol. fecal testing is not necessary unless there is unresolved diarrhea after deworming, or it is otherwise dictated based on clinical illness. coccidiosis is a common finding in large-scale cat cruelty cases; it is found in up to % of cats with diarrhea and % of clinically healthy cats. based on observed diarrhea findings at the scene, within the temporary shelter, or diagnostic test results, it may be reasonable to treat all cats for coccidiosis. ponazuril is an effective treatment for coccidiosis and is easily administered to large numbers of cats, given orally once daily at to mg/kg for to days and repeated if necessary in week. , the stressors the cats have been exposed to along with dietary changes at the temporary shelter can contribute to diarrhea. in addition, many cats from these cases may harbor other enteropathogens, such as tritrichomonas, giardia, or cryptosporidium species, as well as feline enteric coronavirus, which may or may not be a cause of refractory diarrhea. , any additional testing and interpretation should be conducted as discussed later in this chapter. all diagnostic testing decisions for the cat population should be done with consideration for the goals of the operation; the legal impact; the health of the individual cat and the general population; the stress on the cat; the expected time length for housing; the future placement of the cats and the placing agency's responsibilities; the financial and personnel resources; and clinical relevance. for each test considered, both the test itself and the action to be taken based on its result must be appropriate and reasonable. in a large-scale case, tests that may be recommended or conducted in private or shelter medicine practice may not be appropriate or reasonable. the goal is not to cure all animals and eliminate all pathogens prior to the cat leaving the temporary shelter, rather it is to immediately identify and address any important medical issues, improve overall physical and mental health, and address any obvious zoonotic issues. this should be a clear and constant guidepost for decisions made. it cannot and should not be the expectation to test and treat for everything. as with any shelter situation, these cats may be asymptomatic carriers of a variety of pathogens. testing can result in information that is not currently relevant to the health of the animal yet force decisions for unnecessary and inappropriate actions for that individual animal or the general population. for large-scale cruelty cases, it is recommended to test cats for felv and feline immunodeficiency virus (fiv) based on the guidelines established by the aafp. depending on the test results and the original housing at the crime scene (i.e., pre-existing exposure), changes in the housing location within the temporary shelter may or may not be recommended. cats that appear ill without a grossly apparent cause should have routine laboratory work analyzed, including a full biochemistry profile, complete blood count, and urinalysis. such documentation is especially important in legal cases. medication, the possibility of administering medication through canned food or treats, dosing intervals, possibility of multiple pathogens, and risk of side effects. stress reduction plays the single greatest role in the remission and prevention of urtd in cats; therefore, particular attention should be given to providing an enriched environment as a component of the treatment plan. skin and fur conditions are quite common in large-scale cruelty cases. the cats often have urine and/or fecal staining of fur, especially on the feet, usually with associated dermatitis. other issues related to the feet include contact pododermatitis, plasma cell pododermatitis, and overgrown or embedded claws (figure - ) . cat bite abscesses are not uncommon. severe matting may be seen on longhaired cats with fecal soiling or impaction in the perineal area with associated dermatitis (figures - and - ). in addition to fleas and associated dermatitis, there may be other external parasites, such as cheyletiella, lice, and demodectic or sarcoptic mange. stress can cause alopecia due to overgrooming or self-mutilation (figure - ). less commonly, cases of streptococcus canis have been reported in intensively housed cats, often manifesting with skin ulceration and necrotizing fasciitis (figure - ) . dermatophytosis may be seen in some cats but rarely is a widespread issue within the population. cats may be mechanical carriers and never develop clinical lesions themselves; such cats are seldom clinically relevant to the case, the individual animals, or the general population. for these reasons, dermatophyte testing is not routinely recommended on intake of cats or for those without dermatologic lesions. rather, the focus should be on diagnosing and treating cats with suspicious lesions and enacting precautions for handling and cleaning. housing placement within the shelter for cats suspected or diagnosed with dermatophytosis should be based on the considerations previously discussed. population medicine in the distal extremities, may be found. other common findings include decubital ulcers, poor wound healing, and secondary bacterial or yeast skin infections. there are numerous other medical findings that may be seen or develop in these cases: a variety of clinical abnormalities of the skin result from nutritional deficiencies, including starvation. a common finding is a sparse, dry, dull, and brittle hair coat with hairs that epilate easily. seborrhea sicca and patchy alopecia may be seen. loss of hair occurs due to anagen and/or telogen defluxion. in the anagen or growth phase of the hair cycle, there can be loss and/or abnormal growth of hair, resulting in broken hair shafts. with telogen defluxion, there is widespread loss of hair in the quiescent phase of the hair cycle due to large numbers of hair follicles being synchronized in this phase. loss of normal hair color and hair keratinization abnormalities can occur. in cats, decreased melanin deposition due to amino acid deficiencies results in a reddish cast to the hairs, sometimes called red coat (figure - ). erythema or crusting in areas of friction or stretching, such as primary or secondary to other medical conditions, malnutrition, dehydration, stress, and/or an unsanitary environment. often, the investigation findings may provide information on pre-existing conditions through intake paperwork or hospital records. these underlying issues may only be detected with routine blood work and urinalysis; affected cats may require further diagnostic testing, imaging, or hospitalization. the clinical management of large-scale feline cruelty cases starts at the scene and continues to the temporary housing in a shelter or hospital. it is critical that veterinarians understand the importance of the role they play as part of the investigative team and the requirements for documentation in a legal case. the veterinarian may become involved in these cases directly at the scene and shelter or by receiving a patient into the hospital. by the very nature of large-scale cruelty cases, the cats will have a wide range of issues associated with high volume housing and long-term neglect. it is important to be mindful that this will be a fluid situation requiring a process of continuous assessment of the animal's health and behavior to detect early signs of developing issues and initiate treatment. the simple actions of providing appropriate housing, food, routine medical treatments on intake, and overall stress reduction will often result in rapid improvement of cat health. there is a greater chance of recovery-even for the most severely affected cats-when both physical and mental needs are addressed. • oral lesions, including ulcerations associated with urtd, stomatitis, and dental disease • urinary tract issues (e.g., urinary tract infection, idiopathic cystitis, nephroliths, uroliths, crystalluria, and vaginitis) are often the reason the cat was presented to the original shelter or sanctuary the clinician should be cognizant of the possibility for these and other underlying medical issues that may be special considerations in animal cruelty cases recognition and management of stress in housed cats feline care in the animal shelter effects of a synthetic facial pheromone on behavior of cats a synthetic fraction of feline facial pheromones calms but does not reduce struggling in cats before venous catheterization crime scene investigation prevalence of infectious diseases in large scale cat hoarding responses aafp feline vaccination advisory panel report prevalence of enteropathogens in four management models for unowned cats in the southeast united states clinical trial to assess the efficacy of ponazuril for the treatment of coccidiosis in dogs and cats enteropathogens identified in cats entering a florida animal shelter with normal feces or diarrhea american association of feline practitioners retrovirus management guidelines prevalence of upper respiratory pathogens in four models for unowned cats in the southeast united states feline infectious respiratory disease fatal streptococcus canis infections in intensively housed shelter cats veterinary forensics: animal cruelty investigations key: cord- -mvoq vln authors: nan title: autorenregister date: - - journal: med genet doi: . /s - - - sha: doc_id: cord_uid: mvoq vln nan complex mechanisms of dosage compensation regulate the mammalian x chromosome due to the presence of one copy in males (xy) and two in females (xx). x inactivation silences one x chromosome in females in early development, leading to specific epigenetic and structural changes. the inactive x chromosome becomes condensed and forms a bipartite structure within the nucleus, as we have shown by chromatin conformation analyses. specific long non-coding rnas are implicated in the formation of this unique structure. the inactive x chromosome is preferentially located near the lamina or the nucleolus. genes that escape x inactivation tend to be located at the periphery of the condensed inactive x chromosome. such genes are more highly expressed in females, and thus associated with sex-specific differences manifested even in early development. we have found that significant sex bias in gene expression are associated with escape from x inactivation in human tissues from normal males and females, and in tissues from individuals with sex chromosome aneuploidy, including turner or klinefelter individuals. institute for genomic medicine, columbia university medical center, new york, usa a central challenge in human disease genetics is the identification of pathogenic mutations. one key approach to distinguishing benign and pathogenic mutations is to use population genetic data to identify regions of the human genome under purifying selection. here i describe how the residual variation intolerance scoring framework has been applied to identifying pathogenic mutations in and outside protein encoding regions of the genome. next i report how these are related approaches are being used to identify pathogenic mutations in large-scale scale studies in epilepsy and other neurodevelopmental diseases. finally, i discuss how the identification of genetic causes of disease can inform treatment choices. scents indicate things, make promises, attract attention and stimulate imagination, feed anxieties and hopes: they are the salt in the atmospheric soup. we regard seeing and hearing as more important sensory functions, because they contribute more to conscious, cognitive processes of perception -but at moments of the greatest enjoyment we close our eyes and taste the scent, smell the taste. before the spirit and beauty of a person can fascinate us, our nose must become infatuated. the olfactory system in the nose acts as a window, monitoring environmental chemical information and convert chemical stimuli in electrical nerve impulses which are conducted along the olfactory sensory neuron to their glomerular target in the brain. olfactory receptors (ors) activation shows the distinguished (camp-based) transduction pathway for odorant perception. in buck and axel discovered the olfactory gene family, the largest gene family in the human genome, and postulated an exclusive expression in the olfactory epithelium. however, recent whole genome sequencing data from our and other labs show that ors have been found in every tissue of human body which was analyzed by next generation sequencing. the importance of such ectopic expression of ors is raised since the physiological function of some of ors was characterized. when identifying additional expression profiles and functions of or in non-olfactory tissue, there are limitations posed by the deorphanization of ors concerning the activated ligands and by the small number of antibodies available. in contrast to the olfactory sensory neurons which are believed to express all functional or genes (only one or type per cell), cells in non-olfactory tissues tend to express more than one individual or gene per cell. in addition, some of the signaling pathways in non-olfactory tissues seem to involve completely different components in comparison to the olfactory neurons. what is the functional role of these ectopically expressed olfactory receptors? evidences rapidly accumulate that ors participate in important cellular processes outside its primary sensorial organ where they function in odor detection and discrimination. in our lab the functional expression of the first was demonstrated in spermatozoa ( ) . in the meantime we could show the existence and function of ors in the cardiovascular system (heart, blood cells), the gastrointestinal system (small intestine, liver, pancreas), the genito-urinary system (kidney, testis, spermatozoa, prostate), the respiratory system (lung, smooth muscle cells), the skin (keratinocytes, melanocytes) and sensory organs (retina). interestingly we found a broad spectrum of important functions like cell-cell communication and recognition, tissue injury, repair and regeneration, cancer growth, progression and metastasis, nutrient sensing and muscle contraction. nevertheless the functional importance of ectopic ors is still not sufficiently understood. studies seeking to determine the function of ectopic ors are still in its infancy and require further intensive exploration. however, the potential of ors to serve a target for a wide range of clinical approaches is indeed given. this hold promises that the knowledge gained by future investigations would lead to deepen our understanding of or function in health and disease and may provide the basis for the development of applications in diagnosis and therapies in near future. enzyme replacement therapies have been developed over the last years for several of the lysosomal storage disorders (lsd's). the success of enzyme replacement therapy for gaucher disease paved the way for the development of similar treatments for the mucopolysaccharidoses, fabry and pompe disease and lately also for neuronopathic lysosomal storage disorders by intrathecal or intracerebral injections. in addition, small molecule approaches have been developed including substrate reduction therapies and chaperones, which can be used orally. while in gaucher disease enzyme as well as substrate reduction therapy results in reversibility of disease manifestations, with decreases in hepatosplenomegaly, normalization of blood counts and prevention of skeletal disease, this is unfortunately not the case for all patients affected with other lysosomal storage disorders. an important concept is the "window of opportunity for treatment" which is different for these disorders. for example, in fabry disease, early fibrosis fects are well defined, neither the specific mechanisms underlying neurological abnormalities nor the role of decreased cholesterol versus sterol precursor accumulation in disease pathogenesis have been clearly delineated. to identify cellular phenotypes and causative signaling pathways, we derived induced pluripotent stem cells (ipscs) from slos and lath subjects to model these diseases in vitro. slos subjects were known carriers of the most common dhcr mutations, including the intronic splice acceptor mutation c. - g>c and the missense mutation p.t m. while all ipscs demonstrated the expected biochemical defects due to dhcr or sc d mutations, cellular assays uncovered a defect in neural stem cell maintenance resulting in accelerated neuronal formation in slos ipscs. further molecular and biochemical analyses demonstrated inhibition of cholesterol-wnt interactions and loss of wnt/β-catenin activity mediated cellular phenotypes. however, this cellular phenotype was exclusive to slos, as lath ipscs did not exhibit a neural progenitor defect or inhibition of wnt/β-catenin activity. while this work demonstrates the utility of ipscs for modeling rare diseases and identifies signaling deficits potentially underlying slos phenotypes, questions remain regarding cellular and functional consequences, the specificity of lipid-wnt interactions, and the role of other disrupted signaling pathways in mediating developmental and functional deficits in these diseases. unpublished work using a variety of approaches will be discussed comparing the specific effects of cholesterol synthesis mutations on cell fate, functional activity, and lipid modulated signaling pathways to more precisely define the consequences of cholesterol synthesis defects and identify potential targets for patient therapy. induced pluripotent stem cell (ipsc) technology has become one of the major approaches for disease modeling since its first report in . the ability to reprogram cells from somatic into embryonic stem cell-like state and to differentiate them into desired cell types in the culture dish has allowed scientists to carry out the study of several diseases in cells such as neurons which, in the past, could not be isolated from living subjects. williams syndrome (ws), a genetic neurodevelopmental disorder where - genes are hemizygously deleted, is among those. despite cardiovascular abnormalities, its unique neurological phenotypes i. e. hypersociability is of our interest. for several decades, research on different neurological aspects of ws has been conducted in a variety of models such as patient-derived cell lines (lymphoblastoid cells and fibroblasts), post mortem tissue, and mouse models. however, the lack of physiologically relevant cell types such as neural progenitor cells (npcs) and neurons has left a critical gap in our knowledge the disease's cellular and molecular phenotypes. to fill this gap, we took the advantage of the reprogramming technology to capture the genomes of ws subjects in ipscs, which could be then differentiated into npcs and neurons, enabling evaluation of whether the captured genome with hemizygous deletion of those genes leads to relevant neuronal cellular phenotypes. dental pulp cells-derived ipscs of classical ws, rare ws and typical developing (td) subjects were neurally induced via dual-smad inhibition in order to generate npcs and neurons. we discovered that classical ws npcs exhibited increased apoptosis, and, therefore, doubling time, compared to td neurons. this could possibly contribute to the reduction in cortical surface area in classical ws individuals as assessed by magnetic resonance imaging. surprisingly, we found that rare ws npcs behaved similarly to td npcs rather than to classical ws npcs in terms of apoptosis. we confirmed that frizzled , which is deleted in the classical ws but not in our rare ws genome, is responsible for such phenotype via gain-and loss-of-function assays. moreover, classical ws neurons in general showed increased frequency of activity-dependent calcium transient compared to td neurons. finally, classical ws neurons acid alpha-oxidation, and ( .) glyoxylate detoxification. with respect to peroxisomal fatty acid oxidation peroxisomes catalyze the chain-shortening of certain fatty acids including very-long-chain fatty acids, but requires the active help of mitochondria to catalyze the degradation of acetyl-coa and the reoxidation of nadh as produced in peroxisomes. furthermore, with respect to ether phospholipid biosynthesis peroxisomes heavily rely on the endoplasmic reticulum to complete formation of ether phospholipids whereas fatty acid alpha-oxidation also requires the functional interplay between peroxisomes and mitochondria and the same is true for glyoxylate detoxification. recent evidence holds that the interaction between peroxisomes and the different subcellular organelles, including mitochondria and endoplasmic reticulum, is mediated by specific tethering protein complexes which bring organelles physically together thereby allowing metabolism to proceed smoothly. the importance of peroxisomes in metabolism is stressed by the existence of a large group of single peroxisomal enzyme deficiencies of which x-linked adrenoleukodystrophy is best known. our current state of knowledge with respect to the role of peroxisomes in metabolism and the peroxisomal enzyme deficiencies will be presented at the meeting. huntington's disease: rna-sequencing, small rna-sequencing, chip-sequencing and gwas data. department of neurology, boston university school of medicine, boston, ma , usa huntington's disease (hd) is a dominantly transmitted neurodegenerative disease of midlife onset. recently several different unbiased genome wide studies in hd have been performed. these analyses point to a variety of pathological pathways that are associated with important features of the disease, including age at onset, cag repeat size, and the extent of neuropathological involvement. genome wide association studies (gwas) have identified several regions of the genome that contain genes that are associated with the age at onset for hd. the strongest of these is located at q . for rs for which a very rare allele (maf = . %) is associated with an approximate -year younger age at onset for carriers of the minor allele. the same locus contains an independent effect for rs where a more common minor allele (maf = . %) is associated with a . year older age at onset for carriers of this allele. these single nucleotide polymorphisms are in the region of fan , mtmr and several other genes; some of which are not expressed in brain and are not likely candidates for hd modification. eqtl analysis has not resolved which gene may be implicated. other gwas implicated loci include rs at q . and rs at p . . we have sought to combine the information derived from multiple platforms to gain additional insight into the pathways that may be implicated in hd pathogenesis. in this strategy, we have performed mrna-sequencing, small rna-sequencing and chip-sequencing using the h k me mark for active transcription and the repressive mark h k me in human hd brain samples with gwas genotyping. while the striatum is most involved in hd, the extent of neurodegeneration in post-mortem tissue precludes meaningful comparison between disease and control samples, and consequently we studied prefrontal cortex (ba ). several common pathways were seen across these three platforms. mrna-sequencing and mirna-sequencing data identified altered transcriptional profiles implicating developmental pathways involving the hox genes and related homeo-box domain genes (e. g. pitx , pou f , etc.) . notably, micrornas located in hox gene clusters were among those most increased and levels of these correlate with pathological involvement in the striatum. these genes, associated with early embryonic development, are commonly silent in normal adult brain, and were among the most differentially expressed genes in hd brain. these prominent statistical effects are driven by the near total absence of expression in normal brain. pathways implicated in mrna-seq and chip-seq studies, included immune function and regulation of gene expression. these associations were very strong, indicating a large immune reactive response in the hd in the heart is related to unresponsive disease and unfortunately fibrosis may occur already in an early stage, sometimes even without prior hypertrophy. whether earlier intervention will be beneficial is largely unknown. and then: what is early? many unresolved questions exist at this stage, including the following: -what is the natural history and "point of no return" for the different lsd's? -what is the natural history and "point of no return" for subgroups of patients within one lsd's? -what are the long term complications: treatments change the phenotype rather than cure the disease -what is the influence of antibody generation on clinical effectiveness? -how do we manage the extreme costs of these products, especially in light of the many unsolved issues with respect to effectiveness? surprisingly, so far healthcare professionals, governments and industry have failed to systematically address these issues, resulting in insufficient knowledge for potentially lifesaving treatments. early conditional access, followed by a strict, transparent, independent, collaborative evaluation in addition to fair pricing should be explored. after the recent explosion in sequencing throughput, variant interpretation has quickly become the bottleneck in our effort to usher in the era of genomic medicine. while homozygosity for apparently pathogenic variants in the context of disease states is a well-established phenomenon, homozygosity can uncover many medically relevant aspects of the human variome that are difficult to study otherwise. for example, seemingly benign variants may prove pathogenic in the homozygous state. this includes variants with benign prediction using in silico tools as well as variants in dominant genes with no phenotype in carriers because they represent bona fide recessive inheritance. variants that are associated with one phenotype in compound heterozygous states may express themselves quite differently phenotypically when homozygous. furthermore, previously reported pathogenic variants can be challenged when their presence in homozygosity is associated with no abnormal phenotype, thus improving the specificity of the annotation of the morbid genome. homozygosity for lof variants is a special scenario that allows us to study naturally occurring human "knockouts", a powerful tool to study the physiological context of genes in humans. finally, homozygosity in the context of autozygosity provides a robust mapping tool that can greatly aid in the identification of relevant variants, especially those that exert their pathogenic effect in ways that defy detection by our usual algorithms. by expanding the spectrum of phenotypes that are studied, one can unlock the full potential of homozygosity to understand the medical relevance of the human variome in it its full range from embryonic lethal to essentially benign. helmholtz zentrum münchen gmbh, institut für experimentelle genetik, ingolstädter landstr. , neuherberg, germany the inheritance of epigenetic information in mammals across generations has been controversial. some reports provided initial evidence that a paternal high fat diet may propagate obesity and glucose intolerance in offspring, but potential confounders such as molecular factors present in seminal fluid, paternal-induced alterations in maternal care or transmission of microbiomes were not ruled out in these studies. we have shown in mice that a parental high fat diet (hfd) renders offspring derived via in vitro fertilization (f ) more susceptible to develop excessive overweight and type diabetes (t d) in a gender and parent-of-origin specific mode. female, but not male, offspring from obese parents became significantly more obese during a hfd challenge than female offspring from lean parents. body weight trajectories and distribution patterns of individual body weights in female offspring from one obese and one lean parent demonstrate that paternal and maternal germline propagate obesity in a roughly equitable and additive fashion, but likely different mode of action. in contrast, a more deteriorated state of hfd-induced insulin resistance was observed in both f genders, albeit predominantly inherited via the maternal germline. towards the identification of epigenetic information in sperm and oocyte from hfd and low fat diet fed parents, we are currently analyzing their transcriptome and methylome signatures. the status of this analysis will be presented. we report for the first time epigenetic inheritance of an acquired metabolic disorder via mammalian oocytes and sperms excluding confounding factors. such an epigenetic mode of inheritance may contribute to the observed pandemic increase in obesity and t d prevalence rates, especially in an environment where nutrition is abundant. brain which may be a major influence contributing to neurodegeneration. in many instances enrichment of h k me at transcription start sites was not accompanied by a corresponding increase in expression. the apparent inconsistency suggests that common regulatory mechanisms in the hd brain are disrupted and this may contribute to a complex interplay of factors contributing to the neurodegenerative process. often findings in human hd brain samples conflicted with those reported in hd transgenic mouse models, suggesting that one may wish to be cautious in interpreting the significance of either type of study in isolation. the causal pathogesis of huntington disease, new therapeutic approaches r. laufer senior vp discovery and product development global r&d, teva r&d product development mgmt. hatrufa st, netanya, israel huntington disease (hd) is an autosomal dominant neurodegenerative disease characterized by progressive loss of voluntary motor control, psychiatric disturbance, cognitive decline and death - years after motor onset. hd is uniquely caused by a polyglutamine encoding cag expansion in the huntingtin gene (htt), which allows for identification of pre-manifest mutation carriers as much as decades before onset and should facilitate development of disease modifying therapies. yet over years after identification of the hd mutation, available therapies offer only symptomatic relief and are fraught with side effects. development of safe small molecule therapies for hd has been hindered by difficulties identifying and validating tractable drug targets within the disorder's complex pathogenesis. teva pharmaceuticals is developing potential novel treatments based on a mechanistic understanding of disease pathways common to neurodegenerative diseases. the progress of these studies will be reviewed. rare complete gene knockouts in adult humans p. sulem statistics department, decode genetics, sturlugata , reykjavik, iceland loss-of-function mutations cause many mendelian diseases. here have create a catalog of autosomal genes that are completely knocked out in humans by rare loss-of-function mutations. we sequenced the whole genomes of over , icelanders and imputed the sequence variants identified in this set into a total of chip-genotyped and phased icelanders. of the genotyped icelanders, around % are homozygotes or compound heterozygotes for loss-of-function mutations with a minor allele frequency (maf) below % in close to genes (complete knockouts). genes that are highly expressed in the brain are less often completely knocked out than other genes. homozygous loss-of-function offspring of two heterozygous parents occurred less frequently than expected (deficit of per , transmissions for variants with maf < %, % confidence interval (ci) = - ). we are currently systematically phenotyping such human complete knock out. this phenotyping lasts hours and attempts to cover most of the observable diversity in a non-invasive and cost efficient manner. i will demonstrate how using systematic phenotyping can advance the knowledge on individual gene knockout. we use results from in-house transcriptomics, existing animal models and complementary approaches to assess the observation in human. we will also discuss the scrutiny in other population in order to detect such complete knock-out. we will exemplify the impact of founder population and consanguinity in such an odissey. early onset and severe obesity can be inherited via loss of function mutations within the melanocortin pathway of hypothalamic body weight regulation. the most prominent player in this signalling pathway is the fat cell hormone leptin. leptin gene mutations were the first to be linked to monogenic early onset obesity. after binding of leptin to leptin receptors in the arcuate nucleus of the hypothalamus the neuropeptide msh is processed from the precursor pomc and acts as a ligand at the mc receptor. mutations in the leptin receptor gene, the pomc gene and the mc receptor gene were subsequently diagnosed in further patients with extreme early onset obesity. while leptin mutation patients can be treated with recombinant leptin -as shown already in the late s -all other monogenic obesity forms are leptin resistants, and additional leptin failed to decrease body weight. only recently pomc gene deficient patients were successfully treated with the msh-analogue setmelanotide (kühnen et al. ) . common severe obesity is defined by the lack of disease causing monogenic defects. a plethora of gwas identified a large number of snps in common obesity associated with the individual bmi but only to a low amount of not more then %. however, almost all these common obese patients are characterized by high leptin levels suggesting sufficient generation of leptin in the increased fat tissue and a state of leptin resistance. several new data concerning the contribution of epigenetic and genetic variants in the pomc gene locus argue for a role of the melanocortin pathway also in common obesity and imply, therefore, a potentially new treatment option also in common obesity based on msh-analogues. genome-wide association studies have highlighted the role of genetic associations with susceptibility to common inflammatory diseases, highlighting potential new insights into disease pathogenesis and opportunities for therapy. however understanding the functional basis of these associations and delivering translational utility remains a significant challenge to the field. non-coding regulatory genetic variants are most commonly implicated in such studies. recent work highlights how such variants are also major drivers of diversity in the immune response transcriptome. this talk will discuss approaches we are taking to try and establish functional links between immune phenotype-associated regulatory genomic and epigenomic variation, and specific modulated genes and pathways. i will describe insights from the application of expression quantitative trait (eqtl) mapping to define genomic modulators of the global transcriptomic response in different primary immune cell populations and to specific innate immune stimuli in health and disease. this work highlights the extent of local and distant context-specific eqtl, enabling resolution of immunoregulatory variants and the identification of specific modulated genes involving disease associated loci. examples will be described showing how mapping trans-regulatory loci can be a powerful approach for discovery and dissection of gene networks informative for disease. i will also show how we have applied analysis of the genetics of gene expression in patients with sepsis admitted to intensive care, revealing new insights into disease pathogenesis. further progress in this area will require characterisation of associated variants in the context-specific disease relevant epigenomic landscape in which they may act, requiring careful consideration of relevant immune cell types and environmental modulators to study, to-abstracts aktuellen stellungnahme der deutschen forschungsgemeinschaft sollen humane genomsequenzierungen die möglichkeit der rückmeldung von analyseergebnissen enthalten. als orientierung für einen verantwortungsvollen umgang mit dieser frage wird auf die projektgruppe eurat verwiesen. dennoch bleibt das problem der einordnung mitteilungswürdiger ergebnisse aus forscher-und probandensicht und der bereitstellung der für aufklärungs-und rückmeldungsalgorithmen erforderlichen ressourcen. darüber hinaus ist bis heute nicht geklärt, welche kommunikativen prozesse eine ausreichende basis für ein informiertes einverständnis darstellen. diese und weitere fragen möchten wir mit frau prof. dr. med. dr. phil. eva winkler (nationales centrum für tumorerkrankungen, heidelberg), herrn dr. phil. martin langanke (theologische fakultät, universität greifswald) und herrn pd dr. phil. peter burgard (universitätskinderklinik heidelberg) kontrovers diskutieren. die organisatoren werden in die fragestellung einführen, anschließend sind impulsreferate (ca. min) der referenten vorgesehen, bevor eine debatte mit dem publikum angeregt wird. fangerau, f. söhner (düsseldorf) in den er jahren erlebte die humangenetik wie eine reihe anderer medizinischer disziplinen auch eine erhebliche institutionelle ausweitung. in den er und er jahren wurde beispielsweise an den universitäten der brd das gros der humangenetischen lehrstühle, in den ausgehenden er und er jahren auch in der ddr, eingerichtet. ging vom symposium "genetik und gesellschaft" im rahmen des marburger "forum philippinum" die initiative aus, in der ganzen bundesrepublik genetische beratungsstellen zu gründen und damit die genetische forschung (wieder) medizinisch nutzbar zu machen. in dieser phase der etablierung der humangenetik auf akademischer und praktischer ebene setzt das geplante zeitzeugenprojekt ein. es will die entwicklung der humangenetik in ihrem selbstverständnis als quer-und als längsschnittfach (pfadenhauer : ) im deutschsprachigen raum ab den er jahren mit hilfe von expertengesprächen dokumentieren und analysieren. im forschungsprojekt sollen zwei komplexe von fragestellungen bearbeitet werden: ein wissenschaftshistorischer, in dem die entwicklung und anwendung von diagnostischen und therapeutischen techniken im mittelpunkt steht, und ein sozialhistorischer, in dem es um die etablierung und den ausbau der institutionen der humangenetik sowie um den verlauf der das fach betreffenden gesellschaftlichen debatten geht. neben der gründung von instituten und der fachgesellschaft sowie der normierung der ausbildung für ärztliche und naturwissenschaftlich ausgebildete humangenetiker sollen die funktion der historischen reflexion und bearbeitung der facheigenen nationalsozialistischen vergangenheit in den er jahren für die etablierung des fachs und der schwierige institutionelle trennungsprozess von der anthropologie mit ihren wirkungen auf das selbst-und fremdbild der humangenetik analysiert werden (weingart, kroll, bayertz ) . zusätzlich zur entwicklung in der brd sollen dabei auch die entwicklung des fachs in der ddr und mögliche deutsch-deutsche kooperationen zur sprache kommen (in jena befand sich z. b. in den er jahren das zentrale referenz-institut für genetische beratung in der ddr (vogel : ) . das projekt kann sich auf zahlreiche arbeiten zur geschichte der deutschen humangenetik stützen (vgl. kröner , cottebrune cottebrune , weingart ; bennike dysmorphism carrying a pathogenic variant in the ebf gene detected by whole-exome sequencing. five missense, two nonsense, one -bp duplication, and one splice-site variant in ebf were found; the mutation occurred de novo in eight individuals, and the missense variant c. c>t [p.(arg trp) ] was inherited by two affected siblings from their healthy mother who is a mosaic. ebf belongs to the early b-cell factor family (also known as olf, coe, or o/e) and encodes a transcription factor involved in neuronal differentiation and maturation. structural assessment predicts perturbing effects of the five amino acid substitutions on dna-binding of ebf . transient expression of ebf mutant proteins in hek t cells revealed mislocalization of all but one mutant in the cytoplasm in addition to nuclear localization. by transactivation assays, all ebf mutants showed significantly reduced or no ability to activate transcription of the reporter gene under control of the cdkn a promotor that corresponds well with loose association of ebf mutants with chromatin as demonstrated by in situ subcellular fractionation experiments. finally, rna-seq and chip-seq experiments demonstrate that ebf acts as a transcriptional regulator at cis-regulatory sequences and ebf mutant had reduced function due to partial disruption of the dna-binding domain. these findings demonstrate that ebf -mediated dysregulation of gene expression has profound effects on neuronal development in humans and add ebf to the growing list of genes in which mutations cause syndromic forms of intellectual disability. step, we performed wes in further unelucidated uhs cases and identified homozygous nonsense mutations in tgm (transglutaminase ) and in tchh (trichohyalin), respectively. elucidation of the molecular outcomes of the disease causing mutations by cell culture experiments of padi and tgm and tridimensional protein models demonstrated clear differences in the structural organization and activity of mutant and wild type proteins. by immunofluorescence analysis, we could demonstrate a diffuse homogenous cytoplasmic distribution of the wt padi , whereas in the mutants the proteins were observed to form large aggregates throughout the cytoplasm. by use of human anti-citrullinated protein autoantibodies, we could show a strong labelling in the wt whereas the staining of the mutants was barely above background. in order to demonstrate the importance of padi in hair shaft formation, we generated padi knockout mice. electron microscopy observations revealed morphological alterations in hair coat of padi knockout mice. for tgm , we performed a transglutaminase activity assay. the analysis results revealed that the wt had a significantly higher transglutaminase activity in comparison to the truncated protein. here, we report for the first time the identification of uhs causative mutations located in the three genes padi , tgm and tchh. the two enzymes responsible for posttranslational protein modifications, and their target structural protein, are all involved in hair shaft formation through their sequential interactions. these findings provide valuable information regarding the pathophysiology of uhs and contribute to a better understanding of this protein interaction cascade. this could be of further value for cosmetics and pharmaceutics industries paving the way for development of novel products. deadenylases are best known for degrading the poly(a) tail during mrna decay. the deadenylase family has expanded throughout evolution and, in mammals, consists of mg + -dependent ' end ribonucleases with mostly unknown substrate specificity. pontocerebellar hypoplasia type (pch ) is a unique recessive syndrome characterized by neurodegeneration with ambiguous genitalia (mim% ). we studied human families with pch , uncovering biallelic, loss of function mutations in toe , which encodes an unconventional deadenylase. toe -morphant zebrafish displayed mid-and hind-brain degeneration, modeling pch-like structural defects in vivo. surprisingly, we found toe associated with incompletely processed small nuclear (sn)rnas of the spliceosome, which is responsible for pre-mrna splicing. these pre-snrnas contained ' genome-encoded tails often followed by post-transcriptionally added adenosines. human cells with reduced levels of toe accumulated ' end-extended pre-snr-nas, and immuno-isolated toe complex was sufficient for ' end maturation of snrnas. our findings reveal the cause of a neurodegenerative syndrome linked to snrna maturation and uncover a key factor involved in processing of snrna ' ends. the kidney maintains acid-base homeostasis and electrolyte balance through highly specialized cells. in the distal nephron acid secretion is mediated by type a intercalated cells (a-ics) , which contain v-type at-pase-rich vesicles that fuse with the apical plasma membrane on demand. intracellular bicarbonate generated by luminal h+ secretion is removed by the basolateral anion-exchanger ae . dysfunction of type a intercalated cells results in distal renal tubular acidosis (drta) and human mutations in v-atpase subunits and ae are causative for this condition. for the ae r h mutation a dominant-negative trafficking mechanism was proposed to explain ae -associated dominant drta based on studies in mdck monolayers. to test this hypothesis in vivo and to test potential rescue strategies correcting this mistargeting defect, we have generated a r h knock-in mouse strain, which corresponds to the most common dominant drta mutation in human ae , r h. heterozygous and homozygous r h knock-in mice displayed incomplete drta characterized by compensatory upregulation of the na+/hco -cotransporter, nbcn . as expected for the r h mutation, red blood cell ae -mediated anion-exchange activity and surface polypeptide expression were unchanged. surprisingly, basolateral targeting of the mutant ae in a-ics was preserved in contrast to previous studies in mdck cells. instead, we found ae expression in a-ics strongly reduced in a r h dosage-dependent manner. additional cell culture studies in two widely used immortalized renal cell lines verified that targeting and half-life time of mutant ae protein was indeed preserved. surprisingly, atpase expression was reduced and its plasma membrane targeting upon acid challenge compromised. ultrastructural analysis revealed a loss of apical vesicles in a-ics, while we observed lysosomal inclusions and multilamellar bodies. accumulation of p -and ubiquitin-positive material in a-ics of knock-in mice suggest a defect in the degradative pathway, which may ultimately lead to loss of a-ics. highlighting the expression of ae specifically in a-ics, type b intercalated cells were unaffected. we propose that reduced basolateral anion-exchange activity in a-ics inhibits trafficking and regulation of v-type atpase, compromising luminal h+ secretion and possibly also lysosomal acidification. our findings illustrate the considerable, context-dependent complexity of ae -related kidney disease. b. vona , d. liedtke , k. rak , , r. katana , l. jürgens , pr. senthilan , i. nanda , c. neuner , mah. hofrichter , l. schnapp , j. schröder , u. zechner , s. herms , , , p. hoffmann , t. müller , m. dittrich , , o. bartsch , pm. krawitz , e. klopocki , w. shehata-dieler , mc. göpfert , t. haaf although many genes have already been identified as causing non-syndromic hearing loss (nshl), diagnostic rates of approximately % among hearing impaired patients suggest that many more genes are remaining to be identified. nshl is the most common sensory deficit that has a prevalence between one and two per newborns. furthermore, it demonstrates classic genetic heterogeneity with as many as % of coding genes in the genome anticipated to be involved in non-syndromic forms of deafness. autosomal recessive ( - %) and autosomal dominant ( - %) forms dominate inheritance patterns of deafness; however, in a small fraction of cases, x-linked deafness ( - %) can be observed. whole exome sequencing of a german family with diagnostically unresolved nshl revealed a novel missense variant predicted as pathogenic in the gene ferm and pdz domains containing protein (frmpd ) on chromosome xp . . this gene, also known as preso , was first described as a regulator of dendritic spine morphogenesis. previous screening of pathogenic cnvs in array based comparative genomic hybridization among families with heterogeneous x-linked intellectual disability (xlid) showed duplication of xp . including part of frmpd which implicated the gene in xlid. interestingly, a segregating truncating and a de novo missense mutation in frmpd have associated this gene with xlid, a phenotype not observed in our family. mouse expression studies localize frmpd to spiral ganglion neuron peripheral dendrites of the developing cochlea. in addition, we analyzed frm-pd knockdown and loss-of-function zebrafish mutants for innervation and structural defects in the otic vesicle and lateral line neuromasts. posterior lateral line neuromasts are observed with reduced axonal outgrowth that is also likely reduced in the lateral line nerve. abnormal innervation is also apparent in the otic vesicle. fluorescent neuromast labeling marked a significant reduction of overall otic vesicle and lateral line neuromasts in mutants versus wild type zebrafish. scanning electron microscopy revealed a pronounced absence of kinocilia in posterior lateral line neuromasts of frmpd -/zebrafish. furthermore, adult frmpd mutants show significantly delayed acoustically evoked behavioural responses compared to wild type fish indicating hearing impairment. investigation of transgenic drosophila insertion mutants detected a mild auditory phenotype i. e. a reduction in mechanical amplification gain and associated reduction in antennal fluctuation power. our results associate frmpd with x-linked hearing loss and suggest mutations in this gene are correlated with pleiotropic effects abstracts has also been demonstrated to be an important pathobiochemical feature in rtt. to test whether common deficits in mtor signaling could be responsible for the molecular pathogenesis underlying both syndromes, we generated and studied a novel cdkl knockout (cdkl -/y) mouse model and performed in vitro experiments in human cells. in cdkl -/y knockout mice loss of cdkl is accompanied by reduced phosphorylation levels of critical components of the mtor signaling cascade. these findings point at a regulatory role of cdkl /cdkl on mtor activity and function. to gain further insights into the possible mechanism through which cdkl /pi k interaction could regulate mtor signaling, we used hek-t cells as cellular model. following knock-down of cdkl , the amount of pi k protein was significantly reduced compared to controls. to evaluate the contribution of our findings to pathogenesis, we performed rescue experiments in cdkl knock-down hek-t cells using wild-type and patient-specific mutant cdkl constructs. further experiments are ongoing to clarify the molecular mechanism by which cdkl regulates pi k protein level in the cells. inferring expressed genes by whole-genome sequencing of plasma dna medical university graz, graz, austria, university of technology, graz, austria the analysis of cell-free dna (cfdna) in plasma represents a rapidly advancing field in medicine. cfdna consists predominantly of nucleosome-protected dna shed into the bloodstream by cells undergoing apoptosis. we performed whole-genome sequencing of plasma dna and identified two discrete regions at transcription start sites (tsss) where nucleosome occupancy results in different read depth coverage patterns for expressed and silent genes. by employing machine learning for gene classification, we found that the plasma dna read depth patterns from healthy donors reflected the expression signature of hematopoietic cells. in patients with cancer having metastatic disease, we were able to classify expressed cancer driver genes in regions with somatic copy number gains with high accuracy. we were able to determine the expressed isoform of genes with several tsss, as confirmed by rna-seq analysis of the matching primary tumor. our analyses provide functional information about cells releasing their dna into the circulation. institute of human genetics, fau-erlangen-nürnberg, erlangen, germany, institute of medical genetics, university of zurich, schlieren, switzerland rna-splicing is an important mechanism for eukaryotic gene expression and regulation. defective splicing significantly contributes to monogenic disease in humans. indeed, the mutational space for variants affecting splicing is larger than for coding variants. several computational methods have been developed to predict a variant's effect on splicing but lack predictive value outside the canonical splice sites and do not predict aberrant transcripts. thus the plethora of dna variants generated by recent advances in "next-generation" based sequencing (ngs) can be scored for a possible splicing effect, but a laborious wet-lab based confirmation and characterization is still required. rna-seq is widely used for quantification of gene expression and can be used to detect splicing events, but is limited for this use by the variable and often low read coverage of individual congenital anomalies of the kidneys and urinary tract (cakut) are the most common cause of chronic kidney disease in children. as cakut is a genetically heterogeneous disorder and most cases are genetically unexplained, we aimed to identify new cakut causing genes. using whole-exome sequencing and trio-based de novo analysis, we identified a novel heterozygous de novo frameshift variant in the leukemia inhibitory factor receptor (lifr) gene causing instability of the mrna in a patient presenting with bilateral cakut and requiring kidney transplantation at one year of age. lifr encodes a transmembrane receptor utilized by il- family cytokines, mainly by the leukemia inhibitory factor (lif). mutational analysis of further patients with severe cakut yielded two rare heterozygous lifr missense variants predicted to be pathogenic in three unrelated patients. lifr mutants showed decreased half-life and cell membrane localization resulting in reduced lif-stimulated stat phosphorylation. lifr showed high expression in human fetal kidney and the human ureter, and was also expressed in the developing murine urogenital system. lifr knockout mice displayed urinary tract malformations including hydronephrosis, hydroureter, ureter ectopia, and, consistently, reduced ureteral lumen and muscular hypertrophy, similar to the phenotypes observed in patients carrying lifr variants. additionally, a form of cryptorchidism was detected in all lifr -/mice and the patient carrying the lifr frameshift mutation. altogether, we demonstrate heterozygous novel or rare lifr mutations in . % of cakut patients, and provide evidence that lifr deficiency and deactivating lifr mutations cause highly similar anomalies of the urogenital tract in mice and humans. loss of cdkl associated with deficient mammalian target of rapamycin (mtor) signaling in mice and human cells we and other groups have shown that mutations in the x-linked cyclin-dependent kinase-like (cdkl ) gene cause a severe neurodevelopmental disorder with clinical features including intellectual disability, early-onset intractable seizures and autism, that are closely related to those present in rett syndrome (rtt) patients. rtt is caused by mutations in the x-linked mecp gene. cdkl is a serine/threonine kinase and to date knowledge about its functional roles is scarce. we searched for cdkl interacting proteins by yeast-two hybrid screens. one of the candidates identified in these screens is a subunit of the phosphatidylinositol- , -biphosphate -kinase (pi k). the results obtained in yeast could be confirmed in vitro in mammalian cells and in mouse brain by immunoprecipitation experiments and by co-localization studies. pi k phosphorylates membrane lipids which act as docking sites to recruit targets upstream of mtor and thereby regulate among major cellular processes synaptic plasticity, which is the cellular basis for learning and memory. alteration of mtor signaling gene tubes for stabilizing rna immediately after drawing the samples. the subsequent rt-pcr analysis showed that of the variants located at potential splicing sites indeed affect splicing. thus of these variants could be classified as deleterious (iarc class ), while one chek variant could not be unequivocally classified as the rt-pcr analysis identified only % of the mutant transcript indicating continued usage of the constitutive splice acceptor site. this led to the classification as a probably hypomorphic allele. the variants in cdh and mlh did not affect splicing and were classified as benign (iarc class ). none of the rare synonymous and nonsynonymous exonic variants showed any effect on splicing. in conclusion, this analysis allowed the disambiguation of out vus at potential splice sites into a definite category (either iarc class or ). this work highlights the importance of computational splicing prediction and validation using rt-pcr of peripheral blood rna to assess the pathogenicity of vus. this in turn, allows more accurate genetic counseling and clinical management of affected families. gliomas present the major group of neoplasia in the central nervous system. they typically show invasive growth and high recurrence rate and are currently not curable. idh mutations are detected in nearly % of low grade gliomas and are considered to play a key role in low grade glioma development. while it is known that idh / mutation leads to high-levels of -hydroxyglutarate ( -hg) that functions as an oncometabolite, little is known about the influence of idh / mutations on energy metabolism and metabolic reprogramming in the tumor cells. since patient derived idh mutant cells do not grow in cell culture, previous studies from our group and others used transduced cell lines that overexpress idh . in order to develop in vitro models with reduced side effects, we used crispr/ cas to introduce the idh r h mutation in a patient derived glioblastoma cell line. the edited cells expressed idh r h in western blot and expression levels of idh were comparable to the expression in wild type cells. the mutation was stable in long time culture experiments, without signs of senescence. moreover we found elevated -hg levels, proving that the idh r h neoenzymatic function is present in our cell lines. thus, we were able to edit and culture genomic idh r h mutated glioma cells for the functional analysis of the idh r h mutation for the first time without the effects of overexpression models. edited idh r h cell lines showed extended doubling times compared to wildtype cells. measurement of krebs cycle metabolites using mass spectrometry revealed elevated glutamate levels. we found enhanced atp-levels that could be a consequence of decreased atp consumption. additionally, the cells showed reduced viability compared to wildtype cells when cultivated in glycolysis inhibiting media, pointing out the enhanced dependency on glycolysis in idh r h cells. these results indicate changes in tumor cell metabolism and energy household induced by the idh r h mutation. since we and others could show that idh r h can alter nad+ and nadph levels, we tested if the idh r h mutated cells are more susceptible to selective inhibition of nad/p regenerating enzymes. esirna-silencing of nampt specifically decreased cell viability in idh r h but not wildtype cells with a concomitant increase of dead cells. in conclusion, we developed genes. thus, a standardized ngs based approach to characterize potential splice variants is lacking. hence we investigated the utility of hybridization based gene-panel enrichment and ngs of cdna. based on results of computational simulation we selected twenty rna-samples of patients with a known pathogenic splice-site variant in an inherited cancer predisposition gene. these variants were previously characterized by rt-pcr in our lab or in the literature. after rrna depletion and dna digestion we performed first and second strand cdna synthesis followed by "tagmentation"-based library preparation, targeted enrichment using the trusight cancer panel and sequencing on an illumina miseq platform. a computational pipeline was established to enable automated detection of aberrant splicing events by implementing different alignment and splice-junction detection algorithms together with filtering against control data sets. we also considered variant calling for the detection of allelic imbalance and gene-level expression analysis in this data. breast and ovarian cancer (bc/oc) predisposition has been associated with a number of high-and low-penetrance susceptibility genes. advances in sequencing technology has made multigene testing a practical option when searching for genetic variants associated with risk for bc/oc. variants of uncertain significance (vus), though, represent a major problem. we now studied patients fulfilling criteria for brca and testing using the next generation sequencing based trusight sequencing cancer panel on a miseq platform (illumina). data was analyzed after remapping with bwa to hg (grch ) using seqnext software (jsi) for variants in known high and moderate penetrance susceptibility genes (brca / , atm, chek , palb , rad c, rad d, nbn, cdh , tp , mlh , msh , msh , pms ) . besides deleterious mutations we also identified vus. of these, variants ( each in brca , brca , palb , rad c, rad d, cdh , and mlh , and in chek and mlh , respectively) affect possible splicing sites. in addition, synonymous and nonsynonymous variants outside the splicing sites ( in brca , brca and cdh , respectively, in rad d) were not reported in exome variant server or exome aggregation consortium (exac) databases, so far. no families were available to study familial segregation. for all these variants a potential effect on splicing efficiency was predicted by three different computational algorithms (bdgp: splice site prediction by neural network, netgene server and the human splice finder (hsf . ) algorithm). we took advantage that these genes are ubiquitously expressed to investigate possible effects of these variants on mrna splicing using easily accessible peripheral blood. as mrna is notoriously unstable, we used pax-abstracts was evaluated for both the individual markers and their combinations derived from multiple algorithms. pronounced demethylation of all markers was observed at baseline among cases compared to controls. risk of developing lc increased with decreasing dna methylation levels, with adjusted ors ( % ci) of . ( . - . ), . ( . - . ) , and . ( . - . ), respectively, for participants in the lowest quartile of ahrr, p . , and f rl compared to participants in the highest quartiles of each site among controls. the individual markers exhibited similar accuracy in predicting lc incidence, with aucs ranging from . to . . combination of the markers did not improve the predictive performance (auc = . ). the individual markers or their combination outperformed self-reported smoking exposure particularly in light smokers. no variation in risk prediction was identified with respect to age, follow-up time, and histological subtypes. ahrr, p . , and f rl methylation in blood dna are predictive of lc development, which might be useful for identification of risk groups for further specific lc screening, such as ct examination. over the past decades the search for disease causing variants has been focusing exclusively on the coding genome. this highly selective approach has been extremely successful however, recent data have revealed the importance of the non-coding genome in fundamental processes such as gene regulation, d chromatin folding, and pinpointed its role in disease. in this study, we systematically investigate the cis-regulatory landscape of pitx , a homeodomain transcription factor that is exclusively expressed in the hindlimb. mutations and non-coding structural variations at the pitx locus have been shown to associate with a variety of congenital limb defects including club feet, polydactyly, and arm-to-leg transformation (liebenberg syndrome). we performed in vivo enhancer reporter essays in transgenic mice and identified several limb enhancer elements at the pitx locus; surprisingly they all showed both forelimb and hindlimb activity, although pitx is never expressed in the forelimb. capture hi-c experiments revealed a hindlimb-specific chromatin-organization at the pitx locus, which enables its promoter to contact several enhancers bearing a pan-limb activity only in the hindlimb. this tissue-specific chromatin folding plays a determinant role to refine the unspecific limb regulatory landscape toward a highly controlled and hindlimb delimited transcriptional output. to gain a better understanding of the pathology of pitx associated limb defects, we used crispr/cas to generate a set of deletions and inversions in the pitx cis-regulatory landscape in mice. genetic perturbations of the regulated d chromatin conformation lead to an ectopic forelimb expression of pitx , resulting in an arm-to-leg transformation in mice and in human patients respectively. our data further highlight the role of non-coding mutations affecting chromatin folding in congenital disease and give new insights into the regulation of pitx during development and the pathomechanism of associated limb defects. hoxb , a member of the embryonic homeobox transcription regulators, has been identified as the first susceptibility gene specific for prostate cancer (prca). the founder missense mutation g e, which likely originated from finland, can be found in most populations of european ancestry. we determined the frequency of hoxb g e for the german population, assessed in a cohort of unrelated cases, each with positive family history of prca, sporadic prca cases and in controls. additional affected relatives from prca families were included to explore association with aggressive disease in subgroups with high gleason score (> ), advanced tumor stage, or psa at diagnosis > ng/ml. carriers of g e were rare in controls ( . %) and showed increased frequencies in both sporadic ( . %) and familial prca cases ( . %). estimated risks were or = . (p = . ) and or = . (p = . ), respectively. the risk effect size increased with the number of affected individuals per pedigree: or = . (p < . ) for or more, and or = . (p < . ) for or more affected men. the strongest association with clinical features was observed between g e and advanced tumor stage (or = . ; p < . ). in conclusion, the observed frequency of hoxb g e mutation carriers in our study cohort was intermediate as compared to the common prevalence in scandinavia and the rare occurrence in mixed european populations from the us. the risk estimates of hoxb g e and the stronger effect sizes in families with increasing number of affected relatives were in line with a high penetrant germline predisposition. the association between g e status and tumor stage may be of greater interest for clinical practice, but needs further validation. the absolute penetrance of the hoxb g e mutation should be investigated in further studies in order to elucidate its suitability as a genetic predictor for prca. smoking-associated dna methylation markers predict lung cancer incidence homozygous smn loss causes spinal muscular atrophy (sma), the most common lethal genetic childhood motor neuron disease. smn encodes smn, a ubiquitously expressed housekeeping protein, which makes the primarily motor neuron-specific phenotype rather unexpected. sma individuals harbor low smn expression from one to six smn copy genes, which is insufficient to functionally compensate for smn loss. however, rarely individuals with homozygous absence of smn and only three to four smn copies are fully asymptomatic, suggesting protection through genetic modifier(s). previously, we identified plastin (pls ) overexpression as an sma protective modifier in humans and showed that smn deficit impairs endocytosis, which is rescued by pls overexpression. here, we identify reduction of the neuronal calcium sensor neurocalcin delta (ncald) as a protective sma modifier in five asymptomatic smn -deleted individuals carrying only four smn copies. we demonstrate that ncald is a ca + -dependent negative regulator of endocytosis, as ncald knockdown improves endocytosis in sma models and ameliorates pharmacologically induced endocytosis defects in zebrafish. importantly, ncald knockdown effectively ameliorates sma-associated pathological defects across species, including worm, zebrafish and mouse. in conclusion, our study identifies a previously unknown protective sma modifier in humans, demonstrates modifier impact in three different sma animal models and suggests a potential combinatorial therapeutic strategy to efficiently treat sma. since both protective modifiers restore endocytosis, our results confirm that endocytosis is a major cellular mechanism perturbed in sma and emphasize the power of protective modifiers for understanding disease mechanism and developing therapies. mutations affecting coding or regulatory regions of smc cause dysregulation of condensins resulting in a phenotype reminiscent of cohesinopathies cornelia de lange syndrome (cdls) is a dominantly inherited malformation syndrome caused by mutations in genes encoding subunits (smc a, smc , rad ) or regulators (nipbl, hdac ) of the cohesin complex. this dna-bound complex regulates several chromatin-related processes such as chromosome segregation, dna-damage repair, transcription and chromatin structure. the project presented initially started with two children and their mother who showed clinical features reminiscent of cdls. while various sequencing approaches failed to identify the disease-causing mutation, a kb spanning deletion co-segregating with the phenotype was identified by array-cgh. besides the last exons of cylc , encoding a sperm head protein, no other genes were affected. subsequent in-silico analyses predicted the existence of a ~ kb tissue-specific regulatory element within this region, located approximately mb distant from the next protein-coding gene smc , which encodes a subunit of the cohesin-related condensin complex. significant reduction of smc expression was verified in patient's fibroblasts by qpcr analysis. accordingly, a strong dysregulation of smc was observed in hek and sh-sy y cells deficient for the putative kb regulatory element, which was deleted by crispr/cas genome editing. reporter gene assays further highlighted the functional relevance of the identified regulatory element in regulating the smc gene promoter. interestingly, we could prove on protein as well as on mrna level that alterations in smc expression are correlated with the dysregulation of other condensin subunits such as smc in patient's samples as well as in cris-pr/cas -generated cells. in a large exome sequencing project we have identified a smc frameshift mutation in an additional family with two patients who show clinical features overlapping with those seen in our initial family. quantitative pcr analyses in fibroblasts of both subjects also showed significant reduction of smc and smc expression, which is consistent with our findings in the first family. to further investigate whether alterations in condensin gene expression are specific for the dysregulation of smc , we have decreased smc levels in different cell types by sirna. quantitative protein as well as mrna analyses revealed reduced smc /smc expression. our data show for the first time the coordinated expression of different condensin subunits and its relevance for human disease. abstracts human pedigree. cardiac valves initially form through a process called endothelial-to-mesenchymal transition (emt) then subsequently elongate and mature during early juvenile life. expression analysis throughout embryonic and postnatal stages of adamts -/-mice revealed an expression in all cardiac valves after valve formation. high resolution, digital echocardiography showed that mice without adamts expression develop dysfunctional aortic valves early in life, reminiscent of the human phenotype. notably, the expression of adamts in the valve was restricted to valvular interstitial cells and not observed in endothelial cells. functional analysis using proteomic approaches suggest that the presence of ad-amts is necessary to maintain extracellular matrix remodelling during valve development and its maturation. not only do the lof mice fully recapitulate the human phenotype, they also highlight adamts as a novel marker for valvular interstitial cells to specifically target initial post-emt processes as well as serve as an important model to understand an ageing valve phenotype in humans. exome sequencing of bipolar disorder patients with rapid cycling implicates novel candidate genes in disease development bipolar disorder (bd) is a severe neuropsychiatric disorder characterized by recurrent episodes of mania and depression. bd has a lifetime prevalence of about % and a high heritability of about %. although recent genome-wide association studies identified the first susceptibility genes contributing to disease development, the cumulative impact of common alleles with small effect may only explain around % of the phenotypic variance (lee et al. ) . in consequence, rare variants of high penetrance have been suggested to additionally contribute to bd susceptibility. in the present study we focused on bd patients with rapid cycling (rc). rc is a course specifier of bd defined as having at least four recurrent episodes of acute illness within one year. since rc showed strong evidence for familiarity, we hypothesized that bd patients with rc might represent a more defined etiological subgroup and that rare variants of high penetrance might contribute to the development of rc in bd patients. we selected unrelated bd patients with rc of german origin and performed exome sequencing using the illumina hiseq platform. for data analysis, the varbank pipeline of the cologne center for genomics was used. we filtered for rare (minor allele frequency < . %), heterozygous and non-synonymous variants that were predicted to be possibly damaging or disease causing by at least of applied prediction tools. after these filtering steps, we identified a total of different genes which harbored rare functional variants in at least three independent patients. gene set analysis for these genes using consensuspathdb revealed decker , g. nuernberg , , d. hassel , g. a. rappold , mutations in the homeobox gene shox cause shox deficiency, the most frequent monogenic cause of short stature. the clinical severity of shox deficiency varies widely, ranging from short stature without dysmorphic signs to mesomelic skeletal dysplasia (léri-weill dyschondrosteosis, lwd). in rare cases, individuals with shox deficiency are asymptomatic. to elucidate the factors that modify disease severity/penetrance, we studied a three-generation family with five affected individuals with lwd using whole genome linkage analysis and whole exome sequencing. the variant p.phe cys of the retinoic acid catabolizing enzyme cyp c co-segregated with the shox variant p.val ala in the five affected individuals, while the shox mutant alone was present in three asymptomatic individuals. two further independent lwd cases with shox deficiency and damaging cyp c variants were identified. the identified damaging variants in cyp c affected its catabolic activity, leading to an increased level of retinoic acid. we also provide evidence that high levels of retinoic acid significantly decrease shox expression in human primary chondrocytes and zebrafish embryos. individual morpholino knock-down of either gene shortens the pectoral fins, whereas depletion of both genes leads to a more severe phenotype. together our findings demonstrate that shox and cyp c act in a common molecular pathway controlling limb growth and describe cyp c as the first genetic modifier for shox deficiency. heart valve dysfunction in men and mice is caused by loss of function mutations in adamts , a novel marker for valvular interstitial cells on a global perspective defects of the cardiac valves are one of the most common heart abnormalities in humans, with a substantial number of them requiring surgical intervention at least once in their life. several mechanisms have been proposed ranging from acquired to developmental causes, but thus far the majority can not be explained on the molecular level. here we report on the identification of a unique human family affected by multiple dysfunctional cardiac valves early in life. genetic screening revealed a homozygous deletion of the first eight exons in ad-amts , a novel candidate gene for valvular heart defects. to investigate its role in heart valve development, we designed a transgenic mouse model that reconstitutes the loss of function (lof) in adamts found in the statistically analyzing de novo mutations identified in > , id patients highlighted ppm d as a candidate id gene. ppm d is a type c phosphatase that functions as a negative regulator of cell stress response pathways by mediating a feedback loop of p -p signaling, thereby contributing to growth inhibition and suppression of stress induced apoptosis. we identified patients with mild-moderate id and a de novo truncating ppm d mutation. deep-phenotyping of the patients revealed in addition to id overlap for behavioural problems (adhd and anxiety disorder), hypotonia, broad based gait, facial dysmorphisms and periods of fever and vomiting. ppm d is shown to be expressed during fetal (brain) development and in the adult brain. all mutations were located in the last, or penultimate exon, suggestive of escaping nonsense-mediated mrna decay. both ppm d expression analysis and cdna sequencing in patient ebv-lcls support the presence of a stable, but truncated transcript, consistent with this hypothesis. exposure of patient's cells to ionizing radiation resulted in normal p activation suggesting that p signaling is not affected by the truncated protein. however, a cell growth disadvantage was observed. thus, we show that de novo truncating ppm d mutations in the last and penultimate exon cause syndromic id which provides novel insights in the role of cell cycle checkpoint genes in neurodevelopmental disorders. de novo truncating variants in asxl are associated with a unique and recognizable clinical phenotype harvard stem cell institute, department of stem cell and regenerative enriched pathways (q < . ) including actin cytoskeleton and calcium ion binding. subsequently we applied the residual variation intolerance score (rvis) and identified genes which were ranked among the % most intolerant genes in the genome. these genes included the previously reported genome-wide significant bd risk genes syne and mll . in addition, we identified novel, promising candidate genes which have not previously been implicated in bd development such as ryanodine receptor (ryr , affected in six patients) and huntingtin (htt, patients). both genes are ranked among the . % most intolerant genes of the genome. ryr encodes a brain expressed intracellular cation channel that mediates the rapid release of ca + from the endoplasmic reticulum, thus making it a highly plausible candidate gene for contributing to rc. abnormal expansion of a trinucleotide repeat in the htt gene causes huntington disease which is a neurodegenerative disease characterized by motor, cognitive and psychiatric symptoms. the seven most promising genes are currently being followed up by resequencing in larger cohorts of independent bd cases (including patients with rc) and controls of european ancestry using the single molecule molecular inversion probes (smmips) technology. de novo truncating mutations in the last and penultimate exon of ppm d cause a novel intellectual disability syndrome abstracts with gα. signaling properties of g protein complexes carrying mutant gβ subunits were further analyzed by their ability to couple to dopamine d r receptors by real-time bioluminescence resonance energy transfer (bret) assays. these studies revealed altered functionality of the missense mutations r g, g v, a t, p s, p l, a t, and d g but not for l f, h r, and k q. in conclusion, we demonstrate a pathogenic role of de novo and autosomal dominant mutations in gnb as a cause of gdd and provide functional evidence for a loss-of-function mechanism underlying the disease. comprehensive phenotyping and trio-exome analysis of children with neurodevelopmental disease whole exome sequencing (wes) has been proven as a powerful analytical tool to dissect the genetic basis of human hereditary disorders. here, we report on a prospective deep phenotyping and trio-wes study of children affected by previously undiagnosed and diverse complex neuropediatric disorders. all children underwent a standardised and comprehensive clinical work-up in a single centre that included detailed clinical evaluations by pediatricians and clinical geneticists, extensive laboratory and metabolic analyses, analyses of cerebrospinal fluid, mri of the brain and eeg, followed by trio-wes analysis. this systematic approach allowed to identify a pathogenic mutation in a known disease gene in altogether children ( %) and discovered a convincing candidate disease gene in additional children ( %). taken together, this translates into a successful genetic diagnosis of up to % in this cohort. in children with mutations in a known disease gene ( / = . %) the molecular diagnosis substantially influenced the clinical management and drug treatment. we further document an expansion of the phenotype in known disease entities in individuals. the extraordinary high gene discovery rate in our cohort emphasizes the potential of trio-wes even in a clinically inhomogeneous group of individuals with likely genetic disease. however, this requires a multidisciplinary approach including deep and sometimes reverse phenotyping, research-based interpretation of trio-wes identified genetic alterations, extensive review of the literature, use of several mutation prediction and protein-modelling tools, as well as openness and exchange of data with national and international researchers and clinicians working on similar diseases. exome sequencing of pooled dna samples for large-scale screening in individuals with sporadic intellectual disability b. popp, a. ekici, s. uebe, c. thiel, j. hoyer, a. wiesener, a. reis, c. zweier institute of human genetics, fau-erlangen-nürnberg, erlangen, germany high throughput sequencing has enabled identification of many novel disease genes and empowered diagnostic testing for heterogeneous disorders, especially for intellectual disability (id) where more than genes have been implicated. due to this extreme heterogeneity gene panels are ineffective, and expensive exome or genome sequencing is necessary. furthermore, many affected individuals have to be sequenced to confirm candidate genes and to refine the phenotypic spectrum. we now explored if pooling strategies could satisfy the need for a genome-wide, simple, cheap and fast screening technology. the asxl genes (asxl , asxl and asxl ) participate in body patterning during embryogenesis and encode for proteins that are involved in epigenetic regulation and assembly of transcription factors to specific genomic loci. germline de novo truncating variants in asxl and asxl have been respectively implicated in causing bohring-opitz and bainbridge-ropers syndromes, resulting in overlapping features of severe intellectual disability and dysmorphic features. to our knowledge, asxl has not yet been associated with a human mendelian disorder. in this study, we performed whole-exome sequencing in six unrelated probands with developmental delay, macrocephaly, and dysmorphic features. all six had de novo truncating variants in asxl . a careful review en abled the recognition of a specific phenotype consisting of macrocephaly, prominent eyes, arched eyebrows, hypertelorism, a glabellar nevus flammeus, neonatal feeding difficulties, hypotonia and developmental disabilities. although overlapping features with bohring-opitz syndrome and bainbridge-ropers syndromes exist, features that distinguish the asxl -associated condition from asxl -and asxl -related disorders are macrocephaly, absence of growth retardation and more variability in the degree of intellectual disabilities. we were also able to demonstrate with mrna studies that these variants are likely to exert a dominant negative effect, since both alleles are expressed in blood, with the mutated asxl transcripts escaping nonsense mediated decay. in conclusion, de novo truncating variants in asxl underlie a new neurodevelopmental syndrome, with a clinically recognizable phenotype. this work expands the germline disorders that are linked to the asxl genes. functional characterization of novel gnb mutations as a rare cause of global developmental delay over the past years, prioritization strategies that combined the molecular predictors of sequence variants from exomes and genomes of patients with rare mendelian disorders with computer-readable phenotype information became a highly effective method for detecting disease-causing mutations. the drawback of phenotype-based prioritization, however, is that they require a deep and comprehensive feature description to gain good performance. but in routine diagnostics, the naming of phenotypic features varies among clinicians, and sometimes a comprehensive phenotypic overview is not possible because of missing terminology. these gaps can be reduced by including a new layer of phenotypic information using facial recognition technology to detect dysmorphic features from two-dimensional photographs. automated image analysis is in principle able to identify any deviation from the norm and to quantify it objectively. we therefore developed an approach that combines facial dysmorphology novel analysis (fdna) technology with standard phenotypic and genomic features to identify pathogenic mutations in exome data. we have started collecting data from a diverse spectrum of patients with molecularly confirmed diagnoses in a multi-center study, and we present the current results. at the time of abstract submission more than patients from over contributing institutions were evaluated and used for simulation of a training set of exomes. automated facial recognition yields the correct diagnosis amongst the first ten suggested syndromes in more than two thirds of the cases and shows a high correlation with syndrome predictions that were based on expert annotated features. hereby, we could also confirm the diagnosis in cases with only subtle facial features. consequently, we used classical machine learning approaches to integrate scores based on the image analysis, phenotypic description and exome se-after initial evaluation of available computational methods by virtual pooling of exome data or simulated reads using different pooling fractions, we decided to exome sequence individuals with sporadic id in pools of samples each. this was suggested to be the optimal combination with a % detection rate. dna was mixed in equimolar concentrations and submitted for exome sequencing. read data was aligned to the human reference, and variants were called using a ploidy of . resulting variant calls in known id genes (sysid database) were then filtered for loss-of-function (lof) variants and for missense variants that were either previously reported as pathogenic or computationally predicted to be deleterious. furthermore, we screened id candidate genes and haploinsufficiency intolerant genes for lof variants. subsequently, sanger sequencing was used to determine the individual carrying each variant in the respective pool and to test segregation in the parents. this approach resulted in the identification of pathogenic variants (assumed or confirmed de novo) in known id genes (ahdc , ankrd , atp v b , cask, chd , kcnq , kmt a, kras, med l, rit , setd , tcf , wac, zbtb ), two pathogenic variants inherited from a symptomatic or healthy parent, respectively, (zmynd , ifih ), and a homozygous variant in the recessive trappc gene. this included loss-of-function and missense variants. additionally, we identified de novo variants in candidate genes. in our id cohort this resulted in a high mutation detection rate of %. thus, detection of rare variants from exome sequenced dna pools (pool-seq) is feasible and has a high detection rate similar other screening approaches. compared to affected-only exome sequencing this method can reduce costs by more than % with only marginal increase in sanger-sequencing costs and significantly speed up wet lab work with an acceptable increase in computational complexity. in contrast to targeted sequencing methods like molecular inversion probes or hybridization-based panels, our method has the advantage of allowing flexible re-analysis of the same data for new genes. in conclusion, we established exome pool-seq as a method for large-scale, cost-efficient and flexible sequencing in highly heterogeneous but well characterized disorders like id. three years of experience with targeted next-generation sequencing of developmental delay next-generation sequencing (ngs) has opened up new possibilities especially in the search for disease-causing mutations in disorders with common clinical features but a heterogeneous genetic background. the identification of the underlying genetic defect provides a clear diagnosis for patients more and more influencing their management and occasionally even their therapy, and it is the prerequisite for prenatal or preimplantation decisions in the affected family. ngs panels are used widely in clinical settings to identify genetic causes of various monogenic disease groups, such as intellectual disability (hu et al. ) , neurodevelopmental and neuromuscular disorders, among others. however, many new challenges have been introduced both at the technical level and at the bioinformatic level, with consequences including new requirements for interpretation of results, and for genetic counseling. we report on our experience with a targeted ngs panel comprising over brain related genes (mpimg- -test) in the routine clinical diagnostics of patients with syndromic and non-sydromic forms of developmental delay as well as patients with neuromuscular disorders. patients (age - ; mean ) with syndromic (s) or non-syndromic (ns) developmental delay or with neuromuscular symptoms (nm), seen at the genetic counselling unit of our institute, were analyzed with targeted exon enrichment and ngs. chromosomal re-arrangements and copy number variations were excluded in all patients previously by conven-it was recently shown that that clonal hematopoiesis can be driven by somatic point mutations. these acquired mutations occur with normal aging in up to % of older (> y) individuals ( ) ( ) ( ) and few reports in younger individuals. here we present a targeted re-sequencing assay that combines high throughput with ultra-high sensitivity based on single-molecule molecular inversion probes (smmip) ( ) . we have now analyzed dna from healthy blood donors from different age groups ( - ; - ; - ; - and - y) , with no previous diagnosis of cancer, for somatic mutation in loci. those loci included known drivers of clonal hematopoiesis ( ) ( ) ( ) and novel or candidate loci. the improved assay allows low-frequency variant detection with variant levels down to < . %. this improved sensitivity allowed the identification of somatic mutations in a limited set of loci in > % of old individuals, but also report those mutations in individuals of the youngest age group. most prevalent mutations include known hotspot mutations in dnmt a and asxl . here we show that somatic drivers of clonal hematopoiesis are more prevalent and occur in younger individuals than previously reported. these somatic events are age-related. however, the high prevalence and their occurrence in relatively young individuals implicates their origin as a common biological process involved in normal aging. a. m. nissen, j. graf, c. rapp, m. locher, a. laner, a. benet-pagès, e. holinski-feder medizinisch genetisches zentrum -mgz, munich, germany gene dosage abnormalities account for a significant proportion of pathogenic mutations in rare genetic disease related genes. in times of next generation sequencing (ngs), a single analysis approach to detect snvs and cnvs from the same data source would be of great benefit for routine diagnostics. however, cnv detection from exon-capture ngs data has no standard methods or quality measures so far. current bioinformatics tools depend solely on read depth which is systematically biased. we developed a novel approach based on: . utilization of five independent detection tools to increase sensitivity, . different reference sets for different kits and normalization against samples from the same sequencing run to improve robustness against workflow conditions, . definition of special quality thresholds for single exon events to minimize false negatives, . identification of reliable regions by assessment of capture efficiency using a reference set of cnv negative patients to minimize false positives. a cnv quence of the patients and could predict the pathogenic mutation among the top positions in a prioritized exome in more than % of the monogenic cases in our cohort. hence, our results show that computer-assisted facial recognition is not only a promising technology that could be applied in the routine diagnostic workflow, but also a technology that allows diagnosis in cases with non-typical clinical presentation and boosts the diagnostic yield in exome studies. the added value of rapid exome sequencing in critical clinical situations for critical clinical situations, turnaround times (tats) of exome sequencing need to be fast in order to have an impact on clinical decision making. we therefore set out to develop a fast exome sequencing approach (max. days). urgent exomes are preferably sequenced as trios to enable de novo analysis and assist data interpretation. dna library preparation is performed using the sureselect qxt protocol (v , agilent), and sequencing is done on a nextseq (illumina) with a high coverage ( - x). automated file handling allows rapid bwa mapping, gatk variant calling and annotation. a total of one-hundred samples have been sequenced until now using this rapid procedure: trio's, x mother and child, x parents plus children, and single cases. six trios with known aberrations were used for experimental setup. of the remaining families, in families (possible) pathogenic snvs were identified, of which some still need further follow up, whereas families remained negative after inspection of snvs and small indels. for cnv analysis, a trio based reference-free cnv approach is still under development. preliminary data show that all control cnvs ( kb- mb) are detected correctly, and retrospective cnv analyses of the other samples identified three possibly de novo cnvs that need further follow up. shorter tats days were already beneficial for some patients, i. e. an adult male suffering from myelofibrosis and autoinflammatory symptoms. a sting-like phenotype (= stimulator of ifn genes) was suspected, with a possible involvement of the jak/stat pathway. urgent exome sequencing was performed and results were available within days. interestingly, both a somatic variant in mpl (= trombopoetine receptor > myelofibrose) and a heterozygous variant in acp (trap, known immune dysregulation disorder) were identified, both fitting to the patients phenotype. based on these results the medication of the patient was changed, resulting in a substantial improvement of the patients constitution. in conclusion, we have implemented a rapid exome sequencing workflow for urgent cases. the rapid identification of pathogenic variants already had implications on patient treatment, underlying the added value of a fast genetic diagnosis. ement insertion, however, was spliced into the mrna of nabp , leading to a frameshift mutation and a premature stop codon, potentially altering or abolishing gene function. in summary, we have shown that transposon insertions, both common variants as well as rare or de novo variants, can be detected in wes data. such insertions in coding or regulatory regions of disease-relevant genes might therefore explain some of the cases in which no pathogenic coding mutation can be identified by wes. the influence of human genetic variation on epstein-barr virus sequence diversity: a genome-to-genome approach c. hammer , , a. loetscher , , em. zdobnov , genome-wide association studies (gwas) have identified common genetic polymorphisms that associate with clinical manifestation and immune response parameters of various infections. we here present an alternative approach, using variation in the virus sequence as phenotype, which is specific by nature and unique to genomic research in infectious diseases, for genome-to-genome (g g) association studies. building on the unprecedented possibility to combine large-scale human and viral genomic data, we explored interactions between human genetic variation and viral sequence diversity in individuals infected with epstein-barr virus (ebv). the major goal is the identification of key genetic players in the evolutionary 'arms race' between pathogen and host. ebv is the pathogenic agent of infectious mononucleosis and is associated with a broad spectrum of lymphoid and epithelial malignancies, including lymphomas and nasopharyngeal carcinomas. there is also evidence for a role of ebv in the pathoetiology of multiple sclerosis. its genome is approximately kbp long and encodes around proteins, not all of which have been definitely identified or characterized. it is known that high loads of ebv are present in patients with advanced human immunodeficiency virus (hiv)-induced immunodeficiency. we therefore selected immunosuppressed patients included in the swiss hiv cohort study (shcs) with low cd + t cell counts, and quantified ebv copy number in peripheral blood mononuclear cells (pbmcs). cell samples contained more than , viral copies in total and were subjected to target isolation and subsequent enrichment using the sureselect method by agilent biotechnologies, followed by illumina whole-genome sequencing. after data processing and quality control, variable amino acids were called as binary variables, resulting in > variable positions per individual in average. the same patients also underwent genome-wide genotyping to obtain host genetic variation, followed by imputation based on the haplotype reference consortium reference panel. the association analyses are currently ongoing, and we will present the results at the conference. we use logistic regression to test for association between host single nucleotide polymorphisms (snps) and binary ebv amino acid variants. bonferroni correction is applied for multiple testing correction on the sides of both host and pathogen. stratification is taken into consideration by including principal components (pcs) for the host, and phylogenetic pcs for the virus. this project will offer a global description of the adaptive forces acting on ebv during natural infection. we have shown before for hiv that a virus genome associates much more strongly with human genetic variants than clinical endpoints. the analysis of all signals resulting from the interaction between human and viral genomes has the potential to identify novel host defense mechanisms, which could serve as future diagnostic and therapeutic targets. is called in a reliable region if at least two out of five tools are concordant for the respective cnv. the pipeline shows a sensitivity of % and a precision of %. within routine gene panel diagnostics we analyzed a total of patients indicated to have rare mendelian diseases for snv and cnvs. in patients a cnv was detected in genes associated with the respective individual phenotype. interestingly, in several cases the cnv completed the patients report as it was detected in genes with a recessive mode of inheritance where previously only a heterozygous pathogenic snv was found. overall, with the additional analysis of cnvs we increased the diagnostic yield from % (class , single nucleotide events) to %. however, there are still issues in the detection of cnvs from ngs data for routine diagnostics. cnv pipelines are very prone to errors caused by enrichment inconsistencies compared to snv detection tools. the assessment of sensitivity and specificity is difficult due to the lack of datasets to validate cnv detection pipelines. originally, the analysis of cnvs was performed mainly in patients with mental retardation disorders, resulting in a paucity of cnv data linked to other mendelian diseases. moreover, the identification of the actual size and thus the assessment of pathogenicity of a cnv is difficult, because targeted ngs gene panels do not cover all genes. in conclusion, ngs data is a suitable data source for the simultaneous detection of snvs and cnvs for clinical diagnosis; however, with the current tools it is only applicable in accurately validated regions. identification of transposon insertions in whole-exome sequencing data s. lukassen, n. Übelmesser, ab. ekici, u. hüffmeier, ct. thiel, c. zweier, a. winterpacht humangenetisches institut, erlangen, germany % of the human genome consists of transposable element derived sequences, the most abundant of which are l and alu elements, followed by endogenous retroviruses. several hundred of these elements remain active, leading to insertion frequencies of up to one in live births for alu elements and posing a threat to genome integrity. while most studies on transposons employ whole-genome sequencing (wgs) or target-enrichment based sequencing approaches, the most commonly used form of diagnostic high-throughput sequencing is currently whole-exome sequencing (wes). we were therefore interested in investigating transposon insertions in wes data as a possible source of disease causing mutations. we developed a software to call non-reference transposon insertions from single-end wes datasets by split-read mapping and analyzed exomes this way. on average, non-reference insertions were identified in each exome, with an average of . sites per patient identified in < = . % of other patients. of these rare variants, % were deemed plausible by visual inspection. automated confidence calls of the software were concordant with visual inspection in % of cases. in % of cases a plausible insertion was awarded a lower score by the algorithm and in another % not called at all. in % of cases the automated call appeared to be falsely positive, in another % at the wrong position within the same bp window. laboratory validation of convincing insertions revealed a % true positive rate, leading to an estimated specificity of %. when performing calls for reference l insertions on exomes, % ( % - %) of known elements whose flanking regions were covered by at least two reads were correctly identified, leading to a sensitivity of %. we thus estimate the average number of non-reference transposon insertions in our wes dataset to be ( - ). % and . % of sites identified were associated with alu and l elements, respectively, with the majority of calls stemming from evolutionary young transposons still assumed to be active. . % of sites were located within the cds, . % in the utrs of genes, . % spanned an intron/ exon border, . % were intronic and . % of insertions were found in intergenic regions. we then chose insertions within intronic ( ) or utr ( ) regions for further analysis. seven were not detected in the mrna. one intronic alu el-abstracts ws - novel insights into male-pattern baldness pathobiology via integration of differential hair follicle mirna and mrna expression profiles with gwas data male pattern baldness (mbp) is a highly heritable condition and the most common form of hair loss in men. the phenotype is characterized by a distinct pattern of androgen-dependent progressive hair loss from the scalp that is restricted to hair follicles (hf) in the frontal and vertex scalp area. the molecular mechanisms that underlie this characteristic pattern and the differences in androgen-sensitivity between hf subpopulations in the frontal/vertex and the occipital scalp remain however elusive. to gain novel insights into the underlying biology and contributing genes and pathways, we systematically investigated for a differential expression (de) of mirna-and mrna-genes in hf samples from the frontal and occipital scalp area of healthy male donors. array-based genome-wide mirna and mrna profiling revealed expression of mirnas and , mrnas in human hf, of which mirnas ( %) and , mr-nas ( %) showed a de between hf subpopulations. the strongest de mirnas included mir- , mir- and mir- . among the strongest de mrnas were the wnt-signaling inhibitor dkk , the protein kinase pak and the retinoid acid receptor rora. a subsequent pathway-based analysis in mirpathdb revealed that de mirnas targeted numerous interesting pathways. among them the wnt-and mtor signaling pathway which have been implicated in the control of hair follicle cycling, a mechanism that is disturbed in mpb affected hf and other plausible candidate pathways such as estrogen, thyroid hormone signaling or epidermal growth factor binding which have not yet been implicated mpb pathobiology. to yield further evidence for an involvement of de mirnas and mr-nas in the developement of mpb, we subsequently integrated our expression data with association data from a large gwas meta-analysis on mpb (n = , ). of the de mirnas and mrnas, only mirna (mir- b) and mrnas were located within mb of one of genome-wide significant mpb risk loci. notably, the analysis revealed a co-localization of de mirna, de mrna, and nominally significant association signals (p < - ) at other genomic loci, pointing towards a role of these genomic regions in mpb pathogenesis. among them a locus on chromosome q . that comprises the genes encoding the ephrin-type-b receptor (ephb ) and the prostaglandin transporter slco a . interestingly, ephrins have been shown to be regulated by androgens and to play a role in hf formation, proliferation and hair cycling. and expression of prostaglandin d , which is transported by slco a , has been found to be upregulated in balding scalp where it inhibits hair growth. in summary, our systematic analysis of differential mirna and mrna expression and the subsequent integration with genetic association data identified novel potential risk loci for mpb and numerous candidate genes and pathways that are likely to play a role in mpb pathogenesis and emphasizes the importance of data integration of large-scale omic-analyses. palaeontological genomic analyses have shown that interbreeding between anatomically modern humans and neandertals occurred in europe and asia . - years ago. approximately . - % of the modern european and asian genome consists of introgressed dna from neandertals. some of these introgressed regions have been suggested to contribute to several traits and phenotypes including major depression and other mood disorders. in order to further assess the role of neandertal ancestry in cognition and the contribution of genetic risk for psychiatric disorders, we performed genome-wide analyses of neandertal alleles in publicly available psychiatric genomics consortium (pgc) gwas summary statistics with samples sizes ranging from about to individuals for the following phenotypes: educational attainment, attention deficit hyperactivity disorder (adhd), anorexia nervosa, anxiety disorders, autism spectrum disorder, bipolar disorder, major depressive disorder and schizophrenia. we estimated the proportion of heritability explained by snps in neandertal introgressed regions using stratified ld score regression (ldsc) and two sets of previously inferred neandertal introgressed regions. in a secondary analysis, we investigated whether specific functional annotations such as 'utr, promoter regions or histone marks within neandertal regions were significantly associated with selected phenotypes. we identified a modest enrichment of heritability in neandertal introgressed regions in anorexia nervosa, autism spectrum disorder, bipolar disorder and major depressive disorder, although none of the results were statistically significant. several functional annotations, such as h k me histone marks within neandertal introgressed regions, appeared significantly enriched for snps contributing to the heritability of anorexia nervosa and autism spectrum disorder. in bipolar disorder, dnasei digital genomic footprinting regions, h k ac histone marks and super enhancer regions within neandertal regions appeared particularly enriched for heritability. on the other hand, both sets of neandertal regions were slightly depleted of snps contributing to the heritability of schizophrenia. for example, one set of neandertal regions that contained % of all analysed snps only contributed to % of the variance of risk (standard error: . ; p-value: . × - ). in comparison to the rest of the genome, neandertal introgressed regions also contributed less to the heritability of educational attainment, adhd and anxiety disorders, although these findings were not statistically significant. to our knowledge this is the first study to systematically investigate the extent to which snps attributable to neandertal introgressed regions contribute to the heritability of several psychiatric/cognitive phenotypes. we are currently increasing our power to detect snp heritability in neandertal regions by applying the ldsc method to larger pgc datasets. harbor genes involved in the complement system, high density lipoprotein metabolism or extracellular matrix homeostasis. these pathways are known for their pleiotropic role in other conditions, such as cardiovascular disease, auto-immune diseases and cancer. here we aimed to investigate the extend of overlap between the genetic risk of various complex diseases and traits and the genetic risk for amd. methods: first, we catalogued , previously published, genome-wide significant variations associated with complex diseases or traits. next, we computed a genetic score by calculating the (weighted) sum of risk increasing alleles for each disease or trait. consequently, a higher genetic score indicates that an individual has more risk/trait increasing alleles of a given disease or trait. for each score, we computed the association with late stage amd using a dataset provided by the international amd genomics consortium (iamdgc) including , late stage amd cases and , controls. we also assessed the association of each variation individually with late stage amd risk in order to identify novel disease loci with strong evidence for pleiotropy. results: nineteen genetic scores of complex diseases and traits were significantly associated with amd risk (fdr < . ). most notably, all genetic scores related to autoimmunity were elevated in amd patients (p < . × - ), while scores related to cardiovascular disease were reduced in amd patients compared to controls (p < . × - ). we also found that the genetic scores of melanoma and related malignancies were higher in amd patients (p < . × - ). in addition, out of , variants, which were used to compute the genetic scores, were significantly associated with amd (fdr < . ), implicating novel, pleiotropic loci in amd risk. conclusion: our findings demonstrate a substantial overlap between the genetic risk of complex diseases/traits and the genetic risk for amd and provide evidence for novel, pleiotropic loci associated with amd. while our findings highlight common disease pathways that may facilitate to develop multi-use drug targets, they also challenge the notion that gene/genome manipulation could be applied in general terms to eradicate risk for a defined complex disease. worldwide genetic association study of exfoliation syndrome and glaucoma identifies common genetic variants at five new susceptibility loci exfoliation syndrome (pex), a complex systemic disorder of the extracellular matrix, is the commonest cause of secondary glaucoma in aging population and thus a major cause of blindness globally, affecting - million subjects worldwide. inside a large, international collaboration project a genome-wide association study (gwas) was carried out on , pex cases and , controls, recruited from countries across six inhabited continents, with replication in a further independent , cases and , controls from countries. significant association was observed at seven loci, of which two confirmed the already known associated loci at the genetic markers mapping to loxl -and cana a-gene, five are new (p < × - ). the five new loci map to chromosomes q (rs near flt -pomp-slc a , p = . × - ), q . (rs near tmem -arhgef , p = . × - ), p (rs at agpat , p = . × - ), p (rs at rbms , p = . × - ) and q (rs near sema a, p = . × - ). to determine the pathophysiological role of the three most significantly associated loci ( q , q . , p ), we investigated the expression and localization of the six related genes (flt , pomp, slc a , tmem , arhgef and ag- male-pattern baldness (mpb) is characterized by a progressive hair loss from the frontal and vertex scalp that affects ~ % of men at the age of years. epidemiological studies have shown positive associations between mpb and coronary heart disease (chd) and related phenotypes such as blood pressure (bp), diabetes (dm) or elevated blood lipid levels. the results however vary with regard to the associated pattern of hair loss (frontal or vertex) and the assessed endpoint measures for chd. and so far no study has investigated for a shared genetic determinant between the traits. using data from the heinz nixdorf recall study (n = , males) and a large meta-analysis on mpb (n = , ), we aimed at a systematic investigation of the association between mpb and chd on (i) an epidemiological and (ii) a genetic level. , men with vertex balding showed a higher bmi (β = . kg/m ), elevated fasting triglyceride (β = . mg/dl) and lower hdl-c levels (β = - . mg/dl). to assess the genetic overlap between mpb and chd, we created a risk score (rs) from mpb lead snps (p < × - ) and tested for association with chd and related traits phenotypes. no significant associations were observed. however, an age-stratified analysis revealed a % per allele risk increase for chd (hr = . , %ci: . ; . ) and a decrease in fasting triglyceride levels (β = - . ). we next used ld score regression analysis in to test for genome-wide genetic correlation between mpb and chd. the analysis revealed no significant correlations with cardiometabolic (n = ), lipid (n = ) or metabolic traits (n = ). finally, to investigate for a genetic overlap at single loci, we compared the mpb risk loci with reported gwas signals for chd. the analysis identified seven overlapping associations between mpb and bp (n = ); qt-interval length; atrial fibrillation; sudden cardiac arrest; and dm. for the majority of loci, the direction of effect differed between mpb and chd, opposing previous epidemiological findings. positive associations were identified between mpb and diastolic bp (fgf , q . ) and sudden cardiac arrest (atf , q . ). interestingly, fgf is known to stimulate cell growth and proliferation in multiple cell types, including cardiac myocytes and hair follicle (hf) cells, and atf is a hf expressed regulator of cell growth and differentiation that has been shown to prevent foam cell formation, which suggests that fgf and atf -signaling contribute to both traits. thus, our data support an association between mpb and chd related phenotypes and suggest that mpb deserves further evaluation as an additional risk factor for chd. pleiotropic effect of genetic variants associated with complex diseases and traits in age-related macular degeneration purpose: age-related macular degeneration (amd) is the leading cause of vision loss in western societies and is caused by both environmental and genetic risk factors. with regard to the latter, several associated risk loci abstracts otyping, results of which will be presented at the conference. of note, for nonsyndromic cleft lip with/without cleft palate (nscl/p), the most frequent form of orofacial clefting, risk loci have been detected by gwas so far, with some of them reaching (nearly) genome-wide or significant p-values in samples much smaller than cases. in the imputed nscpo dataset none of the presently known nscl/p risk loci showed a p-value < - . our data so far confirm previous molecular and epidemiological findings, that nscpo is genetically distinct from nscl/ p. furthermore, the results indicate that common variants alone might not contribute to the same extent to nscpo as compared to nscl/ p. the correlation between defects at specific imprinted loci and distinct imprinting disorder (id) was accepted for a long time. however, it is now put into question because of a growing number of patients with multilocus imprinting disturbances (mlid), i. e. the aberrant methylation at more than one imprinted locus. in particular, mlid is present in individuals with silver-russell syndrome (srs) and beckwith-wiedemann syndrome (bws), and it has meanwhile turned out that patients with opposite phenotypes can share common epimutation patterns. on the other hand, mlid always occurs as mosaicism and varies in different tissues of the same individual. interestingly, the majority of mlid carriers show only one specific id phenotype, though loci of other ids are affected in addition to the one specific for the phenotype. we become aware of a growing number of patients with unexpected and even contradictory molecular findings in respect to the clinical diagnosis for referral. amongst others, we detected the srs specific icr hypomethylation in p in two of our patients referred as bws. in the first case, the icr hypomethylation was detected only in lymphocytes but was not present in buccal swab dna. the patient only had a slight asymmetry, but showed normal growth and did not exhibit any other feature compatible with bws, nor with srs. the reason for the lack of clinical features is unclear, but is comparable to the observation in monozygotic, but clinically discordant srs and bws twins. here the unaffected twin often carries the epimutation only in lymphocytes whereas the affected one shows the alteration in additional tissues. a reason might be sharing of hematopoietic stem. it can be postulated that the patient presented here is born after an (undetected) twin pregnancy with early loss of the affected twin. in the second case, the initial diagnosis of bws was made due to asymmetry, though overgrowth or other features were not present. further clinical ascertainment did not confirm this diagnosis, but growth of the patient was in the lower percentiles, in concordance with the icr hypomethylation. these cases as well as further cases in our cohort confirm that there is an urgent need to provide detailed clinical data upon requesting molecular diagnostics for imprinting disorders. in fact, the growing number of patients with unexpected results complicates the interpretation and illustrates the broad phenotypic range, but also provides further insights in the etiology of ids and setting of imprinting marks pat ) by qrt-pcr, immunohistochemical-and western-blot analysis in genotyped ocular tissues of pex and control patients. all six genes displayed moderate mrna expression in all ocular tissues analysed, with highest levels in iris, ciliary body, and retina. however, only pomp showed a trend towards reduced expression in the presence of the rs risk allele, in both pex and control patients. in general, both mrna and protein expression of pomp and tmem were significantly reduced up to % (p < . ) in anterior segment tissues in pex eyes compared to controls. no differences in mrna and protein expression were detected for the remaining genes analysed. immunofluorescence analysis showed that pomp, a proteasome maturation protein, is ubiquitously expressed in most ocular cell types and that tmem , a transmembrane protein of unknown function, is primarily localized to endothelial cells of blood vessels and aqueous outflow structures. additionally, protein staining intensities for pomp and tmem were markedly reduced in anterior segment tissues of pex eyes compared to controls and co-localized to abnormal accumulation of pex material on ocular surfaces and in blood vessel walls. thus, at least two of the newly identified loci provide new biological insights into the pathology of pex syndrome/glaucoma and highlight a role for impaired proteasome function as well as vascular and trabecular endothelial dysfunction in the disease pathogenesis. nonsyndromic cleft palate only -evidence for a limited contribution of common variants in contrast to nonsyndromic cleft lip ± palate cleft palate only (cpo) is a common congenital malformation which might occur as part of a syndrome or in an isolated form, i. e., nonsyndromic cpo (nscpo). nscpo has a prevalence of : and is considered multifactorial with genetic as well as environmental factors contributing to the disorder. in a recent study we identified the first genome-wide significant locus for nscpo which has been independently confirmed in another study. in order to discover more nscpo risk loci we performed a genome-wide imputation study with gwas data from case-parent trios with european, asian and african ancestry which was retrieved from db-gap upon approved data access. notably, this gwas dataset had not yet been imputed, and we hypothesized that we can increase power to identify novel genetic associations by increasing the marker density and follow-up of suggestive findings by independent replication. genome-wide genotypes were imputed using impute based on genomes haplotypes, and snps were selected based on info-score > . and minor allele frequency > %. the imputation did not reveal any genome-wide significant snp, however, snps at loci showed p-values < - . loci with more than two variants below this threshold (n = ) were to be replicated using the massarray system (agena bioscience). three independent samples were used: two case/control replication cohorts from central europe ( cases, controls) and yemen ( cases, controls), and one european case-parent trio replication cohort (eurocran study; trios). in a first round we genotyped snps at eleven loci. one variant, rs at chr. q , showed p < . in the replication cohort and after combining replication and gwas data, resulted in a decrease of p-value from . × - to . × - . this indicates that this locus, which includes candidate genes such as igs , a known cell-adhesion molecule with yet unknown function in craniofacial development, might harbour a common risk variant with low effect size. we are currently performing a second round of gen-we report biallelic mutations in cad, encoding an enzyme of de novo pyrimidine biosynthesis, in four patients with developmental disability, epileptic encephalopathy, anaemia, and anisopoikilocytosis. two children died after a neurodegenerative disease course. treatment of two surviving children with oral uridine led to immediate cessation of seizures in both. a four-year-old girl, who was previously in minimal conscious state, started to communicate and walk with assistance after nine weeks of treatment. a three-year-old girl likewise showed developmental progress. blood smears normalised and anaemia resolved. our findings support the efficacy of uridine supplementation rendering cad deficiency a treatable neurometabolic disorder. delineation of the grin a phenotypic spectrum alterations of the n-methyl-d-aspartate (nmda) receptor subunit glu-n a, encoded by the gene grin a, have been associated with a spectrum of neurodevelopmental, speech and epilepsy disorders. we identified previously unreported patients with heterozygous pathogenic variants in grin a, including novel variants. after re-evaluation of all published grin a cases, previously reported patients met the acmg criteria for being pathogenic or likely pathogenic. thus, we are able to collectively review genotypes and phenotypes of individuals with grin a-related disorders. we show that the known phenotypic spectrum is expanded and ranges from near-normal development to severe and unspecific encephalopathy, comprising any disorder of speech development. furthermore, some patients do not display seizures. in contrast to previous reports, gri-n a missense variants cluster within the functionally most relevant domains. we are the first to describe genotype-phenotype correlations in grin a-related disorders, where carriers of pathogenic missense variants tend to have more severe neurodevelopmental phenotypes compared to carriers of truncating variants. the most severe end of the phenotypic spectrum was found to include novel features, such as infantile spasms and arthrogryposis and was associated with pathogenic variants in the pore-forming domain of grin a. the eponymic name galloway-mowat syndrome (gamos; omim ) has been coined for the association of early-onset nephrotic glomerulopathy, microcephaly with variable brain anomalies, and facultative diaphragmatic hernia. it is supposed to be inherited as an autosomal recessive trait and clinical as well as genetic heterogeneity has been suggested. in , wdr mutations were identified as a cause of gamos, but only a few cases have been reported to date. over the last years, we have collected dna samples and clinical data from unrelated families with one or more children affected by gamos or a gamos-like syndrome (glomerulopathy plus variable anomalies of brain morphology or function as inclusion criteria), including consanguineous families. in this cohort, we performed whole exome sequencing followed by targeted analysis by sanger and ngs multigene panel resequencing. in a total of families of this cohort ( %) the probable underlying genetic defect could be identified. in affected individuals from two consanguineous families, homozygous mutations of wdr could be found (vodopiutz et al., ) . thus, this gene accounted for only % of cases of our cohort. the affected child of another family had a novel homozygous mutation in arhgdia. this gene has previously been described in three families to cause early-onset steroid-resistant nephrotic syndrome (gupta et al., ; gee et al., ) , but there is some evidence that non-specific brain anomalies may also be part of the arhgdia-associated phenotype. fourteen and three index patients from unrelated families had mutations in one autosomal (osgep) and one x-linked gene (lage ), respectively, both encoding for components of the keops protein complex that has been implicated in transcription, telomere maintenance and chromosome segregation. no human phenotype has previously been assigned to mutations in this complex. notably, eight unrelated families with an identical mutation originated from the east asian population where the carrier frequency for this allele is . . in one consanguineous family with multiple affected children the disease segregated with a homozygous mutation in the sgpl gene encoding for sphingosine- -phosphate lyase. in four families, the kidney phenotype could be attributed to mutations in genes for non-syndromic nephrosis (nphs , plce , one novel gene), while the brain phenotype was apparently independent. in conclusion, the molecular genetic findings in this cohort confirmed that gamos is exceedingly heterogeneous, and still in almost half of the patients with a gamos-like phenotype the genetic cause remained unclear. on the basis of our findings we are now able to define new biologic mechanisms that are critically involved in both, brain development and integrity of the glomerular filtration barrier. genotype phenotype correlations are emerging. finally, we demonstrate that gamos can also be inherited as an x-linked trait. abstracts taminase gene (tgm ) is mutated in the majority of patients (around %), and its gene product, tgase , is therefore primarily targeted in our approach for protein substitution. patients with arci have an impaired skin barrier function, most of them are born with a collodion membrane and suffer subsequently from varying degrees of hyperkeratosis, erythema, transepidermal water loss and infections. the disease can be life threatening neonatally but lacks a causative therapy and is still only treated symptomatically. therefore, our aim is to develop a personalised, causative therapy where the defective protein is substituted topically via a nanocarrier. therapeutic, human tgase was synthesized in hek cells and assessed by western blot and flow cytometry analysis. enzyme activity was measured by in vitro assay. tgase was then coupled to a polyglycerol-based nanogel (dpg-ng) containing the thermoresponsive linker poly(n-isopropyl)acrylamide (pnipam), stabilising the enzyme as well as adding a thermal protein release trigger at °c, which is favorable for cutaneous applications. immunocytochemical stainings for tgase on monolayered basal keratinocytes that lack tgm expression confirmed the successful uptake of extrinsic tgase into the cells. further analysis over time showed that the enzyme was no longer detectable after h and consequently led us to define a treatment schedule for the following experiments. d full thickness skin models were used as in vitro system to determine barrier function and enzyme activity after treatment with varying concentrations of the dpg-ng/tgase complex. three different sets of skin models were used for these experiments: normal models mimicking the healthy skin with an intact barrier function, models where tgm was knocked down, and models made with arci patient cells with tgm mutations. franz cell tests on treated skin models lacking intrinsic tgase confirmed the impaired barrier activity in disease models, demonstrated an improved barrier function after repeated treatments with dpg-ng/ tgase and showed restored tgase activity using an in situ assay. furthermore, first toxicity tests using mtt revealed high biocompatibility of dpg-ng/tgase after treatment of d and d cell cultures. these findings are successful steps for an advanced topical drug delivery system and are a promising approach for causative therapeutic intervention in arci. after further optimization concerning protein dosage and thorough toxicity tests, we will adapt this system also for the use with other proteins involved in arci. pigmentation disorders (pds) comprise a large group of rare and heterogeneous disorders that are mainly characterized by various coloration abnormalities affecting single parts of the body or the complete integument. the large group of pds includes the autosomal dominant inherited hyperpigmentation disorder dowling-degos disease (ddd). ddd is genetically heterogeneous, and to date causal mutations in three genes, namely krt , pofut and poglut have been identified. after exclusion of mutations in these genes, we performed exome-and sanger-sequencing in six unrelated ddd-patients/families and identified six heterozygous truncating mutations in psenen encoding the presenilin enhancer protein . on closer examination of the histological sections, we came upon a novel feature that distinguished these individuals from previous ddd-cases by the presence of follicular hyperkeratosis. to assess the functional significance of psenen mutations in ddd pathogenesis, we performed mammalian cell culture based studies and knockdown experiments of psenen homolog psenen in zebrafish larvae (zfl). knockdown of psenen in zfl resulted in a phenotype with scattered pigmentation, which mimicked human ddd. in vivo-monitoring of pigment cells in the developing zfl suggested that disturbances in melanocyte migration and differentiation underlie ddd pathogenesis. interestingly, six of the psenen mutation carriers presented with co-morbid acne inversa (ai), an inflammatory hair follicle disorder. all individuals had a history of nicotine abuse and/or obesity, which are known trigger-factors for ai. although psenen mutations have been identified in a small subset (< %) of familial ai previously and the co-manifestation of ddd and ai has been reported for decades, our study is the first to demonstrate experimentally that mutations in psenen indeed can cause co-manifestation of ddd and ai, most likely triggered by predisposing factors for ai. thus, the present report describes a clinically and histopathologically novel ddd subphenotype in psenen mutation carriers, which is associated with an increased susceptibility to ai. protein substitution therapy for autosomal recessive congenital ichthyosis (arci) overall burkitt lymphoma showed a low genomic complexity with a low number of snvs and svs. however, the integration of cnas, snvs and svs allowed us to identify recurrently affected genes, which are involved predominately in the pi( ) kinase pathway, tonic bcr signaling, and cell cycle regulation, chromatin composition and germinal center development. burkitt lymphoma (bl) is the most common mature aggressive b-cell lymphoma in childhood. the genetic hallmark of bl is a chromosomal translocation involving the myc oncogene and one of the immunoglobulin loci leading to myc deregulation. three epidemiologic variants of bl are differentiated: endemic (ebl), which occurs predominantly in equatorial africa and is associated with ebv-infection, sporadic (sbl), which occurs in westernized countries and immunodeficiency-associated. in addition, burkitt leukemia (b-al) is differentiated from bl in cases with more than % of the bone marrow cells being lymphoma cells. another rare bl-variant is myc-positive precursor b-cell acute lymphoblastic leukemia coexpressing tdt and myc (tdt+bl). finally, we recently described a myc-negative variant which shows a typical alteration on chromosome (mnbll). the aim of the present study was to examine the epigenetic landscape of these bl variants. to this end, we analyzed the dna methylation of bl ( sbl, ebl, b-al, mnbll, tdt+bl) using the humanmethylation beadchip and contrasted the findings to diffuse-large b-cell lymphoma (dlbcl) and follicular lymphoma (fl). the majority of lymphoma were recruited in the framework of the icgc mmml-seq and mmml projects. the ebl were obtained from the nci ghana burkitt project. as controls, we used public available dna methylation data from b-cell burkitt lymphoma (bl), including its leukemic variant burkitt leukemia (b-al), is the most common type of pediatric b-cell lymphoma accounting for - % of new cases. its biological hallmark is the ig-myc translocation involving myc and mostly the immunoglobulin heavy (igh) locus or more rarely one of the immunoglobulin (ig) light chain loci. at the cytogenetic level the ig-myc translocation is the sole abnormality in around % of cases. overall, bl is characterized by a low genomic complexity. the aim of the present study was to analyze the genomic and transcriptomic landscape of pediatric/adolescent burkitt lymphoma by sequencing according to the guidelines of the international cancer genome consortium. a total of samples of bl/ b-al from pediatric/adolescent patients entered this sequencing study. all patients were treated in population-based prospective clinical trials. inclusion criteria were besides availability of suitable materials, consent to participate in the study and appropriate diagnosis: age at diagnosis (≤ years), the presence of ig-myc rearrangement detected by fish and/or whole genome sequence (wgs), absence of rearrangements of bcl or bcl genes. we performed wgs of tumor and matched control as well as transcriptome sequencing of the tumor cells according to the standards of the icgc (www.icgc.org). the pathognomonic ig-myc translocation was detected in of of the cases using wgs, but was observed in all cases by fish. an igh-myc juxtaposition was detected in patients and its variants igk-myc and igl-myc in and cases, respectively. we identified two different expression patterns of myc transcripts which were associated with the translocation breakpoint location. on the one hand the canonical myc transcript and on the other hand an alternative transcript with a transcription start site before the second exon. the latter produces an mrna which contains nucleotides not included in the canonical transcript but nevertheless it encodes the identical protein. the integration of single nucleotide variants (snv) and copy number aberrations (cna) identified a total of recurrently (≥ samples) mutated genes. myc, id , tp , ccnd , smarca , arid a, fbxo , ddx x were mutated in ≥ % of samples. in / ( %) cases, the id / abstracts ed. the annotation with the chromatin segmentation data of cd + t-cells from the blueprint project revealed enrichment of changes in methylation in distinct genomic regulatory elements in t-lgl. these differentially methylated functional regions were enriched for a set of transcription factor binding sites, known to be relevant in other lymphoid neoplasms. by bioinformatic analysis of methylation data and integration with gene expression data we identified hypermethylated and hypomethylated genes (e. g. bcl b, themis, zeb , hivep ) which point to candidate pathways potentially deregulated in the pathogenesis of t-lgl. conclusion: our study identified dna methylation changes in a set of candidate genes involved in various signaling pathways, which could potentially be used for diagnosis, prognosis and may become targets for novel treatment options. burkitt lymphoma (bl) is a mature aggressive b-cell lymphoma genetically characterized by a chromosomal translocation leading to ig-myc juxtaposition. treatment of bl is usually very successful particularly in children, with a cure rate of over % even among patients with advanced stage disease. however, the prognosis of the remaining patients experiencing disease progression and/or relapse is still very poor. bl has an overall low genomic complexity, thus secondary chromosomal changes in addition to the ig-myc translocation are rare. however, genomic complexity has been associated with aggressive disease and poor prognosis in various lymphomas including bl. because little is currently known about the underlying genetics of disease progression in bl we aimed at characterizing the molecular changes and characteristics that might lead to the relapse of bl. sequential tumor biopsies from initial diagnosis (id) and follow-up were available from a total of patients ( - years at id), which were divided into two groups: five patients experienced a relapse from their initial bl diagnosed - days after id (group ). in contrast, three patients developed twice a bl, i. e. presented with bl as secondary neoplasms diagnosed - years after id (group ). dna extracted from archival formalin-fixed, paraffin-embedded (ffpe) tissue was used to analyze genome-wide copy number alterations (cna) using the oncoscan® platform (affymetrix) and mutational landscape by whole exome sequencing (wes). analysis of the cna in the paired bl samples (group ) revealed an increase in genomic complexity in / pairs as in id a mean of cna was detected in contrast to . cna in relapse samples (p = . ). of note is that in all pairs, the relapse shared almost all cna which were present in id. wes analysis of group showed similar results in all analyzed pairs. in total, . % of mutations (median number of mutations = ) were shared in id and relapse. nevertheless, a considerable amount of mutations were unique in id and relapse with a median of ( . %) and ( . %) mutations, respectively. on the other hand, mutations detected in samples populations of various differential stages. furthermore, we investigated whole-genome bisulfite sequencing (wgbs) data of sbl and b-al in comparison to germinal center b-cell populations from healthy donors to decipher differentially methylated regions (dmr). these are defined as or more cpgs differentially methylated between two groups. unsupervised dna methylation analysis of bl, fl and dlbcl revealed that all bl variants cluster apart from the non-bl cases. thus, supporting on epigenetic level that all analyzed bl samples are bl variants. multigroup comparison (σ/σ max = . , q < e - ) separated the bl variants roughly in groups: ebl, ebv-positive sbl and all other bl variants. furthermore, this analysis revealed ebl to harbor a massive hypermethylation in comparison to all other bl variants. comparison of the dna methylation using the humanmethylation beadchip data of sbl and b-al revealed cpgs to be differentially methylated (σ/σ max = . , q < . ). in contrast, using the wgbs data of the same samples a total of dmrs could be identified which were mostly located in enhancer and polycomb target regions. in conclusion, we show that all analyzed bl variants share a similar dna methylation profile. interestingly, dmrs between sbl and b-al were mainly located in enhancer and polycomb regions. in contrast, ebl showed a massive hypermethylation in comparison to the other bl variants. thus, the differences identified by dna methylation analysis can improve the understanding of the biological and clinical differences of the bl variants. dürig , introduction: t-cell large granular lymphocytic leukemia (t-lgl) is a mature t-cell leukemia which often arises in the context of autoimmune disease. genetic changes like recurrent chromosomal aberrations are rare. recent studies identified somatic stat and tnfaip mutations in t-lgl cells. however, the molecular events driving leukemogenesis remain largely unknown. objectives: the goal of our study was to characterize the epigenetic basis of t-lgl to better understand leukemogenesis and potentially identify druggable pathways or diagnostic biomarkers for t-lgl. p. johansson , , l. klein-hitpass , g. castellano , k. kentouche , f. nicolau , i. oschlies , e. carrillo-de santa pau , m. przekopowitz , a. queiros , m. seifert , a. valencia , ij. martin-subero , em. murga penas , o. ammerpohl , u. dührsen , r. küppers , j. we analyzed the dna methylome of facs sorted tumor cells of t-lgl cases in comparison to benign αβ t-cell subsets. the infinium human methylation bead chip was used for analysis. we annotated our data with the publicly available chromatin segmentation data of cd + t-cells from the ihec/blueprint project. the expression levels of selected genes were tested by reverse transcription real-time pcr. results supervised analysis of t-lgl compared to benign cd + memory cells resulted in , cpg loci significantly (q < . ) differentially methylat- krawitz , , a. knaus , , m. jäger , , r. flöttmann , t. eggermann , b. hoechsmann , h. schrezenmeier paroxysmal nocturnal hemoglobinuria (pnh) is an acquired disorder of the blood-forming system. typically, affected hematopoietic stem cells (hscs) in pnh harbor a single somatic loss-of-function mutation in the x-linked piga gene. previously, a pnh patient with a different molecular etiology has been described and herein we report three more cases of this new subgroup: a predisposing germline mutation in pigt, which is an autosomal gene of the glycosylphosphatidylinositol (gpi)-anchor synthesis pathway, is followed by a second somatic hit. by means of deep sequencing and array-cgh, we observed acquired deletions of mb to mb on chromosome q in pnh cells that include pigt as well as a region that is commonly deleted in myeloproliferative neoplasms and myelodysplastic syndromes and that is known to be differentially methylated. this results in a complete loss of expression of certain genes at this locus which is also thought to contribute to the clonal expansion. the deficiency of gpi-anchored proteins on pnh cells results in a lack of the complement regulatory proteins cd and daf/cd on the cell surface and leaves them more vulnerable to the c b- membrane attack complex. in contrast to classical pnh without any fully synthesized gpi-anchors, pigt mutations impair the transamidase that links the substrate to the anchor and thus result in an accumulation of unbound gpi molecules. this difference in the pathophysiology can also be visualized in flow cytometric analysis of peripheral blood: while cd and cd surface levels are reduced in all pnh cells, the atypical pnh cells due to a transamidase deficiency can be discriminated by a specific antibody, t mab, that binds free gpi anchors. besides the classical pnh symptoms of anemia, thrombosis, and hemolysis, patients with pigt mutations also manifest with additional autoinflammatory symptoms, such as urticaria, fever, arthralgia and meningitis, and it is hypothesized that the free gpi-anchor that accumulates in affected cells is causally related to autoinflammation. based on these findings, we propose the new entity of atypical pnh. background: the prevalence of metabolic disorders, in particular obesity has dramatically increased worldwide. genetic variants explain only a minor part of this obesity epidemics induced by physical inactivity and over nutrition. epidemiological studies in humans and animal models of di-from patients with secondary neoplasm (group ) were mostly unique to id (= , . %) whereas only . % of all mutations were shared in id and secondary neoplasm samples (= ). furthermore there were no shared cna in the corresponding samples identified by oncoscan® analysis. to sum up, the oncoscan® and wes analysis, of the paired bl group ( ) provide strong evidence for a linear clonal evolution, meaning relapses may directly evolve from the previous lymphoma clone rather than a common precursor. in contrast, results obtained for patients with secondary neoplasm (group ) showed no indication for linear but rather for divergent evolution. thus, analysis of recurrent mutations shared in id and second neoplasm samples can provide important information about disease progression and are therefore subject of ongoing analysis. y. murakami , t. hirata , s. murata , t. kinoshita , m. kawamoto , s. murase , h. yoshimura , n. kohara , n. inoue , m. osato , j. nishimura , y. ueda , y. kanakura , p. m. in runx mutated aml the number of runx mutations, loss of the wild-type allele and the number and kind of additional mutations impact on prognosis a. stengel, w. kern, m. meggendorfer, k. perglerovà, t. haferlach, c. haferlach mll munich leukemia laboratory, munich, germany, mll , praha, czech republic aml with mutated runx show a distinct pattern of cytogenetic and molecular genetic abnormalities and an adverse prognosis. we analyzed the impact of multiple runx mutations and runx wild-type (wt) loss on associated genetic alterations and survival. for this, aml cases with runx mutations (mut) were split in ( ) runx wt loss (n = ), ( ) > runx mut (n = ) and runx mut (n = ). cases were selected for mutation analyses of genes. in cases with runx mut, + was frequently found, whereas in wt loss + was the most abundant trisomy (+ : % in runx mut vs. % in wt loss, p = . ; + : % vs. %, p < . ). cases with > runx mut showed an intermediate distribution (+ : %, + : %). missense mutations were the most abundant mutation type in wt loss cases ( % vs. %, p = . ), whereas in runx mut, frameshift mutations were found more frequently ( % vs. %, p = . ). in cases with > runx mut, both were observed at similar frequencies (missense: %, frameshift: %). mutation analyses of selected cases revealed additional molecular mutations. % of cases showed at least one runx -accompying mutation (range: - ). the median of accompanying mutations was n = in the total cohort and in cases with runx- mut and > runx mut, whereas it was n = in runx wt loss. srsf ( %), asxl ( %), dnmt a ( %), idh ( %), sf b ( %), tet ( %) and bcor ( %) were revealed as most frequently mutated genes. cases with runx wt loss showed a higher frequency of asxl mut compared to the other cases ( % vs. %, p = . ), while u af mut were absent from this group ( % vs. %, p = . ). median overall survival (os) in the total cohort was months. wt loss (os: months) and > runx mut ( months) showed an adverse impact on prognosis compared to runx mut ( months; p = . and p = . , respectively). mutations in asxl and kras and the presence of ≥ additional mutations also negatively impacted os ( vs. months, p = . ; vs. months, p < . ; vs. months, p = . ). in univariate cox regression analysis runx wt loss (hr = . ; p = . ), ≥ additional mutations (hr = . ; p = . ), asxl mut (hr = . ; p = . ) and kr-asmut (hr = . ; p = . ) had an adverse impact on os. multivariate cox regression analysis revealed an independent adverse effect on os for runx wt loss (hr = . ; p = . ) and krasmut (hr = . ; p = . ). for / cases we received samples during course of the disease. in none of these cases, an evidence for a runx germline mutation was found by analyzing the mutation loads, thus all runx mutations are somatically acquired. taken together, we found strong differences between the subgroups in regard of cytogenetic and molecular genetic aberrations as well as regarding prognosis. thus, not only the presence and number of runx mutations but also the conservation of an intact runx allele as well as the number and kind of additional mutations is biologically and clinically relevant. abstracts different chromatin states, where methylation is inversely correlated with active histone marks. using the hardy-weinberg law, we estimate that there are dmrs with a maf> . . we hypothesized that cis-acting dna polymorphisms could be responsible for the inter-individual variation of the dmrs methylation levels. we genotyped . million snps in the five donors and found that / ( %) dmrs have methylation levels highly correlated (> . ) with the genotype of at least one nearby snp (± kb window). this correlation was verified in / dmrs by targeted bisulfite sequencing in monocytes from individuals used for wgbs and from additional individuals. to validate our results in a larger population and possibly find correlating snps outside the ± kb window for the remaining dmrs, we performed genome-wide association studies (gwas) using snp genotypes and illumina k cpg methylation data from blood samples of individuals from the heinz nixdorf recall study. these methylation arrays encompass only cpgs contained in of our dmrs, showing that they fail to identify a great number of potentially important regions. we certified that for these cpgs, monocyte and whole blood dmrs methylation levels were correlated, and performed a gwas with ~ , snp for each of the cpgs. for / cpgs, the correlation peak was near the cpg position. for each gwas, the snp with lowest p-value (in most cases p < e - ) was designated as lead-snp. snps in high linkage disequilibrium (r > . ) to the lead-snps were located within the corresponding dmr or bp to ~ kb from it. many regions are bound by ctcf and other transcription factors. it is likely that snps affect the binding of these factors and thus the methylation state of the region. we conclude that these inter-individual differences in dna methylation are mainly driven by genetic factors. the dystonia (dyt ) protein thap recruits the histone deacetylase hdac to mediate gene repression sektion für funktionelle genetik am institut für humangenetik, universität zu lübeck, lübeck, germany, institut für neurogenetik, universität zu lübeck, lübeck, germany dystonia describes a heterogeneous group of neurological movement disorders characterized by contractions in various muscles resulting in abnormal postures, involuntary twisting and repetitive movements. dystonia (dyt ), a primary torsions dystonia that first has an impact on cranio-cervical muscles causing problems with speaking and eating, is caused by mutations in the thap gene (thanatos-associated domain-containing apoptosis-associated protein ). thap belongs to the family of thap proteins that are characterized by the presence of an evolutionarily conserved specific dna-binding thap zinc finger motif at their n-terminus. in humans thap family members are known, designated thap to thap . interestingly, most of the dyt -causing mutations affect this thap domain. while we have previously described thap -mediated repression of specific target genes, the molecular mechanisms how thap regulates promoter activity are rather unknown. it is known, that other members of the thap family such as thap and thap interact with the histone deacetylase hdac to mediate transcriptional repression. we have performed yeast-two-hybrid and gst pulldown assays to identify a specific interaction of thap with hdac . by the use of truncated thap fragments we were able to narrow down hdac binding to the n-terminal thap-domain. for further functional characterization we have decreased hdac levels by sirna treatment or chemical inhibition and used taqman analyses to quantify the effect on thap -target genes expression. thus, a significant increase of thap -target genes expression was detected in those cells treated with hdac sirna. to further investigate whether the observed increase in gene expression is due to alterations of histone acetylation within the promoter regions we performed chromatin immunoprecipitation (chip) assays followed by qpcr using antibodies specific for different acetylated n-terminal residues of histone as markers for transcriptional active promoters. by this, we detected an increased acetylation within the promoter regions of thap target genes that are dysregulated in cells treated with decreased hdac levels. et-induced obesity indicate that epigenetic changes associated with adverse parental and/or intrauterine factors may contribute to the missing heritability of metabolic disorders. possible adverse paternal effects are likely transmitted by the sperm to the next generation. to prove this hypothesis, we have systematically analyzed the effects of paternal obesity on the sperm epigenome and its implications for the next generation. results: to study the possible transmission of paternal bmi effects to the next generation, methylation levels of eight paternally expressed imprinted genes (peg , peg , peg , peg , peg , peg , nespas and igf ), two maternally expressed imprinted genes (meg and h ), and the obesity related gene hif a were quantified by bisulphite pyrosequencing in sperm of donors (undergoing ivf/icsi) and fetal cord blood (fcb) of resulting offspring (conceived by ivf/icsi with the same sperm samples). hif a showed a significant positive correlation between sperm methylation and paternal bmi. this effect on the sperm epigenome was replicated in an independent cohort of sperm samples. for hif a, paternal bmi also showed a significant positive correlation with fcb methylation. on the other hand, peg /nnat exhibited a significant negative correlation between paternal bmi and fcb methylation. in contrast to pyrosequencing, deep bisulphite sequencing (dbs) allows one to study dna methylation at the single molecule level and enables us to distinguish between maternal and paternal alleles in fcb samples with an informative snp. epimutations which are defined as alleles showing > % aberrantly (de)methylated cpg sites can also be identified with dbs. upon performing dbs on sperm samples, we observed a higher epimutation rate in the high bmi ( - ) group when compared to the low bmi ( - ) group across the four studied genes (peg , hif a, h and nespas). we are presently analyzing dbs data in selected cord blood samples with an informative snp to separately quantify methylation at the paternal and maternal alleles. it is important to decipher the methylation of the paternal allele when studying whether sperm methylation alterations are transmitted to the offspring. conclusions: our results suggest that male obesity is associated with modification of the sperm dna methylome, which may affect the epigenome (in fetal cord blood) of the next generation. allele-specific dna methylation occurs at functionally different regions: ) at imprinting control elements, ) on the silent x chromosome in females and ) across the genome and probably dependent on the dna sequence in cis. the latter is termed haplotype-dependent allele-specific methylation and may contribute to inter-individual phenotypic variation. in a previous study on monocyte to macrophage differentiation, we showed that dna methylation differences between individuals were greater than between the two cell types. to study the genetic basis of these inter-individual differences in dna methylation, we analysed the methylome obtained by whole genome bisulfite sequencing (wgbs) of monocytes from five unrelated donors. for identifying differentially methylated regions (dmrs), we created two synthetic methylomes: one with the highest methylation values of each cpg in the five samples and one with the lowest methylation values. defining a dmr as a region of at least cpgs with a methylation level difference of at least . , we identified dmrs, which cover cpgs and fall into cer, respectively. we show that ns-associated rit mutants intensified signal flux through the mek-erk pathway upon growth factor stimulation. by using heterologous expression systems, we identified the p -activated kinase (pak ) as novel effector of rit . we found that rit interacts with the rho gtpases cdc and rac , both of which are crucial upstream regulators of pak . disease-causing rit mutations enhance protein-protein interactions and uncouple complex formation from growth factors. expression of both wild-type rit and its mutant forms resulted in dissolution of stress fibers and paxillin-containing focal adhesions from the cell center and increased cell movement. we conclude that rit is a potent regulator of actin dynamics, and dysregulated rac /cdc -pak signaling controlling cell adhesion and migration may be one aspect of the molecular basis of ns. medical systems biology, tu dresden, germany, institute for clinical genetics, tu dresden, germany, cancer science institute of singapore, national university of singapore, singapore, institute of molecular biology, mainz, germany telomeres are short repetitive ttaggg sequences that cap the ends of chromosomes. these stretches of dna are covered by proteins and rnas which together protect the putative double strand break from dna repair mechanisms and facilitate replication. however, telomeres shorten with every cell division due to the end replication problem. the ribonucleoprotein telomerase counteracts this process by de novo elongation of telomeric repeats but its expression is mostly confined to the germ line and stem cells. even in the latter its activity is usually not sufficient to completely prevent telomere shortening. all cancer cells are also faced with this challenge and while the majority of cancer cells rely on telomerase, approximately % of cancers ensure sufficient telomere length via the recombination-based alternative lengthening of telomeres (alt) mechanism. to better understand telomere biology we aimed to identify novel telomeric factors by systematically screening for telomere-binding proteins in cell lines from different vertebrates. here, we identified and characterized zbtb , a zinc finger protein, as a novel direct telomere-binding protein across the vertebrate lineage. zbtb is directly binding to telomeric dna in vitro and it is localizing to telomeres in vivo via one specific zinc finger domain in both telomerase-and alt-positive cancer cells. interestingly, zbtb knock-out cells have longer telomeres, suggesting that zbtb limits telomere elongation. in addition, the combination of chipseq, rnaseq and proteome analysis revealed a transcription factor activity for a small, but specific set of target genes of zbtb , linking its telomeric functions to mitochondrial metabolism. in conclusion, zbtb is a novel direct telomere binding protein with transcription factor activity that acts as negative regulator of telomere length. our data show for the first time a functional interaction of the 'dystonia protein' thap with the histone deacetylase hdac and therefore give new insights into the molecular mechanisms of thap -mediated gene repression. interestingly, previous functional studies as well as structure analyses revealed that only a subset of the dyt -causing mutations affecting the n-terminal thap domain alter thap -binding to dna. in ongoing studies we want to investigate the consequences of dyt -causing mutations on thap -hdac complex formation and its relevance in the molecular pathology of dystonia. reproductive homeobox (rhox) genes are clustered on the x chromosome and share a unique amino acid helix-turn-helix dna binding homeodomain. they were identified in several species as having important roles in reproductive tissues, notably in the testis. the human rhox cluster is composed of three genes: rhoxf and two copies of rhoxf (rhoxf a, rhoxf b) which are referred to as rhoxf / b. rhox proteins are expressed exclusively by germ cells in human testis and aberrant rhox methylation is associated with several sperm parameters. because little is known about the molecular mechanism of rhox function in humans, the aim of the study was to identify target genes of human rhox proteins and to investigate the impact of rhox mutations on protein function. using gene expression profiling, we identified genes regulated by members of the human rhox gene cluster. some genes were uniquely regulated by rhoxf or rhoxf / b, while others were regulated by both of these transcription factors. several of these regulated genes encode proteins involved in processes relevant to spermatogenesis, e. g. stress protection and cell survival. one of the target genes of rhoxf / b is rhoxf , suggesting cross-regulation to enhance transcriptional responses. the potential role of rhox in human infertility was addressed by sequencing rhox in a group of patients with severe oligozoospermia. this revealed two mutations in rhoxf (c. g>a and c. c>t) and four in rhoxf / b (- c>g, c. g>a, c. c>t and c. g>a), of which only one (c. g>a) was found in a control group of men with normal sperm concentration. functional analysis demonstrated that c. g>a and c. g>a significantly impaired the ability of rhoxf / b to regulate downstream genes. molecular modelling suggested that these mutations alter rhoxf /f b protein conformation. by combining clinical data with in vitro functional analysis, we demonstrate how the x-linked rhox gene cluster may function in normal human spermatogenesis and we provide evidence that it is impaired in human male fertility. colorectal cancer (crc). here, we proposed the possible molecular mechanisms responsible for crc initiation, progression and invasion using a network biology approach. materials and methods: in order to investigate the underlying crc pathogenesis, the dataset gse consisting of normal tissues, stage i, stage ii, stage iii and stage iv of crc were obtained from gene expression omnibus (geo) and further examined. the differentially expressed genes (degs) were subjected to protein-protein interaction databases and a ppi network was constructed for each crc stage. topological analysis of resulted ppi networks revealed functional hub genes and involved in crc development. furthermore, the overlap genes between four studied crc stages were determined and deeply evaluated to identify deregulat ed biological networks during crc development. a standard real-time pcr was performed to validate the in silico findings utilizing sw and ncm cell lines. results: the most important hub genes (cdk for stage i, ubc for stage ii, esr for stage iii and atxn for stage iv) and sub-networks were identified in crc stages. moreover, several novel biomarkers were also introduced for each crc stage. gene ontology (go) and signaling pathway enrichment uncovered the important roles of wnt, mapk and jak-stat signaling pathways in regulation of crc pathogenesis. functional annotation of overlap genes revealed that cell cycle regulating genes are the most highly regulated genes during crc initiation, progression and invasion. in vitro analyses confirmed deregulation of atxn and cdk , two hub genes of stage iv, in metastatic colon sw cells compared to normal colon ncm cell line. our study provides a new insight into the distinct molecular mechanisms underlying the pathogenesis of crc. the functional hub genes, sub-networks, prioritizes key pathways and novel crc biomarkers were also provided that can be useful in therapeutic programs. targeted next-generation sequencing approaches as well as next-generation whole exome sequencing are becoming more widespread in routine molecular diagnostics for patients with ataxia. however, since ngs at present is not suitable to detect (trinucleotide) repeat expansions, a pre-ngs testing for common polyglutamine expansion scas seems mandatory. but also sca subtypes caused by expansions in non-coding regions of genes like sca , sca , sca , and sca as well as other ataxias known to be associated with repeat expansions like the fragile x-associated tremor ataxia syndrome (fxtas) should be taken into account before applying ngs-based diagnostics. in order to find an optimal diagnostic strategy in future more information about the frequency and phenotypic characteristics of rare repeat expansion disorders associated with ataxia would be helpful. we therefore analyzed a cohort of patients with symptoms of cerebellar ataxia, dysarthria and other unspecific symptoms who were referred to our center for sca diagnostics and showed alleles in the normal range for the most common sca subtypes sca - , sca , sca , and sca . these patients were screened for expansions in sca , sca , sca , sca and fxtas as well as for the pathogenic hexanucleotide repeat in the c orf gene. no expanded repeats for sca , sca or sca were found in the analyzed patients. five patients with ataxia of unknown etiology showed sca cta/ctg combined alleles ( - ) that are discussed to be potentially pathogenic. one -year-old male patient with unclear dementia syndromes was diagnosed with a large ggggcc repeat expansion in c orf . and the analysis of the fmr gene identified one patient with a permutation (> cgg repeats) and seven patients poster *** = für den posterpreis nominiert preventive genetic counseling in neurogenetic disorders needs a better collaborative approach between genetic and neurology clinics -a report of four siblings with unverricht-lundborg disease: genetic counseling is the process of helping people to understand and adapt the medical, psychological and familial implications of genetic contributions to disease. for parents with a previous child or other family member with a known genetic syndrome expands options for preimplantation or prenatal diagnosis for the current or the future pregnancies. however, timely referral by health providers to genetic counselor and for discussing with couples regarding possible options is important. additionally, other factors such as personal decision making especially due to high price of some genetic services and uncertain results cause considerably delays to genetic testing. there are more than various types of inherited neurological disorders in which alterations in genes lead to an inherited condition such as huntington disease, inherited forms of alzheimer disease, ataxia, muscular dystrophies and epilepsies. the knowledge of the causative gene mutations in the affected individual is critical in the possible prenatal diagnosis in other members of the pedigree. therefore a multidisciplinary care team, including neurologist and genetic counselor for the conditions diagnosed as inherited neurological disorders is critical in prenatal setting and consideration of an effective management. here, our report of four siblings affected by a rare form of inherited epilepsy (unverricht-lundborg disease) with an autosomal recessive pattern highlights the importance of the needs for a better collaborative approach in the neurogenetic setting. in fact, the birth of four successive siblings affected by similar neurogenetics disorders in a specific family is showing the need for more attention to this important issue, especially in terms of intersectoral collaboration. poorebrahim hort: / differentially expressed transcription units). these differences in gene expression we detected did not correlate with dna methylation changes at the corresponding transcription regulatory sites. from our results we conclude that altered expression of imprinted genes indeed plays a role in tumorigenesis of germinal center derived b-cell lymphomas. however, the altered transcriptional regulation of these genes seems not to rely on the usual epigenetic mechanisms known from constitutional imprinting disorders. mf. abazari , h. bokharaie , m. asghari , v. poortahmasebi , h. askari , m. investigating the expression of genes associated with autism spectrum disorders to identify sex related differences s. berkel, a. eltokhi, g. rappold institute of human genetics, heidelberg university hospital, heidelberg, germany neurodevelopmental disorders such as autism, attention deficit and hyperactivity syndrome as well as language problems and learning difficulties have a higher prevalence in male individuals compared to females. autism is characterized by impairments in social interaction, communication deficits and restricted and repetitive behaviors. boys are more frequently affected than girls; the ratio of affected boys compared to girls is : for autism and : for asperger syndrome. in this study we aim to elucidate the reason for this gender difference by following up two hypotheses: ( ) risk genes for autism spectrum disorders (asd) might be expressed at different levels in males and females and ( ) asd risk genes might interact with sexually dimorphic pathways. first, we investigated the expression of genes associated with autism spectrum disorders, including the shank gene family, in the brain of male and female mice to identify sex-dependent differences. the rna expression levels were analyzed in five different brain regions (cortex, hippocampus, striatum, cerebellum, thalamus) at different developmental stages (e , e , p , p , p and adult) in male and female mice. we identified a sex dimorphic expression of shank and shank , but not of shank . due to the fact that early brain development is strongly influenced by sex hormones (estrogen, testosterone), we further investigated the influence of these hormones on shank expression in human neuroblastoma cells (sh-sy y) and primary mouse hippocampal neurons. a better understanding of the sex differences in the brain might help to explain the vulnerability for neuropsychiatric disorders like autism and paves the way to discover putative risk or protective factors for these disorders. imprinting defects in temple syndrome are caused by a failure in imprint establishment and/or maintenance j. beygo, c. mertel, g. gillessen-kaesbach, b. horsthemke, k. buiting institut für humangenetik, universitätsklinikum essen, universität duisburg-essen, essen, germany, institut für humangenetik, universität zu lübeck, lübeck, germany temple syndrome (ts ) is a rare imprinting disorder characterised by low birth weight and height, muscular hypotonia and feeding difficulties in the infant period, early puberty and short stature with small hands and feet and often truncal obesity. in a subset of patients with ts , the disease is caused by an imprinting defect (id) affecting the paternal allele of the imprinted region q . the id results in aberrant methylation of the three known differentially methylated regions (dmrs), the germline-derived primary dlk /meg intergenic (ig-)dmr (meg /dlk :ig-dmr), the postfertilization-derived, secondary dmr at the meg promoter (meg :tss-dmr), and the postfertilization-derived, secondary intragenic meg -dmr (meg :int -dmr). the meg /dlk :ig-dmr and the meg :tss-dmr are methylated on the paternal chromosome and hypomethylated in patients with ts and an imprinting defect. the meg :int -dmr is unmethylated on the paternal chromosome and hypermethylated in these patients. both the meg /dlk :ig-dmr and the with alleles in the grey zone ( to cgg repeats), thus suggesting that individuals with fmr repeat expansions in the gray zone may also present with neurological signs. bernhart , , , h. kretzmer , , r. wagener , c. mmml some genes are subject to the mechanism of imprinting, i. e. their expression depends on parental origin. they primarily function in the control of proliferation, fetal development and cellular differentiation. constitutional imprinting disorders are in part also associated with an increased tumor risk. loss of imprinting has been also described as somatic event in tumorigenesis. while this phenomenon has been broadly analyzed in solid tumors, data on alterations of imprinting in lymphatic neoplasms are largely missing. we analyzed the rna expression of transcription units/regions known or supposed to be subject to imprinting in two cohorts of normal b-cells and germinal center derived b-cell lymphomas. the first cohort (mmml) contains samples: burkitt lymphomas (bl), non-burkitt lymphomas (non-bl, including various subtypes like follicular and diffuse large b-cell lymphoma) and normal germinal center b-cell samples (gcbc, as controls). the second cohort (icgc mmml-seq) comprised samples with bl, non-bl and gcbc samples. gene expression was analyzed with affymetrix u a genechips in the mmml cohort and by rna sequencing in the icgc mmml-seq cohort. results of the transcriptional analyses in the icgc mmml-seq cohort were compared to the dna methylation available from a subset of the analyzed samples (kretzmer et al., nat genet, ) . of the transcription units sites, corresponding to transcription units, were present on the applied array used for the analysis of the mmml cohort. a two group comparison revealed significantly differentially expressed sites corresponding to transcription units between bl and non-bl including the plagl and peg genes. in total, and sites corresponding to and transcription units are differentially expressed between bl versus gcbc and non-bl versus gcbc, respectively. comparison of gene expression in the icgc cohort revealed differentially expressed sites corresponding to transcription units between bl and non-bl (overlap with mmml cohort: / differentially expressed transcription units), including again peg and plagl , differentially expressed sites corresponding to transcription units between bl and gcbc (overlap with mmml cohort: / differentially expressed transcription units) and differentially expressed sites corresponding to transcription units between non-bl and gcbc (overlap with mmml co-abstracts maintenance dna methylation of l promoters, spoc could function in targeting g a to l sequences. in conclusion our data implicate the epigenetic reader spoc in the suppression of line elements during germ cell development. s. bens , j. kolarova , m. kreuz , sh. characterization of the expression of the imprinted kcnk -gene in specific brain regions and the phenotypic analysis of kcnk knockout mice a kcnk /kcnk is a maternally expressed imprinted gene whose mutations are responsible for the maternally inherited birk-barel mental retardation dysmorphism syndrome. it encodes a member of the superfamily of k+channels with two pore-forming domains and is involved in the modulation of the resting membrane potential and excitability of neuronal cells. so far, only homozygous kcnk knockout mice with inactivation of both parental alleles were phenotypically characterized. these mice displayed cognitive deficits as well as a reduction of k+ leak current by %. in the light of maternal-specific imprinted expression of kcnk /kcnk and the maternal inheritance of the birk-barel mental retardation dysmorphism, a thorough phenotypic analysis of heterozygous kcnk knockout mice with inactivation of only the maternally inherited allele is also warranted. as first aim of our study, we characterized the parental allele-specific expression of kcnk in various regions of the mouse brain. quantification of allele-specific expression by pyrosequencing (quasep) method was performed for different brain areas from several developmental stages of (c bl/ xcast/ei) f hybrid mice. exclusive expression from the maternal kcnk allele was detected in the dentate gyrus, hippocampus, mesencephalon, medulla oblongata, thalamus and pons. biallelic expression with, however, a strong bias towards the maternal kcnk allele ( - % of the transcripts) was observed in the olfactory bulbs, cortex, cerebellum, striatum and olfactory tubercles. as the second aim of our study, the phenotypes of wildtype, heterozygous kcnk knockout mice with maternal inherited knockout allele (kcnk komat) and homozygous kcnk knockout mice (kcnk kohom) were comparatively examined in a behavioral test battery. due to the already known cognitive defects of kcnk kohom animals and especially the phenotype of the patients with birk-barel syndrome, it was assumed that kcnk komat and kcnk kohom animals show deficits in some of the tests. the spontaneous alternation in the y-maze test was significantly reduced by approximately - % in kcnk komat and kcnk kohom mice compared to wildtype mice indicating a clearly impaired working memory. in addition, kcnk komat and kcnk kohom mice displayed a reduced prepulse inhibition of startle response compared to wildtype mice indicating an impairment of sensomotoric gating, a process to filter out irrelevant information. acoustic startle response as a measure of anxiety levels was also significantly decreased, but only in kcnk kohom mice. our findings shall further elucidate the role of kcnk /kcnk in brain physiology and pathophysiology and open new avenues for treatment of cognitive dysfunctions in birk-barel syndrome. meg :tss-dmr act as imprinting control centres, although the meg / dlk :ig-dmr functions as an upstream regulator of the meg -dmr. so far, the function and regulation of the meg -dmr is unknown. the hypomethylation of the paternal allele in ts -id patients at the meg / dlk :ig-dmr and the meg :tss-dmr point to a failure in the establishment of the methylation imprint or to maintain the methylation imprint after fertilization. in this case, the incorrectly imprinted chromosome would be inherited from either the paternal grandfather or grandmother. to prove this assumption we are investigating the grandparental origin of the affected chromosome in our cohort of ten ts -id families by studying the parent-of-origin specific methylation of the three dmrs in combination with informative single nucleotide variants (snps). at the moment we have identified three families informative for the meg / dlk :ig-dmr, two families for the meg :tss-dmr and two families for the meg :int -dmr. so far we have obtained results in two families for the meg :tss-dmr. we found that in one case the allele harbouring the id was inherited from the paternal grandmother, but in the second case from the paternal grandfather, indicating that the id occurred after erasure of the parental methylation imprints. a complete lack of methylation observed in the majority of ts -id patients is therefore likely due to a problem in establishing methylation on the paternal chromosome, whereas in rare cases with methylation mosaicism, the id is probably due to a problem to maintain the paternal imprint after fertilization. bosch, s. lukassen, j. kaindl, j. schwarz, c. nelkenbrecher, a. herrmann, a. reichel, a. ekici, t. gramberg, t. stamminger, a. winterpacht humangenetisches institut, erlangen, germany, virologisches institut, erlangen, germany spoc /phf is a gene located on human chromosome region p . and mouse chromosome qe . the protein was first described in patients with epithelial ovarian cancer, where its expression correlated with tumour progression and reduced survival time. spoc is a reader of the epigenetic mark h k me / , dynamically associates with chromatin during mitosis and plays a role in chromosome condensation. spoc deficient mice show a pronounced hypoplasia of the testis with a progressive loss of germ cells. although loss of spoc leads to a significantly reduced chromatin condensation of the sex chromosomes in meiosis, the protein is not expressed in spermatocytes but in the undifferentiated precursor cells, the spermatogonial stem cells (sscs). here, we present chip-seq data of mouse testis tissue demonstrating that spoc strongly binds to evolutionary young l elements in undifferentiated spermatogonia. we show that in hek cells overexpression of spoc leads to repression of transposition activity of line-elements strongly indicating a role of spoc in l element suppression. the cell has developed several lines of defence against retrotransposition to maintain genomic integrity, including dna methylation. these defence mechanisms are most elaborate in spermatogonial stem cells since transposition events in these cells would have a dramatic impact on the next generation. therefore, the repression of retrotransposition is of fundamental importance for germ cell development and ultimately the quality of the gametes. moreover, we present medip results showing that the methylation levels of l sequences decrease upon spoc -knockout and demonstrate that the histone methyltransferase g a is strongly upregulated in preleptotene meiocytes of spoc -/mice. g a is expressed from spermatogonia until early meiosis where it regulates h k di-methylation and has been shown to be involved in the repression of l element in mouse spermatogonia. we are able to demonstrate that h k me levels are unaltered in spoc -/mice, suggesting a potential functional link between g a and spoc that does not affect the catalytic activity of g a. since g a can regulate de novo and medizinische genetik · lated to investigate ciliogenesis. data resulting from rnaseq experiments are analyzed by established informatics tools (tophat, cufflinks and derivatives thereof). we will show results from our work in progress and we hope to convince people to intensify rna analyses even in routine labs to uncover hidden mechanism and/or mutations impacting mrna splicing and thereby causing human disease. telomeres are located at the ends of chromosomes and have an essential role in the maintenance of genome stability. after each cell division, a small part of this specialized sequence is lost. when telomeres reach a critically reduced length, the cell either dies through apoptosis or enters a state of permanent cell cycle arrest. it has been demonstrated that telomere biology is directly linked to basic biological phenomena such as aging, tumorigenesis and maintenance of dna integrity. it is known that oxidative stress accelerates telomere shortening in cells, resulting in premature cell senescence. shorter leukocyte telomeres have been observed in type ii diabetes or degenerative disease like dementia and alzheimer disease as well in chromosomal instability syndrome, such as fanconi anemia (fa) and nijmegen breakage syndrome (nbs). any link between telomere length and inflammation has not yet been extensively studied in autoimmune diseases. accelerated length shortening might be related to autoimmune disease predisposition. yet the reasons for this shortening are likely manifold, including the individual genetic background, oxidative stress and chronic inflammation. in order to shed light on these relationships, we investigate genomic dna extracted from blood of patients diagnosed with multiple sclerosis and from patients with huntington disease. the samples were divided into age groups. stepone q-pcr was applied to detect the relative telomere length as a function of age. initially identified differences in telomere lengths still have to be confirmed in larger cohorts. background: intrauterine exposure to gestational diabetes mellitus (gdm) confers a lifelong increased risk for metabolic and other complex disorders to the offspring. gdm-induced epigenetic modifications modulating gene regulation and persisting into later life are generally assumed to mediate these increased disease risks. to identify candidate genes for fetal programming, we compared genome-wide methylation patterns of fetal cord bloods (fcbs) from gdm and control pregnancies. methods and results: using illumina's k methylation arrays and following correction for multiple testing, cpg sites ( of which are associated with genes) displayed significant methylation differences between gdm and control samples. three of four candidate genes, atp a , prkch, and slc a , from our methylation screen and one, hif a, from the literature were validated by bisulfite pyrosequencing. the gdm effect on fcb methylation was more pronounced in women with insulin-dependent gdm who had a more severe metabolic phenotype than women with dietetically treated gdm. however, the effect remained significant after adjustment for the maternal bmi and gestational week in a multivariate regression model. e. g. dekomien , , b. bellenberg , , n. trampe , , r. schneider , , c. prehn , , c. krogias , , r. kropatsch , , m. regensburger , , c. lukas , , r. gold , , human genetics, bochum, germany, ruhr-university bochum, germany, radiology, st. josef-hospital, bochum, germany, neurology, st. josef-hospital, bochum, germany, molecular neurology, erlangen, germany, university of erlangen, germany a pair of monozygotic -year-old twins suffering from hereditary spastic paraplegia (spg ) is described. patients underwent thorough clinical examination and magnetic resonance imaging (mri) and mr-spectroscopy (mrs) at tesla. genetic testing was performed by sanger sequencing and alternative splicing by rna analysis. clinically the patients presented a similar spectrum of symptoms with a higher level of disability in one of the patients. mri studies including morphometry and regional microstructural analysis by diffusion tensor imaging (dti) of the corpus callosum (cc) revealed marked thinning and corresponding increases of axial diffusivity (ad), radial diffusivity (rd) and apparent diffusion coefficient (adc) and reduction of the fractional anisotropy (fa) as compared to healthy controls in all cc sections, particularly in the anterior callosal body. there was marked supratentorial white matter reduction and to a lesser extent grey matter reduction in both patients. involvement of the cortico-spinal tracts was reflected by fa and rd alterations and cervical cord atrophy. the more strongly affected patient showed a higher degree of callosal microstructural damage and cervical cord atrophy. genetic testing of the spg gene revealed two mutations in compound heterozygous state, a known frameshift mutation as well as a novel synonymous exonic splice site mutation. this study shows similar but distinct clinical and imaging findings in monozygotic twins suffering from spg , suggesting individual downstream genetic effects. targeted next generation sequencing techniques tremendously improved our ability to identify sequence variants. however fixing disease causing mutation still lack behind because of several reasons: inappropriate gene specific data bank, insufficient prediction tools, incomplete analysis and others. in addition identified sequence variants are a mixture of severe disease causing mutations and a myriad of variants of unknown pathogenicity. in addition an unknown number of silent mutations, neutral polymorphism and sequence variants deeply buried in introns might severely influence splicing of the premature rna molecule. by solely analysis of the dna sequence this impact onto the integrity of the mrna is completely ignored. in order to catalog the mrna isoforms derived from genes of our interest we started to set up rnaseq technologies in our routine lab. to reduce the amount of data, to improve the power of analyses and to identify rare isoforms of transcripts we use targeted rnaseq to characterize the mrna molecules originating from those genes we are interested in (e. g.: hereditary breast cancer core genes ( genes), hereditary colon cancer ( genes), primary ciliary dyskinesia (pcd)( genes). genes involved in pcd offer the invaluable advantage that the respiratory epithelium where these genes are normally expressed can be sampled from the inferior turbinate of the nose by brush biopsy either from healthy probands or from patients suffering from pcd. in addition to direct preparation of rna from these cilia, cilia carrying cells or tissue can be cultured and manipu-abstracts long-range pcr and direct sequence analysis. the comparative analysis of parental haplotypes with the sequences flanking the deletion breakpoints in the patients revealed the absence of any de novo mutations in breakpoint-flanking regions of prs -mediated and prs -mediated type- nf deletions. we conclude that although nahr is a mutational mechanism causing large nf deletions, there is no evidence for a local mutagenic effect of these recombination events. hence it is unlikely that nahr underlying type- nf deletions involves error-prone translesion polymerases that would increase the de novo mutation rate in breakpoint flanking regions. furthermore, the detailed haplotype analysis of prs , a highly active nahr hotspot mediating the majority of large nf deletions, revealed that non-allelic homologous gene conversion (nahgc) between nf -repa and nf -repc, which results from non-crossover resolution of recombination intermediates, is the major driving force responsible for the haplotype diversity in this region. remarkably, the haplotype diversity patterns observed for nf -repa and nf -repc were markedly different indicating that during nahgc, nf -repa is disporportionately more often the donor sequence used to repair mismachtes in heteroduplex regions than nf -repc. we also noticed a correlation between haplotype diversity and the number of prdm a-allele binding sites suggesting that haplotype diversity and hence the nahgc rate within prs in nf-repa is regulated by prdm . heidelberg center for personalized oncology dkfz-hipo dkfz, heidelberg, germany dna methylation aberrations at differentially methylated region of imprinted genes interfere with the naturally parental-specific mono-allelic expression. that leads to a bi-allelic or absent expression of the imprinted gene, a cause of imprinting disorders (ids). we aimed at analyzing the genome wide dna methylation pattern of two patients with ids, namely transient neonatal diabetes mellitus (tndm) and multi locus imprinting disturbance (mlid), and their respective parents. the dna methylation profiles of these individuals were obtained by whole genome bisulfite sequencing (wgbs) on b cells sorted by magnetic cell isolation. the sequencing libraries were prepared as described in kretzmer et al. [ ] and sequenced on an illumina hiseq machine. wgbs data were processed with the methylctools toolkit. briefly, bisulphite-treated sequences were aligned with bwa-mem using a three-letter approach, and the methylation ratios were quantified for ~ . million out of . million cpg sites (coverage> ) genome-wide. quality control was performed to assess the quality of the dna methylation profiles and genetic fingerprinting was performed on the wgbs data confirming sample origin and family relationship. the wgbs data was further compared to already existing genome-wide human snp array . (snp array) and humanmethylation k bead array ( k) data, resulting in a good accordance with pearson's correlation coefficients > . . we detected an overall dna methylation level around % in all samples. already known dna methylation alterations, e. g. hypomethylation in plagl were validated by wgbs. by searching for differentially methylated regions (dmrs), defined as regions composed of at least five consecutive cpg loci showing a methylation difference between patient and corresponding parents above %, we identified dmrs in the mlid our study supports an association between maternal gdm and the epigenetic status of the exposed offspring. consistent with a multifactorial disease model, the observed fcb methylation changes are of small effect size but affect multiple genes/loci. the identified genes are primary candidates for transmitting gdm effects to the next generation. they also may provide useful biomarkers for the diagnosis and prognosis of adverse prenatal exposures and assessing the success of interventions during pregnancy. the nuclease hsnm b/apollo has a dual function in both dna-repair and maintenance of telomeres. as to the repair of dna interstrand crosslinks (icl), hsnm b/apollo is linked to the fanconi anemia (fa) pathway and cells depleted for hsnm b/apollo (sirna) resemble those from patients with fa. we have identified a single nucleotide polymorphism, rs , which is associated with quantitative differences in hsnm b/apollo expression (mrna). we analyze whether the differential expression relates to the degree of cellular sensitivity to the dna interstrand crosslinks inducing mutagen mitomycin c (mmc) and ionising radiation (ir), which induces, among other lesions, dna double strand breaks. all experiments are realized using lymphoblastoid cells derived from generally healthy donors. results of rt-pcr analysis of hsnm b/apollo expression and of the cell viability assays will be presented and discussed in the context of the potential usefulness of considering rs in predicting individual sensitivity to mutagens relevant in anti-cancer treatment. p-basepi- nahr events causing type- nf microdeletions are not associated with an increased mutation rate in breakpoint-flanking regions m. hillmer , , a. summerer , , v. f. mautner , , l. messiaen , , h. institute of human genetics, ulm, germany, university of ulm, ulm, germany, department of neurology, hamburg, germany, university hospital hamburg eppendorf, hamburg, germany, department of genetics, birmingham, usa, university of alabama at birmingham, birmingham, usa large deletions of the nf gene and its flanking regions are the most frequent recurrent mutations in patients with neurofibromatosis type (nf ). different types of large nf deletions have been identified which are distinguishable in terms of their size and breakpoint position. most frequent are type- nf deletions spanning . -mb and characterized by breakpoints located within the low-copy-repeats nf -repa and nf -repc which exhibit . % sequence homology within -kb. type- nf deletions are caused by non-allelic homologous recombination (nahr). two nahr hotspots have been identified termed prs and prs which encompass -kb and -kb, respectively. approximately % of all type- nf deletion breakpoints cluster within the prs and prs nahr hotspots. in this study, we analysed whether the nahr events causing type- nf deletions would be associated with an increased de novo mutation rate of sequences located in breakpoint-flanking regions. to do so, we sequenced the deletion breakpoint-flanking regions in the patients and compared these sequences with the homologous regions amplified from dna of the patients' parents who are not affected by nf . however, in the germline of these parents, the deletions were mediated by nahr and then transmitted to their offspring. the parental haplotypes within the prs or prs regions of nf -repa and nf -repc were analysed by in the alpl gene and inherited as an autosomal dominant trait can cause milder forms. so far detailed knowledge of the milder forms is lacking. patients with a mutation in the alpl gene were interviewed in a standardized questionaire concerning the different disease manifestations: teeth, bone fractures, pain of bones and muscles and quality of life. subgroups were formed with regard to the localization of the mutations in the three protein domains. patients with mutations clustering in the catalytic site of the molecule showed the most severe odontohypophosphatasia: one individual had premature primary tooth loss, % of patients showed adult tooth loss, % suffered from dental caries. the majority had the first manifestation before the age of . persons suffering from mutations in the two other domains reported a relatively high quality of live with low pain of muscles and bones. unexpectedly in all groups there was no significant difference in the portion of patients with bone fracture. conclusion: the clinical signs of dominant hpp are mostly unspecific. especially dental problems like severe adult teeth loss, an early manifestation of dental caries or enlarged pulp chambers can be a sign of odontohypophosphatasia and a dominant inherited mild hpp. mutations in the catalytic site of the alpl molecule are associated with a more severe odontohypophosphatasia. screening of non-neoplastic lymphatic tissues from children for the igh-myc fusion using a highly sensitive -color fish-assay burkitt lymphoma is a mature b-cell lymphoma which on the genetic level is characterized by the burkitt translocation t( ; )(q ;q ) juxtaposing the igh locus in q next to the myc locus in q . in a minor part of burkitt lymphomas, immunoglobulin light chain variants of the translocation result in overexpression of myc. despite being pathognomonic for burkitt lymphoma, the ig-myc juxtaposition alone is not sufficient on its own for a malignant transformation of the cell. other igh rearrangements like the igh-bcl fusion, typical for follicular lymphoma, were detected in a significant number of healthy individuals. for the igh-myc translocation, only scarce data in healthy individuals exist. this is most likely due to scattering of the breakpoints which are far more difficult to target by pcr than the igh-bcl translocation. therefore, we aimed at investigating if myc-translocation positive cells can also be detected in normal b-cell maturation. considering the epidemiology of burkitt lymphoma being the most common b-cell lymphoma in children, we focused on samples from young individuals. on the one hand, we analyzed non-neoplastic tissue specimen of bone marrow (n = ) (age range - , median age . years) and lymph nodes (n = )(age range - years, median age years). on the other hand, considering the typical clinical presentation of burkitt lymphoma, we included non-neoplastic tissue specimen containing peyer patches (n = )(age range hours- years, median age years). the specimen were analyzed using a four-color fluorescence in situ hybridisation (fish) assay with probes flanking the breakpoints on chromosomes and . in this setting, a positive result comprised the break on both chromosomes (seen as signal split for each locus) and fusion of the involved genes (leading to two different fusion signals). the assay was first validated on controls of cells with a normal male karyotype from healthy individuals as well as on five burkitt cell lines and each five ffpe embedded t( ; ) negative and positive tissues as negative and positive controls. the assay was then applied for the screening of a igh-myc fusion in the above mentioned paraffin-embedded tissues. successful hybridizations of overall , and ffpe sections from bone marrow, lymph nodes and peyer patches respectively could be obtained. trio and dmrs in the tndm trio. in the mlid trio / dmrs showed increased and dmrs decreased dna methylation in the patient's sample. of dmrs, are located in regions potentially associated with transcriptional regulation. further analysis revealed that / dmrs are associated with imprinted genes. in the tndm trio, we detected / dmrs to show hypermethylation in the patient compared to her parents and / dmrs with lower dna methylation. in these trio / dmrs are associated with regions potentially correlated to transcriptional regulation and dmrs with imprinted genes summarized, our results show that wgbs is a well suited and valid method for analyzing dna methylation. while the overall dna methylation levels does not differ between the analyzed patients and parents, a detailed analysis of smaller regions revealed the existence of respectively differentially methylated regions between the analyzed mlid and tndm patient and their parents. supported by bmbf through fkz: gm und gm and gm p-basepi- characteristic mutational profile in children of individuals exposed to ionizing radiation p. krawitz, h. manuel, a. knaus, g. hildebrandt, m. jäger, m. schubach, m. rodriguez de los santos, t. pantel, d. beule, s. mundlos, k. sperling institute for medical genetics and human genetics charite, berlin, germany the dna damaging effects of ionizing radiation are deliberately used in cancer therapy as well as feared in accidents related to nuclear technology. despite its influence on the exposed organism, irradiation was believed to have no major effect on succeeding generations, as irreparable dna damages were thought to result in cell death. recently, however, genome-wide mutation screenings in offsprings of male mice that were irradiated with high dosages showed an accumulation for certain de novo events. we therefore focused on these mutational classes in a small cohort of human individuals that were conceived while or after their fathers were exposed to high frequency radiation. in the whole genome sequences of such offsprings we could confirm de novo rates for single nucleotide variants in the order of - per base as previously reported. interestingly, however, we found de novo translocations of paternal origin as well as increased numbers of clustered de novo mutations that resemble the results from animal studies. this characteristic mutation profile might thus be used as an indicator of irradiation exposure in one of the individual's parents. from the upstream regular rb promoter. to test this hypothesis, we generated a genetic model carrying modifications in the rb promoter and in cpg using crispr/cas technology. data on the establishment of the model and first results will be presented. the gid/ctlh protein complex with its seven core protein members is conserved in all eukaryotic cells. in saccharomyces cerevisiae it functions as an ubiquitin ligase complex and regulates the metabolic switch from gluconeogenesis to glycolysis ( ) . recently, we could show that the vertebrate gid/ctlh complex also functions as an ubiquitin ligase, however substrates and exact function remain unknown ( ) . a growing number of components of the ubiquitin protein system (ups) are described to be regulators of ciliogenesis ( ). defects in such genes are considered to cause ciliopathies, genetic disorders with typical phenotypic variations in patients and model organisms ( ) . first data supports our hypothesis that the ctlh complex plays a major role in ciliogenesis, e. g. the ctlh subunit rmnd a localizes to the basal body which is a modified centriole of primary cilia in nih- t cells and rmnd knock down in xenopus laevis leads to defects in cilia formation of epidermal multiciliated cells. n. reich, m. sandbothe, r. buurman, b. schlegelberger, t. illig, b . skawran department of human genetics, hannover, germany background and aims: hepatocellular carcinoma (hcc) is characterized by genetic and epigenetic changes that lead to a deregulation of important tumor suppressors and oncogenes in a multistep process. one of these epigenetic changes is the elevated expression of histone-deacetylases (hdacs) which contribute to a transcriptional repression of certain genomic regions by remodeling the chromatin structure. thereby, not only the expression of tumor-relevant genes is affected, but also the expression of micrornas (mirnas). selected mirnas have been shown to play important roles in carcinogenesis. we aimed to identify mirnas deregulated by histone deacetylation and to understand their functional consequences in hcc tumorigenesis. methods: histone acetylation was induced by the global hdac inhibitor trichostatin a (tsa) in four hcc cell lines (hle, hlf, huh , hepg ) and two immortalized liver cell lines (thle- and thle- ) in order to identify differentially expressed mirnas and messenger rnas (mrnas) by global expression profiling. findings were validated by transfection of microrna mimics and sirna-mediated knockdown in hcc cell lines, quantitative pcr, western blotting and luciferase reporter assays. results: after hdac-inhibition, hsa-mir- - p was significantly upregulated. the mir- - p holds tumor suppressive potential and its expression is reduced in different types of tumors. one predicted target gene of mir- - p is the hepatoma-derived growth factor (hdgf). this mitogenic growth factor is highly expressed in a variety of cancers, for example in hcc, and its expression correlates with a poor prognosis, irrespective of the tumor type. hdgf is a multifunctional protein that is involved in several signaling pathways, contributing to proliferation and metastasis of cancer cells, induction of angiogenesis and inhibition of apoptosis. incubation of hcc cells with tsa or transfection with mir- - p reduced expression of hdgf. luciferase assays indicate a direct regulation of hdgf by mir- - p. moreover, expression of the death receptor fas, which is a potential downstream target of hdgf, is also regulated by the mir- - p. a translocation t( ; )(q ;q ) was not detectable in any of the investigated tissues. with the established assay we were able to provide a highly sensitive tool for the detection of the translocation t( ; )(q ;q ). however, we did not detect normal b-cells carrying this translocation. this does not exclude that such cells exist. alternatively, the growth advantage conferred by myc may promote the acquisition of secondary genetic changes. this may result in a rapid tumorigenesis, that if occurring these cells only present as full blown burkitt lymphoma. myotonic dystrophy: links to the nuclear envelope p. meinke, s. hintze, s. limmer, b. schoser friedrich-baur-institute, munich, germany myotonic dystrophies (dm) are slowly progressing multisystemic diseases with a predominant muscular dystrophy -making dm the most frequent muscular dystrophy in adulthood. dm is caused by heterozygous dna-repeat expansions in the dmpk gene (dm ) or the cnbp gene (dm ). the repeat-containing rna accumulates in ribonuclear foci and splicing factors are sequestered to these foci, resulting in abnormal regulation of alternative splicing. dm patients show overlapping phenotype presentations with progeroid laminopathies, which are caused by mutations in nuclear envelope proteins. in search for molecular signatures of this overlap, we found an enrichment of nucleoplasmic reticuli in dm and dm patient myoblasts. additional, we found an alternative splicing of the lmna gene -both effects that are associated with progeroid laminopathies. this implies possible shared pathomechanism between dm and progeroid laminopathies. retinoblastoma is a tumor of the retina occurring in young children up to the age of five. it is caused by biallelic inactivation of the tumor suppressor gene rb . we have shown that human rb is an imprinted gene and as such characterized by differential dna methylation of a cpg island (cpg ) in rb intron . cpg is not methylated on the paternal allele and acts as a promoter for the alternative rb transcript, rb -e b. it is argued that expression of rb -e b is causative of the observed skewing of regular rb expression in favor of the maternal allele. a true gametic differentially methylated region (gdmrs) is established in only one of the parental germ lines. it is supposed to be stable during early embryonic development and to be passed on to all daughter cells. we could show that cpg is free of methylation in human sperm. publicly available methylome data on oocytes revealed that cpg is fully methylated in human oocytes. these data are in agreement with cpg being a maternal methylated gdmr. we showed that the level of cpg methylation is percent in blood, as expected. however, in eight tissues of three individuals we observed a gain of methylation at cpg ranging from to percent in liver and skin, and increasing to to percent in the other tissues (heart, kidney, muscle, brain, lung and spleen). interestingly, the degree of methylation was lower in fetal tissue than in adult tissue, as determined for brain and muscle. we also observed gain of methylation at cpg in two human embryonic stem cell lines and induced pluripotent stem cells. this is consistent with the finding of complete methylation at cpg in eight different retinoblastoma cell lines. we therefore conclude that cpg is an unstable dmr. in oocytes, dna methylation of gdmrs is established by transcriptional read-through from an upstream promoter. therefore, we hypothesize that gain of dna methylation at cpg is caused by run-through transcription erozygous state (nomenclature according to hgvs; reference sequence nm_ . ). in silico-analysis by alamut (version . . ) predict the loss of the donor splice site of intron of the atm gene. cdna-analysis was performed and revealed the loss of exon of the atm by a complex activation of two kryptic splice sites. a premature stop codon was generated giving rise to a truncated protein that leads to a pathogenic variant. the results of the genetic analysis are discussed in the context of the clinical findings. identification of the underlying genetic causes of gastric cancer will give a better view of the mechanisms that contribute to the pathophysiology of the disease. gemeinschaftspraxis für humangenetik und genetische labore, hamburg, germany, zentrum für diabetologie bergedorf, schwerpunktpraxis, hamburg, germany about - % of all pregnant women develop gestational diabetes mellitus (gdm) during their pregnancies and diabetes complicating pregnancy is associated with adverse maternal and perinatal outcomes, notably, risk of fetal macrosomia and neonatal hypoglycemia and development of diabetes after pregnancy. gdm is considered to result from interaction between genetic and environmental risk factors. the case of a -year old female german patient with a novel mutation in the pax gene (rare mody gene type ) as a cause of gestational diabetes mellitus is presented. we describe clinical, biochemical and genetic features of the patient, who developed gdm and gave birth to her child by cesarean section. mody genes type - were analyzed. sequencing the pax gene revealed a novel mutation in exon , pax ,c. delc, p.(leu cysfs* ); reference sequence nm_ . ), a deletion of a cytosine leading to a truncated, non-functional protein. to date, no small deletion has been detected in the pax gene. identification of the underlying genetic causes of gdm will give a better view of the mechanisms that contribute to the pathophysiology of the disease. furthermore, early identification may improve options to prevent gdm and complications for the mother and her child. the results of the genetic analysis are discussed in the context of the clinical findings. the modulation of dna methylation is highly flexible and plays an important role during cell differentiation. furthermore, the dna methylome alters considerably during aging. age related changes in the dna methylation of regulatory genes are assumed to have a major impact on carcinogenesis (teschendorff, ) . moreover, it was demonstrated that the chronological age of a human donor can be predicted with high accuracy by analyzing the dna methylation of a specific minor set of cpg loci which are aberrantly methylated during aging (horvath, ) . hence, we intended to investigate the effect of epimutations identified in different lymphoma entities in comparison with the influence of epigenetic changes in sequential b cell differentiation stages on the epigenetic age. the altered expression of the tumor suppressor mir- - p due to chromatin remodeling may play a fundamental role in hepatocarcinogenesis. we expect that histone deacetylation and putative target genes of epigenetically deregulated mir- - p can be targeted by new therapeutic agents. the microrna- family inhibits tgf-β-mediated liver cancer cell migration by targeting sox introduction: modulation of microrna expression is considered for treatment of hepatocellular carcinoma (hcc). therefore, we characterized the epigenetically regulated microrna- family (mir- a, mir- b, mir- c) with regards to its functional effects and target genes in hcc. methods: after transfection of mir- a, mir- b, and/or mir- c, tumor-relevant functional effects were analyzed using in vitro assays and a xenograft mouse model. binding specificities, target genes, and regulated pathways of each microrna were identified by microarray analyses. target genes were validated by luciferase reporter assays and expression analyses in vitro. furthermore, target gene expression was analyzed in primary human hccs compared to normal liver tissue. results: tumor suppressive effects, binding specificities, target genes, and regulated pathways of mir- a and mir- b differed from those of mir- c. transfection of mir- a, mir- b, and/or mir- c inhibited cell proliferation and migration, induced apoptosis, and reduced tumor growth to different extents. importantly, mir- a, mir- b, and, to a lesser degree, mir- c directly targeted sox , which codes for a transcription factor involved in epithelial-mesenchymal transition and hcc metastasis, and thereby inhibited tgf-β-mediated cell migration. conclusions: this study provides detailed insights into the regulatory network of the epigenetically regulated microrna- family and, for the first time, describes distinct tumor suppressive effects and target specificities of mir- a, mir- b, and mir- c. our results indicate that particularly mir- a and mir- b may be considered for mirna replacement therapy to prevent hcc progression and metastasis. novel mutation in the atm gene and activaton of two kryptic splice sites in an year old female patient with gastric cancer gemeinschaftspraxis für humangenetik und genetische labore, hamburg, germany, schwerpunktpraxis, hämatologie, onkologie und palliativmedizin, hamburg, germany, israelitisches krankenhaus, chirurgische klinik, hamburg, germany gastric cancer is a global public health concern, ranking as the third leading cause of cancer mortality. familial aggregation of gastric cancer is common in about % of the cases, and about half of these can be attributed to hereditary germline mutations. however, for most gastric cancer cases, whether genetic events contribute to cancer susceptibility remains unknown. here we present a case report of a patient with gastric cancer, a family history of breast cancer and a novel mutation leading to complex cryptic splicing in the atm gene. ngs panel sequencing and cnv/mlpa analysis of genes associated with gastric and breast cancer were performed. sequencing revealed a novel mutation in intron of the atm gene, atm,c. + g>a in an het-abstracts tions remained unidentified since positive deletion-junction pcr products could not be amplified. to identify the breakpoints of the deletions, we performed custom-designed microarray cgh analysis with a high resolution of probes located within and flanking the nahr hotspots prs and prs . the array analysis suggested that of the deletions exhibit breakpoints within prs , even although previously performed breakpoint-spanning pcrs with primers designed according to the reference sequence of the human genome have been negative in these cases. since prs exhibits high sequence diversity resulting from frequent nonallelic homologous recombination events without crossover, we surmised that haplotype diversity is responsible for the failure of the breakpoint-spanning pcrs performed with primers designed according to the reference sequence. therefore we characterized the haplotype diversity of prs in human individuals and designed deletion-junction pcr primers that facilitate the amplification of rare prs haplotypes. so far, we have identified the breakpoints of four of the type- nf deletions predicted to have been mediated by prs according to the array results. we are confident to identify further breakpoints by extending these analyses using primers suitable to amplify rare prs haplotypes. our findings indicate that the characterisation of nahr hotspots in terms of haplotype diversity is a premise to identify the breakpoints of nahr-mediated microdeletions by means of deletion-junction pcrs. p-basepi- *** array-based dna methylome analyses of primary lymphomas of the central nervous system ulm university, ulm, germany, university of cologne, cologne, germany, christian-albrechts-university kiel, kiel, germany, university hospital muenster, muenster, germany primary lymphomas of the central nervous system (pcnsl) are defined as diffuse large b-cell lymphomas (dlbcl) that are confined to the central nervous system (cns). although pcnsl cannot be distinguished from dlbcl by their morphology as well as their histology, they differ in prognostic outcome. the aim of the present study was to compare the epigenomic landscape of pcnsl and dlbcl. to this end, we analyzed the dna methylation of a total of pcnsl (cryopreserved or formalin fixed and paraffin embedded (ffpe)) using the infinium humanmethylation beadchip array (illumina) and contrasted these findings to dlbcl (kretzmer et al., ) . as controls, we used publicly available dna methylation data from a total of normal brain samples derived from different regions of the cns (gilbert et al., ; jaffe et al., ; kurscheid et al., ; mur et al., ; wockner et al., ) . after normalization of the data we performed thorough filtering and removed the random snps, all loci located on gonosomes, as well as those loci with a detection p-value > . in at least one of the samples, leading to , loci entering subsequent analyses. when comparing the dna methylation profiles of pcnsl versus dlbcl we identified differentially methylated loci (σ/σ max = . ; q < e- ). in order to remove those loci which represent a "brain signature", we compared dlbcl versus brain (σ/ σ max = . ; q < . ) based on the list of the previously identified loci. after removing this "brain signature", we ended up with loci that are differentially methylated between pcnsl and dlbcl. in a next step we wanted to make sure that the differences in methylation at these loci are not due to differences in starting material (cryopreserved versus ffpe) which is known to influence the outcome of the beadchip analysis. therefore, we compared the dna methylation profiles of five cryopreserved versus ffpe samples (derived from the same tissue samples) and identified differentially methylated loci (σ/σ max = . , q < . ). only five loci of both lists overlapped, which were subsequently removed from further analysis so that we ended up with a final list of loci which are differentially methylated between pcnsl and dlbcl. in order to analyze the biological implications of the differentially methylated loci we evaluated an enrichment of known functional groups (ku-additionally, our aim was to analyze whether entity-specific differences in the resetting of the epigenetic clock are generated during lymphomagenesis or derive from modified dna methylation in the germinal center b cells of origin. to address these issues, we performed dna methylation profiling (hum-anmethylation beadchip) of burkitt lymphoma samples (age - yrs), diffuse large b cell lymphoma samples (age - yrs) and follicular lymphoma samples (age - yrs) from the icgc mmml-seq and mmml-consortium (kretzmer et al., ) and the hematopathology section kiel as well as peripheral blood samples of healthy individuals ( - yrs) available from the same project and current publications of our group (kolarova et al., ; friemel et al., ) . in addition, we received b cell subpopulation samples ( - yrs) covering different stages of b cell differentiation that were measured in the same way (kulis et al., ; lee et al., ) . the epigenetic age of the samples was predicted using the "online age calculator" accessible at https://dnamage.genetics.ucla.edu and compared with the corresponding chronological age of the donors. in fact, the epigenetic age of peripheral blood samples of healthy donors was in high accordance with their chronological age (pearson's r . , p-value < . ) while the correlation between epigenetic and chronological age of sequential b cell differentiation stages was slightly lower (pearson's r . , p-value< . ). in contrast, the predicted epigenetic age of the burkitt lymphoma samples was significantly higher than the corresponding chronological age. this deviation may be interpreted as "epigenetic pre-aging". nevertheless, the epigenetic age of diffuse large b cell lymphomas and follicular lymphomas tended to be less affected. in conclusion, we found significant epigenetic pre-aging in burkitt lymphoma samples that seems to be induced during lymphomagenesis and does not derive from altered dna methylation patterns in the germinal center b cells of origin. moreover, no significant shift of the epigenetic age was observed for the other lymphoma entities, healthy blood samples and b cells of sequential differentiation stages. identification of type- nf deletion breakpoints mediated by rare prs haplotypes a. summerer , , m. hillmer , , v. f. mautner , , l. messiaen , , h. institute of human genetics, ulm, germany, university of ulm, ulm, germany, department of neurology, hamburg, germany, university hospital hamburg eppendorf, hamburg, germany, department of genetics, birmingham, usa, university of alabama at birmingham, birmingham, usa neurofibromatosis type (nf ) is a hereditary cancer syndrome with an incidence of in . in % of all nf patients, large deletions encompassing the nf gene and its flanking regions are causing the disease. the majority of all large nf deletions are of type- ; they encompass . -mb and are mediated by nonallelic homologous recombination (nahr) with crossover. the breakpoints of type- deletions are located within the lowcopy repeats nf -repa and nf -repc which exhibit high sequence homology to one another. previous studies suggested that type- deletion breakpoints cluster within the paralogous recombination sites prs and prs spanning -kb and -kb, respectively. in our present study, we investigated patients with type- nf deletions using long-range pcrs to detect breakpoints located within prs or prs . according to these analyses, ( %) of the breakpoints are located within prs and ( . %) in prs . however, ( . %) of the type- deletions were not positive for these deletion-junction pcrs. we surmised that some of these deletions may have breakpoints within the -kb region located between prs and prs . this -kb region also exhibits high sequence homologoy between the nf -reps which is a prerequisite for nahr. indeed, of the type- nf deletions exhibited breakpoints within this -kb region as determined by the analysis of seven overlapping deletion-junction pcrs. however, the breakpoints of dele-esophageal adenocarcinoma (ea) represents one of the most rapidly increasing cancer types in high-income countries. barrett's esophagus (be) is a premalignant precursor of ea and has an estimated prevalence of - % in the population. however, only . to . % of be patients develop ea. within an international consortium, we carried out a gwas meta-analysis in be patients, ae patients and . controls (gharahkhani et al., lancet oncology, ) . in a comprised be/ae analysis, we identified genome-wide significant risk loci, of which seven were previously unreported. the strongest associated new risk variant was identified for rs (p = . × - ), which maps within intron of the cftr gene. cftr encodes a protein that functions as a chloride channel and that is mutated in patients with cystic fibrosis (cf). mutations in cf lead to abnormal viscous secretions with altered chemical composition, resulting in dysfunction of the respiratory system and the gastrointestinal tract. the most common cf mutation is Δf , a deletion of three nucleotides in cftr that results in the loss of a single codon for phenylalanine on protein position . interestingly, cf patients show a highly increased incidence of gastroesophageal reflux, which represents the major risk factor for be and ae. in view of the phenotypic overlap for gastroesophageal reflux and cystic fibrosis, and for gastroesophageal reflux and both be and ae, combined with the association of cftr risk variants in patients with be and ae, it seems plausible that a common pathophysiological mechanism is triggered by cftr. in order to test this hypothesis, we analyzed the association of Δf in a european case-control cohort with be and ae patients. for this, we performed a genotyping assay of Δf in be patients, ae patients and controls. we could not observe a significant association (p = . ). this might be (i) due to insufficient sample power or (ii) due to the fact, that not Δf but other genetic variants at the locus might explain the underlying functional mechanism of the association. fine mapping of all genetic variation at the cftr locus and exten-lis et al., ). remarkably, cpg loci that are differentially methylated during normal b-cell maturation were significantly depleted. in turn we saw an enrichment of loci located in heterochromatin. in summary, we detected more than loci that are differentially methylated between pcnsl and dlbcl, which do not play a functional role in normal b-cell differentiation. replication study of gwas-identified genetic modifiers of age at huntington's disease onset although there is a strong correlation between cag repeat length and age at onset (ao) of motor symptoms, individual huntington disease (hd) patients may differ dramatically in onset age and disease manifestations despite similar cag repeat lengths. since the modifier variations described so far only account for a small fraction of the heritable contribution to the ao, the identification of loci and genes using genome-wide methods appears highly promising. against the background of incomplete understanding of the hd disease pathophysiology, the hypothesis-free approach of gwas offers an ideal starting point for the search of modifier genes. recently, a combined analysis of all gwa data to hd modifiers identified different loci with genome-wide significant signals for association to residual age at motor onset [gem-h. consortium]. interestingly, none of the most significant association signals and none of the trending snps in the european gwa analysis corresponded to any previously suggested candidate modifier genes. in order to be able to better assess these data, we tried to replicate the top ten associated gwas variants in a comprehensive cohort of german hd patients. we only found modest association with one of the top ranked snps (rs ), all remaining variations showed no correlation with the ao. this inconsistency highlights once again the difficulties of modifier searching in hd or any other monogenic disorder, which faces the same challenges as the genetic characterization of complex disorders. with an incidence of . - . / . malignant tumors of the thymus are a rather rare type of cancer. here we report the case of a man of german descent, who presented with a thymoma at age . in the pathological report the thymus tumor was described as an extremely unusual thymoma with partial loss of keratin and massive proliferation of myoid cells. it was subsumed to a primary thymic, partially epithelial neoplasia, resembling an uncommon b /b -thymoma. after the patient's death his widow looked for genetic advice concerning the risk of disease for her children. detailed personal and familial history brought up surprising information: thymoma was one of four cancers in our patient. he developed adenocarcinoma of the colon at age , squamous cell cancer of the nose/upper lip at years and in addition current cancer staging revealed a papillary renal cell carcinoma. according to family history his father and his uncle developed colon cancer with and years, the son of this uncle was diagnosed with colon cancer at age . this cousin of the propositus was referred to genetic counseling, because of msi-high-status and loss of mlh and psm in immunohistochemistry. he was found to have a deleterious mutation in exon of mlh gene (c. c>a, p.tyr stop) resulting in a premature termination of mlh -protein. our patient has never been tested for hnpcc. however a post mortem performed immunhistochemical examination of thymic cancer cells revealed an almost complete loss of mlh nuclear expression suggesting the presence of a mlh germline mutation and indicated hnpcc. considering the loss of mlh in tumor cells it is more than likely that the development of thymoma was the consequence of deficient dna mismatch-repair. there have been reports of rare tumors in hnpcc families in the last years (i. e. clear cell renal carcinoma and uterine sarcoma). pande et al. reported one case of thymoma in their registration of cancer occurrences in mutations carries from hnpcc families [ ] . our case emphasizes the importance of detailed family history and contributes to the discussion of widening the inclusion criteria for genetic counseling and testing for hnpcc. to this day the revised criteria of bethesda are used to identify families at risk. we propose that the established criteria have to be revised and rare tumors should be included. unknown partner genes in leukemias with rare translocations can be identified using targeted rna sequencing c. haferlach, n. nadarajah, m. meggendorfer, n. dicht, a. stengel, w. kern, t. haferlach mll, munic, germany in hematological malignancies fusion genes play an important role and function as therapeutic targets, impressively shown for e. g. bcr-abl and etv -pdgfrb. thus, the identification of fusion genes is the basis for precision medicine, selecting treatment based on genotype and providing markers for disease monitoring. the aim of this study was to test the value of targeted rna sequencing in a routine diagnostic work up. cases were selected harboring rearrangements of kmt a (n = ), runx (n = ), etv (n = ), pdgfrb (n = ), npm (n = ), rara (n = ) and jak (n = ) identified by chromosome banding (cba) and fish analyses. in none of the cases the partner gene could be identified using standard methods. targeted rna sequencing was performed using the trusight rna fusion panel (illumina, san diego, ca) consisting of probes covering genes known to be involved in gene fusions. this assay allows the capture of all targeted transcripts. sequencing was performed on nextseq (illumina, san diego, ca). analysis was performed with the rna-seq alignment app (basespace sequence hub) using star for alignment and manta for gene fusion calling with default parameters (illumina). sive functional analysis are needed to find the causal variant that explains how the cftr locus interferes with the pathomechanism of be and ae. a recent functional study indicated cftr as a tumor suppressor gene in murine and human intestinal cancer, providing further evidence for cftr as a true disease gene for be and ae. background: it has long been established that mutations in brca predispose for pancreatic adenocarcinoma with brca germline mutations identified in - % of familial pancreatic cancer cases. consequently, screening for pancreatic cancer has been recommended for mutation carriers with an affected first-degree relative since early detection has been shown to significantly improve -year survival from - % to %. for brca mutations, however, relevance in pancreatic tumorigenesis is still being discussed with several studies questioning an elevated risk of pancreatic cancer in families with brca mutations while others are suggesting that brca may also play an important role in predisposing to pancreatic cancer. clinical screening for pancreatic cancer commonly remains unavailable to brca mutation carriers and it has even been questioned whether brca should be analyzed in familial pancreatic cancer at all. clinical report: here we report on a year old woman with metastatic pancreatic cancer whose sister had died of pancreatic cancer at years of age. in this family we identified a pathogenic brca -germline mutation (brca : nm_ . :c. dupt,p.(leu phefs* )) by next-generation sequencing using a -gene panel. the index patients' tumor was available for genetic analysis and showed loss-of heterozygosity for brca . this strongly suggests the brca mutation to be causative of the pancreatic cancer development in this patient. when the family was first introduced to genetic counselling there was no evidence of breast-or ovarian cancer in any relatives. only after identification of the mutation did the index person reach out to distant family members and it was thereby revealed that a distant branch of the family had independently been counselled for hereditary breast and ovarian cancer. in this part of the family, however, there had not been any cases of pancreatic cancer. subsequent predictive testing was offered to healthy family members and further mutation carriers could be identified. two women were referred to breast cancer screening. additionally, the mutation was identified in a relative with recurrent metastatic breast cancer at the age of years. for her and the index patient parp-inhibition therapy thus became a possible further treatment option. conclusions: in conclusion we propose next-generation sequencing approaches including the analysis of brca to be used in familial pancreatic cancer. we also argue that brca mutation carriers with pancreatic cancer cases in their family should be offered the same screening program as brca mutation carriers. within the framework of a study this could allow for more precise risk stratification in the future. contralateral dcis is unknown. only the male breast carcinoma was herceptin receptor positive, all other breast carcinomas of the chek mutation carriers were her negative. among our chek positive families we noticed the association with chek mutation and female breast cancer. we observed a contralateral breast cancer, male breast cancer and other tumors in our families as well. the majority of the observed breast cancers was estrogen and progesterone receptor positive and herceptin negative. while benign uterine smooth muscle tumors are among the most frequent human symptomatic tumors, their malignant or borderline lesions are only rare findings. both lesions can show somatic copy number alterations, but their patterns differ, thus constituting helpful diagnostic tools. aimed at an advanced classification of the lesions we have performed molecular inversion probe array analyses of these tumors. besides complex patterns of genomic alterations seen in nearly all cases, two of the lesions presented with copy number neutral uniparental disomies i. e. normal copy numbers with an apparent monoallelic origin. in one case, an upd of part of the long arm of chromosome was detected in a uterine leiomyosarcoma. the tumor showed genetic heterogeneity with gains and losses. in addition, the . mb segment located at q . -q . was clearly of monoallelic origin throughout all cells investigated. all other genetic alterations were restricted only to part of the cells of the sample thus reflecting the presence of tumor cells as well as normal bystander cells which in general characterizes mutations that had arisen during tumor development. in contrast, the upd that was detected in all examined cells clearly suggests its germline occurrence. the second tumor was a leiomyoma-variant of the type with bizarre nuclei. again, besides gains and losses an apparent germline upd was found that covered a . mb segment on chromosomal segment q . . upd for even the whole arm of chromosome repeatedly has been reported not to coincide with phenotypic manifestations. nevertheless, the question arises whether or not the observed upds might be related to a familiar predisposition for uterine muscle tumors. of note, as a result of genome-wide association studies snps on q recurrently have been found to be significantly associated with fibroid development. triple negativity is an independent predictor of germline mutations in breast cancer predisposing genes breast cancer is the most common cancer in women. - % of all tumors are triple-negative breast cancers (tnbc) lacking expression of estrogen receptor, progesterone receptor and human epidermal growth factor receptor . so far, tnbc have been mainly associated with mutations in brca , although recent studies also found mutations in other breast cancer susceptibility genes. a brca / -centered perspective thus may ignore the significance of other predisposing genes, whose relevance appears obvious as dna damage repair by homologous recombination is a complex process involving many proteins. in / cases with rearrangements involving kmt a (n = ), runx (n = ), etv (n = ), pdfgrb (n = ), rara (n = ), npm (n = ) or jak (n = ) the partner genes were identified. these were in kmt a rearranged cases: mllt (n = ), mllt (n = ), itpr , flnc, asxl , dcp b, maml and arhgef . in runx translocated cases partner genes were plag (n = ), prdm , mecom, zfpm , man a , n amt , and kiaa l. prdm , mecom and zfpm have previously been described in the literature as runx partner genes but were not suspected in our cases as partner genes due to complex cytogenetic rearrangements. the other identified partner genes have not been described so far. interestingly, prdm , mecom, zfpm and the newly identified plag are all members of the c h type zinc finger gene family. partner genes identified in etv rearranged cases were: abl , ccdc , clptm l, erg, foxo and cflar-as . wdr , zbtb , nfia and mprip were identified as partner genes of pdgfrb and rpp in an npm -translocated aml. in an all patient a jak -ppfibp fusion was identified leading to classification as a bcr-abl -like all. in an apl patient showing an ins( ; ) (q ;q q ) a zbtb -rara fusion was identified and thus resistance to all-trans retinoic acid, arsenic trioxide, and anthracyclines can be predicted. further in a case with t( ; )(q ;q ) an irf bp -rara fusion was detected. conclusions: targeted rna sequencing was able to characterize rare gene fusions and provided the basis for the design of rt-pcr based assays for monitoring mrd. targetable genetic aberrations were identified, which were not detected by cba enabling more individualized treatment. targeted rna sequencing may be a valuable tool in routine diagnostics for patients with rearrangements unresolved by standard techniques. female carriers of a pathogenic mutation in the chek gene are reported to have a life time risk of about - % to develop breast cancer. there is evidence for increased risks for contralateral breast cancer, male breast carcinoma and other types of tumors. in addition to well-known mutation chek :c. del, other pathologic mutations are being identified in the gene due to the inclusion of the gene in most breast cancer gene panels for dna testing. between - the center for hereditary breast and ovarian cancer regensburg cares for families with pathogenic or probably pathogenic mutations in the chek gene affecting nine female patients and one male patient ( × c. del, × deletion of exon , and × variants considered as likely pathogenic: c. g> c, c. c> t, c. a> c). the mean age of diagnosis of breast cancer (both sexes) was . years (range - years). the patient with the deletion of exon was first diagnosed at years of age and developed a contralateral breast carcinoma (dcis) at years of age. the male patient was diagnosed with breast cancer at years of age and at years with a renal carcinoma. one patient was diagnosed with a papillary thyroid carcinoma at age years and developed breast cancer with years. in out of the families, breast carcinoma diagnosed with . years on average, was reported in the family history. in addition, there were additional malignancies such as prostatic carcinoma, thyroid carcinoma, colorectal cancer, gastric carcinoma, leukemia, cervical carcinoma and malignant melanoma. none of the affected family members was tested for the respective chek mutation. the tumors with an initial diagnosis at years and years were estrogen-receptor-negative and progesterone-receptor-negative. the other of the breast cancers were positive for the estrogen receptor, of the tumors were positive for the progesterone receptor. the receptor status of the abstracts it has been shown that in d culture hescs can be differentiated into neural retina containing organoids. we established this differentiation schedule and started comparative differentiation of wildtype h hescs and the rb null derivative (g , rb mt/mt ) into neural retina. during the first weeks of differentiation into neural retina organoids generated from the rb mt/mt hescs have a smaller diameter and thinner retina layer compared to wildtype organoids. however, during the time-course the mutant organoids began to catch up. thus, at later stages no difference in size and thickness could be observed anymore. comparative immunostainings of cryosections at d show no difference in expression of the markers pax and sox between the wildtype and mutant hescs. further comparative immunostainings for markers specific for neural retina like e. g. rx and vsx at d and d are ongoing and will be presented. exome sequencing identified potential causative candidate genes for unexplained cowden syndrome purpose: cowden syndrome (cs) is a cancer predisposition syndrome characterized by the occurrence of breast cancer, epithelial thyroid cancer, endometrial carcinoma and various other findings such as mucocutaneous lesions and macrocephaly. cs belongs to the pten hamartoma tumor syndrome (phts) primarily associated with germline mutations in pten. in recent years, germline mutations in additional genes (sdhb, sdhc, sdhd, pik ca, akt , sec b) have been described in few patients; however, to date, in - % of patients meeting clinical criteria for cs the underlying cause remains unclear. methods: to uncover predisposing causative genes, the exomes of clinically well characterized, mutation negative patients with suspected cs were sequenced (illumina hiseq) using leukocyte dna. assuming a monogenic disease model, the called variants were filtered for rare (minor allele frequency ≤ % for homozygous/compound heterozygous variants and ≤ . % for heterozygous variants according to dbsnp, evs, and exac), truncating (nonsense, frameshift, highly conserved splice sites), and missense germline variants (predicted to be pathogenic by at least / in-silico tools). for data analysis and variant filtering the gatk software and the cartagenia bench lab ngs software were applied. all candidate genes were included in a pathway analysis (ingenuity). in a first preliminary analysis, we focused on known cancer genes and genes interacting with pten. results: after stringent filtering steps, comparison with large datasets from population-based controls, and detailed manual inspection to exclude artifacts, genes were affected by presumed biallelic variants ( homozygous and putative compound-heterozygous), one of these is a known cancer gene (cbfa t ); in genes biallelic variants were found in - patients. heterozygous variants were found in genes in - patients, but none of these are known cancer genes. in genes, heterozygous truncating mutations occurred in only one patient, of these are cancer genes (msh , wrn, kdm a, pml) . the phenotype of the patient with a msh frameshift deletion fulfilled key features of cs (early-onset metachronous papillary thyroid cancer, breast cancer, endometrial and colorectal cancer), however, the tumor spectrum is partly compatible with lynch syndrome/ hnpcc. examination of the colorectal cancer demonstrated microsatellite instability and a loss of msh protein expression. the pathway analysis of the remaining candidate genes identified several interacting partners of pten (grhl , ehhadh, cstf ). conclusions: preliminary data indicate that exome sequencing might identify potentially relevant causative genes for cs, some of which are recurrently mutated. the present work-up consists of the inclusion of further non-cancer genes, validation of variants by sanger sequencing, testing of to determine the prevalence of mutations we performed panel-based germline mutation testing of high and low-moderate penetrance breast cancer susceptibility genes (brca , brca , atm, cdh , chek , nbn, palb , rad c, rad d and tp ) in consecutive individuals affected with tnbc unselected for age at diagnosis or breast and ovarian cancer family history. age at diagnosis ranged from to years with an average of . and a median of years. in women ( . %) we detected a pathogenic mutation, with a higher frequency ( . %) in the group manifesting cancer before years. deleterious brca mutations occurred in . % of tnbc patients, predominantly frameshifting ( / , . %). the most frequent, both among brca mutations and in total, were the founder mutations c. dupc and c. _ delag. deleterious brca mutations occurred in . % of patients, all but one (c. du-pa) being unique. while no mutations were found in cdh and tp , mutations ( %) were detected in one of the six other predisposition genes (palb , chek , atm, nbn, rad c, rad d). no individual presented more than one mutation. almost half of all deleterious mutations ( . %) were detected in very young women aged years or less. the median age at diagnosis was significantly younger for brca ( years) and brca ( . years) carriers compared to patients without a mutation (p = . e- ; mann-whitney) or compared to non-brca / mutation carriers (p = . ). in contrast, patients with non-brca / mutations were not significantly younger than mutation negative women (p = . ). interestingly, family history had an independent influence on age at diagnosis. taken as a whole, women with family history had a median age at diagnosis years earlier than those without (p = . ). this difference was lost in mutation carriers while it remained in cases without mutation. in summary, our data confirm and expand previous studies of a high frequency of germline mutations in genes associated with ineffective repair of dna damage by homologous recombination in women with tnbcs. many of these women would go untested with current restrictive criteria. in order that each patient receives therapies tailored to her genetic status, gene panel based mutation testing should be offered to all women diagnosed with tnbc, irrespective of age at diagnosis or family history. p-cancg- *** neural retina differentiation of hescs as an in vitro model for retinoblastoma d. kanber, m. hiber, d. lohmann, l. steenpass institute of human genetics, university hospital essen, university duisburg-essen, essen, germany retinoblastoma is the most common eye tumor of early childhood. inactivation of both alleles of the retinoblastoma gene (rb ) results in the development of retinoblastoma. our aim is to establish a human cell-based model for retinoblastoma. using the crispr/cas system we have generated human embryonic stem cells (hescs) carrying a mutation either on one or both rb alleles. all the detected mutations are located in exon of the rb gene and close to the splice donor site of this exon. analyses on dna, rna and protein level were performed for three mutant and one double-mutant clone. the following genotypes were identified by deep sequencing (nm_ . (rb _v )): clone c , c. _ del, heterozygous; clones c and g , c. _ del, heterozygous; clone g , c.[ _ del; c. _ dup] (complex mutation on one allele), homozygous (loss of heterozygosity). the mutations of all four clones result in a premature stop codon in exon . on rna level we detected expression of mutant rb transcripts reflecting the genotype in all clones and an additional mutant rb transcript with skipping of exon in three clones. as the heterozygous clones also showed expression of the wildtype rb transcript, rb protein (prb) could be detected for these clones (c , c , g ) by western blot analysis. however, the double-mutant clone g showed no expression of prb. so far, we have characterized heterozygous and one homozygous clone. another three double-mutant clones are under investigation. the recurrent germline missense mutation g e in the hoxb gene has been demonstrated to predispose to hereditary prostate cancer (prca), despite the underlying pathogenic mechanism is not yet understood. molecular examination of a first set of g e positive tumors sought for somatic characteristics, and suggested that oncogenic ets gene fusions may appear at unusually low frequencies as compared to the general prevalence of ets fusions in prca ( % vs approx. %). hypothesizing that hoxb could predispose to ets fusion negative prca, we have analyzed cases from three european ancestry populations (finland, germany and us) for the coincidence of hoxb g e and the most common ets fusion, tmprss :erg, in corresponding tumor samples. while the prevalence of tmprss :erg fusions was similar among the three study groups (range: . - . %), the frequency of g e genotypes differed markedly between us ( . %), german ( . %) and finnish samples ( . %). despite the expected frequency gradient among study populations, all subsamples showed a strong enrichment of g e mutation carriers among tmprss :erg fusion negative cases as compared to fusion positive cases (center adjusted or = . ; %ci = . - . ; p = . ). consistent with the previous study, the crude frequency of the tmprss :erg fusion in hoxb g e carriers was . % (range . % - . %). examination of disease characteristics highlighted age at diagnosis to be associated with tmprss :erg negative status (per year or = . , p = , ) and by trend, also with the presence of the g e germline variant (per year or = . , p = . ). within the subtype of tmprss :erg fusion negative carcinoma carriers of g e were diagnosed . years earlier as compared to non-carriers ( . ± . years versus . ± . years, p = . ). in conclusion, this study demonstrated a significant tumor subtype specific association for hoxb g e mutation carriers having a higher frequency of tmprss :erg fusion negative prca. meta-analyses from case control comparisons suggested that subtype specific risk of hoxb g e for tmprss :erg negative prca could be as high as or = . , as compared to or = . , when prca is regarded as one entity regardless of fusion status. finally, although tmprss :erg negative prca is usually known to be associated with later ages of diagnoses, hoxb mutations may indicate a subgroup of earlier onset cases within the fusion negative entity. relatives to determine the phase of assumed biallelic variants and segregation with the phenotype where applicable. with to cases in million inhabitants per year adrenocortical cancer (acc) is a rare disease. due to often late diagnosis and limited treatment options prognosis for patients are poor with a year overall survival rate of to %. though knowledge about molecular genetic events in acc increased over the last few years no reliable molecular prognostic factors, no effective targeted cancer therapy and no personalized treatment approach has emerged to date. that's why we intend to establish a reliable method to define a molecular signature of accs that could be used for a prognostic classification of adrenocortical cancers, for planning an individualized therapeutic approach and for the identification of known or potential targetable molecular events in the single patient. in a retrospective study dna from acc and matched blood samples is sequenced to detect somatic single nucleotide variants (snv), small insertions and deletions (indel) and copy number alterations (cnv). sequencing data are then compared to clinical data e. g. tumor stage, resection status, ki -index and time of progression free and overall survival to define molecular prognostic factors. target enrichment of genes that are known to be associated with different entities of cancer is performed with the human comprehensive cancer panel (qiagen) and sequenced on a nextseq (illumina). data are analysed with gensearchngs (phenosystems). znrf , a gene that was also described to be involved in the development and the progression of acc a few years ago, is sequenced separately with sanger and analysed with gensearch (phenosystems). to date tumor samples and matched blood samples from patients were analysed. one or more tumors comprise one or more snvs or small indels in of genes of the panel and in znrf . snvs and small indels are most often found in tp , ctnnb and znrf with frequencies of %, % and % respectively. in of genes cnvs -duplications and deletions -occur. cdk is duplicated in over % of the cohort. mdm gains are found in over %. one can also find three types of cn patterns: a quiet type with low number of copy alterations, a noisy one with high number of chromosomal breakages and a chromosomal one with high frequency of alterations of chromosomal arms. while no correlation between snvs and small indels and clinical outcome could be found so far, cn patterns of the accs seem to correlate with progression free survival and overall survival. patients with a noisy cn pattern have a shorter progression free and overall survival than patients with chromosomal and quiet type. though tendencies in the correlation of molecular markers and prognosis for patients suffering acc can be recognized, further samples need to be analysed to confirm the results. it is planned to sequence another tumor samples and matched blood samples for this retrospective study and to validate the results in a prospective study with another patients. expression of mir- a- p and mir- - p was analysed in serum samples by quantitative pcr. the cohort of gcnis patients consisted of patients with a solitary testicle, who had undergone orchiectomy for contralateral tgct, and patients with two testicles, one of which with gcnis, but no concurrent tgct. twenty men with non-malignant testicular disease served as controls. additionally, in situ hybridisation (ish) with a probe against mir- a- p was performed on four testicular biopsy specimens known to harbour gcnis. sequential step sections of the corresponding tissue blocks were analysed immunohistochemically, using oct antibody to visualise gcnis. the median expression value of mir- a- p in gcnis-patients was . (interquartile range [iqr] = . ) which is significantly higher than the median expression of . (iqr = . ) in controls. both of the two gcnis subgroups had significantly higher mir- a- p levels than controls, with a median expression of . (iqr = . ) and . (iqr = . ), respectively. regarding mir- - p expression, there were no significant differences between gcnis and controls. using a relative quantity of as a cut-off value, the mir- a- p was able to detect . % ( % confidence interval [ % ci] = . - . %) of gcnis, while only % ( % ci = . - . %) of the controls were positive. in the subgroup with previous tgct . % ( % ci = . - . %) of gcnis could be detected and in the subgroup without previous tumour the rate was . % ( % ci = . - . %). the detection rates for all gcnis and for both subgroups were significantly higher than for the controls. ish staining demonstrated the expression of mir- a- p in gcnis cells in two of the four cases. in conclusion, this study indicates a new and minimal-invasive way of diagnosing gcnis by measuring serum levels of mir a- p. this approach is endorsed by the demonstration of mir a- p in gcnis cells by ish staining. however, the sensitivity is still low and thus, the method certainly needs refinement possibly by applying a panel of additional mi-crornas. nonetheless, measuring serum levels of mir a- p may constitute a valuable aid in clinical assessment of men afflicted with high-risk factors of tgct. p-cancg- *** the mir- a- p is a highly specific and sensitive serum-based marker for the diagnosis and follow-up of testicular germ cell tumours testicular germ cell tumours (tgct) are a paradigm of curable malignancies. clinical management largely relies on measuring the serum biomarkers. inopportunely, the markers beta-hcg, afp and ldh are only elevated in about % of patients. therefore, micrornas of the clusters mir- - and mir- / were proposed as novel serum-based markers. we evaluated four of the candidate mirnas (mir- a- p, mir- - p, mir- - p and mir - p) with regard to their usefulness as tgct markers. overall, serum samples from tgct-patients and from controls were analysed using quantitative pcr. the first consecutive patients and controls were analysed for all four mirnas. after roc-analysis only the marker with the greatest discriminative power was studied further. the decline of mirna expression after orchiectomy was quantified in cases and in metastasized cases the marker was analysed repeatedly during the course of chemotherapy. additionally cases with relapsing disease were studied. the mir- a- p featured the highest discriminative power (area under the curve: . ; % confidence interval [ % ci]: . - . ). in the entire cohort, patients could be distinguished from controls with a sensitivity of . % ( % ci: . - . %) and a specificity of . % ( % ci: neuroendocrine tumor of the adrenal gland: an unusual manifestation of tsc c. müller-hofstede, j. horvath, b. dworniczak, p. wieacker institute of human genetics, university of münster, germany we report on a young woman asking for the recurrence risk of the neuroendocrine tumor of her mother deceased at the age of . her mother clinically presented because of therapy-resistent hypertonia, dyspnoe, progressive edema in the legs and face and a caput medusae. mri scan revealed a tumor ( × cm) in the right adrenal gland with lymph node metastases compressing the v. cava inferior and synchronous metastases in lung and liver. laboratory examinations showed highly elevated levels of cortisol and adrenocorticotropin (acth). cerebral mri was normal suggesting an ectopic acth secretion by a non-pituitary tumor. histologically, an undifferentiated, largely necrotic tumor was described so that the neuroendocrine nature of the tumor could not be proven. she died within three weeks after diagnosis. on suspicion of multiple endocrine neoplasia type we initially performed a sequence analysis of men on tumor dna by next generation sequencing without detection of a pathogenic mutation. thereupon the molecular genetic panel analysis (nf , ret, sdhb-d,tmem , tsc , tsc , vhl) uncovered the heterozygous mutation c. c>t (p.arg trp) in the gene tsc . this mutation is already described as pathogenic (hu et al. ). in the tumor dna the allele frequency of the normal allele mounted up to %, whereas the allele frequency of the mutant allele came to % pointing to a loss of heterozygosity (loh). the mutation was confirmed by sanger sequencing. taken all together, we assumed, that the mutation in the gene tsc represents a germline mutation. mutations in the suppressor genes tsc and tsc cause tuberous sclerosis, an autosomal-dominant disorder, resulting in hamartomatous tumors in the heart, brain, kidneys, skin and other organs. once in a while it is discussed whether neuroendocrine tumors (nets) represent a characteristic of tsc. there are some case reports describing nets in the context of tsc, but mainly in connection with nets of the pancreas (e. g. insulinoma) or the pituitary. to the best of our knowledge there exists only one case report of a bronchial carcinoid as a result of a germline mutation in tsc (dworakowska et al. ) and no description of net of the adrenal gland due to a mutation in tsc or tsc . ngs provides the opportunity of wide-spread testing, even post-mortem, in order to get clarification for the descendants. although in our case we could not distinguish if the mutation detected represents a germline mutation or a somatic mutation, we were able to offer a predictive testing to the daughter and other family members. we report on a rare case of net of the adrenal gland because of mutation in the gene tsc . this case illustrates that in the differential diagnosis of nets, tsc genes should also be considered. germ cell neoplasia in situ (gcnis) is the precursor lesion of testicular germ cell tumours (tgct). if detected clinically, this lesion may herald a pending tgct. unfortunately, the only way of diagnosing gcnis is by testicular biopsy and subsequent immunohistochemical examination. therefore, non-invasive methods of diagnosis are required. mirnas of the mir- - and mir- / cluster had been suggested as serum biomarkers of full-blown tgcts. we aimed to explore the utility of these mirnas for the detection of the pre-invasive stage of tgcts and we looked to the expression of two mirnas in serum samples of gcnis patients. psmc ip located on chromosome q is a putative tumor suppressor gene that encodes for the nuclear psmc interacting protein. the protein functions as coactivator of steroid hormone mediated gene expression and is important for rad and dmc -mediated homologous recombination during dna repair of double-strand breaks. recently germline variants in psmc ip, also known as gt , tbip, and hop , have been identified with low frequency in early onset familial breast and ovarian cancer (hboc) patients and in a patient with apparently sporadic early onset breast cancer. somatic variants in psmc ip are frequently observed in breast, ovarian, and fallopian tube cancers. in this study, we analyzed a cohort of brca / mutation-negative hboc (n = ) or early onset sporadic breast cancer patients (n = ) for variants in psmc ip. we identified seven different heterozygous variants in out of index patients: c.- g>a (rs ); c.- t>a (rs ); c.- a>t (rs ); c.- c>g (rs ); c. g>a p.(trp *); c. + g>c (rs ); c.* g>a. these variants were not listed or at very low frequency (< %) in the exac database. carriers of psmc ip germline variants were mostly ( / ) affected by early onset breast cancer (median age of onset years). for three out of seven different variants (c.- g>a, c. g>a, and c* a>g), a possible impact on psmc ip expression or function was observed. the stop mutation c. g>a p.(trp *) was found in two sisters, which were both diagnosed with unilateral breast cancer at age . the premature stop codon is located within the dna-binding domain of psmc ip and is predicted to induce nonsense-mediated mrna decay (nmd). remarkably, c.- g>a was already described in familial breast and ovarian cancer, and was found once in this study in a female that developed unilateral breast cancer at the age of years. the variant c.- g>a (rs ) was shown to induce a slightly, albeit significant decrease of reporter gene expression. the c. *g>a variant was identified in a woman diagnosed with unilateral breast cancer at the age of years. luciferase reporter assays indicated an impaired effect of c. *g>a on microrna binding. germline variants in psmc ip are present in breast and ovarian cancer families. whether mutated psmc ip is a new risk factor for early onset breast/ovarian cancer in families with hboc and/or apparently sporadic early onset breast cancer remains to be shown. . - . %) with this marker. in patients without metastases the mir- a- p expression declined significantly after surgery. in metastasized cases the levels dropped sharply after chemotherapy. all of the relapses had elevated mir-levels, and expression decreased upon chemotherapy. mir- a- p has significantly higher sensitivity than each one of the classical tgct markers and than a combined panel of beta-hcg, afp and ldh ( . % vs . %). in non-metastasised seminoma the mir- a- p expression depended significantly on tumour size. mir- a- p is highly sensitive and specific for tgct. it correlates with the stage of disease and with treatment effects and it therefore fulfils the prerequisites of a valuable serum-based biomarker. the significant association with tumour bulk in localised disease provides evidence for the tgct being the primary source of mir expression. the sensitivity of mir- a- p surpasses that of classical tgct markers by far, and thus it may become the new gold standard for serum diagnostics of tgct in the coming years. co-occurrence of radioulnar synostosis and amegakaryocytic thrombocytopenia (rusat) was initially described as an inherited thrombocytopenia syndrome that is caused by a mutation in hoxa . in three simplex patients, de novo missense mutations in mecom were reported as an alternative origin of the disease (rusat ). mecom, identified as a common ecotropic viral integration site (evi ) in murine myeloid leukemia, is known as a key transcriptional regulator in hematopoiesis and sporadic myeloid leukemia. we report here on a novel mecom mutation cys gly (uniprot q - ) identified by whole exome sequencing in a family with rusat, hearing impairment, hand dysmorphisms, and patellar hypoplasia in four patients spanning three generations. notably, two of four affected individuals in our family developed a myeloid malignancy. the novel mecom missense mutation cys gly affects a heavily conserved cysteine residue in c h -zinc finger motif in the c-terminal zinc finger domain of mecom. this residue is crucial for the tetrahedral coordination of a zinc ion stabilizing the zinc finger conformation and thus, is essential for dna binding of the c-terminal zinc finger domain. our findings reconfirm the causality of mecom mutations and indicate that mecom mutations also need to be considered in familial rusat patients. in addition, we report for the first time that mecom germline mutations targeting the c-terminal zinc finger domain are associated with an increased risk for myeloid malignancies. this extends the rusat -associated phenotype and proposes that mecom germline mutations can cause a genetic predisposition to myeloid malignancy. (z., b. and s., d. contributed equally to this work) many genes that harbor rare mutations which entail a medium or high risk for breast cancer (bc) belong to dna double strand repair and have been identified by linkage analysis or by sequencing of candidate genes in bc families. in addition, a considerable number of common but low risk germline variants have been found in genome wide association studies. however, these predisposing factors yet only explain a fraction of bc cases. with the intention to identify low frequency variants conferring an intermediate bc risk, we performed an association study using a candidate gene approach and testing dna repair capacity with the micronucleus test (mnt) as an additional second phenotype. rs in the slx /fancp gene showed an association with bc that was pronounced in younger cases and was confirmed in a verification cohort (combined analysis of , cases, controls: or = . ( . - . ) , p = . for cases ≤ years). genotyping additional snps and imputation revealed a specific european haplotype of ca. kb length that spans slx and adjacent genes. it is tagged by the observed mutual dependence of the two phenotypes allowed a considerably improved interpretation of the results: (i) the unknown causal variant on the haplotype can be assumed to be present mostly in cases, indicating a rare variant with a rather strong effect; (ii) using this information on the two phenotypes in the association between the mnt results and bc improved considerably the identification of the specific risk among cases (< years) who carried the haplotype. roc curves for bc depending on mnt results revealed that the stratification on carriers of the haplotype increased the auc from . (p = . ) to . (p = . ). both associations can be best explained by a risk variant carried by a fraction of the haplotypes that is enriched in early onset bc cases. slx is the only gene in the tagged region which can be functionally related to both associated phenotypes, while for the other genes no connection to bc or dna repair is reported. inherited dna repair mutations: are they modifiers of brca and brca penetrance and age at onset of hereditary breast and ovarian cancer? background: inherited mutations in brca and brca are the most common causes of hereditary breast and ovarian cancer (hboc). the risk of developing breast cancer by age in women carrying a brca mutation is - % and - % in brca carriers. however, mutations in brca and brca only explain about % of all hboc cases. the lifetime risk varies between families and even within affected individuals of the same family. the cause of this variability is unknown but it is hypothesized that additional mutations or rare variants in genes that are possibly interacting with brca / in different dna-repair pathways contribute to this phenomenon. methods: we obtained samples of patients positive for brca or brca mutations and an age-of-onset (aoo) of breast cancer below or above years of age from the german consortium for hereditary breast and ovarian cancer. panel sequencing was done to screen germline dna for mutations in genes involved in different dna-repair pathways. variants were classified into five classes according to a modified version of plon et al ( ) . only truncating mutations and known pathogenic missense mutations were considered pathogenic or likely pathogenic. results: the patient group with an early aoo ( women) had developed breast cancer at a mean age of . years (± . ) and the control group ( women) had developed breast cancer at a mean age of . years (± . ). a total of , variants were detected in all patients and of these ( . %; % ci, . %- . %) were presumed to be deleterious. mutations were found in genes other than brca and brca . mutations were mainly found in single-strand break repair (ssbr %), double-strand break repair (dsbr %) and checkpoint factors ( %). the rest were found in genes with other functions such as brca / interactors, centrosome formation, and signal transduction. the putative mutations were found in women of the control group ( . %; %ci, . %- . %) compared to women of the patient group ( . %; % ci, . %- . %). the incidence of germline mutations in dna-repair genes did not differ according to the age of onset (p = . ). prevalence of additional germline mutations in dsbr in patients ( %) was not significantly different from prevalence of dsbr mutations in controls . % (p = . ) conclusions: the preliminary results failed to show a difference in mutation load between the two cohorts of brca / carriers sorted by age of onset. larger studies are needed and may provide further insight into the role of mutation load in hboc age of onset of brca / carriers. objective: glioblastoma stem-like cells (gscs) carry stem cell features and therefore seem to be responsible for tumor initiating, maintaining, recurrence and chemo-and/or radiotherapy resisting. the current knowledge on genetic and transcriptomic characteristics of these cells especially in comparison to glioblastoma tissue is still limited. the aim of this study is to compare the genetic and genomic profile of glioblastoma tissue and gscs. thereby, differences in involved genes and affected pathways on dna level as well as on gene expression level are identified. material and methods: peripheral blood and tumor tissue were obtained from patients with glioblastoma. tumor tissue derived explant cell culture and serum-free culture were established. based on multi-parameter magnetic-activated cell sorting (macs) technique, cd and cd labeled cell subpopulations of gscs could be isolated. the tumor tissue, serum-free culture, and the isolated cell subpopulations as well as blood were analyzed by snp array and gene expression (excluding blood) in a paired design. for preliminary characterization of gscs in the serum-free culture we confirmed the stem cell features of gscs by the expression of nestin, sox , and cd (applying immunofluorescence staining). results: our results of snp array analyses showed genetic aberrations in all analyzed cellular entities (tumor tissue and cell subpopulations, e. g. gain of chromosome , loss of q . , loss of q . ->q . , and complete loss of chromosome ). furthermore, distinct genetic differences between the cell subpopulations and tumor tissue were observed (e. g. loss of chromosome and segmental uniparental disomy of p . ->p . , only in cancer stem-like cell subpopulations). in addition, we detected many possibly candidate cancer genes and pathways which may have an influence on tumorigenesis. gene expression analyses revealed strongest differences between fresh tumor tissue and serum-free culture based cells, where more than a third of investigated genes were affected. when contrasting fresh tumor tissue with stem cell marker positive serum-free cultured cells, , genes were upregulated in the stem cell marker positive cells, whereas , genes where upregulated in fresh tumor tissue. within these genes, strongest enriched pathways in stem cell marker positive cells included positive regulation of cell cycle and cancer-related pathways, whereas in fresh tumor tissue predominantly immune-related pathways were found, e. g. myeloid leukocyte activation, inflammatory response and phagocytosis. conclusion: differences between gscs and tumor tissue using snp array analyses and gene expression were detected. our results may help to get more information about the molecular pathomechanisms of glioblastoma. it still needs more investigations on the field of genetic and genomic analyses between gscs and glioblastoma tissue to identify novel potential targets for therapy development. background: fanconi anemia (fa) is a rare inherited chromosomal instability syndrome associated with bone marrow failure as well as myelodysplastic syndrome (mds) and acute myeloid leukemia (aml). one-third of fa individuals exhibit bone marrow cytogenetic clones, notably gains of q and q and/or loss of / q, and % to % of fa patients developed mds/aml. in recent years, the application of high throughput technologies has revealed recurrent somatic mutations in genes implicated in myeloid malignancies. as additional genetic maladies facilitating mds/aml development in fa is lacking, we aimed to elucidate whether these mutations would be present in fa patients with mds/aml. methods: using illumina trusighttm myeloid sequencing panel (san diego, ca), we performed next-generation sequencing (ngs) on dna extracted from bone marrow specimens from fa mds/aml patients registered in the european working group of childhood mds. the sequencing panel targeted genes frequently mutated in hematologic neoplasms. results:. ten of the ( . %) evaluable patients had lesions ( to mutations per patient; missense, nonsense, insertion and duplication) in genes. the presence of a somatic mutation did not appear to correlate with complex karyotype or − / q. all affected genes occurred in isolation with exception of runx and kras. while of the mutations were pathogenic, were variance of unknown significance. mutations in genes involved in epigenetics (dna methylation, chromatin maintenance and cohesin complex; idh , tet , dnmt a, idh , ezh , rad and asxl ) and mutations in transcription factor genes (runx , ikzf and etv ) represented the most frequently affected genes. this was followed by mutations of genes encoding signaling molecules including the ras pathway (kras and ptpn ). altered runx was the most common lesion and occurred in individuals with aml, raeb or raeb-t. one patient with refractory anemia with ring sideroblasts (rars) had a mutation in the spliceosomal gene, sf b . conclusions: while the most common mutations encountered in sporadic cases of mds were in genes involved in rna splicing and epigenetics, these two broad categories of genes appeared to have less influence in our fa patients. most mutations were nonrecurring suggesting that there is no specific mutation pattern of these genes in fa-related mds/aml. however, runx mutations and also mutations involved in genes of the ras pathway appear to play a pathogenic role in fa mds/aml development. taken together, the data suggests that mutations in genes that cause clonal hematopoiesis in the population at large do not contribute significantly to fa hematopoietic clonal disease; however, particularly acquisition of runx and ras pathway alterations promote malignant myeloid disease progression. more extensive studies analyzing more patients are necessary to further define the secondary hits leading to fa myeloid disease. chromatin remodeling is a complex process shaping the nucleosome landscape, thereby regulating the accessibility of transcription factors to regulatory regions of target genes and ultimately managing gene expression. the swi/snf (switch/sucrose nonfermentable) complex remodels the nucleosome landscape in an atp-dependent manner and is divided into the two major subclasses brahma-associated factor (baf) and polybromo brahma-associated factor (pbaf) complex. somatic mutations in subunits of the swi/snf complex have been associated with different cancers, while germline mutations have been associated with autism spectrum disorder and the neurodevelopmental disorders coffin-siris (css) and nicolaides-baraitser syndromes (ncbrs). css is characterized by intellectual disability (id), coarsening of the face and hypoplasia or absence of the fifth finger-and/or toenails. so far, variants in five of the swi/snf subunit-encoding genes arid b, smarca , smarcb , arid a and smarce as well as variants in the transcription factor-encoding gene sox have been identified in css-affected individuals. arid is a member of the pbaf subcomplex, which until recently had not been linked to any neurodevelopmental phenotypes. in , mutations in the arid gene were associated with intellectual disability. in this study, we report on two individuals with private de novo arid frameshift mutations. both individuals present with css including id, coarsening of facial features, other recognizable facial dysmorphisms and hypoplasia of the fifth toenails. hence, this study identifies mutations in the arid gene as a novel and rare cause for css and enlarges the list of css-associated genes. the ubiquitin pathway is an enzymatic cascade including activating e , conjugating e , and ligating e enzymes, which governs protein degradation and sorting. it is crucial for many physiological processes. compromised function of members of the ubiquitin pathway leads to a wide range of human diseases, such as cancer, neurodegenerative diseases, and neurodevelopmental disorders. mutations in the thyroid hormone receptor interactor (trip ) gene (omim ), which encodes an e ligase in the ubiquitin pathway, have been associated with autism spectrum disorder (asd). in addition to autistic features, trip mutation carriers showed intellectual disability (id). more recently, trip was postulated as a novel candidate gene for intellectual disability in a meta-analysis of published id cohorts. however, detailed clinical information characterizing the phenotype of these individuals was not provided. in this study, we present seven novel individuals with private trip mutations including two splice site mutations, one nonsense mutation, three missense mutations, and one translocation case with a breakpoint in intron of the trip gene and clinically review four previously published cases. the trip mutation-positive individuals presented with mild to moderate id ( / ) or learning disability [intelligence quotient (iq) in one individual], asd ( / ) and some of them with unspecific craniofacial dysmorphism and other anomalies. in this study, we provide detailed clinical information of eleven trip mutation-positive individuals and thereby due to its heterogeneous etiology, primordial growth retardation is often a challenge for geneticists and clinicians in respect of diagnosis, therapy and prognosis. thus, pinpointing its genetic origin is required for a personalized treatment and prognosis. one syndrome mainly characterized by intrauterine and postnatal growth is silver-russell syndrome (srs), a clinically and molecularly heterogeneous disorder with a considerable overlap with other syndromes. in only % of patients with the characteristic srs phenotype the diagnosis can be confirmed molecularly, but % of cases remain without molecular diagnosis. in fact, in clinically less well characterized patients referred for diagnostic testing, the detection rate is less than %. however, systematic investigations on the contribution of mutations in genes which may be considered in the differential diagnoses of srs are still missing. we examined patients referred for molecular testing of srs but without molecular alterations associated with srs by ngs. a targeted ngs approach comprising genes implicated in the differential diagnoses of srs or suggested as srs candidate genes was performed. in patients fulfilling the criteria of srs accordingly to our recently developed clinical scoring system, disease-causing variants were found. these patients carried mutations in genes associated with bloom syndrome, mulibrey nanism, kbg syndrome, short syndromes or ig-f r-associated short stature, respectively. indeed, some of the differential diagnoses detected in our cohort have a major impact on clinical management, including cancer screening because of a high risk for tumor development. furthermore, we did not identify any pathogenic mutation in one of proposed srs candidate genes (e. g. mest, grb , copg ), thus raising the question whether these genes are indeed involved in the etiology of srs. we show that a (targeted) ngs approach is an important tool to identify the genetic cause in patients with unexplained growth retardation. furthermore, our data show (positive) clinical scoring in srs should not impede the consideration of differential diagnoses and other molecular causes. submicroscopic deletions of chromosome band p . have been reported in more than patients. common clinical features include intellectual disability/developmental delay, central obesity and behavioural difficulties. myt l became the main candidate gene for id and obesity since it is deleted or disrupted in all published patients. however, reports of deletions affecting only this gene and even more so of deleterious myt l sequence variants are very rare. to our knowledge, until now only two patients with de novo myt l point mutations have been reported. in the present study, we analysed a cohort of individuals with intellectual disability of unknown aetiology and their unaffected parents by whole exome sequencing. we identified de novo myt l sequence variants in two out of patients. patient carried a nonsense mutation (c. g>t, nm_ . ; gly *) whereas patient carried a direct splice site mutation (c. - a>g). according to prediction algorithms, both detected myt l variants are deleterious (patient : sift score , cadd score ; patient : cadd score . ). in addition, patient carried a de novo splice site variant in setd b. however, this variant is predicted to be benign (cadd score . ) as well as a known snv (rs , maf . ). a comprehensive clinical characterisation of the two patients yielded only mild or moderate intellectual disability, behavioural problems and muscular hypotonia as common clinical signs. surprisingly, obesity was only present in patient . postnatal tall stature and transient microcephaly were present in one patient each. this clinical picture is compared to the published phenotypes of patients with myt l point mutations, patients with microdeletions of only myt l and patients with larger p . deletions. with the reduced penetrance regarding obesity, the clinical picture of patients with myt l mutations is becoming more and more unspecific. the retina and anterior neural fold homeobox gene (rax) controls the embryonic eye development and is involved in human autosomal-recessive microphthalmia. so far only a few compound heterozygous mutations in rax have been described in microphthalmia patients. we report a first case of microphthalmia caused by a novel homozygous mutation in rax. the -month-old patient was born to consanguineous parents and presented with extreme microphthalmia, panhypopituitarism and developmental delay. mri of the brain showed bilateral agenesis of the anterior visual pathway and tractus opticus. ocular ultrasound confirmed bilateral anophthalmia. additionally, dysgenesis of the corpus callosum and an abnormal pituitary gland have been detected. the first child of these parents, who died shortly after birth, had also been diagnosed with bilateral anophthalmia. using panel diagnosis of the disease associated genome, we identified the homozygous pathogenic variant c. del, (p. fs) in rax. we performed a segregation analysis and confirmed that both parents are heterozygous for this variant. so far developmental delay and panhypo-expand the clinical spectrum of the trip gene in non-syndromic intellectual disability with or without asd. background: whole exome sequencing (wes) using next generation sequencing has proven to be a powerful tool in determining the underlying genetic cause of rare disorders. here, we show, that clinical follow-up and diagnostic re-evaluation can be crucial for uncovering further disease-causing mutations. clinical report and genetic findings: we report follow-up data of a previously published consanguineous family with two children, a boy and a girl, suffering from severe encephalopathy, hypotonia, microcephaly and retinal dystrophy. wes had shown a homozygous intronic splice variant in pgap (c. - a>g;p.?) causative for the symptoms. both parents were heterozygous carrier for the pgap variant (granzow, paramasivam et al, mol cell probes ) . in the next pregnancy, the unborn child presented hydrops fetalis, omphalocele, short tubular bones and cystic kidneys. chorionic villus sampling showed the fetus to be homozygous for the pgap variant. however, neither of these symptoms fit with a pgap -associated disorder. additional wes of fetal dna and re-evaluation in the family showed a homozygous nonsense variant in ift (c.g t;p.e *) consistent with a diagnosis of mainzer-saldino syndrome (mss) which is characterised by the association of renal disease, retinal pigmentary dystrophy, cerebellar ataxia and skeletal dysplasia, as a second diagnosis in the fetus. again, both parents were shown to be a heterozygous carrier for the ift variant. yet, as omphalocele was not accounted for by any of the identified conditions, a third genetic cause cannot entirely be excluded. alternatively, omphalocele may be a rare manifestation of mss, or be the result of a combination of both disorders. the couple opted for induced abortion. discussion: it is estimated that an individual carries multiple heterozygous variants for autosomal recessive disorders in his or her genome. especially in consanguineous families, this results in an elevated risk for children with more than one disorder. in recent publications of clinical exomes, double diagnoses have been reported in to % of investigated subjects. thus, the possibility of more than one causative gene should be carefully explored when working with wes and re-evaluation in case of additional clinical symptoms within a family should be considered. also, follow-up of families with rare genetic disorders may lead the clinical geneticist beyond the assumed single cause to multiple single gene disorders in the same family. conclusion: using wes, we have identified two independent single gene disorders in a consanguineous family demonstrating that clinical follow-up and diagnostic re-evaluation can be crucial for uncovering multiple disease-causing mutations in one family. we present a case study using molecular cytogenetic approaches on a year old boy presenting with microcephaly-brachycephaly, macroglossia and absent speech development. the boy is the first child of healthy, consanguineous parents of pakistani origin. following an uncomplicated pregnancy, the hypotrophic newborn was delivered at weeks weighing g. in the third month of life, the baby had viral meningitis. regular pediatric follow-up revealed psychomotor delay with hypotonia. creatine kinase, lactate and fibroblast growth factor measured in serum were high. subsequent investigations at the age of months included brain mri, electroencephalogram and muscle biopsy that gave hints of a mitochondriopathy or potential neuropathy of axonal type. due to the suspicion of a complex mitochondriopathy, whole exome sequencing was performed using a sureselect human all exon kit (agilent, mb v ) on a hiseq (illumina). the analysis revealed a heterozygous microdeletion of kb on chromosome q . which was classified as an unclear variant (uv), ehmt -gen was not affected. re-examination of proband's dna using array cgh detected a larger kb heterozygous deletion in the q . region (arr[hg ] q . ( , , - , , ) x ), encompassing exon of ehmt (euchromatin histone methyltransferase ; transcript nm_ . ). haploinsufficiency of this gene results in kleefstra syndrome (omim ), a multisystem disorder due to either microdeletions in q . encompassing ehmt or intragenic point mutations. mlpa analysis (ehmt mpla-kit p ) of parental dna further indicated a de novo origin of the deletion in our proband. a similar deletion has been described previously in a case presenting with clinical features of kleefstra syndrome [ ] strengthening the importance to include the ' part of ehmt in sequencing as well as cnv screening. in summary, our study clearly shows that array cgh is a valuable complementary approach to ngs especially for poorly covered regions in ngs i. e. exon of many transcripts. we report on a three-generation family with variable manifestations including delayed and incomplete tooth eruption, early tooth loss due to short dental roots, acroosteolysis, osteoporosis, tendon ruptures, joint hypermobility, muscle weekness, glaucoma, neurological features, and psoriasis. after detection of elevated cd /siglec -expression on monocytes and an upregulation of interferon-stimulated gene transcripts, singleton-merten syndrome was diagnosed. the novel heterozygous mutation c. c>g (p.thr arg) in ifih was found in three affected family members. singleton-merten syndrome is a very rare autosomal dominant interferonopathy, so far described in not more than four families. until now, only two different gain-of-function mutations in ifih have been detected. mutations in ifih are also associated with aicardi-goutière syndrome and recently features of both conditions were found in the same family. our findings expand the mutational spectrum of singleton-merten syndrome and demonstrate the high intrafamiliar variability associated with mutations in ifih . pituitarism have not been described in association with rax mutations. therefore we conducted array comparative genomic hybridization and karyotyping in the index patient. both tests gave normal results. prenatal diagnosis by chorionic villus sampling in the next pregnancy excluded a homozygous carrier status for this rax mutation. mutations in the phf gene are associated with borjeson-forssman-lehmann syndrome (bfls), an x-linked intellectual disability disorder affecting mainly males. female carriers usually show no or mild clinical signs. however, recent studies described females with de novo phf gene defects (mutations, deletions) and severe phenotypes resembling coffin-siris syndrome [ , ] . here, we report on a girl with a maternally inherited phf mutation and a phenotype resembling those described previously in affected females. the mother had learning difficulties and mild dysmorphological features (hypertelorism, prominent forehead). when seen at age months, the proposita showed muscular hypotonia, was unable to sit and had limited head control (developmental delay months). dysmorphic features included scaphocephaly, hypertelorism, a small flat nose with anteverted nares, low set, prominent ears, a high, narrow palate, absent labia minora and linear skin pigmentation on the thighs. ophthalmologic investigation identified strabism convergens of the left eye, hyperopia and an excavated papilla with a pale optical nerve. ultrasound showed patent foramen ovale, tricuspid insufficiency and a unilateral incomplete duplication of the renal pelvis. karyotyping performed elsewhere was normal ( ,xx). results of a genome-wide snp array analysis (affymetrix cytoscan hd) were also normal. using a targeted ngs approach for syndromic and non-syndromic developmental delay encompassing over brain related genes (mpimg- -test), we identified a heterozygous lof-mutation c. c>t (p.gln *) in the phf gene (encoding phd finger protein ). in addition, a human androgen receptor (humara) assay using blood dna showed a highly skewed x-inactivation ( : ). segregation analysis indicated a maternal origin of the variant. the mother also had skewed x-inactivation in blood. her husband and other daughter tested normal for the c. c>t variant. here, we describe the first female patient with a maternally inherited phf mutation and a severe phenotype. the mild phenotype in the mother might be due to different patterns of x-inactivation or to (undetected) mosaicism. this report represents the th case of a severely affected female patient with a phf gene defect. findings support the assumption [ ] that the female phenotypes of bfls might be more common than previously estimated. toms typical for ada deficiency such as fever, livedo racemosa, abdominal colics, arthralgias, and raynaud's phenomenon were observed months later. cecr sequencing (nm_ . ) revealed two previously described pathogenic missense mutations: c. g>c, p.(gly ala) and c. g>a, p.(arg gln). compound heterozygosity was confirmed by parental analysis. to the best of our knowledge, this combination of mutations has not been described until now. the p.(arg gln) is considered as founder mutation in the dutch population, but first phenotype-genotype analyses did not allow further prediction of clinical outcomes. ada deficiency should be considered in patients with childhood stroke despite the absence of systemic inflammation and cerebral vasculitis. congenital hyperinsulinism (chi) has been described as heterogeneous entity caused by at least different genes. in , tein et al. first described a defective activity of l- -hydroxyacyl-coa dehydrogenase in a -year old patient with hypoketotic hypoglycemic encephalopathy. biochemical markers of l- -hydroxyacyl-coa dehydrogenase deficiency (schad) are high -oh-glutarate excretion in urine and c -oh-carnitine in plasma. the clinical presentation is very heterogeneous with regard to age of onset, severity of symptoms as well as response to medical treatment and leucine-sensitivity. in some patients even a near total pancreatectomy was performed. schad dependent hyperinsulinism (hhf ) is a rare autosomal recessive disorder that is caused by mutations in the gene hadh. here we describe patients from unrelated families out of a cohort of chi patients mainly from central europe. patients and are siblings from unrelated parents. the older brother manifested with hypoglycemic convulsions at the age of weeks. a subtotal pancreatectomy was performed in an outside academic hospital. in further course he developed epilepsy and has been treated with diazoxide and anticonvulsants. the nd child was born with hypoketotic hypoglycemia and chi was diagnosed in first days of life. diazoxide treatment stabilized blood glucose and both children were referred to our pediatric endocrinology at the age of years and months, respectively. mutational analysis revealed the homozygous variant c. - c>g within the region of the splice acceptor site in intron of the hadh gene in both affected children. this change is neither registered in exac nor described in the mutation databases hgmd or in the literature and was predicted to disrupt proper splicing. we then completed mutational analysis in unidentified patients of our chi cohort with diazoxide responsiveness and known or suspected consanguinity. patient was born to consanguineous parents and chi manifested in the girl at neonatal age with hypoketotic hypoglycemia. she was successfully treated with diaxozide. later, she developed convulsions and statomotoric developmental delay. the homozygous splice mutation c. + g>t in intron of hadh was detected in the child. the parents were identified as heterozygous carriers. in patient , a girl born to consanguineous turkish parents, chi manifested at the age of months with hypoglycemic seizures. she responded well to diazoxide treatment. a homozygous missense mutation (c. a>g; p.lys glu) in exon of hadh was detected in the patient and her parents were heterozygous carriers. hadh mutations in case and have been previously described in probands of turkish descent and appear to be founder mutations in the turkish population. in conclusion, we recommend hadh mutation analysis to be considered in chi children with unknown cause and known consanguineous pedigrees or originating from populations with higher prevalence of consanguinity. homozygous or compound heterozygous mutations in cecr (cat eye syndrome chromosome region, candidate ) have recently been identified to causing deficiency of adenosine deaminase (ada ; dada ) with childhood polyarteritis nodosa (pan) (omim # ). this inflammatory vasculitis affects the skin, and inner organs (predominantly kidneys and gastrointestinal tract) and also shows a high risk of ischemic stroke, brain hemorrhage as well as peripheral neuropathy. using whole-exome sequencing it was also found that the six adult patients (aged - ) described by sneddon in (sneddon syndrome, omim # ) likewise carried compound heterozygous cecr mutations. sneddon syndrome is characterized by a combination of dermatologic features (livedo racemosa) and ischemic brain infarctions. recently, clinical and genetic data of more than sixty ada patients have been reviewed and underlined the wide clinical variability in age at onset, clinical findings, outcome of neurological involvement, and additional hematological symptoms. typically, stroke has been reported to follow systemic inflammatory disease and predominantly affects posterior and central brain areas. here we describe one of the rare patients in whom acute mesencephalic stroke preceded systemic inflammation and presented as initial clinical symptom. symp- triploidy is a recurrent finding in prenatal diagnostics. in a small number of individuals, correction of triploidy has been suggested based on the finding of (mosaic) genome-wide uniparental disomy (upd). we here investigated uncultured und cultured amniotic cells (ac) and placental tissue from a fetus, in which ultrasound examination in the + th week of gestation revealed growth retardation, left diaphragmatic hernia with parts of stomach and bowel localized in the chest, dextrocardia, short nasal bone and single umbilical artery. these findings were confirmed at the + th week when the pregnancy was terminated. the pregnancy was conceived spontaneously by a -year-old mother and a -year-old father, both healthy and with uneventful family history. the parents were non-consanguineous and carry a normal karyotype. microsatellite analyses of uncultured ac obtained at initial presentation showed for chromosomes , and a pattern suggesting triploidy with only biallelic presentation. while y-chromosomal sequences were lacking the x-chromosome showed, unexpectedly a rather disomic pattern. metaphase yield on cultured ac was low but showed a mosaic karyotype ,xxx-,+ [ ]/ ,xxx[ ], which was confirmed for several chromosomes by interphase fish. remarkably, a triploid clone was cytogenetically not detected. thus, we performed further analyses using microsatellite markers, oncoscan technology and fish. these studies unraveled in uncultured ac a pattern suggestive of triploidy with the supernumerary chromosomal complement derived from a maternal isodisomy with the notable exception of the x chromosome. in cultured ac and placental tissue for all chromosomes, except x and , a diploid pattern was observed with alleles from both parents identical to those in the uncultured ac. trisomy x was confirmed in both tissues with the supernumerary chromosome x being of paternal isodisomic origin. the trisomy was seen only in cultured ac, and likely represents a pseudomosaic which nevertheless could not be proven due to insufficient yield of mitoses from the parallel cultures. finally, retrospective interphase fish on remnant uncultured ac showed two diploid clones, one disomic (approximately % of nuclei) and one trisomic ( %) for the x chromosome. the most likely explanation for the findings is a mosaicism for one diploid clone with genome-wide maternal isodisomy and a second diploid but bi-parental cell line with paternal trisomy x. given the identity of the (maternal) alleles in both clones our findings suggest that originally a triploid clone due to a maternal division error/inclusion of a polar body ii existed which underwent (erroneous) triploidy rescue resulting in one diploid biparental clone and one haploid clone of maternal origin that underwent haploid rescue resulting in genome-wide maternal isodisomy. the biparental clone with trisomy x either resulted from a sperm with two x-chromosomes or an erroneous x-duplication during trisomy rescue. since the introduction of non-invasive prenatal diagnosis (nipd, e. g. har-mony® test) in , this test is frequently demanded and routinely applied in prenatal centers and medical practices. mostly, nipd is intended to detect autosomal trisomies ( , , ), but also offers the possibility to analyze sex chromosomes. therefore, also sex chromosome aneuploidies (sca) (e. g. monosomy x (turner syndrome), triple x, xxy (klinefelter syndrome), xyy) are incidentally found. so far, in our prenatal center sca were detected in pregnancies by har-mony® test, consisting of three pregnancies with monosomy x (turner syndrome) and two pregnancies with klinefelter syndrome (xxy). triple x and xyy were detected one time each. of the three cases with suspected monosomy x, the diagnosis of turner syndrome could only be confirmed in one case. this fetus also had a hydrops at week + . for the other two fetuses, the chromosomal analysis of amniotic fluid revealed normal female karyotypes ( ,xx). in both cases with suspected klinefelter syndrome, this diagnosis could be disproved by amniocentesis (karyotype ,xy). in the pregnancies with assumed triple x and xyy, the true fetal karyotype was not further determined yet. from our experience, the rate of false positive results concerning the sex chromosome aneuploidies is noticeably higher than reported in two studies of nicolaides and hooks . this has to be strongly considered in the counselling of patients who wish to know the fetal sex by nipd. congenital myopathies and congenital muscular dystrophies: will genetic testing replace muscle biopsy in the near future? congenital myopathies and muscular dystrophies are a group of inherited neuromuscular diseases with early onset and broad genetic and histopathological overlap. the diagnostic approach has considerably changed with next generation sequencing methods available. here, we describe the diagnostic value of genetic and histological methods in a cohort of index patients and hence the efficacy of diagnostic procedures. of patients had a muscle biopsy as a first-tier approach. in of patients muscle biopsy was informative, leading to a classification in subgroups of cm or cmd. however, in only a few of these cases biopsy led to a specific diagnosis (e. g. merosin deficiency). in of patients genetic testing (candidate gene sequencing or ngs) was performed additionally to muscle biopsy as a second-tier diagnostic step, while patients of the whole cohort received genetic testing only. in almost two-thirds of these patients genetic testing identified known pathogenic or most likely pathogenic variations. these findings illustrate that genetic testing is superior to muscle biopsy in accurately diagnosing cm or cmd. in conclusion, we suggest that invasive muscle biopsy should be replaced by genetic testing as first-tier diagnostic procedure in patients with clinical signs of cm or cmd. nmd inhibition increases the amount of gaa-rna in patient's lymphocytes as well as in the cells of his parents. the residual function of the resulting protein has to be investigated. discussion and conclusion: rna analysis in lymphocytes with and without nmd inhibition is a simple method for analysing splice defects in all monogenic disorders with expression of the disease causing gene in lymphocytes. a further advantage for the patient is the use of blood cells instead of fibroblasts, because a skin biopsy can be avoided and analysis times are reduced. the exact characterization of pathogenic variants is an important aspect of diagnosis, prediction of disease severity and genetic counselling. in vitro nmd inhibition in lymphocytes of affected patients allows the characterization of splice defects. in the future successful inhibition of nmd in vitro might help to identify patients, who may profit from a therapeutic intervention with nmd inhibitors. even expression of a partial protein with low or no activity reduces the risk for the patient to develop antibodies hampering enzyme/protein replacement therapy. p-cling- q microdeletion syndrome: a family with short stature and silver-russel (srs)-like phenotype. introduction: the silver-russel syndrome (mim ), first described independently by silver and russell in , is a condition with intrauterine growth retardation, postnatal growth failure and other characteristic features, including relative macrocephaly (defined as a head circumference at birth ≥ . sd score (sds) above birth weight and/or length sds), prominent forehead, body asymmetry and feeding difficulties as recently defined in an international consensus statement. patients and methods: we report here on first degree relatives with a silver-russel syndrome phenotype who presented with prenatal-and postnatal growth retardation, feeding difficulties, a prominent forehead and a failure to thrive. additional features such as dysmorphic facial features, periodically increased sweating, and scoliosis were present in one of the family members only, whereas learning problems and cardiac arrhythmia were present in one other. none of the patients had relative macrocephaly. high resolution array-cgh was performed to screen for cncs and mlpa to confirm the array-cgh result. results: no hypo-methylation of the imprinting center on p nor uniparental disomy of chromosome and were found in the index-patients. high-resolution array-cgh identified a q . microdeletion of . mb (arr[grch q . ( , , , )× ). the heterozygous loss was confirmed by mlpa in the index patient and the other two affected family members (i. e. her brother and mother). the deletion includes the genes hmga , llph, tmbim , irak , helb, grip , and the pseudogene rpsap . conclusion: to the best of our knowledge this is the first report on familial presentation of a silver-russel syndrome due to a microdeletion in q . . none of the patients had relative macrocephaly. supporting the hypothesis by takenouchi et al. that the causative gene for relative macrocephaly resides centromeric to hmga , the region centromeric of hmga is not included in the deletion in our family. spastic ataxia of charlevoix-saguenay (sacs) is an autosomal recessive neurodegenerative disorder and is caused by homozygous or compound heterozygous mutations in the sacs gene. first symptoms of sacs are walking difficulties due to unsteady gait. further typical clinical features include spasticity, ataxia, pyramidal tract signs, nystagmus and dysarthria. here, we report on a -year-old female patient who initially presented with disturbances in motor abilities including frequent falls and high arched foot. cranial mrt was normal while nerve conduction velocity was significantly reduced. the patient's parents did not show any clinical features. since no pmp duplication was detected we performed a gene panel including genes that are associated with hereditary motor and sensory neuropathies (hmsn) and related disorders by using targeted next generation sequencing. we identified the two heterozygous stop mutations c. t>a (p.leu ter) and c. dupt (p.leu phefs* ), located at the same position in the sacs gene. sanger sequencing did not enable us to properly display that there is a transversion and a duplication of the same nucleotide at two different alleles. this exemplifies that, in contrast to sanger sequencing, ngs can illustrate both alleles separately. to conclude, this case was only resolvable by ngs which makes this method appropriate for the detection of compound heterozygous mutations, especially in the rare event when two mutations occur at the same position. background: the precise identification and characterization of genetic variants in monogenic diseases has a wide influence on diagnosis and therapy. about % of pathogenic variants are splicing variants. due to the complex mechanism of splicing regulation it is difficult to predict the effects of variants on mrna splicing. possible consequences are exon skipping, intron retention, generation of novel splice sites or the utilization of a cryptic splice site. common consequences are a frame-shift and the generation of premature termination codon. this leads to rna degradation via the nonsense mediated decay (nmd) pathway. in a patient with the clinical symptoms of non-classical infantile pompe disease and a confirmed acid alpha-glucosidase (gaa) deficiency, we detected two novel, exonic variants in the gaa gene. both base pair exchanges suggested either an amino acid exchange or a splice defect as consequences. however, conventional investigation of the leucocyte mrna of the patient and his parents was inconclusive. degradation of the respective mutated rna by nmd was suspected. we developed an approach in order to characterize novel splicing mutations in a simple and non-invasive manner. material and method: isolated blood lymphocytes from patient and his parents were cultured in standard leucocyte medium supplemented with different concentrations of the nmd inhibitors ocadaic acid, anisomycin, and wortmannin for h. cells were harvested and rna was isolated. the reverse transcribed cdna was amplified in allele specific pcrs and qpcr assays. results: compared to the non-stimulated lymphocyte controls nonsense mediated rna decay was inhibited by anisomycin. the consequences of aberrant rna splicing were detectable: the maternal mutation results in exon skipping, the paternal mutation in intron retention. furthermore vascular ehlers-danlos syndrome (type iv) is considered to be an autosomal dominant disorder caused by heterozygous mutations in col a , which are missense or splice site variants in about % of cases. we here report on a three-year-old female of non-consanguineous parents born with bilateral clubfoot as well as dysmorphic facial features, joint laxity, and mild contractures of finger joints. developmental delay became evident. after trauma at years of age she developed brain haemorrhage. mri diagnosis at this age revealed an additional frontal aneurism as well as frontoparietal polymicrogyria. we identified novel compound heterozygous col a mutations: the nonsense mutation c. c>t (p.arg *) and the c. delc (p.pro leufs* ) frameshift mutation leading to a premature stop codon. further studies showed that the mutations were inherited from each parent who had no features for ehlers-danlos syndrome type iv. only two other families have been reported so far with recessive mutations of this gene and a severe vascular phenotype and polymicrogyria. biallelic mutations of col a seem to be accompanied with a significantly worse outcome compared with heterozygous mutations and polymicrogyria is an additional phenotypic feature. here we describe five patients with epidermolytic epidermal nevi in different degrees of severity with the mosaic mutation c. c>t (p.arg cys) in krt gene. the same mutation has previously been described in patients with ei (bygum et al. ) . we analyzed dna from peripheral blood and/or skin biopsies from affected and unaffected skin with next generation sequencing (ngs) and sanger sequencing methods. using ngs we found this mutation in blood in mosaic states ranging from % to %. the mosaic could only be confirmed by sanger sequencing in the patient with the highest mosaic frequency of %. in four of our patients we investigated skin biopsies from affected and unaffected skin. it is noteworthy, that only one of four patients showed the mutation in heterozygous state of % in the affected skin, whereas the other patients presented a mosaic state also in the affected skin. to exclude a recurrent sequencing artefact at this position, we examined control patients for this mosaic mutation using ngs. in none of these patients we found the same dna change. patients with epidermolytic epidermal nevi have a higher risk to have children with a full-blown ei phenotype. our results show the importance of ngs as the method of choice to explore the molecular genetic basis of epidermolytic epidermal nevi. strikingly, all our patients carry the same mosaic mutation c. c>t in krt . we suggest that this position is a hotspot for postzygotic mutations in krt . non-syndromic hearing loss (nshl), with presently around associated genes, is one of the most genetically heterogeneous disorders constituting nearly % of genetic deafness with a predominantly recessive inheritance pattern. thirty percent of hearing loss (hl) can be connected as a part of over distinct syndromes. next generation sequencing (ngs) technologies have revolutionized pathogenic variant identification. different strategies enhance pathogenic variant detection supporting detailed hl investigation to overcome the many ambiguities associated with clinical heterogeneity. detection of the disease causing variant in correlation with the phenotype can be challenging in small families, in situations with ambiguous clinical histories and allelic heterogeneity. using a clinical and whole exome sequencing approach, we tested over probands as part of a multicentre iranian and german genetics of hl study that included probands primarily with sporadic or dominant hl in a parent-child or parent-sibling trio context. the majority of these probands were pre-screened for defects in gjb and strc. libraries were prepared using trusight one and nextera rapid capture exome enrichment and sequenced using the miseq and nextseq desktop sequencers (illumina). analysis was performed using gensearchngs and an inhouse exome analysis pipeline. around % of cases were resolved from phenotype matching and segregation analysis. interestingly, the fraction of resolved cases was much higher in our iranian cohort (> %) compared to our german cohort (> %) which may be attributed in part to increased consanguinity in the iranian families. we observed likely disease causing variants in syndrome-associated genes including eya causing branchio-oto-renal syndrome, a phenotype that was retrospectively confirmed by acquisition of additional clinical information. with few exceptions, we observed a diverse collection of affected genes in probands from our german collected cohort. contrastingly, the iranian cohort revealed frequent mutations in myo a and otof. furthermore, co-segregation of variants in myo and tecta, with expected dominant hl phenotype, was a hindrance overcome by extensive segregation testing. familial locus heterogeneity was also observed by mutations in cib and slc a segregating in different branches of the same extended pedigree. success in the identification of disease causing variants in known hl genes is contingent upon analysis strategy, clinical information and opportunity for segregation testing. the ability to retrospectively connect an already apparent syndromic phenotype to a syndrome-associated gene without prior knowledge is a powerful application of comprehensive analysis that is not restricted to nshl genes. this work provides an improved understanding of population-specific genetic epidemiology of hereditary hl and highlights the challenges in defining genetic causes in a highly heterogeneous disorder such as hl. vere disproportionate microcephaly (- , sd), corneal clouding, myopia, teeth abnormalities and dysmorphism. panel diagnostic by next generation sequencing for primary microcephaly, including all known genes for seckel syndrome, was unremarkable. microarray analysis (affymetrix® cy-toscan hd) revealed a heterozygous kb deletion, spanning the plk gene. this deletion was confirmed by mlpa (multiplex ligation-dependent probe amplification) analysis. subsequent sequence analysis of the plk gene showed a variant of unknown significance on the second allele. in silico analysis of this variant indicated a significant decrease of the relative splice efficiency at the splice donor site. rt-pcr analysis confirmed altered splicing, resulting in a predominant loss of exon of the transcript and predicting truncation of the plk protein. interestingly, a residual wild-type transcript was also detectable in patient rna, implying that this variant effects splicing only partially. by analysis of the parents, the splice variant and the large deletion were proven to be compound heterozygous. discussion: up to now, only a few patients with plk mutations have been described in the literature. the phenotype comprises primary microcephaly, primordial dwarfism and chorioretinopathy (mccrp ). to our knowledge, we describe the first case of a plk heterozygous whole gene deletion and at least partial biallelic inactivation of the gene, therefore expanding the genetic background of this disorder. furthermore, we give a detailed phenotypic description of a further individual with plk alterations. the girl does not show retinopathy so far. while generalised retinopathy was discussed to be one of the most prominent distinctive features between mccrp and primary microcephaly/seckel syndrome, we consider plk rather to be a further candidate gene pointing towards seckel syndrome. additional investigations on centriole function in patient-derived cells are in progress. pathogenic variants of mitochondrial dna cause a wide range of severe congenital disorders with maternal inheritance and a high transmission risk for female carriers. we report on eight families with an index case presenting with the common pathogenic variant m. t>g (p.leu arg) in the mt-atp gene in virtually homoplasmic form. in five families the mutation was detectable in peripheral blood from the mother in heteroplasmic form. in three families with a sporadic case of leigh syndrome the mutation was not detectable in peripheral blood (or urinary or buccal cells) from the mother, possibly indicating a de novo event. furthermore, one family presented with a de novo nonsense mutation in the gene mt-atp , which was present in peripheral blood of the index case in about % and was not detectable in the mother or the unaffected sister. two female carriers with a heteroplasmy level of % asked for prenatal testing. both pregnancies showed an apparently homoplasmic load of the mutation. mutations in lztfl (bbs ) may be associated with a severe renal phenotype huntington's disease (hd) is a rare autosomal dominant neurodegenerative disorder caused by expanded cag repeats as diagnosed via direct dna analysis. for asymptomatic individuals, predictive testing (pt) can facilitate life planning and diminish uncertainty, but it is also associated with substantial social and psychological challenges. we present a prospective case series of counselees seeking predictive hd testing at the huntington centre north-rhine westphalia (bochum, germany) between and . the international protocol including several pre-test sessions was followed throughout. the aim of this study was to prospectively follow the decision-making process of individuals at risk in our centre and explore their experiences following the decision as well as the impacts of mutation test results by means of standardized questionnaires and a semi-standardized telephone interview one year after the initial counselling session. individuals participated in at least one of the three phases of the survey, including individuals for the telephone interview. in our cohort, almost all interviewees reported a balanced emotional state one year after initial counselling, regardless of the decision for or against the test. the most important motivations for a decision in favor of pt were the ability to plan private life and to eliminate uncertainty. the most important motivations against pt were the fear of an increasing risk for others (e. g. offspring) and the fear to obtain an unfavorable htt mutation result, followed by the considered, willful decision for "wanting to not know". furthermore, we identified evidence for gender-specific aspects in decision-making in line with and expanding our previous observations. this study represents one of the few comprehensive prospective evaluations regarding decision-making and coping strategies related to predictive testing for huntington's disease. we submit that gender-related aspects should be heeded in genetic counselling during the predictive testing and counselling processes. our findings could serve as a basis for more extended prospective evaluations with higher numbers of participants and longer follow-up intervals. institute of human genetics, heidelberg, germany, department of conservative dentistry, heidelberg, germany, cegat gmbh, center for genomics and transcriptomics, tübingen, germany background: plk (polo-like kinase ) has been designated as "master regulator" of centriole assembly. complete loss of plk is lethal in mice, whereas biallelic plk mutations with some retained function have been described in a few patients with microcephaly, growth failure and retinopathy (mccrp , omim # ). this is a heterogeneous entity overlapping with mcph (primary microcephaly) and seckel syndrome. during the last years several new genes have been discovered associated with this spectrum. clinical report and genetic findings: we report on a year old female patient with intellectual disability, primordial dwarfism (- , sd), most se-abstracts linked to rare autosomal recessive diseases with poor prognosis. we then compared couples and filtered for variants present in genes overlapping in both partners. putative pathogenic variants were tested for co-segregation in affected fetuses where material was available and in unaffected siblings. out of eleven couples of mediterranean and arabian ancestry (c: , nc: ) and two non-consanguineous couples of european ancestry, we found five cases ( / , %, c: , nc: ) with both parents being heterozygous carriers of rare potentially deleterious variants in one or more overlapping genes. in four of these couples the underlying genetic cause for pre-or early postnatal child death could be established, in two of the families the diagnosis was confirmed by homozygous detection of the parental variant in the available dna of the affected child. in a consanguineous couple with pathogenic variants for a severe autosomal recessive disorder identified in both parents, the molecular diagnosis for their child that had died at months of age could not be established. out of couples in whom no causative diagnosis could be achieved consented to undergo further wes analysis. identified variants are now used for preimplantation and prenatal diagnostics in all four families in which a causative diagnosis was established. our data show that ngs based gene panel sequencing of selected genes involved in lethal autosomal recessive disorders is an effective tool for carrier screening in parents and for the identification of recessive gene defects in families that have experienced early child death and/or multiple miscarriages. k. komlósi , s. diederich , d. l. fend-guella , u. zechner , s. schweiger , o. bartsch recently an x-linked syndrome with maternally inherited or de novo mutations in taf was described with global developmental delay, intellectual disability (id), delayed speech, characteristic facial dysmorphology, generalized hypotonia and variable neurologic features (mrxs , mim: # , xlr). there have been only three publications of unrelated families, with single-nucleotide changes and with gene duplications including taf (kaya et al., ; o'rawe et al., ; hu et al., ) . we identified a german family in which two brothers ( and years) showed severe intellectual disability, absent speech and understanding, and hypotonia but different neurologic and behavioral phenotypes. besides severe id the older brother also had postnatal short stature (- sd), a severe lennox-gastaut epilepsy and a neurodegenerative course. the younger brother showed autistic behavior and lost his very limited skills at age to . years. both showed mild dysmorphic features (prominent supraorbital ridges, sagging cheeks, long philtrum, long face, thin upper lip, and high-arched palate), oropharyngeal dysphagia and generalized hypotonia. a gluteal crease with a sacral caudal remnant described as a characteristic feature was not seen in our case, and hearing impairment, microcephaly, dystonic movements or tremor were not observed either. the family history was highly suggestive of x-linked inheritance with an affected maternal uncle, a maternal aunt with multiple miscarriages, and two aunts with learning disability. since a previous analysis of known x-linked mental retardation genes had not revealed the cause in the older brother, we used a targeted ngs approach (mpimg -test: > brain related genes) for the analysis of the younger brother. following enrichment a bp paired end sequencing was carried out on an illumina miseq system with > % of target covered > -fold (hu et al, ) . only taf fitted the x-linked model and the phenotype. the unreported hemizygous sequence variant c. g>a (p.asp asn) in exon of taf was deemed pathogenic. it affected a highly conserved residue in the central "duf " domain, where / previously described mutations had clustered. segregation analysis confirmed hemizygosity in the older brother and heterozygosity in the mother with completely skewed x-inactivation ( : ). gonadism and learning disabilities. because of the delayed onset of symptoms, the diagnosis is often established during late childhood. however, in some cases renal morphological changes detected by ultrasound may resemble those usually seen in autosomal recessive polycystic kidney disease (arpkd). however, histologically bbs-kidneys differ distinctly from other polycystic disorders by cystic orientation, localisation, extension, structure and size. bbs genes have been identified to date. mutations in bbs , bbs , bbs and bbs have been found to cause an antenatal presentation of bbs that may in some aspects mimic meckel gruber syndrome (mks). there is increasing evidence that bbs, at least in some families, shows an oligogenic mode of inheritance with three mutations at two bbs loci. yet, only three patients in two families with bbs caused by mutations in lztfl (bbs ) have been reported. their diagnosis was established in childhood and all patients had mesoaxial polydactyly as a distinct manifestation. in contrast to previous lztfl cases, in our family the diagnosis of arpkd was suspected sonographically at weeks gestation (wg). pregnancy was terminated at wg. autopsy revealed postaxial polydactyly of both hands, enlarged spongy kidneys, hemivertebra t and some features of potter's sequence. histological examination of the kidneys showed multiple, not radially oriented thin walled cysts, internally lined by thickened pas-positive basement membranes and microcystic dilatation of collecting ducts. cystic changes were accentuated in the renal medulla. corticomedullar differentiation was mainly preserved. the tentative diagnosis was bbs. fetal dna was investigated using a next generation sequencing panel which included known bbs causing genes. hereby a heterozygous nonsense variant (np_ . : p.glu *) inherited from the mother and a heterozygous missense variant (p.glu lys) inherited from the father of the lztfl gene were identified. furthermore a maternally inherited heterozygous missense variant of unknown clinical significance in bbs was detected (np_ : p.pro ala). our case shows for the first time that mutations in lztfl can lead to a severe prenatal presentation of bbs due to profound renal manifestations with a kidney histology that is not considerably milder but distinct from that observed in mks. it is not clear to which extent the bbs variant may act as a disease modifier. this may challenge genetic counselling and prenatal diagnosis in a further pregnancy. furthermore our case shows that mesoaxial polydactyly is not always present in bbs patients with lztfl mutations and further studies are necessary to establish the frequency of mesoaxial polydactyly and other genotype phenotype correlations for bbs patients with lztfl mutations. p-cling- *** targeted next-generation sequencing analysis in couples at increased risk for autosomal recessive disorders k. komlósi, s. diederich, d. l. fend-guella, j. winter, o. bartsch, u. zechner, s. schweiger genetic childhood disorders leading to prenatal, neonatal or early childhood death are genetically heterogeneous. many follow autosomal recessive or x-linked modes of inheritance and bear specific challenges for genetic counselling and prenatal diagnostics. parents are carriers but unaffected and diseases are typically very rare but with recurrence risks of % in the same family. often, affected children (or fetuses) die before a genetic diagnosis can be established, post-mortem analysis and phenotype descriptions are insufficient and dna material of affected fetuses or children is not available for later analysis. a genetic diagnosis showing biallelic mutations or mutations on the x-chromosome in male fetuses or children is, however, the requirement for targeted carrier testing in parents, risk calculations, and prenatal and preimplantation diagnostics in further pregnancies. we employed targeted next-generation sequencing (ngs) for carrier screening of autosomal recessive lethal disorders in consanguineous (c) and non-consanguineous (nc) couples with one or more affected children. we searched for heterozygous variants (non-synonymous coding or splice variants as well as cnvs) in parents' dnas in a set of genes r. kropatsch , , j. preine , , jt. epplen , department of human genetics, ruhr university, bochum, germany, charcot-marie-tooth disease (cmt), also commonly called as hereditary motor sensory neuropathy, is the most common monogenetic disease of the peripheral nervous system with significant clinical and genetic heterogeneity. the main clinical manifestations of cmt include progressive distal muscle weakness and atrophy, impaired distal sensation, depressed tendon reflexes and high-arched feet. based upon electrophysiological and histopathological features cmt can be divided into predominantly demyelinating or axonal forms. an intermediate form also exists characterized by evidence of both, demyelinating and axonal, impairments. genetically cmt can be caused by mutations in over genes, including the dnm gene encoding dynamin protein, a large gtpase primarily involved in receptor-mediated endocytosis and membrane trafficking. only a small number of mutations in dnm causing cmt have been described so far. we report the case of a -year-old man presenting with backache, ataxic gait and distal muscle weakness of the lower limb considered to be a consequence of the pre-diagnosed disc prolapse years ago. over the past months bilateral progressive weakness of ankle dorsiflexion, foot drop and tingling paresthesia in stocking distribution have occurred. neurological examination disclosed depressed tendon reflexes of the upper and lower limbs. neurophysiologic investigations revealed an axonal sensible polyneuropathy with normal distal motor latencies and nerve conduction velocities. the sural nerve biopsy indicated single unmyelinated or thinly myelinated axons, loss of myelinated nerve fibers, numerous clusters of regenerating fibers without onion bulb formations suggesting an intermediate form of cmt. by using next generation sequencing (ngs) and a multi-gene panel, consisting of inherited neurological disease-associated genes, we identified a heterozygous missense mutation c. g>a, p.asp asn (rs ) in the dnm gene. this particular mutation is located in a highly conserved nucleotide region encoding the catalytic n-terminal gtpase domain. this evidence suggests a pathogenic phenotype caused by the described mutation, which is being underlined by the following facts: public genome database covering harmless variants of the human genome does not report it. additionally, the exac browser with exome sequencing data of > , unrelated individuals, lists the mutation and shows a low allele frequency of . , corresponding to one known heterozygous mutation carrier. other online prediction tools like the mutation taster, polyphen, sift and provean categorize it as pathogenic. in conclusion, the novel dnm mutation is responsible with high probability for the late-onset form of intermediate cmt of the investigated patient. heterozygous mutations in pcdh cause an x-linked female-limited form of an early infantile epilepsy (juberg-hellman syndrome). the phenotype of this syndrome is variable, ranging from benign focal epilepsy to severe, serial seizures, repeating up to more than times a day for several consecutive days. the intellectual outcome of affected patients ranges from normal to severe intellectual disability. psychiatric disturbances are frequent and manifest as autism, schizophrenia or aggressive behavior. neurological features such as ataxia may also be present. women with triple x syndrome usually show a normal physical development. cognitive deficits in vivo functional modeling of taf has already provided evidence for an effect on a neuronal phenotype. the phenotype in patients can be reminiscent of rett syndrome, but with milder regression and normal movements lacking a specific stereotypic pattern (no hand wringing). while severe neurodegeneration has been described in duplications, the present probands clearly showed developmental regression associated with a missense mutation. the analysis of further family members is pending. our case adds to the phenotypic spectrum of x-linked syndromic mental retardation type . targeted enrichment sequencing was successfully applied to identify greenberg dysplasia as cause of fatal anomalies in one fetus of a dizygotic twin pregnancy. p. m. kroisel , , b. csapo , , m. häusler , , l. michelitsch , , s. verheyen , , p. klaritsch , , k. wagner , institute of human genetics, medical university of graz, graz, austria, department of obstetrics and gynecology, gynecologist and obstetrician, weiz, austria in the first pregnancy of a year old kosovarian woman and her year old husband during the th week of gestation one of her dizygotic twins showed a severe skeletal dysplasia with all long bones extremely shortened and partially bended. the thorax was short and narrow. in addition a ventriculomegaly of the brain and an increased nuchal translucency was noticed. a very bad prognosis was expected and an achondrogenesis was suspected clinically. the other twin appeared to be normal. an amniocentesis was performed to potentially identify the genetic basis of the disorder. qf-pcr to rule out common trisomy's and cytogenetics revealed normal results and following a normal agilent k array cgh analysis as a next diagnostic step next generation sequencing by using the trusight one gene panel focusing on three genes including slc a , trip and col a was performed. since no pathogenic mutation was found by this approach, a more extended bioinformatics study was initiated. by filtering out common variants in the more than genes of the panel in our own database or in the exac-and genome databases our search was extended to genes with rare homozygous or compound heterozygous variants. by this strategy it was possible to reduce the potentially causative gene mutations dramatically and among those remaining genes for known very severe skeletal phenotypes just in the lbr gene the homozygous missense mutation c. a>g, p.asn asp was identified in our fetus. since this particular mutation is already known to be pathogenic leading to the lethal greenberg dysplasia (clayton et al., nucleus. ) the diagnosis could be achieved in the affected fetus of the pregnancy of our patient still before completion of the rd week of gestation. both parents were found to be heterozygous for this mutation in the lbr gene. recently it was shown that different mutations of the very same gene can also lead to less severe forms of bone dysplasia. the couple was informed about our results and possible consequences were discussed and offered. the couple however came to the decision not to draw any consequences. both fetuses especially the affected one were well documented sonographically including in a series of d images. in the th gestational week during a sonographic investigation the affected fetus did not show cardiac function and an oligohydramnios was found. since development of the second non affected fetus was still within the normal range, we hope the now single pregnancy will carry on normal until birth. from our finding we would propose that our chosen strategy is straightforward and can be applied in a wide range of pregnancies to identify various up to severe and fatal single gene disorders associated with sonographic anomalies within a few weeks which should provide substantial benefits for these families. after the working diagnosis ps had been established, molecular analyses regarding the recurrent akt mutation (p.glu lys) were performed by sanger sequencing in available affected tissue specimen of all three individuals. this revealed a high level of mosaic state for the akt mutation c. g>a, (p.glu lys) in affected tissues from bone and in meningiomas. re-evaluation of the ngs data from blood (individual i) confirmed the absence of that mutation in all reads, and no mutation was detected by sanger sequencing in dna from blood in individuals ii and iii. thus, a somatic mosaicism leading to a mild proteus phenotype could be confirmed as the underlying genetic cause in all three affected individuals. in conclusion, mild forms of proteus syndrome caused by the recurrent akt mutation in patients with limited regional involvement may be particularly difficult to diagnose and might be underdiagnosed. distal gne-myopathy: rare differential diagnosis of polyneuropathy here, we report a case of a -year-old patient with presumed polyneuropathy and elevated creatine kinase levels ( - u/l). clinical features included atrophic and bilateral paresis of lower legs of the frontal and rear compartment without high arched foot, while sensibility was not affected. additionally, a myopathic emg in m. tibialis anterior and a slight axonal damage in the motor neurography was detected. due to this overlapping neuromyological phenotype we performed a gene panel including genes associated with neuromuscular diseases using targeted next generation sequencing. gene panel analysis revealed the homozygous mutation c. c>t (p.arg trp) in the gne gene. this mutation is described in the literature as cause of a distal gne-myopathy and was also detected in an affected brother (ck u/l), having consanguineous parents. the current case emphasizes that a large gene panel analysis is recommended in case of an overlapping neuropathological and myopathological phenotype. c. landgraf, g. schmidt, s. morlot, b. schlegelberger, b. auber institute of human genetics, hannover medical school, hanover, germany ehlers-danlos syndrome (eds) is a heterogeneous group of connective tissue disorders. according to the villefranche classification, eds comprises six major types as well as some rare specific entities. one of these has been referred to as "eds, musculocontractural type" (mc-eds), "adducted thumb-clubfoot syndrome" or "eds, kosho type". first described in as an eds vi subtype, it recently was identified to be caused by biallelic changes in either the chst or dse genes, resulting in a loss of dermatan sulfate (ds) biosynthesis. characteristic symptoms are multiple congenital malformations such as contractures (club feet, adducted thumbs), visceral and ocular anomalies, generalized joint laxity, scoliosis, muscular hypotonia, fragile, hyperextensible and bruisable skin, as well as a typical craniofacial appearance. distinctive features include hypertelorism, down-slanting palpebral fissures, bluish sclerae, micro-corneae, short nose with hypoplastic columella and long philtrum, thin upper lip vermillion, small mouth, retrognathia, low-set and posteriorly-rotated ears. the psychomotor development is delayed. (chst ) and (dse) patients have been reported as yet. the patient, a -year-old woman using a wheelchair, had club feet, surgically corrected asd ii, muscular hypotonia, the characteristic face and hyperextensible skin with atrophic scars; particularly visible were those and learning disabilities are more common than in the general population and compared to siblings. their motor skills are likely to be somewhat impaired and coordination problems are frequent. in some patients psychological problems were described. furthermore, eeg abnormalities are occasionally observed, with clinical seizures present in up to % of patients. here we report on a -year-old girl with a ,xxx karyotype and early infantile, intractable epileptic seizures, beginning at the age of months. about three years later, she developed severe, serial seizures often related to febrile infectious diseases. in adolescence, the epileptic symptoms became less intense. she additionally showed autistic features, mental deficiencies, hypermobility of the joints and ataxia. array-cgh, fragile x-analysis as well as sanger sequencing and mlpa of the scn a and mecp genes revealed no additional abnormalities, besides the xxx karyotype. in the pcdh gene the heterozygous missense mutation c. a>g (p.asn ser) was identified, whereby the mutated allele seemed to appear in a : ratio compared to the wild type allele. this mutation has been previously described as disease causing. furthermore, three in silico prediction programs (sift, polyphen- , mutationtaster) classified the mutation as pathogenic. the patient's asymptomatic mother had a normal ,xx karyotype and was not a carrier of the pcdh mutation. pcdh -related epilepsy exhibits an unusual mode of inheritance in which only heterozygous females are affected and hemizygous males are asymptomatic carriers. random x-inactivation in the brain of females with pcdh mutations causes a cellular mosaicism, which likely accounts for the pathogenesis by altering the cell-cell-interactions ("cellular interference"). however, the precise mechanism is still unknown. hypothetically, the wide range of phenotypic expressions may be explained by partially skewed x-inactivation and thereby limitation of the cellular interference. hence, an unequal ratio of mutated to wild type cells should give a milder phenotype compared to the fifty-fifty situation. in contrast to this hypothesis, the phenotype in our patient was rather severe. nevertheless, we cannot exclude that the triple x status contributes additionally to the observed phenotypic expression. proteus syndrome (ps, omim ) is a highly variable disorder with asymmetric and disproportionate overgrowth of the body, connective tissue nevi, epidermal nevi, dysregulated adipose tissue, and vascular malformations, caused by a somatic activating akt mutation. we report on three unrelated individuals (two adults and one year old boy) who showed similar clinical findings that not fulfilled the rigorous clinical criteria for ps (biesecker, ) . beside an asymmetric hyperostosis of the skull or facial bones, all three had an ocular dermoid. two individuals developed alveolar hyperostoses and intracranial calcifying meningiomas. only one individual showed skin changes. all three had normal feet and no vascular lesions. molecular analyses in individual i performed in blood revealed normal results for array karyotyping and no relevant variant in whole exome sequencing (trio approach). introduction: incontinentia pigmenti (ip) is a rare x-linked male lethal genodermatosis that affects the neuroectodermal tissue and is always associated with a bullous rash of the skin along blashko lines in female neonates. it is caused by mutations in ikbkg which encodes the regulatory subunit of the ikb kinase complex required for nf-kb activation. ikbkg has a pseudogene (ikpkgp) with identical exons to . the most frequent ip mutation is a recurrent exon _ deletion due to non-allelic homologous recombination with the pseudogene. here, we report a novel deletion of exons and in the ikbkg transcript recognized by rna analysis. patient: we investigated a yr old girl with typical erythematous rash after birth which resolved within - m. apart from a small hyperpigmented area around the right mammilla there were no skin alterations. she had few conically shaped teeth, normal nail and hair structure, no neurological manifestation and normal intelligence. only clinical sign were repeated vitreous hemorrhage of the left eye from age m. family history was negative. methods: analyses on genomic dna extracted from blood included testing for the common ikbkg exon _ deletion by long range pcr and mlpa (p -a , mrc holland), x inactivation analysis in the androgen receptor gene as described, and massively parallel sequencing (mpseq) of the ikbkg gene (trusightone, nextseq, illumina®; data analysis with nextgene/geneticist assistant [softgenetics®] and seqnext [jsi®]; reference sequence grch , hg ). rna was extracted from cultured blood lymphocytes, and the entire ikbkg transcript (nm_ . , exons) was sanger sequenced on cdna level (the a of the start codon is in exon ); the results were analyzed with sequencepilot (jsi). result: genomic dna analyses including mlpa of ikbkg and ikbkgp specific probes in our patient did not reveal a putative mutation. there was a completely skewed x-inactivation pattern. cdna sequencing of ikbkg demonstrated skipping of exon and (r. _ del) which is predicted to cause a frame shift starting from codon p.gln , a premature stop codon amino acids downstream (p.gln glyfs* ) and complete loss of protein function. the loss of exons and is most likely due to an intronic splice variant in intron ; investigations regarding the origin of this deletion are ongoing. conclusion: the presence of the high homologous pseudogene makes sequence analysis of ikbkg challenging. we report a deletion of exons and in the ikbkg transcript that required rna analysis for its identification. due to the skewed x-inactivation and typical clinical picture causality of the detected deletion is certain. the exact genomic cause of this alteration remains to be clarified. also in the era of mpseq, rna analysis may be necessary for detection of deep intronic mutations or the study of genes with homologous pseudogenes, as shown here in the case of ikbkg. primary congenital glaucoma (pcg) and early onset glaucomas are one of the major causes of of blindness in children and young adults' worldwide. both autosomal recessive and dominant inheritance have been described resulting from bowel surgeries due to colon perforation. her older sister who died aged following an acute abdomen had club feet and the typical facial appearance, while three healthy sisters seem to be unaffected. her parents are first cousins of turkish origin and do not show eds symptoms either. the two affected sisters had been diagnosed with a syndromic disorder that could represent a rare form of eds. however, neither a confirmation of the suspected diagnosis nor a classification had yet been achieved. due to the distinctive symptom complex and the presumed autosomal recessive inheritance pattern, we strongly suspected this to be a case of mc-eds. sequencing of the chst gene (reference sequence: lrg_ ) revealed a formerly undescribed homozygous variant (c. c>t; p.pro- leu). the variant changes the highly conserved pro residue which is located in the critical '-phospho- '-adenylyl sulfate binding site and can be classified as likely pathogenic (acmg standards and guidelines, richards et al., genetics in medicine ) . the parents are heterozygous carriers of this variant, respectively. this case represents a unique entity within the umbrella term eds and illustrates the importance of clinical assessment leading to a diagnosis confirmed by genetic analysis. the underlying genetic defect in patients with mitochondrial peo is either a primary mutation of the mitochondrial genome (single, large-scale mtdna deletion or mtdna point mutation) or recessively and dominantly-inherited mutations in nuclear genes involved in mtdna maintenance leading to clonally-expanded multiple mtdna deletions in muscle. the nuclear disease genes are largely implicated in the replication and stability of mtdna, and as such a pathogenic mutation leads to secondary instability of the mitochondrial genome. causal mtdna deletions can be found in a heteroplasmic (mixture of mutated and wild type mtdna) state. however, each tissue/cell has its own biochemical threshold of mutant mtdna load which needs to be exceeded before focal respiratory chain deficiency becomes evident. to investigate this, muscle biopsies of patients with genetically-and clinically-characterized mitochondrial disease of nuclear origin ( polg, twnk, rrm b and slc a (ant )) and healthy controls were analysed using quadruple oxphos immunohistochemistry, quantifying the biochemical phenotype in individual muscle fibres of patient muscle biopsies. this technique is based on quadruple immunofluorescence to detect structural components of complexes i (ndufb ) and iv (coxi), as well as porin (a marker of mitochondrial mass) and laminin (a cell membrane marker to define the boundaries of muscle fibres). further studies on / patients ( polg, rrm b, twnk, slc a (ant )) included the correlation of the biochemical deficiency with the mtdna abnormality in individual cells, following laser microcapture and determination of the size and level of clonally-expanded mtdna deletion within fibres by real-time pcr. our preliminary data from quadruple immunocytochemical studies show that the muscle biochemical phenotype is different in patients with multiple mtdna deletions compared to other mtdna mutations; work is continuing to determine the exact size and level of clonally-expanded mtdna deletion in individual muscle fibres and correlate this with the observed biochemical defects and disease thresholds. abstracts these families, and functional studies, together with phenotype descriptions in the literature, are essential for pathogenic grading. however, several difficulties remain, such as the huge size of the ttn gene (> kb) impeding functional studies, the wide spectrum of phenotypes and variants, the still small patient cohort, and often unspecific immunohistochemical abnormalities in muscle biopsies. the clinical evaluation of ttn variants thus presents a great challenge to the field of human genetics diagnostics. compound heterozygous variants in the qars gene (omim ) have been identified in only four patients with autosomal recessive progressive microcephaly with seizures and cerebral and cerebellar atrophy (mscca), to date. these patients showed severe developmental delay, progressive primary microcephaly, intractable seizures, hypomyelination or delayed myelination, thin corpus callosum, and small cerebellar vermis on brain imaging. here we report on two unrelated girls with progressive primary microcephaly, epilepsy and brain anomalies. trio exome analysis in each of the families revealed two different combinations of compound heterozygous variants in qars. all four variants are highly conserved throughout vertebrates, not reported in any database, yet, and in silico analysis predicted the variants as possibly damaging or deleterious. the first patient was born to non-consanguineous german parents. at birth, she was too short (− . sd) and mildly microcephalic (− . sd). she developed intractable seizures within the first hour of life. her growth continued to be mildly retarded (− . sd at age years) but microcephaly was progressive (− . sd at age years). she did not achieve any of the motor or cognitive developmental milestones, she did not have eye contact. the only interaction with her surrounding was a diffuse reaction to being touched. cranial mri showed no myelination of the supratentorial region, corpus callosum agenesis, simplified gyral pattern of frontal lobes, enlarged cerebral ventricles, and normal brain stem and cerebellum. trio-exome sequencing revealed the compound heterozygous qars variants c. c>t, p.(arg- cys) and c. c>t, p.(arg *). segregation analysis by sanger sequencing confirmed the heterozygous variants in the parents and two non affected sibling of the index patient. the second patient was initially evaluated at days of age when she exhibited myoclonic seizures, intrauterine growth retardation, microcephaly, and elevated lactic acid. at birth, she was microcephalic (hc cm) and microcephaly was progressive (− . sd at age months). cranial mri suggested undersulcation. she has required a gastrostomy feeding tube. trio-exome sequencing revealed the compound heterozygous qars variants c. g>a, p.(gly ser) and c. c>t, p.(arg trp). segregation was confirmed by sanger sequencing analysis. together with the four previously described patients we conclude that compound heterozygous variants in qars are associated with a primary and progressive microcephaly, early onset of intractable seizures and severe developmental delay. brain imaging in the neonate can show simplified gyral pattern as an early characteristic feature. overlapping phenotypes are seen in patients with epileptic encephalopathy, lissencephaly and primary microcephaly. application of ngs panels or exome technology will allow for early diagnosis and further collection of patients for better delineation of the phenotype. with involvement of several genes including cyp b , foxc , pitx , myoc and pax . however, mutations in these genes explain only a small fraction of cases suggesting the presence of further candidate genes. to elucidate further genetic causes of these conditions we performed whole exome sequencing in a patient with pcg and retinal detachment and identified compound heterozygous variants in col a (p.met leu; p.ala- thr). targeted col a screening of additional patients detected three further heterozygous variants (p.arg *, p.gly ser and p.gly- val) in three distinct subjects: two of them were diagnosed with early onset glaucoma and mild form of osteogenesis imperfecta (oi), one patient had a diagnosis of pcg at age years. all five variants affected evolutionary, highly conserved amino acids indicating important functional restrictions. molecular modeling predicted that the heterozygous variants are dominant in effect and affect protein stability and thus the amount of available protein, while the compound heterozygous variants act as recessive alleles and impair binding affinity to two main col a binding proteins: hsp and fibronectin. dominantly inherited mutations in col a are known causes of connective tissues disorders such as oi. these disorders are also associated with different ocular abnormalities, although the common pathology for both features is seldom recognized. our findings expand the role of col a mutations in different forms of early-onset glaucoma with and without signs of oi. thus, we suggest including col a mutation screening in the genetic work-up of glaucoma cases and detailed ophthalmic examinations with fundus analysis in patients with oi. the gene ttn encodes the largest known protein, titin, which plays a key role in structural, mechanical, developmental and regulatory functions of cardiac and skeletal muscles. accordingly, titinopathies are characterized by great clinical and genetic heterogeneity. the clinical spectrum ranges from severe phenotypes with cardiac involvement to pure myopathies at the milder end, including autosomal recessive and dominant inheritance patterns (chauveau et al. , hum mutat; : ) . next generation sequencing analysis identifies a large number of variants of unknown clinical significance; the potential clinical relevance of these variants cannot be assessed with certainty without further studies. three case reports highlight the difficulties in human genetics diagnostics concerning ttn. the first case is of a year-old woman with proximal muscle weakness, slightly elevated ck, scoliosis, and no family history. a heterozygous known pathogenic variant was identified in mex , associated with autosomal recessive congenital core myopathy combined with primary heart disease. additionally, an unknown variant was detected. both variants could be clinically relevant with regard to the patient's phenotype, but this can be neither confirmed nor excluded at this time. the second case is of a month-old finnish girl who presented with severe muscle hypotonia at birth and mental alertness with normal brain mri and eeg. congenital fiber-type disproportion was suspected. a homozygous frame-shift mutation in mex was identified which to our knowledge has not yet been described in the literature. this variant is likely of clinical relevance with regard to the patient's phenotype, but this can be neither confirmed nor excluded at this time. the third case is that of a year-old woman with suspected myofibrillar myopathy. a known pathogenic homozygous frame-shift mutation in mex was detected which is associated with autosomal recessive congenital myopathy with central nuclei. segregation analysis revealed that the healthy parents are heterozygous carriers of this variant. the clinical diagnosis of a ttn-associated disease could therefore be confirmed. ttn variants need to be assessed in combination with detailed clinical and muscle biopsy data. segregation analysis is necessary but not sufficient for the clinical grading of variants. identification of a variant in several independent families, segregation of the variant with disease phenotype in gous pathogenic smad variant c. dupt;p.(ala fs) (ncbi reference sequence nm_ . ). gastric as well as colonic cancer and polyposis was present in the paternal family history. conclusions: ts and other imprinting disorders are likely underdiagnosed, as the main clinical features (e. g. growth retardation, hypotonia) are distinct but unspecific. as exome sequencing becomes a more frequent diagnostic procedure, imprinting disorders caused by mutations in imprinting centers will presumably be diagnosed more often. methylation defects, however, will remain underdiagnosed, without a specific clinical differential diagnosis, which would guide to appropriate analysis of the methylation status. a bowel invagination in early childhood due to a single polyp can be a symptom of jps, especially in the context of a paternal history of polyposis and intestinal cancer; thus, family history should be carefully obtained. in the outpatient clinic, child psychiatrists as well as neurologists thoroughly work up phelan-mcdermid patients according to a standardized protocol by taking medical history, performing physical examination, and, if needed, organizing further supplementary examinations. in addition, a genetic analysis and hair/tissue sampling is performed. since its foundation, a steadily increasing number of so far patients from all over germany has been seen and treated. the outpatient clinic aims at facilitating and accelerating the diagnosis of phelan-mcdermid syndrome, improving medical support for affected patients of all ages, and, last but not least, fostering a better understanding of the causes and pathomechanisms leading to the symptoms of the disease. t. m. neuhann, l. neuhann, c. rapp, a. laner, a. benet-pages, e. holinski-feder medizinisch genetisches zentrum, münchen, germany congenital eye malformations, such as the microphthalmia-anophthalmia-coloboma (mac) spectrum, congenital cataracts, anterior segment dysgenesis (asd), and congenital glaucoma, affect more than : . newborns. the phenotypic spectrum of the aforementioned entities is highly variable and partially overlapping. eye malfomations are very heterogeneous; to date causative mutations have been described in more than next-generation-sequencing (ngs) technology has revolutionized genomic research and has transformed clinical diagnostics. ngs offers enormous potential for providing accurate diagnoses to individuals with previously unresolved syndromes. in the pediatric endocrine clinic, clinicians are often faced with the task of making a diagnosis in children with syndromic short stature. as there may be considerable clinical overlap between short stature syndromes, deriving a clinical diagnosis may prove challenging. furthermore, even if a clinical differential diagnosis is established, often several genes would need to be tested before a molecular diagnosis is made. as access to genetic testing is limited in algeria, we conducted a pilot study on algerian patients with syndromic short stature using a combination of two different ngs modalities, namely whole-exome-sequencing (wes) and mendeliome sequencing (trusight one sequencing panel). a molecular diagnosis could be established in / patients, making the diagnostic rate in this initial cohort %. as patients had novel mutations we could expand the mutational spectra of several genes, namely cul , npr , sos , vps b, and znf . we could thus substantiate the clinical utility of wes and the mendeliome in patients with a diverse array of syndromic short stature syndromes. chromosome harbours an imprinted locus at q . maternal uniparental disomy of chromosome , paternal deletions and paternal loss of methylation at the intergenic differentially methylated region (ig-dmr) and the somatic dmr within meg are associated with temple syndrome (ts , mim ). the phenotype of ts consists of pre-and postnatal growth retardation, early feeding problems and muscular hypotonia, joint laxity, motor developmental delay, premature puberty, and truncal obesity. juvenile polyposis syndrome (jps, mim ) is characterized by predisposition to hamartomatous polyps in the gastrointestinal (gi) tract, specifically in the stomach, small intestine, colon, and rectum, including the risk for gastrointestinal cancer. pathogenic variants in the bmpr a and smad gene are identified in about - % of affected families. we report on a family with two female children. the index patient, an -year-old girl, was diagnosed to have ts due to hypomethylation at the somatic dmr within meg with clinical features reminiscent of prader-willi syndrome in early childhood and milder clinical signs at further age (i. e. mild global development delay, muscular hypotonia, suspected central obesity, no prominent facial dysmorphisms). snp array-cgh analysis was unsuspicious and no deletion of the imprinting center was observed. thus, ts is caused by a sporadic imprinting defect in our patient. her -year-old sister was diagnosed with smad -associated jps after an episode of intestinal invagination due to a polyp, histologically diagnosed as peutz-jeghers polyp, in early infancy. sequencing identified a heterozy-abstracts coding vmat have only very recently been described as causal for brain dopamine-serotonin vesicular transport disease in two families with multiple affected children (rilstone et al., n engl j med , , - ; jacobsen et al., j inherit metab dis , , - ) . the index case presented here is a -year-old girl with severe mental retardation and a dystonic movement disorder. she is the tenth child of a consanguineous arabic couple and was initially referred to neuropaediatric examination at the age of four months due to recurrent oculogyric crises and muscular hypotonia. blood metabolic testing and cerebrospinal fluid (csf) analyses were inconclusive. notably, biogenic amines were within their normal ranges and the differential diagnosis of aromatic l-amino acid decarboxylase (aadc) deficiency could not be confirmed. conventional cytogenetics, subtelomeric screening, array-cgh and different ngs panel analyses did not identify a causative mutation. both parents and all eight living siblings are obviously unaffected. a brother with a known hypotonic movement disorder died at the age of three years due to prolonged seizures with hyperthermia and cerebral edema. by utilizing whole-exome sequencing, we identified a homozygous substitution in the slc a gene of the index case causing an amino acid change (c. c>a; p.pro his) in a conserved transmembrane domain of vesicular monoamine transporter (vmat ). homozygosity for this missense change could also be verified in a dna sample of her deceased brother. an obvious reduction in frequency of oculogyric crises was observed in our index case under therapy with pramipexole already within weeks after start of treatment. furthermore the patient shows less dystonic movements under therapy. the case presented here highlights the importance of considering brain dopamine-serotonin vesicular transport disease as differential diagnosis for early-onset extrapyramidal movement disorders combined with mental retardation even if neurotransmitters in csf are normal. for a large number of individuals with intellectual disability (id), the molecular basis of the disorder is still unknown. however, whole exome sequencing (wes) is providing more and more insights into the genetic landscape of id. in the present study, we performed trio-based wes in patients with unsolved id and additional clinical features, and identified homozygous cplx mutations in three patients with id from two unrelated families. all displayed marked developmental delay and migrating myoclonic epilepsy, and one showed a cerebellar cleft in addition. the encoded protein, complexin , is crucially involved in neuronal synaptic regulation, and homozygous cplx knockout mice have the earliest known onset of ataxia seen in a mouse model. recently, a homozygous truncating mutation in cplx was suggested to be causative for migrating epilepsy and structural brain abnormalities. id was not reported. the currently limited knowledge on cplx suggests that complete loss of complexin function may lead to a complex but variable clinical phenotype, and our findings encourage further investigations of cplx in patients with id, developmental delay and myoclonic epilepsy to unravel the phenotypic spectrum of carriers of biallelic cplx mutations. genes. due their heterogeneity, diagnostic testing for congenital eye malformations was limited in the pre-ngs era. we performed exome analysis in patients with congenital eye malformation (mac spectrum, asd, congenital cataract, congenital glaucoma). primarily, a gene panel comprising genes associated with eye malformations was evaluated. additionally the exome data was evaluated in selected patients as a second step. the panel analysis revealed pathogenic sequence variants in patients and genes (mab l , bcor, nhs, prss , cyp b , foxc , pitx , gcnt ). putatively causative sequence variants were identified additional patients. the diagnostic yield of the panel was highest in patients with non-syndromic microphthalmia/coloboma and congenital cataracts, and lowest in patients with syndromic mac spectrum (i. e. additional systemic features/malformations). ngs based panel testing is a strong diagnostic tool to determine the underlying causes of non-syndromic congenital eye malformations. due to the partially overlapping phenotypes and high heterogeneity it is more sensible to perform large gene panel analysis, as opposed to smaller single phenotype based panels. superactivity of phosphoribosyl¬pyrophosphate synthetase i (prpps) is a rare inborn error of purine metabolism that is characterized by increased levels of uric acid in blood and urine (omim ). the disorder is caused by gain-of-function mutations in the x-chromosomal gene prps . in male patients, disease manifestation is in early childhood. additional clinical characteristics include intellectual disability, hypotonia, ataxia and hearing loss. heterozygous female mutation carriers have a later age of onset and a less severe clinical course. only seven families with prps gainof-function mutations have been reported to date. we report on a -year-old boy with congenital hyperuricemia, urolithiasis, developmental delay, short stature, hypospadias and facial dysmorphisms. his mother also had hyperuricemia that was diagnosed at age years but was otherwise healthy. a novel prps missense mutation (c. g>c, p. leu phe) was detected in the proband and his mother. enzyme activity analyses confirmed superactivity of prpp synthetase. the family reported here broadens the clinical spectrum of prpps superactivity and indicates that this rare metabolic disorder is associated with a recognizable facial gestalt. homozygous and compound heterozygous mutations of the rnu at-ac gene are associated with mopd and roifman syndrome. mopd is characterized by severe microcephaly with brain malformations including abnormal gyral pattern, corpus callosum agenesis or hypoplasia, vermis hypoplasia and intracranial cysts, psychomotor retardation, short stature, skeletal dysplasia, dry skin, sparse hair, flexion contractures, round face with beaked nose and protruding eyes, and premature death with a majority of the patients who die before the age of months for unknown reasons. roifman syndrome was first described as a novel association of antibody deficiency, spondyloepiphyseal chondro-osseus dysplasia, retinal dystrophy, poor pre-and postnatal growth, cognitive delay and facial dysmorphism including long eyelashes, downslanting palpebral fissures, a long philtrum and a thin upper lip. all patients with roifman syndrome reported so far lack brain malformations. the rnu atac gene encodes a small nuclear rna (snrna), which is essential for minor intron splicing. homozygous (g. g>a, g. g>a) and compound heterozygous mutations (g. g>a;g. g>a, g. g>a;g g>a and g. c>t;g. g>a) have been described in mopd . all mutations involve the ' or ' stem loop of the u atac snrna. in contrast, all cases with roifman syndrome investigated so far showed compound heterozygous rnu atac mutations with one allele harboring a mutation in the mopd associated ' stem loop and the other allele showing a mutation in the stem ii site of the u atac snrna, which has not been involved in mopd , so far. thus, the different pattern of the mutations observed in mopd and roifman syndrome may contribute to the distinct features of both syndromes. however, our patient shows, that features of mopd , i. e., brain malformations, may also be present in patients who show roifman syndrome associated rnu atac mutations. this indicates that both syndromes may represent overlapping features of the clinical spectrum of rnu atac mutations. h. roth, h. stöhr, b. h. f. weber institute of human genetics, university of regensburg, germany introduction: inherited retinal degenerations comprise a genetically heterogeneous group of eye diseases with overlapping clinical presentations. up to now, more than genes have been associated with different forms of retinal dystrophies (rd) such as retinitis pigmentosa (rp) or cone-rod-dystrophies (crd) with mutations in and causative genes, respectively. here, we present the results from three patients with remarkable findings and discuss their implications for risk prediction and genetic counseling. methods: targeted next-generation sequencing (ngs) technology based on agilent custom designed gene panels (sureselect) has been established in our diagnostics department to identify causative mutations in a large patient cohort with approximately rd patients. high-throughput sequencing data are routinely analyzed with the clc biomedical workbench. classification of variants was based on bioinformatic analyses using alamut visual software, mutationtaster, sift and polyphen- prediction programs, allele frequencies, amino acid conservation and literature. results. ngs analysis revealed two patients with rp and one patient with crd, each of whom carry putative causative mutations in several rd genes. first, a male patient with a family history of crd, is a carrier of a nonsense mutation p.(arg ter) in rims and two likely pathogenic missense mutations in aipl (p.(tyr phe)) and guca a (p.(pro- leu)), each in a heterozygous situation. mutations in all three genes can cause adcrd. in addition, the patient carried a hemizygous nonsense mutation p.(glu *) in the x-chromosomal rpgr gene. secondly, a female patient with simplex rp was found to be homozygous for a frameshift-causing deletion p.(ser leufs* ) in the impg gene causing arrp. she also carried three heterozygous, likely pathogenic missense mutations in crx (p.(tyr cys)) causing adrp, in the x-chromosomal rpgr (p.(ala val)) and in ush a (p.(ile val)) associated m. s. reuter , a. riess , u. moog , t. a. briggs , , k. e. chandler background: disruptions of the foxp gene, encoding a forkhead transcription factor, are the first known monogenic cause of a speech and language disorder. so far, mainly chromosomal rearrangements such as translocations or larger deletions affecting foxp have been reported. intragenic deletions or convincingly pathogenic point mutations in foxp have up to date only been reported in three families. we thus aimed at a further characterization of the mutational and clinical spectrum. methods: chromosomal microarray testing, trio exome sequencing, multi gene panel sequencing and targeted sequencing of foxp were performed in individuals with variable developmental disorders, and speech and language deficits. results: we identified four different truncating mutations, two novel missense mutations within the forkhead domain and an intragenic deletion in foxp in fourteen individuals from eight unrelated families. mutations occurred de novo in four families and were inherited from an affected parent in the other four. all index patients presented with various manifestations of language and speech impairment. apart from two individuals with normal onset of speech, age of first words was between and years. articulation difficulties such as slurred speech, dyspraxia, stuttering or poor pronunciation were frequently noted. motor development was normal or only mildly delayed. mild cognitive impairment was reported for most individuals. conclusion: by identifying intragenic deletions or mutations in fourteen individuals from eight unrelated families with variable developmental delay/cognitive impairment and speech and language deficits, we considerably broaden the mutational and clinical spectrum associated with aberrations in foxp . h. rieder, f. beleggia, d. wieczorek we report on a -year-old boy with microcephaly, arachnoidal cysts, pachygyria, microgyria, and severe intellectual disability. he also had short stature including shortening and deformation of the femora, brachydactyly, and short ribs with costochondral dysplasia. he showed facial dysmorphism with narrow palpebral fissures, a short nose with a depressed nasal bridge, and a broad mouth with full lips. clinical laboratory investigations demonstrated persistently slightly elevated liver enzymes. exome sequencing revealed compound heterozygous mutations of the rnu at-ac gene, g. g>a;g. g>a, which has been described in an individual with roifman syndrome. we report on a seven-year-old girl, first child of non-consanguineous italian parents, with developmental delay, muscular hypotonia and distinctive craniofacial features (epicanthus inversus, ptosis, broad nasal bridge, mild retrognathia, low-set posteriorly rotated ears and malpositioned teeth in the mandible). because of the tentative diagnosis of blepharophimosis-ptosis-epicanthus inversus syndrome (bpes), conventional cytogenetic analysis, sanger sequencing and mlpa (multiplex ligation-dependent amplification) of foxl were initiated and showed unremarkable results. microarray-cgh revealed a kb microduplication of genetic material on q . : arr[hg ] q . ( _ )x encompassing the genes tubgcp , cyfip , nipa and nipa of maternal origin. patients with q . microduplication have been described to be affected by developmental delay, motor and/or expressive language delay, epilepsy, learning disabilities and/or behavioral problems. however, genotype phenotype correlation is complicated by incomplete penetrance. healthy and mildly affected carriers are reported in the literature. we speculate that the microduplication might contribute but does not fully explain the phenotype of our patient, in particular concerning the craniofacial features. subsequent trio whole-exome sequencing identified a de novo heterozygous mutation in setbp (c. t>a/ p.tyr *) leading to a premature stop codon and most probably resulting in a truncated and functionally impaired protein. mutations in the set binding protein gene (setbp ) on q . have been identified to cause schinzel-giedion syndrome (sgs, omim ), a rare autosomal dominant disorder characterized by postnatal growth failure, severe developmental delay, seizures, facial dysmorphism, genitourinary, skeletal, neurological, and cardiac defects. chromosomal deletions in q including setbp have been reported to cause a milder phenotype known as "autosomal dominant mental retardation- " (mrd , omim ). these observations suggest that the severe sgs phenotype might be the consequence of a gain-of-function or dominant-negative effect of the mutations and that setbp haploinsufficiency results in a different, milder phenotype. so far, the function of the set-bp protein is unknown. the presented case adds up to the yet small number of reported cases of mrd and thereby contributes to the clinical spectrum of setbp haploinsufficiency. this work was supported by "förderstiftung des uksh" (project number: _ ). the demand for genetic counseling had been constant, in germany, over many years. from to around . cases per year on the average and with minor fluctuations were reimbursed by the german sickness funds (public health insurance system; pabst and schmidtke, gendiagnostik in deutschland, bbaw, p. - , ) . in connection with the "genbin "-project, a new nationwide survey was initiated regarding with arrp. finally, in another female rp patient with no family history of rd, we detected a nonsense mutation p.(trp ter) and a likely pathogenic splice site change (c. + a>g) in the arrp gene eys, assuming compound heterozygosity. in this patient we also identified two heterozygous, likely pathogenic missense mutations in hmcn (p.(pro thr)) and cep (p.(arg cys)) underlying dominant and recessive forms of rd. in all three cases, specific mutation(s) could not be uniquely identified as causative. conclusion. results in the three rd cases emphasize that ngs can generate unexpected results that are difficult to interpret, particularly in the absence of segregation analysis and functional data on pathogenicity. the implications for genetic counselling and predictive testing will be discussed. smart qnipt study -detection of fetal trisomy based on methylation-specific quantitative real-time pcr m. sachse, s. werler, j. bonnet, u. neder, h. sperling, s. busche, s. grömminger, w. hofmann lifecodexx ag, konstanz, germany objectives: current non-invasive prenatal testing (nipt) methods for the detection of fetal trisomy (t ) are primarily based on next generation sequencing (ngs) strategies which are quite costly in clinical application and hence are limited to patients who can afford the testing. here, we describe the results of a blinded study with respect to the test accuracy of a newly developed nipt assay based on quantitative real-time pcr (qpcr) for prenatal testing of fetal trisomy (qnipt). methods: in the study maternal plasma samples were collected from , pregnant women and blinded by an independent contract research organization. after extraction of cell-free dna using qiasymphony instrument and methylation-specific digestion of dna samples a multiplex qpcr was performed. the primary qpcr data were finally evaluated with our ce marked data analysis software. results from this analysis and from confirmatory ngs testing were compared with nipt results using ngs. the study results of successfully analysed maternal plasma samples (n = ) demonstrated a positive percentage agreement (ppa; equates to sensitivity) of % (lower -sided % confidence interval of . %; n = / ) and a negative percentage agreement (npa; equates to specificity; n = / ) of % compared to ngs-based results. the negative predictive value (npv) for the novel qnipt and confirmatory ngs testing was % (lower -sided % confidence interval of . %). the average fetal fraction of the examined blood samples was . %. the qnipt assay provided reliable test results in blood samples with a fetal fraction below % and as low as . %. conclusion: our results suggest that the proprietary qnipt assay is a very reliable and robust method suitable for clinical routine in accordance with international medical associations. the assay represents a more cost-efficient solution over ngs testing and will also be able to provide results in the shortest possible time. while current nipt methods require a minimum fetal fraction of % in blood samples from singleton pregnancies, we could demonstrate in the study that our smart qnipt assay can be employed on blood samples with a fetal fraction of as low as . %. in summary, the application of smart qnipt could have the potential to become a nipt solution on a global scale for pregnant women of all ages and risk groups. further studies which aim to include the determination of trisomy and trisomy are currently underway. with respect to the developmental delay of our index patient, chromosome analysis and array-cgh were performed. a microduplication in p . (app. kb) of unknown significance and a microduplication in xq . (app. kb), which comprises the fmr -gene, were identified and shown to be of maternal origin (arr[hg ] p . ( , , , )x , xq . ( , , , )x ). fmr is associated with fragile x syndrome, which is one of the most common causes for x-linked mental retardation. cgg-trinucleotide repeat expansions in the ' untranslated region (> repeats) lead to aberrant hypermethylation of the fmr -promotor and silencing of fmr expression. in contrast, premutations ( - repeats) lead to a higher expression of fmr and cause a clinical syndrome that is characterised by late progressive cerebellar ataxia (fxtas). in line with this gain-of-function mechanism, we hypothesize that the xq . duplication, which could lead to an increased gene dosage of fmr , causes a fra(x)-/fxtas-like syndrome and explain the clinical findings in our family. vengoechea et al. described a patient with a similar duplication, who was affected by developmental retardation, epilepsy and hyperactivity. they discussed the microduplication, which arose de novo in their patient, as the cause for the boy's symptoms (vengoechea j. et al., eur j hum genet., nov; ( ): - ) . in conclusion, we assume a fmr -duplication syndrome in our family with variable expressivity and a different impact on male and female patients. to further prove this hypothesis, we are planning to perform a segregation-analysis within the whole family. background: congenital myasthenic syndromes (cms) are a genetically heterogenous group of disorders leading to weakness of skeletal muscles -especially ocular, bulbar and limb muscles -with onset mostly at birth or in early childhood. the severity of cms can vary significantly ranging from death in early childhood due to respiratory insufficiency to only mild muscle weakness in adulthood. more than genes that are highly expressed in the neuromuscular junctions are associated with cms. mutations in the chrne gene on chromosome p . are responsible for about one half of genetically solved cms cases. they can cause different subtypes of cms with either autosomal dominant or autosomal recessive inheritance. results: here, we report a -year-old boy who was born with bilateral eyelid ptosis and congenital vertical talus of the right foot that needed surgical correction. the boy displayed muscular hypotonia with a myopathic facial expression and delayed motor development. ophthalmologic examination revealed external ophthalmoplegia. a next generation sequencing based gene panel for congenital myopathies detected the homozygous frameshift mutation c. _ dup (p.leu profs* ) in the chrne gene in the boy. gene dosage analysis did not show an exonic deletion in the chrne gene. sanger sequencing confirmed the mutation in a heterozygous state in the boy's father. however, his mother did not carry the mutation in the chrne gene. conclusions: these results suggest the rare event of a (partial) paternal uniparental isodisomy of chromosome as cause of the homozygous c. _ dup (p.leu profs* ) in the chrne gene in the boy. further experiments are currently undertaken to confirm this hypothesis. the annual reimbursement frequencies of the relevant entries in the ebm fee schedule, , , and , for which only specialists in human genetics and subspecialists in medical genetics can account, from until . contrary to the findings in the earlier period the demand for genetic counseling has risen sharply: , (of a total of , ) cases in ; , ( , ) in ; , ( , ) in ; , ( , ) in ; , ( , ) in ; and , ( , ) in . we speculate that the temporal correlation of the rise of genetic counseling demand with the enactment of the german act on testing (february , ) is not coincidental. further factors that might contribute to the increase in demand are the ensuing guidelines of the german commission on genetic testing and cme activities related to attaining a qualification for genetic counseling for specialties other than human genetics. in the course of these activities the awareness for the importance of genetic counseling delivered by specialists in human genetics and subspecialists in medical genetics may have risen. acknowledgements: the "genbin "-project supported by the robert koch-institute through funding from the german federal ministry of health. we gratefully acknowledge the collaboration with dr. michael erhart, zentralinstitut der kassenärztlichen bundesvereinigung (zi-kbv), berlin, germany it is well known that duplications of down syndrome critical region (dscr) on chromosome q can cause down syndrome whereby the distinct phenotype is associated with the involved genes and the size of duplication. however, in literature are hardly any cases with mosaic duplications of dscr described. here we report on a year old boy with some clinical features of down syndrome including distinctive craniofacial dysmorphism, simian crease and sandal gap as well as delayed motor and speech development. no other organ abnormalities are known. conventional chromosome analysis showed no numerical or structural aberration whereas interphase fish analysis revealed three signals for dscr in approx. % of lymphocytes and in approx. % of buccal mucosa cells. array-cgh analysis on dna from peripheral blood confirmed a , mb duplication of chromosome q . q . . the duplication involves among others the gene dyrk a which is reported as a candidate gene for down syndrome. this case presents one of the smallest known duplications within dscr which causes even in a mosaic state a mild phenotype of down syndrome. -year-old boy was referred to our outpatient clinic due to global developmental delay mainly affecting his speech and his fine motor development. in addition, muscular hypotonia and an abnormal gait were reported by the referring paediatrician. his mother, his maternal grandmother, and numerous relatives are affected by gait ataxia. no causative mutation was detected in the maternal grandmother by means of a multi-gene panel for spinocerebellar ataxia encompassing genes. genetic testing for friedreich ataxia was also without pathological findings. cer, but the patient mother's grandfather had a cancer of unknown origin and died at the age of years. because of the suspicion of having a lynch syndrome an immunohistochemistry and microsatellite analysis have been performed on the tissue of the colorectal cancer and the hepatic metastasis. all four mmr proteins were properly expressed in immunohistochemistry in colorectal cancer. just the expression of mlh protein in the hepatic metastasis was focally weakened and inhomogeneous. the microsatellite markers bat , bat , d s (apc), d s and d s (mfd) were all stable, a a t-kras mutation was found. after performing a multi-gene panel (ngs, next-generation sequencing), a gross heterozygous deletion of exon in msh gene has been found in the cnv analysis of the ngs data. this mutation was confirmed with a mlpa and quantitative real time pcr analyses. furthermore, rna expression of msh was reduced to % in blood lymphocytes in comparison to control samples pointing to a potential role of msh loss in the patient's tumor development. we are observing more and more patients with probably pathogenic and pathogenic mutations in one of the mmr genes with normal immunohistochemistry and microsatellite analysis. therefore, we propose that the criteria for performing a molecular genetic analysis of hnpcc/lynch syndrome should be revised. exome sequencing reveals gata mutation in a patient with partial delta-storage pool deficiency and mild thrombocytopenia objectives: we report about a -year-old male patient of russian background with severe and frequent epistaxis and hematoma since infancy. he presented with mild thrombocytopenia and increased mean platelet volume. von willebrand's disease and subhemophilia had been excluded. previously, he was diagnosed with immune thrombocytopenic purpura. he never underwent elective surgery. his parents were asymptomatic. however, his -year-old daughter also suffers from severe bleeding symptoms (multiple, light red hematoma in consequence of minimal trauma). methods: whole exome sequencing (wes) was carried out for the patient, his asymptomatic wife, his symptomatic daughter and her asymptomatic -year-old brother. platelet function was assessed by light transmission-, lumi-aggregometry and flow cytometry. lysates of gel-filtered platelets were analyzed for total granule p-selectin, cd and von willebrand factor (vwf) content by western blotting and for serotonin levels by elisa, respectively. results. platelet function and characterization of the patients granula suggested a delta-storage pool disease (spd). in most cases delta-spd occurs as part of a syndrome, e. g. combined with albinism, immunodeficiency or a thalassemic-like blood disorder. as the patient and his daughter did not show any conclusive phenotype, their dna was subjected to wes. exome sequencing revealed a not yet described gata -mutation close to two zinc finger domains (znf and znf ) in a highly conserved region of the gata gene in the -year old daughter (c. a>c, p.t p, heterozygous) and her father (c. a>c, p.t p, hemizygous). this mutation was absent in wildtype-controls but could also be demonstrated in the indexpatients' asymptomatic mother. only a few mutations are known to be located in this c-terminal region to date. mutations in gata may lead to different clinical presentations, depending on their location within gata (e. g. diamond-blakfan anemia (exon ), x-linked thrombocytopenia (znf ), transient myeloproliferative disorder (intron , exon , exon ) and acute megakaryoblastic leukemia (intron , exon , exon ) in case of down-syndrome). significantly increased hbf-levels (reference level: ≤ , %) in the affected family members of , % ( -year-old daugh- our proposita is a years old woman, who was transferred to our genetic counselling department for the suspicion of m. osler (hereditary hemorrhagic teleangiectasia, hht). during routine check up an anemia was diagnosed. a tumor search was initiated and unexpectedly the ct of the abdomen showed a suspect coin lesion of about . cm in diameter localized in the basal part of the right lung. further investigations revealed a pulmonary arterio-venous malformation which was hemodynamically relevant and already led to chronic right heart overload. a coil embolization was performed. retrospectively, medical history of the patient included episodes of severe epistaxis in childhood and a neurosurgical intervention for intracerebral bleeding at the age of years without permanent neurological deficits. during genetic counselling our proposita mentioned that her years old daughter also suffered from anemia due to multiple polyps of the colon. after polypectomy her hemoglobin values normalized. although histologically the polyps appeared as juvenile ones a mutation search in the apc-gene was initiated by the gastroenterologists without identifying a pathogenic mutation. combining the two pieces of information, we offered a mutation search in the smad gene and a pathogenic mutation c. c>t (p.arg cys) was found in both patients in heterozygosity. colonoscopy in the mother did not show juvenile polyps or gastrointestinal vascular malformations. vice versa, no cerebral or pulmonary arteriovenous malformations could be detected in the daughter. our family illustrates, that the same mutation within a family may phenotypically appear as different diseases. a careful taking of medical history and the knowledge of all relevant diagnostic findings (in this case e. g. the histology of the polyps) can enable the geneticist to offer a precise differential diagnosis leading to a well-directed molecular testing. to our opinion this is still relevant even in the era of ngs-based panels because the more precise the clinical diagnosis and the choice of the genes to analyse the less problems with unclassified variants will arise. the hereditary non-polyposis colon cancer (hnpcc, lynch syndrome) is caused by pathogenic germline mutations in mismatch repair genes (mlh , msh , msh and pms ) causing microsatellite instability (msi) and decreased or lost expression of the appropriate mismatch repair protein (mmr) in the immunohistochemistry (ihc) on tumor material. thus, ihc and msi testing help to identify the mmr gene, which most likely harbors a germline pathogenic variant. msi and ihc testing prior to germline analysis are specified in the s guidelines of hnpcc and if negative normally preclude further genetic analyses. here, we present a year old patient with a synchronous colonic (ceacum) and renal cancer at the age of years. at the time of the diagnosis hepatic metastases of the caecal adenocarcinoma have already been present. histologically, the colonic tumor was a poorly differentiated adenocarcinoma (pt pn) with lymphangiosis and haemangiosis carcinomatosa. the renal cancer showed histology of a moderately differentiated clear cell renal carcinoma. in the family history the year old sister and the parents are healthy. the twin sister of the patient's mother had a collateral breast cancer at the age of years and died two years later. the mother's grandparents had no canmedizinische genetik · p-cling- pitfalls in molecular genetic diagnostics a. tibelius, e. fey, k. hinderhofer institute of human genetics, heidelberg, germany probably every clinical laboratory geneticist may look back on at least one case in his career which has caused him quite a headache. this means those cases with completely unexpected and at a first glance implausible results which could be interpreted correctly only after intensive enquiry and additional testing. here, we report on three of such pitfall cases from our routine diagnostics. case : a -year-old woman, pregnant with monozygotic twins, was referred to prenatal cystic fibrosis diagnosis. she and her partner were carriers of mutations in the cftr gene ( + g>t and g x, respectively). prenatal molecular diagnosis demonstrated that both fetus had inherited only the paternal mutation. routinely, we performed maternal cell contamination analysis by comparing polymorphic microsatellite loci between the maternal and fetal dna. surprisingly, of tested microsatellite loci revealed a discrepancy between the maternal and fetal genotypes, meaning neither of both maternal alleles was present in fetal dnas. a potential confusion of samples was excluded. moreover, the presence of paternal mutation in fetal dnas indicated a correct genetic relationship between awaited children and the partner of pregnant woman. the only one plausible interpretation of the obtained result was a pregnancy by egg donation. afterwards, this suspicion was confirmed by the couple. case : we present a -year-old man with infertility resulting from azoospermia. conventional chromosomal analysis and an additional fish analysis using y probes indicated a ,xx karyotype with no detectable sry. in parallel, a molecular azf (azoospermia factors) diagnostic was performed by a standard multiplex pcr. by this method the absence of sry region and a deletion of regions azfb and azfc, was identified, explaining the observed azoospermia. interestingly, the pcr showed that the azfa region was still present in patient chromosomes, contradicting cytogenetic and fish results. thus, a complementary fish analysis was performed in order to reveal a low-grade y-mosaicism and sry material was detected in % of the cells (a result under the threshold level). based on this observation, pcr conditions for the azf diagnostic were modified and a very weak sry-specific pcr product detected. case : a molecular diagnostics for frax (fragile x syndrome) was requested for a -year-old boy with a slight delay in speech development. his brother was already molecular-genetically diagnosed as having frax. the analysis by southern blot hybridisation in the patient revealed a smear of methylated fragments characteristic for an expanded allele in the full mutation range. surprisingly, two fragments of normal length, methylated and non-methylated, could also be detected in patient's dna. a subsequent aneuploidy mlpa confirmed a supernumerary x-chromosome in the patient consistent with a klinefelter syndrome. these results were verified by an independent cytogenetic analysis. the syndrome of congenital symmetric circumferential skin creases (cscsc and cscsc ) replaces the old term michelin-tire-baby syndrome (mim ) and is characterized by congenital circumferential skin folds, primarily of the limbs, facial dysmorphism, cleft palate and intellectual disability. mutations in the β-tubulin encoding gene tubb or in the microtubule end binding family member mapre are the underlying genetic cause. ter) and , % ( -year-old indexpatient) suggested dyserythropoiesis, although thalassemic features of the blood count were lacking. conclusion: we describe a gata mutation as the cause of a delta-storage pool disorder. imbalanced x-chromosome inactivation might explain the different phenotypes of the gata mutation carriers and will be investigated through allele-quantification based on rna isolated from whole blood and from platelet rich plasma in case of the index patient and different family members. we saw three siblings (aged , , ; two female, one male) with variable signs of retinal disease. all three developed night blindness till the rd decade, furthermore near-sightedness and deterioration of the visual acuity to a various degree at age - . the clinical diagnosis was given as stargardt's disease, fundus flavimaculatus or unspecified retinal degeneration respectively. two more siblings (aged and ) and the mother (died age ) were clinically unaffected. the father (died age ) was reported to have had bad eyesight beginning in the th decade, his father similarly (no further information available). the three affected siblings have a total of five children (age - ), none of them showing clear signs of retinal disease up to now. considering the clinical diagnosis stargardt's disease we analysed the genes abca , elovl , prom and cngb by sanger sequencing. no pathogenic mutation could be detected. afterwards we performed next generation sequencing of several genes associated with retinal dystrophies and found a novel splice site mutation in the prph gene (mim # ). the mutation was confirmed in all three affected siblings by sanger sequencing. considering that mutation pathogenic we could re-diagnose our patients with patterned macular dystrophy type (mim # ). that disease is inherited in an autosomal dominant fashion, corresponding to the pattern of inheritance evident in our family. the etiology of epileptic encephalopathies, characterized by severe, early-onset seizures accompanied by developmental delay or regression, is highly heterogeneous. in recent years, next-generation sequencing approaches have led to the discovery of numerous causative genes; however the spectrum of associated phenotypes still needs to be further explored for many of these genes. we performed multi-gene panel analysis in a little boy of german non-consanguineous parents who showed severe early-onset infantile epileptic encephalopathy and almost absent neurological development. in this patient we identified a novel heterozygous missense mutation in the gabrg gene which was absent in the parents. in silico analyses strongly suggested a pathogenic relevance of this sequence variation which resides within a highly conserved region. so far, gabrg mutations have mainly been associated with milder types of epilepsy such as febrile seizures and childhood absence epilepsy. therefore, our findings extend the phenotypic spectrum associated with mutations in this gene at the severe end. referring on a case report by al marzouqi et al. ( ) , who reported on a girl with bilateral amastia in the context of skewed x-inactivation, we want to underline the importance of mlpa analyses in the case of negative sequencing of the eda gene, as whole exon duplication can be the cause of hypohidrotic ectodermal dysplasia. to our knowledge, the report of al marzouqi et al. has been the only case about this genetic alteration in the literature so far. novel pogz mutation in a patient with intellectual disability, microcephaly, strabismus and sensorineural hearing loss we report on a -year-old male patient with severe intellectual disability, microcephaly, sensorineural hearing loss, ocular abnormalities (strabismus and hyperopia), congenital heart defect (atrial septum defect and pulmonary stenosis) and minor facial abnormalities (thin upper lip, frontal upsweep). next-generation sequencing analysis revealed a novel heterozygous de novo mutation in pogz: c. _ del, p.(thr serfs* ) . the clinical problems of this patient are in accordance with the findings in the previously reported pogz mutation carriers. reports of additional patients with pogz mutations will be needed to establish detailed phenotype-genotype correlations of this novel and probably underdiagnosed syndrome. novel clinical and molecular aspects in two patients with kleefstra syndrome d. wand, b. seebauer, k. heinimann, i. filges medical genetics, university hospital, basel, schweiz the phenotype of kleefstra syndrome is clinically variable but characterized by facial dysmorphism, intellectual disability, childhood hypotonia and variably associated other malformations. haploinsufficiency of ehmt , caused by either heterozygous microdeletions in q . or sequence mutations in ehmt , has been identified to be the underlying causal mechanism. here we present two girls from two unrelated families with clinical signs of kleefstra syndrome. besides the main features such as facial dysmorphism, intellectual disability/developmental delay and childhood hypotonia, the years old girl presented with additional accelerated growth whereas the other girl, years old, showed failure to thrive. both children have no heart defect, renal or urogenital anomalies or severe respiratory infections. we identified two rare variants likely to be causal: a novel heterozygous splice site ehmt variant and a heterozygous microdeletion in chromosome q . , including exons an of the ehmt -gene . these patients broaden the spectrum of kleefstra -associated ehtm causes, contribute to novel aspects of genotype-phenotype correlations and a better understanding of the clinical variability of the disorder. here, we present two girls from two non-consanguines families showing clinical aspects of the syndrome of congenital symmetric circumferential skin creases. additional features are present in both girls. patient is the first child of healthy parents. she was born at + weeks of gestation with a weight of g, a length of cm and a head circumferences of cm. respiratory distress, a cleft palate, a heart defect (atrial septum defect), an anogenital malformation and facial dysmorphism were diagnosed after delivery, additionally to the skin creases phenotype. conventional karyotyping performed on blood lymphocyte cultures and cgh-array analysis showing normal results. patient is the second child of unrelated healthy parents. her older sister is healthy as well. because of an intrauterine growth retardation an amniocentesis with chromosomal analysis was performed, showing a normal karyotype of ,xx. patient was born at + weeks of gestation by caesarean section. the birth weight was g, the birth length was cm and the head circumferences was cm and the apgar score was / / . due to respiratory distress and hypoxia a tracheotomy was initiated. she also presented with cleft palate, feeding difficulties, a heart defect (atrial and ventricular septum defect), asplenia and facial dysmorphism. the skin phenotype was remarkably similar to that of patient with a prominent neck fold and skin creases mainly on the back part, but also at the limbs. in both children the skin folds gradually diminish over the time without any intervention like it was described for michelin-tire-baby syndrome/ cscsc and cscsc patients. for these reason, a disease-causing mutation in the genes mapre and tubb were excluded in both children. to identify a genetic cause, we performed a trio whole-exom sequencing, including the healthy parents and the affected child, in both families. a de novo stop mutation was detected in patient , while no promising results could be detected in patient . further studies, especially functional in vivo studies and analysis of further patients with a similar clinical presentation will answer the question if the above described phenotype is an expanded variant of the congenital symmetric circumferential skin creases or a unique new syndrome. clinical findings in a family with x-linked hypohidrotic ectodermal dysplasia due to a duplication of exon in the eda gene -a case report we want to summarize the phenotypic spectrum in one affected three generation family with x-linked hypohidrotic ectodermal dysplasia. we report on one strongly affected male and slightly affected female carriers, carrying a duplication of exon in the eda gene. reason for genetic assessment was the request of a female for evaluation of a possible risk for occurrence of the familial disorder in a further planned pregnancy. the woman reported an inability to breastfeed and she and her daughter showed conical teeth, a dry skin and sparse hair. the affected male showed absent deciduous teeth, hypodontia of permanent teeth, missing regulation of the temperature due to a lack of sweat glands, bilateral nipple hypoplasia, a dry and wrinkled skin, missing eye lashes, eyebrows and scalp hair and sparse body hair. the fingernails were inconspicuous, whereas the nails of the toes, particularly the nails of the hallux were yellowish and thickened. the affected male had an operation due to a gallstone and cysts were found in one kidney. there was no increased predisposition to infections. the suspected diagnosis of x-linked hypohidrotic ectodermal dysplasia was confirmed by genetic analysis of the eda gene (sequencing and mlpa analysis). a duplication of exon was detected in the affected male patient and was confirmed in the two mildly affected female relatives by realtime-pcr. terminator sequencing mix v . on an abi xl genetic analyzer (applied biosystems) and detected an insertion of bp between the exons and . we located the insertion's sequence in intron of the dmd gene and sequenced flanking sequences of gdna to find the underlying mutation causing the insertion. two hemizygous single nucleotide variants (snvs) surrounding the inserted fragment could be identified. the first variant (c. - a>c) is a common polymorphism (maf according to genomes project: . %) at the position of an existing acceptor splice site. the second variant (c. - a>g) is novel and creates a new cryptic donor splice site with high probability. these two cryptic splice sites create the formation of a bp pseudoexon which produces a frameshift and a premature stop codon (p.asp alafs*) in the dmd gene. in summary, we could genetically confirm the clinical diagnosis of a dystrophinopathy by two divs in dmd. although the insertion of the pseudoexon creates a premature stop codon the patient's clinical phenotype indicates a milder type of becker muscular dystrophy. this contradiction could be explained by the remaining existence of dmd wild type mrna most likely due to a not constantly active cryptic splice site. most interesting about the present case is the fact that a common snv facilitates the creation of a pseudoexon. this makes the region a potential hotspot for divs in the dmd gene which would be worthwhile further investigations. with more than % of all humans preferring to use their right hand, handedness is the most noticeable functional expression of cerebral lateralization in humans. however, the precise molecular mechanisms that regulate handedness and other related forms of cerebral lateralization remain largely elusive. therefore, the question which genetic, epigenetic and environmental factors contribute to human handedness is one of the central questions in research on lateral asymmetries. handedness is a complex, heritable trait, for which polygenic inheritance is assumed, meaning that a large number of genetic factors with a small additive effect contribute to the observed variance in hand preference. to date, genetic association studies have implicated only a few specific genes influencing handedness. particularly interesting is the association between the human androgen receptor (ar) gene and different aspects of handedness, since the interrelationships constitute a conceptual bridge between the theories that invoke testosterone as a factor in the development of cerebral asymmetries with theories proposing that the x chromosome contains a locus that influences the direction of hand preference. in an initial large association study in samples of healthy adults we already demonstrated that handedness in both sexes is associated with the ar cag-repeat length, with longer repeats being related to a higher incidence of non-right-handedness. in addition, we have performed a second association study in an independently collected healthy cohort of more than test persons with comprehensive data on the handedness phenotype. we were able to replicate the association with longer cag repeats being related to a higher incidence of non-right-handedness, especially in females. since longer cag-repeat blocks have been linked to less efficient ar function, these results implicate that differences in ar signaling in the developing brain might be one of the factors that determine individual differences in brain lateralization. dej. waschk, ac. tewes, p. wieacker, s. ledig institute of human genetics, münster, germany the mammalian female and male reproductive tracts develop from the paramesonephric ducts (müllerian ducts, md) and mesonephric ducts (wolffian ducts, wd), respectively. in the absence of testicular differentiation and anti-müllerian hormone, the wd regress and the md give rise to the fallopian tubes, uterus, cervix and the upper part of the vagina. disorders of normal md development in females can manifest as fusion anomalies of the uterus such as septate uterus, bicornuate uterus, unicornuate uterus and uterus didelphys, or more complex malformation patterns like mayer-rokitansky-küster-hauser syndrome (mrkh) or herlyn-werner-wunderlich syndrome. mrkh is characterized by congenital absence of the uterus and the upper two-thirds of the vagina in individuals with a normal female karyotype, most of whom show normal ovarian function. mrkh can further be associated with additional malformations e. g. of the kidneys and the skeletal system. herlyn-werner-wunderlich syndrome is characterized by uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis. despite anomalies of the md occur quite frequently, the etiology of most cases with these disorders remains unknown. the homeodomain transcription factor emx (empty spiracles homeobox ) was found to be critical for urogenital and central nervous system development. previous studies showed that in emx mutant mice, the kidneys, ureters, gonads and genital tracts were completely missing. in order to elucidate whether mutations in emx are causative for md anomalies in humans, we performed sequence analyses of emx (genbank nm_ . ) in our study group of female patients with clinically characterized disorders of the md including patients with mrkh and cases with herlyn-werner-wunderlich syndrome. we found the heterozygous intronic mutation c. - c>a twice in this cohort. this variant has been described earlier (rs ) and is listed in the exome aggregation consortium exac variant with a minor allele frequency of . %. in silico analysis revealed no significant changes for the correct splicing of emx . we therefore consider this variant to be a benign polymorphism. we conclude that mutations in emx are not causative for disorders of the md in our cohort. a. zaum, w. kreß, a. gehrig, s. rost institute of human genetics, würzburg, germany dystrophinopathies are x-linked muscle diseases caused by mutations in the dmd gene (omim: ). due to the huge size of this gene, the detection of mutations is sometimes challenging. despite multiplex ligation-dependent probe amplification (mlpa) and sequencing of all exons, about % of patients do not show any mutations in coding regions and therefore remain without molecular diagnosis. we assume that the majority of these patients have deep intronic variations (div) which are not detectable by standard diagnostic techniques. the index patient analysed is a twelve-year-old boy who was by chance diagnosed with elevated ck levels (up to , iu/i) at eight weeks of age. today he is still able to walk without walking aids but needs assistance when climbing stairs. in , a muscle biopsy revealed complete absence of dystrophin which established the diagnosis of dmd. for the molecular diagnosis, standard diagnostics ascertained no causative mutation. therefore we decided to search for deep intronic mutations. we isolated mrna from muscle tissue of the patient and amplified overlapping cdna fragments using rt-pcr. the fragments were analysed by gel electrophoresis for size differences compared to an unaffected control. the cdna product comprising exons - revealed an augmented fragment size compared to the control and the expected product size (about bp instead of the expected bp). we sequenced the altered cdna product using bigdye recent research in psoriasis has identified pustular psoriatic manifestations as either mendelian traits or as major genetic risk factors in contrast to the numerous associated snps in classical plaque psoriasis vulgaris. autosomal recessive mutations in il rn have been identified in ~ - % of patients with generalized pustular psoriasis (gpp), a rare, severe pustular variant of psoriasis. in addition, heterozygous missense variants in card and ap s have been associated to pustular psoriasis as well and shown to be functionally relevant. in order discover how relevant those genes were in our large gpp cohort of patients recruited all over germany, we screened them for coding variants in il rn, card and ap s by sanger sequencing and for quantitative aberrations by mlpa. we identified homozygous or compound heterozygous il rn mutations in of gpp patients ( %) and single heterozygous mutations in patients ( %). the most common mutations were c. >c>t/ p.ser leu and c. c>t/ p.pro leu, present on %/ % of mutated alleles, respectively. we also identified three so far unreported mutations: c. c>a/ p.ser x, c. - delacct-tc/ p.thr _phe del and c. g>a/ p.val met. according to molecular modeling, c. c>a/ p.ser x resulted in a shortened, de-stabilized protein analogous to c. g>t/ p.glu x. the other two mutations were also predicted to result in destabilized, likely disease-relevant, loss-of-function proteins. heterozygous ap s mutations were detected in two gpp patients, both of whom carried additional homozygous or compound-heterozygous il- rn mutations. gpp patients were heterozygous carriers of rare missense variants in card ( %); of note, two of these patients carried additional mutations in il rn. our genotype-phenotype correlation revealed a similar gender distribution in carriers of il rn mutations and wildtype carriers, but a strong association between bi-allelic mutations in il rn and early age of manifestation (p = . x* - ). as in other autosomal recessively inherited mutations, the frequency of parental consanguinity was significantly higher in patients with two il rn mutations compared to non-carriers. overall, our genetic studies suggest a lower impact of variants in ap s and card in pustular psoriasis than of those in il rn. interestingly, the combination of il rn mutations with either ap s or card congenital prosopagnosia (cp), also known as developmental prosopagnosia or face blindness, describes the inability to recognize faces. cognitive functions such as intelligence as well as the sensory visual capabilities are usually not impaired but people with prosopagnosia are negatively affected in their social life because individuals with the disorder have difficulty in recognizing family members, close friends or colleagues. although the prevalence of cp is estimated at . % and it appears to run in families, the contexts, which genetic, epigenetic and environmental factors contribute to this trait, are largely unknown. therefore we started to establish a large, well-characterized cp cohort for genetic studies. we hypothesize that rare highly penetrant non-synonymous genetic variants could explain some cases of cp. as part of a larger genetic study of patients with cp, we performed family based whole-exome sequencing and targeted re-analysing on four individuals from two families with multiple affected members. by obtaining samples from affected and unaffected members of the same family, we hope to effectively identify de novo and inherited variations. variations are considered on the basis of allele frequency, mutation type, literature and mutation prediction tools, thus generating a list of candidate variations/genes for each patient that is amenable to interpretation and further analyses in the extended cohort. through this approach, we hope to identify causal variations/genes in families and isolated patients with cp. erythrokeratodermia variabilis (ekv) is a rare, autosomal dominant genetic skin disorder with a highly heterogeneous phenotype. to date, three causative genes (gjb , gjb and gja ) are described but further genetic heterogeneity is expected. card mutations are only described for psoriasis vulgaris, generalized pustular psoriasis and pityriasis rubra pilaris. for the first time, we present disease causing card mutations in patients with an "ekv-like" phenotype. it refers to one familial case with two affected individuals, with an autosomal dominant transmission from the mother to the daughter and one independent sporadic case. all patients present typical ekv symptoms. a rash of well-demarcated erythematous and scaly plaques interspersed with distinct islands of uninvolved skin or small reddish papules coalescing into large reticulated scaly plaques and palmoplantar keratoderma. to confirm the suspected diagnosis of ekv, we analyzed a custom designed multi-gene panel by next generation sequencing with genes associated to hereditary skin diseases (agilent haloplex technology). the sequencing results did not reveal any mutation in the genes gjb , gjb and gja , but we found two pathogenic mutations in card . in the familial case c. t>c p.leu pro (rs , enst . ) was detected, while the sporadic case carries c. t>c p.leu pro. we hypothesize that different genetic and environmental factors are involved in the evolution of the phenotype in patients with card mutations. our cases show that classification of unusual skin phenotypes can be challenging without genetic testing. therefore, gene panel sequencing is a cost-efficient and time-saving solution for solving difficult cases with sometimes unexpected genetic background. bipolar disorder (bd) is a complex psychiatric disorder affecting more than % of the world's population. the highly heritable disease is characterized by recurrent episodes of manic and depressive symptoms. as the cumulative impact of common alleles with small effect may only explain around % of the phenotypic variance for bd, rare variants of high penetrance have been suggested to contribute to bd susceptibility. in the present study we investigated individuals of large multiply affected families of european origin using whole exome sequencing (wes). in each family, two to five affected individuals with bd or recurrent major depression were selected for sequencing. wes was performed on the illumina hiseq platform and the varbank pipeline of the cologne center for genomics was used for data analysis. all identified variants shared within each family were filtered for a minor allele frequency < . % and potentially damaging effects predicted by at least four of five different bioinformatics tools. we identified a total of rare, segregating and functional variants implicating different genes, of which were brain expressed. subsequently, we applied the residual variation intolerance scores (rvis, petrovski et al., ) and identified genes that were ranked among the % most "intolerant" genes in the genome. gene enrichment analysis of these genes showed a significant enrichment for a total of pathways (p < . ) including neuron projection, axon development and cell adhesion. for follow up analyses, we prioritized genes that were either found in at least two unrelated families in the present study or that were previously reported in next generation sequencing or gwas studies of bd. in addition, we enclosed the genes that were predominantly driving the significant pathways in the above mentioned gene enrichment analysis. the different approaches of prioritization yielded candidate genes that are currently being followed up by resequencing in cohorts of about independent bd cases and controls of european ancestry. the candidate genes include cdh that encodes a calcium-dependent cell adhesion protein that may play an important role in the morphogenesis of neural cells during the development and maintenance of the brain. for resequencing we use the single molecule molecular inversion probes (smmips) technology that enables multiplex targeted resequencing in large cohorts. the smmips sequences were designed with an empirically variants in several patients indicated an oligogenic inheritance rather than a purely monogenic one. moreover, the oligogenic basis of this group of inflammatory diseases might currently be underestimated, as our study suggests that genetic risk factors other than il rn mutations remain to be identified in the majority of gpp patients. exome sequencing of multiply affected schizophrenia families provides new insights into the pathogenesis of the disorder schizophrenia (scz) is a multifactorial psychiatric disorder with a lifetime risk of ~ % and a heritability of about - %. analysing multiply affected families using whole exome sequencing (wes) is a very promising approach to identify new scz risk factors. in these families, individuals are affected with scz over several generations. it is likely, that in multiply affected families genetic variations with particularly strong effect co-segregate with the disorder and contribute to the development of the psychiatric symptoms. to our knowledge, the present study is the largest study analysing multiply affected scz families using wes worldwide so far. we included families with at least affected members each. from each family, - individuals were exome sequenced on an illumina hiseq and analysed using the varbank pipeline of the cologne center for genomics (http://varbank.ccg.uni-koeln.de) and the clc bio biomedical genomics workbench. we included rare (allele frequency ≤ . % in the exome aggregation consortium dataset) variants that were predicted to be pathogenic (combined annotation dependent depletion score ≥ ; cadd.gs.washington.edu), confirmed by sanger sequencing and co-segregating with the disorder. in total we identified potentially pathogenic mutations in ~ genes. a substantial proportion of these will not contribute to the pathogenesis of scz. in order to further tease out the most promising candidate genes we applied multiple strategies: (i) screening our mutations in independent patient and control cohorts through international cooperations (access to more than , scz patients), (ii) gene-based tests, (iii) pathway-and network-analyses, (iv) gene expression analyses and (v) sequencing of the candidate genes in , scz patients and , controls. analyses are ongoing and will be presented at the upcoming conference. abstracts and our evolution, we know very little about the different mutagenic processes in our germline. of particular interest are a handful of highly recurrent dnm associated with congenital disorders and/or rasopathies, that have been described as driver mutations expanding in the male germline. the mutation itself causes a change in the tyrosine kinase receptor/ras/ mapk pathway, which in turn confers the spermatogonial stem cell a proliferative advantage. selfish or driver mutations are quite common in cancer, but we still know very little about the selfish expansion in the male germline. the reason might be that mutations in the human germline are very rare, and it is rather difficulty to directly measure such rare events. most of our knowledge on germline mutagenesis comes from indirect sequence comparisons or whole genome sequencing of pedigree families, but it renders little information about individual mutagenic events. for this reason, we have adapted an ultrasensitive, next generation sequencing (uss) technology for the measurement of rare mutations to study the expansion of selfish genes in the male germline. as a proof-of-principle, we have sequenced at an extremely high coverage exon and of the fgfr gene in young and old sperm donors. we found an increased mutation frequency for the loci associated with achondroplasia and thanatophoric dysplasia ii in sperm of older donors. our results also show that we can distinguish ultra-rare mutations occurring at a frequency of one in hundred thousand wild type; thus, making this method ideal to discover potential driver dnm that might be expanding with paternal age. s. sivalingam , , a. j. forstner , , , s. herms , , , a. maaser , , c. s. reinbold , , t. andlauer , j. frank , h. dukal , d. schendel , , p. hoffmann , , , t. kircher , u. dannlowski , , a. krug , a. cichon , , , s. witt , m. rietschel , m. m. nöthen , introduction: affective disorders such as major depressive disorder (mdd) and bipolar disorder (bd) are genetically complex and heterogeneous disorders. both genetic and environmental risk factors contribute to the etiology of the diseases. however, the neurobiological correlates by which these risk factors influence the disease development are hardly understood. increasing evidence suggests that epigenetic modifications such as dna methylation have important implications on the development of psychiatric disorders including mdd and bd. several studies revealed that alterations in the dna methylation can modulate gene expression in response to the environment. to investigate this, genome-wide dna methylation analysis of female individuals from three extreme groups (genetic-, environmental risk and healthy controls) was performed. methods: for the genome-wide dna methylation analysis we selected: (i) individuals with genetic risk (at least one st degree relative with a life-time diagnosis of mdd or bd), (ii) individuals with environmental risk (maltreatment in the childhood trauma questionaire) and (iii) matched healthy controls. all individuals were of european origin. processing was done according to the manufacturer's protocol using the infinium methylationepic beadchip (illumina, san diego, ca, usa) covering more than . methylation sites at the life & brain center (bonn, germany). state-of-the-art data processing protocols, including correction for blood cell type heterogeneity, color correction, eliminating probes containing snps and cross reactive probes were used. after quality control trained design algorithm mipgen (boyle et al., ) and sequencing is currently performed on the illumina hiseq platform. our preliminary results strongly suggest that rare and highly-penetrant variants in neuronal and cell adhesion genes contribute to bd etiology. the results of resequencing of a large case/control sample will provide further evidence for an involvement of particular pathways. the use of zebrafish as model system to quantitatively assess the impact of risk variants in non-coding regions in vivo s. l. mehrem , , b. nagarajan , n. ishorst , , a. c. böhmer , , e. mangold , b. odermatt , k. u. ludwig , department of genomics, life & brain center, university of bonn, bonn, germany, institute of human genetics, university of bonn, bonn, germany, institute of anatomy, university of bonn, bonn, germany most human malformations occur early in embryonic development and are present immediately after birth. one common human birth defect is nonsyndromic cleft lip with or without cleft palate (nscl/p), affecting about in , newborns. nscl/p has a multifactorial background with a strong genetic component. recent genome-wide association studies identified several loci as risk factors for nscl/ p. notably, most of them map to non-coding regions and are expected to have a functional impact through regulatory mechanisms. given the early developmental time point of facial development and the resulting lack of accessible human tissue, follow-up analyses of risk variants are challenging. we are hypothesizing here that we might be able to quantitatively detect differences in regulatory activity between wildtype and risk variants located in predicted enhancers by using the zebrafish as model organism. the advantages of using the zebrafish are ( ) ex utero development, ( ) transparency of the fish, ( ) easy manipulation and ( ) relatively short generation times. we applied a dual-luciferase assay plasmid system which is based on a sequential measurement of two luciferases (firefly and sea pansy luciferase) in fish lysates upon injection of a single plasmid. this plasmid, which contains a minimal promoter (minp) and the enhancer region of interest, is microinjected into zebrafish eggs of one-cell stage. after three days, fish are collected, lysed and luciferase activity is measured using a luminometer. for our proof-of-principle analysis we analyzed an nscl/p risk locus on chromosome q (ludwig et al. ) . through database research one enhancer was predicted that contained two strongly associated risk variants. in vivo fluorescence analysis using egfp in zebrafish embryos revealed this enhancer to be active in craniofacial development, but qualitative differences in activity were not observed by eye. upon cloning of the enhancer in the dual-luciferase system, our injection results in vivo indicate that the system is working in principle. however, a high standard deviation between single replicate measurements was observed, probably due to variability in transfection efficiency. we therefore are planning to adapt the protocol in order to screen for positively injected fish embryos. we are currently investigating the functionality of these screening constructs in zebrafish embryos. results will be presented at the meeting. once successful, our approach represents a practical method to quantify the activity of regulatory elements in real time in vivo. this will be of particular importance in the functional follow-up of genetic findings in non-coding regions for the majority of birth defects. previously genome-wide association methods in patients with classic bladder exstrophy (cbe) found association with isl , a master control gene expressed in pericloacal mesenchyme. this study sought to further explore the genetics in a larger set of patients following-up on the most promising genomic regions previously reported. genotypes of markers obtained from cbe patients of australian, british, german ital-and normalization , cpg-sites were tested for genome-wide dna methylation by a linear regression model while accounting for biological as well technical covariates. results: the genome-wide dna methylation analysis of the three extreme groups revealed cpg sites (p < × - ) in the subgroup analysis "environmental risk vs. controls" and cpg sites (p < × - ) in the analysis "genetic risk vs. controls". in addition, we identified cpg sites (p < × - ) in the comparative analysis of "genetic risk vs. environmental risk". none of these cpgs showed significant differential dna methylation after correction for multiple testing. however the hierarchical clustering of the differentially methylated sites provided some evidence for differentially methylated patterns between the subgroups. discussion: our genome-wide dna methylation analysis of the extreme groups provided some evidence for differentially methylated cpg sites which unfortunately did not withstand correction for multiple testing. this may reflect at least in part that the sample size of the present study was too small to detect differentially methylated cpgs at the genome-wide level. a. tafazzoli , , t. vaitsiakhovich , l. pethukova , , , s. redler , , r. kruse , b. blaumeiser , m. böhm , g. lutz , h. wolff , , am. christiano , p. kokordelis , mm. nöthen , , rc. betz , alopecia areata (aa) is a common hair loss disorder that occurs in both sexes and all age groups. aa is thought to be a tissue-specific autoimmune disease directed against the hair follicle. both, gene-based and genome-wide association studies have identified more than susceptibility loci for aa; however, a large percentage of the overall heritable risk still awaits identification. to provide further insight into the immune related nature of aa, we and our us collaborators had each performed an immunochip-based analysis. we recently performed a meta-analysis, combining the data from both studies, and are now aiming to follow-up the best results in an additional german cohort by use of a sequenom assay to identify novel susceptibility loci. we conducted the meta-analysis by using data from the above mentioned two studies on illumina beadchip arrays including a total of , cases and , controls of central european origin. method of synthesis of regression slopes (msrs) was used for the analyses which are implemented in metainer software package. for follow-up step, we chose the most promising candidate snps. these will be examined with the sequenom massarray iplex platform in an independent aa sample comprising , cases and controls. by use of the meta-analysis combining data from the us and our sample, we identified novel loci with a suggestive p-value of pbecker-wu ≤ - (phet ≥ . ). among them, nfkb is the most significant locus (pbecker-wu = . × - ). in order to achieve genome-wide significance, we plan to follow-up the most promising snps in an independent german sample. we considered the most significant loci (lower p-becke-wu value) for the replication step. the experiments are ongoing and results will be presented at the meeting. despite the recent identification of susceptibility loci for aa, our understanding of the genetics of aa is incomplete. identification of new loci may provide novel insights into biological pathways and a better elucidation of disease pathophysiology. q . encompassing only one gene: kcnj . the duplication segregates with the phenotype in the family. kcnj belongs to the same subfamily of potassium channels as the known disease gene for cooks syndrome kcnj and both share several biological functions. recent data show that gain of function mutations in another potassium channel kcnh cause zimmermann-laband syndrome, a congenital malformation syndrome also associated with hypoplasia or aplasia of nails and terminal phalanges. therefore we propose that duplications of kcnj may also cause tissue specific misregulation resulting in digit and nail defects. taken together we show in a three generation pedigree that cooks syndrome is associated with a duplication of kcnj . our data further highlight the emerging role of potassium channels in congenital digit and limb anomalies. case report: deletion of the terminal short arm of chromosome (chromosome p deletion syndrome) without q-duplication with a familial history of a large pericentric inversion of chromosome b. gläser, n. hirt, e. botzenhart, j. fischer, m. leipoldt institut für humangenetik, universitätsklinikum freiburg, freiburg, germany we report on a male patient referred as a newborn with typical clinical features of chromosome p deletion syndrome. conventional karyotyping of lymphocyte cultures confirmed a deletion of the terminal short arm of chromosome with breakpoint in p . the size of the deletion ( mb) could be refined by microarray analysis and assigned to pos : - . parental cytogenetic investigations showed a normal karyotype in the mother whereas the father was revealed to be carrier of a large pericentric inversion of one chromosome . odd crossing-over in the inverted segment of a pericentric inversion in a parent can lead to unbalanced offspring caused by gametes with a terminal deletion of the p-arm together with a duplication of the q-arm or gametes with a duplication of the p-arm together with a deletion of the q-arm. in order to find out, whether the p-deletion in the child is the result of an independent event or if it is related to the structural chromosomal aberration of the father a microsatellite analysis is going to be performed p-cytog- a small supernumerary marker chromosome of the pericentric region of chromosome in a child with intellectual disability: case report and literature review b. hoffmann, g. gillessen-kaesbach, i. hüning institut für humangenetik, universität zu lübeck, lübeck, germany small supernumerary marker chromosomes (ssmc) are reported in . % of newborn infants. we report on a girl, which was born preterm at weeks of gestation via cesarean section due to pathological ctg. the pregnancy was complicated by gestational diabetes. she presented with muscular hypotonia, multiple hemangiomas, dysmorphic features and feeding problems. the body measurements were in normal range. the feeding problems made a tube feeding necessary until the age of four months. facial features consisted in epicanthus, high palate, broad nasal tip and broad nasal root. a brain mri showed periventricular leukomalacia and hypoplasia of corpus callosum. drug-resistant seizures with hypsarrhythmia started at the age of ten months. the affected girl was the only child of healthy non-consanguineous parents. the father also presented with a few small hemangiomas in the face. there was no history of intellectual diasability in the extended family. karyotyping showed ssmc in mosaicism. molecular characterization by array-cgh showed that the ssmc consists of pericentric chromosomal material derived from chromosome (arr [ h g ] p . p . ( , , - , , ) x ~ , q . q . ( , , - , , ) x ~ dn (grch /hg ). ian, spanish and swedish origin and , ethnically matched controls and from cbe case-parent trios from north america were analysed. only marker rs at the isl locus showed association (p = . × - ). a meta-analysis of rs of our previous and present study showed a p value of . × - . developmental biology models were used to clarify the location of isl activity in the forming urinary tract. genetic lineage analysis of isl -expressing cells by the lineage tracer mouse model showed isl -expressing cells in the urinary tract of mouse embryos at e . and distributed in the bladder at e . . expression of isl in zebrafish larvae staged hpf to hpf was detected in the developing pronephros region. our study supports isl as a major susceptibility gene for cbe and as a regulator of urinary tract development. to date, seven patients with interstitial deletions at chromosome q . -q . have been described in the literature. all patients reported had moderate to severe intellectual disability and a characteristic facial phenotype including blepharophimosis, telecanthus, epicanthus, flat malar region, and a thin upper lip vermillion. six of the seven patients had epileptic seizures. by analyzing the deletion's overlaps, two distinct critical regions have been suggested for the facial phenotype as well as for intellectual disability and seizures. here we present another patient with a de novo . mb deletion in q . -q . . the patient shows moderate mental retardation. he has an abnormal eeg, however, only one episode of clinical seizures has been observed so far. the facial gestalt resembles the typical dysmorphic features of the patients with q . -q . deletions reported previously. minor anomalies were short fingers and toes, and a single palmar crease. our report supports the assumption that deletions in q . -q . cause a distinctive and clinical recognizable microdeletion syndrome with characteristic facial features and intellectual disability. since the patient's deletion overlaps with most of the critical region for the dysmorphic phenotype but only with parts of the intellectual disability critical region, the molecular data presented here further narrow down the critical region for the intellectual disability seen in patients with q . -q . microdeletions. p-cytog- *** cooks syndrome is associated with a duplication of the potassium channel kcnj mundlos , , , d. horn , m. spielmann , , institute for medical genetics and human genetics, charité universitätsmedizin berlin, berlin, germany, max planck institute for molecular genetics, berlin, germany, northern ireland regional genetics service, belfast city hospital, belfast, ireland, berlin-brandenburg school for regenerative therapies -bsrt, berlin, germany cooks syndrome (mim ) is a rare autosomal dominant disorder classically characterized by onychodystrophy, and anonychia, with absence or hypoplasia of the distal phalanges of the hands and feet. large duplications including kcnj were shown to be causative for cooks syndrome. recently mouse studies revealed that tissue specific misregulation of kcnj , a potassium channel of the subfamily j, cause hypoplasia of nail beds and abnormal distal phalanges, thus resembling the cooks phenotype. here we report on a three generation pedigree with typical features of cooks syndrome that was negative for kcnj testing. we performed high resolution array-cgh and identified kb duplication on chromosome p-cytog- chromosome q . -q . deletion syndrome -an additional case with sensorineural hearing loss. s. leubner, c. hennig, a. junge mitteldeutscher praxisverbund humangenetik, dresden, germany the chromosome q . -q . deletion syndrome (mim # ) is a contiguous gene syndrome caused by a deletion encompassing the chromosome region q . -q . . initially, it has been described by ballif et al. ( ) . up to now, only a few cases with a microdeletion q . q . have been reported. most of them carry a microdeletion with recurrent breakpoints and similar size of about . mb. the common clinical features of cases with the chromosome q . -q . deletion syndrome comprise mild-to-moderate developmental delay, microcephaly, postnatal growth retardation, heart defects, limb anomalies, and hearing loss. we present an additional male patient with a . mb deletion of chromosome q . -q . , detected by array cgh (cytochip isca × k v . , illumina). our index patient shows typical symptoms of the chromosome q . -q . deletion syndrome like developmental retardation (in particular speech delay), a head circumference at the rd centile, postnatal growth retardation with a body height at the th centile, heart anomalies (right-sided aortic arch, patent ductus arteriosus), and sensorineural hearing loss on both sides. our data improve the characterization of the typical phenotype caused by a chromosome q . -q . deletion and reinforce the suspicion that this region might be associated with sensorineural hearing loss. partial, homozygous deletions of ahi gene causes joubert syndrome type d. meier, a. behnecke, jwg. janssen, u. moog, k. hinderhofer institute of human genetics, university hospital heidelberg, heidelberg, germany we describe a patient who is second child of consanguineous healthy parents from turkey. he was born after weeks of gestation with normal birth parameters ( g, cm, ofc cm). at the age of three months atypical eye movements became apparent. psychomotor development was delayed from the beginning, he presented with hypotonia and later developed ataxia. an abnormal breathing pattern was not noticed. an abnormal mri with hypoplasia of the cerebella vermis at the age of months and the clinical signs described above led to a clinical diagnosis of joubert syndrome. at that time no diagnostic testing was available. he returned to the outpatient clinic of the institute of human genetics at the age of years having developed retinopathy in the meantime. his height was below average (~ cm, <p ) but still within his family's range. aside from the known irregular eye movements he showed nail hypoplasia of the thumbs, and small hands and feet. he was working at a sheltered workshop. the year before, the pediatric department of the university hospital heidelberg had initiated testing of of the by then known genes causative for joubert with no mutation being found (nphp , tmem , cc d a, mks , rp-grip l, ofd- and mks ). the gene associated with joubert syndrome type (omim # ) was not included though. with the external mri not being available at that time we decided to first perform chromosome and array analyseis. the conventional chromosome analysis was without pathological findings. subsequent array analysis by affymetrix® cytoscan hd oligo/snp showed an kb homozygous deletion in q . within the ahi gene, the gene for joubert syndrome type . the deletion encompasses exon to which includes parts of the wd-repeats (tryptophan-aspartic acid (w-d) dipeptide) on the protein level. the homozygous deletion was confirmed by mlpa in the patient and both parents identified as heterozygous carriers. so far, alterations in ahi leading to joubert syndrome comprise homozygous point mutations or small heterozygous deletion/duplications in combination with a second pathogenic mutation. so we here present the first case of a large homozygous deletion in the ahi gene, being causative for joubert syndrome type . we conclude that in un-a review of the literature showed that the few patients with a ssmc of the pericentric regions of chromosome described in literature show early feeding problems, developmental delay, delay in acquired language, difficulties in social skills, difficulties in attention and activity levels or autistic-like behavior. the facial dysmorphic features were not specific. multiple hemangiomas have been reported in some cases. west syndrome or seizures have not been reported so far. the phenotype of our patient is consistent with the literature data, however there are no patients with a ssmc showing the same breakpoints reported so far. especially due to the mosaicism and the rare number of patients described in the literature, no precise clinical prognosis for this patient was possible. the generation of patient-specific induced pluripotent stem cells (ipscs) by reprogramming of adult somatic cells (e. g. skin fibroblasts) represents a novel technology for studying disease mechanisms. for generation of ipscs several reprogramming methods, including the use of integrating vectors and non-integrating vectors, have been developed. since genetic abnormalities can arise during the reprogramming process, genetic quality assurance is indispensable. the aim of this analysis was to compare the genetic stability of ipscs generated using either a dna-integrating or a dna-non-integrating reprogramming technique in order to reveal possible method-specific differences. we studied ipscs derived from patients with parkinson's disease (pd), the second most common neurodegenerative disease worldwide. to monitor the genetic stability, we investigated copy number variants (cnvs) in addition to conventional chromosome analyses in ipscs of ten pd patients and six healthy control individuals. using high-resolution chromosomal microarray analysis (cma), we monitored the formation of relevant cnvs during reprogramming to pluripotency by comparing fibroblasts and ip-scs of the respective individual. to date, fibroblast cultures of all selected probands as well as retroviral reprogrammed ipsc clones and eight sendai-viral reprogrammed ipsc clones were analyzed. aneuploidies were detected in three fibroblast cultures ( %), in five retroviral ipsc clones ( %), and in none of the sendai ipsc clones. de novo cnvs were identified in retroviral ipscs ( %) - clones showed one ( %), nine clones showed two ( %), four clones showed three ( %), and one clone showed four newly arisen cnvs ( %). in seven of eight sendai clones, de novo cnvs were detected ( %). two de novo cnvs were identified in three clones ( %), three cnvs in two clones ( %), four in one clone ( %), and even six de novo cnvs were detected in one clone ( %). additionally, a mosaic gain of the whole long arm of one chromosome was identified in one sendai clone. only of the retroviral reprogrammed clones ( %) as well as one sendai reprogrammed clone ( %) showed no newly arisen cnvs. the cnvs were between kb and . mb in length in retroviral clones and between kb and kb in sendai clones. because almost all cnvs contained genes, including genes involved in neurodevelopment and transcriptional regulation, a biological relevance seems highly probable and changes in cell phenotype cannot be excluded. since ipscs and cells derived thereof -independent of reprogramming methods -often contain aberrations not detected by standard chromosomal analysis, our findings highlight the importance of high resolution cma procedures. in spite of differences in the analyzed number of clones, our results indicate more and larger cnvs in sendai clones than in retroviral reprogrammed clones. supported by forips, bavarian research network induced pluripotent stem cells. abstracts mother's lymphocytes showed a balanced form of the aberrant karyotype found in her son. the healthy mother possesses the insertion ins( ; ) (q . ;q q ), the simultaneous resection of the q ? - q . material and generation of the additional ring chromosome with this material. during meiosis a normal chromosome , the derivative chromosome and the ring chromosome were passed on to the son leading to the unbalanced karyotype as described above. further analysis with pan-centromeric probes and immunohistochemistry with an antibody against cenp-a might confirm the existence of a neocentromere on the ring chromosome which was meiotically transmitted from the mother to the son. the mtor (mechanistic target of rapamycin) kinase is the most important regulator of local dendritic and presynaptic protein translation in the brain. it has been shown to fundamentally influence ampa receptor activity by shifting glua to glua balance and to control the synthesis of several proteins involved in synaptic function and plasticity. both, loss and gain of mtor activity lead to significant disturbances of brain homeostasis and neuronal function resulting in intellectual disability (id), epilepsy, autism and behavioural alterations. in order to analyse mechanisms of homeostatic regulation of mtor-dependent synaptic function we are using a heterozygous tsc knockout (ko) mouse model for tuberous sclerosis (ts). tsc (together with tsc ) is part of a complex that inhibits the mtor kinase. mutations in either of the two genes result in increased mtor activity and upregulated downstream signalling and are causative for autosomal dominant ts. it had been shown previously that mtor hyperactivity leads to a set point shift and significantly influences neuronal homeostasis by altering cell excitability and e/i balance in heterozygous tsc ko animals. according to these studies we hypothesize that this shift significantly leads to synaptic connectivity and plasticity as well as network alternations that result in progressive development of cognitive dysfunction, epilepsy, autism and behavioural alterations over time in ts. we have established a behaviour battery, which consists of a novel object recognition test (nort), a morris water maze test (mwm) and an evaluation of nest building and social interaction to study social behaviour and cognitive performance in heterozygous tsc ko mice in different age groups. interestingly we found that, while two months old animals do not show any alterations, three to four months old animals develop significant disturbances in social behaviour in the social interaction test and in nest building. furthermore, we could show significant changes in cognitive performance of seven to eight months old heterozygous tsc ko mice in the nort compared to three to four months old heterozygous tsc ko animals. these data show that the ts phenotype builds up on shifts of the e/i balance that develop at a very early stage. pharmacological intervention with e/i balance is a promising therapeutic strategy to prevent brain damage caused by congenital hyperexcitability and homeostatic dysfunction. clear cases of a joubert phenotype an array-cgh is recommended besides sequencing to clarify the molecular basis of the phenotype. recently, a new syndrome of intellectual disability (id) with dysmorphisms due to deletions within the chromosomal band q . harboring the tbl xr gene was described. additionally, a specific point mutation in tbl xr causes pierpont syndrome, a distinct mental retardation syndrome. we report four patients in which array-cgh analysis and real-time quantitative pcr of genomic dna revealed tbl xr microduplication. adjacent genes were not affected. the microduplication was verified as de novo by real-time pcr of parental dna in one patient. the other three cases occurred in two generations of a second, unrelated family. we compare the remarkably similar clinical findings in tbl xr microdeletion, point mutation and microduplication cases and expand the tbl xr -associated phenotypic spectrum. among others, intellectual disability, hearing loss and autism spectrum disorders are common features of tbl xr -associated diseases. our clinical observations add to the increasing evidence of tbl xr 's role in physiological brain development and simultaneously demonstrate that opposing genetic disease mechanisms affecting tbl xr can lead to similar id phenotypes. in conclusion, the observed phenotypic overlap indicates that this novel microduplication is a genomic sister-disorder to the q . microdeletion syndrome. neocentromere formation has been reported in more than small supernumerary marker chromosomes (ssmc). here we report the formation of a putative neocentromere within a supernumerary ring chromosome derived from chromosome in a five year old patient with generalized developmental delay, microcephaly and hexadactyly. chromosomal analysis (gtg-banding, resolution bands) of the boy showed an aberrant karyotype with a derivative chromosome demonstrating additional chromosome specific material inserted into the distal part of the long arm (ins( ; )(q . ;q q )), a simultaneous deletion of the chromosomal region q ? -q . on the same homolog and an additional supernumerary small marker chromosome, presumably a ring chromosome in all metaphases tested. in parallel, array-cgh was performed and revealed a gain of . mb in chromosomal region q -q . without a detectable imbalance of chromosome material within the limits of the method ( k array). fish analysis with wcp probes and telomeric probes for chromosomes and confirmed the interstitial insertion of chromosome material into the long arm of the derivative chromosome . the marker chromosome stained completely with a wcp probe but centromere probes for chromosomes and were both negative suggesting the formation of a neocentromere within region q ? q . . in total, the complex rearrangement resulted in a partial trisomy q in the boy as a presumable explanation for the phenotype. the mother has experienced one abortion and the parents have two more children who show a normal development so far. both parents were karyotyped. the analysis of the father was normal ( ,xy). konventional chromosomal analysis of the in flvcr have previously been linked to vision impairment and posterior column ataxia in humans, but not to hsan. using fibroblasts and lymphoblastoid cell lines from patients with sensory neurodegeneration, we here show that the flvcr -mutations reduce heme export activity, enhance oxidative stress and increase sensitivity to programmed cell death. our data link heme metabolism to sensory neuron maintenance and suggest that intracellular heme overload causes early-onset degeneration of pain-sensing neurons in humans. autosomal-dominant familial hypercholesterolemia (fh, omim ) is one of the most common genetic diseases with an estimated prevalence of : to : . three major genes have been associated with the disease: low density lipoprotein receptor (ldlr), apolipoprotein b (apob) and proprotein convertase subtilisin/kexin (pcsk ). we have recently published data on the mutation spectrum in these three genes in about fh patients from germany, however, this screen for mutations was negative in about % of the cases. stap (signal transducing adaptor family member ) was recently suggested to be the fourth fh gene. we therefore screened the stap gene for disease causing variants in a group of fh patients negative for mutations in the three established fh genes by direct dna sequencing (sanger). the newly identified variants will be presented including a phenotype-genotype correlation. phenotype: we present a -year-old girl with developmental delay, craniofacial anomalies, congenital eye anomalies ( . dpt), short stature and behavioral disorder with auto-aggressions. preliminary examinations (array-cgh analysis, karyotyping, diagnostic of metabolism, eeg, cmrt, sequencing of srcap-gene) revealed normal results. methods: in course of the midas-project, we sequenced the index patient and her healthy, non-consanguineous parents on a nextseq platform (illumina, san diego, ca, usa) to perform a trio analysis. for library preparation we used an enzymatic fragmentation approach. exome capture was performed with a sureselect human all exon kit v (agilent, santa clara, ca, usa), targeting coding exons and conserved splicing sites of over . genes. the library of the index patient was sequenced with a -fold mean coverage as -bp paired-end reads. % of the target region were covered -fold or higher. data analysis and variant evaluation was done using the clc genomic workbench . (qiagen, hilden, germany) and annotations from commercial as well as public databases. results: the trio analysis of whole-exome sequencing data from the index patient and her parents revealed variants. we identified the disease-causing de novo adnp mutation c. c>t (p.arg *, adnp), resulting in the introduction of a stop codon in exon / and truncation of the corresponding protein. both of the parents did not carry this mutation. adnp is part of the atp-dependent baf chromatin-remodeling p-monog- the challenge to insert costello syndrome causing hras mutations into human keratinocytes using the crispr/cas editing technology. l. brandenstein, k. kutsche, g. rosenberger university medical center hamburg-eppendorf, hamburg, germany germline missense mutations in the hras gene cause costello syndrome, a rare developmental disorder characterized by a typical facial gestalt, postnatal growth deficiency, intellectual disability, and predisposition to malignancies as well as skeletal, cardiac and dermatological abnormalities. the molecular pathophysiology caused by heterozygous hras gain of function mutations has been analysed in various tissues and cell types, however, up to date the molecular basis for cutaneous manifestations in costello syndrome is largely unknown. to address this question in an appropriate model system, permanent human keratinocyte (hacat) cells carrying costello syndrome-associated mutations in the endogenous hras gene should be generated by using the crispr/cas technology. double strand breaks induced by cas can be repaired in two ways: the error-prone non-homologous end-joining pathway for the generation of knockout models or the homology directed repair pathway, which allows precise editing. the latter enables the introduction of specific point mutations into a cell line by using a single stranded dna (ssdna) as repair template. however, we found that this is a very rare event and its efficiency depends on various factors including used cell line, selected guide rna, length and amount of ssdna and also cas variant. nonetheless, by using cas wildtype, we could insert the disease-associated c. g>t (p.g v) mutation into genomic hras both in hacat cells ( positive clones out of ) and hek cells ( positive clones out of ). in contrast, using the cas nickase protein variant that prevents off target effects, did not result in positive clones. taken together, in months of working with crispr/ cas we gradually gained experience with many problems and pitfalls of this technology and, finally, now we are able to introduce point mutations in cell lines. next, we will use the mutant hacat cell line to gain deeper insight into the function of hras for epidermal homeostasis and its deregulation in costello syndrome. ccdc could also play a role in prenatal development of the mouse retina and brain. embryonic stages of interest comprise <e at the initial development of the eye, e after formation of nasal pits and prominent brain growth, when brain vesicles are initially visible and e where the eye and nasal brain develops. this study aims at characterizing ccdc rna and ccdc protein expression during key steps of prenatal development in the wt mouse and respective ccdc reporter gene expression in the ccdc -/model. methods: ccdc rna expression was analyzed by quantitative ccdc qrt-pcr and ccdc protein expression was determined by sds page and western blot in eye and whole brain homogenates of the mouse at selected embryonic stages (<e , e and e ). in addition, µm sagittal cryosections of mouse embryos were hematoxylin and eosin stained and analyzed for ccdc reporter gene expression by x-gal staining or antibody staining followed by light or fluorescence microscopy. results: ccdc rna and ccdc protein is detected in the wt mouse at different developmental time points in the eye and brain tissue. accordingly, ccdc -/reporter gene expression is evident at prenatal developmental stages in cryosections of whole embryos. conclusion: expression studies of ccdc gene and products in the eye and brain in wt and ccdc -/mice in different developmental embryonic stages are of crucial interest, and the role of ccdc gene and products in prenatal development has to be evaluated in detail in further studies. nn. hauer, b. popp, e. schoeller, ab. ekici, a. reis, ct. thiel institute of human genetics friedrich-alexander-universität erlangen-nürnberg, erlangen, germany the application of next generation sequencing technologies (ngs) has been extremely successful in the identification of the underlying causes of genetic disorders. whereas, most variants are located in coding regions, variants within splice-sites that might lead to alternative splicing affecting protein function or causing mrna decay are less well characterized. even for canonical splice-sites, prediction of the splicing effects for an identified variant is cumbersome. this becomes even more apparent as ngs based exome and genome sequencing tremendously increase the number of variants potentially affecting splice-sites. in our study to identify the underlying causes of idiopathic short stature by whole exome sequencing in more than patients, we observed variants in consensus splice-sites defined as up to bases from the ' and bases from the ' end of an exon. we used several computational methods (splice site finder, maxentscan, nnsplice) to calculate their potential effect on splicing. these results were often inconclusive and did not predict the definite effect on transcripts. therefore we performed rtpcr amplification of the respective regions, electrophoretic evaluation of fragments and sanger sequencing. in case of a suspected alternative splicing the evaluation of the distinct resulting isoform, though, was often hampered by the overlap of sequences. this was especially severe when multiple naturally occurring alternative transcripts were present. to overcome these issues, we established a deep sequencing approach (targeted rtpcr-seq) to identify all present isoforms in the affected patients compared to controls. for this method the rtpcr fragments were normalized to generate an equimolar mixture. libraries for patients and controls, respectively, were generated by ligation of distinct index adaptors for both amplicon pools and subsequently sequenced on an illumina miseq platform. the resulting reads were aligned and visualized as sashimi plots. observed splice-junctions in patients were compared to the controls and public databases. we found concordant results between standard rtpcr evaluation and our rtpcr-seq approach for variants (alternative splicing for variants). for these confirmed variants the specific effect was more obviously ascertained by the ngs based approach. for variant only rtpcr-seq was able to separate multiple co-occurring distinct isoforms, both in controls complex, which is involved in the regulation of gene expression. an influence on neuronal cell differentiation is postulated. mutations in the adnp gene were previously reported in patients with autism and mild to severe intellectual disability. all reported adnp mutations are characterized by de novo mutations that are clustering in exon and severely disrupting the protein-coding sequence, either by the introduction of a stop codon or a frameshift induction. by additionally considering the clinical symptoms, we were able to diagnose the helsmoortel-van der aa-syndrome (hvdas; omim id: ). discussion: the challenge of next-generation sequencing (ngs) approaches in diagnostics is no longer the technical feasibility or costs but the medical interpretation of the large sequencing data sets. besides a robust genetic analysis with focus on disease-associated genes, family anamnesis and detailed information of clinical symptoms in a standardized scheme are important for a reliable diagnosis. here, we present one of over cases that will help to establish the multiple integration of data annotation software (midas), which will enable phenotype-genotype-correlations to enhance the validity of results of genetic analysis, minimize the risk of misinterpretation and enable faster diagnosis in routine patient care. peripheral neuropathies are a group of clinically and genetically heterogeneous disorders, mutations in a large number of genes have been described so far. among patients with charcot marie tooth disease (cmt)/hereditary motor and sensory neuropathies (hmsn), a common duplication of the pmp gene on chromosome p is by far the most frequent mutation; sequence variants in the genes gjb , mpz and mfn account for a considerable proportion of patients but all other associated genetic variants are extremely rare. deletions of the pmp gene lead to hereditary neuropathy with liability to pressure palsies (hnpp) but transition between the different phenotypes may be rather fluid in some instances. next generation sequencing (ngs) has revolutionized cmt diagnostics as a large number of genes can be investigated at a time but it also leads to challenging questions. use of ngs has certainly improved the diagnostic yield in cmt diagnostics and it has repeatedly resulted in unexpected findings. broad molecular testing has already disclosed overlaps between clinical conditions and more surprising results are yet to come. here we report our recent experiences with the diagnostics of neuropathies. our results, different testing strategies, implications for clinical management and genetic counselling will be discussed and possible further steps suggested. (gerding et al., hum mol genet., ) . retinal ccdc protein expression in the wildtype (wt) mouse demonstrates highest levels shortly after birth. moreover, ccdc protein can also be detected early postnatally in mouse brain tissue. therefore, there is strong evidence that p-monog- *** individuals with hereditary trichilemmal cysts present a combination of an inherited high-risk plcd allele (including two sequence variants) and additionally acquired somatic plcd variants in the cysts. trichilemmal cysts are benign tumors derived from the outer root sheath of the hair follicle. they occur most often solitary or multiple on the scalp but can also be found on other body parts. the cysts can develop sporadically or in an autosomal dominant mode of inheritance with incomplete penetrance. in , the hereditary cyst form was mapped to the tricy locus on chromosome p -p . in a familial genome-wide linkage study. we analyzed affected individuals from different tunisian families by whole-exome sequencing. the bioinformatic evaluation revealed no rare, disease causing mutations but the sequence variant c. c>t, p.s l (maf = . , rs , enst . ) in the phospholipase c delta (plcd ) gene within the tricy locus. furthermore, all five individuals present a second variant c. a>g, p.p p (maf = . , rs ) in the same gene. plcd is a member of the phospholipase c family. the enzyme is involved in calcium-dependent intracellular signal transduction and catalyzes the hydrolysis of phosphatidylinositol , -bisphosphate into the second messenger diacylglycerol and inositol triphosphate. homozygous knockout-mice have hair defects and show aberrant skin development with increased progression of skin tumors and intradermal hair-follicle derived cysts. in humans, plcd is highly expressed in the hair follicle but so far only nonsense mutations have been described causing hereditary leukonychia totalis without any skin or hair abnormalities. a segregation analysis of plcd in a tunisian family cohort and one german family ( families, individuals, affected) showed that all affected individuals contain the same two sequence variants. based on these results, we propose that plcd is responsible for the cyst phenotype. cdna sequencing from three different cysts revealed additional acquired somatic sequence variants in plcd . we found c. c>t p.s l in two cysts and the two variants c. c>t, p.s f and c. c>t p.s f in the third one. all three somatic variants are not described in the exac database and the genomes project. allele-specific rt-pcrs were performed with cyst cdna and we could show that the somatic variants are on the same allele as the inherited variants. the acquired somatic cyst sequence variants lie within or respectively near the c domain of the plcd protein. the c domain is involved in the calcium-dependent binding to membrane-integrated phospholipids. depletion of the domain leads to decreased membrane association and protein activity. we assume that the allele with the variants c. c>t and c. a>g is a risk factor for hereditary trichilemmal cysts and that additional acquired rare sequence variants are the genetic trigger for the development of the cysts. and patients. discordant results for variants proposed a higher specificity of the rtpcr-seq. thus, we established a simple amplicon based deep sequencing approach for standard rtpcr fragments to ascertain the effects of specific splice site variants. this technique has proven to be highly scalable, fast and efficient to analyze splice-site variants. p-monog- eif s mutations associated with severe x -linked intellectual disability syndrome mehmo mehmo (mim % ), is a rare x-linked syndrome characterized by profound intellectual disability, epileptic seizures, hypogonadism, hypogenitalism, microcephaly, and obesity. in steinmüller and colleagues described a large family with mehmo syndrome with five affected males in two generations and assigned the disease locus to the short arm of chromosome x (xp . - . ). we took advantage of massively parallel sequencing in four families with mehmo syndrome, including the family reported by steinmüller et al. to identify the underlying genetic cause if this severe disorder. we here show mehmo syndrome is associated with mutations in the x chromosome gene eif s . in three families we identified a c-terminal frameshift mutation (p.ile serfs) and in an unrelated boy who is less severely affected, we identified a novel maternally inherited missense mutation (p.ser arg) in eif s . eif s encodes the gamma subunit of the eukaryotic translation initiation factor (eif ). eif is essential for eukaryotic translation initiation and regulation of the integrated stress response (isr). subsequent studies in patient fibroblasts (p.ile serfs) showed increased isr activation due to the mutation and functional assays in yeast demonstrated that the p.ile serfs mutation impairs eif gamma function to a greater extent than tested missense mutations, consistent with the more severe clinical phenotype of the affected males with ile serfs mutation. our results suggest that more severe mutations in eif s cause the full mehmo syndrome, while less deleterious mutations are associated with a milder form of the syndrome with only a subset of the symptoms. introduction: larger structural genomic duplications or deletions (copy number variations = cnvs) are routinely detected by array comparative genomic hybridization (acgh). while acgh has been established as a robust and effective approach for cnv screening, it remains expensive and is limited by resolution. in addition, commercial mlpa testing today allows the identification of exon deletions or duplications for a limited number of core genes. more recently, massive parallel sequencing of multi gene panels (mgps) has been introduced as a fast and cost-effective tool in routine genetic diagnostic testing to identify causal intragenic sequence alterations not only in core genes but also in those with small contribution to the respective phenotypes. the obtained mgps data may also be bioinformatically assessed to detect exon deletions or duplications within the analyzed genes panels and thus can be expected to further improve the diagnostic yield. methods: more than patients were sequenced with phenotype specific gene panels on a miseq platform (illumina) and analyzed with our bioinformatic diagnostic workflow including a quantitative data assessment using our in house java based bioinformatic script to search for gene or exon deletions. detected deletions were confirmed by an independent method (e. g. mlpa, pcr amplification of the junction fragment or linkage analysis), if available. results: we here report details for six suspected deletions in seven patients detected by our in house bioinformatic workflow: heterozygous gene deletions of pafah b , spastin or arfgef , respectively; two heterozygous cftr deletions of exon and , one homozygous partial sftpb deletion and a homozygous ispd exon deletion. the complete gene deletions of pa-fah b and spastin as well as the cftr deletion of exon and could be confirmed by mlpa. for the partial sftpb deletion both breakpoints could be precisely located within the readout, allowing determining correct deletion size and design of primers to amplify the junction fragment. the homozygous deletion of exon in the ispd gene could be confirmed by pcr and linkage analysis. discussion: diagnostic multi gene panel sequencing after nextera enrichment allows sufficient homogeneity of the obtained patient and control data per target to quantitatively search for constitutional deletions covering two or more adjacent targets. combined data assessment considering the individual clinical data will not only further increase the diagnostic yield but can also be expected to further delineate the mutational spectrum for specific phenotypes by the simultaneous detection of clinically relevant sequence variants as well as cnvs. mgps sequence assessment may also allow to gain new insights into the genomic architecture and origin of target regions and haplotypes, involved in common structural variations. c. niemietz, v. sauer, l. fleischhauer, s. guttmann, s. reinartz groba, a. zibert, h. schmidt universitätsklinikum münster, klinik für transplantationsmedizin, münster, germany various types of somatic cells have been reprogrammed to induced pluripotent stem cells (ipsc) followed by differentiation into hepatocyte-like cells (hlc). recently, cells that shed from the renal epithelial system were shown to be a suitable and convenient source for ipsc generation. in the current study, urine-derived cells (ucs) were isolated from urine donations of patients having familial amyloid polyneuropathy (fap), a neurodegenerative disease caused by mutation of the transthyretin (ttr) gene and wilson disease (wd), a genetic disorder of atp b causing copper accumulation, predominantly in liver and brain. patient-specific hlcs were differentiated in order to study disease-specific mechanisms and to investigate the efficacy of novel compounds. for isolation of renal epithelial cells, urine of fap and wd patients was processed. ucs were reprogramed into ipscs using plasmids resulting in transient expression of factors sox , oct / , klf , and c-myc. after characterization of ipsc that expressed high levels of pluripotency markers, like oct and nanog, a -step hepatocyte differentiation protocol was performed. ipscs were subjected to a treatment with growth factors (activin a, wnt a, fgf , hgf) for days. the hepatic, patient-specific character of differentiated hlcs was assessed by functional analysis, gene expression profiling, genotype analysis, and immunostainings. therapeutic oligonucleotide efficacy targeting ttr was determined by immunocytochemistry, qrt-pcr and western blot analysis. ttr-stabilizing activity of tafamidis was investigated by means of thermal shift assay and western blot analysis. copper chelation by methanobactin was determined by atomic absorption spectroscopy. reprogramming of ucs resulted in stable ipsc lines with characteristic pluripotent marker expression. differentiated hlcs showed high similarity to human hepatocytes in terms of genetic profile and functional activity. small-interfering rnas (sirnas), antisense oligonucleotides (aso) (niemietz et al. , plosone ( ) :e ), and the ttr stabilizing compound tafamidis that are currently assessed in clinical studies were studied in hlcs derived from fap patients. a novel chelator was used to determine intracellular copper accumulation in hlcs derived from wd patients (lichtmannegger et al. , jci ( ): - ). fap-specific hlcs revealed differently expression of key regulators of the protein quality control (pqc) system. our results demonstrate that ipsc derived from urine are excellently suited to study hereditary liver diseases. hlcs could be investigated in the patient-specific genetic background. the efficacy of novel compounds was assessed and individual responses were monitored. involved in gene regulation. by parent-patient trio whole-exome sequencing, we were able to characterize the unterlying genetic cause in the patient, who has undergone multiple diangostic test before without receiving a diagnosis. discussion: although for many congenital syndromic diseases the disease-associated genes are known it remains difficult for physicians to interpret the highly variable phenotypes as well as their variable nomenclature in order to request the appropriate molecular analysis. here we present one of more than cases that will help to establish a database connecting specific phenotypes, using the human phenotype ontology terms, with the each corresponding disease-causing genes (midas). novel compound heterozygous nalcn variants in two brothers with muscular hypotonia and global development delay l. segebrecht , c. weiß , m. jäger , , t. zemojtel , , , d. horn , n. ehmke , institute of medical and human genetics, charité -universitätsmedizin berlin, berlin, germany, spz dpt. pediatric neurology, charité -universitätsmedizin berlin, berlin, germany, berlin-brandenburg center for regenerative therapies -bcrt, charité -universitätsmedizin berlin, berlin, germany, institute of bioorganic chemistry, polish academy of sciences, poznań, poland, labor berlin -charité vivantes gmbh, berlin, germany, berlin institute of health, berlin, germany we report on two brothers aged two and three years, with muscular hypotonia, global development delay, abnormal respiratory rhythm, mild facial dysmorphism, recurrent respiratory infections, and failure to thrive. sequencing of disease related genes identified compound heterozygosity for two novel mutations in nalcn: c. c>a (p.phe leu) and c. + t>c. nalcn encodes a voltage-independent, non-selective cation channel, which is involved in regulation of neuronal excitability. the missense variant c. c>a affects the highly conserved amino acid position phe which is located in segment s of domain iv in the pore-forming unit of nalcn. the variant c. + t>c alters the donor splice site in intron and is predicted to cause skipping of exon , resulting in loss of function of nalcn. biallelic mutations of nalcn are associated with infantile hypotonia, psychomotor retardation and characteristic facies (ihprf ), whereas heterozygous de novo mutations cause congenital contractures of the limbs and face, muscular hypotonia, and global developmental delay. the clinical features of our patients resemble mild ihprf , caused by a biallelic missense mutation in segment s of domain iv. it has been suggested that variants in or close to s and s of the pore-forming domains lead to the above mentioned autosomal dominant condition whereas variants in other regions or loss of function mutations result in autosomal recessive inheritance. this is the first report of a mutation in a s segment, inherited in autosomal recessive manner. our findings indicate that phenotype-genotype correlations in nalcn are more complex than suggested so far. phenotype: in a young undiagnosed patient with developmental delay, intellectual disability and craniofacial dysmorphic anomalies, whole-exome sequencing (wes) identified a de novo insertion in the gene arid b, known to cause the rare congenital coffin-siris syndrome and nicolaides-baraitser syndrome, respectively. methods: as part of the midas genotype-phenotype-correlation project, we sequenced the index patient and his healthy parents on a next-seq platform (illumina, san diego, ca, usa) and performed a trio analysis. for library preparation we used an enzymatic fragmentation approach. exome capture was performed using the sureselect human all exon kit v (agilent, santa clara, ca, usa) to target most of the over . genes. the libraries were sequenced to approximately -fold mean coverage as bp paired end reads. % of the target region was covered -fold or higher. data analysis and variant evaluation was performed using the clc genomic workbench . (qiagen, hilden, germany) and annotations from commercial as well as public databases (dbsnp, hgmd, clinvar, exac). results: we identified a de novo bp insertion in the arid b gene, causing a frameshift mutation that leads to the truncated protein. arid b is part of the atp-dependent chromatin remodeling baf-complex, which is abstracts tient affected by psoriasis carried the surrogate marker snp rs -a for the psors risk variant hla-cw haplotype homozygously; and the same snp was found heterozygous in his prp-affected father. neither the pathogenic variant in card , nor the risk variants for psoriasis described above were found in the healthy mother. whole exome sequencing revealed genetic variants, predicted to have serious consequences in further genes involved in the nf-κb as well as the notch pathway. these variants either segregate with prp or are present in the psoriasis affected individual only. the presence of an individual carrying the same card mutation as his prp-affected relatives but suffering from psoriasis instead strengthens the relation between prp and psoriasis, which has been repeatedly suggested in literature. we propose a balance between familial prp and psoriasis in the family investigated in this study and present genetic variants, which might influence this balance in addition to variants in card . wilson's disease (wd) is an autosomal recessive disease resulting from copper (cu) excess due to mutations in the atp b gene coding for a cu-transporting atpase. wd pathogenesis, however, can not only be explained by gene coding mutations since phenotypes exhibit strong variations despite the same exonic dna makeup in the gene. also in several patients with clinical wd symptoms no gene coding variants are detectable. our former studies revealed decreased liver atp b mrna expression in some wd patients. this decrease was not only observed in patients with nonsense atp b mutations leading to rapid mrna decay, but also in patients with missense mutations and also in some patients with suspected wd without atp b mutations. patients with low atp b expression presented with a more fulminant disease progression. however, we could not detect mutations in the atp b promoter region (c.- to atg) in those patients. there are possibly other deregulating mechanisms responsible for decreased atp b mrna expression. up to now, atp b transcriptional regulation is only poorly characterized. it is known, that four metal responsive elements (mre a, c, d and e) are located within the atp b promoter. gene regulation through mres is often metal-dependent. liver atp b mrna expression revealed also to increase under cu addition in several species by an unknown mechanism. up to now, only one atp b transcription factor (tf), the mrea binding ku protein, is known. the aim of our work was to further analyze the regulation of the atp b gene, especially through mres. to screen for tf-mre interactions and to narrow down the binding site of tf, we performed electrophoretic mobility shift assays (emsa) by incubating nuclear extracts of the liver cell line hle with probes corresponding to atp b mrec, d and e. to identify mre-binding tf matinspector analysis was performed. identified candidate tf were coexpressed with atp b promoter-driven reporter gene to evaluate their impact on reporter gene expression. one in the reporter assay positively tested tf was validated by different emsa experiments. further it was overexpressed with and without addition of metal ions in hle to investigate the impact on endogenous atp b expression. we showed that tf mtf is able to bind to mree within the atp b promoter and significantly increases atp b promoter driven reporter gene expression. mtf binding was primarily mediated by the first three bases of the mre consensus sequence. also for mrec and mred specific protein interaction could be shown and the protein binding site was narrowed down by emsa with protein identification still pending. fur-polyglutamine diseases is the formation of the so called neuronal intranuclear inclusion bodies (nii). as ataxin- is predominantly located in the cytoplasm, the formation of protein aggregates in the nucleus require a nucleocytoplasmic shuttling of ataxin- . we already demonstrated in vivo using transgenic mouse models that the toxicity of expanded ataxin- depends on its intracellular localization: while nuclear ataxin- gave rise to a strong phenotype with a high number of protein aggregates, purely cytoplasmic ataxin , however, even with a highly expanded polyglutamine repeat ( glutamines), was not able to induce a phenotype and even did not aggregate. we further identified and characterized intracellular transport signals (two nuclear export signals, nes, and one nuclear localization signal, nls) within the coding sequence of ataxin- . therefore, it is evident that proteins involved in the nucleocytoplasmic transport machinery recognize these localization signals, control the intracellular localization of ataxin- , thereby influence the toxicity and aggregation of ataxin- and, thus, the pathogenesis of sca . we now screened a library of transport proteins in order to identify the transport protein which is critically involved in the nucleocytoplasmic shuttling of ataxin- . we indeed identified a transport protein which modifies both the formation of aggregates and the intracellular localization of ataxin . while the overexpression of this protein moved ataxin- into the nucleus, its downregulation kept it out of the nucleus. we replicated this correlation in vivo in drosophila and observed in addition to this again a clear link between the intracellular localization of ataxin- and its toxicity i. e. its ability of induce neurodegeneration and a behavioral phenotype. likewise we even confirmed in a mouse model of sca the importance of the identified transport protein as its knockout largely prevented ataxin- from aggregating and alleviated behavioral and movement deficits. understanding the mechanisms behind the intracellular transport of ataxin- could give us clues into the pathogenic functions of expanded ataxin- and ways to mediate the progression of neuronal degeneration in sca . evidence for genetic factors outside card influencing the phenotype of a family with familial pityriasis rubra pilaris and psoriasis familial pityriasis rubra pilaris (prp) is an erythematous inflammatory skin disease caused by heterozygous activating mutations in card , a known activator of the nf-κb pathway. different genetic variants within card have been associated with psoriasis. the purpose of our study was to clinically and genetically investigate affected as well as unaffected members of a family with prp in order to determine the mutation responsible for this severe skin disease in the three affected family members. a father, three of his adult children as well as the mother of one child affected by prp were investigated clinically. in addition we extracted genomic dna from the blood of each individual and performed whole exome sequencing as well as direct sequencing of single genes. clinical investigation confirmed that the father and two of his children were affected by familial prp, with the skin showing the characteristic pattern of prp, early onset and chronic course. a third child was unaffected by prp, suffered however from psoriasis. the mother of one child affected by prp showed no sign of skin disease. genetic investigation revealed a heterozygous missense mutation in exon of card , c.[ c>t], p. present in all investigated individuals with prp or psoriasis. the same mutation has been described before as being pathogenic in a different family with prp. regarding genetic variants associated with psoriasis, we found the risk alleles of three coding variants in card : rs , c. short stature is a common condition of great concern to patients and their families. in most cases it is genetic in origin but the underlying cause often remains elusive due to clinical and genetic heterogeneity. in an unbiased approach we carefully phenotyped patients and randomly selected for whole exome sequencing. sequence variants were analyzed for pathogenicity and the affected genes characterized regarding their functional relevance for growth. all patients received extensive clinical and endocrinological examinations, careful clinical genetic phenotypic evaluation followed by targeted diagnostic assessment for suspected diagnoses. we identified a known disease-cause in only % of patients, the most common causes being cnvs found in %, followed by syndromic monogenic causes in % and turner syndrome in %. whole exome sequencing identified additional mutations in known short stature associated genes ( ) in % of patients who manifested only part of the symptomatology precluding an early clinical diagnosis. here, heterozygous carriers of recessive skeletal dysplasia alleles (acan, npr ) were a surprisingly frequent cause of idiopathic short stature found in . % of cases. we next selected known short stature genes with mutations for pathway analyses of the affected proteins and found that % are involved in the main functional categories cartilage formation, chromatin modification and ras-mapk signaling. in addition we identified further strong candidate genes, of which seven had deleterious mutations in at least two families. interestingly, % of these candidate genes are involved in the main functional categories already identified for the known short stature associated genes further supporting their pathogenicity. finally, in % of the sequenced individuals our findings were of significant clinical relevance regarding preventive measures, symptomatic or even targeted treatment. besides evaluation for orthopedic or developmental issues especially screening for neoplasias (trim , ptpn , nf ), symptomatic treatment for chronic kidney disease (clcn ) and targeted treatment for severe hypertension (pde a) were of clinical relevance for the affected individuals. these results demonstrated that deep phenotyping combined with targeted genetic testing and whole exome sequencing is able to increase the diagnostic yield in short stature up to % with concomitant improvement in treatment and prevention. rigorous variant analysis considering phenotypic data further led us to the identification of further probable novel candidate genes. thermore, we found the endogenous atp b mrna expression to be significantly increased in hle after cu treatment or cu treatment and concurrent mtf overexpression. sole mtf overexpression did not alter atp b expression. we newly identified mtf to bind mree within the atp b promoter. its in vivo role in the pathogenesis of wd needs to be further elucidated. modifying genes have been identified for lung function in cystic fibrosis [ ] , disease severity [ ] and several comorbidities [ ] . within the european cf twin and sibling study, we focus on genes that modify the basic defect, assessed as defective chloride conductance in cftr-expressing epithelia, which we could describe by an association study on patient cohorts selected for informative endophenotypes among f del-cftr homozygous patients [ , , ] . as a first example, rs in fas modifies fas gene expression (p = . , data from intestinal biopsies [ ] ), cf disease phenotype (praw = . , comparing concordant mildly affected f del homozygous sib pairs and concordant severely affected sib pairs; praw = . , comparing unrelated f del homozygous index cases without residual chloride secretion by nasal potential difference measurement (npd) to patients with cftr-mediated chloride secretion; [ ] ) and alters binding affinity for the transcription factors nf-kbp , nf-kbp and hif a [ ] which govern the cellular response to infection and hypoxia. as a second example, the transcription factor ehf, derived as a positional candidate from a north american genome wide scan [ ] , is associated with npd-defined phenotypes (praw = . , comparing index cases with high response to amiloride in npd to index cases with low response to amiloride in npd; praw = . , comparing index cases without chloride secretion in intestinal current measurement (icm) to index cases with cftr-mediated residual chloride secretion in icm [ ] ) and affects the transcriptome of cf patients' intestinal biopsies in favor of a better processing of f del-cftr [ ] which we could confirm in epithelial cell lines as sirna provided against ehf results in a downregulation of mgat and mgat , both of which are key enzymes for the complex glycosylation of proteins such as cftr. these examples indicate that small, albeit carefully selected subpopulations facilitate the identification of genetic variants by an association study that can be validated in functional assays. furthermore, we suggest that while the selection of subsamples within a population with a rare disease such as cystic fibrosis results in a loss of power, findings obtained for more than one endophenotype are indicative for a true-positive finding of a modifying gene. finally, transcriptional regulation influences the cf basic defect. interference with these pathways may results in better f del-cftr maturation, leading to better cftr function in patient's tissue and thereby promoting health in cystic fibrosis. funding by: deutsches zentrum für lungenforschung dzl; mukoviszidose institut ggmbh abstracts at presentation at age years her head circumference was on the th centile, her height below the rd centile, and her weight on the rd centile. she showed a disproportional short stature and mild skeletal signs like clinodactyly of the ths fingers. minor facial dysmorphisms included an oval face, epicanthic folds, upslanting palpebral fissures and a bulbous nose. karyotype was normal and copy number variants were excluded by high-resolution cma. as no aetiological diagnosis could be made clinically we performed whole exome sequencing (wes) and detected a homozygous splice site mutation (c. + g>t) in pik c a (phosphatidylinositol- -phosphate -kinase catalytic subunit type alpha) (nm_ ). sequencing of rt-pcr products from cdna of patient's fibroblasts showed in-frame skipping of exon and , equally affecting all known isoforms. phosphatidylinositol -kinases (pi ks) are lipid kinases involved in a large set of biological processes, including membrane receptor signaling, cytoskeletal organization, and endocytic trafficking. pi kc a is ubiquitously expressed and has been proposed to play an important role in clathrin-mediated endocytosis and regulation of phosphatidylinositol -phosphate (ptdins p) levels. furthermore pik c a has been implicated in the biology of the primary cilium. the patient's distinct phenotype resembles the previously described phenotype in pik c a hypomorphic mice with pre-and postnatal growth retardation and a broad spectrum of renal abnormalities. the complete knockout of mouse pik c a showed embryonic lethality. ongoing studies on the exact consequences of the splicing defect will determine if and how much residual wild-type transcript is retained and if this is a hypomorphic variant. this case is to our knowledge the first description of a pik c a human phenotype. adaption of the crispr/cas genome editing system as a platform for the mutation of nipal as a representative of arci-associated genes in hela cells n. ballin, m-a. rauschendorf, j. fischer institute of human genetics, freiburg, germany autosomal recessive congenital ichthyosis (arci) is a rare genetic disorder with known disease-causing mutations in genes. functional implementations of identified mutations are in most cases still unknown, which is amongst others due to the limited amount of skin biopsies of arci-patients. thus, suitable cell culture models for the investigation of keratinocyte differentiation are highly needed. during the last years the prokaryotic clustered regularly interspaced short palindromic repeats (crispr)/crispr-associated (cas) system has been turned into a potent tool in the field of genome engineering. the cas endonuclease is directed by a short guide rna (grna) to its target sequence, where it generates a dna double strand break (dsb). as cellular repair mechanisms often fail in reconstituting the original sequence, insertion/ deletion (indel) mutations occur potentially leading to a complete gene knock-out (ko). consequently, the crispr/cas system offers a simple rna-programmable tool for in vitro mutation of arci-associated genes. hence, this system was applied in hela cells to target nipa like domain containing (nipal ), the second most frequently mutated gene in arci patients. in this context, functional studies were used to validate nipal as suitable target in hela cells. successful application of the crispr/cas system lead to the generation of a new clonal hela cell line carrying a one basepair insertion in nipal exon (c. insg (ccds . ) ). this mutation was further characterized and potentially results in a complete ko of nipal . this system can now be used as a basis for targeting further arci-associated genes and for transferring the system into keratinocytes, which are the amyotrophic lateral sclerosis (als) is a late-onset progressive, neurodegenerative syndrome. most als cases are sporadic (≈ %). in familial forms, mutations in several different genes have been identified with a repeat expansion in c orf and mutations in sod being the most prevalent. no non-genetic cause of als has been identified. since there are no overt clinical or pathoanatomical differences between sporadic or familial cases, de novo mutations have been suggests in disease pathogenesis and two previous studies provided some evidence for this hypothesis. we present data of patient-parents trios from an international collaborative study. by whole exome sequencing we identified non-synonymous de novo mutations in the patients, however all of them occurred in different genes. there was no concordance between the mutated genes found in our trio set and the two earlier smaller trio studies. in silico analyses suggest that none of the here identified mutations are part of any of the previously postulated molecular pathways. also, gene-gene-interaction analyses failed to find an enrichment of interacting genes. lastly, we demonstrate that the de novo mutations in als patients in this and the two earlier studies are located in genes prone for de novo mutations in general. our results thus indicate that, in contrast to previous reports, de novo mutations do not seem to be a major contributor for als. disproportioned short stature and multiple anomalies in a patient with a homozygous pik c a mutation -a new ciliopathy? we present a year old female with disproportional growth retardation, eye and renal anomalies. she was born small for gestational age as the first child of healthy, consanguineous tunisian parents at weeks after an uneventful pregnancy ( g, cm). during her first year of life, there were severe feeding problems with regurgitation and she developed postnatal growth retardation. developmental milestones were normal. during the second year the girl developed strabismus in both eyes. later on, a cataracta polaris anterior, anomalies of the cornea, hyperopia and progressive retinal degeneration led to profound visual impairment. furthermore, a right kidney agenesis and a complex tubulopathy, as well as increased echogenicity of the single left kidney were diagnosed. r. brumm, m. schmuck, y. dinçer, s. schulz, s. wilson, i. rost, hg. klein, sh. eck center for human genetics and laboratory diagnostics dr. klein, dr. rost and colleagues, martinsried, germany next-generation sequencing may lead to a significant improvement in diagnostic yield for rare, heterogeneous disorders through the ability to simultaneously sequence all genes contributing to a certain indication at a cost and speed that is superior to traditional sequencing approaches. on the other hand, the practical implementation of ngs in a clinical diagnostic setting involves a variety of new challenges which need to be overcome. among these are the generation, analysis and storage of unprecedented amounts of data, strict control of sequencing performance, validation of results, interpretation of detected variants and reporting. especially the variant interpretation emerges as current bottleneck of the diagnostic workflow. here we present midas (multiple integration of data annotation software), a central software system for data integration in a diagnostic laboratory. the goal of midas is to construct a modular software system to integrate data from laboratory information management system (lims), data from the routine sanger sequencing workflow as well as ngs sequencing results and correlate the identified variants with the patients' phenotypical features to aid in variant interpretation and accelerate reporting. the phenotype is systematically recorded using the human phenotype ontology standard nomenclature. in particular, genotype-phenotype correlations identified in one patient are made available for all other cases, to aid the interpretation and build a comprehensive knowledge base. the midas software may thus serve as central information system all diagnostic patient data. midas is implemented in java using direct database access via jdbc, and javafx as graphical user interface. its architecture is designed modular including a dynamic module loader, a user management with ldab connection and basic search functionality. according to available modules the user management and search form are adjusted; granting access for module specific views. as an advantage of this architecture, other molecular diagnostic data, such as arraycgh or mlpa results can easily be integrated by implementing new modules. midas aims to aid molecular diagnostics by simplifying and accelerating data analysis and interpretation, improving patient care. midas is being developed as part of a prospective multicentric study including clinical, diagnostic and software development partners. a grant by the bavarian ministry of economy, media, energy and technology is used to fund this effort. institute of human genetics -medical faculty -rwth aachen university, aachen, germany, izkf aachen -rwth aachen university, aachen, germany with the implementation of next generation sequencing (ngs) based assays as key tool in dna-sequencing, conventional sanger-sequencing has become a standard method to verify single nucleotide polymorphisms (snps) of interest. however, designing specific pcr-and sanger-sequencing primers has always been a rather time consuming task in terms of searching the right genomic sequence, considering known snps that could result in allele-specific amplification, and converting selected primer-sequences to upload them to web-based services. to circumvent this, we developed optimus primer, a python script, that automatically designs respective primers. the script uses the database of the ucsc genome browser to download positional information of genomic sequence (refseq gene: hg ) and common snps (snp common: hg ) in the region of interest. the genomic sequence is downloaded via the ucsc primarily affected cell type in the skin of arci patients. furthermore, it is only a small step to expand the system from generating gene ko to gene editing allowing the introduction of patient-specific mutations in non-patient derived keratinocyte cells. hence, setting-up the crispr/cas system to target an arci-associated gene is an important starting point for future studies to investigate pathogenic effects of arci-causing mutations and to understand arci pathogenesis on a molecular level. in this context, the transfer of the established protocol into keratinocytes offers the possibility to generate d cell culture models of mutations in arci-associated genes and allows in vitro investigation of their implications on the differentiation process. this system would further represent an organotypic model of arci-disease with potential application in screening and identification of chemical compounds for the complementation of existing clinical therapies. background: telomeres cap and protect chromosome ends from degradation and fusion, and are therefore essential for maintaining chromosome stability and genomic integrity. they have a length of to kb (depending on age, sex and cell populations). due to the end-replication problem there is a continuous telomere loss of to bp/cell cycle and thus throughout lifetime. in laboratory practice different methods of telomere length measurement are used to identify patients with bone marrow failure syndromes (e. g. dyskeratosis congenita, aplastic anemia), hematological diseases, or other telomeropathies. each telomere length measurement method has its advantages and disadvantages regarding material required the complexity and feasibility of the method and other parameters. methods: in this study we compared and validated four different methods for telomere length measurement, i. e. southern blot analysis, quantitative pcr (qpcr), quantitative fluorescence in situ hybridization (t/ c-fish) and flow cytometry-fish (flowfish). whenever possible, edta and/or heparin blood samples were collected from a population of healthy individuals of different age groups (newborn - years). depending on the method dna (southern blot and qpcr), metaphases (t/ c-fish) or rather vital cells (flowfish) were analyzed. results: comparison and validation of the telomere length measurement methods allowed us to calculate percentiles for all age groups. percentile curves could be used in diagnostic to identify patients with short telomeres. all methods showed acceptable accuracy, but equally imply the necessity of validation and appropriate controls in each experiment. here, flowfish was the most precise, accurate and reproducible method compared to the other methods. discussion: our study emphasizes the influence of expertise and experience that is required in order to produce robust and reliable telomere length analyses. here, we provide advice on how to choose the appropriate method in general and for individual cases to safely discriminate between natural variability and pathological telomere shortening in individual cases. in the next generation sequencing age, the strongest challenges have shifted from genotyping to handling the myriad of variants detected. whole exome sequencing yields tens of thousands of coding and non-coding variants, a number increased to millions if the whole genome is sequenced. to master this mountain of data, computer-based identification of potential disease mutations is absolutely indispensable. however, current computational strategies are usually generated by computer scientists without integrating human geneticists into software development. this often leads to tools which fulfil their main purpose but are not ideally suited to the needs of human geneticists. to assess the relevance of a suggested disease mutation, geneticists need detailed information about the effect on the protein and about the gene or protein itself. to close this gap, we have developed mutationdistiller, a web-based tool for user-driven variant prioritisation based on biological disease properties. its analysis includes the potential role of a mutated gene in pathogenesis as well as the estimated effect of a variant on gene/protein function. thus, mu-tationdistiller allows human geneticists to use every piece of information they consider relevant. unlike similar tools, its input goes beyond the human phenotype ontology and can include complete diagnoses, biological pathways, gene expression, and gene function. potentially harmful variants are identified by mutationtaster, which provides a deleteriousness score together with data on the actual effect of the variants. mutationdistiller is not restricted to non-synonymous variants but can also handle intragenic non-coding or synonymus variants. moreover, the program incorporates the known modes of inheritance of disease genes and the genotype of the queried variants (including compound heterozygosity). the output page provides all information on one site: the core component is a concise overview table of the most likely disease genes and variants. here, the most crucial information such as the variants' effect on the protein, frequencies in polymorphism databases and known diseases caused by mutations within this gene and their mode of inheritance are listed. more detailed gene and disease information and hyperlinks to external data are provided below, hence offering a comprehensive overview of the available knowledge. this allows geneticists to draw their own conclusions without any tedious collection of relevant information from the internet. a beta-version of the program is freely available at http://www.mutationtaster.org. m. jäger , , m. schubach , t. zemojtel , k. reinert , d. m. church , p. n. robinson , , institute for medical and human genetics, charité, berlin, germany, bcrt, berlin, germany, institute for bioinformatics, department of mathematics and computer science, freie universität, berlin, germany, x genomics, pleasanton ca, united states, department of mathematics and computer science, freie universität, berlin, germany, the jackson laboratory, farmington ct, united states with the grch human genome release in the genome resource consortium extended the previous linear, "golden-path" paradigm of the human genome and introduced a more graph-like model in the sense of regions with alternate loci, representing common alterations in sequence and structure. in whole-genome sequencing (wgs) these stretches of sequence are largely but not entirely identical between the primary assembly and an its corresponding alternate locus can result in multiple variant calls against regions of the primary assembly. this results in characteristic and recognizable patterns of variant calls at positions that we term alignable scaffold-discrepant positions (asdps). we developed an algorithm (asdpex) that analyzes these patterns in the structurally variable regions of the current grch genome assembly. a heuristical approach then infers whether the pattern of variant calls of a sample contains sequences from the primary assembly, an alternative locus, or their heterozygous combination at each of these regions. api and common snps are annotated. in the following step primers are picked using primer (whitehead-institute). the target sequence is either the snp-containing exon in case of exons smaller than bp, or, the genomic region flanking the snp of interest. the positional information of the snp is gathered using the mutalyzer api (lumc). the last two bases of each primer are checked for all snps in the ' end (snp : hg ). the script will be integrated into a website for free easy access and usability (www.optimus-primer.com). the only information needed is the refseq id, the exon, and the cdna position (eg: nm_ . . :c. t>g). the script optimus primer will provide the user with primers in the widely used primer format. the users are also able to download the source from our website, and to run it on a local unix system as a command line tool. mutationtaster : moving towards a comprehensive evaluation of disease causing mutations o. ebner, jm. schwarz, d. hombach, m. schuelke, d. seelow charitè universitätsmedizin, berlin, germany mutationtaster is a free and user-oriented application for comprehensible evaluation of non-synonymous and synonymous as well as non-coding dna sequence variants. as + citations show, the software has been strongly embraced by the clinical and research community. however, its capacities for assessing the functional consequences of non-coding variants are still limited. while mutationtaster is able to predict the variant's effect on major intragenic regulatory features such as splice sites or polyadenylation signals, many other potential effects of intronic or utr variants are not covered by the software yet. variants in the non-coding region of the genome are frequent and thought to cause a substantial part of yet unsolved mendelian diseases. these variants can occur either in extragenic regulatory regions (see abstract on regulationspotter) or in the untranslated regions, including introns, of a gene. unfortunately, their effects are much harder to predict than those of non-synonymous variants. therefore, only few disease mutations outside the coding sequence have hitherto been found and experimentally confirmed. to close this gap, we are advancing the current version of mutationtaster to improve the analysis of intragenic non-coding variants. we do so by implementing additional tests for variants in the ' and 'utr to determine their effect on au-rich elements, microrna binding sites and the influence of secondary structure on gene expression. moreover, we plan to shift from the analysis of exclusively monogenic to complex diseases with cancer being the first disease model to be integrated into mutationtaster . already implemented enhancements of mutationtaster comprise the improved splice site analysis using maxentscan and the integration of mitochondrial polymorphisms from the human mitochondrial genome database. the addition of links to the integrative genomics viewer and the lof-metrics of the exac browser (exome aggregation consortium) streamline the usage of the mutationtaster results and enable researchers to get a detailed view of the relevant variants and associated genomic sequences. taken together, mutationtaster will offer much better capabilities to predict the disease-causing potential of intragenic variants than its predecessor. the software is freely available at http://www.mutationtaster.org neurocure exzellenzcluster, berlin, germany, neuropädiatrie charité-universitätsmedizin, berlin, germany, medizinische genetik charité-universitätsklinikum, berlin, germany, berliner institut für gesundheitsforschung bih, berlin, germany ifications, or genome-wide interactions. all variants which have the potential to influence one or several candidate genes are presented in a graphical interface and ranked according to their predicted effect on the target gene(s). instead of giving scores, we present the potentially affected regulatory features in an intuitive graphical matrix. the software can freely be used at http://www.mutationtaster.org p-techno- genecascade -a one-stop shop for finding disease mutations d. seelow , in the last years, our genecascade software suite for the elucidation of rare diseases has seen some major extensions, mainly for the discovery of non-coding mutations. the website contains a number of tools focusing on the different steps in studying genetic disorders. all applications are web-based, have easy-to-use interfaces and are aimed directly at human geneticists, without any need to install software, use the command line or to try to explain clinical features to it specialists. we think that software should adapt to the user -not the other way around. and, unlike other web shops, its use is completely free. homozygositymapper finds disease-linked regions in consanguineous families. users can upload genotypes from snp chips as well as wes and even wgs data. we display likely disease loci in intuitive graphical interfaces. the results can also be used in our 'downstream' applications such as genedistiller, mutationtaster, or mutationdistiller to identify the actual disease mutation. genedistiller provides a user-driven way to find the best candidate gene for a genetic disorder. users can specify various aspects of the patients' phenotypes and the results are presented in a comprehensive way without the need to manually query other internet resources to collect further information relevant to asses the disease potential. mutationtaster evaluates the disease potential of non-synonymous as well as of non-coding and synonymous dna variants within genes. it does not only display a prediction but also detailed information on the variants' likely effect on mrna and protein. it can either analyse single variants as found by sanger sequencing or complete vcf files from wes or wgs projects. regulationspotter lists information about potentially regulatory dna variants outside of genes. variants are ranked according to their predicted effect on gene regulation. in addition to a score, we provide a user-friendly summary of the functional effects a variant may have. mutationdistiller combines genedistiller and mutationtaster in a single application for convenient variant and gene prioritisation. it offers human geneticists much more freedom to enter the phenotype than similar applications and provides deeper information about the variant and the gene. cnvinspector is aimed at the study of copy number variants. users can upload their patients' (or cohorts') cnvs and compare them with their own healthy controls or public data stored in our database. we include deci-pher to indicate known diseases caused by cnvs at the same position. epossum examines the effect of dna variants on transcription factor binding. as tf binding site prediction is notoriously unreliable, we also give an indication of the statistical relevance of a result. the genecascade website can be accessed at http://www.mutationtaster.org. we investigate in-house wgs datasets and found that on average . ± . of the regions correspond to an alternate locus rather than the primary assembly sequence. filtering these genomes with our algorithm identified around variant calls per genome that colocalized with asdps. our findings suggest the potential of fully incorporating the resources of graph-like genome assemblies into variant calling. our algorithm already uses the information contained in the structurally variable regions of the grch genome assembly to avoid spurious variant calls in cases where samples contain an alternate locus rather than the corresponding segment of the primary assembly. the human phenotype ontology project provides three resources, the ontology of clinical features, disease-phenotype associations and algorithms that enable analysis of data that is described using hpo. this resource is being used for computational deep phenotyping and precision medicine. it enables clinical data integration for translational research. the hpo is being increasingly adopted in software, research projects and companies world-wide. we will discuss the progress and recent developments that the hpo project has made since . this will include the expansion of hpo for common (complex) diseases, novel algorithms for phenotype-driven analysis of genomic variation, cross-species mapping of phenotype data, translation of hpo into several languages and also the addition of a more patient-friendly terminology for hpo terms. millions of patients worldwide suffer from a rare genetic disease. to date, the omim database lists more than diseases with proven or suspected mendelian basis, but the molecular cause is known for less than %. although next generation sequencing has drastically facilitated the discovery of disease mutations, a substantial fraction of whole exome sequencing (wes) projects fail to identify the causal variant. this may be due to the fact that disease-causing mutations are not always located within the coding sequence. whole genome sequencing (wgs) could solve this problem, but we are not yet readily prepared to handle the vast amount of variants which are generated by this technique, as intuitive and reliable software solutions for variant evaluation are missing. the currently existing approaches are not well-suited for a diagnostic setting, because they output a battery of different scores whose interpretation is left to the users. however, human geneticists are specialists for the assessment of symptoms of genetic diseases -not for the analysis of numerical scores indicating different likelihoods of the occurrence of regulatory elements. this is especially true when it comes to the hundreds of thousands of extragenic variants found by wgs, for which effect predictions always face a high level of uncertainty. we consider it crucial to provide geneticists with the information they need to determine the significance of a variant, not to flood them with scores whose meanings are difficult to grasp. to facilitate the interpretation of extragenic variants, we are developing regulationspotter. in contrast to other approaches such as genomiser or cadd, we integrate as much knowledge as possible in a user-friendly fashion to pinpoint the variants which are most likely to disturb the expression of candidate genes. regulationspotter includes different data on regulatory dna elements such as dna methylation, transcription factor binding sites, histone mod-the human exon in the ' end of the murine huntingtin gene. by using a novel object recognition test with a h interval between sample and test phase we have found a profound deficiency of hippocampus dependent long-term memory in heterozygous transgenics. this phenotype was detected as early as weeks of age and is complementary to deficits that we have identified in the hdhcag mouse model previously. motor deficits as well as intranuclear aggregates are described at much later stages in both of these models. we have shown previously that in hd patients, mediated through mtor signaling, translation of mrna carrying expanded cag repeats is elevated (krauss et al., ) . we have also seen that the biguanid metformin antagonizes mtor signaling in neurons in-vitro and in-vivo (kickstein et al., ) . we show here that metformin, by interfering with the mtor kinase and its opposing phosphatase, pp a, regulates local protein synthesis in the brain and is able to suppress the production of disease making protein in early hd. furthermore metformin leads to a significant improvement of movement abilities in a c-elegans model for hd and to a rescue of early cognitive symptoms in the hdhcag animal model. these data suggest that metformin is a very promising candidate for early phase treatment of hd patients. allele-specific suppression of dominant-negative bestrophin mutations a. milenkovic, lm. braun, f. grassmann, b. h. f. weber institute of human genetics, regensburg, germany purpose: retinal pigment epithelium (rpe) differentiated from human induced pluripotent stem cells (hipsc) demonstrated degradation and mislocalization of mutant bestrophin (best ) protein in autosomal dominant best disease (bd). importantly, mutated alleles revealed a dominant-negative effect leading to an impairment of volume-regulated chloride transport, the basic function of the homo-pentameric best channel. here, our study aimed for a proof-of-concept to treat bd by selectively eliminating best mutant transcripts in patient-derived hipscs prior to rpe differentiation via the crispr/cas genome editing technology. methods: adult human dermal fibroblast were obtained from skin biopsies of bd patients and reprogrammed into hipscs. single guide rna sequences (sgrna) targeting best mutations were selected by the "optimised crispr design tool" (zhang lab, mit ) . editing efficiency and specificity of designed sgrnas were tested in hek cells using an established fluorescence-based assay. after transfection of hipscs the percentage of indel formation of on-and off-targets was determined by a pcr-based crispr/cas cleavage detection kit. cas -treated stem cell populations were analyzed for pluripotency and selected for full genome sequencing before differentiation to rpe cells. results: computational design of disease-causing best variants (n k, v m, s r, q r, a v, and i del) offered at least one sgrna with predicted high quality per mutant allele. the guide sequences were cloned into the cas -expressing plasmid px and co-transfected with pcag-egxxfp plasmids containing genomic fragments of ~ bp of either the mutated or wildtype sequence to the corresponding sgrna. as targeted cas cleavage results in reconstitution of the egfp expression cassette by homology dependent repair, the efficiency and specificity of cas cleavage was evaluated on a plate reader by quantifying egfp fluorescence after h of transfection. as a result, out of the sgrnas tested showed high allele-specificity and are now used for targeted genome editing in hipscs. conclusion: so far, there is no treatment for bd although the molecular pathology of best has recently been established. our proof-of-concept study aims to determine whether haploinsufficiency of normal best protein is sufficient to fully or partly restore cellular function in cells of primary bd pathology, namely the rpe. to this end, we will determine the degree of rescue (i. e. reconstitution of volume-regulated chloride conductance) by whole-cell patch-clamp analysis. if successful, our crispr/ cas -driven approach will be useful to treat other diseases with dominant negative effects of the mutated allele. p-therap- *** metformin rescues early cognitive symptoms in the hdhcag mouse model and is therefore a promising candidate for treatment of hd patients. huntington's disease (hd) is an autosomal dominant neurodegenerative disorder that is caused by an unstable glutamine (cag) trinucleotide repeat expansion within exon of the huntingtin gene and leads to cognitive decline and affects motor abilities. in the prodromal phase of the disease patients develop mood swings, personality changes and subtle cognitive impairment. close understanding of clinical signs and molecular mechanisms behind this early stage of hd is an important step for the development of a causal therapy. we have analysed a knock-in mouse model that carries cag repeats and single molecule molecular inversion probes for targeted, high-accuracy detection of low-frequency variation age-related clonal hematopoiesis associated with adverse outcomes clonal hematopoiesis and bloodcancer risk inferred from blood dna sequence age-related mutations associated with clonal hematopoietic expansion and malignancies cancer spectrum in dna mismatch repair gene mutation carriers: results from a hospital based lynch syndrome registry update on kleefstra syndrome characterization of a novel transcript of the ehmt gene reveals important diagnostic implications for kleefstra syndrome national institute of child health and human development abstracts p-monog- novel mutation in hoxc expand the mutation spectrum of pure hair and nail ectodermal dysplasia abstracts in conclusion, targeted sequencing represents an effective, fast, cost-efficient and flexible method, since new candidate genes can be added easily to the panel, for the sequential analysis in chh patients. furthermore, panel sequencing alleviates the uncovering of oligogenic inheritance in genetic traits like chh abstracts p-monog- neurodegeneration in the olfactory bulb and olfactory impairment in the ccdc -/-mouse model for retinal degeneration s. schreiber , e. petrasch-parwez one hallmark of sca and other mechanisms that govern ccdc -deficient degeneration, a detailed evaluation is performed in order to reveal processes that contribute to retinal degeneration during early postnatal development and adulthood. methods: the functional role of ccdc deficiency is investigated by two independent approaches: ) gene expression profiles at p and p are analyzed in retinal tissue of cccdc -/-and wildtype mice (genechip mouse gene . st array, affymetrix) followed by quantitative real-time pcr (qrt-pcr) and ) potential retinal interaction partners of ccdc protein are identified by yeast-two hybrid screening in the wildtype mouse and further analyzed by immunohistochemistry. results: using two screening methods (rna-expression profiles and protein interaction partners), our results indicate that ) the ccdc deficient mouse model reveals early changes in retinal rna gene expression already at p and the highest number of genes differential expressed at p . most expression differences were related to genes associated with the extracellular matrix. further genes are involved in retinal degeneration, angiogenesis, transcription factors and proteolysis. ) the ccdc protein interacts with the proteins eps (epidermal growth factor receptor kinase substrate ) and mpdz (multiple pdz-domain protein). both proteins are expressed in several retinal layers of the retina, confirmed by immunohistochemistry. moreover, mutations in the mpdz gene were already identified in patients with retinitis pigmentosa/leber congenital amaurosis. conclusion: expression profiles reveal expression changes at an early time point of retinal degeneration in the ccdc -/-mouse model enabling further studies on the role of genes and processes involved in early retinal degeneration. in addition, the interaction partners of ccdc , eps and mpdz, are the basis for further studies examining the pathways of retinal degeneration in the mammalian retina including man -and possibly contribute to future studies in man and human disease. ccdc null mutation causes retinal degeneration and dysfunction of medical and molecular genetics and skeletal dysplasia multidisciplinary unit hospital unit of genetics of neurodegenerative and metabolic diseases sel- , ws - , p-compl- ws - p-cling- , p-cling- ws - , ws - , p-cling- , p-cling- , p-cling- ws - , p-cling- , p-cling- , p-monog- p-cancg- p-cling- , p-cling- , p-cling- p-cling- , p-cling- ws - , ws - , p-cling- ws - , p-cling- p-cancg- , p-cancg- , p-cling- ws - medizinische genetik · ws - , p-cling- ws - , p-cling- ddd study . p-cling- ws - , ws - , p-cling- , p-compl- ws - , p-cling- , p-cling- distelmaier f. ws - ws - , p-basepi- , p-cancg- ws - , ws - , p-cling- , p-cling- , p-cling- ws - , p-cling- , p-monog- ws - ekici ab. ws - , p-monog- sel- p-cancg- , p-techno- plen , ws - golla a dfg-workshop göpfert mc sel- , sel- haferlach c. ws - haferlach t. ws - ws - , ws - , p-compl- , p-compl- p-cancg- , p-cancg- , p-cancg- gilissen c. ws - ws - , p-basepi- , p-cling- , p-cling- p-cling- , p-cling- , p-cling- , p-cling- ws - , p-cling- p-cling- , p-cling- , p-cling- ws - , p-compl- p-monog- medizinische genetik · ws - hüffmeier u. ws - ws - , p-cling- seq consortium ws - ws - , ws - , p-compl- p-cling- , p-cling- , p-cling- , p-cling- ws - , p-cancg- ws - , ws - , ws - , p-compl- p-cancg- , p-cancg- ws - ws - , p-cling- , p-cling- , p-cling- , p-cytog- ws - , ws - , p-compl- , p-compl- , p-compl- ws - , p-cling- p-cling- , p-cling- p-cling- , p-cling- p-cling- , p-cling- , p-cling- ws - , p-cancg- ws - , p-cling- ws - , ws - , p-cancg- khor cc. ws - sel- , ws - ws - medizinische genetik · p-cling- , p-cling- , p-cling- ws - , p-compl- , p-compl- ws - , p-cancg- ws - , p-cling- meggendorfer m. ws - ws - , p-cancg- p-cling- , p-cling- , p-cling- p-cling- , p-cling- ws - , p-cancg- ws - , ws - , p-monog- ws - ws - ws - , p-cling- pasutto f. ws - nanda i. ws - nöthen mm. ws - , ws - , ws - , ws - , ws - ws - ws - , ws - , ws - , ws - , p-cling- , p-compl- , p-compl- sel- medizinische genetik · p-cancg- schnapp l. ws - ws - , p-cancg- , p-cancg- , p-cling- ws - , p-basepi- , p-cling- p-cling- , p-cling- p-cancg- , p-cling- salaverria i. ws - ws - , p-compl- ws - , ws - , ws - , p-cancg- , p-cling- , p-cling- , p-cytog- , p-monog- , p-monog- p-cancg- , p-cancg- , p-cling- , p-cling- ws - sel- , ws - , p-compl- the international gamos consortium e ws - , ws - , ws - , p-cancg- , p-monog- , p-monog- sel- , ws - ws - , p-cytog- p-cancg- , p-cling- , p-cling- p-cancg- , p-cancg- , p-cling- stengel a. ws - p-cling- , p-cling- ws - , ws - , ws - , p-cling- , p-cling- , p-cling- , p-cling- , p-cling- p-cancg- , p-cling- ws - ws - , p-cling- ws - witsch-baumgartner m. p-cling- p-cancg- p-cancg- wunderle m. ws - zechner u. ws - , ws - , p-basepi- , p-cling- , p-cling- , p-cling- ws - , p-cancg- , p-cling- edu , p-cling- , p-cling- , p-cling- , p-cling- , p-cling- , p-cling- p-cling- , p-cling- , p-cling- wiesener a. ws - , p-monog- ws - , ws - , p-cancg- , p-cling- , p-compl- , p-monog- ws - ws - , p-cancg- autorenverzeichnis zenker m. ws - , ws - , p-cling- , p-cling- dialog mit shg, p-cling- ws - , ws - , p-cling- , p-monog- ac. koller , , j. strohmaier , ku. ludwig , , fc. degenhardt , m. wulff , , d. breuer , , l. winkler , , f. neukirch , , a. maaser , , a. forstner , , s. sivalingam , , a. reif , a. ramirez , w. maier , d. rujescu , i. giegling , h. thiele , p. nürnberg , , a. fischer congenital hypogonadotropic hypogonadism (chh) is a rare and clinically and genetically heterogeneous disorder. chh is characterized by incomplete or absent puberty caused by the lack or deficient number of hypothalamic gonadotropin-releasing hormone (gnrh) neurons, disturbed secretion or action of gnrh, or both. chh is often associated with anosmia and is then termed kallmann syndrome (ks), as well as with other phenotypes like unilateral kidney agenesis, skeletal abnormalities, midline malformations, and hearing loss. x-linked, autosomal-dominant, and autosomal-recessive, as well as di-and oligogenic inheritance has been described for chh. in the meantime a multitude of genes has been reported to be associated with chh. actually, in fewer than % of the chh cases the underlying genetic cause can be identified. we analyzed a total of patients with chh ( female/ male) by using targeted sequencing of chh-associated genes kal , chd , fgf , fgfr , fshb, gnrh , gnrhr, hs st , kiss , kiss r, nsmf, prok , prokr , spry , tac and tacr and identified pathogenic mutations in chh patients of our cohort. mutations were detected in kal ( patients), tacr ( patients), prokr ( patient), hs st ( patient) and gnrhr ( patient). furthermore, we found in two patients with described pathogenic mutations (one patient with prokr mutation and the other with kal mutation, respectively) additional mutations in nsmf gene and tacr gene, respectively, suggesting digenic inheritance in these cases. pain is necessary to alert us to actual or potential tissue damage. specialized nerve cells in the body periphery, so called nociceptors, are fundamental to mediate pain perception and humans without pain perception are at permanent risk for injuries, burns and mutilations. pain insensitivity can be caused by sensory neurodegeneration which is a hallmark of hereditary sensory and autonomic neuropathies (hsan). although mutations in several genes were previously associated with sensory neurodegeneration, the etiology of many cases remains unknown. using next generation sequencing in patients with congenital loss of pain perception, we here identify bi-allelic mutations in the flvcr (feline leukemia virus subgroup c receptor ) gene, which encodes a broadly expressed heme exporter. different flvcr isoforms control the size of the cytosolic heme pool required to sustain metabolic activity of different cell types. mutations institute of human genetics, bonn, germany, the rild institute, wonford, exeter, uk introduction: ectodermal dysplasias (eds) are a large group of heterogeneous genetic disorders characterized by abnormal development in ectoderm-derived tissues and organs including skin, hair, and nails. among the eds, pure hair and nail ectodermal dysplasia (phned) is a rare genodermatosis characterized by nail dystrophy and sparse or absent hair on the scalp. materials and methods: a family of iranian origin was enrolled in this study. two children from a consanguineous marriage are affected from phned. in addition, the father has alopecia areata (aa) but does not show any nail dysplasia. the mother is unaffected. the paternal and maternal grandfathers had nail dysplasia almost similar to the siblings but did not manifest any hair loss or aa. homozygosity mapping and genedistiller analysis were performed to identify candidate genes. sanger sequencing was used to localize the mutations. results: in total, we identified homozygous regions with almost candidate genes. among these genes were also krt and hoxc , already known to be related to the phenotype of our patients. therefore, we focused our additional analyses on krt and hoxc . sanger sequencing showed a so far unknown homozygous insertion of bp in exon of hoxc . conclusion: we identified an unknown mutation for phned which expands the spectrum of mutations for phned. the hair loss of the father seems rather be due to a distinct type of hair loss, namely aa, which is quite common in the general population. however, the nail dysplasia from both grandfathers is unclear and cannot be examined anymore. it still remains unclear if the nail dysplasia in the grandfathers was due to the same mutation in hoxc or is based on a different mutation. generation of a cell culture model for epidermodysplasia verruciformis by knock-out of ev , a novel gene involved in this genodermatosis e. imahorn , m. aushev , sj. de jong , e. jouanguy , , , jl. casanova , , , ph. itin , , j. reichelt , epidermodysplasia verruciformis (ev) is a rare hereditary skin disease leading susceptibility to certain types of cutaneous human papilloma viruses, mainly β-hpv, and a high risk for development of cutaneous squamous cell carcinoma. homozygous or compound heterozygous loss of function mutations either in tmc or in tmc have been described in several ev patients, but more than / of affected families do not have mutations in one of them. a third gene (ev ) has recently been identified to be mutated in ev patients without tmc or tmc mutation. investigations on the function of this gene may elucidate pathomechanisms of ev. we aim to generate an ev deficient model cell line to study the effects of ev despite the scarcity of patient material. detection of deletions during diagnostic massive parallel ngs gene panel sequencing neuronal differentiation at a later time point. a novel mutation c. a>g, pser gly in des gene in a family with catecholamine polymorphic ventricular tachycardia s. komatsuzaki, p. villavicencio lorini, k. hoffmann institute for human genetics, university hospital halle, germany background: myofibrillar myopathy (omim ) is a heterogeneous neuromuscular disease characterized by progressive muscle weakness, partially with cardiomyopathy and/or arrhythmia. pathohistological examinations show desmin-positive protein aggregations. the mutations in des, cryab, bag , myot, ldb , flnc, fhl , and dnajb have been identified in patients with myofibrillar myopathy. desmin is a intermediate filaments and composed of non-helical n-and terminal head domain and a central a-helical rod domain. till now more than mutations myofibrillar myopathy were identified in patients with and a genotype-phenotype was reported: mutations in rod domain tend to cause neuromuscular symptoms, and mutations in head domain is associated with cardiac symptoms. the head-domain is a serine rich domain and phosphorylated by protein kinase c. almost all reported mutations in head-domain in des are at serine residues (e. g. s i, s f, s f, s f, s y, s t). these findings suggested that the serine residues in head-domain could play an important role in biological function of desmin. here we report a novel mutation c. a>g, ps g in des in a family with catecholamine polymorphic ventricular tachycardia. case: a years old patient developed a syncope in a cold winter. the cardiological investigations revealed a diagnosis of catecholamine polymorphic ventricular tachycardia and the implantation of permanent pacemaker was indicated. his older brother, father and paternal uncle suffered from arrhythmia and all of them received a permanent pacemaker implantation at around years of age. his cousin was died at age of years due to sudden cardiac arrest. we performed a genetic analysis for ryanodin-rezeptor -gen and lamin a gene and no mutation in these gene was identified. next, we performed an exome sequencing. here a novel heterozygous mutation c. a>g, ps g in des was identified. this mutation was also identified in uncle of index patient. the c. a>g, ps g in des was not reported neither in human genome project, nor in exome aggregation consortium. a mutation at serine (p.s i) was previously reported in patients with myofibrillar myopathy with cardiac symptoms. based on these findings, it was strongly supposed that the p.s g in des gene is a causative mutation for myofibrillar myopathy with arrhythmia in our patients. discussion: recent studies suggest that the mutations in des influence not only on muscle stability and myocardial force generation, but also impaired ubiquitin proteasome system, which could be caused by aggregated desmine. generally, phosphorylation of serin and threonine in head-domain of desmin is related to disassembly of filaments. therefore the p.ser- gly mutation in des could cause altered phosphorylation of desmin. the functional abnormalities caused by pser gly in des gene need to be studied. gene dosage manipulation of the chromatin organizer ctcf in the nervous system of drosophila melanogaster results in neurological and morphological phenotypes e. konrad, a. gregor, m. brech, c. zweier institute of human genetics, fau-erlangen-nürnberg, erlangen, germanythree-dimensional organization of eukaryotic genomes is crucial for temporal and spatial regulation of gene expression. architectural proteins, like the ccctc-binding factor ctcf are responsible for establishing and maintaining this organization. ctcf is involved in virtually all chromatin regulating processes including enhancer function, insulation, alterna-for this purpose we used the crispr/cas system to delete the ev coding sequence in an immortalized keratinocyte line. after isolation by facs, single cell clones have been expanded. we screened clones for deletion of the whole gene as well as for the expression of ev . three clones showed no detectable gdna sequence or expression of the ev gene. we found only one wildtype clone without deletion of ev or alterations near the cas cut sites. all clones have been characterized by a snp-array as well as sequencing of the knockout site and the most probable offsite targets. these ev deficient keratinocyte lines are the first cell culture model for ev. it will be a valuable tool to identify cellular pathomechanisms of the disease and allow insight into the control of β-hpv in the general population. hemizygous loss of function of single x-chromosomal genes is the most frequent cause for genetic intellectual disability (id). while a long list of gene mutations have so far been described to be responsible for the disease phenotype, little is known about the underlying neuronal mechanisms. reprogramming of somatic cells into stem cells (ipscs) followed by differentiation into neuronal precursors (npcs) is an important tool for translating research allowing an understanding of network dysfunction in id patients. opitz bbb/g syndrome (os) is characterized by a number of ventral midline defects combined with learning disability, developmental delay and intellectual disability. it is caused by mutations in the x-linked mid gene, which, as we have shown previously, regulates mtor dependent local protein synthesis. in a mouse model, loss of mid function leads to significant disturbance of axonal outgrowth. we have generated ips cells from several patients with os and from one mother that carries a loss of function mutation in the mid gene. by sorting cell clones after reprogramming we have established ips cell clones from this female carrier of a bp deletion in the mid gene (c. _ delctcc) either expressing from the mutated x-chromosome or the non-mutated x-chromosome and have shown that indeed the generated ipsc-clones express either % of the mutated or % of the wildtype mid . we determined this directly using an allele-specific mid -rt-pcr and indirectly by comparing the methylation of humara-alleles. comparison of mutation expressing ipsc-clones with non-mutation expressing ipsc-clones showed that the mid mutation results in significantly smaller cells with reduced s phosphorylation supporting aberrations in the mtor/pp a signaling cascade. when differentiating ipscs into neuronal precursor cells, significantly bigger embryoid bodies (ebs) can be detected in the mutation expressing clones, while the total eb number is higher for the non-mutated mid expressing clones. when further differentiated, ebs from all ipsc-clones form neuronal rosette structures expressing beta-iii-tubulin, with a lower rosette structure count in the mutated mid expressing cells. these data clearly hint a defect in neurogenesis in cells with hemizygous mid mutations. interestingly, while ipscs stably kept the x-incativation pattern of the original fibroblast, during differentiation x-inactivation was lost leading to biallelic expression from both x-chromosomes in the npcs pointing towards an as yet unknown reactivation mechanism of the inactive x-chromosome. we are currently analyzing x-inactivation throughout the differ- mutations in the aminoacyl-trna-synthetase genes sars and wars are associated with autosomal recessive intellectual disability l intellectual disability (id) is the common feature of a very heterogeneous group of disorders, which comprises a broad variety of syndromic and non-syndromic phenotypes. here we present mutations in two aminoacyl-trna synthetases that are associated with id in two independent iranian families. in the first family, we found a missense mutation (c. g>a, p.d n) in the cytoplasmic seryl-trna synthetase (sars) gene that affects the enzymatic core domain of the protein and impairs its enzymatic activity. this probably leads to reduced trnaser concentrations in the cytoplasm. in silico analyses predicted the mutant protein to be unstable. this prediction could be experimentally substantiated by results obtained through studies with ectopic mutant sars in transfected hek t cells. in the second family, we identified a compound heterozygous genotype of the mitochondrial tryptophanyl-trna synthetase (wars ) gene, consisting of a nonsense mutation (c. dela, p.ser alafs* ), which very likely leads to nonsense-mediated mrna decay, in combination with a missense mutation (c. t>g, p.w g). the p.w g mutation affects the mitochondrial localization signal of wars , leading to mislocalization of the mutant protein. thus, when taking aimp into account, which we have recently implicated in the aetiology of id as well, there are now three genes with a role in trna-aminoacylation that are associated with this condition. hence we propose that the functional integrity of t-rnas in general is an important constituent in the development and maintenance of human cognitive functions. dravet syndrome is a rare autosomal dominant genetic disorder with early-onset epileptic encephalopathy is mainly caused by different de novo mutations of the scn a gene encoding the type subunit of voltage-gated sodium channel. whole exome sequencing(wes) enables scanning a large number of genes which not only can confirm the diagnosis but also helpful in understading for possible relationship between clinical manifestations and mutaion. the authors investigate wes in a months term boy with hypotonia and convulsion of normal and relative parent. she had uncontrolled sizure without fever, and developmental delay from months.in treatment protocol anti covulsants changes to valorate, clonazepam and stiripentol as well. a deleterious novel heterozygous splice site mutation in scn a tive splicing, imprinting, v(d)j recombination, chromatin loop formation and defining topologically associated domains (tads). recently, we identified de novo mutations in ctcf in patients with a surprisingly mild phenotype of variable developmental delay or intellectual disability, mild short stature and microcephaly, and behavioural anomalies. apart from observing brain malformations and early lethality or learning deficits in two conditional knockout mouse models, little is known about the role of ctcf in neuronal development and preservation so far. therefore, we utilized the model organism drosophila melanogaster to further explore the role of ctcf in cns development and function. similar to observations in knockout mice, complete knockout or ubiquitous knockdown of ctcf is embryonic lethal in drosophila. we therefore utilized the uas/gal system to induce tissue specific knockdown or overexpression of ctcf in the fly nervous system. we first investigated development and morphology of the larval neuromuscular junctions (nmjs), an established model for synaptic development. while pan-neuronal overexpression of ctcf showed no morphological nmj alterations, pan-neuronal knockdown resulted in fewer nmj branches than in a specific control. additionally, we observed a reduced number of active zones in a hypomorphic mutant line compared to a wildtype control. using the negative gravitaxis assay to examine gross neurological function, we found a highly significant impairment of geotaxis behavior in flies with ctcf knockdown in neurons, motoneurons and muscle and in flies with overexpression of ctcf in glia cells, muscle and motoneurons. currently we are testing learning and memory behavior with the courtship conditioning paradigm. our findings of various neurological and morphological anomalies upon manipulation of ctcf dosage in the fly nervous system emphasize the role of ctcf in nervous system development and function and provide a basis to further study the molecular mechanisms underlying cognitive dysfunction caused by ctcf-deficiency. congenital or early-onset nystagmus (cn) is characterized by involuntary eye movements and shows enormous clinical and genetic heterogeneity. cn may be an ambiguous sign of many different diseases, including retinal dysfunction/degeneration, ocular/oculocutaneous albinism, and severe central nervous system disorders, such as pelizaeus-merzbacher or pelizaeus-merzbacher-like diseases (pmld). due to enormous heterogeneity found among the diseases leading to cn, whole exome sequencing (wes) and panel-based bioinformatics was considered as an approach to rapidly identify disease-associated genetic sequence variants. we have analyzed families with cn-affected patients. herein, we present three clinically different patients who were initially affected with cn, but developed further clinical symptoms of various severities. one of these patients showed features of retinal dysfunction, including night blindness and myopia, while two other patients developed severe phenotypes including mental retardation or pmld. wes identified four genetic variants in genes associated with cn. the first patient showed a hemizygous splice-donor variant (c. + g>a) in the calcium channel voltage-dependent alpha- f subunit (cacna f) gene, the second patient carried a hemizygous variant (c. g>a, p.r h) in the ferm domain-containing protein (frmd ) gene, and the third patient showed two heterozygous variants (c. c>g, p.y * and c. t>c, p.v a) in the gap junction protein gamma- (gjc ) gene. sanger sequencing confirmed the identified variants in the index patients and verified co-segregation in several family members. our results suggest a beneficial role of wes to identify the molecular causes of cn and to rapidly confirm an initially unclear clinical diagnosis. especially, patients with rare and severe disorders (e. g. pmld) will benefit from a wes analysis performed in the early stage of the disease. the ccdc -deficient (ccdc -/-) mouse model exhibits slow retinal degeneration similar to a human retinitis pigmentosa (rp) phenotype (gerding et al., hum mol genet., ) . in order to determine whether ccdc gene expression might also play a role outside the retina, this study aimed at characterizing ccdc protein expression during early postnatal development of the mouse brain. furthermore, morphological and behavioral impact of ccdc deficiency in the mouse brain was analyzed. methods: ccdc protein expression was determined by sds page and western blot in whole brain homogenates and in selected brain regions of interest (olfactory bulb, hippocampus, cortex, striatum, cerebellum, brain stem) during early postnatal development and in adult wildtype (wt) mice. in addition, cryosections of the ccdc -/-olfactory epithelium and bulb (during postnatal development) and the rostral migratory stream (in adult) were analyzed for ccdc reporter gene expression by x-gal staining. selected brain regions were additionally analyzed by electron microscopy. in order to correlate anatomical with behavioral data, olfactory performance was studied in aged ccdc -/-mice compared to ccdc +/+ controls by an olfactory habituation/dishabituation test (yang and crawley, curr protoc neurosci., ) , where olfactory exploration-time during the presentation of neutral and social odors is examined. results: ccdc protein was detected throughout the early postnatal development of the wt mouse brain, decreasing after birth. amongst analyzed brain regions, highest expression of ccdc protein was detected in the olfactory bulb exhibiting similar ccdc levels to retinal expression. accordingly, ccdc reporter gene expression was demonstrated in the mature olfactory bulb glomeruli, the adjacent olfactory epithelium and along the rostral migratory stream in the ccdc -/-mouse brain. interestingly, strong ccdc reporter gene expression in glomeruli of the ccdc -/-olfactory bulb was correlated with signs of degeneration in the ccdc -/-mouse, but not in controls. the degeneration was also reflected by olfactory impairment in ccdc -/-mice, which spent significantly less time for sniffing at initial presentation of unknown, neutral odors and barely responded to social odors. conclusion: besides the retina, ccdc protein plays a crucial role in the olfactory system as shown by its expression there as well as by ccdc deficiency resulting in neurodegeneration and alteration of olfaction-related behavior in the ccdc -/-mice. as impairment of the olfactory sense in multiple neurodegenerative disorders is a common finding, the ccdc -/mouse model is not only restricted to study retinal degeneration but possibly also degeneration of the central nervous system. background: the ccdc -deficient (ccdc -/-) mouse model exhibits slow retinal degeneration similar to a human retinitis pigmentosa (rp) phenotype (gerding et al. ) . in order to gain insights into the molecular disruptions in cilia structure or function lead to a class of human disorders called ciliopathies. joubert syndrome is characterized by a wide spectrum of symptoms, including a variable degree of intellectual disability, ataxia, and ocular abnormalities. here we report a novel homozygous missense variant (c. g>a; p.g r) in the arl b gene, which we identified by whole exome sequencing of a trio from a consanguineous family with multiple affected individuals suffering from intellectual disability, ataxia, ocular defects, and epilepsy. the same variant was also identified in a second family. we saw a striking difference in the severity of ataxia between affected male and female individuals in both families. functional analysis demonstrated that dihydrotestosterone treatment of sh-sy y cells induced a down regulation of arl b expression. both arl b and arl b-p.g r expression rescued the cilia length and shh defects displayed by arl bhennin (null) cells, indicating that the mutation did not disrupt either arl b function. in contrast, arl b-p.g r displayed a marked loss of arl guanine nucleotide-exchange factor activity, despite retention of its gtpase activities, highlighting the correlation between its loss of function as an arl guanine nucleotide-exchange factor and joubert syndrome. s. renner, a. busch, t. bierhals, j. butter, v. kolbe, g. rosenberger institute of human genetics, university medical center hamburg-eppendorf, hamburg, germany taad (thoracic aortic aneurysm and dissection) is a heterogeneous disease that often remains silent until a life-threatening complication occurs. it belongs to the connective tissue disorders and causes % of death in industrial countries. several disease genes have been already identified; however, about % of patients with taad-associated syndromes do not show a mutation in these genes. thus, further heterogeneity is obvious. since individual risk stratification and therapeutic options highly depend on the individually mutated gene, it is very important to identify more disease genes which are aimed to be found by whole exome sequencing (wes). many of the known disease genes encode for proteins that are important for the structure and stabilization of the extracellular matrix as well as for the contraction of vascular smooth muscle cells. one central pathway is the tgf-beta signaling which functions among other proteins via the tgf-beta receptor, its ligand and its downstream target smad / . our project plan includes (i) exome sequencing both in affected individuals within families as well as in sporadic patients, (ii) filtering of raw data and prioritization of sequence variants by using a bioinformatic in house pipeline, (iii) verification of novel putative disease genes in a cohort of mutation-negative patients with taad spectrum disease and (iv) functional analyses to gain deeper insight into the pathobiology of taad. in a first round of wes analysis and variant prioritization, we identified a highly conspicuous sequence variant in three family members with taad. screening of the respective gene in a large cohort of mutation negative patients revealed another variant in two siblings with taad. structural and functional considerations strongly support deleterious effects for both identified putative pathogenic missense variants that affect a novel cell cycle-and/or apoptosis regulating protein. functional analyses did not show an involvement of this protein in tgf-beta signaling. in ongoing experiments, we focus on mutation-induced consequences on cell proliferation, cell cycle progression and apoptosis. indeed, we found inhibitory effects of the missense variants on proliferation by affecting the cell cycle key protein cdkn a. we hypothesize that dysregulation of proliferation and/ or apoptosis of specific cells, e. g. smooth muscle cells, underlies taad.abstracts for screening. positively tested compounds were reanalyzed by whole-cell patch clamp recordings and cell volume measurements. results: the halide assay revealed reproducible halide permeability across wells and, as a control, reliably detected mdckii cells overexpressing wild type best by a decrease of yfp fluorescence to % following seconds iodide stimulation. cells harboring mutant best showed % of default yfp fluorescence after the same time interval. conclusion: the current study established an assay appropriate for high and small-scale compound screening targeting best localization and function. this assay will be used to screen for compounds in mutant cells lines best -t p and best -y n for their ability to improve trafficking to the pm or correcting protein folding to enhance ion permeability. background: neuropeptide y-y receptor (y receptor), an auto-receptor of neuropeptide y (npy) and attractive guanine nucleotide (g) protein-coupled receptor target, has been implicated as a potential therapeutic target for many clinical conditions, including epileptic seizure, depression, pain, and alcoholism. in huntington's disease (hd) patients and animal models of hd, npy-expressing striatal interneurons are selective preserved and increased with advancing disease. however, the potential role of y receptor in hd pathology remains under-explored. aims: to investigate whether activation of y receptor using npy and selective y r ligands could ameliorate behavioral deficits and neuropathology in r / mouse model of hd. methods/techniques: npy and selective y receptor agonist npy - were intranasally administered to r / mice, five days in a week, beginning from weeks of age until weeks of age. in the second study, r / mice received daily intraperitoneal administration of selective non-peptide y receptor antagonist (sf- ) to selectively block y receptor. results/outcome: intranasal application of npy showed significant increase in rotarod performance compared to the saline and sf- treated r / mice (*p < . and **p < . at and weeks of age respectively, n = ). however, treatment with npy - showed a clear trend towards increased rotarod performance at weeks of age compared to the saline and sf- treated r / mice but the difference did not reach significance. also, treatment with npy and npy - showed no significant effect on body weight loss in r / mice, contrasting with previous data obtained with single intracerebroventricular (icv) injection of npy in r / mice. furthermore, intranasal application npy or npy - led to decrease in mutant huntingtin (htt) aggregation and mediated increase in dopamine-and camp regulated phosphoprotein (darpp- ) and brain derived neurotrophic factor (bdnf) levels. additionally, we found that npy and npy - attenuate microglial activation, inducible nitric oxide synthase (inos) expression, and proinflammatory cytokines production in r / mice compared to the saline and sf- treated r / mice. conclusion: taken together, our findings suggest that targeting npy-y receptor might be a potential neuroprotective therapy for hd and other neurodegenerative diseases. best of both world's: a novel, rapid capture protocol that overcomes drawbacks associated with dna fragmentation in established methods j. seggewiß, c. ruckert, p. wieacker institute of human genetics, westfaelian wilhelms-university of muenster, muenster, germany rapid capture protocols are an attractive proposition for clinical sequencing labs, as they enable quicker sample-to-sequencing turnaround times. the fragmentation of input dna for the construction of pre-capture libraries is a bottleneck in established protocols. mechanical shearing is the gold standard, but is laborious using single-tube covaris instruments; and higher-throughput instrumentation is cost-prohibitive to many smaller labs. "tagmentation"-based methods (e. g. the nextera rapid capture system from lllumina, or agilent's sureselect qxt system) employ transposases for fast ond simple library construction. however, these protocols are associated with significant sequence bias, especially with low-quality ffpe samples and are extremely sensitive to dna input -thus requiring meticulous quantification of viscous, high-molecular weight dna. here we describe a newly-developed rapid capture protocol that combines the kapa hyperplus kit (kapa biosystems) with integrated, low-bios enzymatic fragmentation, and agilent's proven sureselect xt target enrichment technology. the streamlined method follows for the preparation of high-quality, sequencing-ready libraries in one working day. the novel enzymatic fragmentation reagent does not require careful quantification of input dna, yielding reproducible fragmentation profiles optimal for capture over the fold range-tested ( - ng) the single-tube kapa hyperplus protocol results in very efficient conversion of input dna to precapture library thereby decreasing duplication rates and increasing the complexity of the library going into the modified, min sureselect fast xt hybridization protocol. our protocol represents a significant improvement for fast routine diagnostics, where robust and reproducible pipelines ore needed to support timely treatment decisions. lmj. braun, a. milenkovic, bhf. weber institute of human genetics, regensburg, germany purpose: human bestrophin- (best ) is a chloride channel controlled by ca + and cell volume and is localized at the basolateral membrane of the retinal pigment epithelium (rpe). so far, there is no therapy for the best -associated diseases, of which the most common is best vitelliforme macular dystrophies (bvmd). in this study, we developed an assay applicable for high and small-scale compound screening targeting best localization and function. methods: to assess best channel function we developed a halide assay. briefly, mdckii cell lines were established, stably expressing wildtype best or bvmd-associated best mutants together with a yellow fluorescent protein (yfp)-based halide sensor. in polarized mdckii cells, wildtype best and best -r c localize regularly at the basolateral plasma membrane (pm) while best -l m and best -y n appear significantly reduced in quantity and grossly mislocalized to cytosolic compartments. cells were stimulated with extracellular addition of iodide known to pass the pm through anion cannels and, as a consequence, intracellularly quench yfp fluorescence. variations in yfp fluorescence levels as a marker for best function were recorded in well plates by a plate reader setup. a small-scale , compound library, commercially available as spectrum collection (microsource discovery systems, gaylordsville, usa) was used key: cord- -yl vanuh authors: herberg, jethro; pahari, amitava; walters, sam; levin, michael title: infectious diseases and the kidney date: journal: pediatric nephrology doi: . / - - - - _ sha: doc_id: cord_uid: yl vanuh the kidney is involved in a wide range of bacterial, viral, fungal, and parasitic diseases. in most systemic infections, renal involvement is a minor component of the illness, but in some, renal failure may be the presenting feature and the major problem in management. although individual infectious processes may have a predilection to involve the renal vasculature, glomeruli, interstitium, or collecting systems, a purely anatomic approach to the classification of infectious diseases affecting the kidney is rarely helpful because most infections may involve several different aspects of renal function. the kidney is involved in a wide range of bacterial, viral, fungal, and parasitic diseases. in most systemic infections, renal involvement is a minor component of the illness, but in some, renal failure may be the presenting feature and the major problem in management. although individual infectious processes may have a predilection to involve the renal vasculature, glomeruli, interstitium, or collecting systems, a purely anatomic approach to the classification of infectious diseases affecting the kidney is rarely helpful because most infections may involve several different aspects of renal function. in this chapter, a microbiologic classification of the organisms affecting the kidney is adopted. although they are important causes of renal dysfunction in infectious diseases, urinary tract infections and hemolytic uremic syndrome (hus) are not discussed in detail because they are considered separately in chapters and respectively. elucidation of the cause of renal involvement in a child with evidence of infection must be based on a careful consideration of the geographic distribution of infectious diseases in different countries. a history of foreign travel; exposure to animals, insects, or unusual foods or drinks; outdoor activities such as swimming or hiking; and contact with infectious diseases must be sought in every case. the clinical examination should include a careful assessment of skin and mucous membranes and a search for insect bites, lymphadenopathy, and involvement of other organs. a close collaboration with a pediatric infectious disease specialist and hospital microbiologist will aid the diagnosis and management of the underlying infection. a tantalizing clue to the pathogenesis of glomerular disease is the marked difference in the incidence of nephrosis and nephritis in developed and underdeveloped areas of the world. in several tropical countries, glomerulonephritis (gn) accounts for up to % of pediatric hospital admissions; the incidence in temperate climates is -to -fold less. this difference might be explained by a complex interaction of several different factors, including nutrition, racial and genetically determined differences in immune responses, and exposure to infectious diseases. a growing body of evidence, however, suggests that longterm exposure to infectious agents is a major factor in the increased prevalence of glomerular diseases in developing countries. renal involvement in infectious diseases may occur by a variety of mechanisms: direct microbial invasion of the renal tissues or collecting system may take place in conditions such as staphylococcal abscess of the kidney as a result of septicemic spread of the organism or as a consequence of ascending infection; damage to the kidney may be caused by the systemic release of endotoxin or other toxins and activation of the inflammatory cascade during septicemia or by a focus of infection distant from the kidney; ischemic damage may result from inadequate perfusion induced by septic shock; the kidney may be damaged by activation of the immunologic pathways or by immune complexes resulting from the infectious process. in many conditions, a combination of these mechanisms may be operative. in the assessment of renal complications occurring in infectious diseases, the possibility of druginduced nephrotoxicity caused by antimicrobial therapy should always be considered. the nephrotoxic effects of antibiotics and other antimicrobial agents are not addressed in this chapter but are covered in chapter . bacterial infections associated with renal disease and the likely mechanisms causing renal dysfunction are shown in > impaired renal function is a common occurrence in systemic sepsis ( ) . depending on the severity of the infection and the organism responsible, the renal involvement may vary from insignificant proteinuria to acute renal failure requiring dialysis. the organisms causing acute renal failure as part of systemic sepsis vary with age and geographic location and also differ in normal and immunocompromised children. in the neonatal period, group b streptococci, coliforms, staphylococcus aureus, and listeria monocytogenes are the organisms usually . responsible. in older children, neisseria meningitidis, streptococcus pneumoniae, and s. aureus account for most of the infections. in people who are immunocompromised, a wide range of bacteria are seen, and, similarly, in tropical countries other pathogens, including haemophilus influenzae, salmonella species, and pseudomonas pseudomallei, must be considered. where h. influenzae type b vaccine has been introduced, however, the incidence of severe systemic infections due to this organism has shown a sharp fall. systemic sepsis usually presents with nonspecific features: fever, tachypnea, tachycardia, and evidence of skin and organ underperfusion. the pathophysiology of renal involvement in systemic sepsis is multifactorial ( , ) . hypovolemia with diminished renal perfusion is the earliest event and is a consequence of the increased vascular permeability and loss of plasma from the intravascular space. hypovolemia commonly coexists with depressed myocardial function because of the myocardial depressant effects of endotoxin or other toxins. the renal vasoconstrictor response to diminished circulating volume and reduced cardiac output further reduces glomerular filtration, and oliguria is thus a consistent and early event in severe sepsis ( , ) . a number of vasodilator pathways are activated in sepsis, including nitric oxide and the kinin pathways. this may lead to inappropriate dilatation of vascular beds. vasodilation of capillary beds leading to warm shock is common in adults with sepsis due to gram-negative organisms but is less commonly seen in children, in whom intense vasoconstriction is the usual response to sepsis. if renal underperfusion and vasoconstriction are persistent and severe, the reversible prerenal failure is followed by established renal failure with the characteristic features of vasomotor nephropathy or acute tubular necrosis. other mechanisms of renal damage in systemic sepsis include direct effects of endotoxin and other toxins on the kidney, and release of inflammatory mediators such as tumor necrosis factor (tnf) and other cytokines, arachidonic acid metabolites, and proteolytic enzymes ( ) . nitric oxide (no) is postulated to play a key role in the pathophysiology of renal failure in sepsis. whether the renal effects of increased no are beneficial or harmful remains unclear. trials of selective no synthetase inhibition did not offer any advantages over saline resuscitation ( ) . no in endotoxemia is possibly beneficial because it maintains renal blood flow and glomerular filtration. activation of coagulation is an important component of the pathophysiology of septic shock and may contribute to renal impairment. activation of multiple prothrombotic and antifibrinolytic pathways occurs, together with downregulation of antithrombotic mechanisms such as the protein c pathway. treatment with activated protein c has been shown to improve outcome of adult septic shock, but has not been confirmed to have benefit in pediatric sepsis, and may carry a risk of bleeding particularly in infants ( ) . the renal findings early in septic shock are oliguria, with high urine/plasma urea and creatinine ratios, low urine sodium concentration, and a high urine/plasma osmolarity ratio. once established, renal failure supervenes, and the urine is of poor quality with low urine/ plasma urea and creatinine ratios, elevated urine sodium concentration, and low urine osmolarity. proteinuria is usually present, and the urine sediment may contain red cells and small numbers of white cells ( ) . the management of acute renal failure in systemic sepsis depends on early diagnosis and administration of appropriate antibiotics to cover the expected pathogens. . in addition, management is directed at improving renal perfusion and oxygenation. volume replacement with crystalloid or colloid should be undertaken to optimize preload. central venous pressure or pulmonary wedge pressure monitoring is essential to guide volume replacement in children in severe shock ( , ) . the use of low-dose ( - pg/kg/min) dopamine to reduce renal vasoconstriction together with administration of inotropic agents such as dobutamine or epinephrine to improve cardiac output may reverse prerenal failure. early elective ventilation should be undertaken in patients with severe shock. if oliguria persists despite volume replacement and inotropic therapy, dialysis should be instituted early, because septic and catabolic patients may rapidly develop hyperkalemia and severe electrolyte imbalance. in most children who develop acute renal failure as part of systemic sepsis or septic shock, the renal failure is of short duration, and recovery can be expected within a few days of achieving cardiovascular stability and eradication of the underlying infection. occasionally, renal cortical necrosis or infarction of the kidney may result in prolonged or permanent loss of renal function. meningococcus n. meningitidis continues to be a major cause of systemic sepsis and meningitis in both developed and underdeveloped parts of the world ( ) . in developed countries, most cases are caused by group b and y strains, particularly after introduction of meningococcal c vaccination, whereas epidemics of meningococcus groups a, c and w continue to occur in many underdeveloped regions of the world ( , ) . infants and young adults are most commonly affected, but cases in adolescents and young children are also common. there are two major presentations of meningococcal disease ( ) : meningococcal meningitis presents with features indistinguishable from those of other forms of meningitis, including headache, stiff neck, and photophobia. lumbar puncture is required to identify the causative agent and distinguish this from other forms of meningitis. despite the acute nature of the illness, the prognosis is good, and most patients with the purely meningitic form of the illness recover without sequelae. meningococcemia with purpuric rash and shock is the second and more devastating form of the illness. affected patients present with nonspecific symptoms of fever, vomiting, abdominal pain, and muscle ache. the diagnosis is only obvious once the characteristic petechial or purpuric rash appears. patients with a rapidly progressive purpuric rash, hypotension, and evidence of skin and organ underperfusion have a poor prognosis, with a mortality of - %. adverse prognostic features include hypotension, a low white cell count, absence of meningeal inflammation, thrombocytopenia, and disturbed coagulation indices ( ) . renal failure was seldom reported in early series of patients with meningococcemia, perhaps because most patients died rapidly of uncontrolled septic shock. with advances in intensive care, however, more children are surviving the initial period of profound hemodynamic derangement, and renal failure is more often seen as a major management problem. approximately % of children with fulminant meningococcemia develop renal failure, which usually occurs - h after the onset of illness ( ) . the pathophysiology of meningococcal septicemia involves the activation of cytokines and inflammatory cells by endotoxin ( , ) . mortality is directly related to both the plasma endotoxin concentration and the intensity of the inflammatory response, as indicated by levels of tnf and other inflammatory markers ( ) . patients with meningococcemia have a profound capillary leak leading to severe hypovolemia. loss of plasma proteins from the intravascular space is probably the major cause of shock ( ) , but myocardial suppression secondary to il- production is also important ( ) . intense vasoconstriction further impairs tissue and organ perfusion, and vasculitis with intravascular thrombosis and consumption of platelets and coagulation factors is also present ( ) . oliguria is invariably present in children with meningococcemia during the initial phase of the disorder. this is prerenal in origin and may respond to volume replacement and inotropic support. if cardiac output cannot be improved and renal underperfusion persists, established renal failure supervenes. occasionally, cortical necrosis or infarction of the kidneys occurs. children with meningococcemia should be aggressively managed in a pediatric intensive care unit, with early administration of antibiotics (penicillin or a third-generation cephalosporin), volume replacement, hemodynamic monitoring, and the use of inotropic agents and vasodilators. if oliguria persists despite measures to improve cardiac output, elective ventilation and dialysis should be instituted early ( , ) . because activation of coagulation pathways occurs, severe acquired protein-c deficiency may result and is usually associated with substantial mortality ( ) . protein c is a natural anticoagulant which also has important antiinflammatory activity. despite evidence for impaired function of the activated protein c pathway in meningococcal diseases ( ) , and adult trials suggesting benefit of activated protein c administration in septic shock (prowess trial) ( ) , pediatric trials of activated protein c showed no clear benefit, and were associated with increased risk of intracranial bleeding in very young infants ( ) . the role of apc therapy in pediatric sepsis remains unclear. most patients who survive the initial - h of the illness and regain hemodynamic stability will ultimately recover renal function even if dialysis is required for several weeks. the least common presentation of meningococcal sepsis is chronic meningococcemia. patients with this form of the illness present insidiously with a vasculitic rash, arthritis, and evidence of multiorgan involvement. the features may overlap those of henoch-schonlein purpura or subacute bacterial endocarditis (sbe), and the diagnosis must be considered in patients presenting with fever, arthritis, and vasculitic rash, often accompanied by proteinuria or hematuria. response to antibiotic treatment is good, but some patients may have persistent symptoms for many days resulting from an immunecomplex vasculitis. staphylococcal infections may affect the kidneys by direct focal invasion during staphylococcal septicemia, forming a renal abscess; by causing staphylococcal bacteremia; or by toxin-mediated mechanisms, as in the staphylococcal toxic shock syndrome. staphylococcal abscess. staphylococcal renal abscess presents with fever, loin pain and tenderness, and abnormal urine sediment, as do abscesses caused by other organisms ( ) . the illness often follows either septicemia or pyelonephritis. the diagnosis is usually considered only when a patient with clinical pyelonephritis shows an inadequate response to antibiotic treatment. the diagnosis is confirmed by ultrasonography or computed tomographic scan, which shows swelling of the kidney and intrarenal collections of fluid. antibiotic therapy alone may result in cure, but if the patient remains unwell with evidence of persistent inflammation despite use of appropriate antibiotics, surgical intervention may be required. percutaneous drainage under ultrasonographic or computed tomographic scan guidance is often effective and may avoid the need for a more direct surgical approach ( , ) . staphylococcal toxic shock syndrome. the staphylococcal toxic shock syndrome is a systemic illness characterized by fever, shock, erythematous rash, diarrhea, confusion, and renal failure. the disorder was first described by todd et al. in in a series of seven children ( ) . during the s, thousands of cases were reported in the united states. most cases were in menstruating women, in associated with tampon use. although most cases worldwide are seen in women and are associated with menstruation, children of both sexes and of all ages are affected ( ) . the illness usually begins suddenly with high fever, diarrhea, and hypotension, together with a diffuse erythroderma ( ) . mucous membrane involvement with hyperemia and ulceration of the lips and oral mucosa or vaginal mucosa, strawberry tongue, and conjunctival injection are usually seen. desquamation of the rash occurs in the convalescent phase of the illness. confusion is often present in the early stages of the illness and may progress to coma in severe cases. multiple organ failure with evidence of impaired renal function, elevated levels of hepatic transaminases, thrombocytopenia, elevated cpk and disseminated intravascular coagulation (dic) is often seen. according to cdc criteria, the diagnosis is made on the basis of the clinical features of fever, rash, hypotension, and subsequent desquamation along with deranged function of three or more of the following organ systems: gastrointestinal (gi), mucous membranes, renal, hepatic, hematologic, central nervous system, and muscle. other disorders causing a similar picture, such as rocky mountain spotted fever, leptospirosis, measles, and streptococcal infection, must be excluded. the staphylococcal toxic shock syndrome is now known to be due to infection or colonization with strains of s. aureus that produce one or more protein exotoxins ( ) . most cases in adults are associated with toxic shock toxin i; in children, many of the isolates associated with the syndrome produce other enterotoxins (a to f). the staphylococcal enterotoxins appear to induce disease by acting as superantigens ( ) , which activate t cells bearing specific v beta regions of the t-cell receptor; this causes proliferation and cytokine release ( ) . the systemic illness and toxicity are believed to result largely from an intense inflammatory response induced by the toxin. the site of toxin production is often a trivial focus of infection or simple colonization, and bacteremia is rarely observed. renal failure in toxic shock syndrome is usually caused by shock and renal hypoperfusion. in the early stages of the illness, oliguria and renal impairment are usually prerenal and respond to treatment of shock and measures to improve perfusion. in severe cases and in patients in whom treatment is delayed, acute renal failure develops as a consequence of prolonged renal underperfusion, and dialysis may be required. in addition to underperfusion, direct effects of the toxin or inflammatory infectious diseases and the kidney mediators may also contribute to the renal damage. recovery of renal function usually occurs, but in severe cases with cortical necrosis or intense renal vasculitis, prolonged dialysis may be required. the management of staphylococcal toxic shock syndrome depends on early diagnosis and aggressive cardiovascular support with volume replacement, inotropic support, and, in severe cases, elective ventilation. if oliguria persists despite optimization of intravascular volume and administration of inotropic agents, dialysis should be commenced early ( ) . anti-staphylococcal antibiotics should be started as soon as the diagnosis is suspected and the site of infection identified. initial empiric antimicrobial therapy should include an anti-staphylococcal antibiotic effective against betalactamase-resistant organisms and a protein synthesisinhibiting antibiotic such as clindamycin to stop further toxin production ( ) . if there is a focus of infection such as a vaginal tampon, surgical wound, or infected sinuses, the site should be drained early to prevent continued toxin release into the circulation. the intravenous administration of immune globulins may be considered when infection is refractory to several hours of aggressive therapy, an undrainable focus is present, or persistent oliguria with pulmonary edema occurs ( ) . with aggressive intensive care, most affected patients survive, and renal recovery is usual, even in patients who have had severe shock and multiorgan failure. relapses and recurrences of staphylococcal toxic shock syndrome occur in a proportion of affected patients because immune responses to the toxin are ineffective in some individuals. panton valentine leucocidin (pvl) producing staphylococcal infection: in recent years there have been increasing reports of severe staphylococcal disease, associated with shock and multiorgan failure, caused by strains of staphylococci producing the pvl toxin. panton-valentine leukocidin (pvl) is a phage-encoded toxin, which profoundly impairs the host response due to its toxic effect on leucocytes (see review ( ) ). pvl producing strains are associated with tissue necrosis and increased propensity to cause abscesses in lung, bone, joint, and soft tissue infections. perinephric abscesses have been reported ( ) . there are increasing numbers of children and adults admitted with fulminant sepsis, and shock due to pvl producing strains, and renal failure is a significant component of the multiorgan failure. in addition to intensive care support, antibiotic treatment of pvl strains should include antibiotics which reduce toxin production, such as clindamycin, linezolid or rifampicin, as well as vancomycin if the strain is resistant to methicillin. beta-lactam antibiotics should be avoided, as there is some data to suggest that pvl toxin production can increased by these antibiotics under some conditions ( ) . immunoglobulin infusion may also be of benefit. aggressive surgical drainage of all collections requires close consultation with orthopedic and surgical teams. the group a streptococci (gas) are a major worldwide cause of renal disease, usually as poststreptococcal nephritis. however, in addition to this post-infection immunologically mediated disorder, in recent years there have been increasing reports of gas causing acute renal failure as part of an invasive infection with many features of the staphylococcal toxic shock syndrome ( ) . acute poststreptococcal glomerulonephritis. acute poststreptococcal gn (apsgn) is a delayed complication of pharyngeal infection or impetigo with certain nephritogenic strains of gas. different strains can be serotyped according to the antigenic properties of the m protein found in the outer portion of the bacterial wall. apsgn after pharyngeal infection is most commonly associated with serotype m . in contrast, in apsgn after impetigo, serotype m is most commonly identified ( ) . on occasions, other serotypes and non-typeable strains have been described as causing gn. the pathology and pathogenesis of the disorder is discussed in detail in chapter . apsgn has a worldwide distribution. epidemiologic differences are observed between pharyngitis-associated and impetigo-associated streptococcal infections. pharyngitis-associated apsgn is most common during school age and has an unexplained male/female ratio of : . it occurs more often in the cooler months, and familial occurrences are commonly described. the latent period is - weeks, in notable contrast to impetigo-associated cases, which have a latent period of - weeks. in many developing countries, children have chronic skin infections, and it may be difficult to establish the latent period with accuracy. impetigoassociated cases are more common in the warmer months, sex distribution is equal, and children tend to be younger. introduction of a nephritogenic strain into a family often results in the occurrence of several cases within that family, and in some cases, attack rates of up to % have been described ( ) . the incidence is linked to poor socioeconomic conditions. renal involvement in apsgn can be mild, and in many patients, the disease may not be manifested clinically. studies of epidemics with nephritogenic strains of streptococci have shown that up to % of those infected had subclinical evidence of renal disease ( , ) . in a typical case a sudden onset of facial or generalized edema occurs. hypertension is usually modest but is severe in % of cases, and occasionally may lead to encephalopathy or left ventricular failure. the urine is smoky or tea colored in - % of cases. pallor, headache, backache, lethargy, malaise, anorexia, and weakness are all common nonspecific features. the urine volume is decreased. proteinuria is present (up to mg/dl), and microscopy shows white cells, red cells, and granular and hyaline casts. urea, electrolyte, and creatinine levels are normal in subclinical cases but show features of acute renal failure in severe cases. it may be possible to culture gas from the skin or the throat in some patients. other evidence of infection with a gas can be obtained through the antistreptolysin-o titer (asot), which is increased in - % of cases. early antibiotic treatment can reduce the proportion of cases with elevated asot to %. anti-deoxyribonuclease b and anti-hyaluronidase testing has been shown to be of more value than asot in confirming group a streptococcal infection in impetigo-associated cases. measurement of anti-m protein antibodies is of more value for epidemiologic purposes than for the diagnosis of individual cases ( ) . decreased c and total hemolytic complement levels are found in % of cases during the first weeks of illness and return to normal after - weeks. penicillin should be given to eradicate the gas organisms. erythromycin, clindamycin, or a first-generation cephalosporin can be given to patients allergic to penicillin. antibiotic treatment probably has no influence on the course of renal disease but will prevent the spread of a nephritogenic strain ( ) . close contacts and family members who are culture-positive for gas should also be given penicillin, although antibiotic treatment is not always effective in eliminating secondary cases. recurrent episodes are rare, and immunity to the particular nephritogenic strain that caused the disease is probably lifelong. antibiotic prophylaxis is therefore unnecessary. most studies suggest that the prognosis for children with apsgn is good, with more than % making a complete recovery. however, % of cases may have a prolonged and more serious course with long-term chronic renal failure ( ) . other streptococci. apsgn has also been described after outbreaks of group c streptococcus infection ( ) . this has occurred after consumption of unpasteurized milk from cattle with mastitis. patients developed pharyngitis followed by apsgn. endostreptosin was found in the cytoplasm of these group c strains, and during the course of the illness, patients developed anti-endostreptosin antibodies. this antigen has been postulated to be the nephritogenic component of gas. in addition, strains of group g streptococci have been implicated in occasional cases of apsgn ( ) . isolates possessed the type m protein antigen identical to the nephritogenic type m antigen of some group a streptococcal strains. streptococcal toxic shock syndrome and invasive group a streptococcal infection. since , there have been several reports of an illness with many similarities to the staphylococcal toxic shock syndrome, occurring in both children ( ) and adults, associated with invasive group a streptococcal disease ( , , ) . patients with this syndrome present acutely with high fever, erythematous rash, mucous membrane involvement, hypotension, and multiorgan failure. unlike staphylococcal toxic shock syndrome, in which the focus of infection is usually trivial and bacteremia is seldom seen, the streptococcal toxic shock syndrome is usually associated with bacteremia or a serious focus of infection such as septic arthritis, myositis, or osteomyelitis ( , ) . laboratory findings of anemia, neutrophil leukocytosis, thrombocytopenia, and dic are often present, together with impaired renal function, hepatic derangement, and acidosis. acute renal failure requiring dialysis occurs in a significant proportion of cases. it is not clear why there are increasing numbers of cases with invasive disease caused by gas, nor why there has been an emergence of streptococcal toxic shock syndrome, and indeed a similar syndrome caused by some pseudomonas and klebsiella strains. the most common antecedent of invasive gas disease is varicella infection, with the streptococcal infection developing after the initial vesicular phase of the disease is subsiding. strains causing toxic shock syndrome and invasive disease appear to differ from common isolates of gas in producing large amounts of pyrogenic toxins that may have superantigenlike activity. another important mechanism is the production by invasive gas of an il protease. il serves as a molecular bridge between receptors on neutrophils and the vascular endothelium. cleavage of this protein prevents neutrophil attachment to the endothelium, and results in uncontrolled spread of the bacteria through the tissues ( ) . in severe cases necrotizing fasciitis occurs with extensive destruction of the subcutaneous tissues, and is often associated with multiorgan failure. the pathophysiology of streptococcal toxic shock syndrome and that of invasive disease is similar in that superantigen toxins that induce release of cytokines and other inflammatory mediators play a role in both conditions. however gas toxic shock is usually more severe, carries a higher mortality, and is more often associated with focal collections or necrotizing fasciitis. treatment of streptococcal toxic shock syndrome depends on the administration of appropriate antibiotics, aggressive circulatory support, and treatment of any multiorgan failure. surgical intervention to drain the infective focus in muscle, bone, joint, or body cavities is often required. antibiotic therapy with beta-lactams should be supplemented by treatment with a protein synthesisinhibiting antibiotic, such as clindamycin, and it is suggested that this limits new toxin production ( , ) . a number of new therapies are in development. firstly, pooled intravenous immunoglobulins are now in widespread use in the treatment of toxic shock, particularly when caused by streptococcus ( , ) . the role of steroids remains unclear, with their hemodynamic benefit set against the detrimental effects of hyperglycemia secondary to gluconeogenesis. ( ) . the benefit of insulin therapy to control hyperglycemia is unclear. a recent study in adults found that intensive insulin therapy increased the risk of serious adverse events ( ) . in contrast to adult patients, in children with severe sepsis, the use of activated protein c (drotrecogin) cannot be recommended, as in a multicenter trial, fatality was increased in the treatment group ( ) . recovery of renal function occurs in patients who respond to treatment of shock and the eradication of the infection. leptospirosis is an acute generalized infectious disease caused by spirochetes of the genus leptospira ( ) . it is primarily a disease of wild and domestic animals, and humans are infected only occasionally through contact with animals. most human cases occur in summer or autumn and are associated with exposure to leptospiracontaminated water or soil during recreational activities such as swimming or camping. in adolescents and adults, occupational exposure through farming or other contact with animals is the route of infection. the spirochete penetrates intact mucous membranes or abraded skin and disseminates to all parts of the body, including the cerebrospinal fluid (csf). although leptospires do not contain classic endotoxins, the pathophysiology of the disorder has many similarities to that of endotoxemia. in severe cases, jaundice occurs because of hepatocellular dysfunction and cholestasis. renal functional abnormalities may be profound and out of proportion to the histologic changes in the kidney ( ) . renal involvement is predominantly a result of tubular damage, and spirochetes are commonly seen in the tubular lesions. the inflammatory changes in the kidney may result from either a direct toxic effect of the organism or immunecomplex nephritis. however, hypovolemia, hypotension, and reduced cardiac output caused by myocarditis may contribute to the development of renal failure. in severe cases, a hemorrhagic disorder caused by widespread vasculitis and capillary injury also occurs ( , ) . the clinical manifestations of leptospirosis are variable. of affected patients, % have the milder anicteric form of the disorder, and only - % have severe leptospirosis with jaundice. the illness may follow a biphasic course. after an incubation period of - days, a nonspecific flu-like illness lasting - days occurs, associated with septicemic spread of the spirochete. the fever then subsides, only to recur for the second, ''immune,'' phase of the illness. during this phase, the fever is low grade and there may be headache and delirium caused by meningeal involvement, as well as intense muscular aching. nausea and vomiting are common. examination usually reveals conjunctival suffusion, erythematous rash, lymphadenopathy, and meningism. the severe form of the disease (weil's disease) presents with fever, impaired renal and hepatic function, hemorrhage, vascular collapse, and altered consciousness. in one series the most common organs involved were the liver ( %) and kidney ( %). cardiovascular ( %), pulmonary ( %), neurologic ( %), and hematologic ( %) involvements were less common ( ) . vasculitis, thrombocytopenia, and uremia are considered important factors in the pathogenesis of hemorrhagic disturbances and the main cause of death in severe leptospirosis ( ) . urinalysis results are abnormal during the leptospiremic phase with proteinuria, hematuria, and casts. uremia usually appears in the second week, and acute renal failure may develop once cardiovascular collapse and dic are present ( ) . the clinical features of leptospirosis overlap with those of several other acute infectious diseases, including rocky mountain spotted fever, toxic shock syndrome, and streptococcal sepsis. the diagnosis of leptospirosis should be considered in febrile patients with evidence of renal, hepatic, and mucous membrane changes and rash, particularly if a history of exposure to fresh water is found. diagnosis can be confirmed by isolation of the spirochetes from blood or csf in the first days of the illness or from urine in the second week ( ) . the organism may be seen in biopsy specimens of the kidney or skin or in the csf by dark-field microscopy or silver staining. serologic tests to detect leptospirosis are now sensitive and considerably aid the diagnosis. immunoglobulin m (igm) antibody may be detected as early as - days into the illness, and antibody titers rise progressively over the next - weeks. some patients remain seronegative, and negative serologic test results do not completely exclude the diagnosis. in one series levels of igm and igg anticardiolipin concentrations were significantly increased in leptospirosis patients with acute renal failure ( ) . leptospirosis is treated with intravenous penicillin or other beta-lactam antibiotics. the severity of leptospirosis is reduced by antibiotic treatment, even if started late in the course of the illness ( ) . supportive treatment with volume replacement to correct hypovolemia, administration of inotropes, and correction of coagulopathy is essential in severe cases. dialysis may be required in severe cases and may be needed for prolonged periods until recovery occurs. infection with s. pneumoniae is one of the most common infections in humans and causes a wide spectrum of disease, including pneumonia, otitis media, sinusitis, septicemia, and meningitis. despite the prevalence of the organism, significant renal involvement is relatively rare but is seen in two situations: pneumococcal septicemia in asplenic individuals or in those with other immune deficiencies presents with fulminant septic shock in which renal failure may occur as part of a multisystem derangement. the mortality from pneumococcal sepsis in asplenic patients is high, even with early antibiotic treatment and intensive support. the second nephrologi syndrome associated with s. pneumoniae is a rare form of hus. in , gasser and colleagues described hus as a clinical entity in children, and they included two infants with pneumonia among the five patients they described ( ) . hus associated with pneumococcal infection is induced by the enzyme neuraminidase released from s. pneumoniae ( , ) . thomsen-friedenrich antigen (t antigen) is present on the surface of red blood cells, platelets, and glomerular capillary endothelia against which antibodies are present in normal serum. neuraminidase causes desialation of red blood cells, and possibly other blood cells and endothelium, by the removal of terminal neuraminic acid, which leads to unmasking of the t antigen. the resultant widespread agglutination of blood cells causes intravascular obstruction, hemolysis, thrombocytopenia, and renal failure. results of the direct coombs test are frequently positive, either from bound anti-t igm or from anti-t antibodies. the diagnosis of thomsen-friedenrich antibody-induced hus should be suspected in patients with acute renal failure, thrombocytopenia and hemolysis after an episode of pneumonia or bacteremia caused by s. pneumoniae. fragmented red blood cells will usually be present on blood film. association with s. pneumoniae is defined by culture of pneumococci from a normally sterile site within a week before or after onset of signs of hus. clues to a pneumococcal cause, in addition to culture results, include severe clinical disease, especially pneumonia, empyema, pleural effusion, or meningitis; hemolytic anemia without a reticulocyte response; positive results on a direct coombs test; and difficulties in abo crossmatching or a positive minor crossmatch incompatibility ( ) . however, when renal disease is seen in the context of severe pneumococcal infection, it is important to maintain a broad diagnostic perspective, because the occurrence of acute tubular necrosis due to septic shock and dic is well described ( , ) . therapy for this syndrome should be with supportive treatment and antibiotics (usually a third generation cephalosporin); dialysis may be required if renal failure occurs. because normal serum contains antibodies against the thomsen-friedenrich antigen, blood transfusion should be undertaken with washed red blood cells resuspended in albumin rather than plasma ( , ) . exchange transfusion and plasmapheresis have been used in some patients, with the rationale that these procedures may improve outcome by eliminating circulating neuraminidase ( , , ) . intravenous igg has been used in a patient and was shown to neutralize neuraminidase present in the patient's serum ( ) . in comparison to patients with the more common diarrhea-associated hus, s. pneumoniae-induced hus patients have a more severe renal disease. they are more likely to require dialysis. their long-term outcome maybe affected by the severity of the invasive streptococcal disease itself, and a significant proportion of surviving patients ( - %) develop end-stage renal failure ( , ) . a recent review of uk cases found an eightfold increase in early mortality as compared to diarrhoea-induced hus ( ) . gastrointestinal infections (escherichia coli, salmonella, campylobacter, yersinia, shigella, vibrio cholerae) the diarrheal diseases caused by escherichia coli, salmonella, shigella, campylobacter, vibrios, and yersinia remain important and common bacterial infections of humans. although improvements in hygiene and living conditions have reduced the incidence of bacterial gastroenteritis in developed countries, these infections remain common in underdeveloped areas of the world, and outbreaks and epidemics continue to occur in both developed and underdeveloped countries. renal involvement in the enteric infections may result from any of four possible mechanisms. regardless of the causative organism, diarrhea results in hypovolemia, abnormalities of plasma electrolyte composition, and renal underperfusion. if severe dehydration occurs and is persistent, oliguria from prerenal failure is followed by vasomotor nephropathy and established renal failure. e. coli, shigella, and salmonella (particularly salmonella typhi) may invade the bloodstream and induce septicemia or septic shock. acute renal failure is commonly seen in infants with e. coli sepsis but is also reported with klebsiella, salmonella, and shigella infections. its pathophysiology and treatment were discussed previously. enteric infections with e. coli, yersinia, campylobacter, and salmonella have been associated with several different forms of gn, including membranoproliferative gn (mpgn), interstitial nephritis, diffuse proliferative gn, and iga nephropathy ( ) ( ) ( ) . in typhoid fever, gn ranging from mild asymptomatic proteinuria and hematuria to acute renal failure may occur ( , ( ) ( ) ( ) . renal biopsy findings show focal proliferation of mesangial cells, hypertrophy of endothelial cells, and congested capillary lumina. immunofluorescent studies show igm, igg, and c deposition in the glomeruli, with salmonella antigens detected within the granular deposits in the mesangial areas. in the iga nephropathy after typhoid fever, salmonella vi antigens have been demonstrated within the glomeruli. yersinia infection has been reported as a precipitant of gn in several studies ( , ) . transient proteinuria and hematuria are found in % of patients with acute yersinia infection, and elevated creatinine levels in %. renal biopsy reveals mild mesangial gn or iga nephropathy. yersinia antigens, immunoglobulin, and complement have been detected in the glomeruli. yersinia pseudotuberculosis is well recognized as one of the causes of acute tubulointerstitial nephritis causing acute renal failure, especially in children; patients have histories of drinking untreated water in endemic areas ( ) ( ) ( ) . the illness begins with the sudden onset of high fever, skin rash, and gi symptoms. later in the course, periungual desquamation develops, mimicking kawasaki disease. elevated erythrocyte sedimentation rate, c-reactive protein level, and thrombocytosis are noticeable, and mild degrees of proteinuria, glycosuria, and sterile pyuria are common. acute renal failure, which typically develops - weeks after the onset of fever, follows a benign course with complete recovery. renal biopsy mainly reveals findings of acute tubulointerstitial nephritis. antibiotic therapy, although recommended, does not alter the clinical course, but reduces the fecal excretion of the organism ( , ) . hus is characterized by three distinct clinical signs: acute renal failure, thrombocytopenia, and microangiopathic hemolytic anemia. it was first described in and was associated with infection by shiga toxin-producing shigella dysenteriae. a major breakthrough in the search for the cause of hus occurred in the s when karmali et al. reported that of children with diarrheaassociated hus had evidence of infection with a strain of e. coli that produced a toxin active on vero cells ( ) . in diarrhea-associated hus in the united states and most of europe, e. coli :h is the most important of these strains. e. coli :h occurs naturally in the gi tract of cattle and other animals, and humans become infected through contaminated food products. most outbreaks have been associated with consumption of undercooked meat, but unpasteurized milk and cider, drinking water, and poorly chlorinated water for recreational use have also been implicated as vehicles for bacterial spread. hus is discussed in detail in chapter . the global epidemic of mycobacterium tuberculosis is growing. several factors have contributed to this increase, including the emergence of the human immunodeficiency virus (hiv) infection epidemic, large influxes of immigrants from countries in which tuberculosis (tb) is common, the emergence of multiple-drug-resistant m. tuberculosis, and breakdown of the health services for effective control of tb in various countries. it is generally estimated that, overall, one-third of the world's population is currently infected with the tb bacillus. there are more than million cases of tb, which result in the death of approximately million people each year. furthermore, - % of people who are infected with the tb bacillus develop tb disease or become infectious at some time during their lives ( , ) . after respiratory illness in children, mycobacteria are widely distributed to many organs of the body during the lymphohematogenous phase of childhood tb ( ) . tubercle bacilli can be recovered from the urine in many cases of miliary tb. hematogenously-spread tuberculomata develop in the glomeruli, which results in caseating, sloughing lesions that discharge bacilli into the tubules. in most cases, the renal lesions are asymptomatic and manifest as mycobacteria in the urine or as sterile pyuria. tuberculomata in the cortex may calcify and cavitate or may rupture into the pelvis, discharging infective organisms into the tubules, urethra, and bladder. dysuria, loin pain, hematuria, and pyuria are the presenting features of this complication, but in many cases, the renal involvement is asymptomatic, even when radiologic and pathologic abnormalities are very extensive. continuing tuberculous bacilluria may cause cystitis with urinary frequency and, in late cases, a contracted bladder ( ) . the intravenous urogram is abnormal in most cases. early findings are pyelonephritis with calyceal blunting and calyceal-interstitial reflux. later, papillary cavities may be seen, indicating papillary necrosis. ureteric strictures, focal calcification, hydronephrosis, and cavitation may also be seen. renal function is usually well preserved, and hypertension is uncommon. in some cases, either the infection itself or reactions to the chemotherapeutic agents may result in renal failure with evidence of an interstitial nephritis ( ) ( ) ( ) . classic symptomatic renal tb is a late and uncommon complication in children, rarely occurring less than or years after the primary infection, and therefore is most commonly diagnosed after adolescence ( , ) . adult studies have shown that - % of renal tb coexists with active pulmonary tb and - % of screened sputumpositive pulmonary tb patients have renal involvement. the diagnosis is established by isolation of mycobacteria from the urine or by the presence of the characteristic clinical and radiographic features in a child with current or previous tb. renal tb is treated with drug regimens similar to those used for other forms of tb, with isoniazid, rifampicin, pyrazinamide and ethambutol administered initially for months, and isoniazid and rifampicin then continued for a further - months. late scarring and urinary obstruction may occur in cases with extensive renal involvement, and such patients should be followed by ultrasonography or intravenous urogram. mycobacteria, both m. tuberculosis and atypical mycobacteria, have also emerged as important causes of opportunistic infection in immunocompromised patients undergoing dialysis and in patients undergoing renal transplantation. the possibility of mycobacterial disease must be considered in patients with fever of unknown origin or unexplained disease in the lungs or other organs. results of the mantoux test are often negative, and diagnosis depends on maintaining a high index of suspicion and isolating the organism from the infected site. renal involvement has been well documented in both congenital and acquired syphilis, with an estimated occurrence of . % in patients with secondary syphilis and up to % in those with congenital syphilis ( , ) . the most common manifestation of renal disease in congenital syphilis is the nephrotic syndrome, with proteinuria, hypoalbuminemia, and edema. in some patients, hematuria, uremia, and hypertension may be seen. the renal disease is usually associated with other manifestations of congenital syphilis, including hepatosplenomegaly, rash, and mucous membrane findings. nephritis in congenital syphilis is usually associated with evidence of complement activation, with depressed levels of clq, c , c , and c . histologic findings are a diffuse proliferative gn or a membranous nephropathy. the interstitium shows a cellular infiltrate of polymorphonuclear and mononuclear cells ( ) . immunofluorescent microscopy reveals diffuse granular deposits of igg and c along the glomerular basement membrane (gbm). mesangial deposits may also contain igm. on electron microscopy, scattered subepithelial electron-dense deposits are seen, with fusion of epithelial cell foot processes ( ) . good evidence exists that renal disease is due to an immunologically mediated reaction to treponemal antigens. antibodies reactive against treponemal antigens can be eluted from the glomerular deposits, and treponemal antigens are present in the immune deposits. treatment of both congenital and acquired syphilis with antibiotics results in rapid improvement in the renal manifestations ( , ) . renal involvement is surprisingly rare in mycoplasma pneumoniae infection considering the prevalence of this organism and its propensity to trigger immunologically mediated diseases such as erythema multiforme, arthritis, and hemolysis. acute nephritis associated with mycoplasma infection may occur - days after the respiratory tract infection ( , ) . renal histopathologic findings include type mpgn, proliferative endocapillary gn, and minimal change disease ( ) . antibiotic treatment of the infection does not appear to affect the renal disease, which is self-limited in most cases ( , ) . since its recognition in , legionnaires' disease, caused by legionella pneumophila, has emerged as an important infectious diseases and the kidney cause of pneumonia. the disease most commonly affects the elderly but has been reported in both normal and immunocompromised children ( , ) . renal dysfunction occurs in a minority of patients ( ) . patients who develop renal impairment present with oliguria and rising urea and creatinine levels. they are usually severely ill, with bilateral pulmonary infiltrates, fever, and leukocytosis. shock may be present, and the renal impairment has been associated with acute rhabdomyolysis with high levels of creatine phosphokinase and myoglobinuria. renal histologic examination usually shows a tubulointerstitial nephritis or acute tubular necrosis ( , ) . the pathogenesis of the renal impairment is uncertain, but the organism has been detected within the kidney on electron microscopy and immunofluorescent studies, which suggests a direct toxic effect. myoglobinuria and decreased perfusion may also be contributing factors, however. mortality has been high in reported cases of legionnaires' disease complicated by renal failure. treatment is based on dialysis, intensive care, and antimicrobial therapy with erythromycin ( ) . steroid therapy may be effective for tubulointerstitial nephritis ( ) . the rickettsial diseases are caused by a family of microorganisms that have characteristics common to both bacteria and viruses and that cause acute febrile illnesses associated with widespread vasculitis. with the exception of q fever, all are associated with erythematous rashes. there are four groups of rickettsial diseases: . the typhus group includes louse-borne and murine typhus, spread by lice and fleas, respectively. . the spotted fever group includes rocky mountain spotted fever, tick typhus and related mediterranean spotted fever and rickettsial pox, which are spread by ticks and mites, with rodents as the natural reservoir. . scrub typhus, which is spread by mites. . q fever, which is spread by inhalation of infected particles from infected animals. rickettsial diseases have a worldwide distribution and vary widely in severity, from self-limited infections to fulminant and often fatal illnesses ( ) . in view of the widespread vasculitis associated with these infections, subclinical renal involvement probably occurs in many of the rickettsial diseases. however, in rocky mountain spotted fever, tick typhus, and q fever, the renal involvement may be an important component of the illness. rocky mountain spotted fever is the most severe of the rickettsial diseases ( , ) . the onset occurs - days after the bite of an infected tick. high fever develops initially, followed by the pathognomonic rash, which occurs between the second and sixth days of the illness. the rash initially consists of small erythematous macules, but later these become maculopapular and petechial, and in untreated patients, confluent hemorrhagic areas may be seen. the rash first appears at the periphery and spreads up the trunk. involvement of the palms and soles is a characteristic feature ( ) . headache, restlessness, meningism, and confusion may occur together with other neurologic signs. cardiac involvement with congestive heart failure and arrhythmia are common. pulmonary involvement occurs in - % of cases. infection is associated with an initial leucopenia, followed by neutrophil leukocytosis. thrombocytopenia occurs in most cases. histopathologically, the predominant lesions are in the vascular system ( ) . rickettsiae multiply in the endothelial cells, which results in focal areas of endothelial cell proliferation, perivascular mononuclear cell infiltration, thrombosis, and leakage of red cells into the tissues. the renal lesions involve both blood vessels and interstitium, and acute tubular necrosis may occur. acute gn with immune-complex deposition has been reported ( ) , but in most cases the pathology appears to be a direct consequence of the invading organism on the renal vasculature ( , ) . renal dysfunction is an important complication of rocky mountain spotted fever. elevation of urea and creatinine levels occurs in a significant proportion of cases, and acidosis is common. prerenal renal failure caused by hypovolemia and impaired cardiac function may respond to volume replacement and inotropic support, but acute renal failure may subsequently occur, necessitating dialysis. rocky mountain spotted fever is diagnosed by the characteristic clinical picture, the exclusion of disorders with similar manifestations (e.g., measles, meningococcal disease, and leptospirosis), and detection of specific antibodies in convalescence. culture of rickettsia rickettsii, immunofluorescent staining, and polymerase chain reaction (pcr) testing of blood and skin biopsy specimens are available only in reference laboratories. antibiotics should be administered in suspected cases without awaiting confirmation of the diagnosis ( ) . doxycycline is the drug of choice for children of any age. chloramphenicol is also effective ( ) . intensive support of shock and multiorgan failure may be required in severe cases, and peritoneal dialysis or hemodialysis may be required until renal function returns. before the advent of specific therapy, mortality was %. today the overall mortality in the united states is still - %. death predominantly occurs in cases in which the diagnosis is delayed. q fever is caused by coxiella burnetii and has a worldwide distribution, with the animal reservoir being cattle, sheep, and goats. human infection follows inhalation of infected particles from the environment. the clinical manifestations range from an acute self-limited febrile illness with atypical pneumonia to involvement of specific organs that causes endocarditis, hepatitis, osteomyelitis, and central nervous system disease ( ) . proliferative gn may be associated with either q fever endocarditis, rhabdomyolysis or a chronic infection elsewhere in the body ( ) . renal manifestations range from asymptomatic proteinuria and hematuria to acute renal failure, hypertension, and nephrotic syndrome. renal histologic findings are those of a diffuse proliferative gn, focal segmental gn, or mesangial gn. immunofluorescent studies reveal diffuse glomerular deposits of igm in the mesangium, together with c and fibrin. c. burnetii antigen has not been identified within the renal lesions. treatment of the underlying infection may result in remission of the renal disease, but prolonged treatment may be required for endocarditis. tetracycline has been used in conjunction with rifampicin, co-trimoxazole, or a fluoroquinolone. nephritis has been reported in association with the presence of a wide range of microorganisms that cause chronic or persistent infection (> table - ) ( , ). it is likely that any infectious agent that releases foreign antigens into the circulation, including those of very low virulence, can cause renal injury either by deposition of foreign antigens in the kidney or by the formation of immune complexes in the circulation, which are then deposited within the kidney. nephritis is most commonly seen in association with intravascular infections such as sbe or infected ventriculoatrial shunts, but it is also seen after focal extravascular infections; ear, nose, and throat infections; and abscesses. renal involvement is one of the diagnostic features of bacterial endocarditis. virtually all organisms that cause endocarditis also produce renal involvement ( > table - ). although endocarditis caused by bacteria is the most common and is readily diagnosed by blood culture ( ), unusual but important causes of culture-negative endocarditis include q fever ( ) and legionella infection ( ) . in the immunocompromised individual, opportunistic pathogens such as fungi and mycobacteria are important causes. the usual renal manifestations of sbe are asymptomatic proteinuria, hematuria, and pyuria. loin pain, hypertension, nephrotic syndrome, and renal failure may occur in more severe cases. the renal lesions occurring in endocarditis are variable, and focal embolic and immune-complex-mediated features may coexist ( , , ) . embolic foci may be evident as areas of infarction, intracapillary thrombosis, or hemorrhage. more commonly, there is a focal necrotizing or diffuse proliferative gn. immunofluorescent studies show glomerular deposits of igg, igm, iga, and c along the gbm and within the mesangium. electron microscopy reveals typical electron-dense deposits along the gbm and within the mesangium ( , , ) . early reports suggested that the renal lesions were caused by microemboli from infected vegetations depositing in the kidney, a hypothesis supported by the occasional presence of bacteria within the renal lesions. most subsequent evidence, however, indicates that immunologic mechanisms rather than emboli are involved in the pathogenesis in most cases: bacteria are rarely found within the kidney, and renal involvement occurs with lesions of the right side of the heart, which would not be likely to embolize to the kidney. immune complexes containing bacterial antigens are present in the circulation, and both bacterial antigens and bacteria-specific antibodies can be demonstrated within the immune deposits in the kidney. serum c level is usually low, and complement can be found within both the circulating and the deposited immune complexes. these features all support an immune-complex-mediated pathogenesis of the renal injury ( , , ) . treatment of the endocarditis with antibiotics usually results in resolution of the gn and is associated with the disappearance of immune complexes from the circulation and return of c levels to normal. the prognosis of the renal lesions in sbe generally depends on the response of the underlying endocarditis to antibiotics or, in cases of antibiotic failure, to surgical removal of the infective vegetations ( ) . in patients previously treated by shunting for hydrocephalus, there is a well-documented association of gn with infected ventriculoatrial shunts. this condition is another example of an immune-complex nephritis similar to that seen in endocarditis ( ) . coagulase-negative staphylococci are the causative organisms in % of cases. the clinical and pathologic findings are similar to those in sbe. presenting features are proteinuria, hematuria, and pyuria, and they may progress to renal failure. immune complexes containing the bacterial antigens and complement are present in the serum, and c is depressed. histologic findings are those of a diffuse mesangiocapillary gn. immunofluorescent microscopy demonstrates deposits of immunoglobulin and c along the gbm, and bacterial antigen can be demonstrated in the renal lesions ( ) . the prognosis for the renal lesion is good if the infection is treated early. this usually involves removal of the infected shunt and administration of appropriate antibiotics ( , ) . the possible progression to end-stage renal disease requires frequent nephrologic monitoring of patients with ventriculoatrial shunts ( ) . there are a few reports in the literature of a similar renal complication occurring in chronic infection of ventriculoperitoneal shunts. gn has been reported after chronic abscesses ( ), osteomyelitis, otitis media, pneumonia, and other focal infections ( > table - ). acute renal failure has been the presenting feature of focal infections in various sites, including the lung, pleura, abdominal cavity, sinuses, and pelvis. many different organisms have been responsible, including s. aureus, pseudomonas, e. coli, and proteus species. this is probably another example of immunecomplex gn. c level is decreased in approximately onethird of reported cases, and immunofluorescent studies reveal diffuse granular deposits of c in the glomeruli of all reported instances, with a variable presence of immunoglobulin. the renal lesion is that of mpgn and crescentic nephritis. the renal outcome is reported to be good with successful early treatment of the underlying infection. the role of viral infections in the causation of renal disease has been less well defined than that of bacterial infections. clearly defined associations of renal disease have been made with hepatitis b virus (hbv), hepatitis c virus (hcv), hiv, and hantaviruses, but the role of most other viruses in the pathogenesis of renal disease is not clearly defined. most viruses causing systemic infection may trigger immunologically mediated renal injury. with increasing application of molecular techniques, it may be that a significant proportion of gns currently considered to be idiopathic will ultimately be shown to be virus induced. in children with immunodeficiency states and those undergoing renal transplantation, viruses such as cytomegalovirus (cmv) and polyoma virus have been recognized to be associated with nephropathy. since the discovery of hepatitis b surface antigen (hbsag) in , hepatitis virus has been shown to infect more than % of the world's population and is a major cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma worldwide. some million people have hbsag in the circulation (who figures). the infection is most common in africa and the orient, where it is acquired in childhood by vertical transmission from infected mothers or by horizontal transmission from other children or adults. in developed countries, transmission in adults occurs more often by blood product exposure, sexual contact, or intravenous drug use. the epidemiology of hbv infection in children is changing following the widespread use of effective vaccination at birth, in both developed and developing countries. hbv is a complex dna virus with an outer surface envelope (hbsag) and an inner nucleocapsid core containing the hepatitis b core antigen (hbcag), dna polymerase, protein kinase activity, and viral dna. incomplete spherical and filamentous viral particles consisting solely of hbsag are the major viral products in the circulation and may be present in concentrations of up to particles per ml of serum. hepatitis b e antigen (hbeag) can be released from hbcag by proteolytic treatment and may be found in the circulation either free or complexed to albumin or igg antibodies. the presence of hbeag correlates with the presence of complete viral particles and the infectivity of the individual ( ) . infection with hbv may result in either a self-limited infectious hepatitis followed by clearance of the virus and complete recovery, or a chronic or persistent infection in which the immune response is ineffective in eliminating the virus. chronic hbv infection with continued presence of viral antigens in the circulation caused by an ineffective host immune response provides the best-documented example of immunologically mediated renal injury caused by persistent infection ( ) . development of chronic hbv infection is positively associated with infection at a younger age, particularly in infancy, where the rate of chronic infection is up to %. in contrast, the likelihood of an acute, symptomatic illness increases with age, to a level where approximately % of infections are symptomatic in children above years. in the early prodromal phase of hbv hepatitis, before the onset of jaundice, some patients develop fever, maculopapular or urticarial rash, and transient arthralgias or arthritis. occasionally, proteinuria, hematuria, or sterile pyuria are observed. the syndrome usually lasts - days and often resolves before the onset of jaundice ( , ) . there have been no histologic studies of the renal changes during this prodromal period. since , numerous reports have linked hbv infection with polyarteritis nodosa (pan). most of these cases have been in adults, but the disorder has also been reported in children ( , ) , where it is estimated that approximately one third of pan cases are caused by hbv ( ) . hbv pan appears to be uncommon in africa and the orient, where infection is usually acquired in childhood, and has declined in incidence following the introduction of hbv vaccination ( ) . hbv pan presents weeks to months after a clinically mild hepatitis but may occasionally predate the hepatitis. after a prodromal illness, frank vasculitis affecting virtually any organ appears. abdominal pain, fever, mononeuritis multiplex, and pulmonary and renal involvement may occur. the renal involvement may appear as hypertension, hematuria, proteinuria, or renal failure (see chapter ) . laboratory investigations reveal a florid acute-phase response, leukocytosis, and anemia. transaminase levels are usually elevated, and hbsag is present in the circulation. the pathology consists of focal inflammation of small and medium-sized arteries, with fibrinoid necrosis, leukocyte infiltration, and fibrin deposition. renal pathology may be limited to the medium-sized arteries or may coexist with gn ( , ) . circulating immune complexes containing hbsag and anti-hbs antibodies are usually present in the circulation ( , ) . c , c , and total hemolytic complement levels are depressed. hbsag, igg, and igm antibodies to hbv and c have been identified by immunofluorescence in the blood vessels ( ) . a positive anca excludes hbv-pan ( ) . although most evidence suggests that the pathogenesis involves an immunecomplex-mediated vasculitis, autoantibody or cell-mediated vascular injury may coexist. if the condition is untreated, the mortality is high ( ) . most studies suggest that steroids or immunosuppressants help to suppress the vasculitis but potentially predispose to chronic infection . ( , ) . successful treatment of hepatitis b-associated pan with nucleoside analogues such as lamivudine or newer anti-viral drugs, either alone or in combination with interferon-alpha and conventional immunosuppressive therapy, has been reported ( ) ( ) ( ) . hbv is now the major cause of membranous gn (mgn) in children worldwide. the proportion of patients with mgn caused by hbv is directly related to the incidence of hbsag in the population, with - % of all cases of mgn in some african and oriental countries being associated with hbv ( , ) (see chapter ) . hbv mgn usually presents in children aged - . there is a striking male predominance; in the united states, % of patients are males ( ) . the virus is usually acquired by vertical transmission from infected mothers or horizontally from infected family members. unlike adults with hbv mgn, children do not usually have a history of hepatitis or of active liver disease, but liver function test results are generally mildly abnormal. liver biopsy specimens may show minimal abnormalities, chronic persistent hepatitis, or (occasionally) more severe changes ( ) . the renal manifestations are usually of proteinuria, nephrotic syndrome, microscopic hematuria, or (rarely) macroscopic hematuria. hypertension occurs in less than % of cases, and renal insufficiency is rare. hbsag and hbcag are usually present in the circulation, and hbe antigenemia is seen in a high proportion of cases. occasionally, hbsag may be found in the glomeruli but is absent from the circulation. c and c levels are often low, and circulating immune complexes are found in most cases. immunohistologic study reveals deposits of igg and c and (less commonly) igm and iga in subepithelial, subendothelial, or mesangial tissue. hbv particles may be seen on electron microscopy, and all the major hepatitis b antigens, including hbsag, hbcag, and hbeag, have been localized in the glomerular capillary wall on immunofluorescence. immunologic deposition of hbv and antibody in the glomerular capillary wall is clearly involved in the glomerular injury, but the underlying immunologic events are incompletely understood ( , ) . passive trapping of circulating immune complexes may be involved, but the circulating immune complexes containing hbsag are usually larger than would be expected to penetrate the basement membrane. hbsag and hbcag are anionic and are therefore unlikely to penetrate the glomerular capillary wall. in contrast, hbeag forms smaller complexes with anti-hbe antibodies and may readily penetrate the gbm. this may explain the observation that hbeag in the circulation frequently correlates with the severity of the disease ( ) . an alternative mechanism for immunemediated glomerular injury is the trapping of hbv antigens by antibody previously deposited in the kidney. anti-hbe antibodies are cationic and may readily localize in the glomerulus and subsequently bind circulating antigen and complement. the third possibility is that the depositions of hbv and antibodies are consequences of glomerular injury by cellular mechanisms or autoantibodies. little evidence supports this view at present ( ) . a transgenic mouse model of hbv-associated nephropathy has been developed, in which hbsag and hbcag is expressed in liver and kidney, particularly tubular epithelial cells, without viral replication. in these mice, gene expression analysis revealed upregulation of acute-phase proteins, particularly c , although measurable serum c levels were reduced. this supports the notion that local persistent expression of hbv viral proteins contributes to hbv-associated nephropathy ( ) . hbv infection has been associated with a variety of other forms of gn in both adults and children. in one small series in children, mpgn was found to be equal in incidence to mgn in the spectrum of hbv-associated gns ( ) . both mpgn and mesangial proliferative gn may be triggered by hbv. in several countries where hbv is common, the proportion of patients with these forms of nephritides who test positive for hbv greatly exceeds the incidence of positivity in the general population ( ) . as with mgn and hbv-associated pan, circulating immune complexes and localization of hbv antigens in the glomeruli have been reported in both mpgn and mesangial proliferative gn, and it is likely that similar mechanisms are occurring ( , ) . several other forms of gn have been associated with hbv, including iga nephropathy, focal glomerulosclerosis, crescentic nephritis, and systemic lupus erythematosus, but the evidence for these associations is less consistent than for the entities discussed earlier ( ) . hbv is normally cleared as a result of cell-mediated responses in which cytotoxic t cells and natural killer cells eliminate infected hepatocytes. it is not surprising, therefore, that the administration of steroids and immunosuppressive agents either may have no effect on hbv disease or may increase the risk of progressive disease ( ) . children with hbv mgn have a good prognosis, and two-thirds undergo spontaneous remission within years of diagnosis. steroid therapy does not appear to provide any additional benefit ( , , ) . antiviral therapy with pegylated interferon-alpha and lamivudine shows promise in facilitating clearance of hbv, and in some cases, elimination of the infection with antiviral therapy in both children and adults is associated with improvement or resolution of the coexisting renal disease. there is considerable effort being put into the development of newer anti-viral agents which avoid the common problems of resistance associated with lamivudine ( - ). hcv is an enveloped, single-stranded rna virus of approximately . kb in the flaviviridae family. there are six major hcv genotypes. hepatitis c is a common disease affecting approximately million people worldwide. in the united states, . million persons are estimated to be anti-hcv positive, and . million may be chronically infected ( ) . an estimated , children in the united states have antibody to hcv and , - , are chronically infected ( ) . children become infected through receipt of contaminated blood products or through vertical transmission. the risk of vertical transmission increases with higher maternal viremia and maternal co-infection with hiv. acute hcv infection is rarely recognized in children outside of special circumstances such as a known exposure from an hcv-infected mother or after blood transfusion. most chronically infected children are asymptomatic and have normal or only mildly abnormal alanine aminotransferase levels. although the natural history of hcv infection during childhood seems benign in the majority of instances, the infection can take an aggressive course in a proportion of children, leading to cirrhosis and end-stage liver disease during childhood. the factors responsible for this more aggressive course are unidentified ( ) . even in adults, the natural history of hcv infection has a variable course, but a significant proportion of patients will develop some degree of liver dysfunction, and - % will eventually have end-stage liver disease as a result of cirrhosis. the risk of hepatocellular carcinoma is significant for those who have established cirrhosis. hepatitis c is currently the most common condition leading to liver transplantation in adults in the ''western world.'' gn has been described as an important complication of chronic infection with hcv in adults. the clinical presentation is usually of nephrotic syndrome or proteinuria, hypertension, or hematuria, with or without azotemia ( ) . mpgn, with or without cryoglobulinemia, and mgn are most commonly described. isolated case reports of other, more unusual patterns of glomerular injury, including iga nephropathy, focal segmental glomerulosclerosis, crescentic gn, fibrillary gn, and thrombotic microangiopathy, have also been associated with hcv infection ( , ) . glomerular deposition of hepatitis antigens and antibodies has been described and is believed to play a role in pathogenesis. cryoglobulinemia is a common accompaniment of gn that is associated with the depression of serum complement levels ( ) . renal failure may develop in - % of patients who have mpgn ( , ) . the presence of virus-like particles as well as viral rna within the kidney sections of patients with hcv-associated glomerulopathies has been reported ( ) . the diagnosis should be suspected if glomerular disease is associated with chronic hepatitis, particularly with the presence of cryoglobulins, but renal biopsy is necessary to establish a definitive diagnosis. hcv infection is relatively common in children with end-stage renal disease and is an important cause of liver disease in this population. acquisition of hcv infection continues to occur in dialysis patients because of nosocomial spread ( ) . elevation of transaminase level is not a sensitive marker of infection in children and hcv enzymelinked immunosorbent assay or pcr testing should be used to increase sensitivity ( ) . hcv-infected renal transplant recipients had higher mortality and hospitalization rates than other transplant recipients ( ) , and hcv infection has been reported to be associated with de novo immune-mediated gn, especially type mpgn, in renal allografts, resulting in accelerated loss of graft function ( , ) . no large randomized, controlled trials of treatment of children with chronic hepatitis c have been performed, although one study (peds-c) is currently recruiting patients into a trial of pegylated interferon +/À ribavirin ( ) . small heterogeneous studies of interferon monotherapy have reported sustained virologic response rates of - % ( ) . in adults, improvement of proteinuria and renal function often follows interferon-alpha treatment ( , ) , but relapses are common after cessation of treatment. combination of interferon with ribavirin in infectious diseases and the kidney patients with chronic liver disease has been shown to increase the rate of sustained response in these patients ( ) . as yet, however, there are few data regarding the use of combination therapy with interferon and ribavirin in children. moreover, interferon-alpha therapy is associated with acute or subacute renal failure in more than one-third of the patients with renal transplants ( ) . hepatitis c may be complicated by systemic mixed cryoglobulinemic (mc) vasculitis, and in some cases by a polyarteritis nodosa (pan)-type non-cryoglobulinemic vasculitis ( ) . treatment with interferon-a (ifn-a) and ribavirin mostly is associated with an improvement of vasculitic symptoms. in some cases, exacerbation and rarely new onset of vasculitis of the peripheral nervous system have been described after this treatment. in fulminant cases immunosuppressive therapy with steroids, and cyclophosphamide, or rituximab may be needed to control life threatening vasculitis prior to antiviral treatment ( ) . cytomegalovirus cmv is one of the eight human herpes viruses. transmission of the virus requires exposure to infected body fluids such as breast milk, saliva, urine, or blood. individuals initially infected with cmv may be asymptomatic or display nonspecific flu-like symptoms. after the initial infection cmv, like all herpes viruses, establishes latency for life but will be periodically excreted by an asymptomatic host. cmv replicates within renal cells, and on biopsy samples from immunocompromised hosts, viral inclusions can be visualized by light microscopy in cells of the convoluted tubules and collecting ducts ( ) . glomerular cells and shed renal tubular cells may have characteristic inclusions, but clinically evident renal disease is rare and is seen virtually only in immunocompromised or congenitally infected children ( , ) . the clinical manifestations of cmv-induced renal disease in congenitally infected infants are variable and range from asymptomatic proteinuria to nephrotic syndrome and renal impairment. in congenital cmv infection, histologic changes of viral inclusions commonly occur in the tubules. in addition, proliferative gn has been reported, with evidence on electron microscopy of viral immune deposits in glomerular cells ( , ) . in cmv-infected immunocompromised patients, immunecomplex gn has been documented with mesangial deposits of igg, iga, c , and cmv antigens within glomeruli. eluted glomerular immunoglobulins have been shown to contain cmv antigens ( ) . cmv is the most common viral infection after kidney transplantation. experience with pediatric kidney transplant recipients suggests a % incidence of cmv infection ( ) . the direct and indirect effects of cmv infection result in significant morbidity and mortality among kidney transplant recipients. cmv-negative patients who receive a cmv-positive allograft are at risk for primary infection and graft dysfunction. patients who are cmv seropositive at the time of transplantation are also at risk of reactivation and superinfection. tubulointerstitial nephritis is a well-characterized pathologic feature of renal allograft cmv disease, which can be difficult to distinguish from injury caused by rejection. histologic evidence of endothelial cell injury and mononuclear cell infiltration in the glomeruli has been reported ( ) . cmv glomerular vasculopathy in the absence of tubulointerstitial disease, causing renal allograft dysfunction, has also been reported ( ) . beyond the acute allograft nephropathy associated with cmv viremia, cmv is known to cause chronic vascular injury. this may adversely affect the long-term outcome of the allograft and may be the explanation for the observed association with chronic allograft nephropathy ( ) . newer techniques for rapidly diagnosing cmv infection are becoming widely available and include shell vial culture, pp antigenemia assay, pcr, and the hybridcapture rna-dna hybridization assay for qualitative detection of cmv pcr. quantitative plasma pcr testing (pcr viral load) is increasingly used for diagnosis and monitoring of cmv viremia in renal transplant recipients. antiviral agents that have been shown to be effective against cmv include ganciclovir, valganciclovir, foscarnet, and cidofovir. ganciclovir remains the drug of choice for treating established disease. intravenous ganciclovir therapy is preferred in children because of the erratic absorption of oral ganciclovir. major limitations of ganciclovir therapy are the induction of renal tubular dysfunction and bone marrow toxicity, principally neutropenia and thrombocytopenia. dosage adjustments are necessary for recipients with renal dysfunction. oral valganciclovir is now used for cmv prophylaxis post-transplant ( ) . use of other antiviral agents such as foscarnet and cidofovir is limited because of nephrotoxicity and difficulty of administration. a number of reports have demonstrated the effectiveness of high-titer cmv immune globulin therapy in reducing severe cmv-associated disease when used in combination with ganciclovir ( , ) . the association of varicella with nephritis has been known for more than years since henoch reported on four children with nephritis that occurred after the appearance of varicella vesicles. varicella, however, is rarely associated with renal complications ( ) . in fatal cases with disseminated varicella and in the immunocompromised individual, renal involvement is more common. cases in which varicella infection caused gn in renal transplant recipients have been reported ( ) . histologic findings in fatal cases include congested hemorrhagic glomeruli, endothelial cell hyperplasia, and tubular necrosis. in mild and nonfatal cases and in non-immunocompromised individuals, varicella is occasionally associated with a variety of renal manifestations, ranging from mild nephritis to nephrotic syndrome and acute renal failure ( ) . histologic findings include endocapillary cell proliferation, epithelial and endothelial cell hyperplasia, and inflammatory cell infiltration ( ) . rapidly progressive nephritis has also been reported. immunohistochemical studies reveal glomerular deposition of igg, igm, iga, and c . on electron microscopy, granular electron-dense deposits have been found in the paramesangial region, and varicella antigens may be deposited in the glomeruli. the features suggest an immune-complex nephritis. elevated circulating levels of igg and iga immune complexes and depressed c and c levels support this possibility ( ) . fulminant disseminated varicella and varicella in immunocompromised patients should be treated with intravenous acyclovir. renal involvement is common during acute infectious mononucleosis, usually manifesting as an abnormal urine sediment, with hematuria in up to % of cases. hematuria, either microscopic or macroscopic, usually appears within the first week of the illness and lasts for a few weeks to a few months. proteinuria is usually absent or low grade. more severe renal involvement with proteinuria, nephrotic syndrome, or acute nephritis with renal failure is much less common. acute renal failure may be seen during the course of fulminant infectious mononucleosis with associated hepatic failure, thrombocytopenia, and encephalitis. it is usually caused by interstitial nephritis that is likely the result of immunopathologic injury precipitated by epstein-barr virus (ebv) infection. however, the identification of ebv dna in the kidney raises the possibility that direct infection might play a role ( ) . the renal involvement must be distinguished from myoglobinuria caused by rhabdomyolysis, which may occur in infectious mononucleosis, and from bleeding into the renal tract as a result of thrombocytopenia. renal histologic findings in ebv nephritis are an interstitial nephritis with mononuclear cell infiltration and foci of tubular necrosis. glomeruli may show varying degrees of mesangial proliferation. on immunohistochemical study, ebv antigens are seen in glomerular and tubular deposits. the prognosis for complete recovery of renal function is good. treatment with corticosteroids may have a role in the management of ebv-induced acute renal failure and may shorten the duration of renal failure ( ) . ebv-associated post-transplantation lymphoproliferative disease is a recognized complication in renal transplant recipients. latent infection of ebv in renal proximal tubular epithelial cells has recently been described as causing idiopathic chronic tubulointerstitial nephritis ( ) . the herpes simplex virus (hsv) causes persistent infection characterized by asymptomatic latent periods interspersed with acute relapses. as with other chronic and persistent infections, immunologically mediated disorders triggered by hsv are well recognized, and it is perhaps surprising that hsv has rarely been linked to nephritis. acute nephritis and nephrotic syndrome have been associated with herpes simplex encephalitis. renal histology shows focal segmental gn with mesangial and segmental deposits of igm, c , and hsv antigens. as with other herpes viruses, hsv has been suggested as a trigger for iga nephritis, mpgn, and membranous nephropathy. elevated levels of hsv antibodies have been reported in patients with a variety of forms of gn, but no conclusive evidence exists of an etiologic role for hsv ( ) . adenovirus and enterovirus, are unrelated ubiquitous pathogens that infect large proportions of the population annually and yet are rarely associated with renal disease. the literature contains scattered reports of acute nephritis after infection with each of these viruses. adenovirus is a major cause of hemorrhagic cystitis and was implicated as the cause of hemorrhagic cystitis in - % of children with this disorder ( ) . boys are affected more often than girls, and hematuria persists for - days. microscopic hematuria, dysuria, and frequency may occur for longer periods. adenovirus types and are the usual strains isolated. picornaviruses, including enteroviruses, echovirus and coxsackieviruses, have been linked with acute nephritis and acute renal failure associated with rhabdomyolysis. coxsackie b virus can be isolated in urine. direct infection of kidney cells is supported by in vitro work demonstrating lytic infection of human podocyte and proximal tubular epithelial cell cultures, although different strains exhibit variable degrees of nephrotropism. renal damage in vivo may have both a direct lytic mechanism and an immune-complex basis ( ) . in the newborn, enteroviruses cause fulminant disease with dic, shock, and liver failure, and acute renal failure may occur. renal involvement from measles virus is uncommon, although measles virus can be cultured from the kidney in fatal cases. an acute gn has been reported to follow measles with evidence of immune deposits containing measles virus antigen within the glomeruli. the nephritis is generally self-limiting ( ) . mild renal involvement is common during the acute phase of mumps infection. one-third of children with mumps have abnormal urinalysis results, with microscopic hematuria or proteinuria. mumps virus may be isolated from urine during the first days of the illness, at a time when urinalysis findings are abnormal. plasma creatinine concentrations usually remain normal, despite the abnormal urine sediment, but more severe cases in adults have been associated with evidence of acute nephritis with impaired renal function. renal biopsy specimens demonstrate an mpgn with deposition of iga, igm, c , and mumps virus antigen in the glomeruli, which suggests an immune-complex-mediated process ( ) . despite the increasing availability of interventions to limit vertical hiv transmission, an estimated , children renal involvement in hiv infection was first described in in adults ( ) ( ) ( ) and in children ( ) , and renal involvement occurs in - % of hiv-infected children in the united states ( ) ( ) ( ) . since the development of highly active antiretroviral therapy (haart), however, the incidence of end-stage renal disease in hiv infection in both adults and children in industrialized countries has declined, but it is predicted that the dramatic decline in aids-related deaths will lead to an ageing population of hiv-infected individuals who will be at risk of non-hiv related renal problems, such that the numbers of hiv-positive esrd patients will increase in the united states ( ) . hiv infection is associated with a number of renal pathologies. hiv-associated nephropathy (hivan) is a syndrome of glomerular and tubular dysfunction, which can progress to end-stage renal failure. it is discussed more fully below. glomerular syndromes other than hivan include mgn that resembles lupus nephritis and immune-complex gn, with iga nephropathy and hcv-associated mpgn being the most common forms. there have also been several case reports of amyloid kidney ( , , ) . the kidneys may be affected by various other mechanisms. opportunistic infections with organisms such as bk virus (bkv) that give rise to nephropathy and hemorrhagic cystitis have been reported in association with hiv infection ( ) . systemic infections accompanied by hypotension can cause prerenal failure leading to acute tubular necrosis. acute tubular necrosis has also been reported in hiv patients after the use of nephrotoxic drugs such as pentamidine, foscarnet, cidofovir, amphotericin b, and aminoglycosides. intratubular obstruction with crystal precipitation can occur with the use of sulfonamides and intravenous acyclovir. indinavir is well recognized to cause nephropathy and renal calculi ( ) . mpgn associated with mixed cryoglobulinemia and thrombotic microangiopathy/atypical-cal hus in association with hiv infections have been reported ( , ) . hivan is characterized by both glomerular and tubular dysfunction, the pathogenesis of which is not entirely known. hivan is a clinico-pathologic entity that includes proteinuria, azotemia, focal segmental glomerulosclerosis or mesangial hyperplasia, and tubulointerstitial disease ( ) . in adults in the united states, there is a markedly increased risk of nephropathy among african american persons with hiv infection. this appears to be true in children as well, but the data are sparse. the spectrum of hivan seems to be coincident with the degree of aids symptomatology. it is thought that hivan can present at any point in hiv infection, but most patients with hivan have cd counts of less than  / cells/ml, which suggests that it may be primarily a manifestation of late-stage disease ( ) . although a spectrum of clinicopathologic entities including mesangial hyperplasia, focal segmental glomerulosclerosis, minimal change disease, and systemic lupus erythematosus nephritis has been described, the classic pathologic feature of hivan is the collapsing form of focal and segmental glomerulosclerosis ( ) . in the affected glomeruli, visceral epithelial cells are hypertrophied and hyperplastic, and contain large cytoplasmic vacuoles and numerous protein resorption droplets. there is microcystic distortion of tubule segments, which contributes to increasing kidney size. podocyte hyperplasia can become so marked that it causes obliteration of much of the urinary space, forming ''pseudocrescents'' ( ) . capillary walls are wrinkled and collapsed with obliteration of the capillary lumina. the interstitium is edematous with a variable degree of t-cell infiltration ( ) . the bowman capsule can also be dilated and filled with a precipitate of plasma protein that represents the glomerular ultrafiltrate. one of the most distinctive features of hivan, however, is the presence of numerous tubuloreticular inclusions within the cytoplasm of glomerular and peritubular capillary endothelial cells ( ) . immunofluorescence testing is positive for igm and c in capillary walls in a coarsely granular to amorphous pattern in a segmental distribution ( , ) . the presence of the hiv genome in glomerular and tubular epithelium has been demonstrated using complementary dna probes and in situ hybridization. proviral dna has been detected by pcr in the glomeruli, tubules, and interstitium of micro dissected kidneys from patients who had pathologic evidence of hivan, but it has also been detected in the kidneys of hiv-positive patients with other glomerulopathies ( ) . a combination of both proliferation and apoptosis of renal cells may cause the loss of nephron architecture. apoptosis has been demonstrated in cells in the glomerulus, tubules, and interstitium of biopsy specimens from hiv-positive patients with focal segmental glomerulosclerosis. in addition, the role of various cytokines and growth factors, specifically transforming growth factor beta (tgf-beta), in the development of sclerosis has been studied ( , ) . transgenic murine models provide some of the strongest evidence for a direct role of hiv- in the induction of hivan. these mice do not produce infectious virus but express the hiv envelope and regulatory genes at levels sufficient to re-create the hivan that is seen in humans ( ) . serial deletion experiments have concluded that the nef and vpr genes are necessary though not sufficient for hivan pathogenesis. additional factors such as genetic predisposition are thought to explain the fact that african americans have a far greater likelihood of developing hivan than other racial groups, and that hivan is more likely in patients with a family history of esrd. hivan can manifest as mild proteinuria, nephrotic syndrome, renal tubular acidosis, hematuria, and/or acute renal failure ( ) ( ) ( ) ( ) . nephrotic syndrome and chronic renal insufficiency are late manifestations of hivan. children with hivan are likely to develop transient electrolytic disorders, heavy proteinuria, and acute renal failure due to systemic infectious episodes or nephrotoxic drugs. early stages of hivan can be identified by the presence of proteinuria and ''urine microcysts'' along with renal sonograms showing enlarged echogenic kidneys. urinary renal tubular epithelial cells are frequently grouped together to form these microcysts, which were found in the urine of children with hivan who had renal tubular injury ( ) . advanced stages of hivan typically present with nephrotic syndrome with edema, heavy proteinuria, hypoalbuminemia, and few red or white blood cells in urinary sediments. hypertension may be present, but usually blood pressure is within or below the normal range. hivan in adults follows a rapidly progressive course, with end-stage renal disease developing within - months, but in children this rapid progression does not necessarily occur. definitive diagnosis of hivan should be based on biopsy results, and biopsy should be performed if significant proteinuria is present, because in approximately % of hiv-infected patients with azotemia and/or proteinuria (> g/ h) who undergo renal biopsy, the specimen will have histologic features consistent with other renal diseases ( ) . when available, haart should be given to children with symptomatic hiv disease. specific treatment of hivan remains controversial. several studies have looked at the role of haart, angiotensin i-converting enzyme (ace) inhibitors, steroids, and even cyclosporin with somewhat encouraging results. however, as yet no randomized case-controlled trials have been undertaken. most of the studies have been small and retrospective, and many have included patients both with and without renal biopsy-proven hivan. cyclosporin has been used to treat hivan in children with remission of nephrotic infectious diseases and the kidney syndrome ( ) . similar responses have been reported to treatment with corticosteroids in various studies ( ) ( ) ( ) ( ) . ace inhibitors have been used with encouraging results ( ) . the general regimen used to treat patients with hiv, including haart, should be applied to children with hivan. the dosages of some medications must be adjusted to the patients glomerular filtration. there are reports of spontaneous regression of hivan with supportive management and treatment with haart, particularly with regimes containing protease inhibitors ( ) ( ) ( ) ( ) . it should be emphasized that the improvement reported with other modalities of treatment such as corticosteroids, cyclosporin, and ace inhibitors always occurs when these agents are given in conjunction with antiretroviral therapy. the kidneys of transgenic mice have been found to have elevated levels of tgf-beta messenger rna and protein ( ) . furthermore, gene expression analysis on tubular epithelial cells from a patient with hivan found upregulation of several inflammatory mediator genes downstream of interleukin and of the transcription factor nfkb ( ) . several other therapeutic options have been suggested, aimed specifically at the presumed role of tgfbeta in the pathogenesis of hivan. treatment directed at its synthesis using gene therapy to block tgf-beta gene expression is being explored. therapy directed at decreasing the activity of tgf-beta using anti-tgf-beta antibodies or other inhibitory substances is also an area of investigation. in addition, blocking renal receptors for chemokines such as rantes (regulated upon derivation, normal t cell expressed and secreted), interleukin- , and monocyte-chemoattractant protein- has been proposed as another possible treatment alternative ( ) . in the haart era, the outlook for hiv patients with esrd has improved, but these patients fare worse than esrd patients without hiv ( ) . most reports of hivinfected patients on hemodialysis have shown poor prognosis, with mean patient survival times ranging from - months. mortality is therefore still close to % within the first year of dialysis. in general, improved survival is associated with younger age at initiation of hemodialysis and with higher cd counts. access complications such as infection and thrombosis tend to occur at a higher rate in hiv-infected hemodialysis patients. cross infection with hiv in dialysis patients is very rare. no patient-topatient hiv transmission has yet been reported in a hemodialysis unit in the united states, although several such cases have occurred in south america ( , ) . peritoneal dialysis is an alternative for hiv-infected patients. the incidence of peritonitis varies across studies, but some studies did report a higher incidence of pseudomonas and fungal peritonitis in the hiv-positive population ( ) . infections with unusual organisms such as pasteurella multocida, trichosporon beigelii, and mycobacterium avium intracellulare complex have also been reported. several studies, however, have suggested that there is no significant difference between the hiv-infected and non-hiv-infected populations. of note is that virus capable of replication in vitro has been recovered from the peritoneal dialysis effluent, and it can be recoverable for up to days in dialysis bags at room temperature and for up to h in dry exchange tubing ( ) . previously, long-term dialysis had been thought to be preferable to renal transplantation, primarily because of the concern that the immunosuppressive therapy required after transplantation could promote progression of hiv/ aids. a multicenter prospective study has been addressing these questions ( ) . data so far indicate that the outcome for liver and kidney transplantation is not considerably different from patients without hiv, with good graft persistence, and a low rate of development of opportunistic infections in those with well-controlled hiv and relatively high cd counts ( ) . the human polyoma viruses are members of the papovavirus family and have received increasing attention as pathogens in immunocompromised patients. they are nonenveloped viruses ranging in size from - nm, with a circular, double-stranded dna genome that replicates in the host nucleus. the best-known species in this genus are the bkv, the jc virus (jcv), and the simian virus sv . bkv was first isolated from the urine of a -year-old man who developed ureteral stenosis months after renal transplantation ( ) . the name of the virus refers to the first patients initials, which is also true of jcv. bkv establishes infection in the kidney and the urinary tract, and its activation causes a number of disorders, including nephropathy and hemorrhagic cystitis. bkv-associated nephropathy has become an increasingly recognized cause of renal dysfunction in renal transplantation patients ( ) ( ) ( ) ( ) ( ) . jcv establishes latency mainly in the kidney, and its reactivation can result in the development of progressive multifocal leukoencephalopathy. there are a few reports of nephropathy in association with jcv infection (see references in ( ) ), but bkv poses a much bigger problem in this regard. recent studies have reported sv in the allografts of children who received renal transplants and in the urine, blood, and kidneys of adults with focal segmental glomerulosclerosis, which is a cause of end-stage renal disease and an indication for kidney transplantation ( ) . seroprevalence rates as high as - % have been reported among adults in the united states and europe. the peak incidence of primary infection (as measured by acquisition of antibody) occurs in children - years of age. bkv antibody may be detected in as many as % of children by years of age, and in - % of children by or years of age; antibodies wane thereafter. bkv infection may be particularly important in the pediatric transplantation population, in whom primary infection has a high probability of occurring while the children are immunosuppressed ( ) . primary infection with bkv in healthy children is rarely associated with clinical manifestations. mild pyrexia, malaise, vomiting, respiratory illness, pericarditis, and transient hepatic dysfunction have been reported with primary infection. investigators hypothesize that after an initial round of viral replication at the site of entry, viremia follows with dissemination of the virus to distant sites at which latent infection is established. the most frequently recognized secondary sites of latent infection are renal and uroepithelial cells. secondary infection has been reported to cause tubulointerstitial nephritis and ureteral stenosis in renal transplantation patients. it may be that renal impairment in immunocompromised patients and in non renal solid organ transplant recipients is found to be frequently associated with bkv infection. the reported prevalence of bkv nephropathy in renal allografts is between and % ( , , , , ) . asymptomatic infection is characterized by viral shedding without any apparent clinical features. viruria, resulting from either primary or secondary infection, can persist from several weeks to years. tubulointerstitial nephritis associated with bkv in renal transplant recipients is accompanied by histopathologic changes, with or without functional impairment. ''infection'' and ''disease'' must be differentiated carefully. bkv infection (either primary or reactivated) can progress to bkv disease, but will not always do so ( ) . furthermore, not all cases of bkv disease lead to renal impairment. however, infection can progress to transplant dysfunction and graft loss, although the diagnosis may be complicated by the coexistence of active allograft rejection. bkv nephritis is reported to have a bimodal distribution, with % of bkv-related interstitial nephritis cases occurring - weeks after transplantation and the remainder of patients developing disease months to years after transplantation ( ) . allograft failure is due mainly to extensive viral replication in tubular epithelial cells leading to frank tubular necrosis ( ) . although damage is potentially fully reversible early in the disease, persisting viral damage leads to irreversible interstitial fibrosis. tubular atrophy and allograft loss has been observed in % of affected patients ( , ) . in most cases, bkv nephropathy in adult renal transplant recipients represents a secondary infection associated with rejection and its treatment. in children, however, primary bkv infection giving rise to allograft dysfunction may occur ( ) . the definitive diagnosis of bkv nephropathy requires renal biopsy. histopathologic features include severe tubular injury with cellular enlargement, marked nuclear atypia, epithelial necrosis, denudation of tubular basement membranes, focal intratubular neutrophilic infiltration, and mononuclear interstitial infiltration, with or without concurrent tubulins. this constellation of histologic features, particularly severe tubulitis, is often misinterpreted as rejection, even by the experienced pathologist. the presence of well-demarcated basophilic or amphophilic intranuclear viral inclusions, primarily within the tubular and parietal epithelium of the bowman capsule, can help distinguish bkv disease from rejection ( , , ) . additional tests such as immunohistochemistry, pcr analysis, or electron microscopy of biopsied tissue aimed at the identification of bkv may be required. a practical diagnostic approach for identifying bkv in renal transplant patients is summarized in > table - . bkv infection may cause ureteral obstruction due to ureteral ulceration and stenosis at the ureteric anastomosis. bkv-associated ureteral stenosis has been reported in % of renal transplant patients and usually occurs between and days after transplantation. ulceration due to inflammation, proliferation of the transitional epithelial cells, and smooth muscle proliferation may lead to partial or total obstruction. high-level bkv replication is implicated in acute, late-onset, long-duration hemorrhagic cystitis after bone marrow transplantation ( ) . there are two case reports in children of renal carcinomas arising in the transplanted kidney in association with bk virus nephropathy. it remains unclear whether infectious diseases and the kidney bk virus itself has oncogenic potential in the transplant setting, but this is possible given that the big t antigen (t-ag) expressed by polyomavirus family viruses has been shown to have the ability to disrupt chromosomal integrity ( , ) . whether patients with asymptomatic viremia or viruria need specific therapeutic intervention is not certain. review of the literature suggests that careful reduction of immune suppression, combined with active surveillance for rejection, will result in clinical improvement. reduction in immunosuppression may precipitate episodes of acute cellular rejection, which need to be judiciously treated with corticosteroids. the outcome of bkv nephropathy is unpredictable, and stabilization of renal function may occur regardless of whether maintenance immunotherapy is altered or not ( ) . some reports favor the use of cidofovir. cidofovir has important nephrotoxic side effects in the usual therapeutic dosage recommended for the treatment of cmv infection, and for bkv nephropathy a reduced dosage regime is generally used. the efficacy of cidofovir in reducing viremia has been demonstrated (see review in ( )). however, spontaneous clearance of viral infection after reduction of immunosuppression (without cidofovir) has also been reported. there are also case studies of the use of leflunamide. presence of bkv by pcr or decoy cells in urine signifies bkv replication. decoy cells are caused by infection of the urinary epithelial cells with human polyoma viruses. the nuclei are enlarged and nuclear chromatin is completely homogenized by viral cytopathic effect. positive pcr results for bkv viruria and presence of decoy cells have poor predictive value. specificity is increased if > cells/ cytospin along with presence of inflammatory cells. presence of antibody is usually indicative of previous infection; however, positive results for bkv dna pcr on serum signifies bk viremia. bkv pcr testing of plasma has proven to be a sensitive ( %) and specific ( %) means to identify bkv-associated nephropathy in adults. viral load has also been used to monitor infection and clearance. however, because primary infection occurs in childhood, it might not be applicable to the pediatric population. the definitive diagnosis of bkv nephropathy requires renal biopsy. histopathology might mimic rejection or drug toxicity. however, characteristic findings have been described. electron microscopy and immune staining are helpful in confirming the diagnosis. pcr assays of viral load in tubular cells have been reported to be a sensitive marker for diagnosis and monitoring. viral hemorrhagic fever involves at least distinct rna viruses that share the propensity to cause severe disease with prominent hemorrhagic manifestations ( > table - ) . the viral hemorrhagic fevers, widely distributed throughout both temperate and tropical regions of the world, are important causes of mortality and morbidity in many countries. most viral hemorrhagic fevers are zoonoses (with the possible exception of dengue virus), in which the virus is endemic in animals and human infection is acquired through the bite of an insect vector. aerosol and nosocomial transmissions from infected patients are important for lassa, junin, machupo, and congo-crimean hemorrhagic fevers, and marburg and ebola viruses ( ) . viral hemorrhagic fevers have many clinical similarities but also important differences in their severity, major organs affected, prognosis, and response to treatment. in all viral hemorrhagic fevers, severe cases occur in only a minority of those affected; subclinical infection or nonspecific febrile illness occurs in the majority. fever, myalgia, headache, conjunctival suffusion, and erythematous rash occur in all the viral hemorrhagic fevers ( ) . hemorrhagic manifestations range from petechiae and bleeding from venepuncture sites to severe hemorrhage into the gi tract, kidney, and other organs. a capillary leak syndrome, with evidence of hemoconcentration, pulmonary edema, oliguria, and ultimately shock, occurs in the most severely affected patients ( ) . renal involvement occurs in all the viral hemorrhagic fevers, proteinuria is common, and prerenal failure is seen in all severe cases complicated by shock. however, in congo-crimean hemorrhagic fever and hemorrhagic fever with renal syndrome (hfrs), an interstitial nephritis, which may be hemorrhagic, is characteristic, and renal impairment is a major component of the illness. dengue is caused by a flavivirus that is endemic and epidemic in tropical america, africa, and asia, where the mosquito vector aedes aegypti is present ( ). classic dengue is a self-limited nonfatal disease; dengue hemorrhagic fever and dengue shock syndrome, which occur in a minority of patients, have a high mortality if not aggressively treated with fluids. after an incubation period of - days, the illness begins with fever, headache, arthralgia, weakness, vomiting, and hyperesthesia. in uncomplicated dengue the fever usually lasts - days. shortly after onset a maculopapular rash appears, sparing the palms and the soles, and is occasionally followed by desquamation. fever may reappear at the onset of the rash. in dengue hemorrhagic fever and dengue shock syndrome, the typical febrile illness is complicated by hemorrhagic manifestations, ranging from a positive tourniquet test result or petechiae to purpura, epistaxis, and gi bleeding with thrombocytopenia and evidence of a consumptive coagulopathy. increased capillary permeability is suggested by hemoconcentration, edema, and pleural effusions ( ) . in severe cases, hypotension and shock supervene, largely as a result of hypovolemia. renal manifestations include oliguria, proteinuria, hematuria, and rising urea and creatinine. acute renal failure occurs in patients with severe shock, primarily as a result of renal underperfusion. however, glomerular inflammatory changes may also occur. children with dengue hemorrhagic fever show hypertrophy of endothelial and mesangial cells, mononuclear cell infiltrate, thinning of basement membranes, and deposition of igg, igm, and c . electron microscopy shows viral particles within glomerular mononuclear cells ( ) . the diagnosis of dengue is made by isolation of the virus from blood or by serologic testing. there is no specific antiviral treatment, and management of patients with dengue shock syndrome or dengue hemorrhagic fever depends on aggressive circulatory support and volume replacement with colloid and crystalloid ( , ) . with correction of hypovolemia, renal impairment is usually reversible, but dialysis may be required in patients with established acute renal failure. yellow fever is caused by a flavivirus, and is transmitted by mosquito bites, typically aedes species. it remains an important public health problem in africa and south america. renal manifestations are common and include albuminuria and oliguria. over the next few days after first manifestation of infection, shock, delirium, coma, and renal failure develop, and death occurs - days after onset of symptoms. laboratory findings include thrombocytopenia and evidence of hemoconcentration, rising urea and creatinine levels, hyponatremia, and deranged liver function test results. pathologic findings include necrosis of liver lobules, cloudy swelling and fatty degeneration of the proximal renal tubules, and, often, petechiae in other organs. the oliguria appears to be prerenal and is due to hypovolemia; later, acute tubular necrosis supervenes. at present, there is no effective antiviral agent for yellow fever. . congo-crimean hemorrhagic fever, first recognized in the soviet union, is now an important human disease in eastern europe, asia, and africa ( ) . severely affected patients become stuporous or comatose - days into the illness, with evidence of hepatic and renal failure and shock. proteinuria and hematuria are often present. the disease is fatal in - % of cases. the virus is sensitive to ribavirin, but in one small trial of i.v. ribavirin versus supportive treatment only, there was no significant improvement in outcome in the treatment group ( ) . rift valley fever is found in many areas of sub-saharan africa. in humans, most infections follow mosquito bites or animal exposure. the infection may present as an uncomplicated febrile illness, with muscle aches and . ( ) . clinical entities include korean hemorrhagic fever, nephropathia epidemica in scandinavia, and epidemic hemorrhagic fever in japan and china. in general, hfrs due to hantaan, porogia, and belgrade viruses is more severe and has higher mortality than that due to puumala virus (nephropathia epidemica) or seoul virus. hantaan is predominant in the far east, porogia and belgrade in the balkans, and puumala in western europe; seoul has a worldwide distribution ( ) . the clinical features of the disease vary. the incubation period is - days. although hfrs occurs with the same clinical picture in children as in adults, both incidence rates and antibody prevalence rates are very low in children under years of age. men of working age make up the bulk of clinical cases ( ) . mild cases are indistinguishable from other febrile illnesses. in more severe cases, fever, headache, myalgia, abdominal pain, and dizziness are associated with the development of periorbital edema, proteinuria, and hematuria. there is often conjunctival injection, pharyngeal injection, petechiae, and epistaxis or gi bleeding. the most severely affected patients develop shock and renal failure. the disease usually passes through five phases: febrile, hypotensive, oliguric, diuretic, and convalescent. laboratory findings include anemia, lymphocytosis, thrombocytopenia, prolonged prothrombin and bleeding times, and elevated levels of fibrin degradation products. liver enzyme levels are elevated, and urea and creatinine levels are elevated during the oliguric phase. proteinuria and hematuria are consistent findings. the renal histopathologic findings are those of an interstitial nephritis with prominent hemorrhages in the renal medullary interstitium and renal cortex. acute tubular necrosis may also be seen. immunohistochemical analysis reveals deposition of igg and c , and the gbm, mesangial, and subendothelial deposits may be seen on electron microscopy ( ) . recovery from hantavirus-associated disease is generally complete, although chronic renal insufficiency is a rare sequela of hfrs. in mildly affected patients, the disease is self-limiting and spontaneous recovery occurs. however, in severe cases, with shock, bleeding, and renal failure, dialysis and intensive circulatory support may be required ( ) . mortality rates vary depending on the strain of virus; rates are - % for hemorrhagic fever and renal syndrome in china and significantly lower for the milder finnish form associated with the puumala virus strain. ribavirin is active against hantaan viruses in vitro, and clinical trials indicate that both mortality and morbidity can be reduced by treatment with this antiviral agent if it is administered early in the course of illness. dosages of mg/kg followed by mg/kg every h for days and then mg/kg every h for days have been used ( ) . lassa fever is a common infection in west africa, caused by an arenavirus, and usually manifests as a nonspecific febrile illness. in % of cases, a fulminant hemorrhagic disease occurs. in severe cases, proteinuria and hematuria are usually present, and renal failure may occur. ribavirin is effective in decreasing mortality. as in other hemorrhagic fevers, intensive hemodynamic support and correction of the hemostatic derangements are important components of therapy ( ) . junin and machupo viruses, the agents of argentine and bolivian hemorrhagic fever, respectively, cause hemorrhagic fevers with prominent neurologic features and systemic and hemorrhagic features similar to those of lassa fever. oliguria, shock, and renal failure occur in the most severe cases. marburg and ebola viruses have been associated with outbreaks of nosocomially transmitted hemorrhagic fever. both viruses cause fulminant hemorrhagic fever. onset is with high fever, headache, sore throat, myalgia, and profound prostration. an erythematous rash on the trunk is followed by hemorrhagic conjunctivitis, bleeding, impaired renal function, shock, and respiratory failure. the mortality rate is high. renal histopathologic findings in fatal cases are of tubular necrosis, with fibrin deposition in the glomeruli. there is no specific treatment for these disorders. the important role played by a number of other recently characterized viruses is only now being recognized, as improved molecular diagnostic techniques allow identification of hitherto unrecognized viruses. two examples of recently described viruses are metapneumovirus ( ) and bocavirus ( ) . while both have significant prevalence, and may make an important contribution to the burden of childhood viral infection, as yet there are no reports indicative of significant renal pathology in association with these infections. influenza virus has been linked with nephritis and acute renal failure. an emerging infectious disease is avian flu, caused by highly pathogenic h n strains which have hitherto been confined to an avian reservoir, and there have been several outbreaks of infection in humans, particularly in the first part of this decade. commonly, these patients develop a flu-like illness with prominent respiratory and gastrointestinal symptoms. renal failure may develop alongside multi-organ failure in the context of acute respiratory distress syndrome ( ) . as yet, there is no clear correlation of degree of initial renal insufficiency, and outcome ( ) . there is little data available on treatment, but based on the known resistance patterns of h n strains, oseltamivir and zanamivir are the preferred agents to be used for treatment of infection with h n . severe acute respiratory syndrome (sars) is a newlyemerged infectious disease which was first seen in south china in . it is caused by a sars coronavirus (sars cov). predominantly, it causes a viral pneumonia, with diffuse alveolar damage; it has considerable mortality ( ) . renal effects are not generally significant in the pathophysiology of sars. however, sars cov has been found in kidney tissue at post-mortem ( ) ( ) . sars cov enters cells via angiotensin converting enzyme (ace ) ( ) , and it is thought that the invasion of kidney tissue reflects the virus' tropism for ace , which is expressed on kidney cells. chronic exposure to infectious agents is a major factor in the increased prevalence of glomerular diseases in developing countries. malaria is the best-documented parasitic infection associated with glomerular disease, but other parasitic infections including schistosomiasis, filariasis, leishmaniasis, and possibly helminth infections may also induce nephritis or nephrosis. malaria is estimated to cause up to million clinical cases of illness and more than million deaths each year ( ) . the association of quartan malaria and nephritis has been well known in both temperate and tropical zones since the end of the nineteenth century. epidemiologic studies provide the most conclusive evidence for a role of plasmodium malariae in glomerular disease ( , ) . chronic renal disease was a major cause of morbidity and mortality in british guiana in the s. the frequent occurrence of p. malariae in the blood of these patients led to detailed epidemiologic studies that implicated malaria as a cause of the nephrosis. after the eradication of malaria from british guiana, chronic renal disease ceased to be a major cause of death in that country ( ) . the link between malaria and nephrotic syndrome was strengthened by studies in west africa in the s and s that demonstrated a high prevalence of nephrotic syndrome in the nigerian population ( ) . the pattern of nephrotic syndrome differed from that in temperate climates, with an older peak age, extremely poor prognosis, and unusual histologic features. the incidence of p. malariae parasitemia in patients with the nephrotic syndrome in nigeria was vastly in excess of that occurring in the general population, whereas the incidence of plasmodium falciparum parasitemia was similar to that in the general population. the age distribution of nephrotic syndrome also closely paralleled that of p. malariae infection ( ) . in some affected patients, circulating immune complexes and immunoglobulin, complement, and antigens were present in the glomeruli that were recognized by p. malariae-species antisera. there is now a view that the patterns of childhood renal disease described in the last century may no longer be representative of the current situation. the variable patterns of renal disease throughout africa may no longer reflect a dominant role for ''malarial glomerulopathy,'' and the relative causative role of tropical infections in nephropathy remains an unanswered question ( ) . most patients have poorly selective proteinuria and are unresponsive to treatment with steroids or immunosuppressive agents. the characteristic lesions of p. malariae nephropathy are capillary wall thickening and segmental glomerular sclerosis, which lead to progressive glomerular changes and secondary tubular atrophy ( ) . cellular proliferation is conspicuously absent. electron microscopy shows foot-process fusion, thickening of the basement membrane, and increase in subendothelial basement membrane-like material. immunofluorescent studies show granular deposits of immunoglobulin, complement, and p. malariae antigen in approximately one-third of patients. in addition to the histologic pattern, termed quartan malaria nephropathy, p. malariae infection is associated with a variety of other forms of histologic appearance, including proliferative gn and mgn ( ) . although quartan malaria nephropathy has been clearly linked to p. malariae infection in nigeria, a number of studies from other regions in africa have not revealed the typical histopathologic findings described in the nigerian studies ( ) . furthermore, quartan malaria nephropathy may be seen in children with no evidence of p. malariae infection or deposition of malaria antigens in the kidney. this, together with the fact that antimalarial treatment does not affect the progression of the disorder, raises the possibility that factors other than malaria might be involved in the initiation and perpetuation of the disorder. although there is undoubtedly a strong association between p. malariae infection and nephrotic syndrome on epidemiologic grounds, the direct causal link is not proven. most likely, a number of different infectious processes, including malaria, hepatitis b, schistosomiasis, and perhaps other parasitic infections that cause chronic or persistent infections and often occur concurrently in malaria areas, may all result in glomerular injury and a range of overlapping histopathologic features. the prognosis for the nephrotic syndrome in most african studies has been poor, regardless of whether the histologic findings were typical of quartan malaria nephropathy or whether p. malariae parasitemia was implicated. treatment with steroids and azathioprine is generally ineffective, and a significant proportion of patients progress to renal failure. p. falciparum appears to be much less likely to cause significant glomerular pathology. epidemiologic studies have failed to show a clear association between p. falciparum parasitemia and the nephrotic syndrome. whereas renal failure appears to be a common complication of severe malaria in adults, it seldom occurs in children. renal biopsy specimens from adult patients with acute p. falciparum infections who have proteinuria or hematuria show evidence of glomerular changes, including hypercellularity, thickening of basement membranes, and hyperplasia and hypertrophy of endothelial cells ( ) . electron microscopy reveals electron-dense deposits in the subendothelial and paramesangial areas. deposits of igm, with or without igg, are localized mainly in the mesangial areas. p. falciparum antigens can be demonstrated in the mesangial areas and along the capillary wall, which suggests an immune-complex gn. the changes, generally mild and transient, are probably unrelated to the acute renal failure that may complicate severe p. falciparum infection ( ) . heavily parasitized erythrocytes play a central role in the various pathologic factors ( ) . renal failure occurring in severe p. falciparum malaria is usually associated with acidosis, volume depletion, acute intravascular hemolysis or heavy parasitic infection that leads to acute tubular necrosis. recent studies have confirmed an important role for volume depletion in children with severe falciparum malaria, who characteristically have evidence of tachycardia, tachypnoea, poor perfusion and in severe cases hypotension ( ) . volume expansion with either colloid or crystalloid results in improvement in hemodynamic indices and reduction in acidosis ( ) . there is growing evidence that volume expansion with albumin is associated with a better outcome than saline or synthetic colloids ( , ) . treatment with antimalarials, correction of hypoglycemia and infectious diseases and the kidney electrolyte imbalance, and volume expansion reduces mortality to less than %. although renal failure is usually associated with infection by p. falciparum, acute renal failure has been described with plasmodium vivax infection and mixed infections ( ) . the term blackwater fever refers to the combination of severe hemolysis, hemoglobinuria, and renal failure. it was more common at the start of the twentieth century in nonimmune individuals receiving intermittent quinine therapy for p. falciparum malaria. blackwater fever has become rare since , when quinine was replaced by chloroquine. however, the disease reappeared in the s, after the reuse of quinine because of the development of chloroquine-resistant organisms. since then, several cases have been described after therapy with halofantrine and mefloquine, two new molecules similar to quinine (amino-alcohol family) ( ) . renal failure generally occurred in the context of severe hemolytic anemia, hemoglobinuria, and jaundice. the pathophysiology of the disorder is unclear; however, it appears that a double sensitization of the red blood cells to the p. falciparum and to the amino-alcohols is necessary to provoke the hemolysis. histopathologic findings include swelling and vacuolization of proximal tubules, necrosis and degeneration of more distal tubules, and hemoglobin deposition in the renal tubules. recent studies indicates a better outcome with earlier initiation of intensive care and dialysis combined with necessary changes in antimalarial medications. schistosomiasis affects million people living in endemic areas of asia, africa, and south america ( ) . the infection is usually acquired in childhood, but repeated infections occur throughout life. schistosoma japonicum is found only in the orient, whereas schistosoma haematobium occurs throughout africa, the middle east, and areas of southwest asia. schistosoma mansoni is widespread in africa, south america, and southwest asia. human infection begins when the cercarial forms invade through the skin, develop into schistosomula, and move to the lungs via the lymphatics or blood. they then migrate to the liver and mature in the intrahepatic portal venules, where male:female pairing takes place. the adult worm pairs then migrate to their final resting site -the venules of the mesenteric venous system of the large intestine (s. mansoni) or in the venules of the urinary tract (s. haematobium). the females release large numbers of eggs, which may remain embedded in the tissues, embolize to the liver or lungs, or pass into the feces or urine. clinical manifestations may occur at any stage of the infection. cercarial invasion may cause an intense itchy papular rash. katayama fever is an acute serum sicknesslike illness that occurs several weeks after infection, as eggs are being deposited in the tissues. deposition of the eggs in tissues results in inflammation of the intestines, fibrosis of the liver, and portal hypertension. with s. haematobium, chronic inflammation and fibrosis of the ureters and bladder may lead to obstructive uropathy ( ) . renal manifestations of schistosomiasis occur most commonly in s. mansoni infection. schistosomal nephropathy usually presents with symptoms including granulomatous inflammation in the ureters and bladder, but glomerular disease (probably on an immune-complex basis) may also occur. renal disease usually occurs in older children or young adults with long-term infection, but serious disease may also occur in young children ( ) . the early renal tract manifestations of schistosomiasis are suprapubic discomfort, frequency, dysuria, and terminal hematuria. in more severe cases, evidence of urinary obstruction appears. poor urinary stream, straining on micturition, a feeling of incomplete bladder emptying, and a constant urge to urinate may be severely disabling symptoms. the fibrosis and inflammation of ureters, urethra, and bladder may be followed by calcification and may result in hydroureter, hydronephrosis, and bladder neck obstruction. renal failure may ultimately develop, and there is a suspicion that squamous cell carcinoma of the bladder may be linked to the chronic infective and inflammatory process. secondary bacterial infection is common within the obstructed and inflamed urinary tract ( ) . the hepatosplenic form of s. mansoni infection may be accompanied by a glomerulopathy in - % of cases, manifested in the majority as nephrotic syndrome ( ) . histopathologic findings include mesangioproliferative gn, focal segmental glomerulosclerosis, mesangiocapillary gn, mgn, and focal segmental hyalinosis ( ) . immune complexes may be detected in the circulation of these patients, and glomerular granular deposition of igm, c , and schistosomal antigens are seen on immunofluorescence. usually schistosoma-specific nephropathy is a progressive disease and is not influenced by antiparasitic or immunosuppressive therapy ( ) , but isolated case reports of remission after treatment with praziquantel have been reported ( ) . the diagnosis is confirmed by the detection of schistosoma eggs in feces, urine, or biopsy specimens. eggs are shed into the urine with a diurnal rhythm, and urine collected between am and pm is the most useful. urinary sediment obtained by centrifugation or filtration through a nuclepore membrane should be examined. in cases in which studies of urine and feces yield negative results in patients in whom the diagnosis is suspected, rectal biopsy specimens taken approximately cm from the anus have a high diagnostic yield for both s. mansoni and s. haematobium infection. biopsy of liver or bladder may be required to establish the diagnosis. antibodies indicating previous infection can be detected using enzyme-linked immunosorbent assay or radioimmunoassay. the tests are sensitive but lack specificity and may not differentiate between past exposure and current infection. praziquantel is the drug of choice for treatment of schistosomiasis. a single oral dose of mg/kg is effective in s.haematobium and s. mansoni infection and is usually well tolerated. the alternative drug for s. mansoni infection is oxamniquine. complete remission of urinary symptoms may occur in renal disease of short duration, but in late disease with extensive fibrosis, scarring, and calcification, obstructive uropathy and renal failure may persist after the infection has been eradicated. there are reports of a drastic decrease in the number of severe hepatosplenic forms of s. mansoni infection after mass treatment of the population in endemic areas with oxamniquine. this also reduced schistosomal nephropathy ( ) . visceral leishmaniasis is a chronic protozoon infection characterized by fever, hepatosplenomegaly, anemia, leukopenia, and hyperglobulinemia. proteinuria and/or microscopic hematuria or pyuria have been reported in % of patients with visceral leishmaniasis ( ) . acute renal failure in association with interstitial nephritis has also been reported ( ) . renal histologic analysis in patients with visceral leishmaniasis reveals glomerular changes, with features of a mesangial proliferative gn or a focal proliferative gn, or a generalized interstitial nephritis with interstitial edema, mononuclear cell infiltration, and focal tubular degeneration. immunofluorescence reveals deposition of igg, igm, and c within the glomeruli, as well as electron-dense deposits in the basement membrane and mesangium on electron microscopy ( ) . circulating immune complexes together with immunoglobulin and complement deposition in the glomeruli suggests an immune-complex cause. renal disease in leishmaniasis is usually mild and may resolve after treatment of the infection. renal dysfunction may be associated with treatment for visceral leishmaniasis with antimony compounds. proteinuria is more common in filarial hyperendemic regions of west africa than in nonfilarial areas. renal histologic analysis has shown a variety of different histopathologic appearances; the most common is diffuse mesangial proliferative gn with c deposition in the glomeruli ( ) . renal biopsy specimens also demonstrate large numbers of eosinophils in the glomeruli, and microfilariae may be seen in the lumen of glomerular capillaries. filarial antigens have been detected within immune deposits within the glomeruli. echinococcus granulosus causes chronic cysts within a variety of organs. in addition, nephrotic syndrome in association with hydatid disease has been reported. membranous nephropathy, minimal change lesions, and mesangiocapillary gn have been described in association with hydatid disease ( , ) . immunofluorescence reveals deposits of immunoglobulin, complement, and hydatid antigens within the glomeruli. remission of nephrotic syndrome has been reported with treatment by antiparasitic agents such as albendazole ( , ) . few reports have been published of renal disease occurring in patients with trypanosomiasis. the trypanosomal antigens can induce gn in a variety of experimental animals ( ) . nephrotic syndrome has occasionally been reported as a manifestation of congenital toxoplasmosis. dissemination of previously latent toxoplasma infection in patients undergoing treatment with immunosuppressive drugs has been increasingly recognized in recent years. reactivation of toxoplasmosis or progression of recently acquired primary infection should be considered in patients undergoing renal transplantation or immunotherapy for renal disease who develop unexplained inflammation of any organ. fungal infections of the kidneys and urinary tract occur most commonly as part of systemic fungal infections in patients with underlying immunodeficiency, as focal urinary tract infections in patients with obstructive lesions, or as a result of indwelling catheters. although candida infection is the most common fungal infection in both immunocompromised and non immunocompromised hosts, virtually all other fungal pathogens may invade the renal tract during severe immunocompromise. urinary infection with candida albicans is most commonly a component of systemic candidiasis in patients who are severely immunocompromised. systemic candidiasis is also seen in premature and term infants with perinatally acquired invasive candidiasis. presentation is usually with systemic sepsis, fever or hypothermia, hepatosplenomegaly, erythematous rash, and thrombocytopenia. systemic candidiasis may be seen on ophthalmologic investigation as microemboli in the retina. the first clue to the underlying diagnosis may be the presence of yeasts in the urine ( ) . candida involvement of the urinary tract may affect all structures including the glomeruli, tubules, collecting system, ureters, and bladder. microabscesses may form within the renal parenchyma, and large balls of fungi may completely obstruct the urinary tract at any level. acute renal failure caused by systemic candidiasis or obstruction of the renal tracts with fungal hyphae is a wellrecognized complication of systemic candidal infection ( , ) . indwelling catheters (which form a nidus for persistent infection) should be removed. successful treatment of non-obstructing bilateral renal fungal balls by fluconazole either alone or in combination with liposomal amphotericin b has been reported ( , ) . in the presence of obstruction, however, percutaneous nephrostomy to relieve the obstruction with antegrade amphotericin b irrigation, coupled with systemic antifungal therapy, is the mainstay of treatment ( ) . amphotericin b is the most effective antifungal agent, but it is not excreted in the urine. local irrigation via nephrostomy provides good results, however. for treatment of urinary tract candidiasis, it is usually combined with fluconazole or -flucytosine, both of which are excreted in high concentrations in the urine. treatment is required for weeks to months to ensure complete elimination of the fungus, and the ultimate outcome is largely dependent on whether there is a permanent defect in immunity. in , levin et al. first described hemorrhagic shock and encephalopathy, which appeared to be distinct from previously recognized pediatric disorders ( ) . other cases have subsequently been reported from several centers in the united kingdom, europe, israel, the united states, and australia, and the syndrome is now recognized as a new and relatively common severe childhood disorder ( ) . hemorrhagic shock and encephalopathy usually affects infants in the first year of life, with a peak onset at - months of age. a prodromal illness with fever, irritability, diarrhea, or upper respiratory infection occurs - days before the onset in two-thirds of cases. affected infants develop profound shock, coma, convulsions, bleeding and evidence of dic, diarrhea, and oliguria. laboratory findings include acidosis, falling hemoglobin and platelet levels, elevated urea and creatinine levels, and elevated levels of hepatic transaminases. despite vigorous intensive care, the prognosis is poor, and most affected infants die or are left severely neurologically damaged ( , ) . a small number of patients have been reported to survive without residual sequelae. the renal impairment appears to be largely prerenal in origin, and when aggressive volume replacement and treatment of the shock results in improved renal perfusion, rapid improvement in renal function is usually observed. in patients with profound shock unresponsive to initial resuscitation, vasomotor nephropathy supervenes and dialysis may be required. myoglobinuria in association with hemorrhagic shock and encephalopathy has been reported. following the description of the mucocutaneous lymph node syndrome by kawasaki in , kawasaki disease has been recognized as a common and serious childhood illness with a worldwide distribution. although the etiology remains unknown, epidemiologic features clearly suggest an infective cause. the disease occurs in epidemics, and wavelike spread has been demonstrated during outbreaks in japan. deposition of amyloid within the kidney is an important complication of chronic and persistent infection. amyloidosis is most common in patients with chronic osteomyelitis and chronic pulmonary infections such as bronchiectasis and is seen occasionally in those with persistent infections such as leprosy or malaria ( ) ( ) ( ) . paediatric emergencies, nd edn. black ja shock in the paediatric patient vasoactive hormones in the renal response to systemic sepsis renal effects of nitric oxide in endotoxemia drotrecogin alfa (activated) in children with severe sepsis: a multicentre phase iii randomised controlled trial treatment of meningococcal disease in childhood pathophysiology and management of meningococcal septicaemia severity of meningococcal disease: assessment by factors and scores and implications for patient management case records of the massachusetts general hospital. case plasma endotoxin as a predictor of multiple organ failure and death in systemic meningococcal disease hemodynamic patterns of meningococcal shock in children role of interleukin in myocardial dysfunction of meningococcal septic shock dysfunction of endothelial protein c activation in severe meningococcal sepsis dysfunction of endothelial protein c activation in severe meningococcal sepsis efficacy and safety of recombinant human activated protein c for severe sepsis renal abscess in childhood: diagnostic and therapeutic progress percutaneous drainage of renal and perirenal abscesses: results in patients toxic shock syndrome associated with phage group staphylococci toxic shock syndrome not associated with menstruation: a review of cases toxic shock syndrome phenotypic distinctiveness of staphylococcus aureus strains associated with toxic shock syndrome the staphylococcal enterotoxins and their relatives toxic shock syndrome: associated staphylococcal and streptococcal pyrogenic toxins are potent inducers of tumour necrosis factor toxic shock syndrome bacterial two-component and hetero-heptameric pore-forming cytolytic toxins: structures, pore-forming mechanism, and organization of the genes perinephric abscess caused by communityacquired methicillin resistant staphylococcus aureus impact of antibiotics on expression of virulence? associated exotoxin genes in methicillin, sensitive and methicillin, resistant staphylococcus aureus clinical and bacteriologic observations of a toxic shock-like syndrome due to streptococcus pyogenes acute poststreptococcal glomerulonephritis. a review of recent developments occurrence of acute glomerulonephritis in sibling contacts of children with sporadic acute glomerulonephritis epidemic glomerulonephritis in israel does antimicrobial therapy of streptococcal pharyngitis or pyoderma alter the risk of glomerulonephritis? medium and long-term prognosis of patients with acute post-streptococcal glomerulonephritis infectious diseases and the kidney nephritis caused by streptococcus zooepidemicus (lancefield group c) acute glomerulonephritis following group g streptococcus infection streptococcus associated toxic shock changing group a streptococcus: the reappearance of streptococcal ''toxic shock severe group a streptococcus infections associated with a toxic shock-like syndrome and scarlet fever toxin a specific c-terminal cleavage and inactivation of interleukin- by invasive disease isolates of streptococcus pyogenes penicillin and clindamycin differentially inhibit the production of pyrogenic exotoxins a and b by group a streptococci improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive streptococcus pyogenes infection intravenous immunoglobulin g therapy in streptococcal toxic shock syndrome: a european randomized, double-blind, placebo-controlled trial intravenous immunoglobulin therapy for streptococcal toxic shock syndrome -a comparative observational study. the canadian streptococcal study group a history of adjunctive glucocorticoid treatment for pediatric sepsis: moving beyond steroid pulp fiction toward evidence-based medicine intensive insulin therapy and pentastarch resuscitation in severe sepsis philadelphia renal lesions in leptospirosis leptospirosis and acute renal failure: clinical experiences and a review of the literature clinical profile of leptospirosis in south gujarat evaluation of hemostasis disorders and anticardiolipin antibody in patients with severe leptospirosis placebo controlled trial of intravenous penicillin for severe and late leptospirosis hämolytich-urämiche syndrome: bilaterale nierenrindennekrosen bei akuten erworbenen hämolytischen anämien hemolytic-uremic syndrome associated with neuraminidase-producing micro-organism: treatment by exchange transfusion hemolytic uremic syndrome associated with pneumococcal sepsis recent advances in understanding the pathogenesis of the hemolytic uremic syndromes glomerular and arteriolar thrombosis in pneumococcal septicemia hemolytic uremic syndrome associated with invasive streptococcus pneumoniae infection hemolytic-uremic syndrome associated with neuraminidase-producing microorganisms: treatment by exchange transfusion hämolytisch-urämisches syndrome bei pneumokok-ken-menigitis und -sepsis. bedeutung der t-transformation prognosis of streptococcus pneumoniaeinduced hemolytic uremic syndrome invasive pneumococcal disease and hemolytic uremic syndrome hemolytic uremic syndrome associated with invasive pneumococcal disease: the united kingdom experience acute renal failure of glomerular origin during visceral abscess glomerulitis in typhoid fever yersinia and chronic glomerulopathy in the savannah region of nigeria typhoid glomerulonephritis acute glomerulonephritis in multi-drug resistant salmonella typhi infection acute glomerulonephritis in salmonella typhi infection urinary tract and renal findings in acute yersinia infection acute tubulointerstitial nephritis in association with yersinia pseudotuberculosis infection acute renal failure associated with yersinia pseudotuberculosis infection in children acute renal failure associated with yersinia pseudotuberculosis infection ampicillin vs. placebo for yersinia pseudotuberculosis infection in children yersinia enterocolitica and yersinia pseudotuberculosis infections sporadic cases of haemolytic uraemic syndrome associated with faecal cytotoxin and cytotoxin producing escherichia coli in stools fact sheet no. . revised. geneva: world health organization global burden of tuberculosis: estimated incidence, prevalence, and mortality by country mycobacterium tuberculosis. in principles and practice of infectious diseases genitourinary tuberculosis revisited urogenital tuberculosis in children genitourinary tuberculosis: review of cases the glomerulopathy of congenital syphilis: an immune deposit disease nephropathy of secondary syphilis: a clinical and padiological spectrum immunopathogenesis of syphilitic glomerulonephritis membranoproliferative glomerulonephritis and mycoplasma pneumoniae infection mycoplasma pneumoniae associated with acute glomerulonephritis mycoplasma pneumoniaeassociated nephritis in children textbook of pediatric infectious diseases rocky mountain spotted fever: clinical, laboratory and epidemiological features in cases acute renal failure in rocky mountain spotted fever kidney lesion in rocky mountain spotted fever acute glomerulonephritis in a patient with rocky mountain spotted fever rocky mountain spotted fever rocky mountain spotted fever q fever: current concepts glomerulonephritis associated with coxiella burnetii endocarditis disseminated legionella pneumophila infection in an infant with severe combined immunodeficiency legionnaire's disease and acute renal failure: base report and review tubulointerstitial nephritis associated with legionnaires' disease the immune complex glomerulonephritis of bacterial endocarditis glomerular nephropathy associated with chronic q fever legionella prostheticvalve endocarditis glomerulonephritis in bacterial endocarditis the immune nature of subacute bacterial endocarditis (sbe) nephritis infective endocarditis in children the clinical spectrum of shunt nephritis the role of complement, immunoglobulin and bacterial antigen in coagulase-negative staphylococcal shunt nephritis membranoproliferative glomerulonephritis associated with infected ventriculoatrial shunt: report of two cases recovered after removal of the shunt the hepatitis b virus hepatitis b infection and renal disease: clinical, immunopathogenetic and therapeutic considerations extrahepatic manifestations of viral hepatitis christian cl vasculitis with hepatitis b antigenemia. long term observation in nine patients hepatitis b-associated vasculitis in an infant polyarteritis nodosa related to hepatitis b virus. a prospective study with long-term observation of patients hepatitis b virus-associated polyarteritis nodosa: clinical characteristics, outcome, and impact of treatment in patients immune complexes of heparins b surface antigen in the pathogenesis of periarteritis nodosa. a study of seven necropsy cases successful treatment of polyarteritis nodosa related to hepatitis b virus with interferon alpha as first-line therapy lamivudine in the treatment of polyarteritis nodosa associated with acute hepatitis b successful treatment of hepatitis b virus associated polyarteritis nodosa with a combination of prednisolone, afpha-interferon and iamivudine infectious diseases and the kidney membranous glomerulonephropathy in childhood hepatitis b surface antigenemia in north american children with membranous glomerlonephropathy the clinico-pathologic features of hepatitis b virus-associated glomerulonephritis gene expression profile of transgenic mouse kidney reveals pathogenesis of hepatitis b virus associated nephropathy hepatitis-b virus associated nephropathies: a clinicopathological study in children strong association between iga nephropathy and hepatitis b surface antigenemia in endemic areas approaches to the treatment of hepatitis b virus and delta-related liver disease hbv associated nephrotic syndrome: resolution with oral lamivudine management of chronic hepatitis b virus infection: a new era of disease control lamivudine and hbv-associated nephropathy the prevalence of hepatitis c virus infection in the united states children with hepatitis c hepatitis c virusassociated glomerulonephritis focal segmental glomerular sclerosis among patients infected with hepatitis c virus hepatitis c virus-associated glomerulonephritis. effect of alpha-interferon therapy a comprehensive study of the association between hepatitis c virus and glomerulopathy hepatitis c infection and the patient with end-stage renal disease hepatitis c infection in children and adolescents with end-stage renal disease hepatitis c virus seropositivity at the time of renal transplantation in the united states: associated factors and patient survival de novo membranoproliferative glomerulonephritis in hepatitis c virus-infected renal allograft recipients hepatitis c virus infection and de novo glomerular lesions in renal allografts design of the peds-c trial: pegylated interferon +/Àribavirin for children with chronic hepatitis c viral infection effect of combination therapy (ribavirin and interferon) in hcv-related glomerulopathy acute renal failure in kidney transplant patients treated with interferon alpha b for chronic hepatitis c vasculitic complications of interferon-alpha treatment for chronic hepatitis c virus infection: case report and review of the literature widespread presence of histologically occult cytomegalovirus glomerulonephritis in congenital cytomegalic inclusion disease immune complexes in congenital and natal cytomegalovirus infection of man glomerulopathy associated with cytomegalovirus virenmia in renal allografts epstein-barr virus, cytomegalovirus and other viral infections in children after transplant cytomegalovirus-induced glomerular vasculopathy in renal allografts: a report of two cases the association of viral infection and chronic allograft: nephropathy with graft dysfunction after renal transplantation antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients infection in organ transplant recipients acute glomerulonephritis associated with varicella infection varicella infection in a renal transplant recipient associated with abdominal pain, hepatitis, and glomerulonephritis nephrotic syndrome associated with varicella infection epstein-barr virus-associated acute interstitial nephritis: infection or immunologic phenomenon? acute interstitial nephritis secondary to infectious mononucleosis an atypical pattern of epstein-barr virus infection in a case with idiopathic tubulointerstitial nephritis an in situ hybridization study of herpes simplex and epstein barr viruses in iga nephropathy and non-immune glomerulonephritis a review of adenoviruses in the aetiology of haemorrhagic cystitis coxsackie b viruses and the kidney -a neglected topic measles and acute glomerulonephritis mumps associated with nephritis associated focal and segmental glomerulosclerosis in the acquired immunodeficiency syndrome renal disease in patients with aids: a clinicopathologic study glomerular lesions in the acquired immunodeficiency syndrome urinary and renal histological changes in children with the acquired immunodeficiency syndrome (aids) nephrotic syndrome associated with acquired immunodeficiency syndrome in children human immunodeficiency virus nephropathy human immunodeficiency virus (hiv)-associated nephropathy in children from the hiv- and hiv-associated nephropathy years later renal pathology of human immunodeficiency virus infection protease inhibitor therapy for hiv infection: the effect on hiv-associated nephrotic syndrome bk virus renal infection in a patient with the acquired immunodeficiency syndrome indinavir-associated interstitial nephritis and urothelial inflammation: clinical and cytologic findings mixed cryoglobulinemia in hiv- infection: the role of hiv- a typical hemolytic uremic syndrome in human immunodeficiency virus- -infected children hiv-associated nephropathy is a late, not early, manifestation of hiv- infection hiv-associated nephropathy: current concepts hiv-associated nephropathy glomerulosclerosis and viral gene expression in hiv-transgenic mice: role of nef pathogenesis of human immunodeficiency virus (hiv)-associated nephropathy increased levels of transforming growth factor-[beta] in hiv-associated nephropathy a steroid responsive nephrotic syndrome in a patient with human immunodeficiency virus infection clinicopathologic correlates of prednisone treatment of human immunodeficiency virus-associated nephropathy cohort study of the treatment of severe hfv-associated nephropathy with corticosteroids prednisone improves renal function and proteinuria in human immunodeficiency virus-associated nephropathy effect of angiotensin-converting enzyme inhibition in hiv-associated nephropathy spontaneous improvement of the renal function in a patient with hiv-associated focal glomerulosclerosis hiv- -associared nephropathy and response to highly-active antiretroviral therapy protease inhibitor therapy for hiv infection: the effect on hiv-associated nephrotic syndrome zidovudine is beneficial in human immunodeficiency virus associated nephropathy hiv- infection initiates an inflammatory cascade in human renal tubular epithelial cells treatment of human immunodeficiency virus (hiv)-associated nephropathy hivan and medication use in chronic dialysis patients in the united states: analysis of the usrds dmms wave study maintenance hemodialysis in patients with hiv-associated nephropathy organ transplant multi-site study. clinical, immunologic and pharmacologic consequences of kidney transplantation in people with hiv infection hivinfected liver and kidney transplant recipients: -and -year outcomes new human papovavirus (bk) isolated from urine after renal transplantation polyomavirus disease under new immunosuppressive drugs: a cause of renal graft dysfunction and graft loss diagnosis and management of bk polyomavirus interstitial nephritis in renal transplant recipients polyomavirus infection of renal allograft recipients: from latent infection to manifest disease infectious diseases and the kidney testing for polyomavirus type bk dna in plasma to identify renal-allograft recipients with viral nephropathy nephropathy due to polyomavirus type bk polyomavirus-associated nephropathy: update in diagnosis pathogenesis and management of polyomavirus infection in transplant recipients bk virus infection in renal transplant recipients prospective study of polyomavirus type bk replication and nephropathy in renal-transplant recipients bk virus infection, replication, and diseases in pediatric kidney transplantation occurrence and significance of papovaviruses bk and jc in the urine polyoma-virus induced interstitial nephritis in two renal transplant recipients: case reports and review of the literature late-onset hemorrhagic cystitis associated with urinary excretion of polyoma-viruses after bone marrow transplantation collecting duct carcinoma arising in association with bk nephropathy posttransplantation in a pediatric patient. a case report with immunohistochemical and in situ hybridization study association of renal adenocarcinoma and bk virus nephropathy post-transplantation clinical course of polyoma virus nephropathy in renal transplant patients epidemiology of haemorrhagic fever viruses virus and hemostasis dengue and dengue haemorrhagic fever glomerular changes in dengue haemorrhagic fever intravenous fluids -getting the balance right comparison of three fluid solutions for resuscitation in dengue shock syndrome epidemiology and clinical features of crimean-congo haemorrhagic fever in southern africa viral hemorrhagic fever-induced acute kidney injury hantavirus: an increasing problem? haemorrhagic fever with renal syndrome, virological and epidemiological aspects different pathohistological presentations of acute renal involvement in hantaan virus infection: report of two cases clinical characteristics of haemorrhagic fever with renal syndrome in children prospects for treatment of viral haemorrhagic fever with ribavirin, a broad spectrum antiviral drug lassa fever: effective therapy with ribavirin human infection with highly pathogenic h n influenza virus renal insufficiency on presentation of bird flu infection: is it correlated to outcome? pathogenesis of severe acute respiratory syndrome fatal severe acute respiratory syndrome is associated with multiorgan involvement by coronavirus organ distribution of severe acute respiratory syndrome (sars) associated coronavirus (sars-cov) in sars patients: implications for pathogenesis and virus transmission pathways angiotensin-converting enzyme is a functional receptor for the sars coronavirus a newly discovered human pneumovirus isolated from young children with respiratory tract disease cloning of a human parvovirus by molecular screening of respiratory tract samples malaria in malaria and renal disease with special reference to british guiana. ii. the effect of malaria eradication on the incidence of renal disease in british guiana immunopathology of malaria the nephrotic syndrome and other diseases in children in western nigeria malaria-induced renal damage: facts and myths clinicopathological features of childhood nephrotic syndrome in northern nigeria quartan malarial nephrotic syndrome renal disease in acute plasmodium falciparum infection in man current knowledge in falciparum malaria-induced acute renal failure severe p. falciparum malaria in kenyan children: evidence for hypovolaemia response to volume resuscitation in children with severe malaria volume expansion with albumin compared to gelofusine in children with severe malaria: results of a controlled trial randomized trial of volume expansion with albumin or saline in children with severe malaria: preliminary evidence of albumin benefit severe acute renal failure in malaria recurrence of blackwater fever: triggering of relapses by different antimalarials philadelphia schistosomal specific nephropathy leading to end-stage renal failure is glomerulopathy due to schistosomiasis mansoni disappearing? characterisation of kidney lesions in early schistosomal-specific nephropathy schistosoma mansoni-induced mesangiocapillary glomerulonephritis: influence of therapy minimal change glomerulonephritis associated with schistosoma haematobium infectionresolution with praziquantel treatment renal involvement in visceral leishmaniasis acute renal failure in visceral leishmaniasis the nephrotic syndrome associated with filariasis minimal change glomerulonephritis associated with hydatid disease reversible nephrotic syndrome due to mesangiocapillary glomerulonephritis secondary to hepatic hydatid disease immune complexmediated glomerulopathy in experimental chagas' disease anuria in a newborn secondary to bilateral ureteropelvic fungus balls the role of percutaneous nephrostomy in the management of obstructing candidiasis of the urinary tract in infants successful treatment of bilateral renal fungal balls with liposomal amphotericin b and fluconazole in an extremely low birth weight infant renal fungus ball in a premature infant successfully treated with fluconazole haemorrhagic shock and encephalopathy: a new syndrome with high mortality in young children haemorrhagic shock and encephalopathy: reflections about a new devastating disorder that affects normal children haemorrhagic shock and encephalopathy: clinical, pathologic, and biochemical fea-mks use of protein-c concentrare, heparin, and haemodiafiltration in meningococcus-induced purpura fulminans quantitative viral load monitoring and cidofovir therapy for the management of bk virus associated nephropathy in children and adults antiviral therapy and prophylaxis for influenza in children infectious diseases and the kidney key: cord- -sxd t tz authors: nan title: poster presentations date: - - journal: dev med child neurol doi: . /dmcn. sha: doc_id: cord_uid: sxd t tz nan what are the perspectives and understanding of healthcare professionals including occupational therapists on treatment and care of babies with infantile spasms and early-onset epilepsy? a qualitative design dm middleton university of roehampton-online, birmingham, uk objective: to explore the perspectives and understanding of allied healthcare professionals (occupational therapists, physiotherapists, speech & language therapists) that work with children and epilepsy in order to guide and advocate for this population group. methods: a qualitative study design using interpretive thematic analysis with the data from participants in semi-structured interviews. results: the professionals had worked across acute and community settings and had previous experiences of working with children with epilepsy with some awareness of these needs. there were themes that emerged: ( ) housing and social needs, ( ) epilepsy, psycho-social and mental health needs, ( ) therapy approaches, ( ) training for allied healthcare professionals, and ( ) adolescents, young girls, women and epilepsy. conclusions: there are gaps in service provision for certain areas and will be shared within the presentation. epilepsy requires additional considerations for safety that other conditions may not require. it is crucial in the interests of public health for children and families with epilepsy to be able to advocate for resources and their specific needs. poster no. time to onset of cannabidiol (cbd) treatment effect and resolution of adverse events in patients with dravet syndrome: pooled analysis of two randomised controlled trials solution) at mg/kg/day (cbd ; gwpcare ) or mg/ kg/day (cbd ; both trials) or placebo for weeks. cbd treatment started at . mg/kg/day and reached mg/kg/day on day and mg/kg/day on day . percent reduction in cumulative convulsive seizure frequency for each treatment day (including previous treatment days) and timing of adverse events (aes) were assessed. results: overall, patients were randomised to cbd and to placebo. cbd led to significantly greater percent reductions in convulsive seizure frequency than placebo in gwpcare (cbd % vs placebo %, p= . ) and gwpcare (cbd %, cbd % vs placebo %, p= . and p= . ). in the pooled data, treatment differences in seizure reduction emerged during titration and were maintained throughout the study, with nominal significance (p< . ) achieved by day for cbd and day for cbd . onset of the first reported ae occurred during titration in % of patients with aes. aes resolved within weeks of onset in % of patients and by the end of the study in %. increases in alt/ast (> upper limit of normal) occurred in ( %) patients for cbd , ( %) for cbd , and ( %) for placebo; all were on concomitant valproate. all elevations resolved, either spontaneously while continuing cbd, after discontinuing cbd, or after reducing cbd, valproate, and/or clobazam dose. conclusions: cbd treatment effect (seizure reductions and aes) may occur early, during titration. the majority of aes resolved during the study. poster no. low dose fenfluramine hydrochloride oral solution provides long-term, clinically meaningful (≥ %) reduction in seizure frequency in dravet syndrome: interim analysis of a long-term openlabel extension study objective: to characterize long-term safety and durability of effect for adjunctive fenfluramine (ffa) in treating dravet syndrome (ds). methods: patients ( - y) with ds entered a long-term openlabel extension (ole) ( ) after completing one of two phase studies: study ( wks; placebo or ffa . or . mg/kg/d [max, mg/d] or study ( wks; placebo or ffa . mg/kg/d [max, mg/d]) . stiripentol was excluded in study but mandatory in study . in , patients received ffa . mg/kg/d for month ; dosing was titrated to effect thereafter. effectiveness and tolerability were assessed at months , , and , then at -month intervals. results: at interim analysis ( -mar- ) , / patients continued into ole; % completed months of ffa (mean dose, . mg/d; median duration, d [range, - d] ). during the entire ole, median percentage change in monthly convulsive seizure frequency (mcsf) for ffa vs pretreatment phase study baseline was - . % (p< . ); clinically meaningful (≥ %) and profound (≥ %) mcsf reduction from baseline were % and %. at month , median and mean longest interval between convulsive seizures were and days (range, - d); % of caregivers and % of investigators rated patients 'much improved/very much improved'. the most common adverse events included appetite decrease, pyrexia, nasopharyngitis, and diarrhea. no valvular heart disease or pulmonary hypertension was observed in any patient. conclusions: treatment with ffa resulted in robust, sustained reductions in mcsf and was generally well tolerated. no valvular heart disease or pulmonary arterial hypertension was observed in any patient at any time. ffa may be an important, novel antiepileptic drug for long-term ds treatment. poster no. zx (low dose fenfluramine hydrochloride oral solution) provides long-term, clinically meaningful reduction of convulsive seizure frequency in young (< years old) dravet syndrome participants: analysis from a long-term open-label study results: a total of of ( . %) participants who enrolled in the ole were < years old upon entry into the phase studies. the median baseline monthly convulsive seizure frequency (mcsf) before double-blind treatment was . seizures/month (range, . - . ) in this patient subgroup (< y). at the time of the ole interim analysis, the median decrease in mcsf in the < years subgroup over the entire observation period compared to baseline was - % (p< . ) compared with - % in the overall study population ( - y). the most frequently reported adverse events included pyrexia, upper respiratory tract infections, decreased appetite, and diarrhea. no valvular heart disease or pulmonary arterial hypertension was observed. conclusions: treatment with zx provided sustained, clinically meaningful reduction in mcsf in ds participants < years old. importantly, effective control of seizures in this young age group might be expected to mitigate the negative neurodevelopmental outcomes reported to be associated with treatment-refractory seizures. the improving provision of epilepsy care for children in england and wales methods: all relevant health boards and trusts (hb/t) were invited to register to participate and identify a hb/t lead. a snapshot survey was completed via a bespoke online platform by the hb/t lead describing local provision as of april . data was analysed by the rcpch including regional and national aggregates and longitudinal comparison to previous , reports. results: hb/t with a paediatric epilepsy service across england and wales registered to participate and submitted data. . % ( / ) of hb/t employed a consultant paediatrician with expertise in epilepsy; . % ( / ) had some epilepsy specialist nurse (esn) provision; . % ( / ) had a defined epilepsy clinic seeing patients at secondary level. . % ( / ) of hb/t had agreed referral pathways to tertiary paediatric neurology services. satellite paediatric neurology clinics were hosted in . % ( / ) of hb/t. conclusions: there are improvements in the overall numbers of epilepsy nurse specialists, paediatricians with expertise and specific clinics for children and young people with epilepsies. the findings led to comprehensive recommendations to hb/ t and commissioners, informed updates to the epilepsy best practice tariff and themes within the nhs long term plan. poster no. diagnosing and managing seizures on picu: an explanatory sequential mixed methods approach tonic clonic seizures. awake and sleep eeg showed temporal focal slowing. she was labelled as non lesional focal epilepsy after a normal mri scan and was discharged on keppra. she had multiple admissions with cluster of brief seizures at the age of , , , , , and months associated sometimes with febrile illness with poor response to intravenous aed's. she was diagnosed with autism at months. nd child: months old younger sibling had seizure onset at months. seizures were tonic in nature, brief, multiple and in clusters over a period of to days. eeg's showed non-specific slowing during seizures. array cgh revealed chromosome p . microdeletion. keppra was commenced and increased but recurrent cluster of seizures at the age of , and months required admission with poor response to iv aed's. family history revealed that half-sister (biological father's daughter who had epilepsy and global developmental delay) was diagnosed with pcdh epilepsy. gene tests were requested on both siblings and both were heterozygous for pcdh mutation. she had delayed social and communication skills from years with a diagnosis of autism at months. rd child: year old half sibling (father's th child from rd relationship) has tested positive for pcdh . her development is normal and so far there have been no seizures. conclusions: pcdh epilepsy is increasingly recognised as one of the early onset infantile encephalopathies. gene testing is likely to yield a diagnosis with a family history or with a typical phenotype. poster no. seizure, developmental and cognitive outcomes in children post hemispherotomy tt tay , dr reed , vj josan , sr rust , jt tan university of manchester, manchester, uk; neuropsychology team, paediatric psychosocial service, royal manchester children's hospital, manchester, uk; neurosurgery, salford royal nhs foundation, manchester, uk; paediatric neuropsychology, royal manchester children's hospital, manchester, uk; paediatric neurology, royal manchester children's hospital, manchester, uk introduction: patients with focal refractory epilepsy secondary to structural hemispheric changes have been shown in retrospective studies to have significantly improved seizure outcomes following hemispheric disconnection. the aim of this study was to report the seizure and cognitive outcomes in our cohort and investigate prognostic factors for seizure outcomes. methods: this was a single-centre retrospective study on children and adolescents who had hemispherotomy for refractory epilepsy in the royal manchester children's hospital between and . results: twenty-two patients were included with median (range) age of seizure onset and of surgery of ( - ) and ( - ) months respectively. median (range) time from seizure onset to surgery was . ( - ) months. the most common aetiologies were antenatal/perinatal middle cerebral artery infarct (n= ) and malformations of cortical development (n= ). at year after surgery and at last follow-up (median [range] [ - ] months), % ( / ) and % ( / ) achieved complete seizure freedom. the number of anti-epileptic medications decreased for ( %) at last follow-up. lateralisation of ictal and interictal eeg (p= . , p= . ), aetiology (p= . ), age of first seizure (p= . ) were not associated with seizure recurrence. five who had formal neuropsychological testing using the wechsler intelligence scale for children (wisc) showed improvement in cognitive abilities across all subsets post-surgery. ten children showed reduction in median vineland adaptive behaviour score, from to . , indicating a failure to progress rather than regression of skills. nine ( %) had newly reported behavioural or psychiatric issues including sleeping problems, challenging behaviours, autistic spectrum disorder. sixteen ( %) were reported by parents/carers to show improved verbal abilities postoperatively while the rest had unchanged verbal abilities. conclusions: we present a cohort of children with early onset seizures who had hemispherotomy at a relatively early age. our cohort showed good seizure outcomes and cognitive improvements. there were no prognostic factors for seizure outcome identified in this small group. the mri phenotype of atp a -related disease contrast, all ahc patients with mri abnormalities ( %) had a hypoplastic corpus callosum. the only patient with normal mri was the patient carrying mutation p.g r, associated with a mild clinical phenotype. of the patients with clinical ataxia (n= ), ( %) had cerebellar atrophy on mri; patients with cerebellar atrophy were not ataxic. two ( %) of the patients with severe intellectual disability had cerebral atrophy. conclusions: atp a mutations have subtle radiological findings, clustering around callosal dysmorphisms, as well as pontine and cerebellar abnormalities that seem to form distinctive mri phenotypes for ahc and capos. study of larger cohorts is required to more accurately define mutation-specific phenotypes and allow for quantitative analysis. poster no. long-term safety and efficacy of adjunctive perampanel in paediatric patients (aged to < y) with partial-onset seizures (pos) or primary generalised tonic-clonic seizures (pgtcs) in study r flamini , a patten , ly ngo pediatric and adolescent neurodevelopmental associates, atlanta, ga, usa; eisai ltd., hatfield, hertfordshire, uk; eisai inc., woodcliff lake, nj, usa objective: study (nct ) was a multicentre, openlabel, single-arm study of perampanel oral suspension ( . mg/ ml) in paediatric patients (aged to < y) with pos (with/ without secondarily generalised seizures [sgs] ) or pgtcs. here, we report long-term ( y) safety and efficacy data of adjunctive perampanel in paediatric patients from study . methods: this analysis included cumulative data from all enrolled patients in the core study ( wks of treatment) and extension phase a ( wks of treatment). assessments included monitoring of treatment-emergent adverse events (teaes), median percent change in seizure frequency per days from baseline, and % responder and seizure-freedom rates. results: of patients enrolled in the core study (pos, n= ; sgs, n= ; pgtcs, n= ), patients entered extension a. of these, patients discontinued extension a; most common primary reasons for discontinuation were adverse events ( . %) and inadequate therapeutic effect ( . %). for all patients, mean (standard deviation [sd] ) time since diagnosis was . ( . ) years and mean (sd) duration of exposure was . ( . ) weeks. during baseline, . % of patients received two concomitant anti-seizure medications. teaes were reported in ( . %) patients; somnolence was the most commonly reported ( . %). median percent reductions in pos, sgs and pgtcs frequencies at weeks - were . %, . % and . %, respectively; these were maintained at weeks - and were . %, . % and . %, respectively. seizure-freedom rates for pos, sgs and pgtcs at weeks - were . %, . % and . %, respectively. conclusions: long-term ( y) adjunctive perampanel is generally safe, well tolerated and efficacious in paediatric patients aged to < with pos (with/without sgs) or pgtcs. poster no. long-term adjunctive perampanel and healthrelated quality of life (hrqol) in paediatric patients (aged to < y) with partial-onset seizures (pos) or primary generalised tonicclonic seizures (pgtcs): study ea portillo , a patten , g meier , m malhotra , ly ngo paediatric neurology unit, department of paediatrics, hospital universitario virgen del roc ıo, sevilla, spain; eisai ltd., hatfield, hertfordshire, uk; eisai inc., woodcliff lake, nj, usa objective: study (nct ) was a multicentre, openlabel study of adjunctive perampanel oral suspension in paediatric patients (aged to < y) with pos (with/without secondarily generalised seizures [sgs] ) or pgtcs. we report long-term ( y) hrqol data using the euroqol dimensions-youth (eq- d-y) scale from study . methods: this analysis included cumulative data from all enrolled patients in the core study and extension phase a ( and wks of treatment, respectively). eq- d-y was assessed at baseline, week and week , and included five domains (mobility, self-care, doing usual activities, pain/discomfort, feeling worried/sad/unhappy). the eq- d-y visual analogue scale (vas) was also assessed; increases in vas correspond with improvements. data are for observed cases. results: all enrolled patients were included in the eq- d-y analyses. the proportion of patients reporting 'a lot of problems' was similar during baseline vs week : mobility, / ( . %) vs / ( . ); self-care, / ( . %) vs / ( . %); doing usual activities, / ( . %) vs / ( . %); pain/discomfort, / ( . %) vs / ( . %); feeling worried/sad/unhappy, / ( . %) vs / ( . %). outcomes were also similar for 'no problems' during baseline vs week : mobility, / ( . %) vs / ( . %); self-care, / ( . %) vs / ( . %); doing usual activities, / ( . %) vs / ( . %); pain/discomfort, / ( . %) vs / ( . %); feeling worried/sad/unhappy, / ( . %) vs / ( . %). mean (standard deviation) change in eq- d-y vas from baseline at week was . ( . ). conclusions: long-term adjunctive perampanel treatment (up to y) does not negatively affect hrqol (based on all eq- d-y domains) in patients aged to < years with pos (with/without sgs) or pgtcs. poster no. efficacy and safety of adjunctive perampanel for partial-onset seizures (pos) in adult, adolescent and paediatric populations (studies , , , ) . in study , patients received perampanel ≤ mg/day (without enzyme-inducing anti-seizure medications [eiasms] ) or ≤ mg/day (with eiasms) ( -week treatment period). efficacy assessments included median percent change in seizure frequency/ days from baseline, % responder rate and seizure-free rate. safety assessments included the incidence of treatment-emergent adverse events (teaes). results: the median percent reduction in seizure frequency/ days was greater with perampanel at ( . %), ( . %) and mg/day ( . %) vs placebo ( . %; p< . ) in adolescent/adult patients and was . % in paediatric patients. the % responder rate during the maintenance period was greater with perampanel at ( . %), ( . %) and mg/ day ( . %) vs placebo ( . %; p< . ) in adolescent/adult patients and was . % in paediatric patients. seizure-freedom rates were greater with perampanel at ( . %), ( . %) and mg/day ( . %) vs placebo ( . %; p< . ) in adolescent/ adult patients and was . % in paediatric patients. teaes occurred in . %- . % of adolescent/adult patients with perampanel - mg/day (vs . % in placebo patients), and in . % of paediatric patients. teaes observed in pediatric patients were similar to those reported in adolescents and adults. conclusions: these studies suggest perampanel is efficacious and generally safe in paediatric, adolescent and adult patients with pos (with/without sgs). methods: patients who completed either of the rcts could enter this ole trial (gwpcare /nct ). patients received gw pharmaceuticals' plant-derived highly purified cbd medicine ( mg/ml oral solution). the primary endpoint was safety. the secondary efficacy endpoints were median percentage change from baseline in drop and total seizure frequency. results: overall, % ( / ) of eligible patients with lgs entered the ole. median follow-up was weeks ( d to wks); patients ( %) withdrew. mean age: years; % ≥ years; % male. baseline median seizure frequency/ days: drop seizures; total seizures. during the extended follow-up, the incidence of adverse events (ae) was %; serious aes %; aes leading to discontinuation %. most common aes (≥ %): diarrhoea, convulsion, pyrexia, somnolence, vomiting, upper respiratory tract infection, and decreased appetite. aes of alanine aminotransferase increased occurred in % of patients. there were deaths; none deemed treatment-related by the investigator(s). median percentage reductions in seizure frequency ( -wk windows over wks) was - % for drop seizures and - % for total seizures. conclusions: long-term treatment with add-on cbd in patients with lgs produced sustained seizure reductions, with no new safety concerns. poster no. management of status epilepticus in children with dravet syndrome jaa holland, u rajalingam paediatrics, hinchingbrooke hospital, huntingdon, uk objective: status epilepticus is reported to be the second greatest cause of mortality in children with dravet syndrome. we aimed to review the evidence on convulsive status management in children with dravet syndrome to guide local practice. methods: literature review. results: pubmed search using search terms 'dravet' or 'scn a' and 'status epilepticus' returned results, of which were relevant. only one of these articles presented specific data on reported effectiveness of medications used in acute seizure management; this was based upon retrospective questionnaire data and defined status epilepticus as seizures lasting minutes or longer. here, the most efficacious agents reported to terminate such seizures within minutes were intravenous barbiturates ( of patients) and benzodiazepines ( of patients). rectal benzodiazepines, chloral hydrate and intravenous phenytoin or lidocaine were reported as less effective. the remaining articles presented expert and consensus opinion, all advising early administration (some at seizure onset) of buccal or intravenous benzodiazepines. provision of rescue medication for home use, with individualised plans, is recommended. one author advocated giving three doses of benzodiazepines sequentially. an article summarising a consensus panel described sodium valproate as a preferred second line option where benzodiazepines are ineffective, but there was no overall agreement on other possible medications. several articles advised caution in using phenytoin in acute seizure management. one source discusses possible harm from high dose barbiturates. conclusions: status epilepticus management for children with dravet syndrome should feature early, rapidly acting benzodiazepine administration. for second line treatment, phenytoin and barbiturates are commonly used in 'standard' status epilepticus management protocols, but there are potentially concerns around their use in this patient group. these concerns, however, appear largely theoretical. in the absence of evidence favouring a specific management protocol, individualised care plans should be designed with involvement of patients and their carers. poster no. zx (low dose fenfluramine hydrochloride oral solution) significantly reduces frequency of generalized tonic-clonic seizures in dravet syndrome: pooled analysis from two phase clinical trials jh cross , a gil-nagel , b gunning , d battaglia , k riney , g farfel , , a mistry , , b galer , , g morrison , , a gammaitoni , , k pagano , great ormond street hospital, london, uk; servicio de neurologia, hospital ruber internacional, madrid, spain; stichting epilepsie instellingen, zwolle, the netherlands; gemelli hospital, rome, italy; mater children's hospital, brisbane, qld, australia; zogenix, inc and int, emeryville, ca, usa; zogenix, inc and int, maidenhead, uk objective: zx (low dose fenfluramine hcl oral solution) significantly reduced the frequency of convulsive seizures in patients with dravet syndrome (ds) in two phase clinical trials. we conducted a pooled analysis of these trials to analyze the effect of zx on the frequency of tonic-clonic seizures (tcs), recently identified as a major risk factor for sudden unexpected death in epilepsy. methods: the frequency of generalized tcs and focal-to-bilateral tcs in patients with ds enrolled in one of two phase clinical trials of zx added to current antiepileptic drug regimens were analyzed. results: patients ( % male, mean age y) were enrolled and randomized to placebo (n= ), or zx . (n= ), . (n= ), or . (n= ) mg/kg/day. the median baseline monthly frequency of generalized tcs ranged from . to . /month in the four dose groups, and decreased during treatment by %, %, and % in the zx . , . , and . mg/kg/day groups, respectively, and by % in the placebo group. focal-to-bilateral tcs were experienced by fewer patients and had a median baseline frequency of . to . / month. during treatment, median percentage reductions in focal-to-bilateral tc frequency were %, %, and % in the zx . , . , and . mg/kg/day groups, respectively, and % in the placebo group. most common adverse events included decreased appetite, diarrhea, and fatigue. no valvular heart disease or pulmonary arterial hypertension was seen in any participant at any time. conclusions: zx substantially reduced the frequency of tcs. zx may be an important, effective new treatment option for ds patients. objective: mutations affecting tbc d have been associated with an expanding spectrum of phenotypes including developmental delay, hearing impairment, doors syndrome and a range of epilepsies. a number of different movement disorders, including ataxia, spasticity and episodic paroxysmal dystonia have also been described. here we report two unrelated patients with biallelic tbc d variants, in whom exerciseinduced dystonia was a major disease feature. methods: both patients were diagnosed through whole-exome sequencing. clinical information was obtained by a review of the medical notes, clinical correspondence and available video footage. results: both patients were found to have compound heterozygous mutations in tbc d , associated with an episodic dystonic/dyskinetic movement disorder reliably triggered by exertion. in the case of patient , exertion of specific body parts induced specific localised symptoms: for example, singing would precipitate orolingual dyskinesia. both girls experienced truncal dystoniaspecifically, lateral flexion of the trunkbrought on by prolonged walking. both girls also had epilepsy; of note, the exercise-induced movements and postures were captured on eeg and had no ictal correlate. conclusions: although tbc d mutations are an established genetic cause of epilepsy, our study further confirms that not all paroxysmal events in people with tbc d mutations are epileptic in nature. tbc d should be included in the genetic differential diagnosis of patients with complex neurological syndromes associated with paroxysmal exercise-induced dyskinesia. objectives: heterozygous de novo rhobtb mutations have recently been reported in developmental and epileptic encephalopathy, but the associated movement phenotypes are not fully delineated. in order to better define the expanding phenotype and movement disorder in rhobtb -related disease, we report a series of unrelated patients presenting with complex movement disorders as well as epilepsy and developmental impairment. methods: cases were identified both in the uk (through the neurogenetic services at great ormond street hospital and the national hospital for neurology and neurosurgery, london), and from international collaborating centres. data were collected retrospectively by the patients' clinicians, using a standardised proforma. results: nine individuals were identified, aged from to years. / had epilepsy. of these, / had achieved seizure freedom at their last review. the commonest seizure types were focal onset with impaired awareness and/or focal to bilateral tonic-clonic seizures. / also had a paroxysmal movement disorder, which included hemiplegic or asymmetrical episodic weakness in / , generalised dyskinesia in / , episodic focal dystonia in / and episodic ataxia in / . all individuals affected by a movement disorder had at least two different types of episodes. movement disorders improved significantly after treatment with carbamazepine in three children. cognitive ability varied from average to severe intellectual disability and in all but one case, developmental delay predated the onset of epilepsy. conclusions: rhobtb mutations cause a complex neurological phenotype associated with both epileptic and non-epileptic paroxysms. paroxysmal events occurring in people with known rhobtb mutation should therefore not be assumed always to be epileptic in nature. our study confirms that a wide variety of movement disorders are reported, including some which fall within the spectrum of alternating hemiplegia of childhood (ahc). rhobtb should thus be considered as a potential gene for ahc, other complex movement disorder phenotypes and epilepsy-dyskinesia syndromes. poster no. evaluating seizure recognition and the use of electroencephalography in the paediatric intensive care unit objective: in the paediatric intensive care unit (picu), seizures are challenging to detect given patient complexity, comorbidity and sedation. this has led to both over-and under-treatment of seizures. there is growing literature on the use of continuous electroencephalography in picu, considered gold standard but not universally available, but little on standard electroencephalography (eeg). this study aims to investigate the indications for eeg requests, their efficacy and the use of antiepileptic drugs (aed) in picu, hypothesising a difficulty in clinically differentiating between epileptic and non-epileptic events and suboptimal use of aeds. methods: this retrospective study examined eeg reports over years at a tertiary picu. data was collected on participant characteristics, eeg indications and findings and aed use. results: eeg reports from participants were included. median age was months (iqr mo- y mo). indications for eeg (often multiple per eeg) included suspected clinical seizures ( %), suspected subclinical seizures ( %), prognostication ( %) and suspected encephalopathy ( %). % of participants with suspected seizures were sedated and % of all participants were encephalopathic. clinical episodes suspected to be seizures were captured in / eegs. only % of these were eeg-confirmed seizures. captured movements shown not to be seizures are qualitatively described. % of patients with suspected seizures had electrographic seizures with no clinical correlate. most confirmed seizures were in participants without pre-existing epilepsy. antiepileptic(s) were changed prior to / captured events. seizures were present in % of these cases, while % had neither clinical nor electrographic seizure activity. / participants with confirmed clinical seizures had aeds changed. conclusion: it is challenging for clinicians to differentiate between seizure and non-seizure movements in picu. moreover, there are issues of over-medication and low event-capture rate with eeg. we propose a multidisciplinary education strategy and investment in ceeg to address these issues. introduction: glucose transporter deficiency syndrome (glut -ds) is a rare neurometabolic disorder causing impaired glucose transport into the brain. in the majority of patients, it is caused by an autosomal dominant heterozygous mutation in the scl a gene. ketone bodies generated by a ketogenic diet (kd) provide the brain with an alternative energy source and is gold standard therapy. we report our experience for our cohort of patients at royal manchester children's hospital. methods: retrospective case note review of patients with glut -ds at royal manchester children's hospital from to . results: patients - male, female. age range to years. average age at diagnosis was years months (range mo- y). there was a history of seizures in of patients with average seizure onset of years months. seizures types were absences ( / ), generalised tonic-clonic ( / ), myoclonic ( / ), myoclonic astatic ( / ), tonic ( / ) and focal to bilateral tonic-clonic ( / ). ketogenic diet was used in all patients for a range of months to years months. no significant adverse effects occurred that required discontinuation. six patients complying with kd are seizure free and not taking antiepileptic drugs (aeds). one of these patients had occasional tonic-clonic seizures with illness and loss of ketosis but has been seizure free for > months. five patients are non-compliant with kdtwo have good seizure control with aeds, potentially limiting motivation, and two (siblings) have a parent with glut -ds and learning difficulties. learning difficulties were reported in patients. other symptoms included ataxia ( / ), dysarthria ( / ), tremor ( / ) and dystonia ( / ). one patient presented with episodic hemiplegia. conclusions: patients with glut -ds are a heterogeneous group leading to challenges in diagnosis, management and prognosis. ketogenic diet has been effective in managing this cohort but compliance was a limiting factor. objective: to conduct a survey regarding the management of relapse in children epilepsy in following weaning off aeds. methods: we conducted an online survey in the east of england (eoe) via the eastern paediatric epilepsy network (epen) regarding the management of relapse in children epilepsy after weaning aeds. epen is a network of paediatricians and nurse specialist with eoe who manage lead in management children with epilepsy within all the dgh's in the region. the questions in the survey asked about various aspects of management of patients after relapse, including the choice of anti-epileptic medication restarted, if started, any further investigations undertaken, and finally, the length of aed treatment before a second attempt at weaning might be considered. results: we received responses from paediatricians in dgh's across eoe. there was a large degree of variation in the responses to all of the questions in the survey. the frequency and semiology of seizures on relapse seemed to play a key role in decision making, as did the thoughts and views of the family and patient themselves. it was interesting to note there was a variation in response to whether any further investigations would be undertaken and if these were deemed necessary. most clinicians responded that they would continue aeds for another years before attempting weaning again. conclusions: there is variability in the management of epilepsy relapse in the eoe and we suspect that this may also be the case nationally. to investigate this further, we would envisage extending the survey nationally, via open ukwhich is an organisation that links the various regional paediatric epilepsy networks across uk. this would enable establishing a standardized guideline for management of epilepsy relapse in the future. objective: de novo dominant mutations in dhdds were recently identified as a cause of developmental and epileptic encephalopathy. dhdds encodes dehydrodolichyl diphosphate synthase, which is essential for dolichol monophosphate synthesis and protein glycosylation. we report two half-siblings with a new pathogenic, maternally inherited dhdds missense variant, c. g>a(p.arg gln), identified through whole-exome sequencing. method: case note and literature review. results: sibling , aged years, presented at months with global developmental delay, hypotonia and frequent absences with eyelid myoclonia. from age , she developed atonic drop attacks, myoclonic seizures, tremor, ataxia and facial dyskinesia. dyskinesia and mobility deteriorated from age and she is now largely non-ambulant. severe learning disability with possible cognitive deterioration and insatiable appetite are also features. sibling , aged years, developed blank spells associated with eyelid flickering at months and atonic drop attacks aged . development delay is present, but progress is greater than her sibling. dyskinesia, tremor, ataxia and deterioration in mobility are features. neither is dysmorphic. eegs on both showed bursts of irregular generalised spike wave associated with head nods and eyelid flutter. photosensitivity was not shown but both were treated with anti-epileptic medication. mri scans are normal. clobazam and zonisamide improved seizure control in both. mother has mild learning difficulties, tremor and dyspraxia. she had generalised tonic clonic seizures, from age to years, well controlled with lamotrigine. compared to the six known cases in the literature, our report confirms atonic seizures and dyskinesia as important features of this disorder, in addition to common characteristics of myoclonic component to seizures, hypotonia and tremor. learning disability is of variable severity. conclusions: this is the first report of familial inheritance of dhdds related developmental and epileptic encephalopathy and describes variable severity of the phenotype within family members. the features described are consistent with those previously observed. objectives: to evaluate whether the duration of treatment has an effect on the relapse rate in children with cae attending a paediatric neurology centre in cyprus, and whether the eeg can be used as a prognostic tool. methods: electronic patient database review of patients with cae, who have discontinued treatment attending the paediatric neurology clinic between years - . results: fourteen patients with cae, off treatment were identified ( male). age at presentation ranged from to years (median . y). all patients underwent an eeg to confirm diagnosis and those who presented with seizures other than absences were excluded. twelve patients were treated with valproic acid (depakine) and with ethosuximide (zarontin). in , absences resolved on first line monotherapy, whilst were refractory requiring combination therapy. positive family history was present in (non-identical twins), attention deficit in , and learning difficulties in patient. all initial eegs were consistent with cae, patients also underwent an eeg post seizure control to confirm resolution. mean time to seizure cessation was . months, mean duration of treatment . years; patients discontinued treatment after year of seizure freedom. prior to withdrawing treatment all patients had an eeg (normal , mildly abnormal with brief generalised discharges , photosensitivity , brief electrographic absence ). relapse occurred in patients who required re-instigation of treatment. mild abnormalities on eeg prior to coming off treatment did not correlate with a higher relapse rate. there was no difference in relapse rate in patients on treatment for , or more years. patients were followed up for a mean of . years. conclusions: treating patients with cae for less than years does not affect relapse rate provided patients are seizure free, also confirmed by eeg normalisation, which may be used as an additional predictor. background: mutations in unc , encoding part of the unc -unc -nalcn channel complex, causes autosomal-recessive severe infantile encephalopathy, this is a rare case of profound global developmental delay with psychomotor retardation. only individuals have been reported to date. unc deficiency is characterized by hypotonia, strabismus, oral motor dysfunction, postnatal growth deficiency, and developmental delay. the majority of individuals do not learn to walk. all individuals lack expressive language. additional features can include nystagmus, extremity hypertonia, a highpitched cry, repetitive and self-stimulatory behaviours, constipation, clubfeet, joint contractures, and scoliosis. there is no loss of skills suggestive of neurodegeneration. case presentation: -year-old, with a recent confirmed diagnosis of unc gene mutation and microcephaly. she had profound global developmental delay, learning disability, bilateral squint with cortical blindness, seizure disorder, sleep apnoea, head drops, movement disorders, feeding difficulty, scoliosis and constipation. term baby with normal anti-natal history. induction of labour for iugr. good apgar, at birth but developed respiratory distress with cardiac problems. birth weight g. neurologically: floppy with reduced muscle tone and microcephaly. had a short neonatal admission and discharged with cardiac, endocrine, neonatal and neurodevelopmental delay follow-up. she had no spoken words and communicated by crying. she was only able to sit transiently and never walked. she was wheelchair bound with gmfcs, macs, cfcs and edacs level each, needing full -hour support from patents and carers. ddd study confirmed unc gene mutation, her cousin was also noted to have same gene mutation via exome sequencing and with similar clinical picture. conclusion: early diagnosis is key for genetic counselling for further children and ensuring global support as reported individuals span ages from birth to year. the diagnosis is established in a pro-band with developmental delay and hypotonia by identification of bi-allelic pathogenic variants in unc on molecular genetic testing. poster no. cognition and disease burden in scn a positive dravet syndromea -year follow-up study development, disease burden and sleep profile of patients with dravet syndrome. methods: this is a follow-up to a study previously involving ds patients with detailed developmental and clinical information available. participants completed a structured postal questionnaire on epilepsy severity and disease burden, the adaptive behavioural assessment system (abas- ), the sleep disturbances scale for children, pediatric quality of life inventory (pedsql) and the strength and difficulties questionnaire. results: / from the original cohort were contactable and ( %) of carers completed the outcome measures. the developmental quotient at follow-up was significantly lower compared to the earlier study (p= . ), and % of affected individuals had a severe or profound learning disability. we observed the steepest decline in cognitive functioning in those that were youngest (age - y) at original study onset (p= . ). poorer developmental quotients correlated with early onset of initial developmental concerns (rs= . ; p= . ), later mobility problems (rs= . ; p= . ), higher levels of behaviour problems (rs= . ; p= . ) and worse pedsql scores (rs= . ; p= . ). carers health and wellbeing was negatively affected in % of cases and in %, at least one of the two carers quit their job due to their child's illness. sleep problems as measured by total sleep scale score were reported in % of patients, whilst % had at least one abnormal sleep scale category. only % of individuals with abnormal sleep scores received treatment. rs=spearman rho correlation coefficient. conclusions: this study highlights the ongoing cognitive decline in ds, particularly affecting younger patients, alongside often untreated sleep problems and a significant disease burden on primary carers. with new therapeutic opportunities on the horizon, early interventions appear crucial to avert the observed severe cognitive decline. poster no. forced normalisation as a factor in behaviour deterioration on the ketogenic diet e hassan , vj whiteley , , hj tan department of neurology, royal manchester children's hospital, manchester, uk; therapy and dietetics, royal manchester children's hospital, manchester, uk; school of health and society, university of salford, salford, uk introduction: there have been a number of reports that demonstrate a correlation between improved seizure management and deterioration of behaviour with psychosis in adults and children. forced normalisation is a concept where there is deterioration in behaviour when better seizure control is achieved with antiepileptic drugs (aeds) or epilepsy surgery. the ketogenic diet (kd) is a treatment option for children with refractory epilepsy with approximately to % showing at least % reduction of seizures and % of those patients reaching seizure freedom months after treatment. although forced normalisation has been discussed in literature following aeds and neurosurgical interventions, it has not been reported following the use of kd. cases: of the children that have commenced on kd over the last years at royal manchester children's hospital, . % responded to the diet (at least % improvement in seizures) and . % were non-compliant. we present patients under the care of the kd service, whose behaviour deteriorated on kd when seizure reduction was > %. the behaviour changes described by parents included poor sleep, unsettled, agitation, head-banging and shouting. five out of the six patients stopped kd treatment, with subsequent improvement in behaviour. conclusions: there are reports that patients on the ketogenic diet with seizure freedom show improvement in their behaviour, unlike our small cohort whose behaviour deteriorated. forced normalisation has been explored in paediatric patients as a cause for behaviour deterioration following surgical and medical management for intractable seizures. the associated factors of deteriorating behaviour have not yet been explored in depth with the ketogenic diet. objective: we wanted to determine how lacosamide was being used in children locally, and what their outcomes were at a year. methods: we undertook a registered, retrospective, clinical audit using hospital electronic records. we ascertained every patient aged < years who had been dispensed lacosamide january -january . the electronic health records were reviewed, and data collected using a standard proforma, including: patient demographics, age of seizure onset, seizure type, ecg and mri findings, baseline seizure frequency, seizure frequency , , and months on lacosamide, maximum dose prescribed (mg/kg/day), and adverse effects at , , and months. results: / ( %) patients were male, the median age was years (range mo to y), with a mean age of onset of years (range mo to y). / ( %) had epileptiform activity on eeg and / ( %) had an abnormal mri. / ( %) had focal seizures. / ( %) had a minimum of one seizure a week. / ( %) had previously tried or more antiepileptic drugs (aeds), and / ( %) had drug resistant epilepsy prior to starting lacosamide (already failed previous aeds). all patients had lacosamide alongside another aed. the mean daily dose of lacosamide was . mg/kg/day (range . - . ). at months, / ( %) of patients reported a > % reduction in seizure frequency. / ( %) remained on lacosamide year after starting, and / ( %) experienced an adverse side effect. conclusions: in this local audit, lacosamide was mostly prescribed for drug resistant epilepsies and was used in polytherapy. a third of patients saw a significant reduction in seizure frequency on lacosamide, although some were also started on other treatments during this period. most patients remained on lacosamide after months, and about in experienced one or more adverse side effect. cacna a is a large gene which encodes for the alpha subunit of a neuronal ion channel and it is expressed widely throughout the central nervous system (cns). pathogenic variants in this gene have been associated with many phenotypes. most commonly episodic ataxia type (ea ) and spinocerebellar ataxia type (sca ). rarer phenotypes include, familial hemiplegic migraine, paroxysmal tonic upgaze, epilepsy, and intellectual disability with autism. here we present the case of an month old girl who presented with new onset paroxysmal abnormal eye movements during an intercurrent illness. the referring clinicians felt these episodes may be epileptic. however, an electroencephalogram (eeg) captured these movements which were non-epileptic downbeat nystagmus. all other initial investigations including cerebrospinal fluid glucose and neurotransmitters were normal as was her neuroimaging. over the next year her nystagmus became constant. she had otherwise normal development. at months her gait was noted to be abnormally unsteady and broad based (even accounting for age). the nystagmus and ataxia changed in severity from day to day, she could have to more severe days followed by to better days, they never completely resolved. she had no family history of abnormal eye movements or ataxia. subsequent genetic testing revealed a cacna a c. g>a p(glu lys) missense variant described only twice previously in ea , both with very different phenotypes to our patient. neither of her parents carried the same genetic variant. this case is the first reported case of this cacna a variant presenting as downbeat nystagmus followed by ataxia. both her age of presentation and her initial presenting features are very different to the typical phenotypes associated with this gene. it broadens the phenotype of cacna a, and also broadens the differential diagnoses associated with abnormal eye movements in infancy. the importance of following up as yet undiagnosed patients who may go on to develop new and revealing symptoms is highlighted. objective: to undertake a questionnaire-based survey retrospectively exploring parents'/carers' recall of, and views on, the safety and risk advice given at the time of their child's epilepsy diagnosis. methods: questionnaires were distributed throughout scotland via scottish paediatric epilepsy network (spen). parents'/ carers' of to -year-old children were asked to complete the questionnaire prior to their seizure clinic appointment. results: questionnaires were suitable for inclusion. seizure burden was evenly distributed: % < seizure/month, % > seizure/month, % > seizure/week and % had absences only. respondents could recall post-diagnosis information being provided on: water safety ( %), taking medication regularly ( %), sports/activities ( %), seizures in sleep ( %), first aid ( %), prolonged seizures ( %) and/or sudep ( %). there was no statistically significant difference in the duration of epilepsy diagnosis between those who could recall information being given (m= . y, sd . ) and those who could not (m= . y, sd . ; t test p= . ). the majority of information was given via clinic discussions ( %). % received written information, % directed to websites and/or independent search ( %). most information was 'just right' ( % water safety, % on taking aed regularly, % on sports/activities, % on seizures in sleep, % on first-aid for seizures). approximately % of respondents want more information on seizures in sleep, water safety and sports/activities. % of respondents felt worried following information about seizures in sleep, % about prolonged seizures and % regarding sudep. conclusions: a substantial proportion of parents'/carers' do not recall receiving safety information on epilepsy despite this being standard practice through spen. this appears to be unrelated to the duration of their child's epilepsy. repeated timely reinforcement may be of benefit. a high proportion of parents'/carers' felt concerned following information provided on nocturnal seizures, prolonged seizures and sudep. this should be recognised with support in place for further discussions. poster no. seizure outcome in responsive vagus nerve stimulation therapy in children and young people v rasiah, n barnes, s carter, k das, r robinson, z tahir, s varadkar great ormond street hospital for children nhs foundation trust and ucl gosh institute of child health, london, uk aim: vagus nerve stimulation (vns) therapy is an established treatment for pharmacoresistant epilepsy. newer responsive-vns (rvns) systems use ictal-tachycardia detection as a biomarker of seizure onset and automatically deliver additional stimulation on detection to abort the seizure. we reviewed the seizure outcomes in children and young people (cyp) implanted with rvns at great ormond street between to . methods: data were collected prospectively on patients who had an aspiresr â rvns inserted during time period of to . reduction in seizure frequency and severity, wean of medications and treatment complications or side-effects were assessed at time-points of year, months, years and years post-implantation. results: cyp (mean age . y) had rvns inserted. at year, % ( / ) had a positive response graded as > % reduction in seizure frequency or severity (i.e., duration), % ( ) had benefit though < % benefit, and % ( ) of cyp were non-responders. this increased at months to % ( / ) of children showing response > %, a further % showed response % and only % ( / ) non-responders. response was over-all sustained, with response lessening in only children between months and years. reduction of medication burden was achieved in % ( / ) (not attempted in all cyp). no patients achieved seizure freedom. replacement of vns from an older model to rvns showed further benefit. complications were infrequent: % ( / ). device removal for infection was required in one child of small body size; successful replacement was possible within the year. conclusions: vns is a useful treatment option for cyp with pharmacoresistant epilepsy. seizure outcomes with rvns in cyp are better than with standard vns. response is sustained. benefit may not be seen by year; therapy should be continued until at least months. in our patients who responded later than -year, further optimisations of duty cycle and current were made. replacement of older vns. devices with rvns led to additional benefit. these findings are consistent with reported outcomes from adult series, though seizure freedom is not seen in cyp. in our centre, cyp who seemed to benefit most were those whose epilepsy was of structural aetiology and those with focal seizures, although our numbers were not large enough to assess the significance of this. poster no. atp a mutation in twins presenting with apnoeic episodes, suspected seizures and possible dystonic events objective: we report the case of monochorionic diamniotic twins presenting at the age of months with infantile seizures and apnoeic episodes. the eiee gene panel revealed a mutation in the gene atp a , supporting the clinical diagnosis of alternating hemiplegia of childhood (ahc). methods: case report. results: twin r presented with staring episodes, eye deviation and tonic posturing of limbs. episodes occurring mainly in clusters, affecting either side and requiring rescue medications for termination. profound apnoeic episodes needing resuscitation were also noted. twin s presented few weeks later with a very similar presentation. developmentally making satisfactory progress with twin r showing only very mild delay. the array cgh from twin r was normal. several investigations were performed including two normal standard eegs, a normal sleep eeg, a normal ecg, an echo showing a small pfo and an mri scan demonstrating a left sided mesial temporal lobe sclerosis. similar mri findings were reported in twin s. investigations such as urine organic acids and amino acids, plasma amino acids, carnitine, acylcarnitine, transferrin glycoforms, mucopolysaccharidosis screen, ammonia and lactate were all normal. pyridoxine was tried with no improvement, levetiracetam was added and afterwards changed to carbamazepine. sodium valproate was commenced eventually after an episode of prolonged clinical seizure. the eiee gene panel revealed a de novo atp a mutation in both twins. flunarizine was commenced following this result. a video telemetry managed to capture both epileptic and non-epileptic episodes in twin r. the epileptic episode was characterised solely as apnoeic episode due to a left temporal seizure activity spreading onto the opposite hemisphere which is concordant with the imaging finding of left mesial temporal sclerosis. conclusions: knowledge of the atp a mutation allowed clinical correlation of a diagnosis of ahc, matching the wide clinical spectrum of ahc including paroxysmal dystonia and epilepsy. poster no. epilepsy in a child development centre population pc kenyon, njv cordeiro, gl duffy rainbow house child development centre, irvine, ayrshire, uk objective: to assess all the cases in a child development centre (cdc) population with epilepsy, to enable characterisation of the caseload. methods: all case notes of children with an epilepsy diagnosis coded on the cdc database were retrospectively reviewed for demographic, investigation and treatment data. results: children were identified. % were diagnosed before a year of age, and over half before their third birthday. % of patients had an eeg, and of these, % had an abnormal eeg. % had genetic testing performed, and of these, % had a genetic cause of their epilepsy identified. % had an mri scan, and of these, % had a structural cause for their epilepsy identified. % had global developmental delay, and % had a diagnosis of learning disability. one third have a diagnosis of cerebral palsy, % have autism spectrum disorder, and % have a hemiplegia. % are seizure free, the majority of whom have their epilepsy controlled with one medication. % had adherence concerns identified. conclusions: compared to a general paediatric epilepsy clinic, this group of children were diagnosed earlier in life, had higher rates of genetic or structural causes identified, and were less likely to be seizure free. results: case . a -year-old with autism spectrum disorder (asd) developed hand waving in front of her face in bright light from years. multiple myoclonic seizures occurred with screen use and her family live in complete darkness. eeg demonstrated photosensitivity, generalised spike-slow wave after hand waving and - . hz spike-wave with myoclonia. clonazepam has been commenced. case . a -year-old with learning difficulties and a family history of generalised seizures presented aged years with forehead rubbing leading to loss of part of her eyebrow. eeg showed photosensitivity and the generalised spike-wave of absences and eyelid myoclonia (em). sodium valproate was used but replaced with lamotrigine due to weight gain. case . a -year-old with a family history of generalised seizures presented aged years with hand waving in front of her face, requiring her nursery to provide a dimly-lit setting. eeg demonstrated generalised polyspikewave, -hz spike-wave and myoclonia with photic stimulation. lamotrigine was ineffective and replaced with sodium valproate. case . an -year-old with likely asd developed hand waving in front of her face in bright light aged years, triggering generalised tonic convulsions (gtc). she had a non-induced gtc in dappled sunlight. there was on-going anxiety and thoughts of self-harm. eeg showed photosensitivity and bursts of spikes-polyspikes. lamotrigine was ineffective; seizures stopped with sodium valproate. conclusions: the self-induced seizures of sunflower syndrome are difficult to treat and are associated with physical, psychological and social impairments. sodium valproate is the most effective medication which may be problematic in this predominantly female patient group. what are the information needs of parents whose child is diagnosed with glutaric aciduria type to help preserve neuro-developmental outcome? objectives: to assess the information needs and support of parents at the time of diagnosis of ga in their child, and how to support them in preventing metabolic decompensation and preserving neuro-developmental function. methods: a focus group with five parents was conducted using a topic guide to direct the discussion, which was recorded and fully transcribed. data were analysed using thematic analysis. two researchers were involved in initial coding of data and key analytic decisions. results: two main themes were identified. 'understanding the condition' explored parent's needs to understand the scientific complexity of ga and to be aware of the 'worst case scenario' associated with loss of metabolic control, and brain injury. parents reported clinicians did not give then enough information on the ga , and were forced to use other information sources, sometimes seeking out scientific papers. information on managing crises was insufficient, with parents not understanding what the doctor meant about commencing the emergency regime when their child was 'sick'. parents reported living in terror of their child experiencing metabolic decompensation and permanent brain injury. 'managing the condition' explained how parents coordinated and controlled the involvement of other carers and outlined parents' need to be active partners in medical management to feel in control. parents wanted to know the results of regular biochemical tests for reassurance, but found they were not easily accessible. parents could not leave their child in the care of another adult because they did not have sufficient knowledgeable about ga or were known to 'cheat' by offering the child food they should not have. the transition into school was a particular challenge. conclusions: the study highlights the importance of addressing parents' initial and ongoing informational needs so they can fulfil their role and protect their child from metabolic decompensation and permanent brain injury. poster no. normal transferrin isoelectric focusing in a child with cog related congenital disorder of glycosylation objectives: congenital disorders of glycosylation (cdg) are a large group of rare multisystem diseases caused by defective linkage of oligosaccharides to newly synthesised proteins or lipids. several cdg subtypes are the result of mutations in subunits of the conserved oligomeric golgi (cog) complex. this includes cog -cdg, an autosomal recessive disorder caused by pathogenic variants in the cog gene. in the two cases previously reported transferrin isoforms were abnormal, consistent with defective n-glycosylation. methods: we describe a -year-old female born to non-consanguineous parents. she presented with severe global developmental delay, dysmorphic features, postnatal progressive microcephaly, complex epilepsy, rhizomelia, spastic quadriplegia, and feeding problems from early infancy. results: mri brain showed global cerebral atrophy, predominantly supratentorial, with relative cerebellar sparing. trio exome sequencing and analysis identified compound heterozygous cog variants in the proband, a maternally inherited pathogenic splice site variant c. + g>a and a paternally inherited likely pathogenic splice site variant c. + g>a. messenger rna analysis showed that the c. + g>a variant caused aberrant splicing, with skipping of exon and the introduction of a premature stop codon in exon , likely to result in nonsense mediated decay. analysis of transferrin isoforms was normal (by both isoelectric focussing and mass spectrometry). since cog -cdg also affects o-glycosylation apolipoprotein ciii (apociii) isoelectric focussing was undertaken, however this too was normal. conclusions: transferrin and apociii isoelectric focusing are screening tests for n-and o-glycosylation defects. however, both have their limitations and some cases of cdg have normal transferrin or apociii glycoforms escaping those screening tests. this is the first case of a patient with cog -cdg with normal biochemical markers to be described. this case also demonstrates the diagnostic power of next generation sequencing for rare metabolic disorders, where the biochemical screening may be inconclusive. poster no. developmental delay in a young infant with nonclassical combined malonic and methyl malonic aciduria (cmamma) caused by homozygous missense mutation in acsf gene kd dayasiri , eg goh , sk kodagali , jb baruteau , ga anand oxford university hospitals nhs foundation trust, oxford, uk; great ormond street hospital, london, uk introduction: acylcoa synthetase family member (acsf ) activates malonylcoa and methymalonylcoa into their respective thioesters. acsf deficiency causes non-classical cmamma, a rare inborn error of metabolism characterised by presence of methyl malonic acid in higher concentrations than malonic acid in urine. the reversal is seen with classic cmamma caused by malonylcoa decarboxylase deficiency (mcd). case report: -and-a-half-month old male infant second born to consanguineous south asian parents presented with severe failure to thrive and recurrent vomiting. his older sibling who had failure to thrive and neuro-developmental delay died at months without a genetic diagnosis. initial blood tests revealed metabolic acidosis, pancytopenia and coagulopathy. neuroimaging was unremarkable. subsequent evaluation revealed normal levels of methionine, homocysteine and red cell folate. significant methylmalonic aciduria with mild malonic aciduria without evidence of other abnormal metabolites (propionyl-coa metabolites: hydroxypropionate, and methylcitrate or tiglylglycine) in urine suggested the diagnosis of non-classic cmamma, confirmed by homozygous missense variants in acsf gene revealed by trio-exome sequencing. neurodevelopmental assessment at months revealed global developmental delay with general hypotonia; gross motor ( - mo); fine motor ( - mo); speech ( - mo) and social (under mo), and without any regression. carnitine was supplemented to avoid secondary depletion caused by the excretion of mma. parents were advised to avoid prolonged fasting and to provide emergency regimen (powdered carbohydrate drink mix) in the event of acute deterioration. conclusions: this report describes an unusual paediatric presentation of non-classic cmamma. urine organic acids allows identification of increased ma and mma excretion and highly suggestive of the diagnosis, thus avoiding additional investigations determination of urinary mma/ma ratio can help differentiating between classical and non-classical forms. methods: we conducted retrospective case note analysis of the five paediatric cases with confirmed diagnosis of the late onset pompe disease, referred to the highly specialised metabolic service. results: three of five patients (current age - y) presented with delayed motor milestones in early childhood (mean age: . y). one patient initially presented with episodes of thigh pain and high ck. in addition, when years he re-presented with recurrent abdominal pain with high ck. the remaining one presented with muscle pain upon exercise with high ck. all apart from one had muscle weakness affecting limb girdle muscles and axial muscles. the remaining one presented with proximal muscle weakness by the age of years. all patients remained ambulant, one developed scoliosis and two were on non-invasive ventilation. cardiac involvement as ventricular dysfunction requiring targeted treatment was observed in one. pathology showed vacuolated deposits in three patients and non-specific myopathic changes in one. four are on enzyme replacement therapy (ert) and tolerated well. conclusions: late onset pompe disease is a multisystem disease and should be considered in cases of isolated respiratory problems, lower back pain, rigid spine, and myopathy or exercise intolerance with elevated serum ck if these symptoms cannot be attributed to another disorder. poster no. delay in diagnosis and misdiagnosis of ataxiatelangiectasia: a systematic review pubmed, scopus). the cochrane library was also searched. the search protocol is available. the inclusion criteria were: all dates, all languages, all ages, human participants and clinical relevance. the exclusion criteria were: no reference to ataxia-telangiectasia within the article, not an original article, animal studies, article not clinically relevant. results: search returned articles; titles and abstracts were reviewed after removing duplicates. full text review includes articles of which case series and case reports were identified ( , exclusions; , articles not found or not accessible). mean age of first sign or symptom of a-t in cases reviewed to date was . months (range - d to mo). the mean age of diagnosis in cases in which it has been reported was . months (range - d to mo). there was a mean time of . months from presentation to clinician, to diagnosis of a-t (range - to mo, median mo) in the cases in which this was reported. / ( . %) cases had a documented alternative diagnosis prior to the diagnosis of a-t. / ( %) of these children were incorrectly diagnosed with cerebral palsy and / ( %) with hyper-igm syndrome. the mean delay from incorrect diagnosis to a diagnosis of a-t was months with the longest delay months. conclusions: this study is the first comprehensive systematic review of scientific literature on ataxia-telangiectasia. we aim to describe the natural history of the condition and, along with results from the natural history of a-t (n-hat) study, systematically define, where possible, the conditions presentation, course, and prognosis. ( %) people with a-t presented with gait ataxia or disturbance, and / ( . %) with truncal ataxia. the most common presenting feature in cases without ataxia were developmental delay, or regression, and choreoathetoid movements. the second most common neurological presenting sign was dysarthria in / ( . %) cases, and at least of these had no associated ataxia. dystonia was a presenting sign in / ( . %) cases, including / ( . %) with no associated ataxia. / ( . %) initially presented with no neurological signs or symptoms. conclusions: this study is the first comprehensive systematic review of scientific literature on ataxia-telangiectasia. these results show that . % of people with a diagnosis of a-t presented initially with at least one neurological sign or symptoms. this completed review will lead into the natural history of a-t (n-hat) study, a longitudinal, retrospective and cross-sectional study. the role of serum oxysterol in the diagnosis of niemann pick c m alcheikh, g connolly, n cluskey, s osullivan royal hospitals belfast health and social care trust, belfast, uk introduction: neimann pick c is a neurovisceral disease that is caused by cellular cholesterol trafficking disruption. historically, the diagnosis of niemann pick c was made using filipin staining and skin fibroblast cultures. recently genetic testing of npc an npc genes are available. mutations of either gene also affect cellular trafficking of cholesterol and detecting oxidative cholesterol metabolities can also be diagnostic of nieman pick c. serum oxysterol can be used as a first line test with subsequent genetic confirmation and has a positive predictive value of > %. methods: we present a case of an -year-old boy who was referred to genetics initially with absence of up gaze, severe restricted downward gaze, developmental delay, regression of skills and frequent falls. in the last year his parents and school observed progressive deterioration of his symptoms with gelastic cataplexy, markedly decreased tone, increasing difficulty with memory loss and slurred speech. these symptoms are strongly suggestive of niemann pick c disease and oxysterols were requested which showed elevated oxysterol level of . ng/ml (normal range . - ). he was started on miglustat. genetics confirmed the diagnosis. results: overall the child's parents report that since commencing the miglustat he is more confident and they have recently seen him hop and skip which they haven't seen in quite a while. conclusions: oxysterol is suitable biomarker for neimann pick c disease and can be used as first line with the genetic confirmation of gene npc and npc at later stage. as modifying treatment with miglustat is available it is important to attempt diagnosing the condition as early as possible and oxysterol level can be used as screening test for neimann pick c when clinically suspected. introduction: biotinidase deficiency is a rare autosomal recessive inborn error of biotin metabolism. biotinidase catalyses biocytin to biotin, a deficiency of which can present with neurological symptoms including hypotonia, seizures, feeding difficulties, lethargy, optic atrophy, and sensorineural deafness. case: a -week-old female presented with a -week history of seizures and developmental delay. examination revealed generalised and axial hypotonia and delayed smile. she continued to have seizures despite initial treatments including levetiracetam and carbamazepine. mri brain was normal and initial interictal eeg on day post admission revealed no significant abnormalities. ambulatory eeg on day showed a focal onset epileptic seizure with sharp and slow wave activity originating predominantly from the left occipito-parietal region. normal investigations included paired plasma and csf glucose, lactate and culture, csf neurotransmitters, microarray and epilepsy gene panel. on day post admission her biotinidase result was reported showing no activity. biotin was commenced at mg once daily and her seizures abruptly stopped. she was discharged home on day and weaned off levetiracetam and carbamazepine. her development was normal at -month follow-up. genetic testing was declined by the family. discussion: biotinidase deficiency can present from the neonatal period up to years of age with a mean age of . months. in recent years our understanding of pathogenic changes in the biotinidase gene has increased through sequencing for novel mutation. this has important implications for families and consideration should be given to offering affected families genetic counselling. treatment is available with oral biotin that rapidly improves symptoms, with seizures usually resolving within days and other symptoms showing improvement within weeks. objective: we present a previously well -year-old boy with a known m. t>c mutation experiencing weeks of vomiting, lethargy and exercise intolerance. method: he was mildly dehydrated, fully consciousness but tachycardic and hypotensive. his ph was . with be - . , hco . and lactate of . . electrolytes, fbc and inflammatory markers were normal. he was admitted to picu for fluid management and sodium bicarbonate. tachycardia persisted during the first hours though he remained stable. he had a good urine output, was on non-invasive monitoring and an echocardiogram was normal. his gas lactate ranged from . to . . the following day he deteriorated with kussmaul respirations, tachypnoea, increased tachycardia and hypotension. venous blood revealed a ph . , pco . hco . be - and lactate . . he became unresponsive with refractory hypotension and multiorgan failure. arterial blood showed a ph . , pco . and a lactate > with indeterminable be or hco . for over hours he had a blood lactate level of > . rhabdomyolysis and acute kidney injury occurred with a ck of > requiring haemofiltration. encephalopathy, with multiple white matter microhaemorrhages on mri brain, and acute liver failure, with thrombocytopenia and coagulopathy, ensued. multiple inotropes were required. the prognosis was very guarded. off sedation he was unresponsive, apnoeic and areflexic however an eeg showed an alpha rhythm which prompted on-going heroic efforts. he required prolonged haemofiltration, ventilation and inotropes with days intensive care. results: the patient made an astounding recovery. he required month of neurorehabilitation and returned to his cognitive baseline, achieving a grades at gcse months later. liver and renal dysfunction resolved. conclusions: this case demonstrates that mitochondrial metabolic crises in melas can be severe and result in profound acid-base derangements. our patient was expected to not survive but uniquely did so without significant neurodisability. neuronal ceroid lipofuscinosis in children from central africa gl fisher, n shah, p watts, ja te water naude noah's ark children's hospital, university hospital wales, cardiff, uk objective: the effective and rapid diagnosis of neuronal ceroid lipofuscinoses (ncls) has become more relevant with the advent of disease-modifying treatments. some ncls have a more stereotyped clinical presentation: we describe two cases in a non-consanguinous family, originally from the democratic republic of the congo, with variant ncl. methods: retrospective case series. results: the index case was initially diagnosed with a focal epilepsy: on review this child had myoclonic seizures in the context of a slow developmental decline, with mild spasticity. ophthalmology was not diagnostically helpful, and a putative diagnosis of ncl was suggested by lymphocyte inclusions. neither enzyme nor dna analysis was available at that stage, although dna was retained. a brother presented with nystagmus and visual inattention in : examination showed myoclonic jerks with a bull's eye maculopathy and an abnormal peripheral retinal vascular leak. mri imaging showed some element of cerebellar atrophy, which on review was also the case with his brother's scans. some lymphocytes ( %) contained fingerprint bodies, suggestive of variant ncl. this was confirmed by dna sequencing which was consistent with a diagnosis of mfsd /cln -related ncl. the identical dna alteration was also found in the index case. conclusions: ncl is not described in children from central africa: the presentation, investigations and laboratory findings and evolution are consistent with that for other children with variant ncl. obesity screening of patients affected by duchenne muscular dystrophy (dmd) in a tertiary paediatric neuromuscular centre and the effectiveness of metformin use in weight control in those with confirmed insulin resistance m neocleous , s spinty , r madhu , p dharmaraj , c degoede , k cooke , c greaves alder hey hospital, liverpool, uk; royal preston hospital, preston, uk objective: to assess whether patients affected by duchenne muscular dystrophy (dmd) who are currently followed up in alder hey hospital, uk are receiving obesity screening when clinically appropriate. to assess whether metformin use in those who are insulin-resistant, has been effective in controlling weight. methods: using the neurology department records, a list of patients with dmd currently under our services and those transitioned to adult services in the last years, was generated. the patient record system, meditech, was used to collect patients' demographics, latest weight/height value and bmi. for patients classified as overweight/obese, completion of obesity screening was assessed as well as initiation of appropriate treatment (metformin). for patients on metformin, the following parameters were collected: weight pre and post-steroids, age of start of excessive weight gain, confounding variables and medications, weight/height/bmi at initiation of metformin and at -monthly intervals, side-effects, cessation of medication and reasoning. results: sixteen out of patients were found to be above the th weight centile. in patients, weight was at or more centiles above height. using the non-dmd standardised bmi classification, patients were identified as being overweight/ obese. patients received obesity screening; were found to be insulin resistant. of those were started on metformin. patients overall were started on metformin. of those exhibited overall weight loss. patients were found to have gained weight and patient showed weight increase up to months post-metformin initiation with subsequent weight loss. conclusions: there is a need for a validated and agreed bmi classification in dmd. screening for insulin resistance in this patient group should be considered for implementation as standard practice, especially if patient is classified as overweight/obese. a larger-scale study would be required to assess the effectiveness of metformin in this patient population. objective: niemann-pick disease (npd) is an autosomal recessive metabolic disorder with a prevalence of . to . / worldwide, marked by varying degrees of lipid storage and foam cell infiltration in tissues, associated with hepatosplenomegaly, pulmonary insufficiency or central nervous system involvement. npd type a and b are allelic disorders caused by mutations in the sphingomyelin phosphodiesterase- gene, smpd ( p . - . ), characterized by a primary deficiency of acid sphingomyelinase activity, resulting in an accumulation of sphingomyelin. in contrast to npd-a, npd-b is the milder, lateronset form, with no neurological involvement. in this paper, we report on three paediatric cases with npd-b who present an atypical phenotype marked by neurological involvement. methods: the three patients were diagnosed at the age of with hepatosplenomegaly. the first is a girl who presented psychomotor regression at the age of and epileptic seizures at the age of . she died at the age of . the second is an years old girl who presented growth retardation, kyphosis and neurodevelopment regression since the age of . the third is a years old boy with a mild phenotype marked by developmental delay and an aggressive behaviour. splenectomy was performed at the age of . results: genetic testing was performed, and all patients presented mutations of the smpd gene, confirming the diagnosis of niemann-pick type b. the c. t>g(p.trp gly) mutation was common in all cases. in addition, heterozygous mutations c. delt(p.ser alafs* ) and del c. _ del were found in the first and second case, respectively. conclusions: all cases present a complex phenotype, marked by psychomotor regression which is atypical for npd type b. the severity of the disease seems to be correlated to the genetic mutation-the most severe phenotype was associated with c. delt. further work is necessary to more clearly delineate genotype-phenotype relationship in npd. objective: acute encephalitis syndrome (aes) is a group of symptoms and signs, which help diagnose encephalitis. since there is no definite treatment for most, role of fluids seems crucial. therefore, the objective of our study was to describe the association of low admission weight and weight loss in the hospital (as clinical marker of dehydration) with outcome of patients of acute encephalitis syndrome. to describe the association between changes in weight and blood lactate levels (at admission and discharge as indicators of hydration and acid base status) and outcome in children with acute encephalitis syndrome. methods: all children aged month to years with fever and altered sensorium and/or new onset seizures from september to september attending kanti children's hospital, kathmandu, nepal were recruited. weight-for-age (wfa) using z score and serum lactate were assessed at admission and discharge. total fluid input and output was monitored daily. results: of the patients, % had low admission wfa or lost weight-after-admission (lwaa) (group a) and % no low wfa or didn't lwaa (group b). there was times risk of death and times risk of bad outcome (death or sequelae) in group a compared to b. bad outcome was significantly associated with less admission wfa, more fluid deficit, and trend for higher admission serum lactate. death was significantly more in those with low wfa, more lwaa, longer illness, more % dextrose and . normal saline, higher sodium and higher urea at admission. methods: we conducted a prospective cross-sectional study recruiting children aged between month to years attending kanti children's hospital, kathmandu, nepal with altered sensorium and two of the following: fever, seizure, focal neurological deficit, csf pleocytosis, electroencephalogram and computer tomography suggestive of encephalitis, over year. in these patients, ve was if csf cell count was < cells/ mm (lymphocyte predominance) and absence of non-viral pathogens in the csf or blood. bm was csf cell count > cells/mm (polymorph predominance) and csf protein > . g/l and csf/plasma glucose < %, and/or positive gram stain and/or bacterial culture. je was ve with ≥ units of anti je-igm in the csf and/or serum. all cns infections were defined as, suspected cases by treating clinician with or without fever with lp showing csf cells > /mm . results: out of , bm was found in %, je % and other causes in %. although who definition of aes was not significantly associated with all cns infections (p= . ), it was significantly associated with ve (p< . , sensitivity %, specificity %, ppv %, npv %) and bm (p< . , sensitivity %, specificity %, ppv %, npv %). conclusion: we validate who aes definition of bm and ve as a significantly useful screening tool for children with these diseases specially in resource poor settings, endemic areas and where confirmatory tests were not easily available. objective: the aim of this case series is to raise awareness of this autosomal recessive encephalopathic syndrome that presents after birth in the multi-ethnic population in england. although aicardi goutieres syndrome (ags) is rare, its importance lies in the fact that that its presentation may be mistaken for other neurological conditions associated with congenital infections. results: all of the patients were seen in our paediatric outpatient neurology clinic. the age of presentation ranged from the neonatal period to the first weeks of life. all patients were of pakistani origin and were from consanguineous marriages. they all had an uneventful antenatal period with normal birth weight and head circumference. the initial presentation seems to be of poor feeding and irritability. further observations include truncal hypotonia, limb spasticity intermittent dystonic posturing coinciding with the onset of poor head growth and chilblains. of our patients had abnormal movements with diffuse slow wave electroencephalogram activity. nystagmus with visual inattention and poor visual acuity were a typical finding in all of them by the age of months. the ct scans showed cerebral calcification in all of them and mri suggested brain atrophy. the most striking abnormality was a raised level of csf interferon-alpha (infa) in an absence of other infection or metabolic disorder. csf inf a is a reliable diagnostic marker and can thus be used to differentiate patients with ags from other conditions. three of our patients had the same gene mutation, rnaseh c. conclusions: ags is a rare disorder, however in patients from consanguineous marriages that depicts microcephaly, poor tone and global developmental delay, diagnosis of ags should be considered. as ags is a progressive neurological condition, early support and prognosis can be provided for affected families. t thomas , ht yeo , sv barron , paediatric neurology, kk hospital, kampong java, singapore; university of newcastle, newcastle, uk objective: we report the association of mild encephalopathy with a reversible splenial lesion (mers) with a primary dengue virus infection. this case implies the existence of a wider spectrum of neurological involvement in dengue virus infections. case description: a -year-old girl presented with acute confusion, dysarthria and bilateral limb weakness following a -day history of fever. symptoms resolved after hours; neurological examination was completely normal. she later experienced a second episode of slurred speech, dysphasia and right arm weakness which lasted an hour. a contiguous lesion involving the genu, body and splenium of the corpus callosum and bilateral posterior periventricular white matter was evident on the mri brain scan, with restricted diffusion and t -hyperintensity. cerebrospinal fluid analysis showed no inflammation and polymerase chain reaction assay for respiratory viruses was negative. her clinical and radiological features were consistent with mild encephalopathy with a reversible splenial lesion (mers). on day of admission, she developed a generalised maculopapular rash with leukopenia (white blood cell count . /l) and thrombocytopenia (platelets /l). serology (igm/igg) for dengue virus was negative and a positive dengue ns antigen was thus indicative of a primary dengue virus infection. she was given fluid rehydration and advised bedrest. at discharge (day admission) she was well with no sequelae. conclusions: mers is a mild form of virus associated encephalopathy (vae), which are a spectrum of clinico-radiological syndromes associated with common childhood viral infections. the clinical and neurological symptoms in our patient occurred early in the course of illness (typical to vae) as opposed to after or late in the illness as is typical for postinfectious encephalopathy syndromes associated with dengue virus infections (e.g., acute disseminated encephalomyelitis). shouldering the burden of sepsis norfolk and norwich university hospital nhs trust, norwich, uk; sheffield children's hospital, sheffield, uk aim: we report a case of a -year-old boy who presented with right brachial plexus neuritis secondary to meningococcal group b sepsis. brachial plexus neuritis or neuralgic amyotrophy (also known as parsonage -turner syndrome) is a rare disorder affecting the brachial plexus. it can be caused by various infectious agents and is characterized by acute onset of intense pain in the shoulder and arm followed by weakness, sensory loss and atrophy. methods: a -year-old boy, previously fit and well presented to the emergency department with an acute onset of excruciating pain in his right shoulder, radiating down his arm and hand with associated paresthesia. few hours later, he developed an evolving non-blanching purpuric rash to the chest, back, shoulder and right arm. he gradually developed weakness in the right arm and sensory loss over the ulnar aspect of the right hand. he then began to complain of headache, photophobia with subsequent vomiting. he was treated for meningococcal sepsis with intravenous ceftriaxone and received three fluid boluses for hypotensive shock with vitamin k correction for his associated coagulopathy. he received analgesia for right shoulder pain. results: blood cultures and blood pcr confirmed neisseria meningitidis group b type, nt subtype. mri of the shoulder showed inflammation consistent with brachial plexus neuritis with motor impairment affecting the right side c to t myotomes and sensory impairment involving the right c dermatome. the patient was treated with oral prednisone and gabapentin whilst receiving neurorehabilitation from physiotherapy and occupational therapy. he made a very pleasing recovery after few months and currently has no motor or sensory deficit of his right shoulder and arm. conclusion: brachial plexus neuritis should be considered in the differential when a child presents with sudden onset pain and weakness of the shoulder and arm. in review of literature, brachial plexus neuritis associated with meningococcal infection has not been described previously. to the best of our knowledge, this is the first reported case of its kind. introduction: previous cohort studies on paediatric multiple sclerosis (ms) have reported very low frequencies for a primary progressive ms course (ppms) ranging from to %. an age-dependent increase in the rate of primary-progressive courses has been well described in the adult ms population. objectives and methods: we describe five patients presenting prior to the age of years and fulfilling the mcdonald criteria for ppms. patients were identified from the national hospital for neurology and neurosurgery (nhnn) and the uk childhood inflammatory demyelination (uk-cid) network. results: patients presented at a median age of years (range: - y), with at least -year history of progressive deterioration of their balance (n= ) or progressive worsening of lower limb function (n= ). over time, all patients developed lower limb spasticity, three patients developed cognitive difficulties, three had visual problems, three had bladder involvement. median edss at years was (range: to ). cerebrospinal fluid (csf) oligoclonal bands were detected in all patients tested. dissemination in space on first mri was seen in all patients with peri-ventricular (n= ), cortical juxtacoritcal (n= ), infratentorial and spinal cord (n= ) lesions. all patients showed new lesions on repeat mri imaging. contrast enhancement was present in out of ( %) during the disease course. three patients had genetic investigations to exclude other mimics. a trial of iv methylprednisolone was unsuccessful in patients. all patients were on symptomatic treatment for spasticity and pain, including oral/intra-thecal baclofen, gabapentin and sativex. conclusions: given the rarity of primary progressive course in paediatric ms, presentation with progressive neurological symptoms and signs in young people should prompt evaluation for genetic causes. nevertheless, our five patients presented with clinical, mri and immunological features consistent with a diagnosis of primary progressive multiple sclerosis. objective: clinical course in nmdar-antibody encephalitis is variable and difficult to predict. we aimed to identify clinical features in the presenting disease episode associated with worse functional outcome and/or relapsing disease course. methods: systematic review of the literature was conducted to identify published cases with individually reported data. clinical and treatment characteristics at first episode, outcome at ≥ months, and monophasic vs. relapsing disease course were recorded. results: cases were identified from articles ( % female; % ≤ years old at onset). % received immunotherapy at first episode: corticosteroids in %, ivig in % and therapeutic apheresis in %. second-line immunotherapies were used in % at first episode, most frequently rituximab ( %), cyclophosphamide ( . %), or both ( . %); emerging second-line treatments (intravenous/intrathecal methotrexate, subcutaneous/intravenous bortezomib, intravenous tocilizumab) were used in . %. life-threatening adverse events or death related to immunotherapy occurred in . %. in a univariate analysis of cases with ≥ months follow-up data, poor final outcome (defined as modified rankin scale [mrs] score - ) occurred in % and was associated with very young or elderly age at onset, movement disorder, decreased consciousness, autonomic dysfunction, mechanical ventilation, higher mrs score in the acute phase, longer hospital stay, extreme delta brush on eeg, abnormal mri, csf pleocytosis and elevated csf protein (all p< . ). a subset of cases followed up for ≥ months were analysed to identify associations with relapsing course, which occurred in %. in univariate analysis, factors protective against relapse were < days delay in first-line immune therapy, therapeutic apheresis, ivig, rituximab and other second-line treatments at first episode (all p< . ). conclusions: worse functional outcome of nmdar-antibody encephalitis is associated with very young or elderly age at onset and worse disease severity in the acute phase. relapsing disease course is associated with delayed or insufficient early immunotherapy. objective: we describe three children with familial hemophagocytic lymphohistiocytosis (fhlh), who presented with an atypical chronic demyelinating illness. an initial working diagnosis of 'clippers' (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) was made in two cases. methods: retrospective case series. results: case : an -year-old girl presented with diplopia and squint with evolving ataxia. mri showed multiple enhancing white matter lesions in the pons, medulla and cerebellum raising the possibility of 'clippers'. her symptoms and neuroimaging responded only partially to treatment with ivig and steroids. genetic testing revealed a compound heterozygote mutation in the rab a gene consistent with griscelli syndrome type with fhlh. case : a -year-old boy had nocturnal headaches with a squint evolving over time. mri showed demyelination and swelling predominantly in the cerebellum. significant radiological resolution with steroids was followed by recurrence of demyelination on weaning steroids. a brain biopsy lesion was consistent with 'clippers'. genetic testing revealed a heterozygote variant in the stxbp consistent with fhlh v. case : a -year-old girl had a -month of intermittent fevers, deranged lfts and recurrent bilateral optic neuritis responsive to steroids/ivig. mri brain showed multiple areas of demyelination largely in the subcortical white matter. oligoclonal bands were positive in the csf. she developed a pleural effusion, high ferritin, deranged coagulation, lymphadenopathy and a rash found to be a cutaneous t-cell lymphoma. genetic testing revealed a homozygous mutation in the unc gene consistent with fhlh . all three children are awaiting stem cell transplantation. conclusions: fhlh can present with an isolated atypical demyelinating illness or with neuroimaging suggestive of 'clippers'. there may be no signs of systemic inflammation. we propose that all children with atypical recurrent cns inflammation and presentations consistent with 'clip-pers' undergo genetic panel testing for fhlh and natural killer cell functional testing. objective: the most common paediatric presentation of mog-ab disease is with acute disseminated encephalomyelitis (adem), or optic neuritis (on). with increasing recognition of the association of mog-abs with seizures in children, we present a case series of affected children. methods: retrospective anonymised case note review of affected children presenting between - , from uk paediatric neurology centres. patients were followed up for median of years (range . - ). results: cases ( female) of mog-ab-positive epilepsy patients were identified; median age at first presentation was (range - y). the most common preceding mog-ab disease was multiphasic adem (mdem ; adem ; adem-on ; adem and transverse myelitis ; nmosd ; on ). median time to recurrent seizure onset was months (range - ). focal epilepsy/seizures were most common ( / ). eeg abnormalities were found in / patients, all demonstrated slowing/encephalopathy which was generalised or focal; epileptiform discharges were reported in patients. brain mri was abnormal in all patients ( with multifocal hazy/ poorly marginated lesions involving grey and white matter; leukodystrophy-like pattern, cortical encephalitis and reported with subtle changes in brainstem). patients received immunotherapy, all required at least anti-epileptic drug (aed) and children continue to have on-going breakthrough seizures. median mrs (modified rankin scale) at last follow-up was (range - ), indicating no significant disabilities despite symptoms in clinical examination, age appropriate behaviour and development. conclusions: focal epilepsy is more common and more likely to follow an mdem presentation in children with mog-abs. with the relapsing nature of mog-ab disease there is a high risk of long-term cognitive impairment. further preclinical studies are urgently required to determine whether this epilepsy is due to ongoing inflammation or as a result of the mri changes commonly seen. this will help inform future management decisions regarding immunotherapy. poster no. maternal mid-gestation cytokine dysregulation in mothers of children with autism spectrum disorder autism spectrum disorder (asd) is a developmental disorder characterised by a spectrum of deficits in social interactions/ communication combined with stereotypical, repetitive behaviours. recent evidence suggests maternal immune activation (mia) during pregnancy may predispose offspring to asd. the aim of this study was to examine the mid-gestation cytokine profile in mothers of children with a subsequent asd diagnosis. maternal-child dyads were recruited to a prospective population-based pregnancy study; the scope study, new zealand. children with confirmed diagnosis of asd at years were enrolled in the nested cohort, along with matched neurotypical controls. cytokine concentrations (pg/ ml; mean [sem]) were examined in maternal serum samples taken at and weeks gestation using mesoscale discovery proinflammatory, cytokine and chemokine assays. of mothers recruited to the scope-nz study, children completed follow-up and had reported asd at years. these were analysed alongside neurotypical matched controls. downregulation of il- a occurred at weeks gestation in cases when compared to controls (mean [sem]). -way anova revealed a relationship between il- a concentration and weeks' gestation f( , )= . ; p= . , and also il- a concentration and asd status f , )= . ; p= . . posthoc uncorrected fisher's lsd revealed a significant difference between cases (- . [ . ] ) and controls (- . [ . ]) at weeks gestation p= . . ifnc is also downregulated at weeks gestation in cases when compared to controls. -way anova revealed a relationship between ifny concentration and weeks gestation f( , ) = . ; p= . . posthoc uncorrected fisher's lsd revealed a significant difference between cases ( . [ . ] ) and controls ( . [ . ]) at weeks gestation p= . . we have shown altered cytokine expression at weeks gestation in mothers of children who progress to develop asd. this adds to the growing body of evidence that maternal immune regulation may play a role in foetal neurodevelopment. objective: acute disseminated encephalomyelitis (adem) is an immune mediated inflammatory cns disorder, predominantly affecting white matter, with a wide differential ( ). here we describe a rare mimic of adem that is essential to consider in order to avoid a catastrophic outcome. case history: a -year old girl presented with a day history of confusion, dysarthria, ataxia and left-sided squint, preceded by weeks of general malaise and headache. examination confirmed encephalopathy and a left third cranial nerve palsy. mri brain was suggestive of adem and mri spine was normal. a recommended work up for adem was performed. rapid resolution of her symptoms occurred following intravenous methylprednisolone for days. years later she presented with acute left lower limb ischaemia and underwent emergency embolectomy of a popliteal arterial obstruction, with myxomatous material identified. preoperative echocardiogram confirmed a large atrial mass which was surgically removed. pathology confirmed an atrial myxoma (am). retrospective review of her initial mri images concluded that embolic phenomena from the am was the most likely explanation of her first presentation. conclusions: am is a very rare primary cardiac tumour and left sided am can embolise to the cerebrovascular system. early identification of am is important as, untreated, it can cause multiple embolic events and sudden cardiac death. % of adults with am present with neurological symptoms and this can mimic multiple sclerosis. am presenting with acute neurological symptoms masquerading as adem in paediatrics has not been previously reported. careful follow up is essential as late neurological complications (including cerebral arterial aneurysms) are recognised. this case highlights that adem is a diagnosis of exclusion and that mimics for acute focal neurology with encephalopathy and t hyperintensities on mri require careful consideration, including embolic phenomena. clinical examination alone does not exclude am and consideration of echocardiography is recommended. we describe an year old boy with a rare demyelinating disorder: balo's concentric sclerosis. a routine optician review raised concerns about papilloedema in an asymptomatic child. a ct brain identified a well-demarcated high-density lesion in the left posterior frontal lobe with surrounding oedema. mri brain with contrast identified the lesion had central rim enhancement and slight diffusion restriction. alternating layers of high and low signal intensity gave it an 'onion bulb' appearance. the differential included balo's concentric sclerosis, a single demyelinating lesion, or a tumour. routine blood tests were unremarkable. csf oligoclonal bands were normal as were other csf indices. markers of immunology, including ana, anca, anti-mog, anticardiolipin, and aquaporin antibodies were all negative, with normal complement levels. esr was mildly elevated when taken during an episode of acute tonsillitis. imaging months later demonstrated an increase in the size of the lesion. a biopsy revealed inflammatory demyelinating pathology mediated by a perivascular and parenchymal t-and b-lymphocyte infiltrate and macrophage activity with associated demyelination lacking a perivenular distribution. there was no evidence of neoplasia, vasculitis, granulomas, or viral infection (including negative pcr testing). no treatment with corticosteroids was given, and the child remained asymptomatic. imaging, at months from presentation, revealed the lesion had substantially reduced in size. there was still a rim of enhancement. as with all single demyelinating lesions, it is difficult to predict the clinical course. we opted to adopt a 'wait and see policy' and offer surveillance imaging and clinical review. balo's concentric sclerosis is a rare demyelinating disease, characterized by concentric lamella of alternating demyelinated and partially myelinated tissues. mri shows one or more concentrically mulitlayered ring-like lesions, usually in the cerebral white matter. most case reports describe cases predominantly in young adults, with few reports of cases in children. objective: cognitive and acquired neurodevelopmental deficits have been reported in children with opsoclonus-myoclonus syndrome (oms) and are associated with more severe and relapsing disease course. however, there is a paucity of data regarding cognitive dysfunction in children with stable neurological disease. we report on serial cognitive assessments of children with oms demonstrating evolving cognitive dysfunction with milder disease course. methods: retrospective analysis of clinical features at presentation, investigations, treatments, clinical course including relapses and neuropsychological testing. results: four children (m:f : ) diagnosed with oms between and months were followed up for to years. neuroblastoma was identified in one child. oms severity scores ranged between to / at presentation. patients underwent immunotherapy in accordance with european oms protocol. all patients were in remission by months (range - mo), with treatment maintained for year. one child remained relapse free whilst other children had one clinical relapse which was immunotherapy responsive again. in all cases, progressive cognitive dysfunction was reported despite being in remission and stable off treatment for months (range of - mo; oms score / and one / ). sequential neuropsychological testing scores showed mean declines in fsiq of ( - ) , viq of ( - ) and piq of (- to ) between time of oms remission/stable disease and longer term follow-up time point ( - y). conclusions: our cases demonstrate progressive cognitive dysfunction occurring in children with oms who have a milder disease and long after completion of treatment. children continued to develop but with a widening gap in comparison with peers. damage to cerebellar-cortical circuits at onset of the disease that becomes more apparent with time or indeed persistent ongoing low grade inflammation may explain this deterioration. the past decade has seen increasing cases of acute flaccid paralysis (afp) associated with enterovirus d (evd ) infection. it presents in clusters approximately every years. we report three cases of afp due to evd that presented in november-december . cases: two patients developed afp following a viral upper respiratory tract infection and one developed lower limb hypotonia and weakness during an inpatient admission with refractory epilepsy. two required admission to the paediatric intensive care unit for respiratory compromise and required tracheostomy ventilation. mri showed acute flaccid myelitis (afm) consistent with evd in / cases, consisting of central cord t hyperintensity in the cervical region over multiple segments with subsequent enhancement of the thalamus and cauda equina on follow-up imaging in one patient; and ventral surface enhancement of the conus and cauda equina in another. mri in the third patient was normal. electromyography and nerve conduction studies were normal in two patients but revealed a severe generalised motor axonal poly-neuronopathy in the third. two patients received intravenous immunoglobulin, corticosteroids or plasma exchange therapy and showed slow motor improvement in a distal to proximal pattern. the one patient without mri changes had received long-term oral corticosteroids but received no additional treatment and returned to baseline neurological function within weeks. discussion: our cases demonstrate the range and clinical course of peripheral neurological presentations secondary to evd infection. we highlight the importance of sending repeat samples from multiple sites when the diagnosis is suspected, given that initial samples tested negative, and of sending samples to a national surveillance laboratory for confirmatory testing. ongoing national and multinational surveillance studies will hopefully continue to advance our understanding and treatment of this disease. poster no. nmda receptor encephalitis a potential complication of biologic therapy for juvenile idiopathic arthritis? n abbassi , t rossor , r close , a skippen , k armon , p bale , g ambegaonkar paediatric neurology, addenbrookes hospital, cambridge, uk; paediatric rheumatology, addenbrookes hospital, cambridge, uk a -year-old girl presented with headaches, confusion and agitation, followed by seizures. she had presented at months with polyarticular arthritis and was managed over subsequent years on methotrexate alone ( y) with added etanercept (anti-tnf alpha, y), tocilizumab (anti il- , y) and abatacept (cd / t-cell modifier, y prior to presentation). flares of disease following a period of control necessitated the changes in monoclonal antibody therapy. at this presentation she was managed on methotrexate, abatacept and mg prednisolone for polyarticular rheumatoid factor negative juvenile idiopathic arthritis (jia). at presentation the patient was agitated, non-verbal and had one generalised seizure. examination demonstrated acute confusion, with increased tone, brisk reflexes and bilateral clonus in her lower limbs. iv ceftriaxone, acyclovir and clarithromycin were commenced. full blood count, liver function tests and inflammatory markers were unremarkable. infective serology was non-contributory. csf was unreactive with normal protein and jc virus pcr negative. mri brain days after presentation showed increased t and flair signal intensity in the white matter of the right parietal lobe, in-keeping with an inflammatory process. eeg showed diffuse slowing with delta brush. she commenced iv methylprednisolone, followed by prednisolone. she continued to deteriorate and underwent plasmapheresis for treatment of presumed nmda receptor encephalitis, subsequently confirmed by anti-nmda receptor antibodies in serum and csf. she was commenced on rituximab (b-cell depletion, anti-cd ), and continued to undergo plasmapheresis over the course of weeks. she gradually improved and was discharged home after a -week inpatient stay. several adult and two paediatric cases of nmda receptor encephalitis are reported in patients on biologic therapy for autoimmune disease. autoimmune diseases are more common in those already affected by one autoimmune condition. it is unclear what contribution an autoimmune history or immunomodulation made on the development of this condition. introduction: the incidence of acute flaccid myelitis (afm) associated with enterovirus infection occurring in biennial clusters since has been reported in the us (bmj , ; :k ) and recently in europe. previously, cases with transverse myelitis (tm) with anterior-horn cell or peripheral nerve involvement have been collectively termed tm-plus (neurology ; ;s -s ). we aimed to identify cases of tm-plus from a retrospective cohort of children to identify potential cases of 'undiagnosed' afm, and to evaluate the clinical and radiological features alongside long-term outcome. methods: consecutive cases of children (< y of age) who presented to a large paediatric neurosciences centre from to fulfilling the transverse myelitis consortium working group criteria modified for the paediatric population (neurology ; : - ) were retrospectively evaluated for additional features of anterior horn-cell involvement (fulfilling criteria for afm (current treat options neurol ( ) : )) or peripheral nervous involvement; and were collectively evaluated with the contemporary tm-plus cohort ( ) ( ) ( ) . results: cases of tm were identified, of which were excluded from further analysis; ms (n= ), adem (n= ). cases of tm-plus were identified, before and after, all associated with a viral prodrome. flaccidity (n= ) and asymmetry (n= ) was noted at presentation, with corresponding nerve conduction studies revealing a motor axonopathy with sensory sparing (n= ) and anterior horn cell involvement confirmed in cases. all cases with anterior horn cell involvement had poor outcomes while both cases with good outcomes had peripheral involvement and normal mri brains. conclusions: tm-plus was detected in our cohort from to with biennial clusters noted in and . the clinical presentation, investigations and long-term outcomes appear consistent in both groups. acute necrotising encephalopathy is more severe when associated with influenza background and objective: acute necrotising encephalopathy (ane) is a rare but potentially life-threatening condition associated with viral infections. a familial and recurrent form (ane ) has been identified by mutations in the nuclear pore ran binding protein (ranbp ). we report the morbidity and mortality when associated with influenza infection. methods: we performed a review of paediatric ane cases from to evaluating the clinical, biochemical, microbiological and neuroimaging appearances as well as outcomes. results: the cohort comprised children ( boys), age ranging from months to years months (< y n= ), of which had a confirmed genetic diagnosis and were ranbp negative. there were episodes of encephalopathy, with recurrences in cases ( ane ). of these episodes had infectious aetiology identified: coronavirus n= , parainfluenza n= , adenovirus n= , h influenzae n= , influenza (h n n= , h n n= ). clinical features of fever and encephalopathy were consistent ( %), and seizures and sixth nerve palsies prominent ( % each). csf revealed absent pleocytosis, normal-elevated protein and negative virology. symmetric involvement of the thalami bilaterally was present in all cases, and all ane cases were associated with haemorrhage and external capsule/claustrum involvement ( % specific and sensitive). the outcome following influenza infection was striking, death n= , vegetative n= , limb motor and movement disorder n= . of these cases had previous episodes of encephalopathy with noninfluenza infection and did have recovery, albeit with moderate to severe disability. all cases were never immunised against influenza infection and suffered grave outcomes. conclusions: influenza infection in ane has the poorest outcome therefore vaccination should be a mandatory consideration for the known cases of ane. introduction: acute flaccid paralysis (afp) is characterized by a rapid onset of limb weakness. we describe six cases of afp in children aged months to years of age who presented to a tertiary paediatric neurology service in the east of england over a -year period from november -november . retrospective analysis of the six cases was performed, reviewing their clinical course and management, as well as their radiological, electrophysiology and laboratory results. results: case , a -month-old boy, presented in november with a viral urti requiring escalation of care to picu due to a significant respiratory compromise. only on subsequent recovery was the child found to have a unilateral upper limb flaccid paralysis. this child was positive for enterovirus serotype d . cases and in our series presented in with acute weakness of the lower limbs with an mri brain and spine showing enhancement of the lumbar spinal roots. both have made a good recovery. enterovirus was not detected in either case. the final three children in our series presented in autumn with weakness of a unilateral upper limb following a viral urti, with all three being positive for enterovirus. unfortunately, they have shown minimal recovery of motor function of the affected upper limb. one child, a year-old girl, showed a more severe clinical course involving a prolonged period of intensive care and a tracheostomy for long-term ventilation. she has undergone neurorehabilitation and an upper right arm nerve transfer. conclusions: in our case series, four patients presented with an acute viral urti associated with an upper extremity weakness, and subsequently all four were positive for enterovirus. clusters of acute limb weakness in paediatric patients have been linked to outbreaks of non-polio enteroviruses, termed acute flaccid myelitis (afm). objective: to present an interesting case of recurrent anti-mog demyelinating disease and provoke discussion regarding possible immunomodulatory therapy. methods: a year old girl presented, initially at years of age, with headache and vomiting. she was initially treated as atypical tuberculosis meningitis based on csf cell counts, but later developed a th nerve palsy and was diagnosed with optic neuritis. anti-mog antibodies were positive and they were commenced on iv methylprednisolone. she clinically improved and was discharged on weaning oral prednisolone, antibodies were negative following treatment. results: a few months later she had her first relapse, with an acute decline in visual acuity. an mri showed new lesions in her optic chiasm and both optic nerves with associated bilaterally reduced visual evoked potentials. she was again treated with iv methylprednisolone, with rapid improvement, followed by a switch to weaning oral prednisolone. anti-mog antibodies were negative following treatment. she was symptom free for years until her second relapse, when she presented with facial palsy, swallowing difficulties and slurred speech. mri showed brainstem and periventricular white matter demyelination, with positive anti-mog antibodies. she was again treated with iv methylprednisolone, followed by oral prednisolone, but was maintained on low dose prednisolone as her anti-mog antibodies remained weakly positive despite being symptom free. these were stopped at patient request due to low mood and abdominal pain in february , with no recurrence of symptoms as yet. repeat mog antibodies have been sent and are awaited. conclusions: this case shows an interesting relapsing/remitting pattern of anti-mog demyelinating disease, which appears to be very steroid responsive, however on her second relapse her anti-mog antibodies remained weakly positive despite steroid therapy. discussion is welcomed on whether prophylactic immune modulation therapy should be considered with this child, such as azathioprine, mycophenolate mofetil or rituximab. objective: to highlight the utility of early mr imaging in children presenting with acute severe encephalopathy and to consider whether there might be a subgroup of children with myelin oligodendrocyte glycoprotein antibody (mog-ab)associated demyelination who might be candidates for early intense immunomodulation. methods: we report two cases with mog-ab-associated acute demyelination who relapsed with new neurological symptoms after initial steroid therapy had been discontinued. results: two toddlers were initially admitted to intensive care with acute encephalopathy and acute symptomatic seizures. both had an initial ct head during picu admission; one was reported normal; the other was suggestive of diffuse cerebral oedema. both children improved with supportive care only and were discharged home within a week. both children presented again over the following to weeks with new neurological symptoms but without encephalopathy. mr imaging demonstrated demyelination and they were treated with steroids. both children relapsed as steroids were being weaned and/or stopped. repeat mr imaging at this stage demonstrated new enhancing lesions. it was subsequently found that both children were mog-ab positive. conclusions: reliance on cranial ct imaging in the context of a young child with acute encephalopathy and seizures can be misleading. prediction of the severity of mog-ab-associated demyelinating syndrome at onset is challenging. mr imaging in the acute phase with early follow up imaging may identify this subgroup. case: hb is a year old boy who presented with sudden onset diplopia and painful ophthalmoplegia, following a day history of frontal headache. on examination, he had a left vith nerve palsy, partial left iiird nerve palsy and normal right eye movements. the remainder of his neurological and general systems examination was normal. his initial ct head scan and pre-contrast mri of the brain were normal. he was discharged from the local hospital following normal blood tests and imaging. clinical course: nine days later, his symptoms worsened including severe vomiting, worsening frontal headache and photophobia. he was treated for a possible underlying infective cause with ceftriaxone and acyclovir. given the broad underlying differential diagnoses, hb had extensive infectious and immunological blood workup which was unremarkable. a repeat mri brain scan with contrast revealed a lesion in the left cavernous sinus, possibly of vascular origin. differentials included cerebrovascular venous sinus thrombosis, tumour and inflammatory causes such as tb, sarcoid and zoonoses. hb continued to be conservatively managed and completed his course of ceftriaxone and acyclovir. repeat mri imaging months later showed some resolution of the lesion and a diagnosis of tolosa-hunt syndrome was provisionally made. hb's symptoms continued to improve and further repeat mri scan months later showed ongoing resolution of the lesion. discussion: according to the ichd- beta classification of tolosa-hunt syndrome, hb fulfilled the diagnostic criteria given his presentation of unilateral headache, granulomatous inflammation of the cavernous sinus on mri, palsies of ipsilateral iiird, ivth and vith cranial nerves. steroid use has been reported to be beneficial although more evidence is required in the paediatric population, refractory cases may respond to azathioprine and methotrexate. objective: we present a case of internuclear ophthalmoplegia unresponsive to steroid treatment which clinically improved with folinic acid supplementation. method: a retrospective chart review. results: our patient presented with acute internuclear ophthalmoplegia, ataxia and bilateral ptosis. she had a background of hypoplasia of the corpus callosum and optic atrophy with visual impairment, learning difficulties and asd. mri brain demonstrated symmetrical high signal intensity in the region of the medial longitudinal fasciculus and periaqueductal grey matter. she was investigated to exclude an inflammatory cause and was treated with high dose steroids. follow up mri did not show any improvement post steroids and there was no clinical improvement. subsequent csf investigations showed a low level of -methyltetrahydrofolate of nmol/l (normal range - nmol/l). she was commenced on folinic acid mg once daily and her symptoms improved. on follow up her eye movements had significantly improved as had her ptosis. follow up mri brain showed partial resolution of the areas of abnormal signal in the periaqueductal grey matter. conclusion: internuclear ophthalmoplegia is a sign usually associated with an inflammatory or demyelinating cause. our case did not respond to steroid treatment but has associated low levels of -methyl tetrahydrofolate and has responded to treatment with folinic acid. this is sometimes associated with underlying mitochondrial disorders but muscle biopsy in this case did not show any evidence of mitochondrial disease. mri brain has shown partial resolution of the abnormal signal in the periaqueductal grey matter. introduction: paediatric intracranial aneurysms are rare. the pattern of disease is different to that in adults and there is far less literature available. i provide a case as an example of the presentation and progress of a child with a dissecting vertebrobasilar artery aneurysm. presentation: -year-old boy presented to his local hospital with sudden-onset headache, photophobia and vomiting. bloods and observations were normaldischarged. symptoms recurred more severely the following day. managed as meningitis. lumbar punctures were 'bloody' and considered failed. mri brain days post-admission demonstrated a vertebrobasilar aneurysm. transferred to the regional neurosurgical centre. transfer to neurosurgical/neurovascular centre: cerebral angiography revealed dissecting vertebrobasilar aneurysm ( mm). fusiform component extending beyond aici/ pica origins. wide-necked saccular component. procedure and progress: loaded with aspirin and clopidogrel. underwent endovascular procedure the following daycoil embolization, flow-diverting stent to the aneurysm. ongoing low dose dual anti-platelet therapy. made an excellent recovery with no neurological deficits. further imaging -x-ray cervical spine for possible arcuate foramen or atlantoaxial instability, normal. ultrasound liver/spleen, normal. discharged home days post-transfer. patient background: past medical historyunder the gp for months of headaches. traumasignificant fall from bicycle years before with forced lateral flexion of the neck. posited that this may have been a contributing factor in aneurysm development. no significant family history. lifestylean active boy, enjoys weightlifting and motocross. weightlifting also posited as a contributing factor. conclusions: i provide a case which i hope will raise awareness of paediatric intracranial aneurysms and stimulate discussion concerning their management and aetiology. poster no. cavernoma in children: cddft experience of two cases d jayachandran, s chandraiah darlington memorial hospital, cddft, darlington, uk aim: to report two cases of congenital cavernoma diagnosed in children presenting with neurological symptoms. cases: case : -year-old female presented with multiple left facial focal seizures in the form of twitches with full awareness. there was no family history of epilepsy. a typical event was captured lasting seconds during the awake eeg and was reported as focal seizure arising from right hemisphere. an mri brain scan showed popcorn balls lesions within the frontal/fronto parietal lobes, one on each side (right>left) with evidence of bleeding. she remains seizure free on carbamazepine. ccm gene results are awaited and neurosurgeon opinion was not for intervention and for local follow up. case : -year-old male had presented with confusion at years of age. he also had transient loss of vision, vomiting, headaches with a few minutes unresponsive episode during admission. with a diagnosis of migraine, he had an mri brain scan as op that showed multiple cavernous haemangiomas in the cerebrum and cerebellum with the largest demonstrating a fluid level in the left parieto-occipital region. family history revealed that father had seizures secondary to brain cavernomas. he was positive for krit (ccm ) mutation. neurosurgeons advised active monitoring and he presented again at years with focal onset seizures with impaired awareness. eeg was normal but mri showed a new cavernoma in the left temporal horn with bleeding. he remains well on carbamazepine with a plan for yearly mri scans. conclusions: congenital cavernomas of brain can be sporadic or familial, can be multiple and in any location including brain stem and can result in physical disability secondary to bleeding. in the majority of cases bleeding is spontaneous and diagnosed on mri scans after a neurological event. objective: foxp -related intellectual disability syndrome is characterised by developmental delay, variable physical features and autism. diagnosis has increased with better access to broad genetic testing. we present a case report of a child with foxp mutation whose presentation was notable for significant cerebral venous ectasia. case: child s presented aged year with gross motor delay (not sitting or weightbearing) along with relative macrocephaly ( st- th centile), strabismus and prominent superficial forehead veins. intracranial imaging was arranged in which ct angiogram raised a possibility of an arteriovenous fistula. subsequent catheter angiography excluded this but demonstrated extensive tortuous cerebral venous ectasia. the venous ectasia was not felt to explain her developmental difficulties. initial genetic testing including microarray and pik ca and pten analysis was normal. s made some developmental progress but remained globally delayed compared with her peers. reanalysis of her dna against a panel of genes associated with intellectual disability identified a de novo heterozygous pathogenic variant in the foxp gene, c. c>t, p.(arg ter) (east anglian medical genetics service). discussion: foxp acts as a transcription factor and is likely to be involved in the development of many different tissue types. a wide range of genetic aberrations affecting foxp , including point mutations and large structural anomalies, lead to overlapping clinical phenotypes. this patient demonstrates many relevant clinical features including developmental delay with autistic traits, relative macrocephaly with a prominent forehead, strabismus and early gross motor developmental delay. however, descriptions of associated neurovascular anomalies in foxp syndrome are scarce, with a single case report recording a venous angioma and none of cerebral venous ectasia to our knowledge. foxp follow up studies and whole exome or genome sequencing may help determine whether there is an additional genetic cause for this child's cerebral venous ectasia or whether it is foxp related. objective: a rcpch guideline was published to increase awareness of stroke in children and standardize best practice. the need for urgent (within h) ct angiography in children presenting with suspected stroke and criteria for thrombolysis were set out. we aimed to review the acute management and investigation of pais in children ( mo to y) since the introduction of the guideline with an emphasis on identifying candidates for thrombolysis. methods: retrospective notes review in a single regional neurology centre over a -month timeframe. results: eighteen cases were identified ( f: m) with two mortalities. age range months- years (mean . y). / presented in peripheral hospitals and / in the regional centre. no cases had pednihss score documented on presentation. / had dedicated vascular imaging (cta/ mra) on initial imaging. / presented with a hemiparesis, / with seizures, / dysphasia, / headache, / ataxia. / cases had a stroke post cardiac surgery, / idiopathic stroke, / post varicella angiitis, / arterial dissection, / cardiomyopathy and / embolic stroke as a complication of central line insertion. / presented with an acute hemiparesis with a clear time of onset. no cases received thrombolysis. / was imaged within hour of presentation. / had vascular imaging (mra or cta) on presentation. / cases was discussed acutely with paediatric neurology; this case was not suitable for thrombolysis due to cardiomyopathy. in retrospect the other / cases were suitable candidates for thrombolysis. conclusions: the results highlight the continued need for enhanced awareness of paediatric stroke as a medical emergency. most acute strokes will present to peripheral hospitals. therefore, there is a need for regional multidisciplinary integrated pathways amongst emergency department physicians, paediatricians and radiologists to ensure prompt vascular neuroimaging and discussion with a paediatric neurologist about the possibility of thrombolysis in suspected pais. poster no. 'a nudge, a fall and a weakness'a common but missed cause of paediatric stroke r shyam , r bahri , , a kumar , v jain department of paediatric neurology, santokba durlabhji hospital and medical research institute, jaipur, india; norwich medical school, university of east anglia, norwich, uk objective: this study retrospectively analysed paediatric strokes with further evaluations and outcomes of strokes related to minor injury, to isolate characteristic features and outcomes in these patients. methods: paediatric patients ( mo to y age), presenting with acute stroke between january to january were retrospectively recruited from a tertiary care hospital in north india. from this cohort, strokes following minor injury were analysed for clinical profile, investigations and outcomes (measured by international paediatric stroke study scoring system, ipss). results: of the total cases, ( . %) were post-minor injury (m: f . : ; mean age . ae . mo). of the remaining (n= ; mean age ae . y) most common aetiologies were moya-moya disease (n= , %) and transient unilateral arteriopathy (n= , %). the post-minor injury group revealed a median time of minutes from trauma to stroke onset. more than / rd ( %; n= ) had transient episodic hemi-dystonia on the hemi-paretic side after a median of days of symptoms onset. % ( / ) of children where results were available had anaemia. ct head in all (n= ) showed calcification of the lenticulo-striate vessels. subsequent brain mri (n= ) confirmed ct findings of basal ganglia ischaemia. mr angiogram and thrombophilia screen (n= ) done in the first few patients were normal and hence not pursued subsequently. follow ups of / ( - mo; median= mo) showed good recovery in the majority ( %; n= / ). the median ipss score for these children was . . conclusions: trivial injury leading to basal ganglia stroke was the most common cause of paediatric stroke, occurring exclusively in less than year-olds. ct head was diagnostic (calcification in lenticulo-striate blood vessels and ischemia) with no further information revealed from vascular imaging or thrombophilia work-up. children were commonly anaemic, a potential causative association. often transient episodic hemidystonia of the hemiparetic side after a few days was witnessed. neurological outcomes in most children with this entity is good. introduction: rcpch launched guidance on paediatric stroke in march . we present a series of paediatric patients who presented with stroke following this publication. we audited this group of patients against the key standards of the rcpch guidance. methods: we retrospectively analysed cases between april and april . we identified cases from a neurology database and audited acute management using rcpch guidance as standard. results: we identified children with stroke in the last years. ages ranged from months to years with a mean age of years at presentation. children had haemorrhagic stroke and had ischaemic stroke. the majority involved the anterior cerebral circulation ( / ). underlying aetiology was identified in patients, of whom had haemorrhagic stroke. of the patients died. only out of patients had brain imaging within an hour of presentation. only one patient was eligible for thrombolysis, however due to contraindication she underwent thrombectomy. discussion: stroke pathways are well developed in adult services. due to the rarity of stroke in childhood and challenges with recognising symptoms, treatment is often delayed. symptoms in children need a high index of suspicion. the findings of this audit support the development of an all wales paediatric stroke pathway. we aim to facilitate activation of the stroke pathway when children present with the fast symptoms. we also hope to increase awareness of stroke in childhood. withdrawn. objective: stroke is a common childhood neurological disorder, affecting at least children in the uk each year. the majority of children have residual sequelae across a wide domain of functions, with significant personal and societal consequences. recent rcpch guidelines have proposed criteria for hyperacute treatments; this would require rapid recognition of the potential diagnosis by clinicians. here we describe the acute care pathway of a group of children with confirmed arterial ischaemic stroke (ais). methods: parents of children aged > days and < years referred to gosh (ais) ( - ) were approached and sent a questionnaire exploring their experience of navigating through the healthcare system on initial presentation. responses were tabulated where possible and reported as frequencies; qualitive results were thematically coded and categorised for analysis. results: / eligible parents responded. and the gp were the first port of call for the majority (n= for each). ten parents stated they had 'no idea' what initial symptoms might represent. when directly asked if they had suspected a stroke, nearly / stated 'no'. f.a.s.t features (f: face a: arm s: speech t: time) were noted in a third of patients and only patients were given a diagnosis of stroke at first presentation. on initial discharge, a correct diagnosis of stroke was provided to patients. notably, the need for improved education of paediatric stroke, for healthcare providers was raised by nearly % of parents surveyed. conclusions: the study demonstrates the need for further education to be delivered in pre-hospital, primary and secondary healthcare settings for recognising acute stroke in children. this will be an essential step in the delivery of hyperacute treatments. background: hereditary spastic paraparesis refers to a heterogeneous group of inherited neurodegenerative disorders characterized by progressive lower limb spasticity and weakness. there is marked genetic heterogeneity in hsp with all modes of inheritance described for the different loci and causative genes implicated up to now. we present a case of a child with a complex diagnosis of hsp with a homozygous missense mutation in nt c underlying hereditary spastic paraplegia spg . case presentation: this child had initially been diagnosed as having bilateral cerebral palsy with diplegic pattern and gmfcs ii. he had gross motor and speech and language delay. there was a family history of consanguinity. mri scans had initially been described as showing evidence of periventricular leukomalacia and he had been referred for consideration of sdr. following tertiary assessment there were clinical concerns that the overall diagnosis may need to be reexplored. review of his mri scans demonstrated similarities to a case series of hsp with a rarer form of hsp (spg ). he subsequently tested positive for spg nt c . a second case with similar clinical findings has now been identified in our region. mri scan findings will be presented. summary: spg is a rare but important cause of a cerebral palsy phenotype and testing for nt c should be considered in the differential diagnosis and investigation of patients presenting with cp. recommendations on patient suitability for sdr has focused on children functioning at gmfcs level ii or iii. sdr has been considered for gmfcs levels iv and v however the decision to progress can be challenging. the goals in these children are significantly different with the focus being around comfort and pain relief rather than mobility. we describe the case of a boy with a mixed pattern movement disorder involving limbs which had initially been managed with oral medications baclofen, trihexiphenidyl and intramuscular botulinum toxin. due to the child having a vp shunt the family didn't wish to consider itb pump. despite optimisation of oral medications and intramuscular botulinum toxin spasticity was a significant issue adversely impacting on quality of life. escalation of baclofen was unsuccessful due to loss of head control and duration of action of botulinum toxin injections appeared to be limited to to weeks before tone increased again. this resulted in significant difficulties with moving and handling. in view of this the option of selective dorsal rhizotomy was explored. the goal was to improve ease of personal care and sleep. post-operative outcomes greatly exceeded the family expectations. along with a reduction in tone in the lower limbs they were delighted to report several unexpected improvements. these included: improved functional ability with the left upper limb which facilitated switch access; improved truncal control making moving and handling easier; a reduction in extension posturing which had been particularly problematic pre-operatively; significant improvement in sleep; improved mood. this resulted in the local team exploring eye gaze technology with him. these functional benefits have significantly improved the quality of life for not only the patient but his family. further research into the benefit of sdr in this group of patients should encompass care and comfort outcomes, sleep assessment and measurement of pain. introduction: clonidine has become increasingly repurposed for the management of childhood dystonia. one potential advantage of clonidine is the availability of patches for transdermal delivery. we aimed to review the use of transdermal clonidine patches in our institution. methods: a retrospective notes review of children and young people (cayp) with dystonia issued transdermal clonidine patches as identified from pharmacy records. results: a total of cayp were identified, median age at initiation of clonidine of years months (range mo to y and mo). prior to initiation of patches / cayp were already receiving clonidine, including acutely receiving iv clonidine infusions. one child with difficult iv access experiencing an acute deterioration of dystonia was lost to follow up following transfer to local services. the commonest indications for transdermal clonidine were concerns about 'on/off' effect of enteral doses (n= ) and concerns about enteral absorption (n= ). transdermal clonidine was discontinued by / cayp ( as patches wouldn't adhere, receiving patches as a temporary bridge from iv to enteral clonidine and due to severe local cutaneous reaction). one additional clonidine naive child experienced significant hypotension with a . µg/kg/hour transdermal dose but tolerated a reduced dose of . µg/kg/hour. follow up for the remaining / children ranged from months to . years (median y). the median transdermal dose was . µg/kg/hour (range . - . µg/kg/h). additional enteral clonidine was used by / cayp. efficacy of transdermal clonidine was difficult to determine, but / cayp retrospectively scored on the clinical global improvement-scale, suggesting significant improvement. conclusions: in cayp receiving enteral clonidine switching to transdermal clonidine patches appears to be well tolerated, with . % of cayp continuing with longer term use. further prospective work is required to determine the efficacy and safety profile of transdermal clonidine. objective: to review the indications for and outcomes following itb for children and young people (cayp) at our centre. methods: patients were identified undergoing itb pump insertion from to . had reports available. a retrospective note review was performed, with data extracted using a standardised data collection proforma. results: median age at itb pump insertion was (range to ). hypertonia was described as dystonia, spasticity and/or dyskinesia. median length of follow up was years (range: mo to y). choice of outcome measure was dependent upon the goals identified for surgery. care provider child health index living with disability (cpchild) data was available for cayp at baseline and cayp at year. cpchild improved from a median score of . to . at year (p= . , wilcoxon signed rank test). burke-fahn-marsden dystonia rating scale (bfmdrs) data was available for cayp at baseline (median: . for motor, for disability), cayp at year (median . for motor, median for disability), all with a clinical picture of dystonia. gross motor function measure (gmfm) was available for cayp at baseline (median= ), cayp at year (median ) and cayp beyond year (median= . ). gmfm and bfmdrs were not statistically significant. pain was measured with paediatric pain profile, available for cayp at baseline, cayp in year and cayp beyond year. median of most troublesome pain improved from at baseline to in year. conclusions: for a heterogeneous cohort of cayp with motor disorders, itb appeared to improve ease of care and comfort, indicated by change in cpchild. multiple measures are required to fully capture benefits seen in this cohort, which should be focused on their individual needs for intervention. objective: to evaluate neurosurgical interventions and outcomes in the management of hemidystonia. methods: the pubmed database was searched including terms 'hemidystonia', hemi-dystonia', 'unilateral dystonia', 'dystonia and (pallidotomy or thalamotomy)', 'dystonia and (dbs or 'deep brain stimulation')' and 'dystonia and (itb or 'intrathecal baclofen')', up to may . papers were included if written in english and presenting outcome data for human participants undergoing a neurosurgical intervention for management of hemidystonia. reference lists of included papers were also reviewed. individualised patient data was extracted. to facilitate comparison across patients with and without validated dystonia scale scores individual patient outcomes were categorised on a -point scale ranging from 'worsened compared to baseline' to 'very marked improvement'. results: we identified reports meeting inclusion criteria, describing unique patients ( < y of age). ablative methods ( / cases) most commonly targeted the thalamus, and dbs ( / cases) the gpi. in recent years dbs is reported far more commonly then ablative surgery. reported follow up ranged from months to years. one patient underwent itb but no further individual data was available. out of the cases had individual outcome data. objective measures were available in dbs and ablation cases, most commonly the bfmdrs. reported outcomes in dbs patients were / worsening compared to baseline, / no change, / slight improvement, / moderate improvement, / marked improvement and / very marked improvement. for the ablative cases / worsened, / no change, / slight improvement, / moderate improvement, / marked improvement and very marked improvement. complications were reported in dbs cases ( shielded battery syndrome, one infection) and ablative cases ( depression and transient hemiplegia). conclusions: available evidence for the neurosurgical treatment of hemidystonia is of low quality, but suggests generally positive results, with few complications reported. introduction: acute flaccid myelitis (afm) is a recently characterised condition causing multiple muscle paralysis and life-changing disability in children. no medical treatment is effective. however, recovery of denervated muscle function is possible via nerve transfer surgery. such treatment is complex, specific to the individual and should be carried out by specialist teams. objective: to describe the clinical features, management and outcomes of nerve transfer surgery following the afm outbreak. methods: retrospective analysis of patients with afm treated with nerve transfer surgery in . surgical criteria: persistent motor deficits (paralysis) months post onset with neurophysiologic signs of denervation and donor nerve availability. results: eight patients (m=f, aged - months; mean ) were referred between march and july . at initial onset/ infection: / had involvement of all four limbs and trunk and / had involvement of the phrenic nerve. mean date of initial assessment within specialist centre was . months post onset (range - ). at this time had upper limb paralysis ( right, left) and had bilateral lower limb paralysis. following consultation, declined surgical intervention and are awaiting surgery. / patients have proceeded to surgery: / cases presented with three-or-more nerve root involvement. nerve-transfers have been performed (median per patient). no surgical complications were encountered. early clinical functional outcomes from this cohort following surgery are currently being collated and evaluated and will be presented in full at conference. conclusion: this study supports international experience that nerve transfer surgery can improve functional outcomes in afm. the delivery of care in the nhs requires coordination and referral to specialist centres. experiences with this cohort will inform decision making and improve patient outcomes and family expectations during the next outbreak of afm. poster no. a catastrophic case of acute flaccid myelitis t chakrabarty , c lundy , g doherty , d bhattacharya , p moriarty , d peake royal belfast hospital for sick children, belfast, uk; royal victoria hospital, belfast, uk objective: acute flaccid myelitis (afm) is a rare but serious neurological condition characterised by acute onset of flaccid weakness in one or more limbs with distinct abnormalities of the spinal cord grey matter on magnetic resonance imaging (mri) and without any features suggesting an upper motor neuron disorder. in recent years, there has been a global increase in the incidence of afm associated in some cases with a non-polio enterovirus, ev-d . the long-term prognosis in most cases remain poor. we present a severe case of afm in a -year-old boy with catastrophic consequences. method: retrospective review of clinical course, neuroimaging, treatment and neurorehabilitation. results: a -year-old boy presented with clinical encephalitis. he deteriorated over hours and developed an encephalopathy, multiple cranial nerve deficits, and complete flaccid paresis requiring picu support. csf weeks apart showed a resolving lymphocytic pleocytosis with increased protein ( . to . g/dl). serial mri brain and spinal cord showed extensive signal abnormality involving thalamus, dorsal pons, medulla, cervical cord, conus along with cauda equina. nerve conduction studies were consistent with a severe acute motor axonal neuropathy. eeg showed a posterior dominant encephalopathy. infective (including edv- ), metabolic, immunological (aqp and mog abs) and genetic (ranbp ) tests were negative. immunomodulation therapies (methylprednisolone, ivig, and plasma exchange) resulted in no clinical improvement. resolution of signal changes in the thalami, brainstem and spinal cord along with mild generalised cerebral atrophy was noted in repeat mri after months. months following presentation he remains fully ventilated with no significant motor improvement despite intensive rehabilitation including use of passive range of movement devices and functional electrical stimulation. conclusion: this is one of the most severe cases of afm, representing the wider spectrum of afm involving encephalopathy, dominant bulbar signs and quadriparesis. mirror movement disorder (mmd) is a rare movement disorder with a prevalence of less than in a million in which involuntary symmetrical movement is observed in the limb contralateral to the voluntary limb movement. we report children with an mmd. case : a -year-old girl following an uneventful pregnancy and normal delivery, born to nonconsanguineous parents presented with difficulties with fine motor activities like writing. parents noticed from age of eight that her left hand would make similar movements to her right hand in activities like writing, combing etc. maternal grandfather has mmd. case : a -year-old girl following an eventful pregnancy and normal delivery to non-consanguineous parents presented with an mmd at age of years first noticed whilst writing and this continues affect her activities of daily living. there is no family history of mmd. both children are neurodevelopmentally normal and have normal mri brain and spine. mmd have been described congenitally due to prenatal insult before weeks gestation, kallman syndrome and klippel-feil syndrome or as an acquired due to hemiplegic stroke and parkinson's disease in adults. pathogenesis is thought to be due to lesions in supplementary motor area, corpus callosum or cervical lesions. mutations in dcc and rad gene are present in % of the cases. the multimodal mri and neurophysiological studies have revealed that the motor system is completely disorganised with abnormal crossing at brain stem level and abnormal communication between both brain hemispheres in these children. there is a positive family history in some cases. the upper limbs are commonly involved. diagnosis is usually clinical and treatment is symptomatic with support at school and limiting repeated complex and sustained movements involving both hands. poster no. acute spinal cord infarction in children: a review of the presentation, aetiological investigations and outcomes in children m shehata, ar hart, cd rittey, e davies department of paediatric neurology, sheffield children's hospital nhs foundation trust, sheffield, uk aims: acute spinal cord infarction is poorly understood in the paediatric population. we reviewed cases presenting to a single paediatric neurology centre in uk between and to explore common themes of presentation, aetiology and outcome. material and methods: cases of spinal cord infarction presenting to a single centre were identified from our spinal database and medical records were reviewed to determine clinical presentation, aetiological investigations, management and outcomes. results: six children/young people were identified, male, female, age range to years. participants presented with symptoms after seemingly trivial movements or trauma, including: being kicked in the back whilst playing football, bending forwards to tie hair up, getting up to walk in the garden, and performing a crab gymnastic movement. had no obvious precipitants. initial presentation was neck or back pain in all patients, progressing to bilateral lower limbs weakness, sensory deficit, lost reflexes, and urinary/bowel involvement. mri imaging failed to reveal the diagnosis when performed early in participant. the level of lesions for each participant were: t - ; t - ; t -t ; c -t ; c -t ; and isolated to the conus. aetiological investigations, including thrombophilia screens, failed to reveal a cause in any participant. initially received steroids because the differential diagnosis included an inflammatory disorder. patients received aspirin, / gained motor improvement but none returned to normal. all had residual bladder problems, had bowel sequelae. conclusions: spinal cord infarction may be related to minor trauma or movements. the association with a chiari malformation is previously described in adults. outcome is poor. although motor improvement can be seen, children do not return to normal functionally. aetiological investigations and treatments vary within a single centre. national recommendations are required to standardise practice. cost of care for long-term ventilation patients r belderbos, v kumar, l alkhalidi east lancashire nhs trust, lancashire, uk background: advances in neonatal and paediatric intensive care have increased the survival of children with life threatening or life limiting conditions. there has been a significant rise in children on long-term home invasive ventilation. high profile cases have been in the media recently with debate on whether such interventions should be implemented focussing on ethics but without evidence of cost benefit analysis. children on long-term invasive ventilation are a high cost group with complex and varying underlying medical conditions requiring input from multiple teams, including hour carers, medical and multidisciplinary team input as well as recurrent hospital and picu admissions. in addition, the cost of equipment and drugs makes this a costly intervention. in any limited healthcare system rationing decisions have to be made: drug and other therapies are subject to health economic analyses. this study aims to assess cost per annum for ltv and a cost benefit analysis. objective: identify patients on ltv including comorbidities. assess cost of ltv to quantify cost-benefit analysis. measure outcomes: death/admissions/recovery. methods: review of patients requiring home long-term invasive ventilation july -july . analysis of costs: clinic visits, hospital admissions, costs of equipment; cost of medication. outcomes and quality of life: mortality, admissions and length of stay; decannulation, ability to communicate and mobility analysis; ability of parents to work. results: patients: died (aged , and y), decannulated, ongoing ltv (aged mo, and y), night package £ pa, accessories £ pa, replaceables/service £ , average cost home ltv around £ pa. conclusions: ltv ventilation is an expensive treatment: its use should be analysed on a cost benefit analysis in a similar way to other available treatments. objective: to assess the feasibility of recruiting to a study, performing and interpreting aeeg in preterm infants, and to assess family and staff members' views. methods: a prospective feasibility study. preterm neonates between and weeks postmenstrual age were recruited for continuous aeeg monitoring using adhesive electrodes whilst receiving nicu care. we studied optimal methods of attaching leads, impedance data, number of electrode changes, and preliminary aeeg findings. staff and parents were asked for feedback on the process and their involvement. results: we recruited . % of eligible babies. nuprep and sorbaderm were the most effective combination for skin preparation. the aeeg recording was good quality if staff were engaged and knew when electrodes needed to be changed. four of the seven ( . %) babies showed seizure activity on aeeg, none of which were diagnosed clinically. babies with seizures were born earlier, had lower birthweights, and had more complications than babies without seizures. feedback showed parents and staff were positive, although staff reported caring for the baby was harder. . % of parents and . % of staff would 'definitely' recommend the study to parents with a premature baby. conclusions: the use of continuous aeeg in preterm neonates in feasible, with similar recruitment rates to other studies in the department, and a positive experience for parents and staff. a high rate of electrical seizures was detected. background: the 'magnetic resonance imaging (mri) to enhance the diagnosis of fetal developmental brain abnormalities in utero' (meridian) study showed improved diagnostic accuracy and confidence for detecting fetal neurological abnormalities compared to ultrasound. the additional information provided by in utero mri altered prognosis in % of women. the meridian study did not report whether the neuro-developmental prognoses given to women varied between clinicians or were accurate. objectives: to assess the variation in prognosis given to pregnant women by clinicians in feto-maternal units for different fetal brain abnormalities. methods: we contacted one clinician at each of the meridian feto-maternal units and asked what percentage chance of normal neuro-developmental outcome they would give pregnant women for fetal neurological abnormalities: isolated ventriculomegaly to mm; unilateral hypoplasia of the cerebellar hemisphere, isolated hypoplasia of the cerebellar vermis, isolated cisterna magna, and isolated blake's pouch cyst. respondents were asked to give a percentage chance of normal outcome, although some used free text to answer. results: responses were received from senior obstetricians in feto-maternal units. there was general agreement for isolated mild ventriculomegaly with respondents replying that to % would have normal developmental outcome. wider variation was seen for posterior fossa abnormalities, with the suggested chance of normal outcome for one condition ranging from to %. conclusion: estimating long-term neuro-developmental outcome based on antenatally detected neurological abnormalities is challenging due to limited high-quality data. our data highlights there is high variation in outcomes offered by different clinicians for the same abnormality. further work is needed to determine what advice is given by obstetricians on the potential developmental outcomes of a wide range of fetal brain abnormalities in current practice, how well these agree with published evidence, and whether the involvement of paediatricians with experience in neuro-developmental disorders improves prognostication. background: in-utero mri (iumri) detects fetal brain abnormalities more accurately than ultrasonography (uss) and provides additional clinical information in around half of pregnancies. there is little published data on whether postnatal neuroimaging beyond months of age changes the diagnostic accuracy of iumri nor its ability to predict developmental outcome. methods: families enrolled in the meridian study whose child survived to years of age were invited to have a case note review and assessment of developmental outcome with either the bayley scales of infant and toddler development, the ages and stages questionnaire or both. a paediatric neuroradiologist, blinded to the iumri results, reviewed the postnatal neuroimaging if the clinical report differed from iumri findings. diagnostic accuracy was recalculated. a paediatric neurologist and neonatologist categorised participants' development as normal, at risk, or abnormal, and the ability of iumri and uss to predict developmental outcome were assessed. results: participants had case note review, of whom ( . %) had mri after months of age. the diagnostic accuracy of iumri remained higher than uss (absolute differ-ence= %, % ci % to %, p< . ). developmental outcome data was analysed in participants: ( %) were normal, of whom ( %) had a normal or favourable prognosis on uss and ( %) on iumr (difference in speci-ficity= %, % ci % to %, p= . ). no statistically significant difference was seen in infants with abnormal outcome (difference in sensitivity= %, % ci - % to %, p= . ). conclusions: iumri remains the optimal tool to identify fetal brain abnormalities. it is less accurate at predicting developmental outcome, although iumri is better at identifying children with normal outcome than uss. further work is needed to determine how the prognostic abilities of iumri can be improved. poster no. introducing hypothermia or not decision algorithm (honda) guideline in the assessment of neonates following hypoxic insult at birth in a district general hospital a sproule, j courtney, m mcgowan ulster hospital, belfast, uk introduction: hypoxic-ischaemic encephalopathy (hie) accounts for up to % of cases of cerebral palsy. hie can be caused by multiple events and occurs in / births. hypoxic insult at the time of birth can result in an encephalopathic state characterised by: need for resuscitation at birth, neurological depression, seizures and electroencephalographic abnormalities. the toby study demonstrated that induction of moderate hypothermia within hours of birth for hours duration in infants who had perinatal asphyxia resulted in improved neurologic outcomes in survivors. therapeutic hypothermia is the only proven neuroprotective treatment for hie. an assessment tool was required as there was no standard proforma for neurological assessment for babies with a low cord ph (< . ) in our district general hospital (dgh). this was to ensure that all infants who met the toby criteria received the appropriate treatment within the recommended timeframe. methods: the honda assessment tool was developed for use in the tertiary neonatal intensive care unit. this assessment tool was adapted to use in a dgh as a guideline. the honda included the criteria from the toby study with a user-friendly flow chart. a comprehensive neurological examination is outlined with text and images to ensure reliable and repeatable findings by different clinicians over time. results: the honda tool ensured a standard algorithm was used to assess those infants who had a hypoxic insult at birth. it has standardised record keeping and repeated neurological examination of at-risk infants. conclusions: the honda is a comprehensive and userfriendly algorithm to ensure those infants who meet requirement for therapeutic hypothermia are being appropriately identified and treated. poster no. foetal exposure to misoprostol and mobius syndrome s tilib-shamoun, a siddiqui, v ramesh king's college hospital, london, uk background: mobius syndrome is a rare condition comprising a collection of specific congenital anomalies, usually congenital lower motor neuron th and th cranial nerve palsies. hydrocephalus, cerebellar hypoplasia, orofacial and limbs deformities have been reported in some. the literature links mobius syndrome to early foetal exposure to misoprostol, a synthetic prostaglandin e analogue widely used for medical termination of pregnancy. for abortions it is used by itself or with the anti-progestogen mifepristone; the combination is % effective during the first trimester of pregnancy. the mechanism by which misoprostol disrupts brainstem development resulting in hypoplasia or absence of central brain nuclei is not elucidated as yet. suggested mechanisms include selective vulnerability to hypo-perfusion and ischaemic injury of the foetal brain stem due to direct disruption of the foetal vasculature or to global foetal hypoxia because of uterine contractions and placental ischaemia. clinical case: we report a case of an infant with known exposure to misoprostol from failed medical termination of pregnancy (top) at weeks gestation, who presented with an abnormally increased head circumference, multiple lower motor neuron cranial nerve palsies ( , and th cranial nerves). his mri scan showed hydrocephalus due to cerebral aqueduct stenosis, inferior vermian hypoplasia and loss of bulk of the right facial collculus of the pons. conclusions: it is vitally important to counsel expectant mothers following exposure to misoprostol and failed top of possible congenital anomalies if the woman elects to continue with the pregnancy. poster no. neurological examination in unwell neonates: health care professionals' perspectives a fadilah, ar hart department of paediatric neurology, sheffield children's hospital, sheffield, uk objective: to explore health care professionals' opinions of neurological examination in unwell neonates. methods: a questionnaire designed to assess views on examining unwell neonates neurologically was distributed to all uk neonatal and paediatric neurology units. questions included likert scales, with scores ranging from to . scores of to were taken to be positive, to negative or equivocal. answers were compared between consultants and other staff members using chi-squared testing, with p< . assumed statistically significant. results: responses were received, although not every question was answered. / ( . %) responders were based in general paediatrics, / ( . %) in tertiary neonatal units, and / ( . %) in paediatric neurology. / ( . %) were consultants. / ( . %) performed a neurological examination in all unwell neonates, / ( . %) in most. . % of consultants felt confident performing a neurological examination, compared to . % of other health care professionals (p< . ). consultants were also more confident at interpreting the results and using them to formulate management and prognosis (all p< . ). / ( . %) did not find a high-quality neurological examination documented routinely in medical notes of half or more unwell neonates. / ( . %) reported using the classical neurology examination adapted for neonates, ( . %) used the hammersmith neonatal neurological examination or an adapted version. the most difficult aspects were fundus and cranial nerve examination. the most frequently cited challenges were: effect of medication; difficulties in interpretation; equipment and lines; experience; time limitations; and risks of handling unwell neonates. / ( . %) wanted a new standardised neurological examination for unwell neonates; ( . %) did not. conclusions: non-consultant grade health care professionals feel less confident performing a neurological examination in unwell neonates. all responders highlighted a number of challenges to performing and interpreting the results. around three-quarters of responders want a new, standardised neurological examination for unwell neonates, which could address these challenges. use of re-standardised griffiths scales of child development ( rd edition) in a healthy cohort at to months of age objective: the griffiths scales of child development (gscd) is an established tool for the developmental assessment of children from birth to years. in , the gscd underwent significant revisions, and was re-standardised using contemporary cohorts. to date, no studies have reported on its use in healthy children post-marketing. our aim is to examine the use of the gscd-iii in a healthy population of infants aged to months and to provide the first published data on the use of the revised griffiths-iii. methods: in a prospective observational study of healthy, fullterm infants, participants were recruited into a randomized controlled trial of infant massage. griffiths iii assessments were performed by aricd-trained practitioners across subscales and a general development quotient (gd) at to months. results: children were considered in the analysis, male: female ratio / . mean (sd) birth weight was . ( . ) kg and mean birth gestational age was . weeks (sd . ). mean (sd) age at assessment was . ( . ) months, with ( . %) children being assessed according to / rounded norms, and ( . %) to / norms. no difference was found in either arm of the study in any subscale. scores were considerably greater than average (dq - ) in all subscales but particularly subscales b, d and gd. mean (sd) developmental quotients (dq) in a= . ( . ); b= . ( . ); c= . ( . ); d= . ( . ); e= . ( . ) and in gd= . ( . ). using the published cutoffs, we found that . % (n= ) of our cohort scored 'above average' or greater in gd. conclusions: we have provided the first data on the use of griffiths-iii in a healthy cohort. scores were higher than expected across all sub-scales. this may be due to the characteristics of our cohort but raises concern that griffiths-iii may overestimate ability in young infants. objective: metabolic investigations are important in the investigation of children with disordered development. the aim of this audit was to determine if paediatric metabolic investigations were ordered as per current best practice evidence at tallaght university hospital, dublin, republic of ireland. methods: we used recommendations from seven publications to guide this audit and identified indications for performing metabolic investigations. we reviewed metabolic investigations sent on paediatric patients at tallaght university hospital from january to december . we identified the clinical indication for investigating patients by reviewing dictated clinic letters available on the hospital intranet and confirmed investigation results by reviewing scanned copies available on the hospital intranet. we compared the indications for metabolic investigations with published expert guidelines. results: metabolic investigations were performed on patients from january to december . six patients had inconclusive results and were referred to the metabolic team at temple street children's university hospital dublin for further assessment. there have been no metabolic diagnoses made to date as per tallaght university hospital dictated letters. of the patients, had a diagnosis of autism spectrum disorder (asd). of those with asd, had a confirmed or suspected intellectual disability. patients ( %) met best practice recommendations for metabolic investigations. of the patients who did not fulfil recommendations, ( %) were for children with asd. conclusions: we identified two areas that could improve patient care by optimising diagnostic yield and improving resource utilisation at the hospital. first, we recommend clinicians send targeted investigations and avoid blanket investigations for children with disordered development, including asd. second, we recommend clinicians include relevant clinical details on request forms to improve diagnostic yield. finally, we question the value of metabolic investigations for intellectual disability in the absence of other clinical risk factors or comorbidities and suggest this requires further study. the early developmental course of babies with sturge-weber syndrome n thapa , t fosi , , v siyani , j sloneem , h richardson , s aylett , university college london medical school, london, uk; ucl great ormond street institute of child health, london, uk; neurodisability, great ormond street hospital, london, uk background: sturge-weber syndrome (sws) is a rare neurocutaneous condition which arises from a mutation in g protein subunit alpha q. the hallmark is leptomeningeal angiomas often associated with a facial port-wine birthmark. seizures, stroke-like episodes and hemiplegia are common clinical presentations. objective: to describe clinical features of infants with sws under years and their developmental trajectory in relation to seizure onset. methods: a retrospective case note review was conducted on children aged below years with sws under clinical review at our centre. the medical history and standardised developmental test results (language, cognition, motor and visuospatial skills) contained in patients' assessment reports were analysed. results: common clinical features of children with sws aged under years were: seizures in patients ( %), hemiplegia in patients ( . %) and glaucoma in patients ( . %). their developmental trajectory was a decrease in the mean percentiles (for language, cognition and motor skills) and mean developmental quotients (for visuospatial skills) over the first months. infants with unilateral brain involvement had significantly higher cognitive percentiles than those with bilateral brain involvement (p< . ), but both groups showed the aforementioned pattern. children with epilepsy had worse language (p= . ) and cognitive outcomes (p= . ) than children without seizure onset. there was seizure onset in the first year in infants ( . %). in these patients, earlier seizure onset was associated with a higher language percentile (p= . ) at age months or at the time of seizure onset. conclusions: following treatment of early seizures in sws language recovery appears to occur over time relative to cognition. the functional plasticity of language might account for these observations. it is proposed that seizure prevention and optimal seizure control in the crucial first year of life will benefit cognitive and language development in patients with sws. objective: rett syndrome (rtt) is a rare neurodevelopmental disorder primarily affecting females, characterized by loss of speech, stereotypies, abnormal hand movements, motor and cognitive impairment. diagnosing rtt before regression occurs remains a challenge and there is an increasing interest in early diagnosis, due to the ongoing gene therapy clinical trial in rtt. methods: retrospective case notes review. the patient was born at term after induction of labour for reduced movements, with meconium-stained liquor, but was well. poor crying and suck noted at birth with gradual deterioration of feeding, with frequent chest infections, necessitating peg-feeding at months. peripheral/axial muscle weakness and hypotonia were noted at this time. mri brain showed mild underopercularisation of sylvian-fissures; thin corpus-callosum. mrs, mri spine, echocardiogram, and eeg were normal. vitamin b deficiency was found, treated with hydroxycobalamin. sleep study showed hypoventilation with frequent apnoeas and low respiratory rate, leading nocturne bipap. emg was myopathic. muscle biopsy showed marginal loss of complex-i activity in the respiratory-chain-enzymes analysis. results: videofluoroscopy showed delayed swallow and disorganised pharyngeal stage leading to peg feeding. over the following months, no regression noted but only minimal motor progression seen; she was interactive and smiled. at months, regression in her motor abilities was notedshe stopped fixing, following and smiling with progressive microcephaly and hand writhing movements. eeg showed epileptic encephalopathy with tonic/myoclonic jerks. whole-exomesequencing showed a de-novo pathogenic mutation in the mecp gene (nm_ . :c. _ del,p.[leu fs] ) and the diagnosis of rtt was confirmed. after months, she restarted smiling and fixing/following and making motor progress but continues to have seizures. conclusions: this case illustrates early-onset features in atypical rtt with central breathing abnormalities, bulbar insufficiency, generalized hypotonia before regression. evidence of mitochondrial dysfunction is in keeping with recent reports suggesting neuronal redox imbalance in rtt as one of the disease pathogenic contributors. objective: neurodegeneration with brain iron accumulation (nbia) comprises a group of rare genetic disorders characterized by progressive extrapyramidal and other neurological symptoms due to focal iron accumulation in the basal ganglia. b-propeller protein-associated neurodegeneration (bpan) is the most recently identified subtype of nbia caused by heterozygous variants in wdr at xp . . we report a new subtype of bpan caused by a de novo wdr variant in a -year-old girl. methods: case report on a new subtype of b-propeller proteinassociated neurodegeneration (bpan) caused by a de novo wdr deletion in a -year-old girl and review of the literature. results: we report a year old girl with bpan due to a large ( bp) de novo chrx:g. , , _ , , del (hg ) deletion in wdr , presenting with early-onset global developmental delay, hypotonia, seizures, and speech apraxia. the patient presented at the age of months with hypotonia and motor developmental delay, following a normal birth history, and at months developed complex partial seizures and later on steroid-responsive electrical status epilepticus of slow-wave sleep (eses). she has made minimal developmental progress and has remained profoundly globally developmentally delayed and cognitively impaired, and has still not achieved independent ambulation. conclusion: we have described the clinical, neurophysiological and neuro-imaging findings in a -year-old girl, the unique combination of which may assist in the diagnosis of further similar cases. bpan is an exceedingly rare, severe and debilitating disorder with a broad spectrum of clinical heterogeneity and variable age at presentation with early-onset symptoms. early detection and diagnosis are very important in order to offer proper genetic counselling to affected families and provide symptomatic treatment to patients. next-generation broad-spectrum genetic analyses will enable early detection of bpan in the paediatric age group in order for patients to be diagnosed prior to reaching adulthood. introduction: how to measure the effectiveness of an early intervention program in low resource setting. can assessments lead to interventions? and with improvements leads to new interventions, can new assessment lead to new interventions? can this system be measured for its effectiveness and improved based on feedbacks and results? an attempt to set up child development centres in low resource countries using software, apps and e-learning. method: years of data in early interventions was analysed in lucknow, india. in phase , children with non-progressive neurological problems were given best available local interventions. only % compliances and improvement were seen. based on the feedback algorithms were written to create individual profile of children based on their skills (uk curriculum of excellence), disability score, information processing preference, educational and behaviour problems. based on the score each child generates an individualised profile and an intervention plan delivered by app for parents (p-bac-drv) and app (t-bac-drv) at child development centres. the assessment is repeated every months and new individualised profile is generated with new set of intervention. in total more than interventions are developed, and the algorithm helps in deciding which main areas to target at one time. result: the current system in low resource settings have either no service or results are close to % prevent disability in non-progressive neurological problems. our system has shown to prevent disability in about % of children. supported by government start up initiative the program has won in top data innovations in india. conclusion: use of technology to provide training, exams and support professionals in the low resources areas is the solution to provide effective services. pattern recognition is the key delivered by software and auto audits has been placed to measure and improve the system. introduction: medical advances in the treatment of cns tumours has enhanced survival but also impacted on levels of residual morbidity and participation. service provision has not increased alongside the improvement in survival, with many patients not being able to return to their previous level of activity and participation following their oncology treatment. nice cancer services for children and young people state: 'children and young people who have had a central nervous system malignancy should receive a specialist neuro-rehabilitation care package'. robbie's rehab, a charity funded physiotherapy service embedded within the southampton children's hospital therapy service, launched june , provides supplementary physiotherapy for children diagnosed with brain and spinal tumours under the care of southampton children's hospital. objective: to accurately identify and quantify the need for this service. method: prospective data was collated and reviewed june -may . results: year : patients; year : patients. new episodes of physiotherapy (average . per month), direct clinical contacts. reasons for accessing the service: need for enhanced intensity of rehabilitation on discharge (n= ), enhanced inpatient rehabilitation (n= ), bridge the gap whilst awaiting community services (n= ), change in symptoms (n= ), pre-op assessment (n= ), support for palliative care planning (n= ), support for complex social and emotional needs (n= ), disease progression (n= ), higher level rehabilitation not fulfilling community criteria (n= ), facilitate access to local exercise facilities (n= ), within oncology clinic for assessment/one-off treatment (n= ), post-op assessment (n= ), individualised goal orientated participation (n= ). patients had an estimated weeks reduction in acute bed days. conclusions: robbie's rehab referrals are for a variety of multifactorial reasons with rereferral often needed within their pathway. it has enabled earlier discharge, improved transition to community services and opportunities for therapy access previously not available. results: our proband presented at weeks with marked stridor and bulbar weakness after a normal pregnancy. he subsequently developed respiratory failure requiring nocturnal bipap and was found to have a type i laryngeal cleft. initially he met developmental milestones but at months developed features of axial weakness with further regression at months with limb weakness and loss of deep tendon reflexes. emg confirmed denervation in genioglossus, as well as proximal and distal limb muscles without evidence of neuropathy. genetics for smn gene and smard were negative. inherited peripheral neuropathy gene panel testing identified a heterozygous missense variant c. t>c, p.(cys arg) in exon . the variant is predicted to alter a highly conserved amino acid, has not been reported before and has not been identified in control databases. in silico prediction tools supports the pathogenicity of the variant. mutagenesis of the equivalent amino acid in mice produces impaired motor control and denervation. conclusions: the gars gene encodes an ubiquitously expressed glycyl trna synthetase which has an integral role in protein synthesis in all eukaryotic cells. missense gars mutations can lead to distal hereditary motor neuropathy as well as a sensorimotor neuropathy phenotype (cmt d) typically with adolescent or early adulthood onset. objective: to discuss sma, which is one of the differentials in a hypotonic child and bring to light the diagnosis is not always cerebral palsy (cp). method: descriptive case report. results: case : -month-old girl admitted to icu with severe pneumonia. case : -month-old boy, both admitted to the intensive care unit with severe pneumonia. case : -month-old girl, presented to outpatient with progressive 'floppy' limb weakness and swallowing and breathing difficulties. case : attended opd with worsening respiratory distress, difficulty feeding, difficulty managing secretions. all had perinatal histories of uncomplicated deliveries but subsequent early respiratory distress and oxygen requirement for the first few days of life. all had been 'floppy' since birth, with severe gross motor delay, feeding difficulties, poor weight gain and recurrent chest infections. cases , and had been diagnosed with cp despite having normal neuroimaging. examination of all children was similar and consistent with clinical diagnosis of sma. findings included an alert, interactive child; frog-legged posture; -limb hypotonia and weakness with legs more affected than arms; absent deep tendon reflexes; bell-shaped chest; and tongue fasciculation. genetic testing for all confirmed homozygous deletion of exon of the smn gene. in all the cases creatinine kinase levels were normal, ruling out myopathy. conclusions: the incidence of sma is / livebirths. it can be diagnosed clinically from pathognomic features when genetic testing is unavailable and should be considered in any hypotonic child, irrespective of perinatal history. a wide clinical spectrum that ranges from early death to near-normal adult life exists. families must be counselled regarding implications of this genetic diagnosis. correct early diagnosis and multidisciplinary intervention can vastly improve outcomes. poster no. syros studylong-term reduction in rate of respiratory function decline in patients with duchenne muscular dystrophy (dmd) treated with idebenone l servais , c lawrence , oh mayer , cm mcdonald , u schara , t voit , e mercuri , gm buyse respiratory function decline in dmd is caused by the underlying weakness and degeneration of the respiratory muscles leading to impaired inspiratory and expiratory effort and associated complications. idebenone reduced the rate of respiratory function decline over weeks in the phase iii delos trial. syros is a long-term study in former delos patients who transitioned to idebenone under expanded access programs following a variable untreated period. here, we aimed to characterize the long-term effects of idebenone on respiratory function. patients were managed according to routine clinical practice. respiratory function was assessed by calculating the annualized decline in forced vital capacity (fvc) and peak expiratory flow (pef), expressed as percent predicted (%p). comparisons were made between treated and untreated periods and to matched external controls. data on bronchopulmonary adverse events (baes) and hospitalizations were collected. data from / former delos patients were available. at delos baseline, mean (sd) age and fvc%p were . ( . ) years and . % ( . %); all patients were glucocorticoid non-users and . % were non-ambulatory. patients were treated for an average (min-max) of . ( . - . ) years compared to an average untreated period of . ( . - . ) years. the annual rate of fvc%p decline was almost halved ( . % vs . %) when comparing these periods. for the external comparisons, declines remained lower across all treatment years (up to y) compared to the matched group of untreated patients. comparable results were seen for pef%p. the risk of baes was reduced by % during longterm idebenone treatment versus untreated periods, leading to fewer hospitalizations due to respiratory causes ( . vs . events per year). long-term treatment with idebenone results in a consistent and sustained reduction in the rate of respiratory function decline for up to years. two placebo-controlled trials of -week duration (phase ii delphi, phase iii delos) showed that idebenone consistently reduced respiratory function decline rate in patients with advanced dmd. long-term data from the delphi-extension (delphi-e) study and syros (delos patients who transitioned to idebenone under an expanded access program) are now presented. the aim was to assess the consistency of the long-term effect of idebenone on respiratory function across both placebo-controlled trials and their respective long-term data collections. delphi-e and syros patients with abnormal (< %) forced vital capacity (as percent predicted, fvc%p) were treated with idebenone for an average of . and . years respectively. annualized fvc%p decline rates were compared to untreated patients from syros or matched external controls (matched for baseline fvc%p) from the cinrg duchenne natural history study (cinrg-dnhs). mean (sd) baseline age was . ( . ) and . ( . ) years in delphi (n= ) and delos (n= ), respectively, and fvc%p was . % ( . %) and . % ( . %). for the first -year period, where data were available for both studies, the average annual decline rate was comparable in treated patients ( . % and . % in delphi-e and syros) and lower than in untreated syros patients and external controls ( . % untreated and . % in cinrg-dnhs). during years to , the annual decline rate was consistently lower than for matched controls. treatment with idebenone resulted in a sustained reduction in the rate of decline in respiratory function across both placebo-controlled week studies and across both long-term data collections, with follow-up time of up to years. the consistency observed across independent datasets adds to the robustness of the treatment effect of idebenone and its potential to modify the course of respiratory function decline in dmd. poster no. a rare mutation in dync h causing a mixed clinical phenotype of spinal muscular atrophy with lower extremity predominance and hereditary spastic paraplegia: a case series in a family el goh , , s jayawant , g anand objective: to describe the identification of a rare mutation in the dync h gene as a cause of a mixed clinical phenotype of spinal muscular atrophy with lower extremity predominance (sma-led) and hereditary spastic paraplegia (hsp). methods: case series of three family members (father and two sons) across two generations. results: there was a history of early childhood-onset, progressive lower limb muscle weakness and atrophy. no relevant family history of neuromuscular disorders was reported on both the paternal and maternal sides of the family. examination revealed markedly diminished tone and power in the lower limbs, with wasting and a positive crossed adductor reflex. there were no abnormalities detected in the upper limbs and sensation was preserved throughout. neurophysiological testing showed moderate to severe chronic denervation of the lower limb muscles with sparing of the peripheral sensory nerves. hsp panel was negative but charcot-marie-tooth (cmt) panel demonstrated a heterozygous sequence change in the dync h gene: c. a>t p.(glu val), which was present in all affected family members. discussion and conclusions: mutations in the dynein gene are typically associated with sma-led or cmt. a mixed sma-led and hsp phenotype has previously been shown to be caused by mutations in bicd . bicd encodes a golgin, which is a component of dynein-based transport, and plays a key role in mrna transport during oogenesis and embryogenesis. we present the first case series of a mixed clinical phenotype of sma-led and hsp occurring due to a mutation in dync h . this was the first observation of the c. a>t p.(glu val) variant at our laboratory and was not listed in the genome aggregation database, suggesting an extremely rare variant. opening the lid on unilateral ptosis in paediatric nf e hassan , e witter , z mughal , l robinson , d weisburg , sa roberts , e hupton , j eelloo , e burkitt wright , , s garg , l lewis , dg evans , , sm stivaros , , , g vassallo , , introduction: neurofibromatosis type (nf ) is a genetic disorder with a birth incidence of in - individuals and prevalence of around in worldwide. ptosis is a welldocumented feature in this condition and is known to be associated with plexiform neurofibromas or in the noonan phenotype, with bilateral ptosis. unilateral ptosis in the absence of a plexiform neurofibroma is not a common feature in nf . we describe a number of patients with nf who demonstrated unilateral ptosis. methods: a retrospective cohort study was carried out using the patient database within the nf service based in st mary's hospital, manchester, uk. children and young adults aged to years with nf were identified via the patient database and patients with a presentation of ptosis were identified. results: six children with unilateral ptosis were identified, four females and two males (ages - , mean= . y). five had unilateral ptosis affecting the right and one the left, with no differences observed between sporadic or familial disease. five patients had complex disease; however, none had any other associated complication to account for the unilateral ptosis apart from nf . they did not meet the diagnostic criteria for noonan syndrome, and none had plexiform neurofibromas in the orbital or peri orbital area. discussion: it is unclear why there is an increased incidence of unilateral ptosis in our cohort of nf patients, in the absence of plexiform neurofibromas and noonan's syndrome. ptosis in nf has been associated with a noonan syndrome phenotype in nf patients. the general hypotonia and myopathy observed in these patients could also factor into the causes for ptosis. further research is necessary to investigate the aetiology of increased unilateral ptosis in nf patients. objective: sma is a severe neuromuscular disorder characterised by progressive muscle atrophy and weakness. scoliosis is a highly prevalent complication and surgery is almost invariably required in 'sitters'. data on secondary outcomes are limited, and this study investigates post-surgical respiratory (fvc%) and motor function, weight gain, pain and satisfaction. methods: we retrospectively reviewed the notes of patients who never walked or lost ambulation (sma type ii/iii) who successfully underwent scoliosis surgery at great ormond street hospital: spinal fusion ( ), magnetic ( ) or traditional ( ) growth rods. we performed phone interviews and run a focus group for families on pre and post-surgical satisfaction. results: median follow-up before and after surgery was . ( . - . ) and . ( . - . ) years respectively. mean annual rate of fvc% decline improved post-surgery in sma ii: - . versus - . (p< . ), with similar trajectories in sma iii. mean annual rate of hammersmith functional motor scale's scores decline did not change significantly (- . vs - . , p< . ), while the revised upper limb module's scores showed a less progressive deterioration (- . vs - . , p= . ). a negative deviation from previous weight curve after surgery was observed in / requiring food supplements ( ); one/ with significant weight loss (> % of total weight) needed gastrostomy. pain was frequently documented, especially hip pain ( / ) requiring painkillers ( ), intra-articular steroids ( ) and surgery ( ). nine/ families participating in the phone interview reported major improvements in posture, physical appearance, self-image; all rated the procedure as very successful. however, / did not report significant improvements in quality of life due to reduced mobility and increased unmet care needs. five families attended the focus group reporting on both positive and negative aspects of their experiences. conclusions: this study provides relevant data and suggestions to improve the current multidisciplinary approach of scoliosis surgery in children with sma. poster no. sunfish part : -month safety and exploratory outcomes of risdiplam (rg ) treatment in patients with type or spinal muscular atrophy (sma) objective: spinal muscular atrophy (sma) is a severe, progressive neuromuscular disease caused by reduced levels of survival of motor neuron (smn) protein due to deletions and/or mutations of the smn gene. while smn produces fulllength smn protein, a second gene, smn , produces only low levels of functional smn protein. risdiplam (rg / ro ) is an investigational, orally administered, centrally and peripherally distributed small molecule that modulates smn pre-mrna splicing to increase smn protein levels. sunfish (nct ) is an ongoing, multicentre, double-blind, placebo-controlled study (randomised : , risdiplam:placebo) in patients aged - years, with type or sma. methods: sunfish part (n= ) is a dose-finding study assessing the safety, tolerability and pk/pd of risdiplam; pivotal part (n= ) assesses the safety and efficacy of the risdiplam dose level that was selected based on results from part . sunfish part included patients of broad age ranges and clinical characteristics (functional level, scoliosis and contractures). an interim analysis of part (data cut-off, july ) showed a sustained, > -fold increase in median smn protein versus baseline after year of treatment. adverse events were mostly mild, resolved despite ongoing treatment and reflective of the underlying disease. despite not being designed to detect efficacy, risdiplam improved motor function measures over months versus natural history. results: safety, tolerability and pk/pd will be reported from all patients in part who have received treatment with risdiplam for a minimum of months. updated part exploratory efficacy data, including motor outcome measures, will also be presented. the clinical benefit of risdiplam is being assessed in part , which is ongoing worldwide. objective: ryr encodes the skeletal muscle ryanodine receptor, an intracellular calcium-release channel that is crucial to excitation-contraction coupling in muscle. gene variants can cause heterogeneous myopathies, including dominantly inherited central core disease. both autosomal dominant (ad) and autosomal recessive (ar) pattern of inheritance have been reported. methods: retrospective case notes review. results: sibling : female, presented during the first year of life with motor developmental delay. at years of age she is able to sit unsupported and crawl but not stand or walk. she has facial weakness, but no feeding difficulties or ophthlamplegia. she has axial and proximal weakness with antigravity power in neck flexors and hip flexors (mrc / ) and sub-gravity power in hip abductors/extensors and knee flexors/extensors (mrc / ). there are severe hip, knee and ankle fixed contractures. power and joint range is normal in upper limbs. muscle biopsy showed type- fibre predominance and core-like structures. sibling : female, presented at birth with feeding difficulties. at months of age she is fully nasogastric fed. there is no facial weakness or ophthlamplegia. she has good head control with active head lift in prone, and antigravity power in hips, knees and ankles. she has mild hip and knee contractures and shoulder girdle weakness. both siblings have been confirmed to be heterozygous for a ryr pathogenic frameshift variant (c. _ dupca p.(met fs)) inherited from father and a likely pathogenic missense variant (c. g>c p.(lys asn)) inherited from mother. both parents are asymptomatic. conclusions: the clinical and pathological features of ad ryr -related myopathy are well recognized but much less is known about ryr -related disorders secondary to an ar pattern of inheritance. we report two siblings with ar ryr related myopathy with similar genotypes but different phenotypic features demonstrating intra-familial variability and expanding current knowledge on this disorder. results: our probands were the second and third children of consanguineous irish parents who were fourth cousins. antenatally, reduced fetal movements and amniotic fluid was noted with both probands. at birth, both had arthrogryposis and the second sibling required prolonged intubation at birth. both had significant developmental delay; a more severe phenotype in the younger. on examination, both had myopathic facies, inability to bury eyelashes, full eye movements, high arches palates, drooling, a weak cry, micrognathia but a preserved suck. they both had long thin fingers, with thumbs held adducted and dimpling of elbows and hands. peripheral reflexes were absent but there were good anti-gravity movements of the lower limbs. both were noted to have pectus excavatum and progressive scoliosis. muscle biopsies showed dystrophic features of fibrosis, hypertrophy and atrophy of fibres and variation in fibre size with increased fibrous connective tissue. occasional central cords and multiple mini cords were also seen in the second proband. whole exome sequencing identified the compound heterozygote mutation (ttn c. delc in combination with ttn c c>tp. (ser leu) and ttn c. g >a p. (asp asn)). conclusions: mutations in the titin gene (ttn) have been implicated in several skeletal and or cardiac phenotypes to date. each individual variant of the compound heterozygote has not been reported as pathogenic mutations and have been detected in the general population at . % frequency. however, the presence of the triple count may certainly account for the severe phenotype of our probands. poster no. gene-replacement therapy (grt) in spinal muscular atrophy type (sma ): long-term follow-up from the onasemnogene abeparvovec phase / a clinical trial objective: sma is a rapidly progressing neurologic disease caused by biallelic survival motor neuron gene (smn ) deletion/mutation. the smn grt onasemnogene abeparvovec (formerly avxs- ; approved in us) treats the genetic root cause of sma and is designed for immediate, sustained smn protein expression. in a phase / a trial (start [cl- ]; nct ), sma patients received a one-time onasemnogene abeparvovec infusion at low dose (cohort , n= ) or high dose (cohort , n= ), and demonstrated improved outcomes versus natural history. no patients in start received nusinersen during the -month follow-up after dosing. sma patients in start could rollover into a long-term follow-up study (study lt- ; nct ). primary objective: long-term safety. methods: sma patients have annual visits ( y), then phone contact (additional y). patient record transfers are requested. safety assessments include medical history and record review, physical examination, clinical laboratory evaluation, and pulmonary assessments. efficacy assessments include developmental milestone evaluation to determine maintenance of the highest achieved milestone in the parent study. results: as of march , patients (cohort , n= ; cohort , n= ) had enrolled in study lt- and had a baseline visit. for patients in cohort , the mean (range) age and time since dosing were . ( . - . ) years and . ( . - . ) years, respectively. all patients in cohort ( / ) were alive. no developmental milestones achieved in start were lost, and new milestones have been achieved, supporting the durability of onasemnogene abeparvovec. updated data will be presented. conclusions: one-time onasemnogene abeparvovec administration at the high dose continues to provide prolonged and durable efficacy with milestone development in lt- . poster no. micu -myopathy: a mitochondrial disorder that mimics a congenital muscular dystrophyreport of siblings with variable phenotypes m fernandez, m sa, v gowda evelina london children's hospital, london, uk objective: micu encodes a selective calcium-channel subunit within mitochondrial inner membrane whose function is essential for buffering cytosolic ca + transients and activating atp production. mutations in micu have been reported in different families with muscle weakness, fatigability and developmental delay, with normal lactate despite being a mitochondrial disorder and persistently elevated creatine kinase (ck) usually in the range of congenital muscular dystrophies (cmd). the phenotypic spectrum is highly variable and keeps expandingother features include progressive extrapyramidal signs, learning disabilities, nystagmus and cataracts. we report the clinical features of siblings from a consanguineous family with the homozygous c. - g>c splicing mutation in micu . methods: retrospective case notes review. results: sibling : boy, older sibling, presented aged years. he had short stature which was investigated when found to have ck of iu/l. he complained of occasional cramps. muscle biopsy showed mild dystrophic changes with reduced alpha-dystroglycan that indicated a possible congenital disorder of glycosylation. his mri brain was normal. he was diagnosed with autism. sibling : girl, diagnosed antenatally with cerebellar hypoplasia, confirmed postnatally as inferior-vermis hypoplasia. presented at years with occasional cramps, mild tightness of tendo-achilles, and ck of iu/ l. her height and weight were on nd centile. muscle mri showed a small area of high signal in the left adductor magnus related to a group of normal vascular structures. neurophysiology studies were normal. no other systemic involvement was seen in either of them. next generation sequencing revealed the micu mutation described. conclusions: our work expands the phenotypical spectrum of micu deficiency and highlights the variability in patients within the same family. targeted analysis of the micu gene in patients with high ck levels resembling a cmd picture may be warranted, even in the absence of prominent muscle features. the role of dystrophin brain isoforms on early motor development and motor outcomes in young children with duchenne muscular dystrophy half of patients have central nervous system (cns) manifestations. two dystrophin isoforms, dp and dp , play an important role in cns function. those lacking dp have a more severe cns phenotype, most marked in those lacking dp and dp . our objective is to determine whether lack of dp and dp also has an adverse impact on early motor development. methods: the northstar ambulatory assessment (nsaa) is a scale of motor function. clinical information for dmd participants was classified by dmd mutation location and effects on isoform expression as follows: dp +_dp + (dp absent, dp /dp present), dp -_dp + (dp /dp absent, dp present) and dp -_dp -(dp /dp /dp absentall isoforms affected). results: amongst to year olds, median total nsaa scores were lower in the dp -_dp + (p= . ) and dp -_dp -groups (p= . ) than the dp +_dp + group, most markedly in the dp -_dp -group. for example, for -year olds, median total nsaa scores were (dp +_dp +), (dp -_dp +) and (dp -_dp -). amongst to year olds, a lower percentage of participants achieved a full score of (normal, achieves goal without assistance) for the nsaa sub-items in the dp -_dp + (p< . ) and dp -_dp -(p< . ) groups than in the dp +_dp + group, most markedly in the dp -_dp -group. for example, amongst -year-olds, percentage of visits for which a full score was recorded for jump were as follows: % (dp +_dp +), % (dp -_dp +) and % (dp -_dp -). conclusions: in addition to the known cns phenotype, young dmd patients lacking dp also exhibit lower median total nsaa scores and greater early motor delay, most markedly seen in those lacking both dp and dp (lacking all dystrophin brain isoforms). this has important implications for patient prognostication and clinical trial design. background: most commonly known as a rare subtype of guillain-barr e, miller fisher syndrome (mfs) has evolved since it was first described in . the syndrome is characterised by a triad of ophthalmoplegia, ataxia and areflexia but clinical variations do occur. it occurs more often in men than woman (ratio : ) with the average age of onset . years. mfs is associated with positive anti gq b antibodies, which is concentrated in cranial nerves iii, iv and viexplaining the link with ophthalmoplegia. clinical case: we present an unusual case of a -year-old boy with background of macrocephaly and pre-existing developmental delay with a previous mri which showed mild signal change in periventricular white matter bilaterally. he was admitted with a subacute history of proximal muscle weakness and fatiguability. he had no obvious focal neurological signs apart from intermittent lid hopping and ptosis. differential diagnosis included myasthenia, demyelinating disorders or an underlying pre-existing luecodystrophy. anti gq b antibodies were checked along with extensive metabolic investigations, lumbar puncture, muscle biopsy, anti-cholinesterase and antimusk antibodies along with repeat mri. all investigations were negative including mri which showed no significant change from previous. the only findings were strongly positive anti gq b antibodies. in the interim, the patient was started on trial with pyridostigmine with significant clinical improvement. conclusion: atypical variants of mfs should be a differential in children with subtle eye signs without ophthalmoplegia. lid hopping and fatiguability should raise the suspicion of mfs and anti gq b antibodies should be tested. pyridostigmine has been reported to be effective in mfs. potential utility of muscle mri in congenital myasthenia syndrome secondary to agrn mutation found on whole exome sequencing (wes) congenital myasthenia syndromes (cms) are caused by genetic defects affecting neuromuscular transmission, resulting in muscle weakness and fatigability. agrin, an extracellular matrix molecule released by the nerve is essential at the neuromuscular junction. the large coding gene agrn, has a number of exons and with increasing variants found on wes, it is time consuming and complex to undertake functional studies to define pathogencitiy. previous reports of agrn mutations have a phenotype with prominent distal leg weakness and changes in the soleus on mri. we describe a differing presentation and striking changes on mri, especially in the posterior compartment of the thigh. a -year-old presented with deterioration in his gait and difficulty climbing the stairs. he was born at term, via a normal vaginal delivery. his parents were consanguineous, and he had three well siblings. he was reported to walk by years. on examination he had a waddling gait and was unable to run or hop. he had proximal weakness with a positive gowers sign, together with weak eye closure. muscle biopsy showed non-specific myopathic features, however an mri of the lower leg found widespread fatty muscle atrophy of the thigh and calf with relative preservation of the adductor longus, rectus femoris and semitendonosis. wes revealed an agrn mutation (c. _ del) and a homozygous mutation in the nebulin gene (not felt to be clinically relevant). single fibre emg confirmed electrodecrement on repetitive nerve stimulation. the patient has been commenced on treatment with salbutamol. our patient had very distinctive changes on mri and nonspecific muscle biopsy changes. muscle mri changes prompted further genetic testing when symptoms fitted a clinical diagnosis of a congenital myasthenic syndrome. with increasing variants found of unknown significance in these patients, collation of mri imaging to try and elucidate patterns of changes will be important. mcardle disease (glycogen storage disease type v) is an autosomal recessive condition caused by pathogenic mutations in both copies of the muscle glycogen phosphorylase (pygm) gene encoding the muscle-specific isoform of glycogen phosphorylase, 'myophosphorylase' exclusively affecting skeletal muscle. it is the commonest form of glycogenosis. mcardle disease shows significant clinical variability, with symptoms ranging from mild discomfort during exercise to marked muscle weakness and rhabdomyolysis with myoglobinuria. the second wind phenomenon is unique to mcardle disease and consists of improved exercise tolerance with a decrease in heart rate after a rest. despite the majority of patients recalling symptoms during the first years of life, mcardle is infrequently diagnosed in children, % of patients being diagnosed after years of age according to a recent review. here we report two patients diagnosed with mcardle disease at the age of and years respectively. case one presented with fatigue and inability to increase pace of walking from the age of . hills lead to earlier fatigue. she was able to participate in gymnastics and dancing. presentation was with fluctuating ck levels ( to ). she had no second wind phenomenon or myoglobinuria. case two presented at years with a history from months of reduced exercise tolerance and myalgia after low intensity physical activity with no evidence of myoglobinuria or second wind. on formal assessment there was no evidence of muscle weakness or functional impairment. ck was persistently raised ranging from to . in the light of symptoms and ck levels a rhabdomyolysis panel was requested in both cases leading to diagnosis. objectives: to explore characteristics of anxiety experienced by young males with duchenne muscular dystrophy (dmd) using: . qualitative analysis of focus group discussions with dmd boys and their parents. . parent-report scales of anxiety/emotional problems. methods: eight boys aged to years with dmd and dmd parents participated in separate child and parent focus groups. perspectives on anxiety were elicited using semi-structured discussions, and framework analysis was applied to identify themes. scores on five parent-report scales were determined and scales were compared for content and sensitivity. results: from group discussions, six characteristics of anxiety were recurrently reported: catastrophic conclusions; rigidly held anxieties; extreme distress; unexpected/unfamiliar; social anxieties; physical changes and needs. many features echo the anxiety phenotype in autism spectrum disorder (asd). four further themes described relevant contextual factors: individual, family, social and environmental responses. from parent-report scales, younger dmd boys ( - y; n= ) had significantly higher total, general and social anxiety scores compared to population means on at least two scales (p< . ; p< . ; p< . ). the older dmd group ( - y; n= ) trended towards higher scores in total, general and separation anxiety (p= . ; p= . ; p= . ) compared to population norms. different scales varied in their diagnostic sensitivity and item content, which may influence their utility in dmd. conclusions: anxiety can be a pervasive and impactful issue in dmd. it appears to have some shared traits with anxiety in asd and may be influenced by situational factors, such as living with a disabling, life-limiting condition. screening with standard anxiety scales may not accurately capture the full spectrum of the phenotype in dmd, therefore further evaluation to determine optimal screening instruments in dmd is warranted. however, multi-modal assessments tailored to dmd are key to identifying those in need of support to optimise the mental well-being of young people with dmd. objective: as part of the clinical psychology service in paediatric neurology we developed a tic management group to support young people and their parents to develop positive coping in relation to their tics. the group combined psychoeducational, emotional regulation and habit reversal therapy (hrt) components. this evaluation aimed to establish the effectiveness of these groups in reducing tics and associated distress. method: twenty-eight children, aged to years and their parents attended one of seven tic management groups facilitated between february and november . these children had been referred to the clinical psychology for support with tics. each group consisted of weekly, -hour sessions with a review session weeks later. a parent group was held in parallel. both the young persons and parent groups were facilitated by the clinical psychology team. homework tasks were provided to support hrt skill practice and consolidation of learning of the group content between sessions. the following pre and post group measures were completed by the young people and their parents: the paediatric index of emotional distress, the yale global tic severity scale, the parent tic questionnaire and session rating scales. measures were collated and descriptive data reviewed. results: % of children found the group was helpful in the management of tics. % of children were 'less bothered by their tics'. % of children felt more confident in controlling their tics. parents reported a greater understanding of tics and a reduction in the severity of their child's tics. conclusions: results indicate the tic management group is effective in building young peoples' understanding of tics, confidence in tic management whilst providing peer support. the findings also indicate that parents found the groups informative and valued the opportunity to share experiences with others. background: patients with epilepsy often have deficits in cognitive, physical, psychological and social functioning, and treatment should aim to alleviate these deficits. epilepsy surgery is considered for medication refractory epilepsy with aims to improve patient quality of life. a recent study highlighted the importance of a multidisciplinary workup prior to epileptic surgery, including a neuropsychiatric assessment. part of this assessment should identify patient expectations of epilepsy surgery, so that these can be addressed peri-operatively. at king's college hospital (kch), london, these assessments are routinely performed by the paediatric liaison service as part of the children's epilepsy surgery service (cess). aim: to analyse retrospective data of pre-operative patient and carer expectations between october -september at kch. methods: a record of patient and carer expectations is routinely recorded as part of kch cess neuropsychiatric assessments. the responses were compiled and analysed using qualitative content analysis. results: a preliminary survey of cases with an average age of (range - ) identified responses that were grouped into broader classifications (cognitive, seizure experience, social process, school experience, mental state and general improvements). simple analysis showed carers most often expected surgery to reduce the need for medications ( %), ablate seizures ( %), increase school performance ( %), independence ( %) and overall quality of life ( %). this compared to child responses, where the most common expectations were a reduction in lifestyle restrictions ( %), a cure for epilepsy ( %), decrease in medications ( %) and increased independence ( %). conclusion: consideration of both child and carer expectations during pre-epilepsy surgery neuropsychiatric assessments is important in order for services to manage each individual's expectations. unmanaged unrealistic expectations may lead to a negative psychological outcome for either child or carer. expectations should be weighed up against an individual's clinical profile. poster no. neural correlates of conversion hemianaesthesia in an adolescent: a novel fmri case study m ray, a zaman, t alam leeds teaching hospital nhs trust, leeds, uk aim: to highlight the novel functional magnetic resonance imaging (fmri) findings in an adolescent with rare conversion hemianaesthesia. methods: we hereby report a right-handed y old boy who presented with inability to perceive sensations on the right half of body without any motor weakness causing him to have frequent injuries on his right leg as well as burns on his right hand without realizing. when he wore a jacket, he felt warm on one side of the body more than the other. his birth and developmental history were non-contributory. neurological examination was unremarkable except for right hemisensory disturbance. the mri of brain and spine, peripheral nerve conduction studies and somatosensory evoked potentials did not show any evidence of dysfunction were normal. he underwent fmri on a t philips achieva. the paradigm consisted of stimulating both the right and left hands and feet with three dissimilar stimuli (cold, brushing, pin-prick-pain) . the order of the stimuli was pseudorandomised and after each stimuli delivery, feedback was obtained. results: both the hand and foot sensory motor cortices were successfully stimulated. irrespective of which hand was being stimulated, there was left hemisphere sensory motor cortex dominance (with the brushing and cold stimuli), however selfreport from the participant confirmed detection of stimuli on the left-side only. there was more sensory-motor activation when the stimuli were delivered to the right hand. pain stimuli successfully activated parts of the 'pain matrix', furthermore enhanced attention effects (frontal pole activations) were observed with right-sided stimulation (supports lack of stimuli detection ability). the pain stimuli were more effective on the hands than foot, reflected by increasing activation and also self-report from the participant. conclusions: the fmri findings are unique and support the evidence of neuroplasticity and the current study paves the way for future studies investigating conversion hemianaesthesia. poster no. chronic paroxysmal hemicrania presenting as facial pain in a child with autism and bipolar disorder: diagnostic challenges case presentation: a boy diagnosed with disintegrative psychosis aged , revised to autism with bipolar disorder, had been on carbamazepine with risperidone for poor mood control. withdrawal of risperidone produced tardive oromotor diskinesia responsive to clonidine. aged , when mood improved on aripiprazole, carbamazepine was withdrawn. he then presented with episodes of distress preceded by withdrawal, unilateral but not side-locked facial flushing, with additional flushing of neck, back and wrists. behaviours included hitting wrists off walls, chewing of hard objects and requesting pressure to his head. episodes occurred - times/ day, lasting - minutes. he showed rhinorrhea and tearing, attributed to crying, during events. the attacks self-terminated. results: mri and electroencephalogram were normal. failed pharmacological trials included paracetamol, amitriptyline, gabapentin and oxcarbazepine. diclofenac provided mild pain relief and morphine reduced the incidence of attacks. reintroduction of carbamazepine resulted in improvement at mg/kg/day but did not eliminate pain. sequencing of scn a was normal. a plan to wean morphine alongside a trial of indometacin, initially at mg twice-daily was successful at mg twice-daily. episodes ceased, including all autonomic features. exacerbation at weeks occurred in context of an intercurrent illness and was managed with an additional dose of indometacin. conclusions: cph is underreported in the paediatric age group. in our case, the patient's inability to describe events, and an additional psychiatric diagnosis added complexity. the possibility of pain as a cause for early psychotic breakdown in a developmentally vulnerable child cannot be excluded. criteria emphasising side-locked headache and autonomic features, and not recognising associated symptoms elsewhere may also delay recognition in children. objectives: piih can be a challenging condition to diagnose and manage with risks of misdiagnosis, permanent sight loss and frequent comorbidities. we aimed to review our practice to identify areas of uncertainty to help formulate important questions to address within a clinical guideline. methods: a single centre retrospective case notes review of all cases referred to neurology with suspected piih (papilloedema confirmed by a consultant ophthalmologist in all cases) during an -month period. results: ( f: m) cases were identified. age range to years. mean years. / had a bmi > th centile. one case was referred to an obesity service. / had a comorbid headache disorder and / had anxiety/depression. all cases had neuroimaging ( mri, ct) with / having dedicated venography. in / cases lumbar punctures (lp) were conducted under general anaesthesia (ga). in / cases lp was not done; due to presence of a chiari malformation and due to procedural failure related to body habitus. intracranial pressure (icp) monitoring was done in one of these four cases. all children were treated with acetazolamide as first line therapy. frusemide, zonisamide and topiramate were also used in single cases. / children had repeat lps due to failure of resolution of symptoms. / cases had sight threatening piih with permanent visual loss in one case. / cases were discussed with neurosurgery. one child with evolving visual failure had an emergency ventriculo-peritoneal shunt. conclusions: important questions raised were: should all obese children with piih have access to a specialised obesity service? should all children have dedicated venographic imaging? how reliable is measuring csf opening pressure under ga? where lp is not possible should icp monitoring always be done? should repeat lps be done for persistent symptoms? should csf diversion surgery be restricted to cases of sight threatening piih only? objective: to describe a case of revesz syndrome due to a de novo missense variant in tinf . case report: a male infant was born at weeks gestation by emergency lscs due to maternal hypertension and reduced amniotic fluid. from week's gestation, reduced fetal growth was identified. the proband was born by at weeks. birth weight was . kg ( . th- nd centile) and occipitofrontal circumference (ofc) was . cm ( nd- th centile). he spent days in the scbu. he developed thrombocytopenia (nadir: /l), which resolved pre-discharge. periventricular calcifications on cranial ultrasound prompted torch screen and ophthalmology review. a right pre-retinal haemorrhage with overlying organised vitreous haemorrhage was identified, which remained stable on subsequent reviews. aged weeks, he was smiling, fixing and following with good head control. aged months, he developed new wobbly eye movements and was no longer fixing or following. bilateral retinal detachments were identified. ct and subsequent mri showed diffuse calcification within the thalami, posterior limb of the internal capsule, deep white matter, cerebellar atrophy and thin corpus callosum. findings on examination included ofc of . th centile, rotatory nystagmus and central hypotonia. whole-exome sequencing identified a pathogenic de novo variant in tinf (c. g>a, p.arg his). he subsequently developed thrombocytopenia and anaemia and is transfusion dependent. discussion: trf interacting nuclear factor- (tinf ), protein regulates telomerase and prevents telomere shortening. revesz syndrome is a severe form of dyskeratosis congentia, with multi-system involvement and early onset in-utero. revesz syndrome is characterised by intrauterine growth retardation (iugr), microcephaly, cerebellar hypoplasia, bilateral exudative retinopathy, intracranial calcifications and progressive bone marrow failure. revesz syndrome is distinguished from hoyeraal-hreidarsson syndrome by the presence of retinopathy. telomere disorders should be considered in infants with a background of iugr, thrombocytopenia, retinopathy and intra-cranial calcifications with a negative torch screen, as early features mimic congenital infection. objective: currently the most commonly reported neurological complication of sca is overt stroke. reversible cerebral vasoconstriction syndrome may be more frequent in patients with sickle cell anaemia than reported at present. the scarcity of prevalence studies however makes it difficult to improve diagnostic accuracy in these patients. methods: a -year-old ghanaian female was rushed to the paediatric emergency room with first episode of sudden severe global headaches initially started hours prior to arrival. the headache was so excruciating that she described it as her heart was beating in her head. there was associated neck pain, back pain, dizziness, and vomiting. there was no fever or dark urine. she was first diagnosed with sickle cell anaemia (genotype ss) at years of age after she was treated for dactilitis. she had since then been in her usual state of health with no history of blood transfusions or surgeries or admissions. she was compliant with her medications (folic acid mg daily). a physical examination and all investigations were also normal. on day six of admission patient had a generalized tonic clonic seizure with some degree of left sided weakness after having her bath. this was aborted with intravenous diazepam and a magnetic resonance imaging (mri) of the brain was requested. the mri of the brain revealed diffuse narrowing of the cerebral arteries with no areas of bleeding or oedema. reversible cerebral vasoconstriction syndrome was therefore suspected. results: the headache rapidly improved after starting nimodipine and repeat angiography at months showed no vasoconstriction, confirming the diagnosis. on follow up she is doing well academically with no neurological deficits. conclusions: the true incidence of rcvs in patients with sickle cell is uncertain, thus sensitizing medical practitioners is important. introduction: status dystonicus (sd) is a life-threatening disorder of generalised, painful dystonic movements and muscular spasm in patients with severe neurodisability. while rare, it may be complicated by rhabdomyolysis, multi-organ dysfunction, and death. infection, pain, gord, and medication failure are common triggers, but in approximately one-third of cases, sd is idiopathic. mordekar et al. ( ) identified a series of patients in whom sd occurred secondary to gi dysfunction. assisted feeding (e.g., via gastrostomy), and aberrant bowel peristalsis may trigger the onset of sd. this was a retrospective analysis which aimed to estimate an incidence rate for feed-induced sd (fisd). methods: patients presenting to sheffield children's hospital over a -year period with sd were identified. episodes were studied to assess for the nature of the onset of sd and as to the likelihood that the trigger was feed related. incidence of fisd as a proportion of total sd was calculated and or calculation performed to explore relative risk of sd between individual trigger factors. results: twenty-four individual episodes of sd were identified. ( %) arose from non-feed-related sources (nfisd), and were felt to be fisd ( %). additional patients were entered into a feed-induced dystonia (fid) group, whom showed clinical evidence of dystonia in relation to gi sources, but not sd. with the exception of infection, the relative risk of sd secondary to gi dysfunction was significantly higher than pain/gord and medication failure combined (or . ( % ci . - . ) and . ( % ci . - . ) respectively). conclusion: gi dysfunction coupled with severe neurodisability could serve as a trigger in a number of previously idiopathic sd cases through disruption of the neuro-enteric axis. however, overlap between triggers for fisd and nfisd, and significant variation between groups is evident, in addition to a lack of statistical study power. large, prospective studies are needed in the future to corroborate with these findings. poster no. dystonia can twist the patient, physician and the scans: hypermanganesemia, a rare cause of dystonia in children r kumar, s ali liaqat national hospital, karachi, pakistan introduction: manganese (mn) is a chemical element with symbol mn and atomic number . mn in the environment can cause toxicity with dystonia and other movement disorders. waterborne mn has a greater bioavailability than dietary manganese. according to results from a study, higher levels of exposure to mn in drinking water are associated with increased intellectual impairment and reduced intelligence quotients in school-age children. we have recently reported a suspected autosomal recessively inherited syndrome of hepatic cirrhosis, dystonia, polycythemia, and hypermanganesemia in cases without environmental mn exposure. the rarity of the disease can become a challenge for the physicians to recognize this as a cause of dystonia in children. it also has a characteristic finding on mri with t hyperintensity in basal ganglia rather than on t . case report: we present a case of a -year-old girl with dystonia who was previously healthy. she has been suffering from this for the last months and currently one of her years old sister started showing similar symptoms. physical examination revealed marked dystonia (score of on baryalbright dystonia scale) and polycythemia (haematocrit ). magnetic resonance imaging (mri) brain showed basal ganglia hyperintensity on t weighted images. hypermanganesemia was suspected and samples send for serum level which came out to be high. water samples were tested, which came out to be normal. chelation was done and the dystonia improved. conclusions: dystonia in children should be thoroughly investigated and rare, treatable causes should not be ignored. objectives: sodium valproate is used primarily for the treatment of epilepsy in children. it is a well-established teratogen, with in babies at risk of developmental disorders and in babies at risk of birth defects. this risk has been known since the s and yet it is estimated that since then children in the uk have been left with disabilities as a result. in , the medicines and healthcare products regulatory agency released guidance for its use, which included a risk acknowledgement form. patient safety alerts were issued in asking all organisations to identify females taking this medication. we aimed to identify all girls taking sodium valproate in the south eastern trust under paediatrics requiring annual risk assessment; patients under the additional care of a neurologist; patients receiving an annual review. methods: patients were identified through paediatric epilepsy nurse records and data collected through the electronic care record and medical notes from august to december . results: % (n= ) of girls with epilepsy currently taking sodium valproate, % under the age of years, % profound learning difficulties/disability and considered to be at low risk of pregnancy, % (n= ) potentially currently at risk, % were under the additional care of a neurologist, % reviewed in the past year. conclusions: sodium valproate must not be considered first line treatment in girls with epilepsy and > % of girls in our trust are not receiving it. of those receiving it, the majority are felt to be low risk due to young age and/or profound disability. we identified two patients at risk and steps were taken to ameliorate this. we have demonstrated good awareness; however lifelong education of families is crucial to reducing the burden of fetal valproate syndrome. rett syndrome (rtt) is neurodevelopmental disorder affecting approximately in - live female births, most commonly associated with mutations in the mecp gene. hand stereotypies and gait disturbance, as well as spasticity and dystonia, have been noted in rtt since the first descriptions of the syndrome. objective: this review aimed to explore the prevalence of reported movement disorders in rtt. data sources and extraction: pubmed and embase databases for papers describing features of movement disorders in rett syndrome. papers were selected for inclusion to be reviewed if they included description of case report, cohort or case-series of patients with rtt which included a description of clinical features of their movement disorder. selected papers were divided into epochs: (i) pre- , (ii) to , and (iii) onwards. results: studies ( in the first epoch, in the second epoch and in the third epoch) reported on movement disorders including stereotypies in rtt patients. hand stereotypies were almost universal in reported cases, diminishing but not disappearing over time. gait disturbance and ataxia/tremor were also very common (> % cases). elements of hypertonia were also common, increasing with age. in earlier descriptions spasticity was commonly described, with more frequent reference to dystonia/rigidity in more recent reports. myoclonus and choreoathetosis are uncommonly reported in rtt. conclusions: movement disorders beyond hand stereotypies are common in rtt, most notably tremor. hypertonia is a common feature seen in rtt, increasing in prevalence with age, and with an apparent change in nomenclature over time, (i.e., early epoch spasticity, late epoch dystonia). dystonia was specifically reported in / cases. further work is required to explore the relative contribution of dystonia and rigidity to hypertonia in rtt, as well as the impact of these impairments when present. introduction: headache is the common complaint in children, and the source of it, a great deal of worry for general practitioners and parents. one of the commonest causes of headache in paediatrics is migraine. methods: a prospective study was conducted to evaluate the demographic data, clinical spectrum and grading the child with migraine by using the paediatrics migraine disability assessment (ped-midas) questionnaire and to start prophylactic treatment for those with the higher grades in the department of paediatrics in tertiary care hospital. all children with migraine from age to years were included while all other types of headache cases were excluded. results: total children with migraine were studied. approximately % children complained of bilateral frontotemporal headache in which . % presented with throbbing type. other associated features were photophobia, phonophobia, nausea and vomiting. % had skipped meal, followed by altered sleep and exam stress as aggravating factors. . % required medication for headache relief. headache duration and frequency was approx. days and days/month. . % cases were diagnosed migraine without aura and . % cases were diagnosed as migraine with aura. loss of full school days due to headache was approx. days for period of months. based on ped-midas score, % of children with migraine had grade i disability while . % and . % cases had grade ii and grade iii disability respectively. correlation of ped-midas score with frequency and severity were significant (p< . ) while with duration of headache was insignificant (p< . ). conclusions: all patients with higher ped-midas grade are warranted prophylactic treatment. both ped-midas scores and grading can be successfully used for assessing the migraine disability and its easier, less time consuming, bedside diagnostic tool, can be used widely in routine clinical evaluation and management. objective: to review the cases referred to this uk-wide study of children with possible variant creutzfeldt-jakob disease (vcjd) and report the differential diagnosis in children presenting age years or older. methods: children meeting the case definition for progressive intellectual and neurological deterioration (pind) were identified via the british paediatric surveillance unit. details were obtained by standard questionnaire. results: between april and august , children had been notified to the study. were found not to meet the pind case definition. had an underlying diagnosis to explain their deterioration, with over different disorders including vcjd cases (the last identified in ). there were children who presented to clinicians when aged years or over, including all the vcjd cases. of the other disorders in this age group the commonest were: mitochondrial cytopathy , adrenoleukodystrophy , lafora body disease , huntington's disease , neuronal-ceroid lipofuscinoses , niemann-pick type c , metachromatic leukodystrophy , sspe , wilson's disease . when reviewed in there was no underlying diagnosis in pind cases; of them had diedonly underwent autopsy. the recent identification of the first patient with vcjd who was mv heterozygous at prnp codon reinforces the need for continued vcjd surveillance, particularly as a study of archived appendix samples from uk hospitals published in indicated that approximately in of the uk population is carrying abnormal prion protein in the gastrointestinal tract. in the absence of a validated vcjd screening test the pind study remains the only means of performing systematic surveillance of the neurodegenerative diseases that make up the differential diagnosis of vcjd. objective: transient lesions in the splenium of corpus callosum (scc) are rare findings in mri brain in paediatrics. in literature, it has been described as reversible splenial lesions syndrome (resles) and mild encephalitis/encephalopathy with reversible splenial lesions (mers). the condition has diverse aetiology and widely variable neurological presentation but the prognosis is usually favourable. we present two cases of resles with predominantly expressive dysphasia but varying causal associations. method: retrospective review of resles case series exploring clinical course, investigations, neuroimaging, treatment and recovery. result: case : a year-old-girl presented with confusion, fever and low oxygen saturation. she had alagille syndrome and partially corrected tetralogy of fallot. her neurological manifestations were expressive dysphasia, dysarthria and difficulties with spatial awareness. interestingly she was able to use occasional words that were abusive in nature. mri showed prominent focus of abnormal signal and restricted diffusion in scc. her blood culture grew staphylococcus aureus and echo revealed infected shunt. treatment involved shunt replacement and prolonged iv antibiotics. repeat mri showed resolution of splenial lesions. she continued to improve neurologically. case : a year-old-girl presented with paroxysmal episodes of head turning, head drop and staring for a few seconds. she refused to feed. she showed emotional lability with expressive dysphasia but preservation of expletives. neurologically she was intact. mri brain showed high signal with restricted diffusion in scc. her blood and csf investigations including mog, aquaporin, nmdar, lyme antibodies were negative except asot was . her eeg was normal. she received a course of ivig and azithromycin. her repeat mri showed resolution of the lesion in splenium. she made complete recovery over next few months. conclusion: splenial lesions are rare but clinically significant but not 'non-specific'. expressive dysphasia is a prominent symptom. awareness of resles/mers will avoid unnecessary investigations and assist in the prognostication. background: the evidence-base on managing paediatric-headaches is sparse resulting in wide variation in practice with nice guidelines commencing over years of age. this study aims to evaluate outpatient management of paediatric headaches. objective: to investigate paediatric headache referrals to a tertiary hospital over a -year period, exploring patient demographics, headache type, role of neuroimaging, management and outcome. methods: this prospective study reviewed headache referrals for the year - . the data was collected following weekly emails to relevant clinicians. the patient demographics, headache classification, imaging, management and outcome were collated on a proforma from the electronic patient-records. results: there were patients. the median age of patients at first outpatient appointment was years (range - y); . % were female. incidence of headaches increased with age. female preponderance of headaches existed in all age groups and was most substantial post-puberty with a . : female-to-male ratio in patients aged to years. migraine was the most common diagnosis, affecting . % of patients. % of referred patients underwent a brain mri scan, all of whom had a normal neurological examination. no mri scans found pathology contributing to headache presentation. % of patients were discharged from neurology clinic after first or second neurology appointment. non-pharmacological management was the most common intervention and consisted of: headache diary, lifestyle advice, education, relaxation techniques. the most common medications prescribed bar simple analgesia were sumatriptan ( %), propranolol ( %) and pizotifen ( %). conclusions: a multidisciplinary and biopsychosocial approach to managing paediatric headaches, consisting of non-pharmacological and pharmacological methods resulted in a positive outcome, with majority discharged from tertiary care after first appointment. prescription of sumatriptan and propranolol first line for acute and prophylactic management respectively, was in accordance with current clinical recommendations. the role of mri scanning for paediatric headaches requires further exploration and perhaps more stringent guidelines. objective: the head-up tilt test (hutt) is the gold standard autonomic function test for identifying disorders of blood pressure (bp) and heart rate (hr) regulation, specifically with excessive falls in bp and or hr, as well as excessive postural tachycardia (pt). the minute active standing test (ast) is quicker and easier to apply, e.g., in an outpatient clinic, and may be more sensitive in demonstrating pt. we aimed to compare the yield of these abnormalities when using ast vs hutt. methods: this was a retrospective, clinical notes review, and registered clinical audit of unselected consecutive children and young people undergoing hutt immediately preceded by an ast. results: data was available on children and young people, ( %) female, aged to years (median ). / ( %) with complete data sets for the first minutes of hutt and the ast had abnormally large drops in bp and or hr on hutt. only / positive on hutt was also positive on ast. however, an additional / ( %) were positive on ast but not on hutt, giving / ( %) positive in total. / ( %) with hr data sets for minute hutt and ast had abnormally large rises in hr on hutt. only / positive on hutt were also positive on ast. however, an additional / ( %) were positive on ast but not on hutt, giving / ( %) positive in total. while hutt yielded more cases with significant falls in bp and or hr than ast ( % vs %), combining the tests gave the highest yield ( %). while ast yielded more cases with significant rises in hr than hutt ( % vs %), combining the tests gave the highest yield ( %). conclusions: we recommend routinely undertaking a minute ast prior to the minute °hutt, in children and young people. objective: the aim of our work is to describe the respiratory function trajectories and their correlation with motor function in a cohort of spinal muscular atrophy type and non-ambulant sma paediatric patients. methods: this is a retrospective -year study in patients recruited in the ismac natural history study (uk, italy, us). the following respiratory data were collected: lung function data (forced vital capacity absolute (fvc) and fvc% predicted, non-invasive ventilation (niv) requirement. recumbent or ulnar length were used as surrogate for height in fvc%pred. calculation. comorbidities affecting lung function such as aspiration were collected. anthropometrics and motor function scores as hammersmith functional motor scale (hfms), revised performance of upper limb (rulm) were noted. we excluded patients in interventional clinical trials and nusinersen therapy. results: data were available for patients: sma , sma . mean age at first visit was . (ae . ) and . (ae ) years for sma and . / ( %) sma and / of significant lesions. a review of practice of asking routine or non-urgent mri requests should be considered in view of an unlikely significant result. retrospective review of brain magnetic resonance imaging referrals in children less than years (r[ ] ) is an ultrarare disease characterised by drug-refractory epilepsy, cognitive impairment and behavioural problems. non-pharmacological treatments should be considered alongside antiepileptic drugs (aeds) early after diagnosis to benefit prompt seizure control and preserve cognitive function. we aimed to understand the use and experience of ketogenic diet therapy (kdt) in r( ) by patients families carers (pfcs) and healthcare professionals (hcps), assessing its efficacy and safety, and contrasting nhs kdt service provision with patient demand. methods: literature searches were conducted on use of kdt in r( ) and similar complex epilepsies. two surveys were developed to gather demographic, diagnostic and clinical care information. surveys were qualitative and descriptive with patient and expert collaborators assessing content accuracy and readability. responses were discussed at a patient and expert workshop. results: the number of responses ( pfcs, hcps) was considered significant given the ultra-rare status of r( ). % of pfcs had tried kdt. seizure activity, behaviour and cognitive outcomes were ranked equally important by hcps and pfcs. significant improvement in seizure activity, cognition and alertness were reported; side-effects were typically mild but with one report of increased seizure frequency. the high rate of comorbidities, older age at presentation, behavioural problems and cognitive impairment can make implementing kdt in r( ) challenging. pfcs report quality of life would be most improved with reduced aed side-effects; hcps report they would consider reducing or withdrawing aeds where kdt is successful. conclusions: kdt may not be suitable for every r( ) patient, but there is a strong consensus that it should be considered as an early intervention. in the uk, nhs kdt services are predominantly available for paediatric patients, with very limited adult access. a detailed health economic analysis illustrating reduced acute care costs and improved quality of life may encourage more widespread kdt implementation. objectives: whole exome sequencing (wes) with a -week result turnaround time has become available on the nhs for children in an intensive care setting. we aimed to determine the diagnostic utility and impact on clinical care of wes in a regional paediatric neurology centre. methods: retrospective case notes review. results: six cases ( m, f) were identified. three patients were dependent on long-term respiratory support. a pathogenic mutation was detected on wes in / cases ( %). one case required 'reverse phenotyping' with an abnormal transferrin glycoform electrophoresis confirming that two heterozygote variants of the rtf gene were consistent with a congenital disorder of glycosylation (cdg). no other variants of unknown significance were found. three children presented with neonatal onset epileptic encephalopathy (two cases had scn a, one case wwox), one child with intractable epilepsy from months of age (rft mutation associated with cdg) and one child with hypotonia and ventilator dependence after a respiratory infection at months of age (ighmbp mutation associated with spinal muscular atrophy with respiratory distress). wes found no pathogenic mutation in a -year-old with intracranial calcification, microcephaly, epileptic encephalopathy and severe developmental regression. in / cases other single genes/panels had been sent prior to initiation of wes with multiple single genes/panels sent in / cases. in / cases wes detected the gene thought most likely based on clinical phenotyping on the request form. conclusions: wes has a high diagnostic yield in this cohort of patients. reaching a prompt diagnosis facilitated withdrawal of care in one case (ighmbp ) and helped to exclude an epilepsy surgery hypothesis in four cases as well as guide prognosis in all cases. wes should be considered as a cost-effective alternative when multiple single genes and/or genetic panels are being sent off in parallel due to clinical urgency. objective: the care provided in the time surrounding the death of a child shapes long-term memories and has potential to impact on the grieving process. there are no specific guidelines for picu staff in relation to what good care looks like at this time. we sought insight into practice across the uk to build an evidence base, improve care provided and share good practice. conclusions: from the survey feedback, we found this was an area that all units believe can be improved. in relation to acps, we hope this will be more widely introduced. we know that % of patients admitted to picu are life limited. these difficult conversations with family help guide management, understand wishes, and formal documentation ensures all staff are aware. several units with higher uptake of hospice/home care found early conversations with families beneficial. units with a dedicated palliative nurse stated this allowed more time with families. we believe this should become a standard of care. staff training is limited in most units. for something so difficult and frequently encountered, it is vital we equip staff better. prioritising children with epilepsy in the first seizure clinic cp white, s brown, ka hapgood, s tuohy children's epilepsy service, morriston hospital, swansea, uk objective: rising demand for limited first seizure clinic appointments was leading to increasing waiting times and the feeling that children with epilepsy were waiting too long for their first assessment. concern was also expressed that families were not receiving our first seizure leaflet or given instructions about capturing any further episodes either on video or by making a written record when initially seen. methods: from april all families were sent a letter acknowledging the referral and asking them to contact the specialist epilepsy nurse if they had any concerns prior to the appointment. later modifications included a seizure information leaflet and a seizure record document. we have analysed the results of the first year of using this system. patients were identified from the clinic database and further information was obtained by reviewing clinic letters. results: our initial concern that the specialist nurse would be inundated with phone calls from worried parents were not realised as only % ( / ) of parents contacted the service before their appointment. these were invariably parents whose children had had a second episode ( / ). had had further generalised tonic clonic seizures. children had eegs performed before their first appointment. this included all the children given a diagnosis of epilepsy. % of these children ( / ) were given a diagnosis of epilepsy made compared to . % of other referrals (p< . ). although a higher percentage of families who were reminded about videoing any further episodes did so the difference between the two groups was not statistically significant. unfortunately, overall waiting times were not affected. conclusions: a simple change to the way in which the service is delivered has led to earlier identification of those children with epilepsy. we are looking at other ways of improving the accuracy and timeliness of the appointments. introduction: paediatric idiopathic intracranial hypertension (iih) is an uncommon disorder and presentation is varied with children presenting to paediatricians, paediatric neurologist, and ophthalmologists. there are many areas of diagnosis and management where evidence is limited. a national adult evidence and consensus-based guideline was published in . no national paediatric guideline exists to aid the further investigations and management of the cases. the iih meeting at the bpna conference in and january set the scene for collaborative work on this topic. aim: to develop a national paediatric iih guideline based on the available literature such as modified dandy criteria, friedman classification and icdh- classification and consensus amongst various members of bpna chan group, members of rcpch, ophthalmology, neurosurgery and radiology, and patients. methods: a core children's headache iih guideline development group was established and has met at four national special interest group meetings between november and september . topics discussed include incidence of papillioedmea, csf dynamics in iih, bpnsu iih data, ophthalmology good practice, regional iih pathways in uk and setting up of the delphi process. the paediatric iih study day in september with invited patient/parent representatives highlighted the impact on families with the disorder with need for better communication about the disorder, clear guidelines and sharing of good practice amongst clinicians. an email list of bpna chan group, rcpch members, ophthalmologists interested in the guideline was created. results: a set of statements were drafted for delphi consensus work. these are currently being reviewed by the core guideline development group prior to being circulated to the wider working group. conclusions: goal setting for the next process with the delphi process to work with the core committee and a wider working group will be presented at the bpna conference . objective: nhs england's marginal rate emergency threshold (mret) and readmission fund funded the chameleon project (twitter account: @chameleonproje ), to improve children's end of life care. this funded a lead disability paediatrician with expertise in paediatric palliative care ( h/wk), a children's palliative care nurse ( d/wk) a network administrator ( d/wk), and additional hours for paediatricians in the critical care, oncology, and neonatal units, and in each of the local district general hospitals (total h/wk). methods: tools were developed to aid identification of children in the last year of life and to support anticipatory care planning. the team attended ward rounds and provided teaching sessions, advice and support. children who died an expected death in the months of the project were ascertained from the child death review teams. non-elective admissions, bed days, and costs were tabulated. we also evaluated the documentation of care plans and post bereavement family feedback questionnaires. results: children died an expected death. the same number died during the previous months. the median number of non-elective admissions reduced from to per child, specialist ward bed days reduced from to ( % reduction). for children admitted to picu in the last months of life, the total picu bed days reduced from to ( % reduction), the median length of stay reduced from days to days, and the maximum length of stay reduced from days to days. the percentage of children who died an expected death who had documented anticipatory care plans rose from % to %. conclusions: the network of clinicians with expertise in paediatric palliative care working together across a region improved anticipatory care planning and reduced admissions and bed days for children in their last year of life: better care with reduced costs. child a, a boy with speech and language delay, presented at years of age with self-resolving episodes of floppiness, ataxia, and disorientation. there was associated muscle weakness and drooling. these unusual episodes occurred to times per week and were often triggered by excitement, especially physical and emotional overstimulation. they lasted from a few minutes to an hour, with no residual deficit. episodes could also be triggered by having late meals (fasting episodes). investigations including an mri/mra brain, eeg, sleepdeprived eeg and video telemetry did not reveal any significant abnormalities. metabolic and endocrine tests were normal. as his presenting symptoms were consistent with episodic ataxia, possibly a periodic paralysis spectrum, a trial of acetazolamide was given, which showed some improvement in the number and severity of the episodes. at years of age, genetic sequencing results revealed child a has a recessive kb deletion within the long arm of chromosome , band q . . this is a homozygous intragenic deletion within the tango gene. tango is a 'transport and golgi organization ' homolog. the function of tango is unknown; however, in previous studies, depletion in drosophila s tissue culture cells was observed to cause fusion of the golgi with the er. a recent study of individuals with tango , illustrated that child a has a clinical phenotype which is consistent with those previously reported in the literature. although seizures are present in % of individuals with tango , child a has not had any seizures to date. although no effective treatments for this rare condition are known, early diagnosis is important so that individuals and their families are aware of the potential encephalomyopathic crises and arrhythmias which occur. further research in elucidating the structure and function of the tango protein may lead to effective therapies in the future. objective: hie affects around . / live births. prognostication relies on clinical progress, neurophysiology, neurological examination, and magnetic resonance imaging (mri). there is limited information on the relationships between mrs brain results and visual appearances of the brain on mri and clinical features. this work studied the use of mrs in this cohort. methods: mrs is used routinely in all neonates with hie in our unit, so approval for this service evaluation was obtained from our clinical governance department. we identified neonates with hie between jan and march who had mri and mrs in the first days of life. medical notes were reviewed, and mri results categorised as normal or abnormal. mrs results and clinical features were compared between mri groups using parametric or non-parametric testing. correlation and regression analyses studied relationships between clinical features and mrs results. p-values of < . were assumed to be significant. results: participants were identified, were excluded because they did not meet our inclusion criteria. data from a total number of neonates were analysed using r studio. babies with abnormal mri scans had significantly lower birth weight (p= . ), gestational age (p= . ), and higher scores in the sarnat staging scale (p= . ). the analysis of the mrs data also revealed that these babies had lower levels of n-acetylaspartate (naa) in their parieto-occipital region (p= . ), as well as higher levels of lactate and lactate to choline both in the parietooccipital region (p= . and p= . respectively). finally, these significant mrs variables were significantly correlated with time to normalisation of lactate in single linear regression. background: more children and young people are surviving with an acquired central nervous system injury (traumatic or non-traumatic). the first nhs england (nhse) specialist specification for paediatric neurorehabilitation services was written in . evidence for benefits of early neurorehabilitaion after adult stroke are compellingevidence for early neurorehabilitation in cyp is emerging. methods: service information was collected from all england and wales pnr units in . results: / units contributed. activity is increasing ( ( / ); ( / ); ( / ). / ( %) are major trauma units ( %) have dedicated coordinators. several units cannot offer daily therapy. most units discharge cyp home. conclusions: considerable neurorehabilitation in-patient activity is taking place but there remains an absence of secure funding, adequate staff, dedicated beds, key members of the mdt, protected time for pro-active patient specific discharge planning. neurorehabilitation is an integral part of the neuroscience clinical pathway and our children deserve a fully resourced service as described in the service specification. tuberculosis/sarcoidosis ( ). out of the sub-categories, the group of refractory seizures/status epilepticus were most likely to have repeated imaging with either ct or mri within years ( %), followed by the group of ventriculo-peritoneal shunt blockage ( %), space occupying lesion ( %) then head injury ( %). out of patients with refractory seizures/ status epilepticus, were already known to have epilepsy. also, most repeated imaging included a subsequent head mri. conclusions: most common indications for ct head were head injury and shunt blockage (as this was a neurosurgical centre). the groups most likely to have repeated imaging were refractory seizures/status epilepticus and shunt blockage. with children presenting with known epileptic seizures in the emergency department, it is important to consider clinical data and seek to devolve decision to image. poster no. isolated radial nerve palsy, a rare presentation of congenital wrist drop c duggan, n mcsweeney cork university hospital, cork, ireland isolated congenital radial nerve palsies are a rare phenomenon and typically spontaneously recover within months. the true incidence is not known, but in a recent study . % of infants presenting to a brachial plexus injury clinic had an isolated congenital radial nerve palsy. patient a is a -week-old male who presented at birth with a left sided wrist drop following a non-traumatic elective caesarean section at + / . his birthweight was . kg ( st centile). movement of the wrist and digits were impaired to absent with preservation of function at the shoulder and elbow. there was a nodule noted in the left upper limb, anatomically superficial to the radial nerve. it was a normal pregnancy with no antenatal or postnatal issues. he attended physiotherapy and occupational therapy who provided a splint. on examination at weeks, there was weakness of the extensors of the left wrist. the rd, th and th digits remained fully flexed at rest and could be extended passively but not actively. extension of the thumb and index finger had recovered at -week review. function at the shoulder and elbow joints were preserved with normal flexion of the wrist and digits. a scar was noted superficial to the radial nerve at the same location as the lesion described at birth. the remaining systemic and neurological examinations were normal with typical development and appropriate growth. the working diagnosis at present is an isolated radial nerve palsy likely caused by in-utero compression. the nodule and scar noted above are consistent with lesions described in a previous case series. these were hypothesised to be areas of fat necrosis secondary to compression; resulting in the palsy. patient a's lack of further neurology such as a generalised brachial plexus palsy makes a birth injury less likely. further investigations and follow-up are awaited. background: valproate is an effective antiepileptic medication. if a woman becomes pregnant while taking valproate, her baby is at risk of congenital malformations ( in ) and developmental disorders ( in ). furthermore, it is associated with an increased risk of autism spectrum disorder and adhd. in , the nhs/hse recommended new restrictions on the use of valproate, including a national pregnancy prevention program (prevent) and avoidance in prescribing to female patients of childbearing potential unless other treatments are ineffective or not tolerated. objective: to review the use of valproate in a well-defined population of at risk females with moderate to profound intellectual disability (id). identify the patients at risk and imbed the guideline into our practice. methods: a retrospective chart review was carried out of all girls aged between and years, attending the daughters of charity disability service (doc) in dublin, ireland. data such as diagnosis, valproate use, degree of id/gross motor function classification system (gmfcs), documentation of menarche and discussion regarding risk of valproate use were recorded. results: in total females aged between and years where identified as currently using valproate out of charts reviewed ( %). of the patients identified, / had moderate id (gmfcs iii) and / had severe to profound id (gmfcs iv-v). / had menarche documented. / had the risk of valproate discussed. conclusions: in our cohort, a significant number of girls remain on valproate. % complied with new guidelines regarding discussions around the risks of valproate; highlighting the % of patients in need of counselling. an annual risk acknowledgement form was placed in their charts to prompt discussion next visit. in children with intellectual disability, conversations regarding contraception are difficult but essential. if valproate is used, then the risks must be fully understood by parents and carers. evaluation of the management of children up to age of years with cerebral palsy in southend university hospital large district university general hospital against nice guidelines (nice guidelines ng ). methods: clinic notes of all registered children with cerebral palsy (cp) up to years of age as of june were included in the study. this was because there was no early data on children above years age. results: patients were age to years and patients age to years. were male and females. had hemiplegic, quadriplegic, diplegic and dystonic cp. only ( %) had gmfcs levels recorded. ( %) were < weeks, ( %) were to weeks and ( %) were term. mri head findings: white matter changes including pvlin ( %), ( %) hie changes, ( %) basal ganglia changes, ( %) congenital brain malformation, ( %) infarction. migrated to area with no mri report. all the children received multidisciplinary team (mdt) input including physiotherapy. comorbidities werechildren on medications for gastro-esophageal reflux - (with peginsertions). for epilepsy - , for dystonia/spasticity - , for constipation - , for poor salivary control - . behavioral issues noted in and was on adhd medications. had botulinum toxin injections and had selective dorsal rhizotomy for spasticity. documented discussion of diagnosis with family was in ( %) patients and none in patients ( %). only % patients had vitamin d levels checked. conclusions: management was in line with nice guidelines. they all had mdt input. there is a need to improve documentation of -evidence of discussion with parents, gmfcs level by age ½ years plus, hip surveillance from age years for gmfcs level iii to v and annual vitamin d levels especially for gmfcs level iii to v, peg fed and children on multiple anti-epileptic medications. poster no. intracranial hypertension in children: an updated systematic review l di genova , n desai , s esposito , p prabhakar pediatric clinic, department of surgical and biomedical sciences, universit a degli studi di perugia, perugia, italy; department of paediatric neurology, great ormond street hospital nhs foundation trust, london, uk; neurosciences, great ormond street hospital nhs foundation trust, london, uk objective: our goal is to provide an overview on paediatric intracranial hypertension. methods: given that the last update of the diagnostic criteria of idiopathic intracranial hypertension was published in , a thorough medline search of all english articles was conducted between and . results: intracranial hypertension may be primary, with a paediatric annual incidence ranging between . and . per children or arise from a secondary cause. misdiagnosis or delayed intervention can lead to poor quality of life and morbidity. in , this condition was reconsidered, due to new accepted values for opening pressure and advances in neuroimaging; the importance to develop effective therapeutic strategies in order to prevent blindness was thus highlighted. to date, the main strategies described involved both medical and surgical approaches; nevertheless, there have been no paediatric intervention studies. disease monitoring plays a key role in the definition of the best timing and modality of treatment. recently, a risk stratification has been proposed with the aim to facilitate an adequate evaluation and proper care of children with intracranial hypertension: visual monitoring could represent an objective tool to manage these patients. in recent years, important evidence for the efficacy of acetazolamide emerged in the idiopathic intracranial hypertension treatment trial. surgical treatment is the modality of choice in children with worsening vision impairment, intractable headaches despite maximal medical management or in case of intolerance to medical therapy. conclusions: there are poor evidences about paediatric intracranial hypertension's outcomes. unfortunately, children's quality of life is heavily influenced by pain and permanent vision loss. standardized therapeutic strategies remains uncertain, highlighting the need for longitudinal studies to identify the best treatment in childhood. in order to alleviate symptoms and prevent permanent chronic sequelae, careful clinical evaluation and ophthalmological monitoring could be a useful guide to better manage this medical condition. objective: cerebral sinovenous thrombosis in childhood is a life-threatening neurological entity with uncertain epidemiology, potentially complicated by secondary intracranial hypertension. in the literature, there is a lack of evidence supporting the main strategies to approach both these medical conditions. our objective is to highlight the value of a prompt diagnosis aiming to define a tailored management approach based on children monitoring. methods: we review the main findings regarding cerebral sinovenous thrombosis and intracranial hypertension in children through illustration of a case with otogenic sinus thrombosis and secondary intracranial hypertension. results: a -year-old boy developed a local venous sinus thrombosis because of the spreading of a primary infective process from his middle ear into the sigmoid sinus complex, facilitated by anaemia and dehydration. the venous outflow disturbances led to secondary intracranial hypertension. the management aimed to treat cerebral thrombosis with anticoagulants and intracranial hypertension through medical and surgical strategies. the insertion of the lumbar-peritoneal shunt was necessary when medical approached failed and visual function deterioration was evident. careful clinical evaluation and ophthalmological monitoring helped us in the tailoring of the best treatment with the aim to alleviate symptoms and prevent sequelae of increased intracranial pressure. in the literature, no paediatric intervention studies regarding the main strategies to reduce intracranial pressure have been published. moreover, there is a lack of evidence supporting the safety of anticoagulation therapy, reducing the possibilities to safely manage cerebral thrombosis in childhood. conclusions: in children, a multidisciplinary approach is essential to manage both cerebral thrombosis and intracranial hypertension and ensure an optimal follow-up, aiming to prevent visual and therapy-related complications, possible relapses and their early diagnosis. from our perspective, monitoring our patient with clinical manifestations and visual status helped us to plan the best timing and modality of treatment and intervention. yearly rate of progression of fvc% predicted (available in n= ) was . % in sma and . % in sma . in sma , fvc% predicted declined steeply from to years of age, followed by a levelling. conversely, in sma patients fvc% predicted declined slower but steadily from years of age. / ( %) sma and / ( %) required non-invasive ventilation due to respiratory infections or hypoventilation conclusions: the results of this ongoing collaborative work suggests that in sma and lung function declines from age and respectively. lung and motor function correlate well in both sma and . this data will help the assessment of the long-term efficacy of new treatments for sma this review aims to study the appropriateness of mri brain referrals following implementation of local changes to improve compliance to the nice cg standard. methods: following an earlier survey (es; / / - / / ) of mri brain referrals for headaches in children over years, key recommendations included adding pop-ups in the neuroimaging request system (ice) of nice cg and headsmart clinical guideline v as well as verbal consent obtained from senior paediatrician before request was made. following these implementations, requests for mri brain were analysed during / / - / / in the same district general hospital. referral was deemed compliant if the nice guideline cg standard were met. results: children were referred for mri brain scan (mean / month vs /month in es). ( %) referrals were compliant (vs % compliance in es). ( %) referrals were 'urgent' (vs % urgent es) and ( %) 'routine' or non-urgent (vs % routine es). ( %) of urgent referrals (vs % es) and ( %) of routine referrals (vs % es) were compliant mri brain guidelines for neuroimaging in less than years exist (headsmart clinical guideline v and nice epilepsy qs ) but are limited. this study aimed to assess current practice of mri brain referrals in children under years. methods: retrospective review of mri brain referrals in children under years performed between mri brain scans were done (m:f . : ) ( %) referrals under headsmart and ( %) of these were urgent requests; significant brain abnormality was seen in ( %) in urgent and ( . %) in nonurgent cases. ( %) referrals under epilepsy qs and ( %) were urgent requests; significant brain abnormality in ( %) in urgent and ( %) in non-urgent cases. ( %) were miscellaneous requests and ( %) were urgent; significant brain abnormality in ( %) in urgent and ( %) in non-urgent cases. overall mri brain showed significant abnormality in urgent requests ( %) compared to non-urgent requests ( %) poster no. investigating factors that influence unplanned admissions and a&e attendances in those with pre-existing neurological conditions in childhood s dowsell , k kananaviciute , r parslow , am childs university of leeds, leeds, uk; paediatric neurology, leeds general infirmary, leeds, uk objective: previous papers have shown increasing demands and costs to the nhs in relation to the inpatient care of children with neurological conditions. unplanned admissions may reflect a lack of effective care and have been shown to correlate with high outpatient clinic did not attend (dna) rates . the aim of this study was to determine factors underlying unplanned admissions and accident & emergency (a&e) attendances in a cohort of patients under the care of the leeds regional paediatric neurology service over a -year period. methods: all children < years who had paediatric neurology outpatient appointments in were identified using hospital databases. clinical and demographic data was extracted from electronic case notes. those without a definitive neurological diagnosis or who had moved to adult services during the study period were excluded. the cohort was cross referenced to a&e databases and admission records from to . poisson regression was used to identify any correlation between specific predetermined factors to assess their influence on a&e attendance and admission rates. results: a cohort of patients was established and had a total of unplanned admissions during the study period. patients had a&e attendances with a total of attendances. higher dna rates, younger age and certain diagnostic categories correlated with increased rates of unplanned admissions. the role of emergency care plans in preventing admission was unclear as only / patients with epilepsy had care plans in place. conclusions: this study confirms the association between increased rates of a&e attendances and unplanned admissions in children with specific neurological disorders and high dna rates. this is relevant for service planning as it highlights the need to target scarce resources towards 'higher' risk patients with more complex diagnoses where more integrated care and support may prevent or reduce unplanned hospital attendances.poster no. audit comparing great ormond street hospital headache clinic diagnoses and management of patients aged to years to nice clinical guidelines a ward , , p prabhakar neurology, great ormond street hospital, london, uk; university of glasgow, glasgow, uk introduction: between / / and / / the gosh headache clinic saw new patients aged to years. the nice clinical guideline (cg ) on the diagnosis and management of headaches in over s covers tension-type headache, migraine, cluster headache and medication overuse headache. this audit aims to compare gosh diagnosis and management to those of the cg . methods: using the patient list from the headache clinic data was gathered by accessing outgoing clinic letters via epic. raw data was collected on; age, gender, description of headache (pain location, quality, intensity, duration and frequency) and associated symptoms, triggers, previous imaging, previous and current treatments. the management data collected include: diagnosis and treatments offered, as well as whether gosh offered lifestyle advice, psychology, occipital nerve block or riboflavin. this data was then compared to cg . results: ( . %) of diagnoses made by gosh matched the cg diagnosis. ( . %) diagnoses differed, with of these due to discrepancy between chronic/episodic and/or presence of aura and due to the vague diagnoses of migraine-type, new daily persistent, migrainous etc. fitting the cg definition of chronic migraine. all but one patient was managed in line with the guidelines. . % of patients had brain imaging prior to attending the clinic, with . % of these reporting positive findings. discussion: despite patients' diagnosis differing between gosh and cg , all but one patient was managed in line with the guidelines. this is likely due to nice recommended management being the same for any type of migraine. improvements could be made in documentation of frequency and duration of headache and aura, as well as more routinely offered lifestyle advice, psychology and riboflavin recorded in outgoing clinic letters. objective: to review the purpose of ct head requests from emergency department of a busy tertiary hospital as part of quality improvement. due to increasing evidence of ct scan radiation predisposing to leukaemia and brain tumours, it is best to keep ct scans to the minimum if clinically indicated. this project reviewed the indications for ct head and also looked at patients who had repeated ct or mri head scans within years. methods: data was collected retrospectively looking at a snapshot period of months between september-november . patients were < years of age and they had a ct head from emergency department at king's college hospital, london. trauma patients were excluded. data was collated with aid of the neuro ct department 'cris' system. results: out of patients, reasons for ct included: head injury ( ), ventriculo-peritoneal shunt blockage ( ), refractory seizures/status epilepticus ( ), space occupying lesion ( ), orbital cellulitis ( ), intracranial haemorrhage ( ) objectives: mutations in kif a are associated with a wide range of neurological disorders, ranging from hereditary spastic paraparesis (hsp) to sensory neuropathies to a severe infantile neurodegenerative disorder. collectively, they are extremely uncommon but likely to be under-recognised. we aim to report the spectrum of kif a-related disorders from a single tertiary neurology centre, with a view to improving understanding and awareness of these rare conditions. methods: affected individuals known to great ormond street hospital were identified through liaison with consultants involved in the care of children and young people with movement disorders. clinical information was collected through a retrospective review of case notes. results: twelve individuals in families were identified. all had heterozygous kif a mutations including three previously unreported variants. severity ranged from a fatal neonatalonset disorder with contractures, absence of visual development, and agenesis of the corpus callosum on mri to hsp with preservation of ambulation into the second or third decade of life and entirely normal mri. upper motor neuron signs were found in / children and a primarily sensory neuropathy was present in / children assessed. / children also had extrapyramidal signs (dystonia). some degree of learning difficulties and/or disorders of mood or behaviour were present in all children. optic atrophy, mr brain white matter changes and epilepsy were also common, especially in those children who were more severely affected overall. conclusions: kif a related disorders are so diverse that it is arguably misleading to consider them as a single disease entity. features common to the majority of affected patients include upper motor neuron involvement, and neuropathy (even in the absence of an obvious sensory deficit), with high risk of other neurological and neurobehavioural comorbidities. objective: ataxia with oculomotor apraxia type (aoa ) is a slowly progressive, autosomal recessive disease characterised by the triad of ataxia, oculomotor apraxia, and sensorimotor neuropathy that results from mutations in the gene encoding senataxin (setx), a dna/rna repair protein essential for genomic stability. we investigated a -year old male with a history of unsteady gate for genetic and molecular changes associated with aoa . in this report we describe a case of aoa with two clear pathogenic setx mutations, one of which is novel, as well as two further setx changes likely to be in cis polymorphisms that have previously been reported as pathogenic. methods: two independent lymphoblastoid cell lines obtained from the patient were used for western blotting of senataxin and protein markers of other autosomal recessive cerebellar ataxias. the setx gene was sequenced to identify possible disease-causing mutations. results: western blotting showed reduced levels of senataxin. serum afp level was elevated at lg/l (normal . - . lg/l). genetic sequencing revealed two clear pathogenic setx mutations. one of these was a novel mutation, c. delg; p.(cys phefster ), a deletion causing a reading frameshift resulting in truncation and loss of expression of senataxin protein from this allele. the other, c. c>t; p.(pro leu) was a missense mutation within the helicase domain which has previously only been reported in the homozygous state in a japanese aoa patient. two further sequence changes, c. a>g; p.(asn asp) and c. c>a; p.(gln lys), were also identified in our patient. conclusions: the reduced senataxin expression and elevated afp levels support a diagnosis of aoa in our patient. genetic analysis found a novel pathogenic mutation and documented the first case of another pathogenic mutation in the helicase domain outside of japan. the case contributes to the growing diversity of setx mutations known to be responsible for aoa . key: cord- -i q gsu authors: nan title: (th) european congress of trauma and emergency surgery: may – , antalya, turkey date: - - journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: i q gsu nan introduction and aims: although liver is well protected by the thoracic cage, it is a frequently injured organ especially by penetrating traumas and also rarely by blunt traumas. retroperitoneally located pancreas and duodenum injury with or without liver injury occur rarely but they are seriously life threatening injuries. for these reasons we aimed to investigate the traumatic liver, duodenum and pancreas injuries as a whole. materials and methods: cases of blunt and penetrating traumas occured in our district are included in this study. in these patients parameters of sex, age, etiology, admission time, stability and physical status on admission, concurrent organ injury, operation type, gradings of injuries, were investigated. results: cases ( , %) suffered from liver injury, while cases ( , %) suffered from hepaticopancreaticoduodenal injury. cases ( %) were caused by penetrating injuries. cases of liver injury group had isolated liver injury whereas cases of the group has additional thoracic injury, cases had great vessel injury, case had orthopedic injury and lastly case had head injury in addition to the liver injury. in the combined hepatic injury group mortality rate was , %. conclusions . in hepatoduodenopancreatic injury group blunt and penetrating injury rates are equal. . duodenum-pancreas injuries occur rarely. liver,with injury rates of cases in this study, is the most frequently injured organ. . mortality rate is higher in the subgroups of patients who admitted to hospital late, and who had concurrent thoracic, orthopedic, and head trauma. background: the incidence of blunt bowel and mesenteric injury (bbmi) has increased recently in blunt abdominal trauma and this is possibly due to an increasing number of high speed motor accidents and the use of seat belts. objective: in this study we sought to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with bbmi. this was achieved by reviewing our experience as a major victorian trauma service in the management of bowel and mesenteric injuries and how this compares to current literature. methods: a retrospective study reviewing consecutive patients who presented to the alfred trauma centre with blunt bowel and mesenteric injuries over years. results: of the patients with bbmi % were male, % were female. % of the patients underwent a laparotomy, % of patients were treated conservatively and % were diagnosed post-mortem. the times from admission to laparotomy were: - h %, - h %, - h %, - h %, - h %, more than h %, respectively. fast (focused abdominal sonography for trauma) was done in and % of this group had a positive fast. while % of patients had a negative fast and % of patients had an equivocal fast. % overall group did not have a fast. computerised tomography (ct) scans were undertaken preoperatively in % of the patients and showed: free gas ( %), bowel wall thickening ( %), fat and mesenteric stranding or hematoma ( %) and free fluid with no solid organ injury ( %). conclusion: the timing of surgical intervention is mostly determined by the clinical examination and the helical ct scan findings in bbmi. fast lacks in sensitivity and specificity in identifying bowel and mesenteric trauma. delayed diagnosis of more than h has significantly higher bowel related morbidity but not mortality. predictors for the selection of patients for abdominal ct after blunt trauma: a proposal for a diagnostic algorithm introduction and objectives: gastrointestinal and mesenteric injuries (gimi) are not common in trauma, and their diagnosis is frequently delayed. our aims were to determine the reliability of ct scan and to assess the clinical significance of a delayed diagnosis. methods: retrospective analysis of cases confirmed at laparotomy. patients were identified at the severe trauma registry of our hospital, between and . results: we found ( , %) gimi out of patients with abdominal trauma, in a registry with . severe trauma cases included. the mean iss and niss were of and , respectively. mortality was of ( , %) patients, of them unexpected. a ct scan was performed in ( %) cases, and only in were there signs suggestive of a gimi. surgery was delayed for more than h in ( %) patients, the most common reason being a false negative result in the ct scan. there was no significant increase of morbidity or mortality in the delayed diagnosis group. conclusion: the overall incidence of gimi was high in our registry ( % in penetrating and . % in blunt trauma). several factors such as the initial lack of symptoms, a low diagnostic sensitivity of the ct ( % false negatives), and the nonoperative management of solid organ injuries, have contributed to a delayed diagnosis in one of every five patients in our series, but this has not led to a significant increase in septic complications in this group. author to editor: ct scan diagnosis of gastrointestinal injuries continues to be a matter of concern. there is controversy on the clinical significance of a delayed diagnosis of small bowel injuries management of rectal injury: reappraisal of old techniques introduction and objectives: due to immunological functions, conservation of injured spleen following abdominal trauma is very important. for this reason nonoperative management (nom) in the last years has been accepted as the ideal treatment in those patents who are hemodynamically stable and do not require a laparotomy; however in case of multiple abdominal solid organ injuries (soi) nom is controversial. methods: we report on a case of a -years-old patient with spleen and renal injury subsequent to blunt abdominal trauma. ct scan revealed a ois iv injury (third degree in graz classification) and an ois iv renal injury. since chances for successful spleen angioembolization were judged poor by radiologist, a laparotomy and partial spleen resection with preservation of one-third of the spleen was performed. immediately after surgery, angioembolization of the renal injury was successfully performed. results: a contrast enhanced ultrasound (ceus) performed on day and day after trauma revealed a hypertrophy of the residual spleen with diffuse distribution of contrast agent in the spleen parenchyma, confirming functional activity of the organ. morphological and functional evolution of left kidney was normal. conclusions: sequential treatment (surgical preservation of the most injured organ followed by immediate angiographic embolization) could be a valid option in case of multiple abdominal soi; furthermore, ceus is an interesting new tool to determine functional activity of residual spleen. introduction: precise timing of cholecystectomy procedure after biliary pancreatitis is still controversial. the major drawback of interval cholecystectomy is the recurrence of pancreatitis within the interval of - weeks. early cholecystectomy (performed prior to discharge), however, have the disadvantages of increased technical difficulty and conversion rates. methods: we reviewed patients with recurrent biliary pancreatitis among a total number of cases of biliary pancreatitis in-between january and january . results: the mean age was . (range - ), and male-to-female ratio was . ( : ). seventeen patients (% ) had a history of previous cholecystectomy. of these patients, (% ) have had early cholecystectomy, and (% ) have had interval cholecystectomy. the rest of the patients (% , n = ) consists of those who have been scheduled for interval cholecystectomy but have had a recurrent episode during the -week interval (% , n = ) or after the -week interval (% , n = ). conclusion: the majority of patients with biliary pancreatitis do not have any recurrent episodes even if they do not have a surgical or an endoscopic treatment. according to our data, however, an influenced percentage of recurrent pancreatitis develops in patients who do not have early cholecystectomy. therefore, we prefer early cholecystectomy in means of reducing the risk of recurrent pancreatitis during or after the -week interval. introduction and aim: nonoperative management (nom) of splenic injury is currently the most common management strategy in hemodynamically stable trauma patients. aim of this study was to asses if the success rates of - % described, mainly in the north-american literature could be confirmed. methods: we conducted a retrospective study of all patients older than year with blunt splenic injury who were admitted to a level i trauma center. a total of patients were identified with blunt splenic injury during the -year study period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: the majority were young men; mean age was years. thirty-three ( %) patients underwent immediate surgical management. sixty-seven ( %) patients were treated with planned nom and ( %) patients underwent angiography and embolization (a&e). we did not encounter early complications following a&e. fourteen patients failed observation due to ongoing bleeding. of these, were treated with splenectomy and three with a&e. the splenic salvage rate after observation was %. the splenic salvage rate after a&e was %. four of the five patients with a rebleeding after initially a&e underwent splenectomy and one patient was treated with reembolization. the overall mortality rate was . %. none of the patients died as a result of splenic injury treatment failure. conclusion: nonoperative management in blunt splenic injuries in our trauma center is a well-tolerated treatment with a success rate of %. the splenic salvage and mortality rate is comparable with the literature which is mainly based on north-american studies. mannheim peritonitis index (mpi) is a scoring system with prognostic significance. we applied mpi to patients with perforative peritonitis (on patients in sri ramachandra medical college) to validate the scoring method. it is a specific score with accuracy and allows prediction of prognosis. aim of the study ( ) to study the incidence and aetiology of perforative peritonitis. ( ) to study the demographics of the study population. ( ) to analyse if mannheim peritonitis index (mpi) is a valid scoring method. p-possum (p < . ) scores in the index surgery. malignancy was the most frequent initial diagnosis in patients with spp and benign diseases in tp. there were no differences on the interval between operations ( ± days tp vs. . ± days spp; p = . ) neither in the number of previous laparotomies (p = . ). tp was associated to emergency index surgery (p = . ) and icu hospitalization (p < . ), mechanical ventilation (p = . ) and vasoactive drugs (p = . ). there were no differences in any of the clinical and biochemical parameters analyzed, neither in sirs (p = . ) or p-possum scores after relaparotomy (p = . ). we found no differences regarding mean hospital stay ( days tp vs. days spp; p = . ) and mortality rate ( % in spp vs. % in tp; p = . ). conclusions: although certain differences exist, the clinical course of postoperative peritonitis seems to depend more on factors other than their secondary or tertiary origin. background and aim: patients with primary acs will often develop a secondary acute respiratory distress syndrome (ards). mechanic pressure is mainly responsibe in pulmonary findings in acs. we aimed the role of aspiration of gastric contents into lower airways in pulmonary complications of acs. methods: the rats were initially divided into five groups (group i-v), and then these groups were divided again into two groups if they are unfed (group ia-va) or fed (group ib-vb). in animals in group i-v intraperitoneal pressure (iap) was applied as follows: , , and cm h o by instillation of isotonic saline solution. results: total scores of lung histopathologic findings were concordant with the degree of iab. when the total scores of histopathologic findings in lungs were compared for each applied iab with control group, the scores were higher in fed animals than unfed animals. histopathologic findings in lungs were observed when increased-iap to mmhg ( cmh o) which was accepted as cut-off value. the comparison of the scores of histopathologic findings in two groups in which the applied iab was lower then the cut-off value were not significantly different from the control group. however comparison of the scores of histopathologic findings equal to or above mmhg were significantly higher then the control group. conclusion: our results show that that pulmonary aspiration related with passive regurgitation in acs has a substantial influence on histopathologic findings seen in this disorder. editor to self: secilmiş bildiri emergency surgery and delayed abdominal closure: results in cases carlos mesquita, marco serô dio, francisco castro-sousa emergency and general surgery departments, coimbra university hospital, coimbra, portugal delayed abdominal closure (dac), in emergency surgery, must be economical, fast to execute and easy to maintain, allowing second look and definitive closure, with minimal prejudices to the abdominal wall. as an alternative to the vacuum closure systems, the aa have been utilising the rotondo and schwab technique (iatsic-dstc course), by the interposition of a plastic towel between abdominal contents and wall. dac has been utilised in patients ( male, female, - ) , median age of ( - ). in five, after abdominopelvic packing for hypovolemic shock conditions. in , after mediastinal and peritoneal decontamination procedures and lavage for septic situations with actual or potential compartment syndrome: three from acute necrotizing pancreatitis, six from dehiscent digestive sutures and two from strangulated hernias. four patients died in the open abdomen situation, one from pancreatitis and three from dehiscent sutures. primary abdominal closure has been possible in : in the cases of packing and in of the of the cases of sepsis. in one case of pancreatitis it has been possible a secondary closure. dac is now accepted like a safe procedure in damage control and compartment syndrome conditions which contributes to ameliorate the results in life threatening situations. than %. this report describes our experience with vacuum assisted closure (vac-)therapy in the management of efs in an oa. materials and methods: nine patients with seventeen high output efs in an oa were treated with vac-therapy from january till january . the abdominal wound was covered with fatty gauzes. small efs were covered with a patch of hydrophilic polyvinylalcohol foam. the entire abdominal wound was covered with polyurethane foam which promotes granulation and seals of the oa preventing further spillage of enteric contents. continuous negative pressure at - mm hg was applied. for large fistulas with protruding mucosa a hole was cut within the polyurethane foam and an ostomy bag was placed over the fistula mouth. surgery with enterectomy was planned - weeks later. results: the vac-dressing was changed every days. three efs closed spontaneously. time between onset of fistulisation and surgery was days (median days). no additional fistulas occured. one patient died postoperatively. conclusions: although previously considered a contraindication to vac-therapy, the oa with efs can be managed with vac-therapy. a taylored application of the foam and a reduced negative pressure seem to allow a safe and reliable way to manage efs. partial enterectomy and abdominall closure is possible after several weeks. introduction: it was the aim of the study to analyze the potential value of microdialysis in the rectus abdominis muscle (ram) compared with conventional monitoring parameters currently in clinical use for the detection of the abdominal compartment syndrome (acs). methods: pigs were anaesthesized, mechanically ventilated and continuously monitored. microdialysis was performed in different abdominal organs, the ram and cervical muscle (distant reference) for glucose, lactate, lactate-pyruvate ratio (lpr) and glycerol. iah was maintained for h. three groups were analysed: control (a), iah mmhg (b) and mmhg (c).cardiopulmonary parameters, urinary output, blood gas analysis and venous lactate were recorded. results: mean arterial pressure and abdominal perfusion pressure remained above clinically defined thresholds during the experiments for groups a and b. in contrast, group c demonstrated a persistent decrease below these thresholds. significant reduction of urinary output was only seen in group c. lactate levels also remained within physiological range in all groups. in contrast, microdialysis revealed a significant increase of lpr in all monitored organs in groups b and c, indicating ischemia and energy failure. of interest, lpr in the ram showed a significant increase already after h of iah in group b. conclusion: microdialysis of the ram detected local metabolic derangements in animals with iah of mmhg while clinically established monitoring tools failed to show organ dysfunction/tissue ischemia. our data suggest that continuous microdialysis in the ram may represent a promising tool for early detecting iah-induced metabolic derangements before manifestation of clinically apparent acs. introduction: to avoid morbidity associated with open abdomen, subcutaneous linea alba fasciotomy (slaf) was introduced for management of abdominal compartment syndrome (acp) in severe acute pancreatitis (sap). we analyzed the efficacy and safety of slaf as a surgical decompressive technique. methods: a retrospective study of a -year period identified patients with sap and acs undergoing slaf. mean age was (range - ) years, were male and had alcohol-induced sap. slaf was performed - days post-admission, in / cases within h. results: the mean (range) preoperative intra-abdominal pressure (iap) was ( - ) mmhg and immediate postoperative iap ( - ) mmhg. the mean decrease was ( - ) mmhg and the decompressive effect was considered sufficient in / cases. two of these developed recurrent acs and required completion laparotomy, as did the with insufficient effect ( - days post-slaf). the mean preoperative sofa score was ( - ) and ( - ) - days postoperatively, the decrease was > in patients with successful slaf. eventually four patients underwent necrosectomy, two following sufficient slaf. the overall mortality and morbidity rates were / and / , no complications were attributed to slaf itself. mean hospital stay was ( - ) days. of the survivors, fascial closure was achieved in two, and planned hernia in four (two with split-thickness skin graft and two with post-slaf hernia). conclusion: slaf is a safe decompressive technique in sap-related acs. it is effective in about - % of cases, but some require completion laparotomy and/or necrosectomy later on. methods: between march and december , patients were managed with vac technique (kci, san antonio). the mean age was . ( - ) , and m/f sex ratio was / . indications were severe abdominal sepsis in patients, mechanical obstruction due to colorectal cancer in patients, pancreatitis in patients, posttraumatic abdominal compartment syndrome patients, evisseration in patients, enterocutaneous fistule in patients. results: as morbidity there were fistulaes and intraabdominal abscess in all patients. four of the patients were died with concomitant disease. there was no mortality related using vac system. thirty five patients ( %) was underwent a delayed primary closure, five underwent secondary healing by granulation, and four underwent split thickness skin grafting. surgical outcomes of severe hepatic injury were retrospectively reviewed. (methods) among patients with hepatic injury treated between and , patients who underwent surgery were included. the study period was divided into early ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , middle ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and late ( ) ( ) ( ) ( ) ( ) phases, and type of injury, surgical procedure performed and patients' outcome were retrospectively reviewed. (results) ( ) percentage of patients undergoing surgery: % ( / ) underwent surgery in the early phase, % ( / ) in middle and % ( / ) in late phase. ( ) timing of surgery: the numbers of patients underwent laparotomy in er, urgent laparotomy in or, and delayed laparotomy (after h) were ( %), ( %) and ( %) in early phase; ( %), ( %) and ( %) in middle; and ( %), ( %) and in late phase, respectively. ( ) surgical procedures performed: for type iiib (jast grading) cases, hepatectomy was performed in % and hepatorrhaphy was performed in %, giving a mortality rate of % in early phase, . % in middle and % in the late phase. for iiib + ivc/hv cases, hepatectomy was performed in all patients, giving a mortality rate of % in early phase, % in middle and . % in late phase. (discussion) with the increase in nonsurgical management, surgical treatment for hepatic injury is performed preferably in patients requiring immediate response, such as laparotomy in er. the surgical outcome of hepatic injury has been improving, with a survival rate of approximately % for type iiib cases and % for iiib + ivc/hv cases. rifat tokyay, tolga taymaz amerikan hastanesi, istanbul, turkey objective: the aim of this study was to assess the unexpected returns (ur) within month of the adult patients and the pediatric trauma patients initially seen in the _ istanbul american hospital emergency department. design: all urs between . . - . . were recorded. initial diagnosis, final diagnosis, initial treatment, final treatment, reason for readmission, and last medical condition were noted. results: eighty eight urs were recorded. final diagnosis of of these patients were surgical. forty one of these surgical patients had ur due to error in diagnosis and five due to error in treatment. fifty two of these patients returned on the same day or the next day, between nd and rd days, between th and th days and between th and th days. male to female ratio was to . three of the patients were pediatric trauma patients, were between - years, and were over . missed final diagnosis were: acute cholecystitis ( ), acute appendicitis ( ), missed fractures ( ), pneumothorax ( ) liver mass ( ), urethral stone ( ), ectopic pregnancy ( ), diverticulitis ( ), subarachnoid bleeding ( ), others ( ). conclusions: acute cholecystitis, acute appendicitis, and missed fractures were the most frequent surgical causes of urs after emergency department discharges. liberal utilization of abdominal sonography and abdominal ct scan may reduce missed acute abdomen in abdominal pain patients and appropriate radiological imaging and meticulous evaluation of the x-rays may reduce unnoticed spinal, pelvic and facial fractures in trauma patients. editor to self: seçilmiş bildiri olabilir introduction and aim: bacteremia sepsis and septic shock might develop rapidly for the patients with infection in bile path. early diagnosis, surgical treatment and antibiotherapy decrease mortality. in this study, the relation between choledocholithiasis, cholangitis and pancreatitis and treatment methods have been evaluated. method: the demographic features, the treatments, the intensity of the illness and mortality rate of the patients in afyon kocatepe university general surgery clinic between the years background: enterocutaneous fistula continues to be a serious surgical problem. they are related with major electrolyte imbalances, malnutrition and delayed tissue healing. our recent experience with enterocutaneous fistulas is reviewed hereby. methods: we analyzed the charts of all patients with enterocutaneous fistula from january to december . fistulas were assessed for localization, type, output, etiology, use of somatostatin analog and fibrin glue, nutritional support, type of surgical intervention, wound vac, and endoscopic findings. results: we identified patients. fistulas were localized as gastroduodenal in five patients, jejuno-ileal in seven, and colonic in eight. there were enterocutaneous and entero-atmospheric fistulas. endoscopy was performed in patients. output was low (< ml) in , whereas high (> ) in patients. seventeen patients developed fistulas due to iatrogenic reasons, six patients had an underlying malignancy, and three patients developed fistulas after pancreatitis. somatostatin analogs were used in patients. conservative treatment was performed in patients, primary surgical intervention in patients, and secondary surgical intervention in patients. fibrin glue was used in patients and was of benefit to . healing was achieved in patients ( %) after mean . days (range - ). two ( %) patients were died. conclusion: there appears to be no strict rule for treatment of enterocutaneous fistulas. liberal use of endoscopy, fibrin glue as well as restorative surgical intervention all play a major role, and should be employed selectively on an individual basis in the management of enterocutaneous fistulas. aim: in this study we aimed to evaluate the patients whose admitted to neurosurgery and anesthesiology intensive care unit (naicu) between and . matherial and methods: the patients whose admitted to naicu between january and january evaluated retrospectively. diagnosis, age, gender, mortality rate, staying day in icu of the all patients were determined. head traumas were obtained in trauma and multitrauma patients. results: total number of the patients those are admitted to naicu were , and of them because of head trauma ( . %). of the cases were pure head traumas ( . %) or politraumas accompanied with head traumas (ht).the rate of ht was . % of all traumas.there were men, women. mean age of men were . and women were . . staying icu were obtained as . days. the mortality rate was found as . % ( cases). operated cases were ( . %) and the cases followed without any operation were ( . %). mortality rate between operated cases were . % ( ) and nonoperated cases were . % ( ) . ht cases were evaluated by glascow coma scale (gcs) as severe (gcs £ ),intermediate ,moderate (gcs ‡ ).the cases which had gcs £ were ( . %). operated cases were ( . %) and of them dead ( . %). the mortality rate of operated cases ( cases) which had gcs = - were . % ( cases). the number of cases were which had gcs ‡ and the mortality rate of operated cases ( cases) were . % ( cases) at this group. the mortality rate of nonoperated cases ( cases) were . % ( cases). conclusion: the higher rate was ht cases when the trauma patients evaluated and mortality rate of nonoperated trauma patients were higher then operated trauma cases. author to editor: this study send for giving knowledge about traumas which admitted to kocatepe university school fo medicine at a period of months. introduction and aim: this study has been carried out to compare conservative and surgical treatment for the acute pancreatic. method: the treatment processes and radiologic outlook of the patients with acute pancreatitis in afyon kocatepe university general surgery clinic between the years and have been observed retrospectively. results: the average age of the patients with acute pancreatic is and . % of them were women. while conservative treatment was applied on patients, surgical treatment was applied on patients. while the etiologic reason was based on a known source for the . % of the patients, no reason was found for the . % of the patients. ercp was applied for six patients within the scope of conservative treatment. necrotizing pancreatitis existed in five patients. surgical debritment and abdominal washing were applied for four of the patients. acute pancreatitis were diagnosed for the . % of the patients after tomography. one of the patients which had surgical treatment died ( . %). there was no mortality for the patients having conservative treatment. there was not a substantial distinction between the two treatment methods in terms of mortality. ten of the patients had laparoscopic cholecystectomy, ten of the patients had open cholecystectomy (one of the patients with abdominal washing), one of the patients had choledochal exploration with t tube drainage and open abdomen. conclusion: the conservative treatment should be prefered though the treatment ways of acute pancreatitis under discussion. there is not a distinction between the tow methohds in terms of mortality. mü nevver moran, emre gundogdu, ismail bilgiç, hayrettin dizen, mehmet mahir Ö zmen department of surgery, ankara numune teaching and research hospital, ankara, turkey our aim was to compare to efficiancy of different scoring systems as a prognostic indicator in acute pancreatitis. medical records of patients ( female) with mean (range) age of ( - ) years who are diagnosed as acute pancreatitis during years were evaluated according to age, sex, etiologic factors, sirs, apache ii, balthazar scores and ranson scores at admission and at h in order to evaluate the correlation with mortality. the commonest cause was gallstone seen in ( %) cases followed by idiopathic in ( %), alcohol in ( %) and other in ( %). there were ( , %) cases with mortality and ( %) patients underwent operation. in survivors mean (sd) age was ( ) years, sirs score was . ( ) , ranson scores at admission was . ( . ) , ranson scores at h was . ( . ), apache ii score was . ( . ), balthazar scores was . ( . ). in the nonsurvivors group of ( , %) cases, the mean age (sd) was ( ). admission sirs score was . ( . ), apache ii score was ( . ), ranson score was . ( . ), ranson scores at h was . ( . ). when both groups were compared sirs score, apache ii score at the admission and ranson score at h were found to be statistically significant (p < . , p = . , and p = . , respectively), and no differences observed in reference to balthazarscore, hospital stay and icu stay (p > . ). although admission sirs score, apache-score and h ranson score were all found to be important prognostic indicators, sirs seems better and most promising indicator as it is easy to use and not requires sophisticated tests. normal in patients ( %). the appendix was divided by endo-loop in %, intracorporeal suturing in % and endo gia in % of the patients. the meso-appendix division was performed by endoclip ( %), ligasure ( %) and bipolar cautery ( %) . conversion to open procedure rate was ( %). mean operating time was min ( - ). mean hospital stay was . days . major complications were as follows: right iliac artery injury (n = ), bladder injury (n = ), post operative bleeding (n = ), intraabdominal abscess (n = ), appendiceal stump leakage (n = ). minor complications were trocar site infection (n = ) and mechanical bowel obstruction (n = ).there was no mortality. conclusion: la is associated with considerably decreased morbidity and might be considered as the treatment of choice in aa. hakan yanar, cemalettin ertekin, korhan taviloglu, ali fuat kaan gö k, emre sivrikö z, gü lay sarıçam, recep gü loglu trauma and emergency surgery service, istanbul university, istanbul faculty of mediine, istanbul, turkey background: gastrointestinal stenting is increasingly employed to relieve passage. it provides a palliation in inoperable cases or anastomotic strictures. in left-sided colonic and rectal obstruction, it allows decompression for a definitive surgery to be performed. methods: between may and december , patients with acute mechanical intestinal obstruction were treated with endoscopic stenting. localization of malignancy, stenting complications, and surgical interventions were assessed. results: there were a total of patients undergoing gastrointestinal stenting. sixteen patients received gastroscopic stents, four patients with esophageal, eight patients with gastric, four patients with duodenal tumors. stenting failed in five patients ( %), and surgery was required in four patients. nine patients were referred to adjuvant oncologic treatment. fourteen patients received colonoscopic stents; in one patient with a left-colon, in nine patients with sigmoid colon, and in four patients with rectal tumors. stenting failed in seven patients ( %), and six patients were operated emergently with a need for stoma in two patients. ten patients were referred to adjuvant oncologic treatment. no patient was died related with procedure. conclusion: gastrointestinal stenting is a useful adjunct in the treatment of patients presenting with acute mechanical intestinal obstruction for palliation as well as for decompression before definitive surgical therapy. introduction and objectives: internal hernia (ih) is a rare entity which occurs due to the protrusion of an intraabdominal viscus through a normal or abnormal mesenteric or peritoneal aperture. ih can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. intestinal obstruction due to ih is very dangerous and lethal because it may be silent, and delay in diagnosis may cause severe abdominal conditions. in this report, we aimed to present patients with ih. methods: seventeen patients who were admitted to our clinic with the diagnosis of ih between january and january were included. patients' demographic data, type of the hernias, type of surgical procedures, length of hospital stay, and prognosis of the patients are evaluated retrospectively. results: there were nine male, eight female patients. mean age of the patients was . years ( - ) . postsurgical ih were seen in eight, paraduodenal in four, transomental in one, sigmoid mesocolon hernia in one patient, and the remaining three hernias were not classified. laparotomy was performed in patients, laparoscopy in and conversion to open surgery in patient. small bowel perforation was found in three patients. seven patients underwent intestinal resection and anastomosis. mean length of postoperative hospital stay was . days ( - ). there was no mortality. conclusion: ih is a rare cause of small bowel obstruction in adults and often present with complications. a high index of suspicion may lead to early surgical intervention and reduce morbidity and mortality. introduction: esophageal perforation is a serious surgical condition in which delay for surgery results in high mortality. application of covered stents is an alternative for emergency surgery. the aim of this study is to analyze the results of esophageal stent application retrospectively. the clinical data and outcome of patients diagnosed and treated for esophageal perforation by endoscopic stent application between february and december were evaluated. results: the mean age of these patients was ( - ) and male to female ratio was / . causes of perforation was mediastinal abscess (n ¼ ), metal stent application (n ¼ ), and balloon dilatation (n ¼ ). stents were applied immediately after perforation in three patients. remained three patients were referred from other institutions and the mean time of delay was h ( - ). perforations were at proximal (n ¼ ) middle (n ¼ ) and distal esophagus (n ¼ ). self expanding covered metal stents were applied in an appropriate position to bridge perforation area in a fashion to cover minimally cm distal and proximal normal esophageal mucosa to all patients under fluoroscopic control. no contrast leak was observed immediately after application and h later. patients were interned and observed under intravenous fluid and antibiotic therapy. except one patient developing transient subcutaneous emphysema no complication was observed. all perforations were closed and the stents were removed at the end of fourth week. conclusion: at the early phase of esophageal perforations covered esophageal stent application can be a better alternative to surgery. introduction: upper gi bleedings are serious conditions which may be life threatening. in seriously bleeding cases the failure of the endoscopic interventions makes surgical intervention necessary. the aim of this study is to present the success rate of endoscopic interventions for upper gi bleeding performed by surgeons. methods: clinical data and the outcome of endoscopic interventions made to of , upper gi bleeding patients admitted to a large community hospitals single surgical endoscopy center between january and september were analyzed retrospectively. results: hemostasis with endoscopic interventions was achieved in ( . %) at initial (n ¼ ) or at second endoscopy (n ¼ ). patients underwent emerging surgery. there was no mortality at the patients treated by endoscopic interventions where as seven patients died after surgery ( . %). conclusion: the outcome of surgery is poor in upper gi bleeding. thus maximum effort should be given to achieve homeostasis by endoscopy. the success rate of endoscopic interventions in this study performed by surgeons is extremely high and satisfying. naomi beks, mariëlle van gameren, sander ten raa, armand van kanten, gert roukema emergency department, maasstad ziekenhuis, rotterdam, the netherlands analgesia use at the emergency department, how evidence-based do we work when dealing with patient with acute abdominal pain? based on a pilot at our emergency department we concluded that it is still common practice to withheld a patient with acute abdominal pain from analgesia till examined by a surgeon or resident. this in contrary to evidence presented in literature which show no negative effect of analgesia use on accuracy of diagnosis in patients with acute abdominal pain. a total of inquiries were send to nurses, physicians and surgeons working at the emergency department of teaching hospitals in the netherlands. we questioned their standard policy on analgesia use in acute abdominal pain. a total of completed inquiries were retrieved, resulting in a response rate of %. there is a difference between the response of nurses and doctors, versus %, respectively. compared to nurses, doctors are more optimistic about the moment analgesia is given. remarkable is the result that % of patients do not receive any analgesia even after examination by a surgical resident and % of the patients have to wait till they are examined by a surgeon is outshining. patients are still withheld from analgesia till a resident or surgeon examines them even though this is not evidence-based medicine. there is no consensus in the netherlands on analgesia use in patients with acute abdominal pain in the emergency department setting. a national guideline for patients with acute abdominal pain is recommended. introduction and objectives: the benefits of laparoscopic appendectomy remain debated in literature. methods: this is a monocentric, retrospective study to evaluate the differences between open and laparoscopic appendectomy for length of hospital stay, wound infection, major complications. retrospective surgical site infection rate evaluation has been possible only for in hospital stay, no further clinical data has been collected regarding outpatient follow-up. results: from january to october we reviewed patients undergoing surgery for acute appendicitis. patients underwent laparoscopic appendectomy ( . %) (group a), patients open appendectomy ( . %) (group b). two different surgical teams, one for laparoscopy and one for laparotomy, performed the procedures. complicated (perforated or gangrenous) appendicitis were in group a ( . %) and in group b ( . %). mean hospital stay group a was . days, . (p = n.s.) group b. mean hospital stay in complicated appendicitis group (a + b) was . days, in uncomplicated (a + b) was . days (p < . ). laparoscopic appendectomy was associated with lower wound infection rate (group a . % vs. group b . %) (p < . ). infection rate in complicated appendicitis (a + b) was . %, in uncomplicated cases (a + b) was . % (p < . ). no mortality in both groups has been observed. one conversion in laparoscopic group was reported. no cases of deep surgical site infection have been observed. conclusions: laparoscopic appendectomy seems to be associated to a lower rate of wound infection. length of hospital stay and rate of major complication seems to be related to gangrenous or perforated appendicitis and not to the surgical technique. significantly lower on postoperative third and seventh day, respectively. conclusions: in this model of general peritonitis, mb significantly reduced adhesion formation. mb is blocking the tnf alpha early postoperative days. early blocking of the activity of tnf-alpha after peritonitis resulted in lower rates of adhesion formation macroscopically. the tnf-alpha can be an important factor for postoperative adhesion formation. results: laparoscopic surgery was performed in patients due to peptic ulcer perforation. seventy-five patients ( %) underwent laparoscopic repair alone or laparoscopic repair with omentoplasty. in the remaining patients ( %), the procedure was converted to laparotomy. amongst ( men / women) patients who were included into the study, the mean age was . ( - ) . in patients ( %, / ) preoperative diagnosis was unclear and the patients were taken to operating theater due to acute abdomen. in all patients, but one, the duodenal defect was repaired by primary suturing; in one patient, simply intra-abdominal lavage and drainage were performed because the omentum was found to seal the defect. omentoplasty was performed in ( %) patients. one and two abdominal drains were used in ( %) and ( %), respectively. mean hospital stay was . ( - ) days. morbidity was % (n = ). early morbidity included bile leakage in three patients, postoperative intra-abdominal bleeding in one. one patient had trocar site hernia. one patient ( -year-old female) died on postoperative day due to sepsis in the intensive care unit. conclusion: laparoscopic primary repair is a safe and efficient method in peptic ulcer perforation. akın tarım, sedat yıldırım, cem aydogan, gö khan moray, mehmet haberal department of general surgery, baş kent university, ankara, turkey introduction: approximately % of multiple trauma patients sustain concomitant burns. complicated management issues arise in these patients as burn and trauma care often conflict. the purpose of this study was to describe the different types of burn injuries seen in burn patients with additional forms of trauma, and to report the survival rate for this patient group. methods: in this retrospective study, patients were admitted to our center with concomitant burns and trauma from - . this study retrospectively analyzed the types of burn injury, extent of burns, types of other trauma associated with the burns, and outcomes. results: of this study group, were male. average age was . ± . . mechanisms included motor vehicle collisions, electrocutions with subsequent falls, one plane crashes, lpg or oxygen tube explosions and other type of explosions. average burn size was . ± . %. the most common traumatic injury was fracture and head injury ( ). management of fractures in burn patients and resuscitation in head injured burn patient represented the most common conflicts in patient care. there were deaths in this series. conclusion: burns are a rare but significant complication in the trauma patient. outcomes are dependent on rapid trauma evaluation as well as effective resuscitation and wound management. given the complexities of their problems, these patients necessitate a balanced multidisciplinary approach to maximize their potential for full recovery. thoughtful compromise between trauma and burn priorities is frequently necessary. introduction: fournier's gangrene (fg) is a rapidly progressive, polymicrobial, synergistic necrotizing fasciitis. in this study we aimed to determine the risk factors effective on the prognosis of the disease. methods: the files of consecutive patients operated for fg during - were investigated retrospectively. the surviving and mortal groups of patients were compared for demographic data, etiological factors and treatment modality besides length of hospital stay and treatment cost. results: the mean age of the patients was . years and female/ male ratio was / . mortality was seen in ( . ) patients and significantly high in female ( . %) (p = . ). the most frequent comorbid disease was diabetes ( . %), etiological factor was perianal abscess ( . %) and etiological source was anorectal region ( . %); and they did not affect the mortality. the most frequent cultivated microorganism e.coli ( . %) was significantly high in the mortal group (p = . ). imipenem was the antibiotic used in all of the patients. the mean number of debridements was , and intestinal diversion was utilized for . % of the patients. fecal decontamination ( . %) of the patients was performed by surgical ( ) and nonsurgical ( ) methods. the length of hospital stay in surviving group ( . days) was higher than the mortal group ( . days) (p = . ). there was no difference between two groups of patients for the length of hospital stay (p > . ). conclusion: female gender, duration of complaint prior to treatment, fournier gangrene severity point and cultivated microorganism (e.coli) were the factors affecting the mortality. aim: post-traumatic coronary aneurysms (ptca) are extremely rare. we report an asymptomatic ptca in a young patient. case: -year-old male, with no significant previous history. admitted intubated and ventilated after a car runover. he had cerebral, thoracic, abdominal, pelvic and lower extremity trauma. initial assessment disclosed eight left fractured ribs with associated pneumothorax; fast was negative, head ct normal. thoracic ct reveled small bilateral hemothoraces and pulmonary contusion, with no evidence of vascular lesions. he also had a fibular, clavicle, and pelvis fracture. control angio-ct at day showed pleural and pericardial effusions and raised the suspicion of left descending ptca, subsequently confirmed with mri. the patient remained asymptomatic with normal ekg and cardiac enzymes throughout this period. a coronariogram confirmed the ptca, that had undergone spontaneous thrombosis, with no further treatment required. discussion: coronary aneurysms (true or false) may occur after blunt thoracic trauma. ptca normally result from controlled rupture post myocardial infarction or cardiac contusion, with gradual wall rupture. although in this patient the diagnosis was made without any clinical manifestation, suspicion is the main key for diagnosis. aneurysms must be considered as a differential diagnosis in patients with thoracic trauma history associated with arterial emboli, congestive heart failure, arrhythmia, chest pain or dyspnea. conclusion: every trauma victim must be exhaustively evaluated. in any case a careful follow-up must be made in thoracic and abdominal trauma victims to decrease the possibility of missing injuries. aim: acute mesenteric ischemia (aim) continues to be highly morbid cause of emergency. early diagnosis and treatment may reduce severity of the disease. the aim of this study is to investigate causes for morbidity and mortality in ami patients. materials and methods: this retrospective study has patients of ami. the patients were classified according to their age, sex, clinical and laboratory findings, comorbidity, etiology, operative procedures, complications. and effect of these causes on mortality and survival was investigated. the results were statistically evaluated. results: of patients were male and were female. mean age was . for females and . for males. the most common symptom was abdominal pain. only one third of patients had diagnosed correctly before operation. amylase was high in % of patients. plain abdominal graphy showed air-fluid levels in all patients. mortality rate was high in patients aging over years (p < . ). there were no relationship between mortality and gender. the patients those who had massive small bowel and colon resection developed high mortality rates ( %). resection of ileocaecal valve also increased the mortality. five patients all of whom developed perforation died. majority of survivors had surgical intervention during first h of ischemic attack. the patients those died due to perforation had delayed surgical intervention. • there is no benefit of routine laboratory findings in early diagnosis of ami. • massive intestinal resection, absence of ileocaecal valve and stomal procedure increased mortality rate. • delay in diagnosis and treatment also caused high mortality. cem aydogan , yahya ekici , ebru sakallıoglu , sedat belli , mahir kırnap , emin tü rk , mehmet haberal department of generel surgery, baş kent university, ankra, turkey institute of burn, fire and natural disaster, baş kent university, ankara, turkey introduction: more than % of all burn patients can be managed on an ambulatory basis. appropriate management of minor burns minimizes further damage. methods: the epidemiology, demographics, and outcomes of ambulatory acute burn patients were reviewed at our center between and . patients who were in aba referral criteria were excluded from the study. results: the patients' mean age was . ± . years (range, - years) . the percentage of patients whose first admission was to our center was . %; the percentage of those referred from another center was . %. scald burns were the most frequently reported cause of burns ( . %). the house was the most frequently reported place at which the burns occurred ( . %). the percentage of stoverelated burns was . %. the upper extremities ( %) and lower extremities ( %) were the most frequently reported places on which the burns occurred. mean tbsa affected and superficial partial thickness burned area were . ± . % and . ± . %. the mean follow-up and the mean number of dressings applied to the burns were . ± . days (range - days) and . ± . (range - ). four patients ( . %) needed skin grafting, and two patients ( . %) were hospitalized for debridement without grafting. conclusions: close follow-up is important in minor burns to minimize further damage. burn centers must play an active role in the care of all burns. the devastating effects of burns can be prevented and decreased by educational programs. stove-related burns remain a problem in turkey. results: mean age was . ± . years. the percentage of the male patients was . %. the mean tbsa affected was . ± . %. the percentages of high voltage electricity injury, lightning injury, and lowvoltage current injury were . , . , and . %, respectively. place of employments ( . %) and outdoors ( . %) were the most frequently reported places at which the burns occurred. the burns mostly occurred in urban areas ( . %).upper and lower extremities were the most frequently affected regions. the percentages of the patients who underwent debridement, grafting, amputation and fasciotomy were . , . , . , and , %, respectively. the percentage of patients who had additional trauma other than electric burn injury was . %. mean hospital stay of patients was . ± . days. the mortality rate was . %. majority of the patients died from septic complications ( . %) conclusion: aggressive multidisciplinary treatment modalities and early debridment, grafting and/or flaps are very important. special considerations are required for public education about electricity and its hazardous effects. governmental supports are needed both in prevention and in therapy. ahmet erkilic, harun analay, sabri mehmet barazi, halil Ç eliksö z, bayram rü zgar burn center, av.cengiz gö kçek general hospital, gaziantep, turkey early staged excision and autogenous skin grafting or temporarily wound coverage with biologic dressing or allograft until autogenous donor sites are available is now conventional treatment for fullthickness burns. typically, tangential excision is performed with a handheld knife thus it may be difficult to control bleeding from the wound bed and difficult to assess the suitability of underlying for accepting a graft. a hydrosurgery system -versajet Ò is available that can be used for tangential burn wound excision. this device offers an easy and more precise way of excising eschar and is particularly useful excising nonviable tissue from the concave surfaces of hands and feet, as well as the eyelids and ears. totally, hydrosurgical tangential excision (hte) were performed for patients with burn, in our burn center in one and half year. several times performing were needed . % of patients (n = ). wounds of patients with - % total burned body surface were covered autogenous skin grafts subsequent to hte. more extensive wounds were covered with biologic dressings temporarily and wounds as soon as suitable autogenous skin grafting was performed. at this interval, burn wounds were shrunk average - % and donor skin poverty was increased. frequently, delaying to excision and coverage of burn wounds may be awful. early excision and early coverage of the burn wounds must be a golden standard for the current treatment of the burns. also hte is becoming a candidate to golden standard at burn treatment. introduction: in our previous study, we examined the treatment results of burn patients older than years, and found a significant increase in mortality with increasing age groups. the aim of the present study was to reevaluate this patient group and also compare these results with the previous study period of to . patients and methods: one-hundred and fifteen patients older than years were admitted to our burn unit during the last years. these patients were divided to three groups with respect to their ages (group a: - years, group b: - years, and group c: older than years). demographic properties of patients, etiology, and extend of burn injury, co-morbidity, length of hospital stay, and mortality rates were recorded. results: during the last years, demographic properties and etiology of burn injury did not changed significantly. however overall survival rate increased from . to % and ld values for burn injury are significantly increased in all age groups. length of hospital stay is significantly decreased in all age groups, especially in group b (from . to . days). co-morbidities did not change over time and sepsis is the leading cause of death in patients ( %). conclusion: in our burn unit, treatment results in patients older than years showed a significant improvement during the last years. introduction and objectives: patients who has weakness of mental and motor functions are under more risk than normal burned injured population. we would like to focus on burn injured cases that have co-exiting morbidities. methods: comorbid patients who applied to burn unit due to burn between january and july were taken into evaluation. comorbid etiologies were seizures ( case), mental retardation ( case) and down syndrome ( case), respectively. results: during follow-up period, one of the cases had aggrevated petit mal convulsion due to devastating effect of burn injury. in one case there was grade pressure sore and urethral infection who was paraplegic patient. weight loss was observed on a geriatric case that had seizure due to insufficient nutrition. conclusion: burn injured cases that have comorbidity, special care, and additional measures should be taken. psychological, neurological or geriatric causes are the factors that affect the recovery of burn defects and success of operation. detailed evaluation of coexisting disorder and additional care are the key points of the comorbid burn patient. aim: the present study was aimed to evaluate the gender differences of burned children in clinical course and outcome. methods: children (aged - ) admitted to our burn center between august and january were retrospectively evaluated. total burn surface area (tbsa), levels of some acute phase markers, grafting need, and hospitalization time were analyzed. results: sixty three patients [ ( . %) males, ( . %) females] were included in this study. the mean age was respectively . ± . years and . ± . years in males and females (p = . ). the mean tbsa burned respectively . ± . % and . ± . % in males and females (p = . ). the mean wbc count in admission was significantly higher in males than females ( . ± . x - /l vs. . ± . x - /l, p < . ), but there was not any significant difference between females and males in crp count. (p = . ). skin graft operation was performed in ( . %) of males and in ( . %) of females (p = . ) and also, we did not find any significant difference between males and females in hospitalization time ( . ± . days vs. . ± . days, p = . ). conclusion: although many studies have showed that critically ill females have a better outcome than critically ill males, any significant difference was not observed between burned male children and burned female children in most of the clinical parameters, except white blood cell counts. introduction and objectives: the goal of our study was to evaluate the preparedness of hospital physicians, emergency physicians and paramedics in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the head of the department of trauma-surgery, emergency medicine and to paramedics by e-mail. among other things we questioned: existence of a hospital emergency-and disaster plan and the yearly exercise of the plan. coordination with the local rescue service as well as existence of decontamination facilities were asked for. replies were analysed statistically with the one-way analysis of variance (anova) test and the turkey-kramer multiple comparisons test. results: altogether, assistant and emergency doctors as well as paramedics answered. % were not conscious of the details of the disaster plan of her hospital while % did not know the plan at all. % of the interviewed doctors did not know her area of responsibility in the case of an internal emergency. % of the interviewed know what to do in case of an mci. % of the interviewed doctors and % of the paramedics did not know her area of responsibility at the treatment of patients contaminated chemically, nuclearly or biologically. conclusions: the preparedness for doctors and paramedics in hospitals and in the preclinical rescue service in the eu and the usa on a mci (mass casualty incident) are insufficient. the emergency medical education of doctors and paramedics should be adapted to the terrorist threats disaster preparedness of chief physicians and hospitals in germany, the eu and the usa for a mass casualty incident introduction and objectives: the goal of our study was to evaluate the preparedness of hospitals in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the chief physician of hospitals by e-mail. things we questioned: existence of a hospital disaster plan and the yearly exercise. coordination with the local rescue service as well as existence of decontamination facilities. replies were analysed statistically. results: altogether, senior consultants, of this senior consultants from germany as well as senior consultants from the usa and the eu, answered. all people claimed to have a hospital disaster plan. % of the german hospitals made an exercise of the plan with tabletop exercises. however, % of chief physicians in the usa and the eu made an exercise of the plan regularly with table top exercises. % of the hospitals in the brd did not have any decontamination possibility of nbc (nuclear, biological, chemical) contaminated patients, while % of the hospitals had this possibility on the spot in the eu and the usa. conclusions: the exercise of the hospital disaster plan in germany is insufficient, compared with the hospitals in the eu and the usa. furthermore the german hospitals are badly equipped in the worldwide comparison to decontaminate patients on the spot. we demand for an increase of the ''exercises'' of the hospital disaster plan (also by tabletop exercises) as well as an improved equipment for the decontamination of the injured. in the two big earthquakes that occurred in the north-west of turkey in in short intervals within less than months there were approximately , cases of death and around , were injured. there were several other deadly earthquakes in the whole world the same year. main survival factors in the post-disaster period are prevention from injuries as well as detecting the location of the survivors and the rescued. the reality of the situation of persons who lost their lives in such traps, the severely injured, and the ones who survived must be analyzed. rational prevention methods against possible crush injuries due to collapsing buildings have been con-sidered in the light of the field and simulation experience we gained and suggestions have been presented to reduce mortality and morbidity. our work has been conducted with the aid of medicine based on proof, appropriate observation as well as sampling and experimental methods. a global approach concerning worst case scenario led by earthquakes has been proposed taking into consideration the different models of behavior in different countries and societies to increase the chance of survival to a maximum and to reduce injuries to a minimum level. due to unlimited possibilities of travelling nowadays, it is not possible to estimate the place, the country or the circumstances under which a person could experience a disaster. carlos alberto godinho cordeiro mesquita ordem dos mé dicos, colé gio de competê ncia em emergê ncia mé dica, lisbon, portugal in portugal there are three official ways to differentiate: specialty (vertical), subspecialty (vertical) and competence (transversal). doctors may access to a subspecialty or a competence as a second step, after a specialty. portuguese medical association (ordem dos mé dicos, om) is the official entity that regulates all the medical and surgical activities in portugal, being his duty to protect the public interest. doctors must be registered with to practise medicine or surgery. om also sets the standards and outcomes for basic medical education. after graduating from medical school and completing their foundation training, doctors usually complete a third and even a fourth stage of postgraduate training, whose standards are set by the colleges. these are responsible for promoting the development of postgraduate medical education and training for all, establishing standards and requirements and making sure they are met across the country. emergency medicine exists as a competence since and goes behind the prehospital acute care. this college is strongly interested in the development of an autonomous college of competence on emergency surgery (trauma surgery included) and it exists, since , an official national working group on emergency surgery education (grupo de trabalho para a formaçã o específica em cirurgia de emergê ncia), with representatives of general surgery ( ), neurosurgery ( ), orthopaedics ( ), thoracic ( ), vascular ( ) , urological ( ) and paediatric surgery ( ) . the general surgeons, iatsic members and dstc instructors, also integrate and lead the national steering committee for dstc, after a recently signed memorandum of understanding. author to editor: the point of the situation, from an organisational point of view, about trauma and emergency surgery education in portugal and the importance for the relationship with portuguese speaking doctors around the world introduction and objectives: practical training in emergency medicine should be an important part of undergraduate education, as every physician should be able to handle medical emergencies. however, adequate practical training is time and personal consuming. this work seeks to determine whether medical students (peer to peer education) can be trained as course instructors in emergency medicine training and if there are differences in the training outcome. methods: the undergraduate training consists of both basic life support (bls) and advanced cardiac life support (acls) courses. after both courses, students have to pass a multiple choice test and have to complete a course evaluation. during the instructor training, all candidates, students and physicians were trained together with theoretical and practical training and were furthermore supervised during their first courses. results: until now, bls and acls trainings were conducted of which % (bls) and % (acls) were run by medical students. there were no significant differences in the written examinations nor in the course evaluations ( = very good to = unsatisfactory) between courses by staff ( . for bls and . for acls) or medical students as trainers ( . for bls and . for acls, respectively). conclusions: peer to peer education can be a useful tool in the manpower consuming practical training in emergency medicine without influencing the learning outcomes or the evaluation. background: non-invasive pelvic ring stabilization (pelvic binding, pb) in shocked patients is recommended by state and institutional guidelines regardless the fracture pattern. the purpose of this study was to determine the adherence to the guidelines, radiological efficacy of the technique, and identification of potential adverse effects associated. methods: analysis of the prospective database of a level trauma center on high-energy unstable pelvic fractures. collected data included patient demographics, physiology, fracture classification, application, and timing of pb, associated injuries and outcomes. pre and post-pb radiographs were compared to evaluate the changes in fracture position. the potential effects of pb on soft tissue complications were assessed by independent experts. results: during the -month study period a total of pb was performed on patients with high-energy unstable pelvic ring injuries. stable patients were less likely to get pb ( %) than shocked patients ( %). the adherence to guidelines was %. analyzing fracture types (ao/ota classification) of shocked patients the adherence was: b %, b %, b %, c %, c %, c %. better radiological appearance was detected in b %, c %, c %, c % types. one femoral artery, four bladder and three rectum injuries were identified in patients with pb applied. there were no association between the complications and the pb. introduction and objectives: in our country, the vast majority of circumsicion is stil not done by physicians. in this study, we evaluated the patients who treated for circumsicion complications in our clinic. methods: a total of children who treated for cicumsicion complication in our clinic between and were evaluated. results: mean age during circumsicion was . months ( - years). out of had not been circumsiced by physicians. complication was bleeding in patients, burred penis in , complete glanular amputation in , and urethral fistula in patient. one suture was enough to control bleeding for the majority of patients with this complications, while general anesthesia required for treating other complications. conclusions: significant number of children still undergo circumsicion between and years old (fallic period) in our country. the vast majority of complications occur when circumsicion is not done by physicians; significant number of these complications require revision under general anesthesia. as a result, circumsicion is still a challenging both public and social problem in our country, and results in high morbidity because the majority is not done by experienced hand. arda demirkan , salih ekinci , onur polat , serdar gü rler , mü ge gü nalp , semih baskan department of emergency, ankara university, ankara, turkey department of general surgery, ankara university, ankara, turkey objective: multiple trauma involves at least two systems of body which abdomen, extremities, chest and head-neck. the aim of this study is to show relationship between the severity of injury and electrolyte changes in multiple trauma patients. method: this is a prospective study which adult multiple trauma patients ( male and female) were studied. the median age was . (range - ) . in all cases, serum sodium, potassium and calcium levels and injury severity score (iss) were obtained on admission to emergency department after trauma. severity of injury was estimated with iss. degree of association between variables was evaluated by spearman's correlation coefficient test. results: the mean sodium levels was . mmol/l, the mean potassium levels was . mmol/l, the mean calcium levels was mg/ dl. there was a negative correlation between calcium and iss, and this is statistically significant (p = . ). while other serum electrolytes (sodium and potassium) did not change according to iss. conclusion: electrolyte abnormalities often occurs in critical ill patients, this imbalance has a prognostic importance particularly in multiple trauma patients. electrolyte changes determinated in early period and appropriate resuscitation is indispensable. we suggest that low calcium levels can be considered for the severe injury. this condition may be related to interrupted calcium mechanism in critical trauma patients. introduction and objectives: preparation is essential to meet the challenge of optimal care for a sudden unexpected surge of casualties due to a major incident. by definition, requirements exceed standard care facilities in qualitative and or quantitative respect and interfere with regular patient care. to meet the growing demand for disasterpreparedness a permanent facility to provide structured, prepared relief in such situations was developed. we describe this facility. objectives: the aim of this study is to find out the effects of melatonin on the erythrocyte and kidney malodyaldehyde (mda) and superoxide dismutase (sod) levels in radiocontrast nephropathy. methods: in this study, new zealand type rabbits were included. the test subjects were divided into four groups six rabbits in each (control, sham, hydration and melatonin groups). blood samples of all subjects were taken in beginning of study. renal tissue was obtained in the control group. the rest received ml diatrizoat sodium intravenously. hydration group was given ml/kg/day iv bolus . % nacl. melatonin group was given mg/kg iv melatonin four times with the same dose isotonic. it was blood and renal tissue samples were taken at the th and nd hours. mda levels were determined with ohkawa method, sod enzyme activity was studied with ransod (randox,uk) superoxide dismutase assay kit. results: the mean renal sod value of the melatonin group ( . ± . nmol/g) was significantly higher than in the sham ( . ± . nmol/g), control ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (respectively p = . , . , . ). the mean renal mda value of melatonin group ( . ± . nmol/g) was significantly lower than sham ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (p = . , . respectively). conclusion: melatonin has a curative effect on the lipid peroxidation caused by the contrast substance in the kidney. in preventing nephropathy resulting from contrast substance, giving melatonin together with hydration can be more effective than giving hydration alone in the clinic. in addition, all datasets entered with voice recognition were complete and available in the system as soon as the patient left the trauma bay. compared to the retrospective cohort % of the patients had incomplete data concerning the vital parameters. conclusion: the introduction of voice recognition technology real time produces more accurate data more quickly. we are convinced that high tech technology will increasingly assist the trauma surgeon and if we are correct it looks like the prediction of don trunkey will come true viz: ''the current possibilities for using digital resources within medical care are merely limited by our own imagination'' introduction and aims: despite the improvements in the diagnosis and treatment, mortality rates are still high following urgent operation for perforated peptic ulcer (ppu). in this study, we analyzed the factors affecting the survival of the patients operated for ppu. materials and methods: the records of the patients operated due to ppu between january and january were analyzed. age, sex, american society of anesthesiology (asa) score, alcohol consumption, smoking, nonsteroidal antiinflammatory drug (nsaid) usage, the time passed from the onset of symptoms to operation, history of previous peptic ulcer disease, diameter and localisation of the ulcer, surgical technique, length of stay, postoperative complications and mortality rates were determined. results: the mean age was and asa score was . primary suture and omentoplasty was the selected procedure in patients while gastrostomy was added to primary suture to another patients. twenty nine patients received primary suture, truncal vagotomy and gastroenterostomy and seven underwent resection. the mean length of stay was days. three patients suffered from atelectasis and pneumonia, one from empyema, eight from surgical site infection and four from leakage. twenty three of the patients experienced respiratory failure and died of multi organ deficiency ( . %). age and asa score were found as factors significantly affecting survival. abdominal cocoon (idiopatic sclerosing encapsulating peritonitis) is a rare disease of the peritoneum which refers to a condition where there is a total or partial encasement of the small bowel by a dense fibrous membrane. the abdominal cocoon is probably a developmental abnormality, largely asymptomatic, and is found incidentally at laparotomy or autopsy. it is an unusual cause of intestinal obstruction. pre-operative diagnosis cannot be often made correctly. complete recovery is expected after removal of the membrane surgically. a -year-old man presented with abdominal pain, swelling and vomiting of two day's duration. there was no history of peritonitis, abdominal surgery or tuberculosis. physical examination of the abdomen revealed a distended abdomen, hypoactive bowel sounds, tenderness and rigidity in the whole abdomen. a tender lump was palpated in the right lower quadrant. routine laboratory workup revealed a total leukocyte count of cells/ml, and normal serum chemistry. pa x-ray of the chest normal. plain abdominal x-ray showed few air-fluid levels. contrast-enhanced abdomen-pelvis computed tomography showed a dilatation up to . cm in small intestine. emergency laparotomy was performed through a right paramedian incision. in exploration, small bowel was observed to be dilated, its mesentery was edematous and the whole small and large bowel was covered by a dense whitish and approximately mm thick membrane. the membrane was partially removed, and adhesiolisis of the intestinal loops was performed without bowel resection. after surgery, the patient was tolerated diet without any complication and was discharged, on hospital day . methods: the data of al-ain hospital trauma registry were prospectively collected over a period of years ( ) ( ) ( ) ( ) . all trauma patients who were admitted to intensive care unit (icu) were included in the study. univariate analysis was used to compare gender, age, nationality, mechanism of injury, systolic blood pressure and gcs on arrival, the need for ventilation, presence of head or chest injuries, ais for both the chest and head injuries and the iss. significant factors were then entered into a direct logistic regression. results: there were patients ( males). mean (range) age was year. . % were uae nationals. the two most common mechanisms of injury were road traffic collisions ( . %) followed by fall from height ( . %). the median (range) iss was . the mean (sd) icu stay was . ( . ) days while the mean (sd) hospital stay was . ( ). the overall mortality was . %. significant factors that have affected mortality included gcs (p < . ), mechanism of injury (p = . ), age (p = . ) and iss (p = . ). the best gcs that predicted mortality was . while the best iss that predicted mortality was . conclusions: rta is the most common cause of serious trauma in uae followed by falls. gcs is the most significant factor that predicted mortality in icu trauma patients. introduction: glutamine is an antioxidant which enhance glutathione levels. in this study our goal is to assess the safety and efficacy of parenteral glutamine on antioxidant capacity and organ dysfunction in septic patients. methods: prospective, randomized study of the septic patients admitted to the surgical intensive care unit (icu). patients were randomized to receive either glutamine (group glu, n = ) or glutamine + n-acetylcysteine (group nac, n = ) or a control supplement-placebo (group pla, n = ) parenterally up to days. organ dysfunction and clinical outcomes were assessed by daily total sequential organ failure assessment (sofa) score over the -day study period. serum total antioxidant capacity (tac) was measured by cuprac method. also we evaluated procalcitonin (prc) and c-reactive protein (crp) levels as infection markers on days , , , and . results: there was no significant differences between the patients' ages, apache ii, sofa scores and infection markers on the day of admission. group glu and nac showed a significant decline of daily total sofa score (glu: p < . , nac: p < . , pla: p = . ) and crp levels (glu: p < . , nac: p < . , pla: p < . ). but prc levels decreased significantly over time just in group glu (glu: p < . , nac: p = . , pla: p = . ). on the other hand, serum tac measurements were not significant. the mean icu length of stay were glu: ± . , nac: . ± . , pla: . ± . (glu/nac: p < . , glu/pla: p < . ), but in group glu the overall mortality was significantly lower than nac and pla groups (glu: %, nac: %, pla: %). conclusion: in septic patients, parenteral supplementation with glutamine results in significantly better recovery of organ function compared with nac and pla. we coud not find any significant relationship between tac levels and clinical outcomes. background: acute renal failure (arf) requiring renal replacement therapy in icu setting is related to high mortality. the purpose of the study is to assess any indicators of improved survival. materıal and methods: retrospective study of trauma patients, who underwent haemodialysis over a period of years (patients with penetrating, blunt trauma and burns). information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily icu records were collected. the majority of patients were initially dialysed with cvvhd and later on with sled. results: of the patients, died and overall mortality was . %. this was highest in the group of burn patients ( %). survival in all patients irrespective of mechanism of injury was unrelated to rts, iss, apache ii and triss. the duration of haemodialysis be-tween the three different trauma mechanism groups was not significantly different. age is not a significant predictor of survival. patients with polyuria at time of initiation of haemodialysis had not a better outcome than those who were oliguric/anuric/normouric. conclusions: arf in trauma patients has a low survival rate. controversial conclusions have been presented in the literature. in our study, none of the parameters reported in previous publications to affect survival was proven as correct, although our number of patients was comparable to that of other studies. as we are still at an early stage of understanding the predictors and the behaviour of renal failure in the trauma patients there is a need for the planning multicentric prospective studies. weaning from mechanical ventilation constitutes a dynamic process, and represents one of the most challenging decisions in the management of critically ill patients. success of weaning depends on multiple factors, and wrong decisions result either in prolonged mechanical ventilation, or reintubation and nosocomial pneumonia. many mathematical indexes have been described and used for decision making with varying successes. we have developed a multiparameter fuzzy-logic decision support system for prediction of success of weaning from mechanical ventilator. after fuzzifying relevant numerical variables, this system evaluates the appropriateness of perfusion, arterial blood gases, mechanical properties, and gas exchange, and converts these to a weaning probability. system has been designed using jfuzzylogic package and uses mamdani center of gravity algorithm for defuzzification. after optimization system has been tested over a software that creates random clinical scenarios within a range that can represent challenging patients. for each scenario jabour' weaning index, rapid shallow breathing index (rsbi) and pressure time index have also been calculated and compared with fuzzy-logic system. results indicate that currently used indexes and especially rsbi, disregard many important parameters and shown a potential to fail in many critical scenarios (in % of simulations). additionally we would like to discuss the potential of fuzzy-logic in clinical decision support, and design and optimization issues. trauma scoring systems used for uniform reporting and evaluation of trauma outcomes include physiologic, anatomic and combined systems. these systems have already been evaluated and shown to have accurate performance. we proposed a possible effect of response to resuscitation on the performance of trauma scoring. data necessary for calculation of iss, rts, triss and ascot systems have been retrospectively collected from the records of last consecutive trauma patients admitted to our surgical critical care unit. score and mortality prediction calculations have been performed over a software developed in our department, at three time points, at admission to er, after h of resuscitation, and at icu admission. additionally a fuzzy-logic inference system which uses physiologic variables as input has been designed for trauma related mortality prediction and applied to the same dataset. performances of scoring systems and fuzzy-logic inference system have been evaluated. results indicated that all systems have good discrimination, but variable calibration characteristics. for all systems evaluated response to resuscitation has effected system performance and scores and predicted mortality values calculated after resuscitation have shown better discrimination. fuzzy-logic inference system designed has shown discrimination characteristics comparable but not better then the other systems, which indicate the importance of inclusion of specific organ injuries in trauma scoring and mortality prediction. daily monitoring of immune/inflammatory status is a fundamental procedure in the icu. in small animal disease models such a surveillance is challenging given the limited blood volume available. to validate a new method for daily immuno-inflammatory monitoring in critically ill (septic) mice, we followed their short/longterm survival, organ function and inflammatory status. furthermore, the reliability of complete blood count (cbc) differential was tested in re-suspended blood cell pellet. female of- and cd- mice were subjected to cecal ligation and puncture (clp). ll blood samples were collected (facial vein puncture) from half of each strain daily for days or on day only. additionally, ll (diluted : ) volume was collected (of- only) and divided to compare cbcs in whole versus resuspended blood. there were no differences in / -day clp mortality. for both strains, changes in circulating interleukin- and chemical parameters (alt, ldh, bun, glucose) were comparable between sampled subgroups. ll sampling in of- mice caused a decrease of % in rbc and % in hb (both p < . ). in cd- animals, both rbc and hb showed a similar decrease of % (p > . ). platelet and wbc counts were unaffected. cbc comparison displayed a high correlation for all cell types (r > . , slope > . ) except lymphocytes (r > . ,slope > . ). this was reproduced in non-clp mice. the results indicate the minimal biological effect of daily sampling upon septic mice. cbc differential from resuspended pellet is highly reliable. this newly validated facial vein punture sampling protocol allows multi-directional monitoring in mouse models of critical illness such as acute peritonitis. introduction: a comparison of the amount of procalcitonin (pct) with that of c-reactive protein (crp) during various types of and severities of multiple trauma., and their relation to trauma-related complications, was performed. the aim of this study was to describe the amount of and the time course of pct and crp induction in patients with various types of and severities of high-velocity trauma. background: to provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (gsw) based on three clinical parameters. methods: all patients admitted to baragwanath hospital, johannesburg, south africa, between october and may for an isolated single craniocerebral gsw were retrospectively evaluated for the documentation of (a) blood pressure on admission, (b) inspection of the bullet entry and exit site, and (c) initial consciousness (n = ). results: conscious gsw victims had an early mortality risk of . %, unconscious patients a more than fourfold higher risk ( . %). patients with a systolic blood pressure between and mmhg had a . % risk of mortality. hypotension (< mmhg) doubled this risk ( . %) and severe hypertension ( mmhg) was associated with an even higher mortality rate of . %. patients without brain spilling out of the wound (''non-oozer'') exhibited a mortality of . %, whereas it was twice as high ( . %) in patients with brain spill (''oozer''). by logistic regression a prognostic index (pi) for each variant of the evaluated parameters could be established: non-oozer: , oozer: , conscious: , unconscious: , £rrsys < mmhg: , rrsys < mmhg: , rrsys mmhg: . this resulted in a score ( - ), by which the individual risk of early mortality after gsw can be anticipated. conclusions: three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral gsw was established. gunshot wounds to the head are associated with poor outcome. we reviewed data to identify prognostic factors. we performed a retrospective study of all patients admitted to a level trauma center with isolated gunshot injury to the head during six and half years. data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial ct scan characteristics. the primary outcome measure was the glasgow outcome scale (gos). seventy-two patients with isolated gunshot wounds to the head were admitted. overall mortality was %. the mortality for patients with an initial gcs of < was versus % for those with initial gcs > (p < . ). fifty percent had pupillary abnormalities on arrival at the emergency department. mortality in this group was versus % in those with normal pupillary reflexes (p = . ). elevated plasma lactate was associated with nonsurvival. thirteen percent of survivors were assessed as able to live independently after their injury. civilian gunshot injury to the head is related to high mortality. indicators of outcome are the admission gcs score, pupillary abnormality, metabolic acidosis, and ct pattern of severe injury. introduction and objectives: the aim of this study is to compare the effects of the mannitol and melatonin on the levels of blood and brain malondialdehyde (mda). methods: in the study, new zealand type rabbits were used. the test subjects were divided into four groups; sham (n = ), control (n = ), mannitol (n = ) and melatonin (n = ) groups. blood cerebrum tissue samples were taken to research for mda in the control group. head trauma was applied with feeney method to the rabbits in the other groups. venose blood samples were taken before and after trauma to observe mda. mg/kg melatonin was given to the melatonin group, and g/kg mannitol was given to mannitol ( %), between and in ( . %), and between and in patients ( . %). mortality rate was % (n = ). patients who died had significantly higher iss (p < . ), lower gcs, (p < . ), and higher head ais (p < . ). conclusions: road traffic collision is the leading cause of head injury in our setting. in this study population, head injury was severe, more than one fifth of the cases were admitted to the icu, and gcs was below in %. patients who died had significantly higher iss, lower gcs, and higher head ais. backgrounds and objectives: benefits of emergency burr-hole craniotomy (or evacuation) for patients with critical head trauma remained unclear. our study objective is to compare the effectiveness of burr-hole craniotomy to decompressive craniotomy using data from a large-scaled, multicenter and nationwide registry of hospitalized trauma patients in japan. materials and methods: among a total of records registered in japan trauma data bank, we selected patients with critical head trauma which were scored as ais (critical injury on the abbreviated injury scale) on head and underwent either of burr-hole craniotomy or decompressive craniotomy. parameters of the trauma injury severity score (triss) were used to adjust the baseline trauma severity. univariate analysis and multivariate logistic regression analysis estimated the relative risk of inhospital death. results: a total of zygomatic and/or orbital fractures were identified with subtarsal ( %), subciliary ( %), transconjunctival ( %) incisions, and laceration ( %). the risk of ectropion was highest in subciliary incisions ( . %, p = . ), however, only one case required operative management. entropion was found in two cases after transconjunctival incisions (p = . ); both required operative management. lid edema was present in . % of subtarsal and . % of subciliary incisions (p = . ). one hypertrophic scar was seen with the subtarsal and two cases with the subciliary approach (p = . ). conclusions: lower eyelid malposition occurs after any lower eyelid incisions for facial fracture repair. ectropion is most commonly seen in subciliary incisions, while entropion is rare. a subtarsal incision has a low risk of malposition, however is associated with hypertrophic scars. although choice of incision can be based on surgeon preference, a thorough patient discussion must include potential complications with each approach. in traumatology things happen quickly, data are often incomplete and therefore misleading and there is also pressure for quick decision. in dealing with the matter we distinct among wrong decisions based on insufficient data and errors due to systemic faults or individual incompetence or negligence. possible systemic faults are at every level of treatment: taking history, clinical examination, diagnostics, decision making, treatment procedures and even rehabilitation. most analysed errors occured when patient was handed over to another team or another level of treatment. haste and insufficient or inadequate report leads to wrong assumptions and -if that is not discovered in time -to wrong treatment. on personal level usual mistake was being satisfied when one injury was found and others were missed to insufficient exam or diagnostics. dealing with unfamiliar drugs lead to overdosage and sometimes death of the patient. to avoid such disasters extra training was added to medical school and medical students systematically approach the subject. at the emergency department adherence to protocols is encouraged, especially in cases of unresponsive patients. on hospital level enough time should be provided for attending physicians to make thorough rounds. this should provide much needed redundancy in the age of maximum efficiency. unfortunately we feel it is still not possible to implement measures of self-reporting as known by the airline industry due to inadequate law regulation! author to editor: measures for preventing medical errors in trauma department is showed. background and aim: missed injuries adversely affect patient outcome and damage physician, as well as institutional, credibility. autopsies are useful in uncovering missed injuries or undiagnosed conditions that contribute to death after injury. the aim of this paper is to analyze and compare medical documentation and autopsies findings in searching for missing injuries in trauma fatalities treated in our hospital. patients and methods: we analyzed data for patients died after trauma in years period (january st, -december st, introduction: immune suppression is a compensatory mechanism in acute inflammation e.g. following trauma. multiple mechanisms underlying this phenomenon include decreased cytokine production, shifts in cytokine balance and unresponsive adaptive immunity. we show in a model of acute inflammation that neutrophils, apart from their established pro-inflammatory characteristics, possess multiple mechanisms mediating immune suppression. methods: healthy male volunteers were given ng/kg e. coli lipopolysaccharides intravenously. blood was taken at various time points. neutrophils were stained with antibodies and isolated by facs. neutrophil receptor-expression, phagocytosis and oxidase were measured. lymphocytes were cultured in the presence of neutrophil subsets and cd /cd or pha. proliferation was measured by incorporation of h. results: distinct neutrophil subsets were identified. - h after administration of lps % of neutrophils displayed a two to threefold decreased expression in innate immune receptors, decreased phagocytosis and oxidase production. another neutrophil subset ( %) inhibited lymphocyte proliferation by % (in the presence of cd /cd or pha) in a : ratio independent of il- , tgfb, arginase or indoleamine - . instead direct delivery of h o appeared to be the mechanism of immune suppression. conclusion: in acute inflammation neutrophils utilize multiple mechanisms mediating immune suppression. firstly refractory neutrophils appear in the circulation. secondly another population of circulating neutrophils effectively suppresses adaptive immunity. these observations dictate an important role for neutrophil-mediated immune suppression following conditions such as trauma, contributing to the susceptibility to infections seen in these patients. sham-group) received a single intraperitoneal injection of either zinc protoporphyrin (znpp), an ho inhibitor, hemin, an ho- inducer, or vehicle. h later, rats were anesthetized and subjected to hts, including bleeding, laparatomy, and reperfusion (inadequate and adequate phase) and were sacrificed h later. ho- mrna was determined by real-time pcr and ho activity was determined in liver homogenate. free iron was measured by electron paramagnetic resonance spectroscopy in nonhomogenized liver tissue. ho- mrna was elevated only in the hts-group pretreated with znpp versus the sham-group. ho activity was increased in all hts groups compared to sham groups, with the most distinctive increase seen in the hemin pretreated groups. plasma bilirubin values showed a similar increase in the groups pretreated with hemin. no significant difference was found in free iron concentration among all groups. our data show that changes of ho activity prior to hts are not associated with elevated free iron, late after reperfusion, suggesting that free iron released from ho is efficiently deactivated. introduction: cells of the innate immune system are essential in the development of inflammatory complications. the activation status of this system can be determined by analyzing expression activation markers on neutrophils in peripheral blood. our research group previously showed that a combination of these receptors, the 'priming score', reflected the inflammatory status of individual patients. hypothesis: systemic activation of the innate immune system attracts functional neutrophils into damaged tissues. dysfunctional neutrophils stay behind in the circulation, causing a paralyzed innate immune system and increased susceptibility to late onset sepsis (> days objectives: our study objective is to stratify risk factors of the second (within hours) and third peak (within days) of trauma death independently. materials and methods: , records from japan trauma data bank were retrospectively analyzed. as outcomes for the analysis, we defined the early and delayed death as deaths within days and those after days, respectively. based on the framework of trauma injury severity score (triss), coded glasgow coma scale (cgcs), coded systolic blood pressure (csbp), coded respiratory rate (crr), injury severity score (iss) and coded age (cage) were used as independent variables to determine the outcomes using proportional hazard analysis. conclusions: in our observation, statistically-significant risk factors of early and delayed trauma death differed. physiological severity largely affected the second peak. in contrast, the third peak mainly correlated to anatomical severity and elderly in age compared to risk for the second peak. especially, an initial hypotension might no longer affect the third peak of trauma death independently. regression analysis including all the parameters of rts as explanatory variables showed the odds ratios of categorical sbp variables predicting the inhospital death. results: a total of , records matched the inclusion criteria. score- , , , , a and b in sbp subcategory consisted of , , , , , , and patients, respectively. inhospital mortality of score- , , , , a and b were , , , , and %, respectively. after adjustment for rts, the odds ratios for the inhospital death of score- , , , , a and b were . , . , . , . , . (reference) and . , respectively. isolated head trauma were more frequent in score- b compared to score- a ( vs. %, p < . ). conclusion: a trauma patient with systolic hypertension ‡ mmhg is scored points in sbp category under rts rule, however, exposed to higher mortality rate similar to patients with points in sbp subcategory and maybe related to isolated head trauma. author to editor: to whom it may concern: we have received a e-mail replied from abstractagent.com which alert the exceed in limitations of abstract submission. the e-mail noticed us, the presenting author of this abstract (akira endo) posted or more abstract as a presenting author, however, the authors of ''increased mortality in trauma patients with systolic hypertension'' believed that akira endo in department of accdm, tmdu, japan surely posted this abstract only. the name ''akira endo'' is common in japan. we suppose that ''akira endo'' of the other institutes were doublecounted. editor to self: seçilmiş bildiri background: the united arab emirates (uae) is developing rapidly, with many foreign construction, farm, and industrial workers at risk of injury. aims: to assess external causes, risk factors, severity, and anatomical region of work-related injuries using a trauma registry. methods: surgical admissions / to / were recorded in the registry at the main trauma hospital in al-ain region, population , . prevention-related variables were analyzed using spss and severity quantified by injury severity scores (iss). results: there were work-related injury hospitalisations, equating to an incidence of about / , workers/year. males accounted for %, ages - years %, and nonnationals %, with % of workers from the indian sub-continent. external causes included falls %, falling objects %, powered machines %, animals %, burns %, and other %. at least % of falls were from relatively high levels. median iss was for all six main external causes. extremities were most frequently injured. mean hospitalisation was . days. % (n = ) were admitted to the intensive care unit and % (n = ) died after admission. conclusions: main external causes were proportionately much more frequent than in industrialised countries, and admissions prolonged. priorities include effective countermeasures for falls from height and falling objects, and for machinery injuries. improved work injury data, access to occupational health services, specific regulations and frequent inspections at all construction sites, workshops, and farms, together with appropriate penalties for safety violations, are essential to reduce incidence and severity of occupational injury among vulnerable migrant workers in the uae. introduction and objectives: immobilization of the spine in trauma patients at risk of spinal damage is performed using a rigid long spineboard or vacuum mattress both during pre-hospital and inhospital care. however, disadvantages of these immobilization devices in terms of discomfort and tissue-interface pressures have guided the development of a new soft-layered long spineboard. we compared tissue-interface pressure and degree of comfort during immobilization on a rigid spineboard, a vacuum mattress and a newly developed soft-layered long spineboard. methods: in this randomized cross-over trial, volunteers were immobilized sequentially on all three devices for min per device. tissue-interface pressures were measured using an xsensor pressure mapping device, including the peak pressure and the peak pressure index (ppi). comfort was rated on a visual analogue scale (vas) after min and after min of immobilization. results: tissue-interface pressures were significantly higher on the standard long spineboard and the vacuum mattress than on the softlayered long spineboard. ppi for the sacrum on the soft-layered long spineboard was significantly lower than on both other devices, with an average ppi close to normal diastolic blood pressures. the participants reported significantly more comfort on the soft-layered long spineboard compared to the rigid long spineboard, both after and min (p < . ). conclusion: using the soft-layered long spineboard, which imposes less pressure on the tissue and provides better comfort than the standard long spineboard and the vacuum mattress, means buying time to optimize the patient's treatment while minimizing tissue damage. background: trauma and emergency surgery models differ all across europe. no definitive model was accepted and work and surgical emergency load are different in each region. we performed a cohort study to analyze the impact of emergency (including trauma) surgery in the general surgical practice at a portuguese university hospital. methods: data on emergency surgical cases and admissions to the surgical service over a -month period were collected and analyzed; this included patient demographics, referral sources, diagnosis, operation, and length of stay (los conclusion: emergency workload represents a significant part of the work for the general surgeons. the emergency surgical cases and admissions had a significant impact in the mortality rates of the general surgery admissions. resource planning and training should be based on more comprehensive, prospective data such as these. background: the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance remain uncertain. the aim of this study was to investigate the cost-effectiveness of hems assistance versus emergency medical services (ems). methods: a prospective cohort study was performed at a level i trauma centre. quality of life measurements were obtained at year after trauma, using the euroqol- d as generic measure. health outcomes and costs were combined into costs per quality-adjusted life year (qaly). results: the study population receiving hems assistance was more severely injured than that receiving ems assistance only. the incremental costs for intramural care were e , for hems treated patients compared with patients treated by ems only, which was mainly determined by the costs of the intensive care stay and the used diagnostics. finally, the costs for hems assistance instead of ems assistance were e , per qaly. the sensitivity analysis showed a cost-effectiveness ratio between e , and e , . conclusion: the costs per qaly for helicopter emergency medical services in the netherlands remain below the acceptance threshold. therefore, hems should be considered as cost-effective. author to editor: this study describes the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance. it investigates the cost-effectiveness of hems assistance versus emergency medical services (ems), and may serve as a reference for future quality of life and cost-effectiveness studies on the subject of hems and severely injured patients introduction: in usual multi-trauma care (utc) each partner has its own ''autonomous'' treatment perspective. clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('supported fast-track multi-trauma rehabilitation service': sftrs), featuring earlier transfer to a specialised trauma rehabilitation unit; earlier start of 'non-weight-bearing' training and multidisciplinary treatment; early individual goal-setting; co-ordination of treatment between trauma-surgeon and physiatrist, may be more (cost-)effective. the feasibility of a multi-centre trial examining the (cost-)effectiveness of sftrs was assessed. methods: data from multi-trauma patients (iss ‡ , complex multiple extremity injuries or complex pelvic fractures) were inventoried. patient characteristics, trauma severity, quality of life, health status, anxiety and depression, and cognitive functioning were assessed in two dutch trauma centres providing utc or sftrs. results: no differences in patient characteristics', trauma severity or discharge destination were found between sftrs and utc. discharge destination was 'home' ( . %), 'rehabilitation clinic' ( . %), 'nursing home' ( . %), 'other hospital' ( . %), 'unknown' ( . %). . % of patients died. however, hospital length-of-stay differed: . (sd: . ) days (sftrs) and . (sd: . ) days (utc). conclusion: adequate patient numbers may be recruited, baseline patient characteristics did not differ between collaborating centres, hospital length-of-stay was reduced in sftrs and adequate patient follow-up is possible. based hereupon, a nonrandomised multi-centre clinical trial started. (isrctn ). the trauma-region of north-west netherlands has consensus criteria for mobile medical team (mmt) scene dispatch. the mmt can be dispatched by the ems-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. although much attention has been paid to improve the dispatch criteria, the mmt is often cancelled after being dispatched. the aim of this study was to assess the cancellation rate and the noncompliant dispatches of our mmt, and to identify factors associated with this form of primary overtriage. methods: we conducted a retrospective case review of consecutive mmt-dispatches during a months period. by means of chart review, data pertinent to prehospital triage, patient's condition onscene and hospital course were collected and analyzed. all dispatches were evaluated by using the mmt-dispatch and mission appropriateness criteria results: median age was . years and . % of the patients was male. of these, patients were trauma victims ( . % blunt trauma). after being dispatched, the mmt was cancelled times ( . %). statistically significant differences between assists and cancellations were found for overall mortality, mean rts, gcs, and iss, mean hospitalization and amount of icu admissions (p < . ). almost % of all dispatches were neither appropriate, nor met the dispatch criteria. fourteen ( %) missions were appropriate, but did not meet the dispatch criteria. conclusions: nearly a half of mmt-dispatches were cancelled and almost % did not meet the dispatch criteria. dispatch criteria for the mobile medical team in our trauma-region need further refinement and compliance. the ''traumax Ò '' hip screw plate is a new device that allows the treatment the fractures both of the neck and the trochanteric area of the femur, expected subtrochanteric area. this plate conserves the characteristics of a dynamic hip screw (compression of the fracture site, good positioning of the pieces of bone, integrity of gluteus muscles) more specific characteristics: this device is modular, allows to choose the length of the barrel adapted to the length of the head screw, the diaphysal screws are locked by a tech nut according to the patented ''surfix'' system. the locked screw gives a good stability even if the bone has a poor density and allows to use a short plate that preserves the piercing lateral vessels of the femur. this short modular screw plate can be implanted by a cm minimal invasive approach using a particular instrumental pipe. during the presentation we will report the results of a prospective study colligating cases of ten french hospitals. a preliminary study of consecutives cases gives prominence to a few blooding with an average of ml, a operative time of an average of mn, a xr exposing time of an average of s. healing bone has been obtained in all cases. the head screw has been placed at the center or just below in %. no complication dues to the plate has been reported; in all cases only one approach has been used. aim: to assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint. methods: the patients ( feet) that had silastic implants inserted were reviewed at an average of years and months (ranging months to years and months). the mean patient age was years. these patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative aofas score was calculated for each. results: the questionnaire revealed that every patient described that their pain had decreased after surgery and feet ( %) were completely pain free. there was a significant improvement in patients' subjective pain scores after surgery (t value £ . ). preoperatively, the mean pain score for all feet was . , whereas post-operative the mean pain score was . . the mean aofas score before surgery was . . this increased to a mean score of . after surgery (p £ . ). this again is a significant improvement. no patient was dissatisfied with the outcome with their surgery. conclusion: these moderate term results are encouraging, with good subjective and objective results. however, long-term follow-up will be required to assess the longevity of this implant • theatre staff should be trained for proper application and cleaning of the exsanguinators • alcohol wipes are good alternative to current practice and should be used for decontamination • we must wash our hands before and after its use • we should use plastic bag over the limb first before using the exsanguinators it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator developed by the author. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanically. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site. it can be used as primary method or soon after external fixation if damaging control concept used. ( ) ( ) ( ) ( ) ( ) and followed-up for a minimum of years formed the study population. a retrospective review of data from electronic patient record (epr), clinical coding, clinic and gp letters was made. age, residential placement, garden's classification of fracture, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. an indepth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions was critically analysed. results: the mean age of patients was years (range - years). the incidence of non-union was % and avascular necrosis at year was %. revision surgery was performed in ( %) cases. complications were more principally in patients who had end-stage renal failure ( %), diabetes mellitus ( %), osteoporosis ( %), and steroid use ( %). conclusion: the complications and revision surgery rate was high in patients with particular co-morbidities despite being undisplaced. comorbidities and patient's age were also strong predictors of healing in addition to fracture configuration. outcome of hip fractures is influenced by complex interplay of multiple factors and not only by radiographic appearance. methods: this is a -year of retrospective study. we had included patients to our study ( females and males) with the average age of . . we used bryan and morrey classification system and included type i and type iii fractures. results: there were type i and three type iii fractures. associated injuries were two dislocations with one mcl injury and two radial nerve symptoms. all the patients had orif with screw and two patients had supplementation of fixation with wires. most patients were mobilized early in weeks time. nine of them treated with miniacutrak screw fixation, four with herbert screws and one lag screw (ao miniscrew). the approach was mainly postero-lateral but for five patients, it was antero-lateral. all patients were clinically and radiologically assessed. average time for radiological union was weeks. on the other hand, one patient had revision fixation because of failure of metalwork. additionally, one patient had capsular release for contraction and another one had removal of screw for prominence of metalwork. average follow-up was . months ( - months). mayo elbow score was excellent for seven patients, good for three patients, and fair for three patients. one patient could not be fully scored due to learning difficulties. we recommend open reduction and internal fixation for all type and type fractures so that function can be regained early. objectives: to report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. methods: a prospective study of the patients with intra-articular calcaneum fractures in the foot&ankle unit of a busy trauma hospital. all the patients were followed up with the calcaneal fracture score. we compared the outcome of surgical management sanders type (group a) and type (group b) fractures with conservative treatment (group c) at years and assessed the medium term outcomes of groups a and b. group c were a consecutive series of patients recruited to the study later than a and b, hence the smaller number in that group. results: patients were included in our study. there were in group a, in group b, and in group c. mean follow-ups for the groups were a = years, b = . years, and c = . years. mean -year scores for the groups were a = . , b = . , and c = . , with statistically significant differences between groups a and c (p = . ), and between groups b and c (p = . ), but no significant difference between groups a and b. at medium-term follow-up (> years), the scores for group a and b were . and . , respectively. there were deep, superficial infections and metalwork removals in total. conclusion: on comparing the medium term outcome to the -year one, group a showed some improvement and group b stayed the same. in this series, contrary to published articles, there was a better outcome at years with surgical treatment than conservative treatment. author to editor: all the authors have agreed with content of the abstract. there was not any conflict of interest for this study. objective: to assess the effectiveness of mobile angiography with a digital subtraction angiography (dsa) technology directly into the emergency room (er) for blunt trauma patients with pelvic injury. materials-methods: this is a retrospective review of a cohort of blunt trauma patients with pelvic injury treated after the direct availability of mobile angiography by trained trauma surgeons into the er for resuscitation. data was collected including demographics, hemodynamic variables, resuscitation intervals form admission through completion of hemostasis, metabolic factors (ph and body core temperature), mortality and transcatheter arterial embolization (tae) related complications. results: twenty-nine patients underwent tae in the er. mean age, shock index, and injury severity score were ± years old, . ± . , and ± , respectively. the interval from the decision to perform tae through initiation of tae and the interval from the decision to perform tae through completion of tae were ± min and ± min, respectively. the mean dbody core temperature (bt) from admission through completion of tae was - . ± . °c. and the mean dph from admission through completion of tae was . ± . . there were clinically significant correlations between dbt and resuscitation interval, and between dph and resuscitation interval. tae was successfully performed in all cases and mortality was %. no tae-related complications were observed. conclusion: immediate availability of mobile angiography into the er by trained trauma surgeons was effective to shorten the time required to restore normal physiology of trauma patients with pelvic injury without leaving the er for resuscitation. introduction: tgf-b is a regulatory protein, involved in fracture healing. the purpose of this study was to investigate the role of tgf-b in human fracture healing, and to verify whether tgf-b is a reliable marker of nonunion. methods: serum samples of patients with long bone fractures were collected over a period of months. patients were assigned to groups: first group contained patients with physiological fracture healing. eleven patients with nonunions formed the second group. healthy volunteers served as controls. results: in patients with physiological healing serum concentrations were initially high. serum concentrations then decreased rapidly after weeks and reached a plateau between weeks and . thereafter, another continuous slight increase of the concentrations was observed between weeks and . in patients with impaired fracture healing tgf-b serum concentrations were initially similar to those with normal healing. a significant increase of the concentration was observed between weeks and , followed by a continuous decline of the serum levels for the remainder of the observation period. significant differences between the concentrations in both groups were observed at weeks and . tgf-b as marker would have detected patients with nonunions at weeks after fracture with a sensitivity of % and a specificity of %. distal metaphyseal radial fractures are extremely common fractures in children (% , ). high rates of displacement occurs during conservative treatment. the aim of this study was to determine the effect of kirschner wire application after closed reduction of radial metaphyseal fractures with high risk of redisplacement. in this retrospective study cases were studied in two groups. in group (n = ), k-wire applied after closed reduction. in group (n = ), only cast was applied following closed reduction. the mean follow-up was months. the compared clinical and radiological parameters were; pain, limb deformity, range of motion of the wrist, angulation of the fracture site, radial distal epiphyseal angle and severity of translation. redisplacement rate was % in group and % in group . this shows, kirschner wire fixation had a positive effect in continuity of the initial reduction (p = . ). age (p = . ), gender (p = . ), reduction quality (p = . ) had no effect on redisplacement. concerning the severity of translation, the risk of redisplacement increases in stage ( - %) and stage (> %) fractures (p = . ). concomitant complete ulnar fracture had also redisplacement risk (p = . ). redisplacement risk increases when the distance of fracture line to epiphyseal line was between and mm (p = . ). there was no significant difference between two groups after last evaluation based on radiological parameters and clinical results (p > . ). as a conclusion; this study shows that kirschner wire fixation prevents redisplacement in early follow-up of first weeks but there is no superiority after months follow-up in distal metaphyseal fractures of children. patients in group c showed the best functional results, the greatest ankle range of motion, the fastest full bearing, the fastest walking on toes and heels, and the shortest duration of physical limitations (walking on uneven ground and sports activities) (p < . for all). in group b, there were two reruptures, in group c one, and in group a there were no reruptures. good functional results and a relatively small number of postsurgical complications advocate the usage of surgical techniques. the best and fastest functional recovery was attained in the group treated with the original technique of percutaneous fixation with two embracing and crossed loops. open surgical reconstruction is indicated only in the case of rerupture after percutaneous suturing. introduction: there are different techniques for arthrodesis of endstage arthrosis of the ankle-joint. internal fixation is the favoured method in many institutions. we retrospectively examined the technique and clinical results of external fixation in a triangular frame. patients/methods: from to a consecutive series of patients with end-stage arthritis of the ankle joint was treated. mean age at the index-procedure was . years, patients were male ( . %). via a bilateral approach the malleoli and the joint-surfaces were resected. an ao-fixator was applied with steinmann-nails. follow-up examination at mean . years included a standardised questionnaire and a clinical examination including the criteria of the aofas-score and radiographs. results: in two cases, due to contracture a pes equinus position had to be accepted. in two cases a further bone transplant was performed at and weeks for unsatisfactory bony union. after mean . weeks, radiographs confirmed satisfactory union and the fixator was removed. in four patients a nonunion of the anklearthrodesis developed ( . %). the mean aofas score improved from . to . points. statistical analysis of the insurance status showed that patients insured under a workers injury compensation scheme had a mean score of . compared to . for the remaining (p = . ). discussion: nonunion rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods in literature comparison. the complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations. implants with multidirectional locked screws have theoretical advantages in the treatment of periprosthetic fractures. in osteoporotic bone they provide a high stability. we concluded a retrospective study of a consecutive series of the outcome of vancouver b and c femoral injuries using two specific locked-implants. from to we treated patients with a periprosthetic fracture of the femur with a locked plate. the mean age at the index procedure was . years, patients were female ( %). in cases ( . %) we saw a hip endoprosthesis, in cases ( . %) a knee endoprosthesis and in cases both ( . %). outcome measures were intra-and postoperative complications, bony union, degree of mobility and social status, barthel-mobility-index and ''stand-up&go'' test. union occurred in cases ( . %) after the index procedure. twice the implant failed, we saw four general complications. the mean duration until full weight bearing status in these patients was . weeks. at follow-up patients ( %) had maintained the same social status as before the fracture. regarding the mobility status patients ( %) had regained their previous level, patients walking without aid before now required a cane and patients a walking frame. the mean barthel-index was points of . the mean stand-up&go time was measured as seconds. conclusion: overall failure rates of osteosynthesis after periprosthetic fractures of up to % are reported ( ). with . % implant related failures and % general complications, the presented methods achieve bony union and mobility in a high percentage of cases. arthroscopic-assisted percutaneous figure introduction: we describe a new arthroscopic-assisted reduction and percutaneous tension band wiring technique for patella fractures that combines the advantages of minimally invasive surgery and stable internal fixation. surgical technique: we reduce the fracture percutaneously by towel clips with the patient in the supine position. we insert two . mm kirschner (k) wires in a caudocranial direction under arthroscopic control. we do four stab incisions to assign the inferolateral (il) and inferomedial (im), superolateral (sl) and superomedial (sm) portals besides the k wire tips. we insert a trocar with its cannula from sl portal to sm portal under the k wires. we take the trocar out and leave the cannula inside. we run -gauge cerclage wire through the cannula in sl to sm direction. we take out the cannula. we perform exactly the same steps directed from sm portal to il portal, from il portal to im portal, and from im portal to sl portal, respectively. finally near the sl portal, wires are secured with a single knot. we check the fixation by c scope. results: radiographic consolidation was achieved in all five patients at an average of months. all patients returned to the activity level previous to fracture. conclusion: this technique presents advantages over open techniques. it is minimally invasive and cosmetically pleasing, permits visualization of reduction and stability, allows concomitant intraarticular pathology to be exposed, and facilitates early rehabilitation. although we did not attempted yet, we believe that even comminuted fractures can be fixed with this technique. ( ) timing of the procedure, ( ) accurate technique, ( ) stable implants for early mobilisation. in this study we present our experience in the treatment of ftp with locking plates trying to define the role of a medial plate. materials and methods: from to we treated patients with a ao c ftp by orif with locking plates. indications for a medial plate were: involvement of the medial joint surface, coronal fracture of the medial plateau and irreducible dislocated medial condyle. all the patients have been followed up clinically with the lysholm and rasmussen scores and radiographically until consolidation. results: all fractures united. one patient underwent knee amputation for septic complication. the mean lysholm score was ''fair'' while the rasmussen score was ''good'', that means that the subjective result was worse than the objective one. patients treated by double plating had a worse clinical result that was not dependent on the quality of reduction. we had three cases of malalignment, one rsd, two superficial infections, two transient nerve palsy. conclusion: complications in our series were frequent and the clinical results not particularly good. the right timing and an accurate surgical technique are essential for a good reduction, newer implants control effectively the fragments but the high energy of the trauma remains the major determinant of the bad outcome of these fractures. introduction: the high percentage of failure of fixation systems in periprosthetic fractures depends on the technical difficulty of the procedure, the presence of the cement mantle and the poor quality of the remaining bone. the lcp system offers an enhanced stability that reduce the implant mobilization, and preserves the bone vascularity, fastening the healing time. we present our results in the treatment of periprosthetic fractures with lcp. materials and methods: consecutive patients with vancouver b fractures were operated on using . lcp. a standard open reduction of the fracture through a lateral approach was used. patients were evaluated clinically and radiologically for a mean follow up time of . months. results: all the fractures united except two where a narrow . plate and too many cerclage wires around the fracture were used. all the patients showed at fu an hhs over points. the anatomical reduction of the fracture led to a faster healing. conclusions: the effect of the position of screws and cerclages in relation to the plate and fracture are discussed. the authors conclude that lcp system, has to be considered the golden standard in the osteosynthesis of vancouver type b periprosthetic hip fractures, permitting early weight bearing and healing in physiological time. it is better to avoid narrow . plates and cerclages at the fracture site. suggestions on the plate length and screw and cerclages position are given depending on the fracture type and length. the role of the anatomical prosthesis in the treatment of proximal humeral fractures ló ránt bardó cz, jános csotye pá ndy ká lmá n county hospital, gyula, hungary, traumatology introduction and objectives: we would like to present the results of the treatment of proximal humeral fractures with endoprosthesis. methods: between and we operated patients with endoprosthesis for proximal humeral fractures. were delta prosthesis, the results of these operations are the subject of an other presentation. patients were treated with anatomical shoulder prosthesis. the results of these were controlled by personal examination (constant score, x-ray) and by the base of the clinical documentation. was hemi-and total endoprosthesis. in cases the operation was acute and in cases for chronic cases. the average follow up time was . month. we categorized our patients in different groups, based on the fracture type and the time of the surgery. results: we compared the cs of the operated shoulder with the contralateral one in each patient group. we have to accentuate the importance of patient cathegorization, because the results can be analyzed properly only on base of these. on the x-rays the prosthesis were in good place, we found no evidence of losening. conclusions: when the indication is good, the prosthetic procedure is the choice for acute or chronic fractures of the proximal hunerus, and the results are good. we confirmed the statistically significancy of the efficacy of the treatment methods between the same analyzed groups. aim: to discover if how often lateral x-ray change the management of fracture neck of femur fractures as an adjunct to the standard ap film. method: orthopaedic consultants and registrar grade orthopaedic surgeons were asked to decide the management of neck of femur fracture solely from an ap film. at a second sitting the same films were shown in a different order in conjunction with the associated lateral hip x-ray. the surgeons were asked to comment on the adequacy of the lateral x-ray and their choice of management using the both films to make a decision. results: less than half of the lateral hip x-ray were adequate when reviewed on the monitors and very few operative decisions were changed with the addition of the lateral x-ray. conclusion: a standard ap film is usually sufficient to plan management in a fractured neck of femur fracture and the additional time, money, and discomfort of obtaining lateral films does not seem justified in these circumstances. an sermon, stefaan nijs, barbara bosch, paul broos department of traumatology, university hospitals gasthuisberg, leuven, belgium introduction: humeral head fractures extending into the shaft often are a challenge to the surgeon. although they are a rather rare entity, they often occur in osteoporotic bone and are difficult to stabilize. however, because of their intra-articular extension, a perfect reduction and stable osteosynthesis is needed. methods: between august and august , patients with a combined shaft and humeral head fracture were operated in our department. a long philos plate was used in all cases through an extended deltopectoral approach. postoperatively, immediate mobilization was allowed. mean follow-up time was months. results: there were three preoperatively existing radial nerve palsies of which two completely and one partially recuperated postoperatively. there occurred no radial nerve palsies which did not exist preoperatively. revision surgery was necessary in two patients because of hardware failure and secondary fracture displacement within the first week after surgery. in both cases, again a long philos plate was used. all fractures were radiographically healed within months; there were no cases of avascular necrosis of the humeral head. most of the patients were subjectively satisfied with the functional result although mobilization of the shoulder was only moderate in nearly half of the cases. conclusion: in conclusion we can say the use of long philos-plates for the treatment of combined shaft and humeral head fractures gives good results when carried out by experienced hands. osteosynthesis with the use of locked nails is an efficacious method for the treatment of long bone fractures and nonunions of extremities. however, it is contraindicated in case of infection. one way to obviate this problem is to coat implants with antibiotic-loaded bone cement. the objective of this work was to evaluate the efficiency of antibiotic cement-coated interlocking nails for osteosynthesis of long bones in case of infection (infected nonunions) or at high risk of its development (severe open fractures). in - , nails with antibacterial cement coating were used to treat patients including ones with severe open long bone fractures (gustilo-anderson type iiia-iiib). these fixators were employed both at admittance of the patients (with an isolated injury) and within - days after it (in case of polytrauma). patients of this group underwent one-step surgery combining osteosynthesis and the closure of soft-tissue defects with local muscular flaps. in patients with infected nonunions of long bones, osteosynthesis was performed after seeding fistula discharge for microflora. none of the patients in the group with severe bone fractures suffered deep suppuration and all achieved consolidation of fractures. one case of recurrent infection associated with extensive necrosis of bone was documented in the group of patients with infected nonunions. the remaining patients had resolution of signs of infectious process, and their nonunions consolidated. the use of antibiotic cementcoated interlocking nails is a promising method for osteosynthesis of long bones in case of infection and at high risk of its development. author to editor: severe open fractures and infected nonunions are one of the most difficult problems in trauma orthopedic surgery. we had only one treatment option for this pathology down to resent times. it was an external fixator, but it has many disadvantages. in we start using antibiotic cement-coated interlocking nail, and we have promising first results. this results we would like to present in eurotrauma . hawar akrawi, david gordon hargreaves department of trauma and orthopaedics, southampton university hospitals nhs trust, southampton, the united kingdom introduction: we describe our clinical experience with a new posterior approach for reconstruction of distal intercondylar fractures of humerus. the maserati approach comprises of a midline proximal triceps split in conjunction with elevation of medial and lateral edges of triceps from the condylar ridges. this approach gives adequate access for accurate reduction and internal fixation of distal and intraarticular humeral fractures. methods: a single consultant series of patients with distal humerus fractures (ao grade -a to -c) were treated using the maserati approach and distal humeral locking plates over -year period at level trauma centre. all cases were reviewed. there were female and male patients with age range from to year. average follow-up was months. these patients were assessed for: . accuracy of reduction of fracture fragments. . complications i.e. infection, triceps weakness, triceps lag and fracture union. . elbow function as per the mayo elbow performance score (meps). results: nine patients had anatomical reduction. no cases of infection or nonunion. one case of delayed union. none of the patients exhibited triceps lag or weakness. the meps was - (mean ). discussion: the maserati approach is a safe approach that provides good access to the articular surface of elbow without compromising the triceps muscle. triceps continuity is preserved, allowing early rehabilitation without the possible co-morbidities associated with other posterior elbow approaches (non-union of olecranon, triceps weakness or triceps lag). author to editor: dear sir/madam, i will be very grateful if you could offer me the opportunity to give a podium presentation about this innovative approach. patients with distal humeral fractures are difficult to manage and with oral presentation, i will be able to demonstrate clearly, with media presentation, the full advantage of this new approach. results: improvement of the neurological deficit was observed in cases. ct control at least of years follow up shows good bone integration of the iliac crest bone in majority of the cases. two patients experienced temporary neurological symptoms, which showed complete remission. the endoscopic procedure for reconstruction of the anterior load-bearing spinal column developed to a standard concept in trauma management. the minimal morbidity of the operative approach, good visualisation of the operative field and angle stable implant make it possible to restore the anterior column on a safe technique. full weight bearing (painless) ranged (un) - (ø ) and (rn) - (ø ) weeks. x-ray healing ranged (un) - (ø ) and (rn) - (ø ) weeks. there was one patient with delay union( weeks) in un group. there were any infection; loss of reduction; re-operation and nonunion in both groups. discussion: we started this study because many studies before preferred reamed nailing but we have long term experience with undreamed nail with the comparable results (retrospective analyze). our hypothesis is that the biological advantages of undreamed nail should display if the perfect technical performance is done. conclusion: there are no significant differences between un and rn groups in our study in this time. we expect recruiting more than patients by the year end and during next years we will be able evidence the data completely. this work was supported by the research project moofvz septic arthritis following acl reconstruction péter frö hlich zentralinstitution for sportsmedicine, budapest, hungary infection after arthroscopic anterior cruciate ligament reconstruction is an uncommon complication, which could be a danger not only for joint function, but also for the joint integrity. we have to differentiate by the clinical recognition of this complication from swelling caused by other conditions (for example suffusion). there is no standardized opinion and method in the field of arthroscopic or open procedure, or necessity of aggressive graft removing. from a consecutive case series of , patients, who underwent anterior cruciate ligament reconstruction between and . we report on patients with postoperative septic complication. of these were extraarticular, and intraarticular manifestation. our protocol is based on infection severity classification modified by gä chter. reliability and significance level of diagnostic criteria (clinical evaluation, laboratory tests, synovial fluid analysis, and bacterial culture) were analyzed. the outcome was determined by early recognition and consequent treatment. there is only one patient, whose acl tendon graft has to be removed. the ikdc score shows the following result: a: , b: , c: , d: , it proved to be similar to the multicenter studies. in the last years we have no more postoperative infection following acl reconstruction by the application our protocol. we will review this protocol. introduction: early fixation of long bone fractures in the multiple injured patient has been recognized as beneficial in minimizing secondary lung and remote organ failure. although early fracture fixation is expedient in px with multiple injury etc may be associated with post-traumatic systemic complication. in this study all pz from a consecutive series of trauma patients with truama team activation admitted between / and / to department of emergency of niguarda hospital in milan were included when they fulfilled all of the following criteria: directly admitted, iss of more than , and survival of more than h. patients with fracture of long bones and/or pelvis with a clear indication for operative treatment and the necessity of immediate fracture stabilization where treat according with dco. all other patients fulfilling the inclusion criteria with minor fracture or thus not requiring immediate fixation formed the control group. iss, rts and ps was calculated at the admission and reevaluated later by the trauma leader. all injury was classified with ao and gustilo classification conclusion: the goals of dco include stopping ongoing injury including local soft-tissue injury and remote organ injury secondary to local release of inflammatory mediators further thought to prevent pulmonary complications by allowing patients to avoid the enforced supine position. this study was conducted retrospectively to evacuate the effectiveness of the trauma team organization and to evaluate the concept of dco by immediate external fracture fixation and consecutive conversion osteosynthesis with regards to time saving, effectiveness and safety. introduction: injury of the soft tissue results in a release of numerous cytokines, which activate fibroblasts of the surrounding tissue to proliferate and to undergo a phenotypic transdifferentiation into contractile myofibroblasts (mfs). in this study we analyzed the hypothesis, that human joint capsule mfs are specifically regulated by the cytokine ifn-c via the modulation of alpha-smooth muscle actin (a-sma) which is responsible for the contractile phenotype. methods: joint capsules were obtained from patients undergoing orthopaedic surgeries. to investigate the functional effect of ifn-c, we cultured mfs in a three-dimensional ( d)-collagen gel contraction model. an alamarblue assay in combination with the collagen gels was established to analyze the viability and the proliferative capacity of mfs upon ifn-c treatment. the effect of ifn-c stimulation on the gene expression levels of the specific mf markers a-sma and collagen i is going to be determined by real-time pcr (rt-pcr). this part of the study is in progress. results: mfs cultured in the presence of ifn-c show a reduced proliferative capacity. moreover, the addition of ifn-c reveals a dose-dependent decrease of collagen gel contraction. these effects were specifically blocked by a neutralizing ifn-c antibody. first results of rt-pcr analysis show an inhibition of a-sma and collagen i gene expression by ifn-c. conclusions: ifn-c reduces mf viability and contractility in a dosedependent way, presumably by down-regulating mf specific genes. this study suggests that ifn-c might be effective in attenuating the contraction of soft tissue in fibrocontractive disorders. with an average age of . years old were included and a retrospective database study was performed. the outcome parameters we analysed were the radiological outcome, the functional outcome and the prevalence of complications. results: the fracture healed in an accurate anatomical position in all patients treated with esin ( %). seven patients ( , %) suffered from irritation around the entrance opening and in four patients ( . %) the pen migrated medially. in eight cases ( , %), this resulted in a reoperation, consisting of remodelling, reposition or removal of the pen. in two cases we saw a refracture after removing the pen. the overall complication rate was . %. dash scores showed an average functional outcome of . points (range: - ) at . months follow-up. conclusion: operative treatment with esin in dislocated midclavicular fractures offers good mid-term radiological results and a good dash score. the overall prevalence of complications was . % and in . % a re-operation was required. the results found in the available literature showed a re-intervention rate of %. prospective randomised research is required in order to determine the right surgical indications and to find out what the long-term results of this relatively new method of fixation are. aim: our main aim was to find out whether there is a place for nonoperative treatment as a definitive primary option in patients with significant medical co-morbidity. methods: we did this audit in collating information on , hip fracture patients across nhs hospitals in england. out of , ( . %) patients were treated conservatively. results: there were males and females patients managed conservatively in our study. during hospitalisation, became bedridden and died. among these patients, were deemed physically unfit for surgery by anaesthetists and by medical consultants. the decision was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. five patients refused surgery and five patients were palliative due to terminal illnesses. patients who did not proceed to surgery had significantly higher mortality rates (overall mortality rate %) suggesting that they were physiologically much worse group of patients. conclusion: as the average life span of our population increases, some hip fractures are now treated nonoperatively because of the possibility of severe or fatal complications due to surgery. often, refusal of surgery by the patient or the patients' family obligates the need for nonoperative treatment. it might be acceptable not to opt for the surgery if the patients are medically very high risk because of these reasons (e.g. acute cardiac event, severe aortic stenosis, multiorgan failure etc). the burden of patients with pubic rami fractures seems to be increasing. more patients with pubic rami fractures are admitted to hospital due to the absolute increase in the number of elderly people. although pubic ramus fractures are generally considered a benign fracture for its inherent stability experience indicated that this fracture is accompanied with a high morbidity and mortality. in a case-control study patients aged over years old with an isolated single fracture of the pubic rami admitted to the hospital were compared for morbidity and mortality to age-and gender matched hospitalized patients without fractures. data was acquired by the patient files. during years patients, with a median age of . (range: - ) years, were admitted with a median length of stay of days (range: - ). the mortality rates of patients with isolated pubic rami fractures at , , and years were significantly higher in the patient group compared to our control group, being: . , . and . %, respectively (p < . ). one third of the mortality is explained by cardiovascular events. during hospital admission a complication rate of . % was found, which was mainly caused by infectious diseases, including urinary tract infection and pneumonia. thirty-three percent of the patients (temporarily) went to a nursing home, because of the incapability to mobilise independently. in conclusion, patients admitted to the hospital for an isolated pubic ramus fracture have significant morbidity and mortality both during hospital admission and during -year follow-up. purpose: comminute fractures of the radial head are challenging to treat with open reduction and internal fixation. radial head arthroplasty is an alternative treatment. the purpose of this study was evaluating our results of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with modular pyrocarbon/metallic prosthesis. methods: from may to september , patients were operated for traumatic injuries in elbow. there were female and male with mean age ( - years). the follow-up was a mean of months ( - months). fractures of the radial head have been classified by mason with a subsequent modification by johnston. the indication for a radial head replacement are comminuted type iii fractures in cases, type iv in cases, and monteggia variant with olecranon and radial head fractures in cases. results: by using the mayo elbow score, patients had good/ excellent results, with fair and poor outcomes. patients showed an average arc of motion from - º to º. complications were three implant dislocations, needed to remove the implant. asymptomatic radiographic heterotopic ossification in elbow was showed in one case and bone lucencies were found in seven cases. we had not seen persistent instability, infection, synostosis, loosening, severe degenerative changes or impingement. conclusion: the treatment of unreconstructible comminute radial head fracture with noncemented pyrocarbon radial head implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated injuries. methods: this retrospective clinical study is a follow-up examination of bony avulsion fractures of the intercondyloid eminence in adults and adolescents treated in our hospital in the last years. after the medical history was recorded, the course of the accident and type of injury was documented (classification according to meyers and mckeever) . also the type of treatment (conservative, arthroscopic surgery or open surgery) and accompanying injuries were analysed. the clinical follow-up examination took place after more than months after the trauma. during the face-to-face interview, physical and radiological examination, the knee function, and especially the stability of the knee-joint were assessed. furthermore the clinical outcome was determined using the lachmann-test and the lysholm-knee-score. results: the patient group consisted of male and female patients aged - years. the patients showed subjective and functionally predominant good to very good results. despite subjective stability and absence of pain, in some patients remained a mild hyperlaxity of the anterior cruciate ligament. conclusion: fractures of the intercondyloid eminence are a rare but serious injury of the knee. the correct diagnosis, classification, and curative treatment of the fracture is indispensable for the flawless function and stability. an individual approach is necessary in every patient. distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. the angle stable plate, often also multidirectional is today the most common stabilisation device. because of the introduction of bulky and bended implants as the micronail or targon dr we decided to test the xs radius nail witch is a , mm or , mm straight nail and witch is introduced after guide wire placement and over drilling with a cannulated drill of the same diameter. it is locked parallel to the joint in different directions with angular stability with threaded wires. methods: radius sawbones were osteotomised corresponding to a a fracture and stabilised with a angle stable plate ( ) and xs nail ( ). , alternating load cycles from - n were performed and the deformation was registered. also a fe analysis with the msc patran/marc software were performed. both types of osteosynthesis showed good stability. the deformation of the xs group however was % lower. also the calculated deformation in the fe study was % lower. also deformation amplitude was lower with . mm compared to . mm in the plate group. the differences however were not significant. both devices show good biomechanical results. the xs nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. styloideus radii and over drilling with a cannulated drill of the same size. the exposure of the n rad.superf. must be performed. first clinical evaluation is presented. angioembolization in severe pelvic fractures: experience of a tertiary centre in united arab emirates results: twelve patients (all males) having a median (range) age of ( - ) years were studied. five were vehicle drivers, four passengers, two pedestrians, and one fall from height. seven had abdominal tenderness while four had abdominal guarding. median (range) systolic blood pressure before angioembolization was ( - ) mmhg and ( - ) mmhg after embolization. nine patients had unilateral internal iliac artery embolization, one had embolization of the pubic bone artery, one had pudendal artery embolization, and one had bilateral iliac embolization and liver embolization. six patients had external fixation of the pelvis after the angioembolization. three patients had a laparotomy, the first had intraperitoneal urinary bladder rupture which was repaired, the second had pelvic packing and diverting colostomy for a severe perineal wound, the third had a liver injury and died on the table. one patient had a thoracotomy with interposition aortic thoracic graft. eleven were admitted to the icu having a median (range) icu stay of ( - ) days. the overall median (range) hospital stay was ( - ) days. only one patient died ( . %). conclusions: angioembolization of severe pelvic fractures with haemorrhage was successful in % of cases and played an important role in the initial management of severe pelvic fractures with haemorrhage. there were nine female and eight male patients passed with a mean age of . years. the knees were assessed at regular intervals and the mean follow-up period was . months (range - ). after initial assessment to confirm absence of trochlear dysplasia, the technique involves plication of the medial retinaculum with a nonabsorbable suture passed percutaneously using a long curved needle under arthroscopic vision and a small incision to bury the knot from the plication. post operative rehabilitation was done with flexion restricted to °for the first weeks followed by a gradual return to normal range of movements with vastus medialis obliquus strengthening exercises. results: patients reported good outcomes with no further episodes of dislocations. one patient who had persistent patellar instability requiring further distal bony-realignment procedure to achieve stability. none of the patients had major complications. conclusion: we report good results with this relatively simple technique of medial retinacular plication and would advocate it as an effectiveless invasive surgical option for patients with recurrent patellar instability in the absence of major trochlear abnormality or significant mal alignment. in a lateral (group a) and in a prone position (group b) with no significant difference in age ( . / . years) as well as pre-and insurgery parameters; no patients were excluded. the complication rate was analyzed by medical records, the radiographic outcome by plain x-rays and ct scans after an average of months postoperatively. comparison of the two patient groups utilized t-tests or chisquare testing of pearson as determined by number of data points for each variable assessed. results: the adequacy of fracture reduction had significantly poorer findings according to matta in a (p = . ), resulting in a significantly higher post-traumatic arthrosis rate (p = . ) defined as helfet iii or iv. no revision surgery was needed; no infection was detected in any group whereas iatrogenic nerve damages ( temporary, persistent) were found only in a. there was no significant difference concerning extensive blood loss, femoral head necrosis, epstein grades, heterotopic ossification classified by brooker and secondary surgery needed. conclusions: due to gravity the femoral head in the lateral position may constrain reduction leading to an inferior radiographic outcome. purpose: the incidence of fracture neck of femur (nof) has been increasing worldwide, due to an aging population. the commonest forms of analgesia are opioids and in some units regional blockade. but regional block is skill dependent and opiates are known to have many side effects. paracetamol is an analgesia that is safe and has an excellent side-effect profile within standard doses. intravenous paracetamol has a far higher predictable bio-availability than oral, within standard dosage. this study is to assess the suitability of using intravenous paracetamol as an alternative. method: prospective study: a change in protocol resulted in all nof's admitted under the care of the senior author being prescribed regular intra-venous paracetamol within standard dosage. prn opioids were available for breakthrough pain. nof's admitted under the care of other consultants remained on the established protocol. opioid usage and pain scores ( - ) were measured. results: results of patients were collected, in intravenous paracetamol group and in the original protocol group. there is a % reduction in opiate usage in the intravenous paracetamol group (p value = . ). there is only a . difference in average pain score between groups (p value = . ). conclusion: the use of regular intra-venous paracetamol results in a significant reduction in the need for opioid analgesia. the pain relief within this group was comparable to that in the control group. a simple change in analgesia protocol to a safer, more predictive agent can result in an improved pre/postoperative period. author to editor: funding: the study received no funding from any source. external fixation has already became on the end of last century as routine temporarily method of fracture bone fixation, especially in the light of damage control. but out of damage control, external fixation has been accepted in many developed countries as routine temporarily method in treatment of complex articular fractures (knee, ankle, elbow). the main reason was absence (night time, weekend) of experienced surgeon who can treat these complex particular fractures, as during the night. sometimes, the skin problem can prolong such fixation for three or more weeks. however, external fixation of tibia and distal radius can be method of choose for definitive treatment not only in open but in closed fractures as well. it becomes justified when high mobile and relatively simple external fixation devices have been developed allowing addition correction of reduction. in this paper, we want to present possibility of using already applied, external fixation device as temporarily method. about week after external fixation done (on femur or tibia) we developed technique existing external fixator to be used as a reduction device. once, desirable fracture reduction achieved, internal fixation is very easy and we do not need fluoroscopy control for reduction, just for internal device fixation by minimally invasive method. using this method, we already treated patients with femur fractures and with tibia fractures. from results obtained it can be concluded that external fixator developed by mitkovic is suitable to function as accurate fracture reduction device providing condition for simple minimally invasive internal fixation. results: with the antegrade nailing technique the mean postoperative constant score was . (flexion . °m abduction . °, pain . ). the elbow extension was free in . %. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % the nail perforated. in complications there was one prolonged bone healing, one pseudarthrosis and one infection. two thirds of the patients were very satisfied with the outcome. in the retrograde nailing technique the mean postoperative constant score was . (flexion . °, abduction . °, pain . ). the elbow extension was free in . %. only % of the patients showed a mild discomfort at the operative approach at the elbow. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % patients showed a postoperatively detected fracture in the supracondyle region. . % of the patients were very satisfied with their outcome. conclusion: the retrograde nailing technique is a save and sufficient method for treating humeral shaft fractures, especially because the rotator cuff is not disturbed. introduction and objectives: the bony bankart lesion is an avulsion fracture of the glenoid that usually occurs after anterior shoulder dislocation. this injury is frequently missed and often creates shoulder instability. therefore, open reduction and internal fixation (orif) of the fragment is recommended. in this study we looked at shoulder function, instability and pain after this operation. postoperative x-rays were reviewed on anatomical reduction. patients and methods: between and , bankart fractures were operated. they were classified according to ideberg. sixteen patients had an ideberg type b fracture and three a type . these patients received questionnaires with a number of validated scoring systems. we used the ases, rowe shoulder score and the dash questionnaire. results: the response was %. all respondents did get a stable shoulder after surgery. two patients regularly experience mild pain. the average rowe score was . (range - ). the average ases score for adl was (maximum score , adl unlimited). the median dash score on the quality of life was . (where means no loss of quality of life). there was a clear positive relationship between the radiological postoperative congruency of the joint, the shoulder function and quality of life. introduction: traumatic dislocation is the most severe form of ligament injury of knee.the purpose of this study is to report our cases in past years. methods: between and , knees in men and women; patients were treated for traumatic knee dislocation in our trauma center. the mean age was ( - ) years at the time of injury. the mechanism of injury were motor vehicle accident in , fall from high in and industrial accidents in patients. patients had additional extremity trauma. vascular injury detected in knees who required immediate reconstruction by vascular surgeons. the orthopaedic stabilization of the initial injury was bridging external fixation in knees included all vascular injuries. patients had fibular nerve palsy. in knees medial collateral ligament, in knees lateral collateral ligament, in knees anterior cruciate ligament, in knees posterior cruciate ligament and in knees posterol ateral corner lesions were diagnosed. one had tuberositas tibia avulsion. multiligament reconstruction was performed on a delayed basis in patients for a minimum of ( - ) month after the injury all patients had functional rehabilitation for a mean ( - ) weeks. results: at an average follow-up of . ( - ) years they were examined for stability and range of motion. all knees having multiligament reconstruction and of the patients in whom nonsurgical treatment was undertaken were stable. patients having multiligament reconstruction had slightly lower knee range of motion hypothesis: computed tomography (ct) is more accurate than bone scintigraphy for diagnosis of a radiographically occult scaphoid fracture. methods: in a study period of year, consecutive patients with a suspected scaphoid fracture but no fracture on scaphoid radiographs were evaluated with ct within h of injury and bone scintigraphy between and days after injury. the reference standard for a true (radiographic occult) scaphoid fracture was either ( ) diagnosis of fracture on both ct and bone scintigraphy, or ( ) in case of discrepancy, clinical and/or radiographic evidence of a fracture. results: ct showed scaphoid and other fractures. bone scintigraphy showed scaphoid and other fractures. according to the reference standard there were nine scaphoid fractures. the prevalence of true scaphoid fractures among suspected fractures was therefore %. ct had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value (ppv) of % and a negative predictive value (npv) of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. bone scintigraphy had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value of % and a negative predictive value of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. summary: this study could not confirm that early ct imaging is superior to bone scintigraphy for suspected scaphoid fractures. bone scintigraphy remains a highly sensitive and reasonably specific study for the diagnosis of an occult scaphoid fracture introduction: the therapeutic management of scaphoid fractures is still surrounded by controversy. immobilisation for non-or minimal displaced scaphoid fractures results in a union rate of more than %. functional outcome is often measured using clinical examination and radiological consolidation. however, the indication of how successful the treatment has been is the functional outcome of the patient. functional outcome of upper-extremity fractures can be measured reliably using the dash (disabilities of the arm shoulder and hand) outcome measure. materials-methods: consecutive patients with non-or minimally displaced scaphoid fractures, treated conservatively, were included. the trauma mechanism, treatment modality, diagnostic modalities, duration of cast immobilization and complications were analysed for all patients. functional outcome was measured using the dash outcome measure. results: patients showed good clinical and radiologic outcome after weeks of cast immobilization with a mean dash of . . six patients consolidated within weeks with a mean dash of . . three patients with four fractures took more than weeks to achieve clinical and radiologic consolidation and had a mean dash of . . the dash questionnaires showed statistically significant differences between patient age, fracture location and duration of cast immobilization. conclusion: conservative treatment of non-or minimally displaced scaphoid fractures results in good functional outcome after weeks of cast immobilization, particularly in young patients with distal or waist scaphoid fractures. objective: pedicle screw instrumentation is the most common procedure in stabilizing fractures of the throracolumbar spine, but yields an immanent potential for iatrogenic damage due to malpositioned pedicle screws. methods-materials: patients undergoing posterior instrumentations were included. preoparative ct scans were used to determine fracture level and classification. postoperative ct scan were evaluated for screw positions of all pedicle screws. cobb angles were compared to calculate the degree of reduction. the position of all pedicle screws was determined according to the classification proposed by zdichavsky. results: pedicle screws were assessed. pedicle screws were classified as optimal (ia, %), ib, iia, iib, iiia and iiib. malpositions were more often the more cranial pedicle instrumentation was performed ( % increase per level, p < . ). malpositions (ib-iiib) occurred more often on the right side of the patient (p < . ). the mean reduction was °. discussion: this study confirms the hitherto felt but unproven suspicion that malpositioning occurs more often in the upper thoracic spine. even more remarkably is the side-dependency in malpositioning. we attribute the higher rate of malpositioned screws on the right side of the patient to the circumstance that the surgeon usually stands on the left side of the patient and visual control of the direction of the pedicle screw during insertion is probably more difficult on the opponent side. we recommend envisioning this fact and -if navigation is not used -changing the position during the procedure. background: u-shaped sacral fractures are rare and highly unstable pelvic ring injuries. surgical stabilization may facilitate early mobilization and reduce mortality. however, limited evidence has prevented the development of a standard treatment algorithm. furthermore, little is known about the quality of life in these patients. purpose: to assess the injury characteristics, choice of treatment and quality of life of patients with u-shaped sacral fractures. methods: eight patients with u-shaped sacral fractures were identified over a -year period. neurological outcome was classified by gibbons' criteria. quality of life was evaluated using the euroqol- d questionnaire. results: there were five women and three men; the median age was years. the injury severity score ranged from to . definitive internal fixation was established after to days. percutaneous iliosacral screws were used in two patients with relatively stable fractures. transsacral plate osteosynthesis was used in one patient with minor displacement. triangular osteosynthesis with transsacral plating was used in four patients with multilevel sacral fractures, highly unstable fractures or traumatic spondylolysis l -s . one patient with an associated l fracture received a triangular osteosynthesis without transsacral plating. early partial weight bearing was encouraged whenever possible. follow-up ranged from to months (median months). four patients kept severe bowel and/ or bladder dysfunction. in the euroqol- d, pain, mood disorders and mobility problems prevailed. conclusion: u-shaped sacral fractures are rare and complex injuries. operative stabilization is tailor-made on the individual fracture characteristics. outcome is dominated by neurological deficits, pain, mood disorders and mobility problems. background: traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. in this study, we aimed to present traumatic amputated patients needed more psychiatric support than the other trauma patients during the hospitalization period in the orthopaedics and traumatology clinic and in the later periods more post-traumatic stress disorder could be observed in this patient group. patients and methods: twenty-two traumatic amputated patients who have been treated in our clinic were evaluated retrospectively. during the early post-traumatic period, between the nd and th day, it was observed whether they needed any psychiatric support treatment. after the th month of the trauma, the patients were referred to the psychiatry department, and it was evaluated whether they needed any psychiatric support treatment by measuring the 'post-traumatic stress disorder scale' (tssb-Ö ). results: twenty-one (% . ) of twenty-two patients were male, one (% . ) of them was female. introduction: intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. to date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures. materials and methods: fresh-frozen cadaver lower extremities were used to simulate an ao/ota -a fracture. six nails (expert tibial nailing system, synthes, salzburg, austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. after nail insertion, alignment in the coronal plane was recorded. results: mean varus malalignment was dependent on the entry point at the lateral tibia plateau. mean varus malalignment was °if nails were inserted at the lateral third, °at the middle third and °after nail insertion at the medial third. if nails were inserted from the medial third, valgus malalignment was recorded in two specimens. discussion: the effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. primary valgus deformation up to °can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion. introduction: treatment of patients with distal radial fractures is primarily based on radiologic parameters. however, correlation between these parameters and functional outcome is questionable. objective: determine the value of radiological parameters for the appropriate treatment of patients with distal radial fractures. methods: a retrospective analysis was performed for a consecutive series of patients with conservatively treated distal radial fractures. axial radial shortening, radial displacement, radial angle, dorsal angle, and dorsal displacement were measured on the postero-anterior and lateral x-rays. functional outcome was measured using the quick dash-score (qds). minimal follow up was months. the radiological findings of patients who met the criteria for conservative treatment were compared to those of patients that met the current criteria for operative treatment (dorsal angulation > °, radial angle > °, radial displacement > mm, radial shortening > mm and step off > mm) but who had been treated conservatively instead. results: in a -year period patients were treated conservatively for a distal radial fracture. the qds was performed in ( %) patients. male female ratio was : , the average age was years (range - ). the mean qds was (sd ± ; range - ). age and female sex associated negatively with the qds. none of the radiologic findings was associated with the qds. half of the patients met the current criteria for operative treatment. the qds of this group corresponded however with that of the correctly conservatively treated patients. introduction: conservative treatment is generally preferred for simple elbow dislocations. in this study, the clinical and radiological results of conservative treatment are retrospectively evaluated. the patients were treated with closed reduction, plaster splint and brace. methods: dislocations of all patients were towards posterior and the average length of immobilization was . days ( - days) after closed reduction. the patients were assessed clinically for range of motion, instability, and atrophy after . months of mean follow up. mayo elbow performance score (meps) was used to evaluate functional outcome. standard elbow x-rays were evaluated for degeneration, heterotopic ossification, and concentric reduction. results: the average age of the patients was . ( - ) years. none of the patients had muscular atrophy. four patients ( . %) reported mild pain with heavy activity. six patients ( . %) had neurological complaints related with ulnar nerve. the average flexion arc and average rotational arc were °and °, respectively. the differences between the contralateral elbow motions were . °for flexion arc and . °for rotational arc. four patients ( %) had minimal residual instability. three patients ( . %) had mild radiographic signs of arthrosis and patients ( . %) showed minimal-mild degree of heterotopic ossification. an average score of . was obtained using meps. only four patients ( %) considered themselves fully recovered. conclusion: closed reduction and immobilization is a universal method for simple elbow dislocations. however, although functional scores were excellent, most of the patients did not consider themselves fully recovered. anterior odontoid screw fixation (aosf) is a valuable treatment after of, reported union rates in the elderly vary between and % when assessed on plain radiographs. in this study union-rates in of treated with aosf in patients aged ‡ years were revisited and risk factors for non-union analyzed. retrospective data review of a prospectively gathered c -fracture patients treated with aosf for of and age ‡ years were included for study. asides demographics and common injury characteristics, injury radiographs and ct-scans were assessed for fracture displacement, type, atlantodental osteoarthritis and particularly focussing on the square surface of of. follow-up ct-scans were assessed for technical failures, odontoid union, number of screws in aosf, square surface of screws used and the related healing surface. there were male ( . %) and female ( . %) patients with a mean age of . ± . years at injury ( - y). mean follow-up with ct-scans was . ± . months ( . - . mo). intervall injury to aosf was . ± . days ( - days). mean square surface of fractures was . ± . mm ( . - . mm ) and mean osseus healing surface was . ± . % ( . - . %). ct-based analysis revealed osseus union in nine ( %), while the remaining nine patients ( %) revealed non-union. in two patients, symptomatic non-union indicated posterior fusion of c - . union-rate significantly correlated with increased fracture surface (p = . ). observable was the trend that using two screws for aosf correlated with increased fusion-rate compared to one screw (p = . ). lifethreathening hemorrhage is often seen in pelvic ring fractures. efficient treatment of this hemorrhage is critical for survival in these patients. the purpose was to analyse the causes of death in hemodynamically unstable patients with a pelvic ring fracture and to determine if standardized treatment will reduce mortality. retrospectively, all data were reviewed of hemodynamically unstable patients with a pelvic ring fracture in the period / / till / / . of all patients, the pathway of treatment was analysed and compared with the standardized treatment protocol in our clinic. all injuries were categorized in injuries in airway, breathing, circulation and disability according to atls Ò principles. death was classified as directly related to the pelvic fracture if the patient required massive transfusions, died within h after admission and had no other body area injury with ais ‡ responsible for persistent hemorrhagic shock. we reviewed the data of patients. / patients died ( %). these patients were significant older and had a significant higher iss and shock class than survivors. two patients died of pulmonary trauma ( %), patients ( %) died of exsanguination(c) and patients ( %) died due to major head trauma. in patients ( %) there was a combination of injuries, which caused death. thus, overall hypovolemic shock contributed to mortality in cases. only in three patients death could be directly related to hemorrhage from the pelvis. two nonsurviving patients ( %) were not treated according to our standardized treatment protocol. in the survivor group this was only one patient. there is no consensus on the treatment of the acute total achilles tendon rupture. treatment modality is chosen on the basis of patient characteristics or the preference of the attending surgeon. using ultrasound, the distance between the two tendon ends in equinus position can be measured. this could form the basis for decision making between conservative-and surgical treatment. this cohort study consists of consecutive patients, between january and january . using ultrasound, patients were assigned to a surgicalor conservative treatment group. a gap of more than mm in maximal equines position was an indication for surgical treatment. seventy-two patients, men and women, received a conservative treatment. in patients the achilles tendon was primarily sutured. in the surgical group the post operative treatment was identical to the conservative treatment. the male-female ratio did not differ significantly (p = . ). the average age was years. sports caused % (n = ) of all injuries. the surgical group showed six re-ruptures versus nine in the conservative group (p = . ). on average, a rerupture occurs after days. no significant difference in major and minor complications (p = . ). outpatient treatment was needed days for the surgical treatment group versus days for the conservative treatment group (p = . ). ultrasound measured distance between the two ends of the achilles tendon in equinus in an acute total rupture can be used as a selection method in making a decision between surgical and conservative treatment. introduction: missile wounds induced by aviation bomb splinters pertain to grave injuries, due to large wound area and high risk of complications. material-methods: patients with large defects, in of casescombined with long bone fractures caused by missile injuries were treated by us in the period of august-november in . every cases were subjected to radical primary debridement with complete drainage. after relevant preparation for soft tissue plastic repair (involving primary radical debridement, primary external fixation, complex drug therapy and repetitive regular debridement) the following repair procedures were undertaken: in four cases, soft tissue defects were covered via rotation of local flaps. in three cases, defects were covered through transplantation of free skin grafts. in four cases, large soft tissue defects were overlayed by vascularized thoraco-dorsal (ld flap). in two of these, bone defect repair was simultaneously performed applying avascular graft taken from hip bone crista. results: in seven cases, transplanted flaps adhered perfectly, without trophic or infective complications. in one case, rotated local flap necrotized due to interrupted perfusion, which was subsequently replaced by free skin transplant. in five cases, fracture consolidation was completed in - months. in remaining two cases (after bone defect repair), consolidation process still proceeds with satisfying rate. conclusion: transplantation of vascularized thoraco-dorsal flap is especially effective for covering large soft tissular defects. soft tissular plastic repair has the double advantage of defect reconstructive ability and prevention from secondary infections, with additional stimulation of bone tissue regeneration. introduction: shoulder arthroplasty remains a valuable treatment for complex fractures of the proximal humerus. however the success of anatomical arthroplasty is mainly dependent of anatomical healing of the tuberosities. even with specific prostheses and fixation techniques in - % of cases anatomical healing is not achieved. using a nonfracture specific trauma prosthesis we achieved better elevation and abduction; however endorotation, exorotation, subjective shoulder rating and complication rate did score poorer than in anatomical arthroplasty. we assumed that the impossibility to refixate the lesser and greater tuberosity fragment, and subsequently the subscapularis and infraspinatus-teres minor tendons, are the main cause for this observation material-methods: we developed a fracture specific reversed shoulder prosthesis allowing for anatomical refixation of the tuberosities. we included patients in the reversed fracture arthroplasty group. function is scored using the constant murley-score. radiographically we evaluate for evidence of scapular notching. complications are recorded. we compare our results to an historical series of delta iii prostheses. results: at months the mean constant score is . points. there was no case of notching. there was one complication, an early infect. the mean constant score in the delta group was points. there was notching present in % of cases. in the delta group there were five reoperations in three patients because of dislocation. conclusion: there is a strong trend to better functional outcome using the fracture specific design. there are less complications and less notching. the possibility to refixate the tuberosities leads to better results. introduction: as fractures of the femur are severe injuries and patients mostly suffer from extensive pain they quickly attract the physician's attention in the emergency room. the literature has shown that injuries to the ipsilateral knee can occur accompanying such injuries. in most cases, these injuries though were diagnosed on delay. excluding cases in which a knee injury was apparent already on admission, we sought to investigate the number and severity of initially undetected lesions to the knee accompanying a femoral shaft fracture and give an overview of the literature. methods: charts and x-rays of patients treated for a femoral shaft fracture from january until december were reviewed. patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. also patients, in whom an injury to the knee had been diagnosed on admission, were excluded. results: fifty-three patients with midshaft femoral fractures were available for analysis. an injury to the knee was diagnosed in cases ( %). there was one partial tear of the posterior cruciate ligament and two grade lesions of the medial meniscus. all lesions were conservatively treated. the shoulder is the most mobile joint of the human body. it has a great range of movement that takes place in all three cartesian planes. this is a complex phenomenon. there is considerable controversy over an ideal method for the functional assessment of shoulder joint complex. various methods have been used but they are often inaccurate and unreliable. thus, a better technique, that is reliable as well as repeatable, is required to measure the movements. the aim of this study is to assess the shoulder movement by fastrak Ò and vicon Ò systems and to compare their repeatability. methods-materials: the functional movement of the shoulder joint was assessed by fastrak Ò and vicon Ò systems. a difference between the two systems was determined and a comparison of repeatability was carried out. a population of healthy male volunteers were asked to perform six different tasks that covered all the movements occurring at the shoulder. these tasks were repeated twice on each side on two different days. the measurements were recorded and a custom-made programme, prepared for each system separately, calculated the angles. results: the recorded data was analysed using repeated measure analysis of variance. it was found that the coefficient of repeatability of fastrak Ò was better than the vicon Ò system for each task and there was no significant difference (p < . ) between the two sides. conclusion: the fastrak Ò system is better than the vicon Ò system for assessing shoulder movements. it can be used in clinical practice. ( - ). we applied sarmiento cast without any padding or little padding immediately. we encouraged the patients moving their arms. the treatment ends upon the presence of a bone callus and absence of pain at the fracture site. during the whole therapy the skin condition is monitored and emphasis is put on the prevention of reflex sympathetic dystrophy. we evaluate the result of the treatment with a focus on the any restriction of the range of motion of joints and the presenting any angulation of the humeral shaft. average follow up time was months ( - ). all fractures were healed without any major problem and we did not face any nonunion and no major angulations axis of the humerus. average union time was months ( - ). the results of nonsurgical treatment of the humerus mid and distal thirds shaft fractures are reported as a less complicated way and have a higher rate of union. this method is practical, efficient, cheap, and safe, if a good cooperation with patients is established and close observation is done. ( ). the aim of this study is to evaluate the surgical anatomical aspects of the minimally invasive hip surgery procedure in cadavers. methods: the mis approach was performed on four specially embalmed cadavers. all cadavers had a normal 'range of motion' of the hip joint. the difference in muscle length and work space were measured in all leg positions. additionally the difference in muscle tension in anterior and posterior luxation was compared with regard to the accessibility of the femoral shaft. results: the length of the medial-and minimal gluteal muscles is reduced in abduction. a difference of more than cm was found between °to °abduction and full abduction. the working space ( . · cm), is limited in the maximum ( °) abduction position. posterior luxation gives a better femoral shaft approach and less/ none muscle tension/damage compared to anterior luxation. the optimal approach to the femoral neck during mis of the hip is achieved during °- °abduction of the ipsilateral leg combined with °retroflexion. the best femoral shaft approach for prosthesis insertion is the posterior luxation. no additional damage, excluding the skin and fascia incision, was seen during posterior luxation. posterior luxation and exorotation of the leg enables straight and direct access to the femoral shaft compared to the access obtained during anterior leg luxation. background: it has been stated that acromial morphology plays an important role in the etiology of rotator cuff pathology. the system most widely used to describe the morphology is the bigliani classification. recently nyfeller introduced the acromial index. we wanted to examine whether there is a correlation between these two parameters and the presence of a rotator cuff tear or an impingement syndrome. methods: we assessed both parameters in four groups of patients each. the first group consisted of patients with operatively treated rotator cuff tears (average age . years) and the second group of patients known with impingement syndrome but documented intact rotator cuff (average age . ). for both groups, an age and gender matched control group was constructed. results: type three acromions were significantly more prevalent in the rotator cuff tear group than in the control group (p < . ). the average acromial index was . + . in the rotator cuff tear group and . + . in the rotator cuff control group, which is not statistically significant (p = . ). in the impingement group, the acromial index was . + . and . + . in the impingement control group. this difference was found to be statistically significant (p < . ). conclusions: patients with a rotator cuff tear appear to have more frequently bigliani type three acromion than age and gender matched, asymptomatic patients. there is no correlation between acromial index and acromial type or age. objective: extracorporeal membrane oxygenation (ecmo) is rarely used successfully in trauma. transfusion related acute lung injury (trali) is also rare in plasma containing blood product transfusion. methods: this is a case report of a trauma patient with life-threatening trali following trauma that was rescued successfully using ecmo. a year old patient was struck by an automobile and suffered a grade ii splenic injury, grade iv-v right renal injury as well as multiple orthopedic injuries. an attempt at angiographic embolization failed as the patient required multiple transfusions and became progressively hypotensive. the patient underwent emergent nephrectomy but rapidly became hypoxic with the pao becoming less than mmhg for over an hour. despite aggressive attempts at ventilation and oxygenation, the endotracheal tube was filled with fluid and hypoxia pursued despite low right heart filling volumes. rescue ecmo was instituted with successful oxygenation. after h the patient recovered from trali and was able to have ecmo discontinued. the patient was weaned off the ventilator within days and the patient had full recovery. the patient did not suffer any hypoxic brain insult. conclusions: although it is often thought that ecmo is unsuccessful in trauma patients, this case demonstrates its potential use in trauma patients. author to editor: will also present as poster findings: a total number of patients (all male; . ± . ) were found. injuries were resulting from gun shot fires (n = ; . %) or stab wounds (n = ; . %). injury sites within the heart were the right atrium (n = ; . %), the right ventricle (n = ; . %), the left atrium (n = ; . %), and the left ventricle (n = ; . %) (more than one site was observed in patients). the accompanying injuries were observed in the spleen (n = ; . %), the lung (n = ; . %), the liver (n = ; . %), and the stomach (n = ; . %). in ( . %) patients emergent thoracotomy was clinically decided with suspicious findings of hypovolemic shock or cardiac injury including low blood pressure, jugular fullness, deeply heard heart sounds, filiform pulse, narrowing of pulse pressure. the rest patients (n = ; . %) were operated after major blood drainage from tube thoracostomy. all the injuries were repaired with sutures, and pericardial fenestration was done in all. mortality was observed in two cases ( . %). patients with penetrating regional wounds should be suspected for penetrating cardiac injuries, since immediate surgical intervention may decrease the risk of mortality. introduction: the use of ''pan-ct'' is discouraged in settings of high imaging demand. this study compared clinical and plain chest film findings to determine need for, and results of, chest ct. methods: during recent month period, patients sustained blunt chest injury either isolated or in setting of multisystem trauma. data was tabulated by a combination of prospective and retrospective analysis. initial injury assessment followed atls protocol. supine chest film, followed by chest ct, were performed in all patients and compared with clinical findings. results: significant clinical findings were defined as tachypnea, decreased air entry, chest wall tenderness and initial oxygen saturation less than %. the presence of two or more of these clinical findings occurred in patients ( %). ct findings in this group included multiple rib fractures ± flail chest, sternal fractures, pneumothoraces, hemthoraces, and pulmonary contusions. higher ais and need for interventions occurred in this group. the co-existence of tachypnea and desaturation correlated with the need for tube thoracostomy in / patients( %) - pre-ct, post ct. conclusions: in patients with blunt chest injury, the presence of two or more of the clinical signs -tachypnea, decreased air entry, chest wall tenderness, oxygen saturation < % -is associated with: ( ) significant chest injury demonstrated on chest ct; ( ) higher correlation with ct findings than plain films alone; and ( ) introduction: complex regional pain syndrome (crps) sustained after trauma has a great negative impact on rehabilitation and activities of daily living. treatment is most often unrewarding. aim: to analyze prospectively the efficacy of endoscopic thoracic sympathectomy (ets) in reducing pain and disability associated with crps. patient and methods: over a -year period, patients ( females and males; mean age . ± . ) with posttraumatic crps underwent unilateral ets. the median duration of crps symptoms before ets was . months (range: . - ) . the sympathetic chain was resected from the second to fifth rib. mean postoperative follow-up was . ± . months (range: - . ). pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (vas) from to . results: one patient ( . %) had a hydrothorax and three patients ( %) complained about contralateral compensatory hyperhydrosis. at month (n = ), months (n = ), months (n = ) and year (n = ) after ets, there was a significant decrease in passive and active vas (p < . ). ten out of patients ( , %) needed less analgesics after surgery, and seven ( %) did not need analgesics at all. the mean sleep duration improved significant from . ± . h preoperatively to . ± . h postoperatively (p < . ). overall, patient satisfaction was % ( out of patients). conclusion: ets is efficient for decreasing pain and improving quality of life, and therefore should be considered in the treatment of crps. author to editor: complex regional pain syndrome (also known as sudeck or reflex sympathetic dystrophy) is a complex disease that trauma surgeons frequently encounter in the post-traumatic period. endoscopic thoracic sympathectomy is not well known among trauma surgeon, although it is an good option in relieving the pain and improving the quality of life. monitoring is accomplished with chest x-ray (cxr), but ultrasound (us) is nowadays established as more sensitive than cxr in detection of ptx. patients and methods: from october , thoracic views for detection of ptx are systematically included in the efast protocol during primary survey for every trauma patients (pts) admitted to our level i trauma center. among hospitalized pts, a selective usguided aspiration for small ptx was applied in three pts (two with a slow reabsorption time, one in a pt requiring hyperbaric oxygen therapy for a soft tissue infection of the leg). in supine position, delimitation of the area of anterior ptx was done with a linear probe, searching for lung points in adjacent intercostal spaces. under local anesthesia, a fr catheter was inserted in the ptx and aspiration monitored in real time by us, until restoration of sliding lung. the day after, after confirmation of normal gliding lung, two pts were discharged and one deemed suitable for hyperbaric oxygen therapy. discussion: small traumatic ptx is generally monitored without treatment. in some pts, drainage is however required, but the procedure is blind if performed on the basis of cxr findings. us allows to precisely define the site and the limits of ptx, insert a small catheter in the right area, monitoring reexpansion of the lung and complete aspiration of ptx and shortening recovery. background and objectives: occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. we report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with penetrating thoracoabdominal injuries. methods: the patients who underwent thoracoscopic management of thoracoabdominal stab injuries between june and june were included into the study. the data were retrospectively analyzed. results: eighteen selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. the procedures were performed under general (n = ) or local anesthesia (n = ). diaphragmatic injuries were repaired by intracorporeal sutures in seven cases and bleeding was controlled in another two cases by electrocautery coagulation. the procedures were simply diagnostic in nine patients. the mean operating time and hospital stay were . min and . days, respectively. there was neither intraoperative or early postoperative complication, nor mortality. in a patient who had intra thoracic adhesions due to prior tuberculosis, unmentioned by the patient preoperatively, adequate exploration could not be achieved during thoracoscopy. the procedure was converted to laparoscopy and laparoscopic gastric and diaphragmatic repairs were performed. conclusion: thoracoscopy seems to be a safe, quick and efficient method in the diagnosis and treatment of diaphragmatic wounds, due to thoracoabdominal penetrating injuries. the nonoperative management is gradually more used in abdominal stab injuries and surgeons can resort to thoracoscopy and laparoscopy as a minimally invasive, diagnostic and therapeutic tool. trauma surgeons should be aware of the benefits of thoracoscopy and must have sufficient skills to carry out this technique. summary: generating acute lung injury by smoke inhalation and analyzing a method to pursuit standardized smoke. methods: a standardized glass, measures of cm width, cm length and cm height used as a closed area. we established a valf system under the glass which allows air inside but does not let it outside. with a hole above the glass, we attached the system to pomp with a hose. and the pomp was attached to a cm radial length balloon by another hose. we put a four ampere electricity owen in to glass and put g cotton to the oven. we burned the cotton for s in the closed area and we fullfilled the balloon with smoke by the pomp in s. rabbits were entubated after being anestesized. we waited seconds for the smoke to reduce down to room tempe rature to avoid thermal damage. after that, we seperated the balloon from the pomp and put it right through rabbits by ambulant air flow and inhalated in min.this procedure repeated for each rabbit. after the procedure ended,the entubation tubes were pulled away and the rabbits were left to spontaneous respiration. rabbits were allowed to standart rabbit bait and water at the th hour. results: we think we used a standardized smoke inhalation model in this study. methods: ten wistar rats were anesthetized and heparinised before the femoral artery was pierced to initiate bleeding. rats were than randomized to control and study groups. mph was poured into the bleeding site and a mass was placed on it. after s, the mass was removed and assessment of hemostasis was done. if bleeding ceased the test was scored as ''passed at s''. if not, additional dose of mph and compression was reapplied for an additional s. if bleeding has stopped after the second application, the test was scored as ''passed at s''. if not, the same procedure was repeated for the last additional s. if bleeding stopped now test was scored as passed at s. similar sequence of trials was done in the control group but without mph. the difference between bleeding periods in two groups was observed. results: application of mph resulted in complete cessation of bleeding in four of five and one of five rats at and s, respectively. in the control group hemostasis could not be achieved in all five rats, even at s. the statistical difference between the groups was significant (p < . ( . - . year) with supracondylar humeral fractures were treated operatively. according to gartland ( %) were type-ii, ( %) were type-iii. at the time of arrival at emergency department, four ( %) children sustained vascular impairment with pink pulseless extremity persisting after reduction. in three cases, a cubital approach was performed. two arteries showed a major lesion (one direct suture, one saphenus vein graft), and one artery showed an entrapment. all lesions showed a normal postoperative pulsation. another three ( %) children sustained a complete paralysis of the radial nerve. these cases were conservatively treated with complete neural restitution. conclusions: urgent anatomical reduction and fixation are crucial. in persisting vascular impairment after reduction, surgical exploration for the restoration of arterial patency should be performed, even in the presence of a pink hand. conversion to open surgical repair was needed in one case due to retroperitoneal bleeding from the iliac arteries. early postoperative mortality was observed in ( %) patients; due to massive coagulation disorder and hemodynamic instabiliy in postop st day and th day. mean follow-up was months (range - months). late mortality was not observed. overall reintervention rate was % (n = ); proksimal re-stenting was needed due to type endoleak in one patient. embolectomy for crossfemoral bypass was needed in one other patient after stenting for aneurysmal abdominal aortic rupture, this patient underwent re-crossfemoral bypass surgery later on. introduction: dislocations of and fractures around the knee are accompanied by injuries of the regional vessels to a certain extent. in any case of suspicion at the scene of accident an immediate transport to an adequate trauma center is the precondition for successful limb salvage. methods: between and , patients with arterial injury after dislocation of or fractures around the knee have been treated. retrospective analysis was performed in order to acquire epidemiologic data. furthermore we investigated the sufficiency of preoperative management and diagnostics. we explored peri-and postoperative complications, such as compartment syndrome, secondary thrombosis, infection and number of revision surgeries and related the data to the final follow up after and months. results: arterial injury was found in four cases of knee dislocation, in seven cases of proximal tibial fracture, and in nine cases of distal femur fracture. seven patients underwent acute angiography, since the year all patients were assessed with cta. seventeen cases were treated with venous interposition, one with a venous patch, and two with direct suture. fasciotomy was performed in all cases. limb salvage was successful in cases. in seven cases secondary amputation was necessary, six of these patients were polytraumatized. discussion: sufficient time management is crucial for the survival of vessel injured extremities, as the time of ischaemia must not exceed h. perfect interdisciplinary coordination and the establishment of specific algorithms are needed in order to decrease the risk of complications and amputations of lower extremities. the survey on the epidemiology of car-motor related accidents in children in kashan, iran iman ghaffarpasand, maneli dorudian tehrani department of surgery, kashan medical university, kashan, iran introduction: the most common cause of death in children is accident and reinforced a lot of taxes on the society. kashan has the second position in trauma ranking of iran so we studied this important issue in the children. methods and material: in this descriptive study, data has been gathered by trained hospital nurses during month in traumatic patients refered to -bed teaching hospital, kashan. the main method is questionnaire filling by direct interviewing. findings: among cases of trauna ( . %) of them was children below years old that cases ( . %) were due to car accident, cases ( . %) were due to motor accident and rest of them ( . %) were pedestrian accident. boys involved . times as girls the most injuries happened was head-injury ( . %). conclusion: these finding suggest that we have to pay more attention to this age group specially - because of the high rate of their involvement. finally as you see the last but not the least, these findings emphasise on protective cap wearing for every persons. managing blunt splenic injury in a level ii trauma center: the laparoscopic option background: the past decades treatment modality of blunt splenic trauma was a point of discussion. where nowadays explorative laparotomy remains the standard of care for hemodynamic unstable patients, treatment of hemodynamic stable patients is less uniform. in this stable population maximum conservative approach seems preferable, though level evidence is still absent. failure of the conservative pathway is backed up by percutanous angioembolisation or laparoscopic salvation. the evolution to minimal invasive access makes laparotomy as a primary care for hemodynamic stable isolated splenic injury superfluous. methods: this paper discusses the initiation of explorative laparoscopy and successive splenectomy in two patients scoring a grade iii posttraumatic splenic injury. grading was based on ct scan imaging using the spleen injury scale defined by the american association for the surgery of trauma (aast). conservative treatment was abandoned because of moderate hemoperitoneum and continuing need for transfusion. results: an uncomplicated laparoscopic splenectomy was performed in both patients. perioperative spleen preserving measures failed because of the extent of the parenchymal lesion. conclusion: performing laparoscopic splenectomy seems a good procedure when conservative treatment for splenic injury fails. this accounts for a rural level ii trauma center where the accommodation to perform safe angioembolisation is missing, knowing that laparoscopic splenectomy is not a straight forward procedure but is made easier because of the growing skills of our surgeons. hepatic portal venous gas (hpvg) is often associated with serious intra-abdominal pathology like ischaemic bowel disease and necrotizing enterocolitis, with reported mortality rates above %, with most requiring urgent operation. however, hpvg has been reported seen on ultrasound or computed tomography (ct) scans immediately after blunt trauma, followed by spontaneous resolution. gastric pneumatosis (gp) has rarely been reported as a trauma-related entity. the combination of hpvg and gp after blunt trauma has been described in very few patients. we report the case of a -year-old woman who presented with an edh requiring craniotomy and an initial abdominal ct scan showing only an ois grade liver injury. a transient increase in serum amylase combined with abdominal distension led to a repeat abdominal ct scan h post injury to rule out pancreatic and duodenal injuries, revealing gp and hpvg. endoscopy demonstrated mucosal erythema of the posterior gastric wall from the fundus to the pylorus. however, the clinical status of the patient was benign, and did not mandate surgical intervention. the patient was treated nonoperatively with nasogastric decompression and antibiotic coverage, and underwent a successful recovery with no abdominal complications. to our knowledge, only one other adult patient has been described with hpvg and gp occurring after an initial normal abdominal ct scan. a gastric resection was performed, and operative treatment was recommended for this combination of entities in trauma patients. our patient shows that treatment strategies in these cases probably should be guided by the clinical status of the patient. introduction and aims: while the number of colorectal injuries due to penetrating trauma are increasing, increased traffic accident rates also cause the number of blunt rectal injuries associated with trauma in traffic accidents to be increased. rectal injuries occur rarely. because of post operative septic complications, morbidity and mortality rates are high. early admission, stability, operation type all play important roles in the fate of the patient. we aimed to investigate these criteria in our patients who have colorectal injuries. material-method: cases who had penetrating or blunt trauma in our district during last years were included in this study. aim of this study is to present three cases with torsion of omentum, that often resemble acute cholecystitis or appendicitis, and the diagnosis is made at the time of exploratory laparotomy. case description: the first case, a -year-old men, presented with a -day history of right hypocondrial abdominal pain, fever and vomiting. the pain increasing in severity while the patient is standing and relieved in supine position. laboratory findings were normal, except for mild leucocytosis ( , /cc). the patient underwent u/s examination, which showed an encysted mass in the right abdomen. a mass, originating from the omentum, was revealed after laparotomy. the mass was excised and an appendectomy was also performed. the second patient, a -year-old female, was admitted in our department with abdominal pain, associated with vomitus. a mild leucocytosis ( , /cc) was observed. an u/s was carried out, which revealed a mass · cm lying besides a stone-free gallbladder. the patient underwent diagnostic laparoscopy and a cystic mass, which was twisted, was resected using bipolar forceps. sixteen of all laparotomies did not reveal any internal organ lesion. of these laparotomies with negative findings, had been operated for stabbing injury and had been operated for gunshot injury. twenty-one cases had single organ injury; whereas, multiple organs were affected in cases. frequencies of organ injuries were as follows: small intestine, colon, stomach, liver, diaphragm, spleen, kidney, and pancreas. the mean duration of hospitalization was . ± days. after surgery, four cases needed intensive care unit; therefore, they were referred to a higher-level healthcare center. among cases whom the treatment was completed in our institution, had complication. conclusion: penetrating abdominal injuries mostly occurred in young males and stabbing injuries were more common. most penetrating injuries can be treated at secondary care centers. however, they should be referred to a higher-level institution after the initial intervention, when necessary. background: both nonoperative management (nom) of blunt hepatic trauma and the damage control laparotomy are significant advances in the management of massively injured trauma victims. methods: this study is a retrospective evaluation of patients admitted with liver trauma during . of them required early surgical procedures, damage control surgery and followed nom. patients were stratified by age, mechanism of injury, ais, initial blood pressure, heart rates, and blood transfusion volume. initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. readmission data including the number of admissions, surgical procedures, and hospital length of stay were then analyzed. the average age of the study group was , years. almost all of these patients were males ( , %) and car crash was the main mechanism involved ( , %). liver injuries were frequently an element of multiple trauma and was associated with cranio-cerebral trauma ( , %) and spleen lesion ( , %). the overall mortality during the first admission was , %, yet . % attributable to the liver trauma and only . % after damage control. conclusions: damage control surgery offers a simple effective alternative to the traditional surgical management of complex or multiple injuries. phase i can be done at a local hospital before transfer to a major trauma center for resuscitation and definitive repair. reasonable surgical procedures based on classification of liver injuries and damage control principles increase the survival rate of severe liver trauma. background: at our department, a simple scoring system based on three criteria (blood pressure below , be below - . and body temperature below °c) has been used to determine the suitability of individual patients as candidates for dcs. objectives: the present study was undertaken to establish a valid strategy for the treatment of severe pancreatic injury and to test the validity of the scoring system used at our department for identifying suitable candidates for dcs. subjects and methods: the subjects of the study were patients with the grater and equal of grade iii (organ injury scale (ois))pancreatic injury treated surgically (type iii in cases and iv or v in cases). results: resection of the pancreatic body and tail was performed in both the groups to treat type iii injury, and all of the cases with type iii injury had favorable outcomes. among the cases with type iv or v injury, all of those patients satisfying two or fewer than two of the criteria of the dcs scoring system survived dcs, while two patients satisfying all the three criteria of the dcs scoring system died after dcs. the two patients who underwent pancreatic duct-forming surgery needed prolonged hospitalization. discussion: our results suggest that dcs should be selected in cases where at least one of the three criteria of the dcs scoring system is satisfied. as a procedure for radical operation, resection of the distal pancreas may be recommended for type iii, and pancreatoduodenectomy for type iv or v. author to editor: our results suggest that dcs should be selected in cases where at least one of the three criteria (systolic pressure below , severe hypothermia with body temperature below °c, and acidosis with be below - . ) of the dcs scoring system is satisfied. this dcs score is accords with the score of another abstract (abs ref ). we did not show the details of the score in another abstract ( ). please refer in our another abstract (ref iatrogenic and traumatic lesions involving common hepatic duct and duodenum can be treated with a primary and contemporary reconstruction, at the condition of hemodynamic stability. we propose a technique which include the following steps: cholecystectomy with intraoperative cholangiography; transection of the common bile duct above the tear, oversewing its distal part; kocherization of the duodenum; a cm long roux-en-y jejunal loop is constructed and brought up retrocolically in the right sub-hepatic space, orientating its antimesenteric side towards the corresponding duodenal wall; termino-lateral hepatico-jejunostomy with a transanastomotic temporary stent in case of small biliary duct's size; a side-to-side jejuno-duodenostomy performed cm distally; a feeding jejunostomy. we remark the following advantages of this procedure: ( ) the rouxen-y biliary diversion reduces the risks of stenosis and cholangitis, frequent after a direct repair of the common bile duct; ( ) an adequate distance between the biliary and duodenal anastomosis prevent entero-biliary reflux; ( ) the duodeno-jejunal anastomosis appears more appropriate, considering the complications after direct repair of large duodenal tears. more aggressive options, such as duodeno-cephalo-pancreatectomy, pancreas-preserving-duodenectomy and segmental duodenal resection, must be considered more risk solutions. introduction: the liver is the most commonly affected organ in abdominal trauma. in our department, the majority of traumatic liver injuries are treated conservatively. this option involves the monitoring of possible complications, such as late rupture, hemobilia, arterio-venous fistula, pseudo-aneurysm, biloma and abscess formation. case: a year-old patient was admitted after a m fall. established diagnoses were: multiple facial fractures, right pneumothorax with pulmonary contusion, right renal artery thrombosis and grade hepatic laceration. the patient was discharged on the st post-trauma day (ptd), after an uneventful course. on the st ptd, he was readmitted for abdominal pain. thoracoabdominal ct revealed an intra-hepatic arterio-venous fistula. angiographic superselective embolization was performed, and the patient was discharged following a control abdominal ct scan that showed resolution of the fistula. he was again readmitted on the th ptd, with abdominal pain, jaundice and gastrointestinal bleeding. an abdominal ultrasound raised the possibility of hemobilia, confirmed by upper endoscopy. a new angiography did not reveal any active bleeding, and an abdominal ct showed satisfactory evolution of the liver lesion. the patient was discharged on the th ptd, asymptomatic. at month follow-up, the patient presents no complaints, other than a new-onset arterial hypertension of renovascular origin. conclusion: arteriovenous fistulae and hemobilia are relatively uncommon sequelae of abdominal trauma. however, these diagnoses should be actively sought in the presence of abdominal pain, especially when associated with jaundice and gastrointestinal bleeding. a multidisciplinary approach is essential for a successful treatment. diaphragmatic hernias constitute frequent complications after thoracic and abdominal trauma ( . - %), especially on the left side ( %) and the diagnosis is frequently delayed. clinical presentation is variable and may include respiratory distress and abdominal pain, frequently attributed to intestinal obstruction, pancreatitis, biliary colic or peptic disease. the authors present a case report of a right diaphragmatic hernia diagnosed years after a thoracoabdominal blunt trauma. the male patient, years old, was admitted in the emergency room with epigastric pain, bloating, slight abdominal distension with months of evolution and recent worsening. he suffered a previous thoracoabdominal trauma years ago, consecutive to a downfall of about eight meters high with lumbar vertebrae fracture (l ) and was submitted to conservative treatment in an orthopaedic ward; x-ray signs of diaphragmatic hernia were unrecognized. actual chest x-ray revealed an elevated right hemidiaphragm and presence of abdominal content in the right hemithorax. mr demonstrated a right hemidiaphragmatic rupture and the presence of abdominal content in the thoracic cavity. patient was operated by laparoscopic approach; a diaphragmatic hernia grade iii (a.a.s.t. classification) was observed and submitted to prosthetic repair. postoperative period was uneventful. patient remains asymptomatic with no signs of recurrence after years. this case is paradigmatic of the difficulty of immediate diagnosis of diaphragmatic hernias, especially at the right hemidiaphragm. high index of clinical suspicion is needed for its early recognition in context of blunt trauma. laparoscopic treatment revealed to be safe and efficient, with the known advantages of minimally invasive procedures. results: their ages were between and , were male and were female. the type of injury was penetrating in , blunt in and blunt and penetrating in patient. in patients, the left kidney was injured, in the injury was at right kidney and in injuries was bilateral. the average transport time to hospital was min ( min- days). one hundred and seventeen out of patients were explored immediately as they hemodynamically unstable position. remaining patients were evaluated with ultrasonography, intravenous urography and computerised tomography. sixty four of these patients were followed conservatively. the injuries in patients followed conservatively were in patient's grade , in grade , in grade . renal units of patients were operated. nephrectomy was done in , nephropathy was done in and renal artery repairing was done in patient. conclusion: nephrectomy and mortality were high because of the long transport time, frequent high grade and high rate of associated organ injuries. rojnoveanu gheorghe sigmoid volvulus is seen more frequently at elderly ages and early diagnosis and treatment decreases its mortality and morbidity rate. we reviewed sigmoid volvulus cases treated in our clinic. patients hospitalized and treated due to diagnosis ofsigmoid colonic volvulus in dr. lü tfi kırdar kartal education and training hospital during - were analysed. treatment modalities, morbidity and mortality rates were analysed. patients were male, were female. mean age was ( - ). sigmoid colon resection and end colostomy was done to patients, sigmoid colon resection and end to end anastomosis was done to patients and nonoperative colonoskopic decompression was applied to patients with sistemic illness and they were prepared for elective sigmoid colon resection and end to end anastomosis. in one patient with anastomosis, anastomotic leakage was detected and end colostomy was applied. two emergently operated patients with sistemic illness died. mortality rate was% . in conclusion, sigmoid volvulus patients with sistemic illness should be prepared to elective surgery with colonic decompression. we think that the best treatment for early diagnosed cases is sigmoid colonic resection and end to end anastomosis. introduction: onset of world war ii, the report concerning diverting colostomy declared reduced mortality rates for colon injury, compared to world war i. in spite that nearly years has passed away, although all therapeutic options, this method -used for the management for colon injury -still include some controversial points. methods: ninety-five patient's characteristics were compared in two groups (patients with or without diverting stoma). clinical findings and patient's characteristics, injury mechanism, localisation of the wound, blood transfusion requirements, fecal contamination, colon injury score (cis), penetrating abdominal trauma index (pati score), evidence of shock, morbidity rate, mean hospital stay, main and additional surgical procedures of patients who admitted to our clinic from to were reviewed retrospectively. results: we have no mortality in both groups, except the first postoperative h. diversion colostomy was performed in patients and primary repair in patients. median hospital stay for primary repair and diversion groups were and days, respectively, (p < . ). respiratory system, septic complications, clinical anastamosis leakage and other complications were similar in both groups. conclusions: although all articles that prompt primary repair, this approach includes some inconvenient points. it is acceptable in military or war originated injuries. diversion mostly is necessary in wounds, related to highly potent and energic fragments. nevertheless, nearly all of the civilian colonic injuries can be treatment with primary repair without diversion since the mechanism of the wound is different than war injuries. dogan gö nü llü , oguz Ç atal , nilü fer yazgan yıldırım , tayfun yucel , ferda nihat kö ksoy taksim trainig and research hospital, _ istanbul, turkey background: the management of haemodynamic stable penetrating injuries of the flank has not been well defined; laparoscopic exploration, closed abdominal examination and triple contrast computed tomography (ct) are alternative modalities. our aims are to explain our experiences in these cases. methods: we reviewed the patients with isolated penetrating flank trauma admitted between and . the flank was defined as area between the anterior and posterior axillary lines, inferior to the fifth intercostal space superior to the iliac crest. results: there were haemodynamic stable patients ( gunshot and stab injuries). there were three patient groups: laparotomy (g ) (n = ), laparoscopy (g ) (n = ) and only closed clinical observation with triple contrast ct scan (g ) (n = ). patients in the g were gunshot injuries; the other two gunshot injuries were tangential and were included in the g . in the g there were four left diaphragmatic injuries, all repaired laparoscopically. one patient with splenic laceration and another with small bowel injury were converted to an open exploration. there were eight negative laparoscopies ( / ).two patients of g ( / ) with negative tomography were submitted to laparotomy after day of closed observation. the mean length of hospitalization in the groups was respectively . , . and . days. introduction: intra and retro abdominal hemorrhage are common following blind and penetrating abdominal trauma. liver, spleen and kidneys are known to be prone to injury and to bleed after an abdominal trauma. hepatocellular carcinoma is a well known disease. however, a renal mass from a primary origin in the liver is rare. this paper presents a patient, who was treated with right nephrectomy for traumatic bleeding from a ruptured renal mass. end diagnosis was metastatic hepatocellular carcinoma. case: the patient was -years-old man. he had no positive medical and surgical history, and no complaint. he was referred to emergency service after traffic accident. during his initial assessment abdominal rigidity and tenderness were found, which were accompanied with tachycardia and hypotension even after fluid resuscitation. fast revealed that there was free fluid in his abdomen, so we decided to operate him. at laparotomy we observed a bleeding tumoral mass in the right kidney and in his liver. he was treated with right nephrectomy and irregular hepatectomy. pathologic examination demonstrated a metastatic hepatocellular carcinoma. conclusion: hepatocellular carcinoma is a well known disease with its common acute complications such as rupture and bleeding. in this case, we observed hcc metastasis to the right kidney although the patient had no medical and surgical history including hcc. bleeding was induced after a blind trauma, was treated with resection. gall bladder (gb) injuries either following penetrating or blunt abdominal trauma is a rare entity and usually misdiagnosed with a delay in diagnosis. the incidence of gb injury is reported to range between . and . % among the surgically treated patients following abdominal trauma. cholecystectomy is the definitive treatment even in severe contusion of a nonperforated gb. simple suture repair or cholecystostomy are also advocated as alternative surgical interventions by some authors. gb is afforded significant anatomic protection from external trauma, since it is partially embedded in the relatively massive liver parenchyme, cushioned by the surrounding omentum and intestines, and shielded by ribcage. clinical symptoms may be minimal or nil initially but gradual clinical deterioration, related to spillage of bile into the peritoneal cavity, can follow. bilous fluid taken by paracentesis or diagnostic peritoneal lavage can only be helpful after a delay as abdominal computed tomography. an year-old male was admitted to our emergency department for the fifth time because of penetrating abdominal trauma of at the right upper quadrant by a knife in a -day-period. he was hospitalized in three of them and operated on at last, because of acute abdomen, since paracentesis revealed bile coloured free abdominal fluid in addition to abdominal guarding, leucocytosis( , /mm ), and fever.the ultimate ultrasonography and computed tomography revealed large amount of free fluid (bile) and minimal intrahepatic hematoma. at laparotomy; full-cut hepatic and cholecystic perforation (both anterior and posterior surfaces) resulted in cholecystectomy. he was discharged on the fourth postoperative day. since almost all reports about the delayed rupture of gb are usually unrecognized gb perforations,a diagnostic delay can only be avoided by a high clinical index of suspicion. sixty-three patients were treated conservatively, whereas patients had laparotomy and patients underwent angiography. of patients transported by ambulance or helicopter, % arrived at the emergency unit within min after prehospital alert. in % the time on scene were longer than min. in this group only % were diagnosed by ct within min after arrival to the emergency unit. conclusion: low volume in trauma care results in substandard handling time. in hospitals with a low volume exposure to trauma, the prehospital response teams and surgeons achieves limited experience, especially in penetrating trauma. exchange programs must be emphasised. author to editor: this study describes the complete workload in primary handled trauma patients in a typical nothern european universtyhospital with very low incidence of penetrating trauma and low volume of blunt trauma. our trauma registry covers % of patients admitted to the hosptial. it is the only hospital in the area, and patients do not bypass the system and are treated elsewhere. the study will point out that prehosptial responsetime and inhosptial procedures are is acceptable, but emergencyroom handlingtime is to long, due to lack of practice. national or european exchange programs for surgical trauma care must be practiced. introduction: explosives create and energize particles that act as projectiles prone to further fragmentation in the body. these fragments may result in secondary injuries. this has been repeatedly described in the orthopedic and neurosurgical literature. in this paper we demonstrate that such a process is also possible for abdominal injuries during or after fascial penetration. material-method: in all abdominal wall injuries, despite negative physical examination of conscious and alert patients we used local wound exploration as a standard approach. finding a full thickness fascial defect, we assumed an intraperitoneal injury and performed laparotomy. result: using this method, we found hollow organ injuries in of ( . %) patients. in ( . %) of these patients at laparotomy, we found multiple, projectile induced injuries in a sprayed distribution. these injuries were found far from the trajectory, in the absence of bone fragmentation. the mean number of peritoneal defects was . , however, for each peritoneal defect, we found an average of . intraabdominal injuries when through and through injuries were excluded. conclusion: local wound exploration is an accurate indicator of possible intraabdominal injuries. although fragments of projectiles would be expected to be distributed along the trajectory, meticulous exploration of abdomen is mandatory because this is not always true. despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. introduction and objectives: nonoperative management of penetrating abdominal stab wounds has been established as standard care recently. it decreased negative laparotomy rate without any increase in morbidity and mortality. in this study we evaluated the outcome of patients managed due to penetrating abdominal stab wounds. intraabdominal injury due to blunt abdominal trauma usually presents acutely. in the absence of peritoneal irritation findings or shock the patients may be treated conservatively. delayed small bowel obstruction after blunt trauma is very rare clinical entity. it may be caused by subclinical bowel perforation, localized bowel ischemia or mesenteric vascular injury. we present a years old man of blunt abdominal trauma that was treated nonoperatively. despite the success medical treatment, months later, the patient presented with abdominal pain and vomiting. the radiologic studies suggested a mechanical intestinal obstruction. at the operation a conglomerated terminal ileal segment causing obstruction was found and the patient is treated by a resection and primary anastomosis. the operative findings may be explained by a subclinical perforation at the time of the trauma. this kind of complication should be suspected in patients with post traumatic patients which presents with signs of intestinal obstruction in weeks after the trauma. nevin kanan, ayfer Ö zbaş department of surgical nursing, istanbul university, florence nightingale school of nursing, ankara, turkey with traumatic injury, kidneys can be thrust against the lower ribs, resulting in contusion and rupture. up to % of patients with renal trauma have associated injuries of other internal organs. injuries may be blunt (automobile and motorcycle crashes, falls) or penetrating (gunshot wounds). approximately - % of all renal trauma cases are blunt trauma injuries; penetrating renal trauma accounts for the remaining - %. blunt renal trauma is classified into one of four groups which are contusion, minö r laceration, majö r laceration and vascular injury. • with a contusion of kidney, healing may take place with conservative measures (i.e. bed rest) • if minö r laceration is present, the patient is hospitalized and kept on bed rest until the hematuria clears. • depending on the patient's condition and the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery) • vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. the patient is often in shock and requires aggressive fluid resuscitation. for the management of patient with renal trauma, nursing diagnoses are: • inefective tissue perfusion (renal) related to interruption of arterial flow • anxiety related to physical injury • acute pain related to physical injury • impaired urinary elimination related to renal damage and shock background: penetrating abdominal buckshot wounds are believed to necessitate emergent laparotomy to rule out any hollow or solid organ injury. recently, nonoperative management has been suggested in selected patients. this paper aims to present two cases with penetrating abdominal buckshot wounds, treated nonoperatively. materials-methods: a chart review has been conducted for patients operated in our institution for abdominal buckshot wounds. demographics, evaluation tools and follow-up parameters has been analyzed and documented. results: a total number of two patients (both male; and years old) were found. both were shot on their left thoracolumbar regions. left and bilateral chest tubes were necessitated after initial examinations, but both denied any abdominal tenderness, although computed tomography showed multiple abdominally located pellets. gastroscopy (n = ), echocardiography (n = ), intravenous pyelography (n = ) were necessitated for further evaluation, but showed no abnormality. the patients were followed up with routine abdominal examinations, vital signs and routine laboratory tests and discharged from the hospital on days and after uneventful recovery periods. discussion: patients with penetrating abdominal buckshot wounds may be followed with nonoperative management instead of routine laparotomy. objective: treatment procedures in cases who were operated due to colon injuries were investigated in this study. material-methods: thirty-two cases who were operated due to colon injuries in our clinic between and were investigated retrospectively. cases were investigated with regard to age, sex, type of trauma, hemodynamic condition, interval between injury and surgery, additional organ injury, transfusion volume, injury site and severity, faecal contamination, surgical procedures, postoperational complications and mortality and factors affecting morbidity and mortality were determined. colonic injury severity scale (ciss), abdominal trauma index (ati) and flint classification were used for evaluating severity of colon injury,severity of additional organ injury and faecal contamination, respectively. systolic blood pressure less than mmhg on admission was referred to as ''shock''. results: males comprised out of cases and mean age was . (range: - ) years. twenty-five cases were injured due to penetrating trauma and left colon injury was the most common ( cases) type of injury. additional intraabdominal organ injury and extraabdominal injury were observed in and cases, respectively. mean interval between injury and surgery was . (range . - ) h. fifteen cases received blood transfusion. five cases had shock on admission. seven cases received stoma surgery while all cases with flint grade more than iii or ati score higher than received colostomy. only cases with high ciss score received resection and anastomosis surgery. complications were observed in cases while mortality occurred in two cases due to hemorrhagic shock. conclusion: routine primary repair cannot always be performed in colon injuries since many factors affect the decision for type of surgery. primary repair may be performed safely in hemodynamicallystable cases with ati score less than and flint grade i-ii. seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report a -years old male who was a front seat restrained passenger involved in a head-on collision. he has presented with lower abdominal and back pain. seat belt mark was seen transversely across the lower abdomen. initial trauma ct scan was normal except for burst fracture of l vertebra which was operated by internal fixation on the same day of admission. the patient continued to have abdominal pain and distention which became clear on the third day. repeated abdominal ct scan on the third day has shown free intraperitoneal air. exploratory laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. hartmann's procedure was performed with end colostomy. the abdomen was left open and temporarily closed using saline iv bags sandwiched between layers of steri-drape. peritoneal toileting was performed four times under general anesthesia with gradual closure of the abdominal fascia over a period of weeks. postoperatively, the patient had urinary retention due to a quada equina injury although he could walk. the presence of seat belt sign and a lumber fracture should rise to the possibility of a bowel injury. author to editor: seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report such a case. fuat ipekçi, muharrem karaoglan, hü seyin toptay, hasan Ş ahin department of general surgery, tepecik education hospital, izmir, turkey introduction and aims: meckel's diverticulum results from incomplete degeneration of omphalomesenteric duct. it is usually diagnosed incidentally during appendectomy; however, sometimes perforation or bleeding may lead the surgeon to the diagnosis. we aimed to investigate the frequency of meckel's diverticulum during emergency laparotomy performed for acute appendicitis and clinical and pathological characteristics of the patients with meckel's diverticulitis and appendicitis. material-method: the material consisted of , patients who admitted to our hospital and treated by appendectomy during a -year interval between the years and . of these patients ( , %) were male and remaining ( , %) were female. all patients were investigated for meckel's diverticulum weather they have acute appendicitis or not. results: meckel's diverticulum was found during out of , appendectomies ( . %). of the cases, were asymptomatic but four patients were symptomatic with inflamed diverticulitis. of these four patients two have normal appendix and other two have secondary appendicitis due to meckel's diverticulitis. all four symptomatic cases were treated by diverticulectomy and appendectomy. all asymptomatic cases were treated by appendectomy alone. no mortality or major morbidity was detected. conclusions: despite of its rarity ( . % in our appendectomy series), meckel's diverticulum must be searched weather the appendix is normal or inflamed. introduction: illegal drug smuggling is a widespread problem. drug packs carried inside body cavities may leak its contents and be dissolved inside the body and signs of toxicity (aka. body packer syndrome) become evident. this case was reported to represent the very first proven patient in turkey. case: a year-old man were brought in the emergency department (ed) from the airport because of severe tremor, palpitation, restlessness associated with hypertension and tachycardia. the patient was cooperative and oriented. on examination, his blood pressure (bp) was / mmhg, pulse rate /bpm, whereas other systems were unremarkable. he was put on cardiac monitor and infusion of glycerol trinitrate was instituted ( mcg/min). urinary toxicologic screen was positive for cocaine and benzodiazepine. after admission to the ed he complained of epigastric distension and abdominal pain and admitted that he had swallowed cocaine packs. his abdominal xrays showed gas-fluid levels and opaque round-shaped mass images. a nasogastric catheter was inserted and gastric contents (approximately , ml) were drained. he was consulted with surgery clinic with a diagnosis of an ileus due to swallowed packs. he was hospitalized in the surgical ward. after supportive treatment and repeated enema applications he excreted cocaine packs in days. he was discharged following clinical stabilization and abdominal x-rays were repeatedly normal. conclusion: toxicologic analysis must be employed in patients who are suspected to have intoxication, to identify life-threatening drugs and vasoactive substances. advanced imaging methods must be exercised to exclude bowel obstruction in these patients. background: pseudoaneurysm is a well recognized complication of pancreatitis. angioembolization is considered to be the first option of treatment. to our knowledge, the case we hereby report is the first one with successful re-angioembolization. case: a -year-old man, with aids, history of cns toxoplasmosis, chronic pancreatitis with pseudocyst secondary to alcohol abuse, was hospitalized for pneumonia. during his hospitalization, he developed abdominal pain and hypotension. after resuscitation, ct angiogram of the abdomen revealed active bleeding into a pseudo-aneurysm, near the head of the pancreas, measuring . x . cm and arising from superior and inferior pancreaticoduodenal arteries. this was confirmed by angiogram. angioembolization distal and proximal to the bleeding area was performed using coils. eight days later, the patient became hypotensive and dropped his hemoglobin again. he was taken for an emergency laparotomy which revealed a cm pancreatic pseudocyst with hemorrhage. the pseudocyst was opened through the medial wall of the duodenum, ligation of the bleeding intracystic vessels, and cysto-doudenostomy were performed. his postoperative course was uneventful and he was discharged home on postoperative day . five days later he was readmitted with hematemsis and anemia. celiac angiogram revealed bleeding from the gastrodoudenal artery which was embolized. he died months later due to hiv nephropathy without any evidence of re-bleeding. objectives: any sort of discomfort in the abdominal cavity that lasts less than week is defined as acute abdominal pain. the purpose of the study was to evaluate the outcome of hospitalized patients with unspecified acute abdominal pain following initial clinical and laboratory evaluation. method: from january to december , patients with acute unspecified abdominal pain were admitted to surgery department. gender, age, definite diagnosis, time from hospitalization to surgery and hospital length of stay were retrospectively reviewed. results: fifty-six of the patients with acute unspecified abdominal pain were females ( %) and were males ( %), median age was years (range - ). while definite diagnosis was confirmed in patients ( %), the initial diagnosis was not changed in patients ( %). distribution of new diagnoses were appendicitis (n = ), gastroenteritis (n = ), genitourinary disorder (n = ), familial mediterranean fever (n = ), inflammatory bowel disease (n = ), mesenteric adenitis (n = ), peptic ulcus perforation (n = ), constipation (n = ), diverticular disease (n = ), pneumatosis intestinalis (n = ), hepatobilier disease (n = ) and intra abdominal tumor (n = ). depending on the cause of abdominal discomfort, patients ( %) required surgical intervention. median time from hospitalization to surgery was h (range - the use of temporary skin substitutes (tss) is a useful technique in the treatment of full-and partial thickness burn wounds affecting a large body surface area. early excision of the eschar is mandatory. but if we cannot find sufficient donor site, tss using seems to best choice. the ideal tss must be has some properties: adherence, control of water loss, safety, flexibility, stability on wound surfaces, bacterial barrier, and ease of application, ease storage and cost effectiveness. case report: a -year-old girl was admitted to our burn center with deep flame burns affecting face, thorax, upper and lower extremity ( %). she underwent an early burn excision on day post-burn day. the whole area excised with hydrosurgically was covered with biobrane Ò and compressive dressing. seven days after we removed biobrane from the upper and lower extremities and grafted the wound bed. face healed spontaneously under the tss and tss covering the thorax was rest intact. after days thoracic tss was removed and grafted and we covered the thorax with biobrane Ò over the grafts again. after days a second grafting was needed. patient was discharged from the hospital th post-burn day. the use of biobrane Ò as a tss after burn wound excision was satisfactory, because it enabled us to delay auto grafting until we were sure of good conditions in the wound bed. also it proved to be a good dressing over the meshed autografts. it reduces the healing time and improved the quality of grafts. introduction: endoscopic examination of the colon during the diagnostic or treatment purposes, perforation incidence is reported between . and . %. determination of risk factors may decrease the incidence with early recognition of the serious complications of surgery may reduce interference. method: we have examined retrospectively the patients in whom colon perforation appeared due to endoscopic analysis of colon carried out at endoscopy unit between january and december . results: total colonoscopy and rectosigmoidoscopy were applied to , patients. in patients ( . %) perforation was observed. the median age was . ( - ), m/f: / . all colonoscopys were made for diagnosis; anemia in two, hemorrhodial disease in one, subileus in two, anal prolapsus in one, right colon tumor suspation in one patients. one sigmoid polypectomy was applied, diverticulosis disease of the colon in two patients, dolichocolon in one, one previous pelvic surgery were observed. perforation zone was observed in sigmoid colon in all patients. four patients were diagnosed in the process of colonoscopy ( . %), were diagnosed in - h ( . %), was diagnosed days later. laparotomy was applied to all patients. perforation zones of patients were fixed primarily and these patients were discharged as cured. one patient who was applied to diversionary ostomy was reoperated due to abdomen collection. no mortality was observed. conclusion: colonoscopic perforation is a rare, serious complication. sigmoid colon is the location where the perforations are mostly observed. although primary fixation is generally efficient in cases of early diagnosis, morbidity increases seriously due to late diagnosis. with more than one stomas. eleven patients were discharged with planned ventral hernias. primary abdominal closure succeeded in four patients. fasciitis due to severe peritonitis and stomas prevented primary closure. eighteen of patient died during treatment, were discharged. sixteen of patients with more than one bag were died, five survived (mortality . %). conclusions: morbidity and mortality were higher in patients with more than one stoma than patients with single stoma. second stoma has a negative effect on primary fascial closure. fasciitis due to severe peritonitis also prevents fascial closure. acute diaphragmatic hernia after minimally invasive esophagectomy the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly effective on mortality. background: resveratrol is a strong antioxidant with antiinflammatory effects. we aimed to investigate the effects of resveratrol on oxidative injury, histopathology and bacterial translocation in induced i/r injury in rats. methods: female wistar-albino rats were randomly allocated into four groups; sham-operated group(laparotomy without i/r injury), i/ r group (laparotomy plus min of ischemia followed by min of reperfusion), alcohol group (only . % ethyl alcohole . ml/day intraperitoneally for both days before surgery and min before ischemia), resveratrol group ( mg/kg resveratrol intraperitoneally both days before surgery and min before ischemia. intestinal tissue samples were obtained for investigation of tissue levels of malondialdehyde (mda), nitric oxide (no), superoxide dismutase (sod), myeloperoxidase (mpo) and histopathologic evaluation bacteriological translocation (bt) in mesenteric lymph node (mln), liver and spleen was also studied. results: resveratrol significantly decreased mda, no and mpo levels in i/r injury (p < . ). sod activity of resveratrol-treated group was significantly lower than sham group and significantly higher than i/r and i/r + alcohol groups (p < . ). histopathologically, the median intestinal injury score in i/r and i/r + alcohol groups was significantly higher than in sham and resveratrol-treatment groups (p < . and p < . , respectively). the incidence of bt differred between the groups i/r and i/r + alcohol in mlm, spleen and liver (p < . ). nevertheless, the treatment with resveratrol reduced bt to mln, spleen and liver, compared to other i/ r groups (p < . gastrointestinal stromal tumors (gists) represent rare neoplasms of the gastrointestinal tract. here we describe a case with gist and thrombocytosis presenting as an acute abdomen. our knowledge, the co-existence of gist and thrombocytosis has not been reported so far. case: a -year old female was admitted to the emergency room with epigastric pain and vomiting over duration of days. physical examination showed abdominal distension, rebound tenderness, and a palpable rlq mass. the laboratory findings were, wbc: . /l, plt · - /l and c-reactive protein . mg/l. a computed tomography scan of the abdomen showed conglomerate of small bowel. the abdominal exploration showed that a · · cm mass was located on small intestine. the mass was completely resected and enteroenterostomy was performed. the histological examination demonstrated whirling sheets of spindle cells which were stained positively for cd (c-kit) and cd , mitotic index > / hpf, while smooth muscle actin and vimentin were focally positive, and keratine, desmin, s- protein were negative. this specific immunophenotype characterized gist. during the post operative follow up, platelets were above normal levels · - /l. therefore, bone marrow biopsy was performed. hiperplasia in megakaryocytes were found. the patient was negative for bcr-abl and philadelphia chromosome. discussion: here we describe a case with gist and thrombocytosis presenting as an acute abdomen. ten percent to % of these tumors are biologically aggressive; signs of malignant potential are metastases and invasion. the current treatment for localized disease is surgical resection. co-existence of thrombocytosis and gist has never been reported. laboratory tests showed no abnormality except white blood cell count of /ll.plain abdominal x-ray and ct did not show any abnormal findings including free air (fig. ) . endoscopic examination of the stomach revealed an ingested toothpick protruding from the prepyloric antrum (fig. ) . the toothpick was deeply fixed into the antral wall. the whole toothpick . cm in length was removed using a loop without damage to the gastrointestinal wall, bleeding or any other complication. after endoscopic removal of the toothpick, her epigastralgia resolved. on the second hospital day, the patient was asymptomatic. medical therapy with proton pump inhibitor was stopped and she was discharged on the third hospital day. conclusion: accidental ingestion of foreign bodies is common and in general harmless. a perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than % of ingested bodies like toothpicks are involved in less than . %. occasionally, the passage of the swallowed item may stop at one of the anatomic bottlenecks of the gastrointestinal tract, which may lead to perforations that may require operative or endoscopic interventions. results: we analyzed the number, causes and rates of emergency operations. the total number of emergency operations was , and , , for the first and second groups, respectively. we observed an % decrease in number of emergency operations for the second group. we also observed that the cause of majority ( % for the first group, % for the second) of the emergency operations was acute abdomen and the rate between the groups did not change. lower extremity amputation and strangulation hernia operations decreased and %, respectively. the number of operations which are caused by ileus and acute cholecystitis increased and %, respectively. conclusions: difference in distribution of emergency operations between two groups was statistically insignificant. however, we observed both an increase and a decrease in small numbers of some subgroups. it is believed that this is related to the change in patient profile and technological improvements in surgery. aim: we hypothesized that one of the most widely used anesthetic agents, propofol, may reduce inflammatory processes, and organ injury induced with cecal and ligation puncture study design: bacterial peritonitis was induced in rats by cecal ligation and puncture. the rats were randomly assigned to three groups. group (n = ) received propofol, group (n = ) received intralipid, group (n = ) was control, which did not receive any injection. all animals were killed days later so we could assess the adhesion score. tissue antioxidant levels were measured in -g tissue samples taken from the abdominal wall. results: the adhesion score was significantly lower in the propofol group than in the control group (p < . ). the catalase levels were higher in the intralipid and control groups than the propofol groups. conclusions: intraperitoneal propofol reduced the formation of postoperative intra-abdominal adhesions without compromising wound healing in this bacterial peritonitis rat model. propofol also decreased the oxidative stress during peritonitis approximately, min after the onset of the operation, a sudden decrease in end-tidal carbon dioxide from to mmhg was noticed. soon after, both systolic arterial pressure and heart rate decreased dramatically. arterial blood gas measurements showed that pco was mmhg at that moment. surgery and insufflation of gas was stopped, ephedrine mg was given intravenously and ventilation with % o was started. trendelenburg position was achieved immediately. a catheter was introduced through the right juguler vein to the right atrium rapidly and - ml gas bubble was withdrawn. soon, hemodynamic measures were recovered. since substantial amount of blood in the peritoneum was noticed, conversion to laparotomy with subcostal incision was performed. at exploration, through and through tear of mm in inferior vena cava was detected. the defect was sutured with / polypropylene. anesthesiologist and surgeon must be aware of this dangerous complication. the emphasis is given to the prevention and prompt recognition of this event to the use of available tools in the management of cardiovascular complications. aim: obstructive jaundice, develops accompanied with high morbidity and mortality rates. the absence of bile in bowels leads to bacterial translocation and ultimately to endotoxemia and septice-mia. _ in our study, observing changes on bowel level during obstructive jaundice and examining its contribution to bacterial translocation have been aimed. material-methods: the study has been carried out at _ istanbul university _ istanbul faculty of medicine experimental medical research center (detam) with approval of _ istanbul university _ istanbul faculty of medicine ethical board for animals. two groups out of male wistar albino rats have been formed. one hour after injecting d-xylose to first group the rats were put to sleep (anesthetized) and specimens of tissue (liver, spleen, mesenteric lymph nodes) and blood were taken for microbiological and biochemical examinations. in the second group an obstructive jaundice has been established by ligation of common bile ducts. the same specimens were obtained after days. findings: in the first group no proliferation on tissue and blood cultures were detected. an obstructive jaundice has been shown in biochemical investigation of blood. d-xylose was found to be . ± . mg/dl. in the second group, proliferation, of mainly e. coli, were detected on cultures and d-xylose was found to be . ± . mg/dl. statistically significant increases were assigned between groups, between tissue and blood cultures (p < . ) and d-xylose values (p < . ). results: detecting statistically significant increases in d-xylose levels in the second group leads to the conclusion that increases in bowel permeability plays an important role in bacterial translocation. conclusions: while wound infections were higher in open appendectomy procedure group, surgical time was higher in laparoscopic procedure group. the achievement of optimal results will be based on increasing surgical laparoscopic experience. objectives: intraabdominal hypertension (iht) in intensive care units is a common problem. investigation of the effects of dexmedetomidine on respiratory system in rats with iht was aimed. patients and methods: adult wistar-albino male rats were anaesthetized by rata ''ksalazin/ketamin'' combination. experimental model of iht( - mmhg) was induced via pressure cuff. rats were left to spontaneous respiration for h prior to randomly division into four groups. the first group underwent no process (control group). in sf group; cc of . % nacl,in the third group; . lg/kg dxmt and in the last, . lg/kg dxmt were intravenously administered. thereafter min passed to observe the effects of dxmt. the rats were killed via cervical dislocation prior to surgery. lung tissues were fixed in % formalin and stained with he. whereas the other cross sections were stained with tunel method,the rest were stained with anti-caspase , , and anti-fas/fasl antibodies for immunohistochemical analysis. results: histological changes in group were the less. there were no atalectatic changes in the same group. pnl infiltration and interalveolar thickness were higher in the . lg/kg dxmt group than others. in indirect immunohistochemical studies, in the . lg/kg dxmt group, immunoreactivity of caspase and were increased. however, the caspase- immunoreactivity was less than caspase- . these results supported that . lg/kg dxmt administration led apoptosis, even though to be delayed, to start and showed that extrinsic pathways was used through apoptotic pathways. it was concluded that low dose of dxmt caused to delay in apoptosis in the lungs. results: a total of microorganisms were responsible for the cris, of which ( . %) were gram-positive bacteria, ( , %) were gram-negative bacteria and ( . %) were candida species. isolated from the microorganisms were: klebsiella pneumoniae ( %), acinetobacter ( . %), enterobacter ( . %), rroteas mirabilis ( . %) pseudomonas aeroginosa ( %), staphylococcus ( . %). patients ( . %) developed crbsis and in patients with positive blood cultures cris were negative. in our study, femoral venous access was associated with a significantly higher incidence of cri and crbsi than jugular and subclavian access; and jugular access was associated with a significantly higher incidence of cri and crbsi than subclavian access conclusion our results suggest that the order for punction, to minimize the cvc-related infection risk, should be subclavian (first order), jugular (second) and femoral vein (third). introduction and objectives: undescended testis is a risk factor for the testicular carcinoma, especially a seminoma. seminoma can be seen at any age, but it is considerably rare in elderly patients. we describe a patient who presented with acute abdomen secondary to an ileum perforation due to the involvement of seminoma. case: a year-old man complaining with right lower abdominal pain and a palpabl mass with a -week history was evaluated. an abdominal computed tomography was showed a large, solid, welldefined intraabdominal mass, measured about · ·x cm in right quadrant of lower abdomen. an exploratory laparotomy was adjudged to perform. whilst the preoperative investigations for surgery were continued, the patient admitted to the emergency service with acute abdomen symptoms, which was started suddenly. he had peritoneal irritation signs. he underwent an urgent laparotomy and a large mass located on terminal ileum mesenter through the retroperiton was detected. dilated ileum segments with omentum wrapped along the antimesenteric border of the distal ileum was found. on separating omentum from ileum, perforation along the antimesenteric border was noted. extended right hemicolectomy and an end ileostomy was performed. histopathologic examination revealed a classical seminoma with extensive tumor necrosis and showed evidence of vascular invasion. conclusions: undescended testes should be considered in men with an intraabdominal groin mass and should be aware of its potential complications. department with diagnosis of acute cholecystitis and on exploration giant gallbladder with giant stone and gallbladder adenocarcinoma. case: a years old female was applied to emergency department with abdominal pain, nausea and vomiting. on physical examination, right upper quadrant tenderness and defence were detected. murphy sing was positive and gallbladder was palpable on subcostal space. in laboratory tests, white blood cell count was , /mm , glucose was mg/dl and liver function tests were minimally elevated. in hepatobiliary ultrasonography, the gallbladder was hidropic ( · cm) and there was a stone ( cm in diameter) and a mass ( · cm) in the gallbladder.cholecystectomy operation was performed. acute cholecystitis + cholelithiasis + adenocarcinoma were reported in the histopathological evaluation. conclusion: the carcinomas of the gallbladder were associated with gall stones in - % of the patients. we concluded that the presence of the symptoms in our patient was delayed due to the magnitude of the gallstone and the excessive size of the gallbladder. perforation of the gallbladder by trans-gastric migration of a sewing needle _ ingestion of foreign bodies is a common problem, especially in the elderly, pediatric, and psychiatric population, but fortunately, most of them pass spontaneously and uneventfully within week.the perforation and migration of ingested foreign objects into the abdominal cavity is very rare and usually leads to a laparotomy. perforation of the stomach by sewing needle with migration to the gallbladder is extremely rare, and none cases have been reported in the literature. a -year-old woman was admitted because of abdominal pain and a history of a swallowed sewing needle month ago. she had been followed-up at her local hospital and referred to our hospital because of the failure of progression of the foreign body. physical examination showed right upper quadrant tenderness, guarding, and a positive murphy's sign. blood analysis showed increased white blood count. she was submitted to abdominal plain x-rays, which revealed a radio-opaque objects in the liver area with the form of the sewing needles. the patient was clinically stable, and a semi-urgent laparotomy was planned. at laparotomy the needle was in the gallbladder and that the end of the needle could be palpated and the site of gastric perforation. removal of the intra gallbladder needle did not cause any problem. we was performed cholecystectomy and primary gastroraphy. the postoperative period was uneventful and the patient was discharged on seventh day of the operation. if there is a history of sewing needle ingestion and failure of progression and also signs of an acute abdomen, the surgeon must carefully evaluate gallbladder. introduction: sigmoid volvulus is an unusual intestinal obstruction form ( ) . it is most common in the middle aged, elderly, institutionalized or neuropsychiatric patients ( ). patients and methods: twenty-one sigmoid volvulus patients were reviewed retrospectively between and .the recorded data were age,gender,admission symptoms,physical examination,radiological, and operative findings, surgical procedure, postoperative complications, mortality, and hospital stay.there were male and female patients. the mean ages of the patients was . years ( - ).the most common symptoms in acute abdomen patients were pain, and tenderness. abdominal distension were the most recorded sign in patient without peritonitis. the mean admission time was . days ( - ). five patients had a history of sigmoid volvulus ( %). leukocytosis and high fever were found in ( %) patients. radiological evaluation of the patients revealed sign of intestinal obstruction (n = , %),frimann-dahl sign (n = , %) and bilateral free air under diaphragm due to perforation of the twisted sigmoid colon (n = , . %). no patient underwent contrast enema examination of the colon. the mean hospital stay was . days ( - days) . two patients without signs of peritonitis were treated by sigmoidoscopy and operated on elective course.patients with signs of acute abdomen were operated urgently. the patients had several associated diseases such as atherosclerotic heart disease, diabetes mellitus, hypertansion, chronic obstructive pulmonary disease, cerebrovascular disease. eight patients ( %) died due to sepsis. morbidity rate was %. wound infection, evisseration pneumonia, and acute renal failure were found in ( %) patients. the principal strategy in treatment of sigmoid volvulus is early nonoperative detorsion followed by elective surgery consist of colectomy and anastomosis on well-hydrated patient. urgent laparotomy is indicated in case of peritonitis. sigmoidopexy is an alternative option but it is usually ineffective and has high recurrence rate. results: ten men and four (six) female were enrolled in the study. mean age was years (range - ). e.coli and acinetobacter were the common organisms cultured. all patients were treated with a common approach of resuscitation, broad spectrum antibiotics, and wide surgical excision. objectıves: acute appendicitis is one of the most common nonobstetric surgical pathology. clinical symptoms and findings are masked due to anatomical and physiological changes of peregnancy, so diagnose and treatment of acute appendicitis in pregnancy generally late. the curent study reported the cases which were diagnosed acute appendicitis in pregnancy and promptly operated in our general surgery clinic. material-methods: we evaluated sixteen cases' data between october and october who admitted to emergencey department with abdominal pain, vomiting, nausea and anorexia complaints and diagnosed as acute appendicitis in pregnancy and operated. results: the average of the cases were . (range - ) and thirteen of them were second, two of them were third and one of them was in the first trimester. the time interval between the onset of the complaints and operation was . (range - ) days. upon physical examination, there were rebound tenderness present in cases, muscular rigitide in three cases, right lower quadrant pain in nine cases and widely irration of all abdominal guadrant in four cases. there were not any maternal mortality and morbity after operation, however in only one case fetal mortality was observed inevitable abortion due to vaginal bleeding. conclusion: in our cases acute appendicitis was diagnosed frequently in the second of the pregnancy with abdominal pain symptoms and rebound tenderness findings. recognition is important because early diagnose and prompt surgical intervention can reduce maternal and fetal mortality and morbity in acute appendicitis. introduction and objectives: conservative management of penetrating trauma has been mainly advocated in centres with a high incidence and large experience with those injuries. our aim was to assess the preventable death rate in our patient population, and the failure rate of conservative management. introduction and objectives: the data about role of amelogenin that is an extracellular matrix protein, during the healing process of the gastrointestinal anastomosis is lacking. in this study, the effects of amelogenin treatment on normal and ischemic colon anastomosis were evaluated. methods: adult male wistar albino rats weighing - g, were divided into four weight-matched groups: normal colon anastomosis group (n = ); amelogenin treated normal colon anastomosis group (n = ); ischemic colon anastomosis group (n = ); amelogenin treated ischemic colon anstomosis group (n = ). sufficient equal volume of amelogenin to entirely cover the anastomosis area had been applied. all animals were killed on postoperative day . bursting pressure levels were measured. peri anastomotic colon tissue hydroxyproline, catalase (cat), cu-zn superoxide dismutase (sod), glutathione (gsh), malondialdehyde (mda) and nitric oxide (no) levels were assessed to evaluate oxidative stress. results: bursting pressure levels of the ischemic colon anastomosis group is significantly lower than the normal colon anastomosis, the amelogenin treated normal colon anastomosis and the amelogenin treated ischemic colon anastomosis groups respectively (p = . , p = . , p = . ). hydroxyproline level of the amelogenin treated normal colon anastomosis group is significantly lower than the normal colon anastomosis and the ischemic colon anastomosis groups respectively (p = . , p = . ). gsh level of the ischemic colon anastomosis significantly lower than the amelogenin treated normal colon anastomosis group and the amelogenin treated ischemic colon anstomosis group respectively (p = . , p = . ). conclusions: amelogenin treatment could support the physical strength of ischemic colon anastomosis and effect oxidant/antioxidant response positively. introduction: meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, occuring in - % of the population. in the majority of patients, meckel's diverticulum is asymptomatic. we report our experience with the management of complicated meckel's diverticulum in adults. methods: between april and january , the data of seven patients ( males and females) aged - years who underwent surgery due to complications of mechel's diverticulum was retrospectively evaluated. results: of the seven patients, three presented with acute surgical abdomen, two had abdominal pain mimicking acute appendicitis, one had incarcerated incissional hernia, and one had intussusception. intraoperative diagnoses were as follows; littre's hernia in one, ileoileal intussusception due to meckel's diveticulum in one, diverticulitis in two, perforation of the diverticulum in three patients. while diverticulectomies were performed in five patients, two had small bowel resections. in addition to, appendectomy was performed in four patient. all the patient had an uneventful recovery except one, who experienced a postoperative wound infection. the hospital stay was - days. ectopic gastric mucosa was found in two cases. in one case, neuroendocrine tumor was detected in the appendix. conclusions: meckel's diverticulum is an uncommon cause of acute abdominal disease in adults. meckel's diverticulum presents distinctive challenges to a clinician, as it is prone to varied complications such as intestinal obstruction, diverticulitis, perforation. the diagnosis of meckel's diverticulum is difficult to establish preoperatively, and index of suspicion is necessary in patients with an acute abdominal illness. introduction: pneumatosis cystoides intestinalis is a pathologhy which is rarely incidentally seen and is characterised with submucosal or subserosal air cysts. there is no surgical indication in asymptomatic cases. surgical treatment is needed in the development of complication or the possibility of risk. a patient who is hospitalized with diagnosis of pyloric stenosis and is detected pneumatosis cystoides intestinalis incidentally at the operation is presented. case: year old male was admitted our emergency department with vomiting weight loss complaints. pyloric stenosis was diagnosed by radiologic and endoscopic examination. he was hospitalized and acute abdominal signs developed. free air was detected in radiologic examination. surgery was performed. pyloric stenosis and pneumotosis cystoides intestinalis in jejenum were diagnosed. biopsy specimen was obtained from the cysts in jejunal serosa. subtotal gastrectomy, gastrojejunostomy and bilateral truncal vagotomy were performed for the pyloric stenosis. result and discussion: there is no surgical indication in asymptomatic cases. pneumotosis cystoides intestinalis commonly accompony pyloric stenosis and perforation of the cysts may bring out acute abdominal symptoms. knowing this pathology, we may avoid unnecessary emercent laparotomies. aim: in urgent surgical procedures for peptic ulcer perforation, there is considerable postoperative morbidity and mortality. this study aimed to describe and analyze the risk factors that determine beforehand morbidity and mortality in cases with perforated peptic ulcer. materıals-methods: age, sex, co-morbid diseases, symptom duration, abdominal air, amount of intra-abdominal liquid, location and diameter of perforation, operation, and the mannheim peritonitis index (mpi) score were prospectively analyzed in cases. significant risk factors that cause morbidity and mortality were determined through a statistical study. results: the study sample consisted of a total of cases ( males and females) with a mean age of (range - ). duodenum and stomach perforations were detected in and . % of the cases. in cases ( . %), a total of complications were detected. the mortality rate was . %. statistical analyses revealed significant relationships between morbidity and > age (p = . ), co-morbid disease (p = . ), perforation location (p = . ), type of operation (p = . ), and mpi score (p = . ). the factors significant for mortality included > age (p = . ), co-morbid disease (p = . ), > h of symptom duration (p = . ), > cc intra-abdominal liquid (p = . ), a perforation diameter of > . cm (p = . ), omentopexy (p = . ), and a mpi score of > (p = . ). conclusion: factors such as age, co-morbid disease, prolonged perforation duration, amount of intra-abdominal liquid, perforation diameter, type of surgical operation, and mpi score were significant for mortality. the present study found that primary suture is a safe procedure for cases with peptic ulcer perforation. introduction: the presence of foreign objects in the rectum is a rare encountered situation. these objects are usually inserted transanally or swallowed as foreign objects. this study was conducted to investigate the results of patients admitted to our clinic with a rectal foreign body. methods: data of patients who admitted to our clinic between and were evaluated retrospectively results: mean age of the population was . . the foreign object was taken out in the proctological position in patients. in patients these methods failed and laparatomy was performed and the objects were taken out transanally without colotomy. in three patients symptoms and signs of peritonitis were significant at admission and all of them were lost because of rectum perforation followed by septic shock. distribution of foreign objects was: six deodorant lids, five glass bottles, two aubergine, a glass, a salt cellar, a piece of plastic pipe, a vibrator, a plastic cover, a chocolate cover, a chicken bone, a fish bone, needles, a spiral, coins and key, a piece of thermometer, teeth prosthesis and soap. mortality was seen in three patients. the presence of foreign objects in the rectum is a rare encountered situation which should always be kept in mind for differential diagnosis. most of these objects can be taken out transanally. if this fails, all efforts must be shown to take it out without opening the colonic lumen. because of potential complications, the surgeon must be careful during intervention. median age of the alive was . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. median age of the dead . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. the most common reason of the aetiology was determined as perinal abscess. diversionary ostomy was applied to six patients. chronic kidney failure, and type diabetes was exist in four patients of dead-group. in addition, in one patient type diabetes and hypertension was observed. conclusion: chronic kidney failure related to hemodialysis and high level of lekucyte number at the moment of appliance are the important prognastic factors of deaths related to fg. computed tomography (ct) has become the mainstream of evaluating all hemodynamically stable patients with acute problems when the attending doctor, is urging for diagnosis. basing a diagnosis solely on radiological data sometimes ignoring medical history and physical examination may lead to unexpected errors. wrong interpretation of radiological images or images with equivocal findings which may delude the radiologist and technical errors (artifacts) are all potential sources of mistakes. the aim of this study is to draw attention to the danger of the modern imaging diagnostic modalities to misguide the treatment of patients who need emergency care. we present some cases we faced in our clinic where radiological images showed pathologic entities which in fact did not exist (false positive errors) but forced us to inappropriate treatment. two patients underwent negative laparatomies with imaging diagnosis of a ruptured gallbladder in one case and free air under the diaphragm in the other. a patient with a severe head injury and a ct scanning showing pneumocephalous was transferred to a tertiary centre to be proved on repeated images that initial diagnosis was mistaken due to a wrong calibration of the gantry. imaging findings do not necessarily represent reality. almost always surgeons rely on ct scans for treatment decisions. it is a hard task for a surgeon to question or ignore the pictures to treat a patient based on medical history and physical examination. experience of radiologist is essential and close cooperation with the attending surgeon is needed to avoid radiological misfindings in emergency cases. author to editor: to be presented as a poster. a full text is available on demand. intentional own insertion of rectal foreign bodies in a married, claimed to be straight male, using antidepressive medicaments because of sexual orientation disorder, resulted in resurgery with the same reason of mechanical intestinal obstruction after years in the same surgery clinic by the same surgery team as an emergency intervention. failure of the nonoperative measures under local, spinal and general anesthesia led to the surgical treatment of the -year-old patient in and , who is now years old during the second event. large bottles were removed through laparotomies and colotomies followed by primary repair to reverse the ongoing ileus, which resolved on the th postoperative days in both events. a surgeon who is called to see a patient with retained foreign body should answer whether the patient had rectal perforation and whether the foreign body could be removed transanally without regional or general anesthesia with or without surgical intervention. in case of children; habitually self inserting objects in her vagina or sexually aggressive behaviour with others, e.g. for a boy ''humping'' toys in sexual positions can be a behavioural indicator of child sexual abuse or assault. hence message is: if in a patient perforation of sigmoid colon or rectum history after anal insertion of foreign body in an otherwise healthy adult becomes habitual,the patient should be send to psychiatric counselling. discussion of the nonoperative measures to remove rectally inserted objects is also an utmost important opportunity constituting the largest part of the report of the present case. necrotizing fasciitis is a highly morbid and mortal condition. as a result of aggressive debridement, wide tissue defects occur. wound cleaning from infective material, granulation process and grafting of wound requires a long time. recently, a vacuum assisted therapy system has begun to use for this kind of wounds. this study discuss the treatment result of vacuum assisted therapy (vac Ò therapy tm ) in two patients with giant abdominal wall defect in view of current literature. case : a years old man had an operation because of an accident on railway. at the time of admission there was a wide defect with necrotizing fasciitis on the right lombar region and anterior abdominal wall. there was a full thickness defect about · cm after an aggressive debridement. it was successfully treated with vac and the patient has been discharged after tissue grafting on the postoperative day . case : a years old man had an operation because of an accident. he was admitted at postoperative day . he underwent an aggressive debridement because of necrotizing fasciitis. the skin, rectus abdominus, transversus abdominus, internal and external oblique muscles and some part of quadriceps femoris on the left side was excised. the sacroiliac joint was also broken and pubis was separated. vac abdomen has been applied on two different sites and the wound has become available for grafting after days of therapy. as a conclusion, vacuum assisted therapy provides safe and accelerated wound healing, improves proper tissue granulation in patients with giant abdominal defect. introduction: bogota bag (bb) is a device used for the temporary closure of the abdominal wall (aw). despite its potential benefits, their use is not widespread and remains controversial in the present. aım: to describe our experience in its management for the temporary closure of the aw in emergency situations. methods: for a period of years, bb has been used in patients (pts), with an average age of . years. six had a secondary peritonitis, one tertiary peritonitis, two haemoperitoneum and one a compartment syndrome established. the technique consisted of the placement of a bag of sterile serum, stitched to the skin with nonabsorbable material. results: the average of bags placed by year was . . no morbidity was associated with the placement and/or replacement of bb. the average time of hospitalization was . days and the average time of income in the icu was . days. in pts, the bag was replacement one or more times. the average number of surgical interventions by patient during the income was . . the average time of permanence of the patient with the bag was . days. sixty percent of patients are alive today. objectıves: the aim of the current study is to assess the role of ultrasonography in the management of acute appendicitis. methods: ultrasonography was performed to patients with acute appendicitis suspicion between and . appendectomy was performed to patients with acute appendicitis diagnosis according to clinical examination after ultrasonography. patients who had a diagnosis different from acute appendicitis with clinical examination were observed. the histopathological findings of patients with appendectomy were compared with their usg findings. results: of patients had acute appendicitis diagnosis by ultrasonography. hystopathological examination showed acute appendicitis in of these patients. patients did not have acute appendicitis. usg showed that patients did not have acute appendicitis. ten of these patients showed gynecological pathology, and six of them showed urinary pathology, and they were all treated appropriately. in eight patients the appendicitis findings became evident in clinical observation; resulting in appendectomy, and histopathological examination showed acute appendicitis. forty patients showed improvement at follow up. no spesific treatment was needed. misdiagnosis rate was determined as . %. the sensitivity, specificity, positive predictive value, negative predictive value and accuracy percentage of ultrasonography in the diagnosis of acute appendicitis was . , . , . , . and . %, respectively. conclusion: ultrasonography has a high degree of accuracy in the diagnosis of acute appendicitis. however, we also conclude that ultrasonography results should always be interpreted in combination with clinical findings. background: hydatid cyst disease is frequent in some regions of the world, including our country turkey, and is most commonly located in the liver and lungs. the hydatid cysts may rupture spontaneously or as a result of trauma. herein, we describe a rare case of retrovesical hydatid cyst which was resulted from rupture of spontaneous rupture of liver hydatic cyst intraperitoneally. case: fifty-four years old male was admitted to emergency department with complaints of frequent urination and abdominal pain lasting for days. there was general abdominal tenderness on physical examination. there was no history of trauma or operation. in his abdominal ultrasonography and tomography there were primary cyst ( · cm), ruptured cyst ( · cm) and retrovesically located cyst ( · cm). indirect hemagglutination test was positive for echinococcus granulosus ( / , ) . laparotomy was performed and all the cysts were excised by partial cystectomy. there was no postoperative complication. the patient was externalized on postoperative th day with albendazol treatment. conclusion: retrovesical localization of hydatic cyst is a very rare. these cysts mostly occur as a result of surgical inoculation caused by inadequate surgery or free intraperitoneal rupture of primary hydatic cyst. in endemic regions, possibility of hydatic cyst should be kept in mind in differential diagnosis of intrapelvic cysts and masses. background: wegener's granulomatosis (wg) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by involvement of the upper airways, lungs, kidneys and may rarely involve the gastrointestinal tract. intestinal involvement may be asymptomatic. we herein report a wg with massive lower gastrointestinal hemorrhage due to colonic involvement. case: the patient complained of dyspnea which started months ago, fatigue, generalized arthralgia and myalgia together with loss of sensation on right upper extremity was applied to emergency and hospitalized by internal medicine department. physical examination revealed a very ill-looking patient, there were positive lung findings for wg and c-anca was positive. we consulted the patient because of hematochesia with abrupt drop of hemoglobin and platelet count. on colonoscopy whole mucosa was full with fresh blood from sigmoid to anal canal. on angiography multiple foci of bleeding were demonstrated on descending and sigmoid colon. embolectomy was not performed because of multiple foci. hemoglobin decrease continued and his clinical condition deteriorated; an explorative laparotomy and total left colectomy was performed. his melena persisted for days but hemoglobin was maintained at after units transfusion after operation. conclusion: we herein report a case with clinical wg who developed a gastrointestinal hemorrhage and treated by surgery. the uremic state and cytotoxic agents given to patients may detoriated the gastrointestinal bleeding. immunosuppressive therapy might exacerbate gastrointestinal complications. the clinicians should be aware of this situation, therefore treatment of these must be performed in centers where angiography and endoscopy are available. background: the aim of this study is to determine the strength and proceeded efficiency of mda, sod, and catalase levels that are indicators of oxidative stress in generalized peritonitis. material-methods: this study was conducted as prospective and randomized with patients who applied at dicle university, department of general surgery between march-september . patients were composed as group (n = ); generalized peritonitis, group (n = ); laparotomy under elective conditions and not present peritonitis; group (n = ) as control group. in order to measure limits of mda, sod, crp and catalase, blood samples were drawn from the patients in group and group on before operation day (bod), st and rd days. the mda values of group on before operation day, st and rd days were compared to group and , the difference were found statistically meaningful. statistical differences noticed between group and mda values on bod, st and rd days. statistical differences were noticed between catalase values measured bod and rd days when group and values compared to group . the sod values of group and group on day were compared to group , meaningful statistical difference was found. statistically meaningful difference was found between the sod values group and on st day. conclusion: values of sod, mda and catalase were noticed usable parameters for the following and detection of severity of generalized peritonitis sinan cumhur karakoç, gü rkan yetkin, _ ismail ethem akgü n, mehmet uludag, bü lent Ç itgez, hamdi Ö zş ahin, cabbar kartal general surgery departmet, Ş iş li etfal training hospital, istanbul, turkey objectıve: we aimed to evaluate the effects of early cholecystectomy on morbidity and patient comfort in patients with acute biliary pancreatitis. methods: patients who underwent cholecystectomy for acute biliary pancreatitis in our clinic between and were evaluated retrospectively. the patients were divided into three groups as early, late and elective cholecystectomy cases. fındıngs: patients who had undergone cholecystectomy operation in the first days until the administration to hospital were classified as the first group (early cholecystectomy). patients who had undergone cholecystectomy between the nd and th weeks until the administration to hospital were classified as the second group (late cholecystectomy). patients who had undergone cholecystectomy after weeks were classified as the third group (elective cholecystectomy). in group , no patient had pancreatitis attacks; of patients in group had recurrent pancreatitis attack in the preoperative period and treated in our clinic. in order of these data, age, height, weight, gender, sgot, sgpt, amylase, bilirubin and the time for waiting for the operation were compared and evaluated statistically. the time for waiting for the operation was found to be p > . , and it was shown to be significant. results: there is a tendency to perform cholecystectomy in patients with acute biliary pancreatitis, after the acute attack is resolved. we believe that the early cholecystectomy prevents the patient from the additional morbidity in patients with acute biliary pancreatitis, by showing this with a statistically significant result in our study. traumatic right sided diaphragmatic hernia is clinically rare and may present with complications in a later period. on the right side presence of liver is thought to be a protective factor for both development of diaphragmatic injury itself and for its complications. we present a case of right sided diaphragmatic hernia due to blunt trauma, which was asymptomatic for years and has been presented with intestinal obstruction. the patient, years of male, has presented with intestinal obstruction and abdominal pain which has been relieved after nasogastric decompression. despite conservative treatment patient has not shown further improvement and has been operated on a semi-elective basis. significant part of small and large bowel, distal portion of stomach, and almost whole of liver had been herniated and reduced by right thoracoabdominal approach. cm wide defect in diaphragm has been repaired with prolene mesh, laparotomy has not been closed and bogota bag has been applied. in the early postoperative period transaminase levels have increased , u, and ct-angiography has revealed patchy areas of low per-fusion in both lobes of liver. after therapeutic anticoagulation liver function has recovered completely, abdomen is closed and oral feeding commenced. at the th postoperative day respiratory insufficiency has occured after witnessed aspiration of gastric contents, followed by multiple organ failure. this case represents a quite late presentation of right sided traumatic diaphragmatic hernia, for which treatment was complicated. this case clearly shows the importance of detailed evaluation and timely treatment of all traumatic diaphragmatic hernias. cem ibis, dogan albayrak, fedayi calta, eren taskin, mehmet ali yagci, ahmet hatipoglu, irfan coskun department of general surgery, medical faculty, trakya university edirne, turkey introduction: amyand hernia is first described by claduis amyand in london in an year old male. it is a rare condition and described as appendix vermiformis in the hernia sac. we present a case of an incarcerated inguinal hernia with appendix vermiformis inside. case: sixty nine years old male with bulging and pain in the right inguinal region is evaluated. right inguinal hernia was detected. after opening the hernia sac, the appendix and ceacum were observed. lichtenstein procedure was performed. the patient was discharged in the second postoperative day. discussion: although the incidence of appendix vermiformis in the hernia sac is . - %, the incidence of acute appendicitis in the hernia sac is . - . % in various reports. the treatment of amyand hernia is related to the appendix found inside. the application of appendectomy to normal appendix in routine hernia repair procedure is controversial due to infection risk. we do not routinely perform prophylactic appendectomy in such patients. we thought that a patient tailored approach is more acceptable. introduction and objectives: hydatid disease is typically asymptomatic. it can become symptomatic due to expansion, rupture or pyogenic infection. rupture of the cyst is the most common complication, followed by secondary infection, jaundice, and anaphylaxis. methods: in this study, we analyzed demographic and clinical characteristics of the cyst hydatic patients who admitted the emergency service due to complications of the cyst hydatic. the medical records of patients, with a final diagnosis of complicated cyst hydatic were reviewed for demographic information, admission symptoms, laboratory findings, evaluation techniques, and outcome. results: ten patients ( men, women) with final diagnosis of complicated ce (cystic echinococcosis) included the study. all of the patients had abdominal pain. while the pain was diffuse in the entire abdomen in seven patients, it was located in the right upper quadrant in three patients. patient's complaints were nausea, vomiting, jaundice, ileus and urticaria. the clinical signs and symptoms of hc rupture are not always severe, but hydatid fluid can irritate, which can cause peritonitis as occurred in our series of patients, all of whom had acute abdominal signs. in this study, % of the patients with ruptured ce had abdominal pain. thus, the clinical presentation of ce rupture is not always silent. the severe clinical presentation and infrequency of ce perforation has been held partially responsible for the misdiagnosis by the surgeon. conclusion: in conclusion; complicated hc may be admitted to emergency service with different clinical pictures especially in endemic regions and must be considered in differential diagnosis. background: to evalute the changes in the pattern of iatrogenıc bılıary injury and consequentıal effects on treatment strategy and outcome. methods: seventy-three patıents treated for iatrogenıc bılıary injury (ibi) between july and november at a tertıary care center in izmir, turkey were retrospectıvely analysed. results: underlyıng diseases were; missed tumor (n: , . %), biliary surgery (n: , %) and hydatıc dısease (n: , , %). in recent years wıth a gradual increase in the avaılabılıty of endoscopıc and radiologial expertise the majorıty of patıents underwent extensıve preoperatıve diagnostic and therapeutıc procodures includıng endoscopıc retrograd panceratography for cases( . %) and percutaneus transhepatıc cholangıography for cases( %). defınıtıve surgery was performed in all patıents except ( . %) of them. roux-en-y hepatıco-jejunostomy was the primary reconstructıon technıque and performed for cases ( %). there was only one ( . %) hospıtal mortalıty. restenosıs developed in ( . %) cases and was reoperated. percutaneus baloon dilatation was faıled in three patıents as a fırst treatment optıon. none of patıents died of dısease related causes durıng the follow-up perıod. conclusion: increased experınece in laparoscopıc biliary surgery might be caused to attempt more challengıng cases and increased bılary tract injurıes. tolga kafadar, ercan gedik, sadullah girgin, bilsel baç, _ ibrahim halil taçyıldız department of general surgery, dicle university, diyarbakir, turkey the aim our study was to determine the independent risk factors affecting patients with upper gastrointestinal hemorrhage who underwent surgery. materials and methods: the medical records of patients with upper gastrointestinal hemorrhage who underwent operation were reviewed for variables including age, gender, shock, association with co-morbidity, pulse rate, hemoglobin levels, white blood cell count, serum urea, creatinine, sodium and potassium levels, time of opera-tion, number unit of blood transfusion, rockall risk score and length of hospital stay. in order to determine the independent risk factors mortality and morbidity, we carried out entered logistic regression analysis. results: morbidity and mortality rate were . % ( patients) and . % ( patients), respectively. the independent risk factors affecting morbidity were serum albumin level [odds ratio (or) = . , % confidence interval (ci) = . - . , p = . ] and rockall score ‡ (or = . , ci = . - . , p = . ), and the independent risk factors affecting mortality were advanced age (or = . , ci = . - . , p = . ), and high rockall score (or = . , ci = . - . , p = . ). conclusion: to decrease the postoperative morbidity and mortality rates in patients with ugih requiring surgery, patients preoperative risk factors should be demonstrated. we believe that establishment of interventional indication on time and evaluation of intraoperative surgical region and technique in combination with the patient-and disease-related factors in patients requiring surgery would help reduce morbidity and mortality rates. blunt thoracic trauma leads to various clinical conditions, such as hemothorax, pneumothorax, pulmonary contusion, and respiratory tract hemorrhage. especially, respiratory tract hemorrhage resulting from pulmonary contusion is so critical to require a clinical challenge. of our experienced survivors, trauma victims (male / , - years old) with blunt thoracic trauma associated with motorcycle accident were transferred to our emergency departments. they similarly suffered respiratory failure (average respiratory rate of ) and hypotension (average shock index of . ) on arrival. immediate after the rapid-developing respiratory failure in relation to lung contusion and endobronchial bleeding, bronchial blockade device and extracorporeal membrane oxygenation (ecmo) were urgently introduced at an average of and min, respectively, and achieved rapid resolution of their respiratory crisis. all of them withdraw from ecmo within days. pulmonary contusion sometimes follows fatal progress, and we consider that quick bronchus blockade and ecmo introduction is the key of survival. emergency departments (ed) in greece are incorporated to the departments of the hospital and are divided in two major areas: one for internal medicine and one for general surgery. every patient has free access to the (ed). the workload and the conditions treated in ed in greece are geographically and social -economically depended. the national health system is represented by one hospital for each prefecture. the general hospital of trikala, is categorized as an urban hospital, with beds, and is covering a population of approximately , people, living in the town and in villages situated in the surrounding mountain area. the department of general surgery is stuffed by general surgeon specialists and seven residences. during , , patients were examined in the surgical ed. in this study we analyze the characteristics of the patients, the number and causes of admissions in the various departments of our hospital and also the transferals to a tertiary center. aim: pneumotosis cystoides intestinalis is a rare entity, and may be associated with pyloric stenosis. materıals-methods: data of a patient operated for pyloric stenosis and pneumotosis cystoides intestinalis in our institution are presented. results: patient was a year-old addicted male, and his body mass index was . kg/m . he had been suffering from nausea/vomiting, bloating and constipation for a few months. a gastroscopic examination revealed atonic gastric dilatation, duodenal ulcer and related pyloric stenosis, and positive serology for helicobacter pylori. an eradication treatment in conjunction with long term proton pomp inhibitors were given, however the patient readmitted to our department with worsening symptoms including vomiting, pain and weight loss after months. repeated gastroscopies and gastric meal x-ray examination revealed pyloric stenosis and the patient decided to have an operation instead of repeated medical treatment. during laparotomy, subserosal foamy air bubbles were observed on the serosal wall of ileum. a partial resection of ileum was necessitated for the suspicion of perforation. vagotomy with finney pyloroplasty was performed in order to cure the pyloric stenosis. the postoperative period was uneventful and the patient was discharged from the hospital on day . the patient has not have a recurrence, gained weight and have no problem since years postoperatively. conclusion: pneumocytosis cystoides intestinalis may be observed in the presence of a pyloric stenosis and necessitates resection if any doubt for perforation is present. granulosus. in this study, a rare appearance of the disease is presented as an abscess located in the retroperitoneal space. results: the patient was years-old male with several comorbidities admitted to our emergency department with fever and left lumbar pain. he had had operated for hepatic hydatid disease years before the admission. physical examination revealed local tenderness and slight hyperemia on his left lumbar region. his laboratory findings showed leucocytosis, and a computed tomography demonstrated a huge retroperitoneal abscess located between spleen and pelvic entrance and denied any pathological finding regarding to the left kidney or adrenal gland. since the general condition of the patient did not allow an operation under general anesthesia, the abscess was drained through a cm long incision located on the hyperemic area under local anesthesia. after complete removal of the abscess and daughter cysts, a drain was left behind, and removed on day . the patient was discharged out of hospital on day , after an uneventful recovery period. discussion: to best to our knowledge, this is the first hydatid disease case presented as a retroperitoneal abscess in the literature. hydatid disease may be kept in mind as a differential diagnosis in the presence of a cystic retroperitoneal mass in endemic regions. ali uzunkö y , zekeriya sayın harran university school of medicine department of general surgery, sanliurfa, turkey osm ortadogu hospital, sanliurfa, turkey introduction and objectives: giant true splenic artery aneurism is rare lesions. these aneurisms have risk of rupture and bleeding. we have performed a giant true splenic artery aneurism. case: the case is a year old female patient. she applied to hospital with complaints of abdominal pain. at the physical examination, there were a moderate splenomegaly and a pulsatile mass in the left upper abdomen. it was shown a giant splenic aneurism at the abdominal computed tomography and colour doppler ultrasonography. colour-doppler abdominal ultrasonography showed about mm splenic artery aneurism. computed abdominal tomography showed a hypo dense mass situated anterior and superior to the pancreas tall and corpus extending up to the splenic helium. the diagnosis was confirmed by ct angiography. the patient was performed with general anaesthesia and left subcostal incision. at the exploration, splenic arterial dilatation and aneurismal sac was shown and aneurysmectomy with splenectomy was performed. there was no complication intraoperatively and postoperatively. the patient was discharged at the postoperative fifth day. there was no complaint at the control examination at the fifteenth day after discharging. conclusions: although giant splenic artery aneurism is rare, but they have risk of rupture and bleeding. there are two options for treatment of these lesions. one of them is aneurysmectomy. it is frequently performed with splenectomy. other option is embolisation. in our opinion, surgery for giant splenic artery aneurism is performed successfully without important complication. author to editor: saved by lookus introduction: an association between the administration of paracetamol and relative hypotension in critically ill patients has been reported by the staff working in the surgical and trauma intensive care unit of istanbul faculty of medicine. methods: a prospective, observational study was undertaken to investigate the effect of paracetamol on systemic blood pressure in two groups of critically ill patients. a dose of mg of paracetamol was administered intravenously to both groups in min time. blood pressure, heart rate were recorded at baseline, at the end of infusion and then at , , min after administration. the differences occured over the observation period was measured by friedman analyse. results: twenty-eight patients with sepsis, were enrolled to group- (anti-pyretic effect) and postoperative patients were enrolled to group- (analgesic effect). analysis of data from all patients showed that systolic arterial pressure (sap) and mean arterial pressure (map) were reduced significantly over the observation period in both groups (sap:p < . for both, map:group- p < . , group- p < . ). sap and map in group- and group- decreased by an average of approximately and % respectively. however, no significant decrease in dap was noted in group- . conclusions: utilization of the intravenous paracetamol for febrile and/or postoperative patients caused a significant decrease in systemic blood pressure after administration. this drug-induced hypotension was clinically relevant to control the required blood pressure. thus, clinicians should be aware of this potential effect, especially in critically ill patients. yazile sayın faculty of health, surgical nursing division, cumhuriyet university, sivas, turkey background: pain is considered one of the most important symptoms which guide diagnosis, treatment and nursing care in the emergency departments. aım: to discuss pain evaluation by nurses in emergency departments and to attract attention towards nurses' responsibility for pain evaluation. methods: qualitative and quantitative data from studies on pain evaluation by nurses were evaluated. results: all studies reviewed showed that about three fourths of the nurses in the emergency departments did not make pain evaluation based on the standards (using pain rating scales, reporting the conditions likely to affect pain evaluation etc.). the nurses included in studies assigned significantly lower scores for pain than the researchers(p < . ;p < . ). all studies revealed the following reasons why triage nurses did not play an effective role in pain evaluation: insufficient knowledge, the idea that doctors are responsible for pain evaluation, doctors not appreciating the value of pain data provided by nurses, insufficient cooperation among members of the health staff, work overload, time constraints, errors in reporting data on pain evaluation and conflicting attitudes and beliefs concerning pain evaluation. it has been reported that only - % of the patients presenting with pain to emergency departments received effective pain management. the most important reason for this low rate has been shown to be deficiencies in pain evaluation due to insufficient multidisciplinary cooperation. conclusion: it can be concluded that nurses in emergency departments are not efficient enough to use interventions which help to evaluate pain for effective pain management. introduction: diverticulosis of the colon is a common condition. complications of diverticulitis often require surgery. perforated diverticulitis may rarely present with spreading superficial sepsis. case: male, years, history of chronic depression. admitted in the emergency department after a -day history of abdominal pain in the left lower quadrant (llq), associated with asthenia, anorexia and weight loss, without diarrhea, constipation or fever. the patient examination showed edema and thickening of the abdominal wall with swelling and redness in the llq. blood chemistry revealed leukocytosis with neutrophilia and elevated c-reactive protein. a diabetic ketoacidosis was diagnosed. the abdominal ct confirmed abdominal necrotizing fasciitis with an abscess, without other intra-abdominal changes. the patient was then submitted to emergency surgery with debridement of the necrotising fasciitis and drainage of the abscess. he was admitted to the icu. further debridement was necessary h later. at d , fecal contamination of the wound was detected, leading to a subsequent laparotomy with identification of a sigmoid inflammatory mass attached to the site of the fistula's external orifice. a hartmannprocedure was performed (histology confirmed the diagnosis of perforated diverticulitis). the patient developed a sirs complicated with a right-side necrotizing pneumonia requiring multiple antibiotic treatment and pulmonary decortication. death occurred at the th hospitalization day. conclusion: necrotising fasciitis as a consequence of perforated diverticulitis is an uncommon but potentially lethal condition requiring prompt surgical intervention. when accessing an abdominal necrotising fasciitis without recognisable source, an elevated index of suspicion is necessary to link it to complicated diverticulitis. fatih baş ak, kü rş ad Ö ztü rk tc sb bozkir community hospital introduction: care of trauma patients may be difficult in small community hospitals. these hospitals are usually staffed by a small number of general practitioners and, perhaps, a general surgeon, and a significant number of trauma cases are brought to them. the records of minor and major trauma patients who admitted to bozkir community hospital between june and december were evaluated. mortality and transfer rate were recorded. general surgeon was not present in first months. the rates of last months when general surgeon has been present were calculated separately. results: trauma patients were admitted in first months ( . %) of these were transferred to larger centers. treatment of remaining ( . %) patients continued in our hospital. mortality rate of first months was . %. three patients requiring immediate surgery died because of absence of general surgeon. patients were admitted in last months. ( . %) of these were transferred to larger centers. mortality rate of last months was . %. three gunshot wound and one penetrating cardiac wound patients were saved with emergent surgery. conclusions: regardless of the sophisticated techniques for dealing with trauma that exist in larger centers, it is the staff of smaller hospitals that often shoulder the initial burden of trauma care. transfer rate is between and % of all trauma cases. our hospital is . h away from larger centers. presence of general surgeon in last months mainly affected the care of patients that requiring immediate surgical attention. metin kement, hakan acar, ilhami soykan barlas, uygar dü zci, cem gezen burn center, kartal education and research hospital, istanbul, turkey aim: fecal contamination which may result in septicemia, graft loss and wound healing delay is the most serious problem for burns in perineal, gluteal and upper thigh regions. temporary fecal containment devices can be used for diverting feaces from burned area. the aim of this study was to evaluate early results of using of these devices in our burn center. methods: twelve patients, who were applied temporary fecal containment devices in our burn center, were retrospectively evaluated in this study. results: ( . %) of the patients were male.the mean age was . ± . year.the mean tbsa burned was . ± . %. ( %) of the patients had burn in all three regions (perine, gluteus and upper thigh). three ( %) of the patients had burn in upper thigh. and ( %) of the patients had burn in gluteal region. the devices were placed intra-rectally on the first admission days of all patients.the mean application time was . ± . days. except minimal fecal leakage in ( . %) patients, any complication was not observed in our cases. local infection confirmed by tissue culture was observed in ( . %) patients including two patients with fecal leakage. besides, in one of these four patients, septicemia was developed and managed successfully with antibiotics and supportive treatment in intensive care unit of our center.one patient with % burn was died on days of application due to multiple organ failure. conclusion: temporary fecal containment devices aim to protect patients' wounds from fecal contamination by diverting feaces. if the safety of these device is proved in further studies, they may reduce the necessities of diverting stoma operation in burn patient. metin kement, ilhami soykan barlas, uygar dü zci, hakan acar, cem fazlı gezen burn center, kartal education and research hospital, istanbul, turkey aım: reactive thrombocytosis which develops secondary to infection, trauma, malignancy or surgery is the most common ethiology of thrombocytosis. although thrombocytosis is a benign and self-limiting condition in most cases, it may result in some thrombotic and hemorrhagic complications. the aim of this study was to evaluate the reactive thorombocytosis in burn patients. material: thrombocyte counts was retrospectively evaluated in consequent burn patients admitted to our burn center between august and january . the correlations between thrombocyte counts and demographic data, total body surface area burned (tbsa), hospitalization time and levels of some acute phase markers also analysed. results: the mean thrombocyte counts were respectively . ± . /mm , . ± . /mm on admission day and second day (p < . ). the number of patients with thrombocytosis was ( . %) in admission, ( %) of them were children. the rate of thrombocytosis was / ( . %) in children,whereas the rate of thrombocytosis was only / ( . %) in adults (p < . ). the mean thrombocyte counts in children and adults were respectively . ± . /mm , . ± . /mm in admission (p < . ). the mean wbc count was significantly higher in patients with thrombocytosis than patients with normal thrombocyte count (p < . ), but there was not any significant difference in crp count (p = . ). and also,we did not find any significant difference between patients with thrombocytosis and patients with normal thrombocyte count in tbsa and hospitalization time (p = . and . , respectively) conclusion: reactive thrombocytosis is seen more frequently in burned children than burned adults and mostly unrelated to degree of burn. background: electrical injuries are related with multiple organ dysfunction as well as high morbidity and mortality. pulmonary compromise is rare, if compared to other organ dysfunctions related with electrical injuries. in this study, we presented a case with pulmonary hemorrhage associated with electrical injury. case: a -year-old previously health man was brought to our emergency department (ed), h following the accident, with electrical injury. initial examination findings were blood pressure / mmhg, heart rate /min, respiratory rate breath /min. glasgow coma score was . decreased breath sounds, bilateral rales and wheezing were determined. there were small necrotic wounds (typical contact injury) on the first finger of left hand and under the right foot of patient. there was no trauma in thoracic wall. blood gas analysis revealed respiratory and metabolic acidosis. the inr and platelet levels were normal. when chest radiograph and thoracic computed tomography were assessed, air bronchograms and symmetric consolidations were determined in the both lungs. patient was intubated and fresh blood was aspirated from endotracheal tube. mechanical ventilatory support was performed the patient due to lung hemorrhage and respiratory failure. patient died after h of admission in the ed. conclusion: multiple organ dysfunction and necrotic skin lesions could be occurred in electrical injuries. electrical injuries on the chest may cause lung infarction because of the direct effect of the electrical current and vascular embolism. possibility of lung injury should be investigated after electrical injury especially in patients with respiratory failure. nebahat yıldız , aysel gü rkan , _ imren aş ar , ayş e hale uysal trauma and emergency surgery service,istanbul university, istanbul faculty of mediine, istanbul, turkey health science of faculty marmara universty, istanbul, turkey introduction and objectıve: the outcome of burn treatment is measured not only by mortality and morbidity, but also by post-burn psychological factors. the purpose of this study was to investigate whether difference in length of hospitalization exist between burn patients with and without mental health problems and if so, why. methods: the descriptive study was retrospective review of patient with burn injuries who had received care at one burn unit in the istanbul from october to december . socio-demographic features of patients, burn criteria (kind, depth, size, location), duration of hospital stay, and psychological problems were tabulated. results: psychological impairment was found in of hospitalized burn patient. there were acute stress disorder in fifteen patient, anxiety in nine, adjustment disorder together with anxiety in eight, depression in seven, post-traumatic stress disorder in six patient. fortyone ( . %) patient had burns which were between i and ii degree and ( . %) patient had burns which were between ii and iii degree. in patient, burned area has been % or more. patients with psychologocal impairment were longer hospital stay and intensive care unit than patients without psychologocal impairment. sixty-four ( . %) patients with psychologocal impairment had been discharge either getting better or recovering completely but unfortunately ( . %) patients died. conclusion: the presence of psychological problems in burn patients have an impact on their burn care. psychological interventions can contribute towards successful outcomes. introduction and objectives: major burns can cause disseminated intravascular coagulation (dic) and is a serious clinical problem. we would like to present dic cases whose burn rate is % according to total body surface area (tbsa) which developed after late postoperative period. methods: two cases over %, nd and rd degree burn injury admitted to our facility. first case who was year old female developed s. aureus and second case was years old female developed p. aeruginosa sepsis which was confirmed by blood culture. in first case dic developed at postburn day and in second case at postburn day. in both cases dic developed after postsurgery day . results: on patients, bleeding points, as leaking, were detected on all over burn areas. at the same period thrombocyte values decreased sharply ( . k/ul). increase in prothrombin time (pt) ( . second) and active partial thromboplastin time (aptt) ( second) values, decrease in fibrinogen levels was observed. cases were discharged from hospital in th day, without any problem. patient was taken for iu erythrocyte suspension and iu platelet suspension in this time totally. conclusion: dic occurs in early period of burning; but it can be formed in later periods, even after defects were recovered by operation. rapid establishment of dic table just before the discharging term from hospital is an unusual and interesting situation. the patients in our study can be accepted as an example of the necessity of observing coagulation parameters in every periods of burn damage. methods: sphere project handbook reviewed by experts in the field of each section, the terms of our country's adaptation has been made. within the framework of the project dissemination, sphere workshops have been organized in various provinces. the ppt slides were adapted to turkey's needs. the project's outcomes have been observed through the pre-post tests and the workshop evaluation forms. results: expert review and the end of the first study, with a high risk of disaster in our country, the handbook was understood to be necessary and useful. in addition to this, the control lists in details but useful and also, the summary tables are useful to take a decision in emergencies. it is also understood that preliminary results from the project is compatible with literatur data. conclusions: developed in each country is adapting to the local experience of the sphere, significant experience with disasters in our country the right to contribute are welcome. indeed, the first application of the new approach by the sphere project's coordination center is monitored with interest. introduction: ( ) initial assessment of trauma patients is a period with a high frequency of treatment protocol deviations and an elevated number of avoidable complications. ( ) the majority of medical errors are diagnostic or cognitive, whereas operative technical complications accounted for less than %, and ( ) general surgery residents (gsr) do not feel well-trained on the management of major trauma patients. aim: describe initial experience with one approach to foster quality improvement in trauma care modifying the method by which we train surgeons. methods: we integrated in the gsr program, simulation based training sessions with other educational tools as lectures and workshops. the scenario objectives were based on research data indicating major deficiencies in trauma care (tc). we incorporated team training and crisis resource management sessions. to review trauma life support diagnostic and therapeutic standardized protocols we run scenarios to train initial assessment, and head, thoracic and abdominal trauma. after every clinical case, residents participated in a video assisted debriefing session leaded by a specialized instructor. an evaluation interview was made after the course. results: all resident viewed the experience as a ''very good'' training modality. many of them felt their time was better spent in the simulator session than in the operating room, and wanted to do it more often or in a scheduled way. some of them complained about evaluating the mannequin and the equipment when compared to the one in their actual work setting. conclusions: integrating patient simulation with traditional surgical training may strength the approach to tc education. introduction: pulmonary embolism is a life-threatening condition and its diagnosis is generally based on clinical suspicion. case: a years old male had been admitted to another hospital with acute dyspnea and syncope and after initial evaluation he had immediately been undergone an operation due to epidural hematoma. he was referred to our emergency department with early diagnosis of acute coronary syndrome after operation because intraoperative and postoperative tachycardia could not be controlled. in his physical examination gcs: , arterial blood pressure / mmhg, heart rate /min and breath rate /min. ecg, echocardiogram and thorax ct findings complied with pulmonary embolism. venous doppler ultrasonograpy findings complied with chronic deep venous thrombosis. thrombolytic or antiaggregant medication could not be started because of epidural hematoma operation. at postoperative h low molecular weight heparin and at h warfarin was administered. in follow-up period his symptoms regressed and there was no complication due to epidural hematoma surgery. he discharged from hospital at day . conclusion: in trauma patients, one of the important issues that have to be considered during clinical evaluation is the primary reason leading to trauma. in this case, the investigation for syncope etiology revealed the haemorrhage and thrombus diagnosis concomitantly. these two diagnoses have opposite treatment strategies and due to this condition we had difficulty in management of the patient. although there are intracranial haemorrhage cases due to pulmonary embolism treatment (thrombolytic or antiaggregant), a similar case report cannot be found in the available literature. introduction and objectives: different societies have different type of snake bites. _ in our actually series, two patient from u.k. and seven patients from south-eastern part of turkey presented with lıke compartment syndrome result of was bitten by a snake to their fingers. methods: four of nine patients applied to our clinic at the day of event, the other five were referred to us after the emergency treatments have been done. all bites were over or distally to the pip joint. after being bitten by snake, patients admitted to our accident and emergency department because they had like as compartment syndrome on the forearm. two of the patients were referred to us very late stage and one of them had partial necrosis and the other had total necrosis already. none of patients had signs of systemic envenoming. results: two patients with local swelling and no other symptoms were discharged. coverage of the defects were performed with full thickness skin grafting in two patients, cross-finger flap in one patient, reverse dorsal digital arter flap in one patient and dorsal interosseous metacarpal flap in two patients. one patient had amputation. none of patients had fasciotomy. conclusions: this study represents the clinical effects and current approaches for the treatment of snake bites to distal finger. all patients presented with compartment syndrome like symptoms on the hand or forearm. these patients should be followed-up very closely. final wounds should be closed either with skin grafts or local flaps. simultaneously, systemic envenoming should be considered. the aim was to evaluate the geriatric patient with abdominal pain in emergency department (ed). methods: the preliminary retrospective study included the period between january and june , , ankara. data were achieved from registration notebooks, manually. the patients separated within age to three groups as - , - , and over. the finalization of management, hospitalization, operation rate, mortality were studied. results: there were ( . %, annually) patients. the mean age was . ± . ( - ), the mean hospitalization duration was days ( - ). the sex and the age of patients can be seen in table . . % (n = ) of them discharged from ed. abdominal ct and usg usage were . % (n = ), . % (n = ) in ed. . % (n = ) patients had both ct and usg. abdominal ct and usg results are showed in tables , . finalization of patient management was demonstrated in table . the operation rate for all patients was . % (n = ). general surgery hospitalization and operation rate were . and . % (n = , n = ). the mortality rate was . % (n = ) in admission. there were not any significant difference between the groups of - and - according to sex, finalization, ct, usg utilization, operation rate (p = . , p = . , p = . , p = . , p = . ) with spss x test, while the number of advanced geriatrics was unsuitable for statistics. conclusions: females and the - age group were common with a complaint of abdominal pain in ed. most of them had hospitalization indications and the primary yard was general surgery with brid ileus. mortality rate was lower than % introduction: nontraumatic epigastric and left upper caudran pain is a common complaint in emergency department. it can include lifethreatened various reasons as cardiac, respiratory, and serious gastrointestinal problems, rarely. case: a year old man had an emesis with recurrent epigastric and left upper caudran pain admitted as second turn to ed in h. physical examination except a slight epigastric sensitiveness, ekg, urine test and biochemical tests, complet abdominal ultrasonography, x-rays were nonspesific on the first day. wbc was . on cbc. his complaints relieved with semptomatic treatment with an mg ranitidine, mg metoclopramide, serum sale on his observation and discharged with suggestions. in second admission with nonspecific physical examination findings, computerized tomography (ct) revealed splenic unenhanced parenchymal areas consistent with splenic infarcts. computerized tomography angiography (cta) showed a small aneurysm of the celiac trunk, a characteristic pattern of caliber irregularities and arterial wall thickening of the splanchnic arteriesincluding splenic artery, common hepatic, right and left hepatic arteries-, suggesting splanchnic arterial mediolysis (figures and are presented with permission of patient's written consent). he was hospitalized to general surgery and started low molecular weight heparin. as clinical and radiologic findings were degrated, he was discharged without an operation. conclusions: splanchnic (segmental) arterial mediolysis is a rare noninflammatory vascular disease of the abdominal splanchnic arteries with slight symptoms. ct for vasculary and internal organs should be performed to diagnose in recurrent complaints beside observing the physical findings. introduction: it is well documented that healing of peptic ulcer perforation (pup) is possible with conservative therapy in selected cases. thus a spontaneously closed pup diagnosed at exploration may not require surgical repair. methods: study included three patients in which diagnostic laparoscopy suggested spontaneously closed pup between and . suggestion criteria were; fibrin cloth on duodenum with or without subhepatic fluid collection, no visible perforation, otherwise normal exploratory findings. omentum minus was dissected and cautiously observed. the stomach was filled with ml diluted methylene blue fluid via nasogastric tube, operation table was tilted to right and up, a gentle pressure on the stomach was made with the shaft of laparoscopic irrigator to fasciculate the passage while the descending section of duodenum was compressed with the shaft of a grasper. duodenum was cautiously observed for min to detect dye leakage in all patients. if no leak was observed, operation was terminated after abdominal irrigation and inserting a catheter to the subhepatic area. therapy for pup was given postoperatively. results: all patients were male and the mean age was ( - ), no leak of dye was observed at operation. nasogastric tube was removed and food intake was allowed at postoperative second day. all patients were discharged on third day. conclusion: although the perforation site is almost always identified at operation, to meet a spontaneously closed pup is also possible. irrigation and drainage alone may be sufficient for these cases after blue dye test as described in this study. the complicated appendix with/without abscess was delivered through the umbilical incision for an open technique safely. this gave our patients the maximum benefits of the minimally invasive surgery with better visualization, reducing equipment needs, less postoperative pain, rapid discharge, no postoperative infections, and excellent cosmetic results. all patients were quite satisfied during follow-up. conclusions: it is concluded that hybrid appendectomy seems to be feasible and reliable for children with complicated appendicitis not suitable for conventional laparoscopic technique. vata was successfully accomplished with obvious advantages, and avoided conversion to the open fashion. background: appendicectomy remains the most frequent emergency operation. the management of these patients varies between surgeons and hospitals. at our centre, it was a routine to review post operative children at months. aims: is to evaluate the need for a routine follow up in children who had appendicectomy. methods: it is a retrospective observational study for consecutive patients between and . a parallel questionnaire was sent to the parents of all the children. results: the average age was . years. % of the patients were found to have normal appendices. % of the patients were discharged within days. % of the patient had intravenous antibiotics for day and % were discharged with oral antibiotics. % had a routine follow up appointment in months time. in % of cases there was no change in the management. on the questionnaire % of the parents thought they were given enough information regarding the procedure. in terms of routine follow ups, % of the parents found it very useful while % found it a little or not useful. conclusion: this study shows that there is no change of the management or a clinical need for the routine follow up. however the patients and their families like to keep a follow up appointment. it is more convenient for the patients and their family to arrange other sorts of follow up like a phone call conversation or a general practitioner follow up. yavuz savaş koca, mustafa ugur, celal Ç erçi, recep Ç etin department of general surgery, sü leyman demirel university, isparta,turkey the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly efective on mortality. reliability of ultrasonography for diagnosing acute appendicitis aylin hande gö kçe , acar aren , feridun suat gö kçe , hakan Ö zkan , alper dursun Ş agban , _ ibrahim aydın , gü rhan Ç elik , gü rol kö roglu s.b. _ istanbul eg itim ve araş tırma hastanesi, istanbul, turkey balıklı rum hastanesi, istanbul, turkey purpose: abdominal ultrasonography is the most commonly used diagnostic tool for diagnosing acute appendicitis,which is one of the most common causes of acute surgical abdomen. _ in this study, we examined the reliability of ultrasonography for diagnosing acute appendicitis. in this prospective study we performed abdominal ultrasonography on patients admitted to our surgical emergency department and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings during . these patients were surgically treated by appendectomy and the materials were pathologically examined. results: patients were admitted to this study. of these patients ( . %) were diagnosed as acute appendicitis, and ( . %) of them diagnosed differently. ( . %) of patients diagnosed as acute appendicitis on ultrasonography examinations were reported as acute appendicitis on histopatological examination. ( . %) of patients diagnosed differently on ultrasonography examination were reported as acute appendicitis on histopathological examination. conclusion: the sensivity of abdominal ultrasonography for diagnosing acute appendicitis is high ( %), but the specificity is low (p = . ). we calculated that the specificity is . , positive predictive value is . , negative predictive value . , accuracy is . . abdominal ultrasonography is a helpful diagnostic tool for diagnosing acute appendicitis.however, it should not be seen superior to anamnesis and physical examination findings. poisoning: a case report background: mushroom poisoning is an important clinical problem which may cause serious complications and death. acute pancreatitis is a rare complication of mushroom poisoning. in this study, we presented a case that developed liver damage and acute pancreatitis following wild mushroom ingestion. case: sixty-six years old women admitted to emergency department with complaints of nausea, vomiting and abdominal pain. it was learned that patient was ingested wild mushroom before h of admittance and her complaints were started after - h of ingestion. in initial examination, general appearance and vital signs of patients were normal and there was epigastric discomfort. laboratory findings were leukocyte , /ll ( . - . ), aspartate aminotransferase u/l ( - ), alanine aminotransferase u/l ( - ), amylase u/l ( - ), lipase , u/l ( - ) on admission. liver and pancreas was determined as normal in abdomen ultrasonographic examination. computerized tomography of the abdomen showed minimal peripancreatic fluid. the patient was observed in emergency intensive care unit and symptomatic therapy was performed. hepatic transaminases and pancreatic enzymes were decreased progressively during the observation. the patient was discharged from the hospital after days clinical course, without complication. conclusion: mushroom poisoning and acute pancreatitis have similar gastrointestinal symptoms and sings. therefore, possibility of acute pancreatitis as well as other organ dysfunctions should be investi-gated in patients with mushroom poisoning. early recognition and appropriate therapy for acute pancreatitis and mushroom poisoning may lead to an improved prognosis and complications. mehmet mustafa altıntaş , , ayhan Ç evik , , yekin Ö zcabı , , gü lay dalkılıç , , hü seyin ekinci , , nejdet bildik , dr. lü tfi kırdar kartal education and training hospital, istanbul, turkey general surgery clinic, istanbul, turkey diagnostic emergency laparoscopy is very helpful in diagnosing acute abdomen and evaluating abdominal trauma. parallel to developments in laparoscopic techniques, its emergency applications are increasing. we reviewed our diagnostic emergency laparoscopy procedures applied to patients with acute abdomen and could not be diagnosed after h of follow-up. we applied diagnostic emergency laparoscopy to patients in dr. lü tfi kırdar kartal education and training hospital during - . in patients laparoscopy indication was undiagnosed acute abdomen. there were four acute appendicitis, two peptic ulcus perforation, two small bowel necrosis, one perforated hepatic hydatid cysts, one iatrogenic urinary bladder perforation, one postlaparoscopic cholecystectomy bile fistula and non-surgical adnexial pathologies. diagnostic emergency laparoscopy was performed in five patients with penetrating abdominal injury. there were small bowel injury in two patients, colonic injury in two patients and no injury in one patient. diagnostic emergency laparoscopy was performed in four patients with blunt abdominal injury. there were grade splenic laceration in two patients, grade liver injury in one patients and intraabdominal bleeding in one patient. in conclusion, diagnostic emergency laparoscopy is a suitable technique in undiagnosed acute abdomen patients which could not be diagnosed after physical examination, laboratory, radiology and follow-up and helps surgeon to diagnose the disease. also diagnostic emergency laparoscopy performed by experienced surgeons prevents negative laparotomy especially in abdominal trauma patients. mehmet ali yagcı, atakan sezer, ahmet rahmi hatipoglu, irfan coskun, zeki hoscoskun, aydın altan department of general surgery, trakya university school of medicine, edirne, turkey introduction: appendectomy is known as the most common nonobstetrical operative procedure in pregnant women with an estimated frequency of / , of all pregnancies.pregnancy continues to obscure the accurate diagnosis of acute appendicitis due to gestational physiological changes.diagnostic delay increases the incidence of perforation, hence increasing maternal and fetal morbidity and mortality. patients and results: four patients of appendicitis during pregnancy were concluded in study between to may ( table ). the mean age was (range - ). three patients presented during three trimester and one in first trimester.the mean time interval of symptoms to the admission is h (range - ).abdominal pain, vomiting, and nausea are the most common complaints.rebound was the main sign observed in all patients.fever was noted in two patients. mean value of wbc count was , per l (range , - , ). ultrasonographic examination was performed to all patients with the diagnosis of acute appendicitis.three patients were operated under general anesthesia and one under regional anesthesia. paramedian incision was applied to three patients and mcburney to the other one. the exploration findings were two perforated, one phlegmonous appendicitis and a normal appendix. no maternal or fetal mortality occured. cesarean section was performed on -week pregnancy during appendectomy due to early onset contractions. adhesiolysis was performed in same case because of postoperative ileus. conclusion: the accurate diagnosis of appendicitis during pregnancy requires a high level of suspicion and clinical skills. delay of operation correlates to more inflammatory changes in the appendix and to higher maternal and fetal complication rates. early laparotomy with appropriate preoperative diagnosis will reduce the fetal and maternal morbidity and mortality. introduction: paraesophageal hernias occur most commonly in elderly and account for % in all hiatal hernias [ ] . although the fundus or corpus of the stomach are most commonly the contents of a paraesophageal hernia, we reported a case in which the gastric fundus and corpus incarcerated in the paraesophageal space, followed by perforation. case: -year-old woman admitted to state hospital following sudden onset of abdominal pain.previously she was diagnosed as esophageal hiatal hernia. on physical examination, abdominal distension with mild tenderness was recognized. pulse rate and blood pressure were per min and / mmhg. the initial laboratory investigations revealed wbc , per ml, urea mg/ dl, creatinine . mg/dl. chest graphy revealed unusual gas shadow in the left thorax (fig. ) . ct demonstrated intraperitoneal free air, ascites, and the prolapsed stomach in the left thorax (fig. ). an urgent laparotomy was performed revealing dirty ascites.the gastric fundus and corpus were incarcerated in paraesophageal space (fig. ) . a perforation mm in size was recognized in the fundus. the perforation was sutured primary and cruroraphy was performed. the patient required respiratory support and died on the th postoperative day due to multiple organ failure and septic shock. conclusion: the contents of paraesophageal hernia commonly include the gastric fundus or corpus. paraesophageal hernias can cause lethal complications, including gastric obstruction, strangulation, perforation, and hemorrhage. paraesophageal hernias can usually be repaired easily, even using the most recent laparoscopic technique ( ). thus, because of the very serious potential complications inherent in cases such as ours that can result from an untreated paraesophageal hernia, we recommend that elective repair be carried out, even in asymptomatic patients. introduction and objectives: the solitary fibrous tumor (sft) of peritoneum, especially arising in lesser omentum is extremely rare. we report a case of lesser omentum soliter fibrous tumor, causing pain and abdominal fullness with its mass effect. case: a -year-old male was admitted to our hospital, due to an intraabdominal mass lesion, epigastric pain, abdominal fullness and vomiting episodes. on physical examination, a hard, non-tender mass was palpated in the epigastric region. computed tomography (ct) showed, an approximate . · . · . cm sized solid mass with fibrous capsula between left liver lobe and stomach. at laparotomy, a yellowish brown solid tumor with hard consistency was found on the lesser omentum. the tumor was not adhered to the adjacent structures and could be resected completely. postoperative course was uneventful and no recurrence was determined during follow up. results: histopathologic examination diagnosed the mass as a sft. the tumoral cells were spindle-shaped and did not present mitotic activity or atipies and showed very low proliferation index with ki (< %) and immunohistochemical positivity for cd and negativity for c-kit (cd ), actin, and s- . conclusion: although sft are rare, especially in the abdomen of adults, are generally benign but malignant cases have been reported. in our case, the tumor has a benign character shows neither mitotic activity nor nuclear atypical. this is the third case of soliter fibrous tumor of the lesser omentum described in the english literature. introduction and aims: a single hamartomatous adenoma of stomach is rare. gastric hamartomatous polyps are usually multiple, familial and assosciated with other syndromes. they are also associated with chronic helicobacter pylori infection, acid hypersecretion and predisposition to gastric cancer. this is the first case of gastric hamartoma which is coexistent with duodenal ulcer perforation. case: a -year old male admitted to our hospital with complaints of stomach ache, nausea and vomitting. because there was free air under right subdiaphragmatic surface on chest x-ray, an emergency operation was performed. there was a perforated ulcer on the first part of duodenum and a large quantity of bile mixed with blood in the abdominal cavity. on further exploration a tumoral mass which was about cm in diameter was found on the stomach corpus. because of possibility of malignancy, a subtotal gastrectomy including the perforation zone was performed. histologically the tumor was well circumscribed and it consisted of uniform, clear cells. at first, it was thought to be metastatic lesion from kidneys or other organs. in this context, all body was scanned however no pathology has been identified. later on, the tumor was approved to be hamartomatous adenoma and helicobacter pylori was positive. postoperative course was entirely uneventful. objectıve: the aim of this work is to determine the level of apoptosis, which is believed to hold an important role in septicemia process that affects mortality and morbidity in obstructive jaundice, in lingers of rats that were experimentally subjected to obstructive jaundice. materials and methods: the experimentals were separated into two goups of eight. choledoch was isolated in each group and while surgery was ended at this level in the control group, choledoch was tied with - silk from two different places and cut between ligatures full fold. experiment animals were operated for the second time in the postoperative seventh day for liver sampling and sacrificationaimed histological analysis through the old incision with anaesthesia provided. to exhibit the p expression immunohistochemically, anti-p clone do- was used as the primer antibody and hrp as the secondary antibody. samples taken for the determination of apoptosis were painted by the tunel method. fındıngs: in the evaluation of apoptotic cells in liver cells, apoptotic cells were observed to widely exist in the liver tissue and it was determined that they exhibited dense accumulation in some regions. in the immunohistochemical evaluation made for evaluation of p expression in hepatocytes, p -positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the experiment group. result: consequently, in this study we determined that in the obstructive jaundice group, both apoptotic index and, as a result of the immunohistochemical studies, p expression increases in the liver. introduction: the risk of leakage from an anastomosis is higher in large intestine. in emergent colon operations primary anastomosis is avoided especially on the left colon, and multi-step procedures are preferred if there is a dirty abdomen. the aim of this experimental study was to compare different suture materials in left colonic anastomosis in presence of peritonitis. metods: this study was conducted on wistar-albino rats by dividing them in groups of equal numbers. after median laparotomy, the whole layer of left colon was cut cm over the pelvic peritoneum and fecal contamination was performed. one day later, the abdomen was opened again under general anesthesia. the abdomen was washed with sf before starting colonic anastomosis. for colonic anastomosis; vicryl + silk was used in the st group rats, pds was used in the nd group rats, and coated vicryl plus antibacterial suture and silk was used in the rd group rats. results: tissue hydroksiproline, anastomosis bursting pressures and histopathologic findings on the anastomosis line were evaluated on the th postoperative day. the highest anastomosis bursting pressure was found in group iii (p < . ). the highest tissue hydroksiproline level was found in group iii (p < . group i-iii, group ii-iii). when histopathologic findings were evaluated by comparing three groups, the healing of the intestine tissue score was found to be highest in group iii (p < . , groups i-iii). conclusion: consequently, it was observed that using antibacterial suture increased resection safety in the presence of peritonitis and anastomosis safety in primary anastomosis. introduction and objectives: the chance of finding the vermiform appendix within an inguinal hernia occurs in approximately one percent of the cases, and is known as amyand's hernia. appendicitis within an inguinal hernial sac is rare. materials and methods: we present two amyand's hernia cases: one with a vermiform appendix and one with a perforated appendicitis. case : an -years-old man presented with a years history of bilateral inguinal mass. ultrasound examination described a hernia which contains mobile bowel segments inside, on the right side. the appendix was obsereved edematous and hyperemic in the hernial sac. an appendicectomy was done. further exploration of the bowels revealed a meckel diverticulitis which was managed by a wedge resection. case : a -years-old woman presented with one week history of an inguinal mass, pain and anorexia. abdominal computerized tomography demonstrated an incarcerated right-sided inguinal hernia.the hernia sac was filled with the perforated appendix. appendicectomy was carried out. results: postoperative recovery was uncomplicated, the patients were discharged without any complication. discussion: acute appendicitis or perforation of the appendix within the hernia sac simulates perforation of the intestine, and does not have specific symptoms or signs. preoperative clinical diagnosis is very difficult and the diagnosis is made intraoperatively. since the absence of any pathognomonic radiological features, the value of preoperative computed tomography is limited. treatment of hernial appendicitis is an appendicectomy with suture hernial repair. the management of a non-inflamed appendix is debatable. the usual practice covers reduction of the appendix, and mesh repair. in the immediate post-operative period the patient had a high output jejunostomy and was dependent on total parenteral nutritional support. a bishop-koop procedure was performed on day and by day , the patient was completely independent of any adjuvant nutritional therapy. five months from primary surgery colostomy was closed. introduction and objectives: the management of pancreatic pseudocysts which occur after blunt abdominal trauma in children is still controversial. in this study, we present our experience therapeutic approach of pancreatic pseudocysts that occur after trauma. methods: we evaluated patients with traumatic pancreatic pseudocysts who admitted to our clinic between and . we performed ultrasonography, computerize tomography (ct) and blood amylase level for all patients. results: there were eight males and one female. the average age was . years (range - years). the mechanism of injury was bicycle handle bar injury in four, falls in three, assault in one and motor vehicle accident in one patient. abdominal pain was the most common symptom. the median size of cysts was . cm (range - cm). the time interval between trauma and pancreatic pseudocysts was days (range - days). of the nine patients, four ( . %) occurred in less than weeks. all patients were initially followed up conservatively. three patients ( %) were successfully treated conservatively, while patients ( %) required intervention either by percutaneous radiological drainage ( ), cystogastrostomy ( ) and external drainage with laparotomy ( ). complication developed in two patients (septic shock, persistent hyperamylasemia). no patient died. conclusion: traumatic pancreatic pseudocysts may occur short after traumatic injury in children. all patients with traumatic pancreatic pseudocysts should be managed by conservative approach initially. however, if the cyst is cause of gastric outlet obstruction or the size of cyst is bigger than cm, interventional management may be required. introduction: splenic abscess is a rare entity,with a frequency of . - . % in autopsy series.mortality rate is still high, up to %, and can potentially reach % among patients who do not receive antibiotic treatment. case : year-old woman presented with fever and left upper abdominal pain for days. hepatomegaly and tender splenomegaly were present.ct of the abdomen revealed · cm hypoechoic lesion in the spleen (fig. ) . initial laparoscopic approach was performed but failed due to inappropriate anatomy. conventional splenectomy was done and at exploration there was · cm abscess in spleen. the patient was dischared on the eighth day of operation. case : yearold woman admitted with femoral artery thrombosis.thromboembolectomy and leg amputation was performed by cardiovascular surgeons.she was consultated with fever and left upper abdominal pain on the second day of operation. ct of the abdomen revealed a · cm mass with air fluid levels in the spleen (fig. ) . splenectomy was performed and a · cm abscess was observed in spleen.the patient died on the second day of operation due to sepsis. a proximal stoma after resection of the perforated small bowel and colon, closure of the distal stump in case of severe generalized peritonitis without the possibility to perform a primary anastomosis. a loop ileostomy to prevent bacterial translocation in case of pancreatitis. retrospective analysis of clinical data of patients admitted between and for emergency operation requiring laparotomy and the construction of one or more small-bowel stomas. patients had ileostomies created for temporary fecal diversion after emergency surgery including bowel obstruction was the most frequent cause of peritonitis ( cases),followed by anastomotic leakage and peritonitis ( ), acute mesenteric infarction ( cases), intestinal perforation ( cases), strangulated incisional hernia ( cases), acute abdomen of crohn disease ( cases), peritonitis carcinomatosa and frosen pelvis ( cases), mean age was . years (range - ), being males and females. overall mortality was % ( patients). patients died on the first days postoperatively. indications, morbidity, mortality and problems involving the ileostomies in emergency abdominal surgery urgency are herein discussed. in the majority of patients with acute abdomen doing ileostomies,lacking of vital capacity of bowel wall as well as insufficiency of previously laid sutures were revealed, which forced a surgeon to resort to resection; in such cases the method of choice for decompression should be the application of ileostomy. postoperative jaundice is often multifactorial. a precipitating or causative factor may be identified but seldom can a specific therapy be offered. the late complications were mainly presented by the biliary ducts cicatricial stricture, the jaundice and cholangitis recurrency. in this report, we described an extremely rare case of a -year-old woman presenting with pain in the right upper quadrant, jaundice, and weight loss in whom a whipple procedure was performed. usg and mr cholangiography showed that dilatation of intrahepatic and extrahepatic bile ducts and hepaticojejunostomy line. mrcp also showed that, there was a closed jejunal loop related with hepaticojejunostomy. obstruction by local tumor recurrence and infiltration of the efferent jejunal conduit between the proximal hepaticojejunostomy and the duodenojejunostomy led to closed loop syndrome and jaundice. frozen sections by direct incisional biopsy revealed a recurrent tumor invasion. a previously unreported late complication after whipple resection of the head of the pancreas was recognized as ''closed efferent loop syndrome'' mimicking obstructive jaundice. the case was accepted as inoperable because of tumor invasion to the jejunum, transverse colon, and surrounding tissue. roux-en y type jejunojejunostomy was performed. the patient had an uneventful postoperative course. introduction: the form of mechanical asphyxia where respiration is prevented by the external pressure on the body: a large weight compressing the chest or abdomen, wedging of the body within a narrow space death in large crowds is traumatic asphyxia. case: a -year-old man was found compressed by a motorboat in the garage while he was working for installation of the boat. the face, neck and upper part of the chest were congested and many petechiae were observed on the conjunctivae. ecchymotic bruises were observed on the right cervical, lower chest, upper abdominal regions and open fracture of the right humerus, ecchymotic abrasion on right anterior superior iliac spine line were detected. subcutaneous haemorrhages in the chest wall and bleeding without subcutaneous haemorrhage in the inferior part of the right sternocleidomastoid region were observed during the internal examination. fractures of the right third and fifth ribs which were accompanied by bleeding in the surrounding soft tissues and muscles, and ecchymoses over the right sixth rib without any fracture were also observed. macroscopic examination of the lungs revealed congestion, subpleural superficial bleeding areas and histopathological examination showed hemorrhagic alveolar oedema. all the internal organs and big vessels were intact. there was no hemorrhage in the thoracal and abdominal cavity. toxicological analysis was negative. conclusions: in the presented case, the impact cause of the chest compression was distinctly determined by the autopsy and criminal investigation. death was reported as asphyxia by the thorax compression without other lethal factors. purpose: the purpose of this prospective study was to evaluate safety of early surgical interventions in the repairment of animal bites with tissue injuries. materials and methods: tissue repairment and/or reconstruction were done, total in patients. of them were dogs', of them were horses' or donkeys' biting between the years - . wound sterilization and debridement were made before repairment. rabies and tetanus prophylaxis were done for all patients. tissue repairments after animal biting were made early and promptly. patients having animal injuries, apart from biting were not included in the study. results: of the patients were male and of them were female. the minimum age of the patient was . and the maximum was , and the average age was . in cases head-neck, in eight cases extremities and in two cases body were biting areas. horses' or donkeys' bitings were seen particulary in ears. in these animals' biting tissue lose was emphased. we prefered primary saturation in cases, skin greft in ten cases and repairment with flap in five cases. finger amputation was required in one of the patients. total ear reconstruction was done gradually in a patient. no infections observed in patients after the surgical interventions. conclusion: we concluded that, early tissue repairments may done after wound sterilization and debridement, safely. treatment plan. multidetector computed tomography (mdct) imaging is an improving and being a widely used method recently in many areas of medicine. it is possible to evaluate the peripheric vascular structures, anatomic variations or vascular pathologies with mdct angiography (mdcta). methods: the arcuate foramen is an anatomical variant of the atlas vertebra: anterior and posterior osseous bridges or ponticles can arch over the vertebral artery, to a greater or lesser degree, transforming the arterial groove into a canal. dissection of the vertebral artery leading to thrombotic occlusion or ischaemia from narrowing of the arterial lumen has been described in trauma. there are fistula between a dural branch of the spinal ramus of a radicular artery and an intradural medullary vein in spinal vascular malformations. mdct angiography is feasible and is an alternative technique in diagnosis spinal vaskü ler malformations. the craniovertebral junction (cvj) is a funnel-shaped structure comprised of the clivus and foramen magnum and the upper two cervical vertebrae. the most frequent neoplastic lesions of the craniovertebral junction are meningiomas, neurinomas, chordomas, paragangliomas, epidermoids, dermoids and chondrosarcomas. conclusion: in this presentation, pathologies seen in craniocervical junction (congenital variation, trauma, vascular malformation and tumor) were discussed with figures and compared with the literature. introduction and objectıves:small bowel obstruction (sbo) is very rare. although the diagnosis is straightforward, some patients with intermittant and low-degree symptoms could be misdiagnosed as psychiatric disease. we presented here a patient with intermittant symptoms of ileus treated as psychiatric disease case: a year old male patient was referred from phsyiciatry clinic to our department with complaints of weight loss, nausea and malnutrition. his medical history revealed a laparoscopic appendectomy months ago. he emphasized that his complaints started shortly after the operation and increasingly got worse. he was admitted to hospital days after operation with symptoms of ileus and managed conservatively. the intermittant abdominal pain and nausea continued. since the pain was intensified after meals, patient refused eating. during the period of months he lost kg of weight. after numerous radiological and endoscopic investigations patient was referred to psychiatry due to persistent anorexia. after short psychiatric medication, he was referred to our surgical unit. multislice abdominal computerized tomography and and enteroclysis of small bowel clearly demonstrated an obstruction in the jejunal segment of the intestine. at laparotomy, small bowel obstruction was detected and segmental resection was performed. postoperative period was uneventful and patient was discharged from hospital on postoperative day . conclusions: the diagnosis of anorexia and nausea due to sbo is relatively difficult. the patients were sometimes misdiagndosed as having psychiatric disease. before starting psychiatric medication, they must be reevaluated for all putative causes of sbo. introduction: endoscopically placed biliary stents are a well-established procedure for the treatment of benign and malignant biliary disease. duodenal perforation may occur at the time of insertion of a biliary endoprosthesis or following endoscopic manipulation of such a stent. methods: we report a case of duodenal perforation complicating stenting for biliary fistula in surgery for hepatic hydatid cyst. case: a -year-old man was admitted to a local hospital following the sudden onset of abdominal pain,distension with nausea and vomiting. he developed a biliary fistula after surgery for hepatic hydatid cyst months ago. endoscopically placed biliary stent was performed for the treatment of biliary fistula at the same hospital months ago.on examination, marked abdominal distension with mild tenderness was recognized. his pulse rate and blood pressure were /min and / mmhg, respectively. abdominal x-ray showed two foreign body images and subdiaphragmatic free air. emergency laparotomy revealed dirty ascites and perforation of the third portion of the duodenum by the plastic stents. the second stent was found at pericecal area. after extraction the plastic stents and irrigation with isotonic sodium chloride solution, the site of perforation in the duodenum was primary reparing and triple tube placement performed. conclusion: endoscopic retrograde cholangiopancreatography (ercp) is considered to be the most difficult endoscopic procedure in gastrointestinal endoscopy, and is associated with potentially severe and sometimes life-threatening complications such as duodenal perforation. surgical statistics indicate the importance of early diagnosis and treatment for duodenal perforation. introduction and objectives: ticks play an important role in transmitting several infectious agents, such as viruses, bacteria, spirochetes, rickettsia, and parasites. in this study, we analysed the demographic and clinic characteristics of the patients who admitted to emergency service due to tick bite. methods: in this study, patients were selected from cases of tick bite admitted to the department of emergency medicine of ankara numune hospital during the - periods. detailed histories and some blood tests of patients were taken, and the body of the tick grasped gently avoiding to inject more salivary toxins. results: totally patients admitted to hospital in this period. the most frequent symptoms at administration were malaise, myalgia, and fatigue. hemorrhagic manifestations were observed in patients and bleeding was from multiple sites in patients. other symptoms were watery diarrhoea, skin eruption, macular rash, and petechia-ecchymosis. in the comparison of the clinical features and laboratory results of the surviving and the patients who died, we found that the rates of fever during hospitalization, confusion, neck stiffness, bleeding from multiple sites and presence of petechia/ecchymosis were higher in the patients who died than in the surviving ones. additionally, the mean values of alt, ast, lhd, ck, ptt, international normalized ratio (inr), and urea were also higher and mean plt counts were lower in the patients who died. conclusion: the acute tick-bite reactions show special histologic features, which are unquestionably related to the particular morphology and physiology of the mouthparts of these arthropods. results: totally patients ( men and women) were evaluated. the mean age was . ( - ) years and the mean follow up period was ( - ) months. the localization of the hernias were as follows: inguinal hernias, seven femoral hernias, two umblical hernias, two paraumblical hernias, one epigastric hernia and one inguinal + femoral hernia. all of these strangulated hernias were treated with prosthetic graft repairing. in addition to these hernia repairs, in the same operation sessions three hydrocele repairs, three omentum resections, two partial small intestine resection and anastomosis, one lymphadenectomy, one orchiectomy and one laparotomy were done when necessary. in the early post operative period four patients died because of other diseases not related with the surgical procedures or hernia itself. wound infections were observed in three patients and they were treated with antibiotics and anti inflammatory drugs. we report a rare case of ileal perforation caused by an ingested cm long fork. a -year-old man presented to the emergency department with exhaustion, weight loss and abdominal pain. he had been having pain in the abdomen, nausea and vomiting for the previous days. the patient had received psychiatric treatment, and started to experience weight loss and exhaustion - months previously. no conclusions could be drawn from physical examination for abdominal tenderness and defence. direct x-ray showed an appearance conforming to a fork in the intestine and subdiaphragmatic free gas. the patient was sent for emergency surgery, with a diagnosis of ileal perforation and foreign-body ingestion. most of the ingested foreign bodies that reach the stomach pass through the alimentary tract without complication. perforation occurs in, % of all cases of foreign-body ingestion, usually in the oesophagus. other sites where perforation can occur are the pylorus, the duodenum, the duodenojejunal flexure, the ileocaecal region and any site of congenital anomalies. long, thin or sharp objects, as seen in our case causing ileal perforation. foreign-body ingestion is a possibility to be borne in mind at presentations to the emergency department, especially those with symptoms described in psychiatric cases. appendicectomy is a common emergency operation, its major complications are uncommon. most complications of appendicectomy occur in the early postoperative period and easy amenable to treatment with conservative medical therapy. appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. the latter occurs rarely after open appendicectomy but accounts for % of the morbidity rate. schloffer tumor (inflamatory granuloma or abscess in the abdominal wall at the operative scar) is rare complication that usually develop months to years postoperatively and late postoperative enterocutaneous fistula has been described in literature as a rare complication of acute appendicitis. we describe one such case where the patient presented with a tender mass under the incision site six months later after appendicectomy. findings of computed tomography were demonstrated thickening in the abdominal wall and abdominal wall abscess like schloffer tumor. abscess was drained. there were not produced any microorganisms in the wound culture. after conservative therapy healing was completed in a short period. one year later, the patient was admitted with complaints. on the examination, passage of undigested food particles through a sore in the appendicectomy incision site. computed tomography were demonstrated fistula tract extending from appendicectomy site to skin. enterocutanous fistula was occured at the appendicectomy incision year later after operation and successfully treated with en-block fistulectomy and right hemicolectomy. postoperative course was uneventfull. patient discharged from hospital at seventh day after operation. objective: vascular insufficiency may lead to hypoxic injury in intestines. the lesions in the colon are called ischemic colitis. mesenteric ischemia is more prevalent in patients getting hemodialysis. in this study we report hemodialysis patients admitted to the emergency department because of acute abdominal symptoms. case year old woman was chronic hemodialysis patient admitted to the emergency room with acute onset abdominal pain.the initial diagnosis was acute appendicitis and she underwent laparotomy. peroperatively isolated cecum necrosis was seen. right hemicolectomy and ileotransversostomy was performed. she died days after surgery because of sepsis. case year old man was chronic hemodialsysis patient admitted to the er because of abdominal pain persisting for h. with an initial diagnosis of acute abdomen a median incision was performed. peropertively widespread peritoneal adherences and isolated cecum necrosis were seen. cecum was resected and side to end ileocolostomy was performed.he died days after his first operation. case year old man was chronic hemodialysis patient admitted to the er with pain localizing to right inferior abdomen. with an initial diagnosis of acute appendicitis laporotomy through a mc burney incision was performed. there was · cm cecum necrosis. cecum resection and end colostomy and ileostomy was performed. the patient was discharged days after the operation without any problem. discussion: ischemic necrosis of cecum is a rare variant of ischemic colitis. in hemodialysis patients requiring colon resection due to ischemic colitis, primary anastamosis should be avoided, diversion stomies should be preferred. agitation is a non-specific constellation of comparatively unrelated behaviours that possess a risk to the safety of the patient or caregiver, impedes the process of care giving or impairs a person's function. the management of agitated trauma patient contains hospital, prehospital, in emergency department and inside of the hospital transports. the reasons of the agitation hypoxia, hypoglycemia, hypovolemia, pain, traumatic brain injury, anxiety disorder, drug and alcohol abuse, psychiatric disorders. pain management has had a limited role in the management of trauma patients, primarily because of the concern that side effects (decreased ventilatory drive and vasodilatation) of narcotics may aggravate preexisting hypoxia and hypotension. health professionals should monitor pulse oxymetry and serial vital signs if any narcotics are administered to a trauma patient. small doses of benzodiazapine sedatives should be titrated cautiously because of the potential side effects of hypotension and ventilatory depression. to control agitated patients with traumatic brain injury include haloperidol, midazolam, and propofol. in the emergency setting, they are most often indicated to control agitated or psychotic behavior that constitutes an imminent danger to the patient or others. to control agitated patients should be a part of the trauma management. we present a protocol for trauma team. there were males ( . %) and females ( . ). eighty percent of the patients were between and years of age. the overall mortality was . % ( patients). eighty percent of deaths occured in comatose patients (p < . ). comatose state, precence of focal motor signs, respiratory irregularities and hypertansion-bradycardia, pupillary changes were determined as the bad prognostic factors. a midline shift greater than mm, hematoma volume greater than ml, accompanying intracerebral and extracranial traumatic pathologies significantly increased the mortality rate. there was no significant statistical correlation between the outcome and the age, sex of the patient, trauma-to-operation interval, thickness, localization and origin of edh and aetiology. results: the primary factor on outcome is glasgow coma scale scores of the patients at the time of surgery. therefore early surgery is crucial in the management of edh which is a dynamic process. introduction: in this study, we have evaluated the incidence and clinical characteristics of the patients for traumatic brain injury (tbi)-associated coagulopathy after tbi retrospectively. methods: retrospective study of all patients admitted to the trauma and emergency surgery intensive care unit (icu) from january through december with tbi. criteria for tbi-coagulopathy (tbi-c) included a clinical condition consistent with coagulopathy in conjunction with a platelet count < , mm and/or international normalized ratio (inr) > . and/or activated partial thromboplastin time (aptt) > s and/or prothrombin time (pt) > . s. the following potential risk factors were included to identify independent risk factors for tbi-c and its association with mortality, age, mechanism of injury (blunt (b) or penetrating (p)), glasgow coma scale (gcs), injury severity scale (iss), presence of polytrauma, icu length of stay (icu-los). results: a total of patients met study criteria. tbi-c occured in . % (n: ) of all patients (b: . %, p: . %). in patients with tbi-c, mean age was . ± . years. the averages of gcs was . ± . , iss was . ± . , icu-los was . ± . days, polytrauma was considered . % (n: ) and the overall mortality was . %(n: ) in patients with tbi-c. conclusions: in our study, tbi-c occured more frequently among patients sustaining blunt versus penetrating injuries. to our knowledge, tbi patients are at considerable risk of developing coagulopathy and anesthesiologists should be aware of this life-threatening syndrome, especially in tbi patients with blunt injuries. erythropoietin (epo), glycoprotein hormone, is a mainly produced by the kidney that stimulates proliferation, growth and differentiation of erythroid precursors in the bone marrow. recently, anti-inflammatory, neuroprotective, antiapopitotic, angiogenic and vasodilatator effects of epo have been also determinated. the purpose of this study was to investigate the effects of rhuepo in reducing the severity of experimental spinal cord injury (sci). ninety adult sprague-dowley rats weighted g (± ) were used for the study. through a dorsal incision, t - laminectomies performed in prone position and clip compression had made for ischemic injury as tator method. the rats divided in three groups. systemic l ( , u/kg) rhuepo had given h before the trauma in the first group, min. later after the injury in the second group and the third was the control group. the rats were killed with high dose intraperitoneal ketamin h later after the injury. the histological examination of injured spinal cord specimens for the potential neuroprotective effects of rhuepo was done. further more the axial spine sections stained with ttc (triphenyl tetrazolium chloride). the ischemic areas were evaluated with a imaging calculation program. we use wet-dry method for determination of ischemic tissue edema. we concluded that administrating a single dose rhuepo ( , u/ kg) has potential neuroprotective effect on experimental spine injury by reducing severity of inflammation and tissue edema in the secondary ischemic area. it has known both early surgery and high dose steroid treatment prevents the neurological function and viability caused of the traumatic secondary spine injury. we present surgically treated a traumatic rotation-compression spinal cord injury caused by a motor vehicle accident. the patient referred to our clinic h after the injury. at the time of admission, he had a localized pain at the thoracic - vertebrae level, loss motor and sensorial function under the level t classified as asia grade a. he was incontinent. in the radiological evaluation we found loss of height at the thoracic th and th vertebrae body, serious spinal column injury include t - burst fracture, laminas and facet joints fractures with three colon damage (denis f). we detected the spinal instability criteria in . we did not see penetrating injury or primary spinal cord injury signs but spinal canal tightness for percent in ct and mri scans. we took the patient to surgery in unusual classical surgery timing. first, decompressing surgery applied to the t - laminas and posterior stabilization with transpedicular screw-rot system. one day after the first operation, t and t corpectomy applied for anterior stabilization with cage-screw system. mega dose steroid had given also before the first surgery. postoperatively early neurological evaluation, he had asia grade c, after second month asia grade d without incontinence. in our opinion the decompressing surgery that applied in h in the patients without complete primary spine injury, has a positive neurological feedback. introduction: it is a rare occurrence with the rate of % in the subjects with spinal infestation cyst hydatic echinococcus granulosus. intradural hydatic cyst is relatively rare when compared with other spinal hydatic cysts. we are presenting here a -year-old female case who applied to emergency service with backache and paralysed legs and was diagnosed with spinal intradural extramedullary hydatic cyst. case: a -year-old female patient applied to emergency service with complaints of a backache started two days ago, paralyses in both legs and being unable to walk. in her neurological examination, a complete motor power loss in the lower extremities and bilateral sensation loss compatible with t dermatoma were detected. in the torako-lomber spinal magnetic resonance imaging (mri), multiple cystic characterized nodular lesions having peripheral contrast with regular contour including right neural foramen and paravertebral zone at the level of t -t and l in the intradural distance were determined. the patient was diagnosed with common spinal intradural extramedullary hydatic cyst exhibiting bone involvement. as the lesion was very broad had paraplegia, we did not consider operation. conclusions: hydatic cyst infestation is a benign disease. if it is not diagnosed early and treated when it involves in some systems rarely as it did in this study, the results can be serious. diagnosis should be confirmed quickly with increasingly common advanced radiological diagnosis methods. the aim in these cases is to eradicate the cysts surgically, however, chemo-therapy and percutaneous drain methods have become more significant recently. introductıon: several guidelines advocate multiple chest radiographs during primary resuscitation of trauma patients. several local hospital protocols include a repeat radiograph before leaving the trauma resuscitation room (tr). the purpose of this study was to determine the value of routine repeat radiograph. methods: one year data of all radiological imaging in our tr were prospectively collected for all patients presented to the tr of the hospital. we counted and assessed the radiographs and classified our findings as either 'new injury detected', 'presence of intervention equipment', or 'deterioration of previously detected injury'. results: in total, patients were included. more than % had two radiographs. eight ( . %) new injuries without clinical relevance were found on the repeat radiograph after an initial normal radiograph. in total patients ( %), had a repeat radiograph to verify the effect of an intervention or position of equipment. in patients ( %) with two abnormal radiographs, newly diagnosed injuries (n = ) or deterioration of known injuries (n = ) were found. in patients ( %) the results of the repeat radiograph had no clinical consequences. conclusıon: our study supports a strategy of omitting a routine repeat radiograph in trauma patients whose initial radiograph is normal. introduction and objective: the neck region is affected in only about - % of all trauma cases, and isolated neck injuries, especially from a blunt mechanism, is even more rare. our objective was to assess the incidence, disability from spinal cord injuries, and preventable deaths in our patients with isolated neck trauma. material and methods: patients were identified at the severe trauma registry of our hospital, between and . the triss method was used to assess preventable deaths. results: we found ( . %) patients with neck injuries out of . patients included in our registry, ( %) from blunt (bnt) and ( %) from penetrating trauma (pnt). only ( %) bnt and ( %) pnt were isolated. the mean iss of the bnt and pnt groups was of ± and ± . , respectively. in the bnt group, ( %) patients had spinal fractures (with spinal cord injuries with permanent disability), had airway injuries and a vascular injury. in the pnt group, patient had a spinal fracture, had vascular injuries and airway injuries. overall mortality was of ( %) patients, in each group, and only one of them was deemed preventable. conclusions: isolated neck trauma is a rare cause of disability and preventable death in our area. most penetrating injuries have a lowto-moderate degree of anatomic severity (ais £ ). for each group. however about applications increased gradually with a peak at o'clock in all groups. patients treated at ed were mostly stricken ( . %) and the busy period was between - h with two peaks at and o'clock. totally, patients were hospitalized mostly in group iii ( . %) regardless of cause (p < . ). patients referred to another hospital were frequently in group iii ( . %) and also in group iv ( . %). mortality was slightly high in group iii. however higher rate ( . %) was seen among patients in group ii. conclusion: midnight hours seemed safe in terms of mortality and severity of trauma. whether the reason for a higher transportation rate at night hours is the severity of trauma or sedation of ed staff is not clear. introductıon: in this study we aimed to investigate and compare the features of child and adult injuries due to bicycle accidents admitted to our emergency department. patients and methods: the study was carried out retrospectively by searching the files of patients admitted to the emergency department due to bicycle accidents, in the emergency department and archive records between the dates of january and december . the patients were divided into two groups as adults and children. age and sex of patients, season or month of injuries, place and mechanism of injury, injury site of the body, diagnosis and treatment modalities, discharge and hospitalization rates were evaluated. results: totally patients were included in the study. % of the patients were in child age group, % were adults. it was determined that number of accidents increased especially in the summer months. . % of accidents concerning children and all of adult accidents occurred in the streets. falling down from the bicycle was the most common injury mechanism in children ( %) and adults ( %). head and neck region was the most common body site subjected to the injury both in children ( %) and adults ( %). % of child patients and % of adult patients were discharged after emergency department follow up and treatment. there was a significant difference between two groups with respect to injury severity. conclusıon: as a conclusion most of the injuries due to bicycle accidents happen in children, in the streets, in summer months and school vacations. conclusıons: road traffic collision is a major cause of trauma and death in al-ain city. seatbelt compliance is alarmingly low and should be enforced. introduction and objectives: the controversy between the ''scoop and run'' versus the ''stay and play'' approach in severely injured trauma patients has been an ongoing issue for decades. the present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the netherlands, have improved outcome. methods: in this retrospective study, files were analysed for all patients admitted to one of six hospitals in the limburg region in the netherlands with a gcs < on admittance over the period january -december . all patients had proven traumatic brain damage on ct or mri. relevant prehospital and clinical data from a similar study conducted years ago were compared to data from the present cohort. the main outcome was mortality. results: the two research groups had similar characteristics. in the historic cohort, basic life support (bls) and the 'scoop and run' method in patients with major traumatic brain injury (tbi) was common, with an average time on scene of . min. nowadays, prehospital care is performed mainly on the level of prehospital advanced life support (als), with average time on scene about four times as long as in the historic cohort. however, the overall mortality rate for the current cohort compared to years ago has not decreased. conclusion: despite more on-site als in major tbi nowadays, there was no reduction in mortality. the team is provided to be ready all the time by making monthly and yearly national education exercises. these exercises are planned with two methods: ( ) as demonstration during education ( ) by creating extraordinary condition simulations aim: _ interpret the support of exercises plans on umke operational agility and to accomplish next plans through this way. material -method: umke teams are divided into two parts after geting their basic educations. first group is planned to exercise in education room with demonstrations. the second is planned to exercise the extraordinary situation simulations in which people(not from the groups) made up and acted as injured and moulage is also used in this group. after the exercises, results are compared according to the criteria for assessment. in the first group's demonstrations it is worked by giving roles to team members in the education atmosphere with existing equipments (chair, table, ladder…). in the second group, worked with the moulaged volunteers and extraordinary situation simulations just like the real(wreck, avalanche, fire…) the results are considered statistically by t test. findings: according to the assessment criterias the first group's average point is . and the second is found as . . (p < . ). discussion and result: exercises in a form of extraordinary situations effected team's performance, operational success and involvement positively. planning the exercises with this data will increase the quality of the educations which planned in the future. nurhan babaoglu, tayfun cucioglu, gö khan akbulut national medical rescue team, ministery of health, afyonkarahisar, turkey entry: umke designed as serving medical rescue in extraordinary circumstances. they carries their approaching skills to the top by managing regional and national exercises. the teams in different cities coordinate and share their knowledge and agility by this exercises. aim: after the workshop oriented educations, criteria are needed to improve and decide the affect of the exercises as numerical which supplies standardization of the teams. material-method: teams are evaluated according to criteria and graded from to . after the exercises, results and the importance of criteria shared with teams. month later same teams evaluated again in exercises. criteria: ( ) equipment ( ) team accordance and work discipline ( ) security and to define work risks ( ) approach to the injured ( ) evaluate the injured people ( ) convert the theory to practise ( ) usage of materials correctly and in proper place ( ) packaging ( ) taking out the injured safely ( ) cleanness of the materials and control of medical bag findings: after antalya umke basic education, team's evaluated and average score was . . this results shared with teams and in next exercises in isparta mean score founded as . . (p < . ) discussion and result: when the evaluation criteria and results shared with the teams, it is confirmed that the teams react better in ongoing situations. it is considered that it will also increase the quality and effectiveness of the education. the criteria for evaluation going to help standardization which can be used by all medical rescue teams will provide a common manner between the groups. hasan Ç elik, gö khan akbulut, nurhan babaoglu, tayfun cucioglu national medical rescue team, ministry of health, afyonkarahisar, turkey umke teams are established in in cities in order to act in disasters and extraordinary circumstances as a medical rescue team. members are chosen among the volunteered medical crew. the team's mission is to support the search and rescue teams medically in extraordinary circumstances. team starts with the first intervention and maintain the stabilization of the injured person before the transport so that prevents the second insult. working principles was not obvious during the establishment phase and this caused chaos at the beginning. by designating the teams responsibilities work distribution reached to the standard. national medical rescue team is consisting of medical personnel who are named as leader, logistic, pigeon, squirrel and courier. the team leader who is chosen from doctors who has experienced in disaster medicine and have knowledge about leadership, provides a common manner and motivation among the team. also directs the intervention to the injured person and coordinates with search and rescue teams just after the fast arrive in extraordinary circumstances. squirrel communicates with injured at first and starts his intervention with the direction of the leader. logistic is responsible for all equipment (spin board, medical bags…). courier provides the equipment transportation between logistic and squirrel. pigeon is responsible for photographing, recording and communicating with the center. this organization type performed in regional and national practises from to and also in train accident in kü tahya. _ it helped maintaining standardization and acquired successful results. author to editor: bu yazıyı ulusal medikal kurtarma ekiplerini (umke) tanıtmak amacıyla hazırladık. eg er uygun gö rü rseniz, umke yi tanıtıcı bir stand açıp medikal çantamızı ve dig er kullandıg ımız malzemeleri tanıtabiliriz. ayrıca bu gü ne kadar katıldıg ımız (pakistan depremi, isparta uçak kazası, kü tahya tren kazası) afet, tatbikat ve eg itimlerimizi(ameliyathane konteynırımızı) power point olarak sunabiliriz. helicopter use as a part of trauma care introductıon: rapid transport and persistence of prehospital care is crucial to decrease the mortalities and morbidities of combat related injuries. hence, helicopters are effectively used by the military although they are austere environments that offer limited space, equipment and resources for the crew and requires higher level of skills for prehospital trauma care. materıal-method: the data were collected from consequent casualties, by the helicopter medical team (a surgeon, anesthesiology technician and a paramedic). during the flight, we triaged the casualties according to wound characteristics (severity, mechanism, location), physiological parameters, and provided basic life support stated by trauma resuscitation course (trk). we transmitted these findings to the military trauma center to provide hospital preparedness. result: injury mechanisms were % explosives and % highvelocity weapons. time to hospital admittance was < min after the injury. most frequent sites of injury (ais - ) were extremities ( %) and thorax ( . %); the frequency of ‡ anatomical site injury was %. capillary refill rates were; < seconds . %, > seconds . %. mean sao , gcs, hr, respiratory rate values were . ± . , . ± . , . ± . , . ± . , respectively. during uninterrupted care, ( %) intubations were performed and % of casualties were operated upon admittance without any onboard mortalities. conclusion: the high energy and lethality of the wounding agents in combat render the helicopter evacuations indispensible. additionally, civilian major trauma patients may benefit from expeditious transport to the closest trauma centers or from rural inaccessible areas within the 'golden hour of trauma'. the most important steps for the treatment of the combat injury causalities are to stop or reduce bleeding and to start fluid resuscitation. peripheral intravenous (iv) line placement is one of the most important procedure in the battlefield conditions. most of the time, fluid resuscitation would be the only available medical treatment for the injured combatant because of the prolonged evacuation period in the battlefield. also, this procedure would be very difficult and time consuming especially under hostile gunfire. excessive blood loss and hypotension may cause the peripheral venous collapse and makes the procedure more difficult. here we described a simple method to make this procedure easier. we offer the forward medical team personal to perform the upper extremity peripheral venous mapping of the combatant before the operation. the medical providers (doctor or paramedic) who would perform the first medical intervention would examine the upper extremities of baddy just before the operation. the medical care provider should determine the suitable situations for the iv line placement. then he should remark the both site of the appropriate vein by camouflage paintings, leaving the probable angiocath insertion sites non-painted. we believe that this method would make the peripheral iv line placement easier and faster for the forward medical team personal in the war conditions. one probable disadvantages of this method is the negative psychological effect on the combatant that makes them to estimate the risk of wounded in a few hours. introduction and objectives: ambulance and emergency care technicians are the key personnel for pre-hospital care of trauma. this study reviews the work anxiety states of some of the students in ambulance and emergency care technicians department, vocational school of health services, marmara university by comparing it with those of the students in radiology department of the same school. methods: this study was developed as a sectional type of study and was conducted on volunteer students from the above mentioned departments. the data were analyzed using the spss . software and employing the frequency distribution, t-test for individual groups, and unidirectional variance analysis methods. results: the study group of subjects was . % female and . % male. . % of the subjects expressed anxiety over their employment in the future; . % of them expressed no work anxiety. the work anxiety points of the subjects were compared in terms of their genders, academic years and departments, and said comparison did not reveal any statistically significant difference (p > . ). conclusions: the work anxiety state is one of the major factors having an impact on professional success, and is a negative state having an impact on one's performance, success and, in turn, psychological state. it would be proper to study the issue of work anxiety by obtaining psychological support, and to cooperate with the actors in this sector to develop solutions. it is concluded that further studies should be conducted on work anxiety and its reasons. in general, emergency patients should be transported to the closest appropriate hospital. if the emergency medical services have identified a specific hospital with better resources to treat seriously injured patients, the patient should be transported to that institution, bypassing closer hospitals. the cooperation is expected between the hospitals, and the development of formal transfer agreements, describing all of the legal, economic, and medical aspects of the relationship are encouraged. ideally, the entire trauma system in a city should be designed on the basis of need and existing resources, with all affected parties involved in the planning, development, and implementation. the goal of the system is to match the needs of an injured patient to the resources of the available facilities so that optimal and cost-effective care is achieved. we conduct six essential questions for the preparation of trauma. is there a legal authority to formally designate hospital's trauma response in your city? what sources were used as a basis for standards of the trauma response in your service area? were the number of hospitals identified for your service area limited based on the results of needs assessment? what type of transport practice occurs in your service area when a field assessment identifies a trauma patient with severe injuries that threaten loss of life or limb? is a trauma registry present in your service area? is there a designated trauma advisory committee that evaluates the performance of trauma care delivery within your service area? we evaluated the role of primary hip arthroplasty (consisting of both total hip replacements and hemiarthroplasty) in these comminuted, osteoporotic or neglected fractures. these patients at-risk were in need of a single definitive surgical plan for early ambulation and preventing complications. typically these patients were elderly with poor mobility and had multiple other medical condition to be able to withstand multiple surgeries. there was a need to obtain the best results with the single, rapid procedure for pain relief and early ambulation. excellent to very good results were obtained in about % of these patients. good results were obtained in about % of these patients and poor results in about %. most of the poor results were the outcomes of complicated medical conditions rather than the failure of the orthopaedic procedure itself. we advocate arthroplasty in neglected, osteoporotic or severely comminuted per-trochanteric fractures for immediate mobilization and optimising outcomes. the role of intra-articular steroids or hyaluronic acid injections in early arthritis may be warranted and perhaps safe. but for patients waiting for a knee replacement these can prove positively dangerous. a meta-analysis has revealed that intra-articular injections given in patients waiting for a knee replacement procedure is fraught with dangers. apart from a high risk of post-operative infection and failure of the procedure, several other side-effects or complications make this risky. there is a higher-than-average chance of quadriceps tendon rupture, delayed wound healing, superficial infections and slower rehabilitation. in comparison hyaluronic injections have been found efficacious in the short term and do not contribute to complications normally attributed to steroids. thus intra-articular injections should be used with caution, repeated injections are best avoided and are certainly contraindicated if a procedure is anticipated to be performed within six months. introduction: pediatric forearm fractures are common. the majority has satisfactory outcome. but poor results do occur and malunion can compromise rotation. we belief that the angulation of the fracture depends on the action of the body and that we can reduce the fracture by completing the action. this way we can perceive a stable anatomic reduction without internal fixation. methods: we undertook a prospective study of distal forearm fractures in children. we included children with a non-displaced angulated metaphyseal distal forearm fracture. the angulation was between °and °.we all reduced them by completing the action of the body. this means a volar angulated fracture is reduced by pronation of the hand and a dorsal angulated fracture is reduced by supination. after the reduction they were casted in an upper-arm cast in pronation or supination depending of the reduction manoeuvre. afterwards the all received weeks of upper-arm cast and weeks of lower-arm cast. results: they all healed without loss of reduction and without further treatment. they all had full recovery of function. conclusıon: non-displaced angulated metaphyseal distal forearm fractures in children can be treated conservatively by closed reduction and plaster cast. background: vascular endothelial growth factor (vegf) plays an important role in the bone repair process as a potent mediator of angiogenesis and influences directly the osteoblast differentiation. inhibiting vegf suppresses angiogenesis and callus mineralization in animals. however, no data exist on systemic expression of vegf with regard to delayed or failed fracture healing in humans so far. methods: one hundred fourteen patients with long bone fractures were included into the study. serum samples were collected over a period of months following a standardized time schedule. vegf serum concentrations were measured. patients were assigned to groups according to their course of fracture healing. the first group contained patients with physiological fracture healing. eleven patients with delayed-or non-unions formed the second group of the study. in addition, healthy volunteers served as controls. results: an increase of vegf serum concentration within the first weeks after fracture in both groups with a following decrease within months after trauma was observed. serum vegf concentrations in patients with impaired fracture healing were higher compared to the patients with physiological healing during the entire observation period. however, statistically significant differences were not observed at any time point between both groups. vegf concentrations in both groups were significantly higher than those in controls. conclusıon: the present results show significantly elevated serum concentrations of vegf in patients after fracture of long bones especially at the initial healing phase indicating the importance of vegf in the process of fracture healing in humans. first, dsbls is applied to . cm proximal to most prominent point of medial malleol of tibia. the dsbls was inserted parallel to the joint surface in frontal and horizontal plane. after the dsbls is applied the selected nail is inserted. reamed imn is used for the tibias with narrow isthmus ( ). the success of di is checked following the insertion of nail with set screw on the dslbs. the unsuccessful attempts are repeated after the reason is removed. the di of tibias were successful and were unsuccessful at the first attempt. in unsuccessful cases, the nails were at the posterior ( ), anterior ( ) and lateral ( ) collum femoris fractures accounts . - % of all fractures. however it is very rare in children ( %). in this study we evaluated pediatric patients who were operated due to collum femoris fracture in terms of avascular necrosis and functional outcome. age of the patients ranged from to . there were seven girls and five boys. two of the patients were admitted to the emergency department due to a fall from height, therefore they had multi system trauma. the remaining ten patients had isolated collum femoris fracture. fractures was classified according to delbet classificaion; seven transcervical and five cervicothrochanteric. locking plate-screw fixation was applied to one patient, other fractures were fixed with two or three cannulated screws. open reduction was applied to four patients and closed reduction to eight. five of the cases were operated in the first h of the fracture, however the remaining seven patients were operated after the first h ( - days) due to late admission. range of motion of the hip joint was limited in only one patient who had polytrauma and operated after the first h. there were three avascular necrosis as acomplication. all of them operated after the first h and all the fracture types were cervicotrochanteric. open reduction was applied to two patients and closed reduction to one. pediatric collum femoris fractures are rarely seen in children but treatment is challenging and open to complications. fracture type, surgical methods, did not effect the outcome, but timing of surgery did. author to editor: in this study we discussed the outcome of pediatric collum femoris fractures, which is a very rare fracture in orthopaedic experience. surgical management of humerus shaft fractures is an increasing interest nowadays. we want to discuss the outcome of conservative, open reduction and internal plate fixation (or _ if) and intramedullary nailing (imn) methods in adults ( - years old). patients had conservative treatment with modified custom made sarmiento brace and of them had union with °- °of malunion. none of the nine have complains and the avarage union duration is weeks ( - ). one patients did not tolerate bracing and undergone surgery. patients had or _ if and had gone second operation for nonunion and had elonged wound drainage. all the fractures healed eventually with in weeks ( - ). no neurovascular complication was observed. patients had imn treatment and had delayed union up to months, had undergone reoperation with or _ if for non-union, had intraoperative fracture of elbow and had shoulder problems with impingement and rotatory cuff problems. avarage union duration was found weeks ( - ). surgical treatment is getting more popular for long bones nowadays. early return of work and social life, anatomic reduction, using no sling or such devices and easy follow up protocols are the facts that popularising the surgical management. but in our series, we had seen multiple types complications that are as high as they are mentioned in literature. with the experience of those patients that had been treated with in this year, conservative treatment methods have to be conserned firstly in suitable and tolerable patients for us. intoduction and objectives: correction of sagittal deformity is important in thoracolumbar burst fractures. the clinical maneuvers needed for reduction and the assessment of correction of the fractured vertebra is not well described. in this prospective series we used the length of the interspinous ligaments as reduction parameter. our aim was to evaluate the efficacy of this assessment technique in achieving good correction. methods: from to patients (m/f / , mean age . ) with unstable thoracolumbar burst fractures were treated by posterior fusion with a standard construct by a single surgeon. all patients were treated with segmental posterior instrumentation with two levels above and two levels below the fracture level fixation by means of pre-contoured rods and distraction technique. with these maneuvers the length of the injured level was tried to be equalized to the mean of upper and lower levels. anterior column was assessed by radioscopy. preoperative and postoperative radiographs were analyzed and local kyphosis (lk), farcy's sagittal index (fsi) and compression percentage (cp) were measured. results: the preoperative lk decreased from . °to . °, fsi decreased from . °to . °and cp decreased from to . . after a minimum follow-up time of years all patients continue to do well with no statistically significant decrease in these parameters. conclusions: assessment of thoracolumbar burst fracture reduction with pre-contoured rods and distraction technique can be made safely by intraoperative measurement of the length of the interspinous ligaments. case: an -year old lady was admitted in our emergency department with a neer -part fracture of the right proximal humerus caused by a fall. she was operated on and received a shoulder hemiarthroplasty. during cementation of the stem the patient became bradycard and acute respiratory arrest occurred. she was resuscitated, but eventually died h postoperatively. postmortem examination revealed embolic bone marrow occluding the pulmonary capillaries. comment: pulmonary embolus after upper extremity surgery is a rare complication. fatal pulmonary embolus is even more rare. when reviewing literature there is no previous case of fatal pulmonary embolus caused by fat emboli described. fat embolism syndrome was first described by zenker in , but its frequency today is still unclear. usually it presents as a multisystem disorder. the most often and most seriously affected organs are the lung, brain, cardiovascular system and skin. it is a self-limiting disease, therefore treatment should be mainly supportive. purpose: lack of knee flexion is a possible complication in severe femur fractures. two different techniques for the treatment of this problem were applied. materıals-methods: from to , patients with severely arthrofibrotic knees were managed with two different operative techniques. the mean age of the patients at the time of the operation was years. we recorded the clinical outcome of patient using judet quadricepsplasty with a follow-up of months, and of two patients using extra-articular mini-invasive quadricepsplasty and intra-articular arthroscopic lysis of adhesions during the same anesthesia session with a mean follow-up of months. all patients were evaluated according to the criteria of judet and the hospital for special surgery knee-rating system. results: the average maximum degree of flexion increased from °p reoperatively to °at the time of the most recent follow-up. according to the criteria of judet, the result was good for knees, and fair for one. the average hospital for special surgery knee score improved from points preoperatively to points at the time of the most recent follow-up. a superficial wound infection occured in one patient. conclusions: if you select the appropriate cases, the judet procedure and mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome. purpose: floating knee and elbow injuries are complex injuries. the types of fractures, soft tissue and associated injuries make this a challenging problem to manage. we present the outcome of these injuries after surgical management. materials and methods: two patients with floating knee injuries(classified by blake and mcbryde) and one patient with floating elbow injuries were managed over an average of months. both fractures of the floating knee injury and the three fractures of the elbow injury were surgically fixed using different modalities. the associated injuries were managed appropriately. assessment of the end result used the karlströ m criteria after bony union. results: mechanism of injury was road traffic accidents in two patients (floating knee) and falling from height for one patient (floating elbow). there were associated injuries, patient was tipiia, patient was tipiib. both these patients had intramedullary nailing for femur fractures. patient had ilizarov external fixation for segmenter tibia fractures, patient had a proximal medial plate for proximal tibia fracture. patient had plates afıxed to all fractures.complications were knee stiffness and delayed union of femur in a patient (second operation required). the bony union time average from weeks for femur fractures, weeks for tibia, weeks for upper extremities. according to the karlstom criteria the end results was acceptable. the average elbow score was / (good). patients with tibial bio-screw fixation there is insufficient evidence from randomized trials to determine the optimal intervention in patients with displaced four-part fractures of the proximal humerus: head preserving surgery with problem to obtain and maintain reduction until bone healing, implant failure, avn of the head, ha with > % tuberosities related complications-resorption, displacement, rsa with high complication rate, moderate function due to restricted rotation and insufficient long-time follow-up. in our presentation we will discuss: • new rsa designs, which improve function and lessen complication rates • question of tuberosities fixation to rsa in proximal humeral fractures • literature overlook of rsa in proximal humeral fractures the goal of rsa is to minimize shoulder immobilization and to start functional rehabilitation immediately. indications are same as for ha + tuberosity osteoporosis and comminution + week or absent rc. decision for if, ha or rsa is often intraoperative. tuberosities fixation is debatable (prolonged immobilization, prosthesis dislocation). functional results are more consistent than in ha, but complication rate is higher (it may be lowered by new prosthesis designs). frequent ct scanning due to incomplete -view x-ray imaging of the cervical spine background: conventional c-spine imaging is still widely used, despite increasing replacement by ct scanning. the aim of this study was to analyze the frequency of incomplete c-spine x-rays ( -view series) in blunt trauma patients. methods: during a -year period we analyzed the frequency and value of -view series of the c-spine. secondary we assessed the reasons for subsequent ct scanning after the -view series according to the following classification: inevaluability, incomplete -view series, evaluation of findings on -view series or for unexplained, persistent clinical symptoms. furthermore we evaluated predictors for incompleteness. results: c-spine injuries were diagnosed in blunt trauma patients ( . %). patients ( %) had their c-spine cleared based on the nexus criteria. patients were primarily evaluated with view series and patients primarily with ct scanning. within the population with primarily -view series ( %) were repeatedly incomplete and ( %) were inevaluable. in the major part of the incomplete -view series no apparent reason could be determined. however, the presence of clavicular fractures (resulting in incomplete radiographs in vs. % without a fracture; p < . ) and rib fractures ( vs. %; p = . ) were associated with incomplete -view series. conclusion: in more than a third of the patients primarily assessed with -view series, the results are incomplete or inevaluable necessitating ct scanning. therefore, the diagnostic value of -view series is questionable. in patients with clavicular and rib fractures -view series can be omitted and primary ct scanning is advised. the treatment of open distal tibia fractures is still discussed controversially and they are a great challenge for surgeons. it is still not clear if there should be initial stabilization with an external fixator or primary osteosynthesis with an intramedullary nail or plate. we retrospectively examined patients with ii°and iiia°open distal tibia fractures which were treated during the last years in our level one trauma center. we treated male and female patients with an average age of years. ten patients were treated with an external fixator and patients were treated with an intramedullary nail or plate osteosynthesis in acute surgery. the patients, firstly treated with an external fixator, were stabilized with reamed intramedullary nailing in eight cases and with locked plating in two cases after wound closure. there was no difference in the duration until bony union in any groups. fewer unplaned revisions (n = ) and no deep osseous infections were found in those patients treated with an external fixator in the acute phase of the injury. patients treated with a definitive osteosynthesis underwent unplaned revisions in six cases and developed deep osseous wound infections in four cases. we therefore recommend that initial treatment with an external fixator should be preferred and after consolidation of the soft tissue, the definitive stabilization should be done with a stabile osteosynthesis system. author to editor: this topic remains of a high interest among trauma surgeons, especially now, that angle stable intramedullary fixation systems run the market. fractures of the clavicle shaft are common and have been typically addressed to nonoperative treatment. but favorable results with the precontured anatomic plates are facilitating surgeons for primary surgical treatment. this study reports the surgical results of adult clavicle shaft fractured patients (age range - ) that had been operated with in last months. all fractures were displaced and none of them was open nor had neurovascular injury. avarege healing time was found weeks ( - weeks). all patients had anatomic reduction postoperatively. of the patients fracture site was grafted with dbm. of patients had sterile wound drainage which was lasted for weeks postoperatively (all were grafted with dbm), of them re-operated ( of them for early implant failure and early implant removal for plate disturbance) and one patient was operated for times ( of them was in another center) for early implant failure, nonunion,wound problems and neurovascular complications. of was healed eventually. of patients were satisfied with the treatment and had a full range of motion at final follow-up and were able to return to pre-injury occupational and activity levels. nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits. however, our study shows that surgical treatment also has high complication rates. there is currently considerable debate about the benefits of primary operative treatment of these injuries because it remains difficult to predict which patients will have these complications. platelet rich plasma (prp) is applied in orthopaedic, maxillofacial and plastic surgery with variable outcome. different growth factors and cytokines are stored in platelets, including platelet derived growth factor (pdgf), contributing to the potential positive effects of prp. the aim of our study was to investigate the properties of pdgf administered locally in a rat femoral non-union model. in our experiment a critical sized osteotomy was performed in the rat femur, which was filled with a spacer, inhibiting bone formation for a period of weeks. in a second operation this spacer was removed and the test item was applied into the defect. we compared the pdgf group (d = ng, c = lg/ml of pdgf in fibrin matrix) with the fibrin alone and blank control groups. four weeks after the second operation, specimens were analysed by x-ray, lct imaging and histology. in group pdgf we found a lct confirmed union in of specimens and the lct evaluated bone volume was median . mm (q = . / q = . ). in the control groups there was a bony bridge in of fibrin and in of blank specimens. the bone volumes were median . mm (q = . /q = . ) fibrin and median . mm (q = . /q = . ) blank, respectively. we did not find a strong tendency for new bone formation in the group treated with pdgf. in our model we observed even a tendency to inhibit bone regeneration for pdgf. introduction and objectıves: hand traumas are one of the most common encountered complex traumas. closing the defects on either dorsal or palmar side of the hand is sometime difficult because of limited local tissue and to provide a tissue the tendon glides underneath. in spite of high risk of donor side morbidity and sacrificing a major artery of the hand, radial forearm flap is the most frequent choice to close the defects at this region. method: in a year time, five patients with severe hand traumas who admitted to our clinic, treated with perforator based three radial artery and two ulnar artery adipose-fascial forearm flaps. the adipose-fascial island flap was raised on one or two of these perforators without sacrificing a major vessel.the flap was transposed to defect region and covered with stsg. in all five patients' donor side was closed primarily. results: the biggest flap size was · cm. there was no flap loss except one patient who had partial flap necrosis and it healed secondarily. the donor side was healed uneventfully in all the patients. there was no tendon adhesion. conclusıon: perforator based radial or ulnar artery adipose-fascial flap is a safe and reliable method for closing defects on the hand. it has both less donor side deformity and fascial component of the flap provides better tendon gliding and less tendon adhesion. however, it requires more experience to raise adipose-fascial flap. introduction and objectıves: one of the most common causes of the lower extremity defect in adult is a road traffic accident. the most challenging issues is to close the defect on the / of lower extremity because local tissue is very limited and mostly damaged due to high energy injury. we investigated the difficulties of how we close the defect on one third of the lower extremity particularly in children, in our unit. method: in a year time, patients under years old admitted to our unit. all patients had gustillo iiib injury and the biggest size of the defect was · cm. one patient had different lesions on the heel the other was on the anterior aspect of tibia. after radical debridement, the wound closed with alt free flap with in first week of admission. different defects on a lower extremity were closed with alt and vastus lateralis muscle free flap with a single pedicle. result: the biggest flap size was · cm. an average pedicule length was . cm and the diameter of the vessel was . cm the average operation time was h min. one flap had partial necrosis and healed secondarily. they had uneventful recovery and discharged on average postoperative days. conclusıon: in children even less than years age, one of the good and suitable options for closing the defect on the one third of the lower extremity is alt as a free flap. stable odontoid fractures can be treated with external immobilization using, e.g., a philadelphia collar (pc) or a halo thoracic vest (htv). it is important to delineate the capacity of both orthoses, halo and philly, for immobilization of the atlantoaxial complex (aac), e.g., for their use in odontoid fracture care. in this in-vivo biomechanical comparison volunteers (mean age = . ± . ) were subjected to flexion-extension radiographs immobilized in a modified htv and a pc. radiographs were analyzed for the segmental rotation angle of c - in sagittal plane (sra c - ) and the absolute rotation angle of c - (ara c - ). separation angles (rsra c - and rara c - ) were calculated from flexion-extension views. concerning restriction of subaxial sagittal plane motion, the htv was more effective than the pc. the difference for the rara c - between the pc (mean . °) and htv (mean . °) yielded significance (p = . ). but, concerning restriction of flexion-extension at the aac, there was no statistical significant difference for the rsra c - between the pc and htv (p = . ). pc (mean . °) was superior to the htv (mean . °) in restricting sagittal motion at c - . in comparison to normals atlantoaxial motion was restricted by . % (pc) and . % (htv). the current study demonstrated that there was no significant difference in restriction of sagittal motion at c - between the pc and htv. in light of the current biomechanical data and a selected review of literature it is concluded that the use of a pc is sufficient for the treatment of stable odontoid fractures. introductıon: although most ankle injuries are associated ligamentous structures, some types of fractures mimic to ligamentous sprain and misdiagnosed as well. most of the ankle sprains undergo radiographic examination and some of type fractures easily are missed even x-ray. the aim of this study is to evaluate the missed talar neck fractures and to emphasize the missed fractures. materıals-methods: misdiagnosed cases were included in the study. average age at the time of trauma was ( - ). all cases evaluated prospectively. if the patients had ankle sprain and their initial x-rays show no evident of fracture, they were involved in the study. the diagnosis of the fracture was figured out by control x-ray, ct scan and mri (except case). all patients were evaluated by the scoring system of american orthopaedic foot and ankle society (aofas introductıon and objectıves: treatment of proximal humeral fractures remains controversial, because of complexity of this kind of fractures. the purpose of this study is to present our first experience using angular stable fixation in and part proximal humeral fractures method: in last mounts we treated patients with this method, men and women (mean age ). anterior approach was performed in every case (mis technique in two cases), and every patients underwent to early rehabilitation. periodical clinical and radiographic control were performed. results: short term results are good with satisfaction of the patient, no pain and acceptable range of motion. we have case of deep infection that need revision surgery and antibiotic treatment. preoperative diagnosis of appendiceal diverticulitis is rare. the incidence of appendiceal diverticulitis ranges from . to . %. % of the diverticulitis of colon cases appear above years of age, and they are mostly in the left colon. case: a year-old male, who had a -year history of episodic right lower quadrant abdominal pain was admitted to the surgical emergency department for worsening of his complaints. the physical examination was only notable for right lower quadrant abdominal tenderness. laboratory findings was normal. on ultrasonography examination signs of acute appendicitis was noted. as the radiological findings did not match with the clinical status of the patient, he was followed up. later, acute abdominal symptoms appeared, and the patient was admitted to the operating theatre. two cm long nodules were seen on the appendix preoperatively. appendectomy was done. the patient was discharged on the first postoperative day. the histopatological examination revealed acute appendicitis signs and two mm long diverticula one of which is inflamed in the middle and the other in the distal part of the specimen were reported. conclusıon: the most common cause of acute appendicitis in adult population is fecaloid. lymphoid hyperplasia, carsinoid tumors, mucosel, parasites, fruit and vegetable seeds are other causes. although appendiceal diverticulitis is rare, clinicians should be aware of its occurrence and tendency for appendiceal perforation. introduction and objective: traumatic intracranial hematoma is the most common complication of the head injury requiring emergency intervention. as most of them are located supratentorially, they can be seen less frequently in the posterior fossa. this study aims to evaluates the clinical, radiological and surgical aspects of traumatic posterior fossa hematomas in patients who were treated at our center. methods: the records of patients with of traumatic posterior fossa hematomas that had been treated at our center between and were reviewed. results: of the cases, had cerebellar hematomas and had epidural hematomas. fall was the most common cause, followed by animal kick, assault and traffic accident. diagnosis and management decisions were determined by cranial computed tomography scans. surgical intervention was performed in cases. the outcome was good in patients. three patients died who had low gcs at admission and additional cranial lesion. conclusions: patients with occipital trauma should be evaluated immediately using cranial computed tomography scans. early diagnosis of traumatic hematomas and prompt surgical intervention in those having mass effect provide good results. introduction: transcranial stab wounds made with a knife mostly produce a classic slot skull fracture and underlying tract hematoma, and often cause severe neurological deficits. an unusual case with combined pareses of oculomotor and trochlear nerves due to penetrating stab wound to the brain is presented. methods: a -year-old boy was admitted to our clinic after an altercation that resulted in the patient sustaining stub wound to his head. results: he was conscious. neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, and infraduction, incomplete convergence and left sided ptosis with dilated pupil. an emergency computed tomographic scan of his brain was obtained, which revealed a left slot fracture at the squamous portion of the temporal bone of the anterior cranial fossa and a frontotemporal intracerebral stub tract hematoma. he underwent emergent surgery. fractured bone pieces and lacerated brain tissue were removed. neurological deficits remained unchanged at months follow-up. conclusions: cranial nerve injury related to the knife wound to the brain is very rare. the penetration site, depth of penetration and trajectory of the object are important in occurring of this injury. prognosis seems to be poor in these cases. introductıon: large number of knee x-rays are done incidentally for patients presenting with knee trauma in accident and emergency. using only one lateral view knee x-ray as a screening tool would reduce the cost by % as per a. verma et al., an interesting proposition. method: we investigated the validity of lateral view knee x-rays alone as a screening tool for detecting fractures around the knee in acute knee trauma. randomly picked x-rays were reviewed. the ap and lateral views were interpreted by a consultant radiologist and the findings used as gold standard for the study. the lateral views alone were independently interpreted on two different occasions by the (a) radiographer (b) emergency nurse practitioner accident & emergency (c) middle grade doctor accident and emergency (d) consultant orthopaedic surgeon. results: there was significant inter observer variation in sensitivity which ranged from to % with the highest sensitivity being achieved by the radiographer. the specificity was generally high with a range from to %. though there was a high validity in the case of the radiographer the sensitivity for the other observers was low. conclusıon: though there could be a significant saving in terms of resources and unnecessary radiation by doing lateral views alone as opposed to the routine ap & lateral views as first line x-rays, we do not recommend using the lateral views alone as a safe screening tool in knee trauma because of high inter observer variation in sensitivity. tk gullett, charalambous p. charalambous, ajay sahu, matt j. ravenscroft stepping hill hospital, stockport, uk introductıon: in distal biceps tendon ruptures, re-attachment to the radial tuberosity should ensure an adequate tendon to bone surface contact to achieve a sound repair and fast tendon to bone healing. method and technique: we are describing a l-configuration reattachment of distal biceps tendon rupture, using a single anterior transverse incision at the cubital fossa crease. each pair of sutures from the most distal anchor is passed through the distal part of the tendon. one strand of each pair is passed in a zig zag fashion through the tendon whilst the other strand is simply passed straight through the tendon in a posterior to anterior direction. the four strands of the proximal anchor are passed so that they form two mattress sutures through the proximal part of the tendon. tightening is then performed in a specific sequence with initially pulling on strand a and b to bring the tendon down to bone and then tightening these to the corresponding suture strand of their pair. the two pairs of sutures are then tied to each other. this second anchor tightening ensures that the tendon is brought down onto the bone in an l configuration increasing the contact surface area between tendon and bone. results: we have used this technique in patients till now with excellent results and no re-ruptures. discussion: our technique is simple to perform and provides a sound repair with a large surface area of contact between tendon and bone. results: out of a % (n = ) response rate, respondents ( male, female) were included in the study. we excluded people with previous hip, knee or back problems. in our study, the symptom scores that is lysholm, oxford and visual analogue scale for pain and function did not show any significant decline with age. on the other hand, the scores measuring activity levels that is tegner and ucla scales declined significantly with increasing age. our normal scores were far ahead of age-matched post operative scores following total knee replacement. there was no difference between males and females. the symptom scores declined with increase in medical problems. conclusıon: our age matched scores were superior to post operative total knee replacement (tkr) scores from the njr. this furthered our motive to create a set of reference knee scores in the normal population which could be used by other studies to compare their results and help improve postoperative outcomes. mesenchymal stem cells (mscs) are multipotent stromal cells that have extensive proliferative potential and the ability to undergo multilineage differentiation. traditionally, osteogenic differentiation of mesenchymal stem cells has been studied in cells isolated from bone marrow and iliac crest. however, these harvest techniques are associated with several problems, including donor morbidity, pain, and limited amount of cells. only a few years ago, adipose tissue has been identified as another source of mulitpotent mscs, which are referred to as adipose derived stem cells (adscs). the aim of our study was to provide a comparative analysis of primary osteoblasts from the iliac crest and osteogenic differentiated mscs from adipose tissue, using osteoblast-specific protein expression. in patients the cells were differentiated into the osteoblast lineage using osteogenic medium (adobs). primary osteoblasts were isolated from iliac crest specimens in patients undergoing osteosynthesis with spongioplasty (female: , male: , mean age ± . ). phenotype marker expression of osteoblast-specific proteins osteocalcin, alkaline phosphase, type i collagen, and cbfa- (runx- ) was analyzed up to days following incubation using rt-pcr, western blot, and immunocytochemistry. additionaly, the following surface proteins of adscs were analyzed: nucleostemin, cd , cd , cd , cd , cd , and cd . rt-pcr analysis revealed that the non-differentiated adscs contained different types of stromal cells with a large variety of cd marker expression. surface protein expression (cd) did not differ significantly in cells isolated from either fat tissue or bone. author to editor: saved by lookus. background: at our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. cases and methods: we examined out of hepatic injury patients, excluding cardiopulmonary arrest cases. the present study was undertaken to establish a valid strategy for the treatment of hepatic injury, and further improvement of the survival rate was evaluated based on the grater and equal of grade iv [organ injury scale (ois)] hepatic injury necessitating emergency room laparotomy. result: interventional radiology (ivr) treatment cases were all stable or responder patients and all survived with effective hemostasis. transient responder or non responder patients that needed hemostasis were treated by emergency laparotomy, and all the cases that eventually expired needed dcs. the mean injury severity score (iss) was . and the mean probability of survival (ps) was . , and hemostasis treatment was started within a mean of . min, yielding a survival rate of . % in the cases with grater and equal grade iv (ois) liver injury that needed emergency room laparotomy. conclusion: our criteria for deciding the therapeutic strategy based on the response to the initial fluid resuscitation seemed to be useful from the viewpoint of hemostasis for liver injury. the key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients to the center as rapidly as possible. author to editor: we show that our classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system is very effective for liver injury strategy. fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. the gamma-nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. a series of fractures of the proximal femur in which this nail was used is reported. the average age of patients was . years (range - years). . % ( patients) of the cases were female. the average duration of the operation recorded was min. in all cases closed reduction was achieved. the mean healing time was . weeks in . % of the cases. there were two cases of delayed consolidation but no pseudarthroses. postoperative complications occurred in cases ( . %). one case of migration of the proximal screw was the most important complication. the most frequent complications ( cases) were seromas and hematomas of the surgical wound, which resolved satisfactorily in all cases. superficial infections ( cases) also evolved favorably, once the appropriate antibiotic treatment had been instituted. no breakages or failures due to implant fatigue were seen. the patient's recovery after suffering the fracture and the operation was evaluated and the % ( patients) recovered their previous walking ability. the overall mortality was . % ( patients) with of the deaths occurring while in hospital. in conclusion, this preliminary study has shown that gamma-nail can be safely used by the average surgeon in the average hospital to treat a common and sometimes difficult fracture. valerio ranieri, loris trenti, aldo rossi, antonio manenti departement of general surgery, university of modena and reggio emilia, modena, italy a years old nigerian woman, at the end of the nd pregnancy, was submitted to a caesarean section for uterine atony. post-operative thrombo-prophylaxis was given. from pod , fever, abdominal pain and increasing tenderness in the right lower quadrant with leucocytosis appeared. ultrasonography showed only small amount of fluid in the douglas pouch, while a contrast-enhanced ct and a rmn revealed a dishomogeneus cylindrical mass of . cm in diameter extending from the right parauterine space towards the duodenum, suggestive of thrombosis of the ovarian vein. laparotomy followed: uterus, ovaries, appendix and bowels were normal. after mobilizing the right colon the ovarian pedicle appeared enlarged and firm; it was dissected, starting from the vena cava, and completely excised preserving the adnexa. post-operative course was uneventful. histology confirmed a suppurative thrombophlebitis; the haematological study ruled out any coagulation abnormality. the patient completed a months low-molecular-weight-heparin treatment. ovarian vein suppurative thrombophlebitis can seriously complicate a caesarean section, till to require a surgical treatment. the imaging is essential for a prompt diagnosis. purpose: to prospectively study the mechanism, distribution of injury, and outcome of patients hospitalized with camel bite injury. methodology: all patients admitted to al-ain hospital with a camel bite were prospectively studied over years (october -october . mechanism of injury including behavior of the camel, distribution and severity of injury, patient's demography, and outcome were studied. results: all patients were males having a median (range) age of ( - ). almost half of them were pakistani. twenty-five were camel caregivers while five were camel riders. seven patients were raised up by the camel's mouth and thrown to the ground while the other patients were only bitten. majority of the injuries were in the upper limb ( ) followed by the head and neck ( ). / upper limb injuries had associated fractures. two patients who were bitten at the neck were admitted to the icu. one of them died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. the median hospital stay was days. one patient died ( %). conclusıon: the behavior of the camel is occasionally unpredictable and the canine teeth of the camel, which are long, can cause severe penetrating trauma despite the small puncture on the skin. care should be taken when handling the camel. author to editor: dear colleague: this is the only prospective clinical study of camel bites in the literature that took us years to collect. the data is very unique and is of great interest. fikri abu-zidan gastrointestinal cytomegalavirus infections occurs predominantly in immunocompromised patients.involvement of the gastrointestinal tract in acquired immunodeficiency syndrome (aids) patients is frequent. however the prevalence of cytomegalovirus appendicitis is exceedingly rare. case: a year-old male infected with the human immunodeficiency virus, who had chronic abdominal pain with subsequent development of acute right lower quadrant tenderness was admitted to the surgical emergency department. his physical examination revealed no other finding than a mass in the right lower quadrant. his abdominal ultrasonography and abdominal ct revealed a plastron appendicitis. so he was hospitalized for medical treatment and discharged after days of treatment. his control abdominal ultrasonography and ct at the second month showed that plastron appendicitis persisted, therefore the patient was rehospitalized. he was discharged after days of medical treatment. after months the patient experienced severe abdominal pain. appendectomy was performed and histopathogic examination revealed a cytomegalovirus infection. the problems related to diagnose cytomegalovirus appendicitis and therapeutic management of cytomegalovirus infections are discussed. conclusion: aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended. introduction: spontaneous intramural hematoma of intestine due to anticoagulan therapy is an unusual reason for acute abdomen. the first symptom is usually severe abdominal pain, nausea and vomiting. the most useful radiographic methods is computed tomography. the treatment approach is conservative and surgical. we present four patients treated our clinics due to intramural hematom. two patients are treated surgically and two patients are treated conservatively. material and method: we carried out four patients diagnosed and treated for intramural hematoma of small intestine between and years in haydarpasa numune training and research hospital second surgery department. we examine in this patients age, sex, etiologcy, hematologic parameters, the treatment approach (conservative and surgery), hospitalization times. results: the mean age of the patients was . years (range - ). all patients were male. the etiological factor was warfarin treatment due to aort valve replacement in three patient and ischemic cerebral disease in one patient. laboratuary parameters were elevated leukocyte counts in all patients. two patients was treated by surgical treatment due to intestinal obstriction and ishemia two patient was treated conservatively (nasogastric decompression and total parenteral nutrition). median hospitalization time was . day ( - ). discussion: when patients using anticoagulan therapy applied to emergency unit with abdominal pain, physicians must remember intramural hematoma as reason of acute abdomen. first choice is conservative treatment however cases of acute abdomen with intestinal obstriction and ischemia require surgical intervention. introductıon: motorcycle accidents continue to be a source of severe injury. the joy and exhilaration of riding motorcycles brings with it the risk of morbidity and mortality associated with these accidents. case: it concerns a -year-old man that in / / entered the emergency room after suffering a motorcycle accident. at the admission he had pain, swelling and deformity of the left knee. radiographs showed tibial plateau fracture type vi of schatzker. he was submitted to surgical treatment with open reduction and ostheosynthesis with liss plate and was orientated to rehabilitation. six months after, the fracture was healed in correct alignment, had normal gait, normal knee range of motion and returned to work. eight months after surgery he suffered another motorcycle accident with left leg trauma, radiographs showed a supracondylar femoral fracture type .a ao-asif and diaphyseal tibial fracture below the plate. he underwent surgical treatment with open reduction and osteosynthesis of the supracondilyan femoral fracture with lcp plate, extraction of the liss plate and ostheosynthesis with diaphyseal lcp plate. eleven weeks postoperatively, he was able to walk without crutches. five months after had normal range of motion of the left limb and was working. conclusıon: tibial plateau fractures are serious injuries and stable fixation without compromising the soft-tissue envelope is often difficult but with the liss plate we can achieve fixation of an associated metaphyseal/diaphyseal fracture component with minimal approach. multiple consecutive fractures are an important source of limb deformity and impairment, which we could prevent in this case. introduction: the optimum management of non-united humeral diaphyseal fractures remains unclear. a number of implants are available utilising varying operative philosophies and balancing operative complication risks. we present two cases of humeral shaft non-union treated with an intramedullary compression nail, a technique which is previously unreported. cases: case : a year old male with a closed fracture of the humeral diaphysis ( -a ). initial failed open reduction and internal fixation with an anterior placed . mm dynamic compression plate (dcp) was subsequently revised to a posterior . mm dcp plus bone graft months later. one year post revision, the fracture had failed to unite and was referred to the senior author. he underwent a stage reconstruction with the t humeral intramedullary nail in compression mode. at month review the fracture had united and at years postoperatively he had full range, pain free shoulder and elbow movement. case : a year old female with a closed diaphyseal humerus fracture ( -a ) treated conservatively in a u slab and functional brace developed a mobile, painful non-union. she underwent the same procedure as above and at months the fracture had united. she was pain free and had full range of elbow movement. shoulder movement was restricted due to co-existing glenohumeral osteoarthritis. conclusion: key tenets of fracture and non-union surgery include the ability to obtain stability and compression. this paper describes the first reported use of an intramedullary nail in compression mode for humeral diaphyseal non-union. fingertip amputations are the most common type of amputation injury in the upper extremity and they are important because of an often disproportionately long period of convalescence. different surgical procedures are available for reconstruction, but none is absolutely satisfactory. twenty-two cases ( patients) of fingertip amputation have been treated by primary skin closure using the v-y plasty (tranquilli-leali). there were men and women. the average age was . years. the procedure was carried out under regional anaesthesia using a tourniquet. all devitalized tissue was excised and the bone was smoothed. a triangular flap with a distal base was developed. the width of the base should be the same as the amputated edge of the nail or the nailbed, and the length should be a little longer than the width. the flap was mobilized and sutured to the nail or the nailbed. finally the volar gap was closed. the average follow-up period was months, ranging from to months. all of the flaps survived and achieved normal or adequate two-point discrimination. two patients had some loss of distal interphalangeal joint extension and five patients had cold hypersensitivity. rapid return to work was possible in most cases. the technique is simple and presents an excellent method for fingertip reconstruction in allen type i, ii and iii injuries. bilateral anterior shoulder dislocation is rare, and his aetiology is via various traumatic insults, atraumatic occurrences, and through extreme muscular contractions like epilepsy. in epileptic seizures is more common to occur posterior bilateral dislocation. the aim of this work is to describe a rare case of anterior bilateral shoulder dislocation after a convulsive crisis. it concerns a case of a -year-old male, with alcoholism history, who entered the emergency room in / / with a generalized tonic-clonic seizure. after, he had bilateral shoulder deformity and swelling. radiographs demonstrated a bilateral anterior shoulder luxation and bilateral greater tuberosity fracture. the dislocation was reduced and both shoulders were immobilized. month later, radiographs showed bilateral reduction maintenance and bilateral greater tuberosity fracture deviation. the patient had extremely restriction of active and passive ranges of motion in both shoulders: in the left had º of active external rotation and º of abduction; in the right º of active external rotation and º of abduction. at this moment surgical procedure was done with bilateral open reduction and osteosynthesis with ''phylus'' plate and was orientated to physical rehabilitation. at the month follow up, he had significantly improved both shoulders range of motion, and returned to the normal daily activities and months later returned to work. displaced fractures of the greater tuber-osities after shoulder dislocation may result in motion limitation and functional disability. open reduction and stable fixation allows for early passive motion of the joint and early return to activities of daily living. introduction and objectıves: direct inoculation, hematogenous spread or underlying medical illness which can predispose a patient easily for osteomyelitis are the causes of a vertebral infection. this case report represents a vertebral osteomyelitis of a patient seen after spine trauma. case: an year-old girl was admitted to our out-patient clinic with a history of progressive back pain. her inflammatory markers were high, physical examination revealed only spinous tenderness to palpation and she had a spine trauma history when she was at nine. radiological evaluation demonstrated lumbar and mild anterior compression, an incomplete intervertebral fusion and endplate irregularities with an intact spinal cord. bilateral sequential transpedicular drainage from l vertebra was performed without any complication. she has a pain free course of months with negative inflammatory markers. conclusions: the management of vertebral osteomyelitis is often challenging and in case of continuing pain and progressive kyphosis, surgical treatment is indicated. beside aggressive surgical procedures, minimally invasive techniques can be an option for the treatment of such cases. . instead of standard screws with diameter of mm using screws with diameter of . mm . instead of , diameter cannulated tunnel using , mm cannulated tunnel results: in use of this new modified method the time of surgery is shorter, the percutaneous surgical technique is simplified, the blooded lose is minimalizied, the surgery can be performed by two persons: the surgeon and the scrub nurse and few special instruments required. conclusion: based on our results we recommend this modified minimal invasive percutaneous osteosynthesis in case of garden iii femoral neck fractures, in garden iv one, especially immobile patients and patients with poor general conditions (asa score iv). introduction: pelvic fracture is one of the serious skeletal injuries, resulting in substantial mortality. the large amount of kinetic energy necessary to fracture the bony pelvis often leads to concomitant thoracoabdominal injury. pelvic fracture and combined injuries need effective initial resuscitation. however, it is hard to predict the mortality due to the complexity of multiple injuries. therefore, the introduction and objectıves: in this study, we aimed to investigate the distribution of the diagnosis in patients who underwent urgent surgical intervention in the operating room. methods: distribution of the diagnosis in patients who underwent an orthopaedic urgent intervention in the year are evaluated retrospectively from the medical records. results: patients with orthopaedic complaints [ male, female; mean age . ( - ) years] were operated on urgently in the year . patients ( shoulder, hip and lisfranc dislocations) had traumatic acute joint dislocation in which closed reduction was unsuccessful without general anestesia, one had supracondylar humeral fracture, one had distal femoral epiphyseal type ii fracture, one had isolated radial shaft fracture with neurovascular injury, one had t spinal fracture dislocation with paraplegia, one had type iii acromiaclavicular ligament rupture, one had quadriceps muscle laceration due to knife wound, one had tendo calcaneus rupture and one had patellar tendon rupture with medial meniscal injury due to knife injury. the mean time from admission to operation was found . h (range - ). conclusıon: it was concluded that the closed reduction of joint dislocations under general anestesia were the major group in orthopaedic urgent intervention. why ankle should be reduced urgently? shahzad sadiq, tariq mahmood worcester acute hospital, worcester, uk fracture dislocation of ankle is common orthopaedic emergency. it is paramount that to avoid soft tissue damage, the ankle is reduced as soon as possible. despite all efforts ankle dislocations could lead to significant blister formation. we reviewed a case series in which ankle joint was reduced with external fixator until skin healing methods: the cases who were admitted to our emergency department between august and and were exposed to traumatic extremity amputation were studied. the medical records such as age, sex, education level, occupation, the way trauma occurred, the affected anatomic zones, performed interventions and hospitalization duration parameters were evaluated. results: the data of subjects were evaluated in this study. mean age was , the rate of female/male was / . . there was a reverse correlation between the education level and occurrence prevalence. . % of the cases were laborers, . % various free self employed and . % were farmers. according to their occurrences, industrial accidents . %, pinching finger in the doorway . % and home accidents . % formed the first three rank. hand finger amputation was . %, toe amputation . % and others were . %. while cases were treated at the emergency service and discharged, cases were referred to related clinics. five cases were referred to other centers and two subjects willingly left our clinic. the mean length of stay was . days. conclusıons: traumatic amputation concerns particularly the young and the people in active work life. since the majority of the cases have hand injuries, they are striking because they cause workforce lose in addition to cosmetic and functional defects. introduction: distal radius fractures are one of the most common injuries regardless of age group. due to their localization they pose a serious threat to the fine wrist movements. for most of the patients the perfect functional result is of a vital importance. open reduction and stable osteosynthesis may help to produces desired outcome. methods: we have compared distal radius radius fractures treated with open reduction and stabilization with . mm synthes lcp and treated with synthes , mm lcp. we have compared the functional results, neurological damage and patient comfort with questionare form. measurements from x-rays were also compared. we have included patients of age between and years, with distal radius fracture. of them with intraarticular fracture. results: intraarticular fractures of distal radius treated with synthes . mm lcp show better functional results compared to synthes . mm lcp. there is no relevant difference depending on used material in extraarticular fractures. conclusıons: we recommend the use of synthes . lcp for intraarticula distal radius fractures for its greater diversity and abillity to stabilize even a small fragments. introduction and objectives: surgical treatment of fractures by using resorbable implants is not too expanded alternative to classical steel or titanium implants. indication for using are intraarticular and periarticular fractures at first of all. the most advantage is no necessary of implants extraction. another one is propagation of load callus during the degradation of material. possibility of making profitable ct and nmr is indispensable.in this paper author presents experiences with using of resorbable screws. methods: at our department there are resorbable cortical screws . , . and . mm bionx made from polyamide polymer with minimal stronghold for weeks and total absorption after years. this screws are determinated for cancellous bones in periarticular areas. we are using them in cases of fracture posterior wall of acetabulum, distal humeral intraarticular fractures, radial head. it can be used for treatment children¢s fractures too. the follow up is same like in ''classical'' osteosynthesis. results: there were no infection's complications, no malfunction screws in our group of patients. the postoperative and ambulatory treatment including physiotherapy was same like in group with classical osteosynthesis. the only one failure was during surgery -we have wraped screw four times because of insufficient pre-drilling and using too much power during insertion. we could recommend resorbable screws as suitable alternative in some type of surgical treatment intraarticular fractures at most. the indication have to be well look over and way of using has to be well understand as well as careful manipulation during surgery. the benefits are no metal material, no extraction in future and profitable ct and nmr. heart valve lesions in blunt cardiac trauma -mechanism, diagnosis and treatment robert lipovec, granc gregorcic department of cardiac surgery, university clinical center maribor, maribor, slovenia because of the variation in diagnostic criteria, cardiac involvement in blunt chest trauma is estimated at approximately %. in contrast to cardiac contusion which is often difficult to validate, traumatic valvular lesions are usually associated with some degree of hemodynamic impairment. patients with positive findings on clinical examination, ecg, cxr and troponine should be screened for valvular lesions by transthoracic echocardiography. blunt injury to cardiac valves can lead to progressive ventricular failure often requiring surgical management. patients with structural damage to the left sided heart valves usually require immediate surgical repair, while right sided valvular lesions can be managed in a delayed fashion. the management is based on type of structural injury and hemodynamic compromise. valvular reconstruction is usually attempted, if possible. the paper outlines historical perspective, mechanisms of injury as well as our experience with diagnosis and treatment of traumatic valvular lesions. two case reports are presented. one patient had a traumatic mitral chords rupture and the other had a tricuspid papillary muscle rupture. both cases were diagnosed immediately and surgically corrected. the ruptured mitral valve was urgently replaced. the tricuspid valve was repaired by delayed surgery. patients in al-ain city, united arab emirates . %, respectively. only the difference between group iia and iib was found to be statistically significant. dıscussıon: rib fractures increase the pain and have a negative effect on breathing during postoperative course. ineffective breathing may cause athelectasis, fever and infection which is associated with increased morbidity. the incidence of rib fractures are higher in anatomical resections in whom the thoracic cavity should be opened widely. a longer incision and step to step opening of the thoracic cavity may decrease the incidence of this undesirable complication. objectıve: this case report describes a surgical method to treat multiple rib fractures by using arch bars. case: a year old male patient was admitted to emergency unit with bilateral flail chest, bilateral multiple rib fractures, bilateral hemopneumothorax and pulmonary contusion. the patient was initially tachypneic and had a shallow breathing. because of the respiratory arrest he was intubated. physical examination revealed crepitation from subcutaneous and oseeous tissues especially on the left hemithorax. after left sided tube thoracostomy cc hemorrhagical drainage and massive air leak was observed. ct scan showed bilateral rib fractures extending from the first to the eleventh ribs, bilateral hemopneumothorax and bilateral pulmonary contusion (picture , ). therefore tube thoracostomy was also administered on the right hemithorax and cc hemorrhagical drainage and air leak occured. because of the thoracic deformity, persistant hemorrhagical drainage and air leak from the left hemithorax, the patient underwent exploratris thoracotomy and damaged pulmonary parenchyma was repaired. multiple rib fractures which damaged the thoracic wall stability severely were fixed by using arch bars (picture ). the patient required mechanical ventilation for days postoperatively. the latest ct scans of pulmonary parenchyma and thoracic wall after arch bar application are seen in pictures and . conclusıon: in this case the conventional rib fixation procedures with kirschner wires or plate plaques could not applied because of multiple small fractured segments. despite various materials suggested in literature, the use of arch bars to repair flail segments with multiple small pieces are not mentioned. tariq siddiqui, kimball maull the trauma center at hamad, hamad general hospital, doha, qatar introductıon: intrathoracic fluid following blunt chest trauma is almost always blood, and derangement in the patient's cardiorespiratory status is directly related to the volume of blood accumulated in the pleural space and the associated compression of pulmaonary parenchyma. tension chylothorax in the setting of bilateral chylothoraces is a rare cause for such a condition. a year old man fell from a height of three meters and presented with back pain. examination disclosed abrasion and tenderness over the right paraspinal area. he was discharged home. four days later, he returned in severe respiratory distress -hypertensive, with rapid pulse, tachypneic and with peripheral cyanosis. there were no breath sounds on the right side and decreased air entry on the left, and bedside ultrasound showed fluid in the right chest. chest x-ray confirmed complete opacification of the right hemithorax and loss of the costo-phrenic angle on the left side. a right tube thoracostomy yielded , ccs of pinkish-white fluid with immediate improvement in cardiorespiratory status. computed tomography disclosed bilateral th and th rib fractures, spinous process fracture of the th thoracic vertebra and bilateral effusions. a left chest tube brought back ccs of additional similar fluid. diliatation of the cisterna chyli in the abdomen with collapse of the thoracic duct were confirmed by mri. conclusıons: post-traumatic tension chylothorax causing cardiorepiratory compromise is rare. in this report, the patient responded to chest tube decompression and dietary measures without complication. author to editor: this report is complimented by excellent illustrations, including ct and mri findings, showing the anatomy of the injury… conducive to poster display. introduction: blast lung injury (bli) is a unique injury rarely seen in the civilian population. our objective was to assess its severity, prognosis and associated injuries as compared to victims with chest wall trauma following explosions. material and methods: retrospective study of victims of the march terrorist bombings in madrid who were treated at the closest hospital. we compared the group with pure bli (bilateral infiltrates in a butterfly pattern, and absence of chest wall fractures) (group i) with that of patients with peripheral infiltrates and chest wall fractures (group ii). results: of patients included in the registry, ( %) had thoracic injuries. ( %) were included in group i, and ( %) in group ii. the mean iss in groups i and ii was of . ± and . ± . , respectively. among the critical patient population in both groups (n = ), those belonging to group ii were in need of a longer period of ventilatory support and had more ventilator-associated pneumonias. in group i, the most frequent associated injuries were tympanic perforation ( . %), º- º burns ( . %) and abdominal trauma ( %). in group ii, º- º burns ( %), followed by tympanic perforation ( %) and skeletal trauma ( %). one patient died in each group ( . vs. . %). conclusions: pure bli patients had a greater degree of anatomic severity, had more severe burns and abdominal trauma than patients with lung infiltrates and thoracic wall fractures. overall prognosis was excellent in both groups. aım: aim of the study was to determine the rate of injuries detectable by ultrasonography in patients suffering from blunt thoracic trauma. materıals-methods: this study include the patients suffering from blunt thoracic trauma who have not any pathological findings in routine radiological diagnostic procedures. ultrasonography of the thorax was prospectively performed in patients with blunt chest trauma additionally to the routine radiological diagnostic procedures. ultrasound findings referring to the rate of detection of fractures, pneumothorax, pleural effusions, lung contusions, haematomas of the lung and chest wall was performed. results: we studied consecutive patients suffering from blunt thoracic trauma who has any pathological findings in routine radiological diagnostic procedures. the findings detectable by ultrasonography were the following: pleural effusion %, haemopneumothorax %, haematoma of the chest wall %, contusion of the lung %. conclusıon: rib fractures and pleural effusions are commonly diagnosed by ultrasonography in patients with blunt thoracic trauma. this study showed that ultrasonography may have superiority to chest-x-ray in diagnosis of rib fractures, pneumothorax, haemothorax, haematomas of the chest wall and pulmonary contusions in blunt thoracic trauma patients. Ş adiye emircan , Ö zlem kö ksal , fatma Ö zdemir , halil Ö zgü ç department of emergency medicine, uludag university, bursa, turkey department of general surgery, uludag university, bursa, turkey aım: the purpose of this study is to define the epidemiologic properties of patients that have been subject to thorax injuries and general body traumas, analyze their condition when they are brought to our emergency department, to determine the correlation of physiological and anatomical risk factors with the mortality rate, and to ensure early diagnosis of severe trauma. methods: trauma cases that had been subject to general body trauma have been retrospectively examined in this study. epidemiological properties of the cases have been determined, their initial condition during initial admission to emergency department have been analyzed, and cases have been assessed in terms of mortality developments. survival probabilities and unexpected mortality rates have been computed using trauma revised score-injury severity score (triss) methodology. results: mortality rates was . %. univariance analysis revealed that hypotension, age, pathologic respiration pattern, blunt injury, accompanying injury, abdominal trauma, high injury severity score (iss), low glascow coma scale (gcs), revised trauma score (rts), triss were the factors affecting mortality. in logistic regression analysis, presence of blunt injuries, triss < , iss > and gcs < have been found independent prognostic factors. strongest factor indicating mortality has found to be triss. in presence of factors affecting mortality, patients with thorax trauma should be evaluated as being of high risk group and therefore diagnosis and treatment strategies must be aggressive. case analysis based on triss model shall further reveal the mistakes that may be made in patient care and may improve patient care. introductıon: penetrating thoracal and cardiac wounds are asssociated with high mortality. we aimed to present our experience in such cases. materıals-method: twenty three patients with penetrating thoracal stab injury, between and , were investigated retrospectively. gender, age, injured areas, extent of thoracal damage, accompanying organ damages and outcomes of these patients were evaluated. results: all patients, except one, were male with a mean age of . years (between and years). in patients penetrating abdominal injury accompanied thorax trauma and one of these patients died peripoeratively. patients out of thoracal trauma had an additional cardiac stab wound and half of them were only pericardial injury. one of these cases went into emergency coronary artery bypass surgery due to lad injury. only four patients required intensive care postoperatively and four patients were lost perioperatively all of which had additional cardiac injury. conclusıon: the overall mortality rate was %, but mortality of patients with additional cardiac stab injury was higher, with a rate of %. suspect of cardiac injury should be considered in patients who are injured close around cardiac area and one should intervene quickly both in diagnosis and treatment. introduction: abdomen and thorax blunt and penetrating injuries, common cases of emergency surgery, cause less complication with proper analysis and surgical intervention. material and method: we retrospectively evaluated patients operated due to thoraco-abdominal blunt and penetrating trauma in _ istanbul training and research hospital last year. results: median age was . ( - ) and all were male. patients were operated due to blunt abdomen in , penetrating abdomen injury in , abdomen and thorax penetrating injury in by general surgeons. abdominal exploration in ( . %) were negative laparotomy. background: we described a patient with dysfunctions of all the nerves and ruptured brachial artery and vein due to closed injury caused by spontaneously reduced dislocation of the elbow. case: a -year-old man fallen down onto his left elbow with small skin erosion and a large area with ecchymosis on the elbow presented. left radial and ulnar pulses were nonpalpable but no sign of acute ischemia was noticed. he had drop hand and could minimally make flexion, opposition, abduction and adduction of fingers. strength of fingers, wrist flexion and thumb adduction were weak. radiography was normal. emergent surgical exploration was performed with prediagnosis of severe closed soft tissue injury and vascular damage. brachial artery and vein had complete disruption with rupture of brachial muscle and the anterior joint capsule. elbow joint could be posteriorly dislocated. artery and vein were repaired with saphenous vein graft. median and ulnar nerves had normal appearance. at postoperative th hour nerve injuries showed complete recovery. he could have normal range of motion in the wrist and hand. sensorial examination was normal. he had a well perfused arm. conclusıon: spontaneously reduced dislocations of the elbow can be sometimes missed. large hematoma and neurologic dysfunction in closed injury of the elbow indicate severe trauma of joint also in case of normal bone structure in radiography. immediate diagnosis and operative treatment of brachial artery injury is mandatory. closed elbow dislocation and multiple nerve injuries may have good results with conservative treatment. we present the case of a y male, with his left lower limb severely damaged by a caterpillar vehicle. he was admitted in the er about min after the accident. he presented with exposed fractures of the femur and leg bones, extensive soft tissue and muscle damage, class iii shock, and an umbilical clamp in the exteriorized femoral artery in the thigh, placed by a fireman in site. the mess (mangled extremity severity score) calculated for this patient was . after the initial assessment in the er the patient was transfered to the or. he had a complete transection of the femoral artery and vein with a severe ischemic foot. despite the mess score, a vascular and bone repairs have been considered. two temporary shunts were placed in both femoral vessels (artery and vein) followed by external fixation of the femur and leg fractures. the definitive vascular repair of the artery and vein was made with autologous saphenous vein after the bone fixation. some damaged skin and necrotic soft tissues were removed, and the reminder skin was only proximated. the limb was functionally and anatomically preserved, with no obvious neurologic deficit, despite subsequent debridements and skin grafts. the authors concluded that in similar cases: introductıon: trauma is responsible for . million of death, % of them in young people. vascular injuries of the upper extremity represent % of all peripheral vascular lesions, the majority of them at the braquial artery. objectıve: report a case of chemical injury of braquial artery. methods: -year-old man was admitted in the emergency room with third degree sulphuric acid burn in the middle third of arm ( % of total body surface area). the radial and ulnar artery pulses were palpable. at the th day after injury, haemorrhage was noted and disruption of braquial artery was clear. a braquial-radial reversed long saphenous vein interposition graft was performed. after surgery palpable radial and ulnar pulses were present, without evidence of nerve injury. results: the chemical burns severity depends on the concentration, properties of the agent and the duration of skin contact. sulphuric acid causes coagulation necroses, with thrombus formation in the microvasculature. its corrosive properties are accentuated by exothermic reaction with water. its burns are more serious than those compared with strong acids, and, as observed in this case, it causes frequently third-degree injuries. besides this, it has the ability to cause continuing tissue destruction, from th hour to th day after injury. this fact could explain why there was no artery lesion at the admission but at the th day. conclusıon: sulphuric acid burn is potential devastating and tend to be prolonged in time, obliging to a continuous monitoring and multidisciplinary approach. introduction and objectıves: the medicolegal studies show that the most frequent mechanisms of the lethal major vascular injuries were stab wounds followed by gunshot wounds and blunt trauma. during the blunt traumas, simple lethal major vascular injuries without any fracture are seen rarely. we experienced a case of common femoral artery and vein transection as a cause of death without any femoral fractures which were caused by blunt trauma. case: during the transportation of wood blocks, a wooden log fell from the truck over the forester, -year-old man. he sustained a crush injury and died in the emergency service on the same day of the trauma. it was learnt that no medical intervention was performed on the case. ecchymotic bruises on the left abdominal-pelvic, femoral, right inguinal, genital region, deformation under the right knee were observed during the autopsy. it was determined that there was a traumatic transection on the left common femoral artery and vein, which was accompanied by massive bleeding in surrounding soft tissues and muscles without any fracture of the left femur. all the internal organs were intact and showed paleness. death was due to internal hemorrhage caused by the transection of the femoral artery and vein. conclusıons: during the examination of the cases who were exposed to the blunt trauma, peripheral vascular injury must be investigated without any delay. if vascular injury was determined in the early times after the trauma, surgical and medical treatment could be performed successfully and the case could survive. introductıon: traumatic internal carotid artery dissection is a rare and grave cause of embolic strokes occurred especially in young age group. if it is not diagnosed early and required treatment is not given, thrombosis can be a serious trouble with permanent neurological deficit and high mortality rate up to %. case: we presented a delayed diagnosed traumatic carotid artery dissection in a year-old female case. there were no ischemic infarct findings in the cerebral ct on admission, but there were cerebral infarct findings in the cerebral ct taken twice because of the left hemiplegia noticed days later when the patient regained her consciousness. we made the diagnosis of the case, forwarded to our emergency service with acute cerebral infarct diagnosis, certain through arterial doppler ultrasonography, cerebral mri, diffusion mri and mr angiography. we did not consider invasive treatment since the neurological damage was permanent and dissection grade was iv according to angiography findings. we did not administrate anticoagulant treatment considering that the patient can turn her ischemic infarct into hemorrhagic infarct. the case was discharged within a week and advised physiotherapy. conclusıon: although the advances in diagnostic methods, diagnosis with traumatic carotid artery dissection is still missed out or delayed as in the case we presented. early diagnosis enables permanent neurological damage to be decreased or vanished. however, the vital factors for early diagnosis are the obtained anamnesis to direct to radiological examinations, detailed physical examination and high clinical doubts. introduction: acute arterial occlusion is a serious clinical condition resulting death of patient or related organs. these are usually older patients with a lot of comorbid conditions. method: _ in our clinic, we retrospectively examined the records of patients who underwent surgical treatment for acute arterial occlusion between january and december . mean age of patients was . years. ( %) of these patients were female, and ( %) were male. embolic occlusions were found in an upper extremity in ( %) patients and in a lower extremity in ( %). the most common source of these emboli was cardiac origin. atherosclerosis, trauma and arterial catheters were the other causes of emboli. ( %) of patients were admitted less than h preoperatively, ( %) were admitted - h preoperatively, ( %) were admitted after a delay of longer than h preoperatively. ( %) of patients were in sinus rythm, ( %) were in atrial fibrillation preoperatively. motor dysfunction of extremity was found in ( %) of patients preoperatively. diagnosis was based on the findings of physical examinations and emergent doppler ultrasonography. any other invasive evaluation was not performed to decrease acute occlusive ischemic period. surgical intervention had performed immediately results: the overall mortalıty rate was % ( ). _ in ( . %) of patients, after setting of demarcation line, amputation was performed. conclusıon: early diagnosis, catheter embolectomy and use of anticoagulation are very important therapeutic modalities for limb salvage and reduction of morbidity and mortality. there was a comorbidity in all patients and cardiac disease and hypertension were the most common ones. the most common laboratory abnormalities were leukocytosis, hypoalbuminemia, hyperamylasemia. there was superiory vasculary necrosis in patients, inferior vasculary necrosis in one patient.one patient had nonocclusive mesenteric ischemia. segmentery resection was performed to patients. abdominoperineal resection was performed to the patient with inferior mesenter artery occlusion. we performed duodenotransversostomy on two patients and only laparotomy on two patients. reoperation was required in five patients. causes of death was multiorgan insufficiency in seven cases, cardiac death in two cases.one patient died due to short intestine syndrome. results: the patient was discharged on postoperative th hours without any complications. conclusıon: single incision laparoscopic appendectomy is a safe and effective technique that can be performed in well experienced centers success. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugal trauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease. recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the teaching of this new method, albeit its good results, has not seen many changes over the years. however, in recent days, we have seen the introduction of new computer technologies in teaching. this methods use simulation, e-learning and even interaction as learning techniques. taking advantage of the mentioned techniques, the authors produced an animated video, using computer-animated drawings that allow demonstrations difficult to reproduce in real life. using simple software and computer video editing, the authors invite you to watch a trauma patient in the emergency room, since his arrival to the end of the primary survey, watching demonstrations of life saving techniques and the stabilization of the patient. the authors present a video of a young male, years of age, ± kg victim of a motorcycle crash, with a fall over cut branches of trees, min before his admission in the e.r. he sustained an impalement with a stick in the fourth right anterior para-sternal space. at admission he was conscious, gcs = , bp = / , hr = /m, sato = %, hemodynamically normal. breath sounds slightly diminished in the left. a left anterolateral thoracotomy as been done, as well a left subcostal lararotomy, since the stick also had penetrated the left hemidiaphragm. the patient had no significant thoracic or abdominal injuries despite the violence of the trauma mechanism. the ''foreign body'' was successfully removed by combined abdominal and thoracic route, and a left chest tube was put in place. the patient recovered very well and was discharged in the eighth day. author to editor: ''english'' corrections are welcome, please! berker bü yü kgü ral, mehmet bekerecioglu al-marashda , amgad elsherif , hani o. eid , fikri m univariate analysis was used to compare patients who died and those who survived. significant factors were then entered into a backward stepwise likelihood ratio logistic regression. results: out of , patients of the registry, patients ( . %) had chest trauma with a mean (sd) age of . ( . ) years. ( %) were males . ( . %) got injured in the street or highway, ( . %) at work place, and ( . %) at home. the main mechanism of injury was road traffic collision in ( %) fall from height in ( . %). ( . %) were admitted to icu. the median (range) iss was ( - ). ( . ) of patients got isolated chest injury, ( . %) had head injury, ( %) lower limb injury, ( . %) upper limb injury iatrogenic rib fractures during thoracotomy: comparision of posterolateral and anterolateral thoracotomies operations for thoracic trauma, extended lung resections and re-thoracotomies were excluded. posterolateral thoracotomy incision was performed for group i ( patients; . %), and anterolateral thoracotomy incision for group ii ( patients; . %). groups were also divided into two groups for the type of resection the percentages for rib fractures for group ia, ib, iia, and iib were . , . , . , and . damage control principles can a be used in all surgical fields . general surgeons must have experience in vascular repair skills . the reperfusion of the limb joão filipe coutinho vasconcelos , sandrina braga , pedro brandão , daniel brandão , miguel maia , joana ferreira , paulo barreto , vítor martins , a. guedes vaz , leonor rios vila nova de gaia, portugal department of plastic surgery rectal prolapse describes the protruding of the entire rectum or some parts of the rectum from anus. it is caused by the weakening of the ligaments and muscles that hold the rectum in place.it is associated with advanced age, long term constipation or diarrhea, childbirth, previous surgery, and sphincter paralysis. trauma may cause sphincter paralysis and can be associated with rectal prolapse. it usually begins with prolapse of the rectum during defecation or val salva movement and usually progresses to a chronic stage. long term prolapse can cause ulcerations, bleeding and in some cases perforation if not reducted. a -year-old male presented with rectal prolapse, bleeding, abdominal pain. he stated that he could not replace the prolapsed segment for days and has been suffering for years since after he fell from a tree and he had massive bleeding during the last h. physical examination revealed that a cm segment of the rectum was prolapsed with the whole layers. there were ischemic and necrotic areas and active bleeding from the mucosa. reduction trial was not successfull. emergent laparotomy was performed. bimanual reduction failed.thus transanal intervention, with sigmoid resection was performed. end colostomy was preferred. no complications occurred the following months and colorectal anastomosis was performed with a preventive ileostomy. although rectal prolapse is usually a benign condition it may cause fatal complications such as perforation, necrosis if not reduced for a long time and surgery should be performed promptly in these cases.ing to the age, diagnosis, treatment results, mortality rates between the years of and . results: summarised in the table .in conclusion, the most of our multitrauma cases caused by traffical accidents, were young. the mortality rate % for multitrauma cases, the percentage of multitrauma cases were . % of all intensive care patients. preventing the accidents is as much important as treatment strategies for multitrauma cases. arif tü rkmen, ertan gü nal, mehmet bekerecioglu, berker bü yü kgü ral department of plastic and reconstructive surgery, gaziantep university school of medicine, gaziantep, turkeyintroduction and objectıves: as personal problems dealing with health, jobs, financial status and the family problems increasing, more suicide attempt subjects are consulted in emergency rooms day-byday. although gunshots to the oro-facial region form - % of the total victims, it is important that seconder deformities resulted with aesthetic, functional and psychological problems were usually encountered after primary surgery. this study reviews cases of self-inflinct gunshot injuries of face and our experiences in early and late managements over a -year period.methods: this study is based on subjects who attempted suicide resulting in extensive facial deformities, not in death between and . demographic details, mechanism and direction of injury, early and late management and seconder deformities were recorded. results: after establishing the airway control and completing the primary survey, all patients underwent debridement and bleeding control. reconstruction of maxillofacial fractures were performed in patients on the day of admission and the remaining within days of injury. following procedures as scar revisions, rhinoplasty, mandible reconstruction, ectropion operations or coverage of palatal defects etc. were performed after earliest months from primary operation.conclusıons: after stabilization of life-threatening injuries, the goals of early management are regenerate of anatomic form and function to include dental occlusion and mouth opening to prevent scarring, contractures of mobile structures and ankylosis. seconder operations required for aesthetic and functional problems should be performed earliest after month from primary operation that all the scar formations and wound healing's were completed. background: injuries of maxillofacial region in patients with polytrauma are frequent but are rarely treated primarily. in order to achieve satisfactory treatment results trauma treatment team must include a maxillofacial surgeon.materıal-methods: the study shows treatment results of polytraumatized patients with maxillofacial injuries. dominant trauma was: maxillofacial in %, craniocerebral in %, locomotor in %, thoracic in % and abdominal in % of cases. treatment of maxillofacial trauma was in % of cases surgical and in % conservative. treatment of other traumas was operative in % and conservative in % of patients. results: early mortality rate was %. four exitus were recorded during the first h, exitus on the th day and exitus on the th post-trauma day. dominant trauma was in exitus craniocerebral, in exitus thoracic and in exitus severe locomotor. long-term treatment results in remaining patients were: for maxillofacial regiongood in patients ( %), satisfactory in patients ( %) and poor in patients ( %); for other regions -good in patients ( %), satisfactory in patient ( %) and poor in patients ( %). conclusıon: existing maxillofacial trauma in polytraumatized patients usually directs treatment toward conservative methods.reasons for this are insufficient number of maxillofacial surgeons in trauma teams and delay of surgical treatment of other present traumas due to difficult anesthesia application. unfortunately, conservative treatment approach induces inadequate treatment results from both functional and esthetic point of view. however, as revealed by hospitalization, transportation, and mortality data, women were exposed to more severe trauma. in addition, poisoning and fall caused more death. the rate of mortality of women seems to be less when compared to literature. conclusıon: bicyclists in non-fatal frontal crashes with cars suffered the most serious injuries from the impact to bonnet and windshield, likely due to highest energy transformation. bicycle helmets, collision mitigation system that alerts the driver or automatically brakes the car, and external airbags protecting the bicyclists from hitting bonnet and windshield, may reduce injuries.author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus bicyclist. journals were completed with traffic notes from police at scene, patents own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. or street ( ais +). third impact in patients gave injuries ( head/neck) at windshield ( ais +) or street ( ais +). thirteen persons, who hit the street as the fourth impact point, sustained three injuries (zero ais +) as contusions of the pelvis and lower back. conclusıon: pedestrians in non-fatal frontal crashes with a car suffered the most serious head injuries at second impact in bonnet, windshield or street. safer passageways for pedestrians might preclude the crash. mechanisms preventing the pedestrian of hitting the bonnet and windshield, may reduce the injuries. author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus pedestrian. journals were completed with traffic notes from police at scene, patients own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. one of the primary characteristics which professions possess is to make the members of a profession have autonomy in decision making and practice. nursing practice is evaluated in relation to professional practice standards and guidelines, rules, etc… application of professional standards requires that nurses use critical thinking for the good of individuals or groups. critical thinking also requires the use of scientifically based and practiced-based criteria for making clinical judgments. these criteria may be practice based on standards developed by clinical practice guidelines developed by individual clinical agencies. for example, intensive care units (icus) are designed to meet the special needs of acutely and critically ill patients. a patient is generally admitted to the icu for one of three reasons. the patient may be physiologically unstable, at risk for serious complications and require intensive and complicated nursing support. despite the emphasis on caring for the patient who can survive death is common in icu patients. it is reported that % of patients admitted to icus will die, and another % may leave the icu but will not survive to discharge. this suggests a need for caution and coordination of care when transferring patients from icus to general units. in this article, the practice guideline which titled ''patient appropriateness for adult icu admissions and discharge'' will be discussed. the terminology for pelvic fractures and its recent modifiers are confusion to the trainee to say the least. we surveyed orthopaedic trainees in the latter part of their surgical rotations. the same set of radiographs were shown to all trainees and their classifications recorded. the same set of radiographs were shown to the trainees again after a period of days. we found significant inter-observer variability ( %) and wide intra-observer variability ( %). though trainees were adept at identifying basic fractures patterns and identifying individual column or lip/wall fractures the complex fracture patterns seems to generate different answers from the same observer at different times. the ct scan was the most effective tool identified for accuracy of the fractured fragments but the more complex assignments resulted in the trainees grouping them differently. results: twenty-one fractures ( . %) healed without complication including five fractures where external fixation was converted into internal one. the mean time to union was . ( - ) months. there were two pin-track infections, two deep infections, and only one nonunion. the femur length was equal to the healthy side in cases, and was shorter by - cm in five cases. mean active knee flexion was °. knee flexion was more than °in patients. conclusions: external fixation is a useful technique for the stabilization of severe open and close highly comminuted femoral shaft fractures. it is safe procedure to achieve temporary rigid stabilization of femur fracture in critical polytraumatized patients before delayed internal fixation (damage control orthopedics). purpose of this study was to determine the factors predicting mortality.methods: a retrospective study was performed on cases of pelvic fracture who visited to emergency department from january to june . data were collected regarding demographic characteristics, mechanism of injury, injury severity score (iss), abbreviated injury score (ais), simplified acute physiologic score ii (saps ii), transfusion requirements, fluid requirements, the finding of angiography, hemoglobin, platelet, prothrombin time ( fractures were managed by using an intraarticular, chevron-shaped olecranon osteotomy in all patients. methods: the mean age was . years. a straight posterior surgical incision was performed. a thin oscillating saw was used to begin the olecranon osteotomy. a small osteotome was then inserted and the osteotomy was completed through the subchondral bone. the posterior elbow capsule was incised. the olecranon fragment and the triceps muscle were reflected proximally to expose the distal humeral articular surface. osteotomy fixations were performed with two intramedullary kirschner wires and dorsal tension band in patients. in four patients, an intramedullary screw and a tension band were used for fixation. results: at the final control, the jupiter classification system was used for the evaluation of the patients. eighty one percent of the patients revealed good and excellent results at the long-term followup. none of the patients showed osteotomy nonunion. the most frequent complication was skin problem due to subcutaneous prominence of the implants.conclusions: the goals of treatment of distal humerus fractures are anatomic articular restoration and rigid fixation. olecranon osteotomy provides good visualization for rigid fixation especially in type c distal humeral articular fractures. this is a useful method for excellent anatomic reduction of the articular surface. conclusions: there could be some steps during primary treatment for discussion. but real mistake was vacillation and delay of reosteosynthesis and spongioplasty even it was cause by risk for infection and possible failure of flap. our case demonstrate that sometimes too much care could be hurtful. introductıon: the population who applied to the public emergency services due to the injuries related to butchering the sacrificial animals during the feast of sacrifice were evaluated. materıals-method: eighty-nine patients who admitted to the emergency services in kirikkale during the feast of sacrifice in were evaluated according to age, sex, application day and time, state of experience, type and mechanism of injury and medical treatment. results: the age average was ± and % of them were male. eighty-eight percent of the patients admitted in the first day. seventy percent of the injuries were penetrating injuries and % of them were blunt. the average time passed after the trauma was min. almost half of the cases were wounded with a knife, % were wounded unintentionally by the others and % of the cases were due to hit of animals. fifty-seven percent of the patients had butchering experience before. ninety-one percent of the cases were hand injuries. thirty percent of the cases had fractures. nine percent of all cases had tendon injury, % of the cases were treated primarily skin suturation. conclusıon: the injuries related to butchering of the sacrificial animals sometimes can be serious. in extremity injuries, the number of tendon cuts and bone fractures can not be underestimated. both equipments and medical staff support for the injured people should be provided and preliminary arrangements should be done during the feast of sacrifice. every butchering job in this period should be given to professionals. introduction: osteoporotic fractures of the trochanteric area are often treated with a gamma-nail or similar implants utilizing a screw applied into the femoral head. one of the main problems of these techniques is the cut out in the femoral head. we biomechanically evaluated a novel technique of cement augmentation of the bed of the screw in a standardised osteoporotic bone model and its capability to reduce the cut out rate. material and methods: utilizing a polyurethane-foam osteoporotic model that has been previously described (specific gravity . g/cm ), a biomechanical testing of a neck of femur screw (tgn, stryker, duisburg, germany) was performed. the screw was implanted according to manufacturers instruction, the migration characteristics were then biomechanically tested (zwick testing machine) with a static stepwise load increase ( n). first these tests were performed without, in a second series with the augmentation of a fast hardening biopolymer (corthoss, orthovita, usa). each series was repeated five times. the transfer from a stable to an unstable condition was biomechanically determined. results: on average the applied load at the moment of failure with critical cut out was n for the non-augmented screws. with augmentation, the average load was , n, the difference was statistically significant.discussion: it appears in biomechanical testing that augmentation of the femoral head can improve the load bearing capabilities and thereby possibly reduce the rate of cut-out failure in osteoporotic bone. we proceed now with further biomechanical testing, grant of the local ethics committee for human testing has been applied for. introductions and objectıves: the aim of this study was to examine the relationship between childs' favourite cartoon stars who can fly and falling down from a high place in two cases. methods: in this paper we presented two similar cases who were seen with a history of falling down from a high place. the first case was a -year old girl who fell down from the third floor of their apartment. on her examination it was learned that she wanted to fly like her favourite magical cartoon star girls. the second case was a -year old boy who fell down from the second floor. while falling down he was screaming to his friends that he was flying.results: on the physical examination of the first case, deformity and crepitation in right femur were found. x-rays showed right femur distal epiphysis salter harris type iv fracture. she was hospitalized due to the pneumothrax in pediatric surgery intensive care unit. the procedure of closed reduction and fixation with multiple kirschner wires was performed under general anestesia. closed body fracture in the left femur was found in case ii. introductıon: the purpose of this study was to compare the biomechanical properties of different possibilities of screw placement in multidirectional palmar fixed-angle plate in distal radius osteotomy cadaver model under loading conditions. methods: an extra-articular fracture was created in pairs of fresh frozen human cadaver radii. the specimens were randomized into four groups. all radii were plated with a volar fixed-angle plate. there were different possibilities of screw placement in the distal fragment:group a: screws were used in the distal row of the plate. group b: screws were used alternately in the distal and proximal row. group c: screws were used in the proximal row. group d: screws were used filling all screws holes in the distal and proximal row of the plate.the proximal fragment was fixed with screws each. the specimens were loaded with n under dorsal and volar bending and with n axial loading. results: group d had the highest stiffness of n/mm under axial compression and was statistically significant stiffer than the other groups. group b had a stiffness of n/mm followed by group a with n/mm. group c showed only a stiffness of n/mm. there were no statistically significant differences under dorsal and volar bending.conclusıons: occupying all screw holes in the distal fragment offered the highest stability. using only the proximal row with screws showed an unstable situation. it is therefore recommended to use at least screws in the distal fragment. perilunate dislocations are the most common type of carpal dislocation. they can be produced by high-energy injuries. the population primarily at risk is male young adults. in perilunate dislocations, the proximal articular surface of the lunate retains contact with the distal radius. the dorsal-perilunate/volar-lunate dislocation is more common. we performed a retrospective study of perilunate dislocations from to . a total of were reviewed. mean age of the patients was . (range - ). all the patients were male. the trauma mechanism was fall from height in and motor vehicle accident in . all the dislocations were dorsal-perilunate/volar-lunate dislocations. all the dislocations were together with ipsilateral scaphoid fractures. all were closed injuries and all were reduced by closed reduction maneuvers. percutaneous pinning was applied for the dislocation and scaphoid fractures. mean follow-up time was months (range - months). when compared with the non-injured wrist, there was limited range of movement in only one patient.no limitation of range of motion in the other patients could be obtained. the patients did not have pain and instability. radiologically no arthrosis of the wrist could be obtained but in all patients there was scaphoid pseudoarthrosis. functional range of motion of the wrist after a perilunate dislocation is independent of the concomitant scaphoid fractures. bostjan sluga, tomaz malovrh traumatology department, university clinical centre, ljubljana, sloveniainfective complications of tibia fractures result in nonunion, bone defects and soft tissue envelope impairment. several methods of treatment have been described to deal with bone defect including callus distraction, fibula transfer, muscle flap and bone grafting. there are many possibilities to encourage bone healing; bone morphogenic proteins, platelet rich plasma, electrical, ultrasound or shockwave stimulation and hyperbaric oxygen therapy. a patient with both tibias infected nonunion is presented. high energy trauma primarily and inadequate debridement secondarily were probably the cause of the healing complications. a middle-age man was injured in a gas explosion and suffered comminuted closed fractures of both distal tibias. after an immediate external fixation we operated him on the th day after the injury, anatomical reduction and internal fixation on both sides was done. an infection developed after weeks. ankle joint arthrodesis was necessary on one side and implant removal, repetitive debridement with bone grafting on the other. we could not cure the infection and the fracture did not heal. after years, operations, days of ciprofloxacin, days of gentamicin, days of vancomycin, days of implanted gentamicin antibiotic beds and the use of cultivated autogenous steam cells clinically evident nonunion was still present. surgery was performed again, a resection of cm of bone and callus distraction with an unilateral frame. despite a fast progress in knowledge and improvement of methods, a radical debridement, preservation or reconstruction of soft tissue coverage, systemic and local antibiotic therapy and appropriate stabilization is still a keystone in infected nonunion treatment. some people who live in some regions of our country trust in bonesetter's skills more than these ones of professional orthopaedist in the hospitals. the fact that some bonesetter's particular skills to cure the non-operative back pain seems to make them credible on closed reduction too. in this case report, right humerus proximal body fractures due to falling were discussed. the case was -year-old male. in the treatment of this case, velpau bandage, closed reduction and plaster cast-splint has been applied after that he was called to the clinic control, but he did not come to control. the parents of the case were aware of the fact he cannot raise enough the right upper extremity and he was taken along to the hospital. from his anamnesis, it has been learnt that the bonesetter has removed the castsplint and, tried to perform closed reduction. actual physical examination showed that there was an arm pain, crepitation and deformity. a diagnose has been made: there was an union right humerus proximal body fractures, so he has to be hospitalised. under general anaesthesia, closed reduction and bandage velpeau were applied. on the rd day of the hospitalisation, the case was externed and was advised to come for a polyclinic control. because of the importance of epiphysis lines of bones and of other complications from the upper extremities fractures, the treatments have to be performed by the orthopaedists or in accordance with them. about this medical issue, families should be made conscious by healthy authorities. there were women and men. the mean age was . years (range - years) and mean follow-up period was months (range - months). posterior kocher-langenbeck approach was used at patients and ilioinguinal approach was used at two patients.results: there were both column, posterior column with posterior wall, transverse with posterior wall and posterior wall fractures. anatomic reduction was obtained at patients and adequate reduction at patients according to matta criterias. harris scoring system revealed excellent at , good at , moderate at and bad at patients. over % of these patients had satisfactory function. there were any pulmonary embolism, deep infection or nonunion detected. one of four patients whom had developed osteoarthritis, managed with total arthroplasty. postoperative sciatic nerve injury was developed at one patient. conclusıon: secondary arthrosis, nonanatomic reduction, unstable fixation and nerve injuries were associated with poor results. our clinical experience for acetabulum fractures were similar to that reported previously at the literature with over % of satisfactory results sedat kocak, birsen ertekin, esma erdemir, abdullah sadik girisgin, basar cander introduction and objectives: quadriceps muscle tears are usually seen in middle-aged and older people. particularly people with chronic diseases (such as diabetes mellitus, renal failure and gout) are prone to develop quadriceps muscle ruptures. we present a case of partial rupture of the quadriceps muscle in a -year-old girl after intramuscular injections. we thought that this patient could be the youngest patient reported with a quadriceps muscle rupture. methods: patient presented to our clinic with left knee pain, limitation in knee flexion and a localized palpable swelling at the anterolateral side of thigh. there was no blunt trauma but it happened while she jumping on the sofa. in her detailed history we learnt that she had a serious upper tract respiratory infection a week ago and used some parenteral antibiotics (twice a day, intramuscular clindamycine for days).results: plain radiographies were normal. mri showed a partial tear of the vastus lateralis muscle matching with the injection sites. the patient was placed in a long leg half-cast which was maintained for weeks. she treated with conservative treatment successfully.conclusions: mr imaging is useful to diagnose and differentiate in this pathology. multiple intramuscular injections may contribute to damage muscles and make them prone to tears with muscle contractions. quadriceps muscle ruptures in children can be treated successfully with conservative treatment. twenty year old female attempted suicide by jumping from a four story high building, resulting in multiple fractures of the limbs and a complex fracture of the body of the fourth lumbar vertebra (l ) resulting in paralysis of the inferior limbs. the l fracture was treated by a neurosurgeon with the extraction of the body of the vertebra, insertion of a cage device and arthrodeses of the third and fifth vertebras using a metal plate and screws, thereby stabilizing the affected segment and decompressing the medullar channel. the approach was achieved by a general surgeon using the technique of localio, that consists in a paramedian incision of the abdomen and the dissection of the retroperitoneal space without entering the abdominal cavity, dissecting and isolating the left ureter and the main vascular structures (iliac vessels and the left iliolumbar vein) in order to allow a good exposure of the three vertebra bodies involved. the patient recovered the complete function and control over the limbs, resulting no neurological sequelae from the fracture. it is of major importance that this procedure be performed by a multidisciplinary team of surgeons, involving a neurosurgeon and a general surgeon, in this way achieving a better result and a lower risk of complications. josef märz department of surgery, regional hospital karlovy vary, czech republicabdominal ultrasonography or ct were applied to ( . %) patients with blunt trauma and ( . %) patients with penetrating trauma. one ( . %) negative laparotomy was applied to patients with blunt trauma. to splenic injuries was splenectomy. sigmoid perforation, diaphragm rupture, bladder rupture were observed and were fixed primarily. one patient died during surgery due to liver and vena cava injuries. patients with penetrating injury were operated due to firearm injury in ( %) and stab wound in ( %), mortality was not. negative laparotomy was applied to ( . %) patients. multiorgan injury was observed in patients. tube thoracostomy was inserted to patients. of the intestine injuries and stomach injury was fixed primarily. two resection and anastomose and three diversionary ostomy were done. conclusion: proper examination must be considered according to the formation of trauma. _ imaging methods have been used less in penetrating trauma, and negative laparotomy is reported to be applied more than in cases of blunt traumas introductıon: chest tube insertion is frequently used by thoracoabdominal surgeons in urgent conditions. occasionally, this invasive procedure may be associated with lethal complications in inexperienced hands. in this study, we analyzed patients with visceral and/or diaphragmatic injuries due to chest tube insertions. methods: six patients with diaphragmatic and visceral injuries subsequent to chest tube insertions between and were evaluated. the diagnosis was established with roentgenogram, biochemistry of the fluid drained from the chest tube and confirmed with computerized tomography in all patients. results: pleural effusion accompanying respiratory distress was the main indication for chest tube insertion in all patients. in five patients, coexistent gastric perforations with diaphragmatic ruptures were detected, also the esophagus was additionally perforated in one patient. partial gastrectomies were performed in three patients, whereas total gastrectomy in one and primary repair required in two patients respectively. five of the patients died from septic complications. the only survived patients with early diagnosis and primary repair was discharged from the hospital on the th day. conclusıon: penetration of a drainage tube through viscera is a wellrecognized but seldom reported phenomenon. in the majority of patients with diaphragmatic rupture, abnormalities can be found at initial chest radiography. if transdiaphragmatic herniation is missing, diaphragmatic rupture is difficult to diagnose by chest radiography alone. computed tomography is often necessary to reveal the correct diagnosis. early diagnosis and treatment are extremely important in the management of these patients. bronchobiliary fistula is a rare condition, arising as a complication of hydatid disease of the liver, hepatic tuberculosis, hepatic malignancy, chronic pancreatitis, hepatic trauma or surgery. conservative treatment is directed at non-surgical approaches of relieving biliary obstruction to allow for normal flow of bile into the duodenum via endoscopy or percutaneous routes. however in complicated cases which failed conservative non-surgical therapy, surgical intervention is usually required. we report a -year-old man who presented with bilioptysis from a bronchobiliary fistula resulting from firearm injury after days. for his current admission, the patient reported a -day history of cough productive of yellow-green sputum coupled with fevers and malaise.this was successfully treated surgically with a right medial lobectomy and t-tube drainage. paget-von schroetter syndrome(pss) refers to spontaneous thrombosis of the subclavian vein and constitutes . - % of all venous thromboses. it is prevalent among young and healthy adult males who engage in sports. a -year-old male presented with pain and swelling of the left arm after a sequence of intense, repetitive weight lifting exercises. upon questioning, he disclosed that he had been engaged with weight lifting for a long time and had complaints for a while. bases on these findings, upper-extremity effort thrombosis was suspected. contrast-enhanced mr angiography revealed near-complete occlusion of the proximal left subclavian vein and collateral formations in the distal were observed. color doppler us showed a heterogeneous thrombotic mass that filled almost the entire proximal segment of the left subclavian vein thrombosis extended into the proximal segment of the left internal jugular vein. furthermore, extensive venous collateral formations were present the left proximal cervical localization. both mr angiographic and sonographic findings were consistent with pss. as the patient had already developed extensive venous collaterals, no surgical intervention was performed. instead, treatment with lowmolecular weight heparin and anticoagulants, was initiated and was continued along with the follow-up for bleeding parameters. as of years clinical follow-up the patient is doing well, and treatment is continued with oral anticoagulants and acetylsalicylic. pss should be considered in the differential diagnosis of effort induced upper extremity pain and swelling. conservative non-operative treatment is acceptable and can be successfully used with favorable long-term outcomes. although, blunt trauma of the extremities is a common diagnosis in emergency clinics, compartment syndrome associated with vascular injury following blunt trauma may be difficult to diagnose. urgent diagnosis and treatment of compartment syndrome is of particular importance for limb salvage or even to save the patients' life. years old male patient was referred to emergency clinic due to blunt trauma of the right lower extremity. right thigh was echimotic and swollen. pallor, coldness and severe pain were present at the lower part of the trauma level. distal pulses were not palpable. acute compartment syndrome of the right thigh was diagnosed that led to an emergent operation. intraoperatively, popliteal artery rupture was diagnosed and repaired with end-to-end anastomosis. fasciotomies were performed at the anteromedial and anterolateral portions of the right leg and anteromedial part of the thigh for the treatment of compartment syndrome. in early postoperative period, distal pulses were palpable. preoperatively present pallor and coldness improved in the first few h. fasciotomies were closed with skin grafts at the th postoperative day. patient was discharged at the th postoperative day with palpable distal pulses and failure of dorsal flexion of the right ankle representing mild neurological injury. possible vascular injury should be kept in mind in a patient with compartment syndrome following blunt trauma of extremities. success of surgical repair depends on the early diagnosis and treatment. late repair may result in neurological complications or even the loss of extremities.conclusıon: acute mesenteric ischemia is highly mortal emergency which should always be suspected in elderly patients with cardiac disease suffering from abdominal pain. acute ischemia of the lower member after injury by firearm -case report patient with years, male sex, admitted at the urgency department after injury of the left lower member by firearm. at the admission presented loss of substance and hemorrhage in the medial and lateral faces of left leg and foot with signs of ischemia. an arteriography of the member was carried out showing infrapopliteal arterial lesions of the three axes. during surgery, fracture and losses of peroneum substance was observed with macroscopic tibial and peroneal common nerves integrities. he was submitted to tibial interposition grafts with subsequent reversed contralateral internal saphena vein bypass.in the th postoperative day it was carried out surgical debridement and plastia with partial skin graft. he presented good cicatricial evolution, with hospital discharge days after, oriented to external consultations of vascular surgery, plastic surgery, physical/ rehabilitation medicine and pain consult. five months after surgery, pain was controlled with the medication instituted, with improvement of the left lower member limitations with physiotherapy, good cicatricial evolution and posterior tibial and dorsalis pedis pulses palpables. dıscussıon: the incidence of arterial wounds following penetrating injury of the members is %. the vascular trauma occurs more frequently in the lower extremities, being the most common clinical presentation acute isquemia. the most frequent causes are vehicle accidents, falls and firearm wounds. in the united states, injuries by firearm represents the first cause of death in young individuals of male sex. the arterial bellow-knee injuries by firearm remain like a challenge, with an associated rate of amputation of to %. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugaltrauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease.recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the next stage of treatment implies surgery. the dstc course, and other similar ones, allow the teaching of surgical damage control to surgeons. in this courses, the surgeon not only learns the theoretical basis of the surgical techniques but also acquires the skills to perform them. more importantly, he learns trauma pathophysiology, so he can perform the difficult task of surgical decision-making. using the same computer-animated drawing technique as in a previous video (primary survey), the authors continue to present a trauma patient, after the stabilization of the primary survey, at the operating room. the patient has a severe abdominal trauma and needs damage control of his lesions, for he is already suffering from the deadly triad: hypocoagulation, acidosis and hypothermia. a year-old male patient was admitted to our hospital for severe abdominal pain. thoracoabdominopelvic ct scan demonstrated incarcerated bowel loops in the right hemithorax. strangulated transverse colon segment and omentum through the defect at the dome of right diaphragma was found at diagnostic laparoscopy. diaphragmatic hernia was primarily repaired with endostitches, and supported with a polipropylene mesh fixed with endotuckers subsequent to reduction of strangulated organs to the abdomen. resection of necrotic intrabdominal organs and a side-to-side stapled colocolonic anastomosis was performed through a subcostal minilaparotomy. drainage of right hemithorax was provided with a tube thoracostomy. the patient was discharged on the th post-operative day without any major complications. introduction and objectıves: single incision laparoscopic procedures are accepted as a step towards pure natural orifice transluminal endoscopic surgery. however, loss of requirement of any perforation of visceral organ and an endoscopic equipment make this technique more popular and easily performable. here in we report our first appendectomy case who was performed with single incision laparoscopic surgery (sils) technique. methods: years old male patient with the diagnosis of acute appendisitis underwent single incision laparoscopic appendectomy. a key: cord- -zhmnfd w authors: straif-bourgeois, susanne; ratard, raoult title: infectious disease epidemiology date: journal: handbook of epidemiology doi: . / - - - - _ sha: doc_id: cord_uid: zhmnfd w the following chapter intends to give the reader an overview of the current field of applied infectious disease epidemiology. prevention of disease by breaking the chain of transmission has traditionally been the main purpose of infectious disease epidemiology. while this goal remains the same, the picture of infectious diseases is changing. new pathogens are identified and already known disease agents are changing their behavior. the world population is aging; more people develop underlying disease conditions and are therefore more susceptible to certain infectious diseases or have long term sequelae after being infected. the following chapter intends to give the reader an overview of the current field of applied infectious disease epidemiology. prevention of disease by breaking the chain of transmission has traditionally been the main purpose of infectious disease epidemiology. while this goal remains the same, the picture of infectious diseases is changing. new pathogens are identified and already known disease agents are changing their behavior. the world population is aging; more people develop underlying disease conditions and are therefore more susceptible to certain infectious diseases or have long term sequelae after being infected. infectious diseases are not restricted to certain geographic areas anymore because of the increasing numbers of world travelers and a worldwide food distribution. the fear of a bioterrorist attack adds a new dimension in infectious disease epidemiology, and health departments enhance their surveillance systems for early detection of suspicious disease clusters and for agents used as weapons of mass destruction. improvements in laboratory techniques and mapping tools help to expand the knowledge of transmission of disease agents and enhanced surveillance techniques are feasible as a result of software progress and reporting of diseases via secure internet sites. surveillance and outbreak investigations remain the major responsibilities in public health departments. epidemiologic methods and principles are still the basis for these tasks but surveillance techniques and outbreak investigation are changing and adapting to improvements and the expanded knowledge. conducting surveys is a useful way to gather information on diseases where surveillance data or other data sources are not available, especially when dealing with emerging or re-emerging pathogens. program evaluation is an important tool to systematically evaluate the effectiveness of intervention or prevention programs for infectious diseases. infectious diseases are a major cause of human suffering in terms of both morbidity and mortality. in , out of an estimated total of million deaths, million were due to infectious diseases (who a,b) . the most common cause of infectious disease deaths were pneumonia ( million), diarrhea ( million) followed by tuberculosis, malaria, aids and hepatitis b. not surprisingly, there is a large imbalance in diseases between developing and industrialized countries (see table . ). morbidity due to infectious diseases is very common in spite of the progress accomplished in recent decades. even in industrialized countries, the prevalence of infection is very high for some infectious agents. serologic surveys found that by young adulthood the prevalence of antibodies was % against herpes simplex virus type , - % against type , % against human herpes virus, % against hepatitis a, % against hepatitis c, - % against hepatitis b, and % against chlamydia pneumoniae (american academy of pediatrics ; mandell et al. ) . annually, approximately , , episodes of diarrhea leading to , hospitalizations and deaths occur among adults in the united states (mounts et al. ). the center for disease control and prevention (cdc) estimates that each year million people in the us get sick, more than , are hospitalized and die as a result of foodborne illnesses (cdc ) . every year influenza circulates widely, infecting from % to % of the world population. the importance of infectious disease epidemiology for prevention it is often said that epidemiology is the basic science of preventive medicine. to prevent diseases it is important to understand the causative agents, risk factors and circumstances that lead to a specific disease. this is even more important for infectious disease prevention, since simple interventions may break the chain of transmission. preventing cardiovascular diseases or cancer is much more difficult because it usually requires multiple long term interventions requiring lifestyle changes and behavior modification, which are difficult to achieve. in , the american commission of yellow fever, headed by walter reed, was sent to cuba. the commission showed that the infective agent was transmitted by the mosquito aedes aegypti. this information was used by the then surgeon general of the us army william gorgas, to clean up the year old focus of yellow fever in havana by using mosquito proofing or oiling of the larval habitat, dusting houses with pyrethrum powder and isolating suspects under a mosquito net. this rapidly reduced the number of cases in havana from in to in (goodwin ) . a complete understanding of the causative agent and transmission is always useful but not absolutely necessary. the most famous example is that of john snow who was able to link cholera transmission to water contamination during the london cholera epidemic of by comparing the deaths from those households served by the southwark & vauxhall company versus those served by another water company. john snow further confirmed his hypothesis by the experiment of removing the broad street pump handle (wills a ). over the past three decades, more than new pathogens have been identified, some of them with global importance: bartonella henselae, borrelia burgdorferi, campylobacter, cryptosporidium, cyclospora, ebola virus, escherichia coli :h , ehrlichia, hantaan virus, helicobacter, hendra virus, hepatitis c and e, hiv, human herpesvirus and , human metapneumovirus, legionella, new variant creutzfeldt-jakob disease agent, nipah virus, parvovirus b , rotavirus, severe acute respiratory syndrome (sars) etc.. while there are specific causative agents for infectious diseases, these agents may undergo some changes over time. the last major outbreak of pneumonic plague in the world occurred in manchuria in . this scourge, which had decimated humans for centuries, is no longer a major threat. the plague bacillus cannot survive long outside its animal host (humans, rodents, fleas) because it lost the ability to complete the krebs cycle on its own. while it can only survive in its hosts, the plague bacillus also destroys its hosts rapidly. as long as susceptible hosts were abundant, plague did prosper. when environmental conditions became less favorable (lesser opportunities to sustain the host to host cycles), less virulent strains had a selective advantage (wills b) . the influenza virus is the best example of an agent able to undergo changes leading to renewed ability to infect populations that had been already infected and immune. the influenza virus is a single stranded rna virus with a lipophilic envelope. two important glycoproteins from the envelope are the hemagglutinin (ha) and neuraminidase (na). the ha protein is able to agglutinate red blood cells (hence its name). this protein is important as it is a major antigen for eliciting neutralizing antibodies. antigenic drift is a minor change in surface antigens that result from point mutations in a gene segment. antigenic drift may result in epidemics, since incomplete protection remains from past exposures to similar viruses. antigenic shift is a major change in one or both surface antigens (h and|or n) that occurs at varying intervals. antigenic shifts are probably due to genetic recombination (an exchange of a gene segment) between influenza a viruses, usually those that affect humans and birds. an antigenic shift may result in a worldwide pandemic if the virus can be efficiently transmitted from person to person. in the past three decades throughout the world, there has been a shift towards an increase in the population of individuals at high risk for infectious diseases. in industrialized nations, the increase in longevity leads to higher proportion of the elderly population who are more prone to acquiring infectious diseases and developing life threatening complications. for example, a west nile virus (wnv) infection is usually asymptomatic or causes a mild illness (west nile fever); rarely does it cause a severe neuro-invasive disease. in the epidemic of west nile in louisiana, the incidence of neuro-invasive disease increased progressively from . per , in the to age group to per , in the to year old age group and jumped to per , in the age group and older. mortality rates showed the same pattern, a gradual increase to . per , in the to age group with a sudden jump to per , for the oldest age group of and older. improvement in health care in industrialized nations has caused an increase in the number of immune-deficient individuals, be it cancer survivors, transplant patients or people on immuno-suppressive drugs for long term auto-immune diseases. some of the conditions that may increase susceptibility to infectious diseases are: cancers, particularly patients on chemo or radiotherapy, leukemia, lymphoma, hodgkin's disease, immune suppression (hiv infection), long term steroid use, liver disease, hemochromatosis, diabetes, alcoholism, chronic kidney disease and dialysis patients. for example persons with liver disease are times more likely to develop vibrio vulnificus infections than are persons without liver disease. some of these infections may be severe, leading to death. in developing countries a major shift in population susceptibility is associated with the high prevalence of immune deficiencies due to hiv infections and aids. in botswana which has a high prevalence of hiv (sentinel surveillance revealed hiv seroprevalence rates of % among women presenting for routine antenatal care), tuberculosis rates increased from per , in to per , in (lockman et al. ) while before the hiv|aids epidemics, rates above were very rare. changes in lifestyles have increased opportunities for the transmission of infectious disease agents in populations previously at low risk. intravascular drug injections have increased the transmission of agents present in blood and body fluids (e.g. hiv, hepatitis b and c). consumption of raw fish, shell fish and ethnic food expanded the area of distribution of some parasitic diseases. air travel allows people to be infected in a country and be half-way around the globe before becoming contagious. by the same token, insects and other vectors have become opportunistic global travelers. aedes albopictus, the asian tiger mosquito, was thus imported in to houston, texas inside japanese tires. subsequently, it has invaded us states. with the advent of nucleic acid tests, it has become possible to detect the presence of infectious disease agents in the air and environmental surfaces. for example, the use of air samplers and polymerase chain reaction analysis has shown that bordetella pertussis dna can be found in the air surrounding patients with b. pertussis infection, providing further evidence of airborne spread (aintablian et al. ) and thus leading to re-evaluate the precautions to be taken. however the presence of nucleic acids in an environmental medium does not automatically mean that transmission will occur. further studies are necessary to determine the significance of such findings. infectious disease agents, when used in bioterrorism events, have often been reengineered to have different physical properties and are used in quantities not usually experienced in natural events. there is little experience and knowledge about the human body's response to large doses of an infectious agent inhaled in aerosol particles that are able to be inhaled deep into lung alveolae. during the anthrax letter event, there was considerable discussion about incubation period, recommended duration of prophylaxis, and minimum infectious dose. this lack of knowledge base has led to confusion in recommendations being made. although the basics of infectious disease epidemiology have not changed and the discipline remains strongly anchored on some basic principles, technological developments such as improved laboratory methods and enhanced use of informatics (such as advanced mapping tools, web based reporting systems and statistical analytical software) have greatly expanded the field of infectious disease epidemiology. molecular techniques are being used more and more as a means to analyze epidemiological relationships between microorganisms. hence the term molecular epidemiology refers to epidemiologic research studies made at the molecular level. the main microbial techniques used, target plasmids and chromosomes. more specifically, plasmid fingerprinting and plasmid restriction endonuclease (rea) digestion, chromosomal analysis including pulse field gel electrophoresis (pfge), restriction fragment length polymorphism (rflp), multi-locus sequence type (mlst) and spa typing to name a few of these techniques. polymerase chain reaction (pcr) is used to amplify the quantity of genomic material present in the specimen. real-time pcr detection of infectious agents is now possible in a few hours. these techniques are becoming more widely used, even in public health laboratories for routine investigations. it is beyond the scope of this text to describe these methods in more detail. applications of molecular epidemiology methods have completely changed the knowledge about infectious disease transmission for many microorganisms. the main application is within outbreak investigations. being able to characterize the nucleic acid of the microorganisms permits an understanding of how the different cases relate to each other. molecular epidemiology methods have clarified the controversy about the origin of tuberculosis cases: is it an endogenous (reactivation) or exogenous (reinfection) origin? endogenous origin postulates that mycobacterium tuberculosis can remain alive in the human host for a lifetime and can start multiplying and producing lesions. on the other hand exogenous origin theory postulates that reinfection plays a role in the development of tuberculosis. the immunity provided by the initial infection is not strong enough to prevent another exposure to mycobacterium tuberculosis and a new infection leads to disease. in countries with low tuberculosis transmission, for example the netherlands, most strains have unique rflp fingerprints. each infection is unique and there are hardly any clusters of infections resulting from a common source. most cases are the result of reactivation. this is in contrast with areas of high endemicity where long chains of transmission can be identified with few rflp fingerprinting patterns (alland et al. ) . in some areas, up to % of tuberculosis cases are the result of reinfection. numerous new immunoassays have been developed. they depend on an antigenantibody reaction, either using a test antibody to detect an antigen in the patient's specimen or using a test antigen to detect an antibody in the patient's specimen. an indicator system is used to show that the reaction has taken place and to quantify the amount of patient antigen or antibody. the indicator can be a radioactive molecule (radioimmunoassay [ria]), a fluorescent molecule (fluorescent immunoassay [fia]), a molecule with an attached enzyme that catalyzes a color reaction (enzyme-linked immunoassay [elisa or eia]), or a particle coated with antigen or antibody that produces an agglutination (latex particle agglutination [la] ). the reaction can be a simple antigen|antibody reaction or a "sandwich" immunoassay where the antigen is "captured" and a second "read out" antibody attaches to the captured antigen. the antibody used may be polyclonal (i.e. a mixture of immunoglobulin molecules secreted against a specific antigen, each recognizing a different epitope) or monoclonal (i.e. immunoglobulin molecules of single-epitope specificity that are secreted by a clone of b cells). it may be directed against an antigen on an epitope (i.e. a particular site within a macromolecule to which a specific antibody binds). plotting diseases on a map is one of the very basic methods epidemiologists do routinely. as early as john snow, suspecting water as a cause of cholera, plotted the cases of cholera in the districts of golden square, st. james and berwick, in london. the cases seemed to be centered around the broad street pump and less dense around other pumps. the map supplemented by other observations led to the experiment of removing the handle on the broad street pump and subsequent confirmation of his hypothesis (snow ) . geographical information systems (gis) have been a very useful tool in infectious disease research. gis are software programs allowing for integration of a data bank with spatial information. the mapping component includes physical layout of the land, towns, buildings, roads, administrative boundaries, zip codes etc. data may be linked to specific locations in the physical maps or to specific aggregates. a gis system includes tools for spatial analysis. climate, vegetation and other data may be obtained through remote sensing and combined with epidemiologic data to predict vector occurrence. however, these tools should be used with caution. they can be useful to generate hypotheses and identify possible associations between risk of disease and environmental exposures. because of potential bias, mapping should never be considered as more than an initial step in the investigation of an association. "the bright color palettes tend to silence a statistical conscience about fortuitous differences in the raw data" (boelaert et al. ) . for statistical methods in geographical epidemiology see chap. ii. of this handbook. web based reporting, use of computer programs and developments of sophisticated reporting and analytical software have revolutionized epidemiologic data collection and analysis. these tools have provided the ability to collect large amounts of data and handle large databases. however this has not been without risks. it remains crucial to understand the intricacies of data collected to avoid misinterpretation. for example, one should be aware that diseases and syndromes are initially coded by a person who may not be very software proficient, using shortcuts and otherwise could enter data of poor quality. what are the questions to be answered? too often one sees epidemiologists and statisticians preparing questionnaires, carrying out surveys, gathering surveillance information, processing data and producing reports, tables, charts and graphs in a routine fashion. epidemiology describes the distribution of health outcomes and determinants for a purpose. it is important to question the goals and objectives of all epidemiologic activities and tailor these activities to meet these objectives. the description of disease patterns includes analysis of demographic, geographical, social, seasonal and other risk factors. age groups to be used differ depending on the disease e.g. diseases affecting young children should have numerous age groups among children; sexually transmitted diseases require detailed age groups in late adolescence and early adulthood. younger age groups may be lumped together for diseases affecting mainly the elderly. gender categorization, while important for sexually transmitted diseases and other diseases with a large gender gap (such as tuberculosis), may not be important for numerous other diseases. geographical distribution is important to describe diseases linked to environmental conditions but may not be so useful for other diseases. surveillance, both active and passive, is the systematic collection of data pertaining to the occurrence of specific diseases, the analysis and interpretation of these data, and the dissemination of consolidated and processed information to contributors to the program and other interested persons (cdc b). in a passive surveillance system the surveillance agency has devised and put a system in place. after the placement, the recipient waits for the provider of care to report. passive case detection has been used for mortality and morbidity data for decades. it is almost universal. most countries have an epidemiology section in the health department that is charged with centralizing the data in a national disease surveillance system collecting mortality and morbidity data. in theory, a passive surveillance system provides a thorough coverage through space and time and gives a thorough representation of the situation. practically, compliance with reporting is often irregular and incomplete. in fact, the main flaws in passive case detection are incomplete reporting and inconsistencies in case definitions. the main advantages are the low cost of such a program and the sustained collection of data over decades. the purpose is to produce routine descriptive data on communicable diseases, generate hypotheses and prompt more elaborate epidemiologic studies designed to evaluate prevention activities. some conditions must be met to maximize compliance with reporting: . make reporting easy: provide easy to consult lists of reportable diseases, provide pre-stamped cards for reporting, provide telephone or fax reporting facilities. . do not require extensive information: name, age, sex, residence, diagnosis. some diseases may include data on exposure, symptoms, method of diagnosis etc. . maintain confidentiality and assure reporters that confidentiality will be respected. . convince reporters that reporting is essential: provide feedback; show how the data are used for better prevention. confidentiality of data is essential, particularly for those reporting health care providers who are subject to very strict confidentiality laws. any suspicion of failure of maintaining secure data would rapidly ruin a passive surveillance program. in an active surveillance system, the recipient will actually take some action to identify the cases. in an active surveillance program, the public health agency organizes a system by searching for cases or maintaining a periodic contact with providers. regular contacting boosts the compliance of the providers. providers are health agencies but also as in passive case detection, there may be day care centers, schools, long term care facilities, summer camps, resorts, and even public involvement. the agency takes the step to contact the health providers (all of them or a carefully selected sample) and requests reports from them at regular intervals. thus no reports are missing. active surveillance has several advantages: it allows the collection of more information. a provider sees that the recipient agency is more committed to surveillance and is therefore more willing to invest more time her|himself. it allows direct communication and opportunities to clarify definitions or any other problems that may have arisen. active surveillance provides much better, more uniform data than passive case detection but active case detection is much more expensive (see tables . and . ). active surveillance systems are usually designed when a passive system is deemed insufficient to accomplish the goals of disease monitoring. this type of surveillance is reserved for special programs, usually when it is important to identify every single case of a disease. active surveillance is implemented in the final phases of an eradication program: smallpox eradication, poliomyelitis eradication, guinea worm eradication and malaria eradication in some countries. active surveillance is also the best approach in epidemic or outbreak investigations to elicit all cases. in the smallpox eradication program, survey agents visited providers, asking about suspected cases and actually investigating each suspected case. in polio eradication programs, all cases of acute flaccid paralysis are investigated. in malaria eradication programs and some malaria control programs, malaria control agents go from house to house asking who has fever or had fever recently (in the past week or month for example). a blood smear is collected from those with fever. a case register is a complete list of all the cases of a particular disease in a definite area over a certain time period. registers are used to collect data on infections over long periods of time. registers should be population based, detailed and complete. a register will show an unduplicated count of cases. they are especially useful for long term diseases, diseases that may relapse or recur and diseases for which the same cases will consult several providers and therefore would be reported on more than one occasion. case registers contain identifiers, locating information, disease, treatment, outcome and follow-up information as well as contact management information. they are an excellent source of information for epidemiologic studies. in disease control, case registers are indispensable tools for follow up of chronic infections disease such as tuberculosis and leprosy. the contents and quality of a case register determine its usefulness. it should contain patient identifiers with names (all names), age, sex, place and date of birth, complete address with directions on how to reach the patient, name and address of a "stable" relative that knows the patient's whereabouts, diagnosis information with disease classification, brief clinical description (short categories are better than detailed descriptions), degree of infectiousness (bacteriological, serological results), circumstances of detection, initial treatment and response with specific dose, notes on compliance, side effects, clinical response, follow-up information with clinical response, treatment regimen, compliance, side effects, locating information; for some diseases contact information is also useful. updating a register is a difficult task. it requires cooperation from numerous persons. care must be taken to maintain the quality of data. it is important to only request pertinent information for program evaluation or information that would remind users to collect data or to perform an exam. for example, if compliance is often a neglected issue, include a question on compliance. further details concerning the use of registries in general are given in chap. i. of this handbook. sentinel disease surveillance for sentinel disease surveillance, only a sample of health providers is used. the sample is selected according to the objectives of the surveillance program. providers most likely to serve the population affected by the infection are selected, for example child health clinics and pediatricians should be selected for surveillance of childhood diseases. a sentinel system allows cost reduction and is combined with active surveillance. a typical surveillance program for influenza infections includes a selected numbers of general practitioners who are called every week to obtain the number of cases presented to them. this program may include the collection of samples for viral cultures or other diagnostic techniques. such a level of surveillance would be impossible to maintain on the national level. surveillance systems are evaluated on the following considerations (cdc b): usefulness: some surveillance systems are routine programs that collect data and publish results; however it appears that they have no useful purpose -no conclusions are reached, no recommendations are made. a successful surveillance system would provide information used for preventive purposes. sensitivity or the ability to identify every single case of disease is particularly important for outbreak investigations and eradication programs. predictive value positive (pvp) is the proportion of reported cases that actually have the health-related event under surveillance. low pvp values mean that non-cases might be investigated, outbreaks may be exaggerated or pseudo outbreaks may even be investigated. misclassification of cases may corrupt the etiologic investigations and lead to erroneous conclusions. unnecessary interventions and undue concern in the population under surveillance may result. representativeness ensures that the occurrence and distribution of cases accurately represent the real situation in the population. simplicity is essential to gain acceptance, particularly when relying on outside sources for reporting. flexibility is necessary to adapt to changes in epidemiologic patterns, laboratory methodology, operating conditions, funding or reporting sources. data quality is evaluated by the data completeness (blank or unknown variable values) and validity of data recorded (cf. chap. i. of this handbook). acceptability is shown in the participation of providers in the system. timeliness is more important in surveillance of epidemics. stability refers to the reliability (i.e., the ability to collect, manage and provide data properly without failure) and availability (the ability to be operational when it is needed) of the public health surveillance system. the major elements of a surveillance system as summarized by who are: mortality registration, morbidity reporting, epidemic reporting, laboratory investigations, individual case investigations, epidemic field investigations, surveys, animal reservoir and vector distribution studies, biologics and drug utilization, knowledge of the population and the environment. traditional surveillance methods rely on counting deaths and cases of diseases. however, these data represent only a small part of the global picture of infectious disease problems. mortality registration was one of the first elements of surveillance implemented. the earliest quantitative data available on infectious disease is about mortality. the evolution of tuberculosis in the us for example, can only be traced through its mortality. mortality data are influenced by the occurrence of disease but also by the availability and efficacy of treatment. thus mortality cannot always be used to evaluate the trend of disease occurrence. reporting of infectious diseases is one of the most common requirements around the world. a list of notifiable diseases is established on a national or regional level. the numbers of conditions vary; it ranges usually from to conditions. in general, a law requires that health facility staff, particularly physicians and laboratories, report these conditions with guaranteed confidentiality. it is also useful to have other non-health related entities report suspected communicable diseases such as day care centers, schools, restaurants, long term care facilities, summer camps and resorts. regulations on mandatory reporting are often difficult to enforce. voluntary compliance by the institution's personnel is necessary. reporting may be done in writing, by phone or electronically in the most advanced system. since most infectious diseases are confirmed by a laboratory test, reporting by the laboratory may be more reliable. the advantage of laboratory reporting is the ability to computerize the reporting system. computer programs may be set up to automatically report a defined set of tests and results. for some infectious diseases, only clinical diagnoses are made. these syndromes may be the consequences of a large number of different microorganisms for which laboratory confirmation is impractical. when public or physician attention is directed at a specific disease, reporting may be biased. when there is an epidemic or when the press focuses on a particular disease, patients are more prone to look for medical care and physicians are more likely to report. reporting rates were evaluated in several studies. in the us, studies show report rates of % for viral hepatitis, hemophilus influenzae %, meningococcal meningitis % and shigellosis %. it is important to have a standardized set of definitions available to providers. without standardized definitions, a surveillance system may be counting different entities from one provider to another. the variability may be such that the epidemiologic information obtained is meaningless. most case definitions in infectious disease epidemiology are based on laboratory tests, however some clinical syndromes such as toxic shock syndrome do not have confirmatory laboratory tests. most case definitions include a brief clinical description useful to differentiate active disease from colonization or asymptomatic infection. some diseases are diagnosed based on epidemiologic data. as a result many case definitions for childhood vaccine preventable diseases and foodborne diseases include epidemiologic criteria (e.g., exposure to probable or confirmed cases of disease or to a point source of infection). in some instances, the anatomic site of infection may be important; for example, respiratory diphtheria is notifiable, whereas cutaneous diphtheria is not (cdc ) . cases are classified as a confirmed case, a probable or a suspected case. an epidemiologically linked case is a case in which ) the patient has had contact with one or more persons who either have|had the disease or have been exposed to a point source of infection (including confirmed cases) and ) transmission of the agent by the usual modes is plausible. a case may be considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission is laboratory confirmed. probable cases have specified laboratory results that are consistent with the diagnosis yet do not meet the criteria for laboratory confirmation. suspected cases are usually cases missing some important information in order to be classified as a probable or confirmed case. case definitions are not diagnoses. the usefulness of public health surveillance data depends on its uniformity, simplicity and timeliness. case definitions establish uniform criteria for disease reporting and should not be used as the sole criteria for establishing clinical diagnoses, determining the standard of care necessary for a particular patient, setting guidelines for quality assurance, or providing standards for reimbursement. use of additional clinical, epidemiological and laboratory data may enable a physician to diagnose a disease even though the formal surveillance case definition may not be met. surveillance programs collect data on the overt cases diagnosed by the health care system. however these cases may not be the most important links in the chain of transmission. cases reported are only the tip of the iceberg. they may not at all be representative of the true endemicity of an infectious disease. there is a continuous process leading to an infectious disease: exposed, colonized, incubating, sick, clinical form, convalescing, cured. even among those who have overt disease there are several disease stages that may not be included in a surveillance system: some have symptoms but do not seek medical attention some do get medical attention but do not get diagnosed or get misdiagnosed some get diagnosed but do not get reported cases reported cases diagnosed but not reported cases who seek medical attention but were not diagnosed cases who were symptomatic but did not seek medical attention cases who were not symptomatic infectious disease cases play different roles in the epidemiology of an infectious disease; some individuals are the indicators (most symptomatic), some are the reservoir of microorganisms (usually asymptomatic, not very sick), some are amplifiers (responsible for most of the transmission), some are the victims (those who develop severe long term complications). depending on the specific disease and the purpose of the surveillance program, different disease stages should be reported. for example in a program to prevent rabies in humans exposure to a suspect rabid animal (usually a bite) needs to be reported. at the stage where the case is a suspect, prevention will no longer be effective. for bioterrorism events, reporting of suspects is of paramount importance to minimize consequences. waiting for confirmation causes too long of a delay. in the time necessary to confirm cases, opportunities to prevent co-infections may be lost and secondary cases may already be incubating, depending on the transmissibility of the disease. surveillance for west nile viral infections best rests on the reporting of neuroinvasive disease. case reports of neuro invasive diseases are a better indicator than west nile infection or west nile fever cases that are often benign, go undiagnosed and are reported haphazardly. for gonorrhea, young males are the indicators because of the intensity of symptoms. young females are the main reservoir because of the high proportion of asymptomatic infections. females of reproductive age are the victims because of pelvic invasive disease (pid) and sterility. a surveillance program for hepatitis b that only would include symptomatic cases of hepatitis b could be misleading. a country with high transmission of hepatitis b from mother to children would have a large proportion of infected newborn becoming asymptomatic carriers and a major source of infection during their lifetime. typically in countries with poor reporting of symptomatic hepatitis, the reporting of acute cases of hepatitis b would be extremely low in spite of high endemicity which would result in high rates of chronic hepatitis and hepatic carcinoma. most morbidity reporting collects data about individual cases. reporting of individual cases includes demographic and risk factor data which are analyzed for descriptive epidemiology and for implementation of preventive actions. for example, any investigation leading to contact identification and prophylaxis requires a start from individual cases. however, identification of individuals may be unnecessary and aggregate data sufficient for some specific epidemiologic purposes. monitoring an influenza epidemic for example, can be done with aggregate data. obtaining individual case information would be impractical since it would be too time consuming to collect detailed demographics on such a large number of cases. aggregate data from sentinel sites consists of a number of influenza-like illnesses by age group and the total number of consultants or the total number of 'participants' to be used as denominators. such data is useful to identify trends and determine the extent of the epidemic and geographic distribution. collection of aggregate data of the proportion of school children by age group and sex is a useful predictive tool to identify urinary schistosomiasis endemic areas (lengeler et al. ) without having to collect data on individual school children. epidemics of severe diseases are almost always reported. this is not the case for epidemics of milder diseases such as rashes or diarrheal diseases. many countries do not want to report an outbreak of disease that would cast a negative light on the countries. for example, many countries that are tourism dependent do not report cholera or plague cases. some countries did not report aids cases for a long time. case investigations are usually not undertaken for individual cases unless the disease is of major importance such as hemorrhagic fever, polio, rabies, yellow fever, any disease that has been eradicated and any disease that is usually not endemic in the area. outbreaks or changes in the distribution pattern of infectious diseases should be investigated and these investigations should be compiled in a comprehensive system to detect trends. while the total number of infectious diseases may remain the same, changes may occur in the distribution of cases from sporadic to focal outbreaks. for example the distribution of wnv cases in louisiana shifted from mostly focal outbreaks the first year the west nile virus arrived in the state in , to mostly sporadic cases the following year in (see fig. . ) . surveys are a very commonly used tool in public health, particularly in developing countries where routine surveillance is often inadequate (cf. chap. iv. of this handbook). survey data needs to be part of a comprehensive surveillance database. one will acquire a better picture from one or a series of well constructed surveys than from poorly collected surveillance data. surveys are used in control programs designed to control major endemic diseases: spleen and parasite surveys for malaria, parasite in urine and stools for schistosomiasis, clinical surveys for leprosy or guinea-worm disease and skin test surveys for tuberculosis. surveillance of microbial strains is designed to monitor, through active laboratory based surveillance, the bacterial and viral strains isolated. examples of these systems are: in the us, the pulsenet program is a network of public health laboratories that performs dna fingerprinting of bacteria causing foodborne illnesses (swaminathan et al. ). molecular sub-typing methods must be standardized to allow comparisons of strains and the building of a meaningful data bank. the method used in pulsenet is pulse field gel electrophoresis (pfge). the use of standardized subtyping methods has allowed isolates to be compared from different parts of the country, enabling recognition of nationwide outbreaks attributable to a common source of infection, particularly those in which cases are geographically separated. the us national antimicrobial resistance monitoring system (narms) for enteric bacteria is a collaboration between cdc, participating state and local health departments and the us food and drug administration (fda) to monitor antimicrobial resistance among foodborne enteric bacteria isolated from humans. narms data are also used to provide platforms for additional studies including field investigations and molecular characterization of resistance determinants and to guide efforts to mitigate antimicrobial resistance (cdc ) . monitoring of antimicrobial resistance is routinely done by requiring laboratories to either submit all, or a sample of their bacterial isolates. surveillance for zoonotic diseases should start at the animal level, thus providing early warning for impending increases of diseases in the animal population. rabies surveillance aims at identifying the main species of animals infected in an area, the incidence of disease in the wild animals and the prevalence of infection in the asymptomatic reservoir (bats). this information will guide preventive decisions made when human exposures do occur. malaria control entomologic activities must be guided by surveillance of anopheles population, biting activities, plasmodium infection to biting acivities and plasmodium infection rates in the anopheles population. surveillance for dead birds, infection rates in wild birds, infection in sentinel chickens and horse encephalitis are all part of west nile encephalitis surveillance. these methods provide an early warning system for human infections. the worldwide surveillance for influenza is the best example of the usefulness of monitoring animals prior to spread of infection in the human population. influenza surveillance programs aim to rapidly obtain new circulating strains to make timely recommendations about the composition of the next vaccine. the worldwide surveillance priority is given to the establishment of regular surveillance and investigation of outbreaks of influenza in the most densely populated cities in key locations, particularly in tropical or other regions where urban markets provide opportunities for contacts between humans and live animals (snacken et al. ). the rationale for selecting infectious diseases and an appropriate surveillance method is based on the goal of the preventive program. outbreaks of acute infectious diseases are common and investigations of these outbreaks are an important task for public health professionals, especially epidemiol-ogists. in , a total of foodborne outbreaks with , cases involved were reported in the us (cdc ) with norovirus being the most common confirmed etiologic agent associated with these outbreaks (see table . ). outbreaks or epidemics are defined as the number of disease cases above what is normally expected in the area for a given time period. depending on the disease, it is not always known if the case numbers are really higher than expected and some outbreak investigations can reveal that the reported case numbers did not actually increase. the nature of a disease outbreak depends on a variety of circumstances, most importantly the suspected etiologic agent involved, the disease severity or case fatality rate, population groups affected, media pressure, political inference and investigative progress. there are certain common steps for outbreak investiga-tions as shown in table . . however, the chronology and priorities assigned to each phase of the investigation have to be decided individually, based on the circumstances of the suspected outbreak and information available at the time. another way to detect an increase of cases is if the surveillance system of reportable infectious diseases reveals an unusually high number of people with the same diagnosis over a certain time period at different health care facilities. outbreaks of benign diseases like self-limited diarrhea are often not detected because people are not seeking medical attention and therefore medical services are not aware of them. furthermore, early stages of a disease outbreak are often undetected because single cases are diagnosed sporadically. it is not until a certain threshold is passed, that it becomes clear that these cases are related to each other through a common exposure or secondary transmission. depending on the infectious disease agent, there can be a sharp or a gradual increase of number of cases. it is sometimes difficult to differentiate between sporadic cases and the early phase of an outbreak. in the st. louis encephalitis (sle) outbreak in louisiana, the number of sle cases increased from to between week one and two and then the numbers gradually decreased over the next weeks to a total of cases (jones et al. ) . . after the initial report is received, it is important to collect and document basic information: contact information of persons affected, a good and thorough event description, names and diagnosis of hospitalized persons (and depending on the presumptive diagnosis their underlying conditions and travel history), laboratory test results and other useful information to get a complete picture and to confirm the initial story of the suspected outbreak. it also might be necessary to collect more biological specimens such as food items and stool samples for further laboratory testing. . based on the collected information the decision to investigate must be made. it may not be worthwhile to start an investigation if there are only a few people who fully recovered after a couple of episodes of a self-limited, benign diarrhea. other reasons not to investigate might be that this type of outbreak occurs regularly every summer or that it is only an increase in number of reported cases which are not related to each other. on the other hand, however, there should be no time delay in starting an investigation if there is an opportunity to prevent more cases or the potential to identify a system failure which can be caused, for example, by poor food preparation in a restaurant or poor infection control practices in a hospital or to prevent future outbreaks by acquiring more knowledge of the epidemiology of the agent involved. additional reasons to investigate include the interest of the media, politicians and the public in the disease cluster and the pressure to provide media updates on a regularly basis. another fact to consider is that outbreak investigations are good training opportunities for newly hired epidemiologists. sometimes lack of data and lack of sufficient background information make it difficult to decide early on if there is an outbreak or not. the best approach then is to assume that it is an outbreak until proven otherwise. . prevention of more cases is the most important goal in outbreak investigations and therefore a rapid evaluation of the situation is necessary. if there are precautionary measures to be recommended to minimize the impact of the outbreak and the spread to more persons, they should be implemented before a thorough investigation is completed. most likely control measures implemented by public health professionals in foodborne outbreaks are: recall or destruction of contaminated food items, restriction of infected food handlers from food preparation, correction of any deficiency in food preparation or conservation. . after taking immediate control measures, the next step is to know more about the epidemiology of the suspected agent. the most popular books for public health professionals include the "red book" (american academy of pediatrics ), the "control of communicable diseases manual" from the american public health association (apha ) or other infectious disease epidemiology books as well as the cdc website (www.cdc.gov). if the disease of interest is a reportable disease or a disease where surveillance data are available, baseline incidence rates can be calculated. then a comparison is made to determine if the reported numbers constitute a real increase or not. furthermore, the seasonal and geographical distribution of the disease is important as well as the knowledge of risk factors. many infectious diseases show a seasonal pattern such as rotavirus or neisseria meningitides. for example in suspected outbreaks where cases are associated with raw oyster consumption, the investigator should know that in the us gulf states vibrio cases increase in the summer months because the water conditions are optimal for the growth of the bacteria in water and in seafood. this kind of information will help to determine if the case numbers show a true increase and if it seems likely to be a real outbreak. . for certain diseases, numbers are not important. depending on the severity of the disease, its transmissibility and its natural occurrence, certain diseases should raise a red flag for every health care professional and even a single case should warrant a thorough public health investigation. for example a single confirmed case of a rabid dog in a city (potential dog to dog transmission within a highly populated area), a case of dengue hemorrhagic fever or a presumptive case of smallpox would immediately trigger an outbreak investigation. . sometimes an increase of case numbers is artificial and not due to a real outbreak. in order to differentiate between an artificial and a natural increase in numbers, the following changes have to be taken into consideration: alterations in the surveillance system, a new physician who is interested in the disease and therefore more likely to diagnose or report the disease, a new health officer strengthening the importance of reporting, new procedures in reporting (from paper to web based reporting), enhanced awareness or publicity of a certain disease that might lead to increased laboratory testing, new diagnostic tests, a new laboratory, an increase in susceptible population such as a new summer camp. . it is important to be sure that reported cases of a disease actually have the correct diagnosis and are not misdiagnosed. is there assurance that all the cases have the same diagnosis? is the diagnosis verified and were other differential diagnoses excluded? in order to be correct, epidemiologists have to know the basis for the diagnosis. are laboratory samples sufficient? if not, what kind of specimens should be collected to ascertain the diagnosis? what are the clinical signs and symptoms of the patient? in an outbreak of restaurant associated botulism in canada only the th case was correctly diagnosed. the slow progression of symptoms and misdiagnosis of the dispersed cases made it very difficult to link these cases and identify the source of the outbreak (cdc (cdc , . . the purpose of a case definition is to standardize the identification and counting of the number of cases. the case definition is a standard set of criteria and is not a clinical diagnosis. in most outbreaks the case definition has components of person, place and time, such as the following: persons with symptoms of x and y after eating at the restaurant z between date and date . the case definition should be broad enough to get most of the true cases but not too narrow so that true cases will not be misclassified as controls. a good method is to analyze the data, identify the frequency of symptoms and include symptoms that are more reliable than others. for example, diarrhea and vomiting are more specific than nausea and headache in the case definition of a food related illness. . what kind of information is necessary to be collected? it is sufficient to have a simple database with basic demographic information such as name, age, sex and information for contacting the patient. more often, date of reporting and date of onset of symptoms are also important. depending on the outbreak and the potential exposure or transmission of the agent involved further variables such as school, grade of student or occupation in adults might be interesting and valuable. . during an outbreak investigation it is important to identify additional cases that may not have been known or were not reported. there are several approaches: interview known cases and ask them if they know of any other friends or family members with the same signs or symptoms, obtain a mailing list of frequent customers in an event where a restaurant is involved, set up an active surveillance with physicians or emergency departments, call laboratories and ask for reports of suspected and confirmed cases. another possibility is to review surveillance databases or to establish enhanced surveillance for prospective cases. occasionally it might be worthwhile to include the media for finding additional cases through press releases. however the utility of that technique depends on the outbreak and the etiologic agent; the investigator should always do a benefit risk analysis before involving the media. . after finding additional cases, entering them in the database and organizing them, the investigator should try to get a better understanding of the situation by performing some basic descriptive epidemiology techniques such as sorting the data by time, place and person. for a better visualization of the data, an epidemic or "epi" curve should be graphed. the curve shows the number of cases by date or time of onset of symptoms. this helps to understand the nature and dynamic of the outbreak as well as to get a better understanding of the incubation period if the time of exposure is known. it also helps to determine whether the outbreak had a single exposure and no secondary transmission (single peak) or if there is a continuous source and ongoing transmission. figures . and . show "epi" curves of two different outbreaks: a foodborne outbreak in a school in louisiana, and the number of wnv human cases in louisiana in the outbreak, respectively. sometimes it is useful to plot the cases on a map to get a better idea of the nature and the source of an outbreak. mapping may be useful to track the spread by water (see john snow's cholera map) or by air or even a person to person transmission. if a contaminated food item was the culprit, food distribution routes with new cases identified may be helpful. maps, however, should be taken with caution and carefully interpreted. for example, wnv cases are normally mapped by residency but do not take into account that people might have been exposed or bitten by an infective mosquito far away from where they live. for outbreak investigations, spot maps are usually more useful than rate maps or maps of aggregate data. depending on the outbreak it might be useful to characterize the outbreak by persons' demographics such as age, sex, address and occupation or health status. are the cases at increased susceptibility or at high risk of infection? these kinds of variables might give the investigator a good idea if the exposure is not yet known. for typical foodborne outbreaks however, demographic information is not very useful because the attack rates will be independent of age and sex. more details on methods used in descriptive epidemiology are given in chap. i. of this handbook. . based on the results of basic descriptive epidemiology and the preliminary investigation, some hypotheses should be formulated in order to identify the cause of the outbreak. a hypothesis will be most likely formulated such as "those who attended the luncheon and ate the chicken salad are at greater risk than those who attended and did not eat the chicken salad". it is always easier to find something after knowing what to look for and therefore a hypothesis should be used as a tool. however, the epidemiologist should be flexible enough to change the hypothesis if the data do not support it. if data clues are leading in another direction, the hypothesis should be reformulated such as "those who attended the luncheon and ate the baked chicken are at greater risk than those who attended and did not eat the baked chicken". to verify or deny hypotheses, measures of risk association such as the relative risk (rr) or the odds ratio (or) have to be calculated (as described in chaps. i. , i. , and i. of this handbook). the cdc has developed the software program 'epiinfo' which is easy to use in outbreak investigations, and, even more importantly, free of charge. it can be downloaded from the cdc website (http:||www.cdc.gov|epiinfo|). measures of association, however, should be carefully interpreted; even a highly significant measure of association can not give enough evidence of the real culprit or the contaminated food item. the measure of association is only as good and valid as the data. most people have recall problems when asked what they ate, when they ate and when their symptoms started. even more biases or misclassifications of cases and controls can hide an association. a more confident answer comes usually from the laboratory samples from both human samples and food items served at time of exposure. agents isolated from both food and human samples that are identified as the same subtype, in addition to data results supporting the laboratory findings, are the best evidence beyond reasonable doubt. . as the last step in an outbreak investigation, the epidemiologist writes a final report on the outbreak and communicates the results and recommendations to the public health agency and facilities involved. in the us, public health departments also report foodborne outbreaks electronically to cdc via a secure web based reporting system, the electronic foodborne outbreak reporting system (efors). the "traditional" foodborne outbreak the "traditional" foodborne outbreak is usually a small local event such as family picnic, wedding reception, or other social event and occurs often in a local restaurant or school cafeteria. this type of outbreak is highly local with a high attack rate in the group exposed to the source. because it is immediately apparent to those in the local group such as the group of friends who ate at the restaurant or the students' parents, public health authorities are normally notified early in the outbreak while most of the cases are still symptomatic. epidemiologists can start early on with their investigation and therefore have a much better chance to collect food eaten and stool samples of cases with gastroenteritis for testing and also to detect the etiologic agent in both of them. in a school outbreak in louisiana, eighty-seven persons (sixty-seven students and twenty faculty members) experienced abdominal cramps after eating at the school's annual "turkey day" the day before. stool specimens and the turkey with the gravy were both positive for clostridium perfringens with the same pulse field gel electrophoresis (pfge) pattern (merlos ) . the inspection of the school cafeteria revealed several food handling violations such as storing, cooling and reheating of the food items served. other than illnesses among food handlers, these types of improper food handling or storage are the most common causes of foodborne outbreaks. a different type of outbreak is emerging as the world is getting smaller. in other words persons and food can travel more easily and faster from continent to continent and so do infectious diseases with them. foodborne outbreaks related to imported contaminated food items are normally widespread, involving many states and countries and therefore are frequently identified. in , a large outbreak of cyclospora cayetanensis occurred in us states and ontario, canada and was linked to contaminated raspberries imported from south america. several hundred laboratory confirmed cases were reported, most of them in immunocompetent persons (cdc ) . a very useful molecular tool to identify same isolates from different geographic areas is sub-typing enteric bacteria with pfge. in the us, the pulsenet database allows state health department to compare their isolates with other states and therefore increase the recognition of nationwide outbreaks linked to the same food item (swaminathan et al. ) . in a different scenario, a widely distributed food item with low-level contamination might result in an increase of cases within a large geographic area and therefore might be not get detected on a local level. this kind of outbreak might only be detected by chance if the number of cases increased in one location and the local health department alerts other states to be on the lookout for a certain isolate. another type of outbreak is the introduction of a new pathogen into a new geographic area as it happened in when vibrio cholerae was inadvertently introduced in the waters off the gulf coast of the united states. in the u.s., however, most cases are usually traced back to people who traveled to areas with a high cholera risk or to people who ate food imported from cholera-risk countries and only sporadic vibrio cholerae cases are associated with the consumption of raw or undercooked shellfish from the gulf of mexico (cdc b). food can not only be contaminated by the end of the food handling process i.e. by infected food handlers but also can be contaminated by any event earlier in the chain of food production. in , an ice cream outbreak of salmonella enteritidis in a national brand of ice cream resulted in , illnesses. the outbreak was detected by routine surveillance because of a dramatic increase of salmonella enteritidis in south minnesota. the cause of the outbreak was a basic failure on an industrial scale to separate raw products from cooked products. the ice cream premix was pasteurized and then transported to the ice cream factory in tanker trucks which had been used to haul raw eggs. this resulted in the contamination of the ice cream and subsequent salmonella cases (hennessey et al. ) . surveys are useful to provide information for which there is no data source or no reliable data source. surveys are time consuming and are often seen as a last choice to obtain information. however, too often unreliable information is used because it is easily available. for example, any assessment of the legionella problem using passive case detection will be unreliable due to under-diagnosis and under-reporting. most cases of legionellosis are treated empirically as community acquired pneumonias and are never formally diagnosed. in developing countries, surveys are often necessary to evaluate health problems since data collected routinely (disease surveillance, hospital records, case registers) are often incomplete and of poor quality. in industrialized nations, although many sources of data are available, there are some circumstances where surveys may be necessary. prior to carrying out surveys involving human subjects, special procedures need to be followed. in industrialized countries, a human subject investigation review board has to evaluate the project's value and ethics. in developing countries, however, such boards may not be formalized but it is important to obtain permission from medical, national and local political authorities before proceeding. surveys of human subjects are carried out by mail, telephone, personal interviews, and behavioral observations. in infectious diseases, the collection of biological specimens in humans (i.e. blood for serologic surveys) or the collection of environmental samples (food, water, environmental surfaces) is very common. personal interviews and specimen collection require face to face interaction with the individual surveyed. these are carried out in offices or by house to house surveys. non-respondents are an important problem for infectious disease surveys. those with an infection may be absent from school, may not answer the door or may be unwilling to donate blood for a serologic survey, thus introducing a systematic bias into the survey results. since surveys are expensive, they cannot be easily repeated. all field procedures, questionnaires, biological sample collection methods and laboratory tests should be tested prior to launching the survey itself. feasibility, acceptability and reliability can be tested in a small scale pilot study. more details on survey methods are to be found in chap. i. of this handbook. sampling . . since surveys are labor intensive, they are rarely carried out on an entire population but rather on a sample. to do a correct sampling, it is necessary to have a sampling base (data elements for the entire population) from which to draw the sample. examples of sampling bases are population census, telephone directory (for the phone subscriber population), school roster or a school list. in developing countries such lists are not often available and may have to be prepared before sampling can start. more information on sampling designs can be found in chap. iv. of this handbook. community surveys (house to house surveys) . . most community surveys are carried out in developing countries because reliable data sources are rare. the sampling base often ends up to the physical layout of the population. a trip and geographical reconnaissance of the area are necessary. the most common types of surveys undertaken in developing countries are done at the village level; they are based on maps and a census of the village. in small communities, it is important to obtain the participation of the population. villagers are often wary of government officials counting people and going from door to door. to avoid misinterpretations and rumors, influential people in the community should be told about the survey. their agreement is indispensable and their help is needed to explain the objectives of the survey and particularly its potential benefits. increasing the knowledge about disease, disease prevention and advancing science are abstract notions that are usually poorly understood or valued by villagers who are, in general, very practical people. if a more immediate benefit can be built into the survey, there will be an increase in cooperation of the population. incentives such as offering to diagnose and treat an infection or drugs for the treatment of common ailments such as headaches or malaria enhance the acceptance of the survey. in practically all societies the household is a primary economic and social unit. it can be defined as the smallest social unit of people who have the same residency and maintain a collective organization. the usual method for collecting data is to visit each household and collect samples or administer a questionnaire. medical staff may feel left out or even threatened whenever a medical intervention (such as a survey) is done in their area. a common concern is that people will go to their medical care provider and ask questions about the survey or about specimen collection and results. it is therefore important to involve and inform local medical providers as much as practical. a rare example of a house to house survey in an industrialized nation was carried out in slidell, louisiana for the primary purpose of determining the prevalence of west nile infection in a southern us focus. since the goal was to obtain a random sample of serum from humans living in the focus, the only method was a survey of this type. a cluster sampling design was used to obtain a representative number of households. the area was not stratified because of its homogeneity. census blocks were grouped so that each cluster contained a minimum of households. the probability of including an individual cluster was determined by the proportion of houses selected in that cluster and the number of persons participating given the number of adults in the household. a quota sampling technique was used, with a goal of enlisting participating households in each cluster. inclusion criteria included age (at least years of age) and length of residence (at least years). the household would be included only if an adult household resident was present. a standardized questionnaire was used to interview each participant. information was collected on demographics, any recent febrile illness, knowledge, attitudes, and behaviors to prevent wnv infection and potential exposures to mosquitoes. a serum sample for wnv antibody testing was drawn. in addition, a second questionnaire regarding selected household characteristics and peridomestic mosquito reduction measures was completed. informed consent was obtained from each participant, and all participants were advised that they could receive notification of their blood test results if they wished. institutional review board approvals were obtained. logistics for specimen collection, preservation and transportation to the laboratory were arranged. interpretation of serologic tests and necessary follow up were determined prior to the survey and incorporated in the methods submitted to the ethics committee. sampling weights, consisting of components for block selection, householdwithin-block selection, and individual-within-household participation, were used to estimate population parameters and % confidence intervals (ci). statistical tests were performed incorporating these weights and the stratified cluster sampling design. in this survey, households were surveyed (a % response rate), including participants. there were igm seropositive persons, for a weighted seroprevalence of . % (with a % confidence interval of . %- . %) (vicari et al. ). program evaluation is a systematic way to determine if prevention or intervention programs for the infectious disease of interest are effective and to see how they can be improved. it is beyond the scope of this chapter to explain program evaluation in detail however there is abundant information available i.e. the cdc's framework for program evaluation in public health (cdc a) as well as text books on program evaluation (fink ) . most importantly, evaluators have to understand the program such as the epidemiology of the disease of interest, the program's target population and their risk factors, program activities and resources. they have to identify the main objectives of the control actions and determine the most important steps. indicators define the program attributes and translate general concepts into measurable variables. data are then collected and analyzed so that conclusions and recommendations for the program are evidence based. evaluating an infectious disease control program requires a clear understanding of the microorganism, its mode of transmission, the susceptible population and the risk factors. the following example of evaluation of tuberculosis control shows the need to clearly understand the priorities. most of tuberculosis transmission comes from active pulmonary tuberculosis cases who have positive sputum smear (confirmed as tuberculosis mycobacteria on culture). to a lesser extent, smear negative culture positive pulmonary cases are also transmitting the infection. therefore priority must be given to find sputum positive pulmonary cases. the incidence of smear positive tuberculosis cases is the most important incidence indicator. incidences of active pulmonary cases and of all active cases (pulmonary and extra-pulmonary) are also calculated but are of lesser interest. the following proportions are used to detect anomalies in case finding or case ascertainment: all tuberculosis cases who are pulmonary versus extra-pulmonary, smear positive, culture positive, pulmonary cases versus smear negative, culture positive, pulmonary cases, culture positive, pulmonary cases versus culture negative, pulmonary cases. poor laboratory techniques or low interest in obtaining sputa for smears or cultures may result in underestimating bacteriological confirmed cases. excessive diagnosis of tuberculosis with reliance on chest x-rays on the other hand may overestimate unconfirmed tuberculosis cases. once identified, tuberculosis cases are placed under treatment. treatment of infectious cases is an important preventive measure. treatment efficacy is evaluated by sputum conversion (both on smear and culture) of the active pulmonary cases. after months of an effective regimen, % of active pulmonary cases should have converted their sputum from positive to negative. therefore the rate of sputum conversion at months becomes an important indicator of program effectiveness. this indicator must be calculated for those who are smear positive and with a lesser importance for the other active pulmonary cases. to ensure adequate treatment and prevent the development of acquired resistance, tuberculosis cases are placed under directly observed therapy (dot). this measure is quite labor intensive. priority must therefore be given to those at highest risk of relapse. these are the smear positive culture proven active pulmonary cases. dot on extra-pulmonary cases is much less important from a public health standpoint. the same considerations apply to contact investigation and preventive treatment in countries that can afford a tuberculosis contact program. a recently infected contact is at the highest risk of developing tuberculosis the first year after infection; hence the best preventive return is to identify contacts of infectious cases. those contacts are likely to have been recently infected. systematic screening of large population groups would also identify infected individuals but most would be 'old' infections at lower risk of developing disease. individuals infected with tuberculosis and hiv are at extremely high risk of developing active tuberculosis. therefore the tuberculosis control program should focus on the population at high risk of hiv infection. often, program evaluation is performed by epidemiologists who have not taken the time to understand the dynamics of a disease in the community. rates or proportions are calculated, no priorities are established and precious resources are wasted on activities with little preventive value. for example, attempting to treat all tuberculosis cases, whether pulmonary or not with dot, investigating all contacts regardless of the bacteriologic status of the index case, would be wasteful. today the world is smaller than ever before, international travel and a worldwide food market make us all potentially vulnerable to infectious diseases no matter where we live. new pathogens are emerging such as the sars or spreading through new territories such as wnv. wnv introduced in the us in , became endemic in the us over the next years. hospital-associated and community-associated methicillin resistant staphylococcus aureus (mrsa) and resistant tuberculosis cases and outbreaks are on the rise. public health professionals are concerned that a novel recombinant strain of influenza will cause a new pandemic. but not only the world and the etiologic agents are changing, the world population is changing as well. in industrialized countries, the life expectancy is increasing and the elderly are more likely to acquire a chronic disease, cancer or diabetes in their lifetime. because of underlying conditions or the treatment of these diseases, older populations also have an increased susceptibility for infectious diseases and are more likely to develop life-threatening complications. knowledge in the field of infectious disease epidemiology is expanding. while basic epidemiological methods and principles still apply today, improved laboratory diagnoses and techniques help to confirm cases faster, see how cases are related to each other and therefore can support the prevention of spread of the specific disease. better computers can improve the data analysis and internet allows access to in depth disease specific information. computer connectivity improves disease reporting for surveillance purposes and the epidemiologist can implement faster preventive measures if necessary and is also able to identify disease clusters and outbreaks on a timelier basis. the global threat of bioterrorism adds a new dimension. the intentional release of anthrax spores, and the infection and death of persons who contracted the disease created a scare of contaminated letters in the us population. with all these changes, there is renewed emphasis on infectious disease epidemiology and makes it a challenging field to work in. detection of bordetella pertussis and respiratory syncytial virus in air samples from hospital rooms transmission of tuberculosis in new york city. an analysis by dna fingerprinting and conventional epidemiologic methods report of the committee on infectious diseases in: chin j (ed) control of communicable diseases manual, th edn geographical information system (gis), gimmick or tool for health district management update: international outbreak of restaurant-associated botulism -vancouver epidemiologic notes and reports restaurant associated botulism from mushrooms bottled in-house -vancouver outbreaks of cyclospora cayetanensis infection -united states case definitions for infectious conditions under public health surveillance cdc ( a) framework for program evaluation in public health summary of infections reported to vibrio surveillance system (http:||www.cdc.gov|ncidod|dbmd|diseaseinfo|files|vibcste web.pdf) accessed norowalk-like viruses": public health consequences and outbreak management updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group outbreaks of gastroenteritis associated with noroviruses on cruise ships -united states diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals epiinfo (http:||www.cdc.gov|epiinfo|) accessed evaluation fundamentals: guiding health programs, research and policy yellow fever. in: cox cr (ed) the wellcome trust illustrated history of tropical diseases a national outbreak of salmonella enteritidis infections from ice cream encephalitis outbreak in louisiana in simple school questionnaires can map both schistosoma mansoni and schistosoma haematobium in the democratic republic of congo molecular and conventional epidemiology of mycobacterium tuberculosis in botswana: a population-based prospective study of pulmonary tuberculosis patients dolin r (eds) ( ) mandell, douglas, and bennett's principles and practice of infectious diseases epidemiology, principles and methods. little, brown and company an uninvited guest at "turkey day trends in hospitalizations associated with gastroenteritis among adults in the united states the next influenza pandemic: lessons from hong kong on the mode of communication of cholera pulsenet: the molecular subtyping network for foodborne bacterial disease surveillance, united states late-breaker report presented at the cdc "annual epidemic intelligence service conference http:||www.who.int|whr | | archives|index.htm) accessed statistical annex. (http:||www.who.int| whr | |archives| |en|pdf|statisticalannex.pdf) accessed cholera, the black one. in: yellow fever black goddess, the coevolution of people and plagues four tales from the new decameron. in: yellow fever black goddess, the coevolution of people and plagues key: cord- -r tg s authors: john, maya; shaiba, hadil title: shiny framework based visualization and analytics tool for middle east respiratory syndrome date: - - journal: advances in data science, cyber security and it applications doi: . / - - - - _ sha: doc_id: cord_uid: r tg s people in the middle east have been affected by the middle east respiratory syndrome coronavirus (mers co-v) since . new cases are continuously reported especially in the kingdom of saudi arabia, and the risk of exposure remains an issue. data visualization plays a vital role in effective analysis of the data. in this paper, we introduce an interactive visualization application for mers data collected from the control and command centre, ministry of health website of saudi arabia. the data corresponding to the period from january , to february , was used in the present work. the attributes considered include gender, age, date of reporting, city, region, camel contact, description and status of the patient. the visualization tool has been developed using shiny framework of r programming language. the application presents information in the form of interactive plots, maps and tables. the salient feature of the tool is that users can view and download data corresponding to the period of their choice. this tool can help decision makers in the detailed analysis of data and hence devise measures to prevent the spread of the disease. mers is a viral disease that was first discovered in when a patient in saudi arabia was diagnosed with critical respiratory distress and kidney trouble [ ] . the infection can either be asymptomatic or show symptoms such as cough, fever etc. along with difficulty in breathing [ ] . the disease has been brought under control in all middle eastern countries except saudi arabia where each month, new cases are still reported. studies have confirmed that this disease is zoonotic and camels are its significant reservoir [ , ] . people in close contact with infected camels and health care professionals who care for infected patients have a high risk of acquiring the infection. many cases of community and household acquired infections have been reported from saudi arabia [ ] . the ministry of health, saudi arabia has issued guidelines for infection prevention, control and management. to the best of our knowledge, there is a lack of interactive visualization tools for mers data visualization in saudi arabia. this work deals with developing an application where users can interactively view information about the infection in the form of plots, tables and maps. the data used in this study was obtained from the saudi ministry of health website and it includes the cases reported in saudi arabia from january , to february , . by viewing the data visualizations, users can analyze mers cases better, find trends, monitor the disease and help authorities set detection and prevention guidelines. the mers data analyzed consists of cases reported during the first two months of the year . the information is present in the form of a pdf file corresponding to the cases reported each week. the cases reported contains details which include the date of reporting and patient information such as personal information, demographic information, camel contact details, description of infection and status of the disease. the latitude and longitude of the regions and cities are stored in separate .csv files. the details of the attributes present in the database are shown in table . shiny is an r package used to create interactive web applications [ ] . the shiny framework is a reactive programming model where browser refreshing is not required to instantiate the output changes when the user modifies the input. it can be used to build web applications without using javascript coding. shiny combines the computational power of r programming language with the highly interactive nature of the web. leaflet package is used to create interactive maps in r based on the javascript library leaflet [ ] . these interactive maps can be rendered in r markdown, shiny apps, rstudioide and r console as it was developed in association with htmlwidgets. the leaflet( ) function is used to create the map widget. the different types of layers which can be included in the map widget are map tile, markers, lines, polygon, popups, raster images, color legends, layer groups, layer control etc. the maps created can be zoomed or downsized interactively. the googleviz package in r facilitates the use of google chart apis [ ] . interactive charts can be incorporated into web pages using google charts. the data stored in r data frames can be visualized in the form of google charts without uploading the information to google. an internet connection is required to view the output rendered by this package. the mers data visualization tool was developed using r programming language. the tool consists of three sections (tabs) namely "different cases analysis", "miscellaneous analysis" and "summary" section. the users can choose the period for which they would like to visualize the mers data. in the case of different cases analysis, the user can view the information as pie charts and maps, or tables. the users can view details about either all the cases together or recovered cases, death cases or hospitalized cases separately. the details regarding the cases can be viewed with respect to all cities, all regions or cities within a region. in the case of the option "cities within a region", the user has to choose a region from the drop down list provided. unlike conventional pie charts, the pie charts created using googleviz package are interactive in nature. by pointing the cursor over a portion in the pie chart, one can understand the actual number of cases in that particular part of the chart. in the map, places are marked based on longitude and latitude of that place. on clicking the marker displayed in the map, the name and number of cases in that place will be displayed as a pop-up. based on the number of cases, markers are assigned colors such as red, orange or yellow. the colors red, orange and yellow represent "large number of cases", "moderate number of cases" and "few number of cases" respectively. the information in figs. and is presented in the form of pie chart and map. the screen shot of the page corresponding to different cases analysis is shown in fig. . the figure depicts the analysis of all mers cases reported for the first two months of the year with regard to cities. it can be inferred from fig. that during that period . % of the patients recovered from the disease and the maximum number of cases ( %) were reported from the city of wadi aldawasir. the analysis based on all cases reported in "all cities within riyadh region" during january to february is shown in fig. . it can be observed from the figure that majority of cases in riyadh region were reported from the city of wadi aldawasir. nearly % of the infected people in riyadh region recovered from the disease. the application page with table output is shown in fig. . it can be observed from the table that people died due to mers in riyadh region during the first two months of the year . the table which displays the information is interactive in nature. when the user clicks a column name in the table, the records in the table are sorted based on values in the clicked column and displayed accordingly. the table also has provision for searching values and selecting the number application page corresponding to "different cases analysis" tab for cities within a region of records to be displayed in a page. the users can also download the details contained in the table. the different cases analysis will help decision makers in gathering information regarding the cases reported in different places. this type of analysis is essential to identify disease prone areas and hence take measures to curtail the spread of infection. the miscellaneous analysis consists of analysis based on age, camel contact and months. the users can analyze the data for all cases, death cases or recovered cases. depending on the user's choice, the analysis corresponding to all cities, all regions or cities within a region are displayed. analysis based on age. the infected people are divided into three age categories namely below years, - years and greater than years. in the case of age based analysis, the information is displayed both in the form of pie chart and stacked bar chart. the pie chart represents the number of cases corresponding to each age group. the stacked bar chart depicts the number of cases in each age group corresponding to the location type selected. the screen shot corresponding to age category wise analysis is shown in fig. . the figure corresponds to the analysis corresponding to all cases reported with respect to cities for the first two months of the year . it is evident from the pie chart fig. that the percentage of cases reported is . %, . % and . % for the age group below years, - years and above years respectively. the age category wise helps in understanding the number of cases reported among people of different age groups. this type of analysis will help in identifying which group has more mortality rate and health authorities may conduct extensive analysis of causes leading to death. analysis based on camel contact. camels have been identified as a carrier of the disease, and hence it is essential to perform analysis of patient cases involving camel contact. depending on the choice of the user, the information is displayed for "all cases", "death cases" or "recovery cases". the analysis is carried out for "all cities", "all regions" or "cities within a region". the details are displayed as pie chart, map and table. the pie chart represents the numbers of cases corresponding to the location type selected by the user. the places where camel contact cases are reported are marked in the map. this can help in analyzing whether the cases pertaining to people with camel contact are clustered in a region or not. the table displays the details of infected people who had contact with camels. the data visualization based on camel contact is shown in fig. . the figure depicts the analysis corresponding to all cases with regard to cities in saudi arabia. it can be observed from fig. that % of the camel contact based cases were reported from the city of wadi aldawasir. camel contact based analysis of mers patients is highly essential to identify places where people in contact with camels have been infected with the disease. this will help health authorities in taking more measures to spread awareness about the precautionary methods to be taken when handling camels. the infected camels in such regions may be identified and isolated to prevent the spread of the disease. month-wise comparison of the data can be carried out for "all cases", "death cases" and "recovery cases". the stacked bar chart for cases reported in different months is plotted based on the location type specified by the user. when the cursor is moved to a region in the bar chart, the number of cases in the particular month will be displayed corresponding to the location. the screenshot corresponding to month-wise comparison is shown in fig. . the figure portrays the analysis corresponding to death cases reported in various regions. the maximum number of death cases were reported in riyadh region during february. monthwise analysis is useful in identifying whether the infection is related to climate. summary based visualization gives a graphical summary of the count of the "status of the patients" for different attributes. the information is depicted in the form of stacked bar charts where the charts are plotted based on the frequency of status of patients corresponding to different values of the attributes. this visualization will help the users in getting an overall idea regarding the distribution of data with regard to the status of the patients. figures and depict the screenshots of the visual summary of data for the first two months of the year . figure confirms the earlier findings that riyadh region and specifically wadi aldawasir city has the highest number of mers cases and death cases. figure shows that most mers patients are male and that people below years are less likely to get infected by mers. elderly patients are more prone to die of mers. the majority of patients were not in contact with camels and death rate was low in the case of patients in contact with camels. many patients acquired the infection from healthcare facilities and high death rate is reported among this group. the users can view information corresponding to their period of interest. the interactive feature of the pie chart prevents the chart from being cluttered with description. the use of maps to represent the information will give an idea regarding the spatial distribution of mers cases. these maps will help the health authorities to identify the areas with large number of cases and hence alert the hospitals and the general public regarding that. the interactive nature of the table helps the users in analyzing the data as per their requirement. a salient feature of the application is that the users can easily download details corresponding to the period of their choice. analyzing the data based on camel contact will aid health authorities to identify the areas where many such cases are present and hence intensify the awareness programs to reduce the rate of infection. in this paper, we have created an interactive visualization tool for mers co-v infection cases based on details of cases reported in saudi arabia. the attributes used include the date of reporting, city, region, age, gender, description of the disease, camel contact and status of the patient. the user can view details regarding all cases, recovered cases, death cases or hospitalized cases for all the cities, all regions or cities within a region. our tool provides the flexibility to view information in the form of charts and maps, or downloadable tables. the analysis is also carried out based on age group, camel contact and month-wise cases. by viewing the maps, users can easily differentiate between places based on the number of cases. moreover, the users can view a visual summary of the number of cases for different values of attributes based on the status of the patients. understanding and analyzing the disease related information can help decision makers in setting guidelines for preventing and controlling the spread of disease. location-based analysis of the infection is highly essential in formulating region specific awareness programs to reduce the rate of infection. isolation of a novel coronavirus from a man with pneumonia in saudi arabia main factors influencing recovery in mers co-v patients using machine learning mers-cov infection of alpaca in a region where mers-cov is endemic middle east respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission key: cord- -hprwqi n authors: löscher, thomas; prüfer-krämer, luise title: emerging and re-emerging infectious diseases date: - - journal: modern infectious disease epidemiology doi: . / - - - - _ sha: doc_id: cord_uid: hprwqi n emerging infectious diseases (eids) are characterized by a new or an increased occurrence within the last few decades. they include the following categories emerging diagnosis of infectious diseases: old diseases that are newly classified as infectious diseases because of the discovery of a responsible infectious agent. europe including great britain as well as in india, china, and japan. emerging vector-borne disease events concentrated in densely populated subtropical and tropical regions mostly in india, indonesia, china, sub-saharan africa, and central america (see figs. . , . , and . ). the identification of new infectious agents in old diseases with unknown etiology is still the basis in many epidemiological studies. such newly detected bacteria and viruses in the last few decades are listed in table . . since the detection of helicobacter pylori in , this infection has been identified as the causative agent in % of b-gastritis cases. the risk of duodenal ulcer is increased by - -fold in patients with helicobacter-associated gastritis. who declared h. pylori as a carcinogen of first order because of its potential to enhance the risk of stomach carcinoma and malt lymphoma in long-term infection. in highprevalence regions for h. pylori, the frequency of stomach carcinoma is significantly higher compared to low-endemic areas (correa et al. ). the identification of h. pylori facilitates curative treatment of most associated diseases in individuals. but the most important epidemiological effect on associated diseases is attributed to increased hygienic standards in industrialized countries with a substantial reduction of h. pylori prevalences in younger age cohorts. transmission of h. pylori occurs mainly in childhood. in western developed countries the overall prevalence is around %, higher in older age groups due to a cohort effect, and this increases with low socioeconomic status (rothenbacher et al. ). in countries with low hygienic standards the prevalences are still high in younger age groups and reach % in developing countries. in developed countries, migrant subpopulations from less-developed regions show significantly higher prevalences in comparison to the nonmigrant population (mégraud ). since the early th century, a characteristic expanding skin lesion, erythema migrans (em), and an arthritis associated with previous tick bites were known. borrelia for many decades. increased outdoor activities facilitated contacts between humans and ticks in the s and the s and increased transmission of borrelia to humans at the northeastern coast of north america, leading to the discovery of borrelia burgdorferi in by willy burgdorfer. three different stages of the disease that describe the stage of infection and the involvement of different organ systems are known: stage , early localized infection; stage , early but disseminated infection; and stage , late stage with persistent infection. lyme disease is endemic at the east coast and in minnesota in the united states, in eastern and central europe, and russia. seroprevalence rates that reflect about % of nonclinical infections vary between and % in the general population in germany (hassler et al. ; weiland et al. ) . in high-risk groups like forest workers in germany the prevalences reach - % (robert koch institute a). in ticks (ixodes) the prevalences are between and % depending on the geographical area and the testing method used [immunofluorescence test, ift and polymerase chain reaction (pcr)]. in most studies the main risk factors of infection are age (children: - years, adults - years), outdoor activities, skin contacts with bushes and grass, and the presence of ticks in domestic animals (robert koch institute b) . the probability of infection (seroconversion) after a tick bite in germany is - % and the probability of a clinical disease is . - . %. the probability that the bite of an infectious tick leads to infection in the host is - %. this depends on the time duration that the tick is feeding on the human body. since the detection of the etiologic infectious agent and the subsequent development of laboratory diagnostic tests in the s, the number of reported cases of lyme disease has increased from to , per year, indicating that it is an "emerging diagnosis." the reported numbers vary depending on the reproduction of the hosting rodents for ticks as well as the contacts between humans and nature (spach et al. ) . ticks may live for several years and their survival, reproduction rate, and activity are directly affected by changes in seasonal climate through induced changes in vegetation zones and biodiversity, hence causing local alterations of the tick's habitat and in the occurrence of animals that are carriers of different pathogens (like small rodents). several studies in europe have shown that in recent decades the tick ixodes ricinus, transmitting lyme borreliosis and tick-borne encephalitis (tbe), has spread into higher latitudes (e.g., sweden) and altitudes (e.g., czech republic, austria), and has become more abundant in many places. such variations have been shown to be associated with recent variations in climate. as a result, new risk areas of both diseases have recently been reported from the czech republic. climate change in europe seems likely to facilitate the spread of lyme borreliosis and tbe into higher latitudes and altitudes, and to contribute to extended and more intense transmission seasons. currently, the most effective adaptive strategies available are tbe vaccination of risk populations and preventive information to the general public (danielova et al. ; lindgren et al. ; materna et al. ). an effective vaccine was licensed for b. burgdorferi in . in europe, where different variants of borrelia are present (mostly b. afzelii and b. garinii), this vaccine is not protective. trivalent vaccines for europe are in clinical trials. in recent years, norovirus infections are increasingly recognized as the cause of large outbreaks of diarrheal diseases in the general population, school classes, nursing homes, hospitals, and cruise ships in western countries with peaks in colder seasons (winter epidemics) (centers of disease control ; verhoef et al. ; robert koch institute a) . this is a typical example for emerging diagnosis due to increasing availability of routine pcr testing for these viruses in stool samples. noroviruses (family caliciviridae) are a group of related, single-stranded rna viruses first described in an outbreak of gastroenteritis in a school at norwalk, ohio, in . five genogroups are known. immunity seems to be strain specific and lasts only for limited periods, so individuals are likely to get the infection repeatedly throughout their life. it is estimated that noroviruses are the cause of about % of all food-borne outbreaks of gastroenteritis. for several years there has been an ongoing epidemic in several european countries due to drift variants of a new genotype (gg ii. jamboree) previously unknown to this nonimmune population (robert koch institute a). as a result of an analysis of outbreaks in the united states between and , direct contamination of food by a food handler was the most common cause ( %), person-to-person transmission was less prevalent ( %), and even less frequently waterborne transmission could be proved ( %) (centers for disease control ). vomiting is a frequent symptom of norovirus enteritis and may result in infectious droplets or aerosols causing airborne or contact transmission. this may explain the difficulty to stop outbreaks in hospitals, nursing homes, and similar settings despite precautions to prevent fecal-oral transmission. also on cruise ships, person-to-person transmission is most likely in those closed settings, and drinking tap water is a risk factor as well (verhoef et al. ). searching for an agent which causes large outbreaks of enterically transmitted non-a hepatitis in asia and other parts of the world, the hepatitis e virus (hev) was first described in and cloned and sequenced in (reyes et al. ). meanwhile, hev has been shown to be a zoonotic virus circulating in pigs and other animals. it is implicated in about % of sporadic cases of acute hepatitis in developing countries and associated with a high case fatality rate in the third trimester of pregnancy ( - %). hev is a major cause of large epidemics in asia, and to a lesser extent in africa and latin america, typically promoted through postmonsoon flooding with contamination of drinking water by human and animal feces. recent data show hev also to circulate in european countries and to be associated with severe and fatal disease not only during pregnancy but also in the elderly and in patients with chronic liver conditions. in patients with solid organ transplants, hev may even cause chronic hepatitis and liver cirrhosis (kamar et al. ) . a recombinant hev vaccine candidate has demonstrated a high protection rate of approximately % during clinical trials in nepal (shrestha et al. ). for years, specific human papillomaviruses have been linked to certain human cancers and have been identified as causative agents of malignant proliferations. in the s the detection of papillomavirus dna from cervical carcinoma biopsies were published, showing that hpv types and are the most frequent (dürst et al. ; boshart et al. ) . the relation of hpv infections and cancer is further discussed in chapter . definition: only infections that are newly discovered in humans are listed in this chapter: hiv, new variant of creutzfeldt-jakob disease (vcjd), hemorrhagic uremic syndrome (hus) caused by enterohemorrhagic escherichia coli, viral hemorrhagic fevers like hanta, lassa, ebola, and marburg fever, nipah virus encephalitis, monkeypox, human ehrlichiosis, severe acute respiratory syndrome (coronavirus infection, sars), and avian influenza (h n ) (see fig. . and table . ). these infections mostly have their origin in zoonotic wildlife (e.g., avian influenza, monkeypox, hantavirus, nipah virus, and filoviruses) or livestock (e.g., vcjd). factors promoting the spread of these infections in humans are contacts with wildlife, mass food production of animal origin, and globalization (migration, transportation of goods and vectors) (see fig. . ). in addition, new strains or variants of well-known pathogens have emerged showing increased or altered virulence such as clostridium difficile ribotype or staphylococcus aureus strains expressing the panton-valentine leukocidin (see also chapter ). the epidemiology of hiv is treated in chapter and that of avian influenza and new influenza h n in chapter . in the year , years after the peak of the bse epidemic in the united kingdom, with an annual incidence rate in cows of . per million bovines aged over months, the first mortalities in humans with a new variant of creutzfeldt-jakob disease were observed in the united kingdom. until , smaller incidence rates of bse cases had been reported by other european countries in indigenous bovines and up to more than , per million in in ireland. from , bse started to increase in switzerland and portugal, from in spain and in recent years has spread to eastern european countries (organisation mondiale de la santé animale ). the infectious agent is a self-replicating protein, a "prion." the source of infection for cows is infectious animal flour. the transmission to humans occurs through oral intake of cow products, most likely undercooked meat and nerval tissues as well as transplants of cornea, dura mater, contaminated surgical instruments, or the treatment with hypophyseal hormones extracted from animal tissues. after a statuary ban on the feeding of protein derived from ruminants to any ruminant and the export ban of all cow products from england, the epidemic of bse in cows and the occurrence of human infections decreased in the united kingdom since . by june the total number of deaths in definite/probable cases of vcjd in the united kingdom was (the national creutzfeldt-jakob disease surveillance unit ). only a few numbers of vcjd were reported from other european countries and the united states (who ). nipah virus encephalitis was first observed in / in malaysia. the disease was transmitted by pigs to laborers in slaughterhouses and showed a lethality of %. the infectious agent was detected in (chua et al. ; lam and chua ) . since then, several outbreaks of nipah virus infections have been observed in asian countries: singapore in , india , and bangladesh since (who a harit et al. ) . the virus has been isolated repeatedly from various species of fruit bats, which seem to be the natural reservoir (yob et al. ). west nile is a mosquito-borne flavivirus that was first isolated from a woman with a febrile illness in uganda in . from the s, west nile fever endemicity and epidemics started being reported from africa and the middle east. severe neurological symptoms were thought to be rare. more recent epidemics in northern africa, eastern europe, and russia suggested a higher prevalence of meningoencephalitis with case fatality rates of - %. in , west nile virus was identified as the cause of an epidemic of encephalitis at the east coast of the united states (nash et al. ) . a seroepidemiological household-based survey showed that the first outbreak consisted of about , infections of which about , developed fever and less than % experienced neurological disease ). since then, epidemics occur during summer months in north america each year, with an estimated , febrile illnesses and over , encephalitis or meningitis cases in the united states in (centers for disease control ). age above years is the main risk factor for developing severe disease. the virus is transmitted mainly by culex mosquitoes, but also by sandflies, ceratopogonids, and ticks, with birds as reservoir hosts and incidental hosts such as cats, dogs, and horses. efforts are made to reduce the transmitting mosquito population and to prevent mosquito bites through personal protection as well as to prevent transmission through blood donations by screening (centers of disease control ). the first case of sars occurred in guangdong (china) in november of , leading to an outbreak with cases in china and hong kong ( cases worldwide) until july . the case fatality rate was . %. a new coronavirus (sars-cov) was identified as the causative agent (drosten et al. ) , being transmitted first by infected semidomesticated animals such as the palm civet and subsequently from human to human. some cases were exported to other countries, causing smaller outbreaks there, canada being the most affected country outside asia with cases, before control of transmission was effective. eight thousand and ninety-six cases were reported worldwide, until july , then further transmission stopped (besides one more case of laboratory transmission in ), indicating an efficient international cooperation in disease control (who b) . recently, sars-cov has been found in horseshoe bats, which seem to be the natural reservoir of the virus. about , - , cases of hemorrhagic fever with renal syndrome (hfrs) caused by hantaviruses are reported annually worldwide, with more than half in china, many from russia and korea, and numerous cases from japan, finland, sweden, bulgaria, greece, hungary, france, and the balkan with different death rates depending on the responsible virus, ranging from . % in puumala to - % in hantaan infections (schmaljohn and hjelle ) . hantaviruses are transmitted from rodent to rodent through body fluids and excreta. only occasionally do humans get infected. different types of hantaviruses are circulating in europe and the eastern hemisphere, predominantly puumala virus, dobrava virus, and tula virus, adapted to different mouse species. depending on the virus type the case fatality rate is between and %. as an example, the annual rate of reported cases in germany was about cases per year from onward. this started to change in with reported cases and rose dramatically to cases in . that year, hantavirus infections were among the five most reported viral infections in germany. reasons for the rise in human infections were an increase in the hosting rodent population due to a very mild winter / and an early start of warm temperatures in spring which led to favorable nutritional situations for the mice influencing their population dynamics. in addition, favorable climatic conditions enhanced the outdoor behaviors of humans facilitating transmission in rural areas (robert koch institute b; hofmann et al. ) . since , a previously unknown group of hantaviruses (sin nombre, new york, black creek canal, bayou-in the united states and canada; andes, in south america) emerged in the americas as a cause of hantavirus pulmonary syndrome (hps), an acute respiratory disease with high case fatality rates (approx. %), causing a new, significant public health concern. a total of cases had been reported until march in states, most of them in the western part of the united states (centers for disease control ). lassa virus was detected for the first time in during an outbreak affecting nurses in a missionary hospital in lassa, nigeria. however, the disease had previously been described in the s. lassa virus is enzootic in a common peridomestic rodent in west africa, the multimammate rat mastomys natalensis, which is chronically infected and sheds the virus in urine and saliva. human infection through direct or indirect contact with rats or their excretions is rather common in some west african countries and estimates from seroepidemiological and clinical studies suggest that there are several hundred thousand cases annually. however, only a minority of infections seems to progress to severe hemorrhagic disease with a case fatality rate of - % in hospitalized cases. the virus can be transmitted by close person-to-person contact and nosocomial spread has been observed under poor hygienic conditions. marburg and ebola viruses, which were first detected during outbreaks in and , respectively, have so far been observed only during several limited outbreaks and a few isolated cases in certain countries of sub-saharan africa. however, very high case fatality rates ( - %), the occurrence of outbreaks that were difficult to control in resource-poor settings, and the obscure origin of these viruses have attracted considerable public interest worldwide. recently, evidence was found for both marburg and ebola viruses to occur in certain species of bats that probably constitute the natural reservoir of these filoviruses (towner et al. ). although the disease burden of these viral hemorrhagic fevers is low, they gained considerable international attention due to -their high case fatality rates, -the risk of person-to-person transmission, -several imported cases to industrialized countries, and -fears of abuse of these agents for bioterrorism. as a consequence, considerable resources have been invested, even in nonendemic countries, in the setting up of task forces and high containment facilities for both laboratory diagnostic services and treatment of patients using barrier nursing. this highly virulent strain of c. difficile expresses both cytotoxins a and b and, in addition, the binary toxin cdt, an adp-ribosyltransferase. due to a deletion in the regulatory tcdc gene, the synthesis rates of toxin a and b are increased by -and -fold, respectively. this strain was detected in for the first time in pittsburgh, usa. since then it has spread to canada, and in it reached europe causing multiple outbreaks in hospitals and nursing homes (warny et al. ) . c. difficile -associated colitis has shown high case fatality rates ( - %) and an increased relapse rate. containment of outbreaks in hospitals and other institutions necessitates isolation of patients or cohorts and strict hygienic measures. during recent decades, a large variety of well known infectious diseases has shown regional or global re-emergence with considerable public health relevance (table . ). globally, tuberculosis is probably the most important re-emerging infectious disease. in developing countries, tb infection still is extremely common and, in the wake of the hiv pandemic, the percentage of those developing overt disease has increased dramatically. worldwide, tb is the most common opportunistic infection in patients with aids. the significance of tb and hiv/tb coinfection is reviewed in chapters and . the re-emergence of some infectious diseases is closely related to the lack or the breakdown of basic infrastructures as seen in periurban slums and in refugee camps in developing countries, or as a consequence of war, breakdown of the civil society, or natural or man-made disasters. cholera is a formidable example for both re-emergence and epidemic spread under those conditions. another important group of re-emerging infectious diseases is caused by various vector-borne infections, such as malaria, dengue fever, and yellow fever. these major vector-borne diseases are treated in more detail in chapter . in addition, there are a variety of re-emerging infections transmitted by arthropod vectors such as various arboviral diseases and some protozoal diseases other than malaria (i.e., leishmaniasis, human african trypanosomiasis). the reasons for the emergence of several vector-borne diseases are rather variable and may range from climatic factors (e.g., global warming, rainfall), lack or breakdown of control, to changes in agriculture and farming and in human behavior (e.g., outdoor activities). these factors are usually quite specific for each of these diseases and largely depend on the specific ecology of the agent, its vectors, and reservoirs. cholera, an acute diarrheal infection transmitted by fecally contaminated water and food, had been endemic for centuries in the ganges and brahmaputra deltas in the th century before it started to spread to the rest of the world. since , six pandemics caused by the classical biotype of vibrio cholerae were recorded that killed millions of people across europe, africa, and the americas. it has been a major driving force for the improvement of sanitation and safe water supply. the seventh pandemic was caused by the el tor biotype, first isolated from pilgrims at the el tor quarantine station in sinai in . it started in in south asia, reached africa in , and is still ongoing. after more than hundred years, cholera spread to the americas in , and beginning in peru, a large epidemic hit numerous latin american countries with . million cases and more than , fatalities reported within years. out of the serogroups of v. cholerae, only o and o can cause epidemics. the serogroup o , first identified in bangladesh in , possesses the same virulence factors as o and creates a similar clinical picture. currently, the presence of o has been detected only in southeast and east asia, but it is still unclear whether v. cholerae o will extend to other regions. since , the re-emergence of cholera has been noted in parallel with the everincreasing size of vulnerable populations living in unsanitary conditions. cholera remains a global threat to public health and one of the key indicators of social development. while the disease is no longer an issue in countries where minimum hygiene standards are met, it remains a threat in almost every developing country. the number of cholera cases reported to the who during rose dramatically, reaching the level of the late s. a total of , cases were notified from countries, including , deaths, an overall increase of % compared with the number of cases reported in . this increased number of cases is the result of several major outbreaks that occurred in countries where cases had not been reported for several years such as sudan and angola. it is estimated that only a small proportion of cases -less than % -are reported. the true burden of disease is therefore grossly underestimated. the absence or the shortage of safe water and sufficient sanitation combined with a generally poor environmental status are the main causes of spread of the disease. typical at-risk areas include periurban slums where basic infrastructure is not available, as well as camps for internally displaced people or refugees where minimum requirements of clean water and sanitation are not met. however, it is important to stress that the belief that cholera epidemics are caused by dead bodies after disasters, whether natural or manmade, is false. on the other hand, the consequences of a disaster-such as disruption of water and sanitation systems or massive displacement of population to inadequate and overcrowded camps-will increase the risk of transmission. chikungunya virus, an arbovirus belonging to the alphavirus group, is transmitted by various mosquitoes. the virus was first isolated in tanzania in and since then has caused smaller epidemics in sub-saharan africa and parts of asia with low public health impact. in , the largest epidemic ever recorded started in east africa, spread to réunion and some other islands of the indian ocean, and then spread further to asia, with more than . million cases in india alone so far. characteristics of the disease are high fever and a debilitating polyarthritis, mainly of the small joints that can persist for months in some patients. now, for the first time, severe and fatal cases have been observed that may be due to certain mutations of the epidemic strain (parola et al. ) . the asian tiger mosquito aedes albopictus has proved to be an extremely effective vector in recent epidemics causing high transmission rates in big cities and leading to epidemics with high public health impact. this southeast asian mosquito species has been shipped by transport of used tires and plants harboring water contaminated with larvae to other continents and, since , ae. albopictus has successfully spread in italy and other parts of southern europe. in august , an outbreak of chikungunya fever occurred in northern italy with more than confirmed cases. the index case was a visitor from india who fell ill while visiting relatives in one of the villages and further transmission was facilitated by an abundant mosquito population during that time, as a consequence of seasonal synchronicity (rezza et al. ). ross river virus (rrv) is another arbovirus of the alphavirus group that causes an acute disease with or without fever and/or rash. most patients experience arthritis or arthralgia primarily affecting the wrist, knee, ankle, and small joints of the extremities (epidemic polyarthritis). about one-quarter of patients have rheumatic symptoms that persist for up to a year. the disease can cause incapacity and inability to work for months. it is the most common arboviral disease in australia with an average of almost , notified cases per year. rrv is transmitted by various mosquito species and circulates in a primary mosquito-mammal cycle involving kangaroos, wallabies, bats, and rodents. a human-mosquito cycle may be present in explosive outbreaks which occur irregularly during the summer months in australia and parts of oceania. heavy rainfalls as well as increasing travel and outdoor activities are considered as important factors contributing to the emergence of rrv epidemics. this flavivirus is transmitted by certain culex mosquitoes and is a leading cause of viral encephalitis in asia with , - , clinical cases reported annually. it occurs from the islands of the western pacific in the east to the pakistani border in the west, and from korea in the north to papua new guinea in the south. only in - infections will lead to encephalitis, which is, however, often severe with fatality rates of - % and with a high incidence of neurological sequelae. despite the availability of effective vaccines, je causes large epidemics and has spread to new areas during recent decades (e.g., india, sri lanka, pakistan, torres strait islands, and isolated cases in northern australia). je is particularly common in areas where flooded rice fields attract water fowl and other birds as the natural reservoir and provide abundant breeding sites for mosquitoes such as culex tritaeniorhynchus, which transmit the virus to humans. pigs act as important amplifying hosts, and therefore je distribution is very significantly linked to irrigated rice production combined with pig rearing. because of the critical role of pigs, je presence in muslim countries is low. crimean-congo virus is a bunyavirus causing an acute febrile disease often with extensive hepatitis resulting in jaundice in some cases. about one-quarter of patients present hemorrhages that can be severe. fatality rates of . - % have been reported in hospitalized patients. cchf is transmitted by hyalomma ticks to a wide range of domestic and wild animals including birds. human infection is acquired by tick bites or crushing infected ticks, and also by contact with blood or tissue from infected animals that usually do not become ill but do develop viremia. in addition, nosocomial transmission is possible and is usually related to extensive blood exposure or needle sticks. human cases have been reported from more than countries in africa, asia, southeastern europe, and the middle east. in recent years, an increase in the number of cases during tick seasons has been observed in several countries such as russia, south africa, kosovo, and greece. in turkey, where before no human cchf cases had been observed, a total of , confirmed cases, including deaths, were reported between and june . the emergence of cchf has been associated with factors such as climatic features (temperature, humidity, etc.), changes of vector population, geographical conditions, flora, wildlife, and the animal husbandry sector. rvf is a mosquito-borne bunyavirus infection occurring in many parts of sub-saharan africa. it infects primarily sheep, cattle, and goats, and is maintained in nature by transovarial transmission in floodwater aedes mosquitoes. it has been shown that infected eggs remain dormant in the dambos (i.e., depressions) of east africa and hatch after heavy rains and initiate mosquito-livestock-mosquito transmission giving rise to large epizootics. remote sensing via satellite can predict the likelihood of rvf transmission by detecting both the ecological changes associated with heavy rainfall and the depressions from which the floodwater mosquitoes emerge. transmission to humans is also possible from direct and aerosol exposure to blood and amniotic fluids of livestock. most human infections manifest themselves as uncomplicated febrile illness, but severe hemorrhagic disease, encephalitis, or retinal vasculitis is possible. in , rvf has been transported, probably by infected camels to egypt, where it caused major epidemics with several hundred thousand infections of humans. it has been suggested that introduction of rvf may be a risk to other potentially receptive areas such as parts of asia and the americas. floods occurring during the el niño phenomenon of in east africa subsequently gave rise to large epidemics and further spread to the arabian peninsula. most recent epidemics occurred in and following heavy rainfalls in kenya, somalia, and sudan, causing several hundred deaths. besides mosquito control, epidemics are best prevented by vaccination of livestock. leishmaniasis, a protozoal transmitted by sandflies, has shown a sharp increase in the number of recorded cases and spread to new endemic regions over the last decade. presently, countries are affected with an estimated million cases worldwide. there are about . million new cases of cutaneous and mucocutaneous leishmaniasis, a nonfatal but debilitating disease with % of cases occurring in afghanistan, brazil, bolivia, iran, peru, saudi arabia, and syria. the incidence of visceral leishmaniasis (vl), a disease with a high fatality rate when untreated, is estimated at around , per year. the situation is further aggravated by emerging drug resistance (table . ) and the deadly synergy of vl/hiv coinfection. epidemics usually affect the poorest part of the population and have occurred recently in bangladesh, brazil, india, nepal, and sudan. for many years, the public health impact of the leishmaniases has been grossly underestimated. they seriously hamper socioeconomic progress and epidemics have significantly delayed the implementation of numerous development programs. the spread of leishmaniasis is associated with factors favoring the vector such as deforestation, building of dams, new irrigation schemes, and climate changes, but also with urbanization, migration of nonimmune people to endemic areas, poverty, malnutrition, and the breakdown of public health. antimicrobial resistance of epidemiological relevance has emerged as a major problem in the treatment of many infectious diseases (table . ). resistance is no longer a problem that predominantly affects the chemotherapy of bacterial infections. it became increasingly important in parasitic and fungal diseases, and despite the short history of antiviral chemotherapy, it already plays a prominent role in the treatment of hiv infection and other viral diseases. resistance is also a problem in some of the emerging infections and will further complicate their treatment and control. resistance of bacterial pathogens has become a common feature in nosocomial infections, especially in the icu and in surgical wards. currently, the number one problem in most hospitals is s. aureus resistant to methicillin (mrsa, see chapter ). however, common problems of resistance also extend to other major bacterial pathogens such as enterococci, various gram-negative enteric bacilli, and pseudomonas species. resistance has developed not only to standard antibiotics (e.g., penicillins, cephalosporins, aminoglycosides, macrolides, or quinolones) but also to second-line antibiotics including carbapenems, glycopeptides, and newer quinolones. however, there is considerable geographic variation. in , the european antimicrobial resistance surveillance system (earss), a network of national surveillance systems, reported vancomycin-resistant rates among enterococci ranging from none in iceland, norway, romania, bulgaria, denmark, and hungary to % of enterococcus faecium strains in greece (earss ) . a surveillance study conducted in the united states hospitals from to showed that % of nosocomial bloodstream infections were caused by enterococci and that % of e. faecalis isolates and % of e. faecium isolates were vancomycin resistant (wisplinghof et al. ) . rates and spectrum of antibacterial resistance of e. coli and other gram-negative enteric bacilli may differ considerably from one hospital to the other. in some important pathogens of hospital-related infections such as klebsiella, enterobacter, and pseudomonas species, resistance to almost all available antimicrobials has been observed. this may complicate the choice of an effective initial chemotherapy considerably. therefore, each hospital has to monitor the epidemiological situation of resistance regularly, at least for the most important bacteria causing nosocomial infections, such as staphylococci, enterococci, gram-negative enteric bacilli, and pseudomonas. even in community-acquired infections, there has been a considerable increase in resistance problems. at present, approximately % of pneumococcal isolates in the united states are resistant to penicillin, and % exhibit intermediate resistance. the rate of resistance is lower in countries that, by tradition, are conservative in their antibiotic use (e.g., netherlands, germany) and higher in countries where use is more liberal (e.g., france). in hong kong and korea, resistance rates approach %. in addition, about one-quarter of all pneumococcal isolates in the united states are resistant to macrolides. this rate is even higher in strains highly resistant to penicillin, and increasingly there is multiresistance against other antibiotics such as cephalosporins. the prevalence of meningococci with reduced susceptibility to penicillin has been increasing, and high-level resistance has been reported in some countries (e.g., spain, united kingdom). although high-dose penicillin is effective in infections with strains of intermediate resistance, most national and international guidelines recommend broad-spectrum cephalosporins such as ceftriaxone as first-line drugs. however, in most developing countries, penicillin and chloramphenicol are the only affordable drugs. in recent years, certain strains of community-acquired s. aureus with resistance to methicillin (cmrsa) have been observed which produce a toxin (panton-valentine leukocidin) that is cytolytic to pmns, macrophages, and monocytes, and which are an emerging cause of community-acquired cases and outbreaks of necrotic lesions involving the skin or the mucosa, and in some patients also of necrotic hemorrhagic pneumonia with a high case fatality (vandenesch et al. ) . development of resistance is mainly determined by two factors: -the genetic potential of a certain pathogen, i.e., mobile elements such as plasmids, transposons, or bacteriophages, genes coding for resistance, and mutation rate. -the selection pressure caused by the therapeutic or the para-therapeutic application of antimicrobial drugs. in the hospital these factors are supported by -microbial strains that are highly adapted to this environment (e.g., rapid colonization of patients, resistance to disinfectants), -an increasing percentage of patients who are highly susceptible to infections due to old age, multimorbidity, immunosuppression, extended surgery, and invasive procedures, and -the frequent use of broad-spectrum antibiotics or combinations of antimicrobial drugs. another source of resistant bacteria has been identified in mass animal production and the use of antimicrobials as growth promoters (e.g., the glycopeptide avoparcin, the streptogramin virginiamycin) or as mass treatment in the therapy or the prevention of infections. the inadequate use of antimicrobial drugs is also an important factor responsible for the development of resistance in community-acquired infections. this is especially true in developing countries where only a limited spectrum of antibiotics is available, where shortage of drugs often leads to treatment that is underdosed or too short, and where uncontrolled sale and use of antibiotics is commonplace. as a consequence, resistance of gonococci is extremely frequent in southeast asia, and resistance of salmonella typhi, shigella, and campylobacter to standard antibiotics is common. some of the still effective second-line antibiotics have to be given parenterally or are not available because they are too costly. a typical example of the consequences of insufficient chemotherapy due to lack of compliance and/or unavailability of drugs is the alarming increase in multiresistance and extreme resistance in tb (see chapter ). resistance is also a problem in parasitic diseases such as malaria (see chapter ), leishmaniasis, or african trypanosomiasis. plasmodium falciparum developed resistance against all major antimalarial drugs as soon as they were used on a broad scale. resistance had contributed significantly to the increase in malaria-associated morbidity and mortality observed in many endemic areas (wongsichranalai et al. ) . a recent report on failures of the new artemisinin combination treatment for p. falciparum malaria at the thai-cambodian border supports fears of the development of resistance to this most promising class of drug at present (dondrop et al. ). resistance against antiviral drugs has developed almost from the beginning of antiviral chemotherapy (table . ). in the treatment of hiv infection, the risk of development of resistance has been drastically reduced by the combination of several drugs with different mechanisms of action (see chapter ). however, drug resistance remains the achilles' heel of the highly active antiretroviral therapy (haart) and may be at a considerable risk of expanding haart to the developing world. today, we have to realize that as we develop antimicrobial drugs, microbes will develop strategies of counterattack. antimicrobial resistance occurs at an alarming rate among all classes of pathogens. even in rich countries it causes real clinical problems in managing infections that were easily treatable just a few years ago. in life-threatening infections such as sepsis, nosocomial infections, or falciparum malaria, there is a substantial risk that the initial chemotherapy might not be effective. in addition, the delay caused by inadequate treatment might favor transmission to other people and support the spread of resistant pathogens (e.g., multiresistant tb). last but not the least, surveillance and control and the necessity to use expensive second-line drugs or combinations of antimicrobials are enormous cost factors. for developing countries this is a major limitation in the treatment and control of infections caused by resistant agents. so, in many ways, emerging resistance contributes to the emergence of infectious diseases. despite the availability of effective strategies for treatment and prevention, infectious diseases have remained a major cause of morbidity and mortality worldwide. however, the problems associated with infections are due to considerable changes. in industrialized countries the mortality caused by infectious diseases has decreased tremendously during more than years. however, during recent years, both mortality and morbidity associated with infections are increasing again. ironically, this is closely associated with the advances in medicine which have contributed to profound changes in the spectrum of both patients and their infections. advanced age, underlying conditions, and an altered immune response are common features in the seriously infected hospital patient today. immunosuppressive therapy is frequently used to treat neoplastic and inflammatory diseases or to prevent the rejection of transplants. some infections, most notably hiv/aids, cause immunosuppression by itself. in the compromised patient, infections are generally more severe or may be caused by opportunistic pathogens that will not harm the immunocompetent host. antimicrobial treatment is often less effective in these patients and tends to be further complicated by antimicrobial resistance which may manifest itself or develop at a higher frequency in the immunocompromised patient. an increasing percentage of infections are hospital acquired or otherwise health care associated. it is estimated that nosocomial infections affect . million patients and contribute to approximately , deaths in us hospitals annually (klevens et al. ). considering the rising number of elderly and immunocompromised patients, a further increase in severe infections can be predicted. in developing countries, the significance of infectious diseases has remained high for ages and despite the advances in medicine. until now, infections are by far the leading cause of both disability-adjusted life years and life years lost. the reasons are obvious and mostly related to poverty and lack of development causing poor and unhealthy living conditions, inadequate health systems, and lack of resources for prevention and treatment. this is, of course, just an integral part of the general socioeconomic problems of developing countries. however, poor health conditions per se are an important obstacle to development, and infections such as hiv/aids in sub-saharan africa can be a major cause of lack of development, increasing poverty, and political instability. generally, the situation of many developing countries has not improved during the last two decades, and the gap between the first and the third world has increased. however, most of the mortality and morbidity associated with infectious diseases is avoidable. as laid down in the millennium goals, a major task of the world community will be to counteract the imbalance between the industrialized and the developing countries and to find strategies to ensure participation in the progress of modern medicine for all. developing countries also carry the main burden of diseases caused by newly emerging and re-emerging infections (table . and . ) . however, the consequences of economical and political crises on emerging infectious diseases are obvious in industrialized countries also-such as the return of diphtheria or the increase in tb and multiresistant tb after the breakdown of the former soviet union. today, all countries worldwide are affected by emerging infections as well as by emerging antimicrobial resistance. in the age of globalization, travel and transport of people, animals, and goods of all kinds have increased tremendously. as a consequence, infectious agents may travel over long distances and at high speed. this is clearly evident with influenza pandemics or outbreaks such as the sars epidemic or with imported cases of viral hemorrhagic fever transmissible from person to person. the spread of antimicrobial resistance or the re-emergence of tb seems to be less spectacular, but the consequences may be at least as important in the long run. management and control of emerging and re-emerging infectious diseases can be very different from disease to disease and has to allow for all relevant factors of the populations at risk and of the specific disease including the ecology of the agent, its vectors, and reservoirs. however, some basic principles apply to all situations: -surveillance -information and communication -preemptive planning and preparedness -provision and implementation of • adequate treatment • adequate control and prevention -international cooperation active and passive surveillance systems with rapid reporting and analysis of data are essential for the early detection of outbreaks, changes in epidemiology, and other events of public health concern (see chapters and ). however, many resourcepoor countries do not have functional surveillance systems. in addition, reporting of infectious diseases may be neglected or delayed because of fears of stigma, international sanctions including trade and travel restrictions, or interference with tourism. classical examples are plague and cholera, but also recent examples such as the bse/vcjd crisis in the united kingdom or sars originating from china showed undue delays between first occurrence of cases and information to the public. although, in outbreaks of new and unknown diseases it may be difficult, or even impossible, to predict or assess the magnitude of the problem and the potential consequences, timely and adequate information and communication is not only obligatory, according to international regulations, but also the best strategy to avoid rumors, misbeliefs, panic, or disregard. in recent years, many countries have installed national plans of action for important epidemiological scenarios and outbreaks such as pandemic influenza, bioterrorism, import of viral hemorrhagic fevers transmissible from person to person, sars, and comparable diseases or outbreaks. all member states of the world health assembly that have so far not been able to install functional surveillance and/or pre-emptive planning are obliged to do so within a maximum of years after their ratification of the new international health regulations (who ) . preparedness not only means surveillance and planning but also has to include the provision of facilities to adequately treat and, if necessary, to isolate patients with infectious diseases of public health importance and relevant epidemic potential and/or at risk of transmission to other persons including health-care workers. task forces and high containment facilities for both laboratory diagnostic services and treatment of patients using barrier nursing have been set up in several countries. however, all health facilities of a certain level such as general hospitals should be prepared by their organization and structure to treat patients with infections of public health relevance such as multiresistant tb under appropriate isolation and barrier nursing conditions. this also applies to hospitals in resource-poor countries. adequate training of health-care workers and strict management have been effective to control outbreaks of highly contagious infections within rural african hospitals lacking sophisticated technical equipments (cdc ) . strategies for control and prevention may be quite different for various emerging infections. effective vaccinations are available only for some infections and are usually lacking for newly emerging infections (table . ). for the majority of emerging infections, control and prevention have to rely on information, education and exposure prophylaxis, interruption of transmission by vector control and control of reservoir hosts (e.g., rodents), and case finding with early diagnosis and treatment. for diseases and outbreaks caused by infections of public health relevance that are transmissible from person to person, containment procedures including isolation and treatment of patients under condition of barrier nursing as well as tracking and surveillance of contacts are warranted by national and international health regulations. here, international cooperation is essential to successfully contain outbreaks and epidemics such as the sars epidemic in . despite dramatic progress in their treatment and prevention, infectious diseases are still of enormous global significance with tremendous economic and political implications. emerging and re-emerging infectious diseases as well as emerging antimicrobial resistance are major challenges to all countries worldwide. for the management of current and future problems, it will be most important to counteract the imbalance between the industrialized world, new economies, and developing countries, and to adequately and timely react to new threats on a global scale. a new type of papillomavirus dna, its presence in genital cancer and in cell lines derived from genital cancer world health organization: infection control for viral haemorrhagic fevers in the african health care setting nipah virus: a recently emergent deadly paramyxovirus helicobacter and gastric carcinoma. serum antibody prevalence in populations with contrasting cancer risks effects of climate change on the incidence of tick-borne encephalitis in the czech republic in the past two decades artemisinin resistance in plasmodium falciparum malaria identification of a novel coronavirus in patients with severe acute respiratory syndrome a papillomavirus dann from a cervical carcinoma and its prevalence in cancer biopsy samples from different geographic regions susceptibility results for e. faecium isolates lyme-borreliose in einem europäischen endemiegebiet: antikörperprävalenz und klinisches spektrum hantavirus outbreak global trends in emerging infectious diseases hepatitis e virus and chronic hepatitis in organtransplant recipients estimating health care-associated infections and deaths in u.s. hospitals nipah virus encephalitis outbreak in malaysia lyme borreliosis in europe: influences of climate and climate change, epidemiology, ecology and adaptation measures. who regional office for europe altitudinal distribution limit of the tick ixodes ricinus shifted considerably towards higher altitudes in central europe: results of three years monitoring in the krkonose mts epidemiology of helicobacter pylori infection : results of a household-based seroepidemiological survey outbreak of west nile virus infection novel chikungunya virus variant in travelers returning from indian ocean islands isolation of a cdna from the virus responsible for enterically transmitted non-a, non-b hepatitis infection with chikungunya virus in italy: an outbreak in a temperate region waldarbeiter-studie berlin-brandenburg zu zeckenübertragenen und andere zoonosen risikofaktoren für lyme-borreliose: ergebnisse einer studie in einem brandenburger landkreis übertrifft die infektionszahlen der vorjahre zahl der hantavirus-erkrankungen erreichte in deutschland einen neuen höchststand prevalence and determinants of helicobacter pylori infection in preschool children: a population-based study from germany hantaviruses: a global disease problem safety and efficacy of a recombinant hepatitis e vaccine tick-borne diseases in the united states the national creutzfeld-jakob disease surveillance unit (ncjdsu) marburg virus infection detected in a common african bat community-acquired methicillin-resistant staphylococcus aureus carrying panton-valentine leukocidin genes: worldwide emergence multiple exposures during a norovirus outbreak on a river-cruise sailing through europe toxin production by an emerging strain of clostridium difficile associated with outbreaks of severe disease in north america and europe prevalence of borrelia burgdorferi antibodies in hamburg blood donors nipah virus outbreaks in bangladesh revision of the international health regulations nosocomial bloodstream infections in us hospitals: analysis of cases from a prospective nationwide surveillance study large outbreak of norovirus: the baker who should have known better epidemiology of drugresistant malaria nipah virus infection in bats (order chiroptera) in peninsular malaysia key: cord- -xhx pzhj authors: nan title: nd world congress on pediatric intensive care rotterdam, the netherlands, – june abstracts of oral presentations, posters and nursing programme date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: xhx pzhj nan we present the results of a prospective population-based audit of paediatric intensive care activity in two comparable communities with markedly different delivery systems. in the trent region of the uk ( . million people), children receive intensive care largely without the supervision of a paediatric intensivist in a variety of hospitals, few of which have designated paediatric intensive care units (picus). critically ill children otherwise receive intensive care in children's wards, special care baby units (scbus) or adult intensive care units. in the australian state of victoria ( . million people), children receive intensive care almost exclusively in one centre -a picu staffed by full time paediatric intensivists. the two regions are otherwise demographically comparable. in both groups, data were collected on all children admitted to an intensive care unit between / / and / / and children who received intensive care (defined by levels of intervention and nurse dependency) in other sites during the same period. values of each variable at first contact with the icu, and the highest and lowest values over the first hours were recorded. the principal outcome was survival to discharge from the intensive care unit. severity of illness was assessed using pim (paediatric index of mortality) and prism. risk-adjusted mortality was compared using flora's z test and logistic regression. the rate of utilisation of intensive care (> admissions in each region) were similar. there was some variation in case mix between the two groups, but crude mortality rates were similar ( . % in trent and . % in victoria). however severity corrected data and other measures of picu performance were dramatically better in' the centralised delivery system. the substantial excess mortality in the trent region provides strong evidence for the benefits of centralisation of paediatric intensive care services. there are considerable difficulties in evaluating the efficiency and effectiveness oflcare in children presenting with respiratory failure during acute medical illness. optimal outcomes for such episodes include survival and the shortest length of stay (los) in intensive care with negligible risk of readmission. we have tried to determine whether or not the time course of acute severe medical illness with respiratory failure is predictable. study i (n= ): a retrospective study of intubated and mechanically ventilated children (> days, < years) with acute severe medical illness. measures: diagnosis, intensive care los in calender days, and survival. results: the underlying diagnosis fell within one of three broad categories: respiratory disease (n= , mortality . %), central nervous system (cns) disease (n= , mortality . %), and systemic inflammation or multisystem (sims) disease (n= , mortality . %. the los in survivors was: respiratory -median (interquartile range) ( - ) days, cns ( - ) days, £p, £ ( -g) days. :i'~'-+cen diag~,~is-rc!ated-grnnp~ (drgs) were identified ( respiratory, cns, sims disease) and each have been characterised by mortality and los. study ii (n= ): a prospective study of patients supported by the hypothesis that los for the above drgs was predictable (compared with study i data). in certain instances attributable causes for variances in los were identified: e.g. disease severity, timing ofdrug therapy, and associated disease. with daily paediatric risk of morality scoring within each drg, four profiles of instability were identified. discussion: the time course of acute severe medical illness with respiratory failure is predictable and variance may be attributable to specific care or diagnostic factors. we are now developing a means of linking drg-specific clinical care pathways with an integrated computerised decision support and education facility at the bedside. the objective of this open, prospective study was to assess the relation between basic patient characteristics as well as effectiveness of treatment on the one hand and resource utilization in pediatric intensive care on the other. as universal, non-monetary indicators of resource utilization we used the therapeutic intervention score system (tiss) and length-ofstay (los), from which indicators for total resource utilization per admission (tisstot) and average daily resource utilization (tiss-mean = tisstot/los) were obtained. overall admissions, totalling days, were included. mortality was . %; non-survivors accounted for . % of overall resource utilization. in non-survivors, both total resource utilization per admission and average daily resource utilization were higher, whereas los was not different from survivors'. severity of illness, surgical status, the presence of substantial chronic comorbidity, emergency admission and transfer from another hospital constituted the major predictive determinants of tisstot (r:= . ) and tissmean (ra= . ) in multiple regression analysis (p< . ). hence these indicators are appropriate non-monetary measures of resource utilization, a considerable proportion of which are determined by a concise set of basic clinical characteristics. subsequently we analysed the relation between effectiveness of care and resource utilization by assessing severity of illness corrected mortality in low, medium and high resource users, respectively. these categories were delineated by percer/tiles of resource utilization (< p , p -ps , > ps ). despite on average long los and high resource utilization in the high risk group, a relatively low standardized mortality was found, probably warranting prolonged intensive treatment in this patient category. summary: objective:the primary purposes of intensive care are to provide treatments to patients with life-threatening physiological dysfunction or to monitor and observe patients perceived to be at significant risk of dying. this collaborative study was performed to describe our patients and their outcome. in order to improve our results we tried to identit~ high risk groups, patients and methods: picus entered the study, the data included all the admissions with > hs. during a days period between the l°june and the th september . the records included: age, sex, weight, mechanical ventilation (mv), post-operative condition (p.op), malnutrition, diagnosis, length of stay, prism score and outcome. student test, mann-whitney or wileoxon were performed for univariate analysis. fisher exact test or chi square for dicotomic variables. risk group analysis was performed by logistic regression, odds ratio and % confidence interval. results: patients entered the study. mean age was . months (ds hh¢# ) and median months. we found significant statistical differences in calculated ,is observed mortality rate comparing malnourished with euthrofic patients; mechanical ventilated (mv) with non mv patients. no differences in ter ~,h of stay or di~ noses were found. effect of the un sanctions on the morbidity rate araong the iraqi small children ( below years old of age ) in bagdad. abdulsamad a.abood / institute of medical technology, bagdad. meningitis is essentially a childhood disease (i). the risk of infection are increased by powerty and overcrowding ( ). the impah'ed immunity may be an important pathogenic factor underlying the susceptibility to infections in undernourished subjects ( ). in general, malnutrition is a man made disease and it begins quite in the womb and ends in the grave (i). small children, below years of age were admitted to the pediatric hospital in washash with meningitis over cold months in i , in contrast to only child admitted with meningitis over the same period in . all of the children who admitted in were frankly undernourished, % of them were infected with enterobacteriae, because they were exposed to faulty hygiene and lack of asepsis. these facts showed precisely that our small children had suffered at most from the un_ sanctions against iraq, because of food, milk and drug shortage, since years which had resulted a severe undernutrition among them, which impaired their immune status. m wells, of riera-fanego, j lipman. baragwanath intensive care unit, university of the witwatersrand, south africa. background the use of prism or other scoring systems in the icu is of great importance for evaluating the efficacy and efficiency of a particular icu, the prism score was developed and validated in the usa and europe but has recently been shown to be inaccurate in a south american population, a south african population as well as several european studies. part of the poor performance of the prism score is as a result of differences in the case mix between the reference population and other paediatric icus. since scoring systems should generally be used only in populations similar to the reference population from which the prediction model was developed, a modification of the prism score is necessary to improve its discriminatory ability in a wide range of patient groups, aim to improve the predictive power of the prism score in a south african paediatdc icu population. patients & methods we analysed prism, demographic and clinical data collected prospectively from consecutive paediatrie icu admissions. the prediction of actual mortality by prism was evaluated by standard statistical methodology (goodness-of-fit test and receiver operating characteristic (roc) analysis), the components of the prism logistic regression equation (prism score, operative status and age) and the physiological variables making up the prism score in addition new variables analysed (nutritional index, the need for inotropes and institution of mechanical ventilation) were subjected to discriminant analysis to determine their association with outcome. results the goodness-of-fit test showed a significant failure of prism to accurately predict mortality over a wide range of expected mortality (chi [ ] = , p = ). prism underpredicted mortality at lower prism scores, but overpredicted mortality in patients with high prisms. similarly roc annysis indicated apoor predic~jve power (az = . ± . ), with an area under the curve significantly less than that for the prism reference population (p = ), prism showed equally poor discriminatory function at all age groups and diagnosfic categories. '~mth the addition of an index of nutrifional status (proportional weight-far-age), and indicators of early respiratory and cardiovascular failure to the logistic regression formula, and a recalibration of the acute physiological score component, the roc can be improved to . ± . , with a good fit described by the goodness-of-fit test (cn ] = , p = . ). discussion the prism score is not accurate in our patient population has been recalibrated in view of the poor discriminatory function that we have shown. part of the inaccuracy derives from the different demographic characteristics of our icu population and a different pattern of diseases. in addition to assessments of acute physiological aberrations, an assessment of nutritional status and early respiratory and cardiovascular failure significantly improve the discriminatory ability of the prism score, these parameters have been devised with a view to improving the accuracy of prism in our population, while not decreasing its accuracy in icus similar to the reference population. in interviewing parents regarding how physicians have communicated bad news, the response i have received is that it has not infrequently been done without appropriate care, understanding and compassion. personal experience and the lessons learned from parents, chaplains and others who deal extensively with these situations have provided me with an approach that has been supportive, compassionate, and caring. an especially difficult communication situation for the intensivist occurs when the parents have to be informed of the death of their child. for the parent, death is the hardest loss of all -the ultimate unalterable loss. circumstances surrounding the death are an important consideration (e.g., a fatal crash caused by a drunken driver, a prolonged illness, a suicide, aids). each produces a different grief reaction. the physician needs to inform parents of their child's death sympathetically coming right out with the news and leaving details until later. allow pauses and time for the paren~ to express sorrow and grief, the best communication may be thoughtful silence and a tender touch. there is disbelief that this happened. it is necessary to repeat oneself. acknowledgment of the parent's "feeling terrible" and the physician's acknowledgment of how terrible he/she feels that the life of the child could not be saved is an important first step in the parent's dealing with this tragic loss. with prolonged resuscitation, it is helpful to have a member of the icu team talk to the parents while the resuscitative efforts are ongoing so that the parents are not left unsupported at this time. a progress report should be delivered in a caring, lucid, and sensitive.manner, indicating that every effort is being made to save the life of their desperately injured child. after a child has died, it is helpful to the family if the physician maintains some contact with them. this should take the form of follow-up telephone calls at approximately , , and months. this can help to screen for depression in the parents. in giving bad news to the family and making every effort to support them through this tragic time, it is necessary to remind oneself that the intensivist has personal needs for dealing with grief and will also require support to pass through this stage. direct evidence that child mortality is lower in specialist pediatric icus comes from studies. a study in oregon (ccm ; : - ) found that mortality adjusted for severity of illness was % of expected in pediatric units and % of expected in general units (p< . ). a study in holland (ccm ; : - ) found that mortality in high risk patients was % of expected in tertiary pediatric units, and % of expected in nontertiary units (p< . ). a third unpublished study, has found that children in victoria (who almost all receive intensive care in a pediatric icu) have a much lower standardised mortality rate than children in the trent region of the uk (where many children receive intensive care in adult icus). there is indirect evidence that icus looking after many children are likely, on average, to perform better than icus looking after few children: numerous studies in many specialities have found that units looking after many cases of a particular disease have better results than units with few cases. see luft hs, "hospital volume, physician volume, and patient outcomes", happ, ; and farley d, medical care ; : - . compared to general icus, medical and nursing staff in pediatric icus are likely to be better at looking ~fter children, and plcu rmos have greater skills in pediatric intubation, ventilation, iv drip insertion and drug doses. picus are more likely to have appropriate equipment to manage children -especially for uncommon but life-threatening situations. icus in pediatric hospitals are more likely to have physicians and surgeons with pediatric expertise available for consultation at all times. the american academy of pediatrics, the society of critical care medicine, the british paediatric association and the australian nh&mrc have all said that children should receive intensive care in'specialist pediatric units. the weight of authoritative opinion, and direct and indirect evidence is strongly in favour of looking after children in dedicated pediatric icus. neurological deficit showed higher cbf values ( . / . ml/ g/ rain.) than the patients with good outcome (mean cbf . sd + . ; cbf . sd _+ . ml/ g/rain}. discussion: in asphyxia decrease of ph is due to reduced tissue oxygenation and indicates the severity of metabolic derangements. co reactivity in newborns with perinatal asphyxia correlates with the lowest ph and therefore may reflect severity of asphyxia. continuous monitoring of cerebral activity is carried out in our unit on all admissions at risk of cerebral dysfunction, a number of monitors are commercially available and we report our experience with the cfam which provides in addition to amplitude integrated eeg analysis, continuous raw eeg display and frequency distribution. bilateral recordings are commenced as soon as possible and continued while clinically indicated. forty one children ranging in ages from weeks to years were monitored for periods from hours to i days, diagnoses included traumatic brain injury ( ), sepsis/meningitis/encephalitis ( t), status epilepticus ( ) and miscellanous others ( ). results are tabulated below. patients status epilepticus * beta activity * background voltage * < i o/zv or more of above * (*z p < , ) asymmetry developed in children, all of whom died. positive predictors of good outcome included a mean background activity of > zzv, the presence of faster frequencies (usually ) in response to sedative drugs and the absence of seizures. all monitoring is performed by the picu staff and increasing expertise in interpretation has resulted in earlier therapeutic and diagnostic interventions. regional it was previously found that histamine, a vasoactive mediator, accumulated in brain compartments (kov~ics et al neurosci lett : ) , and antihistamines prevented brain edema formation (dux et al. neuroscience : ) in asphyxiated newborn pigs. in the present study we investigated the effect of intracarotid histamine injection on the blood-brain barrier (bbb) permeability, left internal carotid artery of newborn pigs ( - h; , - , g; ketamine anesthesia, mg x kg ) was catheterized through the external branch and different doses of histamine ( , - , xi - , - , x , m, respectively, in groups of animals; n= in each) diluted in . ml isotonic saline was injected into the vessel through rain. bbb permeability was determined for a small (sodium fluorescein, sf, da) and a large (evans blue/albumin, eba, kda) tracer ( %, mlxkg , rain circulation time for both dyes) concomitantly in frontal, parietal and occipital cortex, hippocampus, and periventrieular white matter both on left and right sides h after the challenge. then, intravascular dyes were removed by perfusion and bbb permeability for both tracers was quantified by fluorescence spectrophotometry (wavelengths for excitation and emission were nm and nm for sf; and nm and nm for eba, respectively). histamine injection, in doses higher than . m, significantly (p< . ; kruskal-wallis one way anova on ranks followed by dunn's test) increased bbb permeability for both tracers in each brain region. changes in left hemisphere were more intense (p< . ) than those in right one after the doses of xi - and - m in each region, i m histamine administration induced similar edema in both sides. increased intracarotid histamine levels resulted in a dose-dependent vasogenic brain edema formation. histamine might have a pathogenetic role in neonatal hypoxicischemic cerebral injuries. supported by otka f- and h-u.s,-jfno. , $ in coma caused by traumatic brain jnjury, an indication of the likely outcome is provided by the best motor response to pain in the first .$ hours after the insult. in a study in our picu, the proportion of children who died or had a severe disability was % in who had no response to pain, % in with an extensor response, % in with a flexor response, and % in who localized in response to pain. the long term outcome of traumatic brain injury appears to be worse in children < years old. other risk factors in traumatic brain injury are absent basal cisterns, midline shift or subdural haemorrhage on ct scan (or loss of grey-white differentiation in nontraumatic injury); or an intracranial pressure > mmhg despite hyperventilation, mannitol and barbiturate infusion. apart from brain death, there are two findings implying such a poor prognosis that consideration should be given to stopping treatment: first, after traumatic injury, the absence of any motor response to painful stimulus in the cranial nerve distribution (providing drug effects and a post-ictal state have been excluded); and second, in acute brain injury from trauma, infection, hypoxia, or ischaemia, the b{lateral absence of short-latency somatosensory evoked potentials (providing brain stem haemorrhage, subdural and extradural effusions, and decompressive craniectomy have been excluded). in children over months of age, recovery from prolonged coma or a vegetative state is exceedingly rare when more than months have elapsed after traumatic brain injury, and when more than months have elapsed after nontraumatic injury. overproduction of nitric oxide (no) via an inducible isoform of" no synthasc (inos) produces profound vasodilatation in adult septic shock. high nitrate levels have been reported in hypotensive children with sepsis syndrome ]. cardiovascular collapse is a prominent feature of severe meningocoecai disease (mcd). however, systemic vascular resistance (svr) was slightly higher in a group of non-survivors ~ and the rote of no in ivicd remains unclear. children with a presumptive diagnosis of mcd were enrolled. parental consent was obtained. blood was drawn on admission and hrly thereafter. plasma was separated immediately and stored at - °c. the final concentrations reported represent the product of nitrite and nitrate (nox). nox was measured spectrophotometrically using the greiss reaction. children were studied (median age (range); m ( - )). the diagnosis of mcd was confirmed in children, of whom had a glasgow meningococcal score (gms) of" ~ . in this group with severe mcd there were deaths. peak nox was significantly higher (,. ( - ) vs ( - )nmol/ml, median) and systolic btood pressure was significantly lower in children with severe mcd than mild mcd (p< . . wilcoxon rank test). there was a significant correlation between peak nox and gms (spearman's rank correlation r= . (p= . )) and prism (r= . (p: . )). nox production from adm.ission onwards was also higher in the severe mcd group (p: . , kmskal ~wallis). we have demonstrated that plasma nox levels are elevated in children with mcd, correlate directly with the severit ' of disease and are inversly related to systolic blood presssure. similar to hypotensive septic syndrome, mcd appears to be associated with an up-regulation of the l-arginine-no pathway.. non-survivors with mcd have higher svrs and may be relatively hypovolaemic. in our group of severe mcd there was a significantly lower systolic pressure and increased no formation. excess inos expression at different stages in mcd may contribute to the pathology of the disease. the identification of agents which can boost and/or inhibit no reiease may therefore represent different treatment strategies for mcd. u. merz, th. peschgens, g. kusenbach, m. b hle, h. h rnchen in this controlled, prospective study ventilated premature infants with a birth weight < g were randomized to receive treatment with dexamethasone (dex) either on day of life or on day of life. dex was given over days tapering from . mg/kg/day to . mg/kg/day. the infants treated with dex on day of life could be weaned earlier from the ventilator -in median after days (range - ) versus days (range - ) in the [ate treatment group (p = . ). the need for supplemental oxygen was shorter in the early treatment group -in median days (range - ) versus days (range - ) (p = . , ns). the incidence of chronic lung disease was lower in the early treatment group - of infants ( . %) versus of patients ( . %) (ns). to evaluate the long-term efficacy of early dex treatment we performed a respiratory function test in the age of - months using an infant whole body-plethysmograph. the intrathoracic gas volume (itgv), the airway resistance (r.w) and the airway conductance (gaw) were measured and no significant differences could be detected between the groups. the frequency of adverse effects due to dex therapy was found to be without significant differences between the early and the late treatment group. we conclude that early dex treatment had short-term improvements in pulmonary outcome in our study population, long-term efficacy however, remained unproven. several factors contribute to the development of chronic lung disease (cld) in premature infants including structural immaturity of the lung, mechanical ventilation, and oxidative stress. reactive oxygen species are formed during normal cellular metabolism but they are generated in higher concentrations during inflammation or inhalation of high oxygen concentrations. to study the relationship between increased oxidative stress, antioxidants and the development of cld we examined ventilated premature infants with birth weights below t g. infants developed severe chronic lung disease of prematurity (cld), defined by radiological signs of cld and an increased oxygen requirement at a postconceptional age of weeks, and infants had moderate cld with an increased oxygen requirement on day but not at an age of weeks. ventilator settings (fio , peak inspiratory and mean airway pressure) and the incidence of early-onset-sepsis were significantly higher in the severe cld group than in infants with moderate cld or without cld (n= ) during the first week of life. plasma concentrations of the two antioxidative substances bilirubin and uric acid (ua) were comparable in all groups during the first days of life. however, on day seven bilirubin and ua were significantly decreased in the plasma of infants with severe and moderate cld compared to the non cld group (p<o. ). there was no difference between both cld groups. in serially obtained tracheal aspirate fluids (taf) malondialdehyde (mda) was measured by hplc as an indicator of lipid peroxidation reflecting oxygen injury of the lung. ua was found in higher concentrations in taf than bilirubin. ua has been proven to be a potent antioxidant, capable to react especially with hydroxyl radicals and hydrochlerous acid, which play an important role in the induction of lipid peroxidation. infants with severe cld had significantly higher mdnua ratios in taf from day to compared to the non-cld group (p<o. ). mdnua ratios in taf of infants with moderate cld were significantly higher from day on but still lower than in the severe cld group. in addition, the ratio oxidized / reduced glutathione was significantly increased in taf of infants with cld compared to infants without cld between day and . the data support the hypothesis that an imbalance of oxidative stress and antioxidant defense contributs to the onset of cld at the end of the first week of life. introduction. rocuronium bromide (roe), a neuromuscular blocking agent with an onset time dose to that of succinyleholine l'z, has been studied in american society of anesthesiologists' physical status (asa) i or ii pedlatrie patients under non-critical elective conditions. there is a paucity of studies looking at the pharmacodynamics of roc under emergent conditions, involving pediatric patients who are asa iii or iv, without the use of adjuvant inhaled anesthetics ~. methods. with approval of our committee on clinical investigations (irb), roe . mg/kg was administered to asa iii/iv pediatric intensive care patients (age days to months; m:f= : ) on intravenous sedation. the time to reach % a~d % of b~elinc tetanie stimulus response was recorded using a r.elaxogra'ph/qmt- nerve stimulator/recorder (datex, helsiaki). depth of clinical relaxation at the % level was recorded. results. the time from rapid bolus to % was . + . see with a range of - see; and to % was . + . see, with a range of - see. at the % level, excellent clinical relaxation was seen. conduslon. in critically ill children, use of roe at . mg/kg produces rapid onset of neuromuscular blockade and excellent clinical relaxation, such that roe should be considered for rapid sequence intubation. int anesth clin. ; ( ): - . anesthesiology. ; ( ) computed tomography of the chest (ct) in mechanically ventilated adults can detect intrathoracic pathology not appreciated on chest radiographs (cxr) and influence intensive care management. no such data exists for ventilated children. aims: ) to assess if ct provides additional information over cxr regarding extent and nature of intrathoracic disease in ventilated children. ) to determine whether such information alters clinical management, inclusion criteria : ventilated children with cxr changes inconsistent with their respiratory status underwent ct if either a) pao :fio ratio < and/or mean paw> cm h or b) there was an unexplained increase in ventilatory requirement. methods : high resolution ct was performed in patients and spiral ct in patierits, to ensure minimal transport related morbidity, patients were transferred to the ct scanner by a specialised mobile intensive care team. results: in / patients ct demonstrated greater extent of disease than appreciated on cxr but did not significantly alter clinical management. in / patients ct provided additional information regarding the nature of disease present, in / children this involved a further diagnosis and in / children the exclusion of a suspected pathology. new information led to a positive therapeutic intervention in children, prevented inappropriate manoeuvres in , and had no significant effect on acute management in children. conclusions: initial data suggests that in a selected group of mechanically ventilated children chest ct can add to the sensitivity and specificity of intrathoracic diagnosis provided by the chest radiograph and directly influence acute management. case selection criteria and choice of the most appropriate protocol requires further study. pressure control ventilation (pcv) utilizes a decelerating flow pattern which may improve gas distribution and lead to alveolar recruitment. in contrast, volume control ventilation (vcv) employs a constant flow. in children, the effects of pcv as compared to vcv are unclear. the purpose of this study was to determine how these two modes compare in terms of dynamic compliance (cdyn). peak iaspiratory pressure (pip), and mean airway pressure (paw) at equivalent minute ventilation. methods: sixteen infants and pediatric patients ranging in age from day to years were studied. diagnoses included ards ( ), postoperative cardiac surgery ( ), head trauma ( ), and resfrictive lung disease ( ). patients were randomized to pcv ( ) or vcv ( ). initial measurements of gas exchange (abg's) and respiratory mechanics (ventrak, novametrix medical systems) were obtained after a minute stabilizadon period. respiratory mechanics included pip, peep, paw, delivered tidal volume, and cdyn (avolume/apressure). the patients were then crossed over to the alternate mode of ventilation holding delivered tidal volume, peep, inspiratory time, minute ventilation, and fio constant. data were collected after minutes, in each mode the absence of intrinsic peep was confirmed. to assure that the measurements were not affected by changes in clinical status, the patients were returned to the initial mode of ventilation and measurements repeated (final) . patients were ventilated with a siemens c or sv . reselts: data were analyzed using -way analysis of variance with repeated measures. ~ < . vs. vcv) vcv pcv ~ initial ] final ! cdljn . _+ . . _+ . * . _+ . . _+ . i , pip + . l-_t. * _+ , +- , paw . _+ . . i-_ . * . + . . -!-_ . pao _+ +- _+ _+ discussion: at the same minute ventilation, the decelerating flow pattern of pcv resulted in a % increase in cdyn and an % increase in paw while decreasing pip by %. the lack of a significant change in oxygenation may be a result of the limited time in each ventilator mode as well as the inclusion of patients with both normal and abnormal lungs. there was no significant difference in initial and final measurements indicating patient stability. the beneficial effects of iecre~l~iug cdyn and paw while decreasing pip indicate that pcv may be a preferable mode of ventilation in patients with lung injury. further randomized studies examining the effect of pcv on respiratory outcome measures in pediatrics are indicated. prolonged positive pressure ventilation following repair of cdh is associated with a high prevalence of iatrogenic lung injury, in our unit dudng - late deaths after repair of cdh were due to chronic lung disease. since babies requiring assisted ventilation for more than days following surgery were transferred to a cnep chamber to limit lung injury. cnep of - cm of h was combined with positive pressure ventilation via an endotracheal tube dudng the transition phase. immediate reduction of peak inspiratory and positive end pressures were possible and following extubation respiratory support was maintained by cnep v~th appropriate inspired oxygen. overall outcome: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] n= deaths before surgery (%) ( ecmo during - / who were ventilated for more than days received cnep and there were no deaths and no chronic lung disease in that group. cnep assisted ventilation may be an important management option for babies who require prolonged respiratory support to avoid the adverse effects of chronic positive pressure ventilation, introduction so far modes of liquid ventilation (lv) have been used in experimental animals and, exceptionally, in humans: . total liquid ventilation (tlv)-functional residual capacity (frc) is filled by perfluorocarbons (pfc), and slow tidal volume (tv) breathing is performed by pfc. . partial liquid ve, ti,la~ion (page) -only frc is filled by pfc. gas tv is delivered by conventional mechanical ventilation (cmv), high frequency jet ventilation (hfjv) or high frequency oscillation (hfo). the aim of our study is to present our limited experience with page in newborns and infants. page was used in two groups of infants: , in infants with brain death before disconnection from cmv, because recipients for organ transplantation were not available. these infants have relatively normal lungs (fio~ less than . ). infants stayed on page for hour, during that period no ventdator manipulations were made. after page, infant were switched to cmv for next hours. . very critically diseased infants with ards (rds) - on ecmo more than days, before cannulation for ecmo, on hfo because of intractable respiratory failure, preoxygenated rm (miteni, italy) was used in the doses up to ml/kg intratrachealy. blood gases and parameters of pulmonary mechanics were followed (dynamic compliance -c dyn, airway resistance -raw, bicore monitor). page was combined with no inhalation ( - p.p.m, in infants). in both groups ad hoc an approvement from e local ethical commission and informed parental consent were obtained. in the first qroud with relatively normal lung parameters of oxygenation drops after pfc instilation intratracheally and stayed depressed for - hours. slight pco retention occured in both cases during page. c dyn increased almost double during page period, raw drops transitorily after pfc instilation but in minutes they were identical like in prepage period, parameters of oxygenation (peo /fio ) after - hours after page improved and were better than in prepage period. after that time infants were disconnected and died. in the second group no improvement of oxygenation was seen in one ecmo baby, in spite ()f transient improvement of c dyn. in the second ecmo baby, oxygenation improved and flow of pump could be decreased by more than %. none of these babies, however, survived, improvement was only transient in spite of repeated dosis of pfc. in these babies serious problems were to maintain the adequate frc by liquid, because of severe air leak, in babies on hfo/hfjv with severe ards/rds the improvement of oxygenation were seen in all the cases immediately after pfc instiletion for the period of - hours. after that period, pfc dose had to be repeated. two babies of this group survived. conclusion. page is going steadily from tabs to clinical practice. it is simple, could be performed anywhere, cheaper than tlv. however, because liquivent -perflubren (aliance pharmaceutical) is not available in europe, rm of (mitenti, italy) is the only solution, which could be currently used here. before the widespread use of page in clinics, liquid network among most nicus and picus must be built up, the criteria for page must be defined and ethinal-legal problems resolved as well. after resolution of these particular problems page can be life saving procedure for very special part of critically ill newborns end infants. catherine caronia, peter silver, laura nimkoff, cad quinn, jack gorvoy, and mayer san. division of pediartic critical care, medici,, schneider children's hospital, new hyde park, ny , imroduetiun: cystic fibrosis (cf) patients awaiting lung transplantation present a therapeutic dilenuna when severe respir, aory decompemalion occurs, endotracheal intubation and mechanical ventilation is known to have no long term benefits and is associated with high morbidity and mortality. noninvasive respiratory support appears to be a beneficial alternative. methods: we instituted bipap (respironics, inc,, murrayville, pa) in end-stage cf patients who were admitted to the pediatric icu with severe respiratory decompeusation. all patients were awaiting tung transplantation. after a control period, bipap was applied via a tight fitting nasal or facial mask, using the spo~aneous breathing mode, expiratory pressures were set at - cm hhzo. inspiratory pressures were started at cm ~i o and increased in cm i-i increments until the patient's respiratory comfort was achieved and substantiated by non-invasive monitoring. patients were instructed to use bipap during night sleep and whenever subjectively required, data are reported as mean _+ s.d. results: all patiems utilized nocturnal bipap for - hours/day during a follow-up period of - months. compared to their pre-bipap status, the patiems' oxygen requirement and respiratory rate both oz~ cundusion: bipap tl~rapy improves the respiratory status of decompeusatir!g end-stage cf paacnts. it is well tolerated for long term use at home, and provides an extended period of respiratory comfort and stability for cf patients awaiting lung transplantation. l. bindl*, g. kiihl**, p. lasch***, appel**, j.m er**** and the "arbeitsgemeinschaft ards im kindesalter" background acute respiratory distress syndrome (ards) is a therapeutic challenge in pediatric intensive care in view of the high mortality, in about german paediatlic hospitals founded a working group aiming on collaborative clinical research in this field. aims and methods the aim of both a prospective and retrospective survey conducted in german pediatric intensive care units in was to accumulate data on the epidemiology, risk factors, natural history and treatment strategies in a large group of pediatric ards patients who were treated in the tt~ee year period from to .all patients had acute bilateral alveolar infiltration of noncardiogenic origin and a po ~io ratio < mmhg. the influence of sex, underlying disease and single organ failure was analyzed using the fischer's exact test, the influence of additional organ failure on mortality was tested with the cochran-mantel-haenszet statistics. results patients were reported giving an incidence of cases per admissions to pediatric icus. median age was month. in % of the cases, ards was associated with a pulmonary, in % with a systemic underlying disease. in % immunocompetence was impaired. mortality was % and not dependent on age, sex and triggering event. the number of associated organ failures, however, strongly influenced mortalib,. mortafity in immuno-compromised patients was t %. the analysis of treatment modalifies employed in the patients revealed a lack of uniform therapeutic strategies. on the other hand, the patients were exposed to interventions not yet supported by controlled trials. conclusions the observation of the lack of uniform treatment strategies led to the elaboration of recommendations on ventilator therapy and patient monitoring within the working group. the data gathered in this survey provide the basis for the design of prospective multicenter studies urgently needed to evaluate innovative treatment modafities in pediatric ards. recurrent apnea and respiratory failnre due to severe lower respiratory tract disorders such as bronchiolitis or pneumonia are the most common reasons for mechanical ventilation during respiratory syncytial virus (rsv) infection. acute respiratory distress syndrome (ards) has been described as a complication of severe rsv infectionj in contrast to the low mortality rates associated with rsv infection (< %), mortality rates in the range of - % have been reported in pediatric patients with ards. however, studies on ards are usually lumped in respect to causation and the disease course of rsv induced ards has not been previously studied. we examined the lung function abnormalities of infants with rsv induced respiratory failure requiring assisted ventilation, measurements included respiratory mechanics, maximal expiratory flow-volume curves and lung volumes, ards was defined clinically using the criteria which were recently proposed by the american-european consensus conference on ards~: acute disease onset, pao /fio~ ratio _< mrn hg, bilateral infiltrates on chest radiograph and absence of clinical evidence of left atrial hypertension. we calculated the murray lung injury scores modified for use in pediatric patients from total respiratory system compliance, radiographic findings, ventilator settings and blood gas results. we identified infants with severe restrictive lung disease that fialfilled the clinical criteria fbr classification as ards. all had lung injury scores above . which is the recommended cut-off for a diagnosis of ards, twenty-seven infants had obstructive disease consistent with a clinical diagnosis of bronchiolitis. the ards patients were significantly younger, had a longer time of assisted ventilation (p < . ) and a greater proportion of infants with preexisting illnesses (p= . , odds ratio = . ) when compared to the patients with obstructive disease. with the exception of one immunodeficient patient, none of these infants died. given the low mortality despite a clinical picture of severe lung injury, there is evidence that rsv induced respiratory failure may represent a relatively benign cause of ards in pediatric patients, bachmann an audit of patients with severe acute bypoxic respiratory failure (ahrf) receiving highfrequency oscillatory ventilation (hfov) in our unit ( n= , mortality %) revealed that sub-groups with severe underlying disease (n= , mortality %)and those with mu~pie organ failure ( > systems failing, n= mortality %) accounted for all the deaths beyond the neonatal period. v~ therefore hypothesized that in a modem paedistric intensive care unit (picu): a) children greater than one month of age with ahrf do not die in the absence of severe, pre-existing disease or multi-organ dysfunction syndrome, b) respiratory parameters alone will predict outcome poorly in ahrf. method prospect~/e sty/of all adm~ns to our tertiary picu. data it, citing the respiratory parameters (oxygena~n index [ol] , aiveolar-artedal oxygen tension gradient , pao /fio ratio) were collected hourly from the bedside charts throughout admission. patients were included in the study if ahrf was present at admission either none or in combination with other organ dysfun~on. ahrf was defined as the acute (< hour) onset of respiratory dysfunctk:~l with a pao /fio ratio.< for six consecutive hours dunng the first hours of admission (with no evidence of left anal hypertension), x-ray review defined a sub-group of patients with acute respiratory distress syndrome (ards) by the presence of bilateral interstitial infiltrates. results to date children (ages - months, weight . - kg) have been admitted in ahrf. of these also had ards. the overall mortality was . % ( / ), and greater in the ards group than the non-ards group ( t , . % vs, , . %, p< o. ) . it was not possible to predict survivors from non-survivors on the basis of the seventy of the respiratory failure alone, the a-ado on the day of admission (best in hours) was not significantly different between survivors and non-survivors: (mean, + sd)( mmhg +_ , vs mmhg _+_ ). kdl non-survivors were immunodeficient (n= ), previously extmrnsly premature infants (< ),(n= ) or suffedng fcom chronic metabolic or gastrointestinal disease (n= ). no previously normal child died. conclusion the severity of respiratory failure does not allow predioljon of outcome in our patients. we believe that this reflects that modem picu is so effective at providing respiratory support that pre-existing pathology alone de~ prognosis. this suggests that an abnormally regulated host response or abnormal persistence of a pathogen may be required to induce lung injury of sufficient severity that the resulting respiratory failure cannot be supported in a modem picu. introduction: postural changes (supine to prone) is a therapeutic intervention that could be useful in children with adult respiratory distress syndrome. objective: to determine the effects of postural changes in the oxygenation of young children with ards. method,s: a prospective stud ," was performed in eleven subjects aged to months (mean= ) with the diagnosis of ardsreceiving vendlatory support. (mean peep and fio of and . respectively). postural changes was performed every - hours, during a period of time ranging from to days. arterial blood gases were determined before and - n~n after the postural change, no modification in the mechattical ventilation other that changes in the fio were performed. the oxygenation was determined by the index pao /fi (p/f). to study the differences between the oxygenation mean, before and after the postural changes the wilcoxon test for paired samples was used, results: changes were performed ( from supine to prone and from prone to supine). a % increased p/f ratio was obtained after the change from supine to prune. although, not all the patients receiving postural changes improved their p/f. six of them (group i) showed an improve in the p/f when changed from supine to prone, returning to their base line when positioned from prone to supine. no improvement on the p/f was observed in the remaining subjects (group ii)after postural changes (table ) . during the maneuver no complications were observed. two patients had a pneumothorax, not related with the postural change. conclusions: postural changes (supine to prone) is an easy way to improve oxygenation in some children with ards. change to prone change to supine introduction: the common noninvasive diagnostic efforts to identify possible obstruction of the intrathorucic airway, are of limited value. invasive procedures such as bronchoscopy and bronchography may also be noncontributory and entail risks. we evaluated the usefulness of d-ct in the diagnosis and management of pediatric patients with suspected intrathoracic airway obstruction (itao). methods: we used a diagnostic algorithm (see diagram) in patients with suspected itao resulting in respiratory distress. three-dimensioual imaging of the tracheobronchial tree was reconstructed, following high speed spiral ct scan, by specific computer software (advantage window computer work station, general electric, milwaukee, wisconsin). non-ionic contrast medium was injected, in some patients, to delineate the intrathoracie large vessels.. results: eight patients were studied. in patients the d-ct revealed intrathoracic airway abnormalities. these patients underwent further invesive studies which confirmed the following diagnoses: patients had bronchomalacia, had bronchial stennsis due to a dilated pulmonary artery mad patients had subglottie stenosis extending to the thoracic cavity. three patients had no significant disruption in the configuration of the tracheobronchial tree and thus did not require invasive diagnostic procedures. conclusion: computer reconstruction of three dimensional images of the tracheobronehial tree is a safe and reliable diagnostic tool for itao. ards and ecmo; preliminary data from a randomized clinical trial. j fackler, c steinhart, d nichols, d bohn, m heulitt, t green, l martin, k newth, m klein, j ware. many suggest ecmo be considered experimental for ards and undertaken only with careful data collection and reporting. a mtflticenter pediatric rct is in progress to determine whether ) ecmo and/or ) permissive hypercapnia, offer significant advantage for the treatment of ards. methods: all patients aged wk to yr (without congenital heart disease) are eligible for study. data collection begins when a patient receives at least % oxygen and a peep of cm h for hours (stage t). if the predicted mortality reaches % within days (stage ), eligible patients are asked for written consent for randomization. patients are excluded from randomization with significant chronic lung disease, immune compromise, cardiac disease; or profound acute central nervous system damage. the prime outcome variable is survival. at the studies onset, pts were estimated to be required so that pts were randomized per arm. results: patients are enrolled from centers. data are complete on . patients never reached stage (i.e. % mortality). patients improved and died. of the latter, had randomization exclusion criteria even if stage was reached. patients reached stage . had exclusions from randomization and all died. eight patients ( survivors were eligible for randomization; consent was obtained in no case. two patients received ecmo. overall survival is % ( / ). in patients without randomization exclusions, survival is % ( / ). morbidity m survivors (discharge -admission popc or pcpc score >_ ) was seen in none of the stage surviviors and % ( / ) of those who reached only stage !. conclusion: the rct requires completion. the records of hospital in-patients at king faisal specialist hospital and research center who received external cardiac massage as part of their cardiopulmonary resuscitation were reviewed. success of resuscitation was analyzed as ( ) short term (restoration of spontaneous circulation), and ( ) long term (discharge from hospital). of such patients, ( . %) survived the initial resuscitation, and ( . %) were discharged. success of outcome was not related to age, location of patient, time of day, or rhythm at arrest, including asystole. longer resuscitation time was associated with less chance of restoration of spontaneous circulation (p< . ), but not associated with hospital discharge rate. results for patients with congenital heart disease were similar to those with other medical or surgical conditions. in this series, . % of ward in-patients survived to discharge, compared to two "*;'~r ~r;~' ,.,.'her,, the r-e~ult~ were c/ "'~d ~, ~,°(. overall, % of patients who survived the initial resuscitation were discharged from hospital. where resuscitation continued for more than minutes, . % of patients had tong term survival. outcome from asystole was no worse than for other cardiac rhythms, we believe that previous reports of poor outcome from asystole in pediatric cardiac arrest should noi influence decisions to stop resuscitation for pediatric in-patients prematurely. successful restoration of spontaneous circulation with long term survival can be achieved after prolonged resuscitation. abdelmoniem~ lindsey jahusou~,mariano fiallos, university of florida, prudential drive, suite jacksonville, florida usa central acidosis is well recognized as a marker of inadequate tissue perfusiou, and ventilation. however, obtaining central venous blcod is difficult and fraught with complications in the child undergoing cardiopuimonary resuscitation. intraosseous blood may be used instead of central venous blood to judge ph and pcoz during short durations of cardiopulmonary resuscitation and during hemorrhagic shock. the purpose of this study is to compare the ph and pcoz status of intraosseous and central venous during prolonged cardiopulmonary resuscitation after fluid and drug infusion. we hypotbesized that there would be no difference in ph and pco values of simultanecusly obtained intraosseous and central venous blood samples. eighteen ( ) introduction: cardiopulmonary arrest (cpa) in children is usually preceded by a deterioration of cardiac or respiratory function due to sepsis, dehydration and hypovolemia. early recognition of clinical and laboratory signs followed by immediate intervention are essential for prevention of cpa. the purpose of the present study was to identify factors which contributed to high rates of mortality from cpa in patients admitted to a paediatric intensive care unit (p cu). methods: a prospective study was done of all non-surgical patients with cpa who were admitted to the picu, hospital baca ortiz, quito ecuador from january to october . clinical and laboratory variables before and after admission to the picu, time from hospital admission to picu admission and the pediatric risk of mortality score (prism) were recorded on a questionnaire designed specifically for this study. results: of the non-surgical patients admitted to the picu, ( %) were admitted after developing cpa on the general pediatric wards. mean age was + . months, with of patients under months of age. initial diagnoses upon picu admission included meningitis (n= ), respiratory failure (n= ), congenital heart disease (n= ), severe neurological impairment (n= ), end stage neoplastic disease (n= ), hypovolaemic shock (n=l), peritonitis (n=l) and sepsis (n=l). mean time from hospital admission to p cu admission was _+ . hours. the mean prism score upon hospital admission was + . (score > = > % mortality). % ( / ) of the patients died. one of the three survivors had severe neurologie injury. prior to picu admission, patients experienced tac~,cardia (n= ), hypotension (n= ), neurological deterioration (n= ), respiratory, distress (n= ), oliguria (n= ), bradycardia (n= ), metabolic acidosis (n= ), hyponatremia (n= ), hypokalemia (n= ), hypocalcemia (n= ) and severe hypoglycemia (n= ). there were serious delays from the time of development of clinical and laboratory abnormalities to the time of admission to picu. conclusion: in the critically ill pediatric patient, rapid recognition of clinical and laboratory signs of deterioration, followed by immediate intervention, are required to prevent end stage shock and cpa. we found serious delays in intervention following development of important premonitory clinical and laboratory abnormalities in patients less than months of age on the general pediatric wards, which iikely contributed to the dismal % mortality rate. hospitals throughout ecuador should institute immediate improvements in ctinical supervision, and provide training in paediatric advanced life support (pals) to decrease excessively high rates of and mortality from cpa. intraosscous access is recommended by the american heart association and american academy of pediatries as a means of rapid access to the vascular system for childhood emergencies. bone marrow and fat embolism is a concern and has been reported post intraosseous infusion in stable animals but has never been studied in animals subjected to cardiopuimonary resuscitation. we undertook this study to investigate the incidence and magnitude of lat and bone marrow embolism with the use of intraosseous infusion during prolonged cardiopuhaonary resuscitation and after fluid and drug infusion. we hypothesized that there will be no difference in the magnitude of fat embolism between cardiopulmonary resuscitation only and other cxperirnental conditions. thirty-one ( ) piglets were anesthetized, mechanically ventilated, and instrumented (carotid artery, pulmonary artery and intraosseous earmulas ). the animals then underwent bypoxic cardiac arrest followed by chest compressions with the mechanical thumper (michigan insmunents) and mechanical ventilation for a minimum of minutes. the animals were divided in groups: a (n= ) which had no intraosseous, ~'oup b (n= ) had intraosscous with no infi~ion, and groups c (n= ), d (n= ), e (n= ) had intraosseous with infusion of adrenaline, normal saline and sodium bicarbonate, at cessation ofcardiopulmonary resuscitation, representative lung samples were collected fi'om upper and lower lobes of each lung, embedded in ocp and firozen immediately. ltmg specimens were stained using oil red-o dye and observed for fat globules and bone marrow elements. the amount of emboli present was rated as a percentage in relationship to iung tissue, by a pathologist blinded to the experimental groups. buffy coat specimens were collected before and at cessation of cardiopuimonary resuscitation, stained with oil red-o dye and observed for fat globules. percentage of fat present were compared using analysis of variance. fat globules were seen in the prebronchial blood vessels and in intravascular areas throughout all lung fields. there was no difference in appearance or distribution of fat globules between groups. quantity varied in the different groups[(a) %, (b) %, (c) % (d) %, (e) %], but were not statistically significant (p = . ). fat globules in the buffy coat were few and inconsistent with lung findings. fat and bone marrow emboli were present in all experimental conditions, the use of the intraosseous cannula does not increase the magnitude of embolization during cardiopuimonary resuscitation. the decision to use the intraosscous route should not be influenced by the risk of embolization. tzareva iv/,, md*, nedialkova r, md**, *dept. of pathophysiol, *~dept. of child surg. and icu, emergency medical institute pirogov, sofia, among children with blunt abdominal trauma, treated in emi pirogov during the last five years, children had serious disturbances of the basic vital functions, connected with the trauma, and most often with massive haemorrhage, for this reason being an object of reanimation and intensive care. in the group of children who survived - , predominated the trauma of only one abdominal organ (mainly the spleen, rarely the kidneys, the intestine) and only children had injuries of more than one abdominal organ. in the same group, in children the abdominal trauma was combined with chest or head trauma or bone fractures. in the group of children who died - , a profound combined trauma was present. the haemodynamic parameters in all children showed a characteristically significant tachycardia along with normal or even high blood pressure, while hypotonia was present in only % of the children on the first trauma day. despite the fact that only . % of the children had direct chest injury as well, the gas exchange was considerably disturbed - ' of the children were hypoxemic during the first, and % during the third trauma day -in % significant -below . kpa ( mmhg). together with the markable decrease in haemoglobin levels, this determines the pronounced disturbance in oxygen transport. during the first trauma day all the children were acldo~c, and a metabolic alkalosis was present during the following days. twelve of the children with severe combined trauma died within several hours, with the symptoms of irreversible haemorrhagic shock, or in the next - days, developing multiple organ failure. in conclusion, the intensive therapy of children with severe abdominal and combined trauma, should take in consideration the special haemodynamical trauma answer in children, and requires dynamic monitoring of the most influenced homeostatic parameters -blood gases, acid-base metabolism, haemostasis. introduction: endocrine emergencies, other than diabetic ketoacidosis, are uncommon causes of pediatric intensive care unit (picu) admissions. we report our experience of children diagnosed of adrenal insuficiency (ai) admitted in the picu, during the last four years. subjects: five eases of ai requiring intensive care unit admissions are presented. four females anna male, with ages ranging from days to years, none of them had a previous systemic or endocrine diseases that could suggest al the initial clinical manifestations were: dehydration ( ), vomits ( ), abdominal pain ( ), seizures ( ), lethargy ( ) and hyperpigmentation in the muco-genitat area in a newborn male and ambigna genitalia in a newborn female. the reason for their admission in the p cu were: shock in two subjects; three because of hyperkalemia and hyponatremia (k/na: . / ; / ; , / meq/l); and two with severe hyponatremia (na: ; meq/l). laboratory findings: severe hyponatremia ( ), increased concentration of urinary sodium and chloride ( ); metabolic acidosis ( ); hyperkalemia ( ); increased levels of urea ( ) and hypoglycemia ( ). in all of them, the electrolytes abnormalities did not normalize with replacement and only normalized after the administration of hydrocortisone. tile ai was due to: autoimmtme disease in two subjects, congenital adrenal hypoplasia, congenital adrenal hyperplasia secondary to alia hydroxylase deficiency and in one no etiology was found, at the present time, comments: aiis an uncommon disease in the pediatric age. anearly diagnosis is crucial, as if the treatment is delayed could lead to patients death. in subjects with arterial hypotension and electrolytes abnormalities refractory to the usual treatment, they should be treated with corticosteroids, if no etiology is found. although, previously samples must be obtained to make the diagnosis, : denotes the number of cases. gerbaka b; hakme c; akatcherian c. toxics are frequently involved in domestic accidents during childhood; among non medical products ingestion, carbohydrate poisoning is a serious injury often made possible by inadequate stocking. over years, children aged years and less were examined in the emergency department of hotel-dieu de france hospital for carbohydrate ingestion. , % are boys; age goes from months to years (moan = , years). kerosene is found in , % of cases; all were admitted (mean = , days). , % were symptomatic on first examination but % of all children presented signs of gastric ( %) or respiratory ( , %) irritation sometime during their history; , % had neurological signs and , % presented some fever. leucocytosis is found in % of cases; , % of the children received antibiotics. chest x ray was abnormal in , % of cases: mainly parahilar infiltrates were found, all children survived; , % with a normal course ( , days of hospital stay) whereas those who presented complications (severe pneumonia, coma) stayed in the hospital for days (mean) with short course of assisted ventilation for two of them; long term follow up was not possible. we fonnd nick's criteria for hospital admission to be of value: -symptomatic children with normal x ray } to hours monitoring -asymptomatie children with x ray abnormality } -symptomatic children with x ray abnormality: hospital admission -asymptomatic children with normal x ray : no admission. these criteria would have helped to avoid admission in children and would have allowed a short t hours stay for more. we found chest x ray to be mandatory in carbohydrate ingestion; other tests were not helpful, aside arterial blood gases measurement in case of respiratory involvement; we now also advocate more restriction in antibiotic use. prevention remains efficient and should be stressed on. severe liver failure [slf] is a rare but severe condition in infants. we report our experience. patients: slf was defined as liver insufficiency with hepatic encephalopathy and a decrease in the level of factor v to below %. between and , infants (mean : mo) were admitted for slf (neonates excluded). main causes were metabolic disorders ( . %) (tyrosinemian= , hemochromatosis n= , reye's syndrome n= , other n= ), virus-induced flf ( . %) and hematologic diseases ( . %). in cases, the causes remained undetermined. results: olt was contraindicated in cases because of multiple organ failure (n= ), or underlying disease. all of them died within days after admission. patients had no indications for olt, all but one are alive. ( of them was transplanted later for tyrosinemia and died lately (virus induced-slf). among the t infants who underwent emergency olt, are alive and died because of primary non function of the graft. conclusion: slf in infants admitted before their first birthday is a severe condition with an overall mortality rate reaching %. inherited metabolic disorders are the first cause of slf at this age. contraindications for olt are frequent because of underlying disease or multiple organ failure. a number of children undergo primary graft failure after liver transplantation. it is unknown if there is any increased morbidity or mortality following retransplantation. this study seeks to explore these issues. methods: a pediatric intensive care/iiver transplant database is in formation. records of all liver transplant patients are reviewed and abstracted. this data is then computerized to allow analysis. this data provides the source for this study. statistical analysis was performed via student's t-test where appropriate. results: of the patients who have thus far received at our center orthotopic liver ransplants, the records of who underwent transplants form the basis for this review. twenty-three patients underwent multiple transplants, required one additional, three required organs, and one patient survived after a fourth organ transplant, there was no significant difference in age at first transplant between those who received multiple organs and those who did not ( vs, months, p=ns). the anesthesia time for the procedure did not significantly increase tbr subsequent transplants ( . vs, , hours), nor did time in the intensive care unit (t . vs. . days), nor did time on the ventilator ( . vs. . days) subsequent transplants did not predispose to having more bleeding in the intensive care unit for usage of packed red blood cells or platalets was not significantly altered ( vs ml and vs ml respectively). patients who required retransplantatior~ did receive mere fresh frozen plasma (ffp)daring their first transplant than in the subsequent ones ( vs ec, p < . ). however ffp use was not significantly different than patients who did not require retransplant. patients who underwent retransplant had a markedly increased mortality ( %) than the overall mortality for liver transplants at our center ( %), conclusion: children who require another liver transplant have a markedly increased mortality. bleeding and prolonged icu stay is not significantly different between the first and subsequent transplants, fulminant hepatic failure and ortothopic liver transplantation.dr.sasb n,j;centeno,m;entin,e;acarenza,m;ciocca, m:gofii,j;bianco,g;weller, g;imventarza,o. unidad de cuidados intensivos.hospital de pediatria "dr.j.p. garrahan" .buenos aires.argentina. introduction:fulminant hepatic failure (fhf) is a clinical syndrome, defined by the development of hepatic encefalopathy within weeks from onset of illness in a previously healthy person.by far,the most comun cause of pediatric fhf in all series, is acute viral hepatitis.we report our experiences with the pediatric fhf and ortothopic liver transplantation (olt) as attemative of treatment. patients: childrens with fhf diagnosis were admitted at the picu from / / to / / .symptomatic treatment was given to all children and all were put on list for olt,) following the king's college criterion (protrombina time,age,atiologies,bilirrubin,and encefalopathy state). results:etiologic causes corresponded to the childrens were: , hav ( %); , noa nob ( %); ,autoinmune ( %).the age was mean: years (range: month- years).seventeen patients were transplanted, chidmn were discarded because:no donors: ;withdrow of the list: ,because sepsis in and bleeding of cns ;and no admission at list: because genetic syndrome ,massive intestinal necrosis, ,mitral valvulopathy and sepsis, . patients ( %) had at least one complication dudng the post operative period.the most frequent was the acute renal insufficiency(ari) and patients requiered continuos hemofiltration.the gtobal mortality rate was %.the mortality of patients without olt was % and the mortality of patients with olt was %, patients dayed because sepsis, ( candidiasis) and the others because mof.the actuarial survival at year is % and the follow up of months. conclusions:the fhf is a very severe and frequent disease at picu. supportive treatment only is associated with a very poor prognosis and high mortality rate.the most frequent etiology in our country is the hav. the olt is applicable in this cases and is a valid alternative of treatment (mortality in our series %).the ari is the most frequent complication during the post opeative period.in argentina,due the high prevalence of hav,prevention must be considered the main and only way to avoid this catastrophic illness.- to assess the efficacy of gastric intramucosal ph (phi) for evaluation of tissular perfusion and prediction of hemodynamic complications m critically ill children. patients and methods: thirty critically ill children ( boys and girls) whose age ranged from month and years old were studied. a tonometry catheter was placed in the stomach of all patients at their °admission in pediatric icu. intramucosal ph measures were made at the admission and each - hours during the study: a total of determinations were made. the catheter was removed after extubation and/or checking of hemodyrmmic stability of the patient. the intramucosal ph was derived from application of the henderson-hasselbaeh formula using the pco value from the tonometer and the arterial bicarbonate. values of phi between . and . were considered normal. the relationship between phi and severity of patient measured through prism, presence of major (cardiorespiratory arrest, shock) and minor (hypotension, hypovolemia or arrhytlmtias) hemodynamic complications, mortality and stay in the picu, was analysed. results: the admission value of phi was . -t- . (range . - . ). five patients ( %) had an admission phi < . . no relationship was found between an admission phi < . and a higher incidence of hemodynamic complications. sixteen patients ( %) showed some values of phi < during their evolution. patients with phi < . had a higher number of hemodynanuc complications than the rest (p< . ). every cardiorespiratory arrest (cra) and shock cases were related to a phi < . . patients with major complications (cra and shock) had a phi lower (p= . ), as well as a higher number of measurements of low phi (p= . ) than patients with minor hemodynamie complications. the value of phi lower than presented a % of sensibility and % of specificity with regard to hemodymanic complications. there was no relationship between phi < . and prims score and stay in picu. patients with phi < . presented a prims higher than the rest of patients (p< . ). conclusions: the phi value may be an early sign of presence of hem dyaaimc complications in the critically ill child. we tested the hypothesis that gastric intramural ph (phi) can be used as an early sign of failure m weaning pediatric patients because the blood flow from nonvital areas is diverted to meet the increased demands of respiratory muscles. methods: children (mean age ( . _+ . ) years + sd) who were thought by their physicians to be weanable from mechanical ventilation (mv.). these patients were ventilated on serve c ventilators, receiving ranitidine, and had intestinal tonometer (tonometrics, inc.) minutes before obtaining a sample.. all children were placed on pressure support (ps) at levels judged to overcome the resistance of the endotracheal tube and ventilatory circuit ( em h.,o). a sample of arterial blood and a sample oftonometer were obtained during vm and weaning (ps). phi, hemodynamic and respiratory data were recorded during vm and weaning we did not interfere with the primary caretaker's decisions regarding extubation. patients were considered to be successfully weaned if they were able to sustain spontaneous ventilation for more than hours after extubation. paired t-test were used to compare the values obtained during mechanical ventilation with those obtained during weaning trials. unpaired ttest were used to compare values from the group that was successfully weaned (a=i ) with those from the group that were not (b= ). results: we did not find statistical differences in any of those variables mesured during mv for patients who were successfully weaned(group a) and those who were not (group b). gastric phi was in group a: . + . (vm) and + . (weaning); in group b: . _+ . (vm) and . t _+ . (weaning). discussion: although we did not find differences in gastric phi during vm, the group a had a lower value than group b because of the number of cardiac patients ( %) and transfusion therapy, in fins group. in group b % of patients showed a problem in upper airway (subglottic edema, and enlarged tonsils). we found it after extubation. conclusion: ) gastric phi is a good predictor of risk in critically ill patients but maybe because of the small size of the sample, in our study is not of practical value as a predictor of failure in weaning pediatric patients from vm. ) this test is not a predictor of problems in upper airway~ important etiology of failure weaning in children. objectives: i-to determine the prognostic value of the gastric intramueesal phi in mortality and multiple organ dysfunction (sdmo) in critically ill children. -to compare this value, with the pediatrics risk index mortality score (prims). methods: aprospective study was performed with critically illcbildren, aged from mouth to years. the athnittiug diagnosis was: post-surgery ( neurosurgery, spinal fusion and thoracic or abdominal surgery), sepsis, polytraumatism, adult respiratory distress syndrome and with miscellaneous. all the subjects were monitorized on picu admission and treated for their underlying condition. gastric intramucnsal pt{ was measured following the tonometric method, ou admission and every - hours depending on the patients state. the severity of the clinical condition was evaluated using the the prims, on admission (prims-i) and during the first hours, when the clinical condition deteriorate, the worse score was utilized for the statistical analysis (prims- ). to perform the statistical analysis the subjects were divided in two groups, one with the phi< . and the other with phi> . .aunivariate analysis (student's tand wilcoxon two tailed test, chi-square) and multivariate analysis were used. results: out of the subjects dyed. of children developing multiorgan failure (mof) expired. % of the patients admitted to the picu with sepsis, ards and miscellaneous had a phi < . . in contrast, with % of post-surgical and none of the postqraan~atism. the mortaliry rate, in children with a phi< . was % (ci %: . ; , ) and . % (ci %: , ; . ) in children with phi> . (p= . ). mofwas observed in , % of children withphi< . v.s, . % with phi > . .no relatiouship was observed between the phi and the score of prims-i and . perforating an unconditional logistic regression analysis, two independent variables have mortality predictive value: the phi and the prism- . (table i) following induction of anaesthesia, a laser doppler probe (moorsoft instruments ltd) was inserted cm into the patient's rectum, the probe's special design ensuring that the optical prism lay against the mucosa. continuous monitoring of rectal mucosal perfusion ("flux") was continued throughout the operation. after rain cpb at °c, "steady state" readings of nasopharyngeal temperature, mean femoral arterial pressure (map) and flux were recorded over a further min before cpbinduced core cooling to - °c. steady state was defined as a rain period with no change in core temperatures or map. other rain steady state recordings were taken immediately prior to low flow, immediately prior to rewarming and after rewarming to °c, before initiation of any vasoactive drugs. the cpb flow rate was kept at m l k g - min q, the pcv at _+ %, the p~co at . + . kpa and the pro at + kpa. results: initial warm and rewarm map (both mmhg) were significantly lower ( = . ) than during the cold cpb periods ( & mmhg). the mean cold flux before ( ) and after ( ) low flow were both significantly lower (p= . ) than the mean initial warm cpb flux ( ). the mean rewarm cpb flux ( ) was significantly lower than all other flux values (p= . ). there were no siglaificant correlations between map and flux except at the first warm cpb period (r= , , p= . ). conclusions: although hypothermia significantly reduces rectal mucosal perfusion, rewarming produces an even greater reduction in gut perfusion which, considering that mucosal oxygen constmaption is highest during this time, may prove crucial in the postoperative development of mof. therapy aimed at improving gut perfusion during cpb should be directed at the rewanning period in particular. abstract this work is aimed at establishing a clinical procedure for the diagnosis of enteritis necroticans (en), even at the communal level, and to define criteria for diagnosis able to distinguish between acute forms. subjects and method : cases admitted at the institute for protection of children's health dpch), having characteristic symptoms, were examined clinically, by roentgenography of the abdominal cavity, with the analysis of the blood (total protein, electrolytes, hematocrite) and cultures of intestinal fluid and faeces. through surgical operations, the pathological lesions were observed and recorded. results: common epidemiological features: the average age is - years old ( - ) ; male/female : . ; in % of the cases, the disease occurred after a meal rich in protides. the acute toxic form accounted for % : severe shock appearing early, with very severe dehydration associated with profoundly decreased blood protein concentration and lowered natriemia as well. the lesions of the small intestine were expanded, all of them were necrotic. in the surgical form ( %), the predominant feature was an obstruction -peritonitis syndrome, the peritoneal fluid showed a characteristic inflammatory reaction. for the rest of cases % were the internal form, the shock syndrome was less severe, the abdominal distention was light and disappears gradually, the inflammatory reaction of the peritoneal fluid was not so characteristic. conclusion (ino) is a selective pulmonary vesodilator that is rapidly inactivated compared to intravenous vasodilators. these qualities make ino an attractive agent for the treatment of pulmonary hypertension (pittn). the efficacy of ino has been studied in persistent fetal circulation, acute respiratory distress syndrome (ards), and congenital heart disease (chd). potential adverse effects oflno include: nitrogen dioxide (no toxicity, methemoglobinemia, and platelet dysfimction. our objective was to evaluate the safety of ino in pediatric patients (pts). methods: pediatric pts. with phtn from ards or chd were studied under an established, approved protocol conforming to fda guidelines tbr an investigational new drug. informed consent was obtained for each child prior to treatment. no was sequentially titratad from parts per million (ppm) to , , , and ppm at ten minute intervals. parameters monitored before and during therapy included nitric oxide (no) and no~ concentrations (cone.), mean arterial blood pressure (map), and percent methemoglobin (mhg). no and noz levels were continuously monitored using an inline dr~ger electrochemical detection device. ~,litp was continuously measured with an indwelling arterial catheter. mhg was measured by co-oximetry. a mhg level e % or no cone. ~ ppm were considered adverse effects by study criteria. pretreatment map was compared to map at and ppm ino using paired t-tests. ap value < . was considered statistically significant. results: thirty-two mechanically ventilated children with phtn ( with ards, with chd) were studied. five pts. were treated following cardiopulmonary bypass. methemoglobin (met-hb) levels were routinely measured in two prospective clinical studies on no inhalation in pediatric patients with pulmonary hypertension following heart surgery with extracorporeal circulation and in pediatric and neonatal ards patients, the observed differences between the groups prompted in an in vitro study, red blood cells (rbc) of patients sampled before and after surgery with and without extracorporeal circulation (ecc), respectively, were incubated with ppm no for rain, met-hb, atp, and nadht nadph concentrations were compared, during therapeutic exposure no increased met-hb from . - -_ . to . _+ . % in cardiac surgery patients and from . ± , to . ± . % in ards patients (p < . ). rbc's having undergone ecc were more susceptible to met-hb formation (p< , ) whereas intracellular coenzymes did not differ neither between the groups (table) nor before and after no exposure. ecc predisposes to increased methemoglobinemia upon exposure to no both in vivo and in vitro. our data suggest a reduced activity of met-hb reducing enzymes rather than diminished availability of energetic substrates, variation of the inhaled nitric oxide concentration with the use of a continuous flow ventilator. anne pmc de jaegere ~, frans im jacobs , nico gc laheij , john n van den anker t . dept. of paediatrics ~, central instrumentation , sophia children's hospital, erasmus university rotterdam, rotterdam, the netherlands. objective: to investigate the homogeneity of nitric oxide (no) concentration in a delivery system with a continuous flow ventilator. design: bench study, setting: biomedical laboratory. interventions: a nitrogen/nitric oxide (njno) gas mixture was injected at three different sites in the patient circuit: just before and just behind the humidifier, and centimetres before the y-connector. ventilator flow ( , , l/rain), ventilator rate ( to , increments of ) and compliance of the testlung ( . ; . ; . ml/cm h ) were changed. carbon dioxide (co ) instead of n /no was injected at the same points in the circuit. measurements and main results: a) though the flow ratio of the njno and the ventilator gas were kept constant, the no concentration ([no]) raised with increasing ventilator rates. the increase in [no] was up to % when the n /no injection site was close to the y-connector of the ventilator circuit. minimal changes in [no] were noticed when the n~/no was mixed to the ventilator gas before the humidifier. b) analysis of the ventilator flow pattern showed variations at different places in the ventilator circuit. the magnitude cf the p, ow change depended on the meas~:rement site. the closer to the expiratory valve the highest the flow change was. the duration of the flow change was inversely proportional to the adjusted ventilator flow. c) real time measurements of the co concentration ([coz]) showed variations during tile respiratory cycle. these [co ] variations were higher when the co gas was blended closer to the yconnector. conclusions: the ventilator flow variations in relation to the fixed side flow of the n /no gasmixture result in changes of the inhaled [no] during the respiratory cycle. the no concentration during inspiration is always higher then during expiration. this could not be detected with the available monitoring system. to ensure a constant [no] by blending a njno gas balance in a continuous flow ventilator, the site of injection should be as close as possible to the inspiratory outlet. nitric oxide, a potent and selective pulmonary vasodilator, has recently been successfully used to treat pulmonary hypertension of variable etiology in infants and children. side-effects and complications in infants are so far not well known. we describe here two cases in which prolonged ( and- days respectively) high-dose ( - ppm) nitric oxide was used to treat refractor~¢ pulmonary hypertension. one patient was a newborn infant with pulmonary hypertension secondary to a large leftsided diaphragmatic hernia. nitric oxide was begun under conventional ventilation (babylog ) at hours of life with a slight initial improvement in oxygenation. he was then placed on oscillation with the same nitric oxide concentration due to worsening respiratory failure. he died on th day of life. monitored nitric dioxide concentration never exceeded ppm. the other patient was a months old infant with severe pulmonary hypertension due to a complete atrioventricular septal defect. he required high-dose nitric oxide to come off cardiopulmonary bypass after surgical repair of his heart defect. he slowly improved over the week following surgery but developped suddenly respiratory failure due to massive pulmonary hemorrhage and died. surprisingly, a particular autopsy finding in both infants was a massive acute necrotizing tracheobronchitis. we conclude that nitric oxide is an excellent and sometimes lifesaving treatment of pulmonary hypertension in infants. tracheobronchitis has not yet been reported as a possible complication of nitric oxide administration. we suggest that caution needs to be taken with prolonged high-dose administration and this possible complication to be looked for at autopsy. introduction: permissive hypereapnia (ph) is a beneficial strategy for patients with acute respiratory distress syndrome (ards) to minimize barotrauma by decreasing the peak inspiratory pressure (pip). hypercapnia and hypoxia cause pulmonary vasoconstriction, pulmonary artery (pa) hypertension, and, thus, an increased afterload to the right ventricle. this increased afterload may result in increased right ventricular (rv) work load and subsequent rv dysfunction. one therapeutic approach is the use of inhaled nitric oxide (inn), a selective pa vasodilator. the objectives of this study were to test the hypothesis that in a swine model of ards with ph, inn would improve rv work load and not change intrinsic rv contractility. methods: in swine ( - kg), ards was induced by surfactant depletion. hypercapnia was achieved by decreasing the pip while increasing the peep to maintain a constant mean airway pressure, inn was administered in concentrations of , , and ppm in a random order. pulmonary blood flow (qpa) was determined by an ultrasonic flow probe. rv total power (tp) and stroke work (sw) were calculated by fourier transformation of the pa pressure (ppa) and qpa data. preload recruitable stroke work (prsw), a preload and afterload independent measure of ventriculur contractility, was determined by a shen-subtraction method and vena caval occlusion. respiratory failure with pulmonary hypertension in piglets gerfried zobel*, bernd urlesberger*, drago dacar**, siegfried rtdl*, fritz reiterer* and ingeborg friehs** depamnents of pediatrics* and cardiac surgery**, university of graz,austria objective: to evaluate gas exchange, pulmonary mechanics and bemodynamic data during partial liquid ventilation (plv) combined with inhaled nitric oxide (no) in acute respiratory failure with pulmonary hypertension. design: prospecfive~ randomized, controlled study. setting: university research laboratory. subjects: twelve piglets weighing to kg. interventions: acute respiratory failure with pulmonary hypertension was induced by repented lung lavages and a continuous infusion of the stable endoperoxane analogue of thromboxane. thereafter the animals were randomly assigned either for plv or conventional mechanical ventilation. initially perfhiorocarbon liquid ( ml/kg) was instilled into the endotracheal tube over min followed by - ml/kg~. all animals were treated with different concentrations of no ( - - ppm) inhaled in random order. measurements and results: continuous monitoring included ecg, cvp, mpap, map, san and svo measurements. during plv pao /fio increased significantly from _+ . mmhg to ± mmhg (p< . ) within rain, while pao ]fio remained constant at -+ . mmhg. qs/qt decreased significantly from -+ % to -+ % (p< . ) during plv and did not change during conventional mechanical ventilation. static pulmonary compliance (cstat) increased significantly ff~m . r± . to . _+ . ml/cmh /kg (p< . ) during plv and decreased slightly from . _+ . to . e . ml/cmh /kg during conventional mechanical ventilation. the infusion of the endoperoxane analogue resulted in a sudden decrease of pao /fio from _+ to _+ . mmhg in the plv group and from ± to +_ . mmhg in the control group. inhaled no significandy improved oxygenation in both groups (pao /fio : _+ mmhg during plv and +_. mmhg during conventional mechanical ventilation). during inhalation of no mpap decreased significantly from -+ m ± mmhg (p< . ) in both groups. there was no significant change in oxygenation and mpap during inhalation of and ppm no. conclusions : plv significantly improves oxygenation and pulmonary compliance in acute respiratory failure. the additional application of inhaled no further improves oxygenation and pulmonary hemodynamics when acute respiratory failure is associated with severe pulmonary hypertension. inhaled no is very effective in improving oxygenation and pulmonary blood flow even at low doses. the work was supported in part by grants of the austrian nationalbank nr . as in neonates, severe respiratory failure in infants and children can be aggravated by pulmonary hypertension, resulting in further deterioration of oxygenation due to increasing intrapulmonary shunting. we analysed the influence of inhalational nitric oxide (ino) in treatment, course and outcome of severe ards in a pediatric population. since infants and children (age: - months) with ards and oi > (mean value: . ± ) underwent a trial with ino (concentration: , , , and ppm) to prevent further respiratory failure. patients had a significant improvement of their oxygenation (rise of pa > mm hg) for at least hours (responders); mean best ~fficient no dose: . ppm. the non-responders had only a short-term improvement or ino had no effect. in responders and nonresponders there was no significant difference with regard to age, underlying disease, ards severity, time on mechanical ventilation, blood gases and ventilator settings before notrial, nor was there a different grade of pulmonary hypertension (estimated by echocardiography). the only difference was an higher ol in the group of the non-responders: . ± .i vs. . ~ . , p < . . in the group of the respenders there was a secondary deterioration of lung function after i - days on ino in children (transient responders): in these patients, as well as in the group of the non-responders, alternative modalities of treatment (hfov and/or ecmo) became necessary. children ( %) died: transient respenders and non-responders. in infants and children with ards due to different underlying diseases ino can acutely lead to a significant improvement of oxygenation in about % of the cases. the right selection of patients for no therapy and the influence of ino on the survival rate of ards in childhood has to be evaluated in further studies. and pediatric cardiology, university of graz, a- graz purpose: after fontan procedure cardiac output is critically dependent on the pulmonary vascular resistance. even minor elevations of the pulmonary vascular resistance may significantly decrease cardiac output. inhaled no is an effective, selective pulmonary vasodilator in experimental and clinical situations of pulmonary hypertension. the aim of this study is to evaluate the effects of inhaled no on oxygenation and pulmonm , circulation in children after a bidirectional glenn-anastomosis (n-~) or a fontan-like operation (n= ). material and methods: from june t to january children with a mean age of . +~ . (sem) yrs and a mean body weight of . -+ . (sem) kg were treated with inhaled no after glenn-or fontan-like operations. all but one had complex cardiac malformations with single ventricle. all children were mechanically ventilated with an fin > . . inhaled (no) was applied using a rrdcrdproeessor based system which additionally allowed measurement of no/nox using the chemihimniscence method. methemogtobin concentrations were determined times a day. the major indication for postoperative inhalation of no was a high (> mmhg) transpulmonary pressure gradient (tpg--cvp-lap). severe myocardial dysfunction of the single ventricle was excluded by echocardiography. results: the mean duration of mechanical ventilation was . _+ . (sem) days the. mean dose of inhaled no was . -+ . (sem) ppm, the mean duration of no-inhalation was _+ (sem) hours. the mean methemoglobin concentration was . -+ . (sem)%. hemodynamic data and arterial oxygen saturation before inhaling no and minutes later are given in table acute hypoxaemic respiratory failure (ahrf) in children occurs in a heterogenous group of diseases with pulmonary pathophysiological processes ranging from reversible physiological intrapulmonary shunting to fixed structural lung damage. we hypothesized that inhaled nitric oxide (ino), a selective pulmonary vasodilator, might identify those patients with potentially reversible disease, i,e, large response may indicate a greater likelihood ef reversibility and thus survival. a retrospective review of the early response to ino in infants and children (aged month to years, median months) with severe ahrf( with ards). the mean p(a-a)o , pao / fio , oxygenation index (oi) and acute lung injury (all) score prior to the commencement of ino were +_ . , +_ . , _+ , and . +_ . respectively, the magnitude of response to ino was quantified as the % change in oi occurring within minutes of ppm ino therapy. this response was compared to patient outcome data. results. there was a significant correlation between response to ino and patient outcome, kendall tau b r= , , p< . (table) conclusion. in ahrf response to ino appears te define a subgroup of patients with improved outcome compared to nonresponders. we speculate that response to ino may be useful in selecting patients with potentially reversible lung disease for special support therapies such as ecmo. randomised controlled trials are needed to define the role of ino in paediatric ahrf. between may and december , patients (pts) were treated for mas. treatment groups were: group i only : pts; group i conventional mechanioal ventilation (cmv): pts; group ii hfo: pt; group iv hfo+no: pts. therapy was stepwise intensified until oxygenation improved ( i -) ii -) iii --) iv). "high volume strategy" was used with hfo (mawp - cm h ). the initial no-concentration was - ppm, with rapid reduction down to - ppm once oxygenation improved. results: one pt (group it) died of hypoxic-ischemic encephaiopathy (termination of therapy); all other newborn babies survived. in group iv pt and showed barotrauma prior to hfo. pt , and were treated with additional mgci (max. mg serum concentration . - . mmol/i). following the identification of inhaled nitric oxide "no) as a selective pulmonary vasodilator (frostell et al ) [ .+ , + . data are compared to baseline values within each group. *=p< . , **=p< . , ***=p< . l among patients who fulfilled ecmo criteria, improved with no and did not required extracorporeal life support. tltree out of ecmo patients eventually survived. conclusions: m our study low-dose of irthaled no showed a variable effect on oxygenation in newborns with acute respiratory failure. an acute response to no appeared to be correlated with a better short-term outcome and the avoidance of extracorporeal support in ecmo candidates. differently, lack of acute and/or sustained response was associated with death or need for ecmo. although the nature and severity of the underlying disease or the degree of prematurity may play an important role in these patients, we believe lack of acute response to no may be an early predictor of bad outcome, prompting toward alternative treatments such as ecmo or liquid ventilation. *picea s., °bartuli a.,°dionisi-vici c., *dello strologo l., §villani a., §bianchi r., ^salvatori g.,*rizzoni g, °sabetta g. *div. of nephrology, °div. of metabolism, §intensive care unit, ^div. of neonatology. "bambino gesfl" children research hospital. rome, italy. successful prevention of handicaps or death in newborns with ~ depends on rapidity and efficiency of treatment. poor response to nutritional and/or pharmacological treatment requires extracorporeal removal of nh . efficiency and cardiovascular tolerance are often difficult to obtain with peritoneal or hemodialysis in neonates. we report the results of cavhd in newborns with hc. methods: vascular access: femoral vessels. blood flow: - ml/min, dialysate flow: - ml/h. filter: amicon minifilter plusrm(polysulfone membrane; . sq.m.). no ultrafiltrate(uf) production, patients: case with carbamoytphosphate synthetase deficiency (body weight -bw-: . kg) showed hc at day , a relapse of hc occurred at day due to an infectious event. case and (bw: . and . kg), both affected by propionic aeidemia, showed hc at day and day , respectively. plasma nh (~tg/dl) decrease is shown in the complications: transitory ischemia of arterial cannulation limb and transitory thrombocytopenia occurred in case ; surgical repairing of artery after cavt-id was necessary in case ; no cardiovascular instability was observed during cavhd . outcome,'all patients recovered from hc in less than day: case : alive, mild b)iootonia at mos; case : dead after days from cavhd withdrawal for pulmonary hemorrhage; case : alive, normal development at mos. conclusions: ) in newborns with hc, ca~q-id provides good cardiovascular tolerance,high efficiency and quick removal of nh , even without uf production (i.e. only by diffusion). this allows easier management (no need of fluid and electrolyte balance). ) arterial complications seem frequent in neonates treated by cavhd. venovenous circulation could overcome this problem. vb nguyen, m jokie, c leeaeheux paediatric intensive case service, hospital university centre, avenue c te de nacre, caen cedex, france background, the implication of polymorphonuclear neutrophils (pmns) in the physiopathology of children's haemolytic.uraemie syndrome (hus) becomes more and more evident. the purpose of the present study is to role out their impact among other pronostie elements during the course of the disease. patients and methods. diarrheal prodrome and its duration, patient's age, maximal blood nitrogen level, anuria and dialysis time, extra.renal involvements, white enll and pmn counts and thrombopenia duration have been retrospectively analysed in infants with good outcome and in another children with unfavorable outcome. results. neither diarrhoea or its duration, nor children's age, nor blood nitrogen level, nor anuria or dialysis time had any predictive value for the disease evolution in the acute phase of our patients. adversely, extra-nenal involvements was accompanied by severe and complicated courses of the disease (p< , ). the elevation of white cells and pmns (heyon x /i) and pmns (more than x / ) as well as its persistence beyon a week were most frequently observed in complicated forms (p< , , p< , and p< , , respectively). a transient thrombopenia (less than day@ in patients with elevated counts of white cells may be a filrther obvious sign of an unfavorable course of the disease ( < , ). conclusion. the elevated count of white cells and pmns, either alone or associated to one rapid regeneration of platelets, seems enabled to predict an unfavorable evolution of the hus in children. msud results from an inherited impairement of catabolic pathway of branch chain amino-acids. high leucine blood levels may induce acute brain dysfunction. this dramatic complication led us to propose leucine removal procedures as continuous hemofiltration. patients and methods three newborns in acute msud onset were treated by hf, hdf and hd. extracorporeal circulation was performed through a . fr catheter, a circuit with a blood pump (priming volume = ml). patients and procedures characteristics are summarized below in the sucralfate (an aluminium salt of sucrose octa sulfate) is used to prevent and treat upper gastrointestinal bleeding in critically ill patients. with minimal absorption, the potential for side effects is thought to be limited, though aluminium toxicity has been reported in patients with chronic renal failure. these patients may already have had high body stores of aluminium. we report critically ill children with high serum concentrations of aluminium following sucralfate therapy. all had renal impairment. the normal aluminium level is < . gmol/l and in patients with chronic renal failure < . ].tmol/l. none of these patients had known preexisting chronic renal disease. cpb was conducted under deep hypothermia (t,° °c) and cardiocirculatory arrest (cca) or under hypothermia (t,° °c) and low-flow perfusion. continuous holter-electrocardiograms (h-ecg) were recorded from the ilranediate postoperative (po) period on for hours. h-ecg were also recorded prior to the operation and before discharge. following dr were observed: snpraventricutar (sv) and ventricular (v) extrasystoles (es) (> / h), sv and v tachycardia (svt and vt), accelerated junctional rhythm (ajr) and junctional ectopic tachycardja (jet), and nd and rd degree atrioventricular block (avb and avb ). the incidence of po dr was % in the pre-op h-ecg, % on the st, % on the rid, % on the rd po day and % befbre discharge. compared to the pre-op findings, an increased incidence of sves, ves, svt and avb on the st po day was observed, whereas vt and a jr or jet were exclusively observed po. all types of dr were observed up to the rd po day. ty e of dr before discharge was similar to pre-op findings and there was no definitive avb . considering patient groups according to the most frequent isolated op-procedure, the incidence of dr on the first po day was % after asd ii-closure (n= ), % after stthaortal vsd-closure (n=lg), % after correction of a complete avsd (n= ), % after correction of a tetralogy of fallot (n= ) and % after fontan-operation (n= ). incidence and type of dr were not significantly different between groups. longer cpb-dttration and use of cca were risk factors for po ves and vt (p< , and p< , , respectively) whereas use of cca and degree of hypothermia were risk factors for the development of a jr and jet (p< , and p< , , respectively). -our results indicate that po dr after cpb in children m'e frequent but mainly transient. in our series, specific cpb-related parameters are of greater influence than surgical procedure itseif for the development of dr and are discriminant risk factors for particular types of dr. the course of anp, cgmp/anp (as indicator for atrial natriurefic peptide biological activity), and no and no (as indicator for endogenous nitric oxide (no) synthesis) was investigated in i infants (median age months) undergoing cardiopulmonary bypass (cpb). patients were divided into groups according to whether they had (group , n= ) or not (group , n= ) preoperative heart failure (hf) and pulmonary hypertension (pht). group patients had preoperatively significantly higher levels of anp (p< . ), cgmp (p< . ) and no and no (,p< . ) but had significantly lower cgmp/anp (i < . ) than group patients. during cpb, anp was significantly higher in group patients ~< . ). as compared with prebypass values, cgmp/anp was reduced in both groups during cpb (p< . ). cgmp/anp inversely correlated with duration of cpb and aortic clamping time (p< . , respectively). no and no were significantly higher in group than in group patients (p< . ) without any intraindividual change during cpb. from the early postoperative period on anp, cgmp/anp and no and no were similar in both groups. after cpb, anp correlated in both groups with blood pressure (p< , ) and diuresis (p< . ). no and no inversely correlated with pulmonary arterial pressure immediately after cpb ( < . patients after a fontan-type of procedure have elevated central venous pressures (cvp) leading to congestion in the gastrointestinal system and often ascites. purpose of this study was to evaluate whether this causes a different postoperative gastric mucosal ph (phi). methods: we evaluated a series of patients, who underwent cardiac surgery with cardiopulmonary bypass (age: days to years (mean , yrs), weight: . to kg (mean . kg). a commercially available tonometer (tonometics®) for sigmoidal use in adults was inserted into the stomach after induction of anesthesia. the phi measurements were done according to manufacturer recommendations we compared three groups of patients: ) aeyanotic (n= ), among them p with vsd and p with avsd; ) cyanotic (n= ): tof: p, tga: p; ) cyanotic after a fontan-type procedure (n= ). phi were measured at picu arrival and after h. fudhermore we compared lactat levels at these time points. differences between the groups were evaluated with one way anova on ranks with pairwaise multiple comparisons (dunn's method). the relationship between cvp and phi was investigated by regression analysis. results: the median phi for groups i, and were . , . and . at ardval and . , . and . after h respectively. at picu arrival group was significantly (p< . ) different from groups and . there was no significant difference between the latter two groups, after h group was different from group , there were no other significant differences. the median lactate levels for groups t, and were . , , and . at ardval and . , . and . after h respectively. at ptcu arrival group was significantly (p< . ) different from group , after h there were no significant differences. there was a weak negative correlation between cvp and phi: r= - . ; p< . . conclusion: patients after a fontan-type of procedure have lower phi than patients after other cardiac surgical procedures, however, this is only in part due to the elevated cvp and venous congestion. eleven children were investigated months (median) after postoperative mof. iviof was defined as the failure of at least two vital organ systems (kidney, liver, lung, central nervous system) in addition to cardiac insufficiency and high fever. underlying surgical procedure was repair of tetralogy of fallot (n= ), fontan-(n= ) or seuning procedure (n=l). all patients fulfilled criteria for mof in the first postoperative (po) days. six patients needed peritoneal or hemodialysis for days (median) during the po period. one patient showed cerebral infarction due to thromboembolism in the territory of the right internal carotid artery immediately after the operation. the follow-up protocol consisted of extensive investigations of heart-, renalliver-, and lung functions as well as complete neurological and psychological examinations. all patients had adequate cardiac examination. lung function was normal in all but patients who had an obstructive syndrome. only patient showed an isolated decreased creatinine clearance. abnormalities of the liver ftmction tests were only noticed in patients after fontan procedure. severe neurological sequels such as paraplegia (n = ) and diplegia (n-i) were observed in of the patients. the remaining children presented with a delayed graphomotorical and speech development associated with normal intelligence. -in our series the most frequent and severe sequels after postoperative mof were neurological. -abnormal liver fimction tests are more likely to be a consequence of the fontan hemodynamics than a sequel of mof. the optimal dosing schedule of surfactant therapy for the treatment of neonatal respiratory distress syndrome (rds) remains unclear. goal: surfaetant function and the concentration of phospholipids (pl) in tracheal aspirates are compared in a prospective randomized trial involving neonates with rds who received either two or more ( or ) doses of survanta. methods; ventilated neonates < w with rds were treated with survanta oo mg/kg if fio >_ % or mean airway pressure _> , cm hzo, after h a nd dose was given (same criteria), if the support still exceeded the criteria h after the nd dose, the patient was randomized to no extra dose (two}, or to an extra dose of survanta (morel (and a th dose h later; same criteria), pl was measured in tracheal aspirates and corrected for dilution with the urea method. "active" large aggregates and "non-active" small aggregates of surfactant were separated by centrifugation and quantified. surface tension of the large aggregate fraction was measured by pulsating bubble surfactometer, results: neonates were randomized, x two and x more ( x and x doses), gestational age was , ± , w and birth weight ± g. most patients had severe rds with initial ventilation: rate . _+ , , peak inspiratory pressure (pip) , -+ . cm hzo, fio . ± . %. at randomization: rate . ± . , pip . -+ . cm hzo, fio . ± . %, and h after randomization: rate . ± . , pip . _+ . cm hzo, fio . ± . %, without signif, differences between the groups. there was relapse (again fio _> % within h) in group two and t bpd in group more. in total, tracheal aspirates were analyzed. pl was not signif, different before randomization (two . ± . vs more . ± . /jmol/ml), but neither after randomization (two . -+ . vs more . ± ,o /~mol/ml). there was no difference in the % small aggregates (two . ± . vs more . ± . %), the surface tensions (ran/m) were not signif, different (each time two vs more): before randomization . ± , vs . -+ . , in the h after randomization . ± . vs . -+ , , or - h after randomization . -+ . vs . ± . , or - h after randomization . _+ . vs . -+ . . conclusion: neonates who received more than two doses of survanta did not have higher pl, nor a better surfactant function than neonates who received only two doses of survanta. continuation of the trial is necessary to evaluate clinical outcome. may not indicate need for treatment p.c. clemens s.j. neumann university of hamburg, department of pediatrics, klinikum schwerin, wismarsche str.. , d- schwerin. aim of the study: the finding of elevated tsh and decreased t in the newborn usually is classified as "transient hypothyroidism", thus the elevation of tsh is classified as consequence of the lowered t . but on the other hand several data sets show that tsh elevation as well as low t , one independently of the other one, are associated with different kinds of perinatal stress. each of these laboratory deviations, if not associated with the other value being abnormal too, is generally accepted not to be an indication for treatment. from this we conclude, that more pefinatal stress, as in intensive care neonates, may produce tsh elevation as well as low t , but only coincidentially, not the tsh elevation being the consequence of low t , thus not to be classified as "hypothyroidism", thus not indicating treatment. if this hypothesis is right, we should find an association of increasing pefinatal stress with an increasing number of neonates from tsh and t normal via tsh or t abnormal to high tsh and low t . method: in the newborn screening program in germa w we determine primarily tsh, and only in the neonates with elevated tsh, in addition we determine t . thus in our study we asked whether we find an association of increasing perinatal stress with an increasing number of neonates from tsh normal via tsh abnormal while t normal to high tsh and low t . definitions for this study were: tsh elevation = > mu/ (as usual in the german screening programs), t lowered = < p_g/dl perinatal stress score was or or or in dependency of the neonate having stress in none to all of the following three categories: (a) forceps or vacuum extraction or sectio co) birth weight below g (c) at the th day existence of a relevant neonatal disorder (rds, ictems gravis, infection/sepsis, vitium cordis with hemodynamic relevance, severe malformation). results: our data of neonates show a high significant association (chi = , p < . ) of, on one hand, perinatal stress score with normal tsh, versus, on the other hand, perinatal stress score or with high tsh and low t . discussion: facing the background given above, in the intensive care newborn, the constellation of high tsh and low t may be only a coincidential addition of two independent abnormalities. in tbese cases -the high tsh not being the consequence of low t -the classification as "hypothyroidism" is not justified, thus a therapy not indicated. on the other hand of course there exist rare cases with high tsh as consequence of low t thus with hypothyroidism tlms with indication for therapy. unfortunately we have no criteria, that enable a certain discrimination of these two categories thus in respect to the question of therapy or not. conclusion: further research has to be done to learn how to discriminate the coincidential high tsh and low t from the causal constellation of high tsh and low t . until we have certain discrimination criteria we have to treat both groups of neonates. few studies have focused on fa composition of surfactant pc in preterm infants before and after surfactant therapy. methods: tracheal aspirates were collected in venttlated mfants from birth until extubatlon ( / _ /twk ga, .+ g bw). after lipid extraction, t.l.c,, and methylation, fas of pc were quantified by gaschromatography. intralipid a ( . % linoleic acid, : • ) was started h after birth. results: six infants developed respiratory distress syndrome (rds) and received survanta r i mg/kg (sr), all doses within h after birth (ix s r n=l, x s r~ n= , x s r n= ). one child did not develop rds. in alt patients, the patmitate % in pc was ~ % (before sr<=natural composition), increased to ~ % after s r, and remained > % for i h after lx s a, . .+i . h after x, and . .+ . h after doses. in patients, intubated long enough, the palmitate % decreased with a half-life of . _+ . h to a new plateau which was still higher than baseline after week. linoleic acid % was . _+ . (with rds), decreased after s r~ and returned to baseline due to the decrease in patmitate %. thereafter the linoleic acid % increased linearly with . % per h, in patient even up to . %. other fas did not increase after return to baseline. in neonatal medicine the current parameters, arterial oxygen saturation and arterial oxygen pressure, are poor indicators for oxygen delivery and oxygen demand. the purpose of this study was to obtain venous blood samples from the inferior vena cava in stable neonates with respiratory failure and to determine a parameter that reflects more adequately the balance between oxygen delivery and oxygen demand. "l~e study included neonates requiring mechanical ventilation tbr severe respiratory insufficiency. an umbilical venous and arterial catheter were inserted in the inferior vena cava and in the aorta respectively. paired blood samples were obtained at the time that the patients were hemodynamically stable. fifty paired arterial and mixed venous blood samples were analyzed. jnear regression analysis showed the following correlations: in a neonatal intensive care unit adjacent to a delivery room caring for mothers per year, (with a referral of mostly for preterm delivery), virtually every neonate <ls g was seen by the same ophtalmologist, j.o. the incidence of retinopathy of prematurity (rop) was in - of ii cases ( preterms <ls g with % surviving to discharge, and % rop in survivors; % if less than weeks). in - , cases of rop were diagnosed by the same ophtalmologist. were born at less than weeks, of which ( %) survived to discharge, and among those survivors, rop was present in ( %), with rates varying from % at weeks to % at . objective: to compare a method of teicoplanine (teico) infusion using an electrical syringe-pump with a manual injection. methods: infusion of teico was simulated through a standart neonatal i.v. system. the infusion system consisted of an life care infusion pump (abbo'it lab.) with its i.v. set for maintenance intravenous fluid (flow < mi/h) connected to a -way stopcock. an meter extension tubing (vygon lab.) was placed between the stopcock and a neonatal catheter, an another meter tubing (injection tubing) was connected to the stopcock. the volume of the injection circuit was . ml. simulations were realised for weights ( or kg), with a doses of mg/kg and a injected volume of , ml to ml. our goal was to perform a complete infusion in minutes. we compare one method of infusion with an electrical syringe-pump with manual methods: a: teico was infused with a syringe-pump pilot c (becton & dickinson lab.) according to a protocol using ) a priming before connecting the syringe to the tubing (for immediate starting of infusion), ) a programmed volume injected in minutes (the drug volume was greater than the dose prescribed to avoid loss of teico into the syringe), ) a ml wash out was performed over minutes with the syringe pump. b: teico was manually injected in a few seconds in the tubing followed by a ml wash out over minutes. c: idem as b but a nu site valve (medex) was connected to the proximal end of injection tubing to avoid leakage between removal of the teico syringe and connection of the wash out syringe. during each run, serial samples were collected every ten minutes over a one hour period. the samples were assessed using hplc method. results: the amount of drug delivred at minutes was calculated and expressed as a perventage of the total amount of teico prescribed. results are a mean of to rons. a b c kg . + , % , + . % , -+ . % kg -+ , % -+ , % . -+ % conclusion: with a drug volume injected < circuit volume and a valve, a direct i.v. administration of the drug in the circuit followed by a wash out seems an accurate alternative to drug infusion conbroled by a syringe pump and is easier to perform. doxapram hydrochloride is a central and respiratory stimulant which is used in neonatal intensive care units to treat caffeine-resistant apnoes of the newborn. routinely, doxapram is administered intravenously. oral administration would be much easier but data on bioavailability after oral administration are limited (two studies) and show a large variation. we therefore studied the oral bioavailability of doxapram in preterm infants. doxapram treatment was started with an intravenous loading dose of , mg/kg during minutes, followed by a continuous infusion of mg/kg/h. after h the intravenous administration was changed to continuous oral administration with the same dosage, blood samples were collected h after both the intravenous and oral administration and analyzed by hplc-assay. apnoea rates per hours were listed before and after starting doxapram treatment. the median apnoea rate per hours declined from to after both the intravenous and oral administration. the oral bioavailability of doxapram is between and %, indicating that the oral route can be used effectively in these infants . there were no differences in the decline of the apnoea rate after intravenous versus oral administration of doxapram, infasurf r has been comnared with exosurf r in two studies: one as drodhvlaxis and the other a rescue trial. similar. althouah non-sianificant benefits were found for the natural surfactant. in trials there was a sianificant reduction in dulmonarv air leaks for . : % ci . - . for babies treated with natural comnared to svnthetic surfactants. for trials ( babies~ comdarina natural and synthetic surfactants for rds { comdarina survanta r and exosurf r. and one infasurf r and exesurfr% neonatal mortalitv was sianificantlv reduced (or . : % ci . - . with natural compared to synthetic surfactant treatment. in two further trials different natural surfactant drenarations were compared. reduced oxvaen needs for hours after treatment were found for r r infasurf and curosurf respectively when each was compared to survanta r. andarent lonaer-term benefits from these surfactants were not statisticallv sianificant. further trials will be needed to ascertain differences between various surfactant preparations. introduction bacterial meningitis is a common cause of admission in the paediatric age group, and one which still carries a high morbidity and mortality. these complications are strongly associated with a delay in antibacterial therapy. a significant proportion of these patients require mechanical ventilation; it is in this particular group of patients that survival is greatly diminished. the identification of risk factors for mechanical ventilation associated with bacterial meninges may help improving survival by shortening the delay to icu referral. the paediatdc risk of mortality score (prism) is the most widely used scoring system in the paediatric icu literature; the accuracy of prism on predicting outcome in meningitis has been shown to be poor. aim we aimed to describe our population of patients with bacterial meningitis requiring ventilation, and then to identify predictors of survival. methods this study was conducted at the baragwanath hospital in south africa which is an universityaffiliated institution with end average annual paediathc admission of patients. baragwanath icu admits non-neonatal paediatdc patients per year. a retrospective chart review from january to december of consecutive paedistdc icu admissions with bacterial meningitis was performed. results approximately cases of bacterial meningitis are admitted to the general paediatric wards every year; this constitutes ± % of all admissions. the mortality of these patients is + %. during this time ( m, f) patients ( %) were accepted for icu admission, with a mortality of . %. the median age was months (range days to years). the median delay to hospital admission was hours, and the median delay to icu admission was a further hours. the median duration of tcu stay was hours ( for non-survivors, for survivors). the main presenting features were convulsions ( %), altered mental state ( %), fever ( %), respiratory symptoms ( %), headache ( %), and diarrhoea and vomiting ( %). the most common indications for icu admission were seizures ( %), coma ( %), shock ( %), respiratory failure ( %) and acidosis ( %). in % of patients there was a cardiorespirstory arrest prior to admission. the most common organisms in the csf was pneumococcus ( %), haemophilus influenza ( %) and e coli ( %). the presence of leucopenia (wcc < ), a low platelat count (< ), acidaemia (ph< . ), and the need for inotropic support were strongly associated with nonsurvival. tachycardia and hypotension were not significantly essorjsted with poor outcome, as has been previously reported. discussion early diagnosis of meningitis and prompt institution of antibiotic therapy requires a high level of clinical suspicion. paediatric patients with bacterial meningitis that require mechanical ventilation have a poor prognosis. there is little evidence to suggest that nomsurviva[ can be predicted prior to icu admission, but a rapid deterioration requiring ventilation and inotrepic support with evidence of severe sepsis (low platelet count, leucopenia) is nmost invariably associated with a fatal outcome. the long term functional outcome of these patients make this disease even more devastating; the rote of icu in the management of these patients has yet to be fully estanished. objective and study design: a retrospective study was pertbrmed for all patients diagnosed with hemorrhagic shock and encephalopathy syndrome (hse) during to . soroka medical center is the only medical facility in the southern negev region of israel serving a population of - , residents, consisting primarily of jews and bedouins. results: patients ( bedouins and jews) were diagnosed with hse. main features on arrival included profound shock and coma with con~alsions. active bleeding and/or disturbing coagulation tests with falling heuroglobin levels and thrombocytopenia was noted in every case. all infants developed diarrhea shortly after arrival. elevated urea, creatinine and liver enzymes was noted in all cases. annual incidence tbr inlhnts < year of age was : , for bedouins and . : , for jews. patients ranged in age from - wks and arrived at the hospital late night/early morning ( : am-ll: am), during winter/early spring (november-april). all were healthy prior to admission, with short prodromal symptoms of upper respiratory tract or gastrointestinal infection noted in cases. most infants had markedly elevated body temperature on arrival. a history of overwrapping and/or excessive hearing was obtained in of infants. bacteriological and virological cultures were negative in all infants. one infant died and neurological sequelae were observed in all survivors. the high prevalence of hyperpyrexia during sleep in the presence of negative microbiological results with no evidence of excessive hearing, and the high incidence of rise among a closed, culturally isolated society known to have a high incidence of congenital malformations, may support previous assumptions that hse results from hyqperpyrexia, originating in most cases from a "physiologic" heat induced trigger which starts and peaks during the night in previously healthy infants with susceptible, predisposing genetic underlie. approximately % of hospitalised infants with respiratory syaacytial virus (rsv) infection require mechanical ventilation. our general practice is not to use specific antiviral therapy. we have undertaken studies of rsv-infected mechanically ventilated patients without underlying congenital heart disease or immunodeficiency. study i (n= ): a retrospective review of infants (mean post-conceptual age weeks; median duration of intubation was days (interquartile range - ). blinded review of chest x-rays during the first three days of mechanical ventilation revealed a spectrmn of lower respiratory tract findings from marked diffiase consolidation in all zones without hyper-inflation (n= ) to gross hyperinfiation without consolidation (n= ), with the remaining patients have an intermediate picture (n= ). death occurred only in patients who were at the poles of this continuum ( / consolidation and / hyperinflation). patients at these poles could be differentiated by gender predominance, birth gestation, alveolar-artarial (a-a) oxygen gradient (p< . l), oxygenation index (p< . l), peak inspiratory pressure (p< . ), and intubation days (p< . ). study ii (n= ): prospective audit of infants with the aim of verifying the above differentiation. separating patients based on their early x-rays and a-a gradient we confirmed the above predictable difference in duration of supportive therapy (consolidation v intermediate: ( - ) v ( - ) p< . ). severe lower respiratory tract rsv-infecrion in young infants results in different distinctive partems of disease with characteristic radiological and clinical features, and each has a predictable timecot~se. conflicting reports on special therapy should be interpreted with respect to these observations before making conclusions about the efficacy of any specific treatment. the clinical data of children wich suffered from a severe mycosis between jan. -dac. and wich were treated with amphotericin b in spanish hospitals were collected. mean age was + . years; were mate ( %) and female ( %). the most common underlying diseases were leukemimymphoma ( %) and congenital heart defects ( %). the major pathogens isolated were candida albieans ( %), other candida ( %) and aspergillus ( %). and liposomal amphotericin (la) in ( %). in the ca group, the starting dose was , ~ , mg/kg, reaching a maximal dose of . + , mg/kg after . + days. maintenance time was + days and the cumulative dose: ~ rag. in the la group, the starting dose was . ± mg/kg, reaching a maximal dose of . _+ . mg/kg (p< . ) after + days. maintenance time was ~ days (p< . ) and the cumulative dose _+ mg (p< . ). the reasons for la use were: elective in % of cases, previous renal failure in %, and ca inefficacy in %. hepatic or renal function impairment was two times more frequent in la group than in ca group, the antifungal efficacy was % for ca and % for la. therapeutic failure or toxicity induced withdraw of ca in % of cases, vs, , % for la (p< , ). mortality was not different in both groups ( vs. %), adverse effects were related to ca in events vs, only one in la group (p< , ). the commonest side effects in ca patients were fever ( %), chilis ( %) and nausea ( %). in ca group, cases ( %) developped analitical anormalities related with amphotericin, vs. cases ( %) in la patients (p< . ). in the first group, the commonest serum alterations were hypokaliemia ( %), raised creatinine ( %) and bilirrubin ( %). in the second one, hypokaliemia presented in % of cases (p< . ), raised bilirrubin in % and creatinine in % (p< , ), the antifungal efficacy of la is at least the same of ca. from the clinical and analitical points of view, la is much less toxic than ca. la can be used at a greater dose than ca and is safe in children with renal failure. laurence desplanques -serge gottot -christian dageville d~artement de sant~ publique -facult~ xavier bichat - rue henri huchard paris -france -the french << reaped ~> network was created to implement a nosecomial infections (ni) quality care program in nicu and picu, the first objective was to describe the annual ni incidence rate in each icu population : all patients stayed more than hours in icu. methods : n] criteria were defined by the reaped group according to cdc criteria. all data were collected by a medical and nursing team. all infection data were validated by an external investigator. results : patients were admitted over a months period. % were newborns. ni were identified among patients. the overall ni incidence rate (ir) was . % and . °/ person day (from . to . °/ according to age, lowest rate for newborns). septicemia ( % of ni) and pneumonia ( % of ni) were the two main ni. according to age, the septicemia ir varied from . to . °/oo catheter day (lowest rate for newborns) and the pneumonia ir from . to . °/ ventilator day (lowest rate for newborns). there were very few other infections (uti : %, ir : . °/ catheter day). gram positive cocci were isolated in % of septicemia ( % of them were coagulase negative staphylococcal). gram negative bacilli were isolated in % of pneumonia ( % of them were pseudomonas). % of ni were caused by candida, mostly septicemia. the septicemia and pneumonia ir varied according to unit even after adjustment for age. discussion the aminoglycoside antibiotics are frequently used in newborns for the treatment of severe infection and sepsis due to gram-negative microorganisms. the currently recommended dosage schedule for tobra ( . mg/kg q h) does not take into account differences in gestational or postnatal age during the first weeks of life. we questioned the validity of these recommendations and studied the population kinetics of tobramycin to establish predictive equations that enables the clinician to select the appropriate initial dosing schedule. methods tobra trough (t= ) and peak values (t= ) were taken on day - after birth in newborns. tobra was administered as a -minute intravenous infusion already in an adapted dosage schedule: . mg/kg q h in infants with gas < weeks; . mg/kg q h in infants with gas between - weeks and . mg/kg q h in infants with gas > wks, tobra concentrations were analyzed by tdx-assay, a one-compartment model was assumed and non-linear mixed effect modelling (using nonmem) was applied to the data, a trough level < mg/l and a peak level between and mg/l was required, with the present dosage scheme % of the trough levels were too high and almost % of the peak levels too low. calculations showed that the following dosage schedule should result in optimal levels of tobra. preterm infants gas < wks: mg q h preterm infants gas - wks: . mg q h preterm infants gas > wks: the currently recommended dosage schedules for toeira result in high trough and low peak levels. prolongation of the dosing interval and increasing the amount of drug per dose according to the above scheme will improve tobra level control. since january british clinicians have been conducting a randomized controlled trial of neonatal ecmo. mature infants (>- weeks gestation and birthweight kg) with severe cardiopulmonary failure have been randomized to receive continued care in their referring institution or referral to a designated ecmo centre for further management. we now present the preliminary results which have prompted closure of recruitment to this trial. the final outcome will be assessed as intact survival against death or severe disability at one year of age for all the recruited patients. patients were categorised by diagnosis such as isolated persistent fetal circulation, secondary persistent pulmonary hypertension of the newborn or congenital diaphragmatic hernia and by severity of illness at the point of first contact with the clinical coordinators of the trial -judged primarily by the oxygenation index ( before randomization). patients were randomized ( in each arm). hospital outcome data are reported for all patients and year outcomes on t ( survivors). at this stage of the babies allocated to ecmo are known to have died compared to of those allocated to conventional management (rr . ; % ci . - . ; p= . ). fewer deaths have been obsea-ved amongst ecmo allocated babies in all the diagnostic categories used. a % incidence of disability and impah~nent has been observed amongst survivors. this rate is similar in both groups and the survival advantage is not offset by an increased rate of disability or impairment following allocation to ecmo. we consider that these data combined with those available from other studies provide conclusive evidence that the survival to discharge from hospital is substantially higher in patients allocated to ecmo than in comparable infants not so allocated. therefore recruitment to this trial has been closed whist awaiting complete one year outcome data. sigston pe, goldman ap. #keating j. crook r. ~e dj~. great ormond street hospital for children nhs trust, and ~biochemistry department, kings college hospital, london, united kingdom. isoflurane is a safe and effective means of long term sedation in both children and adults in the intensive care setting. the use of isoflurane, by adding it to the sweep gas allows the use of this volatile anaesthetic agent in patients on ecmo, enabling rapid control and weaning of sedation. a potential problem with the long term use of isoflurane is fluoride ion accumulation with the possibility of renal toxicity, the purpose of this study was to assess plasma fluoride levels in patients receiving prolonged isoflurane on ecmo. method: fifteen infants and children (aged day - years, median weeks) receiving ecmo support for either cardiac or respiratory failure were recruited to this study. the patients were sedated with isoflurane as well as intravenous agents (morphine and midazolam). isoflurane was administered ( % - %) via a calibrated vaporiser to the sweep gas, adjusting the level to maintain adequate sedation. blood samples were obtained on a daily basis for plasma inorganic fluoride assay. the relationship between plasma fluoride and amount of isoflurane administered, as %-hours (vaporiser setting in % x hours) was calculated by linear regression. results: the duration of ecmo ranged from to (mean ) hours, during which the amount of isoflurane administered varied from to (mean ) %-hours. blood samples were anaiysed, demonstrating individual peak plasma fluoride levels of . to . #mol/ , mean , p.molli (toxic threshold = gruel/f). the plasma fluoride positively co;related with the %-hours of isoflurane (r = . , p = < . ). conclusion: this study shows that although there is a dose related accumulation of inorganic fluoride ions in patients sedated with isoflurane on ecmq, the peak fluoride levels are well below the suggested toxic threshold. merzel y, lev a, bar yosef g, halbertal m, lorber a ecmo center, picu, emek medical center, israel. the mortality rate of pediatric patients with acute myocarditis is - % according to the severity of myocardial damage. a month old gzrl presented with high fever, respiratory and cardiac failure. diagnosis of acute myocarditis was made and the patient was ventilated with high pressures and fio of . . she required high doses of inotropes. echocardiography revealed a dilated la and lv with severe mr. lvedd was mm and lvsf %. calculated oxygenation index was . she was resuscitated after a cardiac arrest. she was commenced on ecmo (using biomedicus centrifugal pump and avecor oxygenator) at a flow of ml/kg/mm with immediate improvement of hemodynamlcs, oxygenation and pc . resptratory assistance and vasoactive drugs were reduced. the patient was transported by air, on ecmo, to the ecmo cevter. she developed arf and cvvh-d was performed. cardiac fimction started to improve after days. ecmo was discontinued on day . echo revealed lvedd mm and lvsf %. ippv was discontinued on day . on discharge, a month later, her lvedd was mm and lvsf %. she behaves normally for age without neurologic or other medical sequellae. literature search revealed no case of acute myocarditis, as severe, that was treated successfully. survavors of disease this severe usually suffer dilated cardiomyopathy and permanent disability. the use of ecmo allows myocardial rest which prevents long term myocardial damage. introduction ecmo is increasingly used in the care of critically ill newborns. despite the frequent use of betalactam antibiotics in the treatment of these infants there are no data available on the dispbsition of cefotaxime (ctx) and amoxicilfin (am) d ring ecmo. the purposes of this study were to determine the pharmacokinetics of these two drugs in infants on ecmo and consequently formulate appropriate dosing regimens. we therefore studied the pharmacokinetics of ctx ( mg/kg ql h) and am ( mg/kg q h) in term infants on day after birth, blood samples were taken before (t-o) and . , , , , (am) and t h (ctx) after the intravenous bolus injection and analyzed by hplc-assays. . ctx mg/kg q h results in adequate serum levels of ctx in fullterm infants on ecmo, am mg/kg q h results in very high serum trough levels. recalculation based on the known volume of distribution and elimination serum half-life of these infants resulted in the following dosage recommendation: mg/kg q h. persistent pulmonary hypertension of the new-born (pphn) is characterised by rapid fluctuations in pulmonary artery pressure (pap) and a clinical impression of stifflungs. lung mechanics were measured in term infants, mean age . +_ . days who were paralysed and ventilated within the first three days of life. fourteen infants had pphn with systemic or suprasystemic pap measured by echocardiography. in these patients, the respiratory system resistance was . % higher (p < . ) and compliance . % lower (p = . ) during systemic or suprasystemic pap compared to when the pulmonary hypertension had resolved. in contrast, there were no changes in resistance in the infants with respiratory distress syndrome (rds) and no pulmonary hypertension or in the seven infants with normal lungs, where two readings were taken hours apart. the changes in lung mechanics interfered with mechanical ventilation, resulting in a . mmhg rise in paco (p= . ) during pulmonary hypertension. inhalation of nitric oxide ppm resulted in a % decrease in respiratory system resistance and an improvement in oxygenation. the bronchial and vascular smooth muscle was increased by % in postmortem lung samples from eight infants with pphn compared to six age matched post-mortem controls with normal lungs (p< . ). these findings suggest a co-constriction and co-hypertrophy of bronchial and vascular smooth muscle during pphn. anatomically the pulmonary vasculature and bronchi lie in close proximity to each other. thus mediators such as endothelin- released locally may act on both vascular and bronchial smooth muscle to produce the observed vasoconstriction, bronchoconstriction and smooth muscle hypertrophy. prince of wales children's hospital university of new south wales, randwick, n.s.w. australia. introduction an increasing mortality in asthmatic children has been reported. the increased severity of asthmatic illness leads to an increased demand for icu admission, and a corresponding increased need for mechanical ventilation. geographic end environmental factors are thought to be partly responsible for differences in disease sevedty throughout the wodd. for this reason, epidemiological studies from diverse areas are important, risk factors for icu admission, and for the institution of mechanical ventilation should be identified, to optimise icu admission criteria and to avoid unnecessary delays in admitting at-risk patients. aim to document the clinical characteristics of ventilated and non-ventilated asthmatic patients admitted to icu. methods this is a retrospective study of all paediatric asthma icu admissions from january to december . results there were patients admitted to the icu for acute severe asthma in the study period. the male:female ratio was : , the mean age . • . months, the mean prism . - . %, and the mean duration of admission . hours. there was no seasonal variation in admissions. only % ( / ) patients required mechanical ventilation. in % of all patients this was the first presentation with asthma. there were some significant differences between ventilated and non-ventilated patients (see table) . there was a significantly higher incidence of concomitant and nosocomial pneumonias in the ventilated patients ( . % vs . %) as well as segmental lung collapse ( . % vs . %). there were no deaths. discussion the need of mechanical ventilation significantly increases the morbidity of and duration of icu stay of asthmatic patients. younger asthmatic paediatdc patients have a significantly higher risk of ventilation. the need for ventilation is predicted principally from a worsening pco and respiratory acidaemia, which is often independently interpreted by the clinician as respira ory exhaustion. this study has shown that icu admission is important in the management of young paediatdc patients with acute severe asthma and respiratgry fa!!ure. intravenous salbutamoi in the emergency, department management of severe asthma in children. g.j.browne,a. perma,x. phung,m.soo westmead hospital, sydney, australia. it is postulate that if an initial intravenous loading dose of salbutamol is given in severe asthma, a more rapid clinical response will occur, reducing requirements for continued high doses of nebulised salbutamoi with fewer side effects. this double blinded study was conducted in the emergency department of westmead hospital a university hospital in sydney, australia. all children with severe asthma had initial nebuliser therapy ( rag of salbutamol with ml of saline). if asthma remained severe minutes later, they were given a dose of intravenous hydrocortisone ( mg/kg) and either normal saline or salbutamol microgm/kg intravenously. frequent nebulised salbutamoi therapy continued during the initial first hour if clinically indicated. continuous respiratory and haemodynamic monitoring occurred in the first hours. serum potassium and glucose determinations were made at study commencement and hour after intravenous therapy. salbutamol determination was made at study commencement. children remained clinically monitored for the next hours, with their ongoing treatment determined by clinical response. children with severe asthma months to years of age were studied, with given intravenous salbutamol and given intravenous saline. the intravenous satbutamol group (ivsg) showed rapid reduction in asthma severity scale in the first hours, with reduced need for high frequency nebuliser therapy ( _< hourly), occurring . hours.earlier. no clinically significant side-effects were found in either group, although, tremor more frequent in the [vsg. biochemistry and salbutamol concentrations were similar in both groups. the use of intravenous salbutamol (i microgm/kg) in the management of severe childhood asthma is a safe and effective therapy with no significant side-effects and the potential to abort severe asthma attacks in the emergency department. intravenous terbutaline in picu piva j., amantra s, rosso a., zambonato s, giugno k, maia t. introduction: the admission to a picu of children with respiratory failure secondary to an acute obstructive lower airway disease is a common event, especially during winter seasons. these diseases have several causes, but most of them (especially asthma and chronic airway disease) have a good response to the administration of b -adrenergic drugs. objective: to find the dosis of intravenous terbutaline that is safe, efficient and with minimal adverse effects when used in children admitted to a picu with acute obstructive lower airway disease and respiratory failure. material and methods: we study the records of all children that were admitted to our picu during the winter of . only the patients that had respiratory failure and acute lower airway disease and who needed the use of iv terbutaline were selected. the records were divided in two groups: less than months and more than a year old these two groups were compared in the following aspects: the minimal and maximal dosis, and the length of time of use of iv terbutaline, frequency of tachycardia, hypokalemia, and mechanical ventilation. to establish any difference in the two groups we use the t exact test of fisher and x , with p< . , results: during the period of study were admitted patients to the picu, and ( , %) of them used of iv terbutaline. the mean age was . + . month, used iv terbutaline during . + . days ( . to days), the initial rate was . + . p~g/kg/min, and the means of therapeutic dosis was . +l. ~g/kg/min (ranged from . to . ). twelve ( . %) patients had tachycardia art obstacle to the increases in the rate of use of iv terbutaline during any time. mechanical ventilation was necessary in patients ( . %) and ( . %) patients died. the children under year of age used initial dosis of iv terbutaline lower than the children up of year old ( . p.g/ kghnin x . ~tg &g/rain, p< . ), but without difference in the length of use, the maximal dosis, the rate of mechanical ventilation and tachycardia. the frequency of hypokalemia was most common in the group of children under year of age. acute respiratory failure during status asthmaticus may require mechanical ventilation. current therapy includes paralysis, pressure control ventilation (pcv) and permissive hypercapnia to limit pulmonary barotranma and its hemodynamic consequences. asthmatic children exert a significant amount of respiratory effort during exhalation. with paralysis, this expiratory effort is lost. unloading the inspiratory work of breathing while maintaining the patient's expiratory eftbrt using pressure support ventilation (psv), may be beneficial. methods: children receiving pcv (peak inspiratory pressure (pip) = kpa. rate breaths/min) and pco > kpa were switched to psv. children were initially ventilated with psv . kpa and peep = . kpa (servo c). all children received beta agonist therapy, ipratropium and anesthesia with ketamine or inhalational anesthesia, and were breathing spontaneously. respiratory parameters and blood gases are shown be~bre psv, within minutes (start) and when the ph had normalized (during). data are presented as median and range, * p < . compared to before psv. results: children with hypercarbia during pcv responded to psv, normalizing pcos and ph within hours. the mean respiratory rate decreased from a median of ( - ) to ( - ) while the pip was decreased to . ( . - . ) kpa within hours. the i:e ratio also significantly decreased. conclusion: psv permitted patients to active/y exhale while unloading the inspiratory work of breathing. perhaps this strategy shifts the patient's respiratory effort from inspiration to exhalation, thus permitting the child to meet the excess work of breathing caused by bronchoconstriction. maged z. youssef, peter silver, laura nimkoff, and mayer sagv. division of pediatric critical care medicine, schneider children's hospital, new hyde park, ny . introduction: mechanical vemiladon of patients with severe bronchospasm can be difficult, due to poor chest compliance and increased airway resistance. ketarmne is a cormnonly used anesthetic agent that has been shown to have bronchodilator properties. the purpose of this study was to determine ifa continuous infusion of ketamine had an effect on the oxygenation and chest compliance of children with severe lironchospasm who were mechanically ventilated. methods: a retrospective chart review was conducted of pediatric patients in severe bronchospasm who were mechanically ventilated in our picu and treated with a continuous ketamine infusion. all patients were receiving aggressive bronchodilator therapy and adequate sedation prior to keramine. patients were excluded if any new bronchodilator or sedative agents were started within hours of initiation of ketamine treatment. all patients were simultaneously treated with benzodiazepines. for each patient, the pao /fio ~ ratio and dynamic compliance [tidal volume/(peak imp. pressure -peep)] was determined immediately prior to ketamine, and at , , and hours post-ketsmine initiation. data are presented as mean ± s.d., and were a~yzed using one way anova and the multiple comparison method of bonferroni. patients (age . ± . yrs.) received * p< . ketamine for severe bronchospastu during mechanical ventilation in our picu. both . .xto-* * the pao /fio ratio and dynamic . . -.... . compliance increased significantly following initiation of the ketamine infusion (see figure) . the mean ketamine dose was ± mcg/kg/min, and the -, mean infusion duration was ± too-[/ hours. one patient required glycopyrrotate ~' to control excessive airway secretions, and " one patient required an additional dose of o--j i ~-~ ~/me diazepam to control hallucinations after i cessation of ketamine. all patients were t~n~,mr~ *~am~ successfully weaned off mechanical ~l~s ~,~s~on ventilation and discharged from the picu. conclusion: continuous ketamine infusion to mechanically ventilated pediatric patients with refractory broncliospasm results in a significant improvement in oxygenation and dynamic compliance of the chest. reports of adults with status nsthraaticus document significant morbidity and mortality, whereas studies in children have had more varied results. different centers report mechanical ventilation (mv) in to % of admissions, occurrence of pneumothoraces or paeutuomediastinums in to %, and mortality in up to % of patients ~'t . we retrospectively reviewed status asthmaticus admissions to the pediatric intensive care unit (picu) between january and december . seventy-five of these patients were admitted fr~an the emergency department of chla (er admit). the mean length of stay in the picu was . days and the mean length of stay in the hospital was . days. based on patients who had arterial blood analyses, patients had hyperoapnia (pco > ). all patients received oxygen, inhaled albuterol (alb), and cortieosteroid therapy. ninety-five percent of patients also received methylxanthine (mx) therapy. of the admissions, patients ( %) required mv. only of these patients were admitted through our emergency department, whereas the remaining patients were intuhated at outside facilities. twenty-three cases required intr:wenous beta-agonist therapy, either isoproterenol osop) or terbutaline (terb). h~ff of the ea.~es re~%wed were complicated with hypokalemia (k+< . ). c,', ,~lications ofpoeumothoraces or pneumomediastinums were seen in % of ,'r:u~ported patients, but in only % of er admit patients. only % of these were in mechanic.all, )atients. there were no deaths in the review. respiratory mechanics measurements 'are useful in mechanically ventilated children to optimize ventilator settings. nevertheless, the transducers used to measure flow (f) and pressure (p) remain expensive. objective. to evaluate the performances of piezoelectric p transducers ( us dollar) in measuring f and p. methods. we used a previously described monitoring system measuring respiratory parameters [ ] . in this study f was obtained by a differential piezoelectric p transducer (_+ . cmi-i , honeywell) whose sensitivity has been reduced to +_ cmh by an electronic amplification equipment and p by a piezoelectric p transducer (_+ (). cmhzo, honeywell) connected to a grid pneumotachymeter &nt) ffleisch or ). volume (v) ( to ml) obtained by numeric integration off ( . to l/rnin ) and p ( to cmh ) were respectively delivered through a calibrated seringe and an electronical manometer (pic premier) and calculated by the computer. bland and altman analysis was used for assessment of results bias. coefficient of repeatability (cr) was estimated by the standard deviation of repeated measurements of the parameters as calculated in a oneway analysis of variance. results. mean difference (mdi between injected v ( to ml) and measured v using pnt was . ml, sd = . ml. difference and mean v were not correlated. sd of repeated v measurements were not correlated to v. cr was . ml. mdif between injected v ( to ml) and measured v using pnt was lrd, sd = ml sd of repeated v measurements were not correlated to mean v. cr was ml. mdif between injected p and measured p was . cmi-i , sd . cm h sd of repeated p measurements were not correlated to mean p. cr was . cmh . conclusion. inexpensive piezoelectrical transducers can be used to measure f and p and evaluate respiratory mechanics in ventilated children. previous studies have already shown the problem of the reproducibility of pft in preterm ventilated babies. were studied preterm ventilated babies {mean weight gr) in the first week of life in clinically stable condition, measuring flow, airway pressure and esophageal pressure simultaneously. each baby was studied twice with an interval of one hour and each study was done increasing the rate till to inhibit spontaneous breaths. none sedative has been used. only mechanical breaths were analyzed. compliance and resistence were calculated with a computer system using the linear regression method. we expressed quantitatively the intrapatient variability as the percentage of variation of tidal volume, compliance and resistence between the two studies in each baby. then intraclass correlation coefficient test (icc) was applied to confirm qualitatively our results (total agreement = , good reproducibjtity > . ). we h~£ed, an a eept~ble ~efiabirl¢, ~-~r;= '~ . during mechanical ventilation, an air leak (al) and plateau phase duration (pl) may influence dynamic and static compliance (cdy and cst, respectively). this study evaluated the effect of al and pl on two methods of measuring c.dy and est. methods. intubated, ventilated patients in a pediatric intensive care unit were evaluated after obtaining informed consent. patients were intuhated with a cuffed endotracheal tube and ventilated with a serve ( ventilator. cdy and cst were determined using the serve ands~rmedics . objective: evaluate the repercussion in respiratory mechanics and arterial blood gases and the impact of the ventilator adjustments on the auto-peep magnitude. material and methods: the measurement of the auto-peep was performed using an eletronic-pneumatic controlled device with a oclasion valve installed between endotracheal canutla and the ventilator circuit. the d~'ice was connected to a solenoid to detecte the end of inspiratuo phase and thus, the activation of the oclusion valve. the signs of pressure and flow were monitorized using a diferential transducer and it was processed using a pc computer and tmeumoview® software. the stud were divided in phases: phase a. where the ventilator adjustments was performed using the routine of the unit and phase b, where the targets of mechanical ventilation were to minimize the auto-peep. static compliance (crs) was ineasured by the single-breath occlusion technique, using a mean of ten occlusions for analysis. passive respiratory resistance measurements and the tidal breathing flow-volume loops were also obtained., while the ventilatory settings were siguificantly reduced soon atier ecmo was started. before ecmo crs measured in all patienls was . _+t). ml/cmh /kg (mean_+sem). for each patient the ecmo course was divided into four periods, proportional to the duration of the treatment, and the best ~alue of crs in each period was chosen for analysis. as shown on the figure. crs significantly improved (*p< , ) from the second half of the ecmo course in the group of patient that finally were successfidly weaned from ecmo. no change ill compliance was measured in the group of patients who failed to respond to the extracorporeal hmg support our data suggest that compliance measurements during ecmo can be useful togelher with overall clinical evaluation to predict both outcome and duration of cxtracorporeai support in the neonatal and pediatric population. objectives: brain temperature determines the amount of neuronal damage caused by hypoxic insults. thus measuring brain temperature at standardised conditions is in request. we investigated whether brain temperature of neonates varies with head insulation environmental temperature, body activity and time course. patients and methods: we investigated non-invasive brain temperature analogues in healthy prematures tess than two weeks of age in an incubator (gestational age . + . wks; x + sd, weight + g). we measured nasopharyngeal temperature (tnasoph) by a thermistor placed in the nasopharynx via a feeding tube, zero-heatflux temperature (zht) at the temple by a thermistor and healflux transducer, insulated by two pads, as well as rectal and incubator temperatures. patient activity was documented by video taping. measurements were performed during periods of increased insulation ) by turning the head with its measuring site on to the mattress ( ( ) ( ) - ( ) ( ) ( ) ( ) . ( ) ( ) { ) ( ) ( ) - ( ) ( ) ( )i ( ) ( ) ( ) ( ) . ( ) ( ) t ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) web (lmg/kg) at rain ( ) - ( ) ( ) ( ) ( ) - ( ) the vehicle had no effect. paf caused dose dependent rise in ao and pa pressure and reduction in flow to lpa (up to % like the vascular endothelium, the endocardial endothelium (ee) has a significant impact on adjacent myocytes, and may critically alter myocardial function.~ we have previously shown that ee cells are capable of sensing and responding to hypoxia by the release of prostacyclin (pgl). potassium channels in other cell types have been reported to be oxygen sensitive. to determine whether potassium channels modulate the ee hypoxic response, we investigated the effects of three potassium channel inhibitors on hypoxia-induced pg] release from ee cells. methods: ovine endothelial cells were harvested and passaged onto ,~ microcarriers. cells were constantly perfused with normoxic and hypoxic kreb's solution, and with three potassium channel blockers: glibenclamide (gb, #g/ml), tetraethyl-antmonium (tea, ram) and aminopyridine ( ap, i mm), perfusate was assayed for prostacyclin (ria). data were compared by analysis of variance. * p<. compared to normoxic control; # p< . compared to hypoxic control. adrenaline is extensively used for resuscitation in neonates with rds. however, effects of adrenaline on systemic, pulmonary and cerebral hemodynamics have not been defined in newborns with rds. thirteen anesthetized, and ventilated newborn piglets were subjected to repeated saline lung-lavage series while mean systemic arterial pressure (abp), mean pulmonary arteriat pressure (pap), mean left atrial pressure (lap) and mean central venous pressure (cvp), cardiac output and blood flow in the internal carotid artery (ica) were measured. systemic vascular resistance (s~), pulmonary vascular resistance (pvr) and cardiac index (ci) were calculated. sixty minutes after luug-lavage, the adrenaline group (a) (n= ) received adrenaline as a continuous infusion of . lag/kg/mi, while the control group (c) (n= ) received saline. none of the varlables were changed by saline. however, significant increases in abp (p< . ), pap (p< . ), ci (p< . ) and svr (p< . ) were observed after administration of adrenaline, whiie pvr and ica were not modified. mean±sd for abp/pap (p/a), fvr/svr (p/s) and ci (ml/mirdkg) were: ratios of pap/abp and pvpjsvr significantly increased following infusion of adrenaline. these data suggest: ) the cerebral perfusion is preserved during the infusion of adrenaline; ) effect of the adrenaline infusion on the systemic circulation is more pronounced than its effect on the pulmonary circulation in newborn piglets with surfactant deficiency. s demirak~a, ch knothe, kj hagel, j bauer department of pediatrics, justus-liebig-university giessen, frg inhaled no is a short acting selective pulmonary vasodilator. we studied the effects of ppm no and % oxygen during heart catheterization in children (age - years, median years) with heart defects and elevated pulmonary vascular resistance index (pvri) in order to asses the value of no as a tool of decision making for corrective cardiac surgery. patients were eligible for testing when they were more than one year old and had a pathologically elevated pvri in a previous heart catheterization. intubation, 'anesthesia and muscle paralysis were performed in all patients during testing of pulmonary reagibility. calculations of pulmonary vascular resistance and flow were based on the fick method. response to no was assumed when pvri declined more than %, of the patients were responders to no. effects of no and oxygen on pvri, mean pulmonary arterial pressure (mpap) and pulmonary vascular flow (qp) in all responders are described in the table below. cardiac surgery was offered to all responders, and of them were successfully operated. surgery is planned in another patients and parental consent for surgery was not given in one patient. in ebstein disease, during the first days of life, the ability of right ventricle to propel blood to the pulmonary artery is impaired due to high pulmonary vascular resistances. the flow is mainly directed to left atrium through tricuspid insufficiency, right atrium and foramen ovale. to decrease pulmonary resistances and increase pulmonary blood flow, high frequency oscillations, mechanical ventilation, nitric oxide and prostaglandin are required. after few days, a forward circulation is normally established. we cared two newborns with ebstein disease where this approach was hindered by a large pulmonary valve insufficiency. both of them were diagnosed in utero, showing a large tricuspid insufficiency with a non opened pulmonary valve and a ductal left to right shunt. one fetus was hydropic. at birth, blood stream from the ductus arteriosus was directed to the right ventricle through the pulmonary valve insufficiency then to right atrium, left atrium and ventricle, aorta and ductus arteriosus. a low pulmonary blood flow was demonstrated by low mean velocities ( cm/sec). a high reverse flow was seen in descending aorta with a negative flow in the renal artery. both of these newborns were oliguric because of ductus arteriosus steal. pulmonary blood flow doppler evaluation allowed different strategies of ventilation, switching between hfo and conventional ventilation, modulation of pge doses, inhaled pulmonary vasodilators (nitric oxide) and surfactant. the hydropic baby died, the other survived after weeks of intensive care complicated by supraventricular arythmia (wpw). in conclusion, during neonatal period, in ebstein disease, a large pulmonary insufficiency leads to a vicious circle where lungs are excluded, inducing severe asphyxia and high pulmonary resistances. the blood is backward propeled from the aorta through the ductus arteriosus to the right ventricle and atria, then left cavities to aorta. arec must be considered when pulmonary blood flow does not increase despite optimal therapy. guti~rrez-larraya f*, mandoza a*, velasco jm*, zavaneua ( **, gatindo a ~, s&nchez-andrede r, s&nchez jl***, mellon a***, mar f***. pediatric cardiology*, pediatric cardiac surgery**, pediatric intensive care unit***. hospital de octubre. madrid. background: transesophageal pacing (tp) is effective and sate both for diagnosis and treatment of pediatric arrhythmias. material and methods. eleven consecutive patients are included. a tri or quaddpolar or f temporal transvenous catheter with an interpolar distance of to mm was advanced through the nares and positioned to the point with the largest amplitude of atrial deflection, surface ecg and a bi or monopolar electregram were recorded simultaneously, selecting filters when needed ( to mhz). pacing was performed with a programmable stimulator (medtronic ) beginning with ms and increasing ma to and then increasing up to . ms. narula method was selected to diagnose sinusal node disfunction (snd) and overdrive pacing to treat tachyarrhythmias. results. tp was useful in all the patients and no complications were observed: in patients a snd was diagnosed (one needing a definitive pacemaker), in two patients with atrial ratter (ripe ) sinus rhythm was recovered, in one patient with a postoperative junctional ectopic tachycadia we were able to get atrial synchrony with marked bemodinamic improvement, and patients with paroxysmal supraventricular tachycardia sinus rhythm was easily and quickly restored ( of them recquirad repited episodes of tp until pharmacelogycal levels of antiarrhythmic drugs were raised). mean age and weight were months and . kg (one patient had . kg). there was a close relation between height and depht insertion (r= . ). mean stimulation parameters were , ms and . ma. discussion. in experiencied hands tp is an effective and safe way to treat and diagnose cardiac arrhythmias even in newborns. it should be tried before endovenous pacing is stablished and it is faster than pharmacologycal treatment. bailing g., eicken a., sebening w., vogt m., schumacher g., bl~hlmeyer k.; kinderkardiologie, deutsches herzzentrum m nchen, germany to assess the outcome of balloon valvuloplasty in infants with cardiac failure caused by critical aortic stenosis a retrospective study was performed. between and neonates, aged - days (median d), weight .t - , kg (median , kg) with critical valvar aortic stenosis were dilated by balloon (aovp) as the first line treatment. patients received prostaglandin el, needed inotropic drugs and mechanical ventilation. associated cardiac lesions : persistent ductus arteriosus (pda) in patients (restrictive pda in cases), a mitral regurgitation (mivr) in cases ( severe and moderate or mild mivr), angiographic findings of endocardial fibroelastosis (efe) in patients, mitral stenosis (mivs) in , coarctation of the aorta (coa) in , and finally a small musculary ventricular septum defect (vsd) in i patient. vascular approach for ballooning : a. axitfaris in cases ( %) a. femoralis in t ( %) and v. femoralis in cases ( %). the median ratio between inflated balloon and aortic valve diameter was , . dilatation was achieved in all cases. the peak systolic gradient across the aortic valve (pre aovp) ranged from to mmhg (median mmhg) and was reduced to to mmhg (median ; gradient reduction is significant (p < , )). aortic regurgitation (aovr) was absent or mild in , moderate in and severe in patient after aovp. children survived (actual suwival rate: %; early mortalffy: n = ; late mortality: n = ). mid term follow up ( - , years; mean , years) showed an increase of the systolic peak doppler gradient across the aortic valve (median mmhg) but no increase of aovr. re-interventions (re-aovp: n = , commissurotomy: n = , mitral valve replacement n = , resection of subaortic stenosis: n = , resection of coarctation: n = ,vsd-closura: n = ) were performed in patients. rv contractility and pulmonary vascular mechanics(pvm) in immature animal models are poorly underslood. we developed an acute rv injury model to measure rv contractility and pvm in response to commonly used cateehalamines. ten anesthetized piglets ( - kg) were instrumented with micromanometers in the lv, rv, pa, and la. a pulmonary artery flow probe was placed to measure cardiac output(qpa). ultrasonic dimension crystals were sutured to the myocardium and dynamic chamber volumes estimated using shell subtraction methodology. rv injury was induced with - cryoprobe injuries at - to - °c for - minmes each. da at mg/kg/min, db at mg/kg/min, and ep at . mg/kg/min were infused in random order. rv contractility was evaluated by calculating a load independent measure of contractility, the preload recmitable stroke work(prsw), during vena caval occlusions. to describe pvm, input resistances), characteristic impedance(z ), total pewer(tp), and efficieacy f=qimo"p) were measured. measurements were made pre-and post-injury, during infusions, and between infusions. clyoablation decreased prsw ( . _+ . to . + . , p< . ). at the end of the experiment, prsw remained depressed to this level indicating stability of the model. one factor contributing to organ dysfunction for infants undergoing repair of congenital heart defects (chd) is their "inflammatory response" to cardiopulmonary bypass (cpb). this response is characterized by an increase in cytokine release, complement activation and endothelial injury. modified ultrafiltration (muf) is a method for removing tissue water and inflammatory mediators by rapid ultrafiltration followin~ cpb, muf may acutely improve post-operative end organ function. in this study, we evaluated the effects of muf on the pulmonary and cerebral function of infants undergoing cpb for repair of chd. we prosnecrivety randomized infants (.~ mos) to either muf (n= ) or no muf (n= )(control) following correction for chd. the study intervals were ) before cpb, ) immediately after cpb, and ) minutes after cpb. pulmonary function was evaluated by measuring dynamic compliance (cdyn) and airway resistance (raw). for pts (mue= pts; control= pts) exposed to a period of deep hypothermie circulatory arrest (dhca), cerebral metabolism (cmro ) was calculated at each interval using the xe clearance technique for cerebral blood flow measurements and arterial and jugular bulb saturation measurements to calculate cmro . a reduction in cmro has been consistently demonstrated after dhca. the effects of muf on cdyn and on cmro are shown below: p< . vs pre-cpb; # p< . vs post-cpb • p--o. vs. post-cpb this study demonstrates that immediately following exposure to cpb, muf will improve pulmonary compliance. raw was not different between groups. there was no significant difference in hours of post-op ventilation for either group. in those pts exposed to dhca a trend towards better cerebral metabolic recovery compared to control was demonstrated. this is the first technique applied to infants undergoing dhca where cmro after cpb was greater than precpb measm~s. although this may be beneficial to postoperative hemodynamics, ventilatory management and long-term neurologic recovery, more patients and longer follow up will be necessary to verify such an effect. the effects of conventional mechanical ventilation (cmv) on left ventricular (lv). diastolic filling in neonates are not well established. one approach to improve lv filling is the use of cmv to provide a phasic increase in airway pressure {thoracic augmentation). this phasic increase in airway pressure may result in an increase in lv filling similar to that which occurs with cpr. thoracic augmentation has not been evaluated in neonates with ventricular dysfunction who frequently demonstrate increased heart rates. attempts to maintain low peak airway pressures during cmv may result in a prolonged inspiratory time that occurs over multiple cardiac cycles. this may alter lv filling in the later cardiac cycles. to determine the effects of inspiratory time on lv diastolic filling, infants were examined with doppler echocardiography less than hrs after surgery for the arterial switch procedtme. pulsed doppler recordings of the millal valve (mv) were obtained with the inspiratory time adjusted to occur over cardiac cycles ( sec.). a pressure transducer was placed in line with the ventilator, and the respiratory cycle was recorded superimposed on the doppler tracing to provide accurate determination of inspiration and expiration. doppler recordings were obtained from the apical -chamber view and the following measurements were made: peak e and peak a velocities, eia ratio, and deceleration time. compared to the expiratory phase of cmv, the initial beat during the iuspiratory phase of cmv resulted in an increase in mv peak e (. +-. vs . -+ . m/s, p< . ) and peak a (. + . vs . -+ . m/s, p< . ) velocities with no change in mv deceleration times (p<. ). compared to the initial beat during tile inspiratory phase, the third beat during the inspiratory phase resulted in decreased peak e (. + . vs . + . m/s, p< . ) and peak a (. + . vs . + . m/s, p< . ) velocities with no difference in deceleration times. thus, cmv augments lv filling during the initial phase of inspiration. however, as the increase in airway pressure is distributed over multiple cardiac cycles, lv filling falls below baseline levels. these observations indicate that while thoracic augmentation may be beneficial, to optimize lv filling the inspiratory time of cmv must be < cardiac cycles. energy expenditure in pediatric orthotopic liver tranaplantat~on, to determine the actual calorie requirements of critically ill children and evniuate the correlations between measured, stress-p~lictod and repleted energy exponditttm and the severity of illness. des/gn: a prospective, dinlcal study. se~ng: tertiary care pediatric icu in a university hospital. patients: ten patients aged to months with disorders prompting picu admission, including sepsis, respiratory failure, solid organ transplantation, and cardiovascular surgery. inta~entions: all patients were studied within hrs of major surgery or transplantation, or following acute illness. all patienls were severely stressed clinically and all but two were intubated by cuffed tubes, in three of them, still in a stress state, the study repeated on the third day of the disease, energy expenditure mensurements (mee), as well as illness seventy scoring systems, mtfltisystern organ failure scores and various anthropemetric and clinical indices of nutritional status, the stress-predicted energy expenditure (s-pee), the basal metabufie rote (pbmr), the repleted energy (re) and the recommended dietary allowances (rda) were measured or calculated in each patient. multiple regression analysis was used to analyze the data. measurements and main results: although the mean mee was significantly lower than the mean s-pee ( . + kcal/kg/day vs. . : kcal/kg/day, p<. ), it did not differ significantly from the pbmr (mean difference - . kcal/kg/day, range - . to + . kcal/kg/day). the s-pee/mee ratio ranged from . to . , while the re/rda ratio ( . : kcal/kg/day)/( . : kcal/kg/dny) ranged from only . to . . the prism/tiss ratio was not correlated better with mee than the diagnostic category (r~=. vs.. , respectively). the re was positively correlated withthe mee (rz=. , i)=. ) while negative oarrelatian has been found between mee and age, mid-arm circumference, triceps skinfotd and the use of vaseactive agents (r~. , - , -. , p<. and -. resp~lively). concl.m~: if s-pee is used for caloric repletion in the stressed oritic~ly fll el~d, these patients will be substantially overfed by as much as %. although pbmr appears to approximate the mee by ± %, other clinical and nutritional indices should also be ennsidered. objective: to deter .mine..t.he metabpli.c and.nutritional state of mechanically ventilated intants and children m relatmn wlm severity or msease. patients and methods: mechanically ventilated infants and children, median age months (range days to years), were studied. severity of illness was assessed using prism, prism-ii~ and fiss-scores. oxygen consumption (vo ), energy expenditure (mee) and respiratory quotient (rq) were determmed by mdirect calorimetry. total urinary nitroger(tun) and creatinine excretion, levels of albumin and crp were aetermmed in patients. in these patients daily caloric intake and substrate utilization were assessed. they were categorized in subgroups: a partial feeding (recent admission to p cu); b complete feeding. results: mee of the total group (n= ) a) i=intake g/kg/day (% total intake); u=utilization g/kg/day (% total production). nitrogenba]ance was negative in all patients in group a (mean - . -- : mffkg/day) and positive in all but one patient in group b (.mean . ± .d n~g/..kg/day;p= . ). no significant correlations were round between creatinine height index, crp, albumine, jun vs v u /kg conclusions: the mean measured energy expenditure does not exceed predicted resting energy expenditure, but ~ere is a wide range. in a majority ot patients with complete feeding h.igh carbohydrate intake resulted, in high kq and lipogenesis. in patients witla partial teeding the highly negatwe nitrogen'balance suggests that in the early phase of diseasean higher protein intake should be provided. severity of illness scores ann oiocnemicm markers of physiologic stress correlatedpoorly with oxygen consumption. leite,hp; iglesias, s; faria, c; ikeda, a; albuquerque, mp; carvalho, wb pediatric icu -s~o paulo federal university -s~o paulo, brazil objectives: ) to evaluate patterns of use and monitoring of nutritional support in critically ill children; ) to evaluate an education program in nutrition support given throughout the resident physician training in the pediatric icu. patients and methods: records of patients receiving nutritional support during were reviewed. aider this first phase, knowledge and understanding of the role of nutrition support was conveyed to the residents through didactic lectures. in a second phase thedata were reevaluated in children who were given nutrition support in . results: from a total of days ofthempy, the single parenteral route was utilized in , %, the digestive route (tube feeding or oral route) in , %. of this time. a previous nutr~ional assessment was performed in children; no patient had the nutr~on goals set. the nitrogen to nonprotein calories ratio ranged among : and : . only , % of the patients had their estimated caloric needs supplied and this goal was achieved only in those patients who were on enteral tube feeding. patients did not achieved their goals for vitamins. the supply ofoligonleme~s was adequate except the zinc. nutritional monitoring parameters including weight, serum albumin and serum triglycerides were performed in almost all the patients but without uniformity. the reevaluation ofthase parameters showed adequacy of protein and micronutrients supply; however deficiency in nutritional monitoring and infrequent enteral feeding were still detected. conclusion: there were lacks in the implementation of nutritional support, which were partially corrected in the rid phase of the study, although the training of residents may have contributed to give them cognitive skills, it didn't changed policies and procedures as desired. we recommend reinforcement of the education program concerning basic nutritional aspects, and the organization ofa multidisciplinary team in charge of coordinating the providing of nutritional support. plasme free fatty acids (ffa) are the meier energy source for mast tissues. during fasting ffa are released from the breakdown af triglycefides in edipose lissue (at). lipalysis, le. the rote of release o/ ffa, has been megsured in humans by means of stable isotope techniques using labeled pa or glyeerd as traces. no information is avoilob!e io dale on the ro of la. we infused albumin hound u c-pa and u c-la in critically ill infants, receiving kcel/kg/doy of iv glucose end na oral feeding (weight . ,i., kg;, range . - . ; ego : days, range ) and measured simultaneously the ra of pa and la from (he isotopic enrichment of plasma fea by gas chromatography-mass speclrome|ry ai : , : and : hours from tile shod of the infusion. a subcutaneous gluted at biopsy was obtained far fatty acid (fa) composition. we intended to ( ) in fie infants sbjdied atipa ~'os hi her than attla (~p<o.o )' and ihe ra of pa was higher then thai of la (~p= . §). however the ratio el the re's to the respeclive fa in at was higher for la than far pa (*p= . ). in conclusion the ra af la was higher then expected from ~he fa composition of at. we speculate [hat la is preferentially released during tipolysis and its contributuion to the energy metnbolism of the sick infonl could io !orger than what: is normai!y assumed from ihe fa composilion of at and of plasma fea. preoperative starvation can be prevented in infants undergoing non gi surgery by continuing feeds till as long as it is safe to do so. some gi disorders require withholding of feeds for a long period. for these and for infants already suffering from pem~ parenteral feeds are given preoperatively. peroperatively nutrition is maintained by ensuring adequate glucose supply in the infusion fluid and its smooth metabolism. proper placement of feeding tubes are also carried out peroperatively. postoperative early resumption of oral feeds is ensured by new techniques of anaesthesia and pain relief and methods to ensure early return of peristalsis. enteral feeds of pre digested substances and feeds through transanastomotic tubes and through gastrostomies and jejunostomies can prevent starvation in many situations. parenteral feeding is carried out only when enteral feeding is not possible, for example in necrotising enterocolitis~ gastroschisis, short gut syndrome, high enteric fistula and acute pancreatltls. the artedal ketone body ratio (akbr) is established as a valuable tool in the management of adult patients undergoing surgery for severe liver disease.the redox theory emphasises the central role of the liver in preserving homeostasis and the importance of the hepatic mitochonddal redox potential (nad+/nadh) in monitoring liver function and integrity.the akbr (plasma acetoacetate/ hydroxybutyrate) is a measure of hepatic mitochonddal redox status, reduced ratios associated with poorer outcome. the venous ketone body ratio (vkbr) is influenced by peripheral ketone utilisation and therefore thought unreliable in assessing hepatic redox its use has been dismissed as no correlation with the ratio in hepatic venous blood was found. inspite of this. vkbr is used in the diagnosis of lactic acidoses and respiratory chain defects. the objective of this study was to determine the relationship between the akbr and vkbr in a paediatnc intensive care population. children admitted to the paediatdc intensive care unit, with indwelling arterial and central venous lines as part of their routine care, were recruited for the study. the median (range) age was . years ( - . years) with prism score ( - ), simultaneous akbr and vkbr were measured. suppression of ketogenesis was confirmed using a rapid -hydroxybutyrate strip test (ketofilm, genzyme diagnostics) pdor to sampling. the median vkbr . (range . - . ) was lower than median akbr . (range . - , ), there was good agreement between artedal and venous ratios, bland-altman analysis giving a % confidence interval for relative bias of - . to - . . there was a significant correlation between vkbr and akbr r , , p, . (intercept . , slope , ) conclusions; values for akbr tend to be higher than vkbr, however there is a consistent relationship in critically ill children. in paediatdc patients in whom ketogenesis is suppressed, vkbr may be considered equivalent to akbr. this simple test may prove to be a useful adjunct in predicting mortality in cdt{cally ill children. to understand the present status of pediatric intensive care in china, we conducted a survey between october and december, , involving hospitals in provinces and municipalities. the results showed that there were totally icus for pediatric patients, including pediatric icus (picu), neonatal icus (nicu) and pediatric surgical icus (sicu), with total of beds. the physicians to bed and nurses to bed ratios were : . and : . respectively. the average number of equipment per bed was . ventilator, . multi-fnnction monitor and . infusion pump. very few of the icus had portable x-ray machine, biochemical and blood gas analyzers, and hemodialysis machines. the most frequently treated diseases/conditions were pneumonia, intracraniat infections, post-operation and sepsis in picus, and neonatal pneumonia, hypoxic ischemic encephalopathy and sclerema in nicus. pneumonia and respiratory failure accounted for . % and . % of all the diseases/conditions treated in the icus and the mean case fatality rate of respiratory failure was . %. the results of the survey suggest that there is shortage of tcu beds and modern equipment, and treatment is often delayed due to excessively strict criteria for mechanical ventilation. a set of simple, and nationally acceptable criteria for evaluation of severity and cure of the diseases/conditions is urgently required. the medical reports of children were reviewed and each admission was analysed in terms of age, sex, diagnosis, management within the hosp~al, length of hospital stay and type of poisoning. the youngest age was days and the oldest was years. hundred and twelve ( . %) of the children were girls and ( . %) were boys. the most common ( . %) reason of admission was intoxication among all of the cases and the greatest group ( . %) of the poisoned children had ingested medication which was followed by another group of patients ( . %) who had eaten mushrooms. the peak incidence of drug ingestion was salicylate intoxication ( %). forty drug poisoninigs were accidental while was intentional. the majority ( . %) of the cases that committed suicide was between and t years old, and the main cause of suicide was being unsuccessful at school. we conclude that poisoning -especially salicylate intoxication -is still a major problem in turkey and we believe that emphasis on the need to stere all kinds of drugs in a secure place and re-examination of a chin resistant packaging should help to reduce childhood poisoning significantly which is a preventable condition. included were all patients who died in the hospital, except those treated in the neonatal icu (predominantly premature and sga newborns) and those who died in the emergency room. among a total of hospital admissions (excluding the neonatal icu and emergency room), patients died ( . %). of these patients ( %) died in the pediatric icu, ( %) in the ward and ( %) in the operating room. a chronic underlying disease was present in ( %). withholding or withdrawal of therapy was implemented in ( %) children, ( %) died due to failed cpr, ( %) were brain dead and ( %) died following a dnr order. justification for therapeutic restrictions in the patients of the dnr and w/w groups was imminent death in ( %), lack of future relational potential in ( %) and excessive health burden in ( %). withdrawal or withholding of therapy was carried out by extubation in %, vasoactive drugs were stopped in %, and mechanical ventilation was withdrawn in %, analgetics and sedatives were frequently used (in % and %, respectively). hence decisions concerning restrictions of treatment are common in pediatric practice, mostly due to imminent death. patients in which treatment was restricted were characterised by a longer hospital stay, a worse prognosis, a higher frequency of chronic underlying diseases and a lower acute mortality risk. despite restrictions of intensive therapy, most patients were allowed to die in the pediatric icu. background microalbuminuria (mca), a subclinical increase in urinary albumin, reflects glomerular and overall vascular permeability " . an increase in urinary excretion of albumin occurs after burns and trauma. transcanillary albumin escape rate is also increased in response to elective surgery and in critically ill adult patients . we investigated a possible relationship between urinary albumin levels and clinical instability, as measured by pediatric risk of mortality (prism) scores. method we studied consecutive patients (median age of months, range - ). patients whith nephropathies or any abnormality of urine analysis were excluded from the analysis. prism scores, mca (mg. - ) (immunonepbelometric) and urinary creatinine (cu) (mmol.l -!) (jaffb) ( hour collection sample) were determined within hours from admission to the picu. the mca/cu ratio (mg.mmol. "l) was used to correct for urine output variability. diagnoses included respiratory failure ( ), postoperative ( ), neurologic ( ), sepsis ( ), trauma ( ) and miscellaneous cases ( ). pearson's correlation was performed to correlate data. results and conclusions. mean prism score and mca/cu were . ± . sd and - sd, respectively. a significant correlation was found between mca/cu and prism scores (r= . , p< . ). our observations show that, independently of the initial insult, the paediatric unstable patient may have increased capillary permeability, which is correlated with the degree of physiological derangement, as measured by prism scores. microalbuminuria can be rapidly determined since it is routinely used in the management of diabetic patients, it is inexpensive, simple to measure and blood-spearing. therefore, it might have a role in the clinical assessment of capillary permeability and transcapillary albumin escape worldwide the demand for paediatric intensive care services exceeds the supply. in developing countries sporadic access to such services alters expectation of care and can lead to children being either mechanically or handventilated in general paediatric wards. the outcome of children requiring ventilation in a major teaching hospital in india was reviewed.children were ventilated on an adult intensive care unit (aicu) if a bed was available, otherwise in the general paediatric wards. over a year period children were ventilated on aicu with deaths. yearly mortality rates varied between - %. over a month period patients were ventilated on the paediatric wards. of the p~tients over weeks of age died (chi squared .t >p> . ) reasons for the higher mortality rate on the paediatric ward likely include the higher patient:nurse ratio, and more limited resources. a predictor of mortality based on simple physiological observations without the need for expensive blood tests and including chronic health status would be a useful tool. the establishment of a paediatric intensive care unit is proposed to redress the balance of care. to assess the performance of the pediatric intensive care unit of hospital dona estef~nia by an international standard score, the authors did a prospective study of consecutive admissions to the unit during a period of months. mean age was . _+ . months; mean lengh of stay was . + . days. the effectiveness and efficiency were determined by the admission prism. admission efficiency was defined by two criteria: a) mortality risk > % or b) the administration of at least one intensive care unit-dependent therapy. the cumulative observed mortality was . % and the expected mortality was . %, with a standardized mortality ratio (smr) = . . the overall performance of the prism score-based predictive model was found to be good (goodness-of-fit test x [ ] = . ;p= . ). of patients admitted, combining the two criteria (icudependent therapy and mortality risk) an admission efficiency of ( . %) was found, equating to ( . %) of cu days. conclusion: in our study the assessment of the admission efficiency and of the effectiveness of the unit was possible by using the prism score of admission. there was no significant difference between mean values for otiss and ntiss)in level l patients (p= . paired t-test).for level and patients mean value of ntiss was greater than otiss (p< . ). there was a significant correlation between levels using either ntiss or otiss (mean difference level and , level and , ( p < o.oool). conclusions: a new tiss has been developed and used in a picu. nurses were able to accurately score the interventions on their shift. the assignment of patients to intensive care levels correlates with tiss values allowing a quantitative measure of severity. objective : to compare the rate of cerebral palsy (cp) between monochorionic-twins, dichorionic-twins and singletons born at to weeks' gestation. design : two-year prospective cohort study. setting : geographically defined study (region of franche-comt~., france). main outcome measures : type of plasentation was obtained by anatomopathological, or macroscopic examination of placenta and comparison of twins' blood-groups. neurological assessment was performed at two years of age (uncorrected for gestational age) by family doctor (pediatrician or physician), or neonatologist of the icu at tertiary center. sample : of i survivors aged of two years ( % follow-up rate), born between / / and / . triplets and chromosomic malformation were non included. results : thirteen ( %) of the singletons had cp.vs / ( %) of dichorionic twins and / ( %) of monochorionic twins (p= . ). four of the monochorionic twins ( %), / dichorionic twins ( %) and / ( %) nngletons suffer from quadriplegia (p< . ).in a multivariate approach, monochorionic twin placentation was the strongest risk-factor of cerebral palsy (or= . , ic % = a- , p< . ). others risk-factors of cp were : lack of father's profession (or , p< . ), maternal antecedent of abortion (or . , - , p< . ), vaginal delivery (or . , - , p< . ), hyaline membrane disease (or . , . -t , ~ . ). discussion : this is the first population-based study to uplight the role of monochorial twin-placentation as a strong risk factor of cp for premature infants. cp is more severe in monochodonic twins than in other infants. mecanism of cerebrat deficiency is not clear since none of our infants with cp was survivor of an in utero cotwin's death, and none of these infants was exposed to twin to twin transfusion syndrome. were these monochorionic-twins affected by an undiagnosed neurological structural defect that could lead both to prematurity and handicap remains an open question, a vital role of the intensivist is to ensure that knowledge and practice are imparted to trainees in the icu so that patients receive optimal care. teaching effectiveness varies widely leaving gaps in knowledge and practice in the trainee. being an effective teacher should not be a "gift" of a privileged few. the icu provides a fertile ground for using a variety of methods for teaching, e.g. didactic, at the bedside, emergencies, and in the performance ofproeeaures. in this environment, much can be learned. we have embarked upon a program to facilitate this learning process. i) teaching needs to be recognized as the foundation of good clinical care, i.e., patient related, and in its ability to generate discussion and research investigation. ) teaching structurally has many components including the speaker, audience, varying situations, and the message delivered. ) establishment of a program using these components to enhance teaching abilities at all levels, a) evaluate base-line teaching skills initially, b) individualize interventions to improve teaching skills, e) demonstration of learned skills with re-evaluation. this process is analogous to the analysis of a clinical disorder in a patient which, once recognized, interventions are then instituted and then re-evaluated. ) instill the desire to use these attained skills to teach and interest others to teach. teaching excellence should be recognized through awards, honors, and academic advancement. a major emphasis of this program is to provide participants with skills necessary to teach thought processes, decision-making skills (what to do, what to avoid) and implementing appropriate management during stressful emergency situations common to the picu. introduction: many" e-mail based discussion groups exist on the internet to provide medical professionals with a rapidly responsive medium for the international exchange of ideas relating to patient care. several such lists each serve more than a thousand professionals in more than countries, each distributing a dozen or more messages each day to every subscriber. there is very little known about the time being spent by professionals interacting with these lists, and very little known about the impact of the discussions on patient care. we wished to test the hypothesis that these discussion groups provide infortuation which is being used to change the care of individual patients and the general approach to patient problems. methods: in early january a pilot electronic survey was sent to a small fraction (n= ) of the memberships of e-mail discussion groups, picu@its.mew.edu, and nicu-net@u.washington.edu (the full memberships of both. groups (n=t for nicu-net, n= for picu) will be surveyed in early february of ). participants were asked for demographic information, experience and skill level relating to e-mail, time spent with the discussion groups, perceived usefulness of different types of discussions, and the ways in which the discussions were used clinically. the pilot study was analyzed for construct validity by correlating an overall assessment question with a summary of the specific questions. scale reliability was measured by cronbach's alpha statistic. results: the pilot survey response rate was ( %). the majority of respondents were male physicians, with an average age of +_ years, who had completed subspecialty training in intensive care, and were working at a university-affiliated hospital. most had been using e-malt for more than months, and considered themselves moderately adept in that use. % felt that the list helped weekly to keep them informed about current issues and practices in their field(s), and % felt that, at least monthly, they used information from the list(s) that was not readily available in medical journals. overall, % agreed that the list improved their professional competency. when asked to compare the value of months of membership on an e-mail discussion group with more traditional educational media, % compared it with attending a national conference, and % compared it to a journal subscription. cronbach's alpha was . , construct validity testing yielded coeff=. , p <. . conclusior~: internet-based e-mail discussion groups for health care professionals can be an important part of a strategy for maintaining professional competency. despite the very low cost of this medium for most, the value is felt to be comparable to that of t~r more expensive forums for education. further study will include distribution of the full survey in early february of . fronk shann, tony slater, gale pearson and the pim study group we have developed a new score for predicting the risk of mortality in children admitted to intensive care. the score is calculated from only seven variables collected at the time of admission to icu: mechanical ventilation (yes/no), booked admission after elective surgery (yes/no), the presence of any one of specified underlying conditions, both pupils fixed to light (yes/no), the base excess, the pao divided by the fio , and the systolic blood pressure. most scores used to predict outcome in intensive care require the collection of a large number of variables (so many icus do not calculate them routinely), and they use the worst value of each variable in the first hours in intensive care. this means they appear to be more accurate than they really are (about % of child deaths in icu occur in the first hours -so they are diagnosing these deaths rather than predicting them), and they blurr the differences between traits (a child admitted to a good unit who recovers will have a low score; but the same child who is mismanaged in a bad unit will have a high score -the bad unit's high mortality rate will be incorrectly attributed to its having sicker patients). pim was developed in the picu at the royal children's hospital in melbourne, and has been tested in six other picus in australia and one in the uk. objectives: to study the characteristics of the muhiorgan dysfunction syndrome (mds) in children. methods: a retrospective study with all the children with mds diagnosed from january to june is presented. children fulfilled the wilkinson criteria (i). in all of them the number of organs affected and the prims score were determined during the first hours. several groups were performed according to the clinical diagnosis, the hospital of origin and the order of organs affected. results: the subjects studied were an % of the pediatric intensive care unit admissions. of them expired ( %). no differences in age, sex and weight were observed between the children dying and the survivals. the most common causes of mds were sepsis, both nosocomial ( %) and medingococcal (i %) and acute respiratory failure. sixty-fivepercent of the patients were from the hospital wards and the remaining were directly admitted to the pigu from the emergency room. the systems affected were: respiratory ( %), cardiovascular ( %), hematologic ( %), central nervous system ( %), renal ( %) and (hepatic) liver ( %). the organs initially failing were: heart ( %), tung ( %) and central nervous system ( %). the children dying had a larger number of organs with failure than the survivors ( . v,s. . , p< . ).the prmis score was higher in the children expiring than in the survivors ( . v.s. , p < . ). s.mmary: the mds is a common pathology in picu, with a high mortality, the mortality is higher in children with a larger number of organs affected and a higher prism score. sepsis is the most common etiulogy. methods : from june ist to july th , all patients admitted to the pediatric icu were included. the score was measured at day (d ) and day (d ) and we used variables. for each organ system, we defined categories : dysfunction or failure, which we respectively confered or points. results : patients were admitted : newborns, children. were medical and were surgical patients. ( %) patients had two or more organ failure at the admission, ( , %) patients died, which ( %) in the first hours. the mortality rate was the same for children with two or more organ faiiure at d and d : / ( , %) at d , / ( , %) at d . the mean score is different for children who survived or who died : , versus , at d ; , versus , at . when the score is > , the mortality rate is significant. conclusion : in this study, there is a good correlation between the score of severity and the mortality rate but we have few included patients. we need a prospective multicentric study to assess these results and we must compare this score to other scores of severity used in picu. back.qround: injury to the central nervous system is the cause of death in the majority of pediatric trauma victims, studies have identified a wide range of factors associated with poor outcome from brain injury. however, when single features are analyzed, they are not sufficiently accurate predictors. few studies have used a multivariate analysis of these factors and pediatric outcome, methods: clinical and radiographic features of comatose children after traumatic brain injury were analyzed, clinical parameters, the initial cranial ct scan, and demographic characteristics were analyzed for an association with death or vegetative survival at months. a tree diagram in which risk factors may differ within the study subpopulations was constructed using recursive partitioning. results: chitdren with a motor score _< had an -fold increased risk of poor outcome compared to those with motor scores > . among patients with scores of _< , those with abnormal pupillary reflexes experienced a -fold increased risk of death compared to those with normal pupillary reflexes. among patients with a motor score > , an intracranial diagnosis code (no pathology, mild shift _< mm, swelling, shift > mm, surgical mass lesions, or non-operative mass lesions) was highly predicative of poor outcome at months. children with ct findings other than normal or mild swelling had a -fold increased risk of poor outcome. of children with swelling, shift or mass lesions, the pupillary light reflex was associated with outcome. children with abnormal pupils had a -fold increased risk of poor outcome. discussion: a few clinical and radiographic features stratified comatose children into fairly distinct risk groups. information available early after traumatic brain injury in comatose children provides useful prognostic information on the likelihood of death or devastating injury. a retrospective study of children with the diagnosis of epidural hematoma was made during - period. ages ranged between days and years ( % less than year, % between and years, and % older than years), % of them were admitted at the picu. % of the cases were due to falls, % to road traffic accident and % to other causes. on admission gcs was less than in % of the cases and more than in %. diagnosis was made during first hours in % of patients and delayed more than hours in % of them. neurologic impairment was present at admission in % of patients, and delayed in %. even so, % remained without impairment. radiological findings at first ct were skull fracture ( %); epidural hematoma localization was: in the right side ( %), frontal area ( %), temporoparietal ( %) and occipital (t %). associated lesions were: several ( %) or unilateral ( %) cerebral contusions, diffuse brain oedema ( %), unilateral hemispheric oedema ( %) and % showed shifted middle line. four patients died, half of them during the first hours. fully recovered ( . %) and have sequelae of different nature : were left with severe motor disability ( %); at the follow-up t have some degree of neurodisability. next datas keep correlation with death or neurosurgical impairment: only were significative multiple cerebral contusion (p= . ) and brain oedema (p= . ), gcs less than at the admission (p-- . ), shock (p= . ) and remaining cerebral contusion in control ct correlated with death or diasability at discharge. on the other hand, neither surgical drainage volume nor first or highest levels of icp ( cases),nor pupillary abnormalities ( cases) correlated with worse prognosis. conclusion: gcs equal or less than an shock are main factors related to worse prognosis, also multiple cerebral contusions in ct and diffuse brain oedema. the results of a modified gcs were compared to outcome and intensive therapy in children (mean age , t , years) with head and associated injuries ( , % of all cases) of different causes (traffic accidents, falls). the gcs was regularly used inn the course of intensive therapy. according to our own and other experiences the gcs was divided in stages: stage ( - points), stage ( - points) und stage ( - points) palhuiugy wile sp, tdhlg c~'lcb al blood ~ w. sabgcqucntl}. rhc slat,: rerltncd to t tl, iiltlils. the p st,~pem~v~ b}i~g wij!!,:q ! ,:_a!~p!ica!j n~:. ri~;¢ ill the level of sensibflizatjou lo tile cerebn~ anhgrns up to t. -o was flofcd iu i,alicnts. there wa.~ al~ iuclt~a~e ill cerebral vdociij,. ~m d~;'ati a il~ p¢fiphc~ai re~ista/isc of the large ce~'bral ve~ds. neur h;~c ~:yn'.pt,m~at !a~, (s::mno!en~', _r_uscu!~r l~:pot ni& !ryper*'flema) was nbserwed tu lt~ese pal~enls o. cbruc~l ~ nnds. rile ple~c.ut abse~vafion~ suggesl ihal die ~tttdy at" ihe stale ~f hematocr~chcplm/itic bm~ic~ in ckil&en with on emergensy is of abviou.~ !?ece~sib; in co~.te ctin g severe pa~ lo ~-i~mnediately f u wing ne ,:~per,'~fion. background: reconstruction of the heart by three-dimensional ( d) echocardiography provided new information on anatomy of complex congenital heart defects, we assessed the utility of d ultrasound in detecting morphological changes in cerebral anatomy in newborns before and after cardiac surgery. methods: transfontanel cross-sectional ultrasound, scans were obtained in standardized coronal and median sagittal planes. subsequently, rotational scanning was used to acquire the multiple sequential crosssections of the brain. for rotational scanning, a conventional mhz transducer was rotated degrees.scanning took less than one minute and required no sedation, data was stored in the image processing computer which allowed for off-line three dimensional reconstruction of different brain regions.twelve infants aged - (median ) days were assessed before and after cardiac surgery, results: cavity of lateral ventricle, choroid plexus and the periventricular brain parenchyma could be reconstructed in all. accurate estimation of size and volume of lateral ventricle, aqueduct, and other ultrasonographic visible pathological brain lesions could be performed. reconstruction of various brain areas was accomplished in - minutes. the localisation and extension of severe periventricular hemorrhage which was detected preoperatively in one infants was better visualized than in conventional ultrasonography. epicortical and subarachnoidal space could be reconstructed in all and allowed detection of hemorrhage in one case which was not detected by conventional ultrasound. conclusion: d reconstruction of different areas of the brain may provide additional quantitative information on size and volume of the internal ventricle and choroid plexus, and better understanding of the topographical aspects and the extension of intra-and periventricular hemorrhage than conventional cross-sectional ultrasound. introduction: intracranial cerebral blood has been estimated to be % venous, the invasive measurment of venous blood saturation in the jugular bulb provides quantitative information on cerebral oxygen supply and consumption. however, routine oxymetric measurement of blood saturation in the jugular bulb by insertion of a catheter line into the internal jugtdar vein is an invasive procedure which has limited use especially in infants and young children. thus the aim of this study was to investigate the correlation between the non-invasive spectroscopic measurement of rso and the oxymetric determination of the blood saturation in the jugular bulb in infants and children undergoing routine cardiac catheterization.. methods: during routine cardiac catheterization infants and children (age day- year, median , year) the rso was measured continuously using a two chanel cerebral oxymeter (invos a). the sensor was placed in standardized location at the left temporal head side. after the routine oxymetric blood sampling in the superior vena cava the oxymetric catheter was manupilated into the left jugular bulb. after control of the catheter position simultenuous values of the rso were documented. results: over a range of ( - %) sjo , a significant linear correlation was found between the spectroscopic measurement of rso and the oxymetric determination of venous blood saturation in the jugular bulb (r= , , p< , ) and the superior vena cava (r= , , p< , ). no significant correlation was found between rso and the arterial blood saturation in the descending aorta and as well as to the standared hemodynamic parameters. conclusion: meusurement of rso by mrs may provide continuous non-invasive information on cerebral venous blood saturation and thereby possibly on cerebral oxygen supply and consumption in infants and children. these may be of clinical value particulary during and immediately after heart surgery by means of non-pulsatile cardiopulmonary bypass. information on refractory status epilepticus (rse) from developing countries is scarce. we analysed cases of rse admitted over last yrs. the objective was to study etiology end evaluate efficacy of diezepam infusion. median age of the patients was . years irange . months to t . yrs); % were boys. onset of seizures was -t hours (median hours) prior to hespitalisation. the glasgow coma scale score ranged from . (mean+sd + ). the commonest underlying causes were acute cns infections ( / , %; bacterial meningitis, , encephalitis, ) and epilepsy ( / , %). oiazepam infusion in incremental dose (range . - . mg/kg/min) was used in patients over . _+ . days. seizures were controlled n ( %), mechanical ventilation was required in ( %)only, while none had hypotension; % patients survived. thiopental infusion (holus mg/kg followed by . mglkg/min, and increments of . mg/kg/min till seizure control) was used in patients over . _+ . days; seizure were controlled in all, but five patients needed mechanical ventilation, six developed hypotension needing infusion of vasopressoi drugs, out of ( %) died, overall mortality was %, mainly due to acute cns infections (n- ) and prolonged se. the patient was a -year-old gift di~aosed of dov,~'s s~drom¢, tetralogy of fallot. (t.f.) before admission a vasovagal crisis after coughing and vomiting was seen, and she was taken to the emergency room. mother said she had eyanosis in the mucous membranes of the mouth with exercise.on physical examination, she ~as afebrile, normal fundi and neurologic examination was normal. a harsh systolic murmur was hear~ with decrased intensity during bradycardia. chest rx disclosed a decreased pulmonary vascular markings. ecg: synus rhythm, with bradycardia and nodal escape rhyflmas. she was transferred to our picu because of severe h ,pertomc seizure, lost conciousness, and deeembrate poslamng~ ~t cyancx~is. the episode lasted for ~weral seconds, and ceased v~th diazepam. on admission she was lethargy, and neurologlc exammation showed weakness of left leg without babinski, and normal funduscopic. the patient had two episodes of bradycardia and isoproterenol was begun. during those episodes the patient was cyanotic, and the murmur was heard with the same intensity. act scan disclosed a tight parieto-temporai abscess with midline shift, lnmediately after the diagnostic ct, we administered antibiotics, antiedema treatment and it was drained. the abscess culture was negative. a ct control disclosed air and midlme shift. ~ the next two days she had three episodes of h oxia and c'yauosis ceased with o@gen, morphine and propanolol the patient died during a fourth episode. discussion: arrhytmias are uncommon in patients with tetralogy of fallot before surgery. in our case the first diagnosis was sick sinus syndrome vs bradycardia secondary to cyanotic episodes. the incidence of cerebral abscess in children with congenital heart disease (chd) is approximately %. tetralogy of fallot is the most common associated lesion, and is unusual in children under years of age. conclusion: ) brain abscess is a rare complication of patients with cyanotic chd, but should be suggested in patients with °'apparent" sick sinus syndrome. in patients with down's syndrome, t.f.,with cyanotic episodes, and difficult neurologic exploration, a brain ct scan is recommended. guillain-ba~re syndrome (gbs) is an acute autoimmune reaction, directed primarily toward the myelin encasing the peripheral motor nerves= this reaction causes a delay or block in nerve conduction. the presentation often can be very subtle but is followed by rapid loss of neuromuscular power, leading to acute respiratory distress, resulting from weakness of muscles and aspiration pneumonia. there were boys - , , and i i years old with gbs, treated in our icu. two of them due to the respiratory distress were intubated nasotracheally and ventilated mechanically with servo- ooc (siemens-elema, sweden) ventilator. duration of ventilation was i i and days, respectively. plasma exchange was performed in all cases. the numbers of plasma exchange sessions were - in each case. mean amount of plasma exchanged per session was , ml/kg. plasma was substituted with albumin, plasma or saline. the most important aspect of the management of patients with gbs in the icu involves the airway care, prevention and treatment of aspiration pneumonia and the mechanical ventilation if respiratory distress presents. endotracheal intubation should be performed whenever there is evidence of retention of pulmonary secretions, refractory to chest physical therapy, weakness of protective reflexes of the airway, leading to aspiration pneumonia and (or) atelecr~sis. cardiac arrhithmias too, is a main threat to the circulatory stability in gbs. therapeutic plasmapharesis has been shown to be beneficial, reducing the time for weaning from the ventilator and for achieving independent ambulation. however, plasma exchange is expensive and not without significant risks for the patient. some authors find that plasmapheresis is not effective for patients with fulminant course of gbs and blocking of nerve conduction. recent studies have demonstrated that intravenous high-dose immunoglobulin can be equally effective. there were no significant complications associated with plasma exchange. all presented patients survived without residual disability. tetraparesis associated with long-term paneuronium use in an infant. paneuronium is a muscle relaxant used in ventilatory management of patients with respiratory distress in intensive care unit. after the end of sedation some patients were found to have severe tetraparesis. paresis was accompanied by complete areflexia and diffuse atrophy of alt extremity muscles. this neuromuscular complication is caused by prolonged high-dosage pancuronium treatment. in the last years, numerous reports have linked the use of pancuronium bromide with prolonged paralysis, disuse atrophy and areflexia. this side-effect is well known in adults patients but rare in a pediatric intensive care unit. we describe one pediatric observation of tetraparesis after prolonged pancuronium treatment in a -month-old girl, this female infant developed respiratory distress syndrome and was intubated and mechanically ventilated. to decrease chest wall rigidity pancuronium bromide was administered during days. (she received approximately mg of pancuronium bromide). on day the drug was discontinued and the patient had severe tetraplegia and areflexia with normal head movements. electromyograpliy showed absence of any disorder of neuromuscular transmission. this infant showed a recovely of muscles after months. the other causes of peripheral neuropathies were eliminated. electroencephalograms and head scans were normal. the recovery pattern observed in our patient correspond to the process of regeneration after axonal degeneration. it is suggested that these neuromuscular complications were caused by prolonged high-dosage pancuronium treatment (associated with cortieoid and aminoglucosides). polyneuropathy syndrome in adult lc.u. appeared in literature in and is extremely common in long stay cases. the etiology of these disorders remains elusive. it is tempting to ascribe them to administration of drugs (muscle relaxants, steroids, aminoglycosidea), plolonged immobility, malutrition, sepsis and ischemia associated with reperfusion injury. to our knowledge there is only one case report of similar condition in a children i.c.u. (pascucci ) we present a serie of previously healthy children, aged months to years, who admitted in i.c.u with respiratory failure and who following weaning from m.v, remained in profound diffuse hypotonia with proximal and distal muscle weakness for various length of time, recovery of muscle strength occured in a week or months {the longest i months), all children, except one, - days before admission developed symptoms of either respiratory or upper airway infection with fever. on admission viral and bacterial cultures were positive in cases (haemophilus influenze, herpes virus). during treatment patients became septic. muscle histological and neurophusiological investigations have not been done. considering the multifactorial nature of the aquired nmd in adult critically ill pts, is impossible to attribute the muscle weakness of our pts to any specific cause, in conclusion, our findings suggest the need for further investigation of nmd in critically ill children treated in i.c.u. a van esch, ha van steen~l-m , ir ramtal, g derksen-lubsen, idf habbema. febrile status epilepticus (fse) is a prolonged and serious febrile seizure. little is known about the outcome of fse in neurologically normal children. this survey involved patients between months and years of age who had visited due to their first fse, the sophia children's hospital during the period of january till december . patients with a history of neurologic disorders were excluded. patients were identified, % were male. the cause of the fever remained unknown in % of the cases. in all case the fse was generalized and it most frequently occurred at night ( %). the mean age at fse was t. years ( . - . ), the mean temperature . °c ( . - °c). the mean follow up time was . year. twelve children ( %) had neurologic sequelea. the neurologic sequelae varied from speech deficit ( case mild, v - year delayed; case moderate > year delayed) to severe retardation and epilepsy ( cases). speech deficit was detected after a mean period of months (range - ), age, gender, temperature, family history and time of onset were no significant risk factors for neurologic sequelae. duration of seizure [rr . ( . - . )] and more than two drugs to treat fse (rr . (t. - . ) were related to neurologic sequelae. we recommend that fse children should be followed for at least a year to detect possible speech disorders properly and start early intervention. unusual presentation of myasthenlg gra%qs ibtza e. modesto ,v~ abe~gochea a, sanch]s l all, go l varas k folgado s, garcia e. p. .c.u. la fe, valencia. spain case report: the patient was a -year-o!d gift transferred to our pic because of severe respiratory failure. the patient, convaleseem of ehiekenpox, came into contact with horse manure previous afternoon. in the morning, she was lethargy, and irritability, with poor finding, and ~ an episode of coughing, cyanosis and acute respiratory failure after mucous vomiting when she was drinking milk. on admission she had severe respiratory distress, respiratory acidosis, and the sat was %. she was mtubated without difficulty, and was transferred to our p.i.c.u. physical examination reveals stable hemodynamies, pupils equal, round, reactive to light, normal fandi, and muscle relaxation. crusted vesicles diseminats~d. rhonehi over both lungs. hepatomegaly (+) and splenomegaly (+). ~lhe urine, hematologic, and c.s.f. laboratory findings were normal. c.t. scan of the brain, e.e.g., and ekg. revealed no'abnormalities. rx chest disclosed a retrocardiac atelectasis. speci~ts of stool and blood were obtained for cultures and study of c. botul#num toxins. pending receipt of these results, a broad-speotmm antibiotic and acyctovir was begun. the initial differennal diagnosis consisted of laryngospasm associated with aspiraqlon, botulism, and postmfecfious varicella encephalitis. after hours, weatm~ was begun. the neurologic examination showed a low modified glasgow coma ~ale (mgcs), generalized hypotouia and muscle weakness. these data suggested three diagnoses, posfnfecfious encephalitis, residual neuroumsoaar blockade, and excessive doses of sedative and analgesic drugs. after hours she regained skeletal muscle poxver and ufltlcient respiratory effort, the mcgs was acceptable, and blood gases were normal. she was given n~-tigmine and atropine, and her tr~ma was extubated. an acute respiratory failure ocurrs ram. after. chest radioga'aph disclosed a left inferior lobe atelectasis. after hours weaning begun~and the same episode w~as seen. at this point her mother stated that the girl showed weakness of the eyelids or extraneular muscles. it suggested myasthenic syndrome vs ~-barr syndrome. c. botul#num toxins were negative, chotinesterase level ~as normal. edrofoinum test ~as positive. anti-acetyleholine receptor antibodies were negatives. e.m.g. confirmed myasthenia gravis (congenital vs juvenile serenegative). pyridostigmine was begun and the trachea was extubated without complications. conclusion: din the differential diagnosis of weamng failure we must consider ~c gravis~ )myasthenia gravis could resemble encephalitis, because of low ocs, overall if is triggered by viral infection. )in some diseases (this case) gcs could not he an aemuate index of mental state. a burguet*, a menget*, e monnet**, a gasca-avanzi*, c fromentin*, h allemand**, jy pauchard*, ml dalphin*. * r animation infantile potyvaiente chu st jacques besancon cedex. ** d~padement de sant publique besancon cedex, france, objective : to point out that strabism is) of one-year-old premature is a good predictor of a poor neurological outcome at two years of age. design and setting : two-year prospective cohort study and geographically defined study (region of franche-comte, france). main outcome measures : neurological assessment was performed at one and two years of age (uncorrected for gestationnal age). a mailing questionnaire was sent to the famity and fuu-filled by thefamily doctor (pediatrician or physician), or neonatologist of the icu at tertiary center, s was diagnosed at one year of age by the examinator but s was not used to diagnose cerebral palsy (cp). sample : of survivors ( %) evaluated at one and two years of age. results : correlation of one and two years neurological evaluation is weak (kappa= . ). correlation of s at one year and cp at two year is fair (kappa= , ). the goal of this paper is to review evidence related to hypothesis that the "waiting" axons and cells of the transient subplate zone may participate in the structural plasticity of the human cerebral cortex after perinatai brain damage (kostovic et al, metabot brain res : , t ) and to correlate this phenomenon with different forms and mechanisms of structural plasticity. it is our basic assumption that all lesions occuring during cortical histogenesis will lead to more or less pronounced structural reorganization. here we show that various components of the subplate zone participate in several forms of the structural "plastic" responses in the human cortex: modification of convolutional pattern, changes in size of cytoarchitecturat areas~ columnar reorganization, dendritic and synaptic plasticity. the etiological factors which induce lesions and subsequent plastic changes act via the following pathogenetic mechanisms: * disturbances of radial unit formation (rakic); * changes in ingrowth of afferent fibres; * changes in the rate of normally occuring reorganisational events, depending on the critical period for a given histogenetic event. in the present study developmental lesions (localized perlventricular leukomalacia and haemorrhages) were demonstrated by ultrasound in live-born infants ranging between to weeks of gestation. in younger infants ( - w) who died shortly after birth, examination revealed lesions of the white matter with the preservation of the subplate zone. in infants who died one week of more after the lesion, we have observed localized micropolygyria, cavities, condensed layer vi -subplate zone, and columnations of the cortical plate. these changes are less prominent if the lesion occurs after diminishment of the subplate zone (after w). since in the fetal cortex the subplate zone serves as predominant source of growing fibers, transient neurons, trophic factors and contains cellular substrata for migration, this zone is the most likely candidate for major types of structural plasticity. in conclusion, cerebral cortex of the low -birthweight infants is more susceptible to the various lesions but shows vigorous structural plasticity and conspicuous functional recovery due to the growing, transiently located neuron at elements. the mortality due to meningoccocal sepsis is high in spite of important progress in emergency and intensive care medicine. during the last decade multiple scoring-systems have been developed in order to establish a therapeutic approach and to evaluate the final outcome of a meningococcal infection. different clinical and biological data (shock, ecchymosis, peripheral wbc and platelet count, coagulopathy, acidosis, meningism, etc) are taken into consideration and the importance given to these data depends on the scoring-system used. a review of the different scoring-systems is given and a clinical case is presented. we report the case of a year old male, who was transfered to our icu hours after onset of temperature and skin rash. the parents described a fast deterioration of his condition. the boy presented wide spread ecchymosis, high temperature, no signs of meningism, circulatory insufficiency and shock, coagulopathy and low peripheral wbc and platetet count. disseminated intravascular coagulopathy developed promptly. the glasgow meningococcal septicemia prognostic score (gmss) was used and the obtained score reached the highest level ( / ). this corresponds to a % mortality. the patient required mechanical ventilation for days. at admission he received human albumine, fresh frozen plasma, dexamethason, dopamine, dobutamine and a continuous infusion of adrenaline. antibiotical treatment consisted of ceftdaxone. the evolution was favorable and the infant fully recovered. retrospectively the gmss was compared to other meningococcal scoring scales which gave the same mortality ( %). we conclude that the scoring-systems are important to evaluate the seriousness and to assess the therapeutic approach, but they should be used cautiously even when % mortality is predicted by several risk evaluations scoring-systems. the aim of this study was to assess the haemodynamic status on admission and the critical care management of children presenting with meningococcat infection. this was a retrospective study of the charts of consecutive admissions. mean age was . years (+/- . ). the average duration of symptoms prior to admission was . hours (+/- . ). on admission . % were hypotensive, . % had clinical signs of haemodynamic instability and . % of cases that had a blood gas analysis on admission had a metabolic acidosis (bases excess < - .q): the mortality rate was . %. % of patients that died were hypotensive on admission and all had a metabolic acidosis. of the survivors . % were hypotensive on admission, % had clinical signs of haemodynamic instability, % required invasive pressure monitoring and . % were ventilated and received inotropic support. this study demonstrates that at the time of presentation with meningococcal infection children had a high incidence of established haemodynamic instability. successful management of this infection is dependent on early presentation and initiation of therapy and on aggressive support of the cardiovascular and vital organ systems. dept. of intensive care medicine and dept of infectious diseases, our lady's hospital for sick children, crumlin, dublinl , ireland. jude. pediatric intensive care unit, ch&u, lille-france. more than % of children surviving sip (defined as purpura with shock) have snli. objective. to search for a specific hemostatic profile in children with snli. patients and methods. between may and march , children with sip were admitted to our picu : ( . %) died and ( . %) ranged in age from to months (mean : ) survived, of them ( . %) with snli (defined as the need of a surgical procedure). in survivors, two hemostasis studies (between h and h , and h later) included the determination of coagulation factors (routine tests), protein c (pc : amidolytic activity, biogenic), total protein s (ps : elisa, stago), c b binding protein (c bbp : laurell's technique, stago), antithrombin (at : chomogenic test, stago), and plasminogen activator inhibitorl (pail : chromogenic test, biopool). three severity scores were determined at admission : french group of pediatric intensive care, gedde-dahl, and crp. statistical analysis used the wilcoxon's test. results. at admission (lst sample) severity scores and at , pc, ps, c bbp levels were not different between the group with snli and the group without snli ; quick time ( - % vs ± % ; p = . ), vti+x ( . % vs - % ; p = . i) and pall ( - ui/m! vs . ui/ml ; p = . ) were lower in the group with snli. on the nd sample there was no difference between the two groups. kinetics of hemostatic abnormalities was not different between the two groups. conclusion. in the literature, intravascular coagulation (dic), low fibronectin and at were identified as predictors of snli, and a negative correlation was found between the mean size of the skin lesions and pc activity, at , and total ps. in this series, apart from dic, there were no specific hemostatic abnormalities that support the use of treatments such as pc, at , and pail antibodies administration to prevent snli. further studies including more children are needed. the aim of study was to investigate the efficacy of intravenous immunglobulin with enriched igm content pentaglob/n /biotest/. in our pediatric intensive care unit ten septic children /group i/-their average age , years /sd:o, /, of them with gramm negative and one with gramm positive blood cultures, and two with unindentified bacteria-were treated with basis sepsis therapy and pentaglobin. the application of pentaglobin was as follows: , ml/kg loading dose for one hour, followed by a continuous intravenous infusion , - , ml/kg/hour depending on body temperatura /lanser scheme/ for - hours. another ten septic patients /control-group ii/the mean age , years/sd:o, /, their blood cultures were gramm negative bacteria , positive , and the bacteria was not indentified in two cases -were treated with only the basis therapy. results: the duration of intensive treatment decreased from an average , days /sd: , min -max days/ to , days /sd: , min -max days/ in the group treated wit pentaglobin. the difference was significant /x p< , /. in the group i nobody died, but three in the group ii. conclusion: the pentaglobin therapy can improve the efficacy of the basis therapy of sepsis. sinus bradycardia after an episode of sepsis is a rare symptom complex decribed in children with hematologic malignancies. we present a case of postsepsis bradycardia following severe typhlitis and septic shock in a year old boy with relapse common all. blood and ascitic fluid specimen grew clostridium species and pseudomonas aeruginosa. at surgery there was a necrotic gangrenous terminal ileum and cecum, requiring ileocecal bowel resection with ileostoma. while clinically recovering from sepsis he developed bradycardia for hours. extensive diagnositic procedures was given and the heart rate slowly increased to normal range of age. postsepsis bradycardia in children with hematologic malignancies after an episode of sepsis is self-limiting and after careful differential diagnostics warrants an expectative attitude. nitrate level is known to be enhanced during sepsis. serum nitrate is the stable metabolic end-product of endogenous nitric oxide generation. nitric oxide has demonstrated to be a powerful anti microbial final mediator and also a key molecule driving to the lethality of one of the most common complication of sepsis; the endotoxic shock. such facts prompted us to investigate the possible diagnostic and/or prognostic value of monitoring serum level in high risk, presumptive and confirmed sepsis patients. additionally we have explored the usefulness of this mediator as index of therapeutic response. in our study it is demonstrated that there is an important relationship between nitrate level and the occurrence of neonatal sepsis. septic newborn group showed fold higher nitrate level than that of healthy control group. in addition, the group of patients with high risk of sepsis which finally became septics, exhibited fold higher nitrate level at - hours before the first symptoms appeared, when compare with those who did not develop sepsis. however in the presumptive sepsis group, there was no difference between the patients which finaliy ,&'ere considered septics and those which not. in all septic cases, after days of a successful therapy with antibiotics, the level of nitrate diminish fold. our results suggest the utility of monitoring nitrate as index for the diagnosis of neonatal sepsis. the potential benefits of exchange transfusion, plasma exchange, and haemofiltration have all been described in children with overwhelming sepsis. however, little hard evidence exists to prove the benefits of any of these techniques. i have treated five patients with plasma exchange (pe), having been asked to see all these patients at a point when it was felt death was inevitable. two of the patients had staphylococcal, two meningococcal and one enterococcal septicaemia. all patients showed a dramatic haemodynamic improvement following pe with improvement in blood pressure, reduction in inotrope requirement and improvement in tissue perfusion. three patients survived. one of the patients with staphylococcal sepsis and both of the patients with meningococeal sepsis had developing gangrene of the limbs which showed remarkable reperfusion with pe. in two of the patients measurements of cardiac output (co) and systemic vascular resistance (svr) showed ~a reduction in co and a rise in svr over the course of a pe despite the reduction or cessation of vasoconstricting inotropes. many believe haemofiltration is of value in septic shock. a trial with a no treatment limb is difficult to achieve. i believe we now have enough evidence to justify a controlled trial of haemofiltration versus plasma exchange in patients with septic shock and unstable haemodynamic status whilst on inotropic support. during the next several days, cough and chest pain suggested pulmonary embolism confirmed by radiologic evaluation. echocardiographic examination showed multiple thrombosis of the superior vena cava, right atrium and ventricle and pulmonary artery. estimated protein c level was . % (normal range - %); identical deficiency was found in patient's mother and elder sister. cvc was removed, and alter -month heparin therapy and supstitution of protein c with fresh frozen plasma, there was almost complete thrombolysis of the great vessels and cardiac chambers. we conclude that invasive diagnostic and therapeutic procedures in such patients may result in higher risk for severe thrombosis at unusual sites, and numeuos further complications bronchopulmonary dysptasia (bdp) is a chronic pulmonary disease of preterm and term babies treated with mechanical ventilation for respiratory problems of different origin and requiring oxygen therapy days after birth. bpd is a disease affecting the growth and development of pulmonary tissue. such pulmonary }esions heal by squamous metaplasia leading to scar formation and fibrous tkssue r~growth, the pediatric intensive care unit makes the survival of babies w~h very low birth weight ( - g) possible. with the increase in their aulyival, the number of complications in low birth weight babies increases as well. bdp is a very serious complication. therefore the importance of early diagnosis and treatment of bdp must be stressed in order to reduce the consequences. babies with bdp must be under medical suveillance for at least years as the disease needs at least that long for complete resolution. tn the icu of pediatric department at madbor teaching hospital: during the past two years ( - ) newborns were treated with mechanical ventilation. the neonatal and postnatal death rate of all newborns admitted to our icu was , %o.ln the two years from to , newborns were admitted to our icu ( %~ of all newborn babies at maribor teaching hospital), with birth weight - g. in the icu, the survival of these babies and parallel to it the number of complications is increasing. during the mentioned -year period, babies with very low birth weight ( - g) survived: in and in t . in - %, first or second stage bdp was treated,there was no case of third of fourth stage bdp. the treatment consisted of eary removal from mechanical ventilation, oxygen therapy~ intensive treatment of infection, volume and caloric intake contro}, corticosteroid treatment throught weeks with decreasing doses, diuretic end antioxydant therapy. the children are to be reevaluated at the age of and months and again at i and years. oeure j van der, markhorst do, haasnoot k department of pediatrics, pediatric intensive care unit, free university hospital, amsterdam, the netherlands. case summary a %-month . kg girl of african origin was admitted to the pedfatric irtensive care unit with pneumonia and progressive respiratory irlsuffjderey. she was intubated and ventilated by pressure regulated volume controijed ventilation (servo c, siemens, soma, sweden). maximum conditions were inspiratory minute volume . l, peep cm h~o ahd % ~. chest x-ray showed bilateral interstitial consolidation. material obtained by broncho-alveolar lavage showed preumocystis car}nil htv-serology (elisa and westerll blott) and p -antigerl were positive, confirming the diagnosis of pediatric aids. she was then treated with high dose co-tllmoxazoie, penthamldine, z{(~ovudire and steroids iv. because of thee x-ray features, high need for o ( %, pad mm hg), not responding to elevatiofi of peep (max cm h=o) and pao /fio = < (s ). m acute respiratory distress syhdrome (ards) was diagnosed. because conventional ventilation (cv) failure, hfo-v ( ooa, serisor medics,yorba linda, ca) was initiated. starting mean airway pressure (map) of cm h~o was based or map of the cv, oscillatory pressure amplitude (dp) of was, at ii~itial frequency of . hz, adjusted ur~til chest wall vibrations were visible, it was required to raise map to cm h and dp to before optimal lung volume and ventilation were achieved and need for o reduced within hours, this was monitored by frequent blood-gas analysis and chest x-rays. map and dp could slowly be reduced, after a good response the first day, gradually demand reduced and the patient could be weaned from the ventilation. map, dp, fi and oxygenation index (map x pa ~jfio ) are shown in table i. chest x-ray follow-up showed gradually improving lung features, with marked improvement of aereation. after days hf -v she could be succesfully detubated when a map of cm h was acmeved. results : sianificant increase in ventilato~ rate and mean airway pressure was noticed after the change to savi. no differences in oxygenation, co partial pressure and systolic, diastolic or mean blood pressure between imv and savi periods were noted. in infants however an improvement in pao /p .ol/ and decrease in paco was observed after the switch to savi. these babies had a lower initial a/a oxygen tension ratio and required higher initial ventilator rate /p<o. / in comparison to the rest of the studied patients. conclusion:infants with low a/a po ratio who need high initial ventilator rate are likely to obtain benefit from savi.. fumimare hatori, haruo uchida, masao katayama, and rika muto department of anesthesia and critical care medicine chiba children's hospital, chiba city, japan. purpose: this study was made to find out whether the heat and moisture exchangers (hme) was effective enough to humidify in the respiratory management for children. patients: the study population consisted of patients who were provided with artificial airway. they were divided into the two groups: ii with heated humidifier (a) and i with hme (b). methods: hme could be used for those without pulmonary complication and with less leakage around the endotracheal tube. in both a and b groups, (i) we have measured relative humidity, temperature, and absolute humidity at the endotracheal tube connector. for these measurements, humidity sensor system was utilized. ( ) any troubles and complications caused by the artificial airway were investigated. results: (i) in group a, we confirmed the mean values as the relative humidity of . %, the temperature of . ~c, and the absolute humidity of . mg/l. in group b, they were . %, . °c, and . mg/l respectively. no difference was noted between the two groups as to the relative humidity, but the temperature and absolute humidity were lower in group b with a significant difference (p< . ). ( ) in neither of the groups, any respiratory complications such as obstruction or stenosis of the artificial airway were noted. in pediatric icu, hme can be used without any problems under given conditions. titei: objective: evaluate the precision, reproductibility and aplicability of a new device to measure auto-peep in pediatric patients during mechanical ventilation. material and methods: it's an electromc-pneumatic eontolled device with an oclusion valve and a pressure monitor installed between endotracheal canulla and the ventilator circuit. the measurements were performed with a sollenoid conected with to the ventilator to detect the end of inspiration phase and the actwation of the oclusion valve. the signs of pressure and flow were moniturized using a difere~rtial transducer and it was processed using a pc computer and a pneumoviaw® software. the auto-peep also displayed in the ventilator pressure monitor. results: we submitted children with neuromuscular disease or respiratory distress in this study. the incidence of auto-peep was %, with variability between , to cmh . all the measurements were performed times to verify the precision and the reproduetibility and evaluation of the pressure and flow curves. conclusion: the device is low cost, easy to use and can be used without the pneumotacograph. the auto-peep measurement can be done during mechanical ventilation with time cycled, pressure limited and continuous flow, the most commom ventilator used in pediatric patient. resistance was modeled by endotracheal tube (ett) sizes ( . , , , ), and compliance by test lungs ( and ml/crnh ), for each resistance -compliance arrangement, we measured tidal volume (vt) at various frequencies, peak to peak (p-p) and mean airway pressures. results vt increased when ett size increased with all ventilators in accordance with fredberg results (jap, ; : - ) . the maximum vt delivered was smaller with the hfv-babyiog than with the ohf or the sm a at a given frequency (figure on the left). increasing p-p resulted in a linear increase in vt delivery in the - % range of maximum p-p (figure on the right). hfv-babylog didn't provide significant vt increase when p-p was set above % and vt deliven/decreased when mean airway pressure decreased. --i ~ sm a a number of ventilatory parameters had been analyzed with russia-produced monitor humitemp htm (servisinstrument j,-s. co) in newborn infants with rdsn of t-iv stages on cmv, cppv, imv, and cpap steps using respirators of various kinds (stephan-staxel, bear- , newport rezee, sechrist). parameters investigated were: temperature of inspired mixture (t), relative and absolute humidity (rh and ah, respectively), static compliance (c), expired tidital volume (vte), expired minute volume of ventilation (mve). the monitor read these parameters in following ranges; rh-from to %; ah-up to mg/i; mve-up to . i/mini vte-from to ml; t-accurate to %; c-from . to t ml/cm h . continuous monitoring time ranged from to hours, it was noted, that during this time the monitor and transducers had no malfunctions, and it's using didn't require additional calibration, it was found, that humidifiers mr and mr (fisher, paykel) couldn't maintain parameters t and ah continuously (these values varied from , to . c and from , to . mg/i, respectively, when heating regulator position was unchanged). changes of parameters c depended clearly on cppv conditions and rdsn severity (with rdsn of stages i-ii c value ranged from . to . ml/cm h ; and with stages iit-tv-from . to . ). tn newborn suffering from rdsn of stages ii-ltl and ill-lv with pip> mbar, fi > , , peep= - mber, c-from . to . ml/cm h , effectivity of exosurf therapy was studied. in newborns in - hours of therapy pip decreased to . - . , and c increased to , - . ml/cm h . in newborn infants with aad > mmhg and c from , to . mltcm h positive effects of exosurf on lung compliance were not observed. in newborns the monitor had revealed decreased of c (from . - . to , - . ml/cm h ), manifested clinically by pneumothorax. in general, monitor htm made possible; ), to estimate the adequacy of cmv-parameters and regimes in newborn infants; ). to select optimal t and ah values in the respiratory outline in dependence on lung damage severity and infused volume; ). to reveal rdsn severity; ), to optimize indications and adequacy of surfactaot therapy; ). to diagnostieate the air leakage syndrome; ). to effects to some agents (broncholytics, spasmolytics); ). to obtain objective indications for imv/simv and cpap regimes. albano communication is an important aspect of human development and existence, and an inability to vocalise can be a problem in ventilatordependent patients. we present our experience with speaking aids as a means of enhancing verbal communication in four ventilatordependent children in our paediatric intensive care unit. the age of the children ranged from months to years, and the period of ventilation ranged from months to months via a tracheostnmy. they require continuous flow generated pressure limited or control ventilation at rates of - bpm. the reasons for ventilation include tetraptegia following a shrapnel injury; tetraplegia following congenital cervical spine damage; tetraplegia following atlanto-axial subluxation; and critical illness polyneuropathy following adult respiratory distress syndrome from prolonged ventilation for a severe head injury. the first three patients have passy-mnir one-way speaking valves and the final patient has a bivona foam cuffed tmcheostomy tube with a talk attachment in view of recurrent aspiration. an improvement in quaiity of speech has been shown by independent assessment. we will review the present literature on this subject and discuss the advantages and disadvantages of these two types of speaking aids in the light of our experience. the prognosis of antenatally diagnosed cdh is closely related to the degree of ph. there have been attempts to correlate antenatal or postnatal criteria to mortality: none have been demonstrated to be predictive of lethal ph. the aim of this retrospective study was to determine whether antenatal or early postnatal data could correlate with the findings of post-mortem examinations. patients and methods: between july and july , cdh patients have been antenatally and postnatally managed at our institution. twentythree infants underwent a post-mortem examination. ph was assessed by using the lung weight to body weight ratio (lw/bw) and the radial alveolar count (rac). antenatal results: cdh diagnosis was made at weeks of gestation (wg) ( - ). twenty-eight patients had a left sided cdh, had a right sided cdh, and one had a bilateral cdh. herniated organs were stomach none (n= ), or liver alone (n= ), or both stomach and liver (n= the patient was a -yenr-old girl with chronic renal insufficiency see~ to renal dysptasm, two months before admission a kidney trar~ptant was performed. one morah later she showed acute graft rejection with serum ereafinine (cr) level of . mg%. the rejection was unreslxmsive to an increased steroid dosage, and okt was begun with resolution of the rejection. one week arer, new rejection episode was seen marestxmsive to an increased steroid dosage, and transp~ ~s performed five days before admission to our ptc. hemedialysis and peritoneal dialysis (p.d.) each other day, was indicated (g.r.f.< ml/rnin). four days before admission t ~ rose to °c. "lhe diagnosis of opporttmistic pneumoma was made on the basis of tach ,pr',e~ hypoxi~ and diffuse interstitial infiltrates. senma ~ was positive for cytomegaloviras (cmv), and stool culture for c albicans. pentamidine, ganciclovir (dhpg), arai-cmv gamma globulin, eritromicine and amphotericin b was administered. on admission in our picu, trachea was mmbated, (a-a) o gradient was , paofffio~: , lung injury score > with peep level of cm hzo. she had normal fiver function. during te next days she had fever and developed ards. bal was negative. p.d. was of little efficiency. we adjusted pentanfdine, and dhpg doses for severe renal failure, with supplements after hero, sis, and at~rp.d.. during ~ next days she was afebrile, and the chest became radiologlcally normal. after ten days on menhani~al ventilation (mv.), the patient was extubated. cr. level was . rag%, (a-a) oz gradient was , and paoyfioz was , the patiem was discharged with chronic ambulatory p.d. discussion: opportunistic pneumonia is a major complicalaou in imm~romised children, specially after kidney tvansplaraafion. c m.v. infection can result at~r okt administration. in the treatment dhik} dose must be adapted to the degree of renal insu~cieney, with supplements after hemedialysis, and after pd. pneu~y~tis cann# tmeumov~ is ehemeterized by ventilafion-perfusion mistmaeh, decreased pulmonary compliance, hypoxia arld elevated (a-a) oz gradient, with diffuse interstitial infiltrates. in our ease bal was negative. although we did not find the etiology the prevoclons eombh~ation of arairmcrobiat therapy, along with m.v., and supportive measures were the most effective trealme~. conclusion: ) in patients with severe renal failure and life-threatening infections, we must co~ider drug adjuslments. ) in our patient we gave dhpg supplements at~r pd. with excett~at results, although p.d. was of little effiele~. introduction: endotracheal intubation and mechanical ventilation have become an important treatmem for many diseases accompanied by respiratory failure. with the frequent use of this treatment modality, an increasing number of complications associated with endotracheal intubation have gained clinical significance. material and methods: a transversal study was realized to find the prevalence of pulmonary aspiration with endotracheat tubes in infants and children. aspiration was assessed by applying two dyes (evans blue, er)¢rosine sodic) on the tongue and searching for the dye during suctioning in the endotracheal aspirate. the factors, that potentially have influenced the aspiration, including weight, age, sex, cause of respiratory failure, main pressure airway (map), level of consciousness, presence of swallowing and body position were evaluated. all the variables studied had their association with aspiration tested by chi-square method with relative risk considering a confidence interval of %. the results were adjusted by multivariate analysis. results: the overall prevalence of aspiration was . %. among all children who aspirated, compared to those who did not, there was a statistically significant difference in the presence of swallowing (p= . ). the odds ratio to aspiration in the presence of swallowing was . (t. - c.i. %) and the relative risk . . aspiration was not significantly affected by sex, weight, age, cause of respiratory failure, map, level of consciousness and position of the body during the ventilation. conclusion: the endotracheal intubated children frequently aspirate as intubated adults and that preventive measures are ineffective. the presence of swallowing movements is the main risk factor to aspiration of oropharingeal content in intubated patients. clinical features and shortterm outcome skling, rp gie pneumonia is the second most important cause of death in young south african children. the clinical features, intensive care course and outcome of children being ventilated for pneumonia in the developing world is unreported. aim: to describe the clinical findings, aetiology and shortterm outcome of children younger than months with pneumonia requiring ventilation. the data of all babies under the age of six months with a lower respiratory tract infection admitted to the paediatric icu for ventilation were prospectively collected over a period of months. tracheal aspirates and blood specimens were submitted for viral and bacterial cultures. results: forty-seven babies aged to days were ventilated for pneumonia. twenty-six infants had been born prematurely; t had been ventilated during the neonatal period and had bpd. the median duration of symptoms was day, the most common being cough, tachypnoea, apnoea and cyanosis. five babies ( %) died. the mean duration of ventilation was days (range - days) and of ward stay after icu discharge days (range - days), blood euttures were positive in children ( %). viruses were cultured in children ( %). conclusion: ) fifty-five percent of children below months requiring ventilation for pneumonia were premature infants, of whom % had been ventilated during the neonatal period. ) the median duration of symptoms prior to admission was day. ) ninety percent of the children survived and were discharged from hospital. ) viral pneumonia was responsible for % of the admissions. mechanical ventilation and atrial natriuretic factor release ulloa santamarfa, e, p rez navero jl, ibarra de la rosa i, espino hernladez m, velasco jabalquinto mj, frfas p rez m. picu. reina sofia children's llospital. c rdoba. spain. mechanical ventilation effects on renal function decreased diuresis and natriuresis due several factors including anf. several studies have demostrated anf released due increaasing pressure in right atrium. on the other hand, mechanical ventilation, overall peep modality, inhibits peptide release althougt cvp increased is found. this study was designed to demostrate anf stimulation is due rigth atrium stretch which be higher during mechanical ventilation instead of atrium pressure. we desing a prospective study including patients, age range months- years with congenital heart disease. all of them were admitted at pediatric intensive care unit after extracorporeal surgery and were assisted by mechanical ventilation. hemodinamic state was stabilized in all patients and nor renal neither neurological diseases were found. after hours with mechanical ventilation, plasmatic levels of anf were measurement, pvc, pericardical pressure were assessment; all patient were sedated with midazolan and paralized with neuromuscular blocking agent; mechanical ventilation technique was as follow: imv between and , tidal volume and fi o enough to mantain respiratory parameters in normal range. afterwards, at least twentyfour hours in spontaneous breathing, the study was made again in each patient. atrial stretch was assesssment according to following equation: transmural pressure= cvp -pericardial pressure. cvp were significantly higher with mechanical ventilation than when the patient was breathing by himself. ( . +__ . vs . + . mm hg; p< . ). however, transmural pressure during mechanical ventilation were lower than during spontaneous breathing ( . +__ . vs . +__ . mm hg; p < . ) equal, plasmatic anf levels were lower during mechanical ventilation ( . + . vs . + . pg/rnl; p< . ). in conclusion, anf secretion decreases during mechanical ventilation, even with cvp higher. anf release would depend on atrial stretch meassured by transmural pressure, lower in patients with mechanical ventilation and it would not depend on atrial pressure. the paediatric intensive care unit shaikh zayed hospital, lahore is an acute care area devoted to the care of critically sick children upto the age of years. in a bedded unit with limited equipment, constant care is ensured by the presence of at least one nurse aed one doctor round the clock. in this setup we have the facility to ventilate - children at one time, between sep. and dec. , out of patients admitted to icu, ( . %) were below yr of age, while ( %) were below month of age. life support was discontinued in ( . %). total mortality was ( . %), major mortality was in - month age group ( . %), and month to month ( . %). majority of the patients were of sepsis ( . %), cns disorder ( , %) followed by respiratory problems ( . %). it seems therefore that the major indicatiou for ventilation was overwhelming septicemia leading to multiple organ failure, rather than purely respiratory problems. high frequency oscillation (hfo) in the therapy for ards in pediatric patients requiring aggressive conventional mechanical ventilation (cmv) -routine or experimental mode ef pre ecmo therapy. fedora m., nekvasi~ r, vobruba v., srnsky p,, zapadlo m. dpt. critical care medicine, nicu and ecmo center, university children's hospita! brne, nicu of university hospital prague, czech republic. introduction: pediatric patients ( males, female, average age . months, average body weight , kg) with severe ards ventilated with aggressive regimen of pcv or prvc were connected to hfo (sensormedics ) as the last "rescue" therapy due to uncontrollable respiratory failure before intended ecmo. in the course of hfo of them were given no in the concentrations of - p.p.m., were subjected repeatedly to surfactant replacement therapy (alveofact). results: ecmo was needed in no patient, patients survived, patient was disconnected from the ventilator because of brain death in spite of conspicuous improvement of oxygenation and other parameters, some relevant parameters hours before and hours after starting hfo are given in table ~ in all the cases, the disconnection from hfo was carried out through the simv regimen, never directly to cpap. table : the levels of blood gases, oxygenation index (oi), aado ,map,fio and pao /fio ratio hours before and hours after starting hfo. conclusion: although none of the patient had to be subjected to pediatric ecmo, hfo should be carried out only in workplaces having the immediate possibility of using this method in the case of hfo failure. speculation: should not hfo be used ir pediatric patients with ards earlier than aggressive cmv? can hfo ce considered standard, not experimental method of therapy? refractory hypoxemia in premature patients is characterized in a persistent elevation of pulmonary vascular resistance, with right to left shunt through the ductus arteriosus and or foramen oval. we report the case of a vlbw patient (ga w, bw g) who present a severe hypoxemia related to hyaline membrane disease and a pulmonary and systemic infection to group b streptococcus, refractory to conventional ventilatory support and surfactant therapy, associated to hemodynamic failure falling in ecmo criteria used for term infants. a rescue therapy with hfov (sensor medics a) is decided at h of live, the table resume the patient's evolution before and after hfov. at w of postgestational age the patient present a fio of . with a chest x ray compatible with a cld type l at discharge no oxygen requirements was needed and actually he's doing well. conclusion: hfov, using an adequate alveolar recruitment strategy, was effective in the rescue of a severe hypoxemic respiratory failure with a rapid off of ecmo criteria entry in our vlbw premature patient, during the united nmioffs embargo ~nst yugoslavia the prevalence of the ast}nnafic ~acks in c~dldren aratsed. the mo~t common causes have beem dramm~e worsening of life standard, ecom~c disaster in global community, gr~ number of refugees from the other parts of former yugodavia. it wm obviom that mcio-ecoumnical conditions took a part in the exacerbations of previously known cldldhood asthra~, ~av~ of micro-and m~mclimaflc changes, psychosocis] and emotional cryses, lack of medics-m~nts for p~ve~on and tl~rspy of acute asflanatic attacks. about % of d-dldv~ tmslod in our picu for these year~ exp~dvncod ~vcr~ attack for the flint time iu ~jzeir lifts. it has been cu~ ~%~ children in mspir~ry picu of our hos~mt. the scut~ revere attack (more ~asn ~/o of hight clinical score) was detected in % of all children admitted with respirak~ problems. from tl~ mmlysss we exclu&d: bmncldolifis, ~i anomalies, ~eve~ i~ccqions. concerning our drug supplies (which wc~e reduced), we started our therapy by administration of oxygen, ~ta -ago~dst inhalations (but sometimes we had the solution for jet nebulizcm only for o~e inhalation per p~cnt), mwinophyllin and mefl~ylpr~ini~done in/ravenously. % of ih~ asthmatics needed repea~ doses of muinophyl~n pinch.ally, tnch.,ding the fluids. the bronchodilak)r msponm was poor ~r~cl slow, hospital stay in picu was for days and for days in other units sl~rwsvds. tim ~ of their stable condifio~ was hard at borne (or refugees camps), without p~ventkm, so they came bsvk to hospital for morn than times in % of cases, dtrdng ~e je last motlfl~s file dtustion improved, concerning tim drugs supply for prevention, and we hope that these lifc~restening conditions wouldd~ introduction: the incidence of ards is increasing as survival of critically ill patients is higher. the application of new therapeutic modalities have increased the survival rates in (ards) adult patients. objective: to study the therapeutic efficacy of new tleamlents in children with ards material and methods: a retros~ctive study was conducted from to . children with severe ards, (lung severity score > , ) (r), aged days to years, were included. the diagnosis were as follows: interstitial pneumonitis, non interstitial lung infection, with lung aspiration and with clinical sepsis. patients had different tipes of cancer and to suffer inmunodeficiency disease, the first subjects (group t) were treated with conventional measures. from october of new therapeutic modalities were introduced, including: less agressive ventilatory support, postural changes (prone to supine) in subjects, administration of corticosteroids in patients, rfitric oxide in , pe~ssive hypercapnia and administration of exogeans sarfactant in one, pao /fio , d(a-a)o , oxigenation index (oi) and the score of respirator), severity disease were similar in both groups. the two groups evolntiou was compared. results: -ten patients died, from group i and from group ii ( % v.s. : %,ns). -the evolution time, either to exitus or weaning from ventilatory support was higher in group ii ( . v.s. . days in group i, ns), -the incidence of barotrauma was observed in subjects ( . %), from group i and from ii. of these patients % expired. -during the course of the disease, ( %) patients had more than one damaged organ. only in one subjet mof was considered to be the main cause of death. the majority of the patients expired because of their respiratory disease, although, % of them met criteria of mof. -fifty percent of the subjects were infected at the time of death. stmmry: a trend toward a higher survival rate is observed in the subjects receiving the new modalifies therapeutic intervention (corticosteroides, postural changes and permissive hypercapnia). our results are not significative,probably because of the small number of subjects studied. a new doubleaurae~t two-stage et-tube (dl-ett) was desig~aed and tested in the rabbits with acute king injury under conventional mechanical ~entilation_ ventilation efficiency of dl-ett was emrrpared with that of canveniionally t~sed single lumen et-tube (sl-ett). meth~s: dl-ett was specially made out of two sl-ett. vertical crosssections at the distal end of two et-tube (td _ rmn portax) were adhered with each other to form a tracheal stage lumen wifu id . mm the two remained uncut parts of the tubes corlntithted the oval s~ge with two separate imnens. dl-ett and sl-ett were randomly applied to five adult paralyzed rabbits with acute lung injury (by . nffkg oleic acid. iv). a bird inter vetffttator (bird products corporation) was used for time-cycled pressure-limited ventilation at /min of respiratory rate, ern h of peak i_~piratory pressure, l: of ire ratio, ljmin. of flow rate and . of fich. peak inspirntory pressure, mean mrway pressure, posi ve end-expiratory pressure at tip of et-mbe and bemodynamics were measured and recorded continuously. arterial blood and expired gas were measured ~by avl blood gas analyzer) after each stabilization t.~iod of minntes. _analysis w~as by prated t test. result: dl-ett acaltety improve cos removal at all amman. pa(?oz was decreased by t . +_t. (p< . l) and physiologic dead space fraction (v~zvt) reduced by % +- . % (p< . t), compared with dl-ett. there were no significant change in arterial oxygenation. conelus|on: the double-lumen two-stage et-tabe significantly increases ventilation effmiency with simple operation in rabbits v, ith acute hmg injury, lts availability may influence future clinical management of ~ennated patient~. this ~muly was fimded by the science and technology. commiuee of beijing municipality. analis of hemostasis alterations on different coagulation cascades in children with septic shock has shown that coagulation disorder character is dependent on lung affection rate. the initial manifestation of the respiratory distress-syndrome (rds) are characterized by the obvious activation of blood thrombin potential, moderate coagulopathy and not sharply marked endoteliosis, the witlebrand's factor (wf) increase tot - %. progress in the clinical picture of "shock lung" leads to chronometric and structural hypocoagulation with potential hypercoagulation in "mix-test", high level of firbin derivative, thrombocytopenia with thrombocytopaty and the wf increase to ~ %, terminal stages of the rds, as a rule, are characterized by potential hypercoaguletion absense, depletion of at-lit and plasminogen, prevalence of antithrombin and antiaggregating activity, obvious endoteliosis (the wf to increase - %). the arteriowenous difference according to index of the thromboelastography (teg) in the rds ill-iv rates was , % less than in the - rates, disorder of lung filtering ability in severe rds is confimed also by minimal arterio-venous difference of activated euglobulin lyses (ael) in children with the rds ill-iv rates is only , %, while the patients whit rds i-i rates have the ael-activity in arterial blood , times as much than in venous blood. the use of then allows to determine the potential hypercoagulation rate, the at-ill level and fibrinogen quantity during the anticoagulant therapy and also the character of the x-factor activation and thrombocytic hemostasis. the effective therapy component of septic genesis rds in children is the controled coagulation method with the use of the individual selected heparin doses in according to desagregants, kryoplasma, proteolisis inhibitors and trombolytics. it is necessary to avoid the heparintherapy for children with the rds complicated with producting coagulopaties and termal phases of blood disseminated intravascular coagulation (dic). bronchoseopy has been used for evaluation of the potential problems of the airways and for investigation the bronchial specimens for diagnostic purposes. regent technical advances result in performing this procedure at the bedside manner and in critically ill patients. we have performed hronehoaeopy during last three years on pediatric patients with respiratory problems, in % of cases the opentube hroneh seopy was performed (for diagnostic as well as for therapeutic reasons) and collected secretions or bioptic material were examined. the indieatiuns were: acute upper respiratory problems, chronic wheezing, inspiratory strider, tracheal or bronchial bleeding, chronic eongh, retractable atelectssis, severe pulmonary infections, lymph node perforation in lung tuberculosis and soquells like bronehiectssis and fibrosis. our results were: anatomical malformations in %, mueosal oedema with chronic inflammation and thick secretions in %, easuos masses in %, granulation tissue and purulent secretions in foreign bodies and bronehieetasis in %, and only % of eases were normal finding. our exlxdenees pointed that this invasive procedure in carefully selected patients has important role in establishing the diagnosis and in the- introduction: tbg has been a useful investigation in the management of ventilator-dependent infants in our experience. one ml of contrast was hand ventilated into the respiratory tree via their nasotracheal tubes and their anatomy and dynamics demonstrated on radiological screening. case descriptions: three infants who were difficult to ventilate requiring high airway pressures, high peep and a significant oxygen requirement had tbgs. the ages ranged from to months. two cases were complicated by complex cardiac lesions. in all cases there were frequent episodes of desaturation, where hand ventilation proved difficult and various intermittent lobar collapses occurred. microlaryngobronchoscopies (mlb) performed on the infants by experienced paediatric ent surgeons failed to identify the airway problems. more than one mlb was frequently done. concern about introducing contrast into the airways of infants with limited cardiorespiratory reserve combined with an uncertainty about how much extra intbrmafion would be gained often led to a delay in investigation. when performed these fears proved groundless, the anatomy and pathology of the airways were demonstrated in full and the correct therapeutic plan started. in two cases tracheostomy and peep producing patency of bronchomalacic segments allowed weaning to low levels of ventitatory support. in one case tracheal reconstruction was undertaken and in the cardiac cases the respiratory component of the ventilatory dependence was fully assessed. at the age of months, a baby boy with a history of minor respiratory problems, was admitted to hospital with an upper airway infection and severe dyspnoea. shortly after arrival at the icu he had a total airway obstruction. after intubation there were still difficulties to establish a normal gas exchange, and he was tranferred to the regional picu. ct scan and bronchoscopy verified a congenital tracheal stenosis affecting the whole trachea except the upper mm below the vocal cords. the diameter was estimated to less than ram. an unsuccessful attempt was made to dilate the extremely rigid stenosis with a balloon. after the procedure he had a respiratory and circulatory arrest, and he was put on ecmo as a bridge to surgical correction. after stable days on ecmo, surgery was performed during ecmo with a tracheal homograft transplantation. immediately after surgery, ecmo was discontinued. a silastic dumont type stcnt was inserted inside the homogra~, and a nasotracheal tube was placed inside the stent for assisted intermittent mechanical ventilation. repeated bronchoscopies were performed to remove granulation tissue and secretions. at months of age, the stem was removed with an endoscopic procedure. however, the trachea was still soft and collapsable, and another silicon stent was placed inside the trachea for another months period, after removal he had some respiratory problems and he was treated with nebulized salbutamol, mcemic epinephrine and steroids. he was discharged from the hospital at months of age and his condition is now stable. this is the first procedure of its kind in sweden. it was accomplished by international and multidisciplinary collaboration. ecmo may be a bridge to corrective surgery and long time stenting may be necessary in the postoperative period. post mtubation laryngitis ( pil ) is still a frequent complication, occurmg in l - % of intubated patients. inhaled racemic epinephrine has for long been used as an accepted therapy, but this drug is not always available. the authors undertook a randomized, double-blind, placebo-controlled trial to determine the efficacy of inhaled l-epinephrine(le) in the treatment of plu in the period between july/ and may/ , patients were submitted to endotracheal intubation for ventilatory support. atter the extubation procedure patients were considered for enrollement if they met the following criteria: clinical signs of laryngeal estridor and a downes and rafaelly score for upper respiratory obstruction equal to or higher than patients with primary upper respiratory disease were excluded all patients enrolled reeieved either inhaled l-epinephrine % or normal saline. dexametasene ( , mg/kg/day) was given to all patients in both groups. after inhalations, au patients were monitored for a period of - minutes and monitoring included cardiac and respiratory rate, mean arterial blood pressure, arterial blood gases and the dowries and rafaelly score. statistical analysis included, qui-square with the fisher correction test and the z-test for paired variables. thirty eight patients ( , % ) met the criteria for enrollment, to the le group and to the placebo group.there were no significant differences in both groups in regard to age, sex, initial score ( , x , ) and endotracheal tube diameter. the period of ventilatory support and tracheal intubation was significantly higher in the le group ( , x , , p = , ). the follow-up score showed a significant drop only at minutes after the inhalations (p = , ). re-intubation due to laryngitis, occured in patient of the le group and in of the placebo group with no statistical sxgnificance (p = , ). no difference was observed on the monitored hemodynamic variables during the minutes, except for the mean arterial pressure at minutes, being heighar on the placebo group (p = , ). we concluded that, although the l-epinephrine group showed a trend in better scores post-inhalation and fewer re-intubations due to laryngitis, the results were not statistically significant. we especulate that the period of intubation may have affected our results. similarlly there were no differences in the incidence of adverse effects between both groups. objectives:to evaluate the complications of endotracheal intubation in children with upper airway obstruction due to epiglottitis or croup. methodes: during a year period ( - ) all patients with epiglottifis or croup were reviewed to determine the complications of endotracheal intubation, especially upper airway obstruction due to granulomas. results: patients were reviewed. in children (mean age . years) with epiglottitis the mean duration of intubation was . days ( - ). no complications were seen. in patients (mean age . years) with croup the mean duration of intubation until the first extubation was . days ( - days). elective extubation was performed if an airleak was present or after days without airleak but in the absence of fever and obvious secretion. reintubation was not necessary in children ( . %). in this group the mean duration of intubation was . days ( - ). in patients ( . %) reintubation was necessary because of severe upper airway obstruction due to granulomas. mean duration of intubation until the first extubation was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . there seems to be a difference in duration of intubation between these two groups with croup, however it is not significant (p > . ). all the patients with granulomas could be successfully extubated after microlaryngeal surgery, with a mean intubation period of . days ( - ). revealed no complications, where as endotracheal intubation in children suffering from croup showed a high incidence ( . %) of granulomas. however laryngeal steepsis and other serious complications were not sesn~ patients ( days averagely] was obviously seen in ~he peak =one of fl, f resonance and in the zone of high freq,-~ncy :r, ~;~e composition while cases( day~ average;y] :~bowed no abnormality both clinically and isryngoscopica!~y. / patients with catheter placement for more than week~ end p~tie,~ts for less than weeks had t;~ryngeal abnormal change in their larynges,abnormal changes of sound spectrogram were all seen in patients with placement for mope than weeks. our data suggest= ca] the complication of endotracheal intubation was increases with increasing length of time of catheter placsm. entjbut aeriuoa complication is rare i (b] the time limit of pernasal endotraoheal catheter placement is weeks within which the procedure is • comparatively safe and effective means for maintaining e tong term artificial airway. in a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) we diagnosed tbm as an apparent dilatation of the trachea and main bronchi ih four premature infants on continued mv for respiratory distress syndrome (rds). the infants were three boys and one girl with gestational age (ga) - weeks and body weight (bw) - g. mv was provided by bourns cub time-cycled and pressure-limited ventilator to attain normal gas tensions. no jet ventilation was used. chest radiographs were reviewed for a complete evaluation, and for the evaluation of the airway. after the intial subjective diagnosis of tbm, the width of the tracheal and main bronchial air column was measured at the lower level of the first and the third thoracic vertebal body it , t ) and near the carina; the width of the main bronchi below the carina was also measured. in all infants, tbm became apparent close to the lh day, that is, after - weeks of mv. therefore, for the time period from birth to the th day the following ventilatory parameters were reviewed and analyzed: ( ) the percentage of total ventilation time when more than % o concentration was required, ( ) the peak inspiratory pressure, ( ) the positive end-expiratory pressure, and ( ) the duration of high frequency ventilation ( - breaths per minute). also noted were the apgar scores ( and min after birth), the duration of hypotension (systolic bp below mmhg) and circulatory instability, the presence of systemic or tracheal conatal or later infection, the duration of mv, and the final clinical outcome. the records were also reviewed for other possible pertinent data. rigid respiratory endoscopy in children fraga j, amant a s, piva j, nogueira a, palombini b. introduction: the respiratory endoscopy is an important procedure to diagnose and treat many airway's diseases in children. although have had advances in radiologic investigation exams and pulmonary function tests, the direct anatomic visualization of airway is important to the management of many respiratory problems. objective: evaluation the respiratory endoscopies performed with a rigid bronchoscope in a pediatric reference hospital. material and methods: we study the records of all children that were submitted to respiratory endoscopy under general anesthesia from march to march . age, sex, clinical to indicate the procedure, diagnosis and complications of endoscopy were registered. results: three hundred and fifty six respiratory endoscopies were performed. the most common indications for endoscopy were strider ( %), suspected foreign body ( %), atelectasis ( %) and difficult tracheal extubation ( %). the most frequent diagnosis were laryngomalacia ( %) and subglottic stenosis ( %) in the glottic and subglottic areas, and foreign body ( %) and tracheomalacia ( %) in the tracheobronchial area. normal endoscopy was performed in ( %) of the children. only three slight complications of the endoscopy were observed. two patients presented bradycardia during the exam, and the third need tracheal intubation due to post-endoscopic subglottic edema. conclusion: the rigid endoscopy in children is efficient and has no serious complications. near drowning; indicators of acute and long term prognosis bernardien t.mj. thunnissen t, reinoud j.b.j. gemke , loes veenhuizer?, krijn haasnoot , a.johannes van vugh department of pediatrics, ~wilhelmina children's hospital, utrecht, sophia hospital, zwolle, and ~free university hospital, amsterdam, the netherlands. in this retrospective study factors that affect short and long term prognosis after submersion were analysed. all patients that were admitted to a tertiary pediatric icu between january i, and january i, were included. of patients, aged - years, died in the icu, one after hospital discharge. survivors and non-survivors showed significant differences with respect to central temperature, pupillary reactions, arterial ph, pediatric risk of mortality (prism) score and therapeutic intervention scoring system (tiss) upon admission (p < . ). non-survivors more frequently required mechanical ventilation, bicarbonate administration and active reheating. ards was seen in patients ( %), invariably within hours after admission. no patients with cardiac arrest on" admission snrvived without sequelae. hypothermia appeared to have no protective effect on hypoxic damage. survivors with persistent sequelae _> months after discharge had significantly higher prism and t ss scores (mean and , respectively) than those with complete recovery (mean and , respectively). long term cognitive problems were present in / survivors ( %) and emotional disturbances in / ( %). in conclusion, a concise number of clinical and laboratory parameters, representing acute severity of illness, are important prognostic indicators for survival and health status of children after submersion. there were ( %) bronchoscopies, and ( %) were oesophagoscopies.the average age was , years for bronchoscopies, and years for oesophagoscopies. the outcome of the patients was good. no complications were observed. extraction is recomended in every symptomatic patient. orphenadrine is an anticholinergic drug mainly used to decrease symptoms of parkinson disease. orphenadrine has a peripheral and central effect and overdose can result in athetoid movements, convulsions, cyanosis, coma, arrhythmias, shock and cardiac arrest. physostigmine is a specific antagonist of the peripheral and central effects and can be a useful antidote. we report the case of a two and a half year old female who was transfered to our icu for general convulsions. the little girl had, three hours before admission, accidently ingested rag of orphenadrinehydrochlodde (disipal®), which was her grandmothers anti-parkinson medication. three hours after ingestion she presented neurological signs: confusion, unstable walking, and periods of aggression. generalized tonic-clonic seizures appeared who were rebel to administration of multiple anti epileptica but ceased after iv administration of diazepam and endotracheal intubation and ventilation. an episode of ventdcular tachycardia responded well to the iv administration of tidocaine. the levels of orphenaddne in the serum were high at admission ( pg/l) and were present in the blood up to hours after ingestion. high serum levels are, in the literature, associated to a high mortality rate. physostigmine was administered three times at a . mg/kg dose in the first hours. we decribe the noted effects of physostigmine on the different symptoms. the patient survived and could leave the icu after one week. in conclusion: orphenadrine poisoning is a very complicated medical problem associated with high mortality. in severe intoxication, the benefit of physostigmine more than counterbalances its side effects. objective: to define the optimal volume of dilution for endotracheal (et) administration of epinephrine (epi) design: prospective, randomized, laboratory comparison of four different volumes of dilution of endotracheal epinephrine ( . , , and ml of saline) setting large animal research facility ofa universi~ medical center subjects and interventions: epinephrine ( . mg/kg) diluted with four different volumes ( , . . and i rot) of normal saline was injected into the et tube of five anesthehzed dogs. each dog served as its own control and received all four volumes in different sequences at ieast one week apart. arterial blood samples for plasma epinephrine concentration and blood gases.were collected before and . , . . . _ . . , . . , . , . , and minutes after drug administration. heart rate and arterial blood pressure were continuously monitored. measurements and main results: higher volumes of diluent ( and i ml) caused a significant decrease of pao , from :!: tort to ±i torr, compared to the tower volumes of diluent ( and ml), from ± torr tu +_ torr (p< . ). these effects persisted for over minutes. mean plasma epinephrine concentrations significantly increased within seconds following administration for all the volumes of diluent. mean plasma epinephrine concentrations, maximal epinephrine concentration (cmax), and the coefficient of absorption (ka) were higher in the ml and ml groups. the time interval to reach maximal concentration (tmax) was shorter in the ml and ml groups. yet these results were not significantly different. heart rate. systolic and diastolic blood pressures did not differ significantly between the groups throughout the study. conclusions: dilution of endotracheal epinephrine into a ml volume with saline optimizes drug uptake and delivery, without adversely affecting oxygenation and ventilation. the aetiology and outcome of paediatric out-of-hospital cardiac arrest was studied during a -year period in southern finland served by physician staffed emergency care units. the files of prehospital patients less than years old without palpable pulse and spontaneous respiration were analysed retrospectively. fifty patients were declared dead on the scene (dos) and resuscitation (cpr) was initiated in patients. the sudden infant death syndrome was the most common cause of arrest ( %) in the dos patients as well as in patients receiving cpr ( %). asystole was the initial cardiac rhythm in % of the patients in whom cpr was attempted. eight of the hospitalised patients were discharged, of them with mild or no disability, with moderate disability and one in vegetative state. in multivariate analysis the short duration of cpr (< minutes) was the only factor significantly associated with better survival. due to various aetiologies the survival rate from prehospital paediatric cardiac arrest is quite low. on the other hand, hypothermic near-drowning victims seem to have a relatively good prognosis. duration of cpr less than minutes was the best predictor of intact survival, our study supports the previous findings of the importance of early and effective resuscitation efforts for establishing ventilation and perfusion on the scene. in our system well trained physician staffed emergency care units are able to provide immediate and effective als on the scene. on the other hand, these units also appear to be able to refrain from resuscitation when the prognosis is pessimistic. objective: to assess the normal ,gastric intramucosal ph ~hi) by tonometry in healthy children patients and methods: twelve healthy children ( males and females) with age rmaged from months to years scheduled for minor plastic or urologic surgery. children were previously medicated with midazolam ( . mg/kg) and atropine ( . mg~) both i.m.. anaesthetic induction was standardized with -n ( %) administered via facial mask and increased halotane concentrations (up to %). all patients got an endotraeheal tube after iv. administration of femanile ( mcg:jkg) and vecuronium ( . mg/kg) or suxametonio ( mg/kg), pmaesthesia was maintained with o -n ( - %) and isofluorane ( . - %). during surgery, children needed mechanical ventilation and the others maintained spontaneous breathing. ekg, heart rate, blood pressure, and pulse oximetry were moniterized. after anaesthesia, a sigmoid tenometry catheter (tonometrics, inc.) was inserted in the stomach of the patients by direct visualization with laryngoscope and magyll clamps. children were all maintained normoventilated and with normal cardiorespiratery variables. cadet's balloon was £~led with . ml of saline. thirty minutes after the insertion rrd was extracted and rejected, just afterwards the remanent . ml was extracted and immediately analyzed. simultaneously an arterial gasometry by puncture was performed. gastric phi was calculated by the henderson-hasselbalch's equation using the pco obtained from the tenometry catheter and the bicarbonate value obtained from the arterial gasometry. results: average gastric phi was . -i- . , range ( . - . ). objective: demons~ating intramucesai ph (phi) alterations during transport of patients from operative room to pediatric intensive care unit (picu), material and methods: phi measurements were performed with gastric tonometer catheter in t patients undergoing cardiac surgery with cardiopulmona d" bypass (cpb), there was mate and female, the average age = yl ra, average weight = , kg, average time of cpb = rain. the measurements were made at the end of the surged' and when the patients had arrived in the picu statistical aualysis: average and ~andart deviation and test "t" student. objetive: to asses the efficacy of gastric iatramucosad ptt (phi) and arterial lactate levels to evaluate splacalc tissular perfusion in an experimental model of intestinal ischemia. suneets ~nd methods: twelve piglets weights t - kgs. undergoing orthot~ie liver trasplantation. the intestinal ischemia was induced by aortic damping. tonometry catheter (tonometrics inc.) w~s placed in the stomach after artaesthesia and ot intubation. phi ~s determined times and lactate levels was determined fi times in stages: i) pre-ae~hepatic stage (twice: before surgery and before aortic clamping ); ii) end anhepatic stage (only phi): iii) reperfusion stage (a , , and minutes). the phi was derived from application of the henderson-hassdbach formula using the pco value from the tonometer and the arterial bic~rbonate. all pipets received raaitidiila before sttrgery. values of phi above , and lactate levels between and mg/dl were considered nortrm. the results were statistically anaj.izated with anova and bonferroni tests. results: the phi was normal on pre anhepatic stage (> , ) and lactate levels were slightly increased ( , +_ , and , ± , mg/dl ns) . in relalion to we-anhepatics values, phi decreased signncatly at the mid of anhevatic stage ( , _+ , vs , _+ , p< , ), phi remain low in stage iii, at rain ( , + , p< , ) and min(g -+o, p< , ). arterial lactate levels increased significatly in relation to levels in stage i, at rain ( , _+ , p< ,o ) arid rain ( , ± , p< , ) of reperfusion stage. there is a slight improvement on phi and lactate ievels at and t rain althought the differences did not reach significance. cnmments: phi and arterial lactate levels propperly reflect hypoperfusion on the experimental model of acute intestinal isdlemia. b~kground : the paediatrie gallbladder diseases generally described are calculous ¢hol~tstitis, cystic duct obstruction, congenital anomaly of the biliary tract, and inflammation. in the neonatal period, noulithogenie gallbladder disease could be also due to erythroblastosis or hyperalimentation. obieetive : we describe an other type of disease affecting the gallbladder in neonates thought to be related to their vascular vulnerability. methods : four patients with abnormal gallbladder ultrasound not related to classical observations were included. we have studied and reviewed the biological and clinical data, the ultrasound findings and their evolutions. results : four patients, to ~.k-old neonates ~ffth a birthweight be~,een , and , kg, were intubated and under total parenteral nutrition for to days. none of them were symptomatic on repeated clinical evaluations. one newborn developped hypotensien on umbilical bleeding at hours of life. in two cases, signs of cholestasis were discovered : the total bilirubin level has risen to mg/dl; the direct bilirubin level was , mg/dl while the urina were dark and the ~o~,ls :mcolour~. the c~mplct~ ~crology as a!! the culvare~ remained negative. the ultrasound explorations were atypical : in the four eases, an initial increasing broad and thickness of the wall of the gallbladder with an hyperecbogenie inside content, which was not sludge, was discovered. in three eases the images resolved in ten to fifteen days. in one ease, an asymptomatie thrombosis of the vena portu which remained patent was discovered. in this case, at one month, the ultrasound showed images encountered in chronic ebolecystitis and, at one year, the gallbladder appeared atrophic. none of them underwent surgery. conelusiou : the gallbladder diseases are multifactorial. besides the prematurity, the infections, the total parenteral nutrition, the premature neonate is exposed to vascular vulnerability affecting also the gallbladder and this may explain our findings. progress in prognosis of pts with b-nhl had followed the use of multimodality chemotherapy (ct). with the prolonged survival, there are comlications due to myetosupression & desease process. the syndrome of neutropenic enterocolitis (ne) is one of the ominous problems because ofpts increased susceptibility to infection & overwhelming sepsis. this material included neutropenic pts ( - years) with the stages iil& iv of b-nhl who were treated with the modifired bfm- (mtx g/m in -h inf.); males, females. seventeen episodes of ne were observed & only after the first courses of ct ( of after tst, %; of after nd, %). the symptoms existed to days. wbc ranged from to in l~tl (median, ). the first signs of ne were directly correlated to the beginning of the neutropenia & the recovery of neutrophils led to the disappearance of abdominal recovery of neutrophils led to the disappearance of abdominal pain. the conservative treatment included gastrointestinal tract decompression, broad spectrum antibiotics initially, volume & electrolyte substitution, nutritional support, correction of acid-base balance, symptomatic treatment. sixteen pts were treated nonoperatively, died. on autopsy the transmural bowel necrosis due to thrombosis of branches of a.mes.sup, was found. the bowel perforation occurred in one patient, he was undergone laparotomy & hemicolonectomy & survived. we conclude that ne is a frequent complication in neutropenic pts with the st. lii& iv of b-nhl. it occurs after the induction courses of ct. close observation by surgeons, oncologists & pediatric intensivists is mandatory. conservative treatment is effective & more preferable until leucopenia resolves. operation is necessary only for those.with perforation. near infrared spectroscopy as a tool for evaluation of intestinal perfusionpresentation of an animal model. c. scheibenpflug, p. buxbaum and a.m. rokitansky the recent development of and investigations in the so called near infrared spectroscopy ( nirs --transcutanous emission and simultaneous registration of intensity of spectralcolours depending upon modulations of tissue perfusion ) enable physicians to measure and qualify organ perfusion and nowadays is mainly used to control cerebral as well as skeleton muscular blood flow in trauma patients at intensive care units ( icu ). today intestinal perfusion, hypoperfusion , cell damage caused by reperfusion injury, bacterial and toxin translocation are serious problems in critically ill patients at an icu. paediatric intensive care physicians put major concern on intestinal perfusion, which for. instance gains more and more importance, especially in the neonatal period for example as an etiologic factor for necrotizing enterocolitis. we established an animal model, in which we measured intestinal perfusion by nirs under various invasive and noninvasive conditions. methods and results will be referred. for preliminary conclusion we propose near infrared spectroscopy ( nirs ) also as a potent diagnostic tool to determine early intestinal malperfusion in order to prevent lethal outcome. fm'ther investigations in animals as well in paediatric iritensive care patients should be done to estimate our efforts. introduction: following the acute phase of necrotising enterocolitis (nec) starvation of the gut for a period up to weeks is a generally accepted treatment modality in many centres. objective criteria to refeed these patients are hardly available. recently the double sugar test has become available as a parameter for (ab)normal gut permeability ~' . aim of the study: to evaluate the changes in permeability of the small bowel in patients with nec and controls before introduction of enteral feeding. methods: a lactulose! rbarrmose (i/r) test was performed in two groups. group was studied - times within a -week period of starvation (n= , mean gest. age , range - weeks). in group seven different control patients were studied (mean gest.age , range - weeks). the test was performed by giving a patient after at least a hour fast ml/kg bodyweight l/r solution and determination of the /r ratio in a -hour urine sample by chromatography. results: objective: to evaluate the prognostic factors in the response to nitric oxide (no) in children with acute respirator/ distress syndrome (ards) and/or pulmonary hypertension (pht). patients and methods: critically ill children received no inhaled for ands and/or pht treatment. patient before and after cardiac surgery ( cardiac transplants), with bronchopneu~onia, multiple trauma, sepsis and cardiorespiratory arrest. patients showed /j~ds and pht, in with associated ards. we analyzed age, sex, diagnosis, pao , pa /fi , oxygenation index, pht, shock, and sepsis as prognostic factors and response factors to n . results : after no administration oxygenation did not improve in patients ( . %) and pht did not diminishe in one children ( %). patients survived ( %), / ( . % with /d%ds) and / ( %) with pht. the four patients with isolated pht survived , and the patients with pht and ards dead. patients after cardiac surgery presented less mortality ( . %) than the rest of patients ( . %). patients with shock presented higher mortality ( . %) than the rest of patients ( . %). there are no differences in response to no in respect of sex, age, diagnosis, shock, and sepsis. survivors showed higher increase of pao /fi . ± . to no than non-survivors . ± . (n.s). patients with pht showed higher increase in pa /fi to no administration ( ± . ) than patients with ards ( . ± . ), (n.s), but patients with ards showed a higher increase in !, ± . , than patients with pht . ± (p < . ). patients with pa /fi < i showed less increase in pa /fi , . ± . , than the rest of patients . ± . (n.s) conclusions: i. mortality of isolated pht treated with no is less than patients with ap~s. patients with shock and those with pht and ards showed higher mortality. . we have not found any clinical or analytical factor to predict clinical response to no administration. patients showed ards, and severe pht after cardiovascular surgery, in with associated ards. we registered respiratory assistance, blood gases, pao /fi , the oxygenation index (oil, and mean pulmonary pressure/ mean systemic pressure (pap/sap) before and after no inhalation. we measured continuous concentration of no and no by electrochemical method (noxbox, bedfont, airliquide). results: no administration improved oxygenation mean pao from ± tm~g to i ± ~g (p < . ), mean pa /fi fr<xa ~ to £± (p < . )and i from ± to ± (p < . ). patients did not improved with no administration. the oxygenation improved in the first five minutes and the best oxygenation was achieved with - ppm. there is no significant change in pac . pap/sap diminished from ± % to ± % ( p< . ), in one patient there is no response. the no administration was maintained between ~ minutes to days. the effect of no on pulmonary pressure and oxygenation was maintained without change during all the time it was administrated. n concentration were always less than ppm y metahemoglobinaemia less than . %. there are no side effects secondary to no administration. patients survived ( %). concluaions:l.administration of no improves oxygenation in children with ~/eds and diminishes pht after cardiac surgery. .no effect is fast and maintained during the evolution. high frequency oscillatory ventilation in combination with inhaled nitric oxide g~thberg sylvia, md, edberg k e md, phi), dept of paediatric intensive care, children's hospital, s- g teborg, sweden background: for man), years severely sick infants with congenital heart malformations or acute lung disorders have died due to pulmonary hypertension, hypoxia and multiple organ failure. today there are several therapeutic facilities coming up for these infants. ecmo progranunes have been introduced in severul centres as well as improved venlllatory techniques, as high frequency oscillatory ventilatior~ (hfov), which provides adequate ventilation with less risk for hmg injury.. in , the endothelium derived relaxing factor was identified as nitric oxide (no), and extensive studies have sho~-a that inhaled no reduces pnimonm o vascular resistance and improves oxygenation in hypoxic infants with pulmona~ hypertension. material.. from july to january , we have treated severely hypoxic children with combined ttfov-no. seven were newborn, with cdh, one with mas, one with irds, one with paediatric ards due to rsv infection and one with poor oxygenation atler open heart surgery. were between month and years and all had ards of differentorigin but one who was hypoxic after open heart surgery. method: hfov was given by means of sensormedics a oscillatory ventilator to patients, and dr~ger babylog was used in one case. mean airway pwssures varied from - cm h . oscillatory pressures varied from - cm h and ventilatory rates from - hz. fi o varied from , - , . no was administered by nomius classic. no and no was measured in the inspiratory limb with an electrcchemieal device. noconcentration varied from to ppm and the no -concentration between - , ppm. methemoglobin was never more than , % (average , ). duration of treatment varied from to days. combined trealment with hfov and inhaled no improved oxygenation and carbon dioxide elimination in out of treated childretl patients died, due to their underlying congenital heart disease, one of asphyxia due to rsv-infection and one of cdh with progressive hypoxia and multiple organ failure. combined treatment with hfov and inhaled no improves oxygenation in severely hypoxic children. treatment should be slarted early to reduce the risk for chronic lung injury following barotranma and high oxygen concentrations. we speculate that the combined hfov-no may reduce the use of ecmo, and that it may improve outcome in ceotres where ecmo programmes are not introduced. apart from its vasodilative properties nitric oxide appears to act also in physiologic immune defense. intracetlular concentrations of no synthesized by macrophages are in the range of above those produced by vascular endothelium. we investigated the bacteriostatic effect of nitric oxide at concentrations used during inhaled therapy for pulmonary vasodilation in neonates. ten different strains of five species were used (staph. anrens, staph. epidermidis, strop. group b [gbs], e. coil and pseudomenas aeruginosa), which are ~e most often tracheally isolated bacteria in mechanically ventilated premature infants and neonates. we compared bacterial growth of cultures applying three different concentrations of nitric oxide ( ppm. ppm, ppm) m the growth of the same strains in room air for a duration of hours. no bacteriostatic effect was demonstrable at no concentratioes of ppm. e. coil showed decreased bacterial growth at ppm and ppm, however without reaching statistical significance (p= . ). at nitric oxide concentrations of i ppm staph. epidermidis and gbs grew significantly less as compared to colonies of the same strains in room air. no effects were found regarding the growth of staph. aureus and pseudomonas aneruginosa. we conclude that nitric oxide has a selective bacteriostatic effect on some of the most often trachealb, isolated bacteria in premature infants and neonates. this effect appears to be dose-dependant and occurs in the upper range of dosages used with inhaled no therapy. further research is required in order to examine the mechanisms of action as well as specific interactions between different strains of bacteria and nitric oxide. the no,box monitor (bedfont, kent, uk) is used to monitor nitric oxide (no) and nitdc dioxide (no ) during no administration in ventilated neonates. according to the manufacturers specifications the monitor can be applied in cases where airway pressures range from to mbar. we investigated in-vitro the accuracy of the no monitor in a range of ventilatory conditions. using a dr~ger babylog we ventilated an artificial lung. no was administered { ppm no in % nitrogen) with a mass flow controller to the inspiratory tube, at a distance of cm from the y-piece. the no target value was set to ppm. the ventilator was operated in both cpap and ippv modes at different settings. the no sampling tube was placed on two different locations; in the inspiratory tube dose to the y-piece; in the expiratory tube haft way between the y-piece and the ventilator. the no-monitor was ca)ibrated with ppm no at mbar. fig. and show the sensitivity of the no-monitor for respectively static pressure (cpap) and pulsatile pressure (ippv) with the sampling tube located in the inspiratory tube. fig. shows the resur for pulsatile pressure with sampling in the expiratory tube. we conclude that the accuracy of the bedfont no-monitor is dependent upon airway pressure and sampling site, the latter possibly caused by incomplete mixing, pressure and no are linearly related when sampling occured further away from the administration site. based on this study we suggest to place the sampling tube in the expiratory tube. during neonatal care the clinician should be aware of varying inaccuracies depending on the respiratory pressures. hypothesis: availability of therapy with inhaled nitric oxide (ino) decreases ecmo use in patients referred .to a tertiary care hospital for treatment of respiratory, failure unresponsive to conventional therapies. background: at children's hospital of wisconsin (chw) treatment for patients who have failed conventional treatment for respiratory failure, sometimes called "rescue" therapy, has included ecmo since and high frequency oscillatory ventilation since . ino has been in experimental use at chw since may of i and has resulted in the perception of a decreased need for ecmo therapy in those patients referred for rescue therapy. this study was designed to tbst the validity of that perception. study type: retrospective cohort. methods: the medical records of all patients referred to chw from /lj to / / for rescue therapy for severe respiratory failure were included in the chart review. data were collected regarding diagnoses, illness severity, hospital course including interventions and complications, and outcomes. exclusion criteria w~ere the finding of structural heart disease or congenital diaphragmatic hernia as the basis for hypoxemia. qualification for ino treatment included an a-ado - or oi ~- for two hours or -> for twelve hours and echocardiographic demonstration of persistent pulmonary hypertension of the newborn. patients were classified into two groups based on the availability of ino at the time of their hospitalization. results: in the time period of the study, patients were referred for possible ecmo therapy. twelve patients greater than weeks old, with congenital diaphragmatic hernia and with congenital heart disease were excluded from this analysis, leaving patients for study, ino availability reduced ecmo use from of ( %) patients in the ~ino unavailable" group to out of ( . %) patients in the "ino available" group, p=& by fisher's exact test. the fact that the two groups were composed of patients of similar severity of illness is reflected by comparable rates of ecmo and ino rescue therapy ( % vs. %). conclusion: by providing an alternative rescue therapy, ino has reduced the need for ecmo in this group of neonates referred for respiratory failure. introduction: true hepatnrenal syndrome (his) is defined an acute renal failure {arf) in the presence of severe liver disease without other known causes of renal failure. hrs is frequently seen in the course of hepatic cirrhosis• in children, cirrhosis is rare; however, arf can be seen in combination with aseites and liver dysfunction• we describe patients with hepatic dysfunction and aseites in combination with ar~ and abnormal sodium-water handling, leading to the diagnosis of hrs. pathophysiology: three factors are considered in the pathogenesis of hr~: i) hepatic dysfunction, ) deranged hemodynamics, including abnormal blood pressure, reduced effective arterial blood volume and abnormal blood flew distribution, and ) neuro-humoral dysrsgulatiom, including elevated levels of aldosteron, renin, angiotensin-ll, ade, vasodilatim nitric oxide and vasoconstrictor peptide endothelin-l. the main pathogenetic feature is decreased cortical renal blood flow, decrease of glomerulur filtration rate (gfr), vastly increased sodium retention, uliguria, and azotemia. treatment: therapy is based on counteracting sodium and fluid retention by highdose aldosteron antagonists and loop diuretics, improving renal perfusion by lowdose dopamin, and strict restriction of fluid and sodium. interventions as paracenteals of aacites or n peritoneo-systemic shunt are associated with high morbidity and poor outcome in children. reversal of hem by conservative measures can only be attained at early stages of hrl liver transplantation is the only definitive treatment that can reverse ere at advanced stages. patients: the described patients developed severe ascites with insidious renal dysfunction and abnormal sodium-water handling during admission at picu and fullfilled clinical criteria fur hrs. treated according to the cited principles, all patients showed improvement of gfr, with increased natriuresis and gradual decrease of ascites. eventually, renal function normalised completly. conclusion: ere deserves greater recogmitimn in the picu population; diagnosis can be suspected on clinical criteria. with this increased awareness, therapy tun be instituted at an early phase, with better prospects for recovery. positive outcome of hem depends on early recognition of the clinical picture, understanding of the pathophysiology, and early institution of consistent treatment. mtx is an antimetatxflite widely used as chemotherapeutic agents. high dose ivitx (i to ~m ) administered as a prolonged intravenous infusion (over - hours), is often used to treat malignant paediatric diseases. major complications of this treatment are myelosuppression, orointestinal mucositis, dermatitis and impairment of anal function. we report two cases of mtx overd~age occurred in two children ( -year-old. month-old) t~ted for acute lymphoblastic leukaemia. they were treated by cavh and the mtx bhk~d levels rapidly decreasedavoiding multisystemic involvement. establishment of alkaline diuresis and monitoring of plasma mtx levels during treatment is essential to prevent nephrotoxicity. however. leuco',cnn rescue may not prevent the development of potentially lethal toxicities in patients with mtx concentrations persistantl} exceeding t mm. in theses cases, em'ly treatment of mtx intoxication may pm~cnt myelosuppression and reducerenal damage. the goal is to lower the concentration to below mmoll, at which time rescue agents aleme would be expected to be cllcctive. respective indications of these remo',at mctny.:is are still discussed : hacmt~ialysis t~ eharc(~l haemoperfusion should be prolx',sed for massive and acute intoxication. however, rebound has been reported after combined hcmodialysis and hemoperfusion. exchange transfusion may be proposed as a treatment for prolonged and moderate intoxication. peritoneal dialysis is an incflbedve method for remo~ al of mtx. cavh was used in our icu. cavh is a simple method for blood purification and n':dy iluid control. use of cavh was never be reported in this indication to our knowledge. simplicity, rap~d application and gco.l clinical tolerance are the main advantages of this technique. the technique presents ~peclal advantages in terms of low priming volume of extracorporeal circuit, low blood flow, low rate heparinisation. our results show a decreaseof plasma mtx concentration and a rapid reduction of halfqite of elimination (t hours over the period of cavh). moreover, we didn't delec~d rebound after stopping prc,xedure. small size of the i:ratients may present sometime special problems, but these technical problems can be overcome, no severe complication (needing, inlection) were observed during filtration, in summary, aggressive intravenous fluid hydration and alkaliniaation of the urine coupled with careful monitoring of renal function and plasma mtx concentrations during and al'tcr infusion along with lem~overin rescue has reduced the inndcace of life-threatening toxicity after highdose mtx. however, some mtx inu>xication still occurred, leading to se~em toxicity, particularly nephrotoxicity. in these cases, we think that cavh (or cavhd) is a reliable, rapid method without rcix~und increase in plasma mtx concentration or important adverses effects compared to other procedure removal. gouyon jb, germain jf, semama d, pr vot a, desgres j preliminary limited data suggested that hemofiltration and hemodiafiltration may be valuable in some neonates with decompensation of maple syrup urine disease (msud). venovenous hemofiltration (vvhf) and hemodiafiltration (vvhdf) were performed with a new neonatal hemo(dia)filter (miniflow , hospal) on anesthetized rabbits infused with branched-chain amino acids (leucine, isoleucine and valine) and c~-keto-isocaproate. the bcaa and aketo-isocaproate blood levels were close to those previously observed in neonates with msud when extracorporeal blood purification was required. vvhf and vvhdf performances were assessed with two different blood flows (qb = . and . ml/min). vvhdf was performed with dialysate flow rates (qd = , , . , . and . l/h). thus, each animal was submitted to successive procedures. within each studied period, clearances of the bcaa were strictly similar. bcaa clearances obtained by vvhf were similar to ultrafiltrate rates (respectively, . - . and . - . ml/min at high and low qb ; p < . ). the ~x-keto-isocaproate clearances obtained by vvhf were . - . and . - . ml/min at low and high qb (not significantly different). whatever qd value, the vvhdf procedures always allowed higher bcaa and c~-keto-isocaproate clearances as compared with the corresponding v'~hf period with similar qb. bcaa clearances obtained by vvhdf with a . l/h dialysate flow, were . - . mljmin and . - . ml/min at iow and high qb, respectively. the concurrent a-keto-isocaproate clearances were . -,. , ml/min and . _+ , ml/min. at both qb regimens, bcaa clearances provided by vvhdf were markedly higher than values previously obtained with peritoneal dialysis in human neonates with msud. the management of renal failure in the newborn is difficult. when dialysis is instituted peritoneal dialysis (pd) is usually the technique of choice. this is can be problematic and impossible in some patients with pre-existing intra-abdominal pathology. continuous arterio-venous haemofiltration (cavh) has been described in infants but sick preterm infants are not able to support the circuit. i have devised a means of having pumped haemofiltration in small/preterm infants (phis/pi) and describe its use in nine patients ranging in size from to gms for periods of to days. vascular access was achieved through or guage cannulae in either a peripheral artery and a central vein or through two central veins. blood was pumped out using an ivac infusion pump and through a gambro fh haemofilter. a second ivac pump was used to remove haemofiltrate from the filter and a third to infuse replacement solution. removal rate was set to give a clearance of mls/min/ . sq.m and blood flow rate set to between and times the removal rate. heparin was infused into the circuit to prevent clotting of the filter. biochemical and fluid balance control was achieved in all infants. guaranteed fluid removal allowed the administration of full nutritional support. four patients died when treatment was withdrawn because of an untreatable underlying problem. one recovered renal function but died some weeks later from unrelated problems, three survived and recovered renal function and one patient is still on treatment. this system allows a secure means of achieving fluid and electrolyte control in the preterm infant. the use of this technique may allow haemofiltration to become as applicable to preterm infants as it is to older children and adults. unibrtunately, children often receive no treatment, or inadequate treatment for pain and painful procedures. this prospective, multicentric study focuses on the efficacy, safety and side effects of novalgin (metamizol sodium) for this indication. patients and method: novalgin was administered to children, aged between - years, with acute, postoperative or procedural pain. novalgin ( - mg/kg) was given - hourly iv or im respectively, in some cases ( ) in combination with opioids (tramadol , piritramid , butorphanol ). the pain relief was assessed by six-step verbal rating scale (vrs) from to , vital signs were monitored, the side effects, that occured were recorded. results: pain relief was good (vrs less ) in children - . % of study patients. novalgin was very well tolerated, only one patient had adverse reaction -hyperpyrexia following intravenous application of the drug. discussion: novalgin (metamizol sodium) is safe and effective drug in the management of acute pain in children with low incidence of side effects. obie~qve: a prostx~tive study comparing simultaneous, indepeadent ratings conducted by intensi~ sts using an american (comfort) and an european chartwig) sedation scale for mechanically ventilated pediatric patients. measurements and results: the study comprised observations in mechanically ventilated pediatric patients (aged days to years) in a pediatric intensive care unit (from march to january . each patient was sedated by his/her managing physician with opiates, benzodiazepines, barbiturates, used isolated or in combination. each observation consisted of a -mid period of oly~ervatien of the patient in his or her pediatric icu bed, after each observation, the comfort (analyses dimensional physiologic and behavioral subscores -range to paints) and hartwig (analyses dimensional behavioral subsenres -range to points) were performed by the intensivist. we established the comfort scores ~ correspanding to adequate (range to ), excessive (range to ), and inadequate (range to ) sedation; and, hartwlg scores z correslxmding to adequate (range to t ), excessive (range to , and inadequate (range to ). statistical mmlysisj: agreement rate (kappa) and p <. was considere d s!l~nificant. comfort ( . %) ( , %/ ( . %) hap, twig , ( . %) ( . %) ( . %) to the comfort score, the average for adequately sedated, inadequately sedated, and too sedated was . +- . , z _+ . , and a.+_l , respectively. and to the ha~twig scorn, the average for adequately sedated, inadequately sedated, and too sedated was . :k-' . , . -&l , and . l- . , respectively. conclnsion: in our study there were no significantly statistical difference when you apply a more complex scale (conff'ort) or a less complex scale (hartwig) to assess the sedation of mechanically vemilated pediatric patients. the application of local and intravenous morphine infusion after surgery of urinary tract eva nemeth , m.d. semmelweis medical university , first oepartment of paediatrics , budapest , hungary in±roduction:continuous analgesia with morphine may be ~egaroed as a safe and effective method of pain relief during postoperative period. subjects and methods: children /mean age . years/ underwent elective ureteroneoimplanta±ion were randomly selected to receive either morphin intravenously of lo ug/kg/h /group one/ or bladder morphineinfusion ug/kg/h /group two/ after surgery. all patients were prospectively evaluated during their s±ay in the postanaesthetic care unit. cardiac and respirafory rates,blood pressure,sa ~,degree of alertness,pain perception and complaints of the paticnto ~cr~ recorded hourly. pruritus,nausea and vomiting,voiding difficul-±ies,sedation,dysphoria were systematically sough and quoted. statistical analysis was performed by chi square test. results:postoperative analgesia was the same in the two groups,but side effects were less in the bladder morphine group,because of the lower se morphine concentration.the differentes weren't significant in two groups. conclusions:the administration of bladder morphine infusion is a safe and effective method in children. objetive: compare the evaluations of sedation level made by physicians and nurses with the visual analog scale (vas) and the comfort scale (cs) in pediatrics patients receiving difforents modes of intravenous sedation. material ~ method." file evaluations were made by an attending physician and nurse with the vas and by another physician (always the same) using the cs. the observations were divided following the sedation mode: one drug (fentanyl or midazolan), two continuous drugs, one continuous and one intermi~ent drug and two intermittent drug (fentanyl and midazolan). the groups were compared using the t-student test. the groups also were compared between the percentual of agreement of the evaluations of sedation level made by physicians and nurses with the cs and vas using the x . results: we didnk find any statistical difference between the observations made by physicians and nurses with the vas in the differmts modes of intravenous sedation, the average of the observations using the cs betwom one drug and two drugs modes didnk exhibit also statistical difference. the observations made by physicians mad nurses using the the vas when compared with the cs didn't show statistical difference between the sedation level. we found statistical difference only in percentual of concordance of sedation level between physicians and nurses when compared the one and two drugs modes of sedation. conclusion: we didn't find differences in the observations made by physicians and nurses in the sedation level, only in concordance pereentua/ of observations when compared two modes of sedation. the observations using the cs (more complex) didnk show differences when compared with the vas. effects of age, concurrent administration of other pharmacologic agents, and disease [cardiac(n= ) & pulmonary(n= )] on the pk & pd of b were evaluated in volume overloaded infants aged days- mo (n= ). single doses of . , . , . , . , . , , , . , . & . mg/kg iv were given over - min after baseline evaluation. age was used as a continuous vadable to determine its effects on the variability in the pk & pd of b. values for pk parameters were compared between patients in cardiac and pulmonary disease groups. hierarchical multiple regression analyses were used to determine the effects of age, disease and other pharmacologic agents on the variability of bumetanide excretion rate (ber) and pd responses, e.g. urine flow rate (ufr) & electrolyte excretion. cit, cir & cinr increased with age (p< . ) while t, decreased markedly in the first monthe of life (p< . ). ber normalized for dose increased with increasing age. patients with pulmonary disease exhibited significantly greater clearance and shorter t~= (p< . ) than those with cardiac disease whereas vd~ was similar in both groups. the administered dose of b was the primary determinant of ber but increasing age also contributed. penicillin antibiotics decreased ber. dose response curves for ufr and electrolyte excretion were similar between disease groups. more of the variability in ber and pd responses could be accounted for in the pulmonary group than the cardiac group but this was not statistically significant. conclusion: the pk of bumetanide were influenced significantly by age and disease. differences in pk between patients with pulmonary and cardiac disease were primarily due to differences in total clearance. age and the administered dose of b were positive determinants of ber and pd responses while penicillin antibiotics had a negative impact on both, once b reached its site of action, no differences in pd responses were detected between disease groups. the pharmacodynamic effects of bumetanide were evaluated in volume overloaded infants (n= ) aged days- months. single doses of . , . , . , . , , , . , . , . & . mg/kg iv were given over - rain. bumetanide concentration in blood (n=l ) & urine (n= ) samples were quantified by hplc. baseline urine samples were collected over - hours prior to drug administration. determinations of urine volume, electrolytes (na ", k +, ci, ca ++ and mg++), creatinine and osmolality were performed before and at - , - , - , - , - and - hours after bumetanide dosing. changes in urine flow rate and electrolyte excretion were plotted as a function of bumetanide excretion rate which was considered the effective dose of the drug. peak bumetanide excretion rate increased linearly with increasing doses of drug and showed no evidence of approaching a maximum. time course patterns for urine flow rate and electrolyte excretion were similar for all dosage groups. urine flow rate and electrolyte excretion increased lineady up to a bumetanide excretion rate of approximately #g/kg/hr and either plateaued (urine flow rate) or declined at bumetanide excretion rates > #g/kg/hr. bumetanide had no detectable effect on serum electrolyte concentrations, conclusion: maximal diuretic responses occurred at a bumetanide excretion rate of about ;~g/kg/hr. higher bumetanide excretion rates produced no increased diuretic effect. peak bumetanide excretion rate of about #g/kg/hr corresponded to bumetanide doses of . - . mg/kg. neonates using an electrical syringe-pump. authors: tr~luyer j.m., sertin a., bastard v., settegrana, c., bourget p., hubert p. background and objective: many problems can be observed with drug administration by i.v. route, especially in neonates. so we evaluate different protocols of teico delivery using an electrical syringe-pump. methods: we simulate infusion of teico with a syrlnge-pump (pilot c, becton & dickinson lab.) trough d standart neonatal i.v. system. for weights ( or kg) we used doses of teico ( mg and mg/kg) and a dose volume _< . ml. our goal was to perform a complete infusion in minutes. the infusion system consisted of an life care infusion pump (abbott lab.) with its lv. set for maintenance intravenous fluid (flow _< ml/h) connected to a -way stopcock. an meter extension tubing was placed between the stopcock and a neonatal catheter. an another meter tubing (injection tubing) connected the teicoplanine syringe to the stopc, ock. the volume of the injection circuit (from the syringe to the distal part of the catheter was . ml methods of injections were assessed: a: injection of the predetermined volume of teico in minutes with no wash out. b: idem as a but the teico was injected in minutes, followed by a wash out ( ml / minutes). c: twice the required volume was introduced in the syringe and the volume to infuse was programed in minutes, followed by a wash out ( ml/ minutes). d: ]dem as c but a priming was performed before connecting theteico syringe to the tubing. during each run, serial samples were collected every ten minutes over a one hour period. the samples were assessed using hplc method. results: the amount of drug delivred at minutes were calculated. the results are a mean of to runs and expressed as the percentage of the total amount of teico prescribed. a , % , % b % , % c a % , % d , % % conclusiom for accurate and reliable intermittent drug infusion with a syringe pump it is mandatory to use a precise protocol of administration and to take in account ) a priming (for immediate starting of infusion), ) a drug volume greater than the dose prescribed and a programmed volume injected, ) a wash out of the tubing (with a volume ~ , x volume of tubing injection) caz is an antibiotic with activity against the major pathogens responsible for neonatal bacterial infections. we previously reported the pharmacokinetics of caz in preterm infants on day of life which showed that the clearance of caz increased with increasing gestationat age (ga). mean serum half-life of infants with gas < wks was . h. we wanted to investigate the effect of postnatal age on caz pharmacokinetics, we therefore studied caz pharmacokinetics on day - of life in preterm infants with gas < wks. caz ( mg/kg) was administered as an intravenous bolus injection. blood samples were coilected before (t = ), and . , , , , and h after the caz dose and analyzed by hplcassay, the pharmacokinetics of caz followed a one-compartment open model. during newborns with complex congenital heart defects requiering either htx or palliative staged single ventricle repair were admitted to our hospital: hlh n= , unbalanced cavsd, tga with hypopl. rv and hypoplastic aoa. tga with hypopl. rv, sas and dextrocardia. /i children had been admitted with cardiogenic shuck and mukiorgan failure due to intermittend closure ofductus arteriosus; in / stabilization failed. parents were informed about the known and unknown risks of the always palliative surgery; in cases parents denied further therapy. one pafiem with hlh underwent orthotopic htx at the age of month after the ducms art. had been stunted in the newborn period. month later he is still in favourable condition and without any sign of acute organ rejection. / underwent first stage of palliative single ventricle repair: norwood -op. ( ) ( n= ), damus-kaye-stansel -procedure ( ). the clue to adequate postoperative management was to archieve a balanced distribution of flow to systemic and pulm circulation, that is to protect the single ventricle from volume overload and to guarantee sufficient oxygenation and pulmonary development as well. with the centralvenous sato at about % provided maintaining the arterial sato at about _+ % is corresponding with a qp/qs of : . using modified bt-shunts of . mm resp. a central anrtopulm, shunt of mm in one case l severe puim. hypertension, surgery at weeks of age ) there was no excessive pulm. blood flow and no need to increase pvr with inspired co . one child ( norwood at weeks, preexisting pnim_ edema ) developed severe pulur hypertension and parenchymal pulm. dysfunction after prolonged bypass and multiple transfusions due to intraoperative bleeding: hypoxemia could be managed successfully by implanting a second shunt of mm hh later and temporarily using prostacyclin and no; at sternum closure dd later the second shtmt was banded to ram. follow-up ranges - month: all children are at home being assigned for second stage operation at about month of age. establishing clinical practice guidelines has become increasingly important in the current health care environment. significant effort has been focused upon development of post-operetive critical care pathways. however, benchmark data upon which such pathways should be based has not been well reported. length of mechanical ventilation (lmv) and length of stay (los) for children following cardiac surgery, for example, is poorly described. we prospectively recorded the lmv and los in patients who underwent cardiothoracic surgery between / / to / / . only patients who belonged in any one of five categories of congenital heart disease (ventricular septal defect _+ other septal defects (vsd), atrioventricular (av) canal, tetralogy of fallot (tof), transposition of great arteries (tga), and single ventricle physiology (fontan)) were included. eight non-survivors were excluded from the analysis. all patients were admitted to an intensive care unit cu) post-operatively where mechanical ventilation was managed by pediatric intensivists. lmv was defined as the period from post-operative admission to planned extubation. length of stay (los) was defined to be from le from the icu. cytokine patterns during and after cardiac surgery in young children. especially in children, cardiac surgery with cardiopulmonary bypass (cpb) can cause a systemic inflammatory response. this process is thought to be mainly a result of inflammation induced by surgery and exposure of blood to an artificial surface, and of reperfusion injury during weaning of bypass. complement activation, degranulation of granulocytes, induction of free oxygen radicals, endotoxemia and release of cytokines, are important contributing factors. we studied cytokine patterns before, during and after cpb in young children admitted for complex surgery or for septal defect correction. in the first group, significant amounts of il- and il-lra could be detected preoperatively. these findings could reflect the already existing hemodynamic dysregutation. in both groups, cpb procedure upregulated the circulating pro-inflammatory cytokines il- / , but not il- b. at the same time, il-lra became detectable. therefore, we suggest that in these patients the production of the anti-inflammatory cytokine il-ira was not induced by the preceding acnvity ot pro-inflammatory cytoidnes. during cpb, we noticed a sharp decline in the capacity of the leucocytes to secrete il- / . the ex-vivo production of il-lra however, was only slightly attenuated. we conclude that there is a differential regulatory pathway for the induction of il- / and il-lra. in addition, we studied the influence of dexamethasone administration on the cytokine pattern. administration delayed the appearance of il- / and il-ira in the plasma, interestingly, it did only interfere with the ex-vivo production of pro-inflammatory cytokines. the latter supports our hypothesis that production of il- / and of il-lra is regulated by two independent pathways, ( %) of pts. % ofpts < months of age developed metabolic alkalosis as compared with % ofpts > months of age.the infants with metabolic alkalosis received more citrated blood products and furosemide. following cardiac pulmonary bypass the highest ph-values and be-values were observed - hours and - hours, respectively. ii. prospective study: metabolic alkalosis was registerd in t children ( %), of those < month ( %) developed metabolic alkalosis and % of those elder than monms.durmg the postoperative course patients younger than months developed the highest ph-and base excess values after and t hours, in the subset of the older patients maximum ph and base excess was found after and hours, respectively. in one case the top level ofph-value exceeded . , the base excess + mvalb. conclusion: children undergoing cardiac surgery with cardiopulmonary bypass often develop metabolic alkalosis.in contrast to previous reports, we did not observe an association between metabolic alkalosis and mortality, nor greater frequency of cardiac arrythmias or prolonged mechanical ventilation. in context with decreasing serum lactate levels, our data show positive correlation of metabolic alkalosis with postoperative improvement of liver function. respirator, mechanics and weaning outcome in children undergoing cardipvascular surgery. vassallo j., cernadas c., saporiti a., landry l., rivello g., buamsha d., rufach d., magliola r. mechanical ventilation (mv) and acute respiratory failure are common events in children unergolg cardiovascular surgery (cvs), the development of new techniques helped to measure some of the main respiratory mechanics (rm) in a non invasive fashion. our goal was to evaluate the predictive value of these measurements in weaning (w) outcome in these patients, patients and methods: we prospectively evaluated children considered clinically to be ready for w with < kg and > hs mv. patients with diaphragm paralysis and those who failed w because of upper airway obstruction were excluded. before patient extubation the following measurements were recorded during spontaneous ventilation (cpap/t piece) using the cp neonatal pulmonary monitor bicore (lrvine, ca): total respiratory system static compliance (cssr) and resistance (rts), rapid shallow breathing index (rsbi). maximal inspiratory negative pressure (pi max) was measured using an unidirectional expiratory valve. threshold values predicting w success (ws) were: cssr > . ml/cm h , rts < cm h /l/sec, rsbi and pi max > - cm t . w failures (wf) -patient reintubation within the following hs, these values were compared between w success and failures using fisher exact test. an apriori level of statistical significance was chosen at p < . . considered, an increase in tnf-a levels is observed after cardiac surgery (p< . ) with a return to previous values after hours (p< . ). hours after cpb, similar values are observed in groups ii and ill, but there is a further increase in serum tnf-a levels in group i when compared with both other groups (p< . ). we found no statistically differences in any other moment. there was a significant correlation between serum tnf-o levels determined hours after surgery and cpb duration (p< , ). conclusions: cpb in childhood provokes a significant increase in serum tnfa levels, in newborns the inflammatory response is maintained hours after surgery. this enhancement of serum tnf-e levels indicates the existence of a relevant inflammatory response in these patients. introduction: cardiac surgery appears to induce a systemic inflammatory response. we have investigated the behaviour of il- i~ and il- before and after cardiac surgery. patients and methods: we studied serum il- and il- levels from children with congenital heart disease ( boys and girls), aged from days to years, undergoing open heart surgery, before cpb (d we found no statistically differences in the il-i levels in the different groups and moments. there is a significant increase in il- immediately after surgery (p< , ) with similar levels hours after cpb and a significant decrease (p< . ) hours after cpb. preoperatory il- levels were higher in the groups i and tl than in group i (p< . ). hours after cpb serum il- levels in group were significantly higher when compared with group (p< . ). conclusions: cpb in childhood induces a significant transient increase in serum il- levels, strongly relevant in newborns. cpb was not associated to a significant modification in serum il- levels. thus, cpb in childhood induces a dissociated behaviour in the proinflammatory il- and il- & pathways. obiective, to evaluate the effects of amg receipt on the clinical condition during the first hours after birth (t ), the morbidity and mortality in immature outborn neonates. methods. we studied outborn neonates with ga to wks, admitted during the years to . eighteen neonates exposed to amg (ga: , +lwks, bw: _+ g) and neonates did not (ga: , _+ wks, bw: _+ g). results. amg-exposed neonates compared to those not exposed had lower incidence of apgar score at min _< ( % vs %, p<. ), lower incidence of ph t < . ( % vs %, p<. ), decrease need of bicarbonate ( % vs %, p<. ), lower fio (fio min> : % vs %, p<. and fio max > : % vs %, p<. ), lower incidence of intubation ( % vs %, p<. ), lower requirements of surfactant ( % vs %, p<. ) and lower mortality ( % vs % p<. ). there were no differences between the two groups for the following parameters: type of delivery, hypothermia hypoglycemia and anemia during admission, hypernatremia, hypotension (map< mmhg), need of dopamine and or plasma , incidences of ptx pda sepsis nec severe rop major ivh (plus pvl) and bpd and duration of intubation. conclusions. the main beneficial effects of amg receipt on the immature outborn neonates were the decrease of mortality and the decrease of surfactant need. there was no effect of amg receipt upon other severe morbidity in this high risk group of neonates. premature babies are very sensitive on homeostatic disturbances, and often develope intracranial haemorrhage (ich). ultrasound scan of the bram shows four grades of ich: -grade i -only periventricular hyperechogenic areas -grade ii -haemorrhage ham the lateral ventricles -grade ili-dilated lateral ventricles -gtrade iv -intracerebral haemorrhage. the purposes of this study were: to show the incidence of ich in premature babies and its correlation with the gestational age, . to determine the severity of ich . to present the outcome &those babies. in the study were included premature babies successively-born at the department of gynecology and obstetrics before gestational week (g.w.) and grouped in three groups: less than g.w., - g.w., - g.w. to all of them was performed ultrasound scan of the brain. results : . the incidence of ich hi premature babies is % and there is ingh level of correlation with the gestational age: -babies born before t~ g.w. have % incidence of ich and graduated : i grade - %, ii grade - %, iii grade - %, iv grade - % -babies old between - g.w. have incidence of % : i grade - %, i[ grade - %, iii grade - %. -babies older than g.w. have incidence of %: i grade - %, ii grade %, iii grade - % . sixty of premature babies have died and it is . % lethality. in all died ilffant was confirmed the grade of ich diagnosed by ultrasotmd scan of the brain. d. maksimo~ c. z.braiko~ic, n.vunjak. p. ivanovski ( ~iversi~, children's hospital. belgrade, yugosla~, ia infantile intracranial hemorrhage is the most frequent and serious manifestation of late hemorrhagic disease of the newborn caused by ,,~tamm k deficiency in earl?,, ti~fancy. in the last two years, we recorded five cases of infantile intracranial hemorrhage due to "dtamin k deficiency, despite routine prophylax~s (intramuscular vitamin k, mg) , with bpieal clinical presentation: age was - days (average days): vomiting, poor feeding, lethar~'irritabiljty, palor, bulging t ntanelle and convatsiones were present in most cases.two patients developed signs of hemorrhagic shock, with hemoglobin level less than g. . in ~ f \qi level was less than % of predicted value. there was no evidence of head trauma or liver disease in none of patients. four inlants were breast fed, while one, who had diarrheal disea.se, was on adapted milk formula. routine therapy wa.s given (including vitamin k and fresh frozen plasma). two patients were discharged with no sequellae, one developed posthemon'hagic hydrocephalus as a complication and two patients died. late hemorrhagic diseo.se of the newborn is sill/ a significant cause of morbidib' and mortality in earl ' infancy, despite different approaches to prophylaxis developed in recent years. background: neonatal hearing screening in at risk newborns can detect % of the children with a congenital hearing loss. automated abr hearing screening (algo- ) has been introduced for healthy newborns. the aim of this study is to test the validity of this algo- screener in at risk newborns in a neonatal intensive care unit. subjects: at risk newborns (median gest.age: . wks, median birthweight g) selected according to the criteria of the american joint committee on infant hearing. interventions: algo-i automated abr-hearing screening at a level of db was performed in the neonatal intensive care unit. when bilaterally referred, further audiologic screening and/or therapeutic intervention took place. when passed uni-or bilaterally, children enrolled in a) a nation wide screening programme (ewlng) at the age of months and b) in a half yearly follow-up programme in which hearing and speech-and language development were observed according to egan an illingworth. results: screening without disturbance from ambient noise or from routine technical equipment was possible in the incubator, even during nasal cpap therapy. ( %) newborns passed algo- screening. ( %) did not pass bilaterally. of with a congenital rubella died shortly after screening.in of bilateral congenital hearing loss of -> db was confirmed. of the newborns passed were still alive at the age of year. ewing screening was performed in of ( , %). / passed, of had passagere conductive hearing loss, in / no further investigation was performed. all children enrolled in the i/ yearly follow-up programme had normal speech-and language development. in this study all at risk newborns with bilateral congeni "tai hearing loss were detected with algo- screening. screening results showed no false negatives at follow-up. the algo- infant hearing screener can be used as an valid automated abr-screener to detect hearing loss in at risk newborns in a neonatal intensive care unit. gancia gp, bruschi l pnlito e, ferrari g, rondini g -divisione di patologia nc~matate e turapia intensiva -irccs policlinico s. mattco -pavia, italy latrogenic esophageal perforations (iep) in preterm and term infants are seldom reported in litteraturc, in association with difficult endotracheal (et) intubation (with or without stylets), insertion of gastric tube, and pharyngeal suctioning with stiff catheters. crieopharyngeal muscle spasm caused by instrumentation may also lead m a narrowing of lumen, with increased risk of local injury. we report iep observed in intubatcd, mechanically ventilated newborn infants ( male, female, all outborn). a common feature of iep was inability to pass a nasogastric (ng) tube into the stomach, mimicking e~)phageal atresia.~se : birth weight (bw) (i g, gestational age (ga) wk, sepsis. before admission to n cu, the baby underwent multiple et inmbations, because of inappropriate securing of et robe. bloody secretions in pharynx were observed. the endoscopy showed a large lesion at the end of proximal third of the esophagus, case : bw g, ga wk, rds. chest x-ray (cxr) showed a retrostcrnal air leak: the ng tube was stopped }~etwcen d and d and soluble contrast was seen in upper mediastinum.case : bw (/g, ga wk, rds. the endo~opy showed an esophageal lesion. cxr showed a paravertebral route of ng tube and a right pneumothorax.case : bw (i g, cz ,.v!:. rd c. ~!,'.::;;: ::':'_'rvt!~' s l" ~k':.rvrx. cwr, d,,,,vs ~,,mr~e, ~n rhe upper mediastinum and abnormal route of ng tube through a false passage. surgical intervention is needed in case of mediastinitis or mediastinal abscess: conservative management included broad spectrum antibiotics, total parenteral nutrition, antireflux therapy and, if necessary, drainage of air leaks. enteral feeding has been stopped lor days and cautiously resumed after radiographic study. [x~cal sequelae and death are uncommon, but iep occur in newborns with high risk of death due to prematurity and other diseases. in our patients, et intubation has been performed by experienced personnel: therefore the lack of skills in resu~itative procedures is not always the main factor of iep. prevention of iep requires appropriate materials (et tubes, laryngoscope blades, suction catheters), and procedures (positioning of the infant with correct neck estension, firm et placement). sedation and pain control may help to prevent the muscle spasm. aggressive treatment has improved the tong-term outcome of extremely low birth weight neonates (elbw) but it has also increased the chances of iatrogenic lesions. reviewing the charts of our neonates we observed a high number of vascular injuries. from to , neonates were admitted to the neonatal intensive care unit (nicu); of them were elbw ( . %). studying the charts of these elbw we observed cases ( m - f) with vascular lesions ( . %). mean gestational age of these patients was . weeks (rain -max ). mean weight at birth was g . mean weight at diagnosis was g ( - ). in the same period patients with vascular injuries were reported in the neonates over g ( . %). the injuries observed in elbw group were: arteriovenous fistula ( bilateral) at femoral,level, carotid lesion and limb ischemic lesions. aetiology was in cases by venipuncture, in one case umbilical catheter and in the case of carotid lesion a wrong surgical maneuver. no general simptoms were observed. the vessels were repaired with microsurgical technique in six cases: the carotid lesion and five arteriovenous fistula; one case was solved with thrombolitic drugs; an amputation at knee level was required in one case after a long period of medical treatment. the last neonate with an arteriovenous fistula was only observed for parent's will. at follow-up (clinical and by ecodoppler) out of neonates presented normal vascular function without sequelae. from our experience elbw neonates have more chances than older neonates to develop iatrogenic vascular lesions. we advocate an aggressive microsurgery and/or medical treatment to obtain good results and prevent late sequelae. a retrospective comparison between natural surfactants l.j.i.zimmermang m.c.m,van oosten. dept. pediatrics, div. neonatofogy, sophia children's hospital/erasmus university, rotterdam, the netherlands. aim: retrospective comparison of alvofact (in ) versus survanta (in ) as rescue treatment for neonatal respiratory distress syndrome (rds). methods: both surfactants were given at an initial dose of mg/kg (except for alvofact mg/kg for mild rds grade mi). repeat doses were attowed (survanta mg/kg, alvofact mg/kg) up to a maximum of mg/kg, all parameters and outcome criteria were strictly defined beforehand. the initial response (good,mild,no response,relapse) to surfactam therapy was defined on the basis of the decrease in fio . results: there were no signif. differences in patient population and initial parameters: ga ( . +_ . vs a _+ , wks), birth weight (t _+ vs -+ g), severity of rds (grade ill-iv: . % vs . %), apgar scores, cord blood gases, initial ventilatory settings. in ' however, the initial surfactant dose was administered earlier than in ' ( . -+ . vs . _+ . hrs postpartum, p= . ). although the average total cumulative dose was equal in ' and ' ( . -+ , vs . _+ . mg/kg), more doses of alvofact were given compared to survanta { . _+ . vs . _+ . , p=o.o ) and more patients in ' received more than two doses than in ' ( % vs % of patients). there was no difference in the incidence of non-putmonarycomplications. aivofact ( there was a better initial response to survanta and a better respiratory outcome in : in the group < g the duration of ventilation was half in , and in the group >~ og the duration of extra o need was half in as compared to . we speculate that the main reason for this difference is the earlier and initially higher dosing used with survanta compared to that used with alvofact which was given in the same total cumulative dose but over a larger time span. background: e×ogerlous sur&ct~t raplacem~t treatmem has become rou~ne k~ the t~eatme~t of respira~"¢ dim'~ syndrome (i~ds) of pr~e~tur~, wh~eas its effica w th odi~ respiratory diseoses is sdi being wader mvesugatio~. objective: "eac~ mt ereat isto report ottr results of prospect/re, non-randomized "re~-o.e" study oe suffact~t replacement in outhom premamae infa~t~ with rds reruirmg me~aical ventilatioa (nfv). p~tien~ and metho .s: from j-aly to june , / ; ( %) out~ ~¢ infaats, at a mesa age of z , horn's ( boys, ~rls; ~ gestafioan age -+ . weeks, mera~ birth weight _+ g, ~ . i" at minutes) with rds, requiring mv, received bov~e-suff~amt (survanta, ros~/aboti, laboratotie~ columbus, ohio) eadotracheally, as was recomm~aded by maaufacturer. as the c,~:ttrol group o~bom premature infants (ot~ of ; %, admitted with rds from euiy to eune ) were saelected ~d who did not receive surfaaam, compared with ~hctant ~'oup they were admitted for treatmeat e~'li~" aft~" daliv~:y (at the age . :: . hours vs. . +- hours), but they did not diff~ in othe~ baseline dam'a~eri~cs at ~ti~ion. entry crkeda for ~¢fa~aut ~hcadou were fractional i~firat o~ oxtgem r~emeats -fio > . - . , ratio au-lerlal to alveolar oxygea pre~are~ao ~ao < , ~ad oxyge~at,~ i~.dex -ol > . primary o~comes were deter~caned by ~hanges m exs'ge~ab, c~ ~r~d vmtilatic~ ~ the following variable~; ( ) fi'aaic~ of i~spired oxtge~ (fio ); ( ) mesa nnvay presmzre (map) ( ) pag ~ao ratio, ( ) oxyge~ion index (oi). commo~ comphcadces of prem,musty ~d con~ol mechamcal v~ati]al~on (pater dumas merios.s, intracr~nlal haemcrn:hage, air leak, br onchop ulmrmm'y dy~pl~a ~d death) were reg~ded as sec~d,~y outcomes. r~suas: in warfactaat group we observed slg~ .c~t improve~aeat (p< . ) in oxygea~thia md veaatilation at hours all~ e~try k~to the m~dy in compari~ion to nons~fa~m" group. compa~on of secondao' outcomes in ~ts with p,.ds showes table l we did not observe ~y major acute hfe fl:u-eattming complicatlola,s m sxlrlhct~mt grou~ tr/lmediately after stu'~actsmt rcplacemev_t therapy. the duramm of mechmucal ven~ation ~ad oxygen lreau~ent m survivals of both groups did not dafter gmficautl y a-ore ead~ other. condusion: l!a premature mthats with rds treated with surfaaaat replacemeaat therapy we observed decrease m mc~de~ce of tme'~m~o~oraces add de~th (p< . and p< . ), whe~e~s m othe~ observed variables thee was uo ,igmfi~t d~=ecce infectious complications during the therapy of respiratory insufficiency in neonates with birth weight less than g in the course of yearsretrospective study. zitek infants on cmv, cppv, and imv were administered exosurf in dose of - mg/kg twice endotracheally (see table) . in newborns ( . %) hours after surfactant admin fi value decreased by . %, and after hours -by . % compared with initial value; pip and peep values decreased by - cm h and - cm h after hours, and by - cm h and - cm h after day, respectively accompanied by mean decrease of aado from , to . mmhg, qs/qt decrease from . to . % (see table) . mean time of cmv, cppv was . days, imv- - hours, cpap - - hours. respiratory therapy in newborns ( . %) was complicated by pneumothorax (bilateral -in infants chorioangioma is a rela~ively rare placentai malformation associated with considerable mortality and morbidity. a chorioangioma can be regarded as an arterio-venous shunt in the circulatory system of the fetus. this causes volume loading eventually resulting in cardiomegaly and high output cardiac failure. a female neonate (gest age wk, birth weight g, - . sd) was born with an apgar score of and after and rain respectively. the placenta showed multiple chorioangioma. ultrasound of the heart showed a hypertrophic cardiomyopathy. she developed severe hypertension ( / mm hg), treated with nitroglycerine and nitropruside. finally blood pressure decreased when enalaprillic acid was given ( . mg.kg ). we measuered the activity of the renin-angiotensinsystem. an elevation in renin-angiotensin system is shown probably to compensate for the low resistance circulation before birth, hypothesis: the instantaneous cut off of a large arteriovenous shunt did not result in a fast downregulation of the renin-angiotensin system resulting in hypertension. hypertension should be added to the list of complications of chorioangioma of the placenta. the authors studied cases of children's septicemia with blood culture yielding staphylocucetts aurens. the age of patients varied from months to years ( , % from years downward), % of the children caught their disease in the hot season (may to october). the deaths also occured in this season: , % ( / ). following were the anatomo-dinical lesions. -skin %, muscle , %, bone , %, joint . %. -viscera : lung %, heart . %, cerebrum . %, kidney . %, fiver , %. -simple lesion skin-muscle-bone joint: %, no death in this group. the concomitant lesions of the soft tissue,bone-joint and viscera : % with one viscera, % with two viscera, % with three viscera and % with four viscera. -bone lesion : mainly on the long bones ( % on the tibia, % on the femur, the remainder being the mandible ( ) and the humerus), inflammation of' the hip joint was the main one. -i,ung lesion had forms pneumatocele ( cases), bronchopneumonia ( cases), pleural effusion ( cases), multimicroabcess bursting into the pleura ( cases), most multimicroabcesses were lethal : / ( , %), -heart: all thethreelay~rs got le@~r~, % had or layers alrected and death ensued. -cerebrum : the meninges had three forms of lesions purulent meningitis ( cases), obturafing embolns of brain vessels ( cases) and cerebral abcess (one case). the characteristic clinical sign was paralysis and meningismus, phlebothrombosis of eavcrnous finus ( cases)was mually ther~sultofalxil vdfi:h burst there were cases of death with lesion of the meninges and cases of obturating embolns of brain vessels. -the main sign of lesion of the kidney was a change in the components of urine: % got proteinuria, % had leucocytes in their urine, % had erythrocytes in their urine, the urea in their blood increased (over rag%) in . % of cases.the lesion of the kidney seemingly had little relation to death. seven cases of ictertts due to an increase of direct bilirubinemia and a decrease of blood-albumin. -the biological characteristics of the pathogen staphylococci showed that all the isolated specimens had positive coagulaza ; the specimens from the dead patients were less semiti~e to, mad ~t to mali~ overag death rate was . % ( / ). the fungal infection to fusariun species in immunocompromissed child have been reported in the literature with a rare, severe and high, mortality rate in spite.of the use of antifungal drugs. we report a case of successful treatment of a severe disseminated fusariun infection in a ll-year-old boy with acute lymphocytic leukemia (lla-l ), after use a chemotherapy followed by absolute granuloeytopenia. the patient developed fever, skin lesions, pneumonia and fungaemia. fusariun species was cultured from the blood, necrotic skin lesions and lung secretion. the child developed multiple organ system disfunctiou in spite of use broad spectrum antibiotcs and antimycotic therapy needing. uci during days. the patient receive suport treatment (mechanical ventilation, inotropie d~.ugs, diuretics, imunestimulants, blood components, a broad spectrum antibiotes and antifungal agents). we absorved a gradual recovery in the white blood cell count and regression on the sites of infection. the association of preeoce diagnostic and the terapentic with increase in the white blood cell count was the most important in a successful treatment. a year old african-american child suffered a severe pulmonary injury in a house fire. initial survey revealed % total body surface burns, soot on the face, and bloody endotracheal secretions. initial chest radiograph revealed diffuse, bilateral infiltrates. severe respiratory failure with an oxygenation ratio of rapidly developed. he developed a pneumomediastinum and subcutaneous emphysema. although transient improvement occurred with inverse i:e ventilation and surfactant, he became more hypoxic (sac as low as %) and acidotic. on day post injury, he was placed on venc~venous extracorporeal life support (ecls). on ecls day he was decannulated. chest radiograph on ecls day showed an opacity in the left chest. ultrasound of the left chest was consistent with atelectasis rather than pleural fluid. flexible bronchoseopy failed to reveal any obstruction in the left lung. a computed tomography (ct) seen of the chest, which was performed after decannulation, revealed a large loculated collection of fluid in the left, anterior chest. under ct guidance, a f cope loop catheter was inserted and cc of thick blood was removed, follow-up ct performed immediately after this procedure revealed minimal change in the size of the fluid cavity. over the next hr, we instilled urokinase , units over minutes every two hours. a minute dwell time was allowed before draining the fluid. repeat ct scan done at the end of the urokinase infusion showed a marked decrease in the size of the fluid cavity. act scan was not performed prior to decarmulation because the ecls circuit tubing was too short to allow appropriate positioning of the child in the ct scanner. after a ct scan revealed loculated pleural fluid, a simple drainage procedure was diagnostic but inadequate treatment. we were able to successfully dissolve the thrombus after hr of urokinase therapy even though the thrombus was > days old. we suggest that large loculated plenral thrombi which develop as a complication of ecls therapy may be successfully managed with urokinase infusion. introduction: haemorrhages, particularly intracranial, are major complications experienced in - % of neonates treated with extracorporeal circulation. an induced thrombocytopenia and impaired platelet function play a key role in the increased bleeding tendency observed in these patients. the aim of the present study was to establish a dose-respons curve for the effect of a synthetic protease inhibiting agent, nafamostat mesilate (fut- ), on platelet membrane glycoprotein density and platelet activation during experimental perfusion. methods: two identical extracorporeal life support (ecls) circuits were primed with fresh, heparinized human blood and circulated for h. four different concentrations of fut- ( . mg/l blood/h; . mg/l/h; . mg/l/h+ % bolus at the start of the perfusion and & mg/l/h+ % bolus) were used in different perfusion experiments. a total of eight paired experiments were performed. platelet count, plasma betathromboglobulin levels and platelet membrane density of glycoprotein ib and lib/ilia were followed as well as plasma concentration of haemoglobin. results: a protective effect of the agent on platelet count, plasma concentration of btg and platelet membrane gpib could be observed during the first hours of the perfusion when a bolus dose was added. no positive effect could be recorded with the two lower doses used. plasma concentration of haemoglobin was higher in all the fut-circuits compared to the control circuits. conclusion: the addition of a bolus dose of fut- at the start of the perfusion seem to induce a protective effect on platelets during the first hours of perfusion. extracorporeal membrane oxygenation (emco) is a form of invasive cardiopulmonary support that can provide imporary physiologic stabilisation in reversible circulatory failure and or respiratory failure. we reviewed our expierence with extra corporeal membrane oxygenetion in children aged day to year between and . two neonates was succesfully decanulated, but died - well after decanulation due to septic complictions. one child years old, one neonates died on day and day" respectively while still on emco. complication which were and encountered were heavy bleeding in case (child), (neonate) and raceway rupture in case (neonate). problems which are specific developing countries like indonisia are: high cost ( . us for days) difficulty in transportation (transporting intubated baby) from the orgin hospital, lack of knowledge and understanding of the primary physician and nm-ses and difficulty organizing in hours emco team. resnratory mon tor/ng in picu z,zjvkovic, s. mihailovic, o, tosev respiratory monitoring in pediatric intensive care unit picu) provide the importartt informations for understanding of the pathophysiology of the clinical signs, aid with the diagnosis, and assist in therapeutic management and predicting prognosis. pien in children's hospital for ~flmonary diseases and tuberentosis remained for the t~s't two end a half years relatively limited for diagnomic tools and therapeutic regimens, mostly because of the poor fmnaeial suptx~rt. the number of children admitted for aurae asthmatic at.lzek~ severe pneumonias, bronehiolitis, complicated pulmonary tuberculosis, foreign bodies and exacerbations of ehronit'. pulatonary diseases was t . for all patients the respirator' monitoring system means: physie~d examination, ehe~ x rays, capillary bltxxl gas mmlyses (vevv few ehiktren experienced itwasive arterial blt~.~'i gases), noninvasive oxyntctry, measuring of the vital capacity in coopo-able patients, as~d capnography. later on, after the imtial critical illness, a complete hmg fimction tests was performed, as well ,~s bronehoscopy in selected eases, (~lr experience revealed that abotrt % of ehil&en heos suecessthl outcome, without s~lllens , instead they had been tremted in limited conditions. ']'he rest of our patients were previously diagnosed ~s ettronie pulmonary patients, with high risk score system ibr having seqnells 'llae mortality rate were , %. the continuous blood gas monitor, pasatrend (biomedical sensors, ltd., high wycombe, bucks, england) has the capability of measuring ph, pco , and po via an indwelling optical absorption optodelclark electrode sensor that is placed through an intra-arterial catheter. we evaluated the accuracy of the sensor in radial and femoral locations in critically ill pediatric patients. methods: the simultaneous values of ph, pcoz, and po recorded from the paratrend monitor were compared to values measured by standard arterial blood gas analyzer (coming , ciba-corning diagnostics, medfield, ma). criteria for the elimination of data points included a core vs. sensor temp. gradient, and sensor pulled back beyond accepted insertion distance. mean time of monitoring per sensor was hours (range . - . hrs). mean time of radial monitoring was hrs (range . - . hrs) and of femoral monitoring was . hrs (range . - . hrs.). linear regression and bland-altman analysis for bias and precision for each parameter were calculated. results: a total of patients (age range weeks to years) had paired samples of ph, pens, and poz made by the sensor and blood g&s analyzer. the range of measurements were ph . - . , pco, . -i . t(n r, and po - torr. the paratrend monitor demonstrated accuracy that is comparable to the accepted standard of blood gas analysis in a group of critically ill pediatric patients manifesting wide variation in ph, pen , and poz..this technique appears m be very useful especially in the extreme values of the parameters measured. funding provided by biomedical sensors. understanding of pulse oximetry d.semple, l.e.wilson. royal hospital for sick children, edinburgh, eh lf, scotland, uk. pulse oximetry is a useful, non-invasive monitor, routinely used on the itu and increasingly often on the general wards. we used a questionnaire incorporating questions on the theory and clinical uses of the pulse oximeter to assess understanding of pulse oximetry in medical and paramedical staff doctors indicated grade, speciality, pulse oximetry tuition and neonatology experience. doctors, itu nurses, t medical students and physiotherapists completed the questionnaire. some confusion existed between the principles of pulse oximetry and transcutaneous oxygen measurement. wide variations in the lowest acceptable saturation in fit children were seen ( - %), with around % of respondents in all groups accepting values of % or less. some potentially serious mistakes were made in the evaluation of oxygen saturations in the clinical scenarios. there were widespread variations in correct responses at all grades of medical staffing. nurses scored well on more clinically-orientated questions but relatively poorly on theory. only % of doctors (mostly senior grades) had received tuition in putse oximetry. neonatology rotations appeared to confer little additional knowledge on pulse oximetry. few doctors and nurses receive tuition in the use of pulse oximetry a significant proportion of nurses and doctors, of all grades, exhibited a lack o{" understanding of the principles of pulse oximetry. this may result in unsafe use of the equipment and put patients at risk. one can see from the table that blood composition in uv and ua differens in some characteristics, and similar in sgp magnitude. venous-asterlal gradients "gas functiomals" between uv and ua represent the measure of difference in this characteristics. the gradient cari be positive, zero -order or negative and change both in value and in sign but not reach apo (positive) and apco (negative) in absolute significance.minimization of "gas functionals" deviations atom the zero is achieved due to"mutual replacement acts" between po and pco in uv and ua blood. we suggest that presented tests can be useful in full evaluation of gas exchange in newborns. (pap) in the context of pulmonary hypertension is oft desired but rarely achieved. inhaled nitric oxide (no) has been shown to produce this desirable effect, but is relatively difficult to administer or monitor. we wondered whether np, chemicaily related to no but more stable in solution, would produce similar physiologic effects when administered in the convenient modality of nebulization. methods: piglets were anesthetized, mechanically ventilated, and surgically instrumented. systemic blood pressure (bp), pap, and cardiac output (co) were monitored continuously. after postoperative stabilization, . % nac} nebulization was begun, and pulmonary hypertensiorr was induced by reducing fio from . to . . the piglets were monitored for minutes during this hypoxic phase, next, without altering fio or ventilator settings, np ( mg/ml, dissolved in . % nacl, flow ipm) was substitued for . % nacl in the nebulizer circuit. np was nebulized for mins. results: during hypoxia, pao fell from to mm hg. pap rose during hypoxia from to torr (p< . ). ,^fhile bp and co did not change significantly. pap fell during nebulized np in each piglet, (mean apap = to torr; p< . ; mean reduction of hypoxia-induced rise in pap = %; range: to %; p < . ). pvr/svr fell by % during np nebulization (p< . ), while bp and co did not fall significantly ( to tort; to mllkg-min), the reduction in pap began within minutes of the onset of nebulized np, and appeared to reach a plateau by minutes. no tachyphylaxis to nebulized np was noted. nebulized np did not significantly affect pap, bp, or co under normoxic conditions. conclusions: ) like no, np selectively reduced hypoxia-induced pulmonary hypertension without altering systemic bp, ) unlike no, np can be administered by nebulizer, a technique familiar to virtually all health-care providers, and potentially adaptable to both intubated and non-intubated patients. } nebulized np may be beneficial in clinical contexts where inhaled no is impractical. dang phuong kiet and nguyen xuan thu examining cases of purulent pericarditis with various clinical forms treated by surgery, the authors drew the following experiences for their diagnosis. t. clinical factors. purulent pericarditis appeared like a cardiac tamponade in a septicemia due to staphylococci with dassieal symptoms: severe dyspnea, tachycardia, faint heartsound, big liver, prominent cervical vein ; rentgenography of the chest showing enlargement of the cardiac silhouette, a diminution of ventricular pulsations, ~i clear lung field. by an emergency operation, ml of diluted blood were drained. purulent pericarditis and pleural effusion appeared at the same time but at first tile symptoms of purulent pericarditis were masked by the predominant symptoms of plearal efihsion. after the pleura was drained, its pus was no more, the general state was relatively stabilized but there still were big liver, dyspnea, enlargement of the cardiac silhouette while central venous pressure increased. purulent pericarditis appeared late. in the first stage (about weeks) there was no suspected sign. later on gradually appeared such symptoms as dyspnea (during serum transfusion for instance). central veinous pressure also raised. the heart chest diametre increased at first (up to - %) then decreased (down to below % ) but the liver kept on swelling together with the particular changes of electroeaediegramme. now the pericardium had no more pus but get fibrous (up to ram) thus constricting the heart and its main arteries ike pick syndrome). . diagnostic values of electrocardiograms : common signs of ecg related of these purulent pericarditis were: a diminution of voltage, a widespread elevation of the st segment, the tf wave flattened and inverted. however, what should be stressed was : the diagnostic values of an electrocardiogram for purulent pericarditis was mainly in the dynamics of their signs: in the first week, the voltage diminished corresponding to a pericardium containing pus, while the st segment went up then seemed parallel to the fibrosis of the epicardium, the liver swelled, the central velnous pressure increased, the heart/chest dimension ratio decreased, the st segment went down, the t wave became more flat and inverted. between and neonates, aged - days (median ), weight , - kg (median , ) with critical valvar pulmonary stenosis were scheduled for balloon dilation (psvp), children ( %) were on pge and ( %) needed mechanical ventilation. after stepwise dilation a final balloon : pulmonary valve (pav) ratio of % ( - ) was achieved, there was a significant correlation (p< , ) between an adequately sized balloon and freedom of reintervention. two valves could not be passed, four neonates underwent surgical procedures (brock n = , commissurotomy n = ), two children ( %) died of sepsis. / patients ( %) were successfully palliated by psvp in the first month of life. the rv : systemic pressure value fell from % ( - ) to % ( - ), complications included transient dysrhythmias, transient hypoxia, vessel occlusions;- right ventricular outflow tract perforation. in / patients follow up data is available. the residual systolic peak doppler gradient over the pav on the last out patient visit ( - months after psvp) was - mmhg (median ). four children needed repea.ted psvp to months after the initial intervention. conclusion: psvp of critically ill newborns is possible. the risk of mortality is relatively low. psvp in neonates with an adequately sized balloon is a challenging alternative to surgical treatment. post hypoxic-ischemic (hi) reperfusion induces the formation of non protein bound iron (npbi), leading to production of the reactive hydroxyl radical. it was investigated if the ironchelator deferoxamine (dfo) could reduce free radical production and improve neonatal myocardial performance after hi. severe hi was produced in newborn lambs and changes from pre-hl values were measured at , and min post-hi for (mean) aortic pressure (mean pao), cardiac output (co) and stroke work (sw). left ventricular (lv) contractility and co were assessed by measuring lv pressure (tip-manometer) and volume (conductance catheter), using inferior caval vein occlusion to obtain slope (ees) and intercept of the end systolic pv relationship (v ). npbi, reduced and oxidized vitamine c ratio (vcred/ox) and lipid peroxidation (mda) were measured from sinus coronarius blood. lambs received dfo ( mg/kg i.v.) immediately post-hi, control lambs (cont) received a placebo. results: mean pao was stable, co and sw decreased up to and % respectively in cont as compared to pre-hi. in both dfo-groups co and sw remained within the normal range. ees and v decreased in all groups post hi, but did not differ between groups. npbi and mda were higher at min post hi (p<o. ), vcred/ox was lower at min post-hi (p<o.o ) in cont as compared to dfo-group, indicating more oxidative stress in cont. conclusions: dfo reduced the oxidative stress of the heart and prevented co and sw to drop, suggesting a positive effect of iron chelation on the myocardium after h{. from we published reports with analysis of performance of the heart as a whole organ.while analysing the heart performance as a whole, we recognize three block in it located intrapericardially: l."atrial"block -left (la) and rigth (ra) atriums; ."aorta-pulmonary" block-aorta 'bulb (a) and pulmonary artery(pa); .ventricular "three-chambered" block (vb) consisting of: -left (lv) and right (rv) myocardial chambers, both frith blood outflow into "aorta-pulmonary" block vessels, and -spongy (venous) myocardial chamber with the blood outflow through coronary sinus (cs) and thebesiau vein (tv) into "atrial" block. the following conceps are introduced for vb functions assessment "common" systole and "common" diastole of "three-chambered" vb. the process of normal "common" vb systole: -begins with blood ejection from vb spongy chamber into the "atrial" block; -continues with blood outflow from rv and lv into "aorta-pulmonary" block wi~ venous minimums -x-coiiapses -~btmation iu "a~riai" block; -completes with "three-chambered" vb general emptying. at this period the following blood volumes are transferring: -two-from rv and lv(their stroke volumes)into"aor~o-pulmonary"block; -two-from "spongy" chamber .into "atrial" block; -two-from systemic and pulmonary veins into "atrial" block during the process of so called "systolic" membrane suction (at pulling atrio-ventricular valves into rv and lv chambers as blood ejects out of them). it appears to be the regulation of blood inflow to "atrial" block by blond outflow from "three-chambered" vb into "aorto-pulmonary" block. objective: to evaluate the efficacy and complications of transpyloric enteral nutrition(ten) in critically ill children patients and methods~ from june to january children (i boys and girls), aged from days to years (mean l. ± . years) were treated with ten. patients were included after cardiac surgery, with acute respiratory failure, and after cerebral surgery. the indication of ten was mechanical ventilation in patients and failure of nasogastric nutrition in patient. children ( %) had previously received parenteral nutrition. and i fg enteral tubes was inserted into duodenus through nasogastric intubation en patients and by endoscopy in patients. rx and ph determination were used as methods to control tube situation. children received adapted formula, caseine hidrolisate, and enteral formulas. (in patients the nutrition formula was changed during ten). patients were supported with mechanical ventilation during ten, received midazolamperfussion(range to mcg/kg/min), fentanyl (i - . mcg/kg/h), and vecuronium ( . - . mg/kg/h). resulte: ten was used during to days (mean . ± . days). mean maximmnvolume ad~iniateredwas ± ml/kg/day (range ) .patients with midazolam, fentanyl and vecuronitml tolerated ten similar than children without sedatives. complications were diarrhoea patient, abdominal distension and/or important gastric fed residuals patients. pulmonary aspiration or respiratory complications were no registered. ten was ended in one patient due to diarrhoea, in due to change to oral or nasogastric nutrition, children continue yet with ten and was discharged of picuwith ten. conolusion: ten is an useful method of nutritional support in critically ill children with mechanical ventilation and/or nasogastric intolerance. introduction: the enteral nutritional support of the critically ill child may reduce the morbidity and mortality by attenuating, the hypermetabolic and catabolic response, decreasing the gut translocation and the septic complications, improving the bowel mucosa integrity and the wound healing. the aim of this study was to show the safety and tolerance of en. methods: we enrolled consecutive patients admitted to our unit from may to december , mean age . years (range imonth to i years). the prism, mechanical ventilation, inotropic use, opiates and other drugs were recorded. the en was delivered by continuous infusion across a polyuretane tube.we kept the patients head elevated °, and we used cisapride routinely. the gap betweeen admission and the en beginning, average time to meet the nutritional objective, en duration, selected formula, patients outcome and complications were recorded. results: prism groups were - = patients; - = ; - = ; - = ; - = . two patients with mof (multiorgan failure) died. % needed mechanical ventilation.the average time elapsed from picu admission to initiation of en was . days (range to ) and the average duration of the en was . days (range to t ). the average time to meet the nutritional objective was days (range to ). the selected formula were: lactose free infant formula in patients, elemental diet in , pediasure in and jevity in . we recorded vomiting in patients, diarrhea in and constipation in . none of them forced the en suspension. we didn't recorded any case of ~spiration or pneumonia. we found no relation between drugs, selected formula and complications. we think that en may be a safe and well tolerated procedure at the picu setting. generation of free radicals in iipid emulsions used in parenterai nutrition (pn) has been described recently. this seems to be due to high polyunsaturated fatty acid content. we studied lipoperoxidation status and antioxidant parameters presurgically and through the postoperative period ( days) in a group of twelve children (ranging from months to years of age), who underwent heart surgery and received nutritional support with pn. malondiaidehyde (mda), an end product of lipid peroxidation was used as a marker of oxidative stress. it was determined by the yagi spectrofluorometric method. antioxidant activity was measured with an assay based on the inhibition of spontaneous autooxidation of a brain homogenate, and vitamin e in serum by the technique of hansen and warick. erythrocyte mda release fonowing incubation in hzo in vitro was used as a functional measure of tissue vitamin e levels. data were compared using one-way variance analysis. there was not significant differences in the plasma mda production among the values obtained before surgery ( :t: . nmol/ml), postoperative pre-pn ( . +_ . nmol/ml) and through the course of pn ( . : . nmol/ml). levels of vitamin e previous to surgery were , : . #g/ml and decreased to . _+ . #g/ml at hours post-surgery before starting pn. while receiving pn, concentrations of vitamin e increased progressively up to + . l #g/ml (p = . ). pre-surgicai plasma antioxidaut activity values ( :i: %) dimiuished in the first postoperative day ( _+ . %) and then showed a clear increasing tendency, directly correlated with that observed in vitamin e levels. the measurements of the maximal percentage of mda release of erythrocytes in vitro, showed an inverse relationship with plasma vitamin e levels and with the plasma antioxidant capacity: preoperative . + . % and postoperative descending from . + % to _+ . %. our results indicate that during surgery and within hours postsurgery, a decline in antioxidant defenses occurs, in the postoperative period, while patients are on pn and taldng into account our obtained data: the unaltered mda values, the rise of plasma vitamin e levels, the recovery of both functional erythrocyte membrane antioxidant protection and the plasma antioxidant activity, they do reflect that during the intravenous administration of lipid infusions, oxidative damage does not occur, probably due to the addition of vitamin e to pn solutions in order to avoid autooxidation of lipid emulsions. garnitine is one of the essential nutrient in the diet of newborn infants. mother's milk represents the natural eamitine source for the newborn infants. we studied enteral earnitine intake in premature infants eutrophic (eu) and hypotrophic (hy), fed with mothers milk trough consecutive days-from fifth to tenth day of life. mean gestational age was (range - ) weeks for eu and (range - ) weeks for hy. birth weight was ranged - g for eu and - g for hy (p < , ). breast milk carnitine concentration was , i.tmol/i in mothers milk delivered eutrophic babies, and singnificant higher mean coenetration , l.tmol/i, of hypotrophic premature infants (p< , ). breast milk earnitine concentration was ranged between , - , ~moi,'l, and daily carnitine excretion was between , - , p.mol/i, mean , +- , i p.molll. the daily mean carnitine intake was from - , mgkg/d, in eutrophic and , - , mg/kg/d, in hypotrophic premature infants, in milk volumene intake from - mllkgld., the results of this study suggest that premature infants should be fed with own mothers mitk in eady neonatal pedod in attempt to prevent camitine deficiency. keto-acids and parenteral lipid admlnistration. castorina m., antuzzi d., ricci r., rendeli c., polidori g. pediatric intensive care unit -catholic university -roma (italy). some metabolic studies have suggested that the administration of mediumchain tltgticerides (mct) might induce a marked increase in ketone body concentrations; the aim of this study is to evaluate the effective ketogenetic risk of infusing mct emulsions in total parenteral nutrition (tpn). two groups of seriously infected children were examined: a- septic infants were given to tpn with a % of long-chain tryglicerides ( lct). b- septic infants, in wich the lipid source in tpn consisted in a - mixture of lct and mct. the children in the different groups showed similar severity and therapeutic scores (prism, tiss, ~, f~ , f~ ); the lipid intake was the same, corresponding to - . g, ckg bodyweight/day. in all patients a sample of urine was taken six times a day for the whole time of tpn the urine samples were screened by the diphenylhydrazone test, and the ketoacids excretion was confirmed by a chromatography. the urinary excretion of -keto-acids equivalent to p-ohphenyl-pymvate (mcg/ml urine) is summarized in the no significant increases in frequence and/or in severity of acid-base disturbances were found in all studied patients in consequence of the lipid infusion. the patients of b-group showed a lower excretion of -ketoacids. the c~-keto-acids excretion was ever unsignificant and seemed to be correlated with the illness severity more than with the lenght of the tryglicerides chain. this observations let us suppose that the mct, at employed doses, can be safely administred also in childen with metabolic acidosis and/or serious illness. reye syndrome cayetano heredia hospital, lima, peru five patients with reye syndrome were studied; included were those diagnosed from january to march and treated at cayetano heredia hospital. the age of presentation varied from z. to months. the syndrome occurred more frequently in males ( / ); the time of illness at the presentation varied from to lo days, and the following features were found: fever ( / ), akeration in mental status ( / ), seizures ( / ), gastrointestinal illnesses (diarrhea) ( / ), and respiratory insufficiency ( / ) --in this case ventilator)-support was needed, in all cases hepatomegaly, intracranial hypertension, hypokalemia hyponatremia, metabolic acidosis, hyperammonemia and elevation of hepatic enzymes were found. coagulation blood tests were abnormal in three patients. cerebrospinal fluid (csf) showed hypocellularity in all cases (less than cells/ram ). the cultives were negative, and the final diagnosis was confirmed by hepatic biopsy. no deaths were due to reye syndrome. a contribuhon to the study of reye's syndrome the aulhors analysed records of patients meeting all the clinical, biochemical and anatomic criteria put forward by hutrealoch~ and samaha ( ) who were ireated at the emergency and resusdlation depammlt tithe ipch in years. the average age of the children was years (the ~umgest monks and the driest year~ most of lhon ( / ) came from lhe countryside to lhe lmfia~ willfin hours of file oulbreak. a few days previously the patients w¢~ld have fever (some of ahem wilh diarrhea or cough) ,,rod vomit then rapidly fidl into coma and c~nvuksien. they ~me to the imtia~ with the signs of typical increased inlracranial pressure ( stages - according to lovejiy for most cases) but the liver was unllkely big. the main biocheafical dmnge of the blood was acute hepatic thilure -the bllod glucose decreased : (ha the aver~ , n~% ( ) ~ not measured in five cases (glucose a"aces). -the blood ammonia ino~ased riven to microg/dl fin lhe average , n = ) -the percentage of p~in was low, in the average , % (n-- ), % at the lowest (a case ofmekaa lasling five days was ctwed with vitamin k). -got and gpt enzymes increased - times (n= ) besides, tht~re was decompcmated addt~is with lhe average valnes ph = . ; pcoz = ~ mmhg and eli = - ~ ~, (n~). the charadaislic dumge in the ¢~'ebrospinal fluid was a low glucose tx~acenwalien h the average of k mg/dl ( cases of glucose it'aces) ; meanwhile protein decreased in the average of mg/dl ( cases below mg/dl). besides ~here was no inflammatory lesion ~tion) : very serious brain oedona and fatty degeneration of live~ scatteredly or parllally.microso~ically (biopsy and necropsy) in file brain appeared bright space around blood arteries and glioma extended v'lrdmw -robin space, with no inflammatory reaction. liver.-the sa~dure was intact there was no " "mtlammal~s ' cell, the kupffer cells did not show hyperplasia but show a heterogenous deg~nerafion~eart: also showed a fatty degencralion in some areas of the myocard eellkidney: the ihtty degenerati~l scattetedly in the tubular cell. pano~as:fatty degeneration scattetedly in file pancreatic cell. two cases of liver biopsy for lhe rid lime (check before leaving file inslitute) found that fatty degeneration was r~tta~ nearty ff~pletely. the exact muse remained unknown. objectives: to analyse whether there exists serum and urine electrolyte disorder in children with respiratory failure, methods: we have made prospective study of children in our icu during a month period, electrolyte concentrations were measured in serum and urine collected during hours (sodium-na, potassium k, chloride-ci, calcium-ca, magnesium-mg and phosphorus-p). results: average values in serum were: na . +/- , (rv: - ) mmol/i, k . +/- . ( . - . )mmol/i), cl . +/- . ( - ) mmol/l, ca .t +/- . ( . . )mm /i), mg . +/- . ( . - . )mmol/i. average electrolyte levels in hours urine were: na . ~/~ . ( - )mmol/day. k . +/- . ( - )mmol/day, ci . +/- . ( - )mmol/day, ca . +/- . ( . - . )mmol/day and p . +/- . ( . - )mmol/day. conclusions: average serum ci and ca levels were decreased in children with respiratory failure. in urine, average k, ci, ca and mg levels were decreased and urine p concentration was increased. we concluded that serum and urine electrolite disbalance may be expected in children with respiratory failure. the nurse is going to kill me! (icu syndrome) anita duvndam ~, sonia v.d,sluis ~dpt. of pediatrics, div. pediatric intensive care, sophia children's hospital, rotterdam dpt. of pediatrics, div. pediatric tntensive care, juliana children's hospital, the hague. content description: this presentation will provide the critical nurse with background information concerning the identification, the prevention and management of the critical ill child who has developed the icu syndrome. the results of a questionnaire concerning the occurrence of icu syndrome on a picu will be presented. behavioral objectives: at the end of this session the participant will be able to: . describe four clinical symptoms of the tcu syndrome, . identify major sources of picu environmental stress, . discuss nursing's unique role in helping the child to cope with the icu syndrome, . discuss nursing's unique role in preventing icu syndrome. content outline: the icu syndrome is a situation in which the individual is not able to deal with changes in observation and interpretation of both quantity and of patterns of sensory perceptions. in other words the borders between the inner and outer world becomes unclear for the person. the exact incidence of the icu syndrome in the critical care setting is unknown, we have limited knowledge of the occurrence of the icu syndrome in critical ill children. yet critical ill children in our hospitals sometimes show the symptoms of icu syndromes. to be able to identify the occurrence of icu syndrome we developed a questionnaire. the thesis of the questionnaire was: does the icu syndrome occur in critical ill children in the age between three and ten, who have been intubated and/or ventilated in a picu? eighteen questionnaires have been send out to parents of critical ill children in two hospitals. the response was percent. conclusions: . most of the children were anxious (n= ), showed regression (n= ) or had sleeping problems (n-lo) during the stay on the picu. . children showed the same problems after discharge. . there is no relationship between environmental factors and symptoms of the tcu syndrome during the stay. . there is no relationship between preexistential behavior and symptoms of the icu syndrome during the stay. because the lack of a scientific definition for the icu syndrome in children and good criteria for diagnosis, we were not able to get an answer to our thesis. more research is needed. continuous veno venous haemofiltration (cvvh) was adopted as a first line renal replacement therapy in our paediatric intensive care unit (picu) some three years ago. ~/he process of introduction and development of cvvh proved to be an exciting challenge for nurses as indeed it was for the whole multidisciplinary team involved. we have successfully used cvvh in the treatment of over infants and children, weighing between - kg. the range of conditions treated is ever increasing. to date we have not only used cvvh for patients in renal failure and fluid overload, but also to gain biochemical control in tumour lysis syndrome-and metabolic disorders. other distinct patient benefits in comparison with more conventional means of renal replacement therapies are that, it is a continuous controlled treatment being extremely effective in creating 'space' for nutrition, which is especially important in the fluid restricted, catabolic patient. of paramount importance in providing this level of service is the education and training necessary to impart the skills and knowledge for nurses to become expert practitioners in this field. we now have a teem of highly advanced practitioners who have developed their nursing skills to provide even more holistic care for their patients. this group are embracing new challenges and responding positively to the developing service whilst expanding their knowledge base. this paper will discuss the advantages and disadvantages of cvvh as we have experienced, relating i t to the wide variety of patients we have treated. we wish to share how cvvh has become an accepted role of the picu nurse and how the service has been successfully implemented. integrated care pathways (icp's) define the optimum course of events in the care of a patient with a specific condition, within a set timescale. aims and methods: icp's and case management (cm) were introduced to evaluate and improve clinical practice. icp's were developed for patients undergoing surgery for atrial septal defect (asd) ventricular septal defect (vsd) and fallots tetralogy. they were based on the median experiences of the last patients. patients have been managed using icp's. results: analysis of variation from the icp's shows a reduction in the following potentially avoidable causes of variation: delay in extubation has been reduced from % to %, and patients ( %) were extubated earlier than the median. prolonged stay on the intensive care unit (icu) has decreased from % to %, and patients ( %) were discharged to the ward a day earlier than the median. the number of patients receiving inadequate post operative analgesia has decreased from % to %. delayed feeding after operation has been reduced from % to %. unavoidable delays in extubation and discharge from icu occurred in patients ( %) because of haemodynamic instability" or lung problems. cm utilising individualised pathways for these patients has reduced variation in care which can improve patient outcomes. pathways have been developed for other conditions and it is anticipated that approximately, % of patients will be treated using an icp revision of icp's results in continuous evaluation and improvement of the care provided, conclusions: the use of icp's and cm has improved patient care and decreased avoidable delays and variations. the future development of other icp's, combined with a case managed model for selected patients, is seen as a viable method of continuously improving patient care. this paper is a retrospective audit of children who received continuous veno venous haemofiltration (cwh) whilst on the paediatrie intensive care unit (picu), data was collected over a month period from may to january . the girls and boys were aged from day to ½ years (median ½ years) and weighed between , and kg (median . kg). length of admission to picu was to days (median days). sepsis syndrome was diagnosed in cases: of these had bowel necrosis and meningoceccal disease. eight patients had an underlying haematological, oncolngical or immune disorder. the remaining children had inborn errors of metabolism ( ), nephrotic syndrome ( ), or cardiac failure ( ). cvvh was instituted for a variety of reasons. muttiorgan dysfunction was present in % of patients, % had acute renal failure, . % tumour lysis syndrome, . % uncontrollable metabolic acidosis with hyperammoneemia and % required fluid management. treatment was continued for between hours and days (median ½ days). haemofiltration was successful in achieving its desired effect in all except one patient. . % of children with haematological, ontological or immune disorders died despite successful haemofiltration. survival was higher in cases of septicaemia ( . %), nephrotic syndrome ( %) and errors of metabolism ( %). overall mortality was . %. this was attributed to the severity of the underlying disease process rather than the effectiveness of cvvh as a renal replacement therapy. asynchronous defibrillation and synchronized cardioversion deliver direct currents of high amplitude through the chest, to stop ventricular fibrillation or to convert life-threatening arrhythmias. since the human body is partially conductant, it should be possible that after a brief delay of time, a derivation of this monophasic defibrillation pulse is measurable in regions of the defibrillated body, other than the traject between anodal ("sternum") and cathodai ("ape~;") paddles. one could also estimate that health care personnel in the immediate environment of defibrillatoty shocks, are always at risk to possible electric injury. accidents might occur when health care personnel do not stand clear from the patient during firing and create an additional electric path from this patient through their own body. most likely, the nonisolated parts creating a transversal eiectric path, will be the hands of the caretaker. since defibrillation generates touch voltages up to v and - a in ved, short delay's ( to millisec), the total body resistance during skin to skin or skin to paddle contact, is calculated to be as [ow as ohm (percentile tank for the entire population). an experimental protocol was developed to evaluate the conducted currents during defibrillation. mature pigs with a weight of up to kg. were used as animal models. the:,, had barbiturate anaesthesia, inotropic support with dobutamine at l micmgrams/kg bodyweight and all had a sinasat rhythm at the begining of the test-rounds. synchronized defibrillation at j (approx. . j/kg) and asynchronized -at j (whenever ventricular fibrillation or ventricular tachycardia occurred), were attempted, through latero-lateral placed and firmly pressed defibrillation paddles and/or adhesive multi-function electrodes. gel pads were choosen as contactmedium to cross the skinpaddle barrier. subdermal electro-myography needle electrodes were put at different parts and regions of the pig's body, but not between the paddles. these electrodes were coupled to a resistance device of ohm and a measuring computer. we measured monophasic and low current pulses up to , a during the defibrillation burst. thus conducted currents are high enough to produce accidental electric shocks when additional electric paths are created by the caretaker. "llaese are usually harmless, but in some "worst case" (wet or transpiring hands, rings,...) or in association with defectuous equipment, peak currents might be harmfull, and can produce pain, bums, apnae or cardiac (transient or persistant) arrhythmias. maria skogbv. karin mellgren, lars-g ran friberg, g sta mellgren, hans wadenvik. g teborg, sweden. bleeding complications in extracorporeal circulation is partly due to perfusion-induced platelet dysfunction. the aim of this study was to evaluate an in vitro model for investigation of platelet function parameters in an extracorporeat system. study: two complete extracorporeal life support systems were perfused with fresh heparinized human blood for hours. piatetet membrane glycoprotein changes, platelet granule release and platelet count were followed. eight paired experiments were performed. one of the circuits was perfused by a roller pump (polystan) and the other by a centrifugal pump (biomecicus), other components were identical. results: a continuous increase in glycoprotein (gp) ib-negative platelets was seen in both circuits. a marked increase of plasma beta-thromboglobulin concentration and a decrease of the intracellular pool of serotonin was observed, indicating a marked release of alpha as well as of dense granules. the plasma concentration of glycocalioin increased in parallel with a reduced platelet surface expression of gpib, suggesting that the loss of gpib is caused by proteolysis rather than by a downregulation of this receptor protein. conclusion: hours of ecls perfusion induces pronounced platelet degranutation and causes changes of important membrane receptors. this is in accordance with clinical studies, suggesting that our in vitro model does mirror the platelet exhaustion observed in a clinical reality. no significant difference was observed between the two pumps. the purpose of this study was to examine signs of distress exhibited by several patients following the discontinuation of opioids and benzodiazepines (o & b) in a -bed pediatric intensive care unit. the authors compiled a list of all cases of possible withdrawal reactions reported by nurses in the study setting over a one-year period. five cases were selected for study in terms of their wide diversity of relevant circumstances. the cases were examined through a retrospective chart review. data pertaining to analgesic and sedative administration, along with nurses' reports of behavioral distress, were transcribed and coded. a remarkable pattern of behavioral distress was clearly associated with discontinuation of o & b. cessation of benzodiazepines was associated with severe distress. these reactions were characterized by various combinations of crying, irritability, tremors, grimacing, gagging, vomiting, or feeding problems. some of these persisted in spite of large amounts of bolus drug administration. these signs were manifested for to days following cessation of o & b. these findings demonstrate that the rapid weaning of o & b infusions, sometimes following short-term therapy, can cause severe withdrawal reactions. the particular course that a specific patient will follow will likely be modulated by underlying manifestations of "icu psychosis" and unresolved pain and emotional distress. hermana tezano mt, pilaf orive j, latorre garcia j, lizarraga azparren ma, lopez bayon j ucip hospital de cruces. bilbao. spain a female child, one year old, was referred to our unit from another hospital because she had ischemic syntomsjn her right forearm wich started three days before. she had ~i downs syndrome and fallot's tetralogy with a systemic-pulmonary by-pass. nine days before the admission in our hospital she was undergone to a cardiac catheterization by arterial and venous femoral punctures with no incidences. on the admission to the picu her forearm was cold and pale with absence of cubital and radial pulses and slow capilary filling. treatment with heparine was started unsucessfully in the firsts hours, so uroquinase was added that later was changed to rtpa plus brachial plexus blockade. by the time me arterial tlux became more and more evident (doppi~) il bccuute aiat) evident a regional aedema witch made necessary a fasciectomy &the wrist. she also developped necrotic delimitted areas that included her first and fifth fingers. she was discharged from the picu after days and a week later she went to the operating room where an amputation of the distal phalange of the fifth finger was made. the etiolgy of this ischemic picture can't be attributed to the catheterization itself, but probably it should be due to some attempts in arterial puncture in its course, attempts that could be guess by the little marks noticed at the elbow flexure when she was admitted. long maintenance of cardiovascular funtion by assisted ventricular device with membrane oxigenator hermana tezanos mt, pilar orive j. latorre garcia j, lizarraga azparren ma lopez bay n j. ucip. hospital de cruces. bilbao. spain a little girl of three and a half years came to the intensive care unit from the operating room. affected of great vessels transposition with a pulmona~' banding corrected vith rastelli technique, it became impossible to discharge her from the by-pass circulation. it was assumed that this factt was due to a transient myocardial disfunction dfter the surgeon x~ent through the technique and found no wrong step in it. at the picu admission she had an ejection fraction belox~ % (echncardiografy), and was manteined on veutricular assistance with a circuit consisting ofa plate's membrane oxigenator, a bio-medicus pump and pvc rubber tubes, with monitoring of pulmonary', right and left atrial pressures. initially she needed a ventncular support of . l/min with dopamine. dobutamine and adrenaline; gradually the ejection fraction rose to % aliowing a decrease in the mechanical and inotropic support. the organic function ,.'.-as preserved but x-ray of the thorax showed images of pulmonary aedema with an increase in the needs until a fi of . . even though she was placed in a transplant program, she was remouved when the ejection fraction rose to % on the lth da of the evolution. there were no signs of infection (profilactic coverage). on the fifhteen postsurgery day. with a good cardiac sound and an ejection fraction of at least %. it was considered the withdrawal of the ventficular support, but unsucessfully despite the increase ofinotropic drugs, so she died. we think that our patient is a good example of the posibiti~ to mantain x~ith ecmo during a prolonged period of time a potential transplant receiver without major complicatios. joan wierema; ma )an mourik. sophia children's hospital, department of pediatric surger,j, rotterdam, the netherlands. the success of an ecmo program is heavily determined by the organizational structure and the daily availability of both well trained nurses and physicians. until now there is no general guideline to determine the optimal training schedule to set up an ecmo program. objective: to evaluate the set-up of an ecmo program in an area without direct availability of perfusionists of cardiothoracic surgeons. description of the progress: during the preparation of the ecmo program which started november , different phases are identified. first phase, acquisition of experience by training abroad of one physician, staff member of the icu, physician acting as a fellow and one icu nurse with theprimary task to serve as an ecmo coordinator and train the nursing start. in the second phase animal experiments were performed by paediatric surgeons, staff physicians, fellows and nurses. third phase, start of the actual ecmo program, priming by one trained nurse and ecmo fellow, daily care of the patient by nurses, icu nurse taking care of the patient related activities, ecmo trained nurse taking care of the circuit. fourth phase, transition of the tasks for priming the system from the ecmo fellow to the ecmo nurse and changing daily care for the ecmo patient now including the circuit by trained icu nurse with special legislation for ecmo. ongoing training of to nurses working for at least half a year in the icu. during an ecmo run direct contact between the ecmo nurse and one of the staff members; patient data: in a year period neonatal ecmo cases were performed with an overall mortality of %, ranging from over % in meconium aspiration to % in congenital diaphragmatic hernia. in other patients pediatric ecmo (age range month - months) mortality was %. conclusions: ecmo can be established without perfusionists or cardio surgical back up once a predetermined training schedule is available, resulting in comparable results with the international ecmo registry both for neonatal as well as for pediatric cases. mechanical ventilation at home makes normal development of the child with chronic respiratory failure possible. the parents must be encouraged to accept the treatment at home; therefore, they should be enabled to take care of their children all by themselves and the continuous professional support has to be offered to them. it must be stressed that the nurse is the link between the diseased child and his family introducing them into the process of the medical care at home. all the equipment needed for the mechanical ventilation of the child at home (ventilator, suction device, pulse oxymeter, oxygen tanks) has to be provided before the child is discharged. it is paid by the national insurance company. the maintainance service workers will make the necessary installations available and they will renew oxygen and compressed air weekly. the ventilation assembly must not interfere with the childs activities. the related dispensary and nursing service should be notified of the child's condition and the list of the required material (suction tubes, cannulas, desinfectants etc.) has to be made. our experience is so far -from the nursing and medical point of view -satisfactory, however the social status of the parents needs further regulations, omphalocele. mourik m, sophia children's hospital, department of pediatric surgery, rotterdam, the netherlands. in patients with (giant) omphalocde operative closure is impossible due to the lack of intra-abdominal space and a variable degree of pulmonary hypoplasia. consequently conservative treatment allowing epithelialization is the treatment of choice with a high risk of infection and/or sepsis due to a sometimes very long stay in the icu. this conservative treatment consists of daily application of an antibiotic containing powder on the cele which is covered by sterile gauzes. furthermore the enteral intake is started as soon possible. objective: to evaluate whether this treatment renders a high risk for serious infections. patient characteristics: in a year period patients with a giant omphalocele were admitted; mean birth weight g ( - g) mean gestational age . ( - weeks). overall mortality ( %). patients had to be ventilated for a median duration of t days ( , - ). results: patients were discharged at the mean of days following birth ( - ) following complete epithelialization of the omphalocele. following the initial stabilisation period parents were involved in daily care of all patients even during artificial ventialation. enteral intake was started at a median of days ( - ). colonization of the omphalocele was observed within - days in all patients. although infectious periods were observed at regular intervals, sepsis was the primarily cause of death in only of the patients who died, in conclusion: nursing care to prevent sepsis in patients with (giant) omphalocele is feasible for a long period of time and can be performed with simple measures, since june , we have been using nasal cpap in the treatment of respiratory disorders in newborn infants (severe apnea syndrom, tachypnea, hyaline membrane disease). in newborns presenting hyaline membrane disease, we have used cpap and administered surfactant therapy to premature babies out of . clinical data were : mean ga : . + weeks. mean bw : + g. mean administration time was hours. before administration, mean fio was . + . , mean pao . + . kpa and mean a/ao ratio . . all babies were intubated for administration of surfactant (curosurf) and were extubated after half an hour to hours after administration. this treatment failed for seven babies and they were ventilated by oscillation ventilation ; all babies survived. complications : we have observed pneumothorax in cases and cerebral hemorrage. mean duration time of nasal cpap was hours for the babies without assisted ventilation. nurses in charge of babies with nasal cpap should be aware of neonatal care, of the possibility of surfactant administration and of complications during this type of treatment. therefore nurses should know very well the use of nasal cpap, the monitoring during this treatment, the fixation of the system on the baby, nursing of the babies during this treatment and finally should take care of the baby physical and psychological well being. as a conclusion, nurses in intensive care neonatal units should know the possibility of treatment of rds by nasal cpap and should be aware of baby-nursing. emco in the postcardiotomy infan_t : a simplified circuit and reduced management grillet lsabelle, bosson christa, goelz andrea, helmer pascale, icu nurses, tschaut rudy perfusianist aldo castaneda institute, clinique de genolier, suisse to improve postoperative survival of infants with repaired cardiac tessions but severe residual cardiopnlmonary dysfunction, emco was used in infants, ranging in age from l days to months and in weight from , kg to , kg. diagnosis included tga / intact ventricular septum ( ) (both subiected to rapid arterial switch operation because of unsuitable lv function) and tga +vsd ( ). "['he emco circuit included a sarns roller ump, a medtronic minimax plus hollow fiber oxygenator and tubing ( / - / inch) with bioactive surfaces, an arterial canula fr., venous canulas : right atrial fr, left atrial fr., an air oxygen mixer and a sarns heater. the act was kept between - sec. after the infant was connected to emco by the surgical team and the perfusion technologist, the patients were being cared for and controlled exclusively by the cu nurse assigned to the patient and the physician on call for the icu, pump flows of - ml / kg / mln were targeted to insure an adequate urine output, a brisk capillary fill and physiologic left and right atrial pressures. sodium nitroprusside was used to control systemic hypertension while all other inotropic drugs were discontinued. inspired oxygen fraction on the ventilator was reduced to , at a respiratory rate of - breaths per minute. body temperature was maintened close to normal. when the heart started to eject again, inspired oxygen was increased to about , . the preparation for weaning from emco was done by the icu nurse: including oxygen fraction and ventilator rate. weaning from emcowas coordinated by the medical / surgical team and the perfusion technologist. the duration of emco in the patients ranged from to days. three patients ( %) were saccessflly weaned from emco. one of the three died within hours from neurologic complications, unrelated to the emco. the other patients ( both with tga + vsd ) are long term survivors and are doing well. neither the survivors nor the patients who died bad hemorrhagic complications, despite the fact that of the were placed on emco because of failure to wean from cardiopulmonary bypass. the simplified emco circuit worked reliably throughout this experience and no complications occurred nor could any shortcoming be ascribed to the use of this reduced, cost effective management team. years of praciical experience wiih exiracorporeal membrane oxygenation (echo) -the viewpoint of the nursing siaef monika schindler in a training program was started for the introduction of echo in the kinderklinik of mannheim/germsny. years later ( ) the first european echo patient, a days old newborn baby, ~as treated successfully in our institution. with echo, more treatment modalities ~ere available after failure of conventional therapy in eases of severe lung diseases like meeonium aspiration syndrome, congenital diaphragmatic hernia, sepsis/pneumonia, primary persistent pulmonary hypertension of the newborn and -in infants and children -ards (acquired respiratory distress syndrome) due to multiple underlying illnesses. in the first ards patient, a years old girl, was treated successfully ~ith ecmo in mannheim. until now patients (age: i day - years) were treated with echo in our institution; additional patients were transferred to us from other institutions for therapy with echo, but could be treated ~ieh alternative moda]ities of therapy like improved conventional ventilatory support, high frequency oscillatory ventilation (hfov) and inhaled nieric oxide (no), unexpectedly the more ~ide-spread use of hfov and no -also in other ~ntensive care units -did not lead to a reduction of the echo frequency in our hospital. due to this long ecmo practice, which is helpful in many critical situations, a certain routine came up in the nursing staff of our intensive care units; but ecmo continues to be a maximum strain for all co-workers and implies an high personnel and material/financial-expense. but in our opinion the improved survival rates in severe respiratory failure-( % in neonates and % in infants and children, estimated survival rates under continued conventional management: < %) by the use of echo justifies this expense, even in times of less financial support for public health. • analyse the differences between each urdt. method : ni criteria were defined by the rt~a ped group according to cdc criteria. all data were collected by a nursing and medical team. data vere dealed with epi info software. all u-dections data were validated by an external mvestigatol : patients who stay more than hours in an icu were included over a months period. % were newborns, % infants and , % children. ni were idenlified among sll patients, the overall ni incidence rates was , % and , person day, septicemia was the first cause of ni ( %). staphylococcus epidermidis were isolated in % of septicemia cases. pneumonia was the other main ni ( %) with gram negatwe bacille isolated m % ( % of them beei,ng fseudomonas) accordmg to age, the septicemia mcidence rate varied from , ~., to . %,, catheter/day and pneumonia incidence rate from , %, to , % ventilation/daywith the lowest rate for newborns. : this survey was possible thanks to the collaboration between laboratories, bacteriologist, physicians and nurses, and allowed each concerned unit to work together in~tead of every one in his own field. 'lhe results of this survey bring changes in attlhades and empower the different team work the next step is to analyse the ditferent nurses procedures of indwelling central venous catheter in each unit ar)d implement a ni quatity care. program in all nicu anti picu. v~,~jl~j~'v~y : new born in~ra-v~ nous drugs ~md lheir pr~taration mcounter a lot of risk ~)f utters, due to inadapted conditionn~ng to podia)eric and minimal amount injec~.~d, th~ study t~ed to evaluate degrees of do.~age er~o~ dye tt) dru~ preparaek, n i~ nc,:,~atol~gy and to come out w~th ~ method of dihttion able to reduce risk to minima (errors _< %) at the ~eme t~me, ¢o~,~x-tueaces on cost were studioj methnd~ : amikacine was choosen because this antibiotic is regularly ~,~l in neonatology unit and its dosage is easily used by standardiaud method, amikacine doses ( , mg doses and , mg doses) were prepared" by nurse~ form mg for m) vial. each dose w'a~ diluted to obtain mi volume, tallowing usual ward method, for each dilution, amikacine con<entrati('m and it,s volume was measured and used equipment for preparation wa~ regi~tred. "first s utj(m" were prepared diluting ~t'~ mg amikacine pouder inn ) ml glucnse solution bag (viaflex baxter bag with transfer cap), from tho~e "first solution" doses at mg and doses of ~ rng were prepared, amik~cine coc, cenir,)tmn for each preparabon and their volume were measured, ai,~n ntttl~,ber of seringe were tounted. first soiuhon staeiiity was conrroieo aher one week conservation at + '>c. amjkacine concentration were measured by fluorescence process (tdx abbott) after sample dilurion. on a mg/l sample, tovhnical reliahility show~ > ~ % of result mpmductlon and < % of variation due to dilutions. results : when amikacine injection werv pro.pared from araikacme /) mg for mt vial > % do~ge, ermr~ were found in / cases ; ~ % in ,t ,to cases. if preparation is done from amikacine "~it'st soltltion", les.--concenvr~tcd, it i~ more preci,,,e and only one dosage error ~ % ( , %} is found in eli studied doses. in add)inn to )hal if doses were wep,m-'d from one "first soiatiol~' bag, the cost economy sl~ouid b~" of fr~, and ii dos~$ were prepared tram the same bag the saving mtmey should be o{ i its .cencluslon : .ur survey shows th~t h' ntu)nato|ogy the u~ of a "first sohation which can be kept fi~r one week is enable to reduce dosage erroes and i~ co,~tsavmg, regarding [,v. admimst'rahon method the survey is still on, introduction: so-called vein of galen m~iformations ale rare in~racranial embryologycal anomalies, repl~senti~g tess than of symptomatic intracranied artefiovenoas l~alform~tions. the spontlneous prognosis is ~s~u~lly fatal, because of cardiac frilure due to left-to-right shunt thrq~ugh the fistula. recent developments of new techniques of treatment of the malformation and its cardiac consequence have led to a revolution in the practical approach of children w~th galen malformation. our fukfose is to contribute, with our persoaal series of s newborns and infal~ts admitted in our unit after endov~,scular embolization, to a better management of these children. such a management requ!res a rnultidisciplinary approach. intensive care are required prior to embollzation for patients with cardiac failure or cardiogenic shock and after cmbolization in order to insure cardiac and cerebral hemodyna.mic stabilities. this overlooking suppose for the nursing team to understand: prior to embolization : heart failure and cardiogenic shock. after cmbolization : evaluation of neurological and hemodynamic consequences of this proccdure, without forgetting the nursing and psychologic aspects, in concl'iision, this last ten yerrs, these new approaches give to the patients and their famitiy a good reason to hope a total recovew, in our exl)erience, the global mortality is % aad % of children #j-e neurologically normal after embolizafion, ii ii~ i ~ii i ii i i l i iiii~ i ~i iii i background: venous oxygen saturation (svo z) reflects the residuai oxygen after tissue oxygen extraction and represents the relation between tissue oxygen supply and demand. we studied svo and arterial lactate during progressive isovolemic anemia to assess the relation between svo and tissue hypoxia. subjects: ten - day old anesthetized ventilated piglets sao and svq were measured continuously by a fiberoptic catheter (oximetrix, abbott lab.) in the carotid and pulmonary a~epy tissue hypoxia was confirmed by a reduced vo, and an increase in lactate. conclusion: svo reflects better a reduced dp obtained by progressive anemia surfactant replacement improves gas exchange in early-stage adult respiratory syndrome (ards) [ , ], but not in late-stage ards [ ] . we report the first case of successfull treatment of ards after repeated instillation of surfactant.a ten year old boy, weighing kg, presented with hemorragic shock. biphasic-positive-airways-pressure ventilation was performed (evita ii, dr~ger, germany). he had recieved nine units of packed red blood cells and underwent surgical exeresis of two bleeding gastric ulcus. post-operatively, a cardiac arrest required cardiopulmonary resuscitation for three minutes. hemodynamic status was subsequently stabilised. the chest-radiograph showed infiltrates of both lungs without signs of cardiac failure. on the third day, the patient became severely hypoxic with a pao /fio ratio of . gas exchange was not improved by high ventilator settings. peak inspiratory pressure (pip) and ventilatory rates were cmh~o and breaths/min respectively. inspiratory:expiratory time was : and the positive end expiratory pressure (peep) cmh . after increasing the peep level to cmh , we instilled over minutes, mg/kg of porcine surfactant (curosurf, serene france), in two equal volumes in both main bronchus,the spo~ rose to % within rain, the fie could be reduced to . . twenty four hours later, gas exchange worsened again (pao /fio ratio ). we increased the peep from to cmh , and instilled a second dose of surfactant ( mg/kg). again, fie could be reduced within minutes (spo ; fie . .). the patient was weaned from the ventilator and extubated on the tenth day. follow-up at four month showed normal lung function.we demonstrate improvement in oxygenation after repeated exogenous surfactant administrations. we assume that in early-stage ards, surfactant may potentiate shunt-reducing effect of peep as it has been demonstrated in experimental model of ards [ ] , and allow decrease in fie . in case of secondary deterioration, we think that a second dose of surfactant should be administered. . weg jg, balk ra, tharratt rs, et al. ,lama : : - . . spragg rg, gillard n, pdchman p, et al. chest t : : - . . haslam pl, hughes da, mcnaughton pd. et al. lancet : - . . huang yc, caimulti sp, fawcett ta, et al. jappl physiol : - % (ref) . the aim of this study was to verify these data: patients/~lethods: all pts admitted to our multidisciplinary nicu/picu in were included if they were in respiratory failure recruiting conventional mechanical ventilation (cmv) with peep >_ and 'fig -: % or high-frequency oscillation ventilation (hfo) with mean airway pressure _> t cm h for or more houm. diagnosis, maximal ventilatory parameters, barotrauma, organ/ system failures, mechanism of death and glasgow oulcome scale (gos) and months after study entry were prospectively collected. results: patients were admitted to the unit, o whom required mechanical ventilation for a mean duration of . days. overall mortality was %, patients fulfilled study criteria. survivors had gos , pts with preexisting neurological impairment survived with gos . neonatal diseases included hyaline membrane disease ( ), meconium aspiration syndrome ( ) and cardiovascular surgery ( ), pediatric diseases included bacterial ( ) and viral ( ) pneumonia, aspiration ( ) and cardiovascular surgery beyond the neonatal period ( ). - ) . patients and methods: cefotaxim was used as a prophylactic agent in patients in life threatening situations (e.g. multitrauma, neurosurgery atc.). more than % children required cefotaxim for the treatment of severe infections (epiglotitis, meningitis, sepsis, pneumonia mainly in immunodeficient and neutropenic patients) in monotherapy or in the combination with the other antimicrobial agents. results: cefotaxim as a prophylactic drug was successful in all cases ( %). the effectivity of treatment of infections was . % ( patients). the change of antibiotic therapy required patients ( . %). patients ( . %) died, but only in of them ( . %) the obduction confirmed infection. conclusion: we conclude that cefotaxim is very effective and safe antibiotic and represents "golden standard" in the treatment of severe infections in childhood. in order to improve nursing quality, we recently adapted nursing care to the "five nursing functions" (activities of daily living, accompagnment in crisis, treatment, prevention and research) as described by the swiss red cross in accordance to the new educational guidelines of the european community, the aim of this study was to document complications of "treatment nursing function".methods: all treatment complications were prospectively collected by the nursing and medical staff. the nursing staff included patient (pt) name, time of occurence and exact description of complication, proposal for prevention and information of parents. the medical staff reported type of complication together with pt information, diagnosis, medication, treatment and interventions, outcome and referral, all complications were discussed in monthly meetings including nursing and medical staff.results: from january until december , pts were admitted to the picu/nicu for nursing days ( % of total bed occupancy). pts needed endotracheal intubation for an average of . days and pts required nasal cpap. complications in pts were noted ( per pi): inadequate check-up of equipment ; accidental extubation ( in intubated pts); bedsores ; false drug dosing ; wrong drug ; umbilical bleeding ; wrong transfusion setup ; nasal septal necrosis ). there was no mortality due to these complications. exact documention of treatment complications and their meticulous discussion within the medical and nursing staff may improve "treatment nursing function". however, documentation and evaluation of nursing within all "five nursing functions" will be nessecary in order to achieve optimal nursing care. cardiac output determination by thermodilution, using iced injectate has been shown to be valid and reliable in pediatric patients. it has been demonstrated in adult patients that there is no difference in cardiac output values when using room temperature injectate as compared to iced temperature injectate. the purpose of this study is to examine the effect of injectate temperature on cardiac output values in pediatric patients. our study consisted of sixteen pediatric patients who had oximetric thermodilution catheters in place after cardiac surgery and who had cardiac output determined using both iced and room temperature injectate. with each patient, cardiac output was measured once on the day of surgery and again the following day. in each case cardiac output was measured using both iced and room temperature injectate. statistical analysis included a two-way, repeated measures analysis of variance for each individual injectate administered and no significant differences were found in cardiac output. no statistically significant differences were found between groups with regard to the order of injectate administration or volume of injectate used (i,e., or cc's). the correlation coefficients between groups for cardiac output measurements at each injectate administration time, and for the average measurements across times, ranged between . to . (p < . ). preliminary data analysis suggests that cardiac output measurements for children are not effected by the temperature of injectate. a lenghty stay at a paediatric intensive care unit will always have sideeffects on a child's well-being and will put a high strain on the parents. in order to minimize the side-effects longterm intensive care unit opened in at the childrens' hospital. admitted children are all ~ongterm-ill and technically-dependent and the ventilatory support can alter from a tracheostoma to cpap or portable volume ventilator. nutritional support is applied by gastrostomies. a homelike atmosphere surrounds the children, they share a dormitory, a living-room and a dining-room the main purpose is to send the child home with or without technical equipment. this can only be implemented by giving structured education (theory and practice) to all categories involved. the multi-disciplinary team consists of one anaesthesiologist, head nurse, clinical specialist, rn nurses, nurses, one habilitation doctor, one social worker and therapists. twenty-four patients have been admitted to licu during these six years. length of stay was from one day to four years. four are presently staying at the trait. the assessment of pain in children ( - yrs) is still difficult, because children of this age have limited language and cognitive skills. to standardize the assessment of postoperative pain and distress in the intensive care unit an observational mstrument was needed that met several criteria. it should be easy to use in daily routine care. be suitable for the i.c. situation, and in children of - hrs of age. the comfort scale, an observational instrument designed to assess distress in infants in i.c. units, met these criteria. to accommodate the use of the comfort scale in the i.c. units and in research, nurses should be trained to use the scale. an additional requirement was that the inter-rater reliability should be sufficiently high, (cohen's kappa > . ). objectives: ) to introduce the comfort scale in the i.c.u.; ) to examine whether this instrument can easily, be incorporated into routine care; ) to investigate the inter-rater retiabtlity. methods: the comfort scale is an -item instrument specifically designed for use in pediatric i,c, units and contains both physiological items (heart rate, blood pressure) and behavioral items (e.g., alertness behavior, calmness/agitation, body movement, facial expression respiratory response, muscle tension). the observation period is minutes. the scale is supplemented with an item on crying tbr children who are not mechanically ventilated. groups of t.c. nurses were trained by means of video's and observations at the wards. after the training, each nurse completed scores with other nurses, after which the cohen's kappa was computed. when the kappa's for the items met or exceeded our . criterium, a new group of nurses was trained. results: to date, nurses have been trained. nurses find the comfort scale easy" to administer and a valuable addition to routine care in the i.c. unit. the cohen's kappa's were higher than . for all items that the inter-rater reliability was high. the comfort scale is feasible in postoperative care in the i.v. and is considered a valuable instrument to improve and maintain high postoperative quality of care in the i.c. unit. introduction:children with neuro-muscular disease are believed to have a higher resting energy expenditure (ree), because of their increasedwork of breathing.the influence of nocturnal nasal mask ventilation on energy metabolism and nutritional state of these children has not been studied so far.objective:l,ls the ree inereased? . s there an influence of nasal mask ventilation on the ree? .what is the nutritional state? .what is the estimated total energy expenditure(ete) in relation to the caloric intake? methods:a pilot study of patients( - years) .the following measurements were performed:l.anthropometry. .bioelectric impedance- .ree was measured by indirect calorimetry during the day (in bed) with and without nasal mask ventuation,ree was compared with predicted ree according to schofield(pee), .caloric-intake and activities were recorded during hour before measurement. .total energy expenditure was calculated as follows:measured ree x estimated activity factor. results:tin all children weight for height was too low, <p . .aii children had a low % of fat. .according to the healthy group, ree is not increased. ,nasal mask ventilation lowered ree in patients, in patient we measured a clear decrease.conclueion:l.anthropometry and indirect calorimetry were helpful in evaluating the nutritional state. .there is no increased ree,in t patient there is clearly effect of nasal mask ventilation. .when caloric intake was related to ree and level of activity patients had too low caloric intake. .the influence of nocturnal nasal mask ventilation and nutritional assessment should be evaluated longitudinally. increasing awareness that the neonate can percept pain and suffer following surgical procedures, has major impact on pain management. in our unit continuous morphine infusion (t /~g/kg/hr) was introduced from january as a standard medicatton following surgical procedures. before morphine was given as a bolus (i.m., i.v., rectal) of /~g/kg up till four times a day. repeated gifts of morphine were only gwen following observation by the nurse that the child experienced pain. aim of the study: to evaluate pain management before and tbllowing introduction of a continuous morphine infusion for postoperative pain in our icu. patients and methods: term born babies with isolated oesophageal atresia and tracheo-oesophageal fistula were included in the study. the total amount of morphine (/~£/kg/ hours); number of days morphine was given; duration of artificial ventilation was evaluated in a case control study. res ults: - - central venous catheters (cvc) have been increasingly used also at our picu, university medical centre ljubljana. besides advantages, the cvc has brought numerous risks of complications; the catheter sepsis occurs most often and can be fatal for the patient. for example, in we dealt with children aged - years or in other words . cvp per a child treated at our picu. a specialized unit for preparing parenteral natrition started to function in the university medical centre pharmacy in . after that we equipped a special room for preparing other necessary infusion mixtures and organized a team of nurses -"catheter nurses".their tasks comprise: managing cvcs, replacing and installing infusion systems and mixtures made at pharmacy, preparing drugs and some necessary infusion mixtures in special room, permanent training and co-operation with related disciplines, pharmacy, epidemiology, microbiology, etc. all registered nurses at picu have been trained for this work. the routine is as follows: in the morningafter the doctor's visit, we first check the cvc and change the dressings; according to the nurse's observations, the doctor decides whether there is a need to remove or replace the cvc. if the catheter site is inflamed, swollen, or purulent, a swab is taken for microbiological culture and the area cleaned. in case of systemic infection signs, cvc has to be replaced, blood culture taken and the infection treated with antibiotics. the dressings are always changed by two tmcatheter nurses together. afterwards the infusion mixtures for the next hours are prepared for each child. the infusion mixtures which will not be used immediately are kept on + °c; before application they are, of course, warmed to at least room temperature. finally the "catheter nurse" supplies the cvc with new infusion mixtures made at our pharmacy. our observations show that such work requires responsibility and is demanding; but our pemanent care lessens the number of complications. thus the described scheme fulfilled our expectations. perl- perative management of neonates with hypoplastic left heart syndrome muir warren, blondel maryse, foltz rhonda, farine martine, icu nurses, the aldo castaneda institute, clinique de genolier, switzerland both the pre-operative and post-operative physiology of patient with hypoplastic left heart syndrome is critically determined by the puhnonary-tosystemic resistance ratio. a high ratio results in minimum volume work for the right ventricle but is at the expense of important hypoxemia. a low ratio is reflected in minimum hypoxemia but an unfavorable increase in excess ventricular volume work. a resistance ratio of approximately results in an arterial oxygen saturation of % - %, a qp/qs of , and ventricular volume work only twice normal. this latter physiology appears best for oxygen delivery and systemic perfusion with tolerable volume work. carbon dioxide (co ) in the inspired gas is known to increase pulmonary vascular resistance without significantly influencing systemic resistance in the range of to tort partial pressure. hyperventilation with no co in inspired gas decreases pulmonary vascular resistance. thus, managing co may be useful to modulate the pulmonary-to-systemic resistance ratio, in the tast months, patients with hypoplastic left heart syndrome were managed by a norwood procedur e. patients with endotracheal entubation pre-operatively had co added to inspired gas to modulate the pulmonary-to-systemic flow ratio. patients had co added to inspired gas post-operatively. all but patient had characteristically large pulmonaary-to-systemic flow ratio with oxygen saturation mean % preoperatively, even in those patients receiving co , co was accompanied by elimination of metabolic acidosis pre-operatively. the most comlnon partial pressure of co added post-operatively was torr. po ranged from mmhg to mmhg. all surviving patients developed a metabolic alkalosis ( mean) when treated with co . there were deaths, one from drug toxicity, one from excessive post-operative hemorrhage, two from sepsis or mocardial insufficiency. only one patient benefited from catecholamine support which can increase systemic resistance unfaborably. in this experience co was felt to be an important adjunct in some patients pre-operatively and most patients postoperatively to faborably modulate the critically important systemic-topulmonary flow ratio, to maximize oxygen delivery and systemic perfusion, while minimizing excessive right vantricular volume work. key: cord- -a qz tb authors: nan title: th annual meeting of the austrian society of surgery, graz, june – , date: journal: eur surg doi: . /s - - - sha: doc_id: cord_uid: a qz tb nan background. aortic valve replacement (avr) in the elderly with significant co-morbidities is associated with increased operative risk. trans-apical catheter based avr is being evaluated in a phase study. we report the initial results of the first generation equine pericardial cribrier- edwardsvalve. methods. access is through a small antero-lateral thoracotomy with direct puncture of the apex. after initial balloon valvuloplasty the ascendra delivery system is used to position the balloon mounted crimped bioprosthesis under fluoroscopic and transesophageal echo guidance in the native aortic annulus. results. high risk patients (log euroscore . ae , female and male) with a mean age of ae . years were operated. valve positioning was successful in pts (valve size in pts and size in pts) and were converted to full sternotomy and conventional valve replacement performed. deployment time was . ae . min. delivery was achieved without cardiopulmonary bypass in % of patients. however in pts cpb became necessary to treat bleeding complications. there were deaths within days ( valve related, cardiac, abdominal). operative revision was necessary in patients for bleeding and was related to the apical access in , intercostals artery , lung laceration and was diffuse in . hemodynamic evaluation showed satisfactory results in regard to aortic insufficiency (none: , minimal ) and excellent gradients (peak gradient: . ae . mmhg). conclusions. we conclude from our data that trans-apical aortic valve replacement with the cribrier-edwards bioprosthesis can be performed in high risk patients successfully. cardiopulmonary bypass may be avoided. complications may be attributed to the high risk profile of the elderly population treated in the early learning curve. excellent imaging technology in the operating room and excellent collaboration between surgeons and cardiologist as well as anesthetists appears crucial for the successful implementation of this new treatment modality. aortic valve replacement through partial upper sternotomy: a safe alternative to full sternotomy erate to good left ventricular function and without any previous cardiac surgery at our institution. we reviewed retrospectively data on patients ( males, females) who underwent avr through a partial upper sternotomy between and . mean age was . ( - ) years. mean logistic euroscore and mean peak transvalvular gradient were . ( . - . ) and . ( - ) mmhg, respectively. results. mean cross clamp time, mean bypass time and mean operation time were . ( - ) min; . ( - ) min and . ( - ) min, respectively. in patients ( . %) a conversion into full median sternotomy was necessary. patients ( . %) had to be reexplorated due to bleeding. the mean intraoperative and postoperative red blood cell transfusions were . and . , respectively. deep sternum infection occurred in patients ( . %) . mean icu and total hospital stay were . and . days, respectively. there were hospital deaths giving a perioperative mortality of . %. conclusions. avr through a partial upper sternotomy is a safe and effective technique with a similar perioperative morbidity and mortality to conventional aortic valve surgery showing superior cosmetic results. state-of-the-art : mitral valve repairminimally invasive or median sternotomy? background. more than ten years have passed since minimally invasive mitral valve surgery employing different access and different techniques has been introduced. in spite of obvious advantages acceptance by cardiac surgeons is generally low. to define its current position in clinical practice the development of our program, actual indications and results are presented. methods. minimally invasive and conventional mitral valve procedures from to were documented prospectively. indications for the minimally invasive vs. conventional approach through median sternotomy are compared. results. seventy-five patients had minimally invasive mitral valve surgery through a cm minithoracotomy. carpentier type i, ii and iiia lesions involving the posterior, anterior or both mitral leaflets were treted using carpentier repair techniques. combined procedures of the tricuspid valve, asd and modified maze operations were performed in % of cases, patients had prosthetic mitral valve replacement. patient died at home on postoperative day from unknown causes. functional results: residual mi grade : %, grade i: %, grades i-ii: . %, grade ii: . %, grade iii or iv: . reoperations after months: . in in our department % of all mitral valve repairs needing no concomitant cabg or aortic valve operations were performed minimally invasive. conclusions. more than % of mitral valve repairs can be performed minimally invasive with excellent results. as the procedure is superior concerning cosmesis, the procedure is favored by patients and referring cardiologists. at this time disadvantages are neither proven nor suspected, advantages concerning surgical complications and rehabilitation are assumed. insights from cases of remote access perfusion for minimal invasive cardiac surgery n. bonaros , t. schachner , a. Ö hlinger , o. bernecker , g. feuchtner , g. laufer , j. bonatti background. remote access perfusion (rap) is a prerequisite for performance of minimal invasive cardiac surgery on the arrested heart. during implementation several technical challenges may be encountered. in this study we assess the incidence and the influence of these challenges on the perioperative outcome and we describe clinical results in a large patients' series. methods. we retrospectively analyzed patients who underwent minimal invasive cardiac surgery (totally endoscopic coronary artery bypass grafting: , endoscopic atrial septal defect repair: , totally endoscopic mitral valve repair: ) using rap (estech: , heartport: ). intra-and postoperative parameters were analyzed according to the occurrence or not of technical challenges attributed to remote access perfusion. results. we observed no perioperative mortality and no severe complications in this patients' series. technical problems occurred in patients ( %). three patients ( %) underwent conversion to other operative method as severely atherosclerotic peripheral vessels did not allow positioning of the balloon in the ascending aorta. another patients required an additional arterial cannula in the contralateral femoral artery to ensure adequate perfusion. balloon migrations occurred in patients ( %). in cases was a cannula replacement required ( %), in four of which due to balloon rupture. in patients ( %) positioning of the balloon in the ascending aorta required the use of fluoroscopy, as this was not possible under echocardiographical guidance. patients with technical difficulties (group ) had no worse outcome than those in whom no rap-associated problems occured (group ) with the exception of longer total operative time (group : ae min group : ae min, p ¼ . ). ventilation time, intensive care unit stay and hospital stay were all similar in the study groups (p ¼ ns). a comparison between the two cannula types showed only a higher balloon pressure needed for positioning of the estech cannula vs the heartport system ( ae vs. ae , p < . ) although comparable injection volumes were used. conclusions. we conclude that technical difficulties are not rare during rap but in most of the cases can be easily managed at the cost of increased operative time. the postoperative outcome is not compromized provided that major complications are avoided. neoangiogenesis after combined transplantation of skeletal myoblasts and angiopoietic progenitors leads to increased cell engraftment and lower apoptosis rates in ischemic heart failure background. we report on a modified minimally invasive and cosmetic approach of surgical repair of atrial septal defects (asd) i with emphasis on infant patients weighing below kg. methods. from august to july , patients underwent this procedure (mmit-modified minimally invasive technique). the heart was exposed by a limited midline skin incision and partial sternotomy (newly developed sternal spreader, fa. fehling, germany), and the atrial septal defect was closed through a right atriotomy using special new aortic and dual venous cannuals. basic results were matched to those obtained from patients (st-standard technique) . results. atrial morphology was more complex in mmit pts ( overriding svcs, sinus venosus defects), nevertheless op times were accurate and similar to st pts. early extubation was forced and made possible by fast-track methods. totally, asds were directly closed, pts had patch repair. postoperatively we observed mild postpericardectomy syndroms, cholecystitis and pneumothorax requiring drainage in st pts, only pt with mild pericardial effusion was found in mmit group. retention of pericardial effusions was not a risk factor and hospital stay was also not prolonged. conclusions. this approach achieves a cosmetically superior result with newly developed but standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions even in dysmorphic, low weight congenital patients. mmit (pts) . clinical data and follow-up were collected prospectively and analyzed retrospectively. statistical data are shown as mean values and standard deviation. in larger tumors a preoperative interventional embolization was performed. postoperatively pts were seen as outpatients once per year including ultrasound control. results. of the pts with a mean age of . þ . years there were female and male pts. in pts the unilateral tumor was located on the right side, in pts on the left side. at time of diagnosis pts ( = pts ¼ %) presented with bilateral paraganglioma. histological analysis showed benign paraganglioma in pts and malignant paraganglioma in pt. after a follow-up of to months (mean: . þ . months) pts were alive and well whereas pts were lost to follow-up. duplex ultrasound gave no evidence for recurrence of npg in pts. the patient with the malignant tumor is alive and free of recurrence after years and months. the most recent patient with bilateral paraganglioma tested positive for sdh-d mutation. two brothers and sister of this patient were diagnosed with phaeochromocytoma. conclusions. more female patients were affected than male pts. in male patients there was a higher incidence of bilateral paraganglioma of the neck. long-term survival in patients after surgical removal of neck paraganglioma appears not limited. because of the possibility to identify mutations in the sdhgene (sdhd, sdhb, sdhc) further testing of patients with bilateral paraganglioma is mandatory. screening for phaechromocytoma in these pts and evaluation of patients' families is recommended. background. endarterectomy remains the treatment of choice for ica stenosis. one major complication of surgery is cni ( - %) , encouraging transfemoral stent placement for ica stenosis. the aim of this study is to evaluate a possible reduction of this complication by the use of eversion endarterectomy (eea) compared to standard patch endarterectomy. methods. prospective study design in patients treated at a tertiary university based care center. consecutive patients were enrolled into the study. age (median years, range - years), sex (male , female ), medical risk factors (smoking %, hypertension %, diabetes mellitus %) and indication for surgery (asymptomatic stenosis %) were equally distrtributed among both groups ( patients each). all patients were evaluated pre-and postoperatively for cni by an independent neurologist and ent specialist blinded for the operative procedure. results. one patient in the conventional group suffered patch rupture with consecutive stroke days postoperatively. two patients in the conventional group developed cni ( recurrent larygeal and facial nerve deficit, hypoglossal and glossopharygeal nerve deficit). after months of follow up the latter patient showed spontaneous resolution of cranial nerve symptoms. no patient developed cni after eea. conclusions. cni has been detected in % after endarterectomy of the ica in our series. symptoms of cni may be transient, but are disturbing if no clinical improvement is observed. eea requires less operative dissection in the neck compared to standard patch endarterectomy, and therefore seems to be favourable technique with regard to cni development. eea has the potential to curb the current trend toward application of endovascular surgery for ica stenosis. background. total occlusion or stenosis of the common carotid artery is rare and the indications and techniques of surgical treatment are still a matter of controversy. we demonstrate the feasibility of retrograde common carotid endarterectomy. methods. retrospective case report study. participants. in a period of fifteen years thirty-nine patients underwent retrograde endarterectomy of the common carotid artery. twenty-nine patients were males, middle age (min , max ). ten patients were females, middle age (min , max ). symptoms of brain ischemia were present in fifteen patients. retrograde endarterectomy of the common carotid artery and endarterectomy of the internal carotid artery were done together in all patients. indication for retrograde tea was a verified stenosis > % or occlusion of the common carotid artery diagnosed by duplex ultrasound and arteriography. in three patients iatrogenically dissection of the common carotid artery was seen as indication for that procedure. main measurements. postoperative early mortality, stroke rate, medium and long-term endarterectomy patency. results. in all patients who underwent that procedure there was no occurence of major complications or statistically increased mortality. the day mortality was . % ( patients). one of them died in cause of a heart attack and one because of a cerebral bleeding. there was one ipsilateral stroke ( . %) eight month after the procedure. three patients were lost to follow-up. mean follow-up was months ( to ). there were ( . %) late deaths caused by cardiovascular related problems, pneumonia and cancer. in all living patients, controlled by duplex ultrasound, no occlusion or stenosis was found. conclusions. retrograde tea can be done through only one cervical incision for common carotid artery stenosis= occlusion, for tandem lesions of the carotid arteries as well as for iatrogenic dissections of the common carotid artery. compaired to bypass grafting this technique is a faster and easier method. our retrospective study indicates a long-term patency and freedom from neurologic events. stenosis and occlusion of the proximal subclavian artery -surgical or interventional treatment? an analysis of our own patients and international studies m. tomka, a. baumann, p. konstantiniuk, t. ott, t. cohnert division of vascular surgery, department of surgery, medical university of graz, graz, austria background. seventeen percent of all supraaortic occlusions concern subclavian artery, but only % of them fulfil the clinical and angiographic qualification of steal syndrome. methods. since patients with stenosis or occlusion of the proximal subclavian artery were treated on our department. patients underwent end-to-side transposition of the subclavian into the common carotid artery; a carotid-subclavian bypass using synthetic grafts was applied to patients. surgical treatment and evaluation, complications, short and long term patency of our patients were compared to interventional techniques and international literature. results. the primary success rate of both operative techniques achieved %. -days mortality was %, -days morbidity % ( = ) in the transposition group and . % ( = ) in the bypass-group respectively. median follow-up time was months in the transposition-group vs. months in the bypass-group. only in the latter one late occlusion ( . %) was seen. conclusions. our data show a slight (not significant) favour for the transposition, which is consistent with results from other studies. concerning long term patency and infection rates the transposition of the subclavian into the common carotid artery by single incision is to be recommended first choice of treatment. avoiding synthetic grafts leads to optimal compliance. flow in natural direction and less mortality and morbidity rate are ensured. critical, because preoperative ef is predictive for long-term survival. here, we report results from a genomic study in patients with as in compensated and decompensated state and present candidate genes that could be predictive for the progression of heart failure. methods. biopsies from the lv septum of male patients (  a ae yrs) with isolated as undergoing biologic aortic valve replacement (carpentier edwards magna a + ) were harvested either from hearts with normal ef (> %, n ¼ ) or from a group with low ef ( %, n ¼ ) and served as controls. total rna was analyzed on affymetrix hg-u a genechips, which allowed to measure expression levels of more than . human gene transcripts. low level expression analysis was performed using the gc-rma algorithm and statistical significance analysis was done by bayesian t-test. class prediction was performed using the brb arraytools package (nci). results. expression levels clearly distinguished as from cad. annotation of these transcripts revealed a close correlation with the hypertrophic response and progressive fibrosis. these targets completely reflected the current understanding of key processes involved in heart failure. within a list of several ( ) as classifier genes that revealed well-known markers such as the natriuretic peptide precursors a and b and troponin i, we identified: ( ) the connective tissue growth factor ( vs. ; p < . ), known to be triggered by mechanical stress in fibroblasts; ( ) periostin ( vs. , p ¼ . ), an important matricellular component recently shown to be responsible for ventricular dilation. when specifically searching for low ef class predictors, we found potential candidates of unknown function, which were consistently expressed at a higher level only in as with ef < %: ( ) the pom and zp fusion gene ( vs. , p ¼ . ) and ( ) the transcription factor ets variant ( vs. , p ¼ . ). conclusions. in this study we could clearly identify patients with cad from those with as by the help of gene expression profiling. moreover, we were able to identify gene expression signatures that could be predictive for the progression of heart failure. background. despite tremendous advances in immunosuppressive therapy acute rejection still remains a problem following solid organ transplantation. proteome analysis has emerged as a valuable tool for the study of large scale protein expression profiles and biomarker detection. here we applied this novel technology to identify specific biomarkers for acute cardiac allograft rejection. methods. cardiac allografts of c bl= mice were placed into fully mhc-mismatched c h=he recipients. syngeneic transplants served as controls. protein expression analysis was performed using fluorescence two-dimensional difference gel electrophoresis ( d-dige) on day six post transplant. spots of interest were subjected to nanospray ionization tandem mass spectrometry (ms=ms) for protein identification. expression of selected proteins was confirmed by western blot analysis. results. median graft survival of untreated hearts was . ae . days whereas all syngeneic animals showed indefinite graft survival > days. analysis of the d-dige gels revealed a total of protein spots that were significantly regulated by more than . -fold during acute rejection when compared to syngeneic controls. spots with highest altered regulation identified with ms=ms were derived from coronin a, vimentin, protein disulfide isomerase a precursor, skeletal muscle lim-protein , aconitate hydratase, and fumarate hydratase. peroxiredoxin and pyruvate kinase isozyme m were selected for further analyses. western blotting and immunohistochemistry showed significantly higher expression of these proteins during acute rejection compared to syngeneic grafts. conclusions. this study demonstrates that proteomics is a powerful method to detect biomarkers of acute cardiac allograft rejection. identified proteins like peroxiredoxin and pyruvate kinase isozyme m represent novel indicators of acute rejection and may become useful surrogate markers for monitoring the alloimmune response. impact of endothelin-a receptor blockade on myocardial gene expression post mi w. dietl , g. mitterer , m. bauer , k. trescher , w. schmidt , b. k. podesser background. despite promising experimental results of endothelin-a (et-a) receptor blockade in treatment of heart failure (hf), clinical trials failed to confirm these findings. in order to elucidate this discrepancy, we decided to evaluate the impact of et blockade on myocardial gene expression (ge) post myocardial infarction (mi). methods. mi was induced in male sprague-dawley rats using lad ligation. three days post mi, rats were randomized to receive either tbc -na or placebo and to survive either or days. sham-operated rats served as control group. prior scarification, rats underwent echocardiography. following excision, hearts were analyzed morphometrically. rna was extracted from non-infarcted areas of the lv. targets for quantification were identified using affymetrix gene chip + technology and subsequently quantified by real time pcr. results. et-a blockade did not influence morphology or hemodynamics on day , while it significantly improved both parameters on day . in contrast, ge analysis revealed that the majority of mi-induced changes in ge occur early after mi, with the majority of genes returning to baseline after days. five days of et-a blockade resulted in an attenuated expression of mi-induced transcripts (e.g. tnc, spp , sparc, mmp ) involved in post-mi remodeling. conclusions. apparently, endothelin receptor blockade influences early post-mi remodeling. this data adds further evidence that timing is crucial in et therapy post mi: administered to early, myocardial wound healing is disturbed and lv function deteriorates. given in time, excessive ventricular remodeling is attenuated and lv function improves. identification of sex-specific targets in experimental heart failure m. bauer , g. mitterer , w. dietl , k. trescher , w. m. schmidt , b. k. podesser background. sex-specific differences have been reported in ischemic heart failure. the aim of the present study was to screen for diferentially expressed genes in experimental ischemic heart-failure using genechip + technology. methods. mi was induced in male (n ¼ ) and female (n ¼ ) sprague-dawley rats by ligation of the lad. and days post-mi, surviving animals were sacrificed and samples of the non infarcted free wall gained to perform transcription analysis. sham-operated males (n ¼ ) and females (n ¼ ) served as control. extracted rna of animals per group was pooled and affimetrix genechip + technology was used to screen for differentially expressed targets. genechips + were analyzed using the mas . algorithm and the following rules employed comparing mi vs. corresponding sham to identify sex-specific targets: ) increase in expression in one sex and a decrease in the other, ) increase in expression one sex and absent in the other, ) decrease in expression one sex and present in the other. results. our strategy revealed targets differentially expressed. of these targets were expressed differentially on day only, on day , only one target was expressed differentially on both and days post-mi. of this targets were selected for further analysis including: keratins, caspase- , aldehydoxidase- , cdkn- a and triadin and will be evaluated using rt-pcr. conclusions. ) there are sex-specific targets in post-mi gene expression. ) this targets can be identified using gene-chip as screening tool. bilirubin rinse suppresses early mapk activation in cardiac ischemia-reperfusion injury r. Ö llinger , p. kogler , f. bösch , c. koidl , r. sucher , m. thomas , j. troppmair , f. bach , r. margreiter background. heme oxygenase- (ho- ) expression is crucial in preventing ischemia reperfusion injury (iri). bilirubin, a product of heme catabolism by ho- at least in part accounts for the protective effects mediated by ho- , however, the mechanisms by which bilirubin mediates these effects remain to be elucidated and strategies to apply the bile pigment are needed. mitogen activated protein kinases (mapk) are activated upon stress and play an important role in the early phase of iri. we hypothesized that in a mouse model of heart transplantation, a brief rinse with bilirubin of the graft before reperfusion would affect mapk activation. methods. isogenic c bl= hearts (n ¼ =group and time point) were harvested, stored in uw solution at degrees for h and then rinsed with bilirubin at . mm or ringer lactctate as a control before anastomosis. anastomosis time was kept constant at min by using a cuff-technique, subsequently thereafter perfusion was restored. samples were collected at various times. western blot analysis was carried out for total (t) and phosphorylated (p) forms of akt, erk = , jnk = and p mapk. p=t ratio was quantified by imagej and statistically analyzed using anova. results. after anastomosis and before any reperfusion phosphorylation of erk and p mapk was increased when compared to h of ischemia allone. this was not seen when grafts were rinsed with bilirubin. further, at min after reperfusion, phosphorylation of all mapks being investigated was dramatically increased when compared to the non-reperfused isografts. at this time point, bilirubin significantly inhibited phosphorylation of erk and jnk (p < . ) as well as p -mapk and akt (p < . ). conclusions. bilirubin rinse of mouse cardiac isografts causes a dramatic decrease of mapk activation associated with the proinflammatory response to the stress of iri. bilirubin rinse of allografts before implantation might be a potent aproach to avoid early organ dysfunction. improvement of myocardial protection by a selective endothelin-a receptor antagonist added to cardioplegia in failing hearts background. ischemia=reperfusion (i=r) injury due to cardioplegic arrest is a problem in patients with reduced lv function. we investigated the effect of chronic versus acute administration of the selective endothelin-a receptor antagonist tbc- na during i=r in failing hearts. methods. male sprague-dawley rats underwent coronary ligation. three days post infarction group (n ¼ ) was administered tbc- na continuously with their drinking water, groups and received placebo. seven weeks post infarction hearts were evaluated on a blood perfused working heart during ischemia and reperfusion. in group (n ¼ ) tbc- na and in group placebo was added to cardioplegia during ischemia. results. at similar infarct size postischemic recovery of cardiac output (group : ae %, group : ae % vs. placebo: ae %; p < . ) and external heart work (group : ae %, group : ae % vs. placebo: ae %, p < . ) group was significantly enhanced in both tbc- na treated groups while recovery of coronary flow was only improved in group (group : ae % vs. group : ae %, placebo: ae %, p < . ). evaluation of blood gas measurements showed enhanced myocardial oxygen delivery and consumption with acute tbc- na therapy. in addition high energy phos-phates were significantly higher and transmission electron microscopy revealed less ultrastructural damage only under acute tbc- na administration. conclusions. acute endothelin-a receptor blockade is superior to chronic blockade in attenuating i=r injury in failing hearts. ultrastructural and biochemical evaluation indicate an improvement in capillary perfusion by acute tbc- na administration during reperfusion resulting in a better cardiac function post ischemia. therefore acute andothelin-a receptor blockade might be an interesting option for patients with heart failure undergoing cardiac surgery. background. except in inguinal hernia with strong fascia, treatment of these hernias requires a reinforcement of the inguinal wall. different methods have been established based on different approaches and different degree of reinforcement: partially (lichtenstein, rutkow=robbins) or totally (rives, stoppa, wantz, tipp, tep, tapp) . in danish and swedish hernia register a surprisingly high number of female (especially femoral) recurrencies were found emphasizing the problem, as mainly lichtenstein procedure was performed. increasing knowledge of reasons of fascial insufficiency give further hints towards using a total reinforcement of the inguinal region. among these procedures the transinguinal preperitoneal hernioplasty with a memory-ring armed polyprolylene patch (polysoft patch tm ) is new and promising. methods. between . . and . . inguinal hernias in patients have been treated by tipp with polysoft patch tm ( bassum-suhlingen, idstein). operation and patient data were recorded prospective. we operated male and female hernias. after - month patients were interviewed with a standard questionaire. = patients ( . %) answered. results. medial, lateral, combined and femoral hernias were done. = recurrent hernias ( . %), = incarcerated hernias ( . %). intraoperative complications: = ( . %). postoperative complications have been bleedings, infection, wound dissections. haematomas= seromas we have seen preperitoneal in cases, subcutaneous in cases. re-operations and punctions have been performed. a hydrocele has been seen in = cases, an ileoinguinal syndrome we have noted in cases (no resection has been performed). under intention of a preperitoneal repair, patients have got another treatment: lichtenstein, rutkow and shouldice procedures. in = patients ( . %) the positioning of the patch was difficult mainly due to very small or fatty anatomy. longterm results ( year postoperative): . % had some pain or heavy pain, . % had occasional pain and . % had little or some movement problems. there was recurrent femoral hernia ( mm hole with fat; months post op), only one patch has been removed because of strong pain in riding or sitting in low seats. conclusions. tipp is a safe procedure which fulfills the requirement of a total reinforcement of the inguinal wall. the memory-ring armed polypropylene patch covers the inguinal region and makes the procedure easier compared to the predecessors (e.g. wantz). results. there were primary and recurrent hernias. in cases local and in spinal anaesthesia was used. no intraoperative complications occured, all meshes could be placed easily. patient had local pain for weeks. at followup patients were symptom-free, had paresthesia and infra-inguinal swelling. conclusions. parietene mesh is easy and fast to use and gives satisfying early results. since part of the mesh will resorb within year long-term results will have to be awaited. light versus heavy meshes for laparoscopic inguinal hernia repair -a biomechanical study the incidence of recurrence, first of all, has been lowered by a laparoscopic technique. methods. during the last years we have operated on patients for incisional and abdominal wall hernias. results. there were men and women with a mean age of . years. we applied an intraperitoneal onlay meshtechnique (ipom) by a laparoscopic way. twenty-three patients had an abdominal incisional hernia, an umbilical hernia, an epigastric hernia, a trocar-hernia and one patient a spigelian-hernia. the diameter of abdominal wall defects was - cm. in patients a parietex composite-mesh has been used, in a proceed-mesh, in a bard composix-mesh and in one patient two  cm timeshes. mesh-size was  cm to  cm . hernia sacs were left in place, hernia contents, mostly omentum, were replaced into the abdominal cavity. meshes were fixed using endo-clips in patients, tacks in and the salute fixation-system in patients. postoperative follow-up includes a control at week, month and year postoperatively. there were no problems during operation. patients were discharged on the second postoperative day. after a mean follow-up of . months ( - months) two patients have a hernia recurrence, three patients had local pain for one month and one patient had an umbilical infection, which could be managed without the removal of the mesh. conclusions. laparoscopic incisional and abdominal hernia repair has a low incidence of complications and shows a rapid postoperative recovery of patients. long-term follow-up is necessary for evaluation of mesh reactions with regard to infection as well as to adhesion formation with the intestine. background. the fixation of hiatal meshes with perforating devices, such as tacks or sutures, can be associated with potentially life threatening complications [ ] . fibrin sealant (fs, tissucol, baxter biosciences, vienna, austria) is successfully used for atraumatic mesh fixation in inguinal and incisional hernia repair [ , ] . the rationale of this study was to test the potential of fs fixation of hiatal meshes in pigs. methods. in general anaesthesia, domestic pigs were subjected to laparotomy and designated meshes (ti-sure, gfe, nuremberg, germany) were implanted at the hiatus. the titanized polypropylene material was found to be favorable in combination with fs in a previous study [ ] . meshes were sealed with ml of fs, which was applied with a spray system. the observation period was weeks in all animals in order to assess tissue integration after the fs was already degraded. results. all meshes showed excellent integration and no sign of dislocation or perforation into the neighbouring organs. histology was used to confirm. conclusions. fs for hiatal mesh fixation provides a safe and effective alternative to perforating fixation devices in an animal model of repair. background. we aimed to assess the incidence for esophageal, cardiac and gastric cancer. methods. annual incidence data and age adjusted rates for the years to were obtained from statistics austria which operates the nationwide austrian cancer registry. according to icd-o- (international classification of diseases for oncology, third edition), the following categories were considered: esophageal squamous cell carcinoma (c , - ), esophageal adenocarcinoma, (c , - ), cardiac adenocarcinoma (c . , - ) and non cardiac gastric adenocarcinoma (with known and unknown subsite, c . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , esophageal and gastric tumors with ill-defined histology and death certificate only (dco)-cases. results. annual incidence of esophageal squamous cell carcinoma increased from cases in to in , peaked in ( cases) towards ( ) , declined towards and cases in and , respectively. from to adenocarcinoma of the esophagus increased fold ( vs. ). the number of unspecified epithelial neoplasms of the esophagus remained stable ( - cases). dco cases, comprising no histological information, were stable from (n ¼ ) to (n ¼ ), decreased until ( cases) and increased in ( cases). from to adenocarcinoma of the cardia increased . fold ( vs. ) and remained rather stable with about cases per year until ; cases were registered. non cardiac gastric adenocarcinomas and gastric adenocarcinomas with ill-defined location decreased . fold ( vs. ) and . fold ( vs. ), respectively. the numbers of histologically unspecified cases of malignant cardia tumors and dco cases remained rather stable (unspecified: in and in ; dco: cases in and cases in ) . gender distribution shows an increase of esophageal squamous cell carcinoma in females (male:female : ¼ . in to : ¼ . in ) and esophageal adenocarcinoma (male: female ratio vs. ; : vs. : ; ratio . vs. . ) and cardiac adenocarcinoma for males ( : vs. : ; ratio . vs. . ) . age adjusted rates per . population of non-cardiac gastric carcinomas decreases for both sexes (data not shown). we observed an increase of esophageal squamous cell carcinoma in females and esophageal and cardiac adenocarcinoma for males and a decrease of non-cardiac gastric carcinomas for both sexes. endoscopic versus open esophageal resection: a prospective case-control study within the learning curve background. esophageal resection for cancer is followed by remarkable morbidity. endoscopic surgery has been established to reduce the physical burden. in our institution endoscopic and open esophageal resection is performed transthoracally (tse) or transmediastinally (lstme) as appropriate. we aimed to compare outcomes of case matched open and minimal access esophageal resection by a case-control analysis. methods. endoscopic minimal access esophageal resection (mae) has been performed since (mae). a retrospective case control study including patients (prospectively collected data) who underwent mae (tse, , lstme, ) has been undertaken with matched (pairs matched for sex, age, tumour type and type of resection) historical open (oe) cases operated between and (transthoracic esophageal resection tte, , transmediastinal esophageal resection tme, ). groups were comparable regarding age, sex distribution, tumour type (as consequence of matching) as well as regarding tumour stage and comorbidities. results. forty patients (males, ; females, ; mean age ae yrs) were included in the study. there were adenocarcinomas and squamous cell cancers. patients had neoadjuvant chemotherapy (fu=cis). duration of surgery, number of resected lymphnodes, duration of intubation, icu stay and hospital stay was vs. min (p ¼ . ), vs. (p ¼ . ), . vs. . days (p ¼ . ), vs. days (p ¼ . ) and . vs. days (p ¼ . ) in the mae and oe group, respectively. due to preexistent anemia = mae patients received erythrocyte substitution preoperatively, = patients of the oe group needed erythrocyte subsitution perioperatively. = and = patients underwent reoperation for a complication in the mae and oe group. overall surgical morbidity was % ( = ) and % ( = ). postoperative pneumonia was observed in = and = among mae and oe patients. conclusions. during the learning curve duration of mae is significantly longer when compared with oe. morbidity was reduced, icu and hospital stay were significantly shorter after mae, regarding duration of postoperative ventilation there was a trend towards mae. oncological quality was comparable between groups with respect to the number of resected lymph nodes. the need for blood substitution and reoperation was higher in open esophageal resection. even during initial establishment mae seems advantageous for the patient in this case-control study. randomised trials are still missing. does the route of gastric pull-up influence the oxygen supply of the anastomosis? background. microcirculation and oxygen supply at the level of oesophagogastric anastomosis following oesophagectomy are among the crucial factors determining anastomotic healing. methods. twenty-nine patients (mean age . yrs) were evaluated during oesophagectomy and on the intensive care unit by inserting a micro-probe (licox) and continuously recording the interstitial po of the tubulated stomach in the anastomotic region. two different surgical procedures were applied: group ( = ) had gastric pull-up via a retrosternal, group ( = ) via an orthotopic route. the interstitial po values were averaged over specific consecutive periods: intraoperatively after ligation of the short gastric vessels, after ligation of the left gastric artery, after forming the conduit and after gastric pull-up. postoperative measurements were recorded during intubation, while breathing oxygen by mask or by nose delivery, respectively and finally while breathing air. results. before ligating the left gastric artery the interstitial po -levels were significantly higher (mean . mmhg) than after ligation (mean . mmhg; p < . ). comparing the retrosternal ( . mmhg) versus the orthotopic pull-up route ( . mmhg) a significant difference (p < . ) in favour of the orthotopic route could be found after gastric pull-up as well as during each postoperative measurement period. no differences could be detected when comparing the various oxygen supply systems. conclusions. these data suggest that the oxygen supply at the anastomosis of the pedicled gastric conduit reaches higher levels after orthotopic than following retrosternal gastric pull-up. p tailored therapy for esophageal cancerpilot study in reported -year survival rates of % in this group. factors identifying this subgroup of responders and selecting optimal drugs for non responders could dramatically enhance treatment efficacy. several studies suggest that mutations in the p gene may induce drug resistance especially for agents whose effect is based on apoptosis induction, like cisplatin. methods. in order to test the hypothesis that the p genotype is predictive for chemotherapy response, a prospective study was conducted. thirty-eight patients with potentially respectable esophageal cancer were evaluated for the relation between p genotype and response to two different neoadjuvant treatments. p gene mutations were assessed by complete direct sequencing of dna extracted from diagnostic biopsies. response to neoadjuvant chemotherapy was assessed pathohistologically in the surgical specimen. results. twenty squamous cell carcinoma and adenocarcinoma were included. overall the p mutation rate was % ( = ), with % for squamous cell and % for adenocarcinomas, respectively. patients received cis= fu (cisplatin mg=m d -fu mg=m d - , q , cycles), received docetaxel ( mg=m , q , cycles). the overall response rate was % ( = ). patients with p mutation did not respond to cis= -fu ( = ), while all mutant patients responded to docetaxel ( = ). the overall response to p adapted neoadjuvant therapy was %. p adapted treatment was associated with a significant survival advantage (p ¼ . ) after a median follow up of . months. conclusions. a prospective randomized trial was initiated to test the interaction between the predictive marker p and response to respectively. a new method of anti-ischemic graft protection in retrosternal colon esophagoplasty a. albokrinov , a. pereyaslov , r. kovalskiy lviv children's regional clinic hospital, lviv, ukraine; lviv d. halytsky national medical university, lviv, ukraine background. retrosternal colon esophagoplasty is the operation of choice in infants with esophageal atresia with great diastasis. although complications are rare, some cases of graft ischemia are registered. epidural block have beneficial effect on splanchnic blood flow because of drug sympathectomy. methods. we retrospectively analyzed rate of graft ischemia in infants with retrosternal colon esophagoplasty and conventional postoperative course with anticoagulants and antiaggregants (group , n ¼ ). group , n ¼ was investigated prospectively with preoperative catheterization of epidural space (th -th level, lost of resistance test, g size) and . % bupivacaine administration in daily dose of . mg=kg every h. the rest of therapy was equal in all patients. graft status was determined visually. gut motility was considered to restore when stool have been obtained. results. rate of graft ischemia was significantly lower in group then in group ( vs , p < . ). besides this, gut motility restoration in group was significantly earlier ( . ae . vs . ae . days, p < . ). conclusions. epidural block with local anesthetic is an effective method of anti-ischemic protection of neo-esophagus and powerful instrument in gut motility restoration. background. atrial fibrillation (af) is often associated with thromboembolic complications, heart failure and stroke; in addition an increase in mortality, even with adequate anticoagulation, is observed. the maze operation is an effective and accepted method to terminate af, nevertheless the risk for intraoperative bleeding is increased compared to left atrial ablation procedures using variable energy sources. left atrial ablation is an alternative method to convert af into sinus rhythm (sr), as with this procedure linear lesions connecting the four pulmonary veins and the posterior mitral annulus are created with microwave or high frequency technique. methods. a consecutive series of patients ( females, males; age a, range - a) underwent ablation during various cardiac surgical procedures between and . endocardial ablation using either microwave or radiofrequency energy was performed times ( . %) and epicardial with microwave energy in five cases ( . %) . preoperative parameters: ejection fraction . % ae . %; diameter left atrium . ae . mm. forty-one patients underwent mitral valve repair (mvp), patients obtained mitral valve replacement (mvr), patients received aortic valve replacement (avr), patients underwent coronary bypass surgery (cabg) and patients had combined valve surgery (others). results. others combined valve replacement: mvr þ tvp, mvr þ avr; af atrial fibrillation; aflut atrial flutter; pm pace maker no intraoperative or postoperative complications related to the concomitant ablation procedure were observed. one patient died because of multiple organ failure. after a mean follow up period of months ae patients remained in sr ( . %), patients into af ( . %), patients changed rhythm into atrial flutter ( . %) and one patient required a pace maker ( . %). conclusions. in approximately two thirds of patients left atrial ablation is effective in restoration and maintenance of sr in patients with structural heart disease and af. this method represents a valid alternative to the maze technique, reducing myocardial ischemic time and risk of bleeding. midterm results are promising; however for determination of a long term benefit especially regarding thromboembolic events, a higher number of patients and a longer follow up period are desired. background. the study aim was to evaluate the efficacy and outcome of endocardial and epicardial atrial fibrillation (af) ablation in patients undergoing heart surgery. methods. between february and december , patients (mean age years, range - ) underwent left atrial ablation combined with other type of cardiac surgery. in patients endocardial left atrial ablation using a unipolar radiofrequency device (cardioblate tm , medtronic, usa) was performed, mainly in combination with mitral valve (mv) surgery ( mv repair, mv replacements) . in patients epicardial pulmonary vein isolation using microwave energy (flex tm , guidant-boston scientific, usa) was done during aortic valve replacement ( ) and bypass grafting ( ) . indication for atrial ablation was permanent af in all patients. endocardial ablation was performed during extracorporal circulation (ecc) with a mean time of min ( - ), epicardial ablation before ecc with a mean ablation time of min ( ) ( ) ( ) ( ) ( ) ( ) . % of the patients ( ) received amiodarone postoperatively, % ( ) betablocker. patients underwent epicardial cardioversion with synchrus tm (guidant, usa) wires postoperatively. results. the overall mortality was . % ( patients during mv replacement due to posterior bleeding) complications were posterior rupture ( ) , lco with the need of intraaortoc pallon pump ( ), resternotomies for bleeding, and and ( %) pacemaker implantations ( . %). there were no ablation procedure related complications. sinus rhythm (sr) was achieved in % after operation, % at discharge and % at the month follow up. a nodal rhythm was found in % after operation, % at discharge and in % after months. patients developed atrial flutter ( in the group of endocardial and in the group of epicardial ablation). af persisted in % of the patients at month. conclusions. af ablation combined with cardiac surgery is safe and effective. recurrent af is frequent during the first three months after ablation also under therapy with antiarryhthmic drugs. background. patient-prosthesis mismatch is a frequent cause of high postoperative mortality and gradients. the objective of this study was to determine whether mismatch can be predicted at the time of operation. methods. indices used to predict mismatch were valve size, indexed internal geometric area and projected indexed effective orifice area (eoa) calculated at the time of operation, and results were compared with the indexed eoa measured by doppler echocardiography after operation in patients. results. the sensitivity and specificity of these indices to detect mismatch, defined as a postoperative indexed eoa of . cṁ =ṁ or less, were % and % for valve size % and % for indexed internal geometric area, and % an % for projected indexed eoa. conclusions. the projected indexed effective orifice area calculated at the time of operation accurately predicts mismatch, where as valve size and indexed internal geometric area cannot be used for this purpose. excellent long-term results after emergency cardiac surgery d. martin, a. yates, h. mächler, l. salaymeh, d. dacar, b. rigler division of cardiac surgery, department of surgery, medical university of graz, graz, austria background. data from all adult patients undergoing emergency heart surgery between and at the division of cardiac surgery, medical university of graz, austria, were reviewed retrospectively. methods. data were stored in a local cardiac surgery database. the registery included all relevant patients data and euro-score. no patient was lost to follow-up. a series of relevant perioperative data were collected. recorded complications were use of the intra-aortic balloon pump (iabp) and low cardiac output syndrome. hospital and late mortality data were collected from the austrian national populations register. multivariante analysis was performed to determinate predictors for cardiac related death. results. between and patients underwent emergency cardiac surgery at our institution. there were men ( . %) and women ( . %) with an average age of . years. coronary artery bypass was performed in . %, . % combined valve and bypass, . % valve, . % aortic dissection and . % had other procedures. eighty-seven patients ( . %) had a postoperative low cardiac output syndrome. the intra-aortic balloon pump was used in patients ( . %). variables identifying as high risk for perioperative cardiac related death were diagnosis other then coronary artery disease, patients with iabp and high catecho-lamine demand. there were no postoperative wound infections. eighteen patients ( . %) had excessive postoperative bleeding and ( . %) required a late re-intervention. hospital mortality was . % and the late mortality after years was . %. conclusions. the hospital mortality was higher in the emergency group but there was no difference in the long-term results for elective and emergency surgery. early mortality was significant higher in patients operated for other reason than coronary artery disease. background. acute renal failure is a serious adverse event after cardiac surgery, which is associated with high perioperative mortality and prolonged hospitalization. the aim of our study was to evaluate pre-and intraoperative risk factors for the development of acute renal failure requiring hemofiltration (arf) after cardiac surgery. the influence of different methods for evaluation of renal function was investigated. methods. from = through = , patients underwent cardiac surgery at our institution. patients developed arf ( . %), patients suffering from chronic end-stage renal insufficiency were excluded from the study. patient characteristics and operative variables were analyzed. a multivariate logistic regression analysis was performed to determine risk factors for arf. results. patients, who developed arf, were older (p < . , or: . ) as compared to patients who did not develop arf. furthermore, diabetes mellitus (p ¼ . , or: . ), peripheral artery disease (p ¼ . , or . ), cardiogenic shock (p ¼ . , or: . ), congestive heart failure (p ¼ . , or: . ) und emergent surgery (p ¼ . , or: . ) were predictive for development of arf. preoperative serum creatinine was not predictive for arf (p ¼ . , or: . ). classification of preoperative serum creatinine into normal ( . mg=dl), slightly elevated ( . to < mg=dl) and severely elevated (! mg=dl), reveals a correlation with the development of for severely elevated creatinine levels (p ¼ . , or: . ), as well as for slightly elevated levels (p ¼ . , or: . ). calculation of creatinine clearance mwith the cockcroft-gault formula demonstrated a strong correlation with the development of arf (p ¼ . , or: . ). calculation of creatinine clearance with the mdrd formula, however, failed to reveal any correlation with (p ¼ . , or: . ). conclusions. our data indicate, that advanced age, diabetes mellitus, peripheral artery disease, cardiogenic shock and congestive heart failure, as well as emergent surgery independently predict arf after cardiac surgery. even slightly elevated creatinine levels are a risk for the development of arf after cardiac surgery. calculation of creatinine clearance with the cockcroft-gault formula is more suitable for preoperative risk stratifica-tion as compared to calculation of creatinine clearance with the mdrd formula. background. the matricellular protein tenascin-c (tn-c) induces production of matrix metalloproteinases (mmps), inhibits cellular adhesion and mediates cellular deadhesion. these effects are crucial in the dynamic process of cardiac remodeling. it has been reported that tn-c expression is up-regulated in ventricular remodeling following myocardial infarction (mi) in the border zone between scar tissue and non-infarcted area. we analysed the expression of tn-c in the post mi infarcted and non-infarcted area after the treatment with the selective endothelin a (et a )-receptor antagonist tbc -na. blockade of the et a -receptor decreases cell proliferation, lv hypertrophy, and secretion of pro-inflammatory mediators. methods. mi was induced in male sprague dawley rats by lad ligation. three days post mi, rats were randomised to receive either the endothelin antagonist tbc -na (n ¼ ) or placebo (n ¼ ), as control rats were sham-operated without lad ligation (n ¼ ). after days hearts were harvested and tissue samples from scar, peri-infarct and free wall were analysed by western blot using a monoclonal antibody specifically recognizing the egf like domain of tn-c. tissue was homogenized in urea buffer and protein samples were subjected to % polyacrylamide gel sds-page, transferred on to a membrane and immunostained with the anti-tn-c monoclonal antibody and antimouse alkaline phosphatase antibody. additionally on day and echocardiography and morphological analysis were performed to assess the effect of tbc -na therapy on cardiac function. results. infarct size was comparable in all groups (et agroup . ae . %, placebo group . ae . %). during early remodelling on day , in the placebo group, tn-c was upregulated in scar tissue. in contrast, in the et a -group, tn-c was down regulated in scar tissue. on day post mi, no differences were seen in the tn-c levels. echocardiography showed significant improvements in hemodynamics in the et a -group in contrast to controls. conclusions. from these results, we can conclude that ( ) endothelin-a receptor blockade attenuates the development of heart failure post mi, ( ) reduction of tn-c expression seems to have a positive effect on postinfarct remodeling, ( ) tn-c regulation is influenced by et a -blockade and ( ) that tn-c is a marker for lv remodeling after myocardial infarction. background. diabetes is a risk factor for neurocognitive and neurological complications after cardiopulmonary bypass. we sought to determine if temperature management during cardiopulmonary bypass (cpb) affects the incidence of neurocognitive and neurological complications in diabetic patients. methods. in this prospective randomized study, we measured the effects of mild hypothermic ( c, n ¼ ) vs. normothermic ( c, n ¼ ) cpb on neurocognitive function. all patients underwent elective coronary artery bypass grafting (mean age . ae . years, mean es . ae . ) . neurocognitive function was objectively measured by objective p auditory-evoked potentials before surgery, week and months after surgery, respectively. clinical data and outcome were monitored. results. p evoked potentials were comparable between patients operated with mild hypothermic ( ae ms) and normothermic cpb ( ae ms) before the operation (p ¼ . ). patients operated with mild hypothermic cpb, showed marked impairment ( ¼ prolongation) of p evoked potentials week ( ae ms; p< . ) and months ( ae ms; p ¼ . ) after surgery. in contrast, patients operated with normothermic cpb did not show impairment of p evoked potentials week ( ae ms; p ¼ . ) and months ( ae ms; p ¼ . ) after surgery. group comparison revealed prolonged p peak latencies in the patient group operated with mild hypothermic cpb (p ¼ . ) week after surgery. four months postoperatively, no difference between the two groups could be shown (p ¼ . ). operative data and adverse events were comparable between the two groups. conclusions. normothermic cardiopulmonary bypass reduces neurocognitive deficit in diabetic patients undergoing elective coronary artery bypass grafting. ergebnisse. die paclitaxelbehandlung führte zu einer dosisabhängigen reduktion der intimalen hyperplasie im vergleich zur kontrollgruppe (p ¼ . bei mmolar, p ¼ . bei mmolar, p ¼ . bei mmolar und p ¼ . bei mmolar). in der elasticafärbung fanden sich sowohl in der media als auch in der intima meist nur vereinzelte elastische fasern, wohingegen sich in der trichromfärbung in der media insbesondere subintimal reichlich kollagene fasern fanden, die intima selbst jedoch hierfür negativ blieb. immunhistochemisch zeigte sich die media und die intima praktisch vollständig positiv für sma. bei der desmin-färbung fand sich die media ebenfalls fast durchgehend spezifisch positiv für desmin, die intima hingegen färbte sich hierfür jedoch in unterschiedlichen ausmaß ( - %) an. in der proliferationsfärbung mit ki zeigten sich vorwiegend die längsverlaufenden muskelfasern der media stark proliferierend, wohingegen der subintimale mediabereich und die intima nur vereinzelt ki positiv war. schlussfolgerungen. paclitaxelbehandlung reduziert die intimale hyperplasie in der vena saphena im organkulturmodell. elastische fasern, kollagenfasern, sma positive und desminpositive zellen sowie ki positive (proliferierende) zellen weisen unterschiedliche bevorzugte lokalisationen innerhalb der gefässwand auf. heat shock proteins = = = = = = = = = a and s proteasome in on-versus off-pump coronary artery bypass graft patients background. heat shock protein (hsp) , hsp , hsp , hsp and s immune-proteasome are known chaperons. they play a prominent role in housekeeping processes, in the intracellular regulation of the immune system and in apoptosis. serum levels of circulating chaperons are not known in patients undergoing the on-versus off-pump coronary artery bypass graft (cabg) procedure. methods. forty patients were prospectively included in the study (on-vs. off-pump cabg, each n ¼ ). elisa technique was utilized to detect levels of soluble hsp , , , and s immune-proteasome in serum samples. results. on-pump cabg procedure is associated with an increased leakage of heat shock proteins into the vascular bed when compared to off-pump cabg technique. these differences were highly significant for hsp , and min after initiation of cardiopulmonary bypass (cpb) (all, p< . ). concentrations of soluble s immune-proteasome were increased h after operation in on-and off-pump cabg patients (p < . ) and correlated significantly with the serum content of hsps , and at min after initiation of cpb (p < . ). conclusions. our data evidence the spillage of chaperons, normally intracellular restricted proteins, into the systemic circulation. as these proteins are related to immunomodulatory and apoptotic processes, we conclude that the innate immune system is more activated in on-pump as compared with off-pump cabg patients. however, the precise immunological consequence and interpretation requires further investigations. background. in the treatment of ruptured abdominal aortic aneurysm (raaa) the results of open graft replacement (ogr) remained constant but discouraging over the last four decades. provided patients have a suitable vascular anatomy, elective endovascular abdominal aortic aneurysm repair (evar) turned out to be less invasive than ogr and led to improved perioperative mortality especially for patients with severe comorbidities. thus, it is reasonable to assume that endovascular treatment should improve the results of patients with risk factors heavily impaired by rupture of their aaa. the purpose of this study was to test whether the use of both endovascular and open repair for raaa was able to improve results. methods. retrospective analysis of a consecutive series of patients presenting with raaa from october, , until july, . observation period was divided in two periods of months, respectively. during the first period patients were treated by ogr exclusively. period two started with the availability of an evar protocol to treat raaa, according to which patients received open repair while patients underwent evar. kaplan-meier survival estimates were calculated and possible differences were analyzed by log-rank and wilcoxon-test. results. kaplan-meier survival estimates revealed a statistically significant reduction in overall postoperative mortality following the introduction of evar in (p < . ). ninety day overall mortality was reduced from . % during period one to . % during the second period (p < . ). especially survival of patients older than . years was improved ( % vs. . %, p < . ). in parallel there was a significant reduction of the day mortality rate after ogr from . % (i.e. overall mortality) to % (p < . ). conclusions. offering both evar and ogr in the treatment of raaa led to significant improvement of postoperative survival. especially older patients seem to benefit from the less invasive endoluminal technique. fast track concept for infrarenal aortic aneurysm repair c. senekowitsch , r. schwarz , a. assadian , w. hartmann , g. hagmü ller background. the aim and main benefit of the fast track concept in surgery are increased patient comfort and reduced perioperative morbidity and mortality. in abdominal surgery, this concept has proven efficient. we present our experience of fast track aortic surgery. methods. retrospective analysis of prospectively collected data. since initiating this method of perioperative patient management in january , patients underwent infrarenal aortic reconstructions for aortic aneurisms applying the fast track concept. this comprises of modified nutrition and fluid management, anaesthesiological management and a special retroperitoneal access allowing aggressive postoperative mobilisation. results. patients were included in the study, their mean age was years (range - years) none of the patients had surgical complications, no mortality was observed. the icu days were reduced to for all patients. the mean hospital stay was days (range - days). conclusions. hospital stay and icu days could be reduced dramatically compared to standard therapy at our institution. this new concept in aortic surgery is a valid alternative to evar for selected patients. aneurysma der a. lienalis: fallbericht über interventionell-chirurgisches management e. gü nen, j. demmer, c. groß department of cardio-thoracic and visceral surgery, general hospital linz, linz, austria aneurysms of splenic arteries are seldom ( . % of all aneurysms). nevertheless they are disastrous when ruptured since they bleed into the free abdominal cavity without any means of self-tamponade. occurrence of splenic aneurysms is related to female gender, esp. after multiple gravidities. these aneurysms are usually symptomless and tend to rupture during labour pains. this fact explains the reports on ruptured splenic aneurysms in young women from developing countries whereas in western countries most findings are incidental in routine imaging scans. we report on a yo female from chechnya with a huge splenic aneurysm and splenomegaly. she complained about chronic fatigue and nausea. splenomegaly and a pulsating growth in the mid epigastrium were palpable in the physical examination. the wbc blood counts showed severe pancytopenia. ct-scan revealed a calcified aneurysm (Ø cm) of a tortous splenic artery and an enlarged spleen ( cm). we decided to occlude the origin of splenic artery interventionally and and to perform a ''lone splenectomy'' leaving the unperfused aneurysm in situ. the intervention achieved total angiographic occlusion. however during surgery the aneurysm was still under pulsatile pressure. the pulsation ceased on surgical ligation of the proximal splenic artery. subsequently the splenectomy was performed. the patient recovered without surgery related complications. a year after surgery she has normal blood counts. the aneurysm has not shrunk but shifted to left to adopt the space left over by the spleen. background. the transilluminated powered phlebectomy (tipp; trivex + , smith and nephew) was introduced in the year in our hospital. trivex + is a procedure for minimal invasive vein surgery including an illuminator device, a powered vein resector, a light source and a controll unit. the use of tumescent solution allows hydrodissection and facilitates ablation (rotating inner blade of vein resector combined with suction). methods. in an retrospective study we report patients ( males and females; mean age . years; limbs) treated with this technology during the years and . we used a combination stripping the saphenus veins ( ligations of the sapheno-femoral junction, ligations of the popliteo-femoral junction) or ligations of perforantes ( ) if necessary according to sonography. twenty-seven patients underwent single trivex + treatment. . % were done in general anaesthesia. a follow up is proposed to all patients after to months ( patients, . %). results. the average time of surgical treatment was . min, with single trivex . min. the trivex + procedure for one single leg took about min. the average stay was . days. regarding to postoperative complications one patient experienced laceration of the femoral vein ( . %), one profound bleeding caused a revision the same day ( . %). patients developed lokal wound infektion within the first weeks ( . %). during the follow up period complications like swelling ( ), seroma ( ), brown scars ( ), nerve injury=numbness ( ), haematoma ( ) occured. there was no skin perforation, no phlebitis, none of our patients died. conclusions. according to these results the trivex + procedure seems to be a quick and safe treatment for minimal invasive removement of superficial varicosities. background. this randomized, patient and observer blinded trial compared early postoperative outcomes in saphenectomy with either a new bipolar coagulating electric vein stripper (evs) or invagination stripping. methods. the primary outcome was pain at rest and following physical stress (climbing stairs), as assessed by a visual analog scale (vas) h after surgery. secondary outcomes included haematoma formation (diagnosed and measured by ultrasound), duration of postoperative compression, and disability. quality of life was assessed by a disease-specific chronic lower limb venous insufficiency questionnaire (civiq), and the generic short form (sf- ). results. two hundred patients were assigned to three vascular centers, with patients randomized to the evs and to the conventional arm. there were no complications or conversions. pain at rest averaged . in the evs and . in the conventional group (mean difference . , per cent confidence interval (c.i.) . to . , p < . ). following physical stress, mean ratings were . and . (mean difference . , per cent c.i. . to . , p < ). no measurable haematoma was found in the stripping canal of the evs group, while in the conventional arm patients had haematomas within this region (risk difference per cent, per cent c.i. to percent). duration of compression therapy was significantly decreased in the evs group (mean difference days, per cent c.i. to days). in the evs group, patients returned to work after week and after weeks, compared to and patients in group . civiq and sf- ratings favored the evs. conclusions. the evs is a safe instrument. it is effective in avoiding painful haematomas following saphenectomy, reduces recovery time and improves patients' ratings of quality of life. elt in combination with pin stripping in the treatment of epifascial truncal veins a. j. flor background. in the treatment of varicose truncal veins, endolaser treatment has widely been accepted as the method of choice. yet laser treatment -in particular in epifascial veins -may result in a painful contraction. we examine the functional and cosmetic results as well as the patients' comfort, combining elt and pin stripping in patients with epifascial truncal veins. methods. preoperative evaluation is carried out by color duplex sonography. emphasis is laid on patients with a partially epifascial course of the greater saphenous vein (gsv). following extensive evaluation and information of the patient, the decision is made to use endolaser treatment (biolitec, nm) in combination with pin-stripping (retriever-pin by oesch, salzmann medico). a guiding wire is inserted, duplex-controlled or through miniphlebectomy, into the gsv at the point of perforation through the fascia. a laser fiber is then positioned at the sapheno-femoral junction, and laser energy is applied to the intrafascial part of the truncal vein ( - j=cm) depending on the vein diameter. the epifascial part of the vein is then retrieved by the pin stripper. results. until now the combination of endolaser plus pin stripping has been applied in patients. following observation periods of to months, endolaser treatment provides an occlusion rate of %. skin incisions need not be wider than mm. crossectomy can be avoided. patients tend to have more hematomas in the pin-stripped region, yet a hardened, sometimes brown coloured and often painful strand -as often seen in patients treated by endolaser only -can be avoided thereby. conclusions. in about - % of the cases, an epifascial position of the gsv might been detected by duplex sonography. in cases of epifascial course of the truncal vein, decision to use elt treatment alone should be considered critically. in such cases, endolaser treatment combined with pin stripping should result in a higher degree of patient comfort, apparently providing an optimal solution for a minimally-invasive approach. endovenous laser treatment with the nm laser system; years of experience, follow-up of over veins k. freudenthaler background. chronic venous insufficiency is a common desease. the aims are to offer a minimal invasive alternative to traditional surgery such as crossectomia and stripping with less pain for the patient and a short reconvalescence. methods. since years over patients with more than veins have been treated by evlt, by grand saphenous veins a valve repair by venocuff ii was possible. only patients have been treated by traditional crossectomia and stripping. usually the grand and the short saphenous vein as well as the acessoria vein, insufficient perforaters and the giacomini anastomosis are treated by evlt. the treatment is done in general or in local anaesthesia and monitored by permanent ultrasound control. in no case a surgical crossektomia was necessary. after treatment the patient has to wear a compression stocking for two weeks dayover and should not lift heavy duties. results. after treatment the results are verified by ultrasound. the patients are controlled after one week, month and yearly thereafter. the total sucess rate is % in all cases (complete resorption of the treated vein). there were no complications like pulmonal embolia, infects or skin burns. conclusions. the evlt is a very safe treatment of chronic venous insufficiency and offers a minimal invasive alternative to traditional surgery such as crossektomia and stripping. Ö sterreichische gesellschaft fü r chirurgische forschung: die zukunft hat schon begonnen -bedeutung der molekularen biologie fü r diagnostik, prognose und therapie in der gastrointestinalen chirurgie proteomic profiling of the secretome of human liver endothelial cells (hlec) background. liver endothelial cells play significant roles in the physiology and pathology of the liver. they are not simply barrier cells regulating the traffic of blood components to the parenchyma and vice versa, but highly specialized cells with complex roles, including scavenger functions and regulation of inflammation, leukocyte recruitment and host immune responses to pathogens and shaping of the microenvironment by secretion of functionally relevant proteins. thus, investigation of the functional and physiological properties of lec is critical in understanding liver biology and pathophysiology. the aim of this study was to establish techniques to isolate and cultivate human liver endothelial cells and to obtain a protein profile of the secretome of quiescent and vegf-activated hlec. methods. hlec from unaffected tissue of resected liver segments from patients undergoing surgery for liver tumours were isolated using magnetic beads coated with anti-cd -antibodies. cells where cultured in medium ebm- (mv) supplemented with vegf, bfgf, igf, egf, heparin, endothelial cell growth supplement and % fetal calf serum. expression of endothelial cell surface markers cd , cd , cd e, cd and podoplanin as well as fibroblast marker cd was investigated by facs. hlec where starved for h in protein free medium and activated with vegf for further h. supernatants were collected and subjected to shotgun proteomics. human umbilical vein endothelial cells (huvec) served as a control. results. isolated cells where morphologically similar to huvec. % of cells where positive for cd , cd , and cd . % expressed cd . % of cd positive cells where positive for podoplanin. expression of cd was low, but consistent. cd e was induced in % of cells and expression of cd was upregulated fold after h activation with tnf-. shotgun proteomics of the secretome revealed a distinct differ-ence in the secretion pattern of several functionally relevant proteins compared to huvec. conclusions. our results point towards a significant and persistent difference in secretion patterns of functionally relevant proteins between hlec and other endothelial cells both in quiescence and after vegf activation. these findings may lead to a better understanding of physiology of the liver. finally, this study demonstrates the suitability of magnetic bead isolation in combination with in vitro cell culture and proteomics for investigation of hlec functions. hypermethylation of sfrp gene in stool dna test: a future technology in colorectal cancer screening w. zhang, w. hohenberger, k. matzel background. stool dna test is considered as a future technology in screening for colorectal cancer (crc). both genetic and epigenetic changes in shed cells from gastrointestinal tumours into stool could be detected. epigenetic hypermethylation can result in transcriptional silencing of tumour suppressor genes and is considered to be a key event of sporadic colorectal carcinogenesis. sfrp is a tumour suppressor protein that contains a domain similar to one of wnt-receptor proteins and inhibits wnt-receptor binding to its signal transduction molecules. detection of hypermethylation of sfrp gene in human dna isolated from stools might provide a novel strategy for the detection of sporadic crc. our study aims to prove the methylation status of sfrp gene in stool samples, and compare the dna methylation status before and after neoadjuvant radiochemotherapy. methods. to explore the feasibility of stool dna test, fecal samples were obtained from crc patients (crc patients post neoadjuvant radiochemotherapy n ¼ ). twenty fecal samples were obtained from patients without evidence of gastrointestinal disease or neoplasia. isolated genomic dna from stool was modified with sodium bisulfite and analyzed by specific pcr for methylation of sfrp promoter. results. with stool dna test we were able to detect the hypermethylation in the promoter region of sfrp gene in the fecal dna from colorectal cancer patients (p ¼ . ). sensitivity was %, specificity was %. methylation status of sfrp gene was significantly changed after neoadjuvant radiochemotherapy (p ¼ . ). conclusions. the hypermethylation of sfrp gene in the stool dna test has a high sensitivity and specificity for crc and may be valuable for screening purposes, especial for the sporadic crc. compared with current colorectal cancer screening methods, stool dna test is more patient-friendly, non-invasive, more sensitive and specific. the cost-effectiveness of screening may also be improved by using single dna stool test with one sensitive dna marker. the methylation status of sfrp seems to be changed after neoadjuvant radiochemotherapy, which may open new fields for crc research. summarized this new diagnostic tool may yield ben-efits in earlier detection and in the design of better antitumour interventions. background. although the function and interaction partners of the glycoprotein dickkopf- (dkk- ) still remain unclear, gene expression of dkk- has been shown to be upregulated in tumor endothelium of colorectal cancer. for the first time, we analyzed expression of dkk- protein and its potential as a marker of neoangiogenesis in colorectal cancer. methods. we utilized tissue microarrays (tmas) to evaluate dkk- protein expression in microvessels of colorectal cancer samples from patients, in microvessels of adjacent tissue samples from the same patients compared to normal colorectal mucosa tma samples. a second microarray section was stained with cd to quantify neoangiogenesis by defining the microvessel count. results. out of cancer samples with cd positive microvessels, . % were dkk- positive in all microvessels. these samples showed a significantly higher mean microvessel count ( . vessels) than dkk- negative samples ( . vessels; p ¼ . ). dkk- protein expression increased with rising numbers of microvessels per sample (p < . ). out of cd positive adjacent tissue samples, % were dkk- positive. these samples also had a higher mean microvessel count ( . vessles) than dkk- negative samples ( . vessels; p < . ). similar to colorectal cancer tissue, dkk- expression in non-cancerous adjacent tissue increased with rising numbers of microvessels (p < . ). in contrast, all microvessels in normal colorectal mucosa samples demonstrated a negative staining reaction for dkk- . univariate analysis of several clinicopathologic variables in correlation to dkk- expression revealed significant differences in tumor site (colon vs. rectum; p ¼ . ) and mean age (p ¼ . ). survival analysis according to kaplan-meier method showed a statistical trend toward a higher diseasefree survival for patients with dkk- negative samples (p ¼ . ). conclusions. our study demonstrates for the first time that microvessels of colorectal cancer and adjacent non-cancerous tissue are identical concerning dkk- protein expression, but distinct from normal colorectal mucosa. therefore, dkk- can be considered as a putative pro-angiogenic protein in the process of neovascularization, may have the potential to serve as a marker for neoangiogenesis, and may represent a target structure for novel therapeutic approaches. nevertheless, it is mandatory to further confirm these findings using normal tissue sections. background. we have developed the first genetically engineered oncolytic influenza a viruses (ns deletion viruses), which replicate and lyse cancer cells but are apathogenic in normal tissue. infection of influenza a viruses are usually highly dependent on the presence of a serine-like protease (i.e. trypsin), which cleaves the viral entry protein, the hemagglutinin. cancer cells are known to endogenously produce proteases. methods. we here investigate, whether colon cancer associated proteases support lytic growth of the oncolytic influenza viruses in those cells. results. ns deletion viruses grew to high titers in the colon cancer cell lines caco or ht- independent of the addition of trypsin. correspondingly, viral infection rate, cleavage of the hemagglutinin and virus-induced cytopathic was not compromised by the lack of trypsin in these cell lines. zymogram analysis indicated that the caco and ht- associated protease is not trypsin itself but trypsin unrelated. conclusions. the specific activation of the influenza a virus in colon cancer cell lines suggests an effective use of this virus for oncolysis in colon cancer in vivo. background. for decades the bile pigment bilirubin has been considered a toxic waste product of heme catabolism. however, serveral clinical studies show an inverse correlation between elevated plasma bilirubin levels in healthy individuals and the incidence=mortality of colorectal cancer. based on these findings, we hypothesized that bilirubin and its precursor biliverdin may suppress tumor cell growth in vitro and inhibit tumor progression in vivo. methods. in vitro hrt- colon cancer cells were treated with bilirubin at various concentrations or pbs as a control. a casy cell counter was used for proliferation assays. cell cycle progression and apoptosis were analyzed by facs. western blot analysis was carried out using antibodies directed against p , rb, p , parp- and caspase as well as total and phosphorylated forms of erk, mek and akt. further, cells were treated with pharmacological inhibitors of mek and pi -kinase in presence or absence of bilirubin. in vivo, nude mice bearing hrt- tumors were treated with bilirubin i.p. at mg=kg=day or pbs as a control. tumor size was measured using a caliper. statistical analysis was performed using anova. results. bilirubin significantly inhibited proliferation of hrt- colon cancer cells in a dose dependent manner. this mainly was mediated by induction of g =g cell cycle arrest and apoptosis through strong activation of akt, mek and erk resulting in overexpression of the cell cycle regulators p , p , hypophosphorylation of rb as well as an increase of parp- and caspase cleavage. the antiproliferative effects were dependent on akt and erk activation, in that inhibition of upstream pi -kinase and mek reversed the effects observed under bilirubin treatment. in vivo, bilirubin dramatically decreased tumor growth by % (sd ae . ) when compared to the control. conclusions. bilirubin is a potent inhibitor of hrt- colon cancer cell growth in vitro and in vivo, presumably by modulating mitogen activated protein kinase signaling pathways resulting in cell cycle arrest and apoptosis. background. tetrahydrobiopterin (bh ) is an essential cofactor for nitric oxide synthases and thus a critical determinant of no production. recently we have shown that bh depletion contributes to ischemia reperfusion injury (iri) after pancreas transplantation. here we analysed the therapeutic potential of bh supplementation during organ procurement and the early post-transplant period. methods. murine cervical heterotopic pancreas transplantation was performed with a modified no-touch technique. pancreatic grafts were subjected to h prolonged cold ischemia time (cit) and different treatment regiments: untreated (i), bh mm to perfusion solution (ii), bh mg=kg i.m. at reperfusion (iii). nontransplanted animals served as controls (iv). intravital fluorescence microscopy was used for analysis of graft microcirculation by means of functional capillary density (fcd) and capillary diameters (cd) after h of reperfusion. quantitative assessment of inflammatory responses (mononuclear infiltration) and endothelial disintegration (edema formation) was done by histology (h&e) and peroxynitrite formation assessed by nitrotyrosineimmunostaining. results. fcd was significantly reduced after prolonged cit, paralleled by an increased peroxynitrite formation, when compared with controls (all p < . ). microcirculatory changes correlated significantly with intragraft peroxynitrite generation (spearman: r ¼ À . ; p < . ). pancreatic grafts treated with bh either during retrieval (ii) or systemically (iii) displayed markedly higher values of fcd (p < . ) and abrogated nitrotyrosine staining (p < . ). cd were not significant different in any of the investigated groups. histologic evaluation showed increased inflammation, interstitial edema, hemorrhage, acinar vacuolization and focal areas of necrosis after h cit in group i, which could be diminished by both bh treatment regiments (p < . ). conclusions. bh treatment significantly reduces postischemic deterioration of microcirculation as well as histologic damage and might be a promising novel strategy in attenuating iri in clinical pancreas transplantation. methods. forty-seven biopsies obtained from the endoscopic esophagogastric junction in patients ( females, males; age ; range - years) with symptoms of gastroesophageal reflux disease were processed for histopathology and immunohistochemistry. biopsies were stained with routine h&e and immunofluoresence staining using an antibody directed against hydrogen=potassium atpase (h þ =k þ atpase beta) (pot) for detection of parietal cells (pot ¼ monoclonal clonal mouse igg antibody, g clone, dilution : ; product numberma affinity bioreagents d- hamburg, germany). pot detects the beta-subunit of hydrogen= potassium atpase in bovine, human, canine, porcine, rabbit, mouse, ferret, and rat tissues. histopathology in h&e stained sections was conducted according to the paull-chandrasoma classification of columnar lined esophagus (cle) including oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) with or without intestinal metaplasia (im ¼ barrett esophagus). out of biopsies also contained gastric oxyntic mucosa (mucus, parietal and chief cells) and served as controls (these biopsies contained both cle and om). the detection of parietal cells in h&e and pot-staining was compared. results. h&e staining showed that out of patients had cm with im (barrett esophagus), had cm without im. a total of slices was investigated ( h&e pot). pot stained the cytoplasma of parietal cells indicating the presence of biologic active acid pump. in biopsies parietal cells were only detected in pot stained slices, whereas in the other biopsies parietal cells were detected by both h&e and pot-staining. parietal cells were detected in all biopsies containing gastric om. therefore pot did not significantly increase the parietal cell detection rate in cle compared to h&e staining. conclusions. detection of ocm within biopsies from columnar lined esophagus is not significantly increased by the use of an antibody directed against h þ =k þ atpase. h&e staining is adequate for detection of parietal cells within cle. lymphovascular invasion and lymphangiogenesis in adenocarcinoma of the esophagus: impact on patient survival e. rieder , s. schoppmann , s. kandutsch , f. wrba , f. langer , c. neumayer , p. panhofer , g. prager , j. zacherl background. a special feature of esophageal cancer is its early lymphatic spread in comparison with other cancers of the gastrointestinal tract. due to the discovery of specific markers for lymphatic endothelium, selective staining of lymphatic vessels has become possible. in recent studies the prognostic value of peritumoral lymphangiogenesis and lymphovascular invasion in various human malignancies has been shown. tumor-associated macrophages (tam), expressing the lymphoangiogenic growth factor vegf-c, were shown to be related to tumor-associated lymphangiogenesis, lymphovascular invasion and lymph-node metastasis. aim of this study was to assess tumor-associated lymphangiogenesis as well as the role of tams in a cohort of adenocarcinoma of the esophagus. methods. fourty formalin-fixed, paraffin-embedded surgical specimens of patients (age range: - ) presenting with adenocarcinoma of the esophagus at the university hospital of vienna were included into this study. specimens were stained with antibodies against podoplanin, vegf-c and anti-cd . semiquantitative measurements of lymphatic microvessel density (lmvd) and lymphatic vessel invasion (lvi) were carried out. results. it could be demonstrated that lymphangiogenesis occurs in barrett adenocarcinoma and is correlated with lvi. statistical analysis revealed that lvi is associated with disease-free (p ¼ . ) as well as overal survival (p ¼ . ) of patients with barrett carcinoma. furthermore over-expression of vegf-c was seen in barrett carcinomas and vegf-c expressing tams were detected peritumoral and therfore may play a role in lymphogenic metastasis of esophagus carcinoma. conclusions. these preliminary data demonstrate that lymphovascular invasion as well as tumor-induced lymphangiogenesis is associated with patient survival in barrett adenocarcinoma and anti-lymphangiogenic therapies might be a beneficial approach. background. the role of tissue-inhibitor of metalloproteinases- (timp- ) in cancer progression is still unclear. although timp- is an important inhibitor of metastasis-associated proteases, it is often correlated with a bad prognosis. in an animal model, elevated levels of timp- , achieved by adenoviral-gene-transfer, led to induction of hepatocyte growth factor (hgf)-signaling and expression of several metastasispromoting genes in the liver, representing a host-microenvironment with increased susceptibility to a challenge of tumor cells. we examined the expression of candidate metastasis-promoting factors by qrt-pcr. methods. liver-tissues of consecutive metastatic colorectal cancer patients ( males, females; mean age, . ae . y) were obtained. to determine timp- -associated gene expression signatures in the normal liver tissue, specimen were harvested from zones greater than cm away from visible liver metastases and analyzed by quantitative-real-time-pcr (qrt-pcr, taqman + -low-density-arrays) of metastasis-associated genes. results. human liver tissue with elevated timp- levels was associated with an identical pro-metastatic gene expression signatures as previously identified in the animal model, namely increased expression of hgf, pcna, upa, upar, tpa, matriptase, mmp- , mmp- , adam- , cathepsin g, and neutrophil elastase. conclusions. we reveal here for the first time a ubiquitous (human and mouse=different tumor types) timp- -related gene expression profile. this profile, consisting of metastasis-promoting genes, can explain the correlation between tumor aggressiveness in cancer patients and increased levels of timp- and demonstrates the impact of the host microenvironment on its susceptibility to invading tumor cells. this concept is important for future considerations of cancer therapies. Ö gth -herz: varia rv-lv depolarisation-interval as a predictor of longterm-survival of crt-patients: a criteria for intraoperative quality control t. schwierz , s. winter , h. nesser , r. fü gger surgical department, elisabethinen-hospital, linz, austria; cardiological department, elisabethinen-hospital, linz, austria background. for cardial resynchronisation therapy the left-ventricular lead should stimulate the most delayed myocadial area. we introduce a method, established in or dayly routine, for intraoperative verification of the hemodynamically best lead-position. methods. the electrical distance between rv-and lv-lead we verify by measurement of the time between rv-pacing and lv-sensing (depolarisation-intervall). by a cox regressionmodel we analized the data of patients with regard to possible predictors of patients-survival following crt. results. significant predictors of survival were the age of patients (p ¼ . ), lvef (p ¼ . ), biventricularly stimulated qrs-duration (p ¼ . ), reduction of qrs-duration under biventricular stimulation in relation to rv-pacing in % (p ¼ . ), depolarisation-intervall (p ¼ . ), depolarisation-intervall in relation to qrs-duration under rv-pacing in % (p ¼ . ). conclusions. out of the predictors significant for the patients-survival following crt only the depolarisation-intervall can be influenced activly during the implantation procedure. the rv-and lv-lead should be implanted so that the depolarsation-intervall is as long as possible. ideally, the depolarisation-intervall covers the entire qrs-duration under rv-pacing. in that case the lv-lead stimulates exactly the latest depolarisized myocardial area. the fibrin derived peptide b-beta - ameliorates ischemia-reperfusion injury in a rat heart transplant model background. the purpose of this study was to evaluate the protective effect of the fibrin-derived peptide b-beta - on ischemia=reperfusion injury in a rat cardiac transplant model. methods. lew hearts were flushed with chilled ( - c) custodiol preservation solution and either transplanted immediately or stored for or h in the same solution and then transplanted into syngeneic recipients. b-beta - was given i.v. at a dose of . mg immediately after transplantation or added to the preservation solution prior to harvest. at h and d, graft function was assessed and hearts were retrieved for morphological evaluation. at time of harvest, serum samples were collected for troponin level analysis. results. hearts transplanted immediately or after h of cold ischemia did neither show any morphological damage at h nor at days. in contrast, h of ischemia resulted in severe myocardial ischemia associated with an inflammatory response at h. lesions further progressed at days. administration of b-beta - resulted in a significant amelioration of myocardial necrosis together with a diminished inflammatory response. a protective effect towards myocyte damage was further underlined by reduced troponin levels in groups receiving b-beta - . acute cellular rejection after cardiac transplantation -is there a way to reduce the number of biopsies? background. acute cellular rejection significantly contributes to mortality and morbidity after cardiac transplantation (htx). routine endomyocardial biopsies (embs) are performed to early detect and treat cellular rejection. although emb can be performed with little risk, a number of potentially fatal complications are inherent in the procedure. the aim of our investigation was to evaluate the incidence of acute cellular rejection after heart tranplantation and to evaluate possibilities to reduce the number of embs. methods. patients underwent cardiac transplantation from january through december at our institution. the mean age of the patients was . ae . years. . % were female. indication for htx was icmp in . %, dcmp in . % und others in . % of the cases. according to our institutional standard, patients underwent emb weekly during the first month after htx, biweekly during months and , monthly up to month , once in month , and . a total of embs were investigated over a follow-up period of months after htx. results. the majority of embs showed no signs of rejection ( . % ishlt ). mild signs of rejection without therapeutical consequence (ishlt ia) were found in . % of embs. rejection ishlt ib was found in . % of the evaluated embs. the incidence was . % during the first month after htx, in the second month . %, in rd month . %, in th and th month . %, in th and th month . %, and from the th month . %. a moderate rejection (ishlt ii) was detected in . %. during the first month after htx, the incidence was . %, during nd month . %, during rd month . %, in th und th month . %, in th und th month . % and from the th month . %. more severe rejections were rare ( x ishlt iiia ¼ . %, x ishlt iiib ¼ . %) and occurred in month , , and . conclusions. severe cellular rejection after htx is seldom. mild to moderate rejection episodes, however, occur more frequently. in contrast to the traditional emb schedules, rejection hardly ever occurs during the first weeks after htx. most rejection episodes are observed between the second and seventh month after htx. afterwards, the incidence of rejection lowers again. based on these findings, the number of routine embs can safely be reduced, especially during the first weeks after htx. background. renal dysfunction has consistently been one of the greatest risks for mortality with the use of left ventricular assist devices (lvad). we aimed to determine the impact of renal function on survival and time-dependent changes in renal function after lvad implantation. methods. we retrospectively reviewed patients with advanced heart failure (mean age . ae . yrs, % male, % ischemic cardiomyopathy) who received lvad implantation as a bridge to transplant therapy from to . renal function was assessed using the modification of diet in renal disease (mdrd)-derived glomerular filtration rates (gfr). patients were divided into groups based on renal function pre-lvad implantation; group : normal (gfr ! ml=min= . m , n ¼ ), group : impaired (gfr < ml=min= . m , n ¼ ) renal function. results. patient survival was comparable between the groups. the , and -month kaplan-meier estimate of survival was . %, . % and . % for group and . %, . and % for group (p ¼ . ). gfr paired sample analysis in group showed an early increase in gfr from preimplantation ( . ae . ml=min= . m ) to postoperative day (pod) ( . ae . ml=min= . m ; p ¼ . ). there was no increase in gfr from pre-implantation ( . ae . ml= min= . m ) to heart transplantation ( . ae . ml=min= . m ; p ¼ . ). in contrast, gfr paired sample analysis in group showed an early increase in gfr from pre-implantation ( . ae ml=min= . m ) to pod ( . ae . ml= min= . m ; p< . ), and a further increase in gfr from pod ( . ae ml=min= . m ) to pod ( . ae . ml= min= . m ; p ¼ . ). there was a significant increase in gfr from pre-implantation ( . ae . ml=min= . m ) to heart transplantation ( . ae . ml=min= . m ; p< . ). conclusions. renal function improves rapidly after lvad implantation. renal dysfunction does not adversely affect outcome after lvad implantation. methods. bed interdisciplinary paediatric intensive care unit, university hospital. patients. patients after open heart surgery; prospective controlled study. group a received mg tc=kg bodyweight pre-and post operation and h after operation, whereas group b received mg tc=kg bw in the same period. drug levels and routine laboratory parameters were investigated daily in the picu. the aim of both groups was a tc serum concentration of - mg=l by adapting dosage after h. results. in group a tc concentration were . ae . and . ae . mg=l after and h, in group b . ae . and . ae . mg=l (p < . both), respectively. crp values were in group a ae . mg=l and ae . mg=l and in group b ae . mg=l and ae . mg=l (p < . and p < . ), respectively. there were no differences in physiological scoring. conclusions. to achieve drug levels of tc higher than mg=l during the first h after surgery, the higher dosage of mg=kg bw had to be administered initially. the high tc dosage was well tolerated and was associated with significantly lower crp in the first two days. background. the fontan operation eliminates the systemic hypoxemia and ventricular volume overload in congenital patients with single ventricle physiology. retrospectively, we report on our longtern results of surgical palliation and on different concepts concerning tcpc (total cavo-pulmonary connection). methods. between and , a total of patients (mean age . ae . years) underwent surgical fontan palliation at our institution by tcpc technigue. in % of all patients, a staged concept was carried out, patients had a central fenestration ( mm). all of our latest patients in the operation series were palliated -according to the new ''fontan concept'' -with an extracardiac conduit as second step. in , inhalative no (nitric oxyde) therapy was also introduced in the early postoperative phase. results. kaplan-meier overall survival after a mean followup of years was . % (in patients with staged procedure . %, . % in patients with fenestrated fontan). out of patients survived a periopertive fontan take-down. without any exception, we lost patients in the learning curve phase, of them because of neurologic complications, patients died due to low cardiac output (lco). in those patients who were palliated with an extracardiac fontan, mortality was %; furthermore under no-therapy, perioperative mortality also was %. after ae months of follow-up, % of all patients were in nyha i, % in nyha ii, % of all patients were in sinus rhythm. pleuropericardial effusions were found in % of all patients. conclusions. definitive palliation by means of tcpc in patients with congenital single ventricle physiology leads to more than acceptable clinical results. staged palliation, fenestration procedures, extracardiac fontan and inhalative no-therapy were introduced as ''modern'' surgical therapy concepts and resulted in a significant positive influence on perioperative and longterm clinical results. neue erkenntnisse in der mund-, kiefer-und gesichtschirurgie background. as we are living in an aging society, the number of active patients older than is increasing. the impact of age on trauma related injuries, e.g. femur neck fractures, and their outcome has been well documented in the literature. so far, data on a broad cohort suffering from oraland maxillofacial injuries (omfi) are missing. thus it was the aim of the present retrospective analysis to observe the effect of increasing age on trauma related omfi. methods. the records of patients with omfi were collected at the department of cranio-maxillofacial and oral surgery at the medical university of innsbruck in the period from = = to = = . according to the who definition of elderly people the collected values were divided into persons older than years of age and younger. were younger and were older than years. data were registered regarding: diagnosis, age and gender, cause, type and localization of the injury and concomitant injuries. subsequently the data of both groups were compared and statistically analysed. statistical analysis was performed in spss (version . ) using chi-square-test, fisher s exact test and mann-withney u test. this was followed by a logistic regression analysis in order to investigate trends and to demonstrate significant differences between the groups. a value of p< . was considered significant. results. with increasing age the risk for a domestic accident was raising. the accident mechanism in the elderly people was mainly a fall ( . %) or was not reproducible ( . %). there was a significant difference between both groups regarding concomitant injuries. . % of the older and . % of the younger patients suffered from additional neurological symptoms (p < . ). until the age of the risk for concomitant neurological injury is increasing, beyond there is no significant higher risk. the injuries in the older patients were mainly referred to the soft tissue and the mid face. conclusions. thanks to major progress in general health care the percentage of elderly and most notably active old people in our society has been constantly stepping up in the past three decades. the increased number of concomitant injuries in elderly people requires a detailed investigation of the injured patient. furthermore medication and possible cardiovascular disease of the older generation restricts the indication for surgical treatment of these patients. influence of different surface termination on surface energy and subsequently on connective tissue attachment in vivo background. connective tissue attachment is of major significance for the longevity of transdermal=-mucosal implants. a tight soft tissue sealing around the implant prevents from acute and chronic infections. major focus of former investigations has been the influence of different surface roughness on the connective tissue attachment to the implant surface. the aim of the current investigation was to demonstrate the influence of different surface terminations of nano-crystalline diamond (ncd) on surface energy and subsequently its influence on in vivo connective tissue healing. methods. ncd coated titanium membranes were terminated either by hydrogen or oxygen and were compared to pure titanium membranes. these samples were evaluated by contact angle measurement, scanning electron microscopy, atomic force microscopy and electrostatic force microscopy to evaluate the surface potentials. to assess the in vivo integration, the different substrates were randomly distributed and inserted into the sub-dermal layer of wistar rats. animals were sacrificed after , and weeks to investigate the adjacent connective tissue histologically. cell number, connective tissue=implant contact ratio and scar formation were evaluated. statistical analysis was performed using wilcoxon-rank test and kruskal-wallis h-test. p < . was considered significant. results. the ncd coating of the titanium membranes preserved its microstructure. contact angle measurement confirmed h-termination hydrophobic and o-termination hydrophilic. o-termination resulted in a strong polarity, whereas no electrostatic interactions were observed at the hydrophobic surface. the histological evaluation demonstrated a comparable cell number after week in all groups. after four weeks a significantly increased cell number at the o-terminated ncd with a less tight scar formation was observed. furthermore a markedly higher connective tissue=implant contact was observed after weeks at the hydrophobic surface. conclusions. o-termination of ncd renders the surface electrostatically active. the surface polarity promotes connective tissue healing in vivo. furthermore the surface energy is of higher importance compared to the structure of the surface. the o-termination of surfaces thus is a promising technique for a controlled influence of connective tissue adhesion in vivo. the risk of concomitant injuries and complications in cranio-maxillofacial trauma. das risiko von begleitverletzungen und komplikationen in der kiefer-gesichtschirurgie background. the registration of concomitant injuries on patients with cranio-maxillofacial trauma is an important criteria to optimize the healing process and to minimize the incidence of complications due to unlevied diagnostic findings. interdisciplinary, cranio-maxillofacial trauma management includes exact documentation. therefore a large collective of patients was examined against the background of their maxillo-facial trauma to diagnose the additional injuries. methods. between - at the department of oraland maxillofacial surgery among patients with craniomaxillofacial trauma, patients ( . %) with concomitant injuries were registered. data of patients were recorded including age and gender, cause and type of injury, location and frequency of their additional trauma. statistical analyses performed including descriptive analysis, chi square test, fisher's exact test and mann-whitney s u-test. logistic regression analysis determined the impact of different ages on the type of injury. results. within patients (mean age ¼ . ; #:$ ¼ . ) the most common sort of concomitant injury occured during sports, household and play ( . % each). the most frequent type of additional injury was the commotio cerebri in . % ( patients). fracture of the base of the skull occurred in patients ( . %), patients had a fracture of the skull and patients suffered from contusio cerebri. even one patient had a paresis of the facial nerve. in patients injuries of the eye were denoted, among them . % had a contusio bulbi and patients a retrobulbar hematoma. contusio of the lung appeared in . %, blunt abdominal trauma in . % and a fracture of the cervical spine in . % of patients with concomitant injuries. in patients fractures of the facial bone were recorded. soft tissue injuries of the face were found in patients ( . %). in concomitant injuries male persons aged between to are prone to cervical spine fractures (increase of %=year of age) and thoracal injuries (increase of %=year of age), as well as neurological trauma (increase of %=year of age) mainly found in traffic accidents. conclusions. in the catchment area of our department injuries of the neurocranium and the eye were often associated with trauma of the viscerocranium. interdisciplinary and coordinated management is not only important for the initiation of preventive measurements but also for forensic causes. to minimize the complication rate and to optimize the therapy a neurological-, neurosurgical-, as well as eye-consiliary examination should be preferably accomplished at a preoperative stage on the awakened patient. background. orbital injury may lead to incarceration of periorbital tissue and to ocular motility disturbances and diplopia on a long-term basis. however, orbital surgery is not free of risks. the treatment of periorbital lesions demands a precise planning approach in order to secure high success rates without causing iatrogenic damage. we want to demonstrate computer assisted surgery as part of the surgical routine of posttraumatic orbital reconstruction. methods. four cases of posttraumatic orbital deformities are presented. two patients showed protruding bone fragments after unrecognized fractures of the orbital walls. two patients presented with foreign bodies in the orbital cavity after shotgun injuries. in all four patients preoperative acquired ct-data was reformatted on a commercially available d-navigation system. image guided surgery in the orbital cavity was performed using an intraoperatively calibrated high-resolution endoscope. results. the shotgun pellets and the protruding bone fragments were easily detected and removed via a minimal invasive access. diplopia and bulb motility improved significantly. postoperative rehabilitation was restricted to a few days. conclusions. according to our opinion computerized navigation surgery of the orbit can improve the results of surgery in terms of safety and accuracy. these extended techniques should lead to a more direct and less invasive method for approaching orbital lesions or posttraumatic deformities giving the surgeon a high degree of security in sparing vital anatomic structures. background. surgically assisted rapid maxillary expansion (sarme) has become a widely used and acceptable technique to expand the maxilla in adolescents and adult patients. sarme takes the advantage of bone formation at the maxillary edges of the midline, while they are separated by an external force. sarme is indicated in patients with isolated, considerable (more than mm) transverse maxillary deficiency. while surgically assisted palatal expansion is performed in patients after closure of the sagittal palatal suture, conservative rapid maxillary expansion can be used in younger patients. studies concerning such cases show, that just % of the expanded width is located in the area of the palatal suture, while the rest of the extention ( %) are reached by dentoalveolar movements like tipping. the aim of this study was to evaluate the amount of expansion caused by expansion of the maxillary suture and by the dentoalveolar complex. furthermore changes of the nasal cavity should be discussed. methods. all patients included in the study showed a tranverse maxillary deficiency of at least mm. all patients were older than years ( min, max). in all patients a fractional le fort i osteotomie consisting of sagittal osteotomie and osteotomie of the anterior maxilla and the pterygoid bone was performed. ct scans were performed preoperatively and about weeks postoperatively (after the needed expansion). measuring points were defined to evaluate the skeletal and the dental changes after maxillary expansion. conclusions. the results of the current study will be presented. background. the main indication for microvascular reconstruction of the face is the best possible functional and aesthetic outcome. here every special kind of missing tissue is to be substituted. by using the chimera-flap technique a combination of different transplants for individual defect coverage is possible. methods. in seven patients with extended or penetrating defects of the lower face, reconstruction was performed with a double flap technique. a combination of microvascular iliac crest transplants or microvascular femur transplants for mandibula reconstruction and an anterolateral thigh perforator flap (altpf) or saphenus perforator flap for soft tissue reconstruction was performed after ablative tumour surgery. the pedicle of the altpf or saphenus flap was used for elongation of the microvascular bone flap pedicle. all patients had radiotherapy weeks after surgery. results. all patients had good functional and aesthetic results and have been successfully treated with implant retained prostheses. there were no severe postoperative complications. there was no tumour relapse within - months postoperatively. conclusions. the chimera-technique makes good aesthetic and functional outcome possible. the iliac crest transplant is of a good dimension for reconstruction of non-high atrophic mandibles after complete resection. the microvascular femur is well suited for covering partial defects of the mandible. implant placement is possible in both transplant types. the altpf and the saphenus perforator flap have a low incidence of complications and donor site morbidity and can be shaped adequately to a soft tissue defect of the lower face. parry-romberg-syndrom (hemiatrophia faciei progressiva) -interdisziplinäre zusammenarbeit mehrerer ü bergreifender fächer bei der definitiven diagnosestellung und den daraus resultierenden therapiemöglichkeiten zugt gesichts-und schädelskelett. die hemiatrophia faciei progressiva (v. romberg) ist primär durch einen schwund der betroffenen gesichtsseite, an der die haut, das subcutane fettgewebe und bindegewebe und später auch die muskelatur und die gesichtsschädelknochen beteiligt sind. die ausgeprägte gesichtsasymmetrie ist häufiger als ein funktionsausfall ursache der behandlung. nur eine effiziente diagnostik sichert eine gute therapie und gute resultate bei einem romberg-syndrom-patienten. bei der diagnostik wird nicht nur die mund-, kiefer-und gesichtschirurgie herangezogen, sondern interdisziplinär mit der dermatologie, hno, mund-, kiefer-und zahnheilkunde, augenheilkunde, neurologie, psychiatrie, plastischen chirurgie und radiologie zusammengearbeitet. es werden die jeweiligen disziplinen mit ihrem abklärungsgebiet beim romberg-syndrom präsentiert und dargestellt. in jeder disziplin werden die patienten in der dermatologie auf eine sklerodermie, in der neurologie -anhand eines mrtsdie neuralgiformen symptome und in der augenheilkunde die ophthalmologischen symptome, in der radiologie -anhand von bildgebungsverfahren (ct, szintigraphie) die knochenaktivität in bezug auf die fortschreitende knochenatrophie untersucht und abgeklärt. die therapieform wird nach der diagnosestellung und der daraus resultierenden diagnosebestätigung und anhand der symptomatik beim patienten bestimmt. verschiedene therapieoptionen wie eine autologe lipoinjektion, eine fettgewebstransplantation, eine freie mikrochirurgisch-anastomosierende fettgewebslappenplastik oder injektion allogener materialien werden angewendet. die diagnostik und das chirurgische vorgehen werden an zwei fallbeispielen demonstriert. die grundlegenden behandlungsstrategien stammen aus der zeit der beiden weltkriege. Ä nderungen der konzepte ergaben sich im bereich der sekundären rekonstruktion verlorengegangener strukturen sowohl im weichgewebe als auch im hartgewebsbereich durch etablierung neuer operationstechniken, welche die erzielung besserer ästhetischer und funktioneller ergebnisse ermöglichen. neben der beschreibung des traumamechanismuses erfolgt anhand von klinischen fällen die darstellung der versorgungsprinzipien. responsible for preventing fecal incontinence as well as enabling defecation. methods. works on anorectal vascularization are presented and diagnostic tools for clinical practice are discussed. results. filling and drainage of the internal hemorrhoidal plexus can be visualized by transperineal color doppler ultrasound. the terminal branches of the superior rectal artery exclusively contribute to the arterial blood supply of the internal hemorrhoidal plexus. according to anatomical studies an intramural network of anastomoses exists between the superior and inferior rectal arteries. ultrasound studies of the anorectum clearly highlighted a stage-dependent alteration of the morphology and perfusion of these terminal branches in different grades of hemorrhoids. conclusions. hypervascularization of the anorectum is proposed to contribute to the growth of hemorrhoids rather than being a consequence of hemorrhoids. pre-and postoperative assessment of the anorectal vascularization helps to judge the success of a technique for treatment of different grades of hemorrhoids. the doppler-guided haemorrhoidal artery ligation is a new, minimally invasive technique in the treatment of haemorrhoidal disease. since february patients with symptomatic second and third degree haemorrhoids have been treated this way at our department. postoperative complications occurred in , %. one month after treatment % of the patients were symptom-free and satisfied with the results. since there are very little data regarding the efficiency and the patient comfort on the long term, we questioned consecutive patients which had undergone surgery between february until december st . the questionnaire was done via telephone using standardised questions. patients with persisting or recurring symptoms were invited for a control re-examination. the results of this follow-up will be presented. background. guidelines may be helpful to standardize the management of hepatocellular and cholangiocellular carcinoma as the diagnostic and therapeutic spectrum has been considerably enlarged by recent developments. methods. ''state of the art'' guidelines deducted from the literature and from recent consensus conferences are elaborated; issues that remain controversial or not sufficiently documented by data are discussed. results. some standards have been introduced in hepatic surgery such as preoperative evaluation of liver function (and portal branch embolisation if required) or intraoperative ultrasonography. for other essential items such as techniques used for transsection of liver parenchyma or for hemostasis a variety of possibilities is at choice and the decision often depends on the personal attitude of the surgeon. as success of surgery is influenced by so many factors and imponderabilities, exact clinical evaluation is delicate and statements fulfilling the strict criteria of evidence based medicines are rarely found. only in a minority of patients with hepatocellular carcinoma transplantation or resection is possible. for the remaining patients, a variety of therapeutic procedures are warranted with effects difficult to compare given the bias of patient selection and the great inter-patient and inter-institutional variability. in the treatment of patients with bile duct carcinoma, surgery (liver resections for klatskin tumors stage bismuth i-iii, whipple's procedure for more distally localized tumors), if feasible, plays a key role as well. conclusions. excellent interdisciplinary cooperation is the clue to providing ''state of the art'' management of hepatocellular and cholangiocellular carcinoma. treatment not only has to consider tumor type and stage, but also the individuality and the overall condition of every single patient. background. colorectal carcinoma is one of the most common malignant diseases primarily diagnosed in the industrialized world. thanks to standardized surgical procedures and multimodal treatment concepts, the prognosis has improved considerably in recent decades. methods. state-of-the-art treatment of colorectal carcinoma is presented and discussed on the basis of the current literature, including the current status of minimally invasive techniques in the surgical treatment of malignant colorectal disease. results. carcinomas of the colon and rectum are two separate entities as far as biology, probability of local recurrences, metastasis patterns, surgical strategy and multimodal treatment regimes are concerned. operative treatment of colon carcinoma is generally standardized, but the concept of sentinal node biopsy is a new aspect. a metaanalysis of stage ii colon carcinoma showed a survival advantage of up to % for adjuvant therapies including -fu. the mortality rate for stage iii colon cancer could be reduced by - % with adjuvant chemotherapy. the operative standard for rectal carcinoma is heald's technique of total mesorectal excision. for proximal rectal carcinomas, a partial mesorectal excision with a greater distance (at least cm) to the edge of the tumor is adequate. with rectal carcinoma, neoadjuvant radiochemotherapy is more effective at reducing local recurrences and involves fewer complications than does postoperative treatment. accordingly, neoadjuvant radiochemotherapy is indicated at least for t- tumors of the lower and middle thirds of the rectum. in all, total survival and fewer local recurrences are seen with combined radiochemotherapy for rectal carcinoma. a number of randomized prospective studies published since showed comparable long-term results for laparoscopic and open colon surgery. the results of such studies on rectal carcinoma are not yet available. conclusions. the key factors for improving the prognosis of colon and rectal carcinoma are, besides early diagnosis, standardized surgery and multimodal, individualized treatment concepts. prophylactic operations in palliativ surgerya conflict? background. to date approximately % of the eu-citizens decease on malign tumors. here an increased tendency was noticed in the past. this circumstance is present in the surgical day-to-day life. patients with predictable and linited prognosis often require the decision whether a prophylactic surgical procedure would prevent further complications or may declerate progression of malign tumors. methods. the status and progression of patients with oncological focus were analyzed in the department of surgery of the helios-hospital schwerin. two groups were studied. first surgical procedures due to general symptoms of the tumorous disease. second, surgical therapy of specific symptoms as a consequence of the tumor. results. inter-disciplinary diagnosis and discussion were crucial for the decision whether a palliativ-prophylactic operation was necessary or not. futhermore, prophylaxis in palliative medicin and surgery required a multi-disciplinary therapy regime. for the inter-disciplinary decision, guidelines proposed by the established ''tumorboard organization'' were applied. for general symptomatic treatment, palliativ-prophylactic procedures due to pain therapy, gastro-intestinal symptoms, emesis, ileus, ascites, icterus, cachexia, respiratory and urological complications, and wound management were accomplished. conclusions. prophylactic operations are frequent and represent the reality in palliative surgery. the ''tumorboard organization'' was administrable for a structured ultimate therapy decision. here forensic guidelines regarding self-determination, protection of integrity, autonomy of the patient, and euthanasia have to be considered. the perception of the personally responsibility of the attending physician still possess highest priority. background. within the last decade thyroid surgery has been radicalized. two parties have emerged from the discussion. one group, trying to preserve thyroid as central element of the body -the other one, in light of an easy replacement therapy, does not feel the need for that. methods. we compare patients operated from - at our department. one group underwent dunhilloperation (dh) n , the second thyroidectomy (t) n . complication rate and change of therapy were compared, remaining tissue was sonographed. the patient's opinions were sought using questionnaires. results. monitoring period lasted - months. recurrensrate showed no significant difference (dh: . =t: . ) and bleeding results also didn't show any differences. we did notice a higher hypoparathyroidismus rate with the thyroidectomy group (dh: . =t: . ). % of all sonographies in the dunhill group required further investigation because of remaining nodulare tissue. changes with substitution therapy didn't show any differences. the patient's opinions were identical in both groups. conclusions. both techniques require a simple substitution therapy. they are both safe methods, although the hypoparathyroidism is higher with thyroidectomy. on the other had we observed a progress in learning over the years thus we noticed no significance in . when using dunhill procedure, remaining tissue must be checked regularly. in our opinion, it is no benefit for patients with replaced tissue. evaluation of a new needle for thyroid fine needle aspiration biopsy p. wretschitsch , m. glehr , t. kroneis , a. leithner , r. windhager background. to verify the destinction of thyroid tumors, the volume of harvested cells in fine needle aspiration biopsy is one of the significant parameters for histological criteria and diagnosis. in consequence of the new aeration valve, the new needle is deaerated after the aspiration. thereby no blood or other not thyroid-cell elements are aspirated and more thyroidcells are harvested. methods. under blinded setting punctures, for each needle (standard needle, -needle with air valve and multi needle system with air valve), from fresh pig thyroid gland were made and recorded. the measurement was done according the manufacturers recommendations for casy (casy + technology, reutlingen). the aspirated cell material was evacuated into ml casyton (cell-culture liquid, casy + technology, reutlingen) and calculated with the casy (casy + technology, reutlingen) cell counter. total cell amount and amount of vital cell was counted and recorded. statistical analysis was performed using t-test (p < . was considered significant). results. per needle respectively punctures were made and counted. the mean cellular amount of the standard needle was cells=ml. the mean cellular amount of the -needle system with aeration valve was cells=ml. the average of cell amount for the multi needle system (thyrosampler + kurtaran-frass, vienna) was cells=ml. the mean difference between the standard needle and the -needle system with air valve was significant with total cells (p ¼ . ) and with vital cells (p ¼ . ). the difference between -needle and multineedle system was not significant with total cells (p ¼ . ) and with vital cells (p ¼ . ). tag conclusions. the needle systems with the air-valve lead to a significant higher cell amount in needle aspiration biopsy. according to the requirement of cytological diagnosis more cell volume could be harvested, which is a well-defined benefit. does the lunar phase influence the incidence of postoperative haemorrhage after thyroid surgery? a preliminary report background. it is claimed by non-scientific sources that operations carried out at waxing moon or especially at full moon are associated with a higher incidence of postoperative complications. therefore patients referring to lay press confront surgeons with the lunar phase's influence and claim for special dates for surgery. postoperative haemorrhage is a typical complication after thyroid surgery with an incidence of about . %. thus it is a suitable to assess this assumption by evidence-based data. methods. we retrospectively evaluated patients requiring reoperation after thyroid surgery. the exact time of skin incision was evaluated by anaesthesia's reports and its lunar phase was calculated by an online-calculator. results. in a timeframe of days (in all) around full moon patients had to be reoperated, days around new moon patients needed surgical reintervention. patients were operated during waxing moon, the phase that is believed to be a risk for postoperative complications, and patients during waning moon. no differences were seen between the categories st þ th quarter ( operations), the quarters around new moon, and nd þ rd quarter ( operations), the quarters around full moon. conclusions. our study shows no correlation between postoperative haemorrhage after thyroid surgery and lunar phase at initial surgery. these evidence-based data prove, that lunar phase does not influence the risk of bleeding after surgical interventions. these results should serve as information for those patients, who are convinced, not to be operated during full moon phase. the result should also bring the ''superstition'' to a halt. background. recently gender-specific medicine has become the focus of interest. after thyroid surgery we observed more hypocalcaemia-related symptoms in women than in men. our goal was to find out gender-specific differences in the postoperative calcium-and parathyroid hormone (pth)-kinetics. methods. pth-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. a total of women and men underwent extensive thyroid surgery. postoperative calcium levels revealed a non-significant difference of . mmol between women and men on the st postoperative day. perioperative pth-kinetics showed no significant differences too, neither in symptomatic patients, nor in the whole study population. the rate of postoperative hypocalcaemia-related symptoms was about higher in women than in men ( - %, respectively). conclusions. despite of similar perioperative pth-and calcium-kinetics women suffer more often from postoperative hypocalcaemia-related symptoms. the mechanism remains unclear and needs further research in gender-specific postoperative calcium-metabolism. background. grave's disease (gd) is thought to be associated with a higher incidence of postoperative hypocalcaemiarelated symptoms. methods. parathyroid hormone (pth)-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. preliminary data were analysed for patients with an observation period of more than months. results. total or near-total thyroidectomy was carried out in patients with gd and patients with benign euthyroid multinodular goitre. differences between patients with gd and patients with benign euthyroid nodular goitre were found for postoperative hypocalcaemia-related symptoms ( . , . %, respectively). these findings were statistically significant (p < . ). furthermore, no significant differences were found in perioperative pth-and calcium-kinetics between the groups. patients with gd were of a significant (p < . ) lower mean age ( ae ) than patients with benign euthyroid multinodular goitre ( ae ). conclusions. there is a significant higher risk of postoperative hypocalcaemia-related symptoms after surgery for gd compared to benign euthyroid multinodular goitre. there is no significance concerning the risk of permanent hypoparathyroidism in our preliminary data set. background. intraoperative parathyroid hormone [pth] monitoring is an important prerequisite for minimally invasive parathyroid surgery. thus, surgical success essentially depends on the correct intraoperative interpretation of the pth-decay. pth-''spikes'' caused by unintentional ''manipulation'' of the hypersecreting glands during dissection may lead to interpretation problems. it is unclear how often these ''spikes'' occur and how they influence the operative strategy. we evaluated manipulated pth-excretion during surgery in a large number of patients and analyzed its influence on the interpretation of the intraoperative pth-curve. methods. intraoperative pth-values (intact pth, nichols, san jose, california) of patients with primary hyperparathyroidism and single gland disease were analyzed. of these patients, ( . %) were successfully treated with open minimally invasive parathyroidectomy (omip), ( . %) with primary bilateral neck exploration (bne) and ( %) patients had to be converted from omip to bne. to evaluate the occurrence of manipulation, patients were divided into groups: ''moderate'' pth-increase (< pg=ml), ''extensive'' increase (> pg=ml), ''no'' increase (ae pg=ml) and ''decrease'' before excision. changes were referred to the ''baseline''-level which was sampled right after induction of anaesthesia and before incision. intraoperatively, pth was measured before, , and min after removal of the enlarged gland. results. overall ( %) had a moderate increase and ( . %) an extensive increase. no increase occurred in ( . %) and a decrease in ( . %) patients. in patients undergoing omip, ( %) glands were manipulated moderately, another ( %) glands were extensively manipulated, ( . %) had no increase and ( . %) had a decline. in patients undergoing primary bne, ( . %) glands were manipulated moderately, ( . %) extensively and ( %) had no increase. a decrease was observed in ( . %) patients. a conversion from omip to bne was performed in patients because of incorrect preoperative localization by sestamibiscintigraphy and=or sonography. five ( %) of them had moderate manipulation and no patient had extensive manipulation. eighteen ( %) showed no pth alterations and ( %) a decrease, retrospectively. in none of the converted patients a misinterpretation of pth-''spikes'' were the underlying cause. conclusions. the data show that intraoperative manipulation is documented in bne and omip. the ''spikes'' caused by unintentional manipulation were identified by a subsequent prolonged pth-decline but did not lead to a change in the surgical strategy. parathyreoideakarzinome zählen zu den seltenen tumoren und sind für weniger als % aller primären hyperparathyreoi- background. at international meetings, delegates from many countries report an increasing lack of young doctors willing to choose operative specialities. the aim of this study was to evaluate the working conditions for surgeons in austria and to define the most crucial items calling for amelioration. methods. an anonymous survey was prepared and by e-mail all the members of the austrian surgical society were asked to complete a questionnaire which could be reached online by a direct link. it comprised twenty questions and was kept deliberately short in order to require a minimum of time for response. results. just some examples of the essential items can be given here: working conditions (such as working hours and payment) have to be improved. notably the young surgeons require career perspectives that are better and defined more clearly. the time spent for non-medical duties such as organization and documentation must be reduced. more priority is needed for surgical training both in the operating room and in practically oriented courses. conclusions. this evaluation provides the basis for further discussion at a session dedicated to this topic during the austrian surgical congress of . background. surgical training and education is neither standardized nor regulated. there is no validation, no obligatory training goal and no implementary rotation system. recently, the training permission for surgeons in education in the surgical department of kaiserin elisabeth spital has been shortened by the austrian medical association from to years without evidence based data i.e.without the consideration of the underlying number of operations performed in the clinic. methods. the surgical department is a center of thyroid and parathyroid surgery, which also covers the extended oncological cases, minimal invasive surgery, hernia operations and has the largest capacity for acute abdominal diseases in vienna. to analyze the quality of surgical education, the whole number of operations as well as the number of trainees in nd and th training year are tallied for analysis. results. in , a total number of operations ( thyroid and non thyroid operations) have been performed in our surgical department. trainee a ( years of education) performed ( thyroid and non thyroid operations), trainee b ( years of education) operations ( thyroid and non thyroid operations). the non thyroid operations of trainee a included cholecystectomies, herniotomies, appendectomies, operations of colon or small bowel, all other will be listened in detail. trainee a had = , trainee b = gastroscopies=colonoscopies performed. conclusions. the number of operations prove that the goal of training for surgeons in education is easily achievable. the reduction of training permission by the vienna medical chamber was not evidenced by data. however, this procedure has once again raised the insufficient structures in surgical education, the lack of valid training program and standardized approaches for a defined rotation and the obligation for both, senior surgeons and trainees to perform a certain number of teaching operations. a structured reform of rules and regulations for training is necessary. background. the purpose of this study was to review our hospital's experience in a retrospective single-center analysis of all patients undergoing surgery for posttraumatic thoracic pathologies between and . methods. from to october a total of aortic procedures were performed at our institution. eighty eight patients ( . %) underwent an intervention ( surgical procedures, stentgraft implantations) due to a posttraumatic injury of their thoracic aorta. in > % the descending aorta was involved, the injuries consisting of % aortic rupture, . % posttraumatic pseudo-aneurysms and . % aortic dissection. in the surgical cohort . % of the patients had to undergo an emergency procedure, . % an urgent and . % an elective procedure. there were . % female patients and . % male patients with a mean age of . years (range - yrs). results. during the three decades total hospital mortality was . % with a decrease over the years, thus resulting in a hospital mortality of . % ( - ) versus . % ( - ) . hospital mortality in the emergency group dropped from . % ( - ) to . % ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . improved outcome is mainly due to preoperative aggressive control of blood pressure and aortic shear forces using -blockade, intraoperative the use of heparin bounded circuits with cardiopulmonary bypass and most of all, a selectively delayed operative procedure (!). conclusions. although endovascular stent graft techniques continue to evolve, emergent=urgent patients will be anatomically not suitable for stent grafts and long term outcomes have yet to be determined. we therefore still consider selectively delayed surgery in patients with posttraumatic aortic pathology as a cornerstone in the choice of treatment for these patients. combined surgical and endovascular repair of complex aortic pathologies with a new designed hybridprosthesis background. in the present study the use of a new combined surgical and endovascular approach in the treatment of aortic dissection or aneurysm is evaluated. the aim of this technique is to treat extensive aortic diseases in a single stage procedure. the operative and follow up data are summarized in this report. methods. between = and = six patients ( ae years; female) with different aortic pathologies ( dissections, aneurysms) underwent replacement of ascending aorta, aortic arch and stentgraft implantation into the descending aorta using the e-vita open endoluminal stentgraft under circulatory arrest in moderate hypothermia with selective antegrade cerebral perfusion. the stentgraft was deployed under direct vision through the open aortic arch into the true lumen. results. intraoperative antegrade stenting of the descending aorta combined with distal ascending aorta and aortic arch repair was performed successfully in all patients. all patients survived the procedure one patient had neurological deficit, which recovered completely. a complete thrombosed perigraft space was observed in patients after one to eleven days. in two patients a partial thrombosis of the false lumen of descending aorta was observed. one patient underwent thoracoabdominal repair five months later. conclusions. this report shows that a combined surgical and endovascular approach of extended aortic lesions is a feasible option and extends aortic repair in a single stage method without increase of risk. background. to evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. methods. from through , patients (mean age yrs) with aortic arch diseases were treated (arch aneurysms n ¼ , type b dissections n ¼ , perforating ulcers n ¼ ). strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in patients. strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in patients. endovascular stent-graft placement was performed metachronously thereafter. results. two in-hospital deaths occured (myocardial infarction on the day prior to discharge n ¼ , rupture while waiting for stent-graft placement n ¼ ). at completion angiography, all reconstructions were fully patent. four patients had small type ia endoleaks, two of them resolving spontaneously. mean follow-up is months ( - months) . three late deaths occured (myocardial infarction n ¼ , sudden unknown death n ¼ ). one year survival was % and three year survival was %, respectively. redo stent-graft placement was performed in one patient after months (type iii endoleak). the remaining patients had normal ct scans with regular perfusion of the supraaortic branches without any signs of endoleaks. conclusions. mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. extended applications provide safe and effective treatment in patients at high risk for conventional repair. background. to determine mid-term durability of endovascular stent-graft placement in patients with perforating atherosclerotic ulcers (pau) involving the thoracic aorta and to identify risk factors for death as well as early and late adverse events. methods. from through , patients (mean age yrs) presented with pau, seven patients had rupture. seventy-eight percent were unsuitable for conventional repair. mean numeric euroscore was and mean logistic euroscore was . median follow-up was ( - ) months, being complete in all patients. outcome variables included death and occurrence of early and late adverse events. results. in-hospital mortality was %. primary success rate was %. actuarial survival rates at , and years were , and % and actuarial event-free survival rates were , and %, respectively. hemodynamic instability as well as logistic euroscore was identified as independent predictos of early and late adverse events. conclusions. endovascular stent-graft placement in patients with pau is an effective palliation for a life-threatening sign of a severe systemic process. hemodynamic instability at referral and a high preoperative risk score predict adverse outcome. during mid-term follow-up, patients are mainly limited by sequelae of their underlying disease. background. the performance of endovascular stent-graft placement in patients suffering from aneurysms involving the descending aorta originating from chronic type b dissections is unclear. methods. within a two-year period, we treated six patients with this pathology. four patients required extension of the proximal landing zone (autologous double transposition n ¼ , subclavian-to-carotid artery transposition n ¼ ) prior to stentgraft placement. results. supraaortic rerouting procedures and endovascular stent-graft placement were performed successfully in all patients. closure of the primary entry tear, full expansion of the stent-graft and consecutively, thrombosis of the false lumen was achieved in five patients. in one patient with a short proximal landing zone, a persisting type ia endoleak had to be observed. in all patients with successful primary entry closure, a reduction in aneurysm diameter could be seen. mean follow-up is months ( - months). conclusions. endovascular stent-graft placement of aneurysms involving the descending aorta originating from chronic type b dissections may serve as a valuable treatment option in a complex pathology. the chronic dissection membrane can be successfully approximated to large parts of the native aortic wall. a sufficient proximal landing zone is mandatory for early and late success. background. the aim of the study was to determine late vascular events in patients after endovascular stent-graft placement of thoracic aortic diseases. methods. between and a total of patients (mean age a; % male ¼ ) underwent endovascular stentgraft placement of thoracic aortic diseases at our institution. indications were aneurysms (n ¼ ), acute and chronic type b dissections (n ¼ ), penetrating ulcers (n ¼ ) and traumatic transsections (n ¼ ). results. during a median follow-up of months ( - months), in % of patients, late vascular events were observed. the highest incidence was observed in patients after stent-graft placement for type b dissections ( %), closely followed by patients after stent-graft placement for penetrating ulcers ( %). the incidence after stent-graft placement for aneurysms was %. no events were observed in patients after traumatic transsections. interestingly, patients undergoing stent-graft placement due to dilatative arteriopathy developed further dilatations in other regions and patients undergoing stent-graft placement due to obliterative arteriopathy were more prone to sustain obliterative diseases in other vascular beds. conclusion. this study clearly outlines the necessity of a close follow-up in these patients, not only to assess long-term outcome of endovascular stent-graft placement, but also to monitor these patients for new vascular pathologies. tenascin-c as a key factor in the remodeling of the ascending aorta leading to chronic dilatation and acute type a dissection background. the extracellular matrix molecule tenascin-c (tn-c) plays an important role in embryonic development, wound-healing, cancer invasive fronts and myocardial remodeling by loosening the linkage between connective tissue and cells lying within. as there is clear evidence for an involvement in vascular remodeling as well, we hypothesized tn-c being a mediator in the pathogenesis of chronic dilatation of the ascending aorta and acute aortic dissection. methods. ascending aortic wall specimens were obtained from patients undergoing aortic reconstruction due to chronic dilatation of the ascending aorta (n ¼ ) and acute aortic dissection stanford type a (n ¼ ). specimens of patients (n ¼ ) undergoing aortic valve replacement with a macroscopically normal aorta served as controls. formalin-fixed paraffin-embedded specimens were morphologically evaluated by hematoxylin-eosin staining and immunostaining for tn-c expression. results. there were no differences in clinical characteristics concerning age and gender between patients with acute dissection, chronic dilatation and control. patients with a known connective tissue disorder or bicuspid aortic valve were excluded from the study. histologic examination showed a clear difference between chronic dilatation and acute dissection. in chronic dilatation tn-c staining was homogenously distributed throughout the media parallel to the orientation of vascular smooth muscle cells. in contrast specimens in acute aortic dissection showed a focal strong positive staining especially surrounding vasa vasorum and sites of intramedial hemorrhage and subsequent dissection throughout the whole vessel wall with tn-c negative areas in between. whereas in control aorta tn-c expression was almost absent. conclusions. these data suggest a role for tn-c in the remodeling of the ascending aorta leading to chronic dilatation and type a dissection. keeping in mind the differences in tn-c expression between chronic dilatation and acute dissection one may speculate that changes of the vascular wall leading to aortic dissection are mediated or at least accompanied by a change in tn-c distribution. a complicated type b-dissection: how (not) to do it j. demmer , m. alavian , p. pichler , c. groß chirurgie , akh linz, linz, austria; radiologie, akh linz, linz, austria complex type b-dissection is still accompanied with high mortality. we report on a years old male with a weeks ongoing history of thoracic pain. he was admitted to another hospital where a left renal artery stenosis in ct scan was suspected and a stent was applied into the false lumen of this artery. then the patient was transferred to our institution. angiogram revealed a type b-dissection with a hugh entry distal to the left subclavian artery, the coeliac trunk arising from the false lumen but the hepatic arteries adequately collateralized by the superior mesenteric artery. though guidewire insertion to the true lumen of the common hepatic artery was feasible, stent application was not possible.the entry in the proximal descending aorta was covered with an endostent, thoracic pain disappeared immediately. though a slight pain in the right upper abdomen and a moderate raise of got, gpt and y-gt was to be seen for a few days, the patient could be discharged weeks after stenting in good condition without having pain or signs of cholecystitis. another days later he was readmitted in bad condition with signs of peritonitis in the right upper abdomen, , wbc and a massive increase of liverenzymes. laparatomy was performed immediately. the gallbladder presented necrotic, the whole liver dark blue without any pulsation in the hepatic arteries. after choecystectomy an autologous venous bypass from the common iliac to the propriet hepatic artery was performed. the postop. course presented uneventful, angio-ct at postop. day showed a well contrasted bypass. the patient could be discharged at postop. day without any signs of infection and only slightly elevated liverenzymes. background. endovascular aneurysm repair (evar) evolved as a treatment option for high risk patients, in whom previously open graft replacement (ogr) could only be carried out with a high, nearly prohibitive risk or open repair even had to be denied. by employing evar the mortality rates (mr) were lowered to - % in specialized centers. unsolved is the problem of how to deal with patients unsuitable for evar. the hypothesis of this study was to test whether thoughtful watching combined with management of present risk factors or ogr were second best to evar in asa class iv patients with abdominal aortic aneurysms (aaa). methods. out of a total of aaa-patients two groups of asa class iv patients were selected and compared. group consisted of patients who underwent ogr from - . group included patients unfit or unwilling to undergo evar in the period from - . kaplan-meier survival estimates were calculated and possible differences were analyzed by the log-rank-test. results. the day survival was . % in group versus % after days following the denial of operation in group (p < . ). the days survival was again significant with p < . , group % versus group . %. after one year survival was not significant anymore, i.e. group . % versus group . % (p < . ). conclusions. ogr has a significantly worse survival than conservative treatment in asa class iv patients in the first months after operation. after one year both treatment options show similar results. background. abdominal aortic aneurysm (aaa) size has been recognized as risk factor of rupture. several reports presented evidence that aaa with diameters exceeding . cm are associated with increased risk of rupture compared to smaller aneurysms. regarding these findings a diameter of more than . cm is generally considered as indication for exclusion. this analysis was undertaken to determine the influence of aneurysm diameter on long term outcome after either type of elective aaa repair. methods. eight hundred and sixty four consecutive patients underwent elective repair of an infrarenal aaa either by open graft replacement (ogr, n ¼ ) or endovascular aneurysm repair (evar, n ¼ ) from january, , through june, . median aaa diameter was chosen as threshold to discriminate between small and large aneurysms. patient characteristics, distribution of preoperative risk factors and postoperative outcome after either type of aaa exclusion were assessed. survival was compared using kaplan-meier estimates at years. results. overall median aaa diameter was . cm as well as in both treatment groups. analysis of risk factors only re-vealed that patients with larger aneurysms were significantly older (ogr . years vs. . years, p < . ; evar . vs. . years, p < . ) but comparison of individual health status expressed by the american society of anesthesiologists (asa) score did not reach statistical significance. at years, overall survival was higher in patients with small aneurysms ( . vs. . %, p < . ). similar results were obtained in patients undergoing ogr ( . vs. . %, p < . ) as well as evar ( . vs. . %, p < . ). conclusions. patients with aneurysms smaller than . cm have improved survival at years after either type of elective aaa repair. large aneurysm diameter is accompanied with increased age, which might negatively influence long term outcome. thus, the provoking issue to exclude small aaa before they reach . cm may rise again. background. about microsurgical techniques without sutures many references in literature databases are found. among facilities like rings, clips, stents, laser and adhesives the vessel coupling system (coupler + ) is mentioned. thereby two coupling rings interlock, which anastomose the vessels. methods. over the last two years in our division the coupler + was used in nine cases of free tissue transfer for breast reconstruction. in six of them the arterial and venous anastomosis were performed with the coupler + , in three cases only the venous anastomosis was done mechanically. in all cases the anastomosis was end-to-end. results. because of insufficient arterial adaptation in two cases we switched to a conventional procedure with sutures. all the other anastomosis showed a normal flow. except of one partial necrosis of a flap, which was not due to the coupler + , all flaps survived. the mean duration of doing the anastomosis was less than five minutes. conclusions. the coupling system (coupler + ) is a useful, secure and time saving tool for the venous anastomosis when performing a free tissue transfer. for the arterial anastomosis the conventional method is preferable, especially in cases of arteries with thick walls. background. non-operative management of splenic injuries is beneficial compared to surgery in hemodynamically stable patients. aim of this study was to assess whether conservative treatment would also translate into better quality of life post injury. methods. all consecutive patients with splenic injuries between january to february were included. splenic injuries were graded according to aast recommendations [ ] . patients were identified from our electronic inpatient index and stratified by non-operative treatment (non-operative group, nog) or primary surgery (splenectomy) (surgical group, sg). postdischarge quality of life was evaluated by a standardized telephone questionnaire. data are reported as total numbers (%) and statistical analysis performed using chi -tests. significance was assumed if p < . . results. of a total of patients enrolled, ( . %, nog) were treated non-operatively, and ( . %, sg) underwent splenectomy. splenic injury grading was comparable between both groups. after trauma, most patients were able to leave their bed three days after trauma ( rd postoperative (po) day: nog ( . %) vs. sg ( . %), p ¼ . ; st week po: nog ( . %) vs. sg ( . %), p ¼ . ; nd week po: nog ( . %) vs. sg ( . %), p ¼ . ), and the majority felt seriously ill during hospitalization (critically ill: nog ( . %) vs. sg ( . %), p ¼ . ; seriously ill: nog ( . %) vs. sg ( . %), p ¼ . ; not very ill: nog ( . %) vs. sg ( . %), p ¼ . ). unlike sg patients, about half of the nog patients could be discharged one week after trauma ( week: nog ( . %) vs. sg ( . %); p ¼ . ). sg patients significantly longer felt severe pain compared to nog patients ( weeks: nog ( . %) vs. sg ( . %), p ¼ . ; > months: nog ( . %) vs. sg ( . %), p ¼ . ). after discharge, nog patients were able to resume daily life activities earlier compared to patients after surgery ( weeks: nog ( . %) vs. sg ( . %), p ¼ . ; < month: nog ( . %) vs. sg ( . %), p ¼ . ; ! months: nog ( . %) vs. sg ( . %), p ¼ . ). conclusions. patients with non-operative management reported less pain and were earlier able to resume daily life after splenic trauma compared to patients undergoing splenectomy. plantation in order to prevent cmv disease. we recently evidenced immunomodulatory properties of pooled human immunoglobulines. the aim of this study was to evaluate influence of cytotect + and cytoglobin + a) on proliferative properties of peripheral blood mononuclear cells (pbmcs), b) on cell viability and c) on natural occurring cell mediated cytotoxicity. methods. pbmcs from healthy donors (n ¼ ) were stimulated with anti-cd ( mg=ml) or in an allogeneic mixed lymphocyte reaction (mlr). proliferation was determined by incorporation of [h]-labeled thymidine. apoptosis was measured by flow cytometric analysis (annexinv, -aad, cd , cd , cd , cd ). transmission electron microscopy (tem) was utilized to support facs data. antibody dependent cell mediated cytotoxicity (adcc) was determined utilizing a standard europium release assay. cmvig (cytotect + biotest, cytoglobin + bayer) was used at therapeutic concentrations in all experiments. results. cytotect + and cytoglobin + evidenced anti-proliferative properties in t-cell specific stimulation and in mlr blastogenesis assays. this effect was dose dependent and ceased at concentrations of . mg=ml (p < . ). facs analysis and tem pictures revealed that the reduced proliferation was associated with induction of apoptosis in stimulated as well as in resting pbmcs (p < . ). furthermore, adcc against panc- and jurkat cell lines was significantly reduced after preincubation of effector cells with cmvig (p < . ). conclusions. our results provide evidence that cmvig containing drugs possess, in addition to their known application as passive cmv immunization, immunological features related to tolerance induction. background. multichannel intraluminal impedance (mii) monitoring is a new diagnostic tool for esophageal bolus transport and reflux assessment. methods. review on mii technology for diagnosis of esophageal disorders. results. impedance is a measure of resistance to the flow of an alternating electrical current. a low voltage current is applied to surface ring electrodes on a nonconductive catheter. impedance is determined by the conductivity of the medium bridging these electrodes. entry of liquid into the esophageal lumen produces a drop of impedance. gas entry results in a sudden rise of impedance. monitoring impedance in several channels detects direction, velocity and extent of the movement of liquid or gas through the esophagus. stationary equipment combining manometry and impedance is used for simultaneous esophageal motility and transit studies. transport studies using impedance only can also be done with probes intended for reflux testing. saline and a viscous gel are used to assess transport through the esophagus. in a recent study with combined impedance and manometry a significantly higher proportion of patients with incomplete transport of both liquid and viscous boluses ( = , %) presented with dysphagia than patients with complete transport of both ( = , %) or incomplete transport of only one ( = , %) of the test substances. equipment joining impedance with high-resolution manometry is currently being developed. a higher sensitivity and specificity for regional motility and transport abnormalities is to be expected from this technical advancement. portable recorders are available for -hour mii-and ph-monitoring. refluxes are detected by retrograde impedance changes: liquid refluxes are characterised by retrograde drops, gas refluxes by rapid increases and mixed liquid=gas refluxes by a sequence of both deviations from the baseline. the main advantage of impedance technology over conventional ph-monitoring is the detection of refluxes independent of ph. off antisecretory medication refluxes with ph > are mainly encountered postprandially, at a time when regurgitation is commonly experienced by reflux patients. the diagnostic yield of symptom to reflux association analysis is significantly increased by the inclusion of refluxes with ph > . distribution of impedance channels along the catheter facilitates the calculation of reflux exposure at different levels above the lower esophageal sphincter. conclusions. mii is a valuable new diagnostic tool for esophageal transport assessment without radiation exposure. combined mii-and ph-monitoring significantly increases the diagnostic yield of reflux testing. both applications of impedance technology have implications on surgical decisionmaking. trans-illuminated powered phlebectomy w. mayerhoffer the trans-illuminated powered phlebectomy was introduced in austria in about by smith and nephew as the ''trivex system''. a . mm shaver, as used by orthopaedists for cartilage, was used in order to mill out subcutaneous veins in a transilluminated technique. due to only a few and small incisions needed, the method seemed very attractive, so many surgical departments started using this orthopaedic equipment. most surgeons had a lot of complications, such as disastrous extensive haematomas, which made them stop using this method. mean while the trans-illuminated powered phlebectomy has been further developed. instead of the orthopaedic tools, a special phlebologic equipment is used now which allows the vein to be ''sucked'' out in a very non-traumatic order, instead of being milled out. the procedure is standardized and can be reproduced easily. it shows to be a non-traumatic and minimal invasive method to extract subcutaneous varicose veins, leaving a minimum of scares. large clusters of varicose veins are the best indication to use this procedure. the veins are made visible by transillumination in order to be accurately removed through a minimal number of small incisions. the new equipment and the technique will be described and explained. examples and results will be shown. background. total endoprosthesis in wrist joint is a rather new procedure compared to hip and knee surgery. biomechanics of the wrist joint is very complex and therefore designing the carpal and radial component of the prosthesis should respectfully consider this. indication for joint replacement and total endoprosthesis are posttraumtic and degenerative arthrosis of wrist joints. generally we tend to perform a partial fusion depending on where the arthrosis is located, but we have stopped to perform total arthrodesis of the wrist joint due to unsatisfying long term results, according to literature. we perform total endoprosthesis in all cases when a partial fusion is impossible for any reason or a total arthrodesis would be indicated. methods. nine males [ - a] four females [ - a]. seven of nine men suffered from a posttraumatic arthrosis ( slac snac). all patients sufferd from serious reduction of range of motion and severe pain. in one case a partial fusion was converted into a total prosthesis. two women had degenerative alterations of their wrists based on rheumatoid desease. the follow up covered months to years. results. in = cases range of motion was improved impressively and pain was relieved almost completely. seven men displayed a rom of s = = ; pro-supination totally unaffected and free. in one case we found rds. x-ray examination revealed a slightly false implant position of the radial component to us. rom in women was at least s = = . conclusions. in the beginning of wrist joint endoprosthesis results were less well and it was shown that this was due to misunderstanding biomechanical basics of the wrist joint. the fixation of the carpal element was a severe problem, like passing through the cmc , and joint line distally into the basis of the metacarpal bones and since cmc and joints have a rather high rom the distal element consequently often loosened immediately. recent implants respectfully avoid passing through these joints and loosening of the distal element has never been seen in all our cases. in our opinion the endoprosthesis of wrist joint is a real alternative to common procedures in the treatment of wrist arthrosis. background. volar fixed-angle plate osteosynthesis of distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without incurring the disadvantages of the dorsal approach. the aptus + plate is a new fixation implant that was introduced specifically for the purpose of managing dorsal displaced fractures (colles fracture) from the volar aspect. the aptus + system provides stepless multidirectional placement of screws. the range of swivel ae in all directions, can be freely selected by the surgeon. methods. between april and september ( months) we have seen patients with a distal radius fracture. eighty five patients ( women, men; mean age . years) were treated with the medartis + aptus + plate. our therapy regimen: closed reposition in the operating room palmar access along the radial side of the flexor carpi radialis (fcr) muscle plating with subchondral screw placement begin of physiotherapy on the first postoperative day and removeable orfit splint for weeks. results. the clinical and radiological follow up after Ø months showed no secondary loss (relative protrusion of the ulna, dorsal or radial tilting) of correction. compared to the contralateral side the range of motion was decreased for % in extension=flexion, % in ulnar=radialduction, % in pronation=supination. the grip strength was decreased for % compared with the contralateral side. the castaing score shows perfect results, good results, adequate result and no moderate, poor or bad results. conclusions. our data clearly show that secondary correction loss can be avoided with the aptus + system. the system provides a reliable subchondral screw placement and solid support for the joint surface. this new plate makes meaningful early mobilization possible. the palmar approach provides exact fracture reposition and with its good soft-tissue coverage not only reduces the risk of infections but also offers the possibility of not having to remove the plate. a cancellous bone graft is not necessary. background. the arthrosis of the first carpometacarpal joint is one of the most common problems in handsurgery. primarily elderly women are affected by rhizarthrosis. under conservative treatment the continuing progress leads to operation indication, for pronounced pain and insufficiency of conservative therapy options. the huge amount of well-know operation methods shows, that no satisfying option could have been described. next to simple resection procedures, today interposition and suspensionarthroplasties play a key role in the care of arthrosis of the thumb saddle joint. the amount of endoprothetic procedures in the first carpometacarpal joint has been rather small, the results often remained unsatisfying. a rather new concept is the prosthesis elektra, developed by fixano in , that reminds of the classic de la caffiniere prosthesis, first described in . methods. in the years = in our department patients (Ø . years - , male:female ¼ : ) with advanced saddle joint arthrosis were treated with different operation methods: patients received an elektra-prosthesis, patients a resection-suspension arthroplasty martini. thirty seven of these were recorded in the follow-up study. the rest of the patients were deceased, removed or not accomplishable. the follow up examination contained following criteria: dash score, subjective pain scale, range of motion and radiology. results. in the follow-up examination of patients no significant differences in average results of the different operation methods could be investigated. thus, the group of patients with very good results contained significantly more patients with elektra prostheses than patients treated with martini operation. in the opposition a higher complication rate could be seen in patients with elektra prostheses. especially the loosening of the implant cup was a frequent complication in average dash score, subjective pain scale and range of motion showed similar results in both methods. conclusions. our results show that the elektra prosthesis is a good and efficient alternative method to other well-known treatment concepts of rhizarthrosis. the amount satisfying results of the elektra group excel the good results in the martini group. the biggest problem concerning the elektra prosthesis is the high frequency of cup loosening, that is unacceptable high. the treasons for that matter could be complex: . biomechanical problem, because of the converting of a saddle joint to a universal joint, . metallurgic problem that could be solved by the use of different surface material, . vitality problem of the os trapezium because of an unfavourable quotient of metal and bone. unsettled remains, if revision or cementing of the cup could be a possibility to salvage of the implant. a conversion of the procedure to resection methods is possible anytime. so the use of the elektra prosthesis still is a good alternative under the condition of a clear indication and information of the patient about the possibilities of loosing. background. posttraumatic arthrosis as well as loss of function in the pip joint due to rheumatoid disease mean for the patient to be afflicted with pain. in many cases this leads to serious diminution of quality of life and in some cases the patient looses his occupation. it is the goal of implantation of total endoprosthesis to sustain movement and improve the range of motion, but most importantly to exterminate the pain. certainly removement of pain can be obtained by a simple arthrodesis but this of course is less satisfying in comparsion with mobility in the pip joint provided by the prosthesis. since pip joint endoprosthesis is a relativley young and new procedure there are only view experiences found in literature. methods. nine pip-endoprostheses have been implanted without cement so far. in cases posttraumtic arthrosis was the indication for this procedure; in cases rheumatoid destruction of the joint. in all cases the collateral ligmantes were intact. four lpm and sr avantas were used. postoperative the finger was placed on a splint for one week in intrinsic plus position. after days we commenced passive ergotherapiy and after one week we started with active motion. results. mobility was improved impressively in cases. all patients were almost completely free of pain. all pipjoints were stable. there was one patient who suffered from a new trauma after the operation and the proximal component had gotten loose, so we had to convert it to an arthrodeses. in cases we found a significant loss of extensor tendon function. conclusions. development and design of pip endoprosthesis has not found its final goal; this can be told by the variety of pip-joints which are found in the free market. passing throgh the extensor tendon is a sensitive point in the procedure and it should be noted in the preoperative information that there might be a decreased extensor tendon function. nevertheless in our eyes the pip prosthesis represents an intersting alternative to pip-arthrodesis and in cases of failure of the prosthesis it can be easily converted into a classical arthrodesis. osteosynthesis of proximal humeral fractures using a dynamic angular stable plate e. aschauer , l. schmid , c. maier unfallchirurgie, bad ischl, austria; fa. hofer, fürstenfeld, austria background. fractures of the proximal humerus are frequent and represent a therapeutic problem. the proximal humerus plate of the dfd system (double-fix-dynamic) fixes the fragments angular and rotational stable and is implanted minimally invasive. a special instrument allows precise closed reduction. due to the dynamic character of the osteosynthesis bone healing is stimulated. methods. two plates are connected with short screws in linear holes so that they can move against each other. the head fragment is fixed to the main plate with long screws coming steeply from distally. the dynamizing plate fixes this situation to the humeral shaft. for implanting the plate is fixed to a guide instrument, which therefore can be used as a joy-stick. so it is possible to reduct the shaft to the head exactly. to implant the dfd only two small incisions are required. one of cm to slip the plate under the delta muscle and to insert the head screws. and a second of cm proximally to fix the guide instrument and insert the shaft screws. in bad ischl the dfd-php is in use since november . up to now patients were operated. fourty three were female, male. the average age was . years ( - ). in cases it was a dislocated subcapital fracture. nineteen had a threepart-, a fourpart fracture. four fracture dislocations and true headsplits also could be done with closed reduction on this technique. four fractures were located at the anatomical neck. results. our first experiences were very well. currently we cannot report any complications due to the implant. there was no loosening or breakage. we watched no loss of reduction. noticeable was lack of pain immediately after the operation. so the patients came back to their former level of activity very fast. our complications were one infection forcing us to remove the implant -the case came to an end in pseudarthrosis which the patient bears well. another lady suffered a repeated fracture caused by a slight injury. one pseudarthrosis happened due to too early removal. conclusions. with the dfd-php now an implant is available that enables us to expand the indications for head preserving therapy of proximal humeral fractures. especially older people benefit from this method because there is hardly soft tissue damage but nevertheless a reliable stable situation that leads to bone healing in correct position and a good shoulder function. background. treatment of unstable distal metaphyseal tibial fractures with intramedullary nailing remains challenging even in fractures without intra-articular involvement. proximity to the ankle and biomechanical aspects makes the surgical treatment more complicated compared to fractures of the midshaft. intramedullary nailing (imn) is the ''golden standard'' for midshaft fractures but can be challenging in distal metaphyseal fractures. therefore, optimal surgical treatment of these fractures remains controversial. the aim of our study was to evaluate different tibial nails of the newest generation in a biomechanical approach. methods. defined osteotomy was performed in sawbone composite tibial fractures to create an unstable distal tibial fracture model. after nail insertion, distal tibial locking was performed with or locking screws. samples were cyclically loaded with , cycles and increasing load from ae n to and n. defined parameters such as alignment, varus, valgus deformation, antecurvation and recurvation were recorded. samples were then statically loaded until failure. acoustic emission technique was used to detect microfractures of bone, screws and nail. data according to failure of screws and nail were obtained. results. in case of physiological loading ( , cycles; ae n) loss of stability and damage of screws, nails and bone could not observed. failures occurred in loading series. stiffness was significantly higher in tibial nails with distal locking screws. stability of nail-bone construction was significantly higher in nails with distal locking options and in nails with diameter of distal locking screws more than mm. conclusions. intramedullary nailing can be recommened in unstable distal metaphyseal tibial fractures without intra articular involvement. four distal locking screws with . mm diameter should be used. our data suggests that immediate full weight bearing is possible postoperatively in young healthy patients without osteopenia even in this fracture type. because of the rising number of implantation rates of hip and knee arthroplasty as well as the increase number of osteosyntheses of the femur in geriatric patients the periprosthetic fractures are becoming more importance in orthopedic and trauma surgery. osteoporosis and the high rate of comorbidity makes a strong preoperative planning of the operation procedure necessary. prosthesis loosening or defects of the periprostetic bone may indicate a revision arthroplasty. in the new literature ostheosynthesis is usually conducted with locked screw plates as well as with intramedullary locking nail systems. a traditional alternative is the application of a condylar plate. usually used in trochanteric and subtrochanteric fractures of the proximal femur as well as in complex distal femur fractures it is also an effective implant system in periprosthetic fractures. several examples are shown and discussed. we respect to the classification of periprostetic fractures of johanson in our report about patients. six of them underwent a revision arthroplasty and in cases an osteosynthesis was done. five of them include the implantation of a condylar plate. the improved trauma room management by installation of a four-phase watch g. fronhöfer, m. kerl background. since the parameters of the severe traumatised patients of the trauma hospital graz have been collected and analysed at the trauma register of the dgu. according to the recommendation of the dgu a special four-phase watch was installed in to improve the effectiveness of the diagnosis and treatment process optimize in the trauma room. methods. the watchface has the typical colour coded phases and a flipchart shows the prepared standard sequence of trauma room management which has been developed interdisciplinary by surgeons, anesthetists, radiologists and carers. the parameters and the time process are further documented according to the guidelines of the trauma register of the dgu. results. the timelapse to x-ray or ct is reduced, the diagnoses are found quicker and patients can therefore be treated earlier at their adequate therapy. the motivation of the medical team is increased. conclusions. the four-phase trauma room watch has a many advantages and as recommended by the dgu should be installed in each trauma room. background. the treatment of an acute abdomen is without a doubt a domain of the surgical department. there are already specific treatment algorithms in place. due to the ever-present pressure to keep costs to a minimum, as well as the ever-changing technical advancements of diagnostics, it is vital to re-think and possibly modify existing treatment algorithms. therefore, patients in our facility were analyzed. methods. in erlangen, patients with an acute abdomen were treated in the timeframe from january , to december , . the average age was years, and the ratio males:females was : . . all data were collected prospectively through patient histories as well as clinical documentation. consequently, they were retrospectively evaluated. following the case history, labarotory tests and physical examination, sonography of the abdomen was used as the baseline diagnostic modality, as well as conventional radiography of the abdomen. results. of the treated patients, only ( %) required surgery. the average length of stay was days. in patients, a clinical diagnosis of appendicitis was made. in % of these patients, the confirmation of their diagnosis could be made, using the baseline diagnostic modalities. for the rest of the patients, further diagnostic modalities were needed (such as ct). in patients, a primary diagnosis of coprostasis was made. in % of these patients, a conservative treatment could be offered, and the patients left our facility without symptoms. in % of the patients, further diagnostic modalities (radiological and=or endoscopic) showed a finding that required surgical attention. conclusions. in the normal=routine clinical picture of appendicitis, baseline diagnostics are sufficient. however, behind apparently harmless diagnoses such as coprostasis, there are serious illnesses that may be masked. therefore a different course of action must be considered (ct). as a possible side-effect of this course, patients without pathological manifestations could be treated on an out-patient basis, thus reducing total costs. background. the aim of the study was to investigate: i) relevant and combined determinants of the development, management and outcome of a representative patient cohort (n ¼ . ) with acute appendicitis enrolled in a prospective unicenter study through a time period of years (middle europe), and ii) the frequency and impact of specific categories (e.g., characteristics of the medical history, clinical and intraoperative findings, complications), correlation and relative risk factors of the disease and its prognosis. methods. by the mean of a prospective unicenter observational study, numerous characteristics as mentioned in the ''aims'' were documented and influencing variables with significant impact on the outcome were statistically determined. results. ) the wound abscess rate was . %. perforation, surgical intervention on time, acute, gangrenous and chronic appendicitis, age, adverse diseases such as obesity, arterial hypertonus, diabetes mellitus, sex and missing pathological finding intraoperatively showed a significant impact on the postoperative development of a wound abscess. ) the longer the specific appendicitis-related medical history lasted, the i) more frequent a perforated appendicitis occurred (interestingly, this rate significantly increased up to . % through the various time periods), ii) greater the false-positive appendectomy rate was (p < . ), and iii) higher the rate of the required second (subsequent) interventions was ( . %; p < . ), which occurred significantly more often in obesity ( . %) and wound abscess ( . %). ) the mean postoperative hospital stay was days. ) there was a significant decrease of the percentage of patients with no pathological finding of the ''appendix vermiformis" intraoperatively, who underwent appendectomy, in particular, to only . % through the last investigation period from to ( - , . %; - , . %). ) the mortality was . % showing no significant difference between male and female patients (p ¼ . ), between the investigation periods (p ¼ . ) and between the patients with false-positive appendectomy ( . %) and that with acute appendicitis ( . %; p ¼ . ). conclusions. in summary, this study demonstrated a substantial progress of the quality of surgical care within the participating clinics with regard to the rates of false-positive appendectomies, of postoperative wound abscesses and, in particular, to mortality, one of the strongest criteria of quality control. despite this, there is an increasing rate of perforated appendicitis in the investigated cohort. in conclusion, quality control remains an indispensable tool for evaluation and assessment of surgical care even in the most frequent diseases of the daily practice, which can be further improved by a multicenter study setting. acute mesenteric ischaemia -looking at the past, learning for the future e. schröpfer, a. thiede, t. meyer background. acute mesenteric ischaemia (ami) is a rare disease with still -despite all progresses in medicine -a high mortality rate ranging from to % according to literature. the aim of this study was to analyse the outcome of our patients after traditional therapy, in order to be able to conduct new strategies of treatment. methods. in this retrospective study all clinical reports (since = ) containing the diagnosis ami (icd : k . ) were analyzed with regard to initial laboratory findings, pre-operative diagnostics, surgical methods, intra-operative results, etc. results. the diagnosis ami was encoded for patients in the aforementioned period of time. twenty patients had to be excluded from the study, due to other collateral diseases. among the remaining patients (with an average age of . years) died initially (initial mortality . %). the main risk factor ( . %) was arrhythmia absoluta. . % of the patients presented the symptoms of an acute abdomen, . % were suffering from progressive abdominal pain. besides anamnesis, physical examination and laboratory only . % of the patients obtained an abdominal ct and . % obtained a dsa. because of the unambigousness of the anamnestic and clinical findings . % of the patients received an immediate explorative laparotomy without any further diagnostic. conclusions. despite the typical triphasic progression of the ami (intense abdominal pain -apparent recovery -acute spreading peritonitis) and all modern possibilities of diagnostics the mortality rate of ami is still appallingly high. looking at the past, diagnostics as well as therapy should be included in modern findings and open up new possibilities. bckground. data are rare about the impact of infection on postoperative mortality in an unselected surgical population. aim of the study was to analyze whether infection is a significant cause of death in these patients. methods. at a department of general, vascular and thoracic surgery in a secondary to tertiary referral centre, all patients operated from = to = (n ¼ ) were included in a prospective database and analyzed retrospectively. overall mortality rate . % (n ¼ ( abdominal, vascular, thoracic surgery)). . % emergency - . % planned operations. cause of death was defined by clinical chart review and post mortem section. stratification criteria (sex, age group, asa, malignancy, infection prior to surgery, abdominal surgery, emergency operation) were analyzed by multivariate regression analysis. results. cause of death: n ¼ ( . %) infection, n ¼ ( . %) cardiovascular, n ¼ ( . %) progression of malignancy, n ¼ ( . %) pulmonary embolism. subgroup analysis of postoperative death due to infection revealed that . % (n ¼ = ) of patients had infection already prior to surgery and . % (n ¼ = ) developed postoperative lethal infection. mortality caused by infection was . % (n ¼ ) in abdominal, . % (n ¼ ) in vascular and % (n ¼ ) in thoracic surgery. regression analysis identified infection prior to surgery (p ¼ . ) and abdominal surgery (p ¼ . ) as statistically significant independent risk factors for postoperative mortality due to infection. conclusions. postoperative mortality is highly associated with infection. in an unselected cohort of surgical patients those presenting with infection prior to surgery and those undergoing abdominal surgery are at highest risk of death from infection. management of complications in laparoscopic colo-rectal surgery m. hufschmidt, u. obwegeser, a. haid, e. wenzl background. laparoscopic colo-rectal surgery is considered to be a standardized procedure for the two main-indications: diverticular disease of the sigmoid colon and complicated crohn's disease of the ileo-cecal region. moreover these procedures seem to have served as a sort of pacemaker to so-called fast-track-protocols. while the extension of laparoscopic procedures to oncological indications is in a wide-spread controversial discussion, only few publications are considering the impact of complications in the outcome of surgical therapy of benign diseases. methods. a retrospective study of laparoscopic colorectal procedures performed between = and = was undertaken. indications and technical approaches as well as rates of conversion, duration of intervention and hospital-stay are detailed. complications leading to relaparotomy, interventional or conservative therapy are reviewed in detail to analyse their reasons. results. with a conversion-rate of . %, a mortality of . % and an overall morbidity of . % the occuring complications may be categorised in different groups, distinguishing intra-operativly, early or late, major or minor and procedurerelated or intercurrent-ones solicitating either conservative, interventional ( . %) or surgical ( . %) treatment. several causes are being isolated such as learning-curve, body-mass-index, comorbidity, sequelae of previous operations and severity of intraoperative findings. conclusion. as for conversion, complications influence parameters as hospital-stay or feasibility of fast-track-protocols somewhat watering the advantageous results of laparoscopic colo-rectal surgery. a careful analysis is therefore advisable not only to avoid reiterating complications but also to permit the access to oncological colo-rectal laparoscopic surgery as well. background. the value of quality control in general surgery is actually soaring. unplanned reoperation is seen as one of the most important quality measures. however, there is a lack of data regarding the impact of infection as an indication to unplanned reoperation. methods. at our department of general (including kidney transplant), vascular and thoracic surgery in a secondary to tertiary referral centre, all patients undergoing unplanned reoperation from = to = were included in a prospective database. unplanned reoperation was defined as unplanned return to the or within days during hospitalization. targets were unplanned reoperation due to infection, type of infection, type of primary surgery, mortality and a comparison to a former data collection from = - = after starting a monthly review of reoperation data in terms of a morbidity-=mortality conference = . results. one hundred and thirty nine ( . %) of patients were undergoing unplanned reoperation. ( . %) due to infection, ( . %) due to postoperative bleeding and ( . %) due to other indication. subgroup analysis of those reoperated due to infection identified leakage of the anastomosis in % ( = ) and abdominal wall rupture in . % ( = ) as predominant causes to reoperation. other indications to unplanned reoperation were small bowel perforation ( = ), abscess ( = ), leakage of ileostoma ( = ), thoracical phlegmon ( = ), ureter-necrosis ( = ), recurrent infection of lung parenchyma ( = ) and superficial surgical site infection ( = ). mortality in the infection subgroup was . % ( = ) compared to . % ( = ) of all reoperated patients. overall mortality was . % ( = ). furthermore we could achieve a decrease of mortality in infection subgroup from to . % comparing to our former data collection of = - = . an additional analysis of infection germs was not striking. conclusions. postoperative infection is the underlying mechanism leading to reoperation in a significant number of patients. data analysis showed a much higher mortality in these patients. the reported decrease of mortality from to . % maybe attributed to the consequent prospective monitoring and monthly review of reoperation data we had introduced = . gallstone-ileus -nowadays still a remaining important differential-diagnosis to consider at presence of acute abdominal pain r. hammer , p. habertheuer , w. brü nner , c. bauer , n. schreibmayer , f. flü ckiger , p. steindorfer department of surgery, lkh graz-west, graz, austria; department of radiology, lkh graz-west, graz, austria background. - % of all mechanical obstructions in small bowel are represented by gallstone-ileus as a complication of cholelithiasis. as it is frequent in the elderly population (it accounts for almost % of non-strangulated intestinal obstruction in patients > years), there is a high mortality-rate of - % depending on age and co-morbidity. in less than % of patients with gallstones cholecystoenteric fistula occurs (most likely cholecystoduodenal in %, cholecystocolic, cholecystogastric-and cholecystodochoduodenal have also been described). methods. between october -december we performed cholecystectomy on patients and laparatomy on patients due to mechanical obstruction of the small bowel. the frequency of gallstone-ileus can be reported on patients, which underwent surgery due to intestinal obstruction because of gallstones. one recurrence of gallstone-ileus due to the lack of exploration on finding massive postinflammatory adhesions and adherence of the major omentum was seen. in all patients clinical evidence of intestinal obstruction detected pneumobilia as well as ectopic gallstones was confirmed by either plain x-ray or ct-scans. results. at our department a frequency of patients (average age . yrs (range - yrs) males, females) presenting with gallstone-ileus (in a total of patients undergoing cholecystectomy and patients undergoing laparotomy due to small-bowel-obstruction) were treated, that means a rate of gallstone-ileus in . % ( = ) compared to the patients with che, and . % ( = ) in laparotomies due to small-bowel obstructions performed at this period. all patients underwent an one-stage operation, in cases consisting of enterolithotomy and stone-extraction as single procedure only (without dismantlement and exploration of the fistula), in further cases cholecystectomy and suturing of the entero-biliary fistula synchronously were additionally performed. the obstruction occurred  duodenal,  jejunal and  ileal, the location of the fistula situated duodenal in times, once jejunal and  non-explored. the diameter of the obstructing stone varied between and cm (average of . cm), patients recovered well, one expired because of the development of ards. conclusions. gallstone-ileus is a rare diagnosis, nevertheless it should still be kept in mind and considered as important differential-diagnosis in acute abdominal pain as shown on the numerous cases at our department. for reducing perioperative mortality the treatment has to be adapted on patients conditions, if necessary performing enterolithotomy as a single procedure only, and considering to correct the fistula in a second procedure on symptomatic patients. in the program of the austrian surgical convention different working groups and specialised societies are listed up, stating that the specialisation in surgery is increasing. however, the question remains, which fields of specialisation are realistic for a general surgical department with a limited staff? in the last years a main focus of interest has been established for the following fields: endoscopy: gastroscopy, sigmoideoscopy, colonoscopy with interventions is performed by all, ercp by two surgeons of the staff. minimal-invasive surgery: choleystectomy, appendectomy, hernia surgery is performed by all surgeons, colon resections, gastro-oesophageal surgery by three of the staff. endocrine surgery: surgery of the thyroid and parathyreoid gland by three surgeons. specialized breast surgery: such as oncoplastic surgery and breast reconstruction by two surgeons. varicositas surgery: crossectomy and stripping, evlt, trivex, venocuff by two surgeons. the development of specialization in a general surgical unit will be presented. methods. review on cle. results. due to reflux esophageal squamous epithelium is damaged and replaced by cle, which is of esophageal origin and interposed between squamous and gastric oxyntic mucosa (om). the paull-chandrasoma histopathology cle classification includes oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) without or with intestinal metaplasia (im ¼ barrett esophagus). via low (lgd) and high grade dysplasia (hgd), im may progress towards eso-phageal adenocarcinoma (ac; annual incidence . - . %). presence of cle is associated with pathologic esophageal acid exposure and impaired esophageal motility and dysfunction of the lower esophageal sphincter, as assessed by ph monitoring and esophageal manometry, respectively. cle without and with im is assessed in and - % of symptomatic gerd patients, respectively, irrespective of presence or absence of endoscopic visible cle. surveillance endoscopy and biopsy sampling are recommended after - , - and . years for cm, im and lgd, respectively. treatment of hgd and ac stage ia include endoscopic mucosal resection or esophagectomy. esophagectomy is recommended for ac > stage ia. recent studies indicate that antireflux surgery may reverse im and low grade dysplasia (lgd). seven years after ph-monitoringproven effective (n ¼ ), but not ineffective (n ¼ ) nissen fundoplication, im reversed towards cm without progression towards ac. fourty months after nissen fundoplication and bile diversion (n ¼ ), % regressed from im to cm, % remained at im. . years after gastric bypass (n ¼ ), im-patients regressed (n ¼ ) or had im (n ¼ ), none progressed. a recent study compared the effect of proton pump inhibitor (ppi) (n ¼ ) vs. fundoplication (n ¼ ) in patients with cle containing low grade dysplasia (lgd). eighteen months after ppi treatment and fundoplication, out of ( . %) and all out of patients, respectively, reversed from lgd towards intestinal metaplasia. conclusions. cle is defined by histopathology. evidence justifies to investigate impact of effective fundoplication on cle within prospective studies. background. during endoscopy the stomach is considered to commence at the level of the rise of ''gastric'' rugal folds. anatomy studies suggested that rugal folds may contain columnar lined esophagus (cle), the morphologic consequence of gastroesophageal reflux disease (gerd). we investigated the histopathology of endoscopic ''gastric'' rugal folds in gerd patients. methods. seventy-five consecutive gerd patients ( males), age: ( - ) years, prospectively underwent endoscopy, including biopsy sampling from the endoscopic esophagogastric junction (egj): , . , . cm distal and . and . cm proximal to the rise of the rugal folds. cle was cataloged according to the histopathologic paull-chandrasoma classification. results. normal endoscopic esophagogastric junction, visible cle . and > . cm was assessed in ( %) and ( %) and ( %) patients, respectively. histology: all patients had cle at the level of rise of the ''gastric'' folds. in and % of patients cle extended . and . cm, respectively, distal to the rise of the rugal folds. gastric oxyntic mucosa was not assessed above the level of the rise of rugal folds. intestinal metaplasia (¼ barrett esophagus) was assessed histologically in ( %) patients. conclusions. regarding the diagnosis of cle, the esophagogastric junction (egj) cannot be assessed by endoscopy, but by histopathology (i.e. level of transition from cle towards gastric oxyntic mucosa). presence or absence of barrett esophagus can not be excluded by endoscopy. histopathology of multi level biopsy sampling should be considered for definition of egj and exclusion of barrett esophagus in gerd patients. pre-clinical trial of a modified gastroscope that performs a true anterior fundoplication for the endoluminal treatment of gerd background. laparoscopic fundoplication provides good reflux control but side effects due to the surgical procedure are known. different endoluminal techniques have been introduced but all with disappointing results. evaluation of the feasibility and safety of a new device, that enables a totally endoluminal anterior fundoplication for the treatment of gerd. methods. the device is a modified video gastroscope, which incorporates a surgical stapler (using standard . b shaped surgical staples) and an ultrasonic sight. the cartridge is mounted on the shaft and the anvil is at the tip. this enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and the cartridge. sixteen female swine of mixed breed were used in the study, underwent the endoscopic procedure, and were used a controls to monitor weight gain. the study animals were sacrificed at , , and weeks ( pigs each time) and visually inspected for complications, healing and fundoplication. the study was sponsored by medigus ltd. and monitored for compliance with glp regulations by an external company (econ inc.), which is glp certified by the german federal government. it was conducted at the animal testing facility of the charite virchow clinic in berlin. results. the procedure went smoothly in all pigs, median procedure time was min (range - min). at sacrifice the stapled area had healed well, all animals had a satisfactory anterolateral fundoplication, and there were no procedure related complications. conclusions. creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. proof of efficacy must await clinical trials, which are underway. design and instrumentation of new devices for performing appendectomy at colonoscopy g. silberhumer , e. unger , w. mayr , t. birsan , g. prager , j. zacherl , c. gasche background. appendectomy is the most common operation in the gastrointestinal tract. there is increasing interest in interval appendectomy as a treatment for refractory ulcerative colitis. a less-invasive flexible endoscopic method for removing the appendix might offer advantages especially for interval appendectomy in patients undergoing colonoscopy. aim: to design, develop and test new devices for removing the appendix via natural orifice transluminal endoscopic surgery (notes). methods. tests were performed on the bench in colons from adult human cadavers. various prototypes were tested, which could be inserted into the appendiceal orifice to its tip and could invert the appendix at its base in a controlled fashion into the lumen of the cecum. the advantage of using a tubular structure as counter force to aid inversion of the appendix was evaluated. after partial inversion the growing strain was relieved by endoluminal incision of the mesenteric side of the appendix. closure methods with endoloops, clips and thread ties were studied. appendiceal resection was completed by snare diathermy leaving an inverted intraluminal stump. results. the position of the appendix was retrocecal in seven cases, pelvic in two, and pre-ileal or post-ileal in one each. the median length and luminal diameter was mm ( - mm) and . mm ( - mm), respectively. partial obstruction of the lumen was present in = cases. it was possible to advance the guide-wires and retraction devices to the tip of the appendiceal lumen in all cases. partial inversion of the appendix was successful in = tests. the median length of the inverted stump was mm ( - mm) . the tension and volume (due to fat deposit) of the mesoappendix was the main reason for incomplete inversion. complete inversion was achieved by endoluminal incision in = tests. the mean volume of the resected tissue (inverted appendix incl. its mesoappendix) was . ae . ccm. conclusions. despite high individual variability, appendectomy at flexible colonoscopy proved to be feasible and relatively easy. new devices to allow appendix inversion were successfully tested. endoscopic necrosectomy -a feasible and safe alternative treatment option for infected pancreatic necroses in severe acute pancreatitis (case series of patients) u. will , r. gerlach , i. wanzar , f. meyer department of gastroenterology, municipal hospital, gera, germany; department of surgery, university hospital, magdeburg, germany background. endoscopic necrosectomy of infected pancreatic necroses in severe acute pancreatitis is considered an alternative but minimally invasive treatment option instead of the more traumatic open surgery. the aim of the study was to investigate feasibility and outcome of endoscopic necrosectomy in infected organized pancreatic necroses (iopn). methods. through a -year time period, all consecutive patients with symptomatic iopn who underwent this novel endoscopic approach were prospectively documented in a computer-based registry and were retrospectively evaluated (systematic case series). the endoscopic approach comprised: . necrosectomy via the transgastric route under eus guidance; and (optionally). . additional a) transpapillary stenting of the pancreatic duct; or b) percutaneous drainage if indicated. feasibility was characterized by success rate (clearence=downsizing of iopn, hospital stay) and outcome by complication rate (frequency of bleeding or perforation), mortality and shortterm follow-up. results. from = = - = = , patients with symptomatic iopn (maximal diameter, - cm) who underwent endoscopic necrosectomy were enrolled in the study. sixteen of them ( . %) were necrosectomized from all nonviable tissue using - (range) necrosectomies (mean, . ). in = cases ( . %), iopn were incompletely removed. the pancreatic duct was drained through the papilla because of duct disruption or dilatation in = cases ( . %). a percutaneous drainage was placed into fresh, non-organized necroses or because of acute septic problems in = patients ( . %). complications occurred in = subjects (rate, . %): bleeding (n ¼ ) managed endoscopically; cardiac arrhythmia (n ¼ ); no perforation. at the time of discharge (mean hospital stay, . d), i) internal drainage was still in situ (range, - double pigtails) in = individuals ( . %), which was extracted in the post-hospital range of - d; ii) = patients ( . %) were asymptomatic indicated by normal inflammatory laboratory parameters; iii) = subjects ( . %) showed no further iopn whereas in = patients ( . %), there was a -fold (mean) down-sizing of iopn. one patient ( . %) died from cardiac infarction on the th day of hospital stay (intervention-related mortality, %). follow-up investigation (range, - d): = subjects ( . %) developed pancreatic pseudocyst, which was endoscopically approached. conclusions. endoscopic necrosectomy combined with endoscopic placement of a internal (transgastric) drainage or transpapillary stent into the pancreatic duct is a feasible and safe treatment option even in the case of extended iopn with large pieces of necrotic tissue. background. leakage and fistulization of the gastrojejunostomy have been the major drawback of gastric bypass surgery since its first description. most authors agree that operative treatment is the mainstay of therapy in all patients with signs of sepsis. however, intestinal contents causing localized infection may impede healing of sutured leaks in some patients and fistulas develop. as the anastomosis cannot be disconnected or exteriorized for anatomical reasons other forms of treatment have to be applied. results. leakage of the gastro-jejunostomy occurred in three patients after gastric bypass and resulted in formation of a fistula; one fistula developed in a patient days after surgery. coated self-extending stents were implanted endoscopically in all patients. enteral nutrition could be started six days later. stents were removed two months after implantation without problems. weight loss and quality of life after stent removal were excellent in all patients. conclusions. in our experience implantation of coated selfexpanding stents represents a very effective and minimally invasive therapy of gastro-jejunal anastomotic fistulas after gastric bypass when surgical repair is not possible. in these cases application of stents allows septic source control without any other intervention. methods. fetal mri studies were performed on a . t (philips) superconducting unit using a five-element surface phased-array coil, usually after th gestational week. no sedation is necessary. in addition to routine t -weighted (w) sequences, t w sequences (mainly to demonstrate meconium-containing bowel loops), t à w-sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusionweighted sequences (for further tissue characterization) were done. results. one hundred and twenty-six fetuses with extra-cns malformations, prenatally examined with fetal mri, had postpartal or postmortal follow up at the medical university clinic of vienna: among these, congenital diaphragmatic hernias (cdh, ) could be selected for primary repair ( ) because of adequate lung maturity, with extreme lung hypoplasia underwent extra corporal membran oxygenation. cystic adenomatoid malformation ( ) and lung sequestration ( ) were diagnosed, requiring immediate postnatal or later repair. abdominal anomalies ( ): stenosis, obstructions or atresias of small bowel ( ) were treated by adequate therapy from the very beginning. anal atresias ( ) were differentiated into high and low forms, cases which needed colostomy or could be corrected in an one stage repair. nine gastroschisis ( ) and omphaloceles ( ) were delivered pretermly dependent on the amount of eventerated bowels. ovarial cysts ( ) were differentiated from abdominal tumors ( ), the latter requiring immediate surgery, the former only depending on size and content. urologic pathologies ( ) could often be treated conservatively. conclusions. the results of fetal mri do not have an impact on the type of surgical procedure. however, early accurate diagnosis of pathology, including information about vital functions (such as the degree of lung maturity) may influence the decision of the time to perform the operation, to achieve a most successful outcome for the patient. background. common bile duct (cbd) stones represent a diagnostic and therapeutic challenge in pediatric age group. the aim of the study was to evaluate our management of children with suspected cbd stones and to develop an algorithm for the rational use of perioperative ercp, mrcp and intraoperative cholangiography (ioc). methods. between and , children that had undergone laparoscopic cholecystectomy (che) were evaluated for preoperative findings suggestive for cbd stones, preoperative use of ercp or mrcp, use of ioc and findings during surgery. a diagnostic and therapeutic algorithm for cbd stones was developed. results. twelve children ( %) had preoperative findings suggestive for cbd stones. of the children with elevated liver enzymes and abnormal ultrasound findings, ( %) were identified to have cbd stones. five had preoperative ercp which detected and successfully cleared stones in patients. ioc identified cbd stones in children, including one patient with a preoperative negative ercp. of the children with either elevated liver enzymes or abnormal ultrasound, only one stone in the cystic duct was identified by a gall bladder edema in the preoperative mrcp followed by ioc. three children received preoperative mrcp and ioc was performed in . no retained stones were detected postoperatively. conclusions. cases with high suspicion for cbd stones should undergo a preoperative ercp followed by intraoperative cholangiography, if no stones could be found. in case preoperative findings are ambiguous, prevalence of cbd stones is low and we suggest mrcp or ioc as the diagnostic methods of choice. pure esophageal atresia with normal outer appearance -a new subtype? -case report m. sanal , b. häussler , w. tabarelli , k. maurer , c. sergi , j. hager background. isolated esophageal atresia (vogt type ii) is characterized by an agenesia of the midportion of the esophagus. this paper presents a case of such a form of esophageal atresia with a cm long fibrous segment between the two esophageal pouches resembling the subtype ii according the kluth's atlas. methods. thirty-seven week gestation boy born by uneventful vaginal delivery with g birth weight was transferred to our department because of inability to pass a nasogastric catheter. resection of the fibrous segment and primary anastomosis of the esophagus was performed succesfully. results. the postoperative course was uneventful and the patient was discharged on the postoperative day. histological examination of the atretic segment showed an haphazard distribution of not functional lumina and blood vessels. conclusions. kluth has described ten types of esopageal atresia in his atlas; pure esophageal atresia is classified as type ii in which the proximal and distal segments are atretic without a tracheo esophageal fistula. matsumoto described a subtype in which the midportion of the esophagus is atretic and there is a cyst located in the atretic strand. loosbroek also described in a new type of isolated esophageal atresia that included double membranes with a cm gap between them. we describe here a similar case of pure esophageal atresia, showed neither a cyst nor a membrane. extensive review of the literature failed to disclose any similar case showed this kind of histological character. we report our experience with the minimal invasive method of surgical reconstruction of pectus excavatum recurrence. since at our department pectus excavatum patients have been operated on by the modified minimally invasive method of reconstruction (modified nuss technique). seven patients aged . ae . showed a severe recurrence ( patients after ravitch-welsh-rehbein method primarily operated elsewhere, one after explantation of the ''nuss bar'' operated in our department). five patients suffered on reduced physical effort and patients aim for a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with -d reconstruction and spirometry. the following intraoperative events deserve mention: . severe retrosternal scarred tissue complicate the retrosternal preparatory mobilisation of the pericardial sac and the sternal portion of the diaphragm n ¼ . . intraoperative thoracoscopy showed pleural adhesions which were divided thoracoscopically n ¼ . . non compliant stiff thorax due to sternal kinking and=or ossification of the regenerated ribs after ravitch procedure made the following procedures necessary: a. additionally osteotomies of the ossificated ribs (n ¼ ). b. implantation of a second bar (n ¼ ). c. an oblique wedge shaped partial sternal osteotomy (n ¼ ). due to preparation we had intraoperative bleeding episodes of the internal mammaric vessels, lesion of the pericardial sac (scar tissue) and superficial lesion of the right visceral pleura (adhesions). vertebral index changed from preoperatively to a normal range of postoperatively. postoperative cosmetic results were perfect in %. in summary cases with pectus excavatum recurrence are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. former surgical approaches to laparoscopic repairs of morgagni hernias in children involved pros-thetic as well as nonprosthetic repairs. we simplified a nonprostethic laparoscopic method to an easily feasible procedure. methods. two boys with retrosternal diaphragmatic hernias (morgagni) underwent primary laparoscopic repair. a nonabsorbable suture was inserted directly through the anterior abdominal wall and the hernia was tightened in a lateral to medial fashion by a continous suture and tied in the subcutaneous tissue of the xiphoid region. results. two boys, months and five-year old, with coincidentally diagnosed bilateral retrosternal diaphragmatic hernias (morgagni), underwent laparoscopic repair of their hernias. they had an uneventful postoperative recovery, apart from a port site hernia in one. conclusions. this technique for primary laparoscopic repair of morgagni hernia is safe and easy to perform. laparoscopic closure of the defect by suturing the posterior rim of the hernia to the anterior abdominal wall with a continous nonabsorbable suture provides a safe and effective therapy for this type of diaphragmatic hernias. our experience of post-natal diaphragm paralysis treatment in newborns a. kuzyk , a. pereyaslov , r. kovalsky , o. leniv background. the paralysis of right cupula of diaphragm in newborns in many cases is the result of birth trauma and is indicated as erb-duchene syndrome. the paralysis declares itself by the high standing of diaphragm and its paradoxical movements during respiration, displacement of mediastinum and lung compression which bring to heavy respiratory distress, cardiovascular insufficiency development and requires artificial pulmonary ventilation in first post-natal hours. methods. in the period of - , children with post-natal paralysis of diaphragm right cupula and child with post-natal paralysis of diaphragm left cupula have been treated in our clinic. the body weight at birth was - g. the basic symptoms were: hard respiratory distress and cardiovascular insufficiency, pulmonary hemorrhage, depression of the central nervous system. two children with low body weight had been on artificial pulmonary ventilation during period from the birth to surgical treatment. conservative therapy was done from to . months without positive clinical effect -respiratory insufficiency had not been reduced, the children had retarded in physical growth and development. all children were operated on diaphragm goffering from thoracotomy on the affected side. results. after surgery all patients needed artificial pulmonary ventilation during - days. with good clinical results all children were discharged from the hospital. conclusions. the newborns with post-natal diaphragm paralysis with not effective treatment during - weeks needed surgical correction -diaphragm goffering on the affected side. long term experience with the paulprocedure in a large animal model background. this study was designed to assess the long term efficacy of the paul-procedure for abdominal wall defect repair in a large animal model (lam). methods. we created  cm full-thickness abdominal wall defects in goettinger miniature piglets (n ¼ ; body weight: . - . kg). the defect was repaired by the paul-procedure, using an extracellular matrix of xenogeneic origin as an interpositional graft. a weekly examination of the animals followed, including measuring of bodyweight and observation the possible development of a hernia. additional the abdominal cavity was evaluated laparoscopically at , , and months after paul-procedure. the adhesions to the intestine were measured and the neo-abdominal wall was taken for histological examination. results. ( ) the paul-procedure could be performed technical easily in lam. ( ) background. gastroschisis is a relatively rare congenital anomaly in which eviscerated fetal abdominal organs are exposed to amniotic fluid in utero through an anterior abdominalwall defect. since the first surgical treatment of gastroschisis by fear in the evolution of therapeutical concepts is steadly proceeding. methods. a retrospective study enclosing all children with gastroschisis treated at vienna general hospital from to was carried out using patient charts. statistics was performed using spss . . the results are compared with the literature. results. fifty-five children with gastroschisis were treated. birth was performed between and week of gestation ( % caesarean section). diagnosis was established between and week of gestation. in % of the patients primary surgical closure was performed. oral feeds were started on . day, mechanical ventilation was stopped after . days. twenty children developed infection=sepsis=pneumonia ( . %) children developed ileus=perforation=vovolus=nec=patch infection ( . %). thirty four children had single gastroschisis related surgery ( . %), secondary surgery up to operations. mortality was . % ( deaths). conclusions. since bianchi's publication of minimal intervention management for gastroschisis in traditional surgical concepts have often been questioned. our results are comparable with international data. although very tantalizing there are no large prospective randomized multicenter studies that show clear superiority of one or another strategy. epidemiologic data show an increasing incidence of gastroschisis which shows the importance of standardized successful procedures for the future. background. colorectal cancer is one of the most common cancers in western countries with incidence rates that are quite stable through the last years. while surgical therapy with high central vessel ligation and adequate lymph node dissection seems well standardised -in laparoscopy as well as conventional surgery -great efforts have been made in new adjuvant treatment strategies and in treatment of colorectal liver metastases. methods. we report about a consecutive series of more than patients treated with colorectal cancer since . . . data about epidemiology, localisation of the primary, surgical methods, tumor classification, complication and mortality rates and survival will be presented in detail. results. the median age was years, % of the patients were more than years old, . % were female. fifteen percentage were treated with an acute onset like ileus or perforation. thirty five percentage had right sided primary, hartmann procedure was performed in %. about % of patients were operated as stage (uicc), the year survival rates of all groups including stage was %. pathohistological assessment showed % r resections (stage included) and a median lymph node count of (pn). perioperative mortality was %, complication rate with the necessity for at least surgical reintervention was . %. conclusions. we demonstrate that surgical therapy of colorectal cancer is safe and effective in terms of oncological outcome and perioperative morbidity and mortality, although colon resections in our department are typical teaching operations. modern anaesthesia and intensive care allows radical oncological surgery even in the elderly. interdisciplinary treatment keeps its way, exact pathohistological processing and cooperation with the pathologist still is the most important factor in quality assessment of oncology surgery of the colorectum. background. although adjuvant -fu-based chemotherapy showed to increase -year survival in stage iii colon cancer, the role of adjuvant chemotherapy in stage ii colon cancer is still unclear. p , a frequently mutated tumour suppressor gene needed for correct induction of apoptosis, is a promising marker to define subgroups of patients who benefit from adjuvant chemotherapy in stage ii colon cancer. methods. in order to evaluate the clinical relevance of p mutations, we investigated stage ii colorectal tumor biopsies from a previous randomised study of adjuvant chemotherapy, who were randomly assigned to adjuvant chemotherapy or surgery alone. for detection of p mutations we used singlestranded conformation polymorphism analysis. results. p mutation was detected in ( %) of informative tumor dnas. when receiving -fluorouracil-based adjuvant chemotherapy, patients with p mutation turned out to have a significant better disease-free -year survival ( . vs. . %, p ¼ . ). in contrast, when assigned to the surgery alone group there was no significant difference in -year disease-free survival between patient with p mutation and patients with wildtyp p . the difference between the patients receiving chemotherapy as compared to those which did not in respect to the presence of p mutations was significant (p ¼ . ). conclusions. in our patient cohort patients whose cancer had a mutation of p had a significantly better benefit from -fluorouracil-based therapy, what is contrary to previous observations. this discrepant result emphasise the need for a standardisation and validation of the methodology, patient selection and interpretation of clinical data before any prognostic marker can be routinely used. is tme an adequate treatment for low rectal cancer? p. lechner, g. humpel background. two patients who had had neo-adjuvant chemotherapy followed by surgery for cancer in the lower rectum presented with metastases in pre-aortic lymph-nodes after and months, respectively. this rose our suspicion that distant spread may in some cases follow the lymphatic vessels along the aorto-iliac axis. methods. after having performed very low anterior or even abdomino-perineal resection for cancer in the lower third of the rectum, biopsies are taken from nodes at the pelvic wall, along the iliac arteries, and the aorta. these are all compartments that remain untouched during routine tme. results. in one out of four patients we find at least one of the above mentioned groups of nodes to be involved. this is most often the case in patients, in whom the mid rectal vascular bundle requires ligation on at least one side. so there are obviously metastases that cannot be detected during the pathological work-up of the tme-specimen. twenty five p.c. of the patients considered to be n-o are already in dukes' stage c, thus requiring additional treatment. these findings -confirmed by the recent literature -suggest, that metastases may arise via lymphatic vessels along the mid rectal arteries and -further onalong the aorto-iliac vessels. conclusions. after standard tme for low rectal cancer lymph node biopsies should be taken in order to avoid understaging of the disease and to allow accurate patient stratification in clinical trials. transanal endoscopic microsurgery for rectal carcinoma: own experiences after cases p. patri, r. schmiederer, a. tuchmann background. transanal endoscopic microsurgery (tem) is an one access technique for local excision of rectal tumours using gas dilatation of the bowel and a stereoscope for unrestricted vision on the operation field. the tem-technique was invented by buess, theiss and hutterer and has been performed at our department since . sessile benign adenomas of the rectum inappropriate for colonoscopic resection represent the vast majority of cases indicated for tem-procedure, using the advantages of sphincter preserving resection in all thirds of the rectum without considerable access trauma. furthermore, tem can be applied to a highly selected group of rectal carcinoma patients in curative objective, including t g or g l v lesions, classified as low risk carcinomas after hermanek's criteria for malignant potential, with recurrence and -yearsurvival-rates equal to radical surgery. under palliative purposes tem can be considered in more advanced carcinomas such as high risk carcinomas (t g ) or in t - carcinomas without stenosis in patients with high risk for general anaesthesia, rejection of stomal construction or present distant metastases. methods. from = until = tem procedures were performed in patients, males, females, mean age was . years ( - ), the median hospital stay was days . following diagnoses were included: rectal adenomas (n ¼ ), rectal carcinomas (n ¼ ), carcinoids (n ¼ ), fistulas (n ¼ ), gist (n ¼ ) and melanoma (n ¼ ). all patients underwent tem-procedure as described by buess et al., the median operation time was min ( - ). highlighting the carcinoma patients regarding to postoperative histopathology tem was performed in n ¼ tis-lesions, n ¼ t low risk carcinomas, n ¼ t high risk carcinoma, n ¼ t and n ¼ t carcinomas. results. in carcinoma patients undergoing tem for curative objective recurrence rate was . %. if tem was performed in primarily palliative intention recurrence rate was %. no conversion to open technique had to be performed, no postoperative surgical complications were observed, one patient died weeks postoperative due to liver failure following esophageal varices bleeding. conclusions. transanal endoscopic microsurgery is a technically highly demanding but excellent procedure for curative therapy of rectal adenomas and low grade early carcinomas. furthermore, tem is feasible in more advanced carcinomas for palliative purposes. besides the technical advantages the procedure can prevent patients of rectal resection or stomal construction. background. anastomotic leak is the most feared early complication in the postoperative period after low anterior resection. the incidence varies between and %. use of tme technique lessens the percentage of local recurrences but increases the incidence of an anastomotic leak. a surgeon has to assess the risk factors and decide whether to create a protective stomy that protects the patient from fatal consequences of an anastomotic leak. methods. one hundred and three patients who had a low anterior resection without a protective ileostomy in the period - were included in the analysis. data of those who developed an anastomotic leak and those without were compared and the connection between specific risk factors and the incidence of an anastomotic leak was assessed. results. eleven patients ( . %) developed a clinically confirmed anastomotic leak. death after low anterior resection occurred in cases ( . %), in two cases in patients who developed a leak, resulting in a . % mortality rate for anastomotic leakage. there was no difference between males and females (p ¼ . ) and age groups (< vs. > years), (p ¼ . ). tumor localization in the lower third of the rectum was roughly showing statistical importance (p ¼ . ). the stage iv. of disease showed obvious connection (p ¼ . ). connection between the anastomotic leak and preoperative radiotherapy or high asa score (> ) was not established (p ¼ . and p ¼ . ). conclusions. the incidence of an anastomotic leak was comparable with results of other studies. localization of a tumor in the lower third in advanced disease represents an important indication for protective ileostomy. background. while adverse events occur in up to ten percent of all patients admitted to hospitals sentinel events do not happen often. however, these events represent great risks for medical institutions and persons involved. a thorough analysis of sentinel events is mandatory and can be achieved by root cause analysis (rca). methods. root cause analysis has been designed in order to assess underlying human, technical, and organizational factors contributing to adverse events. rca has to be performed in a standardized way by a team approach. the main goal of this analytic technique is to establish a relationship between causal factors and events under systemic aspects. after identifying incidental findings causal statements are formulated and actions are developed. conclusions. root cause analysis is a standardized investigative technique which allows to identify causes of severe adverse events and to develop preventive actions for the future. background. thyroid surgery can be followed by typical complications i.e. recurrent laryngeal nerve injury, postoperative hypoparathyreoidism and postoperative haemorraghe. refined surgical technique has improved the outcome and lowered the risk of complication to a minimum. methods. we analyzed global outcome and individual performance in more than , thyroid operations. the complication rates were compared in consecutive periods representing different surgical techniques and individual surgical performances. the data were repeatedly presented to the surgeons. the effect of this quality control procedure was reevaluated. results. exposure of the recurrent nerve and the parathyroid glands significantly reduced the global rate of post-operative=permanent rlni and hypoparathyreoidism. some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent rlni rates ranged from to . %) and refined dissection of the parathyroid glands (e.g., parathyroid insufficiency ranged from to . %). global outcome and individual performance were compared in periods and presented to the surgeons. the effect of this quality control procedure and the selective improvement of outcome will be shown by data. the extent of resection and the individual refinement of surgical technique was the source of variability. conclusions. refined surgical dissection significantly reduces the risk of complications in thyroid surgery. quality control can improve the global outcome and identify the variability in individual performance. this cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes. recent developments in medical litigation and liability in austria d. schaden , j. pritz krankenhaus der barmherzigen brüder, graz, austria; amt der steiermärkischen landesregierung, graz, austria the recent medical judgements of the highest court (e.g.: wrongful birth ogh ob = h) have been debated very controversially in medical profession and have attracted closer attention to the legal aspects of medical documentation and enlightenment. particularly in the surgical disciplines the patient should be made fully aware and get a detailed information about the risk of treatment failure, possible complications, limits to the procedures and long term outcome. exact information by the doctor is the condition necessary for the patient to give valid consent to the treatment and to avoid medical negligence litigation in these risky specialties. unfortunately these often for the doctors existentially important aspects are not part of the medical or surgical training nor are there any compulsory guidelines of medical enlightenment in the austrian legal practice which creates widespread individualism in all disciplines. we want to give an overview of the latest medico-legal lawsuits and judgements and their consequences for the daily working routine focussing on issues that can result in a doctor or facility being sued. background. every patient has the right to be informed about the consequences of surgery enabling him to give his informed consent. until recently the process of giving this information was not well organized. in the context of improving quality control at the hospital, a uniform process for patient information was established and the training of interns for giving informative talks was standardized and intensified. to measure whether these changes are reflected by an improved patient satisfaction, patients were surveyed before and after the changes. methods. two surveys were performed on patients before and after the improvements were introduced, and the results were compared. results. in each survey and questionnaires were returned. with the improved process the number of patients satisfied with the length of the informative talk rose ( - %, p < À ), less patients wanted a more detailed talk ( - %, p ¼ . ) and more patients considered the sketches on the informed consent protocol helpful ( - %, p <  À ). fewer patients thought the surgery was worse than expected ( - %, p ¼ . ). conclusions. using the new information process, a measurably better patient satisfaction could be observed. thus, by relatively simple means a highly efficient information process can be established even at a large hospital. the discontented patient j. pritz , d. schaden the number of claims after surgical procedures (not only bariatric or cosmetic surgery) is still increasing and patients nowadays are getting better informed about medical malpracti-ce=error in the media and the various possibilities to assert their rights. in austria various kinds of out-of-court settlement are installed to facilitate patient's compensation without the risk of litigation. in many cases misconceptions in the patient-doctor relationship can be solved without motion to court. but how can the terms ''malpractice'' or medical error be defined at all? which conditions must be fulfilled for the motion to court or the medical arbitration committee? we want to give a survey of the activity of the arbitration committee, the members, and the possibilities of compensation. moreover, the different consequences between criminal and civil law should be explained. the role of the expert witness, the course of procedure at the arbitration committee and possible consequences for the doctor or the facility will complete the presentation. background. negative resection margins are significant for prevention of recurrence in liver surgery. preoperative d models of imaging data provide significant improvements for visualization and planning, but intra-operative realisation is still a challenge. possibly navigation technology can improve oncological safety in liver resections. methods. fifty-four of liver resections for liver metastases were selected for intra-operative navigation due to complex anatomical situations. exact surgical plan was documented on virtual d models. planned resection margins were assessed and measured preoperatively. intra-operative d ultrasound data were acquired and localized with an optoelectronic tracking system, thus navigation of surgical instruments was provided in a virtual environment of these registered ultrasound data. surgical resection margins were compared with the surgical plan. results. navigated surgery was realized in of resections. r resection was achieved in of patients. mean histological resection margins were ( - ) mm. maximum deviation from the surgical plan was mm. conclusions. d ultrasound-based optoelectronic navigation is a feasible device for liver surgery, provides optimal anatomic orientation and can realize precise resection margins. background. during liver resection, a low central venous pressure plays a crucial role in reducing blood loss and intra-as well as post-operative morbidity. however, excessive volume restriction could lead to microcirulatory impairment and organ hypoperfusion. in the present study, we evaluated a standardized intra-operative protocol for optimal fluid replacement therapy. methods. in a prospective study, patients for elective liver resection were included. intra-operative fluid replacement was restricted to ml=kg=h in patients with thoracic epidural analgesia or ml=kg=h for patients without thoracic epidural analgesia. following target parameters were defined: central venous oxygen saturation > %, intra-operative lactate levels < mmol=l, urine output > ml=h, central venous pressure < mbar, and norepinephrine dosage < . mg=kg=min. in patients where at least one of the parameter values exceeded the predefined limit, fluid replacement therapy was intensified and dobutamine . mg=kg=h was started. patients were monitored for intra-operative blood loss, intra-and post-operative complications, and length of hospital stay. results. patients that remained within the intra-operative target parameters for central venous oxygen saturation, lactate levels, urine output, central venous pressure, and norepinephrine dosage had lower blood loss, fewer complications, and shorter hospital length of stay. conclusions. the standardized protocol is a good approach for optimal intra-operative fluid replacement and to minimize blood loss, post-operative complications and hospital length of stay. background. bile duct injuries (bdi) are still the most feared complication of laparoscopic cholecystectomy. the patient has to face prolonged postoperative treatment, even life threatening complications; the hospital and the surgeon rising costs and pricely and possibly time-consuming malpractice procedures. the repair of bdi requires special hepatobiliary expertise, but the long-term results even in the best centres are still sobering. there are different types of bdis requiring a tailored approach. we analyzed predisposing factors and types of bile duct injuries treated in our institution. methods. we analyzed our operative and endoscopy database from - for patients treated with bile duct injuries after cholecystectomy. bile duct injuries were classified according to a system proposed in by siewert and colleagues. results. between and a total of cholecystectomies were performed at our institution. there were laparoscopic (lc) and open procedures (oc; inculuding procedures with conversion from lc to oc); during the same period, patients ( females= males, mean age years; range: - ) were treated for bile duct injuries; of these patients were initially operated in an other hospital. there were patients with class i lesions (bile leak of the cystic duct or lesion of luschka ducts), patients with class ii leions (stricture of the cbd). two patients with class iii injuries (incomplete trans-section of the common bile duct) and patients with class iv lesions (transsection of the cbd or chd). thirty four of the initial ( % -all open and converted and laparoscopic) operations were considered difficulty by the surgeon performing the cholecystectomy. of operations were laparoscopic ( - %), converted from lc to laparotomy ( %) and laparotomy from the incision ( - . %). of the original operations, had been performed by an experienced surgeon, by a novice. conclusions. cystic duct leakage is still the most common type of biled duct lesions after cholecystectomy. bile duct injuries occur a s commonly in operations performed by by novices as in procedures done by experienced surgeons. in order to present the current concept for treatment of bpl patients suffering from traumatic brachial plexus lesion (bpl) who underwent microsurgical reconstruction were analysed. within one year in our institution male patients, aging from to years were scheduled for surgery. three suffered from complete, from upper bpl. six patients were diagnosed as supraclavicular lesions and as infraclavicular lesions. patients with diagnosed supraclavicular lesions were scheduled for surgery between and months after trauma. surgical exploration revealed root avulsion and or rupture in all cases. classic intraplexual reneurotisation was performed in patiens, whereas all patients received extraplexual reneurotisation procedures, utilising the spinal accesssory, the ulnar and intercostal nerves. three patients received secondary reconstructive procedures. patients with infraclavicular lesions were treated surgically between and months after injury. in all patients nerve grafts were used to reconstruct the injured fascicles, a nerve transfer was used in case only. one patient required secondary reconstructive surgery. the reconstructive strategy in bpl surgery has been changed dramatically during the last years. the strategy changed from a single surgical intervention one year after the trauma to a prozessual concept consisting of early primary nerve reconstruction and secondary reconstructive procedures. nerve grafting with use of autologuous nerve grafts for ''intraplexual'' reconstruction is still state of the art, additionally nerve transfers were introduced to utilize ''extraplexual'' sources for reeinnervation. regarding this concept most of the patients regain not only some motor function but functionality of their impaired upper extremity. teaching means learning -who benefits from academic teaching duties? p. lechner, g. humpel background. in the department of surgery at the danube clinics intulln, a level i hospital, has been named a teaching institution associated with the vienna medical university. this has certainly led to various organisational changes the results and consequences of which we attempt to identify. methods. all teaching institutions are subject to continuous evaluation by the students. in addition to that, we undertook an extra evaluation aiming at potential organisational and medical improvements from which patients, personnel, and students may benefit. results. ) as the students are available only from . through . o'clock, all organisational routines at the department (staff-rounds, meetings, lectures, etc.) now follow a more rigorous daily schedule. ) bed-side teaching means explaining everything that is undertaken in the presence of the patients. so the patients receive more information on their diseases and treatments. ) students tend to question everything, and so we also call in question many routines ''that have always been performed like that''. this allows us to simplify numerous operating procedures and means continuous organisational learning to the institution. ) for the same reason lecturers -and all those who are involved in teaching (physicians, nurses, and others)have to keep their academic knowledge up-to-date any time. ) teaching during meetings and ward rounds is of course not ''limited'' to university students, but also comprises interns and residents. conclusions. the department's current status as an academic teaching institution turned out beneficial for patients, personnel, and students, concerning professional, technical, and organisational aspects. though the additional workloadespecially in the beginning -must not be under-estimated, the advantages clearly exceed the burdens. background. necrotizing enterocolitis (nec) is the most common gastrointestinal complication of prematurity at the neonatal intensive care unit. the first aim of the study was to investigate the correlation between clinical parameters, extent of disease and mortality, and the second purpose was to analyse the surgical procedures and their outcomes. methods. in a retrospective study we reviewed medical charts of patients who were operated within a five years periode. preoperative blood results and demographic data were collected and evaluated. according to the extent of disease, birth weight and operative procedure different groups were analysed. results. a total number of patients underwent surgical procedures for nec from to , and % (n ¼ ) weighted less than g. in patients focal disease, in patients multifocal disease and in children panintestinal disease were found. preoperative blood tests revealed a median crp level of . mg=dl (normal range . ), median wbcc of . g=l and a median platelet count of g=l. primary laparotomy with defunctioning enterostomy was performed in %. overall mortality was %. conclusions. the extent of disease and the condition of the infants still determines the survival. preoperative blood results are of limited prognostic value. primary laparotomy with defunctioning enterostomy was the preferred technique in our unit, and even in the group of vlbw and elbw neonates surgery was well tolerated. discussion regarding the best operative procedure is still going on and no consensus in the management of nec is agreed on. methodik. während der letzten jahre wurden neugeborene (gestationsalter - wochen, geburtsgewicht - g, alter bei der darmperforation - tage) mit einer oder mehreren dünndarmperforationen beobachtet. die symptome waren jeweils etwa ident: abdominelle distension mit verfärbung der flankenhaut bei initial insgesamt stabilem allgemeinzustand. bei ,,nur'' der kinder zeigte sich im abdomen-leer-röntgen freies gas in der bauchhöhle, bei allen aber war sonographisch intraabdominell freie flockige flüssigkeit festzustellen, ohne nec-typische veränderungen am intestinaltrakt. kinder wurden aufgrund ihres schlechten zustandes nur punktiert=drainiert und antibiotisch behandelt. patienten wurden laparotomiert: bei kindern fand sich die perforation im bereich des jejunum, bei weiteren im unteren jejunum=oberen ileum und bei im terminalen ileum, davon hatte eines und eines perforationen. der betroffene darmabschnitt wurde jeweils reseziert; bei kindern wurde eine end-=end-anastomose durchgeführt, bei den verbleibenden patienten wurde wegen der peritonitis eine doppelläufige enterostomie angelegt. eines dieser kinder verstarb aufgrund einer sepsis-bedingten gerinnungsstörung. eines der beiden drainierten kinder wurde wochen nach der intervention wegen eines ,,verwachsungsbauches'' adhäsiolysiert. ergebnisse. die Ü berlebenschance sehr kleiner frühgeborener nahm während der letzten jahre deutlich zu. parallel dazu mußte bei diesen kindern eine zunahme umschriebener, ätiologisch nach wie vor nicht ganz geklärter darmperforationen zur kenntnis genommen werden. zur behandlung stehen grundsätzlich differente vorgehensweisen zur verfügung: im vordergrund steht eine resektion des lädierten darmabschnittes und, abhängig von den lokalen gegebenheiten (peritonitis ja=nein), entweder eine end-zu-end-anastomose und=oder nur eine doppelläufige enterostomie. als zweite prinzipielle therapieform gibt es die möglichkeit, die bauchhöhle zu punktieren= drainieren, wodurch die affektion auch beherrscht werden kann; im einzelfall kann sie letztlich aber doch nur chirurgisch zu sanieren sein. dieses vorgehen gilt für uns als ultima ratio. schlussfolgerungen. auch wenn eine isolierte darmperforation bei einem kleinen frühgeborenen relativ gut behandelbar ist, sollte durch klärung ihrer Ä tiologie eine prävention dafür möglich werden, da diese kinder wegen ihrer kritischen voraussetzung bereits per se außerordentlich gefährdet sind. the endorectal pull-through procedure (erpt) for hirschsprung's disease g. schimpl background. whereas in the past various operative techniques in patients with hirschsprung's disease (hd) were used, erpt was introduced as a single-stage operation. methods. sixteen patients with hd ( females, males) aged months to years were treated using the erpt procedure and the level of bowel resection was determined by intraoperative biopsies. results. the length of hd was in patients up to the sigmoid colon, in patients up to the transverse colon and one patient had a total colonic hd. two patients required a laparoscopic mobilisation of the left colonic flexure. in the patient with total colonic aganglionosis, the resection of the entire colon and sauer's procedure was performed using a periumbilical laparotomy. oral nutrition was started in all but on the first post operative day and they were discharged after - days. complication occurred in two patients: one had to be reoperated due to misinterpretation of intraoperative biopsies and a second patient with years of age developed a retrorectal abcess which was treated coservatively. in a follow-up, - years postoperatively, all patients are continent and have normal bowel movements. conclusions. erpt is an advance in the treatment of hd and can be performed at any age. it avoids the creation of enterostomies, is a single step procedure with excellent functional results and low complication rates. in long segment hd this procedure can be combined with laparoscopic or open surgical procedures. single-port appendectomy in obese children -a useful alternative? t. petnehazy, h. ainoedhofer, s. beyerlein, j. schalamon background. the rapidly increasing prevalence of obesity among children poses challenging problems in abdominal surgery. there is a growing body of evidence that single-port appendectomy (spa) is a feasible and safe alternative to open appendectomy (oa). very little is known about the clinical outcome of spa in overweight children. we present our experience with the treatment of suspected appendicitis in obese children using spa. methods. from january to december we performed spa in obese children with suspected appendicitis ( females, males, median age of . years). obesity was defined as a bmi > th percentile for age and gender (median weight . kg). in the procedures a -mm instrument was introduced through the umbilicus (combination of a -mm wide angle optic with -mm working channel). after exploration of the abdominal cavity and meckel's search, the appendix was exteriorized through the umbilical trocar and removed by open technique. patients' records were evaluated regarding anaesthetic time, complications, time until reintroduction of solid diet and histopathological findings. results. average operating time was . min (range - min). neither intra-nor postoperative complications occurred. reintroduction of solid diet to all patients was possible on the first postoperative day. the histology is presented in the below table. our results indicate that the advantages of spa such as: excellent evaluation of the peritoneal cavity, minimal rate of intraoperative incidents and superior cosmetic results make this technique a valid alternative for the treatment of appendicitis in obese children. background. ovarian torsion is a surgical emergency. because of unspecific clinical findings, diagnosis can be delayed and therefore may result in oophorectomy. recently preservation of ovarian function by means of laparoscopic detorsion has been proposed even in advanced cases. methods. we retrospectively reviewed patients with diagnosis of ovarian torsion who presented at our institution between and . a total of ovarectomies and detorsion were performed. twenty patients underwent minimal-invasive surgery, in cases laparotomy was performed. in cases a conversion was necessary. the accuracy of preoperative imaging modalities, surgical technique, correlation with postoperative histopathologic findings, complications and outcome were assessed. results. all patients were investigated by means of ultrasound. mri was applied in patients whereas ct-scan was done in patients. histopathological and intraoperative findings revealed simple torsions, twisted cysts and twisted teratomas. sensitivities to detect ovarian torsion were % for ultrasound (us), % for mri, and % for ct. entirely oophorectomies and detorsions in patients were performed. one of these patients presented with asynchronous bilateral ovarian torsion caused by a unilateral benign teratoma. in patients a laparoscopic contralateral oophoropexy was done. mean hospital stay was (laparoscopic) versus days (open approach). the complication-rate was marginal in both groups. conclusions. preoperative imaging is essential to improve the diagnostic accuracy. however, sensitivity only approaches %, emphasizing the importance of surgical exploration when symptoms are compatible with torsion. when a neoplasm is suspected, mri or ct imaging is essential. in order to preserve ovarian function and fertility, laparoscopic detorsion without primary resection should be the procedure of choice. it constitutes an easy, quick and equally safe procedure. the need for contralateral oophoropexy has to be discussed. background. differential diagnosis of lower abdominal pain include beneath common causes such as appendicitis and gastrointestinal infections some not so common diseases as ovarian pathologies in female patients. this may be ovarian cysts but can also be pathologies like ovarian torsions or tumours that have to be operated. however, the differential diagnosis between ovarian cysts and ovarian torsions is often radiologically inclonclusive and therefore makes a surgical intervention mandatory. methods. we analysed retrospectively the data from female patients hospitalised for ovarian pathologies in between and . twenty nine patients underwent surgical intervention for different causes. results. most patients presented with acute abdominal pain demonstrated signs of peritonitis and required pain relief. on the other hand we had patients with only mild clinical signs such as newborns with already prenatally diagnosed ovarian cysts. we found in our patients cases of benign ovarial cysts, cases of benigne teratomas, cases of serous cystadenomas, case of serous cystadenofibroma, case of yolk sac tumor and cases of ovarial torsions. conclusions. diseases of the ovaries are a rather rare but important cause of lower abdominal pain in children and adolescents and requires a mediculous diagnostic procedure and often an urgent surgical intervention. background. adrenal tumors, other than neuroblastoma, are rare in children. the aim of the study was to present the outcome of functioning tumors of the adrenal gland in children. methods. we reviewed medical records of children with adrenal tumors treated in our unit from to . demographic datas, clinical features, operative details, histopathological details and follow up were studied. results. there were children with the mean age . ae . years. two patients had virilizing tumors and presented with an acute abdomen, one patient had conn's syndrome, one patient cushing's syndrome and one patient presented with severe haemorrhagic shock syndrome. all patients were treated surgically. histopathological diagnosis were adrenocortical carcinoma (acc) in two patients, adrenocortical adenoma (aca) in two patient and adrenocortical cyst in one patient. ultrasound sonography, computerized tomography and magnet resonance imaging were used for diagnosis and follow up. patients with acc had advanced-stage disease and died despite total surgical resection and agressive chemotherapy. patients with aca and adrenocortical cyst were cured by surgical resection. conclusions. adrenal tumors constitue less than % of paediatric neoplasm. aca and adrenocortical cyst are cureable by surgical treatment, but the outcome is still poor in cases of acc. endoscopic subureteral injection of bulking agents has become an established alternative to long-term antibiotic prophylaxis and ureteral reimplantation. we evaluated the effectiveness of dextranomer=hyaluronic acid copolymer (deflux + ) and predicting factors for success or failure. a total of ureters= patients with a mean age of . years underwent endoscopic treatment with dextranomer= hyaluronic acid (dx=ha) copolymer. vur in duplex ureters was treated in patients. the presence of voiding dysfunction and renal scars, the volume of deflux injected and the endoscopic appearance of the ureter were recorded. dextranomer-hyaluronic-acid was injected submucosally beneath the intramural part of the ureter at o'clock, but if the appearance was not satisfying or the ureter opens during flow an additional injection at and o'clock was performed. all patients received antibiotic treatment till a voiding cystourethrography (vcug) was performed weeks after injection. ultrasound examination was performed after hours, months, months and one year. success was defined as no reflux on postoperative voiding cystourethrography. a total of ureters underwent to treatments. the overall success rate was %. the cure rate according to reflux grade was % for grade i, % for grade ii, % for grade iii. in vur grade iv and v the endoskopic treatment failed in most cases. there was no case of obstruction at up to month postoperatively. haemorrhage occurred in one patient. in five ureters an increase of vur grade developed. new contralateral vur was seen in six patients. in . % vur was found on postoperative vcug at years after endoscopic treatment. there was no statistic significant difference in volume injected when successes were compared with failures. among children with a small kidney the response rate was %. a positive response was observed in % of children with duplex ureters. the presence of voiding dysfunction had no influence on success. patients in whom endoscopic treatment failed underwent open surgery. the subureteral injection of dextranomer=hyaluronic acid is an effective and well tolerated alternative to open surgery or conservative treatment, also in patients with duplex ureters. in patients, who subsequently require reimplantation, the operative repair does not appear to be compromised. background. almost all patients with symptomatic vur were treated with a cohen procedure and a very high success rat. since we offer the endoscopic procedure with deflux. the outcome of the endoscopic treatment is evaluated. methods. between = and = , patients with refluxing units were treated (i ¼ , ii ¼ , iii ¼ , iv ¼ , v ¼ ). the control after treatment was between and months. additional urological diseases are: solitary kidney ( ), double kidney ( ), neurogenic bladder with mmc ( ), bladder trabeculation w=o neurological disease ( ), cloacal malformation ( ), bladder exstrophy ( ), urethral valve ( ) . age at treatment was between mths and yrs. injection was performed under general anesthesia, bolus was between . and . ml. three patients were additionally treated with botox. results. sixty patients need no further treatment after injection ( resolved and patients have reflux). in of patients, who need a second injection ( overactive bladder), reflux resolved as well as in patients after third injection. in patients with neurogenic bladder and mmc we had no success and further treatment (augmentation) was necessary. in patients reflux worsened and cohen operation was performed. in patients a vcug will performed in the near future and three are lost for control. conclusions. in cases of moderate reflux with no neurogenic bladder it is an excellent method to treat reflux. in cases of neurogenic bladder, we cannot recommend it and cases with bladder trabeculation need an additional medical treatment or operation with a higher success rate. all these patients need a long term follow-up. background. bariatric surgery in austria has a long tradition since , but has always been different to the international trends. in order to obtain an overview of growth and time trends of obesity surgery in austria a nationwide review has been done by the austrian national federation for surgery of obesity every two years since . methods. e-mail requests are sent to every department of surgery in public hospitals and clinics to collect the recent number of operations including revisional procedures. results. the last reviews (including ) showed a steady increase of obesity surgery particularly in the years through the number of operations increased %. since a constant number of interventions of about per year ( : ) had been observed. predominant operation techniques were restrictive procedures: - vbg (vertical banded gastroplasty) and since agb (adjustable gastric banding). since the late nineties austria is a gastric-banding country ( % in ) compared to the worldwide review data ( % in ), but since we observe a steep increase of gastric bypass paralleled by a decrease of agb. by the time of the conference data of the review starting in january will be presented a showing the trend of the last two years. conclusions. bariatric surgery as the only effective treatment against the alarmingly increasing disease of severe obesity is already an important part of the surgical work of some austrian surgical departments. in view of this fact quality control by continuous data collection is of major importance. restrictive bariatric procedures -long term results and complication management k. miller background. vertical banded gastroplasty (vbg) has been in clinical use since and the adjustable gastric band (agb) since . as promising results were achieved with the adjustable gastric bands available in the market, some surgeons came to the conclusion that vbg might be entirely abandoned and replaced by the adjustable gastric band. the aim of this study was to compare the long term outcome of the two different restrictive procedures. methods. within a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , gastric restrictive procedures were performed in the course of a prospective non-randomized comparative trial. we report the outcomes of vbgs and agbs performed by two surgeons. the mean bmi was . ae . for vbg and . ae . for agb. patient selection was performed by admittance to one of the two surgeons. vbg was performed via laparotomy and agb by the laparoscopic procedure. the bariatric analysis and reporting outcome system (baros) was used to evaluate the postoperative health status and quality of life. results. the mean duration of follow-up was months, with a minimum of years (range, - months). the overall follow-up rate was %. in the short-term follow-up of years, no statistically significant difference was registered between agb and vbg in terms of weight loss, reduction of co-morbidity or improvement of quality of life. the -day mortality rate was . % ( patients) for vbg and . % ( patient) for agb. the overall re-intervention rate in the long term was . % for vbg and . % for agb (p < . , or . , % ci . - . ), the re-operation rate . % for vbg and . % for agb (p < . ), respectively. the excess weight loss (ewl) was significantly higher in the vbg group after months ( % for vbg vs. % for agb; p < . ). in the long-term follow-up with a mean value of months, no significant weight loss was registered between the study groups ( % for vbg and % for agb; p ¼ . ). the baros score in the short term ( years) was good to excellent in and % of the vbg and agb groups, respectively. in longterm follow-up the baros score was significantly in favor of the agb group ( . vs. . %; p < . , or . , % ci . - . ). the overall loss of co morbidities was % in both groups. conclusions. this long-term follow-up study shows that vbg and agb are effective restrictive procedures to achieve weight loss, and loss of comorbidities. a statistically significant lower re-intervention and re-operation rate and an improved health status and quality of life were registered for agb. pilot study on the effects of gastric electrical stimulation (tantalus tm ) on glycemic control in morbidly obese patients with type diabetes (t dm) a. bohdjalian , b. ludvik , s. shakeri-manesch , r. weiner , c. rosak , g. prager background. previous work suggests that non-excitatory electrical stimulation, synchronized to the gastric refractory period and applied during meals, can induce weight loss in morbidly obese subjects. the tantalus tm system (metacure n.v.) is a minimally invasive implantable gastric stimulation modality that does not exhibit malabsorptive or restrictive characteristics. aim: to investigate the potential effect of the tantalus tm system on glycemic control and weight in morbidly obese subjects with t dm. methods. in this european multi-center, open label study, t dm obese ( m, f, bmi: . ae . kg=m ) subjects treated either with insulin ( ) or oral anti-diabetic medications ( ) were implanted laparoscopically with the tantalus tm system. the system includes a pulse generator and three bipolar leads and delivers a non-excitatory signal initiated upon automatic detection of food intake. results. twenty subjects have completed one year and exhibit a decrease in hba c from ae . % at baseline to . ae . % (p ¼ . ) and in fasting blood glucose from ae mg=dl to ae mg=dl (p< . ). sixteen subjects on oral anti-diabetic medications showed a decrease in hba c from . ae . % at baseline to . ae . % (p< . ) and an average weight loss of . ae kg (p< . ), self glucose monitoring available at months post-op from subjects shows a significant (p< . ) decrease in hours post-prandial glucose ( ae mg=dl vs. ae mg=dl). in a subset of patients at months of post-operative follow-up we could find an increase in adiponectin ( . ae . vs. . ae . mg=ml, p < . ) and a decrease in fasting ghrelin ( ae vs. ae pg=ml, p < . ). the areas under the curve (auc) measured during meal tolerance test were significantly higher for adiponectin and lower for ghrelin (p < . ) compared to pre-therapy. four insulin subjects have completed one year and showed no significant changes in hba c and weight. conclusions. interim results with the tantalus tm system suggest that this stimulation regime can potentially improve glucose levels and induce weight loss in obese t dm subjects on oral anti-diabetic therapy. further evaluation is required to determine whether this effect is due to induced weight loss and=or due to direct signal dependent mechanisms. background. gastric sleeve resection was initially devised as the first step of the duodenal switch operation in bariatric surgery. later, it was performed as an isolated restrictive procedure, mostly laparoscopically. we present intermediate to long-term results from a large series of laparoscopic sleeve resections (lsg) in three austrian centers. methods. ninety-eight patients ( males, females) who all met the ifso criteria for bariatric surgery were included in this study. the mean bmi was . kg=m (range, - kg=m ). patients with symptoms of gastro-esophageal reflux or large hiatal hernias as well as ''sweet eaters'' were excluded and allocated for a different procedure (usually roux-en-y gastric bypass). ninety-five of the operations were performed laparoscopically: after establishing a pneumoperitoneum of mmhg, four to five working trocars were introduced. beginning opposite the crow's foot, the greater curvature was dissected from the omentum up to the angle of his. the left crus of the diaphragm was always identified to ensure complete resection of the gastric fundus. the stomach was then reduced to a tube over a f gastric bougie with several magazines of an endostapler, the staple line was finally oversewn with a continuous - pds suture. three patients had sleeve resection via an open access. results. after a median follow-up of months, patients had lost . kg=m of their bmi or % of their excessive weight on the average. there were six failures of lsg: three patients had gained weight despite lsg and three patients had lost less than % of their ew within one year. three of these patients underwent gastric bypass operations that were successfully performed laparoscopically. major complications included leaking of the staple line necessitating reoperation (three patients), severe wound infection (two cases, one of them after conventional sg), minor wound infections (three cases), and postoperative gastro-esophegeal reflux (one case), resulting in an overall complication rate of . % for severe and . % for minor complications. there was no operative mortality. conclusions. laparoscopic gastric sleeve resection is an effective and safe procedure with encouraging intermediate results. there is no implantation of foreign material, the procedure is less invasive than malabsorptive techniques. in the case of failure, it can readily be converted to gastric bypass or duodenal switch (with or without biliopancreatic diversion). on the other hand, this method has yet to stand the test of time within the spectrum of bariatric surgical procedures. background. bariatric surgery is indicated in patients with a bmi exceeding and presenting comorbidities or bmi ! . lgb is accepted as one of most successful surgical procedures to treat obesity. aim of study: a prospective analysis of the first patients who had been treated with lgb in our centre. methods. according to our treatment protocol at least dietetic attempts have to be failed to enrol the patient in the surgical program. lgb is performed in patients with a bmi ! with comorbidities or a bmi ! when gastric banding is unlikely to succeed. thirty patients (f:m ¼ : ) with a mean age of ( - ), mean bmi . (sd . %) underwent an antecolic, laparoscopic gastric bypass, performing the gastro-enteric as well as the entero-enteric anastomosis with linear stapler, closure of the enterotomies with manual continuous suture with pds, closure of the mesenteric defect with a non absorbable running suture. the postoperative controls had been performed on month ., ., ., . and . calculating the corresponding bmi. results. perioperative morbidity: two reoperations due to intestinal obstruction, two intraluminal bleeding of the anastomotic suture line, one case treated endosopically, one conservatively, no mortality was observed. the ewl months after performance of lgb was calculated to be % (sd %). conclusions. this series document that acceptable results may be achieved even during the learning curve of laparoscopic gastric bypass. background. in up to twenty five percent of morbidly obese patients restrictive procedures as vertical banded gastroplasty (vbg) or adjustable gastric banding (lagb) do not lead to adequate weight losses. transformation to a gastric bypass represents a therapeutic option in these patients. methods. from to revisional gastric bypass was performed in patients ( after vbg, after lagb, and after sleeve gastrectomy). the main indication for redo surgery was inadequate weight reduction. results. four ( %) surgical complications (incarcerated trocar hernia, intra-abdominal abscess, subphrenic abscess, leakage gastro-jejunostomy) occurred and had to be treated by a reoperation. one patient died of septic shock caused by a subphrenic abscess resulting in gastro-jejunal leakage and peritonitis (mortality rate: %). on follow-up patients after complications lost equal amounts of excess weight compared to uncomplicated cases. conclusions. revisional gastric bypass is a safe and potentially effective option for patients with inadequate weight loss after restrictive surgery. however, postoperative morbidity and mortality rates are higher compared to primary operations. operational cost accounting reflects in an impressive manner the medically already evident advantages for our patients. a laparoscopically performed colon resection with fast tracking costs e . , including pre-and post-surgical hospitalization. the same procedure without fast tracking results in costs of e . , . open colon resection including fast tracking adds up to e . , . conventional procedure without fast tracking even amounts to e . , . furthermore combining the operational results with the economical calculation results in a cost cutting potential of an extra e , per person, who has undergone laparoscopic surgery and was treated with fast tracking. in conclusion it can be stated, that this strategy of treatment means not only a severe post-surgical improvement of quality of life but in addition also shows significant economical advantages. the best method of treatment from both the medical but also the economical point of view is therefore the combination of laparoscopic colon surgery with fast tracking. is the laparoscopic sigmoid resection with a primary anastomosis in acute sigmoid diverticulitis the optimal surgical therapy? background. the late elective laparoscopic sigmoid resection for diverticulitis has become an acceptable therapy for diverticulitis, but the optimal surgical procedure of the acute diverticulitis has not been established. the optimal waiting period after acute symptoms of diverticular disease is still discussed controversial. the resection and primary anastomosis in acute diverticulitis may advance the challenging process for this surgical approach. methods. from may to january a laparoscopic sigmoid resection was performed in patients (male: , female: ) with a sigmoid diverticulitis. the average age was years for the males and years for the females. = patients were operated early elective within days after acute signs of diverticular disease (according to hansen and stock grade iia and iib) by a single surgeon, and = patients late elective by different surgeons. from all patients the clinical course, the operative time, the length of the sigmoid resection, the post-operative hospitalization and the complication rate were evaluated. results. according to the asa-classification = patients were graded as asa i, = as asa ii and = as asa iii. patients were divided in three groups. group i ( = ): early elective operations, group ii ( = ): late elective operations but with intraoperatively signs of an acute diverticulitis and group iii ( = ): late elective operations without manifestations of an acute process. the average operative time in minutes was in group i: (range - ), group ii: (range - ) and group iii: (range - ). the length of the resection specimen was comparable in group i and iii with an average length of mm, in group ii mm. the average extent of hospitalization was in group i: . days, group ii: . days and group iii: . days. none of the patients had conversion to laparotomy. complications were: group i one wound seroma, group ii one ureteral injury, one incision hernia and group iii three wound infections, one anastomotic leak and one incision hernia. since the localization and operative technique of the wound suturing was varied, an incision hernia was not observed. conclusions. the advantage of the early elective sigmoid resection after acute sigmoid diverticulitis is a short one-stage hospitalization with a low complication rate. in experienced centers the laparoscopic early-elective sigmoid colectomy seems to be a feasible and optimal surgical procedure for the acute sigmoid diverticulitis. laparoscopic resections for colorectal diseases: indications, operations, results s. riss, c. bittermann, p. dubsky, f. herbst background. laparoscopic assisted surgery for colorectal diseases has potential advantages over the traditional open technique. several studies reported that the laparoscopic approach offers multiple benefits such as faster recovery, better cosmesis, a lower incidence of adhesion-related complications and incisional hernias. the current study was designed to assess the role and feasibility of laparoscopic procedure in colorectal surgery. methods. from to patients ( females, males) underwent laparoscopic colorectal resections. mean age was (range - years) with a mean body mass index of . kg=m (range . - . kg=m ). indications included benign (inflammatory bowel diseases, diverticulitis, slow transit constipation, colon adenoma, fap) and malignant conditions with curative and palliative intent. all operations were performed or directly supervised by one single surgeon. intraand postoperative parameters were documented and statistically analysed retrospectively. results. over a year period operations in patients were performed, including bowel resections ( malignant) and anastomoses. average duration of operation was min (range - ). the mean time of hospital stay was days (range - ). the total conversion rate was . %. postoperative complications were observed in patients: surgical complications occurred in cases, with patients requiring reoperation (bowel obstruction n ¼ , anastomotic leak n ¼ , trocar hernia n ¼ , anastomotic bleeding n ¼ ). thirteen patients developed medical complications after operation and were treated conservatively. one patient ( . %) died due to cardiorespiratory failure. conclusions. the present study included a wide range of indication criteria. notable, despite a high number of patients with inflammatory bowel diseases, there was a low rate of surgical complications. thus the minimal invasive approach seems to be safe and effective for a broad spectrum of colorectal diseases. rectal carcinoma in the era of ''minimal invasive''-and ''fast track''-surgery p. razek, c. kienbacher, a. tuchmann background. laparoscopic surgery for colon cancer is feasible and effective with good results in regard of postoperative recovery. fast track protocols are changing perioperative treatments to the same aim. at the time there are no randomized studies available to compare the effect of laparoscopy and fast tract strategies to an open and conventional procedure for rectal carcinoma, which is still surgical standard. methods. from to patients were operated laparoscopically for rectal cancer ( males and females; mean age a, a- a). patients staged t were excluded. excessive preoperative surgery (i.e. right hemicolectomy, sigmoid resection, prostate resection), severe cardiac and pulmonary diseases or a high bmi did not effect the indication for laparoscopy. patients, ( %) staged t preoperatively, received chemotherapy and long time radiation. in the first period (-ii= ) patients were treated according to a conservative perioperative management. thereafter ( ) ( ) ( ) a fast track protocol was applied to the following patients. results. abdominoperineal extirpations (n ¼ ), anterior resections in double stapler technique (n ¼ ) and coloanal anstomosis (n ¼ ) were performed. conversion to open surgery was necessary in two cases ( . %), [bulky disease and a narrow male pelvis (n ¼ ), anatomical reasons (n ¼ )]. operation time was long and varied from to minutes (mean minutes). r was achieved in % ( patients with metastatic disease were staged r , one patient with a colonic wall lesion and potential spillage). postoperative stay for the laparoscopic group was days, for the combined laparoscopic þ fast track group was days (in comparison with days for conventional and open surgery). complications, mortality and side effects were reported. conclusions. exceptional view inside a narrow pelvis by the means of laparoscopy creates good conditions for total mesorectal excision and nerve sparing technique. minimal invasive surgery reduces the surgical trauma as a basis for an early postoperative recovery. the combination with a fast track protocol furthermore helps to establish even better results. the importance of laparoscopy in the management of postoperative complications c. kienbacher, p. razek, p. patri, a. tuchmann background. postoperative complications, especially anastomotic leakage after laparoscopic colon surgery are a hazard for all surgeons. most important is to recognize the early signs of complications such as abdominal pain, fever, chill, persisting nausea and vomiting and increasing abdominal swelling. the erlier a reintervention is done the better is the outcome for the patient. requesting a single and sufficient procedure, most surgeons don't even think about a minimal invasive reintervention. from = until = patients underwent laparoscopic colon surgery, patients had to be reoperated. twenty-five patients had a relaparoscopy, only two times we converted to the open procedure. patients had to underwent primarily open abdominal surgery, patients had abdominal wall problems and did not need an intraabdominal procedure. methods. concerning the intraabdomial complications we performed laparoscopic washouts, patients had a laparoscopic incisional hernia repair, patients bleeded from the trocarincisions, a laparoscopic anastomosis resection was performed, patients got a laparoscopic ileostomie, times it was necessary to perform a laparoscopic bowel diversion and times the hartmann procedure was performed minimal invasive. results. the traditional open reinvention was required in patients, all showed a peritonitis and a colon diversion with stomatherapie was done. eighteen patients had a single reintervention. after laparoscopic redos the median postoperative stay was far shorter than after open procedure. patients died. conclusions. laparoscopic reinterventions are feasable in most cases, the advantages are less postoperative pain, shorter hospital stay, quicker return of bowel fuction and improved cosmetic results. compensatory sweating after endoscopic sympathetic block at t background. endoscopic thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis (hh). compensatory sweating (cs) is the most frequent unwanted side-effect of this surgical procedure. recently, clip application (endoscopic sympathetic block, esb) has been introduced as it provides reversibility. furthermore, sympathetic block solely at the level of the th thoracic ganglion (t ) was proposed to reduce cs and still effectively cure palmar hh. the aim of the study was to analyze the outcome of patients treated by esb at the level t with special reference to cs. methods. between and patients (mean age . ae . years) prospectively underwent procedures (one unilateral and bilateral operations). satisfaction rates and quality of life scores have been evaluated. mean follow up was . ae . months obtainable from patients ( . %). results. one hundred and three patients ( . %) had palmar, ( . %) axillary and ( . %) combined hh. at follow-up, all patients with palmar and . % with axillary hh were completely or nearly dry. cs was observed in ( . %) patients. most frequently, the back ( . %), the thighs ( . %), the abdomen ( . %), the feet ( . %) and breasts ( . %) were affected. in . % one single body region was affected, in . % two and in . % three regions became humid. cs significantly diminished quality of life (p < . for both questionnaires). consequently, . % were unsatisfied with the final outcome. however, the vast majority of patients were completely or almost completely satisfied. conclusions. esb at t gives excellent results for palmar and good results for axillary hh. however, cs primarily affecting the back and the thighs diminishes patients' quality of life and satisfaction. right donor nephrectomy, a major challenge is adequate renal vein length, due to vascular anatomy. methods. all patients undergoing laparoscopic donor uretero-nephrectomy between and were included. side of nephrectomy was selected based on selective renal function assessment and vascular anatomy. standard laparoscopic access was gained through trockars, the kidney dissected from its capsule, the vessels isolated, and the ureter transsected. following transsection of the renal artery (proximal closure with clips to maximize retrieved vessel length), and the renal vein (proximal closure with vascular stapler), the organ was procured through a mini-laparotomy connecting two trokars. in laparoscopic assisted right nephrectomy, the vein was retrieved with a vena cava patch using a semi-open approach: following isolation of the vascular structures and ureteral transsection, the confluens of the renal vein with the inferior vena cave was excluded using a curved clamp through a mini-laparotomy in the right upper quadrant. the caval patch was created by cutting the vein closely distal to the clamp, with reconstruction of the vena cava by a running blalock suture. patients undergoing laparoscopic assisted right resection (study group sg) were compared to patients with laparoscopic left nephrectomy (control group cg). data are reported as mean ae standard deviation or total numbers (% . total morbidity was ( . %), including ( . %) infections, and ( . %) postoperative lymphatic leaks. two ( . %) major complications (bleeding ( ) and intraabdominal abscess ( )) resulted in reoperation (sg vs. cg ; p ¼ . ). conclusion. the laparoscopic assisted approach to right kidney procurement is feasible, allows for sufficient length of the right renal vein for transplantation, and donor morbidity is comparable to laparoscopic left nephrectomy. clinical implementation of radius surgical system in mis w. feil, i. pona, t. filipitsch, p. jiru, u. satzinger limited mobility of instruments and absence of depth perception are significant issues in advanced laparoscopy. by that procedures including complex suturing and anastomoses in narrow operating fields in difficult angles of visualisation exceptionally challenge experienced surgeons. the radius surgical system (tübingen scientific medical gmbh, tübingen, germany) consists of manipulators for mis (right and left hand) suitable for mm trocars allowing a freedom of movement comparable to robotic devices. the instrument tip can be deflected by by handle deflection and rotated via handle knob. compressing and releasing of the instrument jaws works conventionally. radius system was implemented in the ekh vienna by = . in advance a -day training course was absolved by the surgical team. radius system was used for a series (n ¼ ; = ) of reflux operations to perform hiatal suturing and fundoplication. in practice handling of radius taking advantage of all features turned out so physically mandatory, that a training course is unanimously recommended even for surgeons with experience in all mis suturing techniques. in pratice the needle could be guided with significantly higher precision if compared to convention needle-holders. even suturing in narrow cavities and in difficult angles became feasible (video). after full accomodation to radius the next step of implementation is the creation of handsewn anastomoses, esp. in bariatric surgery. precision, reliability, safety and tightness of sutures and sewn anastomoses are crucial for the outcome quality of advanced mis procedures. for that the radius surgical system has shown to be extremely beneficial. does lifting of the abdominal wall for the set up of the pneumoperitoneum for laparoscopy increase the safetiness? a. shamiyeh , j. zehetner , h. kratochwill , k. hörmandinger , f. fellner , w. u. wayand background. to evaluate the intraabdominal changes while lifting the fascia with regard to the distance between the fascia and the retroperitoneal vessels and the intestine for access in laparoscopy. fifty percent of all complications during laparoscopic procedures occur during the establishment of the pneumoperitoneum. the blind insertion of the veress needle is the most popular way of access. elevation of the abdominal wall or the fascia is recommended, though the benefit has not been proven yet. methods. for patients scheduled for laparoscopic cholecystectomy the operation started in the ct scan. after orotracheal intubation a ct scan was performed of the umbilical region with cm proximal and distal margin. after a supraumbilical incision the fascia was freed and elevated with stay sutures. during maximal elevation, a second ct scan was performed. the distance between the fascia and the intestinal structures (small bowel) and the retroperitoneal vessels (iliac artery, aorta, vena cava) was measured after both scans and the difference was evaluated. results. lifting of the fascia increased the distance between the fascia and the intestinal structures with a mean of . cm (range . - . cm), the distance between the fascia and the retroperitoneal vessels with a mean of . cm (range - cm). conclusions. elevation of the fascia at the umbilical region prior to the first entering into the abdominal cavity for laparoscopy does increase the safeties due to enlargement of the distance between the fascia and the intraabdominal and retroperitoneal structures. background. despite many years of experience in breast reconstruction even as an immediate one stage procedure, there are still rumours about this technique, even among oncologic surgeons. these are concerning the influence on the oncological outcome, radio-and chemotherapy, severity of the operation, possible complications and patient's satisfaction. the presentation offers answers to most of these rumours from our own experience and the recent literature. methods. one hundred and eighty breast reconstructions were performed between and in our department, as immediate and as delayed procedures. eighty-seven were done with microsurgical autologous flaps and with a latissimus dorsi flap, in the rest various techniques like prostheses and expanders were applied. patient data were collected concerning early and late complications, oncological outcome, influence on radio-and chemotherapy and patient's satisfaction. results. reconstructions with prostheses required shorter operating times, but mostly late revisions were more frequently, especially in combination with radiotherapy. among the group of patients, in whom flaps were applied, only one was lost. with increasing experience, the need for blood transfusions, the postoperative morbidity and the length of the hospital stay decreased. in no case radio-or chemotherapy had to be delayed due to immediate breast reconstruction. secondary axillary lymph node dissection due to a positive sentinel node was possible even after a flap which was pedicled in the axillary vessels. our experience is well reflecting the results of the recent literature. conclusions. despite many existing rumours breast reconstruction, even as an immediate single stage procedure, can be regarded as an operation which does not inflict the oncological therapy. to optimise the results, however, indications must be set very carefully. background. positron emission tomography with the glucose analog [ f]-fluorodeoxyglucose (fdg-pet) has been used for response evaluation in patients with esophageal squamous cell carcinoma (escc) during neoadjuvant radiochemotherapy (rtx=ctx). this prospective study was undertaken to compare fdg-pet assessment of tumor response during rtx=ctx with histopathology in patients with escc, and to correlate the findings with survival. methods. sixty-one patients with histologically proven escc (ct , cn =þ, cm ) underwent preoperative, simultaneous rtx=ctx followed by esophagectomy between and . the patients underwent fdg-pet prior to and weeks after the begin of rtx=ctx ( gray). histopathological response was quantified as the percentage of residual tumor cells. the threshold pre-therapy-to-during-therapy decrease in standardized uptake value by fdg-pet used to define metabolic responders (Ásuv r ) was À %. results. receiving-operator-curve analysis (roc) for determination of metabolic response revealed an area-under-curve (auc) of (p ¼ . ) with a sensitivity of %, specificity ( %), a positive predictive value of % and a negative predictive value of % (p < . ). responder by fdg-pet during the neoadjuvant treatment (p ¼ . ) as well as histopathology (p < . ) showed substantially better survival compared to nonresponders. conclusions. changes in tumor metabolic activity by fdg-pet during neoadjuvant rtx=ctx allows an accurate determination of response due to the multimodal approach in patients with escc. this stratification may lead to a change of the neoadjuvant into a definitive therapy concept in nonresponders (individualized tumor therapy). background. totally endoscopic coronary artery bypass grafting (tecab) requires telemanipulation technologies because attempts using conventional thoracoscopic instrumentation have completely failed. these complex operations take individual and team learning curves and a stepwise approach is necessary. methods. from to cabg procedures were performed using the davinci tm system. a low risk patient population (age ( - ) years, euroscore ( - )) was treated. the following procedures were carried out: endoscopic ima takedown in midcab, opcab, and cabg (n ¼ ), robotic suturing of lima to lad anastomoses through sternotomy (n ¼ ), single vessel tecab (n ¼ ), double vessel tecab (n ¼ ). results. the number of totally endoscopic approaches through ports only increased from % in to % in . there was no hospital mortality and cumulative risk adjusted mortality (cram) plots showed that . predicted events did not occur. given event free procedures clopper pearson estimations revealed a % confidence interval between . % and . % for perioperative mortality. cumulative year survival was %, and year freedom from angina was %. conclusions. introduction of robotic totally endoscopic coronary artery bypass grafting seems to meet current cabg safety standards. initial application in low risk patients and a stepwise approach to completely endoscopic versions of the operation seem worthwhile. using this way single and double vessel tecab can be performed. intermediate term survival and revascularization results appear to be very satisfactory. icu stay was a mean of day in both groups and hospital stay lasted on average . ae . days in the bh group and . ae . days in the ah group (p ¼ . ). the advantages of arrested heart tecab are various -more space through the relaxed heart, -superior anastomosis quality through the arrested heart, -no manipulation of the lad with tapes and a clear operating field through the use of crystalloid cardioplegia, -no occlusion of the lad with the risk of ischemia, and result in shorter anastomosis as well as operating times and do not increase icu and hospital stay. methods. initially an experienced gi-surgeon was trained in an experimental centre in the application in both, open and laparoscopic application of the flexible shaft stapling system. after experimental sessions the system was used in clinical open surgery in cases before the laparoscopic approach was used. for laparoscopic procedures a stepwise learning curve was applied (from laparoscopic appendectomy, colon resection to laparoscopic gastric resection and esophageal resection). for intraabdominal application of the linear stapling device a mm trocar and for the circular stapling device a mm trocar was used. technical problems, operation time and operative complications were prospectively documented. results. the flexible stapling device was used in patients ( conventional, laparoscopic surgery). a mean of stapling procedures (range - ) was performed per patient. during the early phase technical problems were observed in patients ( formation of gastric tube for esophageal reconstruction, three formations of colonic anastomoses). all problems were solved by repetition of the anastomoses. nine leakages ( . %) were observed: two after esophageal surgery ( = ; . %), one after gastric surgery ( = ; . %) and six after colon surgery ( = ; . %). conclusions. the flexible shaft stapling device is safe in open and laparoscopic surgery. technical problems in the early phase were not due to malfunction of the device. the problems and complications are within the limits of conventional stapling. since there is a learning curve for handling, proper training in laparoscopic and open surgery is advised. the new flexible stapling device showed beneficial in special indications in laparoscopic surgery. the handling of the device is possible in any location in the abdomen, which makes procedures like collis-plasty feasible to be performed laparoscopically. circular stapled anastomoses of the colon above the rectosigmoid junction can easily be performed in circular stapling technique. background. intra-und extraplexuale nerventransfers kommen routinemäßig in der rekonstruktion posttraumatischer plexus brachialis läsionen zur anwendung. in den letzten jahren wurden einige neue selektive distale nerventransfers beschrieben, welche ein geringes defizit an spendernerven hervorrufen, möglichst nur motorische fasern beinhalten und ein hohes maß an funktioneller synergie besitzen. in der vorliegenden retrospektiven arbeit werden die operativen details, und langzeitergebnisse von patienten bei welchen diese techniken zur anwendung kamen vorgestellt und analysiert. methodik background. long lasting brachial plexus lesions (bpl) require free functional muscle transplantation to restore some distinct motor function. methods. five patients, receiving a total number of free vascularized muscle transplants are presented. all patients were male, aging , , , and years. patients suffered from obstetrical, from traumatic bpl. unstable shoulder (n ¼ ) and lacking biceps function (n ¼ ) were the indications for surgery. the gracilis muscle was used in cases to replace deltoid (n ¼ ) and biceps (n ¼ ). in one case a rectus femoris muscle was transferred into deltoid position. reinnervation of the muscle transplants at the shoulder was perfomed end-to-side to the spinal accessory nerve. in biceps position the motor nerves of the gracilis were coaptated end-to-end with the ulnar nerve (oberlin procedure, n ¼ ) or intercostal nerves (n ¼ ). results. surgery was successful in all cases primarily. all transplants showed reinnnervation starting months after surgery. stabilisation of the shoulder was achieved in all cases, furthermore of these cases regained active shoulder abduction= flexion up to degree. gracilis in biceps position reached m , are reinnervating. conclusions. free vascularized muscle transplantation seems to represent an useful tool for reconstruction of some distinct, essential motor function in paretic limbs due to bpl. background. since viterbo presented his exquisite results from terminolateral coaptation in small animals a new source for neurotisation seemed to be provided. viterbos results and our own good experience with free functional muscle transplantation encouraged us to use the technique in brachial plexus surgery. in a retrospective analysis we wanted to prove whether or not terminolateral neurorrhaphy produces functional results in brachial plexus surgery. methods. in patients, suffering from minimum c , avulsion and=or rupture a total of terminolateral procedures was carried out: times the suprascapular nerve was connected with the spinal accessory nerve and times the biceps motor nerve with the ulnar nerve, after creation of an epineureal window in all cases. results. patients were investigated . (ae ) month after surgery. the modified oberlin procedures (n ¼ ) showed m . the ss to xi procedures ranged from m (n ¼ ) to m (n ¼ ). multichannel emg evaluation did not reveal isolated function of the reinnervated muscles but action in parallel with the ''source muscles''. in out of procedures the terminolateral neurorrhaphy was sufficient to regain useful muscle function, i.e. to stabilise the shoulder and to add some minimal active function. conclusions. with respect to the severity of the lesions one might consider this an acceptable result. actually we did expect better results from the procedures, as we did achieve m and m function with free functional muscle transplantation and terminolateral neurorrhaphy in children. regarding our experience, the technique represents an useful tool for reinnervation, provided an unimpaired function of the donor nerve. current concept for treatment of obstetrical brachial plexus lesions w. girsch background. for a long time the treatment of obstetrical brachial plexus lesions (obpl) consisted of conservative treatment mainly. surgery was indicated only in severe cases suffering from persistant complete flail arm. gilbert introduced a much more aggressive concept with surgical intervention whenever the biceps is not working at three months of life, a strategy which caused discussions permanently. as a result of this discussion and with respect to clarkes work the concept was modified in the last years again. methods. the diagnosis of an obpl has to be followed by monthly clinical examinations. testing for muscle regeneration is not only focussed on biceps muscle but also on time and topographic course of regeneration. lack of shoulder and biceps activity at three months of life or negative ''handkerchief-test'' at six months represent indications for immediate surgical revision of the brachial plexus (primary early nerve surgery). in cases showing ongoing regeneration the conservative treatment is maintained. relevant deficiencies in motor function (less than % of rom or power in correlation with the unaffected side) at twelfe months of life represent an indication for brachial plexus surgery again (primary late nerve surgery). further nerve procedures, usually isolated nerve transfers (secondary late nerve surgery), can be performed in selected cases up to two years of life. after that time musle transfers and osteotomies (secondary procedures) are perfomed to achieve further increase in function. results. in brachial plexus surgery new concepts of ''extraplexual neurotisation'' and ''end-to-side neurorraphy'' have increased the possibilities of reconstruction by increasing the amount of nerve sources. secondary procedures, including free functional muscle transplantation, have become an integrative part of the overall treatment strategy. conclusions. although obstetrical techniques have improved in the industrialized countries, there still exists an incidience of - obpl per newborns, last but not least with regard to an increasing number of babies weighing more than g. it is known that of obpl recover spontaneously. new investigations have revealed relevant deficiencies in out of of these children at an age of years. actually the number of children requiring surgery is small. but for these children it is important to make the right decisions in time to minimise deficiencies and achieve optimal results. external derotation osteotomy of the humerus in patients with erb's palsy -effects on upper extremity kinematics b. gradl, m. mickel, m. schmidt, g. weigel, a. kranzl, w. girsch orthopädisches spital speising, kinderabteilung, wien, austria background. patients with untreated upper brachial plexus lesions frequently develop an internal rotation contracture of the shoulder, deficient active shoulder abduction and especially external rotation. the humeral derotation osteotomy combined with muscle transfers is one of the most common secondary reconstructive procedures to correct this deformity and improve the upper limbs function. the aim of this study was to investigate the patients' benefit of the surgical intervention. in order to objectively assess the functional outcome an optoelectronic motion analysis system was used to capture and analyze the kinematics of the involved limbs pre-and postoperatively. methods. eight children with secondary deformities following an obstetrical erb palsy were investigated before and after humeral derotation and muscle transfers. the patients' movements were captured by tracking the reflective markers which were applied to the upper limb and the trunk. the motion analysis was finished on the pc, resulting in various kinematic parameters, such as joint angles, motion curves, velocity and acceleration. static data was calculated to measure the amount of the shoulder malposition. results. results of the motion analysis document a dynamic as well as a static improvement of the involved limb in all eight patients. the average effective external derotation of the upper arm was , which means a correction to a nearly physiologic rotational positioning. active abduction increased in of patients with enhancement between and . active shoulder rotation improved in all patients ($ ). the maximum active elbow flexion did not increase, but the motion curves describing the movement changed: the velocity increased ( %), the compensatory shoulder abduction, which was observed during elbow flexion preoperatively in all patients, was reduced to a physiologic extent (compared to healthy probands). conclusions. derotation of the humerus as a secondary procedure allows functional improvement in patients with erb's palsy. this can be assessed by using a d motion analysis system. following global or lower brachial plexus lesions with intact biceps function in combination with missing radial nerve and weak median nerve function a supination contracture of the forearm is resulting. the supinated position of the forearm is functionally useless and often causes neglect of the extremity. five patients underwent surgical correction of this deformity, females (aging , and years) and males (aging and years). the biceps tendon was rerouted to the outside of the radius in cases and to the medial side of the ulna in one case. additionally correction osteotomies of radius and ulna had to be performed in the y old patient. reconstruction of extensor function was done in classical manner by tendon transfers. the tendon transfers did not only reanimate the extensors of carpus and hand but also augmented the light pronation of the forearm. all patients regained normal biceps and some simple hand function. regarding this, all patients started to use the extremity during adl for some, mostly bimanual tasks. correction of the supination contracture was highly beneficial for the patients. the procedure changed a useless extremity into a functioning part of the body. background. reconstruction of the distal weight-bearing area of the foot is surgical challenge, especially in diabetic patients. skin grafts do not provide adequate and permanent coverage of a weight-bearing region. local surgical options to cover these distal skin defects include forefoot amputation, a toe fillet flap and a reverse medial plantar island flap. the reverse medial plantar island flap is based on a very thin and possibly damaged intermetacarpal network. conventional angiography often is not a helpful tool for preoperative assessment, because foot vessels often remain occult. methods. the purpose of this study was to evaluate the viability of the distally based medial plantar flap in cadavers. angiographic imaging was possible in only cadavers reflecting the clinical preoperative assessment. distally based medial plantar flap dissection was done in all cadavers, as well as vascular dissection of the superficial and deep plantar arch. results. we found a well developed deep plantar arch in all cases. the deep plantar artery formed the main feeder of the deep plantar arch in %, while the second proximal perforating artery contributed to the deep plantar arch in %. the superficial plantar arch usually appeared slender and incompletely. conclusions. the distally based medial plantar flap could be dissected in all cadavers, whereas the quality of vessels was varying explicitly. the results of dissection always showed a constant vascular supply, but varying quality of supply. no clinical conclusions can be drawn, considering the slender vas-cular supply of the distally based medial plantar flap. optimized diagnostic angiographic procedures like mra or biplane selective dsa are essential for preoperative assessment planning distally based medial plantar flap. limberflap -salvage procedure for the non healing pilonidalis sinus t. kapp, h. marlovits, j. beck, f. hetzer kantonsspital st. gallen, switzerland background. surgical treatment of pilonidal sinus disease has a significant morbidity and recurrence rate. the rhomboid flap of limberg is a transposition flap that has been advocated for treatment of this condition. we present the technique and our experience. methods. in a prospective study starting in january we analysed consecutive patients ( females), median age years (range - years), with recurrent pilonidal sinus disease. we performed a complete rhomboid excision and closed the lesion by an excentric transposition flap designed to obliterate the middle cleft. morbidity was recorded and patient's satisfaction was analysed by a visual analog scale (vas). results. the median hospital stay was . days ( - days). we found in all patients a primary healing. minor complications were found in two patients. there was one flap oedema and one wound dehiscence, which were conservatively treated. no wound infection was observed. during the median followup of months ( - months) no recurrence occurred and high patient satisfaction was noticed. conclusions. although the limberg flap results in a slight asymmetric gluteal region patient's acceptance is high. fast healing, low complication and recurrence rate are the important advantages for this procedure. treatment of human painful neuromas and complex regional pain syndromes (crps) by co laser welding and regional subcutaneous venous sympathectomy (rsvs) -a new surgical approach w. happak, l. kriechbaumer background. since nearly years the treatment of painful neuromas is an unsolved problem. up to techniques are described with a recurrency rate of the pain between and %. the intramuscular transposition, the implantation into a vein and the end-to-side coaptation of the nerve stump are the state of the art operations. besides for years the treatment of complex regional pain syndromes type ii (crps ii) has been an unsolved problem. therapeutic approaches have included conventional pain medication, physical therapy, sympathetic blocks, transcutaneous or spinal cord stimulation, injections or infusion therapies and sympathectomy. alone or in combination these therapies often yielded unfavorable results. the majority of physicians, dealing with crps patients are convinced that surgical treatment only exacerbates the symptoms, and after the third neuroma pain-operation no improvement can be expected. after unsuccessful anaesthesiologic pain therapy over more than months, patients, with chronic neuroma or phantom pain were operated by co laser welding of the nerve stump in the last years. one third of the patients had or more pain operations. subsequently patients developed a crps type ii at the upper or the lower limb. the exact pain area was determined and the most proximal part where the crps commenced was infiltrated with % xylocain. when the sympathetic, deep, burning pain could be blocked, the subcutaneous veins in the previously determined area were removed surgically in a second step. a visual analogue scale (vas), the nottingham health score (nhs) and physical examinations were used to evaluate outcome of the operation. results. ninety-five percent of surgically treated painful neuromas and crps type ii patients showed significant improvement of limb function, the visual analogous scale (vas) and the nottingham health score (nhs). the medical pain therapy could considerably be reduced. conclusions. the presented data show that the superficial epicritical pain of neuromas can be treated successfully with co laser welding. the sympathetic, deep pain of the complex regional pain syndrome type ii can be treated successfully by a regional subcutaneous venous sympathectomy (rsvs). first clinical study of successful erbium-yag laser vaporisation of cutaneous neurofibromas l. kriechbaumer, w. happak background. with a prevalence of in births neurofibromatosis type i is one of the most common genetic defects. the mode of inheritance is autosomal dominant and affects a gene (nf ), which is responsible for the production of the tumor suppressor protein neurofibromin. the consequence is an uninhibited expansion of neural tissue which leads to cosmetic disfigurement of the patients. in comparison to the plexiform neurofibromas the cutaneous tumors do not undergo malignant transformation. excision and co laser vaporisation were established as standard treatment but cause unattractive scars. methods. in operations on two patients more than neurofibromas were removed with an erbium:yag laser. the tumors were dissected by shooting holes into the skin and vaporising the neurofibromas in-between or underneath. from test areas several biopsies were harvested for er:yag-, co and electrosurgical treatment in vitro to evaluate the difference of thermal necrosis histologically. photographs were taken to assess the cosmetic results. results. the fast healing by second intention as well as the minimal discomfort and scar formation following er:yag laser vaporisation was judged as excellent by patients and surgeons. we did not observe any hypertrophic scarring or lasting dyspigmentation. histologic evaluations revealed minor thermal damage to adjacent tissue resulting from this laser. conclusions. scars and changes in pigmentation resulting from excision or co laser-vaporisation often yield unfavourable results and the treatment is time consuming. er:yag laservaporisation of huge numbers of cutaneous neurofibromas is an uncomplicated and rapid procedure that achieves excellent cosmetic effects. background. lichen sclerosus usually presents a precancerous skin lesion of the genital region. skin grafting of penile defects is difficult because of the flexibility of the underlying recipient bed. this leads to disruption of the vascular ingrowth into the skin graft and compromises the results of the reconstruction. methods. we successfully used a circumferential vacuumassisted closure dressing with an incorporated urethral catheter to secure penile skin grafts in place during the early postoperative period. results. we achieved perfect take-rate of the graft and postulate good functional result concerning the stretched penile position during application of the vac-device. conclusions. a vacuum-assisted closure dressing can be used successfully to secure large and circumferential skin grafts, as well as skin grafts on concealed penises. background. there is a trend in reconstructive surgery towards modern techniques of defect coverage. such techniques are expected to combine high levels of safety, low donor-site morbidity, high aesthetic claims, short patient immobilisation and inpatient periods. the speculative applications for free, microvascular tissue transfers are expanded monthly while traditional reconstructive flap designs are no longer accepted as ''state of the art''. we present a case where modern defect coverage was not successful due to multiple comorbidities, localisation and complexity of the defect, and a step back to traditional flap designs was inevitable. methods. a previously healthy -year-old woman found a tumour on her back four years ago. diagnostic imaging and multiple biopsies revealed a cm-diameter chondrosarcoma with partial osteolysis of th = , tumour reaching into the spinal canal. she underwent radical resection and orthopaedic stabilisation from th -l , followed by chemotherapy and radiation of gy. one year after the operation metastatic lesions were found in both lungs. they were resected by video assisted thoracic surgery. due to resection of the erector trunci, the spine stabilisators loosened, two screws broke and the metal parts penetrated the skin. after local necrectomy, vac-therapy was performed for more than one year. severe headache and massive exsudation of the wound started in , suggesting dural leakage. a reversed latissimus dorsi-flap was performed, additional microanastomosis could not be done due to the very small calibre of the intercostal vessels. after one week, the metal-covering part of the flap showed muscle necrosis and had to be resected. a large fasciocutaneous transposition flap was designed and cautiously raised in steps of delay and could finally cover the defect. results. in this rare case of a chronic vertebral defect including spinal instability and liquorrhea reconstructive aims could not be reached by microsurgical techniques but by returning to traditional local flap designs. the patient is mobile and painfree, and there is no recurrence of liquorrhea since discharge. conclusions. technical advances and refinements in defect coverage are the basis for progress in reconstructive surgery. selected indications for traditional flap techniques still remain in modern reconstructive surgery dominated by microsurgical tissue transfer to cover problem defects. the missing link between tradition and innovation: skin tissue engineering l. kamolz, m. frey background. the need to achieve rapid wound closure in patients with massive burns and limited skin donor sites led to the investigation of in vitro cellular expansion of keratinocytes. the use of cultured epithelial grafts was first reported in the treatment of major burns. since , support for the use of keratinocytes has varied. the factors potentially limiting the use of cultured keratinocytes were cultivation time, reliability of 'take', vulnerability of grafts on the newly healed surface and long-term durability. the aim of this review is to evaluate the real impact of the clinical use of keratinocytes. one of the main aspects is to introduce new methods, which found or will find their way into clinical practice. methods. this study is mainly based on our long lasting experience in cultivating and transplanting cultivated keratinocytes (more than patients and sheets). results. the coverage of burn wounds with viable keratinocytes renders constant and reliable results. understanding keratinocyte-matrix interactions has not only allowed us to influence keratinocyte outgrowth, adhesion, and migration, but also has guided us to modify matrices for enhancing keratinocyte take. due to these improvements we have achieved a proper material in the adequate situation. conclusions. as surgeons, our goal is to help burn patients with the best quality of skin in the shortest time possible. as tissue engineers, we have not achieved the goal of a universal skin product yet, but by continually reviewing new options and using them, the anatomy and physiology of engineered skin substitutes will improve and they will become more similar to native skin autografts. thereby tissue-engineered skin may match the quality of split-skin autografts in future. background. the survival of patients with major burns goes hand in hand with early escharectomy and the survival of skin grafts. methods. the application of topical negative pressure has improved increased graft take especially in difficult anatomic regions. results. securing skin grafts in pediatric burn patients enabled a near % graft take. perfect protection from shear forces, early mobilisation, patient comfort, nursing comfort and abandonment of splinting are major advantages concerning conventional dressings. conclusions. we postulate the application of vac for securing skin grafts as a valuable tool in pediatric burns management. wide meshed grafts and including donor sites protected by silicon layers into the dressing in extensive burns should be evaluated carefully because of possible bleeding. background. versajet is a high -pressure hydrosurgery system, which enables a very precise surgical procedure. this single device technique combining lavage, excision, cleansing and aspiration allows a sharp debridement on any surface, or space. there are lot different indications for the use of versajet in plastic and reconstructive surgery. this system is appropriate for a variety of burn and traumatic wounds. because of the precise handling the use of this device is also in cosmetic surgery possible. methods. in this device a high velocity stream of sterile saline jets across the operating window and into an evacuation collector. because of a physical effect, a localised vacuum is created across the operating window. this holds and cuts targeted tissue while aspirating tissue from the site. therefore it enables to precisely target damaged tissue and spare viable tissue. surgical techniques can be enhanced, for instance the device holds targeted tissue during irrigation and excision. in addition, versajet cleans and cools at the same time as debriding, so additional cleaning techniques are not required. the depth of the skin -debridement is absolute predictable. in about cases the versajet has been used. the range of indications included burns, infected wounds (decubitus ulcers, traumatic wounds, fournier gangrene, necrotizing fasciitis). the advantage of this hydrosurgery system compared to sharp debridement using scalpels, dermatome, etc. is a more rapid and precise debridement, therefore the preservation of viable tissue, the precise and easy treatment of concavities and convexities and a reduction of blood loss could be achieved. histological findings proved the feasibility of an exact abrasion into different layers of the dermis. results. by using the versajet device, a reduction of the debridement procedures, an earlier reconstruction and a shorter time of hospitalisation could be achieved. the most important indication is the treatment of b burn-wounds. in burn cases the necrosectomy with some other devices may be quicker and more useful. although there is a learning curve which is very short, this tool is easy to handle. there has been no adverse effects. conclusions. the versajet-handpiece is a disposable product, but because of the advantages it is at least cost-covering. debridement is highly effective since it enables selective tissue targeting. removal of non-viable tissue is more complete as a result. background. in more than children (age < years) were suffering from burns. the gold standard of surgical care is still under discussion. the aim of the study was to evaluate an optimised treatment regime for scalds in children. methods. between and , children underwent surgical intervention due to salds. thirty-six of them were enrolled into the study. twenty-two children with deep dermal scalds (total-body-surface-area burned (tbsa) . %) were treated by early excision and keratinocyte-coverage (keratinocyte-group). fourteen children (tbsa . %) were treated with autologous skin grafts (skin-graft-group). both groups were comparable according to age, burn depth and tbsa. the complete clinical follow-up was at least months. the scar formations were classified (vancouver-scar-scale (vss) and the need of blood transfusions were administered. results. the use of keratinocytes led to complete epithelialisation. no secondary skin grafting was necessary. skin take rate was % in the skin-graft-group. the mean volume of transfused blood was . ml in the keratinocyte-group and thereby significantly lower than the volume of . ml, which was administered in the skin-graft-group (p ¼ . ). the vss observed in the keratinocyte-group was . and thereby significantly lower than the vss of . in the skin-graft-group (p ¼ . ). conclusions. in children the use of keratinocytes renders constantly reliable results in deep dermal scalds. it minimizes the areas of skin harvesting and reduces the amount of blood transfusions. the fact that also less scarring is observed leads to the conclusion that skin grafting should be restricted to full thickness scalds. background. ventriculo-peritoneal (vp) shunting is the treatment of choice for hydrocephalic children. however, serious complications related to infectious and non-infectious reasons may subsequently appear during lifetime of these patients. as we attend nearly all our patients from birth to adulthood we had to face various kinds of abdominal problems over the years. hydrocephalic children underwent vp shunt placement. outcome and follow-up of these patients were discussed. results. our analysis showed that non infectious complications like: shunt dislocation, kinking and obstruction including some rare phenomenon are well described in literature and can hardly be avoided. but being confronted with various infectious complications we had to change our strategy over the years. severe shunt infection appeared after appendicitis in patients. therefore we consequently performed elective appendectomies since . consecutively we had to face problems with following malone procedure. because of abdominal pseudo cysts after recurrent shunt revisions bacterial culturing methods and antibiotic therapy regimen changed. treatment of post haemorrhagic ventricular dilatation in premature very low birth weight infants had changed over the years from intervention with external drainage, early lumbar punctures, repeated ventricular punctures to implantation of the new ''side-inlet integra reservoir''. conclusions. the lesson we learned out of this retrospective analysis is that treatment of these hydrocephalic patients needs to be designed concerning all problems of the disease during life time period. therefore we think that experience and retrospective analysis is a very important point of view for the future. years' experience with lymphangiomas in children j. burtscher, e. horcher background. the management of lymphangioma in children is still challenging. complete resection is difficult to achieve in some cases and recurrences are common. methods. a retrospective study over a period of years was carried out. fifty-one patients were treated. males and female patients. the involved sites were head and neck, trunk and extremities as well as retroperitoneal, intraabdominal or intrathoracic location. prenatal mri was introduced to plan operative strategy especially for cervical location. results. there were recurrences. recurrence rate was highest in intrathoracal location. there was so significant differences, in terms of outcome, between those who had their surgery immediately at the time of diagnosis and those who had delayed surgery. conclusions. prenatal mri is a helpful tool in planning operative strategies like exit-procedure (ex utero intrapartumprocedure). risk factor for recurrence included location, size or complexity of lesion. background. hemangioma is the most frequent tumor in childhood. in more than % of cases hemangiomas are located in the face and the decision about the need for treatment, and the type of treatment may be difficult. complex hemangiomas need emergent systemic drug therapy, which may be combined with other types of interventional therapy, such as surgery or laser treatment. the aim of this study was to evaluate our experience in the treatment of complex hemangiomas. methods. analysis of complete records of patients who were treated in the period between . . and . . . results. out of patients referred to us, patients ( %) needed hospital treatment ( % girls), mainly because of rapid growth, and complications which were present in patients ( %). the most frequent localization of hemangiomas were the head and neck region ( %) and % of patients had multiple hemangiomas. median age at first referral was months, with % of patients referred to us before months of age. more than half of patients received their first treatment before months of age, and within days after referral. treatment consisted in laser therapy ( %), excision ( %), and additional (or exclusive) drug therapy in % of patients (cortisone, interferon). interdisciplinary treatment was necessary in patients ( %), involving mostly plastic surgeon, dermatologist, pediatric oncologist, pediatric radiologist, ophthalmologist, and psychotherapist. the majority of interdisciplinary treated patients ( %) received initial treatment in other centers, patients ( %) presented with complications, and rapid growth was present in % of patients. parotid hemangiomas (n ¼ ) were treated solely by systemic cortisone treatment (n ¼ ). intra-tracheal hemangiomas (n ¼ ) required often a laser treatment (n ¼ ), in addition to administration of systemic cortisone. massive segmental facial hemangiomas (n ¼ ) needed additional treatment with interferon (n ¼ ). in one case a phaces syndrome was diagnosed and the patient needed a complex therapy. conclusions. the need for treatment of hemangioma must be made on the individual basis. most hemangiomas need only observation. however, patients with complications and=or facial localization of hemangioma with rapid growth require often emergent treatment in medical centers with the possibility for an interdisciplinary management. early therapy may be a precondition for a good cosmetic result. background. treatment of appendicular peritonitis is closely connected with prophylaxis and treatment of surgical complications during postoperative period. the abscess of omentum major is one of such a complications, elsewhere discussed in medical literature. the aim of the study was the reduction in frequency of this complication. methods. during - years we treated patients with the abscess of caul. all of the patients were also treated for the appendicular peritonitis in the past. the time since the discharge from outpatient department to re-admission to the hospital varied within - days. the disease manifested with abdominal pain, increase in body temperature to the febrile grade. all the patients presented with tumour-like abdominal mass of various size. two patients presented with umbilical fistula and purulent effusion. abdominal ultrasound elicited masses with fluid content in patients. laboratory work-out revealed significant increase of tests relevant to endotoxicosis. all patients were operated. five patients underwent dissection of infiltrate, and the total resection of caul. two patients passed drainage of abscess through the anterior abdominal wall. results. all the patients recovered. complications of early and late postoperative period were not observed. patients were on the close follow-up for to years without any sequalae. hospitalisation span was . ae . days. conclusions. . abscess of caul can manifest during early as well as late postoperative period. . management of omental abscess: -complete resection within visually intact tissues; -careful washing of abdominal cavity with antiseptic solutions; -vigorous antibacterial therapy in postoperative period. beneficial effects of mixed hyperalimentation in children with septic form of acute hematogenic osteomyelitis a. albokrinov , a. pereyaslov lviv children's regional clinic hospital, lviv, ukraine; lviv d. halytsky national medical university, lviv, ukraine background. septic form of acute hematogenic osteomyelitis (aho) is severe sepsis with multiple organ dysfunction syndrome (mods) according to accp=sccm consensus conference committee, . mortality and morbidity rates from this remain unacceptably high, in spite of achievements in intensive care medicine. nutritional support is the method of intensive care with proven efficacy, but the ''perfect'' regimen of it is unknown. methods. in - in our clinic children with septic form of aho were treated. they received standard therapy of severe sepsis which included surgical treatment (osteoperforation, suppurative focus drainage, pleural drainage in case of pyopneumothorax), antibacterial therapy, hemodynamic support. all of patients were mechanically ventilated (mv) because of acute hypoxemic respiratory failure on the basis of metastatic pneumonia. regarding to nutritional regimen patients were randomized on two groups: control (enteral alimentation with isocaloric isonitrogenic diet fitting basic energy expenditure (bee) multiplied by coefficient . ), and basic (mixed enteral ( . bee) plus parenteral (protein ¼ g=kgÃday, energy ¼ . bee) hyperalimentation). results. there was strong tendency of patients in basic group to have less pulmonary complications, better gas exchange values, less ventilation days and less intensity of hypermetabolic-hypercatabolic syndrome (see table, à p < . ). conclusions. mixed enteral-parenteral hyperalimentation in children with septic form of aho is an effective method of prevention of pulmonary tissue destruction and respiratory function improvement. background. the aim of this study was to gain information about the mechanisms of injuries and injury pattern at primary and secondary schools in austria. methods. at the department of pediatric surgery in graz and six participating hospitals (klagenfurt, salzburg, steyr, krems, schladming and innsbruck) all children from to years presenting with trauma were included within a two year study period. in total, pediatric trauma cases were filed. data were analyzed regarding personal data, site of the accident, circumstances and mechanisms of accident and the related diagnosis. results. at the department of pediatric surgery, medical university of graz, questionnaires were completed, out of which children had suffered from school accidents ( %). questionnaires from outside hospitals included school accidents ( %) with a mean age of . years in the children from graz and . years in children from participating hospitals. the male=female ratio was : . in general, sport injuries lead to a higher rate of severe trauma ( % severe injuries) compared with other activities in and outside of the school building ( % severe injuries) with ball-sports being the most dangerous activity with a % proportion of severe injuries. over all, the upper extremity was most frequently injured ( %), followed by lower extremity ( %), head and neck area ( %) and injuries to thorax and abdomen ( %). conclusions. half of all school related injuries occur in children between and years of age. there are typical gender related mechanisms of accident: boys get frequently injured during soccer, violence, and collisions in and outside of the school building and during handicrafts. girls have the highest risk of injuries at ball sports other than soccer. background. objects and notably coins are frequently swallowed by children - years old. their precise management on asymptomatically passing the gastro-esophageal junction remains controversial. this study was performed to assess dissolution of specific metals from coins immersed in simulated gastric juice. methods. four types of euro and us coins were immersed in simulated gastric juice for , , and hours. six metals were evaluated by inductively coupled plasma-atomic control group (n ¼ ) basic group (n ¼ ) sofa, mean (sd) . ( . ) . conclusions. coins retained in the stomach will release a number of heavy metals well known to cause dose-dependent poisoning. studies to evaluate their toxicity and absorption are needed to optimize treatment. the surgical tactic on the splenic injury in children a. pereyaslov, s. chooklin, i. korinevska, a. troshkov medical university, lviv, ukraine splenectomy in children often leads to various complications. retrospectively, results of the management of children (range from to years), which underwent surgery due to the liens' injury, were examined. the immunological and hormonal investigations were performed. out of operations in the splenectomy, in cases the splenectomy with the tissue autotransplantation of the lien in the greater omentum and in cases the organ-preservation operations were performed. purulentseptic postoperative complications were noted in ( . %) patients, which connected with the inadequate of the immune answer. the obvious t-cellular immunodeficit, low concentration of igm, decrease of phagocytosis were observed in this category of patients. by that, on the background of activation of the renin-aldosteron system and changes of the eicosanoids synthesis, the danger of the sepsis and septic shock development were arisen. the autotransplantation of the lien tissue did not protect the organism from the purulent-septic complications in the nearest postoperative period. as the answer to the transplanted tissue and necrobiotic processes, which had been occurred in it, the autoimmune processes and reactions of the hypersensitivity of the immediate type (the increase of ige and dna antibodies levels) were intensified. with the goal to prevent complications in the postoperative period the thymic hormones, interferon a, aspirin and dipyridamol were applied. in the remote terms, the postsplenectomy syndrome manifested itself in patients, which underwent the splenectomy in childhood. predisposition to the infections and thrombohemorrhagic processes prevailed. the disturbances of hemostasis are linked with the significant increase of the t-helpers that connected with the intensifying of the il- action, which also evokes the proliferation of the preactivated b-lymphocytes, and, as the result, the obvious synthesis of igg. igg in the composition of the immune complexes can stimulate the function of the neutrophyles. all this promotes to transfering the hageman factor in the active condition, activation of the coagulative and kininogen-kinin blood system, intensification of the fibrinolysis, the deposit of fibrin and the development of the hemorrhages. the autotransplantation of the lien tissue could not enhance defence of the organism in full value. thus, at the traumatic injury of the spleen the prevalence must be given to the organpreserving operations. background. mri of the breasts has been described the most sensitive imaging modality for detection of multicentric or multifocal malignant tumor manifestations. in we began with routine preoperative mri-staging in breast cancer patients. the aim of this study is to analyse the benefit of preoperative mr-imaging regarding surgical treatment and follow up in patients with invasive breast cancer. methods. the retrospectice study (n ¼ ) includes all female patients with histologically verified invasive breast carcinoma, which have been operated at our department between and . exclusion criteria were carcinoma in situ, local recurrence, inflammatory carcinoma and neoadjuvant therapy. demographic, radiological, operative and histological data, standardized follow up (dfs, os) and recurrence rate were analysed. results. surgical treatment consisted in bct ( . %) and mrm ( . %). % of tumors showed an invasive ductal differentiation. lymph nodes were positive in %. tumor size showed the following pattern: pt %, pt % and pt = %. grading was . % (g i), % (g ii) and . % (g iii), respectively. mr-imaging revealed multifocal or multicentric tumor manifestations in % of patients, the mri results changed surgical treatment in % of cases. mean follow up was months. the local recurrence rate was . %, . % of patients developed carcinoma in the contralateral breast, incidence of distant metastases was . %. conclusions. the data confirm the importance of routinely performed mr-imaging in preoperative staging of breast cancer patients. mri-identification of multifocal or multicentric tumor manifestations is essential to choose the optimal surgical treatment and reach a minimal recurrence rate. methods. between july and october patients with operable breast cancer were treated at general hospital feldkirch. of subsequent patients with non-palpable lesions intraoperative sonography was used in (group ), wire localisation in cases (group ). the study was conducted as nonrandomised trial with prospective data collection. results. breast-conserving surgery was performed in % in group and % in group . primary r -resection was significantly higher in group ( %) than in group ( %, p < . ) while median clear margins were . and . mm in these groups (p < . ). both wire localisation and intraoperative sonography proved to be feasible with tumor identification rates of %. conclusions. intraoperative sonography proved to be reliable and feasible in breast cancer patients in the hands of the surgeon. clear advantages next to tumor identification and topographic orientation for excision were organisational acceleration and improvement: discomforting, time and labour intensive wire localisation can be avoided and breast lesions can be excised in a tissue-sparing and breast-conserving technique in a very high percentage. background. extensive intraductal disease represents an important clinical problem in the management of patients with invasive or in situ breast cancer. we present a new method for intraoperative ductoscopy with intraductal biopsy of suspicious lesions. methods. intraoperative ductoscopy was performed in women undergoing operation for breast cancer or nipple discharge. a rigid gradient index microendoscope ( . mm) with a special biopsy device for vacuum assisted biopsy was used for all examinations. ductoscopy findings were documented prospectively and correlated with preoperative mammography and histology of the resection specimen. results. ninety-two percent of the patients were examined successfully. ductoscopy identified intraductal lesions (ie, red patches, ductal obstruction, or microcalcifications) in % of the patients. abnormal ductoscopic appearance was found in more than % of the patients with extensive intraductal disease %. patients with an abnormal ductal appearance on ductoscopy, compared with those with a normal ductal appearance, had a greater incidence of extensive intraductal spread of cancer ( % vs. %) and a greater incidence of positive surgical margins ( % vs. %). ductoscopic biopsy of intraductal lesions was technically successful in all but one case. generally, the quality of the biopsy samples was good. diagnostic biopsy samples were obtained in of patients ( %). two samples contained necrosis and were considered to be non-representative. histological analysis of the biopsy specimens showed papilloma, in situ carcinoma and invasive carcinoma. conclusions. high-resolution ductoscopy is able to detect extensive intraductal disease in a considerable number of women with breast cancer. vaccum assisted biopsy allows intraductal tissue sampling of very small lesions. in selected patients, a combination of both preoperative imaging and intraoperative ductoscopy may help to avoid incomplete resections and re-excisions. background. preoperative chemotherapy (pc) for breast cancer was initially focused on locally advanced tumors. later on it has been established to downstage operable tumors primarily not suitable for breast conserving surgery. now pc is often used as an invivo test for chemotherapy regimens. methods. since the austrian breast and colorectal cancer study group (abcsg) conducted trials with pc. abcsg- analysed the effect of pre-and postoperative versus postoperative chemotherapy alone with cyclophohamide= methotrexate=fluorouracil. abcsg- compared versus cycles of epirubicin=docetaxel þ g-csf regarding the rate of pathologic complete response (pcr). abcsg- analysis the rate of pcr between cycles of epirubicin=docetaxel and cycles of epirubicin=docetaxel=capecitabine ae trastuzumab for her- positive patients. results. from to abcsg- enrolled eligible patients. after a follow up of years recurrence-free survival is worse in the pc arm (hr . , . - . ; p ¼ . ), overall survival doesn't differ significantly (hr . ; . - . ; p ¼ . ). patients were accrued to the abcsg- trial between and . the rate of pcr was significantly higher in patients after cycles than in those after cycles ( . % vs. , %; p ¼ . ). also significantly more patients had a negative axillary status after cycles than after only cycles ( . % vs. . % p ¼ . ). recruitment of abcsg- started in and is still ongoing. conclusions. while pc fails to improve prognosis so far, regimens which improve the rate of pcr have been found and we are still hoping to tranpose this effect in better prognosis. sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer p. schrenk , c. tausch background. sentinel node (sn) biopsy following preoperative chemotherapy (pct) in breast cancer patients is associated with a lower identification rate (ir) and an increased false negative rate (fnr) compared to sn biopsy in patients with primary breast cancer. methods. sn biospy was performed in breast cancer patients with a clinical negative axilla prior to pct. following chemotherapy sn mapping was repeated and the current lymph node status was assessed with axillary lymph node dissection (alnd). results. sn mapping prior to chemotherapy successfully identified a mean of . sns in all patients (ir %). patients revealed a negative sn, a positive sn (micrometastasis in = ). following pct re-sn mapping was successful in = patients (ir %). ir for re-mapping was % for patients with a primary negative sn or a micrometastatic sn compared to % for patients with primary macrometastatic sns. none of the patients with a negative sn biopsy and none of the patients with micrometastasis prior to chemotherapy revealed positive lymph nodes following pct. contrary to that = patients with a macrometastasis prior to pct revealed positive nodes following chemotherapy, and this was irrespective of the type of tumor remission due to pct. the fnr of remapping was % and false negative sns were only found in patients with macromatastatic sns in the primary sn mapping. conclusions. patients with a negative sn biopsy or with a micrometastatic sn prior to pct may forego complete alnd following pct, whereas this may not be valid for patients with macrometastatic sns. sn biopsy following pct is associated with a low ir and a high fnr. background. standard pancreatoduodenectomy (pd) for the treatment of resectable tumors of the periampullary region or the pancreatic head involves a radical pancreatoduodenectomy with an extensive gastric resection. the modified whipple operation aims to preserve the stomach, pylorus and proximal duodenum so as to decrease postgastrectomy complications and improve the patient's quality of life. however, there were still many postoperative complications after pylorus-preserving pancreatoduodenectomy (ppd). unfortunately, in some retrospective studies tumors of the periampullary region and the ductal carcinoma of the pancreatic head are still not differentiated. this methodological problem and the improved surgical strategy (lymphadenectomy, etc.) in combination with the excellent histopathological diagnosis by experienced pathologists are decisive factors in determining the ultimate outcome as demonstrated. methods. patients (all treated at smz-süd -kaiser franz josef spital department of surgery) with a exocrine malignant tumor of the pancreatic head or periampullary region were retrospectively analyzed by comparing a year period before and after . results. in the last period of observation the complication rate and lethality was reduced (there was one cases of death because of technical reasons). the number of r resections (incl. mesoduodenum) improved from % to %. also the number of the resected lymphatic nodes increased from to ( - ). the actuarial year survival rate in patients after resection of a pancreatic ductal adenocarcinoma at r , n stage increased from % up to %. an increase in long-term survival could also be observed in the n-positive group. conclusions. at an oncologic center with optimal interdiciplinary collaboration of the different departments (internal medicine, surgery and pathology) a respectable actuarial year survival ( %) of the pancreatic ductal adenocarcinoma can be achieved without interfusing different tumorentities. the lethality caused by technical reasons should be almost %. detailed information will be discussed during the presentation. background. complete surgical resection remains the only potentially curative treatment, improving -year survival, for patients diagnosed with pancreatic cancer. preoperative administration of chemotherapy or combined radiochemotherapy may present a way in increasing the number of patients were radical surgical therapy is reasonable and feasible. lower perioperative mortality and morbidity rates are reported in high volume centres. methods. between jan. and dec. patients, diagnosed with locally advanced non metastatic pancreatic cancer, received preoperative chemotherapy with neoadjuvante intent. patients had curative surgery at time of diagnosis and adjuvant chemotherapy depending on their stage of disease. a subset of patients have been diagnosed at an far advanced stage of disease and were treated in palliative ways. results. the observed perioperative mortality rate was . % ( = ). a total of ( . %) patients required reoperation because of complications after curative resection. minor complications, which have been treated in conservative ways, occurred in . % of patients. sixteen patients ( = , . %) demonstrated sufficient tumor response to undergo surgical curative resection after neoadjuvante chemotherapy. in this group the median survival time was month ( . - . % ci). median survival time for patients who underwent curative tumor resection at the time of diagnosis, was month ( . - . % ci). for patients, unable to undergo curative surgery after neoadjuvant therapy (n ¼ ), median survival ( month, . - . % ci) did not differ from life expectance of primary palliative treated patients ( . - . % ci). conclusions. we suggest that in several patients, suffering from nonresectable cancer of the pancreas, preoperative chemotherapy significantly rises overall survival to a level so far reserved to patients with operable carcinoma. in other malignancies neoadjuvante chemotherapy is an accepted standard of cancer treatment. there are many potential advantages of neoadjuvant chemotherapeutic regimes for both resectable and advanced pancreatic carcinoma. novel targeted molecular therapies and their combination with established chemotherapeutic agents may lead to higher conversion rates after neoadjuvante therapy and improved -year survival rates in the near future. background. haemodynamic impairments after pneumonectomy are rare complications and present in two different forms or a combination of both. changes in the anatomical situation of the left atrium and elevated pulmonary artery pressure can lead to a significant right-left shunt via a previously closed foramen ovale (pfo) and diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, compressing the right atrium with subsequent inflow obstruction. methods. we retrospectively analysed our patient cohort from to for occurrence of haemodynamic complications requiring surgical intervention after pneumonectomy. results. five patients ( female, males, age ae years) were identified. all underwent right pneumonectomy due to nsclc (n ¼ ) or atypical carcinoid (n ¼ ). two patients were readmitted months and years postoperatively due to increasing platypnoea and orthodeoxia. after closure of a pfo which was found as the underlying pathological mechanism respiratory symptoms were resolved. one patient required reintubation already hours postoperatively; after surgical closure of a pfo the respiratory situation significantly improved. one patient was readmitted due to right atrial inflow obstruction months after right pneumonectomy. underlying cause was a severe diaphragmatic relaxation with compression of the atrium by the liver. after diaphragmatic plication all symptoms resolved. one patient was readmitted months after pneumonectomy and partial atrial resection due to cyanosis and dyspnoea. diagnostics revealed a pfo and a massive raise of the right diaphragm with compression of the right atrium. after surgical correction of the contorted foramen ovale and diaphragmatic plication symptoms vanished. conclusions. haemodynamic alterations due to a reopened foramen ovale or right atrial inflow obstruction are rare however severe complications after pneumonectomy. they occur at variable points in time after pneumonectomy. closure of the pfo either surgical or interventional and=or plication of the elevated diaphragm are mandatory. in our experience these complication occur only after right pneumonectomy. chronic sequels after thoracoscopic procedures for benign disease -long-term results j. hutter, s. reich-weinberger, h. j. stein background. video-assisted thoracic surgery (vats) is recognized to be as effective as open surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity. chronic postoperative pain (cpp) is defined as persisting more than months after the procedure. cpp and other neurological sensations like disesthesia or numbness are found frequently, but little is known about the outcome of those patients many years after the primary procedure. methods. in we retrospectively investigated a group ( . %) out of patients who were identified with sequels at a mean of months after a vats procedure. now at months post-operation we reinvestigated those patients for ongoing sequels. results. from patients were still alive and could be reached for an interview. ( %) were now free of symptoms while ( %) still suffered from sequels. from the group of patients operated on, sequels were now present in ( . % at months vs. . % at months, p ¼ . ) patients. pain was present in ( . vs. . %, p ¼ . ), in three ( . vs. . %, p< . ) even at rest, and in ( . vs. . %, p ¼ . ) patients only at exercise. ten ( . vs. . %, p ¼ . ) patients suffered from pain occasionally e.g. due to changing weather. painkillers were only taken by one ( . vs. . %, p< . ) patient occasionally, and the sequels impacted the life of one woman ( . vs. . %, p< . ) badly. numbness was present in . vs. . % (p ¼ . ) of patients. conclusions. early postoperative sequels are frequently found in vats procedures, but patients with pain even after years have a nearly % chance to eliminate their problems. in addition, numbness and disesthesia seem to disappear almost completely several years after the procedure. intrapulmonary injection of fibrin glue as a treatment of persistent parenchymal fistulas after pulmonary surgery: a case series s. b. watzka , h. redl , b. el nashef background. persistent parenchymal fistulas are a major problem after pulmonary operations particularly in lung emphysema patients. conventional surgical remedies, like over-suturing or stapling of injured lung surfaces are rarely efficient. here we present our preliminary experience with a novel application of fibrin glue as a sealant of persistent parenchymal fistulas. methods. patients with postoperative parenchymal fistulas persistent for more than six days, and not responding to conservative measures, underwent re-operation. lung surfaces not anymore suitable to reconstruction by suturing were sealed by peripheral intrapulmonary injection of fibrin glue. after discharge, the patients were regularly followed-up. in addition, the macroscopic distribution of injected fibrin within lung tissue has been investigated in a porcine in vitro lung preparation. a total of six patients underwent the above described procedure. the primary operation was upper lobectomy in four cases, laser resection in the upper lobe in one case, and empyema evacuation by vats in one case. the mean volume of injected fibrin was ae . ml. in five out of six patients the fistula was stopped permanently. in one case, however, the parenchymal fistula re-appeared and had to be treated by combined application of fibrin glue and hemostyptic tissues. after a mean follow-up of . ae . days, all patients are well and symptom-free. in the animal tissue preparation, the fibrin was macroscopically distributed exclusively in peripheral lung parenchyma. conclusions. in selected cases of persistent postoperative parenchymal fistulas, peripheral intrapulmonary injection of fibrin glue offers a low-risk and efficient surgical option. background. recent case-matched studies demonstrate that stage i non-small cell lung cancer (nsclc) in functionally inoperable patients can be treated by limited resection approaches without compromising the oncological result. the recently introduced -nm nd-yag laser enables the highly selective and parenchyma-saving excision of pulmonary lesions, and was thus originally designed for the removal of multiple lung metastases and more central lesions. in this prospective study, we are evaluating for the first time the mid-term results after local resection of stage i primary nsclc by laser knife in functionally inoperable patients as defined by predicted postoperative fev (ppofev ) less than %. methods. between and , functionally inoperable patients underwent local resection of stage i nsclc by -nm nd-yag laser. we assessed their postoperative course, tumor recurrence, and survival by statistical means. results. postoperative mortality was zero. three patients ( %) had minor surgical complications in the postoperative period (persistent air leak, delayed wound healing). the postoperative respiratory function was unchanged as compared to the pre-operative value. the median follow-up was . months (range - months). recurrence rates ( . %) and actuarial -year survival ( %) were comparable to standard lobectomy results, as reported in the literature. none of the three deaths observed during the follow-up period was cancer-related. conclusions. the -nm nd-yag laser enables the resection of stage i nsclc in functionally inoperable patients under complete preservation of respiratory function, but without jeopardizing the oncological outcome. zentrumsbildung breast-cancer centers -between european visions and regional feasibility h. hauser background. there have been major improvements in the western world in recent decades in early diagnosis of breast cancer, breast conservation and survival. nonetheless, there are blank spaces on the map of europa and very likely of austria as well, where diagnosis and treatment of breast cancer are not optimal. collecting and treating patients with diseases of the breast in a few defined ''breast centers'' should give every patient with breast cancer the same highest quality treatment. methods. in , a working group was formed in florence, italy, to define the tasks to be met by such a center. in , the results produced by this group were published (eusoma ) . the aim of this guideline was to improve quality and quality control in the treatment of breast cancer. one of the main demands made of a breast center is to treat at least new primary breast cancer cases per year. further, a multidisciplinary nucleus team specialized in the treatment of breast cancer should be in place and should hold regular interdisciplinary tumor conferences. this team should include a surgeon=gynecologist, radiologist, pathologist, medical oncologist, radiotherapist, breast-care nurse, data manager, etc.). results. as early as , roohan et al. (am j public health , ) showed that the probability of survival of breast-cancer patients was directly proportional to the treatment volume of the hospital. regardless of tumor stage, patients treated in a hospital that saw less than cases per year had a % higher mortality risk than those treated in hospitals with more than operated cases per year. an operation performed by a breast cancer specialist reduces the mortality risk by % in comparison to operations performed by non-specialists (gillis cr, hole dj bmj , ) . the results of dubois et al. ( ) and others also indicate a better outcome for breast cancer when patients are operated in a specialized hospital with a large number of cases and a suitable interdisciplinary environment. the minimum number of cases of primary new breast cancer cases per year and center recommended by eusoma (but with an evidence level of and so not scientifically verified) would reduce the number of breast centers in austria to about . an analysis of the austrian situation nonetheless showed that many small surgical units produced excellent results, with interdisciplinary cooperation, in some cases together with external services. conclusions. certified, highly qualified interdisciplinary breast centers are intended to provide breast-cancer patients with highest quality care. the extent to which the eusoma criteria can be adapted to the austrian situation remains to be seen. breast cancer centres -can quality only be achieved in high-volume-institutions? b. zeh, g. humpel, p. lechner background. discussion is ongoing about institutional caseload and technical equipment that both may be required for up-to-date-treatment of breast cancer. we present the network architecture our department of surgery at the danube clinics in tulln is part of, aiming at multi-disciplinary diagnosis and treatment of approx. cancer patients per year. methods. . diagnosis: mammogram, ultrasound and mri can -and shall -be performed in an outpatient setting, considering that a close partnership with an experienced radiologist has been established. this is true also for the imaging techniques for staging. . interventional diagnosis with core needle biopsy, mammotome + , ecc., should be left to the surgeon! this may facilitate localisation of a non-palpable lesion during the subsequent operation. . surgery for breast cancer is not that demanding per se, on condition that the technical equipments for sentinel biopsy, specimen radiography, and frozen section are at hand. the procedures must be left to permanent team if surgeons with an individual experience of more than cases each. . systemic adjuvant treatment requires the availability of a clinical oncologist, at our institution on a consultant basis. patients are treated in clinical trials whenever feasible, preferably in those launched by abcsg. . radiotherapy is typically performed on an outpatient basis, disregarding at which institution the previous operation was performed. . follow-up needs to be co-ordinated by a qualified physician. we have established an oncological outpatient department, but co-ordination could also be left to an office-based oncologist. the mandatory management tools for close follow-up as well as for the prevention of unnecessary examinations are it-support and a patient log-book. conclusions. being embedded in a multi-disciplinary network, our institution's self perception is that of a part in a ''virtual centre of excellence''. we think that we are not only able to provide high medical quality, but that this quality is also subject to external control by our partners. background. the expectancy of life of patients with intraabdominal malignancies and peritoneal dissemination is usually poor. the surgical approach of a combination therapy of complete resection of the primary cancer, the peritonectomy and a perioperative intraperitoneal chemotherapy was developed to improve the prognosis of these patients. this treatment is cost-intensive and associated with special technical expertises. the aim of this study was to determine the modalities and to discuss the feasibility of this approach. methods. since june , a combination-therapy of visceral resections, cytoreduction of the peritoneal cancer and a heated intraoperative intraperitoneal chemotherapy was performed in patients ( female, male, average age . years) with visceral malignancies and peritoneal carcinomatosis as a curative approach. the same procedure was designated for six more patients but was not performed because of inoperable tumor masses. mitomycin c ( mg=m ) was utilized for the intraperitoneal chemotherapy and applied to the abdomen using a heartlung machine to guarantee a steady circulation and to keep the intraperitoneal fluid at c. the handling with the chemotherapeutic substance required special protective clothing for the staff as well as the competent disposal of all used materials. results. a multi-visceral resection was performed in = patients. a complete cytoreduction (cc- ) was obtained in eight patients, in one a cc- and in another one a cc- situation remained. the average operative time was minutes (range - minutes). a peridural catheter was necessary for a sufficient postoperative pain therapy. the average time at the intensive care unit was . days (range - days) and the average hospitalization was . days (range - days). no complications were observed associated with the surgery. morbidity was determined by gastrointestinal symptoms like prolonged postoperative ileus. in the follow-up three patients had a recurrence of the malignancy, = with a cystadenocardinoma of the pancreas after three and five months, respectively, and = patients after months with a metastatic sigmoid carcinoma. one patient died eight months after surgery because of malignancy progress. the average expense of this treatment was . eur. conclusions. specialized centres may provide the logistics and expenses to establish this treatment innovation to the surgical approach of intraabdominal malignancies to extend the long-term survival of patients with otherwise poor outcome. prospective studies are needed for additional adjuvant and neoadjuvant concepts in diseases with peritoneal malignancies. background. rectal carcinoma needs careful preoperative staging. in our department neoadjuvant treatment with long term radiation and chemotherapy is standard in patients with carcinoma of low and middle part of the rectal wall. main prognostic factors for long term survival are r resection, sharp dissection of the mesorectal fascia without coning, distal resection margin of at least mm and complete lymph node dissection along the mesentery vessels. there is no recommendation about the lymph nodes that should minimally be dissected in this group of patients until now. methods. we consecutively evaluated patients after neoadjuvant radiochemotherapy (rct) and surgery in terms of survival, local recurrence, perioperative mortality and morbidity. tumor regression grading (trg) and number of dissected lymph nodes (ypn) were analysed and correlated with survival. results. in our series local recurrence rate was lower than %, the r resection rate reached % and sphincter preserving surgery was possible more than %. the median number of dissected lymph nodes (ypn) reached > , the perioperative morbidity was lower than %. especially leakage and anastomotic stenosis with the need for reoperation or dilatation are typical complications of radiation therapy. the tumor regression grade clearly correlates with outcome. conclusions. multimodality treatment of rectal carcinoma including preoperative radiochemotherapy (rct) is well standardised with good results in outcome and morbidity. we show that high numbers of lymph nodes even after rct can be collected and suggest a minimum account of at least . tumor regression grading is a marker with prognostic significance and should be taken into clinical-pathohistological classification. we suppose that some patients are overtreated with preoperative rct. to proof this hypothesis, a randomised multicenter trial -together with german cancer centers -based on mri diagnostic is currently planned. background. the incidence of (hpv)-associated disease of the anal canal is rising. efficient anal screening by cytology is hampered because of poor specificity. hpv testing is proposed in addition to pap testing for the detection of cervical neoplasia. the purpose of this study was to determine the usefulness of a hpv-dna detection test (hc ) to detect hpv-associated disease and to compare two different methods of sample collection. methods. in patients anal samples were obtained using a cervix brush and a dacron swab to test for hr-and lr-hpv-dna. qualitative (positive=negative) and quantitative (rlu's, relative light units) were obtained. patients positive for hpv dna underwent anoscopy. biopsies were taken from visible lesions. results. lr-hpv-dna was found in of patients ( . %) and hr-hpv-dna in of patients ( . %). dacron swab sampling yielded more positive results than sampling by cytobrush ( . % vs. . % for lr-hpv, p < . ; . % vs. . % for hr-hpv, p < . ). a positive correlation of rlus was found for both sampling methods in the total cohort (p< . ), and patients with positive results (p< . ). sampling with dacron swabs yielded higher rlu values compared to sampling with cervix brush for lr-hpv-dna and hr-hpv-dna. conclusions. anal screening for hpv-dna by hc is a useful method for detection of hpv-associated disease. sample collection using dacron swabs identifies more hpv-positive patients, and yields higher rlu values, than using the cervix brush. background. persistent human papilloma virus-(hpv-) infection, immunedeficiency (hikv, immunosuppression after organ transplantation) are known risk factors for anal intraepithelial neoplasia (ain) and squamous cell cancer (scc) of the anus. the incidence in high rik groups is rising (hivpositive, men who have sex with men (msm)). screening programms employing anal cytology or anal colposcopy have been implemented in these risk groups. however, sensitivity and specificity are low for both screening methods. since persistent hpv-infection seems to be a prerequisite for ain and scc it seems reasonable to use hpv-typing as an adjunct to screening in risk groups. methods. three hundred and eighty-five consecutive patients with hpv-associated anal disease were included. sexual orientation, hiv-status, smoking habits and psychological strain were documented. all patients underwent clinical examination, rigid sigmoidoscopy and anal hpv-testing. biopsies from macroscopically visible lesions were taken and categorized in condyloma or the three grade-scale of ain according to the bethesda terminology for reporting results in cervical histology. hpv-testing for low-risk (lr) and high-risk (hr)-types was performed using hybrid capture (hc ). qualitative (positive=negative) and semiquantitative results (relative loight units, rlu's) as an indirect measure of ''viral load'' were obtained. results. hiv-status was the only significant risk factor for hr-hpv-infection in univariate and multivariate analysis. in univariate analysis positive hiv-status and patients tested positive for hr-hpv-dna or both types of hpv-dna were significant risk factors for presence of any type of ain. smoking habits, presence of psychological stress and detection of lr-hpv-dna did not significantly influence presence of ain. in multivariate analysis only presence of hr-hpv-dna was a significant risk factor for ain. univariate interclass correlation showed a significant correlation between grade of anal dysplasia and presence of hr-hpv-dna, grade of anal dysplasia and smoking, grade of anal dysplasia and positive hiv-status, presence of lr-hpv-dna and hr-hpv-dna and presence of hr-hpv-dna and positive hiv-status mean number of rlus for hr-hpv-dna was . for hiv negative patients and . for hiv positive patients. there was also a significant difference in the number of rlus for hr-hpv-dna for different grades of anal dysplasia. this difference was only seen in hiv-positive patients, but not in hiv-negative patients. conclusions. our results show the strong relation between persistent hr-hpv-infection and grade of dyplasia. this warrants hpv-typing to be introduced as an adjunct to screening for ain in risk groups. human papillomavirus and anogenital lesions: burden of illness and basis for treatment f. aigner, e. gander, f. conrad background. human papillomavirus (hpv) infections in the anogenital region have become an immanent disease pattern in daily clinical routine. still there is ignorance concerning the etiology and course of hpv associated anogenital lesions, thus demanding an interdisciplinary approach to this disease, which affects more frequently younger individuals. high recurrence rates and the propensity of high-risk hpv associated lesions for malignant transformation (cervical=anal cancer) led to the assessment of diagnostic and treatment options within our association. methods. the results of a consensus meeting in the framework of the rd innsbruck coloproctology winter meeting based on this topic are presented. results. the incidence of anogenital hpv associated lesions (anogenital warts, anal and cervical intraepithelial neoplasia, ain and cin, and anal=cervical carcinoma) has dramatically increased over the last years. in our centre the number of patients presenting with anogenital warts has been doubled from to , closely associated with an increase of diagnosed anal cancers. in the last two years new cases of ain iii (mean age years; males, females), cases of ain ii (mean age years; males, females) and cases of ain i (mean age years; males, one female) were treated in our proctologic unit and introduced to the gynaecologists. treatment algorithm includes excision, electrocauterization or laservaporisation of perianal or anal warts or ain i, ii and anal ain iii on the one hand and radical excision of perianal ain iii on the other hand. immunomodulatory treatment with imiquimod (aldara + ) should be preferentially applied for recurrent anogenital warts. histological examination of suspect lesions has to be performed routinely. conclusions. hpv associated anogenital lesions should be treated by a multidisciplinary approach. histological investigation of the excised material should be performed routinely as well as patients' surveillance including standard anoscopy and colposcopy in a specialized unit. gigip: tissue engineering und implantat induzierte immunologische reaktionen th -immunresponse to xenogeneic matrix grafts t. meyer , k. schwarz , b. höcht pediatric surgery unit, department of surgery, würzburg, germany; department of anatomy, saarland university, homburg=saar, germany background. extracellular matrix (ecm) biomaterials of xenogeneic origin, such as lyoplant + , pelvicol + or surgis + are beginning to be used as acellular, resorbable bioscaffolds for tissue repair in pediatric surgery. although a vigorous immune response to ecm is expected, to date there has been evidence for only normal tissue regeneration without any accompanying rejection. the purpose of this study was to determine the reason for a lack of rejection. methods. full-thickness abdominal wall defects were created in wistar-wu rats and reconstructed with either a lyoplant + -matrix (b=braun aesculap, germany) or prolene +matrix (polypropylene-matrix [ppp], prolene + , ethicon germany). animals were checked daily for local and systemic complications in both treatment and control groups. bodyweight was recorded and the possible development of a hernia was monitored. after weeks the abdomen was reopened and adhesions to the intestine were determined. histopathology and immunohistochemistry were performed to evaluate the immunological reaction to the xenograft. results. compared to the untreated animals, all rats had a physiological growth and body weight curve: no wound infection could be observed throughout the experiment. only in one rat, treated with a ppp-matrix, an abdominal hernia developed at the implant site. all other animals showed excellent clinical recovery and cosmetic results. ppp animals showed a pronounced inflammatory response indicated by an increased number of fibroblasts. the lyoplant + -matrix implantation induced an infiltration of cd and cd positive cells. in addition an active neovascularization was found, observing a remodelling process. this inflammatory response was significantly milder than in ppp implanted rats. interestingly some cd positive cells were detected in the lyoplant + -group. conclusions. xenogeneic extracellular matrix, such as lyoplant + , induces an immune response, which is predominately th -like, comparable with a remodeling reaction rather than rejection. background. mesh graft infections after hernia repair are an awkward complication. in more extensive infections many surgeons recommend removal of the mesh, due to the difficulty to treat microbes in th infected artificial material. the vac system now offers a new possibility in the treatment of complicated wounds, including mesh infections. methods. in this study, records of patients with mesh graft infections after incisional abdominal wall hernia repair were retrospectively analysed who have been operated on between january st and february th at the department of surgery, general hospital vienna. results. of patients ( %, female and male) operated in the period of investigation were suffering from mesh graft infections ( vypro ii mesh, composix mesh and surgipro mesh). mean age of patients was years. mean duration of wound therapy was days. % of the patients had an extensive infection. in those, topical negative pressure therapy (vac) was used. this led to a preservation of % of meshes in this group. in patients with a wound smaller than cm, infection could be successfully treated in of cases ( %). the type of mesh had an influence, whether it could be preserved. all of vypro ii-mesh grafts ( %), of composix mesh ( %) and of surgipro mesh ( %) could be preserved by conservative treatment. conclusions. data suggest that vypro ii mesh grafts are superior to composix and surgipro mesh regarding mesh graft preservation in case of postoperative mesh graft infection. vac therapy should be considered for successful treatment of more extensive infection. finally, small wounds (< cm) seem to have a good prognosis for mesh graft preserving healing. background. revisional procedures after restrictive bariatric operations are necessary in increasing numbers of patients. these procedures may be performed laparoscopically but represent demanding and in some cases risky operations. a meticulous technique is mandatory in order to achieve good postoperative results. methods and results. laparoscopic roux-y gastric bypass is performed as revisional procedure after laparoscopic gastric banding, sleeve gastrectomy and vertical gastric banding. the indication for a transformation to gastric bypass is inadequate weight loss or weight regain and technical failures of procedures. formation of the gastric pouch may be difficult because of adhesions and formation of a capsula in case of banding. gastro-jejunostomy may be performed by different techniques. conclusions. revisional gastric bypass is a more complicated procedure than primary bypass. in order to achieve good results a number of technical details have to be respected. background. laparoscopic sleeve gastrectomy has become a standard bariatic procedure in the last five years. this procedure has been performed with a number of different techniques using laparoscopic staplers and mobilizing the greater curvuture as primary step of the operation. methods. sleeve gastrectomy with a modified technique starting with the formation of the gastric sleeve prior to mobilisation of the greater curvuture is demonstrated. stapling is performed with linear straight staplers. conclusions. the advanages of performing laparascopic sleeve gastrectomy by a modified technique are shorter operating times, and a better overview especially near the his angle. the modified technique may therefore become a surgical standard in bariatric surgery. we present a video showing the technique of laparoscopic approach for reoperation on cases with complications due to ''lost gallstones'' after laparoscopic cholecystectomy. case is a years old female patient, operated for symptomatic cholecystolithiasis in august . in august she presented with right upper quadrant pain, the computertomography revealed a liver abscess in the right lobe and a retroperitoneal abscess. case is a years old male patient, operated for symptomatic cholecystolithiasis in november . in july he presented with right upper quadrant abdominal pain, the computertomography showed a small suspected abscess formation between liver segment and the right kidney. laparoscopic reoperation was performed the day after diagnosis. in case after adhesiolysis the liver was elevated and the abscess opened to perform rinsage and drainage of the cavity. the ''lost gallstones'' were taken out with a suction device. in case multiple stones were found in the upper abdomen under the peritoneum and in the abscess cavity. adhesiolysis and rinsage was performed. if abscess formation around the liver is seen even years after laparoscopic cholecystectomy, the diagnosis of a complication from ''lost gallstones'' should be suspected. reoperations for ''lost gallstones'' after laparoscopic cholecystectomy can be performed by laparoscopy if the abscess formation is accessible; results will be superior to ct-guided drainage due to the stone extraction by laparoscopy. grundlagen. die isr ist eine technik, bei der auch tiefsitzende karzinome des rektum sphinktererhaltend reseziert werden können. wir haben kürzlich eine operationstechnik entwickelt, bei der dieser eingriff laparoskopisch ohne großen zusätzlichen zeitaufwand durchgeführt werden kann. methodik. dieser eingriff wird nach genauer präoperativer abklärung durch ) digitalbefund, ) endoskopie und biopsie, ) mrt des rektums und ) sphinktermanometrie geplant. ausschließungsgründe für die operation sind: undifferenzierter tumor, t -stadium und schlechte sphinkterfunktion. der abdominelle teil wird im trokarttechnik (  mm optikport,  mm arbeitsport) durchgeführt. die präparation erfolgt entweder mit dem mm ultracision oder dem mm ligasure-atlas. der eingriff wird synchron von abdominell und peranal von teams durchgeführt. dafür wurde eine eigene lagerungstechnik entwickelt. die operation verläuft in folgenden phasen: ) totale mesorektale exzision, ) peranale intersphinktäre resektion des rektum ) bildung eines axialen kolonpouches, ) durchzug des kolon und koloanale anastomose, ) protektive transversostomie oder ileostomie. die präparatbergung erfolgt von peranal, sodass keine zusätzliche inzision am abdomen notwendig ist. der stomaverschluß erfolgt nach wochen. ergebnisse. von den insgesamt intersphinktären resektionen wurden laparoskopisch durchgeführt. die mittleren operationszeiten betrugen bei der offenen isr min, bei der laparoskopischen min. schlussfolgerungen. die laparoskopische intersphinktäre resektion ist ein praktikables operationsverfahren, dass mit vertretbarem zeitaufwand durchgeführt werden kann. die vorteile der laparoskopischen vorgangsweise können derzeit bis auf das hervorragende kosmetische ergebnis noch nicht abgeschätzt werden. schlussfolgerungen. der konsequente einsatz eines hochthorakalen pdks mit adäquater füllung zur schmerztherapie und sympathikolyse war von unserer anästhesieabteilung nicht regelhaft umsetzbar, so dass wir in der oralen gabe von oxycodon plus oraler stimulation des gastrointestinaltraktes eine hervorragende alternative zur durchführung der fast-track-rehabilitation gefunden haben. unsere ergebnisse decken sich mit den resultaten die derzeit von den chirurgischen zentren publiziert werden. die wiederaufnahme-( . %) und die gesamtkomplikationsrate ( %) ist bei längerer verweildauer etwas niedriger. unsere ergebnisse zeigen, dass das konzept der fast-track-rehabilitation gut in einem nicht ausgewählten patientengut umsetzbar ist. aufgrund der ausbildungssituation ist die zahl der lap. eingriffe relativ gering.in der oralen opiod-analgesie haben wir eine unerwartet gute alternative zum pdk gefunden. fast track surgery without thoracic peridural anaesthesia? background. thoracic pda is considered to be one of the main pillars of fast track surgery (fts). our anaesthetists being reluctant to perform thoracic pda as a routine, we decided to make an attempt to do surgery without thoracic pda yet following all other criteria of fts. methods. between jan. and dec. we have performed elective colonic procedures following our modified criteria. in these patients we have prospectively examined those parameters which could be expected to be influenced the most by pda: -postoperative intestinal paralysis -postoperative pain control -rate of complications results. the postoperative need of antiemetic drugs and the time of the first clinical signs of bowel activity (passing winds or stool) were examined as criteria for postoperative paralysis: - . % of patients never needed an anitemetic drug - . % of patients were having bowel activity not later than on po day standard postoperative pain control regimen contained two doses of mg paracetamol and two doses of mg diclofenac iv. as long as needed followed by the same combination given orally. mg of piritramid sc. was presribed as reserve treatment. - % of patients needed the standard iv-regimen for longer than three days - % of patients never needed a single dose of piritramid - . % of patients needed more than two doses of piritramid in the last months of the study only patients ( . %) needed piritramid for sufficient pain control (learning curve of nurses and doctors!). overall we have seen complications ( . % of procedures): background. multimodal fast track rehabilitation is based on modified perioperative fluid management, avoidance of preoperative fasting, effective analgesic therapy using epidural anesthesia, early postoperative mobilisation and immediate oral nutrition in order to accelerate recovery, reduce general morbidity and decrease length of hospital stay. young people seem to be the most suitable patients for fast track rehabilitation, but majority of the patients requiring colorectal surgery is older than years and often has several comorbidities. in this analysis we compared ''fast track'' feasibility and efficacy in young and old patients to examine, whether an age dependent management is required. methods. during one year all patients scheduled for colorectal surgery for colorectal cancer or sigmadiverticulitis on one ward were treated according to our multimodal ''fast track'' program. demographic and perioperative data, postoperative follow up (e.g. first bowel movement, vomiting, intravenous infusion therapy, fluid balance), local and general complications were prospectively assessed and evaluated on the basis of two groups (group a: age< a, n ¼ ; group b: age> a, n ¼ ). results. median postoperative hospital stay was days (a) and . days (b) with one readmission in both groups. the incidence of local and general complications was . % and %, respectively. a aged patient with stenotic rectal cancer with liver metastases and parkinsons disease died because of multiorgan failure. conclusions. the multimodal ''fast track'' rehabilitation concept is feasible in young and old patients. although older patients have a higher morbidity, our data show, that especially older patients benefit from enhanced recovery programs. background. the restrictive perioperative intravenous (i.v.) fluid management is an important element of multimodal fast track surgery. recent studies have shown a better outcome for patients with moderate or restrictive intravenous i.v. fluid therapy, but adequate interdisciplinary standards are missing and therefore optimal perioperative fluid management still remains controversial. in october we started ''fast track'' treatment in colorectal surgery on one ward, in this study we present our experience with modified perioperative fluid management. methods. during one year consecutive patients underwent elective surgery for colorectal cancer or sigmadiverticulitis ( laparoscopically, conventionally). demographic, pre-, intra-and postoperative data (e.g. fluid supply, urine excretion, creatinine, electrolytes, first bowel movement, vomiting), local and general complications were prospectively assessed and evaluated, median age of patients was years ( - years). results. intraoperative i.v. fluid administration was . ml=h=kg. on the first postoperative day patients oral intake was ml ( - ml) with an urine excretion of ml ( - ml). no hypovolemia associated complications were observed, creatinine and electrolytes showed no significant pre-and postoperative changes. general morbidity was % (urinary tract infection, pneumonia). median postoperative hospital stay was days (no readmissions). conclusions. reduced intraoperative and restrictive postoperative i.v. fluid therapy is feasible and has no negative impact on water and electrolyte balance. early oral fluid administration guarantees a sufficient hydration with adequate urinary output and contributes significantly to fast (track) rehabilitation and improvement of patients comfort. background. malignant pleural mesothelioma is a mainly asbestos-related neoplasm with increasing frequency associated with a poor prognosis. extrapleural pneumonectomy was initially performed as a stand-alone treatment in patients with respectable disease, however is currently almost uniformely applied as part of a multi-modal approach. its value and advantage over other therapeutic strategies remain point of discussion. we therefore analysed our experience with extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. methods. we retrospectively reviewed our institutional experience with all consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma from to . patients were analysed with regard to hospital data and outcome. results. forty-nine patients ( females= males, mean age ae years) underwent extrapleural pneumonectomy during the observation period. median icu stay was day, median postoperative length of hospital stay was days. after a mean follow-up of days median survival was days (mean ae days, range - ). year survival was . %, years survival . % and years survival . %. conclusions. extrapleural pneumonectomy as part of a multi-modal treatment regimen is a good treatment option for selected patients with malignant pleural mesothelioma. the long term results of this limited series compare favourable to non-surgical treatment regimens. larger randomised prospective multi-center trials are warranted to establish clear guidelines. background. the accelerated progress in genomics and data analysis technologies give a new view to customized treatment for stage iii lung cancer. the histopathological diagnosis will be accompanied by molecular classification. present treatment for advanced lung cancer is unsatisfactory and nearly % of newly diagnosed patients will die within two years. methods. from to patients underwent neoadjuvant treatment with platin-based chemotherapy followed by surgical resection. a panel of genes (p , p , mib- , cyclind , cycline, ercc ) were identified in pre-and posttherapeutic specimens. the expression profile was correlated to the histological regression grade and survival. results. the investigated different pathways allow an explanation of platin-based chemotherapy resistance and short duration of response according to the gene expression levels. conclusions. a prediction of a patient's prognosis could be improved by combining standard clinical staging methods with molecular-pathological evaluation. background. in the last years the video assisted approach (vats) has become the standard of care for persistent or recurrent (after tube drainage) spontaneous pneumothorax (sp) . but what is the standard treatment in recurrent pneumothorax after primary operation in the era of vats? moreover, we only have little information about the rate of contra lateral pneumothorax in those patients. to find answers to these questions we investigated the patients operated for sp in recent years. methods. we retrospectively analysed patients with sp treated by vats between = and = . only patients with years of age or younger without any underlying chronic lung disease were included. the treatment of choice was bullectomy or apical lung resection with apical partial pleurectomy (app) by vats. results. we identified patients at a mean age of years ( - ) with the female: male ratio of : . . the interval of the study and the operation was at mean of months. the primary vats for sp was successful in % (n ¼ patients). in three patients with primary failure persisting pneumothorax was reoperated by vats (postoperative day , , ) . none of these three patients had a recurrence. of patients treated successfully for spontaneous pneumothorax . % (n ¼ patients) suffered from recurrence at a mean of ( - ) months with one case of a second recurrence. only minor or no adhesions were found at the apex of the thoracic cavity, a bulla was found in one woman. moreover, in all patients an intact neopleura was found. major morbidity was postoperative hemothorax treated conservatively in % (n ¼ patients). interestingly, % (n ¼ patients) developed primary pneumothorax on the contra lateral side at a mean . ( - ) months. all these patients underwent vats without recurrence. conclusions. . successful treatment of sp can be achieved by vats with low recurrence rate, low morbidity and a high primary success rate. . in sp with bullae the role of app is not defined as yet and in recurrence or primary failure a thoracoscopic pleurodesis e.g. with talcum, should be considered. . in the light of the high rate of almost % of contra lateral sp a primary intervention on both sides should be considered. . a study to identify patients of risk for contra lateral sp with e.g. low dose ct in the first event should be considered. background. surgical treatment of myasthenia gravis and thymoma necessitates the complete resection of the thymus with the whole fatty tissue adherent to the pericardium. the aim was to investigate the efficacy and safety of robotic approach. methods. from = to = patients with myasthenia gravis (n ¼ ) or thymoma (n ¼ ) (mean age ae years, male to female ratio : ) were operated with the intention to perform a totally endoscopic, complete resection with the davinci telemanipulator system. in all but one patient a left sided approach was chosen. results. in out of patients the operation was carried out totally endoscopic. two patients had to be converted because of bleeding (patient ) and thymus carcinoma (patient ) requiring extensive resection. in the remaining patients, operative time was ae minutes, intubation time ae minutes. icu stay was day, in hospital ae . days. in all patients it was possible to identify both phrenic nerves and the complete fatty tissue above the anonymal vein along the supraaortal vessels was resected. histology revealed normal persisting thymus tissue (n ¼ ) and thymoma (n ¼ ) -who stage b and b (in cases each); masaoka stage i (n ¼ ), ii (n ¼ ) and ivb (n ¼ ), respectively. all resection borders were free of tumor. in all myasthenia gravis patients acethylcholinereceptor antibodies decreased during follow up. conclusions. complete endoscopic thymus surgery with the da vinci surgical system, is feasible and safe to implement into clinical practice. due to the minimal trauma, patients can return to full activity in a short time period. self-expandable covered metal tracheal type stent for sealing cervical anastomotic leak after esophagectomy and gastric pull-up: pitfalls and possibilities background. the rate of anastomotic leakage after cervical esophagogastrostomy following esophagectomy and reconstruction with the tabulated stomach ranges between and %. the treatment options comprise redo-surgery, endoscopical stapling, glueing or insertion of plastic stents, or conservative management with drainage procedures. the aim of this study was to evaluate the efficacy of self-expandable covered metal tracheal type stents for sealing the anastomotic leak. methods. from = to = , patients with leakage of the cervical esopahgogastrostomy following esophagectomy and reconstruction underwent endoscopic stenting using the self-expandable covered tracheal type device. the extent of the dehiscences ranged from to % of the anastomotic circumference. mortality, morbidity, healing rate of the anastomosis and hospitalisation time were evaluated. results. in all cases stenting was done without any complication. stent extraction could be performed after an average period of days, ranging from to days. in all cases, healing of the anastomosis was satisfactory. patients developed stenosis after removal which was successfully managed by bouginage. stent migration was observed in patients, treated by repositioning in one and two attempts of re-stenting followed by eventual suturing of a small residual leak in the other. conclusions. endoscopic insertion of a self-expandable covered metal tracheal stent represents a safe approach resulting in immediate closure and subsequent healing of cervical anastomotic leakage. there was no leakage-related morbidity, oral intake of food was resumed one day after successful stenting. however, stent dislocation and stricture after stent removal may occur. background. squamous-lined cyst of the pancreas is a rare entity with only about one hundred reported cases. three types of cysts are differentiated: lymphoepithelial, dermoid and accessory-splenic epidermoid cysts. the literature on this entity is limited to reports of single or small numbers of cases. the two most common cystic tumors of the pancreas are serous cyst adenoma and mucinous cystic neoplasms. we herein report the case of a lymphoepithelial cyst of the pancreas. case report. a -year-old man presented with a month history of upper abdominal pain and bloating. the disorders were related to food ingestion and were not followed by nausea or vomiting. he experienced low weight loss. he was in good general health with a normal physical examination and no tenderness in the upper abdomen. laboratory investigation including ca - , cea and hcg were within the normal range. imaging studies with ct, mrt and eus showed a  cm mass in the uncinate process of pancreas with contact on to the mesenterial vessels. the mass presented in ct=eus as a solid, expansive tumor, whereas mrt showed a cystic mass. fine-needle biopsy revealed squamous epithelial cells with sebaceous material, but without atypia. because of the progressive symptoms with compression of the duodenum and to rule out malignancy we resected the cystic tumor. no encasement, invasion or other aspects of malignancy were found. the resection defect was drained with a jejunal y-roux-loop. histological findings showed a benign lymphoepithelial cyst and the patient had an uneventful postoperative and four-month follow-up period. conclusions. establishing a preoperative diagnosis of a lymphoepithelial cyst is not possible. squamous-lined cysts of the pancreas have a low malignant potential, however, there are reports of mature dermoid cysts developing into malignant forms. to distinguish squamous-lined cysts from other cystic lesions of the pancreas, particularly malignant processes, is rather difficult. therefore we recommend a complete surgical removal of every cystic lesion suspicious to be a squamouslined cyst to avoid or treat malignancy. ten year experience with duodenum preserving pancreatic head resection in chronic pancreatitis r. j. klug, f. kurz, m. aufschnaiter kh barmherzige schwestern linz, chirurgie, linz, austria background. the chronic head accentuated pancreatitis is on the rise in industrialised countries. alcohol is the predominant aetiological factor.the incidence is per . inhabitants. in up to % of patients with chronic pancreatitis the head of the gland will be grossly enlarged by an inflammatory mass, often associated with bile duct stenosis and duodenal hold-up.in our institution the standard whipple operation has been replaced by the duodenum preserving pancreatic head resection (dpphr). methods. we present our meanwhile year experience with dpphr. our patients are analysed retrospectively. results. between november and november we performed dpphr in males and females patients. the average age was . years ( - years). the follow-up was done by the aid of an inventory referring to postoperative pain control, development of diabetes, postoperative weight gain and subjective success assessment. the complications are described and discussed as well. the results are presented. conclusions. the dpphr developed by beger about years ago has become the standard procedure for the operative treatment of.chronic head accentuated pancreatitis in our institution. the intervention is demanding but offers the advantages of maximal organ preservation, satisfactory endocrinological and functional results, a justifiable low complication rate as well as a high degree of satisfaction on the part of the patients. segmental duodenectomy at periampullary lesions -an adequate therapy? j. karner, b. sobhian, m. klimpfinger, g. udvadi, f. sellner smz-süd kaiser franz josef spital, vienna, austria background. the radical surgical procedure for treatment of the resectable periampullary tumors is the partial pancreatoduodenectomy or the pylorus-preserving pancreatectomy. in rare selected cases a segmental duodenectomy with reinsertion of the pancreatic and choledochus duct might be suitable alternative to improve the patient's quality of life. methods. about to patients were hospitalized annually with the diagnosis of a pancreatic or periampullary tumor at the smz-süd -kaiser franz josef spital department of surgery. to ensure radical resection either a partial pancreatoduodenectomy or a pylorus-preserving pancreatectomy was performed. in two patients with low-and=or high-grade dyspla-sia of the papilla and the peripapillar mucosa a segmental duodenectomy with resection of the papilla vateri was performed. after radical excision (proven by an intraoperative frozensection diagnosis) a duodeno-duodenal anastomosis with reinsertion of the splinted pancreatic and choledochus duct was performed. results. the postoperative course was uneventful. three months after the operation, clinical follow-up including gastroscopy revealed a normal mucosa of the duodenum and an excellent quality of life. conclusions. accurate surgical technique and pre-(gastroscopy), intra-and final histopathological diagnosis by an experienced pathologist are decisive factors in determining the ultimate outcome. if the histological findings as to benignity are uncertain, resection of the head of the pancreas with or without preservation of the pylorus by an experienced surgeon is indicated. the segmental duodenectomy might be an adequate therapy of the periampullary lesions in carefully selected cases. background. five randomized trials and an increasing number of phase studies confirm the opinion that the combination of peritonectomy-procedures and intraperitoneal chemotherapy positively influence the outcome in patients suffering from peritoneal carinomatosis (pc) of appendiceal tumors, colon cancer, ovarian cancer and gastric cancer as well as rare tumors of the peritoneum per se. nevertheless, according to the literature postoperative mortality was observed in - %, postoperative minor and major morbidity in - %. methods. in the last years patients (pts) suffering from pc arising from different primary tumors were treated at our institution in cooperation with surgical, gynecological or oncological departments in austria and germany. at the time of writing complete records from patients (mean age: . ae yrs, others ) are evaluated for analysis. primary objectives to assess were overall survival and time to progression of intraperitoneal or general disease. factors influencing these parameters were determined. secondary objectives to assess were postoperative mortality and morbidity. results. completeness of cytoredutive surgery, favourable histology (ovary, appendix, colon) and n -stage - (n ¼ pts) made a -year survival rate of % and a -year survival rate of % possible. (updated extended analysis of the different groups of patients will be presented) postoperative mortality within days was . %, within days . %. conclusions. cytoreductive surgery in combination with intraperitoneal, hyperthermic chemoperfusion ae systemic chemotherapy has a curative potential in selected patients. background. an increasing amount of patients confronted with an incurable or chronic progressive disease demands a special palliative procedure in physical, psychosocial and spiritual treatment. medical and nursing staff members in the hospital are not always prepared to handle with these patients and their relatives in a proper way. reasons behind may be lack of time, skills and experiences. deficits in management and in multiprofessional communication complicate the situation. a palliative liaison service provides, in this context, support in pain management, control of severe symptoms, treatment of terminal patients, coordination of professionals, discharge management, cooperation with mobile hospiz teams and support in ethical conflicts. methods. in we asked medical and nursing staff members for the importance and the need of palliative support in their daily routine. from may to december we documented consultations of patients, which means an effort of , hours. in we asked members of the medical and nursing staff in leading positions about the amount of satisfication with the provided support and the acceptance of the instution pls year after the implementation. results. in % of the staff members asked, confirmed the importance of palliative care and % agreed to the cooperation with a palliative liaison service. from may to december , , % of the demands for support came from surgical wards. the primary reasons for the first contact were pains and other severe symptoms. about % of the patients had cancer in the diagnosis. in the extent of satisfaction with the performances of the palliative support team was between , and , (satisfaction is defined until , within a range of to ). % to % from the provided performances were already requested. conclusions. the service of a palliative support team in the hospital was highly accepted already after a short time. more than the half of the consultations took place on surgical wards. we conclude that a palliative support service provides benefits for staff and patients in a difficult situation. especially in a time of rapid medical progress, limited resources and increasing ethical demands of autonome patients, the public health institutions may request for the right balance between curative and palliative settings. background. the ileus is often the sign of an advanced stage of malicious illnesses that require palliative treatment. medicine and especially palliative medicine has changed medical treatment in the way that it now aims at an improvement of life quality. methods. in our hospital cases with patients were analysed. these patients suffered from ileus in connection with an advanced malicious illness. results. an ileus was localised with patients in the field of the small intestine and with patients in the field of colon. cases were treated in a conservative way, cases required operative treatment. primary tumors were found predominantly in the colon and also in the feminine genitals as well as in the stomach. on average the remaining life time was two months. % of the patients with ileus in the field of the small intestine were treated without operation. conclusions. the life time of patients with ileus and advanced malicious illness is short. operations with high risk should be avoided. patients with ileus in the field of the small intestine should be given conservative treatment which in case of failing may be converted into interventional or operative treatment. operation can hardly be avoided with patients with ileus in the field of colon. if available, interventional therapy for the removal of stomach and intestine contents should be applied. the patient's wish is to be considered. treatment should aim at improving the patient's life quality. penetrating abdomino-thoracic injuriesreport of four impressive cases z. halloul, f. eder, f. meyer, h. lippert department of surgery, university hospital, magdeburg, germany background. penetrating wounds are distinguished in impalement and gun shot or stab wounds (stab=impalement injuries more frequently in europe), which are often very spectacular. the aim of the representative case reports is to analyze the kind of injury þ the adequate surgical, in particular, the complex wound management. methods. the impressive case series includes patients with abdomino-thoracic penetrating traumas ( stab=impalement wounds each) who were treated in a surgical university hospital centre during months. results. ( ) impalement injury by a steel pipe i) entering the body above the right kidney behind the liver, through the mediastinum via the right thorax, passed heart and aortic arch up to the left clavicle, ii) approached with sternotomy=median laparotomy to remove the rod including suture of the left subclavian vein only (postoperatively, residual lesion of the left brachial plexus=temporary pneumonia). ( ) one leg of a chair drilled into the left ''foramen obturatorium'' leaving the body at the right anterior iliac spine: initial removal=excision of the gluteal penetration canal. developing abdominal signs= symptoms indicated explorative laparotomy revealing peritonitis because of perforated ileum: segmental resection= anastomosis (postoperatively, i) right inguinal wound necrosis requiring excision=vacuum-assisted closure sealing; ii) remaining paresthesia in the left leg due to sacral plexus lesion). ( ) due to a violent conflict, stabs entered the right thorax while one injured the right pulmonary lobe=diaphragm=liver dome between segment viii&v þ a big scalp avulsion at the left= right parietooccipital site þ a transection of the right biceps muscle approached with right subcostal incision=anterior thor-acotomy=liver packing ( towels removed after d)=suture of the diaphragm=pleural drainages. ( ) stab injury at the left thorax (pneumothorax=lesions of the diaphragm & left third of the transversal colon) and neck (lesions of the pharynx=internal jugular vein) approached with left thoracic drainage=suture of the colonic & diaphragmatic lesions (postoperatively, i) right thoracotomy because of a right pleural empyema due to bronchopneumonia as a consequence of the blunt right thoracic trauma; ii) relaparotomy because of an abscess within the douglas' space; iii) billroth-ii gastric resection because of recurrent forrest-ia bleeding). conclusions. important aspects of such trauma care are immediate life-saving measures, transferral to a trauma centre, first care, prompt diagnostic=initiation of an adequate surgical treatment provided by trauma=general=abdominal=vascular and=or cardiac surgeons (e.g., surgical interventions at vessels= organs=soft tissue) as well as the postoperative course and rehabilitation. if these measures are provided with high medical standards and an interdisciplinary setting, optimal outcome can be achieved in order to prevent fatal outcome, to ensure maximal organ function, and to minimize permanent damages. background. today infections with clostridium perfringens are rare, but still most of the cases turn out lethal, although receiving timely medical treatment. this report deals with three different patients, who were transferred to our surgical department since june . the first patient (male ), with the suspected diagnosis ''femoral hematoma'', a second patient (male ) because of an ''acute abdomen'' and the third patient with suspicion of gas gangrene after chronic ulcer of the right food. methods. first patient: already at the physical examination of the femoral an impressive crepitation was palpable. besides this the man was suffering from myelodysplasia and showed a marked ulcer on the left side of the scrotum. on suspicion of gas gangrene we performed an exarticulation of the left femoral after intensive-care stabilization. besides all efforts this patient died the same day because of an acute circulatory failure. second patient: because of an acute abdomen the second patient received a ct and in suspicion of appendicitis an explorative laparotomy was indicated. furthermore a known haematoma at the right shoulder began to extend in sizeand shortly after the typical crepitation was palpable as well. even though the arm was exarticulated during an immediate operation the patient died because of the massive progressing infection. third patient: this patient was sent to our hospital because of the suspicion of gas-gangrene. during physical examination the typical crepitation was palpable at the right femoral and lower leg with associated emphysema. during operation the wound seemed unsuspicious. immediate examination of the tissue (department of hygienic and microbiology) showed a negative result concerning an infection with clostridum perfringens, so it could be refrained from an amputation of the femoral. entirely some incisions of the skin and the fascia were done. postoperative we kept watch on the wound in short intervals -showing consistent results the patient was transferred to our general ward to be treated because of his chronic ulcer on the right leg. conclusions. once pandora's box has been opened, still % of all gas-gangrene-infections pass off lethal. the first two cases demonstrate that (besides the low incidence of . events per mio. persons and year) infections of clostridum perfringens should always be kept in mind, especially in high-riskpatients. in contrast to this the third patient shows, that severe consequences because of a precipitate indication can be avoided by experience and careful evaluation. results. altogether patients were treated for rsh at our institution during the study period. seven patients were on oral anticoagulation, patients were taking acetylsalicylic, was on clopidogrel and patient was on anticoagulation with low dose heparin, whereas patients had no anticoagulation. a previous trauma event was apparent in six of the cases, one of this patient was on oral anticoagulation, one on acetylsalicylic, one was taking clopidogrel and three had no anticoagulation. rsh was correctly identified by means of ultrasound in of cases, in which this investigation was performed. a ct scan investigation demonstrated the haematoma in all ( of cases) cases. thirteen patients were managed conservatively, patients underwent surgical treatment. eight patients needed blood transfusion and four patients received vitamin k medication. all patients could be discharged from hospital in good general condition. clinical re-evaluation (median follow up years, range month- years) showed all patients were free of symptoms at this time. conclusions. our data confirm the multifactorial aetiology of rsh and the strong association with different forms of anticoagulation. ct scan is the diagnostic tool of choice, whereas identification with ultrasound is strongly dependent on the experience of the examiner. conservative as well as surgical management have good results, with good restitution to fine health of all patients. surgery seems to be only indicated when complications appear (homodynamic instability, severe pain, which cannot be managed conservatively). background. intestinal metaplasia (im) in specialized columnar lined epithelium in the distal esophagus is a precancerous lesion with a cancer risk of . % or case in patientyears. there are no prospective multicenter-data available for germany regarding the cancer-risk and also no data regarding different therapeutic treatment options. the purpose of this study was to evaluate the progression of dysplasia in barrett's esophagus (be) in patients under antireflux therapy -laparoscopic fundoplication (lf) or treatment with proton pump inhibitors (ppi) -based on the data of the german barrett esophagus registry. methods. in a consensus process a protocol was established by pathologists (n ¼ ), gastroenterologists (n ¼ ) and surgeons (n ¼ ). patient history, findings on endoscopy, histopathology and functional diagnostics were collected in a multicentric database. patients gave their informed consent for a central data registration. barrett's esophagus was defined as specialized, intestinal metaplasia in the endoscopic visible columnar lined epithelium of the esophagus independent of its length. the natural and posttherapeutic course of patients with im was registered prospectively. participating centres were free to decide for their own treatment approach for each patient regarding im as well as the underlying reflux disease. patients were followed with routine endoscopy and biopsy every - months. results. since january , patients with be were prospectively registered and analysed. of fourteen participating centres three were surgical (n ¼ ) and gastroenterological (n ¼ ). symptoms of reflux were present in % of patients daily or weekly, in % they were absent. the mean age of patients was years (range - ). two hundred and ninety six were male and female. three hundred and fifty patients ( %) had short-segment-be and ( %) long-segment-be. intraepithelial neoplasia was initially diagnosed in patients (low grade intraepithelial neoplasia (lgien) in , high grade intraepithelial neoplasia (hgien) in , indefinite in ). in the second histological confirmation hgien, lgien and indefinite ien were confirmed. in the other patients ien was excluded. from all patients ( insufficient and on competent lf) have shown progression from im to lgien and one from im to cancer (ppi) in a total of patient-years. conclusions. the current analysis shows a low rate of progression of im to ien for ppi treatment as well as antireflux surgery. this confirms recent reports on barrett's esophagus, that progression is a rather infrequent problem, which cannot be prevented by antireflux surgery or ppi. background. impaired esophageal motility plays an important role in the pathogenesis of gastroesophageal reflux disease (gerd) and its evaluation is important for the assessment of a therapeutic effect. the comparison of szintigraphic, manometric and symptomatic evaluation has not been shown yet. methods. sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying and assessment of symptoms prior to treatment (operation or medical therapy) and months later. in gerd patients with normal esophageal peristalsis the nissen fundoplication was performed, in further patients with impaired esophageal peristalsis a partial posterior fundoplication was chosen and further patients received continous medical treatment with ppi. all groups were comparable regarding age and gender of the patients. esophagitis was most pronounced in those patients who underwent partial posterior fundoplication. results. on endoscopy acute esophagitis resolved in all patients after fundoplication, whereas after months of medical therapy patients still had an acute esophagitis. on manometry there was a significant improvement of the competence of the lower esophageal sphincter postoperatively regardless of the performed technique. however, les relaxation was complete only after the toupet fundoplication but incomplete after the nissen fundoplication. esophageal peristalsis measured manometrically did not improve after medical therapy, was significantly strengthened after partial posterior fundoplication but was worsened by the nissen fundoplication. on szintigraphic evaluation of esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after partial posterior fundoplication. after the nissen fundoplication there was a significant deterioration of esophageal emptying. there was a strong correlation between szintigraphic and manomteric evaluation of peristalsis, preoperatively (rs ¼ À . p < . ) and postoperatively (rs ¼ À . p < . ). evaluation of symptoms showed no change regarding dysphagia after medical therapy and after the nissen fundoplication but a significant improvement after partial posterior fundoplica-tion. globus sensation was significantly improved after partial posterior fundoplication but did not change after medical therapy or the nissen fundoplication. postprandial bloating and inability to belch were significantly more common after the nissen than after partial posterior fundoplication. conclusions. antireflux surgery controls gerd better than medical therapy with ppis. however, partial posterior fundoplication is the more physiologic approach than the nissen fundoplication. background. combined impedance-and ph-monitoring (mii-ph) is a recently introduced diagnostic tool to assess gastro-esophageal reflux. we report our experience with this technology. methods. three hundred and fifty-seven mii-ph studies were performed in patients with clinical signs of gastroesophageal reflux disease (gerd) between may and december . a catheter was introduced into the esophagus via the nose and connected to a portable data logger. ph was monitored cm and impedance , , , , and cm above the manometrically located lower esophageal sphincter. symptoms were entered by the patients by pushing buttons on the data logger. diagnostic criteria for gerd were: pathologic acid exposure: ph < during > . % of total, > . % of upright, or > . % of recumbent recording time. pathologic impedance monitoring: > liquid or mixed liquid=gas refluxes detected by retrograde impedance drops > % from the baseline. positive symptom to reflux correlation: > % of > symptom events within a -minute time window after a reflux episode detected by mii-ph. results. three hundred and nine mii-ph procedures were performed after discontinuation of antisecretory medications for ! days in patients without prior esophageal or gastric surgery (age . ae . years). recording time was . ae . hours. the diagnostic yield of mii-ph is summarized in table . median total acid exposure was significantly higher in males than females ( . vs. . %; p < . ) as was the median number of reflux episodes detected by impedance ( vs. ; p < . ). the median number of symptoms was almost equal ( vs. ; n.s.). positive symptom correlation was significantly more frequent in females than males (p ¼ . ). the overall diagnostic yield of mii-ph was not significantly different between genders. conclusions. mii-ph is a valuable new tool for the diagnosis of gerd with significantly increased diagnostic yield over conventional ph-monitoring. acid exposure and the number of reflux episodes were significantly higher in male than female patients. sensitivity to reflux was significantly higher in females. diagnosis of gerd based on acid exposure alone lacks diagnostic sensitivity, especially in female patients. background. the surgical treatment is the most effective method for weight reduction in morbid obesity laparoscopic adjustable silicone gastric banding (lsgb) for morbid obesity has been reported to provide long term weight loss with a low risk of operative complications. nevertheless, esophageal dilation leading to achalasia-like and reflux symptoms is a feared complication of lasgb. patients undergoing obesity surgery were prospectively included in an observation study. this study evaluates the clinical benefit of routine preoperative esophageal manometry in predicting outcome after lasgb in morbid obese patients. methods. before surgery, each of the patients underwent pulmonary functional test, esophageal manometry and gastroscopy. drug medication and esophageal symptoms were recorded. a review of prospectively collected datas on patients (male , female ), who underwent esophageal manometry routine prior to lasgb for morbid obesity from january -december were performed. aberrant motility and other non specific esophageal motility disorders noted on preoperative esophageal manometry defined patients of the abnormal manometry group. outcome differences in weight loss, emesis, band complications were compared between patients of the abnormal and normal manometry groups after lsagb. results. of the patients tested had abnormal esophageal manometry results, whereas had normal manometry results before lsagb. there was no significant difference in wheight loss between the groups after gastric banding. severe postoperative emesis and achalasia like esophageal dilation occurred more frequently in patients with abnomal manometry results. band related complication were found in both groups. there was no difference in the prevalence of reflux symptoms or esophagitis before and after gb. the lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakend after lsagb. conclusions. postoperative esophageal dysmotility and gastresophageal reflux are not uncommon after lsagb. preoperative testing should be done routinely. low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindication to lsagb. patients with such findings should be offered an alternative procedure, such as laparoscopic sleeve gastrectomy or gastric bypass. background. laparoscopic implantation of an adjustable gastric band (agb) still represents the most frequently performed bariatric operation in austria. however, in recent years a general tendency to gastric bypass procedures can be observed. a mayor cause for this development may be long term problems such as the development of an esophageal dilatation. methods. from january until november , patients ( female, male) were treated with agb for morbid obesity at the krankenanstalt rudolfstiftung in vienna. adjustments of the band were performed under radiologic control weeks after the operation and on demand thereafter. of these patients, patients ( female, male, median age: years, range: - years), an equivalent of %, developed an esophageal dilatation during follow up. the median time from the operation to the occurrence of esophageal dilatation was months (range: - months). at the time of esophageal dilatation the median excess weight loss was % (range: - %), the median filling volume was ml (range: . - . ml). twelve patients had to be reoperated in a median of months (range: month- months) after the dilatation occurred. eleven patients had a gastric bypass operation after band explantation and one was converted into a sleeve gastrectomy. in the other patients a conservative approach has been persued so far, consisting of a deflation of the band and careful refillings after approximately month. eleven patients were already available for follow up a median of months (range: month- months) after the dilatation. ten patients significantly gained weight again. the median excess weight loss was reduced from % (range: - %) at the time of the dilatation to % (range: À - %) at follow up. only one patient managed to lose further weight without radiologic signs of esophageal dilatation after refilling of the band. conclusions. esophageal dilatation is a serious long term complication after agb which occurs approximately years after the operation and leads to a failure of this bariatric procedure in the majority of cases. further studies are needed to identify potential candidates for esophageal dilatation after agb. oversewing of gastric pull up staple line in reconstruction after esophageal resection: counterproductive or helpful procedure? considerable postoperative morbidity and mortality. recent studies have emphasized a notable improvement in morbidity rates at specialized centers. in our analysis we put special considerations on the need for an invaginatig suture of the mechanical staple line used for gastric tubulization. methods. between and , patients were treated for esophageal cancer by resection. perioperative data were collected prospectively. among those patients ( . %) underwent gastric pull-up reconstruction. the gastric tube has been constructed by gias using mm staple cartridges. these patients were included in the presented study. it was put upon the discretion of the treating surgeon, whether the staple line has been oversewn by an interrupted invaginating suture or not in a non-randomized manner. the main endpoint measure of the study is leak rate at the longitudinal staple line of the gastric tube without signs of major gastric ischemia. results. the mean age of the patients was . ae . years, . % of the patients were male. in = ( . %) patients an adenocarcinoma was diagnosed, whereas = ( . %) patients had a squamous cell carcinoma and = ( . %) were classified as others. in = ( . %) patients the gastric staple line was not oversewn (group a). in = ( . %) patients the gastric staple line has been reinforced by an invaginating interrupted suture (group b) . a leak at the staple line has to be reported in = ( . %) patients in group a, whereas no leak was seen in group b (p ¼ . ). two= patients ( . %, a: , b: ) experienced ischemic gastric tip necrosis. other surgical complications were anastomotic leakage ( = patients; . %; a: = , b: = ), temporary recurrent nerve injury ( = patients; . %; a: = , b: = ), anastomotic stenosis ( = patients; . %; a: = , b: = ) and chylus fistula ( = patients; . %; a: = , b: = ). conclusions. no significant difference was found between group a and b. however, all staple line leaks of the gastric tube developed, when the gastric tube staple line has not been oversewn. background. cardia carcinoma (ca) is characterized by different features compared with the remaining gastric ca; its incidence in western countries is increasing. the aim of the study was to investigate diagnostic, therapeutic and outcome measures of cardia ca in daily surgical practice. methods. all consecutive patients with cardia ca out of a pool of patients with histologically confirmed diagnosis of gastric ca who were treated in surgical departments were enrolled in this prospective observational multicenter study through a period of months. detailed patient, diagnostic and treatment characteristics were recorded in a computerbased format for analysis. short-term outcome was characterized by hospital stay, complication rate, morbidity and hospital mortality. results. from = - = = , . patients with gastric ca from surgical departments of each level of care were registered out of them subjects ( . %) with cardia ca. tumor localization was classified in patients according to siewert: typi, n ¼ ( . %); typii, n ¼ ( . %); typeiii, n ¼ ( . %). one hundred and seventy two patients underwent surgical intervention (operation rate, . %) of whom individuals underwent resection (rate, . %). a potentially curative resection could be offered to patients (r resection rate, . vs. . % in all gastric ca). fresh frozen section was only used in resections (rate, . %). of standard resections (distal esophagectomy with proximal or total gastrectomy), systematic d , d and d lymphadenectomy was performed in . , . and . %, respectively. histologic investigation revealed uicc stage i=ii in . % of all operated patients: iii=iv, %; not classified, . %. distant metastases occurred most frequently at the peritoneal site ( . %), liver ( . %) and non-regional lymph nodes ( . %). postoperative morbidity was . %. anastomotic leakage occured in patients ( . vs. . % in total of all gastrectomies in gastric ca) from whom subjects ( . %) underwent surgical reintervention. hospital mortality was . % (n ¼ ) compared to . % in all patients with gastric ca. conclusions. more than % of patients diagnosed with cardia ca show an advanced tumor stage at the time of surgical intervention. not all resections estimated as potentially curative were accompanied by d lymphadenectomy. in particular, to further improve hospital volume and r resection rate, to consequently use intraoperative fresh frozen section for the detection of an adequate tumor-free resection margin and to lower the rate of anastomotic insufficiency, it is suggested to treat patients with cardia ca at surgical centres for optimal outcome ( -year survival rate is being under investigation). deep brain stimulation therapy for psychiatric diseases g. m. friehs brown university, providence, usa background. obsessive-compulsive disorder (ocd) and major depressive disorder (mdd) causes tremendous suffering in those affected and in their families. neurosurgical lesioning procedures have been in existence for several decades and the overall reported success rate is widely quoted in the - % range. over the past years deep brain stimulation (dbs) has become available for a variety of conditions including ocd and mdd and has largely replaced lesoining procedure. methods. we report on our experience with patients with ocd ( ) and mdd ( ) treated with dbs of the anterior limb of the internal capsule (al-ic). patients who did not have multiple medication trials of adequate length and dose and trials of psychotherapy or behavioral therapy were excluded. also, mdd patients were required to have had a full course of electro-shock therapy (ect). patients were evaluated by a panel of independent psychiatrists before being referred for neurosurgery. all patients underwent a routine dbs surgery with implantation of bilateral electrodes into the al-ic. the stereotactic coordinates were - mm anterior to the anterior commissure (ac) and - mm lateral to anatomical midline, the electrode tip reached into the area of the nucleus accumbens. all patients had pre-and postoperative neuropsychology evaluations with testing batteries including the yale-brown-obsessive-compulsive-disorder scale (ybocs), global assessment of functioning scale (gaf) and hamilton-depression scale (ham-d) or the montgommery depression scale (mds). results. patients were followed for - months (average: . years), follow-up was complete for all patients ( %). = patients ( %) with ocd had improvements in their ybocs scores of more than % which was found to be significant (p < . ). also, these patients showed a significant (p < . ) improvement in their overall gaf. it was furthermore noted that the depression scores had a tendency towards improvement. of the five patients with mdd = patients ( %) had a significant improvement in their ham-d scores and gaf scores (p < . ). complications included one postoperative seizure, slight wound healing problems which did not require surgical intervention ( = , %). of note is the fact that the dbs batteries have to be changed very frequently (on average every - months). conclusions. dbs for ocd and mdd is a viable treatment for patients who have failed all other known therapeutic options. it is currently reserved for research centers who have a team of psychiatrists dedicated to the treatment of such patients. controlled studies will be necessary to develop guidelines for electrode placement and programming parameters. background. the number of patients demanding endoscopic neck surgery is rising. the access trauma of the axillary, breast and chest approaches is bigger than in open or video assisted surgery. we tested the feasibility of he sublingual transoral access which is in our opinion the only real minimally-invasive extracollar endoscopic access to the thyroid gland. methods. we performed an experimental investigation in a porcine model. in pigs we made endoscopic transoral thyroidectomys with a modified axilloscope with the help of ultrasonic scissors and a neuro-monitoring system for identification of the recurrent laryngeal nerve. results. the average operation time from the introduction to the removal of the obturator just above the larynx was seconds. the mean operation time was minutes. with the help of the neuro-monitoring system we proved in all cases the function of the recurrent laryngeal nerve on both sides. the pigs were observed for another two hours after operation. during and after the operation no complications appeared. conclusions. we could show that the endoscopic transoral thyroid resection in pigs is possible and save. our results might be useful for using this access for endoscopic thyroid resection in humans. background. actually, the surgical community receives some new impulses from interventionally orientated and skilled gastroenterologist by the so-called ''n.o.t.e.s.'' -natural orifice transluminal endoscopic surgery. this seems to be challenge enough to cooperate and contribute some surgically constructive ideas and critics. the surgical answer -with the intention to develop the arguments for a surgical engagement -to the presently still extra-clinical concept of ''notes'' may be given through an alternative procedure named ''flexible endoscopic minimally invasive transperitoneal'' (f.e.min.in. tra.p.) cholecystectomy. methods. after presentation of ''notes'', it's principles and aims, it's supporting societies and boards and their self-definition, a summary of already existing ''notes''-procedures and description of instrumental developments will be given. in contrast surgical considerations will be focused on more or less established surgical transluminal or even natural-orifice-transluminal techniques. in this context a special attention will be paid to surgical history and the life and times of e.mÜ he and the fact of a nearly-missed change of paradigms. as testimony for surgical endoscopic competence in interventional procedures the hybrid-model of f.e.min.in. tra.p. cholecystectomy will be opposed as surgical pendant to the conceptual idea of ''notes'' throughout a short clip-sequence. results. arguments for a surgical engagement in the development of ''notes'' are based on the following items: conclusions. only a close interdisciplinary cooperation may show weather the idea of ''notes'' will lead to clinical usefulness. it's invasivity as well as it's apparent strangeness to surgical behaviour and thinking should incline to an at least active interest. background. sacral nerve stimulation (sns) proves to be an effective therapy in patients with faecal incontinence. during the past years there were as well some promising results in the therapy of chronic obstipation. this study describes the experience with sns in patients with outlet obstruction. methods. four patients suffering of outlet-obstruction ( women), median age years (range - ) underwent test stimulation with a permanent electrode (tined lead). all patients had multiple previous conservative and operative unsuccessful therapy attempts. when complaints could be reduced by at least % with external stimulation, a permanent stimulator was implanted (two staged procedure). success of treatment was evaluated by: clinical examination, patient satisfaction (visual analogue score;vsa), cleveland-clinic-obstipation-score, and morbidity. evaluations were performed before start of treatment, before implantation and months after implantation. results. three of four patients completed the test stimulation stage successfully and received a permanent implant; median duration of stimulation stage was days (range - ). all these patients had a clear improvement according to their vas and cleveland-clinic obstipations-score. there was no postoperative morbidity. the median follow-up was months ( - ). conclusions. chronic obstipation can be treated successfully with chronic sacral nerve stimulation even after other therapeutic approaches have failed. however, this observation has to be confirmed in larger, controlled trials. background. the stapled transanal rectum resection (starr) is an accepted technique for the treatment of the obstructed defecation syndrome (ods). however, the technique with a circular stapling device (pph- ) is limited in large prolapse and the resection is performed ''blind''. a new device, the contour trans-starr (str g), has been designed with the aim of overcoming pitfalls of the current starr technique. this study describes the new technique and the initial experience in treating outlet obstruction or rectal prolapse. methods. all patients had multiple previous conservative or operative unsuccessful therapy attempts. the procedure was performed in lithotomy position and under spinal or general anaesthesia. the prolapse was sutured at the apex with the goal to obtain a uniform circumferential traction (parachute technique). then the new device was introduced into the rectum and a circumferential resection was performed step by step. success of treatment was evaluated by: clinical examination, ods-score, and morbidity. evaluations were performed before the treatment and months later. results. the study started in january and we estimate to enrol eight patients until the end of may . indications, patient's inclusion and exclusion criteria, morbidity and short term outcome will be discussed. conclusions. with the new device the starr procedure may become easier and more effective in the treatment of ods. however, safety and effectiveness has to be confirmed in larger, controlled trials. leber-gallengang therapeutic options for pyogenic liver abscesses h. cerwenka background. clinical management of pla (pyogenic liver abscess) has changed in the last decades due to constant improvements, for instance, in inventional radiology and antibiotic therapy. in surgical departments, we usually treat a selected group of patients with particularly severe forms. methods. our clinical study comprised a series of patients with pla. antibiotic treatment was modified according to sensitivity testing. additional therapy consisted of percutaneous puncture=drainage, endoscopic papillotomy=stenting and surgical interventions when indicated. results. fifty-eight patients ( %) had single and patients multiple pla. the disease was confined to the right hepatic lobe in % and to the left lobe in %; both lobes were affected in %. etiology was biliary in %, hematogenous in %, posttraumatic in % and cryptogenic or attributable to rare reasons in the remaining patients. microbiological culture was sterile in %, which was at least partly due to antibiotic pre-treatment. staphylococci, streptococci and e. coli were most often identified. anaerobes were found in %. factors associated with the need for surgery included: empyema of the gallbladder, underlying malignancy, perforation, multicentricity, vascular complications (hepatic artery thrombosis) and foreign bodies (e.g., toothpick, infected ventriculo-peritoneal shunt). in patients with biliary fistulae it was crucial to ensure prompt bile flow (for instance, by papillotomy=stenting). conclusions. assessment of underlying diseases is decisive for timely identification of patients requiring more invasive treatment. microbiological testing provides clinically important information for treatment monitoring and modification. special attention must be paid to diagnosis and treatment of concomitant biliary fistulae. therapy methods of hydatid disease from the tradition to the future m. sanal , h. guvenc , j. hager in europe. however there are some regions: upper bavaria, suedwuerttemberg (swabian alb), bathing (black forest), furthermore tirol, kaernten and steiermark, switzerland and north italy involved with this parasite. also people from turkey and the balkans bring the illnesses again and again. this lead to the necessity for physicians to be aware of its clinical features, diagnosis and management. methods. thirty patients with cyst echinococcus (ce) in liver, lung, kidney and spleen were in three different pediatric surgery departments innsbruck, bursa and kocaeli surgically treated. in the patients were cystotomy capitonage, simple cystotomy, unroofing, splenectomy, cyst excision performed. seven patients underwent minimal invasive surgery. results. postoperative bronchopleural fistula resolved spontaneously under negative pressure in five cases. the long-term postoperative results are considered good, with no recurrences observed. conclusions. surgery has remained the mainstay for the treatment of ce. the basic steps of the surgical procedures are eradication of the parasite by mechanical removal, sterilization of the cyst cavity by injection of a scolicidal agent, and protection of the surrounding tissues. pair technique in ce; performed using either ultrasound or ct guidance, involves aspiration of the contents via a special cannula, followed by injection of a scolicidal agent for at least minutes, and then reaspiration of the cystic contents. in the last years video assisted intervention has also been performed successfully. background. group milleri streptococci (gms), a heterogeneous group of streptococci, are associated with purulent infections. methods. retrospective analysis of all consecutive biliary infections due to gms in a four-years period. results. out of gms positive patients the innsbruck medical university within the study period, the biliary tract was affected in ( . %). the mean patient age was . ae . years, with a female:male ratio of : . . polymicrobial infections were present in . %. thirty percent of all patients were immuno-compromised after liver transplantation ( = ). seventy-nine patients ( . %) had clinical signs of infection, which was confined to the gallbladder in ( . %) (group i), while patients ( . %) presented with cholangitis (group ii). underlying diseases in the cholangitis group were biliary complications following liver transplantation in , other causes for mechanic cholestasis in , malignant intrahepatic disease in , ascending infections in and a ductus choledochus cyst in one patient. twenty patients ( . %) had gms positive bile cultures without clinical signs of infection (group iii) obtained during evaluation of cholestasis ( ), status post liver transplantation ( ), bilioma post liver resection ( ), and psc ( ). antibiotics were administered to patients ( . %) in group i, all patients ( . %) in group ii, and one patient ( . %) in group iii. in group i, all patients also underwent cholecystectomy. interventions were required in patients ( . %) in group ii (ercp ( ), external drainage ( ), surgery ( )), and patients ( . %) in group iii (ercp ( ), external drainage ( ), surgery ( )). gms isolates were susceptible to all penicillins, clindamycin and most cyclosporins, but were resistant to aminoglycosides and showed intermediate susceptability to ciprofloxacin. conclusions. the biliary tract was affected in one out of five patients with group milleri streptococci (gms). gms cause infection in % of all cases, and are often associated with mechanical cholestasis. background. peritonitis ossificans is a rare disorder with only few reported cases in literature. metaplastic bone formation in abdominal scars seems to be an own entity with only several descriptions mostly associated with trauma, gun shot wounds and repeated abdominal surgery. we report about a case with development of metaplastic bone formation and peritonitis ossificans after multiple acute surgical interventions. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''peritonitis ossificans'' and ''metaplastic bone formation'' via pub med. results. our patient developed multiple nodular lesions with massive calcifications between the small bowel mesentery (heterotopic mesenteric ossification) after primary adhesive ileus and revision surgery because of colonic leakage. the situation developed within days from a prior abdominal situs without calcification. small bowel fistula occurred and we used abdominal vac therapy. ten weeks later partial secondary closure was performed and no sign of calcification could be observed. histological features showed fatty necrosis and scary tissue with metaplastic cartileage and bone tissue. literature is rare, pathophysiology, therapy and prognosis remains unclear. conclusions. male gender, multiple abdominal surgery or trauma with peritonitis, peritoneal dialysis and pancreatitis seem to be predisposing factors. extensive activation of myofibroblasts appears to be the major cause for hyperproliferation. the prognostic impact depends on secondary complications including postoperative fistula and leakage and intestinal obstructions. actually, literature shows no causative therapy. background. the differential diagnosis of dysphagia predominantly includes gerd, neoplasm, diverticula or achalasia. infrequent causes are diffuse esophageal spasm, scleroderma and other systemic diseases. eosinophilic esophagitis as a cause for dysphagia is found increasingly in recent literature and as a headline topic at congresses. methods. case report of a a old adipose male patient with multiple allergies who was suffering from dysphagia and bolus events for about years. they have been independent from pain, stress, temperature or consistency of food. gastroscopic examination showed a narrow esophagus with fragile, slightly corrugated mucosa. barium radiography and mri did not show any pathology. the patient underwent an esophageal manometry which showed a normal les with normal relaxation, but pressure peaks of mmhg on swallowing and % simultaneous waves. iced water or metoclopramide had no effect. ppi and nitro showed no improvement. sample biopsies of the whole upper gi during a second endoscopy revealed massive eosinophilic infiltration of the whole esophagus. results. the diagnosis eosinophilic esophagitis was herewith confirmed. the patient was treated with orally administered topic steroids (pulmicort spray bid orally for three months). his symptoms improved markedly. conclusions. eosinophilic esophagitis is an uncommon disorder. only publications with all over patients are published. male to female ratio is to . in % of the patients, food allergies can be found. peripheral eosinophilia can be detected in % and high ige in %. most of the patients are in the range of normal weight. the main symptoms are dysphagia in %, food impaction in % and heartburn in % of patients. endoscopically mucosal fragility can be detected in almost all patients, furthermore edema %, rings %, strictures %, corrugated esophagus, papules % and small caliber esophagus in %. eosinophilic infiltration ( =hpf) in the upper and lower esophagus without presence of eosinophils in the stomach or duodenum are detected histologically. the recommended therapy is oral administration of fluticasonpropionate or bethametason spray for two months. the initial response is about %, but relapse is common. systemic steroids are also effective. dilatation should not be performed because of a significantly elevated perforation risk and a high relapse rate. sample biopsies of the upper gi should be taken in every patient with unclear dysphagia since eosinophilic infiltration exclusively in the whole esophagus is pathognomonic for eosinophilic esophagitis and consequently dilatation should not be performed. p cholangiocellular carcinoma of the bile duct after resection of a congenital choledochal cysta rare manifestation background. the risk of malignant degeneration of a bile duct cyst is reduced by an early resection, but the risk of malignant change persists, as we show in our case. only few cases are published in the literature. as the prognose of a malignant degenerated choledochal cyst is very poor, the only useful possibility to minimize the risk of carcinoma is the early cystectomy. based on our case we like to discuss the indication for surgery, incidence of malignant change, risk factors, discovery and diagnosis, detection and prevention, the surgical procedures for the treatment of chledochal cysts and especially whether the typ of surgery have an impact on malignant transformation? methods. we report about a female patient who was examinated by ercp because of recurrent cholangitis. in her medical history we found out that on our patient a cholecystectomy has been carried out at the age of years and in addition to that procedure a congenital choledochal cyst typ i was resected, nevertheless the patient developed a massive cholangiocellular carcinoma which leaded to death at the age of years. after examination using multiphase ct we diagnosed a carcinoma to a great extent, which was inoperable. with the intention to obtain an operable condition, our patient was treated with neoadjuvant chemotherapy which remained unsuccessful. results. there are series of theories in the literature which try to explain the genesis of choledochal cysts, the real reason of their development is not clear, many possibilities for their emergence are discussed: i.e. weakness of the bile duct, distal obstruction, pancreatico-choledochal reflux caused by a long common channel, a wrong estuary of the pancreatic duct in the choledochus or also a pathologic distribution of ganglion cells on the wall of the choledochus. reviewing the worldliterature, the risk of degeneration of choledochal cysts is described differently, but the early resection is always recommended. conclusions. choledochal cysts are associated with an increase in the incidence of bile duct carcinoma. as it is shown, excision of a choledochal cyst is not protection by itself against the development of cancer in the future. after resection patients should have long term follow up. any patient, especially any adult, with recurrent symptoms following cyst related surgery must be evaluated for malignancies in the biliary tract. a surgical treatment after diagnosis of a choledochal cyst is necessary to avoid bile duct carcinoma. background. sporadic lymphangioleiomyomatosis (lam) is a nonmalignant proliferation of immature smooth muscle cells, usually in the lung but occasionally in the retroperitoneal lymph nodes as well. there is perilymphatic, perivascular and, with pulmonary manisfestation, peribrochiolar proliferation and invasion. it is an extremely rare disease (prevalence : ) that exclusively afflicts women of childbearing age. the most common presenting symptoms are dyspnea, cough, recurring pneumothorax or chylous ascites. the definitive diagnosis is obtained by biopsy. lam has a typical histological picture featuring diffuse, sometimes nodular proliferations of immature smooth muscle that stain specifically with the marker hmb- . unlike tuberous sclerosis (ts), sporadic lam is triggered by a mosaic mutation of the tsc- gene in the involved tissue. ts in contrast is caused by a somatic mutation of the tsc- gene. this somatic mutation leads above all to neurological symptoms (a trias of epilepsy, cognitive impairment, dermatological manifestations) but, in some cases, to a pulmonary manifestation of lam. at present, there is no curative treatment for lam, though a trial with gestagens is an option. terminal pulmonary failure is an indication for lung transplant. case report. in the course of a routine sonographic examination, a -year-old woman was found to have an expansive cystic process in the retroperitoneum. abdominal ct showed a pre-aortal lesion measuring .   cm with a partially cystic, partially soft-tissue structure suggestive of a cystic lymphoma or a cystic lymphangioma. the cyst was drained and partially resected laparoscopically. the histological diagnosis was lymphangioleiomyomatosis without indication of malignancy. preoperative chest x-ray and spirometry were within normal limits, but high-resolution thorax ct showed the cystic alterations typical for pulmonary lam. at present, the patient is free of complaints but due to the typical chronic course of the disease, close follow-up is indicated. conclusions. although it is a very rare disease, the diagnosis of a cystic retroperitoneal expansive process should suggest lam as a differential diagnosis. a definitive diagnosis can only be obtained with histology. because pulmonary involvement tends to be the rule, a thorax ct is indicated with primary abdominal manifestation. if there are neurological or dermatological manifestations, tuberous sclerosis should also be considered in the differential diagnosis. fetal mri: what is its worth outside the central-nervous system in extra-central-nervous system regions as it is mandatory in pediatric surgery. since fetal mri is performed at our institution, whenever a congenital malformation is suspected in the prenatal ultrasound. methods. fetal mri studies are performed on . t (philips) superconducting unit using a five-element surface phased-array coil, after th gestational week to avoid the possibility of magnetic fields interfering with organogenesis. no sedation is necessary. in addition to routine t -weighted (w) sequences, t -weighted sequences (mainly to demonstrate meconium-containing bowel loops), t -sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusion-weighted sequences (for further tissue characterization) were performed. results. fetal mri is applied the following pediatric surgery cases: suspected lung anomalies ( cases), abdominal anomalies ( ), anal atresias ( ), esophageal atresias ( suspected), congenital diaphragmatic hernias (cdh) ( ), head-and-neck diseases ( ) and for urologic cases ( ). conclusions. detailed morphological description of congenital malformations is possible with fetal mri which may have a bearing on prognosis. it has become mandatory for antenatal counseling. in some findings such as esophageal atresia, gastroschisis or cdh an antenatal transport can be arranged to a perinatal center. background. in inflammation, activation of coagulation and inhibition of fibrinolysis lead to microvascular thrombosis. thus, clot stability might be a critical issue in the development of multiple organ dysfunction syndrome. activated fxiii (fxiiia) forms stable fibrin clots by covalently cross-linking fibrin monomers. in recent studies, multiple polymorphisms have been described in the fxiii-a subunit gene. the val leu polymorphism affects the function of fxiii by increasing the rate of fxiii activation by thrombin, which results in an increased and faster rate of fibrin stabilization. in the present study, we analysed the influence of the common fxiii val leu polymorphism on inflammatory and coagulation parameters in human experimental endotoxemia. methods. healthy volunteers received ng=kg endotoxin (lps, n ¼ ) as a bolus infusion over min. blood samples were collected by venipunctures into edta anticoagulated vacutainer tubes before lps infusion. for determination of the fibrinogen promoter polymorphism, we developed a new mutagenic separated polymerase chain reaction assay. results. fxiii levels were higher for homozygous carriers of the fxiii v l polymorphism in comparison to wild-typ and heterozygous. homozygous carriers had lower levels of tnf and il- in comparison to wild-type. interestingly, subjects homocygous for the fxiii v l polymorphism had lower monocyte and neutrophil levels throughout the timecourse. the fxiii v l genotype was not associated with clinically relevant differences in plasma d-dimer or f þ levels after lps challenge, which is consistent with the lack of effect on early thrombin generation. conclusions. our findings indicate, that the common fxiii v l polymorphism is associated with differences in the selected inflammation parameters and in monocyte and neutrophil cell counts in response to systemic lps infusion in humans. those findings may have an impact on clinical treatment for patients with inflammatory diseases. p stamm-kader gastrostomy or peg w. h. weissenhofer time-honoured or forgotten? the stamm-kader gastrostomy, introducing a nelaton catheter via a stab incision through the upper abdominal wall, guided by direct vision after laparotomy or using a minilaparotomy or even by laparoscopy can be considered an easy alternative to the widely used peg or similar endoscopic procedures. the ''old'' and simple stamm-kader procedure offers not only direct vision, possibilities of local anaesthesia and a minimum of instruments and therefore costeffectiveness, but is also a welcomed addition to the surgical armamentarium -once learned. the actual procedure includes an abdominal accesswhether minimal or already present in case of operations for bowel obstruction, further a double pursestrig suture between large and small curvature of the stomach, stab incision and introduction of a large lumen balloon catheter, the double pursestring sutures are tied in such a way that a short channel in the stomach wall is formed and then covering sutures between abdominal wall and stomach are tied. the catheter can be used immediately for decompression and early feeding. obviously this is a surgical method and has therefore a much smaller following and tends to be forgotten as there are no ''progressive'' endoscopic devices to be advertised and there is minimal economic interest to be generated for medical companies. nonetheless it is in my opinion and experience an useful route in more ways than the peg or button gastrostomies can ever offer. the blood levels of c-reactive protein (crp), interleukin (il) , , and icam- were measured using the elisa technique in all patient before, immediately after operation, at the first and third day after surgery. the pre-operations levels of crp and all mediators had no differences in both group of patients. significant increase of il- , il- and icam- level was noted in the first group vs. insignificant changes of mediators' levels in patients of the laparoscopic group immediately after operation. the gradually increase of all mediators' plasma levels were noted in first group up to the third day after operation. crp was peaked at the third day in both group, but the increase after open adrenalectomy was more pronounced (p < . ). levels of il- and icam- had strong correlation with the hematological changes that observed in the postoperative period. the cytokines play a pivotal role in the orchestration of the immune response. the increased levels of il- and il- pointed on enhance of th response. activation of th cytokines may provoke the immunosuppression and the catabolic stage and may have adverse consequences for patient recovery. thus, there is a clear correlation between the changes in cytokine levels and the degree of surgical trauma. methods. combined retroperitoneal pancreas-kidney transplantation was performed in a -year-old patient with type-idiabetes and diabetic nephropathy. the patient had a bmi of and had undergone renal transplantation in the right iliac fossa years ago. after mobilization of the colon and mesocolon ascendens, the graft was anastomosed end-to-side to the aorta and to the inferior caval vein. the graft was in a retroperitoneal position. for exocrine drainage a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the colon mesentery. results. the anastomoses could be performed with ease. duration of the pancreas implantation was minutes, minutes for implantation of the kidney in the left iliac fossa. ischemic time was hours. a revision was necessary due to obstruction of the graft ureter. from day after transplantation the patient required no more insulin, and lipase and amylase levels were within the normal range. conclusions. the first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed, that the technique was safe, and had technical advantages as compared with the classic method. it should be especially applied in high risk patients (obesity, severe atherosclerosis). background. recell + is a new medical product for yielding a cell suspension of the skin. in this process cells are removed from the basal layer of a thin split skin graft. the removal of the skin graft, the preparation of the cell suspension and the covering of the defect can be done in one treatment session in the operating theatre. recell + could be used for the coverage of superficial defects in burns, scars, skin resurfacing and vitiligo. the advantages of this new technique are a shorter healing period, better scar quality and the ability of repigmentation. methods. for yielding cell suspension, which is quickly available, a thin split skin graft (thickness . - . mm) is taken. depending on the defect, the size of the split skin biopsie is from  cm for coverage of cm to  cm for coverage of cm treatment area. after separation of the different layers of the skin, the special cell suspension could be prepared. then the cell suspension is immediately sprayed or trickled on the prepared wound area. a special laboratory is not required. the first change of the wound dressing is done week postoperatively. conclusions. the result of this new treatment option is a skin of good quality, colour and function -comparable with the original skin. the first experiences show recell + as an interesting amendment to the previous therapeutical options. however, other studies should be done to fathom the spectrum of the indications and to confirm the first results. p early experience with ductoscopy guided minimal invasive surgery for intraductal breast lesions c. tausch, p. schrenk, e. grafinger-witt, t. gitter, s. wölfl, s. bogner, w. wayand background. intraductal breast lesions which have been diagnosed by radiological ductography are sent to breast surgery. by a cirumareolar incision a poorly defined extent of tissue will be removed. it can be supported by presentation of the main duct by injection of blue dye. taking into consideration that papillomas are benign in - %, it is worthful to minimize the extent of the intervention. this fact and the aim to visualize the origin of most types of breast cancer -the terminal ductolobular unit (tdlu) -induced the development of endoscopes for the milk ducts. methods. after canulating the ductus lactiferous it will be distended by a special dilatator. the endoscope (laduskop + , polydiagnost comp.) is inserted through this dilatator and the inspection of the ductal system is possible til over the fourth bifurcation. endosopes are available with device for flushing and working ducts for biopsies. results. this a first report about the experience with ductoscopy in patients presented with unilateral secretory disease. after successful localisation of an intraductal leason a tissue sparing excision of the affected duct follows guided by the in situ lying ductoscope. conclusions. endoscopy of the mammary duct system is a precious diagnostic tool for onesided secretory disease und is able to minimize the extent of the removed tissue. the role of the method in the perioperative visualisation of intraductal diessemination of breast malignancies needs further evaluation. p ruptured aneurysma of arteria lienalis with massive bleeding because of fibromuscular dysplasia background. fibromuscular dysplasia (fmd), a non-ather-osclerotic=non-inflammatory vascular disease, is a rare cause of visceral artery aneurysmas (vaa). in about % of all cases, vaa presents first with rupture and leads to a overall-mortality of . %. about % of fmd are familial, most likely in female and often as multifocal lesions. patient's history. a years old female patient was admitted to our department with nausea and epigastric pain. former history showed an aneurysma of the iliacal artery treated by iliacofemoral bypass (pathohistological examination of the aneurysma showed fmd), and several episodes of spontaneous subcutaneous haematomas. abdominal ultrasound, x-ray and gastroscopy showed no abnormalities. moderate anaemia without any sign of gastrointestinal bleeding made us perform a ct-scan which showed an intraabdominal and peripancreatic haematoma without any sign of a recurrent aneurysma. under icu-monitoring the patient showed another episode of acute epigastric pain and developed signs of haemorrhagic shock. we performed an acute median laparotomy and found no cause of intraabdominal bleeding. exploration of the peripancreatic haematoma showed the cause of bleeding as a ruptured aneurysma of the central splenic artery. resection of the aneurysma and splenectomy had to be performed. the patient was discharged from the hospital on the th postoperative day. conclusions. ruptured vaa caused by fmd as rare reasons for acute abdominal pain need most aggressive treatment to avoid postoperative mortality. background. today, iatrogenic injuries are the most common cause of hemobilia. the hepatobiliary system is at risk for damage as side effect from procedures such as percutaneous bile drains and liver biopsies. complications of open and laparoscopic surgical procedures can also be responsible for hemobilia. methods. we report of a rare case of iatrogenic hemobilia occurring after laparoscopic cholecystectomy. results. a -year-old patient was readmitted to our department, days after laparoscopic cholecystectomy, complaining about upper abdominal pain and presenting with signs of jaundice (bi ¼ . mg=dl but ap ¼ u=l) and anaemia (hb ¼ . g=dl). the patient, who was a jehovah's witness, refused blood transfusions. on readmission ercp demonstrated fresh active bleeding from the papilla of vater. cholangiography demonstrated obstruction of the common bile duct by intraluminal blood clots. blood clots were retrieved by means of an endoscopic ballon-catheter. ct scan and angiography showed a . cm contrast retaining pseudoaneurysm in the hilus of the liver oroginating from the stump of the cystic duct. interventional radiological selective stenting of the hepatic artery could not be performed for technical reasons. the patient was re-operated, the site of bleeding was identified as the cystic artery stump and surgically controlled with sutures. the patient's further postoperative course was uneventful with quick recovery and without the need for blood transfusion. conclusions. hemobilia is a rare complication after cholecystectomy, which may stem from a pseudoaneurysm of damaged vessels, e.g., the stump of the cystic artery. when management by interventional radiology fails, surgical intervention is mandatory. background. we describe on of the rare cases with a perforated barrett-ulcer resulting in an esophagopleural fistula. the importance of recognizing esophageal disorders and catastrophes in the management of acute abdominal emergencies is emphasized. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''esophageal perforation'' via pub med. results. a young, male, alcohol-addict patient presented to the emergency department after a fall over staircase with serial rips-fracture and only little discomfort. chest x-ray and blood sample were inconspicuous. on the following day patients general condition got worse, a pneumothorax occurred. so it was necessary to install a bulau drainage which encouraged food out of the left pleuracave -therefore an ''esophageal perforation'' was supposed. the patient was transferred, now with a mediastinial sepsis and multi organ-failure, to our medical surgery unit, where primarily a esophageal stent and a thoracotomy with cleansing and drainage of the mediastinum and the pleural cavity was set. but within a week the stent became insufficient and an esophagectomy and a gastrostomy were necessary. after weeks therapy on the intensive care unit, the patient underwent again a thoracotomy with decortication of a pleura callositiy because of the persistence of a fluidopneumothorax. the patient is now disposed to a colon interposition. conclusions. possible risk factors for perforation in general and in this patient included alcoholism, severe gastroesophageal reflux, noncompliance with antacid and ppi blocker therapy and the presence of acid-secreting parietal cells in the barrett's epithelium. misdiagnosis is the most important contributing factor in the continuing high morbidity and mortality of esophageal-perforation as shown by all reported cases. background. the use of ergotamine, e.g., suppositories for migraine headaches, may have systemic as well as local side effects. systemic poisoning is known as ergotism, historically mostly due to the ingestion of rye infected with claviceps purpura fungi. local complications, like rectal ulcers and rectovaginal fistula may require surgical management. methods. we report about the case of a year old female patient with deep anal necrosis, insufficiency of the anal sphincter, anovaginal cloaca and rectal prolapse, as long-term sequelae of ergotamin suppository application. results. the patient was hospitalized for treatment of the rectal syndrome mentioned above. the anoderm appeared completely destroyed, with extensive scarring and manifestation of an anaovaginal cloaca. anal manometry showed almost no anal pressure. anal sonography demonstrated an anterior semicircular defect of the internal as well as the external anal muscles. the patient had already been seen in our hospital two years previously, when a perineal necrosis had raised suspicion of a locally advanced anal cancer. that time, she had refused to undergo further diagnostic work-up (including re-biopsy, etc.) and treatment, after endosonography had suggested an infiltrative process affecting the anal sphincter and the histopathologic diagnosis spoke of a ''tumor necrosis . . . but without viable tumor cells''. now, after exclusion of a neoplastic process, the patient underwent a complex surgical procedure for management of her incontinence syndrome: a laparoscopic resection of the rectum and rectopexy was performed. furthermore sphincter and perineum were reconstructed using an anterior levator plasty and ventral sphincter-overlapping repair. a temporary protective loop ileostomy was created in addition. conclusions. this case describes the -to our knowledgemost extensive local complication due to ergotamine suppositories, in the world literature. it suggests that ergotamine suppositories should be used with precaution, and a close followup by the prescribing practitioner is mandatory. furthermore, patients with unclear inflammatory destructive alterations of the perineum and unexplained rectal syndrome should be asked for ergotamine suppository (ab)use. p intrapancreatic accessory spleen: a differential diagnosis of pancreatic tumour background. according to autoptic studies, accessory spleens may be found in to % of the population and most of them are usually located at or near the splenic hilum. only in to % they are located in the pancreatic tail. we report a rare case of intrapancreatic accessory spleen which radiologically mimicked a tumor in the tail of the pancreas. methods. a -year-old man was diagnosed with a tumor at the pancreatic tail. in the preoperative computed tomography (ct), there was a lesion ( . cm in diameter) in the pancreatic tail and two locoregional lesions ( . and . cm in diameter), which had intensive contrast enhancement. it was diagnosed as a nonfunctioning endocrine pancreatic tail carcinoma with lymph node metastasis. results. intraoperative examination showed two accessory spleens nearby the pancreatic tail. as pancreatic cancer could not be excluded because of the local findings, an oncological left pancreatectomy was performed. histological examination excluded cancer and revealed an intrapancreatic accessory spleen and two accessory spleens nearby the pancreatic tail. conclusions. intrapancreatic accessory spleen should be included in the differential diagnosis of pancreatic neoplasm. a useful diagnostic tool is scintigraphy with technetium- marked, heat shock denaturated autologous erythrocytes. background. sacral nerve stimulation (sns) is a widely accepted therapeutic options for patients suffering from faecal incontinence based on a neurogenic dysfunction. more recently case reports have been published showing a positive effect of this treatment in patients suffering from faecal incontinence after low anterior rectal resection. the purpose of this study was to perform a nationwide survey for this selected indication for sns in order to gain more information by recruiting a larger number of patients. methods. in the period to three austrian departments reported data of patients who underwent sns for faecal incontinence following rectal resection. data were available of patients ( females, males) with a median age of years (min -max ). six patients had undergone rectal resection as a treatment for low rectal cancer. one patient had undergone rectal resection for crohn's disease, one patient subtotal colectomy and ileorectostomy for slow colon transit constipation. results. in all patients test stimulation was performed in the foramen s unilaterally over a median period of days ( - d) . seven patients reported a marked reduction of incontinence in the observation period. five patients reported a marked improvement compared to the baseline of their continence situation. three patients had no further incontinence episodes following the permanent implant. two patients reported ''rare events'' ( - incontinence episodes= month). one patient who had previously reported an improvement of his continence function during his test stimulation complained about repeated urgency problems as well as incontinence episodes. conclusions. despite our observations and the promising results of others the role of sns in the treatment of faecal incontinence following rectal resection needs further research as well as more clinical data by a larger number of patients. p lymphatic vessel invasion in upper gi cancer: an indication for an additive or adjuvant therapy? and ac had significant lower lvi-rates compared to nonresponders. these data warrant prospective data and might result in the future into an additive or adjuvant multimodal therapy. [up to now = recurrencies ( . %) were seen.] all patient data were collected prospectively. in the present study we compared all patients with an operations time of minutes or more with those with operation times < minutes and compared patient related factors (asa, bmi, type of hernia, recurrent hernia, scrotal hernia, incarcerated hernia and situs-related problems) and operation related factors (surgeon's experience, intraoperative problems, anaesthesiologic problems). results. mean operation time was . ae . minutes. operation time did not increase with asa and bmi (pearson coefficient . resp . ). direct hernia were faster operated than indirect, combined or recurrent hernias in total (average time . ae . ; . ae . ; . ae . ; . ae . ). the proportion of recurrent ( . %) and scrotal hernia ( . %) in operations longer than minutes was significantly higher (n.s. resp. p < . ), in incarcerated hernia ( . %)and hernias with long anamnesis and difficult scarred situs ( . %) or combined with additional operations ( . %) as well. in operation related factors individual designed ring-armed patches demanded - minutes more operation time and thus clearly prolonged the operation (p < . ), unexpected intraoperative problems (e.g. in positioning the patch) or complication (bladder injury) as well. in rare cases anaesthesiological problems (insufficient spa) caused delay as well. most important seems to be surgeon's experience. with increasing experience the average operation time and the proportion of long lasting operations decrease. conclusions. while patient's asa and bmi do not influence the tipp operation significantly, hernia type, recurrency, incarceration and scrotal hernia resp scared situs influence the operation clearly. in operation related factors surgeon's experience seems to be most important, intraoperative problems or complications result in an unexpected delay as well. in preoperative planning knowledge of recurrency (previous operation method), scrotal hernia or incarceration or scar-inducing anamnestic factors give hints to a prolonged hernioplasty. p biomechanical analysis of the ventral abdominal wall for incisional hernias c. hollinsky, c. yiwei, j. ott, s. sandberg, m. hermann background. for the therapy of ventral abdominal wall hernias, different reinforcement techniques with mesh are available. nevertheless the outcome of treatment for ventral abdominal wall hernias is currently unsatisfactory. biomechanical load flow calculations are introduced in this study. methods. we took peritoneum and abdominal wall muscles of recently deceased cadavers to determine the friction coefficient for mesh protheses. therefore we placed the mesh between peritoneum and muscles and loaded them with tension. furthermore we analyzed the different fixation elements for their load resisting capacity. results. the prostheses demonstrated a frictional coefficient of m ¼ . . the elasticity module e of polypropylene is ¼ n=cm . for laparoscopic techniques, leight meshes showed an unproportional high bending and sheared off at low loads. for the reinforcement elements, large differences between different tensile load capacities were detected. conclusions. the overlap of the protheses over the hernia orifice should be selected proportionally to the hernia size. light meshes are unfit for the laparoscopic techniques and should not be used for the therapy of ventral wall hernias. p the axillary access in unilateral thyroid resection k. witzel ; universitätsklinik für chirurgie, salzburg, austria; the new european surgical academy (nesa), berlin, germany background. with this study, we intended to find out if it is possible to avoid the typical scar after thyroid resection by using a mm axillary access and a . mm incision in the jugulum. methods. we present the results of our proof-of-concept study with patients. for this technique, a modified axilloscope and ultrasonic scissors were used, which permit a total resection of the unilateral thyroid. results. the feasibility of this endoscopic technique was shown by the successful operation of these patients with uni-lateral pathological findings. furthermore, we showed that this technique allows to resect tissue up to a whole lobe while at the same time finding and identifying the recurrent laryngeal nerve and subsequently verifying the findings by using the neuromonitoring system. conclusions. this study shows that endoscopic thyroid surgery approximates the norms of endocrine neck surgery. the presented method is useful in thyroid surgery for patients with single nodules and a small thyroid gland. background. ventral incisional hernias have a high incidence after laparotomy closure. laparoscopic hernia repair is a minimal invasive technique with less operative trauma. the aim was to assess the reccurence rate and morbidity after the laparoscopic repair. methods. data of all patients with laparoscopic incisional hernia repair operated in our department between december and november were recorded in a prospective data base. forty two patients (m:f ¼ : ) with a mean age of years ( - ) and a mean bmi of kg=m ( - ) were operated. results. conversion rate was % due to intraoperative lesions to small bowel during adhesiolysis. mean operation time was min ( - ). in patients the dual-mesh, in patients the bard composite ex mesh and in patients the parietex mesh was implanted. mean hospital stay was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the morbidity-rate was . % ( hematomas) . four patients complained about prolonged pain. in the long term follow up patient had to be reoperated due to mesh related complications. mean follow up time was months, patients presented with a recidive hernia. conclusions. laparoscopic ventral hernia repair can be performed with acceptable recurrence rate ( . %) and low morbidity ( . %) independent of the used mesh. p outcome of clip removal after endoscopic sympathetic block anecdotal reports are available on clinical outcomes after cr. the aim of the study was to investigate whether cr actually resulted in reversal of compensatory sweating (cs), and whether the initially obtained therapeutic effect on hyperhidrosis of the upper limbs (hh) and the face (fh) and facial blushing (fb) diminished with time. methods. between = and = a total of patients ( females, males) with a mean age of ae years underwent cr after esb. three patients underwent unilateral clip removal due to mild ptosis (one patient with esb , patients with esb ). twenty patients had their clips removed due to unbearable cs. levels of hh, fh, fb and cs were graded by a visual analogue scale ranging from (no sweating= blushing) to (most severe sweating=blushing). mean followup after cr was ae months obtainable from patients ( %). results. the patients who suffered from ptosis started to improve weeks after cr, complete relief was observed months thereafter. in each group with esb and esb , . % of patients underwent cr. only one patient after esb had to be reoperated ( . %, p < . compared to esb and esb ). four patients ( %) reported no change in cs after cr, in patients ( %) cs dissolved completely. overall, cs improved from . ae . to . ae . (p < . ). hh, fh and fb recurred to about % of the initial levels, patients ( %) reached preoperative levels. conclusions. clip removal because of unwanted side effects is more common in patients after esb and esb than after esb . cr results in partial reversibility of cs and causes partial recurrence of the initial complaints. although some patients do not benefit from cr, our study provides valid data that esb is a reversible technique. p acute reinterventions following laparoscopic transabdominal preperitoneal inguinal hernia repairs (tapp) b. walzel, p. patri, p. razek, a. tuchmann background. today the tapp method is a frequently used surgical procedure for treating inguinal hernia. although this type of operation has some advantages compared to open procedures, some complications typical for laparascopy might arise. we report about managing such complications as based on our experience. methods. between january and december tapp was applied in our hospital to (n ¼ ) patients. from among those patients (n ¼ ), ( m, aged - ) laparoscopy had to be repeated because of acute complications which occurred between the st and th postoperative day. three patients presented post op a bilateral tapp. reasons for interventions were: obstruction of the small intestine due to incarceration with a dehiscent peritoneal suture (n ¼ ), hematoma in the area of surgery applied (n ¼ ) and one hemorrhage caused by a trocar (n ¼ ). in three patients (n ¼ ) with a mechanical obstruction of the small intestine, repositioning by laparoscopy of the incarcerated ileus was carried out, followed by a peritoneal suture. in two cases with intraabdominal hemorrhage, the bleeding was stopped and the prolene nets were removed via laparoscopy. in only one of the cases replacement of the net was possible, in the other one the procedure was changed to open surgery for inguinal hernia because of an infected net. in one patient (n ¼ ) hemorrhage due to injury by trocar repair was possible by a simple suture. results. in out of cases the complication was successfully repaired by way of laparoscopy. in one case the shouldice repair was applied. in the other a paralysis of the ileus occurred post laparoscopy, requring a smoothing of the ileus by laparotomy. conclusions. among our patients severe complications following tapp needing surgical intervention occurred but rarely ( . %). frequently treatment by way of laparoscopy was successful. p clip displacement does not effect postoperative outcome after endoscopic sympathetic block p. t. panhofer , c. neumayer , s. nemec , r. jakesz , g. bischof , j. zacherl background. endoscopic thoracic sympathectomy is the treatment of choice for patients with severe primary hyperhidrosis (hh). recently, clip application (endoscopic sympathetic block, esb) has been introduced providing potential reversibility. the clips are visible on x-rays allowing postoperative evaluation. at our institution ganglion oriented procedures are performed taking rib levels into account. the aim of the study was to investigate if failures, recurrences and unwanted sideeffects (compensatory sweating, cs) can be explained by clip displacement. methods. between and , patients (mean age . ae . years) prospectively underwent esb procedures. esb was performed in patients ( . %) with facial blushing (fb), esb in patients ( . %) with facial sweating (fs) and esb in patients ( . %) with hh of the upper extremities following the lin-telaranta scheme. a mm titan clip was placed above and below the corresponding ganglion. two quality of life scores have been evaluated. mean follow up was . ae . months obtainable from patients ( . %). results. ninety-eight patients ( . %) had palmar, ( . %) axillary hh, ( . %) fs and patients ( . %) fb. cs was observed in ( . %) patients. a total of clips ( . %) were displaced in patients ( . %). two patients with fs ( . %) and with hh of the upper extremities ( . %) showed up with side differences regarding placement. in each group, one single patient was found with clips one level below the expected destination ( patients, . %). four patients ( . %) were completely and patients ( . %) partly satisfied after esb despite displaced clips. two patients have been lost to follow-up. moderate cs was observed in one patient ( . %) in each of the fb and fs groups. the patient from the latter group suffered from a mild transient ptosis additionally. two recurrences ( . %) were documented. methods. blood samples were collected from patients before major surgery. whole blood was incubated with escherichia coli lipopolysaccharide (lps) and il- production in supernatants was assessed by enzyme-linked immunosorbent assay. the prognostic impact of ability to synthesize il- before surgery was investigated in patient subgroups with respect to sepsis-related mortality using multivariate binary logistic regression analysis. results. il- synthesizing capability in patients who survived sepsis was significantly higher than that in patients who developed fatal sepsis (p ¼ . ). in multivariate analysis only il- was associated with a lethal outcome from postoperative sepsis (p ¼ . ). the prognostic impact of il- was evident in patients with underlying malignancy (p ¼ . ) and in those who had undergone neoadjuvant tumour treatment (p ¼ . ). when patients were analysed according to the type of neoadjuvant therapy, preoperative ability to synthesize il- had a significant prognostic impact in patients who had neoadjuvant radiochemotherapy (p ¼ . ), but not in those who had neoadjuvant chemotherapy. conclusions. il- production after stimulation of whole blood with lps appears to be useful for the preoperative assessment of risk of sepsis-related death after operation in patients who have undergone neoadjuvant radiochemotherapy. p lipocalin- , regulator or byproduct during ischemia and reperfusion? background. the main focus of this work was to analyze the possible implication of lipocalin- (lcn- ) upregulation for the course of ischemia=reperfusion (ir) during heart transplantation and effects on polymorphonuclear cells (pmn) as well as to investigate the nature of the lcn- producing cell. methods. male inbred c bl= and the lcn- À=À mouse were used in our transplantation experiments. pmn from wildtype and lcn- À=À mice as were isolated and promyeloid cell lines ( d) used to demonstrate the effect of lcn- on cell physiology. western blot, rt-pcr, immunohistochemistry and tunel assay were performed to determine lcn- expression and apoptosis in the graft. cell viability and migration assays after various stimuli (e.g. ir) were applied to elucidate cell growth and viability. results. infiltrating pmn were the major contributors to lcn- expression during ir peaking h after reperfusion. the number of infiltrating pmn was significantly reduced in lcn- À=À recipients. no difference was observed in the apoptotic rate between wildtype and lcn- À=À donors and lcn- expression also increased during acute graft rejection. migration of pmn during reperfusion was negatively influenced by the absence of lcn- or lack of lcn- specific cell surface receptors in the lcn- À=À mice. the promyeloid cell lines responded to ir with increased lcn- mrna and protein levels. conclusions. our data suggest a chemoattractant function of increased lcn- expression in the transplanted heart due to infiltrating pmn. lcn- is a novel inflammatory marker upregulated during ir and acute graft rejection. our observations shed light on a possible function of lcn- to the recruitment of pmn to the site of ir and identify possible targets for therapeutic intervention. p preliminary results of a tumour-lysate loaded dendritic cell vaccination therapy in patients with recurrent or metastatic skeletal malignancies p. t. background. vaccination with tumour-lysate loaded dendritic cells (dc) has shown to modulate potent immune response in several animal models and clinical trials. this study presents preliminary data of patients treated with dc-vaccination for recurrent or metastatic skeletal malignancies. methods. in patients suffering recurrent chondrosarcoma ( ), haemangio-endothelioma ( ), ewing's sarcoma ( ), osteosarcoma ( ), or osseous metastatic disease of renal cell carcinoma ( ) dc-vaccination was applied additional to standard therapy such as surgery and=or chemotherapy and=or radiation. dc precursor cells were obtained from peripheral blood mononuclear cells by apheresis and incubated with autologuous tumor cell lysate gained by surgery. in each patient vaccinations of  e cells ( ¼ . ml) were administered intranodally under sonographic guidance in weekly intervals. delayed type hypersensitivity (dth) controls and standard clinical and radiological follow-up was performed before and after treatment. results. no adverse or side effects were observed in any patient throughout treatment. dth reaction was negative in all patients after therapy. six patients died of disease, patients showed progressive state of disease in terms of local recurrence or pulmonary metastasis, revealed stable disease. helper as well as cytotoxic t-lymphocytes of patients showed in vitro reactivity in terms of cd expression against tumour antigens and against the tracer antigen klh by both cd and cd expression. one patient had no increase of cd and cd expression neither against tumour nor tracer antigen, one patient showed positive immunological reaction against klh but not tumour. conclusions. in all patients with recurrent or metastatic skeletal malignancies investigated in this study dc vaccine therapy was primarily administered at very late stage of disease. the best clinical results could be achieved in patients with metastases of renal cell carcinoma, who both revealed stable disease over more than months. all patients with metastatic disease of recurrent sarcoma showed poor clinical response to therapy, though some showed immunological reaction. the absence of adverse reactions and uncomplicated therapeutic regimen, however, together with monitored immunological responses suggest that the effects of dc-vaccination should be investigated in earlier stages of sarcoma to improve clinical outcome in these patients as well as in all stages of metastatic disease of renal cell carcinoma. p analysis of the risk factors helicobacter infection, overweight, sex, and age in gallstone disease and gallbladder carcinoma in germany background. helicobacter infection of the hepatobiliary system has been proposed as a novel risk factor in the pathogenesis of gallstone disease (gsd) and gallbladder carcinoma (gbc). because there seem to be differences in the incidences of helicobacter infection in various populations, we investigated whether helicobacter infection of the biliary tract is present in germany, a region with a high incidence of gsd, but with a low incidence of gbc. methods. gallbladder tissue from patients who had undergone cholecystectomy were investigated: patients with gsd, cases with gbc, and control patients. the presence of helicobacter spp. was investigated by culture, immunohistochemistry, and a group-specific pcr targeting the s rrna and detecting all currently known helicobacteraceae. results. of the cases investigated, only one patient with gsd was pcr-positive for helicobacteraceae. in this subject, sequence analysis of the s rrna showed closest homology to the s rrna sequence of h. ganmani. helicobacteraceae were not detected by culture or immunohistochemistry. there was a higher body mass index in patients with gsd compared to controls (p < . ). mean age of patients with gbc was significant higher than for gsd (p < . ) or control patients (p < . ), whereas there was no difference between gsd and controls. conclusions. these data suggest that helicobacteraceae play no predominant role in the pathogenesis of gsd and gbc in the german population. the low prevalence of helicobacteraceae in the gallbladder mucosa of german patients could be a possible explanation for the relatively low prevalence of gbc although gsd is frequent. background. apoptosis is implemented in colorectal cancer (crc) development and has emerged as a potential target for cancer treatment at various stages of tumor progression. measurement of the apoptosis (m )=necrosis (m ) ratio may have a role in therapy monitoring. to define the value of preoperative assessment of apoptosis and necrosis we measured these parameters in the sera of crc patients and correlated these values with conventional clinical parameters. methods. we used an enzyme linked immunosorbent assay (elisa) to detect an apoptotic product and necrosis (m and m -antigen) in the sera of patients with crc; uicc i: n: ; uicc ii: n: , uicc iii: n: ; uicc iv: n: ; relapse: n: and healthy controls. results. patients with colorectal cancer showed significant higher m antigen levels than healthy controls (p < . ). when stratified to tumor stages the different preoperative m antigen expressions between healthy controls and tumor patients remained throughout all stages. detailed results are depicted in the following table: m results and the clinical applicability of the m =m ratio are under investigation and will be presented at the meeting. conclusions. levels of circulating m -antigen are increased in patients with colorectal cancer. clinical follow up studies will reveal the usefulness of a ratio value of apoptosis and necrosis. methods. expression of fgf in tumor tissue was determined from tissue specimen obtained from patients with colorectal carcinoma by rt-pcr relative to gapdh. furthermore immunostaining in carcinoma, adenoma, normal mucosa and liver metastases was performed. the biological function of the growth factor was analysed using cell lines expressing high (sw ) or low fgf (caco , lt , vaco ) as a model. low expressors received exogenous fgf while expression in sw cells was knocked down by sirna. the effects on tumor cell growth was determined by mtt and colony formation assays. signaling events were investigated by western blotting. in addition paracrine effects on fibroblasts and endothelial (huvec) cells were investigated using scratch assay for migration and tube formation for blood vessel formation. results. addition of the growth factor to the culture medium of slowly growing colorectal tumor cell lines lt , vaco and caco stimulated growth within hours. the stimulatory effect involved increased phosphorylation of erk = - minutes after factor addition and increased phosphorylation of s - minutes after fgf addition. sw cells that produce large amounts of autocrine fgf were not affected within this time frame, but fgf supported tumor cell survival under conditions of serum starvation. in addition down-modulation of fgf production by sirna significantly reduced colony formation after plating at low density in sw cells and restored sensitivity to exogenous fgf . secreted fgf also affected colonic fibroblasts inducing growth and migration and stimulated huvec cells to differentiate. conclusions. fgf is upregulated during tumor progression in the majority of the investigated patients. we showed that fgf can induce both autocrine and paracrine effects on the epithelial as well as the stromal compartment of colorectal tumor cells to further tumor growth, spread and neovascularization. this makes fgf an oncogene. further studies should prove the clinical relevance of fgf as a prognostic marker and as a potential target in antitumor therapy. p immunohistochemical peculiarities of gastric carcinomas in patients younger than years c. w. schildberg , a. dimmler , s. merkel , t. littwin , w. hohenberger , t. horbach background. young patients ( < years) comprise - % of all gastric carcinomas. therefore, immunohistochemical peculiarities were analyzed in our facility. methods. the examined group had patients. the median age of the group was years ( - years), the ratio male= female was . = . tumor tissue, which was embedded in paraffin, was initially marked, so that it could be further examined using the tissue array technique and consequently immunohistochemically stained. following this, the following markers were analyzed: cox , egfr, e-cadherin, p , tff and cdx . after semi-quantitative representation, a link to data of the tumor register was performed. results. in the younger patients, the diffuse type (laurén-classification) was overwhelmingly represented with %. early tumor stages (i and ii) were distributed similarly with % as advanced stage carcinomas with %. the -year survival rate was %. notable was that stage iiia had a distinctly better -year survival rate with % than those patients with stage ii ( %). in our evaluation of the immunohistochemical stains, it showed that younger patients with the diffuse type showed significantly more down-regulation of cox . this is particularly noticeable when one compares tumor stages ii and iiia ( vs. %). with tff , there was a notable over-expression shown (p > . ) in stage ii and iiia ( vs. %). cdx and e-cadherin were significantly more frequently extracted for the diffuse type. conclusions. it is known that younger patients with worse histological results (diffuse vs. intestinal = %) display a better -year survival rate. in particular, there seems to be a difference between stages ii and iiia. this could be contributed to and explained by a down-regulation or an over-expression of cox or tff . p toxic responses and side effects using various antineoplastic drugs in an experimental setting of peritoneal carcinomatosis in rats a. hribaschek , k. ridwelski , f. meyer , d. kuester , w. halangk , h. lippert background. during the last decade, intraperitoneal (i.p.) chemotherapy against peritoneal tumor spread originating from gi-cancers has been increasingly used. the aim of this systematic comparative study was to investigate various toxic responses=side effects of various cytostatic substances, which had been primarily tested for their efficacy to prevent=treat experimentally induced peritoneal carcinomatosis in rats. methods. using a basic experimental trial, established= novel antineoplastic drugs such as mitomycin ( mg=m ), cisplatin ( mg=m ), -fu ( mg=m ), oxaliplatin ( mg=m ) and cpt- ( mg=m ) (limited dosage adapted according to their ld ) were applied i.p. to prevent=treat peritoneal carcinomatosis induced in rats by transfer of , , tumor cells (colon adenocarcinoma cell line cc- ; cell-lines service, heidelberg, germany) via laparotomy (groups of animals per drug; control groups [sham operation ae tumor cells]). animals were sacrificed under general anesthesia on the th postoperative day and autopsied. toxic responses=side effects were characterized by occurrence of i) necrosis assessed as ''þ'' vs. ''À'' (equal to yes=no) at the peritoneal surface, ii) hepatic necrosis, iii) bleeding at the mesenteric tissue, and iv) death. the cytostatic effects were used as control for the therapeutic efficacy of the agents indicated by tumor weight and '' ae '' detectable tumor growth, which were correlated with the nonfavorable adverse phenomenons. results. (table ) : mitomycin and cisplatin were the most toxic substances (e.g., peritoneal necrosis in and animals out of , respectively) comparing the chemotherapeutic drugs but, however, this correlated with the most pronounced cytostatic effect (no detectable tumor growth). though the use of oxaliplatin showed also a high rate of necrosis (n ¼ = ) and death (n ¼ = ), its therapeutic potential was only low (tumor detectable in each animal). it was not surprising that the occurrence of necroses at the peritoneal surface was the most sensitive characteristic of toxic responses=side effects. in addition, the induction of a treatment-related bleeding was associated with earlier death prior to the th day after tumor cell transfer, the end of the experimental observation period, in the majority of cases. interestingly, cpt- provided the best compromise in decreasing i.p. tumor growth on one hand and an acceptable rate of side effects on the other hand. conclusions. the results suggest that, despite some favorable effects of novel=established cytostatic drugs in i.p. chemotherapy, toxic responses=side effects need to be simultaneously tested even in earlier stages of drug development as well as experimental=clinical studies for an appropriate dose escalation=adaptation. further studies should also focus on other parameters=study characteristics, e.g., i) combination of drugs, ii) various application time=mode (e.g., i.p.=i.v.), and iii) effects on wound=anastomosis healing as well as iv) induction of peritonitis. p retrograde reperfusion via inferior vena cava reduces ischemia= = =reperfusion injury after orthotopic liver transplantation in a rat model methods. in a pilotstudy patients with a significant internal carotid stenosis will be investigated prae-and postoperatively for visual field changes. results. at the time of the congress we will present the study design in detail and early results. conclusions. in case of no changes perioperatively, the study will be closed. in case of perioperative changes a larger prospective trial with additional neurological assessment will follow. p occlusion of the common femoral artery after misplacement of an angio-seal tm vascular closure device t. ott, p. konstantiniuk, t. cohnert background. femoral closure systems are becoming increasingly popular. they promise to shorten both the time to hemostasis and to mobilization. the most frequently used systems are angio-seal(tm), perclose + and vasoseal + . case report. a -year-old male patient underwent successful percutaneous transluminal coronary angioplasty, stenting and hemostasis with angio-seal tm , which, however, was followed by acute deterioration of pre-existing stage iib peripheral arterial occlusive disease (paod) with incomplete ischemia of the right lower extremity and development of a dry necrosis of the right great toe. magnetic resonance angiography showed occlusion of both superficial femoral arteries (afs) and of the right common femoral artery (afc). intraoperatively, the right afc was found was found to be completely occluded by a collagen plug from the angio-seal(tm), which was removed without difficulty. the symptoms improved significantly after the operation. due to the patient's critical cardiac situation, no further reconstructive measures were undertaken. conclusions. the literature indicates that femoral closure systems have led to complications in the form of vascular stenoses or occlusions that are unknown with conventional compression. these systems may be contraindicated in patients with known paod. background. ablation of the vein by endovenous laser treatment (evlt) is a new procedure that is less invasive than surgery and has a lower complication rate. evlt works by means of thermal destruction of venous tissues. methods. we retrospectively analysed the results of the endoluminal laser-treatment, which we applied at patients in a time frame of years ( - ) . we compared them with the effect of the traditional surgical approach ligation and division of the saphenous trunk and all proximal tributaries followed by the stripping of the vena saphena magna. results. there was no significant difference in the rezidiverate between endoluminal laser technique and the traditional stripping of the vena saphena magna. the biggest problem of the laser technique appeared to be a lower sensibility in the range of the inner ankle during a year ( %). in % of the cases the vena saphena magna was rechannelled. and also % reported about a still noticeable cord for a year. ninety six percentages demonstrated remarkable improvement. conclusions. the evlt-procedure is simple and effective. it takes less than an hour and get patients back to their everyday activities right away. with a high success rate and minimal side effects evlt is a new standard in varicose vein treatment. although we know that saphenofemoral recurrence occurs even after correct saphenofemoral ligation, it does not imply that this ligation has become obsolete. background. this study presents long-and short-term results after surgery of currently active, chronic venous leg ulcers, focusing on the effects of ulcer healing, recurrence and concomitant risk factors. methods. between january and march , patients ( legs) with a currently active, chronic venous leg ulcer were surgically treated, based on the two main steps of functional phlebologic surgery: the surgical interruption of reflux in the superficial and perforating veins to reduce venous hypertension in the entire leg and=or the affected area and occasionally, the surgical procedure involving the ulcer. a total of patients ( legs) who came to the follow-up were examined. the data collection included a preoperative examination incorporating medical history and clinical diagnoses and various measurements at the follow-up. results. initial ulcer healing occurred in % of the cases ( legs), % ( legs) of the venous ulcers never healed, and recurrent venous ulcers occurred in % ( legs). conclusions. we conclude that surgery is indicated before an ulcer is intractable to treatment. based on the understanding and identification of the causes and symptoms of venous ulceration we recommend standard surgical methods for the therapy of venous leg ulcers at any stage. background. popliteal artery aneurysm (paa) is a rare condition with an incidence of approximately % in men ( - years). it involves the risk of peripheral embolism or progressive thrombosis that may result in acute or chronic ischemia with claudication or loss of the extremity. distal vessels are increas-ingly embolized through a persistent dispersion of mural thrombi, and the possibilities for surgical vascular reconstruction are limited by the absence of open outflow vessels. case report. a -year-old male patient with an acute ischemic left leg was referred for emergency treatment. he presented with a -year history of intermittent claudication in his right leg. no signals were detected by duplex screening above the foot arteries of the left leg, and typical symptoms of acute occlusion were present. imaging tests revealed a paa on each side (diameter left cm; right . cm). the left paa was completely occluded, the right paa was partially open but the distal popliteal artery and the the posterior tibial artery were already completely occluded. a vascular bypass reconstruction to improve circulation was not possible due to occlusion of the outflow vessels. the patient was treated conservatively (systemic heparinization, i.v. prostacyclin administration). circulation in the left leg gradually improved, with remaining claudication, a free walking distance of m, and rest pain. amputation was prevented for the time being. conclusions. elective surgery for asymptomatic paa > cm is recommended to prevent permanent limited mobility or amputation. the procedure of choice is to ligate the aneurysm and to restore blood flow by a concurrent interposition of a vein segment, from the superficial femoral artery to the open infragenual popliteal artery. the male risk population ( þ) should undergo duplex screening of the popliteal artery. while asymptomatic aneurysms > cm should be treated surgically, smaller ones should be observed, since aneurysms < cm in diameter have a distinctly lower occlusion and amputation rate. in symptomatic cases a revascularisation with venous bypass should be attempted, if there are open outflow vessels to connect the venous graft to. if a vascular bypass reconstruction is not promising a conservativ treatment may prevent amputation. background. three dimensional motion analysis is a new evaluation method of upper extremity function. this video based system provides accurate and reproducible d kinematic data by tracking movements. the method is derived from clinical gait analysis which has already reached global acceptance within this field. it should overcome the deficiencies of subjective investigations. in order to demonstrate the use of the system the analysis of patients with brachial plexus lesions before and after surgical treatment is presented. methods. a d optoelectronic camera system with passive markers was used to capture the possible active rom. twenty seven markers coated with retroreflective tape were applied over anatomical landmarks on both upper limbs and recorded simultaneous by cameras. a -dimensional reconstruction of the position of the markers was done by special designed software. joint centres and joint movements were calculated by using the expert vision and orthotrak software (motion analysis corporation). healthy probands and patients suffering from brachial plexus lesions and receiving primary nerve surgery or secondary reconstructive procedures were investigated. results. the motion curves of all, probands and patients with different questions argue for a reproducible motion sequence. we were able to produce and analyse static data, rom and position of segments as well as kinematic data, especially motion curves of distinct movements. moreover compensatory movements could be investigated. obtained pre-and postoperative kinematic data document the enhancement of the involved limbs' function. conclusions. the method enabled objective analysis of patients suffering from brachial plexus lesions. measured angles are reliable and reproducible but generally lower than angles obtained from physical measurements. this is due to several reasons concerning the biomechanical model. because of the more complex nature of upper limb kinematics the transfer of the system from lower to upper extremity still involves unsolved problems. p thoracic outlet syndrome: objective criteria to indicate surgery g. weigel, b. gradl, m. mickel, w. girsch background. reviewing the literature the indication for thoracic outlet syndrome (tos) -surgery is based on clinical findings only in the majority of the cases due to lack of objective findings. in a retrospective study we have analyzed our cases in order to evaluate objective criteria for surgical intervention. methods. seventeen patients ( men, women aging from to ) were diagnosed clinically times for tos (duration of symptoms months, nrs ). additionally objective investigations were performed: x-ray of the cervical spine to detect a cervical rib; a comprehensive electroneurographic investigation to detect signs of nerve compression; mr-angiography of the subclavian artery with elevated and adducted upper extremity to detect a stenosis of the artery as an indirect sign of compression of the brachial plexus. results. concerning the objective assessment a cervical rib was present in % of our cases. the electroneurographic investigation revealed signs of nerve compression in % of our cases. in nearly % of our cases a stenosis of the subclavian artery confirmed the clinical diagnosis. all patients underwent tos-surgery via a small single supraclavicular incision and recovered from their symptoms. conclusions. in our series we did base the indication for tos surgery not only on clinical examination but also on objective findings, either the presence of a cervical rib and=or positive electroneurographic findings and=or a stenosis of the subclavian artery. the mr-angiography was the most significant investigation to objectify the clinical findings. the presented investigation setup seems to be appropriate to objectively diag-nose tos and indicate surgery. the small supraclavicular incision gave adequate access to perform neurolysis of the brachial plexus, scalenotomy and resection of cervical or first rib without major complications in all cases. background. the necessity of antibiotic prophylaxis in the clinic of child surgery is caused by following: -increase invasive method of investigation; -increase cases of postoperative supurative complication; -high economic expenses; -spreading of polyresistent microorganism. methods. the clinic retrospective investigation of the patients, who were treated in the surgical department of lviv regional children's hospital ''ohmatdyt'' from till yr. the antibiotic prophylaxis was performed in surgical operation of ii category (conventional purity) and iii category (contaminational) of purity, which are accompanied by middle or high individual risk of the development of pyo-septic complications. eighty two of the patients took combined medications of clavulane acid with amoxicillin (augmentin, amoxuclav in dose mg per kg, the others patient took cephalosporinus of i-ii generastion (cephazolinum, cephuroximus in dose mg per kg) conclusions. effective abp allows to reduce the amount of the postoperative complications ( group- %, group- %), postoperative fever ( group- . %, group- . %), duration of the hospital treatment in the group- . days, in the group- . days), and treatment expenses. optimal drugs of choice for abp in the clinic of pediatric surgery are combined preparations of clavulane acid with amoxicillin. the goal of this study was to improve the results of management children with bat. one hundred twenty-eight children with the age ranged from weeks to years were enrolled in this study. among these patients the splenic injury was established in ( . %), liver injury -in ( . %), intraperitoneal hematoma -in ( . %), and retroperitoneal hematoma -in ( . %) of patients. according to the moor's classification grade i of the liver damage was established in patients, grade ii -in , grade iii -in , and grade iv -in one patient. according to the classification of american association of trauma surgery the grade i of splenic injury was diagnosed in patients, grade iiin , grade iii -in , grade iv -in , and grade v -in patients. laparoscopic drainage of abdominal cavity was performed in patients with active bleeding, which stopped by the surgicel + (ethicon) and electrocoagulation, from the hematoma of mesocolon and mesojejunum and in patients with grade i liver and splenic injury. the laparoscopic coagulation with applying of surgicel was performed in all patients with grade ii liver and splenic damage and in patients with grade iii. laparotomy was performed in patients with grade iii and in all patients with grade iv-v. resection of the spleen was applied in patients with grade iii and in two patients with grade iv. for the bleeding control, the surgicel nu-knit + (ethicon) was used in one patient with the grade iv of splenic damage. splenectomy was performed in patients with the grade v. parenchymal suture was used in patients with the grade iii of the liver damage and non-anatomical resection -in one patient with grade iv. retroperitoneal endoscopy with coagulation was performed in all patients with retroperitoneal hematoma. one child died with the grade iv of the liver damage. thus, the endoscopic coagulation with applying of surgicel + is effective in the management of patients with bat. the choice of management dependent of the grade of damage. we used malone antegrade continence enemas (mace), administered through a continent cutaneous appendicostomy or a caecal flap to achieve reliable evacuation and faecal continence in seven children with myelomeningocele and after surgery of anorectal malformation. postoperative complications included one subcutaneous pericaeceal abscess requiring exploration and in one case stenosis of the stoma. except well known and already described complications all seven patients are continent of stool at a mean of months follow-up. despite our efforts to develop an effective bowel management program regarding application of the enema regimen this procedure provided some technical problems especially for children who have had prior appendectomy. so we developed a new simple technique to perform a caecal tube stoma. we also want to demonstrate a new device to simplify handling and application of enemas. the basic idea of a simple method of bowel cleansing like mace is followed by significant improvement in quality of life and more social acceptance of patients. but overall success will be achieved by improvement of technical procedure and handling. extended caecum. the appendix could not be detected. a surgical intervention was decided with the intention for an appendectomy. at the operative sight a caecum duplex was revealed. the lumen of the blind caecum was completely filled by a large fecolith. also the appendix vemiformis was inflammated. caecal duplex resection and an appendectomy was performed. the pathology report described ulcerations and segmental ischemia of the resected caecum. an oxyuriasis of the vermiform appendix was also reported. there was no immediate or delayed post-operative complication. conclusions. approximately % of duplications have been reported to be located within the abdominal cavity. small bowel lesions are the most commonly described ( %), while colonic lesions are found in % of cases. a review of the literature has revealed cases of colonic duplications, that occurs mostly in pediatric patients. surgical intervention is indicated in case of complicated colonic duplications such as obstruction of the colon as a result of direct compression, volvulus, hemorrhage, ulcerations, ischemia or perforation. in most instances duplications can be completely excised as described in our case. special care should be taken of the possible abnormal blood supply to the adjacent intestinal segment. background. reports on complications are part of every medical scientific investigation. regarding the definition of a surgical or post-interventional complication there are different views. this is one reason for the variation width in complication reporting concerning the same interventions in the surgical literature. the following work presents the advantages of a prospectively standardised documentation of complications in a surgical department as a part of a hospital quality management. methods. over a period of one year in patients data sheets about post surgical complications were collected and entered in a electronically data base. all abdominal procedures, including the abdominal wall and additionally varices surgeries were enclosed in the following evaluation. patients were excluded from the investigation when treated in the surgical ambulatory or treated as day-surgical patients. the complication system according to clavien was used to classify the complication grades. this system encloses five grades, lower grading indicating lower level of complication whereas grade three is divided in subclasses a and b (dindo et al. ( ) ann surg : - ) . for statistical analysis the mann-whitney u-test and spearman correlation were used (p < . ). results. out of operations there were ( . %) operations according to our inclusion criteria with patient's average age of . ae . years ( . % male patients). the overall complication rate according to clavien averaged . % (differences between different surgical methods and surgeons are given in a table). referring to general used grading the mean complication rate ranged between . and . %. conclusions. using the system of clavien complication rates appear higher than usual. this is caused by the fact that all post surgical events apart from normal stay slip into the system. the system allows a good comparability between single surgeons and between different operations. results from prospectively entered data evaluation can be used to detect weak points in a team, and to find out technical as well as personal problems. as a consequence, for instance education programs could be provided to compensate weaknesses or the team could be restructured. periodical evaluation of a standardized data bank allows fast reactions to occurring problems and guaranties an adequate surgical complication management. lymphatic vessel invasion (lvi) has been rtx=ctx þ esophagectomy). ( -ac): n ¼ : n ¼ (esophagectomy) vs. n ¼ (ctx þ esophagectomy). results. ( -escc): rtx=ctx led to a lvi-reduction detectable lvirate: ( -escc): rtx=ctx led to significant lower lvi-rates compared to primary resected patients tyrolean cancer research institute, innsbruck, austria; department of pathology germany p the role of fgf in colorectal carcinogenesis institut für krebsforschung p , p , p sachsenplatz - , wien, Ö sterreich. -datenkonvertierung und umbruch: manz crossmedia druckerei ferdinand berger & söhne gesellschaft m. b. h., horn, Ö sterreich. -verlagsort: wien. -herstellungsort: horn. printed in austria p. b. b.= = =erscheinungsort: wien= = =verlagspostamt wien background. survival of patients with lung cancer is strongly affected by lymph node metastases. identification of n disease is thus crucial. we compared the diagnostic accuracy of image fusion of positron-emission tomography (pet) and computed tomography (ct) with that of ct only and that of pet only for mediastinal lymph node staging in patients with non-small-cell lung cancer (nsclc).methods. in patients with proven nsclc a preoperative fdg-pet and ct examination of the body trunk were performed. pet, ct and pet-ct image fusion were evaluated separately; nodal stations were identified according to the mapping system of the american thoracic society. a lymph node was considered to be infiltrated by tumor if the minimal diameter was cm or more in ct, or the standard uptake value (suv) was larger than . in pet. all patients underwent mediastinoscopy, biopsies from lymph node regions were taken (ats . %, ats . %, and ats . %). if primary pulmonary resection was achieved, ipsilateral lymph nodes were dissected and the histological findings were considered for statistical analysis. histological findings were compared with results of ct, pet and pet-ct image fusion. sensitivity and specificity were obtained using the confusion matrix.results. histopathological assessment revealed positive mediastinal lymph nodes out of , sensitivity was . % for ct, . % for pet and . % for image fusion, specificity was . % for ct, . % for pet and . % for pet-ct fusion.conclusions. pet-ct image fusion improves sensitivity, specificity and accuracy in mediastinal staging of nsclc patients. the high negative predictive value of pet-ct image fusion ( . ) may abandon mediastinoscopy in nsclc patients with negative mediastinal pet-ct image fusion. however, larger series are mandatory in order to gain statistical significant power. local resection of stage i primary lung cancer by -nm nd-yag laser in functionally inoperable candidates: a prospective study s. b. watzka , w. grossmann , p. n. wurnig , f. lax , m. r. mü ller , p. h. hollaus background. hydatid disease is a parasitic infestation by a tapeworm of the genus echinococcus. it is not endemic background. in a pathway regarding the management of liver trauma was established in our hospital. the aim of the study was to assess the outcome after implementation of the guidelines.methods. data on all patients with liver injuries managed in our institution in the past years was evaluated. liver trauma was classified using moore's trauma score. additionally, coexisting injuries were assessed.results. from to a total of patients with liver trauma (motor vehicle accidents , falls , horse riding accidents ) were admitted to our trauma unit (median age of . years). grade iii traumas ( . %) were the most common injuries, followed by grade iv ( . %), grade i ( . %), grade ii ( . %), grade v ( . %) and grade vi ( . %). the laparotomy rate varied from . % in grade i injuries to % in grade v injuries, resulting in an overall laparotomy rate of . %. two patients required second look laparotomy for removal of liver packing and one patient required puncture of a posttraumatic bilioma. the most common associated concomitant injuries were right or bilateral rib fractures ( ), pelvic fractures ( ), long bone fractures ( ), laceration of the spleen, spine injuries ( ), and head injuries ( ). the mortality rate of patients with liver trauma ranged from % in grade iv injuries to % in grade i injuries with an overall mortality rate of % ( ). all patients with grade v or grade vi traumas survived ( ). if laparotomy was required because of hemodynamic instability or concomitant abdominal injury the mortality rate increased to %.conclusions. the clinical pathway of management of hepatic trauma in our patients showed favourable results. apart from the grade of liver injury the overall laparatomy rates and mortality rates largely depend on concomitant injuries. colitis cystica profunda is a rare benign disorder of the large intestine characterized by submucosal cyst formation. the clinical appearance of the disease can be highly variable; it can be associated with rectal prolapse and chronic inflammatory bowel disorders such as crohn's disease and ulcerative colitis.we describe a case of colitis cystica profunda associated with rectal prolapse. the female patient had a one-year history of constipation and rectal pain. an altemeier procedure was performed to correct the rectal prolapse. histology confirmed the presence of colitis cystica profunda. the operative and postoperative course was uneventful.it should be borne in mind that colitis cystica profunda can be associated with rectal prolapse. conservative management is usually satisfactory, but a mucosal resection (delorme's procedure) or perineal protectomy (altemeier procedure) is recommended when there is rectal prolapse.p peritonitis ossificans -a rare situation after acute major abdominal surgery m. ruzicka , s. thalhammer , s. stättner , m. mostegel , b. sobhian , j. karner background. treatment of the congenital intestinal obstruction of newborns is one of the main problems of the pediatric surgery.methods. patient p. had been hospitalized to the intensive care unit days after birth with symptoms of absence of stool from birth, frequent vomiting, full-blown abdominal distension. the signs of endotoxicosis, the intestinal loops posterized image through the anterior peritoneal wall, dilatation of the venae anterior peritoneal wall, abdomen lower sections and scrotum edema were noted at the time of admission. x-ray of the abdominal cavity reveals the signs of the low intestinal obstruction, bowel perforation -presence of liquid and free air at the abdominal cavity. diagnosed -the intestinal obstruction, peritonitis and after a short-term of the preoperative preparation patient underwent surgery. atresia of the sigmoid colon, necrotic enterocolitis with the affection of the = of the large bowel, perforation of rising section of the large intestine, the meconium peritonitis were established during surgery. the right side hemicolectome, terminal ileostomy and transverse colostomy. the reoperation at the month was done: ileotransversostomy, descendosigmostomy with the preserving of transverse colostomy were performed. the diameter of the descending large bowel exceeded the diameter of the sigmoid colon by - . times, that's why the anastomosis had been raised by the type ''side to side''.results. within the course of weeks after the radical surgery the child started to have stool passage through the rectum. presently the child's condition is satisfactory, the physical development corresponds to the age norms, stool passage takes place only through the rectum. the final stage of the treatment will be the closure of the transverse colostomy with the complete restoring of the passage of the chyme through the bowels.conclusions. the bringing of the intestinal stomas out with the delayed radical surgery in some case of newborns may significantly improve the prognosis of the results of treatment. background. different inguinal hernia operationtechniques must be compared to their recurrency rate, acute and long term complication rate, patients comfort and duration before returning to daily life, return to work and to sports etc. under economical aspects they should be safe, quick, and require limited resources (personal, equipment, implantate). with increasing economical pressure the latter features gain increasing importance. we therefore made a comparative time analysis between tipp and lichtenstein.methods. between . . and . . hernias were operated in tipp technique and hernias in lichtenstein (lich) technique. patients were from an identical district and comparable in epidemiological data, comorbidity, hernia distribution and in-resp outdoor treatment. each series was performed by surgeon in the same operation unit. implantates used were polysoft hernia patch tm (tipp) and ultrapro mesh tm (lich). total operation time was recorded (min). additionally, operation phases were defined:opening phase: from skin split to preparation phase: from opening of the external aponeurosis to introduction of the mesh repair phase: from introduction of the mesh to the end of the suture of the external aponeurosis closing phase: end of repair phase to skin closure.assuming individual differences between the surgeons and management-associated differences as well as intermethodical differences relative phase intervals were deduced from the original recordings and compared. statistical comparison was done by t-test and pearson correlation coefficient.results. average operation time of lich was ae . min (range - min, median min), average operation time of tipp . ae . min (range - min, median min). up to now there was = recurrent hernia in tipp and = in lich (n.s.). the correlation of preparation phase time and operation time was high (pearson coefficient: tipp . ; lich . ) and lower for repair phase (tipp . ; lich . ). there was no difference in the correlation of the preparation phases in tipp and lich (p < . ). on this basis we estimated the expected time of the compared method to each series, i.e. presumable time for lich in tipp series and vice versa. comparison of lich vs. tipp (expected) and lich (expected) vs. tipp revealed that tipp was faster and required . % time of lich (p < . ).conclusions. tipp and lich show a comparable time effort towards preparation, tipp is significant faster in repair phase enabling a quicker total operation time.p transinguinal preperitoneal hernioplasty (tipp) using a memory ring armed polypropylene patch: which factors influence the operation?quality of life improved significantly in all patients with clip displacement.conclusions. esb has a displacement rate of less than % and gives excellent results for quality of life, which are not diminished by inappropriate clip application. grundlagen. post anal repair ist eine methode zur verbesserung der kontinenzfunktion bei diffuser schädigung des schließmuskels. die methode wurde in den letzten jahren kontrovers diskutiert. langzeitergebnisse wurden nur sporadisch publiziert. methodik. die operation wurde in der technik von parks [i] in steinschnittlage und allgemein-, oder spinalanästhesie durchgeführt. eine präoperative darmreinigung und eine perioperative antibiotikaprophylaxe wurden routinemäßig durchgeführt. prä-, und postoperativ wurde eine sphinktermanometrie in der durchzugstechnik mit einem perfundierten dreilumigen katheter vorgenommen. die auswertung erfolgte mit einem programm der firma gastrosoft. bei der klinischen untersuchung wurde der kontinenz-score nach williams verwendet.ergebnisse background. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in only cases. we report a -year-old woman with a perforated duodenal ulcer, who underwent laparoscopic roux-en-y gastric bypass surgery for morbid obesity months ago.methods. on physical examination, the patient's abdomen was marginally tender to palpation. laboratory findings were unremarkable except for an elevated leucocyte count of . =ml (normal . - . =ml). abdominal radiography and sonography showed no pathology. because of the persistent abdominal pain we performed an abdominal computed tomography scan, which demonstrated free air.results. she was successfully treated by a laparoscopic repair of the perforated duodenal ulcer. after surgery, a standardized analgesic regimen was administered for pain relief. intravenous piperacillin-tazobactam was continued for at least days, then a helicobacter eradication therapy was performed. feeding was resumed on the first postoperative day and the patient was discharched on day six without any complications.conclusions. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in cases. the pathogenesis of ulcer perforations in the excluded sto-mach=duodenum is unclear. of the total cases, free air in the abdominal radiography was only noted in one case. recognizing that free air under the diaphragm will be absent is one of the most important diagnostic considerations when gastric or duodenal ulcer perforation is suspected in the postgastric bypass patient. abdominal ct scan and early surgical exploration remain the treatment of choice.chirurgische forschung p blood interleukin as preoperative predictor of fatal postoperative sepsis after neoadjuvant radiochemotherapy background. a serious impediment in transplantation medicine especially after liver-transplantation is the damage by ischemia and reperfusion. we compared different types of reperfusion within a rat model and investigated the different consecutive ischemia=reperfusion injuries.methods. arterialized orthotopic liver transplantation (olt) was performed in syngenic male lewis rats. the animals were divided into experimental groups: i-and ii-control groups with antegrade reperfusion and group iii with retrograde reperfusion. laboratory parameters as well as histopathological changes of the liver-graft-tissue were evaluated , and hours after olt.results. the got-values showed hours after olt significant differences between group i=ii (antegrade reperfusion) and group iii (retrograde reperfusion) ( . ae . u=l vs. . ae . u=l; p < . ). gpt-as well as got-values were significantly lower in group iii (retrograde reperfusion) hours after olt. evaluation by histopathology revealed significant less areas of necrotic liver tissue within group iii compared to group i=ii (p < . ).conclusions. these results show that the retrograde reperfusion (by order of: infrahepatic inferior vena cava -opening suprahepatic inferior vena cava -hepatic veins -retrograde reperfusion of the liver) has a protective effect on the graft in regard to the ischemia=reperfusion injury. background. clamping of internal carotid artery during carotid endarterectomy (cea) leads to cerebral ischemia in - % of patients. routine carotid shunting has a high morbidity as described in literature. selective carotid shunting under general anaesthesia requires an intraoperative monitoring. the registration of somatosensory evoked potentials (sep) is a well accepted technique.methods. from to we assessed prospectively consecutive cea under general anaesthesia and sep monitoring, without primary shunting. routinely preoperative neurological assessment, duplex sonography and mr-angiography were performed. the onset of a clinical neurological deficit after carotid artery clamping was related to changes in the n =p waveforms in sep-recording. sep was evoked by stimulating median nerve. criteria for shunting was reduction in sep-amplitude > %. routinely postoperative neurological examination and duplex sonography were performed.results. patients underwent cea between and . intraoperativ sep-monitoring was available in patients. in patients ( . %) sep-monitoring was inadequate (primary shunting). in procedures ( . %) sep-monitoring didn't show deviations. significant sep-alterations appeared in of cases ( . %). in cases sep-alterations normalised after shunting without neurological deficits. in cases sep-alterations were reversible after shunting, but were associated with postoperative neurological deficits ( permanent, transient). cases ( . %) had normal sep-findings (false negative), but postoperative neurological deficit occurred ( permanent, transient).conclusions. the selective use of carotid shunting during cea requires an intraoperative monitoring technique. based on our data and literature findings, sep-monitoring is a reliable method to prevent neurological vascular deficits and effectively minimizes shunting frequency.p perioperative changes in internal carotid endarterectomy p. konstantiniuk , t. ott , u. gratzer , i. steinbrugger , a. wedrich , t. cohnert p poland syndrome with partial heart ectopia and dextrocardia r. kovalsky , a. kuzyk , o. leniv , i. avramenko lviv regional children hospital, lviv, ukraine; lviv national medical university, lviv, ukraine; lviv regional children hospital ohmatdyt, lviv, ukrainebackground. poland syndrome is seen in = of the newborns. it can declare itself by its different components and joining of the additional defects in every concrete patient.methods. a girl, born by the cesarean section, with the weight of g and week gestational age was brought to the pediatric surgery clinic on the . . in a couple of hours after birth. when examined the skewness and chest distortion attracted attention, especially on the right side. the oval form defect of the chest wall  cm was seen in the anterior of the chest parasternal on the right in the ii rib level from the costal margin, an also thinning of body of sternum. a part of liver with the size of  . cm covered with peritoneum was projecting form the lower part of the latter. a gastric part of the heart, covered with pericardium and non-epithelized membrane with the upper part directed to the right was projecting over it from the defect. there were no signs of heart and respiratory failure. during the echocardiography the following was discovered: heart rotation in the chest, right ventricular and atrial hypertrophy, good running of the great vessels, not violated valve function and good myocardial contractility. ejection fraction from the left ventricle %. during the intraoperative inspection the diaphragm defect in the right place parasternal triangle with the size of  cm through which the part of liver prolapses. the hepatic lobectomy was done as well as diaphragma defect repair.results. in eight months the plastic operation was done on the defect through the replacement of the front edge of the costal arch and musculocutaneous flap, formed from the greater pectoral muscle. the child was discharged from the hospital in a good shape.plastische, Ä sthetische und rekonstruktive chirurgie background. traditional abdominoplasty aims at elimination of redundant fat tissue and skin as well as tightening of muscular aponeurosis on the abdomen. in the massive weight loss (mwl) patient this procedure often yields only mediocre results. specific areas such as hips, buttocks and the lateral thigh are addressed inadequately.methods. patients after mwl are treated with a central or lower body lifting according to the specific needs at our institu-tion. the central body lift includes a circumvertical dermolipectomy concentrated on the central torso without significant mobilisation of caudal tissues. in the lower body lift, the circumvertical dermolipectomy is located more inferior on the torso with an additional extensive mobilisation of the subcutaneous tissue down to the level of the knee.results. these new innovative techniques led to a much improved contour and results compared to the traditional abdominoplasty procedure. although there is an increase in operative time, postoperative recovery and complications appear comparable according to our initial limited experience. we present in detail representative cases with step-by-step explanation of operative techniques.conclusions. especially after mwl, such as after bariatric surgery, the surgeon has to deal with a tremendous amount of redundant tissue on the lower part of the torso and thighs. traditionally this problem was solved in a staged manner with multiple surgeries, such as abdominoplasty, buttock lift or medial thigh lift. however, in many cases this approach led to unsatisfying results. new innovative techniques allow for an optimal repositioning of the descended tissues und most often to a much improved postoperative result compared to the traditional techniques. a. m. rokitansky, r. j. hahn background. we report our experience using the modified minimal invasive method of pectus excavatum repair in adults. thirty one adults with a mean age of ( - . ) suffering from pectus excavatum have been corrected using by the extended modified minimally invasive repair method. the ravitch= welsh=rehbein technique, performed elsewhere, has corrected patients insufficiently. reduced physical capacity, mild cardiac valve dysfunctions (prolapse, pulmonary valve insufficiency), chest pain in the area of the funnel and reduced ventilatory function were detected. two thirds of the patients emphasized the wish of a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with -d reconstruction and spirometry.methods. retrosternal mobilization and intraoperative stretching of the anterior thorax by long lasting sternal elevation modified the original nuss technique. additionally an oblique wedge shaped partial sternal osteotomy and=or osteotomies of the ossificated ribs were performed. in adults usually pectus pars (ps -implant + fa. hofer austria) should be used.results. due to preparation we observed intraoperative bleeding episode from the internal mammaric vessels, superficial lesion of the right visceral pleura (adhesions). postoperatively we saw pleural effusions, subcutaneous hematoma and two prolonged wound-healing episodes (superficial infections with no necessity of bar removal). vertebral index changed from . preoperatively to a normal range of . postoperatively. postoperative cosmetic results were perfect in %. in summary adults with pectus excavatum are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. minimal invasive av-valve surgery is an increasingly popular procedure in cardiac surgery, but -due to the complexity -still reserved to few selected centers. aim of this study was to present learning curve issues for program introduction. methods. a total of minimal invasive av-valve procedures were performed by a single surgeon and were successful in ( . %). seventy one patients ( . %) underwent av-valve repair, ( . %) received mitral valve replacement. in patients ( . %), concomitant asd closure and=or tricuspid valve repair had to be performed. one intraoperative conversion to valve replacement had to be performed due to residual mitral regurgitation. for calculation of learning curves, regression models with logarithmic curve fit for operating time (ot), aortic cross-clamp (axt) and cardio-pulmonary bypass time (cpbt) for all patients and for patients with posterior mitral leaflet prolapse were applied.results. within approximately consecutive minimal invasive procedures, a steady decline of either ot, axt and cpbt could be observed for the overall surgical population even despite the increasing number of concomitant procedures and was similar in patients with posterior mitral leaflet prolapse. after overcoming this steep learning curve, a mean axt of ae min, a cbp time of ae min and a total ot of ae min is required to treat isolated posterior leaflet prolapse.conclusions. minimal invasive av-valve surgery can be safely introduced into a heart surgery program. however, sufficient number of cases per year are required per surgeon to come over this learning curve. case report. a -year-old male patient without clinical symptoms presented an enlarged heart shadow in a routine radiological examination. the following ct revealed a structure in the pericardial sac that was initially classified as a pericardial cyst. in order to confirm the diagnosis, an ecg-triggered multi-slice ct was performed resulting in the diagnosis of a gigantic coronary fistula originating from the left main coronary artery leading to the right atrium. the shunt volume of the coronary fistula was estimated to be %. echocardiography demonstrated dilatation of the right chambers due to volume overload. since operative mortality was deemed extremely low in this patient surgical correction was advised. after median thoracotomy, initiation of heart lung machine and extensive cardioplegia, the coronary fistula was identified to originate from the left main coronary artery meandering around the posterior side of the left heart with a mean diameter of cm and entering the right atrium at the level of the vena cava superior. the fistula was ligated in the right atrium and at its origin at the branching site of the circumflex artery. to secure optimal surgical outcome bypass grafting was performed to lad (left anterior descending) and its diagonal branch as well as the circumflex artery. postoperatively performed ecg-triggered multislice-ct evidenced successful repair of this anatomical malformation. the postoperative course was uneventful. background. to document severity of illness and to evaluate the predictive value of clinical scoring systems in infants and children after cardiac surgery. prospective study with follow up to hospital discharge. a bed multidisciplinary paediatric icu in a university hospital. between = and = infants and children were admitted after open heart surgery.methods. data relevant to the acute physiologic score for children (apsc), pediatric risk of mortality (prism iii), therapeutic intervention scoring system (tiss ) and organ system failure (osf) score were collected in all patients during the first days of postoperative intensive care. eighty one percentages of the patient underwent a total repair, % had a palliative correction.results. the mean age of the patients was . ae . years. there were survivors (s) and non survivors (ns). the mean duration of mechanical ventilation was . ae . days for survivors and . ae . days for non survivors. on the first postoperative day the mean apsc and prism iii scores of survivors and non survivors were . ae . vs. . ae . (p < . ) and . ae . vs. . ae . (p< . ), respectively. the mean tiss and osf scores of survivors and non survivors were . ae . vs. . ae . (p< . ), and . ae . vs. . ae . (p< . ), respectively. the overall hospital mortality rate was . %. patients with an apsc score < and a prism score < had a survival rate of %, whereas patients with an apsc score > and a prism score > had a mortality rate of %. the area under the receiver operating characteristic (roc) curve for apsc, prism, osf and tiss was . , . , . and . , respectively.conclusions. apsc, prism and tiss describe accurately the severity of illness in infants and children after cardiac surgery, and all physiologic scores identify those patients at increased risk for mortality.p non-bacterial pyopericardium leading to lethal sepsis in a patient with severe humoral immunodeficiency k. mészáros , i. knez , b. rigler , g. p. tilz klinische abteilung für herzchirurgie, graz, austria; abteilung für klinische immunologie, graz, austriabackground. pyopericardium is the accumulation of pus in the pericardium mainly caused by bacterial infection. purulent pericarditis most commonly occurs as a direct extension of an infection from an adjacent pneumonia or empyema. alternatively, a distant infection can haematogenously seed the pericardium. primary pericardial infection is rather rare. pyopericardium is an illness requiring acute intervention by the heart surgeon (pericardial drainage) and adequate medication.methods. a -year-old man was admitted with diffuse chest pain, dyspnoea, tachycardia and nausea. laboratory examination revealed massive leukocytosis and elevation of creactive protein. echocardiogram showed circumferential pericardial effusion without valvular vegetations. after a subsequent clinical impairment to a highly septic state, he underwent surgical pericardial drainage. the pericardium was full of pus of creamy aspect. after continuous pericardial lavage and operative revision in several steps, final sternal closure took place ten days later. no infectious agent could be identified to be responsible for the purulent pericarditis.at the term of next surgery, . litres of serous ascites and . litres of serous pericardial effusion were drained. the patient developed a gangrenous cholecystitis, op-site findings revealed a non-purulent ascites, intra-operative cholangiography was without pathological findings.results. detailed immunological analysis showed a severe decompensated immunodeficiency with adentritocytaemia. the therapy with polyvalent immunoglobulin and imutin was ineffective, the patient died one day later from a therapy-refractory septic shock.conclusions. in cases with unclear non infectious purulent pericarditis, it is of high importance to carry out the correct diagnosis as soon as possible to provide an adequate therapy. background. early results of mi treatment of proximal humeral fractures using the ncb + -ph plate showed promising results reaching points ( % of age related normal value) in the constant score months postoperatively and an acceptable complication rate ( . %). the purpose of this study was to analyze the long-term results focusing on functional outcome and complications.methods. so far out of a total number of cases we have gained the data of patients ( women, men; age in the mean) who sustained fractures of the proximal humerus treated mi with the ncb-ph + plate (zimmer company, winterthur, switzerland). in cases ( %) osteoporosis had been diagnosed preoperatively. radiological follow-up in two planes and functional outcome is assessed clinically (rom) and using visual analogue scale (vas) for pain and function, constant score and a modified adl score (activities of daily living).results. average rom (in degree) for anteversion was , glenohumeral abduction , external rotation and internal rotation . average vas for pain was , points ( ¼ worst) and for function , points ( ¼ best). average constant score was points, average adl score was points ( ¼ best). between and months postoperatively one case ( , %) of sintering of the humeral head and one case ( , %) of avascular necrosis was detected. in cases ( %) of reversed impingement we performed total removal of hardware. four younger patients ( %; age in the average) underwent the same procedure demanding it though not suffering of limited rom or pain.conclusions. in the early results ncb-ph + proved to be an effective mi method of treatment of fractures of the humeral head. the year follow up data show further functional improvement (approx. % of constant score). the complication rate remains low ( = ¼ %). especially, no cases of lesions of the axillary nerve or frozen shoulder were seen. the latter we believe is due to the mi procedure and the early functional treatment which is possible since the ncb-ph + plate creates high primary stability. the long-term results prove the ncb-ph + plate to be a safe and effective method of treatment reaching a functional outcome that enables the mostly old patients to regain an acceptable level of activity. removal of hardware is easy to perform and offers especially in the younger patient a possibility to at least improve patients' subjective outcome. background. the gastrointestinal duplication in adults is a rare congenital abnormality and only few cases are described in the literature. although intestinal duplications are considered to be benign lesions, mostly asymptomatic, they may result in significant morbidity and mortality, if left untreated. this study reports of one case of caecal duplication with an overview of the literature.methods. a -year-old female patient was hospitalised with pain in the right lower abdomen. a relocatable and solid tumor ( cm dm) was palpable. blood examination revealed a slight increase of leu and crp. the gynaecologic examination was entirely unremarkable. the sonography showed only an key: cord- - xvzvdg authors: nan title: national scientific medical meeting abstracts date: journal: ir j med sci doi: . /bf sha: doc_id: cord_uid: xvzvdg nan zero months months months months group a . . * . ** . "* . ** zero months group b . . ** values are means; *p< . and **p< . l~ most other studies show neutral effects on insulin sensitivity, with minimal incidence of glucose intolerance. this may be partly explained by the diversity of age, diagnosis (whether insufficiency or deficiency state), other pituitary deficiencies and replacement therapy, and possibly by dosage ofgh utilised in these studies. clostridium difficile-associated disease (cdad) is primarily a nosocomial condition. community-acquired disease has been described but the incidence is low "). during a recent outbreak, we prospectively reviewed all new cases of cdad to determine what proportion of cytotoxin positive cases were community or hospital acquired. during a month study period, cases were identified. history of diarrhoeal episodes were recorded for each case. selected isolates were typed using pyrolysis mass spectrometry (pms). community-acquired cdad was defined as diarrhoea, on or within hours of admission, in association with a positive stool cytotoxin test for c.difficile and in the absence of hospitalisation within days. sixty-five cases ( %) were hospital acquired. fifteen patients ( . %) had cdad on admission; ( %) were community acquired, ( . %) had been recently hospitalised ( at st. james's hospital, at other hospitals). pms typing of faecal isolates revealed that predominant strains were responsible for the hospital outbreak; one of these strains was also isolated in community-acquired cases. this study suggests that the incidence of communityacquired cdad may be higher than previously reported. we suggest that all newly admitted or transferred patients with diarrhoea should be screened for this organism. several studies have confirmed that activated protein c resistance (apc-r) occurs in - % of thrombosis patients and is therefore more common than congenital deficiencies in the inhibitors of coagulation such as atii , proteins c and s. homozygosity for the factor v (fv) gene mutation is associated with a - fold increased risk of venous thrombosis while heterozygosity is associated with a - fold increased risk. the mutation, however, is highly prevalent in the general population, a prevalence of % has been reported in several european countries. its frequency in the population of northern ireland (ni) has not yet been reported. we screened a group of generally healthy elderly individuals (av. age . ; range - yr on several occasions for apc-r using an assay based on the prolongation of activated partial thromboplastin time by the addition of apc. a mean ratio of . (range . - . ) was measured. seven individuals ( . %) had ratios < . (av. . ; range . - . ). these subjects were then analysed for the fv mutation by pcr amplification and restriction analysis. the individuals with the lowest ratios (av. . ; range . - . ) were found to be heterozygous for the mutation. none of these individuals were deficient for protein c, protein s or atiii. the frequency of apc-r ( . %) within this ni elderly group is similar to that reported by others in the uk whose studies would have included a generally younger population. the successful ageing of these individuals perhaps underlines the low risk associated with heterozygosity. alternatively a higher prevalence of the mutation may exist in the general population of ni, where the incidence of heart disease is one of the highest worldwide. the insulin-like growth factor ii gene (igf ) is imprinted. thus, in contrast to most genes where both maternal and paternal copies (alleles) are transcribed into rna and expressed, gf is normally only expressed from the paternal copy (monoallelic expression). alterations causing biallelic expression of igf may lead to excess growth factor production, and thus, to tumourigenesis. this study evaluated igf expression in a series of childhood cancers. to date tumours have been evaluated using pcr based methodology ( wilm's tumours, rhabdomyosarcomas, miscellaneous). dna was extracted and a polymorphic site apal within the igf gene was amplified and digested. this identified samples as heterozygous for igf , meaning that separate maternal and paternal alleles were distinguishable. rna from these informative samples was extracted, pcr amplified and restriction digested, to identify monoallelic versus biallelic profiles at the expression level. samples with normal imprinting (monoallelic) displayed allele a ( bp) or allele bl/b ( / doublet). biallelic samples displayed both alleles. using this approach / informative wilm's tumours and / rhabdomyosarcomas demonstrated biallelic expression. in conclusion, biallelic expression of igf was detected in a significant number of wilm's tumours and rhabdomyosarcomas, and should be considered; with other genetic alterations, as a candidate mechanism in tumourigenesis. the proinflammatory cytokines, tnf~, il and il- , may mediate host metabolic and immune responses to cancer possibly leading to paraneoplastic phenomena such as cachexia. the cellular origin of these cytokines in the cancer patient, in many cases, remains unknown. we examined proinflammatory cytokine levels intracellularly, using flow cytometry, in pbmcs from oesophageal cancer patients (n= ) and age and sex matched controls (n= ). tnf~ and il- levels were significantly increased (p< . ) in pma stimulated t cells and monocytes from the cancer patients when compared to the healthy controls. these results were confirmed using standard elisa assays. following cotlagenase digestion, increased levels of tnfa and il- ,were detected in oesophageal tumour infiltrating t cells when compared to cells from normal mucosa. there was also increased production of tnf~ and il- , but not il-ib, in malignant epithelial cells when compared to normal and halothane and maintained by % nitrous oxide-oxygen, . - . % halothane, with spontaneous ventilation. tc rose marginally in group and fell in group (not significant, ns). tp in groups and at induction and and minutes were, respectively, (mean + sem, celsius) . + . vs . + . , ns; . + . vs . + . , ns and . + . vs . + . , (p< . ). overall incidence of shivering-was .%, but not significantly different between the groups. the data suggests that preemptive application of the space blanket increases tp in paediatric patients during general anaesthesia and tends to conserve tc. chronic actinic dermatitis (cad) an uncommon, eczematous, photosensitive eruption is diagnosed on history, clinical examination, skin biopsy and abnormal light tests. drug induced photosensitivity may look identical clinically, have a similar history and patients with cad may be treated with potentially photosensitising drugs. we therefore reviewed all patients with cad and compared their monochrumator light tests with patients who had drug induced photosensitivity. phototesting was performed on unaffected skin of the back with an irradiation monochromator; the minimal erythema dose (med) determined for a series of wavelengths between and nm, in patients with drug induced photosensitivity and patients with cad. of ten females, four males with drug induced photosensitivity, age range - (mean yrs), ten ( %), were photosensitive in the uva range ( - nm), the implicated drugs including, quinine, sparfloxacin, amiodarone, doxycycline, mefenamic acid, nalidixic acid, fenbrufen, diclofenac, enalpril and prochlorperazine maleate. three patients with rosacea were photosensitive to doxycycline. the re/nainder ( %), were tested after discontinuation of the drug and their light tests were normal. in the cad group, (four males and three females), age range - (mean . yrs), three patients ( %), were sensitive to uva, uvb and visible light, four ( %) to uva and uvb. in conclusion, uva dissociated from uvb photosensitivity seems a relative but not absolute sign of drug induced photosensitivity. this pattern of light tests should prompt a detailed drug history to elucidate the causative agent. phototesting should be performed while on the offending drug as testing days or weeks after discontinuation will give normal results. patients at risk of bone fractures by measuring bone mineral density (bmd) and markers of bone turnover and to assess the correlation of these with the severity of cld. twenty three patients with cld had bmd measured by dual-energy x-ray absorptiometry scanning of hip and lumbar spine. bone formation was assessed using serum levels of procollagen type peptide, osteocalcin and bone alkaline phosphatase, and bone resorption was assessed using hour urinary excretion of hydroxyproline, pyridinoline and deoxypyridinoline. % and % of patients had evidence of osteoporosis at the lumbar spine and femoral neck respectively. biochemical results showed that % of patients had an increase in all bone resorption markers and % had an increase in markers for bone formation. bmd at the lumbar spine was lower in patients with cholestatic liver disease compared to patients with other types of'liver disease (p= . ). no correlation was found between bmd and patient age, bilirubin, albumin, inr or duration of liver disease. conclusions: osteopenia occurs in up to % of patients with cld due to a high bone turnover state where bone resorption exceeds formation. osteoporosis is most severe in those patients with cholestasis. a detailed profile is presented of all leukaemia and multiple myeloma (icd-o code ) patients registered by the southern tumour registry during the -year period / "). annual age-adjusted rates of . and . per , were seen for males and females respectively. these levels indicate a lifetime (up to yr) risk of in for males and in for females. the main morphological sub-types registered were multiple myeloma ( %), cll ( %), aml ( %) cml ( %) and all ( %). one, two and five-year survival rates were examined; age at diagnosis and lesion type were extremely significant factors in relation to patient outcome. the overall incidence levels indicate that irish rates were relatively high by internatiomil standards r we assessed effects of reducing the volume of hyperbaric bupivacaine by giving half the volume as isobaric bupivacaine. when using . % hyperbaric bupivacaine for spinal blockade, the segmental spread and cardiovascular effects of the block have been shown to be dependent on the volume of local anaesthetic injected. patients undergoing elective surgery were studied in a prospective, randomised, double-blind trial: group ( patients) received their local anaesthetic as two equal aliquots of . % hyperbaric bupivacaine and . % isobaric bupivacaine respectively; group ( patients) received their local anaesthetic as two equal aliquots of . % hyperbaric bupivacaine. there was no significant difference found between the two groups with regard to maximal height of block (group , mean (range), t (t -ti ); group , t (ts-t )), rate of onset of blockade, or time to maximal blockade (group , mean (sem), . ( . ) rain; group : . ( . ) min). there was no difference found between each group in either cardiovascular stability or vasopregsor usage. the administration of a mixture of . % isobaric bupivacaine and . % hyperbaric bupiv/~caine confers no advantages over administration of the same volume of . % hyperbaric bupivacaine alone. propofolis used as a sedative during regional anaesthesia. providing titrateable sedation, it can compromise haemodynamic stability. a propofol ketamine combination provides stable haemodynamics during total intravenous anaesthesia, avoiding emergence phenomena m. we compared two sedative regimes in patients having spinal anaesthesia. following informed consent, patients, asa i-ii, undergoing spinal anaesthesia were randomized to one of two groups (n= ). group i (propofol-ketamine) received loading doses of . mg/kg propofol, . mg/kg ketamine followed by an infusion of . mg/kg/h and . mg/kg/h respectively. group ii (propofol) received bolus . mg/kg and infusion . mg/kg/h. subsequent infusion rates were titrated to effect using a sedation score. heart rate, blood pressure, oxygen saturation, end tidal c and oxygen requirements were recorded. observation continued for the recovery period and patients visited the following day. data were analysed using t-test, chi test and anova. groups were demographically comparable. sedative and respiratory indices were similar for both groups. there was no difference in total propofol requirements between the groups; group i - _+ mg, group ii - _+ : mg (mean _+ sd). there was a large difference in mean arterial pressure, being much lower in the propofol only group. both groups had an uneventful recovery without emergence phenomena. our results do not confirm the described additive effect of andketammc . ketamine.with propofol for sedation propofol ' =~ ) confers haemodynamic stability during spinal anaesthesia. we designed a controlled study to investigate whether there is a direct relationship between the degree of postoperative pain and the development of negative middle ear pressure in adults following tonsillectomy. middle ear pressure was measured by tympanometry. pressures were classified as type a (o to - mmh ), type b (flat) or type c (- to - mmh ) tympanograms. patients with type a tympanograms, undergoing tonsillectomy were enrolled in the study. patients had daily tympanometry whilst in hospital and then weekly until amrmalisatign. a questionnaire incorporating visual analogue pain scores was filled in at the same time. a control group of patients with type a tympanograms, undergoing appendicectomy and endotracheal intubation was used. follo~v up was available on patients. patients ( %) developed type c tympanograms, patients %) type b and ( %) patients remained unchanged. no member of the control group developed any change in middle ear pressure (chi squared = . , p < vol. , irish journal of supplement no. medical science . ). there was no relationship between pain scores for throat pain or otalgia and the development of negative middle ear pressure. patients recorded higher pain scores for throat pain at day then day , only of this group had negative middle ear pressure. middle ear pressure reverted to normal at day in / patients and in the remaining / it was normal at day . this study demonstrates the development of transient negative middle ear pressure following tonsillectomy in % of patients. this change is unrelated to the degree of postoperative pain nor is it associated with otalgia. postoperative ward analgesia remains suboptimal. this may be partially related to inadequate early use of opioids to attain minimum effective analgesic concentration (meac). we examined the incidence and predictors of severe postoperative pain on admission and discharge from our postoperative recovery room (rr). verbal pain scores were obtained in a pilot study of patients on rr admission and discharge. procedures were classed as open cavitary, laparoscopic, orthopaedic, ent or body surface surgery. intraoperative use and dosage of narcotics and nonsteroidal (nsaid) analgesics, anaesthetists' experience (prefellowship or post-fellowship nchd, consultant) were noted, and rr opioid usage recorded. pain scores and analgesic use were examined using mann-whitney, ~ analysis and logistic regression. moderate or severe pain was experienced by % of patients on either arrival or discharge. median intraoperative morphine dosage was mg. opioid use was slightly (median morphine dosage mg, p < . ) higher in patients undergoing cavitary surgery; these patients had the highest pain scores on rr arrival and departure. patients ( %) received > mg morphine intraoperatively. discharge scores of / or higher occurred in patients ( %). opioid usage and pain scores were unrelated to level of training. nsaid use/nonuse was unassociated with differences in opioid use or rr pain scores. no morbidity attributable to analgesic use (desaturation, slow respiratory rate) occurred. nonattainment of meac is frequent after open cavitary surgery. conservative opioid dosages continue to be employed despite inadequate early postoperative pain relief; this does not change with increasing experience. reporting such findings in departmental audit may help to alter perioperative management; such data may serve as a baseline for future interventional studies. diclofenac is frequently used for analgesia after tonsillectomy. recently concern has been expressed about the effect of diclofenac on prolonging bleeding time. one recent retrospective study found its use in tonsillectomy was associated with an increase in reactionary haemorrhage. we designed a randomised controlled study to compare the effects of rectal diclofenac and im pethidine given at induction with pethidine alone, in children undergoing tonsillectomy. fifty nine patients were entered into the study. there were males and females, mean age years, range ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . patients were randomised according to chart number. thirty five patients received rectal diclofenac after induction. twenty four patients acted as controls. there were no significant differences in operating time or operative blood loss between the two groups. in the recovery room the diclofenac group was significantly less restless than tl~e control group (p < . , chi squared test), with less crying, movement and agitation. there was no difference in postoperative recovery and no primary or reactionary haemorrhage. one patient in the diclofenac group developed a secondary haemorrhage. this study demonstrates a significant reduction in restlessness in the recovery room in children receiving rectal diclofenac. no increase in reactionary haemorrhage was demonstrated. diclofenac remains a safe and effective analgesic agent in children undergoing tonsillectomy. elderly patients have decreased dose requirements for many drugs compared to the young. few studies have examined dose requirements of opioids in the elderly when administered via patient controlled analgesia (pca) . we compared the pca morphine requirements between young and elderly patients. records were retrospectively analysed from , consecutive patients receiving pca for post-operative pain. inclusion criteria (i) age less than years or greater than years, (ii) upper abdominal surgery, and (iii) morphine pca usage. patients fulfilled the inclusion criteria. patients were young and were elderly. the mean age in the young was years and in the elderly was years. % were female in the younger group, % were female in the older group. pain scores at rest and on movement were similar in both groups . and . respectively in the young, . and . in the elderly. (p > . , students t-test). morphine usage over hours was + . mg in the young, and + . in the elderly. (mean + s.d.) (p.< . , students t-test). elderly patients required significantly less morphine via pca to achieve the same pain scores as the young. these findings are consistent with studies showing decreased requirements of other drugs in elderly. the erythrocyte sodium-lithium countertransport (slc) is abnormal in essential hypertension and some other forms of cardiovascular disease (cvd) but the considerable overlap in its activity in patients with these conditions and in normotensive healthy subjects remains a strong point against its possible utility as a marker for cvd. we sought to address this issue in greater detail. twenty-nine hypertensive patients ( with family history of cvd) aged . + . years (mean + se) and normotensive subjects ( with family history of cvd) aged . + . years, participated after informed consent. slc were determined in , , , and mm sodium chloride; and the vmax and km of the transporter determined. hypertensive and normotensive individuals with family history of cvd (n = ) had higher slc activity ( . + . vs . + . , p < . ), greater vmax ( . + . vs . + . mmol/lcell.h, p < . ) and lower km . mm (median) vs . (p < . ) than hypertensive and normotensive subjects without such a history (n = ). however, none of these parameters was sufficiently discriminatory as evidenced by the considerable overlap in the scattergrams for the two groups. on the other hand not only was the median quotient vmax/km significantly different . vs . (p < . ), but also the scattergram separated the two groups. this may reflect an effect of hereditary factors on the identified rate-limiting step in the transport system. capsaicinadministration results in depletion of substance-p sensitive nerves. this study was carried out to observe the impact on the morphology of mitral valve endothelium. the experimental group received capsaicin i.p. on day four of life; control animals received drug vehicle only. animals were anaesthetised by chloral hydrate and hearts were removed following perfusion of % glutaraldehyde, and were routinely processed for scanning electron microscopy. normal endothelial morphology showed an ordered and structured pattern, with large raised nuclei covered in discrete microappendages: no zoning was observed over the valve surface. following capsaicin administration, valves were seen to be torn and possessed a denuded endothelium. nuclear bulges changed in both apparent height and area, with the surface partially denuded of microappendages. one month following systemic administration of capsaicin to neonatal rats, a serious alteration of mitral valve endothelium morphology and integrity had occurred. depletion of substance-p may have resulted in mechanical insufficiency of the mitral valve. this study was funded by the health research board. with expanding applications and increasingly aggressive stress protocols, concerns about the safety of dobutamine stress echocardiography (dse) have arisen. the purpose of this study was to analyse prospectively the safety, adverse event profile, and complication rate of dse. prospective data was recorded in a consecutive series of patients undergoing dse for diagnostic evaluation of chest pain, for risk assessment following myocardial infarction or for detection of hibernating myocardium. the maximum dose of dobutamine used was mcg/kg/min in . % of patients and mcg/kg/min in . %. atropine was used in . % long-term outcome following coronary artery bypass grafting may be related to the prevalence of major risk factors and their treatment following surgery. we aimed to establish the prevalence and current management of coronary risk factors in a group of consecutive patients attending our hospital. this is a report of the first patients. data was collected by a structured patient interview, chart review, physical measurements and blood sampling. there were male and female patients, average age . years. the mean length of time since surgery was . years. thirty-nine patients had a recurrence of angina and this occurred on average ll months after surgery. as regards risk factors, were active smokers, were ex-smokers and only had never smoked. two thirds of the patients were taking regular exercise; only took no exercise at all. seventy-two percent of patients had a cholesterol greater than . mmol/l, yet only of the patients were on lipid lowering drug therapy and a further were on a lipid towering diet. twenty-nine patients had a systolic bp > or a diastolic bp > and of these were on antihypertensive therapy. seventy-seven patients were overweight but most of these had received specific advice regarding weight reduction in the preceding year. our results show a high prevalence of treatable risk factors in this high-risk group with inadequate treatment in many cases. new combined primary and hospital care strategies for cardiac rehabilitation and long-term secondary prevention of coronary heart disease are required. if the goal of modern therapy of acute myocardial infarction (ami) is preservation of myocardium, the occurrence of cardiac failure could be regarded as a treatment failure. in recent studies of iv thrombolysis and primary ptca the frequency of left ventricular failure (lvf) following ami has been as low as . %. this very low rate might be explained by selection bias in patients recruited to randomized trials. the purpose of this study was to examine the frequency of lvf in a consecutive alterations in nitric oxide (no) synthesis have been implicated in cardiomyopathy, ischaemic heart disease and septic shock. recent work has suggested a possible role for nitric oxide in cardiac arrhythmogenesis. the effects of inhibiting no synthesis with l-name (n c -nitro -l -arginine methyl ester) on cardiac electrophysiology have not been fully determined. the dominant frequency of electrically induced ventricular fibrillation was determined in l anaesthetised pigs ( - kg) using a fourier transform. the dominant frequency ( . _+ . hz in lead ii) was not altered by treatment ( . _+ . hz) with l-name in a group of pigs ( - kg) the effect of l-name ( mg/kg) was assessed in relation to energy required to defibrillate. there was no significant difference in the energies required to achieve successful defibrillation on % of attempts between the l-name group ( . _+ . j) and the control group ( . _ . j), and on % of occasions, l-name ( . + . j) and control ( . _+ . j). the results show that inhibition of no synthesis has no significant effect on the dominant frequency of ventricular fibrillation or on the efficacy of defibrillation in the pig heart. received either mg ( pts) or mg ( pts) oral flecainide followed by a maintenance dose of mg bd. all pts were euthyroid. none had significant hypertensive, valvular or ischaemic heart disease. pts had normal echocardiograms, had mildly dilated atria. of the pts ( %) converted to sinus rhythm, within hrs and at and days respectively. subsequently, he was found to have paralysis of all the muscle groups of his right upper limb apart from some flexor movements in his fingers with areflexia and sensory loss over the c /c dermatomes. the findings were thought to be in keeping with a brachial plexus.lesion. an mri scan showed a "haematoma" or "fibrosis" around the brachial plexus~ emg studies revealed a complete lesion from c /c with evidence of partial function at c and a good function at c . despite physiotherapy, at follow up months later there was no improvement in the emg findings. though brachia~ plexus injury has always been considered a complication of central venous line insertion <l), there have been no cases described, in the literature in the last years. central lines are mandatory irt major surgical cases but one must always be aware of the possible complications caused by them. body weight (bw) in icu patients fluctuates due to alterations in body mass ( ) and water ( ) and is usually estimated rather than measured. we hypothesised that (i) estimated weights are inaccurate and (ii) changes in true body mass (tbm) are masked by changes in water content. on admission, icu patients whose expected length of stay (los) was > days were placed on a bed incorporating load cells (accuracy of _ . kg). bw was estimated by icu staff. mbw was then recorded hourly under standard conditions. changes in mbw due to pack insertion/dressing changes were excluded. we calculated tbm as mbw minus cumulative fluid excess, corrected for insensible losses c ~. patients received standardized nutritional support from day and urinary nitrogen on day was calculated we studied patients whose mean (sd) age, mbw, los and apache ii score were . yr ( . ), . kg ( . ), . days"( . ) and ( . ) respectively. mean error in estimated weight on admission was . % (nurses) and . % (doctors). mean protein and calorie intake was g and kilocals/day. mean decrease in mbw during icu stay . kg/day (range . kg (gain) to . kg). mean reduction in tbm was . kg/day (range . - . kg/ day) and this correlated with urinary nitrogen loss (r= . ). in icu, (i) estimated weight is significantly inaccurate and should not be used in physiological calculations and (ii) rapid and significant decreases in body mass occur which may be underestimated due to fluid accumulation. dopamine appears to influence pituitary function and is associated with decreased circulating human growth hormone and insulin-like growth factor i m which could exacerbate catabolism, and therefore wasting, during critical illness. at hrly intervals from admission, patients whose expected length of stay exceeded days, were weighed (measured body weight, mbw) under standardized conditions,-using a bed incorporating electronic load cells (accuracy + o. kg). standard demographics, apache ii score and use of dot~amine by infusion was recorded. changes in weight due to removal./ insertion of prostheses, packs/dressings were excluded mbw was converted to true body mass (tbm) using measurements of cumulative fluid balance ( ml = kg) and insensible lossr patients received nutritional support, starting on day , based on their admission mbw. there were no significant differences in mean age, weight, length of icu stay, admission apache ii scores and mean daily protein/calorie intake between patients who had received dopamine by infusion (group d) and who had not (group nd). mean (sd) decreases in mbw during icu stay were . ( . ) kg/day (group d) and . ( . ) kg/day (group nd) (p< . i). mean decrease in tbm was . ( . ) kg/day and . ( . ) kg/day respectively (p< . ). thus group d were losing an additional . kg body mass per week relative to group nd. the use of dopamine by infusion is associated with an accelerated loss of lean body mass during critical illness. adhesion of polymorphonuclear leucocytes (pmns) to pulmonary endothelial cells is an initial step in the inflammatory process characterising the adult respiratory distress syndrome. previous studies using human umbilical vein endothelial cells (huvecs) have suggested that lipopolysaccharide (lps) is a potent stimulus for pmn adhesion to endothelial cells. the aim of this study was to investigate the effect of lps on pmn adhesion to human pulmonary artery endothelial cells (hpaecs). human pmns were coincubated with hpaecs _+ lps ( . - mg/ml) with % serum for hour. the effect of phorbol myristate acetate (pma) ( ng/ml) was also examined. percentage adhesion stimulated by pma was + sd. lps did not significantly increase adhesion at any of the concentrations used. to confirm the activity of lps pmns were incubated at ~ with . - mg/ml lps + % serum for hour and labelled with flourescent antibodies to the mac adhesion molecule complex (cd /cd lb). facs analysis indicated upregulation of both cd and cdllb. thus in the system used, lps did stimulate pmn adhesion molecule expression, indicating that the lack of adhesion reflects a difference in hpaec response to lps compared to that reported for huvecs. this work was supported by the health research board ireland. although inhaled corticosteroid therapy is of undoubted benefit in the management of asthma, dysphonia is a recognised sequela. this study was designed to examine longitudinally the effect of inhaled steroids on the voice and vocal cords of newly diagnosed and previously untreated asthmatics. twenty subjects were recruited and underwent voice and vocal cord assessment prior to and months after starting inhaled steroid treatment. the assessment consisted of ) rating dysphonia using a visual analogue scale, ) acoustical analysis of the voice and ) videostroboscopic examination of vocal cord activity. prior to commencing inhaled steroid therapy for their asthma subjects had normal voices, subjects were mildly hoarse and one was moderately hoarse. vocal cord pathology was noted in subjects, patients had vocal cord nodules and the remainder were noted to have mildly oedematous cords together with a glottic chink. at month follow up, improvement in voice was noted in subjects, one patient felt more dysphonic but there was no change in vocal cord appearance. one subject was noted to have developed a mid glottic chink with no associated change in voice. one subject had clearing of mild vocal cord oedema and improvement in voice. this study demonstrates that % of subjects commencing inhaled steroid therapy for asthma have mild vocal cord pathology. voice is more likely to be improved following use of inhaled steroids for months then made worse. although the relationship between elastin degradation and emphysema is well known, recent evidence suggests that a more complex process of pulmonary remodelling occurs within the emphysematous lung. the aim of this study was to assess the extent of extracellular matrix remodelling by ultrastructural examination of its two major components, elastin and collagen. emphysema was induced in rats by the intratracheal administration of porcine pancreatic elastase ( . u/g body weigh and human lungs were obtained at surgical resection for lung carcinoma. emphysema was confirmed histologically in both animal and human samples by measurement of the mean. linear intercept. matching sections were immersed in . m naoh and % formic acid to digest elastin and collagen respectively. scanning electron microscopy with stereo-pair imaging allowed -d visualisation of elastin and collagen frameworks. the distribution of emphysema was primarily panacinar in rat lungs a'nd centriacinar in human lungs. as expected in both types of emphysema, elastic lamellae were disrupted and perforated with multiple fenestrations. accompanying this disintegration was a marked increase in thickness of collagen fibrils which in some cases coalesced irish journal of medical science imparting a sheet-like appearance to the airspace walls. unique to human centriacinar emphysema, collagen formed helices which spiralled around alveolar septae to form bulky walls between adjacent airspaces. in conclusion, these findings lend support to the novel concept of aberrant collagen remodelling in the pathogenesis of emphysema. small cell lung carcinoma (sclc) is the most aggressive of the four common cell types of lung carcinoma. less than % of patients with sclc are alive two years after diagnosis. staging procedures, treatment regimens and survival results were reviewed in a small regional centre to make a comparison with larger treatment centres. thirty-one cases of sclc seen by one physician from to were reviewed. staging was clinical. treatment was undertaken in conjunction with the local oncology and radiotherapy services. % of patients had limited disease where as % had extensive disease at diagnosis. in patients with limited disease, % were alive at months and there was a % long term survival rate i.e. greater than three years. average length of survival in limited disease was days. survival results were comparable with those treated with chemotherapy alone and combination chemotherapy and radiotherapy. in patients with extensive disease the best results were from those treated with a combination of chemotherapy and radiotherapy with art average survival of days. these figures compare favourably with those from larger multidisciplinary centres. the factors contributing to our relative success may relate to continuity of care achieved in a smaller centre. nasal cpap is a very effective therapy for osa, but is cumbersome, and compliance varies. we prospectively evaluated consecutive osa patients treated with ncpap, who were asked to complete questionnaires before, and to months after starting therapy. this stttdy intended to examine both the patient's subjective response to ncpap and their bed-partner's impressions also. replies were received in ( %) patients. patients were divided i~to groups depending on whether they had a bed-partner, and according to their response to an initiat question assessing overall improvement in sleep quality and daytime al'ertness with ncpap, ranging from (minimal/none) to + (excellent). patients were called responders if they scored > . group a ( pts, %) were responders with bed-partners; group b ( pts, %) non-responders with bed-partners; group c ( pts, %), were responders ( pts, %) and nonresponders ( pts, %) without bed-partners; and group d ( pts, %) had stopped ncpap. nine questions were directed at the bed-partner, and assessed their perception of changes in both the patient's and their own sleep quality, daytime alertness, mood and quality of life, and also to changes in the relationship between patient and bed-partner following institution of ncpap. these questions scored from - (worse) to + (marked improvement). significant improvement in all parameters for the patient (mean + sd = . + . ) were noted in group a. in addition, group a bed-partners reported ~ubjective improvement in the same parameters ( . + . ). group b improvements were less, ( . + . in patients, and . + . in partners). overall, the data indicate a subjective success of therapy in % of patients, but the bed-partner's replies indicate this figure underestimates the true response rate. furthermore, the results show significant improvements in the bed-partner's sleep quality, daytime alertness, mood and quality of life, indicating that successful treatment of osa patients with ncpap also gives significant benefits to their bed-partners. vincent's hospital, dublin. neutrophil collagenase (mmp ) is a member of the matrixmetalioproteinases (mmps), a family of highly homologous zinc endopeptidases which play a crucial role in many physiological processes. the aim of this project was to develop a purification system for mmp from purulent sputum and raise polyclonal antibodies. after initial extraction, contaminating proteins were removed with a zinc chelate affinity column. mmp was then separated, from another closely related mmp, gelatinase b, on a q sepharose ion exchange column using a nacl gradient. the final purification step was carried out with an orange sepharose affinity column. sds-page analysis indicated the presence of purified protein with bands corresponding to latent neutrophil collagenase ( kd) and products of coll~igenase autodegradation at lower molecular weights ( kd & kd). a fold increase in specific activity was observed, with a % final yield, which provided mg quantities of pure enzyme. this work is funded by forbairt and the. irish american partnership. cd is a protein first described as a surface marker on hodgkin's lymphoma cells. recently cd has been demonstrated on th -type t lymphocytes (produce il- , , , l and ), which have a pro-inflammatory cytokine profile. but is not found on thl-type t lymphocytes (produce il- and ifn-gamma). its ligand, cd l, has also been described, cd -cd l interaction has been shown to aid the development oft lymphocyte clones into a th rather than a th phenotype. th -type cytokines are inextricably linked to the aetiology of inflammatory airway disease. firstly we investigated serum cd levels in various patient groups. we have demonstrated significant differences in serum cd levels in the following groups, atopic asthmatics (mean = iu/l, n = ), non-atopic asthmatics (mean = iu/l n = ) and atopic rhinitis/dermatitis (mean = iu/l n = ) and normal controls (mean = iu/l, n = ). secondly we cultured peripheral blood mononuclear cells from allergic individuals and normals. when these cultures were stimulated with house dust mite antigen (der p ) and il- or der p with both il- and i - , surface expression of cd on t lymphocytes could be demonstrated using fluorescent staining and flow cytometric analysis, after days culture in the allergic individuals but not in normals. the presence of i - in the culture increased the degree of surface cd expression. these results are important as they show that allergic individuals have an expandable population of memory t lymphocytes which respond to allergen by expressing cd and developing th- phenotype. most work on cd and th- cytokines has hitherto been carried out an t cell clones. we have developed a relatively simple in vitro system of looking at t lymphocyte response to allergen which will allow the testing of novel therapeutic interventions with a view to modulating the immune response in allergic disease. our work also suggests that even non-allergic patients with inflammatory airway disease may have increased th activity, which has not been shown previously. scimitar syndrome is a rare congenital disorder consisting of a spectrum of abnormalities including hypoplasia of the right pulmonary artery, dextroposition of the heart, anomalous pulmonary venous drainage of the right lung into the inferior vena cava and anomalities of the right diaphragm. bronchiectasis and respiratory tract infections on the right side are the usual clinical presenting features. a year old male patient was referred to the outpatient clinic with a history of recurrent chest infections which were slow to resolve following antibiotic therapy. physical examination revealed decreased air entry, coarse crepitations and a prolonged expiratory wheeze in the right lower lobe. the only abnormalities on routine biochemical and haematological screening were an elevated esr of and a slightly raised white cell count of . a chest x-ray revealed hypoplasia of the right lung when compared to the left. in addition to this there was a vascular shadow present in the right lower robe representing an anomalous pulmonary vein which appeared to drain to below the diaphragm on the night side. bronchoscopy showed a normal left bronchial tree. on the right, no apical segment was detected in the right lower lobe. otherwise no endobronchial lesion was seen. a dynamic computerised axial tomographic scan of the thorax was performed. this showed a dilated anomalous right lower pulmonary vein which was clearly seen to enter the inferior vena cava below the diaphragm. in addition the right lung was again noted to be hypoplastic when compared to the left. these findings were pathognomonic of the scimitar syndrome. "the patient was treated symptomatically and is presently stable. conclusion: scimitar syndrome, with its wide spectrum of abnormalities should be considered when reviewing plain chest x-ray in patients with recurrent right lower lobe respiratory tract infection. recent studies indicate that the ability of circulating neutrophils to regulate surface levels of adhesion molecules may be altered in disease situations. the aim of this study was to determine if changes in neutrophil responsiveness accompanies chronic inflammation in cf. neutrophils in blood samples from cf patients and age-matched control subjects were analysed by flow cytometry for expression of l-selectin and mac- (cd lb) following stimulation by interleukin- (il- ) and fmlp. as expected, both il- and fmlp provoked a decrease in surface levels of l-selectin and an increase in cdi lb levels. however, the magnitude of these changes was significantly lower in cf patients than in control subjects (table) . these results suggest that chronic exposure to inflammatory stimulii in vivo may alter neutrophil responsiveness in cf. given the emphasis on rational prescribing, we reviewed drug use in a bedded long-stay unit. prescribing patterns were analysed on an appointed day thereby obtaining a "snapshot" of prescribing practices. one hundred and ninety four long-stay residents, with a mean age of , were on drugs, the maximum number of drugs per patient was , the minimum and the average . . sixty percent of prescriptions fell within one of the following therapeutic categories:-central nervous system (cns) preparations ( prescriptions), analgesics ( ), gastrointestinal preparations ( ) and cardiovascular preparations (i ). there were ,prescriptions for respiratory drugs and only prescriptions were for antibiotics. the most commonly prescribed cns preparations were anti-psychotics ( ), benzodiazepincs ( t ), anti-depressants ( ). % of all analgesics prescribed ( ) were nsaids. the most commonly prescribed h blocker was cimetidine ( ). nuseals aspirin ( ), digoxin ( ) and captopril ( ) were the most commonly prescribed cardiovascular drugs. % of drugs were issued on an as required basis, i.e. "prn". the most commonly prescribed prn therapeutic classes were analgesics ( prescriptions) followed by gastrointestinal ( ) and cns preparations ( ). these results contrast with prescribing patterns in hospitals and general practice and may provide an insight into the challenges and realities of management in long-stay units. supported by the health research board. evaluation of physician requests to hospital based clinical pharmacist for ( ) drug information, ( ) possible adverse drug reaction (adr) was undertaken over a two year period from jan ' to dec ' (admissions - , , opd attendances - , ). overall requests were made. ( ) drug information: advice/information on new drugs, formulation, dosage, safety consideration prior to drug prescribing was given in cases. ( ) suspected adr: a total of suspected adverse drug reactions were investigated. in cases, no adr link was established, after extensive literature/data base search. adr's were confirmed in cases of which were reported to n.d.a.b. regular on-going interaction between physicians and clinical pharmacy allowed critical analysis of new drugs and heightened awareness of, potential adverse drug reactions in current clinical practice. we previously demonstrated that commonly prescribed medications are not easily identified by patients, doctors or nurses in the hospital setting o, ~. we then investigated the ability of hospital pharmacists, in all, to identify the same commonly prescribed branded and generic drugs. correct identification as follows:-bendrofluazide k ( / ), cimetidine ( / ), diazepam mg ( / ), diazepam mg generic ( / ), digoxin ( / ), ferrous sulphate ( / ), frusemide ( / ), mefenamic acid ( / ), paracetamol ( / ), prednisolone ( l/ ), temezepam ( / ), theoph /lline ( / ). pharmacists had % correct answers compared with % for nurses and % correct for doctors. the pharmacists had no difficulty recognising drugs with brand names written on them e.g. cimetidine, but like nurses and doctors had difficulty identifying the plain white tablets e.g. prednisolone. generic drugs were tess well recognised. a number stated that they were unwilling to definitively identify medication with no clear marking. pharmacists were also asked to list the top prescribed drugs, l got / correct and got / correct. in contrast out of doctors got / correct, got right and only got right. we conclude that hospital pharmacists are generally better than doctors or nurses at identifying commonly prescribed drugs but their knowledge of the top prescribed drugs is not as good at that of doctors. all professionals need assistant in this important task. suggesting reduced activity or more iranians with inherited variants of cholinesterase. one iranian subject with very low activity (dibucaine number below , atypical) had a history of apnea. these data indicate that the frequency of atypical and heterozygote genes for cholinesterase activity leading to prolonged apnea with succinylcholine (suxamethonium) is much higher in iranian than irish populations. this study emphasises the importance of ethnic pharmacology. it is has been advocated that funding for the prescibing of methadone in general practice should be provided separate from the indicative drugs budgeting scheme on the assumption that this may act as a disincentive to g.p.s to take on care of drug addicts. the objective was to analyse the current level and cost of methadone prescribing in general practices in the eastern health board over a six month period. there was a review of methadone prescriptions for gms patients from jan. to jun. . , persons received prescriptions. , scripts were issued. the age-specific prescribing rate for the total population was / , (males /i , , females / , ). males aged - years had the highest age specific rates ( / , ). the cost of methadone prescriptions amounted to s for the six months there was a trend towards an increase in the number of g.p.s who prescribed methadone over the period. only four of the g.p.s ( . %) who prescribed methadone issued in excess of scripts for the period studied. for a small number of g.p.s methadone prescribing is a significant cost item on their budget. in the light of this, government policy should be reviewed with a view to excluding methadone from the indicative drug budgeting scheme. sciences, mashhed, lran. there is increasing evidence that some of the wide variation in the response to medicines has a genetic origin which may be expressed on a racial basis. to further study inter-ethnic differences in pharmacology we compared the activity of an enzyme responsible for the breakdown of endogenous substances and drugs -serum cholinesterase (pseudocholinesterase), dibucaine and fluoride numbers -in irish and iranian healthy subjects. irish subjects had significantly higher serum cholinesterase activity ( . + . vs . + . u/ml, mean + sem, p < . drug prescribing data may reflect changes in therapy and disease pattern. we reviewed current drug use among patients (n = ) in a dublin teaching hospital in "snapshot" fashion on a designated day, and compared it with that obtained in . in , patients received an average of . different drugs each, with % on or more and % on none. by , the average was . (range i - ), with % on or more. the percentage of patients receiving heparin fell from % to %, due mainly to a reduction in use on the medical side. the proportion of patients prescribed hypnotics fell from % to %, while ssri's are now the most used anti-depressants. antibiotic choice changed from amp/amoxicillin to coamoxiclav and the cephalosporins. diuretics remained the most frequently used cardiovascular agents, accounting for % of all drugs used and prescribed for around one quarter of patients. digoxin use remained constant, and by , % of patients were on anti-platelet doses of aspirin. at least four different agents were in use in each of calcium antagonist, beta blocker and ace inhibitor classes. some of these changes in therapy reflect therapeutic advances, changes in disease management, greater choice of therapy and amendment of less than desirable therapeutic practices. on the other hand, some may reflect fashion or pharmaceutical promotion, rather than change as a consequence of evidence-based practice. acknowledgements: pharmacy staff, st. james's hospital and the health research board. studies of in vivo endothelial function in humans have usually involved intraarterial cannulation and the subsequent administration of substances that stimulate the endothelium to produce nitric oxide (no). such techniques are invasive and potentially hazardous. an alternative non-invasive method would be of benefit. animal studies have indicated that reactive dilation of vascular beds may be at least partially endothelium dependent. this study aimed to determine whether reactive hyperaemia in the human forearm was an endothelial dependent process with the potential to be used as a non-invasive method of stimulating the endothelium. ten volunteers underwent brachial artery cannulation and randomly received either placebo or n-monomethyl-l-arginine (l-nmma) ( ~mol/min), an no synthase inhibitor, for minutes. following this reactive hyperaemia was induced by the inflation of an arm cuff to mmhg for minutes and the response to this was measured by strain-gauge plethysmography. when flows had returned to baseline the process was repeated with the remaining substance. results were analysed by repeated me~isures anova. l-nmma resulted in significant reduction of basal forearm blood flow (p< . ). there was no significant difference in reactive hyperaemia with either l-nmma or placebo. in conclusion, no does not contribute to reactive hyperaemia in the human forearm. dublin . home-based infusion therapy has been widely recognised as the optimum for treatment of disease states that require daily intravenous therapy from a patient-care aspect. conditions necessitating intravenous therapies in hiv disease include: cmv retinitis, intractable cryptosporidial diarrhoea, azole-resistent candidosis, nutritional support with total parenteral nutrition, chemotherapy for aids-related malignancies and palliative care in the terminal phase of the disease. the need for such therapies is increasing as patient survival improves. in , the home-infusion service was set up in recognition of the need to treat patients, requiring intravenous therapy, in the home environment. this has been brought about by the development of small, light-weight pumps suitable for ambulatory use, the development of a service for aseptic compounding and the availability of permanent in-dwelling venous catheters. we describe the impact of this service on our patient cohort. to date, sixty-five hiv positive patients have received parenteral therapy at home. patients' age, sex, risk group, cdc stage, cd count, indication for therapy, complication rate and response to treatment are described. the provision of this service has reduced the number and length of patient admissions with associated improvement of quality of life. in addition, it recognises that patients prefer to be treated in the home environment aided by a co-ordinated multidisciplinary approach. since blood alcohol levels over mg/ ml are now illegal for vehicle drivers we have investigated if the commonly held "safe" limit of two drinks will bring the young adult over the legal limit and if this amount of alcohol will affect their psychomotor skills. following informed consent healthy volunteers, nonhabitual drinkers on no medication ( male, female), with a median age of (range - ) years participated and refrained from alcohol for at least days. each drank within minutes two standard drinks ( . ml each ) of . % vodka ( . units of alcohol) plus ml of orange juice at about minutes after a standard mid-day meal. their psychomotor performance was estimated by the number connecting technique at minutes after alcohol consumption and they were also asked to rate their feelings (which included alertness, clear-headedness, competence and attentiveness) using a visual analogue scale of to . blood samples at one and two hours later were collected from the antecubital vein and analysed on the same day for alcohol content using enzymatic methods. mean (+ sem) blood concentrations of alcohol at and hours respectively were . + . and . + . mg/ ml. in males and . + . and . + . mg/l- ml in females. values were significantly higher in females. blood concentrations in females were also higher (p < . ) than in males when expressed per kg body weight. while the blood alcohol in both the genders was considerably lower than the current legal limit in ireland their psychomotor skills as estimated from their task completion time and their answers to questionnaires were indicative of an impaired cns function. thus while drinks may keep many subjects below the legal limit, there is considerable inter-individual variation with females showing higher concentrations and both genders have evidence of impaired performance at these lower levels. a non-linear approach was used to develop an hrv parameter, robust to both data non'-st~itionary and missing data points. unlike the standard chaos approach, using higher dimensional embeddings and time-delays, we employed a onedimensional correlation integral plot. the parameter thus obtained, allows an estimate of the spatial spreading of the attractor (ssa) or spatial variation of rr intervals along a straight line. heart rate data from volunteers ( : to : hr), ~ifter oral placebo or propranolol mg, investigated the ability to detect drug effect. vitamin e (~-tocopherol) is the most important dietary antioxidant in lipid and cell membranes and its intake reversely relates to the incidence of coronary heart disease and certain cancers. estrogen regenerates oxidized tocopherol radical in vitro m but such interaction has not been investigated in postmenopausal women receiving estrogen containing hormone replacement therapy (hrt) although estrogen containing oral contraceptive may reduce plasma vitamin e levep. we studied healthy post-menopausal women (aged - ) ammenorrheic for at least one year. fifteen subjects took a combination of harmogen provera therapy and acted as a control group. blood samples were taken from all subject at baseline and after weeks. in the hrt group, serum fsh levels were greatly reduced ( . + . vs . + . iu/ , p < . , mean + sd, after hrt) with an increased serum oestradiol level (< - . vs . + . umol/ , p < . ). no change occurred in the control group. vitamin e status, measured either as plasma or red cell ~-tocopherol respectively showed no change in both groups (hrt group . + . vs . + . , . + . vs . + . gmol/ , p > . ). we conclude that in post-menopausal women, weeks estrogen containing hrt did not alter vftamin e concentrations in vivo. we assessed the clinical benefit of the newer markers of bone formation: osteocalcin (oc), procollagen carboxyterminal peptide (picp), bone alkaline phosphatase (balp), and bone resorption: carboxyterminal telopeptide of type collagen (ictp) and urinary deoxypyridinoline crosslinks (dpd) over traditional assays such as total alkaline phosphatase (talp) and urinary hydroxyproline (oh/pr) in patients with primary hyperparathyroidism (phpt). patients were sampled basally, then at , , , and hours post surgery and again at . , , and months post op. the mean basal p cp level was + ug/l (normal: - ) this increased to a peak at h ( +_ ug/l), then declined to normal at weeks ( + ug/l). mean basal urinary dpd levels were raised at . + . nm/mm cr. (normal . - , ), they had normalised by months to . -+ . nm/mm cr. mean balp levels were always normal, although normal the yearly mean oc level was significantly lower than the basal value. mean ctp, oh/pr and talp levels were always normal. therefore bone turnover in phpt is best assessed by the newer markers picp and dpd. we have previously described seasonal variation in fibrinogen with higher levels in winter. as fibrinogen is an acute phase reactant, the winter rise may be a response to seasonal infections. the present study investigates this hypothesis by examining seasonality infibrinogen and markers associated with infection: white cell count (wcc), interleukin- ( l- ), human herpes virus (hhv ) and herpes simplex virus (hsv) antibodies. monthly blood samples from healthy volunteers age and over were measured for fibrinogen, wcc, il- , hsv and hhv reactivation over a year time period. a rhythmometric method was used to examine the data for seasonality. statistical significance was measured using the fstatistic. a highly significant seasonal variation (sv), peaking in mid-february, was found for fibrinogen (n= ; sv= . g/ ; f= . ; p< . ). no significant seasonal variation was present for measures of wcc (n= ; sv= . e /l; f= . ; p> . ), hhv (n= ; sv= . au; f= . ; p> . ), hsv (n= ; sv= . au; f= . ; p> . ) or il- (n= ; sv= . pg/ml; f= . ; p> . ). the present investigation does not support the hypothesis that seasonal variation in fibrinogen is a direct effect of the acute phase response, initiated by a seasonal variation in level of infection. the explanation for the seasonal changes in fibrinogen remains unknown. increased plasma homocysteine and reduced plasma antioxidants are risk factors in the development of vascular disease. design: subjects drawn from elderly people living in the community (median age yr, range - yr; female). total plasma homocysteine, vitamin c, gamma tocopherol, retinol and beta carotene were measured by high pressure liquid chromatography. homocysteine levels in elderly males [median (range) = . um ( - . ), n= were significantly higher than in vol. , supplement no. irish journal of medical science elderly females [ . um ( . - . ), n= ]. these values were also higher than in a younger ( - years) male cohort [mean = . um, n= ]. no correlations to vitamin concentrations were found, nor was there a correlation to age within the elderly cohort. within the elderly females, a significant negative correlation with age was found in vitamin c, gamma tocopherol and beta carotene (p< . ). however a significant increase in retinol was noted. a very strong correlation between vitamin c and gamma tocopherol levels was noted in the elderly population sample (p< . after multiple regression). conclusion. homocysteine levels in the elderly are higher than in samples of a younger population. a gender difference is maintained in the elderly. the provision of extended care forms one part of a spectrum of health care for older people. in the eastern health board area all patients over the age of must be assessed by the multidisciplinary geriatric team prior to placement. we report on the experience of the total number of referrals for assessment for extended care to one department of geriatric medicine in a bed teaching hospital. ninety-eight patients listed for extended care in . the mean number of days between listing for long term care and placement was _+ days (range to ). almost one quarter of patients died while in hospital awaiting long term care: this underlines the frailty of patients who are admitted to hospital and request long term care. two patients were transferred to other institutions and patients were able to get home. of the remaining patients ( %) were placed in statutory or voluntary long term care accommodation and only % were eligible (usually financially but in some cases due to significant disability) for nursing home care using the terms of the nursing home act. patients who are listed for long term care through a general hospital are in general very frail, they tend to have a very extended length of stay and the provisions of the nursing home act only apply to a minority. these findings underline the need for provision of adequate statutory and voluntary extended-care places within the eastern health board area. there are over screening assessments for cognitive function and choosing the most appropriate may be difficult. increasingly the importance of behavioural dysfunction is recognised. can any of the cognitive assessments help to predict behavioural dysfunction.'? we compared and contrasted the folstein mini mental state examination (mmse) and the cognitive assessment schedule (cas) of the clifton assessment procedures for the elderly (cape) and compared them with the behavioural rating scale (brs) of the cape. the study was carried out on a total of referrals to the occupational therapy departments by geriatricians in the meath hospital and st. james's hospital. all subjects were over and medically stable. the time scale involved was may-july . the mmse and the cas were administered within the one sitting and each was timed. brs was rated the same day by either a staff or family, member. the average time to complete the mmse ( + s) was longer than the cas ( + s) but this was not statistically significant. the mmse and cas were significantly correlated (r = , p < . ). the cas was significantly correlated with the behaviour scale (r = , , p < . ) whereas the mmse was not. these results suggest that equivalent assessments of cognitive function may be made with the mmse or cas, but a low cas score will be a better prediction of behavioural dysfunction. a spectrum of neurological and myopathological changes are associated with patients in intensive care units. we observed several patients post discharge from icu who presented with unexplained dysphagia which we suspected may be associated with the neurological complications of sepsis. the particular complication of dysphagia as a neurological manifestation of sepsis has not been documented. our descriptive study presents a series of three patients with persistent dysphagia which may represent a similar phenomenon. we selected patients for the study ranging from - years of age and on the basis of medical history including icu stay, sepsis, and intubation. all patients presented with dysphagia as observed on videofluoroscopy. we studied the video findings in-depth in order to ascertain if similar swailow patterns were present in these patients and if this could be correlated with their medical history. each of the three patients presented with similar dysphagia signs. the oral phase of the swallow was moderately atypical but the pharyngeal phase was significantly atypical. it was felt that intubation alone was not the sole causative factor of this dysphagia. the polyneuropathy associated with sepsis in icu may explain the atypical swallow patterns observed in these patients. the severity of the persistent dysphagia can cause serious respiratory and medical consequences. there is a need for further investigation of this phenomenon to identify patients who are at risk. little attention has been paid to the prevaience and phenomenology of behavioural disturbances among medical patients despite awareness of the high prevalence of cognitive vol. , supplement no. impairment in this patient population. we screened consecutive admissions to a department of acute geriatric medicine. patients were evaluated over a week period using a modified version of the brief agitation rating scale. medication use, cognitive function and impact on nursing time were also measured. the prevalence of behavioural disturbance in this population was / ( %). the most frequent behavioural abnormalities were restlessness ( ), complaining ( ) and screaming ( ). the most common underlying disorders were dementia, stroke disease, personality disorder and paranoid psychosis. the behavioural disturbance was only documented in the medical notes in patients ( %) and in only cases was a psychiatric consultation sought. these findings demonstrate that behavioural disturbances are not only common but also under-documented in elderly medical patients and there is a need for training in the detection and management of behavioural symptoms in this patient group. in lower limb trauma where there is severe compound fracture, the successful treatment of this depends on adequate bone and soft tissue debridement. as a result, subsequent bone defects can lead to instability and often require large amounts of bone grafts, and major soft tissue reconstruction is reaquired to obtain skin cover. large soft defects can by reduced bv primary bone resection and shortening of the limb. this will improve the chance of bone healing if performed in the presence of an external fixator, then lengthening at a site away from the traumatised area can gradually restore limb length. two cases are presented to demonstrate .the effect of compression / distraction techniques on soft tissue and bone injuries in these difficult situations. wegener's granulomatosis -wg ( ), churg strauss syndrome -css ( ), polyarteritis nodosa -pan ( ) and unclassified ( ). using the chc definitions, the diagnoses were wg ( ), microscopic polyangiitis -mpa ( ), pan ( ) and undefined ( ). there was concordance in only patients (all wg). there is significant discordance between these two criteria sets. since the acr criteria does not recognise mpa, they tend to overdiagnose wg. in addition, the chc criteria cannot be applied without a biopsy and therefore surrogate features which predict the underlying histology are required to allow more practical application of the chc definitions. the objective was to determine the value of examination of dried freshly produced saliva, under light microscopy, in patients with xerostomia related to secondary sjogrens syndrome. ten patients with known connective tissue disease or rheumatoid arthritis attending rheumatology clinic were enrolled into the study, all with symptomatic xerostomia and dry eyes. all had an abnormal schirmer's test. five normal patients were enrolled, all of whom were without clinical evidence of rheumatological disease. control patients were enrolled who had no clinical evidence of rheumatological disease, a salivary sample was collected and examined by light microscopy. serum was also examined for the presence of anti-ro/la, rheumatoid factor, and anti-nuclear factor. all ten patients demonstrated 'reindeer horn' type ferning of saliva, a pattern of shorter thicker clubbed branches of crystallised mucus, in contrast to the normal ferning pattern of the healthy subjects. conclusion: we have shown in this preliminary report that light salivary microscopy is a simple test easily performed in an outpatient setting which could be a useful diagnostic procedure in sjogrens syndrome. recently, two sets of criteria have been proposed for the nomeclature of primary vasculitides, the american college of rheumatology (acr) classification criteria and the chapel hill consensus conference (chc) definitions. the aim of this study was to determine the concordance of these two systems in a cohort of patients with primary systemic vasculitis. patients with systemic vasculitis were recruited who had a biopsy proven diagnosis or, who had typical clinical features associated with a postive antineutrophil cytoplasmic antibody (anca). the case notes were reviewed and patients were classified according to both sets of criteria. twenty-six patients were recruited, of whom had a positive biopsy. applying the acr criteria, the diagnoses were, primary pulmonary hypertension (pph) typically affects young individuals, and has a high morbidity and mortality. secondary pulmonary hypertension complicating connective tissue diseases likewise carries a poor prognosis. we evaluated the acute and chronic effects of ketanserin, a selective serotonin type- receptor antagonist in patients with pulmonary hypertension in the acute study ketanserin was administered as a peripheral venous infusion during right heart catheterisation. following encouraging results during catheterisation oral administration of ketanserin mg daily in divided doses was instituted. in patient , a year old female with probable pph, serial cardiac catheterisations over a year period showed a significant, sustained reduction in both mean pulmonary artery pressure from mmhg at baseline to mmhg at year (normal - mmhg) and pulmonary vascular resistance units at baseline to units at year (normal < units). in patient , a year old female with limited scleroderma (crest) echocardiography after month's oral ketanserin showed a reduction in estimated peak right ventricular systolic pressure from mmhg at baseline to mmhg (normal range - mmhg). the acute and long term response to ketanserin with improyement in pulmonary haemodynamics in these patients suggests that if a beneficial effect is detected during catheterisation long term oral therapy may be worthwhile. levels were low (< . iu/ ); normal though above average (>- -< iu/l) and moderate high (> -< iu/l) respectively. gonadotrophins for ovarian stimulation were commencing initially at iu for group a & b and at iu for group c. ivf performance was poor in most aspects (total follicles, oocytes & embryos transferred) in group b comparing with group a or c; the cumulative ongoing pregnancy rate (pr) over ivf cycles in group b; was % comparing with . % in group a (p < . ) however there was no significant difference in pr in group c ( %) comparing with other two groups. cycle day fsh screening is predictive of follicular development in ivf. high initial dose of gonadotropins help to improve the pregnancy rate in the presence of moderate high level of fsh. the purpose of this study was to evaluate patient satisfaction with antenatal care provided in the perinatal day centre (pndc). a self administered questionnaire was administered to consecutive patients. the main indications for referral were suspected small-fordates ( %), non-proteinuric hypertension ( %), glucose tolerance testing ( %), reduced fetal movements ( %) and post-term evaluation ( . %); % were nulliparae. thirty-two percent of patients were reviewed in the pndc on the day of referral; the rest within days. twenty eight percent of patients lived more than miles from the hospital and % spent more than minutes in travelling there. eighty five percent of patients scored their level of satisfaction with the service provided in the pndc as > out of ; only . % would have preferred admission; % said that they would prefer to visit the pndc times per week to avoid admission. the main area of dissatisfaction related to the waiting time for review prior to discharge, with . % of patients waiting over hours. patients attending the pndc report a high level of satisfaction; changes to reduce the visit duration have been introduced. to examine the change of taking-up the essential preconceptual measurements; rubella immune status, cervical cytology and prophylactic folic acid intake; following specific advice and publicity through general public meetings with new patients prior to in vitro fertilization (ivf) programme. in we studied new couples for ivf for the presence of some specific pre-conceptual data (group a). in this study we follow-up the same intake in another new women interviewed to commence ivf programme from january till september (group b). in group (b) the taking-up measurements were dramatically improved. however, % and % stilldid not have rubella immunity test and cervical cytology performed; compared to % and % in group (ai respectively (p< . ). while folic acid intake was sustained at > % in both groups. following specific advice the rate of taking-up of preconceptual measurements prior commencing ivf programme was improved. there is a future need for continuous enhancement of the publicity and advice regarding the importance of preconceptual measurements. the aim of this study was to introduce icsi to ireland for treatment of specific cases of male factor infertility. following an introductory proving period using the bovine model, thirtyeight couples with infertility attributed to the male were selected for an icsi attempt. ovulation induction, oocyte retrieval and luteal management were as described for conventional ivf tm. the average age of patients selected for icsi were . + . years and . + . years for the female and male respectively, with an average duration of infertility of . + . years. a year old woman presented with a three day history of parasthesia in her lower limbs and difficulty walking. neurological examination revealed sensory loss in her limbs and truncal ataxia. rombergs sign was positive. pelvic examination revealed a large pelvic mass that was distinct from the uterus. routine blood investigations were normal. csf culture, ct brain and serum electrophoresis were negative. anti-purkinjie cell antibodies were not present. ca- levels were elevated at micrograms/litre. laparotomy revealed a cm left ovarian tumour. a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy was performed. histology revealed a poorly differentiated clear cell adeno-carcinoma of the left ovary. the capsule was intact and peritoneal washings were negative. she made a good postoperative recovery. she received six courses of carboplatin without ill effect. her neurological symptoms resolved. subacute cerebellar degeneration can occur as a paraneoplastic disorder in ovarian carcinoma. the mechanism by which cancer can cause neurological disorders is not fully understood. paraneoplastic cerebellar degeneration occurs with or without the presence of purkinjie cell antibodies. the aim was to review all red cell transfusions in gynaecological surgery in . a retrospective review of blood bank records and individual charts was carried out. patients underwent gynaecological surgery; ( %) were cross matched and ( . %) were transfused. units were transfused. there were no single unit transfusions. the mean number of units transfused per patient was . this accounted for % of all units transfused this year. % of patients were undergoing elective surgery. the overall cross match/transfusion ratio was . intraoperative difficulty was recorded in % of cases. % of patients were transfused perioperatively and % postoperatively. the percentage of patients requiring blood transfusions in the the main individual operation categories was as follows: radical surgery: %; total abdominal hysterectomy and salpingo-oopherectomy, %; vaginal hysterectomy and repair, %; subtotal abdominal hysterectomy, %; vaginal hysterectomy alone . %; and total abdominal hysterectomy alone %. adverse reactions to transfusions were seen in % of patients. conclusion: the majority of patients transfused were undergoing elective surgery. vaginal hysterectomy was associated with greater blood loss than abdominal hysterectomy. only half of all units cross matched were transfused. dilatation and curettage (d+c) is the most common operation performed in the u.k. the liberal use of d+c has been criticised. the objective of this study was to evaluate the use of outpatient endometrial pipelle biopsy and determine its safety in terms of detecting abnormalities. complications and financial costs were also evaluated. data was reviewed from an active gynaecological unit from february to january , using theatre and outpatient records. a total of d+cs and endometrial pipelle biopsies were performed in this period. malignancies were detected by d+c and by pipelle biopsy. a total of and benign abnormalities were detected by each method respectively. there was a higher complication rate in the d+c group but the failure rate was higher in the endometrial pipelle biopsy group. the monetary savings over this period is estimated at s there were no missed malignancies to our knowledge over the year period since endometrial pipelle bioposy was introduced to this hospital. our study indicates that outpatient endometrial pipelle biopsy appears to be safe, efficacious and economical. while ultrasound findings may sometimes be in conflict with clinical examination, it is the case that there are instances when ultrasound findings have, following subsequent laparotomy, been found to be wholly incorrect. it is therefore not surprising that there remain some gynaecologists who view ultrasound with scepticism, preferring to rely solely of their clinical findings. there have been few studies that directly compare clinical, ultrasound and surgical findings in the detection of pelvic masses. the objective of the study was firstly to directly compare the reliability of clinical and ultrasound examination findings in the detection of pelvic masses proven by subsequent laparotomy and secondly to determine the accuracy of ultrasound in detecting malignancy. this was as a retrospective review of women who underwent a laparotomy because of a pelvic mass between january to february . information was obtained from theatre and patient records. real time abdominal ultrasound was used. findings at laparotomy were correlated with clinical and ultrasound findings. the sensitivity and specificity of ultrasound in detecting a uterine mass was % and % respectively. this contrasts sharply with clinical examination (sensitivity = % and specificity = %). similar findings were obtained when ultrasound was compared to clinical examination in detecting ovarian masses. ultrasouud is capable of predicting benign disease with reasonable confidence but the prediction of malignancy is less reliable. in conclusion, ultrasound is more sensitive and specific in detecting pelvic masses compared to clinical examination. vincent's hospital, dublin. osteoporosis occurring during pregnancy or lactation is a rare event despite the homeostatic demands of the foetus for calcium. we investigated the case of a year old woman who, immediately following vaginal delivery of her first child, developed severe back pain due to a vertebral compression deformity of the second lumbar vertebrae. bone mineral density (bmd) was measured by dual-energy x-ray absorptiometry. calcium metabolism and bone turnover were studied. there was a severe reduction in bmd in the spine (z-score = - . ) and f e m o r a l neck ( z -s c o r e = - . ); but, serial measurements showed no further reduction in bmd. indices of calcium metabolism and bone turnover were normal. pregnancy-induced osteoporosis is a severe but self-limited disorder in calcium homeostasis of unknown aetiology. women with low bmd prior to pregnancy may be at increased risk. in view of increased demand, supplemental calcium and vitamin d should be considered during pregnancy and lactation. crumlin, dublin . the aim of this study was to assess the clinical status on admission and the critical care m a n a g e m e n t of children p r e s e n t i n g with m e n i n g o c o c c a l i n f e c t i o n . t h i s was a retrospective study of the charts of consecutive admissions. mean age was . years (+ . ). the average duration of symptoms prior to admission was . hours (+ . ). on admission . % were hypotensive, . % had clinical signs of haemodynamic instability and . % of cases that had a wood gas analysis on admission had a metabolic acidosis (bases excess < - . ). the mortality rate was . %. % of deaths were hypotensive on admission and all had a metabolic acidosis. of the survivors . % were hypotensive on admission, % had clinical signs of cardiovascular compromise, % were admitted to the high dependency unit, % required invasive pressure monitoring and . % were ventilated and received inotropic support. in this study children presenting with m e n i n g o c o c c a l infection have a high incidence of cardiovascular instability. successful management is dependent on early presentation and initiation of therapy and on aggressive intensive care monitoring and support of the cardiovascular i and vital organ systems. the normal crying curve and incidence of colic for term infants are well known. we studied prospectively the crying pattern and the incidence of colic in preterm'infants to determine if prematurity influenced these behaviours. the subjects were consecutive preterm infants admitted to the cork neonatal units for two and a half months from july . a continuous hour diary was completed on each infant by the neonatal nurses, when the babies were on full oral feeding and no longer required intensive care. the parents completed the diaries 'after discharge. colic was defined according to wessel's rule of threes. two unwell babies were excluded. the duration of follow up was from to weeks. fifty infants were recruited and completed the study ( lost to follow up and one withdi'awn due to sepsis). their mean (range) gestational age was ( - ) weeks and birthweight was . ( . - . ) kg. the mean (range) age of crying onset was x(y-z) weeks; crying, peak 'was x(y-z) weeks and crying offset was x(y-z) weeks. one baby developed colic in the period of follow up. conclusions: the incidence of wessel's colic was less than expected in these preterm babies. the crying pattern according to chronological age was different from that clescribed in term babies. in general preterm babies had a delayed onset of crying, but the pattern became similar to term babies when allowance was made for gestational age. the findings'suggest that the crying patterns of early infancy have a developmental basis. we re-evaluated children who had had rs ( - ), with their closest-age siblings using the wechsler scales, coopersmith self esteem inventory and achenback child behaviour checklist (acbc) (duffy j. et al ). the rs patients' means were consistently lower than that of their sibs. however, comparison of mean raw data, using "t-tests", yielded significant differences only in the acbc scores, in that rs children exhibited significantly more problem behaviours than their sibs (p= . ). after categorisation of iq data, further comparisons between the groups (using x ), found rs patients were significantly more likely to score "below average" in tests of verbal iq compared to their sibs (p= . ). age of onset and clinical stage were also found to be more important predictors of outcome. children less than year of age at onset of rs had significantly lower iq scores on all measures of cognitive ability (p= . ) and more problem behaviours (p= . ) than children over year of age. no significant differences were found in comparison with sibs. clinical stage to which rs progressed affected only verbal iq scores. children in whom consciousness had been impaired had significantly lower iq scores than both their sibs and rs children in whom consciousness was less impaired (p= . ). in conclusion outcome remains cautiously positive, with / rs children attending mainstream schools or in employment without apparent difficulties. a national breastfeeding policy was introduced by the department of health in . factors identified for promotion of breastfeeding were based on the who/unicef "ten steps for successful breastfeeding". we present clinical cases which suggest that one step may need to be modified. the charts of breastfed babies admitted to the special care baby unit were reviewed for one year following the introduction of the national breastfeeding policy to this hospital. thirteen term breastfed babies were admitted because of fever and dehydration. none of the babies had water or bottle feed supplements. ten of the thirteen mothers were primigravida. eleven babies were admitted in the six months following the introduction of an exclusive breastfeeding policy. the nursing staff were then alerted to the risk of dehydration, but two further babies of mums committed to exclusive breastfeeding were admitted in the subsequent six months. routine biochemistry, haematology and a limited septic screen was performed in all babies. three of the thirteen babies had lumbar punctures. the mean (range) weight loss on admission was . ( . - )%. the mean (range) plasma sodium level was . ( - )meq/ and the mean (range) urea was . ( . - . )meq/t. there was no growth from the cultures of the blood, urine, csf and swabs. all the babies were given intravenous fluids and parenteral antibiotics for hours. the outcome was satisfactory in all babies and breastfeeding was reestablished in eleven of the thirteen babies. conclusions: the common factor to these babies was inadequate fluid intake prior to admission associated with stricl~ adherence to the policy, and avoidance of all supplements including water. we conclude that the who/unicef step "not to give food or drink other than breastmilk unless medically indicated" is too restrictive in the immediate postpartum period. . % of children reported headache in the previous months . % of girls and . % of boys reported headache (p < . ). . % of children reported daily headache . % of children reported weekly headache . % of children reported monthly headache . % of children reported headache less often than monthly the percentage of children with headache at each frequency, other than daily, increased with increasing age. in girls headache showed a marked rise at ages , and years. reported prevalence of headache in the past year in to year old aberdeen children was % and % was recorded for swedish children aged , , and years old. this study is the first community based prevalence study of headache in irish schoolchildren. our aim was to test the hypothesis that there is no correlation between the type of feeding & swallowing disorder the child has with the neurological diagnosis or the radiological findings. a further purpose was to develop a classification of the feeding & swallowing disorders which would guide us towards a management plan. a retrospective analysis of the data collected between the years - from the feeding & swallowing clinic at booth hall children's hospital was done. children were included in our study ages ranged from months to yrs. all the children were assessed by the members of the feeding & swallowing team and had videofluroscopic assessment by the same radiologist. neurological signs, speech therapy assessments & videofluroscopy findings were compared between children with spastic quadriparesis & those without. significant differences were noted. a clinical classification was devised using cluster analysis. we conclude that there is no causal relationship between the neurological diagnosis & the type of dysphagia. there are three distinct groups of children who require different strategies of clinical management. surveillance commenced in january to continuously monitor the incidence of surgical site infections (ssi). employing modern optical scanning technology (formic for windows version . , formic limited, london) a questionnaire was designed, which required minimal completion time. the questionnaire includes relevant data based on the american national nosocomial infections surveillance system for ssi including the ssi risk index. surveillance commences at the time of surgery and continues until the patient's discharge. optical scanning technology allows rapid reading of surveillance questionnaires thereby bypassing the bottleneck of manual data entry. by october , details of , procedures had been recorded. the crude ssi rate for these patients was . %. the patient risk index used demonstrated that there were increased chances of developing ssi in certain patient groups. seventy-nine per cent of ssi had presented by the th post-operative day. the length of stay increased by an average of days in patients developing ssi. regular feedback to individual surgeons, theatre and ward staff maintains awareness and highlights possible problems. we recommend optical scanning technology to all those engaged in surveillance work. this system would be especially useful were data collected is transported from outlying hospitals to a central receiving centre for collation and analysis. in francis crumpe published a paper ~ in which he described the therapeutic effect of poisonous mussels (psp) on a case of tetanus. he obtained the mussels from tralee ship canal on the occasion of its infrequent emptying, and entertained the idea of using them in tetanus after treating a young girl with psp who recovered after hours. prior to the use of psp he described it's paralytic effect in two cockrels who both recovered. in concluding his successful use of psp he speculated as to the clinical nature and role of the toxin tralee ship canal was opened in . the water was relatively stagnant and would have contained plenty of nutrients. as such it would have been an ideal habitat for toxic algae which may have been brought across the atlantic as spores in bilge water . the emptying of the canal may well have been done at times of algal blooming. this is the first irish report of psp and a most remarkable use of saxitoxin (?) in the treatment of tetanus, antedating the current management by seventy years. this study was carried out to quantify the published research on smoking in irish medical journals; to ascertain the type of research carried out; and to identify the authors of that research. during the years under study, papers explicitly dealing with smoking were published. only papers appeared in forum. there was a decline in published papers in the eighties with a resurgence in the early nineties. of the papers, a majority were observational and ten were editorials. only one paper dealt with smoking cessation, and one with preventive work. general practitioners were poorly represented as authors. one doctor (prof. r. mulcahy) published at least one paper on smoking in each quinquennium since . this study underlines the relative insignificance of smoking as a topic for research in ireland. a major sea change in attitude will be required if the government's targets for smoking cessation are to be realised, particularly if they are to be achieved by relying on the medical profession. radiology represents a major cost centre within a hospital. lack of awareness of cost amongst doctors may result in the inappropriate requesting of radiology services. this study assesses doctors knowledge of the cost to a tertiary referral hospital of commonly performed radioj'ogical procedures and investigations. doctors were asked to estimate the cost of items namely -chest,x-ray, arch aortogram, ultrasound abdo., lumbosacral spine, barium enema, ct brain, ct abdo., ultrasound abdomen, i.v.p. and percutaneous gastrostomy tube insertion under radiological screening. doctors in st. vincent's hospital were surveyed. doctors as a group overestimated the cost of all individual tests, by margins ranging from % (i.v.p. & gastrostomy insertion) to % (ct brain/ct abdo.) the total cost to the hospital of all items was s consultants'overestimated this total cost by %, followed by registrars, interns and s.h.o's who overestimated the total cost by margins of %, % and % respectively . conclusion: doctors tend to overestimate what radiological procedures and investigations cost a public hospital, often by quite wide margins. thus, any excessive requesting of radiology services by docto.rs is not due to a lack of awareness of their true cost to the hospital. (ded) in dublin. secondly, to identify the major cancers contributing to years of potential life lost (ypll) for the ehb, each cca and ded in males and females. in ireland little work has been done to date on disease specific premature mortality. crude death rates weight all deaths equally; in comparison, ypll emphasise deaths among younger persons and provide a measure of the burden of premature mortality. premature mortality for the deds in dublin for the years and was estimated using ypll, which was calculated by subtracting the date of death form . ypll due to each of the major disease groups were ranked for each ded. seventy-one thousand four hundred and sixty-eight & ) years of potential life were lost in dublin in the and . . % of ypll was due to injury and poisoning, . % to cancer, . % to circulatory disease. however, when the major cause of ypll was established for each ded, injury and poisoning was the number one cause of death in . % of the deds; cancers %, congenital and perinatal conditions . % and circulatory disease %. by emphasising deaths in younger individuals ypll is a valuable tool for planning and monitoring local health promotion initiatives. serum total homocysteine (thcy) levels are inversely associated with dietary intake of folic acid and b vitamins and raised levels have been linked with chd. we have examined the association between thcy concentration and the risk of chd in middle-aged men in british towns. we used a nested case control study design, within an ongoing prospective study, thcy concentration was measured in serum samples, stored at entry to the study, from incident cases of myocardial infarction and controls. cases and controls were frequency matched by town and age group. levels of homocysteine [geometric mean ( %c ) were significantly higher in cases than'controls: homocysteine . ( . - . )gmol/l vs . ( . - . )lamol/l; p = , . there was a graded increase in the relative risk (odds ratio; or) of chd in the nd, rd and th quartile of thcy (or . , . , . ; trend p = . ) relative to the first quartile. adjustment for age, town, social class, body mass index, smoking, physical activity, alcohol intake, hypertensive status, serum cholesterol and serum creatinine did not attenuate this association, (or . , . , . ; trend p = . ). the findings suggest that thcy is an independent risk factor for chd with no threshold level. in summer , a diagnosis of cryptosporidiosis was made in a child who had visited a pet farm. this child had participated in a summer project involving children and nine adults. reports of a similar illness among other project members, prompted an outbreak investigation. a cohort study consisting of two phases was initiated. % ( / ) of project participants responded to a self-administered questionnaire in the first phase. thirteen children met the case definition, of whom seven had cryptosporidium detected in their stools. illness was significantly associated with having visited a pet farm. (p< . ). % of those ill sought medical attention, of whom two were hospitalised the second phase of the cohort study was conducted among those who had visited the pet farm. % ( ) were interviewed. illness was significantly associated with play in sand, to which animals had access, at a stream's edge beside a picnic area (p< . ). contact with various animals was not statistically significantly associated with illness. however the small numbers involved may have obscured such an association. this outbreak highlights a potential hazard for children visiting pet farms and also that cryptosporidiosis is a significant but often overlooked cause of morbidity in healthy children. managers of pet farms need to be aware of the potential for transmission of disease to visiting children. strict implementation of hygiene measures is essential to minimise risk. the mrc vitamin trial highlighted the importance of folic acid in the prevention of neural tube defects(l). since , the department of health has recommended periconceptional folic acid supplements. the objective of this study was to document the knowledge and behaviour of women in child bearing years to periconceptional folic acid. a cross sectional community survey was conducted using an interviewer administered questionnaire in dublin. three hundred and thirty five women took part in the study. approximately two thirds / ( . %) had heard of folic acid. knowledge was significantly associated with higher social class and higher education (p< .o ). few / ( . %) had been advised to take folic acid before pregnancy. only / ( . %) of the women in the study were currently taking folic acid supplements. three quarters of the group ( . %) would be willing to take periconceptional folic acid supplements if they knew it would reduce the risk of malformations. the majority ( . %) would prefer to take folic acid in tablet form. this study clearly shows that few women in childbearing years have been advised on folic acid. however, if advised appropriately the majority would be willing to take periconceptional folic acid in tablet form. future publicity campaigns involving all health professionals should address these issues. unstable intra-articular fractures with or without dislocation of the phalangeal joints often lead to joint stiffness ana loss of function. nine patients with comminuted intra-articular phalangeal fractures were treated in our unit by dynamic external fixator using "pins and rubber bands traction system". the mean age was . years, and the follow-up average was . months. five patients had full and good range of motion in the involved joints. three patients had poor results, and one patient underwent open reduction one week following the original procedure. the technique and our results are discussed. this dynamic frame is compact, comfortable for the patient, easy to apply and allows early mobilisation. careful selection of patients and close follow-up in the first few weeks are needed. this study examines how gp's store and handle vaccines. all gp's in a health board region were invited to take part. gp's were interviewed in their practice premises about how they dealt with vaccines fridges were examined and temperature recorded post interview. oral polio was taken from randomly selected fridges for potency testing. cold chain monitors and freeze watch indicators were used to monitor batches of vaccine stored. of the gp's, ( . %) agreed to participate, used fridges to store vaccine, store vaccine at room temperature. of the fridges, ( . %) had the power supply safeguarded, ( . %) had thermometers, ( . %) had vaccine only stored therein. during defrosting, vaccine was inadequately protected in ( . %). of the gp's who use multi-dose vaccine vials, ( . %) keep them for further use at the end of a day/session, store them at room temperature. ( . %) fridges had temperatures outside the recommended range. ( . %) coldchain monitors indicated vaccine exposed to more than ~ ( %) of the oral polio samples showed a reduction in total titre of live virus, however, none were below the minimum acceptable. this study indicates that vaccine potency could be seriously compromised due to breaks in the cold-chain and suggests the need for guidelines to be drawn up, implemented and monitored to ensure the integrity of immunisation schemes. comparison was made with a study carried out in . in addition the range of antimicrobial agents tested included new oral cephalsporins and quinolones that were not then available. three hundred microorganisms isolated from mid stream urine (msu) samples were examined by standard microbiological techniques. antimicrobial susceptibility testing to antimicrobial agents was performed on significant pathogens (> organisms per ml) by disc diffusion test, and minimum inhibitory concentrations of antibiotics was carried out by e test on organisms found resistant by disc testing. by comparison with resistance amongst e.coli, the most commonly isolated pathogen, had increased for the following: ampicillin by % to %, co amoxyclav by . % from %, trimethoprim by % to % and nitrofuradantin by % from %. no increase in resistance occurred to cephradine ( %), or nalidixic acid ( . %). resistance to cefixime, ofloxacin and ciprofloxacin, was %, no resistance was encountered to cefotaxime. for proteus species resistance to ofloxacin, ciprofloxacin and cefotaxime was %, and for enterobacter sp %. enterococci were sensitive to ampicillin and augmentin but the numbers were small. pathogens isolated from patients domiciled in the inner city were significantly more resistant to nalidixic acid ( %), cefotaxime ( %), cefixime ( %), ofloxacin and ciprofloxacin ( %) than those isolated from patients in rural areas. the purpose of this study is to examine the relative importance of obstetric complications ( c%) in the aetiology of schizophrenia and mania. using the dublin psychiatric case register, birth records of patients with an icd- diagnosis of schizophreniaor mania were obtained. these records were evaluated, for obstetric complications using two scales, the lewis, owen and murray scale (lom) it~ and the parnas scale . the mothers of those going on to develop schizophrenia did not differ from those going on to mania as regards maternal age, parity, social class, or period of pregnancy. however, males who developed schizophrenia when compared to males developing mania, experienced significantly more oc's when rated by the lom scale (p= . ) and.more frequent oc's on the parnas scale (p< . ) of greater severity (p= . ). no significant differences were found between females with schizophrenia and those with mania. dublin. the aim was to evaluate the diagnosis, symptomatology and level of functioning of patients presenting with a first episode of psychosis to a catchment area service and a private psychiatric hospital. all patients presenting with a first episode of psychosis were assessed using the scid-p,,the positive and negative syndrome scale (panss) and the global assessment of functioning scale (gaf). fifty-eight patients ( male, female) ranging in age from to years (mean + sd = . + . ) were included in the study. the mean total panss score was . (sd + . ) and was strongly correlated with the gaf score (p < . ) but independent of age (p = . ). males had a significantly lower gaf score compared to females (p = . ) but there was no gender difference in the total panss score (p = . ), twenty-five patients ( %) had a lifetime prevalence of drug abuse or dependence but only patients ( %) had signs of drug abuse or dependence in the month prior to presentation. level of functioning was strongly influenced by the severity of psychopathology. substance abuse is common in individuals presenting with a first episode of psychosis. the aim was to evaluate the presence of involuntary movements in patients presenting with first episode psychosis to a catchment area service and a private psychiatric hospital. patients presenting with first episode schizophrenia and schizophreniform psychosis were assessed for involuntary movements using the involuntary movements scale (a.i.m.s.). patients ( m., llf.), age range - years (mean= . years.) were included in the study. one patient ( . %) satisfied the strict criteria of schooter and kane for spontaneous dyskinesia. patients ( m., if.), had minimal involuntary movements in at least body areas, predominantly orofacial. the total a.i.m.s. score was positively correlated with the number of days spent in hospital per year of follow up (p= . ). the group with involuntary movements were found to have spent more days in hospital per year of follow up, v. days (p= . ). for patients with first episode schizophrenia or schizophreniform disorder spontaneous dyskinesia is not common. however involuntary movements at presentation may be a predictor of poorer outcome. psychiatry has moved from custodialcare towards care in the community. adequate reprovision will have to be made in order to discharge the remaining continuously hospitalized patients. the objectives of this study were to describe a.n entire long-stay hospital population, to examine the differences between the old and new long stay groups within this populatian and to evaluate the needs for community residential and day care facilities in order for hospital closure to take place. the study group consisted of the total long-stay population of st. davnet's hospital, monaghan. the patients were assessed using the community placement questionnaire (cpq) one hundred and twenty four patients were included in the study. fifty-six were female and % were single. the mean age of the total group was . years. the majority suffered from schizophrenia. the assessment revealed a globally disabled group with multiple handicaps. the new long-stay group were disabled as the old long-stay group. the patients were characterised into four groups with regard to placement recommendations. these were a specialist unit for chronically disturbed geriatrics, a geriatric unit, a high support hostel and a medium support hostel. the remaining population of this hospital were highly dependent with multiple handicaps but would live in community with adequate support. there is little difference between the needs of the old long-stay and those of the new long-stay. failure of the immune system to identify self peptides is likely to lead to the development of an autoimmune reaction. susceptibility to autoimmunity is strongly influenced by genes clustered in the hla region (chromosome p) particularly class i (a, b and c) and class ii (d, q and p). it has been suggested that there is an autoimmune component in the aetiology of schizophrenia. of many conflicting reports from case/control studies using hla antigens the most consistent finding has been an increased frequency of hla-a (now split into a /a ). additionally, a susceptibility locus for schizophrenia has been reported near the hla locus. to attempt to confirm the hla a hypothesis, we have genotyped a preliminary sample of familial schizophrenic probands and unrelated controls at the hla-a region, using a pcr-ssop technique. the frequency of hla-a (the major component of a ) in patients and controls respectively was . % vs . %. these findings do not support the hypothesis. some of the discrepancy may be due to unspecific cross-reactions produced by commercial antisera used in the microlymphocytotoxicity method of previous studies. however it is also possible that the hla associatton with schizophrenia may reflect linkage disequilibrium with unidentified gene(s) within the hla region which is less strong in the irish population. schizophrenia is a common mental disorder affecting about % of the general population with a devastating disturbance of mind and personality. family, twin and adoption studies have demonstrated that the disease is largely genetic with a polygenic mode of: transmission. dopamine receptors have been implicated in the aetiology of the disease. as yet dopamine genes have been identified (d -d ). in particular the d receptor is expressed in the limbic regions of the brain, implicated in the control of emotions. association studies of a d polymorphism (glycine to serine substitution at position ,) with schizophrenia have produced conflicting findings, many of which, however, have demonstrated a significant excess of homozygosity, or excess of the -l genotype at this polymorphism. in this study, familial schizophrenics and irish unrelated controls were genotyped. the result show a small increase in the frequency of the - genotype which did not attain statistical significance (patients, . % vs. controls, . %). homozygosity (alleles - and - ) was also slightly increased in the patients (patients, . % vs. controls, . %). the small increase in the frequency of the - genotype and of homozygosity in the patients is in keeping with earlier findings but suggests that the effect, if any, of d sequence variation in the development of the disease is small. lack of information about general practitioners' (gp's) ability to prescribe psychotropic medication may affect patients' compliance. in this study, out of patients attending a psychiatry out-patient clinic completed a questionnaire which documented how many had run out of medication, the steps taken if they had and the role each patient thought their gp played in their treatment. % indicated that their gp knew what their current medication was but only % thought that their gp could provide them with a prescription if they did not have one from the clinic. this figure was similar in those who had ( %) and had not ( %) run out of medication in the past. on running out of medication, % of patients waited until their next appointment, % attended their gp and the remainder either contacted the department or went to a chemist. in conclusion, many patients do not appreciate the entitlement of their gp's to prescribe psychotropics for them. literature regarding whether or not the social class distribution of patients with psychiatric illness may differ from the general population remains controversial. we sought to clarify this by examining social class at the time of birth, to see whether patients with serious psychiatric illnesses (schizophrenia and mania) differ from the general population. paternal occupation of schizophrenic patients, and manic patients, from the dublin psychiatric case register, were obtained from birth registration details and categorised according to central statistics office criteria, the same-sex previous live birth was used as a matched control. there was no difference between the social class of patients with schizophrenia or mania (p= . ). neither patients with schizophrenia (p=b. ) nor mania (p= . ) differed from controls in social class distribution. paternal social class was found to be related to amount of time spenr in hospital (p< . ', mean= . ), and educational age (p< . , mean= . ) and "age at onset of the illness" (p= . , mean= . ). these results suggest that social class of origin may not be related to the development of either schizophrenia or mania. however, social class of origin may be relevant in terms of presentation of schizophrenia for treatment. cognitive function is widely recognised to be impaired in schizophrenia but there is an ongoing debate as to whether this impairment is generalised or localised, progressive or static, similar in both sexes, or related to symptoms. using the positive and negative syndrome scale (panss)'we measured psychopathology in chronic in-patients ( m, f; mean age . + . ) who satisfied feighner criteria for schizophrenia. subsequent to this, we assessed their global cognitive function using the mini-mental state examination (mmse) and their frontal cognitive function using a new instrument, the executive interview (exit). poor performance on the exit was associated strongly with increasing severity of negative (r=- . , p< . ) but not positive (r=-- . , ns) symptoms,'in both males (r=-- . , p< . ) and females (r=-- . , p< . ). overall exit performance declined modestly with increasing age (r=-- . , p< . ) but this phenomenon was co'nfined to females (r=-- . , p< . ; males: r=-- . , ns). mmse performance was also associated with negative symptoms (r=-- . , p< . ) but decreased mm:e prominently with age (r=-- . , p< . ) and showed no gender difference. frontal dysfunction in schizophrenia appears to be intimately related to negative symptoms over the course of severe chronic illness, and may reflect among males a more static' trait deficit than is accessed by the mmse. this study was supported by the stanley foundation. while determinants of the course of schizophrenia are unclear, emerging evidence suggests that the longer psychosis proceeds unchecked before initiation of anti-psychotic therapy, the poorer may be long-term outcome. we have reported that, among older in-patients, increasing duration of initially untreated psychosis in the pre-neuroleptic era was associated with a deterioration to a state of muteness (after controlling for intervening variables). the current survivors of this population have now been examined more extensively using the positive and negative syndrome scale (panss), the mini-mental state examination (mmse) and the executive interview (exit). among these patients (mean age . + . ), after controlling for age and for the duration and continuity of subsequent antipsychotic treatment, increasing duration of initially untreated psychosis was associated with greater severity of negative symptoms (p< . ) and with lower scores on the mmse (p< . ) but not with executive dysfunction on the exit (p= . ). increasing duration of initially untreated psychosis appears to be associated with the evolution of more prominent negative symptoms and cognitive impairment in a manner consistent with an active, morbid process in schizophrenia that can be ameliorated by anti-psychotic drugs. this study was supported by the stanley foundation and the health research board. patients who are selected and who agree to participate in the royal college examinations play an important role. as psychiatrists and exam organisers, we should be aware of the potentially stressful experience which this might present. the purpose of our study was to elicit attitudes to the exam, and also knowledge of the examination procedure. a questionnaire comprising questions was circulated to patients who had participated in the royal college examinations. responses were received from ( %) of the patients. there were males and females in the responding group. none of the patients had previously participated in the examinations. all of the respondents (n= ) felt that the candidate had been polite towards them during the interview. % (n= ) of the patients were nervous prior to the examination, and this group was predominantly female (n= ). % of the patients (n= ) did not know that they would receive payment for their participation. % (n=l ) did not know that they might be physically examined as part of the examination procedure. % (n= ) of the patients described experiences which had been upsetting for them the results of our study suggest that on the whole patients tolerate the exam procedure quite well. one of the central issues concerning physiotherapists in stroke rehabilitation is the emergence of abnormal tone. rehabilitation involves re-establishing a normal postural control mechanism (ncpm)"~. abnormal tone may develop in the presence of severe sensory and proprioceptive loss. the patients' attempts to move and find a stable base can lead to compensatory movement patterns and asymmetrical postures. positioning is used by physiotherapists to influence the distribution of muscle tone and facilitate symmetrical postures. it is essential that the patient is made aware of his 'position in space' as failure to do so presents no feedback regarding movement resulting in inertia ~ ~. standardised positioning charts have been used in hospitals. the physiotherapist liaises with nursing staff regarding correct use on a hour basis. this study looked at the role of a more individualised approach to positioning in the form of a photograph. patients were randomised to two positioning groups group a standard vs group b photograph, and their positioning was scored by a 'blinded' research physiotherapist over an eight week period. the results of a pilot study on a small number of patients revealed that nursing staff preferred a positioning chart individually tailored to the patient's problems. from a physiotherapy perspective, improved postural awareness correlated with better positioning scores in group b. the prevention of compensatory movements, posture is critical in stroke rehabilitation, the use of an individualised positioning chart requires further evaluation. we discuss the case of a fourteen year old boy who presented with bilateral ptosis present since birth, microcephaly and pigmentory retinopathy"!. he was found to have mild facial and proximal limb weakness. creatinine kinase and ldh were raised. muscle biopsy showed ragged red fibres consistent with a mitochondrial myopathy ~ ~. electron microscopy showed abnormal mitochondria. the term mitochondrial myopathy describes a diverse range of clinical disease ~ ~ and this is discussed. she developed a vasculitic skin rash with pruritis and oedema associated adenopathy, low grade fever and mouth ulcers. lab tests showed leucocytosis, eosinophilia and abnormal liver function. skin biopsy indicated an inflammatory picture without vasculitis. ct thorax confirmed axillary and para-aortic adenopathy. lymph node biopsy confirmed a reactive lymphadenopathy. the aim of. this study was to assess the characteristics of patients referred for pudendal nerve studies over a one year period. consecutive patients were asked a standard questionnaire and nerve studies were performed as described by kiff and swash m and swash and snook~ k of the patients, only were male. the age range was from to (mean ). presented with constipation and with faecal incontinence. two had both symptoms. bladder incontinence was presented in of patients. of these, faecal incontinence was the cardinal symptom in patients, constipation in . patients were nulliparous. of the remaining , had a history of complicated births involving forceps ( ), caesarean section ( ), post partum haemorrhage ( ), breech without forceps ( ) . patients had pelvic surgery and one had major trauma. of patients had bilaterally delayed pudental nerve terminal motor latency (pntml). of people had unilaterally delayed pntml, were right sided, were left sided. had normal studi~s. the range of measurements was . - . ms with a mean of . ms. in conclusionl delayed pntml was seen in of patients with constipation and of with faecal incontinence. pelvic surgery and a complicated obstetric history were significant. urological symptoms were also a common association. the p component of the middle latency-auditory evoked potential is attenuated in response to the second of paired clicks in a normal population. in schizophrenia, this attenuation is minimal. in alzheimer's disease (ad), the results have varied between centres depending on the frequency of the stimuli and the interclick interval. we studied ad patients, elderly controls (ec) and young controls (yc) using a paradigm of sets of paired clicks. in contrast to previous studies, our study demonstrates significantly larger absolute p generation and recovery amplitudes in ad patients compared to elderly controls and young controls. the purpose of study was to establish a simple screening vol. , irish journal of supplement no. medical science test to identify asymptomatic intracranial aneurysms (icas). an association between atherosclerosis and icas is recognised. elevated serum lipoprotein (a) [lp(a)] is an independent risk factor for atherogenesis. we aimed to assess the degree of correlation between serum lp(a) and the occurrence of sporadic ruptured aneurysms and familial asymptomatic aneurysms. lp(a) levels were measured in (a) patients with icas and normal controls, (b) first degree relatives of patients with familial subarachnoid haemorrhage (sah). icas were detected by cerebral angiography. patients with sporadic icas had significantly elevated lp(a) levels when compared with matched controls. mean level was . mg/dl in patients and . mg/dl in controls. in the familial studies, out of i subjects with asymptomatic icas had elevated lp(a) levels. one young female with elevated lp(a) had a pre-aneurysmal dilatation at operation. six out of subjects without icas had elevated lp(a) levels; four of these were in the second or third decade of life and may yet develop aneurysms. conclusions: lp(a) has potential as a biological marker for icas. follow-up studies are required on angiographically negative subjects. we have begun a genetic case-control study to establish if particular apoprotein (a) gene polymorphisms can be correlated with the occurrence of icas. post mastectomy breast reconstruction has undergone several changes in the recent years. attitudes have changed towards the problem from both the patient and the reconstructive surgeon, as aesthetic outcome receives a greater emphasis than previously. there is a shift towards using autologous tissue as a means of reconstruction; these new technically difficult procedures entail a longer learning. centralization of this type of reconstruction in highly specialized centres only will serve the patient better. we share our experience of post mastectomy breast reconstruction spread out over the past five years. seventy-eight consecutive cases of breast reconstruction are included in the study. different techniques of breast reconstruction were used with a recent switch to transverse rectus abdominis myocutaneous (tram) flap; we feet that tram flap is the gold standard of breast reconstruction as far as the ultimate cosmetic result is concerned. ours is only a moderate sized study compared to some published, yet it is representative of the experience of most of the plastic surgery units in the british isles. clinically significant paraneoplastic neurologicaldisorders are rare, most are associated with small cell lung, female genital tract and breast carcinoma. the malignancy is often silent and the neurological manifestations vary from encephalomyelitis, cerebellar degeneration, sensory neuropathy to neuromuscular block. prognosis is usually poor. pathogenesis is thought to be related to cross reaction with neurons of antibody produced to tumour antigens. detection of these antineuronal antibodies in serum has assisted diagnosis of paraneoplastic encephalomyelitis in which anti-hu antibodies are present and cerebellar degeneration, in which anti-yo are found. in our lab, we used avidin-biotin-complex immunocytochemistry to detect anti-hu (cortical neuron antibodies) and anti-yo (purkinje cell antibodies) in patients' sera. tests were performed on human frontal cortex and cerebellum, at in and in , dilutions, with positive and negative controls. of sera, were positive. two patients had repeat positives; in one, antibody titre rose in the second sample. subsequent patient review showed positives ( patients) had identifiable carcinoma with paraneoplastic cns signs, had no identifiable malignancy but had no other cause of their cns disorder and are being followed up; details of one patient were unavailable. these results are similar to other centres. the proliferation of tumour cells despite the presence of tumouricidal mediators could be due induction of a heat shock response, a universal cellular defence mechanism in host cells and possibly tumour cells. protection may be mediated either by increasing intracellular levels or surface expression of heat shock proteins (hsp). the aim was to assess the effect of heat shock induction on tumour cell protection against host effector cells. the heat shock response was induced in sw colorectal cells by either sodium arsenite ( - ~tm for hr) or by hyperthermia ( ~ for rain). monocyte (m )-mediated cytotoxicity or flow cytometry to evaluate surface expression of hsp and hsp were assessed. cytotoxicity showed a significant decrease in all treated groups (p< . ) when compared to the control value. there was also a significant decrease in all groups (p< . ) when compared to the ~ value. no significant alteration in surface expression of either hsp or hsp was seen. conclusion: heat shocking tumour cells significantly protects them from m -mediated tumour cell lysis. since the flow cytometric data indicate that there is no concomitant increase in surface expression of hsp and hsp on the tumour cell following heat shock, it can be inferred that induction of intracellular hsp levels are responsible for the protective effect on the tumour cells. a week qol study in consecutive advanced cancer patients was undertaken to compare the subjective question fact-g with simple subjective global tools (visual analog, categorical scales: vas, cas), objective tools (spitzer qli and ecog performance status) and verbatim patient description. we anticipated the high drop out rate enrolling to achieve complete study patients for statistical purposes. the study sample appeared representative of the advanced cancer population in the usa. generally qol was satisfactory despite the severity of illness. there were significant differences in all measures between those who described qol in verbatim responses as positive and negative, particularly cas, vas, and qli (p< . ). there were significant intercorrelations between qli and ps (observer rated), vas and cas (subject rated) respectively (p< . ). taking patient description as the gold standard, simple, global qol measures e.g. vas or cas are as effective as multidimensional ones (fact-g and qli). irish journal of medical science males had more dysphagia. survival from diagnosis was greater for females </= years (female median months, male median months, p< . ). anorexia was associated with reduced survival since diagnosis in the total population and in males. anorexia anddysphagia were associated with reduced survival from referral. advanced cancer patients were polysymptomatic. symptom prevalence differed with age, gender and cancer site. the pattern of g symptoms was related to gender and severe weight loss. specific symptoms were associated with reduced survival. there was a gender difference in survival favoring females. the administration of recombinant interleukin- (rll- ) is limited by the induction of increased microvascular permeability. the in vivo antineoplastic effects of taurine in combination with rll- were investigated and its impact on the associated vascular leak was examined. lung metastases were established in mice via tail vein injection. ten days after injection mice were randomized into treatment groups. on day the mice were sacrificed; lungs were removed, weighed and metastases counted. treatment of tumour-bearing mice with rll- alone resulted in a significant reduction in tumour nodule incidence compared to a control group, while the~group recei'~ing rll- + taurine showed an even fuither reduction in the incidence of lung nodules. animals receiving rll- showed a significant increase in mean wet lung weight compared to control lung weight, while mean wet lung weight of the rll- + taurine group was significantly less than that of the rll- group.and comparable to control values. animals receiving ril- + taurine in vivo demonstrated significantly enhanced splenocyte-mediated antimelanoma activity ex vivo compared to animals receiving rll- alone. thus taurine may have an important role in modulating both metastatic growth and the associated toxicity of rll- immunotherapy. a prospective analysis of symptoms in , patients on initial referral to the palliative care service of the cleveland clinic was made using the paradox relational database. the median number of symptoms per patient was (range - ). the most frequent symptoms were pain %, easy fatigue %, weakness %. anorexia %, > % weight loss %, lack of energy %, dry mouth %,'eonstipation %, dyspnea % and early satiety %. patients years and under had more pain, sleep problems, depression, anxiety, vomiting and headache (all p< . ).'the prevalence of early satiety, nausea, vomiting and anxiety were greater in females; dysphagia nd hoarseness in males. patients with >/= % weight loss had more gi symptoms; of these females had more nausea, early satiety; the progn.o'stic significance of abnormalities in the p tumour suppressor gene and in the expression of its protein in colorectal carcinoma may be influenced by the method of analysis used. we studied p abnormalities in patients with colorectal cancer followed for more than years. single-strand conformation polymorphism analysis (sscp) was used to detect alterations in exons - of the p gene. paraffin sections were examined immunohistochemically for p overe,xpression with the monoclonal antibody do- (dako) both with and without microwave antigen retrieval. abnormalities of the p gene were found in % of cases by sscp analysis but were unrelated to age, sex, tumour size or differentiation. outcome was unrelated to sscp abnormalities (p= . ). overexpression of p protein was seen in % of cases by immunohistochemistry without microwave antigen retrieval and in % of cases with microwaving. poor long-term survival was related to immunohistochemical expression of p protein either with (p= . ) or without (p= . ) microwave antigen retrieval. these results suggest that immunohistochemical detection of the p protein product may be more useful than sscp analysis of the encoding p gene in identifying those at high risk of colorectal cancer recurrence and death. dublin . the anti-tumour activity of tumour infiltrating lymphocytes (tils) is known to be poor and therapeutic manipulation of these cells has met with little success. suppressor macrophages (smo) influence t cell cytotoxicity and proliferation. we hypothesized that smo are a component of the lymphoreticular infiltrate and that these cells may be related to lymphocyte numbers within the tumour. tgf-b may influence macrophage phenotype. colorectal and breast tumours were obtained within an hour of resection. tumours were dissaggregated with collagenase and dnase for three hours. antibodies was used to identify smo (rfd and rfd ) and t cell subsets (cd and cd ) by flow cytometry on the resulting cell suspension. pre-op blood was collected from patients and tgf-b levelsdetermined by elisa. conclusions: we have shown for the first time that smo, defined by the antibodies rfd and rfd , are present within breast tumours. we have also shown that the balance of t cell subsets is different in these tumours and may be related to smo content. circulating tgf-b levels are increased in breast cancer and associated with greater smo numbers. this was not found to be the case in colorectal cancers. these results imply the existence of a fundamental difference in the make-up of the lymphoreticular infiltrate between these cancers. swelling of the upper limb is an uncommon but well irish journal of medical science recognised complication of breast cancer treatment. in severe cases, patients have limited arm function and feel disfigured. in a pilot study, the incidence of arm swelling following complete axillary clearance in the immediate post-operative period and at long term follow-up was investigated. arm volume measurements were performed using an opto-electronic volometer (bosl medizintechnick, hamburg). both ipsilateral and contralateral arm volumes were assessed. the expected volume of the ipsilateral arm volume was calculated using the formula vr = v = mls for right handed people and v = vr = mls for left handed people (vr and v = volume of the right and left arms respectively). the difference between the expected and actual volume of the ipsilateral arm was expressed as a percentage of the expected volume. twelve patients undergoing axillary clearance for breast cancer were prospectively evaluated pre-operatively, hours and days post-operatively. a second group of patients who had had axillary clearance at least months previously (range to months) were also evaluated. there was no significant change in arm volume in the immediate post operative period. clinically detectable arm welling was found on patients who had undergone axillary clearance at least months previously but none had any impairment of arm function. we conclude that axillary clearance can be performed safely and that arm swelling is an uncommon complication. a larger study is planned to investigate factors such as the influence of pectoralis minor division, duration of the operation and the number of axillary nodes retrieved on upper limb volume. epidermal growth factor (egf) is a potent mitogen and has been shown to accelerate healing of epithelial damage both in the skin an.d the gut. in the skin egf is not produced locally as the requisite mrna is not present but egf receptors are present on the surface of basal keratinocytes. egf is produced in various sites in the gi tract including the submandibular salivary glands. we have hypothesised that as there is upregulation of salivary egf production in some enteropathies a similar situation may occur in disorders of the skin with an associated enteropathy. using a sensitive radio-immunoassay, egf activity was estimated in stimulated saliva from patients with various skin disorders, patients with gastrointestinal disease, patients with mixed dermatological and gut disease and normal healthy volunteer controls. elevated egf activity was found in the following groups of patients : skin cancers, psoriasis, acne, oesophagitis and ulcerative colitis. the hypothesis of up-regulation of salivary egf production in skin associated enteropathy was rejected but the discovery of elevated egf activity in skin cancers and psoriasis may have aetiological and therapeutic implications. the malignant fibrous histiocytoma (mfh) is considered an uncommon malignancy. its potential for invasion, metastasis and death of patient has been reported in literature. it can be confused with other tumours including fibrosarcoma. salient histologic features include cells of both the fibrocytic and histiocytic series. mfh with its high recurrence rate and lethal potential merits an aggressive evaluation and treatment. we present unusual case of recurrent mfh treated in our unit with an open question as to what qualifies to be adequate primary surgical excision. the recommended management of localised merkel cell carcinoma has been wide surgical excision, combined with adjuvant radiotherapy in selected cases. the risk of recurrent regional disease is reported to be between % and %. a year old woman with merkel cell tumour on the cheek is presented; this patient was treated exclusively with radiotherapy to a total dose of gy over days. the tumour regressed rapidly during the treatment, and there were no signs of local or regional recurrence. the patient is still alive and free of disease for months. immune in origin with a heightened cutaneous immune response to ultraviolet light. the coexistence of cad and pbc is a new association which has not previously been documented and may not be fortuitous given the similar pathogenesis of both diseases. chronic actinic dermatitis (cad) is a rare photosensitive disorder which primarily affects elderly men resulting in an eczematous reaction to ultraviolet-radiation and sometimes visible light. the pathogenesis has been attributed to an autoimmune process, possibly in response to a photoallergen which has yet not been identified. we report a year old female patient who developed cad four years after being diagnosed with primary biliary cirrhosis (pbc). abnormal monochromator irradiation tests were detected with narrow band ubv, uva and in addition visible light wavelengths. phot provocation tests induced florid vesicular eczema and multiple patch and photo-patch tests were positive, findings typical of cad. immunoglobulin g was elevated at mg/dl and liver histology was typical of pbc with an elevated anti-mitochondrial antibody. routine biochemical and immunological tests were ~ormal and porphyrin screen was negative. azathioprine mg/day induced remission of cad. pbc is an auto-immune disorder where cell-mediated immunity is impaired, suggesting that sensitized t lymphocytes may cause damage to bile ducts. the pathogenesis of cad may be auto- we present two cases of cutaneous polyarteritis nodosa (pan) associated with seronegative arthritis: the first patient, a year old male presented in complaining of a year history of pain, stiffness and swelling affecting his right ankle. he also noted intermittent tender nodules on the dorsum of his foot and over his ankle over the preceding three years. the second patient, a year old male, presented .in complaining of a month history of tender nodules on his shins, and pain and swelling of his right ankle. skin biopsies of the nodules in both cases showed medium vessel vasculitis consistent with polyarteritis nodosa. neither patient had any symptoms or signs to suggest systemic involvement. the only abnormality. n laboratory investigations for vasculitis was elevated esr. x-rays showed periosteal elevation and new bone formation in case , and were normal in case. . bone scan demonstrated increased uptake at the talo-navicular joint in case and at the fight ankle in case . synovial biopsy and mri confirmed the presence of an inflammatory arthropathy in patient . joint involvement has been a prominent feature throughout the course in both cases requiring aggressive treatment with vol. , irish journal of supplement no. medical science cyclophosphamide and systemic corticosteroids in case . cutaneous pan is a localised cutaneous vascular disorder with a benign chronic relapsing course. in one reviewl, of patients had arthralgias but an association with arthritis has not been emphasized in the literature to date. we conclude that this condition may present as a seronegative arthropathy in which the joint symptoms may be the most prominent feature and aggressive immunosuppresive therapy may be required for control. cardiac transplantation patients have an increased risk of skin disease. in our centre, heart transplants were performed with a year survival of %. eighty three patients are now alive and have required dermatological assessment. the mean age of patient was . years, (range - years); males, females. skin infections were diagnosed in of patients. drug side effects, including sebaceous hyperplasia and steroid acne, were common. in the patients who developed skin cancer, mean time from transplant to development of lesions was . years. eleven of patients had non melanoma skin cancers (nmsc), squamous cell carcinomas (scc), basal cell carcinomas (bcc), giving scc/bcc ratio of : . three of patients had multiple skin cancers, one had tumours. nine of patients had actinic keratoses, two thirds of whom had sccs. nineteen of patients had viral warts, two of whom had sccs. viral warts, premalignant and malignant lesions were located on sun exposed sites. skin complications of cardiac transplantation though mild were very common. the observed incidence of nmsc in age matched cardiac transplant recipients, appears much higher than the expected incidence of . per , population (national tumour registry ). regular dermatological assessment of cardiac transplant patients is necessary to detect skin disease and early skin cancer. the increased incidence of warts and skin cancer in renal transplant recipients {rtr} is well known. the oncogenic potential of unusual human papilloma virus {hpv} types has been postulated from warts and in both premalignant and nonmelanoma skin cancer (nmsc). the possible etiological role of sun-exposure in facilitating the development of hpv associated skin disorders is also suggested. a clinical study to assess the risk factors for development of these lesions in rtr attending the dermatology servic& age and sex matched haemodialysis patients were similarly examined as controls. male and female patients with a mean duration of transplant of . years, range to years. a total of nmsc (range to ), scc and bcc, ratio . : , were excised from rtr of which over % had viral warts, mosle commonly occurring on sun exposed sites and always predated the development of neoplastic lesions. both were associated with mean duration from transplantation, years for warts and . for skin cancer and not the type of immunosuppressive treatment. none of the control patients had similar findings. conclusions: the close clinical association of viral wart lesions and development of skin cancer in these patients suggests a close relationship to immunosuppression, in addition to exposure to ultraviolet radiation. this study highlights the high rate of nmsc in rtr. these patients justify early and regular skin assessments soon after transplantation with advice on sun protection. sensitivity to ultraviolet (uv) light may be established by exposure to broad band uva and uvb radiation. the minimal erythema dose (med) can be determined at individual wavelengths using a monochromator. uv action spectra of photosensitive disorders may thus be constructed. we examine the value of this process in distinguishing two clinically similar photosensitive disorders. the radiation from a xenon arc is separated into component wavelengths using the monochromator. each wavelength is focused on unaffected skin, on the patient's back. the patient is exposed to a range of doses of w radiation. the med is determined for a series of wavelengths from to nm. chronic actinic dermatitis (cad) and drug induced photosensitivity are photosensitive disorders which may have similar clinical history and presentation. ten cad and drug induced photosensitivity patients were tested. uva photosensitivity was seen in % of the latter group. the remaining % had normal mlts as the implicated drug had been discontinued prior to testing. cad patients were sensitive to both wa and wb radiation. forty-three percent of these patients were also sensitive to visible light ( to nm). monochromator light test (mlt) results show that uva photosensitivity dissociated from wb photosensitivity is indicative of a drug induced light sensitive disorder. sensitivity to both wa and wb however indicates a diagnosis of cad. mlts can therefore distinguish between clinically similar photosensitive disorders. bartholomew's hospitals, london. patients with mpd have an increased incidence of both thrombosis and haemorrhage suggesting a pivotal role for; platelets in these conditions. this study aimed to examine platelet activation antigen expression in stable patients with mpd and to examine the predictive value of these antigens prospectively. patients with mpd had p selectin and gp measured using a refined minimally manipulative flow cytometric technique. expression of p selectin -median . % (inter quartile range . - . ), control . % ( . .- . ) and gp -median . % ( . - . ), control- . % ( . - . ), were significantly elevated p< . . patients were followed for a median of months. % experienced thrombosis and % bleeding during follow up. at entry to the study % of patients had previously experienced thrombosis, median disease duration deaths, of which were caused by thrombotic events in which the mpd was a major risk factor. increased expression of p selectin or gp expression failed to predict thrombosis or bleeding in this study. nor was any significant retrospective relationship demonstrated. however, previous thrombotic events were strongly associated with future events (p< . ). this association was independent of disease, duration, age and medication. not surprisingly disease duration was also correlated with thrombotic/bleeding events. taurine levels fall in gut mucosal cells during critical illness. however, taurine transport into human intestinal cells is poorly understood. the aim was to establish the efficiency of taurine uptake by enterocytes, and to examine uptake under stressful conditions. to investigate efficiency of taurine uptake, confluent caco- cells were incubated for time points up to h. in a second study, cells were incubated for h with medium containing dexamethasone and / or cytokines. media for both studies was supplemented with [ h]-taurine. radioactivity was related to mg/ml protein to calculate rate of taurine uptake for each time point. study : uptake exhibited a steady linear response which approached saturation at h. maximal uptake occurred at h after which the rate levelled off. study : dexamethasone alone reduced taurine uptake by . % (p< . ) and in combination with tnf-c~ and ifn ~/ it decreased transport by . %. (p< . ). lps alone impaired uptake by % (p< . ). conclusion: we have established the time course over which taurine transport reaches its maximum rate in caco- cells, and that corticosteroids and cytokines significantly impair uptake of taurine in these cells. elderly individuals have an increased risk of infection suggesting that immune responsiveness is altered with age. changes in the level of proinflammatory cytokine production may be an important indication of any such age related change. using flow cytometry we examined intracellular tnfet, il-lf~ and il- in pbmcs from normal healthy volunteers of different ages ranging from up to yr (n= ). tnf and il levels from pma stimulated cd positive cells (t cells) were shown, using this technique, to increase in an age dependent manner (p< . ). no il- was detected in any t cell sample. no significant differences were observed between the different age groups for tnfa, il- g or il- in cd + cells (monocytes). the age related changes detected by flow cytometry have been confirmed using conventional elisas. this novel method of proinflammatory cytokine detection has detected increased tnf and il levels in t cells from elderly healthy volunteers which may help explain some of the exaggerated inflammatory responses seen in elderly patients. detection of proinflammatory cytokines by conventional elisa or bioassay is problematic due to the presence of naturally occurring biological inhibitors. flow cytometry allows the simultaneous detection of both intra and extracellular antigens thus intracellular cytokine levels can be quantified while cell surface markers allow cell type identification. a range of monoclonal antibodies were examined for tnfcx, il-lg and il- using saponin permeabilisation oft cells (cd ), monocytes (cd ) and epithelial cells (ber-ep ). t cells and monocytes were grown in ~culture, t~p :to hr with or without pma activation, and intracellular cytokine levels were shown to increase with time, with the stimulated samples producing more cytol<ine than the spontaneous.samples (p< . ). elisas performed on these same samples (n--: ) correlated well with the flow cytometric results (r= . ). tnf~x, il- and il- are detectable !n monocytes while only tnfa and il- have been detected in tcells and epithelial cells using this methodology. this novel technique will allow us to identify the cytokine producing cell while also avoiding the influence of the extracellular millieu, thus being useful for a number of research and diagnostic applications. all the viral hepatitides are said to be common in the middle east. hepatitis a viru s (hav) seroprevalence is said to be % in the adult population of gulf countries. hepatitis b, c and d seroprevalence are taken from blood banks data which are biased by selection criteria and the background of blood donors. very little is known about hev in the uae. vol. , supplement no. irish journal of medical science the aim was to investigate the seroprevalence of hav, hbv, hcv, hdv & hev in the uae. we prospectively recruited volunteers drawn from all the uae, socioeconomic classes and from different age groups in both sexes. each donated ml. of venous blood and using an indirect enzyme immunoassay were tested for total ig to hav; hbsag using monoclonal antibody t.o hbsag; for hcv antibodies using recombinant antigens hc- , hc- , c- and ns- , ( rd generations); for total ig to hdv and for total ig to hev. positive samples were retested in duplicate for confirmation. this large sero-epidemiological study clearly shows that hav is decreasing in the uae. hbv is low but significant, hcv is similar to southern european countries, hev is lower than expected and hdv does not exist in hbsag carriers in the uae. reactive oxygen and nitrogen species produced by inflammatory cells plays a role in tissue injury and inflammation. taurine, a bamino acid present in high concentrations in leukocytes functions as an anti-oxidant by scavenging the mpo derived oxidant, hypochlorous acid, to form taurinechloramine. experimental colitis was induced in male sprague-dawley rats and randomised into two groups. one group received tap water whilst the second group was supplemented with taurine ( %). these groups were sub-divided into those receiving tnbs/ ethanol (n= ) or saline (n= ). an increase in wcc count, particularly neutrophils was found in colitis. tat~rine was found to reduce the severity of the disease (ns) usin.g a colon macroscopic score. in the first group, respiratory burst activity was reduced in animals that had developed colitis (p< . ) although mpo activity was augmented (p< . ). nitric oxide production was . and . fold respectively higher in inflamed and non-inflamed areas of the colon than that by normal colonic mucosa. animals supplemented with taurine demonstrated attenuated m po activity (p= . ). administration of taurine did not lead to a reduction in nitric oxide production. thus, taurine appears to have a beneficial role in reducing the severity of disease. a reduction in mpo and respiratory burst may be beneficial in reducing tissue damage. to women subsequently identified by a national screening programme which revealed to be positive for rna of hepatitis c, type lb. were referred to this centre for evaluation. had moderate activity by modified knodell index, mean (_+ . ), bridging fibrosis and a mean alt of ( - ). six months dual therapy was administered. two patients withdrew due to depression ( ) and hyperthyroidism ( ). one patient di d not respond. seven responded with normalisation of alt and negative pcr. eight patients showed improved histology (kai +_ . ), fibrosis was unchanged. adverse reactions in the treated group included marrow suppression ( ) and thyrotoxicosis ( ) . at six months follow up four remain in remission with normal alt negative pcr, three have relapsed, (pcr positive, mean alt ( - ). we conclude that despite adverse prognostic indicators in this homogenous group with chronic hepatitis c, lb and long disease duration, dual therapy with interferon and ribavirin achieved results comparable to prolonged high dose interferon in patients with more favourable initial prognoses. the aim of the study is to evaluate a day course of azithromycin in combination with omeprazole in eradication of h.pylori. twenty-four patients with proved h.pylori infection and peptic ulcer disease were treated with omeprazole mg daily for months plus azithromycin mg daily for days. h.pylori was diagnosed on the basis of clo test and histology. this was done at the beginning and months after the treatment. eradication was defined as negative clo test as well as negative histology. out of patients, patients were lost to follow-up. only patients were analysed. sixteen patients responded to treatment and had successful eradication as well as healing of their ulcers. these included patients with gastric ulcers ( . %), patients with duodenal ulcers, patients with gastric and duodenal ulcers and patients with non-ulcer dyspepsia. five patients did not respond including with non-ulcerative dyspepsia. duodenal ulcers and gastric ulcer. however their ulcers have healed and symptoms relieved and they were treated with other h.pylori eradication regimes. conclusion. in this small study we have shown that azithromycin mg oncedaily for days is an alternative safe effective and well tolerated monotherapy for eradication of h.pylori. it has been suggested that hepatitis c virus (hcv) infection is associated with a high prevalence of autoimmune disease, but that this risk may be diminished in patients who received a low viral load at initial infection. the aim was to determine the prevalence of symptoms, signs and markers of autoimmune disease in a group of women vol. , irish journal of supplement no, medical science infected with hcv contaminated anti-d immunoglobulin. patients, mean age . years (range - yrs) were examined. patients ( %) were rheumatoid factor positive. ana was positive in patients ( %) but titres were / in / . thyroid globulin antibodies were found in patients ( %) with also being tm positive. further patients were positive for thyroid microsomal ab. prevalence of apa, ara, sm were %, % and % respectively. one patient had cryoglobulins detected while antibodies against mitochondria and lkm-i were not found only one patient of was symptomatic. these levels of antibodies are no greater than levels in the general population and similar to other groups infected with hcv contaminated anti-d. these results further support the hypothesis that either low viral innoculum or long duration of infection may in some way result in a low level of autoimmunity. a previous study (ilan et al, arch int. med., ; : - ) suggested that lga deficiency disposes towards hepatitis c virus (hcv) infection in some patients. it has also been suggested.that iga deficiency may occur as a result of the viral infection as a secondary event. the aim was to determine the prevalence of selective and partial lga deficiency in patients with hcv infection using a radio-immunodiffusion technique. serum lgg and igm levels were also examined. immunoglobulin levels were measured in patients, women and men, mean age . years (range - years) infected with blood between and . none of the patients were found to have selective or partial iga deficiency. mean iga = . g/l (range . g. - . g/l). furthermore no patient exhibited deficiency of igg or igm. conclusion : no evidence of iga or other immunoglobulin deficiency exists among this group of patients with hcv infection. while it may be possible that lga levels decrease following infection, no evidence exists that this phenomenon persists in the long term. hereditary non-polyposis colorectal cancer (hnpcc) is the most common form of hereditary colon cancer and accounts for up to % of the overall cancer incidence. the disease is inherited in an autosomal dominant manner andis characterised by predominantly right-sided tumours. hnpcc is caused by mutations in one of four mismatch repair genes. these genes are homologues of the bacterial mismatch repair systerfi and their function is to detect and correct defects in dna. the hmsh gene is reported to account for up to % of cases, hmlhi, hpms and hpms account for %, % and % of cases respectively. we have collected eighteen irish hnpcc families which satisfy the amsterdam criteria for the disease. we have screened the entire hmsh gene in eight of these families. a combination of single strand conformational analysis (sscp) followed by dideoxy sequencing was used to detect defects in the dna. sequence analysis revealed the presence of a novel polymorphismin exon in one family and a possible splice site mutation in the remaining ten families, using a novel mutation detection technique. departments of medicine and immunology, university college hospital, galway. serial iga gliadin antibody (igaga) studies are used as a surrogate for repeated small intestinal biopsy to monitor dietary compliance in treated coeliac patients. we have correlated igaga levels with indices of hyposplenism (platelets and erythrocyte "pits") to determine if either index can be used to monitor adherence to a gluten free diet. the study population of biopsy proven coeliacs was stratified according to dietary status into gluten free diet (groups a) and normal diet (group b). the iga gliadin antibody titres were significantly lower in group a than group b ( . : units p = . ). in group a gliadin antibody titres showed a statistically significant correlation with both platelet (p = . ) and pits count (p -- . ) ; in group b gliadin antibody titres correlated with platelet counts only (p - . ). those ona gluten free diet were further subdivided according t ~ reported degree of adherence to the diet (strict diet -sgfd, lax'diet -lgfd). significantly higher gliadin antibody titres were found in lgfd than sgfd ( . ; . p = . ), but the ptatelet and.pit counts were similar in the two groups. igaga is superior to platelet or pit coums in monitoring dietary'compliance in coeliac disease. hospital, galway. iga endomysial antibodies (igaea) are said to be more specific and sensitive indicators of coeliac disease than iga gliadin antibodies (igaga). initially the igaea substrate was monkey oesophagus and more recently umbilical cord. a new commercial product has becomeavailable using primate smooth muscle (accu track -diagnostic slides). we have undertaken a preliminary study to compare the performance of this lgaea assay and igaga elisa in treated and untreated coeliacs, coeliac relatives and controls. the study population consisted of biopsy-proven coeliacs who were stratified according to "reported" dietary status into good gluten free diet (group a), poor gluten free diet (group b) normal diet (group c) and unaffected coeliac relatives (group d) and controls (group e). elevated igaga (> units) were found in the following groups : a %, b %, c %, d %. igaea were positive in a %, b %, c %. with respect to igaga positivity, there were false positive igaeaa %, b . %, c % and false negative -a %, b %, c %, d %. in this preliminary study in untreated coeliac patients the performance of the igaea test was on a par with the igaga assay. alt and fibrosis may be associated with a non-alcohol steatohepatitis and these processes may be synergistic. finally, number and type of riba bands is not a predictor of inflammatory activity. ~stepping hill hospital, stockport, uk sk je. royal oldham hospital, rochdale rd., oldham ol jh. we investigated upper gut bleeding in patients aged years and over. a proforma addressing demography, drug therapy, clinical status, timing of endoscopy / surgery, and outcome was used. consecutive patients (median age years, range - ) were studied over months. ( %) underwent gastroscopy with a % diagnostic yield. patients had severe oesophagitis, had oesophageal malignancy, had gastric ulcers - of which are malignant and had duodenal ulcers. ulcerogenic drugs were implicated in patients. patients were referred for surgery, operated upon with one postoperative death. had haemoglobins of g/dl or less. all malignant lesions were inoperable. the overall mortality was % reducing to % if neoplasla were excluded. co-morbidity influenced mortality. patients were discharged with a median hospital stay of days. information on cause of bleeding greatly influenced management. the prognosis of gut haemorrhage in the very old need not be so poor. a few require surgery but the majority respond to active medical resuscitation which is a key factor in determining outcome. we advocate low threshold for endoscopy, judicious use of ulcerogens and adherence to guidelines on management of upper gut haemorrhage. haemochromatosis (hh), a common recessively inherited disorder of iron metabolism is closely linked to the hla-a locus on chromosome . linkage studies have demonstrated a close association between (hh) and the hla alleles, a and b ("ancestral haplotype"). heterogeneity at the molecular level may account for the variance in clinical phenotypic expression. the aim was to evaluate phenotypic expression of hh in the presence/absence of the a -b ancestral haplotype. probands ( m: f) from unrelated irish families were investigated. phenotypic variability was assessed with regard to l) age; ) % trans.sat.; ) serum ferritin; ) liver bx iron grade; ) body iron stores and )symptomatology. three males were homozygous for a b , were heterozygous for a b and were non-a b . symptomatology, trans, sat., serum ferritin and liver bx grade were not influenced by homozygousity or heterozygousity for a b . conclusion: there were no significant differences in phenotypic expression on comparison of the three haplotype groups. no predominant genotype appears to be responsible for phenotypic severity in irish families indicating the possibility of multiple mutagenicity of the hh gene. of riba positive anti-d associated chronic hepatitis c patients, were pcr positive but had surprisingly mild disease. the disease status of the pcr negative patients was hitherto uncertain and is the subject of this study. / riba positive patients referred to this centre were biopsied because of elevated alt ( ) or florid symptoms which dated from inoculation ( ). histological activity index * , , , , , (f), (f), , (f), , , , , , , , no bile duct damage, lymphoid follicles or aggregates was observed. / had mild periportal fibrosis (f), of these had steatohepatitis with obesity ( ) and impaired glucose tolerance ( ) suggesting dual pathology. we conclude that riba positive, pcr negative patients have minimal disease activity. elevated the association between the hla locus and haemochromatosis (hh) has allowed early identification of affected siblings. it is unclear what proportion of subjects who are predicted to be homozygous or heterozygous for the disease by hla typing develop the disease. studies correlating clinical features with hla type in families from ireland -a putative source of this celtic trait have not been described. the aim was to correlate clinical, biochemical and pathologic features of hh with hla typing in first degree relatives of probands. initial analyses identified homozygous (hh), heterozygous (hn) and normal (nn) individuals. however, / hn individuals had stainable iron on liver biopsy, confirming hh. further hla analysis revealed homozygous x heterozygous matings and identification of all disease haplotypes within each pedigree allowed final classification of hh, hn and nn individuals. vol. . supplement no. conclusion: this study demonstrates the importance of hla typing in the clinical management of families with hh, furthermore, in multiply affected families the incidertce of homozygous x heterozygous matings is high indicating the high degree of "pseudodominance" in the irish population. the degree of acute hepatic failure after severe trauma and sepsis is related to the extent of hepatocyte (hc) damage and cell death resulting from either necrosis or apoptosis. we have previously demonstrated that tnf-ct and lps can directly lead to hc necrosis, but not apoptosis. recent, studies have shown that reactive oxygen intermediates (roi) and nitric oxide (no) are capable of inducing apoptosis in eukariotic cells. however, it is unclear whether roi or no are involved in hc cell death. the aims of this study were to evaluate the role of no and roi in hc cell death (apoptosis vs necrosis). hcs were isolated from sprague-dawley rats, and cultured with the no donor, sodium nitroprusside (snp) or the roi generation system, hypoxanthine-xanthine oxidase (hx-xod) and h . the effect of lps, tnf-t~, and ifn-y alone or in combitmtion with different antioxidants and the no synthase inhibitor, n-methyl arginine (nma) on hcs was also assessed. snp caused a dose-dependent increase in hc apoptosis. roi generated by hx-xod and h did not induce hc apoptosis, but were responsible for hc necrosis. tnf-ct alone failed to induce hc apoptosis, but when ~combined with antioxidants resulted in increased hc no production and apoptosis. this effect was attenuated by nma. snp also induced hc damage and hc necrosis. moreover, tnf-ct-mediated hc damage and necrosis could be further reduced by the combination of antioxidants and nma. these results indicate that roi preferentially induce hc necrosis, but not apoptosis. induction of no resulted in both hc apoptosis as well as hc necrosis, which suggest that overproduction of no may be detrimental during the sirs. irish journal of medical science intervention was not uniform. mean albumin was . g/ . mean weight was . kg. poor cognitive status greatly increased the requirement for dietetic consultation time. lack of dietetic resources results in inadequate monitoring of these patients following discharge. this study highlights the need for a dedicated clinical nutrition service, for medical services for older people. periconceptual consumption of folic acid has been shown to decrease the incidence of neural tube defects. the preventative strategy of universal food fortification with folic acid presents the possible risk of masking the diagnosis of cobalamin deficiency in pernicious anaemia. in addition, the ultimate longterm effect of universal exposure of adult or foetal cells to a synthetic substance, ie. folic acid, is unknown. in this study, the threshold oral dose of folic acid in a number of foods above which metabolically-unaltered vitamin appeared in serum postprandially was determined in a young and elderly population by microbiological assay of serum pre-fractionated by hplc. subjects on a five-day regime of fortified cereal and bread along with their normal unfortified diet. were shown to have a threshold level of ~g/d, abovewhich unaltered folic acid appeared in the serum. individuals given folic acid in either isotonic saline, milkor white bread exhibited a threshold level of ~tg per serving. from patterns of food consumption in ireland, even moderate levels of fortification are likely to lead to some population groups being exposedto excessive amounts of un-altered folic acid in serum. many older people are nutritionally compromised. there is clear evidence that: nutrition intervention reduces morbidity m and mortality in older patients. to identify the spectrum of nutritional abnormalities referred for dietetic intervention and the problems associated with nutritional assessment, elderly patients were alphanumerically selected from files of the department. of nutrition and dietetics. the most common dietetj.c interventions were: use of supplements %; high protein high calorie diet %; nasogastric feeding %; reduction fat %; iron/thiamine assessment %; high fibre diet %; diabetic diet %; nutrition swall w programme %; lipid lowering diet %. some % referred required nutritional supplements, but the profile of an increase in oxidative stress in cystic fibrosis patients has been suggested. activated neutrophjls in the presence of chronic lung inflammation in addition to increased activity of the electron transport chain in cfmay. increase free radical generation. antioxidant protection against free radical attack is likely to be compromised as a i'esult of deficiencies in fat soluble antioxidants vitamins. in the present study stimulated thiobarbituric aoid reacting substances (tbars) were measured to determine the ability of plasma to withstand lipid peroxidation. copper was used to in!tiate the breakdown of lipids to lipid hydroperoxides and eventually to aldehydes, mainly malonyldialdehyde (mda). pooled cf plasm a and pooled control plasma were incubated for , , , , and min. mda complexes with thiobarbituric acid which absorbs at approximately rim. there is a lag phase where antioxidartts vol. , irish journal of supplement no. medical science in the plasma or tissue protect against lipid peroxidation, then a log phase where the protective effect is overcome and finally the reaction reaches a plateau when lipid peroxidation is complete. absorbance at nm was measured in all samples and zero order and first derivative spectra were obtained. the lag phase appears to be longer in the pooled cf plasma compared with controls. plasma t~-tocopherol levels were within the normal range in both groups, indicatin~ an alternative protective effect in cf. mild hyperhomocysteinaemia is an established risk factor for heart disease. a source of homocysteine in humans is the essential amino acid methionine found in protein of animal origin. in an -week study weekly fasting plasma homocysteine levels were examined in a group of healthy male subjects (n= ) under normal dietary conditions (weeks to ) and in response to graded increased methionine intakes (weeks , , ). nutrient intakes, including methionine, were calculated from x -day food records. under normal dietary conditions weekly mean plasma homocysteine levels were not significantly different (anova) from each other ranging from . + . to . + . ~tm/ . doubling daily methionine intakes (supplementing with mg/ kg/d) did not result in a significant increase in plasma homocysteine ( . + . ~m/ ), however, significant increases were achieved when diets were supplemented with methionine at levels of and mg/kg/d resulting in mean plasma homocysteine levels of . + and . am/ + . , respectively. mean plasma homocysteine levels returned to baseline ( . + . ~tm/l) days post supplementation. we conclude that supplementary methionine results in a significant increase in plasma homocysteine only when levels of five times the normal dietary intake are reached. this study is evaluating the use of a synthetic construct which encompasses primer binding sites for lpl and a variety of cytokine and other transcripts, to quantify lpl expression in cultured human monocyte-derived macrophages. following isolation of total rna at various times during cell culture, its reverse transcription (rt) using random hexamer primers generating first strand cdna and specific amplification of lpl cdna targets by polymerase chain reaction (pcr), generates products identifiable on gel electrophoresis. quantitation of message is obtained by incorporating the pawl construct in the rt assay in varying quantities as an internal standard with known amounts of monocyte-macrophage rna (l~tg). pcr amplification of this construct yields size distinguishable products from that produced by the monocyte-macrophage lpl cdna transcript. pcr conditions for the assay have been optimised at cycles of denaturation (tmin @ ~ annealing ( . min@ ~ and extension (lmin@ ~ lpl mrna has been detected in cultured monocytes and macrophages throughout their differentiation. also increased expression of monocyte lpl mrna has been observed following hr incubations with chylomicrons ( t~g/ x mononuclear cells/ ml)-when compared with controls. interestingly, little or no lipase mrna was detectable in circulating monocytes using identical pcr conditions to preparations of mrna from the day and day cultured cells. this methodology will now permit investigation of the factors controlling lpl expression in cultured human monocytic cells. replacement growth hormone (gh) therapy in adult hypopituitarism is attracting increasing interest. in markussis (l) detected premature atherosclerosis by ultrasonography in the untreated patient we have shown plaque regression with patients on replacement gh (norditropin) in a -month trial. females and males were recruited, mean age . years. at each timepoint plaque characteristics were measured by duplex ultrasound. patients showed a large reduction in plaque size (mean %) after four months treatment (p value < ~ l). similarly, highly significant values in cholesterol, hdl and ldl and apo a are achieved. chol hdl ldl apo a pretreatment . . . posttreatment . w . w . w ~ w achieve a high degree of statistical significance (p< . ). the significant reductions achieved in plaque characteristics in six patients studied who showed plaque formation correlates with other parameters traditionally accepted as reducing cardiovascular risk. hypertension is found in approximately % of patients with cushing's syndrome, but the mechanism is poorly understood. previous studies in our unit have examined levels of exchangeable sodium, plasma renin and angiotensin ii and cardiac sensitivity to phenylephrine. one previous study has demonstrated enhanced pressor responsiveness to noradrenaline in a group of patients with cushing's syndrome due to adrenal adenoma. we have investigated the blood pressure response to noradrenaline in patients with pituitary dependent cushing's syndrome and in controls matched for age, sex and bmi. noradrenaline was infused for minute intervals at five different concentrations between . and . mcg.kg.min -~ multiple systolic and diastolic readings were recorded and the infusion was stopped if the systolic pressure became > mmhg, diastolic _> l mmhg or the systolic pressure rose > mmhg. basehne blood pressure in the patients with cushing's disease (cd) was / + / compared with / + / mmhg in the normal controls (nc). in of the patients with cushing's disease, the test had to be stopped before completion of the protocol, whereas this was necessary in only one control subject the change in blood pressure from basehne to the blood pressure value recorded either at the time the test was stopped or at the peak blood pressure reading during equivalent noradrenaline infusions was compared between the matched pairs. the mean change in diastolic pressure was + mmhg in cd compared with + in nc (p< . ). there was no statistically slgmficant difference in either systolic pressure ( + vs + mmhg) or mean arterial pressure ( + vs + mmhg). these results demonstrate an increased diastolic pressor response to noradrenahne tn cushing's disease. increased pressor sensitiwty to uoradrenaline may contribute to the elevated blood pressure seen in cushing's disease. increased plasma homocysteine (thcy) is an independent risk factor for premature vascular disease. patients with insulindependent diabetes have an increased prevalence of cardiovascular disease. accordingly, we measured plasma thcy concentration in such patients ( - y), randomly selected, and in control subjects. in controls, thcy was higher in males than in females (supine: geometric mean ( % ci): , . ( . , ) v . ( . , . ) i.tmol/l, p< . ), as previously described, but there was no gender difference in patients. male patients, without microvascular complications, had lower thcy than controls (supine: . ( . , . ) v . ( . , ) ~mol/l, p< . ), but values in female patients without complications were similar to those of female controls, thcy significantly correlated with age in diabetics but not in controls, thcy increased in patients with increased severity of microvascular complications, partly due to the effect of age. thcy was higher when standing.than when supine in both controls ( ( . , . ) v ( . , . )lalmol/l, p< . ) and patients ( . ( . , . ) v . ( . , . )l.tmol/l, p< . ). the absence of gender difference, the association between thcy and age, and higher levels with increasing microvascular complications suggest thcy could be of pathogemc significance in iddm patients, despite unexpectedly low levels in male patients without complications. differences.between supine and erect samples may be due to haemodilution of albumin-hound thcy in the latter a review of the treatment outcome of thyrotoxicosis with standard dose/doses of radio-active iodine (sdrai) in consecutive patients presented to the endocrinology department, uchg, from december -december was analysed. the mean pre-treatment levels of free thyoxine (ft ) was correlated with the treatment outcome. there was statistically significant difference in the pre-treatment ft between responders and nonresponders to the first dose rai (p = . ). response with hypothyroidism and/or euthyroidlsm was considered successful treatment / ( %) responded to a single dose rai; / ( . %) and / ( %) responded with euthyroldism and hypothyroidism respectively / ( . %) and / ( . %) responded to the second and third doses of rai respectively giving a total response rate of . % and % respectively. interestingly, / ( . %) patients failed to respond even to the fourth dose rai / ( . %) patients with t toxicosis ( females and male). two responded to the first dose (one with hypothyroidism and the other with euthyroidism), the remaining required a second dose, which produced the same results. no statistically significant difference in the response rate between t and t toxicosis (p = . ) was observed. inherent in the st. vincent declaration targets is the need for continuous data collection and audit. we present preliminary information from the mater database, the first prospective audit of patients from a homogenous irish population. , iddms ( m: f) were identified with the following characteristics (mean + sd), age . + . years, duration of dm + . years, bmi . + . (males) and . + . kg/m (females), hbalc . + . % (n< . %). no male:females differences existed in the above nor in macrovascular complication rate . % (predominantly peripheral vascular &sease and lschaemic heart disease). however, males were more likely to be current smokers ( % vs %, p = ). hypertension rates ( . m vs . %f), cholesterol > . mmol/ ( . m vs . %f) were similar but more males had cholesterol < . mmol/l ( . m vs . %f, p < . ). clinical nephropathy was present in . % of males vs . % in females (p< ) . % had clinical peripheral neuropathy. retinopathy will be described elsewhere. . % of females and . % of males had a history of hyperthyroidism and . % of females vs . % of males of hypothyroidism. . % had history of psychiatric disease. conclusion although not a population based study, care of iddm in ireland is almost totally hospital clinic based cigarette smoking is identified as the major problem to be addressed patients with diabetes meltitus (dm) are at a higher risk of developing vascular complications, including coronary artery disease (cad). we performed a detailed analysis of predictors of cad and its seventy in patients with dm and chest pain patients in total single vessel cad (svd) in , double vessel (dvd) in , and triple vessel (tyd) in on cine contrast angiography clinical, biochemical and dobutamme stress echocardiographic findings are tabulated below for patients with angiographically proven coronary artery disease. patients with tvd had a longer duration of dm ( years) and were more likely to have retinopathy ( %) the sensitivity of dse was excellent for severe disease. conclusion' duration of dm, retinoapthy, and a positive dse were the best predictors of severe cad in a diabetic population with chest pain the haemodynamic hypothesis for the pathogenesis of diabetic microangiopathy argues that an initial increase in microvascular flow leads to sclerosis and disturbed microvascular autoregulation. we have recently demonstrated impairment of vasoconstrictor responses to endothelin- , a potent endothelium-derived constrictor substance, in niddm and have suggested that this could contribute to the initiation of microangiopathy the purpose of this study was to determine whether responsiveness to endothelin-i is also impaired in iddm. non-specific vascular smooth muscle contraction was assessed using high dose serotonin eleven patients with iddm and control subjects underwent forearm blood flow (fbf) measurement by venous occlusion plethysmography in response to local infusions of endothelin- ( pmol/min for minutes) and serotonln ( la g/min for minutes) control subjects showed slow onset vasoconstriction in response to endothehn- reaching maximum at minutes (p< . ) the diabetic group did not respond to endothelin-i group differences were significant (p= . ). the two groups showed similar vasoconstriction in response to serotonln. in conclusion, vasoconstriction in response to endothelin-t is impaired m iddm non-specific vascular smooth muscle contraction is preserved. impaired vascular responsiveness to endothehn-i is a possible common mechanism for the pathogenesls of microanglopathy in ddm and niddm. we measured total corrected (tca) and standardised ionised calcium (lca) in a population of intensive care ( cu) patients (with a mean age of + years, % male) to determine the prevalence of abnormalities in circulating calcium and its possible determinants severity of illness was measured by the apache ii score (acute physiological and chronic health evaluation). for comparison of ica we examined subjects undergoing arterial gases which proved to be normal and non-critically hypoxlc subjects ica was measured on arterial gas samples and corrected for ph % of icu patients had a total ca (unadjusted) of < mmol/l. after adjustment for serum albumin, % of icu patients had an tca < mmol/ % of icu patients had a serum phosphate of < . mmol/ ica in controls was . + . mmol/ and . + . mmol/ in hypoxlc non icu patments (ns) ica in icu was lower: . + . (< . ). tca and lca were not slgmficantly related. tca and ica did not sigmficantly differ between patients who died and who survived in the icu, and they were not related to apache ii score. belfield, dublin . from july to june there was a -fold increase m the annual number of specimens submitted to the virus reference laboratory because of a perceived risk of contracting hiv through a needlestick injury, blood splash, human bite, or through occupational exposure. needlestick-associated specimens also comprise an increasing proportion of 'at-risk' specimens, rising from . % m the year july -june to . % in the year july -june . between july and june a total of patients had specimens submitted for hiv antibody testing after a perceived'exposure to hiv of these only patients had more than specimen taken. although the time of putative exposure is rarely avadable, the median interval between st and nd postexposure specimens for these patients is months with / ( %) lying between to months. if the risk of hiv refection from a needlestlck injury is assessed as sufficient to warrant serological investigation, the timing and number of blood samples are important. a negative report from a single early specimen may not indicate an absence of infection a basehne specimen and follow-up specimens at weeks, months and at a minimum of months post-exposure are recommended appropriate serology for other viral mfections (hepatitis b and hepatitis c) should also be considered. since the beginning of a significant sustained increase in the numbers of hepatitis a cases has occurred. the number of cases m was against in . this reverses the continuous fall observed over previous years. the reason for this increase remains unidentified at present this increase has occurred following a dramatic increase in the total number of hepatitis a igm tests carried out by the vrl since february/ march the increase in the number of tests carried out since this time is primarily attributable to increased hepatitis testing following receipt of hepatitis c-contaminated rhesus anti-d immunoglobuhn. analysis of the age profiles of the positive patients and of all the referrals indicates that . % of positive results were found m patients aged yr or less whdst % of all hav igm tests were performed on individuals aged yr or greater. this raises the question whether greater selectivity should be employed when requesting hepatitis a tests studies report compliance rates ranging from to % in hiv negative patients there has been no comprehensive study of compliance in hiv positive patients. accurate measurements of compliance are not easy; easy measurements of comphance are not accurate "). to determine the compliance rate in hiv posmve patients attending st. james hospital, dublin, one hundred consecutive patients attending the service were interviewed (homosexual , ivdu , heterosexual ). the questionnaire was divided into three sections. firstly, a medical review was completed by the clinicmn which included demographic data, cd count, cdc staging, karnofsky index and prescribed medication. secondly, the pharmacy detailed the medication dispensed to each patient. the third section comprised a patient interwew to determine adherence to, and understanding of prescribed drug therapy. we report an overall comphance rate of %. this was unevenly distrtbuted between the two main patient groups ( % in homosexuals, % in ivdu) the following factors were found to mfluence compliance: number of medications, cdc stage, karnofsky index, dysphagia, educational and socio economic factors. we also found that poor patient understanding of the prescribed therapy significantly affected compliance. the aim was to determine the incidence of stds in patients presenting for hiv testing at the department of genito-urinary medicine, saint james's hospital. a retrospective analysis of all patient notes who presented for hiv testing between july ' and december ' was undertaken. according to clinic policy all patients had been screened for the following stds; neisseria gonorrhoea, chlamydia trachomatls trlchomonas vagmalis, candida, human papilloma virus, herpes simplex virus syphilis and hepatitis b in addition intravenous drug users (ivdus) were also screened for hepatttls c all patients underwent pre test counselhng. sex, age, risk groups and diagnoses were noted. patients presented for hiv testing, of whom % were male, % female, wtth an average age of . years. of the total, % were, or had previously been ivdus. of the total ivdus, were heterosexual males were bisexual and were females . % of the male patients were homosexual and % btsexual there were posmve hiv tests ( % of total); males and female. in this group there were patients with hepatitis c, all of whom were ivdus. no other stds were detected in the hiv negative group hepatitis c was diagnosed in , hepatttis b in , anogenital warts in , herpes gemtalis in , syphilis in , n. gonorrhoea in , t. vagmalis in i, c. trachomatls m , g vaginalis in and candldlasis in . this study confirms the importance of std screening in all patients requesting a hiv test. of the total testing for hiv, % had a concurrent std diagnosis although no stds were identified in the hiv positive group this may be more a reflection on the makeup of the irish hiv positive population, the majority being ivdus, rather than a difference m the mode of sexual toxoplasmosis is the most common opportumstlc infection of the central nervous system in aids patients. in clinical practice the diagnosis depends on clinical, radiographic and serological findings coupled to chnical response to therapy brain biopsy is not routinely performed. in this retrospective review, we describe our experience with diagnosing toxoplasmosis we examined (a) the clinical demographics and presentation, radiographic findings, response to therapy and patient outcome (b) role of polymerase chain reaction (pcr) in detecting toxoplasma gondii from blood and csf samples (c) the usefulness of serology in diagnosing acute infection. all cases diagnosed as toxoplasmosls based on the above criteria were reviewed. pcr to detect toxoplasma gondn dna used primers to the b gene giving a bp amphficatton product serological tests used were sabln-feldmen dye test and latex agglutination. there were cases diagnosed ( m, f, cd - ; cdc iv ). panents unknown to be hiv posmve presented with cerebral toxoplasmosis patients were not receiving continuous systemic prophylaxis against pce diagnostic value oft gondii pcr in blood and csf showed a sensmvlty of %, specificity of %, ppv was % and npv was % determination of lg subtype was of limited value % ( ) of patients were seronegatlve of whom % ( ) had histologically proven disease of these latter cases were pcr negative the dye test was of poor predictive value this review confirms the need to combine all parameters in making a diagnosis of toxoplasmosis in lmmunocompromlsed hosts. the performance of the newly developed, rapid and fully automated m~croparticle enzyme immunoassay abbott imx hiv- /hiv- rd generation plus assay for the detection of antibody to hiv- and hiv- including subtype o m human serum or plasma was assessed the assay was evaluated by testmg specimens from blood donors, diagnostic populations and hospitalized patients, hiv seroconverslon panels confirmed hiv-positive specimens, and potentially interfering specimens. the abbott imx hiv- /hiv- rd generation plus assay showed an overall apparent specificity of . % (lower limit of % ci . %) in the tested blood donor populations (n= t). this comparable to the specificity found for the abbott imx hiv-i/hiv- rd generation plus eia ( %) and the axsym h v- /hiv- assay ( %). the apparent sensitivity of the abbott imx hiv-i/hiv- rd. generation plus assay is at least equivalent to that of the abbott imx hiv-i/hiv- rd generation plus eia and the axsym hiv-i/hiv- assay. of hiv-i seroconversion panels tested, the abbott imx hiv- /hiv- rd generation plus assay detected seroconverslon earlier on up to panels, depending on the comparison assay. among specimens from asymptomatic and symptomatic hiv patients, the abbott imx hiv- /hiv- rd generation plus assay detected ( ) including specimens characterized as hiv- subtype o. the abbott imx hiv- /hiv- rd generation plus assay is an extremely sensltlve and highly specific assay for the early detection of antibody to hiv- /hiv- and shows at least an equivalent performance to the abbott imx hiv-i/hiv- rd generation plus eia and the axsym hiv- /hiv- assay. the fully automated imx instrument system offers ease of use and rapid results on a widely accepted and reliable platform. streptokinase (sk), a kd protein produced by group c b hemolytic streptococci, is a widely used thrombolytic agent. anti-sk antibodies arise either as a result of therapeutic administration of sk or following natural mfection with streptococci although the clinical significance of antl-sk antibodies is not clear, there is evidence that some anti-sk antibodies arising from natural infections can interfere with sk activity tn vtvo, resulting in thrombolytlc failure. to facilitate further investigations of these antibodies, we have developed and validated a highly sensitive functional assay, which measures sk neutralisatlon activity of serum independently of other circulating inhibitory factors in the sample, and a rapid and convenient enzymeimmunoassay for the detection of anti-sk antibodies. analysis of over random serum samples from the local blood bank with the enzymeimmunoassay showed the prevalence of antl-sk antibodies to be approximately %. all the positive samples and an equal number of the negative samples randomly selected were analysed by the functional assay the agreement between the results of the two assays was excellent indicating that our enzymelmmunoassay was a convement method for detection of anti-sk antibodies which could neutrahse sk activity m vitro irish journal of medical science tuberculosis drug therapy, isolation precautions and prophylaxis. conventional methods of detection such as microscopy and culture either lack sensitivity and specificity or are timeconsuming. in this study we investigated the use of a pcr based diagnostic assay for the detection of m. tuberculosis in sputum samples this assay has been developed by bioresearch ireland (bri) and raggio italgene. sputum samples were lysed and pcr amplified using an m. tuberculosis complex-specific primers. the results obtained using the bri/c-trak tm technology were initially compared to the amplicor system (hoffman la roche). both probe detection methods represent fast and reliable methods for the detection of m. tuberculosts in clinical samples. this test is designed to eliminate the possibility of obtaining false negatives. strongyloldes stercoralis infection in humans ts endemic in the tropics. as travel is becoming more common, it will be seen more frequently. two cases of this infection in irish people are described. case i. a year old women had travelled and worked in poor rural areas of mexico for one month, three years before presentation. two and a half years later she developed abdominal discomfort, anorexia and sore throat. myalgia, arthralgta and a transient skin rash began to appear in the next month. eosinophilia, mild anaemia and raised liver blood tests were noted. elisa test for strongyloides was positive but parasites were not seeri in the faeces. ivermectin was given and the patient feels better. case ii. a year old nurse had arthralgia, fatigue and some weight loss for months'. on two occasions in the last four years, she had been travelling extensively in s.e. asia for a total of four months. she was admitted to hospital because of acute fever and loin pain. a urinary tract infection was diagnosed. absolute eosinophil count was i'aised . x ^ / . esr was mm/hr. strongyloides elisa was positive and treatment administered as above. strongylotdes is the most important nematode in the returned tropical traveller. it can multiply and persist within the body for long periods of time and it can cause hypertnfection syndrome, a protean fulminating infection of bowel, lungs, blood stream and brain, in those who are lmmunocompromised. diagnosis can be difficult by stool microscopy. thlabendazole has side effects but ivermectin is safe and effective. june , there was an outbreak of c.difficde-associated diarrhoea (cdad) at st. james's hospital. the aims of this study were to determine the incidence and outcome of cdad in hiv positive and negative patients we prospectively reviewed all patients with diarrhoea, a positive c.difftcile cytotoxin assay, and in whom no other infectious cause for diarrhoea was identified demographic data, history of diarrhoeal episodes, risk factors and outcome were recorded. the incidence of cdad in hiv negative patients was . per hospital admissions, compared to per admissions m hiv positive patients. the average number of courses of antibtotlcs received, in hiv negative patients prior to the onset of symptoms was . , and % of this group were exposed to third generation cephalosporins. hiv positive patients received an average of . courses of antibiotics and no patients received third generation cephalosporins. there were no deaths due to cdad in hiv positive patients however hiv negative patients died from severe pseudomembranous colitis in conclusion we documented a unexpectedly low incidence and complication rate of cdad in hiv positive patients this is surprising considering their multiple hospital admissions and exposure to ant~microbial and chemotherapeutic agents. the number of new positive hiv specimens detected at the virus reference laboratory has risen from a cumulative total of m july of to in september of . we examined our data to determine the proportional make up of these positives by major risk group. in august . % of positive specimens were from intra venous drug abusers (ivda) by september ivda made up % of the total positive hiv specimens. positive specimens from homosexual individuals rose fro.m l % of total positives in august to . % in september there were no recorded positive specimens from heterosexual exposure in august but in september . % of positive specimens recorded heterosexual exposure. a further category which includes blood donors, haemophiliacs, transplant patients and organ donors made up % of total positives in august and in september made up . % of total positives. we further examined our data in order to show when these changes occurred by ascertaining how many new positive patients have been discovered per year in each of the main risk groups. see in the united kingdom echovlrus type (echo- ) is regularly isolated, with nearly reports annually to the central public health laboratory. reports increased during - and overall it is the second most commonly reported echovlrus in the u.k. echo- epldemiology is different to that of other enteroviruses; over % of patients with echo- tsolated are less than years of age echo- shows distinctive and unique cytopathogenic features in tissue culture, and based on sequence analyses, it seems to belong to a separate subgroup of picornaviruses. echo- has been associated with respiratory symptoms in premature infants, myocarditis and severe encephalitis. in an outbreak of acute flaccid paralysis associated with echo- was described in jamaica in six patients, four of whom died. we describe three cases of sudden death in infants associated with echovirus type infection case i: s d. born / / ; birth asphyxia and death at two days of age; echo- isolated on from spleen. this study assessed the antibiotic sensitivity of organisms causing urinary tract infections (uti) among genito-urinary medicine (gum) clinic attenders in order to determine whether it is worthwhile giving tetracycline for dipstick (nitrite) positivity, even in the absence of clinical features of uti. we looked retrospectively at laboratory confirmed uti's diagnosed among gum clinic attenders over a period of eight months. we assessed antibiotic sensitivities of the organisms involved, and determined how many dipstick positive urines which were left untreated turned out to be real uti's. % of uti's were due to coliforms and % of these were sensitive to tetracycline. % of uti's were due to staphylococcus saprophyticus, % due to beta haemolytic streptococcus group b, % due to enterococcus, % due to proteus species and % due to coagulase negative staphylococci. % of nephur positive urines were left untreated. % of these were nitrite positive. failure to treat a positive urine dipstick which turned out to be a uti necessitated a further clinic visit for adequate treatment. nitrite positive urines should be treated as a uti, even in the absence of clinical features of uti, either with trimethoprim or tetracycline. the number of untreated uti's and unnecessary extra visits to gum clinics would have been reduced with the use of judicious antibiotic therapy for nitrite positive urines. strains of enterococci resistant vancomycin have been reported with increasing frequency. in , we investigated an increase in the frequency of vancomycin-resistant enterococcus faecium (vref) among patients in the haematology/oncology unit using pulse-field gel electrophoresis (pfge) to genotype these isolates and to assist in establishing the source of these vref. eighteen clinical isolates of vref from blood, urine sputum and-faeces and two environmental isolates were collected from separate patients between march and july . minimum inhibitory concentrations (mics) to several antibiotics including teicoplanin and vancomycin were determined by agar dilution. pfge were performed following smal restriction endonuclease digestion. antimicrobial susceptibility testing revealed high level resistance to vancomycin and teicoplanin; mics > mg/ l and > mg/l respectively. this antibiogram is consistent with the van a phenotype. pfge of all isolates revealed identical patterns indicating clonal spread of vree subsequent implementation or infection control measures reduced the frequency of vref isolation. pfge proved useful in demonstrating clonal spread of vref and.in emphasising the need for infection control measures. a prospective audit of baeteraemia in our bed teaching hospital was carried out from february to march . clinical and microbiological data were collected on episodes of bacteraemia in patients. of these ( %) were hospital acquired and ( %) community acquired. urinary tract and respiratory tract sources were implicated in % and % of community acquired episodes, making e. coli and s. pneumoniae the commonest community acquired isolates ( % and % respectively). other gram negative bacilli accounted for % and s. aureus for %. coagulase negative staphylococci were the commonest hospital acquired isolate ( %) followed by s. aureus ( %), e. coli (i %) and enterococcus spp. ( %). enterobacter spp. were the second commonest gram negative isolate ( %). central venous cannulae were implicated in % of hospital acquired cases. urinary tract infections accounted for %. % of which were catheter related. invasive diagnostic procedures (angiography, prostate and liver biopsies, sinography) were implicated in t episodes. gentamicin resistance was found in % of hospital acquired aerobic gram negative bacilli and mrsa accounted for % of hospital acquired s. aureus. these figures are higher than expected but may be explained by outbreak of mrsa and gentamicin resistant entercobacter spp. which occurred during the study period. the past severalyears have seen a significant increase in the recognition of moraxella (branhamella) catarrhalis as a respiratory pathogen (~). the pathogenic mechanisms employed by the organism are largely unknown, but adherence may play a role ~ ~. in our investigation the haemagglutinating ' activity of isolates of m. catarrhalis was determined by a microtitre method. no isolate agglutinated horse, chick or sheep red blood cells (rbc). seventeen isolates agglutinated human rbc, x~hile of these isolates also agglutinated rabbit red. blood cells. haemagglutination of human and rabbit red blood cells was inhibited by porcine mucin. galactose inhibited the haemagglutiriating activity of the isolates which agglutinate both human and rabbit rbc and yet bad no effect on the haemagglutinating activity of the isolates which haemagglutinate human rbc alone. .electron microscopy studies of the bacteria demonstrated a diffuse outer fibrillar layer on the surface of haemagglutinating positive isolates, thislayer was subsequently removed following trypsin treatment, as was the haemagglutinating activity. a kda trypsin sensitive protein appears to be associated wfth haemagglutinating properties. mrsa is an increasingly important cause of morbidity, and is spreading from large hospitals to smaller community-based facilities and nursing homes. the objective of this survey was to obtain an indication of the size of the mrsa problem in ireland prior to introducing national mrsa control guidelines. a survey of all microbiology laboratories in ireland was carried out over two weeks in spring . for patients from whom mrsa was isolated during the study period standard demographic and clinical data were requested and period prevalence/ discharges was calculated. all microbiology laboratories surveyed responded. mrsa was isolated from patients during the week period. the period prevalence of mrsa/ , discharges was . . males aged + had the highest rate of infection ( / discharges). half of all isolates were from patients in surgical or medical wards, but % were from community-based sources e.g. gps, nursing homes, hospices. thirty-two percent of mrsa patients were infected rather than colonised. mrsa is clearly a substantial problem in ireland. while it is largely a hospital problem at present, the increasing trend for day procedures and shorter stays means that infection will increase in the community. a survey in a university hospital in the usa revealed % of mrsa cases to be communityacquired. tonsil core specimens were cultured for bacteria including mycoplasma, chlamydia and ureaplasma urealyticum in children undergoing tonsillectomy for recurrent acute tonsillitis. serology for chlamydia and mycoplasma pneumoniae was obtained in of the children. the polymerase chain reaction (pcr) was used to investigate the presence of chlamydia pneumoniae in core tonsil tissue. ureaplasma urealyticum was cultured in three children ( . %) and mycoplasma salivarium in two children ( . %). culture was negative for chlamydia pneumoniae and mycoplasma pneumoniae. the complement fixation test for chlamydia species was positive in / children ( %) indicating previous infection. specific immunofluorescence testing for c. pneumoniae was positive for lgg (titre> ) in / ( %). igm antibody to c. pneumoniae and antibodies to c. trachomatis and c. psittaci were not detected. ninechildren ( %) had titres > to m. pneumoniae. pcr failed to demonstrate c. pneumoniae. aerobic and anaerobic bacteria were cultured from all specimens. the culture of ureaplasma urealyticum in . % of our patients indicates a higher rate of colonisation then previously thought. this study irish journal of medical science demonstrates past infection with c. pneumoniae in % and with m. pneumoniae in % of children with recurrent tonsillitis. however c. pneumoniae and m. hominis do not play a significant role in childhood recurrent tonsillitis. multiply resistant enterococci are increasingly common causes of serious infection in hospitalized patients. high level gentamicin resistance (mic > mga) in enterococci further compromises the therapy of such infections. we have identified seven clinical isolates of enterococcus hirae demonstrating high-level gentamicin resistance (hlgr: mic > i mg/ ). to our knowledge this is the first report of hlgr for this enterococcus species. plasmid analysis has demonstrated the presence of a single, large plasmid in all seven isolates, as well as several smaller plasmids in some of the isolates. filter mating experiments have revealed that in all seven cases, hlgr was transferred to a laboratory recipient e. faecalis jh- by conjugation. plasmid analysis of transconjugant strains confirmed transfer of the large plasmid in all cases. based on restriction enzyme profiles, two distinct conjugative plasmids were identified for the e. hirae isolates investigated. at present we are using southern blot techniques with oligonucleotide probes designed to hybridise to the hlgr determinant found in other species of enterococcus. the results will confirm whether or not the same resistance determinant is responsible for the dissemination of hlgr in the genus enterococcus. dublin . aminoglycosides remain commonly used in the treatment of severe gram negative infection and have conventionally been given on a twice or thrice daily basis. single daily dosing offers advantages with respect to less nephrotoxicity, better bactericidal activity, convenience, nursing time, cost and should avoid subtherapeutic dosing which has a significant impact on outcome. we reviewed serum gentamicin assays from january to december to assess potential toxicity and subtherapeutic dosing in patients who received once daily gentamicin and those who received multiple daily dosing. assays were performed in the study period. of those were random assays and not included. there was a trend towards significantly less potentially toxic levels in the once daily group compared to the multiple daily group (p< . ). once daily dosing produced significantly less subtherapeutic dosing (p< . ). over % of peak assays in the once daily group were in the recommended range. we conclude that current practice of multiple daily dosing of gentamicin leads to significant underdosing and more potentially toxic trough levels. measurement of trough assays only in patients who are treated with once daily aminoglycosides is sufficient and will have considerable cost savings. respiratory, syncytial virus (rs virus) is a major respiratory pathogen of infants less than year old. it occurs in annual epidemics during the winter and early spring in temperate climates. during rs virus epidemics a significant number of infants less than months old are hospitalised with symptoms of bronchiolitis and pneumonia. rs virus exists in two antigenically distinct subgroups, a and b which are known to cocirculate in the same community during the same rs virus season. there is much debate regarding the virulence of one strain over the other. using a panel of monoclonal antibodies specifically directed against the two rs virus strains, rs virus isolates from specimens sent to the virus reference laboratory, university college dublin, over seven consecutive rs virus seasons ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were typed and the rs virus subgroup predominance monitored. subgroup a was the most predominant of the rs virus isolates accounting for . % of the total and was found to be the predominant rs virus strain in six out of the seven rs virus seasons studied. subgroup b predominated in a season in which the number of rs virus detections peaked much later than normal. treatment of fungal infections in patients in intensive care unit (icu.) is usually empiric. the aim of this study was to identify candida species isolated from i.c.u. patients and to test their susceptibility to antifungal agents to enable more directed therapy. forty candida sp. from patients in i.c.u. were isolated from the following sites, blood culture ( ), central venous catheter ( ), chest drain fluid ( ), wounds ( ), catheter urine ( ), bronchial lavage ( ), sputum ( ). strains were identified by standard procedures. minimum inhibitory concentrations of amphotoeracin b, -flucytosine and fluconazole were obtained by agar dilution test and e test. the isolates were identified as c.albicans ( ), c.glabrata ( ), c.krusei ( ), c.tropicalis ( ), c.parapsilosis ( ), c.kefyr (i). all the candida species were sensitive to amphoteracin b (mic = -< mg/l), and flucytosine (mi c= < mg/l). c.albicans and c.parapsilosis were fluconazole sensitive (mic = - mg/l). four of eight c.glabrata were fluconazole resistant (mic = > mg/l). c.krusei, c.tropicalis and c.kefyr were also resistant (mic = > mg/l). wbilst there were no major discrepancies between the agar dilution test and the e test, the agar dilution test was laborious and required a high degree of skill. the e test was easier to read and more reliable results were obtained provided the inoculum was carefully standardised. this study shows that azole antifungals should not be ganglion is probably the commonest tumour encountered in the hand and the wrist. it often arises from tendon sheath or lining of a joint capsul. the treatment can be surgical or nonsurgical, the latter includes aspiration with or without injection of steroids. surgical treatment of ganglion can pose a difficult situation to deal with. it requires hand surgeon to deal with one such problem, we present a year old man with tender mass in the hypothenar eminence. during surgical exploration it was obvious that the ganglion was infiltrating the wall of the ulnar artery, and the histology proved this later. the clinical features, management arid the outcome of this unusual case are discussed. ischaemic preconditioning (ipc) of the myocardium with repeated brief periods of ischaemia and reperfusion (i-r) prior to prolonged ischaemia significantly reduces subsequent infarction. following ipc two "windows of opportunity" (early and late) exist during which prolonged ischaemia can occur with reduced myocardial infarction, we investigated if ipc of skeletal muscle prior to flap creation improved subsequent flap survival and perfusion in either early or late windows. the latissimus dorsi muscles (ldm) of sprague-dawley rats were used. group : (control, n= ). the ldm was elevated as a thoracodorsatly based island flap group : (early ipc, n= ). the ldm was preconditioned with two minute episodes of normothermic global ischaemia with intervening minute episodes of reperfusion prior to elevation. group : (late ipc, n= ). the ldm was elevated hours after ipc ischaemia was created by occlusion of the thoracodorsal artery and vein and the intercostal perforators having previously isolated the muscle on these vessels. muscle perfusion was assessed by a laser doppler perfusion imager. one week after flap elevation the percentage of muscle necrosis was measured by computer-assisted planimetry ipc significantly reduced muscle flap necrosis (table) in both early and late windows. muscle flap perfusion was similar in all groups. this study compares the biochemical, serological and histopathological findings in women with chronic hepatitis c virus (hcv) infection with age-matched women with established autoimmune hepatitis (aih). there is increasing evidence of autoimmunity in hcv liver pathology. because of different treatment regimens for hcv (d-interferon) and aih (steroids, immunosuppression), clear distinction between the two diseases is desirable. liver enzymes (alt, ast, alkaline phosphatase), antinuclear factor (anf), anti-smooth muscle (asm) and antimitochondrial (ama) antibodies are compared for both groups of patients. liver biopsies from all women were compared using the grading and staging system of ishak et al ( ) . the results show that while some women in both groups show elevated liver enzymes, positive anf and asm autoantibodies, the values are much higher in aih. similarly aih patients show overall more severe disease on liver histology. both groups demonstrate poor correlation between histological features and autoantibody titre. we conclude that distinction between hcv and a!h is usually possible with liver histology and serology. some women with chronic hcv and positive autoantibodies however," demonstrate a histological and serological picture suggesting that chronic hcv may be mediated by an immunopathogenic mechanism. irish journal of medical science terminal changes only, showed lymphocytic meningitis and of these also had perivascular lymphocytic inflammation (cd positive) in the subependymal regions, brainstem and choroid plexus. two brains showed purulent meningitis and one case had central pontine myelinolysis probably related to profound metabolic disturbance. basal ganglia mineralization, hiv encephalitis (hive) or hiv leucoencephalopathy (hivl) were not present. these findings differ considerably from those described in us cases, in whom the majority have evidence of hiv within the cns. relatively early death from systemic infection may account for the lack of hive/hivl in these cases. the lymphocytic meningitis and perivascular inflammation may represent an immuno-allergic reaction, previously reported as "early" changes, regarded as important in inducing vascular damage which allows subsequent entry of h v into the brain. the aim of this study is to assess apoptosis in areas of interface hepatitis and spotty necrosis in hepatitis c virus (hcv) infected liver biopsies, and to correlate the degree of apoptosis with severity of histological activity. liver biopsies were randomly selected from a group of type lb hcv positive women. these patients were diagnosed by recombinant immunoblot assay (riba) test and the presence of hcv rna was confirmed using the polymerase chain reaction (pcr). apoptosis was demonstrated in the biopsies by the oncor apoptag in-situ hybridisation technique. the average number of apoptotic hepatocytes per portal tract, and within the parenchyma per x objective, was determined. the modified histological activity index (h.a.i.) was used to score each biopsy. comparison of the results shows that increasing numbers of apoptotic hepatocytes are consistently associated with increasing scores for interface hepatitis and spotty necrosis. it is concluded that apoptosis occurs in hcv infected livers and that it correlates with increasing histological activity .indicating a significant role for apoptosis in the pathogenesis of hcv liver disease. and university of edinburgh, scotland. paediatric aids represents only % of cases worldwide, in most published series parental iv drug use was the main risk factor, cns pathology was a late feature of the disease and antiretroviral treatment had been given. we studied eleven brains from romanian children with probable postnatal hiv infection using standard neuropathological stains and immunostains for lymphocyte markers and hiv p antigen. death was due to systemic infection, mostly pneumonia or gastroenteritis; antiretroviral treatment had not been given. three cases showed we studied the role of the p and bcl- genes in the pathogenesis of post-transplant lymphoproliferative disease (ptl). ten cases were examined by immunohistochemical and molecular methods. immunohistochemistry was performed using standard and antigen retrieval methods, with the p do- and the bcl- oncoprotein clone antibodies. dna was extracted from paraffin blocks and subjected to pcr, and single-strand conformation polymorphism (sscp) analysis searching for mutated p genes. samples showing any evidence of aberrant migrations were further analysed by direct sequencing. pcr was also used to detect bcl- gene rearrangements. we employed a technique called representational difference analysis to search for previously undescribed translocations or deletions which may be involved in breast carcinogenesis. dna was isolated from both invasive ductal carcinoma of the breast and normal tissue from the same patient. following restriction enzyme digestion and tigation of oligonucleotide linkers, pcr was carried out on both tumour and normal dna using oligonucleotide specific primers to obtain a representation of each genome (amplicons). digestion with the same restriction enzyme removed the original linkers, and a second set of oligonucleotides were ligated to normal amplicons only. the tumour derived amplicons were subtractively hybridised to the normal and subsequent pcr was used to isolate fragments unique to the normal dna (difference products). this was possible since oligonucleotides were ligated to normal dna only. following a series of further subtractive hybridisations and subsequent amplifications, purified difference product was obtained. difference products in the size range - bp were obtained. following further rounds of subtractive hybridisation and amplification, purified difference product will be sequenced and characterised by comparison with known gene sequences. the chromosomal location of the affected gene will be established by in-situ hybridisation and somatic ceil hybridisation, using the difference product as probe. protein s is secreted by osteoblasts and case reports of reduced bone mineral density in patients with total protein s deficiency have lead to the hypothesis that this inherited disorder is associated with generalised osteoblast dysfunction predisposing to osteoporosis ~. we have assessed bone formation in patients ( male and female) with total protein s deficiency and controls ( male and female) using two recently available sensitive markers; serum osteocalcin (oc) and serum procollagen carboxyterminal peptide (p cp), both secreted by the osteoblast. the mean total protein s level amongst the patients was _+ % (ref range - %), mean oc was . ng/ml (ref ~'ange . - ng/ml) and the mean picp was . + uga (ref range - ug/ ). in the control group, mean oc was . _+ ng/ml and the picp was + ug/ . there was no statistical difference between both groups using either marker. in conclusion bone formation as assessed by serum osteocalcin and p cp appears to be normal in patients with total protein s deficiency. hereditary spastic paraparesis (hsp) is a variably expressed neurodegenerative disorder which exhibits clinical and genetic heterogeneity. hsp can be inherited in an autosomal dominant (ad), autosomal recessive (ar) or x-linked manner. ad-hsp has been linked to a number of loci. we have ruled out linkage to these loci in a large irish family affected with ad-hsp. the aim of this study was to determine whether ad-hsp is linked to spinocerebellar ataxia loci (sca), sca-i & sca-ii. ad-hsp can be clinically similar to sca. dna was extracted from blood taken from co-operating family members. microsatellite markers spanning the sca-i and sca-ii loci were amplified by pcr. individuals were genotyped and linkage analysis was carried out using the linkage set of programs. significantly negative lod scores were obtained for both sca-i and sca-ii loci. d s gave maximum exclusion of cm on either side of the sca-i locus with a lod of - . at a recombination fraction of . . d s gave maximum exclusion of cm on either side of the sca-ii locus with a lod of - . at a recombination fraction of . . other markers examined also outruled linkage to these loci. we conclude that the gene for ad-hsp is unlinked to the major sca loci. serum vitamin b is frequently measured in the investigation of anaemia, and in screening neurological and other disorders. frequently, patients are found with low serum vitamin b level with a normal hb and without clinical abnormalities relevant to vitamin b deficiency. this study was carried out to determine the significance of a low serum vitamin b level. vitamin b measurements were carried out over an month period using a chemiluminescence method (abbott imx). clinical data was obtained retrospectively. of the samples ( . %) representing patients had a low serum vitamin b level (> pg/ml) with a mean of pg/ml ( - ). data was available on patients. ( %) had a hb below the normal range with median serum vitamin b level of pg/ ml ( - ). ( %) had a normal hb, mcv and mchc with a median serum vitamin b of pg/ml ( - ), and had a normal hb with an abnormal mcv or mch. lft's, autoantibodies, schillings test and bone marrow examination data will be presented. in conclusion in patients with a low serum vitamin b level, there was no significant difference in the b levels in those patients with a normal or a low hb concentration. it would appear that serum vitamin b is a poor discriminatory test but that changing the normal range may not help in screening. low serum vitamin b on its own may not appear to provide adequate grounds for lifelong replacement therapy. of in for males and in for females. as expected the overall incidence of hodgkin's was lower with one third of male and one quarter of female lymphoma cases affected by the disease. a distinct age specific pattern is evident depending on lesion type. marked variation in incidence levels were noted throughout the study region. an extremely varied pattern is evident in the survival rates for lymphoma patients. the cork and kerry rates for malignant lymphoma are relatively low when compared with international levelstzl obstetric complications and schizophrenia: methodology and mechanisms perinatal complications and clinical outcome within the schizophrenia spectrum ) negative symptoms, cognitive impairment and duration of initially untreated psychosis in schizophrenia davnet's hospital, monaghan, and royal college of surgeons in ireland retinal pathology in kearns sayre syndrome mitochondrial dna and disease mitochondrial myopathies: clinical features, investigation, treatment and genetic counselling phenytoin induced pseudolymphoma. a report of a case and review of the literature cutaneous reactions in head injured patients receiving phenytoin for seizure prophylazis hydantoin induced pseudopseudolymphoma branhamella catarrhalis: an organism gaining respect as a pathogen correlation between branhamella catarrhalis adherence to oropharyngeal cells and seasonal incidence of lower respiratory tract infections ) epidem ology and survival rates for all lymphoma patients registered in cork and kerry over the eight year period an indepth review of all lymphoma (icd -o code ) patients registered by the sourthern tumour registry during the eight year period / ~l annual age adjusted rates of . . and . per , were seen for males and females respectively. these levels indicate a lifetime (up to yr) risk references . cancer, the irish experience cancer incidence in five continents volume v immunohistochemistry for bcl- oncoprotein without antigen retrieval gave negative results, but with antigen retrieval, showed positive staining in out of cases. no bcl- rearrangements were detected by pcr. the combination of sscp and sequencing confirmed only wild type dna in all cases, p immunohistochemistry by standard methods revealed positive staining in only one out of nine samples analysed. when the antigen retrieval method was employed for this antibody, positive staining was seen in > % of tumour cells in four further cases.our results suggest that p does not play major role in ptld. bcl- overexpression but not rearrangement may contribute to the development of ptld. transplant arteriopathy (ta) is the major cause of death in cardiac allograft recipients. the pathogenesis is unclear. we have previously shown a plasma cell predominance in the infiltrate of ta, leading us to hypothesise a role for epstein-barr virus (ebv) infection in its pathogenesis. an association between cytomegalovirus (cmv) and ta has previously been suggested. the aim of the study was to investigate the role of epstein-barr virus (ebv) and cytomegalovirus (cmv) in the pathogenesis of ta.we performed pcr for cmv and ebv dna and protein (lmp) in seven cases of ta, involving cardiac allografts. restriction mapping was used to confirm that pcr products were either cmv or ebv dna respectively.cmv dna was found in four cases. ebv dna was found in six of the seven cases and ebv lmp staining was present in six cases. ebv was detected in all cases by either pcr or ihc.our results suggest that ebv infection may play a pathogenic role in transplant arteriopathy. the evidence for a similar role for cmv ~s less strong. st. vincent's hospital. hereditary spastic paraplegia (hsp) is a neurodegenerative disorder characterised by progressive spasticity, primarily of the lower limbs. it can be inherited in an autosomal dominant (ad), autosomal recessive or x-linked manner~ we have identified a large irish family (family a) affected with ad hsp that cosegregates with dementia. three. loci have previously been identified that are linked to ad hsp in families of different ethnic origin. the locus on chromosome is reported to be the major hsp locus. the aim of the present study was to examine family a for linkage to the chromosome hsp locus.dna has been extracted from blood taken from all co-operating family members for genotyping. polymorphic microsatellite markers from chromosomal region p - have been amplified by pcr, electrophoresed on a denaturing polyacrylamide gel and detected by silver staining. linkage analysis was carried out using the linkage series of programs. linkage analysis excluded the hsp gene from the chromosome p locusl the most significant marker was d s , with a lod score of- . for recombination fraction . , thereby excluding approximately cm either side of this marker. negative lod scores were also obtained for the other markers chosen (d s , d s , d s , d s ) excluding cm, cm, cm and cm respectively.the current study has therefore successfully excluded linkage of ad hsp in family a to the major locus on chromosome p. further studies are underway to exclude linkage of hsp in this family from other candidate loci, prior to carrying out a genome wide search. the presence of dementia in this family in association with hsp suggests that a new and as yet unidentified gene is responsible. vincent's hospital. eye and ear hospital, dublin. ched is a corneal endothelial dystrophy characterised by diffuse bilateral corneal opacities resulting in impaired vision. both autosomal dominant and autosomal recessive modes of inheritance have been described. another endothelial dystrophy, posterior polymorphous dystrophy (ppmd) has been linked to qll.we have used homozygosity mapping to analyse a pedigree with autosomal recessive ched for linkage to ql. . all affected individuals are offspring of consanguinous matings. homozygosity mapping is based on the principle that these offspring would be homozygous for genetic markers near the disease gene. homozygous regions would be random between different offspring of these matings, except at the di-sease locus shared by affected offspring.dna was extracted from blood taken from family members, of which have ched. allele frequencies were determined in pooled dna from affected individuals. pooled dna from unaffected individuals was used as a control. at the disease locus, a shift in allele frequencies towards a single homozygous allele would be observed in the affected dna pool. pooled dna was genotyped by pcr for polymorphic microsatellite markers in the region of qll. pcr products were separated on a polyacrylamide gel and visualised by silver staining. similar allele frequencies were observed at these loci in both dna pools demonstrating independent assortment of alleles. in addition, affected and unaffected family members were individually genotyped at these loci and no significant loss of heterogeneity in the affected individuals at these loci was observed. these data indicate exclusion of linkage of the ched gene to qll. key: cord- -t swlp authors: linden, matthias; dehning, jonas; mohr, sebastian b.; mohring, jan; meyer-hermann, michael; pigeot, iris; schobel, anita; priesemann, viola title: the foreshadow of a second wave: an analysis of current covid- fatalities in germany date: - - journal: nan doi: nan sha: doc_id: cord_uid: t swlp a second wave of sars-cov- is unfolding in dozens of countries. however, this second wave manifests itself strongly in new reported cases, but less in death counts compared to the first wave. over the past three months in germany, the reported cases increased by a factor five or more, whereas the death counts hardly grew. this discrepancy fueled speculations that the rise of reported cases would not reflect a second wave but only wider testing. we find that this apparent discrepancy can be explained to a large extent by the age structure of the infected, and predict a pronounced increase of death counts in the near future, as the spread once again expands into older age groups. to re-establish control, and to avoid the tipping point when tti capacity is exceeded, case numbers have to be lowered. otherwise the control of the spread and the protection of vulnerable people will require more restrictive measures latest when the hospital capacity is reached. a second wave of sars-cov- is unfolding in dozens of countries. compared to the first wave, this second wave manifests itself strongly in newly reported cases, but less so in death counts. however, already the increasing case numbers put the mitigation strategy at risk, because with case numbers being too high, local tipping points are crossed, which makes the control increasingly difficult, impedes the targeted protection of the vulnerable people, and leads to self-accelerating spread [ , ] . importantly, a tipping point is reached when case numbers surpass the test-trace-and-isolate (tti) capacity of the local health authority, thus potentially long before hospitals are overwhelmed [ ] : when tti breaks down, testing and tracing can only be carried out insufficiently and with considerable delay, which leads to more and more missed chains of infections. thereby increasingly more sars-cov- carriers remain unnoticed, and thus transmit the virus inadvertently -also to people at risk. as unaware carriers are strong drivers of the spread of sars-cov- , the case numbers start to rise more quickly, and the spread spills over to the vulnerable population. in the following, we present evidence for a second wave and the crossing of this tipping point. in germany, as in many other countries, the emergence of the second wave has been questioned, because only the case numbers have been rising since july, while hospitals were not overwhelmed and death numbers stayed almost constant (fig. ) . we investigated this apparent discrepancy using age-stratified case and death reports [ ] , and an age-dependent infection fatality rate (ifr). the ifr is derived from a meta-analysis of seroprevalence studies and extensive pcr tracing programs [ ] . approximately, the ifr increases by a factor of for every years of age, being about % at age . from this age-dependent ifr we predict the temporal evolution of the covid- associated deaths by delaying each age group's observed weekly cases by two weeks and multiplying by the ifr (see supplementary material). (left) , and the number of predicted and actual covid- -associated deaths are displayed for each age group (middle). the observed number deaths (black) in each age group matches well the predicted deaths calculated from the case numbers (color) using an age-dependent infection-fatality rate from a metaanalysis [ ] . despite a rise in total reported cases since mid july (bottom), cases in the older age groups only started to rise in september (blue arrows). as a consequence, a rise in deaths is expected to unfold soon (right). the forecast scenarios a and b (gray, right column) predict a further increase in case numbers and deaths. the recent rise of infections in the older age groups together with the overall rise in cases clearly indicates a loss of control over the spreading and the start of a second wave. the temporal evolution of the predicted covid- associated deaths (color) matches the actually observed ones (black) well in each age group (fig. , right) . even the absolute numbers match, suggesting a low fraction of unobserved sars-cov- infection chains. this agestratified analysis plausibly resolves the apparent discrepancy between the total reported infections and deaths: the rise in reported cases has been mainly driven by younger generations (younger than ), who contribute only little to the absolute death counts, whereas the elderly ( + years) managed to maintain low case numbers until recently. however, in september cases among the elderly started to increase steeply. this finding is not confounded by increased testing, because the test numbers in that age group stayed almost constant [ ] . this spill-over to the elderly strongly suggests a failure to protect the vulnerable people due to an increased number of unaware sars-cov- carriers. moreover, this loss of control over the spread is also marked by the increase of the reproduction number r since begin of october (table i ). the spill-over and the increase of r are clear signatures of crossing the tipping point to uncontrolled spread. during summer , the age groups + apparently were protected well: if the virus had been spreading independently equally among all age groups, an estimated . % to . % of the infected would have died (calculated from the ifr in [ ] ). however, the case fatality rate cfr was only . % in august (table i) . now, with the strongly increasing number of infections among the elderly (fig. ) , the cfr will most likely increase soon. this indicates that protecting the people at risk might be possible whilst case numbers are low, but likely fails under high covid- incidence. for the coming two weeks, the already reported cases clearly predict that the number of weekly deaths will almost double. beyond two weeks forecasts are difficult, because the death counts depend on the not-yet-reported cases. to account for this uncertainty, we display two future scenarios, where in (a) we assume a linear increase, and in (b) an exponential increase in cases (see supplementary material). the resulting forecasts range between and weekly deaths in early november, but case numbers might even grow faster in case the second wave fully unfolds. if the test-trace-and-isolate (tti) system is overwhelmed and stops to function as a powerful means of control, mitigation of the spread breaks down and the rise of case numbers accelerates [ ] . thus, the current development in germany puts the past successful management of the pandemic seriously at risk. to re-establish control and to avoid crossing the tipping point when the tti capacity is exceeded, case numbers have to be lowered without further delay. otherwise the control of the spread and the protection of vulnerable people will inevitably require much more restrictive measures -at latest when the hospital capacity is reached. a. data sources for germany, the age-stratified data used in this document was retrieved from the national health agency, the robert koch institute (rki): both the number of reported sars-cov- cases and the number of deaths are available in age groups of ten years [ ] , and the reported cases are also available with -year stratification up to the age of from [ ] . it was verified that the number of cases in the two sources matches. the time points of the case and death numbers correspond to their reporting dates, and not necessarily to the actual testing or date of death. the population age distribution of germany was retrieved from the united nation's database [ ] . b. ifr calculation the overall goal is to estimate death numbers from past reported cases per age group and compare them to the observed number of deaths. we used an age-dependent infection-fatality rate (ifr) equation, following recent meta-studies [ , ] : let a be the age of an infected person. then the infection fatality rate for this age is estimated as this equation formalizes that at years, the ifr is % and decreases by a factor of every years. the age group + is treated separately as %, in accordance with the supplementary calculations in [ ] . in our analysis, we omit cases below the age of , as the weekly reported death numbers in that group are too low for any meaningful analysis. the equation ( ) is very close to the published one [ ] , but has been rounded to integers for simplicity. for comparison see table ii. as reported cases are available with -year stratification, equation ( ) was evaluated centered in the respective age group. for instance, the ifr of the age group - is approximated as: one has to distinguish this ifr calculation from the cfr calculation which we calculate by simply dividing the number of deaths by the observed cases two weeks before, as discussed in more detail in paragraph h. c. estimating the number of deaths from the reported sars-cov- cases the number of deaths is estimated by multiplying the published weekly number of reported cases in -years-wide age groups by the associated ifr (equation ( )). to obtain the time point of the expected number of deaths, we delayed the number of reported cases by two weeks. this accounts for a one week delay between infection and case reporting, and a three weeks delay between infection and death. thus, the total delay of two weeks between reported case and death amounts to the difference between the infection-case and infectiondeath delay. in addition, two weeks matches a median delay of days, which can be derived from individual case histories supplied by the rki's publicly available database [ ] . an alternative approach would have been to take those case histories, infer a delay-distribution between reporting and death with a one-day temporal resolution and predict daily deaths. unfortunately, the age-groups of this dataset are between and years wide, compared to year groups with weekly temporal resolution [ ] . due to the strong age-specificity of the ifr we opted for smaller age-groups. the observed number of deaths is only available in -years-wide age groups. thus, to match the coarser stratification, we summed the corresponding two -yearswide age groups for all the plots. d. uncertainties of predictions our estimations features a number of uncertainties: the ifr probably decreased over the course of the pandemic because of better treatments. this leads to some overestimation of the ifr as reported by levin et al [ ] , which uses data from early in the pandemic. a fraction of cases remains unobserved, and people at risk may protect themselves better than earlier in the pandemic. moreover, the assumed two-week delay between case detection and death is an approximation, the observed delay of individual cases features a wider distribution. overall however, the evidence indicates that in germany half or more of all cases are currently detected [ ] . in relative numbers across age-groups, uncertainties are smaller, because systematic errors in the ifr and the delay approximations are expected to effect all age groups similarly. e. accounting for non-matching age groups if reported cases are not available with a -year stratification, but only coarser , we distribute the reported cases of the coarser age groups in -years-wide age groups, proportional to the population-age distribution of the respective country [ ] . this approach is necessary for ages above years for germany, where only -years-wide age groups are available: - , - and +. f. prediction we consider two distinct scenarios for the future spread of the virus. scenario a is a linear extrapolation fitted to the reported cases in the respective age groups over the last weeks, which we chose since linear growth can reflect the local and heterogeneous spreading of sars-cov- . furthermore, scenario b is an exponential forecast using the reproduction rate r = . given by the rki [ ] in early october and represents a worser scenario. for the forecast, the corresponding weekly increase of . % is applied to the latest week of age-stratified case numbers. g. effective infection fatality rate the effective infection fatality rate ifr eff is defined as the infection fatality rate given the age distribution of reported cases. it is calculated by weighting the ifr of the age groups (eq. ( )) by the number of current reported cases. this approach to calculate the effective ifr accounts for varying case distributions within the age groups, which therefore leads to a time-dependence of the effective ifr. note that this ifr eff is not a case-fatality rate, because only the age distribution of reported cases is used to weight the ifr(a) in each age group appropriately; this is different from the case-fatality rate, which corresponds to the ratio of observed deaths to reported cases. we used this definition of an effective ifr to calculate the effective ifr for germany assuming eq. ( ) and a case distribution proportional to the population's age distribution: ifr de mix = . . with equal spread across all age groups, % of deaths would originate from the + age group (tabl. ii). with values from [ ] for the age-specific ifr (instead of eq. ( ) h. case fatality rate in order to compare the theoretical effective infection fatality rate to the actual reported deaths, we calculated a case fatality rate. the approach was to divide the number reported deaths occurring two weeks later by the reported cases. this doesn't take into account the wide distribution of delays between infections and deaths. we mitigate the errors introduced by this simple assumption by using at least weeks of data (tab. i). i. testing the steep increase in the number of cases throughout all age-groups starting in october is not driven by increased testing activity: between the end of june and the end of september, the rate of positive tests stayed below % except for the age group - , which stayed between - . % [ ] . until mid-september, it even remained below . % in the age groups - and +. in conjunction with a consistently high number of tests of - per in the age group +, well above the - tests per in the other groups, we assume adequate coverage of that age group, and as a result a constant low number of undetected cases. the twofold increase in overall testing from beginning to end of august, to million tests per week [ ] , was driven by tests in the age groups < , temporarily lowering the fraction of positive tests in those groups until mid-september. from then on the number of tests continues to be around million tests per week, leading to our conclusion that the increase of cases since september is not driven by increased test activity. [ ] evaluated at the center of the age group alongside % confidence interval bounds. the second column list the ifr values used in the analysis, which are calculated using eq. ( ). the right half displays the predicted and observed percentage of deaths in each age group, cumulatively summing over all preceding age groups. for the estimated percentage for germany, the age-specific ifr from the rd column is multiplied with the fraction of population in the age group. the observation refers to deaths in weeks - [ ] . the observed fraction of deaths was almost twice as large as the estimated one in the age group up to years (last two columns), reflecting that the virus spread more among the younger people than expected. these columns also show that . % ( . %) of all deaths are expected among the age group up to , thus almost % ( %) of all deaths are expected to originate from the age groups + assuming age-independent (or age-dependent) spreading. eine zweite welle von sars-cov- breitet sich in dutzenden von ländern aus. die zweite welle zeigt sich zwar stark in neu gemeldeten fällen, aber im vergleich zur ersten welle weniger in der zahl der todesfälle. jedoch gefährden bereits diese steigenden fallzahlen die eindämmung von covid- , denn bei zu hohen fallzahlen werden lokal kipppunkteüberschritten, was die kontrolle erschwert, den gezielten schutz von risikogruppen behindert und zu einer selbstbeschleunigenden ausbreitung führt [ , ] . ein kipppunkt wird erreicht, wenn die täglichen neuinfektionen die kapazität einer lokalen gesundheitsbehördeübersteigen, so dass sie nicht mehr effektiv testen und kontakte nachverfolgen können (tti, test-traceisolate). diese situation kann eintreten lange bevor die krankenhäuserüberlastet sind, und ist daher besonders kritisch [ ] : wenn das tti zusammenbricht, können tests und rückverfolgung nur unzureichend oder mit großen verzögerungen durchgeführt werden, wodurch infektionsketten zunehmend nicht erkannt werden. dadurch bleiben mehr sars-cov- -träger unentdeckt und können das virus unbeabsichtigterweiseübertragen -auch auf risikogruppen. da die unentdeckten träger die ausbreitung entscheidend vorantreiben, steigen die fallzahlen immer schneller und ansteckungen breiten sich auch in vorher effektiv geschützten risikogruppen aus. im folgenden präsentieren wir hinweise für eine zweite welle und dië uberschreitung dieses kipppunktes. in deutschland, wie in vielen anderen ländern, ist die entstehung einer zweiten welle in frage gestellt worden, da nur die fallzahlen seit juli gestiegen sind, während die krankenhäuser nichtüberlastet waren und die todesfälle nahezu konstant blieben (abb. ). wir untersuchten diese offensichtliche diskrepanz anhand von altersstratifiziertn fall-und sterbezahlen [ ] und einer altersabhängigen infektionssterblichkeitsrate (ifr, infection fatality rate). die ifr basiert auf einer metaanalyse von seroprävalenzstudien und umfangreichen pcr-tracing-programmen [ ] . die ifr steigt für jedes . lebensjahr etwa um den faktor und beträgt im alter von jahren rund %. aus dieser altersabhängigen ifr prognostizieren wir die zeitliche entwicklung der covid- -assoziierten todesfälle, indem wir die wöchentlich beobachteten fälle jeder altersgruppe um zwei wochen verzögern und mit der entsprechenden ifr multiplizieren. weitere informationen und ergebnisse finden sich in den "supplementary material". der zeitliche verlauf der vorhergesagten covid- assoziierten todesfälle (farbig) stimmt mit den tatsächlich beobachteten (schwarz) in jeder altersgruppe gutüberein (abb. , rechts). selbst die absoluten zahlen stimmen uberein, was auf einen niedrigen anteil unbeobachteter sars-cov- -infektionsketten hindeutet. unsere altersstratifizierte analyse löst die scheinbare diskrepanz zwischen den insgesamt gemeldeten infektionen und todesfällen plausibel auf: der anstieg der fig. . die anzahl der wöchentlichen covid- -fälle (links) sowie die anzahl der prognostizierten und beobachteten covid- -assoziierten todesfälle werden für jede altersgruppe (mitte) angezeigt. die vorhersage der anzahl der todesfälle anhand der fallzahlen (farbig) stimmt mit den gemeldeten todesfällen (schwarz) in jeder altersgruppe guẗ uberein, wobei eine altersabhängige infektionsfatalitätsrate basierend auf einer meta-analyse [ ] zugrunde gelegt wurde. trotz eines anstiegs der gesamtzahl der gemeldeten fälle seit mitte juli (unten) stiegen die fälle in denälteren altersgruppen erst seit september an (blaue pfeile). infolgedessen erwarten wir, dass bald ein deutlicher anstieg der todesfälle beobachtet werden kann. die prognoseszenarien a und b (grau, rechte spalte) sagen einen weiteren anstieg der fallzahlen und todesfälle voraus. der jüngste anstieg der infektionen in denälteren altersgruppen zusammen mit dem gesamtanstieg der fälle weist eindeutig auf einen kontrollverlustüber die ausbreitung und den beginn einer zweiten welle hin gemeldeten fälle wurde hauptsächlich von den jüngeren generationen (jünger als jahre) verursacht, die nur wenig zu den absoluten todesfällen beitragen, während es bei denälteren menschen ( + jahre) bis vor kurzem gelang, die fallzahlen niedrig zu halten. im september stiegen die fälle beiälteren menschen jedoch steil an. diese beobachtung lässt sich nicht auf die zunahme der durchgeführten tests zurückführen, da die anzahl der tests in dieser altersgruppe nahezu konstant blieb [ ] . diesesÜberschwappen aufältere menschen legt nahe, dass es aufgrund der wachsenden zahl unbemerkter sars-cov- infizierter nicht gelungen ist, die risikogruppen zu schützen. darüber hinaus ist dieser kontrollverlust seit anfang oktober auch durch einen anstieg der reproduktionszahl r gekennzeichnet (tabelle iii). das uberschwappen auf dieältere generation und die zunahme in r sind beides klare zeichen dafür, dass der kipppunkt zur unkontrollierten ausbreitungüberschritten wurde. im sommer waren die altersgruppen + offenbar gut geschützt: hätte sich das virus unabhängig und gleichmäßigüber alle altersgruppen verbreitet, wären schätzungsweise , % bis , % der infizierten gestorben, wenn man von der in [ ] berichteten ifr ausgeht. die todesfallrate (cfr, case fatality rate) lag im august jedoch nur bei , % (tabelle iii) . jetzt, mit der stark zunehmenden anzahl der infektionen unterälteren menschen (abb. ), wird die cfr höchstwahrscheinlich bald ansteigen. dies weist darauf hin, dass ein schutz der risikopersonen möglich ist, solange die fallzahlen niedrig sind, aber wahrscheinlich bei hoher covid- -inzidenz scheitert. für die kommenden zwei wochen kann alleine aufgrund der bereits gemeldeten fälle der letzten zwei wochen vorhergesagt werden, dass sich die zahl der wöchentlichen todesfälle fast verdoppeln wird. prognosenüber mehr als zwei wochen hinaus gestalten sich als schwierig, da die zahl der todesfälle von den noch nicht gemeldeten fällen abhängt. um diese unsicherheit einzugrenzen, setzen wir zwei zukunftsszenarien an, wobei wir in (a) einen linearen anstieg und in (b) einen exponentiellen anstieg der fälle annehmen (methoden in den "supplementary material"). die sich daraus ergebenden vorhersagen bewegen sich zwischen und wöchentlichen todesfällen anfang november. die fallzahlen könnten jedoch noch schneller ansteigen, falls sich die zweite welle voll entfaltet. wenn die kapazitätsgrenze für testung und kontaktnachverfolgung (tti)überschritten ist, brechen die eindämmungsmaßnahmen dieses kontrollsystems zusammen und der anstieg der fallzahlen beschleunigt sich [ ] . die aktuelle entwicklung in deutschland bringt somit die in der vergangenheit erfolgreiche bewältigung der pandemie ernsthaft in gefahr. um die kontrolle wieder zu erlangen und um einÜberschreiten des kipppunktes beiÜberlastung der tti-kapazität zu vermeiden, müssen die fallzahlen unverzüglich gesenkt werden. andernfalls werden die eindämmung der ausbreitung und der schutz der risikogruppen zwangsläufig sehr viel restriktivere maßnahmen erfordern -spätestens wenn die krankenhauskapazität erreicht ist. the challenges of containing sars-cov- via test-trace-andisolate together we can do it: each individual contribution protects health, society, and the economy rki tuesdays' situation reports assessing the age specificity of infection fatality rates for covid- : systematic review, meta-analysis, and public policy implications. medrxiv survstat@rki . api united nations world population database assessing the age-and gender-dependence of the severity and case fatality rates of covid- disease in spain rki) dl-de/by - . arcgis database of the rki's covid- dashboard reconstructing the early global dynamics of under-ascertained covid- cases and infections rki laborbasierte surveillance sars-cov- report of key: cord- -ff ex authors: ricoca peixoto, vasco; nunes, carla; abrantes, alexandre title: epidemic surveillance of covid- : considering uncertainty and under-ascertainment date: - - journal: nan doi: . / sha: doc_id: cord_uid: ff ex epidemic surveillance is a fundamental part of public health practice. addressing under-ascertainment of cases is relevant in most surveillance systems, especially in pandemics of new diseases with a large spectrum of clinical presentations as it may influence timings of policy implementation and public risk perception. from this perspective, this article presents and discusses early evidence on under-ascertainment of covid- and its motifs, options for surveillance, and reflections around their importance to tailor public health measures. in the case of covid- , systematically addressing and estimating under-ascertainment of cases is essential to tailor timely public health measures, and communicating these findings is of the utmost importance for policy making and public perception. vigilância epidemiológica covid- · subindetificação · subdeteção · sensibilidade sistemas de vigilância epidemiológica a vigilância epidemiológica é uma parte fundamental da prática de saúde pública. considerar e avaliar a sub-deteção de casos é relevante na maioria dos sistemas de vigilância, especialmente em pandemias de novas doenças com um amplo espectro de apresentações clínicas, porque pode influenciar os momentos e de decisões em políticas de saúde e a perceção de risco da população. este artigo apresenta e discute evidência inicial sobre a sub-deteção do covid- e os seus motivos, opções de vigilância e reflexões sobre sua importância para informar medidas de saúde pública. no caso do covid- , abordar e estimar sistematicamente a su-deteção de casos é essencial para adequar as medidas de saúde pública, e comunicar essas achados é de extrema importância para a formulação de políticas. epidemic surveillance is a critical component of public health practice. it gives us pictures of reality, informs policy and decision making, gauges health service demand, and feeds forecasts and models. however, surveillance is never perfect and diseases that present with a high proportion of mild, pauci-symptomatic, or subclinical cases can be hard to detect in most indicator-based surveillance systems and become harder to contain [ ] . surveillance pyramids can take different formats and proportions of undetected cases (often mild or asymptomatic). the scientific community is making efforts to address uncertainty about where to draw the lines separating different clinical manifestations and between ascertained and unascertained cases. covid- surveillance is challenging because mild and subclinical cases may not seek health services, cases are advised to avoid health care unless necessary, and testing capacity may be limited (fig. ). in the case of covid- , addressing and estimating under-ascertainment of cases is essential to tailor public health measures. communicating these findings is of the utmost importance for evidence-based policy making and community engagement. in europe in late february there was a fast rise in the number of confirmed cases in italy, and the probability of importation of cases of covid- may have been high in europe until italy stopped movement from northern italy and later from the rest of the country. the rapid rise and characteristics of confirmed cases in northern italy indicated an earlier important undetected community transmission, especially among mild cases. as such, it is possible that in late february many cases from northern italy (and possibly from other european areas) were exported all over europe. these cases may have given rise to mostly undetected transmission chains that remained active in the next months, justifying early enhanced surveillance and control measures that were taken by different governments to buy time for preparedness. the generalized under-detection of imported cases has been confirmed in a study in singapore, which estimated that the overall ability to detect imported cases was % ( % hpdi: - %) of singapore's capacity. in high-quality surveillance locations (based on the global health security index) it was % ( % hpdi: - %) [ ] . in line with these findings, a report by imperial college london estimated that / of covid- cases exported from mainland china remained undetected worldwide (until february ), resulting in several undetected transmission chains. they found countries in europe had relatively low sensitivity for imported cases [ ] . a relevant part of the fast growth in detected cases in italy and other countries could be related to undetected transmission chains from early introduced cases and accumulated a large pool of infected cases. it is likely that a high proportion of imported cases all around europe have not been found, and isolation, contact tracing, and quarantine could not be applied considering the who suspect case definition (as of february , ). although many countries advised travellers returning from certain areas to report (call a health line or medical doctor) if they had symptoms, it is possible that people with mild symptoms may not have followed this advice. consequently, many cases that might have followed from this would not be tested because they lacked a clear epidemiological link (fig. ) . in fact, several articles suggest a major under-ascertainment/under-reporting of total cases in different countries. one study modelled the real dimension of the epidemic in italy from international case exportations and estimated a real size of , cases ( % ci: , - , ), compared to a case count of , on february , , suggesting an under-ascertainment of % ( - %) of cases. in sensitivity analyses, the range of variation was from , to , cases (implying the identification of - % of cases) [ ] . publicly available epidemiological data for hubei, from january to february , , revealed a significant decline in the fatality rate with time. as testing becomes widespread, the detection of milder cases that would not seek health care in the early stages will result in a lower case fatality rate [ ] . another study used data from air travel and cases imported from iran in other middle eastern countries and estimated that there were , ( % ci: , - , ) covid- cases in iran as of february , which meant only . % of all cases had been reported [ ] . other models used reported infection within china, in conjunction with mobility data, a networked dynamic metapopulation model, and bayesian inference, and estimated that % of all infections were undocumented port j public health doi: . / ( % ci: - %) prior to january, , travel restrictions and that undocumented infections were the infection source for % of documented cases [ ] . adding to this we should consider specific surveillance system delays from infection and symptom onset to reporting. we should ask ourselves whether different choic-es at different timings would be made at an individual and policy level if we only looked to the confirmed cases. modelled estimations of total infected and counts of suspect/possible cases that were not laboratory confirmed should be considered and communicated together with uncertainty in model assumptions (fig. ) . some countries initiated earlier and wider testing than others [ ] . some started earlier to test admitted cases of bilateral pneumonia without other aetiology (allowing for earlier consideration of community transmission), and some tested contacts even if asymptomatic. criteria for testing in earlier stages was variable and resulted in very different testing rates [ ] . the different testing strategies and consequent different levels of under-ascertainment may account for some of the differences in the fatality rate found in different countries in europe such as italy and germany ( and . %, respectively) [ ] , though we should also consider the impact of overload of the health systems, characteristics of the specific surveillance system, and population demographics and behaviour. there are various options for surveillance to improve case detection or make estimations (table ) . limited capacity for testing may play a role in testing strategies, forcing some countries to prioritize testing, but it makes discussion and research around under-ascertainment even more relevant in those contexts. underascertainment in surveillance should make us consider an under-ascertained need for specific early measures (for example of social distancing) but also, in later stages, that a much larger part of the population could be immune and social distancing strategies could change, which also raises the importance of serologic surveys in those circumstances to confirm these estimates. one document of the european centre of disease control (ecdc) [ ] reports that "the detection of co-vid- cases and/or deaths outside of known chains of transmission is a strong signal that social distancing mea-sures should be considered." however, with restrictive testing strategies, these signals may be missed. the document states that "the early, decisive, rapid, coordinated and comprehensive implementation of closures and quarantines is likely to be more effective in slowing the spread of the virus than a delayed implementation" and that decisions "will very rarely be purely evidence-based" as social and political considerations will also need to be taken into account. evidence is always incomplete, especially in new pandemics. there is evidence of the effectiveness of public health measures such as travel bans, movement restrictions, and social distancing. a study used a seir (susceptible-exposed-infectious-removed) model to estimate epidemiological parameters before the implementation of measures in wuhan. if these measures had been initiated , , or weeks earlier in china, cases could have been reduced by , , and %, respectively, together with a significant reduction in the number of affected areas [ ] . another study reports that the effective reproduction number in wuhan fell from . ( % ci: . - . ) week before the introduction of restrictions on january , , to . ( . - . ) week later and calculated that in sites with wuhan-like transmission potential in early january, when there were only cases introduced, there is more than a % chance of the infection settling in this population [ ] . other simulation [ ] suggests that to control most outbreaks, for r (number of cases directly generated by one case in a population where all individuals are susceptible to infection) of - , more than % of contacts had to be identified. in most scenarios, highly effective case identification and isolation of contacts could control a new outbreak of covid- within months. however, importantly, the probability of control decreases with delays in the identification of cases and contacts, increased time from onset of symptoms to isolation, fewer cases identified, and increased transmission before symptoms. the oxford covid- government response tracker [ ] describes variation in government responses and explores whether rising stringency of response affects the rate of infection. they calculate a stringency-risk ratio but warn that recorded cases partly depend on how much testing is done, which is likely to co-vary with the stringency of the government's response. regular updated results will be available for anyone. a recent study by the imperial college covid- response team shows that in the uk and us context, suppression requires a combination of social distancing of the entire population, home isolation of cases, and household quarantine of their family members, that may need school and university closures and reports other strategies that may involve social distancing of those > years old. however, the study predicts that transmission will quickly rebound if interventions are relaxed and suggests that intermittent social distancing -triggered by trends in disease surveillance -may allow interventions to be relaxed temporarily [ ] . this strategy needs robust surveillance systems that allow for acceptable sensitivity to timely decide on interventions. we believe these triggers must consider evidence and debate around surveillance system sensitivity and under-ascertainment. as suggested by another imperial college report [ ] , this would be relevant to produce early evidence when exiting the co-vid- social distancing policy after achieving containment. due to different surveillance systems, different measures at different timings, different levels of stringency [ ] , and different demographic and social dynamics, the outcomes within europe may be heterogeneous. undetected introduction of imported cases and many mild undetected cases making up those transmission chains may warrant early measures. by looking at the death epidemic curves (likely less sensitive to variations in surveillance system sensitivity) of different countries we see differences that can be related to earlier detection and implementation of measures (fig. ) . notably, south korea has managed to keep new deaths by covid- low despite being in a relatively advanced stage of the epidemic and is one of the countries with a higher testing rate [ ] . an early study [ ] estimated the transmission potential of covid- in the country and suggested early sustained disease transmission in the region which contributed to the rapid early implementation of social distancing measures to contain the outbreak [ ] . considering uncertainty and under-ascertainment is critical for decision when cases could possibly mean , . delay from exposure and infection to reporting must also be considered. there is at this stage high uncertainty about the behaviour of the disease in europe, the effectiveness of measures in different contexts, and the timing for their implementation. often, measures should be implemented early with imperfect scientific knowledge. on the other hand, estimated total infection numbers can be important to justify measures for public opinion, engage them in preventive action, and reinforce recommendations for those who are tested positive as well as to inform decisions on exiting social distancing policies. more robust models will be produced soon, but models make assumptions based on surveillance data and other sources with different levels of uncertainty. under-ascertainment should be considered, and the best available information and data should be included and pursued by improving surveillance strategies to reduce or better estimate under-ascertainment. with more epidemiological evidence, namely greater certainty in relation to the proportion of asymptomatic infections and their risk of transmission, different surveillance system sensitivity, effective r in different contexts and effectiveness of containment measures and with the results of the first few x cases ffx investigation proposed by who [ ] for covid- models will better take into account underascertainment in different countries. understanding the extent of transmission in different regions can help policy makers tailor their response. acknowledging that "we can't fight a pandemic blindfolded," on march , , the who urged countries to test. under-ascertainment may be of relevance for cov-id- policy. there is uncertainty on this subject and in the studies mentioned in this article and presented reflections. however, it is the role of the scientific community in public health and epidemiology not only to communicate what is certain and based in robust established science, but also of what is uncertain, when it may be of relevance for decision making and can be further researched, discussed, and shared. as in most infectious disease surveillance, under-ascertainment can be a relevant piece of the puzzle for covid- science, policy making, and public opinion and should be systematically addressed and communicated. a novel coronavirus emerging in china: key questions for impact assessment quantifying bias of covid- prevalence and severity estimates in wuhan, china that depend on reported cases in international travelers who collaborating centre for infectious disease modelling; mrc centre for global infectious disease analysis abdul latif jameel institute for disease and emergency analytics relative sensitivity of international surveillance estimation of covid- outbreak size in italy based on international case exportations siettos c. data-based analysis, modelling and forecasting of the novel coronavirus preliminary estimation of the novel coronavirus disease [covid- ] cases in iran: a modelling analysis based on overseas cases and air travel data. medrxiv. . preprint substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov our world in data. how many tests for co-vid- are being performed around the world? world health organization. coronavirus disease european centre for disease prevention and control. considerations relating to social distancing measures in response to the covid- epidemic effect of non-pharmaceutical interventions for containing the co-vid- outbreak: an observational and modelling study centre for mathematical modelling of infectious diseases co-vid- working group. early dynamics of transmission and control of covid- : a mathematical modelling study feasibility of controlling covid- outbreaks by isolation of cases and contacts variation in government responses to cov-id- : version . . oxford: blavatnik school of government abdul latif jameel institute for disease and emergency analytics. imperial college london. impact of non-pharmaceutical interventions [npis] to reduce covid- mortality and healthcare demand report : evidence of initial success for china exiting covid- social distancing policy after achieving containment imperial college covid- response team transmission potential and severity of co-vid- in south korea the first few x [ffx] cases and contact investigation protocol for -novel coronavirus [ -ncov] infection the authors thank daniel thomas, sonia bounder, paula blomquist, and robert withaker for commenting on early drafts and aurora peixoto for artwork. the authors have no conflicts of interest to declare. the authors have no funding sources to declare. all authors contributed in a relevant way to the literature review and writing of the article. key: cord- -m od wj authors: scatti-regàs, aina; aguilar-ferrer, marta carmen; antón-pagarolas, andrés; martínez-gómez, xavier; gonzález-peris, sebastià title: clinical features and origin of cases of parotiditis in an emergency department() date: - - journal: an pediatr (engl ed) doi: . /j.anpede. . . sha: doc_id: cord_uid: m od wj nan to the editor: the mumps virus (muv), or myxovirus parotiditis, continues to cause sporadic cases and outbreaks of disease. this is associated to the progressive waning of immunity against the mumps component of the measles, mumps, rubella (mmr) vaccine in absence of a natural booster (especially from years after administration of the second dose), the use in the --- period of a vaccine that had the rubini strain, which proved to be less effective, and the presence of pockets of unvaccinated people in the population. in spain, cases were notified in and in , a significant increase compared to previous seasons. some of the infectious agents other than muv that may be involved in parotitis as a general clinical presentation include influenza a virus, parainfluenza virus, epstein-barr virus (ebv), adenovirus, coxsackievirus, cytomegalovirus (cmv), parvovirus b , herpesvirus and lymphocytic choriomeningitis virus, as well as gram-positive bacteria, atypical mycobacteria and bartonella species. --- in the paediatric population, these pathogens are probably more frequent causative agents compared to muv. this, combined with the benign course of most presentations, leads many paediatric health care facilities to make the diagnosis without an aetiological investigation. the aim of our study was to establish the viruses involved in cases of parotitis in our area. we carried out a retrospective study through the collection of data corresponding to full years ( and ), including all patients given a diagnosis of parotitis (with swelling of the parotid glands being a requirement for inclusion) in the paediatric emergency department of a tertiary ଝ please cite this article as: scatti-regàs a., aguilar-ferrer m.c., antón-pagarolas a., martínez-gómez x., gonzález-peris s. caracterización clínica y etiológica de los casos de parotiditis en un servicio de urgencias. an pediatr (barc). . https://doi.org/ . /j.anpedi. . . care hospital in barcelona that manages patients up to age years and based on diagnostic judgment of the paediatrician in charge of the patient. per hospital protocol, polymerase chain reaction (pcr) tests for detection of muv in saliva and urine samples were performed in patients with parotitis. serologic tests were added if blood tests were requested by the paediatrician in charge based on his or her clinical judgment. when it came to serologic testing, in case of negative results of the test for detection of muv in saliva, molecular methods were used for detection of influenza a and b virus, respiratory syncytial virus a/b, adenovirus, metapneumovirus, coronavirus nl /oc / e, enterovirus, rhinovirus, parainfluenza virus, ebv and cmv. mump viruses were characterised by partial sequencing of the small hydrophobic (sh) gene. we identified cases of symptomatic acute parotitis ( . % or paediatric emergency visits). the median age of the patients was . years (range, months- . years). the rate of adherence to the protocol for the ordering of tests for aetiological diagnosis was . %, so we were able to obtain data on testing of saliva samples from patients. fig. summarises the results of pcr testing of these samples. another patients received an aetiological diagnosis of parotitis due to muv by serologic testing (positive igm test), adding up to a total of cases caused by muv. the median age of patients with muv infection (in all cases muv genotype g) was . years (range, months- . years), with a predominance of the male sex ( . %). in cases ( . %) there was no known history of contact with a case of parotitis. all patients were correctly vaccinated save for children that had not received any dose of mmr by parental choice and adolescent that had only received dose of vaccine. there were no documented complications, except for patient that developed guillain-barré syndrome with onset the week after the initial visit, who had a favourable outcome. the management of . % of the patients included empiric antibiotherapy despite there being no evidence confirming bacterial infection. table presents the demographic and clinical characteristics of cases of parotitis in which testing was performed for investigation of the aetiology. patients with muv infection were significantly older compared to children with a different aetiological agent (median age, . vs . years; p = . ). the findings in our study, despite the limitations intrinsic to its retrospective design, were consistent with those of other authors, and showed that a significant proportion of cases of parotitis in the paediatric age group may be caused by viruses other than muv (such as ebv, cmv and common respiratory viruses). --- the high frequency of cases with negative results in all tests can be explained by the involvement of other viruses that were not included in the testing (such as human herpesvirus ), technical factors affecting the yield of microbiological diagnosis and the potential presence of non-infectious parotitis cases, among others. viral coinfection was also frequent. lastly, we ought to underscore that muv continues to be a frequent cause of parotitis in our area (especially in older children), even in correctly vaccinated patients, and our findings confirmed that the causative virus continues to circulate in the community with a well-known pattern characterised by incidence peaks every --- years. the aetiological diagnosis and notification of cases can alert the health care authorities of potential outbreaks at an early stage, allowing implementation of containment measures such as administration of a third dose of vaccine in selected patients. waning immunity against mumps in vaccinated young adults non-mumps viral parotitis during the - influenza season in the united states letter to the editor: there is a need to consider all respiratory viruses in suspected mumps cases viral etiology of mumps-like illnesses in suspected mumps cases reported in catalonia effectiveness of a third dose of mmr vaccine for mumps outbreak control hospital infantil vall d'hebron, barcelona, spain b unidad de virus respiratorios, servicio de microbiología, hospital vall d'hebron key: cord- -nqn qzcu authors: chapman, lloyd a. c.; spencer, simon e. f.; pollington, timothy m.; jewell, chris p.; mondal, dinesh; alvar, jorge; hollingsworth, t. deirdre; cameron, mary m.; bern, caryn; medley, graham f. title: inferring transmission trees to guide targeting of interventions against visceral leishmaniasis and post-kala-azar dermal leishmaniasis date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: nqn qzcu understanding of spatiotemporal transmission of infectious diseases has improved significantly in recent years. advances in bayesian inference methods for individual-level geo-located epidemiological data have enabled reconstruction of transmission trees and quantification of disease spread in space and time, while accounting for uncertainty in missing data. however, these methods have rarely been applied to endemic diseases or ones in which asymptomatic infection plays a role, for which novel estimation methods are required. here, we develop such methods to analyse longitudinal incidence data on visceral leishmaniasis (vl), and its sequela, post-kala-azar dermal leishmaniasis (pkdl), in a highly endemic community in bangladesh. incorporating recent data on infectiousness of vl and pkdl, we show that while vl cases drive transmission when incidence is high, the contribution of pkdl increases significantly as vl incidence declines (reaching % in this setting). transmission is highly focal: > % of mean distances from inferred infectors to their secondary vl cases were < m, and estimated average times from infector onset to secondary case infection were < months for % of vl infectors, but up to . yrs for pkdl infectors. estimated numbers of secondary vl cases per vl and pkdl case varied from - and were strongly correlated with the infector's duration of symptoms. counterfactual simulations suggest that prevention of pkdl could have reduced vl incidence by up to a quarter. these results highlight the need for prompt detection and treatment of pkdl to achieve vl elimination in the indian subcontinent and provide quantitative estimates to guide spatiotemporally-targeted interventions against vl. . pkdl has therefore been recognised as a major potential threat to the vl elimination programme in the isc ( ), which has led to increased active pkdl case detection. nevertheless, the contribution of pkdl to transmission in field settings still urgently needs to be quantified. although the incidence of asymptomatic infection is to times higher than that of symptomatic infection in the isc ( ), the extent to which asymptomatic individuals con- (fig. a) . the data from this study are fully de- scribed elsewhere ( , ) . briefly, month of onset of symptoms, treatment, relapse, and relapse treatment were recorded for vl cases and pkdl cases with onset between and (retrospectively for cases with onset before ), and year of onset was recorded for vl cases with onset before . there were vl cases and pkdl cases with onset between january and december in the study area, and vl cases with onset prior to january . over the whole study area, vl incidence followed an epi- demic wave, increasing from approximately cases/ , /yr in to ≥ cases/ , /yr in before declining to < cases/ , /yr in (fig. b) . pkdl incidence fol- lowed a similar pattern but lagging vl incidence by roughly yrs, peaking at cases/ , /yr in . however, vl and pkdl incidence varied considerably across paras (aver- age para-level incidences: vl - cases/ , /yr, pkdl - cases/ , /yr, table s ) and time (range of annual para-level incidences: vl - cases/ , /yr, pkdl - cases/ , /yr, fig. s ). ú ci = credible interval, calculated as the % highest posterior density interval † risk of subsequent vl/asymptomatic infection if susceptible ‡ based on assumed infectiousness § in the absence of background transmission and relative to living directly outside the case household. based on the relative infectiousness of vl and the di erent types of pkdl from the xenodiagnostic data, in the absence of any other sources of transmission, the estimated probability of being infected and developing vl if living in the same household as a single symptomatic individual for month following their onset was . ( % ci: . , . ) for vl and ranged from . to . ( % cis: ( . , . )-( . , . )) for macular/papular pkdl to nodular pkdl. living in the same household as a single asymptomatic individual, the monthly risk of vl was only . ( % ci: . , . ), if asymptomatic individuals are % as infectious as vl cases. the risk of infection if living in the same household as an infectious individual was estimated to be more than times higher than that if living directly outside the household of an infectious individual (hazard ratio = . ), with a % ci well above ( . , . ). the estimated spatial kernel (fig. s ) around each infectious individual shows a relatively rapid decay in risk with distance outside their household, the risk of infection halving over a distance of m ( % ci: , m). mission. we assess the contribution of di erent infectious groups to transmission in terms of their relative contribu- tion to the transmission experienced by susceptible individuals ( fig. a and fig. s ). the contribution of vl cases was fairly stable at around % from to the end of before decreasing steadily to at the end of the epidemic, while the contribution of pkdl cases increased from in to ≥ % in ( % ci: , %) (fig. s ) . only a small proportion of the total infection pressure on susceptible individuals, varying between % and % over the course of the epidemic, was estimated to have come from asymptomatic and pre-symptomatic individuals. reconstructing the transmission tree. by sampling , transmission trees from the joint posterior distribution of the transmission parameters and the unobserved data (as de- scribed in materials and methods), we can build a picture of the most likely source of infection for each case and how infec- tion spread in space and time. fig. shows the transmission tree at di erent points in time in part of the south-east cluster of villages. early in the epidemic and at its peak (figures a and b), most new infections were due to vl cases. towards the end of the epidemic, some infections were most likely due to pkdl cases and there was some saturation of infection around vl cases (fig. c) . the inferred patterns of trans- mission suggest that disease did not spread radially outward from index cases over time, but instead made a combination of short and long jumps around cases with long durations of symptoms and households with multiple cases. . arrows show the most likely source of infection for each case infected up to that point in time over , sampled transmission trees, and are coloured by the type of infection source and shaded according to the proportion of trees in which that individual was the most likely infector (darker shading indicating a higher proportion). asymptomatic infections are not shown for clarity. s/a = susceptible or asymptomatic, e = pre-symptomatic, i = vl, r = recovered, d = dormantly infected, p = pkdl (see si text). gps locations of individuals are jittered slightly so that individuals from the same household are more visible. an animated version showing all months is provided in si movie . there is considerable heterogeneity in the estimated contri- by each vl/pkdl case is typically less than (fig. s a ). the times after onset of symptoms in the infector at which secondary vl cases become infected are typically longer for pkdl infectors than for vl infectors (fig. b) detected after a longer delay than subsequent cases and there will be some delay in mounting a reactive intervention, such as active case detection and/or targeted irs around the index case(s), interventions will need to be applied in a large radius (up to m) around index cases to be confident of capturing all secondary cases and limiting transmission. our results demonstrate the importance of accounting for spatial clustering of infection and disease when modelling vl transmission. previous vl transmission dynamic models ( , - ) have significantly overestimated the relative con- tribution of asymptomatic infection to transmission (as up to %), despite assuming asymptomatic individuals are only - % as infectious as vl cases, by treating the population as homogeneously mixing, such that all asymptomatic indi- viduals can infect all susceptible individuals via sandflies. in reality, asymptomatic individuals do not mix homogeneously with susceptible individuals as they are generally clustered together around or near to vl cases ( , ), who are much more infectious and therefore more likely to infect suscepti- ble individuals around them, even if they are outnumbered by asymptomatic individuals. asymptomatic infection also leads to immunity, and therefore local depletion of suscep- tible individuals around infectious individuals. hence, for the same relative infectiousness, the contribution of asymp- tomatic individuals to transmission is much lower when spatial heterogeneity is taken into account. nonetheless, our results suggest that asymptomatic indi- viduals do contribute a small amount to transmission and that they can "bridge" gaps between vl cases in transmission chains, as the best-fitting model has non-zero asymptomatic relative infectiousness. superficially, this appears to conflict with preliminary results of xenodiagnosis studies in which asymptomatic individuals have failed to infect sandflies ac- cording to microscopy ( ). however, historical ( , ) and experimental ( ) data show that provision of a second blood meal and optimal timing of sand fly examination are criti- cal to maximizing sensitivity of xenodiagnosis. these data suggest that recent xenodiagnosis studies ( , ), in which dissection occurred within days of a single blood meal, may underestimate the potential infectiousness of symptomatic and asymptomatic infected individuals. occurrence of vl in isolated regions where there are asymptomatically infected individuals, but virtually no reported vl cases ( , ), also seems to suggest that asymptomatic individuals can generate vl cases. however, it is possible that some individuals who de- veloped vl during the study went undiagnosed and untreated, and that we have inferred transmissions from asymptomatic individuals in locations where cases were missed. we will in- vestigate the potential role of under-reporting in future work. the analysis presented here is not without limitations. as can be seen from the model simulations (fig. s ) , the model is not able to capture the full spatiotemporal heterogeneity in the observed vl incidence when fitted to the data from the whole study area, as it underestimates the number of cases in higher- incidence paras (e.g. paras , and ). there are various possible reasons why the incidence in these paras might have been higher, including higher sandfly density, lower initial lev- els of immunity, variation in infectiousness between cases and within individuals over time, dose-dependence in transmission (whereby flies infected by vl cases are more likely to create vl cases than flies infected by asymptomatic individuals ( )), where k(d) = e ≠d/is the spatial kernel function that determines . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . bangladesh (protocol # - ) and the centers for disease con- • recovered (i.e. treated for primary vl, vl relapse or pkdl, or self-resolved from pkdl, or recovered from asymptomatic upon infection, individuals either develop pre-symptomatic infection with probability pi or asymptomatic infection with probability ≠ pi (see table s for values of fixed parameters used in the model of . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. whereis the rate constant for spatial transmission between infected and susceptible individuals; k(dij) is the spatial kernel function that scales the transmission rate by the distance dij between individuals i and j; " (Ø ) is a rate constant for additional within-household transmission; ij is an indicator function for individuals living in the same household, i.e. between an exponentially decaying spatial kernel and a cauchy-type kernel in our previous study ( ) (the exponential kernel gave a marginally better fit), we use the exponential kernel here: and asymptomatic individuals, we take the relative infectiousness of pre-symptomatic individuals, h , to be the same as that of asymptomatic individuals (i.e. h = h ). one-hundred and thirty-eight of the pkdl cases underwent one or more examinations by a trained physician to determine the type and extent of their lesions (table s ). data from a recent xenodiagnosis study in bangladesh ( ) pre-symptomatic -- thus, individual j's infectiousness at time t is given by [ ] incubation period. following previous work ( ), we model the incubation period as negative binomially distributed nb(r, p) with fixed shape parameter r = and 'success' probability parameter p, and support starting at (such that the minimum incubation period is month): we estimate p in the mcmc algorithm for inferring the model parameters and missing data (see below). vl onset-to-treatment time distribution. several vl cases with onset before have missing symptom onset and/or treatment times (only their onset year is recorded), and may therefore have been infectious at the start of the study period. in order to be able to infer the onset-to-treatment times of these cases, ot Õ j = min(r Õ j , d Õ j ) ≠ i Õ j (j = , . . . , ni ), in the mcmc algorithm (see below) we model the onset-to-treatment time distribution as a negative binomial distribution nb(r , p ) and fit to the onset-to-treatment times of all vl cases for whom both onset and treatment times were recorded ( figure s a ): to obtain r = . and p = . (corresponding to a mean onset-to-treatment time of . months). assume that all cases not recorded as having immediate recurrence of symptoms su ered treatment relapse and that the time to relapse follows a geometric distribution geom(p ) with pmf: where fitting to the recorded gaps gives p = . (corresponding to a mean time to relapse of . months). relapse cases are assumed to be uninfectious from their treatment month to their relapse time and their duration of symptoms upon relapse is assumed to follow the same distribution as the onset-to-treatment time for a first vl episode (eq. ( )). we assume all relapse cases were treated for relapse before the end of the study, since the latest treatment time for primary vl in a case that while the probabilities of pre-symptomatic or asymptomatic infection in month t given susceptibility up to month t ≠ are, respectively: [ ] model for initial status of non-symptomatic individuals. as there was transmission and vl in the population before the start the probabilities of each non-symptomatic individual initially present (i.e. with vj = ) being susceptible, asymptomatically infected, or recovered from asymptomatic infection at time t = can then be found by calculating the probability of avoiding infection in every month from their birth to the start of the study, summing over the probabilities of being infected in one of the months between their birth and the start of the study and recovering after the start of the study, and summing over the of probabilities of being infected in a month before the start of the study and recovering before the start of the study, respectively: ps (aj) := p(aj > , rj > ) = e ≠⁄ a j [ ] pa (aj) := p(aj ae , where aj is the age of individual j in months at t = . since we assume that non-symptomatic individuals who are born, or who immigrate into the study area, after the start of the study (with vj > ) are susceptible, for notational convenience we define the probabilities for these individuals as ps (aj) = , pa (aj) = pr (aj) = . we estimate the historical asymptomatic infection rate, ⁄ , by fitting the model to age-prevalence data on leishmanin skin test (lst) positivity amongst non-symptomatic individuals from a cross-sectional survey of three of the study paras conducted in ( ) (see figure s ). we assume that entering state r corresponds to becoming lst-positive, as lst positivity is a marker for durable, protective cell-mediated immunity against vl ( , ), and estimate ⁄ by maximising the binomial with these definitions, the complete data likelihood for the augmented data z = (y, x) given the model parameters ◊ = (-, -, ', ", p) is composed of the products of the probabilities of all the di erent individual-level events over all months: the joint posterior distribution of the model parameters ◊ = (-, -, ', ", p) and the missing data x given the observed data y [ ] we do this using a metropolis-within-gibbs mcmc data augmentation algorithm in which we iterate between sampling from the conditional posterior distribution of the parameters given the observed data and the current value of the missing data, t=v j qj(t) + qj(t + ) is a normalising constant to account for the fact that we know that j was not pre- and ", which are non-negative, since there is little information available with which to construct informative priors (table s ) . the mean of the prior distribution foris chosen as m based on our previous findings ( ) . a beta distribution, beta(a, b) , is chosen as a conjugate prior for the incubation period parameter p, since it is a probability (p oe where -= (-, -, ', "), so p can be updated e ciently in the mcmc by drawing from this full conditional distribution rather than using a random walk metropolis-hastings update. ≠ aj, ) for rj, = t + . by repeating the following steps. note that throughout the following we suppress notation of conditional dependencies in the likelihood terms where they are obvious to maintain legibility. the algorithm also accounts for the fact that some individuals were born or migrated or died during the study when updating the unknown pre-symptomatic infection times and asymptomatic infection and recovery times (using the birth/migration/death times as bounds on the proposed unobserved times), but we omit these details from the following description for simplicity. (b) accept the infection time move with probability where (c) i. if aj = : if rj = , if rj > . ii. if aj = t + : a. if a Õ j = t + , then r Õ j = t + , so accept immediately as the likelihood does not change. step (c)ic, except with . iii. if aj oe [ , t ]: a. if a Õ j = , follow step (c)ia, but with q replaced by step (c)ib except with step (c)ic but with . update missing treatment times of vl cases during the study: update the treatment time of the vl case whose treatment time is missing but whose onset time is known, conditional on the treatment time being before their pkdl onset: (a) propose a new treatment time as update the onset and treatment times of all cases who potentially had active vl at the start of the study (t = ) who n( , ) ) " = p ) . update the treatment times of cases who potentially had active vl at the start of the study whose treatment times were not recorded but whose onset times are known, one by one. for each case j: p ) . . update whole relapse period of cases missing both relapse and relapse treatment times: update the relapse and relapse treatment times of all vl cases who su ered relapse during the study who are missing step in the above algorithm may appear complicated, but essentially consists of proposing a new asymptomatic infection is the empirical covariance of the last k ≠ f (k) + samples offrom the chain, with the mean of the last k ≠ f (k) + samples; is the initial guess for the covariance matrix, and k determines the rate at which the influence of on k+ decreases (the weight of halves after the first k iterations). we use k = here. if f (k) = f (k ≠ ) (i.e. if k is odd with f (k) chosen as above), an additional observation is added to the estimate of the covariance matrix if k is even), the new observation replaces the oldest it has been shown that n (k , . /n -), where is the covariance matrix of the posterior distribution, is the optimal proposal distribution for rapid convergence and e cient mixing of the mcmc chain for symmetric product-form posterior distributions as nae oe, and leads to an acceptance rate of . % ( , ) . this corresponds to a scaling of c k = in eq. ( ). however, we are in a context with a large amount of missing data, which is strongly correlated with some of the transmission parameters (see parameter estimates below), so the posterior distribution is not symmetric, and this scaling is not optimal. we therefore follow ( ) and scale c k adaptively as the algorithm progresses to target an acceptance rate of approximately . % for updates to -. we do this by rescaling c k by a factor of x k > every time an acceptance occurs and by a factor of x ‹/(‹≠ ) k < every time a rejection occurs such that the acceptance rate ‹ approaches . % in the long run, if proposal is rejected. in order to satisfy the 'diminishing adaptation' condition ( ), which is necessary to ensure the markov chain is ergodic and converges to the correct posterior distribution, it is required that c k tends to a constant as k ae oe. so that the adaptation diminishes as k increases, we use the sequence where m is the number of iterations over which the scaling factor x k decreases from to . . here, we use m = . model comparison we compare the goodness of fit of models with di erent asymptomatic and pre-symptomatic relative infectiousness (between % and % of that of vl cases), with and without additional within-household transmission, to test di erent assumptions about how infectious asymptomatic and pre-symptomatic individuals are, using dic ( ). dic measures the trade-o between model fit and complexity and lower values indicate better fit. since some variables were not observed, we use a version of dic appropriate for missing data from ( ), which is based on the complete data likelihood l(◊; z) = p(y, x|◊). this is equivalent to the standard version of dic for fully observed data except that it is averaged over the missing data: where d(◊) is the deviance (the measure of model fit), given (up to an additive constant dependent only on the data) by . [ ] the relative contribution of state x to the infection pressure on the ith vl case at their infection time, i.e. the probability that i's infection source is x (fig. b in the main text), is: , x oe {a, e, i, p}. [ ] the probability that the ith vl case is infected from the background transmission is ' ⁄i(ei ≠ ) . reconstructing the epidemic reconstructing the transmission tree. we reconstruct the transmission tree following the 'sequential approach' described in ( ). we draw n samples (◊ k , x k ) (k = , . . . , n) from the joint posterior distribution from the mcmc, calculate the probability that infectee i was infected by individual j conditional on their infection time ei and uncertainty in the parameter values and missing data (over the posterior distribution). we use n = here. calculating transmission distances and times. the mean infector-to-vl-infectee distance and mean infector-onset-to-vlinfectee-infection time for each vl and pkdl infector ( figures a and b in the main text) are calculated from the sample of n transmission trees by averaging the distances and times from each infector to their vl infectees within each tree, and then averaging these quantities over all the trees in which that vl/pkdl case is an infector: where · [ ] the absolute contribution of each infectious state to the e ective reproduction number at time t is: where x oe {a, i} denotes the infectious state, and, as described above, in the main text we split the numbers of secondary infections (rj) arising from vl and pkdl for cases that had both. to assess the fit of the model and simulate hypothetical interventions against pkdl, we create a stochastic simulation version of the individual-level spatiotemporal transmission model described above. we follow standard stochastic simulation methodology for discrete-time individual-level transmission models ( ), converting infection event rates into probabilities in order to determine who gets infected in each month. we assume that an individual's progression through di erent infection states following infection occurs independently of the rest of the epidemic (i.e. is either governed by internal biological processes or random external processes of detection), which enables the simulation of an individual's full infection history from the point of infection. so that we can simulate durations of pkdl infectiousness, we fit a negative binomial distribution nb(r , p ) to the observed pkdl onset-to-treatment times and onset-to-resolution times for self-resolving pkdl cases in the data: given these pieces of information, the simulation algorithm proceeds as follows: negative binomially distributed ( ). the pmf of a size-biased negative binomial random variable x ú corresponding to x ≥ nb is: and assign a pkdl infectious by drawing from cat({h , h , h , hu}, p) . ii. else the individual recovers without developing pkdl, so draw a recovery time: figure s and table s respectively. based on the deviance distributions and dic values, the best-fitting model is the model with additional within-household transmission and the highest level of relative pre-symptomatic and asymptomatic infectiousness (both % as infectious as vl). hence, we focus on the output of this model in the main text and below. and ") and incubation period distribution parameter p for the di erent models are shown in table s . the parameter estimates are very similar across the di erent models and vary in the way expected -the spatial transmission rate constantand background transmission rate ' are lower for models with additional within-household transmission (" > ) and decrease with increasing relative asymptomatic infectiousness h , and the mode foris slightly larger for models with " > (since a flatter kernel shape compensates for the extra within-household transmission). the posterior distributions for the incubation period distribution parameter p correspond to a mean incubation period of . - . months ( % hpdis ( . , . )-( . , . ) months). the log-likelihood trace and posterior distributions for the parameters for the best-fitting model are shown in figure s . the parameters are clearly well defined by the data, as the posterior distributions di er significantly from the weak prior distributions. the corresponding autocorrelation plots are shown in figure s . the high degree of autocorrelation evident for all the parameters is due to strong correlation between the transmission parameters and the missing data, in particular between the spatial transmission rate constantand the asymptomatic infection times. figure s shows thatis strongly negatively correlated with the mean asymptomatic infection timeĀ. this is expected since a higher overall transmission rate leads to show that there is some negative correlation betweenand ', -and ', and " and p. these correlations are not surprising: the more transmission that is explained by proximity to infectious individuals (the higher -), the less needs to be explained by the background transmission (the lower '); the flatter the spatial kernel (the larger -), the fewer infections need to be explained by the background transmission; and the more infections are accounted for by transmission within the same household (the higher "), the longer the incubation period (the lower p) needs to be (due to long times between onsets of cases in the same household). the acceptance rate for the transmission parameter updates (step in the mcmc algorithm) was . demonstrate that the data augmentation algorithm works as expected. figure s shows the incidence curve of vl and pkdl cases for the whole study area and the inferred incidence curve of asymptomatic infections (averaged over the mcmc chain). the number of asymptomatic infections increases and decreases with the number of vl cases as expected given the assumption that the incidence ratio of asymptomatic to symptomatic infection is fixed. the posterior probabilities that individuals were asymptomatically infected during the study (shown in figure s , with is higher). this is as expected given the structure of the model (the decrease in the risk of infection with distance from an infectious individual encoded in the spatial kernel) and the estimates of the transmission parameters. the examples shown in figure s demonstrate that non-symptomatic individuals' asymptomatic "infection" time posterior distributions (red). note that asymptomatic "infection" in months and t + = , represent asymptomatic infection before the study and no asymptomatic infection before the end of the study, respectively. (a) individual who migrated into a house with an active vl case from outside the study area in month and therefore had a high initial probability of asymptomatic infection, followed by further peaks in asymptomatic infection risk in months and with the pkdl and vl onsets of two other household members in months and respectively. (b) individual born in month with a high probability of having avoided asymptomatic infection for the duration of the study. (c) individual who was -years-old at the start of the study with a moderately high risk of having been asymptomatically infected before the study and a small peak in asymptomatic infection risk when a fellow household member had vl onset in month . the role of case proximity in transmission of visceral leishmaniasis in a highly endemic village in visceral leishmaniasis in the indian subcontinent: modelling epidemiology and control feasibility of eliminating visceral leishmaniasis from the indian subcontinent: explorations with a set of deterministic age-structured transmission models elimination of visceral leishmaniasis in the indian subcontinent: a comparison of predictions from three transmission models risk factors for kala-azar in bangladesh increasing failure of miltefosine in the treatment of kala-azar in nepal and the potential role of parasite drug resistance, reinfection, or noncompliance single locus genotyping to track leishmania donovani in the indian subcontinent: application in nepal seasonal and nocturnal landing/biting behaviour of phlebotomus argentipes (diptera: psychodidae) studies on seasonal man sandfly (phlebotomus argentipes) contact at night biting rhythm & biting activity of phlebotomid sandflies seasonal distribution of phlebotomine sand flies-vector of visceral leishmaniasis use of rk for diagnosis of post kala-azar dermal leishmaniasis in nepal bait preference of phlebotomus argentipes (ann. & brunn.) the importance of systems ecology: implications of vector-based field studies and quantitative analysis of vector control programs spatial distribution of phlebotomus argentipes (diptera: psychodidae) in eastern case study evaluating multispatial resolution remotely sensed environmental evidence and microclimatic relative abundance of phlebotominae sandflies with emphasis on vectors of kala-azar national vector borne disease control programme, guidelines on vector control in kala-azar elimination (year?) policy recommendations from transmission modelling for the elimination of visceral leishmaniasis in the indian subcontinent infectiousness of visceral leishmaniasis, post kala-azar dermal leishmaniasis and asymptomatic subjects with their capacity to infect sand fly vectors by xenodiagnosis quantifying the infectiousness of post-kala-azar dermal leishmaniasis towards sandflies clinical and immunological aspects of post-kala-azar dermal leishmaniasis in bangladesh quantification of parasite load in clinical samples of leishmaniasis patients: il- level correlates with parasite load in visceral leishmaniasis study of parasite kinetics with antileishmanial drugs using real-time quantitative pcr in indian visceral leishmaniasis relapse after treatment with miltefosine for visceral leishmaniasis is associated with increased infectivity of the infecting leishmania donovani strain monitoring of parasite kinetics in indian post-kala-azar dermal leishmaniasis quantification of the natural history of visceral leishmaniasis and consequences for control. parasites & vectors characterization and identification of suspected counterfeit miltefosine capsules loss of leishmanin skin test antigen sensitivity and potency in a longitudinal study of visceral leishmaniasis in bangladesh age trends in asymptomatic and symptomatic leishmania donovani infection in the indian subcontinent: a review of data from diagnostic and epidemiological studies estimating parameters in stochastic compartmental models using markov chain methods bayesian inference for partially observed stochastic epidemics bayesian analysis for emerging infectious diseases linking time-varying symptomatology and intensity of infectiousness to patterns of norovirus transmission coupling and ergodicity of adaptive markov chain monte carlo algorithms accelerating adaptation in the adaptive metropolis hastings random walk algorithm weak convergence and optimal scaling of random walk metropolis algorithms. the annals appl optimal scaling for various metropolis-hastings algorithms examples of adaptive mcmc deviance information criteria for missing data models the deviance information criterion: years on (with discussion) methods to infer transmission risk factors in complex outbreak data di erent epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures a bayesian approach to quantifying the e ects of mass poultry vaccination upon the spatial and temporal dynamics of h n in northern vietnam dynamics of the uk foot and mouth epidemic: stochastic dispersal in a heterogeneous landscape the mathworks, inc julia: a fresh approach to numerical computing julia v . . . the julia project nw nw nw nw se se se se se se se se se nw nw nw nw total key: cord- - qp o g authors: xu, liyan; zhang, hongmou; deng, yuqiao; wang, keli; li, fu; lu, qing; yin, jie; di, qian; liu, tao; yin, hang; zhang, zijiao; du, qingyang; yu, hongbin; liu, aihan; jiang, hezhishi; guo, jing; yuan, xiumei; zhang, yun; liu, liu; liu, yu title: cost-effectiveness analysis of antiepidemic policies and global situation assessment of covid- date: - - journal: nan doi: nan sha: doc_id: cord_uid: qp o g with a two-layer contact-dispersion model and data in china, we analyze the cost-effectiveness of three types of antiepidemic measures for covid- : regular epidemiological control, local social interaction control, and inter-city travel restriction. we find that: ) intercity travel restriction has minimal or even negative effect compared to the other two at the national level; ) the time of reaching turning point is independent of the current number of cases, and only related to the enforcement stringency of epidemiological control and social interaction control measures; ) strong enforcement at the early stage is the only opportunity to maximize both antiepidemic effectiveness and cost-effectiveness; ) mediocre stringency of social interaction measures is the worst choice. subsequently, we cluster countries/regions into four groups based on their control measures and provide situation assessment and policy suggestions for each group. coronavirus disease (covid - ) has been recognized as a pandemic by the world health organization in march ( ) . nonetheless, on march , mainland china observed their first day with zero increase of local cases since the outbreak ( ) . this indicates that, aside from the imported cases, the pandemic has been locally close to the end. many experiences and lessons can be shared by the rest of the world from the trajectories of the outbreak and the control strategies in mainland china. one question that is of particular importance is the costeffectiveness of different antiepidemic measures. drawn from the chinese experiences and lessons, three categories of measures have been implemented: a) "regular" epidemiological control and prevention measures, including identification of infected cases, tracing their close contacts, and quarantines for both; b) in-city activity restrictions, including work-from-home, shutdown of schools and public spaces, cancellation of events, and lock-down of residential neighborhoods; c) inter-city travel restrictions, including temperature screening at all transportation terminals, cancellation of flights and trains, and eventually travel bans from/to certain cities. specifically, (b) and (c) are considered "irregular," which contain the spread of disease in an aggressive manner through the suppression of all possible social interactions. however, these measures lead to enormous economic loss, which may mean higher unemployment rates, and shortage of food, medical services, and other necessities. those chain effects may also endanger the lives of certain social groups. fundamentally this is a trolley dilemma, and the life and health of human beings can hardly be evaluated using monetary values. nevertheless, a comprehensive understanding of the cost of each measure-including the opportunity cost of the shutdown economic activities-and the effectiveness of lifesaving can still help policy makers to compare different antiepidemic strategies in a more operable way. further, with these insights, we can then perform a cross-sectional assessment of the situation of the global antiepidemic campaign regarding the aforementioned measures in different countries/regions, such that typical policies can be clustered and prescriptive policy suggestions can be provided accordingly, which also echoes the argument in ( ) . in prior research, scholars have used deductive models to find that the timing of lockdown, including both inter-city travel restrictions and social distancing, significantly changes the size of infected population and the spatial extent of spread ( ) ( ) ( ) ( ) . nonetheless, all prior research only focused on specific instances of policies without discussing generalizable impacts of different measures and lacked a cost-effectiveness assessment of each measure ( ) ( ) ( ) . in this article, based on the transmission pattern of covid- in china, we build a two-layer contactspread model ( fig. ) to recover the whole spatio-temporal transmission process, especially the early-stage numbers and distribution of cases at the prefecture level (see sm , , and ). with this model as a generalizable baseline, we conducted a comprehensive sensitivity analysis for all antiepidemic measures (fig. ) and concluded the following assessment on the effectiveness of the measures, in terms of number of infected cases, and number of infected cities. . containing daily social interaction, parameterized in the model as ! , " for the infected and the exposed populations, is the most effective measure for controlling both the number of infected cases and the spatial extent of the spread. more specifically, we find that a) the controls of ! and " show comparable and substitutable effects in containing the spread of disease, with different elasticity in different stages of the epidemic. controlling " is more effective when the number of cases is small (e.g., fewer than in a city), and ! is more effective when the number of cases is sufficiently large. the implication is that at the early stage of transmission, comprehensive epidemic surveys and contact tracing, alongside with strict quarantine and social distancing, should be used to prioritize the reduction of the social interaction levels of the exposed population ( " ), while after the number of cases has increased to a sufficiently high level, comprehensive testing and identification of all infected cases should be prioritized in order to reduce the social interaction levels of the infected population ( ! ). b) stricter control of social interaction for both ! and " have diminishing returns in reducing the number of cases, but increasing returns in limiting the spatial extent of spread. for example, in one month of simulation, when daily social interaction drops from % to % of the normal level, the number of infected cases drops by %- % (depending on the stage of epidemic), while the number of cities with infected cases drops only by - %; when daily social interaction drops from % to , however, the number of cases drops only by . %- . % for infected cases versus %- % for cities with infected cases. an exception is at the ending stage of the epidemic, when controlling social interaction has increasing returns in both effects. c) the effects of the epidemiological and social interaction control measures are monotonic for the reduction of infected cases and the spatial extent of spread: the stricter they are enforced, the lower number of infected cases and the narrower spatial extent of spread can be observed. . the time of reaching turning point is independent of the current number of infected cases but is only related to the stringency of epidemiological and social interaction control measures, i.e., the relative change of ! , " . when the two parameters are / - / of the normal everyday values, the turning point comes in two weeks and the clearance of cases happens in two to three months; when ! , " are larger than / - / of the normal values, the turning point will never come, i.e., the peak value of case numbers will remain the same as if there are no such measures, but they only delay the time of peak. . except at the early stage and the ending stage, inter-city travel restriction has only minimal effect on both the reduction of infected cases and control of disease spread in a city network. overall, compared with in-city epidemiological and social interaction control measures, the contribution of inter-city travel restrictions to the reduction of the number of infected cases and the spatial spread of disease is much smaller-lower by two orders of magnitudes. when the number of cases is sufficiently large, inter-city travel restriction even exacerbates the situation since it limits the social interaction of infected cases, and "condenses" # locally ( ) . this finding is consistent with that in prior research ( , ) . therefore, to national or regional governments who manage a city network, and to international antiepidemic collaboration, travel restriction should only be regarded as an auxiliary measure at the beginning and ending stage of the spread to protect cities which have not been infected at all, or only with a sufficiently small number of cases. in the latter case epidemiological and social interaction control measures should also be implemented simultaneously to get the health care system and other prevention measures prepared. the simulation-based formal analysis above is consistent with the empirical evidence in china. the lockdown of wuhan, and nationwide strict enforcement of epidemiological control and social distancing policies around january , including the cancellation of all chinese new near gatherings mark the key move of the antiepidemic campaign. at that time point, all other cities in china were at early stages of the epidemic, which guaranteed the effectiveness of the wuhan travel ban. in addition, with aggressive social interaction control in all cities the turning point of the number of cases arrived in two weeks outside of wuhan. in wuhan, the key move was the functioning of fāngcāng hospitals (mobile cabin hospitals) in early february which enabled citywide comprehensive quarantine of the infected population ( ) . this measure reduced the social interaction of infected cases to almost zero, and together with strict social distancing they effectively reversed the trend of spread after two weeks. in terms of inter-city travel restrictions, since they were during the chinese new year and the extended holidays, and overlapped with social distancing measures, the net effect could not be easily isolated empirically. nonetheless, since mid-february the economy had re-opened. by the end of march, the inter-city migration in southern and eastern chinese cities had recovered to the same level as in previous years ( ) , but most cities still observed almost zero increase of infected cases. this further supports that the effectiveness of travel restriction is very limited for the cities with small numbers of cases. another evidence to support this point is the , people who left wuhan right before the lockdown night ( ) . this "escaped" population did not significantly change the effectiveness of the national antiepidemic effort. further analysis on the cost-effectiveness of the measures shows more irregularity and non-linearity, leading to more nuanced relationships (detailed in sm ). here we summarize the most critical general patterns as follows: . the measures which can achieve both high antiepidemic effectiveness (low number of cases and narrow spatial spread) and high cost-effectiveness (smaller loss of economic outputs) only exist at the early stage of transmission. at the early stage, if epidemiological and social interaction control measures can be strictly enforced (sufficiently low ! and " ), it is possible to keep the spread at a low level, with a loss of economic outputs only up to %. the intuition is as follows: based on the assumptions of this article, the early-stage measures only include comprehensive testing, close contact tracing, and quarantine, but do not include indiscriminate restrictions of in-city social interaction and inter-city travel, which incurs high costs. the policy implication is straightforward: for early-stage cities and regions, it is critical to practice epidemiological control interventions, but not to necessarily mobilize the whole society into social interaction reduction. this finding is consistent with the suggestions in ( ). . except for the early stage, it is impossible to simultaneously achieve both high antiepidemic effectiveness and high cost-effectiveness. except for a few "plateaus," the effectiveness of epidemiological and social interaction control measures monotonically increases with the stringency of control measures. however, the cost and cost-effectiveness functions are non-monotonic and there usually exists more than one peak (see details in sm ), which in most cases do not coincide with the effectiveness peak. typically, the costs are the lowest when the control measures are at sufficiently low or sufficiently high levels. while the latter case has been explained in the last point, the sufficiently low control measure scenario basically leaves the whole population to be infected. therefore, the tradeoff between sufficiently low and sufficiently high levels of control measures depend on many technological factors, including the short-term and long-term capacity of healthcare systems, long-term uncertainty of virus mutation, and development of vaccines, as well as many non-technological factors, including the risk averse attitudes for the short term and the long term, the mental discounting between short-term and long-term tradeoffs, and the fundamental value judgement on the "value of lives," the discussion of which are beyond the scope of this article, and will be left for discussion at the end of this article. . lastly, although it is difficult to choose the optimal control strategy, the worst choice is explicit: mediocre control of social interaction, e.g., social distancing with leakage. this choice still incurs - % loss of economic outputs, but only achieves - % reduction in the number of cases, an extent which is insufficient to overturn the epidemic curve. except for moderately delaying the spread of disease which may be taken advantage of to get the healthcare system prepared, this strategy is the worst choice in all other dimensions. with the formal results above, we can now perform a cross-sectional assessment of the global situation of the antiepidemic campaign from a transmission-prevention policy perspective. among the three types of measures (epidemiological control measures, social distancing, and travel restriction), we disregard the travel restriction measure as our results clearly show that it is ineffective for most countries/regions under the current situation (we will discuss the exceptions later). rather, we use two datasets ( , ) which codified the antiepidemic measures chosen by countries/regions as of april (due to the lack of testing data, we use wuhan as a proxy for mainland china), and for the countries/regions analyze the relationship of their two stringency indices, $ and % , i.e., the activity levels of the infected and exposed populations, and the respective effectiveness on the reduction of infected cases. based on the stringency of the two dimensions of antiepidemic measures, we can divide all countries/regions into three groups (fig. ) , each with a different antiepidemic "strategy": elimination, control, and delay. more than countries/regions are not included because of the lack of data. we will also discuss the implications of this fact. . the "elimination" group: this group (up right corner of fig. ) consists of only a few countries/regions, including mainland china (represented by wuhan), hong kong sar, vietnam, uae, bahrain, etc., all with # ≪ , such that the epidemic could be expected to dwarf within a reasonably short time period. mainland china is the most prominent example of this group, where aggressive measures have been taken on both dimensions to reduce the activity of the infected population as well as the exposed population. the measures include effective epidemiological control interventions, such as comprehensive testing and close contact tracing, and also aggressive social distancing measures, such as shutdown of schools, workplaces, and public transport, cancellation of events, and mass disease control education. these measures incur %- % loss of economic outcome in a month, and the loss accumulates as the epidemic is not completely "eliminated". obviously, the underlying value judgment of the elimination strategy is an overwhelmingly high weight on health and lives over any cost-control or costeffectiveness reckoning. although the treasuring for lives is always respectable, long-lasting economic tightening also constitutes a threat to society, especially to the disadvantaged social groups. due to the existence of asymptomatic carriers, false-negative test results, and international imports of cases, a complete elimination of the epidemic is extremely difficult. thus, if the aim is to literally eliminate all cases, the economic losses are highly likely to accumulate to an unbearable level. therefore, we suggest that countries/regions which have followed the elimination strategy consider turning to the "control" strategy (elaborated below) to avoid excess economic losses on the condition that the active number of infected cases has been reduced to a sufficiently low level. we also suggest that these countries/regions keep the travel restriction measures-the most effective measure at this stage of the epidemic indicated by our simulation results. . the "control" group: this group includes south korea, singapore, qatar, norway, slovenia, russia, and new zealand, etc., all with # < , but still not sufficiently small, such that the epidemic can be reduced to a lower level (but not eliminated), depending on the stringency of intervention measures. the singapore in february was the most prominent example within this group, where antiepidemic measures have been mild enough not to affect everyday life by aggressive social distancing. through regular epidemiological control practices, they were managed to maintain a daily increase of infected cases fewer than , and only suffered . %- % loss of economic outcome in a month. the control strategy requires a highly capable epidemic control system. given the aforementioned long-term uncertainties, even with such a capable system, the strategy is still a tightrope-walking game with the risk of abrupt system overload by accidentally untracked surges of infection, which, unfortunately, appears to be the case in singapore in early april. under such circumstances, a timely turn to the "elimination" strategy may be necessary. . the "delay" group: all other countries/regions in fig. belong to the third group, which appears to follow the "delay" strategy, with # > , such that the epidemic will continue to grow. this is often referred to as the "flatten the curve" strategy, which aims not to reduce the epidemic to an as-low-as-possible level within a short period of time, but only to delay its growth through mediocre epidemiological control and social distancing measures. our results show that this is usually the worst scenario in terms of cost-effectiveness. a country/region may opt to this strategy because their tradeoff between short-term certainty (economic loss avoidance) and longterm uncertainty (possible disappearance of the epidemic in the summer, development of vaccines, etc.) leans towards the former. unless they have strong evidence to justify the tradeoff, we strongly suggest they reconsider. moreover, our results show possible directions to improve-enhancing the social interaction control for the infected population through more comprehensive testing or enhancing the social interaction for the exposed population through stricter social distancing measures, whichever sees fit based on the location of the country/region on fig. . rest of the world: more than countries/regions do not appear in fig. due to the lack of data, most of which are third-world countries/regions. although little information is available to us about the situations in these places, we conjecture that they may at this moment be pursuing cost-effectiveness of their antiepidemic interventions because of their limited availability of resources, which we call the "worth every penny" strategy. as our results show that the most cost-effective measures are usually neither the most effective one (actually they are usually very ineffective), nor the least costive ones, the "worth every penny" strategy is not a good option either. if a country/region opts to this scenario solely because of the lack of resources, it should be viewed as a humanitarian disaster, and we call for international aid in this situation. at the end, we acknowledge the extreme difficulty of even trying to lay out the comparison between human lives and economic activities, or the tradeoffs of lives between different social groups. we believe that the ethical discussion should be open to the whole society and hope that this article can contribute to the discussion. ( ) and a network transmission layer based on inter-city migration. through inter-city travel, the numbers of exposed and infected populations are adjusted daily. the model is calibrated using the migration data and the number of reported cases in china. see materials and methods for model specifications. (a) gradient of the first effectiveness function (with the number of infected cases as the metric for effectiveness) at the peak/inflecting stage, displaying decreasing margins, as well as the reverse of the effect of the inter-city travel level as ! and " decreases. (b) gradient of the second effectiveness function (with the number of cities with infected cases as the metric for effectiveness) at the accelerating stage, displaying firstly increasing and then decreasing margins as ! and " decreases. (c) gradient of the second effectiveness function (with the number of cities with infected cases as the metric for effectiveness) at the ending stage, displaying monotonically decreasing margins as each dot represents a country/region. the sizes of the dots indicate the number of infected cases on april , . classical seir model characterizes the dynamics of the susceptible, exposed, infected, and removed population, assuming a certain population size and transmission rate. in closer scrutiny, the fixed transmission rate assumption requires contact-based transmission process ( ) . from the perspective of spatial interaction, this requirement is contradictory to the prior assumption of fixed population. due to the high mobility of modern society, fixed population requires a large spatial scale of the model, e.g., the national scale. moreover, contact-based assumption is valid only at the scale of human daily activities-such scale should not exceed the urban scale to incorporate multiday intercity travels. at a larger spatial scale, human activity is featured by the "return-explorer" dichotomy ( ) . the former spreads outbreaks through daily contact, while the latter "diffuses" the epidemic through long-distance travels. the order of magnitude of the intercity long-distance migration can be massive in china, and related studies have also discussed the effect of this population flow on the spread of covid- outbreak ( , , , ) . thus, the covid- outbreak is actually subject to a "contact-spread" two-step transmission process. therefore, the classic seir model is insufficient to accurately describe the epidemic dynamics in the urban network and needs to be expanded. thereupon, we constructed a series of seir models for all cities, coupled with an intercity network. the node-edge structure of the model corresponds to the above-mentioned contactspread process; and the required data (epidemic parameters of each city, and intercity spatial interaction) are relatively simple. here, the choice of appropriate spatial resolution is critical. on the one hand, while prior research have adopted similar model design, they conducted the analysis mostly at the provincial resolution ( , , ) . according to the analysis above, the provincial level is not the best choice to reflect the intercity-spread mechanism. on the other hand, at too fine spatial scales, such as km-grid, township, or census blocks, modeling results can hardly be verified due to the lack of data, and random errors can be large. attempting to make a compromise between simplicity and completeness, interpretability and prediction accuracy, data spatial accuracy and verifiability ( ) ( ) ( ) , we took cities (administratively called prefectures in china) as the unit of analysis and built a model which we call the spatial-temporal explicit seir model (stex-seir). this model can not only be used to analyze the number of infected cases, spatial range of infection, and dynamics of the covid- outbreak, but can also be used to reveal the arrival time of the first case in each city. we calibrate the model with chinese case statistics. although it does not cover the entire globe, it is still informative to other countries since china has gone through the whole process of the epidemic. the stex-seir model relies on the following assumptions: ) intra-city population is homogeneous, i.e., it is a "meta-population," which is a common practice in the absence of real demographic data; ) omitting the impact of foreign imports and exports of covid- cases: the proportions of imported and exported cases during the covid- outbreak in china are extremely small and can be omitted over the study period. ) virus remains unmuted: although a very large number of mutations have been recorded ( ) , the transmission patterns of the virus have not noticeably changed so far. first step: update the immigrated and emigrated populations, the exposed population, and the infected population (assuming that the inputs and outputs of n, e, and i across cities are completed instantly at the beginning of time t). • ,-./ : lockdown on january ; • -*( -. : measures taken on january ; human-to-human transmission was confirmed on that day. : the proportion of the susceptible turning into the exposed status. second step: seir model in each city: in the above equations: s (unimmune and susceptible population) may turn into infected by contacting infected individuals; e (exposed) is the population who are in the incubation period after being infected; i (infected) is the population being symptomatic and infectious; r (removed) is the population who died or have been cured-they can neither infect others nor be infected again. n: total population in the city, subject to = + + + . other notations: • " : probability that a susceptible is infected and becomes an exposed person; • ! : probability that a susceptible is infected by an exposed person; • : probability that an exposed person turns into infectious status; • : probability of being cured; • : probability that an infected person dies; • " : probability that an exposed person is infectious; • ! : the number of susceptible persons who an infectious individual contact during each step of simulation; • " : the number of susceptible persons who an exposed individual contact during every step of simulation. the case data used in this article come from the national and provincial health commissions in china ( ) . wuhan is the city hit hardest by the epidemic, accounted for . % of the total number of cases. the number of cases in hubei province other than wuhan accounted for another . %. therefore, wuhan and hubei province have very different medical conditions, prevention and control measures from other cities and provinces in china. thus, we assigned different initial parameters for wuhan, other cities in hubei, and cities in other provinces. the initial number of cases in wuhan was set to be , and the initial numbers in other cities in hubei and in other provinces was set to be . according to the national report, the first confirmed infected case in wuhan can be traced back to december , . thus, we chose december , as the starting point for the simulation. according to other studies ( ) , this date is as close as possible to the real starting point of the pandemic, and epidemiological data are only available from this point to calibrate model. the endpoint of model calibration is february , when the epidemic in china was almost over and the model has converged by that time. we will simulate the spread of the covid- epidemic from that date until the end of april as verification and prediction (by the time of writing this article). we used chinese national, provincial, and municipal reports as the baseline to calibrate our model, so that the fitted number of cases would match with the surveyed data. on the one hand, the assumption, based on case statistics, is reliable. reports are released separately by more than cities nationwide and updated daily. panel data from different provinces are inter-validated with other and are also supported by data from other sources (e.g., total mortality rate of the population, or mortality data of similar symptoms such as influenza, pneumonia, etc.). thus, it is extremely unlikely that the data are fabricated continuously without being noticed. on the other hand, research shows that due to delayed diagnosis at the early stage of outbreak, the actual onset date of most confirmed cases is actually one week ahead of the report date ( , ) . considering the incubation period, we pushed the outbreak curve from the reported dates backwards by a few days, thus yielding the baseline for model calibration. the calculation and initial values of , , , , , , , " , ! , " , and ∆ were articulated in section of the supplementary material. among the three basic dimensions of epidemic control (control of the source of infection, cutting off transmission, and protection of the susceptible), we focus on the transmission cuttingoff dimension. specific measures belonging to this dimension can be further divided into three categories: ) "regular" epidemiological control measures; ) in-city social interaction control and ) intercity travel restrictions. these measures can be directly mapped to the three key parameters ! , " , and ∆ (denoted as tl henceforth) in the stex-seir model (table s ) , and thus empower the quantitatively evaluation of the effectiveness and cost-effectiveness of various scenarios. regular epidemiological control measures include thorough epidemiological surveys, close contact tracing, and quarantines of all the infected individuals and their close contacts as early and as possible-especially the close contacts, who may be potential carriers. these measures are reflected in the model by tuning the values of ! and " . it is noteworthy that the limits of the effectiveness of regular epidemiological control measures: • it is very difficult for the close-contact tracing and quarantines to be exhaustive, so they cannot reduce " to , indicating an effectiveness "roof"; • close contact tracing is a tedious work and is heavily manpower dependent. given that the epidemiological control system in regular practice usually has limited capacity. under outbreaks the system could be overloaded and becomes dysfunctional. under these circumstances, more aggressive measures are needed to reduce " . in-city social interaction control measures include work-from-home, shutdown of schools, workplaces, public transit, and public spaces, cancelation of public events, lockdown of residential neighborhood, etc. the effects of these measures are to reduce the chance of close contact between the infected/exposed and susceptible individuals, and are represented in the model by the values of ! and " , especially " , with contributions of different measures aggregated to a final value. we collected the measures adopted in different prior papers and coded them to estimate the final values of ! and " . it needs to be noted that the effects of specific measures are clearly overlapping with each other. for example, when social distancing both at the work and home ends are effectively implemented, the marginal "contribution" of an additional control on public transit usage would be minimal. also, despite of the nominal public orders, the actual stringency of the measures could be flexible in practice. for simplicity, we utilize expert knowledge to estimate the overall efforts, i.e., the values of ! and " . intercity travel restriction includes suspending inter-provincial and intercity buses, trains and flights, closing highways and roads, etc. the purpose is to reduce the intensity of personnel exchanges across cities, thereby reducing the transmission of the infected/exposed individuals. this is represented in the model by the reduction of spatial interaction parameter tl, or ∆ " and ∆ ! . in this paper we use two indicators to evaluate the effectiveness of disease control measures: the number of infected cases, and the spatial extent (represented by the number of cities with infected cases). minimizing the total infected population is a self-explanatory goal from the perspective of epidemic control. since e will eventually be converted to i with a fixed probability, we only need to focus on the infected population i and use the relative change of i over the simulation period (one month) as one indicator of effectiveness. the total antiepidemic effect in all cities is the summation: aside from the total number of infected cases, the spatial extent of the epidemic is also an indicator worth noticing. if the epidemic can be contained within a narrow spatial extent, the medical resources in other cities can be diverted to the infected cities to help, which actually happened in china where medical teams across the country were sent to wuhan for support. we also use the relative change of the number of cities with infected cases during the simulation period (one month) to quantify the effect: the total effect in all cities is the summation: we used the opportunity cost of economic output as the indicator for the cost of the antiepidemic measures. for simplicity, we only used the work-hour loss as a proxy for the economic output loss and did not convert it to monetary values of goods and services. travel restriction leads to reduction in the total number of personnel exchanges between cities. in particular, the outbreak of covid- in china overlapped with the spring festival holidays, and travel restriction apparently caused the migrant workers who previously travelled back hometown not be able to return to cities where they had worked after the holidays. while the impact on economic output is affected by factors such as the productivity difference between the migrant workers and local workers, we can use wages as a proxy for productivity and estimate the differences ( ) ( ) ( ) . calculations show that the average income of migrant workers in was . % of that of the local workers, or roughly the same, so we do not need to adjust for the differences in the model . therefore, this study ignores the role of the above factors. factors such as employment elasticity, which are more difficult to estimate, are also omitted for simplicity. therefore, the loss of economic output of city i at time t from travel restriction is: where _normal is the urban population in the normal status, approximated by the number of urban populations in the same period last year, and " _normal is the " in the normal status. for those who are not affected by the intercity travel restriction, we argue that the indiscriminately implemented in-city social interaction control measures reduce their intensity of social interaction, which in turn reduces their productivity and thus reduces the economic output. more specifically, we used " and ! as the proxy for productivity. it should be noted that lower " or ! is not necessarily the result of indiscriminate suppression of daily interactions but could also be the result of regular epidemiological control measures. a distinction needs to be made between these two situations. it can be reasonably assumed that when the number of the infected cases is small. for example, the daily increase of the number of infected cases does not exceed a certain threshold, the goal of reducing ! and " can be achieved solely by regular epidemiological control measures. therefore, a rational administration will choose not to opt to universal in-city social interaction control measures to avoid collateral loss. what is lost in this case is the output of only those who have been quarantined, i.e., the exposed and infected cases. we admit that it is extremely difficult to estimate such a threshold, which could be highly dependent on specific contexts such as governance capability, the resourcefulness of the epidemic control system, and cultural and geographic factors. although, a numerical estimation would still be of help. there was no opportunity to observe this threshold during the outbreak in china: in the early stage of the epidemic (before january , ), no effective epidemic control practices were taken outside of wuhan, and after january , the country had generally turned to aggressive and universal antiepidemic measures and it is difficult to separate the net effect of the each epidemic control measure. however, the singapore situation in january and february may constitute a good example, where in most cases daily reported new infected cases were under . another remark is that the chinese government sets a threshold of cases for reporting a newly discovered epidemic to the national cdc. in light of these numerical example, we use daily new infected cases as an estimate of the capacity threshold value. therefore, the loss of economic output of city i at time t from in-city social interaction control measures is set as follows. for straightforwardness, we convert the economic output loss into to a relative value: the proportion of the output with regard to that of the baseline (the normal situation). the total output loss ratio of city i during the entire simulation period is and the ratio of total output loss of all cities during the entire simulation period is: in summary, the comprehensive cost-effectiveness function of antiepidemic measures is: particularly, if cost = , it is stipulated that both cost/effectiveness ! , cost/effectiveness equal to . for simplicity, we only calculated the cost and cost-effectiveness functions at the national level (the entire city network). to discover any initial value-dependence of the cost and the costeffectiveness functions, we ran the simulation at different stages of the epidemic. based on the calibrated model, five scenarios with the following starting and ending dates are set: the model is run for days for each scenario, and five indicators are calculated: number of total infected cases, number of cities with infected cases, overall cost, effectiveness/cost ratio with respect to the number of infected cases, and effectiveness/cost ratio with respect to the number of cities with infected cases. we calculated the gradient function of the five indicators with respect to " , ! , and tl to analyze the structure of the solution space. for simplicity, we calculate the gradients discretely at the following points: ! = { , , , , , , , , , }; " = { , , , , , , , , }; tl = { , , , , }, where the five levels of tl correspond to . , . , . , . , and times of the normal intercity travel level. note that the lowest level of tl is not . this is because according to the situation in china (given by baidu migration data), when the tl is the lowest, the travel level is still about % of the normal level, and we believe that the stringency of intercity travel restriction in reality cannot be greater than this level. in contrast, aggressive in-city social interaction control measures can reduce the values of " and ! to levels very close to . we evaluated the antiepidemic situation of countries/regions based on the stringency of activity control policies of the infected and exposed, i.e., the degree of which ! and " are reduced. this takes steps: ) codifying policies and computation of the stringency indices; ) mapping of the stringency indices into values of ! and " ; and ) assessment of the antiepidemic situation based on the results of our analysis. for the exposed, effective activity control measures include close-contact tracing and social distancing. for the computation of the stringency of these measures, we used the data and method provided by the oxford covid- government response tracker ( ) , and computed and compiled the exposed activity control stringency index with six indicators: school shutdown, workplace shutdown, public events cancelation, public transport shutdown, public information campaign, and close-contact tracing. for the infected population, quarantine is the most important measure to reduce their activities, which but also requires testing in the first place. we therefore used the comprehensiveness of testing as the proxy for the infected activity control stringency. as testing policy coding from the aforementioned source is rather coarse, we instead designed an alternative index based on two indicators: tests per million population, and the ratio between cumulative cases and the number of total tests. the compiled index is gained through dividing the first indicator with the second, logarithmically transforming the quotient, and finally normalizing the result to the - range to match that of the exposed population's activity control stringency index. the logarithmic transformation is used only for visualization purposes, as very few countries/regions have much higher original indices. for the testing data, we employed sources from www.worldometers.info/coronavirus/. it should be noted that as mainland china does not publish testing data, we used the data from wuhan as a proxy. for both indices, we use the data as of april . a total of countries/regions are present in the final dataset. analysis results show that there exist two threshold values for both ! and " that correspond to the "elimination" (r << ) and "control" (r < ) strategies, as shown in table s . it should be noted that the effects of the two indicators are substitutable, with the elasticity of ! to be larger. for the mapping from ! to the respective stringency index of a specific measure, it is clear that the mapping should not be linear because of the non-linear transformations we have done. we therefore employed an estimation method based on expert knowledge: to achieve / reduction of ! which is required to "eliminate" the epidemic, it is needed to quarantine as many infected cases as possible. considering that about / to / infected cases are asymptomatic ( ) , this roughly means that all symptomatic cases should be tested. based on the statistics from wuhan and south korea, this requires the tests per million population to be greater than , , and the ratio between the number of cumulative cases and total tests to be smaller than %. converted from the above estimation to the respective stringency index, the value is around . we thus used this value as the boundary between "elimination" and "control". following similar methods, we estimated that the boundary between the "control" and "delay" policy groups to be around . for the mapping from " to the respective stringency index, because all six indicators' contribution to the actual stringency level are roughly equally weighted, we simply conducted a linear mapping between the composite stringency index and " . thus, the stringency index boundary between the "elimination" and "control" groups is , and that between "control" and "delay" is . epidemic parameter estimation is the first and fundamental step in the seir model. in previous studies, choices of these parameters usually adopted mathematical interpretation, such as the inverse of the incubation period or infectious period ( , ) and thus the numbers are not physically interpretable. however, if we consider the actual characteristics of covid- as shown in epidemiological studies, the ambiguity of the model can be greatly reduced. we estimated these parameters based on real-world data, considering errors caused by possible concealment, omission, and late reports. we used close contact tracing data after january to estimate ! , since statistical data in the early stage showed fluctuation due to the lag of reactions from the government. in the equation following, ( ) indicates the number of newly confirmed cases in a day. and ( ) indicates the number of close contacts who are still under medical observation in the same day. we averaged ! ( ) with regard to t and got . , so we set ! to %. in addition, we considered covid- to be infectious in the later stage of the incubation period: there is no evidence of weaker infectivity during the incubation period, and it is assumed that it can be as infectious as during the infected period, indicating " = ! = %. the incubation period is generally - days, and - days in most cases. the median incubation period is days. assuming infectivity in the - days before the end of the incubation period, with an average of days, the ratio of infectious exposed people ( " ) can be calculated as follows d is the average infectious day of the exposed, and e is the median of the incubation period. according to the new coronavirus pneumonia prevention and control program (second edition), suspected cases are those with similar clinical symptoms as infected people. if a suspected case tests positive for nucleic acid test or its viral gene sequencing is highly homologous with sars-cov- , it is diagnosed as a confirmed case. considering the relationship between suspected and confirmed cases, the ratio between new confirmed cases to existing suspected cases is recorded as the ratio of the exposed cases becoming infected cases. this index is a characteristic of the disease itself and is generally the inverse of the incubation period from the mathematical interpretation. therefore, it should be uniform for all cities. this parameter has converged since january and the average value is . ( . %). because of the presence of asymptomatic infections, only considering suspected cases can lead to overestimation. since asymptomatic infections accounted for . % of confirmed cases, we scaled up the suspected cases and the revised to be . %. according to the epidemiology working group of the chinese center for disease control, at least cases existed in hubei province in december , spread in fourteen counties. by january , , there were cases and deaths in cities of provinces. however, in the national epidemic reporting system, the first death was not reported until january in the whole country except wuhan. therefore, we took the results (table s ) published by the epidemiology working group and calculated the mortality rates in different regions at each stage (table s ) . we fitted the mortality rates with the following functions: wuhan: recovery rate is closely related to the capacity of local medical resources and city governments' responsiveness, so we conducted parameter fitting for each city. it is reasonable to believe that the number of cured cases published is reliable since there is no obvious reason for concealing recovery. therefore, the recovery rate is calculated as the ratio between newly cured cases and existed confirmed cases. the recovery rate has changed significantly by time. taking wuhan as an example, the abrupt outbreak led to a lack of medical resources at the beginning. then, aid resources from all over the world were sent to hubei province. in addition, huǒshénshān and léishénshān hospitals were built quickly to treat patients in severe conditions. these efforts contributed to the improvement of recovery rates ( ) . to capture the time-wise changes, we fitted piecewise functions to the recovery rates based on the characteristics of each stage. among the different stages, the early recovery rate in wuhan fluctuated too heavily to fit, so we took the average value in the period as an indicator of the recovery rate. the specific fitted functions are as follows: mainland china except hubei province: close contact tracing is a common epidemiological control measure, especially when early treatment is not clear, and when vaccines are not available. this approach can identify potentially infected individuals, quickly isolate them before they turn to severe patients, and prevent the occurrence of secondary transmission ( ) . social interaction intensities of the exposed and infected individuals are denoted as " and ! respectively in our model. these two parameters are highly related to local population densities. considering that the covid- outbreak occurred during the chinese new year, the intensity of social interaction was significantly higher than usual. wuhan, as china's large transportation hub, may have a higher per capita social interaction intensity than other cities. to address this, we used the contact rate of the infected population during sars (maximumly ) as the initial value of ! ( ). in general, the behavior of the exposed population is less restricted than the infected, so we assume that the maximum contact rate of the exposed is twice as high as that of the infected, which means that the maximum " is . according to the local epidemic reports, the initial values of ! and " in each area can be obtained (table s ) . then, based on the local control policies and response time, we adjusted the contact values at different stages. in january , , zhong nanshan announced that there was a risk of human-to-human transmission of covid- , and some people in wuhan began to consciously reduce their activities. until the citywide lockdown, the number of cases surged, and people began to realize the severity of the situation. then, strategies such as business shutdown, school shutdown, stay-at-home notices, and community shutdown were gradually implemented throughout the country to avoid contact between the susceptible and the infected population. in the late stage of the epidemic, numerous prevention and control strategies, including hospitalizing all confirmed cases and isolating all suspected cases, have greatly reduced the values of ! and " (figs. and ). the initial value of each city's population in our model is that on december . then, the population changed after the new year migration, which can be calculated through the spatial interaction matrix. our research includes prefectures in mainland china, with the time span from december , to april , . the data collected included migration data from the baidu migration map ( ), statistical yearbooks, and local covid- reports. the original baidu migration data is consisted of migration flows of , city pairs among cities from january , to february , . since there was no news of the covid- outbreak in december, the intensity of social activities was not affected and remained the same as normal workdays. in march and april after the outbreak, we assumed that due to the impact of the travel restrictions in most cities, residents' travel remained at a very low level. therefore, the migration data for december was set to be the same as an average workweek from january , to january , , and the intercity migration after february was set to be the same as between february to february . in addition, the numbers of covid- cases in our model and population data for the cities were collected from the national bureau of statistics of china ( ) and the national health commission of china's reports. we collected the publicly announced epidemic control policies of all prefectures in china from january to february . this dataset includes about , documents, among which were issued at the provincial level. we codified the policies into categories: one for longdistance travel restrictions, and the other five for in-city social interaction control measures (table s ) . we further translated the policies into their control stringency in terms of social interaction reduction based on expert evaluation on the policy terms as well as enforcement level inferred from media coverage. we lastly mapped the codified policies to the values of ! and " (figs. and ) . in the baseline (real-world) model, the initial number of cases at this stage was and increased to , after days. the initial number of infected cities were and increased to after days. in terms of the reduction of infected cases, the decreases of the three coefficients, ! , " , and tl all have positive effects, but the effects are non-linear-with all returns diminishing marginally. the marginal contribution of ! and " are roughly comparable and also substitutable, with that of " slightly higher when the level of social interactions is high (i.e., the values of ! and " are high, or close to the ordinary level, which is for ! and for " ), and that of ! higher when the level of social interactions is low (as low as ). however, the marginal contribution of ! and " are both - times higher than that of tl in most cases, and the latter is only significant when the values of ! and " are both very low. when ! ≤ and " ≤ , the number of infected cases will shrink, and will be reduced to after approximately two months (table s ). in terms of the reduction of number of cities with infected cases, the decreases of the three coefficients, ! , " , and tl all have positive and non-linear effects, but with increasing returns marginally. the marginal contribution of ! and " are roughly comparable and also substitutable, with that of " slightly higher when the level of social interactions is high, and that of ! slightly higher when the level of social interactions is low. however, the marginal contribution of ! and " are both - times higher than that of tl in most cases, and the latter is only significant when the values of ! and " are both very low. when ! ≤ and " ≤ , the number of cities with infected cases will shrink, and will be reduced to after approximately two months. since there was no baseline control at this stage, any change in the three coefficients means tighter control on social interactions, and hence a cost to economic output. first, the marginal contribution from the reduction of tl to the cost function is approximately - orders of magnitude lower than that of ! and " such that its impact is mostly negligible. second, the cost function has a ridge along the direction of ( ! = , " = ) and ( ! = , " = ). the global gradient between the ridge and ( ! = , " = ) is moderate, and a lowest plateau appears when ! ≤ where the value of the cost function is . on the other side, the global gradient is much steeper, with a minimal value of the cost function that is also at the corner. the global cost peak appears at ( ! = , " = ), at which point the peak cost slightly exceeds % of the total output. in terms of cost-effectiveness, as the peaks and trends of the cost function and two effect functions are different, the two cost-effectiveness functions show greater non-linearity. in terms of the cost-effectiveness with respect to the reduction of the number of infected cases, two local peaks exist. one is at the "strictest control" point i.e., ( ! = , " = ), when each . % reduction in the number of infected cases is associated with % of economic output cost within a month; another peak occurs at the "non-control" point i.e., ( ! = , " = ), when each . % reduction in the number of infected cases is associated with % of economic output cost within a month. however, in the latter case, there will be no reduction in the number of infected cases at all according to the respective effectiveness function, while the former case coincides with the effectiveness peak. in terms of the cost-effectiveness with respect to the reduction of the number of cities with infected cases, situations are similar, only that a third peak appears at ( ! = , " = ), which is also a hardly effective solution. overall, the best solution considering both effectiveness and cost-effectiveness in whichever terms at this stage of epidemic is at the "strictest control" point (fig. s ). stage: january , to february , . in the baseline (real-world) model, the initial number of cases at this stage was , and increased to , after days. the initial number of infected cities were and increased to after days. in terms of the reduction of infected cases, the decreases of the three coefficients, ! , " , and tl all have positive effects, but the effects are non-linear-with all returns diminishing marginally. the marginal contribution of ! and " are roughly comparable and also substitutable, with that of " slightly higher when the level of social interactions is high (i.e., the values of ! and " are high, or close to the ordinary level, which is for ! and for " ), and that of ! higher when the level of social interactions is low (as low as ). however, the marginal contribution of ! and " are both up to two orders of magnitude higher than that of tl in most cases, and the latter is only significant when the values of ! and " are both very low. when ! ≤ and " ≤ , the number of infected cases will shrink, and will be reduced to after approximately two months (table s ). in terms of the reduction of number of cities with infected cases, the decreases of the three coefficients, ! , " , and tl all have positive and non-linear effects, but with increasing returns marginally. the patterns of marginal contribution of the three coefficients are similar with the "reduction of infected cases" case and we do not elaborate here. first, the marginal contribution from the reduction of tl to the cost function is approximately - orders of magnitude lower than that of ! and " such that its impact is mostly negligible. second, the cost function has a ridge along the direction of ( ! = , " = ) and ( ! = , " = ). the global gradient between the ridge and ( ! = , " = ) is moderate and roughly linear, and a lowest plateau appears when ! ≤ and " ≤ (the "strictest control" scenario) where the cost is a small number ( %- %). on the other side, the global gradient is much steeper with increasing margins, with a minimal value of the cost close to at the corner (the "non-control scenario). one noteworthy character of the cost function is that the value of ! does not affect the position of the peak, but affects its value: keeping " the same, each % reduction in ! reduces the cost function by %- %. the global cost peak appears at ( ! = , " = ), or a "loose control" scenario, at which point the peak cost exceeds % of the total output. the intuition is that in this case, the control on social interactions is not sufficient to reverse the trend curve of the epidemic, and after the number of infected cases exceeding a certain threshold (the capacity "roof" of regular epidemiological measures to contain the epidemic), cities have to opt to a universal control on everyday social interactions to contain the epidemic, inflicting heavy loss on economic output. the global gradients of the cost-effectiveness function for both effectiveness metrics show similar patterns with the previous stage, only with more non-linearity, which is too complicated to be elaborated here. for more details, refer to fig. s . the baseline model witnessed the turning point of the epidemic, when the initial number of cases at this stage was , and reduced to , after days. the initial number of infected cities were and reduced to after days. in terms of the reduction of infected cases, the decreases of ! and " both have positive effects, but the effects are non-linear-with all returns diminishing marginally. the decrease of tl, however, have varying directions of effect dependent on the values of ! and " , with negative effect when both ! and " values are high and positive otherwise. the marginal contribution of ! and " are roughly comparable and also substitutable, with that of " slightly higher when the level of social interactions is high (i.e., the values of ! and " are high, or close to the ordinary level, which is for ! and for " ), and that of ! one order of magnitude higher when the level of social interactions is low (as low as ). however, the marginal contribution of ! and " are both up to two orders of magnitude higher than that of tl in most cases, and the latter is only significant when the values of ! and " are both very low. when ! ≤ and " ≤ , the number of infected cases will shrink, and will be reduced to after approximately two months. higher values of ! and " (looser control on the level of social interactions) will not be sufficient to reverse the epidemic trend curve. and at the non-control scenario, the number of infected cases will grow to approximately , , or times the number at the beginning of the baseline scenario (table s ). in terms of the reduction of number of cities with infected cases, the decreases of the three coefficients, ! , " , and tl all have positive and non-linear effects, but with increasing returns marginally. the patterns of marginal contribution of the three coefficients are similar with the "reduction of infected cases" case and we do not elaborate here. first, the marginal contribution from the reduction of tl to the cost function is approximately - orders of magnitude lower than that of ! and " such that its impact is mostly negligible. second, the cost function has a ridge along the direction of ( ! = , " = ) and ( ! = , " = ). the global gradient between the ridge and ( ! = , " = ) is moderate, and the lowest cost at the corner (the "strictest control" scenario) is a small number ( %- %). on the other side, the global gradient is much steeper, with a minimal value of the cost function close to at the corner (the "non-control scenario). again, the value of ! does not affect the position of the peak but affects its value: keeping " the same, each % reduction in ! reduces the cost function by %- %. the global cost peak appears at ( ! = , " = ), or a "loose control" scenario, at which point the peak cost exceeds % of the total output. the global gradients of the cost-effectiveness function for both effectiveness metrics show similar patterns with the previous stage, only with more non-linearity, which is too complicated to be elaborated here. for more details, refer to fig. s . in the baseline model, the initial number of cases at this stage was , and reduced to after days. the initial number of infected cities were and reduced to (wuhan) after days. in terms of the reduction of infected cases, the decreases of ! and " both have positive effects, but the effects are non-linear-with all returns diminishing marginally. the decrease of tl, however, have varying directions of effect dependent on the values of ! and " , with negative effect when both ! and " values are high and positive otherwise. the marginal contribution of ! and " are roughly comparable and also substitutable, with that of " slightly higher when the level of social interactions is high (i.e., the values of ! and " are high, or close to the ordinary level, which is for ! and for " ), and that of ! times higher when the level of social interactions is low (as low as ). however, the marginal contribution of ! and " are both up to order of magnitude higher than that of tl in most cases, and the latter is only significant when the values of ! and " are both very low. when ! ≤ and " ≤ , or ! ≤ and " ≤ , the number of infected cases will shrink, and will be reduced to after approximately two months. higher values of ! and " (looser control on the level of social interactions) will not be sufficient to reverse the epidemic trend curve. and at the non-control scenario, the number of infected cases will grow to approximately , , or three times the number at the beginning of the baseline scenario (table s ). in terms of the reduction of number of cities with infected cases, the decreases of the three coefficients, ! , " , and tl all have positive and non-linear effects, with increasing returns marginally at most times except when the values of ! and " are both very low-a noteworthy character that is different with the symmetric accelerating stage. another noteworthy character of the effectiveness function is the occurrence of plateaus when ! ≤ , where the change of " and tl will not affect the spatial scope of the epidemic. first, the marginal contribution from the reduction of tl to the cost function is approximately - orders of magnitude lower than that of ! and " such that its impact is mostly negligible. second, the cost function has a ridge along the direction of ( ! = , " = ) and ( ! = , " = ). the global gradient at both sides of the ridge drops close to with increasing margins and plateaus when ! is sufficiently low or high. again, the value of ! does not affect the position of the peak, but affects its value: keeping " the same, each % reduction in ! reduces the cost function by %- %, and when ! < , a plateau occurs where cost is minimal. the global cost peak appears at ( ! = , " = ), or a "loose control" scenario, at which point the peak cost exceeds % of the total output. the global gradients of the cost-effectiveness function for both effectiveness metrics show similar patterns with the previous stage, only with more non-linearity, which is too complicated to be elaborated here. for more details, refer to fig. s . in the baseline model, the initial number of cases at this stage was and reduced to after days. the initial number of infected cities were and reduced to (wuhan) after days. in terms of the reduction of infected cases, the decreases of the three coefficients, ! , " , and tl all have positive effects, but the effects are non-linear-with all returns diminishing marginally. the marginal contribution of ! and " are roughly comparable and also substitutable, with that of " about two times higher at all times. however, the marginal contribution of ! and " are both up to one order of magnitude higher than that of tl in most cases, and the latter is only significant when the values of ! and " are both very low. when " ≤ , or ! ≤ and " ≤ , the number of infected cases will shrink, and will be reduced to after approximately two months. higher values of ! and " (looser control on the level of social interactions) will not be sufficient to reverse the epidemic trend curve (table s ). in terms of the reduction of number of cities with infected cases, the decreases of the three coefficients, ! , " , and tl all have positive and non-linear effects, this time all with decreasing returns marginally -a noteworthy character that is different with the symmetric early stage. plateaus also exist at this stage, when ( ! , " ) is to the left (smaller) side of ( , )-( , ), where any further change of the coefficients will not affect the spatial scope of the epidemic. at this stage, the shape and value of the cost function are both dominated by " . they decrease monotonically and roughly linearly along with the direction of " 's decline, and the effects of ! and tl are very small. at this stage, the epidemic at the baseline has come to an end. although the initial number of cases is roughly equivalent to the initial stage of the epidemic, the strict control at the previous stages has led to a significant reduction in the number of the exposed population. therefore, the cost function at this time is dominated by " , and the peak value of the cost function is only . % of the output, a great reduction compared to those in the previous three stages. since the lift of controls on social interactions will help restore economic output, the peak cost-effectiveness at this stage all occurs when all controls are lifted, at which time economic output will be very close to the normal level (when there is no epidemic). the second highest cost-effectiveness peak appears when the controls are maintained (given the number of infected cases, the controls now are realized predominately through effective epidemiological measures, rather than universal containment of social interactions), where the maximum loss of economic output is about . %. while the former appears tempting, in the long run (about two months later) it is likely to cause a rebound in the epidemic (we only run the simulation for one month, so this effect cannot be directly observed in the model. however, the situation is similar to the initial period of the epidemic, and thus the lift of controls is just equivalent to starting the entire epidemic from the beginning, such that a second outbreak is inevitable if other conditions remain unchanged). the latter, on contrary, appears to achieve a good balance between cost and effectiveness within this study's analytical framework (fig. s ) . table s . threshold values for ! and " of the "elimination" and "control" strategies. elimination (r << ) control (r < ) ! / of the normal value while " is the normal value / of the normal value while " is the normal value " / of the normal value while ! is the normal value / of the normal value while ! is the normal value world health organization, who director-general's opening remarks at the media briefing on covid- national health commission of the people's republic of china a new twenty-first century science for effective epidemic response early phylogenetic estimate of the effective reproduction number of sars-cov- the effect of travel restrictions on the spread of the novel coronavirus modified seir and ai prediction of the epidemics trend of covid- in china under public health interventions the lockdown of hubei province causing different transmission dynamics of the novel coronavirus ( -ncov) in wuhan and beijing the effect of human mobility and control measures on the covid- epidemic in china preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak estimating the value of containment strategies in delaying the arrival time of an influenza pandemic: a case study of travel restriction and patient isolation controlling pandemic flu: the value of international air travel restrictions fangcang shelter hospitals: a novel concept for responding to public health emergencies before wuhan lockdown, where did the , people go? variation in government responses to covid- version . cases and deaths by country, territory, or conveyance epidemic processes in complex networks returners and explorers dichotomy in human mobility covid- control in china during mass population movements at new year should internal migrants take full responsibility for spreading covid- modified seir and ai prediction of the epidemics trend of covid- in china under public health interventions effect of non-pharmaceutical interventions for containing the covid- outbreak in china a comprehensive framework for studying diffusion patterns of imported dengue with individual-based movement data impact of human mobility on the emergence of dengue epidemics in pakistan quantifying the impact of human mobility on malaria new crown pneumonia outbreak data sharing epidemiology working group for ncip epidemic response, the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china risk for transportation of novel coronavirus disease from wuhan to other cities in china why do wages increase with tenure ? on-the-job training and life-cycle wage growth observed within firms private-sector training and the earnings of young workers labor productivity: structural change and cyclical dynamics quantifying sars-cov- transmission suggests epidemic control with digital contact tracing key: cord- - pg authors: mehrotra, sanjay; rahimian, hamed; barah, masoud; luo, fengqiao; schantz, karolina title: a model of supply‐chain decisions for resource sharing with an application to ventilator allocation to combat covid‐ date: - - journal: nan doi: . /nav. sha: doc_id: cord_uid: pg we present a stochastic optimization model for allocating and sharing a critical resource in the case of a pandemic. the demand for different entities peaks at different times, and an initial inventory for a central agency are to be allocated. the entities (states) may share the critical resource with a different state under a risk‐averse condition. the model is applied to study the allocation of ventilator inventory in the covid‐ pandemic by fema to different u.s. states. findings suggest that if less than % of the ventilator inventory is available for non‐covid‐ patients, fema's stockpile of ventilators (as of march , ) would be nearly adequate to meet the projected needs in slightly above average demand scenarios. however, when more than % of the available ventilator inventory must be reserved for non‐covid‐ patients, various degrees of shortfall are expected. in a severe case, where the demand is concentrated in the top‐most quartile of the forecast confidence interval and states are not willing to share their stockpile of ventilators, the total shortfall over the planning horizon (until may , ) is about ventilator days, with a peak shortfall of ventilators on april , . results are also reported for a worst‐case where the demand is at the upper limit of the % confidence interval. an important finding of this study is that a central agency (fema) can act as a coordinator for sharing critical resources that are in short supply over time to add efficiency in the system. moreover, through properly managing risk‐aversion of different entities (states) additional efficiency can be gained. an additional implication is that ramping up production early in the planning cycle allows to reduce shortfall significantly. an optimal timing of this production ramp‐up consideration can be based on a cost‐benefit analysis. while approximately % of covid- cases are mild, the most severe cases of covid- can result in respiratory failure, with approximately % of patients requiring treatment in an intensive care unit (icu) with mechanical ventilation (wu & mcgoogan, ) . mechanical ventilation is used to save the lives of patients whose lungs are so damaged that they can no longer pump enough oxygen into the blood to sustain organ function. it provides more oxygen than can be delivered through a nasal cannula or face mask, allowing the patient's lungs time to recover and fight off the infection. physicians in italy have indicated that critical covid- patients often need to be intubated for a prolonged period of time ( - days) (rosenbaum, ) , further exacerbating ventilator scarcity. limiting the death toll within the united states depends on the ability to allocate sufficient numbers of ventilators to hard hit areas of the country before infections peak and ensuring that the inventory does not run out. harder hit states (such as new york, michigan, and louisiana) are desperately trying to acquire additional ventilators in anticipation of significant shortages in the near future. yet in the absence of a coordinated federal response, reports have emerged of states finding themselves forced to compete with each other in order to obtain ventilators from manufacturers (state health systems, ) . according to new york's governor cuomo, the state has ordered ventilators at the cost of $ /ventilator, but is expected to receive only over the next weeks (ny governor, ). as of march , , according to the u.s. presidential news briefing, more than ventilators have been allocated by fema around the nation. of these, ventilators have been allocated to michigan, to new jersey, to louisiana, to connecticut, and to illinois, in addition to the given to new york (march white house briefing, ) . going forward, the federal response to the covid- pandemic will require centralized decision-making around how to equitably allocate, and reallocate, limited supplies of ventilators to states in need. projections from the institute for health metrics and evaluation at the university of washington, which assume that all states will institute strict social distancing practices and maintain them until after infections peak, show states will hit their peak demand at different time points throughout the months of april and may. many states are predicted to experience a significant gap in icu capacity, and similar, if not greater, gaps in ventilator capacity, with the time point at which needs will begin to exceed current capacity varying by state (ihme, ). in response to the above problem, this paper presents a model for allocation and possible reallocation of ventilators that are available in the national stockpile. importantly, computational results from the model also provide estimates of the shortfall of ventilators in each state under different future demand scenarios. this modeling framework can be used to develop master plans that will allocate part of the ventilator inventory here-and-now, while allocating and reallocating the available ventilators in the future. the modeling framework incorporates conditions under which part of the historically available ventilator inventory is used for non-covid- patients, who also present themselves for treatment along with covid- patients. thus, only a fraction of the historical ventilator inventory is available to treat covid- patients. the remaining demand needs are met by allocation and re-allocation of available ventilators from fema and availability of additional ventilators through planned production. fema is assumed as the central agency that coordinates state-to-state ventilator sharing. the availability of inventory from a state for re-allocation incorporates a certain risk-aversion parameter. we present results while performing a what-if analysis under realistically generated demand scenarios using available ventilator demand data and ventilator availability data for different u.s. states. an online planning tool is also developed and made available for use at https://covid- .iems.northwestern.edu (covid- planning tool, ). this paper is organized as follows. a review of the related literature is provided in section . we present our resource allocation planning model, and its re-formulation in section . section presents our computational results under different mechanical ventilator demand scenarios for the covid- pandemic in the united states. in section , we introduce our companion online covid- ventilator allocation and sharing planning tool. we end the paper with some discussion and concluding remarks. a medical resource allocation problem in a disaster is considered in xiang and zhang ( ) . victims' deteriorating health conditions are modeled as a markov chain, and the resources are allocated to optimize the total expected health recovery rate and reduce the total waiting time. certain illustrative examples in a queuing network setting are also given in xiang and zhang ( ) . the problem of scarce medical resource allocation after a natural disaster using a discrete event simulation approach is investigated in cao and huang ( ) . specifically, the authors in cao and huang ( ) investigate four resource-rationing principles: first come-first served, random, most serious first, and least serious first. it is found that without ethical constraints, the least serious first principle exhibits the highest efficiency. however, a random selection provides a relatively fairer allocation of services and a better trade-off with ethical considerations. resource allocation in an emergency department in a multiobjective and simulation-optimization framework is studied in feng, wu, and chen ( ) . simulation and queuing models for bed allocation are studied in vasilakis and ei-darzi ( ) and gorunescu, mcclean, and millard ( ) . the problem of determining the levels of contact tracing to control spread of infectious disease using a simulation approach to a social network model is considered in armbruster and brandeau ( ) . a linear programming model is used in investigating the allocation of hiv prevention funds across states (earnshaw, hicks, richter, & honeycut, ) . this paper suggests that in the optimal allocation, the funds are not distributed in an equitable manner. a linear programming model to derive an optimal allocation of healthcare resources in developing countries is studied in flessa ( ) . differential equation-based systems modeling approach is used in araz, galvani, and meyers ( ) to find a geographic and demographic dependent way of distributing pandemic influenza vaccines based on a case study of a/h n pandemic. in a more recent covid- -related study, kaplan ( ) proposes a probability model to estimate the effectiveness of quarantine and isolation on controlling the spread of covid- . in the context of ventilator allocation, a conceptual framework for allocating ventilators in a public emergency is proposed in zaza et al. ( ) . the problem of estimating mechanical ventilator demand in the united states during an influenza pandemic was considered in meltzer, patel, ajao, nystrom, and koonin ( ) . in a high severity pandemic scenario, a need of - additional ventilators to avert - deaths was estimated. robust models for emergency staff deployment in the event of a flu pandemic were studied in bienstock and zenteno ( ) . specifically, the authors focused on managing critical staff levels during such an event, with the goal of minimizing the impact of the pandemic. effectiveness of the approach was demonstrated through experiments using realistic data. a method for optimizing stockpiles of mechanical ventilators, which are critical for treating hospitalized influenza patients in respiratory failure, is introduced in huang et al. ( ) . in a case-study, mild, moderate, and severe pandemic conditions are considered for the state of texas. optimal allocations prioritize local over central storage, even though the latter can be deployed adaptively, on the basis of real-time needs. similar to this paper, the model in huang et al. ( ) uses an expected shortfall of ventilators in the objective function, while also considering a second criteria of total cost of ventilator stockpiling. however, the model in huang et al. ( ) does not consider distribution of ventilators over time. in the case of covid- , the ventilator demand is expected to peak at different times in different states, as the demand for each state has different trajectories. only forecasts are available on how the demand might evolve in the future. in this paper, we assume that the planning horizon is finite, and for simplicity we assume that reallocation decisions will be made at discrete times (days). under certain demand conditions, the ventilators may be in short supply to be able to meet the demand. our model is formulated as a stochastic program, and for the purpose of this paper, we reformulate and solve the developed model in its extensive form. we refer the reader to birge and louveaux ( ) and shapiro, dentcheva, and ruszczyński ( ) for a general description of this topic. in this section, we present a multiperiod planning model to allocate ventilators to different regions, based on their needs, for the treatment of critical patients. we assume that the demand for ventilators at each planning period is stochastic. we further assume that there is a central agency that coordinates the ventilator (re)location decisions. the ventilators' (re)location is executed at the beginning of each time period. once these decisions are made and executed, the states can use their inventory to treat patients. both the federal agency and the states have to decide whether to reserve their inventory in anticipation of future demand or share it with other entities. before presenting the formulation, we list the sets, parameters, and decision variables that are used in the model. - : states (regions), indexed by n ∈  ≔{ , … , | |}, - : planning periods, indexed by t ∈  ≔{ , … , | |}, -Ω: ventilators' demand scenarios, indexed by ∈ Ω ≔ { , … , |Ω|}, • deterministic parameters -y n : the initial inventory of ventilators in region n ∈  at time period t = , -i: the initial inventory of ventilators in the central agency at the beginning of time period t = , -q t : the number of ventilators produced during the time period t − that become available at the beginning of time period t ∈  , for t ≥ , n : the percentage of the initial inventory of ventilators in region n ∈  that cannot be used to care for the patients at the critical level, n : the percentage of the initial inventory of ventilators in region n ∈  that the region is willing to share with other regions, among those that can be used to care for patients at the critical level, n : the risk-aversion of region n ∈  to send their idle ventilators to the central agency to be shared with other regions, • stochastic parameters d n,t : the number of patients in region n ∈  at the critical level that need a ventilator at the beginning of time period t ∈  under scenario ∈ Ω, p : probability of scenario ∈ Ω, • decision variables x n, t : the number of ventilators reallocated to region n ∈  by the central agency at the beginning of time period t ∈  , z n,t : the number of ventilators reallocated to the central agency by region n ∈  at the beginning of time period t ∈  under scenario ∈ Ω, y n,t : the number of ventilators at region n ∈  that can be used to care for the patients at the critical level at the end of time period t ∈ { } ∪  under scenario ∈ Ω, s t : the number of ventilators at the central agency at the end of time period t ∈ { } ∪  under scenario ∈ Ω. for notational convenience, we also define the vector we might drop the superscript ∈ Ω from this notation and use the same symbol with a tilde to denote that these parameters are stochastic. for example, we might used. similarly, we define the deci- in this section, we assume that there is no lead time between sending a ventilator by an entity (a region or the central agency) and delivery by another entity. with this assumption, the planning model to minimize the expected shortage of ventilators in order to treat patients at the critical level is formulated as a two-stage stochastic program as follows: where we now explain the model in detail. in the first stage, the central agency makes the "here-and-now" decisions x before the stochastic parametersd are realized. as captured in ( a), the goal of the central agency is to minimize the expected total shortage of ventilators over all time periods t ∈  and all regions n ∈  . the objective also includes a cost, parameterized by of allocating a ventilator by the central agency to a state at a given time. this cost can be set to zero, or set to a small value. in our computations we set = . . in the second stage, once the stochastic parametersd are realized, the "wait-and-see" decisions z n, t , y n, t , s t , n ∈  , and t ∈  , are made. these decisions are scenario-specific, and are indicated by the superscript ∈ Ω, in the extensive formulation given in ( ). constraints ( b) and ( c) ensure the conservation of ventilators for the regions and the central agency at each time period, respectively. constraint ( d) enforces that at each time period, a region is not sending out any ventilator to the central agency if its in-hand inventory is lower than its safety stock, where the safety stock is determined as ndn,t , for t ∈  and n ∈  . constraint ( e) ensures that at each time period, the total number of outgoing ventilators from the central agency to the regions cannot be larger than the available inventory, after incorporating the newly produced ventilators and the incoming ones from other regions. constraints ( f) and ( g) set the initial inventory at the regions and central agency, respectively. the remaining constraints ensure the nonnegativity of decision variables. note that the objective function ( a) and constraints ( d) are not linear. by introducing an additional variable, the term (d n,t − y n,t ) + in the objective function, for n ∈  , t ∈  , and ∈ Ω, can be linearized as e n,t ≥d n,t − y n,t , e n,t ≥ . furthermore, for each region n ∈  and time period t ∈  , constraint ( d) can be linearized as where m is a big number. by incorporating the finiteness of the support ofd, a linearized reformulation of model ( ) can be written as a mixed-binary linear program in the following extensive form: where d n,t denotes the number of patients at the critical level in regions n ∈  that need a ventilator at the beginning of time period t ∈  under scenario ∈ Ω. note that all second-stage variables z n,t , y n,t , and s t , n ∈  , and t ∈  in model ( ) have superscript to indicate their dependence to scenario ∈ Ω. it is worth noting that ( ) (and ( ) as well) considers multiperiod decisions. in the model, the central agency will make decisions for the entire planning horizon using the information that is available at the beginning of planning. for our numerical experiments in section , we used a commercial mixed-integer programming solver to obtain the results. furthermore, we used i + n y n, + ∑ t ′ ≤t q t as a big-m for n ∈  and t ∈  . in this section, we assume that there is a lead time of l time periods between sending a ventilator by an entity (a region or the central agency) and delivery by another entity. with this assumption, ( ) can be generalized as follows: where note that model ( ) is obtained by revisiting constraints ( b), ( c), and ( e) to incorporate lead time in the planning. constraints ( b) and ( c) require the conservation of ventilators for the regions at each time period, where a ventilator sent by the federal agency to a region at time period t − l, t > l, will become available for the region at time period t. constraints ( d) and ( e) ensure the conservation of ventilators for the central agency, respectively, where a ventilator sent by a region to the federal agency at time period t − l, t > l, will become available for the central agency at time period t. constraints ( g) and ( h) enforce that the total number of outgoing ventilators from the central agency to the regions cannot be larger than the available inventory, after incorporating the newly produced ventilators and the incoming ones from other regions. similar to ( b) and ( c), constraint ( e) is also divided into sets for t ≤ l and t > l in ( g) and ( h). by incorporating the finiteness of the support ofd, a linearized reformulation of model ( ) can be written as a mixed-binary linear program in the following extensive form: similar to ( ), model ( ) can be written as a mixed-binary linear program in the following extensive form: y n,t− + x n,t−l − z n,t = y n,t , ∀ ∈ Ω, ∀n ∈  , z n,t ≤ y n,t − ( − )y n, − n d n,t + m( − g n,t ), z n,t ≤ n,t , ∀ ∈ Ω, ∀n ∈  , ∀t ∈  , e n,t ≥ d n,t − y n,t , ∀ ∈ Ω, ∀n ∈  , ∀t ∈  , ( m) the ventilator allocation model ( ), described in section , was implemented in python . . all computations were performed using gurobi . . , on a linux ubuntu environment on two machines. in the first machine, we used cores, with . ghz processor and gb of ram, and set the time limit to hours. in the second machine, we used cores, with . ghz processor and gb of ram, and set the time limit to hours. since projected ventilator need is a key input for the model, it is important to use accurate estimates of the demand forecasts. the forecasts of ventilator needs generated by ihme ( ) were used in our computational study. these forecasts were first made available on march , , and used the most recent epidemiological data and advanced modeling techniques. the available information closely tracks the real-time data (ihme covid- projections, we considered a -day planning period, starting from march , and ending on may , . we generated the random demands in ways that correspond to projected future demands under different mitigation effects. more precisely, we considered six different cases to generate random samples for the number of ventilators needed to care for covid- patients. these cases are listed below: case i. average-i: each of the demand scenarios has equal probability and the distribution is uniform over the range of the ci provided in ihme ( ) we further discuss the demand generation procedure. a demand scenario contains the demand data for all days and states. in all cases i-vi, we assumed that the forecast ci provided in ihme ( ), for each day and for each state, represents the support of the demand distribution. cases i and ii are generated to develop average demand scenario representations that use the information provided in the ci given in ihme ( ) in two different ways. in case i, it is assumed that the mean is the median of the demand distribution (ie, the right-and left-tail of the demand distribution have . probability). we randomly generated a number to indicate which tail to sample from, where both tails have the same . probability of being chosen. once the tail is determined, we divided the tail into equally distanced partitions, and chose a random partition to uniformly sample from. we repeated this process for all days and states. in order to capture the spatiotemporal correlation between demand realizations, we sampled from the same tail and partition for all days and states, although the range from which we sample depends on the ci. in this case, all scenarios are equally likely. in case ii, we randomly generated a number to indicate which tail to sample from, where the top % of the ci (ie, the right tail) has a . probability and the bottom % (ie, the left tail) has a . probability of being chosen. if the right tail is chosen, we set the weight of the scenario to . , and we set it to . otherwise. the rest of the procedure is similar to case i. in order to determine the probability of scenarios, we normalized the weights. demand scenarios in cases iii-v are generated in the same fashion as in case ii, where the only difference is in the probability of which tail to choose from, which is determined by the sampling scheme described in the definition of the case. cases i and ii are intended to parameterize the model to capture the average case. these two cases were considered because our data analysis showed that the confidence intervals on the forecasts provided by ihme covid- projections ( ) were not symmetric. we attempted a log-transformation of the confidence intervals, but found that the log-transforms also provided asymmetric confidence intervals. hence, it was considered more appropriate to generate the demand scenarios using two different sampling schemes. for cases i-vi, we generated scenarios, while in case vi, there is only one scenario which happens at the upper limit of ci. note that in each case, different quantities for the random demandd n,t , t ∈  , n ∈  , and ∈ Ω, might be generated. an illustration of the trajectory of demand scenarios over time is given in figures - for the us and the states of new york and california. the y-axis in these figures represents the demand realization in each sampled scenario. another key input to the planning model is the initial ventilator inventory. as of march , , before the rapid rise of covid- cases in the state of new york, fema had about ventilators in reserve, that is, i = . we used this for our model which suggests ventilator allocation decisions from march , . estimates for the initial inventory of ventilators at different states were obtained from mapping us health system ( ). these estimates are based on a hospital survey (rubinson et al., ; united states resource, ) . the estimates for new ventilator production were obtained based on information provided at the us presidential briefings on march , (coronavirus outbreak, . these estimates suggest that the normal yearly ventilator production capacity is about ventilators/year. however, under the u.s. defense production act, with the participation of additional companies, production of approximately ventilators/month could be possible (coronavirus outbreak, ) . using this information, for the baseline case we assumed that the current daily ventilator production rate is q t = ventilators/day; and it will be increased to q t = ventilators/day starting on april , . we refer to this case, as "baseline production," and analyzed in section . . . we also analyze the case that the ramp-up in production happens on april , or april , in section . . . recall that in the model, parameter is used to indicate the fraction of ventilators used to care for non-covid- patients. additionally, a parameter is used in the model to estimate a state's willingness to share the fraction of their initial covid- -use ventilators. similarly, the parameter is used to control the state's risk-aversion to sending their idle ventilators to fema for use in a different state. we suppose that for all states n, n ∈  , we have n = , n = , and n = . in order to systematically study the ventilator allocations and shortfalls, we used the following parameters: ∈ { %, %, %}, ∈ { . , . , }, and ∈ { %, %, %}. in this section, we present and discuss the numerical results for the case that there is no lead-time, that is, l = or there is a lead-time of day. for most instances, we observed that even obtaining an integer feasible solution to ( ) and ( ) in the time limit was not possible. therefore, we replaced these models with their expected value problem, where the stochastic demand is substituted with the expected demand. then, we solved the resulting model. this heuristic yields an integer feasible solution to model ( ) and ( ) for all instances we tested in the time limit, and we report those results here. in section . . , we provide the results on ventilator shortage and inflow/outflow from/to fema for the case that there is no lead-time. we also analyze the effect of early ramp-up in production and lead-time on ventilators' shortage in sections . . and . . , respectively. in this section, for each setting ( , , ), we solved the expected value problem of model ( ) under cases i-vi. a summary of ventilators' shortage results is reported in tables - . we briefly describe the columns in these tables. column "total" denotes the expected total shortage, and is calculated as where w n,t ≔ (d t,n − i t,n ) + , d t,n ≔ ∑ ∈Ω p d n,t , i t,n ≔ y ,n + fema t,n , and fema t,n ≔ min { ∑ t ′ ≤t x t,n , (d t,n − y ,n ) + } . quantity "worst day" in column "worst day (t)" denotes the expected shortage in the worst day, and is calculated as where t denotes a day that the worst expected shortage happens, that is, t ∈ arg max t∈ ∑ n∈ w n,t . moreover, quantity "worst day-state" in column "worst day-state (t)" denotes the expected shortage in the worst day and state, and is calculated as where (t, n) ∈ arg max t∈ arg max n∈ w n,t . the results in tables - suggest that when up to % of a state's ventilator inventory is used for non-covid- patients, fema's current stockpile of ventilators is nearly sufficient to meet the demand imposed by covid- patients in mild cases (ie, cases i-iii). the ventilator availability situation gets worse in the case where % (or greater %) of the available ventilators must be used for non-covid- patients and states' risk-aversion parameter to send the idle ventilators to fema to be used in a different state is . in this case, if states are willing to share up to % of their excess inventory with other states, then number of ventilators will be required beyond fema's current stockpile to meet demand in cases i-iv. however, if no such sharing is considered, then the need for ventilators would increase to . this situation gets even worse for cases v and vi, where the inventory shortfall on the worst day (april , ) is between and . this shortfall decreases moderately to - if states are willing to share part of their initial ventilator inventory. if parameter goes down to . , the inventory shortfall on the worst day (april , ) is between and . this shortfall decreases moderately to - if states are willing to share part of their initial ventilator inventory. we also analyzed the ventilators' reallocation to/from different states for the setting ( , , ) = ( . , , ), which is the most dramatic case we considered from the inventory and stockpile perspectives. we report a summary of results in table under the two worst demand situations, cases v (severe) and vi (extreme). column "total inflow" in this table denotes the total incoming ventilators to a state n ∈  from fema, and is calculated as similarly, column "total outflow" denotes the expected total outgoing ventilators from a state n ∈  to fema in order to be shared with other states to be used to treat covid- patients, and is calculated as also, column "net flow" represents the difference between "total inflow" and "total outflow." the results in table indicate that in cases vi (severe) and v (extreme), the state of new york requires between and additional ventilators for covid- patients during its peak demand. however, between and of these ventilators can be given to a different state after the peak demand in the state of new york has subsided. the insights about other states can also be obtained from this table. the effect of early ramp-up in production on ventilators' shortage in this section, we consider the cases that the ramp-up in production happens on april , or april , , as opposed to the baseline production, where the ramp-up in production happens on april , . a summary of ventilators' shortage is given in table for the parameter setting ( , , ) = ( . , . , ), under the two worst demand situations, cases v (severe) and vi (extreme). as it is evident from table , early ramp-up in production could save up more than and lives in case v (severe) and case vi (extreme), respectively. in this section, we analyze ventilators' shortage for the case that there is a lead-time of day. a summary of results under case vi is presented in table . it can be seen from this table that, as expected, the inventory shortfall increases with an increase in the lead-time (approximately up to on the worst day). a companion online planning tool is developed in order to view the outputs on the number of ventilators needed and the shortage that might happen under various conditions (covid- planning tool, ) . this website is available at https://covid- .iems.northwestern.edu. the users can choose the demand scenario (cases i-vi) and choose different options for parameter , the fraction of ventilators used to care for non-covid patients, parameter , state's willingness to share the fraction of their initial covid- -use ventilators, parameter , the state's risk-aversion to sending their idle ventilators to fema for use in a different state, and parameter l for lead-time. the results on the website are shown in interactive graphical and tabular formats. a snippet of this online planning tool is given in figure . interested readers can refer to this online companion for more details and analysis beyond what is presented in this paper. the results on covid- planning tool ( ) will be updated as additional computations are conducted and new forecast confidence intervals become available. we have presented a model for procuring and sharing life-saving resources whose demand is stochastic. the demand arising from different entities (states) peaks at different times, and it is important to meet as much of this demand as possible to save lives. each participating state is risk averse to sharing their excess inventory at any given time, and this risk-aversion is captured by using a safety threshold parameter. specifically, the developed model is applicable to the current covid- pandemic, where many u.s. states are in dire need of mechanical ventilators to provide life-support to severely and critically ill patients. computations were performed using realistic ventilator need forecasts and availability under a wide combination of parameter settings. our findings suggest that the fraction of currently available ventilators that are to be used for non-covid- patients strongly impacts state and national ability to meet demand arising from covid- patients. when more than % of the existing inventory is available for covid- patients, the national stockpile is nearly sufficient to meet the demand in mild cases. however, if less than % of the existing inventory is available for covid- patients, the current national stockpile and the anticipated production may not be sufficient under extreme demand scenarios. as expected, the magnitude of this shortfall increases when one considers more and more extreme demand scenarios. overall, the model developed in this paper can be used as a planning tool/framework by state and federal agencies in acquiring and allocating ventilators to meet national demand. the results reported in this paper can also provide a guide to states in planning for their ventilator needs. we, however, emphasize that these results are based on certain modeling assumptions. this includes the process of demand forecast scenario generation, estimates of initial ventilator inventory, and future production quantities. each one of these, as well as other model parameters, can be changed in the model input to obtain more refined results. nevertheless, an important finding is that a state's willingness to share its idle inventory can help address overall shortfall. while this paper has focused on ventilator needs in the united states, such a model can also be adapted for use in international supply-chain coordination of equipment such as ventilators across countries. covid- is expected to have different peak dates and demand cycles in other countries, and one or two additional disease spread cycles are likely until an effective vaccine becomes available. in conclusion, we point out that the model developed in this paper has a one-time planning decision, that is, there are no "wait-and-see" decisions in the model over time. one can also formulate the ventilator allocation problem as a time-dynamic multistage stochastic program, where the decision maker can make recourse decisions as time evolves based on the information available so far on the stochastic demands and past decisions. we are currently working on such an extension. in addition to the model being a one-time planning decision model, the model and its output have some additional limitations. first, the model may have multiple optimal solutions. in a resource constrained environment, alternative solutions may allocate the same number of ventilators differently. the solutions reported in the tables are only one such solution. moreover, these solutions were obtained from solving the models approximately with a prespecified time limit. the solutions from the optimization model presented in this paper depend on the accuracy of ventilator need forecasts. these forecasts are being revised regularly, as additional data based on state-specific mitigation efforts is becoming available. second, the objective function in the model treats the shortfall in large and small states equally. state-specific consideration may allow further refinements to the model. specifically, instead of formulating the objective as an expected value minimization model, we can formulate the objective as a minmax objective of shortfall for each state-thus minimizing the maximum shortfall to any state. such a model is expected to yield a more equitable solution. third, the model in section . . assumes a constant lead time. we can modify this model to allow for state-specific lead times. such a modification will allow one to systematically study the effect of state-specific lead time on the overall allocation efficiency. moreover, if shipment times are of concern and a secondary coordination to a stocking depot is required, the model can be adapted to allow for creation of transshipment depots (warehouses) that serve a cluster of states. in this case, the central agency will first ship the inventory to the warehouse, who will further distribute it to the states in need. in all of these aspects the modeling framework presented in this paper should be considered as a first step in the direction of developing planning models that allow for critical resource sharing over time. nevertheless, the overall conclusions based on the model remain valid: in a resource-constrained environment where the demand of different entities peaks at different time points, it is possible to achieve improved efficiency in resource utilization through supply-demand matching over time. risk aversion to sharing excess supply in anticipation of future demand reduces the efficiency resulting from such sharing. this work has been partially supported by the national science foundation through grant cmmi- . the authors would like to thank ebru bish and nan liu for the constructive comments and suggestions. the authors thank ming hu for getting an expedited review of this paper, and making several suggestions that helped improve an earlier draft of this paper. specifically, the lead time model, and the sensitivity analysis for the production function was added in response to his suggestions. orcid sanjay mehrotra https://orcid.org/ - - - geographic prioritization of distributing pandemic influenza vaccines contact tracing to control infectious disease: when enough is enough. health care management science models for managing the impact of an epidemic introduction to stochastic programming principles of scarce medical resource allocation in natural disaster relief: a simulation approach coronavirus outbreak: trump invokes defense production act (dpa) covid- ventilator allocation and sharing planning tool a linear programming model for allocating hiv prevention funds with state agencies: a pilot study stochastic resource allocation in emergency departments with a multi-objective simulation optimization algorithm where efficiency saves lives: a linear program for the optimal allocation of health care resources in developing countries using a queueing model to help plan bed allocation in a department of geriatric medicine stockpiling ventilators for influenza pandemics the continuing -ncov epidemic threat of novel coronaviruses to global health -the latest novel coronavirus outbreak in wuhan ihme covid- health service utilization forecasting team murray cj. forecasting covid- impact on hospital bed-days icu-days ventilator days and deaths by us state in the next months ihme covid- projections johns hopkins university covid- resource center containing -ncov (wuhan) coronavirus. health care management science mapping us health system capacity needs to care for covid- patients march white house briefing from coronavirus task force estimates of the demand for mechanical ventilation in the united states during an influenza pandemic ny governor andrew cuomo holds coronavirus briefing-nbc news facing covid- in italy -ethics logistics and therapeutics on the epidemic's front line mechanical ventilators in us acute care hospitals lectures on stochastic programming: modeling and theory state health systems strained as coronavirus outbreak spreads united states resource availability for covid- a simulation study of the winter bed crisis characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china chinese center for disease control and prevention a medical resource allocation model for serving emergency victims with deteriorating health conditions a conceptual framework for allocation of federally stockpiled ventilators during large-scale public health emergencies a model of supply-chain decisions for resource sharing with an application to ventilator allocation to combat covid- key: cord- -ao p ra authors: paul, suman; bhattacharya, subhasis; mandal, buddhadev; haldar, subrata; mandal, somnath; kundu, sanjit; biswas, anupam title: dynamics and risk assessment of sars-cov- in urban areas: a geographical assessment on kolkata municipal corporation, india date: - - journal: spat doi: . /s - - - sha: doc_id: cord_uid: ao p ra sars-cov- has been transmitted and outbreak took place in india during the last week before nationwide st lockdown took place. urban areas found more vulnerable and reported nearly % of cases during every phase of lockdown. mumbai, among four metropolitan cities found huge number of containment zones with nearly % of sars-cov- cases indicating clustering of cases. most of the containment zones of sars-cov- cases in kolkata municipal corporation found a significant relation with slum areas. the study primarily tries considering the nature of sars-cov- cases in different urban centres with the help of cartographic techniques. ahp method has been used to determine the factors responsible for such concentration of sars-cov- cases with vulnerability assessment (exposure, sensitivity and resilience) and risks. before nationwide lockdown starts, the share of urban centres found % which has been transformed into nearly % at the end of (rd) phase of lockdown. growth rate of sars-cov- cases found very high for chennai and thane with less number of doubling time to nation. slum concentration and containment density shows a higher degree of correlation in kolkata municipal corporation. risk map also shows the concentration of cases in central and north kolkata with higher degree of diseases exposure and sensitivity. control measures must be taken by the central and state government to minimise the transmission rate of sars-cov- mainly urban areas. as urban area contributing a higher share of sars-cov- cases, a proper management plan must be enforce. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. in the present day context urbanisation becomes a major driver of demographic change of an area. according to united nations report, world's population living in the urban areas has grown from to % during to [ , ] . by , it has been estimated that the world's % population will be reside in urban areas. this kind of urban growth and population concentration leads to sprawling and shanty development outside and within the city respectively. high population density, low per capita spacing, concentration of urban poor make significant impact on the epidemiology of the infectious diseases electronic supplementary material the online version of this article (https://doi.org/ . /s - - - ) contains supplementary material, which is available to authorized users. [ , ] . association between urban poor and risk of pathogen transmission is very high in this scenario. high human to human propagation can easily be spike with such vulnerable condition [ ] . presently, more than million populations in the world are living in slums whereas the figure of india is nearly million [ ] . in , worldwide figure of slum populations were nearly million which has been booming to million in next years i.e. in [ ] . in the current worldwide pandemic situation of sars-cov- , growth pattern, transmission nature and driving factors are the key aspects need to study. december , an outbreak of covid- (as known earlier) has been reported from wuhan city of hubei province in mainland china and rapidly spread into the other provinces of china along with countries within end of january, [ ] . wuhan city has been under full lockdown (travel ban and closure of everything except essential services) from january [ ] . but the decision has been taken by the government was too late as the by novel coronavirus (ncov- ) infections has already transmitted in different parts of mainland china and also in the different countries of the world. this episode is highly correlated with the chinese great migration during the january-february when near about million people are moving towards mainland china (within the country and from outside the country) to celebrate their lunar new year. from mid-february countries of european continent, u.s.a, australia facing a terrible spike of sars-cov- cases which has been not affected india at a large till the end of march, . nearly . million populations has been affected by sars-cov- and the fatality has reached into . million (as on - - ). several countries like united states, russia, brazil, italy, france, united kingdom, germany, turkey, iran has faced a major setback due the this pandemic [ , ] . india has also reached the mark of , confirmed sars-cov- cases after days of first case found. though the time taken by india to reach one lack infected cases much higher than the other countries, but the exponential triggering has been noticed during last week of rd phase of nationwide lockdown (from may, to may, ). nearly % cases are reported from major cities of india and most interestingly, mumbai, delhi, ahmedabad, chennai, thane, pune, kolkata become the most contributing urban centres to sars-cov- cases (as on may, ). high population density and higher concentration of slum population make an interruption for maintaining the social distancing and lockdown effectively [ ] [ ] [ ] . considering such backdrop the nature of spreading of sars-cov- cases in the indian cities need to be analysed. further an attempt has also been made to quantify and assess the hotspot zones along with risks of the concentrated areas of kolkata (one of the metro city) for proper understanding of transmission of diseases in the congested and unhealthy places as a case study [ , , ] . india has only cases of sars-cov- up to march , but all cases has transmitted and grow in a slow but steady in different areas of india especially in urban centres. except kasaragode, a rural base area in kerala, urban areas of maharashtra, delhi, gujarat and rajasthan have shown a large number of sars-cov- positive cases. in this regard, the mumbai, ahmedabad, chennai, pune, thane, indore, delhi, jaipur, kolkata, surat urban centres have been considered for initial analysis as these urban centres contribute more than % of sars-cov- cases during nationwide lockdown periods. from the analysis of urban centres contribution of sars-cov- cases, four megacities of india (i.e. mumbai, ncr delhi, kolkata and chennai) has been further chosen ( fig. ) to find out the nature of relationship between containment zones and sars-cov- cases. as urban centres with high population density and high concentration of slum population faced a risk of rapid transmission of sars-cov- , a risk analysis have also been assessed on kolkata municipal corporation for the better understanding of driving factors of transmission of sars-cov- . the sars-cov- data set has been obtained from indian council for medical research (icmr) and health website which provide the real time data set on the outbreak of this pandemic. another good source of data has been found from 'how india lives'. this website provides different health infrastructure dataset at district level and uploading the real time covid- cases for each day at district and city level. containment zones cities which is a very important source of information to identify the sars-cov- hotspot has been taken from health bulletin, govt. of west bengal. major cities of india are taken for primary level study with duration of before lockdown situation to present day ( - - ) scenario. the slum data set has been taken from unpublished baseline survey report of by the department of bustee services, kolkata municipal corporation. as most of the dataset of slum related indicators found from census of india, dataset, we have to take baseline survey report of kmc. this data base has helped to identify the nature of exposure, sensitivity and resilience of world wise slam households which can assess the nature of risk among the slums. to depict the nature of sars-cov- spatial association, local moran's i statistic has been used to identify the cluster and spatial outlier in the neighborhood for - - dataset [ ] [ ] [ ] [ ] . moran's i highlights the location based cluster form high to low infection and calculated as follows: where zi the number of sars-cov- containment zones at a spatial unit i (ward as an areal unit), z is the overall containment zones in the study area (kmc as a whole) and n is the number of spatial unit which are (no. of wards in kmc) and v is the rate of the variance of sars-cov- containment zones in different wards which is computed as below: this method represents high (positive) and low (negative) values. high-high cluster values show the results cluster up of similar values with q-value range from . to . ( . for %, . for % and . for % of confidence level) and low-low cluster shows the clustering of dissimilar values with same q-values. higher the q-values with lower the z-score value shows the perfect significance of the method applied for study the nature of clustering pattern. the p value is a value of probability. for the pattern study, it is the probability which create spatial pattern using some random process. the small p-value value suggests that the observed spatial pattern is an outcome of random process; hence null hypothesis can be rejected. analytical hierarchical process has been developed by satty [ ] to facilitate priority setting and decision making. ahp now broadly applied in social science research and specifically in hazard and risk analysis. in this method a pairwise matrix has been developed among the set of scale of choices (table ) on the given alternatives [ ] . ahp methods also deliver to judge the nature of consistency of preferences given by the report using consistency ratio when the value has . (cr c . ). the consistency ratio is defined as: where cr is consistency ratio, ri represent random number (table) and ci represent consistency ratio is expressed by for the present work, consistency ratio has been found as . , consistency index as . and the value of random number for n = has been determined . . based on socio-economic data of slum of kolkata municipal corporation and containment zone data and containment zone data from different web sources we have selected the following indicators for quantity exposure, sensitivity and resilience for assessing the risk [ ] infector disease like sars-cov- (see table ). the study considered the following as exposure indicators, number of sars-cov- containment zones/ population (e ), percentage share of slum population to total world population (e ), number of containment zones sq.km (e ), number of slum located in the ward (e ), and percentage slum area to total area of the ward (e ). the study considered the following as sensitivity indicators, hhs size (s ), percentage of hhs size with persons and above (s ), no. of persons in the slum, used community toilet, no. of persons/tube well used (s ), population density (s ) and household density (s ). the study considered the following as resilience indicators, percentage of hhs access to drinking water facility within premise (r ), percentage of hhs access drinking water from treated source (r ), percentage of literate population (r ), average per capita income of the slum located in the ward (r ) and work participation rate (r ). number of containment zones/ population in one of the most important indicators affecting the exposure of sars-cov- cases. according to icmr, the sars-cov- cases are taken the epicenter of this containment zone [ ] . on the basis of data, we have divided the whole data set into categories having high risk factor to low risk factor (above . / population, . - . / population . - . / population, . - . / population and below . / population). share of slum population is another prime indicator to explain the exposure of such infections dieses h h pattern. so the shanty and confected household are very much exposed to such dieses. here, we also divide the whole set of data into categories on the basis of risk factor. density of containment zones in another good indicator for assessing the nature of exposure. as the density is increasing, the exposure of sars-cov- to other persons source: computed by the authors becomes very high. slum area to total area is another crucial factor as areal coverage increase, the congestion pattern of living, unhygienic situation are very much exposed. thus higher the percentage signifies higher risk factor. each of the indicators has been categories under five classes of risk factor and weightage of these indicators have been assigned using ahp method. the exposure index of sar-cov- has been determined using following formula. exposure index ei ð Þ : where e c denote the ward data lies or which class [class [ ] [ ] [ ] [ ] [ ] as mentioned in table and e w is weightage assessed using ahp model. here, in this study purpose identifies the factors which can trigger the intensity and probability of spiking up of sars-cov- cases. household size undoubtedly increases the extent of severity of such h h infectious disease. population belonging in a household also led the situation more badly. when social distancing is addressed nationwide, the poor people of the slums cannot maintain such as due to shortage of space in the households. community toilet and tube well use is also promoting the chances of mass gathering in the slams. many people are living under such shanty places and also depend upon these facilities which can aggravate and spread such infectious disease in the community level. sensitivity index can be expressed in the following manner: where s c denote the ward data lies or which class [class [ ] [ ] [ ] [ ] [ ] and s w is weightage assessed using ahp model. resilience can be defined as reduction and prevention approach to risk any vulnerability for making an area more socio-economically stronghold [ ] . drinking water facility with premises and from treated source, level of literate population are the important indicators for resilience study. on the other hand per capita income and work participation rate is the potential indicator to increase the resilience of the any households. resilience index can be determined as: where r c denote the ward data lies or which class [class [ ] [ ] [ ] [ ] [ ] and r w is weightage assessed using ahp model. on the basis of assessed results from exposure index (ei), sensitivity index (si) and resilience index (ri), risk of the selected wards have been estimated using following methodology as prescribed by ipcc [ ] framework: where ei w is the exposure index, w e weightage of exposure, si w is the sensitivity index, w s weightage of sensitivity, ri w is the resilience index, w r weightage of resilience. results and discussion outbreak of novel corona virus (earlier it is termed as -ncov and later renamed as sars-cov- during the preparation of this manuscript) leading to lockdown (which means entire closure of all services except frontline services and essential services, i.e., banking, fire service etc.) of entire country which took place on and from th april, midnight. till date of the preparation of this manuscript, india already gone through three phases of lockdown (which will end on th may, ) and during these phases, urban centres have been found the most threating situation contributing nearly % of total affected cases of sars-cov- from most popular cities of india. nearly it was may , when india experienced , confirmed sars-cov- cases with death and entered into the list of top fifteen countries of the world. it is only . % sars-cov- cases to rest of the world but it was only . % ( cases) when nationwide lockdown started. the surge of sars-cov- cases as seen by usa, italy, france, germany, brazil, russia was not same in india till may, . cases are found to be doubled in every days at that time. but after may, a large spike has been found till june, which put india in the same bracket as brazil and russia in terms of upward trend in the infected cases and fatalities. the fact that despite of four lockdown imposed by central and state governments combine, the stringent index has been found to fall from (on - - ) to . ( - - ) which make a straightway relation of surging the sars-cov- cases in the different parts of india (fig. ) . another issue is the return back of stranded labour from mainly southern and western states to the eastern portion make this spread to rural areas also. based on the dataset and fig. of sars-cov- of major urban centres, mumbai has been found most cases with one-fifth ( . %) to total country's cases up to th may, when the lockdown starts on th march, it was only . % of whole country with a rapid growth of . , . and . during st phase, nd phase and rd phase of lockdown respectively. doubling rate of cases is . times (mumbai doubled the cases in . days as on . . ) to country doubling time ( . days). ncr delhi also contributes a larger extent of sars-cov- cases with . % which was only . % just before lockdown. a single event at nizamuddin marcus (a religions congregation) makes the situation worse during first phase of lockdown [ ] . a sharp rise or cases (nearly . % to country's total cases) has been experienced during this time which has been slow down gradually. stringent actions have been taken by the respective state governments which reflect in the higher rate of doubling time ( . days) to country's data. after ncr delhi, ahmedabad from state of gujarat originate as a big area of concern for the country which contributing . % of total country's cases at the end lapse of rd phase of lockdown but it was only . % at the starting of st phase of lockdown. during nd phase of lockdown a tremendous spike in the cases of sars-cov- has been experienced by this urban centre. during these phase, most of the cases (nearly %) are related to travel within the country and related to delhi's religious congregation took place is end of march, [ ]. through having higher value of doubling rate ( . days to double) from country's perspective and having decreasing growth rate. number of containment zones gives a clear picture of clustering of cases which signifies the nature of community spreading which is a matter of uneasiness. chennai shows an alarming situation with . % of cases during the end period of rd phase of lockdown which was just . % on . . (just before the lockdown). though the growth rate is decreasing (from . % at st phase of the lockdown and . % at nearly end of rd phase of lockdown) but the doubling time of cases is . days which signifies a great risk. among all the urban centres under study (which are combine contribute : % of cases), chennai has the lowest doubling time which is a matter of concern. on th may , nearly sars-cov- have been outlined to a wholesale vegetable market named koyambedu and authorities have acknowledged it as a coronavirus hotspot [ ] . after cases being reported from the popular market of on the other hand kolkata shows a steady but consistency in growth and spreading of sars-cov- cases. almost in all the lockdown phases, kolkata shows much below transmission of sars-cov- and contributing least to country's tota. doubling rate gives a clear picture of this scenario with almost . days which is a good indication with a population of nearly . million and having nearly . % of slum population lived in this region (census, ). pune ( . %), thane ( . %), indore ( . %), jaipur ( . %) and surat ( . %) contribute nearly . % of the cases to country's total. growth rates of sars-cov- in these urban centres are constantly decreasing which is a good pictogram of action taken by the government of those states as well as social awareness with following social distancing. among all the urban centres, thane shows an alarming situation in doubling rate which is . days and thus thane can be an emerging hot spot like mumbai and chennai if proper action not taken at the earliest. two days before the second phase of lockdown started, india has charted identification of red, orange and green zones which is a strategic approach for defining the area of operation, applying perimeter control, delineating containment and buffer zones. meanwhile ministry of health and family welfare, govt. of india declared districts as 'hotspots' and districts as 'non-hotspots'. ministry also categorises hotspots in two way-(a) clusters-increase in the incidence of sars-cov- with less than cases and there must be epidemiologically linked and (b) large outbreak-when more than cases have been found from a defined geographical area and these cases may not be epidemiologically linked. to combat with this pandemic, state governments have begun to experiment the idea of containment zones to deal with sars-cov- . mechanism of the containment zones is very straight forward, clusters or large outbreak which shown rise of cases and shown rapid transmission either in family or in community must be seated. movement in these zones are very limited which is only for foot line workers and residential movement is completely ban. when large number of cases are found in a smaller number of containment area it may a reflection of large outbreak (ratio is very high) but when large amount of cases with larger number of containment area (the ratio is low) suggest the clustering of disease took place. in case of comparison of confirmed new cases on daily data initiated from the period of first lockdown for four cities is smoothen using five year weighted moving average method. the study considers the weights as defined by using the rule the weighted value of moving average can be calculated from p i¼ x i w i for the corresponding five values of the series. the study deals with the three types of lock down considering them as phase-i (consist of days starting from . . ), phase-ii (consist of days starting from . . ), and the phase-iii (consist of days starting from . . ). the smoothing data set of new cases of ncovid- syndrome is depicted in fig. . the nature of the new cases shows that situation of kolkata is relatively best in compare to other three cities [ ] . whatever be the ways the explosion of new cases are found with some controlled behaviour and even with rare fluctuations. the situations of chennai showing some controlled behaviour up to . . i.e. in the middle of phase-iii lockdown but as the relaxation in the lockdown started the outbreak increases with huge rate. similar path also observable for delhi ncr like chennai, but it includes massive fluctuations. as time precedes the frequencies of fluctuations in case of delhi also increases. the situation of mumbai is worse among the all four cities. the periodic up and downs of the new cases puzzle the governance to control it. the linear trend line for cities shows that the line is steepest for mumbai, and it is more than double of delhi. four metro cities shows different pattern of transmission during end ward of st phase of lockdown to present time. delhi shows a higher ratio between number of sars-cov- cases and containment zones suggesting the larger outbreak for the region. on the other hand mumbai, chennai and kolkata show a clustering scenario of these cases during this time setting. higher number of cases with lower ratio also suggests the expansion of the sars-cov- cases in the new areas in faster rate. in may , mumbai and chennai show nearly same value ( . and . respectively) but with the sars-cov- cases nearly . times to chennai. mumbai city shows a huge spreading along different places in this period of time. during this period, delhi shows a much higher rate fluctuating from . to . (having a highest ratio of . ) and pinpointing the large out break as stated earlier. during this period, kolkata shows a steady pattern having a ratio of . - . . the containment zones caused trouble to the citizens, by restricting the mobility almost entirely and have to depend on government officials and selected venders for maintaining the essential services. this methodology of curtailment of rights is temporary for the containing and stops the spreading of disease. but slums in the urban area cannot fully follow the thumb rules of such containment zone. as these people lives in a shanty, unhygienic environment, and using community toilet with large dependency on tube well for water accessibility are very much susceptible for these h h transmission. mumbai and delhi shows the perfect example of such transmission. dharavi, the world famous slum has been hardly heated by this pandemic. kolkata face a challenge to combat with the spreading of sars-cov- cases in the densely slums concentrated areas [ ] . most of the wards in kmc having more than containment zones where a large percentage of population living in the slums. increasing number containment zones along with number of cases has proven the spatial dispersal of sars-cov- cases in kmc which is needed to be studied further. in kolkata municipal corporation figure shows the time series pattern of the confirmed cases of sars-cov- from st case detected on th march, to th may, when cumulative number were and for kmc and state of west bengal respectively. as kolkata has experienced st case of sars-cov- , here we have taken ward wise containment zone to find out the nature of hot spots located in the municipal area. as per icmr, containment zone confirms the epicentre of cases and due to unavailability of sars-cov- ward wise data; we used number of containment zones as proxy indicator [ ] . figure also confirms that, up to st week of april kolkata municipal corporation (cmc) contributes a huge percentage share to state's total which has been decreasing afterwards. this scenario again found from starting of fourth week of april when kolkata share nearly % of state's total. a huge population of nearly lakh (census of india, ) with a high percentage share of slum population ( . %) is very much vulnerable for transmitting this h h virus where population density, slum density, using per capita community latrine and tube well are high [ ] . figure shows the hot spots for covid- using satscan on the basis of two different dates dataset on containment zones result which identifies two primary clusters and three secondary clusters with high confidence value (p-values are found less than . ) in kmc. the primary clusters are located covering (a) kareya, tiljala, topsia, tansra, survey park region and (b) jorabagan, burtola, girish park area. secondary clusters have been identified to designate more cases likely to aggregate from kmc which are extent from northern portion to south-western portion. these secondary clusters have also the significance values less than . (p-value). the highly decentralized nature of incidence of this disease clearly showed limited hotspots within the city of kolkata. ward no. (tiljala/topsia area) has been found a large number of containment zones in a smaller area and it has increasing very sharp. this area has fallen the primary cluster of central kolkata when ward no. and (banstala, girish park region) are fallen under another primary cluster. the sars-cov- views caused tremendous pressure situation in the wards in kolkata municipal corporation out of wards (fig. a) . containment zones have been found on those wards on - - which has been increased into numbers located in wards. the distribution pattern of containment zones in two different dates has shown a clear increase in spatiality among the wards of kmc. the highest number of zones has been found in the wards located in central kolkata, east suburban and port area and some portion of north kolkata. huge numbers of slums (registered and unregistered) are found in those areas which may play a role of catalyst to spread and transmitted this pandemic [ ]. highest concentrations of containment zones have been found in tiljala, kareya, beliaghata, phoolbgan, razabazar, tala, burtola, jorabagan, girish park, bowbazar, entally, muchipara, and survey park area. total number of containment zones in this area have been covered nearly % of the total containment zones (fig. b) . wards with high containment zones are falling in those wards which have a higher degree of slum population as well as the number. most of the areas under slums are very old and developed before independence [ ] . old shanty dwelling slots with higher family size, higher dependency on community toilet/latrine with water availability source as tube well make the area more risky and vulnerable to this sars-cov- [ ] . as it is already known to everyone that this infection can transmit h h pattern and ro of . , it is really need to assess the scenario of those slums for better approach to stop the transmission and break the chain of this infection. here need the assessment of the risk of those hotspot areas to make a proper evaluation of vulnerability and steps to be taken in coming days. municipal corporation (kmc) here where ew is weightage of exposure, ei w is the ward-wise exposure index, sw is weightage of sensitivity, si w is the ward-wise sensitivity index, rw is weightage of resilience and ri w is the ward-wise resilience index. on the resulted dataset, risk zones have been categorised into classes from very high risk zone to very low risk zone. of the total selected wards under study ( ), are very highly exposed to sars-cov- followed by highly exposed wards ( ), moderately exposed ( ), low exposed ( ) and very low exposed ( ) categories. the exposure index is composed of sars-cov- containment zones density with population, share of slum population and density of slums with areal coverage to ward area made the wards located in north and central kolkata more exposed as these areas are very old and the slums in these wards have an age of more than years. old drainage system, located behind the rail lines and nullas (old sewerage lines) make the situation more worsen. overall the area under gardenreach, metiaburuz ( % of very high exposed wards from this area) with a high percentage of muslim population face the higher degree of exposed of such infections (fig. a) . on the initial stage reluctant situation from government end and non-maintaining the social distancing norm during nation-wide lockdown period make this areas face a terrible trouble and have experienced a number of sars-cov- cases with a large number of containment zones. sensitivity index analysis showing that of the total wards very high sensitivity has been found among wards followed by wards in high sensitive index, moderately sensitivity found among wards when and wards are found in low to very low sensitivity values respectively. high sensitive wards are mostly lies in the north kolkata and partly in central kolkata (fig. b) where population density, household density, latrine and tube well dependency among the slum dwellers are very high which clearly gives the results of very high sensitive zones. these zones settled are much before of independence which has a migration legacy ( , ) . resilience capability among the selected wards of kmc found to be high as more than % of the total wards are characterised by very poor to moderate level of resilience. the wards are very much lagging behind in facilities which can protect them from such infections and the nature of infrastructural development are also found low in nature. figure c shows that the most vulnerable wards (high to very high) located in central and eastern portion of the study area. drinking water facilities, per-capita income and work participation rate are very low in these wards. eastern portion wards of the study area are joined with kmc much later during onwards which shows the less unavailability of facilities in respect to others ( , ) . risk analysis revealed that very high vulnerability has been observed in wards followed by high risk areas with wards (nearly % to total wards under study). as a whole high to very high wards coved nearly % of the studied area (fig. d) this indicates a disquieting situation for such infectious disease. most of the wards located in central and some portion of north kolkata. four wards also most of the containment zones, high slum population share and density with excessive dependency on community toilet and tube well are the driving forces behind this high risk factor in these areas [ ] [ ] [ ] . on the other hand low working population, low per-capita income, high household density in topsia, tiljala, gardenreach, rajabazar, beliaghata, burabazar, jorabagan area make more hazard prone. earlier evidences of dengue fever also found the same type of hotspots in the past years. unhygienic and close spacing of settlements, not maintaining social distancing and very low per-capita space availability (nearly - persons in an - sq. feet room) make the region hotspots and rightly most of the sars-cov- cases found from these places. the spatiality of sars-cov- has wide-ranging expressively from april to may , and it has exhibited consistency in northern and central part of kmc. a grouping of irregular and epidemic patterns of human-to-human exposure has been observed during this period [ ] . by contrast, the distribution curve for cities in india, mumbai has been experienced largest outbreak in india where kolkata has constrains its spike. purely temporal cluster analyses of sars-cov- infection illustrated significant clusters in april and may of . this finding is consistent with previous studies of eifan [ ] , which showed significant peaks in mers-cov incidence between march and may in saudi arabia in . in this study, sars-cov- was observed during mass gatherings in different part of india, which are inconsistent with previous studies [ ] . this indicates another knowledge gap regarding the mode of transmission that needs further investigation. though the transmission and outbreak has not a sudden one, major urban centres have been found more vulnerable to transmit this h h virus. high population density, concentration of high amount of slum population with high household density with low per-capita income shows the main driving factors for such outbreak. the people of those places are compel to break the said social distancing, as the people have a little, very little space for stay in household (in some cases they lived in sq. feet area with - persons), they used to go and use community toilet, tube well sharing with other hundreds of population make the situation more grave ( , , ) . quick preparation and execution of the containment plan, deployment of adequate human resources (mainly from health workers) at ward level, active surveillance in the well-defined geographical area and higher test (rapid antibody test) can minimise the chance of transmission in community level. as the spacing of households is very congested, such actions must be taken without any interference. revision of world urbanization prospects urbanization and global environmental change: st century challenges middle east respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission. the lancet infectious diseases health and health-related indicators in slum, rural, and urban communities: a comparative analysis understanding the spatial diffusion process of severe acute respiratory syndrome in beijing abstract for slums regional disparities of slums, -an overview with special emphasis to kolkata spatial epidemic dynamics of the covid- outbreak in china spread of yellow fever virus outbreak in angola and the democratic republic of the congo - : a modelling study. the lancet infectious diseases modes of transmission of virus causing covid- : implications for ipc precaution recommendations a mathematical model for simulating the phase-based transmissibility of a novel coronavirus spatiotemporal clustering of middle east respiratory syndrome coronavirus (mers-cov) incidence in saudi arabia the influence of urbanization modes on the spatial circulation of flaviviruses within ouagadougou (burkina faso) spread of yellow fever virus outbreak in angola and the democratic republic of the congo - : a modelling study. the lancet infectious diseases finding malaria hot-spots in northern angola: the role of individual, household and environmental factors within a meso-endemic area beyond moran's i: testing for spatial dependence based on the spatial autoregressive model spatial clustering of plasmodium falciparum in bihar (india) from to . spatial information research rapid urban malaria appraisal (ruma): epidemiology of urban malaria in ouagadougou identification of malaria hot spots for focused intervention in tribal state of india: a gis based approach the analytic hierarchy process: planning, priority setting, resources allocation urban flood hazard zoning in tucuman province argentina using gis and multicriteria decision analysis climate change : impacts, adaptation, and vulnerability. part a: global and sectoral aspects. contribution of working group ii to the fifth assessment report of the intergovernmental panel on climate change containment plan for large outbreaks risk assessment of coastal erosion of karasu coast in black sea an impact evaluation study of bsup programme intervention in kolkata metropolitan area (kma), kolkata municipal development authority assessment of water security in socially excluded areas in kolkata, india: an approach focusing on water, sanitation and hygiene a pandemic risk assessment of middle-east respiratory syndrome coronavirus (mers-cov) in saudi arabia a systematic review of emerging respiratory viruses at the hajj and possible coinfection with streptococcus pneumoniae slums in kolkata: a socio-economic analysis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the authors acknowledge the department of bustee service, kmc, hogg buildings ( rd floor), kolkata for providing data support for the study.authors' contributions sp and sb designed the study; sh, ab and bm contributed to data acquisition; sk and sm carried out the statistical analysis; sp and sb drafted the manuscript. all authors contributed to the interpretation of data and revision of the manuscript. all authors read and approved the final manuscript.funding this work has not been supported by any state or central government funding agencies. key: cord- -gqltd u authors: nan title: poster sessions date: - - journal: pediatr pulmonol doi: . /ppul. sha: doc_id: cord_uid: gqltd u nan in this study. the near-fatal group accounted for %. the months to years age group accounted for %. female/male ≈ . / . sixtyone percent of children were from hồ chí minh city. admission to icu increased recently. dyspnea was the chief complaint, accounting for %. cough, wheezing, dyspnea were essential symptoms. fiftly-one percent had a history of asthma. preventer medication ownership was recorded in % of cases. the rate of impaired consciousness was . %. % had a ph < . % and % had a paco > mm hg. chest x-rays showed hyperinflation, infiltrates and atelectasis. time of treatment was days ( , ), days in icu was days ( , ). ten children were intubated, . % received ncpap; . % of children older than year were given mgso , % children were given diaphyllin, % children were given salbutamol and % children were given adrenaline subcutaneously. all intubated patients received pressure control ventilation. inspiratory pressure was to cmh o to achieve tidal volume of approximately ml/kg, mean peep was cmh o, fio was approximately % and i/e was / - / . conclusions: appropriate treatment at first is crucial to lower the number of children to be intubated. mechanical ventilation still remains the last recourse in the treatment of near fatal exacerbations of asthma after mgso , diaphyllin and salbutamol. a- | peanut and brazil nut sensitization profile among asthmatic patients in southern taiwan data on its importance in asian populations. the relevance of cdhr to childhood lung functions is also unknown. this cross-sectional study investigated the associations between cdhr and wheezing illnesses and lung function of preschool children in hong kong. methods: chinese children younger than years of age were recruited from randomly selected nurseries and kindergartens throughout hong kong. the demographic, early-life exposures and allergy phenotypes of these preschool children were recorded by validated and modified isaac questionnaire. these children underwent incentive spirometry to measure their forced expiratory indices. their buccal swabs were collected for dna extraction and tagging single-nucleotide polymorphisms (snps) of cdhr were determined by taqman genotyping assays. genotypic and haplotypic associations between these snps and wheezing and lung function traits were analyzed by multivariable regression and r-package haplo.stats . . , respectively. results: the mean (sd) age of a total of children was . ( . ) years. forty-one percent of them had domestic exposure to cigarette smoking, whereas % and % had wheeze ever and current wheeze respectively. current wheeze was associated with rs and rs of cdhr , with the respective odds ratios (ors) being . and . . these two snps were also associated with frequency of wheezing illnesses over the past months, with ors being . (p = . ) for rs and . (p = . ) for rs . current wheeze was also associated with the -locus gac haplotype of cdhr (or, . and p = . ). two cdhr , snps rs and rs were associated with fev . , fvc and fev . /fvc, and the ggg haplotype was associated with fev . . a- | development and validation of an adherence questionnaire for adolescents with asthma on controller inhaled corticosteroids with asthma on ics at multiple hospitals and clinics in japan. adherence to ics medication was separately evaluated by "confidential" questions to ask frequency of "forgetting to take medicine" by nonmedical study staff. the best model to predict adherence was formed by multivariate logistic analysis. validation of the model was performed using answers to the questions from a separate group of ics-treated asthma patients of the same age. results: responses from adolescents were used as development data set and those from separate adolescents were used as validation data set. a -item logistic model was selected from the development data set. it showed good statistical fit and well discriminated poor adherence with auc at . and . in development and validation datasets, respectively. probability of adherence was calculated as propensity score in the logistic regression model and named as the pediatric asthma adherence questionnaire (paaq) score. the paaq scores for the physicians' ratings of adherence differed significantly in the hypothetical direction. the paaq may be a useful tool to evaluate adherence in adolescents with ics-treated asthma. a- | effect of long-term inhaled corticosteroid therapy on adrenal suppression growth and bone health in children with asthma years diagnosed as having asthma on inhaled corticosteroid therapy for more than months were included as cases. children who were on oral steroids for exacerbations a week before the study, asthma with other chronic illnesses and children over years old to avoid the confounding effects of pubertal growth acceleration seen at this age, were excluded. comparison group consisted of age-matched children with asthma who were not on ics. heights were assessed according to their mid parental heights (mph). serum calcium, alkaline phosphatase and vitamin d levels were assayed in both groups. low dose short synacthen test was performed on cases and serum cortisol at , , minutes of the test was performed to assess hpa axis function. peak cortisol level > nmol/l at minutes was considered to have passed the test and exclude adrenal suppression. the average daily dose of ics was categorized as low, medium and high according to published literature. results: both the associations between long-term ics and growth (chi square value = . , p = . ) and calcium levels (p = . ) were not statistically significant. a significant association was found between long-term inhaled corticosteroid therapy and alp level (p < . ) although the interquartile ranges of serum alp in both groups were within the normal range for the age. there was no statistically significant difference in vitamin d levels in both groups (p = . ), although vitamin d levels were deficient in % of cases and % of controls (< nmol/l). interestingly suppressed cortisol levels were seen in % of cases. cumulative doses of ics in cases were low, medium and high in %, % and % of children respectively. results: total antibiotic use appeared to have decreased year after follow-up in a specialized asthma clinic. both the overall use (p . ) and the use of amoxycillin / clavulanate (p . ) were statistically significant. the use of amoxycillin, cephalosporins and macrolides was also found to be reduced. a statistically significant reduction was also found in the use of antihistamines (p . ). in terms of quality of life, a statistically significant improvement was found in the worry domain of asthma both in children (p . ) and their parents (p . ) as well as in the impact domain for parents (p . ). methods: in this prospective cross sectional study, we enrolled consecutive children between to years of age with poorly controlled asthma (partly controlled and uncontrolled as per gina guidelines) between july to march . we excluded children with cystic fibrosis. the enrolled children were investigated for abpa that included total ige, aspergillus-specific ige, aspergillus-specific igg, skin prick test for aspergillus, serum precipitins, absolute eosinophil count (aec), chest x-ray, and chest ct (in selected patients). abpa was diagnosed as per recent criteria: if both of the following criteria were fulfilled: ( ) total ige > iu/ml and positive skin prick test (spt) to aspergillus or aspergillus-specific ige > . kua/l; ( ) at least of two of following three: presence of precipitating antibody or aspergillus-specific igg > mg/l; chest radiology suggestive of abpa; and total eosinophil count > cells/mm . data were analyzed using stata . . we used the receiver operating characteristic (roc) curve along with area under the curve (auc) to determine the utility of various parameters to differentiate children with abpa from those without. to determine best cut-offs, youden's index was used (sensitivity + specificity - ). results: we included asthmatic children (male: female : ) with mean (sd) age of . ± . years. the prevalence of abpa was / ( . %; % ci, . %, . %). among baseline characteristics including spirometry of included children, only the presence of brownish sputum s | abstracts was greater in abpa children. among diagnostic criteria, all were significantly different between children with abpa and without abpa except aspergillus-specific igg and positive spt. the auc ( % ci) of rocs are shown in figure . the difference between auc of total ige and aspergillus-specific ige vs. aspergillus-specific igg was significant. the sensitivity and specificity of total ige (> iu/ml), aspergillus-specific ige (> . kua/l), aec (> / mm ) and aspergillus-specific igg (> mg/l) cut-offs as defined by diagnostic criteria was % and . %, . % and . %, . % and . %, and . % and . % respectively. the best cut-off values as per youde's index of total ige, aspergillus-specific ige, aec, and aspergillus-specific igg were iu/ml, . kua/l, /mm , and . mg/l, respectively with corresponding sensitivities and specificities of % and . %; . % and . %; . % and . %; and . % and . %, respectively. conclusions: aspergillus-specific ige levels had the best discriminative value followed by total ige, aec, and aspergillus-specific igg for abpa in asthmatic children. the currently proposed cut-off values may not be appropriate for children. reflections and concrete proposals for action: there is need to develop childhood-specific diagnostic criteria for abpa. methods: this is a one-year retrospective study that was conducted in our pediatric intensive care unit (picu) comparing the intervention failure rate of three different noninvasive respiratory support modalities (bi-level positive airway pressure (bipap), continuous positive airway pressure (cpap) and hfnc) for infants and young children between the ages of month and years admitted with the diagnosis of bronchiolitis. a sample size of patients was collected with a median age of months. children who required hfnc were older (mean . months) than children who required bipap ( . months) while the mean age for children who required cpap was ( . months). results: hfnc carried a higher failure rate in comparison with the other two respiratory support modalities ( . % for hfnc n / vs. zero % for cpap n / % and % for bipap n / , p < . ). among the patients who failed hfnc, ( %) were successfully shifted to bipap and weaned off later, while the other were intubated and needed mechanical ventilation. on the other hand, all patients who failed bipap were intubated and mechanically ventilated. no difference was found between the three groups in terms of gender or the causative virus. no respiratory complications or mortality was reported in the three groups. in the bipap group, oxygen requirement was significantly reduced at hours from the start of the intervention and afterward in comparison with the hfnc group (p < . - . ), although not statistically significant with the cpap group. no difference was observed in length of picu stay or hospital stay between the three groups. we did not observe any association between causative virus(es) and the number of er or pulmonology clinic visits for wheezing or recurrent bronchodilator use after discharge from the hospital. in the ba group, we found virus infection only in %, predominantly adenovirus, followed by rv and rsv. in % of the cases, streptococcus pneumoniae was confirmed in the throat swabs vs. only % for isolated moraxella catarrhalis. there were no other bacteria isolated in the ba group. in the cwc group, we found only in % of viral infections mainly hmpv, followed by adenovirus and rv. results: children had been taking antibiotics before hospitalization while the remaining patients were antibiotic naïve. in . % of the cases, we could not prove etiological agent, while bacteria were confirmed in . % and viruses in . % (in . %, we found combined virus and bacteria), and fungi were found in . %. when dividing the cases according to prior antibiotic use, the distribution was: . %, . %, % and . % for antibiotic naïve vs. . %, . %, . % and . % for the others respectively (p = . ). when looking at the bacterial isolates and prior antibiotic use, we did not find any significant difference regarding mycoplasma pneumoniae isolation (p = . ) although there was one for streptococcus pneumoniae (p = . ), mainly due to the standard guidelines to gps to start with penicillin antibiotic for pneumonia. as expected mycoplasma was isolated in older children, while streptococcus was mainly isolated in younger patients. mean age for children with bacterial pneumonia was . years, for those with viral pneumonia . years., for combined (viral+bacterial) . years. and for fungal pneumonia . years (p = . ). the values for crp were lower in cases with mycoplasma and in cases with non-compact infiltrate changes on x-rays (p = . and p = . ). almost / of the children have been immunized with pneumococcal vaccine ( %). the immunized patients had higher numbers of viral and lower numbers of bacterial isolates − . % and . % vs. non-immunized patients − . % and . %, respectively (p = . ). there was no difference in streptococcus pneumoniae isolation and vaccination status, but there was a major drop in mycoplasma isolates in vaccinated patients ( . % vs. . %, p = . ). for the patients with asthma only, we could not identify the microorganism in %, while in . % and . %, we found viruses and bacteria, respectively (co-infection was found in . %). in % of children without asthma, we did not isolate the etiological agent and there was co-infection only in one case, while viral pneumonia and bacterial pneumonia was confirmed in . % and . % respectively (p = . ). all children but were discharged healthy for mean . days in hospital stay. the mentioned patients had severe complications and required surgical intervention. conclusion: in the future, we could expect more viral pneumonia with increasing vaccination coverage and maybe we should reevaluate our treatment guidelines. objective: to compare the need for pediatric critical care in a tertiary children's hospital with a diagnosis of community-acquired pneumonia (cap) or hospital-acquired pneumonia (hap). furthermore, we conducted a pilot study to evaluate the possible medical biomarkers which are associated with longer pediatric intensive care unit stay. methods: an observational, retrospective cohort analysis was conducted in children who were admitted to our tertiary children's hospital with a diagnosis of cap or hap. patient demographics, clinical characteristics, and comorbidity were collected between january and december . the following prospective pilot study was conducted in children who were admitted to our pediatric intensive care unit (picu) due to pneumonia progression. we evaluated the clinical profiles and medical biomarkers. the primary endpoint was the duration of picu stay with associated predicting factors. results: a total of patients with episodes of pneumonia ( males; females) requiring admission to our children's hospital were included. the mean age at admission was . ± . months and the average length of stay was . ± . days. episodes were identified as cap and the other episodes were hap. patients with cap had significantly shorter lengths of hospital stay and duration of icu stay than those with hap ( . ± . vs. . ± . days, p < . ; ± . vs. ± days, p < . ). the most common co-morbidities in cap were neurological diseases and atopy history. among the cap patients, episodes ( %) led to icu admission during treatment course with the most common comorbidities being neurological diseases. however, in hap patients, cardiovascular diseases were the most common co-morbidities as well as those ( . %) who required picu care. the overall mortality rate was . %, with the mortality rate being significantly higher in the hap group (p < . ). the pilot study included children with the diagnosis of pneumonia in picu from jan to dec . neither progressive ards mobility nor mortality occurred. the mean age at diagnosis was . ± . months. the average number of days of picu stay was . ± . days. the median duration of hospital stay was days. patients were divided into two groups: picu stay more than days and less than days. the values of pro-bnp, aado , platelets, crp and ci in patients with picu stay more than days showed a significant difference with those less than days in the initial picu admission (p < . ). however, the values of thoracic fluid content (tfc) or even tfc corrected by cardiac output were not significantly different between the two groups. the levels of sputum -isoprostane and urinary ohdg revealed a trend of decreasing level after disease relief. conclusions: in this study, we found that ( ) hap resulted in significantly longer lengths of hospital stay and picu stay than cap. the possible risk factors for the need of critical care are associated neurological disease in cap and heart disease in hap; ( ) the possible biomarkers of pro-bnp, platelet, crp, ci, -isoprostane and ohdg may predict the duration of picu stay in our pilot study. these results not only help further our understanding of the risk of pneumonia in children who require critical care but also provide chances for better intensive respiratory care. background: pneumonia is a leading cause of respiratory morbidity and mortality in children younger than years of age. the incidence of severe cases of community-acquired pneumonia (cap) in low-and middle-income countries is still high. although severe cap can be diagnosed by clinical features and chest x-ray, it could be useful to measure biomarkers to predict the outcome. the aim of the study was to determine the association between methods: ninety children aged between > days to < years hospitalized with diagnosis of severe cap in the pediatric department of west nusa tenggara province general hospital from january to october were enrolled. data on demographic and clinical characteristics, and laboratory examination were recorded. all subjects were treated in accordance with the hospital cap protocol and prospectively monitored until discharged. results: out of subjects, % were ages < year, % male, % passive smoke exposure, % lived in crowded environment, % came from low family income, % showed infiltrate on chest x-ray % with comorbidity and fe deficiency anemia was the most common ( %). c-reactive protein, esr, lc, and nlr were not significantly associated with hospital length of stay and duration of oxygen consumption (p > . ). after adjustment for crp, lc, nlr, and age, esr was found associated with mortality, with every increase in one log of esr decreasing the log odds of death about . (p = . ). conclusion: higher esr was associated with lower risk of death. however, none of the biomarkers were associated with hospital length of stay or duration of oxygen consumption. keywords: community-acquired pneumonia, outcome, children, biomarker. recurrent episode of bronchial obstruction were enrolled in this study. detailed history, physical examination, blood sample and nasopharyngeal aspirate (npa) collection were performed. the viral etiology of the respiratory tract infections was determined using polymerase chain reaction (pcr) and the concentration of ifn-γ in npa by elisa kits. results: the mean npa levels of ifn-γ in rsv (+) infants - . ( - . ) pg/ml was lower than rsv (-) infants - . ( - ) pg/ml, (p = . ). a gender difference in ifn-γ was detected with significant higher values in girls (or, . ; [ci] . - . ; p = . ). the cytokine ratio did not differ between infants with or without atopic status and family history of asthma. moderate-to-severe bronchiolitis in cases ( %) was associated with lower ifn-γ level (or, . ; [ci] . - . ; p = . ), none of them required mechanical ventilation. decreased ifn-γ production correlated with the recurrent episodes of wheezing (p = . ). objectives: to test the hypothesis that high amplitude bcpap support after acute lung injury may have different effects on gas exchange efficiency and lung injury protection compared to high flow cpap (mimicking hfnc) support in rats with ali. methods: after normal saline lavage lung injury, all rats initially received high tidal volume mechanical ventilation ( ml/kg) for minutes, then were randomly divided into three groups: high amplitude bcpap group using the bubble technique with degrees of expiratory limb (n = ); standard bcpap group using the bubble technique with degree of expiratory limb (n = ); and high flow cpap (mimicking hfnc) group using the high flow technique ( l/min, n = ). all groups were killed . hours after bcpap or high flow cpap (mimicking hfnc) support. arterial blood gases, respiratory rate, peak inspiratory pressure (pip) and mean airway pressure (map) of rat lung during respiratory support, wetto-dry lung weight ratio, lung homogenate and/or bronchoalveolar lavage fluid tumor necrosis factor-α, macrophage inflammatory protein- , interleukin- and total protein levels were measured and compared among groups after study completion. results: the high amplitude bcpap group exhibited a significantly higher pao , lower paco and significantly lower alveolar protein, pip, map, wet-to-dry lung weight ratio and cytokine level compared to high flow cpap (mimicking hfnc) group. high amplitude bcpap group also exhibited a lower cytokine level compared to the standard bcpap group. no difference in gas exchange efficiency was observed between the two bcpap groups. conclusion: high amplitude bcpap support decreases lung inflammation, increases gas exchange efficiency and lung compliance compared to high flow cpap (mimicking hfnc) support in rats with ali, and may have a better lung protective effect than standard bcpap. keywords: bubble continuous positive airway pressure, high-flow nasal cannula, respiratory support, acute lung injury. nontraumatic chylothorax in children is rare and more difficult to treat than traumatic chylothorax. in some cases, they are refractory to conventional treatment, leading to severe morbidity and mortality. thus, the purpose of this study is to analyze the clinical features of chylothorax in pediatric patients in our hospital and seek appropriate therapeutic management. methods: a retrospective review was performed in patients with chylothorax from january to december in the children's hospital of seoul national university. traumatic or postoperative chylothorax was excluded. a total of patients with nontraumatic chylothorax were included in our study. etiology, treatment, and outcome of chylothorax were analyzed. results: nontraumatic chylothorax was diagnosed in patients. male patients ( / = %) were more frequently affected than female ( / = %) patients. eighteen patients were diagnosed before year of age ( %), only two patients were diagnosed after year of age ( years old, years old respectively). the most common cause of spontaneous chylothorax was idiopathic factors, constituting . % ( ), three cases were related to high central venous pressure due to venous thrombosis and recurrent sepsis, cases were related to down syndrome, case was noonan syndrome, and the remaining case was gorham stout syndrome. seventeen patients needed a respiratory support device, of the latter received low flow oxygen supplementation, patients received ventilator support. dietary modification (npo or mct base feeding), conventional medication (somatostatin or octreotide), sirolimus, surgical management were administrated to our patients. in the neonate and infant group, three patients who were related to venous thrombosis died because of recurrent septic shock before chylothorax management was administered. fifteen patients received a dietary modification (npo or mct base feeding) and nine patients improved by conservative management. one patient died due to heart failure before medical treatment. somatostatin or octreotide was used in patients who failed dietary modification, but only one patient improved with octreotide. among the somatostatin or octreotide failure group, patients received surgical management (pleurodesis or thoracic duct ligation). three of these patients improved, although one patient died after thoracic duct ligation operation because of post-op ards. two patients who were diagnosed after -year of age were refractory to nutritional modification and conventional medication such as somatostatin or octreotide. however, lymphatic intervention and surgical treatment were not suitable for these two patients. considering that their underlying disorder consisted of noonan syndrome and gorham stout syndrome, we used sirolimus to treat the refractory chylothorax. after administration of sirolimus, their chylothorax improved compared to before. conclusions: most of the nontraumatic spontaneous chylothorax in pediatric patients occur in newborns and the most common cause of chylothorax in the neonatal and infantile period is idiopathic. on the other hand, nontraumatic chylothorax in childhood is rare and tends more to be accompanied by the underlying syndrome. moreover, the treatment failure rate is higher in the childhood group. in such cases, sirolimus which is an mtor inhibitor, can be beneficial to patients who tend to be refractory and cannot be treated with lymphatic intervention or operation. purpose: specific genetic causes for childhood interstitial lung disease (child) in immunocompetent patients have been identified within the past decade. however, little is known about the pathogenesis of many forms of child, and treatment approach has not been standardized. a national survey was carried out by the japanese society of pediatric pulmonology (jspp) to identify the histopathology and response to current treatment, especially hydroxychloroquine, which is contraindicated for children younger than years old in japan. methods: a questionnaire was sent to pediatricians who registered a child patient to the jspp. we conducted the survey over a period of years, between and . children ( - years) were included in the survey with persistent hypoxemia (pao less than torr or spo less than %) for more than weeks, diffuse infiltrates on ct scanning, and elevated serum markers such as kl- , sp-a, or sp-d. immunodeficiency and other diseases which present with similar symptoms to child were excluded. the questionnaire included information on the patients' clinical symptoms, family history, pathological histology, clinical genetic findings, treatments and clinical outcomes. informed consent was obtained by all patients' guardians before participating in the survey. results: twenty-six cases were identified, including males and females. age of onset was between months and years. fourteen ( %) cases presented in the first year of life. lung biopsy was performed in ( %) cases. five cases showed changes of nonspecific interstitial pneumonia (nsip), case with desquamative interstitial pneumonia (dip), case with cryptogenic organizing pneumonia (cop), case with usual interstitial pneumonia (uip), case with acute lung injury (ali), and cases untagged. genetic testing was performed in ( %) cases. mutation in sp-c gene (sftpc) was detected in cases, atp binding cassette subfamily a member (abca ) in case, nk homeobox (nkx - ) in case, coatomer associated protein subunit alpha (copα) in case, and no mutation was detected in cases. in the first half of the study period, only out of ( %) cases were diagnosed with genetic testing without lung biopsy, which increased to out of ( %) cases in the latter half. prednisolone was used in ( %) cases and hydroxychloroquine in ( %) cases with no onset of retinopathy. conventional treatment with prednisolone or hydroxychloroquine, monotherapy or in combination, resulted in a good response in ( %) cases. three ( %) children died despite all therapies. in addition, it turned out that case was diagnosed as juvenile idiopathic arthritis years after registration. conclusions: this is the first nationwide prospective study regarding child in japan. the histopathology in this study is similar to that reported previously. there is increasing emphasis on genetic studies in the diagnosis of child as it can help avoid unnecessary lung biopsy. corticosteroid and hydroxychloroquine were the main therapeutic agents in our study. hydroxychloroquine therapy was tolerated in many cases, with no significant side effects. methods: twenty three children aged . ± . years with bos after allogeneic hematopoietic cell transplantation were enrolled, and their clinical data were reviewed retrospectively. all subjects repeated the pulmonary function test at an interval of month after occurrence of results: among subjects with bos, ( . %) subjects expired due to respiratory failure, ( . %) subjects underwent lung transplantation, and ( . %) subjects needed o therapy. the mean value of fev % predicted at the diagnosis of bos was . ± . %, and it rose after months ( . ± . %). fev % predicted at diagnosis of bos tended to be lower in subjects with oxygen therapy ( . ± . ) than in subjects without oxygen therapy ( . ± . ), [yj ] although there was no statistical significance. the changes in fev % predicted at months after bos diagnosis were significantly lower in the subjects with oxygen therapy (- . ± . %) than in subjects without oxygen therapy ( . ± . %). however, there was no significant difference in the change over months of fev % predicted values between the two groups at , , and months. in addition, the group with a negative slope of fev % predicted change during the first months had a higher likelihood of o therapy, compared to the group with a positive slope of fev change during the period (hr of . , p = . ). the change in fev during the first months after bos was significantly different between the subjects with and without oxygen therapy. these results suggest active intervention strategy is needed during the first months after bos to improve the prognosis. this study is aimed to assess the effectiveness of hs nebulizations before physiotherapy over conventional physiotherapy in children with non-cf bronchiectasis. objectives: primarily to compare the change in fev from pretreatment phase to posttreatment phase between the two groups. method: we performed a retrospective cohort study of extremely preterm infants born before weeks of gestational age in our nicu. study subjects were divided into two groups: auto group who underwent the automated control of inspired oxygen concentration (auto) with cpap, and manual group who underwent manual control of inspired oxygen concentration (manual) with cpap before introduction of auto in our nicu. we retrospectively investigated the patient characteristics and short-term outcome related to the respiratory system (reintubation rate, duration of cpap, introduction rate of home oxygen therapy) and retinopathy of prematurity (incidence, stage, and therapy rate). the mann-whitney u test and chi-squared test were used for statistical analysis, and logistic regression was used for multivariable analysis. result: a total of infants were eligible for this study. there were and infants in the auto group and manual groups, respectively. in the auto and manual groups, the median (range) of their gestational age in weeks was . ( . - . ) and . ( . - . , p = . ), birth weight in grams was ( - ) and ( - , p = . ), the rate of maternal steroid administration was % and % (p = . ), age at study entry in days was ( - ) and ( - , p = . ). reintubation rate was % and % (p = . ), duration of cpap (day) was ( - ) and ( - , p = . ), and introduction rate of home oxygen therapy was % and % (p = . ). the incidence of total retinopathy of prematurity (rop) was % and % (p = . ), the incidence of rop over stage Ⅱ was % and % (p = . ), and therapy rate for rop was % and % (p = . ) in each group. there was a statistically significant association between the decreasing risk of rop over stage Ⅱ and use of auto by multivariable analysis adjusted for confounding factors (odds ratio: . [ % ci: . - . ], p = . ). discussion: in this study, the incidence of rop over stage Ⅱ was significantly decreased in extremely preterm infants who underwent auto with cpap. it is suggested that exposure to the excessive oxygen levels and the fluctuation of oxygenation are related to the incidence of rop. large studies indicate the strict spo target range. but in fact, the manual control of inspired oxygen concentration during respiratory support is not sufficient for the maintenance of spo within the latter. auto can maintain spo within the target range compared to the manual control of inspired oxygen concentration. auto has the potential to prevent rop by decreasing the exposure to excessive oxygen levels and the fluctuation of oxygenation. several limitations should be considered in our study. this was a retrospective, single-centered, non-randomized study; a further multi-centered prospective study is needed. since their pulmonary function is decreased, lower respiratory tract infections in this population may have a more severe clinical course. in our study, in addition to lung function measurement, we also wanted to see whether there is a connection between mental abilities and pulmonary function. methods: before the examination, a license was obtained from the ethical committee of the university of szeged. conclusions: we could also detect in our smaller population that vlbw patients at the age of to years have lung function test values in the lower normal region of the reference range. this may raise the presumption of the higher susceptibility of these children to respiratory tract diseases also in the later decades of life. bpd patients have lower pulmonary function test results than non-bpd patients. on the other hand, we could not find any connection between low raven test performance and lung function results. background: esophageal atresia (ea) and/or tracheoesophageal fistula (tef) is one of the rare congenital anomalies occurring in out of , - , births. there has been improvement in the survival of these infants during recent decades. the diagnosis of tef with ea is commonly made during the first hours after birth. preoperative flexible endoscopy (fe) is not yet routinely included in the diagnostic and postoperative assessment. this study aimed to evaluate the predictive factors that affected patients' prognosis and the role of flexible endoscopy application in managing infants with ea and/or tef in a tertiary medical center. methods: we enrolled patients who were admitted into our hospital due to suspected ea and/or tef and accepted an fe examination for one or more times between jan. and dec. . all associated medical and surgical records were retrospectively reviewed. the analyzed data included basic characteristics, diagnosis, age of surgical repair, associated anomaly, timing of fe before and after surgical repair, and mortality. factors related to patient's mortality were analyzed. results: a total of patients were enrolled, including ( . %) cases referred from other hospitals. their mean birth weight was ± gm, including ( . %) low-birth-weight infants, ( . %) cases with cardiac anomalies, ( . %) cases aged > days, and ( . %) cases underwent fe before reconstruction. the most common classification of enrolled cases was type c ( . %). additional other airway anomalies were found in ( . %) cases, including tracheomalacia, bronchostenosis, lung hypoplasia, and laryngeal cleft. one case underwent nasaltracheo-fistula-gastric catheter insertion before surgery. the mean age of receiving surgical reconstruction was ± days. the most common postsurgical complication was anastomotic stenosis ( , . %) that required laser therapy ( , . %), balloon dilatation ( , . %), or stent implantation ( , . %). gastroesophageal reflux was also commonly found in ( . %) cases. the overall -year survival rate was . % ( / ). significant factors related to -year mortality were post-reconstruction referral (p = . ), age of reconstruction > days (p < . ), and cardiovascular surgery requirement (p = . ). conclusions: in infants with ea and/or tef, fe is feasible for the early identification of associated airway and esophageal anomaly, as well as postoperative diagnosis and therapeutic interventions. postreconstruction referral, age of reconstruction > days, and cardiovascular surgery requirement were significantly related to -year mortality of infants with ea and/or tef. background: patent ductus arteriosus (pda) is a common cardiovascular complication among premature infants and may be responsible for prematurity-related complications. surgical ligation is considered when medical treatment has either failed or was contraindicated. transcatheter occlusion, which was established in term infants, has recently been applied to premature population. previous reports stated that the complication and success rates were not statistically different between the transcatheter technique and surgical ligation. in this study, our aim was to compare the oxygenation status and oxygen dependence between these two techniques. the basic demographic data, fio change, pulmonary score, intubation days, ventilator-dependent days, oxygen-dependent days and mortality within year were evaluated. results: the birth body weight, gestational age, post-menstrual age on procedure day, body weight on procedure day, pulmonary score and fio before procedure were not different between these two groups. the range of body weight on procedure day was from to gm in group a and from to gm in group b. the overall mortality within year was similar (p = . ). the overall incidence of chronic lung disease was not significantly different ( / vs. / , p = . ). when comparing the fio change before and days after the procedure, the transcatheter closure group had a significant improve- are rare disorders of which the incidence is not precisely known. this malformation might threaten the fetus, but it can also disappear spontaneously, or neonates can be asymptomatic with the malformation. according to previous studies, cpam may increase the risk for lung infections and lung malignancies, which is also the argument used when treating asymptomatic cpam-patients with surgery. purpose of the study: the purpose of the present study was to investigate whether there are differences between the treatment protocols between nordic countries. material and methods: a questionnaire was sent to nordic centers dealing with pre-and postnatal management of patients with congenital lung malformation. this questionnaire was aimed to collect information on pre-and postnatal treatment protocols in the centers involved. results: the treatment protocols of this malformation vary largely in nordic centers. prenatal ultrasound was the primary examination in all centers. magnetic resonance imaging (mri) was used routinely as next prenatal examination in four centers for every cpam-patient with persistent finding in ultrasound during whole pregnancy ( of ). five centers ( of ) used mri if needed for differential diagnosis. various prenatal interventions were used in cases of fetal hydrops caused by cpam. shunting macrocystic lesion was used in out of centers, maternal cortisone in out of . over half of the centers ( / ) consulted and co-operated with centers that performed fetal surgery and out of did consider ex utero intrapartum (exit) surgery. postnatally surgery was performed in every center ( %) for symptomatic cpam-patients. one center ( %) did not remove cpam but instead performed follow-up on asymptomatic patients. four infants used precision flow: three used single prong cannula (tip od . mm), and the remaining infant used double prong, infant cannula (tip od . mm). pharyngeal pressure tended to rise to flow rate dependence with any type of cannula. in patients managed with the optiflow junior, the mean pharyngeal pressure at the flow rates of , , , and l/kg/min for premature size cannula were . , . , . , and . cmh o, respectively, and for neonatal size cannula were . , . , . , and . cmh o, respectively. in patients managed with precision flow, the mean pharyngeal pressure for each cannula at flow rates of , , , and l/kg/min for single prong cannula were . , . , . , and . cmh o, respectively, and for double prong, infant size cannula were . , . , . , and . cmh o, respectively. background: even though it is considered as a screening test, sweat conductivity (sc) analysis seems to be an alternative diagnostic method to the coulometric quantitative test (cqt) for the diagnosis of cystic fibrosis (cf). it is widely accepted that coulometry requires specialized technicians, in addition to being performed only in referral centers. on the other hand, sc sweat analysis is a semiautomated procedure, simpler and faster than the conventional cqt. specially in poor-resource settings, it allows the decentralization of the diagnostic network and, consequently, a wider accessibility to cf diagnosis. to date, there are no studies comparing two concomitant conductivity tests performed in the same patient. objective: to assess the agreement between two sweat conductivity results performed concomitantly in young infants. methods: this was a prospective, cross-sectional study in which two sweat samples were obtained from the two arms among consecutive patients, using the wescor macroduct collection system conclusion: since the strength of agreement was perfect, it reveals a high reliability of sc. apart from its role as a screening test, it seems that it has a place as a diagnostic tool in cf. background: because of frequent exacerbations and pulmonary deterioration in cystic fibrosis (cf), the radiological exposure to chest x-ray and ct scan is frequent in patients with cf, with subsequent potential secondary effect, although also required. lung ultrasound is, abstracts | s currently, a useful method of evaluation in multiples diseases such as: pneumonia, pleural effusion, interstitial syndrome or pulmonary fibrosis; therefore, the use of lus in cf would be of interest aim of the study: evaluation of thoracic ultrasound utility in cf exacerbations. methods: fifty cf patients were included in the study and monitored for years of age. lung ultrasound was performed every months, at clinical and biological evaluation. ct scan was performed during exacerbations and for stable patients, every years timetable (aged over years). ultrasound was performed using a linear high frequency to mhz probe, using a score based on specific artifacts which quantified the presence of consolidation, interstitial syndrome, saccular bronchiectasis and pleural effusion. ct was interpreted using the bhalla scoring system, independently of the lus score. pearson's correlation was used for the evaluation of the relationship between lus score and ct. results: median ct bhalla score was . + - . , and the average lus score = . + - , consistent for moderate morphological lung injury. a good correlation was found in patients with increased lus (> ) and ct score, r= . , p < . . there was no reliable correlation between the lung ultrasound score and ct, therefore, validation of the lus-cf score (r= . , p = . ) was impossible with the currently identified artifacts. for patients in acute exacerbations, alveolarinterstitial syndrome described by multiple b-line artifacts and the presence of lake signs quantifying cystic bronchiectasis were accurately identified by lus and confirmed by ct. methods: we conducted a retrospective descriptive study at the university hospital of montpellier between / / and / / . we collected the various respiratory disorders presented during the follow-up of these children. results: one hundred and two files were examined and patients were included in our study. asthma concerned patients in our cohort ( %) which is more frequent than in our general population ( % in occitania region, france). it was significantly related with atopy (p < . ). respiratory tract disorders were identified in patients ( %). the most common were: tracheomalacia and laryngomalacia. lower respiratory infections were found in patients ( %) and were significantly related to lymphopenia (p < . ) and swallowing disorders (p < . ). infants were tested for hiv using pcr and antibody testing. the association between hiv and arv exposure and lung function during years was assessed using linear regression, adjusted for bmi for age z-score, sex, ethnicity, socioeconomic status (ses) abstracts | s quartile at enrolment and pre-and postnatal smoke exposure (based on urine cotinine). results: a total of infants had at least one lung function measurement and were followed over years, ( %) were heu; ( %) male, ( %) black african ancestry, ( %) mothers smoked during pregnancy, ( %) household tobacco smoke exposure. nine hundred and ten ( %) infants had lung function tested at weeks and ( %) children at years. the majority of heu infants were black african ( % vs. % hu, p < . ), heu infants had less household smoke exposure ( % vs. %, p = . ), lower ses (p = . ) and had higher bmi zscore at years (p = . ) compared to hu; other demographics were similar. at weeks, heu infants had higher tidal volume compared to hu ( . ml, ci, . ; . , p = . ). amongst the heu infants, those whose mothers had triple therapy arvs had lower expiratory flow ratios, tptef/te, compared to those whose mothers had zidovudine (azt) only (- . , ci - . ; - . , p < . ). at years, tidal volume differences were no longer seen, but heu infants had a higher lung clearance index compared to hu ( . , ci, . ; . , p = . ). low antenatal maternal cd count was associated with an average . ml lower tidal volume at years compared to infants whose mothers had cd counts> cells/ mm (ci, . , . ; p = . ). background: chronic wet cough, which is prevalent in indigenous children, is the most common symptom of bronchiectasis and its precursors. early recognition of chronic wet cough leading to prompt and appropriate treatment may potentially prevent progression to bronchiectasis. therefore, timely health seeking for chronic wet cough by families, and its effective management by health practitioners is potentially important to prevent development of bronchiectasis. purpose: to identify the barriers to and enablers for timely health seeking for chronic wet cough by families, and optimal management by health practitioners, for chronic wet cough in aboriginal children. method: a qualitative study was conducted in two communities (one remote town and one very remote community) in the kimberley region of northern, western australia, of which % of the population is aboriginal. data were gathered through individual semi-structured in-depth interviews and focus groups to ascertain: the key enabler described was the provision of culturally appropriate health literacy information. all participants reported that they would seek help for chronic wet cough once they were informed that it could signify underlying disease. furthermore, families suggested that improved health practitioner knowledge of chronic wet cough database. complete monitoring data for the air pollutants (so , no , o , co, pm . and pm ) and meteorological factors (relative humidity, rainfall, and daily average temperature) were collected from environmental protection agency monitoring stations of the taiwanese government. in the present study, each er visit for asthma ae was defined as case day. in bidirectional control samplings, the same weekdays , or weeks before and after er visit for asthma were defined as the control days. multiple correlation coefficients (r) (multiple regression analysis) were used to explain how much of the variance in the ed visits could be explained by a given set of air pollutants. result: as the study cases were divided as male and female, a ug/m increase in the -h averages of pm . and a ℃ increase in temperature were associated with asthma er visit [or= conclusion: in taiwan, asthma ae is closely related to low temperature and indicated air pollution. there is an obvious bias if only a single air pollutant is being considered and neglects the influence of meteorological factors in studying the effects of the environment on asthma. with the result of this study, we can predict asthma exacerbation precisely according to individual age, gender and local air pollution/ meteorological conditions. in days with high risk for asthma exacerbation, patients with asthma should avoid/decrease outdoor activity, dress warmly and maintain inhaled corticosteroid therapy. however, while the path length of the right dorsum manus was not statistically significant, there was a significant difference in completion time between the two groups. the reason considered was that their left hand was their nondominant hand, while their dominant hand needed to be kept clean to touch an asepstic suction catheter. therefore, novice participants were unfamiliar with manipulating suctioning equipment with their left hand, which appeared as a difference in their proficiency. benefits of d cg were reported that the function of a virtual camera improved the accessibility to aois by screen transition, whereas operation was difficult, so they could not realize the effect of learning. advantages of d video was described that it is easy to concentrate because the device was familiar, while there was a negative impression that it was hard to observe aois compared to d cg. there was no significant difference between the groups who watched d video or d cg animation in the frequency distribution of fixation point movement speed analysis. however, considering the unignorable potential of d cg animation as a training tool, we concluded that defining visual criteria for assessing learning outcome of digital contents requires more research in the future. graduate school of nursing, the jikei university school of medicine -tokyo, japan the aim of this study is to compare the level of endotracheal suctioning proficiency between experts and novices, using an eyemark recorder. a head-mounted eye-tracking device (pupil, pupil lab, usa) was used to capture eye movement of the participants. twelve experienced nurses from three healthcare facilities who had more than years of experiences of suctioning, and twelve nursing students from a university who had no experience of providing suctioning for real patients, participated in a simulation scenario of a patient with endotracheal intubation. we utilized cephalothorax realia with a simulated upper respiratory tract from mouth, nose, to a tracheal bifurcation, which did not represent any biological/patholo- showed that . % of students are exposed to environmental tobacco smoke, which causes inflammation of respiratory tracts and a decrease in lung function. urinary cotinine can be used as a biomarker for cigarette smoke exposure. objectives: to examine the effects of environmental tobacco smoke exposure on urinary cotinine level and lung function test in children. methods: subjects were students aged to years-old in jakarta. data were obtained from questionnaire, spirometry and urinary cotinine test using elisa method. results: there were subjects, consisting of in the case group and in the control group. urinary cotinine level > ng/ml was found in . % of the case group and . % of the control group; p = . ; or= . (ci, % . - . ). there were significant differences between urinary cotinine level with number of smokers (p = . ) and number of cigarettes per day (p = . ). no association was found between cigarette smoke exposure and lung function test. there was a significant difference in school absenteeism between the case group and control group; p = . ; or= . (ci, % . - . ). conclusions: children exposed to environmental tobacco smoke there are relatively little data in healthy children and no data that compared these techniques. in children without respiratory disease, we described (i) the bal differential cellular count and its correlation with age, and (ii) compared the differential cytology versus b-bal ( %, iqr - %)). however, when adjusted for age using regression statistics, these differences were not significant. there was no significant difference in the total cell count (nb-bal . x /ml, iqr . - . x /ml versus b-bal . x /ml, iqr - . x /ml) and neutrophil percentage (nb-bal . %, iqr . %- % versus b-bal . %, iqr . - %) between the two groups. there was no significant difference in the differential cytology with age in both b-bal and nb-bal. conclusion: nb-bal provides comparable information on the cellularity components of bal when compared to b-bal and should be considered an alternative. as age influences cellular differential count, age-matched data are required for comparative studies on bal in children. j- | spirometry assessment in children with congenital heart disease after open heart surgery in these spirometry assessments, obstructive type was more common than restrictive type ( . % vs. . %). however, in tof patients, restrictive type was slightly more common than obstructive type. j- | to squeeze or not to squeeze? can the raised -volume passive expiration flow-volume curve be used to estimate pulmonary functions in infants? background: spirometry is an essential tool for assessing patients with lung disease. however, it necessitates cooperation and thus, it cannot be performed in infants. one of the established alternative techniques in infants is the raised-volume rapid thoraco-abdominal compression technique (rvtct) which uses a compression vest to squeeze the chest forcedly after inflating the lungs to near total lung capacity (tlc). although it is an acceptable method, it is far from being perfect since it is not easy to perform. obtaining the raisedvolume passive expiration curve (rvpe) from passive deflation of the lungs from tlc is an easier technique (figure ) . however, to our knowledge, data obtained from the rvpe curve were not assessed for their ability to estimate expiratory airway function in infants. tst was considered positive if induration > mm and qft-git however, anesthetic choice as a risk factor for fever has not yet been reported. objectives: the aim of our study was to explore the role of sedative agents as a risk factor for fever during the hours after the procedure. additional risk factors were investigated as well. multivariate analysis of the data (comorbidities, sedation choice, age, indication for performing the procedure, bal performed and its findings, post-prematurity, ftt, and medications) suggested that only sevoflurane and young age were statistically significant risk factors for fever. chronic treatment with montelukast was found to be a protective factor against fever. we conclude that post-bronchoscopy fever is probably an inflammatory noninfectious process. sevoflurane is a significant risk factor for developing post-bronchoscopy fever by generating such inflammation. the same mechanism may also explain why montelukst has a protective role. conditions were mostly present in young children less than years old while obesity was more common in adolescents. of the treated patients, . % had allergic rhinitis. comparing symptoms before and within months after pap trial, there were significantly less patients with complaints of habitual snoring ( . % vs. . %, p < . ) and excessive daytime sleepiness ( . % vs. . %, p < . ). there was significant improvement in psg parameters with mean oahi decreasing from . ± . /hour tst to . ± . /hour tst (p < . ) and mean spo (oxygen saturation) nadir increasing from . % ± . % to . %± . % (p < . ) after pap therapy. within months of follow up, . % of the patients adhered to pap satisfactorily while the adherence dropped to . % at the time of the latest follow-up. satisfactory usage established before months was associated with favorable long-term outcomes of satisfactory usage or cessation of therapy due to improvement at the latest follow-up (chi square test p = . ). the commonest reported reason for non-adherence was due to nasal obstruction. results: forty-three bemss were placed in infants. the mean bw and mean age were . ± . kg and . ± . months, respectively. there were , and stents located in trachea, carina and mainstem bronchi, respectively. seven infants with stents died without obvious stent-related mortality. among them, stents in children were successfully retrieved by rigid endoscopy. at placement, the diameters of tracheal and bronchial stents were . ± . ( - ) and . ± . ( - ) mm, respectively. these implanted bemss could be gradually and significantly (p < . ) expanded. at the end of this study, all the remaining stents in infants could be kept functional. the diameters of the remaining tracheal and remaining bronchial stents were . ± . ( - ) and . ± . ( - ) mm, respectively. results: eithty -three children were included. males represented . %, average age was . ± months. the rate of ards was . %. the mortality rate in children with this syndrome was . %. septic shock with ards had a higher mortality rate than septic shock without this syndrome ( %). most children with this syndrome were in the moderate and severity range ( . %); . % were ventilated. the tidal volume was . ± . ml/kg and average peep was . ± . cmh o, the medium fio was . ± . %; . % of cases had a tidal volume of to ml/kg. there were no differences in tidal volume, peep and fio between survivor and non-survivor cases. conclusions: ards had a high prevalence in pediatric septic shock and the mortality rate among septic shock cases with this syndrome is still very high. according to the unit policy to transfer to icu which is based on idsa guidelines, % of the patients needed intensive care. hdu care was given for % of patients who required supplemental oxygen to maintain pulse oximetry above %. analysis of length of hospital stay indicated that % of the patients were discharged by the th day and % were hospitalized for to days. there was no mortality among the patients evaluated. conclusions: this retrospective analysis revealed that childhood community-acquired pneumonia is associated with significant morbidity and is an economic burden. the majority ( %) needed therapy beyond first line antibiotics which may indicate significant antibiotic resistance. central sleep apnea (csa) and periodic breathing are unusual findings described in pediatric patients with congestive heart failure. however, csa has not been reported in children with pulmonary hypertension. we hereby report on a -year-old girl with idiopathic pulmonary arterial hypertension (ipah) who had frequent central events in a periodic breathing fashion seen in her polysomnography, which was normalized following medical treatment leading to improvement of the pulmonary pressures. this case supports the importance of psg in pediatric patients with ipah, not only to exclude osa as a potential cause but also to assess for the presence of pb. we also show that the presence of pb might be a sign of disease severity and can be a marker of response to we present two children from a tb endemic region, with microbiologically confirmed tb presenting with parapneumonic effusion containing chyle, that were misdiagnosed initially as pleural empyema. tuberculous pleural effusion occurring with chylothorax is uncommon. the first case is a -year-old girl who presented with localized left-sided chest pain and parapneumonic effusion and a previous liver transplant and long-term intravenous catheter, who was on chronic immunosuppressive therapy. the second case was a -year-old boy who was hiv-exposed but uninfected and presented reports, to our knowledge, on using gastric lavage pcr to diagnose pjp. we report two cases in which p. jirovecii was identified by gastric lavage pcr and was treated appropriately. case was a -year-old preterm, low-birth-weight male infant with down syndrome who had undergone operation for necrotizing enterocolitis and was being administered central venous nutrition. he was started on prednisolone for pericardial effusion because of postpericardiotomy syndrome when he was months old and had been in an nicu for a year. on the day of onset of pjp, he required increased oxygen levels, and infiltrative shadows were observed in both lung fields on chest radiography. further, his ( → )-d glucan (bdg) levels were elevated. p. jirovecii was detected on gastric lavage polymerase chain reaction (pcr), and trimethoprim-sulfamethoxazole was administered for weeks, following which his condition improved. case was an -month-old preterm, very-low-birth-weight male infant who was under central venous nutrition because of digestive tract disease. he was under treatment with hydrocortisone for months because of refractory hypoglycemia and had been in an nicu. on the day of pjp onset, he showed increased oxygen demand, and chest radiography showed infiltration in both lung fields. further, his bdg level was elevated. p. jirovecii was detected on gastric lavage pcr, and trimethoprim-sulfamethoxazole was administered for weeks, following which his condition improved. discussion: about %- % of immunocompetent children carry p. jirovecii in their respiratory tract, and this percentage, depending on the underlying disease, is %- % in immunosuppressed patients. therefore, when p. jirovecii is detected, it is important to distinguish infection from colonization. in these two cases, we suspected pjp on the basis of the clinical symptoms, backgrounds, bdg levels, and observations from image examination, and p. jirovecii was detected on gastric lavage pcr analysis. the patients' condition improved after definitive therapy. to our knowledge, there has been no report of pjp diagnosis by gastric lavage pcr to date, and this diagnostic technique may be useful if it is difficult to collect lower respiratory tract specimens. both patients had cellular immunodeficiency because of long-term steroid administration, although prophylactic treatment with trimethoprim-sulfamethoxazole for pjp had not been administered. this suggests the necessity of prophylaxis. we are reporting a -month-old boy, who was previously hospitalized with recurrent monthly pneumonia since birth until presentation to a regional tertiary center with pediatric respira- tracheal agenesis (ta) is extremely rare and usually fatal. complete or partial absence of the trachea below the larynx can be found, and a tracheoesophageal fistula may exist. there is usually no prenatal symptom, but other congenital anomalies are commonly found. we present a low-birth-weight male infant (gestational age weeks; birth weight g) born with respiratory distress. physical and radiological examination disclosed single umbilical artery, bilateral malalignment of thumbs, sacral dimple, and hemi vertebra. difficult intubation was noted soon after birth. after being transferred to our center with an intubated endotracheal tube, flexible bronchoscopy was performed and found it was an esophageal intubation. a blind pouch at the subglottic level of the trachea without a fistula was observed. diagnosis by computed tomography (ct) with d-reconstruction revealed ta (floyd type ii) with a small esophago-bronchial (eb) fistula at the lower esophagus and linked to the right upper bronchus. at the age of days, esophageal ligation and gastrostomy were performed. at the age of days, with the assistance of dprinting simulation and veno-venous extracorporeal membrane oxygenation (ecmo) support, cervical esophagostomy and tracheoplasty were executed. the cervical esophagus was end-to-end anastomosed to the larynx. after dividing and excision of the eb fistula, the proximal end of the lower thoracic esophagus just above the fistula was end-to-side anastomosed to the right main bronchus. the distal end of the lower thoracic esophagus was ligated. however, pneumothorax, anastomosis dehiscence and repair, narrowing of anastomosis, collapse of esophageal-consisted airway, and bilateral pulmonary atelectasis developed in the following weeks. flexible bronchoscopy aid balloon dilatation and stent implantation were planned. however, massive air-leak to mediastinum and peritoneum, shock and disseminated intravascular coagulation (dic) occurred. initially, nasal cpap (continuous positive airway pressure) was provided for respiratory support; however, intubation was finally performed with high-frequency oscillation use due to fluctuating respiratory condition. series of chest plain film showed progressive diffused infiltration, while high-resolution computed tomography showed bilateral ground glass appearance. in combination of her clinical features and image presentation, lung biopsy was performed due to the high suspicion of diffuse lung disease. oral steroid and azithromycin was administered but her improvement was poor. we did not administer hydroxychloroquine because of her g pd (glucose- -phosphate dehydrogenase) deficiency. recurrent ventilator-associated pneumonia was noted which needed several types of antibiotics. at months of age, a tracheostomy was performed. lung transplantation was offered to the family but they decided to proceed with mechanical ventilation use. due to worsening of clinical condition and resistance to medication treatment, she received palliative extubation after full discussion with her family at the th month. a blood sample was collected for genetic testing before the patient passed away. revolutionized imaging of the "forgotten third circulation", improving our understanding of lymphatic diseases and paving the way for a new treatment modality, lymphatic embolization. we present a -year-old girl with kla whose pleural effusion stabilized following two lymphatic embolization procedures. case report: our patient presented at years with recurrent severe non pulmonary infections. chest radiographs showed prominent diffuse reticular opacities despite the absence of respiratory symptoms or signs. comprehensive immunology and rheumatology investigations were normal, as were exhaled and nasal nitric oxide, ciliary biopsy, bronchoscopy and lavage, echocardiography and oxygen saturation at rest, on exertion and overnight. a chest ct showed thickening of interlobular septae with preservation of parenchymal architecture. a bone scan showed reduced uptake at l , as well as t and the left clavicle in keeping with "vanishing bone disease". at has no effect on osa caused by ca, although rapid maxillary expansion (rme) is reported to be useful for it. objectives: herein, we report the case of a patient with osa likely due to ca that was successfully treated with rme. nights. respiratory event index (rei) were . /h and . /h on nights and , respectively; nadir spo were % and %. as a result, severe osa was diagnosed. since his family did not wish for at, rme was performed. snoring and retractive breathing during sleep disappeared weeks after the start of rme, and months later, ocst was performed again on two consecutive nights. rei had improved to . /h and . /h on nights and , respectively, and nadir spo had improved to % and %. no evidence on the usefulness of rme for osa in children has been established. however, rme was useful for osa likely due to moderate ath and ca in this patient, suggesting that tongue space expansion by rme can be a useful therapeutic method for osa. gorham-stout disease is also known as vanishing bone disease. it is a rare disease of unknown etiology characterized by progressive osteolysis and proliferation of lymphatic vessels. we report cases of gorham-stout disease presenting with recurrent chylothorax and lytic bone lesion. we present a -month-old female infant with fever, cough, and vomit for days. she was transferred to our medical center due to rapid progression to pards within day, and her throat swab cmv pcr test revealed positive. her chest radiograph showed bilateral white-out, and very high ventilator settings were required to maintain oxygenation. cardiac disease was excluded by ultrasonography. intravenous ganciclovir, broad-spectrum antibiotics, and methylprednisolone were given, but the gas exchanges were still poor (oxygenation index= at hours after hospitalization). hfov was then applied (fio = . , map= cmh o, amplitude = cmh o, frequency = , i time = %). after using hfov, the lungs were recruited and the settings could be weaned down gradually. intravenous immunoglobulin was given for suspected viral sepsis. case report: patient a was an -month-old girl with down syndrome, congenital hypothyroidism, small patent ductus arteriosus and anorectal malformation who presented with persistent fever and cough for weeks post stoma closure. on examination, she was tachypneic with a respiratory rate of breaths/minute and subcostal recessions. her breath sounds were reduced over the right lower zone with stony dullness. chest x-ray (cxr) showed right lower lobe consolidation with a loculated parapneumonic effusion. minimal thick stale blood-stained fluid was aspirated during an ultrasound guided thoracocentesis and an unusual mass was seen. hence the chest drainage was aborted and a contrast-enhanced ct angiography revealed a pulmonary pseudoaneurysm within the consolidated lung, adjacent to the right pleural collection. blood investigations showed a drop in hemoglobin from g/l to . g/l. chest x-ray showed an extensive right pleural effusion and ultrasound described a right basal consolidation with a pleural effusion of ml. pleural fluid sample obtained by thoracentesis was purulent with exudate characteristics and a chest tube was inserted for drainage. due to these findings, a thoracic ct scan was performed and revealed atelectasis of the right lung and severe loculated pleural effusion with fluid-filled cavities in the right middle and lower lobes. since the patient was stable, a conservative management was preferred and empiric iv antibiotics, cefotaxime and clindamycin, were started. after days of treatment, pleural fluid culture was positive for s. mitis. s. mitis was sensitive to ampicillin, thus treatment was completed with days of ampicillin and days of cefotaxime and clindamycin with a satisfactory outcome. considering that s. mitis is an innocuous commensal organism of the oropharynx, skin, and gastrointestinal and genitourinary tracts, we looked for primary infection sites. the origin of the infection was a cavity in the third lower molar that extended to the root. the patient had a history of a dental procedure weeks before diagnosis. case report: a nine-month-old male preterm bpd infant with maternal premature rupture of membranes delivered by emergency caesarean section at + weeks gestation due to fetal distress. apgar score was at -minute and at -minutes and birth weight was g. because of respiratory distress syndrome, endotracheal intubation was performed and the patient was transferred to the neonatal intensive care unit. after months of mechanical ventilation support, the endotracheal tube was removed and the patient was treated under niv support. after months of mechanical ventilation support since birth, we decided to make an assessment of the neurodevelopment of the patient by brain mri. conclusion: most of the time, preterm bpd infants with vd who are receiving niv support will be considered as high risk and follow-up for mri delayed because of two reasons: ( ) need of oral intubation with endotracheal tube to guarantee the safety of the respiratory system; ( ) the neonatal mri-ventilator which includes niv mode is too expensive and requires a well-trained respiratory therapist to operate the mri-ventilator. we believed that once we well-prepared the mri-ventilator, infants with vd who are receiving niv support could undergo mri more safely. by sharing this case experience, we hope the profession of neonatal respiratory therapy could receive more attention. we present two cases that were diagnosed after multiple consultations: case . a -year-old girl presented with a history of recurrent episodes of cyanosis during her first months of life, worsening respiratory symptoms and poor exercise tolerance. she was assessed on several occasions by a general practitioner (gp) who did not consider that further investigations were necessary. she also had recurrent epistaxis and was being followed by the local ent specialist who considered the episodes as normal. at the age of two, she was admitted to her local hospital with a lrti, cyanosis and persistent low oxygen saturation levels ( %). she was treated with antibiotics, but given her slow improvement she was referred to our center for further workup. on examination, she presented with failure to thrive, general cyanosis, multiple telangiectasia in oral cavity and nostrils, and clubbing fingers. initial chest x-ray showed abstracts | s ct angiography revealed an arteriovenous malformation (avm) in the middle segment of the right lower pulmonary lobe, multiple intraparenchymal small avms in both lungs and an aberrant artery from the descending aorta that irrigated the right upper lobe. embolization of the main pavm was proposed, however, it was not possible due to its large extension since there was no embolic device according to its size. further discussion in several international forums, a thoracotomy and pulmonary segmentectomy of the right lower lobe was suggested and then performed months after presentation. since then, the patient has been asymptomatic, despite the fact that spo levels have not improved as expected. background: children with cystic fibrosis (cf) have frequent respiratory exacerbations, therefore the occurrence of cough and fever in a cf child raises the suspicion of an acute infectious event, while in a non-cf child this fever/cough association would suggest a pneumonia. what about the presence of tachycardia, which would suggest a different diagnosis, from myocarditis or hyperthyroidism. we herein present the case of a -year-old girl with cystic fibrosis with frequent acute cough, persistent fever and tachycardia attacks. a -year-old girl was diagnosed with cystic fibrosis in infancy, because of a pseudo-barterr syndrome. the child's evolution was very good, with good clinical and biological status, normal pulmonary lung function described by a normal lung clearance index and germ-free cough swab and negative induced sputum. she was monitored according to the national romanian guidelines every months in the regional cf center and annually at the national center, by clinical and biological investigation. no ct or bronchoalveolar lavage was performed until age of years. results: in evolution, her mother noticed episodes of tachycardia months before the actual admission, supposed secondary to play or hospital anxiety, without any electrical ecg alteration. four months before admission, she had a mild exacerbation associated with insignificant chest x-ray findings and she received intravenous cephalosporin. after month, she started to productively cough and fever, with a relatively strong persistence despite ains. her first sixteen emergency situations will be presented in detail using the above format. purpose: obstructive sleep apnea (osa) is a common disorder estimated at %- % in school-aged children. with the obesity prevalence reaching staggering rates globally, osa in obese adolescents is estimated to be to fold higher than their lean peers. there is a paucity of data regarding obesity-related osa in children years and less. this is particularly relevant as osa is associated with neurocognitive deficits. the aim of this study is to evaluate the prevalence of osa among obese toddlers and preschool children and further to determine what other factors may be associated with the presence of osa. methods: a retrospective study involving children < years, identified from two canadian pediatric tertiary care centers who had an in-lab polysomnography (psg). obesity was defined by a bmi of > th percentile for age and gender or a z-score of > . osa was diagnosed if the obstructive apnea-hypopnea index (oahi) was greater than events per hour. results: there were participants included; the mean age was . years (standard deviation [sd] + . ), mean bmi z-score was . (sd + . ). of these, / ( . %) had osa. compared with the non-osa group, the osa group had a higher epworth sleepiness score (p = . ) and were more likely to snore (p = . ). the present study "comparative study of nebulized beta agonist, nebulized adrenaline and any added advantage of % hypertonic saline in bronchiolitis" was undertaken to assess the efficacy. a total number of patients ( patients in each group) were examined below months of age. group a was nebulized with salbutamol, group b was nebulized with adrenaline and similarly, group c was nebulized with % hypertonic saline. comparison of mean ± s.d. of rdai score before and after nebulization was performed in all groups. in each patient from all groups (ie a, b and c), rdai scores were recorded at the time of admission (ie at minutes), at minutes and minutes (after nebulization) and on subsequent days. the mean value of rdai score at admission and discharge was . ± . and . ± . respectively in group a. in group b, rdai score at the time of admission and discharge was . ± . and . ± . , respectively. similarly in group c, rdai score at the time of admission and discharge was . ± . and . ± . , respectively. all the parameters before treatment had a p value > . (not significant at minutes.) and at the time of discharge, the p value became < . (extremely significant). mean differences in hr, rr, rdai score and spo were assessed after subsequent nebulization in all groups. the post treatment values for group a (salbutamol), group b (adrenaline) and group c ( % hypertonic saline) were compared. all groups showed an increase in hr, but group b (mean difference of . ) showed a more increasing trend than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . regarding rr, all groups showed decreased rr, but group b (mean difference of . ) was more significant than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . regarding rdai score, all groups showed improved score, but group b (mean difference of . ) was more significant than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . similarly, all groups showed improved spo %, but group b (mean difference of . ) showed more improvement than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . clinical parameters (heart rate, respiratory rate, rdai score and spo %) in both groups were comparable before nebulization. nebulized salbutamol was given to group a, nebulized adrenaline to group b and nebulized hypertonic saline to group c. different clinical parameters in the groups were compared before and after subsequent nebulization. mean respiratory rates, rdai scores and spo (%) significantly improved in all groups. however, improvement was more significant in the adrenaline group. shorter length of hospitalization was noted in group c (hypertonic saline). no undesirable side effects were noted in all groups. all groups showed a transient increase in heart rate, although more so in the adrenaline group. objectives: endothelial dysfunction (ed) is one of the initial pathological changes ultimately leading to atherosclerosis and consequent cardiovascular disease. children with endothelial dysfunction are at higher risk of developing systemic and pulmonary hypertension, atherosclerosis and cardiac remodeling, with potential long-term adverse outcomes into adulthood. obstructive sleep apnea syndrome (osas) has been found to cause impaired endothelial function in adults. however, the evidence in pediatric osas is limited. the aim of the study is to evaluate endothelial function in a large cohort of children clinically referred for suspected osas, and to identify risk factors contributing to the presence of ed. methods: children aged to years old with habitual snoring (snoring ≥ nights per week) were recruited to this study between june st -march st . all subjects underwent an overnight polysomnography (psg), as well as endothelial function testing using peripheral arterial tonometry (pat) to derive the reactive hyperemic index (rhi). subjects were then divided into osas and primary snorers (ps) groups according to their obstructive apnea-hypopnea index (oahi). results: a total of cases completed the study, with children being diagnosed as osas, and children assigned to the ps group. there were no differences in age, gender and bmi z-score between the two groups (all p > . ). the osa group had lower rhi than that of ps (p < . ). univariate correlation analysis showed that rhi was linearly correlated with age, gender, oahi, oxygen desaturation index, respiratory related arousal index, and oxygen saturation nadir. the relationship between bmi z-sore and rhi was quadratic. rhi and bmi z-sore were positively correlated when bmi z-score< . year follow-up, we regularly performed ekg, cardiac echogram, minute walk testing (smwt) and monitoring of serum bun, bnp and creatinine. also, cardiac catheterization and hemodynamic studies, pet study with uptake of glucose analog -deoxy- -﹝ f﹞fluoroglucose ( f-fdg) and pulmonary perfusion-ventilation scan were performed. we enrolled six patients with es including atrial septal defect type ii ( cases), atrial septal defect type i ( case), right atrial isomerism after total cavopulmonary connection (tcpc) ( case) and ventricular septal defect ( case); the male:female ratio was : . hemodynamic studies revealed that mean pulmonary arterial pressure was ± . mm hg; pulmonary vascular resistance index was . ± . wu*m , except the case receiving tcpc. in addition, three cases of intrapulmonary thrombus in right pulmonary artery, three cases of cerebral stroke and three cases of atrial fibrillation were found. the lung scan revealed that there were nonspecific findings noted in the es patients with or without intrapulmonary thrombus. very interestingly, an increased uptake of f-fdg in the right ventricle was noted in three cases. subsequently, there were two mortalities because of right ventricular failure. and pediatric settings which corresponds to a child of kg weight (tidal volume ml, breaths/min, ratio between inspiratory and expiratory / and peep cm h o). a filter was placed between the endotracheal tube and the test lung model (smartlung adult, imt medical, switzerland) to collect the drug. all components were tested for drug deposition. deposited doses were quantified by spectrophotometry. all measurements were performed five times. results: the percentages of the nominal dose of salbutamol deposited on the filter with the adult model after nebulization and aerosolization, were similar when the device was located before or after the y piece results: flow analysis. during inhalation, the pressure differential (y)/ flow rate (x) relationship was y = . x + . x (r = , ). during exhalation, the pressure differential (y)/flow rate (x) relationship was y = - . x + . x (r = , ). this indicated that the flow rate closely followed the pressure differential (n = ). furthermore, the ap was able to measure flow rate with great stability and reproducibility during all the experiments. results: valve resistance generated at low inspiratory flow rate ( l/min) varied greatly between the different valves ranging from . to . cmh o/l/s; however as the flow rate increased, variations were reduced ( . to . cmh o/l/s at l/min). the ability to close varied strongly from one valve to another: for some valves, expiratory flow did not pass through the inspiratory valve while for others, only partial closing could be achieved ( % of expiratory flow passed through the inspiratory valve). these results were confirmed by measuring the flow through the expiratory valve, maximum ( % of the initial flow rate) when inspiratory valves were completely closed. tilting the chamber did not seem to affect this result. ed measured with pediatric breathing parameters in coordinated and uncoordinated use was similar for four of the custom vhcs while with the other two vhcs, ed was lower. , and a high-speed camera (hxlink ,nac) and two different shapes of membrane models were used in this study. five catheter motions: ) quiescent technique, ) piston technique, ) rolling technique, ) twist technique, and ) dynamic pressure technique, were performed times each and the weight of secretion was measured by a digital scale. the negative pressure was set at kpa, suctioning time was counted seconds. one-way anova and tukey test were used to analyze the obtained data. in experiment , the mean amount of secretion for ) to ) were . , . , . , . , and . , respectively. there were significant differences between ) quiescent technique and ) piston technique (p = . ), ) piston technique and ) rolling technique(p = . ) on a flat membrane model with high viscous sputum. the high-speed camera showed that absorption was started when a catheter tip aperture and two side apertures were sealed with the high viscous sputum. as dynamic pressure technique, sputum was quickly absorbed right after the researcher released her thumb which bent the suctioning catheter. in experiment with high viscous sputum on a tracheal membrane model, mean secretion weight ) to ) were . , . , . , . , and . respectively. there were no significant differences between these five techniques. in experiment with low viscous secretion on a tracheal membrane model, mean amounts of suctioned secretion were . , . , . , . , and . respectively. there were significant differences between ) piston technique and ) twist technique (p = . ), ) piston technique and ) dynamic pressure technique (p = . ). in conclusion, the piston technique could absorb the most amount of secretion when a catheter tip was visible on a flat membrane model, however, the catheter motion which suctioned the most secretion was the dynamic pressure technique in a tracheal model despite the viscosity of the secretion. even though nurses had to carefully apply the level of negative pressure before their procedure, this result indicated that dynamic pressure technique is the most effective catheter motion to remove secretion on a tracheal model. background: respiratory syncytial virus (rsv) infection is the main cause leading to acute bronchiolitis in infants or children less than years of age. children are more susceptible to rsv infection than adults, especially those who have hemodynamic-significant congenital heart disease or heart failure. in this study, we aimed to evaluate the possible risk factors leading to prolonged stay in the pediatric intensive care unit (picu) or hospital stay for chd children with rsv infection. methods: data were retrospectively retrieved of patients who had chd from jan to dec . those patients who had concurrent rsv infections and underwent computed tomography imaging study were included as the study group. clinical presentations were recorded and classified. statistics used descriptive analysis and p < . was taken as significant. results: a total of patients with associated congenital heart disease were included. the mortality rate was about % due to pulmonary edema, dysfunction or cyanosis. the total number of subjects whose age was below year old was similar to those whose abstracts | s age was between and years old. there were chd children with airway problems, including trachea-bronchomalacia, stenosis of the trachea or bronchus. patients aged less than year old had longer hospital stay than those whose age was above year old. the mean picu stay and the intubation period had a similar trend. in the comparison of groups without airway anomalies, the hospital stay in children who had hemodynamic-significant chd or heart failure (without associated airway anomalies) was . days compared to . days in children who did not have hemodynamic-significant chd or heart failure(without airway anomalies) (p < . ). in children with airway anomalies but did not fulfill the criteria of hemodynamic-significant chd or heart failure had longer hospital stay ( . days) than those without airway anomalies but with hemodynamicsignificant chd or heart failure ( . days) (p < . ). conclusions: patients with airway anomalies are not rare in children with chd, although the severity varies. lower airway anomalies were associated with longer hospital stay in chd children who were not hemodynamic-significant or heart failure. we found that airway problem is a risk factor for prolonged hospital or picu stay in chd children with rsv bronchiolitis. to achieve successful and sustainable outcome in chd children with rsv bronchiolitis, it is crucial to have early identification of concomitant airway anomalies in these children. childhood pneumonia and diarrhoea : global burden of childhood pneumonia and diarrhoea key: cord- - u e q authors: nan title: selected abstracts from the th j project meeting, antalya, turkey, march - , date: - - journal: j clin immunol doi: . /s - - - sha: doc_id: cord_uid: u e q nan hans d. ochs the identification of single gene defects involving genes that play crucial roles in adaptive or innate immunity is not only important for confirming a pid diagnosis, but may contribute to optimal therapy, and contribute to genetic counseling, carrier identification and pre-natal diagnosis. to accomplish this, the diagnostician has to consider the inheritance of these disorders: x-linked, autosomal recessive, autosomal dominant and the type of mutation: loss of function, hypomorphic, dominant negative or gain of function. conventional techniques to screen for single gene mutations include flow cytometry to measure disease-specific expression of proteins (cell surface, cytoplasmic or nuclear) or to analyze relevant signaling pathways (e.g. stat b phosphorylation via the il- r; pstat via the il- receptor); and sanger sequencing of mrna or genomic dna using dye-terminator sequencing. next generation sequencing ("by synthesis") has been refined, and is being used increasingly to study families with multiple affected members with an atypical pid phenotype, or to explore consanguineous families with one member affected. whole exome sequencing requires less data analysis, compared with whole genome sequencing, but may miss intronic or regulatory elements. the challenge of whole exome/genome sequencing is to confirm that the multiple variants identified by these techniques are causative for the clinical phenotype of the study patient. however, with increasing experience, next generation sequencing will become a standard procedure for the identification of genetic defects responsible for inherited diseases, including pid. stephen jolles immunodeficiency centre for wales, university hospital of wales, cardiff, uk. immunoglobulin (ig)-replacement therapy represents the mainstay of treatment for patients with primary antibody deficiency and is administered either intravenously (ivig) or subcutaneously (scig). recent developments using a high-purity recombinant human hyaluronidase have allowed the longer term repeated use of this enzyme to facilitate the delivery of immunoglobulin and other molecules including antibiotics, local anesthetics, insulin, morphine and fluid replacement into the subcutaneous space. hyaluronidase facilitated scig (fscig) has helped overcome the limitations on the volume which can be delivered into the subcutaneous tissues by enabling dispersion of scig and its absorption into lymphatics. the rate of facilitated scig infusion is equivalent to that of ivig, and the volume administered at a single site can be greater than ml, an enormous increase over conventional scig, at - ml. the use of fscig avoids many of the systemic side effects of ivig, and has higher bioavailability than scig. over three years of safety data are now available for this approach though longer term safety data and information on anti-hylauronidase antibodies and their relevance will be required. fscig could aid several areas of patient management in both primary antibody deficiency and immunomodulatory indications. key factors influencing how it will be used in future are long-term safety data and cost-benefit analysis. date after the cd deficiency was firstly described in a turkish girl in . the patients with cd deficiency had normal b-cell differentiation in bone marrow, normal absolute number of b cells in peripheral blood and normal bcr repertoire. also, the patients had normal stimulation via the bcr, normal proliferation response upon antigen stimulation but reduced memory-b-cell compartment in peripheral blood. the cd deficiency leads to hypogammaglobulinemia and impaired antigen-specific humoral immune responses after vaccination. we had described thirty carriers in relatives of our two patients with cd deficieny and also showed that the mfi value of cd and cd expressions were lower in the carriers than in controls. during the last five years, it was also showed that the mutations of the other coreceptors of b cells such as cd and cd caused antibody deficiency. in conclusion, the description of cd deficiency reminds the importance of the molecules on b cells and contribute to identify new genetic defects (cd , cd ), and it was showed that coreceptors could affect the expressions and the functions of each other. ege university faculty of medicine, dept of pediatric immunology, izmir, turkey ig class switch recombination deficiencies are rare pids ( : , births) with normal or elevated serum igm and low igg, iga and ige levels, defective or normal somatic hypermutation, defective t/b cooperation ( %), intrinsic b cell defect ( %), susceptibility to bacterial infections begining from the first year of age (impaired b cell immunity) and lack of germinal centres in secondary lymphoid organs. we present a cd l defective case with clinical findings such as recurrent otitis media, recurrent upper and lower respiratory tract infections, sinusitis, arthritis, relapsing polychondritis , ebv-associated cervical lymphoproliferation, cmv infection, bronchiectasis, liver and spleen enlargement, multiple nodules in the liver, chronic diarrhea due to persistent cryptosporidium parvum, fungal pneumoniae, osteoporosis, and schwannoma. this case is remarkable with low igm levels and normal cd l ezpression on activated t cells although he had a novel mutation in cd l gene (a novel missense mutation in cd lg (c. c t), leading to an a. a. change from histidine to tyrosine at position (h y) at the start of the extracellular domain). in addition, we present two cases with cd deficiency with normal cd expression on b cells.both of these cases had homozygous-cd -mutation leading to a longer protein due to deletion of stop-codon. in conclusion; cd molecules although non-functional in b cells, may be normally expressed on cell surface. these cd molecules are unable to trigger signal, because cd l + il activation leads to complete lack of proliferation. evaluation of cd or cd l expression by flow cytometry may lead false results. study of cd l + cytokine (or cd + cytokine)induced b cell proliferation appears as a useful tool for these diagnosis. institute for immunology and physiology (ub ras). yekaterinburg, russia regional children clinical hospital № , yekaterinburg, russia the ural regional center of clinical immunology, which based on children clinical hospital number one (№ ) in yekaterinburg, observe patients from different territories of ural region and neighboring areas. it consists of laboratory department, consultative department, vaccination and treatment rooms, beds and boxes in special departments in the regional children hospital. the close collaboration with j-project started in . this is an example of such collaboration. in patient a. an international consilium was diagnosed a progressive neurodegenerative disease as a manifestation of primary immunodeficiency: x-linked agammaglobulinemia with b-cell deficiency. mri results: unspecified leukodystrophya rapidly progressive multifocal brain lesions with demyelinating, generalized cerebral atrophy, iii degree, signs of periventricular leukomalacia in the anterior horns of the lateral ventricles. the brain biopsy was recommended in order to clarify the nature of the defeat of the pathological process and define the role of the immune mechanisms of its development (held in the neurosurgical department with subsequent histological and immunohistochemical studies). histological and immunohistochemical study of the brain tissue of the right frontal lobe: a signs of productive meningoencephalitis in brain tissue with vasculitis, perivascular and focally moderate diffuse infiltration of mononuclear (accumulation of mononuclear cd rb+, vimentin+), most of which are cd + lymphocytes with granules of granzymeb. around -dystrophy and necrobiosis neurons, intracellular edema, small focuses of gliosis -there are isolated myeloid cells (myeloperoxidase +) and plasma cells with cytoplasmic expression of immunoglobulin light chains lambda and kappa; cells and the extracellular matrix of brain tissue expressing cd antigen and s protein. virological and bacteriological studies of brain tissue and liquor: connection of progressive degenerative changes and infectious process weren't obtained verified acknowledgments of an infectious or autoimmune process has not been received. search for a genesis of cytotoxic process in the brain continues. center for chronic immunodeficiency, university medical center freiburg and university of freiburg, germany the essential role for igg replacement therapy (iggrt) for common variable immunodeficiency (cvid) has been demonstrated in many studies and metaanalyses. while patients with "infection only" reach a nearly normal life expectancy -though still not quality -under iggrt, cvid patients with additional manifestations like inflammatory lung, bowel or liver disease, lymphoproliferative and/or autoimmune disease often require additional immunosuppressive treatment. there is little consensus on the form of immunosuppressive regimen, once steroids have failed, with possibly the one exception of rituximab treatment for autoimmune cytopenia. additional studies are essential to guide therapeutic algorithms. some of these patients suffer from late onset combined immunodeficiency (locid). as in classic forms of combined immunodeficiency, iggrt can be only a part of the treatment strategy, which needs to additionally address the cellular immunodeficiency of the patients. therefore a retrospective survey was performed on patients diagnosed with cvid who underwent hematopoietic stem cell transplantation. the results of this study are currently in revision. in summary, iggrt is the baseline therapy for cvid but does not address sufficiently the immune dysregulation in a subgroup of patients. better predictive markers have to be identified for the selection of patients for additional, potentially even definite forms of treatment in order to prevent the morbidity and mortality associated with these secondary manifestations of cvid. the first department of primary immunodeficiencies in russia was established on the basis of the institute of immunology in , when patients with pid were registered. currently, patients with pid are followed in the department of immunopathology in adults. % of pid adult patients have pid with immunoglobulin deficiency. analysis of this group of adult patients showed that the diagnosis of pid, on average has a delay of - years from the first symptoms. in % of cases, there is an infectious clinical phenotype, % -combined infectiouslymphoproliferative phenotype, % -infectious and enteropathy. the study of immunophenotyping of b-lymphocytes for the degree of maturation in this group of patients was begun. patients are currently included in this study. patients showed complete absence of b-lymphocytes, -the reduction of b-cells, patients of those have a normal amount switched memory b cells (mbc), people -a decrease amount of switched mbc. persons of the group with decreased amount of switched mbc had an expansion of transitional mbc. at present, a clear link of immunophenotypes with specific clinical phenotypes in not found, but this may be due to small sample of patients at the moment, the investigation continues. for the treatment of this category of patients only intravenous immunoglobulins are available in russia. we use drugs in various concentration of russian and foreign production. the availability of immunoglobulins for the adult patients unfortunately is not sufficient in russia, so the recommended pretransfusion level of igg is not achieved in about % of patients. our work presents the experiences of our center with the subcutaneous form of immunoglobulin therapy (scig). we have patients on such therapy. the youngest child is months old. the largest group consists of cvid patients, next-xla patients. we also substitute children diagnosed with the dgs and accompanying hypogammaglobulinemia and some children with subclasses deficiency as well as secondary hypogammaglobulinemia. in most cases we start therapy with intravenous preparates, but there have been some children to whom we proposed the subcutaneous form at the initial stage of the therapy. the main factors which made us change the mode of the drug application were adverse reactions to ivig, poor vein access and the parents`wish. the administration of scig is very rarely complicated by severe adverse reactions (the risk of their incidence amounts to about . %). even patients with serious side effects to previous immunoglobulin therapy and/or blood transfusion can be safely treated with scig. the most common side effects are local reactions but their incidence decreases during following substitutions. we can observe swelling, redness, induration, soreness. but we should remember that more severe side effects are also possible, for example: the first cvid patient presented with fever, weakness, difficulties in breathing during the following infusions. changing the brand of the drug turned out to be a sufficient method of getting rid of side effects. the second patient, also with cvid, suffered from nausea, headache, meningismus. we changed the drug brand, slowed down the infusion rate and introduced premedication with an antihistaminic drug. the third patienta girl with dgs and hypogammaglobulinemia, after having been operated on for hypoplastic left heart syndrome, responded to infusions with high fever, muscle and joint pain, skin changes (erythrodermia). we introduced premedication, changed the drug brand and slowed the infusion rate, yet without any positive effects. in two patients we observed adverse reactions after preparates at a concentration of twenty percent. there were: weakness, chills, fever, headache, and very intense pain in the place of injection. during the subcutaneous treatment of xla patients, we observe significant reduction in the number of infections and days of school absence. despite that, all our patients with xla suffer from chronic sinusitis. similar results occurred in cvid patients, but the severity of infections was the same. the use of scig results in more stable and higher igg through levels especially in xla patients. in our practice, we had only a few cases in which iv form appeared to be better than sc one. in the case of two boys with higm syndrome, we observed recurrent enthesitis of the first patient and progression of lung fibrosis of the other. ivig was better to control platelets levels in the girl with cvid and thrombocytopenia. it has also occurred that parents refuse to allow us to start subcutaneous therapy, giving two main reasons: they feel safer under frequent doctor`s control and they are afraid of making mistakes in procedures. as for the youngest children (below )their fear of needle is independent of its size, which is the third reason. in conclusion, we would like to emphasize that education programmes implemented by doctors and nurses are essential to make this form of therapy easier, safer and more satisfying for patients and their parents. despite intensive investigation into the nature of cvid, the exact molecular defect(s) and pathogenesis of disease remain unknown. our aim was to evaluate the role of t cells in the mechanisms of cvid development. additionally the impact of some innate and adaptive immunity related genes (hla, cytokine gene polymorphism, mbl genes) was investigated. based on previously observed by us constellation of shared immunogenetic profiles a comparison of t-cell phenotype of cvid patients, and elderly/young healthy individuals was performed. ten patients with cvid were enrolled ( male, female; average age - , years) presented mainly with pulmonary infections, followed by bronchoectasis and splenomegaly. our study demonstrated multiple t-and b-cell abnormalities in cvid patients such as: decreased cd +, increased cd + t cells and low cd /cd ratio, loss of naïve and early differentiated t cells, expansion of terminal effectors (cd + cd ra + cd l-) t cells, memory/effectors (cd + cd -cd -) and terminally differentiated (cd + cd +) t cells. excessive t-cell activation reflecting the prevalence of activated t cell phenotype was also detected, due perhaps to an antigen-driven process. the very low numbers of circulating mature (cd + cd +) and class-switched memory (igm-igd-cd +) b cells were pathognomic for our patients and could be used as an additional diagnostic criteria in the national guidelines. furthermore high level of nonclass switched (igm + igd + cd +) b memory cells and suppressed nk cell count was observed. decreased responsiveness to polyclonal stimuli via cd and cd pathway correlated with the loss of cd expression which was more pronounced in the treatmentnaïve cvid patients. these findings were further discussed in the context of the similarities that exist along with markers for immune senescence (lack of cd or expression of cd ). increased frequency of ifn-γ polymorphisms associated with low expression level found could indicate genetically predisposition to high activation of th lymphocytes in cvid and consequently support the concept of impaired th -type responses. in conclusion our study provided new insight into the pathogenesis of cvid. this work was partially granted by medical university sofia, grant# bcg vaccination at birth is the constant element of vaccination programmes in poland. high reactogenic bcg danish vaccine has been replaced in , by bcg moreau vaccine. frequency of disseminated bcg infection, in children with primary immunodeficiencies after bcg moreau vaccine manufactured by biomed, poland were estimated. one thousand five hundred sixty three cases of primary immunodeficiencies were diagnosed in the department of immunology, children's memorial health institute in warsaw between - . among patients with t cell predominant deficiency, group high risk of bcg infection, scid was recognized in children. mendelian susceptibility to mycobactarial diseases (msmd) was detected in four patients: ifgr deficiency and il deficiency -equally in two patients, and nemo -in one. in the group of primary immunodeficiencies regarded to be less prone to mycobacterium infections, cgd was diagnosed in , hies in patients, and xl-higm in patients. disseminated bcg infection was recognized in scid patients, of them died, because of bcg diseases. all patients with msmd developed bcg infection, one with il- deficiency died. during nearly -year-follow-up, no case of tuberculosis or disseminated bcg infection have been diagnosed among cgd , hies and xl-higm patients. early anti -tb drug prophylaxis and usage of wide range of antibiotics in therapy is crucial for cleaning of bcg infection. peter Čižnár ; julia horáková ; peter Švec ; ivana boďová ; sabina Šufliarska ; linda libai veghová ;, marieta hricová st pediatric department, comenius university medical faculty, children`s university hospital, bratislava, slovakia. transplantation unit, department of pediatric haematology and oncology, children`s university hospital, bratislava, slovakia. objectives: severe combined immunodeficiency (scid) is a group of disorders due to more than genetic defects, characterized by increased susceptibility to severe infections and early life death. the diagnosis is supported by the demonstration of low absolute t lymphocyte count variably associated with numerical defects of b and nk cells. patients are very heterogeneous regarding clinical course, immune parameters and clinical outcome. bcg (bacillus calmette-guerin) vaccine, a life attenuated vaccine was the part of slovak immunization program, administered at birth until . a comparison of clinical course of bcg exposed (bcg+) and non-exposed (bcg-) scid patients in slovakia in period of past years are given. results: incidence rate of diagnosed and treated scid in slovakia was calculated to : . , meaning , cases per year. in total cases represent ada patients, il rg deficiencies, case of complete del q and in cases genetic defect was not found by analysis of rag / , il rg, artemis, il ra, jak and ada genes. all patients were confirmed absent trec (t-cell receptor excision circles) copies in a retrospective neonatal guthrie card analysis. seven out of these patients underwent hsct, in the hsc source was a mud. favorite outcome was achieved in of them. half of our patients have been exposed to a live bcg vaccine during neonatal period. patients vaccinated with bcg faced severe complications and organ damage due to generalized skin and organ abscess formation, requiring prolonged (up to months) hospital care and complex antibiotic therapy with more than four types of anti-mycobacterium drugs, for more than years. average length of hospital care for bcg exposed patient was , months vs. , months in non-exposed group (p < , ). no statistical difference was found between the time of recognized first symptoms, and time of diagnosis in bcg + and bcg-group. the clinical presentation of non-bcg vaccinated patient differs in the initial symptoms when failure to thrive and pneumonia at months was the most common finding. post-transplantational recovery in bcg-group was less complicated. conclusions: two major improvements for the outcome for scid patients in slovakia have occurred in past years. early life vaccination for tuberculosis has been retreated and improvements in diagnostics for severe t cell defects have been made, including flow cytometry phenotyping and genetic testing within the middle european countries cooperation, the j-project. bcg and late diagnosis prolongs time for hospital care, immune reconstitution and carries severe complications, consequently it increase the costs of health care and decrease the quality of patients' life. the perspective of newborn screening for scid would be the next major step in improving the outcome of scid patients. ahmed aziz bousfiha ; leïla jeddane ; nahla erwa ; monika esser ; shereen m. reda in africa, primary immunodeficiencies are still largely undiagnosed, with no cases reported in of countries. though the african society for immunodeficiencies (asid) already organized international meetings and training schools, their impact outside the hosting country is still insufficient. at this time, only a few pid patients are reported in africa (less than patients), the majority of whom are in north africa and south africa. so, asid propose the a-project, a training program based on the j-project. some issues prevent effective training for pid in africa: diversity of languages, only a few are initiated to pid, lack of resources for travel expenses, difficulty to access to care and shading by the hiv pandemic. a-project is designed as a one-day training by an african pid expert in a small group of motivated caregivers. this project is adapted to the african context, as it only requests minimum funding and can reach more people. each a-project will be co-organized by asid and a local committee, and shall lead to some commitments to be realized by locals, in particular the establishment of a registry, a network between physicians and scientists and creation of a patient association. moreover, each a-project will be done in the medical language used in the country (english, french or portuguese). the first a-project was already done in benin, and five more are already planned for . our goal is to reach all countries where no patient were reported in years. this clinical program will raise pid awareness in africa and can potentially discover new aspects of the immunity. till very recently primary immunodeficiency diseases (pids) were not being frequently recognized in india. however, the scenario has changed over the last years or so. the indian society for primary immune deficiency (ispid) was founded in - . over the last years the ispid has organized international conferences (at new delhi and mumbai), national conferences (at chandigarh and varanasi) and continuing medical education programmes (at new delhi and lucknow). these meetings have served to act as catalysts for the cause of pids and have resulted in increasing the awareness about these conditions amongst paediatricians and physicians in our country. several centres now have the clinical skills and the technical wherewithal to perform laboratory investigations for these patients. the repertoire of tests includes nephelometery, elisa based tests and flow cytometry. facilities for molecular diagnosis of pids are also being developed at some of these centres. a lot more, however, needs to be done. the clinical phenotype of several pids in india is likely to be different from that in the west . further, the type of infections in these patients is also likely to be different. this is because of the differences in the micro-and macro-environment to which these patients exposed in developing countries. these differences have been well brought in the recent publication on chronic granulomatous disease from our centre . further, the genetic background of the indian population is diverse and several new mutations are likely to be identified amongst these patients. the indian council of medical research has taken up the lead in this regard and is proposing to set up centres for advanced research (cars) in pids - each at the post graduate institute of medical education and research, chandigarh and the institute of immunohematology, mumbai. the foundation for primary immunodeficiency (fpid), usa has also been closely involved in these efforts and has helped facilitate the development of these cars. the field of pid research in india is wide open and we are likely to witness new and exciting scientific developments in the coming years. references: . gupta s, madkaikar m, singh s, sehgal s. primary immunodeficiencies in india: a perspective. annals of the new york academy of sciences ; : - . the prevention of pid's complications, the improvement of the health care of patients with pid, the creation of the registry of the patients with pid, the implementation of the finance regulations for detection and treatment of patients with pid diseases in public health facilities, the training and professional development of medical professionals in this field. objective: to improve the detection and diagnosis of pid diseases and the life quality of patients with pid in the republic of kazakhstan. undertaken activities for realization of the project: . professor. l. marodi visited kazakhstan in october and the meeting was held in ministry of health of the republic of kazakhstan, presentations were given at the international conference held in national research center for maternal and child health, the negotiations with heads of the national medical holding' clinics and scientific center of pediatrics and pediatric surgery were held. international islamic university, kuantan pahang, malaysia. two hundred and sixty three ( ) suspected pid (primary immunodeficiencies) cases were referred to clinical immunologist led clinics in malaysia from - . patients referred were from all states of malaysia and seen at the institute of pediatric, hospital kuala lumpur and university associated hospitals in north and central peninsular malaysia the initial pid patients were seen by - pediatric immunologist between - followed by another , beginning in followed by the other in . there were ( . %) patients with at least abnormality on the immune prameter recorded and regarded as probable pid. however ( . %) were recorded as pid based on existing criteria. (who scientific committee , iuis scientific committee, primary immunodeficiency disease. ) our population were mainly children, % below years and % below year. only were above years. pid were classified as; predominant antibody deficiencies %, combined immunodeficiencies . %, other cellular immunodeficiencies . %, phagogocytic defect . %, immunodeficiency associated lymphoproliferative disorders %. our data differed from most classification where predominant antibody deficiency is most frequent as high as %, (steihm, ) . of the specific pid recorded, x linked a gammaglobulinemia (xla) , hyper igm syndrome (higm) , common variable immunodeficiencis (cvid ), selective iga deficiencies severe combined immunodeficiencies (scid) , di george syndrome (dgs) ,chronic granlomatous disease (cgd) , hyper immunoglobulin e syndrome (hige ) , primary cd deficiencies , ataxia telangiectassi % malaysia comprises of multi ethnic groups with a population of . million in . pid amongst them showed, malays at . %, chinese %, indians . % and others . % whilst the male predominate over female at a ratio of . : . family history of affected sibling or in first degree relative, or early death with suspected infant dying of infection was positive in . % which is higher than in most reports eg egypt . % (reeda ). this could be due to high consanguinity in the population. alternatively the symptomatic sibling of affected patients is more likely to be referred to the clinical immunologist. scid records the most varied organism from the positive microbiological isolate viz bacteria , fungus , virus , parasite . chromobacterium violaceum was seen in cgd patients in which deteriorated with eventual death. as in many national registries diagnostic delays remains prominent. in our series the mean diagnostic delay was o . ± . years. in comparison thailand stands at . ± . years, while france, a median of . years. malaysia remains committed to provide better diagnostic services and improved care of the pid patients through research collaboration with foreign partners with a drive for creating subspecialty training. patient groups aligned to ipopi is now closer to its formation with the creation of its protem committee ensuring that patients' interest will always be guarded aknowledgement. the authors thank all who had contributed directly or indirectly, especially medical officers, nurses, consultant pediatricians especially dr kamarul azhar, institut of pediatrics hkl, laboratory scientists especially dr shanaz murad of the imr kuala lumpur university of manchester, uk although the concept of grouping mendelian disorders associated with an upregulation of type i interferon (ifn) has not been previously recognised in the medical literature, our past and current work argues that this concept has scientific validity and clinical utility. i will discuss the possibility that such conditions can usefully be considered to represent a novel set of inborn errors of immunity, and that the recognition of diseases as type i interferonopathies will have significance for the development of targeted therapies, as well as informing our understanding of viral and retroelement biology, and the pathogenesis of some forms of autoimmunity. classic kaposi sarcoma (ks) is exceedingly rare in children from the mediterranean basin, despite the high prevalence of hhv- infection in this region. we hypothesized that rare single-gene inborn errors of immunity to hhv- might underlie classic ks in childhood. we report here autosomal recessive ox deficiency in an otherwise healthy adult with childhood-onset classic ks. ox is a costimulatory receptor expressed on activated t cells. its ligand is expressed on various cell types, including endothelial cells. the mutant ox protein was poorly expressed on the cell surface and failed to bind ox ligand, resulting in complete functional ox deficiency. the ox -deficient patient had a low proportion of effector memory cd + t cells in the peripheral blood, consistent with impaired cd + t-cell responses to recall antigens in vitro. the proportion of effector memory cd + t cells was less diminished. the proportion of circulating memory b cells was low, but the antibody response in vivo was intact, including to a vaccine boost. together, these findings suggest that human ox is important for cd + t-cell memory, but redundant for immunity to most common pathogens, with the notable and surprising exception of hhv- . the chronic mucocutaneous candidiasis disease (cmcd) is characterized by persistent or recurrent infection of skin, nails, oral, or genital mucosae with candida albicans. il- -mediated immunity has been concerned in host defense against candida on body surfaces. we have investigated nine patients with chronic mucocutaneous candidiasis disease (cmcd) and signal transducer and activators of transcription (stat ) mutations. the novel c. c > a (n k) and c. a > g (q r) mutations in the coiled-coil domain (ccd) and the c. c > t (t m) mutation in the dna-binding domain (dbd) of stat are gain-of-function (gof) for γ-activated factor (gaf)-dependent cellular responses to stat . low proportion of il- a-and il- -producing t cells, lower levels of intracellular il- a and il- by t cells and impaired candidainduced secretion of il- a and il- by leukocytes from cmc patients compared to that in healthy controls were found. the c. c > t (r w) mutation affecting the ccd and the c. c > t (t m) mutation affecting the dbd of stat and resulted in gain-ofphosphorylation and gof. these mutant alleles enhanced the cellular responses to cytokines via stat signalling pathway. these data provide further insight into the mechanism of host defense against candida. heterozygous gain-of-function stat mutation is known as a major etiology of chronic mucocutaneus candidiasis. gof mutation affecting the stat coiled-coil domen (d g) was initially discovered in -year boy with cmc. gof mutation of dna-binding domen (t m) was found in the second our patient with cmc. both patients have early manifestation of recurrent or persistent infections of the skin, mucous membranes, and nails with candida albicans. they also have skin infections with dermatophytes. patient presented from the first months of age with severe recurrent sinopulmonary infections. recurrent pneumonia and chronic bronchitis complicated by bronchiectasis, which resulted in cor pulmonale and congestive heart failure. patient suffered from recurrent hsv infection, recurrent aphthous stomatitis, has several episodes of bacterial skin infections. he also has chronic bronchitis and several episodes of pneumonia, but does not have bronchiectasis. both boys developed esophageal stricture, patient necessitating nissen fundoplication in the age of years. the patients have mild autoimmune features: uveitis (p ) and alopecia (p ). immunological investigation revealed different impairment of immune system: more severe, similar to combined immunodeficiency in p , which declines with age. the p does not have changes in lymphocyte number and immunoglobulin's, but impaired antibody production to pneumococcal antigens. western blotting performed with nuclear extracts of lymphocytes of both patients showed stronger stat phosphorylation after stimulation with cytokines ifnγ, ifnα, il- . mononuclear blood cells from both patients released much smaller amounts of il- a and il- than candida-exposed cells from healthy control. stat activation triggers transcription of interleukin (il)- which is crucial for mounting protective immune responses against fungi. several mutations affecting the stat /il- pathway have been reported, resulting in selective susceptibility to fungal (candida) infection, a hallmark of chronic mucocutaneous candidiasis (cmc). in patients with autosomal-dominant (ad)-cmc we previously reported defective th responses and identified an underlying gain-of-function (gof) stat mutation leading to hyperphosphorylation of stat . how this affects stat or leads to decreased il- remains to be determined. in patients with ad-cmc, we assessed how gof-stat mutations affect stat activation, dna-binding, gene expression, cytokine production and the effect of epigenetic modification. we show that stimulation of stat in the presence of gof-stat mutations leads to significantly reduced transcription of stat -inducible genes (rorc/il- / il- /il- /c-fos/socs /c-myc). this was not due to impaired stat phosphorylation, altered nuclear translocation nor sequestration of stat into stat /stat heterodimers. dna binding to a stat-consensus binding site construct (hsie) was intact but binding to an endogenous stat dna target was impaired. the reduced stat -dependent gene transcription could be normalized by inhibiting stat activation by fludarabine or enhancing acetylation with histone deacetylase (hdac) inhibitors trichostatin a or itf . silencing hdac , hda and hdac indicated an important role for hdac . impaired stat -dependent gene transcription likely underlies decreased th- cytokine production, susceptibility to fungal infections and other pathology seen in ad-cmc patients and could be a new target for defining novel therapeutic approaches for this potentially lethal disease. autoimmune features have been long thought as association with immunodeficiency disorders, but are now viewed as a crucial component of some diseases attributed to the breakdown of self tolerance or defects of immune regulators. it had been previously established that a single gene defect of the foxp gene (foxp in humans) caused widespread autoimmunity in both humans and mice. the clinical syndromes observed in both scurfy mice and humans suffering from ipex are similar to those observed in experimental models in which treg are selectively depleted. in , three groups demonstrated that these diseases were indeed the result of a regulatory cell deficiency. around one third of the patients with clinical manifestation closely resembling ipex syndrome, foxp is not mutated, these patients are referred to as ipex like. here we present a case; a female patient years with multiple autoimmune manifestations; dm, coeliac disease and ulcerative colitis with marked decrease in the percent of cd + cd + foxp + cells. as she has a siblings suffering from dm; the whole family was investigated. the father and the mother had % cd + cd + foxp + cells. background: hids is an autosomal recessive disease, first recognized as a separated entity at . in patients with hids, the activity of mevalonate kinase is reduced to - % of normal levels. hids is caused by mutations in the mevalonate kinase gene (mvk), located on the long arm of chromosome ( q ). it is manifested by cyclic attacks of fever initiated usually during first year of age. the frequency and severity of attacks tend to decrease later in life. materials and method: a retrospective analysis of medical history , clinical course and laboratory findings of two albanian children with periodic fever , diagnosed with hyper igd syndrome. results: case presentation : an -year-old boy admitted to the hospital because of periodic fever spikes, which occurred every - weeks and lasted - days, presented since the first year of life and coincided with the beginning of immunization. he had a tonsillectomy and adenoidectomy at the age of . the fever attacks were associated with chills, malaise, and abdominal pain without gastrointestinal signs. between attacks the patient was free of symptoms. from his family history, recurrent febrile episodes during childhood were reported to his father. physical examination showed normal findings, except for a cervical lymphadenopathy. laboratory: marked increase of erythrocyte sedimentation rate and crp. wbc-ranged from . to /mm . , high asto. serum igd was repeated several times and was always elevated (mean value: serum igd iu/ml). the mutation v i is found from the genetic examination done for gene mutations in chromosome ( q ). he repeated attacks after initial treatment with corticosteroid ,than is suggested. the second case was a four-year-old girl hospitalized five times because of prolonged fever, and diagnosed as pneumonia, tonsillitis, acute otitis media and sinusitis, treated by antibiotics. her laboratory findings were not remarkable except for increased acute inflammatory responses. serum amyloid a (saa) μg/l ( μg/l) and igd was extremely high . iu/ml. genetic examination for two mutations were negative, but reduced mevalonate kinase activity in white blood cells was demonstrated in more thorough investigations. treatment regime: colchicine conclusions: auto inflammatory syndromes always pose diagnostic and therapeutic challenges to the clinicians. the clinical description of the diversity of periodic fever syndromes is helpful in the assessment and management of these patients. although hids is predominantly identified in populations from northern european areas, it has to be considered in children with periodic fever. anastasiia bondarenko ; liudmyla chernyshova ; iryna sychova shupik national medical academy of postgraduate education, kiev, ukraine. dniepropetrovsk regional children's hospital, dniepropetrovsk, ukraine. background. aspergillus is an actual pathogen in chronic granulomatous disease responsible for about % of all infections. in - % lungs are involved and in % -cns. case. we report a case of combined loci in -years old female patient with ar cgd. the child was born from iii pregnancy, ii delivery on th week of gestation with body mass g. she received bcg vaccination at -th day of birth. at months the local inflammation in site of bcg with regional lymphadenitis developed which was treated with isoniazid for months. then bilateral purulent cervical lymphadenitis developed at , and months treated with wide spectrum antibiotics. culture from pus was negative. pcr for mycobacterium tuberculosis complex was negative. at months systemic infection without loci occurred with fever, lymphadenopathy, hepatosplenomegaly, loss of weight, progressive anemia, inflammatory changes in blood for almost months. bacteriological cultures were negative. treatment with wide spectrum antibiotics was insufficient for months. disseminated bcg infection was suspected and -compound amb treatment was started ex juvantibus with positive effect: the fever has stopped, the sizes of lymph nodes, liver and spleen have decreased, the weight of a body normalized. the child suffered from recurrent pyogenic infections, underwent disseminated salmonellosis. at the age of years blood samples were tested at the laboratory of human genetics of infectious diseases, inserm (paris, france). an absence of p phox protein expression detected by western blot conferring a complete defect in cyba due to compound of geterozigous mutations in q . at years primary tuberculosis complex of right upper lobe (mbt -) was diagnosed. at the age of during the unexplained fever multiple formations were identified in the liver, biopsy showed caseosis suspected the mycobacterial nature of lesions but mbt (-). at the age of years because of shade in the left upper lobe and ineffective standard antibiotic treatment the tuberculosis again was suspected. due to ineffective antimycobacterial treatment for months multi drug resistant tubercullosis was considered. anti-tb drugs ii line was appointed without clinical response. fever persisted. mri of brain revealed mass lesion in the left parietal lobe. because of suspected tumor the brain biopsy was done and the pus was obtained. microbiological studies revealed aspergillus fumigatus. at the same time subcutaneous tumor-like infiltrate х mm appeared on chest in a proection of lung lesions. the pus was obtained during thoracentesis. result of microbiological studies: aspergillus fumigatus. drainage of abscesses and intravenous voriconazolum led to dramatic clinical improvement and normalization of blood parameters. conclusion. features of our case is spread lesions of aspergillosis with relatively slow progression of infection. high incidence of tuberculosis in ukraine leads to a high suspicion regarding this infection. diagnosis of tb is mainly based on instrumental studies. radiological and histological differential diagnosis between tuberculosis and other infections with granulomas in cgd is difficult. high suspicion of tuberculosis led to late diagnosis of aspergillosis. great north children's hospital, newcastle upon tyne hospitals nhs foundation trust, and primary immunodeficiency group, institute of cellular medicine, newcastle university, newcastle upon tyne, uk even following the introduction of biologic disease modifying antirheumatic drugs (dmards), a small number of children suffering from severe, refractory autoimmune (ai), rheumatic and/or autoinflammatory disorders will not get into clinical remission (cr) and will potentially further suffer from multiple side-effects of combined and long-term immunosuppressive and anti-inflammatory therapies, in particular severe infections (marodi l, casanova jl. jaci ; abinun m. ped health ). whilst autologous t cell depleted hsct following the immunosuppressive conditioning regimen achieved complete clinical remission in majority of children with severe juvenile idiopathic arthritis (jia) (de kleer im et al. ann rheum dis ) , infection-related mortality remains significant (abinun m et al. mol immunol ) . therefore, following the success of allogeneic hsct in treating children with immunodysregulation, polyendocrinopathy, enteropathy, x-linked (ipex) syndrome (nademi z et al. bmt ) , we treated further children with different severe ai (alps, autoimmune lymphoproliferative syndrome (n = ); complex ai disorder (n = )), rheumatological (jsle, juvenile systemic lupus erythematosus (n = ); jia (n = )) and autoinflammatory disorders (mkd, mevalonic kinase deficiency/ traps, tnf-receptor associated periodic fever syndrome (n = ); eoc, early onset colitis (n = )). overall, of the children are alive (follow up - years), in complete and (complex ai disorder) in partial cr, original disease (alps) relapsed in , and children died ( each with alps and eoc). children had significant, but transient acute (grade - ) and chronic (limited) graft vs. host disease (gvhd), experienced multiple virus reactivation(s), and remarkably we saw significant secondary ai diseases post-hsct (transient nephritic syndrome (n = ) and cytopaenias (n = ); psoriasis, n = ; and thyroid disorders (grave's thyrotoxicosis and hypothyroidism), n = ). our data add to the positive experience and evidence acquired over the last - years (daikeler t et al. bmt ; snowden ja et al. bjh ) to propose the allogeneic hsct as a viable treatment option for the small group of children suffering from severe autoimmune disorders. the wiskott-aldrich syndrome (was) is an x-linked primary immune deficiency disorder characterized by thrombocytopenia, microthrombocytopenia, recurrent, mostly respiratory tract infections, eczema and increased risk of autoimmune disorders and malignancies. was is caused by mutations in the wasp gene which encodes wasp, a -amino acid protein. wasp plays a critical role in actin cytoskeleton organization, signalling and different functions of immune cells. we present here the results of genetic analysis of patients with was from eleven eastern and central european (ece) countries, turkey, iran and azerbaijan. clinical and laboratory information of affected males and carrier females from was families were collected. the wasp gene was sequenced from genomic dna of patients with was, as well as their family members to identify carriers. in this large cohort, we identified unique mutations including novel sequence variants. the mutations were scattered throughout the wasp gene and included single base pair changes ( missense and nonsense mutations), small insertions, deletions, and splice site defects. this study was financially supported by the tÜbİtak project s and bap project tda- - . background: chronic granulomatous disease (cgd) is a rare primary immunodeficiency disorder of phagocytes. resulting in impaired killing of bacteria and fungi. a mutation in one of the four genes encoding the components p phox , p phox , p phox and p phox of the leukocyte nadph oxidase leads to autosomal recessive (ar)-cgd. a mutation in the cybb gene encoding gp phox leads to x-linked recessive cgd. methods: we report here the results of genetically and functionally characterized patients with cgd from turkish families in turkey. results: most of the families ( %) have an ar genotype (% p phox , % p phox and % p phox ) and % have an x-linked genotype. patients with a , a and x phenotypes with oxidase null activity (dhr stimulation index of ≤ . ) were found in patients. however, in p phox deficient cases and in other ar cases with high residual oxidase activity (dhr stimulation index ≥ ) were found in patients. conclusions: residual oxidase activity is similarly lack in the x , a and a phenotype except ar cases with missense mutation. in our cohort, the percentage of ar-cgd was different from european and usa registries (in comparison with % , % and % of p phox , p phox and p phox deficient ar-cgd cases, respectively) with the higher percentage of patients with p phox ( %) and p phox -deficent ( %) phenotypes, and the lower percentage of patients with p phox -deficient ( %) phenotype. the basic difference in our results from those reported is the higher percentage of patients with ar-cgd (% ), which was lower than in the european and usa registries, probably because of the higher prevalence of consanguineous marriage in turkey. introduction: schnitzler syndrome is an autoinflammatory disorder of unknown etiology. at least some of its clinical presentation is mediated through an activation of inflammasome and release of il- , as was repeatedly demonstrated by a prominent therapeutic effect of il- blockade. recent reports bring an evidence of an important role of mitochondria in inflammasome activation and in a pathogenesis of autoinflammatory diseases. we have therefore investigated mitochondrial function and structure in patients with schnitzler syndrome. materials and methods: activity and amount of oxidative phosphorylation complexes (oxphos) were analysed by spectrophotometry, histochemistry and imunoelectrophoretic methods in fibroblast cell lines derived from skin biopsies of three adult male patients with schnitzler syndrome. ultrastructure of mitochondria, mitochondrial network and reactive oxygen species (ros) were analysed by fluorescent and electron microscopy. results: the activities and amount of oxphos complexes i, iii and iv were decreased in patients with schnitzler syndrome. interindividual differences in the degree of impairment (from severe to moderate) in analyzed mitochondrial parameters were found. content of ros, previously suggested as main inducers of inflammasome, were not significantly increased in cells with schnitzler syndrome. we, however, did find consistent and prominent changes in mitochondrial structure of all three patients. disturbed mitochondrial network and mainly abnormal, partially swelling mitochondria with unusual and sparse cristae were characteristic for all patients. we did further notice marked accumulation of neutral lipids in all tested fibroblasts. conclusion: severe structural damage of mitochondria associated with milder functional changes represented a consistent feature found in all tested schnitzler syndrome patients. along with progress in basic and clinical immunology worldwide, the knowledge and activities in the field of primary immunodeficiencies (pids) have developed during last two decades. in , a group of junior doctors and students joined seniors in this filed to establish iranian primary immunodeficiency registry (ipidr). several national and international research projects have been done so far which led to lots of publications, while improving the diagnosis of patients with pids, construction of iranian primary immunodeficiency association (ipia), and establishment of research center for immunodeficiencies were other activities which lead to better management of the patients. organizing annual meeting on clinical immunology and immunodeficiencies, celebrating pi week annually and active participation in the international congresses were all helped in to increase knowledge of physicians in the country. the overall activities in the field of pids led to an increased trend in recognition of more patients in the recent years, which was associated with decreased delay in diagnosis. based on recent report of the registry, published recently in the j clin immunol, more than new patients with pid, in addition to previously reported patients, were presented. predominantly antibody deficiencies were the most common form of disease, followed by combined immunodeficiencies, congenital defects of phagocytes, and other well-defined syndromes with immunodeficiency. the rapid progress in identification and registration of the patients with pids is important not only as of epidemiological aspect, but also as of timely diagnosis and appropriate treatment of the patients. the j project physician education and clinical research collaboration program was launched in in eastern and central europe (ece). in less than years, it has achieved remarkable success. this project aims to increase knowledge in the field of primary immunodeficiency disorders (pid), and to improve the diagnosis and treatment of patients worldwide, particularly in countries with limited economic resources, which currently report fewer such patients than expected. in most ece countries, gene sequencing, which can provide a definitive diagnosis of pid, still remains unavailable. by contrast, such technology is used elsewhere to detect the more than pid-causing genes that have been discovered in the last three decades. thus, pid awareness programs like the j project remain critically important, to improve diagnostic facilities and treatment and to promote clinical research collaboration. this paper highlights the achievements of the j project and the spread of its concepts and spirit to the countries of western asia. primary immunodeficiencis (pid ) are rare genetically determined diseases , occurring with an incidence of per inhabitants. it is heterogeneous group of disorders, from quite commonly found and usually asymptomatic iga deficiency ( in ), to a very rare diseases such as chediak -higashi ( in inhabitants). in , within the framework of a government research project no. pbz-kbn- /p / -" development , improvement and implementation of highly specialized diagnostic procedures for immune-mediated diseases", a network of cooperating national centers for diagnosis and treatment of pid, named polish working group on primary immunodeficiencies (pgr pno) was founded. as a result of joint efforts of the group as well as an implementation of three eu grants [euro-pid -nas qlrt - - ( - , euro-policy -pid sp -ct- - , euro-gene -scan ( , )] the number of centers actively working in the diagnosis and treatment of primary immunodeficiencies increased. up todate pgr pno includes pediatric centers , and since - centers for adults. development and dissemination of new diagnostic and therapeutic standards contributed significantly to the increase in detection pid. with early diagnosis of the disease -the implementation of appropriate treatment, including gamma globulin replacement therapy together with quality of life has improved. in spite of all efforts recognition of pid in poland is very rare and currently is . to , what is almost times smaller than in europe (www.esid.org). at the moment, a nationwide registry of children and adults with pid consists of patients. in september pgr -pno summarized in the annual report the current status of the substitution therapy with intravenous and subcutaneous immunoglobulin therapy in children and adults with pid in poland. on the basis of available information, half of all patients ( children and adults) were diagnosed to have antibody deficiency. these data are similar to the register of a european database esid , where the percentage of patients with pid with a predominance of antibody deficiency is more than % (www.esid.org) development and dissemination of new diagnostic and therapeutic standards as well as a national cooperation contribute significantly to the increased detection of pid. early diagnosis of the disease is followed by earlier implementation of appropriate treatment, including gammaglobulin replacement therapy together with improvement of quality of life. mutations of was were identified in was boys and in heterozygote mothers. frequently genetic damages occur in , , , exones and , intrones: deletions ( ), splice-site mutation ( ), missens ( ), insertions ( ). deletions and insertions lead to stop-codon in cases. nbs patients were homozygous for del mutation and oneheterozygote for del had delt x-cgd: deletions ( ) and nonsens ( ) mutations in different exons of cybb were observed most often. in families was performed prenatal diagnosis: x-scid- , higm - , xla- , was- , nbs- , a-t- , cgd- , xlp- , dnalig - . healthy children - . recurrent severe complicated infections developed in % of pid patients. antibody deficiencies: bacterial infections - %, enteroviral - %, tuberculosis cases, atypical mycobacteriosis - case. combined pid: bacterial infections - %, fungal - %, viral - %, opportunistic (pneumocystis jiroveci) - %, mycobacterial - % ( -complication of bcg vaccination, -tuberculosis or atypical mycobacteriosis). cgd: bacterial - % (staph.aureus, e.coli, b.cepatia, salmonella spp., klebsiella spp.), mycobacterial - % ( % bcg origin, % -tuberculosis), aspergilosis - % immune disregulation syndromes (xlp [ ] and alps [ ]): bacterial infections - %, viral - % (ebv). autoimmune violations were observed in % of all pid cases: % of combined pid, % of antibody deficiencies, % of other well defined syndromes, % of autoimmune syndromes. cytopenias developed in %, vasculitisin %, ulcer colitisin %, arthritisin %. oncology diseases developed in % of patients: mainly in nbs, a-t, was and cvid: t-and b-leukemia's, lymphomas, solid cancer. the study of primary immunodeficiency is a unique model for studying the molecular basis of immunity. question about intravital pid verification is still relevant. a regional center of clinical immunology was established in at the regional children's clinical hospital № , yekaterinburg. the regional clinical hospital № joined the center in . institute of immunology and physiology, ural branch of the russian academy of sciences carries scientific management of the center. the centre works closely with foreign counterparts in the international project j project and it has been one of the centers of jmf since . over years we formed a regional register of patients with primary immunodeficiency, comprising patients: children and adults. analysis of the regional register allows to investigate the causes of deaths in patients with pid. infectious syndrome mortality -sepsis, generalized mycobacterial infection - patients, proliferative process - patients, dominate the mortality structure. creation of specialized immunological centers permit to raise the educational level of the medical staff, precisely identify nosological forms of pid among different groups of patients, to prevent the birth of children with pid, increase the length and quality of life such patients and take part in the collaboration with international experience in the pid. introduction: the aim of this retrospective study is to determine the frequency, and demographic, clinical and laboratory features of adult cvid patients referred to our clinic. materials and methods: we retrospectively evaluated adult patients ( female (% , ), male (% , ); aged to years: median years) who were diagnosed as cvid according to esid and pagid criteria during a year period (january -march ). results: the median current age of patients was , and the median cvid diagnosis age was , years. the diagnostic delay in patients with cvid was , years (median). cvid patients presented lower levels of igm ( patients, , %), iga ( patients, , %) and igg ( patients, , %). according to lymphocyte lmunophenotypes of cvid patients, cd ( patients, , %), cd ( patients, %) and cd /cd ( patients, %) values were observed the most lower ones. discussion: we found that both of the patients with bronchiectasis showed lower levels of immünoglobulins and lower imunophenotypes of b cell than the others that do not have bronchiectasis. in our patients cd , cd and cd /cd values have got enough priority to be mentioned about an immun deficiency. in conclusion, despite recent improvements in diagnostic tools, the diagnosis of mild or moderate cvid is often delayed. however, it seems that the diagnosis of cvid is delayed especially in adulthood on account of the fact that the lack of awareness of these illnesses among the medical professionals all over the world. primary immunodeficiency disease is important in turkey because of the high rate of consanguineous marriage. the lack of awereness about immunodeficiency can cause late-diagnosis and severe complications. the objective of this study was to assess pid awereness before and after clinical immunogy education among medical students. one hundred and thirty-two questionnaires with items ( ) were distributed to seventh somestre medical students and ( %) completed questionnaires were evaluated before (first) and after (second) their education about clinical immunology courses for hours. questionnaire scores (qs) were detected as total correct answers. the mean of the first qs was . ± . and second qs was ± . (p < . ). there was no statistically difference in gender ( m and f). of questions, there were related with pid directly. the correct responses rate less than % before education were of questions. all participants corrected their responses after education. the best improvement was detected in the responses of the clinical signs related with pid. it was remarkable that the participants have known the family history related with pid excellent before education. the majority of the participants ( %) believed that a lymphocyte count of /mm was related to immunodeficiency. nbt and ch test were not found to be related with pid before education. it is also important to increase the awareness of pid among the physicians during their education in medical school and more comprehensive education in pid appears to be useful for medical students. chronic granulomatous disease (cgd) is a rare primary immunodeficiency with mutations in nadph oxidase enzyme complex which causes failure of phagocytic cells to produce superoxide and subsequent intracellular killing of microorganisms. we retrospectively analysed medical records of patients diagnosed with cgd in the last years from immunological diagnostic centres from central and eastern european countries (estonia, poland, belarus, ukraine, czech republic, slovakia, hungary, serbia and slovenia) and russia. genetic sequencing from patients' dna was performed in genetic centres in ljubljana, belarus and netherlands for mutations in known genes involved in cgd pathogenesis: cybb, cyba, ncf , ncf . we included patients with cgd in our cohort, were female. the mean age at presentation of the disease was months and at diagnosis , years. lymphadenitis ( %), dermatitis ( %), enteritis ( %), pulmonary infections ( %), liver abscesses ( %) and septicaemia ( %) were the most common clinical presentation. complications of bcg vaccination ( %) were the most common presenting infection. in total , years of followup in our cohort, the patients suffered different severe infectious episodes ( . per year). respiratory ( %), lymph node ( %) and gastrointestinal tract ( %) infections represented the most prevalent severe infections. we identified different mutations out of genes tested. in patients we identified different mutations in cybb gene, unrelated patients had the same mutation in cyba gene and in patients had typical deletion in ncf gene. in our cohort we observed high incidence of bcg infections as a presenting symptom. apart from high bcg infections patients included in our study had similar frequencies of infections and infecting microorganisms as patients described in previous series. objectives: the aim of this study is to determine the carrier rate in healthy controls from central european and balkan region. methods: we screened more than healthy subjects from countries in the region. exon and was pcr amplified and subsequently sequenced with abi prism genetic analyzer. results: heterozygous mutations were found in % of apparently healthy hungarians, % of slovenians, % of bosnians, % of serbians and in % of apparently healthy macedonians. mutations found in hungarian population were as follows: v a ( ), k r ( ). mutations found in slovenian population were: v a ( ), k r ( ) and e q ( ). mutations found in bosnian population were: v a ( ), k r ( ) and f c ( ). mutations found in serbian population were: e q ( ), k r ( ). mutations found in macedonian population were as follows: e q ( ), k r ( ) and m v ( ). conclusion: we found higher than expected carrier rate in screened populations, from % to %. it is interesting to note that more than half ( %) of detected carriers in all analyzed populations has k r mutation. progress in the field of primary immunodeficiencies (pids) is reflected in national pid registries. data from slovenian pid registry were analyzed. patients' data were collected retrospectively before and prospectively afterward. patients were classified according to international classification and updated regularly. data of patients with different pids were analyzed. interestingly, complement deficiencies are the most common, accounting for % of all entries. second most common are antibody deficiencies with %, followed by well-defined syndromes ( %), immune dysregulation ( %), neutrophil defects ( %), combined deficiencies ( %), autoinflammatory disorders ( %) and defects of innate immunity ( %). prevalence of diagnosed pids in slovenia has changed in the last years; less complement deficiencies and more antibody deficiencies were diagnosed in comparison to previous decades. the number of new pid cases has been gradually increasing, a more prominent increase has been noted in the last years. the prevalence increased most for combined immunodeficiencies, cvid and autoinflammatory disorders. the spectrum of pid entities has also widened in the last decade. three patients with scid were diagnosed and successfully treated in the last three years (incidence - : . births). high prevalence of complement deficiencies reflects early implementation of good complement diagnostic facilities and awareness among infectologists. this group of patients was prospectively collected from . combined immunodeficiencies, cvid and autoinflammatory syndromes were all probably underdiagnosed before due to lack of awareness among physicians. distribution of pid groups is more consistent with esid registry in the last five years. identification and successful treatment of scid patients in the last years is an important quality marker. bulgarian association for clinical immunology was set up in aiming to get together all specialists working in the field of clinical immunology. one of the important objectives of the association was to raise the public awareness and attract attention of specialists, national health system, government and other related societies in order to improve the diagnosis and access to treatment for children and adults with pid. efforts of immunologists led to the following results: . consensus on the diagnosis and treatment of the basic pid groups was created by the pid national working group that was established in , and specific guidelines were disseminated as well. register for pid patients has been set up in bulgaria that allowed the collection of data on the incidence and prevalence of pid and the negative effect of these conditions on the population. . educational program to improve the qualification of the physicians and provide available resources to general practitioners and raise the public awareness were introduced. collaboration with patient's organizations was developed. . treatment of pid patients has been fully covered by the public health system since march . all these steps made it possible to advance the diagnosis and management of pid in our country. pediatric pid patients care -single center experience g. petrova; p. perenovska; s. mihailova; e. naumova umhat "alexandrovska", sofia, bulgaria j-project in bulgaria started in and up to now we have elaborated programme with diagnostic criteria, well equipped laboratory, established some mutual connections with foreign colleagues, held regional meetings, conferences; created clinical standards for treatment and ensured an immunoglobulin treatment and replacement therapy. here are examples of some of the problems we face: . seven-years old boy with hypogamaglobulinaemia (normal number b-ly with abnormal function). ivig had some initial effect, but lately we noted very fast deceleration in the overall health status with possible need of lung transplantation. the case is posing a question what more could we do, could we have prevented this rapid worsening. . ten-month old girl with scid with severe bcg infection after first vaccination, referred relatively late to our center, but successfully transplanted. the case is posing a question about timing of bcg vaccination and of referral to specialized center. . nine-years old girl with unidentified immune deficiency, normal immunological follow up but clinical course as an immune deficiency with very favorable effect of ivig according the parents. the case is posing the question should we stop or should we continue ivig, despite failing to find immunological defect, based on the good clinical response. unfortunately pids are not very well recognized and sometimes the patients are referred late. sometimes poverty and lack of knowledge of patients leads to miscalculation and neglecting of their conditions by themselves, or refusal for specific tests for clarifying the diagnosis. background: although rare, primary immune deficiencies (pid) are manifested with high rate infections as well as with autoimmune and malignant disorders that are treated hardly and inefficiently. pid are not only immunological problem; they require close collaboration between immunologists, pediatricians, ent, lung and gut specialists, dermatologists, hematologists, oncologists, patients and administration. the aim of this study was to summarize the activity on registration and replacement therapy of pid patients in plovdiv region at the university hospital "st. george"-plovdiv for year ( . - . ). methodology: children with pid of humoral immunity hospitalized at the clinic of pediatrics, and adults with hereditary angioedema (hae) were included in the study using immunological and other lab tests, clinical follow up and treatment: iv and sc ig for children with pid and c esterase inhibitor (ruconest, berinert) for hae patients. results: three national workshops and a national conference on pid were hosted and organized in plovdiv since . well established university hospital immunological laboratory, detecting serum immunogloblins, blood lymphocyte populations and subpopulations and complement proteins; clinic of pediatric and genetic diseases and an information center for rare diseases and orphan drugs function in plovdiv. an expert center for diagnosis and treatment of pid was created at the university hospital. it is a team of two competent pediatricians, an immunologist and an allergist. the targets are hospitalized pid children, outpatient pid children and hae adults. the center introduced regular replacement therapy with iv and sc iv and c inhibitor, reimbursed by the national insurance. together with icrdod the experts provide education for patients and parents how to perform sc ig application as well as consultations of patients and relatives about pid.since march indicated reimbursed replacement therapy with iv ig -octagam, started regularly in hospitalized pid children with bruton hypogammaglobulinemia, cvid, omenn syndrome or igg id. these patients, aged form to years, had to hospitalizations for one year. four outpatient children with omenn syndrome or igg subclass deficiency were subjected to sc ig -gammanorm, and hae type outpatients had good response for replacement c inhibitor therapy as follows: conestat alfa (ruconest)in hae adults ( iu/ml weekly), and berinert ( u/kg b.w. weekley)in hae adult patients. conclusions: the expert pid center in plovdiv university hospital provides competent diagnosis, therapy, education and consultations for pediatric and adult pid patients from plovdiv region. the recent introduction of reimbursed replacement therapy for pid patients (hospitalized or outpatients) allows regular immunological and clinical follow up of the diseases. background: intravenous immunoglobulins (ivigs) are scarce biological products used in a broad variety of disorders. tolerance to infusions is usually good but adverse events, including some serious ones, have been reported. methodology: a cohort study aimed for detection of adverse events that occur during and following intravenous immunoglobulin (ivig) infusions at cairo university children hospitals [patients were recruited at neonatal intensive care units (nicu), pediatric intensive care units (picu), general and specialized inpatient wards ] over a time period of six months, from april through september, . the study included transfusions for different disease conditions in patients.three maltose-stabilized intravenous immunoglobulin products were administered to patients. assessments were done before, during and after the infusions. results: there were symptoms and laboratory changes of adverse events during ivig transfusions, with some patients experiencing more than one adverse reaction. adverse events were noted to occur most frequently within to h from onset of ivig infusion (n = , . %). first hour after infusion onset was the most common timing for symptoms of adverse reactions (n = , . %). patient characteristics of those with adverse reactions: adverse reactions occurred in . % of the infusions (n = ) with the majority belonging to the - years old age group (n = , . %), with variable diagnostic categories. ten patients observed during infusions ( . %) had one or more risk factors for complications, while patients observed during infusions ( . %) had no risk factors. the commonest risk factor was administration of nephrotoxic drugs (n = , . %), followed by presence of a suspected autoimmune disorder (n = , . %) and preexisting renal insufficiency (n = , . %). using regression analysis, the predicting variables for each complication were noted .for example ,fever and chills were related to infusion rate and dose whereas the predicting variables for pallor were infusion rate and presence of existing risk factors. conclusions: clinicians should be aware of the high need for special monitoring while infusing ivig to patients with primary immunodeficiency disorders, autoimmune hematological disorders and sepsis. certain diagnosis of a primary immunodeficiency disorders (pid) is most confirmedly performed by investigation of a gene defect, allowing genetic counseling and screening. molecular diagnosis helps both parents and index pid patient by carrier detection and pre-implantation testing for selecting appropriate reproductive decisions. furthermore, for confirmation of diagnosis and establishment of the inheritance pattern genetic analysis is necessary. this survey in all pid cohorts should be considered for long-term planning such as bone marrow transplantation of a pid infant at birth. the result of this testing also is important for screening of newborns and for those in specific family or ethnic groups. the prevalence of pids has been estimated to be more than / worldwide. based on the total population of iran reported in ( , , ), the expected prevalence of pids in iran would be more than , individuals. however, because of the high rate of consanguineous marriages in iran and an increased risk for development of disorders with an autosomal recessive pattern of inheritance, this prediction is likely to be an underestimation. to date, clinically diagnosed patients of pids have been reported in iran, and a definite diagnosis, defined by mutation analysis, was made in individuals. as a result, . % of the expected pid patients have been identified, and among these, . % have been diagnosed at a molecular level. the proportion of genetically definite diagnosis varied between . and % in the different disease categories. this wide spectrum might be due to unknown underlying genetic defects or modifying genes, especially in patients with predominantly antibody deficiency. on the other hand, the latter patients also had the lowest percentage of clinically diagnosed cases. croatia is a small country with inhabitants . according to expected prevalence of pids we expected approximately four hundred patients with pid. for the past few years university hospital center zagreb is the reporting center for esid registry. it is also the national center for diagnosis and treatment of pids, including haematopoietic stem cell transplantation. current pid database is running manually, with the exception of patients reported to esid registry. most of them are of pediatric age, reffered to the hospital from all over the country. the pids patients are classified according to international classification ( iuis-international union of immunological societies ). there are pids patients included in the database at the moment. the majority of them have antibody deficiency. combined immunodeficiency and well defined syndromes appear in equal distribution. other types of pids are reported in small numbers. although no consanguinity was reported, we noticed the geografic distribution of severe combined immunodeficiency patients (scid) mostly in regions, istra and podravina. it can be explained with genetic isolation. the establishment of national online pid registry is in process. the aim is to improve the diagnosis od pid specially in adult patients, who are not included in present database, with exception of the patients diagnosed in childhood. primary immunodeficiency disorders are underdiagnosed in croatia, specially in adults. establishing national pid registry will improve the physicians awareness of pids, which is particularly important for adult patients. we expected the number of diagnosed pid patients will rise. this will give the opportunity to make progress in diagnosis and treatment, and the opportunity for further epidemiological and clinical studies. another patients have well defined immunodeficiency syndromes from which: are with di george anomaly; with wiskott-aldrich syndrome; with ataxia-teleangiectasia; with hyper ige syndrome; with schimke syndrome and are with nijmegen breakage syndrome. in early nineties, two ( ) of our patients had chronic mucocutaneus candidiasis. patients are registered as x-linked scid and with xlinked lymphoproliferative syndrome (xlp). patient has chronic granulomatous disease; have severe congenital neutropenia and have hereditary angioedema. patients are with whim syndrome. patients are with anti-inflammatory disorders: has hyper ig d syndrome (hids) and have familial mediterranean fever. the j-project realization in the republic of kazakhstan allows to update the pid problem, to raise the availability of early diagnosis of pid, to improve the life quality of patients with pid by providing substitution therapy and as a result, the infant mortality and disability rate has been reduced. common variable immunodeficiency (cvid) is the most common primary immunodeficiency (pid) characterised by impaired immunglobulin production and immune dysregulation. chronic and recurrent infections and its results are typical manifestation of this disease. in addition there is a higher risk of autoimmune disorders, lymphoproliferative or granulomatous diseases and malignancies. successful management of cvid patients is based on prevention and consistent therapy of infections with sufficient immunoglobulin replacement and/or antibiotics, prevention and active screening of cvid related complications. in our study we analysed data of patients gained from medical records. these data were also input into czech pid registry and pid registry organized by esid (european organisation for immunodeficiency). we aimed at the period before diagnosis-onset of the symptoms and their characters and the course of the disease-effect of therapy, occurence of the related complications. finally, we compared our data with similar performed studies. chronic and recurrent upper and lower respiratory infections were the most frequent first manifestation of our cvid patients, but developed chronic lung disease or autoimmune disorder as well. in all patients the intravenous or subcutaneous imunoglobulin replacement therapy, eventually combined therapy with antibiotic prophylaxis, was initiated. beside chronic lung disease the most common complications were autoimmunity disorders, especially autoimmune thyroiditis, evans syndrome, trombocytopenia (itp), autoimmune hemolytic anemia (aiha). on the contrary we revealed patients with insuline dependent (type ) diabetes mellitus and cvid. only few case reports have been published with such association. successful management of cvid patients is based on a prevention and a consistent treatment of infections with sufficient immunoglobulin replcement and/or antibiotic therapy, a prevention and an active screening of cvid related complications. such approach can significantly improve the prognosis of cvid patients and the quality of their life. laura zilinskaite ; ieva bajoriuniene , ; raimundas sakalauskas ; brigita sitkauskiene , department of pulmonology and immunology, lithuanian university of health sciences, kaunas, lithuania. background. primary immunodeficiency (pid) is considered to be a rare disease. despite that it is thought that six million people may be living with a pid worldwide. in the hospital of lithuanian university of health sciences (hluhs) patients with suspected immune disorders have been diagnosed and treated since . we aimed to review the structure of pid diagnosed and treated in hluhs during the last five years. methods. data about patients with pid consulted in the hluhs was collected from the department of medical statistics. case histories of these patients were revised and patients' data was collected: onset of symptoms, type and duration of disorder, type of treatment. all patients with pid were divided into several groups according to the classification of international union of immunological societies primary immunodeficiency diseases classification committee ( ). results. there were patients with pid diagnosed in the centre. antibody deficiency was diagnosed for patients: -bruton's disease, common variable immunodeficiency (cvid) and selective immunoglobulin (ig) a deficiency. complement deficiencies were diagnosed for patients: -c esterase inhibitor deficiency and -c deficiency. another well-defined syndrome with immunodeficiency was found in six patients. the most prevalent symptom in patients with predominant igg deficiency was recurrent pneumonias which occurred at the age . ± . yrs. the mean time between the onset of symptoms and confirmation of the diagnosis was . ± . yrs. thirteen patients are on the replacement therapy with intravenous immunoglobulin. these patients had - infections/year before the treatment initiation and only - infections/year during the treatment. •pid center has successful sideproject as regional charitable public organization of invalids "society of patients with primary immunodeficiency diseases in st. petersburg" solovushka (nightingale) "". web site for patients (www.opidspb.ru) was opened due to mutual efforts of pid center staff and patients. pid center laboratory is based on spb pasteur institute central clinical diagnostics laboratory and laboratory of molecular immunology and seroepidemiology. main groups of tests perform for pid patients are: general clinical assays; flow cytometry ( -color assay on facs canto ii); humoral factors assays (ig levels, igg subclasses, post-vaccination igg levels, etc.); burst-test on flow cytometer; genetic analysis of btk, rag , rag ,was, cybb genes. despite of relatively short story of spb pid center it has a variety of completely diagnosted and successfully cured cases of pid including agammaglobulinemia with b-cell in identical siblings, wiskott-aldrich syndrome, chronic granulomatous disease (cgd), etc. introduction: the primary immunodeficiency diseases are a group of disorders caused by basic defects in immune function that are intrinsic to, or inherent in, the cells and proteins of the immune system. there are more than primary immunodeficiency diseases.. laboratory studies are necessary to determine the presence of a primary immunodeficiency diseases. the standard screening tests for antibody deficiency starts with measurement of immunoglobulin levels in the blood serum. these consist of igg, iga and igm levels. the results must be compared to agematched controls. additional studies used to evaluate patients with antibody deficiencies include measuring the different types of lymphocytes in the blood by marking those cells with molecules that can identify the different types. a commonly used test is called flow cytometry that can identify b-cells and t cells present in the circulation. methods: in in our laboratory of immunology is created the sector of examination for the pid and we measure the immunoglobulin levels with a beckman coulter immage immunochemistry system fully automated rate turbidometry and rate nephelometry method. we have determine the aged-matched levels of immunoglobulins in our laboratory. we have install also a new flow cytometer of beckman coulter company and we can determine the b cells by cd marker and t cell with cd , cd and cd marker. this examinations has been of great help in diagnosis of primary immunodeficiencies. results: in years - from the examination of children aged from - years old reported in our laboratory for immunological examination from the pediatric department of uhc mother teresa in tirana we have selected cases with disorders regarding the primary immune deficiencies. we have cases ( cases reported in - and new cases ) with nul b cell in cytoflorometry (b cd cell = %). the level of immunoglobulins was indetectable for igg , iga and igm in the moment of diagnosis. they were boys and the age at diagnosis was and years and actually they are and years treated with ivig. we have classified them as bruton (xla). we have case with low cd b-cell in circulation but only in of them we have done the immunoglobulin level. the low level of cd b cell is accompanied with different kind of hypoglobulinemies: common variable immunodeficiency cvid, with isolated iga deficiency, with igg deficiency and with both igg + igm deficiency. the immunoglobulins disorders : we have classified them according the antibody deficiencies (tab ) and we noted that the most frequent one is the deficiency of iga ( / or . % -from which iga isolated, accompanied with low igm and with low igg ) with average age at diagnosis . years old. in children in the first years of live aged from . to years old we found case with transient hypogammaglobulinemia of infancy. according this survey we can report our cases of primary immunodefiecies in uhc mother teresa of tirana with different classification conclusion: the finding are to be completed with other cases in albania and it is necessary to do the national register for pid in order to estimate exactly the prevalence of this disorders in our country. nyíregyháza-debrecen, hungary the stat mutation was confirmed in as the cause of autosomal dominant hyper-ige syndrome (ad-hies). the disease, which also mentioned in the literature as job's syndrome, is a rare primary immunodeficiency. this disease can be characterized by the following classic triad: recurrent purulent skin infections, cold abscessus which are formed in the ground of chronic ekcematoid dermatitis, pneumatocele, formation causing pneumonia and extremely high ige level. dental training interdependency as well as bone and connective tissue disorders frequently occur in the nonimmunological symptoms as multi-systemic disease. the stat protein has an important role in the area of wound healing, immunity, tumor and neovascularization. we would like to show this in case of -years old kitti whom the perinatal medical history was eventless. there is a frequent hospitalization in kitti's case history since her infancy. due to the age of three months because of serious exsiccotoxicosis, months old bilateral bronchopneumonia and pleurisy required icu care. bronchoscopy was made because of recurrent pneumonia, which excluded the bronchial malformation. lately rather otitis, mastoiditis and airway obstructive symptoms dominated the clinical picture. from serum immunoglobulins-igg is very low, whereas high levels of igewas indicated. on this basis, the diagnosis of job's syndrome was up, which is a negative stat mutations as the molecular genetic test performed demonstrated. the disease has a great clinical importance, since the risk of emergence of serious and often life-threatining complications are high. because of the prevention of disseminated infections, the early detection and the appropriate treatment are essential. in default of causal therapy, the treatment primarily concern to prevention of infections, or their aggressive antibiotic therapy. calcium and vitamin d and as well as histamine on the case of itchy skin symptoms are reccurrended to use. laboratory of molecular immunogenetics, human genetics institute, cnrs and university montpellier , montpellier, france. we performed clinical, immunological and genetic studies of hyper-ige syndrome (hies) patients from hungarian, lebanese, one russian, one polish, and one swedish families with autosomal dominant (ad) or sporadic forms of the disease to reveal cross-ethnicity of recurrent and novel mutations in the signal transducer and activator of transcription- gene (stat ). four patients from hungarian families, and one russian, and one swedish patient carried the heterozygous r w germline mutation at the dna-binding site of stat . the recurrent v m mutation affecting the src homology (sh ) domain was detected in one lebanese and one polish family, and the v del deletion located in the dna-binding domain was unveiled in another lebanese family. a novel h y mutation affecting the dna-binding site of stat in three hungarian patients from a gypsy family was also found. the segregation of this mutation with hies, restriction fragment length polymorphism analysis of stat from patients and controls and the negligible production upon il- stimulation of monocyte chemotactic protein- by the patient's blood mononuclear cells suggested that the h y mutation was disease-causing. these data suggest, that dominant negative mutations of the dna-binding and sh domains of stat cause ad and sporadic cases of hies in different ethnic groups with r w as the predominant mutation found in of the families. functional and genetic data support that the novel h y mutation may result in the loss of function of stat and leads to the hies phenotype. published in molecular immunology. : - . males with an expressed mutation in the sap (signaling lymphocyte activating molecule [slam]-associed protein) gene have an x-linked syndrome characterized by an increased vulnerability to infection with epstein-barr virus (ebv). we evaluated two related male patients with fatal infectious mononucleosis (fim) and mutation in the sap gene. sequence analysis revealed hemizygous g to a transition at nucleotide position in exon in one of the patients, and heterozygosity for this mutation in the genomic dna from his mother and maternal grandmother. this mutation resulted in asparagine instead of glycine in the sequence of the sap protein at amino acid position . to analyse the effect of this missense mutation on protein function cdna was generated by site-directed mutagenesis and cloned in pcmv-flag vector. we found that the mutant sap (sap/g d) protein was defective in protein folding as manifested by the reduced half-life compared to that of wild type sap. furthermore, the sap/g d protein was defective in binding to its philological ligands slam and b . these results suggest that defects in protein folding and ligand binding collectively contribute to the loss of function of the sap protein in patients carrying g d mutation. dedicator of cytokinesis (dock ) deficiency is an innate error of adaptive immunity characterized by recurrent viral, bacterial and fungal infections, very high serum ige concentration and a progressive deterioration of t-and b cell-mediated immunity. traditional sanger sequencing may fail to identify mutations in dock , due to overlapping large deletions in heterozygous patients. we studied the genetic and immunological features of two sisters ( and years of age) born to healthy hungarian parents. mutational analysis of genomic dna and cdna from the patients and parents by a combination of pcr and bidirectional targeted sequencing failed to identify the mutation. however, a multiple ligation-dependent probe amplification (mlpa) assay revealed two previously unknown large deletions, del - exons and del - exons, of dock in both patients. the children's mother was heterozygous for the del - exons mutation, whereas the father carried the del - exons deletion. immunoblot analysis showed an absence of dock protein from the peripheral blood lymphocytes of both patients. these data suggest that the new compound heterozygous del - exons and del - exons mutations result in a loss of dock protein function and a typical dock deficiency phenotype. our findings suggest that traditional sequencing technology may give misleading results in such cases and that mlpa may be indispensible for the definition of the large deletions frequently observed in patients with dock deficiency. we describe here a patient with invasive cryptococcus laurentii infection and the x-linked form of hyper-igm syndrome (x-higm). c.laurentii is an extremely rare human pathogen. this fungus was previously considered saprophytic and non-pathogenic to humans, but it has been isolated as the etiologic agent of skin infection, keratitis, endophthalmitis, lung abscess, peritonitis, meningitis, and fungemia. most affected individuals had a compromised immune system because of leukemia, cancer, diabetes mellitus, aids, or prematurity. repeated isolation of c.laurentii from the oropharynx of an immunocompromised patient has also been docu- the wiskott-aldrich syndrome (was) is an x-linked recessive immune deficiency disorder characterized by thrombocytopenia, small platelet size, eczema, recurrent infections, and increased risk of autoimmune disorders and malignancies. was is caused by mutations in the wasp gene which encodes wasp, a -amino acid protein. wasp plays a critical role in actin cytoskeleton organization and signalling, and functions of immune cells. we present here the results of genetic analysis of patients with was from eleven eastern and central european (ece) countries and turkey. clinical and haematological information of affected males and carrier females from was families were collected. the wasp gene was sequenced from genomic dna of patients with was, as well as their family members to identify carriers. in this large cohort, we identified unique mutations including novel sequence variants. the mutations were scattered throughout the wasp gene and included single base pair changes ( missense and nonsense mutations), small insertions, deletions, and splice site defects. genetic counselling and prenatal diagnosis were applied in four affected families. introduction: mhc-class ii deficiency is an autosomal recessively inherited combined immunodeficiency disorder characterized by less than % expression of hla-dr on b cells or monocytes. it is caused by mutation of genes (ciita, rfxank, rfx , rfxap) regulating transcription factors which controls expression of mhc-class-ii molecules on cell surface. mhc-class ii molecules are expressed on thymic epithelial cells, antigen presenting cells (b lymphocytes, dendritic cells, monocytes and macrophages) and activated t cells. these molecules are of critical importance to immunity, cd + t cell development, antibody production, tolerance induction and inlammatory response. consequently, patients present with clinical findings related to combined immunodeficiency during infancy. material and methods: medical records of thirteen patients with mhc-class ii deficiency, followed-up in ankara university, medical school, division of pediatric immunology/allergy from to , were evaluated retrospectively. findings: during study period, male and female patients were diagnosed with mhc-class ii deficiency. age of diagnosis were between months and years of age. consanguinity were present in eleven out of thirteen patients. most frequent clinical findings during initial diagnosis were failure to thrive, pneumonia and oral moniliasis. lymphopenia was absent in all of the patients, however, low serum igg level was present in all of them. except for the yo female patient with a positive family history and whose hla-dr expression was , %, hla-dr expression was % in the rest of the patients. eight patients underwent hematopoietic stem cell transplantation (hsct). two patients were lost soon after hsct due to complications and three patients died of opportunistic infections. four patients died of severe opportunistic infections without underwent hsct. results: mhc-class ii deficiency is a combined immunodeficiency and not considered a rare disease in our country. to date, only known treatment is hsct. since it has poor prognosis, hsct should be performed before development of chronic viral infections and sequelae related to infections in patients who have hla-matched sibling. fatih celmeli ; giancarlo la marca ; ines santisteban ; michael s. hershfield purine nucleoside phosphorylase deficiency (pnp deficiency) is a rare autosomal recessively inherited type of immunodeficiency. pnp deficiency constitutes about to percent of all combined immunodeficiencies. it is characterized by progressive combined immunodeficiency and neurologic findings which includes ataxia, developmental delay, and spasticity. the immunodeficiency is progressive, with normal immune functions at birth, but severe t cell deficiency with variable b cell functions presented by the age of years . the only curative treatment is the hematopoietic stem cell transplantation (hsct). here, we present a year-old girl with recurrent respiratory tract infections, short stature and spastic paraplegia. immunological, biochemically and genetics investigation revealed pnp deficiency with a t mutation in pnp gene. case report: a years-old girl was referred to our pediatric immunology clinic for recurrent sinopulmonary infections since year of age. she was full term neonate and her parents were not consanguineous. she had a history of prolonged and resistant bronchopneumonia, and an attack of generalized chickenpox complicated with pneumonia. she had also severe zona infection resolved with ulceration in cornea, one year ago. she has been suffering from frequent infections like chronic sinusitis, oral moniliasis, recurrent pneumonia and sclerosing cholangitis. she has also nonprogressive cerebral palsy, spastic paraplegia, behavioral problems and limited motor and mental retardation. there was no family history of recurrent infections or immunological disorders. on her physical examination, there was failure to thrive, (her weight and height < rd p) oral moniliasis, bilateral crepitus ralls, and splenomegaly. she has also marked spasticity with brisk reflexes in lower extremities. laboratory tests revealed lymphopenia: hemoglobin g/dl and platelets /mm wbc /mm , absolute lymphocyte /mm . the laboratory results are shown in the table. lymphocyte proliferation is lower than normal limits in response to pha stimulation (wst assay). ppd response and hiv was negative. antihbs, and antihav were negative despite vaccination. uric acid level , mg/dl. direct coombs was negative, thyroid autoantibodies were within normal limits. genetic analysis revealed homozygous missense mutation (c. g > a), which causes the a t amino acid substitution in pnp gene, in exon , which has previously been reported. additionally, a homozygous g/a polymorphic site in ivs has been detected (c. + g (ivs + g)). discussion: pnp deficiency is caused by mutations in the pnp gene at q . . this gene encodes the protein purine nucleoside phosphorylase, one of the enzymes involved in the purine salvage pathway. adenosine deaminase (ada) deaminates adenosine to yield inosine, which is then converted to hypoxanthine by pnp. pnp also converts guanosine to guanine. a number of metabolites are elevated in the plasma and urine in pnp deficiency, including deoxyguanosine and deoxyinosine. there is an intracellular accumulation of their deoxy triphosphate compounds, particularly deoxyguanosine triphosphate (dgtp). the latter is toxic to t cells, a property similar to deoxyadenosine triphosphate in adenosine deaminase deficiency. in this report, we demonstrate the clinical characteristic of the patient with late diagnosis of pnp deficiency. pnp mutations likely lead to an intense alteration of the enzyme activity which in turn, cause severe and early onset of the clinical findings. however, in our case, the clinical onset of the disease is quite late (after years) which can be explained by the residual activity of the pnp. in conclusion patients with pnp deficiency can be late onset. additionally, late diagnosis of this patient can cause severe comorbidity which limits the chance of bone marrow transplantation. di george syndrome, a disorder caused by a defect in chromosome ( q . deletion), results in the poor development of several body systems. clinical features include congenital heart defects, hypoparathyroidism and thymic hypoplasia or aplasia leading to t-cell immunodeficiency. the aim of our study is to screen and determine the incidence of di george syndrome within only one tube of blood in children with congenital heart anomalies in our population. children who were found to have a cardiac defect during routine visits in pediatric cardiology and neonatalogy departments were included into the study. cases with known genetic syndromes and newborns younger than gestational weeks of age and small for gestational age (birth weight < gr) were excluded. a total of patients were included. there were ( %) males and ( %) females. age ranged between - months ( . ± . months). parental consanguinity was % (n = ) in the study group. the majority of patients diagnosed after murmur was heard during the routine physical examination (n = , %). five patients ( %) diagnosed antenatally. remaining clinical signs on admission were as follows; respiratory distress (n = , %), tachycardia (n = , %) and central cyanosis (n = , %). echocardiagorafic examinations revealed ventricular septal defect (vsd) (n = ), tetralogy of fallot (tof) (n = ), vsd-asd (n = ), aortic coarctation (n = ), double outlet right venticle (dorv) (n = ), transposition of the great arteries (n = ), truncus arteriosus (n = ) and pulmonary atresia (n = ). pulmonary stenosis, endocardial cushion defects, total pulmonary venous return anomaly and hypoplastic left heart were the other defects. q . deletion was ascertained in ( . %) patients; these patients were diagnosed to have tof ( . %), truncus arteriosus ( . %), dorv ( . %), vsd ( . %) and vsd-asd ( . %). preliminary results of the study showed that the frequency of q . deletion is % in patients with known cardiac defects. single tube of blood is enough for flow cytometric and genetic analyses. further studies involving higher number of patients is mandatory to give sufficient information about the exact incidence of the disease. di george syndrome -where do we stand now? małgorzata pac; małgorzata skomska; ewa bernatowska department of immunology, the children's memorial health institute, warsaw, poland di george syndrome (dgs) classically comprises t-cell deficiency (due to thymic hypoplasia), hypoparathyroidism, cardiac malformations,and facial abnormalities. deletions of the long arm of chromosome at position q. are most commonly associated with dgs. syndrome is also found associated with other genetic abnormalities ( p deletions, char ge), certain teratogenic influences (retinoid acid, foetal alcoholic syndrome, maternal diabetes). the dgs phenotype is very heterogenous with variable expression of the different features including the immunodeficiency. the initial treatment emphasis is to control the hypoparathyroidism. correction of congenital heart defects (if present) is usually needed. the best treatment of the immune defects of dgs is still controversial. both hsct and transplant with fetal thymus are the option for complete dgs (cdgs). long term survival after hsct has been reported, though at a lower rate ( - %) compared to survival after hsct for scid. survival in the subgroup receiving matched sibling donor transplants was better at over %. the use of post natal human thymus was pioneered by markert at duke university and has become established as the treatment of choice for cdgs, with the result of out of treated patients survived ( %). more recently this approach has also been used in london, at gosh. . under care of cmhi there are patients fulfilling esid criteria, girls ( . %) and boys ( . %), age / - y.o. in % of them q deletion in locus d s was found. the vast majority children were diagnosed as partial dgs. none of them had significant hypogammaglobulinemia and no regular ivig therapy or antibiotic prophylaxis were required.. the mean number and percentage of cd , cd and cd lymphocytes as well as lymphoproliferative answer to pha and cd in dgs patients were slightly diminished. in many improvement of cellular immunity was observed with age. about % presented with congenital heart disease, requiring surgery, while almost % had the symptoms of hypocalcemia and hypoparathyroidism, next % -speech and learning difficulties. one child was diagnosed as cdgs. scid is a rare, inherited condition, is caused by numerous molecular defects that lead to severe compromise in the number and function of t cells, b cells, and occasionally natural killer cells. seventeen patents with scid were registered during the period from till in the children's clinical university hospital. medical charts of these patients have been reviewed. there were boys and girls. positive family history was in families. mean age at the onset of symptoms and scid diagnosis was . ± . and . ± . months, respectively. pneumonia ( %), candidacies ( %), bcg infection ( %), diarrhea ( %) were the most important infections. anemia and relative lymphopenia were in % cases , growth retardation, hypotrophy had % children . pathogens such as candida albicans ( ), mycobacterium tuberculosis complex ( ), cmv ( ) and others have been identified. totally patients died.two girls are alive ( and months post-transplant). autopsy was done in patients. we saw different changes in thymus and lymphatic nodes. artemis deficiency (n = ), t-b-scid (n = ), t-b + scid (n = ), γc deficiency (n = mutation r w in γ-chain of receptor for il- ), unspecified scid (n = ) were detected. conclusion: generalized bcg infection had % of our scid patients. (incidence of tb is still high . / population in latvia and newborns obligatory are vaccinated on the second to fifth day of life). due to possibility of absence for pid routine genetic identification in only few scid forms were identified precisely. children's hospital, university of freiburg, freiburg, germany. purpose: ipex (immunodysregulation, polyendocrinopathy, enteropathy, x-linked) is a rare x-linked recessive life-threatening disorder characterized by autoimmunity and early death. pulmonary complication related with ipex has not elucidated exactly. here, we report i.e. patients, of which died from severe pulmonary disease. methods: clinical data and laboratory findings included autoantibodies, immunoglobulin levels as well as number of t, b and nk cells were evaluated. foxp expression was performed by flow cytometry. genomic dna was isolated and all exons and exon-intron boundaries of the foxp gene were sequenced by sanger sequencing. results: patient i (pi) presented with nephrotic syndrome at years of age and then developed autoimmune hepatitis without eczema, enteropathy or high ige and died at years of age due to acute respiratory distress syndrome (ards). two cousins of pi had the same hypomorphic splice site mutation leading to normal foxp protein expression and suppressive capacity. however, they exhibited typical symptoms such as eczema, diabetes and enteropathy with eosinophilia at early age (pii, piii) and were transplanted in infancy. one of them had severe respiratory distress right after birth (piii). patient iv from another family presented with chronic diarrhea without autoimmune manifestations and died due to ards. conclusion: lung disease related to ipex syndrome has not been reported before and this entity could be a critical factor in disease outcome. severe combined immunodeficiencies (scids) are a group of primary immunodeficiencies that comprise a number of monogenic disorders characterized by a block in t cell differentiation with or without impairment of b cell and natural killer (nk) cells. without early diagnosis and treatment most children die in the first year of life. a lack or very low number of t-cell receptor excision circle (trec) detected by realtime quantitative polymerase chain reaction assay (qpcr) is consistent with t-cell lymphopenia and has repeatedly demonstrated clinical validity in population based newborn screening for scid. however, the impact of population screening will be less in communities with high consanguinity and family history of scid, in which targeted screening may be more appropriate. here, we screened high risk neonates and infants (with one or more of the following: clinical presentation and/or family history suggestive of pid, failure to thrive otherwise unexplained, lymphopenia) at cairo university hospitals. their full history and clinical examination were recorded. immunoglobulin profile and immunophenotyping of peripheral lymphocytes were performed as confirmatory tests. sixteen classical scid cases were detected, as well as another scid variants (omenn syndrome and major histocompatibility complex class ii deficiency) (totally . % of all subjects screened). the rate of consanguinity in this group was . %. secondary causes of low trecs, other than scid, in our series included: bacterial septicemia ( preterm, full-term), prematurity ( cases), one preterm with omphalocele and facial dysmorphism, one preterm with congenital adrenal hyperplasia, one full term with microvillus inclusion disease, and one full term with idiopathic tcell lymphopenia. this demonstrates that in populations with high consanguinity rates, as in egypt, targeted (non-population based) trecs assay may provide a more efficient screening strategy. case : a is a years old female, st kid of non consanguineous marriage presented with fever for months. one week after the onset of the fever red patches appeared on the face, hands, abdomen, ll. mother sought medical advice and received antibiotics, antipyretics and oral steroids for about one month with no signs of improvements regarding fever. one week later the mother noticed pallor and sought medical advice and the baby was admitted to local hospital and received one bag of blood. and then she was referred to our hospital (zagazig university hospital) where she developed acute pallor again which needed recurrent blood transfusions. dark colored urine occurred in frequent attacks with abdominal enlargement and pain, and interestingly upto this time, no improvement regarding fever, bone pain or pallor. on examination she was underbuilt (all parameters are under rd centile), pallor, tinge of jaundice, generalized skin pigmentation, generalized lymphadenopathy, nd degree clubbing and hsm investigations: cbc (pancytopenia with reticulocytopenia) -lft (increased ast with indirect hyperbilirubinemia)-kft (normal)-ldh (highly elevated u/l)-esr ( ) -fibrinogen ( . gm/ l)serum triglycerides ( . mg/dl)-ebv-vcm igm positive and igg negative -c ( . normal) -rf and ana(-ve) -serum ferritin ( ng/ml) -cd is low -bone marrow biobsy revealed dysplastic changes -l.n. biopsy revealed non specific inflammatory changes. treatment: hlh protocol with no sct prognosis: patient passed initial phase with complete resolution and waiting for bmt case : m is months old boy, nd kid of non consanguineous marriage (the st is healthy years old female) presented with fever and difficult breathing since the age of months. the fever was of gradual onset stationary course and not responding to treatment with antipyretics and antibiotics. one week later the mother noticed abdominal enlargement with red rash over the abdomen that was associated with pallor but there was no evidence of bleeding from any site, no change in the color of urine, no jaundice, no ecchymosis, no joint swelling then he is referred to our hospital (zagazig university hospital). this boy is delivered by nvd at term with no evidence of any problem either during pregnancy or delivery, he is exclusively breast fed and vaccinated as scheduled. examination: his weight was kg, length cm, and head circumference cm all are average for age, he was pale with no jaundice or cyanosis he had hsm and other systemic examination was quite well. children with pid usually are admitting to the hospitals and intensive care units of infants' pathology regional children clinical hospital № , but at a later date, in serious condition, after the development of clinical manifestations in the form of severe generalized infectious disease, or various complications including hematological. the screening technology approves children to be diagnosed in newborn period and to be observing by immunologist and hematologist for the next preventative therapy and bone marrow transplantation or hematopoietic stem cell transplantation. costs for the differential diagnosis and verification of the diagnosis before the manifestation and complications development of pid - usd. costs for the differential diagnosis and verification of diagnosis after manifestation and complications development of pid would be usd in months. economic loss prevention in pid - usd. economic loss prevention in t -lymphopenia - usd. we also should include into account the contribution to the state's economy, which will later be obtained, due to the presence of a healthy member of society. at is an autosomal recessive multisystem disorder characterized by progressive cerebellar ataxia, telangiectasia and increased susceptibility to infections and malignancies, particularly lymphomas and leukemia. laboratory immune investigations typically show decreased peripheral tcells, particularly of naïve t cells, with abnormal in vitro response to mitogens. most at patients have decreased serum iga and igg subclass concentrations. while about % of patients with at show raised serum igm concentrations during the course of the disease, it is unusual to find a high level of igm at onset. as cerebellar ataxia and oculocutaneous telangiectasia are not present at very young age, these patients are often erroneously diagnosed as hyper igm syndrome (higm). to prevent mistaking a-t patients for higm it is proposed to add dna repair disorders as a possible cause of higm. . diagnosis of at, suggested by elevated alfa-feto-protein and increased sensitivity of patients' cells to irradiation, can be confirmed by identifying a mutation in the atm gene.we report female case of at that with diagnosis of hyper igm received ivig but later they had manifestation of ataxia in the course of their disease and then had telangiectasia of conjunctiva. first case was a yrs girl that was suffered from itp and granulomatosis lesion of skin associated with hyper igm before at diagnosis. second case was a years old girl with microcephaly, sever ftt , neurodevelopmental delay , abnormal faces and hypo and hyperpigmentation lesions and anemia. with respect to these manifestation and increased afp ,nijmegan breakage syndrome was suggested. third case was suffered from hyperigm before a t diagnosis for years. we present a patient with a dock deficiency. mutations in the dedicator of cytokinesis gene (dock ) cause a combined primary immunodeficiency syndrome that is characterized by elevated serum ige levels, depressed igm levels, eosinophilia, sinopulmonary infections, cutaneous viral infections, and lymphopenia. onset of the disease was observed at -month of age with severe eczema and recurrent respiratory infections (pneumonia, bronchitis, otitis). at years of age neuroblastoma was diagnosed. from the age of years he started with severe skin infection , subsequently recurrent mucocutaneous aspergillosis was established based on skin biopsy and bacteriological studies. immunological investigations revealed persistent leukocytosis, hypereosinophilia, low level of igm and increased ige up to iu/ml. so hyper ige syndrome was diagnosed and genetically confirmed when a large deletion of the dock -gene was identified. stem cell transplantation was performed in when the patient was y.o. one year later progressive multifocal leukoencephalopathy secondary to infection by polyomavirus jc was diagnosed. but after immunosuppressive therapy with cyclosporine awas suspended our patient's condition improved: the load of polyomavirus jc on plasma showed a decrease; mri brain was essentially stable ; immunological tests showed an initial improvement of subpopulations and proliferative response to mitogens; donor chimerism % stable. Özdemir Öner ; bozdoğan sıla department of pediatrics, division of allergy/immunology, sakarya university, medical faculty, adapazarı, türkiye. background: bronchiolitis and infantile asthma are the most frequent causes for typical wheezing signs in infants. however, when a physician comes across patients with recurrent wheezing are resistant to β -agonist and anti-cholinergic therapy, known as atypical wheezing cases; he should investigate for hypogammaglobulinemia in these patients. aim: here, three cases are reported to make pediatricians aware of hypogammaglobulinemia, which is one of the reasons causing recurrent and persistent wheezing attacks during infancy and beyond. case presentations: case : month-old girl presented to us with complaining of coughing and persistent wheezing. she has been having wheezing and breathing difficulty for the last months after she got upper respiratory tract infection. her symptoms persisted even though she was using religiously nebulized salbutamol + budesonid therapy. before this episode, she had had other wheezing attacks in her past medical history beginning from months of age. in her family history, her father has asthma. physical examination revealed her breathing difficulty. ronchi as well as rales were heard on the auscultation of her lungs. at the fourth day of admission, she was given ivig mg/kg/dose. later, her symptoms did improve and not recur for the last months. laboratory findings showed normal routine biochemistry, complete blood count and sedimentation rate. chest x-ray showed normal findings. echography was normal. ph-metry for reflux investigation was normal. sweat test was normal. in the serological evaluation: low igg level for his age ( mg/dl) was detected at two different times. igg subgroups, igm ( mg/ dl), iga ( mg/dl) and ige ( ) levels were within normal. case : -month-old girl came to our outpatient clinic with complaints of coughing and wheezing. at months of age, she had urinary and upper respiratory tract infections. despite antibiotic therapy, wheezing persisted for months and wheezing severity increased and it did not respond to β -agonist therapy. thereafter, she was admitted to the hospital for days and symptoms resolved. however, she came back to hospital due to recurrence of her symptoms in days. in her family history, grandmother and her cousins have asthma. physical examination showed breathing difficulty. ronchi as well as rales were heard on her lungs. although salbutamol, ipratropium, antibiotherapy (clarithromycin) and anti-reflux therapies were given, her symptoms did not improve for weeks. at the th day of admission, she was given ivig mg/kg/dose. later, her respiratory system symptoms did not recur for the last several months. once she was evaluated for persistent wheezing attacks during admission, biochemistry, cbc, esr were normal. chest x-ray and echography were normal. in serological evaluation: low igg level for his age ( mg/dl) was detected at two different times. igg subgroups, igm ( mg/dl), iga ( mg/dl) and ige (< ) levels were normal. case : month-old boy was brought to us complaints of having frequent lower respiratory tract infections (bronchiolitis). he was experiencing recurrent wheezing attacks almost every other week for the last months. in past medical history, he was diagnosed with trisomy and hypothyroidism at the months of age. he went thru an operation for atrio-venticular septal defect. physical exam revealed dyspnea, tachypnea and wheezing. crackles were heard on the chest auscultation. abdominal, cardio-vascular and the rest of the examination were normal. when he was evaluated for frequent wheezing attacks in our outpatient clinic, routine biochemistry, cbc and esr were normal. chest x-ray showed normal findings. in serological evaluation: low igg level for his age ( mg/dl) was detected twice. igg subgroups, igm, iga and ige levels were within normal. he was given ivig mg/kg/dose. for the last three months, he did not have any lower respiratory tract infection. conclusion: the awareness of immunodeficiency among pediatricians has been greatly improved. recurrent respiratory tract infections are major infections in these patients. thi is a relatively common condition associated with infant hypogammaglobulinemia. in patients with recurrent and/or persistent wheezing symptoms during infancy and beyond, especially resistant to therapy, hypogammaglobulinemia should be excluded from possible diagnoses. background: the acquisition of new food allergy after transplantation or transplant-acquired food allergy (tafa) is usually reported in adults and rarely in children. tafa is described mainly after liver, but also after small bowel/intestinal, lung and heart transplantations. in different studies, the male/female ratio is equal. literature data suggest that children with tafa typically present within the first year after surgery and they are typically allergic to multiple foods. aim: tafa is generally characterized with allergy to multiple foods and increased level of total and/or spesific ige. here, a patient although who had normal total. ige and specific ige test results, he developed reaction to skin prick test for cow's milk is presented and his clinical presentation will be discussed. case presentation: month-old-boy came to our allergy clinic with complaints of vomiting after drinking cow's milk and skin rush on the area where contact ed with chocolate. in his past medical histroy, left lateral segment of liver (donor was his mother) was transplanted to him when he was at months. the liver donor was not recorded as having a history of allergic disease. methylprednisolone and tacrolimus immunosuppression were used after the transplantation, and tacrolimus therapy was continued for prophylaxis of chronic rejection. when he was at months, family fed the patient with cow's milk but hours later he began to vomit. he vomited five times in two hours. then, he developed constipation. rectal irrigation was used. then oral intake stopped for two days. he was thought to be having food protein induced enterocolitis. his vomiting complaints repeated after intake of formula and baby food which include grain. so he fed with special formula including short-chain peptides and free aminoacids and his symptoms improved. past medical history: extrahepatic biliary atresia was diagnosed at weeks age with conjugated hyperbilirubinemia (according to scintigraphy and biopsy results). family history: his father has penicillin allergy and his aunt has asthma. at our outpatient clinic: height and weight were within normal percentiles. physical examination reevaled normal examination findings. laboratory findings: wbc was . /mm , with % neutrophils, % eosinophils and % lymphocytes. his hemoglobin was . g/ dl , platelet count was . /mm . total ige : < and immunocap specific ige against milk, grain and other classsic foods was < . . skin prick test results: saline: x mm, histamine x mm, fresh cow's milk: x mm, other food allergens (peanut, egg, fish, soybean, wheat): x mm. conclusion: our patient seemed to have cow's milk allergy related to liver transplantation. laboratory investigations and clinical presentation of the patient did not look like typical ige-mediated food allergy, which is expected in tafa. patient history: years old male patient, the first pneumonia at the age of followed by times pneumonia attacks/year, otitis media and sinusitis. hospitalization due to respiratory insufficiency caused by bronchiolitis obliterans and diagnosed with hypogammaglobulinemia at the age of . no consanguinity. patient findings at diagnosis ( / ) had hepatospenomegaly, bilaterally cervical, supraclavicular axillar lap, osteoporosis, bronchiolitis obliterans organizing pneumonia, hyper igm, lower igg, iga, ige, low b-cell. no response to tetanus toxoid. İsohemagglutinin antib was ¼. cd ,cd l, aid, taci, baffr, icos gene mutation were negative. protein electrophoresis revealed polyclonal igm increase, immunofixation was no clonality. lymph node biopsy result was available paracortical expantion . cd (+) t and cd were positive. b lymphocyte distribution were normal. malignancy ruled out. no giant germinal centers. evaluation of bone marrow aspiration/ biopsy were abnormal localization of megakaryocytes, dismegakaryopoiesis, blasts in normal range. lymphocyte ratio % mostly consisting of cd + cells, cd + cells were rare, plasma cell ratio was %, amyloid negative. progression of patient, igm level and spnenomegaly were increased and patient had respiratory failure. splenectomy could not be done due to respiratory failure. than patient was treated with rituximab ( mg/kg/week). after rituximab therapy, lymph nodes and splenomegaly were ( cm), regressed and igm level decreased (from mg/dl to mg/dl), increased effort capacity. after month after rituximab therapy splenomegaly and igm level were progressed. splenoctomy was performed. pathological evaluation of the spleen malignancy ruled out. current igm level is mg/dl. conclusion: the most convinient scenerio for this patient would be a csr defect of unknown etiology presented as cvid. the recent litarature revealed genetic defects of some molecules operating in dna repair pathways such as msh , msh , msh , msh , mlh , rad , rad , nbs leading to csr abnormality and impaired antibody maturation. cvid is characterized by hypogammaglobulinemia, recurrent respiratory and gastrointestinal bacterial infections. good's syndrome(gs) is a thymoma-related immunodeficiency and characterized by hypogammaglobulinemia, decreased b cell and variable deficiencies in cell-mediated immunity. case: a -year old male patient presented with a palpable anterior chest wall mass. in , he was diagnosed with rheumatoid arthritis. laboratory showed hypogammaglobulinemia and all autoantibodies were negative. cd + , cd + , cd + cells were < %. bone marrow(bm) examination demonstrated low cd + b-lymphocyte and increase in cd + t cells. tuberculin skin test was positive. t-cell proliferative response was normal. immunizations with h.influenzae type-b and tetanus toxoid revealed no response. anti-b titer was low. taci, btk and icos mutattions were negative. ultrasonography showed hepatosplenomegaly. mild edema, mononuclear cell infiltration (suggested the early stages of extrahepatic biliary obstruction) were detected on liver biopsy. in the medical history, he had reported chronic sinusitis, otitis and bronchitis dating back to rd decade of life. at age , he underwent surgery for thymoma. in follow-up, the computed tomography showed soft tissue mass on the anterior chest wall and pathology was thymoma. discussion: frequent respiratory infections with encapsulated pathogens beginning at the age of , lack of opportunistic pathogen infections, presence of hepatosplenomegaly and rheumatoid arthritis, bm examination findings and successful management of infections with ivig therapy all indicated a diagnosis of cvid. the coexistence of cvid and thymoma has been reported in the literature. introduction: common variable immunodeficiency (cvid) is a primary immunodeficiency disorder characterized by impaired b cell differentiation with defective immunoglobulin production. it has heterogeneous clinical manifestations including recurrent infections, chronic lung disease, autoimmune disorders, gastrointestinal disease, and susceptibility to lymphoma. patients with this disorder have evidence of immune dysregulation leading to autoimmunity. autoimmune cytopenias are a more common presenting disorder in children and may be the initial manifestation of the disease. we want to present a patient presenting with autoimmunue hemolytic anemia and finally diagnosed as cvid. case: a years old, previously healthy female patient applied to emergency clinic with complaint of paleness, light headedness and yellow discoloration of her scleras. her history was not compatible with blood loss. she denied having melena, hemotochezia or hematuria. her mensturation history was also normal. her hemoglobin level was . gr/dl, reticulocyte count was % . , complete blood count was otherwise normal. direct coombs was (+++). for the differential diagnosis of immune hemolytic anemia, viral serology, ana and anti-dsdna were studied, but the results were normal. igg, igm and iga levels were lower than normal normal for her age. other causes of hypogammaglobulinemia were excluded. blood group was arh (+), blood isohemagglutinin were anti a(-) and anti b (-/ +). lymphocyte subsets were also studided. as the patient has reduced immunoglobulin levels with normal lymphocyte subset analysis, she presented after puberty and other defined immunodeficiency states were excluded, she was diagnosed as cvid and monthly immunoglobulin replacement therapy was planned. she had aseptic meningitis after her first ivig transfusion. the ivig preparation was changed with another trade and she did not have any problem during the following treatments. it has been one year since she was diagnosed and she did not have any other medical problems. conclusion: the diagnosis of cvid requires decreased igg, igm and iga levels are also reduced but are less valuable for diagnosis. ige level is checked to exclude other disorders. igg subclass determinations are indicated if antibody titers are decreased but immunoglobulin levels are near normal. hypogammaglobulinemia secondary to other disorders should be excluded. autoimmune conditions can be the presenting signs/symptoms in cvid. autoimmune hematologic disorders may precede, present at the time of diagnosis or develope during the course of cvid in approximately one-half of the patients with autoimmune problems. selective immunoglobuline deficiency is an uncommon dysgamaglobulinemia, in which immunoglobuline levels except igm level are normal. it can be primary or secondary to cancer, autoimmune diseases, gastrointestinal system diseases and immunosuppressive therapy. patients can be asymptomatic or have recurrent infections, asthma, angioedema, autoimmune diseases, celiac disease and bronchiectasis. allergic diatheses are the second commonest presentation of selective igm deficiency. in this presentation, we report a case with asthma and angioedema who has selective immunoglobuline m deficiency. a year old male patient who has been diagnosed with asthma for years with a well controlled asthma for years presented with labial angioedema. he had labial angioedema daily without antihistamines. he did not have any suspected food or drug allergy. he did not have family history of angioedema. physical examination was normal under antihistamine therapy. laboratory evaluation revealed a . % percentage of eosinophils. absolute lymphocyte count was , absolute neutrophil count was cells/mm . immunoglobuline e value was ng/ml, levels of immunoglobuline g and a were within normal limits for age. immunoglobulin m value was . mg/dl ( - ). anti a was / , anti b was ½ positive, antihbs was above mlu/ml. lymphocyte subsets were normal. because of the continuous usage of antihistamines, prick tests could not be done. levels of d was . , d was . ku a /l. thyroid functions, antitpo, c , c and c esterase inhibitor values were normal. antinuclear antibodies and antitransglutaminase lga was negative. immunoglobuline m value of his father was normal, immunoglobulin m value of his brother was . mg/dl ( - ). selective immunoglobuline deficiency is a rarely seen dysgamaglobulinemia. it was reported in children with asthma, but it was not reported in children with angioedema. it can have value in the clinical evaluation of patients with angioedema. cukurova university, department of pediatric allergy and immunology, adana, turkey a patient who is at age of years at present and who has been followed up at the our clinic with xla diagnosis presented with pain in his ankles and wrists and swelling of his right knee. he also was suffering from skin tightening of the lower extremities. his physical examination revealed arthitis of the right knee and sclerotic changes were detected in the skin. skin biopsy was performed and it revealed morphea (localized scleroderma). after the diagnosis of morphea and arthritis, ivig gm/kg and nsaid were applied. following the treatment skin findings and arthritis resolved, however approximately two months later liver enzymes were detected to be high in his routine control. liver biopsy performed to clarify the aetiology of elevated liver enzymes was reported as autoimmune hepatitis. in addition to ivig gm/kg, budenofalk mg/day was started. after months of treatment, his liver enzymes normalized. currently he is being treated with ivig monthly and ursofalk daily. patients with xla typically present with recurrent bacterial infections and it might be associated with some autoimmune diseases. there are not any reports indicating an associaton of autoimmune hepatitis and scleroderma with xla. bruton agammaglobulinemia is an inherited immunodeficiency disease caused by mutations in the gene coding for bruton tyrosine kinase (btk). the median age at the diagnosis of the antibody deficiency is about . years in turkey. here, we report a case of bruton disease presenting with recurrent cervical abscess at two months old infant. a -months-old boy was firstly hospitalized for the treatment of the right cervical abscess at days old. after the recurrence of swelling on the cervical area, the patient was referred to the admitted to hospital secondly. there was no consanguinity between parents and, his family history was unremarkable except four of the mother's cousins, died because of unknown etiology in infancy. on his physical examination, his weight, height andhead circumference were normal range by age. there were no visible tonsils. there was a palpable, mobile x cm mass on right upper cervical area. the molecular analysis of the causal gene for bruton's tyrosine kinase (btk gene) revealed the mutation in exon . this mutation g. delg (c. + del) leads to the changes of amino acid order in the protein with the subsequent changes in activity of btk (at the level of dna: substitution of glutamic acid (p.glu *) causes non-sense mutation leading to the formation of stop codon with premature end of dna transcription to cause stop codon. after initiating the intravenous immunoglobulin with antibiotics, the cervical mass was getting smaller in a short period, and had not observed again. neutropenia was improved within the months. this case is an important example to diagnose bruton disease in early life. it demonstrates that maintaining a high level of clinical suspicion is essential for the diagnosis of bruton disease in a child with recurrent cervical masses. elif azarsiz; neslihan edeer karaca; guzide aksu; necil kutukculer ege university faculty of medicine, department of pediatric immunology, izmir, turkey transient hypogammaglobulinemia of infancy (thi) is characterized by recurrent infections and reduced serum immunoglobulin levels. typically, thi patients recover spontaneously, mostly within - months of age, but sometimes recovery may be delayed until - years. the use of intravenous immunoglobulin (ivig) as an alternative to antibiotic prophylaxis remains contraversial also in symptomatic patients. some authors believe that ivig therapy may cause a delay in the maturation of the humoral immune system because of the interference from passively transfered antibodies. the aim of this study was to investigate the effect of ivig replacement on recovery from immunodeficiency in these patients. patients ( %) received ivig therapy while patients ( . %) showed spontaneous normalization without ivig. the percentages of patients who had more than six times the number of febrile infections in a year decreased from % to % in the group receiving ivig treatment. at admission, before being recruited to ivig therapy, serum immunoglobulin g (igg) levels and anti-hemophilus b (hib) antibody titers were found to be significantly low in cases who were selected for replacement. the percentages of patients who did not have protective levels of anti-hib, anti-rubella or anti-rubeola-igg were also significantly high in ivig cases. there was no statistically significant difference in the age at which igg levels normalized between both groups. patients in the ivig group and non-ivig group reached normal igg levels at the age of . ± . and . ± . months, respectively. in conclusion, ivig infusions do not cause a delay in the maturation of the immune system in thi patients. the very low and non-protective specific antibody responses against previously applied vaccines are important factors to consider when selecting patients for ivig therapy. zoltán ellenes-jakabffy ; ibolya kovács ; mihaela bătăneanţ ; maria cucuruz ; margit Şerban ; lászló maródi department of pediatrics, clinical city hospital oradea, romania. objective: to study the amplitude of the chronic inflammatory phenomena: atopic and autoimmune diseases, as well as their associations in pediatric sigad patients and to study the sigad patients' family history ( st degree relatives) for pids (primary immunodeficiencies). methods: retrospective analysis of the clinical and laboratory records of pediatric sigad patients diagnosed between and at the departments for pediatric immunology of the medical universities of debrecen (hungary), oradea and timişoara (romania). results: out of patients, we found out ( %) with atopic diseases, mostly with respiratory localizations (asthma and allergic rhinitis), ( , %) patients with autoimmune diseases (jia, psoriasis, celiac disease, thyroiditis etc.) and other patients without clinical symptoms of autoimmunity but constantly elevated autoantibody levels. there were patients with coexistent atopic and autoimmune diseases. regarding the family history, we identified families with multiple cases of pids : with multiple sigad, with sigad and cvid, with sigad and higms (hyper igm syndrome). conclusions: the chronic inflammatory phenomena are present in the majority of the studied sigad patients: symptomatic atopic diseases in %, symptomatic autoimmune diseases in , %, that means a cumulative %. there are comorbid associations within the atopic and autoimmune disease groups and also between the two groups. sigad is the most common primary immunodeficiency. it's prevalence is / - / . aim was to assess the prevalence of co-morbidity in patients with sigad in latvian pediatric population and the analysis of some immunological abnormalities in these patients. the study included patients - years old. medical charts have been reviewed. into account were taken the data, which were made at time of diagnosis. patients were divided into groups: st -patients with allergic disease, nd -patients with autoimmune diseases, rd -patients with infectious diseases, th -asymptomatic patients or patients with sigad unrelated diseases. patients with multiple co-morbidities of various disease groups were not placed in any of these groups. each patient group was divided by age: - years, - years - years. results. . % were boys and . % girls. sigad in . % of the cases were diagnosed before years of age (inclusive). % of the patients had co-morbidities: allergic ( %), autoimmune ( . %) or infectious diseases ( . %). patients - years old: children with infectious and autoimmune diseases have . times greater igg than healthy children or children with allergic diseases (p < , ); children with autoimmune diseases has . times more cd cells than children with allergic diseases (p < , ).; children with infectious diseases have . times lower absolute number of cd cells than children with autoimmune diseases (p < , ); patients - years old: children with infectious diseases have . times more absolute number cd cells than children with allergic diseases (p < , ). patients - years old: children with autoimmune disease have . times higher cd /cd index than children with infectious diseases (p < , ) karakina m. l. , , , tuzankina i. a. , , vlasova e. v. introduction: antiepileptic drugs are known to cause immunosupression in some cases. levetiracetam is an anticonvulsant medication used to treat epilepsy in the posttraumatic seizures. we report a rare case of hypogammaglobulinemia and b cell aplasia associated with levetiracetam treatment. case report: a -year-old female was operated for pituitary tumor with transnasal surgery and required second operation for postoperative rhinorrhea. after operation, menengitis developed and antibiotic treatment was administrated. however, there was a poor response to this treatment after one month and craniotomy was performed due to the diagnosis of "shimic menengitis". her seizures occurred as a postoperative complication and levetiracetam was initiated. after the -month follow-up, the findings of menengitis could not be controlled with antibiotherapy. she was referred to our immunology department for chronic menengitis with fever, headache and high cerebrospinal white blood cell count. results: in her clinical evaluation, it was learned that she had previously healthy. laboratory examination showed that decreased levels of igg mg/dl (normal: - ) and iga mg/dl (n: - ). peripheral blood flow cytometric analysis revealed the absence of b cells (cd + b cells; < %). t cell subsets and natural killer cell numbers were normal. neutrophil function, chemotaxis, phagocytosis and oxidative burst activity were found to be normal. isohemaglutinin titer, levels of pneumococal and tetanus specific igg antibodies were also normal. antiepileptic drug was discontinued after epileptic seizure was controlled. b cells gradually increased three weeks later and returned to normal within two months (cd + b cells: . %). conclusion: patients requiring levetiracetam should have serum immunoglobulins measured and lymphocyte subsets analysis performed if they experience recurrent or persistent infections. mustafa gulec ; fevzi demirel ; ugur musabak ; ozgur kartal ; sait yesillik ; abdullah baysan ; ergun ucar ; osman sener gulhane medical school, division of immunology allergic diseases, ankara, turkey. gulhane medical school, department of chest diseases, ankara, turkey. introduction: common variable immune deficiency (cvid) may present with several clinical manifestations involved in different organs and tissues in adults. we present a case with a history of chronic cough for more than twenty years and further diagnosed as cvid. case: a -year-old male who works in a chemistry lab admitted to our clinic with a history of frequent upper respiratory tract infections for more than years. he also had intermittent diarrhea symptoms and his respiratory symptoms have been worsened since . he had been hospitalized due to pneumonia and empyema several times. he had undergone left lower lobectomy due to bronchiectasis in . he had been admitted to intensive care unit due to worsening of his medical condition. he was further diagnosed with cvid and ivig treatment was initiated. he is currently under remission with monthly ivig treatment and without any respiratory or gastrointestinal symptoms. discussion and conclusion: cvid is a clinical disorder in which the humoral part of the immune system is affected. most frequent presenting symptoms belong to respiratory, gastrointestinal systems and skin. however, due to the organ specific physical examination and lack of awareness, the diagnosis is frequently overlooked. in our case, frequent upper respiratory infection, loss of weight, diarrhea, bronchiectasis and empyema with unknown etiology are the most informative clinical signs. medical history is the most important part of patient evaluation. immunoglobulin replacement therapy is a basic treatment in primary immunoglobulin deficiency disorders. immunoglobulin substitution can be given intravenously (ivig) or subcutaneously (scig) for patients with antibody deficiency. both of these treatments are effective in prevention and cure of infections, although differences in advers events profile and patients' quality of life can be seen. the authors describe here their experiences in switching patients from ivig treatment to scig and a few years observation of scig therapy of patients with antibody deficiencies. sirje velbri , mirja varik tallinn children's hospital, tallinn, estonia. north-estonian regional hospital, tallinn, estonia. j clin immunol ( ) : - antibody deficiencies are the most common group of primary immunodeficiencies. the main hallmark of antibody deficiencies are recurrent infections but the patients have also higher risk of autoimmune and allergic diseases. we analysed retrospectively the frequency and character of autoimmune diseases in patients ( children and adult patients) with primary antibody deficiencies. there were ana-lysed patients with xla, patients with cvid, patients with selective iga deficiency, pa-tients with iga/igg subclass deficiency and patients with isolated igg subclass deficiency. autoimmune diseases were found in patients ( , %) besides in children ( %) and in adult patients ( %). in two boys with xla there was not found autoimmune diseases but in patients with other forms of antibody deficiencies in - % of cases. autoiimmune diseases were found more often in iga/igg subclass defi-ciency ( %) than in other forms of antibody deficiencies ( - %). the spectrum of auto-immune diseases differed in adults and child-ren and in different forms of antibody de-ficiencies. immune thrombocytopenia was found in adult patients with cvid or igg subclass deficien-cy, autoimmune connective tissue disorders in iga and iga/igg subclass deficiency. in children there was found mainly thyroiditis, diabetes i type and juvenile arthritis. rostov state medical university. research institute of clinical immunology, rostov-on-don, russia. primary immunodeficiency (pi) is currently one of most important genetically determined immunological clinical pathology which is hard to manage . among different types of pis almost % of cases occurs due to a deficiency in antibodies production. injections of immunoglobulin are current standard in the management of pi. however this treatment is expensive, often is hard for patients, and frequently has limited effectiveness. substitution of immune proteins frequently is inefficient for treatment of severe infectious conditions in pi patients. we investigated maturation, activation and differentiation of immune t-cells in the dynamics of ivig replacement therapy. we observed patients with with cvid ( ) and xla ( people) over a year of regular replacement therapy. we have found that recovery of the humoral component does not affect the maturation and the differentiation of t-cells, but can reestablish activation and regulatory properties. these changes are more evident among patients with cvid, which immuneregulatory and functional potential reestablish faster. obviously, the effects tlymphocytes increase the effectiveness of replacement therapy in patients with xla, cvid common variable immunodeficiency (cvid) is one of the most frequent symptomatic primary immunodeficiencies. the diagnosis is based on significantly decreased levels of immunoglobulins, with poor or absent response to vaccines and by excluding other defined causes of hypogammaglobulinaemia. as suboptimal antibody production is mainly due to b cell defects, therefore, we aimed to study lymphocyte subgroups of cvid patients and to compare the patterns with the clinical presentation in these patients. six adult patients with cvid diagnosis were studied. lymphocyte subpopulations were determined by flow cytometry. for b-cells subgroups cd , cd , igm and igd reagents w e r e u s e d . a l l l y m p h o c y t e s w e r e g a t e d f o r f i n d i n g cd + cd + memory b cells and from this population switched (cd + cd + igd -igm -) and non-switched (cd + cd + igd + igm + ) memory b cells were counted. all patients had normal levels of total lymphocyte count and absolute counts of cd + , cd + and cd + /cd + cells were also normal in all patients. only one patient showed low levels of cd + cells levels. according to paris classification scheme the patients could divided into two subgroups: mb and mb . although almost all our cvid patients had normal number of total b cells, most of them showed reduced number of memory b cells and/or switched memory b cells. all of our patients had very low or absent level of class-switched memory b cells, therefore can be possible associated with a higher risk of granulomatous disease and splenomegaly. detailed investigation of b-cell phenotypes can better characterise cvid patients and can provide more information about possible clinical outcome. background: common variable immunodeficiency (cvid) is one of the most frequent symptomatic primary immunodeficiencies, often related to spectrum of infectious and autoimmune diseases. in cvid patients wide spectrum of gastrointestinal disorders, including infections, are frequently seen. inflammatory bowel disease, helicobacter pylori infection, giardia lamblia infection, campylobacter or salmonella infection have been reported. however, abnormal liver function test and liver disease are found in approximately % of cvid patients. case history: a -year old female patient was admitted to infectious disease department due to recurrent pneumonia and purulent rhinosinusitis. blood analysis confirmed panhypogammaglobulinaemia with impaired responses to vaccinations, elevated liver function tests and anti-hcv positivity, interpreted as old and passed infection. due to cvid intravenous immunoglobulin substitution was started. however, liver function tests remained elevated and with hcv-rna analysis high hepatitis c viral load was detected. chronic hepatitis c virus infection was diagnosed and treatment with peginterferon α- a and ribavirin was started. conclusion: our case emphasizes the need for hcv-rna and hbv-dna analysis in patients with hypogammaglobulinaemia, as the serological detection is impaired and prognosis for chronic hepatitis in immunodeficiency patients is poor. outpaitent clinic of clinical immunology and allergology, east tallinn central hospital, tallinn, estonia background: primary antibody deficiencies are the most frequent primary immunodeficiencies. recurrent respiratory tract infections may result in permanent lung damage in - % of patients, most commonly presenting with the development of bronchiectasis. we aimed to evaluate the lung function and radiographic pulmonary changes in our patients with primary antibody deficiency. material and methods: we reviewed the records of adult patients with a confirmed diagnosis of primary antibody deficiency at our clinic. patients were included in this analysis in whom ct scan was performed during the last months, comprising patients with cvid and two with igg subclass deficiency (median age years; range - years; % females). all patients were on regular immunoglobulin replacement and one of the patients was on prophylactic antibiotic at the time of analysis. mean trough levels of igg were calculated based on the results measured during the last months prior to ct scan. the spirometry was performed according to published protocols. results: all patients demonstrated normal spirometry data based on fev and fvc. two patients had slightly lower mmef rates, however, the changes were not associated with higher rate of infection nor changes in ct scan. none of our patients had bronchiectasis or atelectasis. among parenchymal changes fibrotic lines were most frequently detected. in two patients ground glass due to fibrosis was noted. mean immunoglobulin trough levels in our patients were between . - . g/l, with the median of mean trough levels of all our patients . g/l. when comparing the trough levels to lung function and ct scan results, no significant associations were seen. conclusion: no remarkable changes in lung function or chest ct scan in our patients with primary antibody deficiency were noted. as regular immunoglobulin replacement therapy could have prevented the development of permanent lung damage. rationale: patients with primary immunodeficiencies (pi) (n = ) were treated subcutaneously (sc) with immunoglobulin g (ig) preceded by recombinant human hyaluronidase (ighy) at or week intervals based on their previous intravenous ig (igiv) dose. we report data for a subset of patients aged ≥ years from the final efficacy, safety and tolerability data of a pivotal phase trial of ighy. methods: patients received igiv for months at prestudy doses and frequencies. subsequently, ig % was administered sc, at % of the weekly equivalent of the iv dose, following rhuph infused through the same sc needle at a dose of u/g igg. after a ramp up from a -to a -or -week dose interval, patients received ighy every weeks for months. the primary efficacy endpoint was the mean rate of validated acute serious bacterial infections (sbis) per patient-year during the efficacy period. results: fifty-nine patients received ighy infusions; . % were completed without administration changes due to tolerability concerns or adverse events (aes). median infusion sites/month was . . the temporally associated systemic ae rate was . /infusion (ighy) vs. . /infusion (igiv). the local adverse drug reaction rate was . /infusion. the annual sbi rate was . and . /patientyear for all infections. conclusion: in adults with pi, ighy was effective in preventing infections. the majority of patients received full -to -weekly doses of ig using a single sc site with good local and systemic tolerability. rationale: in a pivotal phase trial of facilitated-subcutaneous (sc) infusion of human immunoglobulin g (igg), %, and recombinant human hyaluronidase (rhuph ) (ighy) in patients with pi, rhuph permitted most patients to have a single-site infusion (every - -week igg dosing) with bioavailability and infusion rates comparable to intravenously administered igg (igiv). we report the final analysis of the long-term extension of the initial phase study, with a duration of up to years of treatment with ighy plus additional follow-up. methods: sixty-six patients who completed the initial phase study enrolled in the extension study. patients continued their pre-study ighy dose/frequency every - weeks. after months, some patients switched to -week dosing to evaluate effects of shorter ighy interval on trough igg levels. from the final analysis, tolerability and safety after up to years of treatment were evaluated. the ighy part of the extension study was followed by a - week observation period during which patients received igg % administered iv, or sc weekly without rhuph . results: in the extension study, patients were treated with ighy and discontinued prior to safety follow-up. following discontinuation of rhuph , patients switched to follow-up. no patients withdrew due to ighy-related reactions (adrs). no serious adrs related to ighy were reported. the maximum ighy exposure for the initial and extension studies combined was years (total exposure = . patient-years; n = ighy infusions); during this time, there were no clinically observable long-term changes in the skin or sc tissue. the rate of temporally related systemic adverse events (aes), excluding infections, was . / infusion. the rate of all local aes was . /infusion. of the ighy infusions administered in the extension study, . % had no administration changes (rate reduction, interruption or discontinuation) due to tolerability concerns or adverse events. the annual rate of all infections under ighy treatment was . /patient-year. reducing the dosing interval from to weeks (same monthly dose) resulted in a % increase in trough igg levels. thirteen patients had at least non-neutralizing anti-rhuph antibody titer of ≥ : with no associated aes; no patients had neutralizing anti-rhuph antibodies. conclusions: in the extension study, ighy was well tolerated and effective, with no serious adrs for treatment periods up to years. over a maximum -year ighy exposure (for an individual patient) in the initial phase and extension studies combined, no long-term changes in skin or sc tissue were observed. the rates of infections and adverse reactions were stable or decreased over the course of the two studies, suggesting no increased risk with continued exposure to ighy. rationale: we report interim analysis of safety, tolerability and pharmacokinetics (pk) of igsc % in patients with primary immunodeficiencies (pi) aged ≥ years in europe. methods: epoch : igsc % or intravenous ig % (igiv) administered at pre-study doses every months. epoch : igsc % administered time per week for months at epoch doses. serum igg trough levels are maintained at > g/l. the primary endpoint is validated acute serious bacterial infection (sbi) rate. results: at the interim analysis in october , patients started the study. during igsc % treatment (n = ), acute sbi episode (pneumonia, moderate in severity) was reported. the infection rate per patientyear was . (igsc %). there were no serious adverse events considered related to any treatment. the rate of local adverse drug reactions (adrs) was . /infusion and all were mild in severity; no severe systemic adrs were reported with igsc %. of igsc % infusions, only . % required slowing or interrupting the administration rate. mean serum igg trough levels were . g/l (igsc %, n = ), . g/l (igiv -week interval, n = ) and . g/l (ivig -week interval, n = ). conclusion: igsc % provided an effective and well-tolerated therapy, with no dose adjustments needed from pre-study ig dose. this study is ongoing to confirm results over months. it is well known, that intravenous immunoglobulin (ivig) is the main therapeutic modality in b-cell primary immunodeficiencies (pid), it decreases mortality and morbidity in these patients dramatically. yet, it is also well known that all ivig products are very expensive, especially considering life-time use and almost normal life expectancy in these patients, if treated correctly. irregular treatment and problems with insurance/state coverage of ivig in some countries stems from this. goal: the goal of our study was to compare medical and other costs, related to the disease in patients with humoral pids with or without ivig treatment. patients: patient with b-cell deficiencies ( % x-linked agammaglobulinemia, all genetically confirmed, % common variable immunodeficiency). the age of patients varied from to years. methods: we analyzed medical and other disease-related costs during years preceding the diagnosis (without ivig therapy) retrospectively and during years on regular ivig therapy. the costs included those incurred by the state (hospitalization, home visits, emergency calls) and by the parents (costs of drugs, private consults, etc). the state costs caused by parents missing work were also considered. for standardization purpose for calculation we used the prices for the end of . results: the patients analyzed fell into different categories: . the st group -( % of patients studied) -patients with several severe infections before therapy, some chronic conditions as a result of those. age of diagnosis varied from years to years (with average time to diagnosis years). in this group costs of ivig treatment were , times higher than before the diagnosis (fig. ). nd group( % of all). patients with late diagnosis (average time to diagnosis years), who had multiple severe infections before the ivig treatment and acquired serious chronic lung complications due to it. in this group the costs before the treatment were higher, than on ivig treatment. . very early diagnosis -within the first year of life (mostly because of preceding family history) ( %). the comparative analysis was not possible, but it was noted that these patients had no history of serious infections before of while on ivig therapy. the only additional costs, besides ivig, were related to bad venous access, requiring occasionally day in-patient hospitalization for ivig infusion. as expected, in all groups, the number of infectious episodes, the number of hospitalizations (fig. ) and doctor visits (fig. ) after beginning of regular ivig treatment dropped dramatically. we also followed patients with xla, who did not receive ivig therapy because of social aspects. both patients died from severe infections. we evaluated this fact in economical prospective: in russia one worker, who works continuously and retires at years of age brings about mln roubles into the state budget (when costs for schooling and routine medical care are subtracted). if one supposes that an xla patient have been diagnosed very early in life, did not form complications prior to therapy and was on regular ivig therapy for life, this sum equals to years on ivig. conclusions: regular ivig therapy not only leads to reduction of infectious episodes, hospitalizations, and as a result improved quality of life. in some cases it even brings down the disease-related costs, incurred by the medical system and the family, and is economically advantageous for the state. introduction: replacement of immunoglobulins is a standard therapy for patients with primary immunodeficiency disease (pidd) characterized by primary antibody deficiency (pad). this poster represents our clinical experiences of initiation of home-based treatment with subcutaneous immunoglobulin (scig) with the patients diagnosed with primary variable immunodeficiency (cvid). case report: the patient (age ) has been treated at our immuno-allergy outpatient clinic since with the diagnosis of hypogammaglobulinemia (igg, iga, igm) with normal b cell count, withsusp. cvid. with the repeated administration of intramuscular and intravenous immunoglobulins (ivig, imig) repeatedly occurred serious adverse reactions, which resulted in discontinuation of the replacement therapy. in february the health condition of the patient worsened due to recurrent bacterial respiratory infections. there was a progressive decrease of serum concentrations of immunoglobulins (igg , g/l, igm , g/l, iga , g/l). the patient was admitted to the intensive care unit of the st internal department, university hospital bratislava, for a subcutaneous immunoglobulin replacement trial. despite serious adverse reactions with previous administration of several types of immunoglobulins, there have not occurred any clinically relevant side effects. conclusion: compared with im or iv formulations and administration, for selected patients, scig is better tolerated, clinically efficacious, safe, and appreciated by the patients. background: common variable immunodeficiency (cvid) is primary immunodeficiency (pid) classically viewed as antibody deficit. although, cvid is considerd to be a humoral immunodeficiency, approximately % of cvid patients have low t-cell counts or abnormal tcell function. despite adequate immunoglobulin replacement patient morbidity and mortality is variable and a number of complications are not those typically seen in pure antibody pid e.g. xla. so, t-cell rather than b-cell phenotype could determine outcome in patients with cvid. many patients with cvid have clinical history suggestive of allergic respiratory disease, but prevalence of asthma and role of atopy have not been well established. apart from recurrent infections and their sequelae, cvid patients suffer from other disease-related complications in up to % of the cases. about % have onset before the age of years. aims: ) to present one more case of tadolescent with cvid and allergic asthma, ) emphasise ultimate need of collaborative network of primary immunodeficiency centers. case report: parents of , y boy were sure that "something was wrong" with their son and were seaking for problem solution for many years. since age , child had frequent respiratory infections. adenoidectomy and tonsillectomy were performed at age . sinuitis was diagnosed several times. boy was complaining of fatique for a long time. last several years, his main problems were fever (max c) usually lasting days till weeks, accompanying running nose, coughing, conjunctival problems; intermittently headache (lasting for a few hours till all day). oral aphtae were present almost every two weeks. he was incompletely vaccinated (bcg, and once diteper). morbilli and varicellae infections passed without complications. in jan he was diagnosed as allergic asthma in sarajevo (allergy to pollen, soya, nuts and antibiotics ("ceclor" and "pancef"). in february was admitted at children's hospital sarajevo for suspected primary mmunodeficiency. he had slightly lower levels of igg and iga (twice measured), normal ige and decreased number of t helper ly. due to suspected pid, boy was checked up in two nearest regional pid centers : hypogammaglobulinemia was confirmed (igg , , iga , , igm , , as well as deficiency of igg , igg and igg ). flow cytometry showed slightly raised concentration of lymphocites b (cd ), slightly raised number of nondifferentiated b cells. cvid was suspected but not proved. in july child visited center for primary immunodeficiencies in munchen, germany, were he was diagnosed ad probable cvid on the basis of hypogammaglobulinemia, lower levels od switch memory b cells, normal number of t-cells, positive antibodies to vaccinations and overcome infection (morbilli, varicellae). allergic asthma was additionaly confirmed in specialised pediatric pulmology hospital in germany (abnormal spirometry, normal ige, positive skin prick test, abnormal fractional exaled nitric oxid test, incipient brochiectasies due to asthma confirmed by high -resolution lung ct scan). low human immunoglobulin replacement was started ( mg/kgbw) as well as antiasthmatic therapy (inhalatory steroids, antihistaminics). excellent therapeutical response were achieved : after one , y follow up, we can confirm patient has excellent general condition, no subjective symptoms, no tiredness, no severe infections. conclusion: diagnosing cvid is challenging task and quite often could be "per aspera ad astra". there is ultimate need of collaborative work of primary immunodeficiency network aimed of diagnosing patients on time. cvid patients with history suggestive of allergic asthma, are negativne on traditional tests, additional test designed to identify allergic asthma might be conducted. common variable immune deficiency (cvid) is a heterogeneous syndrome characterized by hypogammaglobulinemia, recurrent infections, immune disregularity (autoimmunity, autoinflamation) and propensity to malignancies. in the us report, . % of cvid patients had a lymphoid malignancy, and cancers of other sorts developed in % of patients. it is not clear why cvid patients have higher risk of malignancy but chronic antigenic stimulation, chronic inflammation and increased chromosomal radiosensitivity may be the cause. cvid patients with higher igm level, reduced or absent b cell numbers, cd t cells lower than and pli phenotype have higher prevalence of malignancy. allergy and clinical immunology department of rasool e akram hospital has registered cvid patients. mean age of the onset of cvid symptoms was . years. mean diagnosis age was . years with mean diagnostic delay of years. mean follow up time was years (minimum . -maximum y). malignancy occurred in the follow up of patients ( %). one patient had two different malignancies (breast cancer and gi adenocarcinoma). malignancy risk per case was %. hodgkin's lymphoma was the most common type ( % of cancers common variable immune deficiency is a heterogeneous syndrome characterized by hypogammaglobulinemia , recurrent infections , auto immunity and auto-inflammation . more than % of cvid patients have auto immune complications and among them, auto immune cytopenia is the most common. cvid patients with higher igm levelhigher low b cellslower t reg levelslower cd /cd ratio and lower class switched memory b cells have higher prevalence of autoimmunity. allergy and clinical immunology department of this hospital has registered cvid patients. mean age of onset of cvid symptoms was . years. mean diagnosis age was . years with mean diagnostic delay of years. mean follow up time was years (minimum . maximum y). autoimmunity was detected in cases ( %) and cases ( %) had more than one autoimmunity. autoimmunity was the first symptom of cvid in percent of cases. autoimmune disorders should be considered in the follow up of cvid patients. igg is major immunoglobulin and classified subgroups as igg , igg , igg and igg . igg and igg subclasses are rich in antibodies aganist proteins such as the toxins produced by the diphtheria and tetanus, as well as antibodies aganist viral proteins. recurrent ear infections, sinusitis, bronchitis and pneumonia are common in ig g subclass deficiency. ig g is the major subclass of ig g. igg subclass deficiency is very rare. chronic eosinophilic pneumonia is one of the eosinophilic lung disease and is seen rarely. in the presence of peripheral eosinophilia and radiological pulmonary infiltrates diseases suspected. when increase in the number of eosinophils in bronchoalveolar lavage fluids and/or presence of eosinophils in lung tissue diagnosis is confirmed. according to different recording systems chronic eosinophilic pneumonia is % - of the interstitial lung disase. there is not any criteria for diagnosis but also diagnoses is confirmed with suspected findings. symptoms inludes that: )in the presence of respiratory symptoms for two weeks long )eosinophilia at alveolar lavage and\or peripheral blood ( bal fluid cytological examination > % , blood > /mm ) )radiological imaging of the lung peripheral infiltration )exclusion of the other causes of eosinophlic lung disease there is eosinophilia over /mm nearly all patients. one of third or half of patients have diagnosed as asthma. disease begin with systemic symptoms such as night sweats, weight loss, anorexia and pulmoner symptoms such as cough, shortness of breath, wheezing. patients have restrictive or obstructive findings in pft. one of third patients, especially with history of asthma, have obstruction in pft. İn the pathologic biopsy findings include; thickening of alveolar walls and accumolation of eosinophils and lymphocytes. long time used corticosteroids treatment is recomended. relaps is common when treatment is discontinued. we present the patient who has ig g deficiency, chronic eosinophlia and % eosinophils in bronchoalveolar lavage fluid. the patient improved long time used oral steroid then inhaled steroids. this was presented in terms of clinical association. case: a years old female patient who were followed due to asthma in the other center for two years, although use of combination inhaled fluticasone and salmeterol, patient was admitted with cough and sputum production. in thorax ct there were, bronchiectasis at right lower lobe, pneumonic consolidation in the right lower lobe and ground glass opacities. we detected as igg mg/dl ( - mg/dl), iga mg/dl ( - mg/dl), igm mg/dl ( - mg/dl), ige . mg/dl, igg mg/dl ( - mg/dl), igg mg/dl ( - mg/dl), igg mg/dl( - mg/dl), igg mg/dl ( - mg/dl). because eosinophilia ( cells) and symptoms continued, bronchoscopy was performed. left main bronchus was normal, right bronchus were seen dilated. purulent secretion was aspirated on rigt bronchus with flexible bronchoscopy ..in cytological examination % eosinophils was detected in bal. bronchoalveolar lavage cultures was negative. the patient was diagnosed chronic eosinophilic pneumonia and mg/ kg oral steroid was began. ivig was given up to patient; because of frequently recurrent sinopulmonary infection and patient had igg subclass deficiency. in the third month of oral steroid therapy physical examination findings and pft were improved and started inhaled steroid. conclusion: immunodeficiencies often can be seen alone. although, the pathogenesis of immundeficiencies with lung disease is not well understood and associated with interstitial lung disease. therefore, investigations must be include bronchoscopy and bronchoalveolar lavage. scid is a congenital heterogeneous group of diseases characterized by severe impairment of t,b, nk cell development and function. the hematopoietic stem cell transplanted patients with scid in the time period from to were evaluated. male/female ratio is / . median follow-up time is years ( months- years). parental consanguinity ratio was , %. mean age of onset of the symptoms was ± , months. most common clinical findings on admission were; pneumonia ( , %), moniliasis ( , %), diarrhea ( , %), dermatitis ( . %). classification according to t, b, and nk cell counts; (figure ). molecular genetic defects were determined in patients (figure ) are given. there is no difference between age groups according to occurrence of acute and chronic gvhd. death ratio increases with the increasing age. acute and chronic gvhd and number of deaths were significantly higher in peripheral stem cell transplanted patients. there is no statistically significant difference in occurrence of acute/chronic gvhd between b-and b + scid, who had been hla idantically transplanted from family donor. both groups have similar ratios of ivig treatment need after hsct. there is no statistically significant difference in occurrence of acute/ chronic gvhd between nk-and nk + scid, who had been hla idantically transplanted from family donor. both groups have similar ratios of ivig treatment need after hsct. death ratio was similar in groups. bcg dissemination in bcg vaccinated patients is significantly higher in the nk + group. the rate of complications due to severe infections is high and increases with age in patients with scid. hsct is curative, should be considered as early as possible. trec analysis for neonatal screening will give chance for early diagnosis and treatment of the patients. the hyper-ige syndromes are rare pids and are characterized by atopic dermatitis, skin abscesses recurrent pneumonias, elevated serum ige levels and sometimes mucocutaneous candidiasis. we have been evaluating and following up a group of patients with features suggestive for autosomal recessive hyper ige syndrome (ar-hies). homozygous dock mutations were identified in several of these patients. however, two siblings from a consanguineous family in this group of patients showed homozygous block in chromosome p . in homozygosity mapping which includes stk gene. sanger sequencing was performed for stk deficiency and showed a novel c. - delgata mutation in stk gene causing a premature stop codon. clinical manifestations of stk deficiency, also known as a macrophage stimulating (mst ) deficiency, stk deficiency comprise recurrent and severe viral skin infections including molluscum contagiosum and warts, fungal and bacterial infections and autoimmunity which are also the features of ar-hies. our patients's main features include autoimmune cytopenias (aiha and itp), cutaneous viral (molluscum contagiosum and mild perioral herpetic lesion), mild atopic dermatitis, seborrheic dermatitis, lymphopenia (particularly cd lymphopenia), and intermittent mild neutropenia. serum ige level was mildly high in these patients. our results indicates that patients that show clinical phenotype of ar-hies needs to be also evaluated for stk deficiency. determination of the underlying defect and reporting the patients are required for the description of the phenotypic spectrum of pids and the frequency of these diseases as well as for genetic counselling. mendelian susceptibility to mycobacterial disease (msmd) is a rare entity. patients with msmd have susceptibility to salmonella and some other intracellular microorganisms in addition to weakly pathogenic mycobacterial species. il- rβ deficiency, most common form of msmd, is caused by mutations in the il rb gene. patients who have symptoms suggestive for msmd or history of sibling death due to bcgosis were evaluated. the expression of the il- rb was detected in patients and family members by monoclonal antibodies on the lymphocyte surface by flow cytometry after the lymphocytes were stimulated in vitro with pha. mutation analyses was done by sanger sequencing. all index cases were presented either with bcg or salmonella infection. two patients, though they were bcg vaccinated had no clinical symptom, six presented with the symptoms of salmonella infections, two developed leukocytoclastic vasculitis, candidiasis was the accompanying feature in seven. recurrent leishmaniasis that necessitated subcutaneous interferon-γ and prophylactic amphotericine b therapy was present in a patient. in all patients the percentage of lymphocytes with il rβ expression was found to be less than % . prophylactic antimycrobial treatment and in severe and resistant infectious episodes if-γ therapy, should be given. many patients have associated mucocutaneous candidiasis. the prognosis is good unless the patient admits at the later stages of bcg infection. the results of our patients showed that the analysis of the surface expression of il rβ on activated lymphocytes is an effective diagnostic method which can also be used in screening of the patients with probable msmd. ataxia-telangiectasia (a-t) results from the loss of ataxia-telangiectasia mutated gene (atm) function and is a heterogeneous, multisystemic disease and characterized by accelerated telomere loss, genomic instability, progressive neurological degeneration, immunodeficiency, premature ageing and increased neoplasia incidence. even in classic a-t with ataxia and telangiectasia, the onset of clinical symptoms and the rate of progression are variable. here, we report two siblings was diagnosed as a-t with severe and early hypogamaglobulinemia, decreased cd , increased cd ro, no ataxia and telangiectasia, purulent otitis and hemophagocytosis that harbor a rare frameshift mutation of atm gene. Özdemir Öner ; bozdoğan sıla department of pediatrics, division of allergy/immunology, sakarya university, medical faculty, adapazarı, türkiye. department of pediatrics, sakarya university, medical faculty, adapazarı, türkiye. background: the acquisition of new food allergy after transplantation or transplant-acquired food allergy (tafa) is usually reported in adults and rarely in children. tafa is described mainly after liver, but also after small bowel/intestinal, lung and heart transplantations. in different studies, the male/female ratio is equal. literature data suggest that children with tafa typically present within the first year after surgery and they are typically allergic to multiple foods. aim: tafa is generally characterized with allergy to multiple foods and increased level of total and/or spesific ige. here, a patient although who had normal total. ige and specific ige test results, he developed reaction to skin prick test for cow's milk is presented and his clinical presentation will be discussed. case presentation: month-old-boy came to our allergy clinic with complaints of vomiting after drinking cow's milk and skin rush on the area where contact ed with chocolate. in his past medical histroy, left lateral segment of liver (donor was his mother) was transplanted to him when he was at months. the liver donor was not recorded as having a history of allergic disease. methylprednisolone and tacrolimus immunosuppression were used after the transplantation, and tacrolimus therapy was continued for prophylaxis of chronic rejection. when he was at months, family fed the patient with cow's milk but hours later he began to vomit. he vomited five times in two hours. then, he developed constipation. rectal irrigation was used. then oral intake stopped for two days. he was thought to be having food protein induced enterocolitis. his vomiting complaints repeated after intake of formula and baby food which include grain. so he fed with special formula including short-chain peptides and free aminoacids and his symptoms improved. past medical history: extrahepatic biliary atresia was diagnosed at weeks age with conjugated hyperbilirubinemia (according to scintigraphy and biopsy results). family history: his father has penicillin allergy and his aunt has asthma. at our outpatient clinic: height and weight were within normal percentiles. physical examination reevaled normal examination findings. laboratory findings: wbc was . /mm , with % neutrophils, % eosinophils and % lymphocytes. his hemoglobin was . g/ dl, platelet count was . /mm . background: except for antibody deficiency and complement defects, hematopoietic stem cell transplantation (hsct) is the single best curative treatment defined for primary immunodeficiency (pid) so far. in the current study, we aimed to assess the role of pid type, donor type and clinical status on hsct success rates. materials and methods: we retrospectively reviewed the records of a total of hscts procedures performed in patients diagnosed with pid between and , in ankara university pediatric allergy and immunology department. results: of the patients, had severe combined immunodeficiency (scid) and had non-scid. the survival rates following hsct, in both scid and non-scid patients were %. when classified according to the source of donor, patients who had a hla-matched sibling donor (msd) in the scid group had . % survival rate post transplantation, those who had a matched related donor (mrd) had . % and those who received a haploidentical donor had . % survival rates. in the non-scid group there were patients with haploidentical transplants ( omenn syndrome and mhc class ii deficiency) and all patients died. we assessed several potential risk factors associated with survival in scid patients. patients diagnosed over months of age with a pre-existing pulmonary infection, requiring intensive care and/or mechanical ventilation had significantly lower survival rates. conclusion: hsct is the best curative treatment for pid. our results demonstrated that hsct performed from matched family donors or even haploidentical parents is a lifesaving treatment in various types of pid's, especially in scid. introduction: in case of donor availability allogeneic hematopoietic stem cell transplantation (hsct) can be regarded as a definitive therapy for a variety of primary immunodeficiency syndromes (pids), including severe combined immunodeficiency (scid) and non-scid pids. study period: we retrospectively reviewed the hospital records of consecutive children with pid, who had allogeneic hsct in the last years, between january and january . our median follow-up time is , years ( months - , years) patients and methods: the median age of children at hsct was , months ( , months- years). boys/ girls diagnoses were based on anamnestic data, clinical findings, and immunological and genetic analysis. conditioning regimens included busulphan + cyclophosphamide, busulphan + cyclophosphamide + atg, fludarabine + melphalan or fludarabine + anti-cd in b-, t-, nk-scid cases conditioning was not used. indications for transplantation: patients' diagnoses were severe combined immunodeficiency (n = ), wiskott-aldrich syndrome (was, n = ), chronic granulomatous disease (cgd, n = ), xlinked lymphoproliferative disease (xlp, n = ), whim-syndrome (n = ), hyper igm syndrome (cd ligand deficiency, n = ), leukocyte adhesion deficiency (lad, n = ), dock mutation (n = ) transplantations: hscts for children were performed. patients were retransplanted ( pt once, pt twice, pt times), because of rejections. at the first hscts in / cases sibling bone marrow, / sibling peripheral blood, / sibling cord blood, / unrelated cord blood, / unrelated bone marrow, / unrelated peripheral blood, / haploidentical donors were used median cd count was , x /kg ( , x - , x /kg) patients engrafted on median ± day (anc > , g/l) acute gvhd occured in / cases ( pathomorphological findes: distortion of the structure of lymph nodes due to enlargement of paracortical zones and follicules was found in all patients. presumed atypical cells (makrolymphoblastes and berezovsky-sternberg-reed cells), were detected in patients overwise during follow-up for - years in these patients revealed no specific infectious and malignansy. accumulation of proliferating dn cells (a lot of mitoses) was characteristic fiture in lymph nodes and spleen of alps patients. setting of plasma cells in follicular zones in the lymph nodes was reveald in cases, and eosinophilesin , pronounced immunoblast proliferation in , sinus histiocytosisin . multiple hyperplastic follicles, extended sinuses with many phagocytizing macrophages, lymphocytic infiltration was revealed by histological examination of the spleen in all cases. immunohistochemistry findes: t-and b-cells proliferation (ki- expression), atypical location of lymphocyte populations, settings of plasma cells in all lymph node zones. in paracortical zones was found cd +, cd +, cd + cd -, cd + cd -cells in patients, cd +, cd + cells in patient; and in restricted follicular zones -cd +, cd +, hla-dr + cells in patients, cd +, cd + and cd + in patients. the presentation of a case of kimura disease in a patient with was. the was was diagnosed in year months, based on infectious syndrome, atopic dermatitis, hematological syndrome -skin hemorrhages and thrombocytopenia - * /l. after he performed often sars. regularly received ivig at mg/kg, antibiotic therapy with a positive effect -infectious syndrome stopped, controlled hemorrhagic syndrome. since there was a herpes virus infection with frequent exacerbations on the face. patient received acyclovir, valacyclovir, famvir with a temporary effect. in . on the left side of the face -periorbital region, eyelids, malar region appeared the site of soft tissue hyperproliferation - cm in diameter with a thickness of - cm, with moderate moist, painful on palpation, the left eye was closed, the lid margin ciliated dramatically thickened, deformed. in october-november was admitted in diagnostic department, massive antibiotic, antimycotic, antiviral therapy, ivig therapy. the histological study showed the angiolimphoid hyperplasia with eosinophilia without immunomorphological signs of malignant tumor growth. based on histological, immunohistochemical studies of the skin, these clinical and laboratory findings, diagnosis: mass lesion of the left face -kimura disease. patient helded courses of chemotherapy with positive dynamics: mass lesion decreased, erosive surfaces disappeared and now receives romiplostimum, acyclovir, biseptolum, ivig . g/kg time per month. under the observation there is a family k., which is unique in the deletion variants of the same region q. . and the presence of an adult patient with the di george syndrome. clinical manifestations of the syndrome in family members is differ. methods: clinical, laboratory, instrumental and genetic ( dna was isolated using a kit «qiaamp dna mini kit» and dna from dried blood spots was isolated using a commercial kit "dna-sorb-b». mlpaanalysis set salsa mlpa probemix p -b digeorge, genetic analyzer applied biosystems ). mother ( years), had few incidents of pneumonia before years. she was diagnosed ullrich-turner syndrome at age years. all childbirths by caesarean section. she has not any laboratory and instrumental findings of immunodeficiency, endocrinopathy, cardiac and thyroid abnormalities. she has deletion in the starting area of the di george region (lcr -a), including genes cltcl , hira, cdc , cldn , gp bb, tbx , txnrd , dgcr . father ( years), healthy, current smoker. the dna microstructural violations in di george region haven't been identified. son was from i pregnancy, heart defect was set prenatally, marked growth retardation. childbirth at weeks. he had unstable reduced cell parameters and hypogammaglobulinemia, the size reduction of the thymus and congenital heart disease: truncus arteriosus, dc b stage by lang. after days of life operated for congenital heart disease. during the surgical intervention the thymus wasn't found in a typical place. the postoperative period was complicated by sepsis, heart and respiratory failure. received ivig, antibiotic and antifungal therapy. he suffered from sars, severe course, the degree of respiratory failure ( months) -death. in mlpa-dna defined microdeletion disorders starting region di george (lcr -a) -from the -year-old dry blood sample (postmortem study a year old boy with bleeding, eczema and recurrent pyogenic infection was admitted to our department. the child who received treatment in hematology accidentally a few times, but has not had the effect of treatment . laboratory parameters -cd -cells- % ( ), cd -cells - % ( ), cd -cells - % ( ), cd -cells - % ( ), cd / -cells - % ( ), cd / cd - . , hla-dr- , nbt- . igg- . q /l, iga- . q / l, igm - . q / l, ige- u / ml. hb- g / l, erythrocytes- . x / l, leukosytes - . x / l, neutrophils- %, lymphocytes - % ( ), eosinophils- %, monocytes- %, metamielosytes:- %, plateletsrare was observed.normal bone marrow cells, the separation of platelets from meqakariosyt has become weak. the advantage of erythroid unordered have been observed. bone marrow puncture the mielokariosytes - . x / l, meqakariosytes - . x / l, blasts- . %, myelosytes - . %, metamyelosytes - . %, seqments - . % neutrophils-% . , eosinophils- . %, lymphocytes- . %, monocytes- . % erythroblasts- . %, pronormoblasts- . %, normoblasts- . % meqakariosytes - . %, plasmatic cells- . %.his younger brother with eczema, pyogenic infections (furunculosis) was admitted to our department. cd - % ( ) ataxia telangiectasia (a-t), is a genetic disorder caused by the homozygous mutation of the atm gene and, frequently associates with variable degrees of cellular and humoral immunodeficiency. however, the immune defects in patients with a-t are not well characterized. to our knowledge, there is no work on major lymphocyte subpopulations and recent thymic emigrants of a-t patients comparing to age-matched healthy controls. according to esid criteria, patients diagnosed as a-t and agematched healthy children were assigned to the study. both patients and healthy controls were grouped as - , - , - years and older than years. using flow cytometer, major lymphocyte subpopulations and cd + cd ra + cd + recent thymic emigrants (rte) were determined as per cent and absolute cell numbers and compared. no significant differences regarding all lymphocyte subpopulations were observed between age groups of a-t. comparing to the healthy controls, there were a decrease (in t cells, effector memory t cells, b cells, naïve b cells, switched b cells and rte) and there were an increase (in active t cells, naïve t cells and nonswitched b cells) in the absolute number and percent of some cell populations in the a-t group. findings of this study showed effector functions in some cell lymphocyte populations were decreased and could be thought that bone marrow of patients should be tried to increase the cells numbers. however, the study has an important limitation about patient and healthy population. ataxia-telangiectasia (a-t) results from the loss of ataxia-telangiectasia mutated gene (atm) function and is a heterogeneous, multisystemic disease and characterized by accelerated telomere loss, genomic instability, progressive neurological degeneration, immunodeficiency, premature ageing and increased neoplasia incidence. even in classic a-t with ataxia and telangiectasia, the onset of clinical symptoms and the rate of progression are variable. here, we report two siblings was diagnosed as a-t with severe and early hypogamaglobulinemia, decreased cd , increased cd ro, no ataxia and telangiectasia, purulent otitis and hemophagocytosis that harbor a rare frameshift mutation of atm gene. nijmegen breakage syndrome(nbs) is a rare autosomal recessive disease usually presenting at birth with microcephaly. here we present a case of nbs diagnosed at the age of twenty seven who admitted to our outpatient clinic with malaise, loss of appetite, weight loss and dyspnea on effort . she was hospitalized in another centre years before because of pneumonia, pancytopenia, generalized lymphadenopathy, hepatosplenomegaly and hypogammaglobulinemia (very low igg and iga) where she couldn't have any definite diagnosis. her past medical history was remarkable for primary amenorrhea and basal cell carcinoma excision from preaericular region when she was . she had no severe infection history before except frequent upper respiratory tract infections. her parents were consanginous and she had a brother died at months of age. microcephaly together with short stature, multiple palpable lymphadenopathies , splenomegaly and absent secondary sexual characteristics were prominent features in physical examination. direct fluorescence sequencing of the nbn gene showed a homozygous mutation in exon (c. _ delacaaa) which confirmed the diagnosis of nbs in our patient. nbs is mostly diagnosed in childhood. the delay in diagnosis was partly due to the lack of severe infections in her past medical history until she was . another factor that lead to the delay is that it is an unknown disease among physicians in turkey. the longest known survival is years in a patient who had no clinical features of nbs other than primary amenorrhea. as a result, our patient is one of the oldest patients reported in the literature presenting nearly all of the classical features of the disease and carrying the most common pathologic mutation. wiscott-aldrich syndrome (was) is a rare x-linked recessive immunodeficiency disorder characterized by thrombocytopenia, small platelets, eczama, recurrent infections and an increased risk of autoimunity and malignancy. the gene responsible for was is located in chromosome xp . -p - , which consists of exons, and encodes a -amino acid protein. in this study, we aimed to screen was gene mutations and analyze the effects of determined mutations in boys with non-classical was phenotype. ivs + g > a gene alteration in intron of was gene was identified in case , previously. so, rna isolation and then cdna synthesized was carried out. in case , after amplification of exons of was gene by pcr, the amplicons were sequenced. in this patient, g > c alteration was detected in the first base of intron . afterwards, cdna synthesized for detecting the splicing effect. based on the gel image results, cdna found to be base pairs smaller than the normal in case . in case , g > c alteration was detected in the first base of intron and then we determined multiple splicing products. two different splicing mutations (ivs + g > a and ivs + g > c) were detected in two cases with non-classical phenotype. ivs + g > a splicing mutation was stated in the literature, previously, but ivs + g > c mutation was first time identified in this study. whim is rare (< / ), heterozygous, autosomal dominantly inherited pid, caused by mutations in the gene encoding for the chemokine receptor cxcr , mapped on q locus. the altered cxcr / cxcl interaction impairs cellular homeostasis and trafficking, resulting in immunological dysfunctions with abnormal retention of mature neutrophils in the bone marrow (myelokathexis) and consecutive severe neutropenia, variable degree of lymphopenia and hypogammaglobulinemia. whim patients suffer from recurrent bacterial infections since early childhood and later on manifest a specific susceptibility to hpv infections with developing widespread warts. because of rarity of the disease, heterogeneity in clinical presentation and usually incomplete phenotype, the diagnosis is often delayed and whim syndrome is not suspected. a year old boy who is suffering from recurrent bacterial infections, often complicated with bronchopneumonia, with severe neutropenia, but also, with lower level of lymphocytes and still, normal serum immunoglobulin level is presented. he has no developed warts; neither his parents nor relatives have warts. at the age of years was unveiled the diseasecausing mutation in the cxcr gene (c. c > t; p.r x; heterozygote). severe congenital neutropenia accompanied with lymphopenia and findings of mature neutrophils in bone marrow, might be an easy approach for getting closer to the clinical diagnosis of whim syndrome. early identification is important for clinical and therapeutic management, allowing a more comprehensive follow-up and administration of appropriate therapy. we report two cases of congenital heart disease (tetralogia fallot and interruption aortic arch) with confirmed microdeletion chromosome q . by karyotype and fluorescence in situ hybridization analysis (fish). children underwent surgical correction of congenital heart defects with good postoperative outcome, although were complex. the phenotype of these patients can be extremely variable, frequently leading to clinical confusion, diagnostic delay, excess morbidity, early mortality. identification of these patients is essential for their adequate management and genetic counseling. a multidisciplinary approach is fundamental to ensure that the patient will be able to attain his or her maximal potential. the underlying cause of the juvenile periodentitis is not well understood but is now thought to be related to an abnormal immune system and to invading bacteria in the cementum of the teeth. instead painful fissures and recurrent pyogenic infections of the skin seem to be the most common medical complications. however, a number of pls patients with abscesses or pseudotumors of the liver have been described. there have been reports of pls patients with other stigmata such as growth retardation, non-symptomatic intracranial calcifications and mental retardation furthermore, coinheritance of pls and albinism type has been reported. case presentation: a yr old girl admitted to our hospital with chief compliant of skin lesions since early months of birth. in the past medical history; she had skin abscess and failure to thrive. on admission she had erythematous, shiny skin with generalized dry scaly predominantly palmoplantar hyperkeratosis and loss of teeth except four or five molar teeth. she informed that she had malformed teeth since childhood which fell off one by one. she had also poor oral hygiene non-pitting edema on lower extremities. no hepatosplenomegaly detected. family history was negative. she investigated for probable immune-deficiency with regard to skin lesions, history of skin abscess and ftt the lab finding are as following: cbc diff = normal ,crp = neg, esr = , ast = , alt = , alph = , alb = . , total pr = . , urea = , cr = . igg = , igm = , iga = , ige = . , cd = %, cd = %, cd = %, cd = %, cd = %, cd = % conclusion: according to nearly normal lab values and presenting signs such as: generalized pyogenic periodentitis, palmoplantar hyper keratosis and negative family history were attributed to a very rare autosomal recessive disorder with ectodermal dysplasia known as papillon-lefevresyndrome manifesting with palmoplantar hyperkeratosis and severe early onset of destructive periodontal leading to pre-mature loss of both primary and permanent dentitions. nijmegen breakage syndrome (nbs) is a rare autosomal recessive syndrome of chromosomal instability mainly characterized by microcephaly at birth, combined immunodeficiency and predisposition to malignancies. the disease is caused by mutations in the nbs gene, which encodes nibrin, a component of the hmre -rad -p complex involved in cellular response to dna doublestrand breaks. the aim of the present case report was to discuss two siblings with immunologically and clinically different phenotypes of disease presentation and to make an attempt to explain possible genotype-phenotype relation. the two patients and their non-consanguineous parents were clinically, laboratory and genetically investigated. for mother and father we observed no clinical presentation and no immunological abnormalities. sibling no. ( years old boy) had no history of recurrent infections and no deviation in immunological tests. sibling no. . ( month old girl) had recurrent infections since birth and iga, igg and igg deficiency as well as t-and b-cells deficiency. cytogenetic analysis revealed variable percent of spontaneous chromosomal instability which was more severe (in % of chromosomes analyzed) in sibling no. . additionally we sequenced bi-directionally ( amplicons) the dna samples from all family members to survey the germline genetic variation in the nbs gene. the del (exon ) was detected in both siblings in homozygous and in both parents in heterozygous feature. in order to explain different clinical and immunological presentation of two siblings the rest of the nbs exones were analyzed for genetic heterogeneity. no additional changes were observed. in conclusion patients with the same nbs genotype may show different phenotypes. other gene/epigenetic factors seem to play a role in phenotype modulation. omenn syndrome [mendelian inheritance (omim )] is an autosomal recessive form characterized by the presence of fatal generalized severe erythroderma, lymphoadenopathy, eosinophilia and profound immunodeficiency. objective: we studied clinical and immunological presentation of the disease manifestation and frequency c. - delaa (p.k vfs ) in rag gene among eastern slavs population. results: we collected clinical and immunological data of patients ( from belarus, -ukraine, -russia) females, males. age of omenn syndrome manifestation varied from st day of life to yr month. age of diagnosis - days to year months. in patients had classical immunological phenotype t(+/-)b-nk+, pt had tlowb + nk + with cd + tcrgd + expansion. in pts had mutation in rag gene, in had c. - delaa (p.k vfs ) in one or two alleles. at present moment in pts are alive, were transplanted, pt is prepared to bmt. conclusion: this study demonstrates that the most popular genetic abnormalities in eastern slavs children with omenn syndrome is c. - delaa (p.k vfs ) in rag gene. this information may be useful for rapid diagnostic of omenn syndrome in laboratories used sscp (single strand conformation polymorphism) before sequencing. under examination the patient particularly bright phenotype attracted attention: microcephaly, "birdlike" facial features (sloping forehead, nape, hypoplasia of brow ridges, broad nasal bridge and protruding midface, hypoplasia of the mandible). in addition, besides specific anomaly of the facial bones we noted: big ears, sparse hair and clinodactyly of the fifth fingers. clinical and immunological characteristics: the feature of the case is pancytopenia syndrome we have diagnosed at the early stages of observation and which is continued throughout the period of observation. erc - . - . x /l hb - - g/l leuk - . - . x /l neu - - % ( - cells/mcl) plt - - x /l data of immunological examination: iga - , g / l igm - , g / l igg - , g / l (other results of immunological examination are without features) the deep insufficiency of antibody production in our patient was the cause of serious, recurrent, and subsequently chronic bacterial sinopulmonary infections after years old. the results of clinical laboratory and immunological examination without significant features: erc - , - , x /l hb - - g/l leuk - , - , x /l neu - - % ( - cells/ mcl) plt - x /l iga - , g/l - . g / l igm - , g/l - . g / l igg - , g/l - . g / l (other results of immunological examination are without features) the x-linked chronic granulomatous disease (cgd) is a primary phagocytic cell deficiency characterized by severe bacterial and fungal infections of various organs. we report of a years of a male patient with xlinked cgd who presented with recurrent hepatic abscesses as the sole manifestation of the disease. phagocytic and bactericidal activities of granulocytes were studied by using microbiological assays. generation of superoxide anion by blood granulocytes was measured by the ferricytochrome c reduction test. cgd is an immunodeficiency caused by mutations in genes encoding subunits of the nadph oxidase complex. normally, assembly of the nadph oxidase complex in phagosomes of phagocytic cells leads to a "respiratory burst" essential for the clearance of microorganisms. cgd patients lack this mechanism, which results in life-threatening infections and granuloma formations. the leading cause of death are pneumonia and pulmonary abscess, septicemia and brain abscess. in neurogical manifestations various pathogens have been involved including aspergillus spp., s. prolificans, a. infectoria, salmonella and staphylococcus spp. there are only some several reports on fungal brain and spinal cord infection, aspergillus abscess resembling brain tumor, meningitis due to streptococcus and candida spp. in the past years we treated children with cgd. we present the infectological challenge of an x-linked cgd patient with brain abscess. in spite of our effort we were unable to identify its causative pathogen. empiric therapy sometimes resembles polypragmasia in cgd. to decrease mortality and morbidity from fungal infections in cgd the prophylactic use of itraconazole or voriconazole is widely recommended. a relatively new azole, posaconazole is active in pulmonary and cerebral fungal manifestations , indeed may be effective against fungi with inherent resistance to ampb or voriconazole. there was no etiological diagnosis in our case that did not respond to conventional antifungal and antibacterial treatment. based upon the findings and literature data we presume the causative agent might be some kind of moulds. we suppose the use of echinocandin and posaconazole as salvage ("prophylactic") therapy has resulted significant regression of the brain abscess. the diagnosis of chronic granulomatous disease (cgd) was verified in children during the past few years in the department of clinical immunology of regional children's hospital of chelyabinsk (russia). in our opinionin casesthe diagnosis was establishedearly enough. michael w. transferred to the neonatal pathology unit of our clinic at the age of days with vesiculopustules. take into consideration our own experience of observing children with this form of primary immunodeficiency in previous years, the child was conducted immunological examination, in particular, the test of restoration nitroblue tetrazolium by superoxide anionformed when oxygen explodes in leukocyte (nitro blau tetrasolium -nbt-test). this decision is caused by the fact that previously observed children with chronic granulomatous disease, had vesiculopustules in % at birth. the survey has revealed a complete lack of production of reactive oxygen species by neutrophils in the evaluation of nbt-test, which allowed us to suggest the diagnosis of cgd. the baby was banned vaccination against tuberculosis, and after reliever vesiculopustules the boy was discharged home. however, at the age of month the baby suffered from glandular abscess and right-segmental pneumonia. in cbc there is expressed anemia (hb g/l, erythrocytes - . x /l), leukocytosis ( x /l), accelerated esr ( - mm/h). at the age of months in the university of debrecen, medical and health science center debrecen, hungary, molecular genetic studywas conducted by prof. dr. laszlo marodi. it was revealed a mutation in c. g > a in exon of gene cybb (encoding subunit gp -phox), after that the diagnosis of cgd was finally verified. it was assigned a basic preventive antimicrobial therapy by trimethoprimsulfamethoxazole, and itraconazoleto prevent fungal infections. despite this since months the child has repeatedly and consistently suffered from bilateral groin lymphadenitis during the year, acute hematogenous osteomyelitis of the left ulna, pneumonias, purulent mesadenitis, endoperitonitis. the fact that the child aged months was diagnosed sepsisis evidence of the severity of infectious complications. clinical and biochemical blood tests were distinguished by consistently high levels of esr and the presence of leukocytosis, and also severe anemia. now the child is years months, he is undergoing treatment at the department of clinical immunology, russian children's clinical hospital (moscow) after bone marrow transplantation. case history № , christina n. from the early history we know that the girl's newborn period was uneventful. she was vaccinated against tuberculosis in the nursing home (no reaction). it was noted the formation of abscesses after vaccination against whooping cough, diphtheria and tetanus in and . months. in years months she suffered from mezootit. for the first time the girl came under our observation in the children's hospital in chelyabinsk (russia) at the age of years with right segmental pneumonia, complicated by the destruction. after further examination it was diagnosed tuberculosis of intrathoracic lymph nodes to the right with upper lobe bronchopulmonary defeat. to take into consideration given above, it was conducted immunological test that revealed a complete lack of production of reactive oxygen species by neutrophils in the evaluation of nbt-test. on the basis of the history, clinical manifestations and results of immunological examination chronic granulomatous disease was diagnosed. after fourmonth period treatment a recovery came from tuberculosis and child was transferred to outpatient monitoring. in years in this family a second daughter was born -arina n. taking into account revealed immunodeficiency of her sister, the child was not vaccinated against tuberculosis on our recommendations. a six-month-old child was conducted immunological examination, which, like her older sister, also shows a complete lack of production of reactive oxygen species by neutrophils in the evaluation of nbt-test. during the molecular genetic studies of both sisters it was identified identical mutation c. - del gt gene ncf (encoding subunit p phox). now the older girl is and her sister is years old. observing them in the dynamics neither of them do not show any life-threatening infections. thus, the recovery test of nitrobluetetrazolium by superoxide anion formed when oxygen explodes in leukocyte (nitro blau tetrasolium -nbt-test) is a fairly reliable method of early diagnosis of chronic granulomatous disease. chronic granolomatous disease (cgd) is due to defective phagocyte superoxide production leading to impaired microbial killing. it is comprised of a group of five genotypes with a common phenotype, chracterized by recurrent severe bacterial and fungal infections and tissue granuloma formation. patients with cgd often present with pneumonia, liver abscess, skin infections, lymphadenitis, osteomyelitis. a five month old boy was referred to pediatric infection unit by lymphadenitis. on the medical history, he had taken antibiotic therapy for lymphadenopathy when he was months old. the abnormal eye movement was noticed by the family and on the eye examination peripheric chorioretinal hypopigmented lesions were determined when he was months old. İn his labratory examination, viral serology were negative. his parents were not consanguineous. his mother's brother had died at years old. he had history of skin infections and osteomyelitis. his grandmother had been diagnosed as having tuberculosis lymphadenitis one year ago. on his physical examination, his growth was normal, patological findings were horizontal nistagmus, / degree systolic murmur, fistulized lymph tissue on the left submandibuler region. on the laboratory findings; he had anemia and neutropenia. immunglobulin levels and lymphocyte subtypes were normal. his respiratory burst activity was very low. chronic granulamatous disease was thougth in the patient by the clinical and laboratory findings. İt was detected gp phox mutation in the genetical analysis. he was diagnosed as having x-linked cgd. antibiotic prophylaxis (tmpsmx, flucanazol) and interferon gamma were started. he is months old now and he is on the list of match unrelated donor screening. patiens who has history of lympadenitis, skin infections and chorioretinal findings should be evaulated for the x-cgd. leucocyte adhesion deficiencies (lads) are rare autosomal recessive inherited disorders. three different forms of lads have been described so far. in lad-i, the most common leucocyte adhesion deficiency, the function of β integrin cd is lost. . while one of the first signs of the disease consist in delayed separation of the umblical cord, severe infections already start early during infancy. another feature of lad-i includes impaired wound healing. therefore, mortality during infancy is high. a fifty day old boy was referred to the hospital due to diarrhea and leukocytosis. the patient was delivered following an uncomplicated full term pregnancy. the parents were first degree cousins. father's brother and mother's uncle had died during infancy period. his umblical cord had separated on the th day. patient had applied because of diarrhea by starting in the first days of life and leukocytosis was detected ( . / mm ). on the physical examination, his body weight was gr ( th to th percentile) and his height was cm ( th percentile). there was a granuloma on the umbliculus. other systems were normal. in the laboratory examination, leukocyte count was high, immunoglobulins, respiratory burst activity, gaita analysing and culture were normal. in the lymphocyte subtype analysing, cd + b cells ratio was mildly low. cd , cd a, cd b, cd c levels were found to be very low. in the genetic analysing, it was detected two deleterious mutations in the itgb gene. patient had been diagnosed as lad- . he treated by antibiotics and then started prophylactic antibiotherapy. family screened for tissue match. his older sister was found full matched. he was referred to transplantation unit. it was applied bone marrow transplantation when he was months old. presence of delayed umblical cord separation and leucocytosis should be considered in the diagnosis of lad but these patients might have different symptoms such as diarrea. mendelian susceptibility to mycobacterial disease (msmd) is a rare entity. patients with msmd have susceptibility to salmonella and some other intracellular microorganisms in addition to weakly pathogenic mycobacterial species. il- rβ deficiency, most common form of msmd, is caused by mutations in the il rb gene. patients who have symptoms suggestive for msmd or history of sibling death due to bcgosis were evaluated. the expression of the il- rb was detected in patients and family members by monoclonal antibodies on the lymphocyte surface by flow cytometry after the lymphocytes were stimulated in vitro with pha. mutation analyses was done by sanger sequencing. all index cases were presented either with bcg or salmonella infection. two patients, though they were bcg vaccinated had no clinical symptom, six presented with the symptoms of salmonella infections, two developed leukocytoclastic vasculitis, candidiasis was the accompanying feature in seven. recurrent leishmaniasis that necessitated subcutaneous interferon-γ and prophylactic amphotericine b therapy was present in a patient. in all patients the percentage of lymphocytes with il rβ expression was found to be less than % . prophylactic antimycrobial treatment and in severe and resistant infectious episodes if-γ therapy, should be given. many patients have associated mucocutaneous candidiasis. the prognosis is good unless the patient admits at the later stages of bcg infection. the results of our patients showed that the analysis of the surface expression of il rβ on activated lymphocytes is an effective diagnostic method which can also be used in screening of the patients with probable msmd. introduction: mendelian susceptibility to mycobacterial disease (msmd, online mendelian inheritance inman ) is a rare immunodeficiency characterized by predisposition to infections caused by weakly virulent mycobacteria, such as mycobacterium bovis bacille calmette-gue´rin (bcg), environmental nontuberculous mycobacteria (ntm), and salmonella strains in otherwise healthy individuals. il- rb deficiency is the most common form of msmd and is characterized by childhoodonset mycobacteriosis with frequent recurrence. it has been found that patients with il- rb deficiencies are also prone to developing infections with nontyphoidal salmonella species with bacteremia and lymphadenopathy. here we present a girl with recurrent cutaneous leukocytoclastic vasculitis (clv) with salmonella enteritidis due to il- rb deficiency. case report: a four year old girl that had been diagnosed serologically with recurrent salmonella infections, associated with lymphadenopathy and skin eruption was admitted as having henoch-schönlein purpura. she had been vaccinated with bcg and developed left axillary lymphadenitis which spontaneously drained and had recurrent oral monilia plaque. edema and purpuric eruptions were present on the upper and lower extremities and the abdomen.multiple mobile, painful,enlarged submandibular lymph nodes of about x cm in diameter were palpable. skin biopsy showed a dense inflammatory site with eosinophils, neutrophils and fibrin in the upper dermis and dermal vessel wall,compatible with leukocytoclastic vasculitis. serological studies to assess diagnostic markers for vasculitis and infectious agents were all negative. immune work-up were unremarkable other than hypergammaglobulinemia. salmonella enteritidis was identified in blood culture. she responded dramatically to ceftriaxone treatment within a few days and lesions cleared completely. extended immunological and molecular genetic examination of the patient was carried out for il- /ifn-γ pathway defects. on the facs analysis of t cells for cell surface expression of the cytokine receptor chains, she did not express any il- rβ . discussion: in thepresent report, we describe a child with clv with salmonella enteritidis due to il- rb defi-ciency.in a large cohort of patients with il- rb deficiency, ntm, m. tuberculosis, disseminated bcg infection after inoculation with the vaccine, and salmonella infection have been described. sporadic cases with other infectious agents have also been reported. salmonella infections reported in these patients were due to extraintestinal, or septicemic, recurring infections caused by nontyphoidal salmonella species. only two il- rb -deficient patients have been identified with vasculitis due to salmonella strains; both came from turkey, where consanguineous marriages are common. kutukculer and colleagues reported the first case of s. enteritidis-associated clv. sanal and colleagues reported a clv case associated with group d salmonella infection. leukocytoclastic vasculitis is an immune complex mediated disease predominantly involving small vessels of the skin and can be associated with drugs or can be found as a component of other disease, such as infections, connective tissue disorders, and malignancies. infectious agents can cause vasculitis directly or clinically mimic primary vasculitis .multiple infectious agents have been suspected as triggering or contributory factors in the vasculitic process . several factors contribute to the primary vasculitis related to infections: a type or immune-complex reaction, cell-mediated hypersensitivity, abnormal immune regulation, and direct endothelial cell invasion by infectious agents. in our case, extensive evaluation was performed to determine the underlying vasculitis process. clinical and laboratory examinations revealed no association between vasculitis and other infections or an underlying connective tissue disease or medication. she responded well to ceftriaxone treatment, and clinical manifestations gradually resolved within a few days, providing strong evidence that improvement of the vasculitic lesions was due to elimination of the salmonella with antibiotics conclusion: our patient has one of the exceptional forms of il- rb deficiency, with recurrent clv due to salmonella enteritidis. although common presentations for salmonella infection in individuals with il- rb deficiency are lymphadenopathy and bacteremia, it can be present clinically as clv. some infections such as salmonella may be responsible for different types of vasculitis even though they are not common . in this respect, clinicians should be aware of possible infectious causes of vasculitis, and children presenting with unusual recurrent infections caused by non typhoidal salmonella, bcg, or ntm should be investigated for ifn-γ ⁄ il- pathway defects. gülez n.; genel f. dr. behcet uz children hospital allergy-immunology department, izmir, turkiye the complement system is an important part of the innate immune defense and also plays a major role in shaping the adaptive immune response. these functions are required for a good defense against infections, especially bacteria. the c deficiency is a rare disease that is associated with recurrent neisserial infections, especially meningits caused by n. meningitidis. the patient, a seven years old girl was admitted to hospital with high fever and diffuse, purple-coloured skin lesions. her symptoms gave the diagnosise meningococcal meningitis. she had also earlier been diagnosed with the same disease when she was years old. a sister to the patient had died from meningitis at years of age. she has also one older and one younger sister. there is no consanguinity between her parents. the laboratory analyses of the classical pathway measured as complement hemolytic activity (ch ) and c concentration revealed no activity and absence of c , respectively. analysis of serum from her younger sister showed the same results, while her older sister's ch and c levels were found normal. thus, our patient and her younger sister were diagnosed with hereditary c deficiency. the genetic analyses have not been completed yet. we here report the third and fourth cases of c deficiency in turkish patients. interferon-g receptor- (ifngr ) deficiency is caused by mutations in ifn-γ receptor- gene and is characterized mainly by susceptibility to mycobacterial disease. we report a boy with complete recessive ifngr deficiency, afflicted by recurrent mycobacterial diseases with m. bovis, m tuberculosis, m. avium intracellulare and m.fortuitum. genetic analysis showed a homozygous mutation ( inst) in ifngr gene leading to complete ifngr deficiency. in addition, he had atypical mycobacterial skin lesions caused by m.avium intracellulare and he developed scrotal and lower limb lymphedema secondary to compression of large and fixed inguinal lymphadenopathies. to our knowledge, the patient is the first case with interleukin- /interferon − γ pathway defect and severe lymphedema. defects in the il- / ifn − γ pathway must be considered in patients with disseminated or recurrent mycobacterial infections and in patients with severe viral infections, especially in countries where bcg vaccination is part of the national health programme. it must be kept in mind that these patients may develop granuloma-like skin lesions and severe lymphedema. hsct must be applied at the earliest time before developing organ damages. t lymphocyte/nk cells. restricted defective molecules in the circuit and recently discovered cybb responsible for autophagocytic vacuole and proteolysis have been identified in around % of patients with the mendelian susceptibility to the mycobacterial disease (msmd) phenotype. primary defects in oxidase activity in chronic granulomatous disease (cgd) lead to severe, life-threatening infections. the role of phagocytic respiratory burst in host defense against mycobacterium tuberculosis was controversial. previous studied showed that the critical role at reactive oxidants is to serve as intracellular signals for activation of microbicidal enzymes, rather than excretions a microbicidal effect perse.the role of phagocytic respiratory burst in host defense against m. tb is further supported by recent studies discovered immunological defects secondarily affecting phagocyte respiratory burst function and resulting in primary immunodeficiencies with varied phenotypes, including susceptibilities to pyogenic or mycobacterial infections. the patients with severe pid's like scid have broader diverse infections susceptibility and mycobacterial infections as well, however, common variable immunodeficiency (cvid) mostly characterized by a deficiency of immunoglobulins and recurrent sinopulmonary infections. method: we overview the clinical rate of mycobacterial disease in our pid cases and evaluate the complex cases. results: two hundred pid cases were evaluate between - in our clinic, among % of them which diagnosed as msmd nearly all presented with mycobacterial infection. % diagnosed as cgd and interestingly % of them have been experienced mycobacterial disease sometimes in their life, as disseminated bcg or late onset complications of bcg including osteomyelitis or mtb once or more than one episode through their life. also we have presented a cvid patient with disseminated tb and granulomatouse hepatitis, tb arthritis , peritonitis and a patient with lad and nontubercolouse mycobacterial infectiouse abcesses of her skin. conclusion: pid cases like cgd, msmd or cvid which are living in area's with high prevalence of mycobacterial infection could have quiet different presentations and the study of these complex cases has provided essential insights into the functioning of the immune system. despite the conventional view we have confirmed that the generation of rois by phagocytic respiratory burst may play a role in the defense of the host against m. tuberculosis by clinical evidence. goran ristic, srdjan pasic, bojana slavkovic division of clinical immunology, mother and child health care institute of serbia, belgrade chronic granulomatous disease (cgd) is a rare disease caused by mutation in any of the five components of the nicotinamide adenine dinucleotide phosphate (nadph) oxidase in phagocytes, resulting in recurrent, life-threatening bacterial and fungal infections of the affected individuals. our proband male patient presented at age of years with bilateral pneumonia and positive serology for aspergillus sp. the phorbol myristate acetate (pma) stimulated nitroblue tetrazolium (nbt) test showed no reduction ( %) in our patient and partial reduction ( %) in his mother. analysis of the cybb gene showed a deletion of nucleotide g (c. delg) exon causing frame shift mutation and early termination of translation (p.val serfs). this mutation was not previously described. at the moment of diagnosis, his mother was already pregnant, th week of gestation. fetal ultrasound showed that she was carrying a male fetus. the fetal blood sample, obtained by the percutaneous umbilical cord blood sampling, showed male karyotype and the pma stimulated nbt test showed % reduction. there were no complication during pregnancy or delivery and a healthy boy was born. the proband patient underwent allogenic hsct, his sister was the identical sibling donor. in the cases where the family-specific mutations are unknown, partial or complete gene deletions can be recognized by multiplex ligase-dependent probe amplification (mlpa) or array comparative genomic hybridization ( features of the patients with ar-hies dock- deficient and non-dock- deficient group are given in the table . all patients with dock- deficiency presented with cutaneous viral infections or early onset and severe atopic dermatitis. many have also food allergy and/or asthma. neurological complications and malignancy were seen in % and % respectively. sixty seven percent of patients had low t; %, low cd levels; %, high ige. the latter features were shared between patients with or without dock- deficiency, except atopic dermatitis which was mild when present in patients without dock- deficiency and ige levels were only mildly high or normal. we identified stk and coronin a deficiency in two siblings each among the patients who showed overlapping features with ar-hies and do not have dock- deficiency. our results showed that patients with dock deficiency have early onset and more remarkable eczema, food allergy, asthma, more marked eosinophilia, higher ige, low igm levels and development of malignancy. these features may be helpful in differentiation dock patients from patients without dock- deficiency. it seems routine lymphocyte subset study results are not helpful for this differentiation. alişan yıldıran , stephan borte murat elli , tunç fışgın ondokuz mayıs university, school of medicine, samsun-turkiye immunodeficiency center leipzig (idcl) at klinikum st. georg ggmbh, leipzig-germany hsct might be curative for some pids. our immunology and transplantation center was newly established. we retrospectively reviewed all children with pid who diagnosed and received hsct at ondokuz mayıs university or somewhere between june and december . twenty-two patients were identified. four of them were referred to us for hsct from other centers. the median age was months ( month- yr) at hsct. patients' diagnoses were scid (n = ), chs (n = ), leukocyte adhesion deficiency (n= ), mhc class ii deficiency (n= ), chronic granulomatous syndrome (n = ), hlh (n = ), was (n = ) and omenn's syndrome (n = ). seven patients received hla-matched related hsct; twelve haploidentical hsct and two matched unrelated hsct. one scid patient died just after her diagnosis. two patients developed bcgosis secondary to reactivation of pretransplant vaccination. one of them died due to hemophagocytic bone marrow aplasia, and the other has recovered. five patients had graft failure; two of them received no conditioning regimens because of general health status and the other because of cmv infection. at a median follow up of months (range - ), patients are alive, with overall survival of %. we conclude that; our clinic undertakes an important duty in our region for pid patients. also, different pid's could be seen in our region. nerological complication patient (epilepsy, brain infarct) outcome died (one with post -bmt comp., with malignancy all alive department of pediatrics and adolescent medicine department of allergology, rheumatology and clinical immunology, university children's hospital, university medical centre, ljubljana, slovenia. developed.there is no severe life-threatening complications development. we describe here a patient with invasive cryptococcus laurentii infection and the x-linked form of hyper-igm syndrome (x-higm). c.laurentii is an extremely rare human pathogen. this fungus was previously considered saprophytic and non-pathogenic to humans, but it has been isolated as the etiologic agent of skin infection, keratitis, endophthalmitis, lung abscess, peritonitis, meningitis, and fungemia. most affected individuals had a compromised immune system because of leukemia, cancer, diabetes mellitus, aids, or prematurity. repeated isolation of c.laurentii from the oropharynx of an immunocompromised patient has also been documented. invasive c.laurentii infection has not been reported in patients with any form of primary immunodeficiency disorder emphasizing the true rarity of disease due to this fungus. two groups have recently reported that dectin- deficiency due to the mutation of clec a or premature termination of the dectin- signal transduction molecule card may predispose patients to chronic mucocutaneous candidiasis (cmc). we studied the frequency of clec a mutation in healthy individuals, patients with the hyper-ige syndrome (hies), and patients with autoimmune polyendocrine syndrome type (aps- ), all aged between to years. genomic dna was isolated from peripheral blood. monocytes and monocyte-derived dendritic cells (mddcs) were used to study the phenotypic expression of dectin- . clec a gene was sequenced with the big dye terminator cycle sequencing kit. mononuclear cells (mcs) were isolated from heparin-treated venous blood. mdccs were obtained by culturing monocytes isolated by immunomagnetic cell separation assay. receptor expression was assessed by flow cytometry. secretion of il- a by mcs stimulated with killed c. albicans blastoconidia was assessed by elisa. we report here on healthy individuals with homozygous (one year-old man) or heterozygous ( men and women) tyr x mutation in the dectin- gene but no signs of cmc. dectin- levels on monocytes and mddcs were negligible in the homozygous man and the heterozygous individuals displayed intermediate levels of dectin- , between those of the homozygous man and the wild-type controls. markedly lower levels of il- a production were observed in the cells of the man with the homozygous mutation than in the control cells. levels of production of this cytokine were intermediate in heterozygotes. the frequency of tyr x heterozygous individuals was % among healthy donors and % in patients with hies and % in patients with aps . importantly, the year-old hies girl with heterozygous tyr x mutations has never had mucocutaneous candidiasis. we suggest that dectin- receptor-mediated immunity is redundant for host defense against cmc, possibly due to the involvement of multiple lectin receptors in the recognition and uptake of candida. chronic mucocutaneous candidiasis (cmc) is a heterogenous group with recurrent chronic candida infections spesifically involving nails, skin and oropharynx. several immunodeficiencies as dock- deficiency, severe combined immune deficiency, autoimmune polyglandular syndrome type (apeced), il- rβ and il- p deficiencies, card , stat- and stat- can cause cmc. we report here a years old boy, born to consaginous parents with onicomycosis, moniliasis, recurrent pneumonia, recurrent herpetic lesions, autoimmune thyroiditis and trombocytopenia. last admission was due to generalized tonic-clonic convulsion and mycotic aneurism on middle cerebral artery was detected. flow cytometry revealed cd lymphopenia, immunoglobulin values were in normal range. polymorphism on exon for aire gene (t/c heterozygot g g) and heterozygot stat mutation (c. > a; q h) were detected. various stat gof mutations (affecting the coiled-coin domain or the dna-binding domain) have been systematically associated with susceptibility to cmc. autoimmune manifestations associated with stat- mutations have been attributed to increased type interferon. the aneurism formation is not elucidated whether it's due to candida infection or vascular damage directly affected by stat- mutation. purpose: chronic granulomatous disease (cgd) is a rare genetic disease of phagocytic system. affected patients commonly present with bacterial infections associated with pneumonia, abscesses and lymphadenitis. in this study, we investigated the clinical and laboratory findings of our cgd patients. materials and methods: the demographic data (age at diagnosis, initial presenting symptoms, family history, follow-up period), mutation analysis, therapy options, complications, radiological findings and prognosis were evaluated retrospectively. results: among cgd patients, autosomal recessive form was detected in of them. the age at onset was statistically lower in x' linked cgd patients than ar form ( . ± . mo vs . ± . mo; p = . ).respiratory tract infections (sinusitis, otitis, pneumonia) and recurrent abscesses were more commonly seen at onset. microbiological culture revealed a. fumigates from lung biopsy in one patient and s.marcescens from blood specimen in other ones. bcgitis was observed in one patient and five patients received anti-tb therapy. non-infectious complications were granulomatous uveitis, recurrent pericardial effusion, skin granuloma, noduler formation in lung and brain area. conclusion: due to high rate of consanguinity, autosomal recessive inheritance was observed highly in our patient cohort. since, patients with cgd are susceptible to tuberculosis and bcg complications; initiation of tuberculosis prophylaxis is advisable in countries where bcg is still administrated at birth. key words: chronic granulomatous disease, consanguinity, bcg. acquired immunodeficiency research center, isfahan university of medical sciences, isfahan, iranbackground: defects of the immune system in primary immunodeficient diseases (pids) predispose individuals to recurrent infections. complex genetic components for susceptibility to mycobacterial disease have been suggested. natural human immunity to the mycobacteria group, including mycobacterium tuberculosis(mtb), bacille calmette-guérin (bcg) or nontuberculous mycobacteria (ntm) relies on the functional il- / -ifn-γ integrity of macrophages (monocyte/dendritic cell) connecting to key: cord- - ksfpaf authors: nan title: proceedings of the th european paediatric rheumatology congress: part : virtual. - september date: - - journal: pediatr rheumatol online j doi: . /s - - - sha: doc_id: cord_uid: ksfpaf nan introduction: juvenile idiopathic arthritis (jia) represents the most common pediatric chronic rheumatic disease. children with jia present an increased risk of infections, due to the immune-regulatory effects of disease modifying antirheumatic drugs (dmards); many of these infections are vaccine-preventable. nevertheless, suboptimal vaccinations rates are reported in children with jia. objectives: to evaluate vaccination coverage in a population of children with jia and to describe the prevalence of the adverse events following immunization (aefis) in our cohort. methods: a single-centre retrospective study was conducted by reviewing medical records of all jia patients, diagnosed according to ilar criteria, admitted to the pediatric rheumatology unit of university of naples federico ii from january to december . parents were asked to provide the vaccinations records in form of the vaccination booklet. the occurrence of aefis was explored by telephone interviews. introduction: intrarticular corticosteroid injections (iaci) are widely used in the management of patients with juvenile idiopathic arthritis (jia). general anesthesia can be avoided in case of a small number of joints to inject or in older children. however, pain and anxiety may reduce the patient compliance to iaci, and may compromise the accuracy of the procedure. in order to overcame such problems, the use of appropriate methods of pain and anxiety control is advisable. objectives: to assess the effectiveness and satisfaction of patients undergoing iaci with the use of topical numbing agent or under minimal sedation. methods: patients with jia who underwent an iaci of up to joints were recruited. depending on age and number of joints to treat, a group of patients (group a) were injected with the application minutes prior the procedure of a topical numbing agent (prilocaine+lidocaine) to the skin over the injection site. another group of patients (group b) were treated under minimal sedation (ketorolac/tramadol or morphine + midazolam). the physician was asked to record the degree of motion and pain of the patient during the procedure and the patient (or parents for patients aged less than years) was asked to report the degree of pain and satisfaction on a visual analogue scale (vas) from to . results: twenty-seven patients were enrolled for a total of procedures, and of them in group a and b, respectively. the median age at the procedure was years for group a and years for group b. for group a median pain scores for patients, parents and physicians were , and . , respectively. in patients of group b who underwent the iaci under ketorolac/tramadol the median pain scores for patients, parents and physicians were , . and . , whereas in patients treated with morphine median pain scores were , and , respectively. overall, we found that pain as reported by the patient/parent were higher with increase in the number of sites injected (and, consequently, duration of procedure) and age of patient. amount of motion during procedures was overall negligible. the majority of patients/parents was satisfied for the procedures. only patients treated with midazolam had psychomotor agitation during the iaci. conclusion: iaci in a small number of sites without the use of general anesthesia is well tolerated by patients. the level of pain perceived from patients is irrespective of the power of the painkiller used, but seems to correlate with the duration of the procedures. it is possible that, in the paediatric age, the psychoemotional component seems to be decisive, with a progressive loss of tolerance with the increase in the number of injected joints. for gc-ms analysis of the steroid hormone metabolites age and sexmatched healthy controls were matched to each patient. patients were excluded if they were treated with corticosteroids in the preceding months. results: of the metabolites measured, were significantly lower in jia patients before the etanercept treatment compared to the healthy control group. one day after the injection only metabolites were still significantly lower in the jia patients and all the other metabolites normalized and were similar to the control group. urine metabolite ratios reflecting cyp and β-hsd enzymatic activity indicate that these two enzyme activities were lower in jia patients. the slowest recoveries noted were for metabolites of dheas and oh pregnenolone. conclusion: prior to etanercept treatment almost all urine adrenal metabolites were significantly lower mainly due to the active inflammatory process. immediately after the treatment many metabolites raised to normal values as in the control group. the two adrenal enzymes that were found to be affected in jir are cyp and β-hsd . blocking tn alpha immediately restore adrenal function in jia. introduction: patients with juvenile idiopathic arthritis (jia) receive adalimumab treatment. adalimumab is a monoclonal antibody that blocks tnf-α and is structurally and functionally similar to human igg . nevertheless, there are reports of the development of anti-drug antibodies. the production of these antibodies may be associated with treatment failures (a decrease in the effectiveness of therapy or drug inefficiency that developed over time) and hypersensitivity reactions. to our knowledge, there is currently limited information on the availability of adalimumab antibodies (aaa) in patients with jia. objectives: to evaluate the prevalence rate and the clinical significance of aaa in patients with jia on adalimumab treatment. methods: patients with jia were examined, of whom had the oligoarticular form of the disease, of them with uveitis, and patients had the polyarticular form of the disease, of them with uveitis. among them, there were ( %) girls and ( %) boys. the mean age was . ± . years; the mean disease duration was . ± . years. patients received adalimumab (at least year before the study) with concomitant administration of methotrexate (mtx) or adalimumab only - children who did not receive mtx for at least months prior to the study as a result of either adverse events of mtx administration ( patients) or permanent drug remission ( patients). before starting adalimumab therapy, all participants were treated with mtx. the mean duration of adalimumab treatment for these patients was . ± . years. the serum aaa level of antibodies was determined using the enzyme immunoassay (eia) method. this method determines both free and bound antibodies to adalimumab at reference values less than au/ml. a and was used every weeks for months. the values were presented as mean ± standard deviation. data processing and analysis were carried out using pearson's chi-squared test and spearman's correlation test. results: ( %) of the patients enrolled in the study had aaapositive results. the mean aaa level in positive patients was . ± . au/ml. further disease relapses tended to occur significantly more often in aaa-positive patients than in aaa-negative ones (χ = . , p = . ). thus, of ( . %) aaa-positive children had at least exacerbation of the disease within months, compared with of ( . %) in aaa-negative ones. out of ( . %) aaapositives did not take mtx for at least months compared to out of ( . %) in aaa-negative ones. thus, aaas are found to be significantly more frequent without concomitant administration of mtx in the treatment of jia (χ = . , p = . ). there were no observed adverse events or side effects during adalimumab therapy. no significant correlation was found between the presence of aaa and sex, introduction: advances on molecular medicine, illumination of the cytokine network and the immune pathways shed light on the etiopathogenesis for a better understanding of juvenile idiopathic arthritis (jia). however, the fact that the course of the disease differs individually strongly suggests the effect of external factors. objectives: the current study was undertaken to evaluate sociodemographic and sociocultural features, parent behavior, the gestation and breastfeeding period, nutritional status of early childhood in our patients with jia, and to determine their relationship with disease activity, damage index, remission time, and relapse rate. methods: the study was conducted with a face-to-face questionnaire method with the parents of patients with jia and healthy children. the medical patient records were reviewed. juvenile arthritis disease activity score (jadas) , wallace clinical inactive disease criteria, juvenile arthritis damage index (jadi), and relapse rates were used to assess the general medical condition of each patient. results: the median age of jia patients (n = ) was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , with a female ratio of , %. age at disease onset was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) years. the first remission time was ( - ) months. the patients were evaluated according to disease subtypes and treatment modalities. there was no difference in the duration of breastfeeding according to the distribution of the subtypes (p = , ). when the breastfed and formula-fed patients were compared, there was a marginally significant difference in terms of first remission time (p = , ), whereas there was a significant difference in relapse rate in patients who introduced to cow milk early (< months) (p = , ). the early risk factors and their relationship with the disease are presented in table . both breastfeeding durations and maternal literacy levels showed a significant difference in terms of relapse rates (p = , ; p= , , respectively). there was no significant difference in breastfeeding durations and gestational risks between the patients and the healthy group (p = , ; p= , ), respectively. however, the smoking rate among family members was significantly higher in the patient group (p = , ). conclusion: in patients with juvenile idiopathic arthritis, breastfeeding rate and duration did not differ when compared to healthy controls. however, breastfeeding duration, cow's milk commence age, and maternal literacy appeared to be relevant to the relapse rates. going to preschool both influence the remission time and relapse rate. these findings suggest a role for parental attitude and nutritional status during early childhood in the course of jia. none declared introduction: immunogenicity and low trough concentrations have been associated with adalimumab treatment failure in several studies of paediatric inflammatory diseases, indicating the possible value of therapeutic drug monitoring (tdm). adalimumab efficacy may be improved by changing dose or treatment intervals based on drug concentrations. however, lack of standardization, assay heterogeneity, and paucity of research hinder the implementation of tdm in clinical practice. objectives: to assess the relationship of trough concentrations, immunogenicity and adalimumab response in paediatric patients with jia. methods: monocentric cohort study of patients ≤ years with jia treated with adalimumab due to active arthritis. clinical data and plasma samples were collected during routine follow-up. adalimumab trough concentrations were measured by liquid chromatographytandem mass spectrometry (lc-ms/ms). anti-adalimumab antibodies were measured in samples with trough concentrations < mg/l. disease activity was evaluated using the clinical juvenile arthritis disease activity score with joint count (cjadas ). response to adalimumab was defined as at least % reduction of disease activity within months of therapy followed by clinical inactive disease or minimal disease activity after months. the latter was defined as cjadas ≤ . and ≤ . , for oligoarthritis and polyarthritis, respectively, or an active joint count equal to zero when cjadas was unavailable. results: adalimumab trough samples were available from jia patients. although there was no significant difference in median adalimumab dose, trough concentrations were significantly lower in patients with secondary failure compared to primary failure or an adequate adalimumab response (p-values < . ). in addition, there were samples with trough concentrations < mg/l, in the group with secondary failure and in the group with adequate adalimumab response (table ) . conclusion: adalimumab trough concentrations were significantly lower in jia patients with secondary failure compared to primary failure or an adequate response to adalimumab. anti-adalimumab antibodies were present in out of samples with trough concentrations < mg/l. adalimumab trough concentration measurements may identify jia patients that would benefit from increased doses or shorter treatment intervals. in addition, jia patients with primary failure and adequate adalimumab trough concentrations may respond better to biologic agents with other therapeutic targets. although biologic agents have improved disease outcome of patients with jia, concentration measurements using reliable and cost-effective methods, such as lc-ms/ms, could further improve efficacy of biologic agents and guide treat-to-target strategies. introduction: most studies of physical fitness (pf) in juvenile idiopathic arthritis (jia) have shown decreased levels of maximal oxygen consumption (vo max) compared to healthy peers. in jia, boys have higher pf-levels than girls and younger children have higher levels than adolescents, congruently with data of healthy peers. previously, we have shown that more than half of jia-patients had below normative average of vo max. however, monitoring physical activity (pa) using accelerometry, % of boys and % of girls with jia fulfilled the recommendations of who of ≥ hour of pa per day, which was comparable to normative values ( %/ %). moreover, patients reporting engagement more than hours per week in club-sports exceeded accelerometry values of healthy peers. objectives: to explore the association between pf and specific sport habits in to -year-old jia-patients, related to gender, bmi, disease activity, and pain, and comparing the most fit quartile (q ) of patients (respectively boys and girls) to the least fit quartile (q ). methods: sixty patients with jia performed an indirect ergometertest of vo max (watt max test) and answered the physical activity and sport questionnaire (pasq). objective pa-monitoring for one week was conducted using the gt m accelerometer. cut-offs for moderate-high and high intensity pa were set to > and > counts per minute, respectively. disease activity was assessed with the jadas- , current pain and worst pain last week were measured on visual analogue scales (vas) and in a one-week pain diary using the faces pain scale-revised (fps-r). results: girls with jia (n= ) had lower mean pf than the boys (n= ) ( . ± . / . ± . ml/kg/min), being below normative values, respectively. in both genders the most fit boys and girls (q ; . - / . - ) had average to well-above normative average pf. the least fit boys (q ; . - . ) all had pf-levels well-below normative average. in girls q -levels ( . - . ) were well-below to below normative average. we found significant differences between most fit (q ) and least fit (q ) patients regarding patient´s global wellbeing (p= . ) and pain diary (p= . ). these differences were not significant when separating genders, though differences were more pronounced in girls. the least fit girls (q ) had significantly higher disease activity (jadas- ) than the most fit girls (q )(p= . ). the most fit boys and girls (q ) engaged equally in high intensity sports (soccer: / ; / , handball: / ; / , gymnastics: / ; / , rowing: / ; / ). however, more boys than girls played soccer ( / ; / ), whereas more girls preferred sports of lower intensity (riding: / ; / ). eight of boys in soccer and boys in gymnastics or rowing had below average to well-above normative average of pf (q +q : . - ). three girls in gymnastics, girls in soccer, and girls in handball were in q ( . - ) with levels of average to well-above average pf. the third girl in soccer was in q ( - . ) with levels of well-below to below normative average. none of the riding girls were in q and only was in q ( . - . ) (below to average normative pf). comparing accelerometer-monitored values of pa-intensity in girls with low (q ) and high (q ) pf, pavalues of q were significantly lower than in q . the same tendency was observed in boys, but not to significance. conclusion: our results are in accordance with most other studies of pf in jia, adding to the knowledge of gender-specific differences in pf and type and behavior in sport activities. it emphasizes the need of regular pf-testing and guidance in high intensity pa and sport in order to improve pf and avoid the risks of inactivity and lifestyle diseases in jia. pg/ml), which also showed the highest the frequency of detection of its increase. it was absent in sjia ( . ± . pg/ml). the highest values of il- r ( . ± pg/ml) were in the middle age group. the data obtained suggest the compensatory value of increasing il- r and the simultaneous initiation of inflammatory and anti-inflammatory processes during exacerbation of jia. assessment of the ratios of stimulating and inhibiting cytokines showed in patients with uveitis, the ratio of ifn-γ/il- β ( . ± . ) was higher than with other jia (from . ± . in ojia to . ± . in pjia) and ifn-γ/il- r ( . ± . versus from . ± . in ojia to . ± . in sjia). an increase of il- β/il- r ratio was characteristic only for sjia ( . ± . ). all of these ratios increased with disease activity (r= . - . ) & they did not reflect the unpleasant course of the disease. methods: in this multicenter, case-control study, fecal samples were collected from children with jia, with of these samples collected from untreated children ( of whom were treatment-naïve children). samples from children with jia were collected during treatment with mtx as single treatment and samples from children during treatment with etn. of those children, four were treated with etn as single treatment and nine had a combination of etn and mtx. we compared children on single treatment with mtx with untreated children ( treatment-naïve), and children on treatment with etn (nine in combination with mtx) with untreated children ( treatment-naïve). we also did pairwise comparisons of samples taken before any medication was given (n = ) and samples taken during ongoing treatment with mtx (n = ) or etn (n = , four in combination with mtx). the microbiota was characterized by sequencing amplicons from the v and v regions of the s rrna gene. alpha diversity of the fecal samples was measured using the chao- index and the shannon diversity index. to compare these indices between treated children and untreated children, we used a logistic regression model with age at sampling as a covariate. for pairwise analyses, we used the wilcoxon signed-rank test. to analyze the community composition of the microbiota, principal coordinate analysis (pcoa) plots based on bray-curtis distances were generated for visual comparisons, and analysis of similarity (anosim) was used to test for differences. analyses for relative abundances of taxa were performed at three taxonomic levels (phyla, families, and genera), and logistic regression with age as a covariate was used for calculations of differences between treated and untreated children, while the wilcoxon signedrank test was used for pairwise comparisons. significance was set to p < . and corrections for multiple comparisons were made using the benjamini-hochberg method. results: analyses showed no significant differences in α-diversity between children treated with mtx or etn and untreated children, and pairwise comparisons of samples before and during treatment with mtx or etn also showed no differences. pcoa plots for children treated with mtx or etn, in comparison with untreated children, did not show any clustering. anosim showed no significant differences between treated and untreated children. pcoa plots were also made for the pairwise comparisons of children sampled before and during treatment, and according to that analysis the community compositions of microbiota did not change in any uniform way during treatment with either mtx or etn. furthermor, analyses of relative abundances of specific taxa did not reveal any significant results in any of the comparisons, after adjustment for multiple analyses. conclusion: treatment with mtx or etn did not alter the composition of fecal microbiota in children with jia. introduction: juvenile idiopathic arthritis (jia) is the most common rheumatic disease in childhood and an important cause of shortterm and long-term disability if patients are not treated appropriately. by definition, jia clinically presents with peripheral joint inflammation of unknown origin, persisting for at least six consecutive weeks and starting before the age of years. the predominant subtypes, i.e. oligoarticular (oligo) and polyarticular (poly) jia, have long been assumed autoimmune diseases caused by dysregulation of the adaptive immune system, with a central role for autoreactive t cells belonging to the th and th lineages and autoantigens that may include aggrecan, fibrillin, matrix metalloproteinase (mmp)- and heat shock proteins. nevertheless, the original t cell-centered hypothesis has been challenged since it does not cover nor completely explain the full spectrum of immune-pathological phenomena observed in patients. lien.desomer@uzleuven.b objectives: emerging evidence suggests a potentially important role for neutrophils in jia pathogenesis. here, we investigated extensively the phenotypical features of neutrophils present in the peripheral blood and inflamed joints of jia patients. methods: synovial fluids and parallel blood samples from patients with oligo-or polyjia and blood samples from healthy children were collected. multicolor flow cytometry panels allowed for in-depth phenotypical analysis of neutrophils, focusing on the surface expression of adhesion molecules, activation and maturation markers, chemoattractant-and toll-like receptors. multiplex technology was exploited to quantify pro-and anti-inflammatory cytokines in plasma and synovial fluids. results: the vast majority of synovial fluid neutrophils displayed a strongly activated, hypersegmented phenotype with decreased lselectin (cd l) expression and increased numbers of nuclear lobes, upregulation of adhesion molecules cd b, cd b and cd and downregulation of chemokine receptors cxcr / . an elevated percentage of cxcr -expressing aged neutrophils was detected in synovial fluids from patients. strikingly, significant percentages of synovial fluid neutrophils showed a profound upregulation of atypical neutrophil markers, including cxcr , icam- and hla-dr. conclusion: our data indicate that neutrophils present in inflamed joints of jia patients are strongly activated cells with elevated proinflammatory and antigen presenting potential. this detailed molecular analysis supports the notion that a complex intertwining between these innate immune cells and adaptive immune events drives jia. none declared the main factors, associated with incomplete vaccination againts measels, parotitis, rubella and diphtheria in juvenile idiopathic arthritis patients n. lyubimova , i. objectives: the aim of our study was to evaluate the rate and the main factors of incomplete vaccination against measels,parotitis, rubella (mmr) and diphtheria in jia patients. methods: in the present study were included data jia( boys and girls)aged from to years,who received scheduled vaccination before the age of years and before jia onset against measles,parotitis,diphtheria and rubella.incomplete vaccination means the reduced number of vaccine to age.in all patients the ig g anti-vaccine antibodies levels were detected with elisa.jia categories were:oligoarthritis - ,polyarthritis - ,systemic- and enthesitisrelated arthritis- .data presented with median and %> % results: incomplete vaccination against mmr was in ( %)diphtheria in ( %) of the jia patients. the main differences in the studied groups are in the table.there were no differences in sex,jia categories and treatment, except biologics compare to complete and complete vaccination in all vaccines.no differences in antimeasels(p= . ),antiparotitis (p= . ) and anti-rubella(p= . )vaccination between complete and incomplete vaccination group.number of patients with protective level of anti-vaccine antibodies was similar, except parotitis( % vs . %, p= . ).the anti-diphtheria antibodies igg level was lower in the patients with incomplete vaccination group ( . iu/ml [ %ci: . ; . ] vs . [ %ci: . ; . ], p= . )as well as number of patients with protective level( % vs %, p= . ). in the multiple regression model only jia onset age(p= . )and methotrexate treatment duration(p= . ) were predictors of incomplete vaccination against mmr and methotrexate treatment duration(p= . ) and biologic treatment(p= . ) for diphtheria incomplete vaccination.incomplete mmr vaccination influence on the maintenance of the protective anti-parotitis level(p= . )in regression model.in correlation analysis the number of vaccination influences on anti-diphtheria antibodies level(p= . )and number of patients with protective level of anti-diphtheria antibodies(p= . ). the main predictors in logistic regression for incomplete vaccination for mmr were:onset age< years(or= . conclusion: younger onset of jia age, longer duration of jia and methotrexate treatment, biologics and more than biologics are the main predictors of incomplete vaccination againt mmr and diphtheria. introduction: the prevalence of autoimmune thyroid disorders (aitd) has been reported to be higher in patients with juvenile idiopathic arthritis (jia) in comparison to the general population. nevertheless, there is a lack of studies investigating risk factors for aitd development in children with jia. objectives: to investigate the co-occurrence of jia and autoimmune thyroiditis in southern italy and to identify potential predisposing factors to anti-thyroid antibodies (ata) positivity in a jia population. methods: a single-centre retrospective study was conducted. all jia patients admitted to the pediatric rheumatology unit of the university of naples federico ii, from january to december , tested for ata at least once and with a minimum of -months follow-up, were included. for each patient, demographic, clinical and laboratory data were extracted from clinical charts. differences between patients affected by jia with or without ata were analyzed. results: three hundred thirty jia patients ( females; median age . years, iqr . - . ) were included in study. median age at jia onset was years (iqr: . - . ). twenty-three patients [ % ( % ci . - . )] presented ata positivity. twenty-one of them ( . %) were females. anti-thyroperoxidase was positive in / patients ( . %) while patients presented anti-thyroglobulin positivity ( . %). both antibodies were present in / ( . %). patients showed the typical ultrasound findings of autoimmune thyroiditis, resulting in a prevalence of hashimoto's thyroiditis of . % ( % ci . - . ) in our cohort. three female patients developed subclinical hypothyroidism, whereas one male patient presented subclinical hyperthyroidism. the remaining patients were euthyroid. no statistically significant difference was observed in regard to age of jia onset, follow-up duration and jia subtype between the patients with or without ata. the proportion of females was marginally significantly higher (p= . ) in the group with ata positivity compared to children without thyroid antibodies ( . % vs . %, respectively). . % of patients with ata showed ana positivity compared to . % of patients without ata (p= . ). family history for aitd was significantly higher in children with thyroid antibodies positivity (p= . ). anti-tnf-alpha inhibitors were administered in only children ( %) with thyroid antibodies before their detection compared to . % of patients without thyroid antibodies (p= . ). multivariate regression analysis showed that patients with a family history for aitd were about four times more likely to develop ata (or . , % ci . - . , p= . ) and confirmed that ata positivity is less likely to occur in patients undergone anti-tnf-alpha therapy (or . , % ci . - . , p= . ). conclusion: a high prevalence of ata positivity and hashimoto's thyroiditis in patients with jia was found in our wide southern italian cohort. as expected, a positive family history of aitd was found to be associated with a higher risk to ata development during the follow-up. this finding supports the usefulness of an active screening for aitd in jia children, in particular in patients with relatives affected by thyroid disorders. notably, patients treated with tnf-alpha inhibitors resulted less likely to develop thyroid antibodies. further studies are needed to investigate the effect of anti-tnf-alpha therapy on thyroid autoimmunity in jia. introduction: the knee is considered by far the joint most frequently affected at jia onset. nonetheless, jia onset may present with unusual musculoskeletal involvement, eventually leading to a delay in the diagnosis and treatment. objectives: to identify the type and number of musculoskeletal sites affected at jia onset in consecutive patients seen at the study center in an years period. methods: records of patients with new diagnosis of jia from june to may available information in the medical history and standardized joint assessment at diagnosis, were retrospectively reviewed. systemic jia subtype according to ilar classification criteria were excluded. demographic and clinical features, including the type and number of joints at disease onset and diagnosis, were registered. data were analyzed through descriptive statistics. results: of a total of caucasian patients included in the study ( . % females), patients ( . %) had oligoarthritis, ( . %) rf-negative polyarthritis, ( . %) rf-positive polyarthritis, ( . %) psoriatic arthritis, ( . %) enthesitis-related arthritis (era). antinuclear antibody (ana) were positive in patients ( . %). the median age at onset was . years (iqr . - . ). at diagnosis ( . %) patients had only active joint, ( . %) had - active joints, ( . %) had ≥ . as expected the knee, the tibiotalar and the wrist were the most frequently affected joints ( . %, . %, . %, respectively); cervical spine was involved only in patients with polyarthritis (n= ). notably, of patients with monoarthritis at diagnosis presented with large joints involvement, among which n= isolated elbow and n= isolated wrist, and with small joints involvement (table ) . no sufficient data were available regarding the involvement of tendons and bursae, since the standard joint assessment form did not include them. nonetheless, additional patients, not included in the sample analysis, had isolated tenosynovitis involvement at diagnosis (n= both-sided ulnar extensor tendons; n= isolated tenosynovitis of the flexor digiti proprius; n= tenosynovitis of flexors digiti proprii). conclusion: our study confirms the knee, the tibiotalar and the wrist as the most frequently affected joints at jia diagnosis. on the other hand, musculoskeletal sites, such as small joints of hands and feet, the hip and the shoulder, usually involved in polyarticular jia, can be the site of disease presentation in oligo-and also mono-articular jia. further, jia may present with isolated tendon involvement. our results foster not to delay jia diagnosis in persistent synovitis occurring in infrequent joints and to include musculoskeletal sites, other than joints, in the standard articular evaluation. this could be realized by merging clinical and imaging (i.e. ultrasound) musculoskeletal examinations in the same assessment. none declared introduction: treatment response in jia is currently viewed as a binary outcome: response or non-response. however, jia is a heterogeneous disease and it is likely that different, identifiable subgroups of children and young people (cyp) may demonstrate different patterns of disease following treatment. identifying these response subgroups can assist the tailoring of stratified treatment approaches in jia. objectives: to identify subgroups of cyp defined by different trajectories of juvenile arthritis disease activity score (jadas) components following methotrexate (mtx) initiation for jia. methods: mtx-naïve cyp with jia were selected if enrolled prior to january in the bspar etanercept cohort register or the biologics for children with rheumatic diseases study at point of starting mtx. jadas components (active joint count, physician's global assessment (pga, - cm), parental global evaluation (pge, - cm) and standardised esr ( - ) were calculated based on data collected in the year following mtx initiation. multivariate group-based trajectory models were used to explore mtx response clusters across the different jadas components, which were log p transformed for analysis. optimal models were selected based on a combination of model fit (bic, relative entropy, average posterior probabilities), parsimony and clinical plausibility. clinical and demographic characteristics and achievement of acr pedi / by six months were compared across identified groups. results: of cyp selected, the majority were female ( %) and of white ethnicity ( %), with rf-negative jia the most common disease category ( %). six subgroups of cyp were identified with differing patterns of disease activity following mtx initiation. two groups improved across all jadas components: fast improvers ( %), and slow improvers ( %). persistent pga ( %), and persistent pge ( %) groups maintained one persistent disease feature but otherwise improved. one group relapsed ( %) and a final group had persistent disease overall ( %). there were no differences in active joint counts at mtx initiation between subgroups and all ilar categories were represented across each subgroup. however, cyp in persistent disease and slow improver groups had higher chaq, pga and pge scores at mtx initiation. those with persistent disease were also older at mtx initiation. the majority of cyp fulfilled acr pedi response (> % across every group). acr pedi achievement was low at months for slow improvers ( %) and high in the relapse group ( %). between % and % achieved acr pedi response in groups with persistent disease in one jadas component. we identify different patterns of disease activity within cyp initiating mtx, suggesting a simple responder/non-responder analysis at a set point may be over-simplistic. commonly used response measures did not adequately describe these heterogeneous response patterns. understanding both clinical factors associated with, and biological mechanisms underpinning, these subgroups would aid stratified medicine in jia. introduction: despite modern treatment and improved disease control, pain is the most common complaint in juvenile idiopathic arthritis (jia). knowledge about pain thresholds and pain sensitivity among young adults with jia is sparse. objectives: to study pressure pain thresholds (ppts) in young adults with jia, years after disease onset compared with controls. methods: consecutive newly diagnosed children with jia and a disease onset between - from central norway, were included in this prospective population-based long-term follow-up study. children with onset - were part of the nordic jia cohort , . age-and sex-matched controls were drawn from the national population register of norway. inactive disease and remission were defined according to wallace , . at the follow-up between - , data from a clinical examination and blood tests were included in addition to an investigator-blinded quantification of ppts. a digital algometer was used to manually apply pressure three times with an even rate at the upper and lower limb. ppts from jia and controls, and from subgroups of jia defined by disease status, were compared with multilevel models in stata. results: among the participants with jia, % were female, median age was . (iqr . - . ) years, median disease duration was . (iqr . - . ) years, % had an oligoarticular disease (persistent or extended), and % were in remission off medication. in the control group, % were female and median age was . (iqr . - . ) years. results from the multilevel regression model showed significantly lower ppts among participants with jia compared to controls (table ). in the jia group, participants with inactive disease had lower ppts than both jia in remission off medication and jia with active disease ( table ). the results were consistent for both upper and lower limb. conclusion: in this long-term follow-up study of young adults with jia, we found significantly lower ppts compared to controls. this may indicate that young adults with jia have altered pain sensitivity possibly due to accumulated earlier pain experiences. introduction: juvenile idiopathic arthritis (jia) represents the most common chronic rheumatic disease in childhood. non-steroidal antiinflammatory drugs (nsaids) and intra-articular steroids are the first line treatment for jia. systemic steroids, disease modifying antirheumatic drugs (dmards) and biologic drugs are used in children with severe disease. it is not possible at onset of disease to predict when a child can suspend pharmacological treatment, so children affected from jia have to continue pharmacological treatment for several months or years. anecdotal reports showed that rarely jia could present renal involvement due to uncontrolled inflammation or to long exposure to drugs. objectives: because no cohort studies investigating renal injury in children with jia are available, we designed this kind of study in our population. methods: we retrospectively evaluated patients suffering from jia. jia diagnosis was made according to ilar criteria, treatment was assigned with acr recommendations. for each patient we recorded the type and the duration of pharmacological treatment and the presence of renal injury. renal injury was defined by the presence of hypertension (systolic and/or diastolic blood pressure > th percentile for age, sex and height), proteinuria (persistentconfirmation within months-urinary protein/creatinine ratio> . mg/mg for children < years old and > . introduction: juvenile idiopathic arthritis (jia) is a pediatric rheumatic disease with partially unknown etiology and pathogenesis. neutrophils are the most common immune cell present in synovial fluid from inflamed joints in oligoarticular jia, but the role of neutrophils in the immunopathogenesis of oligoarticular jia has not been investigated. objectives: to characterize neutrophil phenotypes and effector functions in the circulation and in the inflamed joint during active arthritis in children with oligoarticular jia. methods: paired samples of blood and synovial fluid from children with oligoarticular jia were investigated regarding surface markers, phagocytic ability and oxidative burst. healthy blood neutrophils exposed to cell-free jia synovial fluid and healthy oral cavity neutrophils were studied as controls for synovial fluid exposure and transmigration respectively. results: synovial neutrophils had a shifted phenotype, characterized by high surface levels of neutrophil activation markers cd b and cd b, and mannose receptor cd and decreased levels of adhesion molecule cd l compared to circulating neutrophils. in comparison to oral cavity neutrophils, synovial neutrophils had higher levels of cd b and a different overall phenotype, suggesting that the phenotype shift in synovial compared to circulating neutrophils is not dependent on transmigration alone. jia synovial fluid in itself induced activation of healthy blood neutrophils, measured as increased cd b levels. synovial fluid neutrophils had impaired ability to phagocytose opsonized e. coli and to produce oxygen radicals upon neutrophil activation with phorbol-myristateacetate (pma) compared to circulating neutrophils. the impaired effector functions in synovial neutrophils was not dependent on the synovial fluid alone, as addition of cell-free synovial fluid to blood neutrophils did not alter phagocytosis and oxidative burst. conclusion: jia synovial fluid neutrophils are activated, have a "polarized" phenotype and impaired effector functions compared to neutrophils in the circulation. this study will help bridge the current knowledge-gap regarding the role of neutrophils in the immunopathogenesis in oligoarticular jia. methods: a case report is described. data was extracted from the medical chart of the patient and a literature review was undertaken. results: a -year-old girl was transferred to our tertiary center after being admitted for prolonged intermittent fevers, abdominal pain, fatigue and polyarthralgias. on examination, there was symmetrical proximal muscle weakness, a vasculitic lower limb rash, facial erythema with eyelid edema (fig. ) and oral mucositis. initial laboratory exams revealed pancytopenia, high muscle enzymes, increased erythrocyte sedimentation rate with moderately elevated reactive c-protein, and hypocomplementemia. she also had non-nephrotic proteinuria, without hematuria.further investigations showed a positive direct antiglobulin test, antinuclear antibodies, antidouble-stranded dna, anti-mi and anti-ku. serositis (pericardial and pleural effusions, ascitis) and hepatosplenomegaly were present. lower limb mri documented diffuse muscle edema. the diagnosis of an overlap syndrome of jsle and iim was established. while being treated for concomitant bacteremia, the patient became ill-appearing, with persistent fevers, worsened cytopenias, low fibrinogen and high ferritin and triglycerides, and a macrophage activation syndrome (mas) diagnosis was assumed. the patient received antibiotics and intravenous immunoglobulin, followed by methylprednisolone pulses, iv cyclosporine (cyc), hydroxychloroquine and supportive therapy with progressive improvement. due to hypertension (possibly related to cyc) and persistent proteinuria a renal biopsy was performed showing class iv lupus nephritis. after achieving clinical stability, cyc was switched to mycophenolate mofetil as an induction treatment, which is ongoing. conclusion: imm with sle os is uncommon, and has seldom been described in children. in addition to fulfilling sle criteria, our patient had clinical, laboratory and imagiologic evidence of imm. the presence of myositis specific antibodies (especially anti-mi ) further supports the diagnosis of an os rather than an atypical presentation of a lupus myopathy. juvenile dermatomyositis appears to be the imm subtype -it is associated with anti-mi , and mild heliotrope and eyelid edema are compatible. facial rash sparing the nasolabial folds is more suggestive of sle. mas is a rare but life-threatening condition that should be suspected in rheumatologic conditions and might be triggered by infections or disease flares. its identification may be particularly challenging at presentation, especially in sle where cytopenias are common. the reported prevalence in adult sle ranges from . % to . %; disease-specific criteria have been proposed. mas has occasionally been described in iim. in a patient with a predisposing condition, persistent fevers and illappearance must always prompt a mas workup, since early diagnosis and treatment are paramount. due to an early referral to a pediatric rheumatology center, the patient received a prompt diagnosis and treatment, which probably improved her prognosis. results: four of the five patients were female ( %) and all aged between and years. four of them had calcinosis at the time of diagnosis, although they may have had symptoms for to months prior to diagnosis. skin involvement was severe requiring multiple systemic and topical therapeutic agents in four out of the five patients -significantly more affected than the muscles. one patient had amyopathic subtype with normal childhood myositis assessment score (cmas) throughout. none of them had cardiac involvement. all had weakly positive anti-nuclear antibodies (ana); but were negative for myositis antibodies except the patient with most severe skin involvement and calcinosis (patient ), who was positive for anti-tif gamma antibodies. two of the three patients with calcinosis at onset had cyclophosphamide as the second line agent (chosen due to calcinosis) following systemic corticosteroids with complete resolution of the lesions after six cycles at mg/m . one patient responded to infliximab, which failed to work after months, following which cyclophosphamide was tried with good response. the other two patients were given cyclophosphamide after they failed to respond to rituximab, which did work for muscle disease. one patient had recurrent episodes of calcinosis needing surgical curettage despite initial response to cyclophosphamide and later ivig. introduction: systemic juvenile idiopathic arthritis (sjia) is a unique form of childhood arthritis. according to current understanding sjia is primarily driven by innate immune mechanisms at disease onset, but can progress towards chronic destructive arthritis, which can involve t cellular immunity. for yet incompletely understood reasons, sjia can be complicated by macrophage activation syndrome (mas), a severe hyperinflammatory condition characterized by a catastrophic cytokine storm resulting in multiple organ failure and high mortality. objectives: the sjia/mas working party (wp) aims to promote knowledge and international multidisciplinary collaboration among experts in the field of mas and sjia and to foster translational research in order to improve the care and outcome of these patients methods: currently pres members participate to the mas/sjia wp. the wp arranges an annual meeting during the pres congress, open to all members activities. the mas/sjia wp core team frequently report about ongoing activities by email. results: several studies are currently ongoing. a project aimed to establish and validate a risk score for mas in sjia patients using routine laboratory parameters of disease activity and severity has already completed the construction phase. recently, building of a validation cohort comprising data form patients from paediatric rheumatologic centers has been accomplished and is awaiting analysis (claudia bracaglia). a second project focused on mas patients with systemic thrombotic microangiopathy (tma) has just completed the collection of patients with mas and tma from centers in countries and results will soon be published (francesca minoia). furthermore, the mas/sjia wp participated in the data collection phase of a project on the development of new criteria for primary hlh (jan-inge henter and annacarin horne introduction: hemophagocytic lymphohistiocytosis (hlh) is an immunological disorder characterized by clinical signs and symptoms of severe uncontrolled inflammation, due to massive release of inflammatory cytokines. a delay in diagnosis is common, and is one of the factors that determine the poor outcome. hlh is classified into primary (phlh) and secondary (shlh). it is important to differentiate between the two as management differs. objectives: to describe the clinical and laboratory profile of hlh in infancy. methods: the electronic case files of children (age< year) diagnosed with hlh at the aims, kochi, kerala, between january and december , was retrospectively reviewed and described. results: eight infants, with age range . months to months, were clinically diagnosed with hlh. all were immunised and had normal development for age. none had a family history suggestive of hlh. third degree consanguinity was present in parents of patient no. and second degree for patient no. . duration of symptoms before presentation ranged from days to days. duration of follow up with us ranged from days to days, for those who expired. all, eight of them, had fever, anemia, thrombocytopenia, hyperferritinemia, transaminitis, raised ldh and crp. lymphadenopathy was present only in patient no. . before starting specific treatment patient no. had pseudomonas sepsis, patient no. had roseomonas gilardii infection; patient no. and were igm cmv positive but their pcr was negative. both of them had received prior blood transfusion. before making a definitive diagnosis of hlh patients were treated for puo, sepsis ? cause and acute liver failure. there was a delay in diagnosis for all patients except patient no. . all of them were treated with hlh protocol with modification according to clinical status of the patient. later, broad spectrum antibiotics, antifungals and antivirals were used for all. anakinra was tried for patient no. . five patients (phlh) succumbed to sepsis and mods and three (one phlh and two shlh) are continuing follow up. hsct was not done in any of them. other clinical features are shown in table . conclusion: making a timely diagnosis of hlh is difficult. differentiating phlh from shlh is very important as the management differs. genetic testing should be done for all infants with hlh. negative genetic study doesn't rule out phlh. the only curative treatment for phlh is hsct. shlh infants, once their primary condition is treated, can have normal survival. hyperbilirubinemia, splenomegaly, neutropenia, hepatomegaly, tissue hemophagocytes and hypertriglyceridemia were more common in phlh. health, kolkata diagnosed as having mas, admitted between july and april was tabulated and retrospectively analyzed . objectives: to evaluate the clinical features, laboratory findings and outcomes in pediatric mas, assess the response to different pharmacological therapies, and finally to identify possible factors associated with an unfavourable outcome. methods: the data of patients diagnosed with mas over the study period was analyzed for the clinical and laboratory features, treatment details, response to therapy and outcome. results: patients were diagnosed as having mas. primary illness was sjia in ( %), sle in ( %) and kawasaki disease (kd) in ( %). all had fever with varying degrees of multi systemic involvement. hyperferritinemia was universally present. in the absence of anakinra in india, pulse methylprednisolone with cyclosporine was used for treating the majority. patients ( . %) expired. patients on biologics and steroids can present with a silent mas which may be difficult to diagnose. conclusion: mas is a near fatal complication with protean manifestations and multi organ dysfunction. hyperferritinemia is characteristic, higher values being associated with increased mortality. patients resistant to steroids and cyclosporine had a poor prognosis. early recognition with aggresive management forms the backbone of a successful outcome as reflected by improved prognosis over successive years. late presentations with multiorgan dysfunction are associated with the poorest outcomes. methods: case report's description results: a two-year-old boy presented with one month history of fever associated with limping gait, cervical lymphadenopathy and skin rash. laboratory tests showed elevation of inflammatory markers and ferritin. by exclusion criteria, sjia was diagnosed and steroid therapy started. after a soft tissue bacterial infection, fever relapsed and laboratory tests were consistent with mas (day ): hb . g/dl, plt /mm ; fdp ug/l, crp mg/l, ferritin ug/l. high doses intravenous metilprednisolone and oral cyclosporin a (csa) were started. on day he presented a systemic capillary leak syndrome and acute myocarditis. he was admitted into the pediatric intensive care unit (picu) where intravenous immunoglobulin and subcutaneous anakinra (ana) were added. on day , due to an introduction: sjögren's syndrome is a systemic autoimmune disease characterized by dry syndrome and lymphocytic infiltration of the exocrine and extraglandular glands. pulmonary involvement in primary sjögren's syndrome occurs in - % of patients, with very heterogeneous manifestations, and occasionally as an initial mani-festation¹. diffuse interstitial lung involvement is one of the most characteristic pulmonary manifestations and the most frequent subtypes in lung biopsy are interstitial lymphocytic pneumonia and nonspecific interstitial pneumonia². objectives: -year-old girl presented to our hospital because of bilateral interstitial involvement with ground glass areas in lower lobes of both lungs on thorax and abdominal ct scan after for kidney stones follow-up. the patient had grade mmrc dyspnoea and dry cough but denied having symptoms of arthralgia or arthritis, photosensitivity, oral and genital ulcers, raynaud's phenomenon or episodes of dry mucosa. she had no history of autoimmune disease nor family antecedents of any autoimmune disease. a physical examination disclosed no finger clubbing or swollen superficial lymph nodes but indicated crackles on pulmonary auscultation. laboratory work showed elevated acute phase reactants, positive rheumatoid factor, positive antinuclear antibodies ( / ), positive cytoplasmic antineutrophil antibodies ( / ) and igg and iga hypergammaglobulinemia. an examination for autoantibodies were negative for anti-ss-a, anti-ss-b, anti jo- , anticentromere and anti-scl- antibodies. iontophoresis with pilocarpine and -minute walk test was also normal. pulmonary function tests demonstrated a mild restrictive impairment and a reduced percent diffusion capacity for carbon monoxide of %. fibreoptic bronchoscopy showed acute inflammation in bronchial mucosa. flow cytometry of bronchoalveolar lavage and cytology showed lymphocytosis with a % of cd and % of cd lymphocytes in bronchoalveolar lavage fluid. finally, a transbronchial lung biopsy lead to a definitive diagnosis, showing mixed interstitial inflammation and lymphocytic follicular hyperplasia with formation of germinal centers, suggestive of a lymphoid interstitial pneumonia of unreleased autoimmune etiology. throughout time, the patient reported progression of her symptoms with increasing dyspnoea, persistent dry cough, xerostomia and arthralgia. schirmer and rose bengal dye test were negative, and a salivary gland biopsy showed interstitial plasmacytosis and no igg plasma cells expression which suggested sjogren's disease. a high resolution computerized axial tomography was requested, suggesting organizing pneumonia in the context of sjogren's disease. methods: several studies indicate that lung involvement in sjögren is more frequent in advanced stages of the disease and rarely as an initial manifestation. sjögren's syndrome in paediatric age is rare and the subtype of secondary sjogren's is the most common. the course is longer, and the symptoms are more heterogeneous than in adulthood . the diagnosis in children is delayed, because children less frequently report dryness and frequently present with extraglandular clinical features suggestive of other autoimmune diseases. a systematic review on primary sjögren's syndrome in male and paediatric population reported a . % of pulmonary involvement in paediatric patients. pulmonary involvement is associated with an increase in the mortality of patients with sjögren's, therefore, it is essential to periodically monitor patients with respiratory symptoms, making an early diagnosis and treatment of the disease. results: -conclusion: we present a case of a patient with childhood sjögren's disease with atypical onset of disease with lung involvement. introduction: sarcoidosis is a multi-system disorder. little is known about its pathogenesis. in children, the early onset sarcoidosis phenotype including blau syndrome is more often seen. , the diagnosis of sarcoidosis is confirmed by demonstrating a typical non-caseating granuloma on a biopsy specimen. other granulomatous diseases should be excluded, in particular mycobacterial infections, crohn's disease and immunodeficiencies. the clinical presentation may vary depending on the organs involved and the age of the patient. , objectives: we are reporting the case of a boy with a presentation of bone sarcoidosis at a young age. this is a rare phenotype in children. methods: clinical details were retrospectively collated using routine clinical records. confirmation of diagnosis was confirmed with bone biopsy. results: a year old non-identical twin boy of ghanaian descent born in the uk had a slowly growing, painless frontal bone mass which started to develop from months of age. he was developmentally normal, with no history of fever, rashes or joint pains. examination findings revealed frontal bossing while the remainder of the musculoskeletal examination was normal. there was no evidence of rashes, hepatosplenomegaly and ocular examination was normal. the patient was initially referred for neurosurgical review with suspected fibrous dysplasia, after an initial mri scan of the head revealed abnormal marrow signal and expansion of the frontal bone, with no soft tissue swelling. however, the ct scan of the calvarium was not suggestive of fibrous dysplasia. consequently, bone biopsy was performed demonstrating inflammation with granuloma formation. he was referred to infectious diseases and rheumatology. there was no travel history and no tb contact. quantiferon tb was negative. infectious work-up was negative especially for mycobacterial infections. rheumatology work-up identified on skeletal survey another bone location: a well-defined lytic lesion in the right distal fibula that was biopsied. infection cultures and pcr were negative. histopathology identified fibrous tissue and poorly formed granulomas. laboratory investigations revealed a mild microcytic anaemia with iron deficiency and eosinophilia. he had normal serum calcium and vitamin d and his esr was mm/hr. ana, anca and rheumatoid factor were negative, and complement c and c were normal. his serum angiotensin converting enzyme (ace) level was raised at nmol/ ml/min (normal < nmol/ml/min). investigations revealed mild renal impairment with normal urinary tests including normal calcium, protein and tubular proteins. ultrasound of the kidneys was normal. chest x-ray was normal. lung function was performed and was normal. dlco couldn't be performed due to low lung volume. vascular and inflammation genetic panel identified a variant in the nemo gene. functional studies excluded nemo deficiency and patient did not display any of the clinical features. however, a pattern of dysregulated t cells response was identified. he was treated with oral steroids and methotrexate. the oral steroids were successfully weaned off. he has been successfully treated with methotrexate mg s/c to initially stabilise disease with no bone growth, and had no significant side effects. repeat mri years later showed increased burden of disease with other newly affected sites however, including the right femoral diaphysis and signal changes in the left tibial metaphysis. based on the mri and increasing musculoskeletal pain, decision was made to escalate to anti-tnf (adalimumab) with good clinical response. conclusion: bone sarcoidoisis is rare in children but this should be considered in the differential diagnoses when granulomatous inflammation is identified on histopathology. response to steroids and methotrexate is usually good but some patients will need escalation to anti-tnf. the most worrisome non-rheumatic condition causing persistent night pain in children which closely mimics arthritis is malignancy , . it is vital to pick up subtle clues at an early stage especially in absence of hematological manifestations , organomegaly and lymphadenopathy. to reveal early clinical clues in pediatric patients with predominant musculoskeletal (msk) night pains who were initially diagnosed as suffering from some form of chronic arthritis but ultimately turned out to be affected by malignancy. methods i gathered a data of five pediatric patients fulfilling above mentioned criteria who were seen at dev children's hospital between january and march . it included demographics, clinical presentation and laboratory results. all above cases reemphasize the need for an extremely detailed history pertaining to characteristics of pain & pattern recognition in pediatric rheumatology. prolonged fever , persistent msk night pain, persistent limp, upper limb and hip joint involvement which is unlikely for jia at onset are proven to be the earliest subtle clues which should not be missed. other constitutional symptoms, respiratory, cardiovascular, ophthalmologic or osteoarticular involvement were absent. growth was unaffected. auditory tests were normal. systemic antibiotic treatment and local steroids were ineffective. laboratory findings were unremarkable, with only mild elevation of esr ( mm/ st hr). ana and anca were absent in repeat meausrements ( months intervals). cardiovascular disease was excluded. abdominal us was normal. on the basis of relapsing bilateral auricular chondritis and confirmatory histological findings revealing inflamed cartilage from the pinna of the ear with chondrocyte degeneration, perichondrial infiltrates of lymphocytes, plasma and polymorphonuclear cells and replacement of cartilage with fibrous tissue perivascular infiltrates of polymorphonuclear cells and lymphocytes, relapsing polychondritis was diagnosed. one month nsaids trial, pending histology results was ineffective. methotrexate sc and steroids mg/kg/d gradually tapered over a -month period were given with significant improvement of auricular inflammation and normalization of markers of inflammation. auricular chondritis worsened after steroid withdrawal and adalimumab was added to treatment with significant improvement of auricular inflammation in months. in the following months auricular chondritis relapsed during uris with mild elevation of esr ( mm st hr) and crp ( mg/l). after months of treatment, in an effort to prolong the intervals of adalimumab administration, bilateral auricular chondritis relapsed. after months of mtx and months of adalimumab administration inflammation was put in complete remission. the following year no flares or involvement of other systems were observed, under methotrexate and adalimumab treatment. conclusion: in this patient isolated auricular relapsing polychondritis was unresponsive to nsaids. steroids and methotrexate greatly improved inflammation but did not induce complete remission. complete remission was achieved by addition of adalimumab to methotrexate treatment, which also allowed for steroids discontinuation. none declared first ever single center study revealing spectrum of rheumatic diseases in children from an indian state of gujarat d. b. pandya, on behalf of dr mehul mitra, pankaj buch, sonal shah, there is very limited information and awareness about pediatric rheumatic and immunodeficiency diseases amongst primary physicians , , in gujarat and to make this matter even worse, we are not having a single exclusive pediatric rheumatology and immunology centre for a population of around million. to guesstimate a status of children with rheumatic and immunodeficiency diseases in gujarat and spectrum of these diseases at dev children's hospital. methods i gathered a retrospective data of patients who attended dev children's hospital between january and january . out of these, children with confirmed diagnosis of inflammatory rheumatic diseases and suspected primary immunodeficiencies were included. patients with non-inflammatory musculoskeletal(msk) pains and non-rheumatic diseases causing msk pains were excluded. my collected data included referral details, demographics, clinical presentation, laboratory results and diagnosis. majority of the cases were referred by pediatricians, orthopedicians, hemato-oncologist and general physicians. main reasons for referral were joint involvement , undiagnosed fever , multisystem disease and elevated inflammatory markers. many physicians had put a diagnosis like rheumatoid/rheumatic arthritis, autoimmune disease or connective tissue disease. almost % of patients had been evaluated with rf, aso titer, ana and joint imaging irrespective of clinical pattern by their primary physicians before referral. fever , msk involvement, extreme fatigue, constitutional symptoms, skin and mucosal involvement were prominent complaints noted by me. family history of rheumatic, primary immunodeficiency (pid) or consanguinity was found in / of patients. anemia of chronic disease, elevated esr and thrombocytosis were almost universal laboratory findings in our cohort. rheumatic diseases in children are not anymore rare but due to lack of expertise and awareness , these children are not getting diagnosed. many cases were advised unnecessary rheumatological investigations even before referral. results: a -year-old female patient was referred to the rheumatology clinic at our hospital with a previous history of fever of °c ( . ºc), loss of appetite, and acute polyarthritis of wrist, knees, and ankles. at that time, laboratory exams revealed a hemoglobin of . g/dl, c reactive protein . mg/l, and antistreptolysin o titers of ui/ml (normal range < ui/ml. clinical symptoms were relieved only after using nsaids. after months, the patient returned to our hospital with a -month history of weight loss and claudication related to pain and daily morning stiffness ( minutes) on her right ankle. new laboratory findings demonstrated positive antinuclear antibodies : , negative rheumatoid factor, and alpha- -acid glycoprotein of mg/dl (normal range: - mg/dl). clinical signs suggestive of chronic arthritis with exuberant swelling of the ankles were observed on physical examination (figure a). she was screened for tuberculosis (tb) and had a positive ( mm) tuberculin skin test (figure b). chest ct revealed infiltrative soft tissue mass in the posterior mediastinum, with homogeneous contrast enhancement (figure c). magnetic resonance imaging of both ankles was performed and demonstrated bilateral and symmetrical tibiotalar arthritis and prominent tenosynovitis of extensors, flexors, and fibularis tendons (figure d). right ankle synovial biopsy revealed no granulomas and joint fluid culture was negative for mycobacterium tuberculosis, confirming reactive arthritis (poncet's) and tenosynovitis, that may follow mycobacterial infection with no infective agent in the joints. conclusion: to our knowledge, there is no report of poncet's disease associated with inflammatory tenosynovitis, showing the particularity of this case. the patient's symptoms resolved after two months of anti-tb therapy. introduction: cacp is characterized by congenital or early-onset camptodactyly (usually bilateral); non-inflammatory arthropathy (more frequently in the wrists, knees, ankles, elbows, and hips); coxa vara (reduction of the angle between the neck and shaft of the femur); and non-inflammatory pericardial effusion (a late manifestation, less frequently reported). recognizing the radiological aspects of this syndrome and differentiating it from jia is crucial since cacp has no effective treatment and jia is usually treated with nsaids and methotrexate ( , ) . objectives: to report a rare case of cacp syndrome mimicking jia. methods: case report and literature review. results: a -year-old male patient presented with arthropathy characterized by painless progressive swelling and restricted movement of the hands, hips, knees, and ankles since the first year of life. he had a family history of camptodactyly from his paternal grandfather. on physical examination, symmetric camptodactyly of the hands and feet was observed (a). he had no history of rash or weight loss and inflammatory markers were unremarkable. the echocardiogram was normal. the pelvic radiograph showed a widening of the joint space and bilateral coxa vara. magnetic resonance imaging (mri) of the hips (b) and knees (c) was performed and depicted large joint effusions (arrows, b and c) with normal synovial thickness and mild synovial enhancement in all joints, without bone marrow edema-like signal. a synovial biopsy of the knee was performed and revealed mild synovial hyperplasia without inflammatory cells. the patient was diagnosed with camptodactyly-arthropathy-coxa vara-pericarditis syndrome (cacp -omim ), a recently described genetic disorder with no gender predominance identified to date ( ). conclusion: an important differential diagnosis of cacp is juvenile idiopathic arthritis (jia), a painful inflammatory chronic arthritis that can cause not only joint effusions due to synovial inflammation, but arthritis was the most frequent extraglandular manifestation. renal tubular acidosis represented the typical expression of renal involvement ( cases). neuromyelitis optica and aseptic meningoencephalitis ( and cases, respectively) were the most typical neurologic manifestations. two cases of interstitial lung disease and one of pulmonary hypertension were reported. almost all patients had autoantibodies, mostly ana ( / patients) and anti-ssa/ro ( / patients). the schirmer test was performed in less than half of the patients, of whom % tested positive. a positive result of minor salivary biopsy was reported in / cases with available data. juvenile idiopathic arthritis was the most frequently associated disease, followed by systemic lupus erythematosus ( and cases, respectively). no significant differences between patients with or without parotitis were found except that patients with parotitis showed increased levels of crp more frequently than those without it (p= . ). patients with anti-ssa/ro had more frequently a positive schirmer test (p= . ). the presence of rf was significantly associated with dry mouth (p= . ), arthritis (p= . ), and rash (p= . ). a positive minor salivary biopsy was more common in children with dry eyes than in those without this clinical feature (p= . ). arthritis was more frequent in patients with other diseases than in those with primary ss (p= . ). we further investigated ss features according to the age groups (≤ years, - years, ≥ years). parotid involvement was inversely proportional to the age and occurred more frequently in younger patients ( % of those ≤ years; p= . ). interestingly, the rate of anti-ssa/ro positivity increased with age ( % of those ≥ years; p= . ). conclusion: even though parotitis was the most frequently reported feature, a wide range of clinical manifestations in children with ss has been reported so far. a better knowledge of css features will help to pave the way for the development of css specific diagnostic criteria. none declared introduction: pachydermodactyly (pdd) is a rare benign fibromatosis, characterized by progressive painless swelling of soft tissue of proximal interphalangeal (pip) joints without inflammation signs. generally pdd affects pip joints of the fingers, rarely of the thumb. the involvement is typically symmetrical, in few cases unilateral. it usually occurs more frequently in young males. etiology is unknown, but it arises from mechanical stimulation of periarticular skin (i.e repetitive rubbing, interlacing, and cracking of fingers). pdd has to be considered in the differential diagnosis of arthritis (i.e. juvenile idiopathic arthritis, jia) and many syndromes (i.e. progressive pseudorheumatoid dysplasia). prognosis is good with cessation of mechanical stimulation the recurrent paroxysmal appearance of inflammatory lumps (local erythematous tender swellings, which partially respond to antiinflammatory agents), accompanied by elevated inflammatory markers during flares, suggest that fop may be an autoinflammatory disease. the episodic formation of bone, often following a trivial injury, suggests that innate immune-related triggers induce tissue transformation through the bmp pathway. moreover, interleukin- β (il- β), a well-known mediator of the innate immune system, has been linked to ho and mineralization in mesenchymal stem cell cultures derived from human bone marrow. we hypothesized that treating fop patients with anti-il- agents could help ameliorate the progression of this devastating disease. we report our experience treating two fop patients with anakinra and canakinumab. objectives: to decrease the frequency of fop paroxysms, and/or limit the symptoms and extent of residual lesions, by using anti-il- agents. methods: patients' data and blood il- levels were analyzed to characterize the efficacy of anti-il- treatments in ameliorating the natural progression of fop. results: a . year old boy and a year old girl were diagnosed with fop, both clinically and genetically (the typical r h mutation was found). various treatments, including high-dose corticosteroids, pamidronate infusions, celecoxib, monteleukast and sirolimus, did not change the course of the disease. both patients are receiving canakinumab (the male patient was initially treated with anakinra). the male patient has been treated for over years. flare rate was markedly reduced from one new lump every days to approximately one every days ( figure ). the lumps involved in almost all of these flares are the same: at the left scapular base and within the sternocleidomastoid muscle. the female patient has been treated for a year, and has not experienced any ho flares during canakinumab treatment. temporarily withholding canakinumab in both patients, led to serious flares weeks after the last dose. notably, while undetectable levels of il- β (< . pg/ml) were found in the three plasma samples obtained from the male patient during treatment with anakinra or canakinumab, high levels (up to . pg/ml, about -fold higher compared to average levels measured in healthy controls) were found in his plasma samples collected during the flare ( figure ). in contrast, il- and il- plasma levels, measured before, during and after withholding treatment, were comparable or slightly higher than those observed in healthy controls ( figure a , b). conclusion: we report here, for the first time, that anti-il- agents were found efficacious in treating two fop patients. we also found markedly increased il- β levels during flares, which normalized following the treatment. we suggest a role for il- β in the pathogenesis of this disease. although it is too soon to conclude whether fop may be included under the umbrella of auto-inflammatory syndromes, anti-il- agents can be effective in ameliorating the natural progression of fop. introduction: musculoskeletal symptoms are one of the common reasons for applying to rheumatology departments in general practice . although inflammatory causes are generally considered in the foreground, it is known that non-inflammatory causes including genetic diseases may also be responsible. the absence of signs of inflammation (morning stiffness, redness, tenderness) and normal inflammatory markers in laboratory findings may support nonrheumatologic diseases . objectives: to present genetic disorders that can mimic rheumatologic symptoms and to answer when genetic diseases should be considered in the differential diagnosis in patients presenting with rheumatological complaints. methods: we retrospectively evaluated patients who applied to hacettepe university pediatric rheumatology department with musculoskeletal compliants between january and december and had been consulted to genetics departmant. the rate and degree of consanguinity, clinical diagnosis, indication for consultation, accompanying musculoskeletal and other findings had been recorded. the diagnosis of genetic diseases were based on physical examination, radiological evaluations and genetic analysis. results: a total of patients, boys ( . %), with a mean age . ± . years were included in the study. the rate of consanguinity was . %. the most frequent referral to the genetic department was the presence of skeletal anomalies (n: ) such as camptodactyly, clinodactyly, and bone shortness accompanying joint findings. other causes include short stature (n: ), joint deformity (n: ), joint hyperlaxicity (n: ), dysmorphic findings such as atypic facial appearance (n: ), accompanying diseases that may be part of a syndrome (n: ), genetic diagnosis suspicion according to the results of radiological examination (n: ) and joint findings without clinical and laboratory signs of inflammation (n: ). distribution of joint involvement in patients with genetic disease were hands, knees, and hips respectively. in the laboratory evaluation of patients presenting with joint swelling and arthralgia, acute phase reactants (erythrocyte sedimentation rate and c-reactive protein concentrations) were within normal reference values. one third of the patients ( . %) had a final diagnosis of a genetic disease. the diagnoses of these patients were as follows; cacp (camptodactyly, arthropathy, coxa vara deformity and pericarditis) syndrome (n: ), trichorhinophalangeal syndrome (n: ), progressive pseudoromatoid dysplasia (n: ), lig syndrome (n: ), m syndrome (n: ), h syndrome (n: ), spencd (spondyloenchondrodysplasia, n: ), and nonspecific connective tissue disease (n: ). conclusion: genetic syndromes with musculoskeletal findings are often unrecognized and misdiagnosed as rheumatologic diseases leading to unnecessary procedures and treatments. summarizing the genetic diagnosis spectrum that can be detected in these patients will increase the awareness of physicians. results: according to the results of observation, the disease was more common in the age group of - years ( %), to a lesser extent among children in the group of - years ( %), less often in the group of - years ( %). when examining infectious agents, zoonotic infection was detected in % (listeria monozytogenes, yersinia enterocolitica). clinical course of nodular erythema in this group was characterized by an expressed activity of the inflammatory process with multiple elements in the lower and upper extremities, joint syndrome, increased esr to ± . mm per hour, crp ± . mg\l. the disease was preceded by an episode of acute infection with an increase in body temperature, intoxication, in some cases with short-term intestinal syndrome, pharyngitis. the rashes were persistent and recurrent, with a slow regression of laboratory activity. streptococcal etiology of nodular erythema was detected in % of cases. there was an increase in esr to ± . mm per hour, crp ± . mg/l, a significant increase in antistreptolysin on average ± % iu / ml. with an increase in individual cases to iu/ml. in % of cases, erythema nodosum developed after an intestinal infection. among the pathogens were identified sh. disenteria, e. coli, yersinia enterocolitica, enterovirus. the disease was characterized by moderate activity, a good response to etiological therapy and a short course of nsaids . an interesting fact was the development of nodular erythema in % of cases caused by the epstein-barr virus in groups of children from to years and - years. they had clinic picture with normothermia, no symptoms of intoxication, periodically occurring elements of nodular erythema on the shins, no blood changes. therapy aimed at eliminating the virus gave a positive result and did not require specific anti-rheumatic therapy. in % of cases, the etiology of nodular erythema was not defined. the clinical course of nodular erythema in children depends on the infectious agent that was the trigger of the pathological process. the higher activity and duration of the disease is caused by zoonotic infection, which requires more active antiinflammatory therapy with corticosteroids, which may be associated with the activation of autoimmunity. this group of children was taken for further observation as a group at risk of developing systemic connective tissue disease. changes in the etiological structure of nodular erythema and treatment tactics require further study. introduction: sjögren syndrome (ss) is a chronic autoimmune disorder characterized by inflammation of the lacrimal and salivary glands leading to oral and ocular dryness. childhood ss is rare and poorly defined and underdiagnosed owing to the lack of childspecific diagnostic or classification criteria. objectives: the purpose of this study is to describe cases with pediatric ss in order to better clarify the characteristics of the disease in the pediatric age. methods: we retrospectively reviewed medical records of patients (pts) with pediatric ss referring to three italian pediatric rheumatology centers. due to lack of childhood validated ss-specific criteria, physician diagnosis was the only inclusion criteria. results: we collected data on pts ( females). the mean age of disease onset is . yrs (median . , range - ). the mean age of diagnosis is . (median . , range - ). the follow up period varied from . to . yrs (mean . , median . ). the most common manifestations were articular involvement (mainly with arthralgia) ( / pts) and parotid/salivary glands swelling ( / pts). xerostomia and xerophthalmia were found in / pts and in / respectively. vaginal dryness was reported only by one pt. fever and fatigue occurred in / and / pts respectively. we also recorded cases of circulating immune complexes manifestations in pts, purpura (n= ) and glomerulonephritis (n= ). we observed an endocrine involvement in pts ( metabolic syndrome, autoimmune thyroiditis). abdominal pain was found in / pts. all pts were positive for autoantibodies (positivity for ana or anti-ssa or anti-ssb or fr) at presentation. rf test results were available in pts, all positive. positive ana (titer> / ) and anti-ssa were present in / pts and in / respectively. hypergammaglobulinemia (range , - . g/dl) was found in / pts ( na). abnormal schirmer test was observed in the half of cases ( / ). minor salivary gland biopsy was performed in pts resulting in histological evidence of focal lymphocytic sialadenitis in / . sonographic evaluation of salivary glands was abnormal in all of the patients ( / ). with regard to treatment, / pts received corticosteroids and eight were also treated with one or more dmards such a hydroxychloroquine (n= ), methotrexate (n= ), azathioprine (n= ), leflunomide (n= ). biological therapy was used in patients for systemic involvement: received belimumab and then rituximab, while the other patients received rituximab. conclusion: xerostomia and keratoconjunctivitis sicca were not common in our series while recurrent parotid swellings were more frequent than what reported in adults. pediatric recurrent parotitis should increase the suspicion for sjögren syndrome. current diagnostic criteria for ss do not include parotitis and therefore, the incidence of ss may be under-recognized in childhood. the disease is not always benign and patients with severe course may need second line treatment including immunosuppressant and biologics. introduction: improving our understanding of pediatric rheumatological (pr) patient population is crucial for pediatric rheumatologists to know rheumatic disease epidemiology and to raise awareness leading to early detection. we didn't find studies of pr disorders presenting in the first year of life. objectives: the aim of this study is to assess the prevalence of pr disorders with onset in the first year of life. methods: we retrospectively studied patients observed in our pediatric rheumatology unit between january st of and december st of . we defined acute (< weeks), subacute (≥ and < weeks) and chronic (≥ weeks). results: a total of patients were observed in years. diseases' onset occurred in the first decade of life in patients ( %) and in the first year of life in ( , %). among the latest group, chronic inflammation was the most frequent group of diagnosis ( %), followed by recurrent inflammation ( %), acute inflammation ( %), infection ( %), infiltrative/ degenerative disorders ( %) and subacute inflammation ( %). the remaining patients ( %) were diagnosed with other disorders classified as miscellaneous. among chronic inflammation group, patients were diagnosed with juvenile idiopathic arthritis ( systemic); had neonatal lupus and one patient had polyarteritis nodosa. among recurrent inflammation group, patients were later diagnosed with pfapa (periodic fever, aphthous stomatitis, pharyngitis and adenitis), were diagnosed with behçet disease and had an autoinflammatory disorder. acute vasculitis was diagnosed in patients ( kawasaki disease and acute hemorrhagic edema of infancy). among infectious diseases group, there were two cases of congenital syphilis with arthritis and two cases of osteomyelitis secondary to bcg vaccination. conclusion: rheumatological diseases presenting in the first year of life are not exceptional. although many patients didn't have a definitive diagnosis at the beginning of the symptoms, many of them were later diagnosed with rheumatic disorders, mostly chronic inflammation ( %), which requires early diagnosis, specific treatment and long-term follow-up. rheumatic diseases must be considered as differential diagnosis in the first year of life in order to avoid delayed intervention and long term disabilities and sequelae. ( ), on the other side measles-induced mas has rarely been reported ( ). objectives: we present the case of a child known to have sjia in remission, who presented a measles primary infection and a secondary kd complicated by mas. methods: a years old girl, not fully vaccinated and known to have sjia in remission under methotrexate, presented for frequent high grade fever of days duration associated with flat flash red spots on the face and trunk as well as the palms and soles. a koplik's spot was identified. conjunctivitis and coryza were also present. initial viral serology, including measles, returned negative. fever persisted and on day , edema of both hands and feet appeared with bilateral cervical adenopathy, erythematous tonsils, gingivitis, cracked lips and hepatomegaly was noted. all cultures were negative and chest x-ray was normal. inflammatory markers rose up. viral serology was repeated and measles igm came back positive. cardiac ultrasound ruled out coronary aneurism and the ophthalmic exam showed no uveitis. kd criteria were met and g/kg of intravenous immunoglobulins (ivig) were administered. after hours of clinical improvement, fever reappeared and the patient returned to be ill looking although the rash regressed. we noted high ferritine( ng/ml) together with low c , decrease in platelets( x /ml) and elevation of hepatic enzymes, ldh and cpk, without increase in the inflammatory biomarkers. mas was suspected and a bone marrow aspirate showed the presence of mild macrophage hemophagocytosis. antibodies for lupus and auto-immune myositis were all negative. steroids were given, fever disappeared, and spectacular clinical and biological improvements were objected. weeks later, desquamation of all extremities was noted. sars-cov- was not investigated because historically this case presented year earlier than the pandemic. results: we hereby report, for the first time, kd and mas triggered by measles infection in a child with sjia in remission. the exact mechanism involved in kd-induced mas and measles-induced mas has not yet been defined but a defective immune response is suspected ( ). conclusion: significant similarities and overlap between measles, kd, sjia and mas make an early diagnosis very challenging ( )( ). the recent covid pandemic emphasizes how a viral illness can be responsible of kd and sometimes degenerating in mas. we report this clinical case as an example of a systemic inflammatory syndrome (sis) taking place after a viral infection to measles. in the era of covid pandemic and secondary sis in children, an additional challenge is present in regions lacking measles vaccine coverage. none declared the musculoskeletal manifestations of scurvy: a diagnostic challenge for the rheumatologist p was a -year-old boy, with autism spectrum disorder, malnutrition and severe food selectivity, admitted to our unit for refusal to bear weight and bruises in lower limbs. the auxological evaluation showed a strongly dystrophic aspect. coagulation profile and main organ function markers were normal. at nutritional biochemical parameters evaluation, iron and vitamin c deficiencies were detected (vitamin c: μmol/l). oral vitamin c therapy was started, with prompt clinical response. p was a -year-old boy with autism spectrum disorder, admitted to our unit for lameness and difficulty in walking for a month. at clinical examination, a mottled skin at lower limbs was noted. joint examination was normal. auxological parameters and main blood tests were adequate for age. given the presence of food selectivity, he underwent serum vitamin c dosage ( μmol/l); hence he started oral vitamin c therapy, with rapid clinical improvement. p was a years old boy who was referred for coxalgia and fever. at clinical examination, pale skin, gingival hyperemia, and pain in mobilization of the left hip were present. microcytic anemia was detected, but main organ and inflammatory markers were normal. no evidence of infection was present. x-ray of femur and knee showed morpho-structural alteration of the distal metaphysis bilaterally. a low intake of fruit and vegetables was reported; hence, dosage of vitamin c was performed, resulting reduced ( . μmol/l). he started vitamin c oral therapy with clinical response. p was a -year-old girl with behavioral disorder and intellectual disability, admitted for fever and right knee swelling which appeared two days after a right leg burning. c-reactive protein and esr were elevated and ultrasound exam confirmed intra-articular knee effusion. suspecting a septic arthritis, antibiotic therapy was started with laboratory normalization and partial clinical improvement. considering the persistence of knee swelling after nine days of intravenous antibiotic therapy, the presence of gingival hyperemia and history of food selectivity, vitamin c dosage was practiced ( μmol/l). oral vitamin c was administered with complete clinical resolution. conclusion: although scurvy is considered a disease of the past, it still occurs nowadays. food selectivity associated to autism is a major risk factor for vitamin c deficiency in childhood. rheumatologists should take into account the diagnosis of scurvy in the diagnostic approach of musculoskeletal disorders in children, especially when development disorders are present. . %), juvenile dermatomyositis (n= ), sarcoidosis (n= ), granulomatous polyangiitis (gpa) (n= ), sting-associated vasculopathy with onset in infancy (savi) (n= ), and oligoarticular jia (n= ). respiratory symptoms were present in ( . %) patients at the time of primary diagnosis. in other patients, the time period between the diagnosis of the rheumatic disease and the onset of the respiratory symptoms ranged from to years. cough, the most common symptom, was present in ( . %) patients. six patients manifested with cough and sputum. six ( . %) patients had shortness of breath and one patient had hemoptysis. on the physical examination of one patient, rales and clubbing were detected. high resonance computerized tomography (hrct) was performed in all patients. hrct findings were as follows; lymphadenopathy in patients ( . %), ground glass appearance in patients ( . %), consolidation in one patient, pleural effusion in one patient, pulmonary nodule in patients ( . %), fibrosis in one patient, cystic lesions in patients ( . %), septal thickening in patients ( . %), bronchiectasis in one patient, and reverse halo sign in one patient. in echocardiographic examination, only one patient had pulmonary hypertension. three patients underwent open lung biopsy, and diagnosis was made with pathological examination of the lung tissue. of these three patients, two ( . %) had lymphocytic interstitial pneumonia (lip), and one patient had chronic inflammation and focal fibrosis. infectious lung disease was not detected in any patient. ten patients ( . %) had interstitial lung disease associated with rheumatic disease, one patient had pulmonary hemorrhage, one patient had pulmonary involvement of gpa, one patient had pulmonary involvement of sarcoidosis. there was no statistically significant difference between the first and last spirometry and dlco values during the follow-up period. mortality was . % ( / ) in this cohort. active disease was significantly associated with abnormal tc, hdl, and tg levels (p= . *), (p= . *) and (p= . *) respectively. multivariate analysis of the factors affecting abnormal cholesterol level revealed that sle is a significant predictor of abnormal cholesterol level . presence of jsle increase risk of abnormal cholesterol times more than cases without jsle. the overall percent predicted was %. active disease is a significant risk factor for abnormal tg with increased risk of abnormal tg by . among cases with active disease than cases with inactive disease. the overall percent predicted was . %. conclusion: children with rheumatic diseases showed significant lipid profile abnormalities. abnormal tc, hdl and tg are significantly associated with active disease. presence of jsle increase risk of abnormal cholesterol. active disease is a significant risk factor for abnormal tg. therefore, lipid levels should be monitored regularly and managed in patients with paediatric rheumatic diseases to minimize the longterm risk of cvd. methods: non-experimental, cross-sectional and descriptive study. a confidential survey was conducted online, aimed at residents and attendings who deal with musculoskeletal pain. were addressed with the definitions of arthralgia, arthritis, myalgia, allodynia and hyperesthesia (between five to seven options) with only one correct answer. correct definitions: arthralgia (pain localized to the joint or periarticular structures, as a only manifestation); arthritis (criterion one or criterion two: -joint swelling or intra-articular effusion / -limitation of joint mobilization associated with at least one of the following: a) pain b) tenderness c) swelling d) heat); myialgia (pain with muscular origin or referred to muscle, regardless of its etiology); allodynia (pain resulting from usually non-painful stimulus); hyperesthesia (coexistence of allodynia plus hyperalgesia -exaggerated responses to tactile and thermal nociceptive and nonnociceptive stimuli the association of pure red cell aplasia (prca) with thymoma led to the discovery of the autoimmune mechanisms involved in the pathogenesis of this rare disease. till date many adult case reports have revealed a strong link between prca and autoimmune diseases, endocrine disorders, rheumatic diseases, autoinflammation and immune dysregulation. [ ] [ ] [ ] [ ] [ ] objectives to stimulate a search for the genetic and immunological roots for a . years old girl with syndromic face, pure red cell aplasia, type diabetes and polyarthritis. methods this is a story of a . years old girl with pure red cell aplasia, type diabetes and polyarthritis. she was normal till months of age. at the age of months, she was diagnosed with type diabetes. she was evaluated by her paediatrician in view of generalized hypotonia, deformed pinna, low set ears, midfacial hypoplasia, blue sclera, umbilical hernia and retracted eyelids. she had multiple episodes of seizures during next few months. to me, she was presented with one year history of polyarthritis with severe pallor requiring frequent blood transfusions. family history was inconclusive. musculoskeletal examination showed polyarthritis involving right knee, bilateral ankles, fingers and toes. further examination revealed haemolytic facies and hepatosplenomegaly. i was not able to make out any facial dysmorphism mentioned earlier by her paediatrician. results: table conclusion early age of onset, pure red cell aplasia, autoimmune and endocrine manifestations with some doubtful facial dysmorphism inspired me to suspect some known or unknown immune dysregulation syndrome in this child. genetic analysis would be the best possible option in this scenario if financial condition permits. introduction: galactosialidosis (gs) is a rare inherited lysosomal storage disorder (lsd) which is characterized by a defect in the lysosomal glycoprotein catabolism. here we report, for the first time, a case of a child affected by gs who presented with recurrent episodes of extensive joint inflammation in both knees. knowledge on gs related inflammatory joint pathology is lacking, which hampers evaluation of possible mechanisms that could give an explanation for the significant arthritic joint abnormalities as observed in our patient. objectives: the aim of this study is to describe the clinical presentation as well as the laboratory, radiologic and microscopic features of this extremely rare presentation of gs. furthermore, we conduct a literature review on lsd's complicated by arthritis in order to evaluate potential mechanisms that could explain the extensive inflammatory joint swelling observed in our patient. methods: in this study we present a -year-old turkish boy who was diagnosed with gs (late infantile form) at months of age. from the age of years, the boy presented with episodes of inflammatory joint pathology of the knee. informed consent was obtained. alongside the case report, a literature review using medline was conducted. an extensive list of known lsd's was combined with the terms: "arthritis", "joint inflammation", "synovitis" and "synovial inflammation". cases in which joint inflammation was based on a probable cause other than the underlying lsd were excluded. results: in the present case, owing to comprehensive examinations (i.e. laboratory tests, imaging and microscopic examination) multiple possible causes for the recurrent inflammatory joint pathology could be rejected (i.e. no signs of infectious arthritis, reactive arthritis, osteoarthritis, arthritis secondary to a malignancy or crystal induced arthritis). a diagnosis which could explain the clinical picture is the jia subtype: ana negative oligo-articular jia. however, microscopic examination showed numerous foamy macrophages with extensive vacuolization in the synovial tissue of the inflamed joint, which is not associated with jia. given the evidence of storage products within the macrophages of the inflamed synovial tissue and no conclusive diagnosis, gs itself should be considered as the primary cause for the recurrent arthritis. an in-depth literature review using medline for data on inflammatory joint pathology in lsd's showed that lsd subtypes (i.e. fabry disease, farber lipogranulomatosis, gaucher disease type , mucopolysaccharidosis ix, a-mannosidosis, fucosidosis and cystinosis) could present with disease related arthritis. multiple potential arthritic mechanisms secondary to storage product accumulation in lsd's have been described, such as: dysregulation of innate immunity and increased upregulation of numerous pro-inflammatory proteins. conclusion: given the evidence of storage products within macrophages of the inflamed synovial tissue and the absence of other etiological clues, our hypothesis is that gs itself is the primary cause for the inflammatory joint pathology in our patient. although, gs cannot be linked directly to joint inflammation, lysosomal defects have been associated to pro-inflammatory effects that possibly could result in arthritic disease. future identification of other patients with gs is required to support the hypothesis of an arthritic clinical phenotype of gs and to assess underlying pathophysiology. introduction: joint pain (jp) is a relatively common complaint among children and adolescents. a painful joint in children for many years continues to maintain the status of the most common symptom of juvenile arthritis. however this symptom should not always be interpreted as a manifestation of rheumatic diseases. objectives: the aim of current review is to debate of the structure in children with the chief complaint of jp. methods: we retrospectively analysed our series of children which attending outpatient department with complaint about pain lasting longer than two months in one or more joints. the clinical, instrumental and laboratory pictures were collected. special attention was paid to certain aspect of medical complaints, a complete and accurate history and physical examination. different categories as possible etiologies of jp in children were systematize and detailed. results: all children were divided into several groups based on their anatomical and physiological characteristics of osteoarticular system: the first group consisted of children under - years old, the second group - children - years old, the third group - children over years old. research suggests that more preschool children were experience bilateral lower extremity pain by "post-walk genesis" due to natural hypermobility, immaturity of sensory innervation of the joints and imbalance of the leg muscles (e.g. growing pains). the second most common cause of jp was associated with intra -or postinfectious factor (viral, streptococcal and chronic focal of infection). the frequency of juvenile arthritis and other rheumatic diseases in children of this age group did not exceed %. special attention was paid to fever, chills, malaise, nightpain and constitutional symptoms with changes in blood lab tests to exclude osteomyelitis (inc specific cause), malignancies manifestation and other bone tumors (less %). the most common causes of joint pain of school-age children were hypermobility syndrome and enthesopathy (primary, secondary). secondary enthesopathy were result of changes in nutrition, rapid growth and excessive exercise. also enthesopathy were manifestation of endocrine, gastrointestinal or infectious diseases. the proportion of children with the onset of chronic inflammatory arthropathy also did not exceed %. hypermobility child's syndrome was characterized by harmless pain (inc low back pain), linked to physical activity (less morning stiffness). over the past decade, we've seen a gradual increase in the number of children ( % were girls) with knee pain by diagnosed patellofemoral and mediopatellar plica syndromes, patellar tendinitis or idiopathic cause. in most cases children was complicated by syndrome of increased anxiety. the share of true chronic inflammatory arthropathies, including spondylitis, in children of this age group did not exceed %. fibromyalgia were diagnosed less %. introduction: a significant part of patients in rheumatologist's practice is children and teenagers with complaints of pain. the further volume of examination and the choice of treatment course depends on the capability of the rheumatologist to define the inflammatory and non-inflammatory genesis of pain. that makes the problem of differential diagnosis very important. objectives: to conduct a comparative analysis of patients with a principal pain complaint to determine if there are significant differences in the groups with the inflammatory and noninflammatory pain genesis. methods: the retrospective study included children who consulted a rheumatologist in the outpatient clinic in the period - without preliminary selection (n = ). of them there were selected children with principal pain complaint (n = ). according to the diagnosis, the children were divided into groups: those who have inflammatory genesis of pain (a, n = ) and those with noninflammatory genesis of pain (b, n = ). the group a included children with such diagnoses as: reactive, poststreptococcal and juvenile idiopathic arthritides. the group b included children with arthralgia, chronic pain syndrome, orthopedic pathology, fibromyalgia. results: . groups a and b differ in the average age of the first complaints onset (t-criterion for equality of means) with a high degree of statistical significance (group a = , years; group b = , years; p = . ). which means that in group a more often than in group b first complaints appear in the age between to while in group b more often than in group a it happens in the age between to . . there was a statistically significant difference in the means between groups a and b in time between the onset of first complaints and the first visit to a rheumatologist (p = . ) also in favor of this conclusion speaks the fact that in group a the number of visits to a rheumatologist in the same year when the first complaints appear is almost times higher than in group b. % of cases in group a consulted the rheumatologist the same year when the first complaints appeared in comparison to group b where only % of patients did the same. below is the table with distribution of cases by the number of years between the first complaints onset and the first visit to a rheumatologist in both groups: conclusion: in children with arthritides, the first pain complaints appear at an earlier age (an average of . ), and in group b (an average of . ). patients with arthritis more often visit a rheumatologist earlier (within year after the first complaints) than those with non-inflammatory genesis of pain complaints. the most common cause of recurrent musculoskeletal pain is growing pain (gp) in children. differential from rheumatic diseases could be challenging in some cases since there are no diagnostic criteria for gp. objectives: to analyze gp characteristics in a large cohort of patients in comparison with other non-inflammatory and inflammatory diseases causing limb pain, and to simplify the gp's diagnosis process by using machine learning (ml) techniques. methods: this is a multicenter cross-sectional study. introduction: it is a well-known fact that the period of intensive growth in children is associated with the processes of active bone mass accumulation and coincides with them in time. one of the most distinctive indicators of an increase in the disease incidence among children for the recent decade (+ , %) can be found in the skeletal disorders resulting from disrupted calcium metabolism and vitamin d deficit. the latter is widespread in ukraine as it is observed in % of schoolers. objectives: establish the specifics of the structural and functional status of the bone tissue in children during the growth spurt, taking account of the degree of vitamin d sufficiency. methods: the examination covered children aged - who were divided into three groups depending on the presence of the growth spurt (gs) and its intensity: group - children who had become - cm taller for the year in question; group - children who had become taller by cm or more, group - children who had experienced no growth spurt. inclusion criteria were the following: no chronic somatic or endocrine pathologies, no musculoskeletal disorders or mineral homeostasis disruptions; physical exertion corresponding to their age; the children had not been taking any complexes of vitamins and minerals, including vitamin d for months before the examination. conclusion: children aged - showed deficiency of vitamin d reaching % which had no correlation with the presence or intensity of the growth spurt. in children who experienced growth spurt, a reduced bmd proved more frequent and correlated with the spurt intensity, however, it did not depend on sufficiency of vitamin d . therefore, during the growth spurt, disrupted mineralization of the bone tissue was influenced not only by the vitamin d deficit but also by the correlation between the bone tissue mineralization rate and intensity of growth in the children. methods: a self-reported question online survey on qol of patients with sjia and aosd was developed by the non-profit organizations, the autoinflammatory alliance, kaisz/vaisz, enca and sjia foundation in english and translated to dutch. respondents were recruited by convenience sampling through online social media posts. data on flares, triggers, family history, and correlation of symptoms with labs were collected in addition to detailed information on qol during and in-between flares. results: between and , there were responses; were from parents of children with sjia, from adults with sjia, and from adults with aosd. interestingly, adults (whether diagnosed with sjia or aosd) were more likely to report pain, fatigue, joint swelling or arthritis, nausea & vomiting, and diarrhea during flares than children. adults were also more likely to describe flares >one month. % of patients reported being "greatly" or "severely" limited during flares. between flares, % reported being "greatly" or "severely" limited while % were "somewhat" limited. % felt their condition affected their studies, job, and career, including % of children with sjia, % of adults with sjia, and % with aosd. respondents were asked open-ended questions regarding their experience with disease flares and impact on their lives, and specifically how sjia and aosd affected work, career and schooling. responses regarding the disease experience were classified into theme areas: ) experience with disease onset and process of diagnosis; ) health care access, quality, and drug safety concerns; ) physical impact of the disease including pain and chronic fatigue; ) social impact of the disease; ) mental health and emotional impact of the disease; ) impact on work, career, and employment; and ) broad impact on life and lifestyle. responses regarding effect on work, career, and schooling were categorized into theme areas: ) physical impact negatively influencing school/work productivity; ) lost work and wages, including unemployment and needing disability benefits, and parents missing work to care for the child; and ) the socialemotional impact as well as negative effects on mental health. about half of patients regardless of age reported the name sjia did not represent well the disease, specifically that it did not emphasize the systemic symptoms, and that the disease gets confused with other types of arthritis. adult patients with sjia did not like to have juvenile in the name. conclusion: children and adults with sjia and aosd report high levels of qol limitation and effect on school, work, and career, both during and between flares. our qualitative data emphasizes the importance of multidimensional evaluation of disease with ongoing input from the patients, which will provide a foundation for asking more relevant research questions to foster better care and improve qol. results: in total participants were included in the study : juvenile idiopathic arthritis (jia) patients, and their parents. the mean age of the patients was . ± . years. significant differences were found between patients and healthy children in such hrqol survey categories like "autonomy" and "financial resources" (p < . ). although quality of life in children's with juvenile idiopathic arthritis was lower than in healthy children in hrqol survey category "self perception" (p < . ). after analyzing data no significantly differences were found between patients and parents' assessment scores in hrqol survey categories (p > . ). conclusion: juvenile idiopathic arthritis has a moderate negative influence on hrqol survey categories "self perception", "autonomy" and "financial resources" (p < . ) according kidscreen- queationnaire. introduction: juvenile dermatomyositis (jdm) is often first identified by parents and carers as the red facial rash develops. the rash can progress and lead to young people being misdiagnosed with eczema, scarlet fever or psoriasis. however, over time the obvious signs of jdm can become "invisible" as treatment calms the rashes and masks the outward signs of jdm, until a flare occurs, when the rashes can be a marker for disease activity or progression. as part of a larger study, children around the united kingdom were asked to discuss their views on whether they wanted people to be able to see their jdm. objectives: to understand the implications for children and young people from having a disease that has visible and invisible phases and whether they want others to see their jdm, or not. methods: children and young people around the united kingdom who were already consented and enrolled into the uk juvenile dermatomyositis cohort and biomarker study were asked to complete a bespoke questionnaire. there was a mix of open and closed questions, and it was administered in paper format to all children and young people between the ages of and years of age for self-completion, either on the paper forms, or via a secure web-based software system. the questionnaires were administered at the end of . numeric data were described and qualitative data were analysed using standard content analysis. results: questionnaire packs were sent out, with ( %) being returned. of these could not be used due to practical reasons, such as only demographic data being completed, which left a sample of . ( %) of the who responded said other people could not see their jdm, with only ( %) saying it was visible and ( %) saying they did not know if others can see it. did not respond to the question as said their jdm has gone away. they were then asked whether it was a good or bad thing for others to be able to see their jdm or for others not to be able to see it. young people left comments as to why it was a good thing, left comments as to why it was a bad thing and left comments to why they said don't know, table presents the top ranking response for the three multichoice answers. conclusion: this study has highlighted the disparity between young people wanting others to see their jdm so that they gain more understanding and empathy from those around them, but equally, wanting their jdm to be invisible, so that they feel the same as their peers. whilst many paediatric rheumatic conditions are in fact invisible, our data illustrate that jdm often gives children and young people a taste of both visible and invisible phases of disease activity. as one young person said "it's not good, nor badit's good that it's invisible sometimes so i can blend in without the disabled stereotype. however, sometimes it needs to be seen so i can be understood and not challenged". disclosure of interest: none declared multidimensional assessment report (j-fimar) which includes comprehensive patient self-report questionnaire and numerical rating scales to measure pain, fatigue, headache, sleep quality, physical function, psychological state, health-related quality of life, satisfaction with illness course. the j-fimar has been devised according to the outcome measure in rheumatology (omeract) guidelines. discriminant ability of the multidimensional tool was evaluated by testing it in a control group including healthy controls and patients affected by active juvenile idiopathic arthritis (jia). the psychosocial consequences of chronic pain were evaluated by using the children depression index (cdi) and the multidimensional anxiety scale for children (masc). the objective sleep quality was measured by overnight polysomnography. results: table shows characteristics and the most represented somatic symptoms in our cohort of jfs patients at the study enter. polysomnography was performed in patients with sleep disturbance; / ( . %) showed an electroencephalographic pattern of alpha wave intrusion in slow wave sleep (sws). the presence of objective sleep disorders was significantly correlated to cdi score rs - , (p≤ , ) and masc , (p= , ). from november to april j-fimar was completed by jfs patients (f ( . %), median age . years [ . - . ], median disease duration . years [ . - . ]) in visits. all patients filled out the questionnaire in a short time (< minutes) and considered it simple and easy to understand. jfs patients showed significantly higher score for pain, fatigue, poor physical function and measure of psychological distress than healthy controls and jia patients (p< . for each item). conclusion: jfs patients presented significantly higher pain experience, functional disability, and impaired quality of life than patients with active jia. a relevant percentage of jfs patients experience sleep disturbances, which were correlated with mood and anxiety disorders. our multidimensional tool was feasible and able to quantify global jfs severity. this multidimensional tool, by measuring the main domains affected by the disease, could be promising to individualize treatment strategy and to test its efficacy. disclosure of interest: none declared introduction: fatigue is a subjective state of overwhelming, sustained exhaustion and decreased physical and mental capacity, which is not relieved by rest. fatigue is the most common complaint in children and teens with an autoinflammatory disease, besides the disease related flares. the purpose for this study was to show that fatigue is a serious issue for children and young people with autoinflammatory diseases. we hypothesized that age, gender and/ or the type of autoinflammatory disease could have differing effects on the fatigue experience. objectives: we aimed to investigate fatigue in children and young people (cyp) with autoinflammatory disease, including how this affected them on a daily basis. methods: cyp with autoinflammatory diseases were invited to complete an online survey, providing details about their fatigue and how it affected them. the survey was developed by the non-profit organizations autoinflammatory alliance and kaisz/vaisz, in english. respondents were recruited by convenience sampling through online social media posts. data on age, gender and disease were collected in addition to information on their experience of fatigue on school and social interaction. a total of cyp (age range - years) with an autoinflammatory disease responded to the survey ( % female). results: the majority of respondents ( %) reported experiencing both mental and physical fatigue. respondents were asked how much their fatigue affected them, on a scale of to ; overall, the mean fatigue score was . . however, young people aged or over reported a significantly higher impact than those aged - years (mean . , p= . ). different autoinflammatory diseases were surveyed: crmo %, caps %, pfapa % also unclassified said (usaid) with %. in the open-response portion of the survey, % of respondents reported that fatigue was physical, as well as mental, in their experience. most ( %) reported that someone had doubted their fatigue in the past; % had found their teachers had doubted them, % had friends who doubted them, and % reported that they felt their doctors had doubted them. children and young people also felt a number of activities made their fatigue worse (table ) ." conclusion: cyp with autoinflammatory diseases experience physical and mental fatigue. health professionals and teachers should listen to patients reporting fatigue, validate their experience, and help find ways to support them. identifying resources to help the patients with fatigue, and referrals to therapy and mental health resources as needed may help the patients to better cope and manage their chronic disease. further studies will include patient engagement in designing questionnaires about all aspects of life and autoinflammatory disease will help our understanding of these complex conditions and how they affect patients. introduction: scleromyositis is the most common overlap syndrome but is rarely observed in childhood. this disorder involves two different autoimmune diseases: systemic scleroderma (ssc) and polymyositis (pm). objectives: to describe the clinical course of a ssc/pm syndrome in a young girl. methods: case report results: an -year-old female was admitted to the neurological unit of our hospital for creatine phosphokinase (cpk) increase and hypertransaminasemia associated to sporadic episodes of right calf pain. familiarity for muscular dystrophy was reported in the maternal branch. muscle tone and trophism were preserved at initial neurological evaluation. laboratory investigation confirmed increased muscle enzyme levels, including cpk (x ) (ck-mm . %, ck-mb . %), aldolase (x ), cardiac troponin (x ) and myoglobin (x ). suspecting a primary muscle disease, she underwent a total body stir-mri which showed a diffuse edema of gluteus medius bilaterally and a muscle biopsy revealing a marked muscle damage with dystrophic aspects and normality of the tested proteins. a genetic extended panel for congenital myopathies resulted negative. after months, a new clinical examination showed the occurrence of general skin induration, sclerodactyly and tightening of the face skin. appearance of dysphagia was also reported, and muscle enzyme increase persisted. in suspicion of an ssc/pm overlap syndrome, she was referred to our unit. nailfold capillaroscopy showed capillary dilatation and branching, megacapillaries and diffuse microhemorrhages. reduction of esophageal contractions amplitude and hypotensive lower esophageal sphincter pressure were observed at esophageal manometry test. high-resolution ct of lungs and pulmonary function testing were normal. skin biopsy showed sclerodermiform findings. immunological studies revealed a positivity of antinuclear antibody ( : ) and anti-ku. anti-pm-scl resulted negative. an oral corticosteroid therapy (prednisone, . mg/kg/day) was started in association with subcutaneous methotrexate ( mg/m /week) and intravenous immunoglobulins (ivig) ( gr/kg every two weeks). improvement of skin manifestation, joint mobility, as well as normalization of serum cpk levels were observed. over months, prednisone and ivig were slowly discontinued up to the ongoing dosage of . /mg/day and gr/kg every weeks, respectively. mtx is still ongoing at the same dosage. conclusion: the diagnosis of overlap connective tissue disease syndromes may be challenging in pediatric age. different symptoms may be prevalent at different stages throughout the course of the disease. in our patient, a localized myositis preceded the ss onset by about four months. even though the use of high dose of corticosteroids is associated to a higher incidence of renal crisis in patients with css, a combined therapy with high doses of oral steroids, ivig and mtx was safe and effective in skin, muscle and joint symptoms in our patient. results: a total of images were obtained from healthy children included in the study and capillary measurements were made. capillary density was significantly higher in group than in groups and . arterial width was significantly lower in group as compared to group and , and in group as compared to group . apical loop width and capillary distance were significantly lower in group compared to group and and . there was no significant difference between the age groups in terms of capillary length and venous width. there was no difference between the groups in terms of capillary morphology. in total image evaluations, capillary tortuosity was < % in . %, and > % in . %, and capillary crossing were < % in . % and> % in . %. while the enlarged capillary was . % and the avascular area was . %, capillary branching, capillary meandering, microhemorrhage, and giant capillary were not detected in any case. there was a good level of agreement between the researchers, as cases with capillaries were evaluated with a good level of agreement (table ) . conclusion: this is the first study to evaluate capillary morphology in healthy turkish children. this study also adds that some special forms such as enlarged capillary and avascular area, which is always named as pathological in adult age, can be seen in healthy children. these data will be guiding in capillaroscopic studies in various patient groups, particularly in children with collagen vascular diseases. methods: patients with jia were tested for hla-b . they were divided into groups: ) hla-b positive and ) hla-b negative. results: patients ( , %) were hla-b positive and all of them are fulfilled the eular criteria of entesitis-related arthritis (era). the group consists of patients ( . %). there's no statistical difference between both groups in active joint count, ana-positivity and uveitis frequency, the rate of use methotrexate and time before biologics. no difference in axial cervical spine ( . %) vs ( . %) (p= . ) and sacroiliac joints ( . %) vs / ( . %) (p= . ) involvement was observed. hla b (+) patients often received pulse therapy with methylprednisolone due to increased inflammatory activity and severe arthritis ( % vs . %, p= . ). other parameters are listed in table . conclusion: patients with hla-b positivity were characterized by male predominance, more often hip involvement, higher laboratory activity and the need for more frequent use biologics. the rate of axial involvement wasn't different in hla-b positive and negative patients, that needs further study and creating more accurate classification criteria for jsa. disclosure of interest: none declared introduction: although gut is increasingly recognized as origin and/or target of inflammation in adult onset spondyloarthritis (spa), the incidence of gut involvement in juvenile spa (jspa) patients is still largely unknown, mostly due to the lack of reliable non-invasive tests. objectives: we performed a cross-sectional study of fecal calprotectin (fcal), a surrogate marker of gut inflammation, in patients with jspa, other forms of juvenile idiopathic arthritis (jia) and noninflammatory (ni) conditions. methods: fcal was measured by commercially available assay in stool samples of enthesitis related (era), psoriatic (psa) and patients with other jia subtypes (oligo-and poly-articular) who fulfilled ilar criteria, as well as in children with ni causes of musculoskeletal pain (ni-msd), regardless of the gastrointestinal (gi) symptoms (table ). fcal was compared among different groups of patients and correlated with demographic data, clinical characteristics, treatment modalities and disease activity measured by jspada. the values were also dichotomized to < mg/kg, - mg/kg, and > mg/kg, which was regarded as normal, slightly increased and increased, respectively. ileocolonoscopy was performed in one patient. our study has shown that fcal levels are significantly higher in era patients compared to other jia (p= . ) and/or ni-msd (p= . ) patients. moreover, almost a third of patients with era had levels of fcal above the range regarded as normal, which adds to the number of evidences for a gut inflammation in this particular type of jia. besides, the fcal levels were higher in those with axial involvement, which further suppots the association of gut and axial inflammation in children with era. although endoscopy remains a gold standard for the diagnosis of gut inflammation, fcal can help to select children with era who might benefit from this invasive procedure, regardless of the gi symptoms, as shown in one patient with the highest fcal concentration in our study. moreover, fcal levels seems not to be influenced by disease characteristic and/or concomitant therapy intake. therefore, fcal should be a part of diagnostic workup in children with any type of jia, but most importantly in those with era. evaluate potential predictor variables of magnetic resonance imaging (mri) sij remission methods: retrospective review of prospectively collected data. we included patients with era (according to ilar criteria) continuously treated with anti-tnf agents for ≥ months who had at least two mris of the sacroiliac joints performed before starting anti-tnf therapy (baseline) and during the follow up ( > months after anti-tnf treatment). si joints were examined using t -weighted images, t fastsuppressed and short-tau inversión recovery. the sparcc-sis was scored by two pediatric radiologists. sparcc-sis assessed the presence, depth and intensity of bone marrow edema (bme) on consecutive six slices in the iliac and sacrum bones . scoring is composed by: bme ( - ), bm intensity ( - ), bm depth ( - introduction: several paediatric patients manifest conditions commonly misdiagnosed as spider bites, which however, can include other arthropods bites; bacterial, viral, and mycotic infections; vasculitis; dermatological diseases; miscellaneous conditions as drug reactions, chemical injuries. objectives: in italy, spiders which are likely to be associated with severe toxin mediated tissue damage are uncommon, especially in urban zones. however, a minor trauma may be a precipitating factor for pyoderma gangrenosum particularly over the legs, in association with inflammatory bowel disease, haematologic diseases and juvenile idiopathic arthritis (jia). methods: we describe a -years old boy with pyoderma gangrenosum complicated spider bite in association with systemic jia (sjia). the patient was in clinical remission after the start of the sjia, occurred two months before, still treated with tapering doses of steroids and canakinumab, with the normalization of inflammatory parameters (crp, esr, saa, ferritin) and clinical manifestations. only a mild arthritis of the knee persisted and for this reason he was still treated with steroids. furthermore, he developed hyperglycemia, requiring insulin treatment. the first dermatological manifestation which he referred was a red dot of the leg skin. in a few days, the erythema enlarged, involving an area of x cm, with oedema, pain, and blisters, evolving in a necrotic lesion, with purulent exudate, surrounded by a haemorrhagic zone. results: haematological controls revealed neutrophilic leucocytosis, increased crp and procalcitonin. he started treatment with intra venous administration of teicoplanin plus ceftriaxone, with no resolution of the clinical manifestations and the reduction of leukocytosis, crp, procalcitonin. a culture swab was performed and was positive for pseudomonas aeruginosa, confirmed by pcr on the culture. he started ciprofloxacin and surgical curettage of the lesion, with the resolution of the lesion and the normalization of biochemical parameters. conclusion: the aspect of the lesion and its evolution were evocative of a spider bite suggested by anamnestic records, complicated by a pyoderma gangrenosum secondary to pseudomonas aeruginosa. the underlying disease, the immune suppressive treatment, with steroids and biological drugs, the hyperglycaemic pattern of the patient allowed the severe evolution of the spider bite. children in treatment with immune suppressive and/or biologic drugs are at high risk of infections. skin lesions, as arthropods bites, can be a facility for superinfection, with possible haematological and systemic diffusion. the strict application of the ilar requirement for the presence of documented arthritis for the diagnosis of sjia, early in the disease course, may result in unnecessary delays in initiating appropriate treatment. in preliminary printo classification criteria for sjia, this mandatory requirement of documented arthritis has been modified. to measure performance of preliminary printo classification criteria for sjia in our indian cohort. methods i gathered a data of seven sjia patients who attended dev children's hospital between jan and jan . my data included demographics,clinical presentation, laboratory parameters and outcome of these patients. all these patients were diagnosed at an early stage by clinical judgement irrespective of fulfilment of ilar criteria. i applied preliminary printo classification criteria for all. average age of selected children ( girls and boys) was . years. conclusion a preliminary printo classification criteria for sjia has been validated in our cohort. there are many raised inflammatory markers in most of these patients other than wbc count. these markers should be considered to be added in supportive laboratory criteria to be more specific towards the diagnosis. it is important to add pid in exclusion list especially in a case of sjia with mas at onset. trial registration identifying number leningrad's regional children' two patient stopped treatment within months from therapy start: due to primary inefficiency ( ) and allergic reaction ( ). five ( / ) patients were-co-administered with cdmards, other with oral gc, and subjects had been previously exposed to other biologic drugs. whole patients stopped therapy due to secondary inefficiency: patients were switched on toc, other children were switched on eta ( ) introduction: systemic juvenile idiopathic arthritis (sjia) is a rare, complex auto-inflammatory disease with significant morbidity including fever, rash, serositis and articular problems. with the availability of interleukin- (il- ) and il- inhibitor treatment, morbidity has significantly reduced and the outcome for sjia patients has improved. however, differences in access to care and differences in treatment strategies between countries in and outside of europe remain a concern. objectives: the single hub and access point for paediatric rheumatology in europe (share) consortium aimed to develop best practices for paediatric rheumatic diseases in order to decrease differences in care between european countries. here, we present the final results of the literature review and a series of consensus meetings on defining overarching, diagnostic and therapeutic recommendations for diagnosis and treatment of sjia. methods: the share methodology has been previously published, including the use of the eular standardized operating procedure for developing best practice recommendations. as per these guidelines, a methodologist provided supervision during the process and consensus meetings. conclusion: hscore seems to perform slightly better than ms-score for the diagnosis of mas in our cohort. early inhibition of il- is discussed to play an important role in the disease course of sjia . assuming that pretreatment with other dmards leads to a later start of therapy with canakinumab, this analysis evaluates the effectiveness of canakinumab as first-line vs. second-line dmard. to evaluate the effectiveness of canakinumab as first used biological dmard in sjia compared to canakinumab in sjia-patients pretreated with other dmards. methods sjia-patients documented in the german biologic registry for pediatric rheumatology (biker), who were exposed to canakinumab, were identified. for the first-line (fl) group dmard naïve patients were selected, prior treatment with corticosteroids and/or nsaids was allowed. patients receiving any dmard prior to canakinumab entered the second-line (sl) group. both groups were compared in a retrospective intention-to-treat-analysis. effectiveness canakinumab treatment showed good effectiveness in sjia both as first-and second-line dmard. after months the use of canakinumab as first-line dmard is associated with higher response rates compared to second-line use. our data support the hypothesis that early treatment with canakinumab is associated with good therapeutical response and a positive effect on the disease course of sjia. results: a total of children ( girls) with sle were identified. median age of symptom onset and diagnosis was years(range - years) and years respectively. the presenting manifestations were fever( ), oral ulcers( ), alopecia( ), malar rash( ), photosensitivity( ), renal involvement ( ), seizures( ) and gastrointestinal complaints ( ) apart from some unusual manifestations of isolated peripheral arthritis( ), isolated bilateral pleural effusion( ), macrophage activation syndrome( ). laboratory investigations: hemogram revealed anemia in children and thrombocytopenia in . urine examination showed nephrotic range proteinuria in child and subnephrotic proteinuria in . microscopic hematuria was noted in pateints. renal function tests were deranged in cases. ana, anti dsdna positivity and hypocomplimentemia were present in all. renal biopsy was done in patients, had class iv, one class iii and one had class v lupus nephritis. all patients were initiated on hydroxychloroquine and photoprotection. children with renal involvement were given pulse methylprednisolone followed by tapering doses of oral prednisolone and intravenous, monthly cyclophosphamide. azathioprine was used as maintenance therapy in all. subcutaneous weekly methotrexate was used in patients. one child (mas) died during disease course. disease continues to be in remission in rest. conclusion: we found a significant female preponderance in our study group. renal involvement was the commonest presentation. some unusual presentations were also seen. early recognition of sle is critical for timely initiation of appropriate treatment. this is the first report of a cohort of pediatric sle from this part of india. introduction: autoantibodies in ahai may be igg/igm/iga. ahai can be divided into primary or secondary (e.g. sle, lymphoproliferative diseases, infections, medications). it is also classified based on the temperature at which the antibody reacts to erythrocytes, and can be warm (igg or iga) or cold (igm or c ). in warm ahai, the antibodies react at temperatures ≥ ºc, not activating the complement system and not undergoing agglutination in vitro. in cold ahai, antibodies react at temperatures below ºc, activating the complement system with in vitro agglutination.mixed aiha (warm and cold) is rare and occurs in < % of aiha cases and can occur at any age, but is extremely rare in children. the prevalence of the mixed form is less than / , , patients with ahai. objectives: to report a rare case of mixed ahai and idiopathic intracranial hypertension(iih) in a -years old female patient with a previous diagnosis of sle and aps. methods: case report and literature review. results: a -years old female adolescent previously diagnosed with sle/aps since was in remission on hydroxychloroquine( mg);azathioprine( mg);aspirin( mg);vitamind ( . iu);calcium( g), and sunscreen. in april , she had a relapse presenting with fatigue, myositis, headache, hypocomplementemia, and severe autoimmune hemolytic anemia (hb of g/dl) (sledai- k= points). mixed ahai was diagnosed base on a direct/indirect coombs test / +;directantiglobulintesting showing anti-iga(weak),anti-igm( +/ +),anti-igg( +/ +),anti-c c(weak),anti-c d ( +/ +);igg / subclasses with a reaction of : ( +/ +);an eleven cell antibody panel positive revealing a cold and warm antibody, and adsorption technique revealing a cold and warm autoantibody. chest ct showed bibasilar subsegmental atelectasis, head ct/mri was normal and lp showed a high opening pressure of cmh o with a normal cell count. after the procedure, the patient reported improvement in the pain and was diagnosed with iih. the patient was screened for secondary causes for ahai (table ) due to the unusual mixed type pattern and serology was positive for chlamydia trachomatis (igm) and mycoplasma pneumoniae (indeterminate-igm/positive-igg) suggesting a recent infectious trigger causing reactivation of the underlying disease with a probable cross-reactivity. the patient treated with -days of clarithromycin. before the infectious screening came back negative, ahai was treated with a single dose of ivig( g/kg) and then, with -days of methylprednisolone( g/day). azathioprine was replaced by mycophenolate mofetil. due to headache recurrence, acetazolamide( mg/day) was started, and the patient referred no pain. the patient was discharged with a resolution of the symptoms. objectives: to our knowledge, the association of gbs and bbe has been described in adults only. methods: we here describe a child presenting at sle disease-onset with an overlap of peripheral (gbs) and central (bbe) nervous system manifestations, highlighting the possible association between these two entities in children. results: an -year-old healthy girl presented with acute ataxia, ophtalmoparesis and altered level of consciousness, rapidly followed by areflexia, facial paresis, swallowing difficulties, sensory deficits, paresis in all four limbs and respiratory insufficiency. these symptoms were accompanied by pleuro-pericardial serositis, proteinuria and hypertension. immunological investigations revealed the presence of positive ana and ds-dna antibodies. the renal biopsy showed a stage iii lupus nephritis. hence, the clinical, laboratory findings and biopsy report led to the diagnosis of psle. brain and spine mri did not show any abnormalities; diffuse slowing compatible with nonspecific encephalopathy was seen on eeg. nerve conduction studies (ncs) confirmed the clinical suspicion of acute polyradiculoneuropathy with proximal interruption of motor nerve conduction, compatible with guillain-barré-like syndrome. csf analysis (performed twice) remained normal. the patient was treated with glucocorticoids, intravenous immunoglobulins, cyclophosphamide as well as plasmapheresis. the neurological and physical symptoms improved gradually with complete neurological recovery four months after onset. conclusion: overlapping forms of bbe/gbs have never been described in association to sle in children. our patient's presentation and evolution fulfilled the criteria for such an overlap, occurring at psle onset. although sle and bbe/gbs are rare entities, our case suggests that there may be a common underlying immune background. this association should be recognized early for rapid and appropriate treatment initiation. infantile antiphospholipid antibody syndrome: acquired and de novo apl appearance in four infants t. giani , g. ferrara , a. mauro , r. cimaz introduction: antiphospholipid syndrome (aps) is a rare condition in the neonatal age. in most cases it is considered a passively acquired autoimmune disease, due to a transplacental passage of maternal antiphospholipid antibodies (apl). exceedingly unusual is the de novo production of apl in newborns and infants. objectives: to describe four infants who developed an early brain stroke with increased and persistent levels of apl, even after six months of life. methods: we reviewed the clinical charts of four such infants, followed from diagnosis up to two years after the disappearance of apl. conclusion: common characteristics of these four children are the development of brain stroke and the increased and persistent apl levels even after six months of life. this opens the window on a gray zone related to the origin of these antibodies (maternal or neonatal) and on their role in the pathogenesis of the infantile brain stroke. patients had over % of their monitoring completed but only had over %. aspects of monitoring that were more time intensive or were required less regularly were most frequently overlooked. there was a statistically significant increase in the percentage of completed monitoring in those patients for whom the lupus checklist was used compared to patients where a checklist was not used (p= . ). conclusion: there is significant room for improvement in the monitoring of these patients with jsle in the rheumatology clinic. this audit illustrates that more diligent use of the lupus checklist and an overall improvement in sustained use of the checklist will help to improve monitoring of these patients. evidence suggests that checklists are underutilised in medicine and wider implementation of this simple tool could improve patient outcomes. , , interventions such as in person or electronic reminders, or audits with feedback to physicians could improve usage over time. the application of the lupus checklist or a similar document in other paediatric clinics is important for comprehensive monitoring of a condition as complex as jsle and has the potential to prevent ongoing damage and medication toxicity in this high-risk population. juvenile onset and this cluster have may more severe kidney, neuropsychiatric or hematological involvement. objectives: the aim of this study was to assess the clinical and laboratory characteristics, disease activity, and treatment response of patients with juvenile sle (jsle). methods: this is a retrospective study involving patients between july and january . the data of patients diagnosed with jsle and followed up for a minimum of months, were collected. the sledai- k scores at initiation and at the follow-up ( st, rd, th, and th months of treatment) were examined. the sledai- k score was considered to be ≤ , for disease remission status. results: a total of children were included in to the study. the female/male ratio was . / and the median age of the patients at the diagnosis was (iqr: . - . ) years. the median follow-up of patients was (iqr: - ) month. four of the patients were diagnosed with monogenic sle. two siblings were diagnosed with c deficiency and two were diagnosed with familial chilblain lupus. the most common clinical findings were found musculoskeletal complaints ( . %), malar rash ( %), oral ulcers ( . %), and fever ( . %), respectively in over all the group. the frequency of involvement of the system and organs was as follows; mucocutaneous . %, musculoskeletal . %, renal . %, hematological . %, serous membranes . %, neuropsychiatric . %, respectively. all patients had anti-nuclear antibody positivity, while . % had anti-ds dna, . % had anti-sm and . % had antiphospholipid antibody positivity. while all patients received hydroxychloroquine treatment, . % of the patients were received were mycophenolate mofetil, . % were azathioprine, . % cyclophosphamide, . % methotrexate and . % were rituximab. the median sledai- k score was (iqr: - . ) at admission, besides it was found to (iqr: - ), (iqr: - ), (iqr: - ) in the st, th and th months of treatment, respectively. while % of the patients had active disease at admission, . % at months, . % at months and . % at months still had active disease (sledai- k > ). patients with initially high sledai- k scores had significantly lower remission rates in the first month (p= . ). it was observed that patients with high sledai- k scores in admission were more resistant to conventional immunosuppressive treatments and the use of rituximab was more frequent in these patients. at least one major organ (renal, hematological, neurological) were affected in % of patients. the remission rate of these patients at months was found significantly decreased compared to the others (p < . ). renal biopsy was performed in patients ( . %). of them had type lupus nephritis (ln), had type , had type , and had type . it was observed that patients with renal involvement were the group that reached remission latest. conclusion: the presence of high initial sledai- k scores and the major organ involvement have poor predictive value to achieve inactive disease. a two year old girl of consanguineous parents presented to hospital at months of age with fever and erythematous macular rash on her cheeks which spread to her nose, chin, and ears. the rash started a month prior, and progressed over her entire body. a skin swab grew staphylococcus aureus but the rash didn't respond to topical antibiotics. review of systems was unremarkable except for longstanding oral thrush and diaper rash. birth and family history were unremarkable. on exam she had a diffuse, erythematous, morbilliform eruption over her face and body. she had facial swelling, orbital edema and vasculitic oral ulcers. she had leukopenia mainly neutropenia, low hemoglobin, with normal platelets. her liver enzymes and erythrocyte sedimentation rate (esr) were high while c-reactive protein, immunoglobulins, c and c were normal. cultures were negative, however she was positive for adenovirus, mycoplasma and ebv (ebv load was iu/ml ). autoimmune hepatitis work up was negative. the direct coombs test, antinuclear antibodies ( : ), ro, rnp and smd were positive. ch came low as well as c q level of mg/dl (normal range - mg/dl). lymphocyte subsets showed reduced cd and nk cells. bone marrow aspiration showed active marrow. skin biopsy showed chronic non-specific inflammation (immunofluorescence and electron microscopy were not available). echocardiogram showed dilatation of the left coronaries. she was treated with intravenous immunoglobulin (ivig) for kawasaki disease with no improvement. therefore pulse steroid mg/kg followed by mg/kg was initiated. her rash, facial swelling and abnormal blood counts improved dramatically. whole exome sequence showed homozygous variant c. g>t p.g c at the c qa gene. while tapering steroids she flared so subcutaneous methotrexate was started. unfortunately, she continued to have rash, leukopenia and high liver enzymes, so treatment was switched to mycophenolate mofetil and hydroxychloroquine. however she did not improve and started to have recurrent bacterial and viral infections that included cellulitis, gastroenteritis and upper respiratory tract infection. we started her on regular ivig, which helped with infections and allowed for weaning of steroids. however she developed alopecia and lower limb spasticity with delayed walking. mri brain and spine was normal. upon reanalysis of the wes, two other homozygous mutations at kif c and apg were identified and associated with spastic paraplegia, but reported as variants of unknown significant. fresh frozen plasma (ffp) transfusions were started, initially weekly, then every two weeks and subsequently every four weeks. the rash disappeared, leukopenia and esr improved and we were able to discontinue steroids conclusion: early-onset sle with a severe course of disease raises the possibility of a genetic etiology. we are reporting, for the first time, a rare missense mutation g>t in exon of the c qa gene that resulted in an amino acid substitution that is pathogenic. interestingly, she had other mutations associated with neurological manifestation that never reported together before and altered her phenotype. she has responded well to ffp as has been reported in a few case reports results: a total of psle under the age of years were included, % (n = ) were males. the overall mean age at diagnosis was . ± . years and median disease duration was . ( - ) years. huv was diagnosed in . % (n = ) of psle cohort. psle with uv were more likely to be males ( % vs %; p < . ), diagnosed at a younger age ( . vs . years; p < . ), have a family history of sle ( % vs %; p = . ) and have conjunctivitis more frequently ( % vs . %; p < . ) than psle without uv. psle with uv were also less likely to have cns involvement ( . % vs %; p = . ) and hematological manifestations such as leukopenia ( . % vs %; p = . ) and thrombocytopenia ( . % vs %; p = . ). in addition, psle with uv were more likely to be associated with low c complement count ( % vs %; p < . ) and positive cytoplasmic anca ( % vs %; p = . ).however, the psle with uv cohort were less likely to be associated with ana ( % vs %; p = . ), dsdna ( % vs %; p = . ) and perinuclear anti-neutrophil cytoplasmic antibodies ( % vs %; p = . ). conclusion: we report a high occurrence of huv in psle cohort ( . %) associated with unique demographic, clinical features and laboratory features. the debate regarding whether huv is a rare subset or unusual type of sle, or is a separate entity altogether, continues. however, the overlap in clinical, laboratory and genetic mutation supports the notion that huv and sle fall into the same spectrum of autoimmune disease with similar disease pathogenesis. however, further studies are needed to reach clear conclusions regarding the relationship between huv and sle. introduction: the last decade has brought a lot to the approaches to the diagnosis and treatment of juvenile arthritis. in russia, the actualization of the problem of diagnosis and treatment of jia required the development of federal standards, which provide the most detailed algorithms for medical care, both at the stage of inpatient and outpatient care. in the regions of the russian federation, the effective use of these documents required a whole range of additional educated activities, both with students of medical universities, as well as with the medical and nursing community, in addition, a set of work was carried out to create a regional regulatory framework. in the total biological therapy pool, % of patients receive tnf-alpha inhibitors, antibodies to il- receive % of patients, antibodies to il- - , %. it is worth noting that when using biological agents in % of cases, the criterion of an inactive disease was achieved by - months, which was characterized by the absence of acute inflammatory symptoms, normalization of esr and crp. monitoring of patients with jia receiving biological agents required the conduct of a number of educational activities for medical personnel, the creation of an additional methodological base. for further training of young specialists at the regional medical university, a program of an additional educational course in pediatric rheumatology was developed and introduced. a regional patient organization was established and also required a set of information activities by the medical community. conclusion: in the saratov region of the russian federation, about % of patients with jia receive biological therapy, which corresponds to the average indicators according to the literature. in the structure of the biological drugs used, the group of tnf-alpha inhibitors is preserved - %. the introduction of modern methods of treatment using biological agents in jia has significantly increased the effectiveness of treatment, but it required the organization of additional information support for medical personnel. disclosure of interest: none declared introduction: immunogenicity and development of anti-drug antibodies have been associated with treatment failure and adverse events during biologic treatment. anti-drug antibodies (adas) have been reported in % of juvenile idiopathic arthritis patients treated with adalimumab. however, their role in reducing adalimumab efficacy is still debated due to conflicting results. no study has been directed toward identification of neutralizing adas in paediatric rheumatic disorders. objectives: aim of our study was to detect adas, along with their clinical relevance, using a new theranostic peptide-base assay in a cohort of children with inflammatory chronic diseases on adalimumab treatment. methods: six candidate adalimumab derived peptide antigens (hc-cdr , hc cdr , hc cdr , lc cdr , lc cdr , lc cdr ) have been developed and optimized to be tested. their performance has been compared with commercial elisa kit and a spr-based optical assay (biacore®). assays have been performed in sera of a cohort of children receiving adalimumab due to an inflammatory chronic disease. mean age, disease duration, concomitant treatment with methotrexate (mtx), ana positivity, disease activity parameters and scores at the time of ada determination have been recorded. chisquare, and fisher exact test were used to compare data. pearson's and spearman's correlation tests were used to determine correlation coefficients for entered variables. results: eighteen ( f, median age . , range . - , yrs) patients were enrolled: affected by juvenile idiopathic arthritis, of whom complicated by jia -associated chronic uveitis, and patients affected by chronic idiopathic uveitis. peptide assay revealed adas in children, biacore in , commercial elisa in . of note, we found total concordance among the tests just in patients. no significant correlation has been proven among the ada determinations. biacore and elisa determination showed significant concordance (r s : . , p< . ). the presence of hc cdr and lc cdr resulted significantly correlated with disease activity (r s : . , p< . ), and, inversely, with disease remission on treatment (r s = - . , p< . ). no patient experienced severe adverse events and no correlation with adas has been revealed conclusion: in chronic rheumatic disorders, novel reliable methods are urgently required to guide clinical decision and support decisions about switching within or between drugs in refractory children. the different methods, since based on different antigenic probes, detect different antibody populations. the present peptide-based assays might contribute to identify neutralizing adas in patients treated with adalimumab. further validation in larger cohort is required. introduction: non-bacterial multifocal osteomyelitis (nbo) is a rare polygenic autoinflammatory disease, which is difficult to diagnose and treat. because of combination of bone lesions with arthritis and/ or axial skeleton damage in most cases the diagnosis of juvenile idiopathic arthritis (jia) or juvenile ankylosing spondylitis (jas) may be establish as a concurrent diagnosis, so this allows to legal use of biologics (ba) for the treatment. objectives: to analyze the single center experience of clinical and laboratory features of multifocal nbo in patients (pts) who were treated by ba for the last years. methods: the study involved a retrospective cohort of multifocal nbo pts treated by different ba in our clinic from to . all of them underwent standard rheumatological examination. in order to examine all localizations of the bone damage, a scintigraphy and/ or "whole body" mri scan was performed. results: among the whole group of pts with nbo (n= ) we identified pts treated by ba (tnf-inhibitors only). the majority were girls (n= , %). age at disease onset was . years in average (me . range . - . ). for legal reason of ba administration, we classified our patients according to rheumatological features as jia or jas. pts had jia ( girls), pts had jas ( girls). among pts had oligoarthritis ( %), had polyarthritis of low limbs (hip, knee, ankle). axial involvement was represented by active erosive sacroiliitis with deep bone marrow edema on mri scan in pts ( %), active spondylitis of several bodies in thoracic spinein ; erosive arthritis with partial ankyloses of facet joints of neck in pts, multiple syndesmophytes in girl. we found that definite axial lesions in nbo developed in very young children (in y.old at minimum), much earlier than in "idiopathic" jas. hla b was presented in pts ( %), pts had ana in high titer (all of those hla b -negative). the pts had bone lesions in different parts of skeleton: vertebral bodies - pts, clavicle - , sternum, ribs - , extremities bones, metaphysic mostly (tibial, fibular - pts), sacroiliac region - pts. extraskeletal manifestations were observed in pts, one in each condition -uveitis, psoriasis pustulosus, acnae conglobate. in a girl with very severe course of disease, not responded to any therapy nbo was combined with familial mediterranean fever. high level of laboratory activity were detected before biologics in pts ( %): esr acceleration up to mm/h, increase of crp up to mg/l. treatment included nsaids (all), methotrexate ( pts), sulfasalazine ( pts, but it was withdrawn in all pts), bisphosphonates ( pt), prednisolone ( pts). because of high activity of nbo with appearance of new bone lesions and persistent arthritis tnf inhibitors were administrated: etanercept in pts, adalimumab - ( as first line, second line), golimumab - . at the start of ba the average age was . years (range . - . ); mean disease duration was , years (range . - . ). there were cases of withdrawals. due to inefficacy etanercept was switched to adalimumab. disease activity decreasing was reached in the most of the patients ( from ). among them pts developed the whole remission with resolving of active arthritis and bone marrow edema spots. skin lesions (psoriasis pustulosis and acnae conglobate) were significantly improved. there were no adverse events during the tnf therapy. conclusion: our experience of the therapy with tnf inhibitors in patients with high nbo activity has shown that this is a good and safe therapeutic option that is expected to prevent progression and bone destruction. . ae were reported for . % of patients, most within to hours after the first or second injection: flu-like symptoms ( . %), hypocalcaemia ( . %) and hypophosphatemia ( %). underweight patients (body mass index < . kg/m²) accounted for % of hypocalcaemia. the frequency of all the ae not significantly decreased with the reduction of the first dose. only one serious hyponatremia occurred corresponding to a patient with renal failure before treatment. conclusion: our results were similar to those previously published: bisphosphonates are safe for osteoporosis in children. in the literature, sae are very rare in children, being limited to anecdotal osteopetrosis in cases of higher doses and long-term treatment, and delayed bone healing. anecdotal osteonecrosis of the jaw in adults has never been described in children. the use of bisphosphonates beforehand requires dietary measures (vitamin d and calcium supplementation). furthers systematic collection on efficacy and safety parameters for each bisphosphonates drug should confirm these data. introduction: the use of biosimilars in rheumatology has increased significantly over the last years and has resulted in considerable cost savings. objectives: to assess the effectiveness and tolerability of the adalimumab biosimilar abp in patients with jia. methods: a database of patients prescribed adalimumab in our service has been screened to identify patients with jia, who switched from the originator to the biosimilar. only patients who had a clinical review since they had started the biosimilar were included. a paired-samples t-test was conducted to compare the number of active joints at the clinic appointment before and after the initiation of the biosimilar treatment. the frequency and type of side effects, the clinical response and the number of patients who switched back to the originator have been collected. results: sixty-one patients who switched to the biosimilar abp between february and february were included. they were comprised of enthesitis-related arthritis (era), polyarthritis, oligoarthritis, psoriatic and systemic jia patients. their baseline characteristics and outcomes are summarised in table. the mean duration of follow-up after the switch to biosimilar was months (range - ). eleven patients ( %) reported side effects; the most common side effect (n= , . %) was injection site reactions and the remaining consisted of anaphylaxis, druginduced lupus, dizziness and bone pain, respectively. seven patients ( . %) reverted to the adalimumab originator, as a result of side effects, because of ineffectiveness and one patient for both reasons. in addition, patients were changed to a different biologic, one patient due to allergy to both the originator and biosimilar and the other two patients had active disease on the originator and biosimilar adalimumab. two patients stopped the biosimilar and remained off any biologic, in the first case this was due to a side effect and in the second case it was patient's choice. on the whole, . % of patients had remained on abp at their last visit. there was no significant difference in the active joint count before the biosimilar was started (mean . +/- . ) and after the switch (mean . +/- . ), (p= . ). introduction: golimumab (gol) is approved for polyarticular juvenile idiopathic arthritis (pjia) in patients of ≥ years but long-term safety data are limited. objectives: prospective monitoring of long-term safety and effectiveness of gol in routine care using the biker-registry. methods: baseline demographics, clinical characteristics, disease activity and safety parameters were compared to a contemporary : matched control cohort using alternative tnf inhibitors or methotrexate without exposure to a biologic. efficacy outcomes were jadas , joint counts and functional status. safety assessments were based on adverse events (ae) reports. results: in this ongoing study, pts initiating gol were matched to with alternative tnfi and biologic-naïve pts. pts starting gol had a longer disease duration (p< . ) and use of gol was significantly more often second line ( . % vs . %, p< . ) and thus disease activity was lower at baseline. pts in the gol cohort used less corticosteroids, otherwise patients were comparable with pts treated with other tnfi (table ). in gol treated ps a marked clinical response was noted at months and beyond, indicating the effectiveness of gol in the treatment of pjia. a significant decrease of the mean jadas . to . (p= . ) after months of treatment was observed, as well as jia acr / / / response rates of / / / %. jadas remission and minimal disease activity was observed in % and . % after months and in % and % after months of treatment. rates of ae, sae and infectious ae were comparable in the gol cohort ( . / py, . / py and . / py), the alternative tnfi cohort ( . / py, . / py and . / py) and the mtx only cohort ( . / py, . / py and . / py). sae reported in the gol cohort were flares of uveitis and of jia (each ) and fibromyalgia syndrome ( ) . sae reported in the alternative tnf cohort was two serious infections (both influenza), one knee ligament injury, one flare of arthritis and one hyperventilation . no case of pregnancy, malignancy or death was reported. conclusion: golimumab seems an effective in treatment of pjia. tolerability was acceptable and comparable to alternative tnfi or mtx. recruitment to the project is ongoing. disclosure of interest none declared introduction: methotrexate (mtx) is one of the most commonly used disease-modifying anti-rheumatic drug in rheumatology practice. it has some side effects that can impair quality of life. the most common of them is associated with the gastrointestinal tract. objectives: the aim of the study is to evaluate and compare the frequency of methotrexate intolerance in adult and pediatric patients. methods: patients with rheumatologic diseases followed in hacettepe university pediatric rheumatology and rheumatology departments who used oral or parenteral methotrexate for at least months were included in the study. methotrexate intolerance was assessed using 'methotrexate intolerance severity score (miss) questionnaire. the miss questionnaire consisted of parts: abdominal pain, nausea, vomiting, fatigue and behavioral symptoms. the patients scored the severity of each symptom separately; : no symptoms, : mild symptoms, : moderate symptoms, : severe symptoms. a total score of or more was defined as mtx intolerance. visual analogue scale (vas) ranging from cm to cm was performed to each patient concurrently with the miss questionnaire. in the pediatric patient group, miss questionnaire and vas assessment were applied to both patients and families. results: a total of patients, of whom were children, enrolled in the study. the mean age for children and adults were . (± . ) and . (± . ) respectively. the most frequent diagnosis of patients was juvenile idiopathic arthritis ( . %) in children and rheumatoid arthritis in adults ( . %). the mean mtx dose in adults and pediatric group was . (± ) mg vs . (± . ) mg (p: . ). the prevalence of mtx intolerance in children and adults were . % (n: ) and . % (n: ) respectively. the mean miss score in the pediatric group was higher compared with the adults ( . ± . vs . ± . , p< . ). similarly, the mean vas scores were higher in pediatric group ( . ± . vs . ± . (p< . )). there was a strong correlation between miss and vas scores between family and child evaluations (p < . , r = . / p < . , r = . ). abdominal pain, nausea, vomiting and behavioral symptoms were observed more frequently in children compared to adults. results: ( %) out of patients were diagnosed with psoriasis denovo. one patient was treated with ada (a girl with undifferentiated arthritis who had positive hla-b , anf and family history of psoriasis -her grandmother had psoriasis), patients were treated with eta (both female, one patient had undifferentiated arthritis, the other had enthesitis-related arthritis; both patients had positive hla -b and anf negative). patients achieved significant improvement after changing tnfalpha inhibitor ( -ada, -eta), patient (was treated with eta) had significant improvement after discontinuation of biological therapy. conclusion: this single-center observational study demonstrates the possibility of developing psoriasis de-novo in patients with jia receiving tnf-alpha inhibitors. although more extensive research is needed, our data suggest that discontinuing the tnf-alpha inhibitor or switching to another tnfalpha inhibitor in patients with psoriasis de-novo should be considered as a treatment strategy in such cases. objectives: long-term surveillance of patients newly initiating toc treatment for at least years compared to a cohort of patients newly initiating a comparator biologic using the biker-registry. methods: baseline demographics, clinical characteristics and disease activity, efficacy and safety parameters were compared. efficacy outcomes were jadas , joint counts and functional status safety was assessed by adverse events (ae) reports. results: patients with matched controls have been recruited. patients starting on toc were older at treatment start ( . vs. . years (y); p< . ) and had a longer disease duration (p< . ). toc was significantly more often a second line biologic (p< . ). baseline jadas ( +/- vs +/- ), chaq-di ( . +/- . vs . +/- , ), esr +/- mm/h vs. +/- mm/h and active joint counts ( +/- vs. +/- ) were comparable. upon toc a substantial response with a significant reduction in jadas from . to . (p< . ) after months of treatment was observed. there were no significant differences between patients from the toc cohort and their matched controls in the jia acr / / / criteria, jadas , jadas remission and minimal disease activity was reached by comparable numbers (toc % and %; control cohort % and %). the total number of ae was comparable (toc cohort n= ae; ( / py); control cohort n= ; ( / py; rr . ; %ci . - . ). more serious ae (sae) were reported with toc. serious infections were documented at lower frequency with toc. uveitis events were documented at significantly higher frequency with tnf inhibitors most likely due to a selection bias (table ) . sae with toc were depression (n= ) in with suicidal intent, exacerbation of jia (n= ), septic arthritis, gastrointestinal infection, abdominal pain, colitis, paronychia and fracture. sae in the control cohort were depression, osteomyelitis, gastrointestinal infection and disease flare. no significant differences regarding cytopenias and elevated transaminases were observed. no gastrointestinal perforation, no vascular events and no deaths occurred. conclusion: toc was effective and comparable to treatment with alternative biologics. tolerability was acceptable. as toc was given as a second-line biologic in the vast majority of patients comparisons between the cohorts have to be interpreted carefully. observation is ongoing. conclusion: in this retrospective cohort study in pediatric patients on rtx-treatment, we found undetectable low drug levels in adapositive patients, indicative for their neutralizing capacity. consequently, the lack of b-cel depletion leads to reduced treatment efficacy. patients with sle seem more susceptible to develop ada. if ada are detected, continuation of treatment seems non-effective and changing medication is advised. certainly when considering that, in this study, anaphylactic reactions only occurred in ada-positive patients. none declared objectives: the aim of this study was to evaluate retrospectively the long-term efficacy and safety of adalimumab in patients with jiaassociated uveitis. methods: we have retrospectively analysed nineteen jia patiens data with associated uveitis from our centre registry between and , treated with adalimumab after failure of treatment with corticosteroids and metotrexate. demografic data and blood samples were collected at different time points while uveitis activity was evaluated by slit-lamp biomicroscopy. adverse events were recorded. results: registry records provided years follow up of jia patients data with associated uveitis. eleven patients were females ( . %) diagnosed as oligo/extended oligoarticular jia while eight ( . %) were males diagnosed as enthesitis related arthritis (era). before adalimumab was prescribed, all patients were previously treated with metotrexate during . years in avarage dose of mg/ m weekly. the mean uveitis duration, before adalimumab administration was months. ten years long follow up period have showed that there were no new relapsis of uveitis while patients were receiving adalimumab and metotrexate. all of our patients were able to gradually tapper and stop treatment with topical steroids two months after adalimumab commencing. seven patients were able to stop biological treatment after . years of adalimumab usage. uveitis relapsed three monts after the adalimumab discontinuation only in one patient. two patient were lost to follow up during the transitional period. no serious adverse events were recorded. conclusion: during the long term follow up period adalimumab have shown good efficacy and safety profile in jia patients with active inflammatory ocular disease. introduction: post-streptococcal syndrome is a systemic immunemediated complication of beta-haemolytic streptococci infection, mostly seen as post-streptococcal arthritis, rheumatic fever or glomerulonephritis. uveitis is an uncommon manifestation of this syndrome. objectives: case report methods: case report results: a previously healthy -year-old female was admitted at the emergency department with prolonged fever, arthritis and red eye. she had a -month history of febrile episodes every two weeks, with axillary temperature ranging from , to ºc. migratory arthralgia affecting both knees and tibiotarsal joints showed up two months after the fever onset and worsened in the previous week, with refusal to walk. non-painful bilateral red eye for several weeks was mentioned. other symptoms were absent. recent infections were denied and family history was irrelevant. physical examination revealed lower limb muscular atrophy, knees pain and impaired function and bilateral tibiotarsal arthritis with inability to walk. ophthalmological observation showed a bilateral non-granulomatous anterior uveitis. sequential laboratory work up revealed a maximum eritrocitary sedimentation rate of mm/h, maximum c-reactive protein of , mg/dl, microcytic hypochromic anemia, positive antistreptolysin o titer (asot) (initial result of that increased to in weeks and later decreased to ) and negative anti-nuclear antibodies. cardiac involvement was excluded. the diagnosis of rheumatic fever with concomitant poststreptococcal uveitis was assumed and the patient was treated with oral and topical ophthalmic corticosteroids with prompt clinical resolution of fever, acute polyarthritis and uveitis. no relapse occurred in a -year follow-up. conclusion: juvenile idiopathic arthritis (jia) is the most common cause of uveitis in childhood. although our patient clinical course could initially raise the possibility of systemic jia (sjia), the criteria that define this entity weren't all present and clinical and laboratory findings were more supportive of rheumatic fever. besides, uveitis occurs exceptionally in sjia, which turned this diagnosis even less reasonable. in our rheumatology unit, among patients diagnosed with jia in years, had uveitis. however, in the group of patients with sjia only one had ocular involvement, a boy with isolated vitritis. post-streptococcal uveitis (psu) typically presents as bilateral, non-granulomatous anterior uveitis, as described in this case. as streptococcal infection is very common among children and many patients may experience subclinical infection. psu should be considered in all patients with uveitis along with positive asot and negative routine investigations for other causes. although psu has been described in literature, to the best of our knowledge, this is the first reported case of concomitant rheumatic fever and psu. . ada was first tapered to every weeks by % of the responders and then to every weeks by % before discontinuing. fewer respondents used or tapered ifx, toc or aba. around % tapered the interval and % tapered the dose and interval for aba, % for toc and % ifx there were differences in the duration of tapering prior to discontinuation of specific medications. for ada it was months in %, months in % ,and months in %. for ifx it was months in %, months in %, and months in %. for toc it was % after weeks, % after weeks and % after weeks. for aba i.v. it was % after weeks, and % after weeks. if combination therapy was used, % tapered the bdmard first, % csdmard first, and % both simultaneously. conclusion: this is the first survey to describe "real world" medication tapering and discontinuation practices of pediatric rheumatologists and ophthalmologists globally. most physicians start to taper medication after months of remission on medication and discontinue after the to months of tapering. we would like to thank all the participating colleagues, who took time to fill out our surve introduction: jia-associated uveitis (jia-u) occurs in - % of children with juvenile idiopathic arthritis (jia) and typically asymptomatic, and sight-threatening complications occur in % of children, (i.e. cataracts, vision loss). frequent ophthalmic examinations are important for early diagnosis and monitoring of uveitis activity. even after uveitis is controlled, risk of disease exacerbation still exists. therefore, frequent ophthalmic screening and monitoring is important for detection and management of jia-associated uveitis (jia-u). s proteins, cytokines, and chemokines detected in aqueous humor of patients with uveitis are also detected in tears. biomarker discovery using tears is promising since collection is noninvasive, feasible, well-tolerated, and close to the target organ. objectives: we aim to determine if s proteins, cytokines, and chemokines levels differ in tears of children with jia and jia-u and in children with jia-u by uveitis activity. methods: tears were collected using schirmer strips from children ≥ years old with oligo-or polyarticular rf negative jia with (jia-u) and without uveitis (jia-no-u), and in children with jia-u at time of active and inactive eye disease. activity was defined by standardization of uveitis nomenclature (sun) criteria. active uveitis was anterior chamber inflammation grade ≥ . + cells. s a , a , and a were measured by elisa, and il- , il- , ip- , mcp- , rant es, and sicam- by luminex assays. biomarker levels were compared in children with ) jia-no-u (n= ) to active jia-u (n= ), and ) jia-u (n= ) at time of active and inactive uveitis. results: children with jia-no-u and jia-u were matched by jia subtype and arthritis activity. they had primarily oligoarticular jia ( %), active arthritis ( %), and were on systemic medication ( %). at time of active uveitis, % had grade . +, and % had + and mean interval between time of active and inactive disease was months. we found that levels of biomarkers in tears of children with jia-no-u compared to active jia-u were similar. although not statistically significant, levels of s a (mean difference , pg/ml [ % ci - to , ], p= . ) and sicam- ( pg/ml [ % ci - to , ], p= . ) were higher when uveitis was active compared to inactive. conclusion: our results suggest that s a and sicam- are potential biomarkers of uveitis activity in jia-u, but not uveitis diagnosis. thus, neutrophils may play a role in the pathogenesis of anterior uveitis which has been reported in an animal model of acute anterior uveitis. identifying biomarkers using tears provides a noninvasive and objective method of monitoring uveitis. limitations are our heterogeneous cohort that varied by arthritis severity and immunosuppression, and minimally active uveitis. we were underpowered to detect statistically significant differences and continue to collect tears prospectively in children with jia-u with goal of n= . despite low uveitis activity, we were still able to detect differences. further studies in larger and diverse cohorts are necessary to assess the role of s a and sicam- in jia-u. objectives: to report an extremely rare presentation of gpa in a year old with acute digital ischemia. a year old boy, with a background of poorly controlled type diabetes and hypothyroidism, initially presented to hospital unwell with diabetic ketoacidosis. treatment was initiated promptly with good response. furthermore, he was found to have weight loss, productive cough and hearing loss over the past months. he was haemodynamically stable, but very pale and cachectic. he had reduced air entry and crackles on the right. there was hypertonia and clonus in his lower limbs. blood tests showed microcytic hypochromic anaemia (hb g/l), normal white cell count, thrombocytosis and raised inflammatory markers (crp mg/l and esr mm/hr). his chest x-ray showed enlargement of the right hilum with consolidation/ atelectasis extending into the middle and lower lobes. mri scans of head and spine were normal apart from fluid opacification in the paranasal sinuses. he was screened for infections including tuberculosis and started on intravenous antibiotics. on day , he developed painful bluish discolouration of his left hand, particularly his thumb, index and middle fingers. his left radial and brachial pulses weren't palpable. a heparin infusion was started. a doppler scan showed occlusion of radial and ulnar arteries proximal to the wrist with no clear thrombus. he had a ct thoracic aorta with contrast which showed proximal left radial artery occlusion and distal ulnar artery occlusion with no evidence of proximal embolic source or vasculitis. it showed multiple perihilar masses (lymph nodes) in the right lung and peripheral parenchymal masses in both lungs, suggestive of atypical infection or connective tissue disease. blood tests still showed raised inflammatory markers(crp mg/l, esr mm/hr and platelets /l). an autoantibody screen showed positive anca with strongly positive anti pr (> u/ml); other autoantibodies, including ana, ds dna and anti-phospholipid antibodies, were negative. he developed further ischaemia with bluish, painful discoloration of his right foot, especially right great toe, with a weakly palpable dorsalis pedis pulse. doppler scan revealed occlusion/narrowing of the posterior tibial artery cm proximal to the ankle. following vascular team advice, he was started on ilioprost infusion to aid reperfusion of the extremities involved, with good results. based on clinical and lab features of systemic inflammation, evidence of upper airway involvement(bilateral conductive hearing loss and sinusitis on mri scan), parenchymal lesions on ct chest and strong pr positivity, a diagnosis of gpa was made. results: our patient responded well to therapy including multiple pulses of high dose methylprednisolone and cyclophosphamide, with improvement of all organs involved and no further digital ischemia. conclusion: although gpa is very rare in children, it is associated with high morbidity and mortality. many studies show that the spectrum of paediatric gpa is not vastly different from adults, except for higher gender bias towards female, more constitutional and musculoskeletal symptoms and higher risk of subglottic stenosis. although there are a handful of case reports of digital ischaemia in adults with gpa, to our knowledge this is the first case report of acute digital ischaemia in paediatric gpa. early diagnosis and prompt treatment with a multidisciplinary team approach is paramount for good outcome. introduction: adenosine deaminase- deficiency (dada ) is a monogenic vasculitis syndrome whose presentation ranges from recurrent fevers and livedo reticularis to systemic vasculitis, hematologic and immunologic abnormalities, and early-onset stroke. it is characterized by biallelic loss-of-function mutations in the encoding gene of ada protein and low levels of ada enzymatic activity in the peripheral blood. the genotype and phenotype features of dada has a wide spectrum. treatment with anti-tnf inhibitors is effective in controlling vascular inflammation and reducing strokes. objectives: to describe two sisters with different presentations of dada and a deletion mutation on exon of the ada gene. methods: medical data was used to describe the clinical manifestations of two siblings. parental informed consent was obtained. results: patient : a -year-old female had presented with fever, rash, arthralgia, hepatosplenomegaly, and coombs positive autoimmune hemolytic anemia (aiha) at the age of years. she had been followed with a suspected diagnosis of systemic lupus erythematosus (sle) and steroids, azathioprine, mycophenolate mofetil had been used. her ana and complement levels were normal. because of unmet classification criteria of sle, genetic testing had been done, and no mutation found in the ada gene. cranial mr and mr angiography was normal. she was referred to our clinic after . years of the first manifestation. physical examination revealed raynaud phenomenon on both hands and feet, livedo reticularis, arthritis, and splenomegaly. laboratory tests indicated an increase in acute phase reactants, cd , cd , and switched memory b cell lymphopenia, and hypogammaglobulinemia. because of prolonged fevers, a thorax ct was obtained and aneurisms of the renal artery were seen. abdominal ct angiography indicated multiple aneurysms of both renal, intercostal, and hepatic arteries. repeated genetic analysis of the ada gene showed a homozygous deletion mutation on exon . she has been followed on anti-tnf and iv immunoglobulin without severe symptoms for a year. patient : the older sister had been followed with a diagnosis of familial mediterranean fever with e q heterozygous mutation because of recurrent fever, abdominal pain, erysipelas-like erythema, elevated acute phase reactants, and splenomegaly. she did not have any other cutaneous or systemic findings. because of parental consanguinity, the ada gene was analyzed and a homozygous deletion mutation on exon was found. she has been followed without any symptoms after anti-tnf treatment. throat swab was negative. abdomen ultrasound showed bowel wall thickening, testis ultrasound was normal. hsp diagnosis was confirmed. methylprednisolone iv was administered for three days, then oral prednisone was started. purpuric lesions, abdominal pain persisted, so we decided to add mmf ( mg/ m /day) and prednisone was tapered in a month. results: thanks to mmf vasculitis lesions and abdominal symptoms disappeared in few days. mmf was continued for a month, tapered in months. there was no evidence of relapse in a months follow up. conclusion: these cases suggest that mmf may be useful to induce and maintain remission of recurrent hsp with gastrointestinal involvement. multicenter clinical trials with long-term follow up to confirm the efficacy of mmf in the treatment of hsp with gastrointestinal involvement are needed. introduction: henoch-schönlein purpura (hsp), the most common childhood vasculitis. cholecystitis is extremely rare in patients with hsp. this is the first case of a libyan child presenting with hsp complicated by calculus cholecystitis hsp nephritis. objectives: our aim is to present an unusual case of gall bladder involvement in an -year-old libyan female affected by hsp. methods: a case reports study results: : we report an unusual case of gall bladder involvement in an -year-old libyan female with hsp. she was referred to a rheumatology clinic due to hsp with chronic calculus cholecystitis and distended small bowel with fluid-like fecal material with no evidence of intussusception on an abdominal ultrasound. the patient had a one-month history of abdominal pain, purpuric lesion on lower limbs and swelling in both feet. she was admitted times to another hospital before being referred to the rheumatology clinic. an abdominal sonography revealed a distended small bowel with fluid-like fecal material with no evidence of intussusception and chronic calculus cholecystitis; they treated her with urosdoxycholic acid tab at mg per day and ibuprofen syrup. then referred to our rheumatology clinic. after days, she showed a purpuric rash over her lower extremities, mainly over her thighs and buttocks, microscopic hematuria, no arthritis, no fever, no abdominal pain; her blood pressure was normal at \ mmhg, and she had normal laboratory tests (cbc, wbc . , hgb . , platelets esr ml\hour, crp mg\dl was negative, c was mg\dl within normal range - mg\dl, c was . mg\dl within normal range - , anca, ana, as well antidsdna ab yielded negative, antistreptolysin-o (aso) titer was todd , lft included total bilirubin , direct , indirect gpt,got, u, creatinine ) except urine routine showed mild microscopic hematuria rbc hpf , protein was nil ) urine for pro-tein disclosure of interest none declared p correlation of serum neopterin levels with disease activity and moneta division of rheumatology, irccs, ospedale pediatrico bambino gesù, roma; university of genova a multinational study of thrombotic microangiopathy in macrophage syndrome clinical impact of a targeted next-generation sequencing gene panel for autoinflammation and vasculitis laboratory biomarkers to facilitate differential diagnosis between measles and kawasaki disease in a pediatric emergency room: a retrospective study a rare case of measles-associated hemophagocytic lymphohistiocytosis in an infant. cureus children's interstitial and diffuse lung disease respiratory complications of the rheumatological diseases in childhood on behalf of dr nishant dharsandiya and dr j.p. keshrani paediatric rheumatology & immunology, dev children's hospital arthritis care res (hoboken) disclosure of interest: none declared development and initial validation of the ms score for diagnosis of macrophage activation syndrome in systemic juvenile idiopathic arthritis development and validation of the hscore, a score for the diagnosis of reactive hemophagocytic syndrome double-blind, placebo-controlled study of anakinra in pediatric and adult patients with still's disease l. schanberg , p. nigrovic duke children's hospital & health center, durham; boston children's hospital, boston; children's mercy kansas city, kansas city; university of alabama at birmingham, birmingham; nationwide children's hospital, columbus; university of iowa hospitals and clinics children and adolescents with sle: not just little adults severe disease presentation and poor outcomes among pediatric systemic lupus erythematosus patients in south africa the checklist manifesto: how to get things right clinical review: checklists -translating evidence into practice the who surgical safety checklist: a review pehlivanoğlu p gastrointestinal henoch-schönlein purpura treated with mycophenolate mofetil: description of two case reports venous vessel wall thickness in lower extremity is increased in male patients with behcet's disease increased vein wall thickness in behçet disease polyarteritis nodosa: a contemporary overview eular / printo / pres criteria for henoch -schönlein purpura , childhood polyarteritis nodosa , childhood wegener granulomatosis and childhood takayasu arteritis : ankara six patients were treated with canakinumab and patients with anakinra. conclusion: it is known that excessive production of il- β can cause inflammatory bone loss and abnormality. vitamin d deficiency and osteopenia/ osteoporosis may cause additional musculoskeletal problems besides arthritis and joint destruction in caps. we think that ca metabolism and bone mineral density measurements should be a part of routine controls in patients with caps. disclosure of interest none declared ab clinical and genetic features of patients with periodic syndrome associated with mutation of the tumor necrosis factor receptor gene and juvenile arthritis having mutations in tnfrsf a gene m active arthritis in / , it was poly in , oligo in . when assessing the clinical symptoms and laboratory activity of patients with jia, it was revealed that in the onset of the disease, systemic manifestations were observed in / : fever in / , rash in / , hepatosplenomegaly in / , pneumonitis in / , carditis in / and lymphadenopathy in / . high laboratory activity was recorded in / . active arthritis in / , it was polys in , oligo in . in all % of patients, the nucleotide variants of the tnfrsf a gene were identified in the study. / of patients were diagnosed with traps. the most frequent heterozygous variant of tnfrsf a gene with nucleotide substitution of c. g>a was found in / of patients, in / of patients it was found homozygous variant with nucleotide substitution of c. g>a, in / of children it was found heterozygous variant with deletion of c. _ del. all of these variants are pathogenic. / of patients were diagnosed with ja: juvenile arthritis with a systemic onset was in / , paucarticular arthritis was in / , in / it was poly rf-and in / it was psoriatic arthritis. it is worth noting to note that in / a heterozygous version of the tnfrsf a gene was detected with a nucleotide substitution c. g> a, however, considering the absence of clinical manifestations of autoinflammatory disease and active articular syndrome in these patients, children were diagnosed with ja. in addition dvoryakovskaya: none declared, a. mamutova speaker bureau of: novartis, k. isayeva: none declared, r. denisova speaker bureau of: novartis covid- and relapsing kawasaki disease: a case report during the pandemia m. c. maggio ab introduction: the pandemia of covid- remains a global health alarm with high incidence of lethality, especially in older age groups who suffer from underlying medical conditions. however, children are less likely to manifest severe conditions. objectives: covid- was correlated to a higher incidence and a suspected increased risk of kawasaki disease (kd) in children anamnestic records revealed a previous kd, without coronary artery lesions (cal), year before. results: he was treated with antibiotics, intravenous infusion of immunoglobulins (ivig) ( gr/kg), acetylsalicylic acid (asa) ( mg/kg in doses/day) and reached defervescence into days. echocardiography excluded cal. the nasopharyngeal swab for sars-cov- was doubt. the second throat swab done the day after ivig infusion, was negative; however, the third nasopharyngeal swab for sars-cov- , done days after ivig infusion, was positive. chest x-ray showed a significant lung interstitial thickening. il- levels were < . pg/ml (n.v. < . pg/ml). he continued treatment with antibiotics, asa ( mg/kg/day), with the progressive resolution of the clinical symptoms and of the normalization of laboratory findings. conclusion: the peculiar outcome of the patient is the correlation of covid- with kd, recently reported as associated. kd is considered as a multifactorial autoinflammatory disease, induced by a cytokine hypersecretion with a systemic vasculitis. covid- is considered a cytokine storm syndrome, with a severe systemic vasculitis. sars-cov- infection could be the trigger that could lead to hyperinflammation of kd. the ivig infusion could explain the transient negative swab for sars-cov- , with the successive positive relieve lasting days, and the normal levels of il- , detected after ivig infusion. relapsing kd is rare ( . - . %); in our patient this event could be triggered by the documented sars-cov- infection. disclosure of interest none declared disclosure of interest none declared ab spectrum of systemic inflammatory syndrome in children during covid pandemic in india d. b. pandya, on behalf of dr haresh dobariya pediatric rheumatology & immunology, dev children's hospital ab rituximab for treatment of resistant paediatric mctd v. paisal, s. compeyrot-lacassagne paediatric rheumatology the diagnosis and classification of of mixed connective tissue disease mixed connective tissue disease in children -case series the value of rituximab treatment in primary sjögren's syndrome juvenile idiopathic arthritis a multifaceted approach is essential for robust rehabilitation m methods: in a retrospective study children ( % girls) aged median (iqr) , ( , - , ) years with oligoarticular onset jia without extra-articular manifestations (oligo-ja) who did not received dmards were monitored. all children were met ilar criteria. ttriamcinolone acetonide (ta) was administered intra-articular at a dose of - mg with an injection interval of - - months which was depended on the activity of the disease. the maximum allowable number of consecutive isolated intra-articular injections (is-iai) was - . a total of active joints were injected with ta: knees - injections, ankles - injections. all children were divided into two groups: active / inactive arthritis based on the effectiveness of local corticosteroid treatment. the average follow-up was and physicians' assessment of jia disease activity efficacy is-iai of ta was no associated significantly with number of active joint of onset oligo-ja, cjadas , serum level of crp mg/ml, esr mm/h, il pg/ml and tnf-α pg/ml, titer of anf. the mean inflamed synovial fluid of il levels abstracts from conferences and relevant studies were added. rcts were included if (i) patients were aged ≤ years, (ii) patients had a previous defined pediatric rheumatic diagnosis and (iii) rct met predefined outcomes. studies were excluded in case of (i) observational or single arm study or (ii) sample size ≤ patients. study design, location, duration, treatment, population, sample size, age criteria, gender, concomitant treatments and primary outcome was extracted. results: out of screened references, references reporting unique rcts in pird. all rcts reported efficacy while / rcts provided safety outcomes and / rcts provided pk data. ten of reviewed bdmards are approved for pirds by the food and drug administration (fda). of these, seven had ≤ rcts. the most common intervention was tnf inhibitors ( %) treatment with intravenous immunoglobulin (ivig) significantly reduces the risk of caas. however, up to % of cases are ivig resistant with a higher risk of cardiovascular complications. currently several second-line treatments are available for refractory kd. nonetheless, the existing literature is still unable to identify which treatment is the most effective. recent studies suggest that a il- receptor antagonist (anakinra) may be an effective therapy in refractory kd. objectives: we report the case of a year-old boy diagnosed with kd refractory to conventional treatment, who developed giant caas successfully treated with subcutaneous (sc) anakinra. methods: case report. results: a year-old boy was referred to our pediatric rheumatology unit days after the onset of a typical refractory kd. he had been previously treated at a local hospital with two doses of ivig ( g/kg), infused respectively and days after the onset of the fever. afterwards, given the persisting fever, doses of pulse intravenous (iv) methylprednisolone (mpdn mg/kg/day) have been used for days followed by oral prednisone ( mg/kg/day). treatment with acetylsalicylic acid ( mg/kg/day q h) was also started. following a transient defervescence the day after the first iv pulse mpdn, fever relapsed and the echocardiography showed caas of left main coronary artery (lmca), left anterior descending (lad) and right coronary artery (rca) rationale and study design for a phase i/iia trial of anakinra in children with kawasaki disease and early coronary artery abnormalities (the anakid trial) the use of interleukin receptor antagonist (anakinra) in kawasaki disease: a retrospective cases series there are few reports of acute kidney injury (aki) in kd, defined as serum creatinine level elevation to more than . times of baseline level. objectives: to describe the case of kawasaki disease complicated by aki methods: a -year-old female was admitted to our rheumatology unit with persistent fever ( days), widespread polymorphous exanthema, change in lips and in oral mucosa. family history was unremarkable. she had no chronic underlying disease nor history of previous hospitalization. at admission, she appeared stable. body temperature was . °c, o saturation was % in ambient area, blood pressure was / mm hg, heart rate was bpm, respiratory rate was breaths per minute. on examination she presented widespread polymorphous exanthema, changes in lips and in oral mucosa, cervical lymphadenopathy and bilateral conjunctival injection. results: exams revealed: white blood cells /μl, hb . g/dl, platelets . /μl, albumin . g/dl, serum sodium meq/l, serum chloride meq/l. transaminases were in normal range. creatinine was . mg/dl disclosure of interest none declared ab paediatric extra-pulmonary large vessel arteritis, a forme fruste of pediatric behcet's disease? we presented two siblings from a consanguineous marriage with different clinical presentations of dada . further, we emphasize that genetic testing should be repeated in the presence of clinical suspicion. introduction: there are several scoring systems developed in japan that are clinically used to stratify high risk kd patients and thus identify the ones that may benefit from early adjunctive therapy. there are increasing reports from all over the world on poor performance of these scores in other ethnic populations. objectives: the aim of our study was to evaluate the kobayashi, egami, sano and kawamura scores in our population which is homogenous caucasian. methods: hospital database was retrospectively searched for code m . of the international classification of diseases, th revision, clinical modification code: mucocutaneous lymph node syndrome [kawasaki] , over the period from january to december . all patients who were seen in this period for the first time for complete or incomplete kawasaki disease, as defined by the american heart association, were included. we applied ivig resistance prediction scores (kobayashi, sano, egami and kawamura scores) to our cohort. only patients who received g/ kg ivig within the first days of the disease were included in this analysis. the scores of prediction models were calculated for each patient and patients were assigned to high-or low-risk group accordingly. results: during the study period a total of children were diagnosed with kd ( . % males, median age . years). all of them were caucasian except one child who was biracial (caucasian and african american). among them, children were hospitalized in the acute phase of the disease and children were seen in the subacute phase of the disease. children were followed-up for at least one year to evaluate persistent coronary artery aneurysms (caa), which were observed in ( . %) patients. among them, were not treated with ivig and received ivig after days of illness. patients were treated with ivig within first days of illness and were included in the calculation of ivig resistance prediction scores. ( . %) were ivig resistant. sensitivity of kobayashi, sano, egami and kawamura scores were . , . , . and . , respectively. specificity of those scores were . , . , . and . , respectively. we found no difference in demographic or clinical characteristics between ivig resistant and ivig responsive patients. patients with ivig resistance had significantly higher alt (p = . ), neutrophil-to-lymphocyte ratio (p = . ) and lower serum sodium (p = . ). conclusion: by applying the japanese scores to our population, we were able to identify most of the low-risk, but missed many of the high-risk patients. our results are consistent with caucasi n based population studies available to date. introduction: varicella zoster virus (vzv) related arterial ischemic stroke (ais) has been described in literature in pediatric age. however, the long-term course of post-vzv vasculopathy need to be inquired: clear information about prevalence of recurrence and severity of clinical outcome are lacking, even if a favorable evolution was initially described, and therapeutic protocols are not currently standardized. objectives: we aimed to describe the clinical, laboratory and neuroradiologic features of children affected by ais due to post-vzv referred to our institute and to present our experience in their therapeutic management. methods: we selected pediatric patients ( females) with ais and a cns confirmed vzv reactivation and/or with a vzv history in the previous months. other causes of pediatric stroke (systemic disease, cardiac disease, trauma, major thrombophilia) were excluded. clinical, neuroimaging, laboratory and treatment data were reviewed, focusing on pediatric score outcome measure (psom) and executive functions final outcome. results: average age of ais onset, vzv primary infection and interval between infection and ais were: years mo (range: year and mo- years and months), years and months (range months- . years), and months (range days- months), respectively. the ais involved the nucleo-capsular region in cases, the cerebral cortex in cases, the thalamus in cases, and the pons in subjects. seventeen patients had inflammatory focal cerebral arteriopathy (ifca). virological confirmation (vzv-dna or anti-vzv igg in the cerebrospinal fluid) was obtained in patients. three patients were treated with trombectomy and one with rtpa. thirteen patients were treated with antiviral agents associated with steroids in cases, with different administration schedules. only in one case steroid treatment was given without association with antiviral agents. one patient received a short course of steroid and antiviral treatment at the time of the stroke and then a more prolonged course after six months at the time of the virological diagnosis. prophylactic antiaggregants were administered to all patients. mean follow-up was years and months (range mo - years) ; ifca was persistent in cases and transient in subjects. four patients presented a recurrence of post vzv arteriopathy, two of them presenting new stroke events. twelve patients presented a variable motor deficit at last follow up. the mean psom score of the cohort at the last visit was (range - ). executive functions were evaluated at last follow up in twelve patients, showing no deficit in seven patients, a mild deficit in two patients and a severe deficit in the last three. conclusion: albeit a favourable evolution was initially described, our experience suggests that vzv-related ais may result in persistent fca and significant neurological impairment in the majority of cases. therapeutic approach, particularly involving steroid administration, still need to be validated. introduction: iga vasculitis/ henoch schönlein purpura (igav/hsp) is the most common vasculitis of childhood and renal involvement is the most serious long-term complication. a better understanding of the pathophysiology of the progression to kidney disease is required for better treatment to be achieved and current biomarkers of ig a vasculitis with nephritis (igavn) lack the predictive value. objectives: in this study, an untargeted metabolomics approach was performed to reveal the underlying molecular mechanism of disease pathogenesis and to find potential biomarkers of plasma samples from patients with igav and igavn.methods: igav was diagnosed according to the ankara criteria in ( ). forty-five patients, including active igav patients (h), igavn (n), and age-and gender-matched healthy controls (c), were enrolled in the study. plasma samples from subjects were collected on the same day of igav(hsp) diagnosis and before steroid or other immunosuppressive treatment initiated. this study has utilized liquid chromatography-mass spectrometry (lc-ms/ q-tof) to investigate the alterations in plasma metabolomic profiles. three separate pools, health controls, active igav , and igavn were created. peak picking, grouping, and comparison parts were performed (metabolite profiling) via xcms (https://xcmsonline.scripps.edu/) software. results: totally peaks were detected for group h, n and c. among them peaks were found to be statistically significant and reliable (p< . ) and of these peaks were found to be changed (fold change > . ) between the groups c and h. on the other hand, peaks were found to be changed (fold change > . ) between the groups h and n. the number of the peaks on the intersection of the peaks found to be changed between the groups (c and h) and (h and n) was . based on putative identification results, peaks were matched with metabolites. we found an up-regulated level of dhap( : ), prostaglandin d /i , methyltetrahydrofolic acid, porphobilinogen and n-acetyl- -o-acetylneuraminic acid/n-acetyl- -o-acetylneuraminic acid, -aminopentanamide / -aminopentanoic acid, glycocholic acid, saccharopine, n -succinyl-l-ornithine, gamma tocopherol, and galactosylsphingosine /glucosylsphingosine in igav patients. in conclusion, we have identified a number of metabolites that may be associated with the pathogenesis of igav. we also suggest that dhap ( : ), prostaglandin d /i , porphobilinogen, -methyltetrahydrofolic acid and n-acetyl- -oacetylneuraminic acid/n-acetyl- -o-acetylneuraminic acid may serve as biomarkers for predicting kidney disease since they were increased only in the patients who developed renal involvement at follow-up. children were divided into four groups: those with jia who didn't receive mtx yet (group ); those who received mtx less than one gram during whole treatment (group ); those who received mtx from to grams (group ); children, received more than grams of mtx (group ). the autoimmune inflammatory process in jia can cause formation of pathological changes in the liver, even before the start of treatment. it is confirmed by a statistically significant correlation of bfgf level in st group with liver steatosis according to ultrasound examination (r = . ) and the level of c-reactive protein (r = . ). this indicates a close relationship between the intensity of the inflammatory process and collagen synthesis activation, which can further provoke liver fibrosis. alterative processes in the liver associated with autoimmune inflammation, as evidenced by the presence of a positive correlation between the level of alt and bfgf (r = . ). upon reaching mtx dose gram and grams, it is possible that compensatory processes in the liver are triggered, as evidenced by the negative correlation between the content of bfgf and hgf (r = - . ).conclusion: the use of modern markers with routine laboratory and instrumental studies is appropriate for the timely determination of the risks of developing irreversible pathological changes in the liver during jia treatment with mtx. objectives: the aim of our study is to evaluate the efficacy of (iag) injections in hip in children with (jia) and to assess the factors predicting the improvement of this management. methods: this is a retrospective study, between and , including patients with jia diagnosed according to the ilar criteria. the socio-demographic data were collected as well as the parameters of the disease. the activity was evaluated by jadas. the functional impact was assessed by the lequesne score. the treatments taken have been specified as well as the infiltrations received. the improvement after infiltration was assessed by jadas and lequesne score.results: fourteen patients were included, with mean age . + . . the mean age at the onset of symptoms was + . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . subtypes of jia according to the ilar were: enthesitis-related arthritis in cases, seropositive polyarticular jia in cases, seronegative polyarticular jia in cases, oligoarticular jia in cases and juvenile psoriatic arthritis in one case. all the patients had hip arthritis, inaugural in % of the cases. of these, . % had a flexion deformity and lower limb inequality. the average lequesne index was . + . . the treatments taken were methotrexate in . % of the cases, sulfasalazine in . % of the cases, and the combination of the two in . % of the cases. eleven patients underwent hip infiltration, and three of them required more than one. eighty one percent improved thereafter. the number of infiltrations was not statistically associated with the lequesne index (p = . ). improvement after infiltration was negatively associated with the prior existence of an inequality of the lower limbs (p = . ). the existence of a flexion deformity was not associated with good results after infiltration (p = . , r=- , ). ten patients ( %) among those who had an infiltration did not have to resort to surgery. conclusion: iag injection is an adjunct therapy in aji with hip involvement offering a good results and delay surgery in the majority of cases. the presence of lower limb inequality is associated with less improvement of iag. conclusion: synovial rice bodies are rarely described in juvenile idiopathic arthritis, even less at disease onset. their presence has not been associated to a worse disease prognosis or joint outcome but awareness of the existence of this particular form of intraarticular loose bodies may encourage the clinician to use lower gauge needle during arthrocentesis procedure; this can prevent arthroscopy, as occurred in our case . arthroscopy may be necessary in some cases to achieve full drainage of the joint. in our series the duration of arthritis correlated with the size of rice bodies and the number and agressiveness of procedures needed to evacuate them. objectives: we described a case of liver involvement in sle presenting with emphasis on the differential diagnosis with autoimmune hepatitis. methods: case report study results: : an -year-old female patient was referred to the rheumatology clinic with complaints icteric sclera for months anorexia, malaise, pain in the both knees, ankles joints and both wrists accompanied by swelling, and remarkable motion limitations. laboratory revealed t bilirubin . mainly direct . with elevated liver enzymes got , gpt , alkp , high glutamyl transpeptidase u\l her wbc . hgb , ptl , except very high esr ml\hr, crp was positive mg\dl, viral screen (hcv, hbsag, hiv) was normal, serology tests ana was positive with high titer , anti ds-dna ab was positive , anti-sm was negative, anti lkm antibodies negative, anti smooth muscle ab negative soluble liver antigen were negative, antimitohondrial ab( m ,m ,m ). ultrasound abdomen revealed mild enlarged spleen, abnormal diffused increased liver echogenicity with early stage of liver cirrhosis treated her by fresh frozen plasma times, vit k mg once\ day then was referred to rheumatology clinic regarding her serology tests & developed arthritis of her joints suspected psle! she was performed liver biopsy showed lesions necrotic inflammatory portal and lobular severe in eosinophilic polynuclear with cirrhosis evoking a syndrome of overlap associating a primary biliary cirrhosis and an autoimmune hepatitis. laboratory data revealed liver dysfunction and liver biopsy suggesting autoimmune hepatitis, and she underwent treatment for hepatitis (prednisolone with azathioprine), urosdoxycholic acid with fat-soluble vitamins k, d&a, e. however, with the elimination of jaundice and decreased hepatic enzyme levels, the prednisolone dose was tapered within months and stopped before they were referred to rheumatology clinic. on her review of systems, she has malar rash, generalized fatigability. on physical examination, we found malar rash, levidoreticularis of her skin, swelling and limitation of movement in the knees, ankles, wrists joints. there was hepatosplenomegaly. laboratory data revealed liver treatment for hepatitis, ana still high titer : , antids dan positive with titer iu\ml, antisma was negative .wbc . , hgb . , plt , esr ml\hr, her ultrasound abdomen: revealed slightly heterogeneous liver with coarse echotexture without focal lesion with liver span cm.these paraclinical results together with the clinical findings strongly suggested systemic lupus erythematosus (sle) as the definitive diagnosis. indeed, in this case, aih was associated with sle, prednisolone orally for months, after that dose was tapered and continued, rapid clinical improvement in arthritis, malaise, and general condition. azathioprine was continued. in addition, daily hydroxycholoquine sulfate overlapping of sle and aih should be suspected when aih patients present with a malar or other skin rash. the prompt diagnosis and adjustment of further treatment plans can improve disease outcomes and prevent liver disease progression. introduction: juvenile systemic lupus erythematosus (sle) is a chronic autoimmune disease characterized by multi-visceral involvement with an unpredictable prognosis. the diagnosis is usually made in young women aged between to years, however, it can affect people at any age and it is classified as a juvenile illness when it starts before the age of . objectives: we are reporting the epidemical, clinical, therapeutical and evolutional characteristics of a series done in the pediatric pole in setif with girls and boy. methods: the average age of onset is years. the average time limits of the diagnosis is months. the clinical features is done with cutaneous, articular manifestations and fever respectively in % % and % of the cases ,followed by kidney damage in % of the cases , the cardiac, pulmonary and ophthalmological participations are reported with low percentage. haematological involvement was detected in % of the patients and the inflammatory syndrome was almost constant. a positive titer of anti-nuclear antibodies and anti-dna is objectified, as well as a reduction in the complement rate. antibodies anti gp and anti cardiolopine are positive in % of cases. kidney damage was diagnosed in % of the cases , and only one case of overlap syndrome with dermatomyosits was reported. concerning the neurological form it was present in only one addolecent girl ,and only one case of familial lupus.results: the diagnosis is based on the classification of the american college of rheumatology (acr) revised on and the new criteria slicc"systemic lupus international collaborating clinics" . the clinical characteristics of our series relies on global data of literature with the predominance of cutaneous and articular involvement. with however some specific characteristics which are individualized by a more advanced age of onset, years on average in our study versus years and years, the rarity of familial forms ( case), a lower percentage of kidney damage ( % versus % and %).the therapeutic management was based on corticosteroid therapy and hydroxychloroquine in the majority of cases, the use of immunosuppressants has been reserved for severe forms. conclusion: lupus is an autoimmune disease with protean clinical manifestations, the prognosis of which is dominated by renal, neurological and thrombotic disorders. cortisonic treatments and immunosuppressants have significantly improved the prognosis for life . trial registration identifying number: lupus is an autoimmune disease with protean clinical manifestations, the prognosis of which is dominated by renal, neurological and thrombotic disorders. cortisonic treatments and immunosuppressants have significantly improved the prognosis for life . onset of inactive and active oligo-ja were not significantly differ. the analysis revealed a correlation between a short phase of beneficial effect after is-iai of ta and risk of activity disease (with an inactive phase of arthritis less than months, the risk activity was or = . , p < . ; with an inactive phase less than months -or = . , p < . ). rtx was administered to patients who had received high-dose cs with - dmards; in all cases combined pulse therapy cs № - was preliminarily used. rtx mg № was applied after mo- y from the debut of the disease. in all cases, its use led to clinical improvement after - mo with normalization of laboratory activity indicators, in cases a decrease in the level of b cells to - . in μl was noted ( with agammaglobulinemia). after months patients had severe infectious complications, of them ended fatally. another patients had a second stroke. the st patient survived, had a kidney allotransplantation, there is no disease activity. the nd patient, in connection with the development of the demyelinating process of cns, attempted to continue therapy using golimumab with ivig. it led to an increase in the infectious syndrome, therefore, we decided to refrain from continuing with itnf as well. the patient died after years from the administration of rtx due to the progression of neurological disorders. cases with auto-inflammatory syndromes were: chronic infantile neurologic cutaneous and articular syndrome received tcz; it was unsuccessful (hyperthermia and rash persisted, eye lesions progressed, there were no increase in height), later switched to anakinra. family mediterranean fever, received adalimumab (ada). the -year-course of ada leaded to the disappearance of articular and abdominal syndrome while maintaining persistent increased levels of esr and crp and periodic fever. the use of tcz in patients with ssd was more successful. the first patient received it subcutaneously for year, cs&dmards ( were used) had already been canceled, lung and kidney lesions were contained, blood pressure normalized, escsg-ai decreased from to , mrss decreased from to . in the second case, the patient received tcz for months i/v, decrease of escsg-ai . to , mrss to were noted, the dose of cs was halved, he also continued treatment with cyclophosphamide. we introduce a -year-old girl patient who has been admitted to our clinic with suspicion of an erythema nodosum. she had painful subcutaneous nodules for weeks, especially on the lower extremities and her face. macroscopically, central necrotizing skin rashes could be seen. she had frank arthritis of both knee and ankle joints. the comprehensive serological diagnosis (including hepatitis serology and anti-streptolysin titer) were normal except for a slight increase in crp , mg/dl and esr mm/h. the patient also complained of abdominal pain and bloody stools. calprotectin was μg/g. a gastro-coloscopy revealed a small mariske and a minimal inflammation of the ileocecal valve, without signs of vasculitis or chronic bowel disease. a skin biopsy revealed leukocytoclastic vasculitis of the small arteries. angiography of the intestinal arteries was rejected by the family. initially we started a treatment with methylprednisolone pulses followed by oral prednisolone. the patient showed a very good response with quick resolution of the skin symptoms and abdominal pain. the medication could be quickly tapered and discontinued at full remission after one month results: pan is classified as a cutaneous pan (cpan) when there are exclusive skin manifestations, besides arthralgia or arthritis. a systemic pan must be diagnosed with the involvement of internal organs. however, cutaneous pan may evolve into systemic pan. in our patient, the skin and joints were primarily affected. if the existing gastrointestinal complaints are part of a systemic pan or chronic bowel disease could not be cleared yet, due to refusal of further investigations. conclusion: cpan must be considered as a suspected diagnosis in patients with necrotizing skin nodules. as transition of the cutaneous into the systemic form cannot be predicted regular monitoring is mandatory. introduction: prevalence of behcet's disease in children is not known, but is probably very low. extra-pulmonary large vessel arteritis in these cases is even rarer as a presenting manifestation. objectives: to report two cases of paediatric extrapulmonary large vessel arteritis with a 'behcet like disease'. methods: we present case reports of two cases who presented to paediatric rheumatology opd to our department. ms. f, a year old girl was referred to us with history of short duration of fever, generalized lymphadenopathy, neutrophilic leucocytosis, thrombocytosis, hyperglobulinemia and high inflammatory markers. on detailed history and examination she was found to have a healed palatal ulcer and her maternal aunt was found to have a history of recurrent oral ulcer, genital ulcer and enthesitis. patient's montoux test was positive but the gene expert for mtb was negative. md-ct showed a circumferential thickening of aorta, subclavian and bilateral renal artery with stenosis at origin of both renal arteries indicating a vasculitis. few necrotic nodes were also noted in lungs. lymph node biopsy suggested a reactive hyperplasia. tissue typing showed presence of hla b , b . she improved clinically with oral prednisolone and mycophenolate mofetil and had no recurrence till her recent follow up visit. second case, master fkn an year old child was referred to us with a background of week history of fever, non migratory arthritis, raised inflammatory markers and a symptomatic severe aortic regurgitation with pandiastolic flow reversal on d echo. his evaluation showed negative montoux, normal igg levels and hla b b on tissue typing. his aortic wall thickness resolved with mg/kg oral prednisolone and mycofenolate mofetil. results: both these cases have features similar to behcet's disease. these cases do not fulfil isg, icbd or icbd criteria for pediatric behcet's disease. however, the aortitis and other clinical features responded well to the treatment in both cases.conclusion: paediatric case with extra-pulmonary large vessel arteritis that do not meet criteria for behcet's disease but have specific clinical or laboratory features do respond well to immunosuppression. therefore, after ruling out other causes of the large vessel vasculitis, a possibility of form fruste of behcet's disease should be under consideration. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. these abstracts have been published as part of pediatric rheumatology, volume , supplement , : proceedings of the th european paediatric rheumatology congress (pres ). the full contents of the supplement are available at https://ped-rheum. biomedcentral.com/articles/supplements/volume- -supplement- . please note that this is part of . key: cord- -i z ju authors: criado, paulo ricardo title: adverse drug reactions date: - - journal: dermatology in public health environments doi: . / - - - - _ sha: doc_id: cord_uid: i z ju adverse events and adverse drug reactions are common in clinical practice. side effects range from the common to the rare and may be confused with other mucocutaneous manifestations resulting from several medications to treat infections, other medical conditions, and in the clinical setting of oncologic treatment. the objective of this chapter to review current data on adverse drug reactions, here classified as (i) severe adverse drug reactions, (ii) uncomplicated cutaneous adverse drug reactions, and (iii) adverse drug reactions caused by chemotherapy drugs, particularly those cases whereby the dermatologist is requested to issue a report and asked to comment on the safety and viability of readministration of a specific drug. we describe aspects associated with these events, presenting a detailed analysis of each of them. • if possible identify the physiopathologic mechanism involved in the reaction; • identify as rapidly as possible the drug inducing the reaction and always opt for its withdrawal; in some circumstances the choice is difficult as there is no alternative drug and its use is essential for the maintenance of life; • a careful and intensive observation is recommended for the occurrence of warning signs regarding the appearance of a potentially severe adverse drug reaction, especially in relation to mucous, oral, ocular, and genital involvement and progression of any present cutaneous eruption; • it is imperative that the drug responsible may be withdrawn on a permanent basis together with chemically related com-pounds, and this advice is also valid for first-degree relatives who can present the same type of reaction. function. the aim of this study is to describe these reactions in order to facilitate recognition and treatment. this group of drug reactions includes anaphylaxis, stevens-johnson syndrome (sjs), toxic epidermal necrolysis (ten), and, depending on the systemic involvement, erythroderma. in this chapter we approach the characteristics and treatment of some adverse reactions to drugs, including anaphylaxis, erythroderma, sjs, and ten. the prevalence of scards is estimated at in , hospitalized patients. sjs and ten are particularly severe [ ] . in general, fatal cutaneous drug-induced reactions occur in . % of clinical patients and . % of surgery patients [ ] . scards may be defined as usually requiring hospitalization, at times in intensive therapy or burn care units for close observation of vital signs and visceral function. this group of drug reactions includes anaphylaxis, sjs, ten, drug hypersensitivity, and, depending on the systemic involvement, erythroderma, acute generalized exanthematous pustulosis (agep), cutaneous necrosis induced by anticoagulants, druginduced vasculitis, and reactions such as serum disease [ ] . quick differentiation between a scard and a less severe eruption may be difficult, although essential. withdrawal of the suspected drug is the surest way of intervening to reduce mortality [ ] . most cutaneous reactions to drugs are usually observed as a morbilliform or maculopapulous exanthema [ , , ] . unfortunately, erythema morbilliform ( fig. . ) most often characterizes the appearance at onset in the severest of cases, including ten, serum disease, and drug hypersensitivity syndrome [ ] . djien et al. [ ] , studying patients with reactions to drugs clinically presenting with erythematous cutaneous eruptions (morbilliform and scarlatiniform exanthema, maculopapulous, and small isolated papules), concluded that three types of severe clinical markers exist with respect to this kind of reaction: fever, lymphadenopathy, and extensive cutaneous affection. the authors excluded specific forms from the study, such as sjs, ten, fixed drug eruption (fde), agep, phototoxicity, and vasculitis. this suggests that in cases of drug-induced reactions with extensive cutaneous affection, with or without lymphadenopathy, a laboratory investigation is required with a complete hemogram and hepatic function test. in , roujeau and stern [ ] put forth clinical and laboratory criteria leading to the suspicion that a reaction to drugs could develop into more severe behavior (chart . ). we next discuss the following reactions: anaphylaxis and anaphylactoid reactions, erythroderma, and the clinical spectrum of sjs and ten (lyell's disease). anaphylaxis is a quick systemic reaction usually presenting a risk to life and resulting in immediate hypersensibility mediated by immunoglobulin e (ige). anaphylactoid reactions mimic anaphylaxis, although they are not related to immunologic mechanisms [ , ] . these reactions lead to a powerful activation of mastocytes, with a massive release of mediators [ , ] . drugs are not the more important cause of anaphylaxis, as they are responsible for merely - % of cases [ ] .drugs that do cause anaphylactic reactions include β-lactam antibiotics (responsible for % of fatal anaphylactic reactions in the united states), cephalosporin, sulfonamides, hemoderivatives, enzymes (trypsin, chymopapain, and streptokinase), insulin (very rare nowadays, owing to use of recombinant human insulin), vaccines (due to preservatives, proteic components, and gelatin; some reports of patients show sensitivity to eggs and allergic reactions to vaccines), allergenic extracts, protamine, and progesterone [ , ] . anaphylactoid reactions may occur with acetylsalicylic acid, nonhormonal anti-inflammatory drugs, iodide contrasts, angiotensin-converting enzyme (ace) inhibitors, and fluorescein [ ] . during general anesthesia, anaphylactic and anaphylactoid reactions may occur. these are difficult to differentiate because of the large amount of medications used, such as anesthetics, muscular relaxants, analgesics, nonhormonal anti-inflammatories, and antibiotics [ ] . their clinical emergence tends to occur suddenly, within -min to -h intervals after contact with the precipitating factor, although delayed reactions are rarer. they show an appearance of pruritus, urticaria ( fig. . ), rhi- lymphocytosis with atypia abnormalities of liver enzymes or function noconjunctival symptoms, angioedema symptoms (especially laryngitis), hypotension, and lung sounds [ ] . the following ailments may be observed: abdominal pain, diarrhea, vomiting, uterine contraction, and cardiac arrhythmia. after a few hours symptoms may reappear during a late phase, although this is by no means automatic [ , ] . patients with anaphylaxis must be identified as fast as possible, and treatment must be initiated immediately [ ] . this reduces the risk of fatal reactions [ ] . the following are signs of anaphylaxis that pose a risk to life: presence of stridor, edema of the glottis, intense dyspnea, lung sounds, hypotension, cardiac arrhythmia, shock, convulsions, and loss of consciousness [ , ] . in patients using β-blockers, anaphylaxis is often severe and may be resistant to conventional treatment [ ] . various conditions must be considered in the differential diagnosis when suspecting anaphylaxis [ ] : cardiac arrhythmias, acute myocardial infarction, food aspiration, convulsive disease, reaction to insulin, pulmonary embolism, syndrome etiology (e.g., the presence of carcinoid tumors or reaction to alcohol and chlorpropamide), hysterical behavior, vasovagal reactions, and fictitious allergic reactions. vasovagal reactions are most often confused with anaphylaxis [ ] . in general they are consequences of procedures such as injections, which present as a clinical condition consisting of facial paleness, nausea, profuse sweating, and syncope, with symptoms improving without treatment to min later [ ] . absence of pruritus in the presence of a slow pulse and normal blood pressure distinguish vasovagal reactions from anaphylaxis [ ] . the treatment of anaphylaxis consists of short-and long-term measures [ ] . the immediate goal is to maintain the permeability of the airways and blood pressure, in addition to administering oxygen in more severe cases [ ] . epinephrine must be administered as soon as possible, with a standard dose of . mg/kg of a : , solution, up to a maximum of . - . ml, subcutaneously every - min until the patient is stabilized. this is a condition characterized by a state of generalized erythema and scaling (exfoliative dermatitis) of the skin. it has the morphologic appearance of various cutaneous diseases such as psoriasis, atopic dermatitis, t-cell cutaneous lymphoma, and reactions to drugs [ ] . the dissemination of a maculopapular condition caused by medication may lead to the emergence of an erythrodermic syndrome. various types of drug-induced cutaneous reactions (including contact dermatitis, photosensitivity, and maculopapulous reactions) would be responsible for roughly . % of erythroderma cases [ ] .the secondary drug-induced erythroderma conditions, as opposed to erythrodermas resulting from other etiologies, most often set in quickly and also tend to regress quickly after withdrawal of the medication being used [ ] . pruritus arises - weeks after starting drug use, in association with diffuse erythema covering roughly % of the body surface, followed by lymphadenopathy and scaling. when acute, large amounts of epidermis are exfoliated; when chronic, it produces small elements [ ] ( fig. . ). pruritus and a sensation of diffuse burning occur [ ] . exfoliative dermatitis leads to systemic complications such as hydroelectrolytic and thermoregulatory disturbances, high cardiac insufficiency, tachycardia, capillary leak syndrome, and infection [ ] [ ] [ ] . the effect of exfoliative dermatitis on the organism depends on the intensity and duration of the process [ ] . common laboratory findings in the erythrodermic state include light anemia, leukocytosis with eosinophil, high ige, an increase of the hemosedimentation process, a drop in serum albumin, and a rise in uric acid [ , ] . increased ige and eosinophil is a nonspecific finding and is found only in secondary drug-induced erythrodermas, although it might also be due to atopic dermatitis [ , ] . multiple cutaneous biopsies performed simultaneously on distinct points of the skin might increase the accuracy of the diagnosis of the base disease [ ] . in drug reactions vacuolar alterations may be observed on the epidermis, as well as necrotic keratinocytes [ ] . the initial treatment of drug reaction in an erythrodermic patient is identical to that for erythrodermas of other causes [ , ] . suspending the drug is the quickest way to improve the patient's condition. one ought to consider the nutritional state and hydroelectrolytic replacement, as well as administering local measures such as antiseptic baths, humid compresses on the crusts, application of soft emollients, and low-strength corticosteroids [ ] . classic oral antihistamines may be prescribed to alleviate the pruritus and anxiety. they provide the patient with a warm and humid environment so as to prevent hypothermia and improve cutaneous hydration [ , ] . symptoms and signs of cardiac and respiratory insufficiency may require emergency assistance and hospitalization [ ] . the most aggressive and debilitating erythrodermic states may require care similar to that offered to sjs or ten patients. the differential diagnosis must be performed with other types of secondary erythrodermas to cutaneous diseases, such as psoriasis, contact dermatitis, seborrheic dermatitis, lichen planus, bullous pemphigoid, and pemphigus foliaceus, as well as systemic diseases such as leukemias, t-cell cutaneous lymphoma, and hodgkin's lymphoma, in addition to erythrodermic states secondary to internal cancer [ , ] . what currently exists is a combination of concepts according to which spectrum of erythema multiforme (em), including em minor and em major (emm), is separated from another spectrum of reactions, which includes sjs and ten (lyell's syndrome), referred to here as the sjs/ ten spectrum [ ] [ ] [ ] [ ] . however, according to assier et al. [ ] , it seems possible to separate emm patients from true sjs patients based on clinical symptoms and disease origin. these authors define the emm pattern as consisting of characteristic mucous erosions and cutaneous lesions (typical targets, with or without blisters), symmetrically distributed and commonly acral. sjs would be represented by mucous erosions and disseminated cutaneous purpuric macules that are frequently confluent, with a positive nikolsky sign and epidermal scaling limited to less than % of the body surface [ , ] . em would include recurrent, postinfectious cases (especially related to herpes simplex and mycoplasma), or eventually related to exposure to medication, with a low mortality rate and without lethality. on the other hand, sjs would comprise a severe adr with high mortality rates and a reserved prognosis for many cases [ , , ] . in , bastuji-garin et al. [ ] put forward a clinical classification of the spectrum that included me bullosa up to ten. to better understand this classification [ ] , we note the characteristics of the dermatologic lesions of which the group consists, defined as follows: • epidermal detachment: refers to epidermal loss, which at times occurs in flaps ( fig. . ). • typical targets: lesions less than cm in diameter, in disc shape, with well-defined borders, and exhibiting at least three distinct zones, namely two concentric halos around a central disc ( fig. . ). • atypical flat targets: lesions that are not raised, but are round or disc shaped, with two zones and/or borders that are not well defined. • atypical raised targets: round or disc-shaped lesions, palpable or raised, but without the two zones and/or well-defined borders. • macules/spots: erythematous or purpuric stains, irregularly shaped or confluent, with or without blisters (fig. . ). insofar as the area of epidermal necrolysis makes up one of the two main factors of prognosis, a consensus was reached on classifying the spectrum [ , ] : (i) sjs in cases with mucous erosions and disseminated purpuric macules and scaling of the epidermis below %; (ii) sjs/ten superposition or transition in cases with epidermal scaling between % and % of the body surface; and (iii) ten in cases with disseminated purpuric macules and epidermal scaling above %; or (iv) in rare cases with disseminated necrolysis (over % scaling) without any of the lesions described above. sjs is an entity characterized by the presence of lesions similar to those of em, but with purpuric macula and widely distributed blisters or even lesions in atypical targets dispersed over the dorsal aspect of the hands, palms, soles of the feet, extensor region of the extremities, neck, face, ears, and perineum; the face ( fig. . ) and trunk ( fig. . ) are prominently involved [ ] . incidence of sjs is estimated at roughly one in three cases per million residents yearly [ ] [ ] [ ] . sjs may be preceded by a discrete maculopapulous eruption similar to exanthema morbilliform [ ] . blister formations are possible, though usually not determined by an epidermal detachment of over % of the body surface [ , , ] . mucous involvement occurs in roughly % of cases, generally on two distinct mucous surfaces; this may precede or follow cutaneous involvement [ , , ] . onset begins with enanthema and edema, which give rise to erosions and pseudomembranous formations on the eyes, mouth, genitals, pharynx, and upper airways [ ] . some - % of cases occur with fever and lesions in the gastrointestinal and respiratory tracts [ ] . its prognosis seems to not be affected by the type and dose of the drug responsible, nor by human immunodeficiency virus (hiv) infection [ ] . the therapeutic options for sjs are limited and controversial [ , , ] . corticosteroids are frequently used [ ] , although some cases have not shown a satisfactory response [ ] . in agreement with most authors, the use of systemic corticosteroids on the initial sjs and ten forms do not currently demonstrate any proven benefits. the advanced forms of this spectrum of relations have clearly deleterious effects on the patient [ ] . the treatment and prognosis of sjs are tackled in combination with that of ten. ten is an entity characterized by extensive scaling of the epidermis in the wake of necrosis (epidermal necrosis) [ , , ] . the term "toxic epidermal necrosis" was introduced by lyell in [ ] . fortunately, it consists of a very rare adverse reaction to drugs. in europe, its incidence is estimated to be at . [ ] cases per million residents yearly [ ] . in aids patients, however, the risk of this reaction does rise, estimated at one case in every , patients yearly [ ] . in general, there is a slight predominance among women ( . - cases in females for every male case). indeed, the disease's occurrence in aids patients ends up balancing out the incidence rate between the sexes [ ] . the initial characteristics of ten are nonspecific influenza-like symptoms, such as fever, sore throat, coughing, and burning eyes. these are considered prodromic manifestations preceding a cutaneous and mucous affection by - days [ ] . an erythematous eruption emerges symmetrically on the face ( fig. . ) and the upper part of the trunk, extending to the craniocaudal region and provoking symptoms of burning or painful skin [ , ] . the individual cutaneous lesions are, for the most part, characterized by erythematous macules with poorly defined contours and a purple center. they progressively spread over the anterior thorax and back [ , ] . less commonly, the initial eruption may consist of an extended scarlatiniform exanthema. in roughly - days or, at times, within a few hours, or more seldom in about a week, complete extension of the cutaneous condition occurs [ ] . at first, some cases may present lesions persisting in sun-exposed areas of the skin [ ] . the apex of the process consists of characteristic denuding of the necrotic epidermis, standing out as veritable red strips or flaps on the areas affected by the base erythema ( fig. . ) [ , ] . the epidermis is raised by the serum content of flaccid blisters, which are progressively confluent and provoke rupture of the blisters and detachment of the skin. this causes an aspect of severe burns on the patient's skin, with the skin denuded, bleeding, and with an erythematouspurple color, as well as continued elimination of serosity, which contributes to hydroelectrolytic unbalance and accentuated protein loss [ , ] . the nikolsky sign is positive over widespread areas of the skin [ , ] . the areas of the skin subjected to pressure, such as the lower shoulders, back, and buttocks, are the first to release epidermal flaps [ , ] . cutaneous extensor affection might determine a state of acute cutaneous failure [ , ] . the cutaneous surface can virtually be % affected, although scalp affection is exceptional [ ] . the mucous membranes are affected in - % of patients, commonly preceding skin involvement by a day or two [ ] . in the order of frequency, the disease afflicts the oropharynx, eyes, genitalia, and anus [ ] . extensive and painful erosions lead to labial crusts, salivation, feeding obstruction, photophobia, and painful urination and evacuation [ ] . severe eye sequelae, with the formation of synechiae between the eyelids and conjunctiva by pseudomembranous conjunctival erosions, and blindness may occur [ , ] . ceratitis and corneal erosions have been reported, as well as a secondary sicca-like syndrome [ ] . high fever or hypothermia may occur because of a thermoregulatory imbalance until complete healing, even in the absence of concomitant infections [ ] . the abrupt drop in temperature is more indicative of sepsis than of fever itself [ ] . psychomotor agitation and mental confusion are not uncommon, and usually indicative of hemodynamic complications and sepsis [ ] . many internal organs are affected by the same pathologic process that involves the skin and determines a spectrum of systemic manifestations [ , ] . systemic involvement occurs, causing erosion in the esophagus and gastrointestinal tract, which may progress to esophageal constrictions, transaminase increases in % of cases (hepatitis in %), pseudomembranous colitis, and pancreatitis [ ] . in the respiratory tract tracheobronchial erosions and secondary pulmonary interstitial edema, with the correction of hypovolemia, can be found [ ] . anemia can be constantly observed, as well as lymphopenia in up to % of patients [ ] . thrombocytopenia is found in % of patients; neutropenia occurs in % of cases, and when present indicates a worse prognosis [ , ] . the medications most commonly causing ten are sulfas, phenobarbital, carbamazepine, dipyrone, piroxicam, phenylbutazone, aminopenicillin, allopurinol, and nevirapine. however, it is necessary to consider that new drugs are continually being reported as triggering ten [ , , , ] . the exact mechanism by which sjs and ten develop is not well defined. some authors have suggested the participation of the altered metabolism of drugs with the predominance of a slow acetylator genotype in sjs and ten patients, and a deficiency in the mechanisms involved in detoxification of reactive intermediary metabolites [ ] [ ] [ ] . in addition to the metabolic mechanisms, there is evidence to suggest that, especially in ten, the epidermal necrosis is mediated immunologically [ , , ] . it is known today that sjs and ten are disturbances mediated by t cells, similarly to acute graft-versus-host disease (gvhd), with cytotoxic t cells being responsible for the epidermal necrosis through an apoptosis in keratinocytes [ , ] . posadas et al. [ ] have shown the association of high tumor necrosis factor α (tnf-α) levels with the severity of the reaction. this cytokine has been related to an induction in the adhesion and activation of t cells and monocytes. it also participates in apoptosis, irrespective of the action of perforins [ ] . it has been demonstrated also that apart from tnf-α, the perforins granzyme b (grb) and fas ligand (fasl) are found to be high in the initial stages of a drug reaction, particularly in sjs and ten. this reinforces the hypothesis of the participation of cytotoxic mechanisms [ ] . nowadays, cytotoxic reaction caused by granulosin liberation from t cells is the major mediator involved in cell apoptosis, and the spectrum of sjs/ten is grouped in type ivc of immune reactions, as classified by pichler. correia et al. [ ] have observed a similar seric cytokine profile between ten and acute gvhd. these authors showed a significantly high serum level of interleukin (il)- and il- in ten and acute gvhd patients as opposed to normal blood donors [ ] . il- is a multifunctional proinflammatory cytokine produced by various cells, including keratinocytes. it consists of a main circulating endogenous pyrogen [ ] . this explains the presence of fever that is unrelated to the infection in the first days of ten and gvhd [ ] . in turn, il- is an endogenous antipyrogen agent. it is produced by keratinocytes with the purpose of blocking inflammatory cytokines such as il- , il- , and tnf-α, in addition to being a powerful suppressant of macrophage, t-cell, and natural killer cell functions [ ] . by contrast, as il- recruits cd + lymphocytes from the peripheral blood, its increase in blister fluid explains the high number of these cells in patients' epidermis [ ] .the elevation of il- creates a natural mechanism against excessive tissue inflammatory reaction [ ] . chosidow et al. [ ] have suggested that the cellular cytotoxic targets are viral antigens with a potential to alter immune responses resulting from exposure to medications. treatment for sjs and ten patients is similar to that for patients who have suffered extensive burns, with a number of rare exceptions [ ] . all patients have to submit to cutaneous biopsy to confirm the diagnosis [ ] . the patient must be observed in an intensive therapy unit, in an isolated and heated environment so as to avoid any cutaneous trauma [ , , ] . the treatment must proceed by suspending any drug that is not essential to the patient's life and begin replacement of intravenous fluid, mainly when an oral mucous lesion obstructs liquids from being ingested [ , , ] . isolation and feeding must be carried out through the nasogastric probe because the patient shows calorie and protein loss [ , , ] . corticosteroids should only be administered within h of the condition's onset. it has not proved to be beneficial after this period because of its delaying epithelialization and increasing protein catabolism, in addition to increasing the risk of infection [ , ] . antibiotic therapy has to be administered to cases whereby a sudden drop in temperature occurs and with a concomitant drop in the general status or increase of cultivated bacteria on the skin with a predominance of a single strain [ , ] . it must be emphasized that during the first days, the most common infections are by staphylococcus aureus and later by gramnegatives (pseudomonas aeruginosa) or candida albicans [ ] . noncontrolled reports and studies on the treatment of ten exist, reporting the use of intravenous immunoglobulin, cyclosporine, cyclophosphamide, plasmapheresis, and anticytokine monoclonal antibodies, among others, in an attempt to curb the process of epidermal necrosis. the value of these studies has been questioned, however, particularly owing to the fact that in most patients who are hospitalized the phenomenon of necrosis virtually comes to a halt [ ] . prins et al. [ ] published a multicenter, retrospective study on intravenous immunoglobulin use in treating ten patients, which obtained excellent results. a -patient cohort, average age years (± ) and consisting of women and men, with a - % variation of epidermal detachment of the total body surface area, was treated. mucous membrane was affected in . % of these patients. the patients received intravenous infusion of gammaglobulins begun on average days after onset of ten (with a variation of - days). it was administered over a period of - days, in doses varying from . to . g/kg (mean total dose of . g/kg). an objective positive response to treatment occurred with a break in the progression of ten, observed in ( %) of the patients. in all there were six deaths. the authors concluded that early use of intravenous gammaglobulin is safe, with a recommended dose of g/kg daily for days in a row. in contrast to the studies of prins et al. [ ] , a french group (bachot, revuz, and roujeau) led a noncomparative prospective study of patients diagnosed with sjs (nine patients), sjs/ten overlapping (five patients), and ten ( patients). they concluded that intravenous gammaglobulin in a -g/kg daily dose, administered for days in a row, did not reduce patient mortality [ ] . until such discrepancies in the results have been cleared up, intravenous gammaglobulin use in treating ten will remain controversial [ ] . however, as the volume of data encourages its application and effective alternative therapies remain lacking, it seems difficult to not suggest a high dose of intravenous gammaglobulin, especially as a way of intervening early in quickly progressing ten cases. whereas mortality rate is low for emm (< %) and sjs (roughly %), it is above % for ten patients with macules [ ] . the mortality rate rises with age range and increased surface area of the epidermal scaling [ ] . we reiterate the classification methodology adopted by multicenter studies, prospectively named scard (severe cutaneous adverse reactions). the results of the latter were recently published based on the analysis of patients and , controls [ ] . this classification system (named scorten) is summarized in chart . . despite the large range and amount of drugs that may pose a great risk of contracting sjs and ten, an annual risk rate of five cases per year among medication users has not been exceeded [ , ] . [ ] [ ] [ ] dress syndrome is an acronym derived from the term "drug rash with eosinophilia and systemic symptoms" coined by bocquet et al. also known as drug-induced hypersensitivity syndrome (dihs), it was first recognized in by chaiken in a patient using an anticonvulsant. there are many synonyms used, most of them referring to the origin of the drugs involved in the drug reaction, such as dapsone syndrome, allopurinol hypersensitivity syndrome or the anticonvulsant hypersensitivity syndrome. although a dermatosis is usual in dress, the extent of skin involvement is variable and therefore the "r" in dress was subsequently changed from "rash" to "reaction." clinically, in its complete form, this syndrome includes an extensive mucocutaneous rash, fever, lymphadenopathy, hepatitis, and hematologic abnormalities with eosinophilia and atypical lymphocytes, and may involve other organs with eosinophilic infiltration, producing damage in several systems, especially in kidney, heart, lungs, and pancreas. this multivisceral involvement differentiates dress from other common skin reactions to drugs. another unique feature of this syndrome is its late onset in relation to the period of introduction of the causative drug, i.e., at around weeks to months, and its possible persistence or worsening despite the withdrawal of the offending drug. the incidence of this syndrome is estimated to vary from one case among , - , drug exposures. adults are more affected than children, and although the precise incidence of drug reaction has not yet been determined, it is much more common than sjs, which has an incidence of . - cases per million person-years, and most cases are sporadic, with no gender predilection. recognition of this syndrome is of paramount importance, since the mortality rate is about - % and a specific therapy may be necessary. the exact mechanism of dress/dihs remains to be determined but, in cases related to anticonvulsant drugs, three components are considered: (i) deficiency or abnormality of the epoxide hydroxylase enzyme that detoxifies the metabolites of aromatic amine anticonvulsants (metabolic pathway); (ii) associated sequential reactivation of herpesvirus family; and (iii) ethnic predisposition with certain human leukocyte antigen (hla) alleles (immune response). this type of reaction is most commonly seen using seven different drug groups: (i) anticonvulsants, such as the aromatic anticonvulsants (phenytoin, carbamazepine, phenobarbital, primidone), mexiletine, lamotrigine, valproate, ethosuximide, and zonisamide; (ii) antidepressants (desipramine, amitriptyline, fluoxetine); (iii) sulfonamides and sulfones (dapsone, sulfasalazine, trimethoprim-sulfamethoxazole, salazosulfopyridine); (iv) anti-inflammatory drugs (piroxicam, naproxen, diclofenac, sundilac, phenylbutazone, ibuprofen); (v) anti-infectives (abacavir, cidofovir, terbinafine, nevirapine, minocycline, linezolid, doxycycline, telaprevir, nitrofurantoin, zalcitabine, spiramycin, metronidazole, piperacillin-tazobactam, ceftriaxone); (vi) angiotensin-converting enzyme inhibitors (captopril, enalapril); and (vii) β-blockers (atenolol, celiprolol). cases have been reported with allopurinol, gold salts, thalidomide, calcium channel blockers (diltiazem), ranitidine, sorbinil, azathioprine, dobutamine, methimazole, propylthiouracil, and efamizulab. the cases more consistent with dress/dihs were caused by aromatic anticonvulsants, dapsone, salazosulfopyridine, allopurinol, and minocycline. other drugs causing less typical cases are reported in the literature, but less frequently. aromatic anticonvulsants have an estimated occurrence of dress/dihs of one case for every , people exposed to the drug, and the reaction is especially common among black patients. the aromatic anticonvulsant drugs that have been associated most frequently with drss/dihs are phenytoin, phenobarbital, and carbamazepine. however, newer anticonvulsant medications also containing aromatic structure (felbamate, oxcarbazepine, zonisamide, and lamotrigine) can also be involved, and the cross-reactivity between the various aromatic anticonvulsant drugs is well documented, varying between % and %. the pathogenic mechanism of idiosyncratic reactions to drugs, such as dress/dihs, has not been fully elucidated. sullivan and shear proposed a multifactorial model for the pathogenesis of dress/dihs. its occurrence would be determined by the combination of exposure to a drug capable of causing adverse reaction given in sufficient dosage and period of use to a susceptible patient. a certain group of drugs associated with dress/dihs, including the aromatic anticonvulsants, is metabolized to reactive oxygen intermediates that appear to be inefficiently detoxified in patients with acquired or pharmacogenetic variations in the metabolism of these drugs. aromatic anticonvulsants such as carbamazepine, phenytoin, and phenobarbital are metabolized by the hepatic cytochrome p enzymes and undergo oxidation by aromatic hydroxylation, with subsequent formation of arene oxides. arene oxides are toxic reactive intermediates that are normally enzymatically converted to nontoxic metabolites by epoxide hydroxylase or glutathione transferase. in addition, spontaneous conversion to nontoxic phenol derivatives can occur. in cases of defective or deficient epoxide hydroxylase, arene oxides can accumulate and cause direct cellular toxicity or immune response ( fig. . ). drug interactions can be important in this syndrome. concomitant use of lamotrigine and valproic acid increases the occurrence of the syndrome. it is thought that the mechanism for this drug interaction is the competition between valproic acid and lamotrigine for hepatic metabolism by glucuronidation, which doubles the halflife of lamotrigine and predictably would increase the possibility of adverse effects. positive patch tests and testing of blast transformation of lymphocytes indicate the presence of an immune reaction in which t cells participate in specific core function. clones of drugspecific t cells have been isolated from patients sensitive to carbamazepine and lamotrigine. several clinical similarities that could be observed between dress/dihs and infectious mononucleosis (im) have led researchers to implicate a possible range of viruses as triggers for this syndrome. in addition, unique features of this syndrome are its late onset in relation to the period of introduction of the causative medication and frequent clinical and laboratory deterioration, as well as episodes of exacerbation despite the withdrawal of the offending drug, so that these characteristics are not necessarily typical of a reaction of specific drug etiology. although there are conflicting views on the pathogenesis of dress/dihs in different parts of the world, recent studies have suggested a close relationship between human herpesvirus (hhv- ) and the development of dress/dihs. sporadic reports have shown that not only hhv- , but also other herpesviruses such as hhv- , epstein-barr virus (ebv), and cytomegalovirus (cmv), can be reactivated during the course of the dress/dihs. results obtained with analysis by polymerase chain reaction showed that various herpesviruses are sequentially reactivated during the course of dress/dihs in most patients. the cascade of viral reactivation is initiated by ebv or hhv- and extends over a period to hhv- and eventually to cmv [ ] . in some patients, the clinical manifestations of this syndrome persist despite discontinuation of the drug involved, coinciding with the reactivation of herpesvirus, as shown in fig. . . the reactivation of hhv- is evidenced by increases in the titers of igg anti-hhv- dna levels, and hhv- is commonly found in the second or third week after the onset of rash, despite the high variability of clinical manifestations among patients with this drug reaction. since the reactivation of hhv- can be detected only in patients with dress/dihs, but not other adrs, in japan this diagnostic test has become sensitive and specific for the diagnosis of all patients with dress/dihs [ ] . the detection of hhv- reactivation seems to be the gold-standard diagnostic test for dress/dihs in japan, with other asian countries and europe helping to confirm the identification of this condition. however, it is still unknown how detection of the viral genome in peripheral blood reflects the true status of viral reactivation in progress in many different organs and systems. specifically, it is possible that in different compartments and organs such as spleen and lymph nodes, different herpesviruses can reactivate in sequential order completely independent of what occurs in the blood, which would explain why blood samples negative for the viral genome are obtained during the clinical activity of dress/dihs. what remains unclear is the role of herpesvirus in early dress/dihs. there are two possibilities: (i) dress/dihs began as an "allergic" immune reaction to a particular drug, which seems to possess an innate ability to stimulate t cells. ( ) in genetically predisposed individuals or by additional factors, an impaired detoxification and accumulation of these metabolites occur ( ), which can cause cellular damage generating danger signs that can stimulate resting t cells, inducing costimulatory pathways ( ). in addition, ethnic predisposition to certain hla types may contribute to the formation of neoantigens from the combination of these intermediary reactive metabolites with tissue macromolecules and formation of haptens ( a), which can be presented via the human histocompatibility complex class i (hla-dr) or class ii (hla-a, -b or -c), to cd or cd t cells ( ) . it was demonstrated that carbamazepine, valproic acid, and amoxicillin are able to exert immunomodulatory actions by inhibiting histone decarboxylase on b lymphocytes, producing a hypogammaglobulinemia that precedes the clinical onset of dress/dihs. the clonal expansion of t cells requires sequential reactivation of latent herpesvirus, and at the same time cd + cla + t cells are produced, which are directed toward skin, cd + ccr + t cells addressed to the lungs ( b), and cd + il- , il- producer and il- cd th + producer that cause tissue and peripheral eosinophilia in the context of t-cell activation is a massive activation of herpesvirus housed in these cells, since the stimulation of t cells by the drug may reactivate the viral genome into the cell. thus, the drug in turn can activate a specific cellular and humoral immune response to herpesvirus. this could explain why different herpesviruses are activated and because in another intense immune process, so-called gvhd, a similar reactivation can be observed. (ii) the viral reactivation can occur but is initially clinically unapparent. however, t cells stimulated by virus present significant crossreactivity with certain drugs, and exposure to these drugs leads to an expansion of t cells specific to the drug (and viruses), which persists even after drug withdrawal due to persistence of viral antigens. the simultaneous appearance of multiple concurrent viral reactivation could be explained by the ability of hhv- and hhv- counterparts to reactivate virus. thus, if the symptoms of dress/ dihs are mediated by both the various gene products and herpesvirus immune responses to viral replication, the frequent deterioration or the several exacerbations that occur despite withdrawal of the offending drug could derive, at least in part, from the sequential activation of this herpesvirus. the viral reactivation may provide a "danger signal" (danger sign) that stimulates massive clonal expansion of both cd + and cd + nonspecific t cells and causes the complete development of the syndrome. shiohara et al. proposed the possibility that the clinical symptoms during the course of evolutionary dress/dihs do not seem to be only mediated by oligoclonal expansion of drug-specific t cells, but also by antiviral t cells that cross-react with drugs. how is hhv- acquired? hhv- infects almost all humans around years of age. most infections arise through the exchange of infected saliva during the first year of life, although perinatal transmission can occur. it was demonstrated that the dna of hhv- can be integrated into the host dna, and once part of the human dna, congenital transmission can occur [ ] . this was also demonstrated in the course of the dress/dihs. the temporal relationship between onset of drug use and the onset of dress/dihs ( weeks to months) suggests that viruses have no primary function in the syndrome, favoring primary pathogenesis related to drug allergy. patients with dress/dihs have decreased total serum igg, iga, igm, and b-lymphocyte count at onset, while there is an expansion of memory t cells that cross-react with both drug and virus. it is noteworthy that the lymphocyte transformation test is negative in the first week of illness and remains negative in % of patients weeks after the onset of symptoms, becoming positive only - weeks after the initial drug reaction. this could be due to the expansion of regulatory t cells (which suppress the proliferation of memory t cells) in the early stages of the disease and its subsequent reduction by apoptosis. several cytokines are increased during dress/dihs. in particular, levels of tnf-α and il- , which are typically proinflammatory cytokines, are elevated in this syndrome before the reactivation of hhv- . interestingly, il- becomes undetectable during viral replication and increases again after the infection in most patients. dress/dihs is an entity distinct from other serious adrs because of the dynamic changes in the immune response observed during the course of the disease. the phenotype of circulating cd + t cells is changed to cd + phenotype at the time of viral reactivation. regulatory t cells are initially increased in number in the circulation and skin, but decrease in parallel the function of the different organs or systems. the reactivation of hhv- is considered a condition requiring immunosuppression, demonstrated on several immune abnormalities in the early syndrome: marked decrease of serum immunoglobulins, the number of circulating b cells, and regulatory t-cell dysfunction. moreover, the participation of skin inflammation may be involved in the induction of immunosuppressive conditions. sugita et al. demonstrated a reduction in the number of plasmacytoid dendritic cells (pdc) in peripheral blood of patients, but an increase in the expression of these cells in skin affected by the rash. the pdc human leukocyte subtypes are capable of producing large amounts of interferon-α (ifn-α), which induces the maturation of b cells in order to produce igg and plays a critical role in antiviral defense. the pdc from circulation may accumulate in the skin and thus reduce the number of pdc in the circulation. therefore, antiviral responses may be reduced, facilitating viral reactivation in peripheral blood and tissues other than the skin. although the terms dress and dihs are often and mistakenly used interchangeably, there is currently a tendency to believe that the dihs represents the most severe cases of dress, with reactivation of hhv- detected in a large majority of patients and only in a limited number of patients with dress [ ] . the most popular hypothesis to explain the immunoallergic reactions to drugs is the theory of hapten/pro-hapten: according to this hypothesis, the drug (or metabolite) is processed by antigen-presenting cells (apcs) and expressed in the cell membrane in the context of hla-a, -b, or -c type i (mhci) or hla-d type ii (mhcii). the complex hla drug (hapten) is presented to native t cells (naive) via their t-cell receptor (tcr), which initiates different types of immune responses, depending on the hla expressed on the apc and the cytokine environment. the story of "hla-drug" correlation truly began in the twenty-first century with abacavir. in , two independent groups observed the abacavir hypersensitivity syndrome and that this was restricted to the allele hla-b* , which conferred an elevated odds ratio (> ). glaxosmithkline (london, uk) led the largest international randomized pharmacogenetic clinical trial to date, which demonstrated the correlation between abacavir hypersensitivity reactions and patients with this allele, and proved that the exclusion of abacavir introduction to the patients with this allele resulted in the disappearance of the syndrome, which was first seen in % of patients overall who received the drug during the first weeks of antiretroviral treatment. this allele test is now routinely used before the introduction of abacavir in several countries. the hla alleles have a high negative predictive value but low positive predictive value in relation to adrs, indicating that these biogenetic markers are necessary but not sufficient to trigger the allergic immune reactions. according to the theory of hla-drug (hapten), the complex hapten only triggers an immune-allergic reaction in the presence of a specific hla allele. thus, prospective hla screening should prevent some patients from having serious idiosyncratic reactions such as dress/dihs, sjs, and ten if they have a specific risk allele by not receiving the drug related to it. hla pharmacogenomics is a recent field of study that has been rapidly developed and implemented into clinical practice and has improved drug prescription, which is likely to become more and more important in coming years. besides causing sjs and ten, carbamazepine also induces other types of adrs, including maculopapular exanthema (mpe) and dress/ dihs. the association between hla-b* and carbamazepine-induced mpe was not detected in populations of ethnic han chinese and hong kong or thai populations. studies involving han chinese residents in taiwan and caucasians showed no association between cases of dress/dihs caused by carbamazepine and hla-b* . these data indicate that the association between hla-b* and cutaneous adrs induced by carbamazepine are specific to sjs/ten. kano et al. showed that in four of their japanese patients ( . %) with dress/dihs in whom reactivation of hhv- was proved, the syndrome was triggered by aromatic anticonvulsants (carbamazepine in ten, phenobarbital in two, and phenytoin in one) had hla-b* . the frequency of this allele was much higher than in the japanese population ( . %). although this difference was not statistically significant after correction for multiple comparisons, the authors proposed that the presence of certain alleles of hla-b on the reactivation of the virus contributed, at least in part, to the association of hla-b allele with dress/dihs. kashiwagi et al. demonstrated a significant association between adverse skin reactions to carbamazepine and hla-a* among japanese patients, including erythema multiforme, erythroderma, dress/dihs, ssj, and other drug reactions. eleven of these patients ( %), including two patients with sjs and others, were carriers of hla-a* and allele frequency was much higher in these patients ( %) than in the japanese population ( . %) (p = × - , odds ratio (or) = . ). in a case-control study in a han-chinese population a strong association between the presence of hla-b* and sjs/ten, or dress/dihs triggered by allopurinol among patients ( %) was found, compared with out of ( %) allopurinol-tolerant patients and out of controls ( %) (p (pc value . × (- ), or = ). japanese patients with different clinical types of cutaneous adrs caused by allopurinol, including sjs, ten, and dress/dihs, had the same hla-b* allele. pirmohamed et al. found an increased frequency of hla-dr and hla-dq in a group of patients with carbamazepine-induced dress/ dihs (respectively p = . , or = . ; p = . , or = . ). it was demonstrated that activation of cd + t cells with il- is essential for the spread of hhv- in vitro. genotyping of patients revealed that they had positive hla-dr (drb * ) and hla-dq (dqb * ). thus, in recent years increased attention has been given to genetic factors as a cause of variation in both the interpersonal effectiveness and adverse effects of medicines. idiosyncratic reactions are often mediated through immune, usually severe, and unpredictable course. the main region of human dna with genetic variations that predispose to drug hypersensitivity reactions is the region hla. this region harbors the gene locus of most diseases and contains many genes associated with immune functions. although strong associations have been demonstrated between certain hla alleles and some types of adverse skin reaction to drugs, there is no definitive evidence or published data concerning the functions involved in these alleles. the activation of t cells restricted to hla is necessary for the induction of immune reactions and, moreover, there is the possibility that some hla proteins have high binding affinity combined with other drugs or a metabolite of the drug through covalent and noncovalent mechanisms. on the other hand, a protective effect of hla has also been suggested. alfirevic et al. reported a potential protective effect of hla-b* against severe adverse skin reactions induced by carbamazepine in caucasian patients. the implications of pharmacogenomics are varied; one example is the recommendation of the us food and drug administration (fda), which currently recommends genetic testing for users of more than ten drugs currently marketed in that country. histopathology of the skin shows a diffuse, dense superficial and/or perivascular lymphocytic infiltrate. eosinophils in the dermis or swelling may or may not be present ( fig. . a ). on some occasions there is a band-like infiltrate with atypical lymphocytes simulating epidermotropism such as mycosis fungoides. fernando et al. described a patient with dress/dihs triggered by carbamazepine whose rash biopsy presented an unusual form of superficial perivascular inflammatory infiltrate, in which tiny granulomas along with a moderate number of lymphocytes were found. the authors speculated that granuloma formation may be due to a sustained exposure to the drug, even after the onset of dress/dihs. the expansion of cd + t cells producing ifn and other cytokines results in recruitment of macrophages which, as a result of maintained exposure to the drug and persistence of cytokine release, promote differentiation into epithelioid cells, which then secrete tnf to promote fusion of these cells into multinucleated giant cells. thus, biopsies of organs involved in dress/ dihs, such as skin and liver, on a significant number of patients may demonstrate the true frequency of granulomatous infiltration in the disease and assist in understanding the pathogenesis of the reaction. the syndrome usually develops within months after drug introduction, more often in weeks to months of the introduction of the drug, or earlier if constituting readministration. fever, often high ( °- °c), which is the most common symptom (seen in - % of cases), and rash ( % of cases) are the first signs, especially when related to antiepileptic drugs. the cutaneous eruption consists of a morbilliform rash, which is indistinguishable from the rash of other less severe reactions ( fig. . b, c) . the face, upper trunk, and upper extremities are initially affected, with subsequent progression to the lower extremities occurring in about % of cases, which later spreads to the legs and the development of erythrodermic rash. the maculopapular eruption later becomes infiltrated with edematous follicular accentuation. swelling of the face, with marked periorbital involvement, is a warning for the diagnosis, occurring in about % of patients, and can be so intense that the patient becomes disfigured. vesicles may arise, and fine bubbles caused by edema of the dermis can be present. no necrosis of the epidermis such as ten occurs, except in rare cases of overlapping dress/dihs and ten. small sterile perifollicular pustules and nonfollicular pustules may appear, which are different from acute generalized exanthematous pustulosis and do not predominate on the main ridges of the skin. often atypical targets may arise. over time the rash becomes purplish, with sharp definition on lower limbs and the resolution of scaling another form of presentation is a picture of exfoliative dermatitis, which may be associated with mucosal involvement, such as cheilitis, erosions, pharyngitis, and enanthematous enlarged tonsils. bilateral edema and infiltration of the salivary glands with xerostomia has been frequently reported. lymphadenopathy is common ( - % of cases), limited to the lymph nodes or generalized, and painful, gradually resolving with the withdrawal of the drug. the lymph nodes may reveal two distinct types of involvement: a benign pattern of lymphoid hyperplasia with maintenance of normal lymph node architecture, and another a b c various hematologic abnormalities are observed, which consist of marked leukocytosis, eosinophilia ( % of cases), and atypical lymphocytes similar to mononucleosis. these findings guide the diagnosis toward dress, but can sometimes be difficult to distinguish from viral infections such as infection by ebv or hematologic diseases. lymphopenia, leukopenia, or leukocytosis usually precedes it, although they often are not detected because they occur several days before establishment of the clinical syndrome. leukocytosis may be high, up to , leukocytes/mm , and eosinophilia reaches values higher than , /mm . the eosinophilia may determine the involvement of internal organs with pulmonary infiltrates. in general, eosinophilia may be observed about - weeks after the onset of the syndrome, or may even occur after the increase in liver enzymes has normalized. hemophagocytic syndrome (hps) can rarely be observed in the course of dress/dihs. hps is associated with and triggered by various conditions, including viral infections, particularly ebv, malignant tumors, or autoimmune diseases. when involved with the course of dress/dihs, hps usually occurs weeks after the onset of drug eruption. there is a decrease in white blood cells and platelets that are detected simultaneously with elevation of lactate dehydrogenase (ldh). bone marrow aspirate reveals hemophagocytosis in an increased number of macrophages. multiorgan involvement may include a wide variety of organs and systems with myocarditis/ myositis, pericarditis, interstitial nephritis ( % of cases), necrotizing granulomatous vasculitis in kidney, brain involvement (encephalitis or meningitis), colitis, and thyroiditis. this potentially fatal visceral involvement form may be symptomatic or not, and begins - weeks after the onset of rash. we observed a patient who developed acute pancreatitis that evolved into a lethal course. there are reports of shock and respiratory distress syndrome with hypotension, pyrexia, hepatitis, and renal failure related to a hydantoin reaction. arthritis or arthralgia may occur in the context of this syndrome, including myositis. liver involvement is the most common visceral manifestation ( - % of patients) after lymphadenopathy. hepatomegaly may constitute a finding on physical examination. hepatitis with isolated elevation of liver transaminases is common ( % of cases), usually anicteric, but liver failure is a leading contributory factor to mortality. liver biopsy shows central lobular necrosis and dense inflammatory infiltrate of lymphocytes and eosinophils or granulomas. the reaction is accompanied by cholestasis and hepatocyte necrosis. in more severe cases, widespread or focal hepatic necrosis may be present. the presence of an active coinfection with hepatitis viruses b and/or c often determines deterioration in liver function and prolonged liver dysfunction. there are few cases reported in the literature of dress/dihs with severe acute hepatitis (defined by the presence of alanine aminotransferase (alt) to more than × upper limit of normal and/or acute liver failure, such as coagulopathy and encephalopathy), mostly observed in women between the second and fourth decade of life, especially in relation to the use of sulfasalazine. about % result in death or liver transplantation, and the course of the disease is apparently unchanged by the use of immunosuppressants. the rapid recognition of the syndrome and prompt withdrawal of the drug can limit the liver damage, although this may be possibly even worse for several weeks and take months to resolve. renal involvement occurs in about % of cases, being particularly evident in cases arising from the use of allopurinol, whereby there was an increase in serum creatinine and urea and decreased creatinine clearance. in urine tests, increased content of eosinophils can be observed. although pulmonary involvement is rarely reported in dress/dihs, interstitial pneumonia with eosinophilia is often observed among patients whose syndrome was triggered by minocycline. possibly the cases with lower intensity of pulmonary manifestations are less reported, leading to a bias in the published literature. pulmonary complications include acute interstitial pneumonitis, lymphocytic interstitial pneumonia, and adult respiratory distress syndrome (ards). myocarditis may develop at the beginning of the syndrome or up to days after establishment. symptoms include heart failure, chest pain, sudden tachycardia, dyspnea, and hypotension in early dress/dihs, but some patients are asymptomatic. the echocardiogram shows a reduction in ejection fraction, chest x-ray demonstrates cardiomegaly, and the electrocardiogram shows nonspecific changes in the st-t segment. there is an increase in enzymes such as cpk and ck-mb, but no apparent changes in levels of troponin- . neurologic complications include meningitis and encephalitis. meningoencephalitis occurs about - weeks after initiation of drug reaction, and may lead to coma, seizures, headaches, disorders of speech, and paresis and paralysis of the cranial nerve. gastrointestinal bleeding may be an abrupt complication caused by ulcers derived from cmv. endoscopic examination reveals arterial bleeding from punched-out gastric ulcerations. kennebeck compiled the frequency of clinical manifestations and laboratory data of the anticonvulsant hypersensitivity syndrome: fever ( - %), cutaneous eruption ( - %), lymphadenopathy ( %), hepatitis ( - %), hematologic abnormalities ( - %), periorbital and orofacial edema ( %), myalgia and arthritis ( %), nephritis ( %), pharyngitis ( %), and pulmonary manifestation ( %). the visceral involvement in acute dress/ dihs until resolution of clinical disease is, therefore, extensive and varied, some of these events being closely related to hhv reactivation: enterocolitis and intestinal bleeding, hemophagocytic syndrome (hps), hepatitis, limbic encephalitis, myocarditis, nephritis, mumps, pneumonia, pleurisy, and the syndrome of inappropriate antidiuretic hormone (siadh). the exclusion of other serious infections, particularly bacteremia, neoplastic diseases (lymphoma, leukemia, hypereosinophilic syndrome, paraneoplastic syndrome), and autoimmune or connective tissue conditions (adult-onset still's disease, lupus erythematosus, vasculitis) is necessary for an accurate diagnosis of dress/ dihs. complications are rare and include limbic encephalitis, thyroid disease, renal failure, splenic rupture, eosinophilic colitis, eosinophilic esophagitis, enterocolitis, and fatal cmv. the mortality rate can reach %, especially in cases related to advanced age, renal impairment, jaundice, and hepatitis with reactivation of cmv. by contrast, cases where there is a reactivation of ebv seem to have a less severe course, but are more likely to later (usually after several years) develop autoimmune diseases such as diabetes mellitus type and autoimmune hypothyroidism. several authors have reported the occurrence of autoimmune diseases and/or the production of autoantibodies after the resolution of dress/ dihs, in a period ranging from several months or years after the resolution of the syndrome, and some are similar to those seen after bone marrow transplant. the related conditions include diabetes mellitus type , lupus erythematosus, hashimoto's thyroiditis, enteropathy, sclerodermiform lesions, gvhd, and bullous pemphigoid. the diagnosis is difficult since there are incomplete or less characteristic clinical features, for example, hepatitis without rash, or merely pulmonary infiltrate with eosinophilia. bocquet, bagot, and roujeau were the first authors who proposed criteria for dress diagnosis. according to these authors the diagnosis is established if there are at least three criteria present: there is still no international consensus on the best criteria for the definition of dress/dihs diagnosis. bocquet et al. and southeimer and houpt have proposed different definitions and nosology for dress/dihs in order to clarify clinical and pathologic characteristics of this syndrome. the japanese study group for severe cutaneous adverse reactions to drugs (scar-j) has adopted other criteria, as presented on chart . . however, the universal adoption of these criteria may be impaired, because one of the criteria is viral replication during the course of infection, and some tests, such as measurement of igg titer anti-hhv- , are not yet routinely available in all hospitals or laboratories. in our view, the criteria adopted by the european group regiscar, published by kardaun et al. in , is the best to meet the needs in the diagnosis of dress/dihs. here the use of a system score for the diagnosis of dress/ dihs was suggested, based on the presence of symptoms and clinical and laboratory signs, as displayed in table . . given the suspicion of the syndrome relevant examinations should be performed, keeping in mind that this syndrome has evolutionary behavior. the initial tests are oriented to verify the data and research into hematological visceral involvement, as proposed by descamps et al. at admission: complete blood count, alt, aspartate aminotransferase (ast), total bilirubin, γ-glutamyl transferase, alkaline phosphatase, sodium, potassium, creatinine and creatinine clearance, -h urine protein and urinary eosinophil count, cpk, ldh, ferritin, triglycerides, calcium and parathyroid hormone, blood glucose, prothrombin time and activated partial thromboplastin time, lipase, protein electrophoresis, c-reactive protein, quantitative pcr for hhv- , - , ebv, and cmv, blood culture, and antinuclear factor. follow-up (two times per week): complete blood count, alt, ast, creatinine, ldh, and other laboratory tests according to changes found on admission tests. evolutive follow-up: quantitative pcr for hhv- , - , ebv, and cmv, complete blood count, alt, ast, alkaline phosphatase, creatinine, ldh, ferritin, and triglycerides. the early recognition of adrs and withdrawal of the offending drug is the most important and essential steps toward clinical improvement. empiric treatment with antibiotics or antiinflammatory drugs should not be administered during the acute disease, since they may confuse or worsen the clinical picture of patients because of an unexplained cross-reactivity between drugs. prognosis is generally worse in the elderly while the recovery is usually faster and usually complete in children. for many years, the treatment of dress has been based on the use of systemic corticoste- the diagnosis is confirmed by the presence of the seven criteria (typical dihs) or of the first five criteria (atypical dihs) a this can be replaced by other organ involvement such as renal involvement b reactivation is detected from the second to third week after symptom onset, through igg anti-hhv- titer elevation roids (dose equal to or greater than - . mg/ kg/day of prednisone or equivalent) with marked improvement of symptoms and laboratory parameters only several days after the start of treatment. systemic corticosteroids should have their dose reduced, after clinical and laboratory control of the disease, slowly over - weeks to prevent recurrence of the symptoms of disease. abrupt deterioration of various symptoms is observed when the withdrawal is accidental or by rapid reduction of the dose of corticosteroids. shiohara et al. recommend that all patients should be hospitalized even when the initial presentation is mild. if symptoms worsen despite the use of oral corticosteroids, other options used in case series are the use of pulsed methylprednisolone ( mg/kg intravenously for days), intravenous immunoglobulin (ivig), and plasmapheresis, or a combination of these therapies. it should be remembered that the immunosuppressive therapies may increase the risk of infectious complications and sepsis. mild cases can recover simply by drug withdrawal and supportive treatment after a few weeks, even without the use of corticosteroids. however, even in mild cases, the monitoring of liver function tests should be conducted and appropriate tests ordered to rule out the involvement of other organs such as lungs, thyroid, and heart. special attention should be given to possible reactivation of cmv, especially in patients with severe dress/dihs. physicians should also pay attention to a proper balance between the needs of corticosteroids for relief of symptoms and been shown that dihs/dress is a manifestation of newly observed immune reconstitution syndrome (irs), and herpes zoster is observed as the most common manifestation of irs after highly active antiretroviral therapy for aids. relevant clues related to dress syndrome include: • dress/dihs is an adr caused by an apparent group of drugs, and one-third of cases are related to anticonvulsants, in addition to sulfonamides and allopurinol, which can cause - % mortality. • the syndrome is characterized by a latency period ranging between weeks and months after the introduction of the offending drug, and its course is marked by apparent sequential reactivation of hhv and subsequent development of autoimmune diseases, providing an opportunity to establish a connection between viral infections and the emergence of autoimmune diseases. • in early dress/dihs hypogammaglobulinemia and reduced peripheral b cells are found, and cd + cd + foxp + (regulatory t cells) levels are high at the beginning of the syndrome, regardless of whether or not patients are treated with corticosteroids. this clonal expansion of regulatory t cells appears to prevent activation of antiviral t cells in an appropriate manner and sequential reactivation of virus is presented in the syndrome. these regulatory t cells have the phenotype ccr + and cla + , which address the skin. in the last stage of the syndrome's activity, phenotype of cytotoxic t cells becomes prominent and cd + lymphocytes are intensely diminished. these cells are depleted over time, suffering apoptosis and becoming reduced after the resolution of the syndrome, which could be a predisposing factor for the development of autoimmunity. pustulosis [ ] agep is a clinical entity that appears in the intertriginous areas or on the face as a diffuse erythema (scarlatiniform) with acute presentation. patients report pruritus or local burning sensation. after this appearance, the erythema is replaced by hundreds of nonfollicular sterile small pustules (< mm in diameter) (figs. . and . ). these pustules may sometimes converge and mimic nikolsky's sign, leading to misdiagnosis as ten. intense edema of the face may occur, with purpuric lesions mainly on the legs and the onset of lesions similar to em of the legs. there may be mucous involvement in about % of the patients, although it is usually mild and self-limited, occurring in just one location. the cutaneous symptoms are almost always accompanied by fever of > °c. frequently there is leukocytosis in the blood count, and eosinophilia may also occur in one-third of the patients. usually this eruption regresses within - days after withdrawal of the drug and in typical cases leaves a lamellar or punctiform desquamation. disease prognosis worsens when there is hyperthermia or infection of the lesions, and when it affects elderly individuals, who should be hospitalized. the drugs described as a cause of agep are most frequently β-lactams (penicillin, cephalosporins), macrolides (azithromycin, erythromycin), cyclines (doxycycline), sulfonamides (trimethoprim, sulfasalazine), chloramphenicol, isoniazid, streptomycin, vancomycin, quinolones (ciprofloxacin, norfloxacin), itraconazole, terbinafine, allopurinol, carbamazepine, phenytoin, diltiazem, nifedipine, chromium picolinate, diclofenac, enalapril, disulfiram, furosemide, hydroxychloroquine, paracetamol, mercury, thalidomide, protease inhibitors, and bamifylline. sidoroff and et al. proposed some characteristics that might aid in the differentiation between pustular psoriasis and agep. in the latter, a history of psoriasis is rare, the lesions are most frequent in the cutaneous folds, the duration of the fever and the pustules is short, and there is usually a history of recent exposure to the drug; arthritis is rare. histopathology may show subcorneal and/or intraepidermal spongiform pustules, edema of the papillary dermis, vasculitis, exocytosis of eosinophils, and focal necrosis of keratinocytes (fig. . ). on the other hand, in pustular psoriasis a history of psoriasis is common, the involvement is generalized, the duration of the fever and the pustules is longer, history of drug exposure is less frequent, arthritis occurs in about % of the patients, and histopathologic recently, britschgi and colleagues demonstrated high expression of il- in these patients. it is known that il- is a chemokine with potent activity in the recruitment of neutrophils, which is produced by the keratinocytes and mononuclear cells of the cutaneous inflammatory infiltration. these authors concluded that agep might be the expression of a reaction whereby a cell bound to the drug triggers a drug-specific cd + and cd + immune response, which results in high expression of il- (type vid in the pichler classification). [ ] in , von piquet and shick described serum sickness in children treated with horse serum containing diphtheria antitoxin. more recently serum sickness has been observed in patients treated with horse antithymocyte globulin or vaccines of rabbit antihuman diploid cells. this constitutes a type iii hypersensitivity reaction, mediated by immunocomplexes deposited on the walls of the vessels, activation of the complement, and recruitment of granulocytes. it presents particular cutaneous manifestations: typically there is erythema in the lateral portion of the fingers and toes that precedes a more disseminated eruption (occurring in % of cases), which frequently is morbilliform (twothirds of the patients) and sometimes urticariform. the presence of urticaria, leukocytoclastic vasculitis, and multiform erythema is rarely observed. in half of the cases there is visceral involvement [ ] . the following clinical findings are common: fever, cutaneous eruption, constitutional symptoms, arthritis, and arthralgia. the disease begins about - days after the initial exposure to the foreign protein. the drugs related with this type of manifestation are the heterologous sera and vaccines. serum sicknesslike reactions can also be caused by penicillin, cephalosporin, minocycline, propranolol, streptokinase, and nonhormonal anti-inflammatories. there are no data on the prevalence of this disease in brazil, although reports of cases of this disease are not infrequent in the medical literature. fractions c and c of the complement are strongly decreased in serum sickness while they are usually normal in serum sickness-like reactions. treatment of the disease constitutes withdrawal of the drug allied to the use of systemic corticosteroids, in addition to antihistamines for symptomatic relief of pruritus when present. careful observation of the clinical course of the patient's systemic involvement is imperative. [ , ] several medications can induce a cutaneous vasculitis-type response, the histopathologic definition of which is the presence of inflammation and necrosis in the wall of the cutaneous blood vessels. clinically it presents as tangible purpura or maculopapular purpuric eruption. this disease can also occur in the form of hemorrhagic blisters, urticaria, ulceration, nodules, raynaud's disease, and digital necrosis. the same vasculitis the disease develops about - days after initiating the drug; however there can be a longer time interval, and any medication instituted within the months prior to the presentation should be considered suspect. given the absence of confirmatory tests for this entity, one should value anamnesis and the correlation with drug exposure, which in general occurs - weeks before onset of the cutaneous picture. however, the exposure can have occurred in periods as disparate as days to years. withdrawal of the drug leads to a rapid resolution of the picture, and systemic corticosteroids can benefit some patients. the process is usually solved without sequels. the clinical, epidemic, and pathologic characteristics of drug-induced vasculitis have been little reported in the medical literature, since there is no consensus in the definition of this disease, with various revisions using different criteria for inclusion of cases. vasculitis attributed to exposure to medicines is rare, but seemingly account for about - % of dermal vasculitis cases. it is difficult to quantify the frequency with which drug-induced vasculitis is strictly cutaneous. clinical experience suggests that most of the cases are confined to the skin and have a selflimited course, although it can be associated with varied degrees of systemic symptoms including arthralgia, indisposition, and fever. visceral involvement is well described and pathologically heterogeneous. glomerulonephritis and interstitial renal disease, varied degrees of hepatocellular damage, and formation of granulomas in the liver have been described, besides involvement of the heart, lungs, and central nervous system. furthermore, there are rare cases of drug-induced vasculitis with renal and hepatic involvement in the absence of cutaneous disease. the drugs most frequently referred to in the literature, in the form of case reports or series studies, as causative of vasculitis are propylthiouracil, hydralazine, granulocyte colony-stimulating factor (g-csf), cefaclor, minocycline, allopurinol, d-penicillamine, phenytoin, isotretinoin, and methotrexate. as many of the cases of drug-induced vasculitis are not reported in the literature, other drugs are also possible important causative agents of this reaction type. other drugs have been reported less often as causal agents of vasculitis: several antibiotics, etretinate, didanosine, zidovudine, acebutolol, atenolol, sotalol, propranolol, chlorothiazide, furosemide, diltiazem, nifedipine, methyldopa, captopril, enalapril, lisinopril, losartan, procainamide, quinidine, antithyroid medications, painkillers and antipyretics, levamisole, tamoxifen, arabinoside c, interferon, interleukin- , sulfasalazine, etanercept, gold, carbamazepine, antidepressants, zafirlukast, chromalin, cimetidine, ranitidine, l-tryptophan, radiocontrast, streptokinase, heparin, coumarin, chlorpromazine, metformin, pimagedine, and diphenhydramine. drugs that induce vasculitis associated with antineutrophil cytoplasmic antibodies (anca) include hydralazine, propylthiouracil, minocycline, and anti-tnfα biological agents. about % of the patients who use propylthiouracil develop anca, a fact that is related to a higher risk of glomerulonephritis. a particularly relevant form among the drug-induced vasculites is propylthiouracil hypersensitivity vasculitis. there are cases with other antithyroid compounds, such as methimazole, thiamazole/ methylthiouracil, and carbimazole, which, similarly to propylthiouracil, contain a thioamide group and cause allergic cross-reactions. although uncommon, nowadays a larger number of case reports of this entity are observed, suggesting that cases were previously not reported or were included among other nosologic entities, since propylthiouracil is a drug classically dedicated to the treatment of hyperthyroidism. the clinical symptoms and signs begin after initiating propylthiouracil. although the duration of drug use is extremely variable, from week to years, it appears under a classic tetrad of symptoms that include fever, sore throat, arthralgia and cutaneous eruption; there can also be myalgia, fatigue, weight loss, conjunctivitis, rhinitis, and hemoptysis. the disease course is that of a systemic vasculitis. there can be a lupus-like syndrome, wegener-like granulomatosis, or nodular-like polyarthritis with multiple involvement of organs, such as kidneys, joints, lungs, and others associated with cutaneous lesions. the cutaneous lesions usually consist of plaques or acral purpuric nodules arranged in a livedoid pattern, with a preference for the extremities (fig. . ) , face, breasts, and characteristically the lobes and helices of the ears, mimicking the leprosy type reaction of lucio's phenomenon. hemorrhagic blisters appear on these lesions that progress to central necrosis of the skin, which can be so extensive that it simulates the clinical presentation of purpura fulminans observed in septic infectious states with disseminated intravascular coagulation. laboratory tests reveal anemia, leukopenia, and platelet depletion in the blood count; increased erythrocyte sedimentation rate, urea, creatinine, transaminases, and bilirubin; hypoalbuminemia; alterations in the coagulation time, prothrombin time, and partial activated thromboplastin time; and immunological abnormalities such as positive anca, rheumatoid factor, and hypergammaglobulinemia can be found. positivity can also be present in anti-ssa, antidouble-stranded dna, anticardiolipin, antismooth muscle antibodies, antimitochondrial, parietal, and antiadrenergic antibodies, besides hypocomplementemia, cryoglobulinemia, and elevation of c-reactive protein. histopathologic study demonstrates a leukocytoclastic vasculitis of the superficial and profound vessels of the dermis. the finding of immunocomplexes deposited in the vascular wall is uncommon, such that some authors have named them pauci-immune anca-positive vasculitis. most of the patients recover completely following withdrawal of propylthiouracil, although some develop impairment of the kidneys or other internal organs, or skin, requiring high doses of prednisone for several months. the dermatologic findings in patients with drug-induced vasculitis associated with anca include plaques and purpuric acral nodules, which appear more commonly on the extremities, face, breasts, and ears. in addition, the patients report the same signs and symptoms as found in other small-vessel vasculites associated with anca (wegener's granulomatosis, churg-strauss syndrome), including glomerulonephritis, pulmonary hemorrhage, and digital gangrene. besides withdrawal of the offending drug, it is generally necessary to use corticosteroids in high doses or in pulse therapy, plasmapheresis, and immunosuppressants for several months. the mortality rate is approximately %. necrosis [ ] this is a rare and severe adverse effect from treatment with warfarin (anti-vitamin k agents), occurring with cutaneous necrosis secondary to occlusive thrombosis in the vessels of the skin and subcutaneous cellular tissue. it usually presents - days after use of the drug, as painful (fig. . ) , with hemorrhagic blisters or necrotic scars in the areas rich in subcutaneous tissue, such as buttocks, breasts, and hip. the risk of this disease increases in patients who are female, obese, and users of high doses of the medication [ ] . the necrotic tissue requires debridement and grafts. this type of reaction has also been described with the use of heparin. this kind of adr is represented by several conditions related to drug exposure, which do not represent life-threatening conditions to the patients except discomfort. there is no severe temporary or permanent remaining lesions or long-term internal organ sequelae and, in most of cases, no mortality or severe impact on patients' health. in contrast to severe adrs, in the clinical setting of uncomplicated cadrs admission to the intensive care or burn unit is usually not necessary for the majority of patients. for this reason, the physician must be able to identify the signs and symptoms that indicate severe cadr [ ] . in particular, dermatologists must pay attention to identifying these reactions, since the skin is among the most common organs or systems of clinical manifestation of adrs and concurs with at least % of adrs [ ] . the most common forms of cadrs are urticarial and exanthematous eruptions, which together constitute - % of all cards [ ] . these two types carry few to no long-term consequences [ ] . the severe adrs (sadrs), described earlier in this chapter, probably represent around % of all adrs [ ] . sadrs often are associated with high levels of morbidity and mortality, and therefore a prompt recognition of the reaction, withdrawal of all possible offending agents, and appropriate triage, hospital admittance, workup, and specific treatment are critical [ ] . regarding studies of severe versus uncomplicated adrs, swanson and colven [ ] proposed a staged patient evaluation as shown in fig. . . signs and symptoms severe adr are listed in fig. . , and in this clinical scenario the physician should have a low threshold to admit the patient to hospital, perform a complete workup including evaluation of other medical specialties, withdraw suspected medications, and initiate adequate therapy when indicated [ ] . another relevant aspect in recognizing the type of adr is the time from medication introduction to the onset of a cutaneous reaction, since this is related to the subtype of adr, as proposed in fig. . [ ] . often patients have been exposed to several medications in the same period, and creating a "drug list" that details the dates of all medications taken is helpful in narrowing down the most probable culprits [ ] . physicians should pay attention to prodromal symptoms (skin pain, fever, malaise, throat pain or discomfort, arthralgia, etc.) that can to precede the cutaneous eruption, and associated internal symptoms (abdominal pain, ocular discomfort, dysuria, respiratory distress, etc.), and proceed to complete physical examination including full skin examination of groin, genitalia, eyes, oropharynx, thorax auscultation, abdomen, and lymph node palpation [ ] . the physician needs remember that several risk factors for the development of more severe cutaneous adrs have been identified, including female gender, older age, viral infections (herpesvirus family or hiv), genetic susceptibility (specific single-nucleotide polymorphisms in the hla region), iatrogenic immunosuppression, underlying immune-mediated diseases, and cancer [ ] . [ , ] exanthematous or maculopapular drug eruptions, sometimes inappropriately designated "drug rashes" or "drug eruptions" by some generalists, are the most common adrs in the skin. the eruption usually occurs between and days after the initiation of a new medication or chemical substance, although it can develop sooner, exanthematous eruptions generally are composed of erythematous macules and/or papules and more rarely by vesicles or pustules, usually with a pattern of symmetric distribution on skin. the eruption often begins on the trunk followed by centrifugal dissemination to the proximal limbs. skin lesions progressively become confluent and may cover large areas of the body (fig. . ). pruritus and/or low-grade fever are often associated with the exanthema. in some patients the exanthema may progress to erythroderma or more severe reactions such as sjs/ten or dress syndrome after some days or weeks. under histopathology examination this type of adr demonstrates interface dermatitis with vacuolar changes in keratinocytes at the basal layer of the epidermis, and upper dermal mononuclear cells infiltrate with some eosinophils. the pathogenesis involves the overexpression of several cytokines of th pattern, such as il- and il- , causing epidermal damage by uncomplicated exanthematous drug eruptions can occur with almost any medication, but the following drugs have higher risks (more than % of patients): allopurinol, aminopenicillins, cephalosporins, antiepileptic drugs, and antibacterial sulfonamides. viral infections may increase the incidence of morbilliform drug eruptions, as seen in the setting of mononucleosis infection under treatment with ampicillin, or in severe exanthema with internal damage as in dress syndrome related to the hhv family (ebv, cytomegalovirus, hhv- and - ). morbilliform reaction is the most common presentation of exanthematous drug eruption. morbilliform is defined as a rash resembling measles and is clinically depicted by erythematous macules and/or papules, often coalescing into larger plaques. many studies have shown that cutaneous biopsy alone cannot distinguish with certainly that a reaction is due to a drug. there are some clues that suggest the diagnosis: (i) epidermis (mild spongiosis is the most consistent feature, with occasional hyperplasia of the epidermis. few lymphocytes are commonly present in the epidermis. in % of biopsies, vacuolization was found in the dermoepidermal junction); (ii) dermis (perivascular infiltrate is virtually always present, composed of lymphocytes and in % of cases scattered eosinophils); (iii) papillary dermal edema; (iv) dilated lymph and blood vessels. the primary differential diagnosis for morbilliform eruptions includes viral exanthemas (e.g., ebv, hhv- , and cmv), bacterial toxin resection (streptococcal or staphylococcal), kawasaki syndrome, and others such as secondary syphilis, scarlet fever, acute hiv, or acute gvhd. the treatment is supportive. the first measure is the withdrawal the causative agent. topical corticosteroids and systemic antihistamines can be administered in the first step. if necessary, this can be combined with a short cycle of systemic corticosteroids (oral prednisone, . mg/kg/day, with progressively tapering dosages over several days). antihistamines are indicated as adjuvant therapy in cases of itching. [ ] [ ] [ ] drug-induced urticaria is the second most common form of cutaneous drug reaction after exanthematous reactions. urticarial eruption can be broken down into simple acute urticarial eruptions, those involving angioedema or anaphylaxis, and serum sicknesslike reactions as previously described in this chapter. simple urticarial reactions caused by drugs consist of erythematous and edematous lesions, which have central clearing with a red border. the lesions can be located anywhere on the body and wax and wane over hours to days. pruritus is an associated symptom. this type of drug reaction takes place minutes to days after exposure to the offending drug. common drugs responsible for urticarial reactions include antibiotics, such as penicillins, cephalosporins, sulfonamides, and tetracyclines, generally due to ige-mediated hypersensitivity reaction. another common class of drugs related to urticarial eruptions is nonsteroidal anti-inflammatory drugs (nsaids). nsaids cause most frequently non-ige-mediated urticaria and angioedema because of their pharmacologic activity of cyclooxygenase- enzyme inhibition, particularly of prostaglandin e , and results in the generation of leukotriene c and activation of inflammatory cells. urticaria and angioedema are associated in about % of cases. regarding ace inhibitors, angioedema is described in . % of patients treated with this class of drugs, and often without urticarial lesions. rarely, angiotensin ii receptor blockers result in the same complication. oral or injectable antihistamines and systemic corticosteroids are sometimes needed for severe acute urticaria and intramuscular epinephrine for angioedema. in cases of isolated angioedema caused by ace inhibitors, epinephrine will not control the symptoms and it is necessary to use the selective bradykinin b receptor antagonist icatibant in this clinical setting. [ , ] this entity is defined as recurrent lesions that, upon repeated uptake of the causative drug, always appear at the same skin or mucosal sites. fdes present as well as circumscribed, single or multiple, often pruritic or burning erythematous, dusky patches (fig. . ) , ranging from several millimeters to over cm in diameter. vesicles or even blisters can develop. as the lesions resolve, they leave residual hyperpigmentation. the hallmark of fdes is geographic memory. if a reaction recurs, it tends to recur in the same location as previously (although a new location can also be involved). lips, hands, genitalia (especially male genitalia), and occasionally oral mucosa are favored sites of fde occurrence, although the lesions can be found anywhere on the skin and mucous membranes. after intake of the offending drug, fde appears within minutes up to several hours (about min to h). the cutaneous lesions can be accompanied by general symptoms such as fever, nausea, dysuria, abdominal cramps, and diarrhea, though rarely. on occasion the disease presents in an atypical form with blunt-margined, non-pigmented, giant (> cm in diameter), urticarial, purpuric, targetoid, linear, reticular, and butterflylike lesions. the histopathologic hallmark is brisk interface dermatitis with varying amounts of epidermal necrosis as well as melanophages and eosinophils in the upper dermis. fdes reveal a reaction pattern with lichenoid or erythema multiforme-like changes. atypical histopathologic reaction patterns such as leukocytoclastic vasculitis, neutrophilic reaction, and a predominantly dermal reaction without pigment incontinence in what is termed nonpigmented fde have been reported. the pathogenesis of fde is based on the new subclassification of delayed type iv immune reactions (werner pichler), a type ivc reaction. in this kind of immune response cytotoxic t cells play a predominant function, whereby autoaggressive αβ + cd + memory t cells persist intraepidermally in previous fde sites and play a central role in new flare-ups during drug recall. under drug exposition, keratinocytes are stimulated to participate in immune response through tnf-α and a rapid expression of icam- molecule, and then stimulate cd + t cells to produce ifn-γ and many drugs have been found to cause fde, with common offenders including sulfonamides, nsaids (e.g., ibuprofen), allopurinol, barbiturates, hydroxyzine, laxatives, tetracycline, phenolphthalein, and feprazone. usually there is only one causative drug (monosensitivity), although sometimes several drugs can induce fdes in the same patient (multisensitivity). the most common multisensitivity is the cross-reaction between chemically related drugs such as tetracyclines. less frequently, multisensitivity can occur because of polysensitivity, whereby two or more chemically unrelated drugs either induce the identical fde lesion or each drug determine flare-ups in separate lesions. treatment is mainly symptomatic with discontinuation of offending agent, topical corticosteroids, and antihistamines. [ , ] this kind of adr produces lesions resembling acne vulgaris, but unlike acne vulgaris, druginduced acneiform eruptions typically are not associated with the presence of comedones (blackheads and whiteheads). acneiform drug eruptions appear as erythematous papules or erythematous pustules on the face and trunk (fig. . ) and proximal extremities, but sometimes can be present on the forearms and legs, an unusual site in acne vulgaris. the most relevant hallmark is the monomorphous pattern of this eruption and the resolution without scarring. drug-induced acneiform eruptions represent only % of drug eruptions. several medications are related to flare-ups of drug-induced acneiform eruptions, the most strongly associated being lithium, androgens, oral contraceptives, corticosteroids, vitamin b complex, and nowadays epidermal growth receptor (egfr) inhibitors for chemotherapy. iodine, bromide, isoniazid, actinomycin d, and phenytoin have also been associated. in the last decade, the use of supplementary complexes by bodybuilders, such as milk and whey proteinbased products, have been reported as being involved in acneiform eruptions. this is an effect caused by elevations of postprandial insulin and basal insulin-like growth factor i plasma levels. treatment involves discontinuing the use of the offending drug, except in the case of egfr inhibitors, when discontinuation may not be possible. benzoyl peroxide, topical retinoids, and topical or oral antibiotics, such as doxycycline, can be used to treat the reaction, similar to the treatment of acne vulgaris. lichenoid eruptions [ , ] drug-induced lichenoid eruptions are uncommon adrs that appear similar or even identical to lichen planus, with shiny violaceous polygonal papules and plaques (fig. . ) . drug-induced lichenoid eruptions can present virtually anywhere on the body surface, but certain clues in the distribution can help suggest drug eruption over lichen planus. drug-induced lichenoid eruptions tend to be absent from the flexor surface of the wrists, genitals, and mucous membranes, whereas these locations are often involved in common lichen planus. lichen planus drug eruptions also often favor sun-exposed areas of the body. several drugs have been reported to be related to drug-induced lichenoid eruptions: gold salts, antimalarials, methyldopa, nsaids, penicillamines, lithium, sulfonylureas, phenylenediamine derivatives, thiazide diuretics, β-blockers, omeprazole, and pantoprazole. the time from initiation of the drug to onset of lichenoid drug eruption varies greatly depen ding on the causative medication. reactions caused by naproxen, for example, tend to occur approximately days after administration. by contrast, certain drugs such as lithium, methyldopa, and acebutolol can develop lichenoid eruptions several years later. hiv infection can contribute to lichenoid drug eruptions on photoexposed areas of the body. treatment typically is symptomatic, with topical corticosteroids a mainstay. once discontinuation of the medication has been accomplished, the eruption resolves spontaneously after a period of a few weeks or months. [ ] [ ] [ ] acute photosensitivity ranges from common polymorphous light eruptions to phototoxicity, or rare photoallergies. photosensitivity refers to reactions that occur when a photosensitizing agent (chromophore substance) in or on the skin reacts with ultraviolet (uv) radiation, often in doses smaller than those associated with sunburn. up to % of cutaneous drug reactions are photosensitivity eruptions. typically, a photosensitivity reaction occurs within hours to days of exposure to sunlight and may last for up to week or more. more frequent reactions are named "phototoxic reactions," in which skin signs resemble moderate to severe sunburn, with erythema, blistering, weeping, and desquamation. photoallergic reactions resemble eczematous lesions, often in subacute or chronic presentation. phototoxic and photoallergic reactions occur in sun-exposed areas of the skin; however, widespread eruptions can occur, which may suggest a systemic photosensitizing agent (photoallergy). these reactions are dose related and are most commonly seen in patients who have been exposed to high doses of both the drug and uv radiation. one's susceptibility to this type of syndrome is variable and likely based on drug absorption and metabolism, as well as the amount of melanin in the skin. piroxicam, fluoroquinolone antibiotics, tricyclic antidepressants, and nsaids are classes of drugs that have been reported to be frequent photosensitizers, with fluoroquinolones being the most potent. other antibiotics, such as tmp-smx and tetracyclines, have also been implicated. recently voriconazole, a third generation of azole antifungal agents, has been reported as a photosensitivity agent, especially in phototoxic reactions (fig. . ), in % of outpatients treated, besides increasing the potential of nonmelanoma skin cancer (particularly squamous cell carcinomas) arising from potential photocarcinogenesis related to voriconazole. phototoxic reactions are the most common dermatologic adverse effect of amiodarone therapy, affecting - % of patients on long-term treatment. photoallergy is considerably less likely to occur, but the risk also increases with prolongation of the therapy. skin changes usually occur after at least months of therapy and with the minimal cumulative dose, which is g. management of photosensitivity reactions includes limiting exposure to sunlight, using potent sunscreen, and wearing protective clothing. oral and topical corticosteroids agents may be employed in the treatment. [ , ] coma blisters are uncommon skin eruptions seen in patients with impaired consciousness. the original case was described in a patient who was heavily sedated because of barbiturate intoxication. subsequently anticonvulsants have been reported, including certain benzodiazepines such as clobazam (fig. . ) , and valproic acid and amitriptyline overdose. there were a few reports of coma blisters and peripheral neuropathy caused by amitriptyline overdose. these blisters are most often seen in pressure areas, particularly over bony prominences in contact with hospital beds. the hallmark histologic feature that defines coma blisters is eccrine gland necrosis in the skin. differential diagnosis with bullous pemphigoid is obtained with a negative direct immunofluorescence biopsy of the skin. until recently, coma blisters were thought to be a self-limiting process that did not require withdrawal of the offending agent. however, in some patients the eruption resolves only upon withdrawal of the drugs. nodosum [ ] erythema nodosum is a skin reaction manifested by tender or painful erythematous subcutaneous nodules, located usually on the extensor aspects of the lower extremities. histologically it is a septal panniculitis without vasculitis. several conditions can be induce and act as an antigenic stimuli, including drugs, benign and malignant systemic diseases, leprosy, and bacterial (e.g., tuberculosis) and fungal infections. frequently the cause is unknown. drugs that may cause erythema nodosum are antimicrobial agents (amoxicillin, penicillin, sulfonamides), bromide, iodine, gold salts, analgesics and antipyretics (including paracetamol), carbimazole, isotretinoin, azathioprine, vemurafenib, gm-csf, oral contraceptives (estrogens/ progesterones), and estrogens. erythema nodosum disappears within a couple of weeks after withdrawal of the causative drug. psoriasis [ , ] drug-induced psoriasis is well documented. such eruptions may occur in patients with pre-existing psoriasis (exacerbation phenomenon) or those without a personal or family history. lesions typically improve with drug withdrawal, although persistent disease is possible. more frequent drugs involved are β-blockers, lithium, antimalarials, nsaids, anti-tnfα agents (fig. . ) , and bupropion. exacerbation of psoriasis caused by the following medications has also been observed: adrenergic antagonists, ifn, gemfibrozil, iodine, digoxin, and clonidine. exanthema [ ] in individuals previously sensitized to an allergen through contact, systemic exposure results in the development of a condition classically termed systemic contact dermatitis. one of the most common manifestations of this condition is socalled baboon syndrome (bs). a subsequent study by hausermann et al. [ ] examined a series of cases of bs and found that about half of the patients exhibited no evidence of prior skin sensitization. for that group the authors proposed the term "symmetric drugrelated intertriginous and flexural exanthema" (sdrife) to describe a peculiar form of drug rash with symptoms similar to those of true bs. bs is historically often equated with a mercuryinduced exanthem in patients with previous contact sensitization. sdrife specifically refers to the typical clinical pattern of this drug eruption, and the following diagnostic criteria are proposed [ ] : ( ) exposure to a systemically administered drug either at the first or repeated dose (excluding contact allergens); ( ) sharply demarcated erythema of the gluteal/perianal area and/or v-shaped erythema of the inguinal/perigenital area; ( ) involvement of at least one other intertriginous/flexural localization (fig. . ) ; ( ) symmetry of affected areas; and ( ) absence of systemic symptoms and signs. several drugs are reported to induce sdrife [ ] : (i) β-lactam antibiotics (amoxicillin, ampicillin, amoxicillin/clavulanic acid, pivampicillin, penicillin v, ceftriaxone, cefuroxime, cephalexin) and non-β-lactam antibiotics (including clindamycin, roxithromycin); (ii) corticosteroids: deflazacort; (iii) radiocontrast barium; (iv) other drugs: sulfate iomeprol, iopromide, monoclonal antibodies (cetuximab, glembatumumab), vedotin (cr , vcmmae), psychopharmaceuticals (risperidone loflazepate ethyl), allopurinol, cimetidine hydroxyurea, heparin (intravenous), ivig, mitomycin c, naproxen, oxycodone, pseudoephedrine, salsalate, terbinafine, and valacyclovir. [ , ] in , freudenthal described full-thickness dermal necrosis associated with intramuscular injection of oily bismuth suspension, which was used to treat syphilis at that time. he described the histologic appearance of these suspended particles deep within the cutaneous arteries, distant from the injection site. this condition was also described by nicolau the following year, and the syndrome more often bears his name despite freudenthal's precedence in the literature. nicolau syndrome is an iatrogenic syndrome caused by intramuscular injection leading to variable degrees of tissue necrosis, with variable severity, including the skin and deeper tissues. intense pain in the immediate postinjection period and purplish discoloration of the overlying skin, with or without a reticulate pattern (livedo racemosa-like pattern), is highly characteristic of this syndrome. intramuscular, subcutaneous, intravenous, and intra-articular injections have been reported to produce this syndrome. the skin necrosis resolves with severe and disfiguring scarring. it is therefore important that dermatologists and cutaneous surgeons are aware of this agonizing and deforming iatrogenic complication of injections. discoloration of the skin may result in necrosis and ulceration, which might involve the subcutaneous tissue and the muscular layer. paralysis of the lower extremities has been reported and attributed to embolization of the medication, mainly resulting from the force of injection from the gluteal vessels into the internal iliac arteries, and ischemia of sciatic nerve. application of cold devices or compress tends to aggravate the tissue injury and necrosis. several drugs are related to ecm: (i) intramuscular injections (vitamin k, nsaids, hydroxyzine, vaccination, bismuth, benzathine penicillin, penicillin g); (ii) intravenous injections (polidocanol %); (iii) subacromial injection (triamcinolone acetate); (iv) subcutaneous injection: pegylated ifn-α, glatiramer acetate; and (v) intra-articular: glucocorticoid. aspirating just before injecting has been suggested as a method of preventing nicolau syndrome, as it is thought to help prevent embolism caused by intra-arterial deposition of medication. however, it is doubtful as to whether nicolau syndrome can be prevented by this method, as the spasm of the vessel or vasocompressive effect in nicolau syndrome is usually difficult to recognize. the essential difference between those cases of ecm and the pathophysiology seen with vascular obstruction by dermal fillers (hyaluronic acid, polymethylmethacrylate microspheres) is that the former often involves inflammatory pathways being activated by the injected material, whereas the latter typically involves a more purely mechanical vascular obstruction (although some dermal fillers may promote blood clotting, hyaluronic acid-based dermal fillers by design are minimally reactive in tissues). the phenomena are similar in that the inciting event is accidental intravascular injection, followed by some degree of intravascular transport, finally resulting in distal vascular obstruction, ischemia, and so forth, such that the ultimate clinical presentation is the same. diagnosis is mainly clinical; cutaneous biopsy reveals necrotic changes caused by ischemia. ultrasonography study of the skin and magnetic resonance imaging help in delineating the extent of damage. prompt treatment has been reported to avert necrosis of the skin. in the immediate post-event period, treatment is based on various approaches to improve blood supply such as pentoxyphylline, hyperbaric oxygen, intravenous alprostadil, and thrombolysis with heparin. intralesional corticosteroid has also been used to reduce inflammation. surgical debridement of the necrotic scar is of utmost importance as it reduces infection and enhances wound healing. [ , ] the autoimmune form. the most commonly used medication associated with this kind of adr is vancomycin; however, other drugs include amiodarone, atorvastatin, captopril, ceftriaxone, diclofenac, furosemide, lithium, metronidazole, penicillin, phenytoin, piroxicam, rifampin, and trimethoprim-sulfamethoxazole. treatment of drug-induced labd includes discontinuation of the causative agent and treatment with topical or systemic steroids, dapsone, and/or nonsteroidal systemic immunosuppressive agents. pemphigoid [ ] this entity is very similar to the autoimmune form. multiple tense bullous lesions appear on the skin and pruritus is a common symptom. often the medications associated with druginduced bullous pemphigoid include furosemide, ace inhibitors (especially captopril and enalapril), penicillin, ampicillin, chloroquine, psoralen-uva treatment, and sulfasalazine. treatment is aimed at discontinuation of the offending drug as well as topical or systemic corticosteroids and steroid-sparing immunosuppressive drugs as indicated. [ ] similar other drug-induced reactions related to counterpart autoimmune conditions, druginduced pemphigus most closely resembles pemphigus foliaceus, with flaccid vesicles or bullae that rupture, creating crusted or desquamated erosions, with mucous membranes often spared. the histologic hallmark of this drug-induced eruption is the acantholysis of epidermal cells, but this phenomenon is not a pathognomonic sign of this type of adr. both autoimmune (idiopathic) and drug-induced pemphigus have a positive nikolsky sign, as observed in the sjs/ten spectrum, although sjs/ten does not demonstrate acantholysis in the skin biopsy. drugs containing thiol molecules (penicillamine, thiopurine, pyritinol, gold sodium thiomalate, captopril) are responsible for % of the cases, and other drugs implicated include levodopa, penicillin, phenobarbital, piroxicam, propranolol, and rifampicin. drug-induced pemphigus can occur any time within the first year of initiation of one of the offending drugs. treatment generally consists of withdrawal of the drug and use of systemic corticosteroids. [ , [ ] [ ] [ ] [ ] the skin, mucous membranes, annexes (sebaceous and sudoriferous glands), and the phaneros (hair and nails) are tissues with rapid cellular proliferation and are thus susceptible to adverse reactions (toxic or hypersensitive) resulting from systemic chemotherapeutic treatment. antineoplastic agents are defined as substances that inhibit or prevent the proliferation of neoplasms. because of their high metabolic rate, the skin, mucous membranes, and annexes are the most important target organs of the toxicity associated with chemotherapy. reactions can present with disseminated exanthematous eruptions, nonspecifically, or as distinct cutaneous lesions. some drugs can trigger localized reactions caused by extravasation to tissues adjacent to the areas of application. exanthematous reactions, such as nonspecific erythema multiforme, are more common, and many of them are attributed to hypersensitivity mechanisms. certain local toxicity, such as alopecia, mucositis, nail alterations, or hand-foot syndrome, is more specific and less common, frequently associated with particular drugs or groups of drugs. the identification of the reaction pattern associated with the trigger drug and of the possible dose-limiting toxicity is of extreme importance to the physician, as is the differential diagnosis with infectious processes and specific manifestations of the neoplasm. [ , [ ] [ ] [ ] [ ] alopecia [ , [ ] [ ] [ ] [ ] alopecia is the most common adverse skin manifestation of chemotherapeutic treatment. there are two types of drug-induced alopecia: the anagen effluvium and the telogen effluvium. in the anagen effluvium hair loss occurs because of the sudden interruption of the mitotic activity of the hair matrix, - weeks after the start of chemotherapy, leading to lack of hair production or its thinning (pohl-pinkus constrictions). the weakening of the hair shaft in this context predisposes the hair to breakage and shedding during the act of combing. they involve the hair, eyebrows, beard, axillary hair, and pubic hair. it is dose-dependent and reversible. new hairs often grow back with a different color and texture. in the telogen effluvium, hairs move prematurely to a resting phase with subsequent loss of normal hair. the antineoplastic agents that most frequently cause the anagen effluvium lead to diffuse hair loss, of sudden onset, from to days after the start of chemotherapy. hair loss becomes more pronounced about - months after the start of treatment. even though hair loss is intense, about % of the pilous follicles are usually in a resting phase at the time of the administration of the drug, and this determines incomplete hair loss. with repeated treatment cycles, alopecia totalis may occur. this type of effluvium is generally reversible when treatment is suspended, and occasionally permanent with the use of cyclophosphamide and busulfan. hair grows around cm per month, possibly showing new texture and color. the chemotherapeutic drugs more often associated with alopecia when used in isolation are: (i) complete alopecia (cyclophosphamide at high dose, doxorubicin, docetaxel, dactinomycin, irinotecan, topotecan, bleomycin, paclitaxel); (ii) incomplete alopecia (etoposide, ifosfamide, mitomycin c, -fluorouracil, melphalan, mitoxantrone, gemcitabine, vinca alkaloids). most reactions can be reversed by dose reduction or by increasing the interval between doses. some toxic effects can be successfully treated or prevented. medication administered before the chemotherapeutic treatment can prevent hypersensitivity reactions. the use of oral antiseptic solutions is useful in the control of mucositis. some dermatologic reactions to new antineoplastic agents, such as egfr inhibitors, have been associated with anticancer efficacy. other adverse effects may be mistaken for reactions to chemotherapeutic drugs and include infections resulting from immunosuppression, paraneoplastic syndromes, gvhd, nutritional deficiencies, development of skin malignancies, and metastatic primitive tumor. there are several classifications of reactions to antineoplastic drugs. the lack of a systematized multidisciplinary approach does not provide all the microscopic data and physiopathogenic mechanisms that delineate the lesions. therefore, the classification adopted didactically groups with the eruptions based on the target cells and mechanism of action of the drugs. preventive measures to limit hair loss have had limited success. hypothermia of the hair scalp or tourniquets applied in this region may reduce the perfusion of the drug in the pilous follicles and delay the start of or minimize hair loss. this procedure is contraindicated for patients with hematologic neoplasms such as leukemias, lymphomas, and other potentially metastatic tumors of the hair scalp. topical minoxidil is not effective in the prevention of drug-induced alopecia, but may shorten its duration. [ , [ ] [ ] [ ] [ ] hair alterations with acceleration of growth and shaft changes are observed with the use egfr inhibitors (fig. . ) . alterations [ , [ ] [ ] [ ] [ ] nail alterations can present with a reduction of the nail growth speed, fragility, lines of discoloration (mees' lines), transversal depressions (beau's lines), hyperpigmentation, onycholysis with subungual aseptic abscesses, photo-onycholysis, paronychia, and pyogenic granulomas of the periungual folds. nearly all antineoplastic agents can lead to reduction of growth speed, nail fragility, mees' lines, and beau's lines. hyperpigmentation can occur after the use of cyclophosphamide, hydroxyurea, fluoropyrimidines such as -fluorouracil, and especially anthracyclines such as doxorubicin and daunorubicin. painful onychomycosis and subungual abscesses are due to the use of taxanes (docetaxel/ paclitaxel) and anthracyclines (doxorubicin). ingrown nails, paronychia, and pyogenic granuloma are associated with the use of tyrosine kinase inhibitors of egfr (fig. . ), such as erlotinib and gefitinib. the fenestration or avulsion of the lamina should be considered when abscesses that involve more than % of the nail bed are present. in these more severe cases, the temporary suspension of treatment, longer intervals between cycles, and dose reduction should be considered. [ , [ ] [ ] [ ] [ ] this rare, nonspecific disease often occurs when chemotherapeutic drugs are used in combination, making it difficult to know which drugs are responsible for causing the disease. cytarabine is the most commonly cited drug; however, others are also implicated, such as bleomycin, chlorambucil, cyclophosphamide, cytarabine, doxorubicin, lomustine, mitoxantrone, busulfan, carmustine, cisplatin, cyclophosphamide, etoposide, -fluorouracil, methotrexate, and thiotepa. some authors consider neutrophilic eccrine hidradenitis (neh) as a paraneoplastic phenomenon, since it has been found in an early case of acute myeloid leukemia not yet treated. it has been associated with hiv infection, nocardia, serratia, enterobacter, staphylococcus, and with patients receiving gm-csf. the mechanism is unknown, but may be due to the excretion of the chemotherapeutic drug by the eccrine glands and its direct toxic effect on the eccrine epithelium. the clinical condition may be preceded by fever and unspecific clinical signs. skin eruptions are distributed in the head, neck, trunk, and extremities, with lesions that vary from erythema, papules, nodules, and pustules to papular plaques. lesions may be purpuric or hyperchromic, single or multiple. they appear between days and weeks from the start of treatment, regressing spontaneously without scarring or sequelae - weeks after the suspension of the drug. the differential diagnosis is vast and includes sepsis, septic embolism in a postchemotherapeutic neutropenic patient, vasculitis, leukemia cutis, hypersensitivity reaction, urticaria, polymorphous erythema, and neutrophilic dermatoses such as sweet's syndrome, bullous pyoderma gangrenosum, and atypical pyoderma gangrenosum. owing to the unspecific clinical presentation of the disease and the great number of differential diagnoses, some authors suggest that neh be included in the diagnostic hypotheses of any ingrown nail and pyogenic granuloma in a patient using erlotinib eruption that may occur in patients undergoing chemotherapy, and its final diagnosis is established by histopathology. therefore, histopathology is essential for conclusive diagnosis. it is constituted by a dense neutrophilic infiltrate, inside and around the eccrine glands, with necrosis of the eccrine epithelium cells. involvement of the apocrine glands has been reported. occasionally, squamous syringometaplasia, hemorrhage and edema of the dermis, spongiosis and/or vacuolization of the basal layer of the epidermis, necrosis of keratinocytes, and mucin deposits inside and around the eccrine glands may occur. in patients with severe neutropenia, the neutrophilic infiltrate may be absent; however, necrosis of the eccrine epithelium is typical. neh is a self-limiting adverse reaction. frequently the process resolves within a month, without treatment. in other chemotherapy cycles, % of the patients may relapse. the efficacy of the prophylactic or therapeutic use of systemic corticosteroids, dapsone, or nonhormonal antiinflammatories is still questionable. [ , [ ] [ ] [ ] [ ] eccrine squamous syringometaplasia is an unusual adverse reaction to chemotherapeutic drugs. it can also be found in association with chronic ulcerations, skin tumors, exposure to toxic agents, and several inflammatory processes. therefore, it is not a histopathologic reaction exclusive to the use of chemotherapeutic drugs. the mechanism of neutrophilic eccrine hidradenitis is unknown, but it can be the result of the excretion of the drug by the eccrine glands and its direct toxic effect on the eccrine epithelium. it is postulated that eccrine squamous syringometaplasia represents the final noninflammatory spectrum of adverse reactions to chemotherapeutic drugs in the eccrine glands. similarly to neh, eccrine squamous syringometaplasia also has an unspecific clinical presentation, constituted by erythematous maculae, papules, and papular plaques or vesicles, localized or disseminated. lesions develop between and days after the start of chemotherapy and improve spontaneously after weeks. the diagnosis is histopathologic, characterized by the presence of squamous metaplasia of the eccrine glands in the papillary dermis. minimal and focal necrosis of the eccrine gland epithelium, fibroblastic proliferation, and edema of the periductal stroma may occur. contrary to neh, the neutrophilic infiltrate is minimal or absent. squamous eccrine syringometaplasia has been described as an accidental histologic finding in other conditions not associated with chemotherapy. eccrine squamous syringometaplasia does not appear to be associated with a specific chemotherapy agent or malignancy. numerous drugs have been related such as cytarabine, mitoxantrone, daunorubicin, cisplatin, -fluorouracil, doxorubicin, cyclophosphamide, etoposide, methotrexate, busulfan, melphalan, and carmustine. eccrine squamous syringometaplasia has been observed in association with palmoplantar erythrodysesthesia syndrome, in radiation-induced memory reactions, and in patients who underwent bone marrow transplantation and received high doses of chemotherapeutic drugs. the condition often spontaneously resolves. [ , [ ] [ ] [ ] [ ] first described in , this syndrome is also known as burgdorf's syndrome, palmoplantar erythema, hand-foot syndrome, and toxic erythema of the palms and soles. it occurs more frequently in patients treated with cytarabine and, fluoropyrimidines, especially capecitabine, which is the oral -fluorouracil prodrug. after alopecia and mucositis, it is the most common adverse reaction to chemotherapy. other agents less frequently associated with palmoplantar erythrodysesthesia syndrome are cisplatin, cyclophosphamide, cytarabine, doxorubicin, daunorubicin, doxifluridine, etoposide, floxuridine, hydroxyurea, mercaptopurine, methotrexate, mitotane, paclitaxel, docetaxel, and vinorelbine. it is estimated that this adverse reaction occurs in - % of the patients treated with different chemotherapeutic regimens. most patients show a prodrome of dysesthesia, with a tingling (pins and needles) sensation on the palms and soles. within a few days the reaction evolves to a feeling of pain and burning with a well-demarcated edema and erythema. the erythema is symmetric and sometimes more pronounced on the soft parts of the distal phalanges. hands are often more affected than feet (fig. . a) . some patients show light scaling with or without erythema. a bullous variant has been described (fig. . b) , representing a more severe form of the reaction, specifically associated with cytarabine and methotrexate. lesions are aggravated if the treatment is not suspended, and the associated pain and edema may limit the movement of fingers. when the drug is suspended, the reaction progressively improves within weeks. in some patients, when treatment is maintained despite the development of erythrodysesthesia syndrome, palmoplantar keratodermia may occur. the reaction occurs more frequently in patients who undergo oral or continuous infusional therapy with fluoropyrimidines ( - %), as compared with those submitted to bolus therapy ( . - %). it is thought that in the pathogenesis of the process the local accumulation of the drug leads to degeneration with necrosis of the sweat glands, because its microscopic aspects are similar to those of eccrine squamous syringometaplasia and neutrophilic eccrine hidradenitis. in the differential diagnosis the following should be considered: polymorphous erythema, erythromelalgia, eccrine squamous syringometaplasia, and neutrophilic eccrine hidradenitis. the most relevant differential diagnosis is acute gvhd. the fundamental difference is that acute gvhd occurs in patients who have received a bone marrow transplant, in addition to extracutaneous involvement with gastrointestinal alterations (abdominal pain and diarrhea, elevation of hepatic enzymes). in cases of acute gvhd without extracutaneous manifestations, differentiation may be difficult. nevertheless, acute gvhd presents with diffuse erythema and can form papules, whereas palmoplantar erythrodysesthesia syndrome shows a well-demarcated erythema and edema. there are no relevant histopathologic differences between them, except for necrosis of the satellite cell in all layers of the epidermis (apoptotic keratinocytes adjacent to lymphocytes) in acute gvhd and sometimes presence of squamous syringometaplasia in palmoplantar erythrodysesthesia syndrome. the differentiation between these two disorders is essential because the use of cyclosporine is necessary to treat acute gvhd, but worsens the patient's pain if used in the treatment of palmoplantar erythrodysesthesia. apart from dose reduction, longer intervals between the cycles of chemotherapy and, as a last resort, the suspension of the drug, there is no specific treatment for palmoplantar erythrodysesthesia syndrome that has proved to be effective in a large series of cases. some treatments have been suggested for small series of patients or case reports. general measures should be taken, such as reduction or suspension of the drug, longer intervals between chemotherapy cycles, dressings, elevation of the extremity, cold compresses, analgesic medication, and emollients. as a specific treatment, pyridoxine can be used if -fluorouracil, liposomal doxorubicin, doxorubicin, docetaxel, and etoposide have been administered; hand cooling (docetaxel); oral corticosteroids (doxorubicin, -fluorouracil); strong topical corticosteroids (liposomal doxorubicin, cisplatin, and -fluorouracil); and topical dimethyl sulfoxide (dmso) at % (liposomal doxorubicin). symptoms can be relieved with lesion care to prevent infection and elevation of the limb to reduce the edema. cooling of hands and feet during treatment reduces the blood flow in these areas and may decrease the severity of the reaction. strong topical corticosteroids have been used with mixed results when associated with emollients. systemic corticosteroids are useful in some situations. pyridoxine (vitamin b ) in doses of - mg/ day can be useful to treat and prevent this reaction, except when cytarabine or vincristine is used. topical dmso at % four times a day for days has cured some cases of palmoplantar erythrodysesthesia syndrome induced by pegylated liposomal doxorubicin. [ , [ ] [ ] [ ] [ ] some authors prefer to associate toxic erythema caused by chemotherapy with clinical lesions that present with painful erythema, with or without edema, often affecting the hands and feet, intertriginous areas such as the axillary and inguinal regions, and less frequently the elbows, knees, and auricular pavilion. these eruptions may have a bullous component, are self-limited, and generally evolve with resolution and scaling associated with postinflammatory hyperpigmentation. many denominations used refer to histopathologic findings or those given by various authors on different occasions. disorders such as eccrine squamous syringometaplasia, neh, acral erythema, and palmoplantar erythrodysesthesia syndrome would be, according to these authors, grouped under toxic erythema caused by chemotherapeutic drugs. the objective to group many disorders under the same denomination seeks to emphasize the superposition of clinical characteristics and promote an easy dialogue between medical specialties and with the patient. the clinical characteristics of the toxic erythema associated with chemotherapy are: ( ) maculae or erythematous and/or edematous plaques on the hands and feet, intertriginous areas, and less frequently on the elbows, knees, and auricular pavilions, often appearing - days after the administration of the drug; ( ) associated symptoms of pain (that may be debilitating), burning, paresthesia, pruritus, and/or hypersensitivity; ( ) pale color, petechiae, and/or sterile blisters, followed by erosion in areas of intense erythema; ( ) scaling and spontaneous resolution without specific treatment; and ( ) chance of relapse if an equal or higher dose is administered. isolated papules may be found in the periphery of plaques. papules and plaques may also be found in the head, cervical region, trunk, and extremities. onset of lesions after - months can be observed. the histologic characteristics observed are atypia (larger cells and nuclei and nuclear pleomorphism), apoptosis of keratinocytes, mitotic figures and bizarre mitotic configurations (astral mitosis), loss of polarity of the epidermal cells and apoptosis of keratinocytes, vacuolar degeneration of the basal layer of the epidermis, dermal edema, and eccrine squamous syringometaplasia. moreover, necrosis of the upper epidermis, similar to the alterations observed in pellagra, may also occur. the inflammatory infiltrates are usually minimal despite their abundant clinical profile. from these observations, it has been suggested that erythema is secondary and results from damage to keratinocytes, leading to the release of cytokines and vasodilation. [ , [ ] [ ] [ ] [ ] acneiform eruption is the adverse effect more often associated with the use of egfr inhibitors. onset occurs week after the start of treatment with the egfr inhibitor as a self-limiting eruption, dose-related, that affects the face, central region of the thorax, upper dorsum and, more rarely, limbs. it presents with follicular erythematous papules, pustules with or without comedones, and scaling of the interfollicular skin (fig. . ) . often an association with the following conditions is observed: acral asteatosis, paronychia with pyogenic granuloma, oral and nasal aphthous ulcerations, and hair alterations. palms and soles are often free of lesions. excessive follicular hyperkeratosis leading to the obstruction of the ostium with formation of a follicular corneal plug, rupture of the glandular wall, and consequent inflammatory process are suggested as pathogenic mechanisms. in the histopathologic examination a prominent corneal plug, with dilated infundibulum, with or without neutrophilic folliculitis, is observed. there is a positive correlation between the severity of the eruption and the tumoral response and survival. we emphasize the need for attention to the eruption to improve adherence to the chemotherapeutic treatment. the use of topical anti-acne agents and oral tetracyclines improve the condition. topical emollients are indicated to treat xerosis. [ , [ ] [ ] [ ] [ ] stomatitis [ , [ ] [ ] [ ] [ ] oral mucositis is the main dose-limiting reaction of most chemotherapeutic drugs. about % of the patients being treated show some type of oral complication. these complications are often associated with drugs that affect the synthesis of dna. the main causative agents are antimetabolic drugs and antitumoral antibiotics. the drugs more frequently associated with stomatitis are bleomycin, dactinomycin, methotrexate, topotecan, and -fluorouracil. unusually, the stomatitis caused by -fluorouracil is related to its continuous infusional administration or to the use of its oral prodrug, capecitabine, and is less frequently observed when -fluorouracil is administrated in bolus. the main mechanism is the direct toxicity of the drug, but it can result secondarily from the indirect effects of the drug on the bone marrow. in patients with head and neck tumors, cisplatin used during radiotherapy acts as a strong radiosensitizer. in these cases there is more tumoral control but also greater severity of stomatitis caused by a boost in the direct effect of radiotherapy. since oral epithelium cells have a high mitotic index (renewal every - days), they become susceptible to the toxic effects of chemotherapeutic drugs. moreover, there is atrophy of the oral mucosa, causing odynophagia, burning, xerostomia, and mucous membrane ulcerations. ulcerations may be initially focal and then become diffuse and confluent, with occasional vesicles and blisters. these alterations are more common in the nonkeratinized mucosa and appear - days after use of the drug. resolution of lesions may occur after treatment is suspended, often within - weeks. spontaneous or induced hemorrhage, especially gingival, may occur when the platelet count is below , /mm . patients at a higher risk of developing stomatitis are those with hematologic neoplasms, those who are under years old (high mitotic activity of the epithelium), and patients with pre-existing oral disease and poor mouth hygiene. preventive measures include proper maintenance of oral hygiene by washing the mouth with water, saline solution, sodium bicarbonate, or hydrogen peroxide. the use of cold water to prevent mucositis induced by -fluorouracil and melphalan in high doses appears to be helpful. other alternative clinical procedures, still not fully proven, consist in the use of chlorhexidine gluconate, β-carotene, and benzydamine chlorhydrate or sucralfate. treatment essentially consists of support with oral care, using agents such as magnesium or aluminum hydroxide and vitamin e. in addition, pain-relief drugs such as paracetamol and opioids (codeine and morphine) may be necessary when the use of topical anesthetics such as benzocaine and lidocaine are not effective. additional complications occur because of secondary bacterial, viral, or fungal infections that may become systemic. palifermin, when used prophylactically, reduces the occurrence and duration of severe stomatitis in patients with hematologic tumors and submitted to bone marrow transplantation. palifermin is a human recombinant factor of keratinocyte growth and protects various epithelial tissues. it acts not only on stomatitis but also on mucositis in general. a possible tumoral stimulating factor still limits its use in patients with epithelial tumors. hyperthermic chemotherapy with mitomycin c [ ] [ ] [ ] peritoneal carcinomatosis frequently signals the terminal stage in some cancers of gastrointestinal and gynecologic origins. cytoreductive surgery and intraperitoneal hyperthermic chemotherapy was introduced in the early s and has become the mainstay of treatment in particular clinical settings for patients with peritoneal carcinomatoses, especially in pseudomyxoma peritonei, significantly improving overall survival rates. there are four case reports of this recently described entity using a new procedure to treat peritoneal carcinomatosis after intraperitoneal hyperthermic chemotherapy with mitomycin c. one of them was described [ ] in a male patient after days of the procedure. the patient developed pain and scrotal necrosis on the anterior aspect of the scrotum (fig. . ) . two possible causes of the scrotal ulcers were proposed. (i) a patent processus vaginalis, allowing mitomycin c to become sequestered in the scrotum, inducing an inflammatory reaction, resulting in scrotal wall inflammation and subsequent ulceration (fig. . ). this was proposed since previous studies have shown that intradermal administration of mitomycin c inhibits wound healing and induces skin necrosis. (ii) local spillage of mitomycin c onto the scrotal skin, with resulting inflammation and ulceration. previous studies with patients on continuous ambulatory peritoneal dialysis (capd) have shown that % of capd patients developed genital swelling [ ] . a possible cause of the scrotal swelling is a patent processus vaginalis causing a communicating hydrocele, which can be found in - % of adult men and may not be clinically evident until capd has begun. patients may develop this complication months after the surgery; hence, any complaint of scrotal pain or discomfort in these patients should warrant immediate investigation and attention, even if the complaints present much later. our group suggests that an image investigation, such as computed tomographic peritoneography, should be considered for male patients prior to intraperitoneal chemotherapy, since this complication is potentially serious for the patient. vasomotor changes [ ] various vascular alterations have been described, probably as a result of a direct effect on arterial smooth muscle fibers or by acting on the autonomic nervous system. manifestations may include blood vessel spasms with livedo, raynaud's phenomenon, and distal necroses, which may be triggered by bleomycin and cisplatin. vasodilatation with erythema and flushing may result from the use of bleomycin, cisplatin, asparaginase, dacarbazine, taxanes, -fluorouracil, doxorubicin, cyclophosphamide, gefitinib, and carmustine. flushing [ ] flushing consists of a temporary erythema of the face, neck, upper chest, ears, or upper abdomen. the mechanism responsible for flushing is a transitory vasodilation mediated by the autonomic nervous system or by the direct effect of circulating substances that act on the musculature of the vessel walls. the nerves of the autonomic nervous system also control the sweat glands so that flushing mediated by these nerves is known as "wet flushing," whereas when the substance acts directly on the vascular wall muscles it is known as "dry flushing." derivatives of biological agents probable mechanism of mitomycin c deposition in a patent processus vaginalis into the scrotum such as l-asparaginase and bleomycin are notorious for causing flushing, which occurs soon after infusion. irinotecan, a topoisomerase i inhibitor, causes dysautonomia, the symptoms of which include diarrhea, bradycardia, and flushing. hormonal agents such as antiestrogens (tamoxifen, anastrozole), lhrh analogs (leuprolide), and antiandrogens (flutamide and diethylstilbestrol) may result in flushing. other agents that also deserve mention include -fluorouracil, carboplatin, cisplatin, cyclophosphamide, dacarbazine, doxorubicin, etoposide, and methotrexate. interaction with uv light [ ] eruptions resulting from photosensitivity are caused by various agents, principally following exposure to uv radiation. phototoxicity caused by dacarbazine, fluoropyrimidines (systemic -fluorouracil, topical -fluorouracil, tegafur, and capecitabine) and vinblastine has been well documented. phototoxicity caused by dactinomycin, doxorubicin, hydroxyurea, procarbazine, brequinar sodium, mitomycin, -thioguanine, and flutamide, as well as by the porphyrin compounds that are used in photodynamic therapy, is uncommon. reactivation of sunburn is a well-documented adverse effect following the use of methotrexate. it occurs when the drug is administered - days after exposure to uv radiation, when the erythema from the previous exposure has been in the process of disappearing. leucovorin does not prevent this reaction. phototoxic reactions resemble intense sunburn in areas of the skin that are exposed to light, with erythema, edema, pain, or pruritus. blisters may be present and desquamation may occur in severe cases. residual hyperpigmentation may persist for months. hydroxyurea has been described as being associated with development of dermatomyositislike eruption due to photosensitivity (fig. . ) [ , ] . hydroxyurea is an anticancer agent that inhibits dna synthesis through its action on the enzyme ribonucleotide reductase [ ] . it is used in chronic myeloproliferative diseases such as polycythemia vera, chronic myeloid leukemia, and essential thrombocytosis, although it has also been prescribed to patients with refractory psoriasis [ ] . patients on long-term therapy with hydroxyurea can develop various side effects, including a wide variety of mucocutaneous manifestations, which appear in - % of patients [ ] . the most common skin changes are facial erythema, hyperpigmentation, xerosis, alopecia, skin atrophy, melanonychia, and ulcers on the [ ] . other less frequent adverse effects are dermatomyositis-like rash and nonmelanoma skin cancer (fig. . ) [ ] . dermatomyositis-like rash resembles true dermatomyositis both clinically and histologically [ ] . it presents as desquamating erythematous papules or plaques on the dorsum of the hands, typically associated with facial erythema and pronounced xerosis of the skin. patients rarely report other accompanying symptoms and there are usually no significant alterations of laboratory tests [ ] . histologically, a lichenoid inflammatory infiltrate is found at the dermoepidermal interface, with vacuolization of the basal layer, dyskeratosis, and, rarely, mucin deposition ( fig. . ) [ ] . diagnosis is made according to the distribution of the lesions and by the temporal relationship between chemotherapy and light exposure. treatment includes discontinuation of the agent and protection from the sun for at least weeks. physical sunscreens are recommended. cold compresses, systemic antihistamines, and topical or oral corticosteroids are used as associated symptomatic treatment. [ ] this is a phenomenon whereby the chemotherapeutic agent induces an inflammatory reaction in an area previously exposed to radiation. these reactions are predominantly cutaneous; however, they may affect internal organs such as the lungs, heart, bladder mucosa, esophagus, oral or bowel mucosa, and supraglottic larynx. it occurs more often with the use of doxorubicin, dactinomycin, and gemcitabine and is less common with bleomycin, etoposide, hydroxyurea, methotrexate, trimetrexate, vinblastine, -fluorouracil, lomustine, daunorubicin, melphalan, cyclophosphamide, cytarabine, docetaxel, edatrexate, idarubicin, paclitaxel, tamoxifen, and vinblastine. the mechanism of radiation recall is unknown but it is probably related to dna repair. relapsing dermatitis or radiation recall may occur between and days following radiotherapy and generally appears hours to days after administration of the chemotherapeutic agent. clinically, the patient may or may not experience a painful erythema with or without vesiculation, edema, desquamation, and pruritus. the borders of the lesion are well defined and correspond to the exact site at which the radiation was applied. in severe cases, necrosis and ulceration may occur. the severity appears to directly reflect the brevity between radiation and chemotherapy as well as the doses of both radiation and chemotherapy. the reaction improves spontaneously within hours or weeks following cessation of chemotherapy, treatment being symptomatic. the use of systemic corticosteroids associated with the discontinuation of chemotherapy generally results in a marked improvement and may permit reintroduction of the treatment. [ ] this occurs when a chemotherapeutic agent increases the toxicity of radiotherapy. this phenomenon may occur in virtually all the organs of the body including the skin, mucosa, esophagus, lungs, heart, digestive tract, kidneys, liver, brain, bladder, and eyes. the agents most associated with exacerbation of radiation are bleomycin, gemcitabine, dactinomycin, doxorubicin, -fluorouracil, hydroxyurea, -mercaptopurine, oxaliplatin, and methotrexate. clinically, the reaction resembles residual dermatitis secondary to acute dermatitis from radiation, with erythema, edema, vesiculation, blisters, or erosions. the reaction generally appears at the site of radiation; however, the area affected may be more extensive. severe mucositis may occur. the reaction is associated with the dose, the type of drug used, and the sequence of time between radiation and the use of chemotherapy. toxicity may be additive or supra-additive (synergic). in supra-additive toxicity, the reaction is greater than that of the sum of each one of the types of treatment alone. treatment is symptomatic: applying cold compresses, taking precautions at the site to prevent infection and avoiding trauma, heat, and uv light. sequelae such as fibrosis, skin atrophy, and telangiectasia-related disorders may occur. [ ] in theory, all chemotherapeutic agents may trigger hypersensitivity eruptions. with certain drugs derived from biological agents such as l-asparaginase, mitomycin c, and bleomycin in addition to paclitaxel, the incidence of hypersensitivity reactions is high. in the case of paclitaxel, this is due to the fact that it is dissolved in cremophor el castor oil. according to the classification system defined by gell and coombs, the majority of hypersensitivity reactions are type i, i.e., ige-mediated. they present as urticaria, pruritus, angioedema, and anaphylaxis. they generally occur within the first hour after use of the drug, but onset may be delayed until up to h after using the medication. type iii reactions occur because of formation of circulating immunocomplexes, and cause eruptions such as polymorphous erythema and vasculitis. nonetheless, l-asparaginase and procarbazine cause urticarial reactions via type iii reactions. allergic contact dermatitis, a type iv reaction, may occur, principally as a consequence of the topical use of nitrogen mustard (mechlorethamine). other severe reactions may occur, such as sjs and ten, as well as exanthematous eruptions, all currently classified as type iv reactions according to the extended gell and coombs classification, i.e., sjs and ten, respectively (type ivc, mediated by fas, granzymes, and perforin) and exanthematous eruptions (type ivb, mediated by t cells with il- production, with chemotaxis of eosinophils). agents [ ] local toxicity [ ] antineoplastic drugs may be classified according to their potential aggressiveness toward blood vessels and adjacent tissues. they may be nonirritating, irritating, or vesicant, causing effects that range from mere local discomfort to tissue necrosis. nonirritating drugs (thioguanine, asparaginase, bleomycin, cyclophosphamide, chlorambucil, methotrexate, hydroxyurea) provoke an edema that is indicative of a site of extravasation; however, they do not cause necrosis or tissue irritation. irritating drugs ( -fluorouracil, carmustine, docetaxel, and etoposide) cause tissue damage that does not progress to necrosis. they trigger erythema, pain, inflammation at the puncture site and along the venous pathway, burning, and local edema, without blistering. the vesicant drugs (dactinomycin, doxorubicin, melphalan, vincristine, vinblastine, and dacarbazine) cause severe skin irritation with pain, erythema, edema, blistering, and necrosis with functional and aesthetic damage. [ ] this is defined as the leakage of a chemotherapeutic drug from the vessel bed to the surrounding tissues, either as a result of vascular rupture or by direct infiltration. the frequency of this event in adults is estimated at . - % and it is more common among children. severe sequelae are rare. the severity of tissue damage is related to the type of chemotherapeutic agent used and the quantity and concentration of the drug administered. cytotoxic agents are classified as irritants or vesicants as a function of their potential for local toxicity. an irritant is defined as an agent that causes an inflammatory reaction, paresthesia, pain, or phlebitis at the puncture site or along the venous pathway. clinical signs include sclerosis and hyperchromia along the passage, as well as burning, increased temperature at the site, discomfort, erythema, and pain at the area of extravasation. necrosis does not occur with this condition. the symptoms are generally short-lived and leave no sequelae. the drugs most associated with this complication are -fluorouracil, carboplatin, cisplatin, bleomycin, mitomycin, dactinomycin, idarubicin, daunorubicin, dacarbazine, ifosfamide, cyclophosphamide, mechlorethamine, carmustine, mitoxantrone, paclitaxel, docetaxel, streptozotocin, vinblastine, vinorelbine, and etoposide. the vesicant agents (melphalan, bleomycin, mechlorethamine, carmustine, mitomycin, mitoxantrone, cisplatin, paclitaxel, dacarbazine, dactinomycin, daunorubicin, streptozotocin, doxorubicin, epirubicin, vinblastine, vincristine, etoposide, vindesine, and vinorelbine) have the potential to cause more severe and long-lasting tissue damage, including necrosis of the affected area. the initial manifestations are often subclinical and may appear immediately following extravasation or after several days or weeks. the initial signs include local burning or paresthesia at the site of infusion, mild erythema, pruritus, and edema. a change in the infusion rate or the absence of venous return in the aspirate may indicate the occurrence of extravasation. after - days, erythema increases and there is pain, a brownish discoloration, induration, dry desquamation, or the appearance of blisters. if the amount extravasated was small, the signs and symptoms may disappear in the following weeks. if a significant amount was extravasated, the following symptoms may appear in the coming weeks: necrosis, formation of eschar and painful, necrotic ulceration with raised, erythematous borders and a yellowish base. there is generally no granulation tissue with these ulcerations. they may resolve slowly or persist, increasing gradually in area. involvement of the tendons, nerves, and vessels may occur if appropriate treatment is not given, leading to severe sequelae such as nerve compression syndrome, a reduction in joint mobility, contractures, neural deficits, and reflex sympathetic dystrophy. cellulitis and the formation of abscesses are rare events. the interval between detecting the condition and adopting the appropriate measures should be short as possible. the nursing team should be trained in this respect. preventive measures should be adopted such as avoiding puncturing emaciated limbs, lower limbs, limbs with multiple punctures, limbs with phlebitis or those that have been subjected to radiation, the ipsilateral limb to a mastectomy, in vena cava syndrome, and in veins that protect joints, nerves, and tendons. it is important to evaluate the venous conditions of the patient and, if necessary, to use an indwelling catheter. the use of common needles for venous access should be avoided. adequate fixation should be performed and blood reflux should be tested, with an infusion of . % saline solution or % glucose-saline solution used for every ml of the chemotherapeutic agent. after administration of all the drugs, ml of saline or glucose-saline solution should be infused to reduce any possibly toxic residues. vesicant drugs should always be given first. in prolonged sessions of chemotherapy (those lasting over an hour) with vesicant drugs, central venous access should be used. always listen to the patient's complaints. if extravasation occurs, stop the infusion immediately. remove the puncture device and elevate the affected limb. in the case of extravasation of drugs such as etoposide, paclitaxel, vinblastine, vincristine, and vinorelbine, apply local heat (leading to vasodilation and dilution of the drug) for min and ice (venous constriction and greater degradation of the toxic metabolites in addition to alleviating pain and inflammation) every min, six times a day in the first h. for the other drugs, apply ice every min, six times a day. when indicated, the specific antidote for the drug in question should be used. the use of intralesional corticosteroid and sodium bicarbonate should be avoided. ulcers that fail to heal may require debridement and grafting. in case of persistent edema and erythema and pain without ulceration that persists despite conservative therapy or in the presence of extensive areas of necrotic tissue or skin ulceration, surgery may be indicated. periorbital edema [ ] edema of the eyelids has been described with the use of gemcitabine. recovery [ ] cutaneous eruption of lymphocyte recovery (elr) is observed in leukemia patients who receive bone marrow ablation. in general, it appears between the th and st days after chemotherapy. this point corresponds to the beginning of the recovery of peripheral lymphocytes following the nadir of leukocyte count induced by chemotherapy. although the exact mechanism has yet to be clarified, it is believed that the eruption is caused by the return of immunocompetent lymphocytes to peripheral circulation with cutaneous cytotoxicity. t lymphocytes and langerhans cells are found on histopathologic evaluation of these reaction sites. clinically, the condition consists of pruriginous, erythematous macules, papules, or papulous plaques that become confluent. erythrodermia may occur. in addition, this condition is associated with an elevation in body temperature that occurs together with the appearance of the eruption. the temperature falls in the following - days and the skin eruption tends to diminish after several days, progressing with desquamation and mild residual hyperchromia. the drugs most associated with these reactions are cytarabine, daunorubicin, amsacrine, etoposide, cyclophosphamide, and vincristine. differential diagnosis should be made with sepsis, viral exanthems, gvdh, leukemia or lymphoma cutis, and drug hypersensitivity or toxicity. histopathology is nonspecific. the most characteristic findings are superficial perivascular mononuclear cell infiltrate, mild epidermal alterations such as spongiosis, vacuolar alteration of the basal cell layer, and loss of keratinocyte maturation secondary to chemotherapy. dyskeratotic keratinocytes are rare and eosinophils are absent. on occasions when the patient was treated with gm-csf associated with il- , atypical lymphocytes with large pleomorphic and hyperchromatic nuclei were found at histopathology. differentiation may be difficult between elr and gvhd. receptor tyrosine kinase inhibitors [ ] anti-egfrs currently consist of panitumumab, cetuximab, erlotinib, and gefitinib. skin toxicity with anti-egfrs is actually more of a pharmacologic effect than a hypersensitivity reaction, since this is a clinical marker of the efficacy of the inhibiting effect of these drugs on the tumor, with the severity of the eruption corresponding to tumor response. the skin effects observed with the anti-egfr are alterations in capillary growth and in the texture of the hair, paronychia with or without secondary infection, or the formation of pyogenic granuloma, generalized asteatosis, skin desquamation, and blepharitis. the most characteristic and intense manifestation is a papulopustular, follicular, comedone, or non-comedo (acneiform eruption) that occurs on the head, neck, and the central portion of the chest and back, which later disseminates. there may be pruritus, which differentiates this reaction from the acneiform eruptions caused by corticosteroids, antiepileptic drugs, and vitamins b and b . acneiform eruptions occur in more than % of patients with use of cetuximab, and this percentage may reach as high as - %. the manifestations generally occur in the first weeks ( days to weeks) after the beginning of treatment (cetuximab and panitumumab). the eruption is dose dependent; however, the duration of the condition does not correlate with the duration of treatment. the acneiform eruptions induced by monoclonal antibodies are more severe and extensive than those resulting from the use of tyrosine kinase inhibitors. blepharitis caused by anti-egfrs may range from mild to intense. histopathology of the papulopustular lesions shows no increase in sebaceous gland activity, comedones, or follicular rupture that would explain the inflammation, differentiating it from acne vulgaris. the follicles are rather wide and at times obstructed by an excess of keratinocytes. in the dermis, neutrophilic infiltrate may be found, particularly involving the follicular infundibulum. intraepidermal acantholysis may be present in association with the eccrine gland ducts. in the lesions of patients using gefitinib, there is an expressive thinning of the stratum corneum layer with loss of the normal basket-weave pattern. paronychia occurs in around - % of patients who are using cetuximab and gefitinib, appearing at - weeks of treatment or sometimes after months. it affects various fingers and the first toes. treatment consists of potent topical corticosteroids. in case of onychocryptosis, anti-egfr may be temporarily interrupted and canthotomy performed. asteatosis occurs in around % of patients, particularly with the use of gefitinib. there is a predilection for the areas previously or simultaneously affected by acneiform eruption. some patients have xerosis of the vaginal mucosa, with dysuria. xerosis may progress to chronic asteatotic eczema (fig. . ) , with a greater susceptibility to staphylococcus aureus infection or hhv- . emollients and topical corticosteroids should be used for the eczema. fissures can be treated with a solution of % propylene glycol under plastic occlusion or a hydrocolloid dressing. adverse drug reactions (adrs) include all unintended pharmacologic effects of a drug except therapeutic failures, intentional overdosage, abuse of the drug, or errors in administration. they can be classified as predictable (type a - % of the adrs) or unpredictable (type b). anaphylaxis an immediate systemic reaction that occurs when a previously sensitized individual is re-exposed to an allergen. it is caused by rapid ige-mediated immune release of vasoactive mediators from tissue mast cells and blood basophils with a potential late component. this is a systemic severe adr affecting skin, mucous membranes, gastrointestinal tract, respiratory tract, and cardiovascular system. drug allergy an immunologically mediated response to a pharmaceutical and/or formulation (excipient) agent in a previous sensitized patient. drug idiosyncrasy an abnormal and unexpected effect that is unrelated to the intended pharmacologic action of a drug and has an unknown mechanism. it is not mediated by a humoral or cellular immune response but is reproducible on readministration. it may be due to underlying abnormalities of metabolism, excretion, or bioavailability. drug intolerance an undesirable pharmacologic effect that may occur at low or conventional doses of the drug without underlying abnormalities of metabolism, excretion, or bioavailability of the drug. humoral or cellular immune mechanisms are not thought to be involved, and a definitive mechanism for such exaggerated responses has not been established (e.g., acetylsalicylic acid-induced tinnitus at low doses). immediate systemic reactions that mimic anaphylaxis but are caused by non-ige-mediated release of mediators from mast cells and basophils. often caused by radiocontrast agents. severe adrs include all adverse effects which are unpredictable life-threatening adrs and need prompt recognition to reduce integumentary and internal organ damage and, thus, morbidity and mortality. uncomplicated adrs include mild or moderate adverse drug effects on healthy patients, not involving life-threatening situations. diagnostic testing for drug hypersensitivity drug-induced reactions: a report from the boston collaborative drug surveillance program on . consecutive inpatients sémilogie et marqueurs de sévérité des toxidermies érythémateuses severe adverse cutaneous reaction to drugs the nature of adverse events in hospitalized patients: results of the harvard medical practice study ii cutaneous drug reactions: clinical types and causative agents: a five-fig. . intense xerosis caused by erlotinib year survey of in-patients ( - ) joint task force on practice parameters of american academy of allergy, asthma and immunology, american college of allergy, asthma and immunology, joint concil of allergy, asthma and immunology anaphylaxis and anaphylactoid reactions. a guide to prevention, recognition and emergent treatment erythroderma: analysis of cases dermatitis exfoliativa: cases admitted in the decade - to the dermatological clinic, karolinska sjukhuset exfoliative dermatitis: a prospective study of patients dermatology in general medicine advances in toxic epidermal necrolysis toxic epidermal necrolysis erythema multiforme: a critical review of characteristics, diagnostic criteria, and causes acute disseminated epidermal necrosis types , , and : study of sixty cases erythema multiforme major and stevens-johnson syndrome are clinically different disorders with distinct etiologies clinical classification of cases of toxic epidermal necrolysis, stevens-johnson syndrome and erythema multiforme epidemiology of erythema exsudativum multiforme majus, stevens-jonhson syndrome, and toxic epidermal necrolysis in germany ( - ): structure and results of a populationbased registry toxic epidermal necrolysis (lyell syndrome). incidence and drug etiology in france the incidence of erythema multiforme, stevens-johnson syndrome, and toxic epidermal necrolysis. a population-based study with particular reference to reactions caused by drugs among outpatients toxic epidermal necrolysis (lyell syndrome) intravenous immunoglobulin therapy for stevens-johnson syndrome effectiveness of early therapy with corticosteroids in stevens-johnson syndrome: experience with cases and a hypothesis regarding pathogenesis treatment of severe drug reactions: stevens-johnson syndrome, toxic epidermal necrolysis and hypersensitivity syndrome o espectro do eritema multiforme (eritema multiforme minor e major) e o espectro da síndrome de stevens-johnson e da necrólise epidérmica tóxica (síndrome de lyell) low n-acetylating capacity in patients with stevens-johnson syndrome and toxic epidermal necrolysis a slow acetylator genotype is a risk factor for sulphonamide-indiced toxic epidermal necrolysis and stevens-johnson syndrome cutaneous adverse drug reactions. stevens-johnson syndrome and toxic epidermal necrolysis delayed reactions to drugs show levels of perforin, granzyme b, and fas-l to be related to disease severity increased interleukin , tumor necrosis factor a, and interleukin levels in blister fluid of toxic epidermal necrolysis drug rashes. what are the targets of cell-mediated cytotoxicity? treatment of toxic epidermal necrolysis with high-dose intravenous immunoglobulins intravenous immunoglobulin treatment for stevens-johnson syndrome and toxic epidermal necrolysis treatment of toxic epidermal necrolysis epidemiology of druginduced severe skin reactions correlations between clinical patterns and causes of erythema multiforme majus, stevens-johnson syndrome, and toxic epidermal necrolysis medication use and the risk of stevens-johnson syndrome or toxic epidermal necrolysis severe cutaneous adverse reactions to drugs -relevant aspects to diagnosis and treatment -part i: anaphylaxis and anaphylactoid reactions, erythroderma and the clinical spectrum of stevens-johnson syndrome and toxic epidermal necrolysis (lyell's disease) drug reaction with eosinophilia and systemic symptoms (dress): a complex interaction of drugs, viruses and the immune system drug reaction with eosinophilia and systemic symptoms (dress)/drug-induced hypersensitivity syndrome (dihs): a review of current concepts drug reaction with eosinophilia and systemic symptoms/drug-inducedhypersensitivity syndrome: clinical features of patients adverse mucocutaneous reactions to chemotherapeutic agents: part i severe cutaneous adverse drug reactions: relevant aspects to diagnosis and treatmentpart ii propylthiouracil-induced vasculitis with antineutrophil cytoplasmic antibody approach to the patient with a suspected cutaneous adverse drug reaction adverse drug reactions and organ damage: the skin a review of cutaneous drug eruptions dermal dendrocytes fxiiia+ phagocytizing extruded mast cell granules in drug-induced acute urticaria fixed drug eruption: state of the art evidence for acne-promoting effects of milk and other insulinotropic dairy products lichenoid drug eruption with proton pump inhibitors getting under the skin of adverse drug reactions cutaneous adverse reactions of amiodarone phototoxicity and photocarcinogenesis associated with voriconazole an update on pediatric cutaneous drug eruptions coma blisters, peripheral neuropathy, amitriptyline overdose: a brief report in vitro interferon-gamma release test in the diagnosis of druginduced erythema nodosum drug induced psoriasis advances in the diagnosis of drug eruptions baboon syndrome resulting from systemic drugs: is there strife between sdrife and allergic contact dermatitis syndrome? contact dermatitis a new proposal for a clinical-oriented subclassification of baboon syndrome and a review of baboon syndrome nicolau syndrome: an iatrogenic cutaneous necrosis complications of the injectable fillers, part : vascular complications cutaneous drug reactions in the pediatric population chemotherapeutic agents and the skin: an update mucocutaneous reactions to chemotherapy cutaneous reactionsto chemotherapy drugs: the art of consultation reações cutâneas desencadeadas por drogas scrotal ulcer developed after intraperitoneal hyperthermic chemotherapy with mitomycin-c scrotal ulcer after intraperitoneal hyperthermic chemotherapy scrotal pain and ulceration post hipec: a case report adverse mucocutaneous reactions related to chemotherapeutic agents: part ii dermatomyositis-like eruption associated with hydroxyurea therapy: a premalignant condition key: cord- -qt worsl authors: nan title: abstract date: - - journal: virchows arch doi: . /s - - -z sha: doc_id: cord_uid: qt worsl nan bladder cancer has served as one of the most important sources of information about the events that underlie the development of human solid malignancies. although "field effects" that alter the entire bladder mucosa appear to initiate disease, tumors develop along two distinct biological "tracks" referred to as papillary and non-papillary that present different challenges for clinical management. more recently, whole organ mapping combined with genomic platforms have identified a novel class of candidate tumor suppressors (forerunner genes) that localize near more familiar tumor suppressors but are disrupted at an earlier stage of cancer development. these studies suggested three steps for the involvement of the model tumor suppressor locus, rb , in tumor development. in the first step, one allele of forerunner (fr) gene and rb is inactivated by deletions. in the second step, homozygous inactivation of the fr genes is accomplished by hypermethylation or mutations. the inactivation of fr genes is associated with the initial clonal expansion of preneoplastic urothelial cells. in the third step, the contiguous tumor suppressor, rb , is inactivated by a mutation, which is associated with clonal evolution into carcinoma in situ progressing to invasive cancer. furthermore, we have discovered that aggressive muscle-invasive tumors express molecular markers characteristic of a developmental process known as "epithelial-to-mesenchymal transition." emerging evidence indicates that urothelial cancers contain subpopulations of tumor-initiating cells (cancer stem cells), but the phenotypes of these cells in different tumors may be heterogeneous, raising questions about whether or not the two major subtypes of cancer share a common precursor. pathology as a medical specialty has been around for about a century and a half, even though the interest in understanding disease, the focus of pathology as an academic discipline, has inspired physicians since the dawn of mankind. understanding disease remains the primary focus of pathology. in the practice of diagnostic pathology, this knowledge, notably through its morphological expression, is applied to the diagnosis of disease through the examination of cells and tissues. relatively new in this field is the notion of pathology as 'the science behind the cure'. this phrase, coined by the pathological society of great britain and ireland, refers to a widening of the scope of pathology: 'understanding disease' continues to be applied to diagnosis and classification, but now also to conceiving of new ways to treat and of new diagnostic tools assisting the physician in choosing the appropriate treatment. targeted therapy, the target being a molecular pathway involved in the pathogenesis of the lesion, along with biomarkers that are predictive for response to treatment, are in the forefront of pathology. targeted drugs that require 'companion' diagnostics, a combination also called 'theranostics', are reshaping the practice of pathology. it is this paradigm shift in pathology that makes it one of the most exciting medical specialties of today. i would love to be a resident in pathology again. the prospects for this mother of disciplines in modern medicine have never been as bright. is this entirely new? certainly, the molecular revolution with 'high-throughput' technologies, array diagnostics such as 'mammaprintr' and 'deep sequencing' to name just a few technologies we have had to become familiar with, have had and will continue to have in the years to come a profound impact on the way we practice pathology. but guiding the surgeon's hand or the pen of the oncologist in prescribing drugs has been a primary responsibility for pathologists ever since examination of cells and tissues was being applied to the practice of medicine. prognostic factors have interested pathologists long before the onset of the molecular revolution. grading and staging of neoplastic disease based upon morphological characteristics remains the mainstay of stratification of patient groups for treatment optimization. and predictive value is not limited to molecular markers: small cell carcinoma of the lung, to name just one example, will not be treated surgically, but chemotherapy is effective, even though as a rule not to the extent that the patient can be cured. we dispose of numerous morphological parameters that are prognostic and predictive. that pathological parameters have predictive value is therefore nothing new. this has become more so with the discovery that steroid hormone receptor expression predicts the response to anti-hormonal treatment and that her /neu amplification predicts the response to her /neu antibodies in breast cancer. it has become clear that the type of c-kit mutation in a gist predicts whether or not the patient will respond to a tyrosine-kinase inhibitor (imatinib), which dose of the drug would be appropriate or which second-generation inhibitor might be used. k-ras mutations will tell the oncologist that the patient will not respond to egfr inhibitors in the form of small molecules (gefatinib) or monoclonal antibodies (cituximab). the latter is also a striking example of the limitations of many of the tools that we dispose of: the k-ras mutation status will tell us who will not respond to the therapy, but not who will. based upon detailed knowledge of the molecular characteristics of many types of cancer, pharmaceutical companies are now developing a host of new drugs and more often than not are teaming up with pathologists to develop diagnostic tests that might predict which patient groups might profit from the new drug. this should not become a hype, the type of buzz that went around the h n pandemic which in hindsight was not justified by what happened in the field. let us remain modest. first of all, the number of diseases for which the combination of new drug and predictive molecular test exists remains limited. secondly, the impact of this new and promising approach to final outcome should keep us modest. for colorectal cancer, new therapies have pro-longed survival, but not cured more patients. thirdly, expectations that we will be able to predict at the level of the individual patient what the best therapy would be and how the disease will respond or progress is an illusion. 'individualized' medicine is still based upon studies on large patient groups with as outcome parameters that with a certain level of probability will indicate what might happen. a lot remains to be studied and developed. this implies also a new role for pathology. we should team up with clinical trials, using this context to conduct biomarker studies that can be implemented in daily practice. we should collaborate with drug developers to get to the desired 'companion' diagnostic tools. for pathology, exciting times indeed. breast lesions mimicking malignancy z. varga* *switzerland cell types arising normally in the breast can occasionally exhibit peculiar overgrowth or nuclear features mimicking malignant cells and thus representing potential diagnostic pitfalls. myoepithelial cell hyperplasia can reach an extensive mass and imitate lobular neoplasia or ductal carcinoma in situ with pagetoid spread. ductal epithelial cells with apocrine phenotype can appear, with highly worrisome nuclear features making the distinction between a high-grade ductal carcinoma in situ and a banal apocrine change at times quite challenging. the evidence of a preserved myoepithelial layer is a commonly accepted morphological criterion for noninvasive processes in the breast. the distinction between adenosis, highly differentiated ductal carcinomas and cancerisation of the lobules through in situ ductal carcinoma can be easily done by decorating myoepithelial cells in immunohistochemical reactions. an important exception to this rule is, however, the benign microglandular adenosis, which completely lacks the outer myoepithelial layer. intraductal epithelial proliferations can be quite florid in their extension. the question whether they represent atypical hyperplasia resp. ductal carcinoma in situ or appear simply within the scope of a florid intraductal hyperplasia occurs often in daily diagnostic service. the use of a distinct and technically reliable diagnostic panel (e-cadherin, basal cytokeratins, hormone receptors, her immunohistochemistry and in situ hybridisation, collagen iv reaction, ki- , s- and myoepithelial markers) can clear the situation in most of these difficult cases and thus can lead to the correct diagnosis. immunohistochemical differentiation of intraductal breast lesions w. p. olszewski* *center of oncology, dept. of pathology, warsaw, poland objective: immunopathological methods, particularly immunohistochemistry (ihc), are now routinely used in all invasive breast carcinoma cases as part of the evaluation of predictive factors (er, pgr, and her ). other ihcdetected antigens are used for the determination of invasiveness (e.g. p and sma), searching of primary (e.g. gcdfp and mammaglobin) or in scientific field as surrogates of genetic subtyping (er, pgr, her , egfr, lmwck, hmwck). increasing breast cancer screening on one hand and advanced surgical methods of biopsy (e.g. core biopsy, vacuum-assisted core biopsy) on the other produce a growing number of pathology material in which pathologists must diagnose on the basis of scarce tissue. most of these cases are noninvasive. however, the spectrum of possible therapies for noninvasive lesions includes observation on one side and mastectomy with radiotherapy on the other. method: therefore, determination of the exact nature of intraductal breast lesions has to be precise and sure. it generates the use of ihc antibodies in intraductal breast lesions. results: in some cases, results of such approaches create new entities. an example of such situation is differential diagnosis between clis and dcis. in a small number of cases, the interpretation of obtained stains (e-cadherin and ck be ) adds entities like positive hybrid lesion and negative hybrid lesion. conclusion: the aim of the lecture was the presentation of increasingly used ihc antibodies in intraductal breast lesions and its correlation with histological features of usual ductal hyperplasia, atypical ductal hyperplasia, lobular neoplasia, ductal carcinoma in situ, and columnar lesions (ccc, ccc+atypia, cch, cch+atypia) . the other topic is ihc expression of surrogates of genetic subtyping in carcinoma in situ. low-grade and high-grade breast cancer pathways i. ellis* *united kingdom tnm g. cserni* *hungary background: the tnm, i.e. the tumour node metastasis classification of malignant tumours, is about years old and was last updated in . although the oncology and pathology communities are expected to use this modified version from , the breast working group and the organizing committee has considered including a brief review of the topic in keeping with the educational aspects of the intercongress meetings of the european society of pathology. method: the lecture will briefly summarize the basic concepts of the tnm classification in general and will focus on the new aspects which are of interest to pathologists dealing with breast cancer specimens. some former proposals to modify the tnm will also be discussed, including the european institute of oncology proposal to abolish the present categories and replace them with coded prognostic data reporting and the replacement of the nodal categories based on the number of involved lymph nodes by categories based on the lymph node ratio (proportion of involved and examined nodes). results: na. conclusion: the tnm has been criticized for not providing enough prognostic information to guide treatment. however, it must be kept in mind that the tnm was not devised for making treatment decisions solely on the basis of the information it provides but for reporting the anatomic extent of disease in a categorical format. tnm still fulfils this aim. no system is perfect, and tnm is not an exception to this. should we use it, let us use it as correctly and uniformly as possible. wednesday, september , . - . , aula duża b gastrointestinal stromal tumours results: gist is defined as kit or pdgfra-driven mesenchymal tumor of the gi-tract, with a characteristic set of histologic features (spindle cell or epithelioid), and generally by immunohistochemical positivity for kit (cd ). dog /ano is a helpful additional marker for the positive identification of gist. current prognostication is based on mitotic activity, expressed as mitotic figures per high-power fields in an area of mm and on tumor size. different criteria are applied for gastric and intestinal gists because the latter, even with the same parameters, have a more malignant behavior. in the differential diagnosis of gist, one has to consider the following facts: wide histologic variation (especially in gastric gists), the fact that gists are the most common mesenchymal tumor in the gi tract and whole abdomen, and occurrence of gists virtually anywhere in the abdomen and rarely in distant peripheral metastatic sites. tumors that have to be considered in the differential diagnosis especially include true smooth muscle tumors, glomus tumor, gastrointestinal schwannoma, clear cell sarcoma, synovial sarcoma, desmoid, inflammatory fibroid polyp, inflammatory myofibroblastic tumor, and the newly described plexiform fibromyxoma and gastroblastoma. conclusion: detailed histologic examination supported by immunohistochemistry and kit/pdgfra mutation analysis will yield optimal diagnostic accuracy. clinical significance of kit and pdgfra mutations in gastrointestinal stromal tumours, inflammatory fibroid polyps and mucosal malignant melanomas j. lasota* *usa gists are the most common mesenchymal neoplasms of the gastrointestinal tract and represent a morphological and biological continuum from small, microscopically detected benign tumors to large sarcomas. kit or platelet-derived growth factor receptor α (pdgfra) oncogenic mutations are a typical molecular feature of gist. kit and pdgfra genes map to chromosome q and encode highly homologous transmembrane glycoproteins. activation of kit regulates important cell functions, including proliferation, apoptosis, chemotaxis and adhesion. imatinib mesylate that specifically inhibits abl, kit, and pdgfra receptor tyrosine kinases has been successfully used in the treatment of clinically advanced, unresectable, and metastatic gists. majority of kit exon mutants respond well to imatinib, while kit exon mutants are less sensitive to imatinib and require more aggressive treatment. also, tumors with the pdgfra asp val substitution, which corresponds to imatinib-resistant kit asp val mutation reported in human mastocytosis, are resistant to imatinib. although many patients benefit from imatinib treatment, resistance often develops due to secondary kit or pdgfra mutations or kit locus amplification. sunitinib mesylate, a multi-targeted inhibitor of kit, pdgfrs, vegfrs, flt , and ret receptor tyrosine kinases and other kinase inhibitors have been used for the treatment of imatinib-resistant gists. the type of secondary kit mutation can indicate response to sunitinib treatment. kit mutations were identified in mucosal mms and pdgfra mutations in gastric and intestinal ifps. although the presence of kit mutation does not necessarily correlate with kit expression in mm, an inhibition of kit receptor tyrosine kinase might still be beneficial in the treatment of selected cases. the histopathology of primary non-scarring and scarring alopecias may be complex. the reason for this is that often, the scalp biopsy provided is inadequate, and the clinical history and pattern of the alopecia are not provided to the dermatopathologist. increased diagnostic yield may be achieved by the combined use of transverse and vertical sections. this requires good communication between the dermatologist performing the biopsies, the dermatopathology laboratory and the dermatopathologist. common forms of scarring alopecias include the lymphocytic, (discoid lupus erythematosus, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade of brocq), the neutrophilic, (folliculitis decalvans, dissecting folliculitis), and the mixed, (acne keloidalis) entities. among the non-scarring alopecias are androgenic alopecia, telogen effluvium, alopecia areata, trichotillomania and traction alopecia. in all cases of primary alopecia, a multi-team approach involving the dermatologist for adequate tissue sampling, the laboratory for appropriate laboratory processing and the dermatopathologist, together with pertinent clinical information affords the best opportunity of arriving at the correct diagnosis. graft versus host disease: an update d. massi* *university of florence, dept. of critical care medicine, italy our current understanding of histopathological features of cutaneous graft versus host disease (gvhd) is largely based on experience gained during decades of ablative hsct, in which day was regarded as the temporal cutoff for the separation of acute vs. chronic gvhd, and traditionally, acute and chronic gvhd were considered to be distinct histopathological entities. acute gvhd in the skin has been generally described as an interface dermatitis, with vacuolar basal alteration, dyskeratotic (apoptotic) keratinocytes in the epidermis and/or adnexal structures, scant dermal lymphoid infiltrate, and lymphocytic satellitosis. in contrast, chronic gvhd has commonly been reported as either lichenoid or sclerodermoid gvhd, characterized by homogenization of dermal collagen bundles, with little or no epidermal involvement. at variance with this dichotomic picture, histology of cutaneous gvhd following reduced intensity conditioning regimens is protean, displaying a variable constellation of histopathological alterations. these changes frequently blur the distinction between clear-cut clinical gvhd categories, as known in the classical ablative hsct setting. sampling errors and other technical issues may occur and may significantly affect the number of false negative cases. the utility of skin biopsies varies according to the pathologist's experience and to the prevalence of gvhd. clinicians' overall perception is that undertreatment of gvhd is much worse than overtreatment of patients without gvhd. therefore, early immunosuppressive therapy in patients with a skin eruption often precedes the results of the histopathological analysis. the pathogenesis and pathology of gvhd will be illustrated by elucidating the selective epithelial targets in the afferent stage and cellular response in the efferent stages. method: our practice in a large cancer center sees drug eruptions in the context of cancer treatment and must often be evaluated within a differential diagnosis with graft versus host disease on our bone marrow transplant service. results: with the advent of specific, targeted therapy for cancer, a new spectrum of interesting and unusual drug eruptions has emerged related to the mechanism of action of these agents. conclusion: this presentation will focus on the unique cutaneous effects arising in association with targeted therapy for cancer. wednesday, september , . - . , aula Średnia b background: the adult onset of nephrotic syndrome has been reported to be associated with underlying cancer in about % of cases. it is believed that the glomerular injury in many instances is due to the deposition of immune complexes in the glomerular capillaries. on the other hand, the course of illness in many cancer patients is complicated by infections, which may also be involved in the pathogenesis of glomerular injury. the malignancy is usually found simultaneously with, shortly before, or within a short time after the diagnosis of glomerulopathy. the glomerular lesion of paraneoplastic nephrotic syndrome usually presents as membranous nephropathy in patients with solid tumors, particularly adenocarcinomas of the lung and gastrointestinal tract. minimal change disease is strongly associated with hodgkin's lymphoma, and the most common lesions observed in patients with chronic lymphocytic leukemia are membranoproliferative glomerulopathy and membranous nephropathy. extracapillary crescentic glomerulopathy, iga nephropathy and focal segmental glomerulosclerosis are rarely associated with neoplasia. method: we present six cases of nephropathies associated with malignancies: lung, gastric and colon cancer, as well as hodgkin's lymphoma and chronic lymphocytic leukemia. all patients were over the age of and were presenting nephrotic syndrome. results: membranous glomerulopathy, minimal change disease and membranoproliferative glomerulopathy were established on the basis of light microscopy, immunofluorescence and electron microscopy. the renal lesions in paraneoplastic nephropathies did not differ from idiopathic forms of glomerulopathies. the clinical and morphologic spectrum of plasma cell dyscrasia continues to expand. while in the most advanced stage of this disease patients are diagnosed with overt multiple myeloma, at the opposite end of the spectrum, mgus is more typical. not infrequently, the underlying disease is clinically silent or can be associated with renal symptoms that prompt further investigation and thus underscore the role of renal pathologists in the early detection of the underlying process. while light chain cast nephropathy affecting distal tubules and light chain amyloid or non-amyloidotic lcdd are well recognized, in recent years, attention has focussed on the pathology affecting the proximal tubules and interstitium. proximal tubulopathy associated with an underlying plasma cell dyscrasia may be very subtle and associated with the formation of crystals or only with light chain restriction detectable in the lysomes within proximal tubules. interstitial nephritis may be associated with a rather nonspecific morphology, and only an enhanced index of suspicion may lead to the discovery of an associated light chain restriction. thus, renal pathologists are in an advantageous position to diagnose the underlying process at an early stage. therefore, it is critical to perform a full investigation of the kidney biopsy, including immunofluorescence studies that employ testing for immunoglobulin light chains, as well as electron microscopy. renal pathologists should be alerted particularly by biopsies that yield seemingly nonspecific or non-diagnostic results. investigations with congo red stain, careful evaluation of immunofluorescence studies, and electron microscopic analysis of organized and related deposits are necessary. non-hodgkin lymphomas and ptld in renal biopsies a. c. feller* *germany cytostatic drug and radiation-associated renal lesions h. regele* *austria malignant tumors might impair renal function in multiple ways. in addition to a direct impact of the tumor or its derivatives like light chains in the case of multiple myeloma, renal injury might also be a consequence of therapeutic interventions. certain cytostatic drugs (especially platin-based compounds), but also irradiation, are long known to cause renal tissue injury. the damage might affect both the tubulointerstitial space and the vasculature. in addition, it was shown that recently introduced biological agents might lead to additional patterns of drug-induced injury. blocking the action of vegf in order to interfere with tumor-induced neoangiogenesis might for example cause renal thrombotic microangiopathy. in my talk, i will discuss the histological patterns of injury caused by the different treatment modalities and the underlying pathogenic mechanisms. the knowledge of these mechanisms might help prevent renal damage. background: the morphological presentation of lung problems in infants and children is not always pathognomonic for a specific diagnosis. basic patterns are not always easily recognized and may be different from the adult situation, even with the same classifying diagnosis. method: as lung neoplasms are seldom seen in children, this overview will focus on non-neoplastic lung disease. results: a main category is interstitial lung disease. the main adult patterns of interstitial disease can also be observed in children, although uip, dip and nsip are rather rare and not always with similar aetiology (e.g. desquamative interstitial pneumonia, associated with smoking in adults). the distribution of the interstitial changes is in those cases similar to adults, but morphological presentation may be different because of a different lung structure. some interstitial patterns are specific for childhood: for example, chronic pneumonitis of infancy, pulmonary interstitial glycogenosis (formerly cellular interstitial pneumonitis) and neuroendocrine cell hyperplasia of infancy, but even so, these are not always easy to discern form the other patterns. if a (wedge) lung biopsy is taken at late stage or only from the most severe abnormalities, a characteristic pattern may be obscured by nonspecific common final pathway changes like fibrosis. conclusion: all diffuse lung diseases in infancy can be caused by many etiologic factors. this means that although there are several hallmarks that can aid in making a proper pathological diagnosis, similar as in adults, proper clinical and radiological information is essential. objective: tobacco and cigarettes are implicated in multisystemic carcinogenesis due to carcinogenic components that induce maintained inflammation, endocrine deregulation and genetic alterations in continuum. as ambience influence acts through a multifactorial behaviour gathering smoking, obesity and dietary mistakes, being sedentary, alcoholism, sexual promiscuity, toxic addition and general pollution, the isolated influence of smoking is reinforced. smoking-related non-tumoral lung diseases comprise copd, rb-ild, dip, acif/ibip, hx (langerhans cell histiocytosis), sarcoidosis (not consistent), eosinophilic lung, constrictive and lymphocytic bronchiolitis, emphysema together with sub-pleural and interstitial fibrosis uip-like or nsip-like, as well as possible combinations of all these diseases and patterns. smoking also increases or exacerbates infections (tp and other bacterial pneumonias, varicella pneumonia and influenza), pulmonary hemorrhage and pneumothorax and vascular walls fibrosis. conclusion: as smoking-related interstitial lung disease (srild) has been proposed to encompass clinical and radiological coordination, it means that molecular pathology achieves its role to define therapy as it is being tried in cancer. despite observed morphology, it is possible to localize the defence response along the bronchial-bronchiolar-alveolar pathway as epithelial and mesenchymal cells develop particular ways of adaptation, either by emt and met. as inflammation stands through fibroblasts, cellular mtor and macrophage activation, also epithelial hyperplasia and metaplasia, install both at bronchial and pulmonary stem cells pool. smoking-related lung diseases are not consistent with a spectrum but rather with expertise to report delicate inflammatory changes in morphology that diverge to interstitial (and vascular) incapacities and/or to pre-neoplastic epithelial lesions and bronchial-pulmonary carcinoma. pitfalls in interstitial pneumonias h. popper* *medical university of graz, institute of pathology, austria interstitial pneumonias can be classified into uip, dip, nsip, op, and dad. whereas dad as an acute interstitial pneumonia is easily separated and diagnosed, due to the presence of alveolar damage and hyaline membranes, the other entities might cause problems in diagnosing. the most important distinction is between uip and the other entities because uip is a rapid progressive and deteriorating disease with a high mortality rate. usual interstitial pneumonia is histologically characterized by the presence of fibroblastic foci, cystic changes called honeycombing, areas of fibrosis and scars, and a temporal heterogeneity, which results in areas of early inflammatory changes, late changes, and also areas of uninvolved lung parenchyma. the disease usually starts from the lung periphery in a patchy distribution pattern. the lower lobes are usually more affected than the upper lobes. the disease starts with tiny lesions where the surface epithelium is destroyed. underneath myofibroblasts are proliferating and the stroma is changed into a myxoid stroma composed of acidic mucopolysaccharides. these lesions are called fibroblastic focus. this repair process is accompanied by a regeneration of pneumocytes, which usually undergo metaplastic changes (bronchiolization, cuboidal metaplasia, stem cell proliferation). finally, this process results in fibrosis. several fibrotic areas might finally confluent into a scar tissue. fibroblastic foci are not only seen in alveolar septa but also in bronchioles and small bronchi. scarring in these airways results in the obstruction of the airways, and the periphery of these airways undergoes a cystic dilation, accompanied by metaplasia of the epithelium; again, bronchiolization and metaplasia, even squamous metaplasia, can occur. mucus produced by the epithelium cannot escape, and therefore, the cystic spaces increase in size, being finally visible at ct magnification. these cystic air spaces form the honeycomb lesions. in uip, fibroblastic foci can be seen in the different stages of development: early stages with lots of myxoid matrix, immature collagen, and many proliferating myofibroblasts and old stages with lots of mature collagen and fibrocytes. honeycomb lesions may present in a florid stage where some fibroblastic foci can be seen within the cysts, or older lesions with lots of mucus, or old lesions with secondary bacterial pneumonia overlying uip. also, the scars can be old, devoid of inflammatory infiltrates, or younger with scattered fibrocytes and lymphocytes. this together forms the temporal heterogeneity of uip. fibroblastic foci are often used as the dominant and even sole diagnostic criterion for the diagnosis of uip. this can result in an incorrect diagnosis since other interstitial diseases can also present with fibroblastic foci. in the presentation, we will review several cases presenting with fibroblastic foci, which can closely mimic and might give rise to an incorrect diagnosis of uip. pitfalls in drug-induced lung pathology b. murer* *italy the role of pathologists in translational research for patients and industry m. dietel* *universitätsmedizin charité, berlin, germany background: due to continuous technical developments and new insights into the complexity of many diseases, e.g. cancer, molecular pathology is rapidly growing gaining center stage in the clinical management of tumors and pharmaceutical development of new anti-cancer drugs. activated signaling components are the targets for the newly developed inhibitors, e.g. small molecules (gefitinib, erlotinib) and therapeutic antibodies (panitumumab, cetuximab). however, the application of the compounds in clinical trials has revealed promising results only when predictive procedures have been available for determining which patients will benefit from targeting therapy, so-called eligibility or predictive tests, e.g. her in breast cancer, kras and egfr mutations in colorectal cancer and non-small cell lung cancer. for the pharmaceutic industry, predictive tissue-based assays are of increasing importance in the development of new targeted drugs. fda and emea stressed this issue several times during the process of approval, and pathology based analyses will become an essential factor in drug development. conclusion: for pathology, the situation to become a partner in the clinical decision, which drug shall be given to the patient and which assay can be made available for a new, is a chance and a challenge in one. the issues to be solved are: ( ) morphology, in particular immunohistochemistry and in situ hybridization, must become measurable, e.g. by virtual microscopy. ( ) the molecular assays must be done absolutely reliably and be reproducible. ( ) quality control, i.e. ring trials/round robin tests, must be passed by all active labs. if these challenges (and some others) are met, molecular pathology is facing an excellent development. the role of biobanking and translational research for the pathologist f. carneiro* *ipatimup, porto, portugal among biobanking initiatives, tumour banks play a pivotal role in biomedical research. the general aim of a tumour bank is to acquire neoplastic and control non-neoplastic samples in standardized conditions for research (basic, clinical or translational) . a tumour bank is a vital new resource for cancer research providing high-quality, wellcharacterized tissue. it is possible for pathologists to collect fresh tissue prospectively during their routine dissection procedures. in this way, the specimens can be optimally sampled and stored for both diagnosis and research purposes. ideally, specimens are sampled immediately after surgery, prior to fixation, to ensure optimal preservation of proteins and nucleic acids. retrospective collection of tumour tissue for study and banking purposes is feasible also because in most countries, pathology laboratories have been legally obliged to file, for at least some years, the formalin-fixed and paraffin-embedded samples that were analyzed. over the last decade, tumour banks acquired a pivotal role in translational research in the field of oncology, providing tools for the evaluation of new predictive factors; evaluation of the value of a known target in a new entity; search for new therapeutic targets; validation of new diagnostic markers; and implementation of new diagnostic procedures, namely development of tissue-based diagnostic tests for guidance of therapy with new drugs introduced in clinical practice. in this scenario, it is a priority to emphasize the central role that pathologists play in translational research, specifically in tumor banking, by the establishment of a bridge between clinicians and basic researchers. limits and perspectives for standardization of tissue processing g. bussolati* *italy the paper by pupo and colleagues is a well-conducted study on the role of the gasotransmitter hydrogen sulphide in angiogenesis. the increased effect of hydrogen sulphide in tumor-derived endothelial cells and its possible effect as a vegf second messenger are of interest in the field of tumor angiogenesis. criticisms: (a) it would be important to show the specificity and non-toxicity of hydrogen sulphide synthesis inhibitor on endothelial cells. ( ) experiments using the cystathionine lyase inhibitor alone on tec proliferation and cytotoxicity are required. ( ) standardization and controls of methods for molecular analysis in archive tissues g. hoefler* *medical university of graz, institute of pathology, austria background: formalin-fixed paraffin-embedded (ffpe) samples represent the vast majority of tissue specimens available from tissue archives, available routine diagnostics, as well as research purposes. these tissues vary among institutions with respect to pre-fixation time, formalin fixation time, concentration and buffer systems used. therefore, it is of utmost importance to standardize the methods for molecular analyses to obtain consistent and comparable results. method: the first and maybe the most important step is the isolation of nucleic acids (dna, rna) from ffpe samples. in a recent multi-centric study performed by european laboratories of the impacts group, the results obtained by different laboratories varied significantly, even when the same commercial kit was used. the dna extraction protocols used by the laboratories ranged from homemade protocols with and without purification steps to commercially available kits. the extractions were performed using the same ffpe specimens. results: for array applications or tests that require accurately determined dna input, silica-based adsorption columns for dna recovery are recommended. for rna extractions, the best results were obtained for chromatography column-based commercial kits, with respect to quantity and quality. quality testing resulted in the successful amplification of -to -bp pcr products from most tissues. modifications of the protocol, especially with regard to proteinase-k digestion, led to significant improvements, also for the performance of commercial kits. the results emphasize the need for standardization and control of methods for molecular analysis in archive tissues to allow the generation of valid and comparable results in both diagnostic and in research settings. approaches to the development of a european network of archive tissues g. stanta* *university of trieste, a.c.a.d.e.m., italy ffpe tissues taken from patients are stored, sometimes for a very long time, in the pathology archives. with this material, it is possible to do very important translational research. any strategy is possible, such as that of large number analysis or rare entity collections. there is the necessity to transform our pathology biorepositories into a biobanking network. this can be done through a european organization that could be developed within the esp and starting from the "impacts" groups, which gained a large experience in molecular analysis validation and standardization of this kind of tissues. a european archive tissue biobank network depends on the willingness of the pathologists to participate, considering that this can significantly improve the diffusion of molecular methods, translational research and consequently acceleration of clinical application of molecular methods among pathologists. this can be done by a voluntary and collaborative participation of pathologists in specific projects, as scientific collaborators. the pathology archives will always be clinical biorepositories, and their function is going to change into a biobank function after accepting participation in a specific project, with the anonymization of the personal data of the patients. the networking system is based on low-cost activities with an easy governance and management of the biobanking system and with guarantees of protection of human material and data. qualification, education and training will be implemented by the network organization and with the collaboration of the esp. with cisplatin mg/m every weeks for four cycles, followed by mastectomy and then conventional chemotherapy. surgery occurred weeks after the final dose of cisplatin. the excised breast tissue and lymph nodes were examined for the presence of residual disease. pathologic complete response was determined by a review of surgical specimens. results: forty patients were enrolled in the study. twentyfour patients had tumors of > cm and patients had positive lymph nodes at diagnosis. thirty-seven patients completed four cycles of cisplatin and three patients completed two cycles. clinical complete response was observed in patients ( %). pathologic complete response was observed in patients ( %). conclusion: platinum-based chemotherapy is effective in a high proportion of patients with brca -associated breast cancers. clinical trials are warranted to determine the optimum treatment for this subgroup of breast cancer patients. clinical outcome of ovarian cancer in respect to polymorphism of low-penetrance genes e. grzybowska*, k. tcza, j. pamua-piat, s. jdru, e. telka, z. kosza, b. zema *centre of oncology-msc memoria, dept. of molecular biology, gliwice, poland objective: we wanted to analyze the influence of modifying genetic factors on the risk of brca(+) and brca(−) breast and ovary cancers and on clinical parameters as the age of onset and survival. method: the study includes three hundred forty-eight anonymous healthy women (control group), persons with ovary cancer, persons with breast and ovary cancer (case group). the patients under study developed breast cancer prior to ovary cancer. rflp and asa pcr were used to analyze mutations in brca genes and polymorphisms in pgr, mdr and tp genes. results: the presence of allele t of pgr significantly decreased the risk of second malignancy (breast cancer; or= . , p= . ). heterozygote ct of mdr gene c t and genotypes ag and at of g t/a were at lower risk of developing ovary cancer. genotype ct of c t polymorphism had protective effect against developing the second malignancy, while allele tt increased the risk of breast cancer. carriers of allele c for tp arg pro polymorphism had a significantly lower risk of developing ovarian cancer (or= . , p= . ) the best survival was found for patients carrying germline mutation in brca gene; the worst survival was observed for the group of patients with breast and ovary cancer and without germline mutation in brca gene. alleles of tp arg pro significantly modified the survival of the group of patients who were diagnosed with breast cancer prior to ovarian carcinoma. the worst survival was connected with rare allele c. conclusion: polymorphic variants of pgr, mdr and tp genes under study modified more the clinical course and the risk of second malignancy than the risk of developing ovary cancer alone. dna testing for high risk of cancers b. górski* *poland genetics of colorectal cancers r. scott* *discipline of medical genetics, school of biomedical sciences, newcastle, australia the study of rare inherited conditions with high penetrance that predispose to colorectal cancer has significantly advanced our knowledge of the genetic basis of disease and represents a paradigm that has served to better understand the molecular mechanisms that underlie the development of disease in persons who have no apparent genetic predisposition. inherited predispositions to colorectal cancer can be divided into essentially two groups: those that present with a premalignant phenotype (such as familial adenomatous polyposis (fap) and the hamartomatous polyposis syndromes) and those like hereditary non-polyposis colorectal cancer, lynch syndrome and muir-torre syndrome. for predispositions where the underlying genetic basis of the disease is known, much has been learned about disease penetrance and the expected spectrum of disease as increasing numbers of mutation carriers are characterized. this has lead to the reclassification of some defined syndromes as a result of the inherited predisposition being identical. improved knowledge about disease penetrance has also resulted in a number of questions being raised with respect to what factors influence disease expression in patients known to harbour a mutation in a colorectal cancer susceptibility gene. of particular interest are additional genetic factors (termed modifier genes) that have been correlated with disease manifestation. more recently, the focus of attention has shifted from familial aggregations of disease where there is a well-defined inherited component to population studies aimed at identifying common low-penetrance disease alleles that are associated with small affect sizes. these studies are significant not only because they are identifying genetic factors associated with colorectal cancer risk but also potential modifier genes that are important in modulating disease expression in persons who harbour a genetic predisposition. eosinophil functions have been associated for a long time with effector activity in adaptive immune responses during parasitic infections and inflammatory processes in allergic manifestations as well as in mucosal responses. the production by eosinophils of a vast array of cytokines as well as their expression of innate receptors and mediators confer to eosinophils a unique contribution both in inflammatory and adaptive responses but also in immunoregulation and innate immunity. eosinophils are customary inhabitants of the gastrointestinal tract, except for the oesophagus. beneficial function of intestinal eosinophils was their ability to defend host against helminths. however, eosinophil accumulation in the gastrointestinal tract is a common feature of numerous gastrointestinal disorders, including inflammatory bowel diseases, intestinal vasculitis, gastroesophageal reflux disease and food allergy. primary eosinophilic gastrointestinal disorders, defined as disorders that selectively affect the gastrointestinal tract with eosinophil-rich inflammation of unknown etiology, include eosinophilic esophagitis, eosinophilic gastroenteritis and eosinophilic colitis and are occurring with increasing frequency. decrease in the rate of parasitic infections in the developed world is associated with a rise in atopic/ allergic disorders and increased hypersensitivity responses to allergens and may represent a driving factor towards the recruitment and activation of gut eosinophils in those disorders. although the pathogenesis of those disorders is still poorly understood, new findings on gastrointestinal eosinophil proliferation and migration mechanisms involving il- and eotaxins provide a rationale for specific disease therapy. the present review will summarize knowledge on the physiology of gut eosinophils and will illustrate some aspects of eosinophilic disorders of the gastrointestinal tract. gastro-oesophageal reflux disease (gerd) and eosinophilic oesophagitis (ee) are the two main non-tumoral diseases involving the oesophagus and can develop in both children and adults. the former, the more frequent, is present in up to % of the western population. it is the consequence of a massive flow of gastric contents back into the oesophagus, leading to symptoms or organ damage. eosinophilic oesophagitis, first reported in and defined as a specific clinicopathological entity in , is characterized by eosinophilic infiltration of the oesophagus. its cause or causes are unknown despite its frequent association with an allergic setting. in , a consensus meeting of the american gastroenterological association institute and the north american society for paediatric gastroenterology, hepatology and nutrition recommended diagnostic criteria for ee. despite this increased knowledge of both pathologies, gerd and ee present considerable clinical and pathological overlap. their distinction remains, however, crucial as their clinical outcome and treatment modalities are quite different. the pathologist has to be aware that the diagnosis cannot be based solely on pathological features. the aim of this presentation was to provide pathologist both clinical and histological diagnostic clues in order to propose the most accurate diagnosis and treatment. eosinophilic enterocolitis a. driessen* *the netherlands eosinophilic gastro-enterocolitis, consisting of eosinophilic gastroenteritis (eg) and eosinophilic colitis (ec), belongs to eosinophilic gastrointestinal disorders whose diagnosis is based on gastrointestinal symptoms, an eosinophilic infiltration in the gut and the exclusion of secondary causes of eosinophilia (collins mh , furuta gt , shifflet a . eg and ec are both rare entities. eg is a predominantly benign disease occurring at any age (peak incidence, third-fifth decade). it may affect any part of the gastrointestinal tract, most commonly the stomach ( - %) and small intestine ( - %). ec is more uncommon, involving the colon and less frequently the rectum. symptoms vary in function of the affected layer of the wall: mucosa ( - %): abdominal pain, diarrhea; muscular layer ( - %): intestinal obstruction; serosa ( - %): ascites. the ethiopathogenesis is not fully clear, but is sometimes related to a food allergy. diagnosis requires a panendoscopy with biopsy. histologic examination may, however, be hampered by the patchy distribution of the mucosal inflammation and the presence of a normal mucosa in association with muscular/serosal involvement. in this case, a full-thickness biopsy may be necessary for diagnosis. microscopic features are the presence of numerous eosinophils in the lamina propria, extending into the epithelium (crypt abscesses) and the submucosa, associated with architectural abnormalities. in mural or serosal eg/ec, eosinophils are predominantly situated in the muscular or peritoneal layer. differential diagnosis includes other disorders with eosinophilia, e.g. inflammatory bowel disease, celiac disease, parasitic infection, vasculitis. several treatment modalities have been described in literature, such as restriction diets, corticosteroids or antihistamines. surgery is restricted to the resection of stenosed segments in mural enterocolitis. systemic eosinophilic disorders and the gi tract a. hoorens* *uz brussel, dept. of pathology, belgium secondary eosinophilic disorders, including infectious, inflammatory, hypersensitivity and neoplastic illnesses, always require exclusion before making the diagnosis of eosinophilic oesophagitis/gastroenteritis/colitis, particularly in case of peripheral blood eosinophilia. parasite infections are well known to present with eosinophilia of the gastrointestinal mucosa. a drug-induced aetiology should also always be considered. gastrointestinal eosinophils may be a feature of connective tissue disease, especially scleroderma, and can accompany vasculitis in polyarteritis nodosa and churg-strauss syndrome. with very pronounced peripheral eosinophilia, hypereosinophilic syndrome (hes) with gastrointestinal involvement, clonal eosinophilia and lymphocytic variant hypereosinophilia should be considered. hes is defined as eosinophilia (≥ . × /l) for at least months, no known cause of eosinophilia, and evidence of organ involvement. the gastrointestinal tract is affected in %. when only the digestive tract is involved, it may prove difficult to distinguish hes and eosinophilic gastroenteritis. involvement of the intestinal tract in hes has been associated with limited prognosis and, in some, a fatal outcome. eosinophilic infiltration of the gi tract in hes should be distinguished from eosinophilic infiltration of the gi tract in lymphocytic variant hypereosinophilia where eosinophilia is associated with phenotypically abnormal and/or clonal t lymphocytes. clonal eosinophilia is characterized by neo-plastic proliferation of eosinophils as part of an underlying myeloid malignancy and can accompany any one of the myeloid malignancies. two distinct subcategories of clonal eosinophilia are recognized: chronic eosinophilic leukaemia, nos and myeloid/lymphoid neoplasms with abnormalities involving pdgfra/pdgfrb or fgfr . accurate diagnosis of all these conditions requires the correlation of endoscopic and biopsy findings together with a careful clinical examination. gi eosinophilia in paediatrics m. walker* *united kingdom eosinophils are powerful innate immune cells home to the gastrointestinal tract and play a major role in both host immunity to luminal pathogens and maintenance of homeostasis of intestinal epithelium in the normal gastrointestinal tract (git) . normal numbers at different git sites are defined in children. however, if in excess, eosinophils may play a key role in the pathogenesis of disease of the git, including primary eosinophilic gastrointestinal disease (egids). data from the world wide web-based registry of egids show that these have a strong genetic and allergic component, % having coexistent atopic disease, % food sensitisation and % with a family member with similar disorders. the most studied egid in children is eosinophilic oesophagitis; symptoms include feeding intolerance and gerd symptoms. endoscopy shows a characteristic linear furrowing, and histological features include ≥ eosinophils/ hpf (peak count). there is a male preponderance and an allergic and genetic component. around - % of children are affected by food allergy, most commonly cow's milk allergy and egg and peanut allergies which may manifest as eosinophil-induced gi disorders. eosinophilic gastroenteritis is manifest as allergic eosinophilic gastroenteritis, allergic proctocolitis and food protein-induced enterocolitis syndrome (fpies) . eosinophilia is also seen in helminth infection, inflammatory bowel disease, coeliac disease and graft vs. host disease where eosinophil density can correlate with disease severity. recent work has implicated duodenal eosinophilia in functional conditions, particularly paediatric dyspepsia, with success in treatment aimed at the eosinophilmast cell axis. parasites and eosinophils in the gi tract g. de hertogh* *uz leuven, dept. of pathology, belgium background: human endoparasites belong to four groups: the protozoa and the nematodes, cestodes and trematodes. about protozoan and helminthic species can cause gastrointestinal (gi) pathology. eosinophils are frequently associated with the lesions present in these conditions. method: pubmed-based review of the associations between gi parasites and eosinophils. results: protozoan parasites may be located on the mucosal surface or in the bowel wall in an intra-or extracellular position. eosinophils can be increased in blood and tissues, notably with isospora belli. dientamoeba fragilis infection may even masquerade as allergic colitis. invasive amoebiasis (entamoeba histolytica) on the contrary has been associated with a decreased number of tissue eosinophils. worms may be observed in the egg, larval or adult stage buried in or attached to the bowel wall. helminthic infections are classically associated with blood and tissue eosinophilia, which can be limited to the place of attachment of the organisms. the number of eosinophils in biopsies can be very high and even suggestive of primary eosinophilic enteritis, e.g. in trichuriasis, anisakiasis and enterobiasis, and with ancylostoma caninum and angiostrongylus infections. alternatively, chronic inflammation with eosinophilia may be confused with ulcerative colitis or crohn's disease, the latter especially if granulomas are present (as with schistosoma mansoni infection and more rarely in strongyloidiasis, anisakiasis and enterobiasis). conclusion: eosinophils are involved in the defense against many protozoan and helminthic gi parasites. the resulting histological picture may at times be confused with other disorders such as primary eosinophilic enteritis and the idiopathic chronic inflammatory bowel diseases. the diagnosis of invasive melanoma is straightforward in most cases. it is based on the recognition of a malignant junctional, in situ component in addition to an invasive dermal component. classical diagnostic criteria are established mainly for superficial spreading melanoma, being the most common melanoma subtype. the morphological spectrum of melanoma is, however, wide, and distinction from both melanocytic naevi as well as non-melanocytic tumours may be challenging in individual cases. in particular, some benign melanocytic naevi may show concerning histological features overlapping with those of melanoma, resulting in significant potential for overdiagnosis. melanocytic lesions notoriously difficult to separate from melanoma include dysplastic naevi, naevi of special sites, halo naevi, recurrent naevi, mitotically active naevi and deep penetrating as well as blue naevi. nonmelanocytic tumours may mimic melanoma by recapitulating a junctional in situ as well as a dermal invasive component showing similar cytological and architectural features, including epithelioid, spindle cell, small cell or desmoplastic differentiation, in addition to immunohistochemical expression of the so-called melanoma markers such as s , hmb- and melan a. these tumours may be of epithelial, haematolymphoid as well as mesenchymal lineage ranging from benign to outright malignant. awareness of the critical entities in the differential diagnosis of melanoma and their differentiating features and diagnostic clues is important to avoid misdiagnosis, especially as the treatment modalities and clinical behaviours may differ significantly. a. batistatou* *greece molecular studies of melanocytic lesions are necessary in order to identify additional prognostic and predictive biomarkers and establish the pathways of relevance for targeted therapy. the advent of biotechnology has also enabled the utilization of molecular testing as a diagnostic adjunct in the microscopic evaluation of difficult melanocytic lesions. Τhe molecular multistep process of melano-magenesis has been correlated to the clark model for melanoma development. the first step of melanocytic hyperplasia and nevus formation has been linked to constitutive activation of the erk-mapk pathway as a result of somatic mutations of braf or n-ras (or h-ras or gnaq). the development of cytologic atypia (dysplastic nevi) is related to alterations in cell growth, apoptosis and dna repair; inactivation of cdkn a; and pten pathways and tp . radial growth phase has been associated with decreased differentiation and deregulated expression of mitf, as well as deficiency in the p ink a-rb pathway. alterations in cell adhesion, such as reduction/loss of e-cadherin, increase of n-cadherin, αvβ integrin, mmp- and increased expression of osteopontin are associated with the development of radial growth phase and metastatic melanoma. alternatively, some melanomas (including acral and mucosal) arise de novo and harbor mutations/ amplifications of kit and amplifications of cyclin d or cdk genes. other less frequent, pathogenetic pathways have also been proposed. in the near future, distinct molecular signatures of gene expression may be useful in identifying melanocytic lesions as melanomas or nevi. for melanomas, refined classification systems based on molecular analysis could provide more accurate prognostic markers and enable targeted therapy. novel targeted therapies in melanoma and the pathologists' role in therapeutic selection a. lazar* *usa background: when melanoma metastasizes, it is a deadly disease with unsatisfactory treatment options. it has become clear that melanoma is composed of multiple genetic subsets of disease that have different oncogene additions and thus distinct therapeutic vulnerabilities. method: many clinical trials and application of targeted therapies outside of the trial setting depend on melanoma subtype and the genetic features of an individual case. pathologists are absolutely critical in this area of testing and in therapeutic selection to enable precision medicine. results: targeted therapies based on the molecular genetic features of individual melanoma cases is beginning to drive targeted therapy selection and can greatly enrich the rate of response to particular treatments. conclusion: this lecture will focus on the genetic features of melanoma currently most relevant to treatment and how testing drives therapeutic selection. in the very near future, such testing will be employed for treatment in virtually all cases of metastatic melanoma. nephron number as determined during nephrogenesis may be one determinant of renal disease and hypertension in later life. various genetic and epigenetic factors, but also maternal or environmental causes, are known to influence nephron number. an involvement of the kidney in the development of hypertension has been postulated for a long time and supported by experimental studies in rats and sheep. brenner and colleagues supposed a direct association between nephron number and blood pressure in humans. their so-called brenner hypothesis postulated that any reduction in nephron endowment leads to hyperfiltration of the remaining glomeruli, followed by glomerular enlargement with glomerular and then systemic hypertension, resulting in glomerulosclerosis, thereby establishing a vitious circle. in line with this theory, an association of low nephron number and development of hypertension was shown in different animal models as well as in two autopsy studies in humans. keller et al. found in caucasian patients with essential hypertension a significantly lower number of glomeruli per kidney than in matched controls. in parallel, mean glomerular volume was more than twice as high in hypertensive patients as in normotensive control patients, indicating compensatory glomerular enlargement. these results were confirmed in a caucasian american population, whereas in african americans, there was no association between glomerular number and blood pressure. the pathomechanisms linking low nephron number and hypertension are only partly understood. among others, inappropriate activation of the renin-angiotensin system, impaired tubular salt handling leading to salt and volume retention, or post-glomerular structural changes have been discussed. the new classification of lupus nephritis: a critical reappraisal a. halon* *wroclaw medical university, poland background: systemic lupus erythematosus (sle) is the prototype of human autoimmune multisystemic disease and has a wide spectrum of clinical manifestations, of which renal failure is the most common and severe. about - % of patient with sle suffer from lupus nephritis (ln), and it is one of the major causes of morbidity and mortality. ln manifests as diverse patterns of immune complexmediated renal disease involving all tissue compartments: glomerular, vascular and tubulointerstitial. iga nephropathy is a disease of a diverse course and outcome. there were several attempts to create a morphological classification that would serve as a tool efficiently defining the potential responsiveness to the immunosuppressive treatment as well as prognosis in individual cases. the last of these proposals, the oxford classification of iga nephropathy, was published in july . the aim of our study was to compare the utility of few functioning classification systems, including oxford and hass classifications and japanese histological grading, as well as our own morphological index of biopsies with iga nephropathy. on the basis of data collected in polish renal biopsy registry, we selected iga nephropathy cases that were characterized by at least years of post-biopsy follow-up, as well as satisfactory tissue material for light microscopy evaluation. microscopical grading was performed by a group of experienced nephropathologists. the lecture will be devoted to the results and conclusions of this study. the myofibroblast. from wound healing to neoplasia. with special emphasis on tissue fibrosis and fibrocontractive conditions. twenty-five years of reflexions w. schürch* *canada the myofibroblast (mf) was discovered in in electron micrographs from experimental granulation tissue. this cell was shown to share features of fibroblasts and smooth muscle cells, hence its name. in due course, it was found to be the principal cell to effect wound contraction, i.e., wound healing. this unique cell was later defined at the histologic, ultrastructural, immunohistochemical, biochemical and pharmacological levels. for the surgical pathologist, the mf is best defined by its ultrastructure. immunohistochemical studies demonstrate a heterogeneous pattern of cytokeletal phenotypes regarding actin isoforms and intermediate filaments. five immunophenotypes were identified. ultrastructural features that define the mf include: (a) stress fibers, i.e., bundles of microfilaments with interspersed dense bodies; (b) well-developed cell-to-stroma attachment sites, i.e. fibronexi, intercellular intermediate and gap junctions; and (d) abundant production of extracellular matrix. mfs have been observed in normal tissues, in granulation tissue and in several pathologic settings which will be discussed in detail. numerous cells can modulate into a mf phenotype: foremost, the local resident fibroblasts, followed by pericytes, vascular smooth muscle cells, liver perisinusoidal stellate cells, kidney mesangial and tubular epithelial cells, bone marrow stromal cells and mesothelial cells. for the development of the mf phenotype, a two-stage model was proposed. following tissue injury, complex changes in the microenvironment occur with the release of cytokines and the concerted action of a permanent feedback between intra-and extracellular tension, transforming progenitor cells into proto-mfs and then into differentiated mfs. three types of pulmonary preneoplastic changes (ppc) are accepted: squamous dysplasia and carcinoma in situ (sd/ cis), atypical adenomatous hyperplasia (aah), and diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (dipnech). sd/cis are associated with the development of squamous cell carcinoma (scc). aah is a pre-invasive lesion for adenocarcinoma (adc), and dipnech may progress to carcinoid. recently, adenocarcinoma in situ (ais, formerly bronchioloalveolar carcinoma (bac)) was included among ppc. pathogenesis of scc and adc is a multistep and multicentric process involving the transformation of the normal bronchial mucosa and alveolar lining cells through a continuous spectrum of lesions. the sequence of ppc for scc includes: hyperplasia > metaplasia (sm) > sd > cis > scc; for adc, it is hyperplasia > aah/ bac > adc; and for carcinoid, it is dipnech > tumorlet. numerous genetic and molecular abnormalities occur in the very early stages of lung carcinogenesis, including hyperplasia and metaplasia and even in normal-appearing bronchial epithelium. it is not known which genetic changes are the most important or at what stage the process is irreversible. sm and hyperplasia can be either a repair or a reactive and reversible process of injured bronchial epithelium. it is found in purely inflammatory settings. these reactive processes usually do not progress to dysplasia and carcinoma. that is, morphology is a gold standard in the diagnosis of both reactive and ppc, and no ancillary studies can be used as a diagnostic aid. the strict histologic criteria are used to assist in the recognition and grading of mucosal lesions. handling the problematic pleural biopsy in suspected mesothelioma cases s. anttila* *huslab jorvi, dept. of pathology, espoo, finland the most challenging diagnostic problems in pleural biopsies include distinguishing between benign mesothelial hyperplasia and epithelioid malignant mesothelioma and between reactive pleural fibrosis and sarcomatoid or desmoplastic mesothelioma. in addition, sometimes rare tumor types, such as lymphohistiocytoid malignant mesothelioma or epithelioid hemangioendothelioma, may mimic reactive processes. the first question to be considered when handling a problematic pleural biopsy is: is the biopsy material adequate and representative as can be judged from clinical, imaging and thoracoscopic findings? if in doubt, a new biopsy should be recommended. the distinction between benign and malignant mesothelial proliferation can be made on morphological grounds only, although immunostains, e.g., for ema and desmin, may favor either a benign or malignant lesion. the most reliable criterion of malignancy is invasion. immunostains for broad-spectrum cytokeratins may aid in recognizing invasion both in epithelioid and spindle cell lesions. in spindle cell lesions, cytokeratins also help recognize the growth patterns of spindle cells. in reactive pleural fibrosis, a layer of cytokeratin-positive cells may be seen parallel to the pleural surface, whereas in sarcomatoid or desmoplastic mesothelioma, the pattern of spindle cells is haphazard or storiform. negativity of immunostaining for cytokeratins in a spindle cell lesion should not automatically lead to a conclusion of a benign process as, e.g., sarcomas and about a quarter of sarcomatoid or desmoplastic mesotheliomas are cytokeratinnegative. correlation of histological and immunochemical findings with clinical and imaging findings is of utmost importance for a correct diagnosis without unnecessary delay. these rare tumours stem from mononuclear phagocytes or antigen-presenting dendritic cells. the latter belong to different cell lineages (either haematopoietic or mesenchymal). histiocytic sarcoma (hs) affects adults and is characterised by an aggressive clinical course in most instances. hs more often occurs at extranodal sides and consists of pleomorphic, atypical, large cells that are cd + , cd + , lysozyme + , cd + , cd r + , and hla-dr + . partial expression of s- is recorded. tumours derived from langerhans cells (lc). they maintain the phenotypic profile (s + , cd a + , langerin + ) and ultrastructural features (birbeck granules + ) of lc. they include lc histiocytosis and lc sarcoma. the former represents a well-known entity, more commonly observed in children: its behaviour varies according to the stage. the latter is a very aggressive disease of adulthood with overt cytological atypia and dismal prognosis. interdigitating cell sarcoma (idcs) is a very rare neoplasm of adulthood that cannot be differentiated from follicular dendritic cell sarcoma morphologically, both being composed of oval fusiform cells growing in fascicles, storiform pattern or °whorls. the diagnosis is based on s- and vimentin positivity in the absence of other lineage markers. follicular dendritic cell sarcoma (fdcs) occurs in adults and more often presents in the lymph node, at times within the context of castleman disease. in % of cases, it has an indolent behaviour. hodgkin lymphomas (hl) consist of two main categories, classical hl (chl) and nodular lymphocyte predominant hodgkin lymphoma (nlphl). the latter occasionally shows large diffuse areas. in particular in small biopsies, this generates a difficult differential diagnosis of t cell/ histiocyte-rich large b cell lymphoma (thrlbcl). immunohistochemistry with a large panel of antibodies may be of help, but cannot solve all problems, and clinical aspects should always be taken into account as well. in view of the important clinical (therapeutic and prognostic) consequences, such cases should also be evaluated by an expert hematopathologist. the second problem is the distinction between chl and primary mediastinal large b cell lymphoma (pmbl) or diffuse large b cell lymphoma (dlbcl) nos. there may be various situations: a mediastinal mass with a synchronous composite chl and pmbl with divergent morphology and immunophenotype. this situation may be more frequent than thought since usually, only a small sample from the mediastinal mass is taken. both lymphomas may also develop metachronously. the coincidence of both lymphoma types is explained by the fact that both lymphomas likely have a common (thymic) origin. indeed, they share many genetic and molecular features as well. more difficult to understand and diagnose are the cases that arise outside the mediastinum with mixed features of chl and dlbcl-nos and cases of otherwise chl that strongly express cd and/ or other b cell markers. in such cases, other diagnoses should be considered as well, such as ebv + dlbcl of the elderly. several cases will be discussed during the session. peripheral t cell lymphomas: a new frontier s. pileri*, c. agostinelli, p. p. piccaluga *bologna university, dept. of haematology and oncology, italy peripheral t cell lymphomas (ptcls) account for about % of lymphoid tumours worldwide. almost half of them show such a morphologic and molecular variability as to hamper any further classification and to justify their inclusion in a wastebasket category termed "not otherwise specified (nos)". the latter corresponds to neoplasms with aggressive presentation, poor response to therapy and dismal prognosis. conversely to b cell lymphomas, ptcls have so far been the object of a limited number of studies aiming to elucidate their pathobiology and identify novel pharmacologic approaches. herewith, the authors revise the most recent contributions on the subject based on the experience they gained in the extensive application of microarray technologies. ptcls/nos are characterised by the erratic expression of t-cell-associated antigens, including cd and cd , recently proposed as targets for ad hoc immunotherapies. they also show variable ki- marking, rates > % heralding a worse prognosis. gene expression profiling (gep) studies reveal that ptcls/nos derive from activated t lymphocytes, more often of the cd + type, and bear a signature composed of genes and related products that play a pivotal role for cell signalling transduction, proliferation, apoptosis and matrix remodelling. this observation seems to pave the way to the usage of innovative drugs, such as tyrosine kinase and histone deacetylase inhibitors whose efficacy has been proven in ptcl primary cell cultures. gep does also allow better distinction of ptcl/ nos from angioimmunoblastic t cell lymphoma, the latter being characterised by follicular t-helper lymphocyte derivation and cxcl , pd and vegf expression. the south saharan african countries are low-resource settings where the histological diagnosis of diseases and consequently the correct managing of the patient are difficult to obtain. telepathology allows doctors working in remote locations to obtain a definite diagnosis through the transmission of tissue specimen via remote telecommunication. in particular, the "virtual slide" system allows capturing a visual image of an entire slide of a specimen which is then forwarded to another location for diagnosis. association pathology beyond borders (apof) in , in a small rural hospital in zambia, to supply to the lack of pathology skilled personnel, started a project to train local staff to become technicians, able to prepare histological and cytological slides and to screen conventional pap smears. the two zambian technicians signed out negative pap smears, and in the presence of abnormal findings, they took pictures of significant diagnostic fields. then the images were sent through internet to experts in italy who, on a rotating roster, were responsible of the final diagnosis. since , the technicians were also able to prepare histological slides from the surgical specimen: digital images of the slides were taken through a scanner and saved in a database in a local server. through a satellite connection and a made-to-measure archival software and web site, pathologists in italy were able to examine the specimen, record their diagnosis and transmit it directly to zambia. in low-income countries where no other possibilities are available, telepathology seems to be a reliable and secure diagnostic tool. leave a mark: organizational models in building and managing a pathology service in developing countries p. giovenali* *ospedale s. maria, della misericordia, perugia, italy the main aim of the ngo association pathologist beyond borders (associazione patologi oltre frontiera, apof) is the improvement of activities related to anatomical pathology in developing countries to raise the health standard in those areas through the performing of histological and cytological diagnoses for therapeutic and preventive purposes, such as screening programs. an essential part of every project managed by apof consisted in the construction and organization of new pathology services or in the implementation of already existing laboratories. while taking into account every particular local environment, needs and available resources, apof decided to export the same models that have proven effective in our context: the technical histological and cytological process, from the surgical sampling to the final report, was set in detail trough precise guidelines with the inclusion of procedures dedicated to process control. similar guidelines were used to update and adjust the diagnostic parameters according to international consensuses. the allocated funds were mainly used for the purchase of equipment and consumables and for the organization of updating courses dedicated to the technical and medical staff. in places where no skilled personnel were available, longer and more in-depth classes were organized for local staff, both in the place or in italy. the staff, once trained, passed also an examination to obtain an official and specific degree. the main purpose of this kind of management was to build a reliable system that could then be directly managed by local staff at the end of the project. the great debate about screening models in developing countries: matching needs and opportunities s. guzzetti* *ospedale evangelico valdese, asl to , turin, italy although in the developed world the importance of the correct diagnosis is appreciated as a critical issue, this is still an evolving concept in some of the developing countries, especially in africa. in particular, there are striking differences in the turnaround time for histopathological diagnosis, in the accuracy of diagnosis that has a profound impact on patients' management and ultimate outcome. the current problems in practice of lymphoid/lymphoma diagnosis include-basing treatment decisions on fine needle aspiration cytology in a large proportion of cases, poor quality histology in a minority of cases where biopsies are performed, complete lack of immunohistochemistry and other supportive investigations, and lack of an update on the current criteria for the diagnosis of various lymphoid pathologies. in africa, a majority of the laboratories still use the working formulation for clinical usage, a lymphoma classification from the early s which is based on morphology alone and does not include many entities recognized in the last years. without accurate diagnosis, any research project and effective patient management cannot be instituted. though there are no magic answers for an issue of this magnitude, on which other aspects are critically dependent, twinning between institutions in the developed countries and developing countries seems to be the most likely longterm approach. examples of twinning approach to childhood cancer diagnosis and treatment have been africa. these programmes have led to improvements in the diagnostic accuracy through capacity building and joint research projects with both direct and indirect technology transfer. the role of apof in low-resource settings: present and future projects for the development of surgical pathology in developing countries v. stracca-pansa* *italy in the last years, the cancer issue in most african countries is more and more dramatic. the who afro and the resolution of the th world health assembly made cancer one of the health priorities in developing countries and pushed african countries to formulate national cancer control programmes. once considered a disease of the rich, the pendulum has swung dramatically, and some % of new cancer cases in the next decade will be in the developing world. many poor countries are unable to cope with the accelerating burden of cancer. the essential purpose of the breast cancer pathology report is to communicate pathologic findings that aid in prognostication and guide the selection of appropriate local and systemic treatment for patients with breast cancer. to be clinically useful, the content of the report must change as new prognostic and predictive factors are validated and others become obsolete. in , the list of useful featuresthose which are grounds for specific therapeutic actions-is relatively short: the anatomic extent of disease in the breast and axilla (ajcc/uicc stage), the specimen margin status, and measures of certain cancer cell proteins (hormone receptors, her- /neu) that predict the likelihood of response to specific adjuvant therapies. histological subtype, carcinoma grade, the presence of lymphatic tumor emboli, the finding of paget disease in a mastectomy specimen are also often reported, but do not inform specific treatments the way that stage, margin status and predictive markers do. in patients with node-negative, estrogen receptor-positive breast cancer, the pathologist selects a paraffin-embedded tumor sample for the oncotype dx assay, which is used to predict the risk of recurrence in patients treated with tamoxifen and may addend the recurrence score to the surgical pathology report. the breast cancer pathology report in is vital to appropriate breast cancer treatment, but can be expected to evolve. in order to assure the quality of pathology in all of sweden, the swedish society of pathology has instituted organspecific quality assurance and standardization groups. these groups consist of dedicated pathologists from many subspecialty areas and are called kvast groups. they meet regularly and their principal work is to formulate and maintain a document with guidelines which has a common framework for all the organ-specific groups. our group prepares the guidelines for breast pathology. the mandatory sections in all the guidelines include clinical background information, instructions to clinicians as how to handle the specimens, what information is needed on the requisition form, gross description, analyses, what information must be reported by the pathologist (gross and microscopic), recommended classification system, administration and miscellaneous. sweden has a national cancer strategy programme emphasizing a patient perspective by focusing the patient process instead of piecing the treatment process together through independent specialities, as has been done previously. in , a group of breast cancer clinicians established a national quality register for breast cancer patients called inca which also include a pathology section. in collaboration with the swedish breast cancer group and the breast kvast group, another group called sweqa works with quality assurance programmes of the biomarkers used in routine pathology; estrogen and progesterone receptors, her status, and histologic grade. the guidelines for breast pathology will require the breast pathologists to participate in the breast cancer patient process by focusing on the standardisation of requisition and pathology reports and quality assurance of biomarkers. working on national guidelines: hungarian guidelines g. cserni* *hungary background: all pathologists feel that the establishment of pathological diagnoses is somewhat subjective. writing national guidelines is useful in order to achieve better consistency in reporting at the level of a geographic area, hungary. as not all countries have their national guidelines on breast reporting, it was thought useful to provide some examples of how guidelines can be constructed and/or adopted. method: the text of the hungarian guidelines on breast pathology reporting was written by a committee of pathologists with expertise in breast pathology. the basis of the new text was a consensus document from years ago. this was rewritten, circulated, and modified several times, and the updated text, ready for wider discussion, was put on the web (internet) along with four other texts (diagnostic radiology/imaging including nuclear medicine; surgery including reconstructive surgery; radiotherapy; and systemic therapy). the url allowing access to the texts was widely circulated on discipline-specific web sites. a consensus conference was organized for live discussion, and written comments were also welcome both from the writing committee members of the other texts and from the wider medical community (the other texts were discussed similarly to allow better congruence). all relevant comments were incorporated and the pre-final text was discussed at the consensus conference. the writing committee finalized the text on the basis of the relevant comments discussed at the conference. the pathology guidelines were scheduled for publication with the other texts in the national oncology journal, magyar onkologia (hungarian oncology). results: na. conclusion: na. working on national guidelines: polish guidelines e. chmielik *, w. p. olszewski, j. rys *oncology institute, dept. of pathology, gliwice, poland objective: the pathologists from the three major oncology centers have worked out the guidelines for breast cancer pathology reporting. method: the proposed report was mainly based on the european and american guidelines as well as on the seventh version of tnm classification and was prepared in cooperation with radiologists and surgeons. guidelines of the pathological reporting of breast cancer were accepted by the multidisciplinary board of the main national specialists representing different medical professions such as pathology, oncologic surgery, medical oncology, chemotherapy and radiotherapy, and afterwards, they were described in the supplement of the polish journal of pathology ( , vol , issue ) the guidelines include the rules of interpretation of needle core biopsies and other diagnostic procedures, as well as the recommendations of gross description and processing of surgical specimens depending on the type of surgical treatment. especially, pathology report of breast carcinoma after neoadjuvant chemotherapy was proposed. special techniques used for diagnosis of breast lesions, their performance and interpretation are also included. results: finally, the histopathological evaluation form of breast cancer has been proposed. in a year after the supplement publication, it is planned to conduct a survey to find out the practical use of those guidelines. on the basis of both the answers to those questions and medicine-based evidence, polish guidelines are going to be compiled. the transplant nephrologist decides to biopsy a given patient on the basis of clinical symptoms and laboratory data. the renal pathologist then makes a histological diagnosis which allows an evidence-based approach to specific therapy, which again will be decided on by the clinician. renal transplant diagnoses generally fall into one of five categories: preexisting donor-related diseases, rejection, drug toxicity, infection, recurrent or de novo renal diseases. although many diagnoses are typically encountered during a certain phase after transplantation, clinical information alone will often not suffice to differentiate between diagnoses, which require a totally opposite treatment regimen. the timing of the biopsy is most important to achieve a successful treatment and to avoid irreversible damage to the transplant. the rule of thumb at our center is to biopsy early in delayed graft function if there is a change in serum creatinine of more than . mg/dl or there is a newly diagnosed or increased proteinuria. sufficient biopsy material, adequate workup including c d and sv immunohistochemistry, and an experienced pathologist are the other prerequisites. a close collaboration between nephrologist and pathologist with regular case discussions not only helps understand the viewpoint of the clinical/pathological partner but will also aid in patient management. pathology in zero-hour biopsies and clinical consequences: hungarian and polish experience a. perkowska-ptasinska*, e. kemeny *poland at the university of szeged, hungary, we carried an original clinicopathological study to assess what type of vascular changes-if any-are associated with late graft dysfunction. we examined in zero-hour biopsies the frequency and severity of nonspecific morphological lesions semiquantitatively. the wall thickness/lumen (w/l) ratio of each artery present in the biopsy was determined by morphometry. among the arterial changes studied, only the intimal fibroelastosis (ife) of moderate degree (frequency, . %) revealed a significant correlation with serum creatinine at months (p< . ). in ife, there was also a significant correlation with the frequency and severity of tubular atrophy and interstitial fibrosis (p< . ). by morphometry, a significant association was found between the mean w/l ratios of arteries and the degree of ife (p< . ). according to hungarian experience, donor kidneys with a moderate degree of ife do indeed have a higher risk of late graft dysfunction. the analogically defined polish retrospective study revealed that the presence of arteriolar hyalinisation in the implantation biopsy was associated with more profound reduction of gfr at rd, th and th months after transplantation in those patients who experienced episodes of an acute rejection (p= . ) within first post-transplant months. this suggests that donor-derived arteriolar hyalinisation predisposes to more severe acute rejection-associated graft damage. new techniques for the identification of hla antibodies g. boehmig* *austria background: it has become evident that antibody-mediated immunity plays a critical role in acute and chronic allograft rejection. according to the banff scheme, serological alloantibody detection represents one of the major diagnostic criteria for antibody-mediated rejection (amr). the design of sophisticated diagnostic tests for prediction and monitoring of amr has become a major goal in transplant medicine. method: an important innovation has been the establishment of solid phase hla antibody detection using flow cytometry, elisa or luminex technology. in this context, luminex-based bead array technology represents an attractive strategy for a detailed analysis of anti-hla reactivity patterns. salivary and mammary glands share an identical ductuloacinar architecture, and thus, it is not surprising that lesions and tumours arising in both organs share considerable histologic similarities. salivary-type tumours are well known in breast; in contrast, breast-like lesions are rarely described in salivary glands. one of the commonest breast conditions, benign fibrocystic disease, was not thought to have a salivary counterpart, but recently, sclerosing polycystic adenosis (spa) was described as a distinctive neoplastic lesion of the major salivary glands. although spa has many histologic similarities to its mammary counterpart, it represents a true neoplastic condition characterized by clonality, focal dysplasia, and a tendency to recur. up till now, secretory carcinoma (sc) has been considered to occur only in the breast. recently, we published a series of salivary gland tumors with histomorphological and immunohistochemical features reminiscent of sc of the breast. this is an unusual, hitherto undescribed, distinctive salivary gland tumor, with some morphological features of both salivary acinic cell carcinoma (acicc) and mammary sc, characterized immunohistochemically by strong vimentin and s- protein positivity. microscopically, the tumours exhibit a lobulated growth pattern, and they are composed of microcystic and glandular spaces with abundant eosinophilic homogenous or bubbly secretory material, which is positive for pas, mucicarmine, muc , muc , and mammaglobin. the decision to undertake the sequencing of the entire human genome stemmed from many sources, in particular rrenato dulbecco's seminal article in science ( ; : - . extraordinary technical advances were required to facilitate this, but few could have predicted the attendant conceptual revolutions. since the publication in of the first draft of the human genome (and the parallel reports of the sequences of many other genomes), our view of the complexity of the organisation and regulation of genomes has increased. the encode project (genome res ; : - ) further highlighted the extraordinary diversity of transcription and demonstrated that the protein coding regions are but a fraction of the transcriptome. the importance of non-coding regions in genome regulation has become manifest, and the diversity of splicing events was previously unsuspected. the previous drip of new information has become a torrent, and 'next-generation' sequencing technologies promise to increase this driving cost of sequencing entire genomes to sub-$ , levels. the timescale of generating data similarly collapses to a mere fraction of that required even years ago. the information load will be immense and new approaches will be needed to deal with the impact of this on clinical decision making. the consequences for these developments are perhaps unfathomable at present, but we are challenged to find ways to take advantage of these developments lest pathology be bypassed by other disciplines. central to this will be educational programmes at the undergraduate and postgraduate level to 'future proof' tomorrows clinicians, including pathologists. new approaches to molecular classification of lymphomas l. leoncini*, s. lazzi, g. de falco, c. bellan, a. onnis, v. mourmouras *university of siena, italy background: the era of molecular diagnostics of lymphoid malignancies started with the cloning of the immunoglobulin and t cell antigen receptor genes. southern blot analysis was applied in clinical laboratories to establish clonality of lymphoid proliferation. this was followed by the cloning of a number of translocation breakpoints in the more common lymphomas. method: the advent of polymerase chain reaction provided an alternative to southern blot analysis as it is simpler and faster. in addition, the amount of clinical material required is much smaller, and it can be performed on archival paraffin-embedded materials. results: gene expression (ge) analyses by use of microarrays (mas) have become an important part of biomedical and clinical research. the resulting data may provide important information regarding pathogenesis and may be extrapolated for the diagnosis and prognosis of non-hodgkin lymphoma (nhl)( ). this genomic technology has revealed that existing diagnostic categories of nhl comprised multiple molecular and clinically distinct diseases. in addition, gene expression profiling studies may lead to the identification of novel targets for the development of new therapeutic agents for nhl. conclusion: more recently, the discovery of a novel class of small non-coding rnas, the micrornas, has opened a new scenario in understanding the regulation of gene expression. mirnas control gene expression at the posttranscriptional level, and deregulation of their physiological function has been revealed to be crucial in cancer. mirna expression profile can be obtained by microarray and is even more informative than gep as a few mirna alterations can specifically identify a tumor (histo) type. egfr mutation analyses in nsclc-experiences of a nationwide ring trial in germany m. dietel* *universitätsmedizin charité, berlin, germany background: since non-small cell lung carcinoma (nsclc) is being predominantly diagnosed at advanced stage, the option of a curative therapy no longer exists in most instances. roughly speaking, the first therapeutic standard measure to treat nsclc consists of a platinumbased chemotherapy, reaching a response rate of - %. recently, new substances have been introduced to treat nsclc, i.e. erlotinib (tarceva®) and gefitinib (iressa®). both inhibit the epidermal growth factor receptor (egfr ). results: for the egfr-inhibitors, it is possible to predict tumor response by egfr mutation analyses. this is the reason why the emea has approved iressa treatment only after such analysis, which has to be performed pretherapeutically. the test has to be done by pathologists who ( ) should reconfirm the diagnosis on an h&e slide; ( ) he then should identify and mark the tumor area, ( ) followed by manual microdissection to assure that at least % of the material is indeed nsclc. ( ) results: molecular tests and gene expression profiles that purport to predict patient outcomes and drive therapeutic decisions are currently favored by oncologists. however, ihc is the only laboratory venue that supplies molecular morphology that may be directly visualized and interpreted. in addition to diagnostic ihc, theranostic and genomic applications are also now in the menu of the pathologist. conclusion: pathologists must be able to emphasize the molecular morphology of ihc and how it can supply theranostic and genomic information in addition to diagnostic applications. our ihc challenges include standardization of the total test and the ability to quantitate results for patient care. most common laboratory pitfalls in ihc s. nielsen* *aalborg hospital, dept. of pathology, denmark most common laboratory pitfalls in ihc immunohistochemistry (ihc) is a well-established technique and used daily in virtually all departments of surgical pathology as a diagnostic, predictive and prognostic tool. however, ihc is an assay influenced by multiple parameters and the final result is highly dependent on the choice and performance of these variables. in the protocol setup for ihc, both the preanalytical, analytical and post-analytical parameters will affect ihc staining, and it is of utmost importance to be familiar with these technical aspects in order to use ihc as a diagnostic tool. in the pre-analytical phase, fixation still is the key element for a reliable result, and it is essential that fixation is standardized with respect to the choice of fixative, time to and time in fixative in order to get consistent results and to avoid false negative or false positive reactions. the implementation of new tissue processing techniques based on, e.g. modified reagents, can also affect the staining result. regarding the analytical phase, the three key elements are: ( ) appropriate epitope retrieval, ( ) a sensitive and specific primary antibody, and ( ) a robust detection system. in external quality programs for ihc, it has been shown that most errors in ihc are related to epitope retrieval and/or the primary antibody. to validate the performance and consistency of ihc, it is necessary to use internal and external controls. especially the use of multi-tissue blocks containing tissues with different levels of the antigen is superior to single control blocks. most common interpretation pitfalls in ihc j. klos* *norway background: the real frequency of interpretation pitfalls in immunohistochemistry is difficult to assess and may vary greatly between laboratories and pathologists. the risk of misinterpretation increases with the greater use of immunostaining as an integral part of theranostic workup, the increasing number and varying quality of available antibodies, as well as the rapidly expanding body of information regarding the complexity of ihc profiles of tumours. growing clinical expectations for pathological evaluation are an additional challenge. method: the presentation will address the most important elements regarding the correct interpretation of immunostaining using aaaspin as a simple algorithm for safer approach. results: a-adequate antibody panel: selection of antibodies is often a consequence of considered differentials, but results of immunostaining may also influence the choice of antibodies in subsequent analyses. a-antibody clone: the spectrum of reactivity and cross-reactivity should be known. according to the banff classification, antibody-mediated renal allograft rejection (abmr) is defined by circulating donor-specific antibodies (dsa), c d deposition in peritubular capillaries (ptc), and histologically detectable graft injury. these diagnostic criteria had primarily been developed and validated in biopsies from patients with early post-transplant dysfunction. results from studies in patients without clinically detectable graft dysfunction, however, cast doubt on the universal applicability of these criteria. in my talk, i will address the following issues: ( ) c d deposits but no abmr? findings in protocol biopsies from patients with stable renal function indicate that c d deposition is not necessarily always associated with renal dysfunction. the low predictive value of c d in these patients might be due to the accommodation of grafts and highlights the fact that the diagnostic impact of c d strongly depends on the clinical context. ( ) abmr but no c d? complement activation likely is not only of diagnostic importance but also part of the pathogenesis of abmr. results from gene expression profiling studies in human graft biopsies and from animal models, however, suggest that there also might be complement-independent mechanism of abmr. especially the lesions of chronic rejection might at least in part result from antibodymediated complement-independent endothelial injury. ( ) are "atypical" staining patterns of diagnostic relevance? c d can, in addition to the diagnostically relevant linear deposition in ptc, also be found in other locations and different staining patterns. it, however, appears that these other/additional staining patterns are of limited diagnostic value, at least for the detection of ambr. during gestation, several microorganisms can infect the foetus and damage the developing nervous system, leading to severe neurodevelopmental sequelae. the acronym torch was introduced to refer to these organisms including toxoplasmosis, other microorganisms, rubella, cytomegalovirus and herpes simplex virus. torch infections share similar clinical features: the maternal infection is regularly asymptomatic, the clinical presentation of infected fetuses and neonates is quite identical, and, sometimes, a clinically silent infection in the neonatal period will be responsible for permanent neurological deficits occurring later in infancy. extensive immunization programs, in developed countries, have led to an impressive decrease of congenital rubella syndrome, and the development of strategies of prenatal diagnosis and antimicrobial therapies has improved the management of congenital infections. despite these significant advances, torch infections remain a worrying cause of vision loss, hearing loss, and neurological disabilities in both developed and developing countries, and new syndromes have emerged such as congenital infections due to human immunodeficiency virus (hiv) and the human parvovirus b . in addition, in the two last decades, growing evidence has supported the hypothesis of a significant association between choriamnionitis and cerebral palsy: brain lesions would result from a production of cytokines through a mechanism of toxicity. a wealth of literature has summarized current knowledge concerning epidemiology, microbiology, diagnosis and the management of congenital infections. in this presentation, we will focus on the neuropathological features of the most frequent intrauterine infections and underscore the invaluable contribution of neuropathological studies in understanding the pathogenesis of developing brain lesions. development and functions of the dura mater w. squier* *united kingdom the dura is more than just a fibrous covering for the brain; it has other functions, including control of venous outflow and uptake of csf. dural development is not complete at birth; it undergoes considerable remodelling in early life. the meninges develop from primitive mesenchyme derived from the neural crest. the dura has two leaflets, the outer periosteal and the inner meningeal which forms the falx and tentorium. between them are the venous sinuses, which drain the entire venous outflow of the brain. bridging veins are few and carry high blood flow. a muscular sphincter at their junction with the dura regulates blood flow when intracranial pressure increases. a venous plexus, most extensive at birth, is found in the posterior falx, tentorium and the parasagittal regions. arachnoid granulations develop at months of postnatal life. originally thought to be responsible for drainage of csf, they more likely monitor csf homeostasis and pressure. fluid channels in the dura may represent a system for the uptake of csf. in early life, blood may reflux into these channels from the venous sinuses, causing intradural bleeding which is common in immature infants. dural bleeding causes symptoms such as seizures and vomiting difficulties and is associated with age-related imaging changes in the underlying brain parenchyma. we do not yet understand the pathophysiology of these observations. mitochondrial encephalomyopathies (me) represent a heterogeneous group of diseases, secondary to respiratory chain dysfunction, impaired atp production and energy crisis in the affected cells. me could be associated with defective nuclear (ndna) or mitochondrial (mdna) genome, resulting in autosomal or maternal inheritance, respectively. although multiple organ involvement is very common, the most affected are tissues with high oxidative metabolism such as cns, myocardium and striated muscle. myoclonus epilepsy with ragged red fibres (merrf), mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (melas), leber's hereditary optic atrophy (lhoa), kearns-sayre syndrome and leigh's disease represent the classical examples of me. precise phenotype/genotype correlations are very difficult due to the presence of overlap syndromes and atypical cases. the topography of lesions in the cns determines symptomatology and varies in these conditions. morphologically, me are characterized by variably expressed mitochondrial abnormalities such as intra-mitochondrial crystalloid inclusions and ragged red fibres (rrf) in muscle biopsies, as well as selective neuronal loss in different cns structures, laminar cortical necroses, microinfarctions and spongy degeneration in the grey or white matter. however, the common and diagnostically useful feature is the presence of cox-negative fibres, abnormal ultrastructure of muscle mitochondria and variably expressed vascular abnormalities. although clinicopathological correlations are often problematic, the involvement of small caliber vessels may explain many focal cns manifestations, while multisystem disease is very likely secondary to mitochondrial dysfunction in the neuronal component. results: kuru in the fore language means to shiver or to shake from fever and cold. ritualistic endocannibalism (eating of the relatives as a part of a mourning ritual, but not as an alimentary habit) was practiced not only in the kuru area but in many surrounding eastern highland groups which never developed kuru. the most striking neuropathologic feature of kuru was the presence of numerous amyloid plaques. conclusion: we may also speculate what would happen if kuru had not been discovered or did not exist. the infectious nature of creutzfeldt-jakob disease would probably not have been suspected until the beginning of the variant creutzfeldt-jakob disease (vcjd) outbreak in the uk. creutzfeldt-jakob disease and gerstmann-sträussler-scheinker disease would have remained for decades as obscure neurodegenerations of merely academic interest. the familial forms of creutzfeldt-jakob disease would not have benefited from prnp gene analysis, but only later would have been studied by linkage analysis and reverse genetics probably. the whole field would have probably remained of only arcane interest to veterinarians until the bse epidemic began to exert its devastating effect. the discovery of vcjd would have been delayed as no surveillance would have been initiated for creutzfeldt-jakob disease. and, perhaps most importantly, the sea change in mentality that has led to the conception of 'protein misfolding diseases', including not only the neurodegenerative but also an increasing number of nonneurological disorders, would have been delayed by decades. cell autocannibalism in central nervous system. the role of autophagy in neurodegeneration and nervous system tumours b. sikorska* *poland background: autophagy is a process by which subcellular constituents and organelles are targeted for degradation in lysosomes. in macroautophagy, proteins and organelles are sequestrated into a double membrane-bound vacuole called autophagosome, formed by the er membranes, under the direction of various proteins including map-lc (a microtubule-associated protein, light chain ). in addition to maintaining cellular homeostasis, autophagy may also contribute to cell damage. recently, autophagy was reported to be involved in many pathological processes including neurodegeneration, inflammatory processes and cancer. the role of autophagy in neurodegeneration is not only in removing protein aggregates but also in inducing the neuronal death. method: autophagy in human neurodegenerative diseases and tumours of the cns was studied using electron microscopy, immunohistochemistry and confocal laser microscopy. results: the presence of autophagy in prion diseases and other neurodegenerative disorders was shown. the extent of autophagy in tumours varied depending on histological type and malignancy. conclusion: although the role of autophagy in neurodegenerative diseases remains unknown, at least three hypotheses must be taken into consideration: ( ) removing protein aggregates, ( ) one of the ways of neuron death, and ( ) formation of spongiform change in prion diseases. the role of autophagy in cancer seems to be dual: on one hand, there is a growing body of evidence supporting the idea that autophagy may represent a tumor suppressor mechanism by reducing intratumoral necrosis, restricting oxidative stress and limiting chromosomal instability; on the other hand, autophagy may be an important process used by tumor cells to escape various types of stress and even therapeutic agents. advances in biology of gliomas w. biernat* *medical university of gdansk, dept. of pathology, poland objective: gliomas are the most common neoplasms of the central nervous system. the treatment of gliomas has been slowly changing for a few decades, and understanding of the glioma biology makes an important basic for the introduction of new treatment modalities. method: the most unfavorable prognosis concerns the group of diffuse gliomas which, due to the infiltrative growth, cannot be cured by surgery. the most common type of diffuse glioma is glioblastoma; this tumor may develop de novo (without preceding lower grade precursor lesion) or as a consequence of progression of malignancy. results: the molecular pathways most commonly seen in primary and secondary glioblastomas have been described, but recently, a new marker, isocitrate dehydrogenase (idh ), was defined as mutated early in the development of low-grade gliomas. the gene encoding this protein is located on chromosome q . idh catalyzes oxidative carboxylation of isocitrate to alphaketoglutarate. nicotinamide adenine dinucleotide phosphate (nadph) is the result of this reaction. idh is somatically mutated in low-grade gliomas and glioblastomas. on the other hand, alterations of the erk/mapk intracellular pathway occur in circumscribed gliomas, e.g. pilocytic astrocytoma. conclusion: all these informations suggest that differential utility of these markersand will be presented. toward "fingerprinting" of brain tumours based on the synchrotron radiation x-ray fluorescence, fourier transform infrared microspectroscopy (ftirm) and discriminant analysis d. adamek*, m. szczerbowska-boruchowska, m. lankosz *medical college krakow, dept. of neuropathology, poland objective: the neuropathologic diagnosis of brain tumours remains burdened by their well-known heterogeneity and difficulty to eliminate subjectivity in diagnosing. method: synchrotron radiation-based techniques were applied to biochemical micro-imaging of brain tumours of different types and various grades of malignancy. the specimens were cryosectioned, mounted on appropriate sample supports and freeze-dried. synchrotron radiation x-ray fluorescence was used for elemental analysis of samples. the level and distribution of p, s, cl, k, ca, fe, cu, zn, br and rb was determined. the biomolecular composition of neoplastic tissues was determined by fourier transform infrared microspectroscopy (ftirm). the composition of the tissues was used to construct a diagnostic classifier for brain tumours using discriminant analysis (da). results: it was found that cu, s, cl, k, and zn are the elements of the highest importance for the discrimination of tumor grade, as well as the tumor type. elemental analysis allowed % accordance with histological type and grade of tumor. the da applied to infrared absorption spectra indicated that lipids, amide i and amide ii, as well as phosphate group are of the highest importance for the discrimination of tumor type and tumor grade. the model obtained allowed differentiation between all investigated tumours and control samples as well as correct group classification in %. conclusion: it is difficult to speculate on the meaning of our findings with the biochemical perspective; however, the da based on elemental and biomolecular composition of tissue may be a potentially valuable method assisting the recognition and maybe grading of brain tumours. ( ) they are benign in the majority of cases; and ( ) the diagnosis of malignancy is based on cytologic features (papillary carcinoma) or on the presence of invasion of the tumor capsule or of blood vessels (follicular carcinoma). the common occurrence of benign thyroid nodules mandates an effective method for preoperative screening. the diagnosis of papillary thyroid carcinoma, by far the most common thyroid malignancy, is based on the identification of specific cytologic features. therefore, fine needle aspiration biopsy (fnab) has easily emerged in the past years as the most accurate and cost-effective tool, indeed a true cornerstone, for the preoperative management of thyroid nodules. standardized terminology to report diagnoses is highly recommended and is being implemented worldwide. the type of genetic alterations in thyroid cancer and the very nature of fnab samples make them ideally suited for molecular analysis. on the other end, the importance of intraoperative frozen section diagnosis has been constantly decreasing over the years as a direct consequence of the widespread application of fnab. it is now usually performed with cases that are suspicious after fnab and may be useful in some cases with indeterminate cytologic diagnosis. how to separate follicular adenoma from follicular carcinoma and follicular variant ptc? m. sobrinho-simoes* *portugal background: the differential diagnosis between fa, fc and fvptc is, at present, the most frequent reason for any consultancy practice on thyroid tumours. we will review this differential diagnostic problem taking into consideration that it only concerns the encapsulated type of fvptc. the poorly circumscribed/infiltrative types of fvptc, as well as the multinodular/diffuse type, do not create any major diagnostic doubts and are easily diagnosed, putting together the pattern of growth and the nuclear features. method: if one sticks to the differential diagnosis of fa, fc and encapsulated type of fvptc, the histopathological diagnostic hints are two: invasiveness (vascular invasion rather than pure capsular invasion) and presence of ptcnuclear features. results: we will discuss what to do whenever such histopathologic findings are not clear-cut enough to support a definitive diagnosis. we will review, in this context, the diagnostic value of immunohistochemical markers of differentiation and/or proliferation and that of molecular markers in a retrospective study of cases of well-differentiated carcinomas of the thyroid that have given rise to metastases and/or to local, clinically aggressive recurrences. the results obtained in this study will be used to determine the best diagnostic options and to support the conclusion that most, if not all, follicular tumours and welldifferentiated tumours of uncertain malignant potential, as well as minimally fc without vascular invasion and noninvasive encapsulated type of fvptc, carry a good prognosis even when treated by lobectomy alone. angioinvasive well-differentiated carcinoma, widely invasive follicular carcinoma, solid variant of papillary carcinoma and poorly differentiated carcinoma: from diagnosis to prognosis m. volante* *university of turin, clinic and biol. sciences, orbassano, italy malignant thyroid tumors are generally divided into welldifferentiated and undifferentiated (anaplastic) carcinomas, the former usually having a low malignant clinical behavior and good prognosis, and the latter being almost all very aggressive and rapidly fatal. diagnostic criteria rely on the recognition of cytological characteristics (i.e. nuclear alterations specific for papillary carcinoma), architectural patterns (i.e. papillary, follicular, solid, trabecular, insular or diffuse), high-grade features (i.e. increased mitotic index, necrosis) and invasive properties (i.e. vascular and/or capsular invasion). all of the aforementioned features are alternatively used as diagnostic hallmarks of specific histotypes, as peculiarities of specific variants, or as markers of aggressiveness, and their recognition is therefore essential to classify and stratify prognostically each individual tumor. the presence of vascular invasion is essential to recognize the malignant nature of a follicular tumor, but its extent is the major prognostic parameter in follicular carcinoma and draws a line between minimally invasive and widely invasive forms that are characterized by distinctive clinical outcomes. necrosis and high mitotic index usually occur in aggressive cases of papillary thyroid carcinoma, but together with the presence of solid/insular/ trabecular growth patterns represent the diagnostic features of poorly differentiated carcinoma, a specific tumor entity that shows a clinical behavior intermediate between welldifferentiated and undifferentiated carcinomas. at variance, the presence of a solid growth pattern in an otherwise typical papillary carcinoma depicts its solid variant, which is more often encountered in children and radiation-exposed individuals but has a clinical behavior usually similar to its conventional counterpart. as indicated by the world health organisation (who), histological grading is a way of predicting the biological behaviour of neoplasms. especially in neuropathological settings, tumour grade is often the key factor determining therapeutic decisions. clinical, radiological, macroscopic, histological and ultrastructural factors may already be summarized in a diagnosis that very well reflects the biology of the respective tumour entity, at least to a certain degree, but usually not in a personalized manner. this is exactly the stage where molecular biology comes into play. in recent years, much effort has been made on molecular characterization of brain tumours as there is an urgent need for specific and sensitive, highly reproducible tumour markers with a prognostic as well as predictive value. state of the art in modern neuropathology therefore ranges from basic immunohistochemical profiling, evaluation of genetic susceptibility, comparative genomic hybridization (cgh) approaches, fluorescence in situ hybridization (fish), screening for genetic hallmark mutations, evaluation of mrna expression of specific growth factor receptors, assessment of promoter methylation status and gene expression profiling to loss of heterozygosity (loh) analyses. the challenge now for pathologists confronted with brain tumours is to integrate knowledge derived from the latest molecular biological methods into the established panel of pure morphology-based investigations. objective: skeinoid fibres are globular brightly eosinophilic pas-positive extracellular collagen deposits seen commonly in gastrointestinal stromal tumours (gist) of the small bowel. ultrastructurally, they display similarity to "skeins of yearn", hence the name. however, hyaline globules are occasionally encountered in leiomyomatous gi neoplasms and may be mistaken for true skeinoid fibres leading, to an erroneous diagnosis of gist. method: we analyzed histologically and immunohistochemically well-characterized true smooth muscle neoplasms of the gi tract for the presence of hyaline globules and examined representative examples of them from formalin-fixed and deparaffinized tissue by electron microscopy. results: pas-positive intracellular and interstitial hyaline globules were detected in all benign paucicellular leiomyomas of the muscularis mucosae (n= ) and the muscularis propria (n= ) irrespective of tumour size and site, and rarely also in the adjacent muscularis propria, but in none of the leiomyosarcomas (n= ) and cellular leiomyoma (n= ). similar to surrounding tumour cells, hyaline globules expressed desmin, alpha-sma and h-caldesmon, but were negative for cd and cd . the mostly ovoid-shaped structures displayed at ultrastructural examination variably oriented bundles of filaments with a diameter of approximately - nm. at the periphery of these inclusions, altered filamentous material was recognized in different stages of degeneration with variable condensed matrix and occasional peripheral condensation suggestive of calcification. true skeinoid fibres were not detected. conclusion: the above findings are consistent with a multistep degenerative phenomenon affecting individual smooth muscle cells in paucicellular gi leiomyomas. awareness of this finding should prevent misinterpretation as gist, particularly in small biopsies. pseudotumours of the kidney j. lloreta-trull* *hospital del mar, dept. of pathology, barcelona, spain several clinicopathologic entities are grouped under the concept of pseudotumour: all of them usually result in a mass effect, therefore mimicking a neoplastic process grossly and sometimes microscopically. in the kidney and the urinary tract, the diseases most often presenting as a pseudotumour are malakoplakia and xantogranulomatous pyelonephritis. in fact, both of them can be considered inflammatory pseudotumours, i.e. inflammatory processes producing a mass effect. a more restrictive use of the term inflammatory pseudotumour applies to a subset of lesions that was initially known as myofibroblastic inflammatory pseudotumour and is currently referred to as inflammatory myofibroblastic tumour. ultrastructural examination reveals the pathogenesis of malakoplakia as a defect in the mechanisms of lysosomal extrusion from histiocytes. thus, the profusion of secondary lysosomes constitutes an optimal milieu for the deposition of calcium salts in typical michaelis-gutmann bodies. on the other hand, the foamy histiocytes of xantogranulomatous pyelonephritis are characterised by a profusion of myelin bodies due to the predominant phospholipid composition of the lysosomes, resulting from chronic destruction of renal tissue and bacterial degradation. inflammatory myofibroblastic tumour is a true neoplastic lesion with myofibroblastic differentiation and a prominent inflammatory background. this is an important differential diagnosis for both malakoplakia and xantogranulomatous pyelonephritis that may have an extensive myofibroblastic component. similar to its crucial role in kidney tumours, electron microscopy is a useful adjunct in the diagnosis of renal pseudotumours and has been essential in the elucidation of their pathogenesis. friday, september , . - . , sala wystawowa b objective: infectious complications have essential value at the conditions caused by primary and secondary immunodeficiencies, including connected with a hiv or immunosuppression therapy. laboratory diagnostics of opportunistic infections in conditions inadequate formation of antibodies is directed on revealing of antigenes of the activator. method: one hundred fifty samples of washing waters of bronchial tubes are investigated at diagnostic or medical bronchoscopy of patients (children and adults) with acute lymphoid ( . %) and myeloid ( . %) leukemia, chronic lymphoid and myeloid leukemia, hodgkin's and non-hodgkin's lymphomas. patients have been surveyed in different terms after transplantation of a bone brain. cytologic preparations were painted h&e, ziehl-neelsen and pas, ich. the cellular structure, condition epithelial cells, a degree of expressiveness and character macrophages activity epithelial and non-epithelial cells, a degree of expressiveness and character inflammations and also the presence of specific activators were estimated. results: data obtained by us testify to the prevalence bacteria ( . %) and viruses ( . %), inflammatory processes in respiratory ways. the changes connected with specific (tumoral), mycoses (aspergillosis, zygomycosis, a candidiasis) and pneumocystosis were less often observed by defeat. in one сase, it was documented as mycobacteriosis. in . % of cases of pathological changes, it is not revealed; in . % of cases, the changes connected with natural return development of pathological process were observed. conclusion: carrying out complex research of a biological material for the definition of character and a degree of expressiveness of pathological process and also the proof of a role of the infectious agent in the development of pathological process is expedient. diagnosis of infections in fine needle aspiration (fna) in immunocompetent and immunocompromised patients b. bode* *universitätsspital zürich, institute of zytology, switzerland fine needle aspiration (fna) is a well-established method for the evaluation of the aetiology of superficial and deep masses. an infectious process has to be considered as a differential diagnosis in all cases, especially in the setting of immunosuppression (hiv infection, transplantation, chemotherapy, inborn defects). fna allows a rapid distinction between neoplastic and inflammatory/infectious lesions. a wide range of pathogens including various viruses (cmv, ebv), bacteria (grampositive cocci, actinomyces, spirochetes, mycobacteria), fungi (aspergillus, cryptococcus) and parasites (toxoplasma, echinococcus) may be identified cytologically. infectious agents may be visualised either direct in standard stainings (cmv, fungi), in special stainings (mycobacteria) or immunohistochemically (spirochetes), either on direct smears or in cell blocks. molecular methods (in situ hybridization, pcr with sequencing) applied to fna specimen help identify and often subtype the pathogen if required (ebv, mycobacterium tuberculosis vs. atypical mycobacteriosis). fna is a particularly convenient method for fresh, sterile sample collection for microbiological examination with culture and drug resistance studies, playing an important role in treatment decision, e.g. in therapy of multiresistant tuberculosis. in some infectious diseases, the final diagnosis may be made by serology following indirect cytological hints in a fna specimen (e.g. toxoplasmosis, hiv). interestingly, infectious agents have been identified as aetiologically relevant factors in several tumor types (ebv in burkitt lymphoma or lymphoepithelial carcinoma, hhv in kaposi sarcoma, hpv in oropharyngeal carcinoma), so that the identification of the pathogens in fnas may play an important role in the precise diagnosis of some neoplasias. usefulness of oral cytopathology in the diagnosis of infectious diseases in immunocompromised patients p. hofman* *france background: cytology is an accepted and widely employed diagnostic methodology used in the early diagnosis of oral cancer. however, the diagnosis of many other specific clinical conditions of the mouth can be made from examination of smears, in particular infectious diseases. method: in recent years, the spectrum of infectious diseases of the mouth has changed. firstly, oral infections observed in immunocompromised patients have dramatically increased owing to the widespread implementation of solid organ and bone marrow transplantation and in the increasing prevalence of hiv infections. secondly, while the occurrence of many oral lesions has decreased significantly since the advent of highly active antiretroviral therapy, the incidence of oral warts has increased. results: in this regard, cytology can be used as a rapid, noninvasive, inexpensive and simple routine procedure in diagnosing infectious diseases of the mouth. the role of the cytopathology laboratory is diagnostic, i.e., to suggest or identify the presence of an infectious agent. however, exogenous structures that can mimic a variety of pathogens can pose a serious challenge. conclusion: the contaminants can be distinguished from microorganisms by their haphazard arrangement and lack of internal structure. moreover, the absences of acute or chronic inflammation, of macrophages or multinucleated giant cells with or without granulomas, and the absence of necrosis are features that should alert the cytologist to the possibility of contamination. finally, ancillary methods can be developed from cytological samples, which increases the specificity and the sensitivity for the diagnosis of infectious diseases in mouth. the the essentials in making a pathology diagnosis a. batistatou* *greece pathology is the discipline concerned with understanding the nature of human disease. pathologists' interpretations of tissue lesions become data, guiding decisions for patient management. cognition, the sum of processes by which the visual input is transformed, reduced, elaborated, stored, recovered and used, is very important in pathology. looking through the microscope at the stained tissue section (global impression and focal search) leads to perception of forms and colours. various regions are examined under low and high magnifications. then the pathologist puts the observed pieces of the colourful puzzle in place. an experienced pathologist proceeds promptly to pattern recognition and probably to diagnosis, while a novice takes more time, usually by not focusing on the significant areas but rather via an exhaustive search of the whole slide. non-verbalized pattern recognition consists of short sequences which result from conversion of longer series of specific features. alternative cognitive methods are diagnostic algorithms and the hypothetico-deductive strategy. experienced pathologists perceive each case as a whole, constituted by parts varying in importance and relevance. and while novices prefer to use analytic reasoning strategies, which are conscious and controlled, experts often use implicit reasoning, which is unconscious and automatic and relies largely on tacit knowledge. pathologists have faith in the analysis of morphology whose power has been appreciated even in the current molecular era. the use of virtual microscopy has a great advantage over the exchange of static images for diagnosis and training since it also allows for the initial steps to diagnosis, i.e. search, detection and perception. pathology diagnoses were asked for in the context of quality control of cervical cytology and dermatopathology. conclusion: in patient care, the dutch pathologists profit from the historical pathology diagnoses dating back to . for quality control of the lcpl, the diagnoses of other pathology laboratories of the hospitals where the patients of the general practitioners were operated provided by the palga are of paramount importance. in , the palga system will also be employed for the nationwide evaluation of the early detection of cervix, breast, and colon carcinoma. virtual microscopy in routine diagnostic procedure of pathology m. dietel* *universitätsmedizin charité, berlin, germany background: virtual microscopy (vm) is now widely applied in pathology. many studies underline the diagnostic security, the technical robustness as well as the versatility of this method. the standardization organizations dicom, hl and ihe call virtual slides as whole slide images (wsi) now and integrate the technology into their standardization strategy. in contrast to the increasing application in educations, the virtual microscopy is far from routine use in surgical pathology. this goes back to several reasons concerning technical and personal requirements: costs (scanning devices and storage), scanning time (between and min for a biopsy and between and min for a surgical specimen) and speed of virtual microscopes in comparison to conventional microscopy. results: caching and prefetching may speed up image loading, the bottleneck in virtual microscopy. the positive effects of different prefetching and caching technologies which depend on the user's behaviour will be discussed. further, the process of secondary diagnostic was evaluated using the "t. konsult pathologie" service of the professional association of german pathologists within the german breast cancer screening program. conclusion: in summary, it could be shown that the safety of diagnostic on wsi is comparable to the conventional diagnostic based on glass slides and a classical microscope. discrepancies go back to problems with the difficulty of the case itself and not to technical problems with virtual microscopy. virtual microscopy in teaching pathology in pomeranian medical university a. kram*, w. domagała *pomeranian medical university, szczecin, poland objective: microscopy is an important way of understanding the morphologic basis of diseases, and a slide seminar is part of the pathology program in medical schools worldwide. virtual pathology which allows seeing the entire digitized microscopic slide on the computer screen has been introduced recently. here, we share our experience in using digitized slides in teaching pathology and also discuss student's survey results. this has been the first implementation of a complete virtual pathology course for students of medicine in poland. method: two hundred twenty-four virtual slides for pathology course for medical students were produced by the use of aperio scanscope cs scanner and hosted in spectrum database. starting from the year , a group of polish-and english-speaking students used glass slides and microscopes in the first year and then virtual slides in the second year. at the end of the second year, on completion of the pathology course, the students were given a questionnaire to evaluate both systems. results: eighty-five percent of students preferred the screen over the microscope. continuous and easy access to virtual slides via the internet was indicated as one of the major advantages of virtual microscopy. some technical problems having an adverse impact on learning efficacy were noted. conclusion: the move to virtual microscopy and computer-assisted pathology teaching appears to be well received by students and enhance their learning ability in the field of pathology. objective: since years, there is an increase of incidence and mortality of adenocarcinoma as compared to epidermoid carcinoma. this increase is particularly notable for women younger than years. adenocarcinoma equals one fourth of cancers of the cervix in some countries like the uk where there is an organized screening program. method: the bethesda terminology has introduced for the first time the cytological diagnosis of adenocarcinoma in situ, the glandular counterpart of high-grade squamous intraepithelial lesion (hsil). results: it is a rare lesion that corresponds to % of abnormal pap smears and . % of all pap smear diagnoses. adenocarcinoma in situ is characterized by periphery radial arrangement of feather-shaped nuclei, cigar stack-shaped pseudostratified strips, rosettes images, hyperchromatic nuclei with granular structure and clean background without necrosis. on the contrary, invasive endocervical adenocarcinoma is characterized by papillary groups, lost of cellular cohesion, polymorphism of the nuclei with one or two prominent nucleoli and tumoral diathesis with dirty background, cellular debris and fragmented red blood cells. the bethesda terminology has maintained the grey zone for glandular cells abnormalities not well defined, included in the diagnosis of atypical glandular cells of endocervical, endometrial or undetermined. conclusion: the efficacy of cytological screening for detecting ais will lead to the increase of the rate of detection of ais. this will have an impact on the incidence and mortality of invasive adenocarcinoma in the coming years. the protective effect is beginning to be seen only recently for women younger than years in australia and in england. squamous lesions of the uterine cervix j. bulten* *radboud university, dept. of pathology, nijmegen, the netherlands cervical cancer is a major cause of death in women and the second most frequent cancer throughout the world, accounting for almost % of all malignancies in women. in this course, an overview is presented of the precursors of squamous cell carcinoma, its mimics, microinvasive carcinoma and cervical squamous cell carcinoma. the cin terminology (cervical intraepithelial neoplasia, grades - ) of richart is most widely used for cervical cancer precursors. nowadays, it is evident that cin is not a continuum, but reflects merely a low-grade entity (koilocytosis, flat condyloma and cin ) and conversely a true intraepithelial neoplastic process (cin - and carcinoma in situ). in diagnosing cin, hpv testing is not recommended. on the contrary, post-treatment hpv testing can predict treatment failure and thus residual cin. in grading cin and to differentiate cin from its mimics as atrophy, immature metaplasia or reserve cell hyperplasia immunohistochemistry (mib and p ) can be applied. due to preceding biopsies, microinvasive carcinoma is frequently overdiagnosed. colposcopy, cytology and immunohistochemistry are not very helpful in diagnosing microinvasive growth. as the diagnosis of (micro-)invasive growth has great clinical implications, cervical excision biopsies or cones should be totally embedded and serially sampled. there are three types of invasive growth, and the invasion depth should always be measured between the last cell of the deepest invasive focus perpendicular to the (expected) site of origin. finally, the several types of squamous cell carcinoma and its mimics are presented. , and unfavorable prognosis (alveolar rhabdomyosarcoma). immunohistochemistry can be used to separate between embryonal and alveolar rms. ap and pcadherin are almost exclusively expressed in alveolar rms, whereas egf receptor and fibrillin are found in embryonal rms. in addition, the myf- expression of alveolar rms is usually much stronger than in embryonal rms. genetic changes have been found for both embryonal and alveolar rms. most alveolar rms have a balanced reciprocal translocation, t( ; )(q ;q ). a smaller subgroup of alveolar rms has a t( ; ) translocation. two other translocations, a t( ; )(q ;p ), which generates a fusion protein composed of pax and ncoa , and a t( ; x) resulting in a fusion protein pax /afx, have been described in single cases. in embryonal rms, a loss of heterozygosity (loh) on chromosome p . has been shown. the involved gene or genes have not yet been clearly identified, but several interesting genes are located in this area like the myod gene, the igf- gene, the ldh (muscle subunit) gene, and the wt gene. a possible imprinting of this gene has also been postulated. infantile fibrosarcoma and malignant fibrous tumours r. alaggio* *anatomia patologica, scienze diagnostiche e terapie, padova, italy background: fibroblastic/myofibroblastic lesions account for % of pediatric soft tissue tumours and include benign neoplasms, reactive, pseudoneoplastic proliferations and, rarely, malignant tumours. the malignant lesions, registered in the italian protocol rms- , are reported to define their clinicopathologic and molecular features. method: forty-eight patients with fibrosarcoma (congenital and adult) were reviewed (table) . four cases, originally diagnosed as cifs, with negative etv -ntrk transcript, were reclassified as composite fibromatosis (two), undifferentiated sarcoma (one) and rhabdomyofibrosarcoma (one) and excluded from this study. results: see some of these lesions are genuine benign neoplasms; others have a reactive nature. nodular fasciitis is a fibroblastic/ myofibroblastic proliferation mostly seen in the subcutaneous tissue, morphologically presenting a loose and culture-like growth pattern. proliferative fasciitis (and proliferative myositis) is, likewise, nodular fasciitis, a fibroblastic/myofibroblastic proliferation with the presence of large ganglionlike cells. myositis ossificans is a benign and reactive lesion. fibrous hamartoma of infancy is a relatively common benign tumour of early childhood which presents three components: fibrocollagenous tissue, immature-primitive mesenchymal cells and mature fat tissue. myofibroma/myofibromatosis is a benign tumour observed in newborns and children within the first years of life, as well as in elderly patients. fibromatosis colli is a rare benign lesion typically seen in the sternocleidomastoid muscle in infants. microscopically, it is a proliferation of fibroblasts in between the muscle fibres forming a "scar-like" pattern. juvenile hyaline fibromatosis is a very uncommon, non-neoplastic lesion. fibroma of tendon sheath is a benign (possibly reactive) lesion related to tendons. calcifying aponeurotic firbroma is the tumour more frequently seen in children. gardner fibroma is an uncommon benign tumour mostly seen in infants, children and adolescents. calcifying fibrous tumour is a rare benign tumor more frequently observed in children and young adults. background: a standard clinical terminology like snomed ct is important not only for pathology information systems but also to integrate these systems with many other hospital information systems (his, pacs, departmental systems, encoding, database patients) and primary care information systems. method: snomed ct includes two hierarchies (morphologic abnormality and disorder) with similar terms. a snomed ct implementation was designed taking into account both the difference between these hierarchies and the relationship between terms located in different hierarchies. this is especially necessary in the postcoordination of clinical expressions and the creation of subsets. results: the january edition of the subset of pathology, which distributes the college of american pathologists (cap), contains , terms, but this subset needs to be improved to give it a clinical use. in sescam, , morphological concepts and specimen concepts were selected to create a minimum basic set for use in pathology information systems. snomed ct is also used in the sescam telepathology portal (project serendipia), developed according to the ihe-anatomic pathology initiative and dicom supplement- for medical imaging. conclusion: a snomed ct implementation strategy should not only include a list or subset of terms, but it must also consider the efficient use of relationships between terms and concept hierarchies, a mechanism for extension and update, and a plan for the coexistence or migration of legacy snomed ii codes. latest developments in data storage devices applicable for virtual slides j. görtler* *belgium structured reports in tumor pathology-how and why g. haroske* *germany objective: among all medical documents, pathology reports are often highly critical for patient care. in terms of information technology and knowledge engineering, presently, these reports are widely lacking adequate structure to support their usage in knowledge retrieval technologies for medical decision making, research, epidemiology, quality management and medical education. method: by means of literature surveys and by a questionnaire sent to vendors of pathology management systems (pms), the degree of structure in pathology reports in pms sold in germany was analyzed and compared with user needs expressed by pathologists. results: pathology reports are widely displayed, stored and exported as free text, identifiable by human beings, but without "observation identifiers" of a coding system not readable by a computer. a few systems allow textual information to be structured in sections partly identified by coding systems as snomed ct, etc. within the sections, the information is still unstructured. at the very beginning are attempts to structure the report as a list of coded items based on templates, which are controlled for identifiers, version, and the underlying concepts and representations. this is by far the most granular structure for computer readability and knowledge engineering. conclusion: there are very different opinions about the aim and degree of structured reporting. although standardization efforts have led to a series of reporting minimum requirements in tumor pathology, their implementation in structured data entry systems is still lacking. tools for data mining in routine pathology will be decisive for all important progress in pathology informatics at all. experiences of virtual microscopy in tma application g. kayser* *germany how to scale image information in virtual slides? k. kayser*, s. borkenfeld, j. görtler, g. kayser *heidelberg, germany objective: the application of virtual slides requires unequivocal definition and scaling of image information. scaling of image information offers the evaluation of diagnosis and content-based image retrieval (cbir). method: theory in principle-image information can be extracted with or without knowledge of its content. knowing its content (for example organ, potential diseases), we can segment biological meaningful objects (nuclei, membranes, etc.) and measure their features (size, gray values, derived parameters). the obtained results can be scaled and associated with the underlying disease. in reverse, knowing the applied algorithms and the object (and structure) features, cbir can be applied. without predefined knowledge, basic image information is mapped on spatial image units (pixels), called texture. they can be quantified by the application of stochastic geometry: each biological meaningful object is composed of so-called primitives (points, fibers, rings, plateaus). their mapping on an object can be used to detect knowledgeindependent content and scalable image information. results: object-and structure-based ( ) and the texturebased ( ) algorithms have been implemented and applied on more than , images obtained from h&e-stained glass slides of different organs (colon/rectum, lung, pleura, thyroid) in search for disease-significant areas (fields of view) and disease classification. the accuracy of the methods in field of view selection was computed to > %, that of prospective disease classification > %. hyperplastic lesions of the appendiceal mucosa are classically divided into two groups: diffuse hyperplasia and localized polyps. localized lesions were usually diagnosed as hyperplastic polyps, but some of these lesions are now better classified as sessile serrated adenomas. both diffuse hyperplasia and polyps are in most cases incidental findings on appendectomy specimens (performed for appendicitis or systematically sampled in a colectomy specimen). however, these lesions are significantly associated with colon adeno-carcinoma, and therefore, their discovery in an appendectomy specimen is an indication of further examination to exclude colorectal neoplasia. diffuse mucosal hyperplasia extends to more than one half of the circumference of the appendiceal mucosa. it exhibits elongated crypts with serrated architecture. the epithelium is composed of columnar cells alternating with large goblet cells in various proportions. the crypt bases are not serrated and are lined by regular cells with no atypia. hyperplastic polyps are supposed to be rare in the vermiform appendix. they are localized lesions, with a histological aspect similar to the corresponding colorectal lesions. similarly to diffuse mucosal hyperplasia, they are characterized by a serrated architecture restricted to the upper part of the crypts and by the lack of any dysplastic features. when lesions associate hyperplastic serrated features in one area and adenomatous (tubular and/or villous) features in another, they are designated as mixed adenomatous and hyperplastic polyps, as tumours of the colon and rectum. however, it is probable that at least part of these mixed lesions represent hyperplastic serrated polyps that have progressed to dysplasia. sessile serrated adenoma (or sessile serrated polyp or serrated polyp with abnormal proliferation) is a more recently described type of colorectal polyp with a serrated architecture. they occur frequently in the right colon, and although they resemble to hyperplastic polyps, they are characterized by subtle architectural and cytological features, especially dilation and serration of the basal part of the crypts. they can be dysplastic or not. the relative frequency of sessile serrated adenomas and other serrated lesions of the appendix is not well established, but it is highly probable that many appendiceal lesions previously designated as diffuse hyperplasia or hyperplastic polyp represent cases of sessile serrated adenomas. both types of lesions have been proven to show decreased expression of mlh and mgmt in a majority of cases and also braf mutation in a significant proportion of cases. these genetic and epigenetic alterations are similar to those observed in sessile serrated adenoma of the colon, which is now considered as a precursor lesion for a subgroup of colorectal cancer. the differential diagnosis of serrated lesions of the appendix also includes adenomas of colorectal type (more often showing villous architecture when compared to colorectal lesions) and low-grade mucinous neoplasms, often referred to as cystadenomas. adenocarcinoma, mucinous neoplasm of the appendix and pseudomyxoma peritonei a. jouret-mourin* *cliniques universitaires st luc, brussels, belgium primary adenocarcinoma of the appendix is unusual. some resemble typical colonic adenocarcinoma in their appear-ance and behaviour, but others are well-differentiated neoplasms or adenoma-like that may be associated with the pseudomyxoma peritonei syndrome without distant metastases. this pathological spectrum is confused because of terminological inconsistencies and the large variety of diagnostic criteria. therefore, there remains a "grey area" between benign and malignant lesions. some authors have recently proposed a new terminology based on the biological potential of the different lesions. lowgrade appendiceal mucinous neoplasm (lamn) is defined as a subset of lesions that have low-grade cytological atypia and minimal architectural complexity. these lesions penetrate into or through the appendiceal wall often on a broad front, without overt invasion and may be associated with pseudomyxoma peritonei. consequently, such lamn category includes the old terms of "tumours of uncertain malignant potential, "pseudomyxoma with adenoma-like histology" and the "low-grade mucinous adenocarcinoma" which can also produce pseudomyxoma. invasive mucinous adenocarcinoma (maca) includes a destructive invasion of the appendiceal wall with high-grade atypia, complex proliferation (i.e. cribriform pattern), desmoplastic stroma, signet ring cells differentiation or undifferentiated tumours. lymph node metastases occur lately, but peritoneal spreading is more frequent. some recent publications have demonstrated that protein immunoexpression profiles offer predictive factors of adverse clinical outcomes, which should further facilitate the classification of appendiceal mucinous neoplasms. appendiceal mucinous tumours can occur in patients who have suffered long-standing ulcerative colitis, familial polyposis and hnpcc syndrome. most of them show microsatellite instability probably given the high frequency of serrated precursor. pseudomyxoma peritonei syndrome is defined as the presence of abundant mucinous material on the peritoneal surface. this entity should be retained as a clinical term. besides exceptional cases of pseudomyxoma reported in association with mucinous carcinomas at other sites, all cases of pseudomyxoma peritonei are related to appendiceal rupture with subsequent transcelomic spread of tumoral cells. some authors have proposed that the same terminology should be used for the appendiceal primaries and the peritoneal lesions since lamn lesions confined to the appendix have the same appearance as those that have spread to the peritoneum. in addition, any tumour capable of producing pseudomyxoma peritonei should be considered as adenocarcinoma. therefore, the classification of pseudomyxoma perotonei includes low-grade and high-grade mucinous adenocarcinoma. the acellularity of the extra-appendicular mucin, based on extensive sampling, must be described in the pathological report because of its prognostic implications. mixed mucus-secreting and endocrine tumours of the appendix j.-y. scoazec* *hospices civils de lyon, hôpital edouard herriot, france vermiform appendix is one of the most frequent sites of mixed endocrine-exocrine tumours in the gastrointestinal tract. one histologic type of mixed mucus-secreting and endocrine tumor is specific for the appendix: this distinctive tumour is known as goblet cell carcinoid. the others are mixed endocrine-exocrine carcinomas raising the same problems of diagnosis and management than in the other digestive locations. goblet cell carcinoid is a highly distinctive clinical and histological entity. in contrast to the much more common pure neuroendocrine tumours of the appendix, which are usually discovered incidentally in young patients, goblet cell carcinoids present a peak of incidence in the fifth decade and are usually symptomatic. at macroscopic examination, goblet cell carcinoids present a very particular pattern of growth, resulting in the thickening of the whole appendicular wall and in a marked reduction in the calibre of the lumen, in the absence of visible tumour mass. this aspect is due to the predominant infiltration of the deepest part of the mucosa and the submucosa by tumour cells, which result in their fibrosis and thickening. at a higher magnification, tumor cells are grouped in small nests formed by large cells, with an abundant, pale, mucus-laden cytoplasm and an eccentric nucleus. these cells are strongly reactive with alcian blue and pas stainings. small endocrine cells are closely intermingled with mucus-laden cells; they are usually difficult to identify by conventional stainings; they are much more easily demonstrated through the immunodetection of endocrine and neuroendocrine markers such as chromogranin a and synaptophysin. finally, some amphicrine cells, with a combination of exocrine and endocrine markers, may be present. the number of endocrine cells admixed with mucus-laden cells is highly variable from one case to another and even from one region to another in the same tumour. there is no minimal amount of endocrine cells required for the diagnosis of goblet cell carcinoid, which is achieved by the combination of a typical macroscopic aspect, the presence of characteristic mucus-laden cells and the demonstration of even a few endocrine cells intermingled with the predominant mucus-producing population. from the molecular point of view, goblet cell carcinoids frequently harbour loss of heterozygosity in q, q and q. goblet cell carcinoids carry a high risk of peritoneal dissemination, but a low risk of distant metastasis. their prognosis is therefore much poorer than that of typical neuroendocrine tumours of the appendix: the -year survival is only % instead of %, all stages included; even for patients with localized disease, it is % instead of %. importantly, the tnm classification of goblet cell carcinoid must follow the criteria used for the staging of appendicular carcinomas, not those recently proposed for appendicular "carcinoids". mixed endocrine-exocrine carcinomas of the appendix combine an exocrine component, usually corresponding to a mucus-secreting adenocarcinoma of variable differentiation and an endocrine component, which may be well or poorly differentiated. the diagnosis of mixed tumour must be made with caution, only if the endocrine component is clearly neoplastic and represents at least % of the whole tumour. the prognosis and treatment are those of the most aggressive component. electron microscopy has been relatively surpassed by immunohistochemistry in pathology, especially for the diagnosis of neoplastic processes. however, its use is mandatory in neurodegenerative and neuromuscular disorders of non-neoplasic origin. ultrastructural examination has been proven to be useful in the following issues: ( ) to understand the physiopathology of muscle disorders. muscular dystrophies are produced by mutations in genes codifying proteins located at different subcellular levels. ultrastructural alterations have been observed at the level where the defective protein is expressed, i.e. plasma membrane alterations in dysferlinopathies, caveolinopathies and sarcoglycanopathies, or nuclear envelope membrane defects in emery dreifuss muscular dystrophy and laminopathies. ( ) to identify structures not visible with light microscopy. this is the case of intranuclear inclusions in oculo-pharyngeal muscular dystrophy, in inclusion body myositis, or tubulo-reticular inclusions seen in several autoimmune disorders and in aids. ( ) to determine the origin of specific anomalies depicted with light microscopy. ultrastructure of tubular aggregates, nemaline bodies, central cores or paracrystalline mitochondrial inclusions has been crucial to define the origin and organization of such changes at the subcellular components of the muscle fiber. ( ) to study in depth lysosomal storage disorders. the identification of different types of inclusions in neuronal ceroid lipofuscinosis according to the phenotype-genotype form of the disease has been especially useful, and so it was for the diagnosis of late-onset forms of glycogenosis type ii, fabry disease or others. in conclusion, electron microscopic examination is crucial to identify the subcellular structural involvement in some muscle disorders and to understand the underlying pathological mechanisms. electron microscopy of peripheral nerve a. vital* *bordeaux university hospital, dept. of pathology, france objective: electron microscopic examination (eme) of a peripheral nerve biopsy (pnb) is particularly valuable to assess the type of nerve fiber lesions, endoneurial deposits and storage materials. method: a well-done pnb, as well as a reliable methodology for fixation and embedding of specimens, constitute a prerequisite for an informative eme. results: if most cases of hereditary peripheral neuropathies are now diagnosed by molecular biology, nerve lesion analysis can direct the search for mutations in specific genes. prominent "onion bulb" formations are associated with pmp duplication. "tomaculae" correspond to pmp deletion, but can also be observed in certain cases of p mutation. other p mutations are mainly associated with irregularly uncompacted myelin lamellae. discrete "onion bulb" formations in association with "pseudo-onion bulb" formations surrounding clusters of regeneration are much suggestive of connexin mutation. abnormal mitochondria point to a mitofusin gene mutation. ultrastructural evidence of macrophageassociated demyelination is very supportive in atypical cases of inflammatory demyelinating polyneuropathy. in some cases of paraproteinemic neuropathy, myelin lamellae may exhibit a regular spacing corresponding to the presence of immunoglobulin m. in others, granular immunoglobulin deposits are identified in the endoneurium. occasionally, the endoneurial deposits have the tubular ultrastructure of a monoclonal cryoglobulin. the presence of osmiophilic lamellar inclusions in schwann cells points to treatment intolerance. at last, eme of a pnb may help in the diagnosis of a hereditary storage disease. conclusion: eme can be decisive to establish the etiological diagnosis of a peripheral neuropathy and must be supported by a reliable methodology. electron microscopy of metabolic storage diseases i. ferrer* *hospital universitari de bellv, institut neuropatologia, spain metabolic diseases of the nervous system in infancy constitute a very complex group of variegated diseases with particular clinical, morphological, biochemical and genetic characteristics. diagnosis of such disorders usually demands the collaboration of different specialists, methods, and skills. this is particularly important in order to avoid unnecessary probes and superfluous additional suffering related with inappropriate complementary examinations and visits. in recent years, molecular and genetic studies have facilitated a correct diagnosis during life, and improvements in therapy have permitted the application of new therapeutic tools in some cases. morphological visualization of determinate lesions in skin, conjunctival, appendicular and, rarely, rectal mucosa, is extremely useful to support a clinical diagnosis. lipidosis, mucopolysccharidosis, mucolipidosis, polyglucosan storage diseases and glycogenosis affect several cell types outside the central nervous system, including axons and schwann cells, endothelial cells, pericytes, smooth muscle fibres, sebaceous and eccrine glands and ducts, and striate muscle. deposits are usually too small to be visible with an optical microscope. yet electron microscopy permits the observation of lysosomal inclusions filled with specific inclusions and deposition of abnormal material in different cells. in addition to metabolic diseases, other degenerative diseases affecting the nervous system in which the diagnosis is mainly based on key pathological markers are also subject to electron microscopy analysis during life. nuclear neuronal inclusion body disease and infantile neuroaxonal dystrophy, among others, can be diagnosed by means of appendicular (or rectal) biopsies and by examining the nerve terminals and skin and conjunctiva, respectively. this presentation will cover a range of sinonasal inflammatory diseases, focussing on those where an improved understanding of pathogenesis illuminates diagnostic histopathology. the categorisation of sinonasal fungus-related diseases is important for prognosis and treatment. fungi are common airborne allergens and can be cultured from the nasal secretions of most healthy individuals. the diagnosis of fungal sinusitis relies on the histological recognition of fungi in sinus tissue, although the morphology of fungal hyphae is of limited value in distinguishing between fungal species. invasive fungal sinusitis is almost always encountered in patients whose immune system is compromised and is associated with necrosis and vascular invasion by fungi. noninvasive fungal sinusitis includes sinus fungal balls and allergic fungal sinusitis, a disease characterised by socalled allergic mucin and scanty fungal hyphae. the pathogenesis of chronic rhinosinusitis involves a complex interplay between environmental factors and genetically influenced immune responses; eosinophils may be seen in both allergic rhinosinusitis and in patients with no evidence of allergy. the differential diagnosis of inflammatory polyps will be discussed. pathologists should be aware of the many sinonasal diseases that may include a component of granulomatous inflammation including mycobacterial infection, cocaine-induced midline destructive disease and wegener's granulomatosis, and of the value of ancillary investigations such as autoantibodies in their differential diagnosis. autoimmunity to type ii collagen is involved in relapsing polychondritis, a multisystem disorder in which destruction of the cartilages of the nose, ears and upper airway is prominent. classification and diagnosis of sinonasal adenocarcinomas i. leivo* *haartman institute, dept. of pathology, helsinki, finland salivary gland-type sinonasal adenocarcinomas can occur in the sinonasal tract, and they resemble the corresponding tumours in salivary glands. the most common types are adenoid cystic carcinoma and adenocarcinoma, not otherwise specified. intestinal-type sinonasal adenocarcinomas mimic the histological appearances of intestinal adenomas, carcinomas, or rarely even the normal intestinal mucosa. occurrence of the intestinal-type sinonasal adenocarcinoma has been associated with long-term exposure to hardwood (beech, oak) dusts. in the woodworking industry, these tumours can be , times more common than in the general population. the average exposure time is years. histologically, the most common appearances resemble colonic adenocarcinomas. if the resemblance is striking, the rare possibility of a metastasis from the gastrointestinal tract should be considered. similar to colonic adenocarcinomas, intestinal-type sinonasal adenocarcinomas stain for ck , cdx- , and muc , but they also stain for ck . thus, the differential diagnosis between a primary intestinal-type sinonasal adenocarcinoma and a metastatic colonic adenocarcinoma cannot be based on histomorphology or immunophenotype alone. then, the recommended approach is colonoscopy. the intestinal-type sinonasal adenocarcinoma is a high-grade malignancy. however, the prognosis of patients with hardwood dust exposure is better than in sporadic tumours. in addition, papillary growth patterns relate to a more favourable outcome. low-grade sinonasal adenocarcinomas have not shown occupational or environmental associations. histologically, they are papillary or glandular, with a single layer of uniform epithelial cells. cytologically, they are bland, but malignancy is revealed by the complexity of architecture and invasive growth. lowgrade sinonasal adenocarcinomas do not express intestinal immunophenotypic markers. background: computer-assisted microscopy (cam) offers proven solutions in immunohistochemical assessments, sharing digital slides with collaborators in different places, storing and organize pathological and clinical data and research. method: we initially developed an in-house system for the creation of digital slides and for remote diagnoses on frozen sections, suggesting that digital pathology would become the new standard in surgical pathology. in our institution, we adopt cam using the aperio scanscope xs for several applications: results: ( ) detection and semiquantitative measurement of equivocal her immunoreactivity and of ki in breast cancer-our data on over cases with comparison between cam and human evaluation and with fish analysis strongly support its feasibility and reliability in routine practice; ( ) to store and analyze tissue microarrays with all associated experimental and follow-up data, permitting fast access to adjacent sections and comparing stains across multiple slides; ( ) to store clinical-pathological data of patients for discussion in multidisciplinary meetings and courses. conclusion: in our opinion, cam provides a unique opportunity for image visualization and analysis, archival and retrieval, which in the near future will probably replace the usual microscopy in routine practice. bibliography . objective: an automated method for immunohistochemical assessment of ki- proliferation index was developed and evaluated. using an open source image manipulation tool, imagej, a macro called ihcj was created for the assessment of immunohistochemistry stainings. the performance of the ihcj macro was evaluated in a tissue microarray series of breast cancer specimens from , patients. the specimens were stained with an anti-ki- antibody, counterstained with hematoxylin and digitized. the ki- proliferation index was calculated both visually and automatically with the ihcj macro ( fig. ) . the prognostic value of the ki- proliferation index was evaluated in uniand multivariate survival analyses. results: in a univariate survival analysis, the hazard ratio of distant recurrence during a median follow-up of . years for the automated ki- medium area fraction was . during the past years, we have completed a transition of the basic and oral pathology practical courses from light to virtual microscopy. after a pilot feasibility study, the entire training set of glass slides was digitized and located on webmicroscope server. giving access to the web, computers have become perfect companions of the students. the study material consists now of over fully digitized slides covering entities in basic pathology and entities in oral pathology. digitized slides are linked with still macro-and microscopic images, organized with clinical information into virtual cases. we undertake a comprehensive evaluation of this new approach at the end of every academic year. in these surveys, students rate the software, the quality of the images, handling of the images, and effective use of virtual slides during the time of the practical. satisfaction surveys demonstrate a steady improvement over the past years as various student suggestions were implemented. an overwhelming majority of our students considered using digitized slides at their convenience as highly desirable. overall, the quality of the images was rated as very good. however, due to the limitation of resolution of few primary scans, we have rescanned these slides at × objective and a , × , -pixel camera to alleviate these problems. our students and faculty consider the virtual microscope as a significant improvement. the administrators of our department consider virtual microscopy as innovative and costeffective because there is no longer the expense of the maintenance and replacement of microscope and glass slides. a web-based examination system for students using webmicroscopy for learning oral pathology j. szymas*, m. lundin, j. lundin *university of medical sciences, dept. of clinical pathology, poznan, poland we have developed and evaluated a user-friendly online interactive teaching and examination system for pathology courses. already in , at the end of the first course, students take a multiple-choice question exam (one correct answer per question). every exam question is linked with a proper virtual slide and the time for the answer is unlimited. this examination system uses advanced html features, and the web browser that can handle frames, javascript and cookies is required. setting the screen to a resolution of , × or higher and decreasing the size of the menu bars if necessary is helpful in viewing the digitized histological slide and the question at the same time. specific instructions about answering the questions are also given at the beginning of the examination. a score is generated for questions which are correctly answered. the scores are accumulated until the student decides to quit the web browser. in the last years, an overall % concordance rate has been achieved on practical examination based on virtual slides connected with multiple-choice questions per student. the online practical examination system was evaluated by the students using a questionnaire. students were asked to reply to a survey to evaluate the usefulness of digitized slides for practical examination. all students preferred the online examination to a traditional microscope and paper-and-pencil examination and all felt that the quality of digitized slides was superior to that of classical glass slide and allowed to make a more accurate diagnosis (rating . out of ). use of gray level co-occurrence matrix in detecting corresponding fragments and evaluating quality of virtual slides s. walkowski*, j. szymas *poznan university of technology, faculty of computing science, poland virtual slides may be acquired using various scanners, produced by different companies. pathologists who examine digital images captured by different scanners may subjectively assess their quality. in this work, an algorithm which may objectively compare the quality of virtual slides is proposed and implemented. in the first step, the algorithm selects some fragments of the slide captured by one scanner. then, it finds these fragments in virtual slides acquired by scanning the same glass slide using other devices. this is done by creating overviews of the whole slides (by zooming them out) and calculating gray level cooccurrence matrices (glcm) for each selected fragment and for the overviews of other slides using windows of adequate size. comparing some of the haralick features of the matrices (especially measures related to orderliness) allows estimating the positions of the fragments in other virtual slides. detected areas, in original resolution, are used to calculate glcm and its haralick features again. this time, measures for evaluating the quality (like contrast) are used. aggregation of the calculated values allows comparing the relative quality of the virtual slides. this method is tested on two sets of ten virtual slides. they were created by capturing the same set of glass slides using two different devices: robotic microscope axioscope (zeiss) equipped with axiocam hrc ccd camera and deskscan (zeiss) with standard equipment. acquired images were stitched and converted by specialized software based on advances in aerial and satellite imaging. color/image quality standardization in whole slide imaging y. yagi* *usa conclusion: vancb in breast lesions assisted the therapeutic decisions. a close interdisciplinary approach assured optimal results ( ). careful initial clinical-radiologic-pathologic correlation should dictate clinical management of equivocal fibroepithelial lesions diagnosed on core biopsy e. resetkova*, c. albarracin, e. arribas, n. sneige *mdacc, dept. of pathology, houston, usa objective: equivocal fibroepithelial lesions (fel) diagnosed on core biopsy (cb) may prove to be either fibroadenoma (fa) or phyllodes tumor (pt) at excision, due to which their management is controversial. method: ( ) to study the outcome of patients with fel on cb over a -year period at our institution. consensus on initial patient's clinical management was reached during a multidisciplinary conference based on correlation of clinical data, radiology, and pathology. ( ) to examine if any clinical, radiologic or histologic parameters could predict final classification, we retrospectively reevaluated imaging findings (mammography and sonography) as well as multiple histologic criteria (e.g. pattern, stromal cellularity, stromal atypia, mitosis, etc.) on cb and correlated these with diagnosis at excision. results: ( ) of excised lesions, were classified as pts, as benign cfels and as fas. in patients with no excision, no evidence of disease progression was observed ( ± months, mean ± sd). fels with indeterminate or suspect imaging findings, larger size, and an equivocal comment such as "cannot rule out pt" in the pathology report were excised more frequently (p= . , p= . and p= . , respectively). ( ) final diagnoses did not correlate with retrospective evaluation of any clinical data, imaging findings or histologic parameters. conclusion: careful initial clinicopathologic and radiologic correlation may select majority of clinically significant lesions for proper surgical management. follow-up may be an appropriate alternative for a subset of patients, given a good correlation. no radiologic or histologic parameters or clinical data on their own are distinctive enough to predict final classification of fels. objective: inconclusive results of the role of topoisomerase a (topa a) in breast carcinoma biology and therapy are partially due to numerous thresholds of positivity measured by immunohistochemical (ihc) analysis. in the presented study, different criteria found in literature of the subject were compared with results of topa a ihcevaluated material ( cases). in our study, we have the possibility to evaluate topa a in breast cancer cells using two methods (immunohistochemistry (ihc) and fluorescence in situ hybridization (fish)) in all cases. as a part of a broader study, we also were able to correlate the results of topa a in in situ carcinoma, benign lesions and breast tissue without pathological changes. we have also analyzed other prognostic and predictive factors as well as clinical outcome. method: using ihc and fish methods, we compared the percentage of stained cells, strength of nuclear stain, presence of co-expressed cytoplasmatic and membranous stain, amplification of topa a gene and also response to anthracyclin-containing chemotherapy from clinical data. results: analyzing the obtained data, we set our own cutoff points. we assumed that the best correlation both with genomic aberrations and other data listed above, which we considered important in this study, is when both the percentage and strength of stain are taken into account. in our study, a cutoff point for positive topa a status evaluated by ihc method is at least % of carcinoma cells with strong ( +) nuclear stain or at least % of carcinoma with intermediate ( +) nuclear stain. conclusion: the presented criteria as defined above correlate with amplification (ratio ≥ . ) and response to objective: the expression of tyrosine kinases in endometrial stromal tumors is controversial. several sporadic responses to imatinib have been observed in metastatic endometrial stromal sarcomas (ess). we therefore aimed to perform a retrospective analysis of possible molecular targets in ess: c-kit, pdgfra and egfr. method: paraffin blocks from patients with previous diagnosis of low-grade ess and high-grade endometrial sarcomas from nine different institutions were examined and reviewed. exons , , , and of the c-kit gene and exons and of the pdgfra gene were amplified by pcr and sequenced. the incidence and distribution of the kit, pdgfra, cd and calponin expression were examined by immunohistochemistry, and egfr amplification was assessed by fluorescence in situ hybridization (fish). results: no mutations in c-kit and pdgfra genes were detected. we observed several polymorphisms: i i, exon ( / ); v v, exon ( / ); p p, exon ( / ); and one case with a double polymorphism v v/ g g. overexpressions of kit, pdgfra, cd and calponin was detected in ( %), ( %), ( %) and ( %) cases, respectively, whereas amplification for egfr gene by fish was not detected. conclusion: expression of kit in cases of ess is infrequent and always weak. pdgfra expression was observed in % of the cases studied. we did not observe any mutations of c-kit and pdgfra or amplification of the egfr gene. so it is unlikely that patients with ess can benefit from therapies with anti-egfr and/or c-kit tyrosine kinase inhibitors. uterine tumors resembling ovarian sex cord tumors. a study of five cases e. bakula-zalewska*, a. nasierowska-guttmejer, a. daska-bidziska, m. bidziski *institute of oncology, dept. of pathology, warsaw, poland objective: uterine tumours resembling ovarian sex cord tumours (utrosct) cause confusion with respect to nomenclature as well as diagnostic difficulties. these tumours belong to the group of low-grade malignant neoplasms, and their clinical course likely depends on the percentage of the sex cord-like component. morphologically, they can be divided into two groups: those with < % sex cord-like areas (type ) and those with more than % (type ). method: five patients with primary utrosct underwent treatment in the cancer center, warsaw, between and . biopsies or excisions from all tumours were examined microscopically and immunohistochemically (ih). treatment and follow-up were correlated to histopathological diagnosis. results: patients ranged from to years of age and tumour size from to cm. tumours contained % to % of sex cord component (two tumours of type and three of type ). by ih examination, the sex cord-like component was keratin-positive in all five cases, while the stromal component was positive for cd and negative for h-caldesmon. in addition, pgr positivity was found in all cases, while sma, ckae / and inhibin was positive in three. four patients were treated with gestagens in addition to surgery. no recurrences were noted in any of these four patients over a -to -year period of follow-up. conclusion: a correct subclassification of sarcomas of utrosct type is of crucial importance since most patients with these rare neoplasms respond well to gestagen therapy and have a good prognosis compared to other endometrial stromal sarcomas. cd expression in serous invasive ovarian cancer and serous ovarian borderline tumors w. pokieser*, s. hauptmann *wilhelminenspital wien, dept. of pathology, austria objective: cd is a cell surface glycoprotein that plays a critical role as adhesion molecule for the guidance of migration of neuronal cells during embryofetal development. it is also expressed on adult neuroendocrine cells, hematological neoplasms, as well as in various carcinomas. method: in this study, we retrospectively investigated the expression of cd in a series of serous ovarian carcinomas and serous borderline tumors and analyzed the significance of this marker with regard to patient outcome. neuroendocrine cells were determined by immunohistochemical positivity of highly specific chromogranin a. patients were treated homogenously by use of radical surgery and combined chemotherapy (carboplatin and taxol) in the case of carcinoma and of surgery alone for borderline tumors. follow-up data were available for all patients. results: sixty-seven cases ( %) of invasive carcinomas, but only of ( %) borderline tumors, were positive for cd (p> . ), indicating that this phenomenon is significantly more present in invasive lesions. cd expression in the borderline tumor was accompanied by the presence of single scattered chromogranin a-positive neuroendocrine tumor cells, whereas in serous ovarian carcinomas, coexpression was only seen in less than a quarter of cases. conclusion: our results demonstrate that cd positivity is much more frequently found in serous ovarian carcinomas than in serous borderline tumors; however, expression of cd had no prognostic effect. on the other hand, cd should not be used as a marker for neuroendocrine differentiation in serous neoplasm. because of different chemotherapies in neuroendocrine ovarian carcinomas, specific neuroendocrine markers like chromogranin a or synaptophysin are recommended in these cases. are the cancer-testis (ct) antigens reliable markers of stem cells in squamous cell carcinoma of vulva? j. sznurkowski*, a. zabrocki *medical university of gdadsk, dept. of gynaecological oncology, poland objective: vulvar cancer represents - % of all gynecological malignancies. squamous cell carcinoma is a predominating malignancy at this site as it accounts for approximately - % of vulvar cancers. analyses of humoral and cellular immune responses to autologous cancer determined cancer-testis (ct) antigens as potential targets for immunotherapy. as their expression has been identified in a variety of malignant neoplasms, they appeared as potential candidates for target therapy, i.e. t cell-mediated immunotherapy of cancer. method: seventy-six patients with verified histopathological diagnosis and full clinical history were included into the study. the slides were incubated with the monoclonal antibody against mage-a , mage-a and ny-eso- . all statistical analyses were performed with the statistical software statistica . the expression of ny-eso- was revealed in one case. the expression of mage-a and magea- was identified in % and % primary tumors, % and % lymph node metastases and % and % local recurrences, respectively. cytoplasmatic expression of these antigens was identified in suprabasal and squamoid cells of scc ( fig. objective: the objective was to investigate the expression of c-kit protein in salivary gland carcinomas and to correlate it to prognosis. method: immunohistochemistry for c-kit protein was performed in carcinomas using formalin-fixed paraffinembedded sections. for the evaluation of reactivity of tumor cells, a combination of the cytoplasmatic and/or membranous staining and the percentage of positive cells were applied. only cases without any staining pattern were considered negative. for prognostic correlation, univariate disease-specific survival curves were calculated by the kaplan-meier method and distributions were compared using the log-rank test. results: of all cases, only six were c-kit-negative, including three low-grade mucoepidermoid carcinomas, two carcinomas ex pleomorphic adenoma and one salivary analogon of secretory mammary carcinoma. the group of ( %) positive tumors was dominated by nine adenoid cystic carcinomas (all but one revealing strong reaction), followed by five acinic cell, three each mucoepidermoid and salivary duct carcinoma, two carcinomas ex pleomorphic adenoma and five other tumors, in all of which positive staining ranged from % to %, with the immunoreaction varying from weak to strong. diseasespecific survival in c-kit-negative (n= ) carcinomas did not differ from that in positive (n= ) cases (χ = . ). conclusion: of all salivary gland carcinomas, only adenoid cystic carcinoma was regularly associated with c-kit expression. immunoreactivity in other subtypes, considering our as well as published data, greatly varies. c-kit expression harbours no significant prognostic information. results: aspirates were cellular showing groups with stroma and single cells. groups had a variable configuration with two major forms. some were large, three-dimensional and puzzle-like, with little ramifications. cells were densely packed and intimately related to metachromatic stroma. others were of medium size with prominent prolongations consisting of an inner core of hyaline stroma surrounded by tumoral cells. ten cases showed cylindromatous stromal structures. seven aspirations were cystic. stroma was homogeneous with non-fibrillary morphology. neoplastic cells showed a variable morphology from small, basaloid to larger ones with epithelioid morphology. moderate pleomorphism was seen in five cases. there were two misdiagnosis of acinic cell carcinoma, and two cases were considered as suspicious of malignancy. after a revision of these cases, two showed features of bca, while in the remaining two, the suspicious of malignancy persisted because of minimal amount of stroma, predominant epithelioid cell morphology and cellular density. conclusion: bca shows characteristic features that allow in many cases a precise diagnosis. it may be difficult to differentiate from epithelial-rich pleomorphic adenoma, and in these cases, a diagnosis including both possibilities seems preferable. in our series, the absence of stroma was responsible for the misdiagnosis with acinic cell carcinoma in two cases. objective: pheochromocytoma and paraganglioma are rare tumors arising from chromaffin cells. almost % of them are part of typical familial syndromes: von hippel-lindau disease (vhl), neurofibromatosis type (nf ), multiple endocrine neoplasia type (men ) and type (men ), pheocromocytoma-paraganglioma syndromes (pgls; sdhb, sdhc, and sdhd) and a newly described syndrome related to tmem gene mutations. recently, sdhb immunohistochemical analysis has been proposed as a promising molecular marker for succinate dehydrogenase mutation-related neoplasms (i.e. pgls). method: all cases of reported pheochromocytomas (n= ) and paragangliomas (n= ) between and were retrieved from the archives of the department of pathology of padova university. ffpe specimens were genetically characterized for familial syndromes. syndromic cases and a control group were semiquantitatively ( , +, +) evaluated for sdhb immunohistochemical expression. results: out of cases, cases showed sdhd (n= ), tmem (n= ), ret (n= ), men (n= ), vhl (n= ), or nf (n= ) germline mutations. the other six sporadic cases were evaluated as control. the three sdhd-mutated cases showed either negative (n= ) or + (n= ) sdhb immunostaining. completely negative staining was also observed in a sporadic case. a strong sdhb immunoreaction was observed in and a weak immunoreaction in four of the remaining cases. conclusion: sdhb immunohistochemical analysis, even not pgl-specific, can be used to triage genetic testing in pheochromocytoma/paraganglioma patients. further multiinstitutional studies should investigate the diagnostic power of this remarkable novel diagnostic tool. objective: inhibition of dipeptidyl peptidase- (dpp- ) activity by sitagliptin has been shown to improve glycemic control in patients with type diabetes mellitus (t dm) by prolonging the actions of incretin hormones, but the real impact of low-dose sitagliptin treatment on pancreatic lesions is almost unknown. this study aimed to evaluate the effects of sitagliptin on the biochemical and histological (pancreatic) parameters of zucker diabetic fatty (zdf, fa/fa) rats, an animal model of t dm. method: diabetic (fa/fa) zdf male rats were treated with vehicle or sitagliptin ( mg/kg body weight per day) during weeks (n= each). the following parameters were assessed: serum glycaemia, hba c, insulin and lipid profile; serum and pancreas oxidative stress (mda) and endocrine and exocrine pancreas histology, estimating and rating inflammatory infiltrate, fibrosis, vacuolization and congestion in a semiquantitative score ranging from (minimal) to (severe and extensive damage). results: sitagliptin in diabetic zdf rats promoted beneficial effects on dysglycaemia, dyslipidaemia, inflammatory profile and pancreatic oxidative stress. endocrine and exocrine pancreas presented a reduction/amelioration of fibrosis severity, inflammatory infiltrate, intra-islet vacuolation, and congestion vs the vehicle-treated diabetic rats. conclusion: the favourable biochemical profile promoted by sitagliptin in the diabetic rats, together with protection against endocrine and exocrine pancreatic lesions, might represent a further advantage of low doses of sitagliptin in the management of t dm. objective: several studies have suggested an increase in the incidence of right-sided colorectal carcinomas (crc). if the crc right shift is true, it is also likely that the incidence of right-sided advanced adenomas (rsaa) should increase in time. method: two large endoscopic datasets (retro and pbp) have been compared. retro contains data from the department of gastroenterology between and . pbp covers data from the polish national colorectal cancer screening program ( ) ( ) ( ) ( ) ( ) . only patients with ad-vanced adenomas who underwent total colonoscopy were included into the analysis. advanced adenoma was defined as: villous or tubulo-villous, adenoma with high-grade neoplasia or ≥ -cm lesion. two definitions of proximality were applied. the first defined right colon is proximal to the splenic flexure and the second, additionally, the descending colon. a logistic regression analysis was used to compare the incidence of rsaa between groups, adjusted for patients' age and sex. results: two hundred and , patients with advanced adenomas were found in two datasets, respectively. both groups differed significantly according to age and sex. to adjust for possible confounders, the multivariate model was fitted. conclusion: there was no statistically significant increase in the proportion of patients with rsaa between both groups when adjusted for patients' age and sex. objective: the aims of this study were to characterize the immunological microenvironment of tumour buds and evaluate the prognostic effect of immune markers and their ratios with tumour budding stratified by mismatch repair (mmr) status. method: paraffin-embedded tumour blocks from patients with colorectal cancer were cut in series and double-immunostained for ck with anti-cd , -cd , -cd , -cd , -cd , -cd , -cd , -foxp , -granzyme b, -mast cell tryptase, -cd , and -tia- and stratified into mmr-proficient and -deficient cases. tumour buds, immune cells and the ratio of immune cells/tumour buds was obtained. results: mmr-deficient tumours showed significantly less tumour budding (p< . ) and greater amounts of cd + , cd + , and granzyme b + cells (p< . ). high amounts of cd + , cd + , cd + , cd + , foxp + , granzyme b + and cd + were linked to improved survival (p< . ). prognostic effects differed between proficient and deficient tumours. marker/budding ratios showed stronger relative risks of death when compared to most markers alone. in lymph node-negative patients, high marker/budding ratios of cd (hr, . ( . - . )), cd (hr, . ( . - . )), cd (hr, . ( . - . )), foxp (hr, . ( . - . )) and granzyme b (hr, . ( . - . )) were independently linked to improved outcome. conclusion: marker/budding ratios for cd + , cd + , foxp + , granzyme b + and cd + are stronger prognostic features than the assessment of immune markers alone. these ratios are independent prognostic factors, particularly in lymph node-negative patients. moreover, our findings underline the considerable confounding effect of mmr status in the evaluation of immune response in colorectal cancer. human crypt stem cell dynamics in juvenile polyposis (jps) and peutz-jeghers (pjs) patients d. langeveld*, f. morsink, v. de boer, j. offerhaus, w. de leng *umc utrecht, dept. of pathology, the netherlands objective: pre-tumour progression is a process that precedes the adenoma-carcinoma sequence; colorectal mucosa appears normal, but cell kinetic and stem cell abnormalities suggest the existence of molecular alterations. pre-tumour progression can be made visible by studying methylation patterns, or tags, in stem cells of the crypt. shibata et al. ( ) showed higher crypt methylation heterogeneity in normal-appearing colonic crypts of familial adenomatous polyposis (fap) patients compared to normal crypt mucosa of non-fap colons. this indicates enhanced stem cell survival, which may be a predictive marker of increased neoplastic outgrowth since longer lived stem cells have the potential to gain more mutations. the objective of this study was to investigate stem cell survival in juvenile polyposis syndrome (jps) and peutz-jeghers syndrome (pjs), a biomarker predictive of pre-tumour progression. method: dna was isolated from laser-microdissected crypts of normal colonic jps and pjs tissue and agematched controls. dna was bisulphite-converted and methylation tags were created by amplifying the cpg islands in the csx gene. sequence analysis of this pool of methylation tags allows characterisation of the heterogeneity among the different tags recovered from multiple stem cell pools. objective: lymph node metastasis is an important prognostic factor in esophageal cancer. vascular endothelial growth factor c (vegf-c) and vascular endothelial growth factor d (vegf-d) are considered to induce both lymph node metastasis and lymphatic involvement in various cancers related to lymphangiogenesis. in many types of cancer, podoplanin (d - ) immunostaining has recently been used to detect lymphatic vessel invasion (lvi), but invasion detected using d - immunostaining for a predictor of nodal metastasis was controversial. we examined the relationship between vegf-c, vegf-d and lvi and clinicopathological features in patients with esophageal cancer who underwent esophagectomy. method: vegf-c, vegf-d and podoplanin expression was examined using immunohistochemical staining in surgically resected tissues. differences in categorical data were assessed by a chi-square test or fisher's exact test. results: podoplanin expression was observed in the endothelial cells of lymphatic channels. none of podoplanin-positive vessels were blood vessels. intratumoral lymph vessels were small and collapsed, while peritumoral lymphatic vessels with lvi were dilated and large. the expression of vegf-c and vegf-d protein was recognized in the cytoplasm of cancer cells, but not in the nucleus. we found that peritumoral lvi significantly correlated with lymph node metastasis (p= . ), pathologic stage (p= . ), tumor depth (p= . ) and tumor size (p= . ). the expression levels of vegf-c and vegf-d were associated with lvi. conclusion: vegf-c, vegf-d and peritumoral lvi may play an important role in lymphangiogenesis and the process of lymphatic metastasis of esophageal cancer. objective: for several anatomical localisations of extranodal marginal zone lymphoma of malt type (emzcl), an association with chronic inflammation caused by microbiological agents (e.g. helicobacter pylori in the stomach) has been described. in the lung, a link between lymphomagenesis and a defined causative organism is still missing. method: a comprehensive diversity survey using s rdna library construction followed by restriction fragment length polymorphism (rflp) analysis, sequencing and phylogenetic tree construction was employed on nine cases each of balt lymphoma and control lung tissues (normal fetal lung, pneumonitis, cancer). this highly sensitive method, hereafter termed "sharp-screening", allows for the identification of the entire bacterial population in the tissue in a cultivation-independent manner. following the results of sharp screening, an alcaligenaceae-specific pcr assay was employed on additional balt lymphoma cases and control lung tissues. results: in eight of the nine cases of balt lymphoma, bacteria of the alcaligenaceae family (alcaligenes, achromobacter, akiw ) were detected, whereas none of the control cases showed the presence of these clades. the subsequently performed alcaligenaceae-specific pcr assay detected bacteria of the alcaligenaceae family in of the independently investigated balt lymphoma cases and in only one of control lung tissues. conclusion: s rdna library construction in combination with rflp screening and phylogenetic analyses (sharp-screening) is a novel, molecular and cultivationindependent tool for the analysis of the microbial environment in chronic inflammation processes. betaproteobacteria of the alcaligenaceae family may be associated with and possibly involved in the lymphomagenesis of balt lymphomas. objective: diffuse large b cell lymphoma (dlbcl) is the most common type of non-hodgkin lymphoma. recently, major advances in the molecular characterization of dlbcl have been made through gene expression profiling studies that provided more insight into the biological heterogeneity within dlbcl. one of the identified molecular subgroups has been termed the "b-cell receptor (bcr)/proliferation cluster" due to the increased expression of bcr signaling cascade components including the spleen tyrosine kinase (syk), which has emerged as an important therapeutic target within tumors of this subgroup. in fact, a recent clinical trial with a syk inhibitor on uncharacterized dlbcls has shown promising results, but only in a subset of patients. method: we employ a novel quantitative tissue-based immunohistochemical (ihc) methodology using markers of activated bcr signaling to assess the activity of the bcr pathway in formalin-fixed paraffin embedded primary dlbcls. results: antibodies to phosphorylated forms of lyn, syk, btk, blnk and akt as well as foxo antibody represent attractive ihc markers to evaluate the activation of bcr signaling and comprise the basis of a biological signature of activated bcr signaling in dlbcl. conclusion: we report on the development of a quantitative tissue-based immunohistochemical (ihc) methodology employing activation-specific antibodies against multiple components of the bcr signaling pathway that will assess the activity of the bcr pathway in formalin-fixed paraffinembedded primary dlbcls. this approach will identify the subset of patient tumors that are actively signaling through the bcr pathway and, therefore, will predict therapeutic responsiveness to targeted inhibition of bcr signaling. enteropathy-associated t cell lymphoma: a clinicopathologic study focussing on prognostic factors and the frequency of defective t cell receptor chains p. czapiewski*, p. fisch, a. schmitt-graeff *medical university of gdansk, dept. of pathology, poland objective: enteropathy-associated t cell lymphoma (eatl) is a rare highly aggressive t cell neoplasm divided into type i (cd − , cd − ) and type ii (cd + , cd + the presence of intra-tumoral neutrophils is an independent prognostic factor in early-stage non-small cell lung carcinomas m. ilie*, v. hofman, c. butori, c. marquette, n. vénissac, j. mouroux, p. hofman *chu de nice, lpce, france objective: cancer-related inflammation has emerged as the seventh hallmark of cancer. in the tumor microenvironment, inflammatory cells, including neutrophils, influence almost every aspect of cancer initiation and progression, including tissue invasion and metastatic potential. however, the influence of intra-tumoral neutrophils in non-small cell lung carcinoma (nsclc) progression is currently unknown. this study was conducted in order to correlate the number of tumor-associated neutrophils (tans) and the prognostic of stage i nsclc. method: immunostainings on stage i ( t n and t n ) nsclc included on tissue microarrays were performed with anti-myeloperoxidase and anti-cd b anti- results: the patients comprised ten women and one man (mean age . ± . years, age range - years). immunofluorescence microscopy showed intense linear staining for igg and c along glomerular and distal tubular basement membrane in all patients. by light microscopy, irregular diffuse or focal extracapillary crescentic glomerulonephritis was found in all patients, associated with necrosis of varying extent in nine. the percentage of crescents was % to %. extraglomerular necrotizing vasculitis of small arteries was present in six patients, and in one, elastica destruction indicative of previous vasculitis was observed. an assessment of the age of histopathologic lesions showed lesions of varying age in all biopsies. active lesions were predominant in four and chronic in three, while active and chronic lesions of equal distribution were seen in four biopsies. conclusion: all our patients with coexisting anti-gbm antibodies and anca were older and all had renal histopathologic lesions of varying age, active and chronic. these results confirm a hypothesis that anti-gbm antibody production may start after injury to the glomerular basement membrane by anca. renal amyloidosis secondary to behçet's disease: clinicopathologic features of cases k. kosemehmetoglu*, d. baydar *ankara ataturk eah, dept. of pathology, turkey objective: amyloidosis is a rare complication of behçet's disease (bd). we describe ten patients with bd and renal amyloidosis. method: kidney biopsy slides were culled from the archives and reviewed. intensity and relative distribution of amyloid deposition in renal compartments were noted. glomerular deposits were classified as hilar (pattern i), mesangial nodular (pattern ii) and mesangiocapillary (pattern iii). chronic tubulointerstitial damage was graded from to ( %, -< %, -< % and ≥ %). amyloid typing was performed by immunohistochemistry. clinical information was gathered from hospital records and computer-based patient data system. results: all patients were male. their age ranged from to . full-blown nephrotic syndrome was present in six cases. duration of bd before diagnosis of amyloidosis differed from to months (mean ), and mean follow-up period was . months. immunohistochemical typing revealed aa amyloid in all ten. four cases showed glomerular-dominant and two cases vascular-dominant amyloid deposition; the rest were co-dominant glomerular and vascular. the frequencies of glomerular amyloid patterns were % for hilar, % for mesangial nodular and % for mesangiocapillary. hilar pattern was associated with vascular-dominant amyloid deposits. severe proteinuria correlated with the presence of mesangiocapillary pattern. grade iii chronic tubulointerstitial injury was detected in three cases. patients were treated with steroids and/or different immunosuppressives. among them, two progressed to endstage kidney failure, one showed remission, two were lost to follow-up, and rest had persistent proteinuria. conclusion: renal amyloidosis in bd has a diverse pathology in terms of preferential location of amyloid deposition and its intensity. patients follow variable clinical courses accordingly. objective: kras is an oncogene that is commonly mutated in various malignancies. mutations in kras are associated with lack of response to anti-egfr treatment in colon and lung carcinomas, and patients must undergo genetic testing to be eligible for treatment. several genetic tests for kras mutation analysis exist, but most are either too expensive or lack the sensitivity to identify a mutation if the percentage of tumor cells in the sample is small. the purpose of the present study was to develop a novel kras mutation detection method that is both cost-effective and sensitive. method: we designed a locked nucleic acid (lna)containing probe that inhibits the amplification of wildtype kras, thereby giving an advantage to mutated kras in pcr reaction (pcr clamping). the sensitivity of this method was evaluated using serial dilutions of plasmids containing wild-type and mutated kras fragments. the method was further evaluated on archived tissue samples of colon carcinoma and compared to direct sequencing and high resolution melting (hrm) methods. results: lna-based probe successfully inhibited the amplification of wild-type kras. the method enabled the detection of as little as % mutated dna in the sample analyzed. the method was superior to direct sequencing when the percentage of malignant cells in the sample was % or less. there was % correlation between the results of pcr clamping and hrm. objective: a newly discovered gene, jk- (fam b), located in chromosome p . plays an important role in the molecular pathogenesis of esophageal cancer. this study aims at examining the role of this gene in colorectal tumors by analyzing the differences in gene mrna expression in both benign and malignant colorectal tumors. the study was performed on colorectal adenocarcinoma, benign adenoma and nonneoplastic colorectal tissues. gene expression levels were determined using real-time pcr. the expression levels were calculated as a ratio of the ct value for jk- to gapdh and expressed as inverse ratio. results: the jk mrna was detected in all colorectal tissues. the mean inverse ratio for jk- gene in adenoma samples was . ± . , which was significantly higher than in non-tumor samples which was . ± . (p= . ). on the other hand, cancer samples had a mean inverse ratio of . ± . , which was significantly lower than in non-tumor tissues (p< . ). the under-expression of the gene in cancer suggests that loss of gene expression may promote tumor progression, that it may act as a tumor suppressor gene, or that it relates to certain genetic events in tumor pathogenesis. however, over-expression of jk- in adenoma samples may indicate that jk- has a functional role in dysplastic benign colon tumors, a function that is disrupted once the tumor progresses to a more invasive form. wednesday, objective: invasive breast carcinoma represents are characterized by invasion of adjacent tissues and a marked tendency to metastasize to distant sites. in order to determine specific prognostics factors, we established histopathologic, immunohistochemical and morphometric profiles of these types of carcinoma. method: in our study, we investigate cases diagnosed with invasive breast carcinoma in which we established microscopic characterization, immunohistochemical profiles (expression of proliferation markers, steroid receptors and her ) and computer-assisted morphometric profiles by determining the mean values for nuclear area, cellular area and n/c ratio with lucia net software. the distribution of markers and histological grade among types of carcinoma was statistically analyzed using the χ test. results: the histological type of invasive carcinoma was: . % ductal carcinoma, % mixed ductal and lobular carcinoma, and . % lobular carcinoma. according to histological differentiation, % was g , % was g and % was g . immunohistochemical expression of er was positive in % and negative in %, for pr was positive in % and negative in % and the expression of her was positive in % and negative in %. ki was intensely positive in %, moderately positive in % and intensely positive in %. p was positive in % cases and negative in % of cases. morphometric analysis revealed that mean nuclear area and n/c ratio increase are concordant with grading, but mean cytoplasmatic area has no characteristic variation. conclusion: the expressions of proliferation markers correlate with carcinoma grading. poorly differentiated and triple-negative carcinoma (er, pr and her ) with intense expression of proliferation markers and increase mean nuclear area have negative prognosis. objective: mapping tumour cell protein networks in routinely processed clinical samples, like formalin-fixed and paraffin-embedded (ffpe) tissues, will be critical for realizing the promise of personalized molecular therapy as only a subset of patients will respond. therefore, techniques being able to detect the entire spectrum of deregulated pathways in tumors before, during, and after treatment are required to assess success or failure of targeted therapies. the aim of our study was to monitor protein networks in ffpe breast cancer tissues with special emphasis on epidermal growth factor receptor (her )mediated signaling pathways to identify and validate new disease markers in order to predict response to current treatments. method: using a recently developed technology for the extraction of full-length proteins from ffpe tissues, we analyzed molecules involved in her -related signaling by reverse phase protein microarray (rppa) in a series of ffpe breast cancer patients. to this end, we evaluated > commercial antibodies for specificity in lysates from ffpe breast cancer samples in western blots and rppa. results: we found her (r's= . ), the egfr (r's= . ) and the receptor of upa (r's= . ) correlating with her . however, we could not demonstrate any significant correlation between her expression and clinicopathological parameters. conclusion: our results uncover molecules linked to her signaling and cancer progression. thus, these finings provide possible new targets for cancer treatment and may assist in optimal patient selection. objective: the pi k/akt/mtor pathway has a fundamental role in signal transduction, and its alterations are of pathogenetic role in human cancer, including breast carcinomas (bc). several drugs may interfere with the altered activation of this pathway, including the recently developed mtor inhibitors. however, few data are available concerning mtor levels in human breast cancer. method: the aim of the present study was to analyze the immunohistochemical expression of mtor and p s k in a consecutive series of bc, with long-term follow-up which had been studied for er, pgr, her , p and mib expression and for pi k and akt mutations. results: mtor and p s k expression were positively associated (p = . ), but were not related to other molecular markers with the exception of high p s k being associated with pi k mutations (p= . ). in the whole series of cases, mtor and p s k are not associated with clinical outcome. however, high mtor are associated with prolonged dfs and os in node-positive cases, in st. gallen high-risk group, and in patients treated with chemotherapy. high p s k expression was associated with prolonged dfs and os in st. gallen high-risk group. conclusion: our data show that mtor and p s k are promising biomarkers in bc whose level of expression may be of prognostic value. objective: lymphangiogenesis occurrence and the biomechanisms in lymph nodes are still unknown. the immunohistochemical application of the usually known lymphatic markers vegfr- , lyve- , prox- , and podoplanin was explored to study lymphatic vessels in tumour metastasis and non-metastatic lymph nodes of breast cancer cases to understand the metastization pathway. method: lymph nodes without and with metastases from cases of invasive breast cancer were selected. serial sections were immunostained for vegfr- , lyve- , prox- , and podoplanin using immunohistochemical protocols in accordance with the respective recommendations. the microanatomical distribution of each antibody in the lymph node, different cell type expression, adjacent mesenchymal structure positivity and neoplastic cell positivity were validated and reported as negative and positive (with the cutoff +, ++, +++ for the neoplastic cells). results: no markedly or obvious staining was obtained for lymphatic vessels. positive staining of metastatic neoplastic cells, lymphoid cells of germinal centres and node pericapsular fatty tissue has been observed. immunostained neoplastic cells revealed a predominant subcapsular and perihilar location. conclusion: the applied primary antibodies were unsuccessfully used as lymphatic markers. the spread of neoplastic cells expressing these markers may have acquired particular characteristics to develop lymphatic dissemination until reaching lymph nodes. lymphangiogenesis in breast cancer continues without demonstration in lymph nodes, while the fatty tissue can be implicated in epithelial mesenchymal transition (emt). this thesis turned up by the proximity of the positive neoplastic cells to the mesenchymal components of surrounding lymph node tissue as adipocytes were immunoreactive. objective: there is a significant percentage of patients with metastatic breast cancer and her receptor overexpression that do not respond to therapy directed with trastuzumab. in these patients, overall survival and diseasefree time are significantly shorter. several mechanisms that explain the resistance to therapy with trastuzumab have been reported. this paper aims to address the study of alterations in one of the signalling pathways of her related trastuzumab in response to breast cancer in order to incorporate into the clinical routine of other predictive biomarkers of response to therapy. method: the study comprised cases of metastatic breast carcinoma with her overexpression (herceptest +) or gene amplification (fish). all patients were treated with trastuzumab. the assessment of pten and pakt expression was based on staining intensity and percentage of stained cells. results: our series showed a statistically significant association between a positive expression of pten and a reduced expression of pakt (p = . ). the positive expression of pten was associated with a better treatment response rate (p = . ). it was also noted that the reduction of pten was associated with a shorter time of progression (p= . ) and a lower overall survival (p= . ). pakt overexpression was associated with a lower overall survival (p= . ). conclusion: our study shows that immunohistochemical expression of pten and pakt could be used as both prognostic and predictive biomarkers in breast cancer. objective: vascular endothelial growth factor (vegf) has been shown to play a major role in tumor angiogenesis in many studies. this study aimed at evaluating the relationship between vegf expression and lymph node metastasis in patients with invasive ductal carcinoma (idc) of the breast. method: in a case-control setting, we evaluated specimens of idc in patients with and without axillary lymph node metastasis. the immunohistochemistry staining was employed for evaluating the expression of vegf in the specimens of both groups. the rate of positive specimens was then compared between the groups. the relationship between the vegf expression and the size and grade of tumors were assessed. results: eighty women with idc of breast, cases with axillary lymph node metastasis and controls without any evidence of axillary lymph node involvement, were enrolled. there were ( %) and ( %) cases with positive expression of vegf in the case and control groups, respectively (p= . ). the mean size of tumor was significantly higher in patients with positive expression of vegf ( . ± . cm vs . ± . cm, p= . ). the current study showed that there is no significant relation between the rate of expression of vegf in cases of idc of the breast and the axillary lymph node metastasis; however, there may be a relation between vegf and the size of the tumor. abnormal membrane cytoskeletal cross-linker ezrin cellular distribution is associated with clinicopathological features in invasive breast cancer a. halon*, p. donizy, l. halon, r. matkowski *wroclaw medical university, poland objective: ezrin is member of the erm (ezrin/radixin/ moezin) protein family which acts as a membrane organizer and linker between the plasma membrane and cytoskeleton and plays a key role in the control of cell morphology, adhesion, polarity, motility and cell survival. the aim of the present study was to elucidate the clinical significance of subcellular expression pattern of ezrin in patient with invasive breast cancer (bc). method: immunohistochemistry for ezrin monoclonal antibody was performed on paraffin-embedded specimens from patients with bc. immunoreactivity was semiquantitatively scored according to remmele immunoreactive score (irs). results: expression patterns of ezrin were divided into cytoplasmic ( , . %), membranous ( , . %), nuclear ( , . %) and apical ( , . %). cytoplasmic pattern was the only one observed in cases ( %) and mixed immunotopography in the others. there were significant positive associations between apical and membranous ezrin localization and favorable tumor characteristics and lack of lymph node metastases. cytoplasmic ezrin staining was associated with adverse clinical outcome. lack of apical ezrin was likely to present with bone metastases in the absence of visceral disease. membranous ezrin localization was correlated with good prognosis both for csos (p= . ) and dfs (p= . ). a multivariate analysis demonstrated that membranous ezrin distribution is an independent prognostic factor (p= . ). conclusion: the switch of ezrin localization from the apical and the membrane to the cytoplasm is correlated with dedifferentiation and adverse features in bc. cellular ezrin distribution contributed to discriminating between patients with lymph node and distant metastases and those with better prognosis. objective: epidermal growth factor receptor (egfr) is a tyrosine kinase growth factor receptor expressed in a variety of human cancers and related with poor prognosis. recently, the astounding development of molecule-targeting drugs such as anti-egfr-targeting drug has attracted considerable interest of oncologists. the objective of this study was to evaluate the expression of egfr in breast carcinomas and its possible relationship with different clinical-pathological parameters. method: one hundred and seventeen breast carcinomas were included in this study. using a standard immunohistochemical technique, the expression of egfr, her , and hormone receptors was investigated. in addition, haematoxylin and eosin-stained sections of these tumors were studied for several morphological parameters. results: egfr-positive expression was detected in nine tumors ( . %). expression of egfr was positively associated with high histological grade (p= . ), highgrade comedo-type necrosis (p= . ), high degree of stroma lymphocyte infiltration (p= . ), pushing tumor margin (p= . ), and hormone receptor-negative her negative status (triple-negative phenotype, p= . ). no significant difference of egfr expression according to age was recognized. conclusion: egfr expression is more often present in the group of triple-negative breast carcinomas, and its expression is associated with features of poor prognosis. egfr expression might be important as a potential target for molecular therapy in breast cancer. objective: the purpose of the study was to assess morphometric parameters of nuclei and nucleoli in invasive ductal breast carcinomas and to compare them with axillary lymph node status. method: histologic sections from tumors were stained with methyl green-pyronin y and measurements were made using a computerized image analysis. the following seven parameters were evaluated: the nucleolar area, long-to-short nucleolar axis ratio, nucleolar shape parameter assessing the degree of nucleolar roundness, the nuclear area, long-toshort nuclear axis ratio, number of nucleoli in the nucleus and the percentage of the nuclear area occupied by nucleoli. results: a statistically significant association between a nuclear area, long-to-short nuclear and nucleolar axis ratio and bloom-richardson (b-r) histologic grade of breast tumors was found in relation to the axillary lymph node status. in b-r grade tumors, the nuclear area was significantly larger in tumors with negative versus positive axillary lymph nodes (p< . ). long-to-short nuclear and nucleolar axis ratios were higher in b-r grade tumors with negative versus positive lymph nodes (p< . ), i.e. the shape of nuclei and nucleoli of tumor cells from node-negative cancers was more elliptic as compared to node-positive ones. objective: the urokinase-type plasminogen activator (upa) and its main inhibitor pai- facilitate migration and invasion of cells in physiological and pathological contexts. both factors are clinically applicable predictive markers in node-negative breast cancer patients used to stratify patients for adjuvant chemotherapy. besides their classical functions within the plasminogen activation system, these factors are shown to play important roles in cell signaling, thus providing new possibilities to interfere with cancer progression and metastasis. although such networks are well described in cell culture systems, their analysis in tissues was hindered because protein extraction and direct analysis was possible only from fresh or frozen material, which may be not available in routine laboratory setting. method: we extracted proteins from formalin-fixed paraffin-embedded tissues, being the main source of archived patient samples in pathology institutes worldwide, by a new protocol developed in our laboratory and analyzed the extracts for interactions of upa and pai- with molecules belonging to signaling cascades relevant in cancer progression in a collective of breast cancer patients using protein microarrays. results: a substantial correlation of upa with erk and stat expression was ascertained, while pai- correlates with akt activation and egfr-related signaling. statistical analysis of upa and pai- protein expression did not reveal a significant correlation of upa or pai- with staging, grading or age of the patients. objective: breast cancer is one of the most common human neoplasms accounting for approximately one quarter of all cancers in females. in young women, the risk is low, but because of the density of breast tissue, by the time a lump can be felt, the cancer is often advanced. fine needle aspiration of breast lesions is routinely performed in our hospital. we reviewed our archives and found the cases of breast cancer in women under years old. method: between january and march , fine needle aspirates in breast lesions were performed in our institution. the aspiration was done using a -gauge needle. conventional and thinprep smears were prepared. estrogen and progesterone receptor studies were part of the routine workup of a breast cancer as well as other markers (c-erb-b , p , e-cadherin, gcdfp- ). results: one hundred and fifty-eight of the cases were carcinomas. ten of these patients were under years old (mean age . ). in eight of these patients, cytology correctly diagnosed seven ductal and a tubular carcinoma. in two cases, the cytologic diagnosis was suggestive of carcinoma, and the excisional biopsy revealed a lobular and a mixed carcinoma. conclusion: it is mandatory in young women that a breast lesion be identified using mainly ultrasound and fine needle aspiration, which are simple and well-tolerated diagnostic tools. however, mammogram may also be recommended for younger women when a family history of breast cancer or other risk factors exist. mgmt protein expression as a potential prognostic marker in breast cancer j. objective: sentinel lymph node biopsy (slnb) is rapidly becoming the standard of care in staging the axilla for early-stage, clinically node-negative breast cancer. this audit reviews the laboratory handling and pathological reporting of sentinel nodes (sns) across kent and has been performed at the request of the kent cancer network breast disease oriented group (dog). method: a retrospective analysis of consecutive breast sn cases from each of the five kent hospitals was carried out. all reports and slides of positive sns were reviewed. detailed structured questionnaire-based enquiries to lead breast pathologists were made. data were entered in microsoft excel and analysed in relation to the standards. all aspects of the pathology service were examined, including macroscopic data (number of sns/case, dimensions, sampling and slicing details) and microscopic data (performance of levels and immunohistochemistry, tnm staging and snomed coding). results: one site was unaware of radioactivity guidelines while another was unaware of national guidelines. twenty-eight percent to % of sns were bisected longitudinally and levels were sparingly used, except at site. tnm staging and snomed coding in the reports were variable. conclusion: this audit demonstrates a substantial variation in sn handling and reporting practice across kent. since the quality of the pathology service in breast cancer is of paramount importance, it is imperative that a standardised approach is achieved in the handling and reporting of sns. to achieve this, recommendations have been made and agreed upon, the success of which will be measured in a reaudit next year. objective: background: the study analyzes the positivism of the p protein and the oncoprotein c-erbb and their implication in the appreciation of prognostic invasive mammary carcinomas. method: in invasive mammary carcinomas, we have realized the immunohistochemical determination of the p protein with the avidine-biotine complex method (abc) using the dako p mouse monoclonal antibody (dilution : ). in invasive mammary carcinomas, we have determined immunohistochemically the c-erbb oncoprotein with the dako rabbit polyclonal antibody, human anti-protein c-erbb (dilution : ). the tumoral tissues were fixed in % formaldehyde and included in paraffin. results: out of invasive mammary carcinomas, ( %) have been p -positive, and out of carcinomas, ( . %) overexpressed the c-erbb oncoprotein. in the studied casuistic, we did not remark any connection between the p expression and the overexpression of c-erbb . conclusion: the presently best-known mutant gene in invasive mammary cancer seems to be the p tumor suppressor gene. we did not remark any connection between the p protein expression and the tumors' sizes, patients' ages, the clinical stage of the disease and the overexpression of c-erbb . the usage of the c-erbb status (her- /neu) in patients suffering invasive mammary carcinomas is a predictor of therapy response. objective: there are only a few entities in the breast which show a chondroid differentiation. the differential diagnosis varies from the harmless choristoma to the also benign pleomorphic adenoma, to the syringioma and phylloides tumour with uncertain dignity to the high malignant metaplastic carcinoma. the differentiation between these different neoplasias is essential for the patient because of the following therapeutical procedures and the prognostic outcome. the final diagnosis in a mammary punch biopsy may be difficult or impossible because of the small specimen and the heterogeneity of the tumour. method: our specimen is taken from a -year-old female. with mammography, new polymorph calcifications were found in the left breast. the results were classified as birads and surgical excision was recommended. one month after mammography, a stereotactic wire-marked diagnostic excision was performed. results: in histological examination, a chondroid proliferation appears with a beginning metaplastic ossification and two small foci of spindle cells and myxoid appearance. no suspicion for malignancy was found in the whole specimen. a chondroid choristoma in the left breast was diagnosed. in mammographic control months later, no calcifications were detectable. so the tumour was totally removed. conclusion: a choristoma of the breast is very rare. in literature, it is described as choristoma (tavassoli ) or as true chondroma (rosen and oberman ). the secured demarcation between the differential diagnosis is only possible at the in whole removed and nearly totally examined tumour. a chondroid differentiation in a mammary punch biopsy should be classified in the category b . a diagnostic excision should be always performed. objective: vascular tumors of the breast are very uncommon, consisting of variants of hemangioma and angiosarcoma. although angiosarcoma related to chronic lymphoedema is the most frequent, it only represents . % of breast tumors. usually, primary angiosarcoma involves young pregnant females, with only six cases occurring in males reported to date. epithelioid angiosarcoma is very unusual; their presence in males has been reported only once before in a young patient. method: this is the second case report of an epithelioid angiosarcoma in a male breast but the first one of poorly differentiated type. it developed in a -year-old patient, unrelated to hormonal dysfunction or treatment. results: the tumor located in the breast parenchyma had a -cm diameter and solid firm multinodular grey colour areas admixed with cystic spaces with hemorrhagic content. microscopically, the tumor was composed of mainly polygonal epithelioid tumor cells with abundant eosinophilic or pale cytoplasm and pleomorphic nuclei, arranged in solid areas and admixed with few spindle cells. less than % of the tumor was composed of more differentiated areas. the tumor cells in both solid and cystic areas were positive for cd and vimentin but negative for cd , er, pr, hmb- , and s- protein. pan-ck was positive in both epithelioid and spindle tumor cells. conclusion: immunohistochemistry is very useful in order to establish a correct diagnosis; factor viii, cd and cd can be used singly or in combination, although they may be lost in high-grade tumors. epithelial markers may be also positive in epithelioid angiosarcoma. wednesday, september , basement the semiquantitative immunohistochemical evaluation of the lymphangiogenesis density at cutaneous melanoma and its correlation with the sentinel lymph node status p. buzrla* *faculty hospital ostrava, institute of pathology, czech republic objective: lymphangiogenesis is a predictor of the sentinel lymph node status at cutaneous malignant melanoma. the aim of our investigation was the immunohistochemical semiquantitative evaluation of the lymphangiogenesis density and its correlation with the sentinel lymph node status. the file comprises patients with cutaneous melanoma, of them having the positive sentinel lymph node. the results of the investigation are partially in harmony with another study. method: for this investigation, the files of patients with cutaneous melanoma radically excised and the sentinel lymph nodes were extirpated. the lymphangiogenesis density was immunohistochemically evaluated using cd and d - (podoplanin). the localization of the lymphangiogenesis in cutaneous melanomas was determined and the lymphatic vessels were counted in mm . after that, we evaluated the correlation between the lymphangiogenesis localization and the invasion depth according to clark, following the correlation of the lymhangiogenesis density with the sentinel lymph node status. results: lymphangiogenesis was dominant in the peritumorous localization of cutaneous melanomas. the lymphangiogenesis density and its localization have no influence upon the lymph node status. the correlation of the depth invasion with the lymph node status was not confirmed. the results of the lymphangiogenesis localization are according to other study papers. we did not confirm the correlation between the lymphangiogenesis density and the sentinel lymph node status. it is necessary to extend the set of investigated patients with cutaneous melanoma and to use the lyve- antibody. the extension of the count of patients with cutaneous melanoma and using other antibodies such as lyve- are necessary in consecutive evaluations. objective: melanoma is a malignant tumor of the neural crest-derived cells named melanocytes. it is an aggressive neoplasm due to its high rate of proliferation and invasion. disruptions in the cellular signaling pathways promote melanoma development and progression. aberrant notch activation has been related to a variety of human neoplasms. we investigate the potential involvement of notch signaling in melanoma development and progression. for this purpose, we analyzed the expression of three essential components of the notch pathway: notch , adam and adam /tace. method: melanoma samples from seven patients were tested and compared with normal skin samples. immunofluorescent staining was performed on -μm-thick cryosections. primary antibodies were applied and incubated overnight at °c. to detect the primary immune reaction, we used fitc-labeled goat anti-mouse secondary antibodies. the samples were examined using light and uv microscopy. for the western blot technique, the western-breeze kit was used. results: notch expression in normal skin was detected in the epidermis and also in hair follicles, sweat glands, sebaceous glands and blood vessels. melanoma cells showed moderate to high levels of expression of notch . adam expression was detected in the epidermis and also in hair follicles. in some melanoma samples, adam over-expression was observed. tace/adam expression was detected only in the epidermis. western blot analysis confirmed the presence of these proteins in cytoplasmatic and nuclear lysates. conclusion: we observed that the notch signaling pathway is activated in melanoma cells. critical members of the notch pathway are potential therapy targets. objective: amelanotic melanoma is a subtype of cutaneous melanoma characterized by little or no pigment on visual inspection; it represents - % of all melanomas. the lack of pigment makes it a great mimic of other benign and malignant lesions, a fact that can mislead the correct diagnosis. method: the study included a group of cases of amelanotic melanomas, aged - years. most of the tumors were thinner than mm breslow and clark levels i to iv. the diagnostic was formulated based on special coloration for the melanic pigment (masson-fontana) and using immunohistochemical techniques (hmb- , vim, s- ). the simultaneous positivity of these markers has shown the melanic aspect of the tumor. bcl- , ki- and p- was performed by standard immunohistochemical staining using monoclonal antibodies. results: bcl- expression was positive in % cases; ki- expression was positive in most of the cases, values between % and %; and p- expression was positive in most of the cases, values between % and %. conclusion: our frequency detection is not related with the size of the tumor, depth, ulceration or mitotic activity. most lesions present expression of bcl- in % of the cases and were associated with good prognosis; p- expression is between % and % and was associated with poor survival. although ki- expression is between % and %, it is not related with the prognosis. it was suggested that p- and bcl- expression could be useful in predicting the biological behaviour. neoplastic embolisations were identified in two cases of the study group. objective: desmoplastic melanomas represent an extreme degree of fibroblastic or myofibroblastic metaplasia accompanied by abundant collagen synthesis. those tumors are in general associated with high incidence of recurrence and metastasis and a poor prognosis. method: a patient p.c., male, years old, presents at the clinical exam a right calcaneo-plantar ulcero-proliferative and multinodular lesion ( / , / , cm), with a few months' course; there is local discomfort and functional impairment. clinical diagnostic was that of kaposi sarcoma and for the histopathology was sent a cutaneous specimen of / / cm that contains the lesion. the specimens were examined using basic histological techniques and immunohistochemistry with antibodies anti-s protein, anti-cd , anti-desmin, melan a, hmb- and pan ck. results: microscopically, it was identified as tumoral proliferation with spindle cells, uniform nucleus, some of them hyperchromatic, prominent nucleoli, some tumoral cells with brown melanic pigment and a rich mitotic activity. immunohistochemical expression was intensely positive for s protein and melan a and negative for hmb , desmin, cd , pan ck, associated with focal lymphocytic inflammatory infiltrate. tumoral proliferation includes adnexal structures of the skin and is ulcerated. the histopathological aspects lead to a desmoplastic melanoma. in spite of the large excision margins sidewise and in the depth, the tumor has reappeared locally after months from excision and treatment, with inguinal ipsilateral metastasis. conclusion: the presented facts suggest a more close attention to the clinical and histopathological differential diagnosis of the tumoral cutaneous lesions in the lower limb extremities. this could influence the surgical therapeutic act. was /nmc. histological exam of skin biopsies revealed in dermis a significant proliferation of irregular, small vascular channels, covered by a single layer of atypical endothelial cells. these channels were predominately arranged around preexistent mature vessels and adnexal structures. they were placed parallel to the epidermis and were marked by cd antibody. with this antibody, we observed that majority of these vessels were intermediary vessels whose proliferation could be suppressed by anti-angiogenic therapy. based on clinical, histological and immunohistochemical aspects, diagnosis of kaposi's sarcoma in early stage was made. chemotherapy was initiated (haart scheme) for months. after this treatment, skin plaques have disappeared and serum level of cd increased at /nmc. conclusion: it is very important to recognize early phase of kaposi's sarcoma and to initiate the treatment in order to improve prognosis of this lesion in hiv-infected and also immusdepressed patients. the objective: skin cancers are one of the most common human malignancies. although the prognosis of these patients has improved in the last decades, there is still a need for novel treatment modalities and prevention from recurrence after the treatment of skin tumors. p is a tumor-inhibiting gene which is believed to be defective in many malignant situations. ki is a non-histonic protein which mainly interferes with the proliferation and has many controlling effects during the cell cycle. this study aimed at evaluating p and ki- expression in skin epithelial tumors by immunohistochemical method. method: in a descriptive setting, biopsy samples- basal cell carcinomas (bccs), ten squamous cell carcinomas (sccs), eight keratoacanthomas (kas) and two tricoepitheliomas (tes)-were immunohistochemically evaluated for p and ki expression during a -month period. the incidence and expression rate of these two variables were separately reported in each group of samples. objective: the coexistence of anti-neutrophil crescentic glomerulonephritis with membranous glomerulopathy is very rare. little is known about the clinical course, treatment and outcome of patients with concurrent coexistence of these nephropathies. method: we present the case of a -year-old man with rapidly progressive renal failure, anti-neutrophil perinuclear antibodies positivity, pulmonary infiltrates and vasculitis. results: the patient was admitted to the pulmonary department due to febrile state, weakness and weight loss. physical examination revealed fine crackles over the left lung, leg edema, and vascular skin lesions on inferior extremities. urinalysis showed proteinuria and hematuria with many rbc casts, and in a -h urine collection, the proteinuria of g was observed. serologic workup was positive for p-anca, negative for c-anca, ana, and anti-gbm antibodies and showed normal levels of c and c . hcv, hbv and hiv infection were excluded. in lab tests, the rapid increase of serum creatinine from . to . mg/dl over weeks was observed. chest ct revealed pulmonary infiltrates of left lung upper lobe. the patient underwent a kidney biopsy which showed necrotizing crescentic glomerulonephritis and membranous glomerulopathy. in light microscopy examination, glomeruli with necrotic lesions and cellular crescents were seen. electron microscopy revealed epimembranous and intramembranous deposits. the patient was treated with steroids; cyclophosphamide and seven plasmapheresis were performed with improvement in renal function. on -year follow-up, his proteinuria had decreased to mg/day and his creatinine had stabilized at . with egfr of ml/min. objective: in the last years, the study of predictive and prognostic markers of non-small cell lung carcinomas (nsclc) has been a continuous challenge. it is well known that the imbalance between akt and pten expressions plays an important role in cell proliferation, angiogenesis and tumor cell invasiveness in various solid malignancies. the aim of our study was to analyze the akt and pten expressions in primitive non-small cell lung carcinomas and, also, in their metastases. method: we have examined akt and pten immunohistochemical expressions in primitive non-small cell lung carcinomas with different stages and in ten metastatic nonsmall cell lung carcinomas: brain, adrenal glands and lungs. results: akt expression was higher in metastatic than in primitive non-small cell lung carcinomas, while pten was over-expressed in % of all tumors. there were no obvious associations between tumor stage and akt/pten expression. there were no correlations between pten over-expression and akt expression. conclusion: akt activation may play an important role in tumor cell invasiveness in non-small cell lung carcinomas, but pten suppressor gene may not be involved in akt activation. objective: the role of mirnas in cancer is a rapidly emerging area of investigation. expression profiling has identified mirna signatures in cancers that associate with the diagnosis, staging, progression, prognosis, and response to treatment. mirnas are ideal biomarkers in ffpe tissue because unlike mrna, mirna integrity is affected very little by formalin fixation. previous studies have shown that mir- overexpression correlated with poor prognosis in nsclc patients. in this study, we investigated the expression of mir- in primary carcinoma and metastasis and near non-tumor parenchyma. method: ffpe samples from surgical specimens and biopsies of seven pulmonary adenocarcinomas and five squamous cell carcinomas and respective metastasis together with normal lung tissue (alveolar and bronchial) from the same case; it was imperative to separate these well-characterized areas by lasercapture microdissection (lcm) prior to rna analysis. results: the expression level of mir- by qrt-pcr was significantly higher in tumor tissues than in adjacent normal tissues (p= . ). the overexpression in the metastasis samples compared to adjacent normal tissue was almost statistically significant (p= . ). conclusion: mir- was overexpressed in tumor tissues relative to adjacent non-tumor tissues. we found an increase in mir- expression in primary carcinoma and metastasis in pulmonary adenocarcinomas when compared with mir- lower expression in squamous cell carcinoma. despite the small sample studied, further investigation may indicate the therapeutic and prognostic relevance of this determination as previous studies suggest that mir- acts as an oncogene and has a role in tumorigenesis through the regulation of tumour suppressor genes. objective: routine diagnosis and prognostic methods may also be useful to add data to clinical information in advanced primary carcinomas if conveniently explored. the evaluation of the potential of h nmr spectroscopy for providing biochemical information of the different histological types and for discriminating between tumour and pulmonary parenchyma as well as biochemical information about different histological types was tried as a preliminary approach. method: small frozen samples of pulmonary tumours were collected together with macroscopically normal parenchyma from surgical specimens before histological classification and mirror tissue was ffpe. paired cases were directly analysed by high-resolution magic angle spinning (hrmas) h nmr spectroscopy ( mhz). the spectral profiles obtained were subjected to multivariate analysis: principal component analysis (pca) and partial least squares regression discriminant analysis (pls-da) with the predictive ability of the statistical models. results: tumor and control tissues were clearly discriminated in the pls-da model with high level of sensitivity ( % of tumor samples correctly classified) and % specificity (no false positives). the metabolites giving rise to this separation were mainly lactate, gpc, pc, taurine, glutathione and udp/utp (elevated in tumors), and glucose, phosphoethanolamine (pe), acetate, lysine, methionine, glycine, myo-and scyllo-inositol (reduced in tumors compared to control tissues). furthermore, pls-da allowed carcinoids to be discriminated from adenocarcinomas and epidermoid carcinomas. conclusion: this preliminary study raised the nmr profile between the different histological types of bronchialpulmonary carcinomas through multivariate analysis and scaled metabolic profiles that may be delineated to improve clinical decisions in future. objective: the rna binding protein hur can stabilize and/or regulate the translation of target mrnas affecting cellular responses. the expression of hur is increased in several cancers, and cytoplasmic immunoreactivity was found to be closely related to poor outcomes. method: we analyzed, by quantitative immunohistochemistry, the expression of hur in lung adenocarcinoma of mixed histologic type from stage i and ii patients. moreover, we evaluated the level of hur expressed both in the nucleus and cytoplasm of tumor cells (t-hur) and evaluated the impact of nuclear/cytoplasmic ratio (n/c) on clinical outcome. results: both t-hur and n/c were not associated with age, tumor diameter and histopathological grading, whereas high t-hur and low n/c were associated with lymph node involvement at presentation. cox's regression analysis, using either t-hur or n/c as continuous covariates, showed that high t-hur and low n/c were associated with the risk of death and metastasis. the plots of the estimates, at -year follow-up, of metastasis-free and overall surviving as a function of t-hur and n/c levels, showed that the increase of t-hur and the decrease of n/c were associated with an increase of risk. in the multivariate analysis, both t-hur and n/c retained an independent prognostic significance relative to metastasis-free and overall survival. conclusion: in conclusion, these data indicate that the over-expression of hur in lung adenocarcinoma cells is an independent prognostic marker of a poor clinical outcome. moreover, the cytoplasmic localization of hur expression is more relevant than the nuclear one for the tumor cell behavior. objective: the eml -alk fusion gene has been detected in - % of non-small cell lung cancers. we evaluated the incidence, prognosis and the characteristics of alkrearranged non-small cell lung cancers and the optimal diagnostic modality to detect alk rearrangements in routine clinical practice. method: seven hundred seventy-nine surgical specimens of non-small cell lung cancer from two institutions were analyzed. to identify alk rearrangements, immunohistochemistry and fluorescent in situ hybridization (fish) examination were performed and compared. the clinicopathologic characteristics of tumors with and without alk rearrangements were analyzed. egfr and kras mutations were determined by dna sequencing. results: we identified ( . %) non-small cell lung cancer with alk rearrangements within our cohort by immunohistochemistry. forty-three ( . %) of the eml -alk tumors were adenocarcinomas. alk rearrangement was associated with never smoking (p< . ) and female (p < ). patients in the eml -alk fusion gene in adenocarcinoma had no effect on progression-free survival and overall survival. immunohistochemical results were correlated with fish results. conclusion: the patients most likely to harbor eml -alk are never smokers with adenocarcinoma. but eml -alk was not an independent prognostic factor. immunohistochemical staining for alk could be used as a screening method to detect alk gene rearrangement. objective: lung cancer is one of the most common malignant tumors worldwide, with a growing incidence. in romania, lung cancer has a prevalence of % and an incidence of %; in terms of deaths from cancer, it ranks first place in males and fourth place in females. method: we analyzed the malignant lung tumors from january to february using information obtained from observation sheets of thoracic surgery clinic and the database of the pathology department of the university emergency hospital bucharest. distribution of cases was followed depending on age, environment, gender, living and working conditions (smoking, toxic, radiation), tumor stage and histological appearance. the analysis of these data shows that most lung tumors occurred in the fifth decade of age and is more common in men. regarding histological type and age, the most common tumors were moderately differentiated squamous carcinomas (the decade iv, v, vi and vii). four patients were hospitalized for another disease (inguinal hernia, uterine fibroma) and were subsequently transferred to the clinic for thoracic surgery for specialist treatment. conclusion: physical examination, identifying the factors contributing to lung cancer appearance and its diagnosis in early stages, as well as an adequate communication between specialists, may contribute to the decrease of mortality as well as socioeconomical costs. objective: lung damage in emphysema has been traditionally attributed to an imbalanced proteases/antiproteases, especially in α -antitrypsin deficiency (aatd). however, activation of lymphocytes with organisation in lymphoid follicles (lfs) seems to play a crucial role in disease pathogenesis. the aim of this study was to quantify the number and distribution of lfs in native lungs from patients transplanted for emphysema. method: we compared two groups of patients with either aatd (n= ) or normal levels (aatn, n= ). bronchiolar, perivascular and parenchymal lfs were evaluated on sections immunostained with anti-cd .results were expressed as lf number per square centimeter of examined tissue and, for bronchiolar lfs, as percentage of airways with lfs. results: lfs, almost absent in normal lungs from donors, were frequent in subjects with severe emphysema both with and without aatd. lf total number was increased in aatd patients as compared to aatn, and this was mainly due to a higher number of parenchymal lfs (median, range: , - vs , - lfs/cm , p= . ). perivascular and bronchiolar lfs were numerically increased in patients with aatd ( , - vs , - lfs/cm ; , - vs , - %), but did not reach the levels of statistical significance. conclusion: lf number is increased in patients with end-stage emphysema, particularly in those with aat deficiency. these results extend our knowledge of disease pathogenesis, suggesting that lymphocyte activation is a crucial event even in aatd-related emphysema, and the excessive lung damage observed in these patients may trigger the persistence of the immune response, possibly with autoimmune mechanisms. objective: (lyg) is a rare angiocentric lymphoproliferative process predominantly affecting the lung. the diagnosis of this condition is often difficult as the physical signs, history, chest x-ray, and routine laboratory investigations are usually nonspecific. nevertheless, it is important to establish a tissue diagnosis as this lymphoproliferative disorder can be refractory to treatment and even progress to overt lymphoma. method: one case of pulmonary lyg in a -year-old nigerian man of ibo extraction treated in our centre in and followed up for a year is presented. the difficulty in making diagnosis is highlighted and treatment modality discussed. results: our patient received two courses of cyclophosphamide and prednisolone before defaulting. there was evidence of some remission, even though incomplete, following the first course of chemotherapy (fig. ) . however, his representation a year later with evidence of relapse was a pointer to the ongoing process of the lesion. whether this case had progressed to lymphoma was difficult to say as he declined a readmission and further investigation. conclusion: a subset of angiocentric lymphoproliferative process including lyg shows clinical response to cytotoxic chemotherapy and steroid when commenced early, as is partly true here. lymphomatoid granulomatosis should be considered in long-standing nodular pulmonary lesion and pleural effusion of uncertain aetiology. immunohistochemical study about pathogenesis of acute respiratory distress syndrome g. simona*, i. jung, l. azamfirei, d. demian, r. solomon, b. grigoroiu *umf, dept. of pathology, targu-mures, romania objective: despite modern treatments, the prognosis of acute respiratory distress syndrome (ards) remains unfavorable and its pathogenesis is not explained enough. in few recent studies, the pathogenetic and prognostic role of vascular endothelial growth factor (vegf) and its receptors was investigated in ards, but the obtained results were controversial. method: we have compared the immunohistochemical expression of cd , vegf-a and its receptors (veg-fr and vegfr ) in normal lung (n= ) and also in early and late ards (within h, respectively, after days). cases with ards were necroptic cases (n= ), and also lung biopsies (n= ). labvision antibodies were used. serum level of vegf was also determined. results: in normal lung, all antibodies marked the endothelial and alveolar cells and also macrophages. in early ards, the intensity of vegf decreased in both endothelial cells and alveolocytes, but increased in hyaline membranes (hm) after - days. vegr marked the preserved alveolar cells and vegfr marked alveolar macrophages. hm were negative for both receptors. in late ards, down-regulation was more prominent for all antibodies. serum level of vegf was up-regulated at the same time with decreasing vegf intensity in lung cells, and also with hm appearance. all dyed patients presented hm, independently by phases of ards. cd marked alveolar macrophages and sometimes hm. conclusion: the formation of hm in ards showed an unfavorable prognosis. strong intensity of vegf and the inconstant presence of cd in hm proved that both destroyed alveolar cells and macrophages are responsible for vegf production, but the increased serum level of vegf also proved its serum extravasations in hm. optimalization of flow cytometric assessment of tnf in alveolar macrophages using multiparametric analysis e. stránská*, p. mandáková, m. vašáková, r. matej *university hospital motol, dept. of pathology, praha, czech republic objective: alveolar macrophages (ams) contribute to the pathogenesis of different lung diseases by producing proinflammatory cytokines. within the frame of the project, which is mainly concerned with cytokine expression in bronchoalveolar lavage fluid (balf) of patients with idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease, we optimized the flow cytometric (fc) examination of tnfα expression in ams. the aim was to determine spontaneous tnfα production, the production during the culture and after stimulation with lipopolysaccharide. furthermore, we focused on antibody selection since ams displayed high level of autofluorescence. method: we examined balf obtained from control patients. tnfα production was assessed immediately after balf delivery, after -h stimulation with lipopolysaccharide (monensin, protein transport inhibitor was added after h of incubation) and also after incubation with monensin only. simultaneously, various concentrations of lipopolysaccharide were tested ( . , and μg/ml). fc detection of ams was simplified using multiparametric analysis, a combination of optical parameters along with the expression of surface markers cd and cd . results: concentration of μg/ml of lps was found to be optimal for ams activation, although all tested concentrations are suitable. the high background autofluorescence of ams can be efficiently reduced by the use of antibody conjugated with long-wave emitting fluorochrome, e.g. apc. objective: the aim of the present study was to contribute to the understanding of the importance of evaluating bone marrow biopsy (bmb) by computer-assisted digital image analysis (cia). moreover, the intention was to investigate the frequency of marrow fibrosis in multiple myeloma (mm) and to correlate it with plasma cell infiltration during the follow-up of patients. method: bone marrow biopsy from patients diagnosed with mm were analyzed at the time of diagnosis and reevaluated after the completion of the therapy. the percentage of plasma cells was estimated on immunohistochemically stained paraffin sections with anti-cd and ig light chains by alphelys spot browser integrated system. the fibrosis was analyzed according to the european consensus on grading bone marrow fibrosis. results: plasma cell percentage at the time of diagnosis ranged from % to % (median %) and in follow-up from % to % (median %). increased fibrosis, which appeared to be restricted to areas of severe plasma cell infiltration, was seen in % of bmb at first diagnosis. in a follow-up study, the percentage of plasma cell infiltration decreased in of , increased in of and remained nearly equal in of mm patients. all patients with disease progression after first-line therapy had increased fibrosis in bmb. the degree of fibrosis correlated with plasma cell percentage, clinical stage and response to therapy. conclusion: in all cases of mm, a bmb is essential at diagnosis as it helps identify a subset of myeloma patients with increased marrow fibrosis and response to therapy. objective: lymphoma is the commonest haematological malignancy in the developed world. we undertook an audit of all laboratory reports from the pathology department of beaumont hospital that confirmed or suspected a diagnosis of lymphoma over an -year period, assessing the following: incidence of lymphoma by age at presentation and gender, site of presentation, type of lymphoma diagnosed, number of cases utilising immunohistochemistry, number of cases where bone marrow staging was performed and the results. method: six hundred forty-seven cases were retrieved from the laboratory database where the histology report provided a definitive diagnosis of lymphoma or strongly suspicious for lymphoma. seventy-seven were diagnosed as hodgkin's lymphoma and diagnosed as non-hodgkin's lymphoma, with cases strongly suspicious for lymphoma. results: the study showed an average age of . years at presentation, with incidence of lymphoma increasing with age and peaking at an age range of - years, reducing thereafter. the highest incidence of hodgkin's lymphoma occurred in the age ranges - and - years. incidence of lymphoma was similar in both genders. b cell lymphoma had the highest incidence, followed by hodgkin's lymphoma. three hundred thirty-one cases had a nodal site of presentation, were extranodal, with the remaining from uncertain site (site labelled, for example, mediastinal mass). brain was the most common extranodal site with cases. immunohistochemistry was performed in % of cases. six percent of cases had bone marrow involvement. conclusion: the incidence of lymphoma for years in beaumont hospital is mostly consistent with the epidemiology established by the who. objective: mpns consist of polycythemia vera (pv), essential thrombocytosis (et), and primary myelofibrosis (pmf). though a number of clinical and diagnostic factors have been determined, the current classification in mpns is still not satisfactory. all mpns are characterized by jak tyrosine kinase (v f) mutation related to the deregulation of intracellular signalling pathways, e.g. ras-erk and pi k-akt, while bcl negatively regulates the pi k-akt pathway. the aim of our study was to attempt to indentify the presence and distribution of erk and bcl expression as factors which might distinguish each mpn. method: expressions of erk and bcl were investigated (immunohistochemistry with envision and dab) on trephine samples in pv, et and pmf patients. anti-erk antibodies were directed to the epitope corresponding to a site near the c-terminal of these molecules. bcl antibodies bind an epitope located between amino acids - of human bcl . finally, sections were studied under light microscope and evaluated using a semiquantitative method. results: there were similarities and differences in terms of erk expression among three mpn disorders. there was a widespread occurrence of anti-erk in the cytoplasm as well as in the nucleus. observed differences concern the levels of expression of this antigen in the nucleus. objective: there is a wide overlap of symptoms and signs among gastrointestinal (gi) graft versus host disease (gvhd) and other gi diseases (infections, drug toxicity, etc.). the diagnosis is based upon histologic and endoscopic findings. accurate diagnosis is important as it determines a specific treatment and contributes significantly to the morbidity and mortality of post-allogeneic stem cell transplant (sct) patients. persistence of gi symptoms despite initial treatment is frequent, and ulterior histologic evaluation may be helpful to address therapy. method: we performed a retrospective study of patients with persistent diarrhea despite treatment based on the first biopsy diagnosis in order to determine the diagnostic value of serial gi biopsy evaluation in sct patients. simultaneous microbiologic analyses of stools and cmv antigenemia monitoring were performed. results: of the first rectosigmoid biopsies, ( %) were diagnosed as gvhd, two ( %) as gvhd with cmv infection, four ( %) as non-cmv infection, and five ( %) as normal or unspecific. second gi biopsies were diagnostic of active gvhd in six ( %) cases, gvhd with cmv infection in four ( %), regenerative changes post-gvhd in eight ( %), cmv infection in three ( %), and normal or unspecific in eight ( %). in out of ( %) patients, the histologic findings of the second biopsy were different compared to the first biopsy, leading to a therapy change in ( %) patients. conclusion: our results showed a reliable diagnostic value for serial gi histologic evaluation that could impact on the therapeutic decision in patients with persistent diarrhea after allo-sct. thymoma with subtotal loss of keratin expression: a potential diagnostic pitfall p. adam* *medical university of tübingen, institute of pathology, germany objective: the differential diagnosis between thymoma and t lymphoblastic lymphoma poses major difficulties in small needle biopsies since both entities contain immature and highly proliferating t cells. one essential diagnostic criterion favouring thymoma is the demonstration of increased numbers of cytokeratin-positive epithelial cells. we describe a series of type b /b thymomas with substantially reduced cytokeratin expression. method: eight thymoma cases were analyzed for the expression of various cytokeratins and other epithelial markers (panck ae / , ck , ck / , cam . , ck / , p , beta-catenin, e-cadherin). as controls, type b and b thymomas and thymic carcinomas arranged on a multi-tissue histoarray were analyzed. results: with regard to cytokeratin expression, three b thymomas were completely negative for panck, ck , ck / and cam . . with regard to the other epithelial markers, seven of seven cases showed a strong nuclear expression of p and strong membranous staining for e-cadherin and beta-catenin. analysis of control cases on a multi-tissue array showed the expression of panck, ck , ck / , cam . and ck / in %, %, %, % and %, respectively. the other epithelial markers p , e-cadherin and beta-catenin were found in %, % and %. conclusion: loss of cytokeratin expression in type b /b thymomas is a potential diagnostic pitfall in the differential diagnosis with t lymphoblastic lymphoma and can be expected in - % of cases. interestingly, thymomas with loss of keratin expression seem to upregulate e-cadherin and beta-catenin. an unusual uterine tumour with signet ring cell features s. rossella*, m. fiche, c. achtari, n. ketterer, l. de laval *chuv lausanne, dept. of pathology, switzerland objective: lymphomas with signet ring cell features are rare, as is uterine dissemination of lymphomas. we report an exceptional case of a uterine tumor combining these two characteristics. method: a -year-old female was diagnosed in with localized nodal grade follicular lymphoma (stage ia). she received local radiation therapy, experienced total remission, and did well until when a systematic ct scan evidenced a pelvic anterior-lateral mass. total enlarged hysterectomy was performed. results: the anterior uterine wall contained a . -cm fish flesh well-delineated mass corresponding to a mostly diffuse and focally nodular proliferation of medium to large cells with extensive signet ring cell changes. tumor cells were cd -, cd -, bcl -, and bcl -positive with a low proliferation rate (< - %); cd underlined a focal follicular architecture. the vacuoles were pas-negative and did not stain for immunoglobulin; ultrastructural analysis revealed nonspecific degenerative vacuoles. no lymph nodes were identified isolated from the surgical specimen. objective: upregulation of the embryonic notch signaling pathway has been observed in several different malignancies, among which is pancreatic ductal adenocarcinoma (pdac). for lack of a receptor-specific blocking antibody, less specific methods were used to suppress notch signaling in earlier research. with use of a receptorspecific monoclonal blocking antibody against the notch receptor (n -ab), we determined the exact effects of notch receptor inhibition on different pdac cell lines. method: after confirming active notch signaling, n -ab activity and specificity were tested with immunofluorescence and qrt-pcr. cells were treated with n -ab and different assays were performed to establish the effects of notch receptor inhibition on growth rate and colony forming potential. in vivo experiments were performed: mice were injected with treated or untreated cells subcutaneously and tumor growth was monitored. results: treatment with n -ab did not influence the growth rate of the cells. colony forming potential did decline upon treatment with notch -ab, although this decline was only twofold. in vivo experiments did not show any differences between the untreated and treated group. conclusion: although notch receptor inhibition did diminish anchorage-independent growth in pdac, this effect was much less profound than previously reported. no effect on growth rate was observed upon treatment with n -ab, which conflicts with the general statement that notch receptor inhibition results in a decline in growth rate. notch should still be looked upon as a potential treatment target, but further determination of the different components of the notch pathway and their role in tumorigenesis seems advisable. objective: due to adverse side effects, efforts are made to reduce the time of daily lateral electrical surface stimulation (less) therapy in the treatment of idiopathic scoliosis in children and adolescents. method: studies were carried out on ten male rabbits, new zealand purebred, aged . months, with b.m. of , - , g. animals were divided into two groups (n= ): ( ) short-term less was applied for h daily during months and ( ) control group without less, but with other experimental parameters as in group . stimulation was performed with scol- (elmech). clinical, macroscopic and microscopic observations were performed. results: similar growth of b.m. was observed in the rabbits from both groups during the first months of the experiment. in month , a slightly smaller increase was observed in the animals from group than in those from group . the mean mass of the suprarenal glands in the stimulated rabbits was . ± . g, while those from the group were . ± . g. a microscopic examination revealed hypertrophy of zona fasciculata with visible overgrowth of glandular cells in rabbits from group . the results of clinical observations as well as morphological lesions indicate the presence of adaptive stress in rabbits stimulated with short-term less. objective: basal cell carcinoma (bcc) is considered a skin cancer with long evolution and low metastatic risk. method: we selected for presentation three cases with bcc operated between and , with a special history and evolution. results: the first case ( -year-old female) developed a small occipital tumour, incompletely explored and excised in another surgical department. we performed ten serial excisions (soft tissue and invaded bone) during years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and used complex reconstructive techniques (local/muscular/free omentum flaps). the second case ( -year-old male) had a neglected frontal tumour invading the orbital region; during a period of years, we performed three excisions and reconstructed the region with skin graft and temporal flap, trying to save the eye. finally, we had to excise the invaded eyeball and we used frontal flap for reconstruction ( ) . the third case ( -year-old female) had a small bcc on the left buttock, which was excised in correct limits and reconstructed with a skin graft ( ). fiveyears later, a new ulcer appeared. the patient neglected the tumour during a period of years. the bcc progressively invaded with a buttock, the upper third of posterior left thigh and the left gluteus maximus muscle, inducing severely altered general status and anemia. we performed a wide excision (including the muscle) and we reconstructed with a fascio-cutaneous flap and skin grafts ( ). conclusion: bcc can be a cancer with a high local aggressivity if the patient or the surgeon underestimates it. objective: eyelids represent a special location of the basal cell carcinoma (bcc) due to the proximity of the eyeball. the aim of this study was to review the clinical and histopathologic features and outcomes of eyelid basal cell carcinomas. the clinical records and histopathologic specimens of patients with eyelid basal cell carcinomas were reviewed and analyzed retrospectively. the main outcome measures are clinical characteristics, lesion size, histologic subtypes, severity of peritumorous inflammation, recurrence rate and prognostic features. results: the most common histologic subtypes were infiltrative, nodular, and basosquamous basal cell carcinomas. of the patients, . % were previously recurrent. recurrent basal cell carcinomas were larger, with longer duration of lesion. basosquamous basal cell carcinomas were more likely to have prior recurrences, larger lesion size, and the highest rate of orbital invasion. perineural invasion was most frequent in morpheaform and basosquamous subtypes. peritumorous inflammation differed between subtypes and was highest in the superficial subtype. the recurrence rate was . %. conclusion: the outcomes were worse than previously reported due to the delay in treatment. the prognostic factors associated with secondary orbital invasion are previous recurrences, aggressive histologic subtypes, longer duration of lesion and larger lesion size. histological assessment of small bowel hypoperfusion lesions in the pig a. l. oliveira*, d. ferreira, h. vala *agrarian superior school, viseu, portugal objective: authors propose the use of a quantitative morphological assessment for helping in studies concerning intestinal hypoperfusion. the method was applied to small intestine mucosa stained with standard hematoxylin and eosin in pigs that underwent severe hypotension due to acute hemorrhage. method: six large white pigs underwent total intravenous anesthesia with propofol and remifentanil. arterial blood ( ml/kg) was passively removed from the femoral artery over min. volume was replaced using ringer lactate in group and hydroxyethyl starch / . in group , with a delay of min after bleeding. onehour after the volume replacement, pigs were euthanized and small intestine samples were taken for histopathological examination. parameters were classified using two specific scales (chiu ; Çetin ; kaplan ) . mucosal loss (ml) percentage and crypt/ interstitium ratio were obtained (faleiros ). results: inflammatory infiltrate was present in all animals, varying from grade to grade . hydropic cellular degeneration and epithelial detachment were more pronounced in duodenum and more noticeable in group . in group , ml percentage was . ± . % in duodenum, . ± . % in jejunum and . ± . % in ileum. in group , ml percentage was . ± . in duodenum and ± % in the other intestinal segments. in the whole small intestine was . ± . % in group and . ± . % in group . crypt/interstitium ratio did not present significant differences between the groups. conclusion: quantitative morphological assessment may be useful in quantifying the degree of mucosal lost in small intestine stained with hematoxylin and eosin from pigs submitted to acute severe bleeding. results: case : the tumor in the thoracic aorta was found at autopsy. histologically, the tumor consisted of isolated atypical cells, suggesting sarcoma. immunohistochemically, tumor cells were positive for cd . the same atypical cells were seen in the intrarenal arteries as emboli accompanied with vasculitides. case : autopsy revealed lymphoplasmacytic lymphoma (lpl) involving kidneys. and more, amyloid deposition in the lungs and mpo-ancaassociated crescentic glomerulonephritis, i.e. mpa, were noted. conclusion: aortic angiosarcoma is an extremely rare lesion, and it is known that the tumor often causes distal emboli and presents vascilitis syndrome. the second case was diagnosed as lpl, mpa and amyloidosis. mpa is known to occur in some patients with malignancy. it has been reported that some malignancies produce vasculitidesinducing factors. in our cases, such factors produced by malignant cells might induce vasculitides. monoclonal antibodies in the diagnostic of spinal metastases g. kropczydski* *zabrze, poland the skeletal system is the third most frequent seat of metastases, and metastatic tumours are the most common bone malignancies. the diagnostic workup of spinal metastases begins with the identification of the primary neoplastic site. the aim of the study was to determine the utility of monoclonal antibodies in the diagnostic workup of spinal metastases. materials and methods: this is a retrospective analysis of patients whose histopathologic examination confirmed the presence of neoplastic foci in the spine. samples of metastatic tumours of patients whose primary tumour sites had not been identified were subjected to an immunohistochemical analysis based on monoclonal antibodies and assays for antigens associated with tumours most often producing bony metastases. results: the monoclonal antibodies and assays were shown to be useful aids for the identification of the histology and location of the primary tumour in patients in whom routine histological assessments had failed to determine the histological type of tumour. conclusions: the length of survival of patients with malignant spinal metastases is influenced by the type of neoplasm and locally radical surgery combined with palliative radiation therapy. in many cases, effective immunohistochemical workup can contribute to halting the progression of the tumour by enabling qualification for appropriate surgical and oncological treatment. origine and frequency of pulmonary bone fragment embolism: an autopsy study n. willi*, t. thiesler, p. ochsner, g. cathomas *kantonsspital liestal, institute of pathology, switzerland objective: pulmonary bone fragment embolism (pbfe) is a rare event observed at autopsy. pulmonary bone marrow embolism (bme) is more common, but both types of embolisms are considered to have little clinical relevance. the aim of this study was to analyze the frequency of pbfe and bme and correlate these events with clinical findings. method: in an autopsy cohort, the frequency of embolic particles of pbme and bme was evaluated by reanalyzing all pulmonary h&e-and elastin-stained (evg) sections. results: in a total of , autopsies, ( . %) pbfe and ( . %) bmes were detected. compared to bme, pbfe were significantly more common in patients with osteomyelitis [ of ( %) versus of , p< . ). in contrast, bme was more common in patients with costal fractures ( of versus of , p< . ), but no patient showed both types of embolism. in addition, pbef and bme were observed in patients with bone metastasis and orthopaedic devices. the highest density ( . particles per square centimeter) was observed in a patient who died immediately following femoral medullary nailing, presenting with the clinical picture of pulmonary thromboembolism. conclusion: in the autopsy cohort analyzed, an incidence of ‰ for pbfe was considerably higher as previously reported and pbef showed a strong correlation with osteomyelitis, and the application of orthopaedic devices and extensive pbfe may lead to death. bme are correlated with rib fracture, but no association between pbfe and bme was observed, suggesting a different pathogenetic mechanism. ( )). results: we performed correct oncological excision in % of the cases; ten patients with bcc needed re-excision. in the same surgical stage, we reconstructed the defect using local flaps for patients ( . %), local flaps and skin grafts for six patients and skin grafts only in the seven cases with mm. the main techniques used were: frontal or temporal flaps for the orbital /nasal regions, naso-genian or fan flaps for the lips and cervico-facial flaps for the cheek. when necessary, full-thickness skin grafts taken from preor retroauricular donor zones were performed ( cases). after surgery, all the patients were examined by the oncologist; only patients diagnosed with squamous cell carcinoma or malignant melanoma accepted the excision of the local regional lymph nodes. conclusion: correct tumoural excision in the face is difficult to perform. the skin graft is the best reconstruction technique from the oncological point of view, but to respect the aesthetic and functional rules, we have to perform flaps. indian ink vs tissue marking dye: a quantitative comparison of two widely used macroscopical staining tool k. kosemehmetoglu*, g. guner, d. ates, e. soylu *ankara ataturk eah, dept. of pathology, turkey objective: the evaluation of the surgical margins is a major concern in surgical pathology and marking of surgical margins with substances; indian ink and tissue marking dyes are widely used. as there is no systematic study comparing tissue marking dyes and indian ink, the most common substances used for the purpose, this study was conducted to compare the two. method: unit price, penetration into the tissue, the spreading area of one drop of dye on tissue paper, brightness under the microscope and the intensity of colors on image analysis program were compared for each of the five colors of rotring's indian ink and thermo-shandon's tissue marking dyes applied on reduction mammoplasty specimens. results: indian ink seemed to be slightly less smudgy than tissue marking dye. indian ink tended to remain on the surface and showed less tissue penetration compared to tissue marking dye with respect to all colors, except yellow. blue color of thermo-shandon and yellow color of both rotring and thermo-shandon had the deepest penetration in fatty tissues. red color of rotring was lost nearly totally after processing. rotring has revealed comparable results to thermo-shandon; even the black and green colors of rotring were more intense. on the other hand, thermo-shandon was better when red, blue and yellow colors are concerned. conclusion: rotring's indian ink is proven to be just as effective as thermo-shandon's tissue marking dye and bares majority of the characteristics of a perfect staining substance, which are easily applied, quickly fixed, durable and cheap, contain no potential contaminants, is worksafe, would not smudge/stain surrounding tissues, and look bright under the microscope without obscuring the view. objective: during the development of anatomy since the fifteenth century, a phenomenon of anatomical museums appeared. method: we present a short history of this phenomenon in europe and give insight into the form of acquisition and exhibition of the preparations. results: the prototypes were "curiosities of nature" collections with one of the first founded by aldrovandi in bologna (sixteenth century). the next famous and focused on the human body were the collections of f. ruysch in the netherlands (seventeenth century). he was performing autopsies in public and after that presented preserved parts or whole bodies and osteological preparation sets as artistic dioramas in a special exhibition house. his collection, sold to peter the great, created the foundations for kunstkamera in sankt petersburg. in the eighteenth century, teachers in surgical and anatomical schools (beginning of anatomopathology) realized the educational power of such collections. museums like the one by h. fragonard in paris, france and hunterian in glasgow were established. the next big collection-narrenturm in vienna-had many exhibits obtained from algemeine krankenhaus. the first typical anatomopathological museum was created by r. virchow in berlin (nineteenth century). virchow's motto was "no day without a preparation". in polish universities, l. bierkowski (cracow) and a. bielkiewicz (vilnius) founded such museums. that time in all europe, anatomopathological collections became popular, gathering preparations: osteological, wet (alcohol, formaldehyde, other preservatives), dry and mummified. the fall of phenomenon started in the second half of the twentieth century. nowadays, we face the era of digitalisation of images but, on the other hand, collections of "plastinated bodies". the ethical and legal aspects become more important. results: macroscopic examination revealed the absence of traumatic lesions and the presence of cardiomegaly, threeelectrode pacemaker inserted in the right ventricle, anomalously coloured myocardium, lung oedema and congestion, chronic stasis liver and cerebral oedema. microscopic examination showed lesions of severe cellular acute cardiac rejection (grade r) in a heart with graft vascular disease. conclusion: the medico-legal autopsy allowed the confirmation of a death of natural cause ( ); the exclusion of infection and neoplasia-frequent and severe causes of morbidity in the heart-transplanted population ( ); the documentation of graft vascular disease, which is related to the time span after transplantation ( ); and the diagnosis and characterization of the acute rejection ( ) as adequate cause of unexpected death, without prodromic signs and symptoms. finally, it allowed the correlation of acute rejection and the suspension of immunosuppressive therapy by the patient-data obtained through the family ( ). all these conclusions may provide information about death causes of the heart-transplanted population dying outside the hospital, which will complement that of transplanted inpatient deaths. objective: sudden death is a possible major complication of congenital cardiac malformations. method: the authors report the case of a -year-old male that unexpectedly died at work while performing a minor effort task. he was apparently healthy, apart from the occurrence of very rare "epileptic attacks". a medico-legal autopsy was performed. results: the autopsy-in the setting of a forensic postmortem examination-revealed heart malformations that are consistent with ebstein's disease of the tricuspid valve, associated (as seldom may occur) to mitral valve dysplasia and patent foramen ovale. the relevance of this case lies upon three facts: ( ) the rarity of the pathological entity, ( ) the survival of the victim until the adult age without surgical intervention and ( ) the fact that the symptomatic announcing event was sudden and unexpected death. objective: the clinical use of doxorubicin (dox) is limited by dose-related cardiotoxicity. one-electron redox cycling of the quinone moiety has long been known to form reactive oxygen species. tirapazamine is a relatively new cytostatic compound most efficient in areas of hypoxia, however under aerobic conditions causing significant oxidative stress. aim: the aim of this study was to assess morphological changes in the myocardium of rats treated with doxorubicin and tirapazamine and evaluate changes in plasma level of a cardiac damage marker, ctni. method: rats were weakly treated i.p. with . mg/kg b.w. of doxorubicin and or mg/kg b. w. of tirapazamine for weeks. control group was given saline. samples of myocardium and plasma were taken a week after last dose. tissue samples were stained with hematoxylin and eosin, van gieson method and selye method and examined under light microscope. results: myocardium of rats receiving a combination of doxorubicin and lower dose of tirapazamine exhibited similar changes as rats administered with doxorubicin solely. animals treated with doxorubicin and higher dose of tirapazamine displayed vacuolization of sarcoplasm, wavy cardiomyocytes and fuxin-positive areas in selye method as well as signs of minor interstitial fibrosis. all described alterations in this group were accompanied by significantly higher levels of plasma ctni. conclusion: both drugs caused cardiac changes in rats, including necrosis, mononuclear infiltrations and minor fibrosis. combination of doxorubicin and higher dose ( mg/kg) of tirapazamine seems to have a synergic effect on changes in myocardium. objective: disturbed glucose metabolism, particularly in diabetes, is an important factor leading to the formation of advanced glycation end products (age). the amount of age and its distribution in the cardiocytes of a diabetic myocardium and in cardiopathies is not yet well understood. studies were performed to assess age deposits in cardiocytes in chronic heart failure. method: the diabetic groups consisted of autopsy cases with diagnosed diabetes, hearts explanted during transplantation with ischemic cardiopathy and diabetes, and eight hearts from dilated cardiopathy with diabetes. the two non-diabetic groups comprised hearts explanted from non-diabetic subjects: with ischemic cardiopathy and with dilated cardiopathy. the control group consisted of samples from healthy heart donors. immunohistochemical localization of age was applied, and a semiquantitative scale was used. results: positive staining was present in both cardiopathic groups with diabetes ( % of cases), then gradually decreased to % in diabetes, nearly % in cardiomyopathy, and to % in the control group. negative staining seemed to be characteristic of control group and nondiabetics, whereas granular and diffuse staining pattern (mixed pattern) was most frequent in diabetic groups. the semiquantitative results supported an increased age accumulation in cases with cardiomyopathy and in diabetes. age staining showed no significant correlation with patient age, bmi or diabetes duration. objective: desmoplastic small round cell tumor (dsrct) is a rare malignant serosa-related tumor involving mostly the pelvic and abdominal cavities, but very uncommon in the paratesticular region. dsrct affects young adults, mainly men, and is classically associated with a bad prognosis. method: we report the case of a -year-old man admitted to the hospital for a progressive enlargement of the right hemiscrotum with a -month history. a preoperative diagnosis of testicular tuberculosis was set and consecutively a right high orchiectomy was performed. at macroscopy, the testicular parenchyma showed no abnormal areas, but the tunica vaginalis was irregular and diffusely enlarged by a whitish to gray firm tumoral mass. microscopically, the tumor consisted of nests of small, round to spindle cells, with scant cytoplasm, surrounded by a mild desmoplastic stroma. an immunohistochemical study was performed for the differential diagnosis. results: immunohistochemically, the tumor cells were positive for ae /ae and nse and negative for lca, chromogranin, synaptophysin and cd antibodies. positivity and a very peculiar staining aspect were noticed with desmin antibody: perinuclear and dot-like, suggesting a dsrct. fluorescence in situ hybridization (fish) was accomplished, demonstrating ewsr rearrangement, which in this immunophenotypical context pleads a diagnosis of dsrct. conclusion: the awareness and the knowledge of dsrct in the paratesticular area are needed for a correct diagnosis. the differential diagnosis of this tumor with other malignancies involving this region is mandatory as it has a different clinical management. comparison of prognosis of gastrointestinal stromal tumors depending on a primary site and a type of mutation w. michej*, p. rutkowski *cancer centre instytute, dept. of pathology, warsaw, poland objective: majority of primary gists originate from the stomach (g) or small bowel (sb). the aim of the study was the analysis of the pathologic and molecular factors influencing the patients' prognosis after resection of primary gists, deriving from the stomach and intestinum, omentum (ng). method: in our department, a group of registered prospectively primary gists cd (+) comprising g-gists ( . %) and ng-gists ( . %) was analyzed; molecular examination was also made using pcr. surgeons from our institute compared our results, observing diseasefree survival (dfs). results: median size of g-gists as compared to ng-gists was significantly lower ( vs. . cm,) and g-gists were characterized by lower mitotic activity (median, / vs. / hpf). in g-gist, the most common detected mutations were exon kit ( %) and exon pdgfra, but in ng-gist exon and kit. prognosis of g-gists was significantly better as compared to ng-gist: -year dfs rate, % vs. %. in ng-gists, the following factors showed negative impact on dfs based on analysis: mitotic index > / hpf, primary tumor size > cm, pathological subtype: spindle. the high prognostic significance of ajcc staging system classification in g-and ng-gists was confirmed also in multivariate analysis. conclusion: reliability of ajcc risk classification after resection of primary gist was confirmed. patients with primary gist, originating from the stomach, have better prognosis as compared with gists located in other places. in both groups, primary tumor size and mitotic activity are still the most important prognostic factors. objective: malignant peripheral nerve sheath tumors (mpnst) are highly aggressive sarcomas which may be encountered either sporadically or in the context of the inherited tumor syndrome, neurofibromatosis type (nf ). epidermal growth factor receptor (egfr) overexpression has been reported in mpnst, which has been implicated in their pathogenesis. we present three cases that have different pathogenetic origins. method: the first patient was a -year-old woman who received radiotherapy to the axillary region following radical mastectomy for breast cancer years ago. she presented with a mass in the axillary region that has been growing during the last . years. second case was a -year-old man who was admitted with a . -cm mass in the right anterior femoral region. the tumor was low-grade and consisted of cartilaginous heterologous component. third case was a -year-old man with congenital café-aulait spots and soft tissue swellings all over his body. he was admitted for soft tissue swellings in the left axilla and in the neck region and years ago, respectively. both of the lesions were diagnosed as plexiform neurofibroma. currently, the patient attended with -cm mass in the gluteal region. pathologic diagnosis was consistent with mpnst. results: the first and the third cases showed a higher egfr expression than the second case. conclusion: we aimed to describe the morphological features and discuss the clinical background and different pathogenetic origins of these three cases with mpnst. the role of egfr overexpression was also evaluated in this case series. results: the cases reviewed belonged to different subtypes of sarcoma, with leiomyosarcoma of greatest incidence ( %). the most affected age at presentation was - . gender distribution was almost equal (m/f : ). the majority ( %) of cases were located in the trunk. ten commonly used immunohistochemical markers were identified, with vimentin being the most common ( %). over surgeons were responsible for the care of these sarcomas. less than half the cases were graded at diagnosis. of those graded, % were high grade, % intermediate grade and % low grade. the size at presentation ranged from to cm (mean . cm). conclusion: soft tissue sarcomas are a widely diverse group of uncommon tumours. we confirmed that our incidence rates are comparable with those published in the usa, with leiomyosarcoma being the most common subtype. of note is that over surgeons were involved in the management of these cases over years. this would suggest a need for a nationalized specialist centre with surgeons experienced in the treatment of these rare tumours. objective: calcifying aponeurotic fibroma is a rare soft tissue tumor of children and adolescents. these lesions are presented as slow-growing painless masses that usually affect the distal part of the extremities. they are locally aggressive tumors that infiltrate the surrounding muscle and fascia. recurrence rate is over %, but malign transformation is very rare. we report a -year-old boy with calcifying aponeurotic fibroma. method: we present a -year-old boy with non-movable firm mass on his leg. it was represented as a × . -cm diameter mass which surrounded the peroneal tendon with an infiltrating contour on x-ray and mri. fibroblastic proliferation areas, dense collagenous stroma, calcification and osteoid matrix were observed histopathologically. the tumor infiltrated peripheral muscle tissues and surrounding vessels and nerves. there were no mitotic figures and evidence of atypia. overall, histopathologic and radiologic features exhibited the same characteristics of calcifying aponeurotic fibroma. conclusion: calcifying aponeurotic fibroma is a locally aggressive tumor with a high rate of recurrence. especially in young patients, those under years of age had higher risk of recurrences. very few cases of malignant transformation have been reported. surgical total excision is suggested if ever possible and is the mainstay of the treatment approach. however, it is not possible in most of the cases because of its locally infiltrative behaviour. differential diagnoses include aggressive fibromatosis, nodular fasciit, fibrosarcomas, monophasic synovial sarcoma and some other malignant spindle cell tumors. surgical management should be conservative; excision and re-excision, if necessary, are preferable to radical or mutilating surgical procedures to maintain the function of the extremity. elastofibroma dorsi: case report. clinicopathological findings s. papaemmanouil* *g. papanikolaou general hosp., dept. of pathology, thessaloniki, greece objective: elastofibroma is a tumor-like lesion of soft tissue characterized by a large number of coarse, enlarged elastic fibers and fatty tissue. its usual location, in the scapular area, deep in the latissimus dorsi and rhromboid muscles, led to the name "elastofibroma dorsi". most of the elastofibromas are usually asymptomatic, unilateral and occur mainly in middle-aged and elderly women. clinically, these lesions may simulate an aggressive soft tissue tumor. method: design: a -year-old woman presented with a slow-growing subcutaneous mass in the right lateral chest wall. ct scan revealed an ill-defined solid mass, lying deep within the latissimus dorsi. the diagnosis of elastofibroma was suspected and the patient underwent a simple excision of the mass. the surgical specimen consisted of a poorly circumscribed mass, measuring × × cm, with gray-white cut surface and elastic consistence. the sections were examined with h+e and elastic stains and followed by immunohistochemical study for a-sma, cd , and h-caldesmon. results: the lesion was composed of a mixture of collagenous stroma, few spindle cells, mature adipose cells and large coarse eosinophilic elastic fibers, which stain with verhoeff-elastica and masson-trichrome. the spindle cells were positive for cd and negative for a-sma and h-caldesmon. the microscope findings confirmed the preoperative diagnosis. conclusion: elastofibroma is an unusual benign lesion cured by simple excision. the irregular elastic fibers may be the result of abnormal elastogenesis. the familial occurrence supports a genetic predisposition to this lesion. the most important differential diagnosis consideration is desmoid fibromatosis. objective: soft part sarcoma (sps) represents a difficult working area, either for the pathologist and the oncologist. prognostic factors are limited in these tumors, and the search for clinically relevant molecular markers is relatively incipient. we have proposed the present study based on previous results by our group on differential gene expression of soft tissue tumors, which showed significant overexpression of the top a gene in sarcomas. as top a is coded by a gene sited in chromosome , we have also included her- -neu. survivine was also included as previous studies have shown a significant correlation with survival in sps. our aim was to evaluate immunohistochemical protein expression of the three genes and also assess the gene copy numbers of top a and her- -neu by fish analysis in sps in order to verify the existence of prognostic value on these parameters. method: paraffin-embedded tissues from patients with sps were included in the study. results: analysis of multiple parameters showed that combined immunohistochemical expression of top a and survivine were significantly associated with overall survival among sarcomas. this association was also valid when only high-grade sarcomas were analysed. there was no correlation between gene amplification and protein expression of top a, or with her- -neu. objective: the inflammatory amelioration of affected joints was characterized by aa-pas and herovici methods in a k/bxn mouse model of spontaneous chronic arthritis that shares many similarities with rheumatoid arthritis (ra) and was used to study the potential of cd + t cell depletion with monoclonal antibodies (mab) to stop and reverse experimental arthritis progression. method: five groups of mice (including control) were treated with specific anti-cd mab (yts and yts . ) with and without thymectomy. cd + t cells from the blood and articular infiltrate of k/bxn mice were characterized for cell surface phenotypic markers and for cytokine production. affected joints were submitted to routine decalcification and paraffin inclusion. results: mice receiving anti-cd mab improved the arthritis score days after treatment. recovery of the cd + t cells was associated with a new increase of the arthritis score after days. thymectomized and anticd mab-treated mice improved arthritis score permanently. anti-cd mab-treated animals normalized the serological levels of tnf-a, ifn-, il- and il- , and histological analysis showed an absence of inflammatory infiltrate. conclusion: to the best of our knowledge, it was shown for the first time that k/bxn mice activated and effector memory cd + t cells are present in the peripheral blood and joints and that they play an important role in arthritis maintenance since treatment with specific anti-cd mabs significantly improved disease signs, supported by histological observations. these results document that cd + t cells should be regarded as major players in the k/bxn model of experimental arthritis alongside cd + t cells and b cells. method: a -year-old woman presented with postmenopausal bleeding. the diagnosis was mixed mullerian tumoral proliferation in the probe cüretage material. later on, total abdominal hysterectomy and bilateral salpingo-oopherectomy was performed. macroscopically, the specimen had a . × × -cm polypoid mass in the uterine cavity. microscopically, there was a tumoral proliferation of swollen epithelioid cells that formed sex cord-like tubular formations and showed trabecular and insular patterns. one-layered columnar cells laid the endometrial glands peripherally of this proliferation. the neoplastic cells had mild hyperchromatism and pleomorphism and mitosis. there was no necrosis. ki- proliferation index was - %; the neoplastic cells were positive for vimentin, estrogen receptor, progesterone receptor, smooth muscle actin and bcl- , but negative for pancytokeratin, cd , hmb- and alpha-inhibin immunohistochemically. results: by the help of these findings, we reported the case as 'pecoma-like epithelioid-type endometrial stromal sarcoma', though hmb- was negative, but the morphological findings were similar. conclusion: we present the case here because of its rareness and to discuss it with the description of additional cases; more insight into their behavior and predictive morphological parameters may be achieved. intestinal-type adenocarcinoma in a background of mature cystic teratoma of the ovary: case report e. kimiloglu sahan*, s. tettkurt, n. erdogan, y. t. ayanglu, u. kafrinoglu *taksim training hospital, dept. of pathology, istanbul, turkey objective: mature cystic teratoma of the ovary, frequently called a dermoid cyst, is the most common of all ovarian neoplasms and represents the majority of benign ovarian neoplasms in women < years of age. malignant transformation of mature cystic teratoma of the ovary occurs in approximately % of all cases. patients found to have malignant transformation in a mature cystic teratoma are likely to be postmenopausal. adenocarcinoma has been reported to occur in . % of cases of mature cystic teratoma. method: the operation of total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed on a postmenopausal woman of years. in the macroscopical sections of the ovary, there were multiple cysts which had . cm of greatest diameter. there were sebum-like material and hair in some of these cysts. microscopically, there was a malignant proliferation of epithelial type that formed tubular, cribriform and polyadenoid formations. the cells of this proliferation were large and pleomorphic and had a high mitotic index. there was necrosis widely. columnar epithelium was lying in the cystic spaces. there were lipid-laden macrophages and histiocytic multinuclear cells, lymphoplasmositer inflamatuar cell infiltration around them. there were hair follicles focally. immunohistochemically, tumor cells were positive for cytokeratin and cdx- diffusely and negative for cytokeratin . results: the diagnosis was intestinal-type adenocarcinoma in a background of cystic teratoma. endoscopically and colonoscopically, there was no tumor in intestines. conclusion: although gastrointestinal epithelium is found in mature cystic teratoma, intestinal adenocarcinoma is uncommon in the ovary. because of its rareness, we present the case here. objective: cervical carcinoma metastasises mainly via the lymphatics. attempts to correlate the expression of various lymphatic markers with lymph node metastasis have provided contradictory results. we investigated the expression of lymphangiogenesis-associated molecules in human cervical squamous cell carcinoma (scc). method: the expression of vegf-d, prox- and d - were evaluated by immunohistochemistry in paraffinembedded tissue samples from cases of invasive cervical scc. correlations with tumour grade, figo stage, lymph node metastases, lymphatic emboli and inflammation were also examined. results: cytoplasmic and/or nuclear vegf-d expression in the tumor cells was found in of ( %) cases and correlated significantly with ln metastasis (p= . ), lymphatic emboli (p= . ) and figo stage (p= . ). d - and prox- were expressed in the lymphatic endothelium, while in of (%) cases, nuclear staining for prox- in the tumor cells was also observed. there was a significant correlation between d - peritumoral lymph vessel density (lvd) and the presence of lymphatic emboli (p= . ) as well as between both intratumoral and peritumoral prox- lvd and the degree of inflammation (p< . ). a significant correlation of vegf-d expression with peritumoral d - and prox- lvd (r= . , p= . and r = . , p = . , respectively) was also noticed. our results indicate that vegf-d seems to be implicated in lymphangiogenesis and in the progres-sion of cervical scc, and d - may be a useful diagnostic tool in the assessment of lymphatic emboli. inflammation also probably plays a critical role in promoting lymphangiogenesis. objective: the protein p (ink a) is overexpressed in cervical lesions associated with high-risk human papillomavirus (hpv) subtypes and , but not in low-risk hpv subtypes and or non-hpv-associated cervical lesions. distinction between low-and high-grade cervical lesions is very important for the management of patients with cervical intraepithelial neoplasia. in this study, we wanted to determine the usefulness of p (ink a) expression in biopsy specimens with indistinct initial histologic diagnosis (cin - ) . method: we applied immunostaining for p (ink a) in consecutive cervical biopsy specimens with equivocal initial histologic diagnosis (cin - ) during the period between january , and december , . results: diffuse positive expression in the lower third of epithelium was found in % ( / ) of cervical biopsies; in % ( / ), the positive expression extended to two thirds of the epithelium, suggesting the diagnosis of cin . fifteen biopsy specimens ( %) were negative or only focally positive for p (ink a), indicating the diagnosis of immature squamous metaplasia. conclusion: the data support the routine use of p (ink a) immunohistochemical evaluation of cervical biopsy specimens for better discrimination of negative, low-grade and high-grade cervical lesions. cervical adenocarcinomas concomitant with cin or squamous cell carcinoma lack gastric phenotype y. wani*, k. notohara *kurashiki central hospital, dept. of pathology, japan objective: uterine cervical adenocarcinoma with gastric phenotype was recently proposed and shows an aggressive clinical course. the aim of the study was to examine whether the gastric phenotype is present in cervical adenocarcinoma in situ (ais) or invasive adenocarcinoma (ac) concomitant with cervical intraepithelial neoplasia (cin) or invasive squamous cell carcinoma (sc). method: fifteen cases of cervical glandular neoplasms concomitant with cin or sc were retrieved from kch files and subclassified by ais+cin (n= ), ac+cin - (n= ), ac+cin (n= ), ac+sc (n= ). of those, ac and sc were independently present and the so-called adenosquamous carcinoma was excluded. in addition, no cases of minimal deviation adenocarcinoma were observed. we evaluated the presence of gastric morphology based on the criteria previously described by kojima et al. (ajsp ) . in immunohistochemistry, the staining of muc and hik was performed and scored as negative; < %, focal; % to < %, diffuse; % or more. ( ) cd expression is increasing in hyperplastic processes and ec, but there are no differences of cd in atypical hyperplasia and endometrial carcinoma. ( ) pten protein expression in eh and ec was variable, but with tendency towards its diminution in cystic glands, atypical hyperplasia and ec. the association between neoplasia of the endometrium and others benign genital lesions: independent or similar mechanism? m. sajin* objective: schwannoma of the uterus is a benign but very rare neoplasia. we report a case of uterine schwannoma occurring in a -year-old woman with a recent history of abnormal uterine bleeding. method: the curettage material was routinely processed and stained with h&e. in addition, immunohistochemistry was performed with antibodies against s -protein, sma, cd , caldesmon, melan a, hmb , cd and mib- . results: in histological investigation, very few preexisting non-neoplastic glands and a tumor with dense fibrillary matrix was seen. the nuclei were oval to bipolar and cells showed no borders. few psammoma bodies were seen in the tumor, also incipient verocay bodies. the tumor cells were intensely positive for s- protein; no reaction with all other antibodies was seen. less than % of tumor cells were positive for mib- . the histopathology and the immunohistochemistry in this case revealed an exceedingly rare example of a uterine (subendometrial) schwannoma. expression of pten, ß-catenin and estrogen receptor in endometrial hyperplasia: an immunohistochemical study s. wojtylak*, b. pieczynska, k. klonowska, a. zawrocki, w. biernat *medical university of gdansk, dept. of pathology, poland objective: type i endometrial carcinomas with endometrioid and mucinous morphology develop in the patients with chronic hyperestrogenism. these tumors show frequent pten ( - % of cases) and β-catenin mutations ( - % of cases). method: the study group consisted of cases of endometrial hyperplasia (eh) and cases of endometrial atypical hyperplasia (eah). as a control group, cases of anovulatory cycle endometria (ace) were selected. the immunohistochemical analysis was performed on the endometrial curettings by means of tissue microarray. for the objective evaluation of analysed proteins, expression h scores (percentage of positive cells) have been used. conclusion: expression of analysed proteins significantly distinguishes endometrial hyperplasia from disordered endometrial proliferation. the most extreme level of abnormal expression of the studied proteins was seen in atypical hyperplasia, confirming its close relationship to endometrial carcinoma. analysis of pten and β-catenin expression may be a useful adjunct in small endometrial biopsies from patients with suspected precursor states for endometrial carcinoma. objective: cotyledonoid-dissecting leiomyoma of the uterus (cdlu, also known as sternberg tumor) is an extremely rare variant of smooth muscle neoplasm. less than cases of cdlu have been reported so far. cdlu is characterized by alarming distinctive gross appearance suggestive of a malignant neoplasm, but paradoxically universally benign clinical behavior. although the histopathological picture of cdlu was well described, there are few if any data which may explain extrauterine overgrowth of the tumor. method: four previously not described cases of cdlu were submitted to histopathologic examination and selected immunohistochemical assays (p , ki , bcl- , wt- , p ). results of immunohistochemical stainings were compared to those previously reported in benign and malignant uterine smooth muscle neoplasms. results: the age of patients with cdlu ranged from to years (median years). grossly, all the tumors were exophytic and composed of irregular nodular protrusions. median diameter of tumors was cm (range - cm). microscopically, the cases were composed of smooth muscle fascicles dissecting the extratumoral myometrium and forming swirled nodules, similarly to previous cdlu reports. nuclear p expression was seen in < % of tumor cells. ki- proliferative index in all cdlu cases was below %. bcl- was expressed focally in a single case and diffusely in three other cases. wt- diffuse nuclear expression was seen in all cases. all cases were p -negative. conclusion: p /ki- /bcl -/wt- /p immunohistochemical expression patterns in cdlu resembled those previously reported in uterine usual type leiomyomas and did not explain the distinctive gross appearance of these tumors. objective: epithelial ovarian carcinoma (eoc) is subdivided into five histological subtypes: serous, mucinous, endometrioid, clear cell, and transitional. the differential diagnosis between these subtypes is mostly unproblematic, but is getting difficult in poorly differentiated tumors. the aim of the present study was to establish an immunohistochemical marker panel in a series of unequivocal highly differentiated eocs that simplify the differentiation in difficult eocs. method: we performed an immunostaining study in a small series of highly differentiated eocs ( cases). after examining the cases with markers, we identified antibodies as useful markers (ca - , cd , ca cd , cd v , cd h, claudin , egfr, fak, opn, p , p , and pr). the percentage of the antibody-marked tumor cells per tumor was observed counted. the f test was used to determine differences between the means of percent expressions of the antibodies. for predicting the histological subtype from the antibodies data, a multinominal logistic regression model was performed. we additionally accomplished a leave-one-out method cross-validation experiment to mimic real-life situation of predicting an unknown histological type. results: in % of the cases, the initial multinomial regression model (using all observations) was able to predict the correct subtype. however, this number reduced to % in the leave-one-out experiment. conclusion: the match of % correct predictions in the full data set is in agreement with another publication ( %) using a similar panel. however, the low number of correct predictions in the leave-one-out experiment affirms that this is no valid panel to distinguish the histological types of eocs by immunohistochemistry. objective: teratomas usually manifest as masses in descended or undescended testes, in extratesticular tissues where germ cells tumors occur and in ovary in females. teratomas are germ cell tumors composed of an array of tissues derived from two or three embryonic layers in any combination. method: our report presents two cases of immature teratomas. the first patient is a -year-old man admitted in surgical department of county hospital of constanta for increased size in the left testicle in last months, and the second case is a -year-old girl hospitalized in the same department for retroperitoneal tumoral mass. ct scan shows in both cases testicular and ovarian mass with nonhomogeneous structure, surrounded by liquidian areas. results: histological exam revealed in both situations immature teratoma with mesenchymal, epithelial adenocarcinoma and neuroepithelial features and mature zones with condroid tissues. there are no specific immunohistochemical markers for teratoma, but individual antibodies can be used to identify particular tissues. in both cases, chromogranin, synaptophysin and afp were positive. there was no correlation found for the rest of ihc markers used for these cases, markers that were positive or negative (plap, beta-hcg, cd , s ). prognosis was favorable after surgery on the young man, but the young woman was given chemotherapeutical support. conclusion: immature teratomas are rare germ cell tumors. the incidence in children is % to % of ovarian and testicular tumors. in both cases, the ihc confirms immature teratoma diagnosis. immature intestinal type of glands were positive for afp, and neuroepithelial structures were positive for chromogranin and synaptophysin that sustain immature teratoma. objective: vascular tumors of the ovary are rare, with only lymphangiomas published in the literature so far. they are usually asymptomatic and represent an incidental finding. histologically, most lymphangiomas are of cavernous type and do not exceed - cm in diameter. we report two unusually large lymphangiomas measuring and cm in diameter, respectively, both of them presenting with ultrasonographical images of malignancy due to the large size and multicystic appearance. method: patients were and years old, respectively, the latter with a clinical history of pregnancies and associated leiomyoma and endometrial polyp. the former was operated for a large pelvic cystic mass which was on microscopic examination diagnosed as a borderline serous tumor of the left ovary. results: macroscopically, they were poorly defined multicystic tumors that on cut section were dramatically reduced in size (deflated), oozing a clear, thin fluid. microscopically, there was an anastomosing network of empty-appearing cystic spaces that were lined by flattened cuboidal cells without atypia. immunohistochemically, their vascular nature was demonstrated as the cells lining the cystic network were positive for cd , cd and d - (podoplanin) and negative for epithelial markers. conclusion: lymphangiomas are benign masses and their histogenesis is uncertain. they may represent a reactive process occurring after impaired or blocked regional lymphatic drainage related to conditions such as chronic follicular salpingitis, radiation therapy or various neoplastic processes. one of our cases lacked any association and the other one was associated with a surface, noninvasive tumour. we thus conclude that our cases are likely to be true neoplasms. placental mesenchymal dysplasia (pmd) with mosaic triploidy and chorangiomas presenting as a partial hydatidiform mole (phm) j. stanek*, m. khalequzzaman *cincinnati children's hospital, dept. of pathology, usa objective: phm may show radiologic, gross, and histological features overlapping with pmd. pmd with aneuplodies has been reported, but not with a mosaic triploidy. method: a , -g male fetus without hemihypertrophy or congenital malformations was born at weeks gestation. the -g dysmature and focally hydropic placenta showed varicose dilatation of focally thrombosed chorionic vessels, and two translucent thin-walled septal cysts grossly suggestive of phm. the stem villi showed myxoid stromal change. there was no trophoblastic hyperplasia or pseu-doinclusions. the chorionic and stem vessels were dysplastic. two . -and . -cm glut- positive capillary chorangiomas were found. results: ,xxy/ ,xy karyotype was revealed by fish. amplification of three microsatellite loci on chromosome p . showed that the predominant cell line was ,xy. there was no evidence of paternal isodisomy of beckwith-wiedemann syndrome. conclusion: this unique pmd case with mosaic diandric triploidy and chorangiomas was grossly suspicious for phm because of the presence of thin-walled translucent "hydatid" vesicles admixed with placental tissue. however, a large for gestational age and dysmature fetus without anomalies and characteristic gross and microscopic placental findings were diagnostic of pmd. the distinction between phm and pmd is clinically valid as phm can be complicated by persistent gestational trophoblastic disease or trophoblastic tumors. the presence of diandric triploidy is not automatically equivalent to phm. objective: the biological role of phosphorylation of the p protein in tumour cells is still investigated. the study evaluated p protein overexpression, p phosphorylated at serine (ser ), serine (ser ), and expression of bax, cas proteins in ovarian neoplasms and their association with clinicopathological parameters. method: the expression of analyzed proteins was examined on malignant and benign ovarian neoplasms using immunohistochemistry. results: differences between the expression of studied proteins in benign and malignant ovarian neoplasms were significant (p< . ). p -ser phosphorylation was associated with advanced stage (p= . ). p protein overexpression was associated with poor differentiated tumour (p= . ), while the differences between cas expression were observed in moderate and poor tumour grade (p= . ). the correlations between bax/p -ser , cas/p -ser and p -ser expression were found in ovarian carcinomas (p< . ). p /cas-positive cancers were associated with poor differentiated (p= . ) and advanced tumours (p= . ). p /bax-positive cases were found in poorly differentiated cancers (p= . ). these immunophenotypes revealed phosphorylation of p at ser and in . % of cases. conclusion: our results suggest that the expression of p protein phosphorylated at ser might depend on the morphological maturity of tumour cells. the revealed associations between bax, cas and p protein phosphorylated at serine and expression indicate that phosphorylation of p protein at ser and might play a role in the regulation of apoptosis-related protein expression in ovarian carcinomas. experimental model of female hormonal sterility received by influence on a bitch rat of long constant illumination s. abuzaid*, i. kuzmina, g. gubina-vakulik, n. kolousova *national medical university, kharkov, ukraine objective: female hormonal sterility is successfully treated. the experimental model of this morbid condition of ovaries is necessary for the approbation of various methods of treatment of female hormonal sterility. in this connection, we have estimated histologically the structural changes of ovaries of a rat after the long maintenance in the conditions of constant illumination. method: two groups of females vistar rats at the age of months are generated: control group (Сgr), six individuals, and basic group (Вgr), six individuals. rats of Вgr within months were contained in the conditions of constant illumination and rat Сgr in other premise, in conditions of usual change of day and night. ovaries are studied histologically. results: the ovary of rats Вgr has reduced dimensions. absence of normal follicles of any degree of maturing and yellow bodies, presence of cystically variated follicles, a considerable quantity of atretic follicles, and presence of white bodies are microscopically observed. it is possible to assume that constant illumination of animals causes stimulation of the production of serotonin and inhibition of the production of a melatonin by a cone-shaped gland. in the beginning, there is a stimulation of a hypothalamus-hypophysial-ovarian axis and then exhaustion of compensatory mechanisms and development of hormonal sterility. objective: the expression of p protein is associated with a high risk of hpv infection. the purpose of this study was to evaluate if overexpression of p ink a protein can be a useful biomarker to detect dysplastic cells in cervical smears of women with normal colposcopic findings but hgsil cytology. method: cases were retrospectively searched in cytology data of the past years. one hundred thirty-nine cervical smears from patients with hgsil were reviewed by two cytologists. the colposcopic results concerning those cases were also obtained from the records. forty-three of ( . %) women had no pathologic colposcopic findings. immunocytochemistry for p was performed on all cases with normal colposcopy and hgsil cytology. the immunocytochemical staining results were estimated and classified into four grades: , ( - % positive cells), ( - % and patchy), (> % and diffuse). results: the p protein expression was not observed in two cases ( . %), whereas it was strong and diffuse in nine patients ( . %). strong and patsy p expression was detected in patients with hgsil cytology and normal colposcopy ( . %). rare positive cells ( - % cells with nucleus stained with anti-p antibody) were present in cervical smears ( . %). conclusion: colposcopy with guided biopsy detects approximately two thirds of cin cases (gage et al., national cancer institute, usa, ) . increased expression of p ink a reflects the increasing expression of viral oncogenes in dysplastic cervical cells. p ink a is a specific biomarker to identify hgsils, so it could be a useful adjunct for the reevaluation women with hgsil cytology and normal colposcopy in order to correct the underdiagnosed hgsils and prevent delay in therapeutic managements. objective: prior to the introduction of computer-assisted screening in the netherlands, it was agreed upon to first validate this method with an a priori agreed upon uniform protocol for validation. aim was a kappa value of . or higher. method: a validation sample set was made of anonymized routine screen samples, enriched for abnormalities (to %). two screeners from one laboratory scored these with either computer-assisted screening or conventional thin-layer cytology. slides were scored dichotomously independently for either mode of screening as either within normal limits or outside normal limits. the procedure was supervised by an external quality pathologist. after a pilot (n= ), the 'set' was transported to other laboratories for the application of a similar protocol. all scores were computed from six different laboratories (n= , ). results: this nationwide validation study required on average weeks in the participating laboratories. first two kappa scores were . ( % ci . - . ) and . ( % ci . - . ) for the two techniques. after months, four additional laboratories had accomplished the validation procedure. cumulative kappa score for six laboratories was . ( % ci . - . , n= , ) all average scores were above the preset norm of . . conclusion: a nationwide validation protocol could be accomplished without complications. the results showed good agreement between computer-assisted screening and conventional screening on thin-layer technique. the validation protocol allows for the implementation of computerassisted screening in programme-based screening in the netherlands since detection rates will not alter in a significant manner. diagnosis of malignant mesothelioma by fine needle aspiration cytology m. almeida*, p. campos *hospital santa maria, patologia morfologica, lisbon, portugal objective: cytopathologic descriptions of mesotheliomas are limited. this study shows the results of fine needle aspiration (fna) cytology in ten cases of malignant mesothelioma. method: material was obtained by ct-guided fine needle aspiration (fna). smears were stained with giemsa and papanicolaou stain, and cell block sections, when done, were stained with hematoxylin and eosin. immunocytochemical (icc) studies were done in smears/cell block using adenocarcinoma markers (cea, ema, cd , ck and ttf ) and mesothelial markers (calretinin, wt , ck / ). results: all mesotheliomas except three of peritoneal origin were from the pleura. there were nine epithelial malignant mesotheliomas (emm) and one sarcomatous mesothelioma (smm). all mesotheliomas except three of peritoneal origin were from the pleura. there were nine epithelial malignant mesotheliomas (emm) and one sarcomatous mesothelioma (smm). in fna, all emms were highly cellular, with a large number of small sheets, and tridimensional clusters with smooth or lobulated contours as well as single cells. the cells were round to polygonal with abundant cytoplasm and well-defined cell borders and the nuclei were predominantly centrally located, round to oval, medium to large with fine chromatin and small but prominent nucleoli; occasional binucleation was noted. the smm showed malignant spindle-shaped cells with scant, ill-defined cytoplasm singly and in loose clusters, in a bloody background. immunocytochemical staining on the smears/cell block were positive for calretinin, ck / ,ck and wt and negative for cd ,cea and ttf . conclusion: cytologic findings coupled with immunocytochemical studies and in combination with radiologic information and clinical history are highly accurate in the diagnosis of malignant mesothelioma. solid pseudopapillary tumor of the pancreas diagnosed on endoscopic ultrasound-guided fine needle aspiration material a. demir*, r. sadik, p. saksena *sahlgrenska university hospital, dept. of clin. pathology and cytology, gothenburg, sweden objective: solid pseudopapillary tumor (sppt) of the pancreas is a rare, low-grade, epithelial neoplasm that is usually discovered incidentally in young women. method: we present a -year-old woman with × -cm round tumor in the caput pancreatis. endoscopic ultrasound-guided fine needle aspiration (eus-guided fna) was performed. smears were stained with giemsa and mc manus. cell block was used for eosin, mc manus and immunohistochemical stainings. results: cell-rich smears showed single cells and aggregates of uniform cells forming branching papillary clusters with delicate myxoid fibrovascular cores. the nuclei of the cells were round or oval; nucleoli were small or inconspicuous. cytoplasms were usually vacuolated. intra-and extracytoplasmic myxoid globules were noticed. tumor cells showed diffuse positivity for cd , progesterone receptor and cd and focal positivity for synaptophysin and ae /ae . chromogranin a, ck / , ck , tag were negative. ki showed low (< %) positivity. the case was diagnosed as sppt based on morphological and immunohistochemical features, which was confirmed on the surgical material. conclusion: distinguishing sppt from other pancreatic tumors, especially pancreatic endocrine tumors, can be challenging. clinical setting, cytomorphologic features, and immunostains of the cell block help distinguish sppt from pancreatic endocrine tumors, acinar cell carcinoma, and papillary mucinous carcinoma. the objective: most countries, including greece, have adopted the triple assessment approach to breast diagnosis, with fnac as the first-line pathological investigation with the exception of microcalcifications. the majority of european countries use similar reporting systems for breast fnac (c -c ), in keeping with the european guidelines for quality assurance in breast cancer screening and diagnosis. method: in order to explore current practice in our hospital, we reviewed breast fnas within a -year period, collected and interpreted by both the cytopathologists and less by the surgeons, where no clinical data were available. results: there were a total of cancers ( %), of which were diagnosed by fna ( as c and as c ). overall, were diagnosed as c ( . %), as c ( . %), as c ( . %) and as c ( . %). of the c , were confirmed histologically (mastectomy specimens), whereas in patients, there was no feedback information. there was one false positive case concerning two separate fibroadenomas, one of which in the mammary tail, sent to the lab as axillary lymph node. in the c category, there were carcinomas, two fibroadenomas, one fibrocystic disease, and had no confirmatory biopsy. in the c category, there were six carcinomas (four ductal, one lobular, one metaplastic), two columnar cell change and one fat necrosis. our results confirm the accuracy of fna in the diagnosis of malignancy and show the major importance of a multidisciplinary approach and knowledge of the clinical and radiologic data by the interpreters of the fnas. benign renal tumors mimicking malignancy in fine needle aspiration biopsy samples: report of three cases h. gutnik*, m. strojan fležar, z. ovcak, j. pižem *medical faculty ljubljana, institute of pathology, slovenia objective: fine needle aspiration biopsy (fnab) is a wellestablished method to diagnose renal tumors. however, it is challenging to diagnose rare benign renal tumors with unusual cytomorphology mimicking malignant tumors. we report three such cases. method: all three kidney tumors were discovered by ultrasound examination, and ultrasound-guided fnab was performed. the first case was a multicystic renal tumor in the right kidney of a -year-old woman. the second case was an atypical cyst in the left kidney of a -year-old man. the third case was a solid tumor in the left kidney of a -year-old woman. results: case : papillary-like structures and macrophages, supplemented by immunocytochemistry, rendered a diagnosis of renal carcinoma, papillary type, while disregarding stromal fragments. histological diagnosis was a mixed epithelial and stromal tumor (mest). case : similar morphology led to the same cytological diagnosis as in the first case with subsequent histological diagnosis of a cystic nephroma. case : small groups of severely atypical cells were suspicious of a malignant tumor, possibly a metastatic one. the histological diagnosis was juxtaglomerular tumor, confirmed immunohistochemically and by electron microscopic examination only after additional clinical data about unexplained arterial hypertension from the age of were obtained. conclusion: cytologic samples of cystic renal tumors should be evaluated cautiously, including the possibility of mest/cystic nephroma group of tumours. the case of juxtaglomerular tumour shows the utmost importance of reporting the relevant clinical data to the pathologist. objective: in some meningiomas, primarily with a large vascular supply, preoperative embolization is performed a few days before surgery in order to soften the tumor and minimize intraoperative bleeding. post-embolization histological changes consist mainly of necrosis, ischemic cellular changes, vascular fibrinoid necrosis and increased proliferative index. these changes may result in overgrading. we have found no description of such changes in the cytological literature. method: we reviewed cases of meningiomas with prior embolization. in of them, relevant cytological changes induced by embolization were present. cytological material was obtained during intraoperative consultation, either by scrapping or squashing of tissue samples. on histology, all of them were grade i meningiomas and showed intravascular embolic material. results: cytology revealed relevant cellular dissociation with frequent single cells. ischemic cellular changes were a common finding and consisted of cell shrinkage, nuclear piknosis and ill-defined cytoplasmic limits. ischemic changes were better appreciated in single cells. eight cases showed histiocytes and neutrophils. confluent areas of necrosis were seen in one case. none of the cases showed cellular atypia or significant mitotic activity. embolic material was seen cytologically in four cases. of the embolized meningiomas, nine of them showed no significant cytological abnormalities. conclusion: embolization of meningiomas induces cytolomorphological changes that may be relevant in some cases. greater cellular dissociation and ischemic changes, as well as inflammation, may result in a worrisome cytological image. when faced with such changes, the pathologist should always consider the possibility of embolization, avoiding overgrading or misdiagnosis. the statistical comparison of different parameters was made using mann-whitney u test and spearman rank order correlation, with the aim of establishing statistically relevant differences and spearman correlation coefficients (r) between glucose in blood and periodontal disease, ageand sex-related, the length of the diabetes disease, the cytological periodontal stage and the length of the periodontal disease, age-related. results: the statistical calculation has revealed important differences of the blood glucose between the cytological periodontal stages and (p< . ), and (p< . ), and and (p> . ). in a similar way, there were also differences between stages and (p< . ), and (p> . ), and and (p< . ). conclusion: the neutrophils that have been drawn by the presence of bacteria or by the erosion areas of the oral and gastric mucosa can promote an increased gravity of the epithelial lesions, suggesting a particularity of the microbial infection at the diabetic patient who has hyperglucidic stress with the modification of the cellular and humoral immunity in the background. objective: treatment of malignant peritoneal effusions is generally palliative; therefore, quality of life issues, as well as the risks and benefits of the therapeutic options, become more critical. cytomorphologic examination alone provides only limited sensitivity for the detection of metastatic carcinoma cells in many cases of serous effusions. early diagnosis and management of peritoneal metastases from cancer patients represent new directions of researches. method: the current study was aimed at differentiating peritoneal liquids encountered in available cases, chosen to show both biochemical patterns (benign and malignant) and in this way to achieve a diagnostic value of the biochemical method. a panel of biochemical markers (tp, alb, ldh, tc, gl, tl, tg, aa, alp, u, tb, db, ast, alt, mg, fe, k) were determined from the resulted supernatant after centrifugation in blood and peritoneal fluid using automatic and semi-automatic biochemistry analyzer. results: thus, of all measured parameters, the highest accuracy in the differential diagnosis between malignant and the benign cases (cirrhosis) was obtained by measuring peritoneal effusions tc ( %), peritoneal fluid ldh ( . %) and saag ( %). conclusion: it is concluded that a suitably chosen panel, consisting of the best specific markers found, can be of great value for the initial differentiation and subsequent guidance in the diagnosis. abbreviations: tp total proteins, alb albumin, ldh lactate dehydrogenase, tc total cholesterol, gl glucose, tl total lipids, tg trglycerides, aa alpha amylase, alp alkaline phosphatase, u urea, tb total bilirubin, db direct bilirubin, ast aspartate aminotransferase, alt alanine aminotransferase, mg magnesium, fe iron, k potassium, pe/s effusions/serum ratio, saag serum-ascitic albumin gradient, sag serumeffusion gradient. objective: hyalinizing trabecular tumor (htt) is an unusual type of thyroid follicular neoplasm that may represent a major diagnostic problem in routine thyroid practice. method: we present the case of a -year-old woman in which a fine needle aspiration (fna) was performed for a . -cm unique nodule, incidentally discovered in the left thyroid lobe. a hemi-thyroidectomy was performed as the aspiration specimen was reported suspicious for papillary thyroid carcinoma (ptc). macroscopically, the nodule was light tan and well circumscribed. in microscopy, it had prominent trabecular architecture and cytological features strongly suggesting a ptc: nuclear enlargement with particularly abundant nuclear grooves and cytoplasmic invaginations. an intratrabecular abundant, homogenous and eosinophilic hyaline material was also noticed. immunohistochemistry, including anti-thyroglobulin, anti-ttf , anti-hbem , anti-ck and anti-mib antibodies, was performed. results: the tumor cells were strongly positive for thyroglobulin and ttf and were negative for hbem , ck- and chromogranin. a characteristic membranous and peripheral cytoplasmic staining was noticed with mib antibody. conclusion: despite the cytological aspect, a diagnosis of htt was made based on the well-circumscribed character of the tumor and the negativity for hbem and ck- . moreover, the unique reactive pattern of mib was an important clue to the diagnosis. careful evaluation is needed in such cases in which cytological criteria are too obviously suggesting a ptc. the differential diagnosis is essential because unlike ptc, htt is considered a benign tumor and has a different behavior and therapeutic approach. objective: thyroid nodules are a common clinical problem and the fine needle aspiration (fna) has become a standard procedure for their clinical triage. its widespread use allows a better selection of patients in need of surgical treatment. method: four thousand three hundred fifty-nine fna were performed between and , always by the same pathologist using a -gauge needle and a cameco suction device. at least three aspirations were carried out, and three to five slides were obtained for each nodule. they were immediately fixed in alcohol and stained with hematoxylin-eosin or with papanicolaou. the cytological diagnosis was classified in four categories: inadequate, benign, suspicious and malignant. six hundred thirty-eight cases had a histological follow-up. the benefits of the cytologic diagnosis were estimated by statistical analysis (epiinfo software version . . ). results: the sensitivity of fna was . % and the specificity . %. there were . % false negative and . % false positive findings. the p value was < . , considered extremely significant. the main causes of diagnostic errors were sampling errors, similar cytological features for different entities, failure to recognize the follicular variant of papillary carcinoma, and coexistence of non-neoplastic and neoplastic processes in the same gland. conclusion: although the sensitivity and the sensibility does not attain %, fna proves to be the most reliable and cost-effective method for distinguishing benign from suspicious or malignant thyroid lesions. limitations of the method included false negative, non-diagnostic and indeterminate or "suspicious" results. nevertheless, the routine use of fna reduces the rate of unnecessary surgery for thyroid nodules. objective: medullary (mtc) and papillary thyroid carcinoma (ptc) have always been considered different from each other, in their cell origin, histopathological features and incidence. we describe one rare case with simultaneous multicentric ptc, classic or oncocytic type, in one lobe and "composite thyroid carcinoma" with mixed features of mtc and ptc in the other one. these tumors were associated with graves' disease. method: surgical specimens were routinely processed, paraffin-embedded, and he-, van gieson-and grimeliusstained. immunohistochemical study included antibodies anti-cytokeratin (ck ), chromogranina (cga), thyroglobulin (tg), calcitonin (ct), and hbme . results: in the right lobe, there were two, tan brown, nodular lesions measuring . and . cm, respectively, consisting of ptc oncocytic type with follicular and focal papillary pattern and a classic variant of ptc. in the lower pole of the left lobe, a grayish nodule of . cm, with trabecular, follicular and focal papillar architecture was detected, presenting small tumor cells, pleomorphic nuclei and occasional cytoplasmic pseudoinclusions. tumor cells showed intense positive expression for tg, ck and moderate reactivity for cga and ct. hbme was focally positive with membrane staining along lateral and abluminal surfaces. conclusion: our case report emphasizes the role of detailed histopathological analysis, especially when thyroid nodules harbor various aspects, and the use of immunohistochemistry in the identification of rare types of thyroidian neoplasm. this case might be explained by the possibility of activating a common tumorigenic pathway for both follicular and parafollicular thyroid cells or a common stem cell. thyroid metastasis of clear cell renal cell carcinoma: a series of three cases l. bejan* *emergency county hospital, dept. of pathology, târgu mures, romania objective: thyroid metastases are extremely rare, the kidney being the most frequent primary tumor site. method: we report three cases of thyroid metastasis of clear cell renal cell carcinoma (cc-rcc), one of them being the primary manifestation of a renal tumor and the other two with a previous -and -year, respectively, history of renal neoplasm. the first case, a -year-old man, was admitted to the hospital with an initial diagnosis of bilateral goiter, while for the other two, a -year-old man and an -year-old woman, the discovery was incidental. results: on gross examination, white grayish illcircumscribed solid nodules were described in the right lobe (one nodule, first case), in the left lobe (two nodules, second case) and in both lobes (multiple nodules, third case). all three cases presented similar microscopic tumoral aspects: a solid architecture, polygonal cells with abundant clear or eosinophilic cytoplasm, distinct cell borders and moderately enlarged nuclei with proeminent nucleoli. since the microscopic aspect did not correspond to any primary tumor of the thyroid, immunohistochemistry was performed. in all cases, the tumor cells stained positive for cd and negative for thyroglobulin, supporting the diagnosis of a thyroid metastasis of cc-rcc. conclusion: thyroid metastases of cc-rcc are uncommon and may represent the first sign of a yet undiagnosed asymptomatic renal tumor or a metastasis from a tumor surgically removed years before (up to years). in setting a correct diagnosis, immunohistochemical studies together with the medical history are extremely important. primary angiosarcoma of the thyroid gland. a case report k. bednarek-rajewska* *poznan, poland objective: primary angiosarcoma of the thyroid is a rare and controversial entity most commonly seen in patients from the alpine regions with a long-standing history of colloid goiter. purpose: we describe a case of primary, poorly differentiated angiosarcoma in a -year-old male who presented with a rapidly enlarging thyroid mass and mild dysphagia during the preceding month. method: a ct scan of the neck revealed a large tumor mass in the upper pole of the left lobe of the thyroid measuring . × . × cm extending into the surrounding adipose tissue and infiltrating the left internal jugular vein. lymphadenopathy was identified in the left submandibular region and lower neck. cytomorphologically, the aspirate was cellular, with variably cohesive clusters of atypical spindle cells and necrotic masses. thyreoidectomy procedure was performed. histologically, the tumor was composed of spindle, polygonal and epithelioid cells with vesicular nuclei and prominent nucleoli growing in solid sheets and occasionally forming cleft-like vascular spaces filled with erythrocytes. extensive necrosis was present. mitotic activity was mitoses/ hpf. immunohistochemical stains showed tumor positivity for cd , vimentin, factor viii, wt- , m-act and cd . conclusion: the prognosis in primary angiosarcoma of thyroid is generally poor especially if the tumor penetrates the capsule of the thyroid or if there are metastases present. the patient developed further metastases in the cervical lymph nodes within few weeks after thyroidectomy despite radio-and chemotherapy. due to the rapid progression of the disease, the patient was scheduled for palliative radiotherapy. the patient succumbed to the disease months after diagnosis. objective: pheochromocytoma can be defined as a paraganglioma of the adrenal medulla and has been called the " % tumor" because approximately % are bilateral, % are extra-adrenal, % occur in children, and % are malignant. aim: in this report, we described the histopathological aspects of pheochromocytoma in correlation with immunohistochemical reaction. method: the study group included cases of pheocromocytoma diagnosed by the chromaffin reaction, he and van gieson's reaction. immunohistochemistry included monoclonal antibodies: chromogranin a, neuron-specific enolase and s protein. results: the patients have encapsulated, usually soft, and, on section, yellowish-white to reddish-brown tumors. the larger tumors had areas of necrosis, hemorrhage and cyst formation. histopathologically, the tumor cells are characteristically arranged in well-defined nests (zellballen) bound by a delicate fibrovascular stroma, which may contain amyloid. the cells vary considerably in size and have a finely granular basophilic or amphiphilic cytoplasm. the nuclei, usually round or oval with prominent nucleoli, may contain inclusion-like structures. lipid accumulation may develop in the cytoplasm and lead to confusion with adrenal cortical tumors. giant, hyperchromatic nuclei are common and are not an expression of malignancy. chromogranin a and nse were positive. sustentacular cells form a peripheral coat around the "zellballen" and were strongly reactive for s protein. conclusion: all our cases were benign, although % of pheochromocytomas are malignant and have a marked tendency to metastasize to skeletal system, particularly the ribs and spine. the sustentacular cells are more numerous in pheochromocytomas associated with men than in sporadic cases. primary carcinoid tumor of gallbladder c. comingle*, Ü. sekmen, g. altaca, b. bilezikçi *baskent university, faculty of medicine, istanbul, turkey objective: primary carcinoid tumor of gallbladder is a rare neoplasm. they usually present as a polypoid lesion. method: we report an incidentally found carcinoid tumor of gallbladder located in the cystic duct occurring in a -year-old male patient detected in cholecystectomy material. results: histopathologically, in cystic duct, an incidental neoplasm measuring mms in maximum diameter was detected, which was grossly unremarkable. the tumor constituted glandular structures. it was not invading muscular layer. immunohistochemically tumor was positive for synaptophysin. patient is alive and well after months. conclusion: definite diagnosis of carcinoid tumor of gallbladder is usually made on histopathological examination after surgery. our case is unique in that it was found incidentally, which was grossly unremarkable. it seems so that surgery alone is a reliable definite management for these small carcinoid tumors. objective: accurate identification of kras mutations has great importance for target therapy. reproducibility and cheapness of different methods are crucial to be safely applied in colorectal routine diagnostic setting. method: one hundred twelve ffep specimens, previously studied by arms/scorpions real-time pcr (therascreen, roche, italy) designed as reference method, were in parallel analysed by other two methods: restriction fragment length polymorphism-pcr (ampli-set-k-ras, bird, italy) and pcr/reverse hybridization tests (k-ras stripassay, viennalab, austria), respectively, called methods a and b. the methods were compared considering the results, costs, and working times. regarding kras genotype, selected samples were: wild type (wt), mutated in codon , and in codon . results: six of wt samples showed mutation on codon : three were false positives of method a and three of method b. two of samples mutated in codon resulted also positive on codon by method b. since method a is based on cleavage action of the restriction enzyme, we have increased both restriction enzyme concentration and digestion time, abolishing the false positives. on the contrary, there was no way of acting on method b. conclusion: although method a does not define the codon mutation type and is time-consuming, it leads to the same results of the reference method operating our slight methodological modifications. method a resulted cheap ( % of the reference kit price), useful and reproducible for routinely kras testing in colorectal target therapy. work was supported by fondazione cassa di risparmio di puglia, italy. objective: colorectal carcinoma (crc) is a worldwide common malignancy; young patients represent a third of all cases, with a rise over the last years. fifteen percent of crc have microsatellite instability (msi) due to alterations in mismatch repair (mmr) genes. familiar msi cases ( %) have germline mutations. sporadic msi crc ( %) have hypermetilated mlh- promoter. braf v e mutation exclusively occurs in sporadic msi crc. immunohistochemistry detects msi cases with high concordance with microsatellite analysis. the objective was to compare histopathology and patterns of expression of mmr proteins and braf v e mutation in patients below and over years old and determine if age is a risk factor for defective mmr protein expression and braf mutations. method: one hundred six patients < years were retrieved. age, sex, location, histologic type, tnm, infiltration and metastatic lymph nodes data were collected. mlh and msh immunohistochemistry and braf rt-pcr mutation was performed in < years and patients > years as control group. student's t, χ and logistic regression analysis were carried out. results: medullary and mucinous types were more frequent among young patients and intestinal type in older patients (p= . ). no differences were noticed regarding clinicopathological stages between groups. mmrp expression was absent more frequently in < and msh was negative in . % of these patients. no braf mutations were detected in any group. conclusion: we found an association between young age and defective mmr expression (or . ). msh lack of expression is more frequently due to a germline mutation. the fact that none of our patients had braf mutation could be partly due to the small sample size or alternate v e or k-ras mutations. objective: angiogenesis plays an important role in the progression of colorectal cancer (crc). evidence from preclinical and clinical studies indicates that vascular endothelial growth factor (vegfa) is the predominant angiogenic factor in crc. vegfa is expressed in approximately % of crcs, with minimal to no expression in normal colonic mucosa. therefore, the aim of this study was to analyze the prognostic impact of vegfa amplification in crc. method: vegfa gene amplification was evaluated in a large series of sporadic crc resections (n= , ) by fish analysis using the tissue microarray technique. spectrum green-labeled probes originated from the fish clone rp - g were used together with spectrum orange-labeled probes for the respective centromere as a reference. the vegfa amplification status was compared to relevant clinicopathological features. results: vegfa amplification was detected in patients ( %) and was significantly associated with higher t stage and higher tumor grade, presence of vascular invasion, right-sided location (p < . ) and b-raf mutation (p= . ). additionally, vegf amplification was associated with worse survival in univariate (p < . ) and multivariable analysis (p< . ; hr ( % ci), . ( . - . )). conclusion: vegfa amplification seems to highlight a small subset of crcs with aggressive phenotype. therefore, fish analysis of vegfa could represent an alternative evaluation system for identifying patients with poorer clinical outcome who could be candidates for anti-vegfa therapies. objective: k-ras oncogene is frequently mutated in colorectal cancer and is currently established as a predictive biomarker for anti-egfr targeted therapy. b-raf is a serine/threonine kinase of the ras/raf/mek /erk signal transduction pathway which is mutated in a subset of k-ras wild-type patients with colorectal cancer. the aim of this study was to examine the mutational status of k-ras and b-raf genes in correlation with tumor clinicopathological characteristics. method: dna was extracted from microdissected formalin-fixed paraffin-embedded tissues. three hundred forty-four cases were screened for k-ras and b-raf mutations at codons and and exon respectively using high-resolution melting analysis, sequencing and/or pyrosequencing. statistical analysis was performed using stata for windows. results: k-ras mutations in codons and were present in out of cases. the most frequent types of mutation were pg d and pg v at codon and pg d at codon . b-raf mutations in exon (pv e) were present in . % of analyzed samples. b-raf mutations were observed in a marginally higher frequency in women, whereas k-ras mutations were positively correlated with patients' age. moreover, there was a higher prevalence of b-raf mutations in low-grade carcinomas (p= . ). conclusion: the detected mutation frequency as well as the prevalence of specific mutation types is in accordance with previous studies. the observed correlation of b-raf mutation with tumor grade implies its importance as a marker of tumor aggressiveness. the applied methods (hrm and pyrosequencing) were proven to be sensitive, fast and accurate for mutation detection in a clinical setting. objective: aberrant activation of the phosphatidylinositol- -kinase (pi kinase)-akt pathway is frequently observed in a wide range of cancers such as breast, colorectal, ovarian and lung. several components of this pathway such as pi k and akt can constitute potential therapeutic targets, and many small molecule inhibitors are in development on early clinical trials. the aim of this study was to examine the possible significance of somatic point mutations in pik ca and akt genes as biological markers or therapeutic targets in primary urothelial bladder carcinoma. method: one hundred twenty-two urinary bladder cancer specimens were screened for activating mutations in exons , of the pik ca gene as well as in exon of akt gene by pcr-sscp and high-resolution melting analysis. mutations were identified for pik ca gene with sequencing and for akt gene with pyrosequencing and statistical analysis was performed. results: four different mutations were detected in exon of pik ca gene ( . %). the mutations were identified as p.a t, p.a v, p.h r and p.g r. one out of cases was mutant in exon of pik ca gene ( . %, p.e k). the akt p.e k mutation was identified in out of bladder tumours ( . %). statistical analysis did not reveal any correlation with clinicopathological parameters (p> . ). conclusion: mutations in pik ca gene are quite frequently observed in bladder cancer, implying their importance as potential targets for anticancer treatment. on the other hand, mutations in akt gene are not a common event in this type of cancer. analysis of dna integrity, morphology, antigenicity with different preservation methods in brain tissue a. saetta*, g. agrogiannis, p. korkolopoulou, a. gavriil, n. kavantzas, e. patsouris, e. michalitsi, a. stamatelli, n. prekete, e. palliou *university of athens, st dept. of pathology, greece objective: due to the potential carcinogenicity of formaldehyde, its replacement by substitute fixatives is recommended and could increase the possibility for application of molecular biology approaches. the aim of this study was to examine dna preservation, morphology and antigenicity of brain tissues after fixation with a formalin-free fixative in comparison with formalin-fixed tissues as well as frozen ones. method: calibrated specimens from six different areas (frontal, parietal, occipital lobes, hippocampus, cerebellum and basal ganglia) of brains from elderly individuals (age > ) were fixed for h in two different fixatives (formalin, formalin-free fixative-rcl ) at room tempera-ture. tissues were stained with hematoxylin-eosin for histological examination and their antigenicity was determined by immunohistochemistry. the integrity of dna extracted from the samples with formalin fixation or formalin-free fixation was compared with that of cryosections with gel electrophoresis and the bioanalyzer. furthermore, pcr-pflps and real-time pcr (high-resolution melting analysis) were performed in order to assess the suitability of the extracted dna for downstream molecular pathological applications. results: immunohistochemistry with antibodies against bamyloid and tau did not reveal any significant differences in reactivity for both fixatives. on the other hand, dna extracted from frozen samples was of comparable integrity with that from formalin-free fixation. amplification efficiency for short dna fragments ( - bp) was similar between all preservation methods; however, long fragments ( bp) could not be amplified from formalin-fixed tissues. the formalin substitute fixative used in this study provided good histopathological quality, and also the extracted dna performed better at the subsequent molecular biological procedures. objective: the molecular mechanisms underlying the development of esophageal cancer remain elusive. the aim of this study was to examine the simultaneous presence of alterations in two main signal transduction pathways, ras/raf/mek/erk and pi k/akt, which are implicated in carcinogenesis. the prognostic significance of perk expression was also investigated. method: genomic dna was extracted from paraffinembedded tissue blocks ( squamous-cell, adenosquamous cell and adenocarcinomas). additionally, in cases, tumor cells were collected using laser microdissection in order to minimize contamination with stromal and normal cells. we searched for somatic mutations in kras, b-raf, egfr, akt- and pik ca genes by performing high-resolution analysis and pyrosequencing. the expression of activated erk protein was assessed by immunohistochemistry. results: k-ras mutation at codon was detected in one lasermicrodissected adenocarcinoma out of specimens ( %), whereas no mutations were found in exon of b-raf gene, in exons and of egfr gene, in exon of akt- gene and in exon of pik ca gene. perk nuclear expression was positively correlated with disease grade and stage and nuclear staining intensity with grade. furthermore, perk cytoplasmic immunopositivity was correlated with tumor grade. conclusion: mutations in k-ras gene are not frequently detected in esophageal cancer, but do exist. the lack of mutations in b-raf, egfr, akt- genes implies that these may not play an important role in the pathogenesis of esophageal cancer. the correlation of perk nuclear expression with stage and grade implicates perk as a marker of local tumor aggressiveness. objective: mutation analysis in ras/raf signaling pathway plays a key role in treatment decision in patients with metastatic colorectal cancer (mcrc). at this time, several methods are available for kras mutation detection; there are also commercially available kits, but validated methods and standardized testing procedures are still lacking. method: genomic dna was extracted from formalin-fixed paraffin-embedded (ffpe) tumor tissues after the evaluation of material by pathologists. for mutation analysis of kras gene, we used three methods: direct sequencing, allelic discrimination and high-resolution melting (hrm). results: we tested tumor samples (primary tumors and metastasis) from patients with mcrc. we identified kras mutation in of ( %) patients using allelic discrimination, while hrm detected mutations in of ( %) patients. due to low burden of tumor cells in two cases and limited sensitivity of sequencing, only patients were evaluated by this method. out of them, four ( %) patients showed positivity. we performed sensitivity testing: allelic discrimination ( % of mutant dna), hrm ( %) and sequencing ( %). conclusion: allelic discrimination is a convenient, fast and sensitive method designed for the detection of specific mutations. test costs are proportional to the number of tested mutations since a specific assay has to be used for each mutation. sequencing has a limited application due to low sensitivity, while hrm represents a sensitive, rapid and cost-limited methodology, but displays higher rate of false positive results if dna is in poor quality. this technique is suitable for routine screening; however, precise identification of mutations is not possible. therefore, a combination of at least two methods is highly recommended. objective: mgmt repairs dna damages and act as a tumor suppressor gene in normal cells, preventing dna mutation. several different approaches for mgmt immunohistochemical (ihc) testing have been used, resulting in a not universally accepted standard. we evaluated the ihc expression of mgmt using five different primary antibodies in invasive breast carcinomas in order to establish the most reliable marker for this protein. the results of immunostaining were compared to qrt-pcr, used as a parameter of reliability of gene expression. method: cases were randomly selected to build a tissue microarray. the five primary antibodies to mgmt were provided by: mt . (neomarkers, genetex and santa cruz), spm (santa cruz) and mt . (zymed). heatinduced antigen retrieval in citrate and the advance™ (dako) detection system were used. ihc was visually analyzed by microscope and automated analyzed by software applied to digital slides. qrt-pcr was performed in all tumors for transcript expression quantification. results: antibody spm (santa cruz) showed the highest sensitivity (p< . ), and antibody mt . (santa cruz) showed the least sensitivity (p< . ). antibody mt . (zymed) showed higher levels of cytoplasm staining, which was not observed in the other antibodies tested (p< . ). qrt-pcr results showed that . % of the samples showed hypoexpression of mgmt when compared to normal breast (p< . ). spm (santa cruz) was the only antibody which showed a positive and significant correlation with the results obtained by qrt-pcr (p= . ). conclusion: this antibody seems to be reliable and effective for research and clinical practice in breast cancer. (supported by fapesp and cnpq). objective: mgmt repairs dna damages and act as a tumor suppressor gene in normal cells, preventing dna mutation. several different methods for mgmt immunohistochemical (ihc) testing have been used, resulting in no universally accepted standard. we evaluated the ihc expression of mgmt of five different primary antibodies in invasive breast carcinomas. method: fifty-nine breast carcinomas were randomly selected for a tma construction. five different primary antibodies against mgmt were used for the ihc study: clone mt . (neomarkers, genetex and santa cruz), spm (santa cruz) and mt . (zymed). heat-induced antigen retrieval in citrate and advance™ ihc detection system were used. ihc was visually analyzed by microscope and automated analyzed by software applied to digital slides. qrt-pcr was performed in all tumors for transcript expression quantification. results: antibody spm (santa cruz) showed the highest sensitivity (p< . ), and antibody mt . (santa cruz) showed the least sensitivity (p< . ). antibody mt . (zymed) showed higher levels of cytoplasm staining, which was not observed in the other antibodies tested (p< . ). fifty-nine samples ( . %) showed hypoexpression of mgmt when compared to normal breast evaluated by qrt-pcr (p< . ). spm (santa cruz) was the only antibody which showed a positive and significant correlation with the results obtained from qrt-pcr (p= . ). conclusion: antibody spm (santa cruz) presented to be the most sensitive and specific antibody for the ihc evaluation of mgmt. this antibody seems to be of reliable and effective use for research and clinical practice in breast cancer. mgmt as a potential prognostic marker in breast cancer j. cirullo-neto*, k. carvalho, l. kagohara, e. olivieri, d. carraro, i. cunha, j. vassallo, f. soares, r. rocha *cancer hospital a c camargo, são paulo, brazil objective: mgmt repairs dna damages, via alkylation, by removing a methyl group from the o position of guanine. it acts as tumor suppressor gene in normal cells and prevents dna mutation. we evaluated mgmt expression in breast tumors, correlating it with other prognostic factors. method: sixty-four cases of invasive breast carcinomas were randomly selected for a tma construction. immunohistochemistry (ihc) was performed for mgmt and also for er, pr, her , ki , p , p , e-cadherin, ck and ck for luminal and basal phenotype classification. ihc was evaluated following the guidelines for each marker most recommended in the literature. fluorescent in situ hybridization (fish) was performed in those cases considered + in order to assess her gene amplification status. qrt-pcr was performed in frozen tissue from our tumor bank for all cases in order to evaluate mrna expression of mgmt. results: fourteen cases were triple-negative ( . %), and among those, seven cases were basal-like carcinomas ( . %). twenty-five cases ( %) were luminal-like type a, four cases were ( . %) luminal-like type b, and one case ( . %) was her -like type. mgmt showed significant lower expression in the basal-like tumors when compared to the luminal-like ones (p= . ). basal-like phenotype tumors presented higher positivity for p and ki than the luminal types (p= . and p= . , respectively). positive p and high ki tumors showed significant lower expression of mgmt (p= . and p= . , respectively). conclusion: mgmt assessment by ihc or molecular biology techniques may represent an important prognostic factor in breast cancer. objective: the col a gene codifies a protein expressed during cartilage and osteomorphogenesis which is present in the setting of several types of infiltrating malignant desmoplasia. our team generated a monoclonal antibody against procol a which was tested for infiltrating ductal pancreatic carcinoma versus chronic pancreatitis differential diagnosis and infiltrating ductal carcinoma of breast versus sclerosing adenosis differential diagnosis. method: to investigate its usefulness in order to assess the presence of invasion in bronchioloalveolar lung carcinomas (bac), we carried out immunostaining with the monoclonal antibody anticol a in a series of nine bac and six lung adenocarcinomas with bronchioloalveolar pattern. the results show lack of staining in seven of nine bac, whereas all six adenocarcinomas with bronchioloalveolar pattern did stain (significance, p= . ). conclusion: our conclusion is that the monoclonal antibody anticol a could be a useful marker of invasion in bac when invasion is doubtful. objective: poly(adp-ribose) polymerase- (parp- ) is a nuclear enzyme that plays a role in dna repair, differentiation, proliferation, and cell death. the polymorphisms of parp- have been associated with the risk of various carcinomas, including breast, lung, and prostate. we investigated whether parp- polymorphisms are associated with the risk of non-hodgkin lymphoma (nhl). method: subjects from a korean population consisting of nhl patients and controls were genotyped for five parp- polymorphisms (asp asp, ala ala, lys lys, ivs + a>g, and val ala) using highresolution melting polymerase chain reaction (pcr) and an automatic sequencer. results: none of the five polymorphisms were associated with overall risk for nhl. however, the val ala polymorphism was associated with reduced risk for nhl in males [odds ratio (or), . ; % confidence interval (ci), . - . for cc genotype and or, . ; % ci, . - . for tc genotype], with a trend toward a gene dose effect (p for trend, . ). asp asp (p for trend, . ) and lys lys (p for trend, . ) polymorphisms revealed the same trend. in an association study of parp- haplotypes, haplotype acaac was associated with decreased risk of nhl in males (or, . ; % ci, . - . ). the present data suggest that val ala, asp asp, and lys lys polymorphisms and the haplotype-acaac in parp- are associated with reduced risk of nhl in korean males. objective: the orphan leucine-rich repeat containing gprotein-coupled receptor lgr (gpr /hg /fex) is a novel marker for adult stem cells in small intestine, colon and hair follicles. it is suspected to have a pivotal role in cell proliferation and tumor formation and seems to be a potential therapeutic target. lgr expression is poorly investigated and neither its function in stem cells nor during tumor formation is known. method: our aim was to identify a lgr antibody with a high specificity among different providers (epitomics®, mbl®, sigma®, biosite®, abgent®) for screening selected human formalin-fixed and paraffin-embedded (ffpe) tissue samples by automated immunohistochemical staining. for proving antibody specificity, in situ hybridization with a crna probe of lgr is carried out on the same tissue samples used for immunohistochemistry. as positive control, we generate a lgr expressing human keratinocyte cell line (hacat) by retroviral transduction. results: the lgr antibody from epitomics® stains the outer root sheath of human hair follicle in anagen, whereas sigma-aldrich®'s anti-lgr antibody recognizes lgr in the inner root sheath. nerve tissue is completely negative using the epitomics® antibody, but contrarily, the anti-lgr antibody from mbl® shows strong staining of purkinje cells as well as of other nerve cells in the cortex and spinal cord. the sigma-aldrich® antibody also shows slight nerval staining, but nuclear. anti-lgr antibodies from biosite® and abgent® are all-around negative under the tested conditions. conclusion: all antibodies were optimized but the ihc results are quite incoherent; therefore, further investigations need to be done. objective: glioblastoma multiforme (gbm) and anaplasic astrocytoma (aa) are astrocytic neoplastic entities of the central nervous system that appear in adults, with high biological and clinical aggressiveness. despite the definition of new neoplasm genetic subgroups, the most relevant information in the prognostic of the patient still comes from factors as patient age, localization and size of the tumour, oedema and mass shifting. metabolic phenotyping may provide new information for a better management of this disease. method: we collected molecular profiles based on hrmas spectra for high-grade glioma biopsies ( gbm and aas). the amount of human tumor tissue analyzed for each subject ranged from to mg. all samples were analyzed by post-hrmas histopathology to assess the tissue integrity and double validate histological diagnosis. results: two major metabolic groups were detected, which included and samples, respectively. most aas were located in the same group. the phospholipid patterns and the glutamine/glutamate metabolic relatives seem to be the most relevant contribution to this grouping pattern. conclusion: hrmas provides high-resolution glioma molecular profiles. one of the groups detected, which include most aa samples, seems to reflect a less aggressive type of tumor. metabolic discrimination between these subgroups includes the levels of some metabolites which can be seen by mrs 'in vivo'. objective: hpv is one of the best-known etiologic agents for squamous epithelia-related neoplastic lesions including the cervix, larynx and skin. in recent years, some of nonsquamous epithelia-driven tumors like stomach, colon and lung adenocarcinomas were reported to be containing hpv. the prevalence of hpv in gastric adenocarcinomas, which is reasonably related to chronic gastritis and gastric intestinal metaplasia, is varied between % and % in large-scale studies. regardless of being 'passenger' or 'driver', to show hpv prevalence in chronic gastritis with metaplasia, the well-known two predisposing lesions of gastric cancers was our aim in the present study. method: dna extracted from formalin-fixed paraffinembedded gastric biopsies of cases was tested for hpv-dna by pcr assay. consensus primers were used. the presence of a -bp fragment was accepted as hpv positivity. results: eight out of biopsies were found hpv-dnapositive ( %). conclusion: hpv may accompany gastritis and metaplasia. hpv deserves more studies for pre-neoplastic and neoplastic gastric lesions to enlighten the 'passenger-driver' dilemma. objective: adamantinoma of long bones (alb) and osteofibrous dysplasia (ofd) are rare, osteolytic primary bone tumours of uncertain origin. to investigate the nature of the proliferating fibroblastic stromal cells in alb and ofd and to determine cellular mechanisms of osteolysis in these tumours, we carried out cell culture and molecular studies on two cases of alb and two cases of ofd. method: alb and ofd cells were cultured on coverslips and dentine in the presence and absence of macrophage colony-stimulating factor (mcsf)-primed cd + monocytes + mcsf + receptor activator of nuclear factor kappa b ligand (rankl). cultures were examined for the osteoclast formation markers tartrate-resistant acid phosphatase (trap), cd and lacunar resorption. alb and ofd cells were examined for osteoblast markers (mineralisation nodule formation, alkaline phosphatase). results: few cultured alb and ofd stromal cells expressed epithelial markers (epithelial membrane antigen [ema] and cytokeratin). ofd cells expressed osteoblast markers. cultured alb and ofd stromal cells showed no ultrastructural evidence of epithelial differentiation. alb and ofd cells were not capable of lacunar resorption, but co-cultures of alb or ofd stromal cells and monocytes resulted in the formation of multinucleated trap + and cd + cells capable of lacunar resorption. our findings indicate that ofd and alb stromal cells express epithelial and osteoblast markers. these cells support osteoclast formation from mononuclear phagocytes via a rankl-dependent mechanism, which may contribute towards the aggressive bone destruction associated with this tumour. objective: supratentorial primitive neuroectodermal tumor (spnet) is an embryonal tumor usually developing supratentorially in children or young adults and composed of undifferentiated or poorly differentiated neuroepithelial cells. it is a relatively rare tumor in middle-aged people and extremely rarely develops after radiotherapy. we report an extraordinary case of spnet in a -year-old female that developed years after radiotherapy of oligoastrocytoma. results: a -year-old female was regularly followed after treatment of oligoastrocytoma of the left frontal lobe. the tumor was subtotally resected and treated with radiotherapy years ago. the patient has persistent mild aphasia and mild right hemiparesis. ct performed due to increased incidence of headaches revealed a cystic lesion of the left frontal lobe, cm in diameter, located below the previous tumor. the recurrence of oligoastrocytoma was suspected; however, the diagnosis of spnet was rendered. conclusion: long survival in patients successfully treated for primary brain tumors may yield in independent treatment-induced primary malignancies of the central nervous system. objective: the interaction between different proteins plays an important role in the metastatic ability of brain tumor cells. the purpose of this study was to evaluate the expression of mmp- , mmp- , cd v , and ki- in gliomas of different grades of malignancy and correlate the expression between the studied proteins in tumors. method: expression of mmp- , mmp- , cd v , ki- was evaluated on formalin-fixed paraffin-embedded tissue blocks divided into: glioblastomas multiforme (n= ), anaplastic astrocytomas (n= ), anaplastic oligodendrogliomas (n= ) and normal brain tissue (n= ) using immunohistochemistry. results: mmp- , mmp- , cd v and ki- expression was found in . %, . %, . %, . % of gliomas, respectively.mmp- immunopositivity was significantly higher in glioblastoma multiforme than anaplastic astrocytomas (p= . ). no immunoreaction for all proteins was found in normal brain tissues. mmp- , mmp- , cd v , ki- immunoreactivity was significantly higher in glioblastomas when compared with anaplastic gliomas (p= . ). in gliomas, the percentage of positive cells and the intensity of the immunostaining were proportional to the degree of malignancy. positive correlations between ki- and mmp- (p= . ), mmp- and mmp- (p= . ), mmp- and cd v (p= . ) were found in malignant brain tumors. objective: gliomas are most common among primary brain tumors, and glioblastomas (gbl) are most fatal among gliomas. surgical operation concomitant with chemoradiotherapy is adopted to treat gliomas. temozolomide (tmz) is a new oral cytotoxic agent with less myelosuppression. epigenetic silencing of o -methylguanine-dnamethyltransferase (mgmt) by promoter methylation is associated with improved survival in gbl treated with tmz. in this study, we investigated mgmt promoter methylation in gliomas treated with concomitant chemoradiotherapy (ccrt) following operation. method: in cases of gliomas including gbl, six anaplastic astrocytomas (aa) and three anaplastic oligo-dendrogliomas (ao), formalin-fixed, paraffin-embedded archival samples were used to evaluate the methylation status of mgmt promoter via methylation-specific pcr. results: mgmt promoter methylation was detected in cases ( . %) of gliomas. mgmt promoter methylation was detected in . % of gbl, in . % of aa, and in . % of ao. gbl with methylation had significantly more prolonged overall survival (mean . months) compared with unmethylated gbl (mean . months, p= . ). methylated gbl also had more prolonged progression-free survival (mean . months) compared with unmethylated gbl (mean . months, p= . ). conclusion: the frequency of mgmt promoter methylation in korean glioma patients was similar to those in western countries. these data indicate that mgmt promoter methylation is prognostically significant in gbl given ccrt. mgmt promoter methylation status is considered to be a valuable predictive factor in the routine clinic for gbl. histopathological examination showed a mixed glioneuronal tumor composed of oligodendrocyte-like cells constituting neurophil-like islands, astrocytic cells and neurons scattered in glial tissue. immunohistochemically, glial tissue was gfappositive and neurophil-like areas and big neurons were synaptophysin-positive. in astrocytic component ki- , the proliferation index was below %. p was negative. results: consequently, the final diagnosis was spinal cord glioneuronal tumor with rosetted neurophil-like islands-who grade . these cases can be confused with oligodendrogliomas, astrocytomas and ependymomas. oligodendrogliomas are distinct with their molecular genetic features. conclusion: our case is unique in that it is the youngest reported patient having this tumor located in the spinal cord. proliferative activity in all subtypes of the glioblastoma b. jarosz*, m. jarosz, r. rola, t. trojanowski *lublin, poland objective: glioblastoma is the most malignant and the most frequent primary brain tumour in adults. it accounts for - % of astrocytic tumours. the tumour has two variants: giant cell glioblastoma and gliosarcoma. the purpose of the study was to show the differences between values of the mib- proliferative indexes of glioblastoma, giant cell glioblastoma and gliosarcoma. method: surgical specimens from patients were formalin-fixed, paraffin-embedded immunostained using mib- antibody. next, proliferative index (pi) was calculated. analysis of variance (anova) was used to test the hypothesis that mean values of mib- pi were equal for each diagnosis group. the mean values of mib- pi were as follows: glioblastoma, . % ( . - , %); giant cell glioblastoma, . % ( . - . %) and gliosarcoma, . % ( . - . %), but there were no statistically significant difference in the mib- pi mean value between diagnostic groups. we observed that proliferative activity shows regional variation and was the most prominent in glioblastoma with small cells. in giant cell glioblastoma, it was much lower. because of the absence of significant differences of mib- pis in our study, in the future, the study will be repeated on cases in each group of that tumour. the extracellular matrix and diffusion barriers in the focal cortical dysplasias of brain-an immunohistochemical study j. zamecnik*, l. vargova, a. homola, p. marusic, p. krsek, k. kuncova, e. sykova *charles university, dept. of pathology and mol. m, prague, czech republic objective: changes in the geometry and composition of the extracellular space (ecs) may influence the epileptogenesis in focal cortical dysplasias (fcd) of the brain. method: tissue ecs volume and geometry (the geometrical factor "tortuosity", reflecting various ecs diffusion barriers) were studied in cortical samples of patients surgically treated for epilepsy, including nine patients with fcd type i and of six patients with fcd type ii, by realtime iontophoretic method. consequently, the samples were subjected to immunohistochemical analysis of the composition of the extracellular matrix (ecm) and morphology of the gfap + glial cell processes. results: in both fcd type i and fcd type ii, the tortuosity of the ecs was significantly increased: . ± . and . ± . , respectively; control = . ± . (mean ± sem). the ecs volume fraction was not significantly changed. when compared to controls, no significant changes in ecm composition were noted in fcd type i. however, we observed an increase in gfap + glial processes in both types of fcd and pathological accumulation and distribution of some ecm molecules (tenascins c and r, hyaluronate, chondroitin sulphate, reelin) in the ecs of fcd type ii. conclusion: the ecs of fcd has increased tortuosity, reflecting the increase of diffusion barriers in the ecs due to gliosis and pathologic accumulation of some ecm molecules. we propose that disturbed extrasynaptic transmission, mediated by the diffusion of neuroactive substances through the ecs of such cortex, represents another factor of epileptogenicity in fcd. support: iga mzcr ns - and mzofnm . hemangiopericytoma of the pineal body: case report s. uyar bozkurt*, n. comingle, b. oz *marmara university, istanbul, turkey objective: hemangiopericytomas are rare mesenchymal neoplasms that presumably derived from pericytes. although hpc mas generally attached to the cranial and spinal dura, intraparenchymal and intraventricular rare tumors have been reported. method: a -year-old male patient presented with headache, nausea and blurred vision months ago. cranial mri revealed contrast-enhanced lesion × cm in diameter in pineal gland location. given the findings of the preoperative imaging studies, the lesion was consistent with parenchymal tumors of the pineal gland. a right occipital craniotomy and resection of the lesion was performed. histologically, the tumor was composed of clusters of monotonous, closely packed, small neoplastic cells. nuclei are oval to round with granular chromatin and inconspicuous nucleoli. mitosis was rare and necrosis was not found. stroma contained dilated, slit-like vascular channels lined by flattened endothelial cells. reticulin stain showed increased reticulin network of investing group of neoplastic cells. neoplastic cells were diffusely immunoreactive with bcl- , but were negative with epithelial membrane antigen, chromogranin, synaptophysin, pgp . , s- protein, and cd . a mib- labeling index was %. results: a diagnosis of hemangiopericytoma was made based on light microscopy and conventional histochemical and immunohistochemical studies. differential diagnosis included pineal parenchymal tumors and meningiomas. the present case provides one unique example of a rare entity to the diverse spectrum of the pineal region neoplasms encountered in neuropathology. objective: neurofibroma is the most frequent neurogenic tumor in the first year of life. it is a benign proliferation of schwann cells, perineurial cells, and fibroblasts, which may occur in association with neurofibromatosis type or sporadically. the most common sites of laryngeal involvement are the aryepiglottic folds and the arytenoids, areas of the larynx rich in terminal nerve plexuses. clinical findings: a -year-old girl presented with airway obstruction and stridor with a progressive nature since birth. direct laryngoscopy: laryngeal tumoral mass, located in the supraglotic area. complete surgical excision was performed. method: all anatomical pieces were fixed in % formaldehyde solution, paraffin-embedded, cut and stained (hematoxylin-eosin and van-gieson). results: macroscopically: -cm whitish multinodular mass, firm consistency, myxoid cut surface microscopically: the submucosal nerve fibers were expanded in a plexiform pattern, infiltrating between the submucosal glands due to a proliferation of small, delicate, wavy, spindle cells with markedly elongated, wavy nuclei with pointed ends and coarse collagen fibres, embedded in a myxoid matrix. immunohistochemistry: positivity of the nervous fibers for cd and s protein. act was negative in the nervous fibers and positive in the blood vessels. ki was negative. histopathology diagnosis: plexiform neurofibroma of the larynx. conclusion: neurofibroma of the larynx is a rare condition that should be considered in the differential diagnosis of children presenting with a submucosal laryngeal mass even without the other clinical signs of nf or nf . it has a high rate of recurrence or residual disease due to the possibility of malignant transformation. objective: brain lesions are highly heterogeneous both clinically and morphologically. the morphological study of these lesions is based in their cellular characteristics, different tissue organization patterns, vascular network, collagen distribution, presence of calcium, etc. mr imaging of excised tissue samples may provide valuable information about lesion structure and microarchitecture, increase the diagnosis specificity and help for better tissue characterization. method: fifteen brain lesions biopsies from the hospital clinico universitario de valencia were fixed with formalin and embedded in a gel matrix for minimizing motion artifacts. mr microscopy images and optical microscopy images were obtained for all of them. mr microscopy images included t , t , t * and dwi. images were subsequently analyzed by hierarchical clustering. results: mr microscopy of brain biopsies shows high resolution and quality. major histological findings (for example, healthy, vascular, proliferative or necrotic tissue) exhibit differential mr parameters values (t , t and diffusion coefficient among others). hierarchical cluster analysis of these parameters revealed different mr patterns correlating with relevant histopathological and immunohistochemical features. conclusion: mr microscopy provides functional, microstructural and biophysical information complementary to that obtained by conventional histopathology. our approach and findings may help in multidisciplinary groups for better integration of histopathology and mri in brain lesion diagnosis. interaction of vesicular monoamine transporter (vmat ) and neuromelanin pigment among the midbrain dopaminergic neurons in man p. pasbakhsh*, d. german *tehran university of, medical science, iran objective: neuromelanin (nm) pigment accumulate with age catecholaminergic neurons in man, and ventral substantia nigra dopaminergic neurons that are most vulnerable to degeneration in parkinson's disease (pd) contain the greatest amount of this pigment. in vitro data indicate that nm pigment is formed from the excess cytosolic catecholamine that is not accumulated into synaptic vesicles via the vesicular monoamine transporter (vmat ). method: using semiquantitative immunohistochemical methods in human postmortem brain, we sought to examine the relationship between the contents of vmat and nm pigment. the immunostaining intensity (isi) was measured for vmat in two regions of the midbrain dopaminergic cell complex. the isi of the cells was related to the density of nm pigment within the cells. we also measured the isi for tyrosine hydoxylase (th) and examined the noradrenergic neurons in the locus coeruleus (lc) in brain -- years of age. objective: human mitochondrial diseases have a relatively high incidence, multiple genetic causes and quite diverse clinical, biochemical and morphological phenotypes requiring a multidisciplinary approach for diagnosis. the study of protein aggregation in muscle fibres in these disorders may offer new insights on their complex pathogeny. method: we studied morphological aspects of the "ragged red" fibres-targeting our interest on the types and location of different protein aggregates. we selected diagnostic muscle biopsies from seven unrelated patients and used histological, histochemical, enzyme histochemical, ultrastructural and immunohistochemical techniques. results: the expression of cytoskeletal, transsarcolemmal, sarcomeric, chaperone type and nuclear proteins revealed that "ragged red" fibres and "ragged red" regions of the fibres accumulate diverse proteins, of which desmin, alpha b crystallin, as well as n-cam, dysferlin and heat shock protein appear to be regular ones. none of our cases had any accretion of plectin, actinin, beta and gamma dystroglycan. other proteins showed variable expression. conclusion: as the list of members in the "protein aggregate myopathies" family is constantly enlarging, the study of protein accumulation in mitochondrial myopathies is of clear interest for the future. note: zurac objective: prostate biopsy is performed to detect carcinoma in those at high risk on the basis of elevated psa and abnormal digital rectal examination. re-biopsy is often performed following an initial atypical diagnosis or rising psa. method: all histopathological reports of prostate biopsies at beaumont hospital, dublin, during the time period january to january were analysed. a total of , reports were retrieved and the data were recorded and analysed. results: all prostate biopsies were grouped into initial biopsy (no previous biopsy recorded) and repeat biopsy (at least one previous biopsy recorded). multiple report parameters were recorded for each biopsy including diagnosis, number of cores taken, number of positive cores and gleason grade, and these were compared for the two groups. in the original biopsy group, all biopsies reported as atypical (but not meeting criteria for carcinoma) were further analysed for changes on follow-up biopsy. in the repeat biopsy group, repeat biopsies performed for increased psa and for previous atypical diagnosis were analysed separately and compared. conclusion: repeat prostate biopsy is often performed for persistently elevated or rising psa and previous diagnosis of atypical changes. our study assessed the likelihood of finding carcinoma in a follow-up biopsy performed for these two reasons. our study also compared the biopsy adequacy and extent and grade of carcinoma found in both initial and repeat biopsies. the findings are significant in determining the likely clinical course and appropriate management of patients with atypical diagnoses and elevated psa. objective: since atypical adenomatous hyperplasia (aah), post-atrophic hyperplasia (pah) and proliferative inflammatory atrophy (pia) of the prostate demonstrate both overlapping histological features and generality of biological properties with prostatic intraepithelial neoplasia (pin) and atypical small acinar proliferation (asap), these processes were proposed in probable precancerous lesions of the prostate. method: we studied the cytological features with the use of morphometry. the expression of amacr and cocktail hwc+p was estimated with the use of immunostaining. for the image analysis, the software wsif imagej and imagescope was used. results: bc layer was fragmented in most of cases pah, pia, aah. the bc loss in pah-pia was % and % accordingly and was below that in pin- %, aah- %, and asap- %. analysis of cytological features and nucleolus frequency showed that pah-pia was similar to pin-asap and above that in aah. prominent nucleolus was identified in atrophy, precancerous lesions and pca. frequency of prominent nucleolus in pah ( % cases, % in cases) and pia ( % and % accordingly) was below that in pin ( % and %), asap ( % and %) and pca ( % and %). amacr expression was moderately strongly positive in precancerous lesions and pca and weakly positive in other groups. area of amacr expression in pin and asap was above that in aah, pah, pia and below that in cases pca. objective: presentation of rare lesions of the prostate. method: a -year-old man, with psa , underwent a needle biopsy of the prostate. a histological examination of biopsique carrots showed an infiltrating tiny lesion within adipose periprostatic tissue at the level of one biopsy of the left lobe nodule. the lesion consisted of little irregular glands and solid nests of atypical cells psa − and ck + , and ck + . we proposed a diagnostic of a metastasis/infiltration of unknown primary origin, likely from the urinary tract. this was confirmed by a cystoscopy revealing a tumor which had a histologic appearance of a choriocarci-noma, finally classed as a poorly differentiated urothelial carcinoma with a choriocarcinoma differentiation. results: the second case concerns a -year-old patient with decompensated cirrhosis admitted to the hospital for a gastroenterology bilan. rectal examination revealed an enlarged prostate. the hemostase was necessary after a core needle biopsy of the prostate. the histological examination demonstrated a highly vascular tumor composed of chief and sustentacular cells arranged in an alveolar pattern. immunohistochemical study confirmed a paraganglioma. there were no signs of malignancy; however, we did not observe any prostatic parenchyma at the tumoral level. conclusion: many significant non-epithelial tumors may arise in the prostate gland; although they are rare, their recognition by the pathologist is essential as their treatment and prognosis are quite variable. the core needle biopsy allows for a diagnostic of a variety of tumors, and one should not ignore, in spite of the absence of clinical symptoms and complementary information, the risk of metastatic lesion in the prostate. latent prostate cancer in association with benign prostatic hyperplasia after the chernobyl accident in ukraine a. romanenko*, a. chekalova, p. harkonen, a. vozianov *institute of urology, kiev, ukraine objective: tumor volume is a powerful predictor of patient outcome in prostatic adenocarcinoma. preoperative assessment of prostate cancer tumor volume is still a big challenge. the present study attempted to identify the most predictive biopsy variables for final tumor volume in radical prostatectomy specimens. method: we reviewed prostate needle biopsies in patients who subsequently underwent radical prostatectomy. the preoperative data collected were: psa, preoperative ultrasound, total prostate volume, number of positive biopsies, total percentage of cancer in the biopsy and gleason score. prostatectomy specimens were entirely embedded and mounted whole. tumor volume was measured using the grid method. preoperative data were compared with final tumor volume in radical prostatectomy specimens by univariate and multivariate analysis. results: the number of positive biopsies (p< . ), total percentage of cancer in the biopsy (p< . ) and gleason score (p< . ) were significant predictors of tumor volume on linear regression analysis. psa value (p= . ) and preoperative ultrasound total prostate volume (p= . ) were not significant predictors of tumor volume. on multivariate logistic regression analysis, we designed a model to predict final tumor volume. this model contains all the predictors mentioned above and significantly correlates with final tumor volume (p< . ). conclusion: preoperative data (gleason score, number of positive biopsies and total percentage of cancer in the biopsy) can be used to predict the volume of prostate cancer with acceptable accuracy. these variables must be mentioned to the clinician in order to help in the therapeutic decision. "negative" histopathology (stage pt ) in a radical prostatectomy specimen after a preoperative diagnosis of prostatic adenocarcinoma m. ligaj*, k. sikora, r. sosnowski *warsaw cancer center, dept. of pathology, poland objective: in rare cases, histologic assessment of the entire radical prostatectomy specimen (rps) after a positive biopsy does not reveal residual tumour. we analyze the incidence of "vanishing prostatic carcinoma" in our institution and present algorithm of pathologic workup of "negative" rpss. method: among rpss from patients treated for prostatic adenocarcinoma (january -december ), ten cases ( . %) showed no residual carcinoma despite complete sampling. a five-step protocol of additional pathologic workup included: ( ) preoperative biopsy review; ( ) "second look" review of the rps; ( ) immunohistochemistry ( betae , p ) performed on suspicious foci; ( ) deeper levels of each block with pin high grade and/or of blocks with areas where cancer was seen in the biopsy; and ( ) block-flipping of regions specified above with deeper levels. results: cancer diagnosis had been made in transurethral resection (turp) specimen (two patients) and core biopsy (eight patients). the turp cases were excluded on the assumption of complete pre-prostatectomy carcinoma resection. biopsy review (protocol step ) confirmed prostatic carcinoma in seven core biopsy specimens ( . %). in one case, diagnosis of adenocarcinoma made in another institution was not confirmed. steps - revealed residual carcinoma in a further four rps. despite full workup, no residual tumour was seen in three rp specimens ( . %). all three "negative" cases had undergone mab prior to rp and showed no clear evidence of residual carcinoma. conclusion: "vanishing prostate carcinoma" is a rare phenomenon, with higher incidence after neoadjuvant hormone therapy. extensive histologic workup of rp specimen reduced the rate of pt rp after a positive core biopsy from . % to . %. objective: large cell neuroendocrine carcinoma (lcnec) of the urinary bladder is a rare tumor with only a few cases reported. the diagnosis is based on the criteria established in lung tumors. we report the clinical and histological data of six patients with lcnec in urinary bladder. method: the clinical charts and histological slides of six patients with the lcnec diagnosis in urinary bladder from a single institute were reviewed. the diagnosis was confirmed by the use of immunohistochemistry with at least two positive neuroendocrine markers (synaptophysin, chromogranin and/or cd ). results: all patients were male. their age ranged from to . the most frequent clinical presentation was gross hematuria. their histology had overlapping features with urothelial carcinoma and was difficult to differentiate without immunohistochemistry. the most useful features were extreme hypercellularity ( / ), lack of exophytic papillary component ( / ), nuclear molding ( / ), finely stipled chromatin ( / ) and exuberant mitotic rate (most > /hpf) with innumerable apoptotic figures. in three cases, there were foci of admixed invasive or in situ urothelial carcinoma, in one case admixed adenocarcinoma. all tumors were infiltrative to muscularis propria at the time of diagnosis, except the most recent one which did not have muscle sampled in resection. distant metastases were found in liver, spleen and bones of one patient. three patients underwent radical cystoprostatectomy; all patients received adjuvant or neoadjuvant chemotherapy, and one was given additional radiotherapy. conclusion: distinction between lcnec and urothelial cancer is important because of likely different therapeutic options. lcnecs are highly aggressive tumors with at least pt disease at diagnosis. objective: bladder cancer's incidence is increasing worldwide. to improve the results of current bladder cancer treatments, new drugs are being tested in single use or in associations. gemcitabine is metabolized to the active diphosphate and triphosphate, which is integrated into the dna and causes cessation of dna polymerization. sirolimus inhibits mtor protein kinase. our aim was to study and compare the effect of gemcitabine and sirolimus in bladder cancer chemically induced in mice. method: n-butyl-n-( -hydroxybutyl) nitrosamine was administered to icr male mice in drinking water for weeks. one group was treated with gemcitabine ( . mg/kg, i.p.) and the other with sirolimus ( . mg/kg, i.p.). all animals were killed at the end of the experiment. results: animals not treated showed a higher incidence of neoplastic and pre-neoplastic lesions than animals treated ( % simple hyperplasia, % nodular hyperplasia, dysplasia %, cis % and invasive carcinoma % objective: the accurate diagnosis of poorly differentiated invasive carcinomas in transurethral resection (tur) specimens using only h&e-stained sections continues to be a challenge for the pathologist. the aim of this study was to evaluate and select an optimal immunohistochemical (ihc) panel of antibodies to establish the urothelial or prostatic origin of poorly differentiated tumors in tur specimens. method: ihc was performed to detect cytokeratin (ck) , ck , high-molecular-weight ck (hmwck), p , prostate-specific antigen (psa) and p s/amacr in cases of poorly differentiated invasive tumors: poorly differentiated prostatic adenocarcinomas (gleason score ≥ ) and high-grade urothelial carcinomas. the youngest patient was while the oldest was years of age. results: the sensitivities for labeling prostate cancers were: psa ( %), amacr ( %), ck ( %), ck ( %), p ( %), and hmwck ( %), while urothelial highgrade carcinomas demonstrated the following rates of positivity: hmwck ( %), ck ( %), p ( %), ck ( %), amacr ( %), and psa ( %). co-expression of ck / was noticed in % of the urothelial carcinoma cases, but it lacked in prostate carcinomas. objective: the authors evaluated the possible influences of ageing on the morphology of testicular intralobular interstitial tissue (tiit). method: the studied material consisted of surgical samples of testicular tissue from cases with orchiectomy for prostate adenocarcinoma. tissue samples were fixed in neutral buffered formalin embedded in paraffin, stained with hematoxylin-eosin and goldner trichrome and immunomarked for cd . images were acquired and measurements were performed with a specialized image analysis software after previous calibration. the assessed parameters were tiit amount (p-tiit) and intralobular vascular network (ivn). ten fields were randomly selected for each case, with × objective. mean p-tiit (mp-tiit)/field, mp-tiit/case and mp-tiit/age group were determined. regression line (rl), slope (m) and significance test for slope (p) were determined in order to assess the correlation of tiit amount changes with ageing. results: intralobular septae showed variable amount of collagen fibers, from simple linear fibrillary assemblies to marked thickening with obvious septal enlargement. the latter were seen mostly in the outer region of the lobules, but without any significant spread. tiit amount had a mean value of % of intralobular parenchyma. rl showed a discrete decreasing trend with ageing (m=− . ) confirmed by "p" value (p= . ). arteriolar wall presented degenerative changes with limited extension and variable intensity. peritubular and intramural capillaries were present in all age groups. endothelial cells revealed no significant changes. objective: angiomyolipoma is a rare neoplasm composed of varying admixtures of blood vessels, smooth muscle cells and adipose tissue. there is a strong association with tuberous sclerosis. we describe the first case report of multifocal renal angiomyolipoma developed on tuberous sclerosis and associated with endometriosis. method: imaging studies in an asymptomatic -year-old woman, affected by tuberous sclerosis with tsc gene mutation, revealed a partially solid and cystic mass measuring cm involving the left kidney and a solid mass measuring . cm in the right kidney. results: the surgical specimen consisted of two left nephron-sparing procedures and one at the right side with firm, pale nodules measuring . , . and . cm. the tumors were composed of spindle and epithelioid cells with an abundant pale eosinophilic or clear cytoplasm with round nuclei, mild atypia and low mitotic activity. rare islands of adipose tissue were observed. in the two left tumors, the predominant smooth muscle cells were associated with some foci of endometriosis. the spindle and epithelioid cells were immunoreactive with hmb and smooth muscle actin. the estrogen and progesterone receptors were positive in stromal and epithelial cells of endometriosis. the spindle cells of angiomyolipoma were positive with progesterone receptors. conclusion: multifocal pecoma of the female genital tract associated with diffuse endometriosis was described by froio et al in , but to our knowledge, this is the first case report of renal angiomyolipoma associated with endometriosis. this association represents a supplementary proof of potential role for hormones in the pathogenesis of angiomyolipoma. translocation-associated renal cell carcinoma ( objective: gastric malt (mucosa-associated lymphoid tissue) lymphoma is closely related with helicobacter pylori (hp) colonization and represents a multistage process from gastritis to lymphoma. for the differential diagnosis of malt lymphoma and reactive inflammation, wotherspoon proposed a histomorphological scoring with two intermediate categories, grades and . genetic studies (ig clonality and/or translocations and chromosomal aberrations) have not brought so far definite arguments to confirm or discard lymphoma in these problematic scores. objective: in gastric adenocarcinoma, overexpression of her has been correlated to tumour location and histologic type and varies considerably in the few published studies, probably due, at least in part, to the racial heterogeneity of patients included. the aim of the present study was to investigate the immunohistochemical expression of her protein in gastric adenocarcinomas of greek patients who live in the area of epirus. method: a total of primary gastric adenocarcinomas were retrieved from the archives of the department of pathology ( men and women). they were all located in the stomach, away from the oesophageal-gastric junction. forty-eight were intestinal type, diffuse type and mixed (lauren classification). immunohistochemical analysis of samples was performed using the polyclonal rabbit anti-human c-erb- oncoprotein (dako) antibody on paraffin sections. her scoring was performed according to published consensus panel recommendations. results: overexpression of her (ihc + and +) was detected in eight adenocarcinomas ( . %). specifically, score + was assigned to five cases ( . %, four intestinal type, one diffuse type) and + to three cases ( . %, two intestinal type, one diffuse type). score + was detected in ten cases ( . %, eight intestinal type, one diffuse type and one mixed), and in cases ( %). in two cases with score +, adjacent dysplastic epithelium was noted, which was also +. the results of the current study are comparable with those of the literature, indicating that assessment of immunohistochemical expression of her in gastric adenocarcinomas could lead to the stratification of patients, the goal being the optimal personalized treatment. the prognostic value of her- /neu expression in gastric cancer patients from lower silesia in poland a. halon*, p. donizy, l. halon, r. matkowski, j. rudno-rudzinska, w. kielan, j. rabczynski *wroclaw medical university, poland objective: overexpression of her- /neu was most widely explored in breast cancer. her- positivity is reported as - % in gastric cancer (gc). the aim of the study was to assess the prognostic significance of her- in gc patients from lower silesia, the southwestern region of poland. method: immunohistochemistry (ihc) for her- monoclonal antibody was performed on paraffin-embedded specimens. ihc expression of her- was evaluated using the remmele scale (irs) and standardised herceptest modified for gc. results: the status of her- protein expression was observed as the following: ( ) objective: breakage or degradation of extracellular matrix (ecm) and basement membrane (bm) is a critical step in tumor progression. matrix metalloproteinases (mmps) and their tissue inhibitors (timps) take important roles in these processes acting in a coordinated manner to form an integrated system. the aim of the study was the evaluation of mmp- , mmp- , timp- and timp- expression and the correlation with clinicopathological parameters and survival in gc. method: formalin-fixed paraffin-embedded tissue sections from gastric cancers were studied for the expression of mmp- , mmp- , timp- and timp- protein by immunohistochemistry. objective: amacr plays role in beta oxidation of branched fatty acids. it is expressed in several neoplasms like prostatic, hepatic and thyroid cancers. it is also believed to be expressed in gastric carcinoma (gc), particularly in better differentiated and less advanced lesions. the aim of the study was to assess amacr expression in gc and its correlation with clinical and histological prognostic factors. objective: brunner's gland hyperplasia is a rare lesion, with fewer than cases having been reported in the literature. it is considered to be a hamartoma, developing from the submucosal glands, usually in the first or second part of the duodenum. most of the lesions described were polypoid and < cm in greatest diameter. often, there is an association with peptic ulcer disease. method: we report the case of a -year-old man who presented with abdominal pain, vomiting and upper gastrointestinal bleeding. the anamnestic data showed chronic ulcer disease. he also was anaemic, with a slight raise in blood eosinophilia. results: the radiological examination of the upper gastrointestinal tract revealed pyloric stenosis due to a polypoid mass measuring cm. preoperative diagnosis of the mass could not be established. the mass was excised and at the same time a vagotomy with pyloroplasty (finney) was performed. brushing cytology of the surgical specimen revealed a great number of aggregated brunner's glands without any atypia, as well as many lymphocytes. a frozen section was negative for malignancy. the histologic diagnosis was that of diffuse nodular brunner's gland hyperplasia (hamartoma) accompanied by lymphocytic infiltration. the rate of cellular proliferation was low. during the postoperative period, there were no complications. a subsequent gastroscopy showed no pathologic findings, and the patient is well at present. conclusion: our case is reported because of its rarity and the difficulties in preoperative diagnosis. the literature is also reviewed. objective: in the differential diagnosis of gist, associated mesenchymal lesion represents an additional challenge. method: a -year-old woman with intestinal occlusion at surgery showed an ileal invagination on polypoid mass of cm and an ileal suberosal nodule of cm. results: the polypoid lesion, ulcerating the mucosa and growing in the muscular wall with subserosal hourglass-like expansion, showed a monotonous hypocellular mesenchy-mal proliferation (cd + , cd − ) with prominent vascular network in myxoid inflammatory stroma. considering the peculiar degenerative, inflammatory pattern of the polyp due to ischemia and the existence of a subset of gist c-kit negative, differential diagnosis was gist (c-kit − ) or inflammatory fibroid polyp (cd + ). after a careful review of the clinical and immunohistochemical and pathological findings, final diagnosis was inflammatory fibroid polyp (ifp). the minor nodule showing a spindle cell proliferation (cd + ) was diagnosed as gist. to our knowledge, no other studies report ifp and gist occurring synchronous in the ileum. conclusion: the correct definition of these lesions is crucial: defining both tumors as gists, prognostic and therapeutic assessment becomes poor (multiple familial or advanced metastatic gist). the recent discovery of pdgfr mutation (the mutually exclusive mutation of wild-type ckit gists) in the ifp questions his reactive nature and raises the possibility of a neoplastic process. then, the questions arising are whether the two tumors represent a fortuitous coexistence or involve the same carcinogenic agents on the same gene (located in the chromosome q) and if the proliferation can be inhibited by sti . objective: melanoma is a rare tumor of the anorectal area and accounts . % to . % of all anal tumours and approximately % of all primary melanomas. besides the positivity with conventional melanocytary immunohistochemical markers s , hmb , melan a are primary anorectal melanomas positive also with marker cd and negative with monoclonal antibody cea. the primary anorectal melanoma is a typical braf mutation (exon + ) and the allelic loss nf associated with neurofibromatosis. method: the melanocytary lesion of a -year-old woman in the anorectal canal was examined with immunohistochemical antibodies: s , hmb , ck ae /ae , cd and monoclonal cea (dako), and fish method with the use of combined sound vysis preb /lsi myb/lsi ccnd /cep (abbot, usa). results: our examination stated positivity with s , hmb , melan a and sporadic positivity with cd and negativity with monoclonal antibody cea. further, amplification of the gene rreb (locus p ) and ccnd (locus q ) was found. the results of our analysis confirm genetic abnormalities associated with melanoma, and our immunohistochemical analysis prefers primary melanoma before metastatic melanoma of the anorectal canal. objective: tumor budding or dedifferentiated single cells/small clusters at the invasive front of colorectal cancer is a histological feature highly predictive of lymph node and distant metastasis and an independent prognostic factor. we hypothesized that the evaluation of tumor budding could complement k-ras analysis to improve the individualized prediction of response to anti-egfr-based therapies in metastatic colorectal cancer (mcrc) patients. method: forty-three patients with mcrc treated with cetuximab or panitumumab were entered into this study. according to the recist criteria, patients had stable or progressive disease (non-responsive, nr), while patients had a partial response (pr). tumor buds were evaluated from whole tissue sections stained for pan-cytokeratin, evaluated in the densest region using a × objective, and "high-grade" tumor budding was defined as buds/highpower field. results: tumor buds and k-ras mutation both correctly classified % of patients. all patients with k-ras mutation (n = ) or high-grade tumor budding (n = ) were nr, of which four patients had both features. all pr were k-ras wild type with low-grade tumor budding. combined, the predictive value of k-ras and tumor budding was %. additionally, high-grade tumor budding was significantly related to worse progression-free survival (hr ( %ci), . ( . - . , p = . )). method: inter-institutional and interdisciplinary cooperation (of pathologists, geneticians, molecular biologists and oncologists of all three centers) during the last months based on mutual exchange of ideas, materials and laboratory protocols and common meetings and seminars. in the centres, the following three methodical options were tested-sequencing, rt-pcr (therascreen®) and snapshot multiplex analysis-and the results of the examinations were retested using another method to verify specificity and sensitivity of the testing. results: k-ras mutations were present in . % of the cases, seven adenocarcinomas and one liver metastasis. egfr was positive in ten cases in tumor cells and in seven cases in the vessels. immunohistochemical overexpression of ras protein was detected in samples. the relationship between the positivity of the k-ras mutation and the positive immunohistochemical reaction for egfr and the ras protein did not reach statistical significance. conclusion: there were no significant correlations between the mutational status of the k-ras gene and the ihc reaction for egfr and ras p protein, proving once more the major role of molecular analyses in colorectal carcinoma anti-egfr therapy. objective: hepatic pedicle triad occlusion is often used to prevent bleeding during hepatectomy despite the ischemia and reperfusion liver injury iatrogenically induced. this study aimed to estimate the impact of selective clamping of the hepatic artery (scha) in hepatocellular function. method: ( ) forty wistar rats were divided into four groups: three groups were subjected to a scha ischemia period for min: (a (n= ) submitted to a continuous scha; b (n= ) underwent an intermittent scha for min with min of reperfusion; c (n= ) underwent an intermittent scha for min with min of reperfusion)) and group d (n= ) without scha. ( ) determination of liver blood markers and hepatic extraction function (hef) using m tc-mebrofenin days before and after surgery. ( ) isolation of hepatocytes from the biopsy performed after surgery to evaluate oxidative stress (dcfh -da), characterization of cell death (annexin-v/propidium iodide) and assessment of mitochondrial membrane potential (jc- probe) by flow cytometry. results: ( ) there was significant increase of blood markers before and after scha, but without differences between groups (ns). ( ) hef maintained normal values without differences between groups (ns). ( ) there were no significant differences in viability and in the type of cell death, as well as in the production of reactive oxygen species between groups (ns). the scha compared to previous studies performed by us where total hepatic pedicle triad was clamped shows an increase of cell viability with a decrease of hepatocyte necrosis and/or apoptosis. scha is a potential alternative to decrease preoperative bleeding, maintaining hepatocellular function. objective: the selective portal vein clamping (scpv) is a potential alternative to decrease preoperative bleeding, maintaining hepatocellular function. this study aimed to evaluate the effect of scpv in hepatocellular function. method: ( ) fifty-two wistar rats were divided into four groups: three groups of animals were submitted to a scpv ischemia period for min (a (n= ) was submitted to a continuous scpv, b (n= ) underwent an intermittent scpv for min with min of reperfusion, c (n= ) underwent scpv for min with min of reperfusion)) and group d without scpv (n= ). ( ) determination of liver blood markers and hepatic extraction function (hef) using m tc-mebrofenin days before and after surgery. ( ) isolation of hepatocytes from the biopsy performed after surgery to evaluate oxidative stress (dcfh -da), characterization of cell death (annexin-v/propidium iodide) and assessment of mitochondrial membrane potential (jc- probe) by flow cytometry. results: ( ) mortality: a- %, b- %, c- % and d- % (p< . ). ( ) there was a statistically significant increase of the ast values (p< . ) and ldh (p< . ), but without differences between groups (ns). ( ) hef significantly decreased (p< . ), but without differences between groups (ns). ( ) there were no significant differences in viability and in the type of cell death or in the production of reactive oxygen species between groups (ns). conclusion: the scpv compared to previous studies performed by us where total hepatic pedicle triad was clamped shows an increase of cell viability with a decrease of hepatocyte necrosis and/or apoptosis. however, scpv above ' should be avoided given the high mortality observed. oxidative stress and liver morphology of rats received doxorubicin and tirapazamine e. korobowicz*, i. syroka, j. dudka, a. korga, r. gieroba *uniwersytet medyczny w lublini, katedra i zakbad patomorfologi, poland objective: tirapazamine (tpz) selectively kills hypoxic tumor cells. doxorubicin (dox) is one of the most effective drugs against a wide variety of cancers. it is widely accepted that oxidative stress is involved in dox organ toxicity. tpz, similarly to dox, is activated to tpz free radical by the action of several nadphdependent reductases and generate reactive oxygen species. nadph is also an essential cofactor for glutathione-dependent enzymes that constitute major cellular defenses against oxidative damage. aim: the aim of the study was to evaluate oxidative stress and liver morphology changes in rat that received tpz in addition to dox administration. method: male wistar rats were treated i.p. with dox ( . mg/kg b.w.) and tpz ( or mg/kg b.w.) weekly for weeks. sevendays after the last treatment, animals were killed and liver samples were analyzed for nadph, mda, gsh levels and histopathological changes. blood samples were analyzed for alt, ast activities and bilirubin concentration. results: anova test revealed significant higher levels of nadph and mda in liver in group receiving a higher dose of tpz with dox vs. dox group. there were no differences between group tpz+dox vs. dox of liver gsh concentration and plasma alt activity, but levels of gsh and alt in all these groups were significantly higher compared to control. microscopically, hydropic degeneration, necrosis, inflammatory cell infiltration and vascular lesion were observed in tpz+dox group. conclusion: tirapazamine causes oxidative stress in liver of rats receiving dox. this study suggests enhanced toxicity by tpz in rat livers which received dox. the influence of tetraiodothyronine-supplemented diet on selected redox equilibrium markers and liver morphology in rats treated with doxorubicin e. korobowicz*, a. korga, j. dudka *uniwersytet medyczny w lublini, katedra i zakbad patomorfologi, poland objective: the toxicity of doxorubicin results from reactive oxygen species generation. ros production depends on tissue-specific enzymatic performance. liver is an organ that is characterized by very intensive activity of these enzymes. as a result, redox equilibrium disorders may appear. moreover, changes in thyroid hormone concentrations are accompanied by ros production. thus, disorders in iodothyronine hormones status may result in the intensification of doxorubicin-induced oxidative stress. aim: the aim of this study was to evaluate the influence of dox and t -associated treatment on selected redox equilibrium markers and histopathological evaluation of the liver. method: rats were treated with dox (. mg/kg, i.p.) once a week for weeks. apart from dox, thyroxin was simultaneously given in drinking water . and . mg/l, respectively. the concentration of lipid peroxidation products-malondialdehyde (mda) and total glutathionewere measured in liver homogenates. liver morphology was evaluated in h+e and pas diastase staining. results: higher levels of mda in liver of all tested groups and at the same time in rats treated with dox plus t lower concentrations of total glutathione compared to control were observed. morphological evaluation of liver did not show any symptoms of necrosis and steatosis, but a decrease in glycogen content in dox+t group compared to dox treatment was noticed. conclusion: thyroxin supplementation causes redox equilibrium disorders and oxidative stress in liver of rats receiving dox. the study revealed the normalizing influence of thyroxin on glycogen deposits that were observed after doxorubicin treatment. objective: dysadherin is a cancer-associated cell membrane glycoprotein that inhibits cell-cell adhesion. in many types of cancer, dysadherin is related to decreased e-cadherin expression, promotes metastasis and is an independent predictor of poor patient survival. dysadherin expression in human hepatocellular carcinoma (hcc) has not been studied to date. method: we studied by immunohistochemistry hcc (grade i, ; ii, ; iii, ; and iv, ) from patients (m/f . , mean age . range - years) with monoclonal antibodies specific for dysadherin (clone ncc-m ) and Εcadherin (clone /e-cadherin). immunostaining of inflammatory and endothelial cells was used as internal positive control for dysadherin (dys) expression. results: non-neoplastic hepatocytes and cholangiocytes were dys-negative. in neoplastic cells (nc), dys-specific immunostaining was mainly membranous, while some cases showed additional nc cytoplasmic positivity. the majority of hcc ( / , . %) had - . % dys (+) Νc, . % ( / ) showed - % (+) Νc, while % ( / ) had > % (+) Νc. dys expression was negatively correlated with e-cadherin expression (p< . ), while a positive statistically significant correlation was observed between strong dys immunostaining (> %+Νc) and tumour grade (p< . ). there was no correlation with tumour size, vascular invasion or other clinicopathological parameters examined. conclusion: normal hepatocytes and cholangiocytes do not express dysadherin. in hcc, increased dysadherin expression is observed in approximately one third of the cases; it is more extensive in high-grade tumours and is related to decreased e-cadherin expression. klippel-trenaunay syndrome with clinical presentation as metastatic liver disease: a case report s. stadlmann*, d. lenggenhager, r. a. kubik-huch, j. h. beer, g. singer *kantonsspital baden, institute of pathology, switzerland objective: klippel-trenaunay weber syndrome (ktws) is a rare congenital malformation characterized by hemangiomata, varicose veins and bone and soft tissue hemihypertrophy. ktws can include additional vascular and lymphatic system abnormalities in various organs, but involvement of the liver is rare. we report a case of ktws simulating metastastic liver disease. method: a -year-old male with ktws presented with a tumor mass in the right abdomen. ultrasonography revealed a -cm cystic abdominal tumor and additional hypodense lesions in liver segments i, ii, and viii. a ct scan additionally showed multiple hypodense lesions in the spleen, peritoneum, lung, right scrotum, soft tissue and enlarged abdominal lymph nodes, highly suspicious for metastatic disease. results: laboratory data values were: gammagt u/ l (normal - ), ldh u/l (normal - ), albumin g/l (normal - ), and alpha feto-protein . μg/ l (normal < ). histopathology of the cystic abdominal tumor mass showed a complex vascular malformation of lymphangioma-hemangioma type. evaluation from two different tumorous liver lesions revealed nodular hepatic tissue separated by fibrous septa with reactive ductules and atypical vessels, consistent with multiple focal nodular hyperplasia (fnh) in the setting of ktws. conclusion: the spectrum of ktws can include arterial and lymphatic system abnormalities beyond the classical manifestation. our findings support the concept that multiple fnh characteristically occurs in a syndromic form and is induced by an irregular blood supply in the liver, with localized hyperperfusion leading to reactive nodular proliferation of liver tissue. microscopic evaluation of metaplastic and dysplastic changes in the mucous of the gallbladder d. lacka*, a. nasierowska-guttmejer *csk mswia, zaklad patomorfologii, warsaw, poland objective: in the intra-and extrahepatic biliary ducts, precancerous changes such as hyperplasia, metaplasia and dysplasia are diagnosed. in the gallbladder, cholecystitis chronica is diagnosed often with a disregard of the features of hyperplasia and metaplasia. generally accepted markers of precancerous changes of the gallbladder and biliary ducts are still to be found. aim: the aim was to define the accumulation of tp protein and mib activity in hyperplasia, metaplasia and dysplasia of the mucous membrane of the gallbladder. method: the material comprises gallbladders operated by laparoscopy and fixed in formalin. specimens were embedded in paraffin. in the microscopic sections with hyperplasia, metaplasia and dysplasia immunohistochemical stainings for tp and mib were done along with mucycarmin and pas with alcian blue stainings (mucous presence). results: the histopathologic diagnosis revealed cases ( %) of chronic calculous cholecystitis, cases of acute inflammation and secen cases of cancer. hyperplasia, metaplasia or dysplasia were found in cases ( . %) with chronic inflammation and accounted for hyperplasia without metaplasia- cases, pseudopyloric or intestinal metaplasia- cases, dysplasia- cases. mucous stain-ings confirmed the presence of pseudopyloric and intestinal metaplasia, which helped distinguish them from adenomyosis focuses. ihc confirmed the accumulation of tp protein and proliferative activity in metaplasia and dysplasia of the mucous membrane. conclusion: mucous stainings and positive tp and mib reactions suggest that metaplasia and dysplasia of the mucous membrane of the gallbladder can be classified as intraepithelial neoplasia changes. more research should be done. objective: we aimed to investigate the relationship between the findings in total or partial hepatectomy specimens. method: one hundred six cases were collected who had total transplantation or partial hepatectomies because of liver cirrhosis (lc), hcc or other hepatic disorders from the archives. then, clinical, histopathologic features and serologic findings of the cases were reviewed. the relationship between the histopathologic features and endoscopic, clinical and serologic results were investigated statistically using comparison tests. results: for the last -year period, data from patients who underwent transplantation or hepatectomy were collected. ninety-five had total, ten had partial hepatectomies, and one had metastasectomy. after the gross and microscopic examination, cases were diagnosed as lc, had hcc, three had parasitic cystic disease and ten had other unusual diseases. among lc cases, had hepatitis b virus (hbv), seven had hepatitis c virus (hcv), three had mixed virus etiology, six were alcoholic and were due to other causes. among lc patients, had hcc. fourteen cases were found to have one, seven had two and had more than two tumors. twenty-two of the hccs were located in the right, while nine had tumors in the left and right; one case had tumors in the right, left and caudate lobe. the results demonstrated that the most common hepatic disorder was cirrhosis due to hbv in the hepatectomy specimens and hcc seen in one third of them. studies with follow-up and response to therapy will form the basis of our future projects. objective: solid pseudopapillary tumor of the pancreas (sptp) represents - % of pancreatic tumors, it affects young women, and surgery is the treatment of choice. histologic features include loosely cohesive, relatively uniform polygonal cells surrounding delicate capillarysized blood vessels. most tumors are positive for betacatenin, cd , progesterone receptors and neuroendocrine markers. mutations in the beta-catenin gene are frequent. although considered benign, they are currently classified as low-grade malignant epithelial neoplasms. method: a -year-old woman presented with abdominal pain. a tumor in the pancreatic head with liver metastasis is diagnosed by tc. fine needle aspiration cytology is diagnostic of sptp. we reviewed four more cases of sptp. results: all five tumors occurred in women < years old that presented with abdominal pain or asymptomatic. tumors ranged from . to cm. four were located in the tail and one in the pancreatic head. all patients underwent surgery with negative margins. one patient had hepatic and nodal metastases as well as lymphatic and perineural invasion. all tumors were positive for cd and cd , three for progesterone receptors. none of the patients presented tumor recurrence ( months to years). conclusion: solid pseudopapillary tumor of the pancreas should be included in the differential diagnosis of pancreatic masses. surgery is usually curative and should also be attempted in rare cases with an aggressive behaviour. despite the characterization of the morphologic and molecular features of this enigmatic neoplasm, more work is needed to uncover its cell of origin and true histogenesis. objective: serous cystic neoplasms (scn) are rare pancreatic tumors. the aim of the study was to describe histopathological characteristics of scn diagnosed in a single center during a -year-long period. method: pathological reports including macro-and microscopic descriptions of scn cases as well as routine slides were retrieved from institutional databases and retrospectively reevaluated. only cases with available original slides were included in the study. results: several clinicopathologic scn subtypes were distinguished: serous microcystic adenomas ( . %), five serous oligocystic and ill-demarcated adenomas ( . %) and a single case of microcystic adenoma coexisting with multiple serous cysts in von hippel-lindau patient ( . %). there were females ( . %) and six males ( . %). median patients' age was years (range - years). fifteen cases ( . %) were localized in the head of the pancreas, ( . %) in the pancreatic body, and five ( . %) in the tail. median tumor diameter was . cm (range - cm, the diameter of three tumors was not known). eleven cases ( . %) were diagnosed in pancreaticoduodenectomy specimens, six ( . %) in middle segment pancreatectomy specimens, and four ( . %) in distal pancreatectomy specimens. six cases ( . %) were enucleated, two cases ( . %) were diagnosed in open biopsy and two ( . %) cases were found during autopsy. conclusion: scn is found in middle-aged or older patients, mainly women. scn may be localized in each pancreatic segment and grow to large masses. the reasons for preferential existence of scn in females remain unknown. p , ki- , cd expressions in gastrointestinal and pancreatic neuroendocrine tumors and the evaluation of these tumors with clinicopathological and prognostic parameters e. kimiloglu sahan*, n. erdogan, s. ceylan, i. ulusoy *taksim training hospital, dept. of pathology, istanbul, turkey objective: gastrointestinal and pancreatic neuroendocrine tumors (gepnets) originate from the cells of the diffuse endocrine system. their molecular genetic mechanism of development and progression is complex and remains largely unknown. the purpose of this study was to review the gastrointestinal and pancreatic neuroendocrine tumors and to investigate these tumours with an emphasis on their clinicopathological characteristics. postoperative period. another patient survived for years and died of unrelated cause. conclusion: pa occurs infrequently in young patients. although some cases are diagnosed early and may be treated with potentially curable surgery, long-term survivals are rather exceptional. granulomatous pancreatitis in a patient with lada type diabetes mellitus v. mandys*, m. kheck, m. andel * rd faculty of medicine, dept. of pathology, prague, czech republic objective: the aim of this presentation was to demonstrate an unusual case of granulomatous pancreatitis discovered in a patient suffering from the lada type diabetes mellitus. method: samples of pancreatic tissue obtained during the postmortem examination were processed by a routine histological technique. the slides were stained with h&e, trichrome and van gieson method. immunohistological methods were used to detect markers of endocrine cells of islets of langerhans and of macrophages. results: a -year-old female patient suffering from diabetes mellitus lada type, generalized atherosclerosis and hypertension died due to pulmonary embolism. lipomatosis of pancreatic tissue was observed during the postmortem examination. histologic examination of pancreatic tissue discovered multiple small non-caseating epithelioid cell and giant cell granulomas replacing the islets of langerhans. conclusion: to our knowledge, our case represents the first description of non-infectious granulomatous pancreatitis associated with diabetes mellitus of lada type. objective: evaluation of crohn's disease (cd) activity is crucial to optimize therapeutic strategies. differentiation between inflammatory and fibrostenotic lesions is decisive since the former are treated with drugs, while the latter require surgery. cd activity is based on a combination of clinical, biochemical, endoscopic and radiologic findings, which cannot reliably distinguish between both entities. in patients with refractory symptoms, therapy decisions rely heavily on histologic diagnosis. method: preoperative mr imaging was performed in cd patients undergoing elective bowel resection. mr evaluated wall thickness, pre-and post-contrast wall signal intensity, relative contrast enhancement, presence of edema, and luminal stenosis. matched histological sections of the mr images were stained with hematoxylin and eosin (he). evaluation of wall and submucosa thickness, percentage of inflammatory and fibrous components in the mucosa and submucosa (masson's trichromic and reticulin stains), submucosal edema, and vascularity (cd stains). results: cases assessed as inflammatory by he had higher early post-contrast signal intensity by rm than fibrostenotic cases (p= . ). submucosal thickness correlated with early fibrosis (reticulin, p= . ), but only a trend with high vascularity (cd ). fibrostenotic cases had submucosal thickness inversely correlated with early signal capture and with relative contrast enhancement. mucosal inflammation was inversely correlated with submucosal fibrosis and thickness (p= . ). established fibrosis (trichromic) had no delayed signal capture (p= . ). conclusion: there is a good correlation between histologic and mr findings. mr may reliably differentiate between inflammatory and fibrostenotic lesions, and it may have an important role as a new pre-surgical biomarker in the management of cd. the role of standard endoscopic biopsy in diagnosis of gastric gastrointestinal stromal tumors managed in the holycross cancer centre, kielce, poland, in years - w. rezner* *holycross cancer centre, dept. of neoplasm pathology, kielce, poland objective: intramural character of growth makes gastrointestinal stromal tumor (gist) difficult or impossible to access by endoscopic biopsy forceps, and therefore, the diagnostic yield of the biopsy does not exceed %, even with the use of special techniques. the aim of the study was to evaluate the role of standard endoscopic biopsy in preoperative assessment of gastric gists. method: from among cases of all gastric gists managed in our institution in the years - , we selected cases where standard forceps biopsy from subepithelial mass was obtained. we excluded five cases with no subepithelial mass visible endoscopically and two cases of small incidental gists in patients operated for other neoplasms. biopsies diagnosed as negative for gist were analysed retrospectively with serial sectioning and immunostains including, where appropriate, cd- , cd- , sma, s- and calponin in search for neoplastic tissue which could have not been apparent in original he-stained slides. results: none of the biopsy samples analysed retrospectively contained neoplastic tissue. material which enabled histopathological and immunohistochemical diagnosis of gist was obtained in out of cases. mucosal ulceration was present in all cases of diagnostic biopsies and in out of non-diagnostic biopsies. conclusion: no gist tissue was originally missed in biopsy material, so the diagnostic yield of standard endoscopic biopsy in diagnosis of gastric gists approached one third of the cases. immunohistochemical markers utilized in differential diagnosis between primary ovarian carcinoma from metastatic colorectal carcinoma a. iliesiu*, m. aschie, m. anca, n. anca, i. poinareanu, a. chisoi, p. corici, v. sarbu, i. aschie *clinical emergency hospital, dept. of pathology, constanta, romania objective: colorectal adenocarcinoma is the most common tumor that metastasizes to the ovary and is often difficult to distinguish from primary ovarian mucinous carcinoma. an immunohistochemical marker cdx- was found to have a diagnostic value in establishing the gastrointestinal origin of metastatic tumors. obtaining the correct diagnosis is difficult but crucial to treatment and prognosis. method: in our study realized in clinical county emergency hospital constanta, we evaluated the immunohistochemical expression of cdx and also the expression of cytokeratin , cytokeratin , cea, muc in cases representing ovarian adenocarcinoma and metastatic colorectal adenocarcinomas involving ovaries. results: searching the tumor registry and pathology database of our hospital, we found that the median age of the study group was years (range, - ). metastatic colorectal adenocarcinoma were almost always negative for muc ( . %), often negative for ck ( . %), focal or diffuse positive for cdx ( . %), diffuse positive for ck ( . %), focal or diffuse positive for muc ( . %), and diffuse positive for cea ( . %). almost all of the primary ovarian carcinomas lacked immunoreactivity for cdx- . in contrast, metastases to the ovary from colorectal primaries showed cdx- immunoexpression. conclusion: cdx- is a useful marker for differentiating primary ovarian carcinoma from carcinomas metastatic to the ovary. ck , ck , cdx and muc ihc staining is a useful adjunctive diagnostic tool to differentiate metastatic colonic tumours from primary ovarian tumours, in addition to clinical history and gross and microscopic findings. multicystic mesothelioma-a case report j. jeruc* *faculty of medicine, institute of pathology, ljubljana, slovenia objective: multicystic mesothelioma or multilocular peritoneal inclusion cyst is a rare tumor with a predilection for pelvic surfaces of the peritoneum. most frequently, it occurs in women of reproductive age who have a history of previous pelvic surgery or infection. results: a -year-old man with no significant past medical history presented with abdominal pain lasting days in the ileocecal region. despite normal white cell count, acute appendicitis was suspected and the patient underwent surgery, during which a multicystic mass measuring . cm in the longest diameter was found. cysts were thin-walled, translucent, with a smooth outer surface, and mostly filled with clear and some with hemorrhagic fluid. histologically, they were lined by a single layer of cuboidal polygonal and focally hobnailshaped cells with small uniform nuclei without mitotic activity. cells stained positive for cytokeratin, calretinin and wt- , but were negative for endothelial markers, cea and estrogen and progesterone receptors. the loose connective tissue between cysts was infiltrated by lymphocytes and granulocytes. the diagnosis of multicystic mesothelioma was made. threemonths after surgery, the patient is doing well. conclusion: the majority of investigators considers this entity to be an unusual type of mesothelial neoplasm that has a tendency to recur locally and may rarely transform into a conventional mesothelioma. some, however, consider the lesion to be a non-neoplastic reactive mesothelial proliferation. multicystic mesothelioma has an indolent course, but approximately one half of cases recur. the differential diagnosis includes malignant mesothelioma, cystic lymphangioma, pseudomyxoma peritonei and mesenteric and omental cysts. collagen iv expression, as staining of the continuous basement membranes of vessels, varied from % in lr gists to % to % in ir and hr tumors, respectively. gamma's correlation test revealed correlation between microhemorrhages and grade (r= . , p= . ), tumor necroses and p (r= . , p= . ), tumor necroses and collagen iv (r=− . , p= . ) and vegf and collagen iv (r=− . , p= . ). conclusion: this study showed that both high p expression and the presence of tumor microhemorrhages are possibly related with unfavorable prognosis. in addition, we found that a tumor necrosis was correlated with a p and collagen iv. smooth muscle tumors with cd /cd positivity cells s. rjabceva* *belarusian medical academy, dept. of pathology, minsk, belarus objective: immunohistochemically, smooth muscle cells are characterized expression of sma and desmin. the aim of this study was to describe the clinicopathological and immunohistochemical features of smooth muscle tumors (smt) with cd /cd positivity cells. method: eleven cases diagnosed as smt were examined by both light microscopy and immunohistochemistry (ihc). i used ihc markers such as cd , cd , smooth muscle actin, desmin, vimentin, nse and s . results: the patients (m/f= : ), with age ranging between and years (mean = . ), had smt. a tumor size varied from . to cm (mean = . cm). tumors were localized in the esophagus ( / . %), stomach ( / . %), colon ( / . %), retroperitoneum ( / . %) and in the pelvis ( / . %). histologically, tumors are composed of elongated or ovoid cells with pale nuclei and eosinophilic cytoplasm which is distinctly fibrillar. immunohistochemically, cells of smt were positive for sma ( %), desmin ( %), vimentin ( %) and nse ( . %), but they were negative for cd , cd and s . i found that the scattered cells of the tumors were characterized by the expression of cd ( / %), cd ( / . %) and s ( / . %). these cells were located diffusely or focally in the smt. the immunophenotype of these cells was similar to immunohistochemical features of the interstitial cells of cajal or the gastrointestinal stromal tumor (gist). conclusion: although the scattered tumor cells revealed cd positivity, the histological finding was similar to smt and was different from gist. smt colonized by cd /cd -positive cells should not be confused with gists. updates of tnm classification: for the better or worse? b. karabulut*, a. m. sonmez, d. turan, n. kursun, a. ensari *ankara university med school, turkey objective: for the prognostic evaluation of tumours, the tnm classification is updated periodically. the use of this classification for colorectal cancer (crc) has caused some problems in the assessment of metastatic lymph nodes. in this study, we have investigated the effect of the updates on metastatic lymph node interpretation and, hence, staging. method: h&e slides of cases of crc were reevaluated microscopically to assess the number of metastatic lymph nodes according to the criteria of tnm , tnm and tnm . clinical parameters such as gender and age of the patients, tumour location, grade, and stage were retrieved from the patients' files. mann-whitney, kruskal-wallis, wilcoxon signed ranks and multiple comparison tests were used for statistical analysis. results: there were men ( . %) and women ( . %) with a mean age of . years (ranging from to ). the tumour was located in the right colon in cases ( . %) and cases in the left colon ( . %). there were three grade ( . %), grade ( . %), and grade tumours ( . %). the number of metastatic lymph nodes was significantly higher in grade tumours compared to grade tumours in tnm , tnm and tnm . according to tnm , significantly more metastatic lymph nodes were determined than tnm and tnm (p< . and p < . , respectively), whereas tnm revealed significantly more metastatic lymph nodes in comparison to tnm (p< . ). conclusion: our results show that there is significant variation between updates of tnm in terms of metastatic lymph node yield which will inevitably cause variation in the tnm classification. objective: metastatic lesions to the mandible are rare, comprising < % of all malignancies. an -year-old woman presented with a painful swelling in the right mandible growing progressively for months. method: computed tomography (ct) showed intraosseous expansile and destructive lesion in the corpus of the right mandible × mm in size expanding to the soft tissue laterally. after administration of contrast material, moderate enhancement was seen throughout the mass. the biopsy showed stromal tumor immunopositivity for cd . the patient had a medical history of ileal tumor resection years ago at another institute which was diagnosed as gastrointestinal stromal tumor (gist) and classified as intermediate risk group for potential of malignancy. results: the mandibular tumor was considered as a metastatic gastrointestinal stromal tumor. no tumor was seen on positron emission tomography (pet)/ct other than the mass in the right mandible. the histopathology of the ileal tumor was seen and the diagnosis was confirmed. imatinib treatment was started at a dose of mg daily. resection of the mandibular mass was planned by plastic and reconstructive surgeons. conclusion: liver and peritoneum are usual metastatic sites for gastrointestinal stromal tumors. to the best of our knowledge, metastasis of ileal gastrointestinal stromal tumor to the mandible has not been previously reported in the english literature. objective: warthin's tumor is the second most common neoplasm of the parotid gland accounting for - % of parotid neoplasms. however, parotid gland is an extremely rare site for extrapulmonary tuberculosis. objective: the purpose of this study was to assess the immunohistochemical (ihc) status of androgen receptor (ar) in various salivary gland cancers. the study group consisted of cases of primary salivary gland cancers from patients (f/m= : , age - years). these were adenoid cystic carcinomas (adcc), adenocarcinomas nos (adc), mucoepidermoid carcinomas (mec), acinic cell carcinomas (acc), carcinomas ex pleomorphic adenomas (caexpa), salivary duct carcinomas (sdc), basal cell adenocarcinoma (bcac) and large cell neuroendocrine carcinoma (lcnec). ihc reactions with monoclonal mouse antihuman androgen receptor antibody (dako, clone ar ) were done on -μm-thick sections cut from representative archival paraffin block. in each positive case, the revealed strength of ar expression was assessed as total score (ts) according to allred score. results: the ar expression was found in five adc nos, four caexpa, four sdc, four acc, three mec, and one adcc and bcac, and calculated ts ranged from three to eight points. ts had eight points in six cases, seven in three cases, six in one case, five in three cases, four in two cases and three in four cases. conclusion: ar expression was found in of ( %) primary salivary gland cancers. the strength of ar expression differed in various salivary gland cancers, and it was most frequent in caexpa ( / ) and sdc ( / ) and less frequent in adc ( / ) and acc ( / ), whereas only found incidentally in others. mena expression in normal and neoplastic salivary glands g. simona* *umf, dept. of pathology, targu-mures, romania objective: recently, studies revealed that human orthologue of murine mena (mammalian ena), an actin regulatory protein involved in the control of cell motility and adhesion, is modulated during breast, colon and pancreatic carcinogenesis. in our previous studies, we observed that mena was modulated during colon and cervix carcinogenesis. in this study, we analysed mena expression in lesions of salivary glands (sg). previous studies regarded only maspin expression in these lesions, a protease inhibitor which is increased in benign tumors but decreased in sg carcinomas. method: we have analyzed mena expression in normal sg (n= ) and also benign (n= ) and malignant (n= ) lesions of sg. for the immunohistochemical staining, we used the murine mena antibody, provided by bd biosciences. mena expression was quantified in cytoplasma of tumor cells. results: all normal sg and their benign lesions were mena-negative. it included ten pleomorphic adenomas and ten warthin's tumors. ductal adenocarcinomas (n= ), independently by their histological grade and also carcinomas with acinary cells (n= ) and squamous carcinomas (n= ), were positive. no difference of mena intensity in positive cases was observed. all lymphomas (n= ) were mena-negative. conclusion: this is the first study in literature about mena expression in sg tumors. our results prove that mena plays a role in carcinogenesis of different organs, including sg, but the exact mechanism is not yet known. in accordance with different previous studies about maspin expression in sg lesions, it seems that these two antibodies are reversely correlated. future studies are necessary in order to elucidate their role in sg tumors. secondary tumors of the salivary glands a. c. faur* *university of medicine, 'v babes' timisoara, romania objective: secondary tumors of salivary glands are rare and constitute about % of all malignant salivary neoplasm. method: a study has been carried out for years on cases of salivary gland tumors, and only one case of salivary metastatic lesion was diagnosed. a -year-old female with a history of a right temporal malignant melanoma was admitted at the plastic surgery department of county hospital of timisoara. sixmonths after the surgery, the patient returned to this clinic with a rapidly growing mass in the right temporal region and right preauricular region. a × -cm diameter tumor was excised with adjacent lymph nodes. a superficial parotidectomy was performed also, preserving the facial nerve and its branches. formalin-fixed paraffin-embedded tissue samples were cut at μm and stained using hematoxylin and eosin (he). results: on he stain, the periparotid and temporal region lymph nodes were infiltrated by malignant melanoma cells. the parotid tissue also had metastatic lesions. the metastatic malignant melanoma lesion consisted of epithelioid neoplastic cells with cytologic and nuclear atypia, large nucleoli, atypic mitotic figures and abundant melanin pigmentation. necrosis and hemorrhage were also seen. conclusion: the parotid gland and its lymph nodes are possible sites of metastasis from head and neck tumors, especially squamous cell carcinoma or melanoma. the rarity of salivary secondary tumors prompted us to report this case. objective: primary intraosseous mucoepidermoid carcinoma of the jaws is a rare lesion accounting for < % of all mucoepidermoid carcinomas reported in the literature. it is a neoplasm of adult life and affects females twice more frequently than males. histologically, it is a low-grade carcinoma usually affecting the mandible. the radiologic presentation is that of uni-or multilocular lesions. their origin still remains controversial. method: we report the case of a -year-old female who presented with a painful swelling in the left maxilla of month's duration. there was no history of previous surgical intervention. clinical examination revealed an ulcerated swelling. cervical lymphadenopathy was absent. results: the radiological examination showed a unilocular compact lesion in the maxilla, not unequivocally diagnostic of malignancy. surgical excision of the lesion together with a small part of the maxilla was performed. grossly, it was a solid mass of relatively soft and only focally bony consistence measuring . cm. on brushing cytology of the surgical specimen, groups of mucous cells without any significant atypia intermingled with aggregates of squamous cells. the histologic diagnosis, confirmed by histochemical and immunohistochemical methods, was that of low-grade mucoepidermoid carcinoma of the maxilla. the postoperative period was uneventful. the patient is on regular follow-up and is disease-free after years. conclusion: our case is reported because of its rarity, and at the same time, the literature is reviewed and speculations about the pathogenesis of mucoepidermoid carcinomas are attempted. odontogenic myxoma (om) in the maxilla: a case report and review of the literature s. papaemmanouil*, n. pastelli *g. papanikolaou general hosp., dept. of pathology, thessaloniki, greece objective: odontogenic myxoma is an intraosseous tumor of the jaws, relatively benign with locally aggressive behaviour. most of the oms are slowly growing with no symptoms. large tumors cause painless expansion. it occurs in patients over the age of and is mostly located in the mandible. method: a -year-old man was presented with a progressively enlarging mass in the maxillary area. the imaging findings revealed a large, rather wellcircumscribed tumor mass in the body of the maxillary bone. the mass was excised by peripheral ostectomy. results: the gross examination revealed a grey-white mass with translucent mucinous appearance measuring × . × cm. the sections were examined with h+e and mucin stains and followed by ihc study for mib- (ki- ). the morphologic, histochemical and ihc data were consistent with an odontogenic myxoma. conclusion: our study comments on the imaging findings of macroscopic and microscopic features and the differential diagnosis of this tumor. the current literature is reviewed. objective: the role of interactions between mmp- , mmp- and kai protein expression as markers involved in aggressive behaviour of tumours is still under investigation. the study aimed to evaluate and compare mmp- , mmp- and kai expression in primary oral squamous cell carcinomas (oscc) and adjacent marginal normal squamous cell epithelium and to estimate their association with each other in relation to clinical variables. method: mmp- , mmp- , and kai expression was evaluated on primary oscc (n= ) and adjacent marginal normal tissues (n= ) using immunohistochemistry. results: significant differences between mmp- and kai expression was found in oscc and marginal normal tissue (p= . , p= . , respectively). in normal tissue, mmp- , mmp- expression was found in basal cell layers and also frequently was observed in stromal tissues with inflammatory component. kai protein was not observed in stromal tissues. no significant differences were observed between mmp- , mmp- , kai expression and tumour grade and stage. inverse correlation between mmp- and kai expression was found in oscc (p= . ). kai -negatve/ mmp- -positive cases were observed mainly in high tumour grade and in advanced stage of tumours. conclusion: inverse correlation revealed between kai protein and mmp- expression in oscc could affect the function of kai suppressor protein and influence the metastatic potential of the tumour cells. our results suggest that accumulation of mmp- and mmp- in the surrounding tissue may enhance local invasion in oscc. expression of mmp- and pten in laryngeal squamous cell carcinoma-biological predictors? m. bodnar*, p. burduk, w. kazmierczak, a. marszalek *collegium medicum, bydgoszcz, poland objective: reliable predictors of laryngeal squamous cell carcinoma (lscc) biology are still missing. the aim of this study was to investigate two newly discovered factors (mmp- and pten) in lscc patients with correlation to the stage of the disease. method: we used specimens from surgical resections selected from patients and divided into controls ( samples) and lscc ( samples). we used standard immunohistochemistry for mmp- and pten expression studies with envision system and dab as a chromogen. antigen expression was classified as followed: -no positive cells, -< %, - - %, -above % positive cells. all results were statistically evaluated using mann-whitney u test and anova, with statistical significance at p< . . results: in patients with lscc, the expression pten was detected in the cytoplasm of % tumor cells and % stromal area (p< . ) while in controls only in % of stromal area (p< . vs lscc). pten expression was decreased in tumor cells in n+ vs n cases ( % vs %). in lscc, mmp- was found in . % of the tumor cells, but in % of stromal area (p< . ). there was no mmp- expression in controls, while expression level ( - scale) was higher in tumor cells versus stromal compartment. mmp- stromal expression in n and n+ cases was % versus % of the area, respectively. conclusion: we might conclude that decreased pten expression in tumor cells predicts lymph node involvement, which then is accompanied by decreased expression of mmp- in stromal area in the main lesion. mucosal large cell neuroendocrine carcinoma (mlcnec) of the head and neck regions: a new clinicopathologic entity k. kusafuka*, m. abe, y. iida, t. onitsuka, t. nakajima *shiuzoka cancer center, pathology division, nagaizumi, japan objective: large cell neuroendocrine carcinoma (lcnec) is well known as a subtype of lung cancer, but it is extremely rare in the head and neck regions. our objective was to establish mucosal lcnec (mlcnec) as a new entity in the head and neck regions. method: we reestimated surgically resected specimens of the primary mucosal carcinoma in the head and neck regions, including basaloid squamous cell carcinoma, during - . the immunostainings for neuroendocrine (ne) markers such as cd , chromogranin-a and synaptophysin were performed. in the cases which were positive for two or three ne markers, we re-diagnosed as "mlcnec". results: only eight cases ( . %) were re-diagnosed as mlcnec. all cases were male and their mean age was . years. three cases occurred in the tongue base, four cases in the larynx and one case in hypopharynx. although seven cases showed numerous regional lymph node metastases, only one case showed death of disease. histologically, mlcnec showed the sheet-like, trabecular, organoid pattern growth of relatively large basaloid cells in which the central necrosis, rosette formation, peripheral palisading, and high mitotic figures were sometimes seen. immunohistochemically, mlcnec indicated to be positive for two or three ne markers. only three cases of mlcnec were immunopositive for ttf- , whereas all cases except one case were only focally immunopositive for p . all cases showed high proliferating activity. conclusion: we propose that mlcnec can occur in the head and neck regions and is a new clinicopathological entity. the prognosis of mlcnec remains unclear. objective: massive ovarian edema is an unusual cause of ovarian enlargement in young women. it is due to the accumulation of edema fluid and in some cases is associated with mature cystic teratoma. the patients are young (average age), with present abdominal pain, menstrual abnormalities or evidence of hypergonadism. the ovarian enlargement is unilateral in % of cases. method: we report a case of a -year-old girl with tumor of the left ovary. grossly, the enlarged ovary's greatest dimension was × cm ( , g), composed of solid mass with large gelatinous and hemorrhagic foci. paraffin sections from samples were stained with heeo and immunostained for vimentin, s protein, sma, desmin and cd . results: histological findings were identical in all slides. ovarian stroma cells were scattered within abundant edematous fluid, and in some foci, hypocellular stroma surrounded follicles. in the cortex, follicles were dilated in fibromatous stroma with rare luteinized cells. cd confirmed the presence of many vessels with thrombi composed of fibrin-causing hemorrhagic necrosis. in some areas of necrosis, we found foci of dystrophic calcification suggesting an older process. conclusion: massive ovarian edema is a lesion which can be misdiagnosed as a neoplasm. the cause is unclear. it has been attributed to intermittent torsion of the ovarian pedicle and interference with its lymphatic drainage. the fibromatosis and massive edema represent two ends of the same disorder. objective: intimal fibroplasia is a variant of fibromuscular dysplasia (fmd), a non-inflammatory and nonatherosclerotic arterial segmental disease, resulting in narrowing of the lumen. fmd of coronary arteries is a rare pathology associated with cardiac and sudden death occurring during infancy, childhood and young adulthood. method: we describe the case of a female infant born prematurely (gestational age + / ) presenting a mild supravalvular aortic stenosis associated with an atrial septal defect and cardiac valvular dysplasia. during the first weeks of life, she developed a progressive obstructive cardiomegaly and she died at day of a cardiogenic shock. results: the autopsy confirmed a marked cardiac hypertrophy and the aforementioned congenital cardiac anomalies. histologically, we observed a myxomatous thickening of the aortic, pulmonary and mitral valves and a significant segmental intimal fibroplasia of all coronary arteries, producing subtotal obstruction of the right coronary artery. the myocardium presented multiple areas of infarction of various ages and foci of interstitial fibrosis with calcifications. sampling of the aorta and its major branches showed mild to moderate intimal fibroplasia of the aorta, celiac trunk, superior mesenteric and left renal arteries. the pathogenesis of fmd is unclear: mural ischemia, hormonal, genetic and mechanical factors have been suggested. this case supports the theory of a congenital origin and emphasizes the importance of an extensive examination of coronary arteries when performing autopsy in paediatric patients as fmd is a segmental disease, and it must be considered in the etiologic differential diagnosis of cardiac and sudden death in paediatric age. increased amount of chorionic disc extravillous trophoblasts (evt) in placental hypoxia j. stanek* *cincinnati children's hospital, dept. of pathology, usa objective: increased amount of evt in the maternal floor was found in preeclamptic placentas. this analysis intends to retrospectively prove that the evt is increased in the whole chorionic disc also in other than preeclampsia clinical conditions at risk for fetal and placental hypoxia. method: frequencies of clinical and placental parameters of consecutive cases with more than five cell islands per full-thickness paracentral section of grossly unremarkable placenta (study group, sg) were compared to all remaining , placentas (control group, cg). results: the numbers of placental septa/cell islands were statistically significantly (p< . ) higher in the sg than in the cg in association with preeclampsia, chronic hypertension, diabetes mellitus, oligohydramnios, intrauterine growth restriction, induction of labor, cesarean sections, low -min apgar score, small placentas, placental infarction, massive perivillous fibrin deposition, decidual arteriolopathy, diffuse placental hypoxia, microscopic chorionic pseudocysts, and maternal floor clusters of multinucleate trophoblastic giant cells. the reverse was seen in the premature rupture of membranes, perinatal mortality, abnormal umbilical cord, acute chorioamnionitis, chronic villitis of unknown etiology, and histological placental meconium staining. conclusion: the amount of chorionic disc evt is increased in association with clinical conditions and placental lesions known to be associated with hypoxia, but is decreased in "non-hypoxic" clinical conditions and placental lesions. counting the placental septa and cells islands can serve as a surrogate test of placental hypoxia, not only in preeclampsia. pseudo-torch and the cerebro-costo-mandibular syndrome j. stanek*, a. oestreich *cincinnati children's hospital, dept. of pathology, usa objective: while the posterior rib gaps and pierre robin sequence are well documented, components of the cerebrocosto-mandibular syndrome (ccms), the "cerebral" part thereof is more variable, including mental retardation in survivors, hydrocephalus, severe hypoplasia of frontal and occipital lobes, abnormal olfactory bulbs, cerebral heterotopias, or gliosis. method: this is a case report of unusual brain findings in ccms, to our knowledge found for the first time at postmortem examination. results: because of fetal hydrops and congenital anomalies found on prenatal ultrasound, a -week pregnancy was terminated to reveal a fetus with multiple rib gaps, dysmorphic facial features, prominent micrognathia, higharched palate, club feet, dysplastic organ of corti, incomplete visceral rotation, pseudoglandular transformation of the pituitary gland, mucosal eosinophilia of the stomach and intestines, microcalcifications of liver, and extensive, diffuse, predominantly perivascular and not only periventricular brain calcifications. there was no laboratory evidence of intrauterine infection either clinically or by in situ hybridization. conclusion: this case illustrates a not yet described pseudo-torch, congenital infection-like, presentation of the ccms with extensive brain calcifications and mucosal eosinophilia of the gastrointestinal tract. extensive brain calcifications were described in other genetic syndromes such as baraitser-reardon syndrome, aicardi-goutieres syndrome, and mitochondrial encephalopathies, but not the ccmc. calcium metabolism can have genetic background in the ccms and explain cerebral dysfunction in at least a subset of the syndrome. objective: alveolar capillary dysplasia (acd) with or without misalignment of pulmonary veins (mpv) is an uncommon congenital cause of persistent pulmonary hypertension of the newborn characterized by a lack of alveolar and vascular development. most are sporadic, but familial acd/mpv has been reported, linked to the gene foxf on chromosome q . -q . . it is universally fatal and diagnosis is entirely dependent on the pathological examination of surgical lung biopsy specimen. four cases of acd, three with mpv, are reported. method: the four neonates were full term, without associated congenital anomalies. they were admitted to the paediatric intensive care unit for hypoxia and severe pulmonary hypertension unresponsive to maximal cardiorespiratory support, including high-frequency ventilation, inhaled nitric oxide and extracorporeal membrane oxygenation. results: surgical lung biopsies performed in three cases and postmortem lung examination in one case showed pathological findings of acd, characterized by poor capillary apposition and density and medial arterial hypertrophy. these lesions were associated with misalignment of pulmonary veins in three cases. the four infants died of refractory hypoxemia during the first months of life. conclusion: these observations emphasize the importance of considering acd with or without mpv in all newborn infants who present a persisting severe pulmonary hypertension without anatomical cause. histological diagnosis based on early surgical lung biopsy may prevent from using costly, invasive and ineffective treatments and procedures such as extracorporeal membrane oxygenation. a case of complete trisomy : autoptic, cytogenetic and radiologic findings e. gradhand*, s. becker, c. richter, d. wand, c. kunze, s. hauptmann *medizin. universität halle, institute of pathology, germany objective: an autopsy of a female fetus of the + nd gestational weeks was performed after an induced abortion due to multiple intrauterine malformations suspecting a chromosomal disorder. method: prior to the autopsy, the -g female fetus was extensively x-rayed. we performed an autopsy including histological examination of all organs. cytogenetic analysis was performed using both chorionic trophoblast and tendon fibroblasts. results: the fetus was characterized by pronounced global hydrops, craniofacial dysmorphy and malformations of both hands and feet. we found a complex cardiac malformation, unilobular lungs, dysmorphic liver and spleen, malrotated and doubled right kidneys, and an aplasia of the left kidney. the parenchymatous organs showed inconspicuous histomorphological architecture. in the cerebrum, no corpus callosum was found and immature neuronal rosettes in both optical nerves were detected. xray showed vertebral clefts, a slight hypertelorism, skeletal dysplasias of both hands, and confluent frontal and occipital fontanelles. cytogenetics turned out a complete trisomy (gtg-banding). conclusion: we present radiological, autoptic and cytogentic findings in a case of a very rare chromosomal aberration which mostly occurs as a mosaic or partial trisomy . this chromosomal abnormality usually induces early abortion. therefore, a fetus with trisomy and a gestational age of + weeks is very uncommon. we found multiple malformations of the skeleton and organs, mostly located in the midline. holoprosencephaly with cyclopia: presentation of two fetuses with multiple congenital malformations and investigation of sonic hedgehog (shh) expression p. papanastasopoulos*, j. coulouras, p. aroukatos, m. repanti, e. farri-kostopoulos, h. papadaki *general hospital agios andrea, dept. of pathology, patras, greece objective: holoprosencephaly is the commonest forebrain developmental anomaly occurring in of , live borns. sonic hedgehog is the major gene implicated in holoprosencephaly. method: two fetuses of -week and -week pregnancies, terminated due to multiple congenital malformations, were autopsied, and paraffin-embedded tissue sections were examined microscopically. shh expression was investigated immunohistochemically in orbital and cns sections. results: twenty-seven-week fetus: karyotype xx; alobar holoprosencephaly, true cyclopia, proboscis formation, pituitary gland anterior lobe agenesis, atretic anus and vagina, hypertrophic clitoris, female internal genitalia, right hand oligosyndactyly, left-sided overriding fourth and fifth toes, ventricular septal defect, hypoplastic left heart complex, truncus arteriosus, asplenia, irregular liver lobation, left kidney agenesis, right kidney cystic dysplasia, hypoplastic right ear auricle, external auditory meatus atresia. thirty-two-week fetus: karyotype xy; alobar holoprosencephaly, synophthalmia, proboscis formation, hypoplastic right heart complex, patent foramen ovale, ostium secundum defect, tricuspid valve and pulmonary artery atresia, pulmonary arteries analogous branching from the aorta. no teratogenetic factors and consanguinity were reported. histological examination revealed scattered rosette-like structures in areas of dysplastic retina in both cases. immunohistochemical expression of shh was negative. conclusion: the absence of shh immunostaining suggests a potential causative role in the pathogenesis of the above phenotypes. even though both karyotypes were normal, the authors could not exclude the possibility of the existence of chromosomal alterations not detectable by routine karyotypic analysis. finally, to our best knowledge, the above phenotypes do not seem to match any known clinical syndromes, and we therefore consider their origin unknown at present. the impact of nutritional colourant tartrazine (e ) on morphological state of thymus of rat descendants i. goryanikova*, i. sorokina *lugansk state medical university, dept. of pathomorphology, ukraine objective: synthetical colourant of yellow colour tartrazine (e ) whose application is prohibited in some countries of eu got widespread use. the aim of the work was the assessment of influence tartrazine to thymus of infant rat descendants month from birth from mothers who had been taking tartrazine during gestation and feeding. method: it was histologically discovered that density of cortical and medullar thymocytes was much higher than in the control group. mitosis is often diagnosed in the subcapsular zone. the most part of thymocytes of this zone is apoptosis amenable, cells with low concentration of dna in the nucleus, with the sings of dystrophy and necrosis often met. thymus medullary substance generally consists of fine lymphocytes. the small bodies of thymus, which are situated in medullary substance, are few in number and fine. results: immunohistochemical investigation with mca defined the signs of thymocyte-interrupted maturation of depletion of cd and cd population and macrophage ed and b lymphocytes cd ra amount rising. conclusion: thymus morphological specification of infant rats with tartrazine intoxication (during month) indicates frank hyperplasia of thymus lymphoid with underlying maturation retention, and component lymphocyte immunological differentiation points to antigenic activation, which influenced the test animals. objective: pleuropulmonary blastoma (ppb), a rare tumor arising during fetal lung development, can be part of an inherited cancer syndrome. about % of children with ppb have a family history of cystic nephroma and rhabdomyosarcoma. it is related to dicer mutations on q and consists in malignant mesenchymal cells and cysts lined by benign epithelium. method: we report our experience in a paediatric pathology center. two girls of and months presented pulmonary lesions, the first purely cystic and the second purely solid, corresponding histologically to early type i and type iii ppbs. results: the first patient underwent an upper lobectomy with an unremarkable postoperative outcome. the second patient presented a thoracic relapse years after initial treatment consisting in upper lobectomy, pre-and postoperative chemotherapy. tumoral karyotype revealed complex clonal chromosomal aberrations, dominated by interstitial q , q deletion and trisomy . no familial history of neoplasia. she is disease-free years after presentation. conclusion: ppb must be taken into account in the evaluation of cystic and even solid pulmonary lesions in children under years. a correct histologic diagnosis is needed to identify early ppb, which may be difficult to differentiate from congenital pulmonary airway malformation (cpam), to appropriately manage patients and to identify an inherited predisposition to ppb. recent data showed that dicer on q , a gene implicated in mirna synthesis, plays a crucial role in lung development. loss of dicer alters mirna-dependent regulation of diffusible growth factors that induce mesenchymal cell proliferation. results: pi ki ranging - % (median %) and topo a ranging - % (median %) were lower in children older than months (> m, p= . and p= . , respectively). the two markers were strongly interrelated (r= . ). higher ki- and topo a correlated with higher mki and adrenal location and inversely with increasing tumor differentiation. the cutoff values of pi ki ≥ % and topo a ≥ % correlated with fatal outcome of the disease. in the subgroup of patients, > m significant correlations between higher values of both pi markers and metastatic stage, unfavorable histology, high mki, mycn amplification, and adrenal localization were observed. at cutoffs ki ≥ % and topo a ≥ %, the markers predicted long-term unfavorable outcome by kaplan-meyer analysis. cox regression analysis indentified pi (assessed jointly as ki ≥ % + topo a ≥ %) as the independent prognostic factor. conclusion: ki and topo a pi markers have prognostic significance and clinicopathological correlations in nb. we propose to include pi to the standard histological assessment protocol of nb tumors. we decided to test the hypothesis that fatal cases of influenza occur mainly in association with important comorbidities as was stated based in previous studies. method: we included in our study patients with fatal ah n influenza. during autopsy, we largely sampled vital organs-brain, lungs, heart, liver, kidney, lymphoid organslymph nodes and spleen and any other diseased organ. results: in our group, sex ratio was male/female = . : ; patients were and years old (mean age . ). nine women were pregnant/parturient ( . %). other patients presented obesity, malignant neoplasia, diabetes mellitus, cardiac diseases and tuberculosis. we analyzed the prevalence of these comorbidities in the general population (see table) . however, patients did not have any comorbidities or any known cause of immunosuppression. conclusion: our study group was heterogeneous with a large age distribution and different associated diseases. we identified new risk factors for fatal outcome in ah n patients (obesity and/or pregnancy) and exclude other diseases as risk factor for severe evolution (diabetes mellitus). we have to emphasise that in half of the cases, there were no comorbidities or special status to actuate the severity of the disease. these findings are reinforcing the statement that the novel influenza has a different behavior than common influenza. objective: we present the first case reporting the exceptional association of whipple's and crohn's disease. method: a -year-old man developed since diarrhea, abdominal pain, weight loss, and polyarthralgia. endoscopy showed aphthous ulcers in terminal ileum and colon. histology revealed a rich collection of epithelioid granulomas in the lamina propria with chronic inflammation. a diagnosis of crohn's disease (cd) was given and steroid therapy was administered. diarrhea and abdominal pain quickly subsided. perduring a severe weight loss, a gastroduodenal endoscopy was performed. oedema with whitish spots in the duodenum was observed. histology demonstrated lymphangiectasia and an infiltration of pas positive foamy histiocytes in the lamina propria. immunohistochemistry for tropheryma whipplei was positive. results: whipple's disease (wd) diagnosis was made and an antibiotic therapy was given. in respect to symptomatic improvement, persistence of the bacterium was demonstrated in the following performed gastric and duodenal biopsies. immunohistochemistry in previous ileal and bowel specimens was positive in the ileum. conclusion: in wd, the macrophages seem to be of central importance in the development of the disease. this infection shares with cd the pathogenetic hypothesis that a defect in cellular immune response contributes to the development of the disorder. evidences also suggest that bacteria play a role in the onset and perpetuation of cd. this case strengthens the immunological hypothesis in the pathogenesis of the disorders. the functional defect of the macrophages caused by wd can explain the amazing number of granulomas in crohn's-affected specimens. the double immunological defect due to cd and cd may contribute to the lack of eradication of the bacteria. objective: the aim of the study was to analyze the experience obtained during pathological diagnosis using digital microscopy and telepathology. method: there were microscopic examinations performed over the internet using a dynamic digital microscope nicon-coolscope, scanners aperio-scanscope and olympus dotslide, between january and march . the study included intraoperative studies, cytology specimens and oligobiopsies. the specimens were prepared and sent electronically by four cytotechnicians and assessed by five pathologists. all diagnoses were verified through routine, light microscopy assessments. results: in cases of intraoperative, frozen sections studies as well as oncologically positive cytological diagnoses, above % agreement was noted between the diagnoses made due to evaluation over the internet and the routine assessment. the agreement of % was achieved in cases of benign lesions and the assessment of bronchial surgical margins. conclusion: ( ) the efficiency of histological slide examination by sending digital images via the internet in cases of intraoperative frozen sections during thoracic surgery or to confirm "positive" results is comparable to the traditional assessment in a light microscope. ( ) application of this method enables surgeons at the hospitals which do not have a readily available pathologist to perform the surgical procedures. objective: optimum diagnosis of glomerulopathies requires light microscopy, immunofluorescence and electron microcopy. in fact, electron microscopy has a confirmatory role in glomerular diseases. in this study, the value of electron microscopy in the diagnosis of glomerulopathies in children was investigated. method: the contribution of electron microscopy to the final diagnosis was graded as necessary-diagnosis could not be reached without it; supportive-it increased the level of confidence in the final diagnosis; and noncontributorythe diagnosis does not need electron microscopy for confirmation. results: one hundred thirty-four cases of renal biopsy with some clinical data are reviewed. the contribution of electron microscopy to the final diagnosis was necessary in cases ( %), supportive in cases ( %) and noncontributory in cases ( %). conclusion: it is concluded that ultrastructural study was an essential tool in the study of renal biopsy in childhood glomerulopathies, suggesting that electron microscopy still remains a useful tool in the diagnosis of glomerular disease. ki- , p , p kip- , p and bcl- proteins were ihc-investigated in bph from all patients. results: the incidences of lpc (gleason score ), chronic prostatitis, proliferative inflammatory atrophy (pia) and prostatic intraepithelial neoplasia (pin) were . %, . %, %, and . % in group and . %, . %, . %, and . % in group , respectively. greatly elevated levels of p , ki- , and bcl- associated with decreased levels of p kip- and p in areas of pia and less lpc and pin in group compared with group patients were obtained with statistically significant differences. conclusion: our study suggests that chronic long-term low-dose radiation exposure might result in the increase of chronic inflammation, and it is now found to be associated with increased incidences of pia and pin in bph accompanied by p , p kip- , and bcl- alteration, which in turn could lead to prostate carcinogenesis. mixed peripheral ductal prostatic adenocarcinoma in radical prostatectomies: a five-year experience in a small spanish community hospital c we performed immunohistochemistry to characterise the expression of the immunoreactivity for synaptophysin, chromogranin, p , ki and cd . results: mean age of the patients was . ± . . thirteen ( . %) of the patients were males and eight ( . %) of the patients were females. the method of statistics we used was spss . . according to spearman's correlation test, there was a good correlation between ki- expression and tumor type (p< . , r = . ). also, there was a good correlation between p expression and tumor type ck and ki- immunohistochemical staining in gastroenteropancreatic neuroendocrine tumours of ( %) were g , of ( %) were g , and of ( %) g . four pancreatic tumours and six gi tumours had distant metastases. of the four pancreatic tumours, two were g , one was g , and one was g ; two stained diffusely with ck , while the remaining two showed weaker staining. three metastatic gi tumours were g and three were g ; allred score for ck was - in five of six ( %) pancreatic adenocarcinoma (pa) is a very rare lesion in young patients. patients in the age of or younger reported previously constituted < % of all patients with pa. the clinical and histopathological data concerning these patients are therefore scanty. the aim of the study was to describe characteristics of young patients with pa treated and diagnosed in a only cases with available original slides were included in the study. results: there were ( . %) cases of pancreatic ductal adenocarcinomas (not otherwise specified), two ( . %) cases of adenocarcinoma associated with intraductal papillary mucinous neoplasm and a single ( %) case of adenosquamous carcinoma. twenty ( . %) patients were males and ( . %) were females. median age of patients was . years (range - ). twenty-one ( . %) patients were treated with pancreaticoduodenectomy, three ( . %) with distal pancreatectomy, and two ( . %) with total pancreatectomy. in seven ( . %) patients, pa was diagnosed in open surgical biopsy specimen (the majority of these patients were treated with palliative surgery) objective: we analysed a series of upper gastrointestinal (gi) adenocarcinomas treated by neoadjuvant chemotherapy (ctx) between and , which all were consistently worked up and evaluated by a standardized tumor regression grading system (trg) in our institution. method: one hundred eight esophageal adenocarcinomas (ea), adenocarcinomas of the esophagogastric junction (aej) and gastric carcinomas (gc) treated by a cisplatin/ -fu-based ctx were included. trg was determined using a four-tiered system based on the estimation of the percentage of residual tumor in relation to the previous tumor bed. results: in total, patients ( %) had a complete tumor regression (trg a) and patients ( %) had a subtotal regression (trg b, - % residual tumor). partial tumor regression (trg , - %) was observed in cases ( %); patients ( %) had minimal or no regression (trg , > %). tumor regression was significantly associated with post-treatment ypt, ypn, ypl category, r status and survival (p< . ) and was shown to be an independent prognostic factor for survival (p= . ). some characteristics relating to the tumor site were, in particular, the higher frequency of total or subtotal tumor regression in ea and aeg (p< . ) and the association of pretherapeutic tumor grading and lauren's classification with tumor regression (p= . ) in gc. conclusion: we present our year's experience of a highly standardized evaluation of upper gi adenocarcinomas after neoadjuvant ctx demonstrating highly objective and prognostic relevant information from a very large collective. we recommend the implementation of a standardised trg system in every pathological report of these tumours. objective: fibroelastotic changes (fec) of the gastrointestinal tract (git) are rare lesions. only cases have been reported in the literature. their role as an own entity is unclear and is not generally accepted. method: after initial recognition of an elastotic lesion in a hemicolectomy specimen, special attention was paid to amorphic accumulations in h&e-stained slides of git specimens. elastica-van-giesson staining was performed to verify the elastotic origin. results: within years, a total number of polypoid lesions were collected. one lesion was found in the ileum and six lesions occurred in the stomach. the remaining cases were colon specimens. in five cases, fec were associated with neoplastic lesions. in cases, however, the accumulation of elastotic fibres was the only histomorphological finding. one patient received intensive short intervals surveillance because of a highly suspicious endoscopic finding in the stomach. in two cases, a clinical relevant stenosis was caused by a submucosal thickening of the bowl wall with massive accumulation of elastotic fibres. right hemicolectomy was performed in both cases. conclusion: fibroelastotic changes are not as exceedingly rare as thought before. they are the only histological finding in a certain number of polypoid lesions in the git. expression of p , vegf and collagen iv in gastrointestinal stromal tumors and its relationship with clinicopathological parameters s. rjabceva*, y. rogov, i. dulinez, m. vozmitel, a. krilov *belarusian medical academy, dept. of pathology, minsk, belarusobjective: gastrointestinal stromal tumors (gists) have a spectrum from minimal indolent tumors to sarcomas. the aim of this study was to assess the expression of p , vegf and collagen iv in gists and to establish immunohistochemical correlations with clinicopathological parameters. method: twenty-four cases diagnosed as gist were examined by both light microscopy and immunohistochemistry (ihc). we used ihc markers such as p , vegf and collagen iv. all tumors were classified by the risk grade system by miettinen et al. results: of the tumors, / . % were classified into low risk grade (lr), / % in the intermediate risk (ir) and / . % in the high risk group (hr). focal necroses ( %, % and %, respectively) and microhemorrhages ( . %, % and %, respectively) were present in gists of all groups. a p expression was correlated with a high risk grade (r= . , p= . ). gists of all groups showed vegf expression ( . %, . % and %, respectively).objective: novel influenza is an acute viral infection of the respiratory tract caused by type a influenza virus, affecting by now the entire world. although the illness is mild and self-limited in a great majority of cases, few patients may have a severe clinical course eventually leading to death. method: we studied necroptic tissue samples from patients submitted over a -month period from a total of , positive cases identified in romania since the outbreak of this type of influenza. data collected included demographic and clinical information. results: most of the patients ( . %) were adults between and years (median age, . years), male/female ration . : . the vast majority of the cases revealed diffuse alveolar damage, interstitial pneumonia and bronchopneumonia, all of them associating severe cytopathic effect in the bronchial and alveolar epithelial cells; cases presented pulmonary ischemic lesions. more than half of the cases ( . %) presented myocardial interstitial inflammatory infiltrate with full-blown picture of myocarditis in patients. of the patients, . % had lymphocytic depletion in lymphoid organs. lymphocytic meningitis, meningothelial hyperplasia, acute tubular necrosis, and liver steatosis were identified in some cases. objective: hpv dna has been identified in almost all cervical cancers, and women with active hpv infection (hpvi) express e /e oncogenes. as only a small proportion of infections progress towards cancer, it is important to distinguish transient hpvis from persistent or progressive ones. method: one hundred ninety-six samples were tested by conventional pap smear, hpv-dna test and typing, e /e -mrna expression from hpv types , , , , . kstatistic value was used in order to identify possible significant associations. results: pap-smear: negative (neg), ( . %); atypical cells of undetermined significance (ascus), ( . %); low-grade squamous intraepithelial lesion (lsil), ( . %); high-grade squamous intraepithelial lesion (hsil), ( . %). one hundred ninety-two of samples ( . %) were positive to the hpv-dna test and of ( objective: etiology of multiple sclerosis (ms) includes the virus infection which plays probably an important cofactor role in the pathogenesis of disease. clinical and morphological analysis of the cases of chronic herpetic meningoencephalitis (chme) and ms permitted to discover two cases of a combination of diseases: man, age years (onset of ms since years), and woman, age years (onset of ms since years). results: autopsy revealed the small plaques in white matter of brain and cord and some foyers of necrosis in frontal lobe and brain stem. the histological signs of chronic inflammation were established in both cases. leptomeninges and brain were infiltrated by lymphocytes and macrophages (perivascular cuffs). the progressive lesions of cortical neurons and proliferation of macroglial cells were constant histological findings. etiological diagnosis of chme was established on the base of typical intranuclear viral inclusion types i and ii in the cells of brain as well as on the revealing of hsv antigens in histological slice. laminar nonischemic necrosis was found in the cortex of frontal and parietal lobes. in the brain stem, necrosis appeared as the small foci of destruction of nervous tissue. in one case, laminar necrosis were detected in white matter of hippocampe. conclusion: thus, the morphological investigation on the light microscopic level permits correctly to recognize the combination of ms and chme. key: cord- - mv x w authors: boin, arjen; fahy, lauren a.; ‘t hart, paul title: guardians of public value: how public organizations become and remain institutions date: - - journal: guardians of public value doi: . / - - - - _ sha: doc_id: cord_uid: mv x w it’s an institution—a phrase we have all come across or may have used. we intuitively understand what it means. there is something special, perhaps mythical, about them. we value these institutions. we may even find it hard to imagine a life without some of these institutions. in this chapter, we offer a definition of institutions and introduce our theoretical framework (based on the work of philip selznick). we introduce the case studies in this book and identify patterns of institution building. perhaps mythical, about them. we value these institutions. we may even find it hard to imagine a life without some of these institutions. some public organizations, too, have achieved this special 'institutional' status: organizations that-in the words of philip selznick ( : ) , the pioneering scholar of institutions-have become 'infused with value beyond the technical requirements of the task at hand'. institutions embody and safeguard certain values that are important to a society (hendriks ) . institutions guard these values against overt attacks and the forces of erosion. the average citizen may never wonder about the critical importance that these public institutions play in their lives. at the same time, academics hardly ever question the importance of institutions. it is simply assumed. this combination of limited public interest and academic conventional wisdom has done little to further research into the way institutions emerge and persevere. in their efforts to protect their institutions, leaders cannot fall back on a full body of academic research findings. such protection is increasingly necessary. government agencies as well as other public sector organizations today face a climate where performance expectations are relentless, transparency and accountability regimes have thickened, and there is little tolerance for failure. critical factors in the broader environment-technology, economic tides, societal beliefs and values, political fault lines and 'rules of the game'-change constantly, sometimes rapidly and deeply. no institution, however powerful and wellregarded, is immune to 'events' and to the churning tides of public opinion. even long-standing institutions face reputational and sometimes existential crises. yet, even in this volatile environment, some public organizations remain deeply valued by the public. they have not just survived challenges and controversies; they have found ways to thrive. they have adapted in the face of crises, preserving their institutional character while meeting newly imposed demands. they have become iconic features of the public landscape. that's why we call them public institutions. this volume is about these public institutions. we have selected twelve organizations that have met selznick's definition for at least a significant part of their lifespan. we examine each of these twelve institutions in some depth to understand their nature, formula and impact. we seek to show what scholars and organizational leaders can learn from them, warts and all. the overarching puzzle that drives the case studies collected here is simple: in this introductory chapter, we explain how in selznick's work and of those that have followed in his footsteps institutions differ from organizations. we then describe the key conceptual and analytical tools that have informed the case studies in this volume, and briefly introduce each of the cases. next, we present a thematic preview of the institutional patterns that emerge when we look across the twelve case studies. we offer these patterns as pointers for classroom discussion, but also as starting points for more empirically informed theorizing about how and why public organizations become institutions (and how they can also 'deinstitutionalize'). finally, we ask a pertinent and perhaps uncomfortable question: can public organizations that effectively and authoritatively guard public value and receive widespread recognition for doing so, continue to flourish in our turbulent and more unforgiving age? when we see one? we use the concept of institution to describe a particular category of organizations. an organization is, in essence, nothing more than an established way of cooperation between two or more individuals (barnard ) . what sets an organization apart as an institution is its pursuit of aims that are widely considered to fulfil a societal need, its reliable performance over time, and its exemplary conduct as perceived by societal constituencies. the cases in the book provide powerful illustrations of these institutional characteristics: • the bbc has been producing a judicious and widely respected mix of news and entertainment, has built itself into a global media brand while adapting successfully to major technological (such as satellite and online television) and regulatory changes (introduction of commercial broadcasting). • the scientific centre for particle physics research cern has gained international recognition as the hub in its field, has kept on pushing the boundaries of knowledge, has educated generations of influential researchers and has sparked the public's imagination both through its mammoth underground research facility (the large hadron collider) and its discoveries (the higgs boson particle) as well as through its spinoff technologies (such as the world wide web). • médicins sans frontières (doctors without borders) has been much acclaimed for its fearless commitment to providing medical care to populations caught in complex and devastating conflicts around the world. it has become a beacon of courageous behaviour in very challenging and dangerous circumstances. moreover, it has repeatedly called attention to the follies and excesses of the humanitarian aid industry, and in doing so has become its moral conscience. these examples suggest that there is something special about institutions: they are regarded as more valuable than just any organization. goodsell ( a: ) refers to mission mystique, which he defines as an organization's 'aura of positive institutional charisma that is derived from the nature of its mission and how well it is carried out'. aura is, of course, a matter of perception: people must recognize something special in what an organization does and how it performs its tasks. this subjective dimension of institutions makes it challenging for social scientists to arrive at a more systematic way of establishing why and to what extent an organization can be categorized as an institution. but it is a challenge that has to be met. selznick's ( ) classic distinction between organizations and institutions provides a helpful tool in this endeavour. he formulated three criteria that can help us identify the institution in a population of organizations (see fig. . ). selznick's framework can also help us track and interpret institutional trajectories: how an organization takes on institutional characteristics and how an institution may deinstitutionalize. let's have a look at these three criteria. distinct identity and unique competence. an institution has a clearly developed and widely recognized identity that communicates to both its members and the outside world what it seeks to achieve and why, what the dominant practices in the organization are, and how it addresses conflicts that occur in the pursuit of its aims. mark moore ( )a self-confessed selznickian-speaks about identity in terms of a 'value proposition' and refers to institutional competence as the 'operational capacity' of an organization. an institution's identity and competences are well-suited to meet societal aspirations and expectations. an institution has fostered a strong alignment between the rationale for its existence and the day-to-day strategies and practices it deploys. this alignment is strong reputation, high legitimacy. an institution is trusted and respected, to such a degree that its existence is sometimes taken for granted. employees are proud to work there and intrinsically motivated to contribute to the cause. the institution's external stakeholders- moore ( ) speaks of an 'authorizing environment'-support the institution through thick and thin by what they say and do. they provide funding, procure its products and services. they trust it to do the right thing in the right manner. they forgive its occasional lapses, to a much greater extent than they would for an organization not endowed with mission mystique. it is hard to imagine that anyone would even propose to abolish it. enduring viability through adaptation. an institution has adaptive capacity, which helps it to stand the test of time. this is not just about changing structures and practices to make the organization more effective or efficient. institutions have the paradoxical ability to change in order to remain the same-changing whatever must be changed to protect the institutional core (ansell et al. ). an institution can consistently deliver on its mission, working in ways that reaffirm its value proposition and satisfy the evolving expectations and norms of its stakeholders. it does what most public organizations find really hard: adopting and implementing reforms that prove to be effective. an important recent study that provides support for much of what selznick was proposing, albeit cast in slightly different language, is that of charles goodsell ( a, b) , who examined the organizational history and development of 'mission-driven' public agencies in the united states, including such iconic institutions as nasa and the national forest service. he provides an in-depth, case-oriented study of what life in public institutions looks and feels like. table . gives us goodsell's matrix of cultural characteristics and organizational practices that his institutions all shared. it provides a useful elaboration of selznick's institutional characteristics. the combination of selznick's and goodsell's institutional characteristics allow us to make a snapshot of any organization in order to determine whether, or to what extent, it qualifies as an institution. importantly, the three criteria can be applied in a dynamic manner: we can 'shoot' a film of the institution's development by applying the criteria at several points in time. that film would show the ebbs and flows of an organization's goodsell ( a: ) institutional status, identifying periods of strong institutionalization but also periods of institutional decline. such a dynamic perspective on institutional development is crucial. institutions are never born as 'institutions', though their architects and foundational leaders may have high hopes for them. they become institutions. they see the light as a small social group, a budding network, a small organization; some develop and gain institutional characteristics. we refer to this as a process of institutionalization (boin and goodin ) . but just as an organization can take on institutional characteristics, an institution can also lose institutional characteristics. institutions can deinstitutionalize (oliver ; suchman ; boin and 't hart ; boin ). its mission can become less relevant, or diluted by mission creep. mission creep refers to the widening of the mission, adopting new ambitions and tasks that distract from the original aims. also, the organizational structure, culture and established practices may lose relevance, hindering rather than helping to achieve the mission. the institution can become ridden with internal conflict, or lose touch with its authorizing environment. institutionalization brings enormous benefits for public organizations. it helps to bind members to a common cause, thus diminishing the transaction costs in the organization. it buttresses against the winds of fashion, as the high level of legitimacy effectively grants a degree of autonomy so that leaders of an institution can chart its course. institutions inspire confidence in those to whom they are accountable and as a result are less scrutinized than other organizations. when an institution is found to have failed or strayed, it is forgiven for more and for longer than organizations that lack their charismatic aura. institutions are, in other words, better prepared to weather the storms of failure, scandal and crisis that any organization faces in its lifetime-provided, as selnick ( ) reminds us, that they remain responsive and adaptive to the environments they work in and from which they derive their public licence to operate (in fact, selznick identified this as the most difficult leadership task). institutions also benefit society. they fulfil certain functions in ways that are appreciated by that society. as the case studies in this book will show, these functions can vary widely. the institutions discussed in this book: • provide fair elections • protect against corruption • offer a trusted source of news • preserve the value of money • create a legal framework that benefits collaboration • preserve cultural traditions • protect the integrity of sports • create conditions for path-breaking research • protect a society against disaster • assist helpless victims of disaster • foster a shared interpretation of complex research findings. a society needs institutions to ensure that we will have fair elections in the future, that we may expect a continued stream of validated news, that we can trust research findings, and be confident that future disasters will not cut the lives of citizens short. but institutions do more than fulfilling useful functions. they guard against the erosion of these functions and protect the values that underlie them. institutions are the guardians of a state's promises; they preserve a society's hopes and ambitions. our fascination with institutions builds on two empirical observations. first, it has been observed that a minority of public organizations live a long life. a majority perishes (a sizeable chunk does not even make it longer than a decade) (lewis ) . second, only a handful of those survivors meets the institutional test set forth by selznick. we therefore conclude that public institutions are exceptions or outliers. we want to get to know these outliers. a key challenge for institutional scholars is dealing with the normative connotations that come with the "institution" concept. we generally reserve the term 'institution' for an organization or a cultural practice that is valued-this is, indeed, exactly how we defined the institution. but what is valued by many, may be highly controversial to others. what is valued in one society is anathema in another. an organization revered in a certain era, may today be discussed as an example of malpractice or organized evil. selznick's three criteria do not resolve this normative conundrum. take, for instance, the federal bureau of investigations (fbi). when applied in a broad-brush, across-lifespan fashion, selznick's criteria would have us regard it as an institution. the fbi has a distinct identity: most people (not just americans) have heard of the fbi and will have an idea of what it represents. the fbi has a unique competence and has existed for a long time. at the same time, it is easy to unearth a range of questionable values it espoused and activities it deployed for extended periods of its existence. for example, the latter decades of long-serving and founding director j. edgar hoover were marked by practices that are now widely recognized as questionable if not outright illegal (jeffreys-jones ) . so what does this mean for selznick's criteria? what does it mean if organizations with dubious identities and questionable competences qualify as an institution? should we reject these criteria and look for others? should we avoid institutions that today are widely viewed as epitomizing questionable values? we feel that selznick's criteria can still be used, but their use needs to be directed and qualified by situating organizations in a particular window of time and then assessing to what extent the institution embodied, advanced or provided stewardship of values deemed important by the society in which it existed. we must take into consideration that the value sets that stakeholders and the community at large apply to an organization can and do change over time. institutions, in other words, are to be taken as organizations that have become effective and legitimate 'guardians of public value' in a certain time and context. when removed from that time and context, certain institutions or certain epochs in their existences or certain practices in which they engaged may well be considered dangerous or deplorable. the intriguing question is how such morally problematic organizations could maintain high levels of internal and external legitimacy at the time (cf. selznick ) . if we suspend judgement, we can learn-even from institutions that in our time and context may look questionable-valuable lessons about their emergence, their value proposition, their governance, their 'formula' for success, their ways of acquiring a public licence to operate, their ways of navigating conflict and tensions, and in some instance, their decline and downfall. an institution tells us something about the society it emerges from and exists in. this is also true for the cases included in this book. the fact that these particular organizations have ended up as specimens of 'guardians of public value' does not mean that we hold them up as being exemplary all of the time and in each respect. most institutions go through periods of mission ambiguity and conflict; they are sometimes at a loss to develop distinctive competence and sustain effective practices, and they may have found it hard at times to adapt to significant changes in their context. each case study will therefore situate the story of the institution in time and space, and treat its institutional (and normative) status as a variable and not as a given. in this book, we study institutions that have done things and done them in ways that were of value to society and were indeed valued by their authorizing environments. moreover, they have not merely 'created public value' (moore ) and gained recognition for doing so, but continued to do so for considerable periods of time. they have acted not just as creators of public value, but as its guardians. our aim is to introduce a set of sensitizing concepts in this opening chapter and see if they can help students, researchers and practitioners grasp and interpret the dynamics of institutionalization that have contributed to their lofty reputation and social status. we are obviously not the first to study organizations as institutions. selznick's work inspired a series of detailed studies and theories that explain how organizations become institutions (diiulio ; wilson ; boin and goodin ; boin and christensen ; goodsell a, b) as well as accounts of how they become deinstitutionalized (boin and 't hart ; alink et al. ; collins ; mair et al. ; ansell et al. ) . there is an entire library of institutional study material, both theoretical and empirical, in many different languages and in different disciplines. this research helps to explain why some public organizations (and not others) become-and remain-institutions. more specifically, it helps to answer three big questions that institutional scholars have endeavoured to answer. • how do institutions emerge? what are the drivers of institutionalization? under what conditions does institutionalization happen? do organizational characteristics matter? does it matter in which 'niche' the organization operates? is institutionalization an outcome of leadership? or funding? particular environmental demands? happenstance perhaps? • how do institutions stay strong and relevant? institutions have to perform a balancing act: distinctive (and cherished) competences must be wielded to satisfy societal expectations and perceptions of their performance. but societal expectations and perceptions of public organizations rarely remain fixed over long periods of time. this simple observation means that institutions are always vulnerable to contextual changes. they must, in other words, adapt to remain an institution-they must remain attuned to changes in both their operating environment (e.g. technological innovations, new products and services, competing organizations) as well as their authorizing environment (e.g. political power structures and governing philosophies). to adapt is also to risk alienation from societal expectations and perceptions. becoming an institution may be one thing, remaining an institution is quite another challenge. • what explains their decline and downfall? many long-standing institutions have 'lost it' and declined into oblivion. whether we think of the roman senate or the dutch east india company, it's clear that these were institutions in their time, remained institutions for a long time, and no longer exist. that prompts the question why institutions lose it. do they somehow lose their capacity to adapt to changing expectations? do their leaders succumb to hubris, dragging the institutions away from society? or are these institutions faced with shocks that are so large and sudden that timely adaptation is simply impossible? these three research questions have been studied by different theoretical traditions of institutional analysis that have been extensively described, summarized and compared elsewhere (peters ; scott ) . to give an impression of the variety in explanations offered by students of institutions, let us just mention four dominant schools here. philip selznick was a pioneer of what is called classic institutionalism. this school focuses on organizations (as pillars of what they called the organizational society), seeking explanations for their emergence, functioning, effects and survival (see f.i. thompson ; wilson ). as we have seen, selznick famously explained how and why institutions differ from 'mere' organizations. this happens when the organization is deeply valued by its employees, stakeholders, political leaders and the public. in explaining the emergence and downfall of these institutions, this approach pays a lot of attention to organizational leaders and the strategies they employ to maintain a relation between their organization and its environment. research in the tradition of new institutionalism shifted attention from the individual organization to a class or type of organizations (meyer and rowan ; deephouse and suchman ) . where selznick might focus on oxford university as an institution, new institutionalists would focus on the university (sui generis) as an institution. this school has done much to conceptualize the political and social environment in which particular types of organizations do or don't evolve into institutions. the key idea is that organizations assume institutional properties by adhering to an 'ideal-type' that reflects how a society thinks about that type of organization. through processes of 'isomorphism' these organizations are thought to adopt the required characteristics without necessarily changing the way they conduct their core business. while the new institutionalists revived a scholarly interest in institutions, this school of thought has less interest in our core question: why do particular organizations become and remain institutions whereas others flounder and perish? in recent years, a small group of political scientists became interested in the survival chances of public organizations. inspired by the pathbreaking work of herbert kaufman ( ) , david lewis ( lewis ( , built a database of us public agencies to test a theory that predicted 'survivors' would have different birth characteristics than non-survivors. a key assumption is that 'normal' organizations are perennially prone to capture, politicization and restructuring (carpenter ) . they can only survive these pressures, or so the theory goes, if they are 'hardwired' against efforts to terminate or co-opt the organization. the premise of this design school has found empirical support: birth characteristics do seem to matter, as they raise survival chances. but they cannot explain which particular organizations will survive and which will perish. subsequent research has shown that design factors can only explain so much. population ecology scholarship, for instance, also seeks to explain why some public organizations survive over time whereas others fold (kaufman ; boin et al. ; kuipers et al. ; van witteloostuijn et al. ) . ecological studies are highly focused on structural and environmental factors. these studies offer support for the design school, but also suggest that there are other factors at work at the population level. their studies reliably show that the 'carrying capacity' of a population is probably the most important factor in predicting survival chances. both the design school and the population ecologists tend to deemphasize the potential role of behavioural and cultural factors in explaining institutionalization. precisely those factors emerge in case studies of organizational and entrepreneurial success in both the public and corporate world (lewis ; peters and waterman ; doig and hargrove ; collins ; malone and fiske ) . also, there are many organizational biographies that describe the genesis, purpose and inner working of public and private institutions, offering in-depth accounts of their performance, legitimacy and endurance (kaufman ; boin ; wetterberg ; carpenter ) . these biographies are not designed to draw general lessons or make comparisons. but they make clear that political and organizational leaders can affect the course of institutionalization. we began this project with a set of ideas that may explain why and how some organizations with a public purpose or public relevance end up acquiring mission mystique and become widely viewed as guardians of public value (and thus also why other organizations do not achieve this). first, we don't think institutions materialize by happy circumstancethey have to be created, maintained and protected. that requires a form of leadership, both within the organization and in its authorizing environment. at the same time, we do not believe that, as the design school implies, institutions are 'created by blueprint'. institutions arise from organizations because they have the capacity to adapt and bounce back from the inevitable crisis. this requires a culture that is conducive to experimenting and learning (de geus ; goodsell a, b) . second, we are convinced that a public organization cannot do without some minimal level of legitimacy (suchman ) . organizations become institutions because they enjoy high levels of legitimacy for long periods of time. while legitimacy is granted (or not) by those whose views count, organizations can actively work to earn that support. they can systematically regain it when it is has been compromised or lost; if these efforts are successful the organization re-institutionalizes. in summary, we see an important relation between leadership and the process of institutionalization. we view institutionalization as a process that is at least partially spontaneous and unplanned. organizations are not designed with a goal in mind to become an institution. but that does not mean that institutionalization simply happens, as a resultant of favourable circumstances or a dose of luck. following selznick, we view institutionalization as an evolutionary process, which can be influenced but not fully controlled by organizational elites (boin and christensen ) . leadership is important as it guides, facilitates and shapes the process of becoming an institution. it is also critical for protecting the institution against the 'forces of fragmentation' (kaufman ) . we conceptualize leadership as a collective endeavour by organizational elites to fulfil a set of tasks (cf. 't hart and tummers ). leadership is not the property of the one individual who happens to occupy the highest rank in the organization. this helps us to escape from simplistic assumptions that institutional success is related to a particular leader (even if that leader stars in the organization's mythology). at the other end of the continuum, we must be careful to relate lapses and pathologies of leadership directly to processes of deinstitutionalization (cf. padilla et al. ; helms ) . in summary, we follow selznick in assuming that organizational leaders can guide the process of institutionalization in three ways (selznick speaks of three executive tasks). a key challenge for any public organization is that it must deliver on its formal (legal) assignment (or policy goals) while serving societal values and aspirations. if the organization solely seeks to deliver what it is built to deliver, the organization can quickly become redundant upon completion of the mission or shifting policy priorities. organizations become institutions when they are perceived to embody societal ambitions while delivering on formal aims. to combine both is no easy task and will require tough choices-in a world of scarce resources, diverging preferences and bounded rationality, more often than not something will have to give. making these choices amounts to a process of character building, which shapes the identity of the budding institution. leaders can help shape this process, by facilitating experimentation that helps to discover the organization's identity and by making critical decisions (boin and christensen ) . leaders also play a key role in communicating a sense of purpose, which keeps the organization aligned, determined and hungry. an organization with a mission needs people (professionals) who fit what the organization is trying to do. selznick made an important point: professionals have to buy into the mission and believe in the underlying values that anchor the institution (cf. kaufman ) . this is especially true for public institutions, in which profit and competition cannot be the motivational drivers of the enterprise. leaders of public institutions need to evoke and harness the 'public service motivation' of their employees (perry and hondeghem ) . when professionals identify with and are energized by the mission, the management is relieved of the burdensome task of command-and-control duties. a high level of decentralization is then possible, as coordination is achieved through shared values (that functions as a 'software of the mind'). the acid test is employees who proudly talk about their work and institution during birthday parties (cf. dilulio ) . institutions, by definition, enjoy a high level of legitimacy. they are valued by their stakeholders and, as often is the case, by society at large. it is a task of institutional leaders to protect and strengthen that relation. in doing so, leaders will face an inherent dilemma that will have to be negotiated time and again. institutions enjoy a high level of legitimacy because they perform a task in an effective, consistent and highly valued way. successful institutions are therefore not inclined to change their practices (which have been proven to work). but societal ambitions and preferences change. however well an institution may perform, they will be confronted with a 'performance deficit'-the gap between societal expectations and perceived performance-sooner or later. if the deficit becomes too wide, an institution faces declining trust and may experience what we have labelled an institutional crisis (boin and 't hart ) . continuous adaptation of mission and work practices is therefore necessary. but such adaptation can rock the internal balance-the shared professional pride-that gives rise to its performance. when an institution changes slowly, it may be forced into reform; when it changes too quickly, employees may rebel. it is a leadership task to preserve a sensible balance. this volume brings together case studies of very different organizations that managed to become institutions and have maintained their institutional status in the face of pivotal challenges, controversies and crises. a multidisciplinary cast of subject matter experts, guided by a shared analytical framework, provide educators and students with a rich array of teachable case studies. the starting assumption underlying this volume is that many factors can shape the trajectory of institutionalization. birth characteristics likely matter, as do the circumstances in which the institution saw the light. leadership matters, both within and around the institution. other institutions may cast their shadow. the same is true for historical contingencies. in short, we do not think it makes sense to hew closely to one particular school of thought, entering into a shadow boxing match with other theoretical schools. it is in this vein that we 'instructed' our authors: we gave them the freedom to identify and analyse factors that seemed to matter most in their individual case-leaving the door open for answers that we have not heard before. each chapter describes the story of an institution: its origins and early years; how it coped with change, adversity and crisis; the role of design, choice, chance and learning in these institutional trajectories. each chapter has something to say about institutional leadership, in particular its balancing act of aligning mission, capacity and support in the face of ever-changing environments. we selected cases that we could reasonably expect to have institutional characteristics (for at least a considerable part of their life spans to date). we also set out to include a wide variety of organizations. our cases cover: • governmental and non-profit organizations from a variety of countries and regions. most cases are situated in the western world, but there are also cases from singapore and india. • very old and relatively young organizations, ranging from the swedish national bank ( ) we selected these cases for pedagogical and not for theory-building or hypothesis-testing purposes. we chose this variety of cases to give instructors and students alike a menu for choice. cases were selected to allow readers to compare two or more most-similar cases, most-different cases, or other clusters of like/unlike characteristics. readers should be able to draw on cases to identify patterns or perform plausibility probes on theoretical claims about institutions and institutionalization. moreover, readers should be able to examine the impact of factors such as institutional contexts, organizational capabilities and institution-building leadership strategies. the authors have been selected because they are experts on 'their' institution, not because they subscribe to our analytical framework. each chapter loosely works around the framework set out above and thus actively encourages the reader to interpret the dynamics of each case. the volume offers case histories of the following organizations: the indian electoral commission has stewarded free and honest elections in the most populous and complex democracy on earth. the commission successfully manages more than . million voting machines, , voting centres, . million government and . million civilian election employees, and more than half a billion voters. the story of its institutional development is one of mandate expansion: institutional leaders using the legal system to enhance the powers it can wield during election time. singapore's corrupt practices investigations bureau was established in to battle the rife corruption present in all sectors of the public service, where bribes, favours and nepotism were fundamental norms of 'doing business'. the bureau had to earn its stripes fighting corruption among the country's most powerful individuals: both in the police force and in the parliament. through a record of successful actions against corrupt individuals, the agency gradually developed substantial authority to investigate any case in which corruption may be involved. the bureau has been a driving force in making singapore one of the least corrupt nations on earth. the british broadcasting corporation (bbc) is one of great britain's most venerable public institutions. it is also the world's oldest (created in ) and largest national public broadcaster (in terms of employees as well as its global reach and authority). through its coverage, the bbc has documented and shaped the transformation of british society. it has maintained a reputation for impartiality and journalistic integrity. it has successfully weathered challenges, incidents and crises and continues to define the standard for quality broadcasting. celebrating its -year anniversary in , the swedish riksbanken is the oldest central bank in the world. its independence from government waxed and waned over time, and finally became firmly cemented in . its public authority helped sweden survive the terrible economic crisis. in response to the global financial crisis that started in , it was the first central bank to adopt negative interest rates to stimulate economic activity. in , it announced that it was considering issuing e-krona, electronic currency (the first central bank to do so). the european court of justice (ecj) is the undisputed guardian of the european union's transnational legal order, issuing landmark rulings and generating jurisprudence at a considerable pace. it was created in and has the power to invalidate the laws of eu member states when those laws conflict with eu law. the ecj serves as the final arbiter of the growing body of international law that has accompanied the economic and political integration of europe. it always faces the challenge of maintaining its authority and legitimacy when the eu's ideals and institutions come under pressure. the amsterdam concertgebouw orchestra has historically been rated as one of the top symphonic orchestras in the world. founded in , it has had only seven chief conductors. it has found ways to balance the twinned but often conflicting imperatives of artistic excellence and financial viability. it remains dependent on government funding, which in the early s became highly uncertain, triggering a mood of crisis that required astute management. the world anti-doping agency (wada) promotes, coordinates and monitors the fight against performance-enhancing drugs in sports. wada's key activities include scientific research, education, development of anti-doping capacities and monitoring of the world anti-doping code. among the youngest organization in our set of cases, it came into being in as an independent foundation with a hybrid public-private structure. it is the chief guardian of the world anti-doping code that has more than signatories, including many states as well as international sports foundations. its work has gained global recognition as contributing significantly to key values in sports such as fair play and the protection of athletes' health and well-being. founded in and based in geneva, the european organization for nuclear research, better known as cern, is a remarkable example of enduring international scientific cooperation in pursuit of one of the most elusive goals ever embraced by any organization anywhere, one that requires sustained and large amounts of public funding. among its key accomplishments are the pioneering of internet technology, the creation of the world wide web, several nobel prize-winning staff members and the discovery of the higgs boson particle. founded in during the french occupation, rijkswaterstaat, the directorate-general for public works and water management of the netherlands, has evolved into an iconic institution. its defining accomplishments are in the area of water management-digging canals, building and maintaining dikes, reclaiming vast tracts of land from the sea ('polders'). its planning and engineering feats are essential to the survival of a country where more than % of its territory lies below sea level and another % is highly exposed to flooding. the institution faced major adaptive challenges when its 'safety-first' paradigm was challenged by the rise of environmentalism. as it strives to transform itself, climate change is presenting another key test of its resilience, ingenuity and collaborative capacity. few humanitarian aid organizations enjoy a global public standing like médecins sans frontières (msf) has. described as the most important humanitarian organization and conscience of the humanitarian world, msf was awarded the nobel peace prize in . it displays a fierce sense of independence. throughout its history msf has often acted controversially, going public with its knowledge about atrocities committed by parties to the violent conflicts in which it operates, as well as explicitly challenging the humanitarian sector's own practices and principles. the intergovernmental panel on climate change (ipcc), founded , is the international body that reviews the latest science and produces assessment reports which inform international negotiations on climate change. it is tasked with establishing a consensus between climate experts and governments, communicating knowledge on climate change to policymakers, negotiators and the public, and for making recommendations on potential courses of action. the ipcc and al gore were co-recipients of the nobel peace prize. the ipcc has also been criticized at times for its work and is a target of climate sceptics. the ipcc's reputation was damaged when its leadership failed to respond effectively to mistakes found in its report. since then it has worked to restore confidence. its reports have been very important in the un climate negotiations and strongly influenced the goals of the paris agreement. within a decade of its inception in the australian competition and consumer commission (accc) had become a trusted institution in the australian regulatory landscape. the product of a merger, the accc soon carved out and dramatized its mission as a crusader for levelplaying fields and fair play in markets. by successfully taking on some of the biggest corporations in the country in both the courtroom and the court of public opinion soon after coming into existence, the new authority quickly gained notoriety. by asserting its independence from political interference, it gained public credibility in a country that has long held its political class in low esteem. the accc has subsequently conserved its enforcement mission by adapting to challenges in the political and business environments, expanding and redirecting its repertoire for regulatory action, and broadening its consumer and small business constituencies. this book revolves around a central puzzle: why do some public organizations become-and remain-institutions? our relatively small and purposefully skewed set of case studies does not allow us to systematically test hypotheses, nor to generalize insights to larger populations of organization types. that said, what we can do is inductively identify possible patterns and relate them to conventional wisdom in academic theorizing and the world of practice. in interpreting these patterns, we can discern possible scope conditions or social mechanisms that may be at play in bringing about the institutionalization (and deinstitutionalization) of public organizations. more specifically, our cases provide food for thought with regard to four often-mentioned patterns of institutionalization. to help readers interpret the case studies, we will now discuss our observations in more detail. in his study of highly successful corporate organizations, jim collins ( collins ( , found that these organizations had one critical characteristic in common: they have in place what collins refers to as a flywheel. collins is, in essence, talking about what across the social sciences has been called a virtuous cycle: a set of processes that reinforce one another (sitkin ; finnemore and sikkink ; boin and christensen ) . within an institution, the virtuous cycle might look like this (see fig. . ): • the cycle starts with the discovery or invention of an effective, efficient and legitimate way to reconcile organizational aims with societal aspirations. this typically happens through a mix of experimentation and smart copying. • successful practices give rise to the emergence of an internal norm: this is how we do things around here. and legiƟmate pracƟces to perform its societal task condiƟons that enable successful pracƟces become internal norms of 'how we do things around here' internal norms serve as lever to purposefully recruit and socialize highquality, highly moƟvated staff effecƟve and dedicated staff help organizaƟon perform well and insƟll confidence in its authorizing environment organizaƟon is wellfunded and enjoys relaƟvely high autonomy to act, experiment, learn and grow • the internal norm makes it easier to recruit and train the right people, which facilitates cohesion and effectiveness. • effective and dedicated people make the organization look good. this results in enhanced funding, support for the mission and strengthened autonomy. • a strong and legitimate organization performs better, which solidifies the internal norm. our case studies bear witness to this virtuous cycle of institutions. consider the following three examples: the intergovernmental panel on climate change (ipcc) began as an informal collaboration of scientists who worried about climate change. by establishing a network of committed and reputable scientists, they created a platform for policymakers to learn about causes and potential solutions. the ipcc established 'input and output legitimacy of the rigorous and extensive process by which the ipcc's teams of expert authors and peer reviewers carry out their work' (paglia and parker, this volume), which increased its epistemic power and reputation. their reports helped to spread awareness about ongoing climate change, which, in turn, led to increased demand for evidence-based science. the growing interest of policymakers (prompted by growing awareness about the threat) helped to mobilize scientists who recognized a podium for their research. the density of scientific expertise secured privileged access to policymakers, which enhanced the importance of the ipcc. singapore's corrupt practices investigations bureau (cpib) began as a small police unit seeking to root out corruption among colleagues. when it busted a drug ring that was run by the police, the cpib became an independent statutory authority. its autonomy enhanced its investigative powers, which were widely and effectively applied. the success of the cpib came to define singapore's status as a 'clean' state. singapore's enhanced international standing reflected back on the cpib, which saw its autonomy and authority strengthened. decades of successful investigations and prosecutions have embedded the institution in singapore's landscape (and indeed in the esteem of the international community). the cpib's effectiveness and singapore's reputation went hand in hand, reinforcing each other over the decades. the world anti-doping agency (wada) was created to address the protracted doping crisis of the s. its chances of success seemed low. but it soon began to command the respect of its stakeholders, initially by formulating standards that made sense. as governments and sports foundations began to accept the standards, they also legitimated the agency. as the agency gained in stature, it could enlarge its role in the global fight against doping. the enlarged role translated into visible successes, which further strengthened its reputation. quite incredibly, the wada managed to become an undisputed authority in the international field of sports. its role in other sports organizations became entrenched, which further helped the standards to take root. institutionalization does not just happen; virtuous cycles do not simply materialize. this prompts the question if and to what extent the actions of leaders matter when it comes to the institutionalization process. the chapters in this book do not give rise to a new or definite take on this critical question. but they certainly provide powerful illustrations of leaders forging practices, crafting norms and protecting the identity and integrity of their organizations-and they show that this can be done in different leadership configurations and employing different leadership styles. let's look at some examples to illustrate this variety: the institutional history of the amsterdam concertgebouw orchestra cannot be written without recognizing its early and long-serving conductor willem mengelberg. he was the archetypical institution builder, translating the aspirations of the founding regents into an ambitious and appealing musical vision for the orchestra. mengelberg then translated this vision into an unprecedented and uncompromising regime of excellence that produced both classical and contemporary symphonic music, while building an international audience. by placing his orchestra squarely on the map, mengelberg forged a broader authorizing environment for his orchestra, extending well beyond the original group of regents. the european court of justice (ecj) began as a technical tribunal. it was hard to imagine at the time how this small court in luxembourg could become an institution, creating conditions that today make european integration a seemingly one-way road. this did not happen because of one leader. it happened because a group of judges-all appointed sometime in the early s-shared a vision and began to build the ecj in light of that vision. these judges were well-known professionals who moved in the insulated elites that pushed for european integration. without seeking the limelight, they exerted the leadership of true institution builders. the founding commissioner of the australian competition and consumer commission, allan fels, not only brought academic expertise and long regulatory experience to the job, but also a brisk determination to give the new agency the institutional clout its predecessors had often lacked. painstakingly independent and politically neutral, fels used the media to create a powerful platform for the accc's 'naming and shaming' of big corporations that engaged in anticompetitive or manipulative behaviour. in prosecuting and winning high-profile cases, he instilled professional pride in its staff and ensured the accc became a highly visible and impactful crusader for consumers. institution building is more than formulating an evocative mission. professionals must be seduced and coaxed to accomplish the mission (leaders cannot do it by themselves). this can be an arduous job, as the chapters suggest. institutions are not, by definition, happy families (certainly not all the time). a public institution must find ways to harness conflict in ways that make it smarter and stronger (coser ). the chapters show how institutions do not always suppress conflict, but manage to canalize it. the european organization for nuclear research (cern) did not become a celebrated scientific institution without tension or strife. bringing together the best scientists in the world and have them compete for funds can be a recipe for disaster. cern developed a form of shared leadership, which allowed this international community of super-smart scientists to evolve 'norms and practices of balance-seeking': balance between funding member states and the spending cern administrators. balance between small and large contributors. balance between centralized lab and infrastructure funding and bottom-up funding of the experiments. balance between getting on with current work and preparing the ground for taking on new challenges and realizing future ambitions that are decades away. balance between the scientists' advances in fundamental physics and the engineers' development of the technological tools required to test them. balance between running a tight ship financially and maintaining the ability to respond flexibly to financial setbacks or emerging expenditures. balance between the patience required to do the work necessary to achieve major scientific breakthroughs and the need to be seen to be active, relevant and impactful in the present vital to maintain the institution's global public and political support base. balance between banking on the authority of established scientific leaders and on empowering the innovative irreverence of emerging research talents. (engelen and 't hart, this volume) the governance of the concertgebouw orchestra has been marked by decades of tension between protagonists of its artistic aspirations and business managers seeking to ensure the organization remained financially viable. it describes how mengelberg, the legendary conductor, waged no-holds-barred battles with a succession of business managers and artistic directors who had the temerity of proposing pragmatic rather than 'perfect' options to address pressing financial challenges. it references the painful, unnecessary and politically costly estrangement of maestro bernard haitink from the orchestra during the latter years of his highly successful tenure. but the story also demonstrates, using coser's ( ) words, the positive functions of social conflict: the many conflicts resulted in a change of the governance model, which finally resolved the long-simmering tensions between artistic excellence and financial viability. the birth of médicins sans frontières was rooted in a conflict of values and criticism of the status quo in mainstream humanitarian aid organizations such as the red cross. witnessing severe atrocities among civilians during the nigerian civil war in the late s, doctors were forced to remain silent under the red cross's principle of 'neutrality'. this motivated a group of french doctors to set up msf as a breakaway organization. it set the organization on a path of fierce independence, going public with inconvenient truths and occasionally engaging in very public withdrawals from theatres of conflict where the integrity of its operations was being undermined by conflicting parties. its contrarian ethos also affected msf's internal culture: its policies and strategies took shape though sometimes sharp disagreements about the right thing to do in war-torn areas. organizations become institutions because they somehow maintain high performance over the course of their existence. institutions have survived many cultural, societal and political contexts changes. institutions face constant threats to its engrained and established formula, yet manage to preserve their virtuous cycle. this requires timely, in some cases even preemptive, forms of adaptation to maintain the flywheel. our case studies suggest how institutions manage to accomplish this. institutions monitor the environment for new demands and potential threats; they probe the internal culture for complacency and newly emerging fault lines that have the potential to compromise the institution's integrity and performance. institutions maintain a culture of learning, innovation and contestation-they are 'charged with vitality' (goodsell a) . rijkswaterstaat provides a fascinating case study in this regard. the traditional institution was at first reluctant to acknowledge that its technocratic paradigm of project planning and management had gone past its sell-by date as a result of changes taking place in dutch society during the s. but once its eyes were opened, it went on a learning journey that continues into the present. rijkswaterstaat keeps trying to reconcile the traditional strength of 'go-it-alone civic engineering' with the 'soft skills' and 'collaborative mindset' required to thrive in a post-paternalistic era. the european court of justice is another intriguing example of adaptive capacity. just when the court had found its institutional footing and delivered hallmark rulings that would cement european integration for decades to come, the european project itself came under intense criticism (in the s). around that time, the most influential judges in the court were set to retire. this confluence of events created a dire need to revisit and rethink the way the court functioned. this brings us to what is known as the paradox of success: the capacity to adapt can be undermined by the successes of the institution. the very strength of an institutional formula sows the seeds of the institution's demise. the operative mechanisms here are not only the kind of hubris, complacence and rigidity foreseen by selznick ( ) as chief forces of erosion of institutional integrity. there is something much more mundane at the heart of it: the dedicated adherence to what has been proven to work well makes it seemingly unnecessary to consider alternative ways of working that may be better suited for dealing with evolving contexts and new challenges. figure . captures how a virtuous cycle can turn into a vicious cycle of deinstitutionalization, which can be described as follows (masuch ; boin and 't hart ; ansell and bartenberger ) : • successful practices give rise to a strong internal culture ('this is how we do things around here') that makes it hard to suggest or even imagine alternative ways of working. • this is perceived by parts of its authorizing environment as a refusal to acknowledge the need for change. • legitimacy declines as a result; criticism begins to mount. • the institution is at a loss of what to do, falling back on practices that are still assumed to work (but actually exacerbate the problem). • as perceptions of institutional performance continue to decline and institutions demonstrate limited or no willingness to change, conditions for an institutional crisis are created. if allowed to continue, this process of deinstitutionalization can create an existential crisis for an institution. it requires exceptional leadership to guide the institution through such a period. for example, the socalled climategate crisis facing the ipcc , when inaccuracies in its fourth assessment report were revealed, opened up the institution to charges of bias, hidden agendas and politicization of its processes and findings. playing into the hands of 'climate deniers', the crisis put pressure on the ipcc to acknowledge its fallibility, which, in turn, appeared to confirm the criticism put forward by its critics. the ipcc survived the crisis by creating procedures that enhanced the integrity of its findings and conclusions. anti-doping watchdog wada was plunged into an institutional crisis of its own making. wada had failed to detect the brazen, systematic subversion of its norms and its compliance regime by the russian sports federations, peaking at the sochi winter olympics. its initial response to whistleblowers, which came forward from within the russian system, was inept. it also proved unable to orchestrate support for firm sanctions. the organization compounded its problems by gullibly declaring its russian counterpart rusada fully compliant again in , a declaration it had to retract when it transpired that the data on which the decision was based had been tampered with. but the crisis did not undermine the belief that without an institution such as wada there can be no credible anti-doping policy. institutions are conceived in this book as 'societal safeguards'. institutions protect our better angels from the detrimental effects of partisanship, moral panics, opportunism (the temptation of the quick fix) and adventurism (the temptation of the sweeping promise). institutions, in other words, protect us from ourselves. this is especially important in a time when public entities are fragile to the whims of public opinion and the impulses of politicians. some argue that today's institutions experience unique challenges (rosanvallon ) . one challenge derives from the rise of what has been called 'monitory democracy' (keane ) . in monitory democracies, all forms of authority, all organizations and all power-holders are continuously vetted, interrogated and challenged by a plethora of accountability regimes. if institutions indeed depend on a certain 'mystique' in gaining and maintaining their elevated status, the question arises whether that mystique can survive the withering challenges of hyper-transparency, the relentless thickening of accountability and the growing vagaries of public emotions and political will (hood ; bovens et al. ; busuioc and lodge ) . the dense web of arrangements and rituals of verification and control has made institutional 'mission mystiques' more fickle. operating in today's more polarized social and political climate may make it hard for institutions to claim that they are serving the 'public interest' (mccoy et al. ) . institutions can, in other words, rely less and less on their legal mandates, their formal autonomy and their professed commitment to certain fundamental values-to ensure their social licence to operate. institutional legitimacy has become more dependent on whether they actually 'perform' (hitting targets, scoring wins) and how they go about performing (i.e. complying with ever more strongly worded and policed procedural norms of transparency, fairness and propriety). a second challenge is grounded in the shift from the machine age to the network age (castells ) . twentieth-century organizing was grounded in hierarchy, specialization and compartmentalization of knowledge, funding, task performance and responsibilities. the dominant ideology of twenty-first-century organizing is one of collaborating across boundaries, pooling of resources, flexible arrangements, shared power and responsibility. in the face of relentless globalization, wicked problems and transboundary crises, public institutions find it hard to position themselves as islands or bulwarks organized around a self-proclaimed mission and accompanying values. today's world is very different from the america of the mid- s where selznick wrote his path-breaking book leadership in administration. collaborative approaches to public innovation, societal problemsolving and dealing with wicked issues and creeping crises have become the new normal (emerson and nabatchi ) . if they are to remain relevant in a network society, public institutions must be able to act as co-creators in hybrid public-private, intergovernmental and transnational collaborations. the question is how institutions can align or even coalesce their operations, norms and identities with network partners in service of a shared purpose without diluting their own institutional character. in modern society, the concept of a focal organization with a distinct mission, structure, value set, membership and value chain may have to be refreshed. but it would be premature at best to announce the impending death of public institutions and the obsolescence of the kind of institutional analysis performed in this book. the virtuous cycles that these institutions create and maintain are needed perhaps even more than before. networks may be important to make complex service delivery or emergency response work, but they don't have the visibility and established identity that institutions enjoy. citizens of monitorial democracies may have become more transactional and less forgiving in how they assess those organizations and their leaders. by the same token, however, in times of turbulence and confusion, citizens (and markets) look for beacons of hope, protection, direction and order. public institutions may well be our best hope in times of turbulence. public institutions are guarding something that is probably older and weightier than the current interests and priorities of any one group or party in the system, however powerful. whether in times of turbulence of relative stability, the pivotal challenge for institutional leaders remains threefold: to make the case for its raison d'être by claiming guardianship of salient, widely desired public values; to motivate people so that the institution delivers on its licence to operate; and to continuously adapt the organization's make-up, beliefs and practices to remain in tune with the norms and demands of ever-changing times. these are no easy tasks. the chapters in this book provide tales and insights that will hopefully prove useful for future institutional leaders. to facilitate classroom use of each case study we have placed questions for discussion at the end of each chapter. a final note. the manuscript of this volume was closed just weeks before the covid- pandemic enveloped and disrupted practically the entire world, thus presenting people, businesses, community organizations, government and international organizations with an unprecedented 'stress test' of their adaptive capacity. it remains to a next group of researchers to investigate whether and how the institutions covered in this book managed to not only survive but productively absorb and adapt to the immense challenges the virus and its many impacts presented. note . the kind of consolidating leadership that is required to ensure the institution stay relevant and valuable externally and continues to cohere internally has been captured nicely by frederickson and matkin ( ) in their essay on public leadership as 'gardening'. institutional crises and reforms in policy sectors: the case of asylum policy in europe tackling unruly problems dynamic conservatism: how organizations change to remain the same the functions of the executive. cambridge crafting public institutions: leadership in two prison systems the development of public institutions: reconsidering the role of leadership institutionalizing upstarts: the demons of domestication and the benefits of recalcitrance does organizational adaptation really matter? how mission change affects the survival of u.s. federal independent agencies institutional crises and reforms in policy sectors oxford handbook of public accountability reputation and accountability relationships reputation and power: organizational image and pharmaceutical regulation at the fda the information age: economy, society, and culture good to great: why some companies make the leap and others don't how the mighty fall turning the flywheel the social functions of social conflict the sage handbook of organizational institutionalism the living company governing prisons: a comparative study of correctional management principled agents: the cultural bases of behavior in a federal government bureaucracy leadership and innovation evaluating the productivity of collaborative governance regimes: a performance matrix. public performance & management review international norm dynamics and political change public leadership as gardening mission mystique: strength at the institutional center mission mystique: belief systems in public agencies poor leadership and bad governance understanding good urban governance: essentials, shifts, and values the blame game: spin, bureaucracy, and self-preservation in government the fbi: a history the forest ranger: a study in administrative behavior are government organizations immortal time, chance and organisations power and humility: the future of monitory democracy coming to terms with termination of public organizations the politics of agency termination: confronting the myth of agency immortality presidents and the politics of agency design: political insulation in the united states government bureaucracy public entrepreneurship: toward a theory of bureaucratic political power is the bbc in crisis the human brand: how we relate to people, products, and companies vicous cycles in organizations polarization and the global crisis of democracy: common patterns, dynamics, and pernicious consequences for democratic polities institutionalized organizations: formal structure as myth and ceremony creating public value: strategic management in government the antecedents of deinstitutionalization the toxic triangle: destructive leaders, susceptible followers, and conducive environments motivation in public management: the call of public service the sage handbook of governance search of excellence: lessons from america's best-run companies good governance: democracy beyond elections institutions and organizations: ideas, interests, and identities the organizational weapon: a study of bolshevik strategy and tactics leadership in administration: a sociological interpretation learning through failure: the strategy of small losses managing legitimacy: strategic and institutional approaches understanding public leadership. london: red globe and macmillan explaining the survival of public organizations: applying density dependence theory to a population of us federal agencies money and power: from stockholm's banco to sveriges riksbank today bureaucracy open access this chapter is licensed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/ by/ . /), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license and indicate if changes were made.the images or other third party material in this chapter are included in the chapter's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the chapter's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. key: cord- -z gysxni authors: aronna, m. soledad; guglielmi, roberto; moschen, lucas m. title: a model for covid- with isolation, quarantine and testing as control measures date: - - journal: nan doi: nan sha: doc_id: cord_uid: z gysxni in this article we propose a compartmental model for the dynamics of coronavirus disease (covid- ). we take into account the presence of asymptomatic infections and the main policies that have been adopted so far to contain the epidemic: isolation (or social distancing) of a portion of the population, quarantine for confirmed cases and testing. we model isolation by separating the population in two groups: one composed by key-workers that keep working during the pandemic and have a usual contact rate, and a second group consisting of people that are enforced/recommended to stay at home. we refer to quarantine as strict isolation, and it is applied to confirmed infected cases. in the proposed model, the proportion of people in isolation, the level of contact reduction and the testing rate are control parameters that can vary in time, representing policies that evolve in different stages. we obtain an explicit expression for the basic reproduction number $mathcal{r}_ $ in terms of the parameters of the disease and of the control policies. in this way we can quantify the effect that isolation and testing have in the evolution of the epidemic. we present a series of simulations to illustrate different realistic scenarios. from the expression of $mathcal{r}_ $ and the simulations we conclude that isolation (social distancing) and testing among asymptomatic cases are fundamental actions to control the epidemic, {and the stricter these measures are and the sooner they are implemented,} the more lives can be saved. additionally, we show that people that remain in isolation significantly reduce their probability of contagion, so risk groups should be recommended to maintain a low contact rate during the course of the epidemic. in late december , several cases of an unknown pneumonia were identified in the city of wuhan, hubei province, china [ ] . some doctors of wuhan conjectured that it could be severe acute respiratory syndrome (sars) cases [ ] . many of the found cases had visited or were related to the huanan seafood wholesale market. on december , the world health organization (who) china country office was informed of these cases of pneumonia detected in wuhan city and, up to january , a total of patients with this unknown pneumonia were reported to who [ ] . in the beginning of january chinese officials ruled out the hypothesis that the cases were of sars [ ] , and a few days later the cause was identified to be a new coronavirus that was named sars-cov- . the name given to the infectious disease caused by sars-cov- is covid- . the first death due to covid- was reported on january and it was a -year-old man in wuhan [ ] . after mid january infected cases were reported in thailand, japan, republic of korea, and other provinces in china [ ] . on january the chinese authorities announced the quarantine of greater wuhan. from that time on the virus rapidly spread in many asiatic countries, reached europe and the united states. on february, with more than . confirmed cases and nearly . deaths globally, who increased the assessment of the risk of spread and risk of impact of covid- to very high at the global level [ ] . on march , with nearly deaths, italian government ordered the total lock-down of the national territory [ ] . and a few days later, on march , who declared that covid- was characterized as a pandemic [ ] . in march several nations across the five continents closed their borders, declared forced isolation for the whole population except for essential workers and/or imposed strict measures of social distancing. detailed information on the actions taken by each country can be found in the report [ ] . at that time who recommended, apart from social distancing measures, that it was essential to test intensively [ ] . the indications were to test every suspected case, to isolate till recovery any positive individual, and to track and test all contacts in the past two days of new confirmed cases. the most common symptoms of covid- are fever, cough and shortness of breath. most of the cases result in mild or no symptoms, but some progress to viral pneumonia and multi-organ failure. at this moment, it is estimate that out of cases needs hospitalization [ ] . it is yet difficult to estimate the mortality of this virus. mortality depends on one side on early detection and appropriate treatment, but the rate itself can only be calculated if the real number of infected people is known. there is enough evidence to assure that a significant portion of the infections is asymptomatic [ , , ] , which makes it difficult to detect them and thus to calculate the effective mortality of covid- . who, by march , estimated a death rate of , % worldwide [ ] . but in some countries, as italy, france, spain and uk, the rate between deaths and confirmed cases up to may is higher than % [ ] . in this article we propose a compartmental model for the dynamics of covid- . we take into account the presence of asymptomatic infections, and also the main policies that have been adopted by several countries in the past months to fight this disease, these being: isolation, quarantine and testing. we model isolation by separating the population in two groups: one composed by keyworkers that keep working during the pandemic and having a usual contact rate, and the other group consisting of people that are enforced/recommended to stay at home. certainly, in the group of people that maintain a high contact rate one can also include people that do not respect social distancing restrictions, that has lately shown to be significant in some countries. we refer to quarantine as strict isolation, and it is applied to confirmed infected cases. testing is supposed to be applied to all symptomatic cases, and to a portion of the population selected using some of the criteria adopted by health organizations (see e.g. [ , ] ). the idea to analyze the quantitative effects of non-pharmaceutical interventions, such as isolation and social distancing, on the evolution of the epidemic was inspired by the work [ ] . for the proposed model, we obtain an expression for the basic reproduction number r in terms of the parameters of the disease and of the control parameters. in this way we can quantify the effects that isolation and testing have on the epidemic. we exhibit a series of simulations to illustrate different realistic situations. we compare, in particular, different levels of isolation and testing. from the expression of r and the simulations, we conclude that isolation (social distancing) and testing among asymptomatic cases are fundamental actions to control the epidemic, and the stricter these measures are and the sooner they are implemented, the more lives can be saved. additionally, we show that people that remain in isolation significantly reduce their probability of contagion, so risk groups should be recommended to maintain a low contact rate during the course of the epidemic. several mathematical models for covid- have appeared recently in the literature. at the time being, the flux of publications is very high, so it is difficult to keep track of everything that is being published. we next mention and describe some of the models more closely related to ours. in [ ] they consider a simple model, with infected and reported infected compartments, and they assume that the transmission rate β is a function of a control u, this is β = β(u). they analyze feedback control strategies, where the control depends on the number of reported cases. in [ ] they consider mild and severe cases, the latter having a reduced transmission rate since they are assumed to be in isolation. they use a time-dependent control c of reduction of contacts for the whole population, and optimize with respect to this control. an seir model with quarantine for suspected and infected cases cases is considered in [ ] , and in [ ] they take into account unreported cases, asymptomatic individuals and quarantine for identified cases. the article is organized as follows. in section we introduce the model, and we discuss its structure. in section we show an expression of the basic reproduction number r in terms of the parameters and we propose an equivalent threshold. estimation of realistic parameters and numerical simulations are given in section , while section is devoted to the conclusions and a description of possible continuations of this research. finally, in the appendix we include the analytical computations of the expression of r and a sensitivity analysis with respect to the involved parameters. we set up a model to describe the spread of the virus sars-cov- through a susceptible population. building upon a usual seir model, we obtain a more structured one, which is tailored on the current experience of the covid- epidemic, and which also allows to convey the effects of the non-pharmaceutical intervention policies being adopted by several countries to face its outbreak. first of all, we normalize to the total population of n individuals, so that all the compartments (and their sub-compartments) introduced below represent the proportion of individuals of the total population in such compartment. we will assume the population remains constant over time (i.e., we neglect the natural birth and death rates). we start by splitting the population in the compartments listed in table . description s susceptible e exposed i infectious a asymptomatic and infectious q infected in quarantine (including hospitalized) r recovered table : list of aggregated compartments more specifically, the compartment s collects all the individuals that are susceptible to the virus. once an individual from s gets exposed to the virus, moves to the compartment e. let us point out that individuals in e, though already exposed to the virus, are not contagious yet. after a given latent time, an individual in e becomes infectious, and thus is allocated to the compartment i. at this stage, after a suitable time, the individual may either remain infectious but asymptomatic (or with mild symptoms), in which case moves to the compartment a, or may show clear symptoms onset, thus being tested and then quarantined either at home or at the hospital, and being assigned to the compartment q. finally, individuals in a and q will eventually be removed from those compartments and will end up either in the compartment r after a recovery time or dead. we will assume that the fraction of asymptomatic individuals among all infected is given by a certain probability α ∈ ( , ). it is intuitive that the presence of a relevant portion of asymptomatic infectious individuals plays a major role in the spread of the epidemic, as observed in the current outbreak [ , ] . indeed, an asymptomatic individual will maintain a high contact rate, and thus might infect more susceptible individuals with respect to an infectious individual with symptoms that is in quarantine. in our model, we always refer to the effective contact rate β, which is given by the product between the transmissibility ν (i.e., probability of infection given contact between a susceptible and infected individual), and the average rate of contact c between susceptible and infected individuals. in tables and we list all the parameters of the model and their description. the model as described so far takes into account several characteristics of the pathogen and its spread in a susceptible population. we now want to add further structural features to the model in order to include the non-pharmaceutical interventions adopted by public policies to contain the epidemic. in particular, we assume the following conditions. i) a part p of the population is in isolation (either voluntarily, or as a result of public safety policies). the remaining −p of the population instead gathers all those so-called "key workers" (such as physicians and paramedicals, workers in logistics and distribution, food production, security, and others), that must continue with a regular activity, thus maintaining a large contact rate and being exposed to a higher risk of infection. we will generically refer to such −p part of population as the active population, as opposed to the population in isolation. in this group we can also include people that simply do not respect social distancing, and thus maintain a high contact rate. a situation like this has been observed in countries were monitoring was not strict and a significant percentage of the population did not respect isolation. ii) the fraction − p of active population has an effective contact rate β, whereas the p part of population in isolation has a contact rate reduced by a factor r, thus its compound contact rate is rβ. we will therefore refer to such portion of the population as in r-isolation. iii) a centralized controller (such as the national health system) may intervene on the system by testing a portion of the population to check for the infectious pathogen. we assume the testing kit to be reliable, that is, we neglect the possibility of false positive/negative. as a rule, then, an individual from the compartment s will always test negative, an individual from i or a always positive, while an individual from e will result positive with a probability δ ∈ [ , ]. in this way, even though the individuals in e are not contagious, we account for the possibility that they might result positive to the test, depending on the stage of development of the pathogen in that specific individual and to the efficacy of the testing kit. let us notice that, in general, the effective contact rate β depends on a variety of factors, including the density of population in a given country/region. however, during a pandemic, even the effective contact rate of the individuals not in isolation may be reduced by increased awareness (for example, maintaining the social distancing), or by respecting stricter safety protocols and by availability of proper personal protection equipment (ppe), including face shields, masks, gloves, soap, and so on. according to the above description, each compartment s, e, i and a is partitioned as follows: s = s f ∪ s r , where s f are susceptible and active, while s r are susceptible and in r-isolation; e = e f ∪ e r , where e f are exposed and active, while e r are exposed and in r-isolation; i = i f ∪ i r , where i f are infectious and active, i r are infectious and in r-isolation; a = a f ∪ a r , where a f are asymptomatic infectious and active, a r are asymptomatic infectious and in r-isolation. the compartment q collects all the infected individuals who have been tested positive, either after onset of severe symptoms, or because of a sample test among the population, according to the procedure described in iii) of the above list. let us stress that, among these compartments, only the individuals in q are aware of being infected, and thus contagious, hence they are either hospitalized or at home, but in both cases they follow strict procedures to reduce their contact rate to . finally, we will use the compartments r for the recovered and immune individuals, and d for the disease-induced deaths. both these last compartments will be removed from the dynamics and will end up in the counter system ( ) . moreover, we point out that the portion p of the population in r-isolation is predetermined at the initial time of the evolution, reflecting the public policy in place in that specific period of time. of course, such fraction p may be updated at a later time, accordingly to newer (stricter or looser) public policies. the first set of constants, related to the pathogen itself (assuming no mutation occurs in the time of epidemic, or if so, the mutation does not affect such parameters of the virus) and its induced disease, are collected in table . a graphical representation of the course of the disease for symptomatic carriers can be seen in figure . description τ inverse of the latent time from exposure to infectiousness onset σ inverse of the time from infectiousness onset to possible symptoms onset θ inverse of mean incubation time (i.e. θ − = τ − + σ − ) α proportion of asymptomatic infections γ recovery rate for asymptomatic or mild symptomatic cases γ recovery rate for severe and critical cases µ mortality rate among confirmed cases δ probability of detection by testing in compartment e figure : disease timeline for symptomatic cases the second set of parameters is related to public policies, and consists of the parameters in table . let us recall at this point that β varies in each territory, depending mainly on population density and behaviour. these constants may be used as control parameters, via the tuned lockdown as decided by the public policies (reflecting on p and partially on r), the awareness of the population in respecting the social distancing among individuals and in the widespread use of personal protection equipment (expressed by β and partially by r), the availability of testing kits, that results in a higher or lower value of ρ. description β(t) transmission rate at time t (proportional to contact rate) r(t) reduction coefficient of transmission rate for people in isolation at time t ρ(t) testing rate of people with mild or no symptoms at time t p(t) proportion of the population in r-isolation table : the extended state variable of the system thus becomes where the description of the compartments is given in table . we focus in particular on the evolution of the variable compartment description e f exposed, not in isolation, not contagious e r exposed, in r-isolation, not contagious i f infected and contagious, not in isolation i r infected and contagious, in r-isolation a f asymptomatic and contagious, not in isolation a r asymptomatic and contagious, in r-isolation q infected and tested positive, in enforced quarantine s f susceptible not in isolation s r susceptible in r-isolation r recovered and immune d dead table : list of extended compartments that follows the model while the evolution of the statesṘ only provides counters for the proportion (over the total population) of recovered and dead individuals, respectively. see the compartmental diagram associated to this model in figure . remark . (about the testing rate ρ) the parameter ρ indicates the proportion of the population presenting either mild or no symptoms that is tested daily. it can also be thought as the inverse of the mean duration that an infected person passes without being tested. for instance, if the system manages to detect, each day, % of the asymptomatic infections, then ρ = . . if we are in an ideal "trace and test" situation (see e.g. south korea [ ] ), in which for each confirmed infection, his/her recent contacts are rapidly and efficiently traced and tested, then ρ will be greater and this will have an impact in the basic reproduction number (see section ). recalling that testing is supposed to be applied, at least, to all sufficiently symptomatic cases, we add a counter for the positive tests t (t) until time t, which evolves according to the equatioṅ having this quantity, one can estimate the total number of tests in each territory using the testing positive rate of that location, which is the ratio between reported cases and tests done [ , ] . remark . (about symptoms and quarantine) in our framework, we assume that all cases with sufficiently severe symptoms are (tested and) quarantined, and we set the parameter α ∈ ( , ) to be the fraction of asymptomatic cases, including the cases with mild symptoms. but we can adapt our model to a scenario in which even severe symptoms are not tested until critical. in this case, with a very large value for α, only a small portion among the symptomatic individuals enters directly to q, while the others need to be tested (according to the sampling testing ρ among the population) to be quarantined. system ( ) is endowed with the set of initial conditions given by the vector with components in the interval [ , ]. setting the cube of states with entries between and , it is easy to check that c is invariant under the flow of system ( ), that is, given an initial condition x ∈ c , the solution x(t) to ( )-( ) remains in c for all t > . we collect here some variations of model ( ) that can be formulated in the same framework considered in this paper. . one might consider a small but not negligible contact rate between susceptible individuals and people in the compartment q, accounting for infections (mainly of medicals and paramedicals) occurred during hospitalization of an infected individual, or for individuals tested positive in enforced quarantine at home, which do not comply strictly to the isolation procedures and end up infecting relatives or other contacts. in this case, the equations for the evolution of the susceptible compartments shall be completed with additional terms involving ε in the following way:Ṡ and the same terms with opposite sign shall appear in the equation corresponding toq. . at the current stage, it is still not clear how long the immunity of a recovered individual lasts, with a number of findings tending towards a rather long immunization period [ , , ] . for this reason, in ( ) we assume that a recovered individual will remain immune over the time framework considered in the different scenarios. however, the model can easily describe the case of recovered individuals becoming susceptible again, by adding a transfer term from the compartment r to s f and s r , with a coefficient depending on the inverse of the average immunization period. similarly, the model can include the case of reactivation of the virus in an individual previously declared recovered (and not newly exposed to the virus), by inserting a transfer term from the compartment r into i f and i r , with appropriate coefficients depending on the probability of the reactivation of the virus and on the inverse of the average time of reactivation. however, at the moment there are not strong evidences supporting such possibility [ ] . . a crucial issue while coping with the outbreak of the epidemic, which leads to the so-called urge of flattening the curve, is whether the number of critical cases in need of intensive care (ic) treatment (due to respiratory failure, shock, and multiple organ dysfunction or failure) would saturate the number of available intensive care units (icus). this parameter can be estimated directly from model ( ), considering for each country the number of available icus and the percentage of positive confirmed cases requiring ic treatment. for example, this percentage has been estimated to be about % for china [ ] , and up to % for italy [ , ] . as an alternative, it would be possible to insert a further compartment c in model ( ) counting the number of the individuals needing icu treatment, by modifying the equations corresponding to the compartments q and d as follows: with suitable coefficients τ c , µ c and γ c denoting the inverse of the time from symptoms onset to critical symptoms, the mortality of critical cases, and the recovery rate for critical cases, respectively. . in this paper we have considered the whole population as a fixed number of individuals during the time period of the evolution. it is of course possible to consider the case of an evolving total population, by including in the model ( ) the natural birth and mortality rate. in particular, newborns of susceptible individuals shall enter the corresponding susceptible compartment, whereas it is not clear whether the offspring of an infectious individual would be infectious, in such case the newborn shall move directly to the compartment i. on the other hand, the natural mortality rate shall act on each compartment of system ( ), as well as on r in system ( ). the basic reproduction number for model ( ) we are interested in determining the basic reproduction number r associated with system ( ). to do this, we assume to fix a time interval [t , t ] such that the coefficients β(t), r(t) and ρ(t) are constant over [t , t ]. this is coherent with the setting of the scenarios simulated in section . , where we assume such coefficients to be piecewise constant functions, sharing the same switching times, that represent different phases of restrictions and policies. thus, according to the calculations given in the appendix a. and the parameters in tables and , we obtain that the value of r for each time interval between two consecutive switching times is given by from this explicit formula for the reproduction number r , we can highlight the qualitative dependence of r on each parameter of the system, in particular: -if the effective contact rate β increases, then r increases. -focusing on the coefficient − ( − r )p, we realize that closer is p to , and smaller is r, that is, as larger is the portion of population in r-isolation and as stricter is the reduction factor r in its contact rate, lower r becomes. -if α increases, that is, if there is a larger proportion of asymptomatic infectious individuals, then r increases. -if σ increases, corresponding to shorter onset time, then r decreases. -if either ρ or γ increase, i.e., either the control action by testing is strengthened, for example through an improved tracing and tracking system, or the recovery rate improves, for example, because of new and more effective treatments, then r decreases. -if δ increases, for example, as a result of improved testing kits able to detect the infection at an earlier stage, then r decreases. moreover, we can characterize the crucial condition r ≤ by means of a simpler expression than ( ), as described in the next result. then r is smaller than (respectively, equal to or greater than) if and only if the same relation holds for t . in particular, if ϕ > (see ( )), then r > and t > . we postpone the proof of proposition . to the appendix a. . a more quantitative analysis of the dependence of the threshold t on the parameters of the model is developed in the appendix a. . if we consider the case of ρ = , that is, the situation without sample testing among the asymptomatic population, then the basic reproduction number r is independent of the latent time τ . in particular, t becomes ( ) gives an expression of r , that is the reproduction number in a totally susceptible population. as the epidemic evolves, a portion of the population becomes immune to the disease, and this makes the reproduction number decrease. more precisely, when p = and all the population has the same contact rate, the time-dependent reproduction number is given by r(t) = s(t)r , where s(t) is the susceptible portion of the population. in our model, since the groups of active individuals and in r-isolation evolve differently (see scenario a and figure below), the time-dependent reproduction number r(t) is given by the formula ( ) where ϕ in ( ) is we do not take into account this time-variation of the reproduction number in our numerical results, since we are only interested in the value of the reproduction number at the beginning of each phase, where s(t) is close to . remark . (on herd immunity) herd immunity is defined as the proportion of the population that needs to be immunized in order to naturally slow down the spread of the disease. it depends on the value of the basic reproduction number in the following way: herd immunity level equals − r . so the bigger r , the higher the herd immunity. in connection with above remark . , we highlight that herd immunity is achieved at the time t when r(t) equals . in table we collect some parameter values estimated in the literature, in order to do realistic simulations. recall the description of the parameters given in tables - . table follow. . the parameter β strongly depends on the population behaviour. we take the value of β from [ ] , where they calibrated an seir model with isolation and estimated the transmission rate β, before lockdown, to be . (with a % confidence interval ( . , . )). . the mean duration of the latent period can be computed using the estimates for the incubation period (i.e. from exposure to symptom onset) and the time from infectiousness onset to symptom onset, so it is reasonable to take τ − between and days. more precisely, in [ ] they fitted an seiqr model to the data from wuhan and estimated a latent period of duration . days with a % ci of ( . , . ). . in [ ] they show the testing results on diamond princess passengers, a cruise ship that was quarantined in february-march , at the beginning of the epidemic. almost all passengers and crew members were tested, resulting in asymptomatic infections among positive-tested persons, which yields an asymptotic rate of . . in [ ] , they studied the infection in the municipality of vo', italy. they estimated a median of asymptomatic cases of . %. with a % ci of ( . , . ). other estimates were given in [ , , ] . . in [ ] , they measured time from infectiousness onset to appearance of symptoms. it resulted in approximate day for fever and - days for cough. furthermore, it has been observed in clinical cases studied in [ ] that the contagious period may start before the appearance of symptoms, and outlast the symptoms end. . the reference [ ] estimates θ to be . based on travellers returning from wuhan. in [ ] it was estimated to be . days. other estimates were given in [ ] . . the estimate of γ is difficult, since for asymptomatic cases is hard to observe and track the time from exposure to recovery. [ ] estimated . days for asymptomatic cases, while [ ] estimated days for mild cases. so it is reasonable to assume γ in the range . - , considering around days between infectiousness onset and symptoms onset. . in [ ] they measured viral shedding duration, and estimated a median of days, with an interquartile range of ( , ) . removing the approximately -day period from infectiousness onset to symptoms onset, we get an iqr for γ − of ( , ) . these values approximate the duration of quarantine recommended to positive-tested cases. . the rate µ depends on the percentage of infections that have been detected, since it is proportional to the ratio between confirmed cases and deaths. who director-general's opening remarks at the media briefing of march [ ] announced an estimated global death rate of . %. in some countries, like italy, the ratio between deaths and confirmed cases up to may is larger that . , while in others, like israel, it is around . . regarding the time a person takes to die from covid- , in [ ] they estimated . days from infectiousness onset to death. . the values of p and r vary in each country/territory depending on the public policies and the population's compliance to these measures. a detailed and real-time survey on the percentage of people under lockdown in each country can be found in [ ] . . as already mentioned in remark . , ρ represents the proportion of the infected asymptomatic population that is tested daily. in a realistic scenario, it would not be reasonable to set a too high value of ρ, let us say, over . , because it would account for detecting more than % of the infected asymptomatic population daily. . it is not yet know "at what point during the course of illness a test becomes positive" (see [ ] ). for the simulations we set δ to and suppose that the tests detect the infection from exposure. in this subsection we consider several scenarios and show their outcomes. many of the graphics are in logarithmic scale, given that the values represent portions of the population, and then can assume very small values. we consider the four different scenarios with the following characteristics: these scenarios a can be seen as: no action, mild lockdown, strict lockdown and strict lockdown with testing among asymptomatic suspected cases. as initial condition we take, in all the scenarios, one exposed case per million inhabitant, this is: the remainder of the compartments start with value . results and parameters for scenario a are given in table and graphics in figure . we can observe the effect of the lockdown on the epidemic. the mild lockdown of a reduces more than half of the infections w.r.t. the no action situation a , while the strict lockdowns a and a induce a reduction of the order of − in total recovered, deaths and positive tests. in particular, comparing a and a we can see that testing and consequent quarantine for positive-tested asymptomatic cases not only reduces the infections and deaths more than %, but also the duration of the epidemic. remark . (about scenario a ) united states had confirmed infections by february th [ ] . many states started their lockdown between march th and march th, which put around % of the population in isolation [ ] . we can assume that day is february th, then day would be in the middle point of the interval when lockdowns started. day (may th) us had , confirmed deaths, while in scenario a gives , , that is larger but not far. scenario a could be a good approximation of the situation in the us until the beginning of may , and the excess in the computed deaths in comparison to real data suggests that deaths could be underreported by %, which is coherent with some recent studies on underreported deaths (see e.g. [ ] ). for scenario a we make a comparison of infections for the two groups: the active one (that continues with the usual contact rate) and the one in r-isolation. by comparing the infections' curves and the cumulative infections, we can give an estimate on the lower chance that people in r-isolation have to get exposed. in this particular scenario, people that are not in isolation have nearly times more chance to be infected. see the graphs in figure , were we show the curves of infections and cumulative infections for each group, normalized by the proportions − p, p. we measure the outcomes. the parameters and results are given in table , and graphics in figure . the parameters that are not specified in table , are repeated from table . for these four scenarios we consider the same testing rate ρ among asymptomatic cases. par. scenarios b and b show cases in which the restrictions are not strong enough. indeed, in both cases the basic reproduction number r remains above also after the lockdown intervention (see table ), and the infection reaches . % and . % of the population, causing the death of . % and . % of the population, respectively, which is a catastrophic outcome. comparing these four scenarios, we shall deduce that, in order to be effective in containing the outbreak, the lockdown shall address at least % of the population reducing their contact rate to about % of their usual contacts. indeed, in the scenario b , the basic reproduction number becomes . after day , meaning that loosening the restrictions of this scenario (while keeping all other parameters unchanged) might turn the r above . we now compare two situations, one in which lockdown starts immediately, just days after the first confirmed cases, and the other for which lockdown starts four weeks later. more precisely, we consider the following two scenarios and measure the different outputs: scenario c : %-isolation of % of the population from day scenario c : %-isolation of % of the population from day the parameters and outputs are given in table and figure . it is evident the impact of delaying the beginning of lockdown on the final outcome: the numbers of recovered and deaths in the scenario c are of the order of times those of the scenario c . as an example, from table one notice that, at the end of the epidemic, the scenario c counts . deaths per million inhabitants, while the scenario c faces deaths per million. moreover, the epidemic in scenario c lasts about days more than in scenario c , thus also undergoes worst economic consequences of the lockdown. we now want to asses the impact of testing timing. for this, we consider the following two scenarios and measure the different outputs: scenario d : %-isolation of % of the population from day , efficient testing before day , reduced testing after scenario d : %-isolation of % of the population from day , few testing before day , massive testing after the parameter values and outcomes of the epidemic in scenarios d and d are given in table and figures in figure . it can be seen the cost in infection and lives it has to start testing late. it is worth noticing that, in spite of a higher total number of tests carried out in the scenario d , the strategy adopted in the scenario d attains a considerably better outcome: indeed, the infections and deaths of scenario d are of the order of w.r.t. the ones in scenario d , and the only difference was doing efficient testing at the beginning of the epidemic. now we fix the parameters β, µ, p, r as in table and we vary only ρ to take the four different values , . , . and . over the whole time period. we get the outcome of figure . from the comparison among these four scenarios, we realize that a high value of ρ, as the result of an efficient tracing and testing strategy, may reduce the number of cumulative infected individuals and deaths of an order of . the simulations were done with python and all the codes are in the github repository github.com/lucasmoschen/covid- -model. in the paper we present an seir model with asymptomatic and quarantined compartments to describe the recent and ongoing covid- outbreak. our model is intended to highlight the strength of three different non-pharmaceutical interventions imposed by public policies in containing the outbreak and the total number of disease-induced infections and deaths: -reduction of contact rate for a given portion of the population; -enforced quarantine for confirmed infectious individuals; -testing among the population to detect also asymptomatic infectious individuals. on one hand we show that, as expected, each of these interventions has a beneficial impact on flattening the curve of the outbreak. on the other hand, the comparison among different scenarios shows the remarkable efficacy of an early massive testing approach, when the limited number of infected individuals makes easier and more effective the tracing of recent contacts of the individual, as in scenario d , and of a timely lockdown, although in the presence of few confirmed infected cases, as in scenario c . in both situations, the timing of the intervention plays a crucial role on the incisiveness of the public safety policy. in addition, we give an explicit representation of the basic reproduction number in terms of the several parameters of the model, which allows to describe its dependence on the features of the virus and on the implemented non-pharmaceutical interventions. this description makes available a valuable tool to tune the public policies in order to control the outbreak of the epidemic, forcing r below the threshold . however, considering the major effects of an enduring lockdown on the economy of the country that applies it, it is desirable to loosen the lockdown measures after the containment of the outbreak. nevertheless, the decision makers and each individual shall be aware that a value of r only barely greater than would lead to an increase in the number of infected and dead by an order of magnitude, thus provoking the collapse of the relative national health system. this is better explained by the following scenarios: consider a situation with constant testing ρ = . and no lockdown where, after the first days of outbreak with a high r (≈ ), the population gains awareness of the risk and manage to reduce its contact rate so as to steer r to either . , or . . figure illustrates the large deviations among the outcome of these three different situations. in order to allow the population to circulate with no restrictions, it is necessary that herd immunity (see remark . ) is achieved. the value that matters to compute this threshold of immunization is the basic reproduction number under no social distancing, which has been estimated in this article and in many others as being, in general, greater than . . so achieving herd immunity would imply to infect at least % of the population, which would lead, with the current mortality rates, to - % of the population dying, which is, obviously, a catastrophic unwanted situation. hence, reinforcing what was said in the above paragraph, until a vaccine or treatment is not found, it is necessary to maintain the value of r below . otherwise, the curve of infections will always be increasing. a. computing r recalling the model ( ), we are able to give an analytic expression of the basic reproduction number r associated to the system. in order to do so, we assume to fix a time interval [t , t ] such that the coefficients β(t), r(t) and ρ(t) are constant over [t , t ]. this is coherent with the setting of the section , where we assume such coefficients to be piecewise constant functions, sharing the same switching times. thus, the following procedure allows to evaluate the value of r for each time interval between two consecutive switching times. it is well known that the reproduction number r is the crucial parameter to establish whether disease free equilibria (dfe) are stable or not [ , ] . we denote by x s the set of dfe, which is given by we can recast system ( ) in the compact forṁ by introducing the stability of ( ) around a dfe x * is related to the spectral properties of the linearized system around x * , whose dynamics is ruled by the jacobian df = (∂f i /∂x j ) i,j= ,..., of f . however, the high dimensionality of df (x) makes it difficult to develop an analytical analysis of its spectrum and its stability properties. we will therefore follow a different approach, deducing the value of r from the result in [ ] , which ensures that r is given by the formula r = ρ(f v − ), where ρ(a) denotes the spectral radius of the matrix a. a comment on the applicability of the results in [ ] is given in remark a. below. since x * is a dfe, we may assume that x * = ( , , , , , , , − p, p), for some p ∈ [ , ] representing the portion of population that is initially in the compartment s r , while the remaining − p fraction of the population is in s f . thus, in our setting, the matrices f and v related to the dynamics ( ) are given by since v is non-singular, we compute thus, one can easily compute the matrix f v − and check that its characteristic polynomial is given by p(λ) = −λ p (λ) , where p (λ) is a second order polynomial of the form p (λ) = λ − βτ ( − p + r p) (ρδ + τ )(σ + ρ) λ − σατ β( − p + r p) (ρ + σ)(ρδ + τ )(ρ + γ ) . p (λ) has one positive and one negative root, given by λ / = βτ ( − p + r p) (ρδ + τ )(σ + ρ) ± √ ∆ , with ∆ = βτ ( − p + r p) (ρδ + τ )(σ + ρ) + σατ β( − p + r p) (ρ + σ)(ρδ + τ )(ρ + γ ) > . since the term βτ ( −p+r p) (ρδ+τ )(σ+ρ) is positive, the value of r coincides with λ , i.e., this is an analytic expression of r , which shows its explicit dependence on the different parameters of model ( ). proposition . gives a convenient equivalent condition to ensure the stability of dfe. remark a. in order to directly apply the results in [ ] , it is required that the eigenvalues of df (x * ) have negative values and, under this assumption, the asymptotic stability of the dfe is established. in our case, the matrix df (x * ) has zero as an eigenvalue of double multiplicity, with associated eigenvectors in the directions of the last two variables, these being s f and s r . it is not hard to see that the results in [ ] hold for our system by simply modifying asymptotic stability to stability in the directions of the susceptible compartments, which has no consequence in the meaning of the threshold r . alternatively, a way to force the system to comply all the technical assumptions from [ ] is adding birth and natural mortality to our model, which has no relevant impact in the results we showed (since the natural daily birth/death rates are of the order of − , hence negligible w.r.t. the other parameters). we remind that proposition . claims the following: for ϕ = βτ [ − ( − r )p] (ρδ + τ )(σ + ρ) and t = ϕ + σα ρ + γ , r is smaller than (respectively, equal to or greater than) if and only if the same relation holds for t . indeed, by a straightforward computation we realize that observe that the implication ⇐= in the equivalence * ⇐⇒ holds true because thus | − ϕ| = − ϕ. in particular, the same chain of relations holds with the equal sign. finally, since r ≤ is equivalent to t ≤ , then also r > is equivalent to t > . in addition, let us notice that, if ϕ > , then both r > and t > . indeed, from the definition of t , since σα ρ+γ ≥ , we have that t ≥ ϕ > , and thus also r > . a. sensitivity analysis of the threshold t the explicit representation ( ) of the basic reproduction number r allows to study the sensitivity of r with respect to the several parameters of the model ( ) . moreover, thanks to proposition . , we know that the threshold t = βτ [ − ( − r )p] (ρδ + τ )(σ + ρ) + σα ρ + γ can be used for an equivalent characterization of the condition r < . for this reason, it is handier to develop the sensitivity of t with respect to the parameters of the model, and deduce its dependence on perturbations of the parameters. we thus compute the normalized sensitivity index s x corresponding to the x parameter, given by and we get that s α = σα ρ + γ + σα > , s γ = − σαγ (ρ + γ )(ρ + γ + σα) < , s σ = − σ[γ + ( − α)ρ] (σ + ρ)(ρ + γ + σα) < , s ρ = − ρ ρ + γ + σα [δ(σ + ρ) + τ ](ρ + γ + σα) (ρδ + τ )(σ + ρ) + σα ρ + γ < . clinical characteristics of the recovered covid- patients with re-detectable positive rna test. medrxiv incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china can the covid- epidemic be managed on the basis of daily data? world health organization covid- pandemic on diamond princess covid- : four fifths of cases are asymptomatic, china figures indicate on the definition and the computation of the basic reproduction ratio r in models for infectious diseases in heterogeneous populations optimal covid- epidemic control until vaccine deployment. medrxiv covid- : investigation and initial clinical management of possible cases impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand evaluating and testing persons for coronavirus disease critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response test, trace, contain: how south korea flattened its coronavirus curve angrist, and blavatnik school of government. coronavirus government response tracker if you've been exposed to the coronavirus clinical characteristics of asymptomatic infections with covid- screened among close contacts in nanjing timeline: how the new coronavirus spread the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application suppression of covid- outbreak in the municipality of the impacts of diagnostic capability and prevention measures on transmission dynamics of covid- in wuhan. medrxiv predicting the cumulative number of cases for the covid- epidemic in china from early data estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship an outbreak of ncip ( -ncov) infection in china -wuhan the chinese doctor who tried to warn others about coronavirus situation report , world heath organization situation report , world heath organization situation report , world heath organization laboratory testing strategy recommendations for covid- . interim guidance, world heath organization world health organization. pneumonia of unknown cause -china q&a on coronaviruses (covid- world health organization. who director-general's opening remarks at the media briefing on covid- - world health organization. who director-general's opening remarks at the media briefing on covid- - novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions. medrxiv covid- and italy: what next? the lancet, health policy modelling the epidemic trend of the novel coronavirus outbreak in china. biorxiv seir transmission dynamics model of ncov coronavirus with considering the weak infectious ability and changes in latency duration. medrxiv can you be re-infected after recovering from coronavirus? here's what we know about covid- immunity the new york times. china reports first death from new virus reproduction numbers and sub-threshold endemic equilibria for compartmental models of disease transmission humoral immune response and prolonged pcr positivity in a cohort of sars-cov patients in the new york city region. medrxiv updated understanding of the outbreak of novel coronavirus ( -ncov) in wuhan clinical presentation and virological assessment of hospitalized cases of coronavirus disease coronavirus cases in us coronavirus testing: criteria and numbers by country reported cases and deaths by country, territory, or conveyance missing deaths: tracking the true toll of the coronavirus outbreak evolving epidemiology and transmission dynamics of coronavirus disease outside hubei province, china: a descriptive and modelling study. the lancet infectious diseases clinical course and risk factors for mortality of adult inpatients with covid- in wuhan we thus notice the same qualitative dependence on the parameters already observed in section . in particular, if we increase k times the parameter β, then t increases k times as well. similar deductions can be made on the other parameters, with the corresponding coefficients obtained by inserting the values of the parameters from table . moreover, from the expression of s τ we realize that, if either ρ or δ equal zero, then t does not depend on τ (as it happens for r as well, as noticed in remark . ). similarly, if ρ = , then s δ = , thus t does not depend on δ. regarding the parameters p and r, their dependence is mutually related as follows: if p = , then t does not depend on r (since s r = ), whereas if r = then t does not depend on p. key: cord- - cjogxz authors: nan title: th annual meeting of the austrian society of surgery. vienna, june – , . guest editors: albert tuchmann, erhard schwanzer, benedikt walzel date: journal: eur surg doi: . /s - - - sha: doc_id: cord_uid: cjogxz nan die transinguinale präperitoneale hernioplastik wurde in ihren grundzügen bereits in den er jahren beschrieben. im deutschsprachigen raum erfuhr das verfahren durch die arbeiten von schumpelick eine gewisse bedeutung. pelissier entwickelte basierend auf diesen grundlagen einen patch, welcher mit einem memory-ring armiert wurde und alle hernienkompartimente der leiste abdeckt. basierend auf durch die autoren seit oktober durchgeführten hernienreparationen wurden die daten prospektiv erfasst und unter anderem die komplikationen und rezidive analysiert. hinsichtlich der intraoperativen komplikationen ergaben sich , % probleme wie blasenläsion und verletzung der epigastrischen gefäße. postoperative komplikationen wurden in fällen ( , %) beobachtet. insgesamt wurden rezidivhernien diagnostiziert (bis monate nach implantation), wobei die verteilung der rezidive uneinheitlich ist. es besteht bislang kein signifikanter unterschied zwischen fixierung mit resorbierbarem oder nicht resorbierbaren nahtmaterial. ungeschlitzte netze zeigen häufiger rezidive. die beschaffenheit des patches begü nstigt im einzelfall wahrscheinlich die rezidiventstehung. netze wurden wegen einer schmerzsymptomatik im bereich des schambeines entfernt ( - d post op), netz wegen schmerzen am netzoberrand m nach implantation. bezü glich der allgemeinen komplikationen unterscheidet sich das verfahren nicht von den gängigen hernienreparationen, die rezidivrate ist auch im längeren beobachtungszeitraum gering. es werden die problemzonen des patches diskutiert. klinisch diagnostizierte hernien ohne peritoneale ausstülpung c. hollinsky, s. sandberg kh floridsdorf, chirurgische abteilung, vienna, austria grundlagen. bei der laparoskopischen transabdominalen präperitonealen meshplastik (tapp) kö nnen leistenoder femoralhernien hinter einem intakten peritoneum verborgen sein. methodik. in einer prospektiv kontrollierten studie wurden alle laparoskopischen hernienoperationen der letzten jahre analysiert. präoperativ wurden alle hernien vom operateur klinisch untersucht und bei unklarem befund wurden ergänzend ultraschall sowie in seltenen fällen ein mrt durchgeführt. intraoperativ wurden alle suspizierten hernien auf das vorliegen eines peritonealen herniensacks untersucht sowie die im präperitonealraum eingesehene pathologie dokumentiert. in einer multivariaten regressionsanalyse wurden eventuelle risikofaktoren auf deren zusammenhang mit einer hernie ohne peritonealdefekt ermittelt. ergebnisse. bei , % der hernien war intraoperativ kein peritonealer herniensack ersichtlich. dabei handelte es sich in erster linie um femoralhernien sowie durch präperitoneales fett ausgefüllte inguinalhernien. bei der multivariaten regressionsanalyse zeigte sich neben der femoralhernie sowohl die bruchpfortengröße als auch das alter als signifikante risikofaktoren für hernien ohne peritonealbeteiligung. schlussfolgerungen. aufgrund dieser ergebnisse sollte bei klinisch diagnostizierten hernien der inguinalregion intraoperativ der präperitonealraum inspiziert werden. feasibility and potential advantages of transporous mesh fixation by a laparoscopic spray system (lss) in inguinal hernia repair excellent fixation accompanied by a reduction of the amount of fs required. investigation of a new self-gripping mesh for hernia repair in a rat model in der modernen hernienchirurgie verdrängen netzbasierte therapien zunehmend die klassischen nahttechniken. in dieser untersuchung haben wir ein neues selbstfixierendes netz (parietene progrip) im tiermodell ratte im vergleich zu einem standardnetz (parietene light) erprobt. ziel war der vergleich der zugfestigkeit tage und monate nach aufbringen der netze auf die bauchmuskulatur. die fixierung erfolgte bei dem progrip-netz nur durch mikrohaken, bei dem parietene light mittels titanklammern, gewebekleber oder ohne fixierung. im zugversuch wurde die scherfestigkeit ermittelt. außerdem erfolgte eine histologische untersuchung auf entzü ndliche reaktionen sowie eine elektronenmikroskopische untersuchung auf materialdegradation. nach tagen zeigten progrip-und stapler-fixierung ähnlich gute zugfestigkeiten ( , n/cm ; , n/cm ), wohingegen mit gewebekleber fixierte netze genauso wenig halt hatten wie unfixierte netze ( , n/cm ; , n/cm ; p < , ). nach monaten waren die progrip-netze signifikant besser auf dem gewebe fixiert verglichen mit stapler, kleber und ohne fixierung ( , n/cm vs. , n/cm ; , n/cm und , n/cm ; p < , ). die histologische untersuchung zeigte nach tagen entzündliche reaktionen im fremdkörperbereich bis in das umgebende bindegewebe. nach monaten ist diese gewebsreaktion deutlich zurückgegangen, es sind kaum noch entzündliche zellen zu finden. stattdessen ist das netzmaterial vermehrt von riesenzellen umhüllt. die progrip-mikrohaken reichen deutlich in die muskulatur und sorgen dort für eine gute verankerung. die elektronenmikroskopische untersuchung konnte keinerlei materialveränderungen nach tagen oder monaten im vergleich zu neuem netzmaterial feststellen. schlussfolgerungen. das progrip netz zeigte eine deutlich bessere fixation im gewebe als der hernienstapler oder der fibrinkleber und ist zu diesen vergleichsfixationen eine kostengünstige alternative. grundlagen. der verschluss von trokarinzisionen ü ber mm wird empfohlen aufgrund des risikos einer narbenhernienentstehung. insbesondere bei adipösen patienten ist dieser verschluss mit herkömmlichen methoden oft schwierig oder nicht durchfü hrbar. in der literatur finden sich hinweise auf eine deutlich erhöhte narbenhernieninzidenz im bereich von trokarstellen nach laparoskopischer narbenbruchoperation. methodik klinik für allgemein-und visceralchirurgie, bassum, germany grundlagen. sonographisch lassen sich präzise befunde zur pathologie der leiste als auch zur postoperativen situation resp. komplikationen erheben. fragestellung. bringt der routinemäßige postoperative einsatz der sonographie zusätzliche relevante befunde zur verlaufskontrolle? methodik. leistenhernien wurden nach transinguinaler präperitonealer hernioplastik (tipp) versorgt und im rahmen der routinemäßigen postoperativen kontrolle nach - tagen zusätzlich sonographisch standardisiert nach netzlage, hämatomen/seromen und samenstrangdurchblutung untersucht. ergebnisse. in allen fällen fand sich eine korrekte netzlage, es fand sich kein rezidiv. in fällen lag eine vermehrte netzwellung vor ( , %), meist medial, selten lateral. in / fällen ( , %) fanden sich hämatome/serome > cm schichtdicke, deutlich häufiger > mm ( / ), kleinere hämatome noch häufiger. keines der tiefen hämatome musste revidiert/punktiert werden, oberflächliche hämatome wurden revidiert, patienten wurden ein-oder mehrfach punktiert. postoperative hydrocelen wurden beobachtet. die durchblutung von samenstrang oder hoden war sonographisch in allen fällen intakt. schlussfolgerungen. die routinemäßige sonographie-kontrolle nach leistenhernienoperation (hier tipp) hat nur gelegentlich therapeutische konsequenzen fast immer zusammen mit dem klinischen befund. aufgrund der ergebnisse sollte daher ein on-demand-vorgehen als ausreichend angesehen werden. in hinblick auf die bestätigung des frühen postoperativen befundes wird die routinemäßige sonographische kontrolle von den meisten patienten aber als positive bestätigung angesehen. das video zeigt eine neue onkoplastische technik beim mammakarzinom. die tumorquadrantektomie wird dabei im rahmen einer reduktionsplastik mit superior gestieltem pedikel durchgefü hrt. der inferiore pedikel, der normalerweise reseziert wird, wird dabei zur defekdeckung genutzt. ist eine resektion des tumors mit darü berliegender haut nötig wird der inferiore pedikel nicht komplett de-epithelisiert, sondern mit hautinsel in den defekt eingeschwenkt. die technik erlaubt rekonstruktion auch von kleinen und mittelgroßen brü sten, sowie von defekten im inneren quadrant der kontralateralen brust. oncoplastic surgery: the use of a breast reduction to improve cosmetic outcome for breast conserving surgery (video) oncoplastic techniques have increasingly been used in the last years in europe and the united states. several techniques have been described. beside the use of local and free flaps after mastectomy the use of breast reduction techniques solved several problems for breast conserving surgery. this video demonstrates one possible technique to improve breast symmetry during breast conserving surgery. skin-sparing mastektomy and immediate reconstruction of the breasta videopresentation grundlagen . die erhaltung der kosmesis im rahmen der chirurgischen therapie des mammakarzinomes ist von zentraler bedeutung. trotz der vielfachen möglichkeit einer brusterhaltenden therapie, zwingen spezielle indikationen auch heutzutage noch zu einer kompletten entfernung des brustdrü dengewebes. dabei kommen immer häufiger hautsparende techniken bis hin zur erhaltung der areola oder sogar der mamille zur anwendung. im rahmen einer videopräsentation soll die technik der skin-sparing mastektomie und sofortrekonstruktion der brust veranschaulicht werden. methodik. von patientinnen, die seit mai an unserer abteilung eine brustrekonstruktion erhielten, konnten in fällen hautsparende techniken angewendet werden. zur präsentation der technik der skin-sparing mastektomie mit sofortrekonstruktion der brust wurde ein operationsvideo angefertigt. ergebnisse. die im video präsentierte technik führt zu einem kosmetisch ansprechenden ergebnis für die patientin. schlussfolgerungen. um fü r die patientinnen optimale postoperative resultate erreichen zu können, sollte die vorgestellte technik einen integralen bestandteil des therapiekonzeptes des mammakarzinoms darstellen und den patientinnen schon nach der diagnosestellung offeriert werden. the treatment of nonhealing and infected sternotomies following cardiac surgery is a challenging task, with increased rates of mortality and morbidity, as well as high costs. local vacuum therapy (v.a.c. system) permits the treatment of deep sternal infections due to continuous aspiration and a sealed dressing which stimulates granulation tissue formation. aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the speed of potential rewiring. after some weeks of v.a.c.-therapy a complete preparation of the substernal structures is necessary. in this context laceration of the right ventricle is a rare, but lifethreatening complication. we describe a new technique for sternal closure after vacuum-assisted wound treatment using nitinol clips which can prevent these severe complications. without any preparation of the substernal tissue the clips can be inserted in the parasternal space with consecutive proper stabilization of the sternum. this new method represents an easy, low-cost and complication-free procedure. der gelegentlich oder ungelegentlich angemahnte ,,hippokratischer eid'' ist kaum wegweiser für chirurgie, keineswegs weltweite norm, operationen werden ausdrücklich verboten. chirurgie muss also auf die praktische ethik zurückgreifen und daraus gültige moralische und wissenschaftliche (cochrane; ) prinzipien ableiten. diese prinzipien beruhen heute auf partnerschaftliche arzt-patient-beziehung, schadensvermeidung, dem bewusstsein und der daraus folgenden demut, dass der eingriff als schwere körperverletzung, unter dem aspekt der möglichen heilung, durchgeführt wird und gerechtigkeit -handeln ohne ansehen der person. darauf basierend wird in der neuzeit gelehrt. dies sollte auch mitverantwortlichen spitalsökonomen vermittelt werden. grundlagen. immer wieder ist man in der ärztlichen tätigkeit mit den begriffen offlabel, offlicence, compassionate use, orphan drug, individueller heilversuch und experimentelle behandlung konfrontiert. leider gibt es für die wenigsten dieser begriffe gesetzliche definitionen im österreichischen recht, sie werden deshalb oft widersprüchlich und manchmal falsch verwendet. ziel dieser arbeit ist es diese begriffe klar darzustellen und ihre gesetzlichen grundlagen aufzuzeigen. methodik. identifikation der gesetzlichen grundlagen mit hilfe des österreichischen rechtsinformationssystems, pubmed suche und google suche. diese daten werden verknüpft und zur begriffsbestimmung verwendet. es werden die jeweiligen rahmenbedingungen zur anwendung dargestellt und die auswirkungen auf die ärztliche haftung aufgezeigt. ergebnisse. auflistung der entsprechenden österreichischen gesetze sowie eu verordnungen und richtlinien. die begriffe offlabel und offlicence sind im österreichischen recht als rechtsbegriffe fremd, dennoch finden sich im arzneimittelgesetz entsprechend anwendbare rahmenbedingungen, dem jedoch zum teil die bestimmungen im allgemeinen sozialversicherungsgesetz gegenüber stehen. die begriffe compassionate use und orphan drug sind durch eu verordnungen und richtlinien geregelt. experimentelle behandlung ist nach dem arzneimittel-und medizinprodukte gesetz nur im rahmen klinischer prüfungen zulässig. schlussfolgerungen. alle angeführten modalitäten sind unter bestimmten rahmenbedingungen, vor allem die qualifizierte einwilligung, in Ö sterreich zulässig. allerdings kann dabei die haftung vom hersteller vollständig auf den behandelnden arzt/ Ä rztin übergehen. grundlagen. abseits von klassischen arzneimittel-(amg) und medizinprodukt-(mpg) studien gibt es immer wieder unklarheiten ob die ethikkommission zu beschäftigen ist oder nicht. die vorliegende arbeit analysiert dazu die gesetzlichen grundlagen Ö sterreichs, der eu und internationaler organisationen, sowie zusätzliche bestimmungen der österreichischen medizinuniversitäten. methodik. identifikation der gesetzlichen grundlagen mit hilfe des österreichischen und eu-rechtsinformationssystems, pubmed suche und google suche. die ergebnisse werden nach rechtlicher bindung vom nationalen recht bis zu internationalen empfehlungen dargestellt. es werden die strafbestimmungen im zusammenhang mit studien analysiert. ergebnisse. in Ö sterreich gibt es drei arten von ethikkommissionen: forschungs-, klinische-und bio-ethikkommission. für die klinische forschung beschränkt sich die weitere analyse auf die forschungs-ethikkommission. die österreichischen gesetzlichen grundlagen reichen vom arzneimittelgesetz (amg) bis zum universitätsgesetz (ug), hinzu kommen die universitären gsp bestimmungen und zahlreiche sonderfälle von anwendungsbeobachtungen bis zu biodatenbanken. auf eu ebene ist die rl / /eg und rl / /eg maßgeblich, international die ich, gcp und who richtlinie für ethikkommissionen. fü r die publikation können zusätzliche anforderungen wie z.b. von wame (world assocation of medical editors) und icmje (international committee of medical journal editors) gestellt werden. die strafbestimmungen im österreichischen recht werden aufgezeigt. schlussfolgerungen. die dargestellte rechtliche situation ist überaus komplex, deshalb wird es notwendig sein an universitäten aber auch extrauniversitär entsprechende beratungsstellen einzurichten. die zunehmenden anforderungen werden zu einer Ü berhäufung der ethikkommissionen mit anträgen führen. ein möglicher ausweg ist die trennung in begutachtungspflicht (für amg/mpg studien) und beratungspflicht wie in deutschland sowie die einführung von institutional review-boards als filter zwischen forscherinnen und ethikkommissionen. background. egfr-targeted therapies are a novel and very effective chemotherapeutic approach for advanced nsclc. how-ever, the predictive factors for therapeutic response are not entirely known. one of the reasons of therapy failure might be the change of egfr status during the course of disease, or an altered egfr status in metastases as compared to the primary tumor. using autopsy material, we compare here systematically the egfr status of nsclc metastases with the primary tumor. methods. autopsy cases from our institution with metastatic nsclc have been retrieved from the archive. the specimens of primary tumor and of all metastases have been stained by anti-egfr and re-evaluated by two independent observers. in addition, basic clinical parameters have been retrieved from the charts. the egfr status in primary tumor and metastases has been compared by statistical means. results. we examined a total of patients. the mean age at death was . years; the male:female ratio was : . most patients suffered from adenocarcinoma ( . %). most patients were in stage iv with multiple metastases at different body sites. while all primary tumors were egfr-positive, only in cases metastases were egfr-negative. both egfr staining intensity and extension of egfr-positive cells were in most cases identical. thus, statistical analysis failed to detect a significant difference in staining behavior between primary tumor and metastases. conclusions. the expression of egfr in metastases of nsclc is almost identical to egfr expression in the primary tumor. thus, in egfr-positive advanced nsclc egfr-targeted therapy is reasonable. grundlagen. es erfolgte eine retrospektive analyse der stationär und operativ behandelten handinfekte an unserer abteilung der letzten jahre. methodik. die krankengeschichten aller patienten die an unserer abteilung wegen eines handinfektes zwischen und operiert wurden sind retrospektiv ausgewertet worden. die patienten wurden in gruppen eingeteilt (panaritien, spritzenabszesse und phlegmonen) und miteinander verglichen. ergebnisse. es wurden patienten ( männer, frauen) mit einem durchschnittsalter von jahren operiert. am häufigsten zeigten sich panaritien ( ) gefolgt von phlegmonen ( ) und spritzenabszessen ( ). die jüngste patientengruppe war mit durchschnittlich jahren bei der operation jene der spritzenabszesse. Ä tiologisch dominierten traumata bei den panaritien und phlegmonen bzw. drogeninjektionen bei den spritzenabszessen. als grunderkrankung zeigte sich bei den panaritien und phlegmonen eine häufung von diabetes und immunsuppression. von patienten mit spritzenabszess waren hepatitis c positiv, von patienten hiv ipositiv. es wurden bis zur vollen abheilung bzw. rekonstruktion insgesamt operationen durchgefü hrt. dies entsprach einer durchschnittlich erforderlichen op-anzahl von , bei panaritien, , bei phlegmonen und , bei spritzenabszessen. die durchschnittliche aufenthaltsdauer war mit tagen bei den panaritien am kürzesten (phlegmone tage, spritzenabszesse tage). insgesamt waren lappenplastiken und amputationen notwendig. schlussfolgerungen. an unserem stark vorselektionierten krankengut zeigte sich das panaritium als die häufigste infektion an der hand mit der geringsten anzahl an notwendigen eingriffen und der kürzesten aufenthaltsdauer. phlegmone mussten wegen des teilweise sehr ausgedehnten befundes bis zu x operiert werden. durchschnittlich sind operationen bis zur völligen abheilung bzw. rekonstruktion nötig. in der gruppe der spritzenabszesse fanden sich in % staphylokokken, % streptokokken, % andere grampositive und gramnegative keime, % anaerobier, , % mischflora und in % kein wachstum. in der gruppe der phlegmonen fanden sich in % staphylokokken, in % streptokokken, in % andere grampositive und gramnegative keime, in % fand sich mischflora und in % zeigte sich kein wachstum. schlussfolgerungen. die kenntnis des keimspektrums ermöglicht eine adäquate kalkulierte therapie bis zum eintreffen des abstrichergebnisses. im rahmen unserer untersuchungen zeigten sich deutliche unterschiede zwischen den keimspektren von patienten mit panaritien, phlegmonen und spritzenabszessen. diese erkenntnis sollte bei der wahl des geeigneten antibiotikums berücksichtigung finden. grundlagen. grundprinzip der plastisch-chirurgischen infektchirurgie ist seit jeher das radikale chirurgische debridement, gefolgt von anfänglicher offener wundbehandlung. seit jahren kommt das v.a.c.-system zur wundkonditionierung erfolgreich zur anwendung. der defektverschluß erfolgt erst bei beherrschung des infektes durch auffüllung des totraumes durch gut durchblutetes gewebe, meist lappenplastiken, bei reiner weichteilbeteiligung auch durch einfache spalthauttransplantate. problematisch wird es, wenn aufgrund der anatomischen situation ein radikales debridement nur bedingt möglich ist bzw. eine keimpersistenz zu erwarten ist. methodik. das v.a.c.-instill + ermöglicht ein -stufenprogramm: instillation -einwirkzeit -vakuumtherapie kommen zyklusartig zur anwendung. bei unseren patienten kam ausschließlich ein lokales antiseptikum zur anwendung. das patientengut hatte eines gemeinsam: debridement und geplante defektdeckung schienen für eine infektsanierung unzureichend. wir berichten über patienten, die wegen hämatogenem handgelenksempyem mit beteiligung aller handwurzelknochen an unserer abteilung in behandlung waren. zur anwendung kam der polyvinylalkoholschwamm. die instillationsdauer war unmittelbar von der wundgröße abhängig. die therapiedauer betrug maximal o tage, der v,a,c,-wechsel wurde drei-bis viertägig durchgeführt. die defektdeckung erfolgte durch lokale oder gestielte lappenplastiken. ergebnisse. in allen fällen konnte trotz eingeschränkter radikalität eines chirurgischen debridements eine infektsanierung erzielt werden. schlussfolgerungen. das v.a.c.-instill + stellt für uns ein wertvolles instrument zur infektsanierung in anatomisch problematischen zonen und eingeschränkter möglichkeit eines radikalen chirurgischen debridements dar. grundlagen. handinfektionen wie panaritien und phlegmone stellen eine große gefahr fü r die integrität der hand dar. der schritt zur chirurgischen sanierung muss sorgfältig gestellt werden und richtet sich nach klinischen sowie radiologischen gesichtspunkten. trotz hohen inzidenzen sind nur wenige daten zum langzeitoutcome von chirurgischen eingriffen bezü glich der verbleibenden funktionalität der hand vorhanden. methodik. um das effektive outcome von solchen eingriffen evaluieren zu können wurden alle patienten chirurgisch sanierter handinfektionen an unserer abteilung im zeitraum von - erhoben und anschließend zu einer nachuntersuchung eingeladen. im rahmen der nachuntersuchung wurden sensibilität, kraft und bewegungsumfang der betroffenen extremität untersucht. mittels eines fragebogens wurden subjektive parameter bezüglich der betroffenen region dokumentiert. ergebnisse. von den ausgehobenen patienten erschienen patienten ( %) zur nachuntersuchung. die durchschnittliche patientenzufriedenheit auf einer skala von - lag bei , , eine deutliche einschränkung der bewegungsfreiheit war nur bei patienten evaluierbar ( %). eine objektivierbare bewegungseinschränkung ging stets mit einer verminderung der kraft, sowie sensibilitätsstörungen im bereich der finger einher. generell kann gesagt werden, dass eine weit fortgeschrittene entzündung, die meist durch zuwarten der patienten zustande kam, das outcome verschlechtert. schlussfolgerungen. je nach ausprägung zeigt sich einerseits eine herausforderung an die chirurgische sanierung, anderseits verlängert sich bei zunehmender schwere der infektion die rekonvaleszenzzeit deutlich und eine restitutio ad integro ist meist nicht mehr möglich. immunhistochemische untersuchungen zur pathogenese posttraumatischer und postinfektiöser sehnenadhäsionen logischer narben. ziel dieser studie war, die rolle des immunsystems bei der entstehung von sehnenverwachsungen zu beleuchten. untersucht wurde sehnenscheidengewebe von patient-innen, die sich einer tenolyse unterzogen. sehnenscheidengewebe von frischen leichen diente als kontrolle. immunsuppressive therapie, neoplastische oder infektiöse erkrankungen sowie chronisch entzündliche erkrankungen waren in beiden gruppen ausschlusskriterien. an gefrierschnitten wurden mit hilfe von monoklonalen antikörpern gegen t-lymphozyten und makrophagen immunhistochemische untersuchungen durchgeführt. dabei wurden die t-lymphozyten subtypisiert und ihr aktivierungsgrad bestimmt. im vergleich zur kontrollgruppe zeigte sich eine statistisch signifikante erhöhung von t-lymphozyten im patientengewebe. auch die zahl der zytotoxischen t-lymphozyten war signifikant erhöht, während die erhöhung der zahl der helferzellen nicht signifikant war. auch die zahl der aktivierten t-lymphozyten war signifikant erhöht. im patientengewebe fanden sich auch vermehrt makrophagen, wobei diese erhöhung nicht statistisch signifikant war. die ergebnisse unserer untersuchungen weisen auf eine zentrale rolle der t-lymphozyten bei der entstehung von sehnenverwachsungen hin. weitere untersuchungen zum aktivierungsweg, zur interaktion zwischen makrophagen und t-lymphozyten sowie zur rolle dendritischer zellen in diesem geschehen sollen zu einem weitergehenden verständnis dieser vorgänge führen. der tiefe infekt der hand -diagnostik und therapie am beispiel zweier fallberichte j. erhart, v. vécsei univ.-klinik für unfallchirurgie, wien, austria grundlagen. der tiefe handinfekt ist vital bedrohlich und beinträchtigt die funktion der hand. diese hängt von einem adäquaten therapeutischen konzept ab. methodik. anhand zweier fallberichte wird das management der tiefen handinfektion dargestellt. fall . nach einem bagatelltrauma ohne hautläsion kommt es zu einem tiefen infekt der hand eines mädchens. aufgrund der unklaren Ä tiologie wird ein mrt der hand angefertigt, alle möglichen ursachen ausgeschlossen, die hand der patientin dorsal und palmar debridiert und mit einem vacuumverband behandelt. im abstrich finden sich dorsal und palmar ß-hämolisierende strektokokken. es wird lediglich ein revisionseingriff zum sekundären weichteilverschluss benötigt. zur durchführung der ergotherapie bedarf es eine maximale schmerzausschaltung unter psychotherapeutischer betreuung. sie erlangt eine sehr gute funktion der hand. fall . ein ausgedehnter defekt der weichteile und knochen der handwurzel und des handrü ckens ist nach tagen septisch. die wunde wird debridiert, die defekthöhlen mit septopalketten gefü llt, mit einem radialislappen gedeckt und zur ausheilung gebracht. nach infektsanierung wird das handgelenk arthrodetisiert, die streckfunktion aller langfinger durch interposition von adduktorensehnen wiederhergestellt. schlussfolgerungen. durch die präsentation des ersten falles weisen wir auf das seltene auftreten eines spontanab-szesses der kindlichen hand hin. trotz der dringlichkeit der operation sollte eine sorgfältige abwägung der lokalisation der inzisionen erfolgen, um eine rasche infektbeherrschung durch radikales, in diesem fall beidseitiges debridement zu erzielen. wir weisen auf die extrem aufwändige nachbehandlung hin. der zweite fall ist wegen der doppelfunktion der regionalen lappenplastik zur gleichzeitigen weichteildeckung und infektbeherrschung erwähnenswert. er zeichnet sich durch einen sicheren erhalt der hand und die vollständige wiederherstellung der fingerfunktion aus. free tissue transfer for complex infections of the handa retrospective analysis grundlagen. schwere infektionen im handbereich bedürfen nach ausgedehntem radikalen débridement und bannung der infektion häufig einer komplexen defektdeckung. diese retrospektive analyse umfasst patienten ( männlich, weiblich), welche zwischen juni und märz mit ausgedehnten infektionen an der hand operiert worden sind. ergebnisse. infektursache war in drei fällen ein hundebiss und in zweien ein bagatelltrauma. in zwei fällen war der hautweichteilinfekt auf den handrü cken, in einem auf die hohlhand beschränkt. zwei patienten zeigten einen kombinierten dorsalen und palmaren infekt. bei einem patienten fand sich neben einer ausgeprägten streck-und beugeseitigen infektlokalisation auch ein handgelenksempyem mit bereits stattgefundener knochenzerstörung. der patienten wurden vor der einweisung in die spezialklinik auswärtig durch stichinzisionen mit drainagen und/oder begrenzte nekrosektomien chirurgisch vorbehandelt. bei drei patienten wurde nach einmaligem débridement, bei zweien nach mehrfachdébridements die indikation zur mikrochirurgischen defektdeckung gestellt. diese wurde mit splited-lat.-dorsi-lappen, serratus-ant.-lappen und lat.-oberarm-lappen durchgefü hrt. alle lappenplastiken zeigten einen unkomplizierten primären heilungsverlauf; in zwei fällen erfolgte eine operative nachkorrektur im sinne von kontrakturauflösung, lappenausdü nnung und liposuktion. der patienten verzeichneten nach intensiver postoperativer ergo-und physiotherapie bereits ab der . postoperativen woche einen vollständigen aktiven faustschluss, sowie spitz-und schlü sselgriff. die rom an hand-und sämtlichen fingergelenken betrug zu diesem zeitpunkt % der nicht betroffenen hand. schlussfolgerungen. der mikrochirurgische transfer von fasziokutanen-oder muskel-lappenplastiken stellt eine zuverlässige methode der defektdeckung bei ausgedehnten handinfekten dar. abhängig von ausdehnung und lokalisation des defektes steht die lappenauswahl zum erreichen eines zufriedenstellenden funktionellen und ästhetischen ergebnisses im vordergrund. background. oncolytic viral therapy may offer a promising alternative in highly aggressive tumors such as malignant pleural mesothelioma (mpm), that are insensitive to established chemotherapy and radiation regimes. in the following study, the oncolytic efficacy of newcastle disease virus (ndv (f aa)-gfp) on mpm is tested and investigated by bioluminescence imaging. methods. ndv(f aa)-gfp was tested for viral cytotoxicity at different multiplicities of infection (moi) against several mesothelioma cell lines in vitro. for in vivo studies, msto h cells were transduced with firefly (photinus pyralis) luciferase (fluc)encoding cdnas (msto td h). tumor-bearing animals ( e cells injected intrapleurally) were treated with either single or multiple doses of ndv(f aa)-gfp ( e plaque-forming units pfu should be given as log ) at different time points (days , , and ) and followed by bioluminescence imaging. results. mesothelioma cell lines exhibited susceptibility to ndv lysis in the following order of sensitivity: msto h > msto td h> h- > vamt > jmn (no effect in the cell lines h- , h- , and hmeso) . in vivo studies with msto td h cells showed complete response to viral therapy in > % of the animals, resulting in eradication of tumor detected by bioluminescence. % of the virally treated animals survived > days after tumor injection. no signs of toxicity were observed in the treatment group. in addition, multiple treatments showed a significantly better response compared with single treatment (p ¼ . ). conclusions. ndv appears to be an efficient viral oncolytic agent in therapy of malignant pleural mesothelioma in a murine model, and warrants further investigation as a potential therapeutic agent. university clinic for surgery, graz, austria; institute for pathology, graz, austria background. isolation by size of epithelial tumour cells (iset) is an innovative method for the detection of circulating tumour cells in blood. we want to report our preliminary experiences with this method. methods. blood of patients with liver metastases from colorectal cancer and of five patients with benign liver lesions was analyzed for the presence of circulating tumour cells. therefore blood samples were filtrated through a translucent polycarbonate filter. epithelial cells were retained on the filter due to their large size and thus separated from smaller blood particles. afterwards the filter was stained and evaluated by light microscopy. tumour cells were identified by cytomorphological criteria's. results. no patient with a benign liver lesion had detectable tumour cells in blood, but eight of the twenty patients with liver metastases. see the following table. the difference concerning the recurrence rate between the two groups was statistically significant (p < . ). conclusions. it is possible to detect circulating tumour cells in blood on basis of their size. the most important advantage of this method is the ability to isolate the tumour cells without damaging their morphology. so the isolated cells can be used for further analysis. grundlagen. höhere konzentrationen im tumorgewebe durch drug targeting erhöhen die responserate sowie das gesamtüberleben. einen neuartigen experimentellen ansatz stellt die applikation von in erythrozyten verkapselten chemotherapeutika ( -fu) dar. im lebertumortragenden modell sollten in erythrozyten verkapseltes -fu erstmals appliziert werden. zielsetzung war die technische machbarkeit einer verkapselung von -fu, die bestimmung der biokompatibilität der -fu-erythrozyten sowie die messung der -fu-konzentration im tumorgewebe. methodik. als tiermodell dienten wag-ratten, denen cc -tumorzellen der leber subkapsulär appliziert wurden. nach ausbildung makroskopisch fassbarer solitärtumoren folgte die applikation von verkapselten erythrozyten der ratte, die nach einem hypoosmotischen dilutionsprozeß mit -fu beladen worden waren. es erfolgte die unterteilung in vier gruppen und zeitpunkten, wobei die applikation von unverkapseltem und verkapseltem -fu systemisch und lokal via arteria hepatica erfolgte. tumorgewebskonzentrationen wurden mittels hplc (high performance liquid chromatography) bestimmt. ergebnisse. es konnte eine ausreichende beladung der erythrozyten mit -fu erreicht werden. der nachweis gelang durch zentrifugieren der erythrozyten und anschließender lyse der erythrozytenmembranen. der Ü berstand wurde dann per hplc gemessen. die tumorkonzentration war signifikant (p < , ) gesteigert durch die verkapselung in erythrozyten sowie durch lokoregionäre applikation. die tumorkonzentration wurde als konzentrationszeitkurve (area under the curve auc) vom zeitpunkt - h dargestellt. freíes -fu -fu verkapselt , mg/ml Á min , mg/ml Á min systemische appl. , mg/ml Á min , mg/ml Á min arterielle appl. schlussfolgerungen. die chemische verkapselung von -fu in erythrozyten der ratte ist möglich, wobei ein hoher grad der beladung der erythrozyten erreicht werden kann. es zeigten sich signifikant höhere -fu-tumorkonzentrationen bei der lokoregionären gegenüber der systemischen sowie bei der verkapselung in erythrozyten. expression of integrin-linked kinase and the progression of early-stage nsclc: a pilot study background. although radical resection of early-stage nonsmall cell lung cancer (nsclc) should warrant cure in almost every case, clinical experience teaches that recurrences appear in up to % of cases. therefore, the prognosis is probably codetermined by additional risk factors, which are not described by the tnm scheme. integrin-linked kinase (ilk) is a known molecular risk factor for metastatic progression. in this study we attempt to verify its role in the progression of early-stage nsclc. methods. all stage ia pulmonary adenocarcinoma patients operated until in our institution have been retrieved from the clinical archive, and a follow-up has been conducted. the pathological specimens of the primary tumor have been stained against ilk, two blinded observers have scored the ilk expression. the results have been compared with the clinical data adopting a basic kaplan meier statistics. results. we examined a total of patients ( males, females) with a mean age of years. median follow-up was . years. twenty-eight patients ( %) were ilk-positive, only four ( %) were ilk-negative. eleven ilk-positive patients experienced a recurrence within five years; from those patients, ten died. this corresponds to a -years recurrence-free survival of ae % and a -years overall survival of ae % in ilk-positive cases. conversely, none of the ilknegative patients had a recurrence nor died within five years. conclusions. ilk-negative stage ia nsclc patients have apparently a better tumor-related prognosis than ilk-positive patients. however, these observations have to be extended unto a larger patient cohort. biliverdin reductase: a crucial enzyme in bile pigment mediated tumor inhibition? background. maximization of liver regeneration represents a promising strategy to improve outcomes after extensive liver resection. here, we investigate the role of lipocalin in liver regeneration. methods. lcn þ=þ , lcn þ=À and lcn À=À mice were subjected to / partial hepatectomy. hepatic proliferation was measured by brdu and pcna immunohistochemistry. hepatic lcn expression was analyzed by qrt-pcr and western blots. serum levels of lcn , il- , and tnf-were determined by elisa. results. hepatic regeneration in lcn þ=þ mice was analyzed at , , and h after partial hepatectomy. the peak of hepatic proliferation as indicated by the number of brdu-and pcna-positive cells was confirmed to be at h post surgery. analysis of hepatic lcn expression showed a -fold upregulation only h after liver resection in lcn þ=þ animals with a stepwise reduction during the observation period ( h . -fold, h . -fold, h . -fold). western blots confirmed significant lcn protein over-expression h after partial hepatectomy. also, serum lcn levels were significantly elevated upon liver resection. to determine the biological relevance of lcn induction on liver regeneration, hepatocyte proliferation was analyzed in lcn þ=À and lcn À=À mice h after partial hepatectomy. the number of brdu-and pcna-positive cells did not differ significantly between the groups. however, lcn À=À animals exhibited a significantly elevated baseline liver regeneration ( . -fold lcn À=À vs lcn þ=þ , p < . ). conclusions. up-regulation of lcn after murine partial hepatectomy is striking but without significant impact on hepatocyte proliferation. our results imply that lcn induction upon liver resection either constitutes a redundant pathway or simply displays an epiphenomenon. effect of the probiotic mixture vsl# on epithelial barrier function, tight junction protein expression, and apoptotic ratio in a murine model of colitis background. changes in epithelial tight junction protein expression and apoptosis increase epithelial permeability in inflammatory bowel diseases. the effect of the probiotic mixture vsl# on the epithelial barrier was studied in dextran-sodium-sulphate (dss)-induced colitis in mice. methods. acute colitis was induced in balb/c mice ( . % dss for days). mice were treated with either mg vsl# or placebo via gastric tube once daily during induction of colitis. inflammation was assessed by clinical and histological scores. colonic permeability to evans blue was measured in vivo. tight junction protein expression and epithelial apoptotic ratio were studied by immunofluorescence and western blot. results. vsl# treatment reduced inflammation (histological colitis scores: healthy control . ae . , dss þ placebo . ae . , dss þ vsl# . ae . ; p ¼ . ). a pronounced increase in epithelial permeability in acute colitis was completely prevented by vsl# therapy (healthy control . ae . (ext./g), dss þ placebo . ae . , dss þ . ae . ; p ¼ . ). in acute colitis, decreased expression and redistribution of the tight junction proteins occludin, zo- , claudin- , - , - , and - were observed, whereas vsl# therapy prevented these changes. vsl# completely prevented the increase of epithelial apoptotic ratio in acute colitis (healthy control . ae . (apoptotic cells/ epithelial cells), dss þ placebo . ae . , dss þ vsl# . ae . ; p ¼ . ). conclusions. probiotic therapy protects the epithelial barrier in acute colitis by preventing ( ) decreased tight junction protein expression, ( ) increased apoptotic ratio. background. to prospectively compare the accuracy of liver fat quantification using chemical shift imaging and h mr-spectroscopy at . tesla field strength in patients undergoing major hepatic surgery. methods. the study was approved by our local irb and a total of patients, planned for metasectomy, were prospectively included after signing informed consent. preoperative . tesla mri (trio, siemens) of the liver included t w d gre single breath hold in-and opposed phase sequences (te . / . ms) and a single breath hold single voxel h mr-spectroscopy (voi cm ; te ms). with chemical shift imaging liver fat was quantified with the relative loss of the liver-to-spleen signal intensity ratio on the opposed-phase images compared to the inphase images. with h -spectroscopy liver steatosis was quantified by calculating the integral of the water and fat spectra. the standard of truth was defined by histopathological analysis of the surgical specimens according to a five-point scale ( -no steatosis; -severe steatosis). spearman's rank correlation was used for statistical analysis. results. both h -spectroscopy and chemical-shift imaging showed a high correlation of the liver steatosis grading compared to the histopathological analysis (r ¼ . and . ). the difference between both techniques was not significant (p > . ). conclusions. both, h mr-spectroscopy and chemical shift imaging at . tesla, allow for a noninvasive preoperative assessment of liver steatosis with high correlation to histopathology. the addition of bevacizumab to xelox/folfox is concidered as standard in the neoadjuvant treatment of colorectal cancer liver metastases. since bevacizumab does not exert direct cytotoxicity, the concept of tumor response as indicator of efficacy upon neoadjuvant therapy containing bevacizumab is being challanged. cytotoxic therapy of liver metastases results in pathologic response of various grades, however the effect of bevacizumab on pathologic response is unclear. we retrospectively analyzed specimen of liver metastases of patients treated with xelox/folfox or xelox plus bevacizumab. we report that bevacizumab, when combined with xelox/folfox, increases the extent of necrosis and decreases the amount of fibrosis in colorectal liver metastases compared to xelox/folfox alone. however, bevacizumab does not change the radiologic response according to recist. we conclude that bevacizumab improves pathologic response which has no counterpart in radiologic response. role of hepatic lymph node involvement within the hepatic pedicle in patients with colorectal liver metastases background. hepatic lymph node involvement in patients with colorectal liver metastases is an important prognostic factor, but the role of lymphadenectomy, especially of the hepatic pedicle, is still unknown. methods. at the medical university graz patients, who underwent liver resection because of colorectal liver metastases between and , were retrospectively reviewed. results. out of patients , % ( patients) underwent combined hepatectomy and node dissection of the hepatic pedicle, whereas patients underwent hepatectomy only. , % ( of patients) were microscopically node positive within the hepatic pedicle and , % ( of patients) were node negative. the -year survival rate for the whole group ( patients), for the node positive group ( patients) and the node negative group ( patients) was , %, , % and , % with a median survival time of days, days and days respectively. the difference was significant (p ¼ , ). tumor recurrence was found in patients ( , %) with a disease free survival (dfs) of days in the whole group, days in the node positive and days in the node negative group. conclusions. patients with positive lymph nodes in the hepatic pedicle are at high risk for a shorter dfs and a decreased -year survival rate and can be safely identified by lymphadenectomy in this area. grundlagen. das kolorektale karzinom führt in % der fälle zu einer synchronen leberfiliarsierung -weitere % der patienten entwickeln vornehmlich in den ersten beiden jahren nach operation des primärtumors metastasen. die radikale chirurgie der lebermetastasen stellt bis dato die einzige chanche auf heilung dar mit -jahres Ü berlebensraten von - %. die rezidivrate nach leber-erstresektionen beträgt - % und nur % dieser patienten sind einer weiteren radikalen leberresektion zugänglich. methodik. die eigenen ergebnisse wurden retrospektiv analysiert und mit den daten der gängigen literatur verglichen. im zeitraum von / - / erfolgten an patienten insgesamt n ¼ leberteilresektionen wegen metastasen eines kolo-rektalen karzinoms; n ¼ patienten wurden einmal und n ¼ patienten mehrfach reseziert. ergebnisse. bei den patienten handelte es sich um männer und frauen in einem durchschnittlichen alter von jahren. bei n ¼ patienten erfolgten eine oder mehrere -bis maximal re-resektionen, wobei in allen fällen eine r- situation erreicht wurde. mortalität und morbidität waren hierbei gering ( bzw. %) und führten zu einem durchschnittlichen stationären aufenthalt von . tagen. inzwischen sind n ¼ patienten -bei einem mittleren Ü berleben von monaten (min , max monate) -verstorben; n ¼ patienten, bei einem mittlerem Ü berleben von monaten (min , max monate) sind tumorfrei am leben. schlussfolgerungen. auch wiederholte leberteilresektionen bei metastasen eines kolo-rektalen karzinoms sind mit einer niederen mortalität und morbidität durchführbar; entscheidend für das langzeitüberleben ist die r- resektion. background. laparoscopic liver surgery has been proven feasible and safe for the treatment of benign and malign liver diseases. however, the complexity of resections and the limitations in instrumentation hamper broad acceptance for advanced liver surgery. herein we describe different technical procedures for minimally invasive liver surgery adding safety to major laparoscopic hepatic resections. methods. three patients ( female, male; age: , , ) underwent laparoscopic major hepatic resections for primary and secondary liver malignancy, respectively. the entire operation was guided by laparoscopic ultrasound to define the resection planes. vascular control of the hepatic inflow and outflow was achieved for the impaired part of the liver. dissection of the parenchyma was carried out utilizing in particular laparoscopic radiofrequency ablation, the harmonic scalpel and laparoscopic staplers. specimen were retrieved in a bag through an enlarged trocar incision. the technique is discussed. results. laparoscopic liver resection was completed in all patients. the operative time was - min. no intraoperative adverse events were observed. blood loss yielded insignificant in and ml in one patient, respectively. specimen were retrieved in a bag through a widened trocar incision. no significant perioperative complication was noticed. histological evaluation revealed sufficient resection margins to the malignant tumours. oral diet was resumed on the first postoperative day. patients were discharged on day , and (due to additional surgery not related to the liver resection). conclusions. we present our technique for laparoscopic major hepatic resections by use of standard laparoscopic instrumentation. comparison of preoperative indocyanine green clearance in patients with colorectal liver metastases pretreated with systemic chemotherapy background. preoperative systemic chemotherapy has become an essential tool in downsizing colorectal liver metastases (clm), helping to render patients with initially irresectable disease resectable and to prolong progression free survival in initially resectable patients. histopathologic examinations of resected non-tumoral liver tissue have raised concerns about chemotherapy-associated liver injury, which might impair the function of the remnant liver. we therefore tried to evaluate whether indocyanine green plasma dilution rate (pdr, % Á min À ), which can easily be measured preoperatively, helps to assess chemotherapy-induced liver damage. methods and results. data of liver resections for clm performed between january and december were analyzed. onehundred-fifteen patients were treated with chemotherapy prior to surgery, patients were resected without pretreatment. patients who received preoperative chemotherapy had a significant lower pdr ( . ae , versus . ae . ; p ¼ . ) reflecting an impaired liver function. the percentage of subjects with an abnormal pdr (pdr ) was significantly higher among those who were treated with chemotherapy prior to liver resection ( . % versus %; p < . ). patients with a pdr stayed longer in the intensive care unit compared to those with a pdr > ( . ae . versus . ae . ; p ¼ . ) and had a significantly longer postoperative hospital stay ( . ae . versus . ae . ; p ¼ . ). the incidence of postoperative complications was increased in those with an abnormal pdr ( . % versus . %; p ¼ . ). conclusions. assessing the pdr preoperatively may help to indentify patients with an impaired liver function after preoperative chemotherapy. grundlagen. die radiofrequenztherapie ist mittlerweile ein etabliertes verfahren zur lokalen tumorkontrolle bei nicht oberflächennahe lokalisierten primären und sekundären lebertumore mit einer maximalen größe von cm. wir eine technik entwickelt, die es ermöglicht große tumore oberflächennahe und damit in unmittelbarer nachbarschaft zu anderen organen, wie magen, colon, niere oder zwerchfell laparoskopisch so zu isolieren, so dass sie anschliessend computerunterstützt abladierbar sind. die ergebnisse und komplikationen werden hier präsentiert. methodik. alle patienten, die im zeitraum von / bis / nach laparoskopischem liver packing radiofrequenzabladiert wurden, wurden eingeschlossen und retrospektiv analysiert. patientendaten, komplikationen, und follow-up sind dokumentiert worden. ergebnisse. patienten (f ¼ , m ¼ ) mit einem mittleren alter von . jahren sind im beobachtungszeitraum wegen eines ccc (n ¼ ), hcc (n ¼ ) und metastasen (n ¼ , colon, rektum, mamma, neuroendokrines karzinom, melanom, rcc) operiert und abladiert worden. die perioperative mortalität betrug , % (n ¼ ) aufgrund eines postoperativen leberversagens. die beobachtete morbidität betrug , % (n ¼ ) und beinhaltete pulmonaembolien, dü nndarmverletzungen mit intraoperativer Ü bernähung, mods, ards, durchgangssyndrom, cervikale plexusläsion, intraparenchymatöse blutung mit angiographischer blutstillung, par-tielle pfortaderthrombose, spätabszess und ein erysipel am unterarm. leichtes fieber und transienter transaminasenanstieg trat bei allen patienten auf. bei patienten wurde wegen eines rezidivs eine neuerliche rft mit liver packing notwendig, patienten wurden ohne packing ein zweites mal abladiert und ein patient unterzog sich einer linksseitigen hemihepatektomie nach rechtsseitiger ablation. schlussfolgerungen. das laparoskopische liver packing ermöglicht eine ablative therapie der leber in patienten, die mit den herkömmlichen möglichkeiten nicht lokal therapierbar sind. die technik ist mittlerweile standartisiert mit geringer mortalität und morbidität durchführbar. grundlagen. ablationsverfahren nehmen einen festen platz in der therapie von lebermetastasen ein. entscheidend fü r den onkologischen erfolg einer ablation ist die erzeugung einer ausreichend großen thermoläsion, die die metastase mit einem ausreichenden sicherheitsabstand vollständig zerstört. ziel dieser studie war es, bei patienten die aufgrund von kolorektalen lebermetastasen eine ablative therapie erhielten mögliche faktoren herauszuarbeiten, die eine unvollständige thermoablation verursachen. methodik. patienten mit irresektablen kolorektalen lebermetastasen. ab erhielten die patienten eine laserinduzierte thermotherapie (litt), ab eine bipolare radiofrequenzablation (rfa). ausschlußkriterien: metastasenanzahl > , metastasendurchmesser > cm, extrahepatische tumormanifestation. bei den offen-chirurgischen ablationen erfolgte eine sonografische punktionskontrolle, die perkutanen ablationen erfolgte ct-oder sonografiegestützt in lokalanästhesie. zur kontrolle der vollständigen ablation (,,r '') erhielten alle patienten - h postinterventionell eine km-gestützte mrt. in abhängigkeit der erreichten ,,r -ablation'' erfolgte die einteilung der patienten in zwei gruppen: gruppe i: ,,r -ablation'', gruppe ii: keine ,,r -ablation''. ,,r -ablation'' ¼ sicherheitsabstand von allseits cm in der postinterventionellen mr-untersuchung. ergebnisse grundlagen. die chirurgische versorgung der leistenhernie galt lange zeit als wenig interessanter standardeingriff und wurde nicht selten dem jungen ausbildungsassistenten überlassen. in den letzten jahren hat sowohl die wissenschaftliche auseinandersetzung als auch das interesse an ergebnisorientierter qualitätssicherung deutlich zugenommen. methodik. in zusammenarbeit mit dem zürser hernienforum wurde an unserer abteilung ein herniendokumentationssystem entwickelt. als basis diente ein software-programm, das für die qualitätssicherungsstudie des bÖ c im jahr geschrieben wurde. dieses wurde im expertengremium auf heutige anforderungen adaptiert und von der hausinternen it in das krankenhaussystem sap integriert. die eingegeben daten können über eine access-datenbank analysiert und ausgewertet werden. ergebnisse. das system ist an unserer abteilung seit . . in betrieb. die dateneingabe erfolgt zu zeitpunkten (im op, nach entlassung, bei follow-up kontrolle) und ist an einer abteilung eines ordenskrankenhauses mit limitierter mitarbeiter-zahl gut zu bewerkstelligen. schlussfolgerungen. nach erfolgreichem testbetrieb kann das herniendokumentationssystem anderen interessierten abteilungen zur verfügung gestellt werden. die anwendungsmöglichkeiten reichen von der eigenen qualitätskontrolle bis zur häuserübergreifenden analyse neuer medizinischer produkte oder op-methoden. laparoscopic ventral hernia repair with ipomexperience from the first cases abteilung für chirurgie, bruck/mur, austria grundlagen. bereits wurde von k. leblanc erstmals ü ber den verschluss einer bauchwandhernie in laparoskopischer ipom (intraperitoneales onlay mesh)-technik berichtet. erst mit der entwicklung verschiedener kunststoffnetze, die immer besser die speziellen anforderungen fü r eine intraabdominelle platzierung erfü llen, kam es zu einer zunehmenden verbreitung dieser technik. es wird ü ber unsere erfahrungen aus den ersten fällen berichtet, wobei das besondere augenmerk den rezidiven und ihren möglichen ursachen gilt. methodik. verwendet wurde in allen fällen ein dreidimensionales, multifaser polyestermesh mit resorbierbarer beschichtung. die eingriffe wurden von operateuren durchgefü hrt. je nach operateur erfolgte die befestigung entweder mit spiraltacks oder einer kombination aus spiraltacks und transfaszialen nähten. ergebnisse. unsere ergebnisse bestätigen, dass in erster linie eine ausreichende Ü berlappung der bruchlücke das rezidivrisiko niedrig hält. dies ist ein grund warum die laparoskopische technik derzeit hinsichtlich bruchlückengröße und lokalisation der hernie noch grenzen aufweist. schlussfolgerungen. unsere erfahrungen mit den ersten durchgefü hrten operationen zeigen, dass mit ausreichender minimal invasiver erfahrung und entsprechender patientenselektion die laparoskopische ipom-technik einen wichtigen platz in der optimalen versorgung von bauchwandhernien einnehmen kann. erfahrungen mit konsekutiven laparoskopischen narbenhernienoperationen grundlagen. die reparation von narbenhernien stellt einen der häufigsten eingriffe dar. in letzter zeit kommt die laparoskopische intraperitoneale onlay mesh technik (lap. ipom) vermehrt zum einsatz. unsere erfahrungen mit dieser methode werden dargestellt. methodik. in einer single center studie wurden patienten, die von august bis november einer lap. ipom unterzogen wurden, retrospektiv untersucht. (demographische daten, comorbiditäten, art und größe der narbenhernien und netze, art der fixation, operationszeiten, stationärer aufenthaltsdauer, komplikationen, rezidive.) ergebnisse. es wurden patienten in die studie eingeschlossen. das durchschnittliche alter der patienten betrug jahre; der mittlere bmi lag bei . % aller patienten litten an diabetes, während % eine copd aufwiesen. die mittlere operationszeit betrug minuten. in % aller patienten wurde ein polyester netz verwendet, in % ein eptfe netz. bei patienten traten insgesamt komplikationen auf. die häufigsten komplikationen waren serome ( , %) und hämatome ( %). , % aller patienten wiesen postoperativ länger andauernde schmerzen auf. in , % kam es zum auftreten eines ileus aufgrund von adhäsionen oder inkarzeration. netzinfektionen und netzausrisse traten jeweils bei , % aller patienten auf. netzinfektionen fü hrten stets zum operativen ausbau der implantate. ein patient verstarb am vierten postoperativen tag an einem multiorganversagen aufgrund einer darmperforation. nach einem medianen follow-up von monaten kam es bei % der patienten zu einem rezidiv. schlussfolgerungen. die komplikations-und rezidivrate in dieser ersten serie ist mit den in der literatur angegeben vergleichbar. wir erachten die lap. ipom technik für eine interessante alternative zu herkömmlichen verschlusstechniken. comparison of different fixation elements for the ipom procedure in a rat model background. long-time complications after the laparoscopic ipom techniques are adhesion formation and recurrence. because of the intraperitoneal position of the foreign body, adhesions could lead to severe complications like ileus or fistula formation. equally insufficient fixation produces recurrent hernias. study design. forty sprague-dawley rats were used in this two-phase, prospective randomized study. polypropylene mesh (parietene composix) samples were positioned intraperitoneal bilaterally to the midline. the randomized mesh fixation groups were suture (su), protack (pt), absorba tack (at) and i-clip (ic). half of the rats in each group were sacrificed and analyzed one week after implantation while the second half were sacrificed and analyzed after two months. measured parameters were strength of incorporation (soi) and adhesion formations. results. after one week the soi of the su fixation was significantly higher than for all other groups. between pt and at the soi was equally and significantly higher than in the ic group. after two months again the soi from the su was significantly stronger than the two fixation groups pt and at. ic was poorly incorporated resulting in few soi. inflammatory reactions were considerably more severe after one week than after two months. adhesion formations were significantly stronger in the groups su and pt compared to at and ic. conclusions. ic showed unacceptable soi and should not be used for mesh fixation. at leads only to few adhesions compared to the nonabsorbable su and pt. to have a good fixation and less adhesions, a combination of different fixation systems should be used. background. research in hernia repair has targeted new atraumatic mesh fixation techniques like surgical adhesives to reduce major complications like chronic pain and adhesion formation. the efficacy and safety of two adhesives, e.g. artiss + fibrin sealant (fs; iu thrombin, baxter, austria) and bioglue + (bg; cryolife, usa) were evaluated in this study. study endpoints were tissue integration and foreign body reaction. adhesion formation formed the secondary outcome parameter. methods. twelve rats were randomized to groups (n ¼ ). groups of onlay hernia repair -mesh fixation with fs (group ) or bg (group ), one group of ipom repair -mesh fixation with sutures and bg (group ). follow up was days. native rat tissue served as control. macroscopical and histological assessment was performed. results. onlay meshes fixed with fs showed excellent results in all evaluation criteria (group ). samples fixed with bg (group , ) showed extensive scar formation. no dislocation and no seroma formation was seen. all of these samples showed moderate to severe signs of inflammation with abscess formation in all samples of group . adhesion formation was scored moderate to severe in all samples of group . histological signs of a moderate foreign body reaction as well as detritus and remnants of bg were seen in all samples fixed with bg (group , ). conclusions. artiss + showed excellent mesh fixation and biocompatibility in onlay hernia repair. bioglue + yields high adhesive strength, but our macroscopical and histological results indicate a reduced biocompatibility. treatment of mesh graft infection following abdominal hernia repair -risk factor evaluation, role of the v.a.c. system and influence of the type of mesh useda retrospective analysis of operations background. commonly, mesh graft infections after hernia repair are treated by rapid removal of the mesh causing high morbidity. new materials of mesh grafts and new procedures of wound management now further challenge the need for mesh removal. risk factor based choice of patients selected for initial hernia repair might partially avoid such complications. methods. four hundred and seventy-six mesh grafts implanted for hernia repair were retrospectively analyzed to determine risk factors for development of a graft infection. we further evaluated the outcome of infected mesh grafts (n ¼ ) treated by best supportive care including vacuum assisted closure system. results. risk factors for mesh graft infection were body mass index (bmi), operation time for hernia repair and the size of the hernia. % of infected mesh grafts could be preserved by conservative means. preservation was possible for % of polyglactin/polypropylene mesh as compared to - % for non-absorbable types of meshes (p < . ). preserved mesh graft showed no recurrent hernias at the site of infection. conclusions. conservative treatment is a valid option for mesh graft infection. polyglactin/polypropylene mesh grafts might be preferentially used for open hernia repair. hernia repair should be preferentially performed when hernias are still small and when high bmi is reduced. biomeshes in experimental ipom repairan overview of own trials background. biomeshes (bm) are a new family of implants designed for the reinforcement of ventral hernias. their use is gaining widespread attention in the usa and some european countries. despite the recommendation to use them specifically in contaminated wound fields and giant hernias, experimental data on their biocompatibility and tissue integration is still scarce. our study group has investigated several biomeshes and tested new methods to possibly enhance the tissue integration (additional perforations; fibrin sealant bm fixation). methods. porcine small intestine submucosa (sis), porcine collagen (pc) and bovine pericard (bp) implants have been tested (n ¼ per group) in a model of open ipom repair. bm were  cm in size and fixated with non resorbable sutures (synthofil, ethicon, germany) to the peritoneum. observation period was days in all groups. primary outcome parameters were adhesion formation, tissue integration and dislocation. foreign body reaction was a secondary outcome parameter assessed in histology (he staining). results. sis, pc and bp showed controversial results when indirectly compared with the established standards of synthetic meshes in ipom repair. problematic findings were obtained for tissue integration and foreign body reaction. conclusions. different bm differ distinctively in terms of important outcome parameters. in our hands they were not superior to synthetic meshes. the potential for improvement for the use of bm will be presented by the authors. mesh coating with vital human amniotic membrane reduces early adhesion formation in experimental ipom repair background. the laparoscopic intraabdominal peritoneal onlay mesh repair (ipom) is an increasingly popular technique for the repair of incisional hernias. the intraabdominal use of synthetic meshes cavity often leads to adhesions between bowel and the implant or fixation devices. this study was designed to assess the impact of vital human amniotic membrane (ha) to cover polypropylene meshes in order to prevent adhesion formation (vitamesh + , vm, proxy biomedical, ireland) in experimental ipom repair. vitality of this biomatrix is considered to preserve its desired physiological characteristics. avital ha has been suggested for this purpose by other study groups. methods. thirty-two rats were assigned to the implantation of vm fixated with non resorbable sutures (synthofil, ethicon, germany) to the peritoneum. vm was covered with with ha. vm was cm in diameter and implanted in open ipom by a laparatomy. the observation period was and days (n ¼ / ). adhesions were rated with the score by vandendael. histology was performed. results. ha markedly reduced adhesions when compared to a historical control group (vm w/o coating). adhesions were found at structures which were not fully covered by ha (protruding sutures, mesh fibers at the edges of vm). ha formed a highly effective barrier preventing adhesions. tissue integration in histology was good. conclusions. vital ha yields anti-adhesive efficacy and showed good biocompatibilty in a xeno model. further research has to elucidate a potential clinical application. biological mesh in complex abdominal wall repairlong term results of use of permacol tm (porcine dermal collagen) in a single institution r. d. pullan, d. j. devon torbay hospital, torquay, uk background. abdominal wall repair (awr) if poor tissues, contamination, intestinal fistula, anastomosis, stoma and mesh impingement on bowel represent formidable surgical challenges. synthetic mesh or suture repair is inappropriate. biological meshes are biocompatible, offer resistance to contamination, minimal adhesion or fistula formation but retain strength. we use permacol tm -crosslinked porcine dermal collagen -in these cases and present data with long follow up. methods. retrospective review of patients treated with permacol tm for: . recurrent incisional hernia ae mesh; . post laparostomy; . enterocutaneous fistula; . contamination by anastomosis; . parastomal hernia. results. twenty-nine patients were identified. with acute or chronic abdominal defects; with parastomal hernia. defects sizes from to cm . median age (range - ) years and follow up ( - ) months. eleven cases awr - with anastomosis, paracolostomy hernia. eight enterocutaneous fistula with deficient abdominal wall; with fistula associated with mesh, all with anastomosis. four recurrent of parastomal hernias. repairs by onlay, inlay and sublay. sixteen cases had no complications. major complications in patients - early deaths (myocardial infarct and multiorgan failure); recurrent hernia, colonic ischaemia requiring relaparotomy and intra abdominal abscess requiring percutane-ous drainage. seven minor complications comprised wound infections, sinus and seroma. there were no mesh rejections and no further complications. conclusions. in difficult anterior abdominal wall repair permacol tm is effective, biocompatible, resistant to infection, contamination and can sit in contact with bowel. background. rectoanal repair (rar), a combination of mucopexy and haemorrhoidal artery ligation (hal), is proposed an ''anorectal lifting'' alternative to stapled haemorrhoidopexy. we retrospectively investigated efficacy and safety for this technique in our center. methods. rar was performed under general anaesthesia in patients ( female, male) with symptomatic haemorrhoids iii ( %) or haemorrhoids ii-iii with simultaneous mucosal prolapse ( %) from march to october . previous anal surgery was recorded in five patients. mucopexy was performed using a conventional anal dilator and vicryl - absorbable sutures at the prolapse sites (median , range - , sutures) with secondary hal (median , range - ) according to the arterial signal detected by a commercial ultrasound device. all patients were discharged on postoperative day with stool softeners and pain medication on demand. median follow up was weeks (range - ). results. the most common adverse event was pain in the first postoperative month, but no severe bleeding complication was reported. persisting pain due to perianal thrombosis was observed in six patients ( %) . two patients ( %) showed residual haemorrhoids ii , one requiring further intervention (rubber band ligation). in eight patients ( %) marginally hyperptrophied but asymptomatic haemorrhoidal piles were still visible. fecal continence did not deteriorate postoperatively. conclusions. rectoanal lifting is a safe and effective and minimally invasive technique for haemorrhoids ii-iii with simultaneous rectal mucosal prolapse. future prospective, randomized studies should investigate the particular benefit of a specially designed doppler-guided proctoscope in rar. therapie der komplizierten rektovaginalen fistel mittels modifizierter martiusplastik ergebnisse. insgesamt traten ( , %) infektionen auf. ( , %) dieser infektion waren rein oberflächlich die haut betreffend, ohne dass eine weitere chirurgische intervention nötig war. in ( , %) fällen kam es zu einer tiefen den patch (dacron , polyurethan ) betreffenden infektion. die tiefen infektionen traten in einem zeitraum von monat bis jahre nach der primären operation auf. in allen fällen wurde eine explantation des kunststoff-patches durchgefü hrt und dieser durch einen venen-patch ersetzt. bei diesen revision traten weder interoperativ noch postoperativ weitere komplikationen auf. keinerlei infektionen zeigten sich in der gruppe der carotiseversionen. schlussfolgerungen. in der carotischirurgie sind infektionen seltene komplikationen. infektionen traten bei uns ausschließlich bei operationen mit durchgeführter patchplastik auf, wobei der polyurethan patch vorteile gegenüber dem dacron patch zu haben scheint. standardtherapie bei einer patchinfektion ist die explantation und der ersatz durch einen venen-patch. die wertigkeit homologer spendervenen in der shuntchirurgie bei ausoperierten dialysepatienten ergebnisse. der erhalt des gefährdeten beines gelang bei patienten ( %), bei konnten durch die urokinasinfusionen ursprünglich nicht dargestellte gefäße zumindest teilweise wiedereröffnet werden. dadurch ergaben sich endovaskuläre therapieoptionen, die vor urokinase nicht möglich waren. lediglich bei einer patientin wurde eine unterschenkelamputation notwendig. die ergebnisse bei diabetikern waren erwartungsgemäß besser. schlussfolgerungen. die systemische urokinasetherapie stellt für bisher als austherapiert eingestufte patienten eine erfreuliche zusätzliche therapieoption dar. unsere ergebnisse insbesondere die beinerhaltungsraten von über % und komplikationsraten sind mit den in der literatur beschriebenen vergleichbar und insgesamt als erfreuliche alternative zu sehen. wir haben aber auch gesehen, dass mit einer solchen ,,induktionstherapie'' wieder neuen optionen einer invasiven therapie möglich werden. die vorteile der urokinasetherapie sind in der guten verträglichkeit den überschaubaren kosten sowie in einer erweiterung der multimodalen gefäßtherapie zu sehen. background. pulmonary retransplantation remains the only therapeutic option in some cases of severe primary-graft-dysfunction (pgd), advanced bronchiolitis-obliterans-sydrom (bos) as well as in some cases of severe airway problems (awp), mainly cicatriceal stenosis. however its value has been questioned due to overall scarcity of donor organs and reports on unsatisfying outcome. we analysed our institutional experience with pulmonary retransplantation to evaluate its value for different indications. methods. we retrospectively analysed all patients undergoing retransplantation out of consecutive primary lung or heart-lung transplantations performed in our department from / - / . we stratified patients according to indication for retransplantation and analysed the outome. results. forty-six patients (mean age ae years, male, female) underwent retransplantation ( bltx, sltx) for pgd (n ¼ ), bos (n ¼ ) and awp (n ¼ ). mean time to retransplantation was ae days in the pgd-group, ae days in the bos-group and ae days in the awpgroup. thirty days, -year and -years-survival after retransplantation were . %, . and . % in the pgd-group and . %, . and . % in the bos-group. all patients in the awp-group are still alive (p bos/pgd ¼ . ; p bos/awp ¼ . ; p pgd/awp ¼ . ). conclusions. retransplantation for bos offers long-term survival-rates in the range of primary lung transplantation for selected patients. long-term survival-rates for retransplantation due to pgd are significantly lower, warranting restrictive use in this indication. in our experience with a limited number of patients, retransplantation for awp has excellent results. pulmonary retransplantation for chronic problems is a worthwhile effort, provided that patients are carefully selected. retransplantation for pgd should be avoided. ecmo support in extended thoracic procedures background. for extended pulmonary resections and complex tracheo-bronchial reconstructions cpb is the standard way for extended cardio-respiratory support. given the extensive experience with ecmo support in lung transplantation in our department, we introduced ecmo also for selected cases of general thoracic surgery (gts). methods. all patients undergoing gts on ecmo support in our institution between may and january . results. nine patients ( female and male with a median age of years, range - ) underwent extended procedures using ecmo. both central (n ¼ ) and peripheral (n ¼ ) cannulation was used. in two cases, ecmo was introduced under emergency conditions due to life-threatening tracheobronchial injury, and was prolonged into the postoperative period after trachebronchial reconstruction. in seven cases the procedure was elective for surgery of bronchogenic carcinoma. ecmo bypass was performed for aortal resection (n ¼ ), for pure carinal resection (n ¼ ), or in combination with central resection of left pulmonary artery (n ¼ ), with reinsertion of left main bronchus to trachea (n ¼ ), and with upper bilobectomy and reinsertion of right lower lobe into the left main bronchus (n ¼ ). no deaths occurred during the first postoperative days. conclusions. this study confirms the safety of ecmo in gts instead of cpb. avoiding cross-table ventilation facilitates visibility and precision. the closed ecmo circuits prevent tumour cell spilling from the operating field. full heparinisation can be avoided, and bleeding complications can be prevented. ecmo support can also be prolonged into the postoperative period. background. the aime of this retrospective study is to underline that a surgical tool respective videothoracocscopy helps to find diagnosis quick! methods. one hundred and ten patients were included in the study male and female, mean age . a (range from to a). indication for inclusion in the study effusion under monitoring, multiple punction without any result. causes for effusion was in all cases unknown before intervention. patients transferred to the surgical unit for diagnosis and therapy were origin in all cases from pulmologists or conservative departments. patients were treated the day after admission by videothoracoscopy combined with sampling, frozen section and if available following therapy immediately intraoperative or the following days. discharge from hospital was done after removal of chest tube and aftercare was in the outpatient department. results. diagnosis was possible in all cases, the gap in between admission on the surgical department and beginning of treatment range from to days mean days. gap in between symptoms, multiple punction and suction without diagnosis range from to days mean . days. in comparison early surgical intervention as videothoracoscopy helps to achiev quick diagnosis and therapy. conclusions. in conclusion we emphasize that early surgical intervention after short conservative try show up with diagnosis and successful therapy. first series of robotic pulmonary lobectomy background. surgical resection is the primary treatment for early stage non-small cell lung cancer (nsclc). different minimally invasive approaches are currently under investigation: in addition to conventional video-assisted thoracoscopic surgery (vats), the robotic technology with the davinci system has emerged over the last years. methods. twenty-seven patients ( women, men; mean age . years) underwent a robotic lobectomy for early stage nsclc (clinical stage ia or ib). results. distribution of resected lobes were left upper lobes , left lower lobes , right upper lobes and right lower lobes . there were intraoperative conversions to open thoracotomy (one major bleeding, two minor bleedings, one variant course of the pulmonary artery). postoperative complications included prolonged air leak ( ) , colonic perforation ( ), and intermittend atrial fibrillation ( ) . length of hospital stay was median ( - ) days. -day mortality was one ( . %). overall median operative time was h and min (range : h to : h, mean : h). after the first seven patients the initial posterior approach was switched to an anterior one, thus enabling an easier hilar dissection. another technical modification during this first series was the introduction of a new vessel-sealing device (hem-o-lok + -clip) instead of ligation/stapling of the major pulmonary vessels. conclusions. robotic lobectomy has been proven to be feasible and save in our initial series in a learning curve setting. longer follow up and randomized controlled trials are necessary to evaluate a potential benefit over open and conventional vats approaches. background. acute post intubation laceration of the trachea is a rare, but serious complication. we report our experience with the transcervical approach and direct correction of the tear through a t-shaped anterior tracheotomy. methods. in a retrospective study we analyzed the course of patients ( female, male; median age . , range - years). in eight patients the tracheal injury was due to emergency intubation and in two patients it occurred during percutaneous tracheostomy. the lesions were located in the membranous part of the trachea and the mean length was , (range - ) cm. all patients underwent surgical repair immediately after diagnosis. the repair was carried out through a cervical transversal and longitudinal t-shaped tracheotomy allowing the exposure of the laceration in the posterior wall of the trachea which was mended by intraluminal running suture with - pds. results. all patients recovered well and were discharged from the hospital. the endoscopic follow-up at , and months shows no evidence for tracheal stenosis or fistula. conclusions. transcervical t-shaped tracheotomy is a minimally invasive approach for the repair of postintubation tracheal injury. this technique allows exposure of the entire length of the trachea and direct suturing of the tracheal wall with excellent results. we recommend this approach for repair of iatrogenic postintubation tracheal lesions requiring surgery. totalrekonstruktion der trachea ( ) mit thoraxtrauma nach jahren the importance of risk management for patient safety in surgery s. kriwanek background. although the concept of risk management is rather new in surgery it is gaining importance to ensure increased patient safety. methods and results. the process of risk managements consists of evaluation, assessment, and reduction of different risks. different analytic procedures as the -f method ( factors method) or the fmea (failure mode and effect analysis) help to stratify risks and classify the urgency of risk-reducing actions. the first and most important application of risk management in surgery must concern operative procedures. conclusions. the concept of risk management represents a new and interesting approach in order to increase patient safety in surgery. grundlagen. mit der kostenreduktion bestehen im krankenhauswesen tendenzen zur verkürzung der stationären verweildauern. bei der bedarfs-und ressourcengerechten aufnahmeund belegungsplanung haben sich in der chirurgie patientenmanagement systeme etabliert und bewährt. die umsetzung eines patientenorientierten entlassungsmanagements ist häufig nicht ohne probleme; beispielsweise ist die aktionsfähigkeit innerbetrieblicher sozial-und medizinischer dienste wegen administrativer und externer reglementierungen blockiert. kann eine anspruchs-und zeitgerechte qualitativ abgesicherte poststationäre häusliche nachversorgung nicht gewährleistet werden, bedeutet dies für patienten egal welcher chirurgischer disziplin ,,krisenmanagement''. methodik. auf der grundlage der konzeption von hospitalto-home + -mobile gesundheitsservices und in zusammenarbeit mit der regional zuständigen kassenärztlichen vereinigung wurde ein klinik-und mobilitätsgestützter gesundheitsservice für das stationäre entlassungs-und poststationäre ,,home-care'' management an der chirurgischen klinik eines universitätsklinikum, hier unter der projektbezeichnung ,,medmobil'' evaluiert. ergebnisse. die zeitgerechte klinikentlassung unter abgesicherter poststationärer weiterversorgung kann mit diesem konzept selbst in komplizierte umständen, wie z.b. bei postoperativen wundheilungsstörungen erfolgen. die fragmentierung von ökonomischer und medizinisch chirurgisch erforderlicher ,,in-time'' leistungserbringung und postoperativer gewährleistung häuslicher versorgungsnotwendigkeiten kann so am ende der prozesskette in übergreifendem interesse gestaltet werden. schlussfolgerungen. unter klinikbedingungen ist das konzept der projektgruppe von hospital-to-home + -mobile gesundheitsservices eine patientenorientierte konsequenz auf die anforderungen des drg-system; insbesondere auch seitens der patienten. interessen der medizinischen leistungserbringer, der krankenhaus-und der versicherungsträger werden auch vor dem hintergrund eines patientenseitigen ,, return-to-invest'' reflektiert. background. skin rejection in composite tissue allotransplantation (cta) is the pace-limiting obstacle for wider adoption in clinical practice. this study aims to identify cytokine network dynamics mediating acute rejection in cta, with focus on skin. methods. using a brown-norway to lewis rat hind-limb allotransplant model, syngeneic [n ¼ ] and allogeneic [n ¼ ] transplants without immunosuppression were studied. skin and muscle biopsies were taken at defined time points between day and . protein levels of cytokines known to be relevant in cellular inflammatory responses were assessed by luminex tm . expression (Ápg/ml) was read by measuring significant differences among pairs of slopes (w/matlab) for characterization of a cytokine network profile. results. in syngeneic transplants, il- a and il- were expressed in skin throughout the period of observation, with highest levels on pod at an average il- a concentration of pg/ml (>  Á from biopsy control (bc), standard deviation (sd) ¼ . %) and il- at pg/ml (> .  Ábc, sd ¼ . %). in allogeneic transplants, il- a and il- levels were similar to the syngeneic. at pod , allogeneics expressed il- b at pg/ml (> .  Ábc, sd ¼ . %), il- at pg/ ml (> .  Ábc, sd ¼ . %) and gro/kc at pg/ml (> .  bc, sd ¼ . %). conclusions. most prevalent cytokines at different time points during skin rejection were identified. this analysis helps understand the pathogenesis, provides a basis for early detection of rejection, and identifies novel targets for therapeutic intervention. disclosure. none. project funded by the austrian science fund (fwf). targeting e-and p-selectin for treatment of skin rejection in limb transplantation background. skin rejection episodes are a frequent problem seen after human hand transplantation. we therefore investigate the expression of e-þp-selectin in skin of human hand allografts and the effect of efomycine-m, a special inhibitor of selectin in a rat limb-transplant-model. methods. skin biopsies from three bilateral hand transplants were assessed by h&e-histology and immunohistochemistry (anti-e-þp-selectin-antibody). efomycine-m was investigated for its effect on skin rejection in an orthotopic rat hind-limb-allotransplant-model (bn-lew). animals received either efomycine-m alone ( mg/kg/weekly s.c. into the graft) or in combination with als ( . ml, pod þ ) and tacrolimus ( . mg/ kg/day for days). untreated animals and animals receiving als þ tacrolimus alone served as controls. skin rejection was assessed by daily inspection and he-histology. results. e-and p-selectin expression in the vascular endothelium were significantly upregulated and correlated well with severity of rejection in human hand allografts. in the experimental trial animals receiving efomycine-m alone rejected on day ae . these animals didn't show prolongation of graft survival in contrast to untreated animals. animals receiving als and tacrolimus rejected on pod ae and histology showed necrosis and massive infiltration of lymphocytes in all tissues. additional treatment with efomycine-m resulted in long term ( days) allograft survival. histology on day showed a lymphocytic infiltrate in the dermis and epidermis and a myointimal proliferation consistent with rejection grade . conclusions. selectins are upregulated upon skin rejection after human hand transplantation. local administration of a selectin-blocker in combination with als þ tacrolimus results in significant prolongation of graft survival but doesn't prevent chronic rejection in a rat limb-transplant-model. xenotransplantation of microencapsulated porcine islet cells in diabetic rats background. xenotransplantation of microencapsulated porcine islet cells might be a possibility to overcome the shortage of human donor organs for pancreas transplantation. several materials for microencapsulation of cells are described in literature which all show severe disadvantages. nacs is easy to produce, does not show any cytotoxicity and cell lines survive for a nearly unlimited time-spam after microencapsulation. however, this material has not been tested for microencapsulation and xenotransplantation of porcine islet cells. methods. porcine islet cell isolation and purification was performed according to a newly modified ricordi method and microencapsulated with nacs. diabetes was induced in sprague dawley rats by intraperitoneal injection of stz. microencapsulated porcine islet cells were transplanted under the kidney capsule of the animals. blood sugar levels were monitored on a weekly basis, porcine c-peptide levels and insulin levels were measured using elisa. after months, the animals were sacrificed, the kidney containing the microencapsulated porcine islet cells was retrieved and processed for histological and immunohistochemical examination. results. after xenotransplantation of microencapsulated porcine islet cells diabetes was reversed in rats. animals stayed normoglycaemic up to four months. functionality of transplanted porcine islet cells was detected by insulin measurement and detection of c-peptide. viability of microencapsulated porcine islet cells after explantation was proven by immunohistochemical viability stains. conclusions. rats stayed normoglycaemic until the end of the study period. no signs of fibrosis could be detected in the surrounding tissue. nacs seems to be a promising material for microencapsulation of porcine islet cells in order to treat diabetes. introducing the cuff technique for hind limb transplantation in rats background. current models for orthotopic hind limb transplantation traditionally utilize a time-consuming, technically demanding micro-vascular suture technique for vascular anastomoses. our objective was to introduce a new simplified vascular ''cuff technique'' which substantially accelerates the surgical procedure and is well suited to study ischemia/reperfusion injury in reconstructive transplantation. methods. syngenic hind limbs were transplanted orthotopically using lewis rats employing either the conventional microsuture technique (n ¼ ) or the new ''cuff technique'' (n ¼ ) for vascular anastomosis. results. all grafts in the microsuture technique and out of grafts in the ''cuff technique'' group survived the endpoint of the study (postoperative day ). microangiography on postoperative day showed no stenosis or occlusion of anastomoses, skin and muscle histology demonstrated normal appearing tissues. conclusions. our newly introduced cuff technique enables for significantly reduced operating time (cuff group: ae min, vs conventional group: ae min), low postoperative morbidity and mortality ( %) and excellent functional results after orthotopic hind limb transplantation. a quantitative analysis of the sensory and sympathetic innervation of the human pancreas the delineation of pancreatic nerve innervation during fetal life may contribute to our understanding of pancreatic pain modalities after birth. to define the peripheral sensory and sympathetic fibers involved in transmitting and modulating pancreatic pain, immunohistochemical detection was used to examine the sensory and sympathetic innervation of the head, body and tail of the normal human fetal pancreas using specimens from fetuses ( - weeks of gestation) following intrauterine death or legal interruption of pregnancy. myelinated sensory fibers were labeled with an antibody raised against neurofilament (nf) and post-ganglionic sympathetic fibers were labeled with an antibody raised against tyrosine hydroxylase (th). choline acetylase (chat) at cholinergic synapses was labeled with a conventional antibody. nf. th, and chat immunoreactive fibers were present in parenchyma of the head, body and tail of the pancreas at variable density, but the relative density of both nf and chat expressing fibers seemed to be increasing head > body > tail, whereas for th, a relatively even distribution was observed. in addition to this set of sensory and sympathetic nerve fibers that terminate in the pancreas, there were large bundles of en passant nerve fibers in the dorsal region of the pancreas that were associated with the superior mesenteric plexus. these data suggest that the pancreas receives a significant sensory and sympathetic innervation during fetal life. understanding the factors and disease states that may alter the distribution of nerve structures can be of significance for the development of therapies in pancreatic disorders of child and adulthood. background. electrospinning of polymers offers an interesting approach to fabricate nanostructured vascular substitutes which match the biomechanical and structural properties of native vessels. in this study we investigated the in-vivo behaviour of electrospun, small diameter conduits in a rat model. methods. vascular grafts with an inner diameter of . mm were fabricated by electrospinning polyether-urethane. prostheses were implanted into the abdominal aorta of rats for either days, weeks, or months. retrieved specimens were evaluated by conventional histology, immunohistochemistry and scanning electron microscopy. results. the overall patency rate of the electrospun conduits was %; neither foreign body-type reactions nor gross evidence of degradation were observed. within month after implantation, midgraft regions were completely covered with endothelial cells. immunohistochemistry revealed a significant immigration of cd þ cells from the luminal side of the graft into the prosthesis wall. within months, vascular specific smooth muscle cells (actin þ , desmin þ ) repopulated half of the conduit wall. conclusions. nanostructured electrospun polyurethane conduits offer biomechanics and bioinertness comparable to native vessels and promote the immigration and differentation of vascular specific cells in-vivo. diskussion. die coloskopische mukosektomie hat den nachteil des meist fragmentierten präparates, gefahr des hinterlassens von kleinen adenomresten, implementierung mehrfacher sitzungen und der narbenstenose durch die fehlende naht. die tem ermöglicht im gegensatz zur coloskopischen mukosektomie die zusätzliche resektion von submukosa und muskularis und somit eine entfernung des adenomrezidivs in toto mit primärer naht. die transanale excision nach parks hat eine - fach höhere rezidivrate als die tem, weshalb der tem unbedingt der vorzug zu geben ist. mit der laparoskopischen vorderen resektion kann wie mit der tem das adenomrezidiv sicher komplett entfernt werden, sie hat aber den nachteil der höheren morbidität, letalität und der schlechteren funktionellen spätergebnisse. im eigenen krankengut hat sich die tem als optimales therapieverfahren zur behandlung von rektumadenomrezidiven bewährt. schlussfolgerungen. die tem ist bei der behandlung des rektumadenomrezidivs alternativen therapieverfahren ü berlegen. the impact of computed tomography in acute appendicitis and obese patients m. von der groeben, v. neuhaus, o. schöb background. acute appendicitis is diagnose by clinical examination, ultrasound and laboratory tests. however, ultrasonography may not be sufficient for a definite diagnosis in obese patients and in the case of meteorism. in this study, the clinical relevance of computed tomography to diagnose acute appendicitis, especially in obese patients, was evaluated in a retrospective study. methods. patients suffering from acute pain in the right underbelly were examined for appendicitis by means of clinical examination, ultrasound imaging and laboratory tests. in case of definite diagnostic findings (n ¼ ), appendectomy was accomplished by laparoscopy. in case of negative ultrasonography findings (n ¼ ), patients were reexamined by ct the same day (n ¼ ) or by ultrasound imaging and laboratory tests the next day after admission (n ¼ ). results. patients with negative initial ultrasonography findings (n ¼ ), duration of anamnesis ranged from to h and ( . %) of these patients were considered as obese due to their body mass index (bmi ! kg/m ). in comparison, only . % of the patients with positive ultrasonography findings were obese. among the patients further examined by ct, ( . %) showed a bmi ! kg/m . duration of anamnesis ranged from to h. in contrast, among the patients reexamined by ultrasound imaging, only two showed a bmi ! kg/m . conclusions. to enhance diagnosis of acute appendicitis in patients with increased bmi ( ! kg/m ) suffering from acute pain in the right underbelly and short duration of anamnesis, it is advisable to directly perform ct of the abdomen instead of ultrasound imaging. outcome of emergency bowel resection for acute mesenteric ischemia background. due to vague early symptoms and lacking specific laboratory values, acute mesenteric ischemia (ami) is often detected late when bowel necrosis has occurred. methods. in a -month period, all consecutive patients with clinical symptoms of mesenteric ischemia were screened for inclusion in this retrospective study. patients with secondary causes for ischemia (strangulation ileus/post resection) were excluded. results are reported as mean ae sd or total number (%). results. sixty-two patients ( . % female; mean age . ae . years) were enrolled. twenty-two patients ( . %) had preoperative arrhythmia. lactate levels upon diagnosis were . ae . mg/dl, leucocyte count . ae . g/l and creactive protein . ae . mg/dl. fifty-one patients ( . %) underwent a ct scan, ( . %) an ultrasound and ( . %) an angiography, which diagnosed mesenteric vessel occlusion in ( . %). fifty-five patients ( . %) underwent surgery, five patients ( . %) were managed non-operatively, and two patients ( . %) died before surgery. revascularization was only possible in patients ( . %). forty-five patients ( . % of operated patients) underwent bowel resection, with primary anastomosis in and stoma creation in patients. second look operation was performed in patients ( . %). in-hospital mortality was . % ( patients). preoperative arrhythmia (p ¼ . ), renal failure (p ¼ . ), vasopressor demand (p ¼ . ), intraoperatively instable patients (p ¼ . ), diffuse bowel ischemia without resection (p ¼ . ), and bowel resection during second look operation (p ¼ . ) were associated with mortality. conclusions. despite modern diagnostic tools, acute mesenteric ischemia is still often diagnosed late. mortality remains high in unstable patients, or when no resection of necrotic bowel is possible during primary surgery. background. intrahepatic cholangiocellular carcinoma (icc) accounts for % to % of primary liver cancer cases. aggressive resection is the mainstay of treatment. methods. between and total patients ( % male, mean age . (ae . ) years) operated for icc at our department were followed up postoperatively. eleven right hemihepatectomies (eight extended), seven left hemihepatectomies (three extended), one segmental resection, two bisegmentectomies (ii iii), and four non-anatomical resections were performed. the median observation period was . (range: . - . ) years. analysis focused on age, sex, tumor size, operating time, histologic resection margin, tumor-node-metastasis (tnm) stage, reoperations, postoperative complications, tumor recurrence, survival rate. we also assessed p protein accumulation, ki index and muc positivity. results. median operating time was . h. mean diameter of the resected tumor was . (range: . - ) cm. histology showed r resection for three patients. eighteen patients ( %) underwent lymph node dissection. major postoperative complications occurred in ten patients ( %). there was one in-hospital death from liver failure. seventeen patients ( %) showed tumor recurrence. median time to tumor recurrence was . ( . - . ) months. total patients ( %) died. median time from operation to death was . ( . - . ) months. survival rate after one year was %, after three years % and after five years %. we found no correlation between p accumulation/high ki index counts/muc positivity and icc prognosis. conclusions. our study shows that outcome after icc is generally poor and only a small number of patients are really cured. lymphknoten-ratio als prädiktiver faktor nach kurativer resektion wegen intrahepatalem cholangiokarzinom für die lymphknotenchirurgie, es konnte auch bisher kein Ü berlebensvorteil für diese eingriffserweiterung gezeigt werden. methodik. zwischen und wurde patienten an unserer institution wegen eines icc operiert. aus dieser kohorte wurden patienten ermittelt, die mit kurativer resektion und lymphadenektomie behandelt wurden. aus diesem kollektiv wurde eine uni-und multivariate analyse prognostischer faktoren für rezidiv (rfs) und Ü berleben (os) durchgeführt. ergebnisse. sowohl tumorgröße als auch uicc stadium waren sowohl für rezidiv als auch Ü berleben prognostisch. ein erhöhter quotient von positiven zu gesamt entfernten lymphknoten (lymph node ratio, lnr) war für die patientengruppe mit positiven lymphknoten prognostisch für rezidiv und Ü berleben (hr für os ¼ . , % ci . - . ; hr für rfs ¼ . , % ci . - . ). in der multivariaten analyse bestätigte sich lnr als ebenso starker prognostischer faktor (adjusted hr [lnr] für os ¼ . , % ci . - . ; hr für rfs ¼ . , % ci . - . ). die anzahl der entfernten lymphknoten hatte keinen einfluss auf Ü berleben oder rezidiv. schlussfolgerungen. lnr ist ein neuer prognostischer faktor für Ü berleben und rezidiv nach kurativer resektion wegen icc. die therapeutische relevanz dieser beobachtung sollte in einer prospektiven untersuchung geklärt werden. background. patients with advanced cholangiocarcinoma have a poor prognosis and until now, no standard palliative chemotherapy has been defined. the purpose of this prospective single-centre phase ii study was to investigate the therapeutic efficacy, safety and k-ras status dependence of cetuximab in combination with gemox in the palliative first line treatment of these patients. methods. patients with locally advanced, metastatic cholangiocarcinoma or gallbladder cancer were treated with cetuximab mg/m followed by mg/m gemcitabine (day ) and mg/m oxaliplatin (day ) every second week. results. from october until july thirty patients ( male, female) with a median age of were enrolled. the overall response rate of evaluable patients ( ) was , %, including three patient with a complete radiological response. patients ( . %) achieved stable disease and only patients ( %) progressed under chemotherapy. nine initially unresectable patients underwent a curative resection after major response was observed ( %). five patients are currently without evidence of disease after a median follow-up of , months post curative liver resection. k-ras mutation was detected in patients ( %). all three patients did not progress under chemotherapy. neither pfs nor os were affected by k-ras status. the median pfs of all patients was . months and median os was . months. conclusions. cetuximab in combination with gemox induces impressive response rates which were unrelated to kras status. pfs and os were remarkably improved and therefore cetuximab in combination with gemox deserves further evaluation in prospective randomized trials. methodik. es wurde eine retrospektive analyse anhand einer pro-spektiv geführten datenbank an der abteilung für unfallchirurgie durchgeführt und jene patienten ermittelt, die im anschluss an ein ausgedehntes trauma im bereich der oberen extremität neben einer knöchernen versor-gung mit einer freien lappenplastik versorgt wurden. der erfasste zeitraum lag zwischen . jänner und . jänner . ergebnisse. die auswertung der datenbank ergab patienten ( weiblich), bei de-nen eine solche freie lappenplastik durchgeführt wurde. jede operation wurde gemeinsam mit einem kollegen der plastischen chirurgie und der unfallchirurgie durchgeführt. in fällen kam es zu einem lappenverlust, wobei daraus in einem fall ein zweiter erfolgreicher freier lappen resultierte und in dem anderen fall eine amputation des betroffenen daumens. im rest der patienten wurde mit der initialen operation das operative ziel erreicht. schlussfolgerungen. die implementierung mikrochirurgisch-rekonstruktiver verfahren an einer großen unfallchirurgischen abteilung führte zu einer deutlichen steigerung in der versorgungsqualität bei patienten mit komplexem trauma im bereich der oberen extremität. trotz eines mitunter sehr aufwändigen operativen verfahrens konnte die zeit bis zur kompletten abheilung deutlich verkürzt werden. facial edema and petechiae, subconjunctival hemorrhage, and occasionally neurological symptoms. case report. a -year-old men was admitted to the emergency department after the heavy metal door had fallen on his chest. his head, neck and upper chest were cyanotic and edematous with subconjunctival hemorrhages. computer tomography of the thorax revealed multiple fractures of the ribs on the left side and signs for pulmonary contusion. on the eight day the facial cyanosis and petechiae almost disappeared, only subconjunctival hemorrhage persisted. discussion. the symptoms are attributed to thoracoabdominal compression or to forceful compression of the thoracoabdominal muscles against a closed glottis. a reflux of blood from the heart through the valveless great veins of the head and neck occurs, the increased pressure is transmited to the capillaries. the blood stagnates and desaturates. characteristic appearance and the patient's history are the most important elements for diagnosis. laryngeal swelling can be severe enough to make the endotracheal intubation difficult. tinnitus or temporary deafness, transient or permanent vision disturbances and lethargy may occur. conclusions. morbidity and mortality are usually determined by the presence and severity of associated injuries. treatment should be directed toward associated injuries. any sign of airway compromise requires early intervention. grundlagen. in dieser retrospektiven studie wird der frage nachgegangen, ob die klinischen und radiologischen langzeitergebnisse den prothetischen ersatz des radiuskopfes in fällen von nicht rekonstruierbaren radiuskopffrakturen sowie von komplizierten luxationsfrakturen des ellbogengelenkes rechtfertigen. methodik. innerhalb eines zeitraumes von jahren ( ) ( ) ( ) ( ) ( ) ( ) ( ) wurden patienten mit derselben bipolaren metallprothesentype (tornier sa, fr) in zementierter technik versorgt. die indikationen waren: isolierte radiuskopftrümmerfrakturen (mason iii; fälle, gruppe ), ellbogenluxationen mit begleitenden radiuskopffrakturen (mason iv; fälle, gruppe ) und monteggia-verletzungen ( fälle, gruppe ). in fällen erfolgte der prothetische ersatz primär, in fällen nach vorangegangener osteosynthese. bei patienten wurde eine radiologische und klinische nachuntersuchung nach durchschnittlich jahren ( - jahre) durchgeführt. das funktionelle ergebnis wurde anhand des scores von geel und palmer (corr ) erhoben. ergebnisse. radiologisch zeigte sich in keinem fall ein hinweis auf eine veränderung der prothese bzw. deren position. im bereich des humeroradialgelenkes fanden sich nur in einzelnen fällen angedeutete zeichen einer arthrose, das capitulum radiale humeri wies in wenigen fällen eine zentrale abflachung auf. das proximale radioulnargelenk war in allen fällen radiologisch unauffällig. geringgradige periartikuläre verkalkungen fanden sich hauptsächlich im bereich der ventralen gelenkskapsel. unter anwendung des o.a. klinischen scores, der sich aus den kriterien bewegungsumfang, gelenksstabilität, kraft und schmerzen zusammensetzt, fanden sich exzellente resultate bei allen patienten der gruppen und . bei keinem dieser patienten bestand eine gelenksinstabilität. die patienten der gruppe (monteggia-verletzungen) schnitten etwas schlechter ab (gutes resultat). hauptverantwortlich dafü r waren einschränkungen in der streckung und den umwendbewegungen. subjektiv waren alle patienten mit dem ergebnis zufrieden und konnten ihre vorherigen beruflichen und freizeitaktivitäten ohne wesentliche einschränkung wieder ausü ben. schlussfolgerungen. obwohl die implantation einer radiuskopfprothese eine sehr selten durchgeführte operation ist, beweisen die guten resultate die sicherheit der methode. die ergebnisse scheinen eher durch die schädigung des ellbogengelenkes infolge des initialen traumas als durch die prothese selbst beeinflusst zu werden. die radiuskopfprothese sollte daher bei entsprechender indikation im sinne einer primären definitivversorgung eingesetzt werden und ihren festen platz im implantatlager jeder größeren unfallabteilung finden. background. gastric bypass after vbg often is a technically difficult and demanding procedure. postoperative morbidity and mortality is significantly higher compared to primary bypass. massive adhesions and scar formation at the gastro-esophageal junction are responsible for the difficulties in this procedure. scopinaro's procedure (a distal gastrectomy with gastro-ileostomy) offers the great advantage of sparing the gastro-esophageal junction and avoiding staple lines through scary tissues. this operation may represent a safe alternative to gastric bypass after vbg. a video of scorpinaro's procedure after vbg will be presented. trotzdem kann durch eine operation nicht in allen fällen ein rezidiv verhindert werden. diese beobachtung und das streben nach noch geringerer invasivität führten zur entwicklung endovenöser therapien. allen gemein ist, dass sie ultraschallgesteuert durchgeführt werden. es kommt zur induktion einer thermischen oder chemischen phlebitis, die in weiterer folge zu einer obliteration der vene führt. der vorteil dieser neuen therapieoptionen ist, dass sie in lokaler oder tumeszenzanästhesie ambulant durchgeführt werden können. die kurz-und mittelfristigen ergebnisse nach laser-und radiofrequenzablation sind in prospektiven und retrospektiven untersuchungen mit den ergebnissen nach einer ,,klassischen varizenoperation'' vergleichbar. langzeitbeobachtungen über jahre liegen nur nach solchen -schritt-varizenoperationen vor. die schaumsklerosierung ist eine wenig invasive und billige therapieoption, hat aber eine hohe rezidivrate. somit stellt die klassische varizenoperation aufgrund der guten kurz-, mittel-und langfristigen ergebnisse immer noch den ,,goldstandard'' in der therapie eines varizenleidens dar. die -schritt-varizenoperation wird heute gering invasiv, kosmetisch orientiert, mit endovaskulären gewebsschonenden stripping-operationstechniken und sicherer präoperativer therapie durchgeführt. sd , ) schmerzen in verlauf der behandelten vene und nahmen im mittel , schmerztabletten (sd , ) ein. im mittel konnte nach , tage ( - tage; sd , ) die täglichen aktivitäten normal wieder aufgenommen werden. bei keinem der behandelten fällen trat eine schwerwiegende komplikation (z. b. tiefe beinvenenthrombose) auf. in % bestanden im bereich der behandelten stammvenen nach monaten parästhesien. in der bare-fiber gruppe bestand eine tendenz zu mehr schmerzhaftigkeit, bei ebenfalls % iger verschlussrate und ansonsten vergleichbarem outcome. schlussfolgerungen. zusammenfassend lässt sich anhand der hier vorliegenden studie zeigen, dass die therapie von vsm mittels elt mit -nm-diodenlaser und radialfaser eine sowohl minimalinvasive als auch sichere und effiziente therapieoption darstellt und eine hohe frühzeitige erfolgsrate bei niedrigem schmerzniveau aufweist.in weiteren studien muss geprueft werden, ob aehnlich gute resultate auch bei weiterer absenkung des energienivaus zu erreichen sind. ergebnisse. es gab keine signifikanten unterschiede bezüglich geschlecht, alter, ceap stadium, bmi oder venendurchmesser in den beiden gruppen. in beiden gruppen wurden vergleichbare mengen an tla verwendet. in gruppe a lag die mittlere efe (endovenous fluence equivalent) bei j/cm und in der gruppe b bei j/cm . in beiden gruppen lag die verschlussrate bei %. die durchmesserreduktion der vsm cm distal der sapheno-femoralen crosse lag bei . auf . cm nach monat und , cm nach monaten. das c der ceap klassifikation verbesserte sich signifikant in beiden gruppen. gruppe a verwendete signifikant weniger schmerztabletten, an weniger tagen. in gruppe a gab es außerdem einen trend zu weniger postinterventionellen schmerzen. ecchymosen waren in beiden gruppen selten ( % in gruppe a, % in gruppe b). schlussfolgerungen. die laserpower beeinflusste nicht die verschlussrate bei der verwendeten hohen efe in beiden gruppen. in beiden gruppen waren ecchymosen und schmerzen seltener als in studien mit - nm. w laserpower reduzierte signifikant die schmerzmitteleinnahme. in beiden gruppen fanden sich gute ergebnisse, es fand sich nur ein geringer, kurzfristiger vorteil für die lasertherapie (kleinere hämatomfläche) bei im weiteren verlauf nahezu gleichem patientenkomfort. die hohen kosten der lasertherapie können somit nur schwer gerechtfertigt werden. eine kombination von crossektomie und laserablation ist eher nicht sinnvoll. die laserablation kann als minimal invasive alternative zum standardverfahren stripping nach umfassender und objektiver patienteninformation (fehlende langzeitergebnisse, mögliches leistenrezidiv durch weglassen der crossektomie) angeboten werden. endovasculäre verfahren in der behandlung der rezidivvarikositas a. j. flor grundlagen. das leistenrezidiv nach crossektomie ist ein häufig zu beobachtendes phänomen und mittels farbcodiertem ultraschall gut nachzuweisen. als ursache sieht man eine neovaskularisation von gefäßstümpfen ausgehend, welche in der literatur mit einer häufigkeit bis zu % angegeben wird. in vielen fällen zeigen sich im ultraschall reanschlüsse an intrafaszial gelegene stammgefäße. methodik. es erfolgt eine eingehende evaluierung mittels farbultraschall. finden sich insuffiziente intrafaszial gelegene stammgefäße, erfolgt die entscheidung, solch ein gefäß mittels elves-verfahren ( nm diodenlaser, in selektierten fällen mit radialsonde) oder mittels farbduplexgezielter schaumverödung zu behandeln. ergebnisse. die endolaser-obliteration mittels elves-verfahren fü hrt in mehr als % zu einem primären komplettverschluss des insuffizienten stammgefäßes. in der ultraschallkontrolle zeigt sich das kontrahierte gefäß, welches sich in weiterer folge zu einem fibrotischen strang umwandelt, um schlussendlich komplett zu verschwinden. die farbduplexgezielte schaumverödung zeigt in vielen fällen rekanalisationen, zum teil mit reflux. in vielen fällen muss die farbduplexgezielte schaumverödung mehrfach wiederholt werden. auffallend ist, dass sich der venendurchmesser im zuge der behandlung mittels schaum deutlich weniger reduziert als beim endolaserverfahren. schlussfolgerungen. endolaser und farbduplexgezielte schaumverödung eignen sich gut zur behandlung insuffizienter stammgefäße bei der behandlung der rezidivvarikositas. sie können in vielen fällen recrossektomien und andere chirurgische zugänge ersparen und sollten somit gerade bei der behandlung der rezidivvarikositas nicht als 'lifestylephänomen' abgetan werden. insbesondere die endolaserbehandlung kann intrafaszial gelegene neovarizen suffizient in einer sitzung schnittfrei verschließen. ergebnisse. auf einer skala von - ( -sehr gut, -nicht genügend) ergaben sich durchnschnittliche werte von . (trokarplatzierung), , (nadelplatzierung), (führungsdrahteinlage), (faszienverschluss), . (lernkurve). schlussfolgerungen. der neue tic -faszienverschlusstrokar ist als leicht erlernbares, verlässlisches system zum verschluss von trokarinzisionen über mm geeignet. langzeiterfahrungen bleiben abzuwarten, jedoch erscheint insbesondere die anwendung bei adipösen patienten und im rahmen von bariatrischen eingriffen sinnvoll. biological mesh in complex abdominal wall repairlong term results of use of permacol tm (porcine dermal collagen) in a single institution torbay hospital, torquay, uk background. abdominal wall repair (awr) if poor tissues, contamination, intestinal fistula, anastomosis, stoma and mesh impingement on bowel represent formidable surgical challenges. synthetic mesh or suture repair is inappropriate. biological meshes are biocompatible, offer resistance to contamination, minimal adhesion or fistula formation but retain strength. we use permacol tm -crosslinked porcine dermal collagen -in these cases and present data with long follow up. methods. retrospective review of patients treated with permacol tm for: . recurrent incisional hernia ae mesh; . post laparostomy; . enterocutaneous fistula; . contamination by anastomosis; . parastomal hernia. results. twenty-nine patients were identified. with acute or chronic abdominal defects; with parastomal hernia. defects sizes from to cm . median age (range - ) years and follow up ( - ) months. eleven cases awr - with anastomosis, paracolostomy hernia. eight enterocutaneous fistula with deficient abdominal wall; with fistula associated with mesh, all with anastomosis. recurrent of parastomal hernias. repairs by onlay, inlay and sublay. sixteen cases had no complications. major complications in patients - early deaths (myocardial infarct and multiorgan failure); recurrent hernia, colonic ischaemia requiring relaparotomy and intra abdominal abscess requiring percutaneous drainage. minor complications comprised wound infections, sinus and seroma. there were no mesh rejections and no further complications. conclusions. in difficult anterior abdominal wall repair permacol tm is effective, biocompatible, resistant to infection, contamination and can sit in contact with bowel. the new flexible conductive bipolar loop-electrode for continuous neuromonitoring of the recurrent laryngeal nerve by vagus nerve stimulation -first experience with the rd and th generation background. ascites leaks (al) in patients with end stage liver disease (esld) are commonly associated with recent interventions or ruptured hernias and are associated with significant morbidity and mortality regardless if they are medically or surgically managed. methods. in a pilot study, esld patients with a median meld score of (range - ) underwent treatment of als with topic fibrin glue injection around the leak after failing conservative therapy. results. mean age of the ten men and four women was (range - ) years. underlying eslds were chronic hepatitis c (n ¼ ), alcoholic ld (n ¼ ), cryptogenic cirrhosis (n ¼ ) miscellaneous (n ¼ ). there were six leaking incisions post emergent hernia repair (one inguinal, two umbilical, one ventral), two leaking/ruptured umbilical hernias, four leaking paracentesis sites, one leaking jp drain canal and one leaking laparoscopy trocar site. average ascites leak volume per day was ml (range ml- ml). all leaks were immediately resolved with a - cc fibrin glue injection. five recurred requireding re-injection ( within h). following injection, albumin levels, mental status and meld-scores improved in the majority of patients within one week. five patients underwent (liver transplantation) lt median (range - ) days post-injection. three patients died (two from sepsis one from metastatic cancer), the remaining patients were not accepted as lt candidates. conclusions. fibrin glue injection is a cost effective, simple and safe bedside procedure that resolves als for several months and allows for recovery in anticipation of lt and definitive repair. background. laparoscopic live donor nephrectomy requires meticulous dissection. therefore we have tested the endosite di digital vision system (viking systems + , biomedica, vienna) for applicability, ergonomic aspects and improved spectral depth perception in live laparoscopic donor nephrectomy. methods. the -dimensional visualisation system combined with high definition head displays (viking + , biomedica, vienna) was used for live donor uretero-nephrectomies in patients. side of nephrectomy was chosen according to selective renal function and vascular anatomy (right side, n ¼ and left side, n ¼ ). standard laparoscopic access was gained through trokars. for the left side, vessels were clipped and transsected laparoscopically. in order to gain length of the renal vein on the right side the graft was retrieved in a ''semi-open'' fashion as described previously by our group. results. mean age of the female patients was ae years. mean operation time, warm ischemia time and length of hospital stay were ae min., ae min. and . ae . days. upon discharge, creatinine levels, urea and c-reactive protein levels were . ae . mg/dl, . ae . mg/dl and . ae . mg/dl, respectively. there was no major complication or any procedure related morbidity such as infections or postoperative lymphatic leaks. conclusions. the -d laparoscopic system offers ergonomic advantages and improved spectral depth perception particularly in complex laparoscopic procedures like live donor nephrectomy. this system couples -d visualisation with traditional laparoscopy thus offering ergonomic advantages for less than one-tenth the cost of the da vinci system which may be of significant importance for the broad spectrum of minimally invasive surgery. background. obesity and vascular anomalies have been considered relative contraindications for living donor kidney transplantation. however, successful transplantation of laparoscopically retrieved kidneys with accessory renal vessels incidentially found upon operation, increasing body mass index (bmi) and donor age rise the question for the limits of live donation. methods conclusions. although a significant proportion of patients in our series qualifiy as ''marginal donors'' lldn is feasable and safe. however, adapted surgical technique and careful monitoring of postoperative renal function is mandatory in these patients. clinical feasibility of a new colonic access device (megachannel tm ) for interventional procedures at colonoscopy: a prospective, multicenter trial background. megachannel tm is a new colonic access system that was originally developed for colonoscopic appendectomy. once in place, the channel protects the colon from perforation risks during rapid, multiple passes of the colonoscope to the right colon. the mm working channel allows rapid and safe delivery of bulky instruments, as the removal of large specimens. methods. the device ( outer diameter, cm in length) was constructed of a wire reinforced polyvinylchloride plastisol tube with a thermoplastic distal tip and a proximal hub with integrated scope-seal. a rounded introducer-plug was fitted onto the distal tip and formed a smooth solid surface between the overtube and colonoscope to prevent tissue entrapment. results. the megachannel tm was applied in patients undergoing colonoscopy. the cecum was reached in / patients within min, with cm ( to cm) of the overtube being inserted into the colon. mild tissue bruises were observed in patients, mild to moderate pain in patients. in patients the megachannel assisted the removal of multiple polyps. in one patient a eus scope was delivered for evaluation of tumor wall infiltration before submucosal resection, in another patient a suction cap was successfully delivered to the right flexure for removal of an incomplete-lifting polyp. conclusions. this new colonic access system (megachannel tm ) can be safely applied into the right colon and is useful for a variety of colonic interventions that require multiple insertion of the scope or delivery of bulky instruments. this instrument might support notes procedures and removal of colonic stents. fast track surgery in acute ileus -first results background. fast track rehabilitation (ftr) is well established in elective surgery, but there is little experience with this concept in emergency colorectal surgery. we present our data of application of ftr in patients with acute ileus. methods. patient were included prospectively, ( . %) with ileus. all patients received a resection (colon / , rectum / ) by laparatomy with primary anastomosis in ( . %) patients. the median age was y ( - ). the level of chronic comorbidity was high: ! asa iii / ( . %). results. the essential modules of ftr could be applied successfully intra-and postoperatively: -thoracic epidural catheter: ( . %) -nasogastric tube removed at the end of operation: ( . %) -necessity of replacement of nasogastric tube: ( . %) -bowel stimulation: ( . %) -normal food intake at st day: ( . %) -normal bowel movement at postoperative day (m): ( - ) -days of stay in the icu (m): ( - ) the rates of major complications were: -insufficiency of anastomosis: ( . %) -wound infection: ( . %) -pneumonia: ( . %) -overall mortality: ( . %) conclusions. -the high mortality was due to the elderly population and concomitant diseases. -no deaths were seen from surgical complications. -based on good acceptance, low rates of major complications and excellent results in gi recovery ftr is suitable for emergency colorectal surgery and can be recommended for therapy of acute ileus. mit der accent ii studie hat die anti-tnf-alpha-therapie einen zentralen stellenwert insbesonders beim fistulierenden m. crohn etabliert [ ] . in weiterer folge stellte sich die frage, inwieweit die notwendige operative therapie des fistulierenden anorektalen m. crohn durch die anti-tnf-alpha-anwendung positiv oder negativ beeinflusst werden könnte [ , ] . als weiteren schritt sehen wir die anwendung dieser therapie mit infliximab, beim schweren anorektalen m. crohn, um voraussetzungen zu schaffen, den operativen eingriff zu minimieren oder weiterreichende auch rekonstruktive eingriffe in dieser region zu ermöglichen. unsere erfahrungen beziehen sich auf insgesamt patienten mit schwerem anorektalem m. crohn, von denen einer anti-tnf-alpha-therapie zugeführt wurden. insgesamt wurden an diesen patienten abszessdrainagen, fistelspaltungen, fistelexzisionen, sowie exzisionen mit mucosa-flap durchgeführt. bei patienten musste wegen schwerer abszedierung oder destruktion eine hartmann-deviation angelegt werden. patienten konnten einer intestinalen rekonstruktion, patienten einer sphinkterrekonstruktion zugeführt werden. bei patienten konnte, bei bestehender fistel, eine größere operation, durch minimierung der symptomatischen belastung der lebensqualität, vermieden werden. wir sehen heute die anti-tnf-alpha therapie als zusätzliche option einerseits weiterreichende operative eingriffe zu vermeiden, oder aber andererseits rekonstruktiv zu ermöglichen. methodik. unter laparoskopisch-assistiert operierten patienten waren ( weiblich), die entweder ein crohnrezidiv ( ) nach offener oder laparoskopischer voroperation oder komplikationen durch vorbestehende entero-enterale, entero-vesicale oder entero-vaginale fisteln ( ), abszesse ( ), gedeckte perforation ( ) oder entzündliche konglomerattumoren ( ) background. hyperthermic intraperitoneal chemotherapy (hipec) combined with cytoreductive surgery (crs) is an important treatment option for patients with peritoneal surface malignancies. for close to ten years the kantonsspital st. gallen has been offering this therapy. methods. since , patients with peritoneal surface malignancies were treated with crs and hipec as described by sugarbaker. hipec was performed using the open coliseum technique with mitomycin ( mg/m ) or cisplatin ( mg/m ) at c for min. results. indications for crs/hipec were pseudomyxoma peritonei ( patients), colorectal cancer ( ), ovarian cancer ( ), mesothelioma ( ) and other rare tumors ( ) . median age of the patients was years, with % males and % females. the mean and median surgical time was min and median postoperative hospitalization days. in-hospital mortality was . %. % of the pmp patients had a second crs/hipec treatment months (median) after the primary treatment. major complications requiring re-surgery occurred in %. over-all survival for pseudomyxoma peritonei patients after primary surgery was % after year and % after years, for patients with ovarian cancer % and %, respectively. conclusions. crs combined with hipec is a valuable addition to oncological surgery. due to the high morbidity, patients have to be carefully selected and surgeons have to learn which patients can profit from the treatment. the list of indications is still expanding and the outcome continues to improve, particularly at high volume centers specializing in this treatment. die praeoperative kombinierte radio/chemotherapie beim rektumkarzinom ab dem stadium t bzw. nþ gilt heute als standardisiertes neoadjuvantes therapiekonzept. voraussetzung ist ein exaktes praeoperatives staging um ein overtreatment zu vermeiden. in den letzten jahren werden vor allem unter chirurgen vermehrt stimmen laut um durch eine exaktere aussage der infiltrationstiefe in hinblick auf die mesorektale schicht und eine hohe chirurgische qualität die anzahl der erforderlichen bestrahlungen zu vermindern. wir berichten anhand der prospektiven colorektalen datenerfassung der patienten an der universitätsklinik für chirurgie der pmu salzburg aus den jahren - über unsere onkologischen ergebnisse, operationsverfahren, kontinenzerhaltungsraten, morbiditäts-und mortalitätsstatistik und tumorremissionsraten auf das strikt eingehaltene interdisziplinäre neoadjuvante therapiekonzept. anhand unserer erhobenen daten mit international vergleichbaren onkologischen resultaten, akzeptabler morbidität und zufriedenstellenden funktionellen ergebnissen wollen wir die sinnhaftigkeit dieses behandlungsalgorythmus unterstreichen. stellenwert der radiotherapie im onkologischen therapiemanagement die radiotherapie nimmt einen fixen stellenwert in der onkologischen gesamtbehandlung ein. der einsatz der strahlentherapie wird nach interdisziplinärer entscheidung -abhängig von der tumorentität, der tumorklassifikation, der tumorlokalisation, der geplanten behandlungsregime und der patientenbefindlichkeit -zeitlich koordiniert. die postoperative strahlentherapie wird generell am häufigsten eingesetzt. bei gastrointestinalen tumoren, hier vor allem beim rektumkarzinom, hat die neoadjuvante radiotherapie die nebenwirkungsreichere postoperative bestrahlung weitgehend abgelöst. durch das neoadjuvante therapiemanagement ist ein deutlich höheres tumoransprechen durch die bessere tumoroxygenierung bei deutlich geringeren spätfolgen, vor allem im dünndarmbereich, bestätigt. die entscheidung über den einsatz einer kurzzeitvorbestrahlung (  gy in tagen) oder einer langzeitbestrahlung (  , gy in wochen) ist abhängig von der tumorgröße, tumorlokalisation und notwendigkeit einer konkomitanten chemotherapie. steht die organ-und funktionserhaltung, vor allem beim analkarzinom, im vordergrund, kommt die definitive radiotherapie mit oder ohne chemotherapie zum einsatz. die chirurgische intervention dient bei dieser indikation als salvage-methode. der intraoperative einsatz der strahlentherapie kann abhängig von der entität und den gerätetechnischen möglichkeiten eine behandlungsoption darstellen. durch die moderne gerätetechnik gelangen zunehmend hochpräzisionsbestrahlungen (intensitätsmodulierte radiotherapie, dynamische arc-radiotherapie), unter anwendung moderner bilddarstellungen am linearbeschleuniger (image-guided-radiation therapy), zum einsatz. background. postoperative morbidity remains a significant clinical problem and may alter´long term outcome particularly after neoadjuvant chemoradiation in patients with locally advanced low rectal cancer. the aim of the present study was to identify a potential long-term effect of postoperative morbidity. methods. analysis of prospectively collected data of ninety consecutive patients who underwent neoadjuvant chemoradiation and curative mesorectal excision for locally advanced (ct / , nx, m / ) adenocarcinoma of the mid and low third of the rectum during a seven-year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results. major postoperative complications occurred in , % and minor complications in . % of patients. hospital mortality and -day mortality was %. infectious complications were seen in . %. the leading causes of infectious complications were anastomotic leakage and perineal wound infection. postoperative morbidity was statistically significantly associated with gender (p < . ), pre-therapeutic haemoglobin level (p < . ), asa score (p < . ), hospitalisation (p < . ), and clinical long-time course (p < . ). moreover, early postoperative morbidity was proven as an independent prognostic factor concerning disease free (p < . ) and overall survival (p < . ). conclusions. early postoperative morbidity in patients with preoperative chemoradiation due to locally advanced low rectal cancer is demonstrated as an independent prognosticator. gender, pretherapeutic haemoglobin level, and asa score indicate patients at risk for early postoperative complications and may therefore serve as predictive features. ergebnisse. bei patienten mit primären ct cn -und ct cn -tumoren wurde bei klinischer kompletter tumorremission nach neoadjuvanter radiochemotherapie ganz auf die operation verzichtet. nach einer medianen nachbeobachtungszeit von monaten ( - ) ergaben sich lediglich in einem fall fernmetastasen der leber und nebenniere. bei zwei patienten mit lokalrezidiven jeweils jahre nach radikaler operation kam es zu kompletter remission nach radiochemotherapie. ein patient blieb ohne reoperation über monate tumorfrei, im zweiten fall mit bekannten lebermetastasen bildeten sich zusätzlich lungen-und knochenmetastasen, jedoch kein lokalrezidiv mehr. nach transanaler vollwandexzision fand sich bei einem patienten nach jahren ein lokalrezidiv mit lebermetastasen. nach radiochemotherapie und kompletter lokaler remission kam es zu zusätzlichen lungenfiliae, jedoch keinem lokalrezidiv. zwei weitere patienten blieben trotz r -resektion des primärtumors nach neoadjuvanter radiochemotherapie ohne nachresektion tumorfrei. schlussfolgerungen. in selektiven fällen von rektumkarzinomen und rezidivtumoren ist durch radiochemotherapie eine vollremission zu erzielen, die langfristig anhält und ein abwartendes verhalten unter engmaschiger kontrolle rechtfertigt. neoadjuvante und adjuvante therapie des rektumkarzinoms im klinischen alltageine aktuelle analyse des im tumorzentrum erfassten patientengutes k. dommisch, j. sauer, k. sobolewski neoadjuvante und adjuvante therapieverfahren beim rektumkarzinom sollen zur verbesserung der lokalen tumorkontrolle und zur hemmung dissiminierter tumorzellen beitragen. diese aussage gilt als allgemein akzeptiert und wird in form der therapieempfehlungen vertreten. die deutsche studie konnte in einer phase- -studie eindeutig zeigen, dass der präoperativen strahlentherapie im vergleich zur postoperativen strahlentherapie der vorzug gegeben werden muss, da sowohl kurzzeit-als auch langzeittoxidität postoperativ signifikant höher waren. die analyse des im tumorzentrum schwerin erfassten patientengutes ( patienten) zeigt, dass nur zwischen - % der betroffenen patienten im durchschnitt in derartige multimodale therapiekonzepte gelangen. das eigene patientengut der letzten jahre umfasste patienten. davon hatten patienten ein rektumkarzinom im unteren und mittleren drittel im uicc-stadium ii und iii. letztlich erhielten patienten ein komplettes neoadjuvantes the-rapieschema ( ¼ %). für eine adjuvante therapie kamen patienten in frage ( mit falsch negativem staying, notfallpatienten und mit einem karzinom im oberen drittel), eine adjuvante therapie konnten aber nur patienten in anspruch nehmen. mit den ursachen und hintergründen dieses doch ernüchternden ergebnisses setzt sich der vorliegende beitrag auseinander. die entwicklungsdynamik in der anwendung dieser therapiekonzepte innnerhalb des letzten jahrzehntes wird differenziert in bezug auf die eigene klinik und die im tumorzentrum erfassten kliniken von unterschiedlichen versorgungsebenen dargestellt. auch werden die patientenseitig vorhandenen gegebenheiten hinsichtlich der durchführbarkeit der diskutierten therapieverfahren angesprochen. background. tetrahydrobiopterin (bh ) is an essential cofactor for nitric oxide synthases (nos) and thus a critical determinant of no production. bh depletion during cold ischemia leads to uncoupling of nos and contributes to reperfusion injury (iri) due to increased superoxide formation. the role of bh during warm ischemia is still largely unknown. methods. ischemic renal injury was induced by clamping the left renal artery for min in male lewis rats immediately after right-side nephrectomy. reperfusion was studied at r (no reperfusion), min(r ), h(r ) and days(r ). animals received either bh ( mg/kg/bw) prior to reperfusion (groupi) or saline(groupii). sham operated animals served as controls(groupiii). renal function was determined by plasma creatinine/urea. bh tissue levels were assessed by hplc. morphologic changes were quantified by h&e histology. peroxynitrite formation was assessed by nitrotyrosine-immunostaining, kidney microcirculation was analyzed by means of functional capillary density and capillary diameters uing intravital microscopy. results. bh tissue levels significantly decreased after min of warm ischemia (p < . ) up to two days(r ,r ) when compared to non-ischemic controls. additional bh treatment prior to ischemia significantly improved renal function at all time points studied following reperfusion (all p < . ). furthermore, bh reduced ischemia induced histologic damage (increased inflammation, interstitial edema, hemorrhage, tubular atrophy and focal areas of necrosis) and diminished peroxynitrite formation and hence nitrotyrosine staining(r -r ).subsequently, microcirculatory changes correlated with kidney peroxynitrite generation, and improved considerably through bh treatment. conclusions. bh treatment significantly improves post-ischemic renal function as well as histologic and microcirculatory function and might be a promising novel therapeutic strategy in attenuating iri. grundlagen. bei der behandlung einer peripheren traumatischen nervendurchtrennung konnte bisher trotz anwendung modernster techniken keine zufriedenstellende funktionelle regeneration erzielt werden. die verzögerte nervenregeneration und die daraus folgende verlangsamte signalüberleitung stellen eine erhebliche einschränkung der muskelfunktion am endversorgungsgebiet der betroffenen nerven dar. ziel der studie ist es, ein neues nervenkoaptationssystem unter verwendung einer neuartigen künstlichen prothese mit der im klinischen alltag verwendeten klassischen nahtkoaptation zu vergleichen. neben der zeit und grad der nervenregeneration wird auch der einfluss der elektrostimulation getestet. methodik. es wurde an weibliche göttinger minipigs mit einem durchschnittsgewicht von ca. - kg der nervus ischiadicus durchtrennt. während die tiere in der gruppe i mittels mikrochirurgischer koaptationsnaht versorgt wurden, wurden die tiere der gruppe ii mit der neuartigen nervenprothese behandelt. die hälfte der tiere in jeder gruppe wurde eine postoperativen nervenstimulation zugefü hrt. das postoperative kontroll-und stimulationsschema beträgt monate, in denen die aussprossung der axone in monatlichen abständen evaluiert wird. ergebnisse. nach den vorliegenden ersten daten konnten wir feststellen, dass mit der nervenprothese ähnlich gute ergebnisse erzielbar sind, ohne dabei sich einer relativ aufwendigen mikrochirurgischen nahttechnik bedienen zu müssen, und in zukunft dadurch auch kein spezielles zentrum für mikrochirurgische operationen aufgesucht werden muss, sonder in jedem chirurgisch tätigem krankenhaus diese prothese eingesetzt werden kann. schlussfolgerungen. falls die ergebnisse der studie die vorläufigen resultate bestätigen sollten, wäre die implantation dieser nervenprothese eine neue und von jederfrau/mann bedienbare therapeutische option zur versorgung peripherer nervenverletzungen. prevention of oxidative stress induced organ damage in a porcine brain dead donor model background. the ''autonomic storm'' initiated after brain death is known to induce a cascade of chemokine and cytokine release which induces oxidative stress and consecutively causes cell damage and diminished organ quality. methods. brain death was induced in pigs by trepanation of the skull and increasing intracranial pressure until brain stem herniation occurred. h after brain death diagnosis, the pigs were randomized in two groups (n ¼ ). group was infused ml of a solution containing alpha-ketoglutaric acid and -mmf over h whereas group received ml nacl. blood samples were taken at defined time points, h after brain death multiorgan donation was performed and tissue samples were taken immediately after organ retrieval and after cold ischemia time (cit). histology and immunohistochemistry were performed to quantify occurrence of apoptosis and of oxidative stress induced cell damage. results. analysis of the blood samples allowed us to describe exactly the chemokine and cytokine cascades initiated during the ''autonomic storm'' in this pig brain dead donor model. histology and immunohistochemistry revealed significantly lower apoptotic cells as well as lower anti-nitrotyrosine positive cells in group when compared to group immediately after explanation and after cit. conclusions. we could diminish oxidative stress induced cell damage and prevent the detrimental effects of the ''autonomic storm'' by applying a solution containing alpha-ketoglutaric acid and therefore achieved better organ quality after multiorgan donation in a pig brain death model. establishing a brain death donor model in pigs background. several factors influencing organ quality and recipient survival after multiorgan donation and transplantation are still unknown and difficult to investigate in humans. therefore the need for an animal model that imitates human conditions might be useful not only to be able to monitor pathomechanisms of brain death and biochemical cascades in the organisms after brain death but also to be able to investigate novel strategies to ameliorate organ quality and functionality after multiorgan donation. methods. in pigs brain death was induced by inserting a catheter into the intracranial space after trepanation of the skull and augmenting intracranial pressure until brain stem herniation occurred. intracranial pressure was monitored continuously and after min brain death diagnostics was performed by a neurologist including eeg examination and clinical examination. donor care was performed according to standard guidelines for h. results. min after brain death induction neurological examination and eeg examination confirmed brain death. all animals showed typical signs of brain death. all symptoms could be treated using standard medication. after h of brain death successful multiorgan donation was performed. after organ retrieval, abdominal and thoracic organs could be analysed for tissue damage and organ quality. conclusions. using this method, a suitable brain death donor model could be establish that will enable us not only to investigate in detail effects and pathophysiology after occurrence of brain death but also to evaluate new strategies to ameliorate organ quality and even to enlarge the donor pool for multiorgan donation. behandlung von gastrojejunalen anastomosenleaks nach roux-n-y magenbypass mit einem oder zwei überlappenden beschichteten metallstents im schweinemodell methodik. in hausschweine wurde eine roux-n-y magenbypass hergestellt. in vier tieren wurde die gj mit einem cm leak an der pouchhinterwand (retrogastrisch) hergestellt. in zwei tieren wurde ein stent platziert, die anderen beiden tiere wurden ohne stent belassen. in vier tieren wurde eine gj mit leak an der pouchvorderwand (anterogastrisch) angelegt, in zwei dieser tiere wurde ein stent und in zwei tieren jeweils überlappende stents platziert. nach wochen erfolgte die euthanasie und obduktion. ergebnisse. die stentplatzierung war in allen tieren erfolgreich. in der retrogastrischen gruppe überlebten beide tiere ohne stents ohne komplikationen mit abheilung der leaks, während die tiere mit stents am . und . postoperativen tag aufgrund von kinking mit obstruktion und drucknekrosen des roux-schenkels verstarben. in der anterogastrischen gruppe überlebte ein tier mit abheilung des leaks, jedoch mit stentmigration nach distal. die übrigen tiere verstarben zwischen dem . und . postoperativen tag. in allen fanden sich durch das distale stentende bedingte drucknekrosen. in einem tier mit einem stent fand sich peritonitis bei persistierendem leakage. in tieren mit zwei stents fand sich einem ein leck der fußpunktanastomose und in dem anderen eine obstruktion durch kinking des roux-schenkels. grundlagen. während lokale verschiebelappen die besten ergebnisse bezüglich der hauttextur ergeben, ist bei ausgedehnten defekten mit lokalen verziehungen und formgebungsproblemen zu rechnen. mikrovaskuläre ferntransplantate zeigen im gegensatz dazu häufig eine andere spenderregion-abhängige hauttextur. der submentale insellappen bietet im gegensatz dazu eine alternative zu den genannten verfahren. in diesem vortrag wird dieser insellappen zur deckung von kinndefekten vorgestellt und über vor-und nachteile gegenüber anderen rekonstruktionsverfahren diskutiert. methodik. bei patienten mit defekten des untergesichts nach ablativer tumorchirurgie erfolgte die defektdeckung mit einem ,,sub-mental-artery-perforator-island-flap''. sechs patienten zeigten primär ein ausgedehntes basaliom der kinnregion. nach doppler-sonographischer identifikation von ein bis zwei submentalen perforator-gefäßen erfolgte die submentale inzision und präparation der perforatoren im bereich der durchtrittsregion des musculus digastricus. der gefäßstiel wurde bis zum gefäßursprung aus der arteria facialis präpariert und das transplantat dimensionsgerecht gehoben. nach transposition in den defektbereich wurde der haut-fett-lappen eingenäht und die entnahmeregion nach lokaler subkutaner unterminierung direkt verschlossen. die klinischen und radiologischen nachkontrollen erfolgten tage, ein, drei, sechs und zwölf monate postoperativ. ergebnisse. alle insellappen konnten komplikationsfrei gehoben werden. der postoperative heilungsverlauf war ebenfalls unauffällig. alle patienten waren im beobachtungszeitraum rezidivfrei. das ästhetische und funktionelle ergebnis war durchwegs zufriedenstellen. schlussfolgerungen. der ,,sub-mental-artery-perforator-island-flap'' ist für die weichteilrekonstruktion im kinnbereich nach basaliomentfernung gut geeignet. die lokalen gewebequalitäten paaren sich mit einer weitgehend freien transpositionierbarkeit des transplantierten gewebes. fallbericht. bei einem -jährigen patienten bestand ein ausgedehnter defekt der frontobasis und des os frontale betont linksseitig nach schussverletzung. im rahmen der primärversorgung erfolgte eine verplattung der orbitaringe, teilentfernung des frontalhirns, eines großen anteils der frontalen calvaria und ein duradefekt-deckungsversuch mit allogenen materialien. in der folgezeit kam es zu einer persistierenden rhinoliquorhoe und einer osteomyeltis der refixierten freien calvariaanteile. in kooperation mit der neurochirurgie erfolgte dann die revision der frontobasis. zur wiederherstellung der frontobasis und des os frontale wurde ein mikrovaskuläres osteoperiostales transplantat vom distalen femur unter einbeziehung proximaler tibiaanteile verwendet. nach der angleichung an die defektsituation wurde das transplantierte periost zur basalen duranarbe und zu einem lokalen calvaria.perioslappen vernäht und mit miniplatten zur übrigen calvaria fixiert. danach wurde der transplantatstiel mit der zur arteria und vena temporalis superficialis anastomosiert und der wundschluss durchgeführt. in einem nachbeobachtungszeitraum von monaten kam es zu keiner erneuten liquoroe oder infektion dieser region. es konnte eine wesentliche verbesserung der schädelform erzielt werden. schlussfolgerungen. das mikrovaskuläre osteoperiostale femurtransplantat kann unter besonderen bedingungen durch die miteinbeziehung distaler tibiaanteile extendiert werden. die gefäßversorgung über das rete articularis gewährleistet eine gute perfusion des medialen proximalen tibiaperiosts. das transplantat ist somit für die deckung ausgedehnter calvariadefekte geeignet. grundlagen. die therapie von patienten mit lippen-kiefer-gaumenspalten birgt fü r chirurgen und kieferorthopäden große herausforderungen. einerseits zeigt sich häufig operationsnarben bedingt ein eingeschränktes sagittales wie transversales oberkieferwachstum, andererseits erschweren zahnnichtanlagen, sowie das fehlen von knochen im kieferspaltenbereich das therapeutische vorgehen. segmentosteotomien sind eine erprobte methode in der behandlung von dysgnathien, sowie zahnfehlstellungen können aber nur eingeschränkt beim wachsenden kind zum einsatz kommen. segmentdistraktion erlaubt eine entsprechende therapie auch beim wachsenden kind. methodik. kinder mit kompletten lippen-kiefer-gaumenspalten wurden untersucht. alle kinder zeigten sehr breite kieferspalten mit zum teil multiplen zahnnichtanlagen. zum schluss der kieferspalten wurden die spaltfernen segmente osteotomiert und mittels individuell angefertigter distraktoren mesialisiert. am fünften postoperativen tag wurde mit der distraktion von mm pro tag begonnen. ergebnisse. bis dato ist die kieferchirurgisch/kieferorthopädische therpie bei zwei patienten abgeschlossen. bei drei patienten ist die distraktionsphase abgeschlossen, nicht aber die kieferorthopädie. schlussfolgerungen. segmentdistraktionen sind ein probates mittel zum lückenschluss bei spaltpatienten mit ausgedehnten kieferspalten, sowie nichtanlagen. der vorteil der distraktion ist, dass die therapie während des wachstums durchgeführt werden kann. die ersten ergebnisse der durchgeführten segmentdistraktionen bei patienten mit kompletten lippen-kiefer-gaumenspalten sollen präsentiert werden. is a sarme possible without detachement of nasal septum? abteilung mund-, kiefer und gesichtschirurgie, graz, austria objectives. die chirurgische gaumennahterweiterung ist ein bewährter eingriff zur lösung der sutura palatina mediana bei einer transversalen größendiskrepanz der kiefer. ziel der untersuchung war die evaluierung einer möglichen bewegung des nasenseptums im rahmen einer chirurgischen gaumennahterweiterung. study design. der chirurgische eingriff wurde als laterale osteotomie und mediane osteotomie ohne lösung des septum nasi durchgeführt. anhand von gewählten radiologischen referenzpunkten wurde die position des nasenseptums im prä-und postoperative ct vermessen und mögliche abweichungen erfasst. conclusions. bei einer durchschnittlichen erweiterung von mm wurde einer winkeldifferenz von , zwischen sagittaler und axialer ebenen gemessen. die sagittalen ebenen erfahren eine abweichung von . die nasalen atemwege zeigen eine zunahme an volumen, ohne eine signifikante Ä nderung der anatomischen gegebenheiten, so erweist sich die chirurgische gaumennahterweiterung als suffizienter eingriff. using bisphosphonates in the treatment and management of systematic illnesses e.g. plasmocytom and metastasizing illnesses is undisputed. however one of the most feared side effects of this systemic therapy is osteonecrosis of the jaw. estimates of the cumulative incidence of bronj range from . - %. with increased recognition, duration of exposure, and follow-up, it is likely that the incidence will rise. pathogenisis seems to be multifactorial. besides prophylaxis the spectrum of therapy of bronj reaches from conservative meassures to radical-surgical rehabilitation by plastic reconstruction with local and microvascular flaps. furthermore experiences of our own patients were compared to relevant literature. summary. concerning our patients ( cases)the biggest percentage of relapse-free patients could be reached through radical surgical rehabilitation, where the obtained defect is to be reconstructed plastically. the results after reconstruction with microvascular iliac crest flap proved to be most effective. the same results could be seen in relevant literature. in case of surgical decortication plastic reconstruction proved to be less difficult but long-term results were not satisfying. concluding there is to say that the present staging system should be changed into a more comprehensive staging system, which would enable us to make even more accurate judgements about risk, prognosis, treatment selection, and outcome for patients with bronj. therefore more prospective clinical studies are required in the future. das calcitonin-nasenspray therapieresistente reparative riesenzellgranulom -ein fallbericht klinische abteilung für mund-, kiefer-und gesichtschirurgie, graz, austria grundlagen. das reparative riesenzellgranulom wurde wegen seinem aggressiven wachstum und seiner progredienz, zwar als nicht neo-plastische veränderung beschrieben, jedoch seine morphologische Ä hnlichkeit mit einem riesenzelltumor rechtfertigte letztendlich eine radikale chirurgische therapie. eine chirurgische entfernung zeigte trotz einer additiv angesetzten calcitonin-nasenspraytherapie ein rezidiv. beim reparativen riesenzellgranulom handelte es sich um eine seltene intraossäre läsion, welche vor dem . lebensjahr auftrat und eine rasche indolente auftreibung des kieferknochens zeigte. methodik. bei einer jährigen patientin war im november ein langsam wachsender schmerzloser tumor im kieferwinkel links diagnostiziert worden. im februar wurde eine exstirpation des tumors durchgeführt und die zähne , wurden extrahiert. die patientin erhielt postoperativ additiv einen calcitonin-nasalspray mit i.e täglich. bei regelmäßigen kontrollen zeigte sich trotz regelmäßiger einnahme des medikamentes nach monaten ein doppelt so großes rezidiv im unterkiefer links. ergebnisse. das rezidiv wurde teilreseziert und operativ mit einem mikrochirurgisch anastomisierten beckenkammknochen im unterkiefer links rekonstruiert. die calcitonin-nasenspraytherapie wurde postoperativ sofort abgesetzt. diskussion. die radikale chirurgische entfernung der läsion unter erhaltung der funktion war eine effiziente therapie, zeigte jedoch bei der entstehung eines rezidivs in diesem fall keinen weiteren anhalt für die fortsetzung des calcitonin-nasensprays additiv. schlussfolgerungen. es wurde anhand eines fallberichtes bei einer -jährigen patientin die therapie einer exstirpation des tumors mit additiver therapie eines calcitonin-nasensprays, dem einer radikalen chirurgischen behandlung, bei einem reparativen riesenzellgranulom, gegenübergestellt und diskutiert. ein rezidiv bei dieser patientin erforderte eine radikale chirurgische teilresektion und rekonstruktion des unterkiefers, wobei eine additive calcitonin-nasenspraytherapie keine vermeidung eines rezidivs bewirkte. die funktion des kieferknochens kann durch neoadjuvante, adjuvante und auch alleinige radiotherapieoptionen ausgelöst verloren gehen, pathologische frakturen und osteoradionekrosen sind als folgen dieser behandlung von patienten mit kopf-halstumoren bekannt. bestrahlungsdosierungen beruhen dabei vor allem auf empirischen konzepten -erfahrungen bei der therapie früherer patienten. in der literatur ist wenig darüber bekannt inwieweit bestrahlter knochen auf stimulierende reize noch reagieren kann, ob die für die knochenhomöostase essentiellen mesenchymalen stammzellen (mscs) die bestrahlung tolerieren und ihr differenzierungspotential darunter leidet. im rahmen der bestrahlung werden neben dem eigentlichen zielvolumen ,,entartete krebszellen'' auch alle gesunden zellen samt den im knochen eingebetteten mscs getroffen. in dieser studie wurden deshalb einerseits humane mscs und andererseits porcine mscs vom unterkiefer des sus scrofa domestica auf ihre bestrahlungssensitivität in vitro und im gewebeverband in drei stufen analysiert. zunächst wurden humane und porcine mscs isoliert und in vitro bestrahlt. einerseits zeigte sich, wie erwartet, eine kohärente abnahme der proliferationskapazität mit zunehmenden dosen, aber andererseits blieb die osteo-und adipogene differenzierungsfähigkeit erhalten, annähernd ähnlich den unbestrahlten kontrollproben. anschliessend wurden die unterkiefer von sus scrofa domestica mit einer dosis von  gy im wochenabstand bestrahlt. zu verschiedenen zeitpunkten (nach , , und wochen) wurden die mscs aus knochenbiopsien gewonnen. interessanterweise bestanden keine signifikanten unterschiede zwischen bestrahlten und unbestrahlten mscs hinsichtlich proliferations-als auch osteogenem differenzierungsverhalten. deshalb wurden in einer weiteren analyse unterkiefer mit und gy bestrahlt und am gleichen tag mscs aus dem bestrahlten knochen entnommen. es zeigte sich kein signifikanter unterschied zwischen gy-proben (unbestrahlt) und gy-proben bezüglich proliferationsverhalten und osteogener differenzierung. aber bei den gy-proben nahm die osteogene differenzierungsfähigkeit signifikant ab. innerhalb von wochen nahm auch die proliferationsfähigkeit bei den gy-proben deutlich ab. danach zeigten sie ein proliferationsverhalten wie die anderen proben. die ergebnisse dieser aufwändigen interdisziplinären kooperation von mkg-chirurgie, anästhesie, strahlentherapie und grundlagenforschung überraschen, da die mscs im knochen bis zu einer bestimmten dosis der bestrahlung widerstehen, jedenfalls besser als ursprünglich erwartet. weitere untersuchungen sind erforderlich, um auszuleuchten, ob mscs durch das umgebende gewebe oder ihre nische etwa geschützt sind oder ob doch periphere mscs neu einwandern und damit die knochenfunktion aufrecht erhalten werden kann. funding: oenb-jubiläumsfondsprojekt nr. . background. gastroesophageal reflux causes dysfunction of the lower esophageal sphincter (les) and columnar lined esophagus (cle) resulting in gastric appearance: this is the dilated end stage esophagus (dese ¼ cle within endoscopically visible gastric folds interposed between squamous epithelium and oxyntic mucosa of the proximal stomach). we report intermediate follow-up data of patients who underwent modified laparoscopic nissen fundoplication (lnf) for gastro-esophageal reflux disease (gerd) with fundic wrap placement around the dese. methods. twenty-nine gerd patients [age . ( . - . ), female)] underwent assessment of quality of life, endoscopy with multilevel biopsies from the esophagogastric junction (for assessment of dese length), esophageal manometry and (impedance-) ph-monitoring before and ( - ) months after lnf ( þ intraoperative endoscopy). the distal limit of the fundic wrap was placed at the level of the peritoneal reflection ( ¼ anatomic esophagogastric junction) and extended proximally over a length of . cm. results. intraoperative endoscopy revealed adequate wrap placement in all patients. follow-up data. background. laparoscopic antireflux surgery is a well established treatment of gastroesophageal reflux disease (gerd). persistent or recurrent reflux, gas-bloat syndrome or dysphagia may result in repeated surgical treatment which are at higher risk of perioperative morbidity and mortality. methods. from march until april , in patients antireflux procedures were performed because of gastroesophageal reflux disease and hiatal hernia. in patients ( %) of which patients were male ( %) repeated antireflux surgery was necessary. retrospective data collection was analysed for postoperative course, perioperative morbidity and mortality after redo-fundoplication. results. redo-fundoplications were made on the ground of recurrent reflux (n ¼ ), herniation of the wrap (n ¼ ) or scarred adhesions and dysphagia (n ¼ ). all procedures were completed laparoscopically. the mean operation time was min ( - min). in patients nissen and in patients toupet fundoplication were performed. intraoperatively there occured in patients lesions of the wrap and in one patient a lesion of the pleura. in one patient laparoscopic revisions with suture was necessary. there were no postoperative in-hospital deaths. the median length of hospital stay was days ( - days). at discharge no patient had relevant symptoms of gastroesophageal reflux. conclusions. reoperative surgery after fundoplication is known to be very technical challenging because of scarred tissue. so it is associated with higher morbidity and mortality. in our case study laparoscopic redo-fundoplication was feasible and with low incidence of perioperative morbidity and no mortality. background. giant leiomyomas of the esophagus bear the risk of malignancy. treatment is a function of size, small tumors might be removed endoscopically with the ever present risk of hemorrhage. large tumors require surgery, the approach depending on the tumor site and size. methods. we report on a symptomatic male patient ( a) suffering from a giant leiomyoma (  cm) in the esophagus. preoperative testing comprising contrast swallow, endoscopy, endoscopic ultrasound, ct, and true-cut biopsy confirmed the diagnosis. patient was found eligible for thoraco-laparoscopic esophageal resection. results. the minimal invasive procedure was carried out with the patient in the left-lateral position. thoracoscopic resec- tion utilized four trocars. the azygos vein was divided with an endo-gia. after transection of the esophagus at the level of the thoracic apex the table was tilted to the right to perform laparoscopic preparation of the gastric conduit. thereafter the stomach was pulled up into the thorax. enlargement of trocar sites was necessary for specimen retrieval. intra-thoracic circular stapled anastomosis was done transorally (orvil + , covidien). procedural time lasted in total seven hours. blood loss yielded insignificant and no intraoperative complication was observed. histology yielded no malignancy. patient started with oral diet on postoperative day and was discharged on day . follow-up after three months was uneventful. conclusions. giant leiomyoma of the esophagus require surgical resection. we present our technique for thoraco-laparoscopic esophageal resection. background. robot assisted laparoscopic surgery is an increasing field. laparoscopic microsurgery, difficult maneuvers like intracorporeal hand sewn anastomoses or a narrow operating field are ideal indications for the operation robot. methods. tertiary referral center with large expertise in robotic surgery. five patients with achalasia, ( m/ f), mean age ( - ), underwent a robot assisted laparoscopic cardiomyotomy (rac) with a partial posterior (toupet) fundoplication. detailed description of the operation technique and review of the literature. results. the rac was feasible without any particular problem and the postoperative course of all five patients was uneventful. the mean operation time was min and min setup-time of the robot. on follow-up six months postoperatively, all patients were free of significant dysphagia and free of reflux symptoms and had a significant weight gain. there are several reports, series and trials about rac available in literature. the general conclusion is that this operation is easy to perform in experienced hands with a significantly lower rate of mucosal perforations, but at higher overall costs. a longer operation time has to be taken into account during the learning curve. discussion. the avoidance of mucosal lacerations and its possible consequences has to be weighted against higher overall costs. conclusions. the rac is the first ''standard laparoscopic'' operation where a clear advantage for the application of an operation robot has been proven. where available, the operation robot should be used for laparoscopic cardiomyotomies. methodik. bei schockraumadmissionen im beobachtungszeitraum mit polytraumata finden sich stumpfe und penetrierende verletzungen des abdomens und/oder des thorax. nach klinischer diagnostik mit obligater sonographie und -bei hämodynamischer stabilität, sowie fehlendem peritonismus oder eviszeration -ct-traumaspirale lässt sich das procedere festlegen: observanz und konservative therapie (n ¼ ), laparo-/ thorakotomie (n ¼ ) oder laparo-/thorakoskopie (n ¼ ). ergebnisse. schussverletzungen wurden regelhaft offen versorgt. alle diaphragmalen läsionen wurden im ct oder per laparotomiam erkannt und therapiert. in lediglich fällen kam eine laparoskopische bzw. thorakoskopische versorgung sicher und sinnvoll -selbst bei mehrfachverletzungen -zur anwendung: es handelte sich um atypische pulmonale segmentresektionen bei stichverletzungen, je eine milzklebung, eine colonübernähung, einen umstieg auf offene milzerhaltende prozedur, eine perikardfensterung und eine rein diagnostische laparoskopie, wobei keine verfahrensabhängigen komplikationen beobachtet werden mussten. schlussfolgerungen. penetrierende verletzungen der brustund/oder leibeshöhle stellen für die chirurgische versorgung eine herausforderung dar: einerseits darf der diagnostik keine läsion entgehen, andererseits muß eine Ü berversorgung mit dem eigenrisiko einer negativen explorationslaparotomie vermieden werden. klinische, sonographische und computertomographischeggf. wiederholte untersuchungen -lassen nur in hochselektiven situationen eine endoskopische annäherung sinnvoll erscheinen, zumal den therapeutischen endoskopischen verfahren technische grenzen gesetzt sind. unbestreitbar ist allerdings ihr wert bezüglich einer harten forensischen dokumentation. bmi , ( , ) kg/m ) mit einer itp laparoskopisch splenektomiert. in einer univariaten analyse wurde der einfluss von alter, bmi, asa-score, krankheitsdauer, medikamentöser therapie, op-dauer, konversion, komplikation, milzgewicht, präoperativen thrombozytenzahlen, thrombozytenanstieg und blutproduktsubstitution auf das langzeitergebnis ausgewertet (anova mit bonferroni post hoc test, kruskal-wallis-test). ergebnisse. die erkrankungsdauer lag bei , ( , - ) jahren. das milzgewicht betrug ( - ) g. die operationsdauer betrug ( - ) minuten. konversionen erfolgten in %. die thrombozytenzahl stieg um % (präoperativ ( - ) tsd/ml, bei entlassung ( - ) tsd/ml). die morbidität war , %, die letalität %. die liegezeit betrug ( - ) tage. das mediane follow-up betrug monate ( , - , jahre). dauerhaft normwertige thrombozytenzahlen konnten bei , % der patienten erzielt werden. patienten zeigten keinen thrombozytenanstieg nach splenektomie, während patienten nach ( - ) monaten eine rezidiv-thrombopenie entwickelten. patienten mit einer primären postoperativen thrombozytopenie < . /ml waren therapieversager ( / ), postoperative thrombozytenwerte zwischen . /ml und . /ml resultierten in partieller ( / ) und kompletter ( / ) remission, während thrombozyten > . /ml überwiegend zu einer kompletten remission ( / ) führten. schlussfolgerungen. die laparoskopische splenektomie ist ein sicheres verfahren bei selektionierten patienten und gilt als chirurgisches standardverfahren bei der therapierefraktären itp. die ansprechrate liegt bei %. die postoperativen thrombozytenwerte sind ein prediktor für den langzeitverlauf, während periopereative komplikationen keinen einfluss auf die rezidivrate haben. grundlagen. die verwendung von sogenannten perforator-lappen in der plastischen chirurgie konnte in der rezenten vergangenheit zum einen zu einer massiven reduktion der hebedefektmorbidität und zum anderen zu einer größeren flexibilität im lappendesign beitragen. vorallem im bereich der mammarekonstruktion ist der deep-inferior-epigastric-artery-perforator-falp (dieap-flap) mittlerweile zu einem operativen standard geworden. in der vorliegenden untersuchung soll die bedeutung der präoperativen darstellung der perforatorgefäße mittels ct-angiographie untersucht werden. methodik. insgesamt wurden an unserer abteilung bei von patientinnen seit mai mammarekonstruktionen mittels dieap-flaps durchgeführt. bei von patientinnen wurde präoperativ eine ct-angiographie zur darstellung der perforatorgefäße vorgenommen. anhand von beispielen sollen sowohl die praktikabilität als auch die vorteile der untersuchung verdeutlicht werden. ergebnisse. in keinem der fälle mit präoperativer ct-angiographie kam es zu einem lappenverlust. die operationsdauer der lappenhebung konnte verkürzt werden, sowie das lappendesign anhand der untersuchungsergebnisse individuell angepasst werden. schlussfolgerungen. die präoperative ct-angiographie der perforatorgefäße zur hebung eines dieap-flap trägt zu einer reduktion der operationsdauer bei und hat einen positiven einfluss auf die realibilität der lappendurchblutung. roughly % of pediatric tumors are present at birth. with the increased use of prenatal imaging these tumors are detected at earlier stages of fetal development and pose a diagnostic and therapeutic challenge as of how to proceed in a situation of potential malignant grow. methods. if on routine prenatal ultrasound a tumor was suspected, axial, coronal and sagittal t -w and t -w sequences were obtained using a . tesla mri. the mri's were performed between the nd- th gw (median gw). no sedation or contrast enhancement was used for this study. results. between and , tumors were diagnosed after exclusion of hemangiomas, lymphangiomas, ovarian cysts and ccam. were teratomas localized to the face ( ), neck ( ), mediastinum( ) sacrococcyx( ). the remaining tumors were a hepatoblastoma, a cystic neuroblastoma, a adrenal cyst and a malignant glioma/pnet. three cases posed a special therapeutic dilemma. the facial teratoma that due to rapid tumor growth had to be delivered by c-section at gw so that chemotherapy could be initiated. one of the cervical immature teratomas had rapid extension and should have been delivered earlier. the fetus with hepatoblastoma had rapid tumor progression and required a hemihepatectomy in the first week of life. conclusions. prenatally detected tumors pose a diagnostic and therapeutic challenge. location, size, extension and vascularity of the tumor will determine the viability of the fetus and therapeutic options including time and mode of delivery. consensus has to be taken by an interdisciplinary team (obstetrician, neonatologist, oncologist, surgeon) and the parents. background. burns are very common in pediatric patients. most children are very young ( < years of age). a variety of none degradable products are available for closed wound management. suprathel tm is a degradable alternative. it is composed of polylactic acid in combination with other biocompatible polymers. it can be used for nd and partial rd degree burns, split skin donor sites and large-area abrasions. methods. between november and november , we treated children between months and years of age, most of them with a and b burns. suprathel tm was used in cases ( %). debridement was performed without undue delay. three days later we applied suprathel tm and two layers of fat gauze to prevent adhesions. in to days intervals the superficial dressing was changed, leaving suprathel tm and the deeper gauze in place. results. changing of the superficial dressing was easy and painless. inspection of the healing progress was possible as suprathel tm becomes translucent. time spent in hospital was reduced, wound healing speeded up, no wound infection was recorded and the cosmetic results were excellent. suprathel tm came off naturally within to days after application. discoloration of the overlying fat gauze was observed and was never caused by infection. occasionally suprathel tm did not adhere initially. conclusions. suprathel tm handling is very simple. the most important benefits are no pain and less change of dressing with good cosmetic results. it is a considerable improvement of the management of nd and partial rd degree burns in children. erfahrungen in der kinderwundambulanz der kinderchirurgischen abteilung der lfkk linz grundlagen. eine der potentiellen anwendungen des monitorings von angiogeneseparametern ist die verwendung als tumormarker. ziel dieser studie ist, etablierte tumormarker wie ca - den angiogeneseparametern unter neoadjuvanter therapie mit bevacizumab gegenüberzustellen. untersucht wurden der pro-angiogene faktor vegf (vascular endothelial growth factor), der durch bevacizumab inaktiviert wird, sowie der angiogeneseinhibitor tsp- (thrombospondin- ). methodik. patienten mit lokal fortgeschrittenem pankreaskarzinom wurden mit zyklen (q wochen) gemcitabin sowie -wöchentlich mit bevacizumab behandelt. blutproben wurden alle wochen jeweils direkt vor der bevacizumab-applikation abgenommen. die angiogenesefaktoren wurden im plasma bestimmt. ergebnisse. im verlauf der therapie kam es zu einem kontinuierlichem abfall von ca - (p ¼ , ). die vegf-spiegel korrelierten positiv mit der bevacizumab-therapie und stiegen bereits mit der ersten behandlung signifikant an (p ¼ , background. endoscopic thoracic sympathetic block (etsb) provides excellent outcome for palmo-axillary hyperhidrosis (hh). the aim of the study was to investigate the long term effects of etsb . methods. between and patients (mean age ae years) underwent etsb procedures in a prospective study. satisfaction rates and two validated quality of life (qol) questionnaires were assessing postoperative outcome (keller: - and milanez de campos: - ; : no symptoms; or : maximal symptoms), respectively. mean follow up was . ae . months. results. one hundred and sixty-two patients ( . %) had palmar and patients ( . %) axillary hh. all patients with palmar hh were completely or almost dry postoperatively whereas patient ( . %) developed recurrence of the primary disease at follow up. among patients with axillary hh, recurrences appeared in . % within six weeks and rose up to . % at follow up. compensatory sweating (cs) and gustatory sweating were observed in . % background. at the time when notes techniques struggle on diverse problems a novel single incision laparoscopic method is developed utilizing the umbilicus as embryonic natural orifice. three intra-umbilical trocars allow a minimal invasive procedure which results in a non-visible postoperative scar. methods. twenty-four patients (age: - a) underwent single incision laparoscopic cholecystectomy ( / - / ) for gallbladder stones and/or cholecystitis. the entire operation was carried out transumbilically following the standardized principles of the laparoscopic technique. one or two (in the initial patients) intraperitoneal suspension sutures helped to expose the anatomical structures. results. in all but two patients single incision transumbilical surgery could be completed. in both cases placement of one and two additional trocars, respectively, was necessary due to severe adhesions from previous surgery. the operative time was in median (range - ) min. no intraoperative adverse events were noticed. estimated blood loss yielded minimal in all cases. cholangiography was successfully carried out in two patients. all returned to oral diet after six hours. they were discharged in median on postoperative day in accordance with local custom. an optimal postoperative and cosmetic result without apparent scar was documented at follow-up. conclusions. this initial series presents for the first time a novel laparoscopic technique for e-notes cholecystectomy utilizing a single ''scar-less'' intraumbilical approach which minimizes the surgical trauma. background. during the past decades anecdotic reports on single incision laparoscopic appendectomy were published. the scientific interest in notes procedures led to a renaissance of this technique in the surge for a minimal invasive approach. we developed a novel laparoscopic transumbilical method utilizing three instruments exclusively through the embryonic ''non-visible'' scar. methods. two patients (both a) underwent single incision laparoscopic appendectomy ( / - / ). the entire operation was carried out transumbilically following the standardized principles of the minimal invasive appendectomy technique. results. both patients underwent surgery for acute appendicitis with perifocal peritonitis. after dissection of the appendicular artery the appendix was transected by use of a loop and a stapler, respectively. the operative time was min and min. no additional trocar had to be placed. no intraoperative adverse events or significant perioperative complication was noticed. estimated blood loss yielded minimal in both cases. one patient suffered from infectious enteritis and mild wound infection postoperatively. oral diet was resumed immediately after the operation. at follow-up patients presented with an outstanding cosmetic result without apparent scarring. conclusions. for the first time instrumental developments allow a novel laparoscopic technique for appendectomy utilizing flexible instruments through a single intraumbilical approach resulting in a non-visible scar. methods. twenty-three patients ( female/ male; age: - a) underwent single incision laparoscopic inguinal hernia repair ( / - / ). the entire operation was carried out transumbilically following the standardized principles of the tapp technique. results. sixteen patients underwent single site surgery ( primary/ recurrence procedures), whereas bilateral hernia repair was necessary in seven patients. the operative time was - min and - min for single and bilateral repair, respectively. one additional trocar had to be placed for dissection or suturing in four patients. no intraoperative adverse events or significant perioperative complication was noticed. estimated blood loss yielded minimal in all cases. in one patient redolaparoscopy was carried out after days for undefined lower abdominal pain. oral diet was resumed immediately after the operation. patients were discharged on postoperative day to in accordance with local custom. at follow-up patients presented with an optimal postoperative and cosmetic result without apparent scarring. conclusions. this feasibility study presents for the first time presents a novel laparoscopic technique for tapp groin hernia repair utilizing a single ''scar-less'' intraumbilical approach which allows further reduction of the surgical trauma. background. on the way to ''no-scar'' techniques we developed a novel method for colorectal resection utilizing three intraumbilical trocars which results in a non-visible postoperative scar. methods. four patients ( female/ male; - a) underwent laparoscopic colorectal resection for diverticulitis and infiltrating endometriosis of the rectosigmoid colon, respectively. the entire operation was carried out transumbilically following the standardized principles of colorectal resection. results. the operative time ranged in total from min to min and for dissection only - min, respectively. no intraoperative adverse events or significant perioperative complications were noticed. specimen retrieval was carried out through the umbilicus. segments measured in length cm to cm. circular stapled anastomosis was performed transanally. estimated blood loss yielded minimal in all cases. oral diet was resumed on postoperative day . patients were discharged on postoperative day to . at follow-up patients presented with an optimal cosmetic result without apparent scarring. conclusions. for the first time a novel laparoscopic technique for sigmoid colon resection utilizing a single intraumbilical approach is presented. this new method is restricted to a limited number of patients but allows further reduction of the surgical trauma and to obviate any visible scar. background. besides the considerable advantages of laparoscopic ventral hernia repair one of the most severe complication is the incisional hernia of the trocar site. one of the key benefits of notes-procedures is to avoid surface incisions leading to a decrease of postoperative pain, infection and port site hernia. the aim of this experimental study was to assess the feasibility of the ipom repair in ventral hernia by transgastric access in a pig model. methods. under laparoscopic control a transgastric approach was utilized to create abdominal wall defects in female, domestic nonsurvival and survival pigs respectively. titanized polypropylene meshes (tisure + ) armed by polypropylene sutures in the four corners were transferred via the umbilical trocar. after suture fixation of each mesh additional endoscopic transporous fibrin sealant fixation (tissucol + ) using a single lumen catheter was performed. the closure of the gastric access was achieved by applying endoclips in nonsurvival and by laparoscopic suturing in case of survival pigs respectively. results. the survival pigs were euthanized at day , and postoperatively. the macroscopical evaluation revealed excellent integration of the meshes without signs of shrinkage or increased inflammation. only in cases out of a total of meshes minimal adhesions in the region of suture fixation were observed. histology confirmed the macroscopical findings. conclusions. the initial results of our experimental study demonstrate the feasibility of a notes repair of abdominal wall hernias. anticipating technical advances of notes-devices this new technique could be auspicious for the future. medical university, lviv, ukraine; childrens hospital, lviv, ukraine recent advances in medicine brought to noticeable growth of premature newborns' survival value. but this fact brought to growth of necrotic enterocolitis morbidity of newborns that often occurs on the background of congenital bowels pathology. from to we treated children with necrotic enterocolitis. the average gestational age of patients was . þ . weeks, average body weight - þ g. seven patients were operated with a stage of necrotic enterocolitis. large intestine hypoplasia was intraoperatively revealed in cases; and after its biopsy congenital agangliosis was diagnosed. the signs of partial bowel obstruction kept after reduction of necrotic enterocolitis effects in from non-operated patients with b- a stages of necrotic enterocolitis; large intestine biopsy of those patients revealed intestinal neuronal displasia type a in one case, intestine neuronal displasia type b in two cases, congenital agangliosis in one case. conclusions. different forms of disgangliosis can be one of the trigger mechanisms for the development of newborns' necrotic enterocolitis. at the same moment necrotic enterocolitis can be one of the first manifestations of congenital disgangliosis. that's why the visual large intestine hypoplasia or keeping of partial bowel obstruction signs after the reduction of necrotic enterocolitis effects of newborns must be the reason for the large intestine biopsy and histochemical investigation of biopsy material for this group of patients. zur angeborenen dilatation von intestinalsegmentenein beitrag zu einem seltenen krankheitsbild accidental ingestion of foreign bodies is a common problem in infants and childhood, but ingestion of magnetic construction toys is very rare. when multiple parts of these magnetic construction toys are ingested, they may attract each other through the intestinal walls, causing pressure necrosis, perforation, fistula formation or intestinal obstruction. a -month old boy presented with a three day history of abdominal pain and bilious vomiting. physical examination revealed a slighted distended abdomen. the white blood cell count was normal, but the c-reactive protein was elevated. ultrasound and x-ray of the abdomen showed a distended bowel loop in the right upper, a moderate amount of free intraperitoneal liquid and four foreign bodies. emergency laparotomy was performed and two perforations in the ileum could be detected. the perforation was caused by a magnetic construction toy and two iron globes. the fourth foreign body was a glass marble. the foreign bodies were removed, both perforations were primary sutured. the child was discharged on postoperative day after an uneventful recovery. parents should be warned against the potential dangers of children's constructions toys that contain these kinds of magnets. interdisziplinärer zusammenarbeit bei kindern mit anorektalen malformationen -erfahrungen des colorektalen teams in linz landes-, frauen-und kinderklinik, linz, austria bei kindern mit anorektalen malformationen besteht eine sehr hohe wahrscheinlichkeit, auch an anderen stellen fehlbildungen aufzuweisen. dies erfordert nicht nur bei der abklärung sondern auch bei der behandlung und nachbetreuung eine enge zusammenarbeit mit anderen fachabteilungen und der pflege. an unserer kinderchirurgischen abteilung in der landes-, frauen-und kinderklinik hat sich ein colorektales team aus Ä rzten und pflegepersonen gebildet, das zum einen die anorektalen malformationen der kinder operiert und nachbetreut, zum anderen als interdisziplinäre drehscheibe zu anderen abteilungen fungiert. mehr bereits bei der abklärung der patienten mittels endoskopie spielt der kinderchirurg eine wesentliche rolle. bewährt hat sich die anwesenheit des gastroenterologen während der endoskopie. sind die indikationen zur operativen intervention beim mb. crohn klar, ist bei der colitis ulcerosa nur die behandlung des toxischen megacolons eindeutig. im allgemeinen wird der chirurg erst am ende der konservativen therapie beigezogen, wenn sich der patient bereits in schlechtem allgemeinzustand befindet oder komplikationen von seiten der nicht ganz harmlosen medikation eingetreten sind. anhand eines -jährigen mädchens mit ausgeschöpfter therapie (sandimun, imurek und prednisolon) möchte ich unser vorgehen darstellen. trotz maximaler konservativer therapie konnten die blutungen nicht gestoppt werden. wegen grundlagen. die pilonidalsinus-erkrankung ist eine in der rima ani lokalisierte granulomätöse erkrankung, verifizierbar mittels ,,blickdiagnose''. trotz ihres häufigen vorkommens gibt es für die erkrankungsstadien der affektion keine allgemein gültigen therapieempfehlungen. methodik. während der letzten jahre wurden kinder/ jugendliche ( mädchen, männliche kinder/jugendliche (alter zwischen und jahren)) wegen einer pilonidalsinus-erkrankung behandelt. waren asymptomatisch, der prozess wurde exzidiert und der defekt linear verschlossen. hatten ein chronisch-entzündliches geschehen: nach exzision des herdes wurde bei einem eine limberg-lappendeckung, bei eine offene wundbehandlung und bei eine karydakis-defektdeckung durchgeführt. die ,,restlichen'' patienten mit abszedierendem pilonidalsinus wurden nach abszessinzision/exkochleation offen wundbehandelt; bei wurde tage später eine karydakis-operation angeschlossen. ergebnisse. bei der patienten mit den defektverschlüssen verheilten die wunden innerhalb von wochen, bei den restlichen (nach karydakis-operation) innerhalb von wochen. die offenen wundbehandlungen führten nach einer behandlungsdauer zwischen / und wochen zu einem adäquaten wundverschluss, davon entwickelten ein sinus-pilonidalis-rezidiv, das exzidiert und neuerlich offen behandelt wurde. diskussion background. as the elderly population is growing, the incidence of patients being diagnosed with pancreatic cancer at the age of and above is rising. even overall morbidity and mortality rates for pancreatic resection decreased the last decades, the indication of major pancreatic surgery in elderly patients is still discussed controversial. methods. during the last ten years patients at the age above a underwent pancreatic resection for adenocarcinoma of the pancreas at the surgical department of the muw. perioperative outcome, histopathological findings and overall survival was investigated and compared to younger patients. results. between and patients ( female and male) at the age of - and patients ( female and male) a and older, had pancreatic resection with curative intent. the pancreatic head was the predominant location within both groups. % of the elderly patients had duodenopancreatectomy almost equal to % of the patients younger than a. there was no significant difference in perioperative morbidity ( . % old vs. . % young) and mortality ( . % old vs. . % young). mortality and morbidity were % and . % in the group of patients a and older. the median postoperative stay in hospital was days (old) and days (young) respectively. there was no observed difference in the mean survival for both groups ( months old vs. months young). conclusions. an aggressive surgical approach for pancreatic cancer is justified in elderly patients, as they can benefit from resection similarly to younger patients. is preoperative tissue diagnosis mandatory for suspect lesions of the pancreas? background. it is still controversial if pretherapeutic cytohistological diagnosis is mandatory for patients with suspect leasions of the pancreas. even transgastric endosonographic biopsy is a save technique, with a sensitivity of - %, a negative result does not rule out malignancy. methods. medical records of patients who underwent surgery at our department, between and , for suspected or biopsy proven pancreatic adenocarcinoma were analysed and literature on preoperative biopsy of suspect pancreatic tumors was reviewed. results. of patients with ductal adenocarcinoma had a biopsy prior to surgical resection. of these % (n ¼ ) were histological diagnosed as adenocarcinoma. patients underwent surgery even after negative cyto-histological workup. patients had partitial pancreatic resection without preoperative biopsy. of patients receiving neoadjuvant chemotherapy % (n ¼ ) had histological diagnosis prior to therapy. on the other hand patients with suspect pancreatic lesions showed pancreatitis and no malignancy after resection. % of them had biopsy with negative result but underwent operation due to preoperative radiological findings and or ca - level. conclusions. preoperative biopsy of potentially respectable suspect pancreatic masses is not mandatory as malignancy cannot be ruled out with adequate reliability. only in patients undergoing neoadjuvant therapy extended effort in receiving positive biopsy cyto-histological result is indicated. wie schlecht sind ,,low volume hospitals''? eine kritische analyse der ergebnisqualität von pankreaskopfresektionen an einer peripherieabteilung dynamic graciloplasty in patients with severe anal sphincter lesiona method still up-to-date? background. until recently the dynamic graciloplasty (dgp) was one of the most effective techniques to create a neo-sphincter despite its complexity. nowadays it has been replaced by less invasive methods in order to treat the fecal incontinence. however dgp still plays an important role and this prospective study shows the results of reconstructive surgery. methods. from january until december seven female patients (average age of . years, range - years) were enrolled in the study. inclusion criteria were severe faecal incontince after failed conservative treatment diagnosis was confirmed by rectoscopy, endo ultrasonography and anal manometry in preoperative form according to the study protocol and the fecal incontinence was recorded using the wexner-score. postoperative complications were classified in four levels according to dindo et al. results. five patients suffered a postpartum sphincter lesion ( > in circumference) and two a congenital atresia of the sphincter muscle. postoperatively, one patient suffered level iii (reoperation) and three others level i complications (hypaesthe- sia distal to extraction area of the m. gracilis, extended aches due to sores in the neurostimulator and electrode area). after completion of the muscle conditioning (eight weeks postoperative) the median wexner-score was reduced from preoperatively (range - ) to ( - ). conclusions. all that exists today for the dgp is a modified indication list. in young patients with irreparable sphincter lesion or congenital atresia of the sphincter muscle the dgp remains an effective method in therapy with moderate morbidity. grundlagen. die versorgung von narbenhernien mittels offener oder laparoskopischer technik kann in wundkomplikationen und hernienrezidiven resultieren. mittels notes techniken könnten diese komplikationen verhindert werden. methodik. in hausschweinen erfolgte die herstellung einer ventralen bauchhernie durch resektion eines runden cm im dm haltenden muskulären defektes. nach wochen erfolgte der transgastrische verschluß der resultierenden hernie mittels eines über einen overtube eingebrachtem biologischen netzes mit cm allseitiger Ü berlappung und fixation mit transfascialen nähten. nach zwei wochen erfolgte eine explorative laparoskopie und nach weiteren wochen wurden die tiere euthanasiert und obduziert. ergebnisse. die größe der hernien lag zwischen und cm . in allen tieren konnte ein hernienverschluss mit einer mittleren operationszeit von ae minuten durchgefü hrt werden. die größe der implantierten netze lag zwischen  und  cm. ein tier verstarb unmittelbar postoperativ an hypoxie. bei der laparoskopischen exploration nach wochen fanden sich in allen tiere massive adhäsionen, ein tier wurde aufgrund einer netzinfektion euthanasiert. die ü brigen tieren ü berlebten die vierwöchige beobachtungszeit. in allen tieren fand sich bei der obduktion ein erfolgreicher hernienverschluss. alle tiere hatten netzinfektionen. schlussfolgerungen. der transgastrische verschluss von großen ventralen bauchwandhernien ist technisch machbar. das sterile transgastrische einbringen des netzes und die verhinderung von netzinfektionen stellen derzeit die größten hürden dar die überwunden werden müssen, bevor dieser eingriff bei menschen in erwägung gezogen werden kann. background. transgastric notes procedures remain difficult due to the lake of innovative flexible endoscopic technology. in particular, independent movement of the instruments from the visual axis has been described as an essential part of complex notes procedures. methods. we present our experience using the endo-samurai tm (olympus) newly designed prototype platform for advanced endoscopic surgery, which is mm in od and which allows of freedom at the instrument tips with a variety of instrument configurations, in an animal model to perform transgastric cholecystectomy. results. a porcine model was used to perform transgastric cholecystectomy with the new device. gastric exit was easily performed using an overtube and needle knife in min. the gallbladder was easily identified and dissected in a manner similar to laparoscopic procedures using graspers and hook cautery instruments with of freedom. good user ergonomics were recorded and the gb was removed without spillage in min. gastric closure was attempted with intracorporeal suturing but was still difficult due to grasping strength of the needle holders and visualization due to loss of pneumo-gastrium. conclusions. the new endosamurai tm device offers substantial advantage to the performance of transgastric notes procedures and may represent the configuration of operating flexible endoscopes of the future. background. laparoscopic cholecystectomy has become standard procedure. natural orifice transluminal endoscopic surgery (notes) will further decrease the operative trauma to the abdominal wall and reduce postoperative pain, wound infection, risk of hernia and hospital stay. we report the first results of transvaginal hybrid-notes cholecystectomy in switzerland. methods. from july to december , women were treated by transvaginal hybrid-notes cholecystectomy. pneumoperitoneum was created through a mm incision in the umbilicus. two rigid trocars ( mm and mm) were inserted in the posterior fornix of the vagina. patient data, operative time, complications and postoperative course were recorded prospectively in each patient. results. the average age of the patients was . years ( - years) and the mean body mass index was . kg/m . all operations were performed without intraoperative complications. the mean operative time was min ( - min). the mean hospital stay was . days ( - days). non steroidal antiinflammatory drugs and paracetamol or metamizol were administered for analgesia. the postoperative course was uneventful. no complications were recorded during the further postoperative follow-up after weeks. conclusions. the transvaginal hybrid-notes cholecystectomy is a feasible and probably safe procedure. operative time was despite of any expected learning courve effects not significantly longer than in laparoscopic cholecystectomy. the posterior colpotomy is a simple approach to the abdominal cavity and wound healing is very rapid. using rigid instruments and techniques wellknown for laparoscopic techniques transvaginal cholecystectomy seems feasible with low operative risk. background. the latency time to develop colonic carcinoma in patients with uretersigmoidostomy (ursig) is usually more than ten years. we present a case of carcinoma in-situ of the colon in which a ursig was present less than six months. method. retrospective chart review. case report. an eighteen-year-old male born with bladder exstrophy underwent a ursig at age of months after a failed bladder closure. four months later the ursig was converted to an incontinent uretero-ileostomy. at eighteen years of age during an operation to construct a continent reservoir carcinoma in-situ of the rectosigmoid was incidentally discovered. the involved bowel was resected and a continent reservoir with the ileal segment and descending colon was created. the patient remains disease free for the next years. conclusions. colonic carcinoma can develop even after very short time with a ursig. when ursig is taken down, the involved colonic segment should be removed. adrenal tumors in children a. pereyaslov , a. dvorakevich , l. burda medical university, lviv, ukraine; regional children hospital, lviv, ukraine adrenal tumors are the rare cause of arterial hypertension in children. prolonged period of diagnosis determines inadequate treatment of arterial hypertension with the development of lifetreating complications. in this study summarized results of treatment children with adrenal tumors during -years period. there were ( . %) children with benign adrenal tumors, including children with hormonally active (cushing's syndrome - , virilizing tumor - , feminizing tumor - , pheochromocytoma - , conn syndrome - ) and -with non-functioning tumors. five ( . %) patients had malignant adrenal tumors: patients had adrenocortical cancer, one -malignant corticochromoblastoma, and one -chromoandroblastoma. adrenalectomy was performed in ( . %) patients. conventional lumbotomy was applied in ( . %) patients and in ( . %) -laparoscopic adrenalectomy. laparoscopic removing of adrenal tumors was performed in children with pheochromocytoma, in -with adrenal cyst and in -with myelolipoma. the retroperitoneal approach was applied in patients and transperitoneal -in patients. there was no conversion during laparoscopic adrenalectomy. two ( . %) children with corticochromoblastoma and chromoandroblastoma did not operated due to the disseminated metastasis at the time of admission and they died at the follow-up. all patients who underwent adrenalectomy were discharged with normal blood pressure and no patient required adjuvant therapy. surgery remains the method of choice in the management of children with adrenal tumors and laparoscopic adrenalectomy may applied in patients independently of tumors' functional activity. damage to the ureter by an iatrogenic injury is a devastating occurrence. congenital ureteral anomalies present an increased risk of injury. case report. we report a -month-old baby that underwent right nephrectomy for a multicystic kidney. the left ureter had been damaged as an interlaced left and right ureter had not been recognized. repair of the damaged ureter had failed and the left kidney had to be drained by a j-stent through the retroperitoneal space into the bladder. the child was transferred to our institution at months. results. we interposed the appendix from the left renal pelvis to the bladder. a double j stent was inserted for four weeks. two years afterwards this child is thriving normally without urinary tract infections and normal renal function. discussion. ureteral trauma if not timely recognized can lead to urosepsis and renal failure. several techniques have been described for the replacement of long ureteral segments: the use of urinary tract tissue, the psoas-hitch technique, pedicled intestinal segments and the yang-monti technique. the appendix is similar in size and length to the ureter and can be easily implantated with an antireflux technique. electrolyte absorption and mucous production by the appendix are negligible. conclusions. only a few case reports exist in which the appendix is used as a replacement of the left ureter. this case adds to those reports and suggests that ureteral reconstruction using the appendix vermiformis seems a viable technique even when used as a replacement of the left ureter. hypospadia is one of the most common deformities of the uro-genital system. a great diversity of procedures for correction of hypospadias is suggested. at our department we use for correction of the so called ''distal'' hypospadia mainly one method: the y-v glanuloplasty modified mathieu technique after hadidi. we investigated the outcome of patients with distal penile hypospadia regarding to complications, voiding function and cosmetic satisfaction. the mean age is located in between the international recommended correction time of - month. the mean observation time is months. beside a good cosmetic appearance with an erectly shape and a wide meatus, we found an adequate voiding function. fistulas occurred after failure of wound-healing in two cases. the use of an additional layer of connective tissue between neo-urethra and skin seemed to be beneficial against occurrence of fistulas. in contrast to other urethroplasties, we do not use any stent or catheter in the y-v glanuloplasty modified mathieu technique and the patients void immediately after the surgical procedure through the neo-urethra. the crucial element is, in our opinion, an adequate pain relief during the first two days so that the patient won't get a voiding problem. the mean hospital stay was - days. all over, we think that the patients benefit from the y-v glanuloplasty modified mathieu technique as for this method we do not use urethral stenting nor any kind of dressing. background. during laparoscopic cholecystectomy (lc) for symptomatic gallstone disease injury of the gallbladder with spillage of stones occurs frequently. subphrenic abscess after lc is a rare complication of this condition and may cause diagnostic dilemmas and delayed treatment. methods. we present a case report of a patient with subprenic abscess formation due to a lost gallstone and a review of the current literature. case. after a stay in india a year old female patient presented with a subprenic abscess formation mimicking a liver abscess and pleural effusion. her medical history implied a hysterectomy for cervical cancer and a lc. the diagnostic and therapeutic management is exactly processed. results. spillage of stones at lc occurs in , - %. in a systematic review the complication rate of lost gallstones is stated to be - %. a large variety of complications, some with serious morbidity, has been described. only cases of subphrenic abscess have been reported previously. conclusions. every effort should be made to extract lost gallstones at lc laparoscopically. no conversion to an open procedure is necessary because of a low incidence of complication rate. composition of gallstones and bacteriological culture of bile is beneficial for prognosis of possible complications and their treatment. lost stones should be noticed in the operation report and the patient should be informed that in the case of complications the diagnostic and therapeutic way can be easier and performed in a shorter time. conservative treatment has a high failure rate. outcome of laparoscopic incisional hernia repair in immunocompromised patients following liver transplantation background. incisional hernias occur in up to % of patients following liver transplantation (ltx). laparoscopic incisional hernia repair (lihr) is well established in immunocompetent patients, and has been increasingly used in transplant patients. we report on our experience with lihr after ltx. methods. in a -month period, all patients undergoing lihr after ltx were included in this retrospective study. results are reported as mean ae sd or total number (%). results. fifteen patients ( . % female; age . . years) were included. mean time from ltx to lihr was . . months. hernia location was midline in ( . %), laterally in ( %) and both in patients ( %). immunosuppression was calcineurin-inhibitor based (tacrolimus % / cyclosporine %) with a tapered steroid regimen in all patients. hernia repair was technically successful in all cases using a polyester mesh ( . . square centimetres) anchored by transmuscular corner sutures and multiple spiral staples. perioperative antibiotic prophylaxis was routinely administered. no complications occurred in the early postoperative course, aside from one subfascial hematoma ( . %). mean length of stay was . ae . days. highest c-reactive protein levels during hospitalization were . ae . mg/dl. after a mean follow-up of . ae . months, ( . %) patients developed recurrent hernias, which were repaired in cases ( open, lihr). conclusions. with the use of perioperative antibiotic prophylaxis, lihr is safe in patients following ltx. no infectious complications occurred, however % of our patients developed a recurrent hernia after a mean follow-up of months. added benefit of diagnostic laparoscopy in patients with suspected acute appendicitis methods. we defined a clinical pathway for diagnosis and treatment in patients with suspected acute appendicitis. in this pathway diagnostic laparoscopy is an early step whereas ultrasonography is not part of the diagnostic steps. the aim of this study was to know the positive predictive value for acute appendicitis and experience the outcome of these patients concerning the diagnostic value of a laparoscopy. results. between apr. and dec. , patients were prospectively recorded. the correct diagnosis was found in ( %) patients. in ( %) patients either the cause of the abdominal pain remained unclear ( patients; %) or a different diagnosis was found ( patients; %). in these patients a list of different diagnoses was found. in ten patients ( . %) even a malignoma was found. conclusions. our defined pathway for diagnosis and treatment in patients with suspected acute appendicitis allows finding the cause of the abdominal complaints in % and in % acute appendicitis was confirmed. due to consequent diagnostic laparoscopy a broad list of differential diagnosis was found including malignant tumours in . %. therefore, diagnostic laparoscopy should be an early diagnostic step in patients with suspected acute appendicitis. ergebnisse. der spitalaufenthalt betrug zwischen und tagen (mittelwert: , tage). in , % der fälle war kein schmerzmittel notwendig, , % benötigten schmerzmittel bis zu tage, , % länger (mittelwert: , tage). die hauptbeschwerden reduzierten sich bei blutungen von , % (präoperativ) auf , % ( monate postoperativ), bei durch prolaps hervorgerufener verschmutzter unterwäsche von , % auf , %. von den bis jetzt nachuntersuchten patientinnen gaben nach monaten , % eine hohe zufriedenheit und beschwerdefreiheit an. bis jetzt erfolgte eine rezidivoperation, vier weitere wegen erneuten prolaps folgen. mit ausnahme von zwei postoperativ aufgetretenen abszessen mit fistelbildung gab es bislang keine nennenswerten komplikationen. schlussfolgerungen. obwohl langzeitergebnisse noch ausstehen, ist diese methode der hämorridenoperationen als komplikationsarm, sphinkterschonend und somit sehr empfehlenswert zu bewerten. sie zeichnet sich zudem aus durch eine hohe patientinnenzufriedenheit, einen kurzen krankenhausaufenthalt, einen geringen schmerzmittelbedarf und eine rasche reintegration in den alltags-und arbeitsprozess. observational study on grade-dependent treatment for hemorrhoidal diseasea single center experience background. hemorrhoidal disease is one of the most common health disorders in western civilization. the aim of this study was to retrospectively analyze the outcome of grade-dependent treatment of hemorrhoidal disease (i-iv) in a single center. methods. all patients suffering from hemorrhoidal disease referred to our unit between july and december were included in this analysis. the patients' medical records were studied in detail. a standardized telephone interview was conducted in all patients who had open hemorrhoidectomy or stapled hemorrhoidopexy. results. a total of patients ( female, male; mean age . , range - years) were assessed. conservative treatment was applied in ( . %) cases, while surgery was performed in patients ( . %) following a grade-dependent strategy. most common comorbidities were skin tags and simultaneous mucosal prolapse. postoperative complications comprised pain ( . %), bleeding ( . %) and fecal incontinence ( . %). patients undergoing stapled hemorrhoidopexy showed significantly higher recurrence rates than after open hemorrhoidectomy ( % vs. %, p ¼ . ). urgency was more common in the stapled hemorrhoidopexy group ( . % vs. . %) and the incidence of anal stricture lower than in the open hemorrhoidectomy group ( . % vs. %). conclusions. grade-dependent treatment of hemorrhoidal disease with respect to the clinical appearance and the extent of prolapse should be standard today. stapled hemorrhoidopexy appears to be an intervention with less postoperative pain and faster recovery than open hemorrhoidectomy, but long-term results include a higher recurrence rate and a higher incidence of fecal urgency and fecal incontinence. background. anal sepsis of cryptoglandular origin might be challenging for patients and surgeons due to recurrences and postoperative fecal incontinence. methods. patients with anal sepsis operated on between january st and december st at the department of general surgery, medical university vienna were retrospectively analyzed in terms of recurrence and postoperative fecal incontinence by chart review and by telephone interview using the vaizey incontinence score. results. operative treatment was given to male and female individuals ( % vs. %) with a median age of years ( - ). patients were availabe for follow-up investigation. after a median of months, patients ( %) had no recurrence after a single surgical procedure. a median of operations ( - ) was performed in patients with multiple procedures. in patients ( %), a fistula-in-ano was detected. vaizey score was in patients with single i þ d procedure. in patients with single i þ d plus fistulotomy, mild incontinence was seen in % and severe incontinence in %. in patients with muliple procedures, mild fecal disturbances were assessed in % and severe disturbances in %. conclusions. treatment of anal sepsis and fistula-in-ano is associated with a high recurrence rate and a substantial risk of fecal incontinence in this analysis. data suggest that a search for a fistula-in-ano should be performed already at the primary operation. in a case of recurrence, high transsphincteric, suprasphincteric or complex fistula-in-ano a specialized coloproctologist should be involved to avoid damage to the anal sphincter muscle. die hohe und rezidivierende analfistel background. studies have reported excellent healing rates for the treatment of cps with different skin flaps. the cosmetic outcome is less investigated. the aim was to enlighten the body image changes and patients satisfaction after limberg flap. methods. from august to december consecutive patients, mean age of . years (ae . ) with cps underwent excision and closure with limberg flap. at days morbidity and time off work were accessed. late infection, recurrence rate, selfesteem (worst , best ), cosmesis ( , ) , body image ( , ), and patients satisfaction ( , ) at one year were analyzed prospectively. results. no major complications such as flap necrosis occurred. minor complications occurred in %, including superficial infection and partial suture dehiscence. mean time off work was . days (ae . ). in patients ( %) occurred a late local infection in the first months. the recurrence rate was . % after one year. self-esteem before and after the operation remained almost unchanged (before . , after . ) (p ¼ . ). mean cosmesis and body image were acceptable, . (ae . ) and . (ae . ) respectively. % estimated their change of body image as acceptable (> ). % of the patients were highly satisfied with the procedure (> ) and mean patients satisfaction was . (ae . ). conclusions. morbidity and recurrence rate after treatment with limberg flap is low and compares favorably to other treatments. change of body image and cosmesis are acceptable in most patients, but are a problem in some and should be addressed preoperatively. background. there are more than a hundred different techniques to operate on a rectal prolapse. for old and frail patients the perineal approach is preferred. the rehn-delorme procedure and the altemeier rectosigmoidektomy are currently the most popular perineal procedures. both are demanding and time consuming. the aim was to develop a procedure, which is easy and fast to perform and has a good outcome. methods. internal rectal redundancy has recently been successfully treated with transanal resection using the contour + transtar tm stapler. this technique has been modified to the perineal stapled prolapse resection (psp). the prolapse is completely pulled out and then axially cut open at three o'clock in lithotomy position with a straight stapler. thereafter the prolapse is stepwise resected with the curved contour + transtar tm stapler. at the end of the circular resection the beginning of it is reached again at three o'clock. the staple line falls spontaneously into place and is oversewed with absorbable monofil sutures to strengthen it and ensure hemostasis. results. in a feasibility study has been shown, that the psp procedure is easy to perform, safe and doesn't need a lot of time [ ] . we present the correct operation technique. important steps are emphasized and pitfalls explained. conclusions. the video shows the psp procedure and how it's done. clinical investigations proved the feasibility of the transtar procedure. it is a safe and effective treatment for patients with ods. the aim of the presented study is to access the functional outcome after the procedure and its impact on quality of life. methods. female patients presenting with ods were enrolled prospectively for the transtar procedure. intussuseption and/or anterior rectocele were confirmed by clinical investigation and by mrdefecography. functional outcome was measured by ods-score, severity of symptoms score (sss) and wexner score at months postoperatively. quality of life was accessed by the cleveland clinical obstipation score (ccos), the gastrointestinal quality of life index (glqi), the american society of colorectal surgeons score (ascrs) and the sf- months postoperatively. results. between january and november consecutive patients, median age years (range - ) were included. eleven patients complained preoperatively fecal incontinence. functional scores improved significantly: ods decreased from a median of ( - ) to ( - ) after weeks (p < . ) and ( - ) after months. sss decreased form ( - ) to ( - ) after weeks (p < . ) and ( - ) after months. median wexner score was pre-and postoperatively (range - and - ). at weeks patients presented fecal incontinence and patients complained of fecal urgency. at months patients were still incontinent, two received a succesfully sacral neuromodulation. fecal urgency persisted in patients. quality of life improved significantly: ccos (p < . ), glqi (p < . ) and sf- (p < . ). in ascrs self-esteem improved (p < . ), the other aspects didn't change significantly. conclusions. the transtar procedure is an effective treatment for patients with severe ods and improves quality of life significantly. however, some patients suffer of incontinence and fecal urgency in the first weeks after the operation. in most of these the symptoms dissolve without further operative treatment. background. in gastric cancer, peritoneal carcinomatosis is a frequent finding and associated with a poor prognosis. the enhanced expression of phosphoglycerate-kinase- (pgk ) and its signalling targets chemokine-receptor- (cxcr ) and its ligand cxcl seem to play a crucial role in enabling diffuse primary gastric tumours to develop peritoneal dissemination. methods. comparative microarray analysis was conducted investigating human specimens from consecutive gastric cancer patients with peritoneal carcinomatosis versus gastric cancer samples without peritoneal carcinomatosis. subsequently selected target genes were evaluated using quantitative real-time polymerase chain reaction (qrt-pcr). further ,,genesilencing'' (sirna-knock-down) concerning cxcr and pgk and transfection (overexoression) of pgk was performed. the obtained results were further confirmed using western-blot, facs-analysis and invasion assays. results. the microarray analysis revealed a significant overexpression of pgk , cxcr and its ligand cxcl in specimens from gastric cancer patients with peritoneal carcinomatosis. further ,,genesilencing'' of pgk and cxcr showed a significant co-regulation on expression and protein level in vitro. the transfection (overexoression) of pgk also revealed a significant upregulation of its signalling targets cxcr and its ligand cxcl on expression and protein level. in addition the transfected cells showed a -fold distinctive property in the invasion assay compared to cancer cells without pgk overexpression. conclusions. overexpression of pgk and its signalling targets cxcr and cxcl in peritoneal disseminated primary gastric carcinomas sustainable indicate a promising regulationpathway promoting peritoneal dissemination. this data may provide new prognostic markers and/or potential therapeutic targets to prevent migration of gastric carcinoma cells into the peritoneum generating peritoneal carcinomatosis. here, we investigated the expression of dkk- protein in gastric cancer and its potential value as a prognostic marker. methods. dkk- expression was analyzed by immunohistochemistry in tumour samples and was correlated with microvessel density (mvd), tumor stage and grading, as well as the clinical outcome of the patients. results. dkk- expression was detected in endothelial cells of the tumour vessels but not in normal vessels in / ( . %) and in tumor cells in / ( . %) respectively. mvd was high and low in ( . %) and ( . %) specimens. in tumor cells, overexpression of dkk- was found in ( . %) and was correlated significantly to pt-stage (p < . ) and uicc stage (p < . ). survival analysis regarding dkk- expression in tumor endothelial cells showed that dkk- is an independent predictor of disease-free survival (p < . ) conclusions. dkk- expression in tumor vessels of patients with gastric cancer identifies a population of patients with relatively favorable prognosis. methodik. bei nach den international anerkannten kriterien (igclc -international gastric cancer linkage konsortium) gegebenen verdacht auf ein hereditäres diffuses magenkarzinomsyndrom wurde eine e-cadherin-mutationsbestimmung (cdh ) erstgradiger familienmitglieder durchgeführt. acht von neun untersuchten familienmitgliedern waren positiv für die cdh keimbahnmutation. in allen fällen konnte präoperativ das vorliegen eines karzinoms durch eine ausgiebige endoskopie ausgeschlossen werden. fünf träger der mutation entschlossen sich nach einer ausführlichen, chirurgischen beratung zur prophylaktischen operation. in einem fall wurde präoperativ eine mukosektomie einer ektopen magenschleimhaut im oesophagus durchgeführt. ergebnisse. aufgrund der indikationsstellung mit verzicht auf eine lymphadenektomie entlang der gefäße des trunkus coeliacus wurde die gastrektomie mit lk-dissektion d- in laparoskopische technik durchgefü hrt. in systemischer aufarbeitung des ganzen magens konnte in allen fällen ein intramukosales monozellulär verschleimendes magenkarzinom nachgewiesen werden. eine lymphknoten-oder gefäßinvasion konnte nicht nachgewiesen werden. es konnten zwischen bis lymphknoten untersucht werden (im durchschnitt untersuchte lk). schlussfolgerungen. die gastrektomie in laparoskopischer technik ist ein onkologisch korrektes, sicheres und für diese indikation gutes verfahren. wir sahen bis auf eine wundheilungsstörung an einer trockareinstichstelle keine chirurgischen probleme. alle vorteile der laparoskopischen technik konnten umgesetzt werden. background. incisional trauma is major factor contributing to perioperative morbidity and mortality. cosmesis and body awareness also play an increasing role in patients' acceptance of cardiac surgery. during the last years it was our effort to increase the percentage of minimally invasive operations. methods. cardiac surgical operations of the last years were evaluated regarding conventional (median sternotomy) approach and minithoracotomy or total endoscopic surgery. indications for either procedure were identified. results indications were extended to complex valvular, bivalvular and other combined procedures. major contraindications are severe calcifications and aortic dilatation. tecab could be performed for single and double vessel revascularisation as well as hybrid procedures including pci. conclusions. an increasing percentage of cardiac surgical operations can be performed minimally invasive. however this evolution has still to be more widespread especially in the era of interventional valve procedures. the heartport access for increased patient mobility and satisfaction t. fleck, w. wisser median sternotomy is the gold standard in cardiac surgery, as it enables superior exposure for nearly all surgical procedures. however, there are disadvantages, namely the risk of sternal dehiscence with or without infection with an incidence of - % and the immobility of the patient for the healing process of the bone. since a total of patients (mean age years) underwent cardiac surgery through a mini right thoracotomy in the icr without rib spreading. the underlying pathology was mvd n ¼ , tvd n ¼ , asd n ¼ , myxoma n ¼ (mean es . ). cpb was established through a . cm incision in the right groin. the aorta was occluded with an endoballon. exposure was satisfactory in all patients. especially in redo procedures (n ¼ ) the necessity of dissection of the entire heart was avoided and this reduced the amount of bleeding and the known risks of redo sternotomy. the indented surgical procedures could be preformed in all patients: mvr n ¼ , asd closure n ¼ , myxoma resection n ¼ , tvr n ¼ . complication and mortality rate was . %. mean icu stay was days, hospital stay days. with the avoidance of a median sternotomy, the mobility of the patient postoperatively is increased. furthermore the patients appreciated the cosmetic aspect and the possibility to return to daily activity, sports and job in a shorter time. from a surgical point of view, the same technical standard of surgical performance can be maintained through this approach after the surgeon becomes accustomed to the instruments and exposure. background. atrial septal defects (asd) apply for - % of congenital heart disease. the standard surgical approach used to be median sternotomy. we reviewed our experience on the development of a minimally invasive surgical technique and its introduction into clinical routine. methods. we reviewed all patients who underwent surgical asd-closure at our institution from / - / . analysis was performed concerning asd-pathology, patient characteristics and operative variables. results. from / through / , patients underwent isolated asd-closure. in that period, operations were performed in a minimally invasive technique through a right-sided minithoracotomy and remote-access perfusion through the right groin. in , the development of the technique started using the heartport-perfusion system ( pts). thereafter we started to use chitwood-clamp. defects were closed by direct suture, by patch closure. during the last three years, the number of patients undergoing minimally invasive surgery, is rising steadily ( : pts, : pts, : pts) . in , the first sinus venosus defect was successfully treated in that fashion. furthermore, the technique is also applicable for treatment of dislocated interventional occluding devices ( pts). the mean age of the patients was . years ( - yrs), mean weight was . kg ( - kg). mean aortic crossclamp time was . min. there was no operative death and no patient had to be converted to median sternotomy. conclusions. minimally invasive asd-closure via a right-sided minithoracotomy has successfully been introduced into clinical routine at our institution. with growing experience even sinus venosus defects and dislocated occluding devices can be operated on safely and with good results. background. the levitronix centrimag device is a centrifugal pump designed for short term support in cardiogenic shock. it is implantable both in adults and also in pediatric pts. we report our experiences using the centrimag device in all forms of cardiogenic shock (postoperative lcos, myocarditis, pre-htx, right heart failure post htx, acute myocardial infarction) in the adult population. methods. we have implanted in a four-year period the centrimag device in adult pts (mean age . years). the cumulative experience was years. the device was implanted in cases as femoro-femoral bypass, in the cases intraoperatively by cannulating the left atrium and the ascending aorta and in the remaining three cases by cannulating the right atrium and the pulmonary artery (right heart failure after htx). the mean support time was . days ( - days) . results. fifty-eight patients ( %) could be successfully weaned from device. in cases ( %) the centrimag was used as a bridge to a more sophisticated device (cardiowest , dura-heart , ventrassist , thoratec , heartmate ii , incor and novacor ). at least pts. ( . %) died on device, mainly caused by multiorgan failure. three pts underwent htx, pts are on support at this moment. conclusions. the levitronix centrimag seems to be safe and effective in the treatment of nearly all kinds of cardiogenic shock achieving rapid and sufficient circulatory support and ventricular unloading. bridge-to-recovery, bridge-to-bridge or bridge-totransplant are possible. grundlagen. das ziel dieser prospektiven studie war es, perioperative klinische parameter zwischen der minimal extrakorporalen zirkulation (mecc) und der konventionellen extrakorporalen zirkulation zu vergleichen. methodik. unter verwendung des mecc-systems wurde eine koronare revaskularisation bei randomisierten patienten (mittleres alter , jahre ( - jahre), (gruppe i) durchgeführt. in der vergleichs-gruppe ii (n ¼ , mittleres alter , jahre ( - jahre) wurden die patienten mit einer konventionellen extrakorporalen zirkulation perfundiert. die einstammerkrankungen, sowie die notfalleingriffe wurden exkludiert. ergebnisse. in den beiden gruppen zeigte sich kein signifikanter unterschied der mittleren aortenklemmzeit ( ae , min vs ae , min), der mittleren extrakorporalen perfusionszeit ( ae , min vs ae , min), der mittleren anzahl der distalen anastomosen sowie in der anzahl der verwendeten erythrozythenkonzentrate. es kam zu keiner tage mortalität. ebenso zeigten die nach , und stunden postoperativ gemessenen laborparameter (troponin t, kreatinin, ck, ck-mb, thrombozyten, leukozyten, hämoglobin, hämatokrit) keinen statistisch signifikanten unterschied. die gemessene laktatwerte zeigten im gegensatz dazu (intraoperativ , vs , , stunden postoperativ , vs , , stunden postoperativ , vs , ) statistisch signifikante vorteile für das mecc-system. die aufenthaltsdauer auf der intensivstation war in der gruppe i signifikant kürzer als in der gruppe ii ( , tage vs , tage). schlussfolgerungen. zusätzlich zu der aus der literatur bekannten reduktion von entzündungsmediatoren finden sich signifikante hinweise einer optimierten perfusion. der mecc-patient ist postoperativ aktiver, leider fehlt dazu ein objektiver parameter. training surgeons to establish a robotically assisted totally endoscopic coronary surgery program background. since ist introduction totally endoscopic coronary surgery (tecab) was standardized during the past decade. additionally younger surgeons needed training in robotically assisted cardiac surgery. methods. in out of robotically assisted (da vinci tm telemanipulator, intuitive inc., sunnyvale, ca) coronary operations parts of the procedure were performed by surgeons trained in endoscopic cardiac surgery. the distinct parts of the tecab procedure were: lima/rima preparation, lipectomy, pericardiotomy, ima to lad anastomotic suturing. conclusions. we conclude that the tecab procedure can well be trained in a stepwise approach. the establishment of a robotically assisted coronary surgery program is feasible after adequate training. obesity has no effect on operative times and perioperative outcome of patients -undergoing totally endoscopic coronary artery bypass surgery background. more and more patients undergoing coronary artery bypass grafting (cabg) are overweight. even though in these patients there is no clear evidence of increased perioperative mortality, it has been shown that they suffer from superficial-and deep wound healing problems more often than normal-weight patients. therefore, avoiding sternotomy in obese patients by using an endoscopic technique could be a promising approach. robotic technology enables totally endoscopic coronary artery bypass grafting (tecab) procedures. we investigated whether the intraoperative times or perioperative outcome after tecab-procedure are negatively affected by obesity. methods. patients (n ¼ , male, female, median age ( - ) years), undergoing arrested-heart tecab procedure were enrolled. the median bmi in this patient cohort was ( - ). in detail, patients were normalweight(bmi kg/m ), patients were overweight(bmi: . - kg/m ), patients were obese (bmi . - . kg/m ) and patients were morbidly obese (bmi ! kg/m ). the heartport/cardiovations tm (n ¼ ) or the estech-rap tm system (n ¼ ) were used for arrested heart tecab procedure with remote access perfusion and aortic-endoocclusion. results. there was no correlation between bmi ( ) left internal-mammary-artery-takedown-time(r ¼ . ; p ¼ n.s.), ( ) lipectomy and pericardiotomy-time (r ¼ . , p ¼ n.s.) ( ) total operative-time (r ¼ À . : p ¼ n.s.), ( ) cardiopulmonary-bypass-time (r ¼ À . ; p ¼ n.s.), ( ) aortic-endoocclusiontime (r ¼ À . ; p ¼ n.s.), ( ) mechanical-ventilation-time (r ¼ . , p ¼ n.s.) ( ) length of icustay (r¼ . ; p ¼ n.s.), ( ) length of hospital-stay (r ¼ . ; p ¼ n.s.). or ( ) occurrence of intraand/ or postoperative adverse events. conclusions. in overweight, obese but also morbidly obese patients the tecab procedure did not increase operative times or the rate of intra-or postoperative complications. this patient groups, therefore, benefits from this less traumatic version of coronary surgery. background. selective decontamination of the digestive tract is still not widely accepted, although it reduces the incidence of nosocomial infections. in a previous retrospective study we have shown a clear reduction of nosocomial infections in patients with esophageal anastomoses receiving selective decontamination. we thus started to apply selective decontamination routinely for esophageal anastomoses. here we report the outcome of a case series of patients receiving this treatment and compared them to historic controls. methods. from , patients with esophageal anastomosis were prospectively registered. patients received polymyxin, tobramyxin, vancomycin (ptv) and mycostatine four times a day orally on average for days starting on the day before surgery. outcome was compared to a historic control treated before without selective decontamination (n ¼ ), which did not differ significantly in age, gender, bmi and asa score. results. a total of patients received selective decontamination. the average age was . years and asa score was . the pulmonary infection rate was . % ( % ci: . - . %) clearly lower than in the historic control ( . %, % ci: . - . %, p ¼ . ). anastomotic leakage rate was . % ( % ci: . - . %) compared to . % ( % ci: . - . %, p ¼ . ) without selective decontamination. the perioperative mortality was only . % ( % ci: . - . %) compared to % ( . - . %, p ¼ . ) previously. conclusions. selective decontamination of the digestive tract significantly reduces perioperative morbidity and mortality in patients with esophageal anastomosis. anastomotic leakage rate could be reduced resulting in a much lower mortality. we suggest that selective decontamination to be used routinely in patients having an esophageal anastomosis. marienhospital, ruhr-universität bochum, herne, germany die therapie des Ö sophaguskarzinoms ist inzwischen zu ca. % multimodal ausgerichtet. jedoch ist immer noch unklar welche modalität zur welcher zeit und in welcher reihenfolge angewandt werden soll. beim lokal fortgeschrittenen plattenephithelkarzinom des Ö sophagus wird generell die neoadjuvante radio-chemotherapie als standard angesehen, teilweise wird diese nach einer so-genannten induktionstherapie durchgeführt. dieses vorgehen ist bis heute jedoch in keiner randomisierten abschließend studie bewiesen, auch wenn eine kürzlich publizierte meta-analyse einen marginalen vorteil der multimodalen therapie beschreibt. nach kürzlich publizierten daten (bedenne et al., asco, , stahl et al. jco ) scheint der vorteil der resektion sich vor allem auf die patienten zu beschränken, die auf die multimodale therapie nicht oder nur unzureichend ansprechen. anders verhält es sich bei den adenokarzinomen des distalen Ö sophagus. nach drei randomisierten studien, die mehrheitlich barrett karzinome einschlossen, ist die neoadjuvante chemotherapie bei lokal fortgeschrittenen adenokarzinomen als internationaler standard angesehen. neuere studien untersuchen derzeit den einfluss der präoperativen radio-chemotherapie auch bei adenokarzinomen des distalen Ö sophagus sowohl auf das rezidiv-freie als auch auf das langzeitüberleben nach resektion. nach ersten daten schient die resektion nicht mit einer erhöhten morbidität oder letalität einherzugehen. im vortrag werden die aktuellen studien und der derzeitige therapiestandard der multimodalen therapie bei karzinomen des Ö sophagus dargestellt. prognose bedeutend verbessert und in zunehmender häufigkeit ist auch eine kurative therapie möglich. besondere fortschritte gab es in der medizinisch onkologischen therapie, wodurch mittlerweile mediane Ü berlebensraten von über jahren erreicht werden können. die chirurgische therapie ist bedeutend sicherer geworden, erlaubt große resektionen auch bei chemotherapeutisch vorbehandelten patienten mit geringer morbidität und schließlich wurde das therapeutische armamentarium durch interventionelle radiologische, nuklearmedizinische und strahlentherapeutische möglichkeiten erweitert. deshalb background. lipocalin- (lcn- , ngal) was recently shown to be highly expressed in various human cancers and increased protein levels were associated with worse survival of patients with breast, gastric or oesophageal cancer. the main focus of this work was to analyze the possible implication of lcn- upregulation in colon cancer development. methods. expression of lcn- was analyzed in various colorectal carcinoma cell lines, paired colorectal carcinoma tissues and normal mucosas by western blot. lcn- immunostaining was performed in colorectal carcinoma resection specimens (intensity score - ) and correlated with clinical parameters. colorectal carcinoma cell lines were treated with various concentrations of recombinant lcn- protein and monitored for growth and survival. results. western blot analysis of colorectal carcinoma cell lines and tissues clearly demonstrated lcn- overexpression in carcinomas compared with normal mucosas in all colorectal carcinoma tissue pairs analysed. immunostaining revealed lcn- overexpression in ( . %) of colorectal carcinoma tissues. intense immunoreactivity was significantly correlated with tumor grading (p < . ). cancer samples of the right hemicolon showed significantly higher lcn- expression decreasing in the left hemicolon and the rectum (p < . ). addition of various concentrations of recombinant human lcn- protein to colorectal carcinoma cell lines did not have any influence on cell growth and survival in vitro. conclusions. our data provide evidence that lcn- expression is upregulated with tumor progression. the correlation of lcn- expression with localisation in the colon gives molecular biological evidence for distinguishing subsites of colorectal cancer. targeting lcn- might be a new therapeutic strategy in colorectal carcinoma. qualitätskontrolle der primären rektumkarzinom -chirurgie in einem nicht selektionierten, konsekutiven patientengut an unserer klinik wurden in zehn jahren patienten neoadjuvant radiochemotherapiert ( wochen) und anschließend mittles tme radikal operiert. die -j-Ü r betrug %. von synchron metastasierten patienten, welche nach therapie des primums metastasektomiert wurden, entwickelten % ein tumorrezidiv, allerdings wesentlich früher als die primär nichtmetastasierten patienten. die hälfte der synchron metastasierten patienten mit tumorrezidiv konnten kurativ re-operiert werden, nur ein patient blieb tumorfrei. aufgrund der schlechten prognose wird in den letzten jahren -analog zum kolonkarzinom -beim synchron metastasierten rektumkarzinom zunehmend eine Ä nderung der behandlungsstrategie diskutiert. die vorstellung, dass eine systemische erkrankung eine systemische behandlung benötigt, wird dadurch bekräftigt, dass eine sekundäre resektabilität von marginal operablen/inoperablen lebermetastasen in bis zu % gegeben ist und auch patienten mit operablen metastasen durch die neoadjuvante chemotherapie einen Ü berlebensvorteil aufweisen. zudem haben wir erfahrungen mit patienten, welche ,,liver first'' therapiert wurden und im falle eines ,,response'' auch das primum eine regression zeigte. sollte somit beim metastasierten rektumkarzinom auf die scheinbar ,,optimale'' neoadjuvante lokaltherapie zugunsten einer systemischen chemotherapie und einer ,,liver first'' taktik verzichtet werden? ist im falle eines ,,response'' auch die chemotherapie in der lage, eine ausreichende lokalkontrolle zu gewährleisten? können wir patienten selektionieren, welche unter systemischer therapie progredient sind, und diesen die neoadjuvante lokaltherapie und operation ersparen? bis dato bleibt die behandlungsstrategie beim synchron metastasierten rektumkarzinom kontrovers. ergebnisse. insgesamt entwickelten % der patienten ein tumorrezidiv, während % rezidivfrei blieben ( -jahres-krankheitsfreie-Ü berlebensrate: %). die in der nachsorge diagnostizierten asymptomatischen rezidive traten bis jahre nach primärbehandlung auf; nahezu die hälfte ( / ; %) dieser patienten konnte in kurativer absicht re-operiert werden. davon blieben % ( / ) innerhalb der nachbeobachtung rezidivfrei. in einer multivariaten analyse zeigten das uicc-stadium (p ¼ . ) und das grading (p < . ) eine signifikante korrelation zum rezidivauftreten. die -und -jahres-Ü berlebensraten dieses kollektivs waren % bzw. %. in bezug auf das Ü berleben war in der multivariaten analyse nur das ypt-stadium (p < . ) ein signifikanter parameter. schlussfolgerungen. bei patienten mit lokal fortgeschrittenem rektumkarzinom können gute onkologische langzeitergebnisse erzielt werden. dazu ist neben der multimodalen therapie auch ein intensives nachsorgeprogramm notwendig, welches asymptomatische rezidive frühzeitig erkennen lässt und kurative re-operationen ermöglicht. background. transcatheter based aortic valve replacement (avr) is a promising procedure to reduce operative risk especially in old patients with significant comorbidities. we report the initial series of transapical and transfemoral-avr including years follow up. methods. access was either antegrade through a anterolateral thoracotomy with direct puncture of the apex or retrograde through the femoral artery. after initial balloon-valvuloplasty the balloon-mounted crimped bioprosthesis was introduced and positioned under fluoroscopic and echo control. since march fifty-nine patients underwent transapical-avr and patients underwent transfemoral-avr. mean age was ae . years, the logistic euroscore predicted risk for mortality was . ae . %. results. implantation was performed on beating heart with a period of rapid pacing for deployment of the valve. cardiopulmonary bypass was used only in the initial patients. in the transapical group patients had to be converted to conventional avr because of malpositioning. thirty days mortality for transapical was %, in the transfemoral group %. echocardiography showed excellent gradients (pmax . ae mmhg) at discharge and years after implantation. small paravalvular leaks without hemodynamic importance were observed in patients ( %) in the transapical group and in all transfemoral patients. conclusions. transcatheter avr with the sapien-edwards bioprosthesis can be performed in high risk patients successfully. complications may be attributed to the high risk profile of the elderly patients and the learning curve of this new procedure. the valve exhibits excellent hemodynamics up to years. however, longer-term valve performance and durability needs to be monitored. drei herzchirurgische notfälle nach percutanen aortenklappenimplantationen background. in symptomatic patients with severe aortic stenosis (as), operative aortic valve replacement is the treatment of choice. however, not only symptomatic as becomes more prevalent in elderly patients but also comorbidities that increase the risk for operative valve replacement. therefore, percutaneous aortic valve replacement (pavr) might be an alternative therapy for high-risk patients. methods. in our institution, patients ( male, female; mean age ae years) with symptomatic severe as and a logistic euroscore > % underwent pavr between may and january . the procedure was performed in the catheterization laboratory via a bifemoral percutaneous approach under local anesthesia and analgesic sedation without surgical cut-down and hemodynamic support. after balloon valvuloplasty, the self-expanding corevalve prosthesis (diameter mm, n ¼ ; mm, n ¼ ) was implanted using the current french delivery catheter system. results. acute procedural success rate was %. device implantation resulted in a significant increase of calculated aortic valve area ( . ae . vs. . ae . cm , p < . ). postprocedural aortic regurgitation was trivial or mild in patients and moderate in seven patients. permanent pacemaker implantation was necessary in four patients due to complete atrioventricular block. major complications were myocardial infarction (n ¼ ), stroke (n ¼ ) and pericardial tamponade (n ¼ ). actually, allcause mortality rate is . % at days and . % after one-year follow-up. conclusions. pavr with the self-expanding corevalve bioprosthesis is an emerging alternative treatment for high-risk patients with symptomatic severe as. complication rate is acceptable and mortality rate lower than predicted by risk calculation. results. median length of stay was days in conventional open repair encomprising days on the intensive care unit. median length of stay in stent-graft placement was days. the day rate on the normal ward is estimated at . . d and the day rate on the intensive care unit is estimated at . . d . median number of stent-grafts used was . . despite substantial higher procedural costs of stent-graft placement ( . . d versus . . d ), total cost performance was lower ( . . d versus . . d ) resulting in a cost difference of . . d . as a consequence, the cost advantage of stent-graft placement turned out to be . %. conclusions. despite substantially higher procedural costs as compared to conventional open repair of descending thoracic aortic aneurysms, endovascular stent-graft placement is cost efficient mainly due to the preventable intensive care stay and the shorter in-hospital stay. background. supra-aortic transpositions followed by endovascular stent graft placement are now an established tool in the treatment of aortic arch pathologies. results remain to be determined. methods. from through , patients (median age, years) presented with aortic arch pathology (aneurysms, n ¼ ; type b dissections, n ¼ ; penetrating ulcers, n ¼ ; traumatic lesions, n ¼ ; aneurysms based on prior surgery for aortic coarctation, n ¼ ). strategy for distal arch disease was subclavian-to-carotid transposition (n ¼ ) or autologous double-vessel transposition through upper hemisternotomy (n ¼ ). for entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n ¼ ). endovascular stent graft placement was performed metachronously. results. in-hospital mortality was . % (n ¼ ). persistent early type i and iii endoleak rate was . %. persistent late type i and iii endoleak rate was . %. overall actuarial survival was %, %, and % at , , and years. mean follow-up is months (range, to ). early and late endoleak formation was independently predicted by the number of prostheses. survival was independently predicted by higher logistic euroscore levels. conclusions. results after supra-aortic transpositions followed by stent graft placement for the treatment of aortic arch pathologies are promising. endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. each type of arch rerouting has turned out to be effective. extended application of these combined treatment strategies substantially augments the therapeutic options. grundlagen. im rahmen einer aortendissektion typ a wird bei herkömmlichen operationsmethoden die aorta aszendens und teile des aortenbogens ersetzt, die absteigende aorta bleibt jedoch unbehandelt. das falsche lumen der thorakalen aorta bleibt in bis zu % der fälle perfundiert. wir berichten über ein kombiniertes chirurgisches und endovaskuläres verfahren für die behandlung komplexer typ a dissektionen unter verwendung einer hybridprothese. methodik. zwischen / und / wurde patienten ( , ae , jahre; männlich, weiblich) mit aortendissektion typ a ( akut, chronisch) die e-vita open endoluminal stentgraftprothese im kreislaufstillstand in moderater hypothermie mit selektiver antegrader hirnperfusion implantiert. der gestentete teil der prothese wird über den eröffneten aortenbogen in die aorta deszendens vorgeschoben, anschließend wird mit der dacron hälfte der prothese der aortenbogen und die distale aorta aszendens ersetzt. ergebnisse. alle patienten überlebten den eingriff ohne neurologischem defizit. eine computertomographie der thorakalen aorta wurde innerhalb der ersten zwei wochen nach der operation durchgeführt, dann im abstand von , und monaten. nach monaten zeigte sich bei von patienten ( , %) eine komplette thrombosierung des falschen lumens bis auf höhe des stentgrafts. ein patient mit chronischer typ a dissektion erhielt monate nach dem ersteingriff einen thorakoabdominellen aortenersatz. der durchmesser der aorta deszendens war in der kontrolle nach monaten bei patienten rückläufig. schlussfolgerungen. bei noch geringer fallzahl zeigen die positiven ergebnisse, dass der simultane chirurgische und endovaskuläre zugang für die erweiterte therapie der typ a dissektion eine gute behandlungsmöglichkeit darstellt, ohne das perioperative risiko zu erhöhen. from trunk to trunkstent-graft coverage of the entire thoracic aorta background. aim of this study was to determine safety and practicability of stent-graft placement in patients requiring coverage of the entire descending aorta. methods. from through , patients (male ¼ , mean age a) underwent stent-graft placement from brachiocephalic to celiac trunk. all patients underwent rerouting of the supraaortic branches to gain sufficient proximal landing zone. indications for stent-graft placement were aneurysms (n ¼ ) and penetrating ulcers (n ¼ ). csf drainage was initiated only in case of neurologic symptoms. in all patients mean blood pressure was kept above mmhg for hours after stent-graft placement. results. arch rerouting and stent-graft placement were performed successfully in all patients. one early type iii endoleak was observed and treated by overstenting. no late endoleaks occured. symptoms of spinal cord malperfusion were observed in patients ( . %). in one patient paraplegia was seen, resolving after csf drainage ( . %). another patient developed signs of chronic spinal cord ischemia ( . %). this patient had undergone replacement of the abdominal aorta years prior to stent-graft placement. in all other patients no signs of spinal cord malperfusion could be detected. conclusions. this study outlines the safety and practicability of the complete coverage of the descending aorta from trunk to trunk. the low number neurologic complications could be explained by aggressive rerouting procedures resulting in sufficient collateral flow from the left subclavian artery and the intended elevation of postoperative blood pressure. csf drainage is not required on a regular basis in these patients. endovascular stent-graft placement in atherosclerotic aneurysms involving the descending aortalong-term results background. to determine long-term durability and need for reinterventions after endovascular stent-graft placement in atherosclerotic aneurysms involving the descending aorta. methods. we performed a prospective follow-up analysis of a consecutive series of patients (n ¼ ) undergoing endovascular stent-graft placement due to atherosclerotic aneurysms involving the descending aorta between and . outcome variables included death, occurrence of early and late type i and ii endoleak formation, the rate of reintervention due to early and late endoleak formation and the survival of the patients. median follow-up was ( - ) months. results. in-hospital mortality was %, whereas two third of these patients underwent stent-graft placement in the acute setting. assisted primary endoleak rate was %. assisted secondary primary rate was %. actuarial survival rates at , and years were %, % and % respectively. a short proximal landing zone and a high number of implanted stent-grafts were identified as independent predictors of the occurrence of early and late endoleak formation. the occurrence of late endoleak formation appeared to be an independent predictor with regard to survival. conclusions. long-term durability of endovascular stentgraft placement in atherosclerotic aneurysms involving the descending aorta is satisfying and the need for reintervention is acceptably low. an extensive landing zone and a low number of stent-grafts are mandatory for early and late success. background. swedish adjustable gastric banding (sagb) is an effective treatment for morbid obesity. the aim of this study was to assess the efficacy and safety of sagb in older patients aged ! years. methods. between / and / , patients were aged ! years. two groups of patients were analyzed: group (n ¼ ) patients aged - years and group (n ¼ ) patients aged - years. results. one hundred and thirty-four patients ( . %) out of entered the study. mean % ewl was . at year and . at years, bmi fell from . to . at years. in the patients, there were patients with complications ( . %) and patients with no complication ( . %). the most common complications were esophagitis, esophageal dilation, port problems and pouch dilation. in group , mean % ewl was . at year and . at years. bmi fell from . to . at years. in the patients, there were patients with complications ( %) and a reoperation rate of . %. in group , mean % ewl was . at year and . at years. bmi fell from . to at years. in the patients, there were ten patients with complications ( %) and a reoperation rate of . %. there was no mortality. conclusions. at -year follow-up, for older patients, sagb is an effective bariatric procedure for achieving weight loss. nevertheless, based on the high complication and reoperation rate, a gastric band-specific patient selection will be necessary. background. study aim was to retrospectively assess whether patients were able to maintain their weight after gastric band removal or deflation and how they felt about gastric banding. methods. total patients ( % female, mean age . (sd . ) years) were included in this study: patients who had their band removed/deflated without further surgical intervention (group , n ¼ ), those who later underwent a second bariatric operation (group , n ¼ ). we evaluated weight gain after band removal/during the time between band removal and second bariatric operation. results. of our patients ( %) suffered a complication ( late pouch dilatations, six band infections, five band migrations, two band leaks) requiring band removal. ten patients wanted their band removed (six) or emptied (four). mean time after band removal, when patients had neither a band nor a second bariatric operation, was . (sd . ) years. five ( . %) patients maintained their weight, four of whom experienced a learning effect, all others gained weight. mean bmi for both groups after the period without a band was . (sd . ) kg/m (vs. . (sd . ) at removal) and excess weight loss (ewl) was . (sd . ) % (vs. . (sd . ) % at removal). of our patients % stated they would not agree to gastric banding again. according to baros, long-term outcome of patients following band removal was a ''failure'' in % of patients. conclusions. long-term outcome following band removal is unsatisfactory in many patients. nevertheless, a minority of patients was able to maintain its weight loss. background. in bariatric surgery studies show that a better quality of life is correlated to increased weight loss. the question remained which type of surgery is superior in quality of life independently from weight loss. methods. in our study we recruited bariatric patients, operated between and ( women/ men) at the mean age of . years (sd ¼ . ) and with a mean bmi of . kg/m (sd ¼ . ). patients eligible for investigation were patients with laparoscopic gastric bypass and patients with adjustable gastric banding (agb). the patients were reviewed in the interval of , , , , , and months after operation. the bariatric analysis and reporting outcome system (baros) was used for the quality of life investigation which has been international established for obesity surgery outcomes. results. with a minimum of years follow-up our patients showed a mean bmi of . kg/m (sd ¼ . ). the statistical analysis (linear regression) showed a positive correlation between quality of life and weight loss, depending on operation method. additionally we used a partial correlation to rule out the influence of weight loss and remarked a significant result (r ¼ . , p ¼ . ). with a t-test it could be demonstrated, that patients with a laparoscopic gastric bypass observed a significant different quality of life, than patients with an agb independent from weight loss (t ( ) ¼ . , p ¼ . ). conclusions. independently of the amount of weight loss, quality of life is different between surgical procedures. wir haben versucht, mit einem standardisierten modifizierten v.a.c. + -system und einer physikalisch-technischen analyse die anwendungstechnik zu optimieren und die suffizienzrate zu erhöhen. methodik. im rahmen einer versuchsanordnung wurden die physikalischen grundlagen untersucht background. the application of the abdominal vacuum assisted closure (v.a.c.) system has become a promising treatment strategy in critical ill patients with abdominal sepsis requiring surgical therapy and open abdomen. however, fascial retraction and high rates of incomplete fascial closure up to % with subsequent high incidence of incisional hernia have been reported in literature. the aim of this study was to analyse the application of the abdominal v.a.c. therapy in patients with abdominal sepsis regarding rate of fascial closure and v.a.c. associated morbidity. methods. the study retrospectively includes all patients with abdominal sepsis requring emergency laparotomy with application of abdominal v.a.c. therapy between november and november at our department ( patients, male/ female; median age , range to ). results. the lenght of v.a.c. therapy ranged from to days (median days) with to v.a.c. changes (median ). complete fascial closure of the abdomen was feasible in patients ( %), partial closure with mesh graft implantation (vicryl, goretex) in patients ( , %), no closure in patients ( . %), and patients died with the v.a.c. system in situ ( . %). incisional site infections and intraabdominal abscesses were observed postoperatively, v.a.c. associated morbidity was . % with enterocutaneous fistulas and bleeding complications. conclusions. the study confirms the feasibility of abdominal v.a.c. therapy in patients with severe abdominal sepsis guaranteeing a high rate of fascial closure and low morbidity. methods. retrospectively reviewed patient records between august and december patients with moderate or high volume output gi fistulae, where conventional treatment had failed to prevent skin excoriaton, had been included. they underwent the fistula-v.a.c. + procedure using the v.a.c. system sized from standard sponge supplies, topical negative pressure (at most mmhg) and ostomy appliances. the v.a.c. + dressing was changed every two days. results. the v.a.c. system was found to be highly effective in controlling the fistula effluent and in promoting healing of excoriated skin. complete healing of fistula was achieved in five patients, intestinal reanastomosis in five patients, palliative care using fistula ostomy appliance in two of twelve patients. conclusions. the modified fistula v.a.c. + system can be an effective and economically viable method of containing fistula effluent and protecting the skin of patients with enterocutaneous fistulae. the v.a.c. + system may also actually promote spontaneous healing. background. surgical site infection (ssi) rates for colorectal surgery range between and %. we performed a surveillance to determine our rate and to identify risk factors. methods. in cases with colon surgery according to the nnis·colo definition or a rectal resection were collected prospectively. ssi was diagnosed following cdc guidelines. followup lasted for days, discharged patients were contacted by phone. results. one hundred and twenty-nine colon and rectal surgeries were surveyed. ssi rate for colon surgery was . % %) . ssi rate after properly timed antibiotic prophylaxis ( - min pre·op) was . % ( . - . %). otherwise the rate was significantly increased: > min pre·op ¼ . % ( . - . %), < min pre·op ¼ . % ( . - . %) or no prophylaxis ¼ . % ( . - . %) (mainly due to antibiotic treatment before surgery). higher bmi or body surface were linked with a higher infection rate (bmi < ¼ . %, ! ¼ . %, p ¼ . , body surface < . m ¼ . %, ! . m . %, p ¼ . ). conclusions. our colo ssi rate is higher than reported by nnis ( . %), but similar to rates obtained under study conditions. since data contribution to nnis is voluntary, a strong bias cannot be excluded. incorrect timing of antibiotic prophylaxis was the key risk factor for wound infections. bolus administration of antibiotics could explain the influence of body size on the ssi rate. patients with a big body size have a lower plasma concentration resulting in higher infection rates. in summary strict adherence to proper timing of antibiotic administration can drastically reduce colorectal ssi rates. first experience about treatment of chronic leg ulcers using ducest (dual cell stimulation) therapy t. payrits, s. viragos, a. ernst, g. klein, f. längle background. ulcus cruris describes a complex medical condition which affects the quality of life of patients considerably. this report refers first results about the treatment of patients with chronic leg ulcers with varied underlying causes. aim. the aim of this study is to achieve granulation tissue by using endogenous growth factors and improving wound perfusion, where other methods failed. the ducest therapy associates the application of prf (platelet rich fibrin) with targeted stimulation of the vagal nerv to encourage peripheral blood flow by use of p-stim. methods. prf combines autologous fibrin sealant and platelets. this biomatrix protects endogenous growth factors against proteolytic degradation and thereby preserves their biological activity. we draw ml blood from the patient to gain ml prf solution. we apply the prf-biomatrix with a spraypen provided by vivostat. for patients with ulcus cruris who have an impaired blood flow in the wound, we use p-stim to improve circulation in the limbs. the p-stim is a miniaturized device designed to administer auriculo point stimulation treatment over several days. the mobility of the patient is a main benefit of this therapy. results. so far we treated patients with refractory ulceras. patients achieved wound healing or a clear improvement of their wound situation. in one patient we could stop the worsening of the ulcer. the lack of woundhealing in that case was due to the non compliance of the patient. conclusions. based on these favorable findings we will evaluate the ducest therapy in a prospective study. background. endo-vacuum assisted treatment (endo-vac) represents a novel approach to treat patients with anastomotic dehiscence following anterior resection for rectal surgery. yet, limited data are available to predict success, compatibility with radio-and/or chemotherapy as well as acceptance by the patients. methods. between september and june patients suffering from anastomotic leakage after anterior rectal resection (n ¼ ) or suffering from leakage of rectal stump following hartmann's procedure (n ¼ ) were treated by endo-vac. we recorded clinical outcome and patient's comfort using a ten point visual analogue scale (vas). results. median time of endo-vac treatment was weeks (range, - ). there were no minor or major complications. in ( . percent) patients the anastomotic leakage healed successfully. three patients showed no response and needed further surgical intervention. the lack of success was due to complexity of leakages, which comprised either more than degree of the circumference or consisted of distant fistulas. formation of granulation tissue was unaffected by chemotherapy. for the question ''alteration in daily life activity'' a median score of (range, - ) was found. measuring ''pain sensation'' during end-vac treatment patients scored a median of (range, - ). conclusions. endo-vac treatment can be recommended as an alternative approach to treat pelvic sepsis following anastomotic dehiscence or rectal stump insufficiency. extended leakages should be treated by different approaches having little probability of successful healing but can lead to discomfort for the patient. radiochemotherapy does not cause a problem for application of the endo-vac. background. carcinoid tumors of the vermiform appendix are reported to be a rare occasion and to contribute to classical ''carcinoid syndrome'' only in the case of distant spread. however, these tumors may present clinical signs even in absence of metastases. methods. one hundred thirthy one appendix carcinoids were identified out of more than , histological specimen, i.e. in . % of all appendectomies. six ( . %) were found at colonic resection for caecal carcinoma and angiodysplastic syndrome. all patients were operated for the the clinical signs of acute or chronic appendicitis. all carcinoid tumors were revised retrospectively for their medical history. results. / ( . %) cases were found in combination with acute inflammation of the appendix, but / ( . %) did not show pathological findings except the endocrine tumor. almost all had hormones of the midgut group as serotonin, nse and chromogranin a in immunochemistry, only one case expressed acth most tumors were located in the tip ( . %), only % infiltrated the mesenteriolum or penetrated the serosa. when the endocrine parameters (serotonin. chrom ogranin a) were determined preoperatively in a group of cases, we failed to establish elevated serum levels in the presence of an carcinoid tumor. conclusions. only fourty per cent of appendix carcinoids present in combination with acute inflammation and are ''incidental findings'' in appendectomy. sixty per cent present with typical signs of appendicits but without any histological proof of inflammation. so the endocrine tumor causes clinical symptomes per se besides carcinoid syndrome. background. net of the appendix makes a part of % of all gastrointestinal net. they mostly appear in younger people and major part is benign, because of little diameter and leak of hormon production. if diameter is about centimetres or above, patients are running a significant risk to produce distant metastasis, generally without a carcinoid syndrome. the recently discussed entity is the goblet cell carcinoid (gcc), whose existence is to accentuate, because of the necessity to treat them like an adenocarcinoma. methods. from to we have done appendectomies. . percent or patients had a net of the appendix. mean age was years, men in proportion to women. most part (n ¼ ) had surgery because of acute appendicitis. only five patients described a long period of pain with cramps and diarrhoe. most part (n ¼ ) of net was located at the tip of the appendix with a diameter range from to mm. results. net was never diagnosed intraoperatively, although % of appendectomies have been done by specialists in surgery. in two cases right hemicolectomy was done primary because of an ileus, in four cases it was done secondary, belonging to tumor size, patients age and gcc. only one patient showed metastatic disease, when having done a second look. all net's immunehistochemically showed an expression of chromogranin a and synaptophysin. conclusions. although diagnose of net was not known when doing appendectomy, prognosis of patients outcome was not influenced in a negative way. why have neuroendocrine tumors (net) of the gut such a bad prognosis? nets in the gut mostly present multifocal disease with predominance of terminal ileum and coecum. diameter of the net mostly is above centimetres, and tumor tissue already infiltrates muscularis mucosae, with or without lymph node metastasis. belonging to the desmoplastic reaction, obstruction of intestine is not rather seen. - % of all net's of the gut are diagnosed by doing surgery because of an ileus. - % have liver metastasis with carcinoid syndrome. in a period from till we operated patients because of guts net. half of them were operated electively within a few days; the others had an acute operation within a few hours in case of ileus. median age was similar with about years. all operations have been done by specialists. in none of the cases diagnose was felt preoperatively. histological results of planned operations all showed well differentiated carcinomas with rate of distant metastasis of %, lymph node metastasis of %, contrary to acute operations, which showed bad differentiated carcinomas in % with rate of distant metastasis and lymph node metastasis of %. according to the enet classification mean part of tumors belonged to stage iiib and iv. median survival in the first group was . ae . , in the acute group ae . months. because of an a priori more radical surgery in planned operations, survival is considerably better. perhaps this point might be the solution in order to improve prognosis of guts net. gastrointestinale frühkarzinome des oberen gi-trakts: eine viszeralmedizinische herausforderung innere medizin , hsk-kliniken, wiesbaden, germany die endoskopische therapie von prämalignen und malignen läsionen im oberen gastrointestinaltrakt hat in den letzten jahren zunehmend an bedeutung gewonnen. dabei war und ist die technische weiterentwicklung im bereich der diagnostik (einsatz einer hochauflösenden videoendoskopie unter einbeziehung einer virtuellen oder realen chromoendoskopie) die integrale voraussetzung, um eine detektion von frü hen neoplastischen veränderungen zu ermöglichen. ebenso stehen dem endoskopiker therapeutisch diverse neue verfahren zur verfügung (resektionsmesser, neue ablationstechniken z.b. halo-ablation), die eine invasive und sichere endoskopische therapie ermöglichen. in einem kürzlich von unserer arbeitsgruppe veröffentlichten -jahres-follow-up von patienten mit einer hochgradigen neoplasie im barrettösophagus bzw. einem barrettfrühkarzinom konnten wir eine erfolgreiche therapie in über % der patienten dokumentieren. bezüglich des plattenepithelfrühkarzinoms des Ö sophagus wurden aus arbeitsgruppen -jahres-Ü berlebensdaten publiziert; hier zeigte sich ein -jahresüberleben von % in der lyoner gruppe vs. % der wiesbadener patienten vs. % in einem japanischen kollektiv. eine weitere arbeit aus japan, in der das technische vorgehen der endoskopische therapie (esd vs. er) evaluiert wurde, konnte in % der patienten ein -jahres-Ü berleben dokumentieren. die in den letzten jahren publizierten langzeitdaten von patienten mit t -tumoren der speiseröhre und des magens beweisen, dass eine endoskopische therapie in kurativer intention bei einhaltung definierter histologischer kriterien die therapie der wahl ist. zusätzlich können die arbeiten belegen, dass es sich hierbei um ein sicheres und komplikationsarmes therapieverfahren handelt, dass entsprechend mit einer niedrigen morbidität und mortalität verknüpft ist. while the use of breast conserving surgery increased during the last century due to strong scientific data regarding oncologic safety, only little has been done to improve the real goal of breast conservation, cosmetic outcome. oncoplastic surgery is the next important development to fulfill the goal of breast conservation. however, only few scientific outstanding original manuscripts are available. this talk gives you an overview about scientific data, future perspectives and possible borders. cariatide study: evaluation of the effect of an educational approach on compliance and adherence to adjuvant aromatase inhibitor therapy for postmenopausal women with hormone sensitive breast cancer the efficacy of ai on reducing breast cancer recurrence, but also aspects of health economy, is bound to the adherence of regular and long-term intake of the medication. aim. the cariatide study evaluates the influence of supporting educational material on compliance and retention time under ai therapy in hormone receptor positive breast cancer patients. furthermore, the study will try to explore which patients -and for what reason -fail to be compliant, and how long it takes until they quit ai therapy. study design. cariatide is an international, randomized, multicentre observational study that will include approx. patients from more than centers in countries. patients will be randomized to either standard adjuvant ai therapy or to standard ai therapy plus additional educational material, which will provide information about attributes of breast cancer, the risks and benefits of endocrine therapy, the risk of relapse and management of long-term endocrine treatment and its side effects. the material includes questionnaires to objectify patient's conception of the disease and its treatment. conclusions. randomization is ongoing and will be finalized by march ; so far, patients have been included in austria. the study will help to identify patients susceptible to compliance failure, to understand the personal reasons of compliance or non-adherence and offering possibilities to improve communication and the design of information material. grundlagen. das -genexpressionsprofil (mammaprint ?? ) ist als unabhängiger prognostischer marker beim lymphknotennegativen und -positiven mammakarzinom etabliert. der prädiktive wert für das ansprechen auf zusätzliche chemotherapie gegenüber hormonaler therapie alleine wird sowohl im adjuvanten als auch im neoadjuvanten setting präsentiert. methodik. tumoren aus studien mit bekannten tumorcharakteristika und therapiedaten wurden unterteilt in niedriges oder hohes risiko entsprechend dem mammaprint profil. die mediane nachbeobachtungszeit war , jahre. der zusatznutzen adjuvanter chemotherapie (cmf oder anthrazykline ae taxan-basiert) wurde mittels gepoolter analyse für metastasenfreies (ddfs) und krankheitsspezifisches Ü berleben (bcss) berechnet. zusätlich wurde die pathologische komplett-remissionsrate (pcr) bei patientinnen nach neoadjuvanter chemotherapie analysiert. ergebnisse. in der adjuvanten analyse wurden mittels genexpressionsprofil % der patientinnen in niedrigrisiko und % in hochrisiko unterteilt. frauen wurden mit hormontherapie alleine behandelt und zusätzlich mit chemotherapie. in der hochrisiko-gruppe zeigte sich ein beträchtlicher zusatznutzen durch chemotherapie: ddfs hazard ratio (hr) , ( , - , ), p < , und bcss hr , ( , - , ), p < , . bei multivariater analyse mit bekannten klinisch-pathologischen prognostischen faktoren waren die ergebnisse konstant. demgegenüber zeigte die niedrigrisiko-gruppe keinen signifikanten vorteil zusätzlicher chemotherapie gegenüber hormontherapie alleine: ddfs p ¼ , und bcss p ¼ , . im neoadjuvanten setting zeigte sich eine pcr-rate von % ( / ) für die hochrisiko-gruppe, während bei niedrigrisiko-patientinnen keine pcr ( / ) beobachtet wurde. schlussfolgerungen. das -genexpressionsprofil mamma-print ist nicht nur ein unabhängiger prognostischer marker; zusätzlich zeigt sich auch der prädiktive wert zusätzlicher chemotherapie sowohl im adjuvanten als auch im neoadjuvanten setting. während die hochrisiko-gruppe signifikant von einer chemotherapie zu profitieren scheint, kann ein niedrigrisiko-profil patientinnen selektieren, die mit hormonaler therapie ausreichend behandelt erscheinen. grundlagen. angiosarkome sind mit nur - % aller weichteilsarkome sehr seltene maligne tumore. ein zunehmendes problem stellen die sekundären angiosarkome nach brusterhaltender therapie eines mammakarzinoms und postoperativer bestrahlung dar. der erfolg einer chemotherapie ist zum heutigen zeitpunkt noch nicht abzuschätzen, nur eine frühzeitige mastektomie erscheint die prognose zu beeinflussen. wir berichten über zwei patientinnen, welche nach brusterhaltender therapie eines mammakarzinoms ein sekundäres angiosarkom der brust entwickelten. kasuistik. im ersten fall wurde eine jährige frau zur beurteilung von neu aufgetretenen vaskulären läsionen an der brust nach quadrantenresektion und wächterlymphknotenbiopsie eines mammakarzinoms im stadium i und postoperativer radiatio zugewiesen. die stanzbiopsie der läsion ergab ein gering differenziertes angiosarkom. im präoperativen staging konnten keine fernmetastasen festgestellt werden. die patientin wurde mastektomiert und erhält adjuvant eine anthrazyklin-monotherapie. bei einer weiteren jährigen patientin wurde im rahmen der onkologischen nachsorge nach brusterhaltender therapie und adjuvanter radiatio eines mammakarzinoms im stadium i ein weit fortgeschrittenes angiosarkom diagnostiziert. der tumor wuchs teilweise invasiv in die tiefe bis zum perikard und bis zur pleura. diese patientin erhielt noch zyklen eines liposomalen doxorubicins, verstarb aber einen monat später. schlussfolgerungen. das sekundäre angiosarkom der brust nach brusterhaltender therapie wird immer häufiger beobachtet, da heute mammakarzinome zunehmend brusterhaltend operiert werden. diese ehemals seltene erkrankung sollte nicht unterschätzt werden. früherkennung ist die einzige möglichkeit, die Ü berlebensraten dieser erkrankung zu verbessern. zur anwendung der intraoperativen sonographie bei der chirurgischen behandlung des mammakarzinoms grundlagen. mammakarzinome werden in den letzten jahren zunehmend in einem frühen stadium mit nicht oder unsicher tastbaren tumoren entdeckt. im ultraschall sind bis zu % aller mammakarzinome gut sichtbar und abgrenzbar. mit hilfe der intraoperativen anwendung des ultraschalls durch den chirurgen selbst können der patienten die unangenehme präoperative nadelmarkierung erspart werden, zudem bietet sie neben vielen organisatorischen vorteilen auch eine wertvolle orientierung bei der tumorektomie. methodik. zwischen juli und dezember wurden am landeskrankenhaus feldkirch mammakarzinome operativ behandelt. in fällen ( %) erfolgte primär eine tumorektomie, intraoperativ kam der ultraschall bei oder % aller dieser eingriffe zur anwendung. in fällen ( %) war der tumor nicht tastbar, bei den restlichen unsicher. intraoperativ erfolgte die begutachtung der schnittränder allein makroskopisch durch den pathologen, nicht jedoch histologisch. ergebnisse. nicht oder unsicher tastbare tumore konnten in allen bis auf fälle sicher aufgefunden werden. metachrone nachresektionen waren mal ( %) erforderlich. davon fanden sich in fällen ( %) im nachresektat keine hinweise mehr für malignes gewebe, in fällen ( %) in-situ-formationen, mal ( %) in-situ-zusammen mit invasiven karzinomstrukturen. bei den nicht auffindbaren tumoren handelte es sich um t a und t b-tumore, die bereits durch die stanzbiopsie schon großteils entfernt waren. schlussfolgerungen. der intraoperative ultraschall in der hand des chirurgen hat sich zum auffinden von nicht tastbaren tumoren und zur orientierung bei der tumorektomie bewährt. die ausdehnung des tumorgeschehens wird jedoch relativ häufig unterschätzt, insbesondere was die in-situ-anteile betrifft. da das brusterhaltende konzept im mittelpunkt der chirurgischen versorgung des mammakarzinoms steht, stellt die postoperative bestrahlung einen goldstandard dar. strahlungsinduzierte tumore als folge dieser therapie sind eine absolute rarität. wir möchten patientinnen präsentieren. beim ersten fall handelt es sich um eine jährige patientin, die vor jahren wegen eines invasiv duktalen mammacarzinoms nach einer brusterhaltenden operation einer bestrahlung zugeführt wurde. vor monaten wurde eine derbe struktur im bereich der op narbe entfernt. die histologie ergibt ein angiosarkom. nach abklärung wurde diese patientin umgehend einer chirurgischen therapie zugeführt. es erfolgte eine ablatio der betroffenen brust. etwas aufwendiger gestaltet sich der . fall. auch hier wurde eine jährige patientin vor jahren wegen eines invasiv duktalen mammacarzinom einer brusterhaltenden operation mit anschließender radiatio unterzogen. vor monaten kam es zum auftreten eines knotens in der axilla der operierten brust. man dachte primär an ein lokalrezidiv und entfernte dies. die histologie ergab ein malignes fibröses histiozytom. die resektion erfolgte damals nicht im gesunden. innerhalb weniger monate kam es zu einem neuerlichen rezidiv. dieses nahm nun die axilla, den gesamten m. pectoralis sowie die thoraxwand im bereich der . und . rippe ein. nun wurde eine resektion unter mitnahme der thoraxwand durchgeführt sowie einer deckung mittel myokutanen lappens. auch wenn diese fälle selten sind, so zeigen sie doch die aggressivität dieser tumorentitäten. daher muss unsere sensibilität dafür feinfühliger werden, um früher zu diagnostizieren und rasch radikal chirurgisch versorgen zu können. darin ist die größte chance zum Ü berleben zu sehen. background. after aortic valve replacement using a tissue valve,patients are treated with coumadin for months. if sinus rhythm is evident, therapy is changed to mg of aspirin a day. these are sts, acc/aha and esc guidelines. clopridigel is well known in cardiology after coronary stenting and also in peripheral vascular surgery. methods. in our -year retrospective analysis patients were treated with clopridogel after biological valve replacement (bavr). the therapy started on the fifth day after surgery and ended after months. in our group we had also patients with combined surgery like valve replacement plus cabg or carotid surgery. all patients underwent echocardiography before dismission and after months. results. in our study group we could not detect any signs of thrombembolic complications or neurological disorders. we found regular function of the valve prosthesis in all cases. one patient had to be re-operated cause of endocarditis of the prosthesis and died after prolonged ventilation problems. in the control group ( patients) we found to cases of intracerebral haemorrhagia,which caused to death. both of them were older then years. conclusions. in the last years the clinical use of tissue valves has increased because of longer durability. many post-operative regimes have been described. clopridogel mg a day is an excellent alternative therapy after bilogical valve replacement. we all know the compliance of elder patients after cardiac surgery. so we have an easy treatment for this group of patients. grundlagen. die zunahme des perkutanen aortenklappenersatzes, berechtigt die notwendigkeit zur evaluation der Ü berlebensrate nach operativem biologischen aortenklappenersatz mit und ohne zusätzlichen aortokoronaren bypass bei patienten ! jahren. in dieser studie wurden risikofaktoren, die die -jahres mortalität beeinflussen, untersucht. methodik. retrospektiv wurden im zeitraum von jänner bis dezember einhundertvierundfü nfzig patienten ( w, m) mit einem medianen alter von , ae , jahren ( - jahre), einen biologischen aortenklappenersatz mit (n ¼ ) oder ohne (n ¼ ) aortokoronaren bypass unterzogen. mittels chi-square test und mann-whitney test wurden die einflussfaktoren auf die Ü berlebensrate untersucht. ergebnisse. das -jahres follow-up zeigte eine Ü berlebensrate von , %. nach isoliertem aortenklappenersatz sind patienten ( , %) und nach einem kombinationseingriff mit koronarem bypass patienten ( , %) verstorben. die präoperativen risikofaktoren in bezug auf die mortalität, wie renale insuffizienz ( , % vs. , %, p ¼ , ), copd ( , % vs. , %, p ¼ , ), diabetes mellitus ii ( , % vs. , %, p ¼ , ), cavk ( , % vs. , %, p ¼ , ), pavk ( , % vs. , %, p ¼ , ), logistischer euro score (median , vs. , , p ¼ , ) und kombinationseingriff ( , % vs. , %, p ¼ , ) wurden evaluiert. die einzelnen risikofaktoren zeigten keinen signifikanten einfluss auf die mortalitätsrate bei patienten ! jahren. schlussfolgerungen. die vorliegenden daten zeigen gute ergebnisse der Ü berlebensraten nach operativem aortenklappenersatz bei patienten über jahren in einem beobachtungszeitraum von einem jahr. results. mean baseline hematocrit serum levels were . ae . %. the mean decrease of hematocrit serum levels was . ae . % after surgery. the mean decrease of hematocrit serum levels in patients undergoing cabg without cpb was . ae . % and . ae . % in patients after isolated valve replacement. one patient died during the operation. four patients died in the postoperative period due to anemia. during followup, being ae months to date, no cardiovascular related adverse event has been observed. conclusions. the decrease of hematocrit serum levels is significantly characterizing the postoperative period of open heart surgery in jehovah's witnesses. in patients undergoing cabg without cpb and in patients undergoing isolated valve replacement, decrease of hematocrit serum levels was lowest. therefore, these techniques should be considered for first choice when appropriate. furthermore, highly normal preoperative hematocrit serum levels and a meticulous surgical technique remain the mainstay of therapy in these patients. grundlagen. routinemäßige intraoperative flussmessung von bypassgrafts dient der qualitätssicherung koronarer revaskularisation. ziel unserer studie war die evaluierung der flussmessung als indikator für langzeitmortalität. methodik. wir messen routinemäßig intraoperativ die flussgeschwindigkeit in bypassgrafts mit dem doppler-flowmeter (cardiomed + ) und speichern die daten in der archimed datenbank. fü r diese studie analysierten wir retrospektiv flussmessungen von cabg patienten, euroscore, lvef, alter, geschlecht fü r den beobachtungszeitraum - . flussmessungen < ml/min > ml/min wurden exkludiert. wir unterteilten die patienten in gruppen: cabg i (gruppe a), cabg ii (gruppe ii), cabg iii (gruppe iii). mittlerer beobachtunszeitraum war , jahre. die datenerfassung war vollständig und mit dem Ö sterreichischen sterberegister abgeglichen. ergebnisse. gruppe a: mittlerer es ( - ) und mittlere lvef ( - ) hatte eine mittlere flussgeschwindigkeit von ml/ min ( - ), mit arteria mammaria interna (ima) ml/min ( - ), ohne ima . ml/min ( - ). altersdurchschnitt . jahre ( . - . ). m/w ¼ %/ %. langzeitmortalität von gruppe a war %. gruppe b: mittlerer es ( - ) und mittlere lvef ( . - ) hatte eine mittlere flussgeschwindigkeit von ml/min ( - ). altersdurchschnitt . jahre ( - . ). m/ w ¼ %/ %. langzeitmortalität von gruppe b war . %. gruppe c: mittlerer es ( - ) und mittlere lvef ( - . ) hatte eine mittlere flussgeschwindigkeit von ml/min ( - ). altersdurchschnitt . jahre ( - . ). m/w ¼ %/ %. langzeitmortalität von gruppe c war . %. gesamtlangzeitmortalität war . %. schlussfolgerungen. zwischen den gruppen zeigte sich kein signifikanter unterschied bezü glich es, lvef oder flussgeschwindigkeit und keine signifikante korrelation derer zur mortalität. flussgeschwindigkeit ist kein indikator fü r langzeitmortalität. the radial artery as arterial bypass graft in coronary surgeryreport of an angiographic evaluation with -or multi-slice computed tomography k. mészáros, a. yates, f. dobaja klinische abteilung für herzchirurgie, graz, austria background. since , the radial artery, additionally to lita and rita, was used as arterial bypass graft material in cabg pts at our institution. the aim of this study is the evaluation of radial artery patency and stenosis with ctangiography. methods. before scanning, all patients were clinically examined and had to fill in a questionnaire concerning their current nyha-and ccs-state, their medication and risk factors. all patients were examined for presence of restrictions resulting from radial artery harvesting in the concerned arm (fine motor skills, sensibility, perfusion etc.). after that, the recent creatinine-level was analyzed in all patients. ct was performed in one group with a new -slice ct-scanner and in the other group with a -slice scanner, depending on the availability of the scanner. graft patency and stenosis was analyzed in cooperation of cardiac surgeons and radiologists in several reconstruction techniques. results. preliminary data of pts showed radial artery occlusions, in all other cases ( %), radial artery was widely patent after a mean follow up of ae months. conclusions. at present, the examination is still under proceeding. first results showed quite satisfying results in radial artery patency, data from all pts will show statistical significant factors impairing radial artery patency. these data will help us to improve long term patency rate of radial bypass conduits. surgical therapy options in ebstein's anomaly in adults n. reiss, u. schütt, r. körfer, j. gummert background. ebstein's anomaly is a rare congenital malformation of the heart, the basic feature of which is dislocation of the tricuspid valve into the right ventricular cavity. the onset of the symptoms and the diagnosis depend on the severity of the valve dysfunction and the right ventricular function and size. the age at diagnosis ranges from birth to adulthood. we report our experience with surgical treatment of ebstein's anomaly in adults. methods. twenty-three pts ( male, female, mean age years, to years) underwent surgical treatment in ebstein's anomaly (tricuspid valve repair in various techniques ¼ , tricuspid valve replacement ¼ ( st. jude medical, hancock), and heart transplantation ¼ ). all pts with mechanical tricuspid valve replacement were introduced in inr-self-management. only four of the patients had previous cardiac surgery. results. twenty pts recovered well after surgery. three pts developed cardiac low-output-syndrome, which was treated by implantation of mechanical circulatory support systems ( thoratec, cardiowest). one pt could be weaned, one pt was successfully bridged to htx and one pt died on device because of multiorgan failure. after a mean time of . years % of pts were in nyha class i or ii. conclusions. surgical therapy of ebstein's anomaly can be performed with good results in the adult population. when valve repair is not feasible we prefer implantation of mechanical valves with consecutive inr-self management. reduction of sternum instability after cardiac surgery with a newly designed thorax support vest methodik. in einer prospektiv randomisierten studie wurden patienten untersucht, die einem herzchirurgischen eingriff unterzogen wurden. die patienten wurden in zwei gruppen stratifiziert: gruppe a wurde unmittelbar nach der herzoperation mit der posthorax + herzweste (fa. epple, wien) zur stabilisierung des sternums behandelt. gruppe b wurde wie bisher mit einer elastischen bandage versorgt. alle patienten wurden durch einen präoperativen risikoscore evaluiert. zahlreiche operative, laborchemische und klinische daten wurden anlaysiert. ergebnisse. die beiden randomisierten gruppen waren bis auf das vorliegen von diabetes, der in der gruppe a häufiger zu beobachten war, seitens der demographischen, laborchemischen und operativen variablen vergleichbar. ( , %) patienten der kontrollgruppe ohne weste entwickelten komplikationen im bereich der sternumwunde, die eine reoperation erforderte. in der gruppe a musste ein patient wegen einer oberflächlichen infektion der sternumwunde reoperiert werden ( , %). dies bedeutet einen signifikanten unterschied zwischen den beiden gruppen bezü glich des auftretens von sternumproblemen (exact fisher's test: , ). interessanterweise traten % der komplikationen nach dem spitalsaufenthalt innerhalb von tagen auf. schlussfolgerungen. der gebrauch der posthorax + herzweste zeigt in dieser prospektiv randomisierten studie eine deutliche senkung der komplikationen im bereich des sternum nach herzchirurgischen eingriffen. background. sine the quantity of icd implantations is steadily increasing the numbers of complications is rising too. one of the issues is how to deal with damaged or infected leads. we report our experience with icd and pm lead extraction, possibility and complications. methods. in a retrospective analysis percentage of lead extraction in icd patients, duration of operation and complications were evaluated. complications were defined as death of patient, surgery repair of vessel, sternotomy, blood transfusion, pericard effusion, infection, pneumothorax, embolic event and bleeding with surgical revision. extraction was done either by manual traction or by extraction tool. results background. to evaluate histopathological findings of intraoperatively gained aortic specimens. methods. between january and october , aortic specimens were evaluated in patients including ( %) thoracic aortic aneurysms, ( %) thoracic aortic dissections as well as ( %) abdominal aortic aneurysms. mean age was ae years. ( %) patients were over years of age and ( %) patients were over years of age. results. medial degeneration was diagnosed in ( %) patients. of these ( %) had thoracic aortic aneurysms, ( %) thoracic aortic dissections and ( %) abdominal aortic aneurysms. severe medial degeneration was found in ( %) patients including ( %) thoracic aortic aneurysms, ( %) thoracic aortic dissections and ( %) abdominal aortic aneurysms ( % of diagnoses in patients < years of age vs. % of diagnoses in patient over years of age). extensive arteriitis was diagnosed in ( %) patients including ( %) thoracic aortic aneurysms, ( %) thoracic aortic dissections and ( %) abdominal aortic aneurysms. marfan's syndrome was diagnosed in ( %) cases ( thoracic aortic aneurysms, thoracic aortic dissection). giant cell arteriitis was found in one thoracoabdominal aortic aneurysm. conclusions. medial degeneration was the most frequently observed histopathological diagnosis irrespective of location and clinical presentation. aging is associated with a higher degree of medial degeneration as well as with a higher percentage of inflammatory disease of the aortic wall. Österreichische gesellschaft für adipositaschirurgie: chirurgie der adipositas und metabolischer erkrankungen teil intermediate weight loss after sleeve gastrectomy s. ali-abdullah, m. schermann, a. landsiedl, s. kriwanek background. the long term effects of sleeve gastrectomy have not been described to the present date. case series report significant reoperation rates due to inadequate weight loss, weight regain, or gastro-esophageal reflux disorder. the aim of our study was to analyze intermediate results to years after sleeve gastrectomy methods and results. twenty-nine patients ( women, men) were operated between or . a standardized procedure was applied. calibration of the sleeve was achieved with a f bougie. one complication (staple line leak) occurred and was treated by a reoperation. at follow up the average excess weight loss was percent. six patients ( %) were converted to a gastric bypass in cases due to weight regain and in patients because of reflux problems ( ). one patient was reoperated after a first step sleeve gastrectomy. conclusions. in our experience sleeve gastrectomy seems to be an effective weight loss operation but reoperation rates are significantly higher compard to roux y gastric bypass. background. the positive long term effects of bariatric surgery on obesity -associated comorbidities and survival depend on minimal postoperative morbidity and mortality. patient safety has therefore, gained a high level of attention in bariatric surgery in the last years. methods and results. patient safety is increased by a variety of steps including correct selection and preparation of patients, implementation of clinical pathways, application of a universal protocol concerning verification of patients and procedures during a ''time out'' at the beginning of every operation, structured intra-und postoperative communication (briefing, debriefing), high awareness of possible complications, guidelines for the diagnosis and treatment of complications, standardized follow-up, and systematic training of safety agenda during education. conclusions. a systematic approach to ensure optimal patient safety is mandatory to enable late benefits of overweight surgery. grundlagen. in der literatur wird die wahrscheinlichkeit einer bandmigration nach ,,gastric banding'' mit ca. % beschrieben. praktisch immer liegt eine bandinfektion zugrunde. fall. wir präsentieren eine jährige patientin mit einem zu % in den magen migrierten magenband. die indikation zur endoskopischen entfernung mittels schneidedraht wurde gestellt. hierbei wurde der port entfernt, der schlauch in der freien bauchhöhle versenkt und anschließend das band endoskopisch mittels schneidedraht (ami) durchtrennt. während der versuche, das impaktierte band endoskopisch herauszuziehen, bemerkten wir eine massive auftreibung des abdomens. aufgrund massiv freier luft (perforationsverdacht) wurde die indikation zur laparoskopie gestellt. nach einbringen des optik -trokars imponierten mm hg druck intraabdominell. laparoskopisch kein hinweis auf hohlorganperforation. somit kann man davon ausgehen, dass die luft während der gastroskopie über das zuvor durchtrennte schlauchsystem in den bauchraum gelangte. die dauer der intraabdominellen druckerhöhung betrug stunde. postoperativ kam es zu einem akuten leberversagen mit massivem transaminasenanstieg (got > , gpt > , ldh > ) und abnahme der lebersyntheseleistung (inr bis , ), wohl infolge der druckbedingten portalen minderperfusion, jedoch ohne enzephalopathie. sonographisch konnte eine adäquate leberperfusion nachgewiesen werden. nach peak am . postoperativen tag waren die laborparameter rückläufig bis zur völligen normalisierung. im rahmen einer exakten leberdiagnostik konnte schließlich eine nash diagnostiziert werden. schlussfolgerungen. eine kurzzeitige portale minderperfusion der leber kann bei bereits vorgeschädigtem organ ausreichen, um zu einem funktionsausfall/akuten leberversagen zu führen. um so eine situation in zukunft zu vermeiden, haben wir be-schlossen, das schlauchsystem einzuknoten, bevor es in die freie bauchhöhle versenkt wird. background. due to the rising numbers of obese patients treated by roux-en-y bypass the problem of choledocholithiasis is of increasing importance. for anatomical reasons endoscopic access to the bile tract may prove difficult or impossible. methods and results. four patients who presented symptoms of choldeocholithiasis after roux-en-y bypass were successfully treated by laparoscopy-assisted transgastric ercp. in cases this procedure was combined with a laparoscopic cholecystectomy. there were no complications related to the procedures. conclusions. in our opinion ''reversed-notes'' is a safe and effective way of treating choledocholithiasis in patients after roux-en-y gastric bypass. korrekturoperationen nach erfolgloser adipositaschirurgie p. beckerhinn, s. schöppl, f. hoffer grundlagen. das laparoskopisch implantierte verstellbare magenband (agb) ist der häufigste bariatrische eingriff in europa. langzeit-komplikationen wie band-slippage, pouch-oder Ö sophagus-dilatationen und mangelnder gewichtsverlust erfordern neuerliche operationen. die offene vertikale band-verstärkte gastroplastik (vbg) war eine der beliebtesten adipositas-operationen der er und er jahre. klammernahtrupturen führten wegen neuerlicher gewichtszunahme zu reinterventionen. der magenbypass (rygbp) ist der häufigste eingriff nach erfolglosen bariatrischen operationen. wir untersuchten die ergebnisse nach korrektur-operationen. methodik. die daten aller patienten wurden prospektiv erfasst. die postoperativen veränderungen bezü glich gewicht, begleiterkrankungen und lebensqualität wurden untersucht. ergebnisse. zwischen und wurden operationen an frauen und männern nach erfolgloser bariatrischer erst-operation durchgefü hrt. das durchschnittsalter betrug zum zeitpunkt der operation jahre, der durchschnittliche bmi kg/m . die erstoperationen waren in fällen ein agb, mal ein vbg, sleeve-gastrektomien und ein magenschrittmacher. dreimal war das band bereits vor der korrekturoperation entfernt worden. revisionseingriffe wurden laparoskopisch begonnen, zweimal musste konvertiert werden. mal wurde nach entfernung des magenbandes in der selben sitzung ein rygbp angelegt. laparoskopische sleeve-gastrektomien wurden durchgefü hrt, dreimal wurde ein neues sagb eingebracht, drei bänder konnten repositioniert werden. revisionspflichtige komplikationen beobachteten wir bei patienten ( %) ( blutungen, trokarhernien, innere hernien, andere). keine leckagen oder todesfälle traten in dieser serie auf. schlussfolgerungen. korrektureingriffe nach erfolgloser adipositas-operation haben eine höhere komplikationsrate als erstoperationen. die guten erfolge in bezug auf die gewichtsreduktion, die verbesserung der assoziierten erkrankungen und die lebensqualität rechtfertigen das etwas erhöhte risiko. grundlagen. rund . Ö sterreicherinnen leiden unter einer adipositas permagna (grad iii) mit einem bmi > bei steigender tendenz. entsprechend nimmt die anzahl der bariatrischen operationen und in weiterer folge die notwendigkeit von konturverbessernden operationen zu. das untere bzw. das obere bodylift bieten die möglichkeit einer straffung von abdomen, oberschenkel, hü fte, gesäß und rü cken bzw. von oberem rumpf, der brü ste und der oberarme in einer sitzung. methodik. anhand von fallbeispielen werden das perioperative management und die einzelnen operationsschritte eines unteren bodylifts in der modifizierten technik nach ted lockwood bzw. eines oberen bodylifts in der technik nach al aly vorgestellt. ergebnisse. bei allen patienten konnte eine deutliche verbesserung der körperkontur erreicht werden. schwerwiegende komplikationen (thrombose, pulmonalembolie) traten nicht auf. schlussfolgerungen. das bodylift ermöglicht das gleichzeitige straffen von mehreren körperarealen mit fließenden konturübergängen in einer sitzung. dies führt nicht nur zu einem besseren ästhetischen behandlungsergebnis, als es die isolierten straffungen der einzelnen körperareale könnten. sondern es trägt auch zu einer reduzierung der sozioökonomischen kosten durch verkürzte spitalsaufenthalte und krankenstände im vergleich zu einzelstraffungen bei. durch das standardisierte behandlungskonzept lässt sich eine hohe patientensicherheit und -zufriedenheit erreichen. integriert in ein interdisziplinäres team aus bariatrischen chirurgen, plastischen chirurgen, internisten, psychologen, ernährungsberatern und sportmedizinern steht eine solche operation am schluss einer langen behandlungsreihe und erleichtert dem patient die rückkehr in ein normales leben. background. thyroid autonomy shows functional and/or autonomous nodular growth. should surgical therapy remove affected tissue radically or selectively, with risk of hypothyroidism or risk of functional/nodular recurrence. methods. a prospective study was conducted from to . pts were stratified in groups. first results in outcome were at months, and after years. late results are available years postoperatively. results. in standard bilateral radical resection, a % need for t -medication is overt, after and years in less than %, with a % risk of recurrence. in selective nodule removement a lower rate of hypothyroidism with a % risk of recurrence is noted. conclusions. aftt should be treated by adequate bilateral resection, selective nodular removement has a high risk of functional and nodular persistance or recurrence. evaluation of parathyroid hormone screening before thyreoidectomy methodik. eine perioperative pth-bestimmung wurde bei konsekutiven normocalcämischen patientinnen durchgeführt. ergebnisse. von patientinnen ( , %) wiesen erhöhte pth-spiegel auf (gruppe a), durchschnittlich , pg/ml (normalbereich - pg/ml, range , - ), bei patientinnen mit normalem pth (gruppe b) lag der wert bei , (range , ) . die ca-werte waren in beiden gruppen gleich (gruppe a , mmol/l, range , - , , gruppe b , mmol/l, range , - , ). bei den patien-tinnen der gruppe a wurden schilddrü senlappen operiert. (von ) nebenschilddrü sen konnten exploriert werden, ohne pathologischen befund, einmal wurde ein nebenschilddrü senadenom als ausdruck eines primären hpt gefunden. postoperativ wies die gruppe a einen durchschnittlichen pth-wert von , pg/ml bei einem durchschnittlichem ca-wert von , (range , - , ) auf, gruppe b einen durchschnittlichen pth-wert von , bei einem durchschnittlichem ca von , (range , bis , ). schlussfolgerungen. präoperativ erhöhte pth-spiegel bei normocalcämie sind bei jedem zehnten patienten zu finden; dabei liegt nur selten ein normocalcämischer primärer hyperparathyreoidismus vor, sondern ü berwiegend eine reaktive hyperparathyrinämie. ein generelles pth screening kann daher nicht empfohlen werden, es ist aber sinnvoll, wenn das präoperativ obligate calcium im oberen normbereich liegt. eine exploration der nebenschilddrü sen ist im rahmen der geplanten schilddrü senoperation angezeigt, eine ausweitung des eingriffs zur -drü senexploration, ,,en principe'' allerdings nicht. reoperation in recurrent goiter is associated with an elevated morbidity predominantly related to recurrent laryngeal nerve palsy between and %. a benefit of intraoperative neuromonitoring (ionm) in reoperative surgery focusing on the recurrent laryngeal nerve palsy rate has not been demonstrated clearly. in a retrospective analysis ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) of nerves at risk (nar) in reoperative thyroid surgery at our institution by using neuromonitoring ( nar) or visual nerve identification ( nar) transient recurrent laryngeal nerve palsy rate was comparable between both groups ( . and . %). however a clear reduction in permanent recurrent laryngeal nerve palsy by using neuromonitoring from . to . % was evident. after standardizing ionm in our clinic, we started a prospective study to confirm this finding and to define the influence of ionm on transient recurrent laryngeal nerve palsy rate. all reoperations in thyroid diseases by using neuromonitoring ( nar) from january were included in this analysis with respect to the transient and permanent recurrent laryngeal nerve paralysis rate. the prospective evaluation of nar in reoperative thyroid surgery shows a decreased transient ( . %) and permanent ( . %) recurrent laryngeal nerve palsy rate by using ionm. ionm decreases the transient and permanent recurrent laryngeal nerve palsy rate in reoperative thyroid surgery and should therefore be mandatory. das intraoperative neuromonitoring (ionm) wird bereits in zahlreichen kliniken zur identifikation des n. laryngeus recurrens (nlr) eingesetzt. während der der präparation ist die funktionsüberprüfung des nerven nur punktuell möglich. methodik. eine neu entwickelte vagussonde (v ; fa. inomed. teningen, deutschland) wird vor der präparation der grenzlamelle in der gefäßnervenscheide zwischen der a. carotis und der v. jugularis in engem kontakt zum n. vagus platziert. die schwellenwerte bis zur maximalen signalstärke der ableitungen über die tubuselektrode werden zu beginn und am ende der operation ermittelt. die stimulation erfolgt mit einer frequenz von hz und einer stromstärke unterhalb der maximalen signalantwort. die ergebnisse einer konsekutiven serie von beidseitigen resektionen (n ¼ nerves at risk) werden dargestellt. ergebnisse. der schwellenwert zur supramaximalen stimulation lag zwischen , und ma. diese werte unterschieden am beginn und am ender der operation um maximal , ma. passagere recurrensparesen wurden in fällen beobachtet. in beiden fällen fiel während der präparation das signal des kontinuierlichen ionm aus, die schädigungsstelle konnte bei erhaltener kontinuität des nerven exakt lokalisiert werden. in beiden fällen zeigte sich ein stimmbandstillstand unmittelbar postoperativ, eine vollständige wiederherstellung der beweglichkeit nach tagen und wochen. die stimulationsdauer des einzelnen nerven lag intraoperativ zwischen und minuten. schlussfolgerungen. das kontinuierliche ionm scheint störungen der leitfähigkeit des nlr sehr empfindlich anzuzeigen. konsequenzen für die operationstaktik müssen in weiteren anwendungen evaluiert werden. aspekte der sicherheit für den motorischen nerven durch eine elektrische dauerstimulation werden diskutiert. grundlagen. diagnostik und therapie der choledocholithiasis werden in der Ä ra der laparoskopischen cholecystektomie unterschiedlich gehandhabt. an unserer abteilung sind indikation und zeitpunkt der ercp/ept abhängig von anamnese, labor, sonographie und routinemäßiger intraoperativer cholangiographie. methodik. zwischen . . und . . wurden an unserer abteilung laparoskopische cholecystektomien ( , % aller galleneingriffe) durchgeführt. bei dieser patienten ( , %) wurde auch eine choledochuspathologie (papillenstenose, choledocholithiasis) diagnostiziert und prae-, intra-oder postoperativ mittels ercp/ept behandelt. schlussfolgerungen. in unserem krankengut hat sich die prae-, intra-und postoperative ercp/ept im rahmen der laparoskopischen cholecystektomie bei cholecysto-und choledocholithiasis sehr bewährt. die routinemäßige intraoperative cholangiographie führte bei , % der patienten zur diagnose und therapie unerwarteter choledochuskonkremente! randomized controlled trial to assess feasibility and efficacy of co insufflation during colonoscopy in moderate and deep sedated patients background. air insufflation during colonoscopy is the considered standard method in most endoscopic centers. notably, several studies reported reduced abdominal pain during and after colonoscopy by using co insufflation in unsedated as well as light sedated patients. the study was designed to assess the feasibility and efficacy of co during and after colonoscopy in moderate and deep sedated patients. the secondary endpoint was to evaluate whether co is able to enhance patient's compliance to undergo colonic cancer screening. methods. three-hundred consecutive patients allocated for colonoscopy were randomly assigned to either co or air insufflation. patients were titrated to a level of deep sedation by propofol alone or to moderate sedation when combined with midazolam. postinterventional pain and satisfaction were registered by a visual analogue scale (vas). colonic cancer screening compliance was questioned separately. results. co insufflation was used in patients, whereas in patients conventional air was applied during colonoscopy. both groups were comparable in regard to age, sex and bmi. neither major nor minor complications were observed. painsensation was significantly lower in the co group min, min as well as h after colonoscopy (p < . ). twelve hours after endoscopy no difference was observed. in contrast, satisfaction level did not show any significant difference. voluntary colonic cancer screening seemed not to be influenced by the type of insufflation gas. conclusions. co insufflation in deep and moderated sedated patients during colonoscopy significantly reduced postinterventional abdominal pain. interestingly, patient's satisfaction was equal in both groups. review: optimal biopsy protocol in gerd patients background. endoscopy in patients with gastroesophageal reflux disease (gerd) aims to assess presence or absence of reflux and cancer risk. remains to be questioned which biopsy protocol adequately meets these requirements. methods. review on a novel histopathology based biopsy protocol. results. in keeping with recent endoscopy and biopsy studies coming from others and our group, gerd causes a specific morphology within the distal esophagus: columnar lined esophagus (cle). cle is interposed between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. the assessment of cle proofs the presence of reflux and includes oxyntocardiac, cardiac mucosa ae intestinal metaplasia (barrett's esophagus). over a sequence involving low-and high-grade dysplasia (intraepithelial neoplasia) intestinal metaplasia may progress towards esophageal adenocarcinoma ( . % annual risk). accordingly barrett's esophagus is recognized as having a cancer risk justifying endoscopic surveillance. based on the zonation of the mucosal types within cle (cardiac mucosa ae intestinal metaplasia and oxyntocardiac mucosa favor the proximal and distal segment of cle, respectively), biopsies obtained from the squa-mocolumnar junction have the highest yield for assessment of intestinal metaplasia (proofing reflux and cancer risk). thus the biopsy protocol should include at least quadrant biopsies from the squamocolumnar junction and biopsies obtained at . cm increments from endoscopically visible tongues or segments of cle. conclusions. four quadrant biopsies obtained from the squamocolumnar junction have the highest yield for the assessment of reflux and cancer risk and should be included into the routine biopsy protocol in gerd patients. variceal bleeding. a danish expirience with the ella-danis stent gastroenheden, hvidovre hospital, hvidovre, denmark background. despite effective treatment modalities such as vasoactive drugs, banding therapy and sclerotherapy, a fraction of the esophageal varices continue to bleed. until recently, the sengstaken-blakemore tube has been the method of choice for those patients. there are, however, numerous disadvantages with the tube. methods. the first seven patients treated with the ella-danis stent (e-ds) in our institution are presented. in all patients other methods to achieve bleeding control had failed. all patients had alcoholic liver cirrhosis. results. in all patients the placement of the e-ds was uncomplicated and variceal bleeding stopped immediately. the e-ds was in place from to days. the removal of the stent was done under endoscopic control by means of an overtube and a biopsy -or rotating forceps. no complications were encountered. conclusions. the e-ds is excellent as rescue therapy in patients with bleeding esophageal varices in cases where other treatments have failed. internet platform for novel gerd management: www.igerd.com background. currently a mixture of symptoms, data obtained from endoscopy, histopathology, function tests and radiology define gastroesophageal reflux disease (gerd). recently an histopathology based concept for gerd diagnosis and management has been introduced (paull-chandrasoma classification). we aimed to create a platform for these novel developments. methods. design of an interactive, easy to use internet-based platform on gerd management for physicians and patients. results. igerd for physicians compares the currently used concept with the novel, histopathology based concept for gerd diagnosis and management. the information is presented using text, images, slide shows and video pod casts (topics: endoscopy videos, biopsy protocol, histopathology, manometry, ph monitoring, impedance technology, treatment algorithms). igerd news summarizes recently published papers on gerd. in addition, igerd provides patient informations. the content is monthly updated by members of the scientific board. igerd can be followed within the internet (www.igerd.com) or the content can be downloaded on a personal computer (pc, mac) and transferred to ipod and iphone, using itunes. with these tools videos and slide shows can be followed using the interactive stop and go function. thus igerd meets the requirements of the present time: actuality, mobility and flexibility. conclusions. igerd represents an interactive internet-based information and e-learning platform for gerd management designed for physicians and patients. temporary placement of self-expanding oesophageal stents as bridging for neoadjuvant therapy background. placement of self-expanding stents is the most commonly applied palliation for dysphagia in non-resectable esophageal or proximal gastric cancer (aeg ii, aeg iii). the aim of this analysis was to assess the efficacy of temporary stent placement for dysphagia relief enabling neo-adjuvant treatment strategies for locally advanced disease. methods. thirty-eight patients scheduled for neo-adjuvant chemo(radio)therapy for locally advanced esophageal cancer (n ), cardia cancer (aeg ii; n ¼ ) or subcardial gastric cancer (aeg iii; n ¼ ) underwent stent placement due to severe dysphagia and weight loss using self expanding plastic stents (n ¼ ) or covered metal stents (n ¼ ). results. stent placement led to an instant dysphagia relief in ( %) of the patients. dysphagia scores were reduced from median . ae . before stent placement to . ae . thereafter. among those patients, ( %) underwent resection of the tumor after completion of the neo-adjuvant therapy, patients ( %) underwent primary resection without receiving chemotherapy and patients ( %) had only chemo(radio)therapy but no surgery. all of them were exclusively nourished orally at least until restaging or surgery. stent related complications were observed as perforation at stent placement (n ¼ ), mediastinitis (n ¼ ), tracheo-esophageal fistula (n ¼ ), bleeding (n ¼ ) and jejunal perforation caused by a migrated stent (n ¼ ). four patients underwent placement of a second stent and patient had bouginage due to stent migration (n ¼ ). conclusions. placement of self-expanding stents is highly effective for instant dysphagia relief enabling adequate oral nutrition during neo-adjuvant therapy, but is limited by a high re-intervention rate. background. anastomotic leak is a potentially life-threatening complication after upper gastrointestinal resektions and bariatric surgery requiring long, cost-intensive and frequently failed treatment. this study has been undertaken to evaluate, whether endoscopic sealing with autologous fibrin glue is an effective treatment for persistent postoperative fistula. methods. between september and january patients who developed non-healing upper gastrointestinal leaks after oncologic (n ¼ ) and non-oncologic oesophageal (n ¼ ), gastric (n ¼ ) or bariatric (n ¼ ) surgery were treated by endoscopic vivostat + autologous fibrin sealing. fibrin sealant was applied in patients without systemic or advanced local sings of infection with a sufficient external drainage of leakage site. location was cervical (n ¼ ), intrathoracic (n ¼ ) and abdominal (n ¼ ). previous leak treatment included surgery, external drainage or/and endoscopic stenting. endoscopic sealing occured after a median interval of days (range - ) after primary surgery. results. fourteen of sixteen patients had complete healing of the anastomotic leak or fistula after one ( patients), two ( patients), tree ( patients) or five ( patient) sealing procedures. in six procedures sealing was completed by simultaneous implantation of a stent. in two patients treatment failed and the healing of the abdominal fistula was achieved by following insertion of a stent on the leakage site. conclusions. autologous fibrin sealing could be successfully used for management of persistent upper gastrointestinal fistula and promotes healing. results after different treatment modalities for achalasia background. achalasia is an esophageal functional disorder with esophageal body amotility and impaired lower esophageal sphincter (les) relaxation causing dysphagia, heartburn and regurgitation. methods. retrospective analysis of patients with manometrically proven achalasia ( females; ae years) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . management included primary dilatation (stark dilator; n ¼ ), primary laparoscopic myotomy and anterior fundoplication (n ¼ ), secondary myotomy following dilatation (n ¼ ), a mix of botox administration and dilatation (n ¼ ) and is unknown in patients. results. follow up manometry was available in / , / and / patients after dilatation, primary and secondary myotomy, respectively. after dilatation les resting pressure decreased from . ( . ; . ; % ci) to . ( . ; . conclusions. primary dilatation is recommended for achalasia, primary myotomy may be considered in younger patients. grundlagen. osteosarkome sind die häufigsten primär malignen, nicht hämatopoetischen tumoren des knochens. ihre inzidenz beträgt , - , pro . einwohner pro jahr. während die Ä tiologie primärer osteosarkome unklar ist, können prädisponierende faktoren wie vorangegangene bestrahlung oder paget's disease sekundäre osteosarkome (mit-)verursachen. das ziel der vorliegenden studie waren die berechnung der inzidenz für Ö sterreich sowie eine analyse möglicher trends während der letzten jahre. methodik. die autoren führten eine retrospektive populationsbasierende analyse der inzidenz von osteosarkomen in Ö sterreich während der letzten jahre grundlagen. präoperatives serum-crp konnte bereits für viele neoplasien als signifikanter prognosefaktor nachgewiesen werden. für das osteosarkom konnte bislang kein serologischer parameter als eindeutiger prädiktor identifiziert werden. ziel dieser studie war es, die prognostische bedeutung des präoperativen serum-crp bei patienten mit osteosarkom zu untersuchen. methodik. aus dem prospektiven wiener geschwulstregister konnten an einem osteosarkom erkrankte patienten ( frauen und männer mit einem durchschnittsalter von , jahren) mit vollständiger dokumentation der prä-und postoperativen crp-werte und nach ausschluß einer begleitenden infektion hinsichtlich ihres gesamtüberlebens und ihrer infektionsrate im rahmen einer retrospektiven datenbankanalysenachuntersucht werden. ergebnisse. der präoperative crp-wert betrug durchschnittlich , mg/dl ( , bis , ) und korrelierte signifikant mit gesamtüberleben, operationsalter und histologischem subtyp, nicht jedoch mit geschlecht, tumor-grading, ansprechrate auf chemotherapie nach salzer-kuntschik, metastasierungsrate und postoperativer infektionsrate. patienten mit parostalem osteosarkom zeigten signifikant höhere crp-werte als in fällen von klassischen osteosarkomen. in der multivariaten analyse hatten sowohl alter als auch der präoperative crp-wert einen signifikanten einfluß auf das gesamtü berleben. patienten mit präoperativen crp-werten < mg/dl zeigten ein -jahresgesamtü berleben von % gegenü ber % fü r patienten mit crp-werten > mg/dl. präoperatives serum-crp war sowohl ohne als auch mit landmark-analyse kein prognosefaktor fü r protheseninfektion bei patienten, die mit tumorporthesen versorgt waren. schlussfolgerungen. präoperatives serum-crp ist ein unabhängiger prädiktor für das gesamtüberleben bei patienten mit osteosarkom. inwiefern es in diesem zusammenhang auch einen prädiktor für das chemotherapieansprechen darstellt und welche prognostische rolle dem protheseninfekt zukommt, erfordert aufgrund der geringen inzidenz größere datenbankanalysen im rahmen von multicenter-studien. methodik. alle gemeldeten fälle von weichteilsarkomen (entsprechend der standard intnernational classification of diseases for oncology, icd-o- ) aus dem krebsregister der statistik austria wurden in unseren datensatz aufgenommen und die altersstandardisierte inzidenz, alters-und geschlechtsverteilung sowie geographische unterschiede analysiert. ergebnisse. insgesamt wurden fälle registriert, mit einem verhältnis männer/frauen von , . die häufigsten entitäten waren: sarkom (nos) ( %), leiomyosarkom ( %), liposarkom ( %), malignes fibröses histiozytom (mfh, %) und fibrosarkom ( %). die durchschnittliche altersstandardisierte inzidenzrate lag bei , / . /jahr. die analyse der jährlichen sowie über drei jahre gemittelten inzidenzen ergab keinen anstieg der inzidenzraten (jährlicher gradient: À , ). im bundesländervergleich zeigten sich regionale unterschiede, mit der höchsten inzidenzrate in tirol ( , / . /jahr). schlussfolgerungen musculoskeletal tumours are rare with an incidence of - patients/year/ million. before any imaging procedure clinical assessment has to be carried out. the first pitfall is a delayed diagnosis. bone tumours are often accompanied with early pain and swelling and these symptoms lead the patient and the physician to perform further investigation. for soft tissue sarcomas, especially for the retroperitoneal localisation, first symptoms lack or are noticed after the tumour has achieved an important extension. another important pitfall is the diagnosis ''haematoma''. every tumour has to be considered as malign until malignancy is excluded in further imaging investigation. there is a number of frequently encountered and management pitfalls in the diagnosis of musculoskeletal tumours and limits in the diagnostic possibilities even for an experienced physicians. interpretation of an mri of a suspected neoplasm can be extremely difficult. this reveals how important an interdisciplinary approach, for the example the tumour board, in the diagnosis is. the final diagnostic skill is the adequate biopsy. biopsy is the key step in the diagnosis of musculoskeletal tumours. possible pitfalls are: the suspected lesion missed, the biopsy is done of the reactive zone of the tumour is and the sampling error. inadequate approach and surgical technique of the biopsy can complicate the tumour resection or even make a limb spearing procedure impossible and necessitate amputation to obtain adequate resection margins. this workout reviews various errors in the diagnosis of bone tumours, soft tissue sarcomas and metastasis and points out how important biopsy is. grundlagen. das Ö sophaguskarzinom wird häufig in einem stadium festgestellt, in dem lediglich palliation möglich ist. hier liegt der hauptfokus an der wiederherstellung der schluckfunktion, manchmal ist auch die abdichtung einer ösophagotrachealen und/oder -bronchialen fistel notwendig. ziel des eingeladenen vortrages ist es, einen Ü berblick über die endoskopischen palliationsmöglichkeiten zu geben. methodik. zusammenfassung publizierter erfahrungen und eigener daten bezüglich der endoskopischen palliation beim inoperablen Ö sophaguskarzinom (ablative und lumenerweiternde techniken, Ö sophagusstents, peg). ergebnisse. in ausarbeitung (eingeladener vortrag). schlussfolgerungen. bei der mehrzahl der patienten sollte eine weitgehend unabhängige schluckpalliation zu erreichen sein. probleme ergeben sich vor allem bei hohem tumorsitz und bei bestehender ösophagotrachealer oder -bronchialer fistel. implikation gefäßmedizin -gastroenterologie und chirurgie Österreichische gesellschaft für gefäßchirurgie, wien, austria die zunehmende spezialisierung und zum teil freiwillige isolation der fachgebiete der medizin, führt dazu, dass die auswirkungen der entwicklungen eines fachgebietes von den übrigen fächern nicht mehr wahrgenommen werden, sodass folgen einer therapie oder prophylaxe nicht richtig erkannt und damit auch nicht richtig behandelt werden. bedauerlicherweise führt die isolierung der fächer auch dazu, therapieempfehlungen ohne rücksichtnahme auf, nicht unmittelbar zugehörende organsysteme, zu erlassen. Ö konomische interessen des medizinalhandels fördern mitunter diese entwicklung. in dem referat wird versucht, einerseits auf die komplikationen, die sich in konsequenz moderner interventioneller endovaskulärer techniken oder sogenannter hybridtechniken ergeben können, hinzuweisen. mit diesen komplikationen sind gewöhnlich primär gastroenterologen und viszeralchirurgen konfrontiert. eine verzögerte richtige reaktion auf die ersten symptome verschlechtert die prognose der betroffenen patienten drastisch, daher ist es essenziell, die möglichen unerwünschten folgen endovaskulärer gefäßprothesen oder stents zu kennen. andererseits führen gelegentlich auch gastroenterologische und viszeralchirurgische interventionelle verfahren zu nachhaltigen gefäßchirurgischen problemen. ein gemeinsamer kongress ist die beste gelegenheit fachübergreifend konsensuell diese probleme zu diskutieren. im zweiten teil des referates wird die prophylaktische cardio-vasculäre gerinnungshemmende medikation kritisch betrachtet. der ü berbordenden zahl der publikationen, die sich mit den vorteilen der gerinnungshemmenden medikation befassen, steht nur eine verschwindend kleine zahl jener publikationen gegenü ber, die auf die adverse events, letalen blutungen und gefahren hinweisen, mit denen vor allem die gastroenterologen, chirurgen und gefäßchirurgen konfrontiert sind. kaum eine gastroenterolgische, oder chirurgische abteilung hat jedoch so eine große fallzahl prophylaktischmedikamentös bedingter blutungen, dass eine wissenschaftlich gewichtige arbeit entstehen kann. nach schätzungen gibt es jährlich weltweit . tote als folge der immer einschneidender in das gerinnungssystem eingreifenden prophylaktischen maßnahmen. wie gehen gastroenterologen und chirurgen mit patienten um, die einer dringenden intervention bedü rfen und wegen eines drug-eluting stents eine kombination dreier gerinnungshemmender medikamente einnehmen mü ssen, da es beim absetzen dieser therapie im ersten jahr nach stentimplantation mit großer wahrscheinlichkeit zu einem sofortverschluss und damit zu einem infarkt background. in , a survey answered by members of the austrian society of surgery revealed severe problems in the working conditions and a serious concern on trainee shortage in surgical disciplines. methods. our results are compared to those of a recent survey in the united states (mailed to all surgeons certified by the american board of surgery in surgery in , surgery in , surgery in , surgery in and respondents; presented at the american college of surgeons th annual clinical congress by kathrin m. troppmann). results. both surveys comprised more than twenty questions each; only selected examples can be given in this abstract. in the u.s. survey, the leading areas requiring improvement in surgeons' quality of life were reimbursement ( %), litigation ( %) and emergency calls ( %). in our survey, a clear majority worked - h per week or more, in the u.s. the average respondent worked a median of h a week, but regarded h per week as ideal. in our survey, only % were satisfied with payment, in the u.s. % were content with their reimbursement with respect to the total number of hours worked, but only % were satisfied in view of their unpredictable schedule and % when considering their responsibility for patients' health and lives. conclusions. although circumstances vary, the results of these two surveys show that many pressing questions are the same and must be tackled in order to overcome the prevailing problems in working conditions and the threat of trainee shortage/resident attrition in surgical disciplines. working models in surgery grundlagen. in den letzten jahren gelang es deutliche fortschritte in der personalisierten krebstherapie zu erzielen. praediktive marker wurden entdeckt die bei manchen patienten ein ansprechen auf eine bestimmte therapie erwarten lassen bzw. anderen patienten eine sinnlose, teure und belastende therapie ersparen. aber auch mit bildgebenden verfahren ist eine beurteilung des therapiansprechens möglich geworden. die auswirkungen dieser entwicklungen auf die onkologische chirurgie werden diskutiert. methodik. die wissenschaftliche literatur und ergebnisse entsprechender studien werden evaluiert und im kontext der eigenen erfahrungen beurteilt ergebnisse. es gibt zahlreiche ansätze um das therapieansprechen für den einzelnen patienten vorherzusagen. dies gilt für vor allem für systemische (neoadjuvante, adjuvante oder palliative) therapien aber auch für die strahlentherapie. die bedeutung für den rein chirurgischen teil des multidisziplinären managements dieser patienten ist allerdings limitiert. dabei sind unterschiedliche entscheidungen zu treffen, für patienten die mit primär unresektablen tumoren behandelt werden und resektabel werden, für patienten die unter einer neoadjuvanten therapie progredient sind und patienten mit bereits primär resektablen tumor die einen guten respose auf eine neoadjuvante therapie zeigen. schlussfolgerungen. die individualisierte onkologische therapie ist von eminenter bedeutung für die behandlung unserer patienten hinsichtlich vermeidung unnotwendiger nebenwirkungen und sinnloser und teurer therapien bzw. für das gesamte onkologischem management. für die chirurgie ergeben sich außer im rahmen der multidisziplinären planung derzeit noch wenig konsequenzen. anforderungen an die chirurgie durch individualisierung der therapie mittels genexpressionsanalyse beim mammakarzinom die chirurgie im zentralen case management bei der behandlung des mammakarzinoms steht neuen und wachsenden anforderungen gegenüber. die individualisierte therapie hat mit bestimmung von hormonrezeptoren und her /neu-status erst begonnen -in den letzten jahren haben techniken wie genexpressionsanalysen die erstellung einer individuellen und besseren prognose als mit klassischen klinisch-pathologischen parametern ermöglicht. genexpressionsanalysen werden in vielen institutionen bereits routinemäßig durchgefü hrt und wurden zum teil bereits in therapierichtlinien integriert (nccn þ asco-guidelines). die indikationen fü r diese tests werden jetzt zunehmend erweitert: während einerseits auch diejenigen kleinen tumoren, welche metastasieren können, z.b. durch das -genexpressionsprofil mammaprint identifiziert und einer notwendigen adjuvanten therapie zugefü hrt werden können, gibt es andererseits auch in hochrisikogruppen wie her -positiven karzinomen einen teil mit guter prognose, der vielleicht kei-ner chemotherapie bedarf. diese multigenassays erweisen sind nicht nur als prognostisch, sondern zunehmend auch als prädiktiv fü r das ansprechen auf (neo)adjuvante chemotherapie und wir wissen immer mehr, wer von welcher therapie profitiert, was essentiell sein wird fü r die notwendige kosteneindämmung und vermeidung von unnötigen nebenwirkungen. in der chirurgie verändert sich die logistik von diagnostik und therapie grundlegend. die schaffung strukturierter tumorbanken wird notwendig, wobei präoperative planung und operation die ersten wichtigen schritte darstellen. in hochrisikosituationen laut genexpressionsanalyse ist eine optimierte lokalbehandlung essentiell und bei hoher wahrscheinlichkeit auf pathologische komplettremission eine präzise prätherapeutische markierung des tumors. die resultate dieser genexpressionsanalysen bringen eine individualisierte adjuvante chemo-und/oder hormontherapie mit sich. jede(r) chirurgin muss sich mit möglichkeiten und grenzen dieser revolutionären techniken befassen, um weiterhin integrativ im tumorboard die besten entscheidungen fü r unsere patientinnen treffen zu können. background. peritoneal carcinomatosis defines tumor dissemination onto the peritoneal surface. hyperthermic intraperitoneal chemotherapy (hipec) after cytoreductive surgery seems becoming the standard treatment in peritoneal carcinomatosis avoiding the risk of tumor cell inoculation after surgery. subsequent adhesion of free tumor cells to human peritoneal mesothelial cells (hmcs) -the first line defense within the abdominal cavity -might lead to the formation of intraabdominal metastases. we investigated within an invitro-model the blockage of tumor cell adhesion by simvastatin (sim), an inhibitor of the -hydroxy- -methylglutaryl (hmg) coenzyme a reductase. methods. hmcs were isolated by enzymatic disaggregation from human omentum majus and expanded in vitro. confluent hmc-monolayers were incubated with fluorescent labelled tumor cells in the presence or absence of sim. in time course experiments, adhesion of skov- (ovarian tumor) and ht- (colorectal tumor) cells to hmcs were determined either by fluorescence microscopy or reader. results. simvastatin reduced the number of adherent skov- and ht cells to hmcs significantly. at concentrations ranging from . to mm, simvastatin reduced the adherence of tumor cells to hmcs up to %. conclusions. our findings suggest that simvastatin might be a novel therapeutic approach in order to reduce the risk of peritoneal metastasis due to tumor cell dissemination during cytoreductive surgery. further investigations also have to include the mechanism on the molecular level. einleitung her- /neu (c-erbb ) Ü berexpression ist assoziiert mit einem höheren angiogenetischen potential und einer erhöhten expression des vaskulären wachstumsfaktors vegf beim mammakarzinom. vorklinische studien haben gezeigt, dass her- /neu eventuell eine zusätzliche rolle bei der regulierung der expression des lymphatischen wachstumsfaktors (vegf-c) und damit bei der lymphatischen metastasierung spielt. sinn dieser studie, war es diesen zusammenhang zwischen der her- /neu expression, der expression des lymphatischen wachstumsfaktors vegf-c, dem ausmaß des lymphangiogenetischen potentials (lmvd) sowie der spezifischen lymphogenen invasion (lvi) in einem kollektiv von lymphknoten-positiven mammakarzinomen zu ü berprü fen. methodik immunhistochemie und insitu-hybridisierung fü r vegf-c, den lymphatischen endothelzellmarker podoplanin sowie fü r her- /neu wurden durchgefü hrt. weiters wurde eine her- /neu fish analyse bei allen karzinompräparaten angewendet. ergebnisse lmvd korrelierte signifikant mit lvi (p . ) und der vegf-c expression (p ¼ . ). weiters konnte eine positive, statistisch signifikante korrelation zwischen der her- /neu-und vegf-c proteinexpression gefunden werden (p ¼ . ). patienten, deren tumore eine höhere her- /neu expression aufwiesen, exprimierten auch signifikant mehr vegf-c und wiesen ein höheres lymphangiogenetisches potential (lmvd) auf. diskussion unsere daten geben den ersten hinweis auf einen klinisch relevanten zusammenhang zwischen vegf-c und her- /neu beim lymphknotenpositiven brustkrebs und damit einen direkten zusammenhang zwischen dem ausmaß einer her- /neu expression und dem lymphatischen metastasierungspotentials beim mammakarzinom ab. diese daten unterstü tzen die bedeutung des her- /neus als konduktor eines aggressiven phenotyps beim mammakarzinom und liefern mögliche hinweise auf die wirkungsweise assoziierter therapien wie dem trastuzumab (herceptin). background. gerd affects up to % of the population in the western world. despite morphological changes in the esophagus, gerd causes significant impairment of the quality of life (qol). we aimed to identify the qol in patients with gerd and to assess the midterm effect of treatment on the qol-scores. in addition we aimed to compare data obtained by esophageal function tests (eft) between the two groups and with pre-interventional qol-scores. methods. ninty-seven patients with gerd symptoms underwent esophageal manometry and h ph-monitoring or combined ph-multichannel-intraluminal-impedance. the patients received either medical or surgical treatment. qol was assessed using the german version of the sf . results. significantly lower pre-interventional sf scores were found for of the dimensions compared with the published normative data for the general us population. conservative treatment could not improve patients qol whereas surgery significantly improved the score for bodily pain. after year significantly better scores for dimensions were found in the surgical group. for of the chosen eft-categories the surgical group showed significantly worse values. when comparing sf scores with data obtained by eft no significant differences in the qol between patients with normal values and those with abnormal findings were found. conclusions. qol represents a reliable tool for assessment of severity of disease and outcome following therapy in persons with gerd. regarding patients qol surgical treatment seems superior to conservative treatment. der hiatus Ösophageuswie groß ist er wirklich? ergebnisse. es wurden männer und frauen obduziert. mittleres alter: j (range - j). gewicht: kg (range - kg), größe , m (range , m), bmi , (range , ) . thoraxumfang , m (range , m) . die mittlere hsa betrug , cm (range , - , cm ). bei allen leichen war die z-linie intraabdominal, der abstand zum his winkel betrug im mittel cm (range , - , cm) . der linke und rechte zwerchfellschenkel war bei allen exakt gleich lang, im mittel , cm (range , - , cm), der querdurchmesser (segment der Ö ffnung) im mittel , cm (range , - , cm). schlussfolgerungen. der durchschnittliche hiatusflächeninhalt beträgt , cm . er ist direkt proportional dem thoraxumfang und unabhängig von größe, gewicht, bmi und geschlecht. background. in patients with gastroesophageal reflux disease (gerd) esophageal acid exposure is assessed with a ph probe placed cm above the manometric lower esophageal sphincter (les). we compared acid exposure within and cm above the les. methods. between / and / , patients with gerd symptoms ( . % females; age . ae years) underwent multilevel ph monitoring ( days off antisecretory therapy) with a catheter including ph probes cm above (level þ ), at (level ) and . cm distal (level À . ) to the proximal les-limit; % time ph < . ( cm above les) < . % was considered normal. les length was > cm in all patients. results. cm above the les, ( . %) and ( . %) patients (no age difference, p ¼ . ) had normal and abnormal acid exposure, respectively. more women had normal acid exposure ( % vs. . %; p ¼ . ). in those with normal acid exposure, time ph conclusions. acid exposure is maximal within the les and may explain why reflux is missed by probe placement cm above the les. normative values or multilevel ph monitoring from asymptomatic persons are required. stellenwert der ösophagealen kombinierten h-impedanz-ph-metrie zur refluxdetektion bei ph-metrie negativen patienten grundlagen. die ösophageale -stunden-ph-metrie gilt als gold-standard zur abklärung der gastro-ösophagealen refluxkrankheit (gerd). sie vermag allerdings nur saure refluxe zu detektieren (ph < ). neuerdings wird die diagnostik zunehmend um die ösophageale kombinierte h-impedanz-ph-metrie erweitert, mit der auch schwach saure oder nicht saure refluxe registrierbar sind. wieviele refluxpatienten bisher mit der alleinigen -stunden-ph-metrie unentdeckt blieben, ist unklar und soll durch die vorliegende studie berechnet werden. methodik. retrospektive analyse aller patienten, bei welchen zur gerd-abklärung u.a. eine ösophageale kombinierte stunden impedanz-ph-metrie durchgeführt wurde. verwendet wurde ein comfortec + mii/ph katheter (fa. sandhill scientific,inc; nr. zan-bs- ) mit einem ph-sensor bei cm, sowie ringelektroden bei drei, sieben, neun, fünfzehn und siebzehn zentimetern von der sondenspitze. vor platzierung der impedanzsonde wurde eine Ö sophagusmanometrie durchgeführt, u.a. zur längen-und lagebestimmeng des les. die platzierung des ph-sensors erfolgte dann cm über dem oberrand des les. die auswertung erfolgte computerunterstützt (,,bioview + '', version z - ; sandhill scientific, inc.) die messdauer betrug jeweils stunden. ergebnisse. es wurden kombinierte stunden impedanz-ph-metrien durchgeführt. bei patienten ( , %) lag der demeester-score im normbereich (< , ). dreizehn dieser patienten mit physiologischem demeester-score zeigten eine pathologische anzahl von > refluxen in stunden ( , %; das entspricht , % der gesamten patientenpopulation). d.h., bei , % der patienten wurde eine pathologische refluxaktivität durch eine alleinige h-ph-metrie nicht erfasst. schlussfolgerungen. bei vorliegen einer unauffälligen ösophagealen h-ph metrie sollte, wenn verfü gbar, noch eine ösophageale h-impedanzmessung angeschlossen werden, um weitere , % der patienten vor einer möglichen fehldiagnose zu bewahren. reflux characteristics and symptoms off and on proton pump inhibitor medication: an impedance-ph-study in patients with gastroesopheal reflux disease background. the influence of proton pump inhibitor (ppi) medication on results of multichannel intraluminal impedance and ph monitoring (mii-ph) is controversial. aim of this study was to investigate the effect of esomeprazole mg bid on mii-ph results. methods. fifty patients ( f, . a, range - a) with heartburn or regurgitation underwent h mii-ph off (ppi paused for days) and on ppi (esomeprazole mg bid for days). patients recorded symptoms, meals and recumbent periods. tracings were automatically analyzed and manually reviewed. variables for comparison were number of acid and nonacid refluxes, heartburn and regurgitation episodes and symptom to reflux correlation by symptom index (si). results. see tables and . conclusions. esomeprazole mg bid resulted in significantly lower numbers of acid but not total number of refluxes. peristant regurgitation on medication was more frequent than persistant heartburn. on ppi reflux monitoring has a lower diag-nostic yield, but contains more clinically useful information in patients with symptoms persisting on ppi medication. the incidence of gastroesophageal reflux after transthoracic esophagocardiomyotomy without fundoplication: a long term follow-up background. evaluation of the long term results of heller's myotomy performed over a lateral thoracotomy without additional fundoplication. methods. fourty patients ( males, females; mean age . years; range: - years) were operated between and . preoperative evaluation included clinical scoring of symptoms, esophagogram, endoscopy, manometry and -hours ph-metry. at the follow-up investigation, the preoperative evaluation was repeated in all patients, adding a histological workup of the distal esophageal mucosa. the mean duration of follow-up after surgery was . years, ranging from to years. results. the clinical scores improved significantly: excellent relief from dysphagia was present in %, little or no regurgitation was found in %, little or no retrosternal spasms were reported by % of the patients. esophagogram showed an overall esophageal dilatation in all patients but no significant obstruction at the esophagogastric junction. endoscopically, . % had candida-esophagitis, % showed signs of a gerd i, . % had a macroscopically insuspect esophageal mucosa. histologically, % showed a mild chronic inflammation. manometry demonstrated distinct hypomotility of the esophagus in all cases, yet no elevated pressure of the lower sphincter; ph-metry showed moderate reflux in %. conclusions. transthoracic cardiomyotomy is a valid method for the treatment of achalasia, but it will not improve the esophageal motility, which slowly deterioriates in these cases. the patient's subjective assessment of the postoperative result was positive in the majority of cases. although fundoplication was not done in any of these patients, none of them showed signs of clinically relevant reflux. methods. review on the dilated end stage esophagus. results. anatomy and biopsy studies in gerd patients revealed the presence of cle within the proximal portion of the endoscopically visible gastric type folds over a length ranging from < . to . cm, where cle (cardiac mucosa ae intestinal metaplasia, oxyntocardiac mucosa) transitioned towards the oxyntic mucosa of the proximal stomach, irrespective of the presence or absence of endoscopically visible cle within the tubular esophagus. fusion of histopathology and function test data indicated that this condition results from a mechanism involving gastric distention induced damage of the lower esophageal sphincter causing reflux, damage and columnar metaplasia with proximal dislocation of the squamocolumnar junction. loss of sphincter function causes gastric type folding of the cle thus giving it a gastric type appearance during endoscopy. this is the dilated end stage esophagus, which is frequently taken for hiatal hernia during endoscopy and may cause the formation of the adenocarcinoma of the cardia (siewert type ii). conclusions. in gerd patients, endoscopy without biopsy sampling of the proximal portion of the endoscopically visible gastric type folds misses the dilated end stage esophagus. differentiation of the dilated end stage esophagus from proximal stomach (hernia) requires the histopathology of biopsies. background. differences in the prevalence of the morphologic manifestations of gastroesophageal reflux disease (gerd), columnar lined esophagus (cle) and barrett's esophagus (be; . % annual cancer risk) in those with and without gerd symptoms is not known. methods. esophagogastroduodenoscopy (egd) with multi level biopsies from the esophagogastric junction ( . cm, . cm above, at and . cm, . cm distal to the level of the rise of the gastric folds) was prospectively conducted in asymptomatic patients (controls; n ¼ ; . %) and gerd patients (n ¼ ; . %); aged between - years ( ae . ) and . % females. columnar lining above the level of the rise of the gastric folds was categorized as endoscopically visible cle (clev). histopathology of cle included cardiac mucosa ae intestinal metaplasia (¼be) and oxntocardiac mucosa; squamous epithelium and oxyntic mucosa (om) were considered as normal lining of the esophagus and the proximal stomach. prevalence of clev and histopathology proven cle was compared between controls and gerd patients. results. there were no significant age-, gender-differences between the groups (p > . ). prevalence of clev (p ¼ . ), histopathology proven cle (p > . ), cle length (p ¼ . ) and intestinal metaplasia (controls: . %; gerd: . %; p ¼ . ) was indifferent between controls and gerd patients. dysplasia and cancer have not been assessed. conclusions. the prevalence of cle and barrett's esophagus was comparable in patients with and without gerd symptoms. our findings may justify to consider screening endoscopy for barrett's esophagus. the aim was to evaluate long-term results of revascularization in significant coronary artery disease (cav). the group contained patients ( % male). the mean htx age was ae yrs (range from to yrs). the mean donor age was ae years. the mean follow-up time after revascularization was ae months. the cumulative incidence of significant focal cav was %. the mean time to development of significant focal cav was ae months (range from months to years). a total of lesions were treated. balloon angioplasty was performed times ( . %). a total of ( . %) bare metal stents (bms) and ( . %) drug eluting stents (des) were implanted. five patients underwent coronary bypass graft surgery. forty four percent of restenosis manifested in the first months after intervention. restenosis was diagnosed during the long-term follow-up time in . % lad, . % in cx and . % in rca stents. within the first months after intervention the mean restenosis rate in bare metal stents counted % and in des %. after months . % of stented lesions remained patent ( . % bms vs. . % des). diabetes mellitus turned out to be the only independent predictor for early restenosis. the cumulative incidence of cav is low. lad is affected by the highest rate of restenosis. intervention of focal lesions in cav patients is feasible and effective as it is in non-transplant coronary artery disease. a trend towards improved patency with des could be observed. background. this study was designed to determine the posttransplant outcome of elective, lvad and urgent patients undergoing cardiac transplantation. methods. the post-transplant outcome of elective, lvad (debakey, duraheart, heartware lvad) and urgent patients (hu) undergoing cardiac transplantation between and was retrospectively analyzed. survival, incidence of rejection, severe infections, cmv-disease and graft vasculopathy (cav) were compared. all patients received immunosuppressive therapy consisting of thymoglobuline, tac/cyclo þ mmf/evl and low dose steroids. kaplan-meier analysis was performed to test differences between the groups. results. patients in the three groups were comparable with regard to primary disease. urgent patients were younger ( ae yrs) than elective ( ae yrs) and lvad ( ae yrs) patients (p < . ). actuarial survival of elective ( %, %, %), lvad ( %, %, %) and hu ( %, %, %) patients was comparable , and years post-transplant (log-rank . ). furthermore, freedom from rejection episodes (elective: %, %, %, lvad: %, %, %, hu: %, %, %; log-rank . ), severe infections (elective: %, %, %, lvad: %, %, , hu: %, %, %; log-rank . ), cmv disease (elective: %, %, %, lvad: %, %, %, hu: %, %, %; log-rank . ) and cav (elective: %, %, %, lvad: %, %, %, hu: %, %, %; log-rank . ) was comparable between elective, lvad and hu patients , , and years posttransplant. conclusions. despite the increased risk of lvad and urgent patients post-transplant outcome is excellent and compares to elective patients. the low incidence of rejections and cav underlines the importance of induction therapy and individualized immunosuppression. background. pgd is a major cause of morbidity and death early after cardiac transplantation. extracorporeal membrane oxygenation (ecmo) is a mechanical support system to support hemodynamics in case of acute heart failure. the aim of this study was to evaluate ecmo as support system for pgd. methods. between and out of ( %) patients, who underwent cardiac transplantation, experienced pgd and received ecmo support. survival, rate of recovery and complications were analysed. results. overall survival was % after weeks follow up. patients ( . %) could be weaned from ecmo and in-hospital survival of these patients was %. duration of ecmo support was days. early experience ( ) ( ) ( ) ( ) with ecmo was significantly worse (survival: % vs. %; p ¼ . ) than later experience ( - ). overall complication rate was %. most frequent complications were bleeding (n ¼ , %; cannulation area (n ¼ ) and hematothorax (n ¼ )) and infections (n ¼ , %), (others: schreib eventuell alle in klammer nach 'others' auf und die gesamtzahl und % dazu, oder ganz weglassen) time of ecmo implantation had no impact on patient survival (problems during weaning off bypass: %; inability to wean off bypass: %, sudden pgd in icu: %; p ¼ . ) conclusions. ecmo is a valuable tool to overcome pgd after cardiac transplantation. bigger experience improves results significantly. however, complications can occur and proper management is of uttermost importance. the aim of the study was to evaluate the pattern of brain natriuretic peptide (bnp) concentration in heart transplant (htx) recipients and its relation to the degree of significant transplant coronary artery disease (cav background. minimally invasive follicular thyroid carcinoma (miftc) is defined to be an encapsulated tumor demonstrating limited unequivocal vascular and/or capsular invasion. considering the indolent behavior of these tumors the necessity of a radical treatment with routine lymph node dissection is questionable. methods. we evaluated our data in periods of time focusing on the necessity of lymph node dissection in miftc: in the first period from to our pathologists reviewed all fol-licular thyroid carcinomas (ftc) and identified those tumors appropriate to the criteria used for diagnoses of miftc. the patients were followed for . years on average. in the second period from to we observed all ftcs demonstrating lymph node involvement. results. in the first group of patients affected with miftc no lymph node metastases could be detected neither at time of diagnosis nor during follow-up time. no distant metastases or recurrent diseases were observed. the few tumors of the second period inducing lymph node metastases were all of widely invasive pattern of growth, none of them was minimally invasive. conclusions. lymph node involvement is generally rare in ftc. the absence of lymph node metastases in our series suggests no need for lymphadenectomy in miftc. we present an unusual case of a metastatic thyroid tumor, of which the primary cancer was an infiltrative high grade transitional cell carcinoma of the urinary bladder. the time from the diagnosis of primary tumor to metastasis was months. the appearance of the thyroid metastasis was like a primary thyroid disease. diagnosis of thyroid metastasis as a consequence of urinary bladder carcinoma was confirmed by intraoperative biopsy, histopathological and immunohistochemical findings. the treatment consisted of radical thyroidectomy in addition to systemic adjuvant chemotherapy. report after -year follow up. diagnosis of hashimoto's thyroiditis: discrepancy between preoperative antitpo-autoantibodies and histological grading in thyroid tissue methodik. bei konsekutiven weiblichen patienten wurden vor der schilddrüsenoperation prospektiv präoperative anti-tpo-bestimmungen durchgeführt und bei der histologischen aufarbeitung speziell auf die bewertung der lymphozytären infiltration und der graduierung (grad - ) geachtet. ergebnisse. von ( , %) patienten wiesen präoperativ erhöhte antitpo-spiegel auf, von ( , %) histologische zeichen einer thyreoiditis. bei den antitpo-positiven patienten wiesen grad , grad , grad und grad auf, zeigten keine lymphozytäre infiltration. bei jenen patienten mit his-tologischen entzündungszeichen ohne pathologischem antitpo-spiegel wurde grad in , grad in und grad in fällen gefunden, kein patient wies grad auf. der schweregrad der thyreoiditis zeigte eine signifikante positive korrelation (p < , ; r ¼ , ) mit der höhe der antitpo-spiegel. schlussfolgerungen. nur % der histologisch verifizierten thyreoiditis-patienten konnten präoperativ durch serologische antitpo-bestimmung erkannt werden. die daten zeigen, dass speziell die milden verlaufsformen der thyreoiditis hashimoto serologisch nicht verlässlich zu diagnostizieren sind. late onset paralysis of the recurrent laryngeal nerve after thyroidectomya rare phenomenon grundlagen. nach postoperativ regulärer stimmbandfunktion kann es in seltenen fällen auch erst im spätpostoperativen verlauf zum auftreten einer recurrensparese kommen. da dieses phänomen in der literatur nur kasuistisch beschrieben ist, wird hier über eine patientenserie berichtet. methodik. vor und nach schilddrüsenoperation wird standardisiert eine laryngologische untersuchung an der eigenen hno-ambulanz durchgeführt. jene patientin, die unsere abteilung -nach unauffälligem postoperativen hno-befund-wegen spätpostoperativ einsetzender stimmstörung aufsuchen, wurden analysiert. ergebnisse background. objective cosmetic analyses are important to reproducibly evaluate the cosmetic outcome after breast surgery and radiotherapy. so far, only subjective irreproducible scores have been used such as the harris scale. we have developed an objective tool to reproducible analyse digital pictures, the ''breast analysing tool'' (bat). the aim of this study was to compare subjective with objective breast cosmesis scores. methods. digital pictures (frontal view) from breast cancer patients ( from porto and from vienna) after breast conserving therapy and radiotherapy were analyzed with the above described software. all calculations were transferred to a breast symmetry index (bsi) ranging between (excellent cosm-esis) and (bad cosmesis). the same pictures were analyzed by experts (surgeons) and non-experts (students) using the harris scale (subjective score from to ; excellent, good, fair and poor cosmesis). these subjective scores were correlated with the objective scores from the bat software using the pearson correlation test. results. all subjective scores significantly (p < . ) correlated with the bat score with a pearson correlation coefficient of . (non-experts), . (experts) and . (overall). conclusion: the technical modifications of the bat-software have lead to the achievement of accurate and reliable results. this qualifies the use of bat in prospective and retrospective trials on breast cosmesis. offen-chirurgische intervention mit hohem komplikationspotential und langem krankenhausaufenthalt zu vermeiden. local hyperthermia combined with external radiation therapy as anti cancertreatment in recurrent breast cancer hyperthermia combined with radiation therapy has been confirmed in several randomised studies to be more effective than radiation therapy alone in various cancers. we evaluated the potential synergistic effect of local hyperthermia and conventional external beam radiation. we used a wave-guide applicator (bsd) with a typical emitting diameter of cm and a frequency of - mhz with a therapeutic depth of cm. hyperthermia was performed for min for at total of six sessions, twice weekly, the temperature was exactly calibrated between and c. immediately after hyperthermia external radiation with gy was applied in a daily fraction of . gy. no major side effects were observed during hyperthermia. patients were treated and followed for during - months. ten of the tumours responded to the treatment ( cr, pr), two patients died of distant metastases within one year. local hyperthermia combined with conventional radiation therapy may be useful tool to promote tumor regression and the local recurrence-free survival in cases of recurrance breast cancer. we conclude that hyperthermia and radiation therapy is effective in treatment breast cancer treatment and should be used in selected cancer patients. sentinel-node biopsy und lymphatic mapping von malignen tumoren mittels eines fluoreszenz-tracers (icg) the potential of plasma proteomics in predicting response to neoadjuvant chemotherapy in breast cancer patients using d-dige resistance to chemotherapy is still a major problem in oncology. especially for hormone receptor negative tumours there are no biomarkers available which identify patients who will not profit from treatment. such a selection would allow for a switch to another more effective chemotherapeutic regimen for these patients. chemotherapy not only leads to the destruction of tumour cells, but also affects actively proliferating healthy tissues as well as the immune system. as shown in another abstract of our group, neoadjuvant chemotherapy of breast cancer patients with epirubicin and docetaxel leads to expression changes of distinct plasma proteins within days. based on these results, we investigated whether such changes can be correlated with the final response to chemotherapeutic treatment assessed weeks later. therefore, plasma was prepared from breast cancer patients before and - days after receiving the first course of neoadjuvant chemotherapy. after the removal of major abundant plasma proteins by affinity chromatography, proteomic analysis was performed using d-dige. eight out of protein spots showed a higher chemotherapy-induced increase in expression (p < . ) in responders (n ¼ ) compared to non-responders (n ¼ ), whereas one protein behaved vice versa. these proteins might be useful in future for an early identification of those patients who will not benefit from this kind of treatment. for further investigation these protein spots will be identified by mass spectrometry and for verification of the d-dige results quantitative d western blots are planned. background. demeester's composite score (cs) is a convenient parameter to assess gastroesophageal reflux activity by h ph-monitoring. ingestion of acidic foods has been reported to compromise the reliability of this parameter. aim of this study was to evaluate the impact of meals on cs. methods. in a consecutive ph-studies exclusion of meals resulted in cs values . higher to . lower than including meals. the range of differences (cs . - . ) was used as a reference for selection of risk group to cross the cut-off value when analyzed without meals. results. of patients with clinical signs of gerd who underwent ph monitoring during one year, had a cs . - . and their studies were reanalyzed. median cs was . ( . - . ) including and . ( . - . ) excluding meals. in eleven patients the cut-off was crossed depending on analysis type. multivariate logistic regression including gender, oesophageal motility, recumbent periods, meals' duration and number of acidic foods/beverages were performed to identify risk factors for changing cs interpretation. prolonged meal duration significantly contributed to changing from normal to abnormal score (or . ; % ci . - . , p ¼ . ). the number of acidic foods consumed significantly raised the probability to change from abnormal to normal score when meal periods were excluded (or . ; % ci . - . , p ¼ . ). conclusions. the exclusion of meal periods from h phmonitoring rarely resulted in a different interpretation of cs. ingestion of acidic foods/beverages and long meal periods were identified as counteracting independent risk factors for crossing the cut-off value. colokutane fistel nach peg-anlage mittels introducer-technik mit gastropexie background. with a part of percent of all malignant gastrointestinal lesions and an incidence of - new diseases referring to persons, gastrointestinal stromal tumors (gist) are rather rare. nevertheless the number of cases is increasing, belonging to better endoscopic and radiological methods, but also because of the better knowledgement in histopathologic and moleculargenetic examinations. methods. in a group of two surgeons and two oncologists, started to discuss about a national registration of patients suffering from gist in austria. criterions for registration were discussed and fixed up in a sheet. also an informed consent for the patients registration was conceived. our concept, aims and visions were presented at the commission of ethics in lower austria, and a positive votum was given at the end of . so we started our official work at the first of january . results. as well the oncologist team as the surgeon group contacted as much centres as possible by phone call or by letter, inviting them to support the registry by bringing in their data. in a short time about centres and also the contact persons were registered. in a second announcement we want to enlarge this number in order to get better results. conclusions. gist registry was started to find out incidence of disease, but also the way of diagnosis and therapy in patients in austria. do we have similar strategies in the (neo-) adjuvant setting and in treating metastatic ore advanced disease or not? colonic retrosternal esophagoplasty in young children with pure esophageal atresia r. kovalskyy , a. kuzyk , o. leniv , i. avramenko lviv regional children hospital ''ohmatdyt'', department of pediatric surgery, lviv, ukraine; department of pediatric surgery, lviv national medical university, lviv, ukraine background. pure esophageal atresia is observed in - % of the newborn with the mentioned pathology. there is still a search for the optimal problem solving of the esophagus patency correction in such patients. this concerns both the choice of methods and the age of the children. methods. since till colonic retrosternal esophagoplasty have been done. the newborns weight was - g. children-born prematurely. newborns had pneumonia. diastases between the esophagus segments equaled - cm. at the moment of operation the children were of - weeks old. body weight was - g. during the first three weeks the newborns had the distal esophagostomy in the necks and gastrostomy. when the weight was stably increasing, the patients had a laparotomy, the segment of colon was chosen for transplantation. usually it was a colon transversum and a part of colon descendens with a. colica sinistra. transplant was put behind the stomach and located retrosternally in anterior mediastinum. proximal transplant ending was sewed in the anterior wall of stomach, distal-was delivered to the neck next to esophagostoma, in - weeks-the anastomosis with esophagus. results. four patients had an anastomotic breakdown in the neck. two of them had the repeated cervical anastomosis, the others had fistula, which closed by itself. the children had a good passage in the transplant. conclusions. to treat the children with pure esophageal atresia without fistula it is possible to use successfully colonic retrosternal esophagoplasty in the early age. background. gastroesophageal reflux disease is associated with columnar lined esophagus (cle). we aim to summarize the novel developments regarding our understanding of cle. methods. review of the recent literature ( - ) on cle. results. gastroesophageal reflux causes damage and columnar metaplasia of the squamous mucosa of the esophagus resulting in the formation of columnar lined esophagus (cle). recent evidence indicates that cle results from refluxinduced genetic changes within the stem cells of the esophageal epithelium inducing the switch from squamous to cardiac mucosa (cm) mediated via bone morphogenetic protein . cm may progress towards oxyntocardiac mucosa (ocm) by inclusion of parietal cells (mediated via sonic hedge hog, ssh, promoting parietal cell maturation) or to intestinal metaplasia (im ¼ barrett's esophagus) by inclusion of goblet cells (mediated via cdx ). shh and cdx pathway is stimulated by acidic and alkaline ph, respectively. thus the proximal location of intestinal metaplasia within a given cle segment is considered to reflect the ph gradient with acidic and alkaline ph in the distal and proximal cle segment, respectively. while shh mediated ocm does not progress towards intestinal metaplasia and cancer, the cdx pathway favors progression of intestinal metaplasia towards dysplasia and cancer. expression of cdx within cle is reduced to control values following elimination of reflux after an effective anti reflux surgery. conclusions. cle results from milieu-dependent esophageal epithelial stem cell changes activated during gastroesophageal reflux. these findings are suggested to explain why antireflux surgery favors regression of barrett's esophagus. successful interdisciplinary management of simultaneous mesenchymal tumor manifestations with synchronous resectionrare and challenging combination of a gastric ''high-risk'' gist and retroperitoneal liposarcoma methodik. anhand eines außergewöhnlichen exemplarischen fallberichtes wird eine -jährige patientin mit einem gist an der kleinen magenkurvatur und einem monströsen retroperitonealem liposarkom links-abdominal mit infiltration der linken niere dargestellt. der gist wurde durch eine tangentiale magenwandteilresektion und das liposarkom in toto zusammen mit der linken niere aufgrund der tumorinfiltration entfernt. im anschluss folgte eine kombinierte radiochemotherapie für das liposarkom. ergebnisse. beide tumoren wurden weitestgehend komplett entfernt. der technisch schwierige eingriff sowie der postoperative verlauf gestalteten sich komplikationslos. histologisch wurde beim magenwandtumor die r -resektion bestätigt und dieser aufgrund seiner größe( , cm durchmesser) und einer mitotischen aktivität( mitosen/ hpf) als ,,high-risk''-gist eingeordnet. die neoplasie des linken retroperitoneums wurde als myofibroblastisch-dedifferenziertes liposarkom (grad nach coindre) mit dem tumorstadium pt b g r im sinne eines unabhängigen mesenchymalen zweitmalignoms klassifiziert und damit ein metastasierungsgeschehen ausschloss. bei histologisch gesicherter r -resektion des liposarkoms erfolgten postoperativ eine additive radiochemotherapie nach vaia-protokoll (adriamycin, ifosfamid, vincristin) und eine bestrahlung des retroperitonealen tumorbettes von , gy gesamtdosis. in der radioonkologischen verlaufskontrolle nach jahren zeigte sich kein anhalt für ein tumorrezidiv. schlussfolgerungen. die komplette tumorresektion stellt die therapie der wahl bei mesenchymalen tumoren dar (ziel: r ). je nach histologischer tumorklassifikation und -sensitivität bzw. resektionsstatus ist eine nachfolgende radiatio und oder chemotherapie erforderlich, was im vorliegenden fall trotz r -resektion des liposarkoms und ,,high risk''-gist eine bisher jährige tumorfreie Ü berlebenszeit ermöglichte. schlüsselwörter. gist, liposarkom, radiatio, vaia-protokoll. surgical aspects of pneumatosis cystoides intestinalis: report of two cases e. schröpfer, l. scheele, c. wichelmann, c. t. germer, t. meyer univ.-klinik würzburg, würzburg, germany pneumatosis cystoides intestinalis (pci) is a rare disease usually caused by an underlying condition. it is defined as air filled cysts within the wall of the gastrointestinal tract. the true incidence is unknown, pci is often an incidental finding on radiographs. we report on two different cases of pneumatosis cystoides intestinalis. both patients underwent surgical treatment in our department. the first patient, a year old white european girl, with down syndrome and leucopenia due to chemotherapy for acute lymphatic leukemia was admitted to our surgical department with acute septic conditions and air filled cysts in the intestine wall. explorative laparotomy revealed acute ischemia of the right colon and resection of the affected intestine was performed. after a short interval in the intensive care unit the patient was referred to the pediatric department. the second patient, a -year old, white european man with urothelial carcinoma of the bladder and carcinoma of the prostate underwent radical cysto-prostatectomy in the department of urology. after several operations due to obstruction of the right common iliac artery the patient presented an acute abdomen and computer tomography revealed pneumatosis intestinalis and ileus of the colon. only adhesiolysis was performed and the patient was discharged into rehabilitation a few weeks after. patients with the radiographic diagnosis of pci should receive a thorough history and physical examination. we discuss the surgical management of pci according to literature and developed an algorithm. gastrointestinale stromatumore (gist): modifizierte therapeutische strategien durch pet/ct background. the liver is a frequent site for metastases of colorectal cancer. due to new chemotherapy agents, strategies and targeted agents response rates and respectability rates have improved. moreover, some patients with neoadjuvant chemotherapy have complete response of the liver tumors and the lesions are no longer visible by preoperative ct-scan or intraoperatively. methods. we report a case of a years old female who underwent right hemicolectomy for caecal cancer in an outside hospital. owing to synchronous liver metastasis in segment iv b neoadjuvant chemotherapy was administered. follow-up ctscan revealed complete response and no tumor was visible in the liver. patient was then referred to our center for further investigations. results. ct-scan and mri showed no visible tumor. with the aid of the ct-scan before neoadjuvant chemotherapy the tumor was measured out and preoperatively a ct-guided hook-wire was placed at the position of the presumptive lesion. afterwards the patient was brought into the operating room and an atypical liver segment resection around the pike of the wire was performed. the operative and postoperative course was uneventful. the histologic specimen was tumor-free also presenting complete pathologic response. after close follow-up of months the patient is free of tumor. conclusions. our approach with the ct-guided wire marking could potentially be a way to remove colorectal liver metastases with complete response to neoadjuvant chemotherapy. to leave lesions in place which are not visible could not be the goal, only a curative resection which removes all metastases should be the aim. rechtsseitiger oberbauchschmerz -ein klarer fall? background. breast cancer metastases to the liver are associated with a poor prognosis. in contrast to colorectal metastases, there are as yet no established guidelines for liver surgery for breast cancer secondaries. methods. our retrospective study compared patients with an average age of . years (range - years) who underwent hepatic resection. both solitary and multiple liver metastases that seemed to be resectable by r were treated. six patients underwent chemotherapy before and patients after the liver resection. nine women received hormone treatment, before and after liver surgery. results. we performed major (hemihepatectomy or more than segments of the liver) and minor (less than segments) resections. the median interval between primary operation and liver resection was . years (range months to years). fifty percent of the women had a solitary metastasis with a median size of cm. there were liver secondaries in both lobes in patients and in one lobe in . no patient died after liver resection. five of the women had a liver recurrence. the -and -year survival rates were calculated as % and %, respectively. conclusions. for selected patients with liver secondaries from breast cancer, surgical resection in combination with chemotherapy can be a safe option with low morbidity and mortality. ergebnisse. innerhalb der neoadjuvanten avastin therapie stiegen tems und cecs signifikant an (p ¼ , bzw. p ¼ , ). ebenso beobachteten wir im vegf verlauf einen rapiden anstieg (p ¼ , ), der einem deutlichen cea abfall gegenüberstand. in der adjuvanten therapie war wiederum ein vergleichbarer vegf anstieg (p ¼ , ) zu beobachten, wohingegen sich sowohl cecs und tems als auch cea kaum veränderten. schlussfolgerungen. der vegf anstieg unter neoadjuvanter und adjuvanter therapie scheint den einfluss von avastin auf die systemische angiogenesebalance widerzuspiegeln. dies steht dem ausschließlich in der neoadjuvanten therapie auftretenden anstieg der cecs und tems gegenüber, welcher nach tumorresektion nicht mehr zu beobachten ist. die vorliegenden daten deuten darauf hin, dass die angiogenese assoziierten zellpopulationen mit der tumormasse in zusammenhang stehen, sich unter therapie signifikant verändern und daher ein potenzial im monitoring der kombinierten avastin-chemotherapie besitzen. rescue approach for unexpected portal vein thrombosis during orthotopic liver transplantation d. kniepeiss, h. müller, d. wagner, e. jakoby, s. schaffellner, f. iberer, k. tscheliessnigg thanks to innovative surgical techniques, portal venous thrombosis no longer is a contraindication for liver transplantation. in case of extensive portal and mesenteric venous thrombosis, cavoportal hemitransposition has been described as a salvage technique but experience is still limited and there is a high risk of serious complications. we present an alternative management of portal vein thrombosis during liver transplantation. a -year-old man with liver cirrhosis underwent liver transplantation. although preoperative doppler ultrasound showed portal perfusion, severe portal vein thrombosis was found during transplantation. obviously, the flow of one variceal vein located cranial to the hepatic artery was interpreted as portal vein flow in the pretransplant ultrasound examination. as a salvage measure, the variceal collateral vein was used for portal end-to-end anastomosis. postoperatively, primary graft function was acceptable and improved day by day. moderate renal failure as defined by the k/doqi-guidelines improved gradually and dialysis was never indicated. persistent ascites required repeated paracentesis during the first month after liver transplantation but medical treatment sufficed thereafter. six months after transplantation the patient has normal liver function and adequate renal function. colour doppler ultrasound shows normal flow in all vessels. there are no ultrasonographic signs of ascites and diuretics are not required. we conclude that when there is portal vein thrombosis, a collateral vein of sufficient calibre in the hilum can be used if present for portal vein anastomosis. in our case the surgical procedure was uneventful; postoperative complications were not serious and were controllable with medical therapy. an in-vitro role of mtor proteins in the protection of hcv infected cells from apoptosis has been proven. the aim of this cohort study was to evaluate the effect of sirolimus as mtor inhibitor on hepatitis c recurrence in liver recipients. hepatitis c virus positive patients were followed up prospectively regarding transaminases, immunosuppressive target levels, hcv rna and influence of donor and recipient factors on viral recurrence and survival. viral recurrence was defined as elevated liver enzymes combined with active hepatitis defined as increasing viral load and/or biopsy proven hcv relapse in the transplanted organ. hcv-positive patients were included received a sirolimus including regimen, patients stayed on calcineurininhibitors. sirolimus patients showed a significant decrease in the hcv pcr levels (p < , ). survival of the sirolimus patients was significantly higher (p < , ) as compared to the other patient cohort. sirolimus has shown to be a potent immunosuppressive agent for patients after liver transplantation. nothing is known about its effect on hcv. this analysis suggests a potential of sirolimus to be evaluated as immunosuppressant for hcv positive liver transplant candidates to suppress viral recurrence. langerhans' cell sarcoma of the spleensurprising diagnosis of a very rare tumor entity during the septic course of a patient background. ccc is a rare tumor disease in western europe with a poor prognosis. these tumors develop from cells of the bile duct epithelia and can appear in several locations along the biliary tract. methods. between and a total of patients were reported at our surgical department because of malign bile duct tumor. patients with histologically confirmed cholangiocarcinoma were included in this study. gall bladder and papillary cancer were excluded. patients were classified into groupsintrahepatic, perihilar and distal-based on the tumor classification established by the john hopkins hospital. data was obtained retrospectively from the surgical, histopathological and clinical records of the patients. results. out of the patients suffered from an intrahepatic ( %), a perihilar ( %) and a distal ccc ( %). the overall resectability rate was % ( % intrahepatic, % perihilar and % distal). the overall perioperative mortality rate was % ( %, % and % respectively). the -, -and -year survival rates in all groups after curative resection were %, % and %; %, % and %; and finally %, % and %. the overall recurrence rate was %. conclusions. cholangiocarcinoma is a malign tumor disease with poor prognosis. tumor location has a decisive influence on the resectability rate and determines therefore the prognosis of the patient. however, when resectability is provided in all groups, location has no effect on the prognosis. das j -ganzkörperszintigramm (gk) ergab multiple speicherungen in der sd-loge und der oberen thoraxapertur, einem rezidiv entsprechend. weiters wurden im abdomen mehrere speicherherde erkannt, die sich im spect/ct in der leber lokalisieren ließen. die sonographie bestätigte den verdacht auf lebermetastasen und auf einen weiteren, paracaval liegenden herd (lymphknoten). aufgrund des massiv erhöhten tg-wertes und der deutlichen speicherung im j-gk-scan wurde eine weitere hochdosierte rjt ( mbq) unter exogener tsh-stimulation veranlasst. posttherapeutisch fanden sich analog zum diagnostischen jod-scan deutliche anreicherungen im hals-und abdomen im sinne von jod-aviden speicherherden. schlussfolgerungen. dieser fallbericht demonstriert, dass bei der nachsorge eines ftc an sehr selten vorkommende tumorlokalisationen wie lebermetastasen gedacht werden sollte. zum anderen zeigt dieser fall auch, dass anatomische besonderheiten im rahmen medizinischer interventionen (z.b. tracheostoma, peg-sonden, div. katheter, etc.), pathologische speicherungen maskieren können. hier stellt die anatomisch/metabolische bildgebung mittels spect/ct ein probates mittel für die differentialdiagnose dar. chemotherapeutic treatment of cancer patients is aimed at eradication of the tumor. in the recent years it became clear that also the immune system contributes substantially the removal of tumor cells. tumor infiltrating leukocytes, however, are commonly suppressed by the tumor in their function which reduces the success of a chemotherapeutic treatment. in a recently published study we demonstrated that replication defective influenza a vaccine virus mutant delns is able to boost the cytotoxic response of peripheral blood mononuclear cells (pbmc's) to tumor cells ''in vitro''. here we investigated whether such a treatment could be used to overcome an immunosuppressive state of pbmc's. pbmc's from healthy volunteers were treated with lps for h. this is known to promote formation of unreactive m -macrophages. then those pbmc's where added to mcf- and panc tumor cells in presence or absence of chemotherapeutic drugs (gemcitabine and cisplatin). lps-treated pbmc's showed a significant lower cytotoxic effect on tumor cells in comparison to untreated cells. this effect was detectable with and without chemotherapy. pre-incubation with delns boosted the cytotoxic capacity of pbmc's and abolished the effect of lps-pretreatment. these data indicate that pretreatment of patients leukocytes with delns might be useful to increase the effect of chemotherapy. background. pancreatic necrosis is a serious complication of acute pancreatitis. the identification of laboratory tests to detect subjects at risk of pancreatic necrosis may direct management and improve outcome. soluble thrombomodulin (stm) has been identified as a marker of poor prognosis in the critically ill. circulating (cell-free) dna in serum or plasma has been investigated as a non-invasive diagnostic tool in a variety of clinical conditions. methods. we studied patients with acute pancreatitis ( -mild, -severe). a thrombomodulin level was determined by elisa. serum creatinine was analyzed on biochemical analyzer. dna was calculated by real time pcr. the degree of pancreatic necrosis was classified by ct balthazar criterion. results. the levels tm, free dna and creatinine of the severe acute pancreatitis group were significantly higher. free serum dna was in correlation with the extent of pancreatic necrosis. increase in creatinine within the first h is strongly associated with the development of pancreatic necroses. pearson correlation coefficient between the degree of necrosis and tm values and between the apache ii score and tm values was statistic significant. conclusions. the plasma tm, free dna may use for identify pancreatic necrosis. high level of creatinine within the first h indicates a high risk of pancreatic necrosis in patients with acute pancreatitis. need an aggressive surgical approach fpr management of giant cystic pancreas neoplasm? resection or palliation? s. dubecz, h. heuberger, m. prager, h. hudler, p. hoffmann, k. vetter the histologically unproven giant cystic pancreas malignancy is a common problem for the diagnostic team and the surgery also. his histological confirmation at the asymptomatic neoplasm are more important the differentiation between of benign or malignant desaeses. in a rare situations, like the presented case, an extremely rare malignant tumors (acinar cell carcinoma) can be resected without any preoperative confirmation. a year old man presented with loss of appetit, history with icterus and changes in bowel habits and negative value with tumour markers. the praeop. investigations were the follows (ct: cm large inhomogen pancreashead tumour, with well anhancing wall, without liver and ln metastases, ercp: cysticmucinous giant tumour in the papilla region, with double duct occlusion, bileduct stanting was not available, histology:any praeop. biopsy was notmalignant). at the exploration we found a large cystic tumour in the pancreashead without propagation to the great wessels: the frozen histology was also negative. instead of originally planed palliation we performed a whipple operation. the early and postoperative period was also complicationsfree ( month follow-up). we demonstrating in details the macro-, and microscopic path investigations (pancreastumor with central haemorrhage and necrosis, solid tubulo-cribriform tissue, cells with hyperchromatic nuclei and granular, with pas pos cytoplasm, with few cells are reactive with chromogranine and synaptophysine). also demonstrating the literature of the this very rare pancreas malignancy. it seems to be possible to achieve a curative result with an aggressive surgical approach at older patient also with a giant benign or semimalignant pancreas neoplasm. minimally invasive methods and surgery at the management of pancreatic pseudocyst methods. two hundred and forty-seven patients were undergo to percutaneous puncture of ppc under ultrasonographic guidance resulted in drainage in patients. transpapillary and transmural approaches for endoscopic internal drainage were used in and patients, respectively. sixty-eight patients were undergo to opened surgery: internal ( ) or external ( ) drainage of ppc, distal pancreatectomy with cystectomy ( ), enucleation of the cyst ( ). results. ppc have been disappeared after percutaneous procedures in . % patients with mature and in . % patients with immature ppc. total success rate of endoscopic drainage of ppc was , %. four patients after surgery have died ( . %) because of bleeding, abscess and retroperitoneal phlegmon. obtained results and experience let us to propose the algorithm for the management of ppc. conclusions. both percutaneous and endoscopic methods are good minimally invasive alternatives for surgery in selected patients, but percutaneous procedures result in higher morbidity and longer hospital stay. the number of successful laparoscopic common bile duct exploration in patients with acute cholecystitis range from % to % because of changes of hepatoduodenal ligament anatomy. background. the purpose of study was to prognosticate possible difficulties and problems for laparoscopic choledochoscopy and bile duct clearance in patients with acute cholecystitis. methods. patients underwent to laparoscopic cholecystectomy because of acute calculous cholecystitis. by usage of blood tests, ultrasonography, x-ray examination of the gastrointestinal tract, ct, mri, endoscopy in ( . %) patients choledocholithiasis, stenosis of vater's papilla or peripapillary diverticulum were revealed and they underwent pre-or intraoperative common bile duct (cbd) exploration. results. prognostic factors for difficult and/or failed laparoscopic cbd exploration were hard masses in the hepatoduodenal ligament (ultrasonographical echopositive paravesicular masses close to the gall bladder neck and/or hyperechogenic strips, that usually occurs in - days after onset of acute cholecystitis), paravesical abscesses, thick ( . mm and more) wall of cbd, multiple stones in the cbd, large stones that completely filling up the cbd, peripapillary diverticulum, sludge with microcholelithiasis. ( . %) patients had conversion because of problems with cbd exploration. conclusions. laparoscopic cholecystectomy with cbd exploration and stone extraction is the method of choice in the treatment of patients with acute cholecystitis complicated with choledocholithiasis. in patients with predicted difficult laparoscopic cbd exploration the preoperative endoscopic retrograde resolution of intracholedocheal problems is favourable. operative treatment of pancreatic cancer: our experience y. i. havrysh , y. i. shavarow , m. p. pavlovskyy , a. t. chykaylo lviv regional hospital, lviv, ukraine; lviv medical university, lviv, ukraine in our surgical department from to we treatment patients with cancer of pancreas. we executed : whiplle procedure, left pancreatectomies, palliative operations, patients were not operated. we diagnosed invasion of pancreatic tumors into colon in patients, into stomach - , into v. portal - , into hepatic artery - . from patients for which one was executed whiplle procedure: male- , female- . age was from to years. we observed mechanical icterus in patients. we used bilio-enteric anastomosis as first stage of the operation in patients and conduction of stent implants in patients. we performed pancreatectomy whiplle in two stages: -resectional stage, -reconstructional stage. conduct a reconstruction on the isolated loops for roux-en-y. we made drainage outside of common bile duck and pancreatic duck. we imposed anastomosis by single-row knotty suture: bilioenteric, gastro-enteric, pancreato-enteric, entero-enteric. post operative complications: bleeding in patients, acute pancreatitis in patients, peritonitis in patients. we observed incapability of stitches of pancreato-enteric anastomosis in a patients. we performed relaparotomy in patients. died - patients: patients died in result of postoperative bleeding, patients -from acute pancreatitis, patients -after peritonitis. life duration of our patients after operation: died till year persons, died till years persons, lived more than years persons, lived more than years patients. endoscopic papillectomy is feasible and safe in suspicious lesions of the papilla of vater (case series of patients) diabetic gastroparesis (dgp) represents a chronic gastrointestinal disorder defined by delayed gastric emptying in the absence of mechanical obstruction. following successful pancreas transplantation dgp remains a major concern in one third of these patients. here we report on the application of intrapyloric injection of botulinum toxin a (botox) in six pancreas recipients. all six patients (four males) with stable graft function suffered from severe and persistent gastroparesis. symptoms of gastroparesis were quantified by the patient-assessment-of-gastrointestinal-symptom (pagi-sym#) severity-index before injection and during follow-up. likewise quality-of-life was assessed (pagi-qol#). total score varies from to . to exclude other possible underlying causes gastric emptying was determined by x-ray and scintigraphic examination prior to treatment. botoxtherapy consisted of u injected equally distributed over the four quadrants of the pylorus. control x-ray was performed h later. clear effects were evident within two weeks following botox-injection in all patients. while the mean symptom score before botox-application was . (range . - . ) early after treatment it decreased to . ( . - ). similarly mean pagi-qol#-index decreased from . ( . - . ) to . ( - . ). two patients required a second injection due to recurrent symptoms. no adverse events were observed. after a follow-up of . days ( - ) five of six patients experience substantial improvements in dgp symptoms and four report considerable amelioration of their quality-of-life. intrapyloric botox-injection should be considered in pancreas transplant recipients suffering from severe dgf if they are refractory to prokinetic and anti-emetic medication. # johnson&johnson pharmaceutical services, llc. abscess in abdominal wall containing calculus -cholecystocutaneous fistula secondary to perforation of gall bladder: a case report background. complications of calculus cholecystitis include abscess up to perforation of gallbladder, which has been classified into acute (free perforation: type ), subacute (abscess walled off by adhesions: type ) and chronic (fistuleous communication in other viscus: type ) perforation refering to modified niemeiers classification. primary manifestation of chronic perforated gallbladder could be presented as cholecystocutaneous abscess/fistula extremely infrequent, whereas fistula in general occurs in less than % of patients with biliary calculus (most likely cholecystoduodenal > %). methods. we encountered a years old patient presenting with swelling at right upper abdomen with slightly elevated wbc and normal liver function test, sonography and ct-scan confirmed abscess and gallbladder adherent to abdominal wall. after cutaneous drainage with spilling of calculus and conditioning with antibiotics preoperatively secondary laparoscopic cholecystectomie and fistulectomie were performed. conclusions. in contrary to frequent cholecystocutaneous fistulas in former times, abscess in abdominal wall as a result of perforation in calculus cholecystitis is a rare entity nowadays due to the advent of sonography, antibiotics and early surgical treatment of biliary tract disease. diagnosis of cholecystocutaneous abscess or fistula might be difficult due to the lack of clinical specifity. anyway it should be considered and kept in mind as important differential diagnosis, therefore be affirmed aided by fistulogram, accurate ultrasonographic and ct-scanfindings and clinched with findings of bilious fluid on drainage. increased preoperative awareness for diagnosis of this condition as well as percutaneous drainage prior to subsequent surgical intervention will diminish rate of morbidity and mortality of the disease. background. acute sigmoid diverticulitis is a very frequent disease in western and industrialized countries. immunosuppressed patients show an increased incidence of complicated diverticulitis and a high risk of colonic perforation. the clinical presentation can range from non-specific signs of abdominal discomfort with delayed diagnosis of perforation to life-threatening abdominal sepsis. the standard surgical management mainly consists of hartmann procedure or primary anastomosis, but is still very controversial due to high morbidity and mortality in both cases. we present four case reports from our department with a short review of literature. methods. between and four patients after organ transplantation (lung  , kidney, liver) were admitted to the department of surgery for acute sigmoid divertculitis with free perforation ( male patients; median age , range - ). two patients underwent a hartmann procedure, two patients had a primary anastomosis. results. the time interval between transplantation and perforation ranged between months and years with two patients having a history of diverticulitis. a dehiscence after laparotomy and an anastomotic leakage required revisional surgery in two patients. postoperative morbidity included acute rejection, pneumonia and acute renal failure. two patients died with mods following pneumonia and acute rejection (bilateral lung transplantation). conclusions. sigmoid perforation in transplant recipients is a rare, but life-threatening event with a high mortality. elective surgical interventions should be considered in patients with high risk of perforation (history of diverticulitis, steroid immunosuppression and heart/lung transplantation). außergewöhnlicher kasus der ausbildung von kolorektalen karzinomen an lokalisationen bei pancolitis ulcerosa eines jungen patienten es ist hinreichend bekannt, dass die colitis ulcerosa als präkanzerose für die generation eines colonkarzinoms gilt. bei einem -jährigen patienten wurde im rahmen einer koloskopie wegen persistierender abdominalbeschwerden eine pancolitis ulcerosa diagnostiziert, die außerdem intraepitheliale neoplasien nachwies. erkrankungsassoziierte incompliance mit temporärer therapieablehnung für jahr führte zu einer beträchtlichen verzögerung der indizierten proktokolektomie, die letztlich ein inzidentelles, simultanes kolorektales karzinom an lokalisationen ergab [  pt c pn ( / ) m ]. eine adjuvante radiochemotherapie konnte aufgrund von wundheilungsstörungen und nebenwirkungen nur verzögert und nicht zeitgerecht durchgeführt werden. der patient war monate postoperativ rezidivfrei, erlag jedoch im verlauf nach einer notoperation bei bridenileus einer sepsis. trotz bekannter prädisposition bei colitis ulcerosa ist die ausbildung eines kolorektalen karzinoms noch immer ein relevantes pathogenetisches geschehen im krankheitsverlauf. insbesondere können diagnoseverzögerung und incompliance das risiko der manifestation maligner läsionen, wie im vorliegenden fall mit multiplen karzinomen, deutlich erhöhen und zu vermeidbar schweren ausmaßen mit sekundären krankheitsbildern führen. mit diesem aussergewöhnlichen fallbericht wird herausgehoben, dass aufgrund multilokulären, lokal fortgeschrittenen (nþ) tumorstadiums trotz erfolgreicher operation und stadiengerechter adjuvanter therapie eine engmaschige onkochirurgische verlaufsbeobachtung und frühe inrervention bei erhöhtem rezidivrisiko dringend verfolgt werden muss. das primäre amelanotische melanom des rektums background. a new surgical technique, the perineal stapled prolapse resection (psp), for external rectal prolapse was introduced by a feasibility study in . this study now presents the first results of a larger patients number with functional outcome in a midterm follow-up. methods. from july to december the psp was performed on patients with external rectal prolapse. the prolapse was completely pulled out and then axially cut open at three o'clock in lithotomy position with a straight stapler. finally the prolapse was stepwise resected with the curved contour + transtar tm stapler at prolapses' uptake. perioperative morbidity and functional outcome was prospectively documented by different scores. results. in all patients, median age years (range - ), psp was performed with no intraoperative complications. % postoperative complications occurred, two patients had a first degree complication (¼ no specific treatment necessary), one patient a second degree (¼ need special medication) and one a third degree (¼ interventional treatment necessary). no mortality. the median operation time was min , the median hospital stay days ( - ). in two patients a reccurence of the prolapse was observed ( %) and treated with a second psp procedure. functional result of of ( %) of the patients were available after a median time of months ( - ) the median reduction of the wexner score was from ( - ) before surgery to . ( - ) postoperatively, p < . . conclusions. the psp is an elegant, fast and safe procedure, with good functional results. colorectal adenocarcinoma in heart transplant recipients background. conflicting data exist whether patients undergoing heart transplantation (htx) are at increased risk for developing colorectal adenocarcinoma (crc). specifically, data on the age matched incidence are rare. methods. the vienna heart transplant database was queried to configure a list of eligible patients. exclusion criteria included: age less than years at the time of transplant, diagnosis of colorectal cancer or patient death less than month posttransplant, and pretransplant history of colorectal cancer. results. a total of patients with htx were eligible for analysis from / through / . the mean follow-up was . years. we identified cases of crc. nine of those patients were between and years of age at diagnosis of crc. thus, the incidence of crc in htx recipients in this age groups is . / , which is -fold higher than the incidence in the general austrian population for crc in this age group. the latter is . / , derived from statistic austria. there was no difference in the incidence of crc in other age groups between the austrian population and htx recipients. median time from transplant to cancer diagnosis was . years. the median survival postcancer diagnosis was . years. conclusions. with the limitation of small numbers of htx recipients and crc available in our study, the incidence of colorectal adenocarcinoma in heart transplant recipients from to years appears to be markedly increased than the general population. our data warrant an intensified crc screening program for htx recipients in this age group. there is growing evidence that chemotherapeutics induce an inflammatory response during the very first course of treatment. we investigated the diagnostic history of patient with either breast or colon cancer. due to their underlying disease they receive different regimes of chemotherapeutic treatment. our standard neoadjuvant treatment of breast cancer is epirubicin and docetaxel whereas patients suffering from colon cancer receive oxaliplatin, irinotecan and -fluoruracil. we hypothesize that chemotherapeutic treatment should be mirrored within the blood plasma proteome. for this reason, blood was taken from both groups on the day before and - days after receiving the first course of chemotherapy. plasma proteomic analysis using d-differential in gel electrophoresis (dige) was performed. differentially expressed proteins were identified by mass spectrometry. using investigations of plasma proteome analysis we validated our findings using western blot. twenty-six out of protein spots showed a more than . fold (p < . ) change within days of chemotherapy, including complement factors c , c and c , alpha hs glycoprotein and alpha -anti chymotrypsin in the breast cancer collective. in contrast, in colon cancer patients the expression level of only out of proteins was affected by the treatment. future investigations will show whether this difference in the treatment induced protein expression changes were related on different chemotherapeutic treatment or different patient collective. lösliches cytokeratin -m -hat potential als postoperativer surrogate marker für den nachweis einer systemischen erkrankung beim kolorektalen karzinom bei einem jahre alten männlichen patienten trat nach einer notwendigen parenteralen infusionstherapie am handrücken eine phlegmone auf, die primär unbehandelt blieb. es kam jedoch zu einem fortschreiten der infektion. schließlich musste eine incision durchgeführt werden, trotz der incision kam es jedoch zu einem handtellergroßen hautdefekt am handrücken rechts mit konsekutivem abriss sämtlicher strecksehnen. der patient war in stark reduziertem allgemeinzustand (zustand nach beckenfraktur, postantibiotische enterocollitis, demenz). trotz des schlechten allgemeinzustandes musste eine rekonstruktion der sehnen und deckung des hautdefektes durchgeführt werden, da sonst der patient in weiterer folge sich selbständig nicht mehr versorgen hätte können. es erfolgte in vitaler indikation die rekonstruktion sämtlicher strecksehnen durch strecksehnenplastik und die deckung des hautdefektes durch einen gestillten hautlappen. gleichzeitig musste eine antibiotische therapie mit metronidacol durchgeführt werden. es erfolgte anschließend eine ruhigstellung und durch diese therapie konnte eine völlige wiederherstellung der handfunktion erzielt werden. zusätzlich kam es zu einer besserung des allgemeinzustandes und der patient kann sich nun selbst versorgen. es wird auf die therapie und auf die ergebnisse eingegangen. neuropathien der oberen extremität präsentieren klinisch oft mit sehr ähnlichen symptomen, obwohl oft sehr unterschiedliche Ä tiologien zu einem eng gefassten klinischen zustandsbild gefü hrt haben können. dies kann entweder zu einer glatten fehldiagnose und entsprechender fehlbehandlung fü hren oder den behandelnden arzt in ein diagnostisches dilemma bringen. bei einer klaren anamnese, welche eine mechanische ursache, wie trauma oder chronische kompression nahe legt, ist natürlich die therapie klar vorgegeben. bei patienten mit unklarer Ä tiologie und klinischer präsentation sollte auch an den seltenen fall einer isolierten neuritis gedacht werden. diese spontan auftretenden lähmungen können auf unterschiedlicher höhe des armnervengeflechtes und den entsprechenden armnerven auftreten und dem unerfahrenen als typische nervenkompressionskasuistik imponieren. bei genauer begutachtung zeigt sich jedoch eine spontan aufgetretene rein motorische lähmung mit entsprechender anamnese und typischen prodroma. die elektroneurographie zeigt eine deutlich erniedrigte spa mit denervationspotentialen als reflexion der rein axonalen schädigung des motorischen systems. in diesem bericht werden wir die typische klinik der häufigsten neuritiden der oberen extremität und deren therapie anhand von fallbeispielen präsentieren und einen diagnostischen und therapeutischen algorithmus vorstellen. die zweizeitige beugesehnenrekonstruktion c. pazourek, u. mildner-deutschmann, p. aspalter, a. pachucki lk mostviertel amstetten, amstetten, austria wir zeigen an mehreren fallbeispielen einen algorithmus zur rekonstruktion von beugesehnen der hand sowie deren sehnenscheiden und ringbänder im rahmen eines zweizeitigen verfahrens unter intermittiernder verwendung eines silastikstabes. wir gehen auf einzelne indikationen ein und entwickeln in der folge ein schema zum zeitlichen ablauf. die op-technik wird beschrieben, ebenso wie zu gewährtigende komplikationen. visceral heme oxygenase- expression is determined by hip to waist ratio and linked to insulin sensitivity grundlagen. das diffuse intravaskuläre b-zell-lymphom (ivl) ist eine seltene, maligne erkrankung, charakterisiert durch eine intravaskuläre proliferation von lymphomzellen mit konsekutiven thrombosen der kapillaren und kleinen gefässe mit nachgeschalteten nachgeschalteten organischämien. jedes organsystem kann davon betroffen sein, die diagnosestellung erfolgt ausschließlich histologisch. eine jährige patientin zeigte seit drei monaten b-symptomatik mit fieberschüben bis zu c, reizhusten und müdigkeit. zusätzlich lagen eine hepatosplenomegalie mit hypoperfusion der milz, erhöhte entzündungsparameter mit anämie, sowie eine hsv-infektion und ein pulmonaler hypertonus vor. methodik. im thorax-ct wurden konfluierende infiltrate in beiden oberlappen und in den apikalen unterlappenanteilen verifiziert, im pet-scan fand sich kein pathologischer fdg-uptake. aufgrund von candida albicans im tracheobronchialsekret bestand der verdacht einer pulmonalen mykose. zur histologischen diagnostik erfolgte eine thorakoskopische keilresektion im segment rechts. ergebnisse. histologisch zeigte sich ein diffuses intravaskuläres großzelliges b-zell-lymphom mit lambda-positivität, positiver immunhistochemischer reaktion auf vegfr und vegfr , sowie cd -koexpression. typischerweise wiesen die arteriolen, venolen und kleinen peripheren gefässe eine vollständige thrombosierung durch tumorzellen auf. die patientin entwickelte peri-operativ ein sirs-artiges bild mit nicht beherrschbarer sepsis, welche den sofortigen beginn einer chemotherapie nicht zuließ. sie verstarb am . postoperativen tag an den folgen des multiorganversagens. in der obduktion fanden sich als ursache des mov tumorzellembolien in allen parenchymatösen organen. schlussfolgerungen. das diffuse intravaskuläre b-zell lymphom zeigt im vergleich zur kutanen manifestationsform eine extrem ungünstige prognose. das Ü berleben ist wesentlich von der frühzeitigen diagnose und dem sofortigen therapiebeginn abhängig. bei ischämischen organläsionen in verbindung mit fieber sollte daher immer an das vorliegen eines intravaskulären lymphoms gedacht werden. die auswirkung von präoperativem aufwärmen auf die performance von unerfahrenen und erfahrenen chirurgen bei der laparoskopischen cholezystektomie das aufwärmen vor der eigentlichen tätigkeit gehört in vielen bereichen, etwa dem spitzensport oder der fliegerei, zur täglichen routine. wir haben die auswirkung von präoperativem aufwärmen an einem laparoskopie -simulator auf die operationsergebnisse bei einer laparoskopischen cholezystektomie, sowohl fü r junge als auch erfahrene chirurgen, untersucht. chirurgen ( mit über jähriger dienstzeit, am beginn ihrer ausbildung) führten jeweils cholezystektomien an einem tübinger boxtrainer, mit beziehungsweise ohne minütigen präoperativem aufwärmen an einem laparoskopie -simulator (lapsim, surgical science), durch. in das ergebnis flossen die operationszeit, die anzahl der instrumentenwechsel, die der leberschäden und jene der gallelecks ein. es zeigte sich, dass die jungen chirurgen bei allen parametern, bis auf die anzahl der instrumentenwechsel von präoperativem aufwärmen profitierten. bei den erfahrenen chirurgen hingegen zeigte sich ein anderes bild: sie benötigten zwar in beiden gruppen gleich lang, wechselten die instrumente gleich oft und es kam zu gleich vielen leberschäden, allerdings kam es in der gruppe mit präoperativem aufwärmen zu mehr gallelecks. präoperatives aufwärmen scheint einen positiven einfluss auf die operationsperfomance von jungen chirurgen zu haben. sie profitieren in hinblick auf die operationszeit, die anzahl von gallelecks und leberschäden. erfahrene chirurgen hingegen scheinen von präoperativem aufwärmen nicht zu profitieren. quality of life after sympathetic block at t for facial hyperhidrosis: results of a disease-specific evaluation background. endoscopic thoracic sympathectomy at the nd thoracic ganglion (t ) is the treatment of choice for patients with erythrophobia according to the lin telaranta classification. unfortunately, the incidence of compensatory sweating (cs) was reported to be higher in case of t sympathectomy. therefore, clip application (endoscopic sympathetic block, esb) has been introduced as it provides potential reversibility. the aim of the study was to analyze the outcome of patients treated by esb at t with special emphasis on the severity of cs. methods. between and patients (mean age ae years) prospectively underwent procedures. satisfaction rates and visual analogue scales (vas) from (no symptoms) to (maximal symptoms) have been evaluated. mean follow up was . ae . months obtainable from all patients. results. the preoperative vas scores ameliorated from . ae . to . ae . six weeks after operation and remained stable during follow up (p < . ). patients ( . %) were free of symptoms, ( . %) improved, whereas unchanged blushing was found in patients ( . %). cs was observed in patients ( . %) with a mean vas score of . ae . at follow up. twelve patients ( . %) rated cs as severe and another patients ( . %) as unbearable. two patients underwent clip removal with improvement of cs. overall, . % would recommend this surgical procedure. conclusions. esb at the nd ganglion presents satisfying postoperative results for the vast majority of erythrophobic patients. furthermore, clip removal offers reversibility of unbearable side effects as cs mainly embarrasses patients' quality of life and satisfaction. experiences of using v.a.c. in the treatment of a complicated, recurring fistula on the small intestine after severe peritonitis p. metzger, m. bergmann, p. herbst, h. rola, f. messenbäck schlussfolgerungen. da es kaum möglich ist unterschiedliche wunden miteinander zu vergleichen konnte kein signifikanter unterschied zwischen den einzelnen systemen gefunden werden. auch bei gleichartigen wunden, bei demselben patienten konnte kein wesentlicher vorteil eines spezifischen systems herausgearbeitet werden. die unterschiede beschränken sich somit auf bedienerfreundlichkeit, schmerzmanagement, patientenkomfort und auf die kostenfrage. background. around one percent of people in industrialised countries will suffer from a leg ulcer at some time. the majority of these leg ulcers are due to venous problems and are so called venous ulcers. the main treatment has been a firm compression and classical wound dressings. additional methods like vacuum assisted closure (v.a.c.) are established in the management of acute and chronic wounds. we report on a case where v.a.c. was used in a -years old female patient with severe sepsis. methods. the patient was transferred to our hospital with a haemorrhagic shock due to a bleeding of a giant septic venous leg ulcer. we performed haemostasis and initial necrectomy under high dose antibiotic therapy followed by two weeks v.a.c. therapy. in two consequent operations we performed mesh grafting of the defect. results. grafts showed complete take-rate. after a total stay of two months the patient was discharged from hospital in good condition and with totally healed ulcer. conclusions. v.a.c. therapy was rapidly efficacious in cleaning the wound, promoting angiogenesis and the formation of healthy tissue. negative-pressure wound treatment may accelerate closure of large leg wounds even in septic ulcers. a close monitoring in these patients is mandatory. in such situations v.a.c. can be seen as a salvage procedure to avoid amputation of the lower extremity and to maintain patients' quality of life. further reports in large series are necessary to confirm our results. schwerste arm-und brustbandphlegmone nach insektenstich: behandlungskonzept offene wundbehandlung nach eröffnung sämtlicher nervenengstellen und debridement der nekrotischen gewebe a. obiltschnig bei einem immunsupprimierten patienten kam es nach einem insektenstich am ellbogen zu einer massivsten rasch auftretenden phlegmone des gesamten arms und der brustwand. der patient wurde zur therapie ins zentralkrankenhaus eingeliefert. es hätte primär nur eine exarticulation im bereich des rechten schultergelenkes durchgeführt werden können. hier wäre die hautdeckung jedoch immens schwierig gewesen. aus diesem grund wurde primär eine ausgedehnte nekrektomie im bereich des gesamten armes durchgeführt. zusätzlich die eröffnung sämtlicher nervenengstellen in der höhe des handgelenkes, des ellbogengelenkes und in der axilla. postoperativ wurden die vitalparameter in der intensivstation überwacht und eine gezielte antibiose durchgeführt. mit unterstützenden hilfsmaßnahmen (niere, lunge) konnte eine normalisierung der entzündlichen parameter erreicht werden. die nachbehandlung der hand erfolgte offen. es erfolgten keine hauttransplantationen, sondern nur die offene wundbehandlung. mit dieser behandlung (waschung -lokalmaßnahmen) konnte ein völliger verschluss der wunde erreicht werden und es wurde auch die funktion der hand wiederhergestellt. anhand dieses fallbeispieles sollte eben die offene wundbehandlung bei infektionen auch mit eröffnung der nervenengstellen diskutiert werden. methods. a retrospective review was performed on patients, who suffered a bite injury during january to december . there were males and females, average age of . years (range - years). the most frequent site of injury were the face and the upper extremities, more than half of the victims were bitten by their pets. bite injuries ranged from relatively minor wounds to major injuries, that included open fractures, nerve and tendon laceration or loss of tissue. the incidence of dog-bites is higher in young children, involving the head, face or neck. in two-thirds of cat bites the upper extremities were effected, usually the hands and fingers. - % of human bite wounds, concerning the middle hand, resulted in an infection. details of their injury treatment and outcome were recorded. results. there were cases of primary infection within h after the bite injury and cases of delayed infection ( - h after bite injury). thirty-two patients required surgery like debridement of devitalized tissue to minimize the wound infection after thorough disinfection and intravenous antibiotic therapy. conclusions. the aim of immediate surgical repair is to obtain a satisfactory cosmetic result with a minimal risk of wound infection. antibiotic prophylaxis makes sense in immunsuprimized patients, children up to two years, bite injuries of the head, face, hands and fingers, and feet. background. we report on three diabetic foot patients suffering from verrucous skin lesions. all patients were suffering from neuropathy and other complications. in two patients partial forefoot amputation had been performed before, followed by split thickness skin grafting. one patient developed atypical malum perforans with verrucous surface with a pea-sized ulcer embedded in macerated horny material over the first metatarsal head. methods. in all three patients verrucous carcinoma of the skin was suspected. clinical findings showed slowly developing cauliflower-like warty tumours with deep sinuses and foul smelling thick greasy material. punch biopsies, respectively histological examination of derided tissue were performed. in all patients histological findings showed verrucous carcinoma. results. two patients were simultaneously suffering from deep neuropathic ulcers and underlying osteomyelitis requiring surgical intervention. transmetatarsal amputation was performed to heal osteomyelitis and to obtain a stable weightbearing foot stump. in one patient deep ulcer debridement was performed followed by offloading. healing was achieved in all patients. final histological findings showed pseudoepitheliomatous hyperplasia with focal papillomatosis according to papillomatosis cutis carcinoides, in case of diabetic neuropathy called vsldn (verrucous skin like lesions in diabetic neuropathy). conclusions. vsldn and diabetic foot ulcers are closely related in their aetiology and pathogenesis, whereas therapeutic strategy has not yet been established. in case of accompanying osteomyelitis required surgical procedure enables histological exclusion of verrucous carcinoma. in case of lacking surgical indication, offloading, professional foot care and compression to avoid friction is the main strategy for therapy and prevention of vsldn. survived suicide shooting through the cavities of pleura, pericard and peritoneum auch wenn die retrograde kontrastfüllung im ct nicht diagnostisch ist! die laparoskopie bietet sich sowohl diagnostisch wie therapeutisch an und ist möglicherweise dem offenen verfahren vorzuziehen. außergewöhnlicher fall eines dermatofibrosarcoma protuberans -ein fallbeispiel mit literaturübersicht grundlagen. das dermatofibrosarcoma protuberans (dfsp) ist ein mesenchymaler maligner tumor, der nur selten metastasiert und durch eine oftmals späte diagnosestellung und langsam infiltrativem wachstum gekennzeichnet ist. die resektion mit einem ungenü genden sicherheitsabstand resultiert in einem lokalrezidiv. berichte ü ber dfsp sind selten aufgrund der geringen inzidenz von weniger als . % aller malignome. in der vorliegenden arbeit wird die bedeutung eines ausreichenden sicherheitsabstands zur vermeidung eines lokalrezidivs aufgezeigt. methodik. ein -jähriger patient stellte sich mit einem an grösse zunehmenden knoten medial des linken schulterblattes vor. klinisch zeigte sich ein  cm großer, derber, subkutan liegender knoten, der gut verschieblich, leicht überwärmt und hämangiom-artig imponierte. ergebnisse. die klinischen befunde ergaben den verdacht auf ein atherom. daraufhin erfolgte eine spindelförmige exzision. intraoperativ präsentierte sich ein kugelig-glattes, prall-elastisches, gräuliches und hämorrhagisches gebilde. auf grund der für ein atherom untypischen befunde wurde eine histologische untersuchung veranlasst. diese zeigte ein unvollständig exzidiertes dfsp. es erfolgte die empfohlene nachresektion mit einem sicherheitsabstand von cm mit der histologischen dokumentation der radikalen exzision. im bisherigen verlauf keine hinweise auf ein lokalrezidiv. schlussfolgerungen. hinter der verdachtsdiagnose eines atheroms kann sich seltenerweise ein dfsp verstecken. die histologische untersuchung eines resektates mit ,,auffälligem'' aspekt ist ein chirurgischer grundsatz. nur so kann ein rezidivfreies Ü berleben erreicht werden und exzessive resektionen mit plastisch-chirurgischer deckung vermieden werden. hydrogen sulphide is a colourless, highly toxic, flammable and mucosal irritating gas which mainly originates during breakdown of organic matter in the absence of oxygen. after inhalation hydrogen sulphide binds to the mitochondrial respiratory enzyme preventing oxydative phosphorylation, thereby causing reversible inhibition of aerobic metabolism and cellular anoxia. the therapeutic use of hyperbaric oxygen for hydrogen sulphide intoxication is not standardised and its use is still controversial. victims of occupational hydrogen sulphide intoxication were referred to our centre between / and / . before admission, % oxygen had been was given by mask (n ¼ ) or by endo-tracheal tube (n ¼ ). two patients had been resuscitated at the site of the accident, in the six severe cases -dimethylaminophenol was administered as antidotal therapy. hyperbaric oxygenation was done immediately after admission in all patients by using the schedule otherwise applied in carbon monoxide-intoxication. out of patients ( . %) died of irreversible cerebral ischemia or pulmonary edema, respectively. the remaining patients recovered without any neurological sequelae and were discharged for outpatient care after a median of . days (range - days). no antidote-related adverse effects were observed. in hydrogen sulphide intoxication hyperbaric oxygenation ensures quick re-oxygenation and counteracts the decrement in oxygen carriage caused by methemoglobinemia due to antidoteadministration. in our experience, hyperbaric oxygenation alone or in combination with -dimethylaminophenol therapy proved a safe tool in the management of mild or severe hydrogen sulphide intoxication, respectively. influence of a new self-fixing hernia mesh on the ductus deferens in the rat model inferior vena cava-associated tumor lesionschallenging vascularsurgical management in a representative case series of patients methodik. anhand einer außergewöhnlichen kasuistik wird die seltene konstellation eines abdominalen fibromyxoiden sarkoms mit nicht vorbeschriebener manifestation im greisen lebensalter, wesentliche aspekte des perioperativen diagnostischen und therapeutischen managements dargestellt und ins verhältnis zu verfügbaren literaturangaben gesetzt. ergebnisse. eine -jährige multimorbide patientin fiel durch erhebliche obstipationneigung mit subileus auf (nebenerkrankungen: z.n. lungenembolie, diabetes, khk, hypertonie, beginnend dekompensierende chronische niereninsuffizienz). anamnestisch z.n. punktion unklarer lebertumorläsion jahre zuvor (histologie: sklerosiertes hämangiom)-klinisch monströse resistenz im mittelbauch. sonographie und ct: monströse teils zystisch, teils mit liquiden anteilen bzw. solide imponierende tumorläsion zwischen leber und magen ohne organzugehörigkeit; angiographisch keine pathologischen tumorgefäße (venöse abflussbehinderung). die transcutane fnp erbrachte keine diagnosesicherung. therapeutisch wurde eine tumorexstirpation in toto mit resektion des omentum majus und atypischer leberresektion im segment ausgeführt. nach histomorphologischem aspekt von leberkapsel ausgegangenes, niedrig malignes sarkom (durchmesser: cm; gewicht: , g). keine leberinfiltration, ü berwiegend myxoider background, spindelzellige, teils pleomorphe tumorzellen mit hyperchromasie, faseriges stroma (immunhistochemisch: glattmuskuläres aktin: þ; desmin/s /Ö strogen-und progesteronrezeptor/cd /cd /cd : negativ). lymphknoten tumorfrei. monate nach tumorresektion war kein tumorrezidiv zu verzeichnen. schlussfolgerungen. der bisher älteste berichtete patient ist jahre alt. der vorliegende fall steht also, insbesondere im hinblick auf das fortgeschrittene alter der patientin und die lokalisation eine ausgesprochene rarität dar. grundlagen. die elektrische impedanz-tomographie (eit) stellt eine nicht invasive methode zur darstellung der lokalen lungenventilation sowie der lungenwasserverteilung dar. intrapulmonale flüssigkeitsverschiebungen können beobachtet werden bei lageveränderungen des körpers oder als pathologische veränderungen wie sie zum beispiel im rahmen eines lungenödems auftreten. interessanterweise kann auch ein direkter einfuß der regionalen lungenventilation zur lage des körpers im raum dargestellt werden. weiters zeigten mehrere studien das lungenteile die unter einem höheren mechanischen stress stehen besser ventiliert werden als die restlichen lungenregionen. methodik. die messungen wurden an gesunden männlichen probanden durchgeführt mithilfe des ,,multichannel impedance spectroscope mxs (osypka medical gmbh). für die dauer der messung wurden die probanden in ein rotierendes bett (rotorest -kci austria gmbh)platziert mit einer kontinuierlichen rotationsgeschwindigkeit von annähernd pro minute. die messungen beinhalteten die waagrechte position sowie einen schwenk jeweils nach links und rechts und endeten wieder in der waagrechten für minuten. mittels image -rekonstruktion konnte der zeitpunkt der ventilation verschiedener areale dann bildlich dargestellt werden. ergebnisse. bei allen probanden konnte bewiesen werden das immer der mechanisch am stärksten belastete lungenabschnitt (linksrotation -linke lunge, rechtsrotation-rechte lunge, waagrechte -posteriore lungenabschnitte) bevorzugt ventiliert werden. schlussfolgerungen. die ergebnisse dieser studie zeigen das eit zukünftig als ausgezeichnete nicht invasive untersuchungsmethode zur beurteilung der lungenventilation dient. mögliche einsatzorte wären zum beispiel intensivstationen, wo auf relativ einfache weise der erfolg von kinetischen therapien verifiziert werden kann. background. lichtenstein hernioplasty is a very common technique for repairing an inguinal hernia and foreign body reaction after mesh implantation is a very rare complication. case report. a -year-old patient with an inguinal hernia came to our department. we did a lichtenstein hernia repair with a paritex polyester mesh ( . cm). five months later the patient came again because of right inguinal pain and swelling. ultrasonography and a ct-scan were done. it showed three liquid formations in the right inguinal region. blood test showed signs of a moderate inflamation, no feaver. we described antibiotics and nsar. a few days later we did a punction which showed pus. a reoperation was performed. an abscess formation subcutaneously was laid open. the smear culture was steril. during the first month post operation the patient felt well, but there was still serous secretion from a fistulous tract. two and a half months post operation an mri scan was performed which showed a abscess formation involving the inguinal canal. at re-operation we found serous fluid, an intact mesh surrounded by inflamated tissue. we removed the mesh, a bassini's procedure was performed and the patient got antibiotics. in the smear culture we couldn't find any microorganismus. histologically a chronic granulomatous foreign body reaction was found. the finding was a proof for a foreign body reaction. in the following controlls the patient didn't have any further problems. methods. we report on two patients, who developed massive postoperative pe and received sildenafil as an adjuct to thrombolytic therapy. results. the first patient underwent gastric wedge resection for a large perforated gastric ulcer after initiation of interferon/stroid therapy for multiple sclerosis. on the evening after discharge, she was admitted to the emergency room with acute dyspnea and cardiac failure and diagnosed with massive pe. she underwent mechanic-pharmacological clot fragmentation (angio-jet device in conjunction with tpa using the power pulse technique). on the intensive care unit, oral sildenafil was started ( mg twice daily), which resulted in significant improvement of right heart failure. the patient suffered renal and hepatic failure, however, ultimately recovered with restored organ function. she is well and alive after more than one year. the second patient developed acute pe four days after liver transplantation for primary biliary cirrhosis. she was treated with systemic thrombolysis. application of sildenafil resulted in significant improvement in cardiac output and right heart failure which caused congestion of the liver allograft. she later developed takotsubo cardiomyopathy and renal failure, however, recovered from these complications and is alive with good graft function after months. conclusions. although the two cases suggest that sildenafil may be a useful pharmacologic intervention in acute massive postoperative pe, a controlled trial is necssary to confirm our findings. chirurgische therapie des katamenialen pneumothorax w. kolb, r. kuster, w. nagel klinik für chirurgie, st. gallen, switzerland grundlagen. der katameniale pneumothorax ist eine seltene ursache eines spontanpneumothorax, der durch eine abdominale bzw. thorakale endometriose verursacht wird. methodik. wir berichten ü ber drei patientinnen, die aufgrund eines rezidivierenden mensassoziierten rechtsseitigen spontanpneumothorax an unserer klinik behandelt wurden. in der vergangenheit waren zwei patientinnen bereits thorakoskopisch mittels einer lungenspitzenwedgeresektion behandelt worden. aktuell erfolgte bei allen drei patientinnen zunächst eine diagnostische thorakoskopie zur diagnosesicherung. in allen fällen erfolgte bei ausgedehntem befall des zwerchfelles eine zwerchfellteilresektion ü ber eine rechtsseitige thorakotomie, in einem fall erfolgte die implantation eines kunststoffnetzes zur defektdeckung. die operationen verliefen durchwegs komplikationslos. histologisch konnte bei allen patientinnen anhand des operationspräparates die präoperativ gestellte diagnose eines katamenialen pneumothorax bestätigt werden. postoperativ wurde eine konservative therapie mit ovulationshemmern begonnen bzw. fortgesetzt. ergebnisse. im rahmen der nachbeobachtungszeit von nunmehr monaten ist bei einer patientin nach pausieren des ovulationshemmers ein neuerliches rezidiv eines spontanpneumothorax aufgetreten, welches durch einlage einer thoraxdrainage behandelt werden musste. die beiden anderen patientinnen sind beschwerde-und rezidivfrei. grundlagen. benigne fibröse tumore der pleura sind in der literatur kaum beschrieben. zu % gehen diese von der viszeralen pleura aus. methodik. an der abteilung für herz-thorax-und gefäßchirugie im lkh klagenfurt wurde ein jähriger männlicher patient aufgrund rezidivierender pleuraergüsse rechts bei bekanntem zwerchfellhochstand rechts vorgestellt. klinisch präsentierte sich der patient mit geringer dyspnoe (nyha ii) nach bereits erfolgten mehrmaligen pleurapunktionen, welche in der zytolgischen diagnostik keine besonderheiten zeigten. ein durchgeführtes pet ct ergab keinen keinen pathologischen fdg uptake, allerdings eine raumforderung beziehungsweise ein fragliches hämatom im bereich des rechten lungenunterlappens sowie den bekannten erguss. ergebnisse. zur weiteren abklärung führten wir eine videoassistierte thorakoskopie (vat) durch. nach endoskopischer absaugung der flüssigkeit konnte ein solitärer tumor, ausgehend vom rechten lungenunterlappen identifiziert werden. die resektion gestaltete sich technisch einfach. der pathologische befund zeigte einen fibrösen pleuratumor ohne malignität ausgehend von der pleura viszeralis mit einer größenausdehnung von , : , : , cm. schlussfolgerungen. benigne fibröse tumoren der pleura sind selten. eine chirurgische resektion sollte angestrebt werden, rezidive werden kaum beschrieben. indikation zur onkologischen resektion und lymphknotendissektion bei acthsezernierendem net der lunge grundlagen. nach histologischem nachweis eines acthexprimierenden malignen neuroendokrinen tumors mittels thorakoskopischer lungen-wedgeresektion wird die indikation zur onkologischen lungenresektion mit mediastinaler lymphadenektomie anhand eines fallberichtes diskutiert. ergebnisse. ein jähriger patient mit dem klassischen bild eines zentralen morbus cushing wies bei unauffälliger craniocerebraler magnetresonanztomographie in der thora-duced by pulmonary vascular endothelial cells, playing a role in the pathophysiology of pulmonary edema. whether pretransplant pulmonary tissue et- mrna could predict pgd in ltx is unknown. et- mrna expression was examined by real time rt-pcr in lung tissue biopsies of donors (mean age ae years) and recipients (mean age ae years) obtained shortly before ltx. the mean ischemic time of the graft was ae minutes. the underlying disease in recipients was chronic obstructive pulmonary disease (n ¼ ), cystic fibrosis (n ¼ ), emphysema (n ¼ ), primary pulmonary hypertension (n ¼ ) and retransplantation (n ¼ ). in % of patients, pgd was diagnosed and scored by oxygenation and radiological characteristics according to ishlt guidelines. expression levels of et- mrna were significantly increased in both donor (p < . ) and recipient (p < . ) tissue in the patient group developing pgd. moreover, donor and recipient et- gene expression correlated with the grading of pgd severity (r s ¼ . ; p < . ). neither pgd grade nor et- expression correlated to patient age or ischemia time of the graft. this study indicates for the first time that pre-transplant et- mrna overexpression in both donor and recipient mediates pgd development due to alteration of pulmonary vascular resistance and permeability. assessment of et- tissue gene expression is thus a sensitive and specific predictor of pgd in ltx and might be beneficial in donor selection and in the prophylactic treatment of recipients by using targeted et- antagonists. surgical closure of the asd was possible with near-normalized paps after ten months of ''conditioning'' medication with bosentan ( mg/day). the patient could be discharged from the hospital on post-operative day under ongoing bosentan treatment. eight months thereafter the patient was in good clinical condition with residual mild pulmonary hypertension. the traditional rule of inoperability of an asd with severe pulmonary hypertension was recently challenged by case reports where asd could be closed after long-time conditioning therapy with prostacycline. we now present a similar case treated with bosentan (an endothelin antagonist), which has several advantages compared to epoprostenol. because it is an oral drug, there are no complications related to an intravenous delivery system which are common under long-time prostaglandin therapy. we conclude that a pre-operative bosentan treatment of a patient with asd ii and severe pah is feasible and may allow surgical correction. lung compression and cardiac displacement resulting from the caved-in chest. in the second case, a -year-old woman that received chemotherapy for an aggressive undifferentiated tumor of the sarcoma group, infiltrating clavicle, humeroclavicular and acromial joints, was chosen for forequarter amputation with resection of thoracic wall. reconstruction also involved a myocutaneous armflap. in the third case, a -year-old woman with a chondrosarcoma of the sternum underwent a subtotal resection of the sternum. reconstruction was performed with an additional dualmesh. the fourth case is about a -year-old woman with a giant tumor of the thoracic wall (fibrosarcoma) treated with radiacal resection ( th to th rib) and a dualmesh patch. the use of the stratos tm system represents a safe and practical approach for the correction of chest wall deformities and the reconstruction of the chest wall after tumor removal. artery disease. the underlying mechanism remains largely unknown. methods. endothelial cells and fibroblasts were established from rat hearts. additionally h c -cardiomyocytes were used. a water bath was designed to avoid distracting physical effects. adherent cells in cell culture flasks filled with culture medium were dunked into the bath. sw ( . mj/mm ) were applied. analysis were performed over a period of days. results. sw stimulate every cardiac cell type to a different extent. each cell type reacts at another timepoint. the distance between applicator and cells, as well as the energy flux density have an influence on the cells' behaviour. between days and the duplication time of treated cells was significantly higher compared to controls. significant differences in the gene expression of mmps, timps and collagen were shown. treated cells do alter their cytoskeleton (vimentin, tubulin, beta-actin), show significantly more proliferation (ki- ) and changes in the expression of adhesion molecules (cd ) as well as connexins , , . no apoptosis was found in the treatment group. conclusions. sw activate proliferation of cardiac cells. moreover cells alter the assembly of microfilaments, thus seem to ameliorate cell migration. changes of the mmp and timp levels and the expression of adhesion molecules seem to be strongly involved in the sw tissue regenerative effect on ischemic myocardium. idiopathic dilated cardiomyopathy (dcm) is characterized by ventricular wall remodeling and an increased incidence of apoptosis. apollon is a member of the inhibitor of apoptosis protein (iap) family that promotes cell survival by ubiquitination facilitating the degradation of pro-apoptotic molecules. traf belongs to the tnf-receptor-associated family ubiquitinated by other iaps after pro-apoptotic stimuli. whether the apollon/ traf system may mediate programmed cell death in dcm is unknown. apollon and traf protein expression was examined in left ventricular biopsies of explanted failing hearts using western blotting in dcm patients and controls. human cardiac cells were transfected with a plasmid containing the human apollon cdna or control vector and were subsequently stressed by hypoxia. apollon and traf mrna expression was then measured in cell lysates by real time rt-pcr and tunel assays were used to determine the apoptotic index. in dcm myocardial tissue, apollon expression was downregulated and traf was upregulated compared to control hearts (p < . ). cell stress resulted in increased apoptosis in cardiac cells in vitro with downregulation of apollon and upregulation of traf mrna expression compared to control cells (p < . ). transfection with apollon increased apollon and decreased traf mrna expression in cell lysates (p < . ) and completely abolished hypoxia-induced apoptosis. these results suggest for the first time that apollon regulates the level of traf and that both apollon and traf are involved in the programmed cell death associated with dcm. upregulation of apollon with subsequent traf suppression might therefore constitute a novel strategy in dcm treatment. monalvenen durchgeführt. zur kontrolle des operationserfolges wurde zusätzlich ein permanenter loop-recorder medtronic reveal tm xt implantiert. ergebnisse. es konnten ganglien isoliert und selektiv abliert werden. postoperativ trat normofrequenter sinusrhythmus ein, ein postoperatives -stunden holter zeigte durchgehenden sinusrhythmus mit einer frequenz von - /min. bei den kontrollen nach und monaten ergab die abfrage des loop recorders einen stabilen permanenten sinusrhythmus ohne aufgezeichnete vorhofflimmerepisoden. schlussfolgerungen. die selektive isolation und ablation der autonomen ganglien im rahmen der vorhofablation bei vorhofflimmern kann zu einer verbesserung der operationserfolges führen, wobei bei unserem patienten die normale sinusknotenfunktion erhalten blieb. perioperative antibiotikaprohyplaxe bei herzchirurgischen eingriffendas erfolgreiche regime der grazer herzchirurgie grundlagen. weichteilinfektionen sind in der herzchirurgie eine bekannte komplikation. in der literatur kommt es in % zu oberflächlichen infektionen, in , % zu tiefen steruminfekten, in - % der fälle wird von postoperativer mediastinitis mit einer sternumdehiszenz berichtet. die mortalität bei den mediastinalen infektionen ist mit - % hoch, die kosten für patienten mit sternalen wundinfekten sind , mal so hoch wie für patienten mit unkompliziertem postoperativem verlauf. methodik. an der herzchirurgie graz wird seit folgendes antibiotisches regime angewendet: eine stunde präoperativ wird cefuroxim iv gegeben, unmittelbar vor hautschnitt teicoplanin, die zweite dosisgabe der beiden antibiotika erfolgt noch an der hlm. das cephalosporin wird für h postoperativ bei cabg verabreicht, bei klappenoperationen bis zum . postoperativen tag. die daten beziehen sich bis zur entlassung ins rehabilitationszentrum. bei langliegern werden antibiotika nur nach vorliegendem antibiogramm verabreicht. alle patienten werden präoperativ auf mrsa mittels nasenabstrich (positiv bei n ¼ ) gescreent. ergebnisse. kam es weder zu postoperativer mediastinitis noch zu chirurgisch behandlungsbedürftigen oberflächlichen sternalen wundinfekten, an der beinwunde war die inzidenz für weichteilinfekte , % (n ¼ ), bei diesen patienten wurden mit einem v.a.c.-system behandelt, in einem fall musste der defekt mit einer spalthaut gedeckt werden. in sechs fällen ( , %) wurde eine sterile sternumdehiszenz noch am tag der wundrevision recercliert. bei keinem patienten wissen wir von chronisch offenen wunden. die mortalität aufgrund von wundinfekten war %. schlussfolgerungen. nach jahren kam es nicht zu resistenzen. die rate an wundinfektionen ist erfreulich gering. unverständlicherweise kommt dieses grazer antiobiotische regime kaum zur anwendung. grundlagen. morbus castelman (angiofollikuläre lymphknotenhyperplasie) ist eine seltene erkrankung vornehmlich der cervikalen und mediastinalen lymphknoten. klinisch imponieren lymphknotenschwellung mit b-symptomatik, splenomegalie und hepatomegalie. die diagnosesicherung erfolgt durch biopsie. wir berichten über eine jährige patientin, welche nach vorangegangenem respiratorischen infekt akute hämoptysen und dyspnoe zeigte. bronchoskopisch fanden sich zeichen einer stattgehabten blutung. im labor waren leukozytose und crp erhöhung auffällig. methodik. im thorax ct fand sich eine ausgedehnte diffuse, tumoröse infiltration des oberen und mittleren mediastinums und beider hili mit umscheidung der supraaortalen Ä ste, der aorta ascendens, vena cava superior sowie der beiden vorhöfe. infolge völliger einmauerung des rechten pulmonalarterienhauptstammes bestand rechts keine perfusion. keine dieser strukturen zeigte eine speicherung im pet, nur an der mesenterialwurzel fand sich ein hypermetaboler herd. der versuch einer mediastinoskopie zur diagnosesicherung scheiterte an der fehlenden darstellbarkeit der strukturen im extrem derb-fibrotischen gewerbe. Ü ber thoracotomie gelang es aus einzelnen, in die fibrösen massen eingelagerten hilären lymphknoten eine diagnose zu stellen. ergebnisse. es fand sich die seltene, plasmazellreiche variante des mb. castleman mit ausgeprägter hyalinisierung und fibrosierung. diese form ist multifokal und zeigt verstärkte il expression und in deren folge unspezifische entzündungszeichen. eine koinfektion mit hhv bzw. mit hiv (in ca. % zu beobachten) konnte ausgeschlossen werden. schlussfolgerungen. durch die einleitung einer therapie mit einem monoklonalen chimären antikörper (rituximab; mabthera + ) wurden eine signifikante besserung der klinischen symptomatik sowie eine deutliche befundregredienz erreicht. germany ziel der untersuchung war es, machbarkeit, therapieergebnisse & ,outcome'' der endoskopischen papillektomie zu untersuchen. methodik. Ü ber einen definierten behandlungszeitraum wurden alle konsekutiven patienten mit tumor-ähnlichen papillenläsionen mit möglicher endoskopischer papillektomie in diese systematische klinische ,bicenter''-beobachtungsstudie einbezogen & in gruppen entsprechend des endoskopischen & eus-befundes sowie der pathohistologischen diagnose eingeteilt. machbarkeit & behandlungsergebnisse wurden durch r -resektionsrate, morbidität (z.b. rate/spektrum von komplikationen) & mortalität charakterisiert; outcome wurde durch rezidivrate & tumor-freies Ü berleben eingeschätzt jahre) eingeschlossen. vor der papillektomie wurde die eus in / ( , %; n ¼ ) der patienten durchgeführt gr. (karzinom/neuroendokriner tumor, n ¼ ): , % (n ¼ ) mit r -resektion gr. (adenomyomatosis, n ¼ ). gr. (nicht einführbarer katheter in die papille bei hochrisikopatienten mit papillenkarzinom jedoch ohne hinweise auf ein tief infiltrierendes tumorwachstum kann sie als sinnvolle therapieoption mit niedrigem risiko & einer ca. % -wahrscheinlichkeit hinsichtlich rezidivfreiheit angesehen werden, wenn r erreicht wird die toxizität des antikörpers (ak) unterscheidet sich von der traditionellen chemotherapie. eine zwar seltene aber schwerwiegende ak-spezifische komplikation ist die gastrointestinale (gi) perforation, die mit hoher morbidität/letalität einhergeht. das ziel bestand darin, an hand eigener exemplarischer und publizierter erfahrungen befund-bezogene besonderheiten dieser außergewöhnlichen pathogenese einer perforationsbedingten peritonitis nach ak-therapie einschließlich therapeutischem ,outcome'' darzustellen. methodik. es wurden patienten mit einer bevacizumab-induzierten perforationsbedingten peritonitis seit klinischer einführung (i) aus dem eigenen patientenklientel recherchiert (design: prospektive fallserie), (ii) literaturangaben gegenübergestellt (historische[retrospektive] vergleichsgruppe) und (iii) hinsichtlich der ergebnisse des chirurgischen managements frauen: n ¼ ; geschlechtsverhältnis: m:w ¼ : ). die durchschnittliche behandlungsdauer bis zum auftreten der komplikation betrug durchschnittlich d patienten verstarben ohne operative versorgung an den peritonitisfolgen. die perioperative gesamtmorbidität betrug , % (n ¼ / ) in allen fällen mit primärer anastomose (n ¼ ) trat im verlauf eine anastomoseninsuffizienz auf ( %). die rate der wundheilungsstörungen betrug die peritonitis nach gi-perforation infolge einer bevacizumab-therapie stellt eine seltene akassoziierte, aber ernstzunehmende, da lebensbedrohliche komplikation dar. die im zusammenhang mit der neoangiogeneseinhibition gestörte wundheilung bedingt abweichungen im management gi-perforationsereignisse im vergleich zur etablierten chirurgischen standardversorgung klinik für viszeral-, transplantations-und thoraxchirurgie das amelanotische melanom des rektums (amr) ist eine seltene erkrankung, dessen chirurgische therapie derzeit kontrovers diskutiert ist. die transrektale ultraschalldiagnostik (eus) besitzt in der diagnostik und nachsorge eine entscheidende bedeutung der literatur wurden innerhalb von jahren anhand von repräsentativen fallberichten für amr im rahmen einer klinischen bicenterbeobachtungsstudie zur qualitätssicherung in der rektumchirurgie wird über das therapeutische spektrum dieser seltenen befunde und maßnahmen in abhängigkeit vom individuellen verlauf berichtet die patientin verstarb jedoch monate nach der erstdiagnose. schlussfolgerungen. die prognose des amr ist unabhängig von der chirurgischen therapie schlecht. die lokale tumorresektion mit einem sicherheitsabstand von cm ist das primäre verfahren der wahl, die apr hingegen sollte den verbleibenden fällen vorbehalten bleiben severe facial hyperhidosis (fh) bothers patients' every day life and leads to human withdrawal and social phobia. the aim of the study was to assess pre-and postoperative quality of life (qol) using a disease-specific qol questionnaire after limited endoscopic thoracic sympathetic block at t (esb ) for fh. methods. fifty patients underwent esb procedures in a prospective study between and at a mean follow up of . ae . months. a validated disease-specific qol questionnaire by milanez de campos ( - ) and a visual analogue scale (vas; - ) concerning the extent of fh were evaluated by annual telephone calls ( : no symptoms; or : maximal symptoms). results. vas scores decreased from . ae . preoperatively to . ae . postoperatively and to . ae . at long term follow up (p < . ). patients ( %) were completely or almost dry postoperatively. side effects, such as compensatory sweating (cs) and gustatory sweating were each ae . at a year follow up (p < . ) endoscopic sympathetic block at t reduces fh efficiently and improves qol. cs impairs qol substantially emphasizing the importance of clip removal induce clip removal as final retreat strategy -cava-inferior(vci)-assoziierte tumorläsionen stellen eine außerordentliche herausforderung im interdisziplinären behandlungskonzept von viszeral gefäßwandinfiltration und (iii) intraluminalen tumorzapfen mit alteration des blutstroms im gefäßchirurgischen patientenklientel eines chirurgischen zentrums prospektiv erfasst und retrospektiv ausgewertet. ergebnisse. es wurden insgesamt patienten operativ behandelt: leiomyosarkome der vci ( , %), retroperitoneale tumore (seminommetastase, paraganglion; , %) als auch von außen infiltrierende tumore und cholangiozelluläres karzinom mit vci-adhäsion ( , %) und tumorzapfen ( , %; nierenzell-/ nebennierenrindenkarzinom). die tumorresektionsrate betrug %. op-technisch wurde die vci entweder ü ber die tumorbefallene strecke komplett durch eine gefäßprothese ersetzt, eine partielle wandresektion mit anschließender patchplastik, die tangentielle resektion mit primärer naht oder die ausschälung des cavathrombus nach cavotomie vorgenommen. die tumorzapfen wurden mit/ohne vci-resektion erfolgreich reseziert eine operation vci-assoziierter tumore ist nur bei aussichtsreicher r -resektion sinnvoll patients underwent -or -mm mechanical aortic valve replacement, receiving either a carbomedics top hat valve (n ¼ ; mean age, ae years) or a standard carbomedics one (n ¼ ; mean age, ae years) at our institution. median follow-up time was . months. we performed echocardiographic follow-up austria neben dem angeborenen av-block haben zunehmende fortschritte der herzchirurgie mit tendenz und notwendigkeit, immer komplexere operationen zu immer frü heren zeitpunkt auszufü hren, zwangsläufig zu einem gelegentlichen bedarf postoperativer schrittmacherimplantation im säuglingsalter gefü hrt angeborene herzfehler bestanden bei säuglingen und erforderten herzoperationen mit folgender, meist iatrogener rhythmusstörung bei allen säuglingen wurde der generator zunächst in einer submuskulären tasche des rechten mittel-oder unterbauches eingebracht, die elektroden entweder epikardial platziert oder über die rechte a. subclavia ( ) bzw. die a. jugularis ( ) eingebracht, in einem fall transatrial. im kollektiv mit angeborenem av-block gab es keine perioperativen todesfälle, bei angeborenem herzfehler sind patienten ( , %) verstorben: ein neugeborener mit g körpergewicht und komplexem syndrom nach verschluss eines ductus botalli und im insgesamt wurden bei diesen patienten bislang folgeeingriffe vorgenommen ( , /patient): vorrangig wachstumsbedingte anpassungen des systems sowie aufrüstung im betriebsmodus. die moderne schrittmacherchirurgie gewährleistet auch im neugeborenen-und säuglingsalter eine uneingeschränkte entwicklung mit hervorragender lebensqualität, nur durchbrochen von hauptsächlich wachstumsbedingt erforderlichen folgeeingriffen acknowledgments. this study was supported by mammamia. we also thank all experts and non-experts for their time-consuming subjective evaluation. methodik. der -jährige bechterew -patient wurde aufgrund einer perforierten sigmadivertikulitis mit stercoraler peritonitis notfalllaparotomiert, wobei eine stomasituation nach hartmann angelegt werden musste, sowie eine dünndarmteilresektion mit einem endständigen ileostoma erfolgte. es entwickelte sich eine stercorale peritonitis, welche mit einem ,,kci-v.a.c.-abdominaldressing'' im sinne eines laparostomas behandelt wurde. weiter entwickelte sich eine dünndarmfistel. nach frustranen reoperationsversuchen entschied man sich, die gegebene fistelsituation seitens des therapieansatzes als zweites stoma zu behandeln und arbeitete daher auf einen entsprechenden bauchdeckenverschluss hin.um eine schnellere abheilung zu erreichen, entschied man sich schließlich nach der v.a.c.-versorgung für eine defektdeckung mittels mesh-craft-transplantat. dieses konnte mittels v.a.c.-verband zum anheilen gebracht werden.nach klinischer stabilisierung erfolgte eine dünndarm-reanastomosierung. allerdings entwickelte sich in der folge erneut eine anastomoseninsuffizienz mit ausbildung einer dünndarmfistel. eine konservative verbandstechnik gestaltete sich in dieser situation als schlichtweg unmöglich. da aufgrund der vorgeschichte eine erneute spalthautdeckung der wieder klaffenden bauchwunde nicht möglich erschien, kam wieder eine versorgung mit einem v.a.c.-system zum einsatz.ergebnisse. die wundfläche konnte damit in wenigen wochen auf fast die hälfte reduziert und mittels stomaplatte versorgt werden. die verbandstechnik erlaubte es, dass durch eingeschultes pflegepersonal eine verbandsüberwachung und sogar neuanlage möglich wurde.schlussfolgerungen. die erreichten ergebnisse bei diesem primär lebensbedrohlichen krankheitsbild und der rezidivierenden entwicklung von dünndarmfisteln wären ohne innovative chirurgisch-pflegerische betreuung und der wochenlang durchgeführten v.a.c.-therapie wohl kaum zu erzielen gewesen, das verfahren konnte klar überzeugen. unterdrucktherapiebesteht ein qualitativer unterschied zwischen den verschiedenen systemen? tumor-induced bleeding by affection of the axillar artery due to recurrent tumor growth of breast carcinoma with successful endovascular treatment grundlagen. die tumor-induzierte blutung aus einem stammgefäß ist ein seltenes ereignis, kann jedoch lebensbedrohlich in erscheinung treten.methodik. es wird die suffiziente alternative option der blutstillung bei einem außergewöhnlichen casus mit fortgeschrittenem tumorleiden und infiltrationsbedingter blutung demonstriert, die kaum konventionell angehbar erschien.fallschilderung und therapieergebnis. eine -jährige patientin wurde mit hämorrhagischem schock intubiert und beatmet ü ber die rettungsstelle eingeliefert und reanimiert. in der anamnese war ein z.n. operativer spaltung eines schweißdrü senabszesses links-axillär vor jahr mit chronischer wundheilungsstörung (mikrobiologischer abstrich: gram-negative stäbchen, candida) bei inflammatorischem mamma-karzinom links (histologisch durch tumor-pe gesichert) und erfolgter palliativer strahlenchemotherapie bekannt. die sofortige notfallangiographie via a. femoralis sinistra erbrachte eine blutung aus dem proximalen segment der a. axillaris sinistra. in gleicher sitzung wurde interventionell-radiologisch ein selbstexpandierender endoluminaler stent (  mm viabahn + , gore, flagstaff, usa) ü ber die arterienläsion hinweg platziert, die eine umgehende suffiziente blutstillung erbrachte. die abschließende kontrollangiographie zeigte die korrekte stentlage mit sicherer peripherer perfusion im brachialen abstromgebiet ohne weiteren blutungsnachweis. am . postinterventionellen tag wurde die patientin nach zwischenzeitlicher antiseptischer wundpflege links-axillar entlassen.schlussfolgerungen. die endovaskuläre versorgung umgrenzter arterieller läsionen ist eine geeignete option, in schwierig zugänglichen arteriensegmenten aufgrund der anatomischen lokalisation, begleiterkrankungen und therapiekonsequenzen eine suffiziente blutstillung herbeizuführen und eine aufwändige, grundlagen. ,,omphalozele'' und ,,Ö sophagusatresie'' sind als einzelfehlbildungen häufig mit zusätzlichen malformationen vergesellschaftet. Ä ußerst selten ist das gleichzeitige vorkommen von omphalozele und Ö sophagusatresie, in der internationalen literatur sind nur einige wenige fallberichte zu finden.methodik. bei einem feten wurde sonographisch in der . ssw eine omphalozele diagnostiziert. die chromosomenanalyse (normaler weiblicher karyotyp) war unauffällig. das organscreening und die verlaufskontrollen ergaben keinen hinweis auf assoziierte fehlbildungen. bei der postpartalen untersuchung des neugeborenen war, abgesehen von der omphalozele und einem präaurikuläranhang rechts, klinisch und bildgebend keine zusätzliche malformation festzustellen. während der bauchwanddefektkorrektur kam es plötzlich zu beatmungsproblemen, zurückzuführen auf eine Ö sophagusatresie typ iii b nach vogt. nach anlage einer ,,schusterplastik'' wurde die tracheoösophageale fistel durchtrennt und, da das kind stabil blieb, eine endzu-end-Ö sophago-Ö sophagostomie angeschlossen.ergebnisse. der postoperative verlauf gestaltete sich, abgesehen von einer sich spontan schließenden leckage der Ö sophagusanastomose, komplikationslos. drei zusätzlich diagnostizierte kleine ventrikelseptumdefekte blieben asymptomatisch. das kind entwickelte sich in der folge aufgrund einer schweren schluckstörung allerdings nur bescheiden.diskussion. die intrauterine realisierung von mehrfachfehlbildungen ist schwierig. aber auch postpartal gelingt der nachweis einer fehlbildungskombination nicht immer. im seltenen fall kann eine gravierende fehlbildung gleichzeitig mit einer zweiten korrekturbedü rftigen, u.u. erst intraoperativ verifizierbaren anomalie vorkommen. die kombination von omphalozele und Ö sophagusatresie, einhergehend mit ventrikelseptumdefekten und einem präaurikuläranhang, ist ungewöhnlich und konnte keiner/m der in frage kommenden fehlbildungsassoziationen/-syndrome (vacterl-assoziation, charge-syndrom, schisis-assoziation) zugeordnet werden.schlussfolgerungen. wenn bei einem neugeborenen eine komplexe fehlbildungskombination zu keiner/m assoziation/ syndrom ,,paßt'', ist die prognoseeinschätzung in hinblick auf outcome und zukünftige entwicklung des betroffenen kindes schwierig. background. the prognosis of colorectal cancer is primarily determined by anatomic extend of disease and by amenability to radical resection. results of treatment in patients who underwent resection for colon and rectal cancer in two time periods were compared, before and after introduction of multidisciplinary tumor board in the second period. methods. in order to improve the results of colorectal cancer, a multidisciplinary tumor board was set up and beside the strict adoption of tme principles, an oncological treatment has been systematically included in the management. patients with colorectal cancer underwent a potentially curative resection between and . results were analyzed for two groups of patients given different diagnostic approach and treatment regimens during two consecutive year periods.results. the -year survival rate of r resected patients with colon cancer stage i and iii in the period - was significantly higher than of patients operated on between and (stage i: % vs. %; stage iii: % vs. %). similarly, the -year survival rate for r resected patients with stage iii rectal cancer between and was significantly better than that for patients operated on during the early period ( % vs. %).conclusions. patients who underwent r resection for colon and rectal cancer during the period - showed a significantly improved -year survival rate compared to those operated on between and . improved survival in these patients is to a great extent attributable to improvements in clinical practice combining surgery with other modalities of treatment. schlussfolgerungen. trotz der oft schwerwiegenden grunderkrankung der patienten und dem aggressiven infektionsmuster der zygomycosen und der daraus resultierenden schlechten prognose kann eine solche infektion bei chirurgischen handeln gepaart mit einer optimalen antimykotischen und intensivmedizinischen therapie überlebt werden. context. adipose tissue (at) macrophages are key suspects to cause obesity-associated insulin resistance. besides inflammatory mediators promoting insulin resistance, at macrophages express the hemoglobin scavenger receptor cd and the downstream enzyme heme oxygenase- (ho- ) that protect from free hemoglobin-induced oxidative stress and metabolize hemoglobin to anti-inflammatory mediators, respectively. background. aim of this study was to evaluate the association of cd and ho- expression in visceral and subcutaneous at with obesity, metabolic parameters, body fat distribution, and at inflammation.methods. morbidly obese patients (bmi > kg/m ) who underwent laparoscopic surgery for gastric banding (n ¼ ) were matched for age and sex to lean control subjects (bmi < kg/m; n ¼ ).main outcome measures. cd and ho- as well as the macrophage marker cd mrna expression was analyzed in visceral (omental) and subcutaneous at. moreover, serum concentration of soluble cd was determined by elisa.results. cd expression was highly upregulated in human at and soluble cd serum concentration was elevated in obesity. also ho- was upregulated in at and expressed exclusively in macrophages. while cd expression strictly correlated with macrophage abundance as assessed by cd expression, ho- upregulation by obesity exceeded the increase of cd , indicating a regulation within macrophages. strikingly, waist to hip ratio negatively correlated with relative visceral expression of ho- (p ¼ . ) and visceral ho- expression negatively correlated with homa-ir (p ¼ . ).conclusions. visceral ho- expression is determined by body fat distribution and attenuates obesity-induced insulin resistance. do we need to substitute vitamin b parenterally after gastric sleeve resection? background. daily oral multivitamin supplementation is recommended for patients after restrictive bariatric surgery, whereas after malabsorptive procedures or major gastric resections, parenteral substitution of vitamin b (vitb ) is mandatory.sleeve gastrectomy (sg), a mainly restrictive procedure, has been established in many bariatric surgical centers in the last few years, either as a definitive measure or as a first step before major malabsorptive procedures. the resected stomach volume has been reported between and ml. sg therefore amounts to a subtotal ( - %) gastrectomy.we analyzed serum values of vitb in order to assess the need for parenteral vitb supplementation in sg patients.methods. between jan. and aug. , patients ( females, males) underwent sg at our department. postoperatively, all patients were advised to take a multivitamin supplement daily. serum values of vitb were obtained after a median follow-up of months (range, . to months).results. fifty-two of patients displayed serum values of vitb within the normal range ( - pmol/l according to our laboratory). the median serum level of vitb was pmol/l (range, to pmol/l). neurological symptoms of vitb deficiency or macrocytosis were not observed.conclusions. vitb deficiency after sg is rare. on the other hand, the median serum level in our sg patients was far below the median laboratory value ( pmol/l), and eight values were within the so-called ''gray area'' ( - pmol/ l). this perhaps indicates incipient vitb deficiency and warrants further observation of rbc indices and serum vitb values in sg patients. grundlagen. die perforation der neoblase, nach zystektomie, ist selten. in der literatur sind solche spontanrupturen als einzelne case reports beschrieben. als ursache sind ischämien der neoblase oder mal-compliance des patienten bei der ,,blasenent-leerung'' zu nennen. in der vorliegenden arbeit wird erstmalig die laparoskopische neoblasen-Ü bernähung beschrieben. methodik. ein -jähriger patient, mit status nach zystektomie mit orthotoper anlage einer ,,ileumblase'' wegen rezidivierendem blasenkarzinom (t g ), präsentierte sich mit zunehmender dysurie, und fehlender vollständiger blasenentleerung. es zeigte sich bei der notfallaufnahme ein akutes abdomen, mit generalisierter peritonitis. in der computertomographie des abdomens fand sich freie flüssigkeit, jedoch keine freie luft und eine prall gefüllte ersatzblase. die katheterisierung der blase brachte keine beschwerdeverbesserung, auch war die retrograde füllung mit kontrastmittel nicht diagnostisch. laborchemisch bestand eine leukozytose von , g/l bei einem crp von mg/l.ergebnisse. in der notfallmäßig angeordneten diagnostischen laparoskopie zeigte sich im bereich des unterbauches freie flüssigkeit und fibrinauflagerungen im bereich der ersatzblase. nach füllen der neoblase mit ca. ml methylenblau konnte eine ,  , cm messende perforationsstelle, welche laparoskopisch übernäht werden konnte. der postoperative verlauf war unauffällig, entlassung des patienten mit klarer instruktion zur regelmässigen blasenentleerung nach tagen.schlussfolgerungen. das auftreten einer spontanruptur der neoblase ist selten. daran denken und die diagnose erzwingen background. posters are used widely at surgical meetings to present news of clinical and scientific research. posters are presented in special areas preferably at meeting points and provide a relaxed environment for exchanging ideas. especially for young scientists and surgeons poster presentations often are the first scientific contacts to the surgical community. many societies award ''best poster prices'' however mostly without uniformly agreed assessment methods. we generated poster assessment guidelines in a checklist to evaluate posters at surgical meetings.methods. according to well published guidelines for the designing and presentation of posters we constructed an evaluation checklist consisting of three main parts: presentation, design of the poster, background and purpose of the poster (scientific impact).results. the table shows our recommendation for the checklist in three parts.conclusions. awarding poster prices are stimuli especially for young scientists to participate at surgical conferences and meetings. however it can be very disappointing if great efforts have been applied to prepare posters and presentations and it is not possible to see through the evaluation process.therefore the evaluation process has to be objective as well as open and above board. the posters should be evaluated by independent scientist of different institutions. our assessment guidelines and checklist meet these mentioned requirements.an examination of the quality will show if this tool is applicable or not. background. complications after extensive thoracic surgery can be complex and life threatening, and diagnostic pathways are potentially difficult. we present the case of a years old patient who postoperatively developed an acute displacement of mediastinal structures by abdominal viscera after extrapleural pneumonectomy. methods. the patient was treated with extrapleural pneumonectomy in a curative intention. diaphragm was reconstructed with an artificial mesh implant after a major part of the diaphragm had to be resected. the mesh was fixed with interrupted non-absorbable sutures.results. due to failure of the diaphragmatic reconstruction and subsequent displacement of abdominal strucutes, acute displacement of the mediastinal structures occurred. initial x-ray led to the false diagnosis of suspected tension pneumothorax with a classical picture of mediastinal shift. the correct diagnosis was diagnosed by ct scan only. the treatment of choice therefore was operative revision and not the placement of a chest tube for decompression.conclusions. this rare but very dangeours complication after extensive cytoreductive surgery for malignant pleural mesothelioma is important to know for every general surgeon. interestingly the displaced stomach was massively bloated due to ''air trapment'', which led to the false diagnosis. only retrospectively, a very thin line in conventional x-ray was found being the stomach wall. in situations of postoperative impairment of a patient's condition after extensive thoracic surgery, we recommend to perform further diagnostic measures with early ct scan. in this situation placement of a chest tube would have been potentially harmful to the patient who recovered without further complication. erfolgreiche konservative therapie des postoperativen chylothoraxein klinischer algorithmus grundlagen. der chylothorax nach thorakalen chirurgischen eingriffen ist eine seltene aber wegen seiner metabolischen und nutritiven konsequenzen gefürchtete komplikation. die optimale therapie -konservativ versus operativ -wird kontrovers diskutiert. chirurgische reinterventionen sind häufig, neben dem nochmaligen operativen trauma und einer potentiellen versagensrate, mit einer erhöhten morbidität und mortalität assoziiert.methodik. alle konsekutiven patienten, die in unserer einrichtung während eines -jahreszeitraumes eine abdomino-thorakale Ö sophagusresektion wegen eines Ö sophaguskarzinoms erhielten, wurden in dieser studie prospektiv erfasst und im rahmen des internen qualitätsmanagements auf ihr komplikationsspektrum untersucht. bei diagnose eines postoperativen chylothorax' erfolgte primär die konservative therapie entsprechend eines an unserer einrichtung inaugurierten und etablierten therapiealgorithmus'.ergebnisse. von dezember bis november unterzogen sich patienten einer subtotalen Ö sophagusresektion wegen eines Ö sophaguskarzinoms. insgesamt drei patienten entwickelten einen postoperativen chylothorax, jeweils rechtsthorakal. dieser konnte nach klinischer und laborchemischer diagnosebestätigung (detektion von chylomikronen, triglyceridlevel > mg/dl) in allen fällen erfolgreich mittels ( ) totaler parenteraler ernährung, ( ) nahrungskarenz, ( ) pleuraler drainage sowie, ( ) subkutaner octreotidgabe, gefolgt von einer, ( ) speziellen oralen diät (mct-fette) therapiert werden. die mittlere behandlungsdauer dieser konservativen therapie betrug tage.schlussfolgerungen. beim vorliegen eines postoperativen chylothorax' sollte zunächst konservativen therapiemaßnahmen im stufenschema der unbedingte vorzug gegeben und diese ausgeschöpft werden. das chirurgische vorgehen hingegen ist frühzeitig bei versagen konservativer therapien sowie beim auftreten von komplikationen zu favorisieren. operability of advanced central lung tumors usually is limited and the prognosis is dismal. however, combination of chemoradio induction therapy owns the potential for significant downs taging of the tumor and can bring the patient back to operability, even in advanced tumor situations.we present the case of a years old patient with nsclc (t , n , m ; stage iiib) of the right upper lobe and infiltration of the carina. induction therapy with cycles of gemzar and cisplatin combined with gy local mediastinal radiation resulted in a major clinical response (yt , yn , m ; stage iib). this was followed by surgical resection (upper bi-lobectomy, resection of the carina, end to end anastomosis of the left main bronchus into the trachea, re-implantation of the right lower lobe into the left main bronchus; all performed under temporary ecmo support). pathological investigation revealed a complete response with no vital tumor cells left.this report demonstrates the potentials of modern combination therapy of extended lung tumors, emphasizing the value of aggressive induction therapy, followed by a technically demanding operation, in case of good clinical response. response to induction therapy, together with completeness of surgical resection, remains the most significant prognostic parameters for outcome.keywords. nsclc, carinal resection, ecmo, neoadjuvant chemo-radiotherapy, complete response. pulmonary benign metastasizing leiomyomatosis (bml) is a rare smooth muscle cell disorder of the lung. the prevailing treatment option is a primary excision of the nodules or if unresectable a long-time hormone therapy. herein, we present a case of bml in which a wait-and-see strategy after diagnosis has been decided.a -year-old female was admitted to the medical university of vienna presenting with multiple, bilateral suspect pulmonary tumor masses in . subsequent diagnostic workup revealed a bml. the patient refused a surgical intervention and hormone treatment was abandoned because of the patient's heavy menopausal disorders. as malign transformation of bml is uncommon a wait-and-see strategy was agreed upon. however, the patient was lost to follow-up, until in , years later, she developed expiratory rhonchus. a thoracic-ct revealed eleven intrapulmonary circumscribed circular foci. in addition the left lower-third was filled up with tumor mass and a giant cyst (diameter cm) extended into the thoracic cave. the nodules and the tumor mass were excised and the patient fully recovered without any evidence of a remaining disease. pulmonary bml nodules have been shown to stay constant for a long time. if resectable, a surgical excision is recommended as first line therapy. our case report indicates that a wait-and-see strategy is feasible but could lead to severe complications. we therefore conclude that a primary excision of bml tumor masses is preferable in order to avoid complications leading to more extended surgical interventions. background. pulmonary re-transplantation (prt) remains the only therapeutic option in some cases of severe primary graft dysfunction (pgd), advanced bronchiolitis obliterans sydrome (bos), and in some cases of severe airway problems (awp), mainly cicatriceal stenosis. however, its value has been questioned due to the overall scarcity of donor organs and reports indicating unsatisfactory outcome. we analyzed our institutional experience with prt to evaluate its value for different indications.methods. we retrospectively analyzed all patients undergoing prt in our department from august to august . we stratified patients according to indication for prt and analyzed the outcome.results. forty-six patients (mean age ae years, male and female) underwent prt ( bilateral lung-transplantations, single-lung-transplantations) for pgd (n ¼ ), bos (n ¼ ) and awp (n ¼ ). mean time to re-transplantation was ae days for pgd, , ae days for bos and ae days for awp. thirty-days, -year and -years survival rates after prt were . , . and . % for pgd; . , . and . % for bos. all patients with awp are presently alive (bos vs. pgd: p ¼ . ; bos vs. awp: p ¼ . ; pgd vs. awp: p ¼ . ). long-term survival rates for prt due to pgd are significantly lower, warranting restrictive use in this setting. in our experience prt for awp has shown excellent results.prt for chronic problems is a plausible approach, provided that patients are carefully selected. prt for pgd should be avoided.herzchirurgie /chirurgie der thorakalen aorta grundlagen. hämodynamisch wirksame stenosen der aorta, insbesondere am thorakoabdominellen Ü bergang sind eine seltene entität. Ü bliche behandlungsstrategie ist die konventionelle, chirurgische versorgung, neben der weiteren option einer axillo-bifemoralen bypassoperation. die endovaskuläre stent-graft insertion dient als behandlungmethode erster wahl für zahlreiche thorakale und abdominelle aortenpathologien. insbesondere bei älteren und multimorbiden patienten zeigt sie ihre vorteile.methodik. wir berichten von zwei patienten, die aufgrund von angina abdominalis, sowie claudicatio intermittens an unser zentrum transferiert wurden. in der computertomographie zeigte sich jeweils eine symptomatische stenose der aorta am thorakoabdominellen Ü bergang (,,coral-reef aorta''). aufgrund des hohen operationsrisikos, das sich insbesondere in den euroscores (numerisch bzw. ) zeigte, wurden beide patienten mittels transfemoraler, endovaskulärer stent-graft insertion versorgt.ergebnisse. beide patienten konnten wenige tage nach dem eingriff entlassen werden. die abschließenden kontrollen mittels computertomographie zeigten jeweils den stent-graft in korrekter position und voller entfaltung, sowie distal davon vollständig wiederhergestellte, antegrade perfusion. die patienten waren zu diesem zeitpunkt beschwerdefrei und zeigten auch in einer ct-kontrolle nach monaten keine veränderung dieser situation.schlussfolgerungen. gleich anderen aortenpathologien, wie perforierende ulcera, ist diese sogenannte korallenriffaorta das fortgeschrittene stadium eines obliterativen, atherosklerotischen chronisch-systemischen prozesses. gerade deshalb ist der allgemeinzustand dieser patienten meist sehr schlecht, weshalb minimal invasive therapieoptionen vorteilhaft erscheinen. obgleich wenig erfahrung mit der endovaskulären versorgung der aortenstenose am thorakoabdominellen Ü bergang existiert, könnte diese option zur behandlungsstrategie erster wahl werden, indem sie minimale invasivität mit maximaler effektivität vereint.paraplegia after thoracic surgery has been reported in the literature. the paraplegia rate after intrathoracic operations ranges between . and % overall. after vascular surgery for ruptured aneurysm of the thoracic aorta paraplegia has been reported up to %. however; this specific complication is greatly reduced for planned surgery ( . %). the thoracoabdominal approach for oesophageal resection is associated with a risk of . %. it is unclear, whether thoracotomy alone, regardless the extent of other surgical procedures bears a risk for paraplegia. the blood supply of the spinal cord in adult is highly variable. we report on a case of paraplegia after an uneventful thoracotomy in a year-old man. indication for surgery was an epiphrenic diverticulum of the oesophagus. paraplegia after thoracotomy is a rare but typical complication and should be mandatory included in informed consent. background. total supra-aortic rerouting as well as double vessel transposition followed by endovascular stent graft placement are now an established tool for the treatment of various aortic arch pathologies. however, details about the motion of the aortic arch after this procedure remain unknown. moreover, no perfectly fitting risk stratification score exists for outcome prediction of this specific patients.methods. we applied a fully automated method to quantify the deformation patterns of the aortic arch in a gated ct sequence. the aorta is detected and segmented by an active surface approach, that accurately identifies the vessel wall in all frames. the correspondences of landmarks on the vessel wall are established by tracking the deformation during the cardiac cycle, resulting in a dynamic deformation model of the structure.results. with help of this model, global and local deformation properties like stretching and bending were measured. after registering the models acquired pre-treatment, post-transposition, and post-stent-graft-placement we compared these local properties and were able to quantify the change caused to the aortic arch motion.conclusions. this new method of automated computational motion analysis of the aortic arch may establish a risk stratification score for outcome prediction after supra-aortic rerouting followed by endovascular stent-graft placement. background. simultaneous surgical repair and endovascular treatment are now a common approach for various aortic pathologies. for minimizing the risk of an untreated descending aorta after surgical repair of ascending aorta in acute stanford type a dissections a new type of bare-metal stents was established.methods. from august to january we performed combined surgical and endovascular treatment with the djumbodis dissection system in patients (mean age ) suffering from acute type a dissections.results. early results after treatment obtained by gated ct scans were satisfactory. nevertheless, thrombosis of the false lumen was not enhanced in most patients. combined surgical and endovascular approaches need stent devices with a self expanding capability, since the djumbodis stent seems to be not that attached to the aortic wall during systolic excursion.conclusions. additional implantation of the non-covered, non-self-expanding djumbodis device in the distal arch and the proximal descending aorta does in most cases not enhance thrombosis of the false lumen in patients undergoing surgery for acute type a dissections. the most limiting factor seems to be the non self-expanding capability of the device. the purpose of this study was to evaluate outcome in patients with a small aortic root receiving either a standard carbomedics or a top hat mechanical aortic valve. cox regression analysis revealed age, previous cardiac surgery, additional procedures at the time of valve replacement, nyha iv and severely impaired lvef to be independent predictors of survival.mechanical aortic valve replacement in the small aortic root is associated with substantial perioperative mortality. nevertheless, long-term outcome is satisfying. because the type of prosthesis does not predict outcome in the multivariate cox model, we conclude that use of the top hat prosthesis can be recommended for the challenging cohort of patients with a small aortic root. klinische abteilung für herz-thoraxchirurgie, wien, austria stumpfe thoraxtraumen können unabhängig vom unfallmechanismus und schweregrad des traumas zu mitralklappeninsuffizienz führen. die unterscheidung zwischen vorbestehender schädigung und traumatischer genese ist unter begutachtungsmedizinischen aspekten von großer bedeutung.kasuistik: ein jähriger gendarm wurde im rahmen einer Ü bung in knie-ellenbogen-position mit auf dem rü cken stehendem kollegen von einer mauer aus einer höhe von meter herab fallenden sandsäcken getroffen und erlitt ein hws-und bws-trauma. erst monate später wurde erstmalig ein herzultraschall durchgefü hrt und ein sehnenfadenabriss mit höhergradiger mitralinsuffizienz diagnostiziert und drei jahre nach dem trauma ein mechanischer herzklappenersatz vorgenommen.als häufigste ursache fü r eine posttraumatische insuffizienz der mitralklappe besteht ein papillarmuskel-abriss, seltener ein ausschließliches trauma der sehnenfäden. die literatur der jahre bis enthält berichtete fälle von isoliertem abriss von sehnenfäden mit höhergradiger mitralinsuffizienz, zwei davon als autoptische diagnose. das alter der in % männlichen betroffenen lag zwischen und jahren, im mittel , jahre. als unfallursache dominierten verkehrsunfälle unterschiedlicher art (n ¼ ; %) und in einzelfällen sturz aus meter höhe, gegen ein boot oder vom pferd sowie ein pferdetritt. das intervall zwischen ereignis und operativer versorgung durch rekonstruktion oder prothetischen ersatz lag zwischen tagen und jahren, in % ( von ) jedoch unter einem monat.die frage der ursächlichkeit ist meist retrospektiv zu beantworten. häufig sind fokussierte untersuchungsbefunde nicht verfügbar und bleibt die genese letztlich spekulativ. daher sollten nach jedem thoraxtrauma eine echokardiographie und anlässlich jeder herzoperation nach anamnestischem ereignis eine detaillierte makroskopische und histologische befundung durchgeführt werden. simultaneous mitral valve and lung surgery for complicated endocarditis and abscessing pneumonia over a thoracotomy approach a -year-old man developed severe sepsis after a blunt chest trauma. the patient suffered from presternal and cervical abscesses, mediastinitis, septic arthritis of the right shoulder, abscesses in the right and severe infective endocarditis of the mitral valve. after subcutaneous and mediastinal abscess drainage, hemodynamic stabilisation,and control of sepsis, biological mitral valve replacement and concomitant resection of the right lower pulmonary lobe were performed over a muscle sparing cm right anterior-lateral thoracotomy. restoration of the shoulder could be performed days later. the patient was discharged after weeks and is well one year after surgery. asd repair after a -month treatment with bosentan in a patient with severe pulmonary arterial hypertension large congenital type ii atrial septal defect (asd ii) can lead to precapillary pulmonary hypertension (pah) if not repaired in early childhood. once severe pulmonary hypertension or eisenmenger's syndrome have developed, asd closure is problematic due the increased risk of right ventricular failure and pulmonary hypertensive crisis. however, single case reports have demonstrated that a surgical correction of an asd is feasible, but requires long-time pre-and post-operative prostacycline treatment.we report the case of a patient with asd ii (  mm) and severe pulmonary hypertension (mpap mmhg). successful background. sternal wire fixation was first used in and since then was the preferred method for sternal closure, as it is inexpensive, fast and effective.however, as cardiac surgery patients get older and more debilitated, the risks of wire closure, namely breaking or cutting through porous bone often resulting in sternal nonunion and wound infection. therefore, alternatives are needed to ensure a reliable sternal closure.methods. during january to december a total of patients with am mean es of (mean age . years) underwent closure with the sternal talon. indication was copd and adipositas in patients each, delayed sternal closure in , parasternal sternotomy in and secondary closure after sternal wound infection and v.a.c. therapy in patients.results. all patients had combined procedures (cabgx and ake or mkr or both) with a mean operating time of min. the sternal talon was easy and convenient to use, with a mean implantation time of min. none of the patients developed a sternal nonunion or wound infection during follow up.conclusions. the sternal talon offers the advantage of a rigid sternal fixation without injuring the bone as it pulls the two sternum halves together, without cutting or screwing through the bone, thus preserving the bone integrity. full sternal closure is achieved in a minimum of time in contrast to other rigid fixation devices. through the non touch technique, patients experience less pain and can be mobilized in a shorter time. we want to share our experiences with the application of the stratos tm system (strasbourg thoracic osteosyntheses system) for the correction of chest wall deformities and reconstructive surgery of the chest wall after tumor removal.this system uses a titanium implant consisting of two adaptable rib clips and a length connecting bar.we will discuss one case of a benign condition and three cases of reconstructive surgery of the chest wall after radical resection of malignant tumors that were treated with the above described system. ergebnisse. im schnitt wurden , venensegmente bevorzugt vom oberschenkel entnommen.bei gleichzeitiger präparation der linken arterie mammaria tritt durch die endoskopische venenentnahme kein zeitverlust auf.in ( , %) fällen kam es zu einer verletzung der vsm. bei ( , %) patienten war eine konversion aufgrund einer starken blutung notwendig und bei eingriffen ( %) zusätzliche inzisionen.postoperativ beobachteten wir lediglich eine wundinfektion ( , %), welche mittels v.a.c. + system und anschließendem sekundärem wundverschluss behandelt wurde.schlussfolgerungen. die endoskopische entnahme der vsm ist eine sichere und mit weniger postoperativen komplikationen verbundene methode im vergleich zur konventionellen präparation.dies sollte einen routinemäßigen einsatz weiter fördern. prophylactic low-energy shock wave therapy improves wound healing after vein harvesting for coronary artery bypass graft surgery background. wound healing disorders after vein harvesting for cabg surgery increase morbidity and lower patient satisfaction. low-energy shock wave therapy (swt) reportedly improves healing of diabetic and vascular ulcers by overexpression of vascular endothelial growth fractor and downregulation of necrosis factor kappab. in this study, we investigate whether prophylactic low-energy swt improves wound healing after vein harvesting for coronary artery bypass graft surgery.methods. one hundred consecutive patients undergoing cabg surgery were randomly assigned to either prophylactic low-energy swt (n ¼ ) or control (n ¼ ). low-energy swt was applied to the site of vein harvesting after wound closure under sterile conditions using a commercially available swt system (dermagold; tissue regeneration technologies, woodstock, ga). a total of impulses ( . mj/mm( ); hz) were applied per centimeter wound length. wound healing was evaluated and quantified using the asepsis score.results. patient characteristics and operative data including wound length (swt ae cm versus control ae cm, p ¼ . ) were comparable between the two groups. we observed lower asepsis scores indicating improved wound healing in the swt group ( . ae . ) compared with the control group ( . ae . , p ¼ . ). interestingly, we observed a higher incidence of wound healing disorders necessitating antibiotic treatment in the control group ( %) as compared with the swt group ( %, p ¼ . ).conclusions. as shown in this prospective randomized study, prophylactic application of low-energy swt improves wound healing after vein harvesting for coronary artery bypass graft surgery. myocardial regeneration by shock wave therapyan in-vitro examination background. inflammation and thrombogenicity are important issues in cardiovascular tissue engineering. this in-vitro study was designed to investigate the influence of platelet alpha granule release on polymorphonuclear leukocytes (pmn) adhesion and activation on the decellularized porcine matrix.methods. cryostat sections of decellularized porcine heart valves were sequentially incubated with platelet-rich plasma (prp) and isolated, autologous pmn. to block -granule release platelets were pre-incubated with either cytochalasin d (cytd) or iso-butyl-methyl-xanthine (ibmx). to investigate the involvement of the complement system, specimens were exposed to prp that had been pre-incubated with mm edta. at the end of the incubations, specimens were fluorescently stained for cd , thrombospondin- (tsp- ), cd , cd b, and the complement factor ic b.results. laser scanning microscopy revealed the binding of multiple platelet aggregates to the decellularized porcine tissue surface. platelet adhesion was associated with up regulated expression of tsp- . pre-treatment of tissue specimens with prp induced a strongly enhanced binding and activation of subsequently added pmn. inhibition of platelet -granule release by either cytd or ibmx markedly reduced the secretion of tsp- correlating with a decreased pmn adhesion and cd b expression. although inhibition of complement activation by addition of edta to prp inhibited ic b deposition, it failed to prevent pmn binding.conclusions. the decellularized porcine heart valve matrix represents a high thrombogenic surface. activated platelets induce subsequently pmn adhesion and activation. the platelet/pmn interaction seems therefore to play a key role in the early, non-specific inflammatory response towards the decellularized xenogenic matrix independent from complement activation. acute cellular allograft rejection (acr) remains a significant problem in cardiac transplantation. calreticulin (crt) is a ca þ binding chaperone suppressing activity of the sarcoplasmic/endoplasmic reticulum ca þ -atpase (serca a) responsible for ca þ homeostasis in cardiac muscle. acr is associated with apoptosis and crt induces apoptosis in mature cardiomyocytes. whether myocardial crt expression plays a role in ca þ -dependent apoptosis in acr is unknown.crt and serca a mrna expression was quantified by real time rt-pcr in routine endomyocardial biopsies (embs) of transplanted patients (n ¼ ) at , , , , , , and weeks post-transplant and when clinically indicated. the apoptotsis was assessed in embs with tunel assays. graft rejection was histologically diagnosed and scored according to ishlt guidelines.myocardial mrna expression of crt was significantly increased (p < . ) while serca a mrna levels were decreased (p < . ) in acr grades r- r compared to embs with grade at all post-transplant weeks. moreover, crt mrna expression were significantly elevated in acr grades r- r compared to grade r (p < . ). in addition, significant positive correlation between increased crt expression (r s ¼ . ; p < . ) and negative correlation between decreased serca a (r s ¼ À . ; p ¼ . ) and the degree of emb apoptosis was observed.these results suggest that crt is involved in disruption of intracellular calcium regulation and mediates ca þ -dependent cellular apoptosis in cardiac grafts with acr. moreover, assessment of crt levels could be an accurate and quantitative method to diagnose and score acr. further studies are necessary to establish the benefit of targeting crt in the cardiac acr treatment. methodik. im tierexperiment wurde bei schafen am kardiopulmonalen bypass die aorta ascendens geklemmt und kristalloide kardioplegielösung infundiert. nach min wurde nachkardioplegiert. in der gruppe i (n ¼ ) wurde nadh zur kardioplegielösung beigegeben. in der kontrollgruppe (gruppe ii, n ¼ ) wurde kardioplegie ohne nadh zusatz verwendet. nach min wurde die aortenklemme geöffnet und das herz reperfundiert. nach einer reperfusionsphase von min und stabilisierung der hämodynamischen und elektrophysiologischen parameter wurde der kardiopulmonale bypass beendet. nach weiteren min wurden myokardstücke aus dem linken ventrikel entnommen und mit patch-clamp technik untersucht. weitere stücke wurden mit der gefrierzange entnommen und in flüssigem stickstoff bis zur weiteren analyse gelagert.ergebnisse. in gruppe i kam es zu einem signifikanten atp anstieg (p < , ) im vergleich zur kontrollgruppe. der unterschied an atp werten spiegelt eine verbesserung des metabolischen zustandes in der nadh gruppe wider. weiters wurde der ladungszustand der zellen, der den energiestatus repräsentiert, verbessert.schlussfolgerungen. nadh zusatz könnte durch seine positiven effekte auf den metabolismus in herzmuskelzellen ein potenter pharmakologischer und therapeutischer ansatz sein. isolation und selektive ablation von autonomen ganglienplexus bei linksatrialer vorhofablationcase report grundlagen. autonome ganglien-plexus haben als trigger einen einfluss auf die entstehung von vorhofflimmern. durch selektive ablation dieser ganglien im rahmen der pulmonalvenenisolation konnte gezeigt werden, dass der erfolg der ablation von % auf % zunimmt.methodik. bei einem -jährigen patienten wurde im rahmen der mitralklappenrekonstruktion wegen permanentem vorhofflimmern eine linksatriale vorhofablation mit medtronic cardioblate + maps durchgeführt. intraoperativ wurden die autonomen ganglien am rechten und linken atrium durch hochfrequenzstimulation am schlagenden herzen epikardial isoliert. als positive antwort wurde eine verlängerung der rr-intervalle um mindestens % gewertet. diese stelle wurde mit dem cardioblate + maps pen selektiv abliert. anschließend wurde am offenen herzen die endokardiale ablation mit isolation der pul- key: cord- -bl ahsxk authors: sarfo, anthony kwabena; karuppannan, shankar title: application of geospatial technologies in the covid- fight of ghana date: - - journal: trans indian natl doi: . /s - - - sha: doc_id: cord_uid: bl ahsxk the sars-cov- infections continue unabated in ghana and globally. the identification of country dynamics of the virus, its spread, and country-specific interventions in tackling the menace including the application of geospatial technologies. this research sought to highlight the use of geospatial technologies in the fight against covid- in ghana with best practices from china where the infections originated from; present the trends in ghana and model near future trends of the virus. it was evident that just as other places, ghana has employed geospatial technologies and continues to ply unchartered paths in solutions. the trend in ghana is in line with a population concentration and tends to record higher figures in the southern parts. it is modeled that through incessant mobility patterns, infections will spread through to the middle parts and then the northern parts. the research, therefore, recommends the use of infrared scanners to augment testing practices and enhanced tracing of infected persons as well as the use of drones for the distribution of essential services. later part of saw the development of one of the world pandemics, covid . the infection believed to have originated from a laboratory in the city of wuhan in december shereen et al. ) . a pathogen later identified as a novel beta-coronavirus ( -ncov) which was later renamed as sars-cov- ) affected thousands of people in china (provinces-guangdong, hubei, henan, zhejiang,among other towns and cities-shanghai and beijing) and traveled rampantly among other countries like japan, thailand, germany, republic of korea, united states, viet nam, and singapore. although coronaviruses are not new (sun et al. (gao et al. ) . indicatively, covid- affected people in just days as against times taken to affect the same figure by mers (two and half years) and sars ( months) (kamel boulos and geraghty ). consequently, the outbreak of new sars-cov- coronavirus was declared by world health organization as constituting a public health emergency of international concern (pheic) on january , (sohrabi et al. ; who ) . the rate of infection of covid- is unprecedented and the world is on uncharted paths. the coronavirus world meter (https ://www.world omete rs.info/coron aviru s/), as of may , , : gmt, reported that confirmed cases stood at , , with total global deaths and recoveries standing at , and , , respectively. active cases stood at , , with, % and % being in mild and serious/critical conditions. globally, it is the americas that have been presently greatly affected (fig. ) . africa has had its share of the global pandemic though the rate of infection is believed to be slower than other regions (world health organization ). nonetheless, africa, as at / / , : gmt, had recorded , cumulated cases ( . % global share), deaths ( . % global share) and , recoveries ( . % global share). more than half of the countries in africa had been hit by the covid- , with south africa being the most affected with , cases (the economist ). since it recorded its first covid- case on march (undp ghana a, b), ghana has seen a rise in confirmed cases from the country's capital, accra, and spread on wings of mobility to almost all parts of the country. protocols such as the washing of hands, observing social/ physical distancing, personal hygiene, and personal protective equipment have been subscribed to by the government and health services which, have been mainly observed by the general populace. with the incessant increase in the recorded cases, current and modeling of future trends are indispensable in understanding the concentration and the spread of the infection. the application of geographic information systems and remote sensing in tracking and combating contagion has been long-standing in literature since the early days of . although it was done through conventional mapping, the phenomenon was applied in italy for plague containment. throughout the times to around various mapping methods were applied to track and understand the spread of many infectious diseases including cholera, fever, and even the influenza pandemic. computerization of systems for geographic information in the s contributed to the possibilities to analyze, visualize and detect patterns of diseases which have heightened its usage such that out of papers published in health gis literature, ( . %) focused on mapping infectious diseases in a review conducted in (lyseen et al. ). since then, applied health geography, through web-based tools, has seen many revolutions (boulos et al. ; gong et al. ; tanser ) . in recent times, the quest to protect lives in epidemic times necessitates the ingestion of data from sources into such tools and the display of results in interactive and real or near real-time dashboards, which have become very useful means by which many governments display spatial specific information on the covid- . kamel boulos and geraghty ( ) revealed that china, as of january , relied on a dashboard developed by the johns hopkins university's center for systems science and engineering (jhu csse) based on esri arcgis online services and generated over million views. this indicates people's interest in tracking health threats which came quite handy for persons with internet access to have unfettered access to tremendous information about the covid- . subsequently, china adopted a device to support informed personal decisions about seeking medical treatment and self-quarantine. it was named close contact detector's platform/app co-launched by china electronics technology group corporation and china's national health commission. this app coupled with worldpop analyses aided in the mapping of mobility patterns and tracking of infected cases or pandemics, hence, giving credence to how powerful spatial analysis methods are in modeling the spread of disease, pattern detection, delineating and hotspots and determination of possible future occurrences (gardner ) . china has made various gis and remote sensing applications in the fight against covid- (kamel boulos and geraghty ). notable among them is the use of drones for critical medical supplies (huber ) , detection of outbreak source (yu et al. ) , disinfection (brickwood ) , and selection of appropriate sites for construction of health facilities (bbc news b). ghana, just like other african countries (e.g., nigeria), has implemented various gis and remote sensing methods to track, understand, and monitor covid cases. these measures and tools include dashboards, mobile app, and drones. first of all, ghana has used dashboards to present information and to show the trends of covid- in ghana. although there are many dashboards developed for the same purpose, two of these dashboards are paramount, and the other developers depend on these dashboards for data and figures based on which theirs is developed. these dashboards are that of the ghana statistical service and the ghana health service. the ghana statistical service dashboard, indicated as the "ghana covid monitoring dashboard" is made up of basically five panes. the cases pane presents data on the cumulative case count, the map pane indicating the spatial distribution of the cases on a map, the trend pane which presents trend analyses of cases (cumulated, active, recovered, and death), the news pane provides accesses on / / : gmt. https ://covid .who.int/?gclid =cjwkc ajwqp p brb teiwa fpid- qcjb dvfk f-dv cv odsoe wrz-nrlce - encv peki zufwj lswom hocns aqavd _bwe explanatory information of the cases reported and the health pane with information of health spot in the country (fig. ) . the second dashboard is that of the ghana health service. the dashboard, powered by sanbus geospatial limited, has four parts. the first part gives a regional breakdown of confirmed cases. the second part presents the aggregated figures for confirmed, recoveries, and death cases at the time of publication. the third part presents the spatial distribution of the confirmed cases on a choropleth map with data symbolized per category and given in proportional circles indicating the intensity of the phenomenon per each region. the fourth part gives information on covid- segregated into gender distribution (fig. ) . from the two dashboards, it can be teased out that, ghana's case of covid- stood at persons with recoveries and deaths. the confirmed cases consist of % of males and %. the gender disparity is in line with happenings globally and corroborates studies are done, suggesting that men are susceptible to covid- pandemics (ducharme ; jin et al. ). on the th of april, through the ministry of communication, ghana launched a mobile app called gh covid tracker (bbc news a). according to the ministry, the free to download mobile app intended to provide assistance and to varyingly augment the state's efforts to identify and trace persons who have come into contact with infected persons (ministry of communications ). it offered a platform for a personal assessment of conditions and gives results that influence decisions to seek medical care should the person be at a higher risk. the app was fashioned to aid early detection of the infection and had gps fitted into it to track movement and cases(yakubu ). drone technology and its remote sensing abilities make it useful in the areas of limited human interactions, appropriateness, and less time consuming (huber ) . drone technology has been adopted as part of measures ghana has put in place in the covid- fight. knott ( ) reports that, ghana was the first country in west africa to use drone technology in the fight against the pandemic. aside from drone's use for disinfection exercises at public places and institutions, the technology has been leveraged for rapid transport of critical items, personal protective equipment, and even the transportation of covid- samples to the testing centers (nunoo ; reuters ) . this has aided in the rapid testing of cases, tracing, and management of the situation and among the four top countries that have done more tests per population in africa (myjoyonline.com ) . although the use of geospatial technologies and measures has resulted in many good outcomes, more spatial analyses can be put in place to present the covid- pandemic spatially, hence indicating its distribution in the determination of future outcomes. this is the focus of the research. data used for this study are population and covid- data of ghana. population statistics population data, synthesized into regions, was derived from ghana statistical service (gss) as of c. regional outlines in shapefile were extracted land-use planning and management information system of land use and spatial planning authority. covid- data was added to the regional boundaries (in universal traverse mercator zone n) with the join table algorithm. covid- data presented and used for this paper was derived from many sources, including ghana health service, ghana statistical service, and the world health organization dashboards. this was to establish the consistencies in the data used. geospatial technologies presents varying means by which phenomenon is interpolated and presented for better understanding (bagyaraj et al. ; balamurugan et al. ; shankar and kawo ) . its application is in various fields and many human endeavors. although many interpolation options exist, in forecasting the possible trends in ghana situation, the universal kriging (linear with quadratic drift semivariogram model) and inverse distance weighted (idw) interpolation algorithm were used. childs ( ) and kawo and shankar ( ) reveals that kriging applies statistical interpolation, which makes it a powerful and effective option for diverse applications, including pollution modeling, geochemistry, and health. it works with the assumption that the direction and distance between sample points reflect spatial correlation, which is useful in the explanation of variation in the surface (shankar et al. ). there is a derivation of predictive values from the measure of relationships in samples using sophisticated weighted average techniques. using the universal kriging (linear with quadratic drift semivariogram model) enables the modeling of trends in data. the only possible shortfall with the use of kriging models is that point values are not specifically considered which will plausibly cause interpolated values to be lower or higher than real values. on the other hand, the inverse distance weighted interpolation algorithm assumes that for each input point, there exists a local influence that diminishes with distance. inferable, this method is applicable when there is an assumption that the data been modeled or phenomenon being studied and mapped decreases in influence as the distance from the core increases. specifically to the covid- , although inconclusive, many writers (e.g., loayza ) have identified a possible association of its spread to population densities and distribution. these characteristics identified the two interpolation techniques hence, make them appropriate for health modeling and its use in modeling covid- trends in ghana. the following sections present a picture of the pandemic situation in ghana, which has placed the debate on covid- within the context of the global and regional outlook, as well as data sources and methods. the ensuing section seeks to present three basic things; thus, the geographical context, current situation, and infection patterns and modeling of future occurrences and spatial dynamics. this study was carried out in ghana. ghana is part of the africa continent (west africa) and has a land area of , sq. kilometers (condit et al. ) . ghana is surrounded by togo, burkina faso, ivory coast, and the gulf of guinea with a heterogeneous population of about million as of . there are administrative regions in ghana, with the capital town being accra. accra and ashanti are the most populous regions due to the concentration of activities and infrastructure, while kumasi and accra enjoy urban primacy. immigration issues are on the rise, given the porous nature of the borders, the bilateral arrangements with neighboring countries, and the liberalization of trade. as a result, there has been an over-concentration of people, especially in the southern part of the country, resulting in high density and higher occupancy rates. due to this, greater accra and ashanti are the most populous regions, with two big cities (kumasi and accra) enjoying urban primacy (fig. ) . since ghana recorded its first case in early march, the rate and tempo of infection and transmission have been varying and moderate as compared to the global trend. in the early times of mass testing, periods between the first recorded case to st of march saw the number of infected cases rising from to (about . % increase). subsequently, the rate of release of information on infection affects the rate of infection. based on that, the rate has been erratic as, table reveals. nonetheless, the aggregate infection rate per the number of tests (general surveillance, enhanced contact tracing, and quarantined cases at tamale and accra) carried out from march to may totaling , persons, was . % (ghana statistical service ). comparing ghana's population and confirmed cases, it can be deduced that, . % of the ghana's population has been affected by the covid- . covid- induced deaths in ghana and rate is very low as compared to other regions. from th march to th may , ghana had recorded deaths attributed to covid- . the rate of increase for cases has been varying over the period and it is based on the release of information on infection by the appropriate ministries. nonetheless, the aggregate deaths are about . % of the reported cases, which is far less than that of china ( . %), usa ( . %), and the globe, which stands at . %. this in a wider array corroborates the mild impact of covid- in africa. as asserted by some studies (the economist ). explanatorily, recorded cases were as a result of underlying health and comorbidity conditions (such as hypertension, anemia, tuberculosis, diabetes mellitus, etc.) with about % being a person without any underlying health conditions. a major proportion is aged with few accounts of younger age as low as years and the highest being years (ghana health service ). recoveries increase astronomically hovering around persons as of th may. geographically, the spread of the pandemic in ghana has spatial connotations. from the table two major urban areas, kumasi and accra, and by far, ashanti and greater accra regions, have greatly affected and recorded higher figures. ashanti and greater accra regions have accumulated . % (greater accra- . %, ashanti- . %) of the reported cases the third highest hit region makes up just . % of the confirmed cases. comparing population distribution and covid- cases (fig. ) , there is seemingly a link in infection trends and the regional level of ghana's population distribution.. ghana is populous in the southern part of the country owing to the trend of development. on aggregate, areas such as greater accra, ashanti, and northern regions are the most populous. also, western, central, eastern, volta, and the upper east are second-most populous regions. these are followed by ahafo, oti, and upper west regions. the least populous regions are bono east, savannah, and north east. covid- cases reveal a similar trend. it can be deduced from fig. , that the impact of the infection is felt at populous areas in the country. at a glance, the greater accra and ashanti region has recorded many cases, which have transcended to the central and eastern regions. again, relatively fewer cases have been recorded in the other regions except for bono east, ahafo, and savannah regions with no cases as of th may . the situation and trends of infection can be associated with high dense, intense market activities and population concertation in these areas which makes observing social/physical distancing and other health protocols problematic. at large, corroborates the findings of many studies with evidence from china ( see barr and tassier ; fang and wahba ; florida ) such that population concentration areas contribute to the spread and intensity of covid- . prediction of possible trends and outcomes is indispensable for planning and to influence policy direction. therefore, the research seeks to use geospatial technology as a tool to predict possible spatial spread based on available data. the modeling was based on current covid- cases, population dynamics, mobility dynamics, and the attack rate. it is envisaged that greater accra and ashanti regions with higher attack rates will record higher numbers as compared to the other regions, all things being equal. as indicated in the previous section, the over million population of ghana is not evenly distributed. the distribution seen spatially to be clumped rather than random and influenced by migration issues, causing population concentration and higher densities in the southern part. the concentration will lead to further infections and transmission in the populous regions and be transmitted to other abutted regions (table ) . available data collected by vodafone ghana (based on origin-destination matrix -odm) on mobility patterns in ghana portrayed a relatively low movement of people between regions (fig. ) . data collected from april to may based on anonymized, aggregated data structure and produced by the count of subscribers' trips between any two localities indicated a negative trend implying a reduction in trips made during this period. the duration of data collected spanned from before covid- induced restriction was imposed in ghana, during the imposition and some few moments after the imposition. although these are data on movement, it is invariably associated with the possible movement of infected persons and inter-regional and community spread. vodafone subscribers constitute about % of telecommunication users in ghana as of (kuuire ) . the data was used based on its availability and the assumption that mobility patterns will not differ for other telecommunication networks in ghana, hence, it will not affect the outcome of the modeling. as indicated by fig. areas, travelers from accra (greater accra region), the first order and populous region disproportionately moved to central and eastern region. these are followed by regions such as ashanti, upper west, and western regions. relatively, lesser trips and movements were recorded in the savannah, oti, and northern regions. the trend for the ashanti region presents a no different scenario. people's movement was relatively low in the lockdown moment and during the lockdown but relatively increased times after the lockdown. there was a comparatively fair distribution of movement from the ashanti region to other regions. indicatively, from fig. , the majority of trips were made to the greater accra and central regions after the lockdown. these are followed by bono east, eastern, and ahafo regions. regions recording the least movement of people after the lockdown included volta, savannah, and northern regions. overall, aggregate data on mobility (fig. ) shows a concentrated movement in the southern part of the country with intensity spreading to the other regions. the trend will be influenced by migration issues to and from the infected regions. from the above-mentioned, the trend of the infections can be modeled in ghana. from fig. , the inverse distance weighted interpolation reveals a much concentration of cases in the southern part of ghana. greater accra and ashanti regions remain hot spots for the covid- cases, which will gradually extend to eastern, central, and volta regions as well as the upper part of the country. additionally, a modeled trend with the universal kriging interpolation reveals future occurrences in the covid- cases of ghana categorized into mainly into five. these are the highest risk areas, higher risk, high risk, low risk, and lower risk areas. greater accra, volta, central, eastern regions, and some part of western region lies in the highest risk zone. the higher risk areas comprise oti, ashanti, western, and some part of bono east regions. also, the high-risk areas include western north, bono, ahafo, bono east, and some parts of northern regions. savannah and northern regions constitute the low-risk areas with the lower risk areas being north east, upper west, and upper east regions. the study was set to tackle three primary objectives, thus, highlighting the application of geospatial technologies in the fight against covid- , present data and trends, and modeling of the possible future trend in the covid- cases in ghana. the study revealed that geospatial technologies are applicable in the fight against the global pandemic. many gis and remote sensing tools have been used in various endeavors, all of which contribute to efforts put in place to tackle the pandemic. moving from manually tracking cases, many countries, including ghana, have resulted in the use of dashboards, tracker apps, and uncrewed aerial vehicles to distribute personal protective equipment (ppes) and to enhance testing and trace and treatment of the covid- . may . the trend of infection has been likened to population concentration corroborating the assertion made by many writers. the tempo and trend of covid- were modeled using universal kriging and inverse distance weighted interpolation algorithms. the modeling was based on mobility dynamics, current covid- cases, population dynamics, and the rate of sars-cov infection in ghana. it was revealed that the covid- situation will be concentrated in the southern part of ghana and will extend from greater accra and ashanti regions to eastern, western, central, and volta regions. through issues of mobility patterns, the infections will extend to the middle belt of ghana then gradually to the northern part of the country. this finding is very instrumental and forms the basis for the allocation of resources to affected areas and devising of containment measures to reduce the rate of spread to the yet to be affected regions and possibly prevent spread. based on the aforementioned, the study advocates of continuous and innovative use of geospatial technologies in the fight against covid- . additional to the app and drones currently being used, the country can consider the use of infrared scanners of quick detection of infected persons in motion and even contact tracing. security agencies fig. regional level mobility patterns. adopted from vodafone ghana ( a, b) maintaining order in the communities can have these scanners as part of their gears or worn like spectacles. these can be done amidst the observance of the health protocols and adequate physical/social distancing to prevent infections from asymptomatic patients. detection of covid- cases early will enable prompt treatment, hence, averting fatalities. secondly, there should be readily available data in varying forms for further geospatial analyses to inform policy formulation and interventions. are crowded cities the reason for the covid- pandemic dataset on the suitability of groundwater for drinking and irrigation purposes in the adopted from vodafone ghana ( a, b) fig. future trends in covid- cases on ghana sarabanga river region distribution and trend analysis of covid- in india: geospatial approach coronavirus: ghana govment covid- tracker mobile app be solid tech intervention or needless app?-bbc news pidgin coronavirus: days of hospital building in seconds-bbc news. coronavirus: days of hospital building in seconds web gis in practice viii: html and the canvas element for interactive online mapping xag introduces drone disinfection operation to fight coronavirus outbreak. xag introduces drone disinfection operation to fight coronavirus outbreak animal movement in heterogeneous landscapes: an experiment with eleodes beetles in shortgrass prairie why is covid- striking men harder than women?|time urban density is not an enemy in the coronavirus fight: evidence from china what we know about density and covid- 's spread breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid- associated pneumonia in clinical studies modeling the spreading risk of -ncov ghana statistical service ( ) covid- updates|ghana real-time gis data model and sensor web service platform for environmental data management general aviation news: aviation international news gender differences in patients with covid- : focus on severity and mortality geographical tracking and mapping of coronavirus disease covid- /severe acute respiratory syndrome coronavirus (sars-cov- ) epidemic and associated events around the world: how st century gis technologies are supporting the global fight against outbr groundwater quality assessment using water quality index and gis technique in modjo river basin, central ethiopia ghana, drones help combat covid- timeline: battle of the ghana telecommunication companies-tech nova smart containment and mitigation measures to confront the covid- pandemic: tailoring the pandemic response to the realities of developing countries a review and framework for categorizing current research and development in health related geographical information systems (gis) studies ministry of communications ( ) launch of gh akufo-addo's claim that ghana leads covid- testing in africa is false.-french news agency (afp)-myjoyonline coronavirus tips: how ghana dey use drone technology fight covid- pandemic-bbc news pidgin reuters ( ) ghana turns to drones to enable faster coronavirus testing-reuters hydrogeochemistry of the paravanar river sub-basin groundwater quality assessment using geospatial techniques and wqi in north east of adama town covid- infection: origin, transmission, and characteristics of human coronaviruses world health organization declares global emergency: a review of the understanding of covid- based on current evidence the application of geographical information systems to infectious diseases and health systems in africa the smouldering pandemic-why covid- seems to spread more slowly in africa|middle east & africa|the economist mobility analysis to support the government of ghana in responding to the covid- outbreak insights into the effect of mobility restrictions in ghana using anonymised and aggregated mobile phone data overview who ( ) no title. covid- public health emergency of international concern (pheic) global research and innovation forum african countries move from covid- readiness to response as many confirm cases. regional office for africa the outbreak of covid- yakubu m ( ) gov't officially launches gh covid- tracker app decoding the evolution and transmissions of the novel pneumonia coronavirus (sars-cov- /hcov- ) using whole genomic data conflict of interest the authors declare no conflict of interest. key: cord- - v ku o authors: bellos, ioannis; pandita, aakash; panza, raffaella title: maternal and perinatal outcomes in pregnant women infected by sars-cov- : a meta-analysis date: - - journal: nan doi: . /j.ejogrb. . . sha: doc_id: cord_uid: v ku o evidence concerning coronavirus disease- (covid- ) in pregnancy is still scarce and scattered. this meta-analysis aims to evaluate maternal and neonatal outcomes in covid- pregnancies and identify factors associated with perinatal viral transmission. medline, scopus, central, web of science and google scholar databases were systematically searched to june . overall, observational studies and case reports/series were included. fever was the most frequent maternal symptom, followed by cough and shortness of breath, while about % of infected were asymptomatic. severe disease was estimated to occur in % of women in case reports/series and in % ( % ci: %- %) in observational studies. two maternal deaths were reported. the rate of neonatal transmission did not differ between women with and without severe disease (or: . , % ci: . - . ). preterm birth occurred in . % and % ( % ci: %- %) in data obtained from case series and observational studies, respectively. stillbirth occurred in cases and neonatal deaths were observed. vertical transmission was suspected in cases. fever was the most common neonatal symptom ( %), followed by shortness of breath ( %) and vomiting ( %), while % of neonates were totally asymptomatic. in conclusion, the maternal and neonatal clinical course the infection is typically mild, presenting low mortality rates. the risk of vertical transmission is suggested to be low and may not be affected by the severity of maternal disease. further large-scale studies are needed to clarify the risk factors associated with viral transmission and severe infection in the neonatal population. hubei region, canhina, in december [ ] . it is caused by the novel coronavirus sars-cov- (severe acute respiratory syndrome coronavirus ) which is a single-stranded rna virus, subgenus sarbecovirus of the genus betacoronavirus, probably originated from bats [ ] . covid- rapidly triggered a global health emergency alert and spread to numerous countries, causing the who to announce the start of a new pandemic on march [ ] . according to the th april who bulletin, confirmed cases and deaths have occurred globally so far [ ] . data concerning pregnant women and neonates is still scarce and scattered and evidence regarding management of pregnancy, delivery and neonates in case of suspected or confirmed covid- diagnosis in either the mother or the offspring remains fragmented [ , ] . to date, the incidence of covid- intended as a positive nasopharyngeal swab for sars-cov- in newborn babies is roughly . % [ ] and neonatal symptoms, such as mild respiratory distress and transient thrombocytopenia, seems mainly related to late prematurity or elective c-sections due to severe maternal conditions, rather than to the neonatal infection itself [ ] . although horizontal transmission seems predominant not only in adulthood but also in infancy and childhood, the shortage of data regarding pregnancies impede to draw conclusions about vertical transmission, which seems rare but still possible [ ] . the new challenge for obstetricians and neonatologists during the sars-cov- pandemic is to find a balance between implementing special measures to ensure the safety of both patients and healthcare providers and encouraging bonding and interaction between the newborn and the mother. moreover, some questions are still to be addressed, such as the effects of sars-cov- infection during the first trimester of pregnancy or the causes underlying the apparent lower incidence and severity of covid- in neonates born to affected mothers. the purpose of the present study is to systematically accumulate current literature knowledge in the field and evaluate maternal and perinatal outcomes among pregnant women infected by sars-cov- . in this line, this meta-analysis aims to shed light on the transmission pattern of the virus to neonates, as well as to clarify the disease course of covid- infection in this specific population. j o u r n a l p r e -p r o o f newborn"[mesh] or pregnan* or neonat* or infant* or newborn). no language restrictions were applied during literature search. the following data were planned to be extracted from each of the included studies: name of first author, country, maternal age, medical history (diabetes mellitus, hypothyroidism or polycystic ovary syndrome), symptoms (fever, cough, shortness of breath, diarrhea, nausea/vomiting, myalgia, fatigue, headache, sore throat, nasal congestion, abdominal pain, chest pain), radiological signs, presence of co-infection (bacterial or influenza), laboratory tests (lymphopenia, thrombocytopenia, increased creactive protein, procalcitonin, ferritin, liver function tests and d-dimers), type of treatment, pregnancy outcomes (fetal distress, premature rupture of membranes-prom, placenta previa, preeclampsia, preterm birth, cesarean section, stillbirth), maternal outcomes (admission to intensive care unit-icu or death), neonatal outcomes (gender, gestational age, birthweight, -minute/ -minute apgar score, horizontal/vertical transmission, admission to icu, mechanical ventilation, sepsis and death). observational studies of incidence data were evaluated by taking into account the following parameters: sample frame, representativeness and size, subjects and setting, coverage bias, classification bias, outcome measurement, statistical analysis and response rate [ ] . the quality of case reports and case series was assessed by judging the potential risk of bias concerning the domains of selection, ascertainment, causality and reporting [ ] . for each domain, "major concerns", "some concerns" or "no concerns" of bias risk were assigned independently by two researchers, while any disagreements were resolved by discussion with all authors. the pooled analysis was separately performed for case reports/series which provided individual participant data and observational studies reporting aggregate data. regarding the analysis of case reports/series, descriptive statistics were calculated and cases were categorized depending on the transmission of sars-cov- in neonates. subsequently, maternal characteristics and perinatal outcomes were compared between the two groups. continuous variables were expressed as median and interquartile range, while the mann-whitney u test was implemented to test differences in medians [ ] . the comparison of categorical variables was performed using the chi-squared or the j o u r n a l p r e -p r o o f fisher's exact test [ ] . multivariate logistic regression analysis was performed to assess the relative importance of maternal factors (country, age, comorbidities, symptoms and pregnancy complications) in the prediction of perinatal transmission. statistical significance was defined as p-value < . . missing data were treated by pair-wise deletion [ ] . pooling of observational studies was performed by proportion meta-analysis using a random-effects (dersimonian-laird) model [ ] . confidence intervals (ci) were set at %. inter-study heterogeneity was quantified by calculating the inconsistency index (i ), with values > % denoting significant heterogeneity [ ] . publication bias was assessed by the visual inspection of funnel plots and the potential presence of asymmetry was evaluated by the egger's regression test [ ] . the cutoff of p-value < . was used to define the significance of egger's regression test. in case of smallstudy effects suspicion, the trim-fill method was implemented to provide new estimates accounting for statistically imputed missing studies [ ] . meta-regression analysis was used to evaluate the potential influence of country (china vs. other). in case of statistically significant outcomes, subgroup analysis was performed to assess the exact effects of study country. statistical analysis was conducted in r- . . ("metafor" [ ] package). the outcomes of the literature search are schematically illustrated in figure . overall, , records were identified and , of them were initially screened after removal of duplicates. the majority of them were then excluded for not meeting the eligibility criteria and thus a cohort of articles was retrieved as full-texts. subsequently, studies [ ] [ ] [ ] [ ] were excluded, as studies examined infants and children but not neonates [ , ] , while another did not report any perinatal outcomes of pregnancies infected by sars-cov- [ , ] . as a result, the present meta-analysis was based on observational studies [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and case reports/series , including a total of neonates born to women with sars-cov- infection. characteristics and comorbidities. on the other hand, evaluation of observational studies raised concerns mainly in the domain of sample size, while moderate risk of classification bias may have arisen from studies defining sars-cov- infection based exclusively on clinical or radiological criteria. the maternal and perinatal outcomes of pregnancies infected by sars-cov- are presented in the majority of neonates were delivered by cesarean section ( . %), with preterm birth (< weeks) occurring in . % of cases. other pregnancy complications included premature rupture of membranes ( . %), fetal distress ( . %), preeclampsia ( . %) and placenta previa ( . %). moreover, women ( %) developed severe disease and were admitted to icu, while of them ( . %) eventually died ( table ). the median gestational age at delivery was weeks, while the median birthweight was estimated to be g with . % of neonates being small-for-gestational age. in addition, stillbirth occurred in cases and neonatal deaths were observed ( table ). both neonatal deaths occurred in sars-cov- -negative neonates that were born to mothers with severe disease requiring admission to the icu. transmission of sars-cov- was confirmed in cases. the maternal characteristics and perinatal outcomes were similar between pregnancies with and without viral transmission, with the exception of maternal hypothyroidism (odds ratio: . , % ci: . to . ). multivariate regression j o u r n a l p r e -p r o o f analysis indicated that hypothyroidism was the only factor associated with increased perinatal transmission (p-value: . ), while no association was found for maternal age, other comorbidities, symptoms or pregnancy complications. importantly, the rate of neonatal transmission did not differ between women admitted to the icu and those with the non-severe form of the disease (or: . , % ci: . to . ) ( table ) . vertical transmission was assumed to occur in cases [ , , [ ] [ ] table . fever was the most common symptom ( %), followed by shortness of breath ( %) and vomiting ( %), while % of neonates were totally asymptomatic. the outcomes of complete blood count were reported for cases; of them presented lymphopenia and another thrombocytopenia. moreover, two neonates needed mechanical ventilation, while another one received noninvasive positive pressure ventilation. neonatal sepsis occurred in two patients and one of them developed septic shock requiring inotropic support, although survived, was extubated and finally discharged. eleven observational studies were included, comprising neonates born to sars-cov- -positive women (appendix , suppl. table ). proportion meta-analysis indicated that the incidence of asymptomatic pregnant women was % ( % ci: - %), while fever was present in % ( % ci: % to %), cough in % ( % ci: % to %), shortness of breath in % ( % ci: % to %) and diarrhea in % ( % ci: % to %) of women. severe disease was estimated to occur in % ( % ci: % to %) of cases. the majority of neonates were delivered by cesarean section ( %, % ci: % to %), while the rate of preterm birth was calculated at % ( % ci: % to %) (appendix , suppl. figures - ) . inter-study heterogeneity was evaluated to be significant as i values ranged from % to . %, being highest in the outcomes of cough (i : . %) and cesarean section (i : . %). asymmetry of funnel plots was detected in the outcomes of asymptomatic disease (p-value= . ) and severe disease (p-value= . ) (appendix , suppl. figures - ) . the adjusted estimates according to the j o u r n a l p r e -p r o o f trim-fill method indicated similar rates of asymptomatic disease ( . %), but significantly lower incidence of severe disease ( . %) after accounting for potential missing studies. no fetal or neonatal deaths were reported by observational studies, while only cases of viral transmission were described by studies (suppl. table ). meta-regression analysis indicated that study country exerted significant effects on the outcomes of shortness of breath, severe disease and cesarean delivery (appendix , suppl. table ). specifically, the incidence of shortness of breath and severe disease was significantly lower in studies conducted in china ( . % vs. % and . % vs. . %, respectively). moreover, the rate of cesarean delivery was significantly higher in studies in china ( % vs. %). the outcomes of the meta-analysis of case reports/series compared to those of observational studies are depicted in figure . worldwide, sars-cov- is taking its toll on health systems and has caused hospitals and healthcare providers to rearrange facilities and habits to ensure the highest degree of safety to patients and workers. the shortage of data regarding covid- in the neonatal age represents a further challenge for obstetricians and neonatologists, who are called to face a rather unknown enemy. moreover, perinatal care to the mother-neonate dyad requires special considerations due to the peculiarity of their condition, since bonding and close interaction between the mother and her baby are crucial for their well-being. unfortunately, the paucity of supporting data impedes to draw conclusions at this point. to date, the vast majority of neonatal information is scattered and fragmented, since it is derived from case reports or small case series. to the best of our knowledge, the present meta-analysis is the largest one to date, providing pooled outcomes from observational studies and case reports/case series. the clinical course of covid- is typically mild during pregnancy, with % of infections being asymptomatic. the reported rates of severe disease were significantly higher in studies conducted in countries other than china, probably reflecting publication bias during the first wave of sars-cov- . the most common symptoms were fever and cough, followed by shortness of breath, while gastrointestinal symptoms were rare. radiological signs of pneumonia were almost ubiquitously present. cesarean section rates were high, mainly due to concerns about perinatal transmission. the incidence of preterm birth was remarkable ( . % in case reports - % in observational studies), although the risk of preeclampsia and placental previa were estimated to be low ( . % and . %, respectively). symptomatic patients with covid- are regarded as the main disseminators, but asymptomatic individuals should not be underestimated. the main transmission routes are droplets, contact, and aerosol transmission, although fecal-oral transmission should be also considered since sars-cov- rna has been detected in fecal samples. [ ] our results confirm that horizontal spread from caregivers (primarily the mother) to the neonate is the most likely way of transmission in this population. hence, it is recommended that in case of asymptomatic or mildly symptomatic sars-cov- positive mothers, general hygienic measures should be taken. specifically, the neonate's crib should be distanced from the mother's bed by at least two meters and the mother should wear a surgical face mask when breastfeeding or looking after the neonate. [ ] vertical spread remains doubtful, in keeping with the absence of reported cases of intrauterine transmission for sars-cov- and mers. [ ] vertical transmission was suspected in cases due to positive placental/amniotic fluid sars-cov- pcr testing or detection of neonatal igm antibodies against the virus shortly after delivery [ , , [ ] [ ] . alzamora et al. [ ] reported a severe presentation of maternal covid- during pregnancy, followed by the finding of positive rt-pcr in nasopharyngeal swab of the neonate at hours of life, despite immediate isolation from the mother. moreover, dong and coll. [ ] described the case of a newborn with early elevated igm antibodies to sars-cov- born to a mother with covid- . hypothyroidism was suggested as a potential predisposing factor for perinatal transmission. overall, six women with hypothyroidism were included and neonatal sars-cov- positivity was detected in of these cases. this association remained significant in multivariate regression analysis after taking into account the effects of country, maternal age, other comorbidities, symptoms and pregnancy complications. the increased incidence of neonatal transmission may be based on the effects of thyroid hormones on placental function and maturation since subclinical hypothyroidism has been linked to increased rates of placental abruption and preterm birth [ ] . in this context, thyroid hormones have been proposed to affect placental development by modulating inflammatory and apoptotic processes [ ] , especially by altering the placental immune profile and intrauterine trophoblast migration [ ] . nonetheless, whether the potential effects of thyroid dysfunction on placental barrier may facilitate vertical sars-cov- transmission remains to be elucidated by further studies in the field. nonetheless, the understanding of the mechanisms related to vertical transmission remains to be determined. one could speculate that vertical transmission is more likely in case of significant viral j o u r n a l p r e -p r o o f load in maternal samples, or critically-ill patients. however, there is currently no evidence to support any conclusion in this respect, while potential answers may be expected from the intercovid study group [ ] . the present findings suggest that the clinical presentation of covid- in neonates may range from asymptomatic to severe respiratory distress. the most common symptoms were fever and dyspnea, although gastrointestinal manifestations, such vomiting and milk refusal may occasionally be the only ones in neonates [ ] . sporadic cases of neonatal infections (pneumonia or sepsis) requiring mechanical ventilation have been also described [ , , ] , while zhu et al. [ ] reported on a latepreterm who died on the ninth day of life due to refractory shock, multiple organ failure, and disseminated intravascular coagulation. some laboratory findings, such as thrombocytopenia and lymphopenia, appear rather common in neonates born to covid- mothers, even when transmission to the offspring is not confirmed either on serology or nasopharyngeal swab; these findings have been proposed to resemble those of certain late-acquired torch (toxoplasmosis, other, rubella, cytomegalovirus, and herpes) infections and thus have prompted some authors to suggest the inclusion of sars-cov- among torch complex [ ] . since the beginning of covid- epidemic in china, in some cases, mothers with suspected or confirmed sars-cov- infections have undergone cesarean section in the absence of other obstetrical indications with the aim to reduce the odds of intrapartum transmission. [ ] notably, currently available case series show a higher than expected number of preterm deliveries and cesarean sections. according to our data, the rate of cesarean delivery was . % and % in case reports and observational studies, respectively. this can be in part explained as a consequence of obstetric decision to deliver due to the severity of the maternal infection (bilateral pneumonia with respiratory insufficiency and shock) [ ] . since cesarean deliveries entail the exposure of a greater number of health care workers compared with spontaneous vaginal delivery and are linked to an increase in neonatal morbidity, the decision to deliver via cesarean should be cautiously weighted. to date, clear findings on whether spontaneous vaginal delivery favors neonatal infection are lacking. hence, for the time being, the mode of delivery and anesthesia is best advisable as per maternal and fetal indications and spontaneous vaginal delivery should generally be preferred. [ ] j o u r n a l p r e -p r o o f whether skin-to-skin contact increases the risk of sars-cov- transmission is yet to be clarified [ , ] . it is advisable to share decision-making with the parents before delivery regarding the potential risks and benefits of skin-to-skin care and kangaroo mother care, taking into account also risks of exposure to both the neonate and to health care providers. [ ] delayed cord clamping is unlikely to increase the odds of vertical transmission, since the fetus has exchanged the same blood supply during the entire pregnancy. therefore, if vertical transmission was possible, it would probably have occurred before delivery. currently, there is no evidence supporting the abolishment of delayed cord clamping, which is still recommended in all vigorous neonates for at least seconds [ ] . despite some authors advocate for a cautious approach and recommend feeding preterm neonates on pasteurized breast milk (donor or maternal) or formula. [ ] however, according to the present findings, all breast milk samples have been tested to be negative for sars-cov- and thus breast milk of a covid- mother cannot be regarded as a transmission vehicle. moreover, similarly to the - sars-cov- epidemic, specific sars-cov- antibodies are likely to pass via the breast milk from the covid- mother to the infant within a few days after the onset of the disease, thus possibly modulating the clinical expression of the infant's infection [ ] . the present meta-analysis gathered all the available evidence in the field, by searching literature databases without applying any language restrictions. both case reports/series and observational studies were included and separately analyzed, providing a comprehensive approach concerning the perinatal effects of sars-cov- infection. specifically, analysis of case reports/series provided a cohort of neonates with individual participant data enabling the assessment of factors potentially associated with neonatal transmission of the virus. on the other hand, the present outcomes are limited by inconsistent reporting of important clinical and laboratory characteristics leading to missing data in several variables. moreover, inter-study heterogeneity of observational studies was estimated to be significant, reflecting potential methodological differences concerning patient selection and outcome reporting. the effects of study country was assessed by conducting metaregression analysis; importantly, studies conducted in china reported significantly higher incidence of cesarean delivery, reflecting the remarkable variance of labor protocols among different regions. in addition, inter-study heterogeneity may be present, as different periods of evaluation may be characterized by different treatment strategies due to the rapid change of policies regarding the management of the pandemic. it should be also noted that publication bias was suspected, especially regarding the outcome of severe maternal disease, implying that its incidence may be currently overestimated by the available studies in the field. many questions regarding the impact of the novel coronavirus sars-cov- are still to be addressed. firstly, the possibility of vertical transmission in utero or at birth should be clearly demonstrated, since the sporadic cases of positive nasopharyngeal swabs or igm testing in neonates might be due to pcr and elisa assay differences. greater reliability and reproducibility of assays used worldwide are strongly warranted. moreover, it is not clear whether a neonate with positive igm should be considered infected and, consequently, contagious even in case of negative nasopharyngeal swabs. secondly, data regarding sars-cov- infection during the first trimester and possible embryotoxicity are still completely lacking. in this respect, a deeper investigation regarding the capacity of sars-cov- to infect the placenta is also needed. in the present study, hypothyroidism was identified as a potential predisposing factor for perinatal transmission; however, the sample size was small and thus further research is warranted in order to reach firm conclusions about the causality of this relationship. lastly, preliminary evidence is reassuring about breastfeeding, however more confirmatory data are needed on breast milk and viral load. importantly, the implementation of pointof-care immune assays and virologic assays would help early identify infected but asymptomatic women who present in labor, aiming to improve perinatal management. maternal and neonatal covid- infection is linked to a variety of clinical manifestations, although asymptomatic and mild cases are most commonly seen during the third trimester. the incidence of neonatal transmission is suggested to be low and independent of maternal disease severity. currently, table . clinical characteristics of infected and non-infected neonates. table . clinical outcomes of neonates infected by sars-cov- . world health organization. who | pneumonia of unknown cause -china genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding world health organization. who announces covid- outbreak a pandemic world health organization. covid- situation reports covid during pregnancy: a systematic review of reported cases maternal and perinatal outcomes with covid- : a systematic review of pregnancies a systematic scoping review of covid- during pregnancy and childbirth breastfeeding and coronavirus disease- : ad interim indications of the italian society of neonatology endorsed by the union of european neonatal & perinatal societies novel coronavirus disease (covid- ) in newborns and infants: what we know so far the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data methodological quality and synthesis of case series and case reports testing for differences with the nonparametric mann-whitney u test statistical notes for clinical researchers: chi-squared test and fisher's exact test the prevention and handling of the missing data meta-analysis in clinical trials measuring inconsistency in metaanalyses bias in meta-analysis detected by a simple, graphical test the trim-and-fill method for publication bias conducting meta-analyses in r with the metafor package a pregnant woman with covid- in central america covid- : nine in pregnant women with infection when admitted for delivery are asymptomatic, small study finds detectable sars-cov- viral rna in feces of three children during recovery period of covid- pneumonia the first infant case of covid- acquired from a secondary transmission in vietnam a coefficient of agreement for nominal scales descriptive statistics and normality tests for statistical data management of traditional cardiovascular risk factors in ckd: what are the data? clinical characteristics and laboratory results of pregnant women with covid- in wuhan, china clinical course of coronavirus disease- in pregnancy characteristics and outcomes of pregnant women admitted to hospital with confirmed sars-cov- infection in uk: national population based cohort study clinical findings and disease severity in hospitalized pregnant women with coronavirus disease (covid- ) clinical characteristics of pregnant women with a sars-cov- infection in washington state the impact of sample non-normality on anova and alternative methods correlation coefficients: appropriate use and interpretation index for rating diagnostic tests chapter : definition, identification, and prediction of ckd progression chronic kidney disease annual data report: epidemiology of kidney disease in the united states diagnosis and management of atherosclerotic cardiovascular disease in chronic kidney disease: a review global prevalence of chronic kidney disease -a systematic review and meta-analysis clinical analysis of neonates born to mothers with -ncov pneumonia novel coronavirus infection in newborn babies under days in china unlikely sars-cov- vertical transmission from mother to child: a case report cesarean section in a pregnant woman with covid- : first case in portugal asymptomatic covid- infection in late pregnancy indicated no vertical transmission clinical manifestations and outcome of sars-cov- infection during pregnancy clinical characteristics of neonates born to mothers with covid- analysis of vaginal delivery outcomes among pregnant women in wuhan, china during the covid- pandemic lack of vertical transmission of severe acute respiratory syndrome coronavirus emergency cesarean section on severe acute respiratory syndrome coronavirus (sars-cov- ) confirmed patient association of covid- infection with pregnancy outcomes in healthcare workers and general women mortality of a pregnant patient diagnosed with covid- : a case report with clinical, radiological, and histopathological findings preterm delivery in pregnant woman with critical covid - pneumonia and vertical transmission prenat diagn :pd. lung ultrasound and computed tomographic findings in pregnant woman with covid - an uncomplicated delivery in a patient with covid- in the united states severe acute respiratory syndrome coronavirus (sars-cov- ) vertical transmission in neonates born to mothers with coronavirus disease (covid- ) pneumonia covid- in pregnancy with comorbidities: more liberal testing strategy is needed sars-cov- infection with gastrointestinal symptoms as the first manifestation in a neonate a case of neonatal coronavirus pneumonia mother's delivery of newborn dyspnea should we worry? clin infect dis possible vertical transmission of sars-cov- from an infected mother to her newborn late-onset neonatal sepsis in a patient with covid- clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records clinical features and obstetric and neonatal outcomes of pregnant patients with covid- in wuhan, china: a retrospective, single-centre, descriptive study infants born to mothers with a new coronavirus (covid- ) covid- in pregnancy: early lessons second-trimester miscarriage in a pregnant woman with sars-cov- infection severe covid- during pregnancy and possible vertical transmission novel coronavirus in a -day-old neonate with clinical signs of sepsis, a case report first case of neonate infected with novel coronavirus pneumonia in china death of a neonate born to a critically ill mother with covid- : a case report asymptomatic covid- infection in pregnant woman in the third trimester: a case report first case of neonate with covid- in china pregnant women with new coronavirus infection: a clinical characteristics and placental pathological analysis of three cases clinical characteristics and risk assessment of newborns born to mothers with covid- premature infant born to a convalescent mother with covid- in mid-term pregnancy primer caso de infección neonatal por sars-cov- en españa clinical analysis of ten pregnant women with covid- in wuhan, china: a retrospective study vaginal delivery after days of a pregnant woman diagnosed with covid- : a case report vaginal delivery report of a healthy neonate born to a convalescent mother with covid-- a case of novel coronavirus in a pregnant woman with preterm delivery coronavirus disease in china covid and acute coagulopathy in pregnancy managing covid- -positive maternal-infant dyads: an italian experience covid- -related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure la gestione del neonato con infezione sospetta o accertata da sars-cov coronaviruses -drug discovery and therapeutic options subclinical hypothyroidism and pregnancy outcomes biological functions of thyroid hormone in placenta maternal thyroid dysfunction affects placental profile of inflammatory mediators and the intrauterine trophoblast migration kinetics global study to assess the effects of covid- in pregnancy launched | university of oxford n neonatal early-onset infection with sars-cov- in neonates born to mothers with covid- in wuhan, china sars-cov- : is it the newest spark in the torch? neonatal resuscitation and postresuscitation care of infants born to mothers with suspected or confirmed sars-cov- infection of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected chinese expert consensus on the perinatal and neonatal management for the prevention and control of the novel coronavirus infection neonatal resuscitation where the mother has a suspected or confirmed novel coronavirus (sars-cov- ) infection: suggestion for a pragmatic action plan breastfeeding and coronavirus disease- : ad interim indications of the italian society of neonatology endorsed by the union of european neonatal &amp small-for-gestational age risk of bias evaluation of observational studies table . maternal characteristics of pregnancies infected by sars-cov- outcomes of meta-regression analysis regarding the effects of country (china vs. other) funnel plot regarding the outcome of asymptomatic pregnant women funnel plot regarding the outcome of fever funnel plot regarding the outcome of cough funnel plot regarding the outcome of shortness of breath. open circles indicate missing studies funnel plot regarding the outcome of diarrhea. open circles indicate missing studies funnel plot regarding the outcome of severe disease. open circles indicate missing studies funnel plot regarding the outcome of cesarean section all patients (n= ) key: cord- - b a cri authors: nan title: hematopoietic tumors date: - - journal: withrow & macewen's small animal clinical oncology doi: . /b - - . - sha: doc_id: cord_uid: b a cri nan the etiology of canine lymphoma is largely unknown and likely multifactorial; however, current investigations are shedding significant light on the subject. recent advances in molecular cytogenetics (see chapter , section a), including gene microarray techniques, have been and currently are being applied to investigations of chromosomal aberrations in dogs with lymphoma. [ ] [ ] [ ] breen's group has documented gain of canine chromosomes and and loss of chromosome as the most common aberrations in a group of cases analyzed. the recent publication of the canine genome and the commercial availability of canine gene microarrays (e.g., genechip canine genome . array; affymetrix santa clara, california) certainly will lead to advances in our understanding of the genetic events in lymphoma in the very near future. several genetic predispositions have been reported for a pedigree of bull mastiffs, a group of related otter hounds, a family of rottweilers, and a breeding pair of unrelated scottish terriers. germ line and somatic genetic mutation in the p tumor suppressor gene (see chapter ) and the n-ras gene have been documented in bull mastiffs and in a dog with lymphoma, respectively. [ ] [ ] [ ] in addition, differences in the prevalence of immunophenotypic subtypes of lymphoma among different breeds have been shown to indicate heritable risks. , b epigenetic modifications also have been investigated in dogs with lymphoma; deoxyribonucleic acid (dna) hypomethylation (see chapter , section a) was a feature of neoplastic cells in most lymphoma cases and in one third of the leukemia cases investigated and likely is involved in malignant transformation of lymphoid cells. in humans, characteristic chromosomal abnormalities are being described with increasing frequency as more precise banding and other high-resolution techniques are applied. chromosomal aberrations are nonrandom in human lymphoma, and several aberrations serve as markers for various subtypes of lymphoma. in addition, several oncogenes that may play a role in the pathogenesis of lymphoma have been detected based on the identification of cytogenetic abnormalities. [ ] [ ] [ ] chromosomal aberrations also have been reported in canine lymphoma. [ ] [ ] [ ] a study of dogs with lymphoma demonstrated a treatment advantage in dogs with trisomy of chromosome ( % of the dogs studied), as evidenced by an increase in duration of the first remission and overall survival time. as our knowledge of molecular events and tumorigenesis has expanded, several molecular aberrations have been implicated in various canine tumor types, and some associated with lymphoma have been identified. altered oncogene/tumor suppressor gene expression, epigenetic changes, signal transduction, and death-pathway alterations are common in human lymphomas and likely are also involved in the dog. as mentioned earlier, n-ras and p aberrations, although rare in dogs, have been implicated in some dogs with lymphoma. [ ] [ ] [ ] [ ] [ ] [ ] telomerase activity (see chapter , section d) also has been documented in canine lymphoma tissues. [ ] [ ] [ ] alterations in cellular death-pathways, particularly the bcl- family of proapoptotic and antiapoptotic governing molecules, have been implicated in human non-hodgkin's lymphoma and currently are under investigation in canine lymphoma. the hypothesis that a retrovirus may be involved in the pathogenesis of canine lymphoma has not been confirmed. however, viral particles with properties similar to those of retroviruses have been identified in short-term cultures of canine lymphoma tissue. [ ] [ ] [ ] [ ] in physician-based oncology, a direct association has been made between helicobacter infections and the development of gastric lymphoma. although this has not been shown definitively in dogs, evidence indicates that helicobacter infection in laboratory beagles results in gastric lymphoid follicle formation, which is considered a precursor of mucosa-associated lymphoid tissue (malt) lymphoma in humans. some evidence has accumulated that implicates phenoxyacetic acid herbicides, particularly , -dichlorophenoxyacetic acid ( , -d) , in the development of human non-hodgkin's lymphoma. , a population case control study of non-hodgkin's lymphoma in kansas farmers reported a twofold to sixfold higher risk in individuals who frequently mixed or applied herbicides (specifically , -d). a published, hospital-based case control study of dogs indicated that owners in households with dogs that developed malignant lymphoma applied , -d herbicides to their lawn or employed commercial lawn care companies to treat their yard more frequently than owners of dogs without lymphoma. the risk of canine lymphoma was reported to rise twofold (odds ratio, . ) with four or more yearly applications of , -d. the results of this study since have drawn criticism, and three follow-up investigations have not validated the assertion of increased risk. [ ] [ ] [ ] in another study, dogs exposed to lawn treatment within days of application were more than times more likely to have urine levels of , -d of µg/l or higher. the highest concentration was noted days after application. in a study of dogs with lymphoma, the tumors of dogs with known exposure to , -d were analyzed using polymerase chain reaction (pcr) technology for cellular n-ras oncogene mutations. the ras genes influence cell proliferation and may induce differentiation through signal transduction pathways. mutation in the ras genes results in ras proteins that promote cell growth. one dog in the series showed a mutation of n-ras, indicating that such mutations are uncommon in canine lymphoma, a finding similar to that for humans with lymphoma. in an environmental case control study performed in europe, two variables, residency in industrial areas and use of chemicals (defined as paints or solvents) by owners, modestly increased the risk of lymphoma; however, no link was found between the use of pesticides and risk. a weak association between lymphoma in dogs and exposure to strong magnetic fields was observed in a preliminary epidemiologic study. in this hospital-based, case control study, dogs categorized as having high or very high exposure had an increased risk of lymphoma (odds ratio, . ). more thorough studies are necessary to evaluate this association further. impaired immune function has been identified in dogs with lymphoma. , immune system alterations in the dog (e.g., immune-mediated thrombocytopenia), independent of age and gender, have been associated with a higher risk of subsequent development of lymphoma compared to the normal population. , additional evidence for the role of the immune system in the development of lymphoma comes from observation in human transplantation patients. individuals with immunosuppression have a higher risk of lymphoreticular cancer, , and organ transplant patients have a higher incidence of non-hodgkin's lymphoma. a case of lymphoma that developed in a dog after treatment with cyclosporine, although only one case, supports a link to immunosuppressive therapy in the species. the classification of malignant lymphoma in dogs can be distinguished on the basis of anatomic location, histologic criteria, and immunophenotypic characteristics. the most common anatomic forms of lymphoma, in order of decreasing prevalence, are the multicentric, craniomediastinal, gastrointestinal, and cutaneous forms. primary extranodal forms, which can occur in any location outside the lymphatic system, include the eyes, central nervous system (cns), bone, testes, bladder, heart, and nasal cavity. eighty percent of dogs with lymphoma develop the multicentric form, which is distinguished by the presence of superficial lymphadenopathy (figure - ) . lymph node enlargement usually is painless, rubbery, and discrete and may be localized initially to the mandibular and prescapular nodes. most animals are asymptomatic at the time of presentation, but approximately % to % have a history of weight loss, lethargy, anorexia, and febrile episodes. , diffuse pulmonary infiltration also may be seen in % to % of affected dogs, as detected by radiographic changes (figure - ). [ ] [ ] [ ] [ ] based on bronchoalveolar lavage, the actual incidence of lung involvement may be higher. , hepatosplenomegaly is the most common manifestation of abdominal involvement and usually is associated with an advanced stage of multicentric disease. the alimentary form of lymphoma is much less common, usually accounting for % to % of all canine lymphomas. this form is reported to be more common in male dogs than female dogs, similar to observations in humans. dogs with infiltrative disease of the intestinal tract show weight loss, anorexia, panhypoproteinemia, and evidence of malabsorption. , primary gastrointestinal (gi) lymphoma in dogs usually occurs multifocally and diffusely throughout the submucosa and lamina propria of the small intestine, with frequent superficial ulceration and occasional transmural infiltration of the serosa. lymphocytic-plasmacytic inflammation can be seen adjacent to or distant from the primary tumor. pathologically, some of these neoplasms may resemble plasma cell tumors, and aberrant production of immunoglobulins may occur. histopathologically, distinguishing between gastrointestinal lymphoma and lymphocytic-plasmacytic enteritis (lpe) can be difficult. some have suggested that lpe may be a prelymphomatous change in the gi tract. a syndrome of immunoproliferative intestinal disease characterized by lymphocytic-plasmacytic enteritis has been described in basenjis, which subsequently develop gastrointestinal lymphoma. in addition, plasma cell-rich areas with heterogeneous lymphomatous infiltration may resemble lesions of lpe. only a few reports specifically identify the immunophenotype of the lymphocyte subpopulations in alimentary lymphoma. historically, it was presumed that they most likely originate from b cells; however, recent evidence suggests that most gastrointestinal lymphomas in dogs originate from t cells. the boxer and shar-pei breeds appear to be overrepresented in alimentary lymphoma and are reported to have morphologic features (epitheliotropism) consistent with t-cell disease. lateral thoracic radiograph of a dog with diffuse interstitial infiltration with lymphoma secondary to multicentric lymphoma. the mediastinal form of lymphoma occurs in approximately % of cases. this form is characterized by enlargement of the craniomediastinal lymph nodes or the thymus, or both ( figure - ) . however, as previously noted, % of dogs with multicentric lymphoma have radiographic evidence of craniomediastinal lymphadenopathy. hypercalcemia is reported to occur in % to % of dogs with lymphoma and is most common with the mediastinal form. , in a study of dogs with lymphoma and hypercalcemia, ( %) had mediastinal lymphoma. the mediastinal form in dogs is most commonly associated with a t-cell phenotype. , cutaneous lymphoma can be solitary or more generalized and usually is classified as epitheliotropic (mycosis fungoides) or nonepitheliotropic. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] cutaneous lymphoma may also involve the oral mucosa, and extracutaneous involvement can occur, most often in the lymph nodes, spleen, liver, and bone marrow. canine epitheliotropic cutaneous lymphoma is the most common form of cutaneous lymphoma and usually originates from t cells, similar to its development in humans. in dogs the t cells are cd + cells, whereas in humans they are mostly cd + cells. a rare form of cutaneous t-cell lymphoma is characterized by generalized skin involvement with evidence of circulating malignant t cells in the peripheral blood. these lymphocytes usually are large ( to mm in diameter) and have folded, grooved nuclei. in humans this is called sézary syndrome, which also has been reported in dogs and cats. , , , b-cell cutaneous lymphomas usually spare the epidermis and papillary dermis and affect the middle and deep portions of the dermis. hepatosplenic lymphoma is a relatively uncommon, distinct presentation in the dog marked by a lack of peripheral lymphadenopathy in the face of hepatic, splenic, and bone marrow infiltration with malignant lymphocytes, usually of t-cell origin. biologically, this form of lymphoma is extremely aggressive and poorly responsive to therapy. in humans the tumor usually is composed of γδt cells (i.e., t cells that express the γδt-cell receptor), and this immunophenotype has been confirmed in at least one dog in the veterinary literature. [ ] [ ] [ ] intravascular (angiotrophic, angioendotheliomatosis) lymphoma is a distinct form of lymphoma defined as proliferations of neoplastic lymphocytes within the lumen and wall of blood vessels in the absence of a primary extravascular mass or leukemia. it has been reported several times in the veterinary literature, and in most cases it involves the central and peripheral nervous system (including the eye). [ ] [ ] [ ] [ ] [ ] [ ] the b-cell immunophenotype is most common in humans; however, in most reported cases in dogs, the origin is either t cell or null cell (neither b nor t cell), although one case of a b-cell phenotype has been reported. lymphomas arise from a clonal expansion of lymphoid cells with distinctive morphologic and immunophenotypic features. many histologic systems have been used to classify non-hodgkin's lymphoma (nhl) in humans, and some of these have been applied to lymphoma in the dog and other species. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the national cancer institute (nci) of working formulation and the updated kiel system have been adapted to canine tumors with some success (tables - and . the world health organization (who) also publishes a histologic classification scheme, which uses the revised european american lymphoma (real) system as a basis for defining histologic categories of hematopoietic tumors in domestic animals. this system incorporates both histologic and immunohistologic criteria (b-and t-cell immunophenotype). the clinical relevance of this system is likely to be high; however, it awaits further investigation. more recently, the oncology committee of the american college of veterinary pathologists (acvp) has established a lymphoma subcommittee to formulate a classification system for lymphoma that has clinical relevance. the subcommittee has obtained information from an international group of veterinary oncologists and pathologists, and its report is expected to be completed by . the working formulation (wf) was developed to allow investigators to "translate" among the numerous classification systems so that clinical trials could be compared in humans. most of the larger compilations agree that most canine lymphomas are intermediate or high grade; however, diffuse immunoblastic forms appear to predominate in the united states, whereas the follicular large cell variations predominate in europe. a comparison of european and american classifications is warranted based on this discrepancy. the wf categorizes tumors according to pattern (diffuse or follicular) and cell type (e.g., small cleaved cell, large cell, immunoblastic), but it does not include information about the immunophenotype of the tumor. the wf subtypes are related to the biology of the tumor and patient survival. the updated kiel classification includes the architectural pattern, morphology (centroblastic, centrocytic, or immunoblastic), and immunophenotype (b cell or t cell) of the tumor cells. in both systems, the tumors then can be categorized as low-grade, intermediate-grade, or high-grade malignancies. low-grade lymphomas composed of small cells with a low mitotic rate typically progress slowly and are associated with long survival times but are incurable. high-grade lymphomas with a high mitotic rate progress rapidly but are more likely to respond to chemotherapy and, in humans, are potentially curable. several features of canine lymphomas become apparent when the wf or updated kiel classification is applied. the most striking difference between canine and human lymphomas is the scarcity of follicular lymphomas in the dog. [ ] [ ] [ ] [ ] some diffuse lymphomas in the dog initially may be follicular, but these may progress to the more aggressive, diffuse form by the time of diagnostic biopsy. only a small percentage of canine lymphomas ( . % to %) are considered lowgrade tumors. , , , most low-grade small cell lymphomas are t cell in origin. high-grade lymphomas occur frequently if the diffuse large cell lymphomas, classified as intermediategrade in the wf, are considered high-grade, as in the updated kiel classification (in which they are labeled diffuse centroblastic lymphomas). canine lymphoblastic lymphomas are uncommon. , most high-grade lymphomas are of b-cell origin. however, a documented difference exists in the prevalence of the various lymphoma immunophenotypes based on breed. for example, cocker spaniels and doberman pinschers are more likely to develop b-cell lymphoma, boxers are more likely to have t-cell lymphoma, and golden retrievers appear to have an equal likelihood of b-and t-cell tumors. to be clinically useful, these classification systems in the end must yield information about response to therapy, maintenance of remission, and survival. some studies suggest that the subtypes in the wf can be correlated with survival, and the kiel system may be useful for predicting relapse. , in most studies, high-grade lymphomas show a complete response to chemotherapy significantly more often than low-grade tumors. however, dogs with low-grade tumors may live a long time without aggressive chemotherapy. dogs with t-cell lymphomas have shown a lower rate of complete response to chemotherapy and shorter remission and survival times than dogs with b-cell tumors. , , , furthermore, t-cell lymphomas tend to be associated with hypercalcemia. [ ] [ ] [ ] in the veterinary literature, % to % of lymphoma cases in dogs are b-cell lymphoma; t-cell lymphomas account for % to %; mixed b-and t-cell disease accounts for as many as %; and null cell tumors (i.e., neither b-cell nor t-cell immunoreactive) represent fewer than %.* the development of monoclonal antibodies to detect specific markers on canine lymphocytes has made immunophenotyping of tumors in dogs routinely available in many commercial laboratories. such techniques also can be performed on paraffin-embedded samples and on cytologic specimens obtained by fine-needle aspiration. [ ] [ ] [ ] [ ] [ ] the rappaport classification system, proposed in for human nhl, described the architectural pattern (follicular or diffuse) and the cytologic features (well differentiated, poorly differentiated, or histiocytic) of the tumors. , the term histiocytic was applied to tumors in which most of the lymphocytes had larger diameters, more vesicular nuclei, and more prominent nucleoli than those of lymphocytic or undifferentiated lymphomas; it also was used because the malignant cells have some morphologic features of benign histiocytes. however, immunophenotyping has failed to document a biologic relationship between these cells and true histiocytes, therefore the term now is largely considered a misnomer. furthermore, this subgroup of histiocytic lymphomas included tumors with different morphologic and immunophenotypic features. the rappaport classification has not been useful in providing prognostic information or in guiding therapy in dogs with lymphoma because of the low number of follicular tumors in dogs, the problematic "histiocytic" subgroup, and the failure to account for different morphologic and immunologic cell types. one criticism of these classification systems is that they fail to include extranodal lymphomas as a separate category. although differences between nodal and extranodal tumors in biologic behavior and prognosis are well recognized, comparative information about the histogenesis of these tumors has been lacking. for example, in humans, small cell lymphomas arising from malt are composed of cells with a different immunophenotype from that of other small cell lymphomas (i.e., malt lymphomas typically are negative for both cd and cd ). - except for cutaneous lymphoid neoplasms, detailed characterization of extranodal lymphomas in dogs has not been done. although cutaneous lymphoma is a heterogeneous group of neoplasms that includes an epitheliotropic form resembling mycosis fungoides and a nonepitheliotropic form, most cutaneous lymphomas have a t-cell phenotype. , to summarize, it is important to determine the histologic grade of canine lymphomas as low (small lymphocytic or centrocytic lymphomas) or intermediate to high (diffuse large cell, centroblastic, and immunoblastic lymphomas). furthermore, determining the immunophenotype of the tumor provides useful information. response rates to chemotherapy are better in animals with b-cell tumors and intermediate-to highgrade lymphomas. dogs with low-grade lymphomas can have long survival times without aggressive therapy. the clinical signs associated with canine lymphoma are variable and depend on the extent and location of the tumor. multicentric lymphoma is the most common form ( %), and generalized painless lymphadenopathy (see figure - ) is the most consistent finding. in addition, hepatosplenomegaly and bone marrow involvement are common. most dogs with multicentric lymphoma do not have dramatic signs of systemic illness (who substage a) (box - ), however, a large array of nonspecific signs can occur, such as anorexia, weight loss, vomiting, diarrhea, emaciation, ascites, dyspnea, polydipsia, polyuria, and fever (who substage b). , , [ ] [ ] [ ] dogs with t-cell lymphoma are more likely to have constitutional signs (i.e., substage b). polydipsia and polyuria are particularly evident in dogs with hypercalcemia of malignancy. dogs also may have a history of or clinical signs related to blood dyscrasias secondary to marked tumor infiltration of the bone marrow (myelophthisis) or paraneoplastic anemia, thrombocytopenia, or neutropenia. these signs could include fever, sepsis, anemia, and hemorrhage. dogs with gastrointestinal or alimentary lymphoma usually have nonspecific gi signs, such as vomiting, diarrhea, weight loss, and malabsorption. [ ] [ ] [ ] the mesenteric lymph nodes, spleen, and liver may be involved. the mediastinal form of lymphoma is characterized by enlargement of the craniomediastinal structures or thymus or both (see figure - , a), and clinical signs are associated with the extent of disease or polydipsia and polyuria from hypercalcemia. these patients commonly have respiratory distress caused by a space-occupying mass and pleural effusion, exercise intolerance, and possibly regurgitation. dogs with mediastinal lymphoma also may have precaval syndrome, characterized by pitting edema of the head, neck, and forelimbs secondary to tumor compression or invasion of the cranial vena cava (figure - ) . signs in dogs with extranodal lymphoma depend on the specific organ involved. cutaneous lymphoma usually is generalized or multifocal. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] tumors occur as nodules, plaques, ulcers, and erythremic or exfoliative dermatitis. epitheliotropic t-cell lymphoma (e.g., mycosis fungoides) has a chronic clinical course with three apparent clinical stages. initially, scaling, alopecia, and pruritus are seen ( figure - , a). as the disease progresses, the skin becomes more erythematous, thickened, ulcerated, and exudative. the final stage is characterized by proliferative plaques and nodules with progressive ulceration (figure - , b) . oral involvement also may occur, which can appear as multicentric, erythematous, plaquelike lesions or nodules on the gums and lips ( figure - , c). dogs with primary cns lymphoma may have either multifocal or solitary involvement. - seizures, paralysis, and paresis may be noted. ocular lymphoma is characterized by infiltration and thickening of the iris, uveitis, hypopyon, hyphema, posterior synechia, and glaucoma ( figure - ). in one study of cases of canine multicentric lymphoma, % had ocular changes consistent with lymphoma, and in a series of cases of uveitis in dogs, the condition occurred secondary to lymphoma in % of the cases. , anterior uveitis was most often seen in advanced stage disease (stage v). dogs with intravascular lymphoma usually have signs related to cns, peripheral nervous system (pns), or ocular involvement, [ ] [ ] [ ] [ ] [ ] [ ] including paraparesis, ataxia, hyperesthesia, seizures, blindness, lethargy, anorexia, weight loss, diarrhea, polyuria, polydipsia, and intermittent fever. dogs with pure hepatosplenic lymphoma usually have nonspecific signs such as lethargy, inappetence, and weakness. the differential diagnosis of lymphadenopathy depends on the dog's travel history (i.e., relative to infectious disease) and the size, consistency, and location of the affected lymph nodes. other causes of lymphadenopathy include bacterial and viral infections, parasites (toxoplasma and leishmania spp.), rickettsial organisms (salmon poisoning, ehrlichia sp.), and fungal agents (blastomyces and histoplasma spp.). the potential for hypercalcemia to accompany systemic hormone-like substance, parathyroid hormone-related peptide (pthrp), elaborated by neoplastic cells; however, it also can be related to the production of several other humoral factors, including interleukin- (il- ), tumor necrosis factor-alpha (tnf-α), transforming growth factor-beta (tgf-β), and vitamin d analogs (e.g., , -dihydroxyvitamin d). , - several investigators have reported that hypercalcemia in dogs with lymphoma is most commonly associated with t-cell lymphoma. , , , other paraneoplastic syndromes that may be encountered include monoclonal gammopathies, neuropathies, and cancer cachexia. , for most animals suspected of having lymphoma, the diagnostic evaluation should include a thorough physical examination; complete blood count (cbc) with a differential cell count, including a platelet count; serum biochemistry profile; and urinalysis. ultimately, obtaining tissue or cytologic specimens for a definitive diagnosis is essential. a thorough physical examination should include palpation of all assessable lymph nodes, including those palpable by rectal examination; in the authors' experience, a significant proportion of dogs have rectal polyps consisting of aggregates of neoplastic lymphocytes. the mucous membranes should be inspected for pallor, icterus, petechiae, and ulceration, because these signs may indicate anemia or thrombocytopenia secondary to myelophthisis or immune-mediated disease or may be evidence of major organ failure or uremia. abdominal palpation may reveal organomegaly, intestinal wall thickening, or mesenteric lymphadenopathy. thoracic auscultation may reveal the presence of a mediastinal mass or pleural effusion or both. an ocular examination that includes funduscopic assessment may reveal abnormalities such as uveitis, retinal hemorrhage, and ocular infiltration in approximately one third to one half of dogs with lymphoma. , complete blood count, biochemistry profile, and urinalysis anemia, the most common lymphoma-related hematologic abnormality, , usually is normochromic and normocytic (nonregenerative), consistent with anemia of chronic disease. however, hemolytic anemia may also occur, and regenerative anemias may reflect concomitant blood loss or hemolysis. in addition, if significant myelophthisis is present, the anemia may be accompanied by thrombocytopenia and leukopenia. in animals with anemia or evidence of bleeding, a reticulocyte count, platelet count, and coagulation studies also may be indicated. thrombocytopenia may be seen in % to % of cases, but bleeding is seldom a clinical problem. (i.e., stage v disease) from primary lymphoblastic leukemia (discussed later) is important, because the prognoses are entirely different. hypoproteinemia is observed more often in animals with alimentary lymphoma. if the dogs has a high total protein or evidence of an increased globulin fraction on a chemistry profile, serum proteins should be evaluated by serum electrophoresis. monoclonal gammopathies have been reported to occur in approximately % of dogs with lymphoma. serum biochemical abnormalities often reflect the anatomic site involved. in addition, approximately % of dogs with lymphoma are hypercalcemic ( % to % of those with mediastinal involvement and approximately % of those with t-cell lymphomas). , , in cases of hypercalcemia of unknown origin, lymphoma should always be considered high on the differential disease list, and diagnostics directed at this possibility should be undertaken (see chapter ) . the presence of hypercalcemia also can serve as a marker for response to therapy. elevations in serum urea nitrogen and creatinine can occur secondary to renal infiltration with tumor, hypercalcemic nephrosis, or prerenal azotemia from dehydration. increases in liver-specific enzyme activity or bilirubin concentrations may result from hepatic parenchymal infiltration. serum globulin elevations, usually monoclonal, occur infrequently with b-cell lymphoma. a urinalysis is part of the minimum database used to assess renal function and the urinary tract. for example, isosthenuria and proteinuria in the absence of an active sediment may indicate renal disease, and hematuria may result from a hemostatic abnormality. it is important to remember that isosthenuria in azotemic dogs with hypercalcemia does not necessarily indicate renal disease, because the high calcium levels interfere with tubular concentration capabilities through disruption of antidiuretic hormone (adh) control. abnormalities in serum levels of alpha fetoprotein, alpha- glycoprotein, zinc, chromium, iron, and endostatin also have been investigated in dogs with lymphoma. [ ] [ ] [ ] [ ] the clinical and biologic significance of these alterations has yet to be elucidated. morphologic examination of the tissue and cells that comprise the tumor is essential to the diagnosis of lymphoma. care should be taken to avoid lymph nodes from reactive areas (e.g., mandibular lymph nodes); the prescapular or popliteal lymph nodes are preferable. also, lymphoid cells are fragile, and in preparing smears of aspirated material, only gentle pressure should be applied in spreading the material on the slides. in most cases, a diagnosis of lymphoma can be made on evaluation of fine-needle aspirates of affected lymph nodes or other tissues. typically, most of the cells are large lymphoid cells (larger than neutrophils), and they may have visible nucleoli and basophilic cytoplasm ( figure - , a) or fine chromatin with indistinct nucleoli. because tissue architecture is not maintained in cytologic specimens, effacement of the lymph node or capsular disruption cannot be detected. therefore, marked reactive hyperplasia characterized by increased numbers of large lymphoid cells may be difficult to distinguish from lymphoma, and small cell lymphomas may have few cytologic clues that point to their malignancy. also, classification of lymphoma into the subcategories that comprise the low-, intermediate-, and high-grade forms, which has been attempted using the cytologic appearance and immunophenotypic analysis, is performed most accurately on histologic sections. for accurate histopathologic evaluation, an entire lymph node, including the capsule, should be removed, placed in buffered formalin, and submitted to a pathologist. although needle core biopsies may be satisfactory, it is important to avoid crush artifact or inadequate sample size. most pathologists prefer whole node biopsies because they provide the maximum amount of information. effacement of the normal nodal architecture by neoplastic lymphocytes and capsular disruption are characteristic findings ( figure - , c and d). diagnostic ultrasonography and ultrasound-guided fineneedle aspiration or needle biopsy have been very useful for evaluation of involvement of the liver, spleen, or abdominal lymph nodes. [ ] [ ] [ ] [ ] [ ] if possible, the diagnosis should be made by sampling peripheral nodes, avoiding percutaneous biopsies of the liver and spleen. however, if there is no peripheral node involvement, it is appropriate to biopsy affected tissues in the abdominal cavity. with alimentary lymphoma, an open surgical wedge biopsy of the intestine must be obtained, ideally without entering the intestinal lumen, and adequate tissue must be obtained; this is important because of the difficulty involved in differentiating lymphoma from lpe. endoscopic biopsies may be inadequate because only a superficial specimen is obtained; however, more aggressive endoscopic biopsy techniques combined with more accurate histopathologic assessments are improving the diagnostic yield of these less invasive techniques. in many dogs with primary gastrointestinal lymphoma, an inflammatory, nonneoplastic infiltrate (e.g., lpe) may be misdiagnosed on biopsy specimens that are too superficial. cytologic examination of cerebrospinal fluid (csf), thoracic fluid, or aspirates of an intracavitary mass is indicated in animals with cns disease, pleural effusion, or an intrathoracic mass, respectively. in one study of dogs with cns involvement, csf analysis was diagnostic in seven of eight dogs. the characteristics of the csf included an elevated nucleated cell count in the seven dogs, and % to % of the cells were atypical lymphoid cells. the csf protein concentration was higher in five of seven dogs, ranging from to mg/dl (the reference interval was less than mg/dl). for cutaneous lymphoma, punch biopsies ( to mm) should be taken from the most representative and infiltrative, but not infected, skin lesions. staging procedures for cutaneous lymphoma vary, and the stage has shown no prognostic importance. molecular techniques can be used to establish a diagnosis of lymphoma or to further characterize a tumor after the initial diagnosis has been made. tissues and cells from peripheral blood, lymph nodes, or other sites can be analyzed by histochemical and cytochemical, immunohistochemical and immunocytochemical, flow cytometric, and pcr techniques. for example, the tumor's immunophenotype (b cell or t cell), proliferation rate (e.g., expression of ki- , proliferating cell nuclear antigen [pcna], and argyrophilic nucleolar organizer regions [agnors]), and clonality (pcr for antigen receptor gene rearrangement [parr]) can be determined. , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the availability of such analyses is increasing, although currently only the immunophenotype consistently predicts the prognosis in dogs. part iv • specific malignancies in the small animal patient immunophenotyping typically is used to determine the type of cells that make up the lymphoma, but sometimes the technique is helpful for making the diagnosis of lymphoma. when a diverse population of lymphocytes is expected in a tissue, the presence of a homogeneous population of the same immunophenotype is supportive of a neoplastic process. the immunophenotype of a lymphocyte is identified by determining the expression of molecules specific for b cells (e.g., cd a) and t cells (e.g., cd ). although tumor cells sometimes have morphologic characteristics that typify a particular immunophenotype, exceptions occur, and morphology cannot be used as the sole determinant of the type of lymphocyte. for example, in a series of nine high-grade t-cell lymphomas and leukemias in dogs, the cells had a plasmacytoid appearance, typically associated with b-cell lymphoma. similarly, anatomic location does not always predict the immunophenotype. in a series of cases of gastrointestinal lymphoma in dogs, often considered a neoplasm of b cells, the neoplastic cells were identified as t cells (cd positivity) in % of the cases. for accurate determination of the immunophenotype, antibodies against lymphocyte markers are applied to tissue sections (immunohistochemistry), cytologic specimens (immunocytochemistry), or individual cells in a fluid medium (flow cytometry). flow cytometric evaluation of cells from needle aspirates also is feasible. for t cells, markers include cd (pan t), cd (helper t), and cd (cytotoxic t); for b cells, the markers are cd a (see figure - , b) and cd . interestingly, aberrant expression of cd molecules has been reported in canine lymphoma. in a study of dogs with lymphoma, tumor cells from six dogs were positive for both t-and b-cell cd markers; however, a clonality assay (discussed later) revealed clonality for either the t-cell or the immunoglobulin receptor but not both. this indicates that in some cases of b-and t-cell lymphoma, the malignant cells may coexpress b-and t-cell cd markers. antibodies against these molecules are used to determine the immunophenotype; however, they also have a potential use as a therapeutic modality if tumor cells could be targeted using these antibodies. histologic assessment of markers of multidrug resistance and apoptotic pathways (e.g., p-glycoprotein, p , and bcl- proteins) currently are being evaluated in dogs with lymphoma. however, their significance requires further evaluation. , , [ ] [ ] [ ] [ ] clonality assay occasionally the diagnosis of lymphoma and the differentiation of malignant verses benign proliferation of lymphocytes is not possible based on standard histologic and cytologic criteria. in these cases, advanced molecular analyses are necessary to help confirm a diagnosis. clonality is the hallmark of malignancy; that is, the malignant cell population theoretically should be derived from expansion of a single malignant clone characterized by a particular dna region unique to that tumor. for example, in a dog with t-cell lymphoma, all the malignant cells should have the same dna sequence for the variable region of the t-cell receptor (tcr) gene; likewise, in a dog with b-cell lymphoma, the tumor cells should have identical dna sequences in the variable region of the immunoglobulin receptor gene. conversely, in reactive lymphocytosis, the cells are polyclonal for their antigen receptors. using this knowledge, investigators have used polymerase chain reaction (pcr) pcr techniques to amplify the variable regions of the t-cell and immunoglobulin receptor genes to detect clonal lymphocyte populations in dogs ( figure - ) . [ ] [ ] [ ] [ ] uniform size of polymerase chain reaction (pcr) products as an indicator of clonality. each panel shows four pcr reactions on a single dna sample. the first lane (left) in each panel is a positive control that indicates that dna is present (any nonrearranged gene would be an appropriate target for this reaction). the middle two lanes represent two different reactions that amplify immunoglobulin cdr , and the fourth lane shows tcrγ cdr amplification. the samples are separated on a polyacrylamide gel. a, lymph node aspirate from a normal dog. b, lymph node aspirate from a dog with histologically confirmed multicentric b-cell lymphoma. c, lymph node aspirate from a dog with histologically confirmed t-cell lymphoma. (from avery pr, avery ac: vet clin pathol : - , .) in physician-based medicine, such assays of clonality are approximately % to % sensitive and have a false positive rate of approximately %, and recent studies report similar rates in the dog. false negative and false positive results can occur with clonality assays. for example, cells from a dog with lymphoma may be negative for clonality if the clonal segment of dna is not detected with the primers used, if the malignant cells are natural killer (nk) cells (rare), or if the malignant cells are present in too low a frequency to be detected. false positive results occur rarely with some infectious diseases, such as ehrlichiosis and lyme disease. in these cases a diagnosis should be made only after the results of all the diagnostic tests are considered, including histologic and cytologic evaluation, immunophenotyping, and clonality studies, in conjunction with the signalment and physical findings. molecular techniques, in addition to aiding the diagnosis, could also be useful in determining early recurrence, more accurate clinical staging, and so-called molecular remission rates, because they are more sensitive than standard cytologic assessment for the peripheral blood, bone marrow, and lymph nodes. after a diagnosis has been established, the extent of disease should be determined and correlated to the clinical stage of disease. the who staging system routinely used to stage dogs with lymphoma is presented in box - . most dogs (more than %) are presented in advanced stages (stage iii or iv). some type of imaging and an assessment of bone marrow involvement may be indicated for staging. the degree to which thorough staging is implemented depends on three factors: whether the result will alter the treatment plan; whether relevant prognostic information will be gleamed; and whether the client needs to know. in addition, when different protocols are compared with respect to efficacy, consistent and similar staging systems should be used to avoid so-called stage migration, which results when one staging methodology is more accurate than another. the effect of stage migration currently is being evaluated in veterinary patients with lymphoma, and until the concept has been thoroughly explored, the impact on the prognosis should be considered when different published outcomes are compared. a bone marrow aspirate or biopsy (from the proximal humerus or iliac crest) is indicated for complete staging and in dogs with anemia, lymphocytosis, peripheral lymphocyte atypia, or other peripheral cytopenia. in one study of dogs with lymphoma, % had circulating malignant cells and were considered leukemic, whereas bone marrow examination indicated involvement in % of the dogs. the presence of a few prolymphocytes and large lymphocytes with nucleoli in the circulation of dogs with lymphoma may indicate bone marrow involvement. it is important to remember that these cells also can be seen with gi parasitism, immune-mediated hemolytic anemia, and other immune-mediated diseases. recently, circulating tumor cells in dogs with stage iii lymphoma were identified using a clonality assay (parr). the assay is more sensitive than routine microscopy in detecting malignant cells in circulation, but the correlation of these results with staging and prognosis has not been determined. bone marrow evaluation offers prognostically valuable information, but if the client is committed to treatment regardless of the stage of disease, it is not necessary. evaluation of thoracic and abdominal radiographs may be important in determining the extent of internal involvement. approximately % to % of dogs with multicentric lymphoma have abnormalities on thoracic radiographs; one third have evidence of pulmonary infiltrates, and two thirds have thoracic lymphadenopathy (sternal and tracheobronchial lymph nodes) and widening of the cranial mediastinum (see . [ ] [ ] [ ] [ ] craniomediastinal lymphadenopathy is detected in % of dogs with lymphoma. abdominal radiographs reveal evidence of sublumbar (iliac) and/or mesenteric lymph node, spleen, or liver involvement in approximately % of cases. , in the authors' practice, in typical cases of canine multicentric lymphoma, imaging is limited to thoracic radiographs because no prognostic difference exists between dogs with stage iii disease and those with stage iv disease (i.e., liver or spleen involvement); however, the presence of craniomediastinal lymphadenopathy is prognostically significant (see prognosis later in this section). if clinical signs attributable to abdominal disease are present, further imaging of the abdomen is warranted. in addition, as stated previously, abdominal ultrasonography can be important for obtaining ultrasound-guided intraabdominal samples for diagnosis. it is also useful for the diagnosis of gastrointestinal and hepatosplenic lymphoma. [ ] [ ] [ ] , advanced imaging modalities, including computed tomography (ct), magnetic resonance imaging (mri), and positron emission/computed tomography (pet/ct), are becoming more commonplace in veterinary practice, and their usefulness is only now being fully determined. [ ] [ ] [ ] [ ] [ ] the therapeutic approach to a particular patient with lymphoma is determined by the stage and substage of disease, the presence or absence of paraneoplastic disease, the patient's overall physiologic status, the financial and time commitments of the client, and the client's level of comfort with regard to the likelihood of treatment-related side effects. because most canine lymphomas are intermediate-to high-grade tumors, histopathologic characterization has played a less important role in determining the optimal treatment. without treatment, most dogs with lymphoma die of the disease in to weeks. with few exceptions, canine lymphoma is considered a systemic disease and therefore requires systemic therapy to achieve remission and prolonged survival. systemic chemotherapy continues to be the therapy of choice for canine lymphoma. in general, combination chemotherapy protocols are superior in efficacy to single agent protocols. single agent protocols, except for doxorubicin, have a lower response rate that is not as durable as combination chemotherapy. in rare cases in which lymphoma is limited to one site (especially an extranodal site), the animal can be treated with a local modality, such as surgery or radiation therapy, as long as the caregiver and clinician are committed to diligent re-evaluation to document subsequent systemic involvement. many chemotherapy protocols for dogs with lymphoma have been developed over the past to years (table - ) . , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] most complex combination protocols are modifications of chop protocols initially designed for human oncologic use. chop represents combinations of cyclophosphamide (c), doxorubicin (represented by the h, for hydroxydaunorubicin), vincristine (o, oncovin) and prednisone (p). conventional chemotherapy induces complete remission (cr) in approximately % to % of dogs, with median survival times of to months depending on the protocol used. approximately % to % of dogs live years or longer after initiation of these protocols (figure - ) . response rates and the duration of response vary according to the presence or absence of prognostic factors discussed in the prognosis section. the cost to the owner depends on the drug or drugs selected, the size of the animal, the frequency of administration, and the laboratory tests needed to monitor toxicity. dogs that respond to chemotherapy and achieve complete remission usually are free of clinical signs associated with lymphoma and subsequently return to a very good quality of life. treating dogs with lymphoma is gratifying, because a high percentage have a complete response. most dogs tolerate chemotherapy well, and in our experience only a minority of dogs develop significant toxicity. studies assessing clients' perceptions of medical treatment for cancer in general and lymphoma in particular generally report a positive experience; most owners felt that the treatment was worthwhile, that it resulted in improvement in their pet's well-being, and that the animal's quality of life during treatment was good. , very few clients expressed regret about having the lymphoma treated with a multidrug protocol. with lymphoma, the fundamental goals of chemotherapy are to induce a complete and durable (longer than months) first remission (induction), to reinduce remission when the tumor recrudesces (or the patient relapses) after achievement of a remission (reinduction), and finally to induce remissions when the cancer fails to respond to induction or reinduction using drugs not present in standard protocols (rescue). a previously unanswered question in the treatment of lymphoma was whether long-term maintenance chemotherapy was useful after an initial course of aggressive induction chemotherapy that lasted months or less. long-term maintenance chemotherapy has been shown to be ineffective in humans with hodgkin's disease, nhl, and multiple myeloma. however, the initial induction course of chemotherapy in humans is much more aggressive than that used in veterinary patients. although no randomized studies have been performed to address the therapeutic benefit of long-term maintenance chemotherapy in dogs, comparisons of dogs treated with chop-based protocols in which all treatment was stopped after months of induction therapy were compared with sequentially treated, historical controls that received a nearly identical protocol that included long-term maintenance therapy. the dogs that received the shortened, less expensive, no-maintenance protocol had comparable remission and survival durations and were more likely to achieve second remissions when they relapsed after completion of chemotherapy than their counterparts that received long-term maintenance therapy. other studies, although not prospective randomized trials, suggest that aggressive induction or discontinuous therapy (i.e., induction without maintenance) is as good as or superior to protocols that use an extended maintenance phase. , , , these data, taken together, suggest that maintenance therapy is not necessary and indeed may be inappropriate for dogs with lymphoma that are treated with similar combination chemotherapy protocols. single agent chemotherapy with known activity for dogs with lymphoma agents include vinblastine, actinomycin-d, mitoxantrone, chlorambucil, methotrexate, dtic, -aminocamptothecin, ifosfamide, cytosine arabinoside, gemcitabine, lomustine, and dolastatin- . - of these, cytosine arabinoside, ifosfamide, dolastatin- , and gemcitabine appear to have only minimal activity. except for doxorubicin, induction with single agent chemotherapy does not result in durable remission durations compared with standard combination protocols. the efficacy of incorporating these newer drugs with single agent activity into standard combination protocols awaits further investigation. providing precise treatment recommendations for the wide variety of clinical settings of dogs with lymphoma is difficult, especially in light of the plethora of published combination drug protocols (see table - ). because of the large and ever increasing number of protocols available, several factors should be considered and discussed with caregivers on a case-by-case basis in making the choice of protocol. these factors include the cost, time commitment, efficacy, toxicity, and experience of the clinician with the protocols in question. with the increased availability of generic drugs, protocols are becoming affordable to a larger segment of veterinary clients. in general, more complex combination chemotherapy protocols are more expensive, more time-consuming (i.e., requiring repeated office visits and closer monitoring), and more likely to result in toxicity than simpler, single agent protocols. however, as a general rule, more complex combination protocols result in longer remission and survival durations than single agent protocols. the earliest treatment protocol used in veterinary patients was a non-doxorubicin-based combination chemotherapy (i.e., cyclophosphamide, vincristine, and prednisone [cvp]), a relatively simple, easy protocol that is well-tolerated and results in a % to % cr rate and a median survival time of to months. , however, it has been clearly established that the standard of care combination protocols used in dogs with lymphoma include doxorubicin, and all are essentially variations on the chop protocols previously discussed and listed in table - . although many of these chop protocols include l-asparaginase, which is added either at initiation or at varying times throughout the protocol, several studies have confirmed that the addition of l-asparaginase in induction protocols does not result in clinically relevant increases in remission rate, speed of attaining remission, or first-remission duration; therefore its use is best reserved for rescue situations (discussed later). , , , regardless of the veterinary chop-based combination protocol used, they all generally result in an % to % cr rate with median survival times of months. about % of dogs are long-term survivors (longer than years), and some are cured. the chop protocol used by the authors at the time of publication (box - ) generally is well tolerated by dogs. this protocol does not have a maintenance therapy arm, and all treatments stop at weeks if the animal is in complete remission. if client factors or other considerations preclude a chop-based protocol, single agent doxorubicin can be offered as an alternative, with the patient receiving five doxorubicin treatments ( mg/m given intravenously every weeks). the expected complete response rate will range from % to % with an anticipated median survival time of to months. , , , if financial or other client concerns preclude the use of more aggressive systemic chemotherapy, prednisone therapy alone ( mg/kg given orally daily) often results in a short-lived remission of approximately to months. in these cases, it is important to inform clients that should they decide to pursue more aggressive therapy later, dogs with previous prednisone therapy are more likely to develop multiple drug resistance (mdr) while receiving single agent prednisone and to have shorter remission and survival durations with subsequent combination protocols. this is especially true after long-term prednisone therapy and in dogs that have experienced a recurrence while receiving prednisone. , therefore, the earlier a client opts for more aggressive therapy, the more likely it is that a durable response will result. a cbc should be performed before each chemotherapy treatment. a neutrophil count of at least /ml and a platelet count of , /ml should be present before the chemotherapeutic drugs are administered. if the neutrophil count is below /ml, it is best to wait to days and repeat the cbc. if the count has risen above cells/ml, the drug can be safely administered. a caveat to these restrictions: in dogs presented before initiation of chemotherapy that have low neutrophil and platelet counts because of bone marrow effacement, myelosuppressive chemotherapy is instituted in the face of cytopenias to "open" the bone marrow and allow counts to normalize. with regard to breeds likely to have mdr- gene mutations (e.g., collies; see chapter ) and which therefore are at risk for serious, unexpected chemotherapy toxicity, the authors initiate a chop protocol out of sequence, beginning with non-mdr- -associated drugs, such as cyclophosphamide. this ensures treatment of the lymphoma while allowing sufficient time for analysis of mdr- gene mutations (see chapter ) before mdr- -associated drugs are initiated. eventually, most dogs that achieve a remission relapse or experience a recrudescence of lymphoma. this usually represents the emergence of tumor clones that are inherently more resistant to chemotherapy than the original tumor; so-called mdr clones that either were initially drug resistant or became so after exposure to selected chemotherapeutic agents. , [ ] [ ] [ ] evidence suggests that in recurrent lymphoma in dogs, tumor cells are more likely to express the mdr- gene that encodes the protein transmembrane drug pump often associated with multiple drug resistance. , , other causes of relapse after chemotherapy include inadequate dosing and frequency of administration of chemotherapy and failure to achieve high concentrations of chemotherapeutic drugs in certain sites, such as the central nervous system. at the first recurrence of lymphoma, reinduction should be attempted first by reintroducing the induction protocol that was successful initially. special attention must be given to the cumulative dose of doxorubicin that will result from reinduction; also, a baseline cardiac assessment, the use of cardioprotectants, alternative drug choices, and client education should all be considered. in general, the likelihood of a response and the length of the reinduction are half those seen in the initial therapy; however, some animals enjoy long-term reinductions, especially if the patient had completed the initial induction regimen and was off chemotherapy when the relapse occurred. a reinduction rate of nearly % can be expected in dogs that have completed chop-based protocols and then relapse while off therapy. if reinduction fails or the dog does not respond to the initial induction, use of so-called rescue agents or rescue protocols can be attempted. these are drugs or drug combinations that typically are not found in the standard chop protocol and are withheld for use in cases of drug resistance. the most common rescue protocols most commonly used in dogs include single agent or combination use of actinomycin d, mitoxantrone, doxorubicin (if doxorubicin was not part of the original induction protocol), a doxorubicin/dacarbazine combination, lomustine (ccnu), l-asparaginase, and the combination mechlorethamine, vincristine (oncovin) procarbazine, and prednisone (mopp). , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] overall rescue response rates of % to % are reported, but these responses usually are not durable, and median response times of . to . months are typical. a small number of animals will enjoy longer rescue durations. despite the plethora of published chemotherapy protocols for dogs with lymphoma, it appears that veterinary medicine has achieved about as much as it can from the currently available chemotherapeutic drugs in standard settings, because no dramatic improvement has been made in the -month median survival "wall" and the % -year survival rate. advances in remission and survival durations await the development of new methods of delivering or targeting old chemotherapeutic drugs and the development of new generation chemotherapeutics or novel nonchemotherapeutic treatment modalities. mechanisms of avoiding or abrogating mdr, enhancing tumor apoptosis (programmed cell death), and targeting treatments with immunoconjugates (i.e., antibody-directed therapies), as well as novel immunomodulatory therapies, are all active areas of investigation in both human and veterinary medicine. drug resistance can develop in cancer patients after exposure to selected chemotherapeutic agents and often is associated with expression of p-glycoprotein (see chapter ) . p-glycoprotein acts as a drug efflux pump that actively extrudes drugs from tumor cells, preventing a cytotoxic drug from reaching the cellular site of action. mdr and p-glycoprotein are controlled by the mdr- gene. , , mdr has been reported in canine lymphoma after treatment with chemotherapy. , , in one study, expression levels of messenger ribonucleic acid (mrna) that encodes the canine mdr- gene was characterized in canine cell lines and lymphomas. although expression of mdr- mrna correlated with in vitro drug sensitivity, it did not correlate with in vivo doxorubicin sensitivity in dogs with lymphoma in this study. methods of increasing the time that tumor cells are exposed to chemotherapeutic drugs theoretically should enhance tumor killing. these methods could intralymphatic (il) administration of an autologous killed lymphoma tumor cell vaccine has been done in dogs in which remission was achieved with a combination chemotherapy protocol. in a study that compared dogs that received chemotherapy and then il vaccination with dogs that received chemotherapy alone, the median remission times were and days, respectively (p < . ). unfortunately, the survival times for the two groups were not significantly different ( days for chemotherapy plus il vaccine and days for chemotherapy alone). dogs that responded had significant increases in specific antibody to lymphoma antigens compared to those that did not respond. another immunotherapy approach involved mab- , a murine-derived anticanine monoclonal antibody (igg a). this antibody mediates antibody-dependent cellular cytotoxicity (addc) and complement-mediated cellular cytotoxicity (cmcc), , and it prevented outgrowth of canine lymphoma xenografts in nude mice. in a noncontrolled clinical study, dogs were treated with chemotherapy (l-asparaginase, vincristine, cyclophosphamide, and doxorubicin). after two cycles of chemotherapy, dogs had achieved complete remission and were treated with an intravenous infusion of mab- daily for days. the median survival time of the dogs treated with mab- was days. the -year survival rate was . %. the median number of chemotherapy cycles in the first year was three, and the median number of mab- cycles was . . the mab- antibody went off the commercial market in the mid- s. definitive randomized trials to determine its effectiveness are still lacking. most dogs with lymphoma have the multicentric form and need systemic chemotherapy for effective treatment of the disease. however, surgery has been used to treat solitary lymphoma (early stage i) or solitary extranodal disease. in such cases, careful staging is necessary to rule out multicentric involvement before the local disease is treated. the benefit of surgical removal of the spleen in dogs with massive splenomegaly remains unclear. , in a published report, dogs with lymphoma underwent splenectomy for a massive spleen and subsequently were treated with chemotherapy. within weeks of splenectomy, five of the dogs died of disseminated intravascular coagulation (dic) and sepsis. the remaining dogs had a complete response rate of %, and seven of these, which were followed until their death, had a median survival time of months. splenectomy should be considered only if the lymphoma is in remission in other sites and if the splenic enlargement is caused by lymphoma that is not responsive to chemotherapy. in dogs with lymphoma, splenectomy also can be considered as a treatment for uncontrolled hemolytic anemia and persistent thrombocytopenia. the role of radiotherapy for the management of lymphoma in dogs currently is under investigation. the use of whole body irradiation without bone marrow transplantation has yielded poor results. however, radiation therapy may be indicated in selected cases. - the indications are: • local stage i or stage ii disease (i.e., nasal lymphoma, cns lymphoma) • palliation of local disease (e.g., mandibular lymphadenopathy, rectal lymphoma, mediastinal lymphoma accompanied by precaval syndrome, localized bone involvement) • whole body irradiation combined with bone marrow or stem cell transplantation • staged half-body irradiation after chemotherapyinduced remission the use of staged half-body irradiation after achieving remission with induction chemotherapy has undergone preliminary investigation as a form of consolidation or maintenance. , in these investigations, radiation therapy is delivered either to the cranial or the caudal half of the dog's body in two consecutive gray daily fractions; then, after a rest of or weeks, the other half of the body is irradiated in a similar fashion. although these preliminary investigations were not randomized, their results suggest that radiation therapy, either after completion of chemotherapy or sandwiched between chemotherapy sessions, when dogs are in either complete or partial remission, is safe and should be investigated more extensively to determine whether a significant therapeutic gain could be realized. in general, the veterinary literature offers little information on the treatment of the various extranodal forms of lymphoma in dogs, therefore the ability to predict outcome is limited. the authors recommend that, after extensive staging, local therapies (e.g., surgery, local radiation therapy) should be used in cases in which disease is localized to a solitary site. if multiple extranodal sites are involved or if they are part of a more generalized process, systemic chemotherapy should be given. most dogs with alimentary lymphomas have diffuse involvement of the intestinal tract. involvement of local lymph nodes and the liver is common. chemotherapy in dogs with diffuse disease has been reported to be unrewarding for the most part. however, in the authors' experience, more aggressive, chop-based protocols (which are used extensively for multicentric lymphoma in dogs) have resulted in several cases of durable remission for alimentary lymphoma. solitary alimentary lymphomas are rare in the dog, but if the tumor is localized and can be removed surgically, the results with or without follow-up chemotherapy can be encouraging. most cns lymphoma in dogs results from metastasis of multicentric lymphoma. however, primary central nervous system lymphoma (pcnsl) has been reported. , if tumors are localized, local radiation therapy should be considered. few studies have reported on the use of chemotherapy. in one study, cytosine arabinoside (ara-c) at a dosage of mg/m was given intrathecally by bolus injection after withdrawal of an equal volume of csf. the dose was diluted in to ml of lactated ringer's solution and was injected twice weekly for a total of six treatments. this treatment was combined with systemic chemotherapy and cns irradiation. overall, the response rates were low and of short duration (several weeks to months). the treatment of cutaneous lymphoma depends on the extent of disease. solitary lesions may be treated with surgical excision or radiation therapy. fractionated radiation therapy (to a total dose of to gy) has been associated with long-term control. diffuse non-t-cell lymphoma is best managed with combination chemotherapy, although the response rate is less than in multicentric lymphoma. in one study, investigators reported that combination chemotherapy with cyclophosphamide, vincristine (oncovin), cytosine arabinoside, and prednisone (coap) induced longterm remission in some cases. five of six dogs with diffuse non-t-cell cutaneous lymphoma attained a complete or partial remission, with a median remission duration of longer than days and a median survival of longer than days. retinoids, such as isotretinoin (accutane) and etretinate (tegison), have been used successfully in canine and human t-cell cutaneous lymphoma. , in one study, dogs with cutaneous lymphoma were treated with isotretinoin ( to mg/kg given orally daily), and two were treated with etretinate ( . to . mg/kg given orally daily, continuously). eleven of these dogs had t-cell cutaneous lymphoma, and six of the dogs achieved remission. in another study, four dogs with t-cell lymphoma were treated successfully with isotretinoin for , , , and months. in the authors' experience, retinoid treatment must be given for at least months to note a response. polyethylene glycol (peg)-l-asparaginase ( mg/kg given intramuscularly weekly) induces responses in dogs with cutaneous t-cell lymphomas, although remissions are not durable, and no cures have been noted. prednisone may also be necessary to control pruritus. in the authors' experience, pegylated-liposomal doxorubicin (doxil) has produced remissions in approximately % of cases. although most of these were short-lived responses, remissions of year or longer occasionally have occurred. a preliminary abstract reported activity for oral ccnu with cutaneous lymphoma in dogs. all seven dogs (five with mycosis fungoides [mf] and two with nonepitheliotropic disease) that were treated with ccnu ( mg/m given orally every weeks) achieved a complete response, and two of those responses were relatively durable ( and months). a larger cohort needs to be treated before definitive response rates and durations can be given. topical chemotherapy is another strategy for treating cutaneous t-cell lymphoma, although it is rarely used in veterinary medicine because of "patient compliance" problems. mechlorethamine (mustargen) can be applied topically as an aqueous solution or an ointment base. the aqueous solution is prepared by combining mg of mechlorethamine with ml of tap water. the ointment is prepared by mixing mg of mechlorethamine with ml of absolute alcohol and further combining enough xipamide (aquaphor) to prepare g of ointment. hair must be removed before application. gloves must be used when the drug is applied, because mechlorethamine is carcinogenic and can cause contact hypersensitivity in humans. the response to therapy varies, and the treatment often is only palliative. the prognosis for canine lymphoma varies and depends on a number of factors, such as the location of disease, the extent of disease (the clinical stage), the presence or absence of clinical signs (the substage), the histologic grade, the immunophenotype (t cell or b cell), exposure to previous chemotherapy or corticosteroids and subsequent development of mdr (see chapter ), altered cell death processes (apoptosis), the proliferation rate of the tumor, the presence of concurrent medical problems or paraneoplastic conditions (e.g., hypercalcemia, weight loss, and liver insufficiency), and possibly gender.* although canine lymphoma is rarely curable (fewer than % of cases), complete responses and a good quality of life during extended remissions and survival are typical. factors that have been shown to influence survival are shown in table - . the two factors most consistently identified as being prognostically important in dogs with lymphoma are the immunophenotype and who substage (see figure - ). many reports have confirmed that dogs with cd -immunoreactive tumors (i.e., t-cell derivation) are associated with significantly shorter remission and survival durations. † this holds true primarily for dogs with multicentric lymphoma, because the immunophenotype of solitary or extranodal forms of lymphoma has not been thoroughly investigated with respect to the prognosis. in addition, it has been shown that dogs with b-cell lymphomas that express lower than normal levels of b antigen (expressed in % of nonneoplastic lymphocytes) also have shorter remission and survival durations. dogs with who substage b disease (i.e., clinically ill) also do poorly compared to dogs with substage adisease (see figure - ). ‡ dogs with stage i or stage ii disease have a better prognosis than dogs with more advanced disease (stage iii, iv, or v). , in some studies, an elevated serum calcium (over . mg/dl) has been shown to be a negative prognostic factor , ; however, this rarely holds true with multivariate analysis because hypercalcemia is associated with the t-cell phenotype. the histologic grade (subtype) has been found to influence the prognosis in some studies; however, our ability to predict outcome based on subtype is still quite limited. dogs with lymphoma classified as intermediate-or high-grade (large cell, centroblastic, and immunoblastic) tend to respond to chemotherapy but can relapse early. dogs with low-grade lymphomas (small lymphocytic or centrocytic) have a lower response rate to chemotherapy, yet have a survival advantage over dogs with intermediate-or high-grade lymphomas ( figure - ) in that the course of disease may be more indolent. using the working formulation, dogs with low-grade lymphomas have a survival advantage compared to dogs with intermediate-or high-grade tumors. recently, proliferative assays (e.g., analysis of bromodeoxyuridine [brdu] uptake, ki- antibody reactivity, and agnor indices) to measure the proliferative activity of tumor cells have been shown to provide significant prognostic information in dogs treated with combination chemotherapy. , , , [ ] [ ] [ ] however, the results of different studies are contradictory. in two trials, dogs that had tumors with short doubling times, high agnor frequencies, or high ki- immunoreactivity had a better prognosis than dogs with long doubling times or low agnor frequencies. , in other trials, the low-proliferating tumor groups were associated with a better prognosis. , in one trial, the proportion of tumor cells undergoing apoptosis was modestly predictive of remission duration. the anatomic site of disease also has considerable prognostic importance. primary diffuse cutaneous, diffuse gastrointestinal, hepatosplenic, and primary cns lymphomas tend to be associated with a poor prognosis. cutaneous lymphoma tends to progress slowly, and in our experience the responses to systemic chemotherapy are less durable. localized lymphomas in the skin can be managed with radiation therapy or surgery or both, and these tumors have a better prognosis. in some dogs with lymphoma, significant involvement in the bone marrow may be present (i.e., tumor cells comprise more than % of all nucleated cells) and circulating malignant lymphocytes may be present in the peripheral blood. these dogs tend to have an overall poor prognosis. in some cases it is difficult to determine whether the disease arises from the bone marrow (e.g., acute lymphoblastic leukemia [all]) or is a diffuse lymphoma with extensive involvement in the marrow. immunophenotyping is helpful in these cases, because the tumor cells in all typically are cd positive. gender has been shown to influence the prognosis in some studies. , neutered females tend to have a better prognosis. males may have a higher incidence of the t-cell phenotype, which may account for the poorer prognosis. other reported potential biomarkers of the prognosis include circulating levels of glutathione-s-transferase, thymidine kinase, and vascular endothelial growth factor (vegf). - one report suggests that a history of chronic inflammatory disease of several types predicts a likelihood of early relapse. these putative prognostic indicators require confirmation in larger trials. lymphoid leukemia is the proliferation of neoplastic lymphocytes, which usually originate in the bone marrow but occasionally may originate in the spleen. the neoplastic cells may or may not be circulating in the peripheral blood. lymphocytic leukemia is more common than nonlymphocytic leukemia and other myeloproliferative disorders (mpds). the true incidence is not known. in a series of cases of all, german shepherds accounted for % of the cases, and the male to female (m:f) ratio was : . in this study, the median age was . years (range, to years), and eight dogs were younger than years of age. recently, all was reported in a -week-old greyhound. well-differentiated or chronic lymphocytic leukemia (cll) is seen less frequently than all but more commonly than mpd. the median age is to years. the m:f ratio has been reported as . : ( dogs) and approximately . : in dogs with granular lymphocytic (gl) t-cell cll. in a large study of dogs with cll, no gender predilection was found in dogs with b-cell or non-gl cll; female dogs were overrepresented among dogs with gl cll, (m:f ratio, : . ). , as with lymphoma, the etiology of lymphoid leukemia is unknown. retroviruses have been implicated in diverse animal species such as cats, cattle, fish, snakes, birds, rodents, and nonhuman primates. a retroviral cause in dogs has not been proved. however, a retrovirus with morphology typical of lentiviruses has been isolated from mononuclear cells obtained from the peripheral blood of a dog with all. in humans, acute leukemia has been associated with exposure to radiation, benzene, phenylbutazone, and antineoplastic agents. [ ] [ ] [ ] [ ] [ ] [ ] the alkylating agents can cause chromosomal damage and are clearly carcinogenic. human t-lymphotropic virus type (htlv- ) is a proven cause of leukemia in a large cohort of human patients from the southern islands of japan. , the etiology of cll is less clear, but genetic factors likely are important. extrapolation of predisposing factors across species is not warranted, and the etiologic factors for dogs may be quite different from those for humans, given the difference in the predominant immunophenotype of the neoplastic cells (discussed later). in all, the blast cells infiltrate the bone marrow, and the result is variable degrees of anemia, thrombocytopenia, and neutropenia. infiltration of the spleen and liver is common, and extramedullary sites (e.g., the nervous system, bone, and gi tract) also may be involved. some animals may have lymph node involvement and develop generalized lymphadenopathy. the lymphocytes of cll are virtually indistinguishable morphologically from normal small lymphocytes, and they have a low proliferation rate. the accumulation of lymphocytes likely results from their prolonged life span. in b-cell cll, the marrow is infiltrated with mature lymphocytes, and the extent of infiltration is less than that seen with all or mpd. the neoplastic cells in gl t-cell cll originate in the spleen, and bone marrow involvement may or may not occur. dogs with cll tend to have a mild anemia, and granulocytes and platelets are only mildly reduced. splenomegaly is common, and lymph nodes can be slightly to moderately enlarged. despite the well-differentiated appearance of the lymphocytes in cll, these cells may function abnormally. part iv • specific malignancies in the small animal patient paraneoplastic syndromes include monoclonal gammopathies, immune-mediated hemolytic anemia, pure red cell aplasia and, rarely, hypercalcemia. , hypercalcemia was reported in a giant schnauzer with b-cell cll, which is highly unusual given that hypercalcemia is associated with t-cell lymphoproliferative disorders. in one study of dogs with cll, % had monoclonal gammopathies. the immunophenotypes were not reported, but a monoclonal gammopathy is associated with production of immunoglobulins by the leukemic cells (b cells). the immunoglobulin is usually igm or iga. the term macrogammaglobulinemia is used to describe igm gammopathy (see chapter , section d). dogs with cll and an igm monoclonal gammopathy are said to have waldenström's macroglobulinemia. dogs can also develop hyperviscosity syndrome (see chapter , section d). reports of the immunophenotype of neoplastic cells in canine leukemias are increasing in frequency. one consistent finding in acute leukemias (either all or acute myeloid leukemia) is the presence of cd on the blast cells. this marker is useful for distinguishing all (cd -positive) from cll and lymphoma with bone marrow infiltration (cd -negative). in one study of cases of cll, eight dogs were associated with a cd -positive t-cell phenotype. in a larger study of cases, only % of the cases had a b-cell immunophenotype, whereas % were identified as t-cell cll (cd -positive). in % of these t-cell leukemias, the cells had the morphology of gls, and most of them were cd -positive. these findings are difficult to reconcile with the high frequency of monoclonal gammopathies reported in the earlier study. it also should be noted that this differs from human clls, which typically are lymphoproliferative diseases of b cells. dogs with all usually have a history of anorexia, weight loss, polyuria, polydipsia, and lethargy. splenomegaly is typical, and other physical abnormalities may include hemorrhages, lymphadenopathy, and hepatomegaly. anemia, thrombocytopenia, and an elevated white blood cell (wbc) count are common. the anemia may be severe and usually is characterized as normocytic and normochromic (nonregenerative). wbc counts usually are increased despite neutropenia because of an increased number of circulating lymphoblasts (more than , cells/ml). however, some dogs may be leukopenic. neoplastic lymphoblasts may infiltrate the bone marrow extensively, resulting in depression of normal hematopoietic elements. dogs with cll often are asymptomatic, although some owners report lethargy and a decreased appetite. mild lymphadenopathy and splenomegaly may be present. most dogs tend to be mildly anemic (packed cell volume [pcv] less than %) and thrombocytopenic ( , to , platelets/ml). the wbc count usually exceeds , cells/ml but can vary from normal to more than , cells/ml, owing to an increase in circulating mature lymphocytes. lymphocytosis is persistent, and granulocytes usually are present in normal numbers. in some dogs the disease is identified incidentally when the patient undergoes evaluation for an unrelated problem. the clinician must consider the signalment, history, physical findings, cell morphology, and immunophenotype to diagnose the lymphoid leukemias accurately. a knowledge of the profile of lymphocyte subsets in the peripheral blood of normal dogs is helpful for determining whether a particular subset has expanded. approximately % of circulating lymphocytes in dogs are t cells, and about % are b cells. nk cells and double-negative (cd −cd −) t cells account for the remaining fraction. in the t-cell fraction, helper t cells (cd +) outnumber cytotoxic t cells (cd +). lymphocytic leukemia should be a consideration if atypical lymphocytes are in circulation, if the immunophenotype of the lymphocytes in circulation is homogenous, or if a phenotype typically present in low numbers has increased. differential diagnoses for lymphocytosis include certain infectious diseases (e.g., chronic ehrlichiosis), postvaccinal responses in young dogs, il- administration, and transient physiologic or epinephrine-induced lymphocytosis. reactive and neoplastic lymphocytoses sometimes are difficult to differentiate. in these cases, pcr assays are used to determine the clonality of the t cell or immunoglobulin receptor genes in a population of lymphocytes (see earlier discussion). , , infiltration of the bone marrow by neoplastic lymphoid cells is the hallmark of all and is seen in most cases of cll; careful examination of peripheral blood and bone marrow by experienced cytopathologists is essential for establishing a diagnosis of lymphocytic leukemia. if adequate diagnostic bone marrow cannot be obtained by aspiration, a bone marrow core biopsy should be performed. in all, lymphoblasts predominate in the bone marrow and also are present in peripheral blood. infiltration of bone marrow by lymphoblasts is accompanied by a decrease in the granulocytic, erythroid, and megakaryocytic cell lines. perhaps the distinguishing feature of lymphoblasts is the nuclear chromatin pattern, which is more condensed than the chromatin in myeloblasts. lymphoblasts are larger than neutrophils, have a high nucleus-to-cytoplasm ratio, and blue cytoplasm, which in some cases is intensely basophilic ( figure - , a) . nucleoli, although present, are less prominent in lymphoblasts than in myeloblasts. nevertheless, these cells cannot be easily distinguished from blast cells of other hematopoietic lineages, and lineage-specific markers on the cells must be identified by immunocytochemistry or flow cytometry. the most frequently used markers are cd for t cells and cd a for b cells. as mentioned earlier, cd is found on blast cells of both lymphoid and myeloid lineages, and positivity for cd helps to confirm leukemia of immature cells (acute leukemia) and to distinguish all from stage v lymphoma. immature and differentiating lymphocytes may stain strongly for alkaline phosphatase activity, which suggests that this cytochemical staining procedure is not specific for myeloid leukemia. , , in b-cell and non-gl t-cell cll, the lymphocytes are small mature cells ( figure - , b) that appear in excessive numbers in bone marrow ( % or more of all nucleated cells) early in the disease. infiltration becomes more extensive as the disease slowly progresses, and eventually the neoplastic cells replace normal marrow. the lymphoid lineage of the cells in cll typically is easy to identify, and immunophenotyping is done to determine the lymphocyte subset. in dogs, most cases of cll are t-cell (cd +) proliferations. in gl cll, the neoplastic cells originate in the spleen. a separate clinical staging system has not been developed for lymphocytic leukemia. currently, all dogs with leukemia are classified as stage v based on the who staging system for lymphoma (see box - ). although a specific clinical staging system for cll has been used in humans, it has not been evaluated in the dog. similar to other infiltrative bone marrow malignancies, all causes morbidity by suppressing bone marrow function. neutropenia, thrombocytopenia, and anemia may be severe. therapy must be aggressive; to restore hematopoiesis, a . to logarithmic reduction in leukemic cell numbers (to less than million cells) must be achieved. patients need supportive therapy, such as fresh whole blood, broad-spectrum antibiotics, fluid therapy, and nutritional support. patients must be monitored carefully for bleeding and thrombosis, which may signal the development of dic. all requires aggressive chemotherapy. consistently efficacious protocols for all have not been developed in veterinary medicine. chop-based protocols, similar to those used for lymphoma (see , tend to be used as treatment protocols for dogs with all. in one report on the use of vincristine and prednisone in dogs with all, % of the dogs responded to vincristine and prednisone, % with a complete remission and % with a partial remission. with the addition of doxorubicin and l-asparaginase, it is anticipated that response rates will increase over those previously reported using vincristine and prednisone alone; however, the relative rarity of all limits the ability to identify effective protocols. a b because of the indolent nature of cll in many animals, the question of whether all dogs with the disease should be treated is controversial. , most oncologists recommend observation over active therapy when the discovery of cll is incidental, when no physical or clinical signs are present, and when no significant hematologic abnormalities are identified. therapy should be instituted if the animal is anemic or thrombocytopenic, is showing evidence of significant lymphadenopathy or hepatosplenomegaly, or has an excessively high wbc count (over , lymphocytes/ml) (box - ). the most effective drug evaluated thus far is chlorambucil. chlorambucil is administered at a dosage of . mg/kg or mg/m given orally once daily for to days. the dosage then can be reduced to . mg/kg or mg/m given orally once daily. for long-term maintenance, a dosage of mg/m given orally every other day can be used. the dosage is adjusted according to the clinical response and bone marrow tolerance. chlorambucil should be administered without food to increase the rate of absorption. corticosteroids are lymphocytolytic and lead to cell death by apoptosis. studies in humans have shown that the antitumor activity of chlorambucil combined with prednisone is better than that of chlorambucil alone. when the bone marrow is heavily infiltrated with cll cells, and neutropenia, thrombocytopenia, and anemia occur, use of a more aggressive alkylating agent (usually cyclophosphamide [ mg/m given once]) when initiating oral chlorambucil and prednisone therapy can be considered to increase the speed of initial remission; however, this modification of the protocol has not been scrutinized in clinical trials. if chlorambucil or cyclophosphamide fails, the choice of treatment is combination chemotherapy similar to that presented in box - . the treatment of cll is primarily palliative, and complete remissions are rare. because of the indolent nature of this disease, however, survival times have been in the range of to years with a good quality of life. , in humans, splenectomy has been shown to increase survival significantly in individuals with aggressive forms of cll; however, splenectomy in dogs with cll has not been evaluated. the phenotypic expression of cll usually is stable over months to years. however, the disease may evolve into an acute phase, and some dogs develop a rapidly progressive, pleomorphic (immunoblast) lymphoma. in humans, this is called richter's syndrome. the prognosis for response to treatment is poor for this form. in general, the prognosis for all in the dog is very poor. in a study of dogs treated with vincristine and prednisone, the dogs achieving complete or partial remission ( %) had a median survival time of days, and few dogs survived longer than months with that protocol. in one case report, a dog with all was treated with an infusion of a large volume of fresh canine plasma and whole blood, and a complete remission was maintained for months without additional therapy. this is a very unusual response, which indicates that normal blood contains some antileukemic factor or factors. as stated before, cll is a slowly progressive disease, and some animals do not require therapy. one dog was observed for almost years without treatment. for dogs that are treated, normalization of wbc counts can be expected in % of cases. in one report of dogs treated with vincristine, chlorambucil, and prednisone, the median survival time was approximately months, with an expected % survival at years. in other studies, dogs treated intermittently with chlorambucil and prednisone have had remissions of to months. david m. vail the lymphomas (malignant lymphoma and lymphosarcoma) are a diverse group of neoplasms that have in common their origin from lymphoreticular cells. they usually arise in lymphoid tissues, such as lymph nodes, spleen, and bone marrow; however, they may arise in almost any tissue in the body. lymphoma is one of the most common neoplasms seen in the cat. the feline leukemia virus (felv) was the most common cause of hematopoietic tumors in the cat during the so-called felv era of the s through the s, when % to % of lymphoma cases were associated with felv antigenemia. [ ] [ ] [ ] [ ] [ ] [ ] [ ] several studies have documented the potential molecular means by which felv can result in lymphoid neoplasia. , however, over the past years in north america, a profound change has occurred in the viral status, presentation, signalment, and frequency of anatomic sites in cats with lymphoma, as documented by two large studies of feline lymphoma involving more than cats. , the change in the epidemiology and characteristics of lymphoma in cats appears to coincide with the widespread integration of clinically relevant felv diagnostic assays (indirect immunofluorescence assay) and the affected animal elimination regimens of the late s; it was further enhanced by the appearance of commercially available felv vaccines in the late s. the decline in felv-associated lymphoma was mirrored by a decline in the overall prevalence per year of felv positivity in cats tested, as characterized by reports from the tufts veterinary diagnostic laboratory from to , and by louwerens' group, which reported a decline in felv association in more than cases of lymphoma in cats brought to the university of california-davis veterinary teaching hospital. in these reports, felv antigenicity represented only % to % of the cats with lymphoma. the incidence figures for feline lymphoma generated before the use of felv vaccination and testing became widespread suggest that lymphoma accounted for % to % of all hematopoietic tumors in the cat , ; because hematopoietic tumors (lymphoid and myeloid) represent approximately one third of all feline tumors, the estimated incidence of lymphoid neoplasia was per , cats at risk. in one series of cats with hematopoietic tumors, % had lymphoma and % had leukemias and mpds ( % of the mpds were categorized as undifferentiated leukemias, most likely myeloid in origin). an important fact that louwerens' study revealed is that despite a sharp drop in felv-associated lymphoma, the overall prevalence of lymphoma in cats is increasing. this appears to be due to an increase in the number of affected cats and the relative frequency of the abdominal (particularly the intestinal) anatomic form of lymphoma in the species (figure - ) . as might be expected, along with a shift away from felv antigen-associated tumors came a shift away from the traditional signalment and relative frequency of anatomic sites. , this observation is supported outside north america by the similar signalment and anatomic frequency data obtained in australia, where felv infection is quite rare. [ ] [ ] [ ] [ ] the median age of approximately years now reported in north america for lymphoma in cats is considerably higher than the median age of to years reported during the felv era. , - , , , the median age of cats within various anatomic tumor groupings has not changed, and anatomic forms traditionally associated with felv, such as the mediastinal form, still occur in younger, felv-antigenemic cats. similarly, the alimentary form occurs most often in older, felv-negative cats. , , [ ] [ ] [ ] table - presents an overview of the characteristics of the various anatomic sites of lymphoma in cats. younger cats with lymphoma tend to be felv antigenemic and are more likely to have mediastinal or multicentric lymphoma. most cats with spinal lymphoma ( % to %) also are felv antigenemic. , older cats usually are felv negative and develop alimentary lymphoma. , , , , [ ] [ ] [ ] [ ] in a large compilation of australian cases, male cats and the siamese/oriental breeds were overrepresented. similar breed findings have been observed in north america, but similar gender findings have not emerged. , the siamese/oriental breeds appear to have a predisposition for the mediastinal form that affects a younger population (median age, years). evidence also indicates that feline immunodeficiency virus (fiv) infection can increase the incidence of lymphoma in cats. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in contrast to felv, which plays a direct role in tumorigenesis, fiv appears to have an indirect role, likely secondary to the immunosuppressive affects of the virus. shelton and colleagues determined that fiv infection alone in cats was associated with a fivefold increased risk for the development of lymphomas. coinfection with felv further potentiates the development of lymphoproliferative disorders. experimentally, cats infected with fiv have developed lymphoma in the kidney, alimentary tract, and liver and in multicentric sites. fiv-associated lymphoma is more likely to have a b-cell immunophenotype whereas t-cell type is predominantly associated with felv. , , , , [ ] [ ] [ ] [ ] some have suggested that fiv infection may be associated more often with alimentary lymphoma of b-cell origin, , which may be related to chronic dysregulation of the immune system or activation of oncogenic pathways. however, in another large compilation of cases, fiv antigenemia only rarely was associated with alimentary lymphoma. , [ ] [ ] [ ] [ ] genetic and molecular factors as discussed in chapter , section a, recent advances in molecular cytogenetics (see chapter , section a), including gene microarray techniques, are being used in investigations of chromosomal aberrations in veterinary species with lymphoma. the previously mentioned predisposition of the oriental cat breeds to the development of lymphoma suggests a genetic predisposition and indicates heritable risks. , as our knowledge of molecular events and tumorigenesis has expanded, several molecular aberrations have been implicated in various feline tumor types, and some associated with lymphoma have been identified. altered oncogene/tumor suppressor gene expression, epigenetic changes, signal transduction, and deathpathway alterations are common in human lymphomas and likely are also involved in the cat. n-ras aberrations, although rare in cats, have been implicated. telomerase activity (see chapter , section d) also has been documented in feline lymphoma tissues. , other factors implicated in feline lymphoma include alterations in cellular proliferation and in cell cycle and death (apoptosis) pathways, particularly the cyclindependent kinase cell cycle regulators and the bcl- family of proapoptotic and antiapoptotic governing molecules, which have been implicated in human nhl. , environmental factors evidence that exposure to environmental tobacco smoke (ets) is a risk factor for lymphoma in humans has prompted investigations in cats. in one report, cats with any exposure to ets had a relative risk of developing lymphoma of . ; the relative risk for cats with or more years of exposure was . . immune system alterations in the cat, such as those brought on by fiv infection, have been implicated in the development of lymphoma. [ ] [ ] [ ] [ ] [ ] [ ] [ ] in a report on feline renal transplant recipients, nearly % developed de novo malignant lymphoma, which bolsters support for a link to immunosuppression in the species. these findings are similar to those seen in immunosuppressed human organ transplant patients. although definitive proof is lacking, a growing body of indirect evidence suggests that lymphoma may be associated with a state of chronic inflammation, such as in intestinal and nasal lymphoma. in particular, an association has been suggested between intestinal lymphoma and inflammatory bowel disease , - ; however, others have not found support for this concept. additional support for this association is provided by a recent report that suggests that cats with vaccine site-associated sarcoma, a syndrome directly linked to inflammation, are also at risk for the development of lymphoma. although no direct evidence exists, a link between diet and the development of intestinal lymphoma in cats has been suggested. this association is supported by the relative and absolute increase in the intestinal form of lymphoma over the past years and by the fact that several dietary modifications in cat food have occurred in a similar time frame in response to conditions such as urinary tract disease. further investigation is warranted to prove or disprove such assertions. lymphoma can be classified on the basis of anatomic location and histologic criteria. several systems of anatomic classification exist for lymphoma in the cat. some categorize the disease into mediastinal, alimentary, multicentric, nodal, leukemic, and individual extranodal forms. others have combined various nodal and extranodal forms into categories of atypical, unclassified, and mixed, while still others have combined intestinal, splenic, hepatic, and mesenteric nodal forms into one category (intra-abdominal). for the purposes of this discussion, the "mixed" form is defined as cases involving multiple sites in which no primary site categorization was possible. some discrepancies in the discussion of frequency inevitably will result from the variations in classification used in the literature. the relative frequency of anatomic forms and the immunophenotype may vary with geographic distribution and may be related to genetic and felv strain differences, as well as to the prevalence of felv vaccine use (see table - ). in most larger studies, most cases of lymphoma in cats (approximately % to %) are of the b-cell immunophenotype; however, the mediastinal, leukemic, and purely hepatic forms are more likely to be of t-cell derivation. , cats with t cell-rich b-cell lymphoma (hodgkin's-like lymphoma) and nk-like t-cell lymphoma (non-t, non-b-cell) have been described. , as with dogs, most lymphomas in cats have an intermediate-grade or a high-grade histology according to the working formulation (wf) criteria. , alimentary/intestinal lymphoma alimentary/intestinal lymphoma can manifest as a purely intestinal infiltration or as a combination of intestinal, mesenteric lymph nodes, and liver involvement. some reports limit the alimentary form to gi involvement, with or without extension to the liver. approximately two thirds to three fourths of reported cases are of the b-cell immunophenotype. most patients are older cats, and very few cases appear to be associated with felv antigenemia. , , , [ ] [ ] [ ] [ ] [ ] [ ] however, some discordance on these points is seen in the literature. in one smaller report, most alimentary cases sampled were found to be of the t-cell immunophenotype. the population size was relatively small in comparison and may represent a geographic variation. the epitheliotropic form of intestinal lymphoma also has been reported to be more commonly t-cell in origin. , a canadian group investigated formalin-fixed archival lymphoma tissue in cats and found a nearly even distribution between the b-cell and t-cell immunophenotype; they also found that approximately two thirds of the samples were felv positive by pcr techniques. , - some felv-negative tumors may be derived from transformation of multipotent lymphoid or monocyte precursors or fiv-transformed b lymphocytes. , , , the most common site of involvement in the alimentary tract is the small intestine ( % to % of cases), followed by the stomach (approximately %), ileocecocolic junction, and colon. , , the tumor can be solitary or diffuse throughout the intestines (figure - ) , muscle layers, and intestinal submucosa, resulting in annular thickening that leads to partial or complete intestinal obstruction. in a series of colonic neoplasias part iv • specific malignancies in the small animal patient necropsy specimen from a cat with intestinal lymphoma. note the generalized thickening of the small intestine and the associated mesenteric lymph node involvement (arrows). in cats, lymphoma was the second most common malignancy ( %), exceeded only by adenocarcinoma. an abstract report has described chronic lymphocytic-plasmacytic enteritis in cats that progressed to overt lymphoma after to months of conservative therapy. the mediastinal form can involve the thymus and the mediastinal and sternal lymph nodes. pleural effusion is common. in two large compilations, % of cats with thymic disease and % of cats with pleural effusion were documented as having lymphoma. , occasionally the tumor extends from the thoracic inlet and can be palpated in the ventral neck region. hypercalcemia is common with mediastinal lymphoma in dogs but is rare in cats with lymphoma. [ ] [ ] [ ] pthrp has been detected through immunoradiometric assays in cats with hypercalcemia of malignancy, including one cat with lymphoma. most cats with mediastinal lymphoma are young and felv positive, and their tumors are of the t-cell immunophenotype.* involvement of peripheral lymph nodes alone is very unusual in cats with lymphoma, representing approximately % to % of cases. , in contrast, approximately one fourth of all other anatomic forms of lymphoma have some degree of lymph node involvement. one third of cats with nodal lymphoma are of the t-cell immunophenotype and are felv antigenemic. , as lymphoma progresses, bone marrow infiltration with malignant cells and hepatosplenomegaly may develop. recently an uncommon and distinct form of nodal lymphoma in cats, referred to as hodgkin's-like lymphoma, has been reported. this form typically involves solitary or regional nodes of the head and neck and histologically resembles hodgkin's lymphoma in humans. , , these tumors generally manifest as an enlargement of a single mandibular or cervical node and immunophenotypically are classified as t cell-rich b-cell lymphoma by immunohistochemical analysis. , none have been associated with either felv or fiv. several reports of nonneoplastic peripheral lymphadenopathy in cats have been published. [ ] [ ] [ ] [ ] [ ] this condition resembles lymphoma clinically, and it has histologic features that also may resemble those of lymphoma. [ ] [ ] [ ] [ ] [ ] affected lymph nodes may be two or three times normal size. in one report, the syndrome was called distinctive peripheral lymph node hyperplasia (dplh) of young cats. these cats tend to be young ( to years old), and many have had episodes of fever or previous viral infections, or they may have hypergammaglobulinemia (polyclonal gammopathy); most are felv negative. histopathologically, the nodal architecture is severely distorted, showing loss of subcapsular and medullary sinuses. the cell population shows an admixture of histiocytes, lymphocytes, plasma cells, and immunoblasts and occasionally effaced lymphoid follicles. the lymph nodes regress spontaneously in most of these cats. the histologic changes noted in these lymph nodes resemble the histologic features of acquired immunodeficiency syndrome (aids)-related lymphadenopathy in humans. in another report, benign lymphadenopathy in cats was associated with argyrophilic intracellular bacteria. the most common extranodal sites for lymphoma are the kidneys, nasal cavity, eyes, retrobulbar space, cns, and skin. renal lymphoma can be primary or associated with alimentary lymphoma. based on several studies, the median age for cats with renal lymphoma is approximately . years. one fourth of cases are felv antigenemic, and most are of the b-cell immunophenotype. , , , the frequency of renal lymphoma is reported to be approximately % of all lymphomas. extension to the cns is a common sequela to renal lymphoma and occurs in % to % of treated cats. nasal/paranasal lymphoma usually is a localized disease; however, systemic extension occasionally is seen. , , neoplasia accounts for most nonviral nasal/paranasal disease in cats, and lymphoma has been reported to represent nearly one third to one half of these cases. [ ] [ ] [ ] it occurs primarily in older, felvnegative cats (median age, to years). at least three fourths of cases are b cell in origin, and most are intermediate grade or high grade histologically. , - a subset of epitheliotropic t-cell nasal lymphomas has been reported. cats that are concurrently felv positive are more likely to have concurrent systemic disease. in the older literature, cns lymphoma was most often seen extradurally in the spinal canal of felv-positive cats ( % to %). , , however, in more recent reviews, both spinal cord and intracranial lymphoma occurs mostly in older, felv-negative cats, and spinal cord sites are more commonly intradural than extradural. , after meningioma, lymphoma is the second most common tumor involving the cns in cats. feline cns lymphoma may be primary or may occur secondary to multicentric involvement (especially of the renal system or bone marrow). [ ] [ ] [ ] [ ] bone involvement is rarely seen radiographically. multiple cord regions and the brain are involved in nearly % of cats with spinal lymphoma, and more than % of these patients have other organ (e.g., renal) and bone marrow involvement. , , only one third of cases of intracranial lymphoma are primary and confined to the cns, and all cats tested have been fiv negative. cutaneous lymphoma generally is primary but can be seen secondary to multicentric involvement. it commonly is seen in older cats (median age, to years) and gender sex or breed predominance has not been found. [ ] [ ] [ ] [ ] [ ] although patients usually are felv negative, one case report using pcr techniques found evidence of felv provirus in tumor dna. cutaneous lymphoma can be solitary or generalized. two forms of cutaneous lymphoma have been distinguished histologically and immunohistochemically. [ ] [ ] [ ] [ ] [ ] in most species, the epitheliotropic form, sometimes referred to as mycosis fungoides, is composed of t lymphocytes, whereas the nonepitheliotropic form usually is composed of b lymphocytes. in contrast, one report of nonepitheliotropic cutaneous lymphoma in cats found that five of six cases were of t-cell derivation. neoplastic t lymphocytes are large and have abundant cytoplasm and convoluted nuclei (mycosis cells). they usually form intraepidermal nests of five to cells, which are separated from surrounding keratinocytes by a clear space (pautrier's microabscesses). the b-cell lymphomas show lymphocytes deep in the epidermis, with sparing of the papillary dermis and epidermis. a recent report described cases of cutaneous lymphocytosis, an uncommon disease histologically resembling well-differentiated lymphoma. solitary lesions were most common, and all were composed primarily of t-cells, although two thirds had some b-cell aggregates. cutaneous lymphocytosis was characterized as a slowly progressive disorder, but internal organ infiltration developed in a few cases. a cat with cutaneous t-cell lymphoma and circulating atypical lymphocytes has been reported. the circulating cells were lymphocytes with large, hyperchromatic, grooved nuclei. in humans, cutaneous t-cell lymphoma with circulating malignant cells is called sézary syndrome, which also has been reported in dogs. [ ] [ ] [ ] [ ] a number of histopathologic grading systems have been used to classify human nhl, including the wf (discussed earlier in the chapter). most recently, the wf was used to classify more than cases of feline lymphoma. low-grade lymphoma was found in % of the cases, intermediate-grade disease in %, and high-grade lymphoma in %. about . % were plasmacytomas. more than one third of the tumors were the immunoblastic type. lymphoblastic lymphoma, a subtype of the high-grade tumor, accounted for less than %. similarly, in a large group of cases compiled in australia (n = ), % of the cases were mediumto high-grade disease as classified by the wf. also as discussed earlier in the chapter, who has published a histologic classification scheme that uses the revised european american lymphoma (real) system as a basis for defining histologic categories of hematopoietic tumors of domestic animals. this system incorporates both histologic criteria and immunohistologic criteria (b-and t-cell immunophenotype). the clinical relevance of this system is likely to be high; however, it awaits further investigation and evaluation. in a series of cases of alimentary lymphoma, % were the high-grade lymphoblastic type. however, in another report, many of the intestinal lymphomas had several characteristics of malt, as described in humans; that is, a tendency to remain localized in the lamina propria, a relatively indolent clinical behavior, and an excess of low-grade tumors. the age of affected animals varied considerably with various subtypes, but in general, low-grade tumors tended to develop in older cats (over years of age), and high-grade tumors tended to develop in younger cats (under years of age). a less commonly reported, distinct form of alimentary lymphoma has been described and classified as large granular lymphoma. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] these lesions are granulated, round cell tumors that also have been called either globule leukocyte tumors or large granular lymphocyte lymphoma, although they probably are variations of the same disease. large granular lymphocytes are characterized by abundant cytoplasm with prominent azurophilic granules. this population of cells includes nk cells and cytotoxic t cells. several reports have identified their immunophenotype as cd , cd -like, perforin positive, and cd negative; these cells also have been described as having a t-cell receptor gene rearrangement. these tumors commonly originate in the small intestine, especially the jejunum or mesenteric lymph nodes; however, most cases show widespread metastasis to the lung, myocardium, salivary gland, and spinal cord. leukemia also has been reported with this disease. affected cats generally are felv negative. large granular lymphocytes must be differentiated from several other granular cell types that may be found in the small intestine, including enterochromaffin cells, mast cells, and eosinophils. the clinical signs associated with feline lymphoma vary and depend on the location and extent of disease. the alimentary form is most commonly associated with an abdominal mass that originates in the gi tract. the condition often is associated with enlarged mesenteric lymph nodes or other organ involvement. in % to % of cases, a palpable abdominal mass or thickened bowel loops are present. , , , , clinical signs may consist of weight loss, anorexia, diarrhea, and occasional vomiting. in approximately half of cases, the only historical finding is anorexia and weight loss. other reported presentations include abdominal distention, splenomegaly, persistent thrombocytopenia, and pica. hematochezia and tenesmus may be present if the lymphoma involves the colon. polyuria and polydipsia have been reported in approximately % of cases. in a small percentage of cases, the patient may have signs consistent with an acute abdomen as a result of intestinal perforation and concurrent peritonitis. clinical signs of the mediastinal form of lymphoma include dyspnea, tachypnea, and a noncompressible anterior mediastinum with dull heart and lung sounds. , [ ] [ ] [ ] [ ] in rare cases, horner's syndrome may be present as a result of involvement of the sympathetic nerve as it ascends around the first rib, and edema of the head may be caused by pressure on the cranial vena cava. pleural effusion is common; the pleural fluid is characterized by serohemorrhagic to chylous effusion, and in most cases neoplastic cells (lymphoblasts) are identified. , cats with the nodal form of lymphoma have variable clinical signs, depending on the location and extent of disease; however, these cats often are depressed and lethargic. peripheral lymphadenopathy as the only physical finding is a very uncommon presentation for cats. as stated earlier, an uncommon and distinct form of nodal lymphoma in cats is hodgkin's-like lymphoma. this form typically involves a single mandibular or cervical node, and the cat usually does not have any overt clinical signs. , in cats, unlike in dogs, peripheral lymphadenopathy without organomegaly is more often hyperplastic or reactive and does not represent lymphoma. the extranodal sites include the kidneys, skin, eyes, nasal area, and cns. renal lymphoma is most consistently bilateral, even in cats that appear to have unilateral disease. in general, the kidneys are uniformly enlarged; however, they may also feel lumpy and irregular on palpation. more than % cats have signs consistent with renal insufficiency. cats with cns lymphoma most often have signs associated with thoracolumbar involvement. , the most common sites are between the second thoracic and fourth lumbar vertebrae. signs include gradual or sudden onset of weakness, upper motor neuron paralysis to the bladder, tail flaccidity, hyperpathia in the region of the lesion, and progressing ataxia. the neurologic dysfunction may be insidious or may progress rapidly. cats with cervical spinal cord or nerve root involvement generally show peracute tetraparesis and diminished sensation in the thoracic limbs. those with cervical root involvement may show root lesions (root signature), such as lameness and hyperesthesia upon shoulder extension. common presenting signs for intracranial lymphoma, in decreasing order of frequency, include anorexia, ataxia, lethargy, altered consciousness, and aggression. cats with nasal lymphoma usually have signs localized to the nasal passage. in a large compilation of cases, the presenting complaints, in decreasing order of frequency, were unilateral nasal discharge (bilateral is less common), facial deformity, dyspnea, and epistaxis. - stertor, anorexia, epiphora, exophthalmia, sneezing, and regional lymphadenopathy also can occur. cutaneous lymphoma may be solitary or diffuse and manifest with alopecia, erythema, and crusted papules. minimal peripheral lymphadenopathy may also be present. in most cats the signs have a prolonged duration (i.e., several months). [ ] [ ] [ ] [ ] [ ] nonspecific signs all cats with lymphoma, regardless of the site, may have secondary bone marrow infiltration that leads to anemia and a leukemic blood profile. anemia is a common condition in cats with lymphoma, and at least % have moderate to severe nonregenerative anemia. signs related to paraneoplastic hypercalcemia (pu/pd) can occur in cats, but the syndrome is much less common than in the dog. in one survey of hypercalcemia in cats, approximately % were diagnosed with lymphoma of various anatomic types. one case of hypereosinophilic paraneoplastic syndrome and one case of symmetric cutaneous necrosis have been reported in cats with lymphoma. , a number of disease conditions can be confused with lymphoma in cats (table - ) . for most cats suspected of having lymphoma or leukemia, the diagnostic evaluation should include a cbc with differential cell count, platelet count, serum chemistry profile, and a test for felv and fiv. bone marrow aspiration or biopsy may be indicated to evaluate for possible involvement and complete staging of the extent of disease. bone marrow evaluation is particularly indicated if anemia, cellular atypia, and leukopenia are present. histopathologic evaluation of lymph nodes or involved organ tissue (procured by means of surgical incision, endoscopy, or needle core biopsy) is essential for a definitive diagnosis. in the cat, lymph node fine-needle aspiration alone is not sufficient in most cases because of the difficulty involved in distinguishing lymphoma from benign hyperplastic lymph node syndromes unique to the species; these include idiopathic peripheral lymphadenopathy, plexiform vascularization of lymph nodes, and peripheral lymph node hyperplasia of young cats. [ ] [ ] [ ] [ ] [ ] whole lymph node excision is preferred in these cases, because determination of the orientation, invasiveness, and architectural abnormalities may be necessary for diagnosis. additional site-specific cytologic or histologic assessments may be warranted when extranodal sites are suspected. histologic and cytologic samples also can be analyzed by various histochemical and immunohistochemical techniques to determine the immunophenotype (b cell or t cell), tumor proliferation rate (e.g., ki- , pcna, agnors), and telomerase activity (see chapter , section d), and histologic subtype (low, intermediate, or high grade). , , , , , , the availability of such analysis is increasing, but currently none has proved to be predictive of outcome in cats. serum chemistry profiles can help establish the overall health and clinical staging of cats, but the results are not specific for a diagnosis. elevated liver enzymes may indicate hepatic infiltration with lymphoma, and elevated blood urea nitrogen (bun) and creatinine levels may indicate renal lymphoma. for cats with alimentary lymphoma, hypoproteinemia and anemia are reported to occur in up to % and % of cases, respectively. , hypercalcemia is rare in cats but has been reported in patients with lymphoma at various anatomic sites. , - elevated globulin levels may indicate the presence of a monoclonal gammopathy with or without serum hyperviscosity (this is a rarely reported paraneoplastic syndrome in cats with lymphoma). , hypoglycemia was reported in approximately one third of cats with lymphoma in an australian study. serum alpha -acid glycoprotein concentrations have been reported to be elevated in cats with lymphoma, but no clinical relevance has been associated with this finding. most cats with alimentary lymphoma develop a palpable abdominal mass or thickened intestinal loops. approximately one third of patients have a mass that can be visualized on abdominal radiographs, and about % have ultrasound abnormalities. , the ultrasound abnormalities may include mesenteric lymphadenopathy in % to % of cases, an intestinal mass or thickening in approximately % of cases, and possibly splenomegaly (approximately % of cats with ultrasonographic changes in the spleen have lymphoma ), hepatomegaly, or effusion. , in one compilation of cases, the lesions appeared ultrasonographically to be localized in % of cases and diffuse in %; however, at surgery only % were resectable. for alimentary lymphoma, especially if primary gi lymphoma is suspected, caution must be exercised when endoscopically obtained tissue is used because of the difficulty in differentiating lymphoplasmacytic gastroenteritis from primary, diffuse, intestinal lymphoma. however, diagnosis of this disease by means of endoscopically derived biopsies is improving with more advanced techniques and instrumentation. a wedge biopsy through serosa and muscularis, avoiding the mucosa, may be necessary to establish a diagnosis in cases in which endoscopic samples are equivocal. as an alternative, because nearly half of alimentary lymphomas have secondary mesenteric lymph node involvement, ultrasound-guided biopsy specimens or fine-needle aspirates may be adequate for a diagnosis. for cats with mediastinal lymphoma, diagnostic suspicion may begin with a noncompressible cranial thorax on physical examination and conformation of a mediastinal mass or pleural effusion on a thoracic radiograph (figure - ) . fine-needle aspiration of any suspected mass or cytologic evaluation of pleural fluid may be sufficient to establish a diagnosis. in most cats the finding of a monotonous population of lymphoblasts establishes a diagnosis. , , however, definitive diagnosis of lymphoma in cats with a mediastinal mass and concurrent chylothorax can be challenging. the ct appearance of these lesions has been in chylous effusions, the pleural fluid triglyceride concentration is greater than in the serum; however, anorectic cats have lower triglyceride levels in the pleural fluid. a major differential diagnosis for mediastinal lymphoma is thymoma. the cytologic features of thymoma were recently described, and although these were found to be distinct from lymphoma in many cases, the diagnosis was challenging because of a preponderance of small lymphocytes in thymoma. mast cells can also be seen in up to % of aspirate samples from thymomas. diagnostics for most extranodal forms of lymphoma are site specific. in cats suspected of having spinal lymphoma, survey radiographs of the spine rarely reveal osseous lesions. myelograms, ct, or mri is indicated, and in approximately % of cases, an extradural or intradural mass is detected. , , , most lesions occur at a thoracolumbar or lumbosacral location. fluoroscopic-guided, fine-needle aspiration of epidural lesions may yield enough tissue for a cytologic diagnosis. in most of the cats evaluated in one study, csf analysis revealed a clear, colorless fluid with a mixed pleocytosis (mean, cells/µl; range, to cells/ul) and an elevated protein content (mean, . mg/dl; range, to mg/dl). malignant lymphocytes were identified in six of cats evaluated with csf analysis. in a report of intracranial neoplasia, one of two cats with lymphoma had lymphoblasts in the csf fluid. bone marrow and renal involvement are common in cats suspected of having cns lymphoma, and cytologic assessment of these organs generally is easier than in spinal sites. if nasal lymphoma is suspected, a biopsy specimen can be obtained either by intranasal procurement or by flushing one hemicavity with a bulb syringe and saline while occluding the contralateral cavity and collecting samples flushed out the nasopharynx (figure - ). thorough staging to make sure that the disease is confined to the nasal passages is recommended, because this presentation can be treated locally with radiotherapy if systemic involvement is ruled out. a ct scan is indicated to determine local involvement and to plan radiotherapy if it is to be pursued. for cutaneous lymphoma, punch biopsies ( to mm) should be taken from the most representative and infiltrative sites, although overtly infected skin lesions should be avoided. complete staging to rule out systemic disease is also recommended for cats with cutaneous lymphoma, because local therapies can be applied in cases of solitary disease. in the case of renal lymphoma, physical examination findings of massive and often bilateral renomegaly raise the index of suspicion. the radiographic appearance is a smooth to irregular renomegaly ( figure - , a) that is most consistent with either renal lymphoma or polycystic kidney disease. the disease usually is diffuse throughout the renal cortex ( figure - , b) , and transabdominal needle aspiration or core biopsy is diagnostic in most cases. a who staging system exists for the cat that is similar to the one used in the dog (see box - ). however, because of the high incidence of visceral involvement in the feline species, another staging system is used more often (box - ). because lymphoma in cats is more varied with respect to location and anatomic types, staging systems generally are less helpful for predicting response. occasionally the diagnosis of lymphoma and the differentiation of malignant and benign proliferation of lymphocytes is not possible based on standard histologic and cytologic criteria. in these cases, advanced molecular analyses may be helpful for confirming a diagnosis. clonality is the hallmark of malignancy; that is, the malignant cell population theoretically is derived from expansion of a single malignant clone. this was discussed earlier in the chapter for lymphoma in the dog (see section a and figure - ) , and the same assays can be applied for advanced diagnosis of lymphoma in cats. investigators have used pcr techniques to amplify the variable regions of the t-cell and immunoglobulin receptor genes to detect clonal lymphocyte populations in cats, and these techniques appear to be a useful adjunctive diagnostic tool, although they are undergoing a more thorough assessment. molecular techniques may also prove useful for assessing early recurrence, for more accurate clinical staging, and for providing so-called molecular remission rates, because they are more sensitive than the standard cytologic assessment of peripheral blood, bone marrow, or lymph nodes. our knowledge base for treating cats with lymphoma is less well established and less predictable than that for dogs, primarily because of the greater variation in histologic type and anatomic locations observed in felines. the chemotherapeutic agents most often used to treat feline lymphoma are similar to those used for dogs and humans with lymphoma (see section a); they include doxorubicin, vincristine, cyclophosphamide, methotrexate, l-asparaginase, ccnu, and prednisone.* in general, cats tolerate chemotherapy quite well. selected published protocols for the treatment of feline lymphoma are detailed in table - . most current combination protocols in north america are modifications of chop protocols initially designed for human oncologic use. in europe, cop (i.e., without the addition of doxorubicin) is used more often in cats with lymphoma, and one compilation reported results similar to those for chop. some studies with relatively few case entries have reported limited activity for doxorubicin as a single agent in cats with lymphoma , ; however, larger studies using combination protocols have more consistently reported that the addition of doxorubicin is necessary to attain more durable responses. , in european and australian studies that reported less favorable doxorubicin responses, the patient populations consisted of a higher proportion of the mediastinal form in siamese cats, a population less frequently included in north american reports. , the protocol the authors use in their practice is presented in table - . this protocol has been used in many cats with various forms of lymphoma and is well tolerated. currently, our canine lymphoma protocols (see section a) discontinue chemotherapy by week , and we have sufficient data exist to show that in dogs, this short, maintenance-free protocol is as good as if not superior to longer maintenance protocols. because long-term maintenance protocols have not proved superior to maintenance-free protocols in dogs and humans with lymphoma, the same likely holds true in the cat, although no data exist to document this. until such time as evidence to the contrary exists, we recommend discontinuation of chemotherapy at week in cats that have attained complete remission. although doxorubicin appears to be the most effective agent for treating cats with lymphoma in north america, the species generally is less tolerant of doxorubicin than are dogs, and significant toxicity results when it is used at the dog dosage of mg/m given intravenously every weeks. however, at lower dosages (e.g., mg/m or mg/kg, given intravenously) doxorubicin can be used without significant toxicity. , the major toxicities noted with doxorubicin are anorexia, myelosuppression, renal toxicity and, if perivascular leakage occurs, severe tissue damage. clinical doxorubicin-induced cardiac toxicity has not been documented in cats, but no information indicates that cats are resistant to myocardial damage. renal toxicity has been produced experimentally in rats and box - • single tumor (extranodal) with regional lymph node involvement • two or more nodal areas on the same side of the diaphragm • two single (extranodal) tumors with or without regional lymph node involvement on the same side of the diaphragm • resectable primary gastrointestinal tract tumor, usually in the ileocecal area, with or without involvement of associated mesenteric nodes only rabbits and has been reported in cats. [ ] [ ] [ ] in our experience, the incidence is significant enough that renal function in cats should be monitored closely (i.e., serial creatinine and urine specific gravity analysis) before each therapy session. a stealth liposomal form of doxorubicin has been shown to increase the likelihood of renal toxicity and therefore is limited in its use in this species. a small number of cats with lymphoma have been treated with single agent ccnu at dosages ranging from to mg/m given orally every to weeks. , although activity was noted, only partial responses were reported. little is known about the treatment of solitary or regional nodes of the head and neck that closely resemble hodgkin's lymphoma histologically. , one study described the clinical outcome in four cats with this condition; these researchers found that the course of disease was prolonged, but after surgical excision of the single affected node, only one cat showed recurrence months after surgery. a second surgery was performed in this cat, and a second recurrence was noted, again months after excision. cats with granular cell lymphoma or globule leukocyte tumors tend to respond poorly to chemotherapy, although durable responses have been reported. currently, too few cases have been treated with aggressive chemotherapy to allow an assessment of response to therapy for this disease. a distinct form of intestinal lymphoma in cats that is composed of small, mature lymphocytes has been referred to as lymphocytic lymphoma. this syndrome has been reported to respond well to oral prednisone ( mg/cat/day) and chlorambucil ( mg/m given once daily for consecutive days out of every weeks). a complete response rate of % was reported, with median remission and survival durations of and months, respectively. radiation therapy has been used effectively to treat localized lymphoma, such as epidural, mediastinal, and nasal lymphoma. total doses of to gy usually result in a complete remission. in one study, cats with localized lymphoma were treated with radiation, alone or with chemotherapy, at doses of to gy. eight of the cats achieved complete remission, with a median remission duration of just over years. radiation therapy also has been used effectively to treat nasal lymphoma. complete response is the norm ( % to %), and median remission durations exceeding . years can be expected in felv-negative cats with disease confined to the nasal and paranasal cavities. for nasal lymphoma, radiotherapy appears to be superior to chemotherapy, for which reported median remission durations are to days. very little has been published about the treatment of cutaneous lymphoma or mycosis fungoides in cats; however, a report of a complete response to ccnu exists. cats with a solitary mass should be treated with surgical excision, although clinical staging is necessary to rule out possible internal involvement. combination chemotherapy can be considered if multiple sites are involved. if the disease is localized to a small region, radiation therapy usually is also effective. mycosis fungoides may be treated effectively in dogs with retinoids, such as isotretinoin (accutane) at a dosage of to mg/kg given orally daily or etretinate (tegison) at a dosage of . mg/kg given orally daily; however, no providing precise treatment recommendations for the wide variety of clinical settings of cats with lymphoma is difficult. our current recommendation is to treat cats with lymphoma using the chop-based protocols (see table - ). doxorubicin alone ( mg/m given iv every weeks for five total treatments) or palliative prednisone therapy is offered if the client declines more aggressive therapy. nutritional support is especially important, particularly for cats with alimentary lymphoma. a feeding tube may need to be placed in cats undergoing chemotherapy for alimentary lymphoma, particularly if anorexia is a factor (see chapter , section b.) ultimately, most cats with lymphoma that are successfully treated with chemotherapy have a relapse of the disease. this often represents a recrudescence of the tumor in a more drug-resistant form. at the first recurrence, reinduction first should be attempted by using the induction protocol that was successful initially. in general, the likelihood of a response and the length of the response are half those for the initial therapy; however, a subset of animals enjoy long-term reinduction. if reinduction fails or if the cat does not respond to the initial induction, so-called rescue agents or rescue protocols can be attempted. these are drugs or drug combinations that typically are not found in the standard chop protocol and are withheld for use in drugresistant cases. a number of rescue protocols have been reported in the veterinary literature and were reviewed previously. , the most common rescue protocols advocated for cats with resistant relapse include single agent use or combination use of mitoxantrone, doxorubicin (if doxorubicin was not part of the original induction protocol), ccnu, and mopp. in general, overall rescue response rates of % to % are reported, but these responses usually are not durable; median responses of . to months are the norm. a small subset of animals enjoy longer rescue durations. in general, cats do not enjoy response rates as high or remission and survival durations as long as dogs with lymphoma. complete response rates range from % to % after combination chemotherapy, and overall median remission and survival durations are approximately and months, respectively. , , , , however, a significant proportion of cats ( % to %) that achieve a complete response with combination chemotherapy enjoy more durable overall remission and survival times (i.e., year or longer). the response rate and the length of response vary according to the presence or absence of several prognostic factors. the wide variation in frequency and the great heterogeneity of anatomic forms of lymphoma in cats make specific prognostications more difficult than in dogs with lymphoma. most studies have lumped anatomic groups together to produce remission and survival data, and individual group numbers generally have been too small to apply statistical analysis with meaningful power. that being said, the factors that appear to be most strongly associated with a more positive prognosis in cats are a complete response to therapy (figure - ) , which unfortunately cannot be determined before treatment; negative felv status ( figure - ) ; early clinical stage (figure - ) ; anatomic location; and addition of doxorubicin to the treatment protocol. , , , unlike in the dog, cd immunoreactivity has not been established as a negative prognostic factor in the cat. early reports may contradict more recent studies partly because of the decline in felv-associated lymphoma, and patients reported in the early literature may not equate to more recent populations studied. in general, felv-negative cats that achieve a complete response on chop-based protocols have a high likelihood of long-term survival, proportion alive with approximately % alive at . years after diagnosis. for cats with alimentary lymphoma, median survival times of to months are expected with chemotherapy that includes doxorubicin. , , in one study of cats with alimentary lymphoma in which the treatment protocol did not include doxorubicin, the median survival time was only days. mediastinal lymphoma in felv-positive young cats is associated with the poorest prognosis, and survivals times of approximately to months are expected with chemotherapy. , , in contrast, older, felv-negative siamese cats with mediastinal lymphoma appear to experience remission rates approaching %, and responses tend to be quite durable. overall, cats with nasal lymphoma have the best prognosis, because local radiotherapy (or chemotherapy if radiotherapy is not available) generally results in excellent control, with median survival times approaching . years. , however, cats with nasal lymphoma and concurrent felv infection have much shorter survival durations. renal lymphoma is associated with a shorter survival time, with published medians ranging from to months. , , , in a study by mooney and colleagues, cats with primary renal lymphoma were treated with combination chemotherapy. a complete response (cr) was noted in cats ( %), and nine ( %) had a partial response. the median survival times were months for the cats that showed a complete response and month for those that showed a partial response. the duration of response to chemotherapy did not correlate with the degree of renal insufficiency except in cats with a bun higher than mg/dl. extension to the cns occurred in % of these treated cats. the investigators revised their chemotherapy protocol to include cytosine arabinoside, which can penetrate the blood barrier, theoretically to prevent or reduce cns metastasis; however, definitive improvement with this modification has not been documented. few studies have reported on the results of treatment of cats with spinal lymphoma. in one study of four cats treated with chemotherapy (l-asparaginase, vincristine, and prednisone) combined with spinal radiation (n = ) or surgical cytoreduction (n = ), most of the cats were euthanized by months, although one cat survived months. in another study of nine cats treated with chemotherapy (vincristine, cyclophosphamide, and prednisone), three cats achieved a complete response with a duration of weeks and three achieved a partial response with a duration of weeks. one cat treated with dorsal decompression laminectomy and chemotherapy survived months. although the numbers are small overall, the prognosis for spinal lymphoma is poor. section c of this chapter presents a complete discussion of leukemias and mpds, including a general discussion of hematopoiesis, etiologies, lineage classification, and descriptions. the classification of leukemias in cats is difficult because of the similarity of clinical and pathologic features and the transition, overlap, or mixture of cell types involved. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] leukemia is a neoplastic proliferation of hematopoietic cells that originate in the bone marrow. cell lineage includes myeloid cells, neutrophils, basophils, eosinophils, monocytes, lymphoid cells, megakaryocytes, and erythrocytes. box - presents a classification scheme for the leukemias identified in the cat. leukemias also must be classified according to their degree of differentiation. well-differentiated leukemia is referred to as chronic leukemia, and poorly differentiated leukemia usually is called acute leukemia; this distinction is very important in the therapeutic management and prognosis of leukemias. cats with acute leukemia usually show signs of severe anemia (pale mucous membranes), splenomegaly, and febrile episodes. cats with chronic leukemia may have a longer duration of signs and mild anemia with or without splenomegaly. in cats suspected of having leukemia, bone marrow aspiration or biopsy usually is diagnostic. the preferred sites for bone marrow aspiration are the proximal humerus and the iliac crest. cats with acute leukemia are likely to have malignant cellular infiltrates in organs other than the bone marrow. the bone marrow aspirate must contain more than % abnormal blast cells to support a diagnosis of an acute leukemia. in cats suspected of having cll, infiltration of the bone marrow with more than % mature lymphocytes helps confirm the diagnosis. all cats with leukemia should be tested for felv and fiv. determining the lineage of some leukemias can be challenging; most can be distinguished from one another by histologic appearance, histochemical stains, immunohistochemical analysis of cell surface antigens, and flow cytometric analysis of the leukemic cells for cellular antigens that identify their lineage. , , , in addition, examination of blast cells by electron microscopy may reveal characteristic ultrastructural features. the french-american-british (fab) classification system (box - ) is considered useful in cats with myelodysplastic syndromes, and almost all these patients are felv antigenemic. , lymphoid leukemia is the most common leukemia in cats. approximately % of cats with lymphoma also have a leukemic blood profile. all is the most common lymphoid leukemia. all is characterized by the presence of poorly differentiated lymphoblasts and prolymphocytes in the blood and bone marrow. most cats with all have normal to low wbc counts. a few cats have leucocytosis with circulating blasts. a moderate to marked anemia is common. bone marrow aspiration usually reveals extensive infiltration with lymphoblasts. approximately % to % of cats with all are felv positive, and most malignant cells have a t-cell phenotype. cll, which is rarely reported in cats, is characterized by the presence of well-differentiated, small, mature lymphocytes in the peripheral blood and bone marrow. , although most of these cells are of the t-cell lineage (particularly t helper), b-cell cll has been reported. , , most cats with cll have an elevated wbc count (i.e., over , /µl), and most are felv negative. the total leukocyte count varies and may range from leukopenia to marked leukocytosis. chronic granulocytic leukemia (gl) must be distinguished from leukemoid reactions associated with infections. acute gl is characterized by a large percentage of myeloblasts and/or progranulocytes in the blood and bone marrow. myeloblasts can be difficult to distinguish from lymphoblasts, but the former have a finer chromatin pattern, a smaller nucleus-to-cytoplasm ratio, more prominent or multiple nucleoli, and sometimes cytoplasmic granules. it is not uncommon in cats with gl to have no recognizable neoplastic cells in the peripheral blood. the bone marrow is hypercellular as a result of granulocytic leukemia cells. , , , myelomonocytic leukemia (mml) results from malignant transformation of both neutrophils and monocytes. this form of leukemia is one of the most common forms reported. monocytic leukemia (ml) is a rarely reported leukemia. it generally is considered an acute leukemia regardless of the morphologic appearance of the cells. eosinophilic leukemia (el) is rarely diagnosed in cats and is considered a variant of chronic granulocytic or myeloid leukemia. , felv has induced el experimentally. mature eosinophils outnumber immature stages, and anemia is uncommon in cats associated with el. cats usually have an eosinophil count of , cells/µl or higher with or without immature cells in the peripheral blood. the bone marrow shows hyperplasia of eosinophilic precursors, and the myeloid to erythroid ratio (m:e) is significantly increased. organ infiltration, such as in lymph nodes, the spleen, and the liver, can be seen. in establishing a diagnosis of el, it is important to rule out eosinophilic enteritis, parasitism, eosinophilic granuloma complex, and allergic disorders. diagnosing el can be very difficult because of the hypereosinophilic syndrome (hes) seen with other disease conditions in cats. [ ] [ ] [ ] hes is characterized by a marked increase in the eosinophil count, bone marrow hyperplasia of eosinophilic precursors, and multiple organ infiltration by mature eosinophils. most cats have signs related to gi involvement. basophilic leukemia (bl) is considered a variant of chronic granulocytic leukemia. only one confirmed case of basophilic leukemia has been reported in the cat. it is important to differentiate bl from systemic mastocytosis with mast cell leukemia. mast cells have numerous cytoplasmic granules and round nuclei. basophils have segmented nuclei and cytoplasmic granules that superimpose on the nucleus, giving it a moth-eaten appearance. erythremic myelosis [ ] [ ] [ ] [ ] erythremic myelosis (em) is an mpd characterized by excessive proliferation of erythroid elements, which results in an increase in nucleated erythrocytes (rubriblasts to metarubricytes). severe anemia is common, and the peripheral blood shows numerous nucleated erythrocytes, moderate to marked anisocytosis, and an increased erythrocyte mean cell volume. the bone marrow contains a preponderance of normal-appearing erythrocyte precursors. some cats undergo blast transformation to myeloblastic, granulocytic, or a poorly differentiated leukemia (previously called reticuloendotheliosis). the transition from erythremic myelosis to erythroleukemia to acute granulocytic leukemia is well recognized in humans. , , erythroleukemia, or acute erythremic myelosis, can develop from blast transformation of erythremic myelosis. primitive erythroid precursors in the blood and bone marrow predominant. primitive cells resembling myeloblasts often are present in low numbers. [ ] [ ] [ ] [ ] primary erythrocytosis is rarely reported in cats, and the diagnosis is based on an elevated pcv ( % to %) with low to normal serum erythropoietin activity. most clinical signs are associated with an increased red blood cell (rbc) volume, which increases blood volume and viscosity, causing impaired blood flow, stasis, and tissue hypoxia. neurologic signs such as seizures, blindness, and mental depression are common. the oral mucous membranes may appear brick red. it is important to differentiate this condition from secondary polycythemia caused by renal tumors, chronic hypoxia, and right-to-left cardiac shunts. [ ] [ ] [ ] megakaryocytic leukemia is characterized by abnormal megakaryocytic hyperplasia in the bone marrow. the megakaryocytes are morphologically abnormal, and some are small (dwarf megakaryocytes) and have few or no nuclear lobulations. thrombocytopenia or thrombocytosis may be present. in humans this form of leukemia often is associated with extensive marrow fibrosis and an increase in reticulum or collagen. primary thrombocythemia is a very rare, chronic mpd characterized by proliferation of megakaryocytes and elevated platelet counts exceeding million. giant platelets and platelets with abnormal morphology may be seen in the peripheral blood. one case has been reported in the cat. [ ] [ ] [ ] [ ] [ ] malignant histiocytosis, a rare condition in cats, is characterized by systemic proliferation of malignant macrophages (histiocytes) and their precursors. a distinguishing characteristic of this disease is erythrophagocytosis. hepatosplenomegaly with progressive anemia (sometimes coombs positive) and thrombocytopenia are characteristic. the erythrophagocytosis may be confused with a possible immune-mediated anemia. bone marrow biopsy, rather than aspiration, and splenic biopsy may be necessary to establish a diagnosis. special stains using acid phosphatase and nonspecific esterase with fluoride inhibition (naphthol butyrate substrate) may be necessary to indicate macrophage origin. metaplasia [ ] [ ] [ ] [ ] myelofibrosis and myeloid hyperplasia are characterized by abnormal growth and differentiation of erythroid, myeloid, and megakaryocytic cell types with varying proliferation of fibroblasts in the marrow. anemia, leukopenia, or thrombocytopenia or varying combinations are common. myelofibrosis has been diagnosed in felv-positive cats and is directly associated with the virus rather than a consequence of myeloproliferative disorders. myeloid metaplasia may terminate in acute leukemia and therefore may be considered a preleukemic event. the use of chemotherapy to treat all has been disappointing. a % complete response rate has been reported with a cop regimen. , , , in cats treated with cop for all, four achieved a cr and cats had a partial response. the median remission was months (range, to months). one report described a short-term remission in a cat with lymphoid leukemia that was treated with a low dose of cytosine arabinoside ( mg/m given subcutaneously twice daily). cll can be treated with chlorambucil ( . mg/kg given orally or mg/cat given every other day) and prednisone at a dose of mg/kg given orally daily. cats with cll have a better prognosis and survive to years when treated with chlorambucil. as in humans and dogs, treatment can be withheld if the patient has no significant clinical signs and no profound cytopenias. in one study, a cat with cll remained stable without chemotherapy for over a year. the prognoses for acute nonlymphoblastic leukemias generally are very poor, although some exceptions exist. a treatment regimen consisting of a combination of cytosine arabinoside and cyclophosphamide and multiple blood transfusions was effective at inducing a response for months in a cat with acute megakaryocytic leukemia. hydroxyurea (hydrea) can be used to treat chronic myeloid leukemia and primary erythrocytosis. cats with primary erythrocytosis that go untreated are reported to survive to + weeks. , phlebotomy alone every to months was used to treat one cat, which survived longer than months. hydroxyurea treatment for primary erythrocytosis was used in eight cats, and all survived longer than year. hydroxyurea is available in mg capsules, and the dosage is to mg/kg given orally daily. some cats have been given mg every to days, but methemoglobulinemia and hemolytic anemia with heinz bodies has been seen. a better recommendation is to have the drug formulated into mg capsules, which is a more appropriate dosage. however, care must be used in making these capsules because hydroxyurea is potentially carcinogenic. a recommended treatment schedule for hydroxyurea is mg daily to every other day, depending on the type of leukemia under treatment. the drug is tolerated very well at this dosage. a case of acute ml in a cat undergoing treatment with cytarabine, doxorubicin, vincristine, and prednisolone has been reported; a partial remission was noted for approximately months, and the cat survived for months after diagnosis. a retrospective study subcommittee to re-examine criteria for a classification system and to spearhead large multi-institutional studies to validate the criteria. mpds are uncommon or rare in the dog; they occur times less frequently than lymphoproliferative disorders. accurate information about the incidence and other epidemiologic information await consistent use of a uniform classification system (see later discussion). no known age, breed, or gender predisposition exists, although large breed dogs have been overrepresented in some retrospective studies. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in dogs, the etiology of spontaneously occurring leukemia is unknown. genetic and environmental factors (including exposure to radiation, drugs, or toxic chemicals) probably play a role. in humans, acquired chromosomal derangements lead to clonal overgrowth with arrested development. chromosomal abnormalities have been reported in dogs with acute myeloid leukemia (aml), chronic myelogenous leukemia (cml), and lymphoid leukemia. , however, because karyotyping is difficult to perform in dogs, owing to the large number and morphologic similarity of their chromosomes and their resistance to banding, definition of the genetic factors in canine mpds awaits application of molecular techniques and use of the canine genome map. , , certain forms of leukemia in dogs have been produced experimentally by irradiation. [ ] [ ] [ ] in contrast to mpds in cats, no causative viral agent has been demonstrated in dogs, although retrovirus-like budding particles were observed in the neoplastic cells of a dog with granulocytic leukemia. a review of normal hematopoiesis can aid the clinician's understanding of the various manifestations of mpds. hematopoiesis is the process of proliferation, differentiation, and maturation of stem cells into terminally differentiated blood cells (a simplified schematic is presented in figure - ) . pluripotent stem cells differentiate into either lymphopoietic or hematopoietic multipotent stem cells. under the influence of specific regulatory and microenvironmental factors, multipotent stem cells in bone marrow differentiate into progenitor cells committed to a specific hematopoietic cell line, such as erythroid, granulocyticmonocytic, or megakaryocytic cells. maturation results in the production of terminally differentiated blood cells-erythrocytes, granulocytes, monocytes, and platelets-that are delivered to the circulation. in some cases, as in the maturation of reticulocytes to erythrocytes, final development may occur in the spleen. the proliferation and differentiation of hematopoietic cells are controlled by a group of regulatory growth factors. , of these, erythropoietin is the best characterized; it regulates erythroid proliferation and differentiation and is produced in the kidneys, where changes in oxygen tension are detected. the myeloid compartment depends on a group of factors, collectively referred to as colony-stimulating factors (csfs). these factors act at the level of the committed progenitor cells but also influence the functional capabilities of mature cells. some of these factors have a broad spectrum of activity; others are more restricted in their target cells and actions. csfs are produced in vitro by a multitude of cell types, including monocytes, macrophages, lymphocytes, and endothelial cells, and these cells likely play a role in the production and regulation of these factors in vivo. the gene for thrombopoietin also has been cloned, and this hormone alone apparently can induce differentiation of megakaryocytes and platelet production. recombinant forms of many of these hormones are becoming increasingly available. the clonal disorders of bone marrow include myeloaplasia (usually referred to as aplastic anemia), myelodysplasia, and myeloproliferation. a preleukemic syndrome, characterized by peripheral pancytopenia and bone marrow hyperplasia with maturation arrest, is more correctly called myelodysplasia because the syndrome does not always progress to overt leukemia. this syndrome has been described in cats, usually in association with felv infection, but it has only rarely been recognized in dogs. [ ] [ ] [ ] [ ] mpds may be manifested by abnormalities in any or all of the different cell lines, because hematopoietic cells share a common stem cell. in addition, transformation from one mpd to another may occur. mpds are classified in several ways. the terms acute and chronic refer to the degree of cellular differentiation of the leukemic cells, but these terms also correlate with the biologic behavior of the neoplasm. disorders resulting from uncontrolled proliferation of cells incapable of maturation lead to the accumulation of poorly differentiated, or blast, cells. these disorders have been called acute mpds or acute nonlymphocytic leukemias, but they now are included under the umbrella term acute myeloid leukemia. disorders resulting from unregulated proliferation of cells that exhibit progressive, albeit incomplete and defective, maturation lead to the accumulation of differentiated cells. these disorders are called chronic mpds. they include polycythemia vera, cml and its variants, essential thrombocythemia, and possibly primary myelofibrosis. mpds are further classified by the lineage of the dominant cell type or types, as defined by romanowsky stains, special cytochemical stains, ultrastructural features, and immunologic cell markers, and they recently have been classified into subtypes (see later discussion). acute leukemias have a more sudden onset and are more aggressive. in both acute and chronic disorders, however, abnormalities in proliferation, maturation, and functional characteristics can occur in any hematopoietic cell line. in addition, normal hematopoiesis is adversely affected. animals with leukemia usually have decreased numbers of circulating normal cells. the pathogenesis of the cytopenias is complex and may result in part from production of inhibitory factors. eventually, neoplastic cells displace normal hematopoietic cells, a process called myelophthisis. anemia and thrombocytopenia are particularly common. neutropenia and thrombocytopenia result in infection and hemorrhage, which may be more deleterious to the animal than the primary disease process. despite the disseminated nature of the disease at the time of diagnosis, parenchymal organ dysfunction usually occurs only in very advanced cases of mpd. aml is rare and is characterized by aberrant proliferation of a clone of cells without maturation. this results in the accumulation of immature blast cells in the bone marrow and peripheral blood (figure - ) . the wbc count varies, ranging from leukopenia to counts greater than , /ml. the spleen, liver, and lymph nodes commonly are involved, and other tissues may be infiltrated as well, including the tonsils, kidneys, heart, and cns. no characteristic age has been noted, and even very young dogs may be affected. the clinical course of these disorders tends to be rapid. production of normal peripheral blood cells usually is diminished or absent, and anemia, neutropenia, and thrombocytopenia are common. infection and hemorrhage are common sequelae. occasionally, malignant blasts are present in the bone marrow but not the peripheral blood; this is called aleukemic leukemia. subleukemic leukemia suggests a normal or decreased wbc with some neoplastic cells in circulation. in the animal leukemia study group was formed under the auspices of the american society for veterinary clinical pathology to develop specific morphologic and cytochemical criteria for classifying acute nonlymphocytic leukemias in dogs and cats. recognition of specific subtypes of leukemia is necessary for the accumulation of accurate, useful information about prognosis and response to treatment and for comparison of studies from different sites. in this group proposed a classification system following adaptation of the french-american-british (fab) system and criteria established by the national cancer institute workshop. the group members examined blood and bone marrow from dogs and cats with mpds. romanowsky-stained specimens were examined first to identify blast cells and their percentages. lineage specificity then was determined using cytochemical markers. the percentage of blasts and the information about lineage specificity were used in combination to classify disorders as acute undifferentiated leukemia (aul), acute myeloid leukemia (aml, subtypes m to m and m ), and erythroleukemia with or without erythroid predominance (subtypes m and m er) (see box - ). except for acute promyelocytic leukemia (subtype m ), all these subtypes have been described in dogs. however, because this modified fab system has only recently been adopted, the names given to these disorders in the literature vary considerably. in addition, in the absence of special cytochemical staining, immunophenotyping, and/or electron microscopy, the specific subtype of leukemia often has been uncertain, making retrospective analysis of epidemiologic information, prognosis, and response to therapy confusing at best. although defining specific subtypes may seem to be an academic exercise owing to the uniformly poor prognosis of acute leukemias, this information is critical to improving the management of these diseases. because of the low incidence of mpds, national and international cooperative efforts are required to accumulate information on the pathogenesis of specific subtypes and their response to different treatment modalities; use of a uniform classification system is an essential first step. different forms of aml are shown in figure - , a-e. the most frequently reported forms of aml in the dog are acute myeloblastic leukemia (m and m ) and acute myelomonocytic leukemia (m ). [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] megakaryoblastic leukemia (m ) also is well recognized in dogs , [ ] [ ] [ ] [ ] [ ] [ ] [ ] and may be associated with platelet dysfunction. monocytic leukemias likely have included those with and without monocytic differentiation (m a and m b), , but in some cases the diagnosis may have been chronic myelomonocytic or chronic monocytic leukemia (see later discussion). there are few reports in dogs of spontaneously occurring erythroleukemia (m ) in which the leukemic cells comprise myeloblasts, monoblasts, and erythroid elements. , auls have uncertain lineages, because they are negative for all cytochemical markers. these leukemias should be distinguished from lymphoid leukemias by flow cytometric analysis of the leukemic cells for cellular antigens that identify their lineage. in addition, examination of blast cells by electron microscopy may reveal characteristic ultrastructural features. chronic mpds are characterized by excessive production of differentiated bone marrow cells, which results in the accumulation of erythrocytes (polycythemia vera), granulocytes and/or monocytes (chronic myelogenous leukemia and its variants), or platelets (essential thrombocythemia). primary myelofibrosis as a clonal disorder of marrow stromal cells, characterized by proliferation of fibroblasts with accumulation of collagen in bone marrow, is not recognized in animals. myelofibrosis is considered a response to injury and may occur secondary to mpds. polycythemia vera (pv) is a clonal disorder of stem cells, although whether the defect is in the pluripotent stem cell or the hematopoietic multipotent stem cell is still unclear. in humans, progenitor cells have an increased sensitivity to insulin-like growth factor (igf- ), which stimulates hematopoiesis. whether this hypersensitivity is the primary defect or occurs secondary to another gene mutation is unknown. in any case, the result is overproduction of rbcs. the disease is rare and must be distinguished from more common causes of polycythemia, including relative and secondary absolute polycythemia (see later discussion). in pv, neoplastic proliferation of the erythroid series with terminal differentiation to rbcs occurs. the disease has been reported mostly in middle-aged dogs, and no breed or gender predilection has been noted. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] pv is characterized by an increased rbc mass, evidenced by an elevated pcv, rbc count, and hemoglobin concentration. the pcv typically is in the range of % to %. the bone marrow is hyperplastic, although the m:e tends to be normal. in contrast to the disease in humans, other cell lines do not appear to be involved, and transformation to other mpds has not been reported. the disease in dogs may be more appropriately called primary erythrocytosis. cml is a neoplastic proliferation of the neutrophil series, although concurrent eosinophilic and basophilic differentiation can occur. cml can occur in dogs of any age. , [ ] [ ] [ ] [ ] [ ] neutrophils and neutrophilic precursors accumulate in the bone marrow and peripheral blood and invade other organs. the peripheral wbc count usually, but not always, is higher than , /ml. both immature and mature neutrophils are present (see figure - , f). mature forms usually are more numerous, but sometimes an "uneven" left shift is present. signs of dysplasia may be evident, including hypersegmentation, ringed nuclei, and giant forms. eosinophils and basophils may also be increased. the bone marrow is characterized by granulocytic hyperplasia, and morphologic abnormalities may not be present. erythroid and megakaryocytic lines may be affected, resulting in anemia, thrombocytopenia or, less commonly, thrombocytosis. cml must be distinguished from severe neutrophilic leukocytosis and "leukemoid reactions" caused by inflammation or immune-mediated diseases. leukemoid reactions also can occur as a paraneoplastic syndrome. in humans with cml, characteristic cytogenetic abnormalities are present in all bone marrow cells, signifying a lesion at the level of an early multipotent stem cell. typically these individuals have a chromosomal translocation, resulting in the philadelphia chromosome. no consistent cytogenetic abnormalities have been demonstrated in spontaneously occurring cml in dogs. variants of cml are chronic myelomonocytic leukemia (cmml) and chronic monocytic leukemia (cmol). these diagnoses are made based on the percentage of monocytes in the leukemic cell population. besides accumulating in the bone marrow and peripheral blood, leukemic cells invade the red pulp of the spleen, the periportal and sinusoidal areas of the liver, and sometimes the lymph nodes. other organs (e.g., the kidneys, heart, and lungs) are less commonly affected. in addition, extramedullary hematopoiesis may be present in the liver and spleen. death usually results from complications of infection or hemorrhage secondary to neutrophil dysfunction and thrombocytopenia. in some cases, cml may terminate in "blast crisis," in which a transformation occurs from a predominance of well-differentiated granulocytes to excessive numbers of poorly differentiated blast cells in the peripheral blood and bone marrow; this phenomenon is well documented in the dog. , , basophilic leukemia, although rare, has been reported in dogs and is characterized by an elevated wbc count with a high proportion of basophils in the peripheral blood and bone marrow. [ ] [ ] [ ] hepatosplenomegaly, lymphadenopathy, and thrombocytosis may be present, and these dogs have all been anemic. basophilic leukemia should be distinguished from mast cell leukemia (mastocytosis). whether dogs develop eosinophilic leukemia remains in question. reported cases have had high blood eosinophil counts and eosinophilic infiltrates in organs. , one dog responded well to treatment with corticosteroids. the distinction between neoplastic proliferation of eosinophils and idiopathic hypereosinophilic syndrome remains elusive. disorders associated with eosinophilia (e.g., parasitism, skin diseases, and diseases of the respiratory and gi tracts) should be considered first in an animal with eosinophilia. one distinguishing feature should be clonality, with reactive eosinophilia comprising polyclonal cells and the neoplastic condition arising from a single clone. as clonality assays become more available, this discrepancy may be resolved. in humans, essential thrombocythemia, or primary thrombocytosis, is characterized by platelet counts that are persistently higher than , /ml. no blast cells are in circulation, and marked megakaryocytic hyperplasia of the bone marrow without myelofibrosis is present. thrombosis and bleeding are the most common sequelae, and most patients have splenomegaly. other mpds, especially pv, should be ruled out, and the patient should have no primary disorders associated with reactive thrombocytosis, such as inflammation, hemolytic anemia, iron deficiency anemia, malignancies, recovery from severe hemorrhage, rebound from immune-mediated thrombocytopenia, or abscence of a spleen. in addition, certain drugs, such as vincristine, can induce thrombocytosis. essential thrombocythemia has been recognized in dogs. , [ ] [ ] [ ] [ ] in one dog, the platelet count exceeded million/ml, and bizarre giant forms with abnormal granulation were present. the bone marrow contained increased numbers of megakaryocytes and megakaryoblasts, but circulating blast cells were not seen. other findings included splenomegaly, gi bleeding, and increased numbers of circulating basophils. causes of secondary or reactive thrombocytosis were ruled out. basophilia also was reported in a more recent case. in another dog, primary thrombocytosis was diagnosed and then progressed to cml. in some cases reported in the literature as essential thrombocythemia, the dogs had microcytic hypochromic anemias. because iron deficiency anemia is associated with reactive or secondary thrombocytosis, care must be taken to rule out this disorder. however, spurious microcytosis may be reported if a dog has many giant platelets that are counted by an analyzer as small rbcs. microscopic review of the blood film may be helpful in these cases. primary myelofibrosis with clonal proliferation of marrow fibroblasts has not been reported in dogs. in humans, myelofibrosis is characterized by collagen deposition in the bone marrow and increased numbers of megakaryocytes, many of which have morphologic abnormalities. in fact, breakdown of intramedullary megakaryocytes and subsequent release of factors that promote fibroblast proliferation or inhibit collagen breakdown may be the underlying pathogenesis of the fibrosis. focal osteosclerosis sometimes is present. anemia, thrombocytopenia, splenomegaly, and myeloid metaplasia (production of hematopoietic cells outside the bone marrow) are consistent features. the extramedullary hematopoiesis is ineffective at maintaining or restoring normal peripheral blood counts. in dogs, myelofibrosis occurs secondary to mpds, radiation damage, and congenital hemolytic anemias. [ ] [ ] [ ] [ ] in some cases the inciting cause is unknown (idiopathic myelofibrosis). concurrent marrow necrosis may occur in cases of ehrlichiosis, septicemia, or drug toxicity (estrogens, cephalosporins), and some speculate that fibroblasts proliferate in response to release of inflammatory mediators associated with the necrosis. myeloid metaplasia has been reported to occur in the liver, spleen, and lungs. extramedullary hematopoiesis is ineffective at preventing or correcting the pancytopenia that eventually develops. dysfunction of the hematopoietic system can be manifested by a variety of abnormalities that comprise myelodysplastic syndromes (mds). in dogs, in which the syndrome is rare, cytopenias usually are seen in two or three lines in the peripheral blood (anemia, neutropenia, and/or thrombocytopenia). other blood abnormalities can include macrocytic erythrocytes and metarubricytosis. the bone marrow typically is normocellular or hypercellular, and dysplastic changes are evident in several cell lines. if blast cells are present, they account for fewer than % of all nucleated cells, although this threshold may be altered to fewer than %. myelodysplasia sometimes is called preleukemia because in some cases it may progress to an acute leukemia. [ ] [ ] [ ] in humans and in cats, mds are clonal disorders and are considered neoplastic. dogs with mpds have similar presentations regardless of the specific disease entity, although animals with acute mpds have a more acute onset of illness and a more rapid clinical course. a history of lethargy, inappetence, and weight loss is common. clinical signs include emaciation, persistent fever, pallor, petechiation, hepatosplenomegaly and, less commonly, lymphadenopathy and enlarged tonsils. shifting leg lameness, ocular lesions, and recurrent infections also are seen. vomiting, diarrhea, dyspnea, and neurologic signs are variable features. serum chemistries may be within reference intervals but can change if significant organ infiltration occurs. animals with msd may be lethargic and anorectic and may have pallor, fever, and hepatosplenomegaly. in pv, dogs often have erythema of mucous membranes because of the increased rbc mass. some dogs are polydipsic. in addition, neurologic signs may be present, such as disorientation, ataxia, or seizures, and these are thought to be the result of hyperviscosity or hypervolemia. hepatosplenomegaly usually is absent. peripheral blood abnormalities are consistently found. in addition to the presence of neoplastic cells, other abnormalities may be present, including a decrease in the numbers of normal cells of any or all hematopoietic cell lines. occasional nucleated rbcs are present in the blood of about half of dogs with acute nonlymphocytic leukemia. nonregenerative anemia and thrombocytopenia are present in most cases. the anemia usually is normocytic and normochromic, although macrocytic anemia sometimes is present. pathogenic mechanisms include the effects of inhibitory factors, leading to ineffective hematopoiesis, myelophthisis, immune-mediated anemia secondary to neoplasia, and hemorrhage secondary to thrombocytopenia, platelet dysfunction, or dic. anemia is most severe in acute mpds, although both anemia and thrombocytopenia may be milder in animals with the m subtype (acute monocytic leukemia). in myelofibrosis, the anemia is characterized by anisocytosis and poikilocytosis. in addition, pancytopenia and leukoerythroblastosis, in which immature erythroid and myeloid cells are in circulation may be present. these phenomena probably result from the replacement of marrow by fibrous tissue, with resultant shearing of red cells and escape of immature cells normally confined to bone marrow. in pv, the pcv is elevated, usually in the range of % to %. the bone marrow is hyperplastic, and the m:e usually is in the normal range. the neoplastic cells often are defective functionally. platelet dysfunction has been reported in a dog with acute megakaryoblastic leukemia (m ), and in cml, the neutrophils have decreased phagocytic capacity and other abnormalities. one exception to this was a report of cml in a dog in which the neutrophils had enhanced phagocytic capacity and superoxide production. the authors hypothesized that increased synthesis of granulocyte-macrophage colony-stimulating factor (gm-csf) resulted from a lactoferrin deficiency in the neoplastic neutrophils and mediated the enhanced function of these cells. in all cases of mpd, the diagnosis depends on the examination of peripheral blood and bone marrow. acute mpds are diagnosed on the basis of finding blast cells with clearly visible nucleoli in blood and bone marrow. most dogs with acute leukemia have circulating blasts. these cells may be present in low numbers in peripheral blood, and the smear should be searched carefully, especially at the feathered edge. even if blasts are not detected in circulation, indications of bone marrow disease, such as nonregenerative anemia or thrombocytopenia, usually are present. occasionally neoplastic cells can be found in csf in animals with invasion of the cns. smears of aspirates from tissues such as the lymph nodes, spleen, or liver may contain blasts but usually contribute little to the diagnostic workup. examination of blasts stained with standard romanowsky stains may give clues to the lineage of the cells (see figure - , a to c and e). in aml, in addition to myeloblasts, some progranulocytes with their characteristic azurophilic granules may be present. in myelomonocytic leukemia, the nuclei of the blasts usually are pleomorphic and have round to lobulated forms. in some cells the cytoplasm may contain large azurophilic granules or vacuoles. blasts in megakaryocytic leukemia may contain vacuoles and may have cytoplasmic blebs. in addition, bizarre macroplatelets may be present. although these distinguishing morphologic features may suggest a definitive diagnosis, cytochemical stains or immunophenotyping usually is required to define the lineage of the blasts. several investigators have reported modification of diagnoses after cytochemical staining. , it is especially important to distinguish aml from lymphocytic leukemia to provide prognostic information to the owner. the animal leukemia group recommends the following diagnostic criteria (figure - ). using well-prepared romanowsky-stained blood and bone marrow films, a minimum of cells are counted to determine the leukocyte differential in blood and the percentage of blast cells in bone marrow or blood or both. in bone marrow, blast cells are calculated both as a percentage of all nucleated cells (anc) and nonerythroid cells (nec) and are further characterized using cytochemical markers. [ ] [ ] [ ] neutrophil differentiation is identified by positive staining of blasts for peroxidase, sudan black b, and chloracetate esterase. nonspecific esterases (alpha-naphthyl acetate esterase or alphanaphthyl butyrate esterase), especially if inhibited by sodium fluoride, mark monocytes. canine monocytes may also contain a few peroxidase-positive granules. acetylcholinesterase is a marker for megakaryocytes in dogs and cats. in addition, positive immunostaining for von willebrand's factor (factor viii-related antigen) and platelet glycoproteins on the surface of blasts identifies them as megakaryocyte precursors. , [ ] [ ] [ ] [ ] [ ] alkaline phosphatase (ap) only rarely marks normal cells in dogs and cats but is present in blast cells in acute myeloblastic and myelomonocytic leukemias. however, because of reports of ap activity in lymphoid leukemias in dogs, its specificity as a marker for myeloid cells is not certain. omega-exonuclease is a specific marker for basophils, which are also positive for chloracetate esterase activity. blood and bone marrow differential counts and cytochemical staining should be performed and interpreted by experienced veterinary cytopathologists. if erythroid cells comprise less than % of anc and the blast cells account for more than %, a diagnosis of aml or aul is made. if erythroid cells are more than % of anc and the blast cells are more than %, a diagnosis of erythroleukemia (m ) is made. if rubriblasts comprise a significant proportion of the blast cells, a diagnosis of m er, or erythroleukemia with erythroid predominance, can be made. (it should be noted that in the human aml classification system, the blast threshold has been lowered to %.) in some cases, electron microscopy is required to identify the lineage of the blast cells. for example, megakaryocyte precursors are positive for platelet peroxidase activity and contain demarcation membranes and alpha granules. , both these features are detected at the ultrastructural level. immunophenotyping, used to identify cell lineages in human patients, awaits development of appropriate markers for animal species (see later discussion). hematopoietic cells from humans with leukemia often have abnormal chromosome patterns. cytogenetic abnormalities have been found in leukemic cells from a small number of dogs. , it is not clear whether chromosomal aberrations are primary (causative) or secondary (caused by the leukemia). if consistent karyotypic patterns can be identified and correlated with leukemic subtypes, cytogenetic analysis eventually may yield important diagnostic and prognostic information and become a valuable tool for evaluating remission and predicting relapse. although morphologic and cytochemical analyses have formed the mainstay of cell identification, newer technologies now are used routinely to classify leukemias by using monoclonal antibodies to detect antigens associated with certain cell types. cells can be immunophenotyped using flow cytometric analysis or immunocytochemistry. both lymphoid and nonlymphoid acute leukemias are positive for cd . many lymphocyte markers, including cd , cd , cd , cd , bone marrow erythroid cells cd , cd , cd , and igg, are available for dogs and can be used to rule out lymphoblastic leukemia in dogs with acute leukemias. , other markers include myeloperoxidase (mpo) and cd b for myeloid cells and cd for megakaryoblasts. some overlap in the expression of these cell antigens occurs. for example, canine (but not human) granulocytes express cd . it is best to use a panel of antibodies (similar to using a battery of cytochemical stains), because antigens often are expressed on multiple lineages, and lineage infidelity can occur. these tests have become more valuable with the availability of canine reagents. currently, the myeloid neoplasm subcommittee of the acvp oncology committee recommends that the following immunophenotyping panel be done on bone marrow and/or blood smears to characterize animal leukemias: for b lymphocytes, cd a; for t lymphocytes, cd ; for myeloid cells, mpo and cd b; for megakaryoblasts, cd ; for dendritic cells, cd c; and for acute leukemias, cd . owing to the degree of differentiation of cells in chronic mpds, these disorders must be distinguished from nonneoplastic causes of increases in these cell types. to allow a diagnosis of pv, tests first must establish that the polycythemia is absolute rather than relative. in relative polycythemias, plasma volume is decreased from hemoconcentration, dehydration, or hypovolemia, and the absolute red cell mass is not increased. splenic contraction also can result in relative polycythemia. absolute polycythemia, in which the rbc mass is increased, usually occurs secondary to tissue hypoxia, causing appropriate increased production of erythropoietin. in rare cases, erythropoietin may be produced inappropriately by a tumor (e.g., renal cell carcinoma) or in renal disease (pyelonephritis) or localized renal hypoxia. [ ] [ ] [ ] these causes of polycythemia should be eliminated by appropriate laboratory work, thoracic radiographs, arterial blood gas analysis, and renal ultrasonography. in humans with pv, plasma erythropoietin (epo) levels are low. epo levels in dogs with pv tend to be low or low-normal, whereas in animals with secondary absolute polycythemia, the levels are high. , samples for determination of epo concentrations should be taken before therapeutic phlebotomy to treat hyperviscosity and, owing to fluctuations in epo levels, should be repeated if results are incongruous with other information. cml in dogs has no pathognomonic features, and other common causes for marked leukocytosis with a left shift (leukemoid reaction) and granulocytic hyperplasia of bone marrow must be eliminated. these include infections, especially pyogenic ones; immunemediated diseases; and other malignant neoplasms. in cml, maturation sometimes appears disorderly, and variation in the size and shape of neutrophils may occur at the same level of maturation. in addition, neoplastic leukocytes may disintegrate more rapidly and appear vacuolated. because of the invasive nature of cml, biopsy of the liver or spleen may also help distinguish true leukemia from a leukemoid reaction, assuming the animal can tolerate the procedure. if characteristic cytogenetic abnormalities can be found in dogs with cml, this analysis may be helpful. basophilic leukemia is diagnosed by finding excessive numbers of basophils in circulation and in bone marrow. basophilic leukemia must be differentiated from mastocytosis based on the morphology of the cell type present. basophils have a segmented nucleus and variably sized granules, whereas mast cells have a round to oval nucleus that may be partly or totally obscured by small, round, metachromatic-staining granules. this distinction usually is easy to make; however, in basophilic leukemia, changes in the morphology of the nucleus and granules make the distinction less clear. essential thrombocythemia has been diagnosed based on finding persistent and excessive thrombocytosis (more than , /ml) without circulating blast cells and in the absence of another mpd (e.g., polycythemia vera), myelofibrosis, or disorders known to cause secondary thrombocytosis. these include iron deficiency anemia, chronic inflammatory diseases, recovery from severe hemorrhage, rebound from immune-mediated thrombocytopenia, and absence of a spleen. thrombocytosis is transient in these disorders or abates with resolution of the primary disease. in essential thrombocythemia, platelet morphology may be abnormal, with bizarre giant forms and abnormal granulation. in the bone marrow, megakaryocytic hyperplasia is a consistent feature, and dysplastic changes may be evident in megakaryocytes. spurious hyperkalemia may be present in serum samples from dogs with thrombocytosis from any cause because of the release of potassium from platelets during clot formation. measurement of the potassium in plasma is recommended in these cases and usually demonstrates a potassium concentration within reference interval. platelet aggregability has been variably reported as impaired or enhanced. in the one dog in which it was measured, the plasma thrombopoietin (tpo) concentration was normal. whether tpo plays a role in essential thrombocythemia or is suppressed by the high platelet mass is unclear. elucidation of the pathogenesis of this disorder should be aided by the recent cloning of the genes for thrombopoietin and its receptor, the proto-oncogene mpl. in mds, abnormalities in two or three cell lines usually are manifested in the peripheral blood as neutropenia with or without a left shift, nonregenerative anemia, or thrombocytopenia. other changes include macrocytosis and metarubricytosis. the bone marrow typically is normocellular or hypercellular with an increased m:e, and blasts cells, although increased, account for fewer than % of the nucleated cells. this blast threshold may be changed to fewer than %, and in a report of dogs with primary or secondary mds, in all but one dog the blast cell percentage was less than %. dysplastic changes can be detected in any cell line. dyserythropoiesis is characterized by asynchronous maturation of erythroid cells, typified by large hemoglobinized cells with immature nuclei (megaloblastic change). if the erythroid component is dominant, the mds is called mds-er (see box - ). , in dysgranulopoiesis, giant neutrophil precursors and abnormalities in nuclear segmentation and cytoplasmic granulation can be seen. finally, dysthrombopoiesis is characterized by giant platelets and micromegakaryocytes. myelofibrosis should be suspected in animals with nonregenerative anemia or pancytopenia; abnormalities in erythrocyte morphology, especially shape; and leukoerythroblastosis. bone marrow aspiration usually is unsuccessful, resulting in a "dry tap"; this necessitates a bone marrow biopsy taken with a jamshidi needle. the specimen is processed for routine histopathologic examination and, if necessary, special stains for fibrous tissue can be used. because myelofibrosis occurs secondary to other diseases of bone marrow (e.g., mpd), chronic hemolytic anemia, or bone marrow necrosis, the clinician should look for a primary disease process. because of the poor response of acute nonlymphocytic leukemias, treatment has been unrewarding to date. however, little information is available on the response of specific subtypes of leukemia to uniform chemotherapeutic protocols, partly because of the rarity of these disease processes and the paucity of cases in the literature. the clinician is advised to contact a veterinary oncologist for advice on new protocols and appropriate management of these cases. the therapeutic goal is to eradicate leukemic cells and re-establish normal hematopoiesis. currently, this is best accomplished by cytoreductive chemotherapy, and the agents most commonly used include a combination of cytosine arabinoside and an anthracycline (e.g., doxorubicin or cyclophosphamide), vincristine, and prednisone.* in humans, the introduction of cytosine arabinoside has been the single most important development in the therapy of acute nonlymphocytic leukemia. in dogs, a regimen of to mg/m of cytosine arabinoside, given by slow infusion (over to hours) daily for days and repeated weekly, has been used. doxorubicin ( mg/m given intravenously every to weeks) can be administered at intervals alternating with cytosine arabinoside. if remission is achieved, as evidenced by normalization of the hemogram, the coap protocol (cyclophosphamide, vincristine, cytosine arabinoside, and prednisone), as described for canine lymphoma, could be used as maintenance therapy. , another protocol that has been used to treat acute myeloblastic leukemia is presented in table - . regardless of the chemotherapy protocol used, significant bone marrow suppression will develop, and intensive supportive care will be necessary. transfusions of whole blood or platelet-rich plasma may be required to treat anemia and thrombocytopenia, and infection should be managed with aggressive antibiotic therapy. because of the generally poor response, the major thrust of therapy may be to provide palliative supportive care. for pv, therapy is directed at reducing the red cell mass. the pcv should be reduced to % to % or by one sixth of its starting value. phlebotomies should be performed as needed, with administration of appropriate colloid and crystalloid solutions to replace lost electrolytes; ml of whole blood per kilogram of body weight can be removed at regular intervals. in humans, phlebotomy continues to be the therapeutic approach used most frequently. radiophosphorus ( p) has been shown to provide long-term control but can be used only in specialized centers. the chemotherapeutic drug of choice is hydroxyurea, an inhibitor of dna synthesis. this drug should be administered at an initial dosage of mg/kg for days; the dosage then is reduced to mg/kg given orally daily. the major goal of treatment is to maintain the pcv as close to normal as possible. cml is best managed with chemotherapy to control the proliferation of the abnormal cell line and improve the quality of life. hydroxyurea is the most effective agent for treating cml during the chronic phase. , the initial dosage is to mg/kg given twice daily. treatment with hydroxyurea should continue until the leukocyte count falls to , to , cells/ml. , , the dosage of hydroxyurea then can be reduced by % on a daily basis or to mg/kg given biweeky or triweekly. in humans, the alkylating agent busulfan can be used as an alternative. an effective dosage has not been established in the dog, but following human protocols, . mg/kg/day given orally is administered until the leukocyte count is reduced to , to , cells/ml. despite response to chemotherapy and control for many months, most dogs with cml eventually enter a terminal phase of disease. in one study of seven dogs with cml, four underwent terminal phase blast crisis. in humans, blast crisis may be lymphoid or myeloid. in dogs, the lineage of blast cells often has not been determined. these dogs have a poor prognosis, and the best treatment to consider, if any, would be that listed in table - . few cases have been reported, but one dog was treated successfully with a combination chemotherapy protocol that included vincristine, cytosine arabinoside, cyclophosphamide, and prednisone. treatment is controversial in humans because of the lack of evidence that asymptomatic patients benefit from chemotherapy. patients with thrombosis or bleeding are given cytoreductive therapy. hydroxyurea is the drug of choice for initially controlling the thrombocytosis. no standard therapeutic regimen exists for mds. often, humans receive no treatment if the cytopenias do not cause clinical signs. transfusions are given when necessary, and patients with fever are evaluated aggressively to detect infections. growth factors, such as erythropoietin, gm-csf, granulocyte colony-stimulating factor (g-csf), and il- , are sometimes used in patients who require frequent transfusions to increase their blood cell counts and enhance neutrophil function. , in one case report, human epo ( u/kg given subcutaneously every hours) was administered to a dog with msd because of profound anemia. the rationale for the erythropoietin was to promote terminal differentiation of dysplastic erythrocytes. the pcv increased from % to % by day of epo treatment. this dog remained in remission for longer than months. other factors that induce differentiation of hematopoietic cells include retinoic acid analogs, , dihydroxyvitamin d , interferon-alpha, and conventional chemotherapeutic agents, such as -thioguanine and cytosine arabinoside. the propensity of these factors to enhance progression to leukemia is not known in many cases, but the potential risk exists. in general, the prognosis for animals with chronic mpds is better than for dogs with acute mpds, for which the prognosis is grave. the prognosis for pv and chronic myelogenous leukemia is guarded, but significant remissions have been achieved with certain therapeutic regimens and careful monitoring. animals commonly survive a year or longer. , the development of blast crisis portends a grave prognosis. the pathophysiology and therapy of nonlymphocytic leukemia in humans is being studied intensively. the mpds have been demonstrated to be clonal, with abnormalities evident in all hematopoietic cell lines. leukemogenesis likely is caused by mutation or amplification of proto-oncogenes in a two-step process that initially involves a single cell and is followed by additional chromosomal alterations that may involve oncogenes. , these alterations are manifested as chromosomal abnormalities. environmental factors known to cause leukemia are exposure to high-dose radiation, benzene (chronic exposure), and alkylating agents. new classification systems have incorporated genetic mutations, more accurately reflect prognoses, and facilitate use of consistent categorization among institutions. therapeutic modalities under investigation or development include combination chemotherapy, immunotherapy, cytokine therapy, drug-resistance modulators, proapoptotic agents, antiangiogenic factors, signal transduction-active agents, and bone marrow transplantation. the prognosis for chronic mpds is better than for acute mpds. for acute nonlymphocytic leukemias, the prognosis is better for children than adults; only % of adults who receive chemotherapy maintain remissions for longer than years. the spontaneous canine diseases probably occur too infrequently to serve as useful models. mpds have been induced experimentally in the dog by irradiation and transplantation in an attempt to create models for study. many similarities between human and canine mpds exist, and veterinary medicine may benefit from any therapeutic advances made in the human field. plasma cell neoplasms arise when a cell of the b-lymphocyte plasma cell lineage proliferates to form a malignant population of similar cells. this population is believed in most instances to be monoclonal (i.e., derived from a single cell), because the cells typically produce homogenous immunoglobulin, although some examples of biclonal and polyclonal plasma cell neoplasms exist. a wide variety of clinical syndromes are represented by plasma cell neoplasms, including multiple myeloma, igm (waldenstrom's) macroglobulinemia, and solitary plasmacytoma (including solitary osseous plasmacytoma and extramedullary plasmacytoma). based on incidence and severity, multiple myeloma is the most clinically important plasma cell neoplasm. although multiple myeloma (mm) represents fewer than % of all malignant tumors in animals, it accounts for approximately % of all hematopoietic tumors and . % of all primary and secondary tumors affecting bones in dogs. , early studies indicated a male predisposition, but subsequent reports do not suggest a gender predilection for the dog. , older dogs are affected most often (average age, to years). , , in one large case series, german shepherds were overrepresented based on the hospital population. the true incidence of mm in the cat is unknown, although it is a much rarer diagnosis in that species than in the dog. mm accounted for only one of and four of tumors in two large compilations of feline malignancies and . % of all malignancies and . % of hematologic malignancies in another report. [ ] [ ] [ ] mm occurs in aged cats (median age, to years), most often in domestic shorthairs, and no gender predilection has been consistently reported, although a male preponderance may exist. , , mm has not been associated with coronavirus, felv or fiv infection. the etiology of mm for the most part is unknown. genetic predispositions, molecular aberrations, viral infections, chronic immune stimulation, and exposure to carcinogen stimulation all have been suggested as contributing factors. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] support for a familial association in cats comes from cases reported among siblings. evidence exists that molecular mechanisms of cellular control, including overexpression of cell cycle control components such as cyclin d (see chapter ) and receptor tyrosine kinase dysregulation, may be involved in canine myeloma and plasma cell tumors. , in rodent models, chronic immune stimulation and exposure to implanted silicone gel has been associated with development of mm, , as have chronic infections and prolonged hyposensitization therapy in humans. viral aleutian disease of mink results in monoclonal gammopathies in a small percentage of cases. working in the agricultural industry, petroleum products, and irradiation are known risk factors for the development of mm in humans. [ ] [ ] [ ] progression of solitary plasma cell tumors to mm has been reported in both dogs and cats, and a single case of a b-cell lymphoma that progressed to mm has been reported in the dog. , pathology and natural behavior mm is a systemic proliferation of malignant plasma cells or their precursors, which arise as a clone of a single cell that usually involves multiple bone marrow sites. malignant plasma cells can have a varied appearance on histologic sections and cytologic preparations. the degree of differentiation ranges from cells that resemble normal plasma cells in late stages of differentiation ( figure - ) to very large, anaplastic round cells with a high mitotic index, representing early stages of differentiation. , , , in cats with mm, most plasma cells ( % in one report) are immature and have marked atypia, including increased size, multiple nuclei, clefted nuclei, anisocytosis, anisokaryosis, variable nucleus-to-cytoplasm ratios, decreased chromatin density, and variable nucleoli. nearly one fourth of the cells have "flame cell" morphology, characterized by peripheral eosinophilic cytoplasmic processes. malignant plasma cells typically produce an overabundance of a single type or component of immunoglobulin, referred to as the m component ( figure - ) . the m component may be represented by any class of the entire immunoglobulin or by only a portion of the molecule, such as the light chain (bence jones protein) or the heavy chain (heavy chain disease). in the dog, the m component usually is represented by either igg or iga immunoglobulin types in nearly equal incidence, whereas the ratio of igg to iga in cats is approximately : .* if the m component is the igm type, the term macroglobulinemia (also waldenstrom's macroglobulinemia) often is applied. several cases of biclonal gammopathy in dogs and cats have been reported. , , [ ] [ ] [ ] [ ] [ ] two cases of nonsecretory mm have been reported in dogs. rarely, cryoglobulinemia has been reported in dogs with mm and igm macroglobulinemia, and it has been reported in a cat with igg myeloma. , [ ] [ ] [ ] cryoglobulins are paraproteins that are insoluble at temperatures below °c. they require blood collection and clotting to be performed at °c before serum separation. if whole blood is allowed to clot at temperatures below this, the protein precipitates part iv • specific malignancies in the small animal patient in the clot and is lost. pure light-chain m component is rare but has been reported in dogs. the pathology associated with mm is a result of high levels of circulating m component or of organ or bone infiltration with neoplastic cells, or both. associated pathologic conditions include bone disease, bleeding diathesis, hyperviscosity syndrome, renal disease, hypercalcemia, immunodeficiency (and subsequent susceptibility to infections), cytopenias secondary to myelophthisis, and cardiac failure. bone lesions can be isolated, discrete osteolytic lesions (including pathologic fractures [ figure - , a]) or diffuse osteopenias (figure - ). approximately one fourth to two thirds of dogs with mm have radiographic evidence of bony lysis or diffuse osteoporosis. , , , skeletal lesions in cats with mm were rarely reported in the older literature, but more recent reports document lesions in % to % of cases. [ ] [ ] [ ] bones engaged in active hematopoiesis are more commonly affected, including the vertebrae, ribs, pelvis, skull, and proximal or distal long bones. skeletal lesions are rare with igm (waldenstrom's) macrogammaglobulinemia, in which malignant cells often infiltrate the spleen, liver, and lymph tissue rather than bone. , , [ ] [ ] [ ] bleeding diathesis can result from one or a combination of events. m components may interfere with coagulation by inhibiting platelet aggregation and the release of platelet factor ; causing adsorption of minor clotting proteins; generating abnormal fibrin polymerization; and producing a functional decrease in calcium. , [ ] [ ] [ ] approximately one third of dogs and one fourth of cats have clinical evidence of hemorrhage. , , in dogs, nearly half have abnormal prothrombin (pt) and partial thromboplastin (ptt) times. thrombocytopenia may also play a role if bone marrow infiltration is significant (i.e., myelophthisis). hyperviscosity syndrome (hvs) represents one or a constellation of clinicopathologic abnormalities resulting from greatly increased serum viscosity. the magnitude of viscosity changes depends on the type, size, shape, and concentration of the m component in the blood. hvs is more common with igm macroglobulinemias because of the high molecular weight of this class of immunoglobulin. iga myelomas, usually present as a dimer in the dog, may undergo polymerization, resulting in increased serum viscosity. , , igg-associated hvs also can occur, albeit less frequently. high serum viscosity occurs in approximately % of dogs with mm and can result in bleeding diathesis, neurologic signs (e.g., dementia, depression, seizure activity, and coma), ophthalmic abnormalities (e.g., dilated and tortuous retinal vessels, retinal hemorrhage [ figure - ], and retinal detachment), and increased cardiac workload with the potential for subsequent development of cardiomyopathy.* these consequences are thought to be a result of sludging of blood in small vessels, ineffective delivery of oxygen and nutrients, and coagulation abnormalities. hvs was reported less commonly in cats with mm in the older literature but has been reported in association with igg-, iga-, and igm-secreting tumors. , , , [ ] [ ] [ ] in four of nine cats with mm, the relative serum viscosity was above control ranges. renal disease is present in approximately one third to one half of dogs with mm, and azotemia was observed *references , , , , , and - . in one third of cats in one report. , , the pathogenesis of renal failure often is multifactorial. it can develop as a result of bence jones (light-chain) proteinuria, tumor infiltration into renal tissue, hypercalcemia, amyloidosis, diminished perfusion secondary to hyperviscosity syndrome, dehydration, or ascending urinary tract infection. , , [ ] [ ] [ ] normally, heavy-chain and light-chain synthesis is well balanced in nonneoplastic immunoglobulin production. in mm, an unbalanced excess of light-chain products may result. light chains have a low molecular weight and normally are filtered by the renal glomerulus; their presence can result in protein precipitates and subsequent renal tubular injury. the presence of light chains in urine without a concomitant monoclonal spike in serum, although rare, is indicative of pure light-chain disease. tubules become obstructed by large laminated casts containing albumin, immunoglobulin, and light chains. , , [ ] [ ] [ ] bence jones proteinuria occurs in approximately % to % of dogs with mm, and in two recent surveys, it occurred in approximately % of cases.* hypercalcemia is reported in % to % of dogs with mm and is thought to result primarily from the production of osteoclast-activating factor by neoplastic cells. , , other factors have been implicated in human mm, including elevated levels of various cytokines, tnf, il- , and il- . in two dogs with mm and hypercalcemia, serum elevations in circulating n-terminal pthrp were noted. hypercalcemia may also be exacerbated by associated renal disease. initially thought to be a rare event in cats with mm, hypercalcemia was noted in % of recently reported cases. , , susceptibility to infection and immunodeficiency long have been associated with mm and often are the ultimate cause of death in affected animals. , , a b a, radiograph of a distal femur in a dog with severe osteolysis and a pathologic fracture secondary to a plasma cell tumor. b, radiograph of the same pathologic fracture after surgical repair with rush rods and bone cement. the local site was treated with adjuvant radiation. the dog was continued on chemotherapy for more years and did well. infection rates in humans with mm are times higher than normal and usually represent pneumonia or a urinary tract infection. the response to vaccination also has been shown to be suppressed in humans with mm. normal immunoglobulin levels often are severely depressed in affected animals. in addition, leukopenias may develop secondary to myelophthisis. variable cytopenias may be observed in association with mm. approximately two thirds of dogs with mm have a normocytic, normochromic, nonregenerative anemia , , ; this can result from marrow infiltration (myelophthisis), blood loss from coagulation disorders, anemia of chronic disease, or increased erythrocyte destruction secondary to high serum viscosity. in dogs with mm, similar factors lead to thrombocytopenia in nearly one third of the dogs and leukopenia in nearly one fourth. in cats, approximately two thirds are anemic, one half are thrombocytopenic, and one third are neutropenic. , cardiac disease, if present, usually is a result of excessive cardiac workload and myocardial hypoxia secondary to hyperviscosity. , myocardial infiltration with amyloid and anemia may be complicating factors. in one report nearly half of the cats with mm had a cardiac murmur, for which the etiology was not established. clinical signs of mm may be present up to a year before diagnosis in dogs (median, month). in one cat, m-component elevations were detected years before clinical presentation. , in the latter case, the m-component elevation was consistent with monoclonal gammopathy of unknown significance (mgus). mgus (i.e., "benign," "essential," or "idiopathic" monoclonal gammopathy) is a benign monoclonal gammopathy that is not associated with osteolysis, bone marrow infiltration, or bence jones proteinuria. mgus also has been reported in dogs. , signs of mm can vary, depending on the wide range of possible pathologic effects. tables - multiple retinal hemorrhages on the fundus in a cat with hyperviscosity syndrome secondary to multiple myeloma. several reports. , , , , bleeding diathesis usually is represented by epistaxis and gingival bleeding. funduscopic abnormalities may include retinal hemorrhage (see figure - ), venous dilation with sacculation and tortuosity, retinal detachment and blindness. , , , [ ] [ ] [ ] cns signs may include dementia, seizure activity, and deficiencies in midbrain or brainstem localizing reflexes secondary to hvs or extreme hypercalcemia. signs reflecting transverse myelopathies secondary to vertebral column infiltration, pathologic fracture, or extradural mass compression also can occur. , , , , one case of ataxia and seizure activity in a dog with extramedullary plasmacytoma (emp) secondary to tumor-associated hypoglycemia has been reported. in addition, paraneoplastic polyneuropathy has been reported in a dog with mm. a history of chronic respiratory infections and persistent fever may also be present in cats. hepatosplenomegaly and renomegaly can occur as a result of organ infiltration. bleeding diathesis due to hvs is less common in the cat, but epistaxis, pleural and peritoneal hemorrhagic effusions, retinal hemorrhage, and central neurologic signs have been reported. , , polydipsia and polyuria can occur secondary to renal disease or hypercalcemia, and dehydration may develop. hind limb paresis secondary to osteolysis of lumbar vertebral bodies or extradural compression has been reported in cats. , the diagnosis of mm usually follows the demonstration of bone marrow plasmacytosis (see figure - ), the presence of osteolytic bone lesions (see figure - ), and the demonstration of serum or urine myeloma proteins (m component; see figure - ). in the absence of osteolytic bone lesions, a diagnosis can also be made if marrow plasmacytosis is associated with a progressive increase in the m component. in the cat, because the degree of bone marrow infiltration may not be as marked, some have suggested consideration of plasma cell morphology and visceral organ infiltration in cases with demonstrable m-component disease in the absence of marked marrow plasmacytosis (less than %). all animals suspected of having plasma cell tumors should receive a minimal diagnostic evaluation, including a cbc, platelet count, serum biochemistry profile, and urinalysis. particular attention should be paid to renal function and serum calcium levels. serum electrophoresis and immunoelectrophoresis are performed to detect a monoclonal spike (see figure - ) and to categorize the immunoglobulin class involved. heat precipitation with electrophoresis of urine is performed to detect bence jones proteinuria, because commercial urine dipstick methods are not capable of this determination. definitive diagnosis usually is done by bone marrow aspiration. a bone marrow core biopsy or multiple aspirates may be necessary because of the possibility of clustering of plasma cells in the bone marrow. normal marrow contains fewer than % plasma cells, whereas in myelomatoid marrow, this level often is greatly exceeded. current recommendations require the presence of marrow plasmacytosis greater than %; however, a % cutoff in cats recently has been recommended, with special attention to cellular atypia. patel and colleagues comment that even the % threshold is problematic, and cellular atypia and visceral organ involvement should be considered equally important. routine thoracic and abdominal radiographs are recommended. occasionally, bony lesions can be observed in skeletal areas on these standard films, and organomegaly (liver, spleen, and kidneys) is observed in most cats (figure - ) . abdominal ultrasound scans are recommended in all cats suspected of having mm, because they reveal one or more abdominal tumors in nearly all such patients. these include splenomegaly with or without nodules, diffuse hyperechoic hepatomegaly with or without nodules, renomegaly, and iliac lymph node enlargement. skeletal survey radiographs are recommended to detect and determine the extent of osteolytic lesions, which may have diagnostic, prognostic, and therapeutic implications. nuclear scintigraphy (bone scans) for clinical staging of dogs with mm has been performed; however, because of the predominant osteolytic activity with osteoblastic inactivity, these scans seldom give positive results and therefore are not useful for routine diagnosis. in physician-based oncology, bone mineral density analysis (dexa scan) to document osteoporosis and mri scans of bone marrow are commonly used for staging; however, neither of these has been applied consistently in the veterinary literature. in rare cases, biopsy of osteolytic lesions (i.e., jamshidi core biopsy; see chapter ) is necessary for diagnosis. in one case of mm in a dog, splenic aspirates were diagnostically helpful. if clinical hemorrhage is present, a coagulation assessment (e.g., platelet count, pt, and ptt) and serum viscosity measurements should be done. all animals should undergo a careful funduscopic examination. table - shows the overall frequency of clinical diagnostic abnormalities in dogs and cats with mm, as compiled from published series involving at least five cases each. a clinical staging system for canine mm has been suggested ; however, currently no prognostic significance has been attributed to it. molecular diagnostic techniques for mm have had limited use thus far in veterinary oncology; however, pcr techniques have been used to determine the clonality of the immunoglobulin heavy-chain variable region gene in feline plasmacytomas and myelomas (see section a of this chapter and figure - ) . the use of this technology in cases in which the diagnosis is not straightforward awaits further investigation. disease syndromes other than plasma cell tumors can be associated with monoclonal gammopathies and should be considered in any list of differentials. these include other lymphoreticular tumors (lymphoma, extramedullary plasmacytoma, chronic and acute lymphocytic leukemia), chronic infections (e.g., ehrlichiosis, leishmaniasis, fip), and mgus.* therapy for mm is directed at both the tumor cell mass and the secondary systemic effects. all diagnostic procedures should be completed before primary therapy is started to ensure a complete diagnosis and to procure baseline values for monitoring response. in most dogs with mm, chemotherapy is effective at reducing the myeloma cell burden, relieving bone pain, allowing for skeletal healing, and reducing levels of serum immunoglobulins. it also can greatly extend both the quality and duration of most patients' lives. , complete elimination of neoplastic myeloma cells is rare, but the chemotherapeutic drugs currently available can make mm a gratifying disease to treat for both the clinician and the client. however, eventual relapse is to be expected. only one half of cats with mm respond to chemotherapy, and most responses are short-lived. however, several long-term responses (i.e., longer than year) have been reported, and treatment should be attempted when educated clients decide on a therapeutic option. † melphalan, an alkylating agent, is the chemotherapeutic drug of choice for the treatment of mm. , in the dog, an initial starting dosage of . mg/kg is given orally once daily for days and then reduced to . mg/kg given orally once daily continuously. addition of prednisone therapy is thought to increase the efficacy of melphalan therapy. prednisone is started at a dosage of . mg/kg given orally once daily for days and is then reduced to . mg/kg given orally every other day until the drug is discontinued after days of therapy. melphalan, however, is continued at . mg/kg/day until clinical relapse occurs or myelosuppression necessitates a dose reduction. most dogs treated with this melphalan/prednisone combination tolerate the regimen well. the most clinically significant toxicity of melphalan is myelosuppression, particularly a delayed thrombocytopenia. a cbc, including a platelet count, should be performed biweekly for months of therapy and monthly thereafter. if significant myelosuppression occurs (usually thrombocytopenia or neutropenia), the dosage or the treatment frequency may need to be reduced. the author has successfully used an alternative, pulse-dosing regimen for melphalan ( mg/m given orally daily for consecutive days every weeks) in a small number of cases in which myelosuppression was limiting the more conventional, continuous low-dose therapy. the author now uses this pulse-dose regimen as a first-line treatment with the caveat that long-term response data are lacking. melphalan/prednisone therapy also can be used in cats with mm; however, the protocol appears to be more myelosuppressive in cats than in dogs, and careful monitoring is required. in the cat, a dosing schedule similar to that for the dog has been reported , ; . mg/kg (approximately . mg, or ⁄ of a mg tablet) is given orally once daily for to days, then every other day until clinical improvement occurs or leukopenia develops. one report has advocated long-term continuous maintenance ( . mg/kg given orally once every days). cyclophosphamide has been used as an alternative alkylating agent or in combination with melphalan in dogs with mm. , , no evidence indicates that it is superior to melphalan therapy. in the author's practice, cyclophosphamide is limited to patients with severe hypercalcemia or widespread systemic involvement in which a faster acting alkylating agent may alleviate systemic effects more quickly. cyclophosphamide is initiated at a dosage of mg/m given intravenously once, at the same time oral melphalan therapy is started. because cyclophosphamide is less likely to affect thrombocytes, it may be substituted in patients in which thrombocytopenia has developed secondary to long-term melphalan use. chlorambucil, another alkylating agent, has been used successfully for the treatment of igm macroglobulinemia in dogs at a dosage of . mg/kg given orally once daily. , few or no clinical signs of toxicity result from this dosing schedule. ccnu, yet another alkylating agent, has been used in a limited number of cats with mm, and a partial response has been reported with a dosing schedule of mg/m given orally every days. evaluation of the response to therapy evaluation of the response to systemic therapy for mm is based on improvement in clinical signs and clinicopathologic parameters and radiographic improvement of skeletal lesions. , subjective improvement in clinical signs of bone pain, lameness, lethargy, and anorexia should be evident within to weeks after initiation of therapy. objective laboratory improvement, including reduction in serum immunoglobulin or bence jones proteinuria, usually is noted within to weeks. radiographic improvement in osteolytic bone lesions may take months, and only partial resolution may occur. ophthalmic complications (including longstanding retinal detachment) and paraneoplastic neuropathies can be expected to resolve along with the tumor mass. , in one report on cats that responded to melphalan and prednisone, clinical improvement was noted in weeks and serum protein and radiographic bone abnormalities were greatly improved by weeks. as previously discussed, mm does not resolve completely, and a good response is defined as a reduction in measured m component (i.e., immunoglobulin or bence jones proteins) by at least % of pretreatment values. reduction in the serum immunoglobulin levels may lag behind reduction in bence jones proteinuria, because the half-lives are to days and to hours, respectively. for routine follow-up, quantification of the elevated serum immunoglobulin or urine bence jones protein is performed monthly until a good response is noted and then every to months. repeat bone marrow aspiration for evaluation of plasma cell infiltration occasionally may be necessary. this is particularly prudent when cytopenias develop during chemotherapy and drug toxicity must be differentiated from marrow recurrence. long-term control of complications such as hypercalcemia, hvs, bleeding diathesis, renal disease, immunosuppression, ophthalmic complications, and pathologic skeletal fractures is achieved by controlling the primary tumor mass. however, therapy directed more specifically at these complications may be indicated in the short term. if hypercalcemia is marked and significant clinical signs are present, standard therapies, including fluid diureses with or without pharmacologic agents (e.g., calcitonin), may be indicated (see chapter ) . moderate hypercalcemia typically resolves within to days after initiation of melphalan/prednisone chemotherapy. hvs is best treated in the short term by plasmapheresis. , , , , whole blood is collected from the patient and centrifuged to separate plasma from packed cells. packed red cells are resuspended in normal saline and reinfused into the patient. bleeding diathesis usually resolves along with hvs, but platelet-rich plasma transfusions may be necessary with thrombocytopenia. renal impairment may require aggressive fluid therapy in the short term and maintenance of adequate hydration in the long term. careful attention to secondary urinary tract infections and appropriate antimicrobial therapy are indicated. ensuring an adequate water intake at home is important, and in some cases owners must be taught home subcutaneous fluid administration. continued monitoring of renal function is recommended, along with follow-up directed at tumor response. patients with mm can be thought of as immunologic cripples. some have recommended prophylactic antibiotic therapy in dogs with mm, but in humans, no benefit for this approach has been observed over diligent monitoring and aggressive antimicrobial management when indicated. cidal antimicrobials are preferred over static drugs, and nephrotoxic antimicrobials should not be used. pathologic fractures of weight-bearing long bones and of vertebrae, resulting in spinal cord compression, may require immediate intervention in conjunction with systemic chemotherapy. orthopedic stabilization of fractures should be performed and may be followed with external beam radiotherapy (see figure - , b) . recently, inhibition of osteoclast activity by bisphosphonate drugs has been shown to reduce the incidence and severity of skeletal complications of mm in humans. this class of drugs may hold promise for use in dogs and cats with various skeletal tumors. rescue therapy may be attempted when mm eventually relapses in dogs undergoing melphalan therapy or in the uncommon patient that initially is resistant to alkylating agents. the author has had success with the vad protocol, a combination of doxorubicin ( mg/m given intravenously every days), vincristine ( . mg/m given intravenously on days and ), and dexamethasone sodium phosphate ( mg/kg given intravenously once a week on days , , and ); this regimen is used in -day cycles. although most dogs initially respond to this rescue protocol, the duration of response tends to be short, lasting only a few months. high-dose cyclophosphamide ( mg/m given intravenously every days) also been has used as a rescue agent, although with limited success. liposomal doxorubicin produced a long-term remission in a dog with mm that had been resistant to native doxorubicin. because mm ultimately is a uniformly fatal disease in most species, including humans, significant effort is being put into investigational therapies for this disease. currently, bone marrow ablative therapy and marrow or stem cell rescue, thalidomide (and other antiangiogenic therapies), bortezomib (a proteasome inhibitor), arsenic trioxide, the bisphosphonates, and several molecular targeting therapies are under investigation; however, their use in veterinary species is limited or completely absent at present. nonetheless, the promise of molecular-targeted therapies is foreshadowed by a case of a dog with mm that was resistant to melphalan, prednisone, and doxorubicin ; this dog achieved a partial response to tyrosine kinase inhibitor therapy (su ; see chapter , section b) that was maintained for months. the prognosis for dogs with mm is good for initial control of the tumor and a return to good quality of life. in a group of dogs with mm, approximately % achieved a complete remission (i.e., normalization of serum immunoglobulins), % achieved a partial remission (i.e., immunoglobulin levels less than % pretreatment values), and only % did not respond to melphalan/prednisone chemotherapy. long-term survival is the norm, with a median of days reported (figure - ) . hypercalcemia, bence jones proteinuria, and extensive bony lysis are known negative prognostic indices in the dog. the long-term prognosis for dogs with mm is poor, because recurrence of the tumor mass and associated clinical signs is expected. eventually, the tumor no longer responds to available chemotherapeutic drugs, and death follows from renal failure, sepsis, or euthanasia for intractable bone or spinal pain. , the prognosis for mm in the cat is not as favorable in the short term as it is in the dog. , , , although most cats (approximately %) transiently respond to melphalan/prednisone-or cyclophosphamide-based protocols, most responses are partial and not durable. typically, cats with mm succumb to the disease within months. [ ] [ ] [ ] , , however, long-term survivors (longer than year) have been reported. , , , , one investigator grouped mm in cats into two prognostic categories, based on criteria known to predict disease behavior in dogs (table - ) . although no rigorous statistical analysis was performed on this small group of cats (nine), the median survival times were days for cats with disease categorized as "aggressive" and days for those with disease categorized as "nonaggressive." experience in dogs with igm macroglobulinemia is limited. , response to chlorambucil is to be expected, and in nine treated dogs, % achieved remission, with a median survival time of months. solitary collections of monoclonal plasmacytic tumors can originate in soft tissues (extramedullary plasmacytoma) or bone (solitary osseous plasmacytoma [sop]). a number of large case compilations of cutaneous plasmacytoma have been reported in the dog. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] plasmacytomas represented . % of all canine tumor submissions in one large compilation of cases. in this series of cases, the most common locations in the dog were cutaneous sites ( %) (figure - ) , the mucous membranes of the oral cavity and lips ( %) (figure - ) , and the rectum and colon ( %). the skin of the limbs and head (including the ears) is the most frequently reported cutaneous site. , , all other sites accounted for the remaining % of cases; these sites may include the stomach, spleen, genitalia, eyes, uterus, and liver. the american cocker spaniel, english cocker spaniel, and west highland white terrier (and perhaps yorkshire terriers, boxers, german shepherds, and airedale terriers) have an increased risk of developing plasmacytomas, and the median age of affected dogs is to years. , cutaneous and oral emp in dogs typically manifests as benign tumors that are highly amenable to local therapy. the natural behavior of noncutaneous/nonoral emp appears to be somewhat more aggressive in the dog. gastrointestinal emp has been reported in a number of sites in the veterinary literature, including the esophagus, stomach ( figure - ) , , small intestine, and large intestine. , , [ ] [ ] [ ] metastasis to associated lymph nodes is more common in these cases; however, bone marrow involvement and monoclonal gammopathies are less commonly encountered. in nine cases of colorectal emp, only two dogs experienced recurrence after surgical excision, and two cases involved multiple lesions. emp of the trachea, liver, and uterus also have been reported in a dog, and all had a benign course after local resection. [ ] [ ] [ ] most cases of sop eventually progress to systemic mm; however, the time course from local tumor development to systemic mm may be many months to years. , sops reported in the dog have involved the zygomatic arch and the ribs. plasmacytomas are less common in cats, and fewer reports exist in the literature. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] they occur in older cats (mean age, . years) with no significant gender predilection. the skin is the most common site; other sites include the oral cavity, eye, gi tract, liver, subcutaneous tissues, and brain. two reports exist of cutaneous emp in cats that progressed to systemic disease; one cat developed lymph node and distant metastasis, the other progressed to mm. cutaneous plasmacytoma on the limb of a dog. clinical signs associated with solitary plasmacytomas relate to the location of involvement; in the rare cases involving high levels of m component, hvs may occur. most cutaneous plasmacytomas are solitary, smooth, raised pink nodules that measure to cm in diameter (see figure - ), although tumors as large as cm have been reported. combination of data from large series shows that more than % of the tumors occur as solitary masses, and fewer than % occur as part of a systemic mm process. , [ ] [ ] [ ] the cutaneous and oral forms of emp usually have a benign course and no related clinical signs. gastrointestinal emp, however, typically produces relatively nonspecific signs that may suggest alimentary involvement. colorectal plasmacytomas usually cause rectal bleeding, hematochezia, tenesmus, and rectal prolapse. one case of ataxia and seizure activity in a dog with emp secondary to tumor-associated hypoglycemia has been reported. sop usually is associated with pain and lameness (if the appendicular skeleton is affected) or with neurologic signs (if vertebral bodies are involved). diagnosis of sops and emps usually requires tissue biopsy or fine-needle aspiration. the cells that make up a b solitary plasmacytic tumors in both cats and dogs have been classified histologically as mature, hyaline, cleaved, asynchronous, monomorphous blastic, and polymorphous blastic cell types. no prognostic significance has been observed with this classification system, although it has been suggested that the polymorphous blastic type may act more aggressively in the dog. , , with poorly differentiated solitary plasmacytic tumors, immunohistochemical studies directed at detecting immunoglobulin, light and heavy chains, and thioflavine t may be helpful for differentiating the lesions from other round cell tumors. , , , [ ] [ ] [ ] immunoreactivity has been demonstrated for canine igg f(ab) and vimentin. a variant characterized by an igg-reactive amyloid interspersed with the neoplastic cells also has been described. in addition, pcr techniques can be used to determine the clonality of the immunoglobulin heavy-chain variable region gene in plasmacytomas and myelomas, which may be diagnostically useful in difficult cases. thorough staging is important in dogs and cats with plasmacytomas that are at higher risk for systemic spread. staging, which must be done before therapy is started, should include bone marrow aspiration, serum electrophoresis, and skeletal survey radiographs to ensure that the disease is confined to a local site. this is most important for sop and gastrointestinal emp because of these tumors' relatively high metastatic rate; it is less important for cutaneous and oral plasmacytomas because of their typically more benign behavior. in addition, endoscopic evaluation of the entire gi tract is recommended with gastrointestinal emp. cutaneous plasma cell tumors in the dog are almost always benign and have an excellent prognosis after conservative surgical excision. successful therapy with melphalan and prednisone has been rarely applied for a local recurrence or incomplete margins in dogs and cats. , radiation therapy has been used infrequently for cases that are nonsurgical. surgery is recommended in combination with radiotherapy for sop when the lesion results in an unstable long bone fracture (see or the patient is nonambulatory because of neurologic compromise caused by a vertebral body sop. in the latter case, spinal cord decompression, mass excision, and possibly spinal stabilization may be necessary. radiotherapy can be used without surgery, when fractures are stable, as a palliative measure for bone pain or, in the case of vertebral sop, if the patient is ambulatory and stable. good local control usually is achieved, but most patients eventually develop systemic mm. , , sop of the axial skeleton can be managed by excision or radiotherapy alone. whether systemic chemotherapy should be initiated at the time of local therapy for sop when systemic involvement is not documented is the subject of debate. systemic spread may not occur for many months or even years beyond the primary sop diagnosis in humans and dogs, and studies in humans reveal no benefit from initiation of systemic chemotherapy before documentation of subsequent systemic spread. , similarly, emp of the gi tract in humans most often is treated with surgical excision and thorough staging of disease. systemic therapy is not initiated unless systemic involvement is documented. systemic chemotherapy has been used following excision of a gastric emp in a cat, but the utility of adjuvant therapy in the species is unkown. long-term follow-up of patients with a solitary plasmacytoma is indicated so that recurrence of disease and systemic spread can be recognized. in patients with sop, careful attention should be paid to the serum globulin levels, bone pain, and the radiographic appearance of bone healing. restaging of the disease, including bone marrow evaluation, is indicated if systemic spread is suspected. the prognosis for solitary plasma cell tumors generally is good. cutaneous and mucocutaneous plasmacytomas usually are cured by surgical excision. , in large compilations of cases in dogs, the local recurrence rate was approximately %, and nodal or distant metastasis occurred in only seven of cases ( %). , [ ] [ ] [ ] new cutaneous plasmacytomas at sites distant from the primary tumor developed in fewer than % of cases. one caveat: the author has encountered a handful of cases of aggressive multiple cutaneous plasmacytoma that eventual resulted in the death of the affected dogs. neither the tumor cell proliferation rate (as measured by ki- immunohistochemistry) in the dog nor histopathologic grading in dogs and cats was prognostic in large compilations of cases, although it has been suggested that the polymorphous blastic type may act more aggressively in the dog. , , the presence of amyloid and overexpression of cyclin d (prognostic in human plasmacytomas) were not shown to be prognostic in dogs. most dogs with emp of the alimentary tract and other abdominal organs (e.g., liver, uterus) that is treated by surgical excision alone or in combination with systemic chemotherapy (if metastasis is present) can enjoy long-term survival. , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in a compilation of nine dogs with colorectal plasmacytoma, two had local recurrence at and months after surgery; after surgery alone, the overall median survival time was months. dna ploidy and c-myc oncoprotein expression in biopsy samples were determined to be predictive for emps in dogs; however, tumors that were malignant all were from noncutaneous sites (i.e., lymph node, colon, and spleen), therefore location appears to be as predictive. as previously discussed, lymphatic leukemia in dogs: an epizootiological clinical and haematological study survey of animal neoplasms in alameda and contra costa counties, california. ii. cancer morbidity in dogs and cats from alameda county immunohistochemical identification of b and t lymphocytes in formalin-fixed, paraffin-embedded feline lymphosarcomas: relation to feline leukemia virus status, tumor site, and patient age development of virus non-producer lymphosarcomas in pet cats exposed to felv comparison of virus-positive and virus-negative cases of feline leukemia and lymphoma treatment and prognostic factors in lymphoma in cats: cases ( - ) chemotherapy of lymphoma in cats hematopoietic tumors: feline retroviruses a novel truncated env gene isolated from a feline leukemia virus-induced thymic lymphosarcoma transduction of notch in feline leukemia virus-induced thymic lymphoma feline lymphoma ( cases): proliferation indices, cd immunoreactivity and their association with prognosis in cats receiving therapy feline lymphoma in the post-feline leukemia virus era feline viral neoplasia the cat: diseases and clinical management hematopoietic tumors of cats the risk to humans from malignant diseases of their pets: an unsettled issue feline hematopoietic neoplasms clinical and anatomical features of lymphosarcoma in cats immunophenotypic and histological characterization of cases of feline lymphosarcoma efficacy of doxorubicin as an induction agent for cats with lymphosarcoma retrospective study of cases of feline lymphosarcoma lymphoma in the cat: an approach to diagnosis and management spinal lymphoma in cats: cases feline spinal lymphosarcoma: a retrospective evaluation of cats results of chemotherapy for cats with alimentary malignant lymphoma: cases ( - ) alimentary lymphoma in cats: cases prognostic value of argyrophilic nucleolar organizer region (agnor) staining in feline intestinal lymphoma malignant colonic neoplasia in cats: cases survey of animal neoplasms in alameda and contra costa counties, california. ii. cancer morbidity in dogs and cats from alameda county neoplastic diseases feline immunodeficiency virus (fiv) and feline leukemia virus (felv) infections and their relationship to lymphoid malignancies in cats feline lymphoid hyperplasia plexiform vascularization of lymph nodes: an unusual but distinctive lymphadenopathy in cats argyrophilic intracellular bacteria in some cats with idiopathic peripheral lymphadenopathy renal lymphoma in cats: cases radiation therapy and hyperthermia radiotherapy with and without chemotherapy for localized lymphoma in cats investigation of nasal disease in the cat: a retrospective study of cases nasopharyngeal diseases in cats: a retrospective study of cases feline nasal and paranasal sinus tumours: clinicopathological study, histomorphological description and diagnostic immunohistochemistry of cases tumors of the nervous system and eye prevalence of diseases of the spinal cord of cats feline intracranial neoplasia: retrospective review of cases characterization of feline immunoglobulin heavy chain variable region genes for the molecular diagnosis of b-cell neoplasia the hematopoietic system vertebral lymphosarcoma in a cat mycosis fungoides in two cats a case of mycosis fungoides in a cat and literature review cutaneous lymphosarcoma in the cat: a report of nine cases cutaneous lymphosarcoma and leukemia in a cat cutaneous t-cell lymphoma in a cat immunophenotypic characterization of cutaneous lymphoid neoplasia in the dog and cat clinical, morphological and immunohistochemical characterization of cutaneous lymphocytosis in cats sézary syndrome: diagnosis, prognosis, and critical review of treatment options mycosis fungoides in a dog: demonstration of t-cell specificity and response to radiotherapy canine cutaneous lymphoma cutaneous lymphosarcoma and leukemia in a dog resembling sézary syndrome in man cutaneous t-cell lymphoma with sézary syndrome in a dog histological classification of hematopoietic tumors of domestic animals feline large granular lymphoma lymphoma involving large granular lymphocytes in cats: cases large granular lymphocyte leukemia/lymphoma in six cats globule leukocyte tumor in six cats granulated round cell tumor of cats hypereosinophilic syndrome and eosinophilic leukemia: a comparison of hypereosinophilic cats hypereosinophilic syndrome in cats: a report of cases hypereosinophilic syndrome in cats treatment of feline myelogenous leukemia: four case reports erythremic myelosis in a cat myeloproliferative disorders in the cat. part . progression from erythroleukemia into granulocytic leukemia leukocytes in health and disease myeloproliferative disorders in dogs and cats polycythemia vera in a cat polycythemia vera in a cat with cardiac hypertrophy primary erythrocytosis in the cat: treatment with hydroxyurea a review of polycythemia vera in the cat megakaryocytic myelosis in a cat acute megakaryoblastic leukemia in one cat and two dogs cytosine arabinoside chemotherapy for acute megakaryocytic leukemia in a cat essential thrombocythemia in a cat feline malignant histiocytosis and the lysozyme detection malignant histiocytosis in a cat malignant histiocytosis in a cat malignant histiocytosis in a domestic cat: cytomorphologic and immunohistochemical features malignant histiocytosis in cats feline myeloproliferative disease: changing manifestations in the peripheral blood bone lesions in cats with anemia induced by feline leukemia virus myelosclerosis in a cat classification and clinical manifestations of the hemopoietic stem cell disorders a report of the animal leukemia study group: proposed criteria for classification of acute myeloid leukemia in dogs and cats myeloproliferative disorders in animals acute myelomonocytic leukemia with neurologic manifestations in the dog acute myeloblastic leukemia in a dog a -year-old rottweiler with weight loss a potentially misleading presentation and course of acute myelomonocytic leukemia in a dog acute megakaryoblastic leukemia in one cat and two dogs acute monocytic leukemia in a dog acute nonlymphocytic leukemia in a dog morphologic classification and clinical and pathological characteristics of spontaneous leukemia in dogs the use of cytochemistry, immunophenotyping, flow cytometry, and in vitro differentiation to determine the ontogeny of a canine monoblastic leukemia hematopoietic malignancies cytogenetic analysis of leukaemic cells in the dog: a report of cases and a review of the literature trisomy in a canine acute leukemia indicating the pathogenetic importance of polysomy in leukemias of the dog classification of myeloid neoplasms: a comparative review working with canine chromosomes: current recommendations for karyotype description erythroblastic malignancy in a beagle irradiation-induced erythroleukemia and myelogenous leukemia in the beagle dog: hematology and ultrastructure acute monocytic leukemia in an irradiated beagle retrovirus-like particles associated with myeloproliferative disease in the dog hemopoietic stem cells, progenitor cells, and cytokines the hemopoietic colony stimulating factors cloning and expression of murine thrombopoietin cdna and stimulation of platelet production in vivo preleukemic syndrome in a dog clinicopathologic aspects of acute leukemias in the dog myelodysplastic syndrome in two dogs use of human recombinant erythropoietin and prednisone for treatment of myelodysplastic syndrome with erythroid predominance in a dog thrombocytosis associated with a myeloproliferative disorder in a dog myeloproliferative disease in the dog and cat: definition, aetiology and classification the leukemia complex acute myelomonocytic leukemia in a dog acute myelomonocytic leukemia in a dog clinical-pathological findings and cytochemical characterizations of myelomonocytic leukaemia in dogs acute myelomonocytic leukemia in a dog tumors of the lymphoid and hemopoietic tissues acute myelomonocytic leukemia manifested as myelophthisic anemia in a dog acute myelomonocytic leukemia in a dog unusual cytochemical reactivity in canine acute myeloblastic leukemia megakaryocytic leukemia in a dog myeloproliferative disorder involving the megakaryocytic line megakaryoblastic leukemia in a dog megakaryblastic leukemia in a dog platelet dysplasia associated with megakaryoblastic leukemia in a dog radiation-induced megakaryoblastic leukemia in a dog identification and characterization of megakaryoblasts in acute megakaryoblastic leukemia in a dog monocytic leukaemia in the dog erythroleukemia in a dog, pratique medicale and chirurgicale de l three cases of erythroleukemia in dogs blood cell markers current opinion in hematology polycythaemia vera in a bitch polycythemia vera in a dog polycythemia vera in dogs polycythemia vera in a dog diagnosis of canine primary polycythemia and management with hydroxy-urea polycythemia vera and glomerulonephritis in a dog greydanus-van-der-putten swm: polycythaemia vera in a dog treated by repeated phlebotomies polycythaemia vera in a dog polycythaemia vera in a dog chronic myelogenous leukemia in the dog blastic crisis in chronic myelogenous leukaemia in a dog chronic myelogenous leukaemia with meningeal infiltration in a dog chronic granulocytic leukaemia in a dog with associated bacterial endocarditis, thrombocytopenia and preretinal and retinal hemorrhages chronic granulocytic leukemia in a dog chronic myelogenous leukemia and related disorders treatment of basophilic leukemia in a dog basophilic leukemia in a dog basophilic leukemia in a dog eosinophilic leukemoid reaction in a dog chronic granulocytic leukaemia/eosinophilic leukaemia in a dog essential (primary) thrombocythemia probable essential thrombocythemia in a dog successful treatment of suspected essential thrombocythemia in the dog essential thrombocythemia in a dog: case report and literature review diagnostic and hematologic features of probable essential thrombocythemia in two dogs a review of myelofibrosis in dogs pathogenesis of myelofibrosis: role of ineffective megakaryopoiesis and megakaryocyte components development of a myeloproliferative disorder in beagles continuously exposed to pyruvate kinase deficiency anemia with terminal myelofibrosis and osteosclerosis in a beagle myelofibrosis in the dog: three case reports enhanced granulocyte function in a case of chronic granulocytic leukemia in a dog cytochemical reactions in cells from leukemic dogs cytochemical characterization of leukemic cells from dogs clinical diagnosis and management of acute nonlymphoid leukemias and chronic myeloproliferative disorders schalm's veterinary hematology monoclonal antibodies that define canine homologues of human cd antigens: summary of the first international canine leukocyte antigen workshop (claw) inappropriate erythropoietin production from a renal carcinoma in a dog with polycythemia renal carcinoma associated with secondary polycythemia in a dog secondary polycythemia associated with renal disease in the dog: two case reports and review of literature serum erythropoietin concentrations measured by radioimmunoassay in normal, polycythemic, and anemic dogs and cats serum erythropoietin concentrations in polycythemic and anemic dogs, proceedings of the ninth annual veterinary medicine forum (acvim) factitious hyperkalemia in dogs with thrombocytosis thrombopoietin: the primary regulator of platelet production cytologic evaluation of primary and secondary myelodysplastic syndromes in the dog how to collect diagnostic bone marrow samples hematopoietic neoplasms, sarcomas and related conditions myeloproliferative disease in the dog and cat: clinical presentations, diagnosis and treatment current chemotherapeutic treatment approaches to the management of previously untreated adults with de novo acute myelogenous leukemia radiophosphorus ( p) treatment of bone marrow disorders in dogs: cases ( - ) enzymes and random synthetics busulfan versus hydroxyurea in long-term therapy of chronic myelogenous leukemia blast crisis of chronic granulocytic leukemia: morphologic variants and therapeutic implications myelodysplastic disorders treatment of myelodysplastic syndromes with hematopoietic growth factors treatment of myelodysplastic syndromes with all-trans retinoic acid sustained haematological response to high dose oral alfacalcidol in patients with myelodysplastic syndrome treatment for the myelodysplastic syndromes acute myelogenous leukemia the world health organization (who) classification of the myeloid neoplasms prognostic factors for multiple myeloma in the dog primary and secondary bone tumors in the dog multiple myeloma in the dog diagnosis and management of monoclonal gammopathies a retrospective study of feline neoplasms tumors and tumor like lesions multiple myeloma in cats: a retrospective study multiple myelomas in cats a resume of the current status of the development of plasma cell tumors in mice induction of plasmacytomas with silicone gel in genetically susceptible strains of mice multiple myeloma and prolonged stimulation of res the development of myeloma-like condition in mink with aleutian disease clinico-pathological aspects of canine cutaneous and mucocutaneous plasmacytomas phase i dose-escalating study of su , a small molecule receptor tyrosine kinase inhibitor, in dogs with spontaneous malignancies multiple myeloma and family history of cancer multiple myeloma: a case control study a case-control study of multiple myeloma in whites: chronic antigenic stimulation, occupation and drug use progression of a solitary, malignant cutaneous plasma cell tumour to multiple myeloma in a cat evolution of a b-cell lymphoma to multiple myeloma after chemotherapy histological classification of hematopoietic tumors of domestic animals immunoglobulin a myeloma in a cat with pleural effusion and serum hyperviscosity multiple myeloma in the cat hyperviscosity syndrome with igm monoclonal gammopathy and hepatic plasmacytoid lymphosarcoma in a cat serum hyperviscosity syndrome associated with multiple myeloma in two cats serum hyperviscosity syndrome associated with igg myeloma in a cat biclonal gammopathy in a dog with myeloma and cutaneous lymphoma immunoglobulin a and immunoglobulin g biclonal gammopathy in a dog with multiple myeloma biclonal gammopathy associated with immunoglobulin a in a dog with multiple myeloma monoclonal gammopathies in the dog: a retrospective study of cases ( - ) and literature review multiple myeloma in cats: variable presentation with different immunoglobulin isotypes in two cats nonsecretory multiple myeloma in two dogs neurologic complications of iga multiple myeloma associated with cryoglobulinemia in a dog monoclonal cryoglobulinemia with macroglobulinemia in a dog monoclonal immunoglobulin g cryoglobulinemia and multiple myeloma in a domestic shorthair cat light-chain myeloma in a dog cervical cord compression as a neurologic complication in an igg multiple myeloma in a dog different biological behaviour of waldenstrom macroglobulinemia in two dogs macroglobulinemia in the dog, the canine analogue of gamma m monoclonal gammopathy macroglobulinemia with hyperviscosity syndrome in a dog serum hyperviscosity syndrome associated with iga multiple myeloma in two dogs plasma cell tumors plasma cell neoplasms ocular lesions in a dog with hyperviscosity secondary to an iga myeloma blindness in a dog with igaforming myeloma ophthalmic disease as the presenting complaint in five dogs with multiple myeloma bone destruction and hypercalcemia in plasma cell myeloma parathyroid hormone (pth)-related protein, pth, and , -dihydroxyvitamin d in dogs with cancer associated hypercalcemia hypercalcemia in two cats with multiple myeloma infections complicating multiple myeloma and chronic lymphocytic leukemia infection, antibody response, and gamma globulin components in multiple myeloma and macroglobulinemia a benign hypergammaglobulinemia mimicking plasma cell myeloma idiopathic monoclonal (iga) gammopathy in a dog vertebral plasma cell tumors in dogs hypoglycemia and polyclonal gammopathy in a dog with plasma cell dyscrasia multiple myeloma with associated polyneuropathy in a german shepherd dog plasma cell sarcoma in a cat plasma cell neoplasms fine-needle aspiration of the spleen as an aid in the diagnosis of splenomegaly characterization of feline immunoglobulin heavy chain variable region genes for the molecular diagnosis of b-cell neoplasia use of plasmapheresis and chemotherapy for treatment of monoclonal gammopathy associated with ehrlichia canis infection in a dog monoclonal gammopathy associated with naturally occurring canine ehrlichiosis hyperviscosity syndrome associated with lymphocytic leukemia in three dogs monoclonal gammopathy in a dog with visceral leishmaniasis gastric extramedullary plasmacytoma in a dog hematological toxicity and therapeutic efficacy of lomustine in tumor-bearing cats: critical assessment of a practical dosing regimen the treatment of multiple myeloma therapeutic plasmapheresis multiple myeloma in a cat response to liposome-encapsulated doxorubicin (tlc d- ) in a dog with myeloma extramedullary plasmacytomas in dogs: results of surgical excision in cases mucocutaneous plasmacytomas in dogs: cases cutaneous plasmacytomas in dogs: a morphologic and immunohistochemical study cutaneous plasmacytomas with amyloid in six dogs primary cutaneous plasmacytomas in the dog and cat an immunohistochemical study of canine extramedullary plasma cell tumours prognostic value of histopathological grading in canine extramedullary plasmacytomas colorectal plasmacytomas: a retrospective study of nine dogs esophageal plasmacytoma in a dog extramedullary plasmacytoma of the gastrointestinal tract in two dogs primary igg secreting plasma cell tumor in the gastrointestinal tract of a dog a solitary plasmacytoma in a dog with progression to a disseminated myeloma metastatic extramedullary plasmacytoma of the colon and rectum in a dog extramedullary plasmacytoma in the trachea of a dog uterine extramedullary plasmacytoma in a dog a primary hepatic plasma cell tumor in a dog part iv • specific malignancies in the small animal patient solitary plasmacytomas of bone and extramedullary plasmacytomas histopathologic and immunophenotypic characterization of extramedullary plasmacytomas in nine cats intracerebral plasma cell tumor in a cat: a case report and literature review intraocular extramedullary plasmacytoma in a cat extramedullary plasmacytoma and immunoglobulin-associated amyloidosis in a cat immunohistochemical staining of neoplastic and inflammatory plasma cell lesions in feline tissues immunoglobulin-producing tumours in dogs and cats identification of immunoglobulin light chains in canine extramedullary plasmacytomas by thioflavine t and immunohistochemistry gastric extramedullary plasmacytoma in a cat analysis of dna aneuploidy and c-myc oncoprotein content of canine plasma cell tumors using flow cytometry most patients with sop eventually develop systemic disease, but long, disease-free periods usually precede the event.the prognosis in cats is less well defined, owing to the scarcity of reported cases. if disease is confined to a local site and/or regional nodes, surgical excision and chemotherapy can result in long-term control; however, early, widespread metastasis and progression to mm is also reported in cats.* key: cord- -tnw hbm authors: einian, majid; tabarraei, hamid reza title: modeling of covid- pandemic and scenarios for containment date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: tnw hbm the impact of covid- pandemic on the global health and world's economy have been profound and unseen since the spanish flu of - . as of now, many countries have been severely affected, partly because of slow responses to the crisis, ill-preparedness of their health system, and the fragile health infrastructure and the shortage of protective equipment. this note evaluates various scenarios, based on an estimation of number of identified and unidentified infected cases, and examines the effectiveness of different policy responses to contain this pandemic. our result, based on an estimation of the model for iran, show that in many instances the number of unidentified cases, including asymptomatic individuals, could be much bigger than the reported numbers. the results confirm that in such circumstances, social distancing alone cannot be an effective policy unless a large portion of the population confine themselves for an extended period of time, which is not only difficult to implement, but it could also prove extremely costly and damaging to the economy. an alternative policy, this note argues, is to couple effective social distancing with extensive testing, even to those who are asymptomatic, and isolate the identified cases actively. otherwise, many lives will be lost, and the health system will collapse, adding to the ongoing economic troubles that many countries have started to encounter. as the impacts of the coronavirus-covid- -rattle the world on its path to more than countries and territories (as of march ), countries show astonishingly similar behavior, at least in the first phase, of this pandemic. similar to some deadly diseases that affect individuals, it seems that the society and/or the governing authorities of many countries, go through the similar stages as individuals, namely denial, anger, blame, depression, and acceptance. we understand form scientists, that the sooner a patient accepts her sickness, the sooner she can receive treatment and care. a prolonged process to reach acceptance, makes it more difficult to effectively tackle the disease, and in many instances, if left untreated with unfortunate deadly outcomes. for instance, iran is a prime example of a country that has prolonged the denial phase, and in doing so, has created a situation that might lead to a catastrophic outcome and could result in a human tragedy. the authorities in iran broke the news by announcing the death of two covid- victims on february , , just a day before nationwide parliamentary elections. although it is almost impossible to know the exact date and the number of infected people prior to the official announcement, the number of new cases suddenly jumped from zero on february to around cases a week later. iran initially refused to quarantine the holy city of qom, the source city of covid- in iran, and let the virus spread all over the country, and in a matter of a few weeks, all cities reported new cases of infected patients. today, the pattern of pandemic in iran indicates that, even after one month, the country is still grappling with the early stages of this terrible diseases and is unable to move on to the stage which it accepts the reality and takes extra-ordinary but necessary measures to confront the spread of the virus. the data pattern in iran shows a high death rate at the beginning of the pandemic, which then declined and reached the global average after a couple of weeks. similarly, the pattern of identified cases has been very different across countries. for instance, while the crisis started sooner in iran than many other countries, infected cases rose quickly in europe and the us, and surpassed those of iran. this is in despite of complete shutdown in many european countries and many states in the us. similar to many other countries, this might have been due to the lack of resources for testing and identifying infected individuals. this is why this note tries to account for identified as well as unidentified cases and simulate a model-based number of infected population. we use a modified susceptible, exposed, infected, and recovered (seir) model to simulate the spread of covid- . although the model is fairly sophisticated, it is easily understood and it is estimated with available public data. the results for iran show that active cases might be significantly higher than officially reported by to times in an optimistic scenario of shelter-inplace policy of percent of the population. in a scenario where half of the individuals confine themselves, still around three million individuals get infected of which thousand will die. therefore, the under-reporting of infected cases, although unintentional, not only undermines the integrity of responses, but ultimately puts more people at risk as they go unrecognized and untreated and continue to spread the virus with no end in sight. the note examines multiple policy scenarios and their effectiveness. although the model is estimated for iran, many countries are in similar stages of the pandemic or soon will be in the same stage and therefore, based on the results, extreme measures need to be adopted to save lives and stop further spread of the virus. social distancing alone cannot stop this disease except if more than percent of the population confine themselves for quite an extended period of time. however, if the number of testing increases massively, and countries' authorities successfully isolate infected individuals, the pandemic can be controlled before the summertime, even with a less degree of confinement. while the paper simulates various scenarios of containment, it does not address the economic cost of each scenario. in line with recent findings, the note argues that a fast and aggressive multi-layer intervention is needed to have a substantial dent of the transmission. what the paper calls for is a clear and transparent strategy by governments to implement social distancing and aggressive testing. the testing, should be targeted to geographic locations that the virus is wide spread, to airports and cruise ships, to road travellers, and anyone who has been in areas that are hot spot or has been in any contact with someone in affected locations over the past two weeks. the strategy should not "just" focus on those that show symptoms but should include "all" who might have been exposed. in this exceptional environment, governments can use temporarily a combination of location data and credit card information to track covid- in their countries and use surveillance tools to monitor quarantined individuals. deterministic compartmental models are simple yet powerful models in describing this kind of epidemic outbreaks. we developed a variant of the seir model for the epidemic dynamic and control of covid- , using seven state variables and a minimal number of parameters to avoid over-fitting. the model is estimated for iran, but it can be estimated for other country examples. it is different from a standard seir model by distinguishing hidden and identified infected cases. indeed, standard seir models are estimated assuming that all infected people are reported. such an assumption for the novel coronavirus pandemic is largely unreasonable, as many infected people show no or mild symptoms and as the testing procedure is not available in mass, many remain undetected. thus, we divide infected compartment into infected but not reported (i) and infected, detected and reported (q) groups. we assume that identified cases are less infectious by taking self-precautionary measures and/or due to hospitalization. while unidentified cases can largely continue to infect the rest of the population. the model, therefore, . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . distinguishes between the confirmed infected individuals, which are observable in data, and the total infected individuals. in reality, the number of confirmed cases is a function of medical tests and the preparedness of the healthcare system. covid- has an infection capability during the incubation (pre-symptomatic) period. in addition, based on the detection method, there exists a delay between the time that an individual is infected and the time this person is detected. state variables and parameters of the model in equations ( . )-( . ) capture these characteristics. figure shows the schematic diagrams illustrating these states (compartments). we denote the share of susceptible individuals with no resistance to the disease in the population by s t . e t is the share of people who are exposed to the virus but are not yet infected nor infectious. i t is the infected population share who are undetected and hence un-quarantined. these individuals can be either symptomatic or pre-symptomatic. a share of these individuals, q, are detected and move to somewhat quarantined population q t . among both infected populations, r t = r i t + r q t recover and for some time become resistant to new infections. finally, we assume those who are detected are the individuals who need medical assistance and those that their general health condition might have deteriorated quickly. a share of these individuals, δ, pass away (d t ). finally, due to the high pace of the current outbreak, the model is a closed model in the sense that there are no new birth and death, except for the disease itself. in a simple sier model, people are removed (hence the letter r in seir) from the analyzed population due to either immunity/ resistance to the disease or death. dividing the recovered into "recovered from i" and "recovered from q" groups, and keeping in mind that we only have data on recovered from q and number of deaths (d), we can fit the model compartments to these series. the values of β i and β q depend on the contact rate between individuals and the probability of transmission in an encounter. /σ is the mean latent period and /γ i and /γ q are the mean infectious periods for each group of patients. finally, γ i and γ q are the recovery rates and δ is the death rate among the q group. the model is simulated by solving a deterministic ordinary differential equations (ode), given the parameters (β , β , σ, γ i , q, γ q , δ) and the initial conditions to obtain a realistic simulation of the baseline model and possible scenarios, we needed to estimate or calibrate these parameters and initial conditions. since we are at the beginning of the epidemic cycle and the full distribution is not yet revealed, the model cannot be properly fit to a probability distribution function. as a result, the model is estimated by minimizing the differences between actual and predicted share of cases for observable data series which are q, r q , and d based on an extension of drake ( ) . the model is estimated using iran's official data for the number of confirmed, recovered and death cases . as there are limited observable state variables, we fix or restrict a few parameters based on the reports in the literature to avoid over-fitting. first, based on the genomic studies on the phylogeny of sars-cov- , two genetic mutations of the virus has happened in iran (the nextstrain team, ) , first between january th and january th , and the second between january th and january th . thus, the virus was present in iran before january th , long before the first official record of the disease in iran (february th ), but not before january st as the parent mutation has occurred in hubei, china between january st and january th . so, the starting time of the simulations should be between january st and january th . initial values for observable states are obviously zero. second, we pin down the relationship between β i and γ i , and between β q and γ q , such that β q γ q = . , i.e., the minimum basic reproduction value and β i γ i to be equal to maximum basic reproduction number of . , based on various reported values . third, the relationship between γ q and δ is fixed at . percent to match the case fatality rate with the one estimated by baud et al. ( ) . without these restrictions, the parameters and initial states can be estimated, but the issue of over-fitting resides and leads to misspecification. based on the optimization, the epidemic started on jan th with infected and exposed people. in the absence of any control measures and/or changes in individual behaviors, we would expect a peak of infection (some of identified and unidentified patients) to occur around may , (figure ). as discussed in the previous section, we fix r i = . and r q = . in this scenario for the whole epidemic period. under this assumption, percent of the population will be infected by around may th . as the epidemic progresses, at the peak, around million identified individuals will be sick and will need medical assistance. in total, in an uncontrolled epidemic, around thousand iranians will die from this disease, not accounting for all other patients who will not get proper medical assistance during this period due to an overwhelmed medical system being. in a cabinet meeting, iran's minister of health mentioned that the maximum capacity of intensive care of all hospitals in iran stands around , beds. under the baseline scenario and without any control measures, at a percent hospitalization rate of identified cases, all icu beds in iran will be filled by april and even all hospital beds will be filled on may (figure ). some , individuals will die per day around mid-june (figure ). . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint although iran initially refused to fully quarantine the holy city of qom and later the other cities, the government started to react to the epidemic by cancelling all cultural, religious and sportive events, and closing of universities and schools in several cities. the authorities refused to quarantine areas affected by the outbreak and instead asked people to remain inside their houses on a voluntary basis, without any enforcing measures. some religious sites remained open until mid-march. unlike every year in late march (persian new year) the authorities urged the public to avoid travelling for the two-weeks holidays. however, according the official statistics, roads were still busy, and millions of people travelled, making the self-quarantine policy ineffective. in the absence of firm suppression policies , we simulate the model based on the changes in the behaviors of the public by comparing i) the baseline or uncontrolled scenario, ii) with complete isolation of identified infected cases, iii) case isolation and self-quarantine, iv) intensive testing, identification of cases and quarantine, v) a combination of previous scenarios, vi) abandoning shelter-in-place policy one month after the peak of the epidemic under scenario v. scenario (ii) is implemented by assuming β q = , meaning that as soon as an individual is reported as infected, all necessary measures are taken to stop contagion from this person to other people. china forced hospitalization of all "confirmed cases" and not just those who required hospital care, to reduce onward transmission in the household and potentially in other social settings. results show that this scenario is not effective and the epidemic progress almost at the same rate with and without complete isolation of identified cases. scenario (iii) is implemented by choosing smaller values for β i of the base scenario, as it depends on the contact rate between individuals, in addition to β q = . adding social distancing saves many lives (figure ), but at this stage of the epidemic at least to percent of the population should practice shelter-in-place. sadly, if only one quarter of the population continue regular contacts with each other, the number of death cases can easily surpass a quarter of a million, and clearly, this policy will not be enough to overrun hospitals' maximum capacity (figure ). we implement scenario (iv) by assuming that the health authorities will increase number of testing by folds. this helps isolate infected cases, provides patients with necessary medical assistance and decelerates spread of the disease to the rest of population. this policy would shift individuals from i group to q group, enforcing better implementation of precautionary measures and control of contagion. the results are shown in figure . even in this case, more than percent of the population will contract the disease and the death toll will remain very heavy. only by combining this scenario with previous scenarios, one can be hopeful to control the epidemic and save lives. figure : total death count in case isolation and partial self-quarantine in different levels. . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https: //doi.org/ . //doi.org/ . / scenario (v) shows the result for the combined policies, assuming that only percent of the population respect the shelter-in-place policy, while testing and identification process intensify by folds. figure shows the results for the combined policy. if implemented immediately, the total number of deaths by end-june will remain below thousand individuals. the maximum number of infected cases (i + q) will reach its maximum at , on may th and the majority of the population will not contract the virus. finally, in the last scenario, we assume that last set of policies were effective enough to reach the peak of the epidemic on may and the shelter-in-place policy continues by an additional -days period. as a result, businesses and government will open on june , while the intensive testing continues. we assume that as the shelter-in-place policy ends, all individuals remain vigilant and take hygiene measures. under this scenario, social interaction reduces by percent compared to normal times. as a result, the number of patients in need of intensive care surpasses the total icu beds capacity before the end of june, while it remains below the total number of hospital beds in the country until the end of year. . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint figure : ending the shelter-in-place policy -days after the peak of scenario (v), assuming that intensive testing continues and social interaction diminishes by percent. table reports the number of death and recoveries at end- . obviously, the combined set of policies, described in scenario v yields the best outcome with the lowest fatality and infected cases. comparing scenario iii and iv, we conclude that a combined intensive testing, identifying infected individuals, and quarantine is a more effective policy than just a shelter-in-place policy. as discussed, scenario vi is the same as scenario v, assuming that the authorities end the shelterin-place policy -days after the peak of the pandemic. unfortunately, under such scenario the death toll can be still multiplied by times compared to the scenario where social interactions are just reduced and kept low by percent. if the social interaction is increased to normal times, the death toll can be times larger than in the scenario v. many governments are impatient to open their countries businesses. they are rightly worried about the economic cost of a prolonged shutdown of economic activity. there are already outcry across countries by those who have lost their jobs. many in low income and developing countries cannot afford to stay in home for long, since there are not enough safety nets to protect the most vulnerable. on the other hand, even in advanced economies, the ripple effect of a lengthy and uncertain shutdown of the economy is too painful. this is the reason that countries' authorities have to start implementing a broad range of decisive actions. such policies should be put in place to save lives of thousands of people, alleviate pressures on the health system, and provide an opportunity for the people to go back to a normal living setting. these comprehensive set of measures include isolation of infected cases, shelter-inplace, and intensive and extensive testing. good examples are germany, south korea and not surprisingly china, where it not only hospitalized all cases, but also enforced a population-wide . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / scenario d r i ii iii iv v vi table : end of results social distancing to curb the contagion. unlike the current approach in some countries, where only the symptomatic cases are tested, the authorities should provide intensive and extensive testing and try to identify almost-all infected cases. this process would identify asymptomatic but infected cases and stop them of spreading the virus. this is key for a successful containment policy. given the geographic distribution of the pandemic, the testing should focus on the most affected locations first and then expand to those people who have visited the hot spots or have been in contact with anyone in those areas, while everyone practice social distancing. a combination policy, as discussed above, not only reduces the number of infected, and ultimately the death toll, but it shorten the shelter-in-place period and consequently lowers the economic cost. correspondence real estimates of mortality following covid- infection. the lancet infectious diseases fitting epidemics in r how scientists quantify the intensity of an outbreak like covid- impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) time-varying transmission dynamics of novel coronavirus pneumonia in china novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions pattern of early human-to-human transmission of wuhan the novel coronavirus, -ncov, is highly contagious and more infectious than initially estimated genomic epidemiology of novel coronavirus estimating clinical severity of covid- from the transmission dynamics in wuhan, china key: cord- -ivhqeu authors: battiston, pietro; gamba, simona title: covid- : $r_ $ is lower where outbreak is larger date: - - journal: nan doi: nan sha: doc_id: cord_uid: ivhqeu we use daily data from lombardy, the italian region most affected by the covid- outbreak, to calibrate a sir model individually on each municipality. these are all covered by the same health system and, in the post-lockdown phase we focus on, all subject to the same social distancing regulations. we find that municipalities with a higher number of cases at the beginning of the period analyzed have a lower rate of diffusion, which cannot be imputed to herd immunity. in particular, there is a robust and strongly significant negative correlation between the estimated basic reproduction number ($r_ $) and the initial outbreak size, in contrast with the role of $r_ $ as a emph{predictor} of outbreak size. we explore different possible explanations for this phenomenon and conclude that a higher number of cases causes changes of behavior, such as a more strict adoption of social distancing measures among the population, that reduce the spread. this result calls for a transparent, real-time distribution of detailed epidemiological data, as such data affects the behavior of populations in areas affected by the outbreak. the basic reproduction number, or r , represents the average number of secondary cases produced by a single infected case in an otherwise susceptible population, and it is typically used as a reference value to assess the transmissibility of an infectious disease in a given population. given a number of individuals susceptible to infection, a disease with higher r will infect a larger number of individuals. there is hence an obvious positive relationship between the r and the resulting size of an outbreak (tildesley and keeling, ). however, the value of r during an outbreak does not only depend on exante features of a virus or a population, but potentially also on the response of both population and authorities to the outbreak. this is particularly true in the context of the covid- pandemic, to which most countries in the world have reacted with some form of social distancing measures, or lockdown. in absence of a vaccine or effective drugs, these measures are the best weapon to reduce the number of deaths, as well as the number of intensive care unit beds required (kucharski et al., ; flaxman et al., ; ferguson et al., ; greenstone and nigam, ) . in the present study, we analyze data on the diffusion of covid- in lombardy, the region of italy most heavily affected by the pandemic provide an accurate description of the early phase of the outbreak in such region). specifically, we employ daily data on the number of individuals positive to covid- at the municipality level, focusing on a period in which the entire country was subject to a lockdown. all municipalities under analysis share the same public health system and, in the period considered, were subject to the same social distancing regulation. however, at the start of the period, they were characterized by a strong heterogeneity in the number of cases, both in absolute terms and in terms of cases per capita. we study a period beginning on march , , that is, more than two weeks after the lockdown regulation was put in place, and ending with april , when such regulations still held: this means that movements across municipalities are severely restricted, requiring any travelers to present a valid (typically work or health related) justification for their journey. we fit a susceptible-infected-recovered (sir) model on data from each municipality and find that the estimated r is negatively correlated with the prevalence in the municipality at the beginning of our period. this result holds both when considering the absolute and per capita number of cases and is robust to different specifications and sample disaggregations. we present and compare different complementary explanations for this finding. early and widespread testing increases the reported number of cases and might allow the authorities to slow the spread of the pandemic by isolating known cases. at the same time, where the number of cases is higher, the population might comply more strictly with the lockdown measures, thus reducing the rate of spread: we show in section . why the latter mechanism is most likely to drive our results. we employ count data of per-municipality recorded cases, updated daily and distributed by regional authorities. we do not rely on data on recovered and deceased individuals, as such data are not available with the required geographical disaggregation. data are available starting from march , and cover a period of twenty-one days during which lockdown measures were always in place. we verify that only minimal deviations appear between regional data and the aggregation of municipal data. out of municipalities in lombardy, had at least one recorded covid- case as of this date. figure a displays the number of cases (size of the dots) and the cases per capita (color of the dots) as of march for each of these municipalities. similarly, figure b displays the number of new cases (size of the dots) and the number of new cases per capita (color of the dots) recorded in each municipality between march and april . it should be noted that official data concerning the covid- outbreak in italy has been found to be strongly incomplete, both in terms of positive individuals and of casualties: several researchers have estimated an outbreak size much higher than that suggested by official numbers (flaxman et al., ) , while others have corroborated this with an analysis of anomalies in death rates. moreover, local testing strategies are known to have deviated from who guidelines and have changed over time, also depending on available resources: towards the end of our period of interest, more subjects with mild symptoms were tested. for this reason, some researchers have put forwards adaptations of the sir model that account for a threshold in the note: dot size represent absolute numbers, colors represent cases per one thousand inhabitants. capacity of the health system. such problems are not specific to italy, as official data from a number of countries have been questioned. more in general, the difficulty in obtaining reliable data on the number of infected, deceased and recovered individuals calls for refinements of traditional epidemiologic models (atkeson et al., ; riccardo et al., ) . given our research question, these caveats are of limited importance. indeed, the focus of the present work is to document differences in response across municipalities, rather than to precisely estimate the epidemiological parameters or expected duration of the covid- outbreak in lombardy. data on population size is obtained from the italian national istitute of statistics (istat). we fit a sir model on each municipality in the period of twenty-one days beginning in march . given the short time span considered, we employ a simplified sir model which does not account for natural rate of mortality. hence, the model is entirely defined by setting few parameters: β, which determines the rate at which susceptible (s) individuals become infected (i); γ, which determine the rate at which infected individuals become recovered (r); the initial number of infected and recovered individuals, and the population size n (= s + i + r). we take population size from official statistics. we hence consider a discretized version of the continuous sir model -each period corresponding to a day -and automatically explore the parameter space for β, γ, and the initial value for i and r, looking for the combination that provides the best fit. specifically, the goodness of fit is maximized by minimizing the sum of square residuals between the cases count and the sum of the i and r pools sizes. the initial values for the free parameters are set to those calibrated on the entire lombardy region. note: fit between data and the corresponding sir model for lombardy region (left) and the most affected municipalities at the beginning of our period of interest in absolute and per capita terms, respectively (center, right). given that the sir model assumes a non-null initial population of infected individuals, we only consider the municipalities satisfying this condition. we further drop municipalities which had new cases recorded on only one or two dates, hence reducing to municipalities. although this sample selection might in principle affect our results, we show in section . that this is not the case. figure a displays the fit between data at the regional level and the corresponding simulated sir model. figures b and c are the equivalent for milan and castiglione d'adda: these are the two municipalities which, at the beginning of our period of interest, had been most heavily hit in absolute and per capita terms, respectively. note that a weekly fluctuation can be observed for all municipalities: this is in line with documented evidence that less tests are processed during the weeekend, and the effect reverberates on the number of positive detected cases with a delay of two to three days. we expect these fluctuations to affect the entire region homogeneously. once we find the best sir parameters for each municipality, we regress the estimated r (the ratio of the estimated β and γ) on the outbreak size within the municipality as of march . we focus on the per capita number of cases, as we expect any effect to be related to the prevalence of the outbreak -a same number of cases will be perceived in a very different way in milan or in a small municipality. figure shows the distribution of the estimated values of r : the mean estimated value is . ( . when weighted on population), while the median is . a strong heterogeneity (which can be partly attributed to statistical noise -several municipalities count only a few cases each) can be observed across municipalities: in what follows, unless differently specified, we trim data by dropping . % of outliers on each side of the distribution of r , hence reducing to municipalities. in only few of these ( ) the value of r appears to be larger than the critical threshold of : that is, in the vast majority of municipalities, the outbreak is expected to spontaneously extinguish without requiring herd immunity. table presents the results of the regression analysis. we see a negative and strongly significant relationship between the initial number of cases per one thousand inhabitants and the estimated r (column ( )); this relationship is robust to controlling for population size (column ( )), and to both the absolute number of cases and the inverse of population size (column ( )), i.e., a full interaction model where the the per capita count represents the interaction term (kronmal, ) . the coefficient for the per capita number of cases can be interpreted as the reduction in r resulting from an increase of one case per one thousand individuals in the prevalence of the outbreak. the value of - . observed in column ( ), which we consider as our baseline specification, indicates a sizeable effect: for reference, given that the prevalence in milan as of march was of around . % , the above mentioned result suggests that had it been . % , the average r would have been around . instead than the observed . . the same negative and strongly significant effect is observed if we focus on the absolute number of cases as explanatory variable, controlling for the population size (column ( )). it should be noted that any intrinsic characteristic of municipalities -such as demography, location, structure of the economy -which might explain a larger outbreak size should also favor a larger r (mills, ) . thus, controlling for such characteristics is expected to further reduce the coefficient for cases% . there are a few reasons that might explain why a larger outbreak should result in a subsequent lower r . the first might be related to herd immunity, by which areas where the outbreak is initially more present have less scope for further spread because a large share of individuals have already caught, and possibly developed immunity to, the virus. this is in principle not a problem of our approach, as the sir model accounts for this effect and should estimate an r net of it -in other terms, r describes the evolution of the outbreak in an hypothetical situation in which the pool of susceptible individuals is never reduced. however, the problem might still arise if the count data employed severely underestimate the actual spread of the virus: the number of positive cases could actually be much larger than the detected one, leading to an estimated r lower than the real one because of the undetected effect of herd immunity in reducing the rate of contagion. the underestimation of infected population might also suggest an alternative explanation of the result related to test capacity: to the extent that a lower detected prevalence reflects a lower ability of authorities to identify infected individuals, it should then correlate with a lower ability to isolate, hospitalize and cure them, and hence to a faster outbreak growth. a third, social, explanation is instead that wherever the local population is aware of a larger prevalence of the disease, it reacts by changing its behavior towards a stricter application of social distancing rules, thus leading to a lower r . in what follows, we provide evidence in favor of this hypothesis. we start by analyzing the first possible explanation: several sources have argued that the actual size of the infected population might lie between four and ten times the official reported numbers. in the most affected muncipalities in our sample during the period analyzed, infections per one thousand inhabitants have been recorded, and according to the most pessimistic estimates this would mean that up to % of the population was infected. while most municipalities have a number of recorded cases per one thousand inhabitants which is orders of magnitude lower, to avoid the possibility that an even partial herd immunity effect might be driving the results, we reestimate our main model on subsamples of municipalities according to their initial number of cases per capita. specifically, we split the sample according to quartiles of cases per capita on march . the results, presented in columns ( ) to ( ) of table , show that our findings are not driven by herd immunity, as the coefficient for cases% is negative in each quartile. the absolute value of such coefficient is actually much larger for municipalities with a low prevalence than for those with a higher prevalence, and is strongly significant in the first two quartiles, hence including municipalities with cases per one thousand inhabitants or less. we then consider the second possible explanation: that a lower detected prevalence signals a lower detection ability, and that this naturally correlates with lower ability to track and quarantine infected subjects, hence raising the subsequent rate of diffusion. in order to disentangle this test capacity explanation from the third, social, one, we sketch two simple models of how these would be expected to affect r . let us represent with u t the unknown real number of infected subjects per one thousand inhabitants, at time t in a given municipality, and with i t the corresponding known number. we are interested in the extent to which unidentified infected subjects (which are u t −i t cases per one thousand inhabitants) will raise the r for the municipality in the subsequent period. more specifically, we can assume that identified and unidentified patients form two different pools of infected subjects and that the latter has a much higher β -probability of infecting susceptible individuals -that leads to a corresponding higher r . since β enters linearly in r -and assuming for simplicity that γ is constant -the relationship between u t − i t and r would be expected to be linear. moreover, it is well known that not only identified patients are subject to a stronger form of isolation, but also close contacts of such patient (some of which are not infected) are recommended to selfquarantine: this does not happen in municipalities with a larger number of undetected cases, which implies that the effect of each unidentified patient should be more than linear in increasing the r . this would imply a linear or concave relationship between cases% and r . vice-versa, any social explanation is based on the assumption that inhabitants react to the news of the cases in their municipality. given any concave function describing this reaction, a same increase in per capita cases will be perceived as more important if the initial number of cases is lower. that is, we can expect inhabitants of two towns with respectively and known cases per one thousand inhabitants to differ in their compliance with social distancing prescriptions more than inhabitants of two towns with respectively and known cases per one thousands inhabitants: a same difference of one percentage point in prevalence will have a weaker effect on people behavior were prevalence is higher. this alternative explanation pre- dicts a convex relationship (given the negative sign) between cases% and r . to disentangle between the test capacity and the social explanation, we enrich our basic model by introducing a quadratic term in cases% . this is done in column ( ) of table . we see that the quadratic term has a positive sign and is strongly significant, while the sign of the linear term is still negative and has increased in absolute terms. hence, while this does not allow us to exlude that the other explanations might play a role, we can conclude that the social explanation is the main driver of the negative relationship between cases% and r . (jones et al., ) describes two possible opposite reactions to the covid- oubreak: a precautionary attitude that leads to a stricter adherence to guidelines, and a "fatalism effect" according to which an individual who is more likely to be infected in the future "reduces her incentives to be careful today". our results provide strong evidence in favor of the first mechanism. in addition to the quantile analysis previously described, we verify that our main result also holds consistently across the provinces (lower level administrative regions) of which lombardy is composed. results are displayed in figure a . we see that, for each province, the effect of cases% on r is negative: although the small sample size results in only few provinces reaching statistical significance, it is clear that no specific area of lombardy is alone responsible for our findings. in order to verify that our results do not strictly depend upon the period considered, we replicate our analysis over different -days moving windows within our period of analysis. for each subperiod, we fit the r for each municipality and regress it on the number of cases per thousand individuals at the beginning of that subperiod. in accordance with the selection procedure described in section , we reduce this analysis to the municipalities that feature at least one case on march and, in each window, have new cases recorded in at least two dates. the results are shown in figure b . for comparability, we also display the value of the coefficient estimated for the entire time period on the same restricted sample of municipalities. we find that the effect of interest is robust, that is, the coefficient for the cases% is consistently negative and strongly significant for each subperiod. its absolute value is significantly decreasing over time; that is, the effect of the number of cases on the r in the following days appears to be stronger in the earlier days of the outbreak. while there might be multiple explanations for this, we only remark that the rate of growth of the epidemic has been consistently decreasing: whether individual behavior reacts not just to outbreak size, but also to its change over time, is an issue for further research. finally, we verify that all results reported in table , including statistical significance, are virtually unchanged if we do not trim the data as previously described. while an accurate predition of the date of extinction of the outbreak deserves more sophisticated epidemiologic models riccardo et al., ) that are out of the scope of the present paper, we can analyze to some extent the relationship between the predicted date of extinction and the number of initial cases. ( ) and ( ), . cases in columns ( ) and ( ). * p< . ; * * p< . ; * * * p< . in general, the relationship between infected population at time t and expected date of extinction of the outbreak within a sir model depends on the size of r : if the latter is smaller than -i.e., the outbreak is spontaneously slowing -then a smaller outbreak will extinguish sooner; viceversa, if r > , a larger outbreak will sooner reach a level of herd immunity, and hence die out. since, according to our data, most municipalities in lombardy display an r < , we focus on this case. while for a same level of r we expect the predicted time to extinction to increase with the initial outbreak size, the fact that the r is negatively related to initial outbreak size -and that a lower r leads to a quicker extinction -leaves theoretically undetermined the relationship between initial outbreak size and duration of the outbreak. in order to shed light on this indeterminacy, we proceed to simulating the sir model for each municipality until the predicted size of the infected population decreases below either (i) . cases for one thousands inhabitants or (ii) . cases and we consider the number of periods elapsed as the outbreak duration. we then regress the outbreak duration, defined in these two different ways, over the initial (i) number of cases per capita (columns ( ) and ( ) of table ) and (ii) absolute number of cases (columns ( ) and ( ) of table ), respectively. results from table show that the relationship between outbreak size and extinction date is non-trivial. first, the relatively few municipalities with r > do influence significantly the results -as already discussed, the expected effect of outbreak size for a same r is reversed in such cases. second, if we restrict to r < , the relationship is positive and significant when reasoning in per capita terms, but not in absolute terms. it should also be mentioned that the results depend on the thresholds adopted in the definition of outbreak extinction. in general, given that r < determines the exponential decay, a lower threshold will mean that the date of extinction is further away for municipalities with a relatively low number of cases and relatively high r . summing up, the results of predicting the extinction date are to be interpreted as cautionary: municipalities with smaller outbreaks might get rid of them sooner than others with more infected individuals (column ( ) of table ), but this result does not generalize to the absolute outbreak size (columns ( ) and ( ) -the former even featuring a negative sign). plans for a gradual exit from lockdown should take into account that the relationship between outbreak size and expected outbreak duration is difficult to pinpoint -as well as the possibility that a larger outbreak might bring the population closer to herd immunity, making it more resistent to a new outbreak. we show that in lombardy, during a lockdown, the basic reproduction number for covid- reacts negatively to the initial size of an outbreak at the municipality level, an effect which cannot be explained by the population having reached herd immunity. limited test capacity -and hence a limited ability by health authorities to isolate and treat affected individuals -appear sir models by design tend to infected subjects only for t → ∞ and different authors pick different thresholds as denoting outbreak extinction. notice that the most appropriate value crucially depends also on the extent to which the outbreak is underestimated by available data. to have at most a marginal role in explaining our result. instead, we show that the population's behavior is key to slowing down the contagion and in particular that information about local outbreaks impacts on diffusion rates. this effect is consistent across all provinces and it is robust to the sample period considered. the fact that the effect is particularly strong in municipalities characterized by a smaller outbreak suggests that individuals react more strongly to the first few cases. this aspect is confirmed by the convex relationship we find between the initial size of the outbreak and the r : the marginal effect on behavior of each new case seems to decrease in the number of cases. our results provide evidence in favor of a precautionary rather than fatalistic individual attitude towards the outbreak. they call for considering the population as an integral part of the decision making process, and for a timely and transparent provision of epidemiologic data. how deadly is covid- ? understanding the difficulties with estimation of its fatality rate impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand estimating the number of infections and the impact of nonpharmaceutical interventions on covid- in european countries. imperial college covid- response team does social distancing matter? university of chicago, becker friedman institute for economics working paper potential short-term outcome of an uncontrolled covid- epidemic in lombardy, italy optimal mitigation policies in a pandemic: social distancing and working from home spurious correlation and the fallacy of the ratio standard revisited early dynamics of transmission and control of covid- : a mathematical modelling study. the lancet infectious diseases demographic science covid- is r a good predictor of final epidemic size: foot-and-mouth disease in the uk compute values of the parameter π i−l = π i × ( − δ π,i ) and π i,r = π i × ( + δ π,i ) (the right and left candidate values for parameter π), . compare count data and the simulation obtained with each of the three candidates π i,l , π i and π i,r by computing the sum of squared residuals, . select the candidate value which results in the smallest error as new parameter value π i+ , . if the value did not change (that is, π i+ = π i ) optimization procedure for simplicity, the procedure for fitting the sir model is implemented over the parameters r and γ rather than β and γ, where r = β γ . for each parameter (including the initial values i =Î and r =r), the procedure is initialized by deriving reasonable values based on tuning the model to regional aggregated data.then the procedure works as follows (i denotes an iteration, δ π, is set to . for each parameter π): key: cord- - am l ms authors: nan title: spr date: - - journal: pediatr radiol doi: . /s - - - sha: doc_id: cord_uid: am l ms nan dear colleagues, i confess i haven't read many "welcome letters" at the beginning of the spr program book over the years. perhaps the only defensible benefit of this is that there is no preconception about the content of this message…or the length. i will be brief. this meeting is about building bridges…bridges from our past to the future and bridges between all of us who believe fundamentally in maintaining or improving the health of our children. the content, which is detailed on subsequent pages, speaks for itself. this material will be presented during the sessions with an appreciative look back at past accomplishments-the legacy of our subspecialty-with a vision to the future of pediatric imaging. we can only measure how broad and deep our successes have been by connecting with these beginnings. looking beyond the titles (and the speakers), i think you will see that the material is not only about techniques and tactics but about ideas, insights, energy, all conspiring in the creative process … an aggregate for excellence in pediatric imaging. the content is also punctuated by a strong presence of our clinical colleagues. again, this builds bridges. how can we maintain and expand these relationships? moreover, the connections between science and clinical practice are evident in the structured blending of scientific papers and topical presentations by both imaging and clinical experts. this blending is also "fraternal" in that there will sometimes be disagreement and critical commentary, but this is essential in the advancement of medicine. support and criticism make a stronger mortar. in the end, this gathering is about fostering a connected community, including technologists, nurses, physicists and other allied health experts including industry experts. finally, the emblem of pediatric radiology has always been embossed by cooperation, passion, commitment, and humanistic care. i believe the program content, the presenters and you, the participants, all embrace this. i hope that you will feel the spirit and the passion of the meeting and all of us will in many ways be better able to care for children because of this-even if you never read this message! donald p. frush the gold medal of the society for pediatric radiology is our most distinguished honor. the spr medal is awarded to pediatric radiologists who have contributed greatly to the spr and our subspecialty of pediatric radiology as a scientist, teacher, personal mentor and leader. marilyn goske has always wanted to make a differenceand what a difference she has made! her role as an educator, and her lifelong commitment to improving training for residents, fellows, faculty, medical staff and radiologic technologists has resulted in many wonderful initiatives that have benefited all in pediatric radiology. the work she is most proud of-the cleveland clinic web based curriculum, working with the leadership of spr's philanthropic campaign for children, launching the image gently campaign and the pediatric research component within the american college of radiology's dose index registry share a common theme: educating others in providing the best care possible for children. born in berea, ohio, marilyn's father, george, was a chemical engineer. her mother, cornelia aka "corky", loved writing as one of the first women journalists for the associated press and later teaching, passions she passed on to her daughter. while marilyn was blessed with a strong female role model in her mother, it was her brother, james, who was her cheerleader, always pushing her to dream big. he encouraged her to follow in his footsteps first at ohio university, then on to the ohio state college of medicine to pursue an md degree during an era when nursing would have been a more conventional goal. marilyn met her husband rick on a double date in college-unfortunately, they were with different dates! luckily, they were able to get together for an actual date with each other months later. they quickly became engaged and married within a year of that first true date. when rick started his residency in internal medicine, marilyn transferred to the university of connecticut school of medicine in farmington. it was here that she met her first pediatric radiologist-and what a giant-mike ozonoff! when rick moved on to a neurology residency in rochester, new york, marilyn followed and met another pediatric radiology giant: beverly wood, at strong memorial hospital. beverly proved to be a wonderful teacher, mentor, co-researcher and lifelong friend. marilyn describes beverly as inspirational and "fearless" in trying new technologies. it was during her time in rochester that marilyn went to her first spr meeting and, not surprisingly, won the caffey award for her work on "experimental neonatal intraventricular hemorrhage: clinical, radiographic and pathologic features." by then marilyn had two young children and moved on to the private sector, practicing part-time for several years first in rochester, then in cleveland, ohio. her years in private practice were particularly helpful in learning the importance of patient oriented service-and paved the way for her intuitive public relations strategies when designing the image gently campaign in later years. dr. goske was asked to join the cleveland clinic in , as the first full-time section head of pediatric radiology. it was here that she built a new section and spearheaded the web based education program for pediatric radiology residents with co-founder janet reid. this important free web site with modules is used widely by over radiology residencies nationally and internationally. her passion for education continued, inspiring her to complete a medical education fellowship focused on professionalism within the cleveland clinic lerner college of medicine. her work towards this fellowship has led to many creative educational initiatives including yearly educational summits at the spr. she was named chair of the professionalism committee of the rsna where she along with her committee have sponsored interactive workshops on this topic dear to her heart. dr. goske's energy and effective leadership skills brought her to become involved in the society for pediatric radiology, first as the coordinator for spr's first video-taped course in . mentors diane babcock and carol rumack proposed her for the nominating committee. this was followed by chair of the membership committee, where she organized the first formal survey of the society, then as a board member, then as secretary, and finally as president and chair of the board of directors, completing years on the spr board. working together with stuart royal, she successfully energized the campaign for children raising funds for the research and education foundation of the spr and expanded the work of prior presidents in further organizing the corporate support committee. marilyn's years as president and chairman of the board of the spr were highly successful with many unique strategic goals. she was instrumental in the founding of the junior spr. she led the wonderful spr national meeting in miami which included the first educational summit to enhance knowledge in adult learning and resident competencies. most people would rest after completing their arduous year as president but as chairman of the board, marilyn was just beginning! she moved to cincinnati children's hospital, joining the radiology department and was named the dr. corning benton endowed chair for radiology education where she got to work with dr. janet strife, another influential mentor and friend. acknowledging spr's long focus on reducing radiation doses in the imaging of children but concerned about the lack of change in practice by a majority of radiologists despite increasing reports of possible side effects, marilyn developed a public relations and awareness campaign. her goal was to inspire all to work towards decreasing radiation exposure to children when possible. with the help of many, she founded the alliance for radiation safety in pediatric imaging and the image gently campaign, initially focusing on ct. her ability to encourage numerous experts and societies to work together and get involved in "child sizing the amount of radiation used" has resulted in a groundswell of research and activity in this area. currently organizations with over , members have joined the alliance including international societies. the web site, www.imagegently.org, has been immensely successful filled with free information pamphlets in over languages, pqi projects, and modules for parents, physicians, and technologists. the image gently campaign has received several awards including the associations advance america honor roll, rt image magazine group with the "most influence in radiology" and the most effective philanthropy program from aunt minnie. image gently has spawned the creation of the adult-focused image wisely campaign. the alliance has been named by the joint commission, u.s. food and drug administration, and the american medical association in their influential statements on radiation dose as providing much needed guidance and information. marilyn's exceptional talent is inspiring and coordinating experts in multiple fields to work together towards common goals. she continues to work hard on the image gently campaign with more safety and quality messages planned for the coming years. she is also proud of her work with the acr dose index registry and quality improvement registry in ct scans in children in working toward developing diagnostic reference levels with a talented consortium of pediatric radiologists, medical physicists and technologists. she has acted as a national and international expert in her work with the international atomic energy agency, the world health organization and the national council on radiation protection in medicine and the fda. dr. goske's multiple committee appointments are taken seriously, and her work is always meticulous, well thought out, and brought to successful completion. she has been an active member of numerous national and international societies including the john caffey honorary society, acr, rsna, espr, aawr, and scorch. it is important to remember that dr. goske is also a successful researcher with numerous grants obtained through the spr ref including the thorne griscom education award and the rsna scholar grant. she has published over peer-reviewed articles, electronic publications, chapters, and presented scientific exhibits as well as given numerous scientific presentations. an articulate and engaging speaker, she has been invited to give over lectures locally, nationally and internationally. while marilyn has been very focused on her work with the spr, she believes that it is her amazing family and their love that really fuels her life. her husband rick is an internationally known neurologist and researcher in multiple sclerosis. her adult children jamie and brian, both in manhattan, remain close, and spending quality time together as a family remains the joy of her life. whether it is relaxing together in florida cooking or fishing, or taking an exotic vacation to india, being with rick, jamie and brian makes her the happiest. marilyn's genius is partly refusing to take "no" as an answer. along the way, at every turn there were those who believed that what she wanted to do couldn't be done. her approach was to draft the nay-sayers to the team and charge ahead with their willing and enthusiastic help. daniel burnham might have been talking about marilyn and not about his plan for the city of chicago when he said: make no little plans; they have no magic to stir men's blood and probably themselves will not be realized. make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die, but long after we are gone be a living thing, asserting itself with evergrowing insistence. as an amazing change agent, inspirational leader, and wonderful role model, the spr is proud to honor marilyn goske with the gold medal. she made big plans! dorothy i. bulas, md pioneer honorees were first acknowledged in as a means to honor certain physicians who made special contributions to the early development of our specialty. it is time to reevaluate the meaning of the pioneer honoree. the subspecialty of pediatric radiology has been in existence now for more than years. we are beyond "the early development"; we must recognize other pioneering paths and should consider contributions to the subspecialty beyond the bounds of a modality, a technique, an observation or a change in practice. whatever this advancement is, it must be forged with vision, innovative ideas, and the ability to enable and sustain science and application. george s. bisset, iii, m.d. why george bisset? has he been part of the pediatric radiology landscape these last ten years? been part of the dialogue that has been increasingly influential across all of radiology, a conversation steeped in a deep tradition of excellence in diagnosis and treatment, and the safety and welfare of our children? been a leader in science and application? part of the landscape? no. but he has been beyond that and has worked tirelessly within the horizon, surveying…a step before, but guiding us on towards our destiny. a conversant? part of the dialogue? maybe. but he has been defining thought and concept upon which such conversation is born and nurtured. part of the science and application? yes, as much as anyone who promotes, who facilitates and sustains discovery, then here we are. horizons, innovation, and the gift of en-abling…what else is needed to define a true pioneer? how was this done? simply stated, george bisset has devoted at least the last decade to the advancement of our specialty in truly novel ways through his leadership, especially in rsna and the abr. in the rsna, as the scientific program committee chair several years ago he was instrumental in the conception, development and implementation of the integration of scientific papers and refresher course topics. this has been a resounding success, is currently used in other categories during rsna and is a model for other meetings, including the annual meeting for the society for pediatric radiology over the past few years. pediatric radiology was first in this effort. george continued to endorse topics that were marquees for pediatric radiology over the year in his education role on the rsna board of directors. he endorsed and implemented the pediatric campus concept at the rsna. early returns are that this was an extremely successful model to consolidate experts in pediatric radiology (and those interested in this subspecialty), pertinent science, education and administration. george is now the president of rsna, perhaps the most widely respected scientific and educational organization for our profession across the globe…and i would argue, with more promise for our future success in pediatric radiology than has ever existed. and george bisset, who through two terms as the pediatric trustee for the board of trustees for the abr, again, was on the horizon of a critical, sometimes perilous, and complete transformation of our certification examination process, always mindful of his constituency and colleagues, his duty as a physician, and the public and patients. this required delicate diplomacy, forward thinking, professionalism, and enlistment of a cadre of experts from within our subspecialty to assure excellence in pediatric radiology through abr certification. he was also a leader in the development, validation and implementation of the imagerich computer based examination model (the pediatric caq) now the standard for the new abr examinations. with these successes in mind, who better to embody the concept of bridging horizons that is the theme for this entire meeting? if you were looking for more numbers and accolades, i apologize. here are some: more than contributions to medical and scientific literature, advancing care through pediatric body ct and mr imaging research, a litany of presentations and invited lectures, vice chairs, chairs, chiefs, boards of directors, committee member and committee leader, clinical excellence including as a pediatric cardiologist and interventional radiologist, a superb speaker and author.… all are on his cv but i believe serve really as signposts for his gifts, some of those mentioned above, that a cv simply cannot convey. he could have played it safe with all of these successes on his cv. but pioneers don't play it safe. they are on the horizon, too busy defining thought and enabling (our) advancement-building bridges. i believe it is time to reevaluate the meaning of the pioneer honoree and i have the greatest honor and pleasure of introducing george s. bisset, iii for the pioneer award for . linked with past awardees, he continues an exceptional legacy and i don't believe his explorations and discoveries are finished… donald p. frush, md the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. in , david kushner was recognized by the spr with its first presidential recognition award for his vision and foresight in working with both the american college of radiology (acr) and the society for pediatric radiology (spr) in developing an important new relationship and for his service to the spr. in summarizing his considerable efforts for that award, i noted that he "contributed substantively to the increased visibility of the spr within the acr. his tenure as our treasurer placed our organization on a firm financial foundation." with the current award, the society recognizes his indefatigable continuing efforts on our behalf including: his work with the acr: . establishing a pediatric radiology caucus at the annual acr meeting, . convincing the acr of the value of managing specialty societies by making the spr its first successful new model for imaging society management, . advocating tirelessly for pediatrics and children's health within the acr by serving on the council steering committee and then as acr council vice speaker and speaker, . helping establish the first pediatric commission, assuring that pediatric issues will receive support of the college and its resources while serving on the board of chancellors of the acr for the past five years. the spr's "image gently" campaign was a beneficiary of this pediatric commission of the board of chancellors, . continuing to shepherd and contribute to the pediatric component of the acr practice guideline process. his work with the spr: since his earlier award, david has served as: foundation from to , including the launch of the formal fundraising effort, "the campaign for children," . spr president - , organizing and running a very successful meeting in savannah, . chair of the board of directors of the spr from to , including leading a strategic planning process that resulted in a new, more focused division of labor amongst board members and defined board responsibilities. david was born in fargo, north dakota, received a ba from the university of minnesota, and received his medical education at the university of pennsylvania. this was followed by two years of training in pediatrics at children's hospital, boston. he then did a two-year fellowship at the national institute of health in bethesda, performing research in embryology and teratology. he returned to massachusetts general hospital for training in diagnostic radiology. this was followed by a year of residency in pediatric radiology at children's hospital boston, followed by a one-year fellowship. he then became director of the pediatric radiology section at massachusetts general hospital, a position he held from to . from to , david was chief of the division of diagnostic imaging and radiology at children's national medical center in washington, dc attracting a strong faculty, training many fellows and promoting research. during that time, he served as a volunteer radiologist and pediatrician to inner city healthcare systems aiding the indigent and homeless, and developing telemedicine capabilities linking free clinics with radiology experts. in , our man inside the beltway moved a bit outside by accepting the medical directorship of radiology at the children's hospital of the king's daughters in norfolk, virginia, and professor of radiology and pediatrics at the eastern virginia medical school. he assures me that life there is good, being a bit more "laid back" with fishing and sailing just outside the door. he also finds time for italian cooking and practicing jazz on his several guitars. fortunately for all of us in the spr, david is close enough to our central office and the acr that he will be able to continue work on our behalf for many years to come. the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. the spr presidential award is given in recognition of stuart's numerous significant and outstanding contributions to the spr over many years of service. the awardee is selected by the honors committee, a committee comprised of the three most recent past presidents of the society. dr. royal is a proud native of birmingham, alabama. he is a second generation physician who came naturally to his desire to care for children as the son of a pediatrician, arnold royal, who took care of children in the birmingham community until he was years old. dr. royal attended rice university in houston, texas followed by md and ms degrees from the university of alabama at birmingham. he subsequently moved to san francisco, where he completed a pediatric internship followed by a diagnostic radiology residency at the university of california, san francisco. dr. royal credits dr. charles gooding at ucsf for influencing his decision to pursue a career in pediatric radiology. during his internship stuart observed dr. gooding make a plain film diagnosis of tapvr, type on a severely ill and perplexing newborn, and he was immediately hooked into radiology. while at ucsf dr. royal was also appointed as a national institute of health research fellow in the department of radiology. following residency, stuart completed a fellowship in pediatric radiology at the children's hospital medical center in boston. from boston, stuart returned to his roots in birmingham, alabama in , where he was appointed as a pediatric radiologist at the university of alabama and subsequently the children's hospital in birmingham. in recognition of his outstanding leadership skills and accomplishments at the children's hospital, dr. royal was appointed as the radiologist-in-chief in , and subsequently the harry m. burns endowed chair of pediatric radiology. he also holds appointments as clinical professor of radiology and pediatrics at the university of alabama at birmingham and serves on the children's hospital board of trustees. at alabama dr. royal has earned the high esteem of his colleagues, referring physicians, and staff for his outstanding clinical acumen as a diagnostic radiologist and for his undaunting commitment to excellent care of children. colleagues describe stuart as one who fosters a strong work ethic, high commitment to teaching, and sincere compassion for children. in , stuart was the recipient of the children's advocate award by childcare resources for improving the quality of care and access to radiological services for underserved children in birmingham. stuart has been married to the love of his life, barbara royal, for the past years. stuart and barbara are the proud parents of two very accomplished children, jeremy a budding radiologist in training at the university of alabama, and rachael, who has an mba and works as a vice president for moody's in new york. stuart and barbara are also the proud grandparents of three grandchildren. in conversation, stuart is quick to pull out his iphone and share the latest pictures of family members while recounting their latest activities and milestones. throughout his professional career, dr. royal has worked tirelessly to advance the mission of the society for pediatric radiology. he is past president and chairman of the board of the spr and has served on numerous spr committees. he ran a highly successful spr meeting in new orleans in . those in attendance will recall the jubilant parade stuart led through the streets of new orleans to culminate the meeting. as president and then chair of the spr board, stuart played a critical and instrumental role in bringing the spr management contract under the umbrella of the acr. the synergy achieved by the spr-acr relationship has yielded results well beyond a simple management contract. pediatric radiology and spr now have a voice at the "radiology table." stuart has also been a strong advocate for supporting translational research to advance the care of children via imaging. to help achieve this goal, he has worked aggressively to secure increased funding for the society of pediatric radiology research and education foundation. following the launch of the ref's campaign for children in , stuart made it his personal mission to work with the leadership of the society, both past and present, to discuss major gifts to the foundation. through stuart's personal effort, the foundation received pledges for many significant leadership gifts, including from spr pioneers drs. hooshang taybi and ed singleton and from himself and barbara. the spr is highly fortunate to have benefited from stuart's numerous contributions and dedication to the care of children. the society is very proud to bestow the president's award on dr. stuart a. royal. the society extends honorary membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children. this evening, dr. harvey l. neiman, whose leadership of the american college of radiology is resoundingly praised, is the recipient of the honorary member award. for , as in when his contributions were similarly recognized, dr. neiman's selection by the society for pediatric radiology honors committee was made in appreciation for the strength of his efforts to further the spr's philosophy, goals, and programs for responsible diagnosis and treatment of the young patient as embodied in the acr and spr's "image gently" campaign. image gently has succeeded not only in raising awareness of the great diagnostic benefits we can offer to pediatric patients but also directs us to acknowledge the downside of overzealous diagnostic efforts where excessive radiation becomes a risk. importantly, the "image gently" campaign, an upbeat, positive program rather than a punitive one, a smile rather than a frown, makes pediatric and all radiologists aware that their best practice reflects balanced, educated, up-to-date utilization of state-of-the art technology with exercise of responsible leadership in protecting the pediatric patient. for adults, awareness of the need for patient protection is communicated in image wisely. dr. neiman's vision and successful achievements are evident on every page of his curriculum vitae. a consummate strategist in assembling teams to make forward-looking goals a reality, harvey now stands at the top of our specialty as the first physician executive director of the american college of radiology. at this time in big-business medicine, as we see the physician, leader of the patient care team, being diminished to one of many "providers," it is so important for our patients' well-being for us to recognize the obligations commanded by our training, clinical experience and commitment. dr. neiman's recognition of the need for physicians' leadership in improving the quality of patient services and his development of programs in all areas of the college's activities have been just short of miraculous-image wisely for adults, quality and safety including the performance guidelines and accreditations, education, government relations, economics, imaging metrix, acrin, and the new radiology leadership institute-to name only a few. all have contributed significantly to the care of our patients and the stature of our specialty. dr. neiman was born in detroit and attended mumford high school. from wayne state university, he received his b.s. in and his md in . harvey's postgraduate training was at the university of michigan, where he was a resident in radiology ( - ), chief resident ( , and a - fellow in angiography (cardiovascular radiology), receiving abr certification in and a caq in vascular and interventional radiology in february . dr. neiman often expresses his gratitude to and profound respect for his mentor and beloved chief at the university of michigan, dr. william martel. dr. neiman was chief of cardiovascular radiology at walter reed army hospital and a lecturer in cardiovascular radiology at the afip from - . in , he joined the northwestern radiology faculty, rising to professor in , and for ten years he headed up the section of angiography and sectional imaging, advancing its technology and honing the skills of northwestern's radiology residents. harvey also offered a highly sought-after fellowship in interventional radiology, us, and ct. in , dr. neiman left northwestern to assume the chair in medical imaging at the western pennsylvania in pittsburgh. i was the first woman to have completed his fellowship in us, ct, and interventional radiology at northwestern and accompanied him to pittsburgh. his tenure at west penn attests to his talent in making his visions a reality: the department became a highly respected, successful academic private practice notable in many areas including ultrasound, breast and women's imaging, and interventional radiology. harvey instituted an excellent radiology residency program in as well as fellowship programs in in the areas of excellence noted above. during the years since harvey received his md, he has been awarded honors from many national, international, and specialty societies, has been an invited lecturer over times on ultrasound, interventional radiologic, radiologic educational, management, turf issues, disruptive and new technology topics to name just a few. dr. neiman, who was a founder of the sru (society of radiologists in ultrasound), has to his credit peer-reviewed articles, scientific presentations and exhibits, a text co-authored with dr. james yao, angiography of vascular disease ( ) , and book chapters. he has received many honors including fellowship in the american college of radiology, american institute of ultrasound in medicine, society of radiologists in ultrasound and the society of cardiovascular and interventional radiology (now sir). as part of his strong commitment to the future leaders of radiology, for diagnostic radiology he has served as a member of the residency review committee of the accreditation council for graduate medical education. he has been a member of the american college of radiology and its committees and commissions for many years including the commissions on education, ultrasound, and economics. he also served as chair of the commissions on ultrasound and economics. from to , he was a member on the acr board of chancellors, serving as its chairman - . he was president of the radiology advocacy alliance from to . in , nine years ago, dr. neiman became the acr's executive director. he currently serves in this position, where his excellent business skills, knowledge of health policy and economic issues, and strong administrative background have furthered our specialty. his goal, to ensure that the acr's resources benefit all radiologists and patients across all economic strata, is evident in his actions at the college. harvey has a devoted, wonderful family that often included me and my youngest daughter on many pittsburgh occasions. his beautiful, elegant wife of many years, ellie neiman, is here tonight to celebrate with him the spr's recognition of his many achievements. dr. neiman has two accomplished, lovely daughters, jennifer, extremely successful in her marketing career, and hilary, an attorney. jennie's husband, dr. seth kligerman, one of many young radiologists whom harvey has mentored, is on the radiology staff at the university of maryland. how harvey has had time between, through, and among all of these achievements to have become mentor, colleague, and friend to me and to so many others who have been inspired by his ability to see into the future and to shape it in a positive way is remarkable. now that dr. neiman has taken all of radiology under his wing, not just its component parts, the future of our specialty, one of the best, can be assured but also recognized for its centrality to all of medicine. it is my honor and privilege to introduce to you harvey l. neiman md, facr as this year's society for pediatric radiology honorary member. the singleton-taybi award is given in honor of edward singleton and hooshang taybi, in recognition of their personal commitment to the educational goals of the spr. initiated in , the award is presented annually to a senior member of the spr whose professional lifetime dedication to the education of medical students, residents, fellows, and colleagues has brought honor to him/her and to the discipline of pediatric radiology. it comes as no surprise to those who know him that dr. daneman, "dr. d" as some of us call him, has been named the recipient of the singleton-taybi award in recognition of his many years of dedication to the education of residents, fellows, and colleagues. born in south africa in , he received his medical degree at the university of the witwatersrand, johannesburg, receiving the harwood-nash award for the most successful student in surgery. initially, dr. d thought he would become a pediatric surgeon; but after passing the part i examination offered by the royal australasian college of surgeons, he changed his mind and began his training in diagnostic radiology. he chose a radiology residency at the royal prince alfred hospital, in sydney, australia. this included a year in pediatric radiology at the royal alexandra hospital for children in sydney where his interest and love of pediatric radiology began. dr. d then had the foresight to pursue pediatric radiology fellowship training at the hospital for sick children in toronto, canada. after completing the fellowship, he was immediately offered a position as staff radiologist at "sick kids." he became director of body imaging in and radiologist-in-chief in serving in that capacity for years. his management style was simple but effective. he chose staff that were young, but smart and innovative. he nurtured them and provided them with all the tools they needed to become successful professionals, like him. but contributing to his own department was not enough for him. he also found the time and strength to contribute, teach, train, and help pediatric radiologists in the most remote portions of the globe in every continent, which resulted in recognition from prestigious organizations in places such as south america, israel, europe, taiwan and australia: he is an honorary member of the european society for pediatric radiology and the sociedad latinoamericana de radiologia pediatrica as well as other national societies. dr. d is an "institution" inside the great institution that is sick kids. his teaching is unique and praiseworthy in being enthusiastic, provocative, and fun at the same time. his lectures have been regarded as both instructive and practical by his students and trainees due to his special gift of making the most complicated things look as simple as possible. in sharing his diagnostic knowledge and know-how, he passes his own, innate teaching spirit on to his apprentices. he has earned several awards for this, including the outstanding teacher award granted by the university of toronto fellows at sick kids for the past consecutive years. dr. d receives numerous invitations to present at national and international meetings and symposia and has been invited as a visiting professor to more than a hundred institutions across the globe. he does not only teach us the ins and outs of pediatric radiology, but he makes sure that we learn to love it and understand the importance not only of good practice but also the imperative to pass knowledge on by teaching and publishing. dr. d is someone who inspires us to reach beyond our limits, someone we want to emulate. he shares his knowledge, his wisdom, and his advice freely. he shares with us the most incredible secrets of his own career, so we understand from his personal experience. dr. d never tells you what to do, he suggests to you, in an incredible articulate fashion, what you want to do yourself. dr. d has been and is for many of us, more than an educator, more than a mentor, he is our "coach." well before this concept was introduced into medicine by a. gawande , dr. d intuitively had the vision to "coach" his trainees, trying to get the best out of them, without pressure, but with love and passion, and especially emphasizing the importance of achieving a worklife balance in order to prevent the now so common "stress and burnout" affecting the radiology community . he warned us that many high achievers reach their goals only at the expense of their personal lives, but dr. d has been as successful personally as he is professionally. his wonderful wife of years, louise, his two daughters and his recently newborn granddaughter serve as sources of strength and pride. he is a truthful and generous friend to many, both in and out of radiology. it is not uncommon for many of us, who came through sick kids, to come back and visit and be invited to his house to share a wonderful dinner with other invitees, who may be radiologists from north america or from other parts of the globe visiting sick kids to learn from him. dr. daneman's research has widely influenced the field of pediatric radiology. examples include the work of dr. daneman and his colleagues on intussusception, which has promulgated the use of ultrasound for diagnosis, and the use of air enema for reduction. this approach has been adopted as standard practice at many institutions in north america and across the globe. to share his research with others in the field, dr. daneman has authored or co-authored more than publications, including peer reviewed articles and book chapters on a wide range of topics related to the imaging of children. dr. d is one of those rare people who are irreplaceable. he is a superb teacher, a gifted academician, a capable administrator, and a person called "friend" by so many of us. we are thrilled and proud to present our society's singleton-taybi award to dr alan daneman in recognition of his lifelong accomplishments and personal commitment to the educational goals of the spr. we cannot imagine anyone more deserving of this award than dr. d. thank you "coach"! monica epelman, md and oscar navarro, md john caffey, md - dr. caffey was regarded throughout the world as the father of pediatric radiology. his classic textbook, pediatric x-ray diagnosis, which was first published in , has become the recognized bible and authority in its field. the seventh edition of this book was completed several months before his death in . it has been among the most successful books of its kind in the medical field. dr. caffey was born in castle gate, utah on march , . it is interesting that he was born in the same year that roentgen discovered the x-ray. dr. caffey was graduated from university of michigan medical school in , following which he served an internship in internal medicine at barnes hospital in st. louis. he spent three years in eastern europe with the american red cross and the american relief administration, and returned to the united states for additional training in medicine and in pediatrics at the universities of michigan and columbia, respectively. while in the private practice of pediatrics in new york city at the old babies hospital of columbia university college of physicians and surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in . he frequently expressed appreciation and admiration for the late ross golden, chairman of radiology at columbia presbyterian hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him. dr. caffey's keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in . dr. caffey received many awards in recognition of his achievements. outstanding among these were the mackenzie davidson medical of the british institute of radiology in , the distinguished service award of the columbia presbyterian medical center in , the outstanding achievement award of the university of michigan in , the howland award of the american pediatric society in , the jacobi award of the american medical association in , and the gold medal award of the american college of radiology in . he had been a member of the american journal of roentgenology. he was a counselor of the society for pediatric radiology and was an honorary member of the european society of pediatric radiology. dr. caffey's contributions to the pediatric radiologic literature were many. he was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. infantile cortical hyperostosis was described by him and is called "caffey's disease." dr. caffey in first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. it was dr. caffey who first recognized and descried the characteristic bony changes in vitamin a poisoning. he recognized and described the findings associated with prenatal bowing of the skeleton. in , three years after his retirement from babies hospital, he joined the staff of the children's hospital of pittsburgh as associate radiologist and as visiting professor of radiology and pediatrics at the university of pittsburgh school of medicine. although dr. caffey came to children's hospital and the university of pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. in pittsburgh, he made four major new contributions to the medical literature. he described the entity, "idiopathic familial hyperphosphatasemia." he recognized and described the earliest radiological changes in perthes' disease. he called attention to the potentially serious effects of shaking children, and used this as a subject of his jacobi award lecture. he described, with the late dr. kenny, a hitherto unrecognized form of dwarfism that is now known as the caffey-kenny dwarf. the john caffey society, which includes as its members pediatric radiologists who have been intimately associated with dr. caffey, or who have been trained by his students, was established in . this society is now among the most prestigious in the field of radiology. his book and the society named in his honor will live on as important memorials to this great man. his greatness was obvious to all who worked with him. he was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. his dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. he was concerned with the written and spoken word and was a skilled semanticist. his book and his articles are masterpieces of language and construction. he stimulated and was stimulated and loved by all who had the privilege of working with him. radiology and pediatrics have lost a great man, but they shall ever have been enriched by his presence. interstitial lung disease, which is more common in infants than older children, is defined as a rare heterogeneous group of parenchymal lung conditions primarily due to underlying developmental or genetic disorders. affected infants typically present with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. mainly due to a lack of evidence based information regarding underlying pathogenesis, natural history, imaging findings, and histopathologic features of interstitial lung disease, the understanding of interstitial lung disease in infants has been limited in the past. however, in recent years, the understanding of interstitial lung disease in infants has been substantially improved primarily due to: ) advances in imaging technology for better detection; ) improvement of thoracoscopic techniques for lung biopsy; ) established pathologic criteria for consistent diagnosis; and ) development of new classification system based on underlying etiology of the interstitial lung disease. in fact, several forms of interstitial lung disease in infants that exhibit distinct clinical, radiological, and pathological patterns are currently emerging. the overarching goal of this article is to review a new classification system, imaging findings, and pathological correlation of interstitial lung disease in infants. improved understanding of this often challenging disorder can aid in early and accurate diagnosis, which in turn, will result in improved patient care. large airway disease in pediatric patients: impact of advanced post-processing techniques catherine m. owens, bsc mbbs mrcp frcr the introduction of multidetector row computed tomography (mdct) scanners has altered the approach to imaging the pediatric thorax. in an environment where the rapid acquisition of ct data allows general hospitals to image children instead of referring them to specialist pediatric centers, it is vital that general radiologists have access to protocols appropriate for pediatric applications. this lecture will focus on the main principles of volumetric ct imaging that apply generically to all mdct scanners and in particular we describe the reconstruction techniques for imaging the pediatric thorax and the low-dose protocols used in our institution on a -slice dual source ct scanner. examples of important clinical applications with the impact and added value of post processing are also given. neoplasms, by definition, comprise an abnormal uncoordinated proliferation of cells that persists even after the inciting stimulus as ceased. the resulting mass may be benign or malignant and arise from any tissue that is normally found in the location where the mass develops. thus, tumors of the chest may arise from bone, lung, pleura, lymphatics, muscle, etc. whether benign or malignant, chest masses may be incidental findings on imaging obtained for other reasons. this presentation will focus on malignant tumors of the chest, address the imaging characteristics and staging of the most common chest malignancies and discuss characteristics that may aid in distinguishing these lesions from their corresponding benign or infectious counterparts. included in this presentation will be the most common chest wall malignancies (ewing family of tumors and rhabdomyosarcoma), mediastinal malignancies (lymphoma, germ cell tumors, and neurogenic malignancies) and pulmonary primary malignancies (pleuropulmonary blastoma and carcinoid). the changing appearance of selected tumors in patients treated with new targeted therapies will be introduced. lung disease is the most common chronic disease of childhood, but young children cannot perform the breathing maneuvers required for the most commonly used method for assessing lung function, spirometry. ct provides exquisite structure information about the lung but concerns regarding the long-term consequences of the relatively high radiation dose limit its use particularly in the pediatric population. magnetic resonance imaging (mri) has the potential to provide regional information about the lung without the use of ionizing radiation. while conventional proton mri has found widespread clinical application in most organs of the body, mri of the lung lags behind because the lung is intrinsically difficult to image with mri. the strength of the mr signal depends on the physical density of protons in the tissue being imaged and the local environment of the protons. the lung has a low physical density and thus a low proton density so little mr signal is generated by the lung. furthermore, the magnetic susceptibility effects from its many air-tissue interfaces cause what little signal is generated to rapidly decay so that the lung typically appears dark on conventional proton mr images. a variety of strategies have been developed to overcome the inherent difficulties of mri of the lung, resulting in recent substantial improvements in image quality. additionally by administering an inhaled gaseous contrast agent, such as the hyperpolarized noble gases helium- or xenon- , direct visualization of lung airspaces in an mr image is possible. a number of unique strategies for evaluating the structure and function of the human lung using hyperpolarized gas mri have been developed. although the level of structure detail possible with lung mri may never equal that of ct, mri may nonetheless has the potential to provide clinically useful information and be a sensitive, effort independent test of pediatric lung disease. for a matter of time, we will focus in this presentation only on the following: intestinal malrotation a normal visceral situs can be inferred sonographically in relation to the right-sidedness of the superior mesenteric vein, to the retromesenteric location of d and to the right iliac position of the ileocecal valve. conversely, intestinal malrotation is likely when the aforementioned features are reversed. in addition, cdu can display the whirlpool pattern in case of midgut volvulus or internal hernia, alleviating the need for preoperative opacification. the reliability of us in diagnosing intussusception is well documented since the early s. the value of us in predicting the success or failure of pneumatic reduction and/or bowel necrosis is more debatable, based upon a coexisting bowel occlusion, the presence of interloop fluid, bowel wall changes (intramural air, dilated mural vascular channels), absent blood flow at cdu. the continuous down-grading of us in comparison to ct, and the opposite conclusions of various series regarding imaging of pediatric appendicitis are based upon different prerequisites and definitions. historically and in most usa institutions, sonography reports are either negative (entire normal appendix), positive (abnormal inflamed appendix), or equivocal (non-visualization or partial visualization of appendix). the equivocal group is then logically investigated by a subsequent abdominal ct. in europe, some usa centers, and in our practice, us reporting include groups and take into account ancillary findings: . normal appendix (blind-ended, lamellated, compressible, < mm in diameter, without peristalsis; . appendix not depicted, no secondary signs; . appendix not depicted, with one of the following: hyperchoic mesenteric fat, fluid collection, local dilated small bowel loop; . appendix inflamed. group represents most cases of perforated appendicitis, groups and the negative sonogram. ct is then indicated only in obese patients and to assess the feasibility of percutaneous interventions. inflammatory bowel disease in the recent literature, mr enterography is often preferred to ct enterography. small bowel series look prehistoric and us is rarely mentioned. sonography however is very valuable both for screening children presenting with abdominal pain, diarrhea, weight loss, or gi bleeding and for following the course of the disease and searching for complication. hypervascularization has been proved to parallel the disease activity. initially mentioned by dr. rita teele, the interest of us for differentiating high-intermediate/low varieties of imperforated anus has been re-emphasized more recently. a perineal rectal cul de sac distance of mm is quoted as the significant cut-off value. us can also display rectourinary fistulae outlined by air. update on mdct and mri of hepatobiliary disease in children: what's new lisa h. lowe, md a variety of disorders may affect the pediatric liver. recent advances in histopathological knowledge and imaging techniques have led to important changes that radiologists must be aware of in order to allow for an accurate limited differential, and in some cases, specific, diagnosis. this presentation will focus on recent developments that have lead to a better understanding of the embryopathogenesis for fibropolycystic liver diseases (including choledochal cysts and caroli disease), histopathological findings that have led to new classification systems for of pediatric vascular anomalies, technological advances and contrast agents in magnetic resonance imaging that are useful to characterize and limit the differential diagnosis of hepatic masses. diagnostic errors in pediatric abdominal imaging: diagnostic pearls and pitfalls george a. taylor, md this presentation reviews the types of diagnostic errors in abdominal imaging occurring over a -year period in an academic pediatric radiology practice. radiologists engage in two interrelated processes when interpreting imaging studies: perception and analysis. failures in perception (failure to identify an important finding) are a common source of diagnostic error in pediatric imaging, while failures in the analytic portion of the process (over-or faulty interpretation of a finding) are not as common. under-interpretation of findings can be related to a number of perceptual and visual phenomena including visual isolation where attention is selectively focused on a main area of the image while less or no attention is given to secondary areas, and satisfaction of search which occurs when additional lesions remain undetected after detection of an initial lesion. many analytic errors are the result of commonly used heuristics or shortcuts in reasoning. these include the availability heuristic in which likelihoods are based on memory of a similar case, the framing effect in which a different diagnosis is reached based on how the information is presented, and the anchoring heuristic in which the initial impression is difficult to change, despite conflicting new information. another recognized pitfall is blind obedience, in which a diagnostician stops thinking when confronted by authority. this authority can be human or technical (reliance on a laboratory value). finally, diagnostic errors can result from an attitude of overconfidence. examples of these heuristics and strategies to minimize cognitive errors will be discussed. marta hernanz-schulman, md, faap, facr this session will consider abdominal masses that present in the neonatal period, spanning developmental, inflammatory and neoplastic conditions. time constraints do not allow an exhaustive list or description, but the more important or frequent lesions are discussed. the presentation is subdivided by systems. the renal section discusses various conditions presenting with hydronephrosis, such as ureteropelvic junction obstruction and duplication anomalies, followed by autosomal recessive polycystic kidney disease and multicystic dysplastic kidney, cystic entities commonly presenting in the perinatal period. neoplastic renal entities include lesions with benign behavior, such as ossifying renal tumor of infancy, with the discussion extending to entities with very poor prognosis such as clear cell sarcoma and rhabdoid tumor, while discussing the congenital mesoblastic nephroma, its histologic subtypes and the differences in their presentation, imaging findings and clinical behavior. suprarenal lesions include the adrenal hemorrhage, congenital neuroblastoma and subdiaphragmatic sequestration. hepatic lesions include developmental anomalies that present as mass lesions, such as choledochal cysts, vascular lesions such as congenital and infantile hemangiomas, and neoplastic lesions such as the mesenchymal hamartoma and hepatoblastoma. differences in clinical presentation, imaging characteristics and behavior of the lesions are discussed. the section on pancreatic lesions discusses pancreatic cysts and pancreaticoblastoma. gi tract and mesenteric lesions include duplication cysts, lymphangioma, and meconium pseudocyst, and their relationship to bowel obstruction and persistent perforation. ovarian cysts can present as large masses in neonatal girls, and should be high in the differential diagnosis of large masses encountered in female infants; the imaging characteristics of simple and complicated cysts are described, as well as their course and potential complications. pediatric procedures: from imaging to intervention the spectrum of vascular anomalies in pediatric patients: multimodality imaging evaluation and current treatment patricia e. burrows, md vascular anomalies are categorized into two main groups, vascular tumors and vascular malformations. genetic and molecular regulation of vascular genesis of angiogenesis, and mutations responsible for some of the vascular malformations, have been delineated. in order to implement future targeted treatment of vascular lesions, accurate diagnosis is important. imaging modalities that are effective in distinguishing the various types of vascular anomalies and demonstrating the extent include ultrasonography with doppler interrogation, mri and various forms of mr vascular flow imaging, conventional angiography and venography. techniques used to image lymphatic channel anomalies, conventional lymphangiography, lymphoscintigraphy and infrared fluorescent lymphangiography. in this presentation, common forms of vascular anomalies will be described and rare or recently recognized anomalies will be mentioned. current treatment of the different forms of vascular anomalies will also be discussed, including pharmacotherapy using beta blockers, angiogenesis inhibitors and mtor inhibitors. endovascular techniques used in treating vascular malformations, including embolization and sclerotherapy will be presented. pediatric vascular disease is extremely varied, with a wide range of conditions requiring diagnostic or therapeutic intervention. technological improvements in non-invasive imaging modalities such as mri and ct have reduced the need for diagnostic angiography; however, with advances in interventional techniques, arteriography in the pediatric patient is now often performed for therapeutic reasons. pediatric arteriography presents unique issues and challenges. tremendous variability in patient size and physical maturity limits the ability to standardize technical aspects of performing arteriography. in addition, radiation protection, sedation/anesthetic support, monitoring of fluid balance, and maintaining patient warmth must be considered. a regimented protocol for assessment of the pediatric patient must be followed, with review of the indications for the study requested, and review of patient-specific issues such as coagulation profile, concurrent medical disease, patient weight, and anesthetic concerns. appropriate patient monitoring is imperative to ensure patient safety. vascular access can be quite challenging. ultrasound and micropuncture access techniques have tremendously improved successful access while reducing associated complications. the smallest catheter that can accomplish procedure objectives should be used. for most diagnostic cases, french systems can be used for children> kilograms, while french catheters are preferred in those < kg. intraprocedural heparinization ( - iu/kg) is also more often used, especially in children weighing less than - kg. rates and volumes of contrast injected for pediatric arteriography are not standardized, as in adult patients. in general, contrast dose should be limited to - ml/kg, and - ml/kg in premature infants and neonates. all these new technique are less invasive, improve patients' outcomes and reduce morbidity. they are also cost-effective as patients are discharged home earlier and recover faster from the intervention. the future holds promising new technologies such as high-intensity focused ultrasound (non-invasive method of thermal ablation) and nanoparticles for drug delivery. pediatric interventional radiology will continue to be an essential part of these minimally invasive therapies. musculoskeletal imaging: from planning to performance kirsten ecklund, md the purpose of this talk is to review advanced mr imaging techniques currently being used in the evaluation of pediatric musculoskeletal tumors. the goals of these techniques include improved image resolution and quality, lesion tissue characterization, and increased acquisition speed. diffusionweighted (dw) and perfusion imaging will be emphasized; however, whole body, metallic artifact mitigation, and volumetric sequences will also be discussed. dw mri is based upon the brownian motion of water within extra and intra-cellular spaces which depends upon tissue cellularity. dwi can aid in the differentiation of benign from malignant lesions, which generally have restricted diffusion. there is even greater potential for dwi in the assessment of tumor response to therapy. the apparent diffusion coefficient (adc) maps are critical to accurate interpretation of diffusion sequences. adc maps distinguish between restricted diffusion and t effect, both of which appear bright on dwi. both qualitative and quantitative tissue assessments can be made with dwi. challenges for dwi in the pediatric musculoskeleton include susceptibility artifacts from bone, motion vulnerability, and geometric distortion at larger fields of view. our current protocols and parameters for dwi will be presented. contrast-enhanced (dce) mr using one of a variety of vendor specific sequences. qualitative and quantitative assessments of inflow and distribution of contrast have been shown to help differentiate between benign and malignant lesions and to evaluate drug efficacy during therapy. this technique is especially promising in those patients undergoing antivascular and antiangiogenic therapy. tal laor, md congenital abnormalities of the musculoskeletal system can result in alterations of limb size, configuration, and/or segmentation. these disorders often affect both the osteocartilaginous skeleton as well as the surrounding soft tissues and can be localized or diffuse. in this session, we will focus on the imaging features of several congenital abnormalities that result in a small or short limb, in altered configuration of a limb, or in abnormal segmentation. deformities of both upper and lower limbs will be examined. like congenital abnormalities, developmental disorders of the pediatric musculoskeletal system can be limited to a single area or can affect numerous sites within the body. for example, neonatal brachial plexopathy is a localized disorder that produces characteristic musculoskeletal alterations about the shoulder girdle and elbow of affected children. the alterations of morphology and function of the shoulder develop over time with growth of the child and change in response to a variety of therapies. we will review the features of developmental anomalies of the pediatric musculoskeletal system and evaluate the role that imaging plays in the initial evaluation and in the subsequent assessment of these children during treatment. multimodality imaging of skeletal trauma in children: using all of the tools peter j. strouse, md skeletal trauma is a common indication for imaging throughout the pediatric age range. newborns may suffer birth trauma. infants and toddlers may be subject to abusive injury. children of all ages may suffer accidental injury. older children and adolescents are increasing hurt in sporting activity and vehicular accidents. fracture patterns vary with maturation of the child. interference with normal growth is a potential complication. imaging of skeletal trauma begins with radiography. proper anatomic and age specific radiographic technique assures optimal diagnostic yield. radiography suffices in most cases to diagnose fracture or confirm normalcy. "clinical correlation" aids in diagnosis. ultrasound, ct, mri and nuclear medicine may play a role in specific instances where plain radiographs are non-diagnostic or to better delineate certain fractures. arthrography and conventional tomography have occasionally been used in the past and tomosynthesis may prove useful. follow-up radiographs may be useful for diagnosis or confirmation of some fractures. this presentation will focus on the imaging of acute skeletal injury. technique and approach for plain radiography will be emphasized. specific indications and roles for ancillary imaging techniques will be defined and illustrated with representative cases. although classically thought of as a disease of adulthood, stroke is much more common in the pediatric population than was once appreciated. this may be due to many factors, not the least of which is increased awareness due to the presence of subspecialty stroke teams now fairly commonplace in many children's hospitals, and the fairly recent advent of more advanced imaging technique such as diffusion-weighted imaging (dwi) and its routine use in imaging the central nervous system (cns) in the child and adolescent. causes of stroke in children can be protean, and range from idiopathic on one end of the spectrum, to traumatic on the other, with many causes in between, many of which may not be intuitive to the clinician without further research. moyamoya disease and its many causes, such as sickle cell disease (scd), trisomy and neurofibromatosis type i (nf i) can all lead to stroke in children, as can congenital clotting deficiencies such as factor v leiden deficiency and congenital cardiac lesions with their resultant shunting of blood between the left and right cardiac circulations. although usually arterial in nature, strokes may arise from the venous system in clinical scenario of venous thrombosis with resultant venous infarctions. factors contributing to venous thrombosis in children and adolescents can be due to dehydration (especially in the very young), severe iron deficiency anemia, inflammatory bowel disease and exogenous hormone ingestion such as is seen with oral contraceptives (ocp) in young women. advanced imaging techniques for neuroimaging in pediatric patients: where are we now? blaise v. jones, md the past decade has seen a large number of advanced imaging techniques introduced to the clinical armamentarium of the pediatric radiologist. from the development of multidetector ct scanners that can obtain whole head diagnostic studies in less than s to the routine use of t mr imaging, technical advances have dramatically changed our ability to diagnose and manage neurological disorders in children. however, all of these advances are not of equal clinical utility, and it is imperative that the pediatric radiologist be well versed in their judicious and appropriate application. this presentation will discuss the effective use of volume ct scanning, cta, swi, asl, fmr, pmr, and other advanced imaging techniques in the diagnosis of neurological disorders presenting in childhood. at the conclusion of the presentation the attendee will have a better understanding of how to ideally apply these technologies in practice. a spectrum of abnormality in pediatric neck: practical imaging choices and interpretation caroline d. robson, mbchb learning objectives: . become familiar with an optimized imaging approach for head and neck infections . recognize the complications of head and neck infections . recognize the utility and interpretation of imaging for neck masses this talk will cover the imaging approach and interpretation of findings in head and neck infection and neck masses. infection includes acute complicated sinusitis, coalescent mastoiditis, neck infection and local and intracranial complications. optimized imaging protocols and image interpretation for neck masses will also be discussed and illustrated. acute complicated sinusitis is diagnosed when acute sinusitis is accompanied by orbital symptoms (e.g. proptosis) and/or mental status changes, seizures or other neurological findings. coalescent mastoiditis is diagnosed when otomastoiditis is accompanied by tenderness and/or swelling over the mastoid process. ct and mr provide complementary information. ct is obtained with contrast. mr sequences include fatsuppressed t , t , diffusion, and fat-suppressed contrastenhanced t weighted images with mr venography. intracranial complications include epidural abscess, subdural empyema, meningitis, cerebritis, brain abscess, venous thrombosis and venous infarction. the limitations and usefulness of ct in the diagnosis of neck abscess will be illustrated. the imaging approach to masses depends on patient age, and the size and location of the mass. us, ct, mr, and nuclear medicine studies provide complementary information. as for infection, optimized imaging approaches and key imaging features for various masses will be discussed. embryology and diagnostic approach in spinal dysraphism l. santiago medina, md, mph and esperanza pacheco-jacome, md congenital anomalies of the spine are malformations that can be confusing due to the complexity of their embryology, and to the sometimes unclear classifications and terminology. the purpose of this review is to give a clear and basic understanding of the different stages of the embryological development of the spinal cord, starting with the bilaminar disc in the first week of gestation. during the second week, the formation of a trilaminar disc (gastrulation), the notochord, and the formation of the neural tube or neurulation. also, a review of the development of the distal cord: conus medullaris, filum terminale, ventriculus terminalis, by a different mechanism, canalization and retrogressive differentiation. beside the embryological review, a case correlation will be presented using mr imaging to demonstrate these malformations. open spina bifida entities include meningocele and myelomeningicele. closed or occult spinal dysraphism (osd) is characterized by a spinal anomaly covered with skin and hence with no exposed neural tissue. osd spectrum includes dorsal dermal sinus, thickened filum terminale, diastematomyelia, caudal regression syndrome, intradural lipoma, lipomyelocele, lipomyelomeningocele, anterior spinal meningocele and other forms of myelodysplasia. several studies have shown that mri and ultrasound have better overall diagnostic performances (i.e., sensitivity and specificity) than plain radiographs for detection of occult spinal dysraphism. for h n , most patients had mild illness but a small percentage required mechanical ventilation and icu admission. the high risk groups include children < years old and those with chronic medical conditions in particular neurodevelopmental impairment. pediatric mortality was . % of all deaths associated with the pandemic reported in the u.s. in both conditions, the most prominent radiographic and ct features were airspace disease including ground glass opacities (ggo) and consolidation, commonly with multi-focal and bilateral involvement. pleural effusion, adenopathy and cavities were absent. in some patients with viral infection, respiratory symptoms may be mild but are complicated by neurological manifestations. a brief review of mri features in h n related encephalopathy including acute necrotizing encephalopathy (ane) will be given. bernard f. laya, do tuberculosis (tb) is a worldwide major public health problem with one-third of the world's population being infected. it is a leading cause of death and disability from infection worldwide. children are amongst the most vulnerable group because of their immature immune status. a child usually gets tb infection after being exposed to a sputum-positive adult. depending on many factors, the infection can lead to latency or tb disease. it can affect virtually any organ in the body and can be devastating if left untreated. tb in children remains a diagnostic challenge. in addition to history of tb exposure, signs and symptoms, laboratory and microbiologic tests, medical imaging remains a valuable tool in its diagnosis. although findings are nonspecific, the radiograph is the most commonly ordered initial imaging tool for screening and diagnosis of pulmonary and musculoskeletal involvement. computed tomography and magnetic resonance imaging offer more detailed assessment especially in cranial and abdominal involvement. medical imaging is also utilized to follow up patients during or after anti-tb treatment. knowledge of the common imaging patterns, pitfalls and dilemma are very important in establishing the diagnosis of tb in children. the pathophysiology of pediatric tb will be discussed as it correlates with imaging findings. the wide spectrum of imaging manifestations in various modalities will be presented. imaging updates along with pitfalls and dilemma in the interpretation will also be discussed. tb can affect almost every organ system but the author will present cases that are more commonly encountered. and concurrent ct/ pet-ct (k . ) panels. there were more indeterminate nodule predictions by pet-ct (n of ; %) and concurrent ct/pet-ct (n ; %) than by ct alone (n ; %). the overall accuracy of ct alone was %, pet-ct alone % and concurrent review %. worst case sensitivity and specificity were % and % for ct alone, % and % for pet-ct alone, and % and % for concurrent ct/pet-ct. conclusions: pet-ct assessment of pulmonary nodules in children is feasible but limited by non-diagnostic quality ct images and atelectasis caused by sedation. subjective assessment of nodules by pet-ct does not appear to improve the ability to distinguish benign from malignant histology in children with solid malignancies. semi-quantitative nodule assessment using the standardized uptake value may improve the performance of pet-ct in this setting and will be investigated in the future. purpose or case report: nec is the most common lifethreatening medical/surgical emergency of the gastrointestinal (gi) system in neonates, with an incidence up to % in infants weighing < g. with advances in treatment of nec, increased survival rates result in rise in post-nec gi complications such as feeding intolerance. development of post-nec bowel strictures results from healing of involved bowel and can result in bowel obstruction. it has been routine to study the bowel of infants after medical treatment for nec by contrast enema and small bowel follow-through prior to initiating feeding. however, in order to "image gently" we are attempting to decrease the radiation exposure to these patients. we postulate that in patients with no abnormal bowel dilation prior to initiation of feeds, the incidence of colonic stricture would be so low that routine enemas would be unnecessary and could be eliminated from the workup. recorded as present or absent in anatomic abdominal regions defined as: and -from the dome of the diaphragm to top of l to the right and left of midline, respectively; and -from top of l to the iliac crest to the right and left of midline, respectively; -from the iliac crest to the top of the sacrosciatic notch; -below the top of the sacrosciatic notch. we assessed the frequency of findings in each region and how often findings in regions and were associated with findings in regions - . % confidence intervals were calculated. results: the fewest pertinent findings were present in region in . % ( / ) ( % ci: . - . %) of radiographs. findings included: abnormal bowel % (n ), bowel gas paucity . % (n ), pneumatosis . % (n ), inguinal hernia . % (n ) and osseous abnormalities . % (n ). pertinent findings were present in region in . % ( / ) ( % ci: . - . %). findings included: abnormal bowel . % (n ), bowel gas paucity gas . % (n ), pneumatosis . % (n ), free air . % (n ), and abnormal bowel with pneumatosis . % (n ). among patients with an abnormality in region , ( . %) also had an abnormality within at least one of regions through . among the patients with an abnormality in region or , ( . %) also had an abnormality within at least one of regions through . catheter/tube tips were located in region in . % (n ) and region in . % (n ) of radiographs, respectively. pneumatosis was present most frequently in regions ( . %), ( . %), and ( . %). free air was present most frequently in regions ( . %), regions and ( . % each). conclusions: our preliminary data suggest that pertinent findings on neonatal portable abdominal radiographs are rarely isolated to the pelvis, implying that gonadal shielding of regions and should not compromise diagnostic accuracy. purpose or case report: the purpose of this study was to determine the sensitivity, specificity, and positive and negative predictive value of ultrasound in diagnosing appendicitis when the appendix is visualized, using three diagnostic categories: positive, negative, and equivocal. the -category diagnostic accuracies for appendiceal diameter and radiologist impression were compared. methods & materials: a retrospective study was performed evaluating all right lower quadrant ultrasound reports dictated over a -month period. included studies were interpreted as positive, negative, or equivocal for appendicitis. report impressions that did not specify one of these categories and studies where the appendix was not seen were excluded. the pathologic diagnosis of appendicitis was considered the gold standard for a positive diagnosis. because virtually all pediatric surgical cases in the region are referred to our hospital, it was assumed that the patient did not have appendicitis if surgery was not performed. logistic modeling using appendiceal diameter as the independent variable established cutoff diameters of ≤ mm negative, > mm positive, and <x≤ mm equivocal. sensitivity, specificity, and positive and negative predictive values were calculated for both methods. results: of the patients imaged during the study period, ( %) met the inclusion criteria; ( %) reports did not categorize the impression and in ( %) studies the appendix was not seen. surgery was performed on ( %) subjects, of which ( %) had a pathologic diagnosis of acute appendicitis. using the radiologist impression, there were true positives (tp), false positives (fp), false negatives (fn), and true negatives (tn), for a sensitivity of % ( % ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases reported as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. using appendiceal diameter, there were tp, fp, fn, and tn, for a sensitivity of % (ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases categorized as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. conclusions: the use of diagnostic categories enables high ppv and npv with a relatively low number of equivocal cases. using appendiceal diameter alone results in higher ppv than that of the radiologist impression, but also yields a higher number of equivocal cases. purpose or case report: intussusception is an obstructive condition that a segment of the bowel invaginates into adjacent bowel and is an urgency that needs to be reduced as soon as possible to prevent bowel ischemia or necrosis. when it occurs in the infants and young child, it usually develops idiopathically and reduced by the technique such as air enema under the fluoroscopic guidance or saline enema under the ultrasound guidance. the success rate of the non-surgical reduction has reported over %. the pneumatic reduction is to introduce air into the patients' rectum via a ballooned foley catheter by hand pump. a mercury manometer connecting with the foley catheter calibrates the pressure of insufflation, and the recommended maximum pressure is mmhg. the hydrostatic reduction is to drip saline from a bag at the height of ft that may be different according to the institute's guidelines. until recently, in both techniques, the precise measurement of the intraluminal pressure was not possible. with the purpose of intraluminal pressure monitoring, we introduced a specific digital pressure gauge that can measure both pneumatic and hydrostatic pressure in various units and can give the collected data to our workstation. with the data, we purpose to make the curve of intraluminal pressure during the procedure and to compare the pattern and difference in both techniques of reduction, which permits suggesting the better technique for reducing the intussusception. from february , we performed the intraluminal pressure monitoring in children; cases of pneumatic reduction and cases hydrostatic reduction. the results indicated that the curves were similar in both techniques. however, the hydrostatic reduction tended to need longer time and higher pressure difference than the pneumatic reduction. we assumed that a higher flow rate and more fluctuating introduction of pressure in the pneumatic reduction made the difference between both methods. purpose or case report: anecdotal evidence suggests that some pediatric brain tumors, particularly pilocytic astrocytomas, demonstrate greater enhancement on delayed post-contrast t weighted mr imaging compared to early post-contrast imaging. our goal was to compare immediate post-contrast imaging with delayed post-contrast imaging in pediatric brain tumors. methods & materials: the research protocol was granted exempt status by the institutional review board (comirb# - ). between november and march , all patients for whom an mri of the brain was ordered to follow-up known brain tumor or to evaluate new brain tumor underwent a modified protocol that included both immediate and min delay post-gadolinium images. the modified protocol sequence order was dwi, t mprage, contrast injection, immediate post-contrast t mprage, t , flair, min delayed post-contrast t mprage. this sequence allowed both immediate and delayed post-contrast imaging to be performed without scanner downtime. a total of unique patients met inclusion criteria of an enhancing primary brain tumor with the delayed imaging performed within a window of - min. these studies were evaluated independently by pediatric neuroradiologists (ns and lf) and a radiology resident (jm) to compare the degree of lesion conspicuity and edge discrimination, and to determine an overall preference. in cases of discrepancy between reviewers, final grading was determined by group consensus. results: delayed post-contrast images were preferred in / tumors ( %), immediate post-contrast images were not preferred in any case, and / cases were graded as equivalent ( %). notably, delayed imaging was preferred for / pilocytic astrocytomas ( %). in / cases ( %), the improvement in conspicuity and edge discrimination on delayed imaging was felt to have a potential impact on clinical management, e.g. by extending resectable or treatable tumor margin. conclusions: delayed post-contrast imaging can be performed easily by reordering existing mri protocols, and no scanner downtime is required for this protocol change. our results indicate that pediatric brain tumors (particularly pilocytic astrocytomas) often enhance more conspicuously on delayed imaging, that no diagnostic confidence is lost on delayed imaging, and that clinical management may be more accurately guided. -directions) were retrospectively reviewed, after irb approval. both sporadic (n ) and nf- associated optic gliomas (n ) were included. tumors confined to intraconal optic nerve were excluded due to technical limitation of epi dwi within the bony orbit. apparent diffusion coefficient (adc) of the solid portions of the tumor was measured using the region of interest method both at baseline and on follow-up mri. results: for the patients, required treatment (surgery and/or chemotherapy) for symptomatic tumor progression ( sporadic opg and cases of nf- ). median follow-up interval was . years (range: months to . years, sd . years). there was no difference in adc values between sporadic and nf- associated opg. opg that required therapy had significantly higher baseline mean adc ( x - mm /s, sd . ), whereas opg with low mean adc ( x - mm /s, sd . ) remained clinically asymptomatic or stable (stratified mann-whitney test, p . ). an increase in mean adc of x - mm /s doubled the odds the patient will require treatment (or . , % ci: . - . , p< . ). enhancement patterns did not predict tumor behavior or nf- status (fisher's exact test, p . ). conclusions: significantly higher mean adc was seen in opg that required therapy for tumor progression. mri may be a useful prognostic tool in further defining a subset clinically significant sporadic or nf- associated opg. purpose or case report: fast brain mri imaging has recently been introduced for assessing brain ventricles in patients with ventriculo-peritoneal shunts (vps). however, there is minimal literature on how this method could be beneficial for other indications. compared to ct, this method reduces lifetime cumulative radiation dose and has multiplanar capabilities. it is much faster than full brain mri, reducing exam costs and potentially reducing the need for sedation. however, fast brain mri has lower resolution than a standard brain mri and cannot detect hemorrhage. the goal of our study is to retrospectively assess additional clinical applications for fast brain mri. methods & materials: patients who had undergone fast brain mri were found in xenobase, a database which references deidentified electronic medical records at our institution. xenobase was then used to identify subgroups by diagnosis. one of the most common diagnoses was arachnoid cyst. after irb approval, patients with fast brain mri and arachnoid cyst were identified so that their fast brain mri could be compared to any full brain mri and to clinical outcomes. fast brain mri findings were excluded if there was not a full brain mri within year. agreement with full brain mri, and documented effect on clinical management were coded for statistical review. results: between and , there were arachnoid cyst patients with fast brain mri exams. in members of this group, fast brain mri was used alone or in comparison with a full brain mri in the decision to follow or discharge the patient. exams failed to report a pituitary cyst and mass effect which were reported on prior exams. patients had no complications in the year following their fast brain mri. the most common complication was headache ( cases). conclusions: fast brain mri reduces radiation exposure, time, cost, and the need for sedation in vps patients. these benefits may cautiously be extended to other patient groups also requiring routine imaging, such as those with arachnoid cysts. disclosure: the authors disclose that they will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: susceptibility-weighted imaging (swi) is a new technique that exploits susceptibility differences in different tissues, to provide a different type of tissue contrast. swi is a gradient echo sequence utilizing both phase and magnitude data to achieve exquisite sensitivity to tissue magnetic susceptibility effects. it is extremely sensitive to even minute amounts of paramagnetic substances and therefore for detection of blood products (hemosiderin, ferritin), deoxygenated blood, calcium, iron, and small vein depiction. it is particularly suited for vascular imaging, especially in cerebral ischemia. swi has been shown to be more sensitive in detecting cerebral microbleeds than is conventional t *-weighted gradient-recalled echo imaging (gre) partly because of its inherent sensitivity, increased spatial resolution and the thinner slices acquired. recent studies have shown that swi detected more microbleeds in more patients, irrespective of their location and that swi may be more sensitive in detecting traumatic lesions than ct or mri. methods & materials: between january and october we have performed swi on pediatric patients (from day to yrs old) affected with different pathologies. mri was performed using either a -or . -t magnet (achieva ; philips healthcare, best, the netherlands). among these patients also received a classic gre sequence. results: our experience confirms a greater sensibility of swi than gre in detecting microbleedings and larger bleedings. swi is much more helpful in patients younger than year since it can distinguish hemorrhagic and non hemorrhagic punctuate white matter lesions detected as hyperintensities on t -w images. it is more accurate in distinguishing petechial hemorrhages and ischemic foci in patients with germinal matrix hemorrhages. swi can provide important diagnostic information not only in vascular pathologies but also in tumors showing the altered tumor microvascularity, the degree of intratumoral necrosis and the presence of subtle defects of the bbb within the surrounding parenchymal tissue. the technique also allows the detection of possible bleedings in infectious lesions. conclusions: swi is a valuable technique in the evaluation of a wide variety of intracranial pathologies in the pediatric population and its use is advisable on a routine basis. purpose or case report: a common problem with pediatric mr imaging is motion. diffusion-weighted imaging (dwi) is highly sensitive to the effects of both rigid-body motion and brain pulsation. the resulting motion artifacts can manifest in several ways, and include blurring (motion between volumes), slice 'drop-outs' (motion during the diffusion encoding), and aliasing (motion during the parallel imaging/ghost calibration scan). in order to improve image quality in pediatric dwi and avoid the potential for repeat scans, we have implemented our grappa-accelerated diffusion tensor (dt)-epi sequence on over , pediatric patients at our institution, and have developed tailored reconstruction software to correct for large motion and reduce the need for general anesthesia (ga). methods & materials: grappa-accelerated epi dti data was collected on patients at . t and , patients at t between the ages of month and years old. with these data, we investigate the use of a method to select the best grappa and ghost calibration weights; d rigid-body realignment with importance weighting; a new volume rejection criterion for large motion; together with other procedures to lower image noise and reduce phase artifacts. all image reconstruction was performed using compiled threaded matlab code on the vendor's (ge) multiprocessor reconstruction hardware. results: using the maximum motion detected from the d realignment procedure on the , dti exams, % of patients did not move (either through co-operation or ga, denoted here by < mm of motion); % of patients moved between - mm; % between - mm; % between - mm; and % between - mm. except for patients in total, the motion correction steps employed here were extremely robust in correcting for motion. in addition, the motion correction steps employed here do not blur or negatively affect the data on non-moving patients. conclusions: our proposed integrated reconstruction scheme suggests that correcting for different types of motion at different stages of the dti acquisition is critical to provide scans of diagnostic quality. apart from the very rare instance ( . %) where the patient moved continuously an extensively throughout the scan, our motion correction procedures employed here are extremely robust. using this scheme, we show that highly diagnostic motion-corrected dti data can routinely be read on our patient database within min. . participating sites followed mutually agreed upon vendor-specific dti protocols used for neonates in clinical practice: ss-epi; b ;~ mm voxel; - directions; te~ msec; acquisition; parallel imaging; multi-channel ( - ) head coil. tensor data was analyzed at one site using internally developed software in idl. b and eddy current distortion were assessed by analyzing grid line distortion on acr slice ; deviations from linearity were measured in the phase encoding direction. acr slice was used to assess snr of the center and periphery of the b image, and fractional anisotropy (fa) of the phantom, which should approach . deviations from specified sequence parameters were recorded. results: both siemens scanners had some image degradation due to vibration susequently corrected by the vendor. nonlinear gridline distortion was highest on the ge followed by philips but was corrected with the use of nd order shimming. eddy current distortion was consistently smaller than acquisition voxel size after image registration. te varied from - msec; acquisition bandwidth range was - hz/pixel. the mm slice thickness was problematic on clinical ge scanners resulting in non-isotropic voxels. across vendors, snr was consistently higher in the image periphery than center by a factor of . - . ). the greatest difference was showed in patients with fhc. no association was found between the value of ldl-c and imt. the . % received drug treatment at the time of evaluation. in dbt- a no association was found between the imt and the levels of hba c and lipids. and in the ob group found no association between imt and bmi z score. fhc %, % of dbt- and % of ob showed atherosclerotic plaques and intima irregularities. conclusions: the imt ultrasonography was able to demonstrate that patients with chronic diseases, with increased cardiovascular risk in adulthood, showed early alterations of carotid intima media in children. this allows clinical applications of preventive and therapeutic guidance. a benchmark for precision of flow assessment was determined from differences between aortic and pulmonary arterial flows, which should agree. the precision of flow when utilizing a slow flow structure (vein) and a fast flow structure (artery) was then determined, serving as an indicator of the precision of slow flow measurements. this was done in pairs for the upper body (svc flow vs difference between ascending and descending aortic flow), lower body (ivc flow vs descending aortic flow) & total body (svc flow+ivc flow vs ascending aortic flow). paired t-tests were used to identify significant differences in the respective arterial and venous flow rates. with an f-test, the relative precision of the arterial flow (determined from aortic and pulmonary arterial flow) was compared against the precision of agreement between upper, lower, and total body flows, each of which has a slow flow venous component, thus assessing precision of venous flow measurement. results: arterial & venous flow measurements were strongly correlated for the upper body (r . ), lower body (r . ) and total body flow (r . ); net aortic and net pulmonary trunk flow rates were also tightly correlated (r . ). moreover, there was no significant difference in the precision of arterial & venous flow measurements (t-test, p . ). lower venc ( cm/s or lower) improves the accuracy and precision associated with low velocity venous flow, a finding that tended to but it did not reach statistical significance. conclusions: with -d pc mri, the accuracy and precision of venous flow quantification are comparable to arterial flow quantification, though venc settings may improve venous flow assessment. disclosure: dr. tariq has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the spatial resolution requirements for imaging tiny target vessels in neonates have so far precluded its use of cemra in this patient population. the purpose of our study, therefore, was to explore the potential of high resolution cemra at . t in neonates with suspected congenital vascular anomalies methods & materials: neonates (mean age . days, range - days; mean weight . kg, range . kg- . kg) underwent cemra at . t. cemra was performed under controlled apnea on a -channel . t system using either a -channel head-neck coil ( pts) or a -channel adult knee coil ( pts). gd contrast delivery was calculated based on a total dose of . mmol /kg. parallel imaging factors of - were used, generating . x . x . mm voxels in an acquisition time of - s. images were scored for quality and the presence of artifacts independently by two observers. the cemra series were evaluated to identify pulmonary arterial and venous anatomy. extra-pulmonary vascular anatomy was divided into sections for image quality assessment on mpr. results: the mra data sets had high mean image quality and low mean artifact grading scores. no significant difference was evident between the two observers for scoring image quality and artifact (p . ), and there was good interobserver agreement (k . , % ci: . - . ). the pulmonary arteries were confidently visualized to at least the nd order branches in all patients, at least the rd order branches in ( %). out of evaluated segments, ( %) were graded as the vessel "very well visualized with excellent definition of vessel" pa abnormalities were diagnosed in patients and pv anomalies in patients. correlation was made with open surgical findings in cases, confirming the cemra diagnoses with no discrepancy between the operative and imaging conclusions. the results of our study suggest that high resolution cemra at . t is extremely promising in neonatal cchd and, in combination with echocardiography, may often provide comprehensive information for treatment planning. with appropriate use of physiological motion compensation, parallel imaging and coil configuration, voxel volumes less than . mm are routinely achievable. purpose or case report: it is not well understood whether transfusion-dependent children (mainly those who have hereditary anemias subject to excessive iron levels from regular blood transfusions) with no or mild cardiac iron overload and without signs of heart failure exhibit early changes in cardiac dysfunction. this study aims to evaluate intramyocardial deformation and subsequent cardiac dysfunction in such patients using the cardiovascular magnetic resonance technique of myocardial tagging as well as assess iron overload by another cardiovascular magnetic resonance technique of t star (t *). we hypothesize that transfusion dependent children undergoing chelation therapy will be at high-risk for cardiomyopathy despite normal or slightly elevated iron levels and no signs of heart failure due to progressive myocardial deformation as assessed by myocardial tagging; that is, we expect abnormal mechanical parameters to exist despite t * values which correspond to normal or slightly elevated myocardial iron levels. methods & materials: patients (mean age yrs) requiring regular blood transfusions for various reasons (e.g. thalassemia, sickle cell disease, other anemias) were investigated using harmonic phase magnetic resonance tagging and t * imaging. various myocardial mechanical parameters were quantified and correlated to cardiac iron levels as measured by t *. results: children with no overt signs of heart failure (as measured by ejection fraction and volume indices) exhibited normal t * iron levels in combination with global circumferential abnormal myocardial strain and children exhibited regional strain. conclusions: this preliminary data suggests that transfusiondependent children without overt signs of heart failure exhibit early signs of cardiac dysfunction (an effect of strain as assessed by myocardial tagging) in direct relation to normal or slightly elevated myocardial iron levels (as measured by t *). a larger sample size of children could support the idea of abnormal myocardial mechanics being a diagnostic imaging marker for the development of myocardial iron overload and eventual iron-mediated cardiomyopathy. the choice of coil and field of view varied according to the age and size of the patient. imaging was performed on a . t magnet (philips mri system). after the cine gradient echo time of flight sequences were acquired, the dynamic keyhole mr angiographic sequence was applied in the coronal orientation. this sequence commenced - s after initiation of the first bolus administration of - ml of undiluted gadopentetate dimeglumine ( . mmol/ml, magnevist) at a rate of - ml/sec followed by - ml of saline at a rate of ml/sec. image acquisition was repeated multiple times without delay for s during shallow breathing. contrast material was administered through a peripheral or central venous line, and sometimes via simultaneous bilateral extremity injections. rarely manual hand injection was performed. the parameters were as follows: centra k-space filling, acquired voxel size - . x - . x - , reconstructed voxel size . - x . - x - . , number of dynamics - , keyhole percentage - %, sense (parallel imaging) factor x - x , dynamic times - . s, and injection rate - cc/second. image analysis was based on original contrast-enhanced data sets, mip and volume rendering. the quality of the mrv was graded by a subjective scale from - ( excellent, no limitations; nondiagnostic). comparison with unenhanced mr venographic sequences and doppler ultrasound were available in all cases. results: d mrv provided diagnostic information on patency of venous segments in all cases, including the presence of venous occlusion or stenosis, the segments involved, and collateral venous pathways. conclusions: d mr venography using the method outlined is a reliable means of estimating central venous thrombosis in children, using short dynamic scan times with high spatial and temporal resolution, creating an effect similar to conventional venography. paper #: pa- analysis of optimal phase interval for prospective ekg-triggered cardiac ct in children prakash masand, md, texas children's hospital, savivek bogale, lorna browne, rajesh krishnamurthy purpose or case report: evaluate high temporal resolution cine mri of the heart in children to determine relationship of heart rate to the optimal motion free interval during the cardiac cycle, and to derive a chart depicting optimal reconstruction intervals across a range of heart rates which could be applied for prospective ekg triggered ct imaging of the heart. methods & materials: pediatric patients who had high temporal resolution cine steady state free precession sequence ( frames acquired across a single cardiac cycle) performed as part of a mri/mra of the heart from - were included. a single reader analyzed the high temporal resolution cine data to determine the location and duration of the motion-free phase interval in systole and diastole for heart rates ranging from - bpm. the following information was collected: age, heart rate, duration of systole and diastole, ekg phase and phase percentage of motion-free interval, and duration of motion-free interval. heart rates were grouped in ranges of ( - , - , - etc.), with at least patients in each group. wilcoxon sum rank test was performed to compare the static durations of systolic and diastolic phases for each heart rate group. two-tailed p-values< . were considered to indicate statistical significance. a chart matching heart rate range to the optimal phase of image acquisition and reconstruction was created. results: optimal reconstruction intervals for motion-free imaging of the heart in systole and diastole, and single best phase for a given heart rate are as follows: (please see table ) mean duration of the motionless phase in systole and diastole for a given heart rate is as follows: (please see table ) conclusions: this is the first time that variability in location of the motion-free interval within the cardiac cycle with respect to heart rate in children has been studied in rigorous fashion. this chart will have immediate application in the so-called 'target scan', which uses prospective ekg triggered acquisition of data in combination with half-scan reconstruction to minimize radiation dose with respect to retrospective ekg gated imaging. results: a total of patients were found to have aberrant pda by ccta. nine patients had a pda emanating from the brachiocephalic artery to the pulmonary arteries and one patient had pda emanating from the carotid or the subclavian artery according to the operative report. all ten patients had echocardiography in addition to ccta. nine of the ten patients underwent surgery. one patient was lost to follow up. comparison between ccta and echocardiography to operative report showed the following: out of the echocardiograms agreed completely with ccta and operative report. out of the echocardiograms did not report aberrant pdas which were seen on ccta and confirmed during surgery. in one patient, the echocardiogram reported a double aortic arch which was found to be an aberrant pda from the left brachiocephalic artery; a finding that changed the surgical management and pre-surgical planning. the results were statistically significant with a p value of < . . conclusions: diagnostic accuracy of ductus arteriosus anatomy is important in pre-surgical planning and management of patients with ductal dependent pulmonary circulation. cardiac ct angiography is more accurate as compared to echocardiography in diagnosis of aberrant patent ductus arteriosus. ) in patients younger than year of age. the prospective ecg-gated protocol scanned % of the cardiac cycle with msec padding in patients with heart rates greater than bpm. two experienced radiologists evaluated the image quality and course of the coronary arteries. image quality was assessed based on the degree of homogeneity of vascular enhancement, presence of stair-step artifacts, image signal and noise as well as the overall subjective image quality based on a point scale. the course of the left and right coronary arteries was also evaluated based on a point scale, focusing on how well the evaluator was able to visually follow the coronary artery from its origin to its termination. radiation dose was recorded and compared. results: the mean score of the homogeneity of vascular enhancement, stair step artifacts, image noise and signal, overall image quality, and score given to visualization of the course of the coronary arteries showed no significant difference (p> . ) in the retrospective and prospective ecg gated groups. the mean estimated effective dose was significantly lower for the prospective ecg gated group compared to the retrospective group, ( . msv vs . msv) respectively (p< . ). conclusions: prospective ecg-gated cardiac mdct provides comparable assessment of coronary anatomy, image quality with significantly less radiation dose when compared to the retrospective ecg-gated mdct. prospective ecg gated cardiac mdct is a powerful adjunct to the treatment and surgical planning of pediatric patients with congenital heart disease less than yr of age with lower radiation dose. methods & materials: pediatric neuroradiology lectures were recorded and made available to radiology residents at a university program through on-line streaming video viewed through an internet link. topics included brain tumors, phakomatosis, and congenital brain malformations. one lecture per week was recommended prior to case conferences that reviewed the same topic. pre-and post-tests and a feedback survey were administered. nonparametric paired sign test and analysis of covariance were used to evaluate changes in test scores overall and according to feedback responses. spearman's partial rank correlation coefficient was used to evaluate the relationship between the number of viewed videos and test scores. results: twenty-nine residents completed the pre-test and the post-test. the means (sd) scores were . % ( . %) and . % ( . %) respectively. there was a significant improvement in test scores (p . ). residents that agreed/strongly agreed that the streaming technology lectures were convenient had greater improvement than those who did not ( . vs. - . %, p . ). similarly, those who agreed/strongly agreed that being able to replay a lecture was helpful had greater improvement than those who did not ( . vs. - . %, p . ). finally, those who agreed/ strongly agreed that the streaming technology lecture format was a better teaching tool had greater improvement than those who did not ( . vs. - . %, p . ). significant positive correlation between number of videos watched postconference and improvement was present (spearman's rho . , p . ). conclusions: on-line streaming video with live case conferences enhances radiology resident learning of pediatric neuroradiology. step (mpps) software provided an accurate measurement of scan time. visual charting made gaps in utilization apparent. technologists and nursing notes correlated to gaps identified barriers and opportunities for improvement. nursing and anesthesiology reduced redundancies. standardized protocols lead to more consistent scan times. appointment access for sedated mri was measured by the third available appointment. results: manually entered data points were time consuming, inconsistent and unreliable. the process improvement was most effective when fewer more reliable data points were used to evaluate the effect of change. the program resulted in a reduction of appointment access for sedated mri from days to days with no change in the hours of operation. magnet utilization was increased from % to %. induction outside the scan room provided the most efficient process tested. we ranked first in utilization in a children's healthcare cooperation of america (chca) survey as measured by exams per scanner. patient preference for a.m. scheduling was shown by survey and corroborated by scheduling data. consistent scan times were achieved by protocol standardization augmented by indication driven decision support. conclusions: a consise definition of mr utilization established a metric that was used in the process cycle of analyze-optimize-measure. anesthesia induction outside the magnet was the most efficient practice but required collaboration between nursing, mr technologists and anesthesiology. protocol standardization were valuable aspects of process improvement essential to optimizing parallel sedation. these adjustments reduced appointment access from days to days, increased utilization from % to % and produced a number one rank in utilization by chca survey. we exploited the synonym option in epic order entry to translate indications into procedures mapped to specific protocols for mri neuroimaging. the order screen allows the provider to enter an indication. that indication is linked through a synonym option to a specific exam and protocol. the recommendation is based upon institutionally created clinical care guidelines, and can be accepted with a single click to complete the order. the requesting provider retains the option to override the recommendation. an step in process development utilized an order queue established within the epic inbasket. a pediatric radiologist monitored the queue and communicated with referring providers to obtain additional history and educate toward best imaging practice. these interactions facilitated development of a robust index of clinical indications used to create the synonym pool. results: mri neuroimaging indications were expanded into a robust data set linked to specific mri exams aligned with specific protocols. the synonym option within epic created the opportunity for the requesting provider to simply enter an indication which drives the procedure and recommended protocol. provider satisfaction has been high and concurrence with recommendations nearly universal. conclusions: indication driven order entry was achieved through the synonym option in order entry within the epic emr. imaging recommendations are based upon institutional clinical care guidelines developed through consensus. a robust compilation of pediatric mri neuroimaging indications has been created and linked to specific exams and protocols. compliance with the indication driven recommendation has been high. modifications of the current system are currently under development for all cross sectional modalities and organ systems. paper #: pa- cost-effectiveness of routine neonatal renal ultrasound in non-syndromic complex congenital heart disease elfrides traipe, tch, extraipe@texaschildrens.org; jill v. hunter, marthe munden purpose or case report: to assess the prevalence of abnormal renal ultrasound in non-syndromic complex congenital heart disease (cchd) and assess the cost-effectiveness of routine renal ultrasound in this population. we restrospectively reviewed the initial neonatal renal ultrasound and any subsequent renal imaging in patients with non-syndromic cchd. etiologies included hypoplastic left heart syndrome (hlhs), transposition of the great vessels (tga), coarctation of the aorta (coa), truncus arteriosos (ta), double outlet right ventricle (dorv) with or without patent ductus arteriosus. patients were recruited consecutively as part of a prospective trial for pre-and post-operative magnetic resonance imaging of the brain. results: the neonatal pre-operative renal ultrasounds were analyzed in female and male patients. only of the patients showed any congenital renal anomaly. this patient was born with hypospadias, that would have routinely stimulated neonatal follow up. conclusions: knowledge of embryology would not lead us to anticipate a high co-incidence of congenital renal and cardiac pathology. based on this statement and our findings, our recommendation to improve cost-effectiveness is not to perform routine neonatal renal ultrasound in non-syndromic cchd, but only if otherwise clinically indicated. purpose or case report: to conduct a meta-analysis of the diagnostic performance of contrast enhanced voiding urosonography (cevus) in comparison to voiding cystourethrography (vcug) or direct radionuclide cystography (drnc). a literature search was conducted for studies published on cevus in the pediatric age group. studies were included if the ultrasound contrast agents (usca) levovist® (bayer-schering pharma, germany) or sonovue® (bracco, italy) were used and enough data was available to extract x tables. if the cevus was compared to both vcug and drnc in the same patients the results for each were analyzed separately. a bivariate hierarchical model that takes into account the heterogeneity in cevus sensitivity and specificity in different studies was used for the assessment of the summary diagnostic metrics. the summary roc curve was derived and presented graphically from the parameters of the model. additionally, the % confidence intervals (ci) and the positive (lr+) and negative (lr-) likelihood ratios were calculated. results: out of publications only comparative studies fulfilled the inclusion criteria. these encompassed cevus studies in comparison with vcug and with drnc with regards to detection of vesicoureteric reflux. in studies the usca levovist® and in sonovue® were used. a total of children with pelvi-ureteral-units (puus) were included in the meta-analysis. cevus compared to vcug and drnc had a sensitivity of % (ci: - ) and a specificity of % (ci: - ) with lr+and lr-of . and . , respectively. the performance of cevus was better when compared to drnc than to vcug (sensitivity %, specificity % versus % and %, respectively. the meta-analysis of the diagnostic performance of cevus regarding the urethra included patients ( boys). excellent imaging of urethral anatomy was reported in over % of the patients. however, currently there is only one comparative study with patients available. in this study % sensitivity and % specificity were reported. conclusions: sufficient evidence is available clearly demonstrating the high diagnostic performance of cevus compared to vcug or drnc regarding the detection or exclusion of vur in children. these findings combined with the absence of radiation should be convincing reasons for promoting the widespread use of cevus in children. disclosure: dr. darge has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: prenatal ultrasound (us) has increased identification of infants with asymptomatic renal pelvic dilatation. society for fetal urology (sfu) grading is used in the sonographic evaluation of pediatric hydronephrosis. based on us findings, a nuclear medicine diuretic renogram may assess renal function, which could result in operative intervention. standardized protocols for diuresis renography, the "welltempered renogram," already exist; however, no current study has assessed effect of intravenous hydration (iv) status with us in the evaluation of childhood hydronephrosis. our study assesses the effect of hydration on sfu grading. in this prospective irb approved study, pediatric patients diagnosed with pelvicaliectasis requiring a diuretic renogram were recruited to undergo pre and post hydration renal us. a urinary catheter was placed followed by renal us pre and post iv hydration ( ml/kg normal saline bolus). imaging was performed by the same sonographer on the same us machine. a well-tempered renogram was then performed. all images were reviewed by two blinded radiologists, one pediatric radiologist who assigned sfu grades to each kidney. results: data were collected from studies, with ages ranging from weeks- years, with an average age of months. there were unique patients. of these, underwent a single renogram, underwent two renograms, and underwent renograms. one patient had a solitary kidney due to mcdk. thus, there were usable paired sonograms ( kidneys) for analysis. sfu grades were compared in the pre-and post-hydration us for each kidney. two-sided statistical tests were done to assess whether sfu grades changed significantly after hydration (sign test). of ( %) kidneys remained the same grade post hydration. when there was a difference, most demonstrated an increase ( of kidneys and p< . ). no change in sfu grade pre-and post-hydration differed by more than . only kidney went from grade to grade . sfu above grade is considered clinically significant. no kidney that was grade - pre-hydration became grade - post-hydration. when sfu is dichotomized grade - vs. - , there was no significant change in grade from pre to post hydration (p ). conclusions: hydration does not appear to have a clinically significant effect on sfu grade. therefore, performance of a "well-tempered" us is unnecessary. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. study type was significantly associated with both total and weighted score (both p < . ). rus was better and mag was worse than vcug, rnc, and dmsa, which did not differ from each other. other factors associated with worse total scores included patient age - years (p< . ) and non-white race (p . ). gender, prior testing history, wait time, and parent education were not associated with total scores. in the multivariate model, rus remained the best, mag the worst, and dmsa, vcug, and rnc in the middle (p< . ). compared directly, dmsa and vcug total score did not differ (p . ). conclusions: this study documents significant differences among gui studies with respect to the patient and family experience, but there was no overall difference between dmsa and vcug. these findings may be useful to aid decision-making when considering gui for pediatric patients. we retrospectively reviewed the imaging findings of consecutive patients with histologic diagnosis of cd ( males, females; mean age . years; age range - years) who underwent mre between / / and / / . the mre was performed in a siemens avanto . tesla scanner. standard departmental volume of polyethylene glycol and fluid were administered for bowel distention. the imaging protocol included dwi with eight b values ranging between sec/mm and sec/ mm and gadolinium enhanced dynamic d vibe (volume interpolated breath hold exam) in the coronal plane. the studies were qualitatively evaluated in a blinded fashion by two board certified radiologists. disease activity was defined as bowel wall thickening and enhancement in the gadolinium enhanced images. dwi abnormality was defined as bowel thickening, increase signal on dwi images and decrease signal on adc maps of the ileum. intra voxel incoherent motion (ivim) dwi parameters were used as quantitative biomarkers for the analysis of slow diffusion (d) and fast diffusion fraction (f). results: gadolinium enhanced vibe images identified abnormal thickening and enhancement of the ileum in / ( %) patients. dwi identified abnormal signal in / ( %) patients. the sensitivity and specificity of the qualitative dwi for identifying ileitis, as shown by gadolinium enhanced imaging, were % and %, respectively. quantitative analysis showed statistically significant difference in ivim maximal values for f (fast diffusion fraction) between abnormal (mean . , std . ) and normal (mean . , std . ) ileum segments (p . ). there was statistically significant difference in ivim maximal values for d (slow diffusion) between abnormal (mean . μm /ms, std . μm /ms) and normal (mean . μm /ms, std . μm /ms) ileum segments (p . ). abnormal loops of bowel had decreased slow and fast diffusion parameters. conclusions: diffusion weighted imaging has excellent sensitivity and specificity for the detection of active ileitis in pediatric cd. furthermore, quantitative ivim model parameters provide effective biomarkers for this condition. ivim dwi has the potential to assess bowel inflammation without intravenous contrast enhancement and further increase our understanding of cd. methods & materials: forty pediatric patients (median age . years, range . - . ) with suspected (n ) or confirmed ibd (n ) were included and underwent gastroileocolonoscopy with biopsies followed by mre (median interval days, range - ). the mre results were compared with macroscopic and microscopic assessment of the ileum. the clinical importance of the mre results was registered. results: crohn disease (cd) was diagnosed in cases, ulcerative colitis (uc) in , and ibd unclassified (ibdu) in three. macroscopic ileitis was detected in / ( %) of cd cases and in / ( %) of uc (backwash ileitis). microscopic inflammation was found in another four cd cases and one ibdu patient. in total, discrepancy between macroscopic and microscopic inflammation was found in cd, uc and one ibdu patients. the sensitivity of mri was % (against macroscopy and/or microscopy) to % (against macroscopy alone), while the specificity was % and %, respectivley. mre findings was decisive for diagnosis in / ( %) and led to treatment adjustments in / ( %) in the following six months. conclusions: mre is a reliable method for imaging of intestinal inflammation in pediatric ibd, and can be supportive or essential for clinical treatment decisions. results: of children with ec, had ct imaging of the abdomen and pelvis. these children ranged in age from months to years (mean . years +/− . ) with a male predominance (n , %). the most common presenting symptoms were abdominal pain (n ), bloody diarrhea (n ), and rectal bleeding (n ). ec was characterized as a dense and predominant eosinophilic inflammatory infiltrate in the lamina propria and/or epithelium without granulomas. ct scans were abnormal in ( %). no colonic luminal contrast was present in patients, and in one of these, the colon appeared normal. abnormal ct findings included cecal wall thickening (n , %), mucosal enhancement without colonic wall thickening, (n , %), mesenteric lymph node enlargement (n , %), terminal ileal thickening (n , %), jejunal and ileal thickening (n , %), and pneumatosis (n , %). of the patients with cecal involvement, primarily involved the cecum with less severe or no ileal or downstream colonic involvement. pneumatosis extended along the length of the colon with rectal predominance. conclusions: the predominant ct finding in our ec series was wall thickening, most severe in the cecum with variable extent downstream with mild or no involvement of the terminal ileum. although there is overlap, these findings are different from the most common patterns encountered with ulcerative colitis or crohn disease and should raise the possibility of ec in children presenting with abdominal pain and bloody diarrhea. purpose or case report: timely identification of childhood arterial ischemic stroke (ais) is critical to development of acute treatment strategies. we present our experience prior to and following development of a pediatric stroke alert system (sas). through multi-disciplinary collaboration in a tertiary care setting, a pediatric sas was established in . we describe the system, imaging protocol evolution, and impact upon the time between admission and mri initiation (time-to-mri) in patients with childhood ais. of patients in our stroke database (comirb # - ), % met inclusion criteria for stroke alert initiation (acute focal neurological deficit within h). eleven pre- and nine post- patients met criteria. we compared the time-to-mri between these two groups, utilizing a two-tailed t-test. results: the pediatric sas has two phases: i-neurological evaluation and ii-imaging and treatment consideration. phase i stroke alert is initiated when a child presents with an acute focal neurologic deficit. if neurology confirms stroke symptoms and ct head is negative for an alternative etiology, a stroke alert is called prompting an emergent brain mri. if mri confirms an acute stroke, hyperacute therapies are considered. initial mri protocol included dwi, t , flair, d tof cow mra, d tof neck mra and fat saturated t neck imaging. after internal quality review, t mprage brain and contrast enhanced d neck mra were added. the sequence order was also altered so diagnostic sequences were scanned first (dwi and cow mra). there was a trend towards decreased time-to-mri in the post- group (mean min, sd +/− ) as compared to the pre- group (mean min, sd +/− ; p . ). conclusions: institution of a pediatric sas improved urgent neurologic evaluation and demonstrated a trend towards shorter time-to-mri. ongoing quality review has enhanced imaging quality and decreased time-to-mri. continued refinement of pediatric sas's will be critical to the success of recently funded phase i clinical trials in the evaluation of hyperacute therapies. results: there were female and male infants. the mean post-gestational age at presentation was days (range - days), while the corrected age was less than days for all patients. patients presented with seizures and signs of infection; presented with lethargy and later proved to have protein c deficiency. mri was performed - days from presentation in these patients. another patient with known protein c deficiency underwent mri at d for followup of screening us abnormalities. there were a total of deep cerebral white matter lesions: frontal, parietal, temporal lobe. lesions were fluid signal cavities with restricted diffusion. larger lesions had dependent debris. all lesions had associated hemorrhage and most lesions had evidence of adjacent small vessel venous thrombosis. lesions imaged after gad showed peripheral enhancement. three lesions were seen to increase in size on follow-up imaging. three patients, with meningitis confirmed via microbiology and with presumed meningitis by csf counts, underwent surgical aspiration of a total of lesions. all specimens were sent for pathology and culture and were negative for microorganisms. conclusions: recognizing the mr appearance of necrosis and liquefaction after deep white matter cerebral venous infarction in neonates can distinguish this entity from cerebral abscess and potentially avoid an unnecessary neurosurgical aspiration procedure. all four children were initially treated with aspirin but experienced recurrent events on therapy. all four were subsequently anticoagulated. two children have remained on warfarin for - years without recurrent events, while the other two had recurrent events despite adequate anticoagulation. these two children underwent uncomplicated coil embolization of the affected vertebral artery segment, and they have remained symptom-free for five and months since then. conclusions: dava was diagnosed by ca in / patients. all four children with dava in our series suffered recurrent strokes despite aspirin therapy. two of the four experienced further strokes on anticoagulation, necessitating endovascular therapy. these findings suggest that dava in children may require ca to diagnose, and that it may be refractory to standard adult therapies. ongoing multicenter efforts in childhood ais should further evaluate the diagnostic approach and recurrence risk of childhood dava. ) and cerebral gray matter abnormalities were present in ( %). posterior fossa lesions were seen on us in . % , but mastoid views were included in only % of the centrally read us. conclusions: in the largest extreme preterm cohort to date with near-term mri and serial us, % had mod-severe wma on brain mri, similar to previous reports. cerebellar abnormalities were detected more frequently by mri than by us. neurodevelopmental outcomes at - months and school age will assess the relative and combined values of mri and us as outcome predictors. , an analysis technique based on task-free resting state fmri recording, can be useful in assessing disruption of connectivity in certain disease states, including epilepsy. in healthy control subjects, functional connectivity reveals strong bilateral interhemispheric connectivity in such system as sensory-motor, visual, auditory as well as dorsal attention and default mode networks. in patients with epilepsy associated with unilateral diffuse hemispheric disease such data is limited. differences in the pattern of activation would suggest alteration in connectivity in these entities. this finding would impact the typical interpretation of this data that is becoming routinely collected for epilepsy pre-surgical evaluation. methods & materials: siemens (erlangen, germany) system, -tesla (trio) scanner was used for imaging (epibold sequence, te ms, flip angle °). resting state fmri scan were performed in both awake and anesthetized patient. awake patients were instructed to relax and rest while keeping their eyes open. analysis was performed using functional connectomes project scripts based on afni and fsl software packages. resting state data were analyzed for connectivity with the following seeds: somatomotor, visual, auditory, and default mode (posterior cingulated cortex (pcc)). results: we applied this technique to evaluate patients with hemispheric seizure disorders, including rasmussen's, neonatal infarct and migration disorders. all the subjects demonstrated some deviation from typical interhemispheric connectivity with a spectrum of findings. the figure below shows connectivity patterns in a patient with cortical dysplasia. while some interhemispheric connectivity remained in somatomotor (sm) and auditory (a ) systems, it was disrupted in visual (v ) and default mode (pcc) networks. variable patterns were found across the cases that corresponded to lesion side, supportive of disruption in interhemispheric connectivity as measured by fmri. conclusions: resting state functional connectivity patterns are well documented in healthy subjects. these results suggest that interhemispheric connectivity disruption is a typical feature of unilateral diffuse hemispheric disease though variable in presentation, either being limited to select systems or demonstrating broad disconnect between the two hemispheres. these results should be carefully considered when evaluating data for pre-surgical epilepsy evaluation. purpose or case report: premature birth is associated with white matter injury leading to a wide ventricular system. however,normative standards for ventricular size are lacking for this particular group.aims: we aimed to, in a controlled, population based norwegian cohort of ex-prematures without major handicaps, and for men and women separately,to ) create standards for radiological indices of ventricular dilatation, )investigate associations of these measurements with subjectively assessed ventricular size, ) examine differences in ventricular size between ex-prematures and healthy controls methods & materials: the initial birth cohort included neonates, birth weight below g (low birth weight)born within hordaland county, norway, between april st and august th . of eligible survivors (without major handicaps)underwent mr examination during the period january to may . of these were expremature (born before gestational age weeks) and were included in this sub-study. based on t weighted images, the ventricular size was subjectively judged as being normal, mildly, moderately or severely dilated by an experienced paediatric neuroradiologist, while objective measurements were performed in a blinded fashion, by a second observer (sma) using an imaging software program (nordic ice®). results: the normative standards for the ventricular system in ex-premature young adults showed wide variations, in particular for the occipital horns. the agreement between subjective and objective assessment of ventricular size was good. ex-prematures had smaller heads than those born term (control group). there was no difference in ventricular size between the two groups, even after adjusting for head size. ex-premature males had larger ventricles than females; however, the difference disappeared after adjusting for head size. conclusions: young adults born prematurely with a birth weight below g do not have larger lateral ventricles than healthy controls born term, even after correcting for a smaller head size. paper #: pa- best practice for reproducibility when measuring t *: implications for liver and cardiac iron assessment mark ferguson, md, radiology, seattle children's hospital, markferg@uw.edu; randolph otto, seth d. friedman purpose or case report: patients with red blood cell transfusion-dependent conditions receive high amounts of iron that can lead to abnormal iron accumulation in tissues resulting in organ damage. while the liver is the dominant excess iron storage organ, iron related cardiotoxicity is a leading cause of morbidity and mortality in patients with transfusion-dependent thalassemia. therefore, accurate determination and tracking of tissue iron levels in both the liver and the myocardium is important for patient prognostication as well as monitoring treatment changes. while multi-echo gradient echo mri (t *) is widely used and validated method employed for iron assessment, less attention has been given to derived metrics. specifically, the literature almost exclusively reports and uses the mean value for t * from a pixel-wise (pw) map. infrequently used is the median. the median is a potentially superior metric than the mean because it is insensitive to outliers. outliers will always occur in data because of either noise or imperfect vessel exclusion. to compare mean versus median on reproducibility of t * measurement, subjects who had paired heart/liver measurements were examined. the entire liver (excluding vessels) and the interventricular septum myocardium were traced on representative images from each series. mean and median t * values were generated from the pixel maps. r * ( / t *) and coefficient of variation (cv) were computed on a patient-by-patient basis. these measures were then summarized for the group. results: markedly higher r * values were observed in both heart and liver using median summary measures (liver: t − . , p . , heart: t − . , p . ). these findings were accompanied by lower cv's (better reproducibility) for the median approach (liver: t . , p . ; heart: t . , p . ). conclusions: the consistent difference in derived t * values between the methods (median>mean) should be considered when comparing derived r * values to established normal ranges. cv data support that using the median as the final summary metric will always outperform mean metrics for measuring change in r *. this finding has immediate implications for the scientific literature and for guiding therapeutic management over time. results: twelve children (age mo- yo; m:f : ) with gsds ( abca mutations, sp-c mutations, undefined mutation) and children (age wk- yo; m:f : ) with other dlds (including pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia of infancy, lymphocytic interstitial pneumonia, lipoid pneumonia, diffuse alveolar damage, granulomatous infection, capillaritis and other pulmonary hemorrhage syndromes) were identified. ct findings with highest sensitivity for gsds were ground glass attenuation ( %), parenchymal cysts ( %), and interstitial thickening ( %). parenchymal cysts, honeycombing, and pectus excavatum were more specific for gsds compared to other dlds (p< . ). the combination of either parenchymal cysts and honeycombing or ground glass attenuation and pectus excavatum provided the highest specificity ( %) but low sensitivity ( %). the combination of parenchymal cysts and ground glass attenuation provided good specificity ( %) and modest sensitivity ( %). no combination of findings provided both high sensitivity and specificity. conclusions: ground glass attenuation is the most sensitive finding for gsds, while parenchymal cysts, honeycombing, and pectus excavatum are more specific findings for gsds than other chronic dlds of childhood. however, no single finding or combination of findings on chest ct is both highly sensitive and specific for gsds, and chest ct cannot substitute for genetic testing or lung biopsy for the differentiation of gsds from other dlds. pes were observed in scans of patients without a history of congenital heart disease (chd), and pes in scans of patients with a history of chd. z-axis scan lengths for the chest ct exams ranged from . - . cm. a z-axis scan length of cm centered . cm below the carina captured all pes in all patients, and a length of cm centered . - cm below the carina in patients with chd. a z-axis scan length of cm centered cm below the carina was sufficient to capture at least one pe in all patients, and a length of cm centered - cm below the carina in patients with chd. the radiation effective dose of the chest ctpa exams ranged from - msv. limiting the z-axis scan length on ctpa exams to cm or cm would have resulted in a % or % decrease in z-axis coverage, respectively, and estimated radiation effective dose reduction of - % due to less radiation exposure to the intrathoracic structures, thyroid gland and upper abdominal viscera. conclusions: limiting the z-axis scan length coverage for ctpa exams based on a model of the typical anatomic distribution of pes relative to the reference level of the carina permits a substantial reduction of radiation dose in children without reducing the sensitivity for detection of pulmonary emboli. purpose or case report: to determine whether the addition of multiplanar reformation mdct images affects reader performance parameters and provides added diagnostic value compared to the use of axial ct mdct images alone for diagnosing pe in children. this was an institutional review board-approved retrospective study of consecutive pediatric patients who underwent ctpa for clinically suspected pe. two faculty pediatric radiologists and two radiology residents independently reviewed each study initially using only axial mdct images and later using mpr mdct images in any x-, y-, or z-axis for detecting pe. diagnostic accuracy, confidence level, and interpretation time of mpr mdct images were compared to axial mdct images using mcnemar's test and paired t-tests. the kappa coefficient was calculated to assess interobserver agreement. diagnostic accuracy was compared between faculty pediatric radiologists and radiology residents by logistic regression whereas confidence level, interpretation time, and added diagnostic value were evaluated with analysis of variance (anova). results: the final study cohort consisted of ctpa studies from children ( m/ f; mean age . years). nine ( %) of ctpa studies were found to have pe. diagnostic accuracy in correctly detecting pe ranged from . to % (mean . %), with no significant differences between the use of axial and mpr mdct images. logistic regression indicated no significant difference in diagnostic accuracy of detecting pe between faculty pediatric radiologists and radiology residents for axial mdct images (p . ) or mpr mdct images (p . ). confidence level and interobserver agreement were significantly higher and average interpretation time was longer in evaluating pe with mpr mdct images compared to axial mdct images for all reviewers (p<. ). compared to faculty pediatric radiologists, significantly greater increases in confidence level, interobserver agreement, interpretation time, and added diagnostic value using mpr mdct images compared to axial mdct images to diagnose pe were found for radiology residents (p< . ). conclusions: use of mpr mdct images in diagnosing pe on ctpa in children significantly increases confidence, interobserver agreement, and interpretation time among faculty pediatric radiologists and radiology residents. because mpr mdct images provide significantly greater improvements in reading parameters for residents than for faculty members, their routine use should be encouraged for trainees. paper #: pa- chest ct in children, anesthesia and atelectasis beverley newman, md, radiology, stanford university, bev.newman@stanford.edu; elliot krane, terry e. robinson purpose or case report: in spite of advances in ct equipment and speed, sedation/ anesthesia is required in many young children for optimal quality ct for detailed parenchymal evaluation; resultant atelectasis is a common and important quality issue. our purpose was to evaluate the safety and effectiveness of a standardized lung recruitment technique. methods & materials: with irb approval and parental informed consent, controlled ventilation, low dose, chest ct's (cooperative effort between anesthesia, pulmonology and radiology) were performed in children ( had - cts) ( f, m; ages . - . yrs, mean . yrs). indications included cystic fibrosis ; ciliary dyskinesia ; chronic or interstitial lung disease ; evaluate pulmonary metastases . ct parameters were - kvp, - mas, iv contrast . various prior methods employed by the pediatric anesthesiologists to maintain lung inflation had unpredictable results (a brief survey showed / nonintubated anesthetized cases had problematic atelectasis). a standardized intubation technique was therefore adopted: .use of a tight fitting face mask during induction and iv placement, inspiratory pressures of - and peep of . . introduction as early as possible using an appropriately sized cuffed endotracheal tube. . alveolar recruitment maneuvers- - s breaths to cm h o/ ( - in st cases). . three breaths at / , inspiratory breathold followed by - cm on th breath for scout and inspiratory scan, and complete ventilator disconnection for expiratory scan. recruitment breaths repeated before each scan. two experienced readers reviewed and scored the images on a point scale for overall quality and atelectasis. results: all studies were completed safely with no procedural complications. one child had propofol-related postoperative emergence delirium. all ct scans were diagnostically good to excellent with small subsegmental atelectasis in ( / were the initial cases with lower recruitment pressures) and segmental atelectasis in . cases had prior cts, without this technique, that were suboptimal due to moderate procedural atelectasis, in spite of tracheal intubation in the majority of cases. conclusions: an intubation lung recruitment technique can be performed safely and consistently by different individuals using a standardized protocol. procedural atelectasis that affects quality is reliably absent and repeat sequences are not needed. obtaining a high-quality dynamic airway imaging study is critical for accurate interpretation and subsequent medical decision-making. the ideal mri sleep study is one that allows successful completion while maintaining spontaneous breathing without artificial airway, which can be an anesthesia challenge. dexmedetomidine has been shown to have sedative properties paralleling natural sleep with minimal respiratory depression. we hypothesized that dexmedetomidine compared to propofol would have less effect on upper airway tone and airway collapsibility and provide favorable conditions with less airway interventions required during dynamic mri airway imaging in children with osa. in this prospective study, we examined the requirement for airway intervention for propofol ( - mcg/kg/m) and dexmedetomidine( - mcg/kg/h) in children and adolescents with osa. severity of osa was analyzed by overnight polysomnography. for children with history of mild osa there was no intervention unless oxygen saturation decreases below %; while for children with history of moderate/severe osa, an artificial airway was placed when oxygen saturation decreased below %. results: demographics and osa severity by polysomnography were comparable. requirement for artificial airway by severity of osa as documented by polysomnography will be shown. mri sleep studies required airway intervention in / ( %) children in the dexmedetomidine group versus / ( %) children in the propofol group. mri sleep studies were successfully completed without the use of artificial airways in children ( %) in the dexmedetomidine group versus children ( %) in the propofol group. conclusions: safe and effective anesthetic management is a key factor in obtaining good quality mr images of the airway. although there was no statistical significant difference in the need for airway intervention between drugs, dexmedetomidine provided acceptable sedation for mri sleep studies with less airway intervention in children with osa. dexmedetomidine may be the preferred agent for sedation during mri sleep studies in children, and may offer benefits to children with sleep disordered breathing requiring anesthesia or sedation for other diagnostic imaging studies. an open mouth and administration of cpap resulted in smaller ap diameter of the retroglossal airway compared to images without cpap due to cpap pressure pushing the tongue posteriorly. in patient volume of oral cavity anterior to the tongue increased from . ml to . ml. meanwhile, the ap diameter of the retroglossal airway decreased from . to . mm ( % decrease). in patient the mouth was initially closed but parted when the pressure of cpap was added with the oral volume increasing from . ml to . ml. the ap measure of the retroglossal airway decreased from . mm to . mm ( % decrease). in patient the mouth was then closed and cpap reapplied resulting in an ap measurement of . mm ( % increase). the ap diameter difference between cpap and no cpap were tested with paired t-test, but were not statistically significant (p . ). conclusions: positive airway pressure on a patient by full facemask and an open mouth can have an adverse effect on the retroglossal airway. this adverse effect is an important consideration in the use of positive airway pressure to support airways for osa, or during emergency resuscitation when a full facemask is used. paper #: pa- the purpose or case report: a nanoparticle blood pool iodinated contrast agent (nctx) has been designed and tested in preclinical animal models. we report data in animal models exemplifying its advantages over conventional contrast in the setting of ct pulmonary angiography methods & materials: nctx blood pool nanoparticles of nm diameter with an encapsulated total iodine concentration of~ mgi/ml were administered by intravenous injection to mice, rabbits, dogs, pigs and sheep. (these studies were actually conducted for other purposes and a review of the data revealed the similarities that motivated this paper.) total injected volumes were~ ml/kg in large animals, and as high as ml/kg in small animals to provide satisfactory vessel enhancement. iohexol or iopamidol was administered for comparative studies with conventional contrast. in a subset of pigs, iatrogenic pulmonary arterial emboli were introduced prior to contrast administration. toxicity studies were conducted in mice and monkeys. results: the visualization of pulmonary vessels using nctx blood pool nanoparticles was generally at least equivalent to using conventional contrast, and superior in several cases, particularly in small veins and when bolus timing of the conventional contrast was suboptimal. in all cases, satisfactory vessel enhancement was achieved for a duration of several hours following a single infusion of nctx blood pool nanoparticles. there was no evidence of renal toxicity, and only transient elevation of hepatic enzymes at relevant dose levels. conclusions: nctx nanoparticle blood pool agents demonstrate several advantages over conventional glomerularfiltered iodinated contrast agents for ct pulmonary angiography in animal models, including no nephrotoxicity, no dependence on bolus injection technique, superior depiction of small veins, and capability of re-imaging for follow-up studies without needing contrast re-injection. potential applications in human pediatric subjects include the diagnostic and post-therapeutic evaluation of cardiopulmonary anomalies and pulmonary embolism, especially in patients with renal insufficiency or tenuous vascular access. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- cardiovascular image quality using a nanoparticle ct contrast agent: preliminary studies in a pig model rajesh krishnamurthy, radiology, texas children's hospital, rxkrishn@texaschildrens.org; ketan ghaghada, prakash masand, abhay divekar, eric hoffman, ananth annapragada purpose or case report: image quality in a separate study using a long circulating, liposomal-based nanoscale blood pool iodinated contrast agent (nctx) suggests clinical utility in pediatrics, potentially reducing difficulties in contrast-ct of children with congenital heart disease (chd) including the size of intravenous cannula, need for accurate timing, inability to simultaneously opacify multiple targets of interest (requiring repeated contrast administration and/or repeated imaging). methods & materials: six pigs (average weight kg) were imaged after slow intravenous infusion of nctx ( mg i/ml) at an iodine dose of approximately mg i/ kg ( . ml/kg). retrospective ekg gated ct imaging was performed h later using a -slice dual-source ct scanner at and kvp. two radiologists analyzed and graded (on a -point scale with : unreadable, : excellent) images aimed at anatomic structures relevant to chd. quality of images obtained at and kvp were compared. uniformity of contrast opacification was measured using a roi-based ctnumber method at various intracardiac and extracardiac sites and mean non-uniformity was calculated. results: there was excellent agreement between the two readers on all counts at kvp. kvp images received lower scores for coronary morphology ( / ), and aortic valve visualization ( . / ), but were comparable in other aspects. pulmonary artery and pulmonary vein branch visualization extended up to the th generation in all cases. visualization of coronary artery branches was possible up to the second generation, with good arteriovenous separation. subtle morphologic features including crista terminalis, thebesian valve, foramen ovale, membranous septum, and chordae of the mitral valve were demonstrated in all cases. automated functional analysis and myocardial mass quantitation was feasible in all cases. there was no significant difference in blood pool attenuation between the atria, ventricles, and extracardiac vasculature on quantitative assessment. no image artifacts were visible on the reconstructed images. conclusions: these findings suggest that nctx promises to be superior to conventional contrast agents for ct imaging of complex congenital heart disease, due to the absence of nephrotoxicity, avoidance of repeated contrast administration, and reduced number of scans performed. avoiding the need for accurately timed scans precludes the need for large bore intravenous access. these attributes make it a promising agent that warrants further studies. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- theoretical cost and x-ray dose reduction in pediatric congenital heart disease imaging by the use of a nanoparticle contrast agent robert bell, the university of texas-houston; rajesh krishnamurthy, gabriela espinosa, christopher petit, ananth annapragada purpose or case report: the purpose of this study is to determine the effective, population averaged reduction in costs and radiation dose that can be achieved in the diagnosis of congenital heart disease by use of a nanoparticle long circulating blood pool contrast agent. methods & materials: a markov model of the decision tree followed at the texas children's hospital in the image based diagnosis of congenital heart disease was constructed in treeage software. the model included ct angiography, mr angiography, cardiac catheterization, and echocardiography diagnostic modalities. patient records, accumulated between and were examined to inform the model. the radiation dose and cost for each step were encoded as penalty functions. markov simulations were run for two decision trees: ( ) utilizing ct angiography and ( ) replacing conventional ct angiography with blood-pool agent based ct angiography. the overall population x-ray dose and accrued cost was calculated for each pass through the model. results: x-ray dose distributions for the example populations showed substantial reductions per ct study, as much as %. averaged over the population, since a sizeable fraction of patients are diagnosed without ever being exposed to any x-ray based modality, reductions were more modest, but still substantial. costs per ct study were slightly higher when the blood pool contrast agent was used. when the diagnostic probability using the blood pool agent increased, it led to an automatic overall cost reduction. conversely when the diagnostic probability remained unchanged, costs rose, commensurate with the increased cost of the contrast agent. conclusions: the use of a blood pool contrast agent for ct angiography leads to substantial reduction in radiation dose in the setting of congenital heart disease. cost reductions are more modest, and are driven almost completely by the reduction in the number of mr and invasive angiography procedures resulting from increased diagnostic success using blood pool based ct angiography. the model as constructed does not account for potential workflow changes that might result from the use of a new contrast agent. actual reductions realized may therefore be higher. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- frequencies and patterns of situs discordance in chest and abdomen justin boe, stanford, justinj.boe@gmail.com; beverley newman, shreyas vasanawala, frandics chan purpose or case report: incidence of situs anomalies, including heterotaxy and situs inversus, is estimated at . % of population. as the first step in the segmental analysis of structural heart disease, the determination situs position is of fundamental importance. abdominal situs, as defined by splenic position and morphology, and cardiac situs, as defined by atrial morphology, are usually but not always in agreement. echocardiographers also employ the relative position of the great arteries and vein at the hiatus to determine cardiac situs. we evaluate the frequencies of discordances among abdominal, hiatal and cardiac situses. methods & materials: with retrospective irb approval, imaging records from to were reviewed for the diagnosis of cardiac situs inversus and heterotaxy. patients who had cardiac ct or mri were included. images were evaluated on a d-processing station by a cardiac radiologist. cardiac situs was determined by the morphology of the atrial appendages. when an atrial appendage was not adequately visualized, cardiac situs was assessed by the relative position of the main pulmonary artery and bronchi. hiatal situs was determined by the relative position of the aorta and the systemic venous return, and abdominal situs by the position and morphology of the spleen. results: thirty-five cases were identified, with cardiac ct and mri. patients' age ranged from day to years old. in the abdomen, the numbers of situs inversus, asplenia, and polysplenia were ( %), ( %), and ( %). for the heart, the numbers of situs solitus, inversus, rightisomerism, and left-isomerism were ( %), ( %), ( %) and ( %). the abdominal and cardiac situses were discordant in ( %) cases. polysplenia had the highest number of discordance with the heart. hiatal situs was discordant with the abdomen in cases ( %) and with the heart in ( %) cases. conclusions: situs disagreement between the abdomen and the heart is not uncommon and they should be documented separately in radiology reports. hiatal situs, as used by echocardiographer, disagrees with the cardiac situs in a quarter of the cases. it should be used with caution in the segmental analysis. paper #: pa- diminished asl intracranial perfusion in children with neurofibromatosis type kristen yeom, md, stanford university, kyeom@stanford. edu; cynthia campen, patrick barnes purpose or case report: neurofibromatosis type (nf ), a neuro-cutaneous syndrome affecting / children is associated with moyamoya syndrome (mms). however, no comparisons of cerebral perfusion in patients with nf and nf -associated mms to healthy controls exist. we hypothesize cerebral blood flow (cbf), as measured by magnetic resonance imaging (mri) arterial-spin-labeled (asl), is diminished in children with nf compared to healthy controls, with the lowest levels seen in patients with nf -associated mms. methods & materials: twenty children aged - years with nf , four with mms, and age-matched controls underwent asl cbf on a t magnet. pseudocontinuousspin-echo-asl technique was used. measurements were taken bilaterally in cerebral cortical-subcortical regions, and the deep gray nuclei. trends in measurements as a function of disease severity were tested with the jonckheere-terpstra test for ordered alternatives. a bonferroni-adjusted p-value less than . was considered significant. results: we identified / areas with significantly diminished asl cbf (ml/ g/min) in patients with nf (midrange), and nf -associated mms (lowest) compared to healthy controls (highest). these included the: thalami (left: p . , right: p . ); superior/middle temporal lobes (left: p . , right: p . ); temporooccipital lobes (left: p . , right: p . ); occipital poles (left: p . , right: p . ); centrum semiovale (left: p . , right: p . ); and left parietal lobe (p . ). conclusions: cerebral perfusion diminishes in a graded fashion in children with nf and nf -associated mms, particularly in the posterior circulation and the mca-pca posterior watershed zones. future studies may demonstrate an important role for asl in the presymptomatic diagnosis of cerebral vasculopathy, and the definition of nf -related vasculopathy patterns. paper #: pa- cingulate gyrus mri sign in pediatric nf patients: a novel imaging marker nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; nabila hai, rhea udyavar , amir noor, gilbert l. vezina, maria t. acosta purpose or case report: we observed a magnetic resonance imaging (mri) signal abnormality in the anterior cingulate gyrus of pediatric patients with neurofibromatosis type (nf ). the cingulate gyrus could play a role in cognitive deficits of nf patients. the first objective here is to document inter-rater reliability scores for visual detection of this sign. the second objective is comparing adc values of the cingulate gyrus in areas of visually abnormal mri signal in nf patients to matched normal mris to confirm a pathophysiological basis of the visual mri sign. methods & materials: retrospective analysis, irb approved, nf patients and matched controls. in the visual assessment part, two blinded neuroradiologists rated presence or absence of mri signal abnormality in the cingulate gyrus in three different age groups of nf patients mixed with normal controls. cohen's kappa inter-rater reliability coefficients were calculated. the same blinded neuroradiologists evaluated the cohort one year later, this time by agreement at the workstation. in the adc measurements part, two researchers, one blinded, manually placed roi's in the anterior and posterior cingulate regions of nf patients and their matched controls, and student t-test was used to assess for significance of differences in measured values. results: cohen's kappa for the three age groups showed very good agreement (kappa coefficients were either . or . ). rater agreement at the workstation was %. all subjects with a positive finding also had nf and the sign was not seen in any of the normal controls. the prevalence of the sign was %. adc measurements showed significantly higher adc values in the anterior cingulate gyrus of nf patients when compared to normal controls and also when compared to the posterior cingulate gyrus in nf patients. conclusions: our results show that visual t /flair mri abnormalities in the anterior cingulate gyrus are present in % of patients with nf from ages to years. adc measurements confirm a pathophysiological basis for this finding. future correlation with clinical manifestations, such as learning and behavioral manifestations in patients with nf , are under way to further evaluate the clinical importance of this finding. tract-based spatial statistical analysis of diffusion tensor imaging in pediatric patients with mitochondrial disease seth friedman, phd, seattle children's, seth.friedman@ seattlechildrens.org; andrew v. poliakov, sandra l. poliachik, dennis w. shaw purpose or case report: often diagnosed at birth or in early childhood, mitochondrial disease presents with a variety of clinical symptoms, particularly in organs and tissues that require high energetic demand such as brain, heart, liver, and skeletal muscles. in a group of pediatric patients identified to have complex i or i/iii deficits, but with white matter tissue appearing qualitatively normal for age, we hypothesized that quantitative dti analyses might unmask deficits in microstructural integrity. methods & materials: dti and structural mr brain imaging data were collected in pediatric patients with confirmed mitochondrial disease and clinical control subjects matched for age, gender, scanning parameters, and date of exam. paired tract-based spatial statistics (tbss) were performed to evaluate differences in fractional anisotropy (fa) and mean diffusivity (md). results: in patients with mitochondrial disease, significant widespread reductions in fa values were shown in white matter tracts. md values were significantly increased in patients, having a sparser distribution of affected regions compared to fa. results of tbss statistical analysis will be shown. to be shown in green is the mean fa skeleton which represents the centers of main white matter tracts. all results p<. . red and yellow represent a significant increase, blue and light blue represent a significant decrease. conclusions: despite qualitatively normal appearing white matter tissues, patients with confirmed mitochondrial disease have widespread microstructural changes measurable with quantitative dti. this supports the evaluation of such metrics in other populations where gross imaging features may be normal. to extend our studies to patients with other plp mutations, we analyzed the brains of male pmd patients (ranging in age from to ) and female carriers for whom the plp genotype had been determined and analyzed by mri. for each patient we measured, white matter volume (wmv) and the intercaudate distance (icd). the mri data were correlated with functional disability scores (fds) using a system we developed for clinical evaluation of pmd patients and which was validated by assessments of pmd patients. brain volume and segmentation were measured using nih image . . the average number of coronal slices analyzed from each patients mri was slices. when graywhite contrast was not adequate, then the intercaudate distance (icd) and intercaudate ratio were measured as described in caon et. al., ( ) . results: comparison of the mr measurements and the fds demonstrated that white matter volume inversely correlates with functional disability, suggesting that the initial disability does correlate with the extent of myelination. the intercaudate distance also correlated with the fds, and may usefully substitute when gray-white matter segmentation is not possible. conclusions: pmd is a clinically and genetically heterogeneous disease caused by mutations in the gene encoding the major cns myelin protein, proteolipid protein (plp). myelin is a major target of disease pathogenesis in most cases of pmd, but how the various mutations cause clinical disability is not fully understood. our data demonstrate that the extent of brain white matter atrophy, measured directly by volumetric fractionation, or indirectly by analyzing the intercaudate ratio, is significantly correlated with the patient's functional disability. white matter atrophy is thus the main cause of clinical disability in patients with pmd of all ages and mutation type. paper #: pa- maturational effects on language localization in children demonstrated by fmri susan palasis, md, children's healthcare of atlanta at scottish rite, spalasis@yahoo.com; binjian sun, laura l. hayes, richard a. jones purpose or case report: language localization is of paramount importance when contemplating surgery in children with intractable epilepsy or brain tumors. the potential risk of injury to language centers in the developing pediatric brain needs to be weighed against the potential benefits of surgery. in the past, language localization was crudely and invasively determined using the wada test. most institutions are now transitioning to non invasive localization using functional mri (fmri). the purpose of our study was to analyze language localization relative to age in children using age appropriate language paradigms and fmri. methods & materials: forty three healthy, english speaking, right handed children underwent fmri evaluation for language localization. the studies were performed on a t system. three novel age appropriate language block paradigms were utilized, targeted both to expressive and receptive language processing. these paradigms were the auditory category decision task (audcat), the auditory description decision task (addt), and the listening task. the spatial statistical maps generated by the fmri data were fused to the d anatomical mri dataset. language areas were localized and statistical analysis was performed with age as the variable in a general linear model. results: our results demonstrate a distinct trend in language localization and lateralization with brain maturation. in the young age groups (less than years) the localization tended to be less focused and bilateral in the frontal and temporal regions of the brain. in the older age groups (greater than years), language became more localized and lateralized to the expected left sided pattern. the findings were more robustly demonstrated with the addt task and were statistically significant (p< . ). conclusions: our study clearly demonstrates the plasticity of language centers in the maturing pediatric brain. this observation is significant for neurosurgical planning and rehabilitation in the pediatric population. ( ) no slc a mutations were found in , and subjects, respectively. significantly higher association with slc a mutations was found in bilateral eva+v/c dysplasia ( / ). double mutations of slc a is more often associated with combined eva+ v/c dysplasia, while a single mutation with eva only. cochlear aplasia without eva ( / ) and snhl with normal imaging ( / ) are less likely associated with slc a mutation. conclusions: slc a mutation is highly associated with eva and v/c dysplasia. once eva with or without v/c dysplasia are found at imaging, genetic investigation is recommended for slc a mutation because of possible thyroid involvement. moderate-severe hie who were randomized to cooling ( . °c for h). there were in the hypothermia group and in the control group. all mris were reviewed by a cental reader masked to the clinical findings, groupings, and outcomes. the mri findings were scored according to pattern and extent of injury, including involvement of the cerebral hemispheres, basal ganglia, thalami, internal capsules, and other structures. brain injury scores were correlated with death or disability at months postnatal age. results: no mri abnormalities were observed in of infants ( %) in the hypothermia group and in of infants ( %) in the control group (p . ). infants in the hypothermia group had fewer areas of injury ( %) as compared with the control group ( %, p . ). there were of the infants with death or disability at months. the brain injury score correlated with outcome of death or disability (p . ) and disability among survivors (p . ). conclusions: fewer areas of brain injury on mri were observed following whole-body hypothermia. the mri brain injury score is a marker of death or disability at months following hypothermia for term hie. . presence or absence of the "red dot" on fa color maps was correlated to clinical (ataxia, oculomotor abnormalities etc.) and morphological data, and to fa and md measurements. results: the "red dot" was absent in js and hgpps (genetic cross wiring impairment diseases) and present in coma and wvs (no reported gene abnormalities so far) as in normal controls. js and coma presented on mri molar tooth appearance. hgpps presented "split pons" appearance. js and coma patients presented oculomotor apraxia, wvs and hgpps palsy of the horizontal gaze. mirror movements were found in js and in wvs. ipsilateral responses are present in hgpps. wvs presented multiple cranial nerves impairment. in js, fa and md values of scp, pt and pc were significantly lower than in normal controls (p > . ). in hgpps high fa and low md were found in pc and pt (p > . ) and normal in scp. conclusions: the "red dot" absence is unrelated to morphological or clinical abnormalities. absence of the "red dot" is associated to abnormal measurements of fa and md in pc and pt( low in js and high in hgpps). these findings indicate a pivotal role for the pc in the physiopathology of these diseases. the "red dot" absence seems to be a marker of genetic cross wiring diseases. in this view, coma and wvs should not be considered as part of these diseases. sonographic predictors of intermittant testicular torsion in the pediatric patient jennifer williams, md, pediatric radiology, texas children's hospital, jlwilli @texaschildrens.org; marthe munden purpose or case report: intermittent testicular torsion (itt), defined as sudden onset unilateral scrotal pain with spontaneous resolution, is difficult to confirm both clinically and sonographically. the purpose of this study was to determine if sonographic predictors exist for diagnosing itt in the pediatric patient. methods & materials: a search of the pacs data system for patients presenting with suspected intermittent testicular torsion was performed. fifteen patients with a total of episodes presenting over a year period were found. a retrospective review of the medical records for clinical presentation, surgical outcome, and comorbidities was performed. scrotal ultrasound images and reports were reviewed for testicular size and echotexture, testicular flow, epididymal appearance, vascular bundle appearance, and presence of hydrocele. results: an abnormal appearance of the vascular bundle was found in % of episodes ( / ). initial absence of testicular flow followed by reperfusion during the scan was seen in % of episodes ( / ); % had increased flow ( / ), % had decreased flow ( / ), and % had normal flow ( / ) . nine of the patients had surgery; of these were found to have evidence of itt and was found to have acute testicular torsion. of patients with itt, % ( / ) had an abnormal vascular bundle. testicular flow was not initially visualized but returned during the exam in % of patients ( / ), was increased in % of patients ( / ) and was decreased in % patients ( / ). conclusions: itt is a difficult diagnosis. the most reliable sonographic indicator is an abnormal spermatic cord, found in % of episodes and % of surgically proven itt. dedicated views of the spermatic cord must be obtained in order to differentiate an abnormal epididymis from an engorged vascular bundle (the so-called pseudomass). attention to testicular flow is of particular importance. while visualization of a transition from no or decreased testicular flow to normal flow during the sonogram is certainly diagnostic of itt, increased testicular flow should not lead to false reassurance. purpose or case report: testicular torsion is a common acute condition in boys requiring prompt and accurate diagnosis. the objective was to evaluate ultrasound accuracy and findings, and clinical predictors in testicular torsion in boys presenting to the stollery pediatric emergency department (ed) with acute scrotal pain. methods & materials: retrospective review of us, surgical and ed records for boys aged month to years, presenting with acute scrotum from to , was performed. age, demographics, clinical symptoms, physical findings, us and surgical techniques, findings and diagnoses were recorded. surgical results and follow-up were used as the gold standard as all pediatric urology in our region is performed at our centre. results: patients presented to ed with acute scrotum with the following diagnoses: testicular torsion, possible torsion-detorsion, torsion of appendix testes, epididymo-orchitis, and other. of us performed, boys had torsion confirmed by surgery. there were inconclusive us reports, none of which had torsion at surgery or follow-up. the false positive rate of us was . % ( patients), and there were no false negatives. six torsion patients had no us. median time from ed to us and surgery for torsion patients was and min. six patients had non-salvageable testes. diagnostic accuracy of us compared to surgery was % for torsion and % for other. sonographic heterogeneity was seen in % of patients with testes that the surgeon felt were non-viable at surgery and % of patients with viable testes (p . ). sudden-onset scrotal pain ( %), abnormal position ( %) and absent cremasteric reflex ( %,) were most prevalent in torsion patients. conclusions: color doppler us is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. despite heterogeneity on pre-operative us, many testes were felt to be salvageable at surgery. rate of salvage of torsion was high. common symptoms and findings of torsion were sudden onset of pain, abnormal testicular position and absent cremasteric reflex. paper #: pa- diagnostic twists of tubal torsion srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; anjum n. bandarkar, dorothy bulas purpose or case report: fallopian tube torsion is a rare cause of acute pelvic pain in a young female and requires prompt diagnosis for immediate surgical intervention. our purpose is to review varied imaging findings of surgically proven cases of tubal torsion. methods & materials: retrospective review of our data base from to revealed cases of surgically proven fallopian tube torsion. ages ranged from to years of age. all had pelvic ultrasound performed, cases had additional ct performed for acute pelvic pain. results: us findings included thickened dilated tubular hypoechoic structure ( ), cystic mass ( ); adnexal ( ), midline ( ). five cases had normal ovaries bilaterally ( with paratubal cysts). ct imaging findings include dilated, fluid filled, thickwalled tube with internal hyperdensity ( hu) likely debris/ hemorrhage in case. additional findings included cystic adnexal mass ( cases), beak sign ( case) and increased vascularity ( case). secondary signs included free fluid ( ), peritubular fat stranding ( ), vascular congestion and thickening of the broad ligament ( ) and enlarged draining vein ( ). laparoscopic salphingectomy was performed in cases (including cases with isolated tubal torsion). laparoscopic detorsion was performed in a total of cases. in addition, laparoscopic cyst drainage was performed in out of these cases. detorsion with paratubal cystectomy and hemorrhagic ovarian cystectomy was performed in of the cases. conclusions: imaging diagnosis of tubal torsion can be difficult. it can occur in isolation with a dilated thickened tubular structure adjacent to a normal ovary or potentially mimic appendicitis, pyosalpinx, complex adnexal cyst or cystic adnexal neoplasm. presence of normal ovaries, beaked tapered tubular structure with intratubal fluid level and hemorrhage may help in making the diagnosis. it is important to recognize this entity in a patient with acute pelvic pain to facilitate prompt tubal sparing surgery. paper #: pa- adjusted renal length in pediatric bone marrow transplant recipients nicholas bodmer, md, university of washington, nbodmer@gmail.com; teresa chapman, sangeeta hingorani, marguerite parisi purpose or case report: bilateral nephromegaly has been observed in the bone marrow transplant (bmt) patients at our institution. this study aims to quantify this observation, thereby providing radiologists with an adjusted baseline agedetermined renal growth curve for bmt patients. methods & materials: a retrospective clinical chart and imaging review was performed on patients who underwent bmt between and and who had abdominal imaging including the kidneys. ultrasound, ct, and mri exams were used for renal length measurement. renal lengths were assessed for each age group, first as an average length of all the patients within that age group overall, and subsequently as an average renal length by age group divided into the following time frames after transplantation: - days, - days, - days, and + days. clinic chart information collected included bun, creatinine, weight, and medication use. results: renal length was measured using imaging cases, distributed across each age group as follows: - months, n ; months- . years, n ; . - . years, n ; . - . years, n ; . - . years, n ; . years and higher, n . renal lengths were greater, on average, within every age group, compared with previously established normative age-related renal lengths (rosenbaum et al.) . the augmented renal lengths universally were observed in the - day post-transplantation timeframe. return to normal renal lengths typically occurred by months post transplant. clinic chart review revealed that the majority ( %) of patients received nephrotoxic medication within two weeks of imaging. conclusions: pediatric bmt patients have larger kidneys in the absence of known renal disease than age-matched peers. a revised, age-based renal length chart for post-bmt patients has been generated which should help prevent the misdiagnosis of nephromegaly in this population, eliminating unnecessary diagnostic evaluations. multiple etiologies to explain renal enlargement in these patients are possible, including fluid overload, nephrotoxic medication, or direct effect of the transplant. purpose or case report: mr urography can be a comprehensive exam for anatomical and functional pediatric renal evaluation. quantification of renal function may benefit when dynamic contrast enhanced images can be obtained at high spatiotemporal resolution and with minimal respiratory motion artifacts. though respiratory triggering may decrease motion artifacts, it results in loss of temporal resolution by a factor of about three. a two-echo gradient echo sequence with segmented outer k-space sampling and view-sharing/dixon image reconstruction (disco, differential subsampling with cartesian ordering) was chosen as a starting point due to its high temporal resolution. it was then modified to enable respiratory triggering while maintaining temporal resolution of one temporal frame every one to two respirations, with segments of k-space only acquired in the expiratory phase of respiration. imaging parameters were: °flip angle, ± khz bandwidth, tr~ . , matrix x , fov - cm, slice thickness mm, and x spatial acceleration. with irb approval and informed patient consent consecutive patients referred for mri renal function evaluation were recruited (age range; . to . years, mean±sd: . ± . years; males % females %), and scanned on a ge t mr using a -channel torso array with the respiratory-triggered high spatiotemporal resolution technique to extract regional gfr maps. two readers by consensus assessed image qualitative snr, motion artifacts and volumetric fat-water suppression performance. results: data acquisition was obtained to completion in all subjects without triggering failure. temporal resolution was approximately s for two respiratory cycles. no case had major fat suppression failure, whereas minor fat suppression failure was seen in % ( % c.i. to %). all cases had diagnostically acceptable snr. no motion artifacts were noted in / cases, while some artifacts with ghosting in / cases. regional gfr maps could be successfully extracted for each patient without the need for image registration. attached figure shows image quality. conclusions: view-sharing offsets loss of temporal resolution from respiratory triggering. thus, high spatiotemporal resolution renal dynamic contrast enhanced respiratory triggered images can be obtained with minimal motion artifacts in a pediatric clinical setting to evaluate renal function. disclosure: dr. chowdhury has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: the study cohort was selected from the irb approved children's oncology group aren b study. cases are evaluated for pre-operative wt rupture based on central review of surgical/pathology findings. wt cases with rupture were matched to wt controls by age and tumor weight (within months and g). ct scans were independently reviewed by blinded radiologists, for presence/absence of rupture and the following ct signs: poorly circumscribed mass, perinephric fat stranding, peritumoral fat planes obscured, retroperitoneal fluid, ascites beyond cul-de-sac, peritoneal implants, ipsilateral pleural effusion, intratumor hemorrhage. sensitivity, specificity of ct for assessing pre-operative wt rupture was determined. the relationship between ct signs and rupture was assessed by mcnemar's test, and the most predictive ct signs determined by backward selection multivariate logistic regression. results: sensitivity, specificity for detecting wt rupture were: reviewer - . %, . %, reviewer - . %, . %. kappa coefficient for interobserver agreement was substantial: . (p< . ). all ct signs tested, except peritoneal implants and intratumoral hemorrhage, had significant association with tumor rupture (p< . ). for reviewer , ascites and fat stranding around tumor were most predictive (odds ratio . and . , p< . ). for reviewer , ascites and retroperitoneal fluid were most predictive (or . and . , p< . ). conclusions: ct has high specificity but relatively low sensitivity for detecting preoperative wt rupture. the presence of ascites beyond cul-de-sac is the best indicator of preoperative rupture, followed by fat stranding and retroperitoneal fluid. paper #: pa- the failed pyeloplasty: evaluation with mr urography damien grattan-smith, children's healthcare of atlanta, damien.grattansmith@mac.com; ricahrd jones, stephen little, wolfgang cerwinka, hal scherz, andrew kirsch purpose or case report: to identify imaging characteristics associated with failed pyeloplasty seen with mr urography. we have performed mr urography in children following pyeloplasty. from this group, children had follow-up surgical intervention with repeat pyeloplasty or balloon dilatation of the upj. imaging features reviewed included degree of hydronephrosis, calyceal transit times, renal transit times, signal intensity versus time curves, as well as functional analysis based on volumetric and patlak differential function and change in the asymmetry index. results: all children who underwent a second surgical procedure had delayed calyceal transit times. the degree of hydronephrosis and renal transit times were either stable or worse when compared to pre-operative evaluation. functional derangement could show stability, slight improvement or deterioration. the asymmetry index estimated the severity of the obstruction. conclusions: mr urography is valuable in the evaluation of children who have undergone pyeloplasty. the calyceal transit time appears to be the most reliable discriminator when comparing successful and failed pyeloplasty. calyceal transit times may be prolonged before the hydronephrosis becomes progressive. disclosure: dr. grattan-smith has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: initial attempts at interpreting functional mr urography (fmru) can be challenging. a time intensive navigation through a multitude of both subjective and objective functional results is necessary to render a useful interpretation. this is a guided review of fmru, noting the important functional findings in high-grade unilateral pelvicalyceal dilatation (pcd), in the absence of ureterectasis, with a contralateral normal kidney allowing for an optimal functional comparison. methods & materials: a retrospective functional evaluation of cases with unilateral pelvicalyceal dilatation (pcd), without prior pyeloplasty, was conducted. the fmru studies were carried out according to a standard protocol and post-processing using the chop-fmru software. this included iv hydration, bladder catheterization and iv furosemide administration. fifteen minutes after diuretic administration, a dynamic coronal d fat saturated t sequence was performed in a supine position over min. a sagittal d t and delayed single coronal t , both fat saturated, followed in a supine and/or prone position. the following functional features were evaluated: visualization of the ureter, the presence of a contrast-urine level and swirling of contrast in the dilated renal pelvis. the functional results included in the analysis were calyceal transit time (ctt), renal transit time (rtt), time-to-peak (ttp), parenchymal volume (pv), differential renal functions (volumetric-vdrf, patlak-pdrf and volumetric patlak-vpdrf) and the difference between vdrf and pdrf. results: patients were comprised of males and females with an age range of . - . years (median . yrs). of the kidneys with pcd, the ureter was visualized in , during the dynamic sequence, / during supine delay and / only in prone position. a contrast-urine level was present in of the dilated systems, and swirling in . the ureter was visualized during dynamic sequence in all contralateral normal kidneys and at no time was swirling or a contrast-urine level identified. the average functional parameters are seen in table . a statistically significant (p< . ) difference between the normal and dilated pelvicalyceal systems was achieved in ttp, pdrf and vpdrf for this small sample size. conclusions: awareness of multiple functional features and the range of calculated results may aid in subsequent combined interpretation of the fmru with the morphologic analysis. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. and . demographics, clinical presentation , diagnostic studies and treatment outcomes were evaluated. post-procedure imaging was evaluated for clot burden reduction (patency) and residual venous stenosis by two-reader consensus. results: ten patients ( male; female, mean age years, range - ) presenting with acute upper extremity swelling and pre-procedure imaging revealing % occlusion of the axillary and subclavian veins received successful endovascular therapy. all patients underwent infusion catheter placement for thrombolysis with tissue plasminogen activator or urokinase. patients received additional pharmacomechanical treatment. angioplasty was also performed in all patients. the mean treatment duration was h (range - ). post-procedural imaging revealed that of patients achieved - % patency (clot burden reduction) and patient achieved - % patency. the residual venous stenosis was graded: patients had - % stenosis, patients had - % stenosis and patients had - % stenosis. all patients were discharged on full anticoagulation therapy with low molecular weight heparin. patients had surgical rib resection postthrombolysis with an average length of time from thrombolytic therapy to surgery being days (range - ). patients had re-thrombosis events during the follow-up period (mean months; range - ), with one re-thrombosis event occurring within one week of thrombolytic therapy, prior to surgery and the other two occurring - weeks post-rib resection. there were no procedure related complications. one patient was lost to follow-up after initial successful catheter directed therapy. conclusions: percutaneous endovascular techniques such as pharmacomechanical thrombolysis and angioplasty appear to be feasible and safe options for paget schroetter syndrome in otherwise healthy adolescent patients. in attempt to prevent rethrombosis and chronic symptoms, we refer all patients for adjunctive surgical decompression. future larger studies are needed to address optimal strategies for these patients. combined d fluoroscopy image guided percutaneous intervention with real-time optical sensing at the tip of a needle for tissue characterization rami nachabe, philips, rami.nachabe@philips.com; john m. racadio, drazenko babic, ross schierling, jasmine hales, benno hendriks purpose or case report: to investigate the feasibility and potential of real-time tissue characterization at the tip of a needle with diffuse optical spectroscopy (dos) sensing capabilities during d fluoroscopy guidance using cone beam ct and dedicated needle path planning software. methods & materials: a c-arm x-ray system that combines fluoroscopy and d imaging from a cone beam ct was used to image a woodchuck with hepatocellular carcinoma (hcc). the imaging system enabled needle path planning, which was used to perform insertion and navigation of a needle toward the liver tumor. the needle was integrated with optical fibers for real-time tissue spectral sensing at its tip. optical spectra measurements were obtained continuously as the needle passed through healthy liver tissue and then into the tumor. from the diffuse optical spectra measurements, the following clinical parameters were extracted for tissue characterization: blood volume fraction, blood oxygenation, lipid volume fraction and tissue light scattering (related to tissue density). the tissue parameters were compared for healthy liver and tumor using the kruskal-wallis test. results: the tissue density of the healthy liver was lower than that of the tumor. higher blood and lipid volume fractions as well as oxygenation levels were observed in the healthy liver as compared to the tumor. all differences were statistically significant (p< . ). additionally, a much wider heterogeneity in tissue density was observed in the tumor as opposed to the healthy liver. conclusions: differences in tissue properties between tumor and healthy liver enable discrimination between these two types of tissues. adding real-time optical sensing at the tip of a needle to d fluoroscopy image guidance is a feasible technique that complements the imaging information with relevant physiological parameters; it facilitates more precise definition of tumor boundaries despite any target motion during needle insertion. disclosure: dr. racadio has disclosed that he is a consultant for philips healthcare and receives travel reimbursement. rami nachabe, drazenko babic and benno hendriks are employees of philips healthcare. methods & materials: two children aged months and months were treated at this institution for liver failure resulting from urea cycle disorders, with a hepatocyte transplant procedure. the recipient liver was irradiated prior to transplant to facilitate engraftment. the procedure involves the injection of prepared hepatocytes from a suitably screened, compatible donor, via a main portal vein branch into the recipient liver. in both procedures access to the umbilical vein was achieved by the surgery service and a french arterial sheath was placed. a french angled catheter was used for diagnostic runs and to access the right and left main portal vein. a french fogarty catheter (edwards lifesciences, irvine, ca) was placed to isolate each portal vein branch in turn and hepatocytes injected using hand injections. pressures in the main, right and left portal veins were measured and hand injections of contrast made at regular intervals. careful attention must be paid for evidence of pruning of portal branches, indicating occlusion of small portal branches, or portal to hepatic vein shunting. if shunting is seen, infusion must be stopped as embolism of hepatocytes into pulmonary arteries may result with serious clinical sequelae results: in both patients, the desired number of hepatocytes were successfully delivered into the recipient liver. in both cases, mild pruning of the portal vein branches was evident at the end of the procedure. portal vein presssures remained steady. there was no venographic or clinical evidence of pulmonary arterial embolization. conclusions: the interventional radiologist plays a central role in the hepatocyte transplant procedure. familiarity with catheterizing portal branches from an umbilical vein approach, measuring venous pressures, using small occlusion catheters and recognizing venographic end points such as portal vein pruning and portal to hepatic vein shunting are necessary to the safe and successful completion of this new technique. purpose or case report: the aim of the study was to evaluate the trends in term of type of tube placed, number of procedures per year, number and age of the patients as well as the number of procedures per patient and the interval of time between two placements, and finally the irradiation burden borne by the patients. methods & materials: after reb approval the radiologic files of the patients who underwent naso-duodenal-jejunal (ndj) or gastro-jejunal (gj) or jejunal (j) tube placement under fluoroscopy over the past five years ( to ) were extracted from the ris and reviewed. the results were tabulated as a single batch and stratified by year. results: eighty-nine patients representing procedures ( ndj, , gj, j) were included. only patients underwent a single procedure. the average number of procedures per patient was . with a maximum of during the study period. the average patient's age was . months (sd . , median . ). the average fluoro time per procedure was . min (sd . , median . ). the average interval between two procedures was days (sd , , median ). the average fluoroscopy time per patient combining those having a single procedure and those having multiple ones, was . min (range . to . , sd . , median . ). conclusions: fluoroscopic placement of enteric tubes delivers a significant amount of irradiation. our data led to two interventions with respect to insertion and management of the tubes. on one hand, when the attempt pursued by a radiologist is not successful after min of fluoroscopy other strategies should be considered including another operator or an alternative technique for tube positioning. on the other hand, information will be distributed toward the clinicians and nurses in order to improve the management of these tubes and avoid fortuitous displacement which was responsible of a significant amount of repeated procedures leading to undue irradiation. purpose or case report: to evaluate drug elution pharmacodynamics of doxycycline in an albumin-based solution, as used in percutaneous imaging-directed therapy of aneurysmal bone cyst (abc) and microcystic lymphatic malformation (lm) methods & materials: doxycycline mixed with % human serum albumin (hsa), and doxycycline mixed with saline solution (both mg/ml) were evaluated using a fluid diffusion chamber system over h, recording ph and doxycycline concentration. static ph and doxycycline concentrations were recorded every min for the first min, then every min for a total of h, averaged over trials in each of the hsa and saline systems. statistical analysis evaluated standard deviation and rate of change for the trials in each system. drug elution dynamics data were correlated with clinical experience in the doxycycline/albumin treatment of patients ( treatments) with aneurysmal bone cyst (abc) and patients with lymphatic malformation microcysts. results: drug elution was linear in both the hsa and saline systems, with statistically significant (p<. ) slower elution drug release from the albumin system as compared with the doxycycline and saline solution, both over and h. purpose or case report: to describe a successful interventional radiologic approach to the management of paget schroetter syndrome presenting as acute arm swelling in adolecent athletes. methods & materials: institutional review board approval was obtained for this retrospective study. five patients aged to years (mean . years) were treated at this institution over a year period all presenting with acute arm swelling (july -july ). ultrasound confirmed subclavian vein thrombosis in all cases. all were treated with placement of an infusion catheter (ev , plymouth, mn), infusion of tissue plasminogen activator (tpa) at a rate of mg/hour overnight and aspiration of remaining clot with a "trellis" (bacchus vascular, santa clara, ca, usa) thrombectomy device. results: clot was successfully removed in all five patients. complete clearance of clot was confirmed by contrarst venography in all cases. in four patients balloon angioplasty of a narrrowing at the junction of the subclavian and brachiocephalic veins was carried out. in one, the thrombus recurred within h. the patient was retreated the next day with aspiration of clot using the "trellis" device and an infusion catheter placed with low dose ( . mgs/hour) tpa commenced until surgical review; this patient was operated on within h of final thrombolysis. all patients were seen by a vascular surgeon with an interest in this condition. all underwent surgical decompression; at end of the study period all patients were asymptomatic. conclusions: interventional radiologic management of acute axillo-subclavian thrombosis due to paget schroetter syndrome is safe and highly successful in the adolescent population. early recurrence of thrombus is not uncommon and prompt surgical consultation with a view to early surgical decompression is recommended. purpose or case report: diagnostic reference levels (drl) or target radiation dose ranges for pediatric ct scans are needed in the u.s. the first u.s. pediatric ct dose index registry (quircc) within the american college of radiology recorded estimates of patient radiation dose using a new method (ssde) based on body width(bw) for the purpose of developing diagnostic reference levels (drl). in addition to developing drl at the th percentile, the purpose of this study was to determine the ssdes associated with the lower range of acceptable image quality through subjective image quality evaluation. methods & materials: six children's hospitals participated in a retrospective review of abdominal ct with iv contrast on patients < yrs of age. from exams, each site submitted de-identified images for selected cases based on ssde and patient width. a total of cases were selected from the lowest, first quartile and median ssde. six investigators reviewed images from each case under identical viewing conditions and rated them for subjective quality according to a score sheet and reference scale of images with known quantum mottle. cases were considered non-diagnostic if at least of reviewers ranked them as such. results: first, second, and third quartile ssde and ctdi-vol values from sites for each bw will be shown. / cases were ranked non-diagnostic by the reviewers. / non-diagnostic cases were below the th percentile based on ssde. / of "non-diagnostic" cases had ssde less than the th percentile. the unacceptable case with ssde above the th percentile ( cm, ssde . mgy) was due to subcutaneous metal implant with artifact. the quircc th percentile using ctdivol for a yr old is . mgy which is % lower than the acr ct accreditation data's published th percentile. conclusions: this consortium developed target dose ranges (drls) for ct of the abdomen with iv contrast for routine exam indications based on evaluation of image quality that establish lower and upper ranges ( - percentile) of patient dose(using ssde) associated with clinically acceptable images. this study demonstrates that pediatric radiologists in this consortium are comfortable interpreting images at or above the percentile ssde and judged all but one image within this target range as diagnostically acceptable. table ). with the exception of neonate chest, most used age-based techniques; only two centers reported using thickness. no survey used grids for wrist images, while / of the surveys used grids for chest and abdomen exams in -year-olds. at the most common sid there was up to a kvp variation ( year-old chest ap) and up to -fold variation in mas ( year old scoli lat). only two surveys used equipment that displayed the new iec exposure index. conclusions: participants report variability in the techniques and methods used to acquire common radiographic studies, reflecting differences between detector types and users. radiologists, technologists, medical physicists, manufacturers, and the fda have an opportunity to work together to standardize the techniques based on detector type to optimize radiation exposure for pediatric radiographic exams. disclosure: dr. don has indicated that he performs contract research for carestream and that he is on the speaker's bureau for siemens and receives an honoraria. purpose or case report: this study assesses community adoption of ct radiation dose guidelines after a -year international initiative to reduce medical radiation exposure in children. size-specific dose estimates (ssde) from community pediatric body ct scans are compared to ssde from matched scans obtained at a children's hospital that adheres to image gently campaign principles. we reviewed pediatric ct scans ( chest (c), abdomen/pelvis (ap), chest/abdomen/ pelvis (cap)) transferred from community imaging centers to our university children's hospital between july and february . community scans were acquired with variable parameters and reconstructed with traditional filtered back projection (fbp). comparison was made to children's hospital ct scans, performed in accordance with principles of the image gently campaign. because iterative reconstruction (ir) software was added to our scanner during the study, enabling us to reduce ctdivol by %, children's hospital scans were divided into two groups: a) scans obtained with standard weightbased pediatric protocols and fbp (october -october ; c, ap, cap) and b) scans obtained with reduced-dose weight-based pediatric protocols and blended ir/ fbp (october -april ; c, ap, cap). ctdivol and greatest lateral dimension were recorded from each scan and were used to calculate ssde. mean ssde from community scans was compared to mean ssde from children's hospital groups a and b. statistical analysis was performed with student's t-test. results: patient age range was - years in both community and children's hospital groups. mean ssde for community c, ap, and cap scans was . , . , and . times higher than mean ssde for matched scans in control group a (p< . ) and . , . , and . times higher than mean ssde for matched scans in control group b (p< . ). conclusions: ssde was significantly higher for community pediatric body ct scans than for matched scans performed at a children's hospital that adheres to image gently campaign principles. results suggest that more community outreach and education are required in implementation of low-dose ct protocols outside of children's hospitals. concurrent use of ir provides a means of achieving even greater ssde reduction than is possible with fbp alone and should be encouraged. paper #: pa- optimization of tube voltage and current in size-based pediatric ct imaging: a phantom study boaz karmazyn, md, radiology, riley hospital for children, bkarmazy@iupui.edu; yun liang, keith kaser, peter johnson, mervyn cohen purpose or case report: determine the change in ct dose index (ctdivol) required to maintain the same quantum mottle noise when using lower tube voltages ( and kvp) relative to kvp in different sized cylinder water phantoms (cwp) representing a wide range of pediatric body sizes. we performed mdct scans of , , , and cm cwp. thirty scans were performed for each phantom. the tube currents ranged from to mas with increments of mas, and the tube voltage levels were , , and kvp. the noise (standard deviation in hu) was measured using center region of interest (roi) that was % of phantom's area. two other rois (each % of the area) were placed at the center and periphery of the phantom images to measure noise gradient. results: in the smallest ( cm) cwp, approximately the same noise level was maintained with all three tube voltages without a significant change in ctdivol. for the , , and cm phantoms, the average ctdivol needed to be increased by %, %, and %, respectively, to maintain same noise level when the voltage was decreased from to kvp. the average ctdivol needed to be increased by %, % and % to maintain the same noise level in the , , and cm cwp when the tube voltage was decreased from to kvp. the difference between central and peripheral noise increased on average by . %, . %, . %, and . % in the cwp of , , , and cm, respectively. in each cwp, the central to peripheral noise difference was more pronounced (up to . % more) with decrease in kvp from to or . conclusions: noise measurements in the water phantom model indicate that tube voltage could be decreased from to in cwp of cm without significant change in ctdivol. it is also possible to decrease the voltage from to kvp with a minimal (< average %) increase in dose in cwps of , , and cm. the noise gradient increases with larger cwp and smaller kvp. paper #: pa- comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging using -row and -row ct jennifer johnston, md, radiology, cincinnati children's hospital medical center, jhtai@yahoo.com; daniel j. podberesky, erin angels, terry t. yoshizumi, greta toncheva, donald p. frush purpose or case report: to compare effective dose (ed) estimates, image noise, and scan duration for pediatric chest, abdomen and pelvis protocols using -row and -row ct scanners in various acquisition modes. methods & materials: organ doses were measured using mosfet dosimeters. dose, scan duration, and noise measurements were made in a -year-old anthropomorphic phantom for conventional helical, -detector helical and volume acquisition modes for chest, abdomen and pelvis protocols on a -row ct, and for helical mode on a row ct (aquilion one and aquilion , toshiba medical systems, otawara, japan) using similar scan parameters representing currently used clinical protocols. mean organ doses from three runs for each protocol, in combination with icrp tissue weighting factors, were used to obtain ed for each protocol. noise was measured as the standard deviation of hounsfield units in equivalent locations at levels for each protocol with an roi tool. ed and noise were compared with a paired t-test or sign test. results: compared to helical acquisitions on the -row ct, ed of all tested acquisition modes on the -row volume ct were significantly lower for chest, abdomen/pelvis (ap) and chest/abdomen/pelvis (cap) protocols (table) . scan durations were lower across the board on the -row volume ct. compared to acquisitions on the -row ct, noise was in general similar to those on -row ct protocols, but some acquisition protocols on the -row ct produced greater noise (table) , specifically volume acquisition for chest ct and -detector helical and volume modes for ap and cap protocols. conclusions: dose savings can be achieved for chest, ap and cap ct examinations on a -row ct scanner compared to helical acquisition on a -row ct, with shorter scan durations. image noise was in general comparable between protocols. although noise differences between some modes did reach statistical significance, the impact on overall image quality will need to be studied further. paper #: pa- the observed to expected total fetal lung volume as a predictor of short-and long-term morbidity in surviving infants with congenital diaphragmatic hernia emily stenhouse, the royal hospital for sick children, emilysten@doctors.org.uk; neil patel, judith simpson, watt andrew, gregor walker, carl davis purpose or case report: observed-to-expected total fetal lung volume (o:e tflv) is a validated mr measure which we have previously demonstrated to be significantly reduced in non-surviving infants with congenital diaphragmatic hernia (cdh). our aim was to investigate the relationship between o:e tflv and short-and long-term morbidity outcomes in surviving infants with cdh. methods & materials: a retrospective analysis of cases of isolated left-side cdh referred to our institution for fetal mr evaluation between - weeks. mr imaging studies were performed on a . t philips system using a phased array body coil. the observed tflv was calculated by multiplying the summed area of the region of interest by the section thickness. the expected tflv was calculated with a formula previously described in the literature using the gestational age of the fetus. the observed tflv was expressed as a percentage of the expected tflv at a given gestation. morbidity outcome data was obtained from the case records of all surviving infants. specific measures of illness severity relating to short-term intensive care management and long-term outpatient management were recorded. differences in o:e tflv between outcome groups were assessed by t-test. results: liveborn infants with isolated left-side cdh and antenatal mr scans were identified. scans were performed at - weeks gestation. infants survived to discharge; gestation . ( . - ) weeks, birth weight . ( . - . ) kg. median length of admission was ( - ) days, median duration of follow-up was . ( . - . ) years. o:e tflv was significantly lower in non-surviving infants; vs. %, p . . o:e tflv was significantly lower in infants who received high frequency oscillation ventilation (hfov) versus those who were conventionally ventilated ( % vs %, p . ). o:e tflv was also significantly lower in those infants who had a length of admission greater than the median of days ( % vs. %, p . ). o:e tflv trended lower with other measures of increased morbidity; inhaled nitric oxide use, patch repair of diaphragm, rehospitalisation within year, supplemental feeding at discharge, gastro-oesophageal reflux, and developmental delay. conclusions: as well as predicting survival, lung volume measurement by o:e tflv is a promising predictor of outcome and morbidity in surviving infants with cdh. further studies in larger populations are required to provide quantitative predictive risk data. characterization of the inherent acoustic noise of a dedicated nicu mri system jean tkach, phd, cincinnati children's hospital medical center, jean.tkach@cchmc.org; yu li, ron g. pratt, christopher villa, beth m. kline-fath, charles dumoulin purpose or case report: we have developed a small foot print . t mri scanner specifically for neonatal imaging that can be easily installed in a neonatal intensive care unit (nicu). the scanner has a maximum patient bore diameter of . cm (without rf coil), and roughly twice the gradient performance of the best conventional adult whole-body . t mr systems. it is known that sensory stimulation such as acoustic noise can elicit autonomic instability in both term and preterm neonates. the inherent noise properties of the nicu mri system were measured as part of the initial safety evaluation of the system and compared against that of a conventional . t mri system. to evaluate the inherent acoustic noise characteristics of the nicu mri scanner, sound pressure level (spl) measurements were performed on it and on a conventional adult sized whole body . t hdx ge mri system (ge healthcare, waukesha, wi). a brüel & kjaer model sound level meter (brüel & kjaer sound & vibration measurement a/s, denmark) was used to perform the spl measurements for several different mr acquisitions (spin echo, gradient echo, fast rf spoiled gradient echo, fully balanced steady state free precession, gradient echo echo planar, and diffusion weighted) using acquisition parameters consistent with clinical protocols. the mr sequences, acquisition parameters, noise measurement equipment and methodology were identical for the two mr systems. the maximum spl in units of a weighted decibels (dba) was recorded for each of the mr acquisition/mr system combinations evaluated. results: the maximum spl values measured during each of the mr acquisitions were lower for all sequences (average . dba (range - dba)) for the nicu mri unit as compared to the conventional mri scanner ( table ). the average measured maximum spl value, reported in dba, across all acquisitions was . ± . for the nicu scanner, and . ± . for the conventional mri scanner. the highest spl values were measured for the diffusion-weighted sequence: and dba, for the nicu and conventional mri scanner respectively. conclusions: because of the smaller dimensions of the gradient coils in the nicu mri system, acoustic noise is less than that of conventional mri scanners despite the superior gradient performance of the smaller coils. the lower inherent acoustic noise level of the nicu system provides improved safety for the neonate, and facilitates siting of the unit in the nicu. disclosure: dr. tkach has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. paper #: pa- late neurologic events in extremely premature infants carlos guevara, md, radiology, duke university, cjg @duke.edu; brett bartz, caroline l. hollingsworth, caroline w. carrico, michael c. cotten, charles m. maxfield purpose or case report: germinal matrix hemorrhage (gmh) is a major complication of prematurity. persistence of germinal matrix and immature neurovascular autonomic regulation in the premature neonate is thought to predispose to gmh. most gmh in premature population occurs during the first days of life, and yet the persistence of the germinal matrix to weeks gestation may allow for post-natal gmh outside of the immediate perinatal period. to our knowledge, this is the first systematic review of late gmh (after the first week of life) in a large population of extremely preterm neonates (less than weeks of gestation). this irb approved retrospective review included patients weighing less than g or born at less than weeks of gestation from through . the study population included infants who had a head ultrasound (hus) within the first week of life and at least one follow hus after the first week of life. all hus were reviewed by three experienced pediatric radiologists for the presence and grade of ich or late developing hemorrhagelike lesions (hll). infants with and without hll were evaluated for several clinical variables, including neurodevelopmental outcomes (bayley scales). results: average gestational age of study population was . weeks. the incidence of gmh in the first week of life was % grade , . % grade , . % grade / , and . % posterior fossa. new echogenic foci (hll) at the caudothalamic groove were seen in . % after the first week of life. % of these lesions were bilateral. a four-fold increase in incidence of hll was seen in infants < g compared to those> g. higher grade hemorrhages were not seen in this patient population, although % of infants had late posterior fossa hemorrhages. the clinical course of infants with hll trended towards a higher incidence of stressors, but this was not statistically significant. the psychomotor development index scores were lower than those infants without hemorrhage. conclusions: small hll at the caudothalamic groove are common in extremely preterm infants after the first week of life. higher grade ( - ) hemorrhages were not seen. there were no cases of intraventricular extension and no direct complications. if isolated, this finding necessitates no follow-up imaging, but may be associated with poor neurodevelopmental outcome. disclosure: dr. guevara has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: tof/apv is a rare congenital heart lesion in which pulmonary arteries may become aneurysmally dilated and compress adjacent airways. pulmonary arterioplasty is often required to relieve tracheobronchial compression in addition to intracardiac repair. the purpose of this study was to review pre and postnatal imaging findings and their impact on patient management and clinical course. methods & materials: a retrospective database search identified infants with tof/apv between - ( fetal diagnosed cases and diagnosed postnatally). for fdc, prenatal ultrasound (us) and fetal mri were correlated with postnatal ct for the size of the central pulmonary arteries, airway compression, and presence / distribution of air trapping/atelectasis. for all cases postnatal ct findings (between - days of age) were correlated with clinical management and outcome. results: prenatal diagnosis of tof/apv was suggested sonographically, based on dilated central pas, between - weeks gestational age (ga). fetal mri, performed between - weeks ga confirmed the diagnosis and aneurysmal central pas and demonstrated air trapping &/or atelectasis in / with normal appearing lungs in fetus. size of the pas ( / ) and presence and distribution of lung abnormality ( / ) correlated closely between fetal mri and postnatal ct, although detailed visualization of the central airway/ vascular relationships were better defined on ct. fetal mri identified an unexpected diaphragmatic hernia (dh) not seen on us. for the pnd cases, ct showed aneurysmal pas and airway compression with air trapping &/or atelectasis in / infants. seven infants with airway obstruction on ct required pulmonary arterioplasty; infant with no air trapping did not have arterioplasty. / operative patients survived, one with concomitant dh died at age days due to hemorrhagic shock. one fdc was inoperable due to poor cardiac function and died at age days. conclusions: prenatal mri correlates well with postnatal ct for assessing pulmonary artery size and location and severity of lung abnormality in patients with tof/apv, this allows for appropriate management planning and may negate the need for an immediate postnatal ct. ct accurately depicts the location and extent of airway compression and resultant air trapping or atelectasis, serving to guide the need for and extent of the arterioplasty procedure. paper #: pa- craniosynostosis syndromes: prenatal findings by us and mri eva rubio, md, cnmc, rubioeva@yahoo.com; anna blask, alexia egloff, dorothy bulas purpose or case report: craniosynostosis with associated malformations is a feature of several related syndromes resulting from a fgfr or twist genetic mutation. syndromes include apert, crouzon, pfeiffer, and carpenter syndromes. our purpose was to review imaging findings which aid in suggesting the diagnosis prenatally. we retrospectively reviewed prenatal us and mri findings in cases with prenatal ( with postnatal/molecular) diagnosis of a craniosynostosis syndrome: cases of apert, case of carpenter, and cases of pfeiffer syndrome. results: / cases were correctly diagnosed prenatally. in the second trimester findings may be subtle, with mild calvarial changes; digit abnormalities, in particular, may elude the imager in unsuspected cases. although the diagnosis could be made with either modality, the full spectrum of abnormalities was best appreciated using a combined imaging approach of mri and us. by us many salient features were depicted: turribrachycephaly/trigonocephaly/cloverleaf ( / ); syndactyly ( / ); polydactyly ( / ). agenesis of the corpus callosum was identified by us in ( / ) cases. conversely, mri, performed in all cases, contributed additional observations not well seen by us: the fetal airway was well delineated in all cases ( / ); a low lying spinal cord was noted ( / ), midface hypoplasia ( / ) and migrational/sulcation abnormality ( / ). additional findings of absent ductus venosus with biliary atresia ( / ), abdominal wall defect ( / ) and renal anomalies ( / ) were seen with both modalities. reimaging in later pregnancy depicted important changes ( / ), including worsening hydrocephalus and resolution of suspected airway occlusion. conclusions: us and mri are complementary modalities in evaluating fetuses with craniosynostosis. airway patency, midface hypoplasia, spinal cord abnormalities and intracranial abnormalities are often better seen with mri. fetal activity, digits, bone detail, and cardiac anomalies are better appreciated by us. findings may be subtle in the second trimester. repeat imaging in later pregnancy may reveal specific information affecting delivery planning. paper #: pa- pcpra best paper hyperpolarized carbon- mrsi for pediatric disease john mackenzie, md, department of radiology and biomedical imaging, ucsf, john.mackenzie@ucsf.edu; yi-fen yen, linda nguyen, jeffrey gu, john kurhanewicz purpose or case report: to study the potential of carbon- mr spectroscopic imaging ( c-mrsi)-a radiation free molecular imaging strategy-for the detection and treatment monitoring of pediatric disease. methods & materials: the potential of c-mrsi to detect pediatric disease was tested in rodent models of pediatric arthritis. animals were induced with arthritis and subsequently given intravenous hyperpolarized c-pyruvate, and imaged. the amount of c-lactate produced from pyruvate in normal and arthritic joints was measured both at single points in time and dynamically at either or tesla. the c-mrsi data were compared with clinical measures of arthritis, cell stimulation studies, and joint changes on conventional anatomic mri and histology. results: alterations in lactate production as measured by c-mrsi appear to depict sites of arthritis and correlate with other more established but potentially less reliable or more invasive measures of disease status. imaging robust mouse models of pediatric disease may be feasible at telsa. this method may also be translated from high-field to clinical equipment with reasonable hardware and software modifications that allow detection of hyperpolarized c compounds. c-mrsi depicts increased lactate production at specific regions of inflammation within arthritic joints and is confirmed by histological inspection and anatomic mri. on average, lactate production is increased by % in areas affected by inflammation. conclusions: the intravenous injection of hyperpolarized carbon- compounds and subsequent imaging with c-mrsi provides a unique molecular imaging strategy to noninvasively monitor pediatric disease. this non-invasive imaging strategy may eventually provide clinical utility for several pediatric diseases involving inflammation, infection and tumor. disclosure: dr. mackenzie has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: using the hemangioma-vascular malformation clinic registry at cincinnati children's hospital, we searched for patients diagnosed with khe whose evaluation included mri. twenty such patients were found, although three of the patients had no pre-therapy mris. the imaging studies were reviewed by the authors with assessment of the following characteristics: location, margin definition, soft tissue involvement, and pre and post contrast signal intensity. results: location: lesion location was as follows: trunk ( ), extremity ( ), extremity plus trunk ( ), and head/neck ( ). signal: all lesions were dark on t weighted sequences with diffuse enhancement after contrast administration. the majority of the lesions were bright on t weighted sequences, but there were cases that had heterogenous to low t signal (with all involving the retroperitoneum). of the cases, only one had both high arterial and venous flow by mri. margin definition: four of the lesions had well defined borders (greater than % well circumscribed) with minimal to no adjacent infiltration/edema. two of those four cases were exophytic masses. the remaining cases were poorly defined lesions with adjacent infiltrative fluid signal intensity and enhancement. tissue/organ involvement: tissue/organ involvement was counted if abnormal fluid-signal intensity or enhancement was identified at that site. review of these cases showed fifteen patients with muscular involvement. dermal and subcutaneous involvement was observed in all but cases, with the uninvolved lesions being isolated and deep. additional sites of suspected involvement included bone ( ), pleura ( ), penis ( ), and pancreas ( ). conclusions: khe is a rare neoplasm of infancy with a spectrum of features by mri. poorly defined lesions are much more frequent than well-circumscribed masses. however, pathologic correlation of such infiltrative margins is usually not available as treatments after biopsy are primarily medical rather than surgical. common additional mri features include predominant involvement of muscle, subcutaneous fat, and skin over viscera and bone with lesions generally showing increased t signal and enhancement. is dedicated chest ct needed in addition to pet ct for evaluation of pediatric oncology patients? ibrahim tuna, montefiore medical center, dristuna@yahoo. com; jeffrey levsky, jeremy rosenblum, rosanna ricafort, benjamin taragin purpose or case report: to evaluate the diagnostic accuracy of low dose ct performed during pet-ct as compared to dedicated chest ct in the assessment of pulmonary findings in children with malignancy. the institutional review board approved this hipaa compliant research. pediatric oncology patients, ages between - , with known solid malignant tumors who were referred to pet-ct and standard chest ct within days for staging or assessment of treatment response between - and - were eligible for this retrospective study. radiology reports were reviewed for potential discrepancies. two radiologists re-evaluated the standard chest ct and low dose chest ct portion of the pet ct of the discordant cases, while comparing with the most recent prior studies. studies were scored for pulmonary nodules, bony metastasis, adenopathy, and pleural effusions. true discrepancies were assessed by a panel of pediatric oncologists to judge whether the differences in reports might lead to a significant change in management. results: ( female, male) patients were identified. radiologic reports of different patients ( female, male) had potential discrepancies based on review of the reports. the primary tumors were rhabdomyosarcoma (n ), hodgkin's lymphoma (n ) and others (n ). reevaluation of the original images showed true discrepancies in . % ( / total ). in studies, the discrepancy had no clinical significance. in studies, a pulmonary nodule was identified on standard chest ct which was not described on the pet-ct. both of these patients had rhabdomyosarcoma. one of these patients had findings that pediatric oncologists considered significant enough to alter patient management. conclusions: we found a low false negative rate for clinically significant findings on the low dose portion of pet-ct as compared to standard chest ct. in the future, improvements in acquisition technique and post processing of the ct portion of the pet-ct may further improve its diagnostic utility, obviating the need for a routine separate diagnostic ct, thereby minimizing radiation exposure in these young patients. methods & materials: low-dose cta examinations were performed in pediatric patients over a three year period to evaluate suspected vascular traumatic injury with some patients receiving scans of more than one area of the body. areas scanned in this include the head and/or neck (n ), chest (n ), abdomen and/or pelvis (n ), upper extremity (n ) and lower extremity (n ). in of these patients, suspected vascular injury was due to a history of either blunt (n ) or penetrating (n ) trauma. patients were referred directly from the emergency department, while were inpatients and the remaining were referred from an outpatient setting. patients ( f: m) ranged in age from to years old (mean age ). studies were performed on a -channel mdct scanner with or kv, to mas, . to . mm section thickness, reconstructed with % overlap, and . to . pitch. contrast medium was power-injected using weight-based protocols to optimize iodine delivery. exams were interpreted on a workstation using advanced imaging techniques. patient radiation dose was calculated in all cases. clinical outcome was assessed through a month follow-up when possible. results: all studies were technically adequate. . % (n ) of studies revealed no vascular injury, while . % (n ) revealed acute vascular pathology. vascular injuries included vascular occlusion (n ), vasospasm (n ), narrowing/dissection (n ), pseudoaneurysm (n ), and transection (n ). extravascular traumatic findings were demonstrated in . % (n ), including fractures, lung injury, soft tissue hematomas, and a ruptured baker's cyst. of the patients with acute vascular findings, . % (n ) underwent surgical management (including for vascular injury), while . % (n ) were managed conservatively. one patient with active extravasation was managed with angiographically-guided embolization. in no case was catheter angiography required to confirm cta findings. conclusions: low dose cta is a reliable means to screen pediatric patients emergently for acute vascular injury. vascular and non-vascular pathology can be diagnosed noninvasively for efficient patient management. paper #: pa- elasticity measurement by acoustic radiation force impulse (arfi) technique of normal liver, kidney and spleen in healthy children mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; myung-joon kim purpose or case report: there are many previous studies about using acoustic radiation foce impulse (arfi) value to measure the elasticity of tissue, mainly the liver in adult patients. however, there was limited study about arfi measurement in the children. the purpose of this study is to evaluate the arfi value in the normal liver, kidney and spleen in healthy children and to evaluate the effect of sex, age, and body mass index (bmi). the study prospectively enrolled healthy pediatric volunteers who are under years old, and underwent abdominal ultrasonography and arfi between july and august . arfi velocity measuring was performed by - mhz linear probe for children under years old and - mhz convex probe for older children. arfi velocity was measured three times at each organ. however this measurement was stopped if the child cannot tolerate. results: two hundred two children (m:f : ; mean age, ± . years) were enrolled. and arfi measurement was performed only two time for some organs in three children. the mean arfi value was . ± . m/s in liver, . ± . m/s in right kidney, . ± . m/s in left kidney, and . ± . m/s in spleen. arfi velocity was not different between boys and girls. however, arfi velocity was different between right and left kidneys (p . ). the arfi value of right kidney, left kidney and spleen was correlated with age, height, weight and bmi (p< . ). however, the arfi value of liver was not correlated with these parameters. conclusions: arfi measurement is feasible in children with only three times acquisition for each abdominal organ. the mean arfi velocity was increased according to the age, height, weight and bmi in kidney and spleen, but it was constant in liver. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: diagnostic image quality can be achieved over a wide range of radiation exposure in digital radiography. "exposure factor creep" or "dose creep'" in which technologists tend to increase dose to avoid the appearance of noise has been well described. using the alara principle, acceptable images can be achieved while minimizing dose. at our institution "dose creep" has been observed in bedside pediatric chest radiography. to address this we coupled a data mining tool with a continuous quality improvement (cqi) initiative which educates individual technologists on appropriate technique. methods & materials: radiation dose in digital radiography is estimated from an exposure index, a proprietary format that varies among manufacturers. our institution uses a fuji computed radiography system which calculates an s, or sensitivity value, that provides an approximation of the radiation dose to the imaging plate, using an inverse scale. overexposed bedside chest radiographs were defined by a s value less than . a data-mining program was developed to extract from the dicom header the s value and other relevant information, on a monthly basis. these data were used to provide training and feedback on a one-on-one-basis. results: with ad hoc feedback and group training initiatives prior to implementation of this new system, approximately . % ( / ) of bedside chest radiographs were overexposed over a four month period. after one-on-one intervention with the technologists, preliminary findings reveal a trend towards fewer overexposed radiographs with approximately . % ( / ) with s< . conclusions: our tool provides a simple method for systematically identifying overexposed radiographs and the corresponding responsible technologists. we anticipate that this personalized educational program will continue to reduce the proportion of overexposed radiographs and thus the radiation dose to our pediatric patients. purpose or case report: ensuring radiation protection for children undergoing ct scans is challenging due to rapidly changing technology, differences in ct equipment and potential lack of understanding of unique aspects of scanning children. the joint commission has named technologists' training as an "action" item. we developed online training modules to fill potential gaps in ct technologists' education. methods & materials: four modules were created by pediatric radiologists, radiologic technologists and medical physicists; were developed by education/training experts from major ct vendors (ge, philips, toshiba, siemens) through the medical imaging technology alliance. modules were created as microsoft word documents containing de-identified images and edited by education specialists at the american society of radiologic technologists and the alliance for radiation safety in pediatric imaging. they were converted to audio/video format using question/answer narration. vendor modules were created in microsoft powerpoint format and edited. all modules were converted into adobe captivate learning program to achieve uniformity of appearance. modules are hosted on the asrt server and linked to the image gently website. a certificate may be printed as documentation of completion. results: all modules are available at www.imagegently.org. two introductory modules discuss basics of ct equipment and medical physics related to radiation dose in children. the third and fourth modules discuss dose-saving strategies for neu-roct and body ct. four vendor-produced modules address unique aspects of equipment design such as automatic exposure control and dose saving strategies for children. conclusions: through collaborative efforts with medical imaging professionals and vendors, we have developed free online modules addressing radiation protection for children. ct technologist training in specific dose saving strategies for children is variable and limited. these modules have the potential to improve ct technologists' understanding of equipment. end confusion which focused attention on improving communication with patients and families. there is little research regarding health literacy (hl) in radiology. the purpose of our study was to determine if an educational intervention (brochure) improves hl for parents whose child will undergo a fluoroscopic study. methods & materials: an education exemption was obtained from the irb. a multidisciplinary team developed brochures for fluoroscopic procedures. participants were randomly selected and asked to complete a survey to assess their knowledge of the procedure and use of radiation both before and after reading a brochure. a final survey to rate and gain feedback about the brochure was completed. results: median age of children whose parents participated (n ) was years. vcug was most commonly performed ( %). prior to the brochure, % of participants knew the name of the test their child was having. after the brochure, % knew the name (p < . ). prior to the brochure, % felt informed about the test, whereas % felt informed after (p<. ). test scores showed an improvement in parent knowledge about the procedure with a median increase of points after the brochure (scale of - ; p<. ). even after reading the brochure, % of parents wanted more information. prior to the brochure, % of parents knew the test involved radiation compared to % afterwards (p<. ). parents improved their understanding of the relative amount of radiation compared to background from % before to % after the brochure (p<. ). overall, % rated the brochure > on a -point scale with % rating the brochure (p<. ). written feedback was uniformly excellent. conclusions: improving hl for parents is part of the mission of radiology medical professionals. our study demonstrates that there is room for improvement in communicating with parents about fluoroscopy. straightforward information for parents provided as a brochure improves their understanding of radiologic fluoroscopic procedures. paper #: pa- compendium of resources for radiation safety in medical imaging anum minhas, duke university, anum.minhas@duke.edu; donald frush purpose or case report: diagnostic imaging, including ionizing radiation modalities, maintains a foremost role in evaluation of medical disorders. there is increasing awareness and need for information across varied sectors about low level radiation and potential risks. many medical/scientific organizations have resources discussing radiation risk and management. however, there is no one resource compiling the same available information. methods & materials: websites, including those of national and international medical organizations (e.g., acr, "image gently" alliance, iaea) were reviewed for information on radiation dose, risk, justification, optimization, guidelines (which included general information about improvement in quality and dose reduction without specific mention of optimization techniques), appropriateness criteria, and general principles of radiation safety for radiography, fluoroscopy/angiography, and ct. this information was divided by modalities and separated into adult and pediatric populations. information from organizations that were not arbitrarily considered to be national (e.g., subspecialty society, regional organization, individual institution/practice) was not reviewed. the resources were then organized into tables, organized by modality. websites with training modules were noted as well. results: websites were explored. overall, less information is available about medical radiation safety in children compared to adults. across both, most information is available on ct, then fluoroscopy, and finally radiography. across all groups and modalities, there is no information available for patients/parents on optimization, appropriateness, or guidelines, with the exception of adult radiography where there were some guidelines. conclusions: this compendium on medical imaging radiation serves as a collective resource for communities including the public and regulatory organizations. additionally, the compendium can be used to determine redundant or deficient areas, providing opportunities for more comprehensive and efficient efforts in medical radiation protection for patients. inappropriate and cloned histories in children: how big a problem is it? leann linam, md, radiology, uams/ach, llinam@uams. edu; chetan c. shah, s bruce greenberg purpose or case report: acr standards require appropriate clinical history for obtaining imaging examinations. cloning clinical histories is a federal violation. our purpose is to determine the frequency of inappropriate histories (ih) and/or cloning histories (ch) at a tertiary children's hospital. methods & materials: three pediatric moc radiologists reviewed clinical histories for radiographs obtained at a tertiary children's hospital on randomly selected dates ( weekdays and weekend day) for appropriateness and cloning. appropriate histories have associated icd- codes. cloning is defined by identical clinical histories occurring on consecutive days and could be clinically appropriate or inappropriate. only the first patient radiograph on a day was included. χ testing was performed to determine significant differences. results: % ( / ) of exams had ih. ih were significantly more common in inpatients than outpatients (p< . ). nicu examinations accounted for % of all ih and were significantly more frequent than other inpatient locations (p . ). the cvicu examinations accounted for % of all ih and was the second most common patient location for ih, but not significantly different from other inpatient locations (p . ). the increased frequency in ih on the weekend reflects a change in patient mix with fewer outpatient examinations performed than on weekdays and was not significant (p . ). the most common ih included: evaluate ett or evaluate lungs ( each). cloning only occurs in inpatients and was combined with ih in % of patients with ch. the nicu accounted % of ch which was significantly greater than other inpatient locations (p . ). conclusions: in radiographs had ih which can lead to misdiagnoses or nonpayment by insurance companies. inpatients, especially the nicu were the most common patient locations. cloning was also a common problem and was frequently combined with ih. identifying the extent of ih allows for corrective educational measures to be instituted which should improve compliance with existing medical and legal standards for ordering radiographs. paper #: in vivo validation of size-specific dose estimates (ssde) through breast entrance skin dosimetry (esd) during pediatric chest ct angiography sjirk westra, md, radiology, massachusetts general hospital, swestra@partners.org; xinhua li, mannudeep kalra, bob liu, suhny abbara purpose or case report: ssde is a new ct dose measure that corrects scanner console ct dose index (ctdi) for cross-sectional body diameter, being a better estimate of absorbed dose in individual patients of varying body size. ssde has been developed through phantom studies and computer simulations of ct dose, but has not yet been validated in vivo. the purpose of our study was to determine correlation between ssde and measured breast entrance skin dose (esd) for pediatric chest cta across a variety of scanning techniques, scanner models and patient sizes. methods & materials: our study was irb-approved, with waiver of written informed consent. during consecutive chest cta exams done on different scanners over a period of years, we measured mid-sternal esd as an approximation of breast dose with skin dosimeters, which was also expressed as mammogram equivalents. for each scan, we recorded patient age, weight, effective ma, kvp, console ctdivol- cm and dlp- cm (from which we calculated age-adjusted effective dose (ed)). we measured effective chest diameter Ø to convert ctdi to ssde, and we correlated ssde with measured breast esd, using linear regression. we evaluated image quality with regard to answering the clinical question. (table) , due to systematic introduction of automatic exposure control, low kv and high pitch scanning techniques. all studies were of diagnostic image quality to address the clinical question. conclusions: ssde is a valid measure of ct dose in pediatric patients undergoing chest cta over a wide range of scanner platforms, techniques, and patient sizes, and may be used to model breast and other organ dose, and to document results of dose reduction strategies over time. purpose or case report: the purpose of this project was to create an automated system capable of quantifying slice-byslice ct image quality and radiation dose data based on patient size. the information generated from this system should enable size-specific optimization of ct scan parameters in order to obtain images of diagnostic quality at the lowest possible radiation doses. methods & materials: a mathematical model was developed to predict ct image noise based on kvp, effective mas, and water-equivalent diameter of the patient. a conical water phantom was used to calibrate the model on multiple scanners and accounting for different operational modes and scan parameters, including tube voltage (kvp), tube current (effective mas), bowtie filter, and focal spot size. a software application was created to process image data from the scout topogram and incorporate dicom metadata from the axial images. a database and data viewing application were developed to display individual and aggregate study data. all of these systems were integrated and automated to enable real-time monitoring of image quality and radiation dose as a function of patient size. results: since the completion of the automated system, ct exams have been processed. a search application allows the user to find an individual study or a collection of studies based on parameters such as body part imaged or study protocol. the viewing application displays slice-by-slice patient diameter, radiation dose, and image quality for each study. radiation dose estimates are adjusted for patient size, yielding size-specific dose estimates. the application also graphs individual study data compared to those of comparative studies that are included in the search. conclusions: we have successfully developed an automated system that monitors ct image quality and radiation dose data based on patient size. the system enables simultaneous real-time monitoring of all studies performed on all ct scanners at our institution. specifically, the system enables size-specific radiation dose estimates at every scan level. this system will be used to guide protocol adjustments in order to optimize ct image quality and thus optimize radiation dose. disclosure: dr. larson has disclosed that he has a patent application in process through cchmc for ct radiation dose reduction. purpose or case report: at many institutions, ct scan parameters for children are determined by patient age or weight. aapm task group recommends cross sectional body dimension, such as patient width to determine size specific dose estimates. the purpose of our study was to develop prediction models of body width based on patient age and weight and compare these models with actual measured body widths for children undergoing body ct. methods & materials: children's hospitals participated in a -month retrospective review of abdominal ct scans on patients < years of age after local irb approval. recorded values included patient width(cm) from an axial image at the level of the splenic vein, patient age (yrs) and patient weight (lbs). a regression model for predicting patient width as a function of age and weight was determined. results: exams, had all measurements. both age and weight were significant predictors of patient width (p<. ). there was also a significant interaction between weight and age (p<. ), indicating that the relationship between patient width and weight depended on the age of the patient. the r for the regression model for predicting patient width from age and weight individually were . and . respectively. the r for the model including both age and weight and their interaction was . leaving % of the variation unexplained. the regression equation for this model is: patient width . + . x age(yrs)+ . x weight(lbs)- . x age x weight. despite the r of . for the model using both age and weight, the average error (rmse) for predicting patient width compared to a direct measurement of width was . cm. the plot of observed minus predicted values (residuals) versus predicted values indicates that the best model (combination of weight and age) results in measurable errors of predicted patient width relative to direct measurement. conclusions: a combination of both patient age and weight results in a more accurate patient width prediction than using age or weight alone. while age and weight can be used to predict body width, this is not sufficiently accurate for generating ct protocols. therefore, direct measurement of body width form either physical measurement on the patient or from the scout view or an axial image is preferred to select appropriate scan parameters for pediatric abdominal ct. paper #: pa- automated size-adjusted dose monitoring for pediatric ct dosimetry olav christianson, clinical imaging physics group, olav. christianson@duke.edu; ehsan samei, donald frush purpose or case report: the potential health risks associated with low levels of ionizing radiation have created a movement in the radiology community to minimize radiation dose during ct imaging; this is especially important for pediatric patients due to their increased sensitivity to radiation. it is thus essential to accurately assess the risks to pediatric patients undergoing ct imaging. current efforts to monitor radiation dose, however, are limited because they do not account for differences in risk from ionizing radiation due to variability in patient size, age, and gender. in this context, we developed an automated size-adjusted dose monitoring program capable of performing patient-specific risk estimation to facilitate protocol optimization. methods & materials: dicom routing software was used to send dose reports and scout images to an image repository on a dosimetry server. optical character recognition was used to extract dose-relevant data from dose reports; patient size was determined from corresponding scout images. based on anatomical location, risk estimation conversion coefficients (qfactors) were determined for each series in the dose reports. the q-factors were adjusted according to patient size, age, and gender and then multiplied by the dlp to estimate the risk to each patient. this process was applied to the cohort of pediatric patients undergoing ct examination at our institution. to evaluate the impact of including patient size, age, and gender, risk estimates were obtained excluding and including the dependencies on size, age, and gender. the results were computed in units of cancer incidence per cases exposed (cpt). results: the average patient-generic risk estimate for a pilot group of patients undergoing body ct was . ± . cpt. by including patient size, the risk estimate was increased to . cpt± . cpt. by including patient age and gender, the average risk estimate was further increased to . cpt± . cpt. conclusions: we developed a new size-adjusted dose monitoring program for pediatric ct dosimetry. comparisons between patient-generic and our new patient-specific risk estimates show that failure to consider patient size, age, and gender resulted in risk estimates that were too low by a factor of seven. additionally, the increase in standard deviation we observed demonstrates that our method of including patient size, age, and gender is sensitive to the inherent variability in the patient population. disclosure: dr. christianson has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: treatment of prenatally diagnosed lung masses is controversial, with many specialists recommending elective surgical removal in the first year of life because of a reported or perceived increased risk of infection and malignancy, while other centers recommend a conservative approach to management. the natural history of unresected lung masses is not clear. in our center, our standard recommendation is prophylactic resection of asymptomatic lesions, although not all families choose this option. we asked whether respiratory morbidity increased during the time prior to elective resection of prenatally diagnosed lung masses. methods & materials: ninety-eight pregnant women carrying fetuses with chest masses were imaged by ultrasound (us) and magnetic resonance imaging (mri). medical records of the liveborn infants were retrospectively reviewed. results: fetal diagnosis of a lung mass was made at a mean of weeks gestation (range - wks). intrauterine fetal demise was documented in pregnancies. there was one elective termination of pregnancy. three infants were lost to follow up. thus, outcomes were available for children ( % m, % f) with prenatally diagnosed lung masses. significant respiratory morbidity (rm) was defined as the occurrence of pneumonia, asthma, chronic coughing or wheezing, or respiratory symptoms severe enough to require an emergency room visit or hospitalization. of the children who had surgical removal of their lung mass, ( %) had rm prior to surgery. fifteen out of children did not have surgery but have been followed expectantly, and of ( %) developed some form of rm. fifteen of ( %) infants had immediate and significant rm (tachypnea, grunting, increased work of breathing, increased oxygen requirements or need for intubation) in the newborn period leading to urgent surgery (range of age at surgery: - d; mean . d). of the initially asymptomatic infants, ( %) developed rm prior to elective removal of the mass (range - weeks, mean weeks). of the lesions removed, histology revealed: cystic adenomatoid malformation (ccam) %, ccam + sequestration %, sequestration %, congenital lobar emphysema (cle) %, ccam+cle %, other %. conclusions: the risk of respiratory morbidity appears to be increased during the time prior to elective resection of prenatally diagnosed lung masses, which may be important for parents and pediatric specialists to consider when deciding whether to remove an initially asymptomatic lung mass. purpose or case report: it is now accepted that fetal mri with its superior tissue resolution can be very helpful in clarifying anomalies detected during obstetrical ultrasound. this is particularly the case with intracranial abnormalities, although indications are expanding. the current english medical literature, though, appears to be focused on evolving mri techniques and how mri compares to ultrasound with regards to image quality and detection of additional findings which may alter the diagnosis. however, we found no study specifically evaluating the clinical relevance and impact of the information obtained by fetal mri to the specialists who counsel and treat these patients. a "satisfaction and clinical impact" survey was created and sent to all the members of our fetal diagnosis and treatment group, asking specifically how the clinicians rated their satisfaction with this type of imaging, its influence on their counseling and on various clinical decisions, both prenatal and postnatal. results: we received responses from specialists in different clinical disciplines. the greatest number of respondents came from our obstetricians ( %), many of whom perform their own ultrasounds, and from members of our medical geneticists/genetic counselors ( %), although % of respondents were from various other clinical disciplines, both medical and surgical. there was a surprisingly high degree of satisfaction overall with the quality of the images and with the type and amount of information provided. most respondents indicated they felt fetal mri was "moderately" or "extremely" useful for their particular clinical decisions, and most respondents agreed that fetal mri impacted "moderately" or "significantly" on counseling and management of these pregnancies. impact appeared greatest on the counseling of the parents and their decision to terminate/pursue the pregnancy, and the least impact was on issues around delivery. conclusions: fetal mri, in addition to providing images of better quality, particularly in certain conditions, has clinical value in that it directly impacts on the counseling of parents and on clinical decisions. - . ultrasound reports were reviewed to determine sonographic diagnoses. selected patients from this cohort underwent mri using ge . tesla magnet without contrast (sequences included ssfse, fiesta, fgre or dual echo in planes). the images were reviewed and multiple characteristics were assessed for specifiying the area of obstruction. the features included: presence of normal fluid-filled bowel, small rectum for gestational age, signal of meconium in the rectum, and meconium filled dilated bowel. results: cases of sonographically suspected bowel obstruction were identified during the study period; of these underwent fetal mri. of these cases, had normal mri and postnatal outcomes, cases did not have postnatal findings available, and had postnatal meconium peritonitis but no obstruction. one case of congenital chloride diarrhea was diagnosed by fetal mri. a variety of bowel abnormalities were observed amongst the remaining cases. proximal obstruction was diagnosed in cases: jejunal atresia (n ) and multiple atresia (n ). distal obstruction was diagnosed in cases: ileal atresia (n ), meconium plugging (n ), closed gastroschisis (n ), enteral duplication cyst (n ), and imperforate anus (n ). characteristic patterns of features were identified amongst these cases that specified the location of obstruction. these patterns of findings allowed accurate localization of the level of obstruction in all cases when compared to postnatal findings. distal obstruction was characterized by normal fluid-filled small bowel and high t signal in distended loops. jejunal atresia was characterized by multiple loops of dilated bowel with high t signal primarily in the left upper quadrant. small rectum for gestational age was not consistently associated with proximal or distal atresia. conclusions: evaluation of fetal mri with attention to specific features allows localization of bowel obstruction. this may aid in counseling and postnatal management, including the need and type of postnatal imaging study. early diagnosis and treatment of ph may prevent clinical deterioration. pvt may produce a spectrum of imaging appearances, which has not been fully recorded in the literature. the goal of this paper is to review the spectrum of imaging appearances of neonates and survivors of neonatal pvt with special emphasis on the role of us and to correlate these findings with the clinical findings including outcome. methods & materials: a retrospective review of consecutive neonates admitted between - and diagnosed with pvt was conducted. diagnosis was established by us at a mean age of days (range: - ). health records, initial and follow-up (f/u) imaging were reviewed. findings were classified as non occlusive, single branch, pvt (grade ); occlusive pvt (grade ) and pvt with extensive parenchymal ischemia (grade ). results: pvt was diagnosed in patients, of whom were followed up to for years or longer. twelve patients were excluded due to liver disease, expired and were lost to f/u. of the in whom f/u was available, at the time of initial diagnosis, grade pvt was present in , all were on the left. grade pvt was diagnosed in and grade pvt in . on f/u physical exam, findings were unremarkable in / patients. liver function tests (lft) and thrombophilia assessment were available in children, mild lft abnormalities were noted in and children had evidence of thrombophilia. us exams were available in / children. among the survivors of neonatal pvt, us was regarded as normal in only children; showed left lobar atrophy (lla), had slowly progressive splenomegaly without other signs of ph, and developed clinically significant ph requiring shunting. conclusions: pvt has a wide spectrum of imaging appearances, it is possibly underdiagnosed and clinically unsuspected. varying degrees of lla are likely a sequela of clinically silent left pvt. us is a sensitive method for the detection of disease and assessment of progression. paper #: pa- fetal mri in arthrogryposis hedieh eslamy, md, radiology, lucile packard children's hospital, hkeslamy@gmail.com; erika rubesova, louanne hudgins, britton rink, richard a. barth purpose or case report: to present the fetal mri findings in fetuses with a prenatal diagnosis of arthrogryposis and correlate with postnatal outcome or autopsy results. arthrogryposis refers to contractures involving more than one joint which often represent deformational changes secondary to decreased or absent fetal movement. prognosis varies widely dependent on diagnosis, ranging from isolated contractures in amyoplasia to lethality in some cases. we hypothesized that fetal mri may demonstrate central nervous system (cns) pathology and muscle abnormalities which are important for predicting postnatal outcome. methods & materials: we identified fetuses with a diagnosis of arthrogryposis between january and october . all had fetal mri which was performed on a ge . tesla magnet, with ssfse, fiesta and fgre sequences in planes. the fetal mri's were evaluated for cns and muscle abnormalities. the extremities were evaluated for: muscle mass, increase in subcutaneous fat (indicative of muscle atrophy), and extremity joint positioning. these findings were subsequently correlated with the clinical exam of the neonates, pathology in the abortus and karyotype when available. results: results of fetal us, amniocentesis, fetal mri and post-natal or post-termination outcomes will be summarized. five fetuses had ≥ limb joint contractures. a sixth case had neck hyperextension and lateral flexion associated with akinesia and hydrops. on mri, no structural brain or spine abnormalities were identified. the abnormalities detected in the extremities were: severe decrease in muscle mass associated with increased subcutaneous fat ( cases); normal muscle mass ( cases); moderate decreased muscle mass associated with increased subcutaneous fat ( case). in the cases that delivered, the diagnoses were amyoplasia ( ) and distal arthrogryposis ( ). in a fourth case that underwent elective termination, autopsy was consistent with amyoplasia. two cases are pending delivery. conclusions: while fetal mri can be useful to rule out cns anomalies, it may also provide important information on decreased muscle mass as an important prognostic sign in a fetus with arthrogryposis. in our series, severely decreased muscle mass was predictive of amyoplasia, and joint contractures limited to hands and feet with preserved proximal muscle mass was predictive of distal arthrogryposis. both diagnoses are associated with relatively good prognosis and usually normal intelligence. purpose or case report: the purpose of this study is to assess the effects of iterative reconstruction technique (irt) on image quality metrics measured in child-sized anthropomorphic phantoms as kvp is changed. methods & materials: ct scans were performed on anthropomorphic phantoms with sizes of , & years (atom phantoms, cirs, norfolk virginia) using low dose pediatric chest protocols ( . , & msv) to determine baseline noise and dose levels. subsequently three voltage levels ( , & kvp) were used while adjusting mas to maintain baseline ctdivol and without mas adjustment which allowed varied ctdivol. images were reconstructed using % filtered back projection (fbp) and blends fbp: ir ( : , : , & : ) . parameters including ctdivol, dose length product, scan length, kvp, and mas, were recorded for each scan. image noise, contrast:noise (cnr), and signal:noise (snr) data were recorded from rois in phantoms and dilute iodine contrast filled syringes ( , , . %). results: as kv is lowered from to , image noise is doubled if mas is not increased to maintain ctdivol, and cnr is increased but snr is decreased due to the increased image noise. as kvp is lowered from to , image noise is increased nominally ( - %) if mas is increased to maintain ctdivol; therefore the increase in cnr and decrease in snr is negligible. ctdivol is reduced > % in all phantom scans as kv is reduced from to . irt reduces image noise by up to % [range - %] in all phantom sizes and in clinical images. as ctdivol is maintained in patient scans, image noise, cnr, and snr are reduced in patients (p< . ), resulting in improved image quality. conclusions: when lowering kvp, compensation with increases in mas is necessary to maintain ctdivol. however, lower target ctdivol can be achieved when adding irt as image noise can be decreased. for these phantoms, cnr and snr improved using all [selected] levels of ir, even when kv was reduced, resulting in lower ctdivol in phantoms. at all kvp settings when irt is applied, image noise is reduced, resulting in improved cnr and snr for all phantoms. disclosure: dr. bardo has indicated she is in the speaker's bureau and receives an honorarium from koninklijke philips. paper #: pa- adaptive iterative dose reduction in evaluation of the pediatric abdomen with ultra-helical -channel mdct jeffrey hellinger, md, stony brook university, jeffrey. hellinger@yahoo.com; bernice hoppel, richard mather, monica epelman purpose or case report: radiation reduction is paramount for pediatric patients. ultra-helical -channel mdct allows for rapid acquisitions at low dose. we evaluated the ability of a new adaptive iterative dose reduction algorithm (aidr) to reduce noise in low-dose ultra-helical pediatric abdominal ct scans. aidr is an iterative algorithm that adaptively reduces noise in the raw and image domains while preserving image structure. the raw data from consecutive low-dose pediatric abdomen exams was gathered. a dose simulation tool which adds noise to raw projection data was employed to simulate tube current at / of baseline ma. data were reconstructed with both standard filtered back projection and with aidr. regions of interest were drawn in the liver and lumbar musculature to determine the signalto-noise (snr), contrast-to-noise (cnr) and overall diagnostic quality of each data set. statistical significance was determined using a student's t-test. subjective image quality was evaluated by two reader blind review using a five point scale ( excellent, unacceptable). results: the snr and cnr were significantly lower for the % dose reduction datasets compared to the original filtered back projection reconstructions (snr: . vs . , p< . ; cnr: . vs . , p . ). when aidr was applied to the % dose reduction data, the snr and cnr improved to be superior to the native case (snr: . vs . , p< . ; cnr: . vs . , p . ). the average image quality score for the low dose datasets with aidr was . compared to . with standard filtered back projection at the baseline ma conclusions: aidr significantly improves the image quality of pediatric abdominal ct images. with a simulated % reduction in dose, aidr produces images with significantly greater snr and cnr. the subjective image quality scores for aidr showed dramatic improvement over standard filtered back projection. aidr processing algorithms with ultra-helical mdct will allow % reduction in radiation exposure while achieving the same diagnostic quality as compared to routine pediatric abdomen mdct radiation protocols with filtered back projection processing algorithms. purpose or case report: to explore incorporating asir into pediatric head ct protocols, to reduce patient radiation dose while maintaining image quality. methods & materials: an alderson rando head phantom was estimated to approximate the size of a -year-old child's head, and was scanned at decreasing % ma intervals ( to %, to ma) relative to this institution's age-based head ct protocols. each of these studies was then was reconstructed at % asir intervals ( % to %), and a mm roi was obtained in a consistent location behind the frontal bone to estimate noise (sd). using this phantom data, our ventriculoperitoneal (vp) shunt follow-up ct protocol was modified, and patients were scanned at % asir with approximately % ma reductions relative to our normal age-based mas. these asir studies were then anonymously compared to older non-asir head ct studies from the same patients (with identical kvp/slice thickness) by two blinded attending pediatric neuroradiologists. all studies were evaluated subjectively for diagnostic utility ( - ), sharpness ( - ), noise ( - ), and artifacts ( - ). - mm rois were drawn in consistent locations to estimate noise in air, bone, csf, and white matter (wm). results: the phantom study suggested similar same noise levels at % ma/ % asir ( . ) and % ma/ % asir ( . ). patients (average , range to years) were then scanned at approximately % ma reductions, with an average of days (range to days) between the asir study and prior non-asir study. the average ctdivol and dlp values of the % asir studies were . mgy and . mgy-cm, and for the non-asir studies were . mgy and . mgy-cm, representing statistically significant decreases in the ctdivol ( . %, p . ) and dlp ( . %, p . ) values. there were no significant differences between the asir studies and non-asir studies in respect to diagnostic acceptability (p . ), sharpness (p . ), or noise (p . ). there was a non-significant trend that the asir studies had a lower artifact score ( . vs . , p . ). there was good to perfect (kappa . to . ) agreement. the asir studies had statistically significant decreased csf noise ( . vs . , p . ), but no noise differences were seen in air (p . ), bone (p . ), or wm (p . ). conclusions: our findings suggest that asir can provide dose reductions in pediatric head ct without affecting image quality. purpose or case report: to validate the t map as a noninvasive quantitative biomarker of fatty infiltration of muscles and to determine whether the t map can differentiate between boys with dmd and healthy boys. methods & materials: two groups of boys with similar ages (range - years) were evaluated: boys with dmd (mean age . years) and healthy boys (mean age . years). mr images were performed at t. fatty infiltration of the pelvic and thigh muscles on t -weighted images (wi) was graded from to . on t maps with and without fat suppression, the muscle with the greatest fatty infiltration on t -wi was selected, and a region of interest was placed to obtain t values. t values from t maps with fat suppression were subtracted from values of t maps without fat suppression and designated as the "t fat value." t fat values were obtained from the same muscles in all boys. comparison was made between the t fat values of the two groups. the upper reference limit of the reference interval (ri) of t fat values was obtained from the control group to establish the normal range and applied to both groups to determine the accuracy of the t map. results: the gluteus maximus muscle had the greatest fatty infiltration on t -wi. median t fat value was . msec for dmd ( % ri . , range . - . ) and . msec for the control group ( % ri . , range . - . ). when applied to the two groups, the upper reference limit of the ri for control patients yielded % sensitivity, % specificity, % positive predictive value, and % negative predictive value. conclusions: utilization of t maps for the quantitative measurement of fatty infiltration of muscles can clearly differentiate between dmd and normal control boys with a high degree of accuracy and precision. this advanced noninvasive technique may potentially replace invasive muscle biopsies currently used for diagnosis. purpose or case report: prior work has shown that the gluteus maximus muscle has the greatest t relaxation time on mr imaging using t mapping in boys with duchenne muscular dystrophy (dmd). however, an increased t value on t relaxation time mapping may reflect both fatty infiltration and inflammation of the muscle. fatty infiltration characteristically follows inflammation in this disease process. therefore, the purpose of this study was to determine the contribution of each component (fat and inflammation) within gluteus maximus muscles and to correlate each component to clinical assessments. methods & materials: forty-six boys with dmd (ages: - years) were recruited. mr imaging of the pelvis using t maps with and without fat suppression were performed. the t map "fat values" (t value calculated from the t map without fat suppression [fs] minus t map with fs) and the t map "inflammation value" (t value from the t map with fs) were obtained. clinical assessments typically used to evaluate dmd patients (including clinical functional score, ft run, gower score, and step-up time) were also performed. spearman correlation coefficients between fat and inflammation values and the clinical assessments were calculated. results: there was a statistically significant correlation between the fat value of the gluteus maximus muscle and each clinical assessment test (p< . ). however, the inflammation value of the gluteus maximus muscle did not correlate with any clinical assessment. conclusions: in dmd, the amount of fatty infiltration of the gluteus maximus muscle has excellent correlation with clinical assessment. the amount of inflammation of the gluteus maximus muscle, however, does not correlate with clinical function. therefore, further study is needed to determine whether components (fatty infiltration or muscle inflammation) of the single most involved muscle reflect the components of all the muscles of the pelvis and thighs and whether the cumulative muscle involvement of each component represents clinical disease severity. utility of contrast-enhanced mr imaging in children with osteonecrosis: does gadolinium help? lamya atweh, md, radiology, texas children's hospital, laatweh@texaschildrens.org; robert c. orth, wei zhang, r. paul guillerman, herman kan purpose or case report: at our institution, gadolinium contrast-enhanced mr sequences are often obtained to assess epiphyseal and non-epiphyseal osteonecrosis in children. several studies have shown that dynamic contrast-enhanced sequences may provide prognostic information about long-term complications and healing of osteonecrosis. to our knowledge, no studies have determined the added value of routine post-contrast mr imaging in assessing acute complications related to chronic osteonecrosis. the purpose of this study was to evaluate the utility of intravenous gadolinium contrast in the mri identification of complications in children with an established diagnosis of osteonecrosis. methods & materials: patients were restrospectively identified (age range: . years to . year; m:f : ) with an imaging diagnosis of chronic osteonecrosis who underwent contrast-enhanced mr studies between / and / . the pre-and post-contrast mr images were consensus reviewed by two caq pediatric radiologists. pre-and post-contrast images were reviewed at separate times. the pre-contrast images were available during the review of post contrast images. studies were assessed for: osteonecrosis location (epiphyseal, non-epiphyseal osteonecrosis, or both), joint effusion, marrow edema, and epiphyseal collapse. % confidence interval (ci) and cohen's kappa coefficient(κ) was calculated to assess observed agreement. results: the diagnosis of osteonecrosis without complicating features was made in . % (ci: . - . %) ( / ) of pre-contrast studies and . % (ci: . %- . %) ( / ) of post-contrast studies. when chronic osteonecrosis with complicating features was identified,pre-and postcontrast images idenfied joint effusion in . % ( / ) and . % ( / ) (κ . , p< . ); marrow edema in . % ( / ) and . % ( / ) (κ . , p< . ); and epiphyseal collapse in . % ( / ) and . % ( / ) (κ . , p< . ), respectively. myositis or muscle strain was incidentally diagnosed in . % ( / ) pre-contrast and . % ( / ) post-contrast (κ . , p < . ) studies. conclusions: the high observed agreement between the pre-and post-contrast mr images shows that the addition of intravenous gadolinium may not be necessary in the majority of children with chronic osteonecrosis. paper #: pa- systematic protocol for assessment of the validity of bold mri in a rabbit model of inflammatory arthritis at . tesla michael chan, bhsc, university of toronto, mw.chan@ utoronto.ca; afsaneh amirabadi, anguo zhong, antonella kis, rahim moineddin, andrea s. doria purpose or case report: blood oxygen level-dependent (bold) mri has the potential to identify regions of early hypoxic and vascular joint changes in inflammatory arthritis. at this point, there is no standard protocol for data analysis of bold mri measurements in musculoskeletal disorders. standardization of the technique is paramount to compare results between studies and assess the validity of this technique in tissues outside the blood-brain barrier. our objective is to optimize bold mri reading parameters in a rabbit model of inflammatory arthritis by determining the diagnostic accuracy of ( ) statistical threshold values (r> . vs r> . ), ( ) summary measures of bold mri contrast [ the mean of the % bold signal differences within the region of interest (roi) (diff_on_off) and the percentage of suprathreshold voxels within the roi (pt%)], and ( ) voxel activation algorithm (positive, negative, and positive_negative). methods & materials: using bold mri protocols with a carbogen stimulus on a . t magnet, we imaged injected and contralateral knee joints of juvenile rabbits at baseline, and days , and after a unilateral intra-articular injection of carrageenin. nine non-injected rabbits served as controls. receiver operating characteristic (roc) curves were plotted to determine the diagnostic accuracy of the reading parameters. the bold measures from [(injected knee-control knees)/control knees] were counted as positive cases, while the bold measures from [(contralateral knees-control knees)/control knees] were regarded as negative cases. areas under the curve (aucs) were calculated to determine the most accurate parameters. results: using diff_on_off and positive_negative activations as constants, r> . was found to be more accurate than r> . (p . at day ). comparison of diff_on_off and pt% yielded no statistically significant difference (p> . ). finally, positive_negative activations for diff_on_off and negative activations for pt% using r> . were the most diagnostically accurate (auc . , p< . at day , and auc . , p< . ). conclusions: from the results of this study, the most diagnostically accurate and clinically relevant reading parameters included the use of a more lenient threshold of r> . , a diff_on_off measure of bold contrast, and a positive_negative voxel activation algorithm. pt% may used as an ancillary measure of bold contrast. quantitative versus semi-quantitative mr imaging of cartilage in blood-induced arthritic ankles andrea doria, md, phd, diagnostic imaging, the hospital for sick children, andrea.doria@sickkids.ca; ningning zhang, carina man, pamela hilliard, ann marie stain, victor blanchette purpose or case report: to cross-sectionally compare the ability of a scoring system (semi-quantitative method) with a manual segmentation technique (quantitative method) to evaluate the status of the articular cartilage of growing ankles of children with blood-induced arthritis. methods & materials: boys, with hemophilia (a, n ; b, n ) and with von willebrand disease, median age (range, - ) underwent a high resolution mri protocol at . tesla, x-rays, and physical examination using the hemophilia joint health score (hjhs) system. two blinded radiologists scored the mri examinations for cartilage items (horizontal component: surface erosions, scores - and vertical component: cartilage degradation, scores - ) according to the semiquantitative method (international prophylaxis study group mri scale). an experienced operator applied a validated quantitative d-mri method (horizontal components: ac, vc, vctab, thctab; vertical component: thccab) to corresponding high resolution mr images of ankles. results: internal correlation of the semi-quantitative method components was substantial (r . , p< . , tibia) to high (r . , p< . , talus) in any site of investigation, but it was site-specific with the quantitative method, being significant only in the talar trochlea (r . , p< . ). external correlation of corresponding components of the semiquantitative and quantitative methods was moderate (r . , p . ) to poor (r . , p . ) for horizontal components, and non-existent for vertical components. components of the semi-quantitative method highly correlated with lifetime number of previous ankle bleeds (r . - . , p< . ), pettersson x-ray (r . - . , p< . ), and hjhs scores (r . , p< . ). this correlation was poor (r . , p . ) to moderate (r − . , p . ) for horizontal components of the quantitative method. conclusions: the biologic concepts of the semi-quantitative and quantitative mri methods are distinct for assessment of ankles. the semi-quantitative method is valid for assessing cartilage changes in cross-sectional studies of blood-induced arthropathy, however the quantitative method is suboptimal or less powerful for this purpose. paper #: pa- shoulder mr arthrography in skeletally immature patients nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email. chop.edu; camilo jaimes, victor ho-fung, diego jaramillo purpose or case report: there has been a well documented increase in sports participation in children which has lead to an increase in sports-related injuries. to date, there are no studies describing the value of shoulder mr arthrography compared with the gold standard, arthroscopy. we retrospectively reviewed mr shoulder arthrograms obtained in pediatric patients between and who underwent subsequent shoulder arthroscopy. interpretation of the images was performed by three pediatric radiologists who were blinded to the arthroscopy findings. images were evaluated in consensus and independently. assessment included evaluation of the osseous structures, labral-ligamentous complex, joint space and the rotator cuff interval. the mr results were compared with reported surgical findings. sensitivity and specificity were calculated. results: nine patients were excluded due to technical reasons. of the remaining patients, were boys ( . - . years, mean . years) and were girls ( . - . years, mean . years). at arthroscopy, patients ( %) had injury to the anterior inferior glenoid labrum. mr sensitivity was % for depiction of bankart-type injuries with a specificity of %. patients ( %) had hill sach lesions and mr had sensitivity of % with specificity of %. superior labrum anterior posterior (slap) tears ( %) were identified at arthroscopy with mr sensitivity of % and specificity of %. overall, mr arthrography had a positive predictive value of % for identification of a surgical lesion. agreement between the observers was high. interobserver reliability was calculated with an intraclass correlation coefficient (icc)of . with a cronbach's alpha of . . conclusions: mr shoulder arthrography can accurately depict labral and osseous injury and provides pertinent preoperative information. a novel multi-channel mr coil for improved pediatric elbow coil imaging suraj serai, phd, cchmc, suraj.serai@cchmc.org; randy giaquinto, kathleen emery, charles dumoulin purpose or case report: single flex coils or adult size coils are currently used for imaging the pediatric elbow. this frequently results in uncomfortable patient positioning, motion, poor fat suppression, low snr and there is currently lack of a dedicated pediatric elbow coil in the commercial market. our goal was to explore the usefulness of a new coil array dedicated for pediatric elbow imaging and to compare quantitative & qualitative imaging findings to commercially available coils. methods & materials: an eight channel elbow coil was designed. the coil frame was designed to be rigid and lightweight. seven identical loop coils were built into a polycarbonate frame and an eighth coil built into a paddle that fits into the top frame. the coil elements were constructed with heavy copper to provide a high q-factor and increased snr. the complete coil including electronics & covering, weighs only . kg. mr imaging under irb approval was performed on a ge . t scanner using a routine clinical elbow protocol including t w, pdw, t w, fat-sat, non-fat-sat, d & d sequences. subjects were positioned feet-first with the elbow on the side & were subjectively assessed for comfort level. images obtained from the new coil & from the current commercial coils were compared for snr. results: scan positioning was reported to be comfortable. snr was between - % higher as compared to the routine coils. fat saturation was uniform, indicating that the magnetic susceptibility of the coil is well-matched to human anatomy. anatomical detail depiction was subjectively better for anatomic features such as trochlea. detection & diagnostic confidence of elbow disorders were improved with the new coil & greatly decreased motion artifacts were observed. conclusions: the new pediatric elbow coil provided excellent image quality, patient acceptance and clinical performance improvements over existing coils. the open coil design also allows for imaging of the elbow in a partially flexed position or in a cast. the advantages provided by the new coil are expected to include shortened image acquisition times (via parallel imaging) & increased snr. disclosure: dr. serai has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. incremental value of knee radiography in the interpretation of pediatric knee mri yen-ying wu, texas children's hospital, yxwu@ texaschildrens.org; robert c. orth, wei zhang, r. p. guillerman, herman kan purpose or case report: the acr appropriateness criteria recommendation for the imaging work-up of knee pain is radiography followed by mri. in many cases, mri is performed prior to review of radiographs or the referring subspecialist does not feel radiographs add value, particularly when ligamentous injury is suspected. the purpose of this study is to determine if radiography adds incremental value in the interpretation of knee mr studies electively referred by pediatric sports medicine and orthopedic subspecialists. knee mri studies referred from pediatric sports medicine physicians or pediatric orthopedic surgeons between / and / (n , ages - years, m:f : ) with accompanying radiographs were identified. patients were separated into groups based on mri findings: normal, ligamentous injury, or osteochondral injury (osteochondral lesions, bone contusions/fracture, and avulsion injury). knee radiographs were consensus reviewed by two caq pediatric radiologists blinded to mri findings and categorized into the same groups. radiograph and mri findings were compared and categorized into groups: neutral if radiograph and mri findings were the same, misleading if findings were discordant, or helpful if radiographs improved mr interpretation. the latter group was analyzed for impact on mr diagnosis. results: for knee radiographs, were normal, showed ligamentous injuries, and showed osteochondral injuries. when radiographs were interpreted as normal (n ), by mr % were normal, % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. when radiographs were interpreted as ligamentous injury (n ), by mr % were normal and % had ligamentous injury. when radiographs were interpreted as osteochondral injuries, by mr % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. subset analysis of true positive radiographs (n ) found % to be helpful and % to be neutral in mr diagnosis. for radiographs considered helpful, % resulted in a change in mr diagnosis. in regards to the influence of radiographs on mr interpretation, % ( / ) were misleading, % ( / ) were neutral, and % ( / ) were helpful. conclusions: a minority of pediatric knee radiographs aided mr diagnosis, and none resulted in a change in diagnosis. pediatric knee mri and interpretation should not be predicated on radiologist review of knee radiographs in this subset of patients. paper #: pa- sonographic evaluation of pediatric skeletal lesions: is it worthwhile? henrietta rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; amish patel, neil lester purpose or case report: the purpose of this paper is to demonstrate how ultrasound(us) may serve as a readily available, cost-effective, non-invasive, non-ionizing, practical tool for the evaluation of a variety of skeletal abnormalities in the pediatric age range. we reviewed the clinical and imaging findings in patients seen during the past years in whom us demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or ddh. results: us proved useful in the following situations: evaluation hard superficial immobile mass (osteoma shin) ( ), absent medial end clavicle on x-ray in region of neck mass (us showed abc medial end clavicle)( ), to determine if soft tissue mass involves adjacent bone nodular fasciitis surrounding clavicular head ( ), for diagnosis and followup fracture (displaced/non-displaced) in infants ( ), diagnosis osteomyelitis in patients with cellulitis ( ), question of fracture underlying cephalohematoma or subgaleal hematoma ( ), rib mass (osteochondroma) ( ) or mass costochondral junctions (contour deformities costochondral cartilage) ( ), firm posterior knee mass (baker's cyst) ( ), firm anterior knee mass (septated cystic mass suprapatella region due to rheumatoid disease) ( ), immobile hard scalp mass due to epidermoid cranial vault ( ), painful mass occipital bone with soft tissue components extending through the skull externally and internally due to langerhan's histiocytosis ( ), indeterminate mass clavicle clinically thought to be post-traumatic sequellae, resolved on follow-up ( ), assessment craniosynostosis ( ), for differentiation of pathological entity from normal anatomic structure (lump on back of slender baby proved to be normal posterior spinous process) ( ). conclusions: us is worthwhile for evaluation of wide range of pediatric skeletal abnormalities and helps to determine if the a lesion is one that is "touch" or "don't touch". to maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, laboratory and other imaging findings. in equivocal cases or in those patients in whom the field of view (fov) is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, us serves to triage those patients in whom further imaging is necessary. high incidence of vertebral fractures in children with acute lymphoblastic leukemia months after the initiation of therapy mary ann matzinger, md frcp(c), university of ottawa, matzinger@cheo.on.ca; nazih shenouda , brian lentle, josée dubois, helen r. nadel purpose or case report: vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (all). to date, the incidence of vertebral fractures during all treatment has not been reported methods & materials: we prospectively evaluated children with all during the first months of leukemia therapy. lateral thoracolumbar spine radiographs were obtained at diagnosis and months. vertebral bodies were assessed for incident vertebral fractures using the genant semi-quantitative method, and relevant clinical indices such as spine bone mineral density (bmd), back pain and the presence of vertebral fractures at diagnosis were analyzed for association with incident vertebral fractures. results: of the children, ( %, % confidence interval [ci] % to %) had a total of incident vertebral fractures, of which ( %) were moderate or severe. thirteen of the children with incident vertebral fractures ( %) also had fractures at the time of diagnosis. vertebral fractures at diagnosis increased the odds of an incident fracture at months by an odds ratio of . ( % ci . to . , p . ). in addition, for every . standard deviation reduction in spine bmd z-score at diagnosis, there was . -fold increased odds for incident vertebral fracture at months ( % ci . to . %, p . ). conclusions: children with all have a high incidence of vertebral fractures months after diagnosis, and the presence of vertebral fractures and reductions in spine bmd zscores at diagnosis are highly associated clinical features. purpose or case report: to provide objective measures of acetabular morphology utilizing volume-rendered ct and to better characterize normal acetabular development in adolescents. implications for the diagnosis of femoroacetabular impingement (fai) will be discussed. methods & materials: hips in consecutive patients ( female, male; ages - years) who underwent abdominal and pelvic ct for non-hip related complaints were retrospectively examined. examinations were performed for a variety of complaints, including abdominal pain, nephrolithiasis, vomiting etc. patients with obvious hip pathology were excluded. pelvic rotation was eliminated, and pelvic inclination was measured and corrected to °u tilizing a volume rendered ct model. measurements of femoral head diameter (fhd), anterior femoral head coverage (fhca), and posterior femoral head coverage (fhcp) were obtained. femoral head area (fha) was defined as π(fhd/ ) . percent anterior femoral head coverage (%fhca) was defined as (fhca/fha)* . percent posterior femoral head coverage (%fhcp) was defined as (fhcp/fha)* . acetabular version by volume-rendered ct (avvr) was defined as (fhcp/fhca). results: average pelvic inclination angle (sd) was . ( . ) for females and . ( . ) for males. average (sd) %fhca was . ( . ) for males and . ( . ) for females. average (sd) avvr was . ( . ) for males and . ( . ) for females. among males, average avvr decreased with subject age. on the other hand, there was little change in average avvr with age among females. conclusions: average avvr is greater for females than males, and this difference becomes more striking with increasing subject age. this represents an unexpected finding given the reported increased incidence of "pincer" type fai among females. characterization of acetabular morphology among adolescents with clinical fai should consider subject age and gender. in this regard, volumerendered ct is capable of providing an objective measure of acetabular morphology. mistakes in musculoskeletal plain film interpretation james crowe, pediatric radiology, texas children's hospital, jecrowe@texaschildrens.org; george s. bisset purpose or case report: to evaluate the mistakes made by trained pediatric radiologists when interpreting radiographs of the extremities obtained for the evaluation of outpatient acute pain (mostly post-traumatic). we retrospectively evaluated all radiographs and associated interpretations obtained during a month period from april , , to october , , of the elbows, wrists, knees and ankles in pediatric outpatients who presented with acute pain in the affected area. all radiographs were previously interpreted by a caq-certified pediatric radiologist varying in experience from year to years. abnormals were identified, including elbows, wrists, knees and ankles. all radiographs were determined to be "as dictated", missed significant finding, or overcall. attention was focused on the missed findings and overcalls. results: findings were as follows: elbow radiographs- missed findings and overcalls, wrist radiographs- missed findings and overcalls, knee radiographs- missed findings and overcalls, ankle radiographs- missed findings and overcalls. this resulted in a total of missed findings ( . % of abnormals) and overcalls ( . % of abnormals). of the misses, % were fractures. the highest mistake percentage occured in the ankles where the combined misses and overcalls approached %. this was also the location where we found the highest percentage of missed fractures ( . %) conclusions: when just abnormal cases were considered, fully trained pediatric radiologists have a mistake rate of approximately . %, if misses and overcalls are included. from a quality improvement perspective, we will review all of the types of misses and overcalls to expose common themes. longitudinal assessment of osteoporosis in a blood-induced hemophilia rabbit model using quantitative ultrasound kuan-chieh wang, university of toronto, kc.wang@ utoronto.ca; afsaneh amirabadi, anguo zhong, christopher tomlinson, andrea s. doria purpose or case report: the reduction of physical activities in hemophilic patients may lead to bone demineralization and consequent osteoporosis. quantitative ultrasound (qus) is free of ionizing-radiation, relatively inexpensive, and easy to use that making this technique suitable for follow-up of hemophilic children with clinical suspicion of osteoporosis. to our knowledge, no previous study has investigated the value of qus for longitudinal assessment of growing bones in an animal model which is paramount for clinical translation of the technique once change in measurements could relate to either the baseline pathology or physiologic bone growth variability. the objective of this study is to investigate the intra-and inter-operator reliability of qus over time, and its ability to discriminate bone loss in pathologic vs control knees of a rabbit model of blood induced arthritis. methods & materials: sixteen juvenile white new zealand rabbits distributed into two groups: received intraarticular blood injections over weeks (n pathologic and contralateral knees), and noninjected rabbits were used as controls (n knees). midshaft tibia speed-of-sound (sos) was measured at baseline, and weeks and of the experiment. two operators scanned each site twice at each time point. qus measurements were compared to microct (reference standard) on week to validate the study results. results: the sos measured in the control group increased significantly (p< . ) over the week period. there was not such an increase in the arthritis sos value (p> . ). in both groups the overall intra-operator coefficient of variation of sos measurements was % at baseline and decreased to % at week likely due to increased tibia size. the inter-operator reliability was % at baseline and % at week . with regard to the effect of bone growth on qus measurements for the control group (n ), sos values increased by . m/s, whereas for the pathologic group (n ), they only increased by m/s. statistically significant differences in ratios of sos between final/baseline results were noted (p . ) between the pathologic and control groups. conclusions: the longitudinal use of qus has an acceptable intra-and inter-operator reliability. even accounting for the significant impact that bone growth has on qus measurements over time, qus can differentiate pathologic from control knees in the proposed animal model and holds potential for clinical use in the assessment of osteoporosis in hemophilic children. methods & materials: the study was approved by the institutional review board. pediatric patients with abdominal tumors ( malignant and benign lesions) underwent diffusion-weighted mr imaging (dwi) on clinical . t (n ) and t (n ) mri scanners. adc maps were generated from b dwi and adc values were retrospectively and independently measured by two radiologists. adc values of benign and malignant tumors were compared with the welch two sample t-test. a p value of . was considered to indicate statistical significant differences. in addition, a receiver operating curve analysis (roc) was performed to determine the optimal cut-off adc value for differentiating benign and malignant tumors. results: the mean adc value (mm /sec) of benign tumors was . x - for the first reader and . x - for the second reader. the mean adc value (mm /sec) of malignant abdominal tumors was . x - for the first reader and . x - for the second reader. the differences between benign and malignant tumors were statistically significant (p< . for both readers). roc analysis revealed an optimal cut-off adc value for differentiating malignant and solid tumors as . x - mm /sec. conclusions: diffusion-weighted imaging with adc maps can be used to differentiate between benign and malignant pediatric abdominal tumors. creation of a database to evaluate imaging findings in long-term survivors of pediatric malignancy alexander towbin, md, radiology, cincinnati children's hospital medical center, alexander.towbin@cchmc.org; seth hall purpose or case report: over the past years, there have been significant improvements in the treatment of pediatric malignancies. improved therapy has led to an increase in the number of long-term survivors. many of these survivors are now experiencing late effects as a result of the original disease process or its treatment. these late effects are frequently identified on imaging. the purpose of this study is to create a database of the imaging findings of long-term survivors of pediatric malignancy in an attempt to begin to classify the findings and identify associations. methods & materials: after irb approval, the institutional cancer registry was searched to identify all patients younger than years of age who were diagnosed with a solid tumor between and . patients were included in the database if they survived for more than years from the date of their initial diagnosis. the electronic medical record system was then used to obtain demographic and treatment information for each included patient. the dictated reports from all cross-sectional imaging studies evaluating the chest, abdomen, or pelvis performed more than two years from the date of diagnosis were then reviewed. each positive imaging finding was classified by the involved organ. results: after querying the institutional cancer registry, patients were identified who met the inclusion criteria for this database. the most common neoplasms were neuroblastoma, wilms tumor, and astrocytoma. of the included subjects, had imaging of the chest, abdomen, or pelvis. overall, reports were evaluated and classified. findings were most commonly identified in the lungs, musculoskeletal system, kidneys, liver, and lymph nodes. conclusions: a database examining the late effects in longterm survivors of pediatric malignancies was created. this database has the potential to help identify the radiologic manifestations of the complications of cancer therapy and thus help guide rationally determined long-term risk-benefit ratios in the treatment of pediatric malignancies. imaging followup of lymphoma in pediatric patients: is pelvic ct necessary? javier lopez bueno, md, children's hospital of eastern ontario, jlopezbueno@cheo.on.ca; nishard abdeen purpose or case report: pelvic ct is often included in the imaging followup of patient with lymphoma before, during and after treatment to assess response to treatment and monitoring for relapses. while such followup is expected to improve detection of relapse, there is little objective evidence of its effectiveness in lymphoma. anecdotally, there are few pelvic relapses in pediatric patients with lymphoma regardless of primary site. we hypothesize that pelvic ct could be avoided as part of the followup without adverse impact on survival or in the detection rate of relapses, and with subsequent significant reduction in the radiation dose, particularly to the gonads. methods & materials: research ethics board approval was obtained. patients diagnosed with lymphoma and with at least one year of followup at our tertiary care pediatric hospital were included. sex, age, type of lymphoma, stage, primary site, site of relapse if any as well as the number of ct scans of the head, neck, chest, abdomen and pelvis were recorded. results: a total of patients met study criteria. there were males and females, with an average age of . years (range - years). eighteen patients had hodgkin disease ( %) and eleven had non-hodgkin lymphoma ( %). mean length of followup was . years (range - years). an average of . pelvic scans per patient were performed for surveillance (range - ). three relapses were detected. of these only one was in the pelvis, in a patient whose initial t cell non-hodgkin lymphoma was extensive and involved the neck, chest, abdomen and pelvis. conclusions: this study suggests a low incidence of pelvic relapse in pediatric patients with lymphoma. the routine use of pelvic ct in surveillance protocols may therefore be of little benefit while imposing a significant radiation burden. our study is limited by small sample size and short length of followup. further large scale studies are required. (esft) is performed by measuring the size of the tumors before and after chemotherapy. the proposed method of measuring tumor size, however, differs amongst recist . (response evaluation criteria in solid tumors), who (world health organization) and cog (children's oncology group) response criteria. in our project, we assessed whether response classification differs between the three different methods. methods & materials: after irb approval, we retrospectively analyzed mri studies of patients with ewing sarcoma who were treated at stanford and ucsf medical centers. tumor size was assessed before and after therapy. tumor measurements were obtained using recist . (longest single diameter), who (longest diameter and perpendicular diameter), and cog criteria (three measurements to calculate tumor volume). tumor response was assessed by the differences in sizes of the tumors before and after treatment using four response categories: progressive disease (pd), stable disease (sd), partial response (pr), and complete response (cr). concordance between the three response classification systems was assessed using cohen's kappa (k) coefficient and percentage of disagreement per response category. results: the k statistic for concordance in cog/who, cog/ recist and recist/who were . , . and . respectively. disagreement rates for recist/who, cog/ who, and cog/recist were . , . , and . % respectively. using tumor volume, twenty-six patients were reclassified: twenty-four cases of stable disease coded by recist were reclassified as progressive disease by cog and two cases of partial response coded by recist were reclassified as complete response by cog. conclusions: this study demonstrates poor agreement between the recist . and cog response criteria in esft. given the degree of discordance between response criteria in esft, evaluation of the prognostic impact of each of these classification systems may guide selection of the optimal system for future use in this disease. imaging recognition of chylous ascites following surgery for abdominal neuroblastoma zeyad metwalli, md, baylor college of medicine, metwalli@bcm.edu; r. p. guillerman, heidi v. russell, eugene s. kim purpose or case report: surgical resection is a standard part of multimodality treatment of neuroblastoma, the most common abdominal malignancy of infancy and early childhood. chylous ascites is a rarely reported complication of surgery for abdominal neuroblastoma, and is likely underrecognized, posing the risk of nutritional deterioration and sepsis. to facilitate early diagnosis and institution of appropriate therapy, we present the salient imaging findings of the largest known series of chylous ascites following surgery for abdominal neuroblastoma. methods & materials: all patients with abdominal neuroblastoma complicated by post-operative chylous ascites over a five-year period at a large children's hospital were identified by a database search. a retrospective review of the imaging studies and clinical charts was conducted. results: chylous ascites developed following surgical resection of abdominal neuroblastoma in of patients, with the diagnosis made between postoperative days and . four cases were high-risk neuroblastoma and one was intermediaterisk neuroblastoma. all cases involved resection of an adrenal mass and dissection around the abdominal great vessels. all cases manifested with abdominal distention on physical exam, and ascites was suspected clinically in cases. computed tomography (ct) in all cases revealed a large volume of ascites of near-water attenuation (range of − to . hounsfield units). the cases imaged with ultrasound (us) showed hypoechoic or anechoic ascites without septations. the chylous ascites resolved after - months of treatment with dietary fat restriction, medium chain triglycerides, intravenous octreotide, or peritoneal catheter drainage. conclusions: chylous ascites is an under-recognized complication of surgical resection for abdominal neuroblastoma, occurring in % of patients in this series. the diagnosis is supported by the demonstration on ct or us of a large volume of ascites causing abdominal distention - weeks post-operatively. the ascites is typically near-water in attenuation rather than fatty in attenuation and should not be misattributed to peritonitis, hemorrhage, bowel leak, or early tumor recurrence. cervical spine injuries in patients with suspected physical abuse nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; zarir p. khademian, tanya hinds, katherine deye, allison m. jackson, eglal shalaby-rana purpose or case report: to evaluate the incidence and nature of cervical spine injuries and relationship to posterior fossa abnormalities in children who underwent brain and cervical spine mri as part of the clinical workup for suspected physical abuse. methods & materials: authors retrospectively analyzed records of eighty-five children less than three years of age who were documented by the child protective services at a level one pediatric trauma center over a period of four years ( ) ( ) ( ) ( ) ( ) . only patients who underwent both mri imaging of the cervical spines (c-spine) in addition to brain imaging as part of the clinical workup were included. cspine and posterior fossa of brain mris were independently reviewed by two pediatric neuroradiologists, both blinded to clinical details. c-spine abnormalities (bone marrow edema, cord edema, intrathecal blood, disc pathology, soft tissue/ ligamentous injury, vascular injury) were documented and correlated with abnormalities seen in the posterior fossa (blood, brainstem edema, cerebellar edema). results: at this time, / patients have been reviewed. twenty patients ( %) had both cervical spine injuries and posterior fossa abnormalities. there were no patients with isolated cervical spine injuries without posterior fossa abnormalities, but there were five patients ( . %) that had posterior fossa abnormalities in the absence of c-spine injuries. fifteen patients ( . %) did not have any spinal or posterior fossa imaging abnormality. none of the patients had bone marrow edema, disc pathology, or intrathecal blood. one patient had vascular neck injury and cord edema. conclusions: our results show that the incidence of cervical spine injury in children under investigation for abusive head trauma is as high as %. our data show further that cervical spine injury predicted posterior fossa injury in all patients, while presence of posterior fossa injury predicted concomitant c-spine injury in only %. the incidence of c-spine trauma we found in these patients is higher than reported elsewhere in the literature and may impact whether or not routine c-spine mri will be included in national imaging guidelines for children under investigation of abusive head trauma. pediatric skull fracture andre loyd, phd, biomedical engineering, duke university, aml @duke.edu purpose or case report: skull fractures are often seen in the setting of non accidental trauma (abuse) abuse, and are usually attributed to falls from heights above m. part of the difficulty in assessing height is due to uncertainties in actual distance. objective: to determine what types of skull fractures can occur in pediatric and adult post-mortem human specimens during controlled impacts on hard surfaces from various heights. methods & materials: skull fracture patterns in postmortem human specimens from a unique bank of pediatric specimens ( -week gestation to -years-old, n ) were subjected to controlled drops from both arbitrarily low heights ( and cm) and high heights ( m) onto an aluminum platen. the specimens were dissected from the neck at the occipital condyles and intracranial were sealed inside the head using pmma. the heads were dropped on to five different impact locations. fractures were identified using palpation and high resolution mdct. results: no specimens between -weeks-gestation and days-old sustained fractures from the - cm drops. three out of four ( %) specimens ages between -and -months old fractured due to the or cm drops. the -and -year-old specimens and all adult specimens survived the - cm drops. all specimens subjected to the m drop fractured. the specimen between -months and -months sustained either a linear fractures or diastatic fractures from the cm and cm drops. the results indicate that some aged infants and young children can sustain skull fractures by being dropped or falling from relatively low heights. drops, as low as cm, can cause linear and diastatic fractures in pediatric skulls. the presences of compliant sutures and fontanelles in neonatal heads allow the head to deform during impact. these data add very important information to mechanisms of skull fractures across ages, including ages in which child abuse is a consideration. evaluation of a new classification system for temporal bone fractures in children aimed at increasing prognostic value badriya al-qassabi, md, mcgill university, albahlania @ yahoo.com; lucia carpineta, rania ywakim, bahar torabi, andrew m. zakhari, lily h p. nguyen purpose or case report: to compare a new classification of temporal bone fractures which specifically evaluates involvement of the otic capsule against the traditional classification system (transverse versus oblique versus longitudinal), to evaluate whether this new classification is able to better identify patients at risk of adverse otologic outcome and neurologic complications in the pediatric population. methods & materials: a retrospective hospital chart review was performed by ent colleagues searching for all patients with temporal bone fractures seen at our center over the past years. this was followed by a blinded review of the ct heads by a resident and a trained pediatric radiologist with neuro expertise. these cts were evaluated for petrous involvement, otic capsule involvement and any associated intracranial lesions. this information was then correlated with clinical outcome measures including post-traumatic hearing deficit, facial nerve palsy, persisting csf leak and global neurologic sequelae. the new classification was compared to the traditional one, and specifically analysed for the ability to better predict the clinical outcomes. results: expectedly, pediatric temporal bone fractures were infrequent and otic involvement even more rare. fractures with involvement of the otic capsule (versus otic sparing) were found more frequently in boys. they were also more likely to be associated with immediate otologic signs and neurologic findings on presentation. these fractures also had the highest association with conductive hearing deficit (> %) and were twice as likely as otic sparing fractures to be associated with immediate facial nerve palsy and with more important concomitant intracranial injuries such as midline shift. conclusions: while our numbers are small, our results suggest a trend that when temporal bone fractures show involvement of the otic capsule, there is higher risk of adverse otologic outcome and neurologic complications even in the pediatric population. absence of a causal relationship between mr detected subdural hematomas (sdh) in neonates with hypoxic-ischemic encephalopathy (hie) deniz altinok, children's hospital of michigan; jay shah, harut haroyan, gulcin altinok, nitin chouthai purpose or case report: the existing controversy regarding subdural hemorrhages noted in patients with hie is an important discussion in the medical, legal and child-welfare realms. it is our goal to provide additional information to this critical debate through mr findings on patients with clinically diagnosed hie. methods & materials: all patients born with clinically diagnosed hie, and treated at children's hospital of michigan in the past years were examined; those with head mri taken within days of life were selected. in total, patients fit the criteria, this included: males and females, and an age range of - days at scan (average age of days at scan). all traumatic births, coagulopathies, and other pertinent clinical findings were noted. mr imaging was reviewed and reported by a blinded pediatric neuroradiologist, these reports were then compared to the "original read". results: all patients were confirmed radiologically to have hie. the causes of hie in all cases examined were either intrauterine/delivery asphyxia, aspiration, or congenital disease. of these cases, the findings were: sdh, parenchymal hemorrhages, intraventricular hemorrhages, cephalohematomas, subarachnoids, large subcutaneous hemorrhage and instance of mca stroke. all patients with mr detectable sdh had or more confounding factors ( meningitis, coagulopathies, chest compressions, cardiac malformation, pph, severe pulmonary hemorrhage requiring transfusion of plasma and prbc). conclusions: it has been hypothesized that sdh is often found incidentally in children diagnosed with hie, this is however a dubious conclusion considering our results. in fact, the presence of sdh and hie concomitantly is low even when including a population with traumatic births such as ours. sports-related concussion in children: an mri and mrs study kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; todd a. maugans, james l. leach, mekibib altaye purpose or case report: the pathophysiology of sportsrelated concussion (src) is poorly understood, especially for children. following src and mild traumatic brain injury in adults, a few mri and proton mrs studies have identified axonal injury with declines in the neurometabolite n-acetyl aspartate (naa). we wanted to examine a src adolescent population with proton mrs, diffusion tensor imaging (dti) and other mri methods within h of concussion and with short term followup to determine if there were differences in imaging metrics with age and sex matched healthy control participants. methods & materials: twelve children, ages - years, who experienced src were evaluated with impact neurocognitive testing, t -weighted mri, susceptibility weighted imaging (swi), dti, proton mrs, and phase contrast angiography (pca) at less than h, days and days or greater post-concussion. healthy, age and sex matched controls for each src participant were recruited and evaluated at a single time point. quantitative imaging metrics included fractional anisotropy, metabolite concentrations, and global cerebral blood flow (cbf). group comparisons were examined by paired t-test or wilcoxon signed rank test. correlational data employed spearman rank correlation. results: impact results revealed significant differences in initial total symptom score (tss), and reaction time (rt) for the src group compared with the control group, with tss resolving by a mean of days and rt at days. no evidence of structural injury was observed qualitatively for either group. analyses between groups or over time within the src group found no decreases in naa or elevation of lactic acid upon mrs, and no changes in fractional anisotropy upon dti. within the src group, significant changes in the global cbf were observed. improvement towards control values occurred by days for % and by days for % of src group participants. conclusions: pediatric src affects global cbf without evidence of structural or metabolic injury. predictive value of high resolution mr imaging of brain and sella in children with clinical optic nerve hypoplasia for hypopituitarism charles glasier, radiology, arkansas childrens hospital, glasiercharlesm@uams.edu; raghu h. ramakrishnaiah, julie shelton, chetan c. shah, paul h. philips purpose or case report: to review the spectrum of cns abnormalities and their incidence in children with optic nerve hypoplasia and to calculate the sensitivity and specificity of magnetic resonance imaging in predicting endocrine abnormalities. methods & materials: this is an irb approved retrospective study of children with clinical optic nerve hypoplasia who underwent mri of the brain and orbits as part of the clinical workup in a tertiary care pediatric hospital. high resolution mri studies were performed on . tesla scanners. mri studies were reviewed for optic nerve hypoplasia, absent or ectopic posterior pituitary, absent pituitary infundibulum, absent septum pellucidum, migration anomalies and hemispheric injury.radiologists were blinded to patients endocrinologic status.all patients had clinical evaluation by a pediatric neuro-ophtalmologist and endocrinologist. a standardized panel of serologic testing that included serum cortisol, acth, tsh, and free t levels were performed on all patients. statistical analysis was performed to determine the sensitivity and specificity of mr findings in predicting endocrinologic deficiency. results: study included children( males and females) who had clinical optic nerve hypoplasia. the mean age of the study population was yr (sd: . yr). children had unilateral and children had bilateral optic nerve hypoplasia by mri. children had absent posterior pituitary bright spot and had ectopic posterior pituitary, had absent infundibulum, had complete callosal agenesis, partial callosal agenesis and had callosal thinning. had absent septum pellucidum. had hypopituitarism. of the patients with hypopituitarism had abnormal abnormal pituitary on mri, had absent septum pellucidum, and child had migration abnormality. none had corpus callosal abnormality. the sensitivity and specificity of mri in predicting hypopituitarism by demonstration of abnormal pituitary is % and % respectively. the positive predictive value and the negative predictive value is % and % respectively. among the patients with normal endocrinologic function, none had pituitary abnormalities on mri. conclusions: pituitary abnormalities are the most common intracranial abnormality in patients with optic nerve hypoplasia followed by absent septum pellucidum. detection of pituitary abnormalities by the mri has high specificity and high negative predictive value for endocrine abnormality. paper #: pa- ct imaging pearls for shunted pediatric brains srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; nadja kadom purpose or case report: shunted pediatric patients frequently present emergently with symptoms that could indicate shunt malfunction, such as headache and vomiting. here, we present imaging pearls on non-contrast head ct in shunted children. methods & materials: illustration of each of the following: . shunt tip and volume averaging-consider location of side holes and use of multiplanar reformatted images. . shunt at burr hole-consider radiolucent shunt parts. . shunt rupture in the neck-remember to investigate the lower extracranial shunt parts. . shunt in cyst/subdural shunt (vs dislocation)-consider primary shunt location in a cyst rather than shunt dislocation. . enlarged temporal horns-look for it. in infants occipital horns may dilate first. . enlarged rd ventricle-look for bulging of lateral walls. . sulcal effacement-use the "three shades of gray" rule. . small cisterns-detecting shape distortion can help. . periventricular edema-easily overlooked because of similar low density compared to ventricular fluid. . slit-ventricle -requires cautious reporting. conclusions: careful evaluation of ct images in shunted pediatric patients can reveal important clues for making an accurate diagnosis, even when prior images are not available. successful treatment of mice with creatine transporter deficiency kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; diana m. lindquist, matthew r. skelton, gail j. pyne-geithman, joseph f. clark purpose or case report: creatine transporter deficiency (ctd) is an untreatable x-linked mental retardation syndrome with severe cognitive and speech impairment. patients are identified by an absence of creatine in the brain on mr spectroscopy (mrs) and distinguished from two creatine synthesis deficiency syndromes with genetic testing. for ctd, the absence of the transporter (slc a ) prevents creatine from crossing the blood brain barrier and entering brain cells. a brain specific ctd knockout mouse was developed replicating key features of the human disease and establishing an animal model for treatment of ctd. we report the successful treatment of the ctd knockout mouse and present confirmation by mrs. methods & materials: brain specific knockout and littermate control mice were randomly assigned and treated with on one of three supplements: agentx (confidential), creatine or maltodextrine as placebo. h and p mrs data were collected on a t mr system (bruker). mice (n ) were studied with mrs after weeks of supplementation. single voxel h data were acquired on a ul voxel covering the cerebrum using a double spin echo sequence. p data were acquired with an isis sequence from the same voxel. metabolite quantification was performed with jmrui and compared between groups and over time with statistical tests for significance (t-tests, anova). results: creatine and phosphocreatine levels in the brain were all significantly higher after weeks supplementation of agentx in knockout mice, compared to creatine and placebo fed knockout mice (phosphorus mrs [ ul brain voxel] with phosphocreatine (pcr) ( ppm) observed only in agentx treated knockout mice. adenosine triphospate (atp) gamma (− . ppm), alpha (− . ppm) and beta (− ppm) peaks are noted in all three knockouts. conclusions: successful treatment was achieved in a slc a brain specific knockout mouse for the second largest known cause of x-linked mental retardation in humans, ctd. disclosure: dr. cecil has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. prevalence of abusive injuries in siblings and contacts of abused children kenneth feldman, md, general pediatrics/children's protection program, university of washington/seattle children's, kfeldman@u.washington.edu purpose or case report: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and cps professionals are common and screening is highly variable. our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. this was a multi-center, observational cohort study of child abuse teams who shared a common screening protocol. data were collected for all children < years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children < years, skeletal survey and physical exam for children < months, and physical exam, skeletal survey and neuroimaging for children < months old. results: among , children evaluated for abuse, met criteria as "physically abused" and these had contacts. for each screening modality, screening was completed as recommended by the protocol in approximately % of cases. of contacts who met criteria for skeletal survey, new injuries were identified in ( . %). none of these fractures had associated findings on physical examination. physical examination identified new injuries in . % of eligible, examined contacts. neuroimaging failed to identify new injuries among imaged, eligible contacts less than months old. twins were at significantly increased risk of fracture relative to other non-twin contacts ( . % vs . %, or . ). conclusions: these results support physical examinations and skeletal survey, regardless of physical examination results, for contacts of abused children < months of age. too few children had cranial imaging to change recommendations to image contact children less than months old. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child. they support including contacts in evaluations and interventions (foster care, safety planning, social support) designed to protect physically abused children. the project was supported by the health resources and services administration/maternal shown that pediatric rib fractures may be a marker for significant intrathoracic injury. this information has been used to suggest that children with rib fractures and no underlying intrathoracic injury may have sustained them due to insufficient bony mineralization and minor trauma rather than inflicted injury. methods & materials: irb approval was obtained for a retrospective review of all children under years of age with imaging diagnosis of rib fracture over a -year period at two university hospitals. children with prior thoracotomy, previously recognized metabolic bone disease, and prematurity < weeks were excluded. medical records were reviewed and children with documented abuse or accidental trauma were evaluated. children with indeterminate injury mechanisms were excluded. sixty-six patients with rib fractures were included in analysis, due to abusive injury and due to accidental trauma. children were analyzed for associated intrathoracic, abdominal or intracranial injury, additional fractures and retinal hemorrhage. results: abused children were younger ( . +/− . months) than accidentally injured children ( . +/− . months, p< . ). children with rib fractures due to accidental trauma had a higher incidence of intrathoracic injury compared to those due to abusive injury ( % vs %,p< . ). there was no difference in the incidence of abdominal or intracranial injury between groups. mortality and icu admission rates were similar. abused children had a higher total number of rib fractures (mean . vs . , p< . ) and were more likely to sustain additional fractures outside of the thoracic cavity ( % vs %, p< . ). conclusions: abuse is a more common cause of rib fractures in young children than accidents. children with rib fractures due to abusive trauma are less likely to have intrathoracic injury compared to those sustaining rib fractures due to accidental trauma. this suggests differences in mechanism of injury between groups. pediatric elbow fractures: a different angle on an old topic shannon zingula, md, pediatric radiology, cincinnati children's hospital medical center; kathleen emery, christopher g. anton purpose or case report: the most common elbow fractures classically reported in pediatric orthopedic texts are supracondylar (sc) ( - %), lateral condylar (lc) ( %), and medial epicondylar (me) fractures ( %) with fractures of the proximal radius (including but not limited to fractures of the radial neck) being relatively uncommon ( - %). our experience at a large children's hospital suggests a different distribution. purpose: ) to describe the frequency of different elbow fracture types in a large pediatric population, and ) to determine the fracture types that were occult on initial radiographs but detected on follow-up. methods & materials: review of medical records identified children, median age years and interquartile range for age of - years (range, . - years) diagnosed with elbow fractures at our institution from october through july . initial and follow-up radiographs were reviewed in blinded fashion independently by two experienced pediatric musculoskeletal radiologists to identify fracture type(s) on initial and follow up radiographs. note was made of fractures identified on follow up only. results: the most common fractures included sc (n , %), radial neck (rn) (n , %), and lc fractures (n , %). as compared to classically referenced incidences, rn fractures were seen significantly more (p< . ) and me fractures (n , %) significantly less (p . ) than would be predicted. in patients without fracture seen on initial films, occult fractures were seen on follow up; sc (n , %) and rn fractures (n , %) were most common. the frequency of rn fractures compared to the overall group ( % vs. %) approached but did not reach statistical significance (p . ). patients with one fracture had additional fractures seen on follow-up not seen initially with olecranon fractures most frequent (n , %.) this was significantly more common than the number identified on initial radiographs (n , %) (p< . ). conclusions: sc fractures are the most frequent elbow fracture seen initially and in follow up followed by rn and lc fractures in a distribution different than classically described. the relatively high frequency of rn and olecranon fractures detected on follow up speaks to their potentially occult nature. careful attention to these areas is warranted in patients with initially normal radiographs. purpose or case report: previous studies have found that fractures involving the spine, hands and feet are rare on skeletal surveys for suspected child abuse, leading some authors to suggest eliminating views of these regions from the initial skeletal survey protocol. the purpose of this study was to assess this recommendation by performing a historical review of these injuries in a population undergoing screen-film based skeletal surveys for suspected abuse. this cross-sectional, retrospective irb approved study reviewed the reports of the initial skeletal surveys of all children < years of age with suspected abuse imaged between april, and december, . infants underwent skeletal surveys according to acr standards acquired on a mammographic type screen-film imaging system with at least line pairs per millimeter resolution. studies in toddlers were performed using a par speed screenfilm system. results: % ( / ) of all skeletal surveys demonstrated positive findings, and % ( / ) had > fracture. . % ( / ) of all studies had fractures involving the spine, hands or feet. of all positive skeletal surveys, . % ( / ) had fractures involving the spine, hands or feet, and . % ( / ) of all patients with > fracture on skeletal survey had fractures involving these regions. conclusions: these data, acquired in the screen-film era, suggest that fractures of the spine, hands and feet may not be rare in infants and toddlers in cases of suspected child abuse. the benefits of eliminating views of these regions from the initial skeletal survey should be carefully weighed against the cost of missing these potentially important injuries in at-risk pediatric populations. purpose or case report: dating fractures is critical in cases of suspected infant abuse, but there are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. we previously reported a scientific scheme for dating fractures in infants based on an analysis of subperiosteal new bone and callus formation in birth-related clavicular fractures. we hypothesize that when used as a guide this system can significantly improve the ability of radiologists to accurately date fractures in young infants. methods & materials: radiographs of presumed birthrelated clavicular fractures in infants - months were reviewed by pediatric radiologists with (reader a) and (reader b) years experience in two reading sessions separated by one year. for the first read, no guidelines were provided. training was carried out prior to the second session, and readers were given the dating scheme as a guide during fracture analysis. readers were asked to provide an estimate of the minimum and maximum fracture age in both sessions. the primary outcome was whether or not the reader's estimated range for fracture age included the actual fracture age. a secondary outcome was the width of the estimate of fracture age. these outcomes were compared across the two reading sessions. results: the rate of correct response significantly increased after training for each reader (reader a: % to %, p<. ; reader b: % to %, p . ). the width of estimated fracture age after training was significantly smaller for each reader (reader a: mean width days to days, p<. ; reader b: days to days, p . ). conclusions: our results suggest that the ability of a radiologist to accurately date fractures can improve significantly when provided with a scientifically based system outlining patterns of fracture healing. this scheme can be applied in radiologic practice and may prove particularly useful in cases of suspected abuse, where fracture dating often has forensic implications. purpose or case report: to demonstrate the acute and subacute features of proximal femoral physeal fractures in the abused child. also to demonstrate how to recognize this injury in patients with unossified femoral heads. the database of patients with suspected non-accidental trauma, accumulated over years, was reviewed. out of a total of patients ( %) were proven to be cases of non-accidental trauma, as determined by the child abuse pediatrician. from these patients, the cases of proximal femur growth plate fractures were identified. results: patients with proximal femur growth plate fractures were identified for a prevalence of . %. one patient had bilateral proximal femoral fractures, for a total of fractures in patients. were boys, were girls with ages ranging from . mos to yrs mos. in patients, the fracture was revealed on imaging performed because of refusal to bear weight; in the other patients, the fracture was found during imaging for the skeletal survey. the fracture was on the left side in cases and on the right side in (the patient with bilateral fractures). in all of the fractures, there was lateral displacement of the femoral shaft. in fractures, the femoral head was not yet ossified simulating the appearance of a dislocation. location of the femoral head in the hip joint was verified by ultrasound or ct (ct abdomen had already been done in patient) thus delineating the presence of a physeal fracture. / fractures were salter-harris i and the other were salter-harris ii fractures. the fracture was acute in cases and subacute in cases. in these subacute cases, periosteal reaction and/or calcifying subperiosteal hemorrhage was present in , and irregularity and scalloping of the metaphysis was present in the other . conclusions: proximal femoral growth plate fractures are quite uncommon in non-accidental trauma. the injuries are typically salter-harris i or ii fractures, seen more often in the healing phase. in the presence of an unossified femoral head, the laterally displaced femoral shaft can simulate hip dislocation; this can be clarified with hip sonogram. purpose or case report: in recent years, metal stents have been used to overcome airway obstruction in children for whom no better surgical option is available. these devices are not designed for use in the airway, however, and may cause significant complications. bioabsorbable airway stents may avoid some of the problems associated with metal stents. methods & materials: this is a retrospective review of all endoluminal insertions of bioabsorbable airway stents at a single institution from april to september . custom-made polydioxanone stents of various sizes (ella dv, ella, czech republic) were used. results: twelve stents were inserted in the airways of seven children. indications were: recurrent obstruction after slide tracheoplasty ( ), persistent airway compression after correction of a congenital cardiac lesion ( ), collapse of stem cell supported tracheal homograft, tracheomegaly following fetal balloon insertion, and syndromic tracheobronchomalacia (tbm). eleven stents (diameters to mm) were placed in the trachea and one in the left main bronchus. two stents had to be removed and replaced for technical reasons (one was too long and the other too narrow). the child with syndromic tbm died when treatment was withdrawn because she could not be weaned from the ventilator. the remaining children are alive at a median follow-up of nine months (range to months). the granulation tissue response was similar to that seen after placement of metal stents. the stents were observed to absorb gradually over a period of approximately three months, requiring serial stenting in two children. conclusions: bioabsorbable airway stents are more difficult to insert than metal stents. they cause similar early complications, especially granulation tissue formation, but appear to avoid potential long-term complications of metal stents, including vascular erosion and growth limitation. disclosure: dr. mcclaren has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: renal angiomyolipomas (amls) in tuberous sclerosis complex (tsc) grow at a faster rate, exhibit a wider and more problematic range of symptoms, and hemorrhage more frequently than sporadic amls. we examined the efficacy of prophylactic embolization of renal amls in tsc in decreasing tumor size, alleviating symptoms, and preventing hemorrhage while preserving renal function. we retrospectively reviewed the charts and imaging studies of consecutive patients who underwent transarterial, transcatheter embolization of amls. tumor volume was measured from available ct or mri imaging before and after embolization. pre-and postembolization symptoms and creatinine levels were documented. results: patients had available follow-up imaging at a mean of months post-embolization. the mean preembolization tumor volume was ml and postembolization was ml; median decrease in volume was %. using the schwartz method, the mean glomerular filtration rate before embolization was calculated to be . ml/min/ . m . after embolization the mean value was statistically unchanged at . ml/min/ . m . none of the patients experienced renal hemorrhage or symptom recurrence during the follow-up period. conclusions: selective embolization of renal amls in patients with tsc decreases tumor volume, relieves symptoms and reduces the risk of future hemorrhage while preserving renal function. etoh was injected percutaneously with g needle; transductal ablation performed through a f micropuncture sheath. drug volumes, technical difficulties, percentage reduction in saliva production, family reported clinical significance, and complications were recorded. results: salivary gland ablation (sga) included bilateral smg and slg ablation without parotid gland ablation in cases, and with unilateral parotid gland ablation in cases. one case of bilateral parotid gland ablation following surgical resection of bilateral smgs. mean etoh dose for smg . ml, and . ml for slg. one case of focal skin necrosis was noted; no other complications. patient families reported response to sga in / cases ( %) with mean saliva production of %. greatest health and family impact was reported with elimination of hospitalizations for recurring aspiration pneumonia ( cases), elimination of choking in bed ( cases) , and improved patient sense of self-hygiene in cases. one complication occurred with temporary marginal mandibular nerve paralysis (resolution in months). conclusions: percutaneous and transductal sga is feasible, safe, and effective in this small patient series, offering an alternative to surgical salivary gland resection, or treatment option following failed surgical intervention. paper #: pa- mr-guided procedures in children: initial experience joao amaral, md, diagnostic imaging, the hospital for sick children, joao.amaral@sickkids.ca; michael temple, dimitri parra, philip john, bairbre connolly purpose or case report: the primary purpose of this study was to review our initial experience with mr-guided procedures in children. our secondary objective was to share some aspects on how to start an mr-guided program in a tertiary pediatric center. patients with lesions identified only on magnetic resonance (mr) imaging were selected to undergo an mr-guided procedure. patients' demographic data, primary diagnosis, referring team's clinical suspicion, lesion's anatomical location, tissue adequacy for pathology, final diagnosis and clinical follow up were reviewed. aspects of starting a program of mr-guided procedures, safety concerns, imaging and technical challenges, and mr compatible materials were also addressed. results: to date, procedures ( bone biopsies, soft tissue biopsy and pre-surgical needle localization) were performed in patients during months. there were girls and boys with a mean age of . years ( y mo- yrs). one patient had a nasopharyngeal carcinoma, cardiofacial syndrome, wilm's tumor and had no previous medical issues. the clinical suspicion for procedures in patients was metastatic disease and for procedures in patients was primary malignancy or infection. lesions were located in the tibia ( -metaphysis and diaphysis), femur ( -metaphysis and epiphysis), thigh ( -soft tissues), sacrum ( ) and retroperitoneum ( ). all biopsies provided adequate tissue for diagnosis. needle localization and hook deployment was also accurate. malignancy was excluded in all patients. final diagnosis included chronic recurrent multifocal osteomyelitis (crmo), osteomyelytis, fibrous tissue, osteoid osteoma, and scar tissue. mean follow up was . months. no patient required a second procedure to confirm the diagnosis. conclusions: mr with its unique soft tissue resolution and lack of ionizing radiation is an excellent method to guide interventions in children. one of the greatest advantages of this method is the precise target localization especially in lesions located in the bone marrow or lesions better identified on mr. special safety measures, specific mr compatible material (needles, surgical instruments), dedicated imaging techniques to reduce or increase material/needle artifact and careful technique are paramount. - . m, f; . - months, mean . months, median months, mode months. sonographic approach expanded as our experience grew over months. studies performed by a single pediatric radiologist. bilateral sonography included: interscalene and supraclavicular neck, nerve roots at neural foramina, cervical spinal canal, diaphragm during spontaneous respiration, rhomboid muscle, serratus anterior muscle, posterior shoulder, all performed and interpreted blind to other imaging. results: interscalene and supraclavicular neck evaluated in all patients. all exhibited echogenic interscalene portion of brachial plexus.size and extent of traction neuroma varied. nerve roots at foramina noted in axial and coronal planes. in cases enlarged root(s)noted. cervical spinal canal studied in patients: cord oscillated normally, no syrinx, cord concentric in canal. intracanalicular traction pseudomeningoceles on concurrent ct myelography or mri were not apparent on us. in cases a "clumped" retracted nerve root on the cervical cord was later found to correspond to a pseudo-meningocele on ct myelogram. otherwise, cervical spinal canal us was unremarkable in cases. diaphragm motion was evaluated in patients during spontaneous respiration; no phrenic nerve palsy. rhomboid muscle was evaluated for atrophy in patients; had atrophy. the rhomboids are innervated by the dorsal scapular nerve which arises solely from c , prior to c joining the brachial plexus. intact rhomboid indicates that the central c root is intact. serratus anterior muscle, innervated by the long thoracic nerve (c ,c ,c ), was evaluated for atrophy in patients; had atrophy. dynamic evaluation of the posterior shoulder looking for posterior laxity was evaluated in patients; had laxity. posterior shoulder dislocation or subluxation is a known sequela of brachioplexopathy which sometimes requires muscle transfer when the child is older. conclusions: comprehensive us evaluation of perinatal brachioplexopathy detects: extent of traction neuromafibroma from the interscalene region peripherally toward clavicles (important for neurosurgeon), thick nerve roots, phrenic nerve diaphragm palsy, muscle atrophy from denervation, and posterior shoulder subluxation. us misses: intracanalicular traction pseudomeningoceles. paper #: alt- impact of the image gently campaigns in adult-focused hospitals: a survey of practice leaders brett bartz, duke university medical center; donald frush, kimberly applegate, michael callahan, laura coombs, marilyn goske purpose or case report: the alliance for radiation safety in pediatric imaging is an organization that uses social marketing to promote radiation protection for children and effect change across radiology practices. the impact of the alliance's image gently campaigns on practice patterns in radiology practices has yet to be assessed, especially outside of freestanding children's hospitals. the purpose of this investigation was to assess the impact of the image gently campaigns on academic and private practices/institutions that treat children but primarily serve adults. a web-based survey was emailed to leaders in radiology practices (n ) who do not practice at freestanding children's hospitals utilizing the acr's pred database. the survey consisted of questions designed to measure the recognition and impact of the image gently campaigns, including the impact on practice patterns. results: a total of practice leaders in u.s. states and territories responded for a response rate of . %. the majority ( %) of sites image pediatric patients in their practices. respondents consisted of department chairs ( %), group presidents/ceos ( %), and division chiefs ( %). the majority ( %) of respondents described their practice as a hospital-based private practice without a dedicated pediatric radiology division. the vast majority ( %) of respondents was familiar with the image gently campaigns; % of respondents reported that image gently had effected a change on how they imaged children. specifically, respondents (%) reported that the campaign caused a modification to lower dose protocols for head ct ( %), chest ct ( %), and abdominal/pelvic ct ( %). slightly more than half of respondents ( %), however, estimated that the image gently campaign resulted in no modification of pediatric fluoroscopy exposure. conclusions: to our knowledge, this is the first survey evaluating the impact of the image gently campaigns. there is near universal recognition of the campaigns, which have impacted practice patterns beyond the freestanding children's hospital in ct, but not in fluoroscopy. reliability of shear-wave velocity using different frequencies in acoustic radiation force impulse (arfi) elastography mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; suyon chang, myung-joon kim purpose or case report: although there are many studies about acoustic radiation force impulse (arfi) measurement, standard protocol has not been established. and a new probe with high frequency has been developed which can be applied for pediatric patients. the purpose of this study was to assess the reliability of shear-wave velocity (swv) at various depths using different frequencies to suggest standard measurement in arfi elastography. methods & materials: arfi elastography of both the elasticity phantom and normal liver was performed at different depths ( - cm) with convex ( - mhz) and linear ( - mhz) probes. ten valid swv measurements at each depth were performed. it was repeated ten times with the phantom and it was done in healthy volunteers (m:f : , age - years; mean . ). the mean value and standard deviation of swv were calculated. results: in both the elasticity phantom and the liver, variability of swv was different between the depths in both probes. the depth with lower variability in the phantom was and cm with the convex probe and cm with the linear probe. in the liver, the depth with lower variability was cm with the convex probe and and cm with the linear probe. in comparison of two probes, the linear probe showed lower variability at and cm depth in the phantom and at cm depth in the liver whereas the convex probe showed it at cm depth in both the phantom and the liver. conclusions: in arfi elastography, measurement of depth shows different variability in both low and high frequency probes. to obtain the most reliable measurement of swv, using high frequency probe is recommended for - cm depth and using low frequency probe is recommended for - cm depth. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging -year-old fetuses sabah servaes, children's hospital of philadelphia; teresa victoria, ann johnson, sandra kramer, richard markowitz, diego jaramillo purpose or case report: to demonstrate normal anatomy and pathology of medical museum specimens without disturbing the specimens. methods & materials: nine fetal specimens from a medical museum were imaged with ct and mri ( . t and . t) when possible with the specimens in their preserving fluid and containers. results: the fetal specimens are estimated to be approximately years old. one specimen is from the first trimester, seven are from the second trimester, and one is from the third trimester. normal anatomical structures at various stages of development including the brain (and varied sulcation pattern), lungs (lobar anatomy), and skeletal structures (several developmental features such as the ossification centers, perichondrial structures, and marrow cavitation) can be evaluated using imaging without causing harm to the specimens. pathologic entities including anencephaly and sirenomelia are also evaluated demonstrating features of these entities. conclusions: imaging historical fetal specimens provide an opportunity to evaluate normal developmental changes and pathological entities and also to gain a better understanding of the museum pieces without damaging the museum specimens. pediatric ct interpretations: does a tertiary care radiologist make a difference? wendy d. ellis, monroe carell jr. children's hospital at vanderbilt university; sumit pruthi, david johnson, christopher eakins, chang yu, marta hernanz-schulman purpose or case report: to determine whether a substantive difference exists between the pediatric imaging reports of community radiologists and reinterpretations by tertiary care radiologists at a free-standing children's hospital; and how those interpretations were related to the final diagnosis. methods & materials: this retrospective review examined the computed tomography (ct) reports of all pediatric patients referred to our tertiary care children's hospital over a month period ( / / - / / ). the outside reports and the requested second interpretation reports were compared and their content categorized as "agreement" vs. "disagreement: major or minor". a representative sample of major disagreements in which there was reliable followup information was correlated with the final diagnosis to determine if there was added value provided by the reinterpretation. results: ct scans from patients were submitted for reinterpretation. disagreements were found in / cases ( . %); with . % ( / ) classified as major disagreements. among the neurologic cases, major disagreements occurred in patients ( . %) and minor disagreements in patients ( . %). among the body scans, major disagreements occurred in cases ( . %) and minor disagreements in cases ( . %). in the cohort of cases reviewed for final diagnosis, the second read interpretation was more accurate in . % of cases with a p-value of < . (neurologic . %, p < . ; body . %, p < . ). conclusions: in our review, discrepancy rates between community and tertiary care radiologists in interpretation of pediatric ct scans were substantial, with discrepancies occurring in more than % of cases. further review of the cases for final diagnosis, showed that a significant number of the tertiary care interpretations were more accurate. possibilities that may account for this discrepancy include subspecialty training and elapsed time since performance of the study, which might provide additional clinical data in some cases. diagnostic ct scans performed at outside institutions should not be repeated considering added radiation burden to the child and additional expense. our data indicates there is added value to the reinterpretation which impacts the accuracy of the report (as assessed by the final diagnosis), and should be recognized by payors as integral to optimal patient care. ionizing radiation exposure from radiography in the neonatal intensive care unit-per-patient cumulative effective doses amaya basta, radiology and biomedical imaging, ucsf; jesse courtier, john mackenzie purpose or case report: to better understand the levels of exposure to ionizing radiation for infants in the neonatal intensive care unit (nicu). we retrospectively collected the number and types of radiographs performed per infant in our nicu by searching our radiology information system database over a five-year period. we focused on the most common examinations ( % of all radiographs) and assigned each an estimated equivalent dose based on published literature: chest and abdomen . micro sieverts (μsv), one-view chest . μsv, abdomen . μsv, twoview chest . μsv, two-view abdomen μsv. we then calculated a cumulative equivalent dose (ced) for each infant based on the number of each type of examination they received. descriptive statistics were generated to depict the distribution of number of examinations and ced. results: over five years, , infants cared for in our nicu received at least one radiograph of the chest and/or abdomen. the number of examinations obtained on these infants was . , , , (mean, median, minimum, maximum). the st quartile was and the rd quartile was examinations. the cumulative equivalent dose these infants received was . , . , . , , . μsv (mean, median, minimum, maximum) . the st quartile was . and the rd quartile was . μsv. two hundred infants ( . % of the study population) received a ced of over μsv. conclusions: descriptive statistics provide a valuable assessment for the broad range of radiation that infants receive in the nicu. although the distribution is skewed towards a low level of exposure, a subset of patients ( . %) received a ced of over μsv. identification of factors that cause infants to enter this group will be important for future dose reduction strategies. poster #: cr- congenital cardiac fibroma: a case report earic bonner, meharry medical college, ebonner @email. mmc.edu; seth crapp, david parra purpose or case report: a -week-old male presented to his pediatrician with a ii/vi systolic ejection murmur along the left sternal border. he had mild tachypnea without cyanosis. his oral intake was adequate with no evidence of failure to thrive. he was referred to a pediatric cardiologist who performed an ecg and a transthoracic echocardiogram. the ecg showed normal sinus rhythm at beats per minute with no abnormalities. the transthoracic echocardiogram showed a x x mm homogeneous mass originating from the anterior free wall of the right ventricle, and mild dilation of the right ventricle. mild dynamic subpulmonary stenosis and a secundum atrial septal defect were also noted. although the murmur was significantly louder at one month follow-up, a repeat echocardiogram did not reveal any increase in the size of the mass. at months of age, a cardiovascular magnetic resonance imaging (cmri) study under general anesthesia was performed. cmri revealed a x x mm cardiac tumor that was causing narrowing of the right ventricular outflow tract. the tumor was hypointense on t -weighted imaging and hyperintense on t weighted imaging, with positive delayed enhancement. these findings, along with the size and location of the mass, are consistent with a diagnosis of a cardiac fibroma. chest mra, that was also performed, showed normal extracardiac vascular anatomy with no evidence of peripheral branch pulmonary stenosis. cardiac fibromas do not usually increase in size; however, the concern is the child's risk of arrhythmias. frequent holter monitoring was recommended for this patient. considerations were also made for an electrophysiology study in the next - years to determine the risk of ventricular ectopy. at that point, the patient can be assessed for the possibility of resection of the fibroma. purpose or case report: treatment of pulmonary atresia is complex and demands intricate solutions. one solution is the creation of a conduit between the right ventricle and the main pulmonary artery. the lifespan of these conduits is limited by progressive occlusion over time, which can be treated with endovascular stent placement in lieu of surgical re-intervention. however, these stents are at high ( %) risk for fracture, typically at the stent waist. the radiologist should be aware of this complication, as they may be the first to identify it on chest radiograph. the purpose of this electronic poster is to familiarize radiologists with this entity by presenting cases of stent fracture and migration. methods & materials: over a month period, we identified three children with rv-pa stent fractures and associated stent migrations on chest radiography. imaging analysis was focused on the appearances of these fractured stents. patient management and outcomes were reviewed. results: three children, males, female (ages , , and years) were found to have asymptomatic rv-pa conduit stent fractures with fragment migration. one chest xray was performed in the er for fever and cough; one was pre-op for gi surgery; one was done to confirm abnormal findings seen on a routine cardiac echo. the time between stent placement and fracture detection ranged from to months. two patients had stent fractures and embolizations to the right ventricle that required open surgery to remove stent fragments. the third patient had embolization to both pulmonary arteries, but did not require treatment. all patients did well. conclusions: stent fractures and migrations are a relatively common complication of rv-pa conduit stent placement. pediatric radiologists need to be aware of this complication in order to provide value-added interpretations. purpose or case report: we describe the case of a week stillborn fetus with a . cm diameter craniopharyngioma detected by ultrasonography. a g p woman in her third decade had ultrasonographic examination showing hydrocephalus, polyhydramnios and an intracerebral mass. the nature of the mass was uncertain and intracerebral hemorrhage was considered. the pregnancy was terminated at weeks gestation. at postmortem examination the decedent was a g male fetus with a head circumference of . cm and a crown-rump length of . cm. anterior and posterior fontanelles appeared large. no other external abnormality was found. the placenta was unremarkable and cytogenetics on placental tissue showed a normal male karyotype. examination of fetal viscera was remarkable for mildly underweight adrenal glands ( . g, expected . g) and hepatomegaly ( . g, expected . g). intracranial csf was increased in volume. there was a suprasellar . cm diameter somewhat gritty, but smooth-surfaced tumor. the brain and tumor together weighed g. the floor of the cranium and sella turcica were grossly normal. histologic examination of the tumor showed an adamantinomatous type craniopharyngioma with characteristic epithelium, stellate reticulum, focal keratinizing squamous epithelium and calcification. pre-and postnatal mri of caudal regression syndrome claire b. beaumont, md, university of arkansas for medical sciences, cbbeaumont@uams.edu; nafisa k. dajani, leann e. linam purpose or case report: caudal regression syndrome is a rare form of caudal dysplasia characterized by a spectrum of findings including agenesis of the lumbosacral vertebra, multiple orthopedic deformities in the lower limbs, as well as anomalies of the gastrointestinal and genitourinary tracts. the mechansim of caudal regression syndrome is not completely understood but is believed to be secondary to a defect in the induction of caudal elements. mri is a valuable tool for identifying the specific anomalies involved with caudal regression syndrome on a case-by-case basis. the following is a case from our institution which includes both pre-and postnatal mri. unsuspecting tuberous sclerosis diagnosed on neonatal cranial ultrasound vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; puneet gupta, richard thomas, vaseem iqbal, jan najdzionek. purpose or case report: tuberous sclerosis (ts) is a rare autosomal dominant genetic disorder causing hamartomatous proliferation in number of organ systems. because the classical triad of epilepsy, mental retardation and adenoma sebaceum is not commonly seen on clinical examination, imaging plays a central role in the diagnosis and treatment of tuberous sclerosis. central nervous system features of ts include subependymal nodules, cortical tubers, subependymal giant cell astrocytoma, white matter bands and cysts. in patients with ts, cerebral involvement in the form of subependymal nodules is seen in % to % and white matter abnormalities are noted in % to % of cases. knowledge of expected radiological features is thus important in making the correct diagnosis. recent studies have indicated that earlier appearance of brain lesions indicate a greater risk of mental retardation and a more severe clinical course. we present a case of a -day-old neonate who was referred to us with concerns for hydrocephalus. the cranial ultrasound demonstrated multiple echogenic subependymal nodules of varying sizes and mild asymmetry of the ventricles. the differential diagnosis included ts, torch infections, and x-linked subependymal heterotropia. areas of increased echogenicity were noted within the white matter of the left frontal lobe, which favored ts. subsequently, an mri was performed to validate these findings and assess for additional white matter lesions. the mri showed classic manifestations of ts that included periventricular lesions and streaky, linear, wedge-shaped hyperintensities on flair imaging. a noncontrast ct scan was also performed which revealed classic calcified subependymal nodules. cardiac rhabdomyoma and renal angiomyolipoma are the other recognized manifestations of ts and were respectively excluded by subsequent echocardiogram and renal ultrasound. pyloric atresia with epidermolysis bullosa: fetal mri diagnosis with postnatal correlation arnold c. merrow, md, radiology, cincinnati children's hospital medical center, carl.merrow@cchmc.org; jason s. frischer, anne w. lucky purpose or case report: pyloric atresia (pa) is an uncommon disorder, accounting for % of congenital gastrointestinal atresias. up to % of cases have associated anomalies, the most common of which is epidermolysis bullosa (eb). prenatal findings have been reported sonographically for each of these anomalies, both in isolation and in the rare case of association. a case of isolated pa has been reported by fetal mri. we present the first reported case of pa with eb diagnosed by fetal mri with corroborative postnatal imaging and surgical findings. the mother of this child was initially referred to the fetal care center of cincinnati at weeks gestation for a possible myelomeningocele diagnosed by prenatal ultrasound at an outside facility. these ultrasound images were not available for review at the time of our workup. a fetal mri was the first study to be obtained at our institution. the mri showed no myelomeningocele or brain anomalies. the stomach was moderately enlarged throughout the exam and did not empty. subjective polyhydramnios was also noted. no duodenal dilation was seen, and there was minimal fluid in the distal bowel loops. this constellation of findings raised concern for pyloric atresia, resulting in a careful search for any sign of epidermolysis bullosa due to a known association of these disorders. prominent debris was seen layering dependently in the amniotic fluid and in the dilated fetal stomach, and the external ears were abnormally small and misshapen. the pa-eb association was proposed as the underlying diagnosis based on our mri findings. it was also postulated that skin blistering over the lumbosacral spine at the time of the prior outside ultrasound could have mimicked a myelomeningocele, thus prompting the referral to our center. at delivery, the baby had numerous skin defects, and the ears were malformed. an abdominal radiograph obtained after nasogastric tube placement and air injection showed no gas beyond the stomach. a pyloric ultrasound showed a distended stomach without a patent pyloric channel to the duodenal bulb, consistent with pyloric atresia. a skin biopsy confirmed epidermolysis bullosa, and the patient underwent a resection of the pa with gastroduodenostomy. the baby subsequently expired less than two weeks later, most likely due to sepsis based on wound cultures and autopsy results. our case demonstrates the ability of fetal mri to diagnose this rare condition and highlights the key imaging manifestations of the pa-eb association. disclosure: dr. merrow has indicated that he is an author for amirsys and receives a royalty accordingly. purpose or case report: we demonstrate a case where the changing position of the contrast filled appendix lead to the diagnosis of malrotation, with review of the embriology of intestinal rotation. a newborn preterm female presented with a golf ball sized umbilical mass, that reduced by itself, thought to represent an umbilical hernia vs omphalocele. she was unstable to undergo an upper gi exam under fluoroscopy, therefore a limited contrast study was performed at bedside and was inconclusive for malrotation. subsequent nicu radiographs showed changing position of the appendix filled with residual contrast, visiting all quadrants of the abdomen in a random pattern over a few days period. this confirmed our suspicion for malrotation. it is well know that in malrotation the position of the cecum can be variable, most commonly located in the right upper quadrant or left lower quadrant. to our knowledge it has not been described yet that the changing position of the appendix can lead to the diagnosis of malrotation. through this case we display the embriology of the intestinal rotation and the radiologic signs of malrotation. poster #: cr- mr imaging patters of liver transplant complications in the pediatric population edward richer, md, emory university, richerej@gmail. com; adina alazraki, jonathan loewen purpose or case report: pediatric liver transplantation is a relatively common surgery, with more than transplants in the united status annually. the spectrum of post transplant complications has been previously described, primarily utilizing ultrasound. as mri has become a more widely used technique in pediatric imaging, and ultrasound findings may be non-specific, knowledge of mr imaging patterns is an important adjunct in the post-transplant evaluation. we present a spectrum of complications, including vascular, biliary, hepatic parenchymal, and systemic complications. methods & materials: using an electronic record system, we identified pediatric patients with prior liver transplantation who subsequently underwent abdominal mri at our institution and were found to have a post transplant complication. patient management and outcomes were reviewed. results: our review of a subset of the available patients shows vascular complications to be the most commonly encountered abnormality at our institution, including hepatic artery stenosis/thrombosis, and portal vein stenosis/ thrombosis, cavernous transformation of the portal vein. biliary complications were relatively common, including bilary stenoses and bilomas. hepatic parenchymal and systemic complications, such as ptld, were less common. we demonstrate the mr imaging patterns of these complications. conclusions: pediatric liver transplantation is a relatively common surgery, and the mri appeance of post transplant complications warrants illustration as abdominal mri becomes more widely used in pediatric imaging. we present a pictorial review of common patterns of complication. imaging of progressive familial intrahepatic cholestasis (pfic) matthew d. dobbs, md , radiology, vanderbilt university medical center, matthew.dobbs@vanderbilt.edu; sumit pruthi, stephanie e. spottswood purpose or case report: progressive familial intrahepatic cholestasis (pfic) is a relatively rare pediatric liver disease due to a genetic mutation (abcb gene on chromosome q - ) in a bile salt export protein causing cholestasis leading to chronic inflammation within the biliary system. the diagnosis is made clinically with detection of a low ggt in the face of an elevated bilirubin and alkaline phosphatase. genetic testing confirms the diagnosis. one of the subtypes, type , was shown in to be highly related to the development of hepatocellular carcinoma. the vast majority in children in this study developed hcc at less than years of age. radiological contribution to the management of these chronic liver disease patients is to perform surveillance imaging to detect hcc. due to the rarity of this condition, almost no reports exist in the radiological literature describing the imaging features or management of this condition. our presentation will review the imaging findings in our small population of pfic type patients on us, ct, and mri. we will also review suggested surveillance imaging techniques and imaging algorithms. renal rhabdoid mimics wilms tumor vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; paul montgomery, jan najdzionek, vaseem iqbal purpose or case report: in the past most pediatric renal tumors have been classified together under the umbrella of wilms tumor. however, over the last decade with advancement in imaging, several distinctive imaging features specific to renal tumors have been recognized which aid in their classification as being distinct pathologically. we present a case of rhabdoid tumor where in the primary tumor arose from the kidney. it had classical imaging features of wilms tumor. we want to highlight that even with the most sophisticated imaging techniques, specific renal tumors cannot always be diagnosed with preoperative imaging and how this alters the management and prognosis for child with a renal mass. in our case, the postoperative findings, pathology and immunohistochemical techniques confirmed a rhabdoid tumor. differentiation of these two tumors is essential since in patients with rhabdoid tumor survival is poor with -year overall survival rates of % for stages i and ii and % for stages iii, iv, and v. on imaging, there are several features that suggest the diagnosis of rhaboid tumor. these include subcapsular fluid collections, linear calcifications outlining tumor lobules, and vascular invasion. also, a pertinent feature of rhabdoid tumor due to its aggressive nature is the presence of lung metastasis ( %) and synchronous malignant brain lesions ( %). these findings were not present on our case, which led us in formulating a diagnosis of wilms. our patient is unusual in the fact that the local renal findings and absence of metastasis, synchronous malignant lesions, and vascular invasion led us to an incorrect diagnosis of wilms tumor. in conclusion, we would like to stress that diagnosis of rhabdoid tumor of the kidney on imaging presents a challenge because of its imaging similarity to wilms tumor. ectopic ureters in young infants: mru findings shin-lin shih, md, department of radiology, mackay memorial hospital; yi-fang chen, chun-chao huang, fei-shih yang purpose or case report: to localize the terminations of ectopic ureters by mri methods & materials: mr urography (mru) was conducted in four female patients with hydroureter and a suspected ectopic orifice. mr imaging was performed with a t mr scanner (achieva; philips). the imaging protocol mainly consisted of a single-shot t -weighted turbo spin echo sequence with a slice thickness of mm and multiplanar reformations. the ages of the four patients were day, days and months (for two). the latter two patients presented with urinary tract infection. the newborn patients presented with abnormal prenatal examination. the pertinent findings and descriptions of a variety of renal anomalies were described. results: the locations of the ectopic ureters were two in the vagina, one in the uterus and one in the bladder neck. the associated renal anomalies were a right duplex kidney in four, a left duplex kidney in one, a left ectopic dysplastic kidney in one and vesicoureteral reflux in one (confirmed by vcug). conclusions: mru may demonstrate the exact point of termination of an ectopic ureter and also the associated renal anomalies. poster #: cr- acquired polycystic kidneys in neuroblastoma survivors richard bellah, , radiology, the children's hospital of philadelphia, bellah@email.chop.edu; bernard kaplan, camilo jaimes, yael p. mosse, jill p. ginsberg, kevin e. meyers purpose or case report: neuroblastoma (nbl) is the most common extracranial solid malignancy of childhood. with current therapy, the prognosis and long term survival of patients affected by this condition has dramatically improved. nevertheless, the treatment for nbl may account for some complications further in life. in patients with neuroblastoma, acute renal failure can occur usually as a result of a thrombotic microangiopathy associated with bone marrow transplantation. in addition, end-stage renal disease has been reported in long-term survivors of nbl. this exhibit describes and illustrates the first case series of five patients with treated nbl in whom the imaging features of polycystic kidney disease (pkd) developed over time, and in some cases, as progressive renal failure ensued. methods & materials: medical and imaging records were reviewed (irb approved) of patients with treated nbl in whom pkd became apparent during the course of followup imaging. results: five patients displayed findings of pkd on us and/or ct. three of the five patients (where images were available) had normal renal imaging at time of nbl diagnosis. the mean age at nbl diagnosis was . years (range . - . yr). the mean age at time pkd was detected was . years (range - yrs). none of the patients had a family history of pkd, or had previously undergone dialysis. all patients received chemotherapy and total body irradiation prior to bone marrow transplantation. four patients survived nbl therapy but eventually developed end-stage renal disease. conclusions: an association between acquired pkd and nbl has not been previously reported. the etiology of this observation is still unclear, but a toxic insult is likely to account for the renal changes. further research is needed to establish the epidemiology, prognosis, and etiology of this association. abnormal migration of the retention anchor suture in a case following gastrostomy tube insertion surendra narayanam, mbbs, dmrd, dnb, division of image guided therapy, department of diagnostic imaging, the hospital for sick children, nrssbabu@gmail.com; joao amaral, luke toh, bairbre connolly, vicente deoliveira, dimitri parra purpose or case report: during percutaneous gastrostomy tube placement, retention anchor suture(s) are deployed into the stomach to tack the anterior gastric wall to the abdominal wall. in our practice the thread of the retention anchor suture is cut at days and the metallic portion passes pre rectum. we report an interesting and very rare migration of the metallic portion of the retention anchor suture in post-primary gastrostomy tube insertion. an -month-old girl, with a mitochondrial disease and severe hypotonia underwent percutaneous gastrostomy placement. during the procedure the retention anchor suture thread snapped and the metallic portion of the suture remained within the stomach. day post procedure, the child became uncomfortable, so a gastrostomy tube check was performed. the suture was not visible in the abdomen on abdominal x-ray or fluoroscopically. on close review of the images, the suture was found projected over the distal esophagus. initial impression was the anchor suture had refluxed into the esopahgeal lumen. careful attempts were made to remove it along with the nasogastric tube, from above under fluoroscopic control. however on withdrawal of the nastogastric tube, the retention anchor suture moved enbloc with the nasogastric tube. once removed the retention anchor suture was confirmed to be within the nasogastric tube. this case illustrates the importance of examining the chest x-ray carefully before assuming a retention anchor suture has passed. to understand the appropriate post procedural radiographic workup and its technique for timely diagnosis. . to learn the potential complications of delayed diagnosis. pediatric retroperitoneal synovial sarcoma ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: pediatric synovial sarcoma most commonly affects the extremities, especially the lower thigh and knee region; other primary sites such as the retroperitoneum have been only infrequently reported. we report an extremely rare case of a retroperitoneal synovial sarcoma masquerading as retroperitoneal hematoma in a -year-old white female with non-traumatic back pain and non-contrast enhanced ct findings of right quadratus lumborum and psoas region presumed hematoma. coagulation studies revealed factor xi deficiency also known as hemophilia c. however, on follow-up imaging, the presumed retroperitoneal bleed persisted and a subsequent mr examination revealed a solid enhancing mass. ct, mr, and fdg-pet findings as well as a brief histopathology are discussed. our case is rare in the regards that the tumor occurred in an uncommon retroperitoneal location in a pediatric patient and was mimicking a retroperitoneal hematoma which posed a significant diagnostic challenge. despite a rare entity, synovial sarcoma among other sarcomatous lesions maybe considered in the differential consideration of a spontaneous retroperitoneal hematoma even in hemophiliac patients. longitudinal bracket epiphysis michael jubang, geisinger, mjjubang@geisinger.edu; farzad sedaghat, william j. malone, george wu, william mirenda purpose or case report: longitudinal bracket epiphysis is a rare anomaly with multiple synonyms such as delta bone, triangular bone, and congenital angular deformity. the purpose of this case report poster is to discuss an -month-old male born with an adducted right great toe with a broad nail and a notch in the center of the distal phalanx. the review will discuss radiographic findings, the natural progression of the disease, the treatment options, the mri findings used for pre-surgical planning, and associated pathology. whole body mri in pediatric non oncologic diseases: pictorial review ramy el jalbout, md, radiology, chu sainte justine, ramy.jalbout@yahoo.com; vijay moorjani purpose or case report: with the advances in scanning techniques and the scanning sequences, the role of wbmri is expanding. mri has a great role in the pediatric population owing to its inherent advantages namely lack of radiation, high tissue specificity, and high diagnostic yield at the level of the entire body under a single sedation. unlike the application of wbmri in the assessment of metastasis and bone marrow involvement in leukemia, its role in systemic diseases is yet to be further investigated. certain diseases such as crmo are very often multifocal. the extent of osteonecrosis in patients on steroids, dermatomyositis and the lesions related to child abuse are very often wide spread in the skeleton. we intend to present some of the findings of these pediatric systemic and multifocal diseases on wbmri. chronic relapsing multifocal osteomyelitis (crmo): crmo can be acute or chronic and is multifocal. the abnormality manifests as high signal intensity. wbmri can guide for the best site for biopsy and provides monitoring for response to treatment. osteonecrosis: only few small studies evaluated the usefulness of wbmri in the diagnosis of both the symptomatic and asymptomatic sites of osteonecrosis in all patients on steroid therapy. wbmri is more sensitive than conventional radiographs. the abnormalities are typically geographical areas of high stir signal intensity. myopathies: wbmri has also the role of detecting the extent of idiopathic inflammatory myopathies such as dermatomyositis in the entire skeleton. child abuse: wbmri has a low sensitivity for the highly specific fractures that are pathognomonic for child abuse. conclusions: wbmri is a useful examination in the pediatric patient that is radiation free, quick and allows imaging of the entire body. it is an adjunct to dedicated mris to look for multifocality and extent of systemic diseases such as crmo, osteonecrosis in patients on steroids and dermatomyositis. it has a great potential as a screening examination but at the same time can detect both the symptomatic and the asymptomatic lesions in the bone marrow and muscles that are otherwise not seen on conventional radiography. it also allows guidance for biopsy and monitors response to treatment. mobile "cerebroliths" in hemihydranencephaly: a case report usha d. nagaraj, md, the ohio state university medial center, usha.nagaraj@osumc.edu; brent adler purpose or case report: hydranencephaly is a congenital central nervous system disorder manifested by the replacement of the cerebral hemispheres with a thin membranous sac filled with cerebrospinal fluid and necrotic debris. hemihydranencephaly is an extremely rare brain condition in which the vascular anomaly is unilateral, with fewer than cases previously reported in the literature. this is a case of a -month-old male who presented to the ophthalmologist for evaluation of possible leukocoria of the right eye. the patient had a history of a difficult vaginal delivery that required forceps delivery with possible associated trauma to the right eye. dilated fundoscopic exam revealed retinal calcifications. this caused a clinical concern for retinoblastoma and ct and mri of the orbits were obtained. ct demonstrated profound dilatation of the left lateral ventricle with only a thin rim of cortex surrounding it. there was some midline shift to the right with mild dilatation of the right lateral ventricle. the thalami and brainstem were spared. there were multiple soft tissue bodies that layered in the dependent portion of the left lateral ventricle, which were isodense to grey matter. mri revealed similar findings consistent with hemihydranencephaly involving the left cerebral hemisphere. there were multiple round soft tissue masses that measured up to cm in size that layered posteriorly in the left lateral ventricle. these masses were isointense to grey matter on t and hyperintense on t . when the patient was placed with his head turned to the left, these masses moved to the dependent portion of the left lateral ventricle. the orbits were normal on both ct and mr. these soft tissue collections are presumed to be mobile collections of infarcted brain tissue. this unusual appearance has not been described in the radiology literature. we review the ct and mr findings and review the relevant literature. purpose or case report: citrullinemia type i is a rare inborn error of urea cycle metabolism resulting in hyperammonemia. in the classic form, the newborn presents with poor feeding, vomiting, progressive lethargy and signs of increasing intracranial pressure - days after birth, rapidly progressing to apnea, coma and death if left untreated. we present a case of a term infant who presented to the hospital on the th day of life with a typical history of poor feeding and profound hypotonia. upon admission he had multiple episodes of apnea and hemodynamic instability prompting intubation and intensive support. laboratory evaluation revealed multiple abnormalities, most notably, hyperammonemia ( umol/l) and elevated citrulline (> umol/l). mri of the brain performed on the th day of life showed findings consistent with term hypoxic ischemic encephalopathy with restricted diffusion in bilateral rolandic cortex and subcortical white matter, bilateral caudate heads and lenticular nuclei, bilateral insular cortex, and bilateral cerebral peduncles. the genu of the corpus callosum, bilateral deep frontal white matter, and the left parietal white matter also demonstrated restricted diffusion suggesting infarction secondary to thrombosis of deep intramedullary veins. an area of restricted diffusion in the right parietal cortex was suspicious for superficial venous infarct. review of the literature reveals that this case of neonatal citrillunemia has unique mri findings. while our patient had diffusion changes with some shared similarities to the previous two cases in the literature, there are also findings consistent with deep intramedullary venous thrombosis and infarction. poster #: cr- duplicated internal auditory canal: a rare anomaly of the temporal bone ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: duplicated internal auditory canal (iac) is a rare anomaly of the temporal bone, which is usually associated with sensorineural hearing loss. only a few cases have been previously described in literature. we describe an extremely rare case of duplicated right internal auditory canal in a six month-old patient with a history of down syndrome. a six month-old male with trisomy presented with profound bilateral sensorineural hearing loss. the patient failed the newborn hearing screening tests. past medical history was unremarkable for recurrent ear infections. on focused physical examination, the auricles were normal appearing. external auditory canals were patent bilaterally revealing clear and translucent tympanic membranes. patient did not reveal a facial palsy. subsequently, a high resolution computed tomography (hrct) of the temporal bone was performed. duplicated appearance of the right internal auditory canal with separation of facial and vestibulocochlear segments was noted. the facial nerve canal demonstrated normal caliber while there was significant narrowing of the cochlear canal near the fundus. significant stenosis of the vestibulocochlear segment of the duplicated iac was identified at the porus acousticus. dehiscent right posterior semicircular canal was also seen. an enlarged right vestibule was also noted. a single iac was identified on the contralateral side with significant stenosis at the porus acousticus. high-resolution magnetic resonance imaging of iac was recommended which revealed normal appearance of the bilateral cochlear and vestibular nerves. duplication of the iac is an extremely rare anomaly involving a redundant osseous canal extending from the cerebellopontine angle through the otic capsule bone toward the labyrinth or cochlea. a duplicated iac may or may not be associated with congenital sensorineural hearing loss secondary to aplasia or hypoplasia of the vestibulocochlear nerve. to evaluate for structural abnormalities that may preclude cochlear implantation, it is important to evaluate pediatric patients with sensorineural hearing loss radiologically. although hrct is the best imaging modality for evaluation of osseous iac, the iac contents are best viewed on mri in oblique sagittal planes of the iac using a -d volumetric steady state sequence. neuroimaging in hemiplegic migraine: cases and review of the literature nicholas v. stence, md, children's hospital colorado-radiology, nicholas.stence@childrenscolorado.org; sita kedia, john a. maloney, jennifer armstrong-wells, timothy bernard purpose or case report: hemiplegic migraine (hm) is a rare variant of migraine with aura. it is characterized by a motor deficit lasting up to h that is fully reversible. little neuroimaging data for hm exists in the literature. we report our experience with two pediatric cases of hemiplegic migraine. we also review published cases of pediatric hm with abnormal findings on neuroimaging. methods & materials: cases and presented to our institution with severe headache (ha), acute right-side weakness, aphasia, and altered mental status (ams), which did not resolve after h. magnetic resonance imaging (mri) and genetic testing are reviewed for these cases. the literature was reviewed for pediatric cases with neuroimaging changes during hm attacks. results: initial mri, including diffusion-weighted imaging (dwi), was negative in both patients within h of onset. repeat mris at h (case ) and h (case ) were both positive for mild hyperintensity on trace diffusion images, and corresponding reduced diffusion on adc maps, involving regions of the cortex and juxtacortical white matter in left middle cerebral artery distributions. these findings completely resolved at months in both cases. mr angiograms (mra) were negative in both cases. case had a family history of migraines and was found to have an unreported mutation in atp a gene at a highly conserved location in vertebrates. case had a family history of hm and was found to have an indeterminant mutation in the cacna a gene. infectious, metabolic and hypercoagubility work up was negative. case required inpatient rehabilitation and at year follow up was requiring speech therapy. case resolved completely. in the literature, cases of hemiplegic migraine with neuroimaging changes were reported. all cases had prolonged hemiplegic migraines (symptoms> h) and showed cerebral edema with or without restricted diffusion. conclusions: all eight hm cases in the literature with abnormal findings on neuroimaging had prolonged attacks. mris for our two cases and two cases reported in the literature were initially normal at admission. mild swelling and restricted diffusion developed in our two cases after h, and resolved on follow up mris. subtle findings on diffusion and t imaging may lag behind the clinical picture in hm, therefore serial neuroimaging may be useful in individuals with prolonged symptoms. most cases eventually show resolution clinically and on mri. correlation of neurosonographic anatomy with matching mr scan planes denise castro, hospital for sick children, denisecastro @ gmail.com; pam rasalingham, omar islam, don soboleski purpose or case report: new high-resolution mr sequences have allowed for exquisive anatomic detail and enables reconstruction of images in any scan plane desired. this ability allows for precise matching of mr image planes with the standard oblique coronal, sagittal and axial images obtained during routine neurosonography. the purpose of this poster is to correlate the morphology demonstrated on neurosonography with the mr image, utilizing this ability in order to enhance our understanding of the neuroanatomy distinguishable on sonographic imaging. we believe this will allow a better appreciation of the subtle differences in echotexture of neuroanatomic structures which are often ignored or overlooked on neurosonography and help improve our detection of subtle sonographic abnormalies. ectopic cerebellum in the posterior cranial fossa: report of a case and review of the literature usha d. nagaraj, md, the ohio state university medical center, usha.nagaraj@osumc.edu; daniel boue, lisa martin purpose or case report: cerebellar heterotopia is a common congenital anomaly frequently encountered in the form of cell rests around the fourth ventricle. however, isolated well-differentiated cerebellar ectopia is extremely rare. of the previously reported cases in the literature, only have presented as a discrete, extraaxial mass and none have been described in the posterior cranial fossa. we present a case of a -year-old male who initially presented with persistent daily headaches. physical exam including a detailed neurologic exam was within normal limits. non-contrast computed tomography (ct) of the brain was initially performed, demonstrating no abnormalities. further work-up with magnetic resonance imaging (mri) was performed, which revealed a well-defined, extra-axial mass superior to the cerebellum and inferior to the tentorium, immediately beneath the vein of galen. the mass was isointense to grey matter on t and t sequences and there was no significant enhancement on post-contrast images. there was mass effect on the vermis and the cerebellar tonsils were displaced mm below the foramen magnum. neurosurgery was consulted and the mass was removed for diagnosis and treatment of the patient's symptoms. the mass was easily identified intra-operatively and gross total resection was accomplished successfully. pathologic analysis of the mass revealed well-formed cerebellar tissue without evidence of neoplasia. to the best of our knowledge this is the only case of ectopic cerebellum presenting as a discrete extra-axial mass in the posterior cranial fossa. our case shows that an extra-axial mass that parallels grey matter on all sequences can be a presentation of ectopic cerebellum. we describe the ct and mri findings, surgical and histopatholgical results and review the relevant literature. pediatric isodense acute subdural hemorrhage jeffrey s. kao, md, msee, university of kansas-wichita, run boston@gmail.com; debbie desilet-dobbs purpose or case report: the density (attenuation coefficient) of subdural hemorrhage (sdh) in computed tomography (ct) is important in assessing the acuity of sdhs. an acute sdh is traditionally described as hyperdense and then becoming isodense in approximately weeks when entering the subacute phase. in this report, we document the case of a pediatric patient with the new appearance of an acute sdh within h of the prior ct that was isodense. greater than % of the collection was isodense, with a small focus of hyperdensity. acute sdhs are known to be isodense to gray matter in patients with anemia (wp smith, am j neurorad ). however, the hemoglobin and hematocrit was within normal limits. in addition, acute sdhs that are only a few hours old can have a mixed hyperdense and hypodense appearance because of uncoagulated blood before clotting takes place (j provenzale, ajr ) . thus, an acute sdh can have an isodense appearance in a non-anemic patient. radiologists should consider the possibility of an acute sdh with an isodense appearance, especially in case of possible non-accidental trauma where timing of an injury is important. undifferentiated sarcoma of the esophagus in an year-old male: case report and radiologic/pathologic correlation michael e. daniel, md, ut southwestern / children's medical center dallas, michael.daniel@utsouthwestern. edu; lisa sutton, sandy cope-yokoyama, neil j. fernandes purpose or case report: mesenchymal neoplasms of the gastrointestinal (gi) tract occur infrequently in the adult and are extremely rare in the pediatric population. the occurrence of these lesions in the esophagus is limited to a collection of case reports in the available literature. most esophageal mesenchymal tumors in the pediatric gi tract are benign leiomyomas. the vast majority of malignant mesenchymal tumors in children are categorized as either sarcomas or gastrointestinal stromal tumors (gist). we report a case of a high grade undifferentiated sarcoma of the distal esophagus in an year-old male. while this tumor most closely resembles a gist, the immunohistochemical profile of the lesion is not typical of any distinct mesenchymal neoplasm. a review of the literature demonstrates a single case report of a likely benign undifferentiated mesenchymal neoplasm of the distal esophagus in an adolescent. to our knowledge, this is the first reported case of an undifferentiated esophageal sarcoma in a pediatric patient. we provide radiologic and pathologic features of the above lesion, and review the typical imaging and pathologic characteristics of mesenchymal gi neoplasms. potential airway management issues in sedated children kimberly fagen, md, ms, children's national medical center, kfagen@childrensnational.org; nadja kadom, ira cohen purpose or case report: many pediatric imaging studies require sedation. it has been shown that a variety of health care professionals other than anethesiologists may provide sedation, including advanced practice registered nurses, nurse practitioners, physician assistants, fellow level trainees, emergency medicine physicians, intensivists, pediatricians and, last but not least, radiologists. moderate sedation, also called "conscious sedation", does generally not require an anesthesiologist as there is usually adequate spontaneous ventilation and no airway intervention required. however, in case of a complication during the imaging study intubation may become necessary. for patients with certain congenital or acquired conditions emergent intubation may be very difficult and should be brought to the attention of an anesthesiologist prior to inducing moderate sedation. the four "d's" is a quick way to assess potentially difficult airways that necessitate consultation with anesthesia prior to moderate sedation: dentition (incisor/tooth size, dental alignment, and macroglossia), distortion (swelling from infection, tumor, or trauma), disproportion (hyoid-chin ratio, such as with micrognathia), and dysmobility (jaw or cervical spine movement issues, i.e. trauma or atlanto-occipital instability). presence of some of these features may be an indication to consider general anesthesia for sedation; at the very least, anesthesiologist's awareness of a potentially difficult intubation adds to patient safety during moderate sedation. purpose or case report: lymphangiomatosis describes the presence of multiple lymphangiomas often with multiorgan involvement; typically bones, spleen, mediastinum and lungs. although lymphangiomatosis has been described in patients ranging from birth up to years, it most frequently presents in childhood. the lesions can occur in any tissue in which lymphatics are normally found, with a predilection for neck and chest involvement. the clinical presentation is variable including pleural or pericardial effusion, hemoptysis, protein wasting enteropathy, peripheral edema, hemihypertrophy and disseminated intravascular coagulopathy. the coexistence of lytic bone lesions and chylothorax serves as an important diagnostic clue. we describe typical radiographic, ct and mri findings in the appropritate clinical setting that narrow the differential diagnosis and raise concern for this rare entity as the etiology for the patient's symptoms. we report a -year-old girl and year-old boy with pulmonary lymphangiomatosis with typical presentation and imaging findings. results: bilateral interstitial infiltrates, pericardial and pleural effusions are evident on chest radiograph. sampling of the pleural fluid demonstrates chylous effusion. ct scans of the thorax reveal diffuse smooth thickening of interlobular septa and bronchovascular bundles with extensive infiltrative involvement of mediastinal fat. osseous and splenic lesions are demonstrated both on ct and mr. differential diagnosis includes interstitial edema, lymphoma and sarcoidosis. conclusions: the natural history of pulmonary lymphangiomatosis is characterized by progressive growth and compression of adjacent structures. therapy should aim to decrease the compressive effects, to control chylous effusions, and to maintain cosmesis. the success of surgical resection is limited by inability to separate lymph collections from normal structures. characteristic clinical and radiographic presentation, chylothorax, and extrathoracic lymphatic dysfunction should prompt a consideration of lymphangiomatosis and prevent delay in diagnosis. aortic arch congenital anomalies: what the radiologist needs to know luana stanescu, radiology, seattle children's hospital, stanescu@u.washington.edu; stephen done purpose or case report: . review classic imaging findings in congenital aortic arch anomalies which can improve detection on radiographs and barium esophagogram . describe pertinent embryologic basis of the radiologic findings . describe correlative imaging findings on ct and/or mri in dedicated cases . describe common diagnostic pitfalls methods & materials: after obtaining institutional irb approval we reviewed various patients presentations with this condition and analyzed images to characterize this particular entity and it's manifestations for better definition of diagnostic criteria. results: radiographs and barium esophagogram: algorithmic approach in reviewing chest radiographs in order to improve detection of aortic arch anomalies; classic findings and common pitfalls. cross-sectional imaging (ct and mri): what the surgeons need to know before surgical repair; detection of associated cardiac anomalies. sample cases: double aortic arch, double aortic arch with complete or partial atresia of one of the arches. conclusions: major teaching points of this exhibit are: . review of classic features of congenital aortic anomalies on radiographs, esophagogram, ct and mri with pertinent embryologic basis . describe the utility of various imaging modalities in congenital aortic anomalies, emphasizing common pitfalls. cardiovascular and mediastinal imaging in children with unexpected clinical presentation shunsuke nosaka, md, radiology, national center for child health and development, nosaka-s@ncchd.go.jp purpose or case report: children with cardiovascular and mediastinal diseases can be congenital or acquired in etiology. they usually present with straightforward clinical course. in certain situation, however, some of the children show unexpected clinical presentation predominantly with those of neighboring organs such as respiratory tract, hepatobiliary system, and gastrointestinal tract. these unexpected presentations can be the cause of delay in proper diagnosis and treatment. the purpose of this exhibit is demonstrate a variety of imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. this exhibit is case based presentation of cardiovascular and mediastinal imaging in children including tips, pitfalls and lessons learned among patients presented with unexpected clinical presentation. diagnostic imaging modalities for cardiovascular disease usually consist of various combinations of plain radiography, ultrasound, ct, mr imaging, fluoroscopy, nuclear medicine, and angiography. the general concept of alara-as low as reasonably achievable-should always be utilized when radiation-producing modalities are indicated in children. the diseases included will be double aortic arch found during workup for the cause of aspiration pneumonia, unilateral pulmonary vein atresia presented with recurrent episodes of pneumonia, severe mitral regurgitation secondary to chordal rupture mimicking fluminant hepatic failure, myocarditis initially present as acute abdomen, cardiomyopathy as unusual initial presentation of neuroblastoma, and thymolipoma mimicking gradual development of cardiomegaly. conclusions: it is important for radiologist to be familiar with imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. cardiac embryology made easy: a novel teaching approach using claymation andrew phelps, children's hospital boston, aphelpsmd@ gmail.com; purpose or case report: congenital heart disease can be an intimidating subject for radiology residents, and cardiac embryology is key to its understanding. however, this can be an equally intimidating topic to teach! various diagrams and animations are available in textbooks and online, but much like advanced origami, many of these resources suffer from being visually too complex for the first-time learner. to overcome this teaching obstacle, i created my own cardiac embryology animations using modeling clay and incorporated them into a comprehensive didactic lecture on congenital heart disease. methods & materials: cardiac embryology animations were created using modeling clay, a digital camera, and microsoft powerpoint. surface and cross-sectional views were generated, depicting the key events in cardiac embryology: heart tube formation, cardiac looping, chamber division, truncus arteriosus division, and pulmonary venous connection. example models are shown in figure . results: in this lecture, the animations are presented alongside actual embryonic heart photographs. the lecture then uses the embryology knowledge as a basis to explain the common congenital heart diseases and their mri appearances. examples of septal defects, ventricular hypoplasia, and transposition of the great arteries are presented, among others. conclusions: understanding cardiac embryology is required in order to approach congenital heart disease in a logical fashion. modeling clay animations are a cheap and easy way to simplify this complex topic. arterial tortuosity syndrome: an introduction to the clinical and radiologic manifestations in the pediatric population neal desai, umkc som, neal @gmail.com; suchit patel, ayushi gupta, marius hubbel, doug rivard purpose or case report: . to describe the clinical findings of arterial tortuosity syndrome and give a brief discussion of the disease process. . to describe the radiologic manifestations of arterial tortuosity syndrome. . to give a brief discussion of loeys-dietz syndrome-a disease with similar arterial findings, but with unique molecular characteristics from arterial tortuosity syndrome. . to use this knowledge to help establish the diagnosis and reduce mortality. methods & materials: arterial tortuosity syndrome overview • epidemiology • molecular basis • pathophysiology • review of signs, symptoms and presentation • brief discussion of treatment differential diagnosis of arterial tortuosity syndrome • loeys-dietz syndrome-similarities and differences radiologic findings and discussion • chest radiograph • computed tomographic angiography • magnetic resonance angiography-neck • magnetic resonance angiography-head • conventional angiography making a diagnosis • sample case report • review questions conclusions: arterial tortuosity syndrome is a rare disease whose chief manifestation is severe cardiovascular connective tissue defects. due to the nature of these defects and the significance of rapid intervention, it is important to be aware of and recognize the radiologic manifestations associated with arterial tortuosity syndrome in the presence of appropriate clinical history to help offer a better prognosis to the patient. dynamic pulmonary computed tomography for evaluation of cardiopulmonary disease shilpa v. hegde, md, arkansas childrens hospital, university of arkansas, shilpavhegde@gmail.com; s. bruce greenberg purpose or case report: dynamic pulmonary computed tomography (dpct) is a wide-detector ct technique that allows for continuous chest imaging during respiration. when combined with intravenous contrast, the technique is a unique tool for evaluation of cardiopulmonary abnormalities in children with cardiopulmonary abnormalities. the purpose of this poster is to illustrate the technique of dpct for evaluation of cardiopulmonary disease in children with congenital heart disease and persistent respiratory distress. methods & materials: methods and materials: dpct exams with intravenous contrast were performed on infants with a history of congenital heart disease and palliative surgery. four continuous msec gantry rotations were obtained with respiratory rates set at /minute. the imaging was accomplished during the time of a single respiratory cycle. kvp and low ma resulted in effective dose of≈ . msv. eight respiratory phases were reconstructed to create d and mpr cine loops for evaluation of cardiopulmonary abnormalities. results: cardiopulmonary abnormalities were detected in all patients. patency of sano shunt, blalock tausig shunt or patent ductus arteriosus stent was established. intimal thickening was identified in one sano shunt. hypoplastic branch pulmonary arteries were present in infants and pulmonary vein thrombosis in infant. left bronchomalacia was identified in four of five infants and best or only identified on the expiratory phase of respiration. left lung air trapping was present in two patients. conclusions: dpct with intravenous contrast is the ideal study for evaluation of the post-operative infant with congenital heart disease and persistent respiratory distress. the role of low-dose ct angiography in the evaluation of renovascular hypertension in children jessica kurian, md, chop, kurianj@email.chop.edu; monica epelman, kassa darge, els nijs, jeffrey hellinger purpose or case report: historically, the evaluation of renovascular hypertension has been accomplished via us and conventional angiography. based on the reported adult experience we introduced renal ct angiography (cta) for the evaluation of renovascular hypertension in mid- . our institution has a robust, well-established protocol, which results in reproducible, high quality images. we aim to present our imaging strategies for the evaluation of these patients and to discuss and illustrate the role of low-dose cta with -d imaging as a noninvasive alternative in the evaluation of pediatric renovascular hypertension. methods & materials: we used our department information system to identify pediatric patients (< years of age) who had documented renovascular hypertension confirmed either by conventional angiography and/or surgery during a -year period. we present our protocol and discuss the indications, limitations and benefits of renal cta. ct thin slice data, obtained employing dose reduction strategies, was reviewed and reconstructed in d and d renderings. pertinent us and mr studies as well as demographic and clinical data were reviewed and recorded. several causes for renovascular hypertension were documented and relevant ct angiographic findings were selected for presentation. results: radiation dose ranged . - msv. fibromuscular dysplasia was the most common diagnosis followed by neurofibromatosis type . vascular pathology included stenoses, beading, occlusions, and aneurysms. disease was noted in the extraparenchymal renal arteries in approximately % of the cases. the choice of the imaging modality for the investigation of renovascular hypertension in pediatric patients remains controversial. in the authors' experience, cta with -d imaging is a valuable, non-invasive diagnostic tool for the evaluation of pediatric renovascular hypertension. low dose protocols can reduce the radiation exposure associated with ct. this method can spare patients the complications associated with conventional angiography. fetal mri: brain, head and neck malformations-a pictorial essay sumit singh, md, children's hospital of wisconsin, sumitsingh @yahoo.com; mohit maheshwari, teresa c. gross kelly, tushar chandra, ibrahim s. tuna, craig johnson purpose or case report: the purpose of the exhibit is to illustrate various brain, head and neck massses/vascular anomalies on fetal mri. we will also briefly discuss the normal fetal brain anatomy as seen on fetal mri. methods & materials: major indications for fetal mri include evaluation of inconclusive sonographic findings in cases of cns malformations. in our institute patients are scanned on . t mr scanner. a body surface six channel phased array coil is used to maximize signal to noise. all the scans are checked by a neuroradiologist to make sure adequate plane imaging of the brain or other lesion in question were performed. plane scanning of the fetal body is also performed for the laterality determination of the lesion and also screen for other congenital anomalies. results: prenatal usg is frequently inconclusive for evaluation of complex fetal brain and head and neck anomalies. most studies suggest that mri after first trimester is safe. in addition, advent of rapid mri sequences like single shot fast spin echo (ssfse) have helped in reducing scan time and motion artifacts leading to availability of diagnostic quality images. these have led to increasing use of mri as supplemental tool to further investigate inconclusive fetal sonographic findings. mri provides better anatomical delineation of these complex abnormalities. it helps in making appropriate diagnosis with high confidence and aids in appropriate obstetric and prenatal/neonatal surgical planning or intervention. this educational exhibit will illustrate few common fetal anomalies. these will include agenesis of corpus callosum, malformation of cortical development, posterior fossa malformations, ventriculomegaly, in-utero stroke, orbital abnormalities and some fetal neck masses/ vascular malformation. correlation and confirmation with the postnatal mri will also be provided for some cases. conclusions: technical and therapeutic advances have driven the development of fetal mri. it is an important adjunctive tool for prenatal imaging in those instances in which a complex anomaly is suspected by sonography, when fetal surgery is contemplated, or when a definitive diagnosis cannot be determined. it has prognostic implications and may help in optimal and timely obstetric and neonatal management. purpose or case report: this educational report will provide a review of the imaging appearance of intradiaphragmatic and subdiaphragmatic pulmonary sequestrations on fetal mri. the proposed pathophysiology, review of sequestration subtypes, and surgical management options will also be described. case examples will be provided to illustrate the fetal mr imaging findings of these variants of pulmonary sequestration that help support the diagnosis. specifically a "triangle sign" of t hyperintense tissue directed toward the diaphragm will be demonstrated. illustrative case examples will be placed in the context of a differential diagnosis for subdiaphragmatic masses seen on prenatal imaging. imaging signs that help make a diagnosis of these pulmonary sequestration variants and separate this entity from other lesions will be emphasized. poster #: edu- mri of the fetal head and neck masses alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; joshua shimony, per amundson purpose or case report: fetal magnetic resonance imaging (mri) is a useful problem solving tool for abnormalities detected by prenatal ultrasound (us). masses of the head and neck region can vary from benign incidental lesions to devastating neurological lesions and life threatening tumors. we share our experience in characterizing these lesions by prenatal mri, that can have a bearing on follow up imaging, perinatal management and overall prognosis. we did a retrospective review of all fetal mri studies performed at our tertiary care children's hospital between / and / , to identify fetuses with head and neck masses. we reviewed the maternal demographic and clinical data, prenatal ultrasound, fetal outcomes and post natal imaging (when available). results: out of the fetal mri studies, had dominant head and neck masses. majority were encephaloceles ( occipital, parietal). the remaining included variety of masses such as nasal glioma, teratoma ( ), epidermoid cyst, hemangioma and lymphatic malformation ( ) . mri played a useful role in distinguishing encephaloceles from other masses based on underlying bone defect and intracranial extension. it also helped in characterizing other masses based on location and signal characteristics. the presence and degree of airway compromise was determined. intracranial anomalies associated with encephaloceles including callosal dysgenesis, cerebral and cerebellar hypoplasias, migrational disorders and spinal anomalies were also correctly identified. conclusions: we present the prenatal mr imaging findings of a spectrum of head and neck lesions, correlating with prenatal ultrasound, postnatal imaging and clinical or pathological outcomes. purpose or case report: the immaturity of the cns in neonatal infants makes neurologic assessment difficult. neuroimaging plays an essential role in the assessment of brain injury by helping to indentify the injury and expected neurologic outcome. cranial ultrasound (us) is usually the first neuroimaging modality used since the technique is portable, does not involve radiation and can be used sequentially. magnetic resonance imaging (mri), however, is the most sensitive imaging modality for the detection of hypoxic brain injury. the goal of this presentation is to compare the us and mri performed within a -hour interval, and evaluate these findings to improve the interpretation of the us which is usually the first methodology used to evaluated these patients. we performed a retrospective review of the neonatal imaging studies with us and mri performed within -hour interval on preterm and term newborns with clinical history of hypoxia-ischemia. the imaging findings of the two modalities, mri and us, were correlated with the pattern and severity of the injury and brain maturity. results: diffuse white matter abnormalities were observed in % of the patients by us or mri. the ultrasound identified diffuse increased echogenicity which did not show correlation with mri in % of patients. focal white matter abnormalities were better identified by mri on non-cavitary leukomalacia which is the most common pvl observed in premature neonates with low birth weight and the most difficult to identified using us. cavitary leukomalacia showed strong agreement in both methodologies. the mri identified % more cases of intraventricular hemorrhage, however, the corresponding increase in hemorrhage was of minimal clinical significance. in most cases extra axial hemorrhage was better identified by mri. conclusions: after viewing this exhibit, the viewer will gain a better appreciation and understanding of the neuroimaging characteristics of hypoxia-ischemia in us and mri, and thus improving the interpretation of the us which is usually the first imaging modality used to evaluate this patient population. purpose or case report: the most common thoracic lesions found on prenatal imaging, congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital diaphragmatic hernia (cdh), usually have characteristic imaging findings previously described in detail. however, common entities presenting with atypical findings and rarer thoracic entities do occur and can be characterized by fetal magnetic resonance (mr) imaging. the purpose of this educational exhibit is to show examples of atypical presentations of common thoracic lesions and more unusual thoracic entities on fetal mr. when applicable, prenatal mr is compared with prenatal ultrasound, postnatal imaging, operative findings, or pathology. methods & materials: using a radiology information system database, the reports of all fetal mr exams at our institution from january through january were reviewed. when unusual thoracic findings were described in the report, all prenatal and postnatal images (when available) were evaluated. in the cases selected, medical charts were reviewed for operative findings and pathologic reports. results: the cases to be described, both pulmonary and extrapulmonary in location, include: hybrid lesion in a horseshoe lung, cpam extending across the midline, bilateral bps, bps located within the mediastinum, bps located within the leaves of the diaphragm, ectopia cordis and cdh as components in pentalogy of cantrell, cdh with herniation of liver into the pericardium, elongated esophageal duplication cyst, chest wall lymphatic malformation, and tight double aortic arch causing congenital high airway obstruction syndrome (chaos). conclusions: after studying this educational exhibit, the reader will be acquainted with a variety of unusual fetal pulmonary and extrapulmonary lesions, with emphasis on fetal mr. prenatal and postnatal imaging findings in megacystis-microcolon-intestinal hypoperistalsis syndrome (mmihs) mary kitazono, chop, mkitazono@gmail.com; richard bellah purpose or case report: to review the classic constellation of findings seen in prenatal and postnatal imaging of megacystis-microcolon-intestinal-hypoperistalsis syndrome (mmihs), as well as to illustrate additional imaging features that are variably seen in this syndrome. the imaging database at our children's hospital was searched for all cases of mmihs diagnosed since . all available prenatal and postnatal imaging studies were reviewed in patients with a diagnosis of mmihs, and representative images are provided with a description of the findings. results: since , patients ( girls, boy) have been diagnosed with mmihs at our institution, including on prenatal mri and us. the characteristic prenatal imaging findings include marked urinary bladder distension, bilateral pelvicaliectasis, and dilated, tortuous ureters, as well as a diminutive colon containing no or minimal t w-hyperintense meconium on mri. postnatal imaging studies also characteristically demonstrate a massively distended urinary bladder (with no apparent mechanical cause of obstruction) as well as a small, unused colon with dilated, hypoperistaltic small bowel seen proximal to the microcolon. additional findings which are variably seen include intestinal malrotation, stomach and esophageal hypoperistalsis or aperistalsis, gastroesophageal reflux, and biliary stasis. conclusions: although a rare syndrome, the constellation of imaging findings in mmihs is pathognomonic, and recognition of the classic pattern of findings can allow the radiologist to make a diagnosis of mmihs in both the in-utero and postnatal setting. early diagnosis is essential for allowing prenatal counseling regarding this generally fatal disorder, as well as to optimize early management options. purpose or case report: gastric mass lesion are uncommon. this presentation is an educational review of pediatric gastric mass lesions including gastro-intestinal stromal tumor (gist), inflammatory myofibroblastic tumor (pseudotumor). burkitt's lymphoma, squamous cell carcinoma, gastric teratoma, gastric varices, gastric hamartoma, gastric polyp and hypertrophic pyloric stenosis (hps). clinical presentation is varied with upper gi bleeding, feeding intolerance, pain, weight loss and fatigue manifesting. the imaging work-up might initially have been endoscopy or ultrasound. cross section imaging (ct mr) can be invaluable. the role and impact of fdg pet on the management, staging and follow up of the oncologic pathology will be emphasized. imaging findings in megacystic microcolon intestinal hypoperistalsis syndrome, a rare disease kiery braithwaite, pediatric radiology, emory-egleston, kieryb@yahoo.com; kiery braithwaite, paula dickson, marianne m. ballisty purpose or case report: megacystis microcolon intestinal hypoperistalsis (mmih) syndrome is a rare congenital form of severe functional intestinal obstruction which is more commonly found in females. the presenting clinical and imaging features of this disease can often mimic other causes of proximal bowel obstruction in the neonate. in combination with its common association with intestinal malrotation, the clinical picture of mmih syndrome may be confusing at times. awareness of additional imaging features characteristic of mmih syndrome may help the radiologist suggest this diagnosis. the purpose of this study is to enhance the ability of the pediatric radiologist to suggest this rare diagnosis by recognizing this unusual constellation of imaging features. we retrospectively reviewed the clinical data and imaging studies of four patients with mmih syndrome at our institution. imaging studies included plain radiography, ultrasonography, fluoroscopy, and cross sectional imaging. the initial presentation and clinical outcome was also reviewed. results: the clinical presentations of our patients, who were all female, were somewhat varied but typically included symptoms of intestinal obstruction. the diagnosis of mmih syndrome was made in our patients from the first few weeks of life through early childhood. the four patients demonstrated imaging features characteristic of this disease including a very large dilated bladder, severe bilateral hydroureteronephrosis, gaseous distention of the stomach and proximal small bowel, intestinal hypoperistalsis, and a very small colon. the clinical course of these patients that we observed was also quite variable, with some patients dying in neonatal period while another patient continues to do reasonably well at years old after a multi-organ transplant. conclusions: mmih syndrome is a rare and frequently lethal disease. the ability of the pediatric radiologist to recognize this constellation of imaging findings can help the clinical team arrive at a diagnosis of mmih syndrome. more prompt diagnosis can aid in the development of a long term management plan for the patient and in counseling the family regarding the prognostic implications of this disorder. pathologies of omphalomesenteric duct remnant: radiologic-surgical correlation swapnil bagade, md, pediatric radiology, mallinckrodt institute of radiology, bagades@mir.wustl.edu; geetika khanna, rebecca hulett purpose or case report: . to facilitate understanding of embryology of the omphalomesenteric(vitelline) duct and normal anatomy of the umbilicus. . review the spectrum of omphalomesenteric duct malformations and diversity of clinical presentations of these remnants. . illustrate the imaging findings of omphalomesenteric remnants, from the common such as meckel's diverticulum to the uncommon such as the omphalomesenteric duct cyst, with surgical correlation. methods & materials: cases with complications of persistent omphalomesenteric duct were collected from the joint surgery/radiology conferences at a tertiary level children's hospital. imaging features were correlated with intraoperative findings. conclusions: preoperative diagnosis of complications related to the omphalomesenteric duct remnants can be challenging because clinical and imaging features overlap with other etiologies of acute abdomen. knowledge of the embryologic, clinical, radiologic, and surgical characteristics of omphalomesenteric duct remnants will aid in early and accurate diagnosis. neonatal bowel obstruction-a pictorial essay tanmay patel, university of kentucky; harigovinda challa purpose or case report: bowel obstruction is the most common abdominal emergency in the newborn period and in most cases is secondary to a congenital anomaly requiring early surgical intervention. however not every case of abdominal distension or dilated bowel is secondary to mechanical bowel obstruction or underlying surgical condition. radiologic imaging forms a central role in the work up of newborns with suspected intestinal obstruction. the role of the radiologist is to identify whether or not mechanical obstruction is present; if obstruction is identified on initial radiographs, to determine the level of obstruction, and finally to identify the etiology of obstruction. initial plain radiographic evaluation also helps to determine the subsequent diagnostic or therapeutic approach. methods & materials: a retrospective review of multiple radiographic and fluroscopic examinations in patients with diagnosis of neonatal bowel obstruction was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: neonatal intestinal obstruction generally presents with nonspecific symptoms such as abdominal distention, vomiting, or failure to pass meconium depending on the level of obstruction and time of occurrence of underlying congenital lesion/atresia in the intrauterine life. initial plain radiographs of the abdomen reveal dilated bowel loops when obstruction is present. high intestinal obstruction is suspected when only few dilated loops are identified, while multiple dilated bowel loops are seen in low obstruction. most cases of high obstruction may not need another diagnostic imaging test. all cases of distal intestinal obstruction require water soluble enema to identify the etiology of obstruction. in conditions like functional immaturity of the colon, and meconium ileus water soluble enema is therapeutic and thus surgery can be avoided in most cases. the objective of this presentation is to present an educational exhibit of classical imaging findings of various types of neonatal bowel obstructions, and how to differentiate between them. conclusions: bowel obstruction is the most common abdominal emergency in the new born period. most cases are secondary to a congenital surgical condition and early diagnosis and treatment significantly reduces mortality and morbidity. radiographic evaluation plays a central role in the diagnosis and treatment of these conditions. poster #: edu- d t -weighted mrcp in the pediatric population-a pictorial review nathan egbert, mbbs mph, university of michigan, nathaneg@med.umich.edu; jonathan r. dillman, peter j. strouse purpose or case report: to demonstrate the utility of d t -weighted magnetic resonance cholangiopancreatography (mrcp) in the pediatric population, and to illustrate the mrcp findings of various conditions affecting in the pediatric pancreaticobiliary system. we identified all mrcp exams performed on pediatric patients (< years of age) from january , through august , by searching institutional electronic medical records. we then identified representative d t -weighted mrcp images of various conditions affecting the pediatric pancreaticobiliary system. results: representative d t -weighted mrcp images (including source, maximum intensity projection, and volume rendered images) from the following conditions will be presented: abnormal biliary narrowing/stricture (including sclerosing cholangitis, anastomotic strictures following kasai procedure & liver transplantation, and "pseudostricture"), biliary atresia, choledochal cyst (including various subtypes, based on todani classification), choledocholithiasis & cholelithiasis, congenital anomalies of the pancreaticobiliary system (including pancreas divisum and anomalous pancreaticobiliary junction), pancreatobiliary system trauma (including main pancreatic duct transection), and other rare conditions affecting the pancreaticobiliary system (including rhabdomyosarcoma of the biliary tree). conclusions: d t -weighted mrcp has become an extremely useful tool in the evaluation of children with suspected disorders of the pancreaticobiliary system. since mrcp has distinct advantages over alternative diagnostic techniques, such as endoscopic retrograde cholangiopancreatography (ercp) or percutaneous cholangiography, including lack of ionizing radiation and noninvasiveness, mrcp is a much preferred initial study for pediatric pancreaticobiliary imaging. this pictorial review is intended to highlight the d t weighted mrcp appearances of various pancreaticobiliary conditions occurring in the pediatric population. purpose or case report: magnetic resonance enterography (mre) is rapidly emerging as an important imaging tool for the diagnosis and follow-up of inflammatory bowel disease (ibd). its lack of ionizing radiation makes this imaging modality especially vital to the pediatric population. using a casebased approach, we will demonstrate the usefulness of diffusion-weighted imaging (dwi) as part of a comprehensive mre protocol for the assessment of ibd in children. the basics of dwi will be discussed with particular attention to abdominopelvic techniques. the role of mre dwi for the evaluation of pediatric crohn disease (cd) and ulcerative colitis (uc) will be reviewed using a case-based approach. key images from pertinent imaging studies will be identified by searching institutional electronic medical records and presented with relevant clinical data. results: a review of pediatric mre examinations suggests dwi can be used to detect the following: ) small and large bowel segments affected by ibd (both cd and uc) ) abdominopelvic abscesses (including within the mesentery, body wall, iliopsoas muscle, and liver) ) abnormal lymph nodes ) sacroiliitis ) perianal disease (including abscesses and other penetrating complications). conclusions: dwi has the potential to play a very important role in the diagnosis and follow-up of pediatric ibd. this mre technique is particularly useful for detecting a variety of disease-related complications. as the exact meaning of bowel wall restricted diffusion is poorly understood to date, continued investigation will be necessary to determine the clinical and histologic significance of this finding. cases of cf involving the gi tract were collected from clinical workflow encounters of the authors and from the main hospital medical records database. relevant imaging studies were reviewed for known gi manifestations of cf. these imaging studies were correlated with clinical histories and available intraoperative and pathologic findings. results: cf involvement of the gi tract presents over a wide range of ages, organs involved, and associated symptoms. these manifestations can generally be divided anatomically into those involving the alimentary tract, hepatobiliary system, and pancreas. alimentary tract manifestations consist of meconium ileus in uncomplicated and complicated forms (with the latter including secondary intestinal atresia, volvulus, and perforation with meconium peritonitisdistal intestinal obstruction syndrome, constipation, rectal prolapse, duodenal fold thickening, and appendiceal dilation. hepatobiliary disorders secondary to cf include microgallbladder, cholelithiasis, biliary ductal abnormalities, neonatal hepatitis, and cirrhosis (including complications such as portal vein thrombosis and ascites). pancreatic expressions of cf include fatty infiltration, calcifications, and cysts/ cystosis, frequently in the setting of malnutrition and/or stooling abnormalities. this exhibit will demonstrate the spectrum of clinical and radiologic gi findings in this disease from the fetal and neonatal period through adolescence across a range of imaging modalities. conclusions: gastrointestinal manifestations of cystic fibrosis occur frequently in the pediatric population and may be the earliest clinical expression of the disease. familiarity with the variety of gastrointestinal imaging findings of cystic fibrosis can expedite appropriate diagnosis and therapy, particularly in those children in whom the primary disease is not clinically suspected. beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix kelly dietz, md, cincinnati children's hospital; arnold c. merrow, daniel j. podberesky, alexander j. towbin purpose or case report: primary acute appendicitis (or appendiceal inflammation caused by a superimposed bacterial infection in the setting of appendiceal obstruction) is by far the most common pathology of the appendix, and imaging evaluations to exclude this diagnosis occur daily in the pediatric radiology setting. the clinical and imaging differential diagnosis in a patient with right lower quadrant pain and suspected appendicitis is a broad but well-recognized list that predominantly involves structures adjacent to the appendix including the ovaries, small and large bowel, and ureters. there are, however, less common pathologies primarily involving the appendix which can create an imaging diagnostic dilemma in the setting of right lower quadrant symptoms. our goal is to review the imaging and clinical manifestations of these less commonly encountered appendiceal abnormalities. methods & materials: cases of appendices that were abnormal by imaging but ultimately determined not to be due to primary acute appendicitis were collected from clinical encounters by the authors as well as through a search of the radiology and pathology report databases. clinical course, surgical findings, and pathology reports (if available) were subsequently reviewed through the main hospital medical records system. results: the collected cases demonstrate a wide range of additional pathologies of the appendix outside of primary acute appendicitis. a variety of imaging modalities were employed in the workup of these cases. examples reviewed in this exhibit include crohn's disease, ulcerative colitis, cystic fibrosis, carcinoid tumor, inguinal hernia with incarceration, retained foreign body, pinworm infestation, and ileocolic intussusception. conclusions: despite the frequency of primary acute appendicitis, there is a differential diagnosis when an abnormal appendix is found by imaging. familiarity with these alternative diagnoses may be particularly helpful in guiding management of the patient whose clinical presentation is not typical for primary acute appendicitis. methods & materials: a hospital pacs database search from the past years for patients with bws. selected cases, with multimodality imaging, were cross-referenced with pathology reports from patient records database. results: intricate abdominal pathologies are depicted utilizing multimodality imaging, such as plain films, us, ct, mri and pet/ct, and with pathologic correlation. cases with highlight the following: liver: hepatoblastoma, nonspecific hepatobiliary cysts, multiple hemangiomas mimicking metastatic disease; adrenal: dysplastic organomegaly mimicking neoplasm; pancreas: diffuse and focal hyperplasia in the setting of hyperinsulinism, organomegaly; renal: neprocalcinosis, including medullary sponge kidney, nephroblastomatosis, organomegaly; adnexal: ectopic paraovarian adrenal tissue mimicking metastatic lymph node; urinary bladder: benign fibro-uroepithelial polyp. conclusions: diagnosis of bws can be difficult when the classic clinical and radiological findings are not present. these few cases highlight the unusual abdominal pathologies, so when detected, a radiologist can aid in the appropriate diagnosis and help guide therapy for these young patients. this poster will discuss pharmaceuticals the fda considers investigational for their intended use. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. radiologic-pathologic review of pancreatic masses encountered at a tertiary pediatric hospital over a -year period no kwak, md, radiology, long island jewish medical center, kwak_nb@yahoo.com; karen naar, jeanne choi-rosen, lee collins, sukhjinder singh, anna thomas purpose or case report: review of pathologically proven pancreatic masses in pediatric patients encountered at a tertiary pediatric hospital over a -year period. describe the key morphologic features and other pertinent findings using various imaging modalities. correlate pathologic and radiologic findings. methods & materials: illustrate the various imaging characteristics of pathologically proven pancreatic masses including pseudocyst, pancreatoblastoma, solid pseudopapillary tumor, acinar cell carcinoma, ductal adenocarcinoma, lymphoma, pancreatic neuroblastoma, and inflammatory myofibroblastic tumor. correlate pathologic and radiologic findings. identify the key imaging features that allow narrower differential diagnosis. results: pancreatoblastoma and solid pseudopapillary tumor are the more commonly encountered pediatric primary pancreatic tumors. both are bulky and heterogeneously enhancing tumors with solid and cystic elements. pancreatoblastoma occurs more commonly in young children. internal hemorrhage and fibrous capsule favor solid pseudopapillary tumor which more commonly occurs in adolescent girls. ductal adenocarcinoma, acinar cell carcinoma and an inflammatory myofibroblastic tumor, which were pathologically proven in our pediatric patients, are exceedingly rare entities. the imaging findings of these cases and their pathology when available will be presented, as well as a quick literature review of these rare tumors. illustration and correlation of the pathologic and radiologic findings. conclusions: pancreatic masses in children are rare but in general have a better prognosis than in adults. salient imaging findings for the various tumors encountered at a tertiary care center with pathologic and radiologic correlation. evaluation of hepatoblastoma with gadoxetate disodium-typical, atypical, pre and post treatment evaluation arthur b. meyers, radiology, cincinnati children's hospital, arthurbmeyers@yahoo.com; alexander j. towbin, daniel j. podberesky purpose or case report: gadoxetate disodium (gd-eob-dtpa) is a hepatobilliary mri contrast agent that is widely used in adults for characterization of liver tumors and is being increasingly used in pediatric patients. hepatoblastoma is the most common primary hepatic malignancy of childhood. the purpose of this presentation is to describe our experience with the use of this agent in the mri evaluation both before and after initiating therapy in patients with hepatoblastoma. methods & materials: the radiology report system at our institution was queried for all patients with pathology proven hepatoblastomas who underwent a liver mr with administration of gadoxetate disodium between / / and / / . the mr imaging characteristics of the patient's primary hepatoblastoma pre-and post-therapy (when available) and post treatment findings (when available) were reviewed. results: mri studies in different patients were reviewed. the patients ranged in age from months to years. patients had pre and post treatment evaluation with gd-eob-dtpa enhanced mri, patient had only pretreatment evaluation and patients had only post treatment evaluation. of the hepatoblastomas did not take up gd-eob-dtpa during the hepatocyte phase and were therefore low signal intensity during the hepatocyte phase of imaging. this was useful in the pretreatment evaluation of hepatoblastoma, particularly in defining the relationship of the tumor to hepatic and portal veins. post treatment gd-eob-dtpa imaging allowed characterization of the biliary anatomy and demonstrated the communication of a postoperative fluid collection with the biliary tree, consistent with biloma. atypical hepatoblastoma showed uptake of gd-eob-dtpa on hepatocyte phase imaging, similar to what has been described in adults with atypical hepatocellular carcinoma. conclusions: gadoxetate disodium enhanced mri is useful in the imaging evaluation of hepatoblastoma, particularly in defining the relationship of tumor to vascular and biliary anatomy and in characterizing post-treatment complications. disclosure: dr. meyers has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging of the gallbladder and biliary tree in pediatric age group ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; s. pinar karakas, unni udayasankar, neil vachhani, ellen park purpose or case report: interactive educational exhibit to illustrate the embryology, anatomical variants as well as congenital and acquired diseases of the bile ducts and gallbladder in pediatric patients. methods & materials: a)the embryology of the gallbladder and biliary tree will be demonstrated with diagrams. b) imaging techniques for gallbladder and biliary tree including us, ct, mri, ercp and intraoperative cholangiogram will be discussed. c)imaging findings of various lesions with special emphasis on key findings that can lead to accurate diagnosis will be discussed. d)an appropriate list of differential diagnosis will be provided. e)an algorithm for the assessment of suspected biliary pathology will be presented. f)the exhibit will be interactive and the reader will answer questions about the discussed entity, related imaging algorithm and management. results: a)discuss congenital anomalies including duplicated and septated gallbladder, choledochal cyst, caroli disease, situs abnormalities and biliary atresia. b)discuss infectious and inflammatory conditions including cholecystitis, kawasaki's disease, sclerosing cholangitis and hepatitis. c)discuss iatrogenic complications including post transplant biliary stricture and leak. d)discuss benign and malignant neoplasms invoving the gallbladder including polyps, ptld and rhabdomyosarcoma. conclusions: this exhibit will demonstrate a logical approach to imaging of the congenital and acquired diseases of the gallbladder and biliary tree based on the embryology and underlying pathology. postnatal work up of congenital uronephropathies-a pictorial essay harigovinda r. challa, radiology, university of kentucky, hch @uky.edu purpose or case report: the use of obstetric ultrasound routinely in the prenatal care has lead to the discovery of many fetal anomalies. uronephropathies in the newborn represent one of the largest groups of anomalies amenable to neonatal management. since these uropathies are detected mostly in asymptomatic patients the treatment is mainly preventive. the pediatric radiologist has a key role in the post natal work up and management of these patients with prenatally diagnosed neprhouropathies and familiarity with the congenital urinary tract abnormalities is necessary. methods & materials: a retrospective review of multiple radiographic, sonographic and fluroscopic examinations performed in the newborn babies and infants with prenatal diagnosis of urinary tract abnormalities was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: numerous anomalies can be detected in utero, including anomalies of renal number, position, morphology, collecting system dilation and bladder, urethral abnormalities. of these postnatal work of congenital hydronephrosis is the most common routinely encountered clinical entity. renal ultrasound is the initial examination in the evaluation in all cases of prenatal hydronephrosis, which is best performed around postnatal day . if collecting system dilatation persists on postnatal ultrasound, further imaging work up with vcug, radionuclide imaging may be required depending on degree of dilatation. conclusions: uroneprhopathies are increasingly detected in the prenatal life with increasing use of obstetric ultrasound. the objective of this presentation is to demonstrate in a pictorial essay of different neprhouropathies and their workup in newborns. isolated fallopian tubal torsion: causes, imaging findings, and how to suggest the diagnosis jesse courtier, md, ucsf dept of radiology, jesse. courtier@ucsf.edu; amaya m. basta, rebecca maine, pierre-alain cohen, shinjiro hirose, john d. mackenzie purpose or case report: the purpose of this educational report is to describe the rare entity of isolated fallopian tubal torsion in the pediatric population and depict the cross sectional imaging findings that help make a diagnosis and guide management. the proposed pathophysiology, predisposing factors, and surgical management will be described. an illustrative case example of -year-old female patient will be provided with surgical correlation. the exhibit will review imaging findings on us, ct and mri that help support the diagnosis including, dilated tubular structure in the pelvis, normal ovaries, and corkscrewing and beaking of the proximal fallopian tube. isolated fallopian tubal torsion will be placed in the context of a differential diagnosis for girls presenting with pelvic pain and the imaging signs that help make a diagnosis of isolated tubal torsion and separate this entity from other causes of pediatric pelvic pain will be emphasized. multimodality imaging characteristics of genitourinary rhabdomyosarcoma rhea udyavar, md, george washington university medical center, rudyavar@gwmail.gwu.edu; amir noor, pranav k. vyas purpose or case report: in this pictorial essay, we will demonstrate salient imaging features of mr, us, and ct modalities for the diagnosis of genitourinary rhabdomyosarcoma in male (n ) and female (n ) children ages - years, evaluated at our institution over the past years. background information, including tumor biology, staging, and treatment will also be discussed. the swollen scrotum: ultrasound technique and differential diagnosis kelli r. schmitz, md, oregon health & science university, schmitzk@ohsu.edu; roya sohaey purpose or case report: to review the ultrasound protocol for the performance of scrotal ultrasound and illustrate the ultrasound appearance of conditions resulting in scrotal swelling in pediatric patients. a retrospective review of the imaging database at a tertiary pediatric referral center was performed to identify pediatric patients who presented with scrotal swelling and underwent diagnostic ultrasound. when available, surgical/pathologic correlation was obtained. results: a variety of pathologic processes result in scrotal swelling. causes illustrated include: testicular torsion, epididymitis/orchitis, hydrocele, varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular neoplasm. conclusions: the causes of scrotal swelling are myriad, including infectious/inflammatory, developmental, traumatic, and neoplastic etiologies. in children, the clinical presentation of a swollen scrotum is nonspecific, and ultrasound plays a key role in making the correct diagnosis. experiences of starting a functional mr urography program at a university hospital: trials and tribulations steven l. blumer, bsc, montefiore medical center/albert einstein college of medicine, sblumer@montefiore.org; ibrahim tuna, amanda north, benjamin taragin, netta blitman, terry l. levin purpose or case report: starting a functional mru program can be challenging as there are numerous potential hurdles to overcome. this presentation describes the process of starting a functional mr urography (fmru) program at a university hospital and discusses the difficulties encountered starting such a program. selecting a sufficient patient referral base, resolving common and uncommon technological issues, and education of clinicians, patients and technical staff are some of the challenges that will be discussed. conclusions: awareness of the common pitfalls in fmru imaging and close partnering with referring physicians can make establishing a functional mru program easier. despite many potential obstacles, the benefit of exquisite anatomical and functional information provided by fmru in children, without exposure to ionizing radiation, greatly outweighs any challenges. disclosure: dr. blumer has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. pictorial review of ultrasound findings in boys presenting to emergency department/urology with acute scrotum teresa liang, faculty of medicine, university of british columbia, teresaliang @gmail.com; peter metcalfe, william sevcik, michelle noga purpose or case report: testicular torsion is a common acute condition in adolescent boys. rapid and accurate diagnosis is critical. diagnosis is currently based on history, physical findings, and ultrasound (u/s) with doppler. the objective of this poster is to demonstrate ultrasound findings from a retrospective review of acute scrotum over years, and to demonstrate some pitfalls of the technique with regard to testicular torsion diagnosis. we reviewed the u/s, surgical and ed records at the stollery children's hospital for boys aged month to years, presenting with acute scrotum from july , to . age, demographics, clinical symptoms, and physical findings, u/s and surgical techniques, findings, diagnoses and follow-up were also recorded. results: patients presented to uah stollery ed with acute scrotum: were diagnosed with testicular torsion ( inguinal torsion), were suspected of a torsion-detorsion, torsion of appendix testes, epididymitis/orchitis, and other diagnoses including hydroceles, varicoceles, epididymal cysts, abscesses, cellulitis and hematomas. for the patients who had ultrasound, % sensitivity and % specificity for testicular torsion. the ultrasound findings including size, vascularity and echogenicity associated with both salvageable and necrotic testicles including use of color and pulse doppler will be reviewed. the sonographic findings and pictorial examples associated with the more common acute scrotum etiologies will be presented. sonographic findings from problematic cases (those with inconclusive ultrasound reports or false positive reports) will also be addressed. conclusions: ultrasound imaging problem case examples and characteristic findings of common acute scrotum presentations at stollery hospital at the university of alberta are reviewed in this poster. primary and secondary amenorrhea in pediatric patients: from the beginning to the end cesar cortes, md, miami children's hospital, n c @ hotmail.com; yanerys ramos, ricardo restrepo, alejandro diaz, lorena sequeira, edward lee purpose or case report: to describe the role of imaging in evaluating patients with primary and secondary amenorrhea and to illustrate the normal imaging findings of the reproductive organs in the pediatric population as well as the imaging findings of the different etiologies causing amenorrhea. a search of the literature is done to determine the different etiologies of amenorrhea and the role of imaging in their evaluation. first, we will focus on the normal physiologic hormonal influence and changes of the girl's reproductive organs since birth until adolescence on ultrasound and mri. images of the normal appearance of the female reproductive organs as well as imaging findings of the different common and uncommon etiologies of amenorrhea will be shown. then, specific reference will be made to crucial related concepts such as minipuberty of infancy, latest criteria for polycystic ovarian disease and ovarian failure syndrome among others. finally, the treatment, either medical or surgical will be briefly discussed. results: causes of amenorrhea in children range from disorders affecting the hypothalamus, pituitary gland, adrenal glands, and ovaries, as well as uterine and vaginal structural abnormalities. even though history and clinical exam are essential in evaluating a patient with amenorrhea, the pediatric radiologist plays a pivotal role helping guide the area to be imaged and thus the modality that should be used. mri and ultrasound are the main modalities in the evaluation of amenorrhea. conclusions: ultrasound and mri are the main imaging modalities used in the evaluation of amenorrhea in children and are usually part of the work up. amenorrhea in children can have implications in girl's fertility allowing pediatric radiologists to play an important role in helping not only the patient but also their offspring. imaging of mullerian duct anomalies in children kelly k. horst, md, radiology, university of michigan, khorst@med.umich.edu; maryam ghadimi mahani, deepa pai, jonathan r. dillman, peter j. strouse purpose or case report: the purpose of this educational exhibit is to provide an up-to-date appraisal of mullerian duct anomalies presenting in the pediatric population. the appearances of anatomic variants on ultrasound and mri will be used to illustrate the strengths and potential pitfalls of these imaging modalities. methods & materials: patients who have previously undergone ultrasound and/or mri in the course of their clinical workup within the university of michigan health system (umhs) were identified using electronic medical records. imaging reports were reviewed by a single author in order to identify relevant imaging findings (interesting anatomic variations, associated anomalies, etc.). pertinent images from these imaging examinations were de-identified and saved to a secure hard drive. the medical record was accessed by a single researcher to obtain relevant information regarding the patients' clinical presentations. in cases of corrective surgery, pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of mullerian duct anomalies were reviewed within the pediatric population. clinical manifestations were correlated with imaging appearances. conclusions: mullerian duct anomalies represent a range of developmental variants. although functioning ovaries and age-appropriate external genitalia are characteristic, there may be anomalies ranging from uterine and vaginal agenesis, to duplication of the uterus and vagina, to minor uterine cavity abnormalities. müllerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems, and pediatric patients in particular may present with these associated anomalies. menstrual abnormalities may represent a more typical presentation in the adolescent age group. this is in contrast to the adult population, which may be more likely to present with infertility. the variation in clinical presentations make mullerian duct anomalies difficult to diagnose and, because surgical techniques for correction and treatment depend on the underlying anatomy, understanding these variants in the context of imaging studies is important to their diagnosis and management. patient had radiographs which showed an irregular left humeral metaphysis with an associated fracture. patient had a phase bone scan that showed slightly increased uptake on the angiographic and blood pool phases and increased activity on the delayed phase in the right femur. radiographs showed a moth eaten appearance of the right femur with soft tissue swelling. patient had radiographs that showed periosteal reaction in the right tibia with an associated fracture. patient , in addition to radiographs, had an mri that showed osteomyelitis of the left humerus and scapula with an associated subperiosteal abscess. patient had multi focal osteomyelitis that was demonstrated on radiographs by irregular cortices and periosteal reaction involving the upper and lower extremities. conclusions: neonatal osteomyelitis is an uncommon entity that can have severe complications if not diagnosis and treated promptly. it is important to review cases and to review the appearance of neonatal osteomyelitis on multiple modalities. radiographs will usually demonstrate periosteal reaction and possibly soft tissue swelling. additional studies may be obtained to evaluate for complications, such as abscesses or involvement of the joint space. purpose or case report: review the epidemiology of ddh. describe the critical diagnostic imaging findings of ddh. understand the role of imaging accompanying treatment. methods & materials: images including radiographs, ultrasound, ct and mri will be used to demonstrate the current and historical role of imaging in caring for patients with ddh. discussion of the importance of reducing radiation exposure when choosing imaging studies will be included. results: radiographs and ultrasound are used primarily in making the diagnosis of ddh. ultrasound and mri are most often used during the course of treatment to assess its effectiveness. mri is increasingly utilized without sedation for patients in spica cast. conclusions: imaging is critical in the care of patients with ddh. pediatric musculoskeletal ultrasound of the proximal lower extremity (pelvis to thigh) julia rissmiller, md, dept of radiology, children's hospital boston, julia.rissmiller@childrens.harvard.edu; howard christianson, michael j. callahan purpose or case report: to review indications for ultrasound of the proximal lower extremity (pelvis, hip and thigh), and to illustrate the practical use of ultrasound in evaluation of the proximal lower extremity, emphasizing the sonographic appearance of various musculoskeletal disorders. ultrasound is a well-established modality for the evaluation of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. in general, ultrasound has a more limited role for the primary evaluation of other pediatric musculoskeletal disorders including trauma, articular and periarticular diseases and tumors or tumor-like processes. advantages of ultrasound, a relatively non-invasive technique, include excellent spatial resolution, low cost, lack of ionizing radiation, lack of need for sedation, and the ability to image the patient in real-time. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. we present ultrasound examples of pathology involving the proximal lower extremity (pelvis, hip and thigh). cases include developmental hip dysplasia, hip effusion, osseous metastasis to the iliac bone, osteomyelitis of the hip, femoral acetabular impingement, rectus femoris hernia, vascular malformation, ewing's sarcoma and myositis ossificans. results: a range of images from pediatric diagnostic ultrasounds performed of the proximal lower extremity (pelvis to thigh) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: ultrasound is an excellent modality for evaluating the proximal lower extremity in children, beyond the current indications of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. a multi-modality pictorial review of lesions of the epiphysis in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; jacqueline urbine, evan geller, peter pizzutillo purpose or case report: to review the imaging spectrum of epiphyseal lesions in infants and children. a retrospective review of our imaging database was performed to identify studies with either primary lesions of the epiphysis or processes that affect the epiphysis. results: multiple epiphyseal lesions were elucidated primarily by radiography, with cross-sectional imaging included where clinically necessary. congenital lesions include the epiphyseal dysplasias represented here by chondrodysplasia punctata. epiphyseal infarction may due to multiple etiologies including slipped capitol femoral epiphysis, developmental dysplasia of the hip, sickle cell disease, or idiopathic reasons. neoplasms may occur in the epiphysis, including chondroblastoma and histiocytosis. traumatic lesions include fracture and avulsion. osteomyelitis can occur in the epiphysis as well. pseudolesions that mimic pathology will also be reviewed. other pathologies that can affect the epiphysis include juvenile idiopathic arthritis and hemophilia. conclusions: a wide spectrum of congenital and acquired pathologies may affect the epiphysis in the infant and child. plain radiography, computed tomography, and magnetic resonance imaging all contribute to the diagnosis of these varied lesions. purpose or case report: we aim to present the spectrum of common and uncommon hip disorders in pediatric population. we will formulate a systematic approach and present a flowchart to workup and characterize hip diseases. methods & materials: relevant imaging appearances of normal as well as pathological hip will be presented. normal hip anatomy will be discussed through anatomic drawings and radiological images (plain radiographs, ct, usg, and mri). we will illustrate the various anatomic landmarks, measurements and lines on plain radiographs and ultrasound of hip. results: evaluation of limp and hip pain in the pediatric population has undergone rapid evolution. surgical treatment for these disorders continues to be refined, and our ability to identify patients along the spectrum of disease continues to improve. yet, despite our advances, obtaining an accurate diagnosis can remain challenging, especially in the setting of mild structural abnormalities. many imaging studies can be used to evaluate the bones and soft tissues, but conventional radiography is the primary imaging modality for most clinical conditions. plain radiographs usually are obtained first because they are sensitive and specific for a wide range of bone pathology. more sophisticated imaging modalities including radionuclide scintigraphy (bone scan), ultrasonography (usg), computed tomography (ct) and magnetic resonance imaging (mri) are reserved for specific clinical situations. each of these imaging modalities has specific advantages and disadvantages. it is the aim of this review to guide in selecting and interpreting the appropriate imaging modality for a variety of common disorders. this exhibit will illustrate imaging features of developmental dysplasia of hip, perthes disease, slipped capital femoral epiphyses, hip malformations in syndromes, femoral acetabural impingement, labral disorders, septic arthrits and other disorders. the role of various imaging modalities in evaluation of these disorders will be discussed, along with common imaging pearls and pitfalls. conclusions: a systematic approach is necessary for evaluation of pediatric hip disorders. familiarity with normal appearances, pitfalls and specific imaging of these entities is essential for proper diagnosis and management. osteoid osteomas: a pain in the "night" diagnosis nancy k. laurence, md, the children's hospital of philadelphia, nkang @gmail.com; monica epelman, richard markowitz, camilo jaimes, diego jaramillo, nancy chauvin purpose or case report: a common benign bone-forming lesion, osteoid osteoma comprises approximately % of all benign bone tumors. the tumor is composed of a nidus of vascular osteoid tissue and woven bone lined by osteoblasts, frequently with considerable surrounding inflammation. the radiolucent nidus surrounded by variable degrees of reactive sclerosis usually leads to a straightforward diagnosis; however, sometimes the diagnosis of osteoid osteoma can be challenging, as it may have a non-specific and misleading appearance on different imaging modalities, particularly on mri. the purpose of this exhibit is to review the typical and atypical features of osteoid osteomas on different imaging modalities. we present diagnostic dilemmas of osteoid osteomas from our institution and how imaging characteristics can aid in diagnosis. we performed a retrospective review of our imaging database to identify cases of typical and atypical osteoid osteomas, with special emphasis on cases which posed a diagnostic dilemma on imaging. results: when osteoid osteomas occur in atypical locations the diagnosis can be elusive. when located in the intraarticular space there is often minimal or absent cortical thickening and there may be a joint effusion with synovial hypertrophy. phalangeal lesions may cause extensive bone marrow edema and surrounding soft tissue swelling. both of these types of osteoid osteomas can be mistaken for infection. the recently described "ct vessel" or "vascular groove" sign, a low density vascular groove adjacent to the nidus, is highly specific for osteoid osteoma. in the authors' experience, a rim of sclerosis surrounding the nidus may aid in diagnosis on mri and can be identified as an outer hypointense halo on all sequences. we illustrate the findings in cases of atypical osteoid osteomas which may be difficult to diagnose including intraarticular, phalangeal, and vertebral osteoid osteomas. we also show examples of the newly described sign which has high specificity for osteoid osteoma. conclusions: imaging findings in osteoid osteomas can be misleading and cause misdiagnosis, especially in atypical cases. knowledge of their appearance in atypical locations and specific findings can aid in the correct diagnosis. ultrasound of normal entheses in the growing skeleton nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email.chop. edu; pamela f. weiss, monica epelman, diego jaramillo purpose or case report: ultrasound is an underutilized modality in the evaluation of the pediatric musculoskeletal system. evaluation of tendon insertions about the elbow, knee and foot can be easily performed with ultrasonography. a good knowledge of the age dependent normal ultrasound appearance of the entheses is crucial in order to evaluate for pathology, such as trauma or ethesitis-related arthritis. this exhibit will serve to provide the reader with a practical approach to imaging when assessing tendon insertions. optimal patient positioning and transducer selection will be discussed. in addition, important anatomic landmarks will be described to allow for reproducibility and avoiding pitfalls. methods & materials: transverse and longitudinal ultrasound images of entheseal insertion sites were performed on healthy girls and boys between the ages of and years. ultrasound of the elbow was performed while in full extension and the insertions of the common flexor and common extensor tendons were evaluated. the quadriceps and patellar insertions were imaged with patients in the supine position, with the knees flexed at degrees. the achilles tendon and plantar fascia insertion were evaluated with the patient prone, with the feet hanging off the edge of the table. results: tendons demonstrated the expected fibrillar pattern with parallel echogenic lines. the appearance of the entheses changed as the insertion matured from sonolucent cartilage to echogenic bone. conclusions: using a systematic approach and knowledge of the normal anatomy, sonography of the tendons of the elbow, knee and foot can easily be performed in children. pediatric musculoskeletal ultrasound of the distal lower extremity (knee to ankle) howard christianson, md, radiology, children's hospital boston, howard.christianson@childrens.harvard.edu; julia rissmiller, michael j. callahan purpose or case report: ultrasound is a well-established technique in children for evaluation of the painful hip, developmental dysplasia of the hip, soft tissue infection, palpable masses and foreign bodies. in general, ultrasound has a somewhat more limited role for the primary evaluation of several other pediatric musculoskeletal disorders in the setting of trauma, articular and periarticular diseases and tumors and tumor-like conditions. inherent advantages of ultrasound include excellent spatial resolution, a lack of ionizing radiation, a relatively non-invasive technique and lack of a need for sedation. real-time imaging allows problem solving not available with other modalities which is well suited for musculoskeletal applications, particularly in the setting of trauma. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. the purpose of this study is to illustrate the practical use of ultrasound in the evaluation of the distal lower extremity (knee to ankle) emphasizing the sonographic appearance of various musculoskeletal disorders. examples include: ) cystic lesions around the joints: baker's cyst, synovial cyst, ganglion cyst and suprapatellar bursitis; ) infectious processes: pretibial, subperiosteal and intramuscular abscess; ) tumor and tumor like lesions: nerve sheath tumor, tumoral calcinosis; ) trauma related injuries: sinding larsen johansson, tibialis anterior muscle herniation, hematoma. methods & materials: cases selected for presentation from a series of diagnostic musculoskeletal ultrasounds performed at our institution. results: a range of images from diagnostic ultrasounds performed of the distal lower extremity (knee to ankle) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: selected musculoskeletal ultrasounds of the distal lower extremity are presented to familiarize the audience with the sonographic appearance of various musculoskeletal disorders and to highlight the tremendous potential of ultrasound in evaluating musculoskeletal disease in children and adolescents. role of conventional and dynamic contrast enhanced magnetic resonance imaging in diagnosis of hemihypertrophy syndromes in children shrey k. thawait, md, phd , radiology, yale university-bridgeport hospital, sthawai @jhmi.edu; gaurav k. thawait, sally e. mitchell, laura m. fayad, john a. carrino, kate puttgen purpose or case report: hemihypertrophy syndromes in children are complex and there is some overlap among these conditions. hence, establishing a diagnosis can be challenging. identification of the correct vascular anomaly associated with these overgrowth disorders helps to correctly classify the disease into one of the several syndromes, which in turn guides management. in this educational poster, we will review the definition, clinical presentation, conventional magnetic resonance imaging (mri) and contrast enhanced magnetic resonance angiography and venography (mra / mrv) features of hemihypertrophy syndromes in children. methods & materials: . learn the diagnostic criteria for overgrowth syndromes in children such as klippel-trenaunay syndrome (kts) and parkes weber syndrome (pws) with special emphasis on associated vascular anomalies. . gain knowledge of high resolution mri technique for evaluation of vascular anomalies associated with the hemihypertrophy syndromes. . understand the additional value of dynamic contrast enhanced mra / mrv in the differentiation of the hemihypertrophy syndromes in the pediatric age group. results: . mri technique for a dedicated "vascular anomaly protocol" consisting of fat saturated t weighted, pre contrast axial t weighted, and post contrast triplanar t weighted fat saturated imaging will be described. . special emphasis will be provided on dynamic contrast enhanced mra/mrv. . conventional and dynamic mri features of clinically proven cases of hemihypertrophy syndromes will be demonstrated. conclusions: systematic mri interpretation utilizing a dedicated vascular anomaly protocol enables the radiologist to correctly identify the hemihypertrophy syndrome, and provide detailed extent of disease. correlative ultrasound, mri imaging and physical examination of elbows in hemophilic children andrea s. doria, md, the hospital for sick children-diagnostic imaging, andrea.doria@sickkids.ca; frederico xavier, arun mohanta, carina man, ningning zhang, pamela hilliard purpose or case report: .to report a systematic ultrasound (us) protocol for assessment of hemophilic elbows. . to discuss advantages and disadvantages of us and mri for evaluating hemophilic elbows in comparison with physical examination. .to illustrate us and mri findings and associated pitfalls in hemophilic joints. background: the value of physical examination for assessment of early arthropathic changes in hemophilic joints is unknown. us does not require sedation in young children, but involves operator training and standardized technique. mri is the reference standard imaging modality for assessment of pathology in hemophilic joints. standardization of a systematic protocol for data acquisition and interpretation of us findings and understanding of the correlation of findings between physical examination, us and mri in hemophilic elbows is essential for the use us as an outcome measure both in clinical practice and research. so far such information is not available for growing elbow joints. methods & materials: eight hemophilic boys (age range/ median, - / years) with a history of prior elbow bleeds underwent us and mr imaging, and physical examination on the same day. corresponding images on us and mri were highlighted to illustrate abnormalities and pitfalls. soft tissues (effusion/hemarthrosis,synovial hypertrophy,hemosiderin deposition) changes were characterized as small, moderate, or large. erosions, cartilage and subchondral abnormalities were graded based on depth or extent of articular changes. results: . us is helpful for discriminating synovial hypertrophy, joint effusion/hemarthrosis, and large hemosiderin deposition which otherwise generates susceptibility artifacts on gradient-echo mri obscuring adjacent tissues. . us can visualize erosions, cartilage and subchondral abnormalities at the joint periphery. however,differentiation between subchondral cysts and erosions is usually unfeasible by us. . prior knowledge of the degree of joint maturation is essential for an accurate evaluation of cartilage loss by us. . physical examination has limitations for assessment of early joint changes in contrast to us. conclusions: us can be useful for assessing hemophilic elbows, with advantages over mri in the evaluation of soft tissues. further development of an us-mri atlas on normal cartilage in growing joints is needed for definition of the value of us in the assessment of minimal osteochondral abnormalities. digital atlas of skeletal surveys of common skeletal dysplasias shawn parnell, mbbs, md, dnb, radiology, seattle children's hospital, shawn.parnell@seattlechildrens.org; corey wall, edward weinberger purpose or case report: skeletal dysplasias are conditions of abnormal bone and cartilage growth which result in short stature. developing expertise in the radiographic evaluation of skeletal dysplasias can be difficult, as more than dysplasias exist. exhaustive description of individual dysplasias can be found in hard copy textbooks, without the ability to compare individual dysplasias side by side. by providing radiographic images and descriptive text of thirteen common skeletal dysplasias and two comparative normal skeletal surveys, we aim to facilitate understanding of the terminology and highlight the differences in imaging appearances one may commonly encounter in interpreting skeletal dysplasias. methods & materials: initial skeletal surveys and/or follow up radiographs obtained for evaluation of skeletal dysplasias at our institution from to were compiled and reviewed for best quality images. selected images for each case were labeled according to body part and view, to include ap and lateral views of the spine and skull and ap views of the extremities and pelvis. for neonates, ap and lateral babygram images were used. the software program used for viewing the atlas, written in c#, may be freely downloaded. it permits linked scrolling and resizing of the images, and simultaneous comparison of different cases is available. cases may be viewed as unknowns or in a selfteaching mode. results: radiographic images for thirteen common skeletal dysplasias and two comparative normal skeletons (neonate and child) are provided within an interactive digital atlas. cases include achondroplasia, pseudoachondroplasia, cleidocranial dysplasia, thanatophoric dysplasia, diaphyseal dysplasia, multiple epiphyseal dysplasia, osteopetrosis, osteogenesis imperfecta, multiple hereditary exostoses, dysostosis multiplex, fibrous dysplasia, asphyxiating thoracic dysplasia (jeune syndrome), and spondyloepiphyseal dysplasia. conclusions: by displaying radiographic images of several common skeletal dysplasias in an interactive and comparative format with descriptive text, understanding of basic radiographic terminology and appearances will be facilitated. purpose or case report: . to classify various pediatric msk soft tissue masses . to describe pathogenesis, imaging appearances and differential diagnosis of these lesions methods & materials: radiology and clinical medical records were reviewed and pediatric patients with musculoskeletal soft tissue masses were identified. representative images were collected as examples of each lesion. the lesions were then classified into different groups based on the similar pathology and etiology. brief discussion is done for each of these masses with their multimodality imaging appearances. results: the search yielded pediatric soft tissue masses of multiple different etiologies, including post-traumatic (hematoma, fat necrosis, fibromatosis coli, myositis ossificans), inflammatory or infectious (cellulitis, abscess, granuloma annulare, retained foreign bodies), pseudotumors (synovial cysts, ganglion cysts, vascular malformations) and neoplastic lesions (fatty, vascular, neural, fibrous, muscular). multiple different imaging modalities were used to evaluate these masses, including ultrasound, ct and mri. representative examples of different lesions and their appearances on different imaging modalities will be presented and an organized approach to the diagnosis of these lesions will be discussed. conclusions: musculoskeletal soft tissue masses are relatively common in children. majority of these are benign; however, up to % of these lesions can be malignant "sarcomas". multiple different imaging modalities often provide complimentary information in the work-up of these lesions. despite multimodality imaging approach, tissue diagnosis or short interval follow-up is still often required when the mass does not show typical features of a benign etiology. pediatric radiologists should be familiar with various pediatric msk soft tissue masses and their imaging appearances, and should be able to guide appropriate management. results: elbow mri examinations were reviewed on children aged months to years with ( %) of these investigating clinical instability in children. mechanism of injuries included congenital dislocation ( %), traumatic dislocation ( %), fracture or avulsion ( %) and other injuries ( %). the patient's with congenital elbow dislocations most commonly presented with radial head dislocation and associated dysplasia or flattening, effusion and less frequently dysplasia of the olecranon or capitellum. patient's with traumatic dislocations were frequently associated with ligamentous or capsular disruption, bone oedema and epicondylar avulsion with effusion, loose osseous bodies and fractures less often. the epicondylar avulsions and ligamentous or tendon injuries occurred equally often in those few patients with unspecified injury mechanism. conclusions: a number of the bony, ligamentous, articular and developmental anomalies evident on elbow mri have been illustrated highlighting the importance of careful and systematic review of all elbow structures when presented with a child with elbow instability. accurate identification of these abnormalities is vital to facilitate their appropriate management. methods & materials: from our computerized radiology information system, we retrieved all patients that have foot ultrasound for evaluation of vertical or oblique talus deformities in the last years ( / - / ). the us was performed by a pediatric radiologist using a high resolution linear and tight convex curve probes with foot in neutral, plantar flexion and dorsiflexion. all medical charts, ultrasound scans and foot radiographs were reviewed by a pediatric radiologist. results: we identified nine patients' with foot deformities who were suspected of vertical or oblique talus and were evaluated by ultrasound. seven patients are male; two of them had initial foot radiographs that were not diagnostic. two female patients had unilateral oblique talus deformity. there were patients with vertical talus deformity; three of them had bilateral deformities. conclusions: us can directly visualize the unossified navicular, the talar cartilage and their alignment. dynamic us can. ultrasound evaluation of costal chrondral pathologies in children presented as anterior chest wall mass or pain nucharin supakul, md, radiology, riley hospital for children, tanyasupakul@yahoo.com; boaz karmazyn purpose or case report: to summarize our experience with the use of ultrasonography (us) for evaluation of costal cartilage pathology presented as anterior chest wall mass. methods & materials: from our computerized radiology information system, we retrieved all patients that have chest wall ultrasound for evaluation of a mass in the last . years ( / - / ) . the us was performed by a pediatric radiologist using a localized scan with high resolution linear probe. all medical charts, pathology results, ultrasound scans and other imaging studies were reviewed by a pediatric radiologist. results: ten patients were found with costal chrondral pathologies. nine patients presented with anterior chest wall mass and one with chest wall pain. eight patients had angular deformity of a single costal cartilage and one patient had biopsy proven osteochrondroma, presented with anterior chest wall mass. one patient had a non-union fracture after motor vehicle accident, presented with anterior chest wall pain. in patients with rib deformity, the mass was non-tender. nine patients had prior imaging study including chest x-rays (n ), ct scan (n ), breast mr (n ). all these studies were negative. conclusions: us optimally demonstrated costal cartilage abnormities. chest radiographs and cross sectional studies were negative. we therefore recommend using high resolution chest wall us in children with negative chest radiograph and anterior hard chest wall mass. challenges in pediatric marrow imaging-boning up on current mr techniques srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; neha kwatra, nabile safdar purpose or case report: a wide range of pathologies demonstrate similar findings when imaged using conventional mr sequences. however, pediatric musculoskeletal imagers are increasingly leveraging newer techniques to add specificity to their diagnoses when abnormal marrow signal is detected. the purpose of this educational exhibit is to review the application of current mr techniques to pediatric marrow imaging across the spectrum of normal, variant, and pathologic processes. methods & materials: cases with potentially overlapping imaging appearances on conventional mr sequences, including hematopoetic marrow, sickle cell disease, osteomyelitis, chronic recurrent multifocal osteomyelitis, and infiltrative neoplasms, will be presented. the basis of various mr techniques including chemical shift imaging, "whole body" marrow imaging, diffusion weighted imaging, and fat-water separation techniques such as dixon or ideal (ge) will be reviewed. the strengths and weaknesses of such techniques in differentiating between infection, neoplasm, and normal variation will be emphasized through the case examples. challenges and pitfalls in the imaging of these pathologies using such techniques will be discussed. results: current mr imaging techniques add specificity to diagnoses of marrow pathology which are otherwise difficult to differentiate using traditional sequences alone. the use of opposed phase imaging can be helpful in differentiate hematopoietic marrow or infection from infiltrative and neoplastic conditions. "whole body" marrow imaging may serve as an alternative to other modalities which involve significant radiation exposure. the use of diffusion weighted imaging is a promising, but developing, technique being applied to marrow pathology. conclusions: pediatric bone marrow mr imaging is a challenging area for a vast majority of the radiologists. understanding normal developmental bone marrow changes and being aware of the pitfalls is crucial to render accurate diagnosis. current techniques such as ideal, chemical shift imaging, and "whole body" mri have a potentially important role in further characterization of marrow abnormalities. radiologists beware: unusual imaging manifestations in child abuse eglal shalaby-rana, mbbs (hons), children's national medical center, erana@childrensnational.org; allison m. jackson, tanya hinds, katherine deye purpose or case report: to present less common imaging manifestations of injuries in child abuse that may not be readily recognized as possibly abusive injury. methods & materials: through bi-monthly review of cases with the child protection team over a period of years, the imaging studies of patients with suspected non-accidental trauma were recorded. of the pts with suspected nonaccidental trauma, outcomes were available in patients. the child protection team concluded ( %) were cases of non-accidental trauma with reasonable medical certainty. this data base was reviewed for less common injuries that were found in these medically confirmed cases of child abuse. results: less common manifestations of abuse identified by radiographs included salter-harris injuries in the proximal humerus, and proximal femur. pelvic fractures were rare and when present were associated with sexual abuse. severe chest wall injury, with associated rib fractures, causing complete or near-complete white-out of the chest was occasionally encountered. soft tissue injures, such as hematomas were found in various locations in the body including the buttocks and anterior abdominal wall, were imaged on ultrasound and ct. paraor prevertebral injuries, with or without associated bone injury were identified; one infant presented with retropharyngeal soft tissue swelling. mri identified cervical spine injuries which included ligamentous injury and intrathecal hematomas. conclusions: while classic metaphyseal lesions and rib fractures are the most common, specific injuries documented by radiologic work up of suspected non-accidental trauma, less common injuries to the soft tissue and skeletal system may occur as a result of child abuse. the ability of the radiologist to recognize these uncommon manifestations of demonstrated in axial, coronal, and sagittal planes. the ligament of interest will be denoted by arrows. at the conclusion of the anatomy section, there will be a self assessment exam. the participants then will be asked to identify the ligament. if answered correctly, a summary slide will be displayed and, if common, images of the relevant pathology will be demonstrated. if an incorrect answer is indicated, a slide will appear denoting the incorrect answer with explanation. conclusions: hopefully, with review of this educational exhibit, the participant will have a better understanding of the relevant ligamentous anatomy of the ankle and hindfoot. purpose or case report: the purpose of this educational exhibit is to demonstrate the pathologic sonographic findings, one might encounter in the pediatric ankle. a systematic methodological approach including patient positioning, transducer orientation and sonographic technique are vital for ideal sonographic assessment of the pediatric ankle. using a data search program from a large academic institution, pediatric ankle ultrasounds performed in the last years were reviewed. pathologies include trauma, inflammation/infection, masses and congenital abnormalities. examples of normal anatomy will be included particularly when demonstrating ligament and tendon pathology. the normal side was often assessed for comparison purposes. results: ankle sonography is a useful modality to evaluate commonly encountered pathologies in the pediatric ankle. radiographically occult fractures may be discovered. ligament and tendon pathology, such as tears of the anterior talofibular ligament, high ankle sprain and peroneus longus tendon tears, can be easily detected. signs of infection that can be radiographically occult such as subtle periosteal reaction or fluid collections can be identified. finally, "lumps and bumps" can be characterized. for example, one of the most commonly encountered masses in the pediatric ankle is a ganglion cyst which can be well characterized sonographically. awareness of imaging pitfalls is also critical to avoid misdiagnosis and to guide appropriate management. conclusions: with basic ultrasound skills and knowledge of normal anatomy, sonography of the pediatric ankle is a useful modality to evaluate soft tissue structures and other pathologies. it is comparable to mri and allows for dynamic evaluation without need for anesthesia. resonance angiography (mra) using time resolved imaging is a relatively new technique that has become increasingly utilized in the diagnosis of vascular anomalies. we will describe the technique used at our institution, time resolved imaging of contrast kinetics (tricks, ge healthcare, milwaukee, wi), and the parameters that can be adjusted to optimize the exam. we will review key imaging features of hemangiomas and vascular malformations in various modalities, with a special emphasis on the tricks appearance. we performed a retrospective review of all the tricks studies performed at our institution for suspected vascular anomalies. in addition to the mr imaging features, we specifically analyzed the t weighted with fat saturation post tricks enhancement and the temporal tricks enhancement pattern. we reviewed all additional imaging including plain film, ultrasound, and ct and correlated the radiographic imaging with the available clinical and histopathologic features. results: we present illustrative cases of hemangiomas, kaposiform hemangioendothelioma, venous malformations, arteriovenous malformations, lymphatic malformations, and other pitfall lesions. we propose a diagnostic algorithm that relies heavily on the post contrast t weighted with fat saturation post tricks enhancement pattern and the temporal tricks enhancement pattern. conclusions: time resolved contrast-enhanced mra has become an increasingly important adjunct in the diagnosis of vascular anomalies. optimization of the exam technique and familiarity of the tricks imaging appearance is essential and can often assist in accurate lesion characterization. purpose or case report: vertical expandable prosthetic titanium rib (veptr) is increasingly used in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. in contrast to spinal fusion surgery, veptr allows for growth while stabilizing the deformity. we review the indications, pre-operative imaging, normal radiographic appearance, and complications of this device. methods & materials: on review of the literature, the indications for veptr have expanded in the past several years to include thoracic insufficiency, idiopathic and neuromuscular scoliosis, and chest wall defects. we illustrate the normal radiographic appearance of the three common configurations of veptr (cradle-to-cradle assembly, cradle with lumbar extension assembly; cradle-to-ala hook assembly). we discuss the potential complications of veptr, including infection, rib fracture, dislodged hardware, and neurological injury, with an emphasis on imaging diagnosis. results: there is a relatively high rate of reported complications with veptr in the literature. therefore, awareness of the growing number of indications, as well as the expected and unexpected appearance of this device, aids in radiographic diagnosis of complications. conclusions: vertical expandable prosthetic titanium rib (veptr) is gaining acceptance in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. recognition of the indications, normal radiographic appearance, and complications of this device will facilitate timely and accurate diagnosis. disclosure: dr. philips has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. spectrum of pediatric spinal neoplasms: an interactive tutorial benjamin t. haverkamp, md, radiology, university of missouri-kansas city, haverkampbt@umkc.edu; salvador f. iloreta, maha jarmakani, lisa lowe, seth gibson purpose or case report: the objective of this educational electronic exhibit is to provide the radiologist with an approach to pediatric spinal neoplasms. emphasis will be placed on narrowing the differential diagnosis using a combination of lesion location, characteristic imaging findings, relevant history, and associations. the exhibit format will include a casebased review of various pediatric spinal neoplasms, radiologicpathologic correlation, and a brief discussion of imaging findings useful in guiding surgical management. an interactive selfassessment exam will be presented at the end of the exhibit. results: a review of the specific etiologies will be presented with classification as intra-and extra-medullary and extradural lesions. radiologic images will be related to gross and microscopic pathology. conclusions: after viewing this exhibit, the learner will be able to: . recognize the clinical, imaging, and pathologic characteristics of pediatric spinal neoplasms. . understand relevant imaging findings useful in surgical management. . test their understanding of the presented material through an interactive exam. poster #: edu- craniosynostosis jason tsai, mbchb, children's hospital boston, jason. tsai@childrens.harvard.edu; diana p. rodriguez purpose or case report: to review the normal developmental appearance of the cranial sutures with computed tomography (ct) and to describe ct findings of the various forms of craniosynostoses. in this irb-approved retrospective study we reviewed ct images of subjects diagnosed with craniosynostosis between and september . we included patients with single-suture synostosis, isolated bilateral coronal synostosis, pansynostosis, and combined craniosynotoses. additionally, we identified individuals with normal appearing sutures from to years of age imaged with head ct to describe the pattern of normal development of the cranial sutures. results: a description of the normal developmental ct appearance of the cranial sutures using computed tomography has been provided. of the group of patients with craniosynostosis the following variables were recorded: age at presentation, the pattern of sutural fusion, skull shape, presence of hydrocephalus, genetic testing, and types of surgical correction. conclusions: we have demonstrated the normal developmental ct appearance of the cranial sutures and the ct patterns of the various forms of craniosynostoses, with clinical, genetic and surgical correlation. posterior fossa tumours: a pictorial review sam byott, md, manchester children's hospital, sambyott@ hotmail.com; neville wright, vivian tang, abdu shabani, stavros stivaros purpose or case report: posterior fossa tumours account for - % of childhood brain tumours. the most common differentials include pilocytic astrocytoma, medulloblastoma and ependymoma. mr imaging is crucial to diagnosis, staging and identification of complications such as hydrocephalus and haemorrhage. soft tissue characteristics alongside tumour location, invasion and clinical history facilitate radiological discrimination prior to surgery. however, there is significant clinical equipoise with regards to the imaging appearances in a significant proportion of cases making definite diagnosis difficult. the aim of this study is to evaluate the radiological findings and correlate with histological data. this will allow identification of the key morphological features that discriminate different tumours. these can then be presented to educate fellow radiologists. methods & materials: radiology pacs and patient notes were used to collate radiological, histological and clinical data. results: there were patients presenting at our institution with posterior fossa tumours. had pilocytic astrocytomas, had medulloblastomas and had ependymomas. one patient had an atypical teratoid rhabdoid tumour (atrt). traditional features alongside more advanced mr characteristics were correlated with histology, and the features allowing for discrimination of tumour types are presented in this pictorial review. conclusions: posterior fossa tumours have a highly variable radiological appearance. we present a range of appearances and describe the important morphological features that allow radiological discrimination of tumour type. poster #: edu- dt imaging of the pediatric spine teresa c. gross kelly, children's hospital of wisconsin, tkelly@chw.org; ibrahim s. tuna, mia s. kelly, tushar chandra, sumit singh, mohit maheshwari, hervey d. segall purpose or case report: some abnormalities of the pediatric spine can be challenging. we have discovered that in many such cases, diagnosis of spinal lesions can be faciliated by using the dt weighted sequence. the purpose of this educational poster is to demonstrate the remarkable usefulness of dt weighted images for delineating pathology of the pediatric spine. methods & materials: lesions of the spine that will be reivewed in this educational exhibit will be categorized as: ( ) vascular ( ) due to infection/inflammation ( ) neoplastic/ neurogenic ( ) congenital ( ) traumatic/iatrogenic ( ) endocrine/metabolic. the imaging characteristics of lesions found in the pediatric spine will be described and the utility of d t -weighted mr sequences for the evaluation of these lesions will be discussed. finally the role of imaging in the treatment planning of abnormalities of the pediatric spine will be addressed. results: this educational exhibit will provide numerous examples of how d t -weighted imaging can elucidate diagnosis of lesions involving the spine. examples include enhancement of the cauda equina in guillain barre syndrome, lipomatous malformations, spondylolysis in children with low back pain, thecal cysts, filar cysts, metastasis, hydromyelia and ventriculus terminalis. conclusions: d t -weighted images of the spine performed in the sagittal plane with coronal and axial reformations, as well sagittal oblique reformations (scotty dog reformations) for evaluation of spondylolysis, can facilitate the evaluation of lesions involving the pediatric spine. the normal pediatric spine: a pictorial review of mr anatomy and development in the infant, child and adolescent ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; teresa c. gross kelly, tushar chandra, mohit maheshwari, sumit singh, hervey d. segall purpose or case report: radiological evaluation of the pediatric spine can be more challenging in child than in the adult patient due to the wide range of normal anatomic variants and synchondroses, combined with the unique effects of trauma in children. mri is an excellent imaging modality for the evaluation of the pediatric spine. however, in order to provide an accurate interpretation of acute posttraumatic changes in the pediatric spine, particularly in the setting of abusive head trauma, a fundamental knowledge of normal anatomy, variants and pathology of the pediatric spine is required. the aim of this educational exhibit is to illustrate normal mri anatomy of the spine in the infant, child and adolescent. methods & materials: this exhibit will first describe basic spinal embryology and development of the vertebra and spinal cord, followed by mri depiction of the developmental anatomy of the spine from infancy through adolescence. the changing appearance of the spinal canal, spinal cord and vertebral bodies with age will be illustrated using normal cases from the radiology database. sagittal and transverse diameter of vertebral bodies, thickness of the dural thecal sac, dimensions of the spinal canal, normal bone marrow signal changes, vertebral body heights, level of conus medullaris, prevertebral and paraspinous soft tissues and epidural fat thickness will be described and changes according to age will be pointed out. results: in early life, the spinal cord extends to the inferior aspect of the bony spinal column. because the vertebral bodies grow longitudinally faster than the spinal cord does, the conus medullaris may change. ossification of the vertebral bodies and posterior elements is nearly complete by age , with a resultant decrease in the spinal canal diameter. the nucleus pulposus becomes smaller after years and spans approximately half the disk space in the sagittal plane. the spinal cord is elliptical in cross section in the cervical spine and demonstrates a difference in signal between the normal gray and white matter of the spinal cord which should not be mistaken for intramedullary pathology. conclusions: a solid understanding of normal spine anatomy and embryological development is essential in evaluation of pediatric spine, mainly in the setting of trauma. familiarity with normal anatomic variants is essential to provide an accurate interpretation of pathology in the pediatric spine. spectrum of intracranial cystic lesions in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; eric faerber purpose or case report: to review the imaging spectrum of intracranial cystic lesions in the pediatric population. methods & materials: a retrospective review of our imaging database was performed to identify studies obtained in which the findings included intracranial cystic lesions. results: multiple cystic lesions were elucidated primarily by computed tomography or magnetic resonance imaging. these lesions can be divided into nonneoplastic and nonneoplastic tumor-associated cysts. the nonneoplastic cysts, which is the largest group, include: cavum septi pellucidi and cavum veli interpositi, choroid plexus cyst, enlarged peri-vascular spaces, pineal cyst, the large spectrum of arachnoid cysts, colloid cyst, epidermoid cyst, rathke cleft cyst, and porencephalic cyst. nonneoplastic tumor-associated cysts include: craniopharyngioma, optic glioma, pilocytic astrocytoma, hemangioblastoma, and ganglioglioma. conclusions: intracranial cystic lesions are relatively common entities in the pediatric population. a wide spectrum of nonneoplastic and nonneoplastic tumor associated pathologies are presented using both computed tomography and magnetic resonance imaging. kelly, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a comprehensive review of imaging features, classification and management of pediatric spinal cord tumors. we also aim to elicit the differences between pediatric spinal cord tumors and their adult counterparts. we will summarize the differences between the individual tumors based on histological cell types and the pertinent implications on management and outcome methods & materials: this exhibit will provide an overview of the common as well as uncommon tumors of the pediatric spinal cord. various classification systems for these tumors-anatomical as well as histological will be discussed. we will illustrate the relevant imaging findings that can help in differentiating these tumors. results: pediatric spinal cord tumors account for % to % of all pediatric central nervous system tumors. mri is the mainstay for the initial diagnosis as well as the post surgical evaluation and surveillance of these tumors. pediatric and adult spinal cord tumours differ both in terms of anatomical location as well as histology. the disease and treatment related morbidities are also different in children as compared to adults. astrocytomas, ependymomas, glioneural tumors and csf metastasis represent the vast majority of cord neoplasms in the pediatric age group. some of cord tumors may also be associated with inherited syndromes (like neurofibromatosis type ) or may have genetic predisposition. these would also be discussed. we will also illustrate and discuss common non neoplastic spinal masses that may mimic tumors. conclusions: pediatric spinal cord tumors have varied clinical presentations, imaging appearance and outcome. this review would improve the understanding of these tumors thereby helping in diagnosis, management and follow up of these uncommon neoplasms. multi-modality imaging of pediatric head and neck lesions jason au, md, oklahoma university health sciences center, jasonmau@gmail.com; anthony alleman, mahmoud elkaissi, roy jacob purpose or case report: the purpose of this study is to present a side by side comparison of the multi-modality imaging features of pediatric masses. using cases that have been imaged with multiple modalities, the exhibit will delineate the sonographic, mr, and ct appearance of congenital, infectious, and neoplastic head and neck lesions in the pediatric population. methods & materials: a restrospective search of pacs was performed on studies completed at the oklahoma university medical center on the oklahoma university health science center campus from january to the present. ultrasound, ct, and mr examinations were selected that depicted relevant pediatric head and neck pathology. all studies were de-identified prior to image export. results: over twenty representative cases of pediatric infections, fibrous tumors, cystic neoplasms, vascular malformation, bony tumors, developmental anomalies, and other neoplasms were selected for inclusion. results: pictorial review of cases including the following representative cases: myelonmeningocele associated with arnold chiari malformation, lipomyelomeningocele, tethered cord with spinal lipoma/fibrofatty filum, tethered cord and dermal sinus tract, and chiari i with syringohydromyelia. several unique cases including the following will be presented as well: thoracic meningocele with arnold chiari malformation, terminal myelocystocele, diastematomyelia, and myelomeningocele without arnold chiari malformation. while mri demonstrates the cranio-cervical junction and the cervicothoracic spinal cord better than ultrasound, ultrasound often allows for improved resolution of the distal spinal cord, lumbosacral spinal canal, and spinal dysraphism structures near the skin surface in the neonate. conclusions: congenital spinal malformations are complex and variable in imaging appearance. it is important to understand the classification in order to determine the appropriate management and prognosis. in the neonatal period imaging should be performed with ultrasound and mri studies, as they may provide different and complementary information. conclusions: hypoxic ischemic injury is a common condition resulting in a wide spectrum of severe neurological defects. while in the past treatment only consisted of supportive care for hii, recent advances have yielded promising treatment options if initiated within a limited time window. thus due to the severity of the disease and the need for rapid intervention, it is important to recognize radiological manifestations of hii along with its clinical signs and symptoms to offer a better prognosis to the patient. craniosynostosis: looking beyond the sutures tushar chandra, md, children's hospital of wisconsin, drtusharchandra@gmail.com; teresa c. gross kelly, mohit maheshwari, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a framework upon which the diagnosis of the various types of craniosynostosis can be facilitated. our goal is to provide an efficient way to evaluate craniosynostosis for the radiologist in clinical practice. we plan to accomplish this goal by providing a succinct review of the sutures, an overview of the various classification schemes for craniosynostosis and potential complications associated with premature sutural closure. the role of imaging in the evaluation of craniosynostosis will be described and the features of craniosynostosis that are most important to the craniofacial surgeon will be elucidated. finally, surgical strategies for the repair of craniosynostosis and postoperative findings will be described. results: some of the forms of craniosynostosis may have a genetic basis, but many are spontaneous in nature. untreated progressive craniosynostosis can lead to inhibition of brain growth, and an increase in intracranial pressure. mdct with mip and d surface reformations is the preferred modality for diagnostic evaluation of craniosynostosis. it is also a robust modality for post operative assessment and long-term follow up. mri is a useful adjunct for assessment of associated intracranial anomalies and complications. timely and appropriate imaging is essential to assess for potential complications of craniosynostosis which may include intracranial hypertension, anomalies of external and middle ear, hydrocephalus, chronic tonsillar herniation, cranial base deformity, impaired venous drainage, enlarged emissary foramina and veins and optic atrophy. on the other hand, positional plagiocephaly should not be misinterpreted as craniosynostosis. surgical management is typical for nonsyndromic craniosynostosis, which involves correction of craniosynostosis between three to six months of age. conservative management is the mainstay for syndromic craniosynostosis. postoperative follow up imaging for surveillance for ventricular size and signs of raised intracranial pressure are necessary. conclusions: craniosynostosis is a challenging area of pediatric neuroimaging. knowledge of the sutural anatomy, an understanding of the potential intracranial complications caused by premature sutural closure, as well as the role that imaging plays in presurgical planning, can provide a practical way for the radiologist to evaluate craniosynostosis in a fast-paced clinical setting. poster #: edu- the perinatal brain and spinal cord-imaging across a life border: a case-based approach anand dorai raju, md, radiology university of tennessee, araju@uthsc.edu; harris l. cohen, matthew whitehead, asim choudhri purpose or case report: to review normal and abnormal perinatal ultrasound (us) and magnetic resonance (mr) imaging findings and note their significance for the analysis of the fetal and neonatal brain as well as spinal cord and vertebral column using a case based approach. to highlight us and mr capabilities in allowing correct perinatal diagnosis of congenital and acquired central nervous system abnormalities. methods & materials: cases will be shown of normal and abnormal anatomic findings in fetal and neonatal brain and spinal cord imaging. key teaching points necessary for the diagnosis of such brain abnormalities as ventriculomegaly, chiari malformations, holoprosencephaly, and agenesis of the corpus callosum as well as dandy walker malformations and avms will be discussed. intraventricular hemorrhage, periventricular leukomalacia, anoxic injuries and infectious abnormalities will be reviewed. abnormal anatomic findings in fetal and neonatal spine evaluations for congenital and acquired abnormalities and key teaching points necessary for the accurate diagnosis of tethered cord, myelomeninocele, caudal regression syndrome, hydromyelia, diastomatomyelia and sacrococcygeal teratoma will be reviewed. some diagnostic difficulties and controversies will be addressed. conclusions: ultrasound aided by mri can provide ready diagnosis to many central nervous system abnormalities involving fetuses and neonates. ever improving perinatal imaging experience and technique allow for better prenatal as well as postnatal diagnosis. cases showing such imaging and key points helping such imaging diagnoses will be reviewed. overview of imaging of pediatric extraocular orbital tumors srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; nadja kadom, gilbert l. vezina purpose or case report: to show the spectrum of benign and malignant extraocular orbital tumors in children. methods & materials: we reviewed the cross-sectional imaging of orbit (ct and mr) done in the last years. specific imaging signs of extraocular tumors including benign and malignant tumors such as hemangiomas, lymphangiomas, optic nerve glioma, optic nerve sheath meningioma, pseudotumors, rhabdomyosarcoma, orbital myofibroma, eosinophilic granuloma and neuroblastoma metastases will be shown. important imaging features that should be considered when formulating a differential diagnosis will be described. conclusions: the spectrum of diseases affecting pediatric orbit is substantially different from what we see in the adults. it is not easy always to differentiate between different tumors. important imaging characteristics will help us towards better differential diagnosis. in this exhibit, we will illustrate ultrasound anatomy of the neonatal spinal cord. discussion of the normal anatomic variants and pathological conditions of the spinal cord will be provided. representative images of a variety of common and uncommon pathological conditions of the spine will be presented to illustrate teaching points. in abnormal cases, follow up mri images will also be illustrated for comparison. results: ultrasound is a robust screening modality for evaluation of the lumbosacral spine in neonates. it is cheaper, readily available, safer first line imaging modality in neonates suspected to have spinal malformations. under able and well trained operator, diagnostic accuracy of spinal ultrasound approaches mri. however, mri remains the gold standard for imaging evaluation of spine. normal variants that simulate disease processes like ventriculus terminalis, prominent filum terminale and central echo complex will be presented. congenital malformations of the cord such as tethered cord, hydromyelia, lipoma, diastematomyelia, myelomeningocele, lateral meningocele and presacral masses will also be discussed. conclusions: ultrasound is a very useful screening technique for evaluation of pathological conditions of lumbosacral spine in neonates. this review would improve the understanding of utility and limitations of ultrasound in evaluation of neonatal spinal malformations. purpose or case report: although mri is the standard for detecting epilepsy and brain tumor abnormalities, pet-ct is performed to ascertain metabolism related to epileptogenic regions or characterize tumor metabolic activity. asymmetric metabolism often correlates to structural abnormalities like cortical dysplasia. metabolic activity often correlates with tumor aggressiveness or grade. fdg pet is commonly used to assess seizure and tumor metabolism. the lesser utilized amino acid pet tracers (c methionine, fdopa) show increasing value with lower grade tumors due to high tumor to normal tissue contrast. literature is accumulating regarding c methionine (cmet) in the detection of lesions like cortical dysplasia and its ability to delineate low grade seizure related tumor lesions. despite the established fdg and accumulating cmet literature, little information exists about the imaging seen with both in pediatrics. as these studies are increasingly viewed as part of fusion mri images, there is more scrutiny of focal metabolism correlating with mri findings and less interpretative reliance on abnormality based solely on asymmetry. methods & materials: review of patients who underwent cmet and fdg brain pet-ct was performed. each was imaged on a philips scanner and had prior mri. studies demonstrating a variety of tumors, postoperative findings of residual or recurrent tumor, and pseudoprogression were selected. epilepsy cases with structural cortical abnormalities or seizure-associated tumors were also selected. cmet and fdg studies were analyzed by pediatric neuroradiologists and the imaging findings correlated with prior mri and any pathology or follow-up imaging. pictorial galleries of the cmet and fdg imaging patterns were created. results: pathologically proven low-grade glial tumors showed increased cmet uptake and no hypermetabolism on fdg. high-grade tumors showed increased uptake on cmet and hypermetabolism on fdg. patients with residual or recurrent tumors showed uptake similar to their original tumor. granulation tissue and pseudoprogression changes showed increased uptake on cmet and no hypermetabolism on fdg. epilepsy surgery patients with cortical dysplasia or low grade glial tumors showed increased uptake on cmet and fdg hypometabolism. conclusions: this study illustrates the variety of findings on cmet and fdg pet-ct in pediatric patients clinically evaluated for brain tumor and epilepsy. this atlas provides readers with a guide to the appearance of these findings on an emerging imaging technique. pediatric head and neck neoplasms: a multimodality pictorial review alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; marilyn j. siegel purpose or case report: neck masses are common in children and most occur in the suprahyoid region. knowledge of the fascial spaces involved in conjunction with imaging features can help in diagnosis. in this pictorial review, we present a multimodality imaging approach based on anatomy of the suprahyoid fascial spaces for evaluation of pediatric neck tumors. methods & materials: radiology information system (ris) at our tertiary care children's hospital was queried to identify patients with suprahyoid neck masses who had imaging performed between july and present. a variety of conditions having congenital, inflammatory, neoplastic, or vascular origin were identified and the anatomic location in the neck as well as imaging and clinical findings were retrospectively reviewed. results: the imaging evaluation included ultrasound, ct and mri. lesions arose within the following fascial spaces of the suprahyoid neck: superficial, carotid, masticator, submandibular, sublingual, parotid, parapharyngeal, visceral, retropharyngeal and prevertebral. key imaging features important in diagnosis included lesion vascularity, calcification, necrosis and bone invasion. we discuss and illustrate these imaging findings and relate them to specific suprahyoid fascial spaces. specific lesions include vascular and lymphatic malformations, teratoma, nerve sheath tumors, thyroglossal duct and branchial cleft cysts, pleomorphic adenoma, dermoid cyst, ranula, lymphadenopathy, abscess, lymphoma, rhabdomyosarcoma, neuroblastoma and nasopharyngeal carcinoma. conclusions: knowledge of fascial spaces of the suprahyoid compartment and key imaging features on multiple modalities can aid in the diagnosis of pediatric neck masses. pediatric sinusitis: spectrum of imaging findings with clinicopathologic correlation roy jacob, md, university of oklahoma, drjacobr@gmail. com; paul digoy, robert s. glade, anthony alleman purpose or case report: the clinical spectrum of sinusitis in children can range from uncomplicated bacterial sinusitis to invasive fungal sinusitis. most cases respond favorably to medical management. however, complications occasionally occur due to the spread to adjacent structures. imaging plays an important role in characterizing the disease and guiding the clinical and surgical planning and treatment. this electronic presentation outlines the following- . review radiologic anatomy and unique characteristics of pediatric sinuses. . review the clinical features, pathophysiology, and microbiology of sinusitis. . review of ct and mri imaging characteristics of sinusitis with representative cases such as complicated sinusitis and invasive fungal sinusitis. . review the treatment approaches of sinusitis. methods & materials: a retrospective search of pacs was performed on studies completed at the ou children's hospital in oklahoma city for the last three years. ct and mr examinations were selected that depicted relevant disease processes. corresponding nasal endoscopic pictures were obtained from cases which required surgical management. all studies were de-identified prior to image export. results: over fifteen representative cases of the clinical spectrum of sinusitis and its complications were selected for inclusion. conclusions: this educational exhibit provides a concise review of imaging, clinical features, and treatment of pediatric sinusitis. findings will be richly illustrated with radiological and clinical images. microcephaly or hydrocephalus. knowing the embryology of the cerebellum and th ventricle is important to perceive the development of posterior fossa malformations and to further understand the imaging findings. several classifications schemes have been proposed from a pure embryologic to an imaging-based approach using some essential findings such as the size of the posterior fossa, the presence of csf collection or expansion of csf space, and the size and morphology of the cerebellum. mr is the gold-standard for adequately access and characterize the posterior fossa structures. this pictorial essay will review the mr findings of some of the most common posterior fossa malformations including dandy-walker malformation, persistent blakes pouch, mega cisterna magna, arachnoid cyst, paleocerebellar hypoplasia, cerebellar agenesis, cerebellar and pontocerebellar hypoplasia, cerebelar cortical malformations, isolated brainstem hypoplasia/dysplasia and chiari malformations. we will provide a practical approach to the mr findings of posterior fossa malformations in children. conclusions: mr plays a crucial role in identifying and characterizing malformations of the posterior fossa structures. it should give a logical approach to these complex malformations thus guiding the refereeing physician into the clinical approach and in determining further investigations. results: neuroimaging features of abnormal thalami as encountered in the pediatric population were detailed, and wherever applicable, the relevance of additional mr imaging sequences and techniques to determine etiology was described. while there was considerable overlap in imaging appearances, making a precise diagnosis was found to be challenging in difficult cases, and by and large, a stepwise approach was successfully formulated and used to: . diagnose the more emergent conditions and to . devise a management algorithm for the less acute abnormalities. conclusions: bilateral thalamic lesions are occasionally encountered in pediatric neuroimaging and have a limited differential; a good knowledge base and adequate technique are imperative to tease out the precise diagnosis and institute appropriate management. cortical developmental abnormalities in pediatric seizure patients ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; mohit maheshwari, teresa c. gross kelly, sumit singh, tushar chandra, hervey d. segall purpose or case report: to describe various cortical malformations with illustrative examples. we will also briefly discuss the embryology, genetic basis, classification schemes and characteristic imaging findings . methods & materials: this exhibit will illustrate three main categories of cortical malformations: neuronal proliferation, migration and organization. understanding of this complex topic would be facilitated by brief discussion on the embryological basis and proposed genetic causes of some of these cortical malformations. classification schemes on embryology and imaging will be discussed. characteristic imaging findings of these malformations will be discussed and examples from the authors database will be shown. results: neuroimaging in pediatric seizures is challenging. mri is considered the imaging modality of choice because of superior soft tissue contrast and better ability to characterize the pathologic process. we will also discuss the dedicated seizure protocol which is used in our institute. pet-ct imaging can also provides additional information in cases where mri is negative, inconclusive or does not correlate with eeg/clinical findings. brief discussion on advanced imaging techniques will also be presented. malformations are frequently detected in infancy. however, if the initial mri scan performed in infancy is negative, a repeat scan after years of age may be helpful. conclusions: evaluation of cortical malformation in seizure patients still remains a challenging area of pediatric neuroimaging. reviewing of the embryological basis, classification schemes and characteristic imaging findings would improve the understanding the cortical malformations and interpreting the images. poster #: edu- sprs best poster cystic neonatal lesions associated with the spinal cord: discussion and differential diagnosis for these uncommon lesions jacob pirkle, md, jpirkle@mc.utmck.edu, james boyd, brian dupree purpose or case report: to review intradural cystic neonatal spine lesions and discuss the various causes and appearance of these lesions. this poster presentation provides a brief review of neonatal cystic spine lesions, including their etiologies, and presents the targeted audience (radiology resdients, fellows, and practicing radiologists) a helpful differential diagnosis of these lesions based upon their imaging appearance. methods & materials: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. results: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. conclusions: neonatal spine ultrasound is often performed to evaluate for abnormalities related to the presence of sacral dimples, cutaneous stigmata, skin tags, hairy tufts, during the evaluation of other congenital anomalies, or when prenatal ultrasound/mri demonstrates an abnormality warranting postnatal follow-up. the identification of cystic spinal cord lesions is relatively rare in the neonate. however, the etiology of these lesions can often be deduced or surmised based upon the location and the imaging appearance of the lesion. the most common cause of a cystic intramedullary spinal lesion is ventriculus terminalis, with a reported incidence of . %. additional lesions include transient dilatation of the central canal, filar cyst, syringohydromyelia, intramedullary arachnoid cyst, and myelomalacia related to in utero/birth trauma. extremely rare etiologies in the neonate include epidermoid/dermoid, cavernous malformation, intranatal cystic infections etiologies, neuroepithelial cysts, and cystic neoplasms. mimics include diastematamyelia, spinal lipomas, and intramedullary hematomas. numerous imaging examples of these lesions are provided in the accompanying poster. brain mri in peroxisomal disorders: a pictorial essay bruno p. soares, md, radiology and biomedical imaging, university of california at san francisco, bruno.soares@ucsf. edu; leonardo vedolin, guido gonzalez purpose or case report: our presentation aims to illustrate the brain mri patterns in peroxisomal disorders. peroxisomes are intracellular organelles involved in important cellular processes including beta-oxidation of very-longchain fatty acids and plasmalogen production. peroxisomal disorders can be categorized into disorders of peroxisomal biogenesis, in which the peroxisomes are abnormally formed and several peroxisomal functions are deficient, and in defects involving a single peroxisomal function, in which the structure of the peroxisome is intact. disorders of peroxisomal biogenesis include zellweger syndrome, neonatal adrenoleukodystrophy, infantile refsum disease and rhizomelic chondrodysplasia punctata. numerous disorders are caused by loss of a single peroxisomal function including x-linked adrenoleukodystrophy and acyl-coa oxidase deficiency. clinical findings in peroxisomal disorders include dysmorphic features, hepatic dysfunction, neurodevelopmental delay, retinopathy and hearing impairment. methods & materials: pictorial essay illustrating brain mri patterns in peroxisomal disorders, including disorders of peroxisomal biogenesis and disorders with loss of a single peroxisomal function. results: brain abnormalities in peroxisomal disorders have a wide spectrum of patterns. neuronal migration disorders with abnormal myelination are typically seen in zellweger disease and neonatal adrenoleukodystrophy. specifically, the association of abnormal myelination with germinolytic cysts is suggestive of zellweger syndrome. classic x-linked adrenoleukodystrophy typically shows posterior central white matter involvement and symmetric demyelination also involving the corticospinal tracts and corpus callosum. a similar pattern of white matter involvement is seen in acyl-coa oxidase deficiency and infantile refsum disease. conclusions: brain mri helps narrow the differential diagnosis and guides subsequent evaluation in infants presenting with clinical features concerning for peroxisomal disorders. therefore, knowledge of the brain mri patterns in peroxisomal disorders is important for the radiologist interpreting neuroimaging studies. clots in tots: role of imaging in diagnosis of acute stroke and its causes in children asif abdullah, c.s. mott children's hospital of the university of michigan, asifa@med.umich.edu; ellen hoeffner, augusto elias purpose or case report: stroke is a major cause of morbidity and mortality in children. long-term neurologic deficits occur in % to % of infants and children after arterial ischemic stroke. limited awareness regarding pediatric stroke among physicians and in general community is a major concern. imaging plays crucial role in the diagnosis of pediatric stroke. the goal of this presentation is to provide awareness to the reader about the role of imaging in childhood stroke and its myriad causes in children. we will provide a case based approach to imaging diagnosis of acute pediatric stroke based on three categories: ( ) arterial ischemic stroke, ( ) cerebral venous thrombosis, and ( ) hemorrhagic. arterial ischemic stroke (ais) is classified according to the pediatric stroke classification (psc). psc includes eight subtypes of ais: ( ) sickle cell disease, ( ) cardioembolic disease, ( ) moyamoya syndrome, ( ) cervical arterial dissection, ( ) stenoocclusive cerebral arteriopathy, ( ) other determined etiology, ( ) multiple probable etiologies, and ( ) undetermined etiology. we will describe the role of computed tomography (ct) and magnetic resonance imaging including angiography (mri/mra) in identifying these causes in relation to available clinical data. the etiologies of cerebral venous thrombosis related infarction would be discussed from an imaging perspective with a case-based approach with emphasis on mrv and swi techniques. finally, we will focus on hemorrhagic causes of childhood stroke such as vascular malformation, aneurysm, neurocutaneous disorders, coagulopathy, and a variety of other causes from an imaging standpoint. perfusion imaging in pediatric stroke demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for the role of this technique in pediatric stroke. results: the most important factors in the diagnosis of childhood stroke are causal investigation, appropriate laboratory tests, and imaging studies. imaging is frequently the first step in the evaluation of an acutely ill child. conclusions: pediatric stroke is a debilitating disease that requires urgent multidisciplinary approach for diagnosis and treatment. in cases of both ischemic and hemorrhagic origin, the radiological approach to be obtained in emergency setting leads to the initial screening and the first therapeutic possibility. methods & materials: this exhibit will illustrate the characteristic imaging findings of vascular anomalies in the head and neck region. vascular anomalies are divided into vascular tumors and vascular malformations which include slow flow malformations (capillary malformations, venous malformations, lymphatic malformations and their combinations) and high flow malformations (arteriovenous fistula and arteriovenous malformations). complex malformations are also seen in several syndromes including klippel-trenaunay syndrome, phace syndrome, etc. cases from author's database will be used for illustration. results: a review of clinical manifestations, characteristic imaging findings and interventional treatment strategies in cases of head and neck vascular anomalies will be presented with pre and post treatment imaging features. ultrasonography and mri are the mainstay in diagnosis of these malformations. ct scan and catheter angiography may occasionally be needed for diagnosis and treatment planning. various imaging findings and main treatment options will be listed. conclusions: head and neck vascular malformations are common in pediatric population. understanding the characteristic imaging findings and clinical presentation is essential in evaluating the vascular malformations. interventional procedures are generally the preferred treatment modality, either alone or in association with surgery in majority of these cases. isolated cortical diffusion restriction in pediatric brain mri ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; sarah stock, s. pinar karakas, unni udayasankar, janet r. reid purpose or case report: diffusion-weighted imaging continues to emerge as a powerful neuroimaging tool. isolated cortical restricted diffusion is a particularly striking pattern with specific differential in the pediatric population. we aim to review this specific imaging pattern supplemented by case examples and key physiologic and imaging concepts. methods & materials: review the concept of diffusion restriction a) pathophysiology b) specific imaging appearances pictorial review of pediatric conditions that lead to cortical restricted diffusion: a) post ictal change b) infection-i. meningoencephaliitis ii. herpes c) hypoxic ischemic injury d) infarct: venous and arterial e) posterior reversible leukoencephalopathy f) mitrochondrial cytopathy g) metabolic: hypoglycemia. discuss certain artifacts. summary table and differential clues conclusions: the pattern of isolated cortical restricted diffusion has specific differential diagnosis in the pediatric population. the radiologist should be aware of this as use of dwi continues to grow. this exhibit with familiarize the reader with common conditions that specifically affect the cortex and produces true restricted diffusion. methods & materials: high resolution ct scan and mri are mainstay of diagnosis and assessment in patients with sensorineural hearing loss. in this exhibit we will present a pictorial review of ct scan and mri images of various causes of sensorineural hearing loss (snhl) that are seen on imaging. reviewing the embryologic basis of these anomalies would enable better understanding of this complex subject. results: the new system classifies these malformations according to descending order of severity into complete labyrinthine aplasia, cochlear aplasia, common cavity, cystic cochleovestibular malformation or incomplete partition-i (ip-i), cochleovestibular hypoplasia, and incomplete partition-ii (ip-ii). there is a lot of confusion in literature pertaining to mondini deformity. the new classification divides incomplete partition into ip-i representing cystic cochleovestibular malformation and ip-ii representing the classic mondini deformity with three components (cystic cochlear apex, dilated vestibule, and large vestibular aqeduct). recently a subclassification of ip-i and ip-ii has been proposed (subdividing into typical and atypical subtypes)[ ]. this will be discussed briefly. isolated large vestibular aqueduct without associated cochlear abnormalities will also be discussed. we will discuss the relevant embryology with correlations of malformations to the timing of embryologic insult. conclusions: the new classification system provides precision in description of inner ear malformation. this also helps in providing a uniform scale for comparison of effectiveness of cochlear implant for different malformations. purpose or case report: congenital cranial nerve anomalies often present as sensory and/or motor deficits of unknown etiology in the pediatric age group. the early recognition of a definitive cranial nerve abnormality using high-resolution imaging can focus further clinical investigation and shorten the time to diagnosis. methods & materials: to promote appropriate recognition of cranial nerve anomalies, we present the imaging findings of the most commonly affected cranial nerves and provide correlation with clinical presentation. all studies were performed on a . t magnet with dedicated high resolution imaging of cranial nerve exit zones. results: ours is a tertiary care pediatric hospital with an extensive neuroimaging database. we intend to review all known cases of cranial nerve anomalies from the prior years and present interesting and representative images including optic nerve hypoplasia as part of septo-optic dysplasia, kallman syndrome, duane retraction syndrome, and mobius syndrome. conclusions: congenital cranial nerve anomalies present with varied symptomatology including anosmia, impaired vision, occulomotor deficits, and hearing loss. additionally, clinical manifestations of cranial nerve anomalies can be difficult to recognize in the pediatric age group. effective imaging and prompt diagnosis is crucial to initiate appropriate clinical management. purpose or case report: mr is the standard for evaluation of tumors or epilepsy. pet-ct imaging is often performed to ascertain metabolic asymmetries related to epileptogenic regions or to better characterize the metabolic activity of tumors. a baseline for normals with pet-ct fdg- and c methionine does not exist. methods & materials: retrospective review was performed of the pediatric patients who underwent pet-ct with c methionine and fdg. representative studies were selected for patients imaged during infancy (< yr), early childhood ( - ), childhood ( - ), late childhood ( - ), teenage ( - ). c methionine and fdg studies were analyzed for normal patterns of uptake and any trends identified across the stratified age groups. representative pictorial image galleries of the c methionine and fdg imaging patterns through development were created. results: the pattern of radiotracer uptake on c methionine differed from that of fdg. the c uptake remained low level throughout development compared to fdg uptake, which was robust in much of the cortex. the cortical fdg uptake within the frontal lobes progressively increased with age. the c uptake within the brainstem and thalamus was equal to cortex throughout development. the fdg uptake within the basal ganglia was equal to cortex while the brainstem and thalamic uptake was generally less than cortex. several anatomic structures showed robust c uptake not seen on fdg. these included the lacrimal, submandibular and parotid glands. incidentally, the pituitary gland and hippocampus consistently showed c uptake equal to cortex contrary to their appearance on fdg. our institutional protocol regarding the performance of combination c methionine and fdg brain pet-ct studies is presented. conclusions: this study illustrated the normal appearance of brain pet-ct imaging performed with c methionine and fdg in a representative cohort of the pediatric patients through development. normal variance imaging patterns and developmental trends seen with each radiotracer was demonstrated. the pediatric cerebellum: a pictorial review of normal anatomy using mri and diffusion tensor imaging ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; sumit singh, teresa c. gross kelly, mohit maheshwari, tushar chandra, hervey d. segall purpose or case report: the aim of this educational exhibit is to illustrate normal anatomical and functional anatomy of the cerebellum in the pediatric patient. the cerebellum receives sensory input from the brain and spinal cord and integrates this information to coordinate motor control. in addition, the cerebellum also plays a role in some cognitive functions such as attention and language. the first step toward understanding how cerebellar abnormalities can lead to neurological dysfunction, is to provide a solid understanding of the neuroanatomy and functional pathways of the cerebellum. we will describe basic cerebellar embryology, the various cell types and gross anatomy using mr images as well as dti fiber tractography. methods & materials: this exhibit will describe the microstructure, gross anatomy and functional pathways of the cerebellum through illustrations, mr images, diffusion tensor imaging (dti) and pathological correlation. first embryology of the cerebellum will be described, followed by mri depiction of the developmental anatomy of the cerebellum from infancy through adolescence. finally dti tractography images will be used to delineate functional pathways to and from, as well as within, the cerebellum. pathological specimens will be photographed to further illustrate gross anatomy. results: afferent white matter pathways travel mainly via the inferior and middle cerebellar peduncles. the main efferent cerebellar white matter pathway is through the superior cerebellar peduncle. transverse fiber tracts are present in the vermis. there are mainly two main systems of cerebellar white matter fibers which are easily visualized with dti color mapping; however more anterior components of dti tracts are intermixed with afferent white matter projections following the middle cerebellar peduncle. conclusions: knowledge of the precise neuroanatomy and white matter tracts of cerebellum may elucidate our ability to comprehend the clinical manifestations of cerebellar diseases in children. a solid understanding of normal cerebellar anatomy, development and functional fiber tracts in the pediatric patient can provide a baseline that may help predict the clinical outcome of various diseases or interventional procedures. gastroesophageal reflux scintigraphy: a low radiation alternative to gerd evaluation in children vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; feraas jabi, jan najdzionek, vaseem iqbal purpose or case report: gastroesophageal reflux disease (gerd) is among the common causes for failure to thrive, recurrent cough and aspiration in children. early diagnosis of gerd is essential in avoiding long-term sequelae such as growth delay, chronic lung disease, esophageal stricture, and esophagitis. gastroesophageal reflux scintigraphy, a noninvasive imaging modality, has been applied for detection of gerd and gastric emptying in children over the past few decades. the radiation burden is considerably small given that a very low dose of radioactivity via a short half-life radioisotope like technetium- m tagged to oral sulfur colloid is administered to a patient. this feature makes reflux scintigraphy especially attractive as the patient can be scanned for prolonged and delayed periods without increasing radiation dose permitting not only identification but also assessment of severity of gerd. characterizing gerd severity is essential in determining how aggressive the pediatrician should be with therapy. gastroesophageal reflux scintigraphy also allows a child to be fed their regular meal tagged to radiopharmaceutical without altering food taste. qualitative and quantitative parameters like gastrointestinal transit and gastric emptying time can be measured, respectively. scintigraphy is highly sensitive to low grade reflux making it very desirable for monitoring response to therapy. while scintigraphy like all other imaging modalities,has limitations, it continues to be an excellent technique for gerd identification and characterization as well as in monitoring response to gerd therapy. the pediatric kidney-a review of common and uncommon renal anomalies ruby lukse, staten island university hospital, drjosemorey@gmail.com; josé morey, jeremy neuman, arnold brenner, oren herman, adam bernheim purpose or case report: renal parenchymal imaging in nuclear medicine has long been performed with mtcdimercaptosuccinic acid (dmsa) due to its sufficient binding to the renal tubules to permit renal cortical imaging. dmsa is of particular value when high-resolution images of the renal cortex are needed. this poster will be a pictorial review of common and uncommon congenital anomalies evaluated on dmsa imaging, such as horseshoe kidney, pelvic kidney, sshaped kidney and crossed-fused ectopia. the poster will also correlate planar imaging findingss with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: in this poster we will review the differential diagnoses of congenital anomalies that give the appearance of hydronephrosis on renal imaging of the pediatric patient. we will show a pictorial review of both common and uncommon congenital anomalies such as congenital megaureter, ureterocele, uretero-pelvic junction (upj) obstruction, uretero-vesicular junction (uvj) obstruction and posterior urethral valves (puv). we will also review common mimickers of hydronephrosis such as multicystic dysplastic kidney (mcdk) and pseudo-obstruction secondary to bladder overdistention. the poster will also correlate planar imaging finds with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the pediatric bone scan-a review of neoplastic pathology shrita smith, staten island university hospital, drjosemorey @gmail.com; josé morey, jeremy neuman, arnold brenner, daniel klein, purpose or case report: bone imaging continues to be the second greatest-volume of nuclear imaging procedure performed today, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of malignant conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of malignant and benign neoplasms in the pediatric population, such as osteoid osteoma, langerhan cell histiocytosis (lch), osteoblastoma, ewing's sarcoma, lymphoma, osteosarcoma and osseous/hepatic metastatic disease from neuroblastoma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the many faces of duplex kidneys on dmsa scans-a pictorial essay neha kwatra, children's national medical center, nskwatra@childrensnational.org; massoud majd purpose or case report: renal duplication is the most common malformation of the urinary tract and is often seen in children with urinary tract infections (uti). the purpose of this study is to learn to recognize duplex kidneys on dimercaptosuccinic acid (dmsa) scintigraphy, review their entire spectrum of findings and correlate with other imaging modalities. methods & materials: dmsa scintigraphy is routinely performed in the nuclear medicine department with a single-head gamma camera (siemens e.cam, schaumberg, illinois). about . h after injection of dmsa, posterior and posterior oblique images are obtained using parallel and pin hole collimators. differential renal function is also calculated. dmsa scan reports containing the words "duplex" or "duplicated" from - were populated using a radiology search engine (montage health care solutions inc.). the images were then reviewed in pacs and representative examples were selected for the poster. the scans were evaluated for renal position, size, contour, any evidence of duplication and parenchymal damage. results: patterns of duplication included non complicated duplex kidney recognized by asymmetric renal size and a prominent cortical bar separating the two moieties, complicated duplex systems with hydronephrosis, scarring or pyelonephritis of one or both moieties. a small nonfunctioning upper moiety was sometimes evidenced by just an indentation along the superomedial aspect of the larger lower moiety. cases with bilateral duplex kidneys were also seen. illustrative examples of each will be provided. correlating findings on other imaging modalities will also be included. conclusions: establishing the diagnosis of duplex kidney on a dmsa scan requires a careful systematic review of the images. the findings can be subtle and it is important for the radiologist to recognize them. correlation with other modalities such as ultrasound or voiding cystogram can be complementary. the assessment of parenchymal function of the upper and lower moieties separately on dmsa scintigraphy can be of immense value in patient management and in choosing surgical options. poster #: edu- f-fdg pet/ct imaging of pediatric brain tumors, neurofibromatosis (nf ) and non-lymphomatous head and neck tumors. lisa states, md, radiology, chop, states@email.chop.edu; purpose or case report: this educational poster will review the current literature and summarize the value of f-fdg pet/ct in standard clinical practice in the evaluation of pediatric brain tumors, nf plexiform neurofibromas and malignant peripheral nerve sheath tumors, and nonlymphomatous head and neck tumors. normal variants and pitfalls will be reviewed. comparison with other pet tracers will be briefly discussed. case examples will be used to illustrate the value of f-fdg pet/ct in grading, staging, assessment of therapeutic response and detection of residual or recurrent disease in various pathologic entities. results: examples of cases will include: benign brain tumor, residual brain tumor in the post-operative bed, brain metastasis, malignant peripheral nerve sheath tumor in nf , head and neck rhabdomyosarcoma, mandibular osteosarcoma, and infection. conclusions: an understanding of the value of pet molecular imaging is essential to the success of the next phase of hybrid imaging with pet/mri which has the potential to play an important role in the development of new diagnostic and therapeutic approaches for the treatment of pediatric brain tumors, nf , and pediatric head and neck tumors. disclosure: dr. states has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the pediatric bone scan-a review of non-malignant pathology josé morey, staten island university hospital, drjosemorey@ gmail.com; jeremy neuman, arnold brenner, vinh phan, cheryl lin purpose or case report: bone imaging continues to be the second most performed nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of benign conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of non-malignant diseases in the pediatric population, such as acute osteomyelitis secondary to salmonella enterobacteriaceae and tubercle bacillus (tb), chronic osteomyelitis, reflex sympathetic dystrophy, spondylolysis, bone infarcts in the setting of sickle cell disease, fractures (occult/stress), ankylosing spondylitis, dermatomyositis and non-accidental trauma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: we review the radiologic features of pathologic conditions linked to diesel exposure. the hydraulic fracturing ("fracking") technique is increasingly used in many areas of the country to extract natural gas from rock formations. diesel fuel, or fluids containing diesel, are one component of fracking fluid and create a potential for ground water contamination and risk to air quality. the toxic effects of diesel exhaust are described in the literature, and include asthma, hydrocarbon pneumonitis, and leukemia. there are no scientific data currently available on the effects of chronic diesel ingestion. methods & materials: multi-modality examples of pathology were obtained from a radiology database at a tertiary care pediatric hospital. the specific cases displayed are not known to have diesel exposure, but are intended to serve as representative examples of the type of pathology that may be encountered in the setting of chronic diesel exposure. results: imaging findings of asthma include hyperexpansion, atelectasis, peribronchial thickening, and air-trapping. hydrocarbon pneumonitis may demonstrate low attenuation consolidation and subsequent pneumoatocoeles with ct. leukemia may present on plain radiographs with lucent metaphyseal bands and with marrow infiltration on mri. conclusions: in conjunction with other symptoms not necessarily evaluated in the radiology department, including rhinitis, laryngitis, acute coronary syndrome, and dementia, the radiologist may suggest the diagnosis of diesel toxicity, particularly in populations that may be at high risk of exposure. pediatric radiology in the philadelphia region: a historical review* richard markowitz, md, children's hospital of philadelphia, markowitz@email.chop.edu purpose or case report: the specialty of pediatric radiology in the philadelphia region has grown and evolved over the past eight decades originating from early "visiting" radiologists to drs. hope and kirkpatrick, the "giants" of the s and ' s, to over fifty practicing pediatric radiologists today. clinical excellence, commitment to teaching, and advancement of knowledge through research remain the goals and ideals, much as they were many years ago. philadelphia has been a fertile home and environment for this evolution, mostly because of outstanding leaders and role models who have trained and influenced generations of pediatric radiologists. developments and leadership at the children's hospital of philadelphia, st. christopher's hospital for children, and a.i. dupont institute are highlighted. the purpose of this poster is to tell the story of the growth and development of pediatric radiology in this area and to explore the intellectual origins, professional "genealogy," and legacies left by those who created and those who have carried on this tradition. *note: this material is based on a previously published article: pediatric radiology ( ) : - and "addendum" (pediatric radiology : - ), but never presented at spr. superficial lumps and bumps henrietta k. rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; diane belvin, neil lester purpose or case report: superficial soft tissue masses in the pediatric age range can be quite challenging to the pediatrician and the imager. the purpose of this presentation is to demonstrate the efficacy of duplex/color doppler ultrasound for the diagnosis and follow up of a large gamut of superficial lumps and bumps. methods & materials: we reviewed our experience during the past years using ultrasound to evaluate superficial soft tissue masses that had been encountered in many parts of the body, from the skull to the soles of the feet, in a large group of patients ranging in age from newborn to years. all sonograms were performed after obtaining pertinent clinical information as well information regarding the clinical characteristics of each of the masses, e.g. location, consistency (firm [solid], compressible [cystic]), fixed or easily movable, smooth or irregular surface, tenderness. the masses were palpated by the imaging team and duplex/color doppler ultrasound was performed. comparison sonographic views of the opposite side were obtained as needed. clinical followup and surgical/pathological correlation was obtained in most of the patients. results: most of the masses were benign and included a wide variety of etiologies. most often, us was sufficient for assessment of soft tissue masses if the entire mass was included in the field of view. if the lesion was too large for the field of view or malignancy was suspected, ct/mri were required preoperatively. nuclear medicine studies are reserved for midline masses likely due to ectopic thyroid and pet was used for more complete evaluation of a lesion that was likely malignant. conclusions: duplex/color doppler ultrasound (us) is the modality of choice for evaluation of superficial lumps and bumps! this modality allows for rapid acquisition of information without the use of ionizing radiation, intravenous contrast material, or sedation/anesthesia. reliable information can be rapidly acquired regarding the size, shape, borders, location, internal consistency, vascularity, vascular encasement/displacement. correlation of the ultrasound and clinical findings helps narrow differential diagnosis. sonography helps to determine what is the next best step: watchful waiting (clinical observation, follow-up us), surgical resection, or us guided interventional procedure. present day imaging of down syndrome rupa radhakrishnan, md, radiology, university of cincinnati college of medicine, radhakrp@ucmail.uc.edu; alexander j. towbin purpose or case report: down syndrome is a common genetic condition characterized by unique physical traits and multisystem anomalies. the purpose of this exhibit is to portray the imaging findings of down syndrome and discuss with illustrative examples, the use of imaging in multidisciplinary management. methods & materials: published literature was reviewed to identify the multisystem imaging findings in down syndrome. the electronic medical record system was then searched to find illustrative case examples from our institution. results: in patients with down syndrome, abnormalities can be found in the musculoskeletal, cardiovascular, respiratory, gastrointestinal, and central nervous systems. abnormalities can range from emergent, life threatening conditions such as malrotation with midgut volvulus to chronic conditions such as scoliosis. examples of abnormalities from each organ system and the modalities used for diagnosis and management are described. cardiovascular system: echocardiogram and cardiac mri and ct are useful in evaluating congenital heart disease associated with down syndrome. respiratory system: micrognathia with macroglossia and hypotonia predisposes patients to sleep apnea which can be evaluated with dynamic mri. chest ct demonstrates subpleural cysts which are characteristic of this syndrome. gastrointestinal system: fluoroscopy and/or radiographs are the mainstay in diagnosing many gastrointestinal disorders including duodenal atresia, malrotation, annular pancreas, imperforate anus, and hirschsprung disease. central nervous system: choroid plexus cysts may be identified on prenatal ultrasound in a fetus with down syndrome. imaging is used in the evaluation of epilepsy, hearing loss and alzheimer disease that is more common in these individuals. musculoskeletal system: multiple skeletal anomalies can be present in patients with down syndrome. radiographs are often used as the method of identifying and, if needed, following the anomalies. prenatal imaging: increased nuchal translucency is the earliest imaging finding. other features of down syndrome can be identified on prenatal ultrasound or mri. prenatal imaging is helpful in determining the prognosis of the fetus and in guiding management. conclusions: modern day multidisciplinary management has improved quality of life and survival in individuals with down syndrome. imaging plays a critical role in guiding management in these individuals. imaging the spectrum of lymphatic malformations in the pediatric patient andrew schapiro, md, radiology, university of wisconsin, aschapiro@uwhealth.org; kara gill, bradley maxfield purpose or case report: lymphatic malformations (lm) occur as a result of abnormal development of the lymphatic system during embryogenesis. as % of lm present by years of age, these lesions represent an important pediatric entity. lm can often be suspected clinically in an infant with the classic presentation of an asymptomatic, soft mass in the head, neck, or axilla. however, myriad presentations are possible as lm occur in numerous other anatomic locations, can be multiple, and can be a component of mixed vascular malformations. in addition, the true extent of lm is often not apparent clinically. given these considerations and the implications for proper management, imaging plays an important role in the assessment of lm. the purpose of this exhibit is to review the spectrum of radiographic, ct, sonographic, and mr imaging findings of a variety of lm presentations. methods & materials: cases of lymphatic malformation in pediatric patients identified at a single institution over the past ten years with available imaging were reviewed utilizing pacs. results: images of lm involving the head and neck, chest, abdomen, retroperitoneum, extremities, and skeletal system were identified. in addition, cases of lymphangiomatosis and mixed venolymphatic malformation were identified. various imaging modalities including radiography, ct, sonography, and mr were represented. conclusions: adequate knowledge of the imaging characteristics of lm across multiple modalities enables proper diagnosis, assessment of disease extent, and guidance of appropriate therapy in pediatric patients. results: ct and mr imaging findings in nine cases will be presented. they include ) congenital absence of the inferior vena cava with thrombosis of the external iliac vein secondary to venous stasis ) pyelophlebitis complicating ruptured appendicitis ) left iliac vein thrombosis in a patient with may-thurner syndrome ) splenic vein thrombosis complicating pancreatitis ) splenic vein thrombosis following splenectomy ) renal vein thrombosis in an infant of a diabetic mother ) adrenal vein thrombosis as the presenting sign of antiphospholipid syndrome ) budd-chiari syndrome associated with underlying myeloproliferative disease ) iliac vein thrombosis as a manifestation of behcet's syndrome (hughes-stovin syndrome, a variant of behcet's syndrome, which presents with systemic venous thrombosis and pulmonary artery aneurysms will also be discussed). conclusions: thrombosis of large abdominal and pelvic veins in children and adolescents is uncommon. certain conditions, both congenital and acquired, predispose to the development of venous thrombosis. ct/mr imaging defines the extent of thrombosis, and demonstrates additional findings that may elucidate the nature of the underlying condition leading to clot formation. purpose or case report: because abnormal gait in a young child has a wide range of causes, imaging plays a critical role in establishing the definitive diagnosis. the purpose of this exhibit is to review the clinical clues (age, duration, laboratory markers) and imaging findings of the causes of abnormal gait in a toddler and to assess the strengths and limitations of radiographs, ultrasound, magnetic resonance imaging (mri), and computed tomography (ct). methods & materials: cases, from a single institution experience with various causes for abnormal gait in a toddler, are reviewed and categorized into congenital, traumatic, inflammatory, neoplastic, or neuromuscular etiologies. results: there are various causes of abnormal gait in a toddler. the congenital causes include spinal dysraphism, proximal and distal skeletal deformities and dysplasias. the traumatic causes include non-accidental trauma, toddler's fracture, foreign body, and soft tissue injuries. the inflammatory causes include juvenile idiopathic arthritis, transient synovitis, and infection, including osteomyelitis, septic arthritis, discitis, cellulitis, and abscess. the neoplastic causes include various neurogenic, bone, and soft tissue tumors. the neuromuscular causes include cerebral palsy and spinal bifida. the combination of clinical presentation, supporting laboratory findings, and classic imaging findings help to distinguish the possibilities and often allows confident diagnosis. conclusions: knowledge of imaging findings and clinical factors can demystify the diagnosis of abnormal gait in a toddler. familiarity with the clinical presentation can ensure the performance of the appropriate diagnostic studies, timely diagnosis, and effective treatment. nonaccidental causes should never be overlooked. ultrasonography has become an important tool in the radiologist's armamentarium, augmenting radiography, mri, and ct. approximately different contrast agents for mri and ct are now commercially available for use. although most of them are fda approved in adults, information on usage and safety in children is not readily available. the most important reason is lack of controlled studies in children, especially for the age of - years. however, the lack of fda approval has not limited the use of these promising agents in children. in fact, there is widespread off-label use of these agents in most major pediatric hospitals in the country. based on a review of relevant literature in children, and based on a survey of radiology faculty at major pediatric hospitals, this poster will address the gap between approved use and reality in the setting of pediatrics. results: using a tabular format, this poster will provide a list of mr and ct contrast agents that are available for clinical use, their relevant clinical properties (ionic or nonionic, viscosity, linear or macrocyclic, degree of relaxivity for mri, iodine concentration for ct, cost, dosage, halftime, incidence of allergic reactions, nephrogenic systemic fibrosis and other adverse reactions), fda approval status (for ages - days, days- years, and - years), common pediatric applications, and contrast injection protocols for common applications. conclusions: to enlighten imaging personnel about usage and safety of contrast agents in children. disclosure: dr. krishnamurthy has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. a pictorial essay and literature review of the spleen in sickle cell disease david hindson, md, boston medical center, david. hindson@bmc.org; heather imsande, philippa sprinz, ilse castro-aragon purpose or case report: the morbidity and mortality of sickle cell disease (scd) results from acute and chronic infarction events that affect almost every organ. repeated infarction has some of its greatest visual and physiologic impact within the spleen. continuous hemolysis, sequestration and vaso-occlusion within the spleen result in loss of splenic function early in life and frequently autosplenectomy thereafter. by years of age, approximately % of children with hemoglobin ss disease will have diminished splenic function, putting them at increased risk for infections. treatments for scd have evolved over the last years, and among others include penicillin prophylaxis and immunizations, hydroxyurea and transfusion therapy (or hypertransfusion program). imaging findings are a reflection of the different treatments and their efficacy. methods & materials: our institution cares for a large group of patients with sickle cell disease, from birth to adulthood. this offers an unprecedented opportunity to document the imaging findings of the spleen with different treatment regimens, and over many years. the splenic size and morphology can be followed, by ultrasound, in a very straightforward way. we have compiled a pictorial essay of the various imaging characteristics of spleens from infants to adults. we also performed a literature review to compare and supplement the findings of our images. results: there is a spectrum of imaging findings in the spleen of patients with scd that changes from birth to childhood. the findings range from the normal appearance of a spleen to a calcified spleen, and include regenerative nodules, fibrosis, altered parenchymal echotexture, increased echogenicity, and changes in size, including enlargement secondary to sequestration. the ultrasound characteristics not only change with advancing age, but also appear to depend on whether or not the patient has received specific treatments, and at what age treatment was initiated. conclusions: the ultrasound appearance of the spleen in patients with scd is variable. treatments such as blood transfusions and hydroxyurea, patient compliance with therapy and type and severity of the disease are some of the factors that affect imaging characteristics. cystic fibrosis: not just for children cindy miller, md, radiology, yale-new haven hospital, cindy.miller@yale.edu purpose or case report: cystic fibrosis has been recognized for hundreds of years with the first descriptions of it including such anecdotes as mothers licking the foreheads of their children and knowing that if it tasted salty, an early death could be predicted. it was not until that the disease was first named by dr. dorothy andersen, and for the following years, treatment was largely supportive, and imaging was essentially done with plain films alone. in with the elucidation of the cftr gene, there was an explosion of knowledge which included the range of increased awareness and understanding of the suspected etiology, imaging findings and significance of the ductus bump. the contribution of d imaging for evaluation of the pediatric central airways jessica kurian, md, the children's hospital of philadelphia, kurianj@email.chop.edu; monica epelman, david a. mong purpose or case report: evaluation of the central airways in children has historically been accomplished by flexible bronchoscopy, an invasive technique associated with inherent risks and complications. multidetector ct (mdct) with volume rendering offers a noninvasive alternative for airway evaluation. in this educational exhibit, we will review imaging techniques and clinical applications of mdct for the assessment of large airway maladies in children. methods & materials: mdct imaging in children with a variety of tracheobronchial disorders is reviewed. for each entity, the characteristic clinical features are described, and key imaging features are illustrated. emphasis is placed on the contribution of d techniques for characterizing complex airway anomalies. dose reduction strategies are also highlighted. results: the entities reviewed in this exhibit include, but are not limited to, congenital anomalies of tracheobronchial branching, airway malformations associated with situs, and congenital or acquired airway compression and/or obstruction. conclusions: mdct with volume visualization is a useful adjunct for evaluation of the pediatric central airways in a variety of pathologies. as a noninvasive technique, it avoids sedation risks and spare patients from complications associated with conventional flexible bronchoscopy. low dose protocols should be used to minimize radiation exposure. bronchopulmonary foregut malformation that result from abnormal budding of the primitive foregut. currently, many such anomalies are initially detected by prenatal ultrasound and are further delineated by fetal magnetic resonance imaging (mri), while others may be incidentally detected on postnatal radiologic examinations or later in life in the setting recurrent pulmonary infection. imaging plays a very important role in the diagnosis and characterization of these lesions and assists surgical planning. the purpose of our educational exhibit is to illustrate the common and uncommon radiologic appearances of cpams using various imaging modalities, including radiography, computed tomography, prenatal and postnatal ultrasound, and prenatal and postnatal mri. methods & materials: all pediatric and adult cpam (including both sequestration and ccam) patients were identified using electronic medical records. pertinent imaging reports (including radiography, prenatal and postnatal ultrasound, ct, and prenatal and postnatal mri) were reviewed by a single author in order to identify relevant imaging findings. relevant images from these imaging examinations were de-identified and saved to a secure hard drive. medical records were accessed by a single researcher to obtain relevant demographic information as well as data regarding the patients' clinical presentations. in cases of corrective surgery, operative and pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of pediatric and adult cpam were identified and presented in a variety of clinical contexts. their appearances were reviewed through multiple imaging modalities. conclusions: congenital pulmonary airway malformations are varied in their clinical presentation and imaging appearance. the purpose of this pictorial essay is to enhance understanding of their diagnosis and to use a multidisciplinary approach in order to highlight imaging aspects that may alter clinical management. disclosure: dr. horst has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the imaging evaluation of cystic lung disease in children: an evidence-based approach jordan caplan, md, pediatric radiology, lucile packard children's hospital, stanford university, caplan@stanford. edu; beverley newman purpose or case report: the goal of the poster is to provide a framework for use when confronted with cystic lung disease in a child. methods & materials: the differential diagnosis for the types and causes of cystic lung disease in children will be presented using an evidence-based, age appropriate approach. categories of disease discussed and illustrated with case examples will include: a. congenital cystic bronchopulmonary malformations b. infectious cysts c. autoimmune/inflammatory/vasculitic disease with cavitating lesions d. neoplastic conditions e. collagen/soft tissue abnormalities f. mimics of cystic lung disease results: the pathophysiology, imaging appearance, and demographics of the above entities will be reviewed with attention to relevant recent literature. important educational points include the differentiation of bronchopulmonary malformations from neoplasm, notably pleuropulmonary blastoma (ppb), the relationship between lung cysts and ppb, and the management and surveillance of lung cysts in children. conclusions: an evidence-based approach to the broad spectrum of causes of cystic lung disease in children is a useful starting point in forming a concise and pertinent differential diagnosis. an understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding patient management. pediatric interstitial lung disease (ild): a pictorial review with radiologic and pathologic correlation hollie west, md, diagnostic radiology, vanderbilt university, hollie.c.west@vanderbilt.edu; melissa a. hilmes, sudha p. singh, jennifer soares, lisa young purpose or case report: while adult interstitial lung disease is a well-described and fairly well understood group of disease processes, pediatric interstitial lung disease (ild) remains a subject of uncertainty and misunderstanding for many clinicians and radiologists. confusion surrounding the phenomenon of pediatric ild stems not only from the rarity of the disease, but also from the extensive list of disease entities that can produce ild, the existence of certain patterns that are restricted to infants and children and the fact that patterns of ild manifest differently in a child's developing lung than in an already developed adult lung. imaging plays an important role in diagnostic work-up of this disease and can guide lung biopsy in specific patient populations. methods & materials: the irb approved retrospective study will show patients at our institution over a year period diagnosed with various types of ild, including pulmonary insterstitial glycogenolysis (pig), diffuse neuroendocrine cell hyperplasia (nehi), surfactant deficiency diseases, and lung diseases associated with other systemic processes such as downs syndrome and inflammatory bowel disease. we will include patients with biopsy proven ild and will provide examples of the major ilds, including clinical, radiologic and pathologic correlation. our pictorial review will describe the radiologic patterns associated with the different forms of ild, emphasizing what the radiologist needs to know and how to be helpful to a multidisciplinary team in the diagnosis and treatment of these diseases. results: the study will report the frequency of ild at our institution, including a breakdown of the various subtypes of ild. we will show examples of the subtypes with correlative chest radiography, computed tomography, and pathology. we plan to highlight specific differentiating factors between the different diseases and demonstrate how a radiologist can be helpful in collborating with clinicians in diagnosing and treating these diseases. conclusions: pediatric ild can be a confusing topic for radiologists. increasing knowledge and awareness of these diseases, their clinincal presentation, work up, and treatment is important for pediatric radiologists who work as part of of a multidiciplinary team. poster #: sci- ct radiation dose delivered by community hospitals and imaging centers stephen little, children's healthcare of atlanta, stephen. little@choa.org; damien grattan-smith, bonnie johnson purpose or case report: to evaluate and compare ct radiation dose for pediatric abdominal and cranial ct examinations performed by community hospitals and imaging centers. methods & materials: consecutive ct examinations ( cranial, abdominal) from community hospitals and imaging centers were reviewed following transfer of care. the examinations were performed between january and july . consecutive ct examinations ( cranial, abdominal) performed at our own institution were also reviewed. ctdivol and dlp were obtained from the dose report for each examination ( cm-phantom for abdominal exams, cm-phantom for cranial exams). patient age and weight were obtained from the medical record. results: average ctdivol for abdominal ct performed by local community hospitals and imaging centers was . mgy, while average ctdivol was . mgy for abdominal ct performed at choa. there was a wide variation in ct radiation dose delivered. while some sites delivered a ct radiation dose comparable to our own, others delivered a substantially greater dose. in fact, % of pediatric abdominal ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy using the cm phantom). low kvp technique for imaging small children was infrequent. multi-phase examinations were more often performed, resulting in additional elevation in ct radiation dose when dlp is considered. average ctdivol delivered by local community hospitals and imaging centers for cranial ct was mgy compared to a ctdivol of mgy for cranial ct performed at choa. % of pediatric cranial ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy for - years, mgy for > years). conclusions: despite ongoing efforts at education, there is wide variation in ct radiation dose delivered for pediatric abdominal and cranial ct examinations performed by local community hospitals and imaging centers. appropriate use of dose check software on newer scanners may help reduce the number of children subjected to excessive ct radiation dose. ultimately, each site performing pediatric ct must take responsibility for minimizing radiation dose while producing diagnostic quality exams. the impact of adaptive statistical iterative reconstruction on ct image quality parameters -a phantom study karen thomas, md, radiology, hospital for sick children, karen.thomas@sickkids.ca; nancy ford, angjelina protik, paul babyn purpose or case report: to quantify the effect of adaptive statistical iterative reconstruction (asir) on ct image quality parameters. methods & materials: phantom (catphan ) studies were performed on a ge hd -slice scanner to investigate the impact of a) % asir compared to routine filtered back projection using variable kvp ( - ) and mas ( - ), and b) incremental asir % ( , , , , %), scanning at mas and variable kvp ( - ). pitch, acquisition fov and detector width were kept constant. image noise, spatial and contrast resolution, contrast noise ratio (cnr) and wiener spectrum analysis were performed on . mm ax, mm ax mpr and mm cor mpr series. results: % asir resulted in a mean decrease in noise of % ( . mm ax), % (ax mpr) and % (cor mpr) and improvement in cnr of - %. incremental advantage was seen with stepwise increase in asir %. however, application of asir was associated with a small reduction in spatial resolution ( - % at % asir). low contrast detectability (lcd) improved except at the smallest target lesion size. image quality effects at very low mas and at high asir % will be presented. conclusions: image noise reduction and improvements in cnr and lcd with asir hold considerable potential for dose reduction in pediatric ct. this study provides quantitative data that may be used to design asir-enhanced protocols with consideration of diagnostic task, balancing image quality benefits and potential pitfalls. pictorial essay on cardiac mr for congenital heart disease on t mr scanner with rf multi-transmit technology (tx) taylor chung, md, diagnostic imaging, children's hospital & research center oakland, taylorchung @gmail.com purpose or case report: this is a pictorial essay (e-poster) to show artifacts on cine ssfp images pre-tx and post-tx upgrade on congenital heart disease cardiac mr; to illustrate methods prior to tx-upgrade to minimize artifacts. disclosure: dr. chung has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. revisiting the relationship between anthropometric parameters and left ventricular mass abdullahi adamu, md, phd, ahmadu bello university, scorpion kd@yahoo.com purpose or case report: the purpose of this study was to find the correlation between anthropometric parameters and left ventricular mass in normal adolescents and young adults. methods & materials: healthy individuals in the age range to years ( males and females) were included in this study. anthropometry was performed with standard anthropometry kit and measurements of height, weight, body surface area (bsa), upper arm circumference and upper hip circumference were taken. echocardiography was performed and the american society of echocardiography (ase)-recommended method was employed for calculation of left ventricular mass (lvm). statistical analysis was performed using statistica . (stat soft, usa). results: the mean value of lvm for all our subjects was found to be . ± . g. there was significant correlation between lvm and height (r . , p< . ), weight (r . , p< . ) and bsa (r . , p< . ). correlation with upper arm circumference was moderate (r . , p< . ), while it was found to be weak with upper hip circumference (r . , p< . ). diagnostic. both field strengths can be used successfully for cardiac and vascular imaging. the decision as to which to use is weighted by local availability and the relative requirement for detailed vascular vs intra-cardiac imaging. disclosure: dr. nguyen has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. poster #: sci- color coded d cardiac cta of congenital heart disease: a five year experience nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; randy richardson purpose or case report: post-processing of cardiac computed tomography angiograms can be performed on a commercially available workstation to create color coded d volume rendered images of the segmented heart and great vessel anatomy in patients with congenital heart disease. these studies optimally demonstrate complex anatomy, streamlining communication between members of the healthcare team and providing a tool for communicating complex anatomy and treatment options with families. these studies have been ordered with more frequency over the past five years. we retrospectively reviewed the types of congenital heart disease demonstrated by cardiac d cta over the past five years at a congenital heart center. methods & materials: color coded cardiac cta postprocessing was performed from ecg gated prospective and retrospective cta data on a commercially available workstation for / patients over the past three years. the anatomy was initially segmented and colored into individual parts of the anatomy of the heart and great vessels as follows rv purple, lv light red, aorta red, pulmonary arteries blue, systemic veins and right atrium aqua, pulmonary veins and left atrium pink, pda or collaterals green, airway yellow, coronary arteries neutral. the anatomy was then reassembled and images obtained every °in a °rotation for display. results: d color coded cta images were used in the treatment and care of congenital heart patients for the following types of congenital heart diseases: cases of complex anatomy (tga, truncus arteriosus, hlhs, tricuspid atresia, tof…), coronary artery anomalies, cases of pulmonary atresia or stenosis, cases of systemic and venous anomalies, cases of coarctation or interruption of the aortic arch, and tracheobronchial tree anomalies. conclusions: color coded cardiac cta post-processing is an effective and viable method for demonstrating anatomy in complex congenital heart patients. it is an excellent tool for demonstrating anatomy which is difficult to see by echocardiography such as: coronary artery anomalies, pulmonic atresia, aortic arch coarctation or interruption, and tracheobronchial anomalies and/or stenosis. neuroimaging in the evaluation of hie in term neonates post hypothermia therapy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu; jatinder bhatia, leann vanlandingham purpose or case report: to illustrate and review the potential utility of brain mri, ct and ultrasound in hypoxic ischemic encephalopathy in newborns treated with hypothermia. neuroimaging studies including brain ultrasound, ct and mri of fifteen term newborns treated in our institution with therapeutic hypothermia, since april were evaluated retrospectively. more relevant lesions are depicted and the diagnostic and prognostic value of the findings is discussed and compared with a review of the literature. results: recent studies showed that patients treated with cooling had a more favorable prognosis than was suggested by the clinical grade of encephalopathy compared with infants treated with standard care. our institutional protocol includes the performance of mri, and ultrasound. ct is performed when is a clinical impossibility of perform mri. brain ultrasound was performed in all the patients. mri scans were obtained in neonates. ct was obtained in patients. all mri studies included dwi. the utility of dwi and adc maps as an aid in diagnosis of non-ischemic lesions is becoming increasingly established. mri evidence of brain injury was visible on basal ganglia in cases with negative ultrasound. abnormal signal intensity in the posterior limb of the internal capsule coexists with lesions in the basal ganglia and thalami have been associated with abnormal motor outcome. the remaining newborns did not develop significant mri evidence of brain injury. it has been suggested that the ability of mri to predict subsequent neurological impairment is unaltered by therapeutic hypothermia. further research is needed for defining the relation between mri findings and cooling. it is possible that imaging findings might be delayed in cooled infants. conclusions: mri offers the highest sensitivity in detecting anoxic injury of the neonatal brain. mr biomarkers in combination with clinical markers may identify patients with adverse outcome with therapeutic implications. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: to correlate bowel wall diffusionweighted imaging (dwi) apparent diffusion coefficient (adc) values with multiple mr enterography (mre) and clinical findings in pediatric small bowel crohn disease. methods & materials: pediatric crohn disease patients with mre exams containing diffusion-weighted imaging and demonstrating terminal ileitis were identified. minimum bowel wall adc values were tested for correlation/association with other mri findings and clinical parameters (including laboratory values). results: there is negative correlation between adc value and degree of bowel wall thickening (r (−) . ; p . ). lower adc values were significantly associated with striated pattern of arterial phase postcontrast enhancement (p . ), greater degree of arterial phase postcontrast enhancement (p . ), and presence of stricture (p . ). adc values were not associated with diseased bowel length, degree/pattern of delayed postcontrast enhancement, degree of mesenteric inflammation or fibrofatty proliferation, or clinical markers of inflammation. conclusions: restricted diffusion in pediatric small bowel crohn disease is associated with other mri findings of that are suggestive of active disease, including degree of bowel wall thickening and degree and pattern of arterial phase postcontrast enhancement. our data also suggests that dwi may be useful when attempting to characterize small bowel strictures as either predominantly inflammatory or fibrotic, although further investigation is needed. quantification of blood flow into and out of the liver with d phase contrast mri in the pediatric patient binh huynh, md, radiology, stanford, bhuynh@stanford. edu; shreyas vasanawala, albert hsiao purpose or case report: the ability to probe blood flow dynamics in the liver may aid management of children with liver disease, including shunt fractions in portal hypertension and arterial flow fraction in diffuse liver disease. the purpose of this study is to evaluate the ability to measure blood flow into and out of the liver with time resolved volumetric ( d) phase contrast mri in the pediatric patient. methods & materials: nineteen consecutive patients were retrospectively identified who underwent d flow imaging through the level of the hepatic vessels on . t and t magnets. a software enabling d flow program was utilized to first assess for the feasibility of measurement of flow in the hepatic artery (ha), portal vein (pv), splenic vein (spv), superior mesenteric vein (smv), supra (sivc) and infrahepatic (iivc) inferior vena cava. if measurable, calculations were performed to evaluate for internal consistency by comparing the sum of smv and spv flow to pv flow. calculations were then performed to compare hepatic inflow (pv+ha) to hepatic outflow (sivc-iivc) and for the percentage of pv and ha contribution to hepatic inflow. results: of the nineteen patients, all of the above mentioned six vessels were visualized and measurable in two patients, both of which were imaged on the . t magnet. in the remaining patients, flow measurements were limited by respiratory motion artifacts obscuring the smaller vessels, and severe eddy currents, particularly in patients imaged with the t magnet. the evaluation for internal consistency demonstrated an average of . % ( . % & - . %) difference between smv+spv and pv flow. hepatic inflow was found to closely match the measured hepatic outflow with an average difference of . % ( . % & . %). the portal vein was found to contribute . % and . % to hepatic inflow, while the hepatic artery contributed . % and . %. conclusions: measurement of hepatic flow with phase contrast mri is more challenging than assessment of thoracic flow. when respiratory artifacts are minimal, vessels can be identified and measurements have internal consistency and good agreement between hepatic inflow and outflow at . t. conversely, flow measurements were limited at t by eddy currents. thus, ongoing efforts are aimed at mitigating respiratory motion artifacts at . t. poster #: sci- mri findings in post-fontan hepatopathy adina alazraki, md, radiology, emory university/children's healthcare of atlanta, adina.alazraki@choa.org; pinar bulut, kiery braithwaite, miriam vos, rene romero, nitika a. gupta purpose or case report: as advances in congenital heart disease continue to improve both mortality and quality of life, associated complications are becoming more prevalent. amongst patients who have had fontan repair for hypoplastic left heart syndrome, tricuspic atresia, or other right heart dysfunction, it is well known that liver disease is a complication. we describe the mri findings in post-fontan patients and propose mri as a useful tool to the hepatologist's evaluation of these patients. methods & materials: irb approval was obtained for a retrospective review of patients who underwent fontan repair and were subsequently referred for hepatology evaluation between - . all but one patient was scanned on a siemenstriotrim t magnet; one patient was scanned on a ge twinspeed . t magnet with an equivalent protocol due to orthodontics. a standardized departmental protocol was utilized. mri findings were correlated with age at surgery and years since surgery. mr images were reviewed independently by pediatric radiologists and compared with the dictated report in the patients record. results: patients underwent mri of the abdomen. patients had mri incompatible hardware and patients were not scanned secondary to insurance denial. patients were divided into groups based on elapsed time since surgery: less than years, - years, - years, and greater than years.(table ) mr images were evaluated for the presence of fibrosis, congestion and any other hepatic abnormalities. fibrosis was determined based on a specific pattern of delayed reticular enhancement in combination with liver morphology. congestion was deemed present if there was increased t signal in the liver parenchyma or periportal regions in combination with cloud-like enhancement on dynamic post-contrast images. all patients demonstrated morphologic changes in the liver with varying degrees of hepatic fibrosis and hepatic congestion. fibrotic changes were often non-uniform, and thus could be underdiagnosed by biopsy. interestingly, patients, %, had focal arterially enhancing lesions speculated to represent vascular proliferative lesions, however, none warranted biopsy. conclusions: it is established that patients who undergo fontan develop hepatic abnormalities. mri is a reliable, non invasive technique that accurately demonstrates these findings. mri may be a more sensitive method to evaluate the etiology and full extent of hepatic disease. poster #: sci- complications within the interventional radiology division of a tertiary care children's hospital: initiatives for ongoing quality and practice improvement brian dillon, children's hospital boston, brian. dillon@childrens.harvard.edu; pamela sanborn, yolanda milliman-richard, darren orbach, stephan voss purpose or case report: between and , procedure-related complications occurring within the division of interventional radiology at our institution were recorded and classified according to level of severity. the goals of this study were to determine rates of procedurebased complications based on severity, to establish thresholds for complications, and to determine whether measurable trends in complications over time were evident. methods & materials: between and , , interventional procedures were performed within the division of interventional radiology at our institution. adverse events were characterized both according to level of severity (using an institutional point severity scale), and with brief descriptions of individual events. adverse events were reviewed monthly at the division's morbidity and mortality conference, with respect to procedure type and operator. based on review of our interventional radiology data and benchmarks rates used for diagnostic errors, threshold complication rates were established by consensus between the department quality improvement committee and the division of interventional radiology. for severe events (level and ) there is no allowable threshold; all such events were subjected to both internal and institutional review. results: the overall complication rate was less than % for all procedures performed. the complication rates for the respective severity levels were: level ( . ), level ( . ), level ( . ), level ( . ), and level ( . ). the severity of a given complication was not associated with procedural complexity. no operator-specific trends were identified. conclusions: since , the society of interventional radiology has offered guidelines and strategies for improving safety and quality in interventional radiology. however, no specific benchmark data or procedural recommendations are available for pediatric interventional procedures. our results demonstrate rates of complications well below published overall complication rates for interventional radiologic procedures. this database of procedure-based complications serves as a foundation for a quality improvement program that allows review of complications with respect to specific procedure types, individual operators, and procedural complexity, in an effort to institute an ongoing and continuous process of quality improvement within interventional radiology. purpose or case report: dysosteosclerosis (dss), an extremely rare dense bone disease, features short stature and fractures and sometimes optic atrophy, cranial nerve palsy, developmental delay, and failure of tooth eruption in infancy or early childhood consistent with osteopetrosis (opt). bone histology during childhood shows unresorbed primary spongiosa from deficient osteoclast action. additionally, there is remarkable progressive flattening of all vertebrae mimic ppi blocking mineralization. during ehdp treatment for gaci, in our patient prolonged high dose ehdp resulted in severe skeletal deformity resembling hypophosphatasia which was reversable with drug stoppage. methods & materials: a -year-old boy with gaci referred for profound, acquired, progressive skeletal deformity. he was receiving mg/day of ehdp and was wheelchair bound. we studied him and his response to stopping ehdp. results: skeletal radiographic findings resembled pediatric hypophosphatasia with pancranial synostosis, widened physes with metaphyseal osteosclerosis, "tongues" of radiolucency, along with cupping and fraying, and long-bone bowing. in addition there were large intra and extraarticular calcifications. radiographic features of bp-induced opt included femoral erlenmeyer flask deformity and osteosclerosis (lumbar sine dxa z-score + . ). biochemical parameters of mineral homeostasis were essentially normal although serum osteocalcin was low and he had markedly elevated serum levels of creatine kinase and trap- b consistent with osteopetrosis (opt). after stopping ehdp, he improved quickly with remarkable healing of his rachitic appearing skeleton and decreased joint calcifications. conclusions: our patient with gaci had profound skeletal deformities from high-dose ehdp therapy that significatly improved with drug stoppage. magnetic resonance imaging in the evaluation of infants with hypoxic ischemic encephalopathy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu purpose or case report: to illustrate and review a spectrum of brain abnormalities of infants with hie. defining the most useful approaches and mri sequences, to facilitate identification and early diagnosis of lesions with the potential to predict outcome and abnormal neurodevelopment. methods & materials: reviewed available evidence on mri strategies for evaluating infants with hypoxic ischemic encephalopathy. different cases illustrating lesions are presented and discussed for proper diagnosis correlating physiopathology and imaging appearance. more relevant findings are depicted with didactic illustrations. identifying studies where new techniques such as dwi, adc, dti, swi, or mrs adds significant diagnostic value to the overall interpretation. results: mri is routinely performed as a very sensitive method for detection of hie lesions. advanced mr techniques, such as dti, dwi, adc, mrs, swi offer the possibility of detecting injuries at a time when intervention is theoretically possible. the understanding of the physiopathology allows for prediction of the location and extent of lesions, facilitating identification and appropriate classification. the identification of infants with potentially abnormal neurodevelopment, offers the opportunity to provide therapeutic neurodevelopmental interventions in early childhood. mrs is the best mr biomarker to predict neurodevelopmental outcome in asphyxiated full-term neonates. brain metabolite ratios and regional adc values may vary between mr systems and coils. development of normal values for each institution is required, and support of physicists is mandatory. conclusions: mri continues to evolve as a valuable adjunctive tool routinely obtained in nearly all cases of hie. advanced mri techniques increase sensitivity of conventional t and t -w images and outperform computer tomography and ultrasound for confirming the diagnosis of hypoxic-ischemic brain injury or providing prognostic information for the care of patient with hie. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. posterior fossa abnormalities in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to demonstrate various conditions involving the posterior fossa in children with emphasis on importance of embryologic development of cerebellum in reaching a correct diagnosis. methods & materials: this pictographic presentation displays the imaging features of cases encountered in our clinical practice on . tesla magnetic resonance (mr) imaging. results: with the advent of mr imaging, there has been a revolution in identification and characterization of malformations of the brain this is especially true in posterior fossa, where the sensitivity and specificity of mr imaging with its multidimensional imaging capability are far superior to those of computed tomography (ct) in the detection of subtle morphologic abnormalities. however, there is still a great deal of confusion regarding their classification, terminology, and spectrum of expression and this is where neuroembryology is of great help. this exhibit demonstrates : ) review of embryology and normal anatomy of cerebellum. ) mr appearance of spectrum of conditions involving posterior fossa in children which includes developmental abnormalities (dandy-walker complex, arnold chiari malformations, cerebellar dysplasia/ hypoplasia, joubert's syndrome, etc.), cysts (arachnoid cyst, giant cisterna magna etc.), tumours (medulloblastoma, ependymoma, hemangioblastoma etc.) and miscellaneous conditions. significantly reduces dose ( / of other gadolinium based contrast agents), and doesn't require trigger imaging. conventional mri provides important information regarding the anatomical extent, size, and relation to critical anatomical structures thus when combined with twist, mri provides the best information without use of radiation in children. functional connectivity mri in pediatric brain tumor patients with and without epilepsy andrew v. poliakov, phd, radiology, seattle children's hospital; david bauer, edward novotny, seth d. friedman, dennis shaw, jeff ojemann purpose or case report: functional connectivity mri (fcmri) is a way to evaluate cortical networks across different modalities such as motor, sensory, vision, and the default mode network using functional magnetic resonance imaging. fcmri relies on correlation in fmri image intensity that occurs between functionally connected regions. this effect can be seen in awake as well as anesthetized patients. we evaluated these pathways in pediatric patients with brain tumors. methods & materials: patients were randomly selected from our tumor database. inclusion criteria included age less than , history of brain tumor resection, and complete fcmri data. imaging was performed on a t siemens trio system. functional mri data were acquired as part of a clinical imaging protocol over . - min using a gradient echo, echo-planar sequence. preprocessing of fmri data followed by independent component analysis (ica) was performed using fsl software. functional connectivity analysis was performed using software provided by functional connectomes project, based on afni and fsl software packages. correlation maps were produced by extracting the bold time course from a seed region, computing the correlation coefficient between that time course and the time course from all other brain voxels, correcting for multiple sampling and degrees of freedom and thresholded at a z value of . . results: fourteen patients were included in the study, eight female and six male. tumor types include ganglioglioma ( ), pleomorphic xanthoastrocytoma ( ), juvenile pilocytic astrocytoma ( ), ependymoma ( ), anaplastic astrocytoma ( ), glioblastoma multiforme ( ), and primitive neuroectodermal tumor ( ). seven patients had tumor-associated epilepsy, and seven patients did not. the figure shows connectivity patterns in the motor network in patients without (a) and with (b) epilepsy. in the patients without epilepsy, functional connectivity was often displaced but not decreased or absent. in the patients with epilepsy, we observed decreased or absent functional connectivity. similar results were found for default mode network: connectivity was diminished or absent in the patients affected by epilepsy. conclusions: fcmri is a novel technique that may prove useful for evaluation and presurgical planning by giving us insight into how tumors disrupt function. functional connectivity was often displaced but relatively preserved in the patients without epilepsy. it was disrupted or absent in the patients with epilepsy. poster #: sci- corpus callosum dti measurements in neurofibromatosis type and normal controls nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; amir noor, rhea udyavar, marine bouyssi-kobar, iordanis evangelou, maria t. acosta purpose or case report: many patients with neurofibromatosis type (nf ) have corpus callosum enlargement; pathogenesis and underlying pathophysiology are unclear. the goal of our study is to investigate the pathophysiological basis of corpus callosum enlargement in nf patients through mri diffusion tensor (dti) measurements. methods & materials: retrospective study, irb approved. patients consecutively selected from institutional data base; inclusion criteria: established diagnosis of nf , brain imaging with dti sequence, abnormally high corpus callosum to skull ratio; excluded were patients with complications of nf that could affect size of the corpus callosum. age and gender matched normal controls were randomly selected from the radiology data base. roi were placed manually over the corpus callosum for dti measurements using dti-studio by two independent researchers, one blinded to diagnosis. results: fifteen nf patients and matched controls were analyzed. the corpus callosum to skull ratio was found to be significantly different between the experimental and control group (p . ). for nf patients we found: a trend to lower apparent diffusion coefficient (adc, p . ), significantly higher radial diffusivity (p . ), significantly lower axial diffusivity (p . ), and significantly lower fractional anisotropy (fa, p . ). conclusions: the significantly lower axial diffusivity in nf can indicate that there are more crossing fibers in the corpus callosum of nf patients than in normal controls. further studies using comparative dti tractography may be helpful in further investigating this stipulation. the significant increase in radial diffusivity can be explained by a variety of factors, including thinner myelin sheaths, increased interstitial fluid, smaller axons, or a combination thereof. the trend of lower adc may indicate low axonal diameter, as adc has been shown to more strongly correlate with axonal diameter without the myelin sheath. in future studies we will correlate abnormal corpus callosum dti markers with cognitive functions in nf patients to see if relationships exist that can be used as predictors of cognitive deficits in nf patients. screening for vitamin d deficiency in children with suspected non-accidental fracture conor kain, md, tripler army medical center; veronica rooks, laura keller, jordan pinsker, allyson cordoni, sarah frioux purpose or case report: determine if routine screening of vitamin d levels after suspected non-accidental fracture detects vitamin d deficiency and changes clinical outcomes. methods & materials: after irb approval we reviewed all skeletal surveys performed at tripler army medical center (tamc) in the last years and selected the children who were evaluated for suspected non-accidental fracture. we determined if -hydroxyvitamin d [ (oh)d] level was requested for these patients and characterized the provider's clinical suspicion of vitamin d deficiency as high or low. per the institute of medicine report and endocrine society guidelines we defined vitamin d deficiency as a (oh)d level of less than ng/ml. we calculated the prevalence of children with low (oh)d levels whose providers had low clinical suspicion for vitamin d deficiency. results: skeletal surveys were done at tamc from november to july . were performed after identifying a suspected non-accidental fracture. of these patients children from ages to months had (oh)d levels requested. for children whose providers had a low pre-test suspicion for vitamin d deficiency, the prevalence of vitamin d deficiency was . % ( % binomial ci . - . , of cases. these results indicate that at least one out of every three hundred children evaluated for nonaccidental fracture could have vitamin d deficiency despite a low clinical suspicion by their provider, although the actual rate is likely much higher given that we found one in eight cases. the child we identified with a low vitamin d level whose provider had no suspicion for rickets was treated with ergocalciferol and continued to be evaluated for abuse. conclusions: routine vitamin d level screening after nonaccidental fracture may detect vitamin d deficiency in children for whom there is low clinical suspicion. as our population resides at a low latitude and receives greater than average sun exposure, the rate of deficiency in children with suspected non-accidental fracture may be much greater in other areas. comet tails and dirty shadows: the secrets behind artifacts in pediatric ultrasound adam edelstein, pediatric radiology, massachusetts general hospital; anuradha shenoy-bhangle, katherine nimkin purpose or case report: to review common ultrasonographic artifacts, explain what causes them, and show how they can be used to aid in diagnosis in a variety of pediatric conditions, including less common entities. methods & materials: ultrasonographic images in patients less than years of age were reviewed. cases were selected that showed classic artifacts which helped with the diagnosis of a variety of entities. results: ultrasound artifacts include comet tail, reverberation, ring down and "dirty" shadowing. these can be used to help characterize a variety of pediatric conditions including gossypiboma, bezoar, subcutaneous foreign body, complications of nec, and staghorn calculus. artifacts can also be used to confirm the presence of stool or bowel gas. conclusions: familiarity with ultrasonographic artifacts is critical for tissue characterization and can help narrow the differential diagnosis in difficult pediatric cases. cardiac cta: non-vascular ring tracheobronchial compression secondary to enlarged patent ductus arteriosus in infants with congenital heart disease. nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; todd chapman, randy richardson purpose or case report: tracheobronchial compression or narrowing secondary to a vascular ring has been well documented. the purpose of this study is to describe the frequency of airway compression secondary to an enlarged patent ductus arteriosus detected by ccta without the presence of a vascular ring. methods & materials: a retrospective study of ccta exams in infants was performed over the period between / / and / / . ccta was performed with a -slice mdct, with ekg gating, followed by three-dimensional reformations. results: of the congenital heart disease infant patients, there are patients with tracheobronchial compression or narrowing. of these patients, patients reported to have patent ductus arteriosus as the primary cause of tracheobronchial compression or narrowing. approximately % of patients with airway compression in patients with congenital heart disease are secondary to an enlarged and/or tortuous patent ductus arteriosus. none of these cases were due to a vascular ring. of these patients, , , and patients demonstrated to have mild, moderate, and severe airway compression respectively. conclusions: tracheobronchial compression or narrowing secondary to vascular ring with a patent ductus arteriosus has been well documented. in this study, we demonstrate that a significant percentage of airway compression in patients with congenital heart disease without a vascular ring is due to a tortuous enlarged patent ductus arteriosus. cardiac cta is uniquely equipped to evaluate airway compression due to an enlarged patent ductus arteriosus and can help improve patient care in congenital heart disease patients with respiratory symptomatology. pediatric liver mr elastography: a primer suraj serai, phd, cchmc, suraj.serai@cchmc.org; daniel j. podberesky, alexander j. towbin purpose or case report: a wide variety of pediatric liver disorders may be complicated by the development of liver fibrosis and ultimately cirrhosis. with early interventions, the progression to hepatic fibrosis can be slowed, halted, and in some cases reversed. liver biopsy has long been considered the gold standard for assessing the presence and degree of liver fibrosis. however, liver biopsy has disadvantages, due to its potential sampling error, risk of complications, relatively high cost, intra-and inter-observer variability, and, in general, poor acceptance by pediatric patients and their parents. mr elastography (mre) is a relatively new, non-invasive technique that provides a safe, rapid and cost-effective method for objectively evaluating of a wide variety of hepatic diseases by quantitative stiffness evaluation of the liver-parenchyma. the purpose of this exhibit is to review our clinical experience with this technique and illustrate the application of liver mre in the pediatric population at our medical center. methods & materials: a review of pathogenesis and staging of liver fibrosis in children and current methods available for assessing liver fibrosis will be provided. a review of mre physics and technique, including the specific liver mre protocol used at our institution will be illustrated. we will review widely-used and emerging clinical indications for liver mre, as well as benefits and limitations to the technique, supported by brief literature review. results: in addition to sharing our liver mre technique, we will illustrate clinical case examples from our institution of a variety of liver disorders including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, storage disorders, cardiac disease, and idiopathic elevated liver enzymes. conclusions: this educational exhibit will review our experience with liver mre, a safe, newly available technique which will play an increasingly important role in the noninvasive evaluation of pediatric liver disease. poster #: sci- spectrum of tuberculosis in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to present a spectrum of tuberculosis (tb) in the human body which commonly involves pulmonary, nervous, musculoskeletal, gastrointestinal and genitourinary systems. this pictographic presentation displays the imaging features of tb cases encountered in our clinical practice with reference to plain x-rays, ct and mri as appropriate. results: with the advent of the newer modalities, the utility of the plain skaigram has been largely limited a initial screening tool only. whereas ct scores over mri in pulmonary tb (parenchymal disease, lymphadenopathy, pleural effusion, empyema, miliary disease) and abdominal tb (spectrum from mesenteric lymphadenitis to visceral involvement), the magnetic resonance (mr) imaging is much better in diagnosing cns tb (tuberculoma, abscess, meningitis, subdural empyema and myelitis). in musculoskeletal and genitourinary tb, ct and mr imaging may be preferred based on the stage of disease and the character of the lesion. cardiac involvement (pericarditis) is among the less common affections of tb. conclusions: tuberculosis is a multisystem disease that can affect virtually any part of the body from head to toe. tb demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site and therefore can mimic numerous other disease entities. hence it is imperative for radiologists to understand the typical disease distribution, patterns and imaging manifestations of tb. janet l. strife, md carol m. rumack md ole a. eklof, md clement c. faure, md andres giedion, md denis lallemand, md arnold lassrich md donald r. kirks, md beverly p. wood, md hooshang taybi md marta hernanz-schulman, md, facr m. ines boechat, md, facr neil d. johnson, mbbs dorothy i. bulas, md *deceased singleton-taybi award investigator award this award is given to the author of the best paper presented by a resident or fellow at the spr meeting md ricardo faingold, md andrea doria, md nina m. menezes, phd anthropometric parameters are a strong determinant of lvm in healthy individuals kiyarash mohajer, pierangelo renella, paul j. finn purpose or case report: despite theoretical advantages of higher field strength ssfp cine imaging, time-resolved magnetic resonance angiography (tr-mra), and high resolution contrast-enhanced mra (ce-mra) were performed. two readers independently evaluated the data for image quality, vessel and cardiac chamber definition, and presence of artifacts. snr and cnr were calculated. results: % of ssfp cine images at t were rated as good or excellent quality with % having mild and % having moderate artifacts (k . ) % of arterial and venous phase ce-mra images were considered good or excellent cardiac chamber definition was considered good or excellent in % of arterial and venous phase ce-mra images (k . ). % ce-mra images showed good or excellent definition of the thoraco-abdominal vessels on average, both readers scored cine ssfp images higher at . t and cemra images higher at . t. overall diagnostic performance was high at both field strengths. conclusions: mri of pediatric patients with chd and vascular abnormalities at . t is feasible. relative to . t, snr and cnr are both improved at higher field strength and higher resolution cemra is achievable t are more prevalent, they rarely render cine imaging non-poster # exclusion criteria were lack of correlating us or follow up information. two pediatric radiologists blinded to us findings reviewed the mr images and analyzed the contents of abdominal wall defect, organ location and attachment; spine anomalies; umbilical cord and limb anomalies. results: our search yielded patients. all fetuses had ventral wall defects, small thorax and eviscerated liver and bowel. in two cases kidneys were in extracorporeal location. in / there was no membrane covering extruded organs. in five mr showed organs attached to the placenta or uterine wall (mainly bowel and liver) mahmoud al-hawary and, by adolescence, paradoxical metaphyseal osteopenia with thin cortical bone. reports of consanguinity indicate autosomal recessive inheritance our studies, spanning ages - mo, showed weight %, but length diminishing from~ % to − . sd. head circumference was + sd. she had frontal bossing, blue sclera, normal teeth, genu valgum, and unremarkable joints. radiographs showed orbital and facial sclerosis, basilar thickening, "bone-in-bone" appearance in the pelvis, sclerotic long bone ends, and fractures of ribs and extremities. progressive metaphyseal widening occurred as vertebrae changed from ovoid to flattened and became beaked anteriorly. consistent with opt, serum pth concentrations reflected dietary calcium levels. serum bone alkaline phosphatase, osteocalcin, and trap b were sub-normal. iliac crest contained excessive primary spongiosa and no osteoclasts. splice sites and exons were intact for the genes encoding cholride channel , t-cell immune regulator , opt-associated transmembrane protein the hallmarks include stippled epiphyses, nasal hypoplasia, and hypoplastic distal phalanges and developmental delay. punctate calcifications are seen not only in the epiphyses but also in the paravertebral regions. paravertebral puncta are commonly associated with defective ossifications in the cervical spine. the malformation of the cervical spine causes spinal canal stenosis and instability, which occasionally necessitate surgical intervention none of the cases had brain infarction. conclusions: tortuousity and luminal narrowing of the cervical arteries is a common finding in cdp-bt. this previously unknown malformation is an important factor to discriminate patients at increased risk of cerebral ischemia, particularly in patients undergoing surgical intervention. disclosure: dr. okabe has indicated that she will discuss or describe severe skeletal toxicity from protracted etidronate therapy for generalized arterial calcification of infancy william h. mcalister, md, mallinckrodt institute of radiology campbell sheen purpose or case report: generalized arterial calcification of infancy (gaci) is an autosomal recessive disorder caused by deactivating mutations within the gene for ectonucleotide pyrophosphatase phosphodiesterase- (enpp ). enpp on osteoblasts, chondrocytes, and vascular smooth muscle cells hydrolyzes nucleotide triphosphates to nucleotide monophosphates and inorganic pyrophosphate (ppi) can time-resolved contrast-enhanced mra (twist) classify soft tissue vascular anomalies in the head and neck in children accurately? aylin tekes, md children from - years of age were enrolled. twist and conventional mri was performed (triplanar t -weighted [t -w] imaging with fat saturation, pre-contrast axial t -weighted [t -w] imaging, and post contrast triplanar fat-suppressed t -w imaging). twist was performed in coronal plane using blood-pool mr contrast agent (ablavar-lantheus) to enhance image quality and spatial resolution of mra. two pediatric neuroradiologists evaluated all patients in two different sessions, days apart: one session conventional mri with contrast was evaluated, in the second session twist was evaluated. clinical evaluation and/or percutaneous venogram/lymphogram data were the gold standard. results: our patients had diagnosis of infantile hemangioma (n ), venous malformation (n ), and lymphatic malformation (n ). twist alone could accurately classify / , conventional mri with contrast could accurately classify / . conventional mri with contrast combined with twist could accurately classify all cases. conclusions: twist offers high temporal resolution in the order of seconds, and provides functional data about the dynamics of contrast enhancement comprising the arterial, venous and delayed venous phases kiery cr- , sci- edu- , edu- edu- , edu- , pa- edu- , pa- a- , pa- , pa- , pa- , pa- edu- , edu- , edu- , edu- , edu- , edu- , edu- edu- , edu- , edu- , edu- , edu- , edu- suraj sci- , pa- , pa- edu- pa- , edu- , pa- the society for pediatric radiology gratefully acknowledges the support of the following companies in presenting the th annual meeting and postgraduate course: cme committee reviewers for this activity have disclosed any relevant financial relationships. no conflicts of interest exist.abuse and offer potential mechanisms of injury may help make the diagnosis of child abuse. the pediatric elbow-mri findings with multimodality correlation michael guandalini, md, royal children's hospital; murray bartlett purpose or case report: to describe and illustrate elbow abnormalities identified by mri performed in a cohort of pediatric patients with multimodality correlation. methods & materials: retrospective review of mri elbow studies performed at the royal children's hospital, melbourne between and . the studies were reviewed by a pediatric musculoskeletal radiologist and pediatric radiology fellow with patient demographics, clinical indication, findings and selected images recorded. results: elbow mri examinations were reviewed on children aged months to years ( boys, girls) with equal numbers of left and right sides examined. clinical indications included previous trauma in cases ( %) and nontraumatic conditions in ( %). the most common traumatic indication was suspected or confirmed fractures or avulsions ( %) followed by osteochondral or cartilage injuries ( %), growth arrest ( %), loose bodies ( %) and ligament injuries ( %). hemophilia ( %) was the most frequent nontraumatic indication followed by neoplasm ( %). mild to severe arthropathy, fractures, physeal growth arrest, subluxations, osteochondral lesions and loose bodies were the most frequently demonstrated abnormalities. ligament strains and tears, bone oedema, neuromuscular abnormalities, infections and several neoplasms including lipomas, vascular/lymphatic malformations and bone tumors also featured. conclusions: this pictorial review illustrates the broad range of abnormalities one might expect to encounter on pediatric elbow mri studies, highlighting the major features and corresponding appearances on ct and plain x-ray. spectrum of patellar tendon avulsive injury on mri in children: differentiation between acute and chronic avulsive injuries of the inferior patellar pole and tibial tuberosity zeyad metwalli, md, baylor college of medicine, metwalli@ bcm.edu; herman kan, scott rosenfeld, r. p. guillerman purpose or case report: the extensor mechanism of the knee is an intricate component of the joint and is frequently injured in pediatric athletes. due to the strength of the patella tendon, trauma to the anterior knee is often manifested by avulsive injuries, which may occur on an acute or chronic repetitive basis. purpose: this pictorial review will illustrate differentiating radiographic and mri features of acute and chronic avulsive injuries of the pediatric knee. outline: . anatomy and physiology a. discuss the anatomic differences of the pediatric and adult knee extensor mechanism b. pathophysiology and biomechanical basis for chondro-osseous avulsion injuries versus tendon tears in the skeletally immature. purpose or case report: the purpose of this educational exhibit is to demonstrate the magnetic resonance imaging (mri) appearance of the ankle and hindfoot ligaments using an interactive approach. methods & materials: a tesla siemens mri scanner with a multichannel ankle coil was utilized in the acquisition of images of ankle and hindfoot. three dimensional volume acquisition proton density images will be used to demonstrate the ligamentous anatomy of the ankle and hindfoot in axial, axial oblique, coronal, and sagittal planes. results: the exhibit will begin with an interactive review of the ankle and hindfoot ligamentous anatomy with each ligament poster #: edu- cns imaging findings in hemophagocytic lymphohistiocytic syndrome rupa radhakrishnan, mbbs, md, dnb, radiology, university of cincinnati college of medicine, radhakrp@ucmail. uc.edu; marcia k. kukreja, alexandra filipovich, alexander j. towbin purpose or case report: hemophagocytic lymphohistiocytosis (hlh) is a rare, life threatening condition caused by an uncontrolled proliferation of activated lymphocytes and histiocytes with high levels of inflammatory cytokines. the organs most commonly involved in this disorder include the liver, spleen, lymph nodes, bone marrow and central nervous system (cns). the purpose of this exhibit is to review the cns imaging findings associated with hlh, its complications, and its management. the published literature was reviewed to identify the potential imaging findings hlh. the electronic medical record system was then searched to find illustrative case examples from our institution. cases demonstrating the primary imaging findings as well cases highlighting complications of the disease or its therapy were selected. results: cns involvement is common in hlh with approximately % of patients demonstrating neurological symptoms. ct findings of cns involvement include diffuse parenchymal atrophy, low attenuation lesions in the white matter and calcifications. mr findings include diffuse leptomeningeal and perivascular enhancement, t hyperintense lesions with nodular or rim enhancement as well as confluent white matter lesions, and diffuse parenchymal volume loss of the cerebrum and cerebellum. restricted diffusion has been demonstrated in some lesions. ring enhancing parenchymal lesions have been described representing active demyelination. intracranial hemorrhage may occur as a result of thrombocytopenia and coagulation abnormalities. sepsis with opportunistic organisms can involve the cns and produce intracranial findings such as parenchymal abscesses. cns changes, such as posterior reversible encephalopathy syndrome, are also seen with the commonly used immunomodulatory regimen used in the treatment of hlh. conclusions: this exhibit will aid the viewer in identifying the cns imaging findings of hlh as well as the complications of the disease and its therapy. while the cns imaging findings are not specific, they may help the radiologist formulate a diagnosis in association with the other clinical and imaging findings; furthermore, imaging can help the clinical team in managing the disease and its complications. methods & materials: medical records of our pediatric patients with palpable head masses over the last years, were reviewed and images were collected. correlation of us of these lesions with other imaging modalities and/or pathologic diagnosis was done. results: us appearances of various head masses including congenital/developmental (encephalocele, meningocele, dermoid, occipital protuberance), traumatic (cephalhematoma, subgaleal hematoma, calvarial fracture), inflammatory/infectious (sebaceous cyst, histiocytosis, dermatitis), vascular (malformations, pseudoaneurysm) and neoplastic (benign and malignant lesions including metastases) etiologies, will be illustrated with case based approach. mri and/or ct or tissue diagnosis can be problem solving. role of ultrasound guidance for percutaneous procedures (biopsy, sclerotherapy) will also be described. conclusions: ultrasound can play an important role in the delineation, diagnosis and guiding further management of pediatric palpable head masses. us can differentiate various scalp lesions and suggest the underlying calvarial defect or involvement to some extent, helping to narrow the differential diagnosis for such lesions. color doppler us can be useful to detect vascularity within the lesion or vascular lesions. given that us is often requested for the evaluation of palpable head masses, pediatric radiologists should be familiar with their sonographic features. posterior fossa malformations-a pictorial review rui santos, md, bc children's hospital, ruiradiologia@gmail. com; khalid khashoggi, angela t. byrne purpose or case report: posterior fossa malformations are a group of central nervous system anomalies that may be detected during pregnancy or present early infancy with features that include hypotonia, developmental delay, mutations responsible for the disease and proposals as to mechanism of action of the mutation with respect to disease manifestations. this preceded the development of hypotheses regarding the relationship between genotype and phenotype and the attempt to utilize imaging modalities that could better assess disease activity as it related to functional status. the purpose of this exhibit is to briefly review the history pre- and to focus on the numerous ways in which the understanding has improved since that time. conclusions: . there are over different mutations of the cftr gene responsible for cystic fibrosis with varying prevalence throughout the world. . the class of mutation often dictates its particular mechanism of action. . there is some relationship between genotype and phenotype-particularly with respect to pancreatic involvement. . newer imaging modalities including ct and mri with or without hyperpolarized helium are better predictors of disease severity than is plain film. imaging pulmonary tuberculosis in infants: what are the most useful diagnostic radiological findings? handan cakmakci, pediatric radiology, dokuz eylul university hospital, handancakmakci@gmail.com; nevin uzuner, filiz tetik purpose or case report: early diagnosis and treatment are very important for infants with tuberculosis. infantile pulmonary tuberculosis is more symptomatic, and the risk of severe and life-threatening complications such as tuberculous meningitis or miliary tuberculosis is higher. bacteriologic confirmation of the disease in children is difficult and in younger infants (< months), the tuberculin skin test is frequently negative. therefore, radiological findings play important role in diagnosing tuberculosis in infants. the purposes of this study are to identify chest x-ray and lung ct findings in pulmonary tuberculosis of infants and consider the most useful diagnostic findings of these age group patients.methods & materials: chest radiographs and chest ct images of infants who were diagnosed in our hospital from to were retrospectively reviewed. the study group included boys and girls ranging in age from to months (mean age, months). chest x-ray and computed tomography images were analyzed considering air space consolidation, nodular lesions, cavitating lesions, mediastinal enlargement, hyperinflation, bronchial narrowing, atelectasis pleural effusion on plain radiography and additional mediastinal calcific or caseating lymph nodes on ct images.results: air space consolidation was seen on out of chest x-ray and computed tomography images. nodular lesions were seen out of chest x-ray and computed tomography images. cavitating lesion was seen on out of chest x-ray and computed tomography images. mediastinal enlargement suggesting lymph node was seen out of chest x-ray and computed tomography images. hyperinflation, bronchial narrowing was seen out of chest x-ray and computed tomography images. atelectasis, pleural effusion was seen out of chest x-ray and out of computed tomography images. mediastinal caseating lymph nodes, mediastinal calcific lymph nodes were seen out of computed tomography images. conclusions: frequent and the most useful diagnostic radiological findings of pulmonary tuberculosis in infants are mediastinal or hilar lymphadenopathy with central necrosis and air space consolidations. disseminated nodules including miliary lesions and airway complications are also detected in this age group. ct can show detailed parenchymal lesions and tuberculous lymphnodes especially calcified ones. the ductus bump: radiographic findings of this normal variant and differential diagnoses anusuya mokashi, staten island university hospital, anusuya.mokashi@gmail.com; jeremy neuman, cheryl lin purpose or case report: the ductus bump: review of radiographic findings, differential diagnoses and current controversies. the ductus bump was first described in by berdon et al as a transient physiologic mass in the chest in newborn infants. some controversy remains as to the exact etiology and clinical significance. although initially thought to represent a dilated ductus arteriosus, recently it has been suggested that it actually represents a ductus arteriosus aneurysm that spontaneously resolves. others contend it represents dilation of the infundibulum of the closing ductus. regardless of etiology, the time of discovery, location, and rapid resolution are characteristic of this entity. in this presentation we will review the radiographic and echocardiogram findings of the ductus bump, as well as discuss the differential diagnosis. the frontal radiographic findings are a round mass to the left of the vertebral spine projecting from the mediastinum near the aortic arch. this mass does not indent the esophagus and it cannot be seen on the lateral view. it is classically said to resolve within the first few days of life. the controversy regarding the etiology has also led to some disagreement involving the clinical significance and appropriate follow up, which will also be discussed. after reviewing this educational poster, the reader will have conclusions: abnormalities of the posterior fossa are often difficult to differentiate solely on the basis of their radiologic appearances alone. however, an accurate diagnosis is essential for proper treatment planning and genetic counselling. therefore it is imperative for radiologists to be well versed with the normal anatomy and development of cerebellum so as to correctly diagnose the various posterior fossa abnormalities.poster #: sci- imaging of oculoauriculofrontonasal syndrome with low-dose -dimensional computed tomography paritosh c. khanna, md, radiology, seattle children's hospital, pkhanna@uw.edu; kelly evans, gisele ishak, joseph gruss, michael cunningham, anne hing purpose or case report: oculoauriculofrontonasal syndrome (oafns) combines elements of abnormal morphology of the frontonasal and maxillary processes of the face. the aim of our exhibit is to demonstrate the low-dose computed tomography (ct) features of this syndrome, in seven patients who have been followed at seattle children's hospital (sch) over years. we underscore the imaging features of this condition, and describe additional features including bony nasal abnormalities not previously described in the literature, to improve imaging recognition of this spectrum. we present d ct imaging features of a series of eight patients with oafns. in keeping with the alara (as low as reasonably achievable) concept and the image gently recommendations (www.imagegently. org), ct head and face studies were obtained on six of eight patients at sch, while two had prior exams at outside institutions. using a -slice multidetector ct scanner (ge lightspeed vct, waukesha wi), low-dose ct ( kv, mas or lower depending on age) of the head and face was obtained. planar bone window and d surface rendered images were analyzed. results: our series of patients demonstrated bifid nasal bones, uni-or bilateral mandibular hypoplasia, temporomandibular and zygomatic dysplasia and bony external auditory canal abnormalities. one patient had an interfrontal bone with a frontal bony defect that was contiguous with the metopic suture. we describe additional previously unidentified ct anomalies of the nasal bones, anterior nasal spine and nasal septum. these structures are involved in all patients who had ct imaging available, although unique features are present in each case. conclusions: ct is the mainstay of imaging of craniofacial anomalies in the post-natal period, both pre-and postoperatively. in addition to our low-dose ct imaging findings of oafns, novel nasal bone anomalies identified by our group serve to identify a new subset of patients with this syndrome and may help refine the phenotype of the oafns spectrum. key: cord- -oz x a s authors: agrawal, shubhada; bhandari, siddharth; bhattacharjee, anirban; deo, anand; dixit, narendra m.; harsha, prahladh; juneja, sandeep; kesarwani, poonam; swamy, aditya krishna; patil, preetam; rathod, nihesh; saptharishi, ramprasad; shriram, sharad; srivastava, piyush; sundaresan, rajesh; vaidhiyan, nidhin koshy; yasodharan, sarath title: city-scale agent-based simulators for the study of non-pharmaceutical interventions in the context of the covid- epidemic date: - - journal: nan doi: nan sha: doc_id: cord_uid: oz x a s we highlight the usefulness of city-scale agent-based simulators in studying various non-pharmaceutical interventions to manage an evolving pandemic. we ground our studies in the context of the covid- pandemic and demonstrate the power of the simulator via several exploratory case studies in two metropolises, bengaluru and mumbai. such tools become common-place in any city administration's tool kit in our march towards digital health. : timeline of covid- cases, recoveries and fatalities in india taken from [ ] . see [ ] and [ ] for detailed information on how covid- progressed in india. covid- is an ongoing pandemic that began in december . the first case in india was reported on january . the number of cases and fatalities have been on the rise since then. as on august , there are , , cases (of which , , have recovered) and , fatalities [ ] ; see figure for a timeline of covid- cases, recoveries and fatalities in india. while medicines/vaccines for treating the disease remained under development at the time of writing this paper, many countries implemented non-pharmaceutical interventions such as testing, tracing, tracking and isolation, and broader approaches such as quarantining of suspected cases, containment zones, social distancing, lockdown, etc. to control the spread of the disease. for instance, the government of india imposed a nationwide lockdown from march to april , and subsequently extended it until may to break the chain of transmission and also to mobilise resources (increase healthcare facilities and streamline procedures). to evaluate various such interventions and decide which route to take to manage the pandemic, epidemiologists resort to models that predict the total number of cases and fatalities in both the immediate and the distant futures. the models used should have enough features to enable the evaluation of the impact of various kinds of non-pharmaceutical interventions. broadly three kinds of models have been used to study this epidemic. the first set of models takes a curve-fitting approach. they rely on simple parametric function classes. the parameters of the model are fit via regression to match observed trends. the second set of models addresses the physical dynamics of the spread at a macroscopic level. these are meanfield ordinary differential equations (odes) based compartmental models (e.g. susceptible-exposed-infected-recovered (seir) model and its extensions) based on the classical work of kermack and mckendrick [ ] . here the population is divided into various compartments such as susceptible, exposed, infected, recovered, etc., based on the characteristics of the epidemic. one then solves a system of odes that captures the evolution of the epidemic at a macroscopic scale . localised versions of these are spatio-temporal mean-field models that lead to partial differential equations . the third set of models, and the focus of this work, are agent-based models . a very detailed model of the society under consideration, with as many agents as the population, is constructed using census and other data. the agents interact in various interaction spaces such as households, schools, workplaces, marketplaces, transport spaces, etc. see figure for a schematic representation of an agent-based model with the aforementioned interaction spaces. these interaction spaces are the primary contexts for the spread of infection. a susceptible individual can potentially get infected from an interaction in one of these spaces upon contact with an infected individual. once an individual is exposed to the virus, this person goes through various stages of the disease, may infect others, and eventually, either recovers or dies. other models work at an intermediate level by modelling the social network of interactions, e.g., [ ] , but we shall focus more on agent based models. there are several advantages of using agent-based models. first, since modelling is performed at a microscopic level unlike the macroscopic level in compartmental models, agentbased models are well suited to capture heterogeneity at various levels. for instance, the agedependent progression of covid- in individuals (severity, the need for hospital care, intensive care, etc.) can be incorporated in agent-based models. second, individual behavioural changes, known to be important in certain diseases such as aids, can be easily modelled. third, agent-based models are well suited to study the impact of various non-pharmaceutical interventions, such as "lockdown for a certain number of days", "offices operating using the see [ ] for a state-level epidemiological model for india and [ ] for a combination of the two approaches. for a paper in the indian context see [ ] . there are other agent-based simulators that have informed policy decisions. see [ ] for uk and usa related studies specific to covid- , see [ ] for a covid- study on sweden, see [ ] and references therein for many agent-based models and their comparisons, and see [ ] for a taxonomy of agent-based models. (so-called) odd-even strategy", "social distancing of the elderly", "voluntary home quarantine", "closure of schools and colleges", etc. explicit modelling of these contexts of infection spread also enables studies of control measures targeting the interaction spaces. fourth, there is an important difference between the actual infected number in the population, which is what the differential equations-based models predict, and the reported cases. the latter is invariably based on those that come to hospitals/clinics seeking health care, or those that are identified due to random testing, followed by contact tracing of such index cases. as a consequence, reported cases provide a biased estimate of the actual infected number in the population. agent-based simulators have the capability to track such biased estimates of prevalence. in this work, we describe our city-scale agent-based simulator to study the epidemic spread in two indian cities and demonstrate how digital computational capabilities can help us assess the impact of various interventions and manage a pandemic. we now provide sample outcomes for bengaluru and mumbai for covid- under various interventions. these outcomes have been generated using our city-scale agent-based simulator. bengaluru and mumbai have estimated populations of . and . crore people respec- the census figure for bengaluru is . crore and for mumbai is . crore (mumbai city only, not the mumbai urban area whose census estimate is . crore). bengaluru's population is estimated to be . crore. reliable data is not available for mumbai city's population. we have used estimated population for bengaluru and census estimate for mumbai. social distancing of the elderly, closure of schools and colleges, % occupancy at workplaces, and case isolation. this is the fourth shaded region in the plots. • from may onwards, continued contact tracing (following the indian council of medical research (icmr) guidelines as much as possible) and associated quarantining and case isolations, but otherwise an unlocked bengaluru. soft ward containment continues to be in force. by soft ward containment, see figure , we mean linearlyvarying mobility control that turns an open ward into a locked ward when the number of hospitalised cases become . % of the ward's population; in the latter locked scenario, only % mobility is allowed for essential services. • past studies [ ] - [ ] have indicated that masks have been effective in reducing the spread of influenza. anecdotal evidence seems to suggest that masks are effective for covid- . the ministry of home affairs (mha) order of april [ , annexure ] made the wearing of masks in public places compulsory. this was reemphasised in the mha order of may [ ] . we assume that masks are mandatory from april onwards. • it is often the case that when there are several restrictions in place, only a fraction of the population complies with these restrictions. getting the entire population to comply is often a big challenge and requires significant and persistent messaging (including communication, rewards, punitive measures). we assume a compliance factor of . up to may , which means that percent of the population adheres to the government guidelines like social distancing, wearing masks in public places, etc., and . thereafter. the reduction could be attributed to behavioural changes due to lockdown fatigue. • a brief lockdown during - july was implemented in bengaluru. we compare two scenarios, one with this lockdown and one without this lockdown. as one can anticipate, simulation of the above scenarios requires a significant level of sophistication in the modelling and implementation. we describe how we do these in the coming sections, but now focus only on the outcomes. the trend for the reported cases is roughly captured, but fatalities are over-predicted. this is surprising since the reported cases continued to be high in the third week of july. for a more detailed study of these plots, we refer the reader to section iii-a. at this stage, we only observe that the public health benefit of the lockdown is clear from the pictures, reduced peak at the expense of a brief second wave. armed with these predicted outcomes under the two scenarios, public health officials can now weigh the benefits of the lockdown against its economic consequences. ) mumbai: for mumbai, we simulate the following scenario. • workplaces open with a small strength of % during - may , as per government of maharashtra directions. this is the fifth shaded region. during this period, social distancing of the elderly and school and college closures remain in force. • workplace strengths increase to % in june, to % in july, and to % in august, with commensurate capacity increases in the local trains. social distancing of the elderly and school and college closures remain in force. in addition voluntary home quarantine and case isolation come into play. • throughout the simulations, soft ward containment is in force. • it is often difficult to comply with social distancing directives in high population density areas, like in slums, with many common essential facilities. in mumbai, we model compliance to be . in high density areas and . in other areas. • throughout the simulations, contact tracing, associated quarantining, testing, and further tracing are enabled. • we will compare the above scenario, with local trains enabled, and will contrast it with another hypothetical scenario having no local trains. is our hope that such tools become common place in a city administration's tool kit, and are used to the fullest extent before drastic interventions with wide-scale impact, e.g., lockdown, are imposed. with additional modelling of activity, mobility, and behaviour, and use of high quality data on the migrant labour force in urban areas, we speculate that we could have anticipated certain behavioural outcomes seen in india after the lockdown announcement (e.g., migrant population movement). broadly, the steps involved in agent-based modelling are the following: build the simulator, calibrate it, validate it, and use it for estimating how the pandemic will evolve. . simulator. the simulator itself consists of four parts. synthetic city. a synthetic city generator builds a synthetic city with individuals and various interaction spaces. individuals are assigned to various interaction spaces such as households, schools/workplaces, communities and transport spaces. in doing this we capture the demographics of the city, the school size distributions, the workplace size distributions, the commute distances, the neighbourhood and friends' interaction networks, the transport interaction spaces, etc. these fix the "social networks" on which individuals interact and transmit the virus. table i for some examples. many of these involve reduction in changes in contact rates as a consequence of the interventions. the values to set could be based on observed mobility patterns. for example, according to the covid- community mobility report for india in april [ ] in table ii, prepared by google based on data from google account users who have "opted-in" to location history, there was significant reduction in mobility during the lockdown period compared to the baseline period of january to february . this informs the nominal contact rate choices in the interventions' definitions in table i and later in other tables. . calibration. once the simulator is ready there are still unknown parameters that need to be identified. these include the contact rates at various interaction spaces, the number of infections to seed, the time at which these infections should be seeded, the compliance parameters, etc. the purpose of the calibration step is to identify these parameters to capture the city specific trends and contact rates. we do this by choosing the initial number to seed, the time at which these are seeded, and the contact rates so that the initial trend of the disease is matched. once calibrated, we can run our simulator for a certain number of days and understand how the epidemic spreads. . validation. we next have to validate our simulator, so that we can understand the predictive power of the simulator. for this, we look for phenomena in the real data that have not been explicitly modelled and we check if the simulator is able to capture these phenomena. for specific details, see section iv. . use of the simulator in an evolving pandemic. it is often the case that in evolving pandemics, predictions do not match reality as time unfolds. models are often gross oversimplifications of the underlying complex reality and assumptions are often wrong or may need updating as the pandemic evolves. the purpose of models in an evolving pandemic is not merely to predict numbers, in which task they will likely fail, but more to enable principled decision making on intervention strategies. they enable a study of the public health outcomes of one strategy versus another. armed with these comparisons, public health officials can make more informed decisions. needless to say, these are often more complex and involve several aspects beyond just public health, e.g. economy, psychology, education, political climate, to name a few . for a proposal on how to simulate economic and public-health aspects together, see [ ] . one of the powerful features of the agent-based simulator is its ability to explicitly control various interaction spaces and study the outcomes. we demonstrate this feature via the case studies for bengaluru and mumbai listed in table iii . we compare the following three scenarios in bengaluru: • no intervention other than contact tracing, testing and associated case isolation. • indefinite lockdown starting from march onwards. this naturally will have enormous economic and societal cost, but we focus only on the direct covid- public health outcomes. • scenario- in table iv: soft ward containment, case isolation with testing and contact tracing, and a one-week lockdown during - july . we assume a compliance of % until may (i.e. during the initial karnataka-wide lockdown followed by the nation-wide lockdown) and a compliance of % starting may , for all these scenarios. that is, % (resp. %) of the population comply with the restrictions in place until may (resp. starting may ). under these scenarios, we plot the following: daily cases (figure ), daily fatalities ( figure ), cumulative cases ( figure ), cumulative fatalities ( figure ) and estimated hospital beds and critical care beds ( figure ). we make the following observations. • as one would expect, the least number of cases, fatalities and hospital beds requirements correspond to the "indefinite lockdown" scenario. however this scenario has serious impact on the economy, livelihoods, etc. • in terms of the daily number of cases, the no intervention scenario had a peak around june (with roughly , cases), whereas the present scenario in bengaluru (i.e. scenario- in table iv ) had a much lower peak around july (with around cases), followed by another peak around end of august. similar trends can be seen in the fatalities estimates as well as the hospital bed estimates. our health care system would have struggled with the no intervention scenario, and the present scenario in bengaluru helped mitigate and delay the peak of the epidemic. • the second predicted peak in scenario- in table iv is due to the one-week lockdown during - july . • towards the end of july, we overpredict the number of daily fatalities and underpredict the number of daily cases. this could be because of two reasons: ) the number of tests has increased significantly during mid-july due to which there is a likely surge in the number of asymptomatic cases. as a consequence, a reduction in the number of daily cases due to the one-week lockdown during - july is not observed in the reported number of daily cases; such a reduction is visible in our estimates because the testing regime is assumed constant through the period in our simulator. ) there is a delay in reporting the fatalities. as the reported number of daily cases follow an exponential trend during early-mid july, one would expect a similar trend in the reported daily fatalities during end-july, as shown in our prediction of the daily fatalities under scenario- . however, we see a reduction in the reported number of daily fatalities during after july . this could be due to a possible delay in reporting the daily fatalities, or an effective use of the rapid point-of-care antigen test kits, or a combination of both. testing of these hypotheses require further investigation. b. case study b: impact of opening offices at % capacity with higher compliance versus lockdown at lower compliance the degree of compliance among the population to public health directions/guidelines is an important factor that affects the epidemic. to understand the importance of compliance, we compare the following scenarios for bengaluru: the present bengaluru (i.e. scenario- in table iv ), an unlocked bengaluru (i.e. scenario- in table iv) , and an unlocked bengaluru with a higher compliance of % starting may (i.e. scenario- in table iv with % compliance during march - may and % compliance starting may ). as before, we plot the following: daily cases (figure ), daily fatalities ( figure ), cumulative cases ( figure ), cumulative fatalities ( figure ) and estimated hospital beds and critical care beds ( figure ). we make two important observations: • in terms of the number of cases and fatalities, the present bengaluru (i.e. scenario- in the general populace on the public health impact of their actions, to induce more prosocial behaviour, and to ensure greater compliance. this was the approach taken by sweden, a country with a population of about crore. • comparing scenario- and scenario- , we see that the effect of the one-week lockdown during - july is very minimal in the long term as far as the cumulative number of cases and fatalities are concerned. however, there is a significant difference in the cumulative number of cases and fatalities between scenario- and scenario- with a higher compliance of % starting may . this suggests that, given that vaccines for covid- are not yet available, short-term lockdowns' benefit is restricted to mobilising resources and preparing the healthcare system in the short term. on the other hand, higher compliance has a greater impact in reducing cases and fatalities. • trains-off: suburban trains are not operational throughout. as indicated in table v , we assume a compliance factor of % in non-slums and % in slums. we plot our results in figures - . • from the plots, we see that the phased opening of suburban trains starting june gives a marginal increase in the number of cases, fatalities and hospital beds compared to the trains-off scenario. this suggests that trains can be operated with enforcement • although we match the daily fatalities curve very well, we over-predict the daily number of cases. we believe that this is due to the limitation on the testing capacity on the ground. because of this, the test results of many people arrive late and cases get reported with a certain delay. it is also worth mentioning that, although we overpredict the daily number of cases, we correctly capture the growth rate of the daily number of cases as well as the cumulative number of cases. we study the impact of two containment strategies for bengaluru: soft ward containment (i.e., linearly-varying mobility control that turns an open ward into a locked ward when the number of hospitalised cases become . % of the wards population; in the latter locked scenario, only % mobility is allowed for essential services, see figure ) and neighbourhood containment (i.e., when an individual is hospitalised, everyone living in a m surrounding area undergoes home quarantine). soft ward containment is a more feasible strategy than strict ward containment since the average ward population in bengaluru is about , . as we use a corrected version of the reported number of daily fatalities from brihanmumbai municipal corporation (bmc). the initial reported daily fatalities curve from bmc had a very large peak at june . the corrected data adjusts the daily fatalities curve until june so that the peak on june gets re-distributed to the previous days in a suitable way. the number of hospitalised cases in the ward increases, more public health wardens could be deployed and help reduce mobility and interaction in the ward. in figures - , we plot these two scenarios. we observe that neighbourhood containment is more effective than soft ward containment, in terms of cases and fatalities. to compare various levels of strictness with which policies are enforced, we now consider the opening scenario indicated in table v we now study the impact of opening schools. in figures - , we compare the following two scenarios: • schools-closed: the present scenario in bengaluru, i.e., scenario- in table iv, • schools-open: scenario- in table iv with schools open from september . as expected, both these scenarios follow the same trend until about mid-september, after which the disease spread increases in the latter. around early november, we observe a between - % increase in the cumulative number of cases and the cumulative number the first step in our agent-based model is to model a synthetic city that respects the demographics of the city that we want to study. our city generator uses the following data as input: • geo-spatial data that provides information on the wards of a city (components) along with boundaries. (if this is not available, one could feed in ward centre locations and ward areas). • population in each ward, with break up on those living in high density and low density areas. • age distribution in the population. • household size distribution (in high and low density areas) and some information on the age composition of the houses (e.g., generation gaps, etc.) • the number of employed individuals in the city. • distribution of the number of students in schools and colleges. • distribution of the workplace sizes. • distribution of commute distances. • origin-destination densities that quantify movement patterns within the city. taking the above data into account, individuals, households, workplaces, schools, transport spaces, and community spaces are instantiated. individuals are then assigned to households, workplaces or schools, transport and community spaces, see figure for a schematic representation. the algorithms for the assignments do a coarse matching. the matching may be refined as better data becomes available. the interaction spaces -households, workplaces or schools, transport and community spaces -reflect different social networks and transmission happens along their edges. there is interaction among these graphs because the nodes are common across the graphs, see figure for various interaction spaces and figure for a bipartite graph abstractions of these interaction spaces. an individual of school-going age who is exposed to the infection at school may expose others at home. this reflects an interaction between the school graph and the household graph. similarly other graphs interact. we now describe how individuals are assigned to interaction spaces. the households are then assigned to wards so that the total number of individuals in the ward is in proportion to population density in the ward, taken from census data. a population density map is given in figure in past works, given the structure of educational institutions elsewhere, educational institutions have been divided into primary schools, secondary schools, higher secondary schools, and universities. the norm in indian urban areas is that schools handle primary to higher secondary students and then colleges handle undergraduates. we view all such entities as schools. we assign students to schools on a ward-by-ward basis. in each ward, we have a certain number of students. we pick a school size from a given school size distribution and instantiate the unemployed fraction in bengaluru, from the census data, is just over %, even after taking into account employment in the unorganised sector. similar is the case with mumbai. this may have some bearing on the epidemic spread. a school of this size and place it randomly in that ward. students who live in that ward are picked randomly and assigned to this school until that school is filled to its capacity. we repeat this procedure until all students in that ward gets assigned to a school, and then we repeat this procedure for all wards. this procedure could lead to at most one school per ward whose capacity is more than its sampled capacity. assignment of workplaces: workplace interactions can enable the spread of an epidemic. in principle, bengaluru's and mumbai's land-use data could be used to locate office spaces. the assignment of individuals to workplaces is done in two steps. in the first step, for each individual who goes to work, we decide the ward where his/her office is located. this assignment of a "working ward" is based on an origin-destination (od) matrix. an od matrix is a square matrix whose number of rows equals the number of wards, and its (i, j)th entry tells us the fraction of people who travel from ward i to ward j for work. in the second step, for each ward, we sample a workplace size from a workplace size distribution, create a workplace of this capacity and place it uniformly-at-random in that ward. we then randomly assign individuals who work in that ward to this workplace. similar to assignment of schools, we continue to create workplaces in this ward until every individual working in that ward gets assigned to a workplace, and we repeat this procedure for all wards. for bengaluru, the od matrix is obtained from the regional travel model used for bengaluru. for mumbai, based on the "zone to zone" travel data from [ ] , an origin-destination matrix was extrapolated based on the population of each ward. the above assignments could be improved further in later versions of this simulator. community spaces: community spaces include day care centres, clinics, hospitals, shops, markets, banks, movie halls, marriage halls, malls, eateries, food messes, dining areas and restaurants, public transit entities like bus stops, metro stops, bus terminals, train stations, airports, etc. while we hope to return to model a few of the important ones explicitly at a later time, we proceed along the route taken by [ ] with two modifications. in our current implementation, each individual sees one community that is personalised to the individual's location and age and one transport space personalised to the individual's commute distance. for ease of implementation, the personalisation of the community space is based on ward-level common local communities and a distance-kernel based weighting. the personalisation of the transport space is based on commute distance. details are given in section iv-c. age-stratified interaction: the interactions across these communities could be age-stratified. this may be informed by social networks studies, for e.g., as in [ ] which has been used in a recent compartmentalised seir model [ ] . smaller subnetworks: we create smaller subnetworks in workplaces, schools and communities, and associate certain number people to these smaller networks with the interpretation that people in a smaller subnetwork have high contact rate among them compared to the others. in some more detail, we create "project" networks at each workplace consisting of people in that workplace having closer interaction, a "class" network in each school consisting of students of the same age, a random community network among people in a given ward to model daily random interactions, and a neighbourhood subnetwork among people living in a m× m square . these subnetworks are later used for identifying and testing/quarantining individuals based on a contact tracing protocol. the output of all the above is our synthetic city on which infection spreads. figure provides an indication of how close our synthetic city is to the true city in terms of the indicated statistics. we have used a simplified model of covid- progression, based on descriptions in [ ] and [ ] . this will need updating as we get india specific data. an individual may have one of the following states, see figure : susceptible, exposed, infective (pre-symptomatic or asymptomatic), recovered, symptomatic, hospitalised, critical, or deceased. we assume that initially the entire population is susceptible to the infection. let τ denote the time at which an individual is exposed to the virus, see figure . the incubation period is random with the gamma distribution of shape and scale . ; the mean incubation period is then . days ( . days in [ ] and . in [ ] ). individuals are infectious for an exponentially distributed period of mean duration . of a day. this covers both presymptomatic transmission and possible asymptomatic transmission. we assume that a third of the patients recover, these are the asymptomatic patients; the remaining two-third develop symptoms. estimates of the number of asymptomatic patients vary from . to . . though we have explored other asymptomatic fractions, we restrict attention here to / . symptomatic patients are assumed to be . times more infectious during the symptomatic period than during the pre-symptomatic but infective stage. individuals either recover or move to the hospital after a random duration that is exponentially distributed with a mean of days . the probability that an individual recovers depends on the individual's age . it is also assumed that recovered individuals are no longer infective nor susceptible to a second infection. while hospitalised individuals may continue to be infectious, they are assumed to be sufficiently isolated, and hence do not further contribute to the spread of the infection. further progression of hospitalised individuals to critical care is mainly for assessing the need for hospital beds, intensive care unit (icu) beds, critical care equipments, etc. this will need to be adapted to our local hospital protocol. let us reiterate. once a susceptible individual has been exposed, the trajectory in figure takes over for that individual. further progressions are (in our current implementation) only based on the agent's age. at each time t, an infection rate λ n (t) is computed for each individual n based on the prevailing conditions. in the time duration ∆t following time t, each susceptible individual moves to the exposed state with probability − exp{−λ n (t) · ∆t}, independently of all other events. other transitions are as per the disease progression described earlier. time is then updated to t + ∆t, the conditions are then updated to reflect the new exposures, changes to infectiousness, hospitalisations, recoveries, contact tracing, quarantines, tests, test outcomes, etc., during the period t to t + ∆t. the process outlined at the beginning of this paragraph is repeated until the end of the simulation. ∆t was taken to be hours in our simulator and is configurable. additionally, each individual has two other parameters: a severity variable c n and a relative infectiousness variable ρ n , see [ ] . both bring in heterogeneity to the model. severity c n = if the individual suffers from a severe infection and c n = otherwise; this is sampled at % probability independently of all other events. infectiousness ρ n is a random variable that is gamma distributed with shape . and scale (so the mean is ). the severity variable captures severity-related absenteeism at school/workplace, associated decrease of infection spread at school/workplace, and the increase of infection spread at home. if the individual gets exposed at time τ n , a relative infection-stage-related infectiousness is taken to be κ(t − τ n ) at time t. for the disease progression described in the previous section, this is in the presymptomatic and asymptomatic stages, . in the symptomatic, hospitalised, and critical stages, and in the other stages. to describe the infection spread at transport spaces, let t (n) = if agent n uses public transport and let t (n) = otherwise. let a n,t = if at time t agent n is either (i) compliant and under quarantine, (ii) hospitalised, (iii) critical, or (iv) dead, and let a n,t = if none of the above is true and agent n attends office at time t. we model the effectiveness of masks by reducing the ability of an infectious individual to transmit the infection by %, if a mask is worn (see [ ] - [ ] ); let m n = . if agent n wears a face mask in public transport and m n = otherwise. let β h , β s , β w , β t , β c , β * h , β * s , β * w and β * c denote the transmission coefficients at home, school, workplace, transport, community spaces, neighbourhood network, class network, project network and random community network, respectively. these can be viewed as scaled contact rates with members in the household, school, workplace, community, neighbourhood, class, project and random community, respectively. more precisely, these are the expected number of eventful (infection spreading) contact opportunities in each of these interaction spaces. it accounts for the combined effect of frequency of meetings and the probability of infection spread during each meeting. for a susceptible individual, the rate of transmission is governed by the sum of product of contact rate β and infectiousness in all the interactions spaces. to model infectiousness, we consider three scenarios. interactions without age-stratification: this is the simplest model where interactions within each network is assumed to be homogeneous. a susceptible individual n (who belongs to home h(n), school s(n), workplace w(n), transport space t (n), and community space c(n)) sees the following infection rate at time t: where h c,c (t) = n :c(n )=c f (d n ,c(n ) ) · ζ(a n ) · i n (t)β c r c κ(t − τ n )ρ n ( + c n (ω − )) the expression ( ) can be viewed as the rate at which the susceptible individual n contracts the infection at time t. each of the components on the right-hand side indicates the rate from home, school, workplace, transport space, and community. the additional quantities, over and above what we have already described, are as follows. the parameter α determines how household transmission rate scales with household size, a crowding-at-household factor. it increases the propensity to spread the infection by a factor n −α . we have taken α = . , see [ ] . a common parameter ω indicates how a severely infected person affects a susceptible one, as will be clear from below. (this is to be tuned at a later stage and is set to now). the functions ψ s (·) and ψ w (·) account for absenteeism in case of a severe infection. it can be time-varying and can depend on school or workplace. we take ψ s (t) = . and ψ w (t) = . while infective and after one day since infectiousness. school-goers with severe infection contribute lesser to the infection spread, due to higher absenteeism, than those that go to workplaces; moreover, the absenteeism results in an increased spreading rate at home. the function ζ(a) is the relative travel-related contact rate of an individual aged a. we the function f (·) is a distance kernel that can be matched to the travel patterns in the city. finally, our choice of the infection rate from the community space is a little different from the rate specified in [ ] , in order to enable an efficient implementation. when the distance kernel is f (d) = /( + (d/a) b ) and d a, i.e., the wards are small, then our specification is close to that indicated in [ ] . we take a = . km and b = . , based on a fit on data for bengaluru. as one can see from ( ), we have one community space but with contributions from various wards. this enables inclusion of 'containment zones' and the associated restriction of interaction across such zones, as we shall soon describe. age-stratified interactions: if this is enabled, the home, school, workplace and community interaction rates have an extra factor m h n,n , m s n,n , and m w n,n in the summand which accounts for age-stratified interactions. each of these depends on n and n only through the ages of agents n and n . the resulting contact rate for individual n at time t is then: where h c,c (t) is given in ( ) . computational complexity can be reduced by focusing only on the principal components of m h , m s , and m w . interactions with smaller subnetworks: in this situation, we have additional contact rate parameters, one for each smaller subnetwork: let β * h , β * s , β * w and β * c denote the transmission coefficients at neighbourhood network, class network, project network and random community network respectively. then, an agent n (who belongs to neighbourhood network h (n), class s (n), project w (n) and random community c (n), in addition to home h(n), school s(n), workplace w(n), transport space t (n), and community space c(n)) sees the following infection rate at time t: λ n (t) = n :h(n )=h(n) n α h(n) · i n (t)β h κ(t − τ n )ρ n ( + c n (ω − )) + ζ(a n ) n :h (n )=h (n) n h (n) · ζ(a n )i n (t)β * h κ(t − τ n )ρ n ( + c n (ω − )) (larger neighbourhood interaction) + ζ(a n )f (d n,c(n) ) n :c (n )=c (n) f (d n ,c(n ) ) × n :c (n )=c (n) f (d n ,c(n ) )ζ(a n )i n (t)β * c κ(t − τ n )ρ n ( + c n (ω − )) (close friends' circle interaction) (project network interaction) where h c,c (t) is given in ( ) . the subnetwork interactions are stronger contexts for disease spread. contact tracing targets exactly these subnetworks for additional testing, case isolation or quarantine. two methods of seeding the infection have been implemented. • a small number of individuals can be set to either exposed, presymptomatic/asymptomatic, or symptomatic states, at time t = , to seed the infection. this can be done randomly based either on ward-level probabilities, which could be input to the simulator, or it can be done uniformly at random across all wards in the city. • a seeding file indicates the average number of individuals who should be seeded on each day in the first stage of infectiousness (presymptomatic or asymptomatic). this could be done based on data for patients with a foreign travel history who eventually visited a hospital. a certain multiplication factor then accounts for the asymptomatic and the symptomatic individuals that recover without the need to visit the hospital. the seeding is done at a random time earlier in the time line, based on the disease progression. we calibrate our model by tuning the transmission coefficients at various interaction spaces under the no-intervention scenario in order to match the cumulative fatalities to a target curve. we assume a common upscaling factorβ for the transmission coefficients of smaller subnetworks, i.e., we set β * w =ββ w , β * s =ββ s and β * h = β * c =ββ c . we assume that β = , indicating that the subnetworks account for % of the overall contacts. the following heuristic iterative algorithm inspired by stochastic approximation is then used to identify the best choice of the free parameters. where [exp(m * − m(n))] /a a = min{max{exp(m * − m(n)), a}, /a}, Λ h (n) (resp. Λ w (n), Λ c (n)) is the fraction of infections from home (resp. workplace, community) in the nth where Λ * h = Λ * w = Λ * c = / , and m * is the target slope (the target slope is similarly computed from the cumulative fatalities data in log scale; for example, the india fatalities curve in the range - gives a slope of m * = . ). once the slopes are matched, assuming that the simulator starts on march , we find the delay between the fatalities curve from the simulator and the target data. we then use the resulting contact rates and the above calibration delay to launch our simulations. to avoid any oscillatory behaviour of the calibration algorithm, we also set the scale factor in each of the above update steps to be [exp((m * − m(n))/n)] we do not calibrate β t , the transmission coefficient at transport space. for the calibration step we take this parameter to be zero while tuning the other parameters. a heuristic justification is as follows. bengaluru travel interactions will likely be captured through the local community interactions, and we keep it zero throughout, even in the case studies. for mumbai however, local trains are a key mode of daily transportation with a population of the order of lakh travelling daily using this mode in normal times. however, trains were stopped in mumbai prior to the national lockdown and were running below capacity for at least a week before that. moreover, the initial infections were seeded by travellers that came from abroad. the primary mode of travel for this group is unlikely to be rail transport. so we disabled the transport space while calibrating by setting β t = . subsequently for the trains on/off case study, we used a heuristic calculation of β t ; see [ , section iv]. the above procedures identify the contact-related parameters. other parameters are the distance kernel parameters, the parameter α that accounts for crowding in households, the age-stratified interactions, the distribution parameters for individual infectiousness, the probability of severity, etc. these are set as follows: the simulator has the capability to accommodate interventions and compliance. table viii describes some of the interventions in [ ] , some adapted to suit our demographics, and some new interventions involving the nation-wide -day 'lockdown' in india and various scenarios of 'unlock'. these are fairly straightforward to implement -we modulate an individual's contact rate with an interaction space (both into the interaction space and out of the interaction space) by a suitable factor associated with intervention. for example, one could easily implement and study cyclic exit strategies as done in [ ] . the triggers for cyclic controls could be based on signals such as the number of individuals that are hospitalised, as done in our soft ward containment. yet another one is to quarantine or case isolate based on contact tracing, as we will describe next. our simulator also includes a framework to study the impact of early contact tracing and testing. we assume that contacts of an individual in the smaller networks such as neighbourhood network, project network, class network and random community network can be identified and tested/quarantined. the current contact tracing protocol quarantines certain primary contacts and tests a subset of these (e.g., symptomatic primary contacts). in our implementation, based on our study of icmr's testing protocol, given an index case, all household members, a fraction of the friends circle, a fraction of the inner school/workplace circle, and a fraction of the neighbourhood community are termed as primary contacts of this index case. all of these are quarantined, and a fraction of the symptomatic and another fraction of the asymptomatic among these are tested. those who test positive become new index cases and spawn further contact tracing. the testing fractions are calibrated to match the actual reported cases and the test-positivity rate. we list some limitations of our simulator. • we do not have activity modelling in our simulator. as a consequence, weekly and daily patterns on interactions are not taken into account; for instance, the absence of interaction in workplaces and schools during weekends/public holidays, an increased interaction in public transport during morning and evening peak hours etc. are not taken into account in our model. instead, all these factors are abstracted into a single infection rate for each individual prescribed by ( ), ( ) and ( ). • some of the data that we need in our simulator, such as the household size distribution, workplace size distribution, school size distribution, commuter distance distribution etc., can perhaps be difficult to obtain for some cities. • we have too many free parameters in our model. this can lead to overfitting resulting in high generalisation error. • the framework is computationally intensive. • since the disease spread model has quite a bit of stochasticity (e.g., the incubation time), we need to perform multiple runs of our simulator and take an average of the outputs. we do not have an estimate on the variability of our outputs across multiple runs; such an analysis will be essential to determine the number of runs we need to perform in order for our outputs to be close to the average. generation of a synthetic city is performed via the following steps. ) data gathering and data preparation involves the following. for instantiating households in high-density areas, we sample locations either from a geojson file with boundaries of the high-density areas or from a collection of pre-sampled locations of households in high density areas. common areas where community interactions take place are instantiated at the ward centres, assumed to be the centroids of the polygons. these tasks are accomplished using the following python packages: numpy, random, pandas and shapely. the outputs of this stage are collections of the instantiated individuals, their assigned households, schools, workplaces, transport and community areas. (c) additional processing for generating city files: before generating the city files, additional processing is done on the dataframes which includes computing the distance of the individuals to their respective ward centres. this stage uses the pandas package for processing and generating the city files in the json file format for each instantiated collection namely the individuals, households, workplaces, schools, community centres, and distance between wards. the disease progression part of the simulator is broadly implemented as follows. there are four time steps on a given day. at each time step, we go through each susceptible agent and find out the infection rate given by either ( ) • contact tracing requires us to maintain a list of contacts made by each agent. in our implementation, we assume that each individual has a certain number of contacts that we can trace (which is random, but independent of n). as a result, the space complexity becomes o(n) instead of o(n ). • in the age-stratified interaction as well as od-matrix based distance kernel, we consider dominant terms of the age-based contact rate matrix as well as od-matrix by doing a principal component analysis and by focusing on a few important components. this helps simplify the summations in ( ). these optimisation features appear to be novel features of our simulator. in this work, we built an agent-based simulator to study the impact of various nonpharmaceutical interventions in the context of the ongoing covid- pandemic. we demonstrated the capabilities of our simulator via various case studies for bengaluru and mumbai. some of the key features of our simulator include age-stratified interaction that captures heterogeneity in interaction among people in a given interaction space, the ability to implement various interventions such as soft ward containment, phased opening of workplaces and community spaces, a broad class of contact tracing based testing and case isolation protocols, etc. these features help our simulator to capture the ground reality very well and provide us with realistic predictions. some future directions include bringing in movement of people into and out of the city and studying the impact of various mobility patterns, modelling and studying the impact on public-health oriented decisions on the economy, incorporating activity modelling into our simulator and using the simulator to obtain district-scale or country-scale predictions. we hope that such agent-based simulators find a regular place in every public health official's tool kit. ministry of health and family welfare, government of india covid- india-timeline: an understanding across states and union territories crowdsourced covid -india database containing papers of a mathematical and physical character indsci-sim a state-level epidemiological model for india a minimal and adaptive prediction strategy for critical resource planning in a pandemic spatio-temporal predictive modeling framework for infectious disease spread impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand intervention strategies against covid- and their estimated impact on swedish healthcare capacity modeling targeted layered containment of an influenza pandemic in the united states a taxonomy for agent-based models in human infectious disease epidemiology modelling disease outbreaks in realistic urban social networks face mask use and control of respiratory virus transmission in households mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial respiratory virus shedding in exhaled breath and efficacy of face masks physical distancing, face masks, and eye protection to prevent person-person covid- transmission: a systematic review and meta-analysis consolidated revised guidelines on the measures to be taken by ministries/departments of government of india, state/ ut governments and state / ut authorities for containment of covid- in the country mha order dt. . . on phased re-opening (unlock ) covid- community mobility report epidemiologically and socio-economically optimal policies via bayesian optimization urban poverty and transport : the case of mumbai. the world bank strategies for containing an emerging influenza pandemic in southeast asia projecting social contact matrices in countries using contact surveys and demographic data age-structured impact of social distancing on the covid- epidemic in india estimates of the severity of coronavirus disease : a model-based analysis the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study european centre for disease prevention and control's covid- website covid- epidemic study ii: phased emergence from the lockdown in mumbai adaptive cyclic exit strategies from lockdown to suppress covid- and allow economic activity key: cord- -kdgo rqb authors: nan title: hematopoietic tumors date: - - journal: withrow and macewen's small animal clinical oncology doi: . /b - - - - . - sha: doc_id: cord_uid: kdgo rqb nan the lymphomas (malignant lymphoma or lymphosarcoma) are a diverse group of neoplasms that have in common their origin from lymphoreticular cells. they usually arise in lymphoid tissues such as lymph nodes, spleen, and bone marrow; however, they may arise in almost any tissue in the body. although the annual incidence of lymphoma is difficult to predict in the absence of a national canine tumor registry, it is clear that it represents one of the most common neoplasms seen in the dog. the annual incidence has been estimated to range between to per , dogs at risk. [ ] [ ] [ ] the annual incidence rates at specific ages are estimated to be . per , for dogs less than . year of age and per , in the -to -year-old group. lymphoma comprises approximately % to % of all canine neoplasia and % of all canine hematopoietic malignancies. , in a review of the veterinary medical data base program (vmdp) at purdue university from to , the frequency of canine lymphoma patients presented to veterinary institutions increased from . % of total case load to . %, and it appears the frequency is continuing to increase. a similar trend is present in physician-based oncology; non-hodgkin's lymphoma (nhl) represents % of all new cancer cases, the fifth leading cause of cancer death, and the second fastest growing cancer in terms of mortality in humans. middle-aged to older (median age of to years) dogs are primarily affected. a decreased risk for lymphoma is reported for intact females. breeds reported to have a higher incidence include boxers, bull mastiffs, basset hounds, st. bernards, scottish terriers, airedales, and bulldogs; breeds at lower risk include dachshunds and pomeranians. , etiology the etiology of canine lymphoma is likely multifactorial and largely unknown; however, investigations are currently shedding significant light on the subject. recent advances in molecular cytogenetics (see chapter , section a), including gene microarray techniques, have been and are currently being applied to investigations of chromosomal aberrations in dogs with lymphoma. [ ] [ ] [ ] [ ] [ ] [ ] [ ] the publication of the canine genome and the commercial availability of canine gene microarrays (genechip canine genome . array, affymetrix, inc.) have led to advances in our understanding of genetic events occurring in lymphoma. breen's group has documented gain of dog chromosomes and and loss of chromosome as the most common aberrations in a group of cases analyzed. chromosomal aberrations have also been associated with prognosis in dogs with lymphoma. a study of dogs with lymphoma demonstrated a prognostic advantage in dogs with trisomy of chromosome ( % of the dogs studied) as evidenced by increase in duration of first remission and overall survival time. germline and somatic genetic mutations and altered oncogene/tumor suppressor gene expression, epigenetic changes (e.g., dna hypomethylation), signal transduction, and death-pathway alterations (e.g., bcl- family) are common in human lymphomas and have been reported in the dog as well (see chapter , section a, and chapter , section b). these include n-ras, p , rb, and p cyclin-dependent kinase aberrations. [ ] [ ] [ ] [ ] [ ] [ ] additionally, differences in the prevalence of immunophenotypic subtypes of lymphoma among different breeds indicate heritable risks. additionally, telomerase activity (see chapter ) has been documented in canine lymphoma tissues. [ ] [ ] [ ] the hypothesis that a retrovirus may be involved in the pathogenesis of canine lymphoma has not been confirmed. however, serologic detection of epstein-barr virus infection, linked to some forms of lymphoma in humans, has been documented in dogs with lymphoma and is currently being investigated. in humans, a direct association between helicobacter sp. infections and development of gastric lymphoma has been made. although this has not been definitively shown in dogs, there is evidence of helicobacter sp. infection in laboratory beagle dogs resulting in gastric lymphoid follicle formation that is considered a precursor of mucosa-associated lymphoid tissue (malt) lymphoma in humans. in humans, evidence has accumulated implicating phenoxyacetic acid herbicides, in particular , -dichlorophenoxyacetic acid ( , -d) , in the development of nhl. a published hospital-based casecontrol study of dogs indicated that owners in households with dogs that develop malignant lymphoma applied , -d herbicides to their lawn and/or employed commercial lawn care companies to treat their yard more frequently than owners of dogs without lymphoma. the risk of canine lymphoma was reported to rise twofold (odds ratio [or] = . ) with four or more yearly owner applications of , -d. the results of this study have come under criticism, and three additional follow-up investigations have not validated assertions of increased risk. [ ] [ ] [ ] in another study, dogs exposed to lawn treatment within days of application were greater than times histopathologically, distinguishing between gi lymphoma and lpe can be difficult. some have suggested that lpe may be a prelymphomatous change in the gi tract. a syndrome of immunoproliferative intestinal disease characterized by lpe has been described in basenjis, which subsequently develop gi lymphoma. in addition, plasma cell-rich areas with heterogeneous lymphomatous infiltration may resemble lesions of lpe. only a few reports specifically identify the immunophenotype of the lymphocyte subpopulations in alimentary lymphoma in dogs. historically, it was presumed that they most likely originate from b cells; however, recent evidence suggests that most gi lymphomas in dogs arise from t cells and often exhibit epitheliotropism. , the boxer and shar-pei breeds may be overrepresented in cases of alimentary lymphoma. , the mediastinal form of the disease occurs in approximately % of cases. this form is characterized by enlargement of the cranial mediastinal lymph nodes, thymus, or both ( figure - ). hypercalcemia is reported to occur in % to % of dogs with lymphoma and is most common with the mediastinal form. in a study of dogs with lymphoma and hypercalcemia, ( %) had mediastinal lymphoma. the mediastinal form in dogs is most commonly associated with a t-cell phenotype. , cutaneous lymphoma can be solitary or more generalized and usually is classified as epitheliotropic (mycosis fungoides) or nonepitheliotropic. canine epitheliotropic cutaneous lymphoma originates from t-cells, [ ] [ ] [ ] [ ] [ ] [ ] similar to its development in humans. in dogs, these more commonly represent cd + cells, whereas in humans they are typically cd + cells. a rare form of cutaneous t-cell lymphoma, characterized by skin involvement with evidence of peripherally circulating large ( to µm in diameter) malignant t-cells with folded, grooved nuclei, has been described. in humans, this is referred to as sézary syndrome and has been reported in both dogs and cats. [ ] [ ] [ ] nonepitheliotropic cutaneous lymphomas form single or multiple dermal or subcutaneous nodules or plaques; histologically, they spare the epidermis and papillary dermis and affect the middle and deep portions of the dermis and subcutis. more likely to have urine levels of , -d at µg/l or higher. the highest concentration was noted days after application. in an environmental case-control study performed in europe, two variables, residency in industrial areas and use of chemicals (defined as paints or solvents) by owners, modestly increased the risk of developing lymphoma; however, no link was found with pesticide use. a weak association between lymphoma in dogs and exposure to strong magnetic fields was observed in a preliminary epidemiologic study. in this hospital-based case-control study, the risk of developing lymphoma categorized into high or very high exposure was increased (odds ratio = . ). more thorough studies are necessary to evaluate this association further. proximity to environmental waste was implicated in two european studies; however, it was felt to be a risk indicator rather than a risk factor and would require further case-control investigations. , impaired immune function has also been implicated in dogs with lymphoma. immune system alterations in the dog such as immunemediated thrombocytopenia, independent of age and sex, have been associated with a higher risk of subsequently developing lymphoma when compared to the normal population. , additional evidence comes from observations in human and feline transplantation patients. in a case-control study of cats undergoing renal transplant, % of cases developed cancer ( % of those were lymphoma) while on cyclosporine immunosuppressive therapy compared to . % of control cats, none of which developed lymphoma (or, . ; p = . ). a case of lymphoma developing in a dog following treatment with cyclosporine also exists. one report suggests an association between the immunodysregulation observed in dogs with atopic dermatitis and the risk of developing epitheliotropic t-cell lymphoma; whether this is associated with the disease or the immunomodulatory treatments commonly applied is unknown. classification of malignant lymphoma in dogs is based on anatomic location, histologic criteria, and immunophenotypic characteristics. the most common anatomic forms of lymphoma, in order of decreasing prevalence, are multicentric, gastrointestinal (gi), mediastinal, and cutaneous forms. primary extranodal forms, which can occur in any location outside the lymphatic system, include the eyes, central nervous system (cns), bone marrow, bladder, heart, and nasal cavity. the pathologic characteristics of the various anatomic classifications will be discussed in this section and clinical characteristics will be described in subsequent sections. eighty-four percent of dogs with lymphoma develop the multicentric form, which is usually characterized by the presence of superficial lymphadenopathy (figure - ) . the alimentary form of lymphoma is much less common, accounting for % to % of all canine lymphomas. this form is reported to be more common in male dogs than female dogs. primary gi lymphoma in dogs may occur focally but more often affects multiple segments, with thickening of the wall, narrowing of the lumen, and frequently mucosal ulceration. , histologically, there is infiltration of neoplastic lymphocytes throughout the mucosa and submucosa, with occasional transmural infiltration. liver and local lymph nodes are often secondarily involved. lymphocytic-plasmacytic enteritis (lpe) can be seen adjacent to or distant from the primary tumor. pathologically, some of these neoplasms may resemble plasma cell tumors, and aberrant production of immunoglobulins may occur. species. the national cancer institute (nci) working formulation and the updated kiel system have been adapted to canine tumors with some success. the world health organization (who) also publishes a histologic classification scheme, which uses the revised european american lymphoma (real) system as a basis for defining histologic categories of hematopoietic and lymphoid tumors in domestic animals. this system incorporates anatomic, histologic, and immunophenotypic criteria (b-and t-cell immunophenotype), with the goal of enabling accurate and reproducible diagnosis of specific neoplastic disease entities. this theoretically should assist in better tailoring of treatment protocols, better correlation of prognosis, and better comparative capabilities. , ; some of the less common categories in the who system were not represented and are not listed. the who system provides accurate and consistent reproducible diagnostic results similar to the system used in human pathology; accuracy among a group of pathologists examining cases was at % agreement, and accuracy in evaluating the six most common diagnoses ( % of the cases) was %. clinical studies are needed to correlate the various categories of disease with biologic behavior, response to treatment, and prognosis. preliminary results indicate dogs with indolent lymphoma (e.g., marginal zone lymphoma, follicular lymphoma, b-or t-cell small cell lymphoma, t-cell-rich b-cell lymphoma, and t zone lymphoma) maintain normal activity and appetite levels even during advanced stages of disease and experience long-term survival even with limited or no therapy. [ ] [ ] [ ] [ ] the working formulation (wf) was developed to allow investigators to "translate" among the numerous classification systems so that clinical trials could be compared in humans. most of the larger compilations agree that most canine lymphomas are intermediate or high grade; however, diffuse immunoblastic forms appear to predominate in the united states, whereas the follicular hepatosplenic lymphoma is a relatively uncommon, distinct presentation in the dog marked by a lack of significant peripheral lymphadenopathy in the face of hepatic, splenic, and bone marrow infiltration with malignant lymphocytes, usually of t-cell origin. , biologically, this form of lymphoma is extremely aggressive and poorly responsive to therapy. in humans the tumor usually is composed of γδt-cells (i.e., t-cells that express the γδt-cell receptor), and this immunophenotype has been confirmed in at least one dog in the veterinary literature. intravascular (angiotropic, angioendotheliomatosis) lymphoma is a distinct form of lymphoma defined as proliferations of neoplastic lymphocytes within the lumen and wall of blood vessels in the absence of a primary extravascular mass or leukemia. it has been reported several times in the veterinary literature, and in most cases it involves the cns and peripheral nervous system (pns), including the eye. [ ] [ ] [ ] [ ] [ ] [ ] the b-cell immunophenotype is most common in humans; however, in most reported cases in dogs, the origin is either t-cell or null cell (neither b-nor t-cell), although one case of a b-cell phenotype has been reported. pulmonary lymphomatoid granulomatosis (plg) is a rare pulmonary infiltrative and/or nodular disorder characterized by a heterogenous accumulation of lymphocytes (both b and t, although some evidence suggests primarily a t-cell origin), neutrophils, plasma cells, and macrophages, often arranged angiocentrically. [ ] [ ] [ ] [ ] whether this syndrome is a true lymphoma or a prelymphoma state is debatable. clinical signs are related to respiratory compromise, and various chemotherapeutic protocols have been used with reported results varying from rapid progression to long-term clinical remissions. lymphomas arise from clonal expansion of lymphoid cells with distinctive morphologic and immunophenotypic features. many histologic systems have been used to classify nhl in humans, and some of these have been applied to lymphoma in the dog and other percentage of canine lymphomas ( . % to %) are considered low-grade tumors. high-grade lymphomas occur frequently if diffuse large-cell lymphomas, classified as intermediate grade in the wf, are considered high-grade, as in the updated kiel classification (in which they are labeled as diffuse centroblastic lymphomas). a documented difference exists in the prevalence of the various immunophenotypes based on breed. for example, cocker spaniels and doberman pinschers are more likely to develop b-cell lymphoma, boxers are more likely to have t-cell lymphoma, and golden retrievers appear to have an equal likelihood of b-and t-cell tumors. to be clinically useful, these classification systems in the end must yield information about response to therapy, maintenance of remission, and survival. some studies suggest that the subtypes in the wf can be correlated with survival, and the kiel system may be useful for predicting relapse. , in most studies, high-grade lymphomas achieve a complete response (cr) to chemotherapy significantly more often than low-grade tumors. however, dogs with low-grade tumors may live a long time without aggressive chemotherapy. , dogs with t-cell lymphomas have shown a lower rate of cr to chemotherapy and shorter remission and survival times than dogs with b-cell tumors (with the exception of lowgrade t-cell subtypes). , , , furthermore, t-cell lymphomas tend to be associated with hypercalcemia. , large cell variations predominate in europe. a comparison of european and american classifications is warranted based on this discrepancy. the wf categorizes tumors according to pattern (diffuse or follicular) and cell type (e.g., small cleaved cell, large cell, immunoblastic), but it does not include information about the immunophenotype of the tumor. the wf subtypes are related to the biology of the tumor and patient survival. the updated kiel classification includes the architectural pattern, morphology (centroblastic, centrocytic, or immunoblastic), and immunophenotype (b-cell or t-cell) of the tumor cells. in both systems, the tumors can then be categorized as low-grade, intermediate grade, or highgrade malignancies. low-grade lymphomas composed of small cells with a low mitotic rate typically progress slowly and are associated with long survival times but are ultimately incurable. highgrade lymphomas with a high mitotic rate progress rapidly but are more likely to respond initially to chemotherapy and, in humans, are potentially curable. several features of canine lymphomas become apparent when these classification systems are applied. the most striking difference between canine and human lymphomas is the scarcity of follicular lymphomas in the dog. , some diffuse lymphomas in the dog may initially be follicular, but these may progress to the more aggressive, diffuse form by the time of diagnostic biopsy. the most common form of canine lymphoma is diffuse large-cell lymphoma, a highgrade tumor most commonly of b-cell origin. , , only a small particularly evident in dogs with hypercalcemia of malignancy. dogs may also be presented with clinical signs related to blood dyscrasias secondary to marked tumor infiltration of bone marrow (myelophthisis) or paraneoplastic anemia, thrombocytopenia, or neutropenia. these could include fever, sepsis, anemia, and hemorrhage. diffuse pulmonary infiltration is seen in % to % of dogs with the multicentric form, as detected by radiographic changes (figure - ) . , based on bronchoalveolar lavage, the actual incidence of lung involvement may be higher. , in the veterinary literature, % to % of canine lymphomas are of b-cell origin; t-cell lymphomas account for % to %; mixed b-and t-cell lymphomas account for as many as %; and null cell tumors (i.e., neither b-cell nor t-cell immunoreactive) represent fewer than %. , , [ ] [ ] [ ] the development of monoclonal antibodies to detect specific markers on canine lymphocytes has made immunophenotyping of tumors in dogs routinely available in many commercial laboratories. such techniques can be performed on paraffin-embedded samples, from tissue microarrays, on cytologic specimens obtained by fine-needle aspiration (fna) of lesions, or by flow cytometric analysis of cellular fluid samples (e.g., peripheral blood, effusions) and lesion aspirates. the rappaport classification system, proposed in for human nhl, describes the architectural pattern (follicular or diffuse) and the cytologic features (well differentiated, poorly differentiated, or histiocytic) of lymphoma. , this system has not proved useful in providing prognostic information or in guiding therapy in dogs with lymphoma because of the low number of follicular lymphomas in dogs, the problematic "histiocytic" subgroup, and the failure to account for different morphologic and immunologic cell types. one criticism of the rappaport, kiel, and wf classification systems is that they fail to include extranodal lymphomas as a separate category. the who system does include anatomic location as a factor in determining certain categories. although differences between nodal and extranodal tumors in biologic behavior and prognosis are well recognized, comparative information about the histogenesis of these tumors is lacking. for example, in humans small-cell lymphomas arising from malt are composed of cells with a different immunophenotype than that of other small-cell lymphomas (i.e., malt lymphomas typically are negative for both cd and cd ). except for cutaneous lymphoid neoplasms, detailed characterization of extranodal lymphomas in dogs has not been done. although cutaneous lymphoma is a heterogeneous group of neoplasms that includes an epitheliotropic form resembling mycosis fungoides and a nonepitheliotropic form, most cutaneous lymphomas have a t-cell phenotype. , to summarize, it is important to determine the histologic grade of canine lymphomas as low (small lymphocytic or centrocytic lymphomas) or intermediate to high (diffuse large cell, centroblastic, and immunoblastic lymphomas) and the architecture as diffuse or follicular. furthermore, determining the immunophenotype of the tumor provides useful information. response rates to chemotherapy are, in general, better in animals with b-cell tumors and intermediate-to high-grade lymphomas. dogs with low-grade lymphomas can have long survival times without aggressive therapy. the clinical signs associated with canine lymphoma are variable and depend on the extent and location of the tumor. multicentric lymphoma, the most common form, is usually distinguished by the presence of generalized painless lymphadenopathy (see figure - ). enlarged lymph nodes are usually painless, rubbery, and discrete and may initially include the mandibular and prescapular nodes. in addition, hepatosplenomegaly and bone marrow involvement occur commonly. most dogs with multicentric lymphoma present without dramatic signs of systemic illness (who substage a) (box - ); however, a large array of nonspecific signs such as anorexia, weight loss, vomiting, diarrhea, emaciation, ascites, dyspnea, polydipsia, polyuria, and fever can occur (who substage b). dogs presented with t-cell lymphoma are more likely to have constitutional (i.e., substage b) signs. polydipsia and polyuria are i involvement limited to a single node or lymphoid tissue in a single organ. † ii involvement of many lymph nodes in a regional area (±tonsils). iii generalized lymph node involvement. iv liver and/or spleen involvement (±stage iii). syndrome, characterized by pitting edema of the head, neck, and forelimbs secondary to tumor compression or invasion of the cranial vena cava (figure - ) . signs in dogs with extranodal lymphoma depend on the specific organ involved. cutaneous lymphoma is usually generalized or multifocal. [ ] [ ] [ ] tumors occur as nodules, plaques, ulcers, and erythemic or exfoliative dermatitis with focal hypopigmentation and alopecia. epitheliotropic t-cell lymphoma (e.g., mycosis fungoides) typically has a clinical course with three apparent clinical stages. initially, there will be scaling, alopecia, and pruritus ( figure - , a), which can mimic a variety of other skin conditions. as the disease progresses, the skin becomes more erythematous, dogs with gi or alimentary lymphoma are usually presented with nonspecific gi signs, such as vomiting, diarrhea, weight loss, and malabsorption. , , mesenteric lymph nodes, spleen, and liver may be involved. the mediastinal form of lymphoma is characterized by enlargement of the cranial mediastinal structures and/or thymus (see figure - ), and clinical signs are associated with the extent of disease with resulting respiratory compromise or polydipsia/ polyuria from hypercalcemia. commonly, dogs are presented with respiratory distress caused by a space-occupying mass and pleural effusion, exercise intolerance, and possibly regurgitation. additionally, dogs with mediastinal lymphoma may present with precaval a c b intravascular lymphoma usually present with signs relative to cns, pns, or ocular involvement. [ ] [ ] [ ] [ ] [ ] [ ] these include paraparesis, ataxia, hyperesthesia, seizures, blindness, lethargy, anorexia, weight loss, diarrhea, polyuria, polydipsia, and intermittent fever. finally, dogs with pure hepatosplenic lymphoma usually are presented with nonspecific signs of lethargy, inappetence, and weakness and often are icteric. , the differential diagnosis of lymphadenopathy depends on the dog's travel history (i.e., relative to infectious disease) and the size, consistency, and location of affected lymph nodes. other causes of lymphadenopathy include infections caused by bacteria, viruses, parasites (toxoplasma sp., leishmania sp.), rickettsial organisms (salmon-poisoning, ehrlichia sp.), and fungal agents (blastomyces and histoplasma sp.). the potential for hypercalcemia to accompany systemic fungal diseases may further complicate differentiation from lymphoma. discrete, hard, asymmetric lymph nodes, particularly if they are fixed to underlying tissues, may indicate metastatic tumors such as mast cell tumor or carcinoma. immunemediated diseases (e.g., pemphigus, systemic lupus erythematosus) also may result in mild-to-moderately enlarged lymph nodes. the thickened, ulcerated, and exudative. the final stage is characterized by proliferative plaques and nodules with progressive ulceration (figure - , b) . oral involvement may also occur and this can appear as multicentric erythematous plaque-like lesions or nodules associated with the gum and lips ( figure - , c). extracutaneous involvement can also occur, most often in the lymph nodes, spleen, liver, and bone marrow. nonepitheliotropic cutaneous lymphomas form single or multiple dermal or subcutaneous nodules or plaques; histologically, they spare the epidermis and papillary dermis and affect the middle and deep portions of the dermis and subcutis. dogs with primary cns lymphoma may be presented with either multifocal or solitary involvement. [ ] [ ] [ ] seizures, paralysis, and paresis may be noted. ocular lymphoma is characterized by infiltration and thickening of the iris, uveitis, hypopyon, hyphema, posterior synechia, and glaucoma. , in one study of cases of canine multicentric lymphoma, % had ocular changes consistent with lymphoma, and in a series of cases of uveitis in dogs, % were secondary to lymphoma. anterior uveitis was most commonly seen in advanced stage of disease (stage v). dogs with • figure - a, early epitheliotropic cutaneous lymphoma in the scaly, plaque stage in a dog. b, advanced epitheliotropic cutaneous lymphoma in the nodular stage in a dog. c, oral mucosal epitheliotropic cutaneous lymphoma in a dog. c count (cbc), with a differential cell count, including a platelet count; a serum biochemical profile; and urinalysis. optimally, ionized calcium should be measured. ultimately, obtaining tissue or cytologic specimens for a definitive diagnosis is essential. a thorough physical examination should include palpation of all assessable lymph nodes, including a rectal examination; in the authors' experience, a significant proportion of dogs will have rectal polyps consisting of aggregates of neoplastic lymphocytes. inspection of mucous membranes for pallor, icterus, petechiae, and ulceration should be undertaken as these signs may indicate anemia or thrombocytopenia secondary to myelophthisis or immunemediated disease or may be evidence of major organ failure or uremia. abdominal palpation may reveal organomegaly, intestinal wall thickening, or mesenteric lymphadenopathy. the presence of a mediastinal mass and/or pleural effusion can be suspected following thoracic auscultation. an ocular examination, including funduscopic assessment, may reveal abnormalities (e.g., uveitis, retinal hemorrhage, ocular infiltration) in approximately one-third to onehalf of dogs with lymphoma. , anemia, the most common lymphoma-related hematologic abnormality, is usually normochromic and normocytic (nonregenerative), consistent with anemia of chronic disease. however, hemorrhagic and hemolytic anemias may also occur, and regenerative anemias may reflect concomitant blood loss or hemolysis. additionally, if significant myelophthisis is present, anemia may be accompanied by thrombocytopenia and leukopenia. , in animals with anemia or evidence of bleeding, in addition to a platelet count, a reticulocyte count and coagulation testing may be indicated. thrombocytopenia may be seen in % to % of cases, but bleeding is seldom a clinical problem. neutrophilia can be seen in % to % of dogs and lymphocytosis occurs in approximately % of affected dogs. circulating atypical lymphocytes may be indicative of bone marrow involvement and leukemia. it is important to differentiate multicentric lymphoma with bone marrow involvement (i.e., stage v disease) from primary lymphoblastic leukemia (see later), as the prognosis for each is entirely different. hypoproteinemia is observed more frequently in animals with alimentary lymphoma. in dogs with a high total protein or evidence of an increased globulin fraction on a chemistry profile, serum proteins may be evaluated by serum electrophoresis. monoclonal gammopathies have been reported to occur in approximately % of dogs with lymphoma. serum biochemical abnormalities often reflect the anatomic site involved, as well as paraneoplastic syndromes such as hypercalcemia. in cases of hypercalcemia of unknown origin, lymphoma should always be considered high on the differential disease list, and diagnostic testing directed at this possibility should be undertaken (see chapter ) . in addition, the presence of hypercalcemia can serve as a biomarker for response to therapy and early recurrence. increased urea nitrogen and creatinine concentrations can occur secondary to renal infiltration with tumor, hypercalcemic nephrosis, or prerenal azotemia from dehydration. increases in liver-specific enzyme activities or bilirubin concentrations may result from hepatic parenchymal infiltration. increased serum globulin concentrations, usually monoclonal, occur infrequently with b-cell lymphoma. urinalysis is part of the minimum database used to assess renal function and the urinary tract. for example, isosthenuria and various differential diseases or conditions that can resemble canine lymphoma are listed in table - . canine lymphoma also may be associated with paraneoplastic syndromes (see chapter ) . anemia is the most common lymphoma-related paraneoplastic syndrome. paraneoplastic hypercalcemia is also common and is characterized clinically by anorexia, weight loss, muscle weakness, lethargy, polyuria, polydipsia, and rarely cns depression and coma. lymphoma-induced hypercalcemia in most cases results from parathyroid hormonerelated peptide (pthrp), elaborated by neoplastic cells; however, it can also be related to the production of several other humoral factors, including interleukin- (il- ), tumor necrosis factor-α (tnf-α), transforming growth factor-β (tgf-β), and vitamin d analogs (e.g., , -dihydroxyvitamin d). , , as previously discussed, hypercalcemia is most commonly associated with the t-cell immunophenotype. other paraneoplastic syndromes that may be encountered include monoclonal gammopathies, neuropathies, and cancer cachexia. for dogs suspected of having lymphoma, the diagnostic evaluation should include a thorough physical examination; complete blood • variable, depending on organ/system involved *the existence of this disease is controversial; in most cases, the disease has been reclassified as a lymphoid neoplasm. prescapular or popliteal lymph nodes are preferable if also involved. also, lymphoid cells are fragile, and in preparing smears of aspirated material only gentle pressure should be applied in spreading material on the slides. in most cases, a diagnosis of lymphoma can be made on evaluation of fine-needle aspirates of affected lymph nodes or other tissues. typically, most of the cells are large lymphoid cells (> times the diameter of a red blood cell [rbc] or larger than neutrophils), and they may have visible nucleoli and basophilic cytoplasm (figure - , a) or fine chromatin with indistinct nucleoli. because tissue architecture is not maintained in cytologic specimens, effacement of the node or capsular disruption cannot be detected. therefore marked reactive hyperplasia characterized by increased numbers of large lymphoid cells may be difficult to distinguish from lymphoma, and small cell lymphomas may have few cytologic clues that point to malignancy. also, classification of lymphoma, which has been attempted using cytologic appearance and immunophenotypic analysis, into subcategories that make up the low-, intermediate-, and high-grade forms is performed most accurately on histologic sections (discussed previously). proteinuria in the absence of an active sediment may indicate renal disease, and hematuria may result from a hemostatic abnormality. it is important to remember that isosthenuria in azotemic dogs with hypercalcemia is not necessarily indicative of renal disease as the high calcium levels interfere with tubular concentration capabilities through disruption of antidiuretic hormone (adh) control. several abnormalities in serum have been explored as biomarkers of lymphoma in the dog. examples include alpha-fetoprotein, alpha- glycoprotein levels, zinc, chromium, iron, endostatin, vascular endothelial growth factor (vegf), lactate dehydrogenase, c-reactive protein haptoglobin, and antioxidants/oxidative stress markers. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the clinical, biologic, and prognostic significance of these alterations is yet to be definitively characterized. morphologic examination of the tissue and cells that constitute the tumor is essential to the diagnosis of lymphoma. care should be taken to avoid lymph nodes from reactive areas (e.g., mandibular lymph nodes), unless those nodes are the only ones enlarged; the immunophenotyping is used to determine the type of cells that comprise the tumor, but this technique also can be helpful for making the initial diagnosis. - , when a heterogenous population of lymphocytes is expected in a tissue, documentation of a homogeneous population of the same immunophenotype is supportive of a neoplastic process. the immunophenotype of a lymphocyte is identified by determining the expression of molecules specific for b-cells (e.g., cd a, cd ) and t-cells (e.g., cd ). although tumor cells sometimes have morphologic characteristics that typify a particular immunophenotype, exceptions occur, and morphologic appearance cannot be used as the sole determinant of immunophenotype. for example, in a series of nine high-grade t-cell lymphomas and leukemias in dogs, the cells had a plasmacytoid appearance, typically associated with b-cell lymphoma. similarly, anatomic location does not always predict the immunophenotype. for accurate determination of immunophenotype, antibodies against lymphocyte markers are applied to tissue sections (immunohistochemistry), cytologic specimens (immunocytochemistry), or individual cells in a fluid medium (flow cytometry). flow cytometric evaluation of cells obtained by needle aspiration is also feasible. for t-cells, markers include cd (pan t), cd (helper t), and cd (cytotoxic t); for b-cells, the markers are cd a ( figure - , b) , cd , and cd . increasingly, aberrant expression of cd molecules has been reported in canine lymphoma. in a study of dogs with lymphoma, tumor cells from six dogs were positive for both t-and b-cell markers; however, a clonality assay (see later) revealed clonality either of the t-cell or the immunoglobulin receptor but not both. this indicates that in some cases, the malignant cells may co-express b-and t-cell markers. antibodies against these molecules are used to determine the immunophenotype; however, they also have potential utility as a therapeutic modality if tumor cells could be targeted using these antibodies. assessments of markers of multidrug resistance and apoptotic pathways (e.g., p-glycoprotein, p , bcl- proteins) have been evaluated in dogs with lymphoma. , , , a, b however, their clinical significance and utility await further evaluation. occasionally, diagnosis of lymphoma and differentiation of malignant versus benign proliferation of lymphocytes are not possible based on standard histologic and cytologic criteria. in these cases, advanced molecular analyses may be helpful to confirm a diagnosis. clonality is the hallmark of malignancy; that is, the malignant cell population theoretically should be derived from expansion of a single malignant clone characterized by a particular dna region unique to that tumor. for example, in a dog with t-cell lymphoma, all the malignant cells theoretically should have the same dna sequence for the variable region of the t-cell receptor gene. for accurate histopathologic evaluation, an entire lymph node, including the capsule, should be removed, placed in buffered formalin, and submitted to a pathologist. although needle core biopsies may be satisfactory, it is important to avoid crush artifact or inadequate sample size. most pathologists prefer whole node biopsies because they provide the maximal amount of information. effacement of normal nodal architecture by neoplastic lymphocytes and capsular disruption are characteristic findings (figure - , c and d). diagnostic ultrasonography and ultrasound-guided fna or needle biopsy have been useful for evaluation of involvement of the liver, spleen, or abdominal lymph nodes. [ ] [ ] [ ] aspiration of ultrasonographically normal splenic tissue is rarely contributory to a diagnosis. if possible, the diagnosis should be made by sampling peripheral nodes, avoiding percutaneous biopsies of the liver and spleen. however, if there is no peripheral node involvement, it is appropriate to biopsy affected tissues in the abdominal cavity. when gi lymphoma is suspected, an open surgical wedge biopsy of the intestine is preferred in most cases to differentiate lymphoma from lymphocytic enteritis. if associated abdominal lymph nodes also appear involved, image-guided biopsies may be associated with less morbidity than intestinal biopsies. multiple samples may be necessary to accurately diagnose segmental disease. endoscopic biopsies may be inadequate as only a superficial specimen is obtained; however, more aggressive endoscopic biopsy techniques combined with more accurate histopathologic, immunophenotypic, and molecular assessments are improving the diagnostic yield of these less invasive techniques. [ ] [ ] [ ] [ ] in many dogs with primary gi lymphoma, an inflammatory nonneoplastic infiltrate (i.e., lpe) may be misdiagnosed on biopsy specimens that are too superficial. the application of assays for clonal expansion (e.g., parr-see next section on molecular diagnostic techniques) does not appear as yet to be as accurate for endoscopically derived intestinal biopsies as with other solid lymphoid tumors in dogs. cytologic examination of cerebrospinal fluid (csf), thoracic fluid, or mass aspirates is indicated in animals with cns disease, pleural effusion, or an intrathoracic mass, respectively. in one study of dogs with cns involvement, csf analysis was diagnostic in seven of eight dogs. characteristics of the csf included an increased nucleated cell count in the seven dogs, and % to % of the cells were atypical lymphocytes. the csf protein concentration was increased in five of the dogs, ranging from to mg/ dl (reference interval: < mg/dl). for cutaneous lymphoma, punch biopsies ( to mm) should be taken from the most representative and infiltrative, but not secondarily infected, skin lesions. application of immunophenotypic and clonality assessments of cutaneous biopsies can aid in differentiating lymphoma from benign lymphocytic lesions. , , molecular techniques can be used to establish a diagnosis of lymphoma or to further characterize the tumor after the initial diagnosis is made. tissues and cells from peripheral blood, lymph nodes, nonlymphoid sites, and effusions can be analyzed by various molecular means to aid in cases that represent a more difficult diagnostic challenge, particularly in cases where reactive lymphocytosis and lymphoma are both possible based on standard histologic or cytologic assessment. these include histochemical and cytochemical, immunohistochemical and immunocytochemical, flow cytometric, and polymerase chain reaction (pcr) techniques. for example, a bone marrow aspirate or biopsy (from proximal humerus or iliac crest) is recommended for complete staging and prognostication and is indicated in dogs with anemia, lymphocytosis, peripheral lymphocyte atypia, or other peripheral cytopenias. in one study of dogs with lymphoma, % had circulating malignant cells and were considered leukemic, whereas bone marrow examination indicated involvement in % of the dogs. the presence of a few prolymphocytes and large lymphocytes with nucleoli in the circulation of dogs with lymphoma may indicate bone marrow involvement. it is important to remember these cells also can be seen with gi parasitism, immune-mediated hemolytic anemia, and other immune-mediated and infectious diseases. as discussed previously, tumor cells within the peripheral and bone marrow compartments can also be identified using clonality assays (parr) that are more sensitive than routine microscopic examination in detecting malignant cells; however, the prognostic significance of the knowledge gained with more sensitive staging methodologies is yet to be determined. although bone marrow evaluation may offer prognostically valuable information, it is not necessary to perform the procedure if the client is committed to treat regardless of stage. evaluation of thoracic and abdominal radiographs may be important in determining the extent of internal involvement ( figure - ) . approximately % to % of dogs with multicentric lymphoma have abnormalities on thoracic radiographs, with one-third having evidence of pulmonary infiltrates (see figure - ) and twothirds having thoracic lymphadenopathy (sternal and tracheobronchial lymph nodes [see ) and widening of the cranial mediastinum (see figure - ). , pulmonary infiltrates usually are represented by an interstitial and/or alveolar pattern; however, nodules (rarely) and bronchial infiltrates can also occur. pleural effusion may also be present. cranial mediastinal lymphadenopathy is detected in % of dogs with lymphoma. , abdominal radiographs reveal evidence of involvement of medial iliac (sublumbar) and/or mesenteric lymph node, spleen, or liver in approximately % of cases. in the authors' practice, for the typical cases of canine multicentric lymphoma, imaging is limited to thoracic likewise, in a dog with b-cell lymphoma, the tumor cells should have identical dna sequences in the variable region of the immunoglobulin (ig) receptor gene. conversely, in reactive lymphocytosis, the cells are polyclonal for their antigen receptors. using this knowledge, investigators have used pcr technology to amplify the variable regions of the t-cell and immunoglobulin receptor genes to detect the presence of clonal lymphocyte populations in dogs (see figure - of chapter ). these techniques are reviewed in chapter and elsewhere. in physician-based medicine, such assays of clonality are approximately % to % sensitive and have a false-positive rate of approximately %, and recent studies report similar rates in dogs. false-negative and false-positive results can occur with clonality assays. for example, cells from a dog with lymphoma may be negative for clonality if the clonal segment of dna is not detected with the primers used, if the malignant cells are natural killer (nk) cells (rare), or if the malignant cells are present in too low a frequency to be detected. false positives occur rarely in some infectious diseases (e.g., ehrlichiosis and lyme disease). in these cases, a diagnosis should be made only after considering the results of all the diagnostic tests, including histologic/cytologic evaluation, immunophenotyping, and clonality studies in conjunction with signalment and physical examination findings. these molecular techniques, although helpful for diagnosis, could also have utility in detecting early recurrence and in determining more accurate clinical stage and so-called "molecular remission rates" because they are more sensitive than standard cytologic assessment of peripheral blood, bone marrow, or lymph nodes (covered subsequently in section on treatment response). proteomics comprises, simplistically, methodologies that analyze the entire protein component or protein signature of cells (the proteome). protein components of a cell (normal or malignant) change over time with upregulation and downregulation of gene expression in response to varied stimuli (e.g., growth factors, environmental cues). it may therefore be possible to use the field of proteomics to identify serum biomarkers of malignancy (i.e., cancer-specific protein markers) and to further analyze response to therapy or even to predict which therapies are appropriate for an individual patient's tumor. although in its infancy in veterinary oncology, preliminary investigations of the proteome of dogs with lymphoma have been reported - ; however, they have yet to reach the level of sophistication in which useful output would have an impact on clinical decision making. after a diagnosis has been established, the extent of disease should be determined and categorized by the clinical stage of disease. the who staging system routinely used to stage dogs with lymphoma is presented in box - . most dogs (> %) are presented in advanced stages (iii to iv). diagnostic imaging and assessment of bone marrow involvement may be indicated for staging. the degree to which thorough staging is implemented depends on whether the result will alter the treatment plan, whether relevant prognostic information is gleamed, and whether the clients need to know the stage prior to initiating (or declining) a treatment plan. additionally, when comparing different treatment protocols with respect to efficacy, consistent and similar staging diagnostics should be used to avoid so-called "stage migration, " which results when one staging methodology is more accurate than another. the impact of stage migration on prognosis should be considered when comparing different published outcomes. radiographs as there is no prognostic difference between dogs with stage iii and iv disease (i.e., liver/spleen involvement), whereas the presence of cranial mediastinal lymphadenopathy is of prognostic significance (see prognosis section). however, if there are clinical signs attributable to abdominal disease or if complete staging is necessary (e.g., for clinical trial inclusion), further imaging of the abdomen is warranted. abdominal ultrasonography can be important for obtaining ultrasound-guided intraabdominal samples for diagnosis. it may also be useful for the diagnosis of gi, abdominal nodal, and hepatosplenic lymphoma. ultrasonographic (including doppler ultrasound) assessment of peripheral lymph nodes has also been explored ; however, its clinical applicability is questionable because cytologic assessment of peripheral nodes is easy, inexpensive, and of higher diagnostic utility. advanced imaging modalities, including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), or pet/ct imaging, are becoming more commonplace in veterinary practice and their utility is only now being determined. - pet/ct imaging is the current standard of care for following and indeed predicting durability of treatment response in human patients with lymphoma, and both [ f]fluorothymidine ( flt) pet/ct and [ f]fluoro-d-glucose ( fdg) pet imaging have been reported in dogs with lymphoma. - flt-pet/ct functional and anatomic imaging shows promise for the evaluation of response to cytotoxic chemotherapy in dogs with lymphoma and for predicting relapse before standard clinical and clinicopathologic confirmation (figure - ) . the therapeutic approach to a particular patient with lymphoma is determined by the stage and substage of disease, the presence or absence of paraneoplastic disease, the overall physiologic status of the patient, financial and time commitment of the clients, and their level of comfort with respect to likelihood of treatment-related success and/or side effects. without treatment, most dogs with lymphoma will die of their disease in to weeks after diagnosis, although significant variability exists. with few exceptions, canine lymphoma is considered a systemic disease and therefore requires systemic therapy in order to achieve remission and prolong survival. the majority of canine multicentric lymphomas are intermediate to high grade, and, currently, histopathologic and immunophenotypic characterization has not played a significant role in determining the initial treatment protocol. it is hoped that in the near future, sufficient data will emerge to better tailor treatment protocols chosen for dogs with lymphoma based on these and other yet to be characterized parameters. that being said, systemic multiagent chemotherapy continues to be the therapy of choice for canine lymphoma. in general, combination chemotherapy protocols are superior in efficacy to single-agent protocols. single-agent protocols result in lower response rates that are not as durable as combination chemotherapy, which is summarized in table - in chapter . in rare cases in which lymphoma is limited to one site (especially an extranodal site), the animal can be treated with a local modality such as surgery or radiation therapy (rt) as long as the client and clinician are committed to diligent reevaluation to document subsequent progression to systemic involvement, should it occur. many chemotherapeutic protocols for dogs with lymphoma have been developed over the past to years (table - ) . , significant limitations arise when comparing efficacy studies in the that is, clinical trials are inherently costly, and because most of the known effective drugs are unregistered off-label human generic (i.e., off patent) drugs, the incentive for pharmaceutical-funded, sufficiently powered, randomized field trials is low, resulting in a general lack of comparative data. despite the plethora of available combination protocols, most are modifications of chop protocols initially designed for human oncologic use, and currently randomized prospective evidence does not exist to clearly recommend one over the other as long as the basic "chop" components are present. chop represents combinations of cyclophosphamide (c), doxorubicin (h, hydroxydaunorubicin), vincristine (o, oncovin), and prednisone (p). conventional chop-based chemotherapy induces remission in approximately % to % of dogs, with overall median survival times (msts) of to months. approximately % to % of treated dogs will be alive years after initiation of these protocols (figure - ). veterinary literature for the various published protocols. few of these studies include sufficient numbers for adequate statistical power and even fewer compare treatment protocols in a randomized prospective fashion. in addition, staging, inclusion, and response criteria vary considerably between reports. therefore evaluations of efficacy among various protocols are subject to substantial bias, making direct comparisons difficult and indeed precarious. a recurring theme in the concluding statement in most of these published protocols is some variation of "prospective randomized trials will be required to confirm these suggestive findings. " in an attempt to better standardize response criteria and outcome reporting of future trials, the veterinary cooperative oncology group (vcog) has recently published response evaluation criteria (v . ) (see subsequent response evaluation section). the greatest obstacle to the performance of prospective randomized comparative lymphoma trials in veterinary oncology is financial; • ("treatment holidays") are not uncommonly required in individual cases, only a minority of dogs develop significant adverse events requiring hospitalization. , studies assessing client perceptions of medical treatment for cancer in general and lymphoma in particular report a positive experience; most owners feel treatment was worthwhile, that it resulted in improvement in the well-being of their pet, and that quality of life during treatment was good. , very few clients express regret about treating lymphoma using a multidrug protocol. with lymphoma, the fundamental goals of chemotherapy are to induce a complete durable (> months) first remission (termed induction), to reinduce a remission when the tumor recrudesces (or the patient relapses) following achievement of a remission (termed reinduction), and, finally, to induce remissions when the cancer fails to respond to induction or reinduction using drugs not present in the initial protocols (termed rescue). an unanswered question in the treatment of lymphoma has been whether long-term maintenance chemotherapy is useful following an initial course of aggressive induction chemotherapy lasting months or less. long-term maintenance chemotherapy has not been shown to be of significant value in humans with most forms of nhl; however, in humans, the initial induction course of chemotherapy is much more aggressive than that used in veterinary patients. although no randomized prospective studies have been performed to address the therapeutic benefit of long-term maintenance chemotherapy in dogs, most comparisons of dogs treated with chop-based protocols do not show any clear advantage for a maintenance or consolidation phase after induction therapy.* indeed, in most reports, dogs receiving shorter, less costly protocols that do not include a prolonged maintenance phase have comparable remission and progression-free survival (pfs) durations and appear to more readily achieve second remissions when they relapse following completion of chemotherapy than their counterparts receiving long-term maintenance. these data, taken together, suggest that maintenance therapy is not beneficial for most dogs with lymphoma. until well-designed randomized prospective trials indicate otherwise, the author (dmv) prefers protocols that utilize an aggressive induction without maintenance. the most effective, currently available chemotherapeutic agents for canine lymphoma include doxorubicin, l-asparaginase, vincristine, cyclophosphamide, and prednisone-most of which are represented to one degree or another in most first-line multiagent chemotherapy protocols. other drugs that have documented activity are often considered second-line agents and include lomustine, vinblastine, actinomycin-d, mitoxantrone, mustargen, chlorambucil, methotrexate, dacarbazine (dtic), -aminocamptothecin, ifosfamide, cytosine arabinoside, and gemcitabine. of these, cytosine arabinoside, ifosfamide, and gemcitabine appear to have only minimal activity. with the exception of doxorubicin, induction therapy with single-agent chemotherapy does not typically result in durable remission durations when compared with standard combination protocols (see table - , chapter ). incorporation of other standard cytotoxic drugs with single-agent activity into standard chop-based protocols has not resulted in significant gains, and most are reserved for subsequent rescue settings. response rates and duration of response vary according to the presence or absence of prognostic factors discussed subsequently in the section on prognosis in this chapter. the relative cost of the various protocols to the client depends on the drug(s) selected, the size of the animal, the frequency of administration, and the laboratory tests required to monitor adverse events and response. dogs responding to chemotherapy and undergoing complete remission are usually free of clinical signs associated with lymphoma and subsequently return to a very good quality of life. treating dogs with lymphoma is initially gratifying because a high percentage enjoy a complete response. most dogs tolerate chemotherapy well, and although dose reductions and treatment breaks initiation or at varying times throughout the protocol, several studies suggest this does not result in clinically relevant increases in remission rate, speed of attaining remission, or first-remission duration, and therefore the author reserves its use for rescue situations. , , , if client or other considerations preclude a chop-based protocol, single-agent doxorubicin ( mg/m , intravenous [iv], every weeks for total treatments) is offered along with a -week tapering oral prednisone regimen (same prednisone regimen in box - ) as a less aggressive and less costly approach. the expected cr rate will range from % to %, with an anticipated median survival of to months. , , , the addition of oral cyclophosphamide ( mg/m daily for days starting on the same day as doxorubicin) to single-agent doxorubicin resulted in a numerically but not statistically superior outcome in a recent randomized trial comparing doxorubicin/prednisone with doxorubicin/cyclophosphamide/ prednisone (pfs of . months versus . months, respectively). this trial was only powered to detect a threefold difference in pfs; therefore larger trials should be undertaken to confirm any benefit. if clients are reticent to include iv medications, the author often recommends a protocol of oral lomustine (ccnu; mg/m by mouth [po] every weeks for treatments) and prednisone. this protocol has been associated with short median remissions ( days) in only one small case series ; however, in the author's experience, a subset of dogs have remained in remission for several months on this protocol when clients decline iv medication. if financial or other client concerns preclude the use of systemic chemotherapy, prednisone alone ( mg/kg po, daily) will often result in short-lived remissions of approximately to months. in these cases, it is important to educate clients that, should they decide to pursue more aggressive therapy at a later date, dogs receiving single-agent prednisone therapy are more likely to develop multidrug resistance (mdr) and experience shorter remission and survival durations with subsequent combination protocols. [ ] [ ] [ ] this is especially true following long-term prednisone use or in dogs that have experienced a recurrence while receiving prednisone. therefore the earlier that clients opt for more aggressive therapy, the more likely a durable response will result. a cbc should be performed prior to each chemotherapy treatment. a minimum of neutrophils/µl (some oncologists use a cut-off of neutrophils/µl) and , platelets/µl should be present prior to the administration of myelosuppressive chemotherapy. if the neutrophil count is lower than /µl, it is best to wait to days and repeat the cbc; if the neutrophil count has increased to more than cells/µl, the drug can be safely administered. a caveat to these restrictions is that for dogs presented prior to initiation of chemotherapy with low neutrophil and platelet counts due to bone marrow effacement, myelosuppressive chemotherapy is instituted in the face of cytopenias in order to clear the bone marrow of neoplastic cells and allow hematopoiesis to normalize. in those breeds likely to have mdr gene mutations (e.g., collies; see chapter ) and therefore to be at risk for serious chemotherapeutic toxicity, the author will initiate a chop protocol out of sequence, beginning with non-mdr -associated drugs, such as cyclophosphamide. this ensures treatment of the lymphoma while allowing sufficient time for analysis of mdr gene mutations prior to initiating mdr substrate drugs. no specific protocols have been scrutinized for treating dogs that are doublemutant for mdr ; however, if using mdr substrate drugs, the author initiates at a % dose reduction. subsequent dose modifications (increased or decreased dosage) can be implemented, several factors should be considered and discussed with caregivers on a case-by-case basis when choosing the protocol to be used. these factors include cost, time commitment involved, efficacy, adverse event profiles, and experience of the clinician with the protocols under consideration. it is now clearly established that "standard of care" combination protocols used in dogs with lymphoma are essentially variations of "chop" protocols (see table - ). specific details regarding dose and timing of the chop protocol currently preferred by the author (dmv) are outlined in box - . this protocol does not have a maintenance therapy arm, and all treatments cease at weeks, provided the animal is in complete remission. although several other chop-based protocols include l-asparaginase either at † in dogs < kg in body weight, a doxorubicin dose of mg/kg is substituted for mg/m . molecular and biologic markers of minimal disease. advanced functional and anatomic imaging (i.e., pet/ct) are the current standard for assessing treatment response and early relapse of lymphoma in humans and have also been investigated in dogs (see . [ ] [ ] [ ] as this technology becomes available to a broader veterinary population, its clinical application will surely increase. molecular detection of mrd applies clonality and pcr techniques previously discussed in this chapter. beyond diagnostic applications, these techniques have been applied to determine cytoreductive efficacy of various chemotherapeutic drugs and to document and predict early relapse in patients prior to more conventional methods. - regarding biomarkers of mrd, preliminary investigations have suggested serum lactate dehydrogenase activity, thymidine kinase activity, and serum c-reactive protein may be candidates in the dog. as we become more proficient at defining mrd, the pressing clinical question becomes how we use this information. theoretically, such information could suggest when more aggressive therapy or alternative therapy should be instituted in patients who have not achieved a "molecular remission" or who are undergoing early relapse; however, until we determine what these interventions should be, their clinical utility remains theoretical. eventually, the majority of dogs that achieve a remission will relapse or experience recrudescence of lymphoma. this usually represents the emergence of tumor clones or tumor stem cells (see chapter ) that are inherently more resistant to chemotherapy than the original tumor, the so-called mdr clones that either were initially drug resistant or became so following exposure to selected chemotherapy agents. evidence suggests that in dogs with recurrent lymphoma, tumor cells are more likely to express the mdr gene that encodes the protein transmembrane drug pump often associated with mdr. a, b, mdr represents only one of the plethora of mechanisms that lead to drug-resistant disease (see chapter ) . other causes for relapse following chemotherapy include inadequate dosing and frequency of administration of chemotherapy, failure to achieve high concentrations of chemotherapeutic drugs in certain sites such as the cns, and initial treatment with prednisone alone. at the first recurrence of lymphoma, it is recommended that reinduction be attempted first by reintroducing the induction protocol that was initially successful, provided the recurrence occurred temporally far enough from the conclusion of the initial protocol (e.g., ≥ months) to make reinduction likely. attention must be given to the cumulative dose of doxorubicin that will result from reinduction, and baseline cardiac assessment, the use of cardioprotectants, alternative drug choices, and client education should all be considered. in general, the length of the reinduction will be half that encountered in the initial therapy; however, a subset of animals will enjoy long-term reinductions, especially if the dog completed the initial induction treatment protocol and was currently not receiving chemotherapy for several months when relapse occurred. nearly % to % reinduction rates can be expected in dogs that have completed chop-based protocols and then relapse while not receiving therapy. , the duration of a second chop-based remission in one report was predicted by the duration of the interval between protocols and the duration of the first remission. if reinduction fails or the dog does not respond to the initial induction, the use of so-called "rescue" agents or "rescue" protocols may be attempted. these are single drugs or drug combinations that are typically not found in standard chop protocols and are depending on adverse event levels observed, particularly neutrophil counts at nadir. with some exceptions, multicentric t-cell lymphoma, when compared with multicentric b-cell lymphoma, is associated with similar initial response rates, but significantly lower response durability (e.g., pfs) following chemotherapy (including chop-based protocols).* additionally, the effectiveness of a single treatment of doxorubicin in the treatment of naïve dogs with lymphoma in one retrospective case series suggested a lower initial response rate for t-cell, compared with b-cell, immunophenotypes. this has led many to question whether dogs diagnosed with t-cell lymphoma should be treated with standard chop-based protocols or with alternative protocols. this is a valid question; however, the answer remains elusive because adequately powered randomized controlled trials do not currently exist in the literature to show superiority for an alternate protocol in this scenario. a retrospective study of an l-asparaginase and mopp (m, mechlorethamine; o, oncovin; p, procarbazine; p, prednisone) protocol suggested improvement in pfs in dogs with either confirmed t-cell lymphoma or lymphoma with hypercalcemia and no immunophenotypic classification. however, differences in determining pfs, response evaluation, and study population in this retrospective study did not definitively confirm superiority. further, some have advocated early inclusion of lomustine (ccnu) into protocols for treating multicentric t-cell lymphoma based on moderate success of lomustine-based rescue protocols in dogs failing chop. as yet, no randomized trials have documented superiority with this approach. ultimately, superior protocol development for t-cell lymphoma awaits careful, randomized, prospective trial assessment. until such time, the author prefers to initiate chop-based induction and switch to lomustinebased rescue at the first sign of progression. vcog has recently published response evaluation criteria (v . ) to standardize reporting of outcome results and comparisons among protocols for peripheral nodal disease. the most important of these outcome measures and the preferred temporal outcome criterion for assessing protocol activity is now considered to be pfs, which is defined as being from the time of treatment initiation until tumor progression or death from any cause. this brings veterinary outcome reporting more in line with human standards. because the majority of dogs with lymphoma eventually experience recurrence following chemotherapy-induced remissions and because methodology for differentiating complete and partial responses is analysis dependent, pfs removes many sources of bias. further, overall survival in published reports invariably includes patients who go on to receive varied rescue protocols that bias the overall result, making it a less comparable outcome. widespread application of these standardized criteria should allow more suitable comparisons in the future. superior methods of detection of minimal residual disease (mrd) or early recurrence have been investigated in dogs with lymphoma and include advanced imaging and detection of despite the plethora of published chemotherapeutic protocols for dogs with lymphoma, it appears we have achieved as much as we can from currently available chemotherapeutics in standard settings. the -month median survival "wall" and the % to % -year survival rates have not improved dramatically. further advances in remission and survival durations await the development of new methods of delivering or targeting traditional chemotherapeutic drugs, new generations of chemotherapeutic drugs, or novel nonchemotherapeutic treatment modalities. mechanisms of avoiding or abrogating mdr, enhancing tumor apoptosis (programmed cell death), tumor ablation, and immune-system reconstitution, as well as novel immunomodulatory therapies for lymphoma, are all active areas of investigation in both human and veterinary medicine. drug resistance can be inherent in cancer cells or develop following exposure to selected chemotherapeutic agents and often is associated with increased expression of members of the adenosine triphosphate (atp)-binding cassette (abc) transporter superfamily (e.g., p-glycoprotein pump), many of which efflux various withheld for use in the drug-resistant setting. the most common rescue protocols used in dogs include single-agent use or a combination of actinomycin d, mitoxantrone, doxorubicin (if doxorubicin was not part of the original induction protocol), dacarbazine (dtic), temozolomide, lomustine (ccnu), l-asparaginase, mechlorethamine, vincristine, vinblastine, procarbazine, prednisone, and etoposide. some rescue protocols are easy and convenient single-agent treatments, whereas others are more complicated (and expensive) multiagent protocols, such as mopp. overall rescue response rates of % to % are reported; however, responses are usually not durable, with median responses of . to . months being typical, regardless of the complexity of the protocol. a small (< %) subset of animals will enjoy longer rescue durations. table - provides a summary of canine rescue protocols and published results. - current published data from rescue protocols do not include sufficient numbers for adequate statistical power nor do they compare protocols in a randomized prospective fashion. therefore evaluations of efficacy among various protocols are subject to substantial bias, making direct comparisons difficult and indeed precarious. choice of a particular rescue protocol should depend on several factors, including cost, time commitment required, efficacy, toxicity, and experience of the clinician with the protocols in question. as the complexity of rescue protocols does not yet appear to be associated with significant gains in rescue durability, the author tends to choose simpler and less costly protocols (e.g., ccnu/l-asparaginase/prednisone) ( table - ) . however, the use of multiple varied rescue protocols, switching as needed based on response, continues as long as clients are • nr, not reported. *few of these protocols include sufficient numbers for adequate statistical power and fewer compare treatment protocols in a randomized prospective fashion. in addition, staging, inclusion, and response criteria vary considerably between protocols presented. therefore evaluations of efficacy between the various protocols are subject to bias, making direct comparisons difficult and indeed precarious. † various temporal response endpoints were used, including disease-free interval, time to progression, and progression-free survival. ‡ prednisone often used concurrently. performed. , although efficacy was established, enhancement of remission or survival durations over equivalent doses of native doxorubicin was not observed. in the past decade, enhanced durability of first remissions in humans with non-hodgkin's b-cell lymphoma has been achieved primarily through the institution of monoclonal antibody (mab)based therapies (so-called r-chop protocols); the "r" refers to rituximab, a recombinant chimeric murine/human antibody directed against the cd antigen, a hydrophobic transmembrane protein located on normal pre-b and mature b lymphocytes. following binding, rituximab triggers a host cytotoxic immune response against cd -positive cells. unfortunately, rituximab does not have therapeutic activity in dogs due to a lack of external recognition of a similar antigen on canine lymphoma cells and the inherent antigenicity of human-derived antibodies in dogs. , another immunotherapy approach involved mab- , a murinederived anticanine mab (igg a). it mediates antibody-dependent cellular cytotoxicity (addc) and complement-mediated cellular cytotoxicity (cmcc). - it also prevented outgrowth of canine lymphoma xenografts in nude mice. in a noncontrolled clinical study of dogs treated with chop-based chemotherapy and mab- , enhanced overall survival was observed; however, the antibody was removed from the commercial market in the mid- s without definitive randomized trials being performed. several laboratories throughout the world are currently working to characterize and develop effective mab therapies for use in dogs. several antitumor vaccine approaches have been applied in dogs with lymphoma. a tumor vaccine extract using killed lymphoma cells combined with freund's adjuvant was administered to a small number of dogs after remission induction with combination chemotherapy. prolongation of median survival was noted in the treatment group; however, a subsequent study revealed that prolongation was likely due to the freund's adjuvant. an autologous killed lymphoma tumor cell vaccine has been intralymphatically administered to dogs placed in remission using a combination chemotherapy protocol, and, although modest gains were reported in remission times, no survival advantage was found. an exploratory vaccine study targeting telomerase (see chapter , section d) and one using rna-loaded cd -activated b cells in dogs with lymphoma have also been conducted. these studies involved small numbers of nonrandomized patients and lacked controlled populations for comparison. in a randomized study of dogs with lymphoma comparing chop-based chemotherapy with chopbased chemotherapy and a human granulocyte-macrophage colony-stimulating factor (gm-csf) dna cationic-lipid complexed autologous whole tumor cell vaccine, a small measure of immunomodulation was documented by delayed-type hypersensitivity; however, significant improvement in clinical outcome was not noted. although little well-supported activity is reported to date with these immunomodulatory approaches, our basic understanding of methodologies is expanding. most dogs with lymphoma have multicentric disease and therefore require systemic chemotherapy to effectively treat their disease. chemotherapeutic compounds from cells (see chapter ). p-glycoprotein is under the control of the mdr gene. mdr has been reported in canine lymphoma following exposure to chemotherapy. a, , expression levels of mrna encoding the canine mdr gene have been characterized in canine cell lines and lymphomas. although expression of mdr mrna correlated with in vitro drug sensitivity, it did not correlate with in vivo doxorubicin sensitivity in dogs with lymphoma in this study. additionally, quantitative analysis of mrna for different drug-resistance factors was performed in dogs with lymphoma. these dogs were divided into drug "sensitive" and "resistant" categories based on response to a chop-based protocol; however, significant differences in expression were not observed in this small study. methods of increasing the time that tumor cells are exposed to chemotherapeutics should theoretically enhance tumor killing. these methods could include long-term continuous infusions (impractical in many veterinary situations), increasing the frequency of treatments, or enhancing the circulation time of drugs used. in one study, dogs with lymphoma received lower dose doxorubicin weekly rather than a higher dose every weeks (thereby decreasing c max , which is associated with cardiotoxicity) in order to potentially increase the time of drug exposure. no benefit was noted, and, in fact, remission rates were inferior. studies evaluating pegylated long-circulating doxorubicin-containing liposome drug delivery systems in dogs with lymphoma have also been • . increase in alt activity > × upper limit of normal (or × baseline if higher than upper limit of normal at initiation)-institute drug discontinuation and reinstitution/dose reduction depending on normalization of alt. practice. , because of the high cost, limited accessibility to relatively sophisticated equipment, and management requirements, these types of procedures are limited to preliminary investigations at a few centers. currently, long-term results in significant numbers of treated cases have yet to be presented. in general, the veterinary literature suffers from a paucity of information on treating various extranodal forms of lymphoma in dogs, and our ability to predict outcome is thus limited. in general, it is recommended that, following extensive staging, in those cases where disease is shown to be localized to a solitary site, local therapies (e.g., surgery, local rt) can be used. in contrast, if multiple extranodal sites are involved or they are part of a more generalized process, systemic chemotherapy should be chosen. most dogs with alimentary lymphoma are presented with diffuse involvement of the intestinal tract, and involvement of local lymph nodes and liver is common. chemotherapy in dogs with diffuse disease has been reported to be unrewarding for the most part , , ; however, more aggressive chop-based protocols used extensively for multicentric lymphoma in dogs have resulted in durable remissions in a small subset of cases. solitary alimentary lymphoma is rare in the dog; however, if the tumor is localized and can be surgically removed, results (with or without follow-up chemotherapy) can be encouraging. cns lymphoma in dogs usually results from extension of multicentric lymphoma. however, primary cns lymphoma (pcnsl) has been reported. [ ] [ ] [ ] if tumors are localized, local rt should be considered. few studies have reported the use of chemotherapy. in one study, cytosine arabinoside (ara-c) at a dosage of mg/m was given intrathecally; this treatment was combined with systemic chemotherapy and cns radiation. overall, the response rates are low and of short duration (several weeks to months). treatment of cutaneous lymphoma depends on the extent of disease. solitary lesions may be treated with surgical excision or rt. fractionated rt (to a total dose of to gy) has been associated with long-term control. diffuse cutaneous lymphoma is best managed with combination chemotherapy, although the rate and durability of response is generally less than in multicentric lymphoma. the most widely used protocols for epitheliotropic cutaneous t-cell lymphoma include ccnu ( to mg/m po, every weeks) along with prednisone. , although response rates approach %, median remission is approximately months; occasionally, durable remissions are encountered. the author has added l-asparaginase to this protocol (see table - ), and although anecdotally it appears to improve response, comparative data are not available. sporadic reports of other therapies for cutaneous lymphoma in small numbers of cases include the use of coap (cyclophosphamide, vincristine [oncovin], ara-c, and prednisone), retinoic acid analogs (e.g., accutane, etretinate), l-asparaginase and pegylated l-asparaginase, topical mechlorethamine (mustargen), and recombinant human α-interferon. all of these reports involved small numbers of cases and resulted in limited response rates with short durations. a form of cutaneous lymphocytic infiltration has recently been characterized as an indolent t-cell lymphoma based on clonality. however, surgery has been used to treat solitary lymphoma (early stage i) or solitary extranodal disease. careful staging is necessary in such cases to rule out multicentric involvement prior to treating local disease. the benefit of surgical removal of the spleen in dogs with massive splenomegaly remains unclear. , , in an older report, dogs with lymphoma underwent splenectomy to remove a massively enlarged spleen and were subsequently treated with chemotherapy. within weeks of splenectomy, of the dogs died of disseminated intravascular coagulation (dic) and sepsis. the remaining dogs ( %) had a cr, and dogs had a mst of months. no staging or histologic information was provided, so the information appears of limited usefulness, although those with follow-up lived approximately year. in two reports of indolent nodular lymphoma of the spleen (marginal zone lymphoma [mzl] and mantle cell lymphoma [mcl]), outcome was available on seven mzl cases, including three cases that did not receive adjuvant chemotherapy after surgery, , and only one died of lymphoma following splenectomy. in a recent report of indolent lymphomas, four splenic lymphomas (three mzl and one mcl) underwent splenectomy alone and all survived greater than year with none dying of their primary disease. splenectomy should be considered if the lymphoma is not documented in other sites following thorough staging, if lymphoma is an indolent form histologically, or if splenic rupture has occurred. of note, no control population consisting of dogs that did not undergo splenectomy exists, so the natural history of indolent splenic lymphoma remains uncertain. radiation therapy, although its use is limited in the treatment of lymphoma, may be indicated in selected cases. indications are as follows: . curative intent therapy for stage i lymph node and solitary extranodal disease (i.e., nasal, cutaneous, spinal lymphoma). . palliation for local disease (e.g., mandibular lymphadenopathy, rectal lymphoma, mediastinal lymphoma where precaval syndrome is present, localized bone involvement). . total body radiation combined with bone marrow or stem cell transplantation. . whole or staged half-body rt following chemotherapyinduced remissions. in the latter case, staged half-body irradiation sandwiched between chemotherapy cycles or following the attainment of remission by induction chemotherapy has been preliminarily investigated as a form of consolidation or maintenance. , - radiation therapy was delivered to either the cranial or the caudal half of the dog's body in to gy fractions, and following a -or -week rest the other half of the body was irradiated in a similar fashion. although these preliminary investigations were not randomized, they suggest that rt applied when dogs are in either complete or partial remission is safe and warrants further investigation to determine if a significant therapeutic gain can be realized. a pilot study of low-dose ( gy) single-fraction total body irradiation in seven dogs with relapsed drug-resistant lymphoma, although safely applied, resulted in only partial nondurable ( to week) remissions. total body irradiation (and/or ablative chemotherapy) for complete or partial bone marrow ablation followed by reconstitution with bone marrow or stem-cell transplant in dogs, although a recognized model in comparative research settings, , is still in its early phases of development and application in clinical veterinary it is associated with slow progression and long-term survival following corticosteroid management; however, it does have the potential to progress to high-grade lymphoma. the prognosis for dogs with lymphoma is highly variable and depends on a wide variety of factors documented or presumed to affect response to therapy. although rarely curable (< % of cases), crs and a good quality of life during extended remissions and survival are typical. factors that have been shown to influence treatment response and survival are summarized in tables - * and - . † the two prognostic factors most consistently identified are immunophenotype and who substage (see figure - ). many reports have confirmed that dogs with cd -immunoreactive tumors (i.e., t-cell derivation) are associated with significantly shorter remission and survival durations. ‡ this holds true primarily for dogs with multicentric lymphoma because the immunophenotype of solitary or extranodal forms of lymphoma has not been thoroughly investigated with respect to prognosis. additionally, it has been shown that dogs with b-cell lymphomas that express lower than normal levels of b antigen (expressed in % of nonneoplastic lymphocytes) also experience shorter remission and survival durations. recently, low levels of class ii mhc expression on b-cell lymphoma predicted poor outcomes. dogs presented with who substage b disease (i.e., clinically ill) also do poorly when compared with dogs with substage a disease. , , , , dogs with stage i and ii disease have a better prognosis than those dogs in more advanced stages (stage iii, iv, and v). histologic grade (subtype) has been found to influence prognosis in some studies; however, our ability to predict outcome based on subtype is still quite limited. dogs with lymphoma classified as intermediate or high grade (large cell, centroblastic, and immunoblastic) tend to respond to chemotherapy but can relapse early. dogs with low-grade lymphomas (small lymphocytic or centrocytic) have a poorer response rate to chemotherapy, yet have a survival advantage over dogs with intermediate-and high-grade lymphomas ( figure - ) in that the disease may be more indolent. several case compilations have documented that dogs with indolent lymphoma (e.g., mzl, mcl, t-zone) experience prolonged survivals, often in the absence of any or aggressive chemotherapy. [ ] [ ] [ ] proliferative assays such as analysis of bromodeoxyuridine (brdu) uptake, ki antibody reactivity, and argyrophilic nucleolar organizer region (agnor) indices to measure proliferative activity of tumor cells have been shown to provide prognostic information in dogs treated with combination chemotherapy. results of different studies are contradictory, however. in two trials, dogs having tumors with short doubling times, high agnor frequencies, or high ki immunoreactivity had a better prognosis than those with tumors with long doubling times or low agnor frequencies. , in other trials, the low-proliferating tumor groups were associated with a better prognosis. , additionally, in one trial, the proportion of tumor cells undergoing apoptosis was modestly predictive of remission duration. the anatomic site of disease is also of considerable prognostic importance. primary diffuse cutaneous, diffuse gi, hepatosplenic, and primary cns lymphomas tend to be associated with a poor ‡ rights were not granted to include this figure in electronic media. please refer to the printed publication. prognosis. dogs with indolent cutaneous t-cell lymphocytic infiltration experience long-term survivals. sex has been shown to influence prognosis in some studies. , neutered females tend to have a better prognosis; male dogs may have a higher incidence of the t-cell phenotype, which may account for the poorer prognosis. reported biomarkers of prognosis, summarized in table - , include circulating levels of glutathione-s-transferase, thymidine kinase, lactate dehydrogenase, serum c-reactive proteins, and vegf. finally, one report suggests that a history of chronic inflammatory disease of several types predicts likelihood of early relapse. these putative prognostic indicators require further confirmation in larger trials. lymphocytic leukemia is typically defined as proliferation of neoplastic lymphocytes in bone marrow. neoplastic cells usually originate in the bone marrow, but occasionally in the spleen, and may or may not be circulating in the peripheral blood. although our ability to diagnose lymphocytic leukemias using flow cytometric and molecular diagnostic techniques has increased significantly in the past decade, little information on treatment and prognosis is available except for chronic lymphocytic leukemia (cll). differentiating between true leukemia and stage v lymphoma can be difficult and arbitrary and is often based on lack of significant lymphadenopathy, degree of blood and bone marrow involvement, and immunophenotypic characteristics. lymphocytic leukemia is more common than acute myeloid leukemia and myeloproliferative disorders (mpd), but the true incidence is unknown. german shepherd dogs and golden retrievers may be overrepresented. , lymphocytic leukemia can occur in dogs of any age but typically occurs in middle-aged to older dogs (mean of to years); cll usually occurs in older dogs (mean of years). , , , a significant sex predilection is not reported. as with lymphoma, the etiology of lymphocytic leukemia is for the • acute (large cells with an immature cytologic phenotype). immunophenotypic assessment using flow cytometric and molecular assays can further characterize these two major subtypes; however, some discordance exists in the veterinary literature. three primary subtypes of cll are reported in dogs, based primarily on immunophenotyping , , : ( ) t-cll, which is the most common form, with cells in the majority of cases being cd + granular lymphocytes; ( ) b-cll, which is the next most common subtype; and ( ) atypical cll, which represents a combination of immunophenotypes (cd − , cd + ; cd + , cd − , cd − ; cd + , cd + , cd + ; and cd + + cd + *). this is in contrast to cll in humans, which is primarily a disease of b-cells. in cll, lymphocytes often are indistinguishable morphologically from normal small lymphocytes ( figure most part unknown. genetic factors likely play a role and have been compared between dogs and humans. retroviruses have been implicated in diverse animal species such as cats, cattle, fish, snakes, birds, rodents, nonhuman primates, and humans; however, there is no proven evidence implicating a retroviral cause in dogs. in humans, acute lymphocytic leukemia (all) has been associated with genetic factors and exposure to radiation, benzene, phenylbutazone, and antineoplastic agents. extrapolation of predisposing factors across species is not warranted; in fact, etiologic factors in dogs may be quite different from those for humans given the difference in the predominant immunophenotype of the neoplastic cells (see later). lymphocytic leukemias can be subdivided based on cell size, maturity, genetic aberrations, microrna expression, and immunophenotype.* the simplest classification divides leukemia into two groups: chronic (small cells with a mature cytologic phenotype) and *note that either cd or cd can be used for assessing b-cell lineage in this context. *references , , , , - . chromatin from disintegrated cells also is visible. (wright's stain, × objective.) b, peripheral blood from a dog with chronic lymphocytic leukemia (cll). note the small lymphocytes of normal morphology (smaller than the neutrophil). (wright's stain, × objective.) constitute the remaining fraction. in the t-cell fraction, helper t-cells (cd + ) outnumber cytotoxic t-cells (cd + ). lymphocytic leukemia should be a consideration if atypical lymphocytes are in circulation, the immunophenotype of the lymphocytes in circulation is homogenous as determined by flow cytometric analysis, a phenotype typically present in low frequency has increased, or if clonality is documented (e.g., by parr analysis). other differential diagnoses for lymphocytosis include infectious diseases, such as chronic ehrlichiosis, postvaccinal responses in young dogs, il- administration, and transient physiologic or epinephrine-induced lymphocytosis. in some cases, reactive and neoplastic lymphocytosis are difficult to distinguish. expansion of neoplastic lymphocytes in bone marrow is the hallmark of all and, in most cases, cll. careful examination of peripheral blood and bone marrow by an experienced cytopathologist is important in establishing a diagnosis of lymphoid leukemia; in cases of marked lymphocytosis with atypia, peripheral blood can be used for analysis of immunophenotype and clonality, and examination of bone marrow is not essential. if diagnostic bone marrow cannot be adequately obtained by aspiration, bone marrow core biopsy should be performed. in all, lymphoblasts predominate in the bone marrow and are also present in peripheral blood, and other lineages are decreased. in b-and t-cell cll, the lymphocytes are small mature cells that occur in excessive numbers in bone marrow (≥ % of all nucleated cells) early in the disease. in t-cll, lymphocytes may contain pink granules. infiltration becomes more extensive as the disease slowly progresses, and eventually the neoplastic cells replace normal marrow. a separate clinical staging system has not been developed for lymphoid leukemia. currently, all dogs with leukemia are classified as stage v based on the who staging system for lymphoma as presented in table - . because of the indolent and often asymptomatic nature of cll, the decision to treat is often based on the clinical and laboratory findings in the individual dog. most oncologists recommend active surveillance (monthly or bimonthly physical examination and cbc) over active therapy for patients when cll is identified incidentally, there are no accompanying clinical signs, and other significant hematologic abnormalities are not identified. if the animal is significantly anemic or thrombocytopenic, is showing evidence of significant lymphadenopathy or hepatosplenomegaly, or has an excessively high lymphocyte count (e.g., > , /µl), therapy should be instituted. the definition of "excessively high" varies among oncologists, and a standard has not been established in veterinary medicine. the author (dmv) prefers to base treatment decisions on the presence of significant constitutional signs and peripheral cytopenias. currently, the most effective drug available for treatment of cll is chlorambucil. chlorambucil is given orally at a dose of . mg/kg or mg/m po once daily for to days; the dose can then be reduced to . mg/kg or mg/m po daily. for long-term maintenance, a dose of . mg/m every other day can be used. the dose is adjusted based on clinical response and bone marrow tolerance. oral prednisone is used concurrently with chlorambucil at doses of mg/kg daily for to weeks, then . mg/kg every other day thereafter. the addition of vincristine or the substitution of cyclophosphamide for chlorambucil has been advocated in animals that do not respond to chlorambucil. origin (cd + ,cd − , cd − , cd − ). in general, these cells tend to be intermediate-sized or large cells with moderate amounts of basophilic cytoplasm. perhaps the most distinguishing feature of lymphoblasts is the nuclear chromatin pattern, which typically is more condensed than the chromatin in myeloblasts. lymphoblasts are larger than neutrophils, have a high nuclear : cytoplasmic ratio, and contain blue cytoplasm that in some cases is intensely basophilic (see figure - ). nucleoli, although present, are less prominent in lymphoblasts than in myeloblasts. nevertheless, these cells cannot be distinguished easily from blast cells of other hematopoietic lineages, and identification of lineage-specific markers by immunocytochemical or flow cytometric analysis is required to ascertain the lineage. if the cells express cd , a stem cell marker, an acute phenotype is implied , ; however, both myeloid and lymphoid lineages express cd , and our ability to differentiate all from acute myeloid leukemia (aml) relies on detection of other markers, including t-and b-cell markers and myeloperoxidase, a myeloid marker. dogs with cll are often asymptomatic, but some owners report lethargy and decreased appetite. mild lymphadenopathy and splenomegaly may be present, although late in the disease splenomegaly may be marked. the white blood cell (wbc) count is usually greater than , cells/µl but can vary from normal to greater than , cells/µl because of an increase in circulating mature lymphocytes. lymphocytosis is persistent and granulocytes are usually present in normal numbers. other than lymphocytosis, hemograms of dogs with cll tend to have few abnormalities when lymphocytes are less than , /µl. , , in some dogs, the disease is identified incidentally when the animal is undergoing evaluation for an unrelated problem. mild anemia, neutropenia, and thrombocytopenia are common but may become marked as the disease progresses and lymphocyte counts increase above , /µl. despite the well-differentiated appearance of the lymphocytes in cll, these cells may function abnormally. paraneoplastic syndromes include monoclonal gammopathies, immunemediated hemolytic anemia, pure red cell aplasia, and, rarely, hypercalcemia. , in one report of dogs with cll, % had monoclonal gammopathies (usually igm or iga). the immunophenotypes were not reported, but a monoclonal gammopathy would be more likely to occur in b-cll. dogs with all usually are presented with clinical signs of anorexia, weight loss, and lethargy. splenomegaly is typical and other physical abnormalities may include hemorrhage, lymphadenopathy, and hepatomegaly. infiltration of bone marrow by neoplastic lymphoblasts may be extensive, resulting in significant depression of normal hematopoietic elements or myelophthisis. , , , , anemia, neutropenia, and thrombocytopenia are typically much more severe than with cll and may become life threatening. infiltration of extramedullary sites such as the cns, bone, and gi tract may also occur and can result in neuropathies, bone pain, and gi signs, respectively. consideration of signalment, history, physical findings, and morphologic appearance and immunophenotype of cells is essential in making an accurate diagnosis. it is helpful to know the profile of lymphocyte subsets in the peripheral blood of normal dogs to determine if a particular subset has expanded. approximately % of circulating lymphocytes in normal dogs are t-cells, and about % are b-cells. nk cells and double-negative (cd − , cd − ) t-cells animal, nat cancer inst treatment of cll is primarily palliative with rare complete remissions. owing to the indolent nature of this disease, however, survival times have been in the range of to years with a good quality of life. , the phenotypic expression of cll is usually stable over months to years. however, the disease may evolve into an acute phase, and some dogs will develop a form of lymphoma that is rapidly progressive and characterized by the presence of pleomorphic immunoblasts; in humans, this is termed richter's syndrome. the prognosis for response to treatment is poor for this form of lymphoma. much of the morbidity in dogs with all results from effacement of bone marrow (myelophthisis) and subsequent life-threatening peripheral cytopenias. neutropenia, thrombocytopenia, and anemia may be severe. patients often require supportive therapy, such as fresh whole-blood transfusions, broad-spectrum antibiotics, fluid therapy, and nutritional support. careful monitoring for sepsis, hemorrhage, and dic is important. specific treatment of all requires aggressive chemotherapy. consistently efficacious protocols for all have not been developed in veterinary medicine, and there are few published reports. chop-based protocols, similar to those used for lymphoma (see table - ), have been used by the author (dmv) for dogs with all; however, responses and durability of response are generally disappointing. the standard of care in humans with acute leukemia generally involves bone marrow ablative treatments with stem cell or marrow replacement, a protocol not generally available in veterinary oncology. in general, cll is a slowly progressive disease, and some animals will not require therapy for some time after diagnosis; one dog was reported to survive almost years without treatment. for those dogs that are treated, normalization of lymphocyte counts can be expected in % of cases. in one report of dogs treated with vincristine, chlorambucil, and prednisone, mst was approximately months with an expected % survival at years. in larger compilations of cases that include immunophenotypic analysis, treatment protocols were poorly documented, although most received chlorambucil and prednisone; in dogs with follow-up, for dogs with t-cll, b-cll, and atypical cll, median survival was , , and only days, respectively. in this group of dogs, young age and anemia were also associated with a poor prognosis. in another series with limited treatment information, dogs with cll of a cd + immunophenotype that presented with less than , lymphocytes/µl or greater than , lymphocytes/µl had median survivals of and days, respectively. prognosis for dogs with all is generally very poor. in a study of dogs treated with vincristine and prednisone, the dogs achieving complete or partial remission ( %) had a mst of days, and few dogs survived longer than months with that protocol. in one report of cases of all with a cd + phenotype, dogs had a median survival of days (ranged from to days), even though the majority received a chop-based treatment protocol. additionally, dogs with b-cell all (cd + ) in which the lymphocytes were large cells (forward scatter lymphocyte/forward scatter neutrophil ratio of > . the lymphomas (malignant lymphoma or lymphosarcoma) are a diverse group of neoplasms that have in common their origin from lymphoreticular cells. they usually arise in lymphoid tissues such as lymph nodes, spleen, and bone marrow; however, they may arise in almost any tissue in the body. lymphoma is one of the most common neoplasms seen in the cat. epidemiologic reports prior to suggested that lymphoma accounted for % to % of all hematopoietic tumors in the cat, , and since hematopoietic tumors (lymphoid and myeloid) represent approximately one-third of all feline tumors, it was estimated lymphoid neoplasia accounted for an incidence of per , cats at risk. in one series of cats with hematopoietic tumors, % had lymphoma and % had leukemias and mpds, of which % were categorized as undifferentiated leukemias, most likely myeloid in origin. mediastinal form that is not felv associated and represents a younger population (median of years). felv was the most common cause of hematopoietic tumors in the cat in the so-called "felv era" of the s through the s when approximately two-thirds of lymphoma cases were associated with felv antigenemia. several studies have documented the potential molecular means by which felv can result in lymphoid neoplasia (see chapter , section c). as one would predict, along with a shift away from felv-associated tumors came a shift away from traditional signalment and relative frequency of anatomic sites. this is also supported outside of north america by similar signalment and anatomic frequency data observed in australia where felv infection is quite rare. , the median age of approximately years now reported in north america is considerably higher than the median ages of to years reported in the felv era. , , - the median age of cats within various anatomic tumor groupings has not changed, and anatomic forms traditionally associated with felv such as the mediastinal form still occur in younger, felv antigenemic cats. similarly, the alimentary form occurs most often in older, felvnegative cats. table - presents an overview of the characteristics, including felv antigenemic status, of the various anatomic sites of lymphoma in cats. as our ability to interrogate felv associations on a molecular basis has improved (e.g., pcr amplification and fluorescent in-situ hybridization), several reports exist defining the role or potential role of felv in cats with and without felv antigenemia. [ ] [ ] [ ] [ ] [ ] [ ] collectively, these studies indicate felv proviral insertion exists in a significant proportion of feline lymphoma tissues and is more common in those of t-cell origin, particularly the thymic and peripheral lymph node anatomic forms. they also suggest that several common felv integration sites exist. there is also evidence that feline immunodeficiency virus (fiv) infection can increase the incidence of lymphoma in cats. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in contrast to the direct role of felv in tumorigenesis, most evidence available felv vaccines appearing in the late s (see the later section on viral etiology). the decline in felv-associated lymphoma was mirrored by a decline in the overall prevalence per year of felv positivity in cats tested as characterized by reports, including the tufts veterinary diagnostic laboratory from to , , and by the louwerens group, who reported a decline in felv association in over cases of lymphoma in cats presenting to the university of california at davis veterinary teaching hospital. in these reports, felv antigenicity declined to represent only % to % of cats presenting with lymphoma. importantly, louwerens' study revealed that despite a sharp drop in felv-associated lymphoma, the overall prevalence of lymphoma in cats is increasing. the increased prevalence appears due to an increase in the number and relative frequency of the alimentary (and in particular the intestinal) anatomic form of lymphoma in the species. this is supported by an epidemiologic survey of cases of feline intestinal lymphoma; ( %) were from the years following and only % were from cases diagnosed in the years prior to . the true annual incidence rate for lymphoma in cats is currently unknown. with respect to feline pediatric tumors, a study in the united kingdom (n = pathology specimens) found that ( %) represented hematopoietic tumors, of which ( %) were lymphoma-note that felv status was unavailable for this compilation of cases. the typical signalment for cats with lymphoma cannot be uniformly stated as it varies widely based on anatomic site and felv status and therefore will be discussed individually under sitespecific discussions. in general, based on two large compilations (n = ) of cases in north america, , siamese cats appear overrepresented and although a . : male to female ratio was observed in one, no association with sex or neutering status was observed in the other. in a large compilation of australian cases, male cats and the siamese/oriental breeds were overrepresented, and similar breed findings have been observed in north america, although similar sex predilections have not been found. within the siamese/ oriental breeds, there appears to be a predisposition for a • felv, feline leukemia virus; id, insufficient data; cns, central nervous system. common = > % of clinical presentations; moderate = %- % of clinical presentations; uncommon = %- % of clinical presentation; rare = < % of clinical presentations. *data may include overlap or mixing of sites and represents the post-felv era. † as the primary site of presentation, rather than extension or progression. ‡ includes those reported as "intraabdominal" in which intestinal is a documented component. support for this concept. additionally, an association between gastric helicobacter infection and gastric malt lymphoma in cats is suggested in one study, and because this is a recognized syndrome in humans, it warrants further investigation. a although no direct evidence exists, a link between diet and the development of intestinal lymphoma in cats has been suggested. support is offered by the relative and absolute increase in the alimentary form of lymphoma in the past years and the fact that several dietary modifications in cat food have occurred in a similar timeframe in response to diseases, such as urinary tract disease. further investigation is warranted to prove or disprove such assertions. lymphoma can be classified based on anatomic location and histologic and immunophenotypic criteria; often, the two are intimately associated because certain histologic and immunophenotypic types are commonly associated with specific anatomic locations necessitating discussions within the individual anatomic categories that follow. the largest compilation of feline cases subjected to rigorous histologic classification was reported by valli and others using the nci wf. who has also published a histologic classification system that uses the real system as a basis for defining histologic categories of hematopoietic tumors of domestic animals. this system incorporates both histologic criteria and immunohistologic criteria (e.g., b-and t-cell immunophenotype). regarding anatomic location, as discussed previously, a profound change in presentation, signalment, felv antigenemia, immunophenotype, and frequency of anatomic sites has occurred in cats with lymphoma in the "post-felv" era (see table - ). because of this shift, characteristics of feline lymphoma discussed in this chapter will be primarily limited to reports collected from cases presenting after . several anatomic classifications exist for lymphoma in the cat, and some categorize the disease as mediastinal, alimentary, multicentric, nodal, leukemic, and individual extranodal forms. others have combined various nodal and extranodal forms into categories of atypical, unclassified, and mixed, and others have combined intestinal, splenic, hepatic, and mesenteric nodal forms into one category termed intraabdominal. some discrepancies in the discussion of frequency will inevitably result from the variations in classification used in the literature. the relative frequency of anatomic forms and their associated immunophenotype may also vary with geographic distribution and may be related to genetic and felv strain differences, as well as prevalence of felv vaccine use. alimentary/gi lymphoma can present as a purely intestinal infiltration or a combination of intestinal, mesenteric lymph nodes and liver involvement. the tumors can be solitary but more commonly diffuse throughout the intestines. some reports limit the alimentary form to gi involvement with or without extension to the liver. lymphoma is the most common tumor type found in the intestines of cats, representing % of cases in an epidemiologic survey of intestinal tumors in the species. the siamese breed is reported at increased risk. , while lymphoma may occur in cats of any age, it is primarily a disease of aged cats with a mean age of approximately years for t-cell alimentary lymphoma and years for b-cell lymphoma. , , [ ] [ ] [ ] no consistent sex bias is noted. anatomically, alimentary lymphoma is nearly times more likely to occur in the small intestine than the large intestine. in a series of colonic points toward an indirect role for fiv secondary to the immunosuppressive effects of the virus. shelton determined that fiv infection alone in cats was associated with a fivefold increased risk for development of lymphoma. coinfection with felv will further potentiate the development of lymphoproliferative disorders. experimentally, cats infected with fiv have developed lymphoma in the kidney, alimentary tract, liver, and multicentric sites. fivassociated lymphoma is more likely that of the b-cell immunophenotype rather than the t-cell predominance associated with felv. it has been suggested that fiv infection may be associated more commonly with alimentary lymphoma of b-cell origin, , and this may be related to chronic dysregulation of the immune system or the activation of oncogenic pathways; however, fiv antigenemia was only rarely associated with alimentary lymphoma in other large compilations of cases. , - as discussed earlier in section a, recent advances in molecular cytogenetics (see chapter , section a, and chapter ), including gene microarray techniques, have and are currently being applied to investigations of chromosomal aberrations in veterinary species with lymphoma. indeed a predisposition of the oriental cat breeds to develop lymphoma suggests a genetic predisposition and indicates heritable risk. , altered oncogene/tumor suppressor gene expression, epigenetic changes, signal transduction, and cell deathpathway alterations are common in lymphomas of humans and are likely also involved in the cat. several genetic factors have already been discussed as they relate to felv associations. additionally, n-ras aberrations have been implicated, although they are rare in cats. furthermore, telomerase activity (see chapter ) has been documented in feline lymphoma tissues. , alterations in cellular proliferation and in cell-cycle and death (apoptosis) pathways, in particular the cyclin-dependent kinase cell-cycle regulators and the bcl- family of proapoptotic and antiapoptotic governing molecules, have also been implicated in feline lymphoma. [ ] [ ] [ ] evidence for exposure to environmental tobacco smoke (ets) as a risk factor for lymphoma in humans has prompted investigations in cats. in one report, the relative risk of developing lymphoma in cats with any exposure to ets and with or more years of exposure to ets was . and . , respectively. a large european study documenting an association between proximity of waste management and cancer in dogs failed to show increased risk in cats. immune system alterations in the cat such as those accompanying fiv infection has been implicated in the development of lymphoma. [ ] [ ] [ ] as is the case in immunosuppressed human organ transplantation patients, two reports of immunosuppressed feline renal transplant recipients document increased risk of lymphoma following transplant and associated immunosuppressive therapy. , in both studies, nearly % of transplanted cats developed de novo malignant lymphoma. although definitive proof is lacking, there is a growing body of indirect evidence to suggest that lymphoma can be associated with the presence of chronic inflammation, which theoretically could be the case with intestinal and nasal lymphoma. in particular, an association has been suggested between intestinal lymphoma and inflammatory bowel disease , - ; however, others have not found with malignant pleural effusion and a mediastinal mass present. peripheral blood involvement was present in % of cases in one report and % in another. affected cats are generally felv/fiv negative. the mediastinal form can involve the thymus, mediastinal, and sternal lymph nodes. pleural effusion is common. in two large compilations, % of cats with thymic disease and % of cats with pleural effusion were documented as having lymphoma. , hypercalcemia occurs frequently with mediastinal lymphoma in dogs but is rare in cats. the majority of cats with mediastinal lymphoma are young (median age to years), felv positive, and the t-cell immunophenotype. , , [ ] [ ] [ ] the disease is confined to the mediastinum in most cases. there also exists a form of mediastinal lymphoma occurring primarily in young, felv-negative siamese cats that appears to be less biologically aggressive and more responsive to chemotherapy than felv-associated forms. involvement limited to peripheral lymph nodes is unusual in cats with lymphoma, representing approximately % to % of cases. , in contrast, approximately one-quarter of all other anatomic forms of lymphoma have some component of lymph node involvement. one-third of cats with nodal lymphoma are t-cell immunophenotype and felv antigenemic; however, complete categorizations have not occurred in the post-felv era and this may no longer be true. , , , peripheral nodal lymphoma was the most common anatomic form of lymphoma reported in a recent compilation of cases in cats under the age of year, representing a full third of cases in this age group. as lymphoma progresses, bone marrow and hepatic infiltration may develop. an uncommon and distinct form of nodal lymphoma in cats referred to as "hodgkin's-like" lymphoma has been reported. , this form typically involves solitary or regional nodes of the head and neck (figure - ) and histologically resembles hodgkin's lymphoma in humans. affected cats generally present with enlargement of one or two mandibular or cervical nodes initially, and tumors are immunophenotypically classified as t-cell-rich, b-cell lymphoma. one case each of inguinal node, multicentric nodal, and neoplasia in cats, lymphoma was the second most common malignancy ( %), second only to adenocarcinoma. there is some discordance in the literature regarding the histologic type (primarily cell size: small versus large), immunophenotype, and architecture involved with gi lymphoma. while studies (often older or smaller reports) suggest a majority of b-cell immunophenotypes, , larger, more recent reports , , indicate the majority represent mucosal low-grade t-cell immunophenotypes. conversely, the vast majority of b-cell gi lymphomas in cats are large cells and intermediate or high grade. , the largest compilation to date (n = ), by moore and others, classified gi lymphomas based on immunophenotype, then as either mucosal (infiltrate confined to mucosa and lamina propria with minimal submucosal extension) or transmural (significant extension into submucosa and muscularis propria). they then compared infiltration patterns with the who classification scheme, as well as documenting anatomic location, cell size, presence of epitheliotropism, clonality, and outcome data. this information is summarized in table - . of the cases, none tested serologically positive for felv and only for fiv. four cats had concurrent large b-cell lymphoma (stomach, cecum, or colon) and small t-cell lymphoma of the small intestine. topographically, t-cell variants are much more likely to occur in the small intestine ( %) and rarely in the stomach or large intestine. conversely, b-cell variants were often multiple and often occurred simultaneously within the stomach, small intestine, and ileocecocolic junction. the vast majority of t-cell variants were mucosal (equivalent to who enteropathy-associated t-cell lymphoma [who eatcl] type ii), and the vast majority of b-cell tumors were transmural (equivalent to who eatcl type i classification). regarding cell size, nearly all mucosal t-cell tumors were composed of small lymphocytes, and slightly more than half of transmural t-cell and all b-cell variants were composed of larger cells. epitheliotropism is present in approximately % of t-cell tumors but is rare in b-cell tumors. other abdominal organ involvement is common, and in one report of cases of low-grade t-cell intestinal lymphoma, liver and mesenteric involvement was documented in % and % of cases, respectively. hepatic lymphoma can occur concurrently with gi lymphoma or be confined solely to the liver. , most are t-cell and clonal or oligoclonal based on pcr analysis. a less common, distinct form of alimentary lymphoma, large granular lymphoma (lgl), also occurs in older (median age to years) cats. , , - these granulated round cell tumors have been termed globule leukocyte tumors, although they are likely variations of the same disease. lgl is characterized by lymphoblasts described as to µm in diameter with a round, clefted, or cerebriform nucleus; variably distinct nucleoli; finely granular to lacey chromatin; and a moderate amount of basophilic granular cytoplasm that was occasionally vacuolated. prominent magenta or azurophilic granules are characteristic (see figure - , chapter ). they are granzyme b positive by immunohistochemistry. this population of cells includes cytotoxic t-cells and occasionally nk cell immunophenotypes-most are cd + , cd + , and cd − and have t-cell receptor gene rearrangement. , in one report, nearly % expressed cd (integrin). approximately % express neither b-or t-cell markers and are thus classified as nk cells. these nk tumors commonly originate in the small intestine, especially the jejunum, are transmural, often exhibit epitheliotropism, and at least two-thirds present with other organs involved-most with mesenteric lymph node involvement and many with liver, spleen, kidney, peritoneal malignant effusions, and bone marrow infiltration. also, thoracic involvement may occur • figure - a cat presented with mandibular lymphadenopathy that was confirmed to be hodgkin's-like lymphoma following histologic assessment. • frequent sequela to renal lymphoma and occurs in % to % of treated cats. cns lymphoma can be intracranial, spinal, or both. cns lymphoma made up % of reported cases of extranodal lymphoma, % to % of intracranial tumors, , and % of spinal cord tumors, making it one of the most common malignancies encountered in the cns in cats. although some discordance exists in the literature, cats with cns lymphoma are younger (median ages of to . years reported), and % to % of cases are felv antigenemic. [ ] [ ] [ ] approximately two-thirds of intracranial cases are part of a multicentric, extracranial process, and approximately % of spinal lymphoma cases occur in multiple spinal cord sites with one-third also involving intracranial locations. [ ] [ ] [ ] in a compilation of cases of intracranial tumors in cats, diffuse cerebral and diffuse brainstem involvement was most common for lymphoid malignancies. spinal lesions are usually both extradural and intradural, although they can be limited to one or the other compartment. feline cns lymphoma may be primary but more commonly (approximately %) represents a multicentric process (especially renal or bone marrow). , a paucity of information exists on the immunophenotype of cns lymphoma. laryngeal lymphoma made up % of cases of extranodal forms in one report and represented % of all laryngeal disease in the species. , it occurs in older cats (median age years), is not associated with felv, and may be a solitary lesion or occur in the presence of other multicentric sites. no information on immunophenotype is available. cutaneous lymphoma is a rarely encountered anatomic form in the cat. it is usually seen in older cats (median age to . years), with no sex or breed predominance, and is not associated with felv/fiv. , it can be solitary or generalized, often affecting the head and face and is generally a slow chronic disease. two forms of cutaneous lymphoma have been distinguished histologically and immunohistochemically. most reports in the cat are epitheliotropic and consist of t-cells, although unlike the disease in dogs, adnexal structures are often spared. a report of nonepitheliotropic cutaneous lymphoma in cats also found five of six cases to be of t-cell derivation. cutaneous "lymphocytosis, " an uncommon disease histologically resembling well-differentiated lymphoma, was characterized in cats. solitary lesions were most common, and all were composed primarily of t-cells, with two-thirds having some b-cell aggregates. cutaneous lymphocytosis was characterized as a slowly progressive disorder; however, a few cases went on to develop internal organ infiltration. two case reports exist of cats with cutaneous t-cell lymphoma and circulating atypical lymphocytes. , the circulating cells were lymphocytes with large, hyperchromatic, grooved nuclei, and one case was immunophenotyped as a cd / cd population. in humans, cutaneous t-cell lymphoma with circulating malignant cells is termed sézary syndrome. ocular lymphoma was identified in of cases of extranodal lymphoma in one report. in a compilation of cases of intraocular tumors, ( %) were lymphoma ( b-cell and t-cell). it was presumed but not proved that the majority were part of a systemic multicentric process. the clinical signs associated with feline lymphoma are variable and depend on anatomic location and extent of disease. the alimentary form is most commonly associated with nonspecific signs associated with the intestinal tract. in the more conjunctival involvement have been reported. , histologically, lymph nodes can be effaced by either nodular or diffuse small to blastic lymphocytes with characteristic bizarre or multinucleated cells (reed-sternberg-like cells) (figure - ). no association with felv or fiv has been documented. the most common extranodal sites for lymphoma in cats include nasal (including nasopharyngeal and sinonasal), kidney, cns, laryngeal and tracheal, ocular, retrobulbar, and skin. nasal lymphoma is the most common extranodal lymphoma in cats. it is usually a localized disease; however, % have local extension or distant metastasis at necropsy. the majority of nonviral nasal/paranasal disease in cats are neoplasias, and lymphoma represents nearly one-third to half of these cases. [ ] [ ] [ ] it occurs primarily in older (median age to years; range to years) felv/ fiv-negative cats and at least three-quarters are b-cell in origin, although t-cell and mixed b-cell/t-cell immunophenotypes can be seen in approximately % to % of cases. , , , siamese cats appear overrepresented, and one report observed a : male-tofemale ratio. most are of intermediate-or high-grade histology. , epitheliotropism is common if the epithelium is present in the biopsy. renal lymphoma is the second most common form of extranodal lymphoma after the nasal form, occurring in approximately one-third of cases. it can present as primary to kidney lymphoma or occur concurrent with alimentary lymphoma. in more contemporary reports, the median age at presentation is years, although % occurred in cats under year of age. , the vast majority of cases are not associated with either felv or fiv. the greater median age and lack of felv/fiv association are in contrast to reports compiled prior to the post-felv era; in earlier studies, the median age was approximately . years, % of cases were felv antigenemic, and the majority constituted a b-cell immunophenotype. little contemporary information exists on the immunohistologic classification of renal lymphoma; however, in australia where felv is not a significant problem, most renal lymphoma is b-cell and intermediate to high grade. extension to the cns is a hodgkin's-like nodal lymphoma usually present without overt clinical signs. , cats with nasal lymphoma are typically presented with nasal discharge ( % to %), sneezing ( % to %), upper respiratory noise (stridor, stertor, wheezing; % to %), facial deformity ( % to %), anorexia ( % to %), epiphora ( % to %), and occasionally increased respiratory effort and coughing. , , the nasal discharge is usually mucopurulent, although epistaxis is present in up to one-third of cases. regional lymphadenopathy can also occur. the median duration of clinical signs prior to diagnosis is months (range of to days). cats with renal lymphoma present with signs consistent with renal insufficiency: inappetence, weight loss, and polyuria/ polydipsia. , on physical examination, renomegaly (usually bilateral, lumpy, and irregular) is palpated in the majority of cases (figure - ) . cats with cns lymphoma can present with constitutional signs (anorexia, lethargy) and signs referring to intracranial lesions, spinal lesions, or both. , [ ] [ ] [ ] , intracranial signs may include ataxia, altered consciousness, aggression, central blindness, and vestibular abnormalities. in a study of cats with seizures, of those diagnosed with intracranial lesions, % were due to lymphoma. clinical signs referring to spinal cord involvement may include paresis or paraplegia (> %; tetraparesis in %), ataxia, pain, and constipation, and nonspecific constitutional signs (e.g., anorexia, lethargy, weight loss) are also common. , in cats with spinal cord involvement, neurologic examination may further reveal tetraparesis, lower or upper motor neuron bladder, tail flaccidity, and absent deep pain; approximately one-third of signs will be asymmetric and most refer to thoracolumbar involvement. the neurologic dysfunction may be insidious or progress rapidly. common low-grade small cell forms, weight loss ( % to %), vomiting and/or diarrhea ( % to %), and anorexia ( %) are the most common findings, and icterus is uncommon ( %). , , abdominal palpation is abnormal in approximately % of cases, with half consisting of intestinal wall thickening and one-third having a palpable mass. clinical signs are usually present for several months (median: months). in contrast, although the lymphoblastic high-grade forms tend to cause similar clinical signs, they progress more rapidly with signs present for days or weeks and are more likely to present with a palpable abdominal mass originating from the gi tract, enlarged mesenteric lymph nodes, or liver. , , icterus is also more common in large cell forms. hematochezia and tenesmus may also be present if the colon is involved. rarely, cats may present with signs consistent with an acute abdomen due to intestinal obstruction or perforation and concurrent peritonitis. cats with intestinal lgl are presented with anorexia, weight loss, lethargy, and vomiting. , a palpable abdominal mass is present in approximately half of lgl cases, and hepatomegaly, splenomegaly, and renomegaly are common. abdominal effusions, pleural effusions, and icterus are observed in less than % of cases. the clinical signs associated with the mediastinal form of lymphoma include dyspnea, tachypnea, and a noncompressible anterior mediastinum with dull heart and lung sounds. rarely, a horner's syndrome and precaval syndrome may be observed. pleural effusion is common and characterized by serohemorrhagic to chylous effusion, and in most cases, neoplastic cells (lymphoblasts) are identified. , cats with the nodal form of lymphoma present with variable clinical signs depending on the extent of disease; however, they are often depressed and lethargic. peripheral lymphadenopathy, as the only physical finding, is an uncommon presentation. cats with • figure - a , ventrodorsal projection of a cat with renal lymphoma. massive, bilateral renomegaly is observed. b, necropsy specimens of a cat with bilateral renal lymphoma illustrating the diffuse cortical nature of the disease that is most common. the reader is referred to chapter for a general discussion of flow cytometric analysis and molecular diagnostic techniques, as well as the molecular diagnostic techniques section in section a of this chapter for specific applications to lymphoma. parr applications in cats have been described as being approximately % sensitive for the diagnosis of feline lymphoma ; however, assessment of specificity has not been clearly established. clonality assessment tools (e.g., primers) for both ig and t-cell receptor variable region genes have been developed in cats. [ ] [ ] [ ] [ ] assessments of tumor proliferation rates (e.g., ki , pcna, agnor), telomerase activity, and serum protein electrophoresis can also be performed on involved tissues in cats; however, consistent prognostic value across the anatomic, histopathologic, and immunophenotypic variants of lymphoma in cats is not well characterized. if these ancillary assays are helpful with respect to prognosis or diagnosis, they will be discussed in site-specific discussions to follow. thorough staging, including a bone marrow aspiration or biopsy, peripheral lymph node assessment (clinically normal or abnormal nodes), and thoracic and/or abdominal imaging, is indicated when ( ) solitary site disease is suspected (in particular, extranodal sites) and a decision between locoregional therapy (i.e., surgery and/or rt) versus systemic therapy (i.e., chemotherapy) is being considered; ( ) it provides prognostic information that will help a caregiver make treatment decisions; and ( ) complete staging of the extent of disease is required as part of a clinical trial. bone marrow evaluation may be of particular interest if anemia, cellular atypia, and leukopenia are present. a who staging system exists for the cat that is similar to that used in the dog (see box - ); however, because of the high incidence of visceral/extranodal involvement in the feline species, a separate staging system has been evaluated and is often used (box - ). because lymphoma in cats is more varied with respect to anatomic locations, staging systems are generally less helpful for predicting response. alimentary/gastrointestinal lymphoma the diagnosis of large cell, high-grade alimentary/gi lymphoma is generally less complicated than for the more common low-grade gi type. the former (including lgl) is often diagnosed with physical examination, abdominal imaging (e.g., ultrasound), and cytologic or histologic assessment of needle aspirate or needle biopsy samples from intestinal masses, enlarged mesenteric lymph nodes, or liver because mass lesions and gross lymphadenopathy are more commonly present. if obvious abdominal masses are present on physical examination, transabdominal needle aspiration may be possible without the aid of abdominal imaging. less commonly, abdominal exploration is necessary if lesions are more subtle or not amenable to transabdominal sampling. further staging via thoracic imaging, peripheral lymph node aspiration, and bone marrow assessment may be performed, but rarely contributes prognostic information or alters treatment decisions because the disease is already widespread and systemic therapy is required. in contrast, low-grade, small cell gi lymphoma is more commonly associated with modest (or palpably absent) intestinal thickening without mass effect and is clinically similar if not identical in presentation to benign inflammatory bowel disease (ibd). cytologic assessment alone is often not sufficient for diagnosis; in one study, eight of nine cases in which mesenteric lymph nodes were confirmed histologically as lymphoma, cytologic assessment incorrectly indicated benign lymphoid hyperplasia. the key elements necessary for the diagnosis of low-grade, small cell gi lymphoma signs associated with laryngeal lymphoma in cats most commonly include dyspnea, dysphonia, stridor, gagging or retching, and rarely, coughing. , cutaneous lymphoma may be solitary or diffuse with a varied presentation. , in decreasing order of likelihood, lesions may include erythematous patches, alopecia, scaling, dermal nodules, or ulcerative plaques. nasal hypopigmentation, miliary dermatitis, and mucosal lesions are rarely observed. peripheral lymphadenopathy may also be present. in most cats, the duration of signs will be prolonged, lasting several months. cats with ocular lymphoma are presented with uveitis or iridial masses, as well as signs related to systemic involvement of disease. all cats with lymphoma, regardless of site, may be presented with nonspecific constitutional signs that may include anorexia, weight loss, lethargy, or depression. secondary bone marrow infiltration may lead to anemia-at least % of affected cats have moderateto-severe nonregenerative anemia. signs related to paraneoplastic hypercalcemia (pu/pd) can occur in cats, however, much less commonly than in the dog. in one survey of hypercalcemia in cats, approximately % were diagnosed with lymphoma of various anatomic types. for most cats with suspect lymphoma, the diagnostic evaluation should include a baseline assessment consisting of a cbc with differential cell count, platelet count, serum chemistry profile, urinalysis, and retroviral (felv/fiv) screen. serum chemistry profiles can help establish the overall health of the animal, as well as, in some cases, suggest site-specific tumor involvement; for example, increased activities of liver enzymes may indicate hepatic infiltration and increased blood urea nitrogen (bun) and creatinine may indicate renal lymphoma. for cats with alimentary lymphoma, hypoproteinemia and anemia are reported to occur in up to % and % of cases, respectively. , , hypercalcemia is rarely seen in cats but has been reported in cats with lymphoma at various anatomic sites. hypoglycemia was reported in approximately one-third of cats with lymphoma in one australian study. in a series of cats with various anatomic forms of lymphoma, serum albumin concentrations were significantly lower and β-globulin concentrations (as measured by protein electrophoresis) were significantly higher than a healthy control population. the use of various imaging modalities in cats with lymphoma depends on the anatomic site and will be discussed in site-specific discussions to follow. cytopathologic or histopathologic evaluation of lymph node or involved organ tissue, procured via needle aspirate cytology (see chapter ), surgical, endoscopic, or needle-core biopsy (see chapter ) is required for a definitive diagnosis. fna cytology alone may not be sufficient in some cases, owing to difficulties encountered in distinguishing lymphoma from benign hyperplastic or reactive lymphoid conditions. in such cases, whole lymph node excision and/or involved organ biopsy is preferred because orientation and information regarding invasiveness and architectural abnormalities may be necessary for diagnosis. additionally, involved tissue, needle aspirate, and fluid samples can be further interrogated by various histochemical, immunohistochemical, flow cytometric analysis (e.g., size and immunophenotypic assessment), and molecular techniques (e.g., parr to assess clonality) to further characterize the disease process and refine the diagnosis in equivocal cases. the stomach, liver, spleen, colon, and pancreas, and occasionally, mild effusions are observed. as mentioned previously, although aspirate cytology may be sufficient for diagnosis of large cell intermediate-or high-grade alimentary lymphoma in cats, it is rarely diagnostic for low-grade, small cell intestinal lymphoma, and tissue procurement for histologic and ancillary assessment is required for diagnosis (and differentiation from ibd). the debate still rages as to whether endoscopically obtained tissue is sufficient for diagnosis or if fullthickness tissue procured during laparotomy or laparoscopy is necessary in light of similarities with ibd. , , , as previously discussed, histologic features that help differentiate intestinal lymphoma from ibd include lymphoid infiltration of the intestinal wall beyond the mucosa, epitheliotropism (especially intraepithelial nests and plaques), heterogeneity, and nuclear size of lymphocytes. , although the presence of transmural involvement is highly suggestive of lymphoma, the lack of transmural infiltration is not pathognomonic for ibd; transmural infiltration is common with b-cell and large t-cell (including lgl) intestinal lymphoma but is observed in the minority of low-grade t-cell intestinal lymphomas that represent the largest group in cats (see table - ). for these reasons, if the differentiation of lymphoma and ibd is equivocal after standard histopathologic assessment, the addition of immunophenotypic and parr analysis in a stepwise fashion, as proposed by kiupel and others, may be ultimately necessary for a definitive diagnosis. their study of cats with either lymphoma or ibd found that, although standard histopathology was highly specific for diagnosis of lymphoma ( % specific, % sensitive), sensitivity was enhanced by the addition of immunophenotypic analysis ( % specific, % sensitive) and further enhanced by parr analysis ( % specific, % sensitive). for cats with mediastinal lymphoma, diagnostic suspicion may begin with a noncompressible cranial thorax on physical examination and confirmation of a mediastinal mass/pleural effusion on thoracic radiograph. fna of the mass or cytologic evaluation of pleural fluid may be sufficient to establish a diagnosis. in most cats, the finding of a monotonous population of intermediate-or high-grade cells will establish a diagnosis. however, definitive diagnosis of lymphoma in cats with a mediastinal mass and concurrent chylothorax can be challenging. ct appearance may be helpful but generally does not contribute to a definitive diagnosis. if lymphoblasts are not identified in the pleural chylous effusion, then cholesterol and triglyceride concentrations can be measured. in chylous effusions, the pleural fluid triglyceride concentration will be greater than in the serum; however, anorectic cats will have lower triglyceride levels in the pleural fluid. a major differential for mediastinal lymphoma is thymoma. the cytologic features of thymoma can be distinct from lymphoma in many cases, but the diagnosis can be challenging because of a preponderance of small lymphocytes in thymoma. mast cells can also be seen in up to % of aspirations from thymomas. the addition of immunophenotypic and clonality assessment may be helpful in equivocal cases. if nasal lymphoma is suspected, advanced imaging (ct, mri), rhinoscopy, and biopsy are usually necessary for diagnosis (see chapter , section b). ct or mri is useful to determine the extent of involvement and to help plan biopsy procurement and rt if that treatment option is pursued. ct characteristics associated with sinonasal tumors in cats include the presence of a unilateral or bilateral nasal/sinus mass or fluid, bulla (and differentiation from ibd) include abdominal imaging (usually ultrasound), procurement of tissue for histopathology, and if necessary, assessment of immunophenotype and clonality. abdominal ultrasound will be abnormal in approximately % to % of cats with low-grade, small cell gi lymphoma. , , , diffuse small intestinal wall thickening is the most common finding; % to % of cats with lymphoma will have ultrasonic evidence of wall thickening, which predominantly involves the muscularis propria, and submucosa, although mucosal thickening can also occur. focal mural masses are uncommon. mesenteric lymphadenopathy is also common and reported in % to % of affected cats. these ultrasonographic findings are by no means pathognomonic for lymphoma, however, because % to % and % to % of cats with ibd also have ultrasonographic evidence of intestinal wall thickening and lymphadenopathy, respectively. , mucosal thickening is more common, and muscularis propria thickening is less common in ibd than lymphoma. less commonly, cats with low-grade intestinal lymphoma will have ultrasonographic abnormalities in other abdominal organs such as stage • a single tumor (extranodal) with regional lymph node involvement • two or more nodal areas on the same side of the diaphragm • two single (extranodal) tumors with or without regional lymph node involvement on the same side of the diaphragm • a resectable primary gastrointestinal tract tumor, usually in the ileocecal area, with or without involvement of associated mesenteric nodes only • two single tumors (extranodal) on opposite sides of the diaphragm • two or more nodal areas above and below the diaphragm • all extensive primary unresectable intraabdominal disease • all paraspinal or epidural tumors, regardless of other tumor site or sites • stages - with liver and/or spleen involvement yield enough tissue for a cytologic diagnosis. ct or mr also reveals multifocal disease in the majority of cats with intracranial lymphoma. , csf analysis may be helpful but is rarely definitive for lymphoma. one of cats with confirmed spinal lymphoma in one study and of with confirmed intracranial lymphoma in another had evidence of lymphoblasts in the cns, and an increased protein content was commonly found. in cats suspected of cns lymphoma, bone marrow and renal involvement are often present, and cytologic assessment of these or other more accessible organs is generally more easily attainable than from spinal sites. for cats suspected of cutaneous lymphoma, punch biopsies ( to mm) should be taken from the most representative and infiltrative sites, while avoiding overtly infected skin lesions. immunophenotypic and parr analysis often are helpful in definitive diagnosis. complete staging to rule out systemic disease is also recommended for cats with cutaneous lymphoma because local therapies can be applied in cases of solitary disease. our knowledge base for treating cats with lymphoma is less well established, and outcomes are less predictable than that in dogs, primarily due to the greater variation in histologic type and anatomic location observed in the species. this is further complicated by the plethora of papers that "lump" very small numbers of cases representing multiple anatomic/immunophenotypic and histologic subtypes (e.g., small cell versus large cell variants) together when reporting survival analysis following chemotherapy. this provides only general observations rather than important specific outcome information (i.e., response rate and durability of response) that can vary significantly with respect to anatomic and histologic subtype. in general, canine lymphoma is most commonly intermediate-high grade and nodal, whereas cats more commonly present with gi or extranodal (±nodal extension), small cell, low-grade, and/or indolent forms. as will be discussed subsequently, the author bases most treatment decisions on assessment of whether the individual case represents a low-grade (e.g., indolent, small cell variants) versus an intermediate-or high-grade (e.g., large cell) lymphoma. finally, much of the early work on chemotherapy protocol development for cats with lymphoma occurred during the felv era, and care should be exercised when applying this information in the post-felv era. in general, cats tolerate chemotherapy for lymphoma quite well, most clients are happy with their choice to initiate treatment, and quality of life generally improves following commencement of therapy. , the chemotherapeutic agents used most commonly to treat intermediate-or high-grade lymphoma in cats are similar to those used for dogs and humans with lymphoma (see section a in this chapter) and include doxorubicin, vincristine, cyclophosphamide, methotrexate, l-asparaginase, ccnu (lomustine), and prednisone. most combination induction protocols currently employed in cats are modifications of chop protocols initially designed for human oncologic use. , - chop represents combinations of cyclophosphamide (c), doxorubicin (h, hydroxydaunorubicin), vincristine (o, oncovin) and prednisone (p). in general, chopbased protocols are appropriate for cats with large cell, intermediate-and high-grade lymphoma involving any anatomic site (e.g., peripheral nodal, mediastinal, and renal forms) but should not be first-line therapy for small cell, low-grade variants. as in the dog (see section a in this chapter), a plethora of modifications are used with chop-based protocols, although virtually no quality comparative data exist to compare outcomes, and as such, the protocol used should be based on cost, ease, client/veterinarian preference, and level of comfort. the current chop-based protocol in use by effusion, and lysis of associated bony structures. , a biopsy can be procured either by intranasal procurement (with or without rhinoscopy) or by flushing one hemicavity with a bulb syringe and saline while occluding the contralateral cavity and collecting samples flushed out of the nasopharynx (figure - ). thorough staging (i.e., regional node assessment, thoracic and abdominal staging, and bone marrow assessment) to ensure the disease is confined to the nasal passages is recommended, if local rt without systemic chemotherapy is being considered. in the case of renal lymphoma, physical examination findings of massive and often bilateral renomegaly will raise the index of suspicion. radiographic appearance is smoothto-irregular renomegaly (see figure - , a) . ultrasonographic imaging usually reveals bilateral (> %), irregular renomegaly with hypoechoic subcapsular thickening. approximately one-third of cases will have ultrasonographic evidence of other abdominal organ involvement. the disease is usually diffuse throughout the renal cortex (see figure - , b) and transabdominal needle aspirate or core biopsy is diagnostic in most cases. in cats with suspected spinal lymphoma, survey radiographs of the spine will rarely reveal osseous lesions. myelograms, ct, or mri are indicated, and in approximately % of the cases, an extradural or intradural mass will be detected. , , , most lesions occur at a thoracolumbar or lumbosacral location, and they are often found in more than one location. image-guided needle aspiration of epidural lesions may used in cats in europe, and one compilation reported similar results to chop. a cop protocol commonly employed in cats is presented in table - . some studies with relatively few case entries have reported limited activity for doxorubicin as a single agent in cats with lymphoma , ; however, larger studies using combination protocols have more consistently reported the addition of doxorubicin as necessary for the attainment of more durable responses. , interestingly, in a report of cats having relapsed following cop-based protocols (without doxorubicin), only % responded subsequently to doxorubicin-containing rescue therapy. a small number of cats with lymphoma have been treated with single-agent oral ccnu (lomustine) at a dosage range of to mg/m every to weeks. , whereas activity was noted, only partial responses were reported. l-asparaginase, which is often included in protocols for lymphoma in cats, has a much shorter asparagine-depleting effect in cats (lost by days) than in dogs and in one study in cats with lymphoma resulted in only a % response rate. in general, cats with intermediate-and high-grade lymphoma treated with chop-based or cop protocols do not enjoy the same level of success as dogs. bearing in mind that these reports group together a wide variety of subtypes having dissimilar prognoses (see subsequent site-specific treatment sections), the overall response rates tend to be in the % to % range with median remission and survival durations of and months, respectively. , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] alimentary/gastrointestinal lymphoma representing the most common presentation for cats with lymphoma, the large majority have the small cell, mucosal, t-cell variant that carries a good prognosis, often with less aggressive chemotherapy protocols (e.g., oral chlorambucil and prednisone). , , , chlorambucil ( mg/m po, every weeks [preferred by the author] or mg po every other day) and prednisone or prednisolone (initially to mg/kg po daily, reduced to . to . mg/kg every other day over several weeks) results in response rates (i.e., resolution of clinical signs) of greater than % and median survivals of approximately years or longer. , , cats who relapse with this protocol often will subsequently respond to alternative alkylators, such as cyclophosphamide or lomustine. anecdotally, many will also respond the author is presented in table - . this protocol has been used in many cats with various forms of intermediate-and high-grade lymphoma and is generally well tolerated. at present, most canine lymphoma protocols (see section a in this chapter) discontinue chemotherapy by the th week, and we have sufficient data to show shorter, maintenance-free protocols are as good if not superior to longer maintenance protocols; however, similar comparative data do not exist in the cat. until such time as evidence to the contrary exists, the author presently recommends discontinuation of chemotherapy at week in cats who have attained a complete remission. doxorubicin alone ( mg/m , every weeks for total treatments) or palliative prednisone therapy is offered if clients decline more aggressive chop-based therapy. cats are generally less tolerant of doxorubicin than are dogs; therefore a lower dosage ( mg/m iv or mg/kg iv) is used (see chapter ) . cardiac toxicity does not appear to be a clinically significant problem in cats, although renal toxicity is more commonly encountered in the species and renal function should be monitored (i.e., serial bun, creatinine, and urine specific gravity) closely prior to and during therapy. the use of cop (i.e., chop without the addition of doxorubicin) is often • nasal cavity following thorough staging (node cytology, thoracic and abdominal imaging, bone marrow aspiration), then rt is the treatment of choice. crs in the order of % to % are reported, with reports of median survivals following rt of . to years. , cats that do not achieve a cr with rt have a median survival of approximately . months. total radiation dosage does affect survival durations, and a total dose greater than gy is recommended. the addition of chemotherapy has not been shown to enhance survival for cats with locally confined disease; combinations of rt and chemotherapy result in similar response rates and survival times. , , chemotherapy (cop-or chop-based protocols) used in the absence of rt is a reasonable alternative, with complete response rates of approximately % and median survivals of approximately years reported for cats achieving cr. the author's preference is to initiate systemic chemotherapy only for ( ) cases that have confirmed disease beyond the nasal passage, ( ) cases that relapsed following rt, or ( ) cases in which rt is unavailable or declined. ing treatment for cns lymphoma exist, and although an occasional case experienced durable response to systemic chemotherapy, generally less than % will respond and median survivals of to months can be expected. , , laryngeal/tracheal lymphoma the vast majority of cats with laryngeal or tracheal lymphoma respond to either rt (if localized) or systemic chemotherapy ( % cr to cop-or chop-based protocols) (figure - ) . whereas the authors experience is that most have durable responses and survival durations typically approach or exceed year, the only case series (n = ) reported a median survival of . months following achievement of a cr. ing the treatment of cutaneous lymphoma or mycosis fungoides in cats ; however, a report of a cr to lomustine exists. cats with a solitary disease could theoretically be treated with surgical excision to vinblastine chemotherapy if they no longer are responsive to alkylators. in contrast, cats with b-cell or large t-cell (including lgl) or small t-cell lymphoma that is transmural typically do not enjoy a durable response to therapy and survivals are much shorter. , , , median survivals range from to days, even in cats treated with more aggressive cop-based protocols. in the author's experience, these variants are more likely to respond to chop-based protocols than chlorambucil/prednisone; however, durable responses occur only in a minority of cases. in particular, lgl appears to carry a grave prognosis , ; in compilations of cats with lgl, median survivals of approximately months were reported, including cats receiving either cop or chop-based protocols, which resulted in only a % response rate. nutritional support is especially important for cats with gi lymphomas. it may be necessary to place a feeding tube in cats undergoing chemotherapy, particularly if prolonged anorexia is present (see chapter , section b). recently, two preliminary studies evaluated rt, either as rescue following recurrence or in addition to chemotherapy for the treatment of intestinal lymphoma in cats. , eleven cats ( small cell, large cell, and lgl) that progressed following chemotherapy received abdominal radiation ( gy in fractions over days) and resulted in a median survival of months, although numbers were small and % were lost to follow-up. a second report of eight cats (seven with large cell lymphoma) underwent weeks of chopbased combination chemotherapy, followed weeks later by whole abdomen radiation consisting of daily . gy fractions. although three cats died within weeks of rt, five enjoyed durable remissions. these preliminary promising outcomes warrant further investigation. felv-positive cats is generally associated with a poor prognosis, and survival times of approximately to months are expected following chop-or cop-based protocols . , in contrast, young felv-negative siamese cats with mediastinal lymphoma experience remission rates approaching %, and responses tend to be more durable (median ≈ months). the treatment choice for peripheral nodal lymphoma in cats depends on whether the individual case represents a low-grade (e.g., indolent, small cell variants) versus an intermediate-or high-grade (e.g., large cell) lymphoma; the latter are best treated with chop-or cop-based protocols and carry a less favorable prognosis, whereas the former generally respond to less aggressive chlorambucil/corticosteroid protocols and enjoy durable responses. less is known regarding the treatment of hodgkin's-like lymphoma involving solitary or regional nodes of the head and neck. , clinical outcome following surgical extirpation of the affected node (or nodes if a reasonable number) is often associated with long-term, disease-free intervals and survivals of approximately year, suggesting it is a more indolent form of lymphoma. eventual recurrence in distal nodes following surgical excision is common, and the author currently offers clients the option of adjuvant chlorambucil/corticosteroids following surgery-this theoretically may have benefit; however, insufficient data exist to document a survival advantage with this approach. the use of chemotherapy to treat all has been disappointing. using cop-based protocols, cotter reported a % cr rate. cll can be treated with chlorambucil ( . mg/kg po or mg/cat qod) and prednisone ( mg/kg po daily); however, little information exists regarding outcome. as in humans and dogs, if significant clinical signs or profound cytopenias are not present, treatment can be withheld-one cat with cll remained stable without chemotherapy for over a year. the prognoses for acute nonlymphoblastic leukemias are generally very poor, although some exceptions exist in case report form in the historic literature. or rt, although clinical staging is necessary to rule out possible further systemic involvement. for multiple sites, combination chemotherapy may be considered. as previously discussed, the prediction of outcomes in cats with lymphoma is not generalizable due to the wide spectrum of histologic and anatomic subtypes encountered. much has been mentioned in the previous treatment sections, and tables - and table - summarize prognostic parameters for lymphoma in cats. for a complete discussion of leukemias and mpds, including a general discussion of hematopoiesis, etiologies, lineage classification and descriptions, see section c of this chapter. the classification of leukemias in cats is difficult because of the similarity of clinical and pathologic features and the transition, overlap, or mixture of cell types involved. [ ] [ ] [ ] [ ] [ ] most case-series reports are from the felv era and generally only single case reports exist from the more contemporary post-felv era, which further confuses our understanding of the biology and outcome. for this reason, only a simplistic discussion, primarily relating to the lymphoid leukemias will be presented here and the interested reader is again referred to section c for a general discussion of nonlymphoid leukemia. for cats with suspected leukemia, peripheral blood assessment (e.g., cbc with differential, flow cytometric analysis for size and immunophenotype, and parr [for lymphoid leukemias]), and bone marrow aspiration or biopsy may contribute to a diagnosis. the preferred sites for bone marrow aspiration are the proximal humerus or iliac crest. cats with acute leukemia are likely to have malignant cellular infiltrates in organs other than bone marrow. a bone marrow aspirate with greater than % abnormal blast cells is sufficient to make a diagnosis of an acute leukemia. in cats with suspected cll, infiltration of the bone marrow with more than % mature lymphocytes helps confirm the diagnosis. all cats with leukemia should be tested for felv/fiv. determining the lineage of some leukemias can be challenging; most can be distinguished from one another by histologic appearance, histochemical stains, or immunohistochemical or flow cytometric analysis of the leukemic cells for cellular antigens that identify their lineage (see chapter and section c in this chapter). , , in addition, examination of blast cells by electron microscopy may reveal characteristic ultrastructural features. the french-american-british (fab) classification system is considered useful in cats with myelodysplastic syndromes and almost all will be felv antigenemic. , lymphoid leukemia all was the most commonly encountered type of leukemia in cats in the felv era; however, it is much less common today. all is characterized by poorly differentiated lymphoblasts and prolymphocytes in blood and bone marrow. approximately % to % of cats with all were felv positive, and most malignant cells have t-cell immunophenotypes ; however, little information is available in the contemporary literature. cll is rarely reported in cats and is characterized by welldifferentiated, small, mature lymphocytes in peripheral blood and aberrant proliferation of cells with defective maturation and function leads to reduction of normal hematopoiesis and invasion of other tissues. these disorders have been classified based on biologic behavior, degree of cellular differentiation, and lineage of the neoplastic cells (granulocytic, monocytic, erythroid, megakaryocytic, or mixed). newer classification systems in humans have incorporated genetics and molecular genetic analysis; these are currently areas of active investigation in the study of animal leukemias. in the animal leukemia study group made recommendations for classifying nonlymphoid leukemias in dogs and cats. more recently, the oncology committee of the american college of veterinary pathologists (acvp) has been reexamining criteria for a classification system and spearheading large multiinstitutional studies to validate the criteria. long-term produced experimentally following irradiation. [ ] [ ] [ ] in contrast to mpds in cats, no causative viral agent has been demonstrated in dogs, although retrovirus-like budding particles were observed in the neoplastic cells of a dog with granulocytic leukemia. pathology and natural behavior a review of normal hematopoiesis will aid in understanding the various manifestations of mpds. hematopoiesis is the process of proliferation, differentiation, and maturation of stem cells into terminally differentiated blood cells. a simplified scheme is presented in figure - . pluripotent stem cells differentiate into either lymphopoietic or hematopoietic multipotent stem cells. under the influence of specific regulatory and microenvironmental factors, multipotent stem cells in bone marrow differentiate into progenitor cells committed to a specific hematopoietic cell line, for example, erythroid, granulocytic-monocytic, or megakaryocytic. maturation results in the production of terminally differentiated blood cellserythrocytes, granulocytes, monocytes, and platelets-that are delivered to the circulation. in some cases, as in the maturation of reticulocytes to erythrocytes, final development may occur in the spleen. proliferation and differentiation of hematopoietic cells are controlled by a group of regulatory growth factors. , of these, objectives of these studies are to define molecular lesions, establish prognostic markers, and target effective therapeutic approaches. myeloid neoplasms are uncommon or rare in the dog and occur times less frequently than lymphoproliferative disorders. accurate information about incidence and other epidemiologic information await consistent use of a uniform classification system (see later discussion). there is no known age, breed, or sex predisposition, although in some retrospective studies, large-breed dogs have been overrepresented. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in dogs, the etiology of spontaneously occurring leukemia is unknown. it is likely that genetic and environmental factors (including exposure to radiation, drugs, or toxic chemicals) play a role. in humans, acquired chromosomal derangements lead to clonal overgrowth with arrested development. at the end of the last century, chromosomal abnormalities were reported in dogs with aml, chronic myelogenous leukemia (cml), and lymphoid leukemia. , however, because karyotyping is difficult to perform in dogs because of the large number and morphologic similarity of their chromosomes and their resistance to banding, defining genetic factors in canine myeloid neoplasms has awaited application of molecular technologies and use of the canine genome map. erythropoietin is the best characterized; it regulates erythroid proliferation and differentiation and is produced in the kidney, where changes in oxygen tension are detected. the myeloid compartment depends on a group of factors, collectively referred to as colonystimulating factors (csfs). these factors act at the level of the committed progenitor cells but also influence the functional capabilities of mature cells. some of these factors have a broad spectrum of activity; others are more restricted in their target cells and actions. csfs are produced in vitro by a multitude of cell types, including monocytes, macrophages, lymphocytes, and endothelial cells, and these cells likely play a role in the production and regulation of these factors in vivo. the gene for thrombopoietin also has been cloned, and it appears that this hormone alone can induce differentiation of megakaryocytes and platelet production. recombinant forms of many of these hormones are increasingly available. clonal disorders of bone marrow include myeloaplasia (usually referred to as aplastic anemia), myelodysplasia, and myeloproliferation. a preleukemic syndrome, characterized by peripheral pancytopenia and bone marrow hyperplasia with maturation arrest, is more correctly termed myelodysplasia because the syndrome does not always progress to overt leukemia. this syndrome has been described in cats, usually in association with felv infection but has only rarely been recognized in dogs. [ ] [ ] [ ] [ ] these clonal disorders may be manifested by abnormalities in any or all lineages because hematopoietic cells share a common stem cell. in addition, transformation from one form to another may occur. myeloid neoplasms are classified in several ways. the terms acute and chronic refer to the degree of cellular differentiation of the leukemic cells, but these terms also correlate with the biologic behavior of the neoplasm. disorders resulting from uncontrolled proliferation or decreased apoptosis of cells incapable of maturation lead to the accumulation of poorly differentiated or "blast" cells. these disorders are included under the umbrella term, acute myeloid leukemia (aml). disorders resulting from unregulated proliferation of cells that exhibit progressive, albeit incomplete and defective, maturation lead to the accumulation of differentiated cells. these disorders are termed myeloproliferative neoplasms (mpn) and include polycythemia vera, cml and its variants, essential thrombocythemia, and possibly primary myelofibrosis. myeloid neoplasms are further classified by the lineage of the dominant cell type(s), defined by romanowsky stains, special cytochemical stains, ultrastructural features, flow cytometric analysis, and immunologic cell markers, and they have been classified into subtypes (see later discussion). aml has a more sudden onset and is more aggressive. in both acute and chronic disorders, however, abnormalities in proliferation, maturation, and functional characteristics can occur in any hematopoietic cell line. in addition, normal hematopoiesis is adversely affected. animals with leukemia usually have decreased numbers of circulating normal cells. the pathogenesis of the cytopenias is complex and may result in part from production of inhibitory factors. eventually, neoplastic cells displace normal hematopoietic cells, and this is termed myelophthisis. anemia and thrombocytopenia are particularly common. neutropenia and thrombocytopenia result in infection and hemorrhage, which may be more deleterious to the animal than the primary disease process. aml is rare and is characterized by aberrant proliferation and/or decreased apoptosis of a clone of cells without maturation. this results in accumulation of immature blast cells in bone marrow and peripheral blood (figure - , a to e) . the wbc count is variable and ranges from leukopenia to counts up to , /µl. spleen, liver, and lymph nodes are frequently involved, and other tissues, including tonsils, kidney, heart, and the cns, may be infiltrated as well. there is no characteristic age, and even very young dogs may be affected. the clinical course of these disorders tends to be rapid. production of normal peripheral blood cells is usually diminished or absent, and anemia, neutropenia, and thrombocytopenia are common with infection and hemorrhage occurring as frequent sequelae. occasionally, neoplastic blasts are present in bone marrow but not in peripheral blood. this is termed aleukemic leukemia, whereas subleukemic suggests a normal or decreased wbc count with some neoplastic cells in circulation. in the animal leukemia study group was formed under the auspices of the american society for veterinary clinical pathology to develop specific morphologic and cytochemical criteria for classifying acute nonlymphocytic leukemias. recognition of specific subtypes of leukemia is required to compile accurate and useful information about prognosis and response to treatment, as well as to compare studies from different sites. in , this group proposed a classification system following adaptation of the french-american-british (fab) system and criteria established by the nci workshop. group members examined blood and bone marrow from dogs and cats with myeloid neoplasms. romanowsky-stained specimens were examined first to identify blast cells and their percentages. lineage specificity was then determined using cytochemical markers. the percentage of blasts and the information about lineage specificity were used in combination to classify disorders as acute undifferentiated leukemia (aul), acute myeloid leukemia (aml, subtypes m to m and m ), and erythroleukemia with or without erythroid predominance (m and m er). a description of these subtypes is presented in table - . canine karyotyping is difficult, but with advancements in molecular cytogenetic analysis, chromosome painting, and genomic hybridization, aml in dogs can now be analyzed at the base-pair level, , and missense mutations in flt , c-kit, and ras sequences have been identified in dogs with aml, similar to what has been found for human aml. in addition to serving as diagnostic and prognostic markers, cytogenetic lesions may be therapeutic targets. as cytogenetic abnormalities continue to be identified, this information will need to be incorporated into classification schemes. with the exception of acute promyelocytic leukemia or m , all of these subtypes have been described in dogs. however, because this modified fab system has been adopted only recently, the names given to these disorders in the literature vary considerably. in addition, in the absence of cytochemical staining, immunophenotyping, or electron microscopic evaluation, the specific subtype of leukemia has often been uncertain, making retrospective analysis of epidemiologic information, prognosis, and response to therapy confusing at best. although defining specific subtypes may seem to be an academic exercise owing to the uniformly poor prognosis of acute leukemias, this information is critical to improving the management of these diseases. because of the low incidence of aml, national and international cooperative efforts will be required to accumulate information on the pathogenesis and response to different treatment modalities of specific subtypes. utilization of a uniform classification system is an essential first step. different forms of aml are demonstrated in figure polycythemia vera (pv) is a clonal disorder of stem cells, although whether the defect is in the pluripotent stem cell or the hematopoietic multipotent stem cell is still not clear. in humans, progenitor cells have an increased sensitivity to insulin-like growth factor , which stimulates hematopoiesis. it is not known whether this hypersensitivity is the primary defect or is secondary to another gene mutation. in any case, the result is overproduction of red blood cells (rbcs). the disease is rare and must be distinguished from more common causes of polycythemia, including relative and secondary absolute polycythemia (see later discussion). in pv, there is neoplastic proliferation of the erythroid series with terminal differentiation to rbcs. the disease has been reported in dogs that tend to be middle-aged with no breed or sex predilection [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and is characterized by an increased rbc mass evidenced by an increased packed cell volume (pcv), rbc count, and hemoglobin concentration. the pcv is typically in the range of % to %. the bone marrow is hyperplastic, although the myeloid : erythroid (m : e) ratio tends to be normal. in contrast to the disease in humans, other cell lines do not appear to be involved, and transformation to other mpns has not been reported. the disease in dogs may be more appropriately termed primary erythrocytosis. in humans, acquired jak gene mutations are identified in % of patients with primary polycythemia, and recently an identical mutation in the jak gene of one of five dogs with primary polycythemia was reported. in dogs, cml is more similar to chronic neutrophilic leukemia, a rare form of mpn in humans, than to cml in humans because it is a neoplastic proliferation of the neutrophil series, although concurrent eosinophilic and basophilic differentiation can occur. cml can occur in dogs of any age. , [ ] [ ] [ ] [ ] [ ] neutrophils and neutrophilic precursors accumulate in bone marrow and peripheral blood as well as in other organs. the peripheral wbc count is usually, but not always, greater than , /µl. both immature and mature neutrophils are present, as demonstrated in figure - , f. mature forms are usually more numerous, but sometimes an "uneven" left shift is present. signs of dysplasia may be evident, including hypersegmentation, ringed nuclei, and giant forms. eosinophils and basophils may also be increased. the bone marrow is characterized by granulocytic hyperplasia, and morphologic abnormalities may not be present. erythroid and megakaryocytic lines may be affected, resulting in anemia, thrombocytopenia, or less commonly, thrombocytosis. this disorder must be distinguished from severe neutrophilic leukocytosis and "leukemoid reactions" caused by inflammation or immune-mediated diseases. leukemoid reactions can also occur as a paraneoplastic syndrome. in humans with cml, characteristic cytogenetic abnormalities are present in all bone marrow cells, signifying a lesion at the level of an early multipotent stem cell. typically, these individuals have a chromosomal translocation, resulting in the philadelphia chromosome or bcr-abl translocation between chromosomes and . the analogous chromosomes in dogs are chromosomes and , and bcr-abl mutations have now been reported in three cases of cml in dogs. variants of cml are chronic myelomonocytic leukemia (cmml) and chronic monocytic leukemia (cmol). [ ] [ ] [ ] these diagnoses are made based on the percentage of monocytes in the leukemic cell leukemia (m ).* megakaryoblastic leukemia (m ) also is well recognized in dogs , - and may be associated with platelet dysfunction. monocytic leukemias have likely included those with and without monocytic differentiation (m a and m b), , but in some cases the diagnosis may have been chronic myelomonocytic or chronic monocytic leukemia (see later discussion). there are few reports in dogs of spontaneously occurring erythroleukemia (m ) in which the leukemic cells include myeloblasts, monoblasts, and erythroid elements. [ ] [ ] [ ] auls have uncertain lineages because they are negative for all cytochemical markers. these leukemias should be distinguished from lymphoid leukemias by flow cytometric analysis of the leukemic cells for cellular antigens that identify their lineage. in addition, examination of blast cells by electron microscopy may reveal characteristic ultrastructural features. mpns, previously termed chronic myeloproliferative disorders, are characterized by excessive production of differentiated bone marrow cells, resulting in the accumulation of erythrocytes (polycythemia vera), granulocytes and/or monocytes (cml and its variants), or platelets (essential thrombocythemia). primary myelofibrosis as a clonal disorder of marrow stromal cells, characterized by proliferation of megakaryocytes and granulocytic precursors with accumulation of collagen in bone marrow, has been *references - , - , - . • myelodysplastic syndrome with erythroid predominance out this disorder. however, spurious microcytosis may be reported if a dog has many giant platelets that are counted by an analyzer as small rbcs. microscopic review of the blood film may be helpful in these cases. myelofibrosis primary myelofibrosis has been reported only rarely in dogs and is usually a secondary, or reactive, process. , in humans, myelofibrosis is characterized by collagen deposition in bone marrow and increased numbers of megakaryocytes and granulocytic precursors, many of which exhibit morphologic abnormalities. in fact, breakdown of intramedullary megakaryocytes and subsequent release of factors that promote fibroblast proliferation or inhibit collagen breakdown may be the underlying pathogenesis of the fibrosis. focal osteosclerosis is sometimes present. anemia, thrombocytopenia, splenomegaly, and myeloid metaplasia (production of hematopoietic cells outside the bone marrow) are consistent features. in dogs, myelofibrosis occurs secondary to mpds, radiation damage, and congenital hemolytic anemias. [ ] [ ] [ ] [ ] in some cases, the inciting cause is unknown (idiopathic myelofibrosis). there may be concurrent marrow necrosis in cases of ehrlichiosis, septicemia, or drug toxicity (estrogens, cephalosporins), and there is speculation that fibroblasts proliferate in response to release of inflammatory mediators associated with the necrosis. myeloid metaplasia has been reported to occur in the liver, spleen, and lung. extramedullary hematopoiesis is ineffective in preventing or correcting the pancytopenia that eventually develops. dysfunction of the hematopoietic system can be manifested by a variety of abnormalities that constitute myelodysplastic syndrome (mds). in dogs, in which the syndrome is rare, there usually are cytopenias in two or three lines in the peripheral blood (anemia, neutropenia, and/or thrombocytopenia). other blood abnormalities can include macrocytic erythrocytes and metarubricytosis. the bone marrow is typically normocellular or hypercellular, and dysplastic changes are evident in several cell lines. if blast cells are present, they make up less than % of all nucleated cells, although this threshold is being changed to less than %. , myelodysplasia is sometimes referred to as preleukemia because, in some cases, it may progress to acute leukemia. [ ] [ ] [ ] based on reported cases, poor prognostic indices include increased percentage of blast cells, cytopenias involving more than one lineage, and cellular atypia. primary mdss are clonal disorders and are considered neoplastic. complex classification schemes for human mds, based on percentages of blasts in bone marrow, cytogenetic analysis, cytopenias, need for transfusions, and other variables, comprise at least nine subtypes; their applicability to veterinary medicine is unknown. three subtypes are proposed for dogs and cats and include mds with excessive blasts (mds-eb), in which blast percentages are greater than % and less than %, and progression to aml may occur; mds with refractory cytopenia (mds-rc) with blast percentages less than % and cytopenias in one or more lineages; and mds with erythroid predominance (mds-er) in which the m : e ratio is less than and prognosis is poor. larger studies are needed to determine the utility of this classification scheme and other potential prognostic indices, such as sex, age, and felv positivity. in addition to accumulating enough cases, another confounding factor to studying and classifying mds is the presence of reversible mdss population. bcr-abl translocation has also been reported in a dog with cmol. in addition to accumulating in bone marrow and peripheral blood, leukemic cells also are found in the red pulp of the spleen, the periportal and sinusoidal areas of the liver, and sometimes lymph nodes. other organs such as the kidney, heart, and lung are less commonly affected. in addition, extramedullary hematopoiesis may be present in the liver and spleen. death is usually due to complications of infection or hemorrhage secondary to neutrophil dysfunction and thrombocytopenia. in some cases, cml may terminate in "blast crisis, " in which there is a transformation from a predominance of well-differentiated granulocytes to excessive numbers of poorly differentiated blast cells in peripheral blood and bone marrow. this phenomenon is well documented in the dog. , , basophilic and eosinophilic leukemia basophilic leukemia, although rare, has been reported in dogs and is characterized by an increased wbc count with a high proportion of basophils in peripheral blood and bone marrow. [ ] [ ] [ ] hepatosplenomegaly, lymphadenopathy, and thrombocytosis may be present. all the dogs have been anemic. basophilic leukemia should be distinguished from mast cell leukemia (mastocytosis). whether dogs develop eosinophilic leukemia remains in question. reported cases have had high blood eosinophil counts and eosinophilic infiltrates in organs. , one dog responded well to treatment with corticosteroids. the distinction between neoplastic proliferation of eosinophils and idiopathic hypereosinophilic syndrome remains elusive. disorders associated with eosinophilia such as parasitism, skin diseases, or diseases of the respiratory and gi tracts should be considered first in an animal with eosinophilia. one distinguishing feature should be clonality, with reactive eosinophilia comprising polyclonal cells and the neoplastic condition arising from a single clone. as clonality assays become more available, this discrepancy may be resolved. in humans, essential thrombocythemia, or primary thrombocytosis, is characterized by platelet counts that are persistently greater than , /µl. there are no blast cells in circulation, and marked megakaryocytic hyperplasia of the bone marrow without myelofibrosis is present. thrombosis and bleeding are the most common sequelae, and most patients have splenomegaly. other mpds, especially pv, should be ruled out, and importantly, there should be no primary disorders associated with reactive thrombocytosis. these include inflammation, hemolytic anemia, iron deficiency anemia, malignancies, recovery from severe hemorrhage, rebound from immune-mediated thrombocytopenia, and splenectomy. in addition, certain drugs such as vincristine can induce thrombocytosis. essential thrombocythemia has been recognized in dogs. , [ ] [ ] [ ] [ ] in one dog, the platelet count exceeded million/µl and bizarre giant forms with abnormal granulation were present. the bone marrow contained increased numbers of megakaryocytes and megakaryoblasts, but circulating blast cells were not seen. other findings included splenomegaly, gi bleeding, and increased numbers of circulating basophils. causes of secondary or reactive thrombocytosis were ruled out. basophilia was also reported in a more recent case. in another dog, primary thrombocytosis was diagnosed and then progressed to cml. in some cases reported in the literature as essential thrombocythemia, the dogs had microcytic hypochromic anemias. because iron deficiency anemia is associated with reactive or secondary thrombocytosis, care must be taken to rule or thrombocytopenia are usually present. occasionally, neoplastic cells can be found in cerebrospinal fluid in animals with invasion of the cns. smears of aspirates from tissues such as the lymph nodes, spleen, or liver may contain blasts but usually contribute little to the diagnostic work-up. examination of blasts stained with standard romanowsky stains may give clues as to the lineage of the cells (figure - , a to c and e). in myelomonocytic leukemia, the nuclei of the blasts are usually pleomorphic, with round to lobulated forms. in some cells, the cytoplasm may contain large azurophilic granules or vacuoles. blasts in megakaryocytic leukemia may contain vacuoles and have cytoplasmic blebs. in addition, bizarre macroplatelets may be present. although these distinguishing morphologic features may suggest a definitive diagnosis, cytochemical staining or immunophenotyping are usually required to define the lineage of the blasts. several investigators have reported modification of diagnoses following cytochemical staining. , it is especially important to distinguish aml from lymphocytic leukemia in order to provide accurate prognostic information to the owner and institute appropriate therapy. the animal leukemia group has recommended the following diagnostic criteria, summarized in figure - . using wellprepared romanowsky-stained blood and bone marrow films, a minimum of cells are counted to determine the leukocyte differential in blood and the percentage of blast cells in bone marrow and/or blood. in bone marrow, blast cells are calculated both as a percentage of all nucleated cells (anc) and nonerythroid cells (nec) and are further characterized using cytochemical markers. [ ] [ ] [ ] neutrophil differentiation is identified by positive staining of blasts for peroxidase, sudan black b, and chloracetate esterase. nonspecific esterases (alpha-naphthyl acetate esterase or alpha-naphthyl butyrate esterase), especially if they are inhibited by sodium fluoride, mark monocytes. canine monocytes may also contain a few peroxidase-positive granules. acetylcholinesterase is a marker for megakaryocytes in dogs and cats. in addition, positive immunostaining for von willebrand's factor (factor viii-related antigen) and platelet glycoproteins on the surface of blasts identifies them as megakaryocyte precursors. , [ ] [ ] [ ] [ ] [ ] alkaline phosphatase (ap) only rarely marks normal cells in dogs and cats but is present in blasts cells in acute myeloblastic and myelomonocytic leukemias. however, owing to reports of ap activity in lymphoid leukemias in dogs, its specificity as a marker for myeloid cells is not certain. omega exonuclease is a specific marker for basophils, which are also positive for chloracetate esterase activity. blood and bone marrow differential counts and cytochemical staining should be performed and interpreted by experienced veterinary cytopathologists. if erythroid cells are less than % of anc and the blast cells are greater than %, a diagnosis of aml or aul is made. if erythroid cells are greater than % of anc and the blast cells are greater than %, a diagnosis of erythroleukemia (m ) is made. if rubriblasts are a significant proportion of the blast cells, a diagnosis of m er, or erythroleukemia with erythroid predominance, can be made. it should be noted that in the human aml classification system, the blast threshold has been lowered to % and similar recommendations are being made for aml in dogs and cats. in some cases, electron microscopy is required to identify the lineage of the blast cells. for example, megakaryocyte precursors are positive for platelet peroxidase activity and contain demarcation membranes and alpha granules. , both of these features are detected at the ultrastructural level. immunophenotyping, used to identify cell lineages in human patients, awaits development of that occur secondary to immune-mediated, infectious, and other diseases in both dogs and cats. dogs with myeloid neoplasms have similar presentations regardless of the specific disease entity, although animals with aml have a more acute onset of illness and a more rapid clinical course. a history of lethargy, inappetence, and weight loss is common. clinical signs include emaciation, persistent fever, pallor, petechiation, hepatosplenomegaly, and, less commonly, lymphadenopathy and enlarged tonsils. shifting leg lameness, ocular lesions, and recurrent infections are also seen. vomiting, diarrhea, dyspnea, and neurologic signs are variable features. serum biochemical analytes may be within the reference intervals but can change if significant organ infiltration occurs. animals with mds may be lethargic and anorectic and have pallor, fever, and hepatosplenomegaly. in pv, dogs often have erythema of mucous membranes owing to the increase in rbc mass. some dogs are polydipsic. in addition, neurologic signs such as disorientation, ataxia, or seizures may be present and are thought to be the result of hyperviscosity or hypervolemia. hepatosplenomegaly is usually absent. peripheral blood abnormalities are consistently found. in addition to the presence of neoplastic cells, other abnormalities, including cytopenias of any lineage, may be present. low numbers of nucleated rbcs are present in the blood of about half the dogs with acute nonlymphocytic leukemia. nonregenerative anemia and thrombocytopenia are present in most cases. anemia is usually normocytic and normochromic, although macrocytic anemia is sometimes present. pathogenic mechanisms include effects of inhibitory factors leading to ineffective hematopoiesis, myelophthisis, immune-mediated anemia secondary to neoplasia, and hemorrhage secondary to thrombocytopenia, platelet dysfunction, or dic. anemia is most severe in aml, although both anemia and thrombocytopenia may be milder in animals with the m subtype (acute monocytic leukemia). in myelofibrosis, the anemia is characterized by anisocytosis and poikilocytosis. in addition, pancytopenia and leukoerythroblastosis, in which immature erythroid and myeloid cells are in circulation, may be present. these phenomena probably result from replacement of marrow by fibrous tissue with resultant shearing of red cells and escape of immature cells normally confined to bone marrow. in pv, the pcv is increased, usually in the range of % to %. the bone marrow is hyperplastic, and the m : e ratio is usually in the normal range. neoplastic cells are often defective functionally. platelet dysfunction has been reported in a dog with acute megakaryoblastic leukemia (m ), and in cml, neutrophils have decreased phagocytic capacity and other abnormalities. one exception to this was a report of cml in a dog in which the neutrophils had enhanced phagocytic capacity and superoxide production. the authors hypothesized that increased synthesis of gm-csf resulted from a lactoferrin deficiency in the neoplastic neutrophils and mediated the enhanced function of these cells. in all cases of myeloid neoplasms, diagnosis depends on examination of peripheral blood and bone marrow. aml is diagnosed on the basis of finding blast cells with clearly visible nucleoli in blood and bone marrow. most dogs with acute leukemia have circulating blasts. these cells may be present in low numbers in peripheral blood, and a careful search of the smear, especially at the feathered edge, should be made. even if blasts are not detected in circulation, indications of bone marrow disease such as nonregenerative anemia increases in these cell types. in order to make a diagnosis of pv, it must first be established that the polycythemia is absolute rather than relative. in relative polycythemias, plasma volume is decreased from hemoconcentration, dehydration, or hypovolemia, and the absolute rbc mass is not increased. splenic contraction can also result in relative polycythemia. absolute polycythemia, in which rbc mass is increased, is usually secondary to tissue hypoxia, causing appropriate increased production of erythropoietin. rarely, erythropoietin may be produced inappropriately by a tumor (e.g., renal cell carcinoma) or in renal disease (pyelonephritis) or localized renal hypoxia. [ ] [ ] [ ] these causes of polycythemia should be eliminated by appropriate laboratory work, thoracic radiographs, arterial blood gas analysis, and renal ultrasonography. in humans with pv, plasma erythropoietin (epo) levels are low. epo levels in dogs with pv tend to be low or low-normal, whereas in animals with secondary absolute polycythemia, the levels are high. , samples for determination of epo concentrations should be taken prior to therapeutic phlebotomy used to treat hyperviscosity and, owing to fluctuations in epo levels, should be repeated if results are incongruous with other information. there are no pathognomonic features of cml in dogs, and other common causes for marked leukocytosis with a left shift ("leukemoid reaction") and granulocytic hyperplasia of bone marrow must be eliminated. these include infections, especially pyogenic ones; immune-mediated diseases; and other malignant neoplasms. in cml, maturation sometimes appears disorderly, and there may be variation in the size and shape of neutrophils at the same level of maturation. in addition, neoplastic leukocytes may disintegrate more rapidly and appear vacuolated. because of the invasive nature of cml, biopsy of liver or spleen may also help to distinguish true leukemia from a leukemoid reaction, assuming the animal can tolerate the procedure. if characteristic cytogenetic abnormalities can be found in dogs with cml, this analysis may be helpful. basophilic leukemia is diagnosed by finding excessive numbers of basophils in circulation and in bone marrow. basophilic leukemia must be differentiated from mastocytosis based on the morphology of the cell type present. basophils have a segmented nucleus and variably sized granules, whereas mast cells have a round-to-oval nucleus that may be partially or totally obscured by small, round, metachromatic-staining granules. this distinction is usually easy to make; however, in basophilic leukemia, changes in the morphology of the nucleus and granules make the distinction less clear. essential thrombocythemia has been diagnosed based on finding persistent and excessive thrombocytosis (> , /µl) without circulating blast cells and in the absence of another mpd (e.g., pv), myelofibrosis, or disorders known to cause secondary thrombocytosis. these include iron deficiency anemia, chronic inflammatory diseases, recovery from severe hemorrhage, rebound from immune-mediated thrombocytopenia, and absence of a spleen. thrombocytosis is transient in these disorders or abates with resolution of the primary disease. in essential thrombocythemia, platelet morphology may be abnormal, with bizarre giant forms and abnormal granulation. in the bone marrow, megakaryocytic hyperplasia is a consistent feature, and dysplastic changes may be evident in megakaryocytes. spurious hyperkalemia may be present in serum samples from dogs with thrombocytosis from any cause due to the release of potassium from platelets during clot formation. measuring potassium in plasma is recommended in these cases and usually demonstrates a potassium concentration within reference interval. platelet aggregability has been appropriate markers for animal species (see later). increasingly, cytogenetic abnormalities are being identified in animal leukemias; cytogenetic analysis may yield important diagnostic and prognostic information and become a valuable tool for identifying targeted therapeutic approaches. although morphologic and cytochemical analyses have formed the mainstay of cell identification, newer technologies now are routinely used to classify leukemias by using monoclonal antibodies to detect antigens associated with certain cell types. cells can be immunophenotyped using flow cytometric analysis or immunocytochemistry. , , [ ] [ ] [ ] [ ] cells from both acute lymphoid leukemia and aml are positive for cd . many lymphocyte markers, including cd , cd , cd , cd , cd , cd , cd , and igg, are available for dogs and can be used to rule out lymphoblastic leukemia in dogs with acute leukemias. , other markers include myeloperoxidase (mpo) and cd b for myeloid cells and cd for megakaryoblasts. there is some overlap in expression of these cellular antigens. for example, canine (but not human) granulocytes express cd . it is best to use a panel of antibodies (similar to using a battery of cytochemical stains) because antigens are often expressed on multiple lineages, and lineage infidelity can occur. these tests have become more valuable with the availability of canine reagents. currently, the acvp oncology committee recommends that the following immunophenotyping panel be done on bone marrow and/ or blood smears to characterize animal leukemias: for b lymphocytes, cd a; for t lymphocytes, cd ; for myeloid cells, mpo and cd b; for megakaryoblasts, cd ; for dendritic cells, cd c; and for acute leukemias, cd . because of the degree of differentiation of cells in mpn, these disorders must be distinguished from nonneoplastic causes of lymphoma, could be used as maintenance therapy. , another protocol that has been used in treating acute myeloblastic leukemia is presented in table - . regardless of the chemotherapy protocol used, significant bone marrow suppression will develop, and intensive supportive care will be necessary. transfusions of whole blood or platelet-rich plasma may be required to treat anemia and thrombocytopenia, and infection should be managed with aggressive antibiotic therapy. because of the generally poor response, the major thrust of therapy may be to provide palliative supportive care. in treating pv, therapy is directed at reducing rbc mass. the pcv should be reduced to % to % or by one-sixth of its starting value; phlebotomies should be performed as needed, administering appropriate colloid and crystalloid solutions to replace lost electrolytes; ml of whole blood/kg of body weight can be removed at regular intervals. in humans, phlebotomy continues to be the therapeutic approach used most frequently. radiophosphorus ( p) has been shown to provide long-term control but can only be used in specialized centers. the chemotherapeutic drug of choice is hydroxyurea, an inhibitor of dna synthesis. this drug should be administered at an initial dose of mg/kg for days and then reduced to mg/kg po daily. the major goal of treatment is to maintain the pcv as close to normal as possible. cml is best managed with chemotherapy to control the proliferation of the abnormal cell line and improve the quality of life. hydroxyurea is the most effective agent for treating cml during the chronic phase. , the initial dosage is to mg/kg twice daily. treatment with hydroxyurea should continue until the leukocyte count falls to , to , cells/µl. , , then the dosage of hydroxyurea can be reduced by % on a daily basis or to mg/ kg given biweekly or triweekly. in humans, the alkylating agent busulfan can be used as an alternative. an effective dosage has not been established in the dog, but following human protocols, . mg/kg/day po is given until the leukocyte count is reduced to , to , cells/µl. variably reported as impaired or enhanced. in the one dog in which it was measured, the plasma thrombopoietin (tpo) concentration was normal. it is unclear whether tpo plays a role in essential thrombocythemia or is suppressed by the high platelet mass. elucidation of the pathogenesis of this disorder should be aided by the recent cloning of the genes for thrombopoietin and its receptor, the proto-oncogene mpl. in mds, abnormalities in two or three cell lines are usually manifested in peripheral blood as neutropenia with or without a left shift, nonregenerative anemia, or thrombocytopenia. other changes include macrocytosis and metarubricytosis. the bone marrow is typically normocellular or hypercellular with an increased m : e ratio, and blasts cells, although increased, constitute less than % of nucleated cells; in a report of dogs with primary or secondary mds, in all but one dog the blast cell percentage was less than %. dysplastic changes can be detected in any cell line. dyserythropoiesis is characterized by asynchronous maturation of erythroid cells typified by large hemoglobinized cells with immature nuclei (megaloblastic change). if the erythroid component is dominant, the mds is called mds-er (see table - ) . , in dysgranulopoiesis, giant neutrophil precursors and abnormalities in nuclear segmentation and cytoplasmic granulation can be seen. finally, dysthrombopoiesis is characterized by giant platelets and micromegakaryocytes. myelofibrosis should be suspected in animals with nonregenerative anemia or pancytopenia, abnormalities in erythrocyte morphology (especially shape), and leukoerythroblastosis. bone marrow aspiration is usually unsuccessful, resulting in a "dry tap. " this necessitates a bone marrow biopsy taken with a jamshidi needle. the specimen is processed for routine histopathologic examination, and if necessary, special stains for fibrous tissue can be used. because myelofibrosis occurs secondary to other diseases of bone marrow such as chronic hemolytic anemia or bone marrow necrosis, the clinician should look for a primary disease process. treatment of acute nonlymphocytic leukemias has been unrewarding to date. however, we have little information on the response of specific subtypes of leukemia to uniform chemotherapeutic protocols, in part due to the rarity of these disease processes and the paucity of cases in the literature. the veterinarian is advised to contact a veterinary oncologist for advice on new protocols and appropriate management of these cases. the therapeutic goal is to eradicate leukemic cells and reestablish normal hematopoiesis. currently, this is best accomplished by cytoreductive chemotherapy, and the agents most commonly utilized include a combination of ara-c plus an anthracycline, such as doxorubicin or cyclophosphamide, vincristine, and prednisone.* in humans, the introduction of cytosine arabinoside has been the single most important development in the therapy of acute nonlymphocytic leukemia. in dogs, ara-c, to mg/m , given by slow infusion ( to hrs) daily for days and repeated weekly, has been used, as well as several other variations using subcutaneous injections of cytosine (see chapter ) . doxorubicin, mg/m iv every to weeks, can be administered at intervals alternating with ara-c. if remission is achieved, as evidenced by normalization of the hemogram, the coap protocol (cyclophosphamide, vincristine (oncovin), ara-c, and prednisone), as described for canine • benzene (chronic exposure), and alkylating agents. new classification systems have incorporated genetic mutations, more accurately reflect prognoses, and facilitate use of consistent categorization among institutions. therapeutic modalities under investigation or development include combination chemotherapy, immunotherapy, cytokine therapy, drug-resistance modulators, proapoptotic agents, antiangiogenic factors, signal transduction-active agents, and bone marrow transplantation. the prognosis for mpn is better than for aml. for acute nonlymphocytic leukemias, the prognosis is better for children than adults, with only % of adults receiving chemotherapy maintaining remissions for more than years. the spontaneous canine diseases probably occur too infrequently to serve as useful models. myeloid neoplasms have been induced experimentally in the dog by irradiation and transplantation in an attempt to create models for study. many similarities between human and canine myeloid neoplasms exist, and veterinary medicine may benefit from any therapeutic advances made in the human field. despite response to chemotherapy and control for many months, most dogs with cml will eventually enter a terminal phase of their disease. in one study of seven dogs with cml, four underwent terminal phase blast crisis. in humans, blast crisis may be lymphoid or myeloid. in dogs, it is usually difficult to determine the cell of origin. these dogs have a poor prognosis, and the best treatment to consider, if any, would be that listed in table - . it has now been documented that a subset of cml in dogs may be associated with a bcr-abl chromosomal abnormality (the so-called "raleigh chromosome") similar to the "philadelphia chromosome" translocation responsible for a large majority of cml in humans. while imatinib mesylate (gleevec) is known to be an effective therapy for cml in humans, bcr-abl kinase inhibitors have, as yet, not been investigated for this subset of cml in dogs. few cases have been reported, but one dog was treated successfully with a combination chemotherapy protocol that included vincristine, ara-c, cyclophosphamide, and prednisone. treatment is controversial in humans because of the lack of evidence that asymptomatic patients benefit from chemotherapy. patients with thrombosis or bleeding are given cytoreductive therapy. hydroxyurea is the drug of choice for initially controlling the thrombocytosis. there is no standard therapeutic regime for mds. often, humans receive no treatment if the cytopenias do not cause clinical signs. transfusions are given when necessary, and patients with fever are evaluated aggressively to detect infections. growth factors, such as epo, gm-csf, g-csf, and il- , are sometimes used in patients who require frequent transfusions to increase their blood cell counts and enhance neutrophil function. , in one case report, human epo was administered ( u/kg sq, every hours) to a dog with mds because of profound anemia. the rationale for use of epo was to promote terminal differentiation of dysplastic erythrocytes. the pcv increased from % to % by day of epo treatment. this dog remained in remission for more than months. other factors that induce differentiation of hematopoietic cells include retinoic acid analogs, , dihydroxyvitamin d , interferon-α, and conventional chemotherapeutic agents, such as -thioguanine and ara-c. the propensity of these factors to enhance progression to leukemia is not known in many cases, but the potential risk exists. in general, the prognosis for animals with mpn is better than for dogs with aml, in which it is grave. the prognosis for pv and cml is guarded, but significant remissions have been achieved with certain therapeutic regimes and careful monitoring. animals commonly survive a year or more. , development of blast crisis portends a grave prognosis. the pathophysiology and therapy of nonlymphocytic leukemia in humans are being studied intensively. myeloid neoplasms have been demonstrated to be clonal, with abnormalities evident in all hematopoietic cell lines. leukemogenesis is likely caused by mutation or amplification of proto-oncogenes in a two-step process that initially involves a single cell and is followed by additional chromosomal alterations that may involve oncogenes. , these alterations are manifested as cytogenetic abnormalities. environmental factors known to cause leukemia are exposure to high-dose radiation, blurring of the distinction between mm and multicentric noncutaneous emp in cats and these two mrds will be discussed together in this species. although mm represents less than % of all malignant tumors in animals, it is responsible for approximately % of all hematopoietic tumors and . % of all primary and secondary tumors affecting bone in dogs. , in a compilation of bone marrow disorders in dogs (n = ), mm represented . % and . % of all abnormal samples and neoplastic processes, respectively. further, in a compilation of serum protein electrophoretic samples (n = dogs), mm accounted for . % of abnormal and . % of neoplastic processes encountered, respectively. early studies suggested a male predisposition, although subsequent reports have not supported this. , older dogs are affected with an average age of between and years. , , in one large case series, german shepherd dogs were overrepresented based on the hospital population. the true incidence of mm in the cat is unknown; however, it is a more rare diagnosis than in the dog, representing only of and of tumors in two large compilations of feline malignancies and . % of all malignancies and . % of hematologic malignancies in another report. - mm represented . % and % of abnormal and malignant serum protein electrophoretic samples, respectively, in a compilation of feline samples. mm occurs in aged cats (median age to years), most commonly in domestic short hairs and no sex predilection has been consistently reported, although a male preponderance may exist. , , , mm has not been associated with corona virus or felv or fiv infections. the etiology of mm is for the most part unknown. genetic predispositions, molecular aberrations (e.g., c-kit), viral infections, chronic immune stimulation, and exposure to carcinogen stimulation have all been suggested as contributing factors. , - suggestion of a familial association in cats follows cases reported among siblings. evidence exists that molecular mechanisms of cellular control, including overexpression of cell cycle control components like cyclin d (see chapter ) and receptor tyrosine kinase dysregulation may be involved in canine myeloma and plasma cell tumors. , in rodent models, chronic immune stimulation and exposure to implanted silicone gel have been associated with development of mm, , as have chronic infections and prolonged hyposensitization therapy in humans. viral aleutian disease of mink results in monoclonal gammopathies in a small percentage of cases. exposure to the agricultural industry, petroleum products, and irradiation are known risk factors for development in humans. [ ] [ ] [ ] additionally, progression of solitary plasma cell tumors to mm has been reported in both dogs and cats, and a single case of a b-cell lymphoma progressing to mm exists in the dog. , pathology and natural behavior multiple myeloma is a systemic proliferation of malignant plasma cells or their precursors arising as a clone of a single cell that usually involves multiple bone marrow sites in dogs. in cats, as previously stated, a blurring of the distinction of mm and multicentric noncutaneous emp within the mrd occurs because widespread abdominal organ involvement without significant bone marrow infiltration has been described in a significant proportion of cases in european compilations. , because both mm and multicentric noncutaneous emp have a similar clinical course and widespread systemic involvement with hyperglobulinemia in cats, they will be  section d ig-secreting lymphomas and leukemias (including plasma cell leukemia). mm is the most important mrd based on clinical incidence and severity. there appears to be some discordance and below ° c and require blood collection and clotting to be performed at ° c prior to serum separation. if whole blood is allowed to clot at temperatures below this, the protein precipitates in the clot and is lost. pure light-chain m component is rare but has been reported in both dogs and cats. , the pathology associated with mm is a result of either high levels of circulating m component, organ or bone infiltration with neoplastic cells, or both. associated pathologic conditions include bone disease, bleeding diathesis, hyperviscosity syndrome, renal disease, hypercalcemia, immunodeficiency (and subsequent susceptibility to infections), cytopenias secondary to myelophthisis, and cardiac failure. bone lesions can be isolated, discrete osteolytic lesions (including pathologic fractures) (figure - , a) or diffuse osteopenias, or both (figure - ) . approximately one-quarter to two-thirds of dogs with mm have radiographic evidence of bony lysis or diffuse osteoporosis. , , the incidence of radiographic skeletal lesions in cats varies tremendously within reports, from as few as % in european case series to as high as % in north american case series. , , , , those bones engaged in active hematopoiesis are more commonly affected and include the vertebrae, ribs, pelvis, skull, and proximal or distal long bones. skeletal lesions are rare with igm (waldenström's) macrogammaglobulinemia, in which malignant cells often infiltrate the spleen, liver, and lymph tissue rather than bone. , [ ] [ ] [ ] bleeding diathesis can result from one or a combination of events. m components may interfere with coagulation by ( ) inhibiting platelet aggregation and the release of platelet factor- ; ( ) causing adsorption of minor clotting proteins; ( ) generating abnormal fibrin polymerization; and ( ) producing a functional decrease in calcium. to very large anaplastic round cells (often referred to as plasmablasts), with a high mitotic index representing early stages of differentiation. , , , , binucleate and multinucleate cells are often present (see figure - , chapter ). in cats with mm in a north american case series, the majority ( %) of plasma cells were immature and had marked atypia, including increased size, multiple nuclei, clefted nuclei, anisocytosis, anisokaryosis, variable n : c ratios, decreased chromatin density, and variable nucleoli; nearly one-quarter had "flame cell" morphology characterized by peripheral eosinophilic cytoplasmic processes. however, in a european compilation of feline multicentric noncutaneous mrd cases (n = ), % had well-differentiated morphologies. the authors of this latter case series developed a grading system dependent on the percentage of plasmablasts within the neoplastic cells in which well-differentiated, intermediate-grade, and poorly differentiated have less than %, % to %, and % or more plasmablasts, respectively. malignant plasma cells typically produce an overabundance of a single type of or component of immunoglobulin, which is referred to as the m component (figure - ) . the m component can be represented by any class of the entire immunoglobulin or only a portion of the molecule, such as the light chain (bence jones protein) or heavy chain (heavy chain disease) of the molecule. in the dog, the m component is usually represented by either iga or igg immunoglobulin types in nearly equal incidence, whereas the ratio of igg : iga in cats is approximately : in some reports and approximately : in others. , [ ] [ ] [ ] [ ] [ ] , that being said, in the author's (dmv) experience, the vast majority of canine cases are of the iga type. if the m component is the igm type, the term macroglobulinemia (waldenström's) is often applied. several cases of biclonal gammopathy in dogs and cats have been reported. , , , [ ] [ ] [ ] [ ] [ ] [ ] several cases of nonsecretory mm have been reported in dogs. , rarely, cryoglobulinemia occurs in dogs with mm and igm macroglobulinemia and has been reported in a cat with igg myeloma. , [ ] [ ] [ ] cryoglobulins are paraproteins that are insoluble at temperatures a b nonneoplastic immunoglobulin production. in the case of mm, an unbalanced excess of light-chain products may be produced. light chains are of low molecular weight and are normally filtered by the renal glomerulus, and their presence in urine can result in protein precipitates and subsequent renal tubular injury. the presence of light chains in urine without a concomitant monoclonal spike in serum, although rare, is indicative of pure light-chain disease. tubules become obstructed by large laminated casts containing albumin, immunoglobulin, and light chains. , , , bence jones proteinuria occurs in approximately % to % of dogs with mm. , , bence jones proteinuria is reported to occur in approximately % of cats with mm/mrd. , hypercalcemia is reported in % to % of dogs with mm and is thought to result primarily from the production of osteoclast-activating factor by neoplastic cells. , , other factors, including increased levels of various cytokines, tnf, il- , and il- have been implicated in human mm. in two dogs with mm and hypercalcemia, serum elevations in circulating n-terminal pthrp were noted. hypercalcemia may also be exacerbated by associated renal disease. hypercalcemia, initially thought to be a rare event in cats with mm, occurred in % to % of recently reported cases. , , , susceptibility to infection and immunodeficiency have long been associated with mm and are often the ultimate cause of death in affected animals. , , infection rates in humans with mm are fifteen times higher than normal and usually represent pneumonia or urinary tract infections. response to vaccination has also been shown to be suppressed in humans with mm. immunoglobulin levels are often severely depressed in affected animals. in addition, leukopenias may be present secondary to myelophthisis. variable cytopenias may be observed in association with mm. a normocytic, normochromic, nonregenerative anemia is encountered in approximately two-thirds of dogs with mm. , , this can result from marrow infiltration (myelophthisis), blood loss from coagulation disorders, anemia of chronic disease, or increased erythrocyte destruction secondary to high serum viscosity. rare erythrophagocytic forms of mm have also been reported in both dogs and cats and may contribute to anemia. , similar factors lead to thrombocytopenia and leukopenia in nearly one-third and onequarter of dogs with mm, respectively. in cats, approximately twothirds, half, and one-third will be anemic, thrombocytopenic, and neutropenic, respectively. , , cardiac disease if present is usually a result of excessive cardiac workload and myocardial hypoxia secondary to hyperviscosity. , , myocardial infiltration with amyloid and anemia may be complicating factors. nearly half of cats with mm in one report presented with a cardiac murmur, the etiology of which was not established. three cats with hvs presented with congestive heart failure, murmurs, and echocardiographic signs consistent with hypertrophic cardiomyopathy. clinical signs of mm may be present up to a year prior to diagnosis with a median duration of one month reported in dogs. , in one cat, m-component elevations were detected years prior to clinical presentation. in this latter case, the m-component elevation was consistent with monoclonal gammopathy of unknown significance (mgus). mgus (i.e., benign, essential, or idiopathic monoclonal gammopathy) is a benign monoclonal gammopathy that is not associated with osteolysis, bone marrow infiltration, or bence jones proteinuria. mgus has also been reported in dogs. , signs of mm can be variable based on the wide range of pathologic effects one-quarter of cats have clinical evidence of hemorrhage. , , , in dogs, nearly half have abnormal prothrombin (pt) and partial thromboplastin (ptt) times. thrombocytopenia may also play a role if bone marrow infiltration is significant (i.e., myelophthisis). hyperviscosity syndrome (hvs) represents one of a constellation of clinicopathologic abnormalities resulting from greatly increased serum viscosity. the magnitude of viscosity changes is related to the type, size, shape, and concentration of the m component in the blood. hvs is more common with igm macroglobulinemias due to the high molecular weight of this class of immunoglobulin. iga-secreting myelomas (usually present as a dimer in the dog), may undergo polymerization resulting in increased serum viscosity. , , igg-associated hvs can also occur, albeit less frequently. high serum viscosity occurs in approximately % of dogs with mm and can result in bleeding diathesis, neurologic signs (e.g., dementia, depression, seizure activity, coma), ophthalmic abnormalities (e.g., dilated and tortuous retinal vessels, retinal hemorrhage [ figure - ], retinal detachment), and increased cardiac workload with the potential for subsequent development of cardiomyopathy.* these consequences are thought to be a result of sludging of blood in small vessels, ineffective delivery of oxygen and nutrients, and coagulation abnormalities. hvs has been reported in cats with igg-, iga-, and igm-secreting tumors. , , [ ] [ ] [ ] [ ] [ ] in several of these cases, relative serum viscosity was increased above control ranges. renal disease is present in approximately one-third to one-half of dogs with mm, and azotemia was observed in one-third of cats in one report. , , , the pathogenesis of renal failure is often multifactorial and can ensue as a result of bence jones (light-chain) proteinuria, tumor infiltration into renal tissue, hypercalcemia, amyloidosis, diminished perfusion secondary to hyperviscosity syndrome, dehydration, or ascending urinary tract infections. , , , normally, heavy-and light-chain synthesis is well balanced in serum biochemistry profile, and urinalysis. particular attention should be paid to renal function and serum calcium levels. if clinical hemorrhage is present, a coagulation assessment (e.g., platelet count, pt, ptt) and serum viscosity measurements are indicated. all animals should undergo a careful funduscopic examination. serum electrophoresis and immunoelectrophoresis are performed to determine the presence of a monoclonal m component (see and to categorize the immunoglobulin class involved. heat precipitation and electrophoresis of urine may be performed to determine presence of bence jones proteinuria possible. tables - and - list the relative frequencies of clinical signs observed in the dog and cat, respectively, based on a compilation of several reports.* bleeding diathesis is usually represented by epistaxis and gingival bleeding. funduscopic abnormalities may include retinal hemorrhage (see figure - ), venous dilatation with sacculation and tortuosity, retinal detachment, and blindness. † cns signs may include dementia, seizure activity, tremors, and deficiencies in midbrain or brain-stem localizing reflexes secondary to hvs or extreme hypercalcemia. signs reflective of transverse myelopathies secondary to vertebral column infiltration, pathologic fracture, or extradural mass compression can also occur. , , , , one case of ataxia and seizure activity in a dog with emp secondary to tumor-associated hypoglycemia has been reported. additionally, paraneoplastic polyneuropathy has been reported in a dog with mm. a history of chronic respiratory infections and persistent fever may also be present in cats. hepatosplenomegaly and renomegaly can occur due to organ infiltration. bleeding diathesis due to hvs is less common in the cat; however, epistaxis, pleural and peritoneal hemorrhagic effusions, retinal hemorrhage, and central neurologic signs have been reported. , , [ ] [ ] [ ] [ ] [ ] polydipsia and polyuria can occur secondary to renal disease or hypercalcemia, and dehydration may develop. hindlimb paresis secondary to osteolysis of lumbar vertebral bodies or extradural compression has been reported in cats. , diagnosis and staging the diagnosis of mm in dogs usually follows the demonstration of bone marrow plasmacytosis (see , the presence of osteolytic bone lesions (see , and the demonstration of serum or urine myeloma proteins (m component) (see . in the absence of osteolytic bone lesions, a diagnosis can also be made if marrow plasmacytosis is associated with a progressive increase in the m component. in the cat, because the degree of bone marrow infiltration may not be as marked, it has been suggested that consideration of plasma cell morphology and visceral organ infiltration (figure - ) be given in cases with demonstrable m-component disease in the absence of marked (< %) marrow plasmacytosis. , , all animals suspected of plasma cell tumors should receive a minimal diagnostic evaluation including a cbc, platelet count, • because commercial urine dipstick methods are not capable of this determination. definitive diagnosis usually follows the performance of a bone marrow aspiration in the dog. a bone marrow core biopsy or multiple aspirations may be necessary due to the possibility of uneven clustering or infiltration of plasma cells in the bone marrow. normal marrow contains less than % plasma cells, whereas myelomatous marrow often greatly exceeds this level. current recommendations require more than % marrow plasmacytosis to be present, although a % cutoff in cats has been recently recommended with special attention to cellular atypia. even the % threshold is problematic in cats, and cellular atypia and visceral organ involvement (assessed through needle aspiration cytology or tissue biopsy) should be considered equally important in the species. , , rarely, biopsy of osteolytic lesions (i.e., jamshidi core biopsy; see chapter ) is necessary for diagnosis in the dog. in one case of mm in a dog, splenic aspirates were diagnostically helpful. overall frequencies of clinical diagnostic abnormalities for dogs and cats with mm are compiled from published series having at least five cases each and are listed in table - . histochemical and immunohistochemical analyses of cells or tissues suspected of mrd are more often applied in the case of solitary plasmacytomas or where emp is suspected in the absence of marrow involvement and will be discussed in subsequent sections; however, they have been occasionally useful in the diagnosis of mm. molecular diagnostic techniques for mm have received limited use thus far in veterinary oncology; however, determining clonality of the immunoglobulin heavy chain variable region gene has been performed in feline plasmacytoma and myeloma using parr techniques (see chapter ), and use of this technology in cases where diagnosis is not straightforward awaits further investigation. the author has used parr analysis both before treatment and after clinical remission in a small number of dogs with mm involved in clinical trials and documented its utility ( ) for initial diagnosis and ( ) to characterize molecular remission. routine thoracic and abdominal radiographs are recommended in suspected cases. occasionally, bony lesions can be observed in skeletal areas on these standard films, and organomegaly (liver, spleen, kidney) is observed in the majority of cats. , abdominal ultrasound is recommended in all cats suspected of mm because this modality reveals involvement of one or more abdominal organs in the majority of cases. , these include splenomegaly with or without nodules, diffuse hyperechoic hepatomegaly with or without nodules, renomegaly, and iliac lymph node enlargement. in one case series in cats, % of organs with ultrasonographic abnormalities were subsequently confirmed to have plasma cell infiltration. skeletal survey radiographs are recommended to determine presence and extent of osteolytic lesions, which may have diagnostic, prognostic, and therapeutic implications. although nuclear scintigraphy (bone scan) for clinical staging of dogs with mm has been performed, due to the predominant osteolytic activity with osteoblastic inactivity present, scans seldom give positive results and are therefore not useful for routine diagnosis. in physician-based oncology, bone mineral density analysis (dual-energy x-ray absorptiometry [dexa] scan) to document osteoporosis, mri scan of bone marrow, and pet/ct are commonly used for staging; however, these modalities have not been applied consistently in the veterinary literature. a clinical staging system for canine mm has been suggested ; however, at present, no prognostic significance has been attributed to it. • disease syndromes other than plasma cell tumors can be associated with monoclonal gammopathies and should be considered in any list of differentials. these include other lymphoreticular tumors (b-cell lymphoma, extramedullary plasmacytoma, chronic and acute b-lymphocytic leukemia), chronic infections (e.g., ehrlichiosis, leishmaniasis, fip), and mgus.* agent may more quickly alleviate systemic effects of the disease. cyclophosphamide is initiated at a dosage of mg/m iv, once, at the same time oral melphalan therapy is started. because cyclophosphamide is less likely to affect thrombocytes, it may be substituted in those patients in which thrombocytopenia has developed secondary to long-term melphalan use. chlorambucil, another alkylating agent, has been used successfully for the treatment of igm macroglobulinemia in dogs at a dosage of . mg/kg po, once daily. , little or no clinical signs of toxicity result from this dosing schedule. chlorambucil has also been used in cats with mrd. lomustine (ccnu), yet another alkylating agent, has been used in a limited number of cats with mm and a partial response has been reported following dosing at mg/m po, every days. evaluation of response to systemic therapy for multiple myeloma is based on improvement in clinical signs, clinicopathologic parameters, and radiographic improvement of skeletal lesions or ultrasonographic improvement of organ involvement. , , subjective improvement in clinical signs of bone pain, lameness, lethargy, and anorexia should be evident within to weeks following initiation of therapy. objective laboratory improvement, including reduction in serum globulin, immunoglobulin, and calcium, along with normalization of the hemogram, is usually noted within to weeks ( figure - ) . radiographic improvement in osteolytic bone lesions may take months and resolution may only be partial. ophthalmic complications (including long-standing retinal detachments) and paraneoplastic neuropathies can be expected to resolve along with tumor mass. , in cats responding to chemotherapy, clinical improvement is noted in to weeks and serum protein and radiographic bone abnormalities were greatly improved by weeks. , as previously discussed, complete resolution of mm does not generally occur and a good response is defined as a reduction in measured m component (i.e., immunoglobulin or bence jones proteins) of at least % of pretreatment values. reduction in serum immunoglobulin levels may lag behind reductions in bence jones proteinuria because the half-lives are to days and to hours, respectively. for routine follow-up, quantification of the increased serum globulin, immunoglobulin, or urine bence jones protein is performed monthly until a good response is noted and then every to months thereafter. repeat bone marrow aspiration or imaging (in the case of visceral disease) for evaluation of plasma cell infiltration may be occasionally necessary. bone marrow reevaluation is particularly prudent when cytopenias develop during chemotherapy, and drug-induced myelosuppression must be differentiated from myelophthisis due to neoplastic marrow recurrence. the long-term control of complications, including hypercalcemia, hvs, bleeding diathesis, renal disease, immunosuppression, ophthalmic complications, and pathologic skeletal fractures, depend on controlling the primary tumor mass. therapy directed more specifically at these complications may, however, be indicated in the short term. if hypercalcemia is marked and significant clinical signs exist, standard therapies, including fluid diureses, with or without pharmacologic agents (e.g., calcitonin), may be indicated (see chapter ) . moderate hypercalcemia will typically resolve within to days following initiation of melphalan/prednisone chemotherapy. therapy for mm is directed at both the tumor cell mass and the secondary systemic effects they elicit. all diagnostic procedures should be completed before initiating primary therapy to ensure a diagnosis is complete and baseline values are procured for monitoring response. chemotherapy is effective at reducing myeloma cell burden, relieving bone pain, allowing for skeletal healing, and reducing levels of serum immunoglobulins in the majority of dogs with mm and will greatly extend both the quality and quantity of most patients' lives. mm in dogs is initially a gratifying disease to treat for both the clinician and the companion animal owner, although complete elimination of neoplastic myeloma cells is rarely achieved and eventual relapse is to be expected. unlike dogs, only one-half of cats with mm will respond to chemotherapy and most responses will be short-lived; however, several long-term responses (i.e., > year) have been reported and treatment should be attempted when educated clients decide on a therapeutic option.* melphalan, an alkylating agent, is the chemotherapeutic of choice for the treatment of multiple myeloma. , in the dog, an initial starting dose of . mg/kg po, once daily for days, is then reduced to . mg/kg po, once daily continuously. the addition of prednisone therapy is thought to increase the efficacy of melphalan therapy. prednisone is initiated at a dosage of . mg/kg po, once daily for days, then reduced to . mg/kg every other day prior to discontinuation after days of therapy. melphalan, however, is continued at . mg/kg/day until clinical relapse occurs or myelosuppression necessitates a dose reduction. the vast majority of dogs on melphalan and prednisone combination therapy tolerate the regimen well. the most clinically significant toxicity of melphalan is myelosuppression, in particular a delayed thrombocytopenia. cbcs, including platelet counts, should be performed biweekly for months of therapy and monthly thereafter. if significant myelosuppression occurs (usually thrombocytopenia or neutropenia), reduction of the dosage or treatment frequency may be necessary. an alternative pulse-dosing regimen for melphalan ( mg/m po, daily for consecutive days every weeks) has been used successfully by the author in a small number of cases in which myelosuppression was limiting more conventional continuous low-dose therapy. this pulse-dose regimen is now being used first-line by the author with the caveat that long-term response data are currently lacking. melphalan and prednisone therapy can also be used in cats with multiple myeloma; however, it appears this protocol is more myelosuppressive than in the dog and careful monitoring is required. in the cat, a dosing schedule similar to the dog has been reported , ; . mg/kg (approximately . mg, or one-quarter of a mg tablet) once daily for to days, then every other day until clinical improvement or leukopenia develop. long-term continuous maintenance ( . mg/kg, once every days) has been advocated. an alternative protocol advocated in the cat uses melphalan at mg/ m , once every days continuously, and appears to be well tolerated. cyclophosphamide has been used as an alternative alkylating agent or in combination with melphalan in dogs and cats with mm. , , there is no evidence to suggest it is superior to melphalan therapy. in the author's practice, cyclophosphamide is limited to those cases presenting with severe hypercalcemia or with widespread systemic involvement in which a faster acting alkylating *references , , , , , . water intake at home is important, and occasionally, educating owners in subcutaneous fluid administration is indicated. continued monitoring of renal function is recommended along with follow-up directed at tumor response. patients with mm can be thought of as immunologically impaired. some have recommended prophylactic antibiotic therapy in dogs with mm ; however, in humans, no benefit for this approach over diligent monitoring and aggressive antimicrobial management when indicated has been observed. cidal antimicrobials are preferred over static drugs, and avoidance of nephrotoxic antimicrobials is recommended. pathologic fractures of weight-bearing long bones and vertebrae resulting in spinal cord compression may require immediate surgical intervention in conjunction with systemic chemotherapy. hvs is best treated in the short term by plasmapheresis.* whole blood is collected from the patient and centrifuged to separate plasma from packed cells. packed red cells are resuspended in normal saline or other crystalloid and reinfused into the patient. bleeding diathesis will usually resolve along with hvs; however, platelet-rich plasma transfusions may be necessary in the face of thrombocytopenia. renal impairment may necessitate aggressive fluid therapy in the short term and maintenance of adequate hydration in the long term. careful attention to secondary urinary tract infections and appropriate antimicrobial therapy is indicated. ensuring adequate the prognosis for dogs with mm is good for initial control of tumor and a return to good quality of life. in a group of dogs with mm, approximately % achieved a complete remission (i.e., serum immunoglobulins normalized), % achieved a partial remission (i.e., immunoglobulins < % pretreatment values), and only % did not respond to melphalan and prednisone chemotherapy. longterm survival is the norm, with a median of days reported (figure - ) . the presence of hypercalcemia, bence jones proteinuria, and extensive bony lysis are known negative prognostic indices in the dog. the long-term prognosis for dogs with mm is poor because recurrence of tumor mass and associated clinical signs is expected. eventually, the tumor is no longer responsive to available chemotherapeutics and death follows from renal failure, sepsis, or euthanasia for intractable bone or spinal pain. , the prognosis for mm in the cat is not as favorable in the short term as it is in the dog. , , , , whereas most cats (approximately %) transiently respond to melphalan/prednisone or cop-based protocols, most responses are partial and not durable. typically, cats with mm succumb to their disease within months. , , , however, long-term survivors (> year) have been occasionally reported.* in one european case series, seven cats undergoing melphalan or cop-based therapy had a median survival of . months. one investigator grouped mm in cats into two prognostic categories (table - ) based on criteria known to predict behavior in dogs. although no rigorous statistical analysis was performed on this small group of nine cats, the median survival for cats in "aggressive" and "nonaggressive" categories was days and days, respectively. experience in dogs with igm macroglobulinemia is limited. , [ ] [ ] [ ] response to chlorambucil is to be expected, and in nine treated dogs, % achieved remission with a median survival of months. orthopedic stabilization of fractures should be undertaken and may be followed with external-beam rt (see . recently, inhibition of osteoclast activity by bisphosphonate drugs has been shown to reduce the incidence and severity of skeletal complications of mm in humans. this class of drugs may hold promise for use in dogs and cats with various skeletal tumors; however, they have not been adequately evaluated in mrd. when mm eventually relapses in dogs and cats undergoing melphalan therapy or in the uncommon case that is initially resistant to alkylating agents, rescue therapy may be attempted. the author has had success with vad, which is a combination of doxorubicin ( mg/m iv, every days), vincristine ( . mg/m iv, days and ), and dexamethasone sodium phosphate ( . mg/kg iv, once a week on days , , and ), given in -day cycles. whereas most dogs initially respond to this rescue protocol, the duration of response tends to be short, lasting only a few months. high-dose cyclophosphamide ( mg/m iv, every days) has also been used with limited success as a rescue agent. liposomal doxorubicin has produced a long-term remission in a dog with mm previously resistant to native doxorubicin. mm is ultimately a uniformly fatal disease in most species, including humans, and thus significant effort is being placed on investigational therapies for this disease. currently, bone marrow ablative therapy and marrow or stem cell rescue, thalidomide (and other antiangiogenic therapies), bortezomib (a proteasome inhibitor), arsenic trioxide, the bisphosphonates, and several molecular targeting therapies are under investigation; however, their use in veterinary species is limited or completely absent at present. the promise of molecular targeted therapies is, however, foreshadowed by a case of a dog with mm that was resistant to melphalan, prednisone, and doxorubicin that subsequently achieved a partial response to tyrosine kinase inhibitor therapy (toceranib; see chapter , section b) that was maintained for months. rights were not granted to include this figure in electronic media. please refer to the printed publication. to be of low biologic aggressiveness, and most do not recur following surgical excision. conversely, the majority of sops eventually progress to systemic mm; however, the time course from local tumor development to systemic mm may be many months to years. , sops have been reported in the dog involving the appendicular skeleton, as well as the zygomatic arch, and ribs. sops are less common in cats, and fewer reports exist in the literature. , , [ ] [ ] [ ] [ ] [ ] they occur in older cats (mean ages to years), with no significant sex predilection. the skin is the most common site; however, other sites include the oral cavity, eye, gi tract, liver, subcutaneous tissues, and brain. reports exist of cutaneous emp in cats that progressed to systemic mrd. , , clinical signs associated with sops relate to the location of involvement, or in those rare cases with high levels of m component, hvs may occur. most cutaneous plasmacytomas are solitary, smooth, raised pink nodules from to cm in diameter (see figure - ), although tumors as large as cm have been reported. combining large series, greater than % occur as solitary masses and less than % occur as part of a systemic mm process. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] , cutaneous and oral emps usually have a benign course with no related clinical signs. gi emp, however, typically presents with relatively nonspecific signs, which may suggest alimentary involvement. colorectal plasmacytomas usually present with rectal bleeding, hematochezia, tenesmus, and rectal prolapse. one case of ataxia and seizure activity in a dog with emp secondary to tumor-associated hypoglycemia has been reported. sop is usually associated with pain and lameness if the appendicular skeleton is affected or neurologic signs if vertebral bodies are involved. the diagnosis of sop and emp usually requires tissue biopsy or fna for diagnosis. cells making up solitary plasmacytic tumors in both cats and dogs have been histologically classified into mature, hyaline, cleaved, asynchronous, monomorphous blastic and solitary collections of monoclonal plasmacytic tumors can originate in soft tissues or bone and are referred to as extramedullary plasmacytoma (emp) and solitary osseous plasmacytoma (sop), respectively. the systemic, multicentric, biologically aggressive emp syndrome encountered in cats , has been discussed in the mm section and will not be included in this discussion. a number of large case compilations of cutaneous plasmacytoma have been reported in the dog. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] the most common locations for emp in the dog are cutaneous ( %; figure - ), the mucous membranes of the oral cavity and lips ( %; figure - ) , and the rectum and colon ( %). the skin of the limbs and head (including the ears) are most frequently reported cutaneous sites. other sites accounted for only % of the remaining cases and can include stomach, spleen, genitalia, eye, uterus, liver, larynx, trachea, third eyelid, sinonasal cavity, and intracranial sites. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the american cocker spaniel, english cocker spaniel, and west highland white terrier (and perhaps yorkshire terriers, boxers, german shepherds, and airedale terriers) are at increased risk for developing plasmacytomas and the median age of affected dogs is to years of age. cutaneous and oral emp in dogs are typically benign tumors that are highly amenable to local therapy. there exists, however, a rare form of multiple cutaneous plasmacytomas in dogs that is part of a more generalized biologically aggressive mm process. , the natural behavior of noncutaneous/nonoral emp appears to be somewhat more aggressive in the dog. gi emp have been reported on a number of occasions in the veterinary literature, including the esophagus, stomach, , and small and large intestine. [ ] [ ] [ ] [ ] metastasis to associated lymph nodes is more common in these cases; however, bone marrow involvement and monoclonal gammopathies are less commonly encountered. colorectal emps tend • • figure - a cutaneous plasmacytoma on the limb of a dog. cases of sop in cats were recently reported; one was treated with external-beam rt and one managed with melphalan chemotherapy and both enjoyed durable remissions of greater than years. similarly, emp of the gi tract in humans are treated most commonly by surgical excision and thorough staging of disease. systemic therapy is not initiated unless systemic involvement is documented. systemic chemotherapy has been used following gastric emp in a cat; however, the utility of adjuvant therapy in the species is unknown. long-term follow-up of patients with sop is indicated in order to recognize both recurrence of disease and systemic spread. careful attention is given to serum globulin levels, bone pain, and radiographic appearance of bone healing in cases of sop. restaging of disease, including bone marrow evaluation, is indicated if systemic spread is suspected. prognosis for solitary plasma cell tumors is generally good. cutaneous and mucocutaneous plasmacytomas are usually cured following surgical excision. , , in large compilations of cases in dogs, the local recurrence rate was approximately %, and nodal or distant metastasis occurred in only of cases ( %). , [ ] [ ] [ ] new cutaneous plasmacytomas at sites distant from the primary developed in less than % of cases. neither tumor cell proliferation rate (as measured by ki immunohistochemistry) in the dog nor histopathologic grading in dogs and cats were prognostic in large compilations of cases, although it has been suggested that the polymorphous-blastic and plasmablastic type may act more aggressively in the dog and cat. , , the presence of amyloid and overexpression of cyclin d (prognostic in human plasmacytomas) were not shown to be of prognostic value in dogs. dogs with emp of the alimentary tract and other abdominal organs (e.g., liver, uterus) treated by surgical excision alone or in combination with systemic chemotherapy (if metastasis is present) can enjoy longterm survival in the majority of cases.* in a compilation of nine dogs with colorectal plasmacytoma, two dogs had local recurrence at and months following surgery, and the overall median survival was months following surgery alone. dna ploidy and c-myc oncoprotein expression in biopsy samples were determined to be prognostic for emps in dogs; however, those that were malignant were all from noncutaneous sites (i.e., lymph node, colon, spleen). therefore location appears to be as predictive. as previously discussed, the majority of cases of sop will eventually develop systemic disease; however, long disease-free periods usually precede the event. the prognosis in cats is less well-defined because of the paucity of reported cases. if disease is confined to a local site and/or regional nodes, surgical excision and chemotherapy can result in long-term control; however, early, widespread metastasis and progression to mm is also reported in cats. † survey of animal neoplasms in alameda contra costa counties, california. ii. cancer morbidity in dogs and cats from alameda county the epidemiology of canine leukemia and lymphoma cancer incidence in pet dogs: findings of the animal tumor registry of animal neoplasia: a systemic review tumors of lymphoid and hematopoietic tissue cancer statistics hormonal and sex impact on the epidemiology of canine lymphoma the occurrence of tumors in domestic reduced expression of cyclin-dependent kinase inhibitor p kip in feline lymphoma bcl- and mib- labeling indexes in cats with lymphoma environmental tobacco smoke and risk of malignant lymphoma in pet cats association between waste management and cancer in companion animals incidence and risk factors for development of malignant neoplasia after feline renal transplantation and cyclosporine-based immunosuppression the prevalence of malignant neoplasia in feline renal-transplant recipients feline epitheliotropic intestinal malignant lymphoma: cases inflammatory bowel disease mimicking alimentary lymphosarcoma in a cat tams tr: inflammatory bowel disease lymphocytic-plasmacytic enterocolitis in cats: cases gastric helicobacter species as a cause of feline gastric lymphoma: a viable hypothesis the histologic classification of cases of feline lymphoproliferative disease using the national cancer institute working formulation histological classification of hematopoietic tumors of domestic animals alimentary lymphoma in cats and dogs feline gastrointestinal lymphoma: mucosal architecture, immunophenotype and molecular clonality low-grade alimentary lymphoma: clinicopathological findings and response to treatment in cases immunophenotypic and histologic classification of cases of feline gastrointestinal lymphoma diagnostic algorithm to differentiate lymphoma from inflammation in feline small intestinal biopsy samples histopathologic classification of cases of canine and feline non-hodgkin lymphoma according to the who who classification of tumors of the haematopoietic and lymphoid tissues histopathological and immunohistochemical evaluation of cases of feline lymphoplasmacytic enteritis and low-grade alimentary lymphoma histopathologic features, immunophenotyping, clonality, and eubacterial fluorescence in situ hybridization in cats with lymphocytic cholangitis/ cholangiohepatitis molecular pathogenesis of feline leukemia virus-induced malignancies: insertional mutagenesis feline immunodeficiency virus (fiv) and feline leukemia virus (felv) infections and their relationship to lymphoid malignancies in cats: a retrospective study neoplasia associated with feline immunodeficiency virus infection in cats of southern california molecular characteristics of malignant lymphomas in cats naturally infected feline immunodeficiency virus molecular analysis of tumours from feline immunodeficiency virus (fiv)-infected cats: an indirect role for fiv characterisation of lymphosarcomas in australian cats using polymerase chain reaction and immunohistochemical examination feline immunodeficiency virus (fiv)-associated lymphoma: a potential role for immune dysfunction in tumourigenesis feline immunodeficiency virus status of australian cats with lymphosarcoma feline immunodeficiency virus integration in b-cell lymphoma identifies a candidate tumor suppressor gene on human chromosome q malignant lymphoma associated with experimentally induced feline immunodeficiency virus infection lymphosarcoma in experimentally induced feline immunodeficiency virus infection monoclonal gammopathy and lymphoma in a cat infected with feline immunodeficiency virus large granular lymphoma in a fiv-positive and felv-negative cat results of chemotherapy for cats with alimentary malignant lymphoma: cases ( - ) alimentary lymphoma in cats: cases ( - ) prognostic value of argyrophilic nucleolar organizer region (agnor) staining in feline intestinal lymphoma malignant colonic neoplasia in cats: cases n-ras mutations in a feline lymphoma: low frequency of n-ras mutations in a series of feline, canine and bovine lymphomas telomerase activity as a marker for malignancy in feline tissues molecular cloning of the feline telomerase reverse transcriptase (tert) gene and its expression in cell lines and normal tissues expression of bcl- in feline lymphoma cell lines clinical, morphological and immunohistochemical characterization of cutaneous lymphocytosis in cats sézary syndrome in a cat cutaneous lymphosarcoma and leukemia in a cat classification of feline intraocular neoplasms based on morphology, histochemical staining and immunohistochemical labeling outcome of cats with low-grade lymphocytic lymphoma: cases feline gastrointestinal lymphoma: cases ( - ) retrospective study of cases of feline lymphosarcoma diagnosis and treatment of chylothorax associated with lymphoblastic lymphosarcoma in four cats spinal lymphoma in cats: cases feline spinal lymphosarcoma: a retrospective evaluation of cats hypercalcemia in cats: a retrospective study of cases haematological and biochemical findings in cats in australia with lymphosarcoma agarose gel serum protein electophoresis in cats with and without lymphoma and preliminary results of tandem mass fingerprinting analysis molecular diagnostics of hematologic malignancies characterization of feline immunoglobulin heavy chain variable region genes for the molecular diagnosis of b-cell neoplasia characterization of feline t cell receptor gamma (tcrg) variable region genes for the molecular diagnosis of feline intestinal t cell lymphoma t-cell receptor γ chain variable and joining region genes of subgroup are clonally rearranged in feline b-and t-cell lymphoma a new subgroup of immunoglobulin heavy chain variable region genes for the assessment of clonality in feline b-cell lymphomas lymphoma in the cat: an approach to diagnosis and management ultrasonographic evaluation of the muscularis propria in cats with diffuse small intestinal lymphoma or inflammatory bowel disease comparison of endoscopic and full-thickness biopsy specimens for diagnosis of inflammatory bowel disease and alimentary tract lymphoma in cats chronic inflammatory and non-inflammatory diseases of the gastrointestinal tract in cats: diagnostic advantage of full-thickness intestinal and extraintestinal biopsies description of clinical and pathological findings, treatment and outcome of feline large granular lymphocyte lymphoma feline large granular lymphocyte (lgl) lymphoma with secondary leukemia: primary intestinal origin with predominance of a cd /cd (alpha)(alpha) phenotype natural killer-like t cell lymphoma in a cat review of thymic pathology in cats and dogs pleural effusion in cats: cases chemotherapy with cyclophosphamide, vincristine and prednisolone (cop) in cats with malignant lymphoma: new results with an old protocol t-cell-rich b-cell lymphoma in the cat feline hodgkin's-like lymphoma: cases ( - ) extranodal conjunctival hodgkin's-like lymphoma in a cat feline extranodal lymphoma: response to chemotherapy and survival in cats nasal and nasopharyngeal lymphoma in cats: cases investigation of nasal disease in the cat-a retrospective study of cases feline nasal and paranasal sinus tumours: clinicopathological study, histomorphological description and diagnostic immunohistochemistry of cases chronic nasal discharge in cats: cases survival analysis of cats with nasal lymphoma: a multi-institutional retrospective study renal lymphoma in cats: cases ( - ) intracranial neoplasia in cats: localization, tumour types and seizure patterns feline intracranial neoplasia: retrospective review of cases tumors affecting the spinal cord of cats: cases prevalence of diseases of the spinal cord of cats laryngeal disease in cats: a retrospective study of cases cutaneous epitheliotropic t-cell lymphoma in the cat: a review of the literature and five new cases cutaneous lymphosarcoma in the cat: a report of nine cases immunophenotypic characterization of cutaneous lymphoid neoplasia in the dog and cat evaluation of cholesterol and triglyceride concentrations in differentiating chylous and nonchylous pleural effusions in dogs and cats association between clinical characteristics, computed tomography characteristics, and histologic diagnosis for cats with sinonasal disease computed tomographic evidence of bulla effusions in cats with sinonasal diseases association between renal hypoechoic subcapsular thickening and lymphosarcoma in cats owners' perception of their cats' quality of life during cop chemotherapy for lymphoma therapy for australian cats with lymphosarcoma efficacy and toxicosis of vecap-c treatment of lymphoma in cats combination chemotherapy in feline lymphoma: treatment, outcome, tolerability and duration in cats response rates and survival times for cats with lymphoma treated with the university of wisconsin-madison chemotherapy protocol: cases a comparison of doxorubicin and cop for maintenance of remission in cats with lymphoma treatment and prognostic factors in lymphoma in cats: cases ( - ) chemotherapy of lymphoma in cats liposome-encapsulated doxorubicin (doxil) and doxorubicin in the treatment of vaccineassociated sarcoma in cats efficacy of doxorubicin as an induction agent for cats with lymphosarcoma single agent chemotherapy with doxorubicin for feline lymphoma: a retrospective study of cases rescue therapy with doxorubicin-based chemotherapy for relapsing or refractory feline lymphoma: a retrospective study of cases hematological toxicity and therapeutic efficacy of lomustine in tumor-bearing cats: critical assessment of a practical dosing regimen phase i evaluation of ccnu (lomustine) in tumor-bearing cats effects of l-asparaginase on plasma amino acid profiles and tumor burden in cats with lymphoma treatment of lymphoma and leukemia with cyclophosphamide, vincristine, and prednisone: ii. treatment of cats treatment of feline gastrointestinal small-cell lymphoma with chlorambucil and glucocorticoids references . lichtman ma: classification and clinical manifestations of the clonal myeloid disorders evolutionarily conserved cytogenetic changes in hematologic malignancies of dogs and humans-man and his best friend share more than companionship a report of the animal leukemia study group. proposed criteria for classification of acute myeloid leukemia in dogs and cats prognostic markers for myeloid neoplasms: a comparative review of the literature and goals for future investigation myeloproliferative disorders in animals acute myelomonocytic leukemia with neurologic manifestations in the dog acute myeloblastic leukemia in a dog a -year-old rottweiler with weight loss a potentially misleading presentation and course of acute myelomonocytic leukemia in a dog acute megakaryoblastic leukemia in one cat and two dogs acute monocytic leukemia in a dog acute nonlymphocytic leukemia in a dog morphologic classification and clinical and pathological characteristics of spontaneous leukemia in dogs the use of cytochemistry, immunophenotyping, flow cytometry, and in vitro differentiation to determine the ontogeny of a canine monoblastic leukemia hematopoietic malignancies acute myelomonocytic leukemia manifested as myelophthistic anemia in a dog acute myelomonocytic leukemia in a dog unusual cytochemical reactivity in canine acute myeloblastic leukemia acute myelomonocytic leukemia (aml-m ) in a dog with the extradural lesion a dog with acute myelomonocytic leukemia megakaryocytic leukemia in a dog myeloproliferative disorder involving the megakaryocytic line megakaryoblastic leukemia in a dog megakaryoblastic leukemia in a dog platelet dysplasia associated with megakaryoblastic leukemia in a dog radiation-induced megakaryoblastic leukemia in a dog identification and characterization of megakaryoblasts in acute megakaryoblastic leukemia in a dog acute megakaryoblastic leukemia in a dog : a report of cases and review of the literature chemotherapy in canine acute megakaryoblastic leukemia: a case report and review of the literature myeloperoxidasepositive acute megakaryoblastic leukemia in a dog cd +, cd + acute megakaryoblastic leukemia in a dog clinical, histopathological and immunohistochemical findings in a case of megakaryoblastic leukemia in a dog monocytic leukaemia in the dog erythroleukemia in a dog, pratique medicale and chirurgicale de l three cases of erythroleukemia in dogs spontaneous erythroblastic leukaemia (aml-m er) in a dog blood cell markers current opinion in hematology polycythaemia vera in a bitch polycythemia vera in a dog polycythemia vera in dogs polycythemia vera in a dog diagnosis of canine primary polycythemia and management with hydroxy-urea cytogenetic analysis of leukemic cells in the dog: a report of cases and a review of the literature trisomy in a canine acute leukemia indicating the pathogenetic importance of polysomy in leukemias of the dog canine cytogenetics-from band to base pair update on genomics in veterinary oncology classification of myeloid neoplasms: a comparative review working with canine chromosomes: current recommendations for karyotype description erythroblastic malignancy in a beagle irradiation-induced erythroleukemia and myelogenous leukemia in the beagle dog: hematology and ultrastructure acute monocytic leukemia in an irradiated beagle retrovirus-like particles associated with myeloproliferative disease in the dog hemopoietic stem cells, progenitor cells, and cytokines the hemopoietic colony stimulating factors cloning and expression of murine thrombopoietin cdna and stimulation of platelet production in vivo preleukemic syndrome in a dog clinicopathologic aspects of acute leukemias in the dog myelodysplastic syndrome in two dogs use of human recombinant erythropoietin and prednisone for treatment of myelodysplastic syndrome with erythroid predominance in a dog thrombocytosis associated with a myeloproliferative disorder in a dog myeloproliferative disease in the dog and cat: definition, aetiology and classification the leukemia complex ras, flt , and c-kit mutations in immunophenotyped canine leukemias acute myelomonocytic leukemia in a dog acute myelomonocytic leukemia in a dog clinical-pathological findings and cytochemical characterizations of myelomonocytic leukaemia in dogs acute myelomonocytic leukemia in a dog tumors of the lymphoid and hemopoietic tissues pathogenesis of myelofibrosis: role of ineffective megakaryopoiesis and megakaryocyte components megakaryozytenleukose beim hund development of a myeloproliferative disorder in beagles continuously exposed to sr pyruvate kinase deficiency anemia with terminal myelofibrosis and osteosclerosis in a beagle myelofibrosis in the dog: three case reports enhanced granulocyte function in a case of chronic granulocytic leukemia in a dog cytochemical reactions in cells from leukemic dogs cytochemical characterization of leukemic cells from dogs clinical diagnosis and management of acute nonlymphoid leukemias and chronic myeloproliferative disorders monoclonal antibodies that define canine homologues of human cd antigens: summary of the first international canine leukocyte antigen workshop (claw) hematologic abnormalities and flow cytometric immunophenotyping results in dogs with hematopoietic neoplasia: cases identification of acute myeloid leukemia in dogs using flow cytometry with myeloperoxidase, mac , and a canine neutrophil-specific antibody flow cytometric patterns in blood from dogs with non-neoplastic and neoplastic hematologic diseases using double labeling for cd and cd inappropriate erythropoietin production from a renal carcinoma in a dog with polycythemia renal carcinoma associated with secondary polycythemia in a dog secondary polycythemia associated with renal disease in the dog: two case reports and review of literature serum erythropoietin concentrations measured by radioimmunoassay in normal, polycythemic, and anemic dogs and cats serum erythropoietin concentrations in polycythemic and anemic dogs. proceedings of the th annual vet med forum (acvim) factitious hyperkalemia in dogs with thrombocytosis thrombopoietin: the primary regulator of platelet production cytologic evaluation of primary and secondary myelodysplastic syndromes in the dog how to collect diagnostic bone marrow samples kruth sa: polycythemia vera and glomerulonephritis in a dog greydanus-van-der-putten swm: polycythaemia vera in a dog treated by repeated phlebotomies polycythaemia vera in a dog polycythaemia vera in a dog identification of jak mutations in canine primary polycythemia chronic myelogenous leukemia in the dog blastic crisis in chronic myelogenous leukaemia in a dog chronic myelogenous leukaemia with meningeal infiltration in a dog chronic granulocytic leukaemia in a dog with associated bacterial endocarditis, thrombocytopenia and preretinal and retinal hemorrhages chronic granulocytic leukemia in a dog chronic myelogenous leukemia and related disorders bcr-abl translocation in a dog with chronic monocytic leukemia extreme monocytosis in a dog with chronic monocytic leukaemia a dog with myelodysplastic syndrome: chronic myelomonocytic leukemia treatment of basophilic leukemia in a dog basophilic leukemia in a dog basophilic leukemia in a dog eosinophilic leukemoid reaction in a dog chronic granulocytic leukaemia/eosinophilic leukaemia in a dog essential thrombocythemia probable essential thrombocythemia in a dog successful treatment of suspected essential thrombocythemia in the dog essential thrombocythemia in a dog: case report and literature review diagnostic and hematologic features of probable essential thrombocythemia in two dogs a review of myelofibrosis in dogs a retrospective study of the incidence and the classification of bone marrow disorders in the dog at a veterinary teaching hospital myeloproliferative disease in the dog and cat: clinical presentations, diagnosis and treatment current chemotherapeutic treatment approaches to the management of previously untreated adults with de novo acute myelogenous leukemia radiophosphorus ( p) treatment of bone marrow disorders in dogs: cases ( - ) enzymes and random synthetics busulfan versus hydroxyurea in long-term therapy of chronic myelogenous leukemia blast crisis of chronic granulocytic leukemia: morphologic variants and therapeutic implications myelodysplastic syndromes (clonal cytopenias and oligoblastic myelogenous leukemia) treatment of myelodysplastic syndromes with hematopoietic growth factors treatment of myelodysplastic syndromes with all-trans retinoic acid sustained haematological response to high dose oral alfacalcidol in patients with myelodysplastic syndrome treatment for the myelodysplastic syndromes acute myelogenous leukemia the revision of the world health organization (who) classification of the myeloid neoplasms and acute leukemia: rationale and important changes myeloma-related disorders in cats commonly present as extramedullary neoplasms in contrast to myeloma in human patients: cases with clinical follow-up multiple myelomas in cats • figure - necropsy specimen of a spleen from a cat with multiple myeloma showing diffuse plasma cell infiltration serum protein electrophoresis in dogs multiple myeloma in the dog diagnosis and management of monoclonal gammopathies a retrospective study of feline neoplasms tumors and tumor like lesions multiple myeloma in cats: a retrospective study serum protein electrophoresis in cats myeloma-related disorders in cats commonly present as extramedullary neoplasms in contrast to myeloma in human patients: cases with clinical follow-up multiple myelomas in cats a resume of the current status of the development of plasma cell tumors in mice induction of plasmacytomas with silicone gel in genetically susceptible strains of mice multiple myeloma and prolonged stimulation of res the development of myeloma-like condition in mink with aleutian disease clinico-pathological aspects of canine cutaneous and mucocutaneous plasmacytomas phase i doseescalating study of su , a small molecule receptor tyrosine kinase inhibitor, in dogs with spontaneous malignancies multiple myeloma and family history of cancer multiple myeloma: a case control study a case-control study of multiple myeloma in whites: chronic antigenic stimulation, occupation and drug use progression of a solitary, malignant cutaneous plasma-cell tumour to multiple myeloma in a cat evolution of a b-cell lymphoma to multiple myeloma after chemotherapy histopathologic, immunohistochemical, and cytologic analysis of feline myelomarelated disorders: further evidence for primary extramedullary development in the cat histological classification of hematopoietic tumors of domestic animals multiple myeloma in the cat biclonal gammopathy in a dog with myeloma and cutaneous lymphoma immunoglobulin a and immunoglobulin g biclonal gammopathy in a dog with multiple myeloma prognostic factors for multiple myeloma in the dog primary and secondary bone tumors in the dog a retrospective study of the incidence and the classification of bone marrow disorders in the dog at a veterinary teaching hospital treatment of three cats with hyperviscosity syndrome and congestive heart failure using plasmapheresis bone destruction and hypercalcemia in plasma cell myeloma parathyroid hormone (pth)-related protein, pth, and , -dihydroxyvitamin d in dogs with cancer associated hypercalcemia hypercalcemia in two cats with multiple myeloma infections complicating multiple myeloma and chronic lymphocytic leukemia erythrophagocytic multiple myeloma in a cat phagocytic plasmacytoma in a dog a benign hypergammaglobulinemia mimicking plasma cell myeloma idiopathic monoclonal (iga) gammopathy in a dog cervical cord compression as a neurologic complication in an igg multiple myeloma in a dog vertebral plasma cell tumors in dogs hypoglycemia and polyclonal gammopathy in a dog with plasma cell dyscrasia multiple myeloma with associated polyneuropathy in a german shepherd dog plasma cell sarcoma in a cat fine-needle aspiration of the spleen as an aid in the diagnosis of splenomegaly characterization of feline immunoglobulin heavy chain variable region genes for the molecular diagnosis of b-cell neoplasia plasma cell neoplasms use of plasmapheresis and chemotherapy for treatment of monoclonal gammopathy associated with ehrlichia canis infection in a dog monoclonal gammopathy associated with naturally occurring canine ehrlichiosis hyperviscosity syndrome associated with lymphocytic leukemia in three dogs monoclonal gammopathy in a dog with visceral leishmaniasis hematological toxicity and therapeutic efficacy of lomustine in tumor-bearing cats: critical assessment of a practical dosing regimen the treatment of multiple myeloma therapeutic plasmapheresis multiple myeloma in a cat bisphosphonates and cancer biclonal gammopathy associated with immunoglobulin a in a dog with multiple myeloma monoclonal gammopathies in the dog: a retrospective study of cases ( - ) and literature review multiple myeloma in cats: variable presentation with different immunoglobulin isotypes in two cats detection of biclonal gammopathy by capillary zone electrophoresis in a cat and a dog with plasma cell neoplasia nonsecretory multiple myeloma in two dogs monoclonal gammopathy without hyperglobulinemia in dogs with iga secretory neoplasm neurologic complications of iga multiple myeloma associated with cryoglobulinemia in a dog monoclonal cryoglobulinemia with macroglobulinemia in a dog monoclonal immunoglobulin g cryoglobulinemia and multiple myeloma in a domestic shorthair cat light-chain myeloma in a dog light-chain multiple myeloma in a cat different biological behaviour of waldenstrom macroglobulinemia in two dogs macroglobulinemia in the dog, the canine analogue of gamma m monoclonal gammopathy macroglobulinemia with hyperviscosity syndrome in a dog plasma cell tumors plasma cell neoplasms serum hyperviscosity syndrome associated with iga multiple myeloma in two dogs ocular lesions in a dog with hyperviscosity secondary to an iga myeloma blindness in a dog with iga-forming myeloma ophthalmic disease as the presenting complaint in five dogs with multiple myeloma immunoglobulin a myeloma in a cat with pleural effusion and serum hyperviscosity hyperviscosity syndrome with igm monoclonal gammopathy and hepatic plasmacytoid lymphosarcoma in a cat serum hyperviscosity syndrome associated with multiple myeloma in two cats serum hyperviscosity syndrome associated with igg myeloma in a cat primary igg secreting plasma cell tumor in the gastrointestinal tract of a dog colorectal plasmacytomas: a retrospective study of nine dogs metastatic extramedullary plasmacytoma of the colon and rectum in a dog solitary plasmacytomas of bone and extramedullary plasmacytomas histopathologic and immunophenotypic characterization of extramedullary plasmacytomas in nine cats intraocular extramedullary plasmacytoma in a cat extramedullary plasmacytoma and immunoglobulin-associated amyloidosis in a cat immunohistochemical staining of neoplastic and inflammatory plasma cell lesions in feline tissues immunoglobulin-producing tumours in dogs and cats identification of immunoglobulin light chains in canine extramedullary plasmacytomas by thioflavine t and immunohistochemistry immunohistochemical and histochemical stains for differentiating canine cutaneous round cell tumors immunohistochemical detection of multiple myeloma /interferon regulatory factor (mum /irf- ) in canine plasmacytoma: comparison with cd a and cd imaging diagnosis-fdg-pet/ct of a canine splenic plasma cell tumor survival data for canine oral extramedullary plasmacytoma: a retrospective analysis use of strontium- plesiotherapy for the treatment of a lingual plasmacytoma in a dog solitary plasmacytoma of bone in two successfully treated cats gastric extramedullary plasmacytoma in a cat analysis of dna aneuploidy and c-myc oncoprotein content of canine plasma cell tumors using flow cytometry response to liposomeencapsulated doxorubicin (tlc d- ) in a dog with myeloma extramedullary plasmacytomas in dogs: results of surgical excision in cases mucocutaneous plasmacytomas in dogs: cases cutaneous plasmacytomas in dogs: a morphologic and immunohistochemical study cutaneous plasmacytomas with amyloid in six dogs primary cutaneous plasmacytomas in the dog and cat an immunohistochemical study of canine extramedullary plasma cell tumours prognostic value of histopathological grading in canine extramedullary plasmacytomas extramedullary laryngeal plasmacytoma in a dog solitary extramedullary plasmacytoma of the canine larynx extramedullary plasmacytoma of the third eyelid gland in a dog sinonasal plasmacytoma in a cat solitary intracerebral plasmacytoma in a dog: microscopic, immunohistochemical, and molecular features extramedullary plasmacytoma in the trachea of a dog uterine extramedullary plasmacytoma in a dog a primary hepatic plasma cell tumor in a dog anaplastic atypical myeloma with extensive cutaneous involvement in a dog immunoglobulin a multiple myeloma with cutaneous involvement in a dog esophageal plasmacytoma in a dog extramedullary plasmacytoma of the gastrointestinal tract in two dogs for gi emp (including colorectal emp), endoscopic evaluation of the entire gi tract is recommended. a single case report of the use of pet/ct imaging for extramedullary splenic plasmacytoma in a dog exists; however, its utility remains unknown. cutaneous and oral plasma cell tumors in the dog are almost always benign and carry an excellent prognosis following conservative surgical excision. , [ ] [ ] [ ] [ ] [ ] [ ] , emps of the trachea, liver, and uterus have also been reported in dogs, and all had a benign course following local resection. [ ] [ ] [ ] successful therapy with melphalan and prednisone has been rarely applied for a local recurrence or incomplete margins in dogs and cats. rt has been used infrequently for cases that are nonsurgical, including the application of strontium- plesiotherapy for lingual plasmacytoma in a dog. surgery is recommended in combination with radiotherapy for those cases of sop in which the lesion results in an unstable, long bone fracture (see , or the patient is nonambulatory from neurologic compromise resulting from a vertebral body sop. in the latter case, spinal cord decompression, mass excision, and possibly spinal stabilization may be necessary. radiotherapy can be used alone (i.e., without surgery) in those cases where fractures are stable, as a palliative measure for bone pain, or in the case of vertebral sop if the patient is ambulatory and stable. good local control is usually achieved; however, most go on to develop systemic multiple myeloma. , , sop of the axial skeleton can be managed by excision or radiotherapy alone. there is controversy as to whether systemic chemotherapy should be initiated at the time of local therapy for sop when systemic involvement is not documented. systemic spread may not occur for many months to even years beyond primary sop diagnosis in humans and dogs, and studies in humans reveal no benefit derived from initiation of systemic chemotherapy prior to documentation of subsequent systemic spread. , two polymorphous blastic cell types; however, no prognostic significance has been observed following classification, although it has been suggested that the polymorphous-blastic type may act more aggressively in the dog. , , a different classification was proposed for emp in cats based on percentage of plasmablasts (see previous section), and some prognostic importance has been documented. in the case of poorly differentiated plasmacytic tumors, immunohistochemical studies, directed at detecting immunoglobulin, light-and heavy-chains, mm- /interferon regulatory factor- (mum /irf ), and thioflavin t, may be helpful in differentiation from other round cell tumors. , , , [ ] [ ] [ ] [ ] [ ] immunoreactivity has been demonstrated for canine igg f(ab) and vimentin. a variant characterized by an igg-reactive amyloid interspersed with the neoplastic cells has also been described. a panel of mabs (recognizing tryptase, chymase, serotonin, cd a, cd , cd a, cd , mhc class ii) in association with a histochemical stain (naphthol as-d chloroacetate) has been advocated for use on formalin-fixed, paraffin-embedded sections of cutaneous round cell tumors to help classify poorly differentiated round cell tumors (mast cell tumors, histiocytomas, lymphomas, and plasmacytomas). additionally, clonality of the immunoglobulin heavy chain variable region gene can be performed in plasmacytomas and myelomas using pcr technology, and this may have some diagnostic utility in difficult cases.it is important to thoroughly stage dogs and cats with plasmacytomas that are at higher risk for systemic spread if contemplating local or locoregional therapy without systemic therapy. this should include bone marrow aspiration, serum electrophoresis, abdominal ultrasound, and skeletal survey radiographs to ensure the disease is confined to a local site prior to initiation of therapy. this is most important in cases of sop and gi emp due to their relatively high metastatic rate and less important for cutaneous, oral, and colorectal plasmacytomas because of their more typical benign behavior. key: cord- - x ztp n authors: piasecki, tomasz; mucha, piotr b.; rosi'nska, magdalena title: a new seir type model including quarantine effects and its application to analysis of covid- pandemia in poland in march-april date: - - journal: nan doi: nan sha: doc_id: cord_uid: x ztp n contact tracing and quarantine are well established non-pharmaceutical epidemic control tools. the paper aims to clarify the impact of these measures in covid- epidemic. a new deterministic model is introduced (seirq: susceptible, exposed, infectious, removed, quarantined) with q compartment capturing individuals and releasing them with delay. we obtain a simple rule defining the reproduction number $mathcal{r}$ in terms of quarantine parameters, ratio of diagnosed cases and transmission parameters. the model is applied to the epidemic in poland in march - april , when social distancing measures were in place. we investigate scenarios corresponding to different ratios of diagnosed cases. our results show that depending on the scenario contact tracing could have prevented from % to over % of cases. the effects of quarantine are limited by fraction of undiagnosed cases. taking into account the transmission intensity in poland prior to introduction of social restrictions it is unlikely that the control of the epidemic could be achieved without any social distancing measures. the epidemic of sars-cov- infection triggered an unprecedented public health response. given the lack of effective vaccine and treatment in , this response included a variety of travel restrictions and social distancing measures [ ] . while these measures help to slow down the epidemic they come at significant economical and societal cost [ ] . as an alternative an approach focusing on rapid diagnosis is increasingly recommended [ ] and prior to lifting social distancing measures largescale community testing should be in place [ ] . testing efforts are complemented by identifying and quarantining contacts of the diagnosed cases. of note, by isolating the asymptomatic contacts from their social networks, this strategy takes into account the pre-symptomatic and asymptomatic spread of the infection [ , ] , believed to be one of the key drivers of fast spread of covid- . as an example, wide spread testing in general population followed by isolation of the infected helped to reduce covid- incidence by % in an italian village of vo'euganeo [ ] . a modelling study in france offers similar conclusions arguing that relaxing social lock-down will be only feasible in case of extensive testing [ ] . while there is already a number of studies estimating the effects of general social distancing measures [ , , , ] , less is known about the impact of quarantine. hellewell et al. [ ] investigated the potential of rapid isolation of cases and contact tracing to control the epidemic, finding that prohibitively high levels of timely contact tracing are necessary to achieve control. however, new technologies may offer sufficiently fast alternative to traditional contact tracing, in which case the epidemic could be still controlled by contact tracing [ ] . our aim is to develop a seir-type model which incorporates the effects of quarantine and validate it in a setting in which measures to reduce contacts are in place. we apply it to investigate the role of quarantine in poland. the first case of covid- in poland was diagnosed on march th. social distancing measures were rapidly introduced during the week of - th march including closure of schools and universities, cancellation of mass events and closure of recreation facilities such as bars, restaurants, gyms etc. as well as shopping malls. religious gatherings were limited. finally, borders were closed for non-citizens [ ] . these measures were fully in place on march th. further, beginning at march th restrictions on movement and travel were introduced (lockdown). wearing face covers became obligatory on april th. the restrictions were gradually lifted beginning at april th. we focus on modelling the time period when the social distancing measures were in place and then consider different scenarios of relaxation of the restrictions with possible improvement of testing and contact tracing. we note that the procedures for quarantine were in place even before the social distancing measures. they initially focused on individuals arriving from covid- affected areas in china. when the epidemic started spreading in european countries people who came back to poland from these countries were advised to immediately seek medical attention if they experienced any symptoms consistent with covid- . however, adherence to these recommendations was not evaluated. as soon as the first case was diagnosed in poland quarantine for close contacts was also implemented. this paper aims to define a deterministic population model describing the epidemic in classical terms of susceptible, exposed, infectious, removed. in our model the quarantine becomes a separate state that removes individuals from susceptible and exposed states. we show that the reproductive number in our model is given by a simple formula referring to the parameters of transmission and transition, but also to parameters describing the quarantine. we demonstrate that in a real life scenario (case study of poland) the quarantine effectively reduces the growth of infectious compartment. increasing the efficiency of contact tracing and testing may may to some extent compensate lifting up the social distancing restrictions. we introduce a modification of the classical seir model including effects of quarantine. to underline importance of that extension we call it seirq. formally the model is described by a system of ordinary differential equations with delay dedicated to the quarantine. the following states are included in the model: s(t) -susceptible e(t) -exposed (infected, not infectious) i d (t) -infectious who will be diagnosed i u (t) -infectious who will not be diagnosed r d (t) -diagnosed and isolated r u (t) -spontaneously recovered without being diagnosed q(t) -quarantined the figure . presents the schematic representation of the model. a susceptible individual (state s), when becoming infected first moves to the state e, to model the initial period, when the infected individual is not yet infectious. next the cases progress to one of the infectious states i d , i u at the rates κσ and ( − κ)σ, respectively. in general, moving through the i d pathway concerns these individuals who (independently of quarantine) would meet the testing criteria, as relevant to the local testing policy, e.g. testing of people with noticeable symptoms. we shall emphasize that from the point of view of analysis of spread of infection, the quantity i u shall be regarded rather as not recognized infections, not necessarily asymptomatic or mild. with this interpretation the value of κ can be influenced by intensity of testing. the creation of state e is via i d and i u with transmission rates β d and β u , respectively, normalized to the total population size n = s + e + i d + i u + r d + r u + q, which is assumed to be constant in time, births and deaths are neglected. the transition parameter σ is assumed identical for both groups, relating to the time between infection and becoming infectious. the infectious individuals then move to the state r d , which is the state of being diagnosed and isolated (and later recovered or deceased), with the rate γ d corresponding to the observed time between onset and diagnosis. on the other hand r u contains people who spontaneously recovered with rate γ u . our model includes an additional state of being quarantined (q). to mimic the situation of contact tracing, individuals can be put in quarantine from the state s (uninfected contacts) or the state e (infected contacts). these individuals stay in the quarantine for a predefined time period t . we assume that the number of people who will be quarantined depend on the number of individuals who are diagnosed. an average number of individuals quarantined per each diagnosed person is denoted as α. however, as the epidemic progresses some of the contacts could be identified among people who were already infected, but were not previously diagnosed, i.e. the state r u . we note that moving individuals between the states q and r u has no effect on the epidemic dynamics, therefore we assume that only individuals from s and e are quarantined and we reduce the average number of people put on quarantine by the factor s(t) s(t)+ru(t) . further, to acknowledge the capacity limits of the public health system to perform the contact tracing, we introduce a quantity k max , describing the maximum number of people who can be put in quarantine during one time step. we also assume that among the quarantined a proportion θ is infected. after the quarantine, the infected part θk(t − t ) goes to r d and the rest ( − θ)k(t − t ) returns to s. taking all of the above into account, the model is described with the following seirq system: where k(t) = min{ s(t) s(t)+ru(t) αγ d i d (t), k max }, and α, β d , β u , γ d , γ u , θ, t ≥ . ( . ) we assume that the parameters α, β d , β u , θ, γ u and γ d depend on the country and time-specific public health interventions and may therefore change in time periods. due to proper interpretation of the equation on e we require that β d ≥ θαγ d to ensure positiveness of e. . basic reproductive number, critical transmission parameter β * . based on the general theory of seir type models [ ] , we introduce the reproductive number it determines the stability of the system as r < and instability for r > (the growth/decrease of pandemia). this quantity not only explains the importance is testing (in terms of κ) and quarantine (in terms of α), but also gives an indication on levels of optimal testing and contact tracing. we underline that this formula works for the case when the capacity of the contact tracing has not been exceeded (k(t) < k max ). the details of derivation of ( . ) are provided in the appendix, section a. . we shall emphasize the formal mathematical derivation holds for the case when i and e are small comparing to s. therefore the complete dynamics of the nonlinear system ( . ) is not fully determined by ( . ) . however in the regime of epidemic suppression, which is the case of covid- epidemic in poland, i and e are small compared to s and so the formula ( . ) reasonably prescribes spreading of infection in the population. the critical value r = defines the level of transmission which is admissible, taking into account the existing quarantine policy, in order to control epidemic. as the level of transmission depends on the level of contacts, this provides information on the necessary level of social distancing measures. the formula ( . ) indicates that improving the contact tracing may compensate relaxation of contact restrictions. the key quantity is θα. indeed the system with the quarantine has the same stability properties as one without k, but with the new transmission rate β new d = β d − θαγ d . in order to guarantee the positiveness of e, β new d must be nonnegative. it generates the constraint the above condition also implies the theoretical maximal admissible level of quarantine. we define it by improving the targeting of the quarantine, i.e. by the highest possible level of θ: as long as the k max threshold is not exceeded the effect of the increase in θ or in α play the same role at the level of linearization (small i, e). however, in general it is not the case and for the purpose of our analysis we fix α. for our analysis we assume β d = β u = β. the reason is that, both i d and i u contain a mixture of asymptomatic and symptomatic cases and although there might be a difference we lack information to quantify this difference. then using formula ( . ) we compute critical values β * (κ, θ, α) defined as it shows the upper bound on transmission rate β which still guarantees the suppression of pandemic. we shall omit the dependence on γ d , γ u as these are fixed in our case, and denote briefly β * (κ, θ, α). in the case of maximal admissible quarantine ( . ) we obtain which can be regarded as theoretical upper bound for β if we assume "optimal admissible" quarantine for fixed κ, for which the epidemic could be still controlled. it must be kept in mind though that the condition ( . ) means that we are able to efficiently isolate all persons infected by every diagnosed, therefore is unrealistic. the resulting β * (θ max , κ) should be therefore considered as a theoretical limit for transmission rate. all simulations are performed using gnu octave (https://www.gnu.org/software/octave/). the underlying tool for all computations is a direct finite difference solver with a day time step. basic assumptions for data fitting. we estimate the transmission rates β by fitting the model predictions to the data on the cumulative number of confirmed cases. since people with confirmed diagnosis are efficiently isolated, they are immediately included into r d . therefore, the quantity fitted to the data is r d (t). the crucial assumption behind our approach is that the parameter β changes twice during the period of analysis. the reason is that we can distinguish two important time points in the development of epidemic in poland. the first is initial restrictions including school closure effective march , which was accompanied with restrictions on other social activities. as we do not take migration into account in our model, we assume that the effect of border closing is reflected in β. the second turning point was a lockdown announced on march . for simplicity we comprise the effect of above measures in two jump changes in β in t ∈ {t , t } and choose t = , t = . with t = corresponding to march it means small delay with respect to the above dates which can be justified by the fact that new cases are reported with a delay of approximately days. choice of fixed parameters (tab. . ). we assume that the parameters σ, γ u represent the natural course of infection and their values could be based on the existing literature. the parameter σ describes the rate of transition from non-infectious incubation state e into the infectious states i d or i u . the value of σ takes into account the incubation period and presymptomatic infectivity period. γ u relates to the period of infectivity, which we select based on the research regarding milder cases, assuming that serious cases are likely diagnosed. further, κ is a parameter related both to the proportion of asymptomatic infection and the local testing strategies. since the literature findings provide different possible figures, for κ we examine three different scenarios. parameters γ d , θ and α are fixed in our model for the purpose of data fitting, but informed by available data. one of the scenarios of future dynamics of the epidemic (section . ) considers possible increase of θ. parameter γ d was estimated basing on time from onset to diagnosis for diagnosed cases, and θ as rate of diagnosed among quarantined. furthermore we fix the parameter α by comparing the number of quarantined people obtained in simulations with actual data. the capacity level of public health services is set in terms of possible number of quarantined per day k max , as double the level observed so far. detailed justification of the values of fixed parameters collected in the following optimization algorithm. in order to fit the values β , β , β we use a standard gradient descent algorithm. the error function is defined as mean square difference between the cumulative number of diagnoses and the r d (t) predicted from the model. for the initial values the error function is optimized only for a limited number of possible conditions, as these mostly impact β , which is less relevant for future predictions. to estimate confidence intervals we use a method of parametric bootstrap. the optimisation procedures are described in the appendix, section a. , where we also show precise errors of data fitting. dataset. the data series contains cumulative number of confirmed cases of covid- in poland from march (first confirmed case in poland) till april , which amounts to observations. the data are taken from official communications of the ministry of health. as explained in table . and appendix (section a. additional data sources were used for choosing θ, α and γ d . in table . we show estimated values of β i , where i = , , correspond to the time intervals when different measures were in place, and the r for the third time interval. given the social distancing measures in place early april , as well as the quarantine levels, the reproductive number was below , independently of the value of κ, which relates to testing effectiveness. the figure . shows the fit of the models assuming different levels of κ. good fit is found for all three models although predictions start to differ in the middle-term prognosis. we proceed with predictions assuming that the restrictions are continued, i.e.keeping β = β (note that the estimated β is different for each κ). we calculate the epidemic duration (t max ), the peak number of infected (i max d , i max u ) and the final size of the epidemic (r d (t max ), r u (t max )). in order to show the influence of quarantine we compare the situation with quarantine, keeping the same θ, α, to the situation without quarantine, setting αθ = . the results of the development of the epidemic during the first days are shown on for κ = . the difference between the scenarios with and without quarantine is visible but not striking. however for κ = . and κ = . a bifurcation in the number of new cases occurs around t = leading to huge difference in the total time of epidemic and total number of cases. these values are summarized in the table . . we note that given the epidemic state in the first half of april for all values of κ the model predicts epidemic extinction both with quarantine and without quarantine. however, since the epidemic is very near to the endemic state, the predicted duration is very long, especially if no quarantine is applied. using the formula ( . ) we can compute critical values β * . in table . we show the values of β * (κ, . , ) and for convenience recall also estimated values of β and r, listed already in table . . moreover we compute β * (κ, , ), i.e. without quarantine and show values of r for our estimated values of β and the same γ d , γ u but without quarantine. comparing the estimated values of β (table . ) for all cases of κ are only slightly below β * . eliminating the quarantine, for the estimated values of β , we have different situations depending on the actual value of κ. in case κ = . , so assuming that currently only % of infections are diagnosed, the low values of r are due to low β rather than the effect of quarantine (controlling epidemic by social contact restrictions). in effect even if we remove the quarantine we have still r < , but very close to . on the other hand if κ = . or κ = . we estimate higher β , which corresponds to the situation of controlling the epidemic by extensive testing and quarantine. for these cases, if we remove the quarantine, we end up with r > . the quantity β − θαγ d represents effective transmission rate due to diagnosed cases. in particular it shows by how much the transmission could be reduced by improved contact tracing (θα) and faster diagnosis (γ d ). these results confirm that the higher is the ratio of undiagnosed infections, the weaker is influence of quarantine. in the next section we verify these results numerically. our second goal is to simulate loosening of restrictions. in particular we want to verify numerically the critical thresholds β * listed in table . . for this purpose we assume that at t = we change β. for each value of κ we consider scenarios: (a) current level quarantine: i.e. quarantine parameters θ = . , α = are maintained; (b) no quarantine is applied starting from t = ; (c) the maximal admissible quarantine is applied, meaning that θ max = β αγ d (see ( . ) ). in this case α = . as long as the limit k max is not reached there is no difference whether we increase α or θ, the decisive parameter is αθ. increasing α would lead to reaching k = k max earlier and hence worse outcomes. the results confirm that around β * a rapid increase in the total number of infected occurs, coinciding with the peak total epidemic duration. thus the numerical computations confirm that the critical β * calculated for the linear approximation in the section . are adequate, with a small bias towards lower values. the case κ = . shows that the influence of quarantine is not high, even for the maximal admissible case, when we are able to efficiently isolate all persons infected by every diagnosed. a striking feature in the behaviour of total number of infected are jumps for certain critical value of β observed for κ = . and κ = . , both in case θ = . and θ = θ max . the values of r d and r u before and after these qualitative changes are summarized in table . . a closer investigation for these values of β shows that in all cases the jump occurs for the first value of β for which the limit number of quarantined, k max = , is achieved. notice that immediately after passing the threshold the values become very close to those without quarantine. we propose a simple seir-type model (seirq), which includes the effects of testing and contact tracing. the model formulation allows to calculate an interpretable formula for the reproductive number r ( . ). as typical for this class of models, r depends on transmission parameters β. increasing β corresponding in e.g. to higher frequency of social contacts increases r. decreasing β, for example in consequence of widespread use of face masks, has the opposite effect. on the other hand γ d reflects the time to diagnosis and the formula indicates that more rapid diagnosis is associated with lower r. in addition, our model offers a clear interpretation of the quarantine effect. the transmission rate due to diagnosed cases, β d , is decreased by the factor θαγ d indicating that both the number of quarantined per diagnosed individual (α) and proper targeting of the quarantine (the infection rate among the quarantined θ) equally contribute to this factor. also the parameter related to testing: the delay in diagnosis, γ − d , plays similar role. this quantifies the potential of a wide range of interventions to improve testing and contact tracing, as outlined in e.g. in ecdc recommendations [ ] . in particular, as the number of people put in quarantine per each case and the infection rate among the quarantined impact r in similar fashion, our results support the recommendations to focus on the high risk contacts when the resources do not allow to follow all contacts. our model takes into consideration only the effective contact tracing, i.e. the situation when the infected contacts are identified and put in quarantine before they become infectious. people who are identified later would be modelled as passing through one of the i states to the r states. this means that the number of quarantined in our model can be also increased by faster contact tracing. the timely identification of contacts may be a significant challenge in the quarantine approach given that the incubation time can be as short as days in % of cases [ ] . as mentioned by other authors [ ] , the delays in manual contact tracing are usually at least days and under such circumstances the contact tracing and quarantine alone may be insufficient to control the epidemic. this could be improved with digital contact tracing. notably, mixed contact tracing strategies implemented in south korea indeed helped to control the epidemic at the early stages [ ] . the use of "smart contact tracing" with mobile phone location data and administrative databases were also key to rapid identification and self-quarantine of contacts in taiwan [ ] and implementation of such strategy helped singapore to control the epidemic without major disruptions of social activities [ ] . we note that the quarantine effect relates only to transmission due to diagnosed cases. as expected, in order to control the epidemic the transmission due to undiagnosed cases has to be negligible. this can be controlled by general measures such as lockdown, which universally decrease the frequency of social contacts and are therefore likely to reduce β u . in our model the part of r representing transmission due to undiagnosed cases is scaled by ( − κ) , the parameter relating to the efficiency of the testing system. again, the examples of singapore as well as the italian village of vo'euganeo show that the widespread testing complementing the efficient contact tracing was essential to suppress epidemic. testing unrelated to epidemiological links decreases ( − κ) factor, thus making the factors impacting transmission due to diagnosed cases, such as quarantine, more powerful to decrease r. further, our model allows to study the effect of the situation, in which the contact tracing capacities are exceeded. in this situation the epidemic is likely to quickly develop to the levels observed without quarantine. it is therefore quite crucial to implement the aggressive contact tracing system, when the epidemic is still at low levels and it is possible to bring the epidemic to suppression phase. we demonstrate the high impact of contact tracing and quarantine on the observed numbers of cases in poland. this effect was coupled with substantial reduction in the transmission parameter β resulting from social contact restrictions. depending on the scenario, β decreased by % to %, bringing r below . the estimated effect of the quarantine in poland would depend on which of the considered scenarios regarding testing efficiency was the most relevant to our situation. in our model the quarantine is estimated to be the most effective for the scenario in which most of the cases are diagnosed (κ = . ). testing strategies that comprise testing of all individuals with symptoms of respiratory illness could theoretically identify up to % of infected, assuming they would all present to medical care. this could be coupled with random screening of high risk individuals, in e.g. health care workers, or -in case of high incidence -even random screening of entire community to achieve the κ of the order of . . the polish clinical recommendations specifically mention only testing all individuals with severe infections [ ] . in addition testing is provided to health care workers. the severe course corresponds to approximately % of all infections [ ] . therefore, the κ = . scenario is unlikely to be realistic in poland. we believe that the plausible current κ in our country lies between . and . . for these scenarios the model shows that the control of the epidemic is largely achieved through suppression of β. in case of relaxation of social contact restrictions, the efforts should be focused on increasing the level of testing in order to decrease the proportion of undiagnosed cases as well as maintaining or increasing the effectiveness of quarantine. for smaller κ, even substantially increasing the effectiveness of quarantine does not allow to go back to the level of social contacts from before the epidemic (β ). finally, the contact tracing effort was manageable in poland due to relatively small number of cases. should the case load increase substantially longer delays in contact tracing would occur, which can substantially decrease the effects of quarantine [ , ] . limitations and future directions of research. we do not consider the likely reduced transmission from undiagnosed cases who are more likely to be asymptomatic or paucisymtopmatic cases (β u < β d ). the reduction factor for infectiousness of asymptomatic is still under investigation. one study found a -fold lower viral loads in asymptomatic cases [ ] , but another estimated the transmissibility reduction by % [ ] . moreover, we did not have sufficient data to include this additional parameter. we calibrated our model only to diagnosed cases, which were officially available. calibration to mortality data is another approach successfully implemented in e.g. [ ] that potentially removes bias due to different testing policies. as there were relatively fewer fatalities in poland and little data on clinical progression we decided on simplified model without explicit modelling of the outcomes. furthermore, we did not consider the sub-optimal adherence to quarantine. it is likely that some individuals would not fully comply to strict quarantine rules. however, only anecdotal evidence for such phenomenon is available at this time. in our model it would decrease the effective αθ, which was chosen to fit to observed number of people put in quarantine. finally, the analysis of r is suitable for small size of epidemic, when s ≈ n . for other cases the results are still useful, but the approximation may be biased, as we have shown for β * . due to little available data and policy changes we did not have sufficient data to determine which κ scenario is the most appropriate. in conclusion we present a simple model, which allows to understand the effects of testing, contact tracing and quarantining of the contacts. we apply the model to the data in poland and we show that despite a substantial impact of contact tracing and quarantine, it is unlikely that the control of the epidemic could be achieved without any reduction of social contacts. [ a. optimization algorithm. in order to fit the values β , β , β we use a standard gradient descent algorithm. namely, we define error function as where {r d (κ, t)} t= is the vector of computed values of r d and {data(t)} t= the vector of data (cumulative number of confirmed cases). at each step we approximate the gradient of the error function with respect to β , β , β by differential quotients and move in the direction opposite to the gradient. the algorithm reveals a good performance provided we start sufficiently close to the minimum, which is not difficult to ensure in our case. it remains to choose the initial data. a closer look on results of simulations shows that the choice of initial data mostly influence the fitting in the beginning of period under consideration and hence the value of β , while for analysis of future scenarios β is the most important. taking all this into account we do not struggle for sharp optimization of data fitting with respect to initial data and restrict to the following heuristic choice. it is natural to assume i u ( ) = −κ κ i d ( ). concerning the choice of e( ) we assume it in a form e( ) = m(i d ( ) + i u ( )). we set initial values i d ( ) ∈ { , , } and for each value we set i u ( ) according to the above formula and three values of e( ) corresponding to m ∈ { , , }. for each of these combinations we run the optimization algorithm looking for the best fit of β i , i = . . . . we have repeated this approach for κ ∈ { . , . , . }. it turns in that for all values of κ the best fit was obtained for i d ( ) = and m = . more careful analysis around i d ( ) = did not improve the quality of fitting, therefore: a. choice of fixed parameters . the parameter σ describes the rate of transition from non-infectious incubation state e into the infectious states i d or i u . the median incubation time from exposure till the onset of symptoms was estimated at to days [ , , ] . however, there exists evidence that typically infectivity preceeds symptoms, by to days [ , , ] . a modelling study identified the rate of transition between the non-infectious and infectious states at . [ ] , which corresponds to an average time lag of . days untill the case becomes infectious. . the parameter γ u represents the period of infectivity during the natural course of disease. we discuss the period of infectivity, especially as applied to mild cases. the median duration of viral shedding was estimated among chinese hospitalized patients. overall it was days, but it was shorter among cases with milder clinical course [ ] . a study among patients in hong kong confirmed viral shedding longer than days among a third of patients, although the peak level of shedding was noted during the first week of infection [ ] . in the mission report from china who reports viral shedding in mild and moderate cases to last - days from symptom onset. among younger and asymptomatic or mild cases the shedding may be shorter: in a study among initially asymptomatic youngsters the median duration was . days [ ] . . the value of κ generally depends on the testing policy. however, recommended testing policies often rely on the presence of respiratory symptoms. this is also the case in poland. it was observed that some infected people never develop symptoms, although the precised rate of such truly asymptomatic infections is still under investigation. some studies may be biased by a too short follow-up time. a small study among residents of a long-term care skilled nursing facility found that even though more than half of individuals with confirmed infection were asymptomatic at the time of test, majority of them subsequently developed symptoms. the proportion of people who remain asymptomatic may be higher among younger individuals [hu] . a study among japanese nationals repatriated from wuhan suggests the proportion of asymptomatic infections is about % [ ] . an analysis among the passengers of diamond princess ship, where a covid- outbreak occurred, taking into account this delayed onset of symptoms estimated the proportion of asymptomatic infections to be about %, even though almost % were asymptomatic on initial test. in addition, large scale screening implemented in italian village vo'euganeo indicated that % to % of infected individuals did not report symptoms [ ] . similarly, in population screening in iceland % were asymptomatic at the time of screening [ ] . it may be stipulated that some of the people diagnosed through screening developed symptoms latter, consistently with the findings from the diamond princess study. on the other hand a sizable proportion of infected people, especially at younger ages, experience only mild symptoms, for which they may not seek medical attention. in the study of li [ ] , the proportion of undocumented cases was estimated as %. . the parameter γ d was estimated basing on a sample of case-based data available in routine surveillance, by fitting gamma distribution to the time from onset to diagnosis, for cases who were not in quarantine before diagnosis. time from onset to diagnosis was estimated based on surveillance data available in the epidemiological reports registration system for covid- , as of . . .the system collects epidemiological data on cases diagnosed in poland and is operated by local public health departments. all cases eventually are entered into the database. however, substantial reporting delays are noted. there were altogether cases registered in the system, including ( . %), who did not have symptoms at the time of diagnosis. plausible onset date and plausible diagnosis date were available for cases ( . % of cases that were not asymptomatic) gamma distribution was fitted by maximum likelihood to cases who were not diagnosed in quarantine. the observed and fitted distributions are shown below (figure a. ). we next fitted gamma-regression model with week of diagnosis as an explanatory variable. we found no significant trend in time. we therefore adopted the average time from onset to diagnosis to be . days, and taking into account the probability of asymptomatic spread we assumed the parameter γ d to be / . . . next we base θ on available data. we calculate prevalence of infection among the quarantined individuals, according to data published by the chief sanitary inspectorate on the number of cases diagnosed among quarantined people and the total number of quarantined. we used a series of data . - . to estimate a likely value of θ. we chose this time period due to data availability. data are shown on the figure below. during this time period there was an increasing trend in the proportion of diagnosed from . % to . % a. . we presume that this parameter could change with changing procedures of contact tracing and testing. however, since no detailed data were available, for the modelling purposes we chose a simplifying assumption that θ is stable (i.e. we always take a similar group of contacts under quarantine) selecting an average value of . %. this proportion could be also viewed as attack rate among the contacts of cases. the proportion in poland is in line with what was observed in korea, where an estimated attack rate was . % [ ] , although household attack rate was higher (> %) in other studies [ ] . . furthermore we fix the parameter α. here we make another simplification assuming this parameter to be constant. the main difficulty is a lack of precise data concerning the number of newly quarantined people per day, distinguishing between reasons of quarantine (travel related or contact tracing relate). at the beginning of epidemic in poland the average amount of quarantined following one diagnosed case was definitely higher. moreover, people coming back from abroad were subject to obligatory quarantine starting from march and constituted a considerable part of quarantined in the second half of march and beginning of april. in particular, around polish citizens staying abroad came back within a special program of charter flights operated by polish airlines which ended on april . we can assume that after this date the ratio of people coming from abroad among all people subject to quarantine was negligible. as our model does not take migration into account, we have to take into account only quarantine from contact. for above reasons, for fitting α we restrict our analysis only to a period of weeks of april. assuming already θ = . we then choose α minimizing the square error between the number of quarantined from the data and computed k(t). this way we obtain α = . taking these into consideration we set the values of parameters collected in table . . bootstrap. to estimate confidence intervals we use a method of parametric bootstrap. we generate m = sequences of perturbed data assuming that for each time t ∈ { , } the increment of r (i.e. daily number of new diagnoses) is a random number from poisson distribution with mean value equal to increment of observed data. model parameters are also perturbed, see below. for each series of perturbed data we estimate the values of β i and take estimated confidence intervals as appropriate quantiles of obtained sets. in order to estimate confidence intervals for r d (t), shown on panel a of figure . , we proceed as follows. for each sequence of perturbed data we compute fitted r d (t). this way we obtain a set of curves {r distribution of parameters. following other authors [ ] as well as experimental data, for the uncertainty analysis we used the following distributions of the parameters. . /γ d ∼ gamma(a , b ), where the shape parameter, a = . and scale parameter b = . . /γ u ∼ gamma(a , b ), where the shape parameter, a = and scale parameter b = . /σ ∼ gamma(a , b ), where the shape parameter, a = and scale parameter b = . . α ∼ p oisson(α ), where we assume constant α = ; . θ -is not sampled for the uncertainty analysis. as the results depend on the quantity αθ, we rely on the distribution of α. we take n = (approximate average of daily number of diagnosed cases from the data). we approximate the mean value of n samples from gamma distribution using central limit theorem. namely, we generate based on the classical approach to epidemiological models we address the basic question concerning the propagation of the disease. namely, how many persons are infected by one infectious individual, a quantity which is usually called reproductive number, r. in order to compute this quantity we use the approach from [ ] . we look at the system assuming s ∼ n and e, i d , i u are close to zero, then we consider the following linearizatioṅ then one deduces (see [ ] ) that if we define r = max{eigenvalues of t Σ − } then the system is stable for r < and it is unstable for r > . stability of system (a. ) means that the whole vector (e, i d , i u ) is going to zero, it follows that the main system ( . ) also tends to the zero solution for (e, i d , i u ). instability implies that for "almost all" small data, the vector (e, i d , i u ) is growing in time (exponentially fast), causing the nonlinear system also evolves far away from the trivial state, i.e. e, i d , i u rapidly grow. by (a. ) we have hence the stability of our system is determined by the following factor: to make a final comment, let us note that in case of spread of pandemia, as r d , r u grow, the above analysis become less reliable. recall that β is normalized by n , so as s/n is not close to one and the analysis of stability becomes more complex. this behavior is illustrated by figures . , . and . , where we observe deviation from predictions based on ( . ), covid- ) in the eu/eea and the uk -ninth update an investigation of transmission control measures during the first days of the covid- epidemic in china clinical characteristics of coronavirus disease in china. the new england journal of medicine early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. the new england journal of medicine the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application. annals of internal medicine substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) presymptomatic transmission of sars-cov- -singapore public health -seattle & king county; cdc covid- investigation team. asymptomatic and presymptomatic sars-cov- infections in residents of a long-term care skilled nursing facility potential presymptomatic transmission of sars-cov- rapid asymptomatic transmission of covid- during the incubation period demonstrating strong infectivity in a cluster of youngsters aged - years outside wuhan and characteristics of young patients with covid- : a prospective contact-tracing study clinical characteristics of asymptomatic infections with covid- screened among close contacts in nanjing estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship estimation of the asymptomatic ratio of novel coronavirus infections (covid- ) covid- : identifying and isolating asymptomatic people helped eliminate virus in italian village iceland lab's testing suggests % of coronavirus cases have no symptoms factors associated with prolonged viral rna shedding in patients with covid- temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov- : an observational cohort study geneva:who; epidemiology and case management team contact investigations of the first cases in the republic of korea household secondary attack rate of covid- and associated determinants medrxiv . . the construction of next-generation matrices for compartmental epidemic models public health interventions to mitigate early spread of sars-cov- in poland estimating the number of infections and the impact of non-pharmaceutical interventions on covid- in european countries.imperial college london modelling the covid- epidemic and implementation of population-wide interventions in italy feasibility of controlling covid- outbreaks by isolation of cases and contacts quantifying sars-cov- transmission suggests epidemic control with digital contact tracing viral dynamics in mild and severe cases of covid- centre for mathematical modelling of infectious diseases covid- working group. early dynamics of transmission and control of covid- : a mathematical modelling study contact tracing for covid- : current evidence, options for scale-up and an assessment of resources needed epidemiology and case management team contact investigations of the first cases in the republic of korea. osong public health res perspect containing covid- among , persons in contact with the diamond princess cruise ship passengers who disembarked in taiwan: big data analytics evaluation of the effectiveness of surveillance and containment measures for the first patients with covid- in singapore acknowledgments. this work was partially supported by the polish national science centre's grant no / /m/st / (harmonia). key: cord- - lpjo a authors: dos santos, bruno pereira; de gouveia, giovanna cristiano; eller, sarah; pego, ana miguel fonseca; sebben, viviane cristina; de oliveira, tiago franco title: is covid- the current world-wide pandemic having effects on the profile of psychoactive substance poisonings? date: - - journal: forensic toxicol doi: . /s - - - sha: doc_id: cord_uid: lpjo a nan recent times have shown an increasing number of intoxication cases, resulting in damaging public health issues all around the globe, and brazil is not an exception [ ] . most of the cases observed denoted the use of psychoactive substances, such as recreational drugs and medication for psychiatric use [ ] . currently, with the covid- pandemic, both strict lockdown and general social distance rules have been recommended. the application of such public health control measures resulted in personal behavior alterations, considering that, during quarantine, individuals find themselves deprived of any social interactions, which can ultimately modulate the profile of poisonings [ ] . the present study seeks to verify possible temporal changes in the poisoning profiles of rio grande do sul state, southern brazil, due to the covid- outbreak. for this purpose, data was gathered from cases of intoxication by the five main classes of psychoactive substances: anticonvulsants, antidepressants, antipsychotics, benzodiazepines, and recreational drugs, arriving at the toxicological information center of rio grande do sul, from march to july and from march to july ( table ). the data analyzed are comprised of a wide range of incidents, verified by the many variables obtained, such as age, gender, circumstance of exposure, and location of exposure. out of the cases attended by our team during the quarantine, a reduction of − % in comparison with the same period in the last year was observed; cases were included in the five classes of substances evaluated. as for the four classes of psychiatric drugs tested, their combined number decreased by − . %, while illicit drugs and alcohol intoxications alone rose by + . %. the reported numbers clearly indicated a change in poisoning profile as compared to . within recreational drugs (alcohol, amphetamine, cocaine, ecstasy/mdma, inhalants, lsd, and marijuana), the highest incidence of cases were alcohol, from to cases (+ . %) and cocaine, from to cases (+ . %). a substantial increase was also found for other substances such as marijuana which rose from to cases (+ . %) and ecstasy/mdma, from to cases (+ . %). situations generated by the pandemic, such as stress, isolation, and financial insecurity can result in increased alcohol and drug consumption and misuse [ , ] , thus explaining an expected rise in intoxication cases. unlike recreational drugs, a medication used for psychiatric treatment showed a decrease. the class of antidepressants presented an expressive reduction, of − . %, followed by anticonvulsants (− . %), benzodiazepines (− . %), and antipsychotics (+ . %), given that the last two maintained a certain stability in comparison with the remaining substances. within the class of antidepressants, the compounds with the highest incidence were fluoxetine, which decreased from to cases (− . %); amitriptyline also showed a reduction from to cases (− . %), and finally sertraline from to cases (− . %) reported. as for anticonvulsants, these have shown a much lower absolute reduction, with carbamazepine, from to cases (− . %), valproic acid, from to cases (− . %), phenobarbital, from to cases (− . %) and topiramate, from to cases (− . %). as it can be seen, benzodiazepines showed much less decrease than antidepressants in absolute numbers during the interval studied of quarantine. clonazepam, the group's main representative, showed a decrease, from to cases (− . %), while diazepam increased from to cases (+ . %). the main variation observed with antipsychotics were chlorpromazine, with an increased from to cases (+ . %) and risperidone, from to cases (+ . %). within this scenario, the reduction in medication for psychiatric treatment was mainly guided by a decrease in suicide attempts reaching a decline of − . %. as shown in table , antidepressants presented a decrease of − . % followed by anticonvulsants with − . % and benzodiazepines with − . % for suicide attempts. the analyzed data indicates a reduction on suicide attempt rates that can be correlated to a possible modulation within the intoxication profile of individuals due to social isolation, where people have been asked to stay confined within their homes with family and friends, which can be a protective factor associated with the occurrence of suicide attempts [ ] . however, we observed an increase in the number of cases with recreational drugs as suicidal agents ( , cases; , cases). in addition, the cases of self-medication increased for all classes of medicines evaluated in this study. while quarantine can be effective in reducing the number of suicide attempts, the number of individual accidents has increased expressively (table ) , mainly associated with recreational drugs, anticonvulsants, and benzodiazepines, especially accidents with children up to years old. the age variable is one of the most relevant parameters, as it shows a clear tendency of who, in fact, is more vulnerable in these cases of intoxication. for instance, children aged - years showed a serious increase in cases of intoxication by recreational drugs, of + %, followed by more than + % in anticonvulsants and benzodiazepines. much likely, due to the implementation of the isolation measures, which involved the closing of schools, resulting in children staying home for a much longer period. according to the results obtained, the use of recreational drugs during quarantine has increased, as well as the number of accidents associated with children and with the same compounds. furthermore, individuals over years old, showed a substantial increase in the consumption of recreational drugs, with + . % and only + . % in antipsychotics, as opposed to other classes which decreased, justifiable by a reduction in suicide attempts. considering the exposure site, cases at home had an expressive increase simply for recreational drugs. despite the possibility of an increase in home poisonings, this number has not changed significantly, as most cases already occurred at home. however, in both the site and circumstance variables, large numbers that stood out were the "unknown" results, increasing in most classes, which causes serious difficulties for the medical staff to deal with in cases of intoxication since these variables are of extreme importance for a rapid and effective medical intervention. another variable that has considerably changed was gender. within the recreational drugs group, for instance, cases involving women increased by + . %, while cases with men rose with + . %. nonetheless, other classes showed a reduction in the number of female attendances and, curiously, male attendances in benzodiazepines and anticonvulsants increased, even considering the general decline of the groups. in conclusion, we observed a change in the poisoning profile during quarantine, possibly due to the modification in habits and behavior of the population caused by social isolation. a significant increase in the incidence of cases by recreational drugs has been noted, in almost all aspects, while the cases involving medication for psychiatric use decreased, mainly because of the decline in suicide attempts, in a way as a possible protective effect. the statistics observed in contradicted our pre-pandemic period epidemiological data in , indicating a strong influence of the quarantine. therefore, the results show how the environment and social activities can modulate human behavior and that some factors such as gender and age can influence the intoxication profile. these numbers are of paramount importance for toxicovigilance and can be used as a projection for other states and countries because measures to prevent poisoning cases during quarantine can be adapted to reduce the damage caused indirectly by the outbreak of covid- . a fast and simple approach for the quantification of illicit drugs, medicines, and pesticides in blood and urine samples by uhplc-ms/ms multivariate analysis applied in dataset of poison control center of são paulo control centre members, descatha a ( ) covid- : home poisoning throughout the containment period [the corrected version first appears in lancet public health alcohol use and misuse during the covid- pandemic: a potential public health crisis? lancet public health :e the covid- pandemic and its impact on substance use: implications for prevention and treatment suicide mortality and coronavirus disease -a perfect storm the authors would like to acknowledge the financial support from coordination of improvement of personal higher education -brazil [capes -finance code ]. conflict of interest the authors declare that they have no conflict of interest.ethical approval this article does not contain any studies with human participants or animals performed by any of the authors. key: cord- -qb fea authors: cruz-aponte, mayte'e; caraballo-cueto, jos'e title: balancing fiscal and mortality impact of sars-cov- mitigation measurements date: - - journal: nan doi: nan sha: doc_id: cord_uid: qb fea an epidemic carries human and fiscal costs. in the case of imported pandemics, the first-best solution is to restrict national borders to identify and isolate infected individuals. however, when that opportunity is not fully seized and there is no preventative intervention available, second-best options must be chosen. in this article we develop a system of differential equations that simulate both the fiscal and human costs associated to different mitigation measurements. after simulating several scenarios, we conclude that herd immunity (or unleashing the pandemic) is the worst policy in terms of both human and fiscal cost. we found that the second-best policy would be a strict policy (e.g. physical distancing with massive testing) established under the first days after the pandemic, that lowers the probability of infection by %. in the case of the us, this strict policy would save more than thousands lives and almost $ . billion to taxpayers when compared to the herd immunity case. during the covid- pandemic, many policymakers are usually facing two separated sources of information: economic models that usually predict an economic collapse [ ] and epidemic models that focus on death counts [ ] . however, both the economic and mortality figures are key policy variables during a pandemic but few articles integrate both approaches [ , ] . in particular, no research (to our knowledge) has analyzed both the fiscal and mortality impact of different mitigation measurements. in this article we strive to fill that gap by approximating the impact of physical distancing and patient care on the death toll and government budget, in a attempt to find the optimal conditions to balance it all. vaccination or therapeutics can eradicate epidemics from the population, like the case of smallpox [ , ] but when a newly discovered virus hits the population, the entire world is at risk because everyone is susceptible as in the case of the novel sars-cov- that is impacting us in [ ] . in the case of an imported infection (i.e. not an endemic epidemic), the first-best strategy would be to control borders, identify, treat and isolate infected individuals. this occurred in the u.s. with the ebola virus, which never became an epidemic [ ] . but when a virus is already circulating in a territory and there is no antidote or massive testing and contact tracing available, social or physical distancing is an alternative to mitigate a pandemic and provide the scientific community time to research and find alternative measures such as an effective treatment or a vaccine. also, physical distancing measure gives fragile healthcare systems the leverage to take care of chronically ill patients without saturation of existing capacity. what are the fiscal and human costs of all these measurements in the short and long run? thus, two research questions drive this study: what is the optimal physical distancing policies in a country and what are the implications of these policies for both the government budget and loss-of-life? we constructed an enhanced mathematical sir (susceptible, infected, recovered) epidemic model [ ] to simulate the covid- epidemic in the us in an attempt to estimate the fiscal impact and the optimal conditions to mitigate this ongoing pandemic. we found that a policy of no physical distancing or a race towards herd immunity is not the optimal policy choice when both human and fiscal costs are considered. in section we lay out our methodology. in section we show the dynamics associated to our calibrated system of differential equations. in section we discuss our results and in section we conclude and recommend public policies. we first describe a simple economy with three sectors; businesses, government, and a household sector with two actors. in the second part of this section we describe our epidemic model. in this economy, the household sector is mobile within the country and is composed of l workers and u individuals that are not working. thus, employment is less than full. this characterization allows us to consider the supply shocks associated to the covid- pandemic [ ] , where laborers are impeded to work fully because of lock-downs or infections affecting members of the household sector. firms produce goods and services i, which require x amount of l. a fixed amount of total output y is predetermined to be produced in period t= and is given by, y = x i * l i . however, firms are able to adjust its output when external changes hit the labor stock. the total output that considers the impact of such external changes is observed in, y t = yh t where h t = dl/dt. we hold the following assumptions over h: • if physical distancing is implemented at t= , h t = − . during the physical distancing. when the physical distancing ends in t=n, and h t=n = . this setting let us capture the v-shape growth that is being projected [ ] in the post-covid- period. • if no physical distancing is implemented, the pandemic ends in t=n+j, h t=n+j+ = , and h t<j = − . . this decline is lower than the lower bound estimate of fourteen percent decline in output constructed by jp morgan for the u.s., a country that did not declare a general lock-down [ ] . in our case, n+j+ equals days. • if physical distancing is implemented late at t=i, with j<i, h t = − . during the physical distancing, h t=n = . when the physical distancing gets relaxed, the pandemic ends in t=n+i. in our case, n+i equals on the other hand, the government sector has a fixed level of expenditures predetermined in period t= , that includes money transfers to low-income u. tax revenues c are governed by, where τ is the tax rate. if there is a pandemic, the government spends m v in the treatment of each infected individuals. in order to assess the fiscal impact that a pandemic such as covid- will convey by the epidemic dynamics we construct an epidemic model, with the addition of a fiscal impact differential equation based on the previous section that quantifies the impact in the budget of the country. the epidemic model is a typical sir-type model with the epidemiological classes needed for the evolution of covid- within the population. there are six epidemiological classes defined susceptible (s) individuals that progress to incubate the virus in the exposed (e) class when they have an effective contact with an infected symptomatic individual (i) with probability βsi n using mass action or if a susceptible individual had contact with an asymptomatic (a) individual with a lower probability of infection than a contact with a symptomatic governed by the factor βsµa n . treated individuals (t) are assumed to be quarantined, hence, they are not considered to be able to transmit the diseases in the context of this modelling approach. after days of incubating the virus a proportion of individuals becomes symptomatic and the rest are asymptomatic (estimated here at % [ ] ). infected individuals that are asymptomatic recover without further complications, symptomatic individuals that get critically ill seek treatment while the mild cases recover. following the related literature cited in table below, symptomatic and treated individuals have a probability of dying due to health complications estimated at %. in table below there is a description of the parameters used. the system of differential equations for covid- , is now presented in equations to . in particular, the system is described as: next couple of sections. pandemic. the parameter values in our table were taken from a recollection of the events developing on covid- and the literature. perturbations around the means showed in table may affect the quantitative magnitude of our figures, but results are qualitatively similar after such perturbations. in other words, our findings for the second-best scenarios are robust to deviations of our parameters: such deviations will largely scale up or down the quantitative aspects of each scenario. the parameters of the model were fitted or estimated to maintain a basic reproductive number relatively close to . . for comparison purposes lets note that the of seasonal influenza ranges approximately within . to . [ ] . for the influenza a-h n the was estimated to be between . to . . in particular, the basic reproductive number is the number of secondary cases a single infectious individual generates during the period of infectivity on a completely susceptible population. we assume that the entire population is susceptible such that s ≈ n and that the epidemic has not started in t= . the individuals that can potentially infect the population in our model are infected individuals that are either symptomatic or asymptomatic. treated individuals are assumed to be quarantined. following the related literature [ ] , we use the next generation operator to compute the . let the vector f be the rate of new infections flowing to the latent compartment and the vector v to be the rate of transfer of individuals out of the compartment that are able to transmit the disease. then, using our sir system of equations we define in order to compute , let the gradient of f be defined as f = ∂f ∂e , ∂f ∂a , ∂f ∂i and let the gradient of v be define as v = ∂v ∂e , ∂v ∂a , ∂v ∂i then we get: then is the spectral radius of the second generation operator ρ(fv − ) also know as the dominant eigenvalue of the matrix fv − . hence, , which means that the basic reproductive number is: our intention in this article is to study the impact of the covid- epidemic in an attempt to estimate the optimal conditions to mitigate the fiscal and mortality impact associated to this pandemic. thus, the stability of the system and equilibrium points will not be addressed, only the was computed. we focused our efforts on simulating scenarios, which are presented in the next set of sections. in order to go through the methodology of our simulations we lay out simple in the long run, herd immunity has a higher death toll and implies more government expenditures than the alternated intensity of physical distancing, as shown in table . in particular, with no physical distancing would die , more individuals than in the alternated scenario and the government would lose $ . trillion more than in the varying physical distancing. note that under the alternated scenario scientists have approximately days to find an antidote with a very low number of victims, vis-a-vis days under the no distancing case. figure : varying physical distancing starting two days after the epidemic: lowering the infection rate % for four-week intervals and increasing it between % to % for eight weeks intervals as described on table . figure , , and on figure , we illustrate the simulated figures that are obtained when we shorten the length of the cycles showed previously. here we are also holding the assumption that the pandemic started in day two. the variation in the probability of infection is shown in the gray line, which goes first to an extreme reduction of % for four weeks, then is relaxed to % for eight weeks, then two cycles of extreme measurement for four weeks followed by a relaxation of table . we observed that the strict alternated scenario of figure would save the federal government $ . billion more than in the relaxed scenario of figure , while mortality is virtually the same. in other words, the distancing cycles shown in table appear to be less optimal than in the more restrictive case of table . table . since there is no infection curve in the restrictive and permanent case, the budget of the government is mostly affected by the decline in tax revenues caused by lowered economic output. however, when infection rate is lowered just by %, the government budget becomes highly impacted after day : once infection starts to increase, the public sector is affected by both spending more in treatment and by the reduction in tax revenues caused by the economic collapse. in the case of no physical distancing, even though economic output decreased, the federal budget is highly reduced by the treatment cost. at the end, if there is an opportunity to implement a persistent and early public health policy, it would be better to do it intensely (e.g. by combining a strong physical distance with massive testing): otherwise, the relatively human and fiscal cost would increase significantly. how would the figures change if the persistent measure is implemented late? the evolution of infection and mortality is similar, but there are differences in the long run for the associated fiscal costs. when the infection is reduced by % or %, the associated cost of the pandemic to the government decreased by $ . billion than when the public health policy is implemented earlier like in figure . this difference arises because the economy was not halted during the first weeks of the pandemic. that is, even in the case of these late decisions the government is better off in implementing the strict measure: death toll does not change while fiscal costs perform much either in day or day after the pandemic (see appendix b). in figure we show the effects of lowering the probability of infection within the whole u.s. population for different time intervals. when infection is reduced by % for eight weeks, mortality is , lower than in the herd immunity case and the fiscal cost of the pandemic is the minimum with respect to any of the scenarios presented in this article. that is, this short and strong distancing policy would have a lower death toll ( deaths) than in the alternated scenario of figure , but with a lowered fiscal cost ($ . billion less). figure if the infection rate is reduced by % for twenty four weeks, the death toll is a bit higher than in the case of a strong policy for eight continuous weeks. in either case, the pandemic would kill at least , fewer individuals than in the herd immunity case. in terms, of budget, the longer period under distancing induces a larger fiscal decline than in the case of the eight-week distancing. however, the herd immunity is again the most costly option in terms of both death and government budget. these results reveal that if a policymaker is going to implement distancing measures, overall better results would be found with a strict measure for a short period than with a weak measure for a long period. in fact, in terms of human and fiscal costs, we can state that this strong policy for eight continuous weeks is the preferred option after the case of figure . we acknowledge that our model may not be exported to developing countries where the lock-down can also result in deaths of individuals from starvation: given the low safety nets and salaries in many poor countries, lack of employment can severely reduce dietary intake resulting in other serious health-related issues or death. in that case, we recommend adding a death variable associated to forced unemployment. such an approach exceeds the scope of this paper. we like to thanks dr. ricardo gonzález-méndez from the university of puerto rico school of medicine as well as dr. ricardo j. cordero-soto from california baptist university for their insights and suggestions. the usual disclaimers apply. • both authors contributed equally in the designed, codification and preparation of the article. all authors have approved the final article. • this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. • declarations of interest: none vaccine or effective treatment is not implemented before the physical measures are lifted, the epidemic will raise again. a policymaker would like to find an easier mechanism than a cyclical regime to combat the pandemic. in figure b . we show the case where just one restrictive policy that declines the infection rate by % is applied for days. the probability of infection is then kept by a permanent reduction of % to account for people being more careful and taking measures to avoid being infected. in this case the peak of the distancing curve arrives much later than before at approximately day . as expected, more lives ( persons) are saved than in the alternated cycles of figure but now the federal budget is almost halved. note that in any of these scenarios, no physical distance or herd immunity is an optimal solution, either in terms of human or fiscal cost. figure b . cdc estimates that % of coronavirus patients don't have symptoms the eradication of smallpox the smallpox story: life and death of an old disease revenue statistics -the united states compartmental models in epidemiology - ebola outbreak in west africa no evidence yet that recovered covid- patients are immune, who says the macroeconomics of epidemics. (w ) macroeconomic implications of covid- : can negative supply shocks cause demand shortages? the great lockdown real-time estimation of the risk of death from novel coronavirus (covid- ) infection: inference using exported cases and corona virus disease- (covid- ): the epidemic and the challenges estimated cost of treating the uninsured hospitalized with covid- , (kff assessing the fallout from the coronavirus pandemic adaptive cyclic exit strategies from lockdown to suppress covid- and allow economic activity the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study federal spending on the elderly and children risk factors for pandemic influenza a (h n )-related hospitalization and death among racial/ethnic groups in new mexico impact of h n on socially disadvantaged populations: systematic review quantifying the transmissibility of human influenza and its seasonal variation in temperate regions reproduction numbers and sub-threshold endemic equilibria for compartmental models of disease transmission in this example we start physical distancing measures on day (i.e. t pdon = after the start of the epidemic) and lower the transmission rate % for two weeks (i.e. t pdof f = two weeks after implemented + t pdon = ). then, measures are relaxed for two weeks. at this time the infection rate is decreased by %, assuming people are a little bit more careful by washing their hands or using cloth masks. after these two weeks, when cases start to increase again, the physical distancing measures are taken more strictly, thereby decreasing the infection rate by % for six weeks. thus, we found the famous "flatten the curve" scenario in which we all desire to maintain our health system unsaturated. if a key: cord- -lkv bgf authors: vakkuri, ville; kemell, kai-kristian; jantunen, marianna; abrahamsson, pekka title: “this is just a prototype”: how ethics are ignored in software startup-like environments date: - - journal: agile processes in software engineering and extreme programming doi: . / - - - - _ sha: doc_id: cord_uid: lkv bgf artificial intelligence (ai) solutions are becoming increasingly common in software development endeavors, and consequently exert a growing societal influence as well. due to their unique nature, ai based systems influence a wide range of stakeholders with or without their consent, and thus the development of these systems necessitates a higher degree of ethical consideration than is currently carried out in most cases. various practical examples of ai failures have also highlighted this need. however, there is only limited research on methods and tools for implementing ai ethics in software development, and we currently have little knowledge of the state of practice. in this study, we explore the state of the art in startup-like environments where majority of the ai software today gets developed. based on a multiple case study, we discuss the current state of practice and highlight issues. the cases underline the complete ignorance of ethical consideration in ai endeavors. we also outline existing good practices that can already support the implementation of ai ethics, such as documentation and error handling. ai systems have become increasingly common in software engineering projects [ ] . while much of the media attention is on flashier systems such as autonomous vehicles, less high-profile ai systems such as decision-making support systems have become increasingly widespread in various organizations. ai systems often operate under the surface in the form of e.g. recommendation algorithms, making the high-profile systems in the middle of the media hype only the tip of the iceberg. over the last two decades, progress on ai has been accelerating rapidly. ai systems are now widely used in various areas and for various purposes. examples include medical systems [ ] , law enforcement [ ] , and manufacturing industries and industry . [ ] , among numerous others. as the field progresses, the already impressive potential of ai systems becomes even larger, including applications such as general ai systems, the likes of which are already being developed by the technology giants such as alphabet. it is exactly because of this impressive potential and impact of these systems, especially in the future, that their potential negative impacts should also discussed more. ai systems are ultimately still software. they are affected by largely the same requirements as any other software system. ai development projects are still for the most part conventional software engineering, with machine learning related tasks only comprising a small portion of these projects [ ] . however, ai systems are unique in terms of their effects on various stakeholders to the point where they can even exert society-wide influence. moreover, these stakeholders often have little power in opting out of using these systems. e.g. it is difficult to avoid having a firm filter your job application using ai or trying to avoid being monitored using ai-based surveillance systems if such systems are in place in the area. various system failures have already highlighted some of the potential issues these systems can have in practice. past incidents that have received global media coverage, even smaller incidents can be costly for the affected organization(s). for example, the national finnish broadcasting company, yle , utilized ai for moderation purposes in its services. having already changed its processes to suit the automation of the moderation, the organization ultimately ran into problems with the ai moderator system. though the software was working fine on the technical level, the socio-ethical issues forced the organization to revert back to human moderators. many of these issues are ultimately rooted in ethics. ai ethics has thus become a new non-functional requirement to address; an -ility among the likes of quality, maintainability, and scalability. existing methods have focused on tackling these functional and non-functional requirements. however, no such methods currently exist for ai ethics [ ] , with the existing tools and methods largely being technical and limited to narrow contexts in ml as opposed to being project-level methods. in the absence of methods, how are ethics currently implemented? much of the current literature in the area has been theoretical, and our understanding of the state of practice in ai ethics is currently lacking. [ ] ai ethics literature discusses various aspects of ai ethics that should be taken into account, but bridging the gap between research and practice in the area remains an on-going challenge [ , ] . guidelines for implementing ai ethics exist, but their effect on the start of practice remains unknown. thus, to begin bridging this gap in the area, we conduct an empirical study to help us understand the current state of practice. we do so by means of a multiple case study of three projects focusing on healthcare systems. the goal of this study is two-fold: ( ) to help us understand the current state of practice in ai ethics; and ( ) to discover existing good practices that might help in implementing ai ethics. out of these two goals, the first is a theoretical contribution while the second one is a practical one. the specific research question of the paper is as follows: rq: how are ai ethics taken into consideration in software engineering projects when they are not formally considered? ethics in software development and interactive systems design in general has a history of over years. for example, bynum [ ] introduced the idea of adapting human values in design before the rise of human computer interaction and other human-centric paradigms. theoretically grounded approaches such as value sensitive design (vsd) and its variants have provided tools to design technology that takes into account human values in the design process [ , ] . as more progress is made in the field of ai systems, old theoretical scenarios in ai ethics are slowly becoming reality. this calls for new methods to manage the ethical issues arising from these new systems [ , ] . indeed, vallach and allen [ ] argue that ai and ai-based systems produce new requirements to consider. specifically, they propose that designers implicitly embed values in the technologies they create [ ] . ai and other complex systems force designers to consider what kind of values are embedded in the technologies and also how the practical implementation of these values could be carried out and how these systems could be governed [ ] . yet, little is currently known about software development practices and methods in the context of ai ethics, as empirical studies in the area are scarce. our results from an existing study suggest that ai ethics are seldom formally implemented in se projects, [ ] . similarly, there are currently no project-level methods that could aid in implementing ai ethics [ ] . on the other hand, various tools that can support specific elements of ai ethics do exist, such as tools for managing machine learning [ ] . however, they do not help developers implement ai ethics in general. in this light, it can be said that ai ethics has hardly been incorporated into mainstream se literature yet. the reason why ai ethics has received little attention in the prior engineering literature is three-fold: ) prior research has been predominantly philosophical, ) the field has not sensed the need to address ethical concerns and ) thus it has not been part of the education system. though some practice-focused research does exist (e.g. [ ] ), most of the research on ai ethics has been conceptual and theoretical in nature. these studies have e.g. focused on defining ai ethics in a practical manner through various constructs in the form of values. for the time being, this discussion on defining ai ethics has come to center around four values: transparency [ , ] , accountability [ , ] , responsibility [ ] , and fairness (e.g. [ ] ). not all four of these values are universally agreed to form the core of ai ethics, however, as we discuss in the following section while presenting our research framework. following various real-life incidents out on the field (e.g. amazon's biased recruitment ai ), ai ethics has also begun to spawn public discussion. this has led to governments, standardization institutions, and practitioner organizations reacting by producing their own demands and guidelines for involving ethics into ai development, with many standards and regulations in the works. countries such as france [ ] and germany [ ] have emphasized the role of ethics in ai, and on an international level the eu began to draft its own ai ethics guidelines which were presented in april [ ] . moreover, iso has founded its own ethical, trustworthy ai in iso/iec jtc /sc artificial intelligence subcommittee [ ] . finally, some larger practitioner organizations have also presented their own guidelines concerning ethics in ai (e.g. google [ ] and microsoft [ ] guidelines). thus far, these various attempts to bring this on-going academic discussion out on the field have been primarily made in the form of guidelines and principles. out of these guidelines, perhaps the most prominent ones up until now have been the ieee guidelines for ethically aligned design (ead), born from the ieee global initiative on ethics of autonomous and intelligent systems alongside its ieee p ™ standards working groups, which were branded under the concept of ead [ ] . existing literature has shown us that guidelines and principles in the field of ict ethics do not seem to be effective. mittelstadt [ ] argue that ai developers lack the professional norms and methods to translate principles into practice in successful way. to this end, mcnamara et al. [ ] also argue based on empirical data that the acm ethical guidelines had ultimately had very little impact on developers, who had not changed their ways of working at all. in this light, this is likely to be the case with the aforementioned ai ethics guidelines as well, as mittelstadt suggest [ ] . this notion is further supported by morley et al. [ ] who argue that developers focused on practicality are unlikely to adopt them when the competitive advantage of ead is unclear. to assist in the data collection and analysis in this study, we devised a research framework based on prominent literature in the area. this research framework and the justifications behind it are further discussed in an existing paper [ ] (fig. ). as the basis of the framework, we utilized the art principles of dignum [ ] , which consist of accountability, responsibility, and transparency. these have been central constructs in the area, having also been featured in the ead guidelines of ieee. transparency is required for accountability and responsibility (line .c), as we must understand why the system acts in a certain fashion, as well as who made what decisions during development in order to establish accountability [ ] . whereas accountability can be considered to be externally motivated, closely related but separate construct responsibility is internally motivated. the concept of accountability holds a key role in aiming to prevent misuse of ai and in supporting wellbeing through ai [ ] . accountability refers to determining who is accountable or liable for the decisions made by the ai. dignum [ ] in their recent works defines accountability to be the explanation and justification of one's decisions and one's actions to the relevant stakeholders. in the context of this research framework, accountability is used not only in the context of systems, but also in a more general sense. we consider, e.g., how various accountability issues (legal, social) were considered during development. dignum [ ] defines responsibility as a chain of responsibility that links the actions of the systems to all the decisions made by the stakeholders. we consider it to be the least accurately defined part of the art model, and thus have taken a more comprehensive approach to it in our research framework. according to the ead guidelines, responsibility can be considered to be an attitude or a moral obligation for acting responsibly [ ] a simplified way of approaching responsibility would be for a developer to ask oneself e.g. "would i be fine with using my own system?". in addition to the art principles, we utilized the three ai ethics categories presented by dignum [ ] to make these constructs more practical. dignum suggests that ai ethics can be divided into: • ethics by design (integration of ethical reasoning capabilities as a part of the behaviour of artificial autonomous system, e.g. ethical robots); • ethics in design (the regulatory and engineering methods supporting ethical implications of ai systems); and • ethics for design: (codes of conduct, standards, and certification processes that ensure the integrity of developers and users) [ ] . in this paper, we focus on the ethically aligned development process, and therefore the last two categories were included into the research framework. finally, aspects of commitment were utilized in the framework to aid data analysis. specifically, we utilized the commitment net model of abrahamsson [ ] to approach the implementation of ethics into practice and have an explaining theoretical framework to examine ethics role to developers. from this model, we focused on concerns and actions. concerns were analyzed to understand what ethical issues were of interest to the developers. actions were then studied to understand how these concerns were actually tackled, or whether they were tackled at all. in commitment net model, actions are connected to concerns because when actions are taken, they are always driven from concerns [ ] . on the other hand, however, concerns can exist without any actions taken to address them. the dynamic between actions and concerns was considered a tangible way to approach the focus of this study: practices for implementing ai ethics. developers actions could be likened to practices that were taking during the development. on the other hand, analyzing the concerns that developers have opens a view to understanding e.g. whether the developers perhaps wanted to implement ethics but were unable to do so. this section is split into three subsections. first, we discuss the cases of the case study. in the second and third ones we discuss the data collection and analysis, respectively. we conducted a multiple case study featuring three case projects. in all of the case projects, ai systems were being developed for the healthcare sector. these cases are outlined in the table below (table ) . we chose to utilize a qualitative case study approach due to the exploratory nature of the topic, as the research area is novel as far as empirical studies are concerned. healthcare cases were selected due to the assumption that ethical consideration would be more common in healthcare-related projects due to the nature of the area in closely dealing with human well-being (e.g. the tradition of bio and medical ethics). indeed, healthcare systems can, for example, influence the decisions made by doctors or their patients related to the health of the patients. moreover, due to the emphasis on taxfunded public healthcare in finland, where the cases were from, the area is particularly regulated. these regulations impose some ethical requirements on software systems as well, especially in relation to handling patient data, which is considered particularly sensitive data from a legal point of view. in the paper title, we characterize these case projects as being startup-like because the projects shared various characteristics typically associated with software startups. first, agile methods were commonly utilized in the projects. secondly, the projects were all characterized by notable time pressure. thirdly, the projects operated with scarce resources. fourthly, the cases were centered around the development of functional prototypes, which were intended to as proof-of-concept type artifacts. however, the prototypes were being developed with real customers and tested in practice. finally, the projects exhibited exploratory approaches that focused on experimentation. currently, much of the on-going ai development is happening in startups [ ] , even if the multinational organizations receive much media coverage in relation to ai. in characterizing them as startup-like, we consider them to be representative of the current ai development projects. data from the cases were collected using semi-structured interviews [ ] . this interview strategy enabled the interviews to be conducted in a way that allowed for flexibility from the interview questions, but without steering too far from the topic. the interview instrument used in the interviews can be found externally as a reference . all interviews were conducted as f f interviews and the audio was recorded for transcription. the analysis was conducted using the transcripts. the interviews were conducted in finnish. this was done so that the respondents would not give shorter responses due to being uncomfortable with communicating in english, especially while being on record. the respondents from the cases were either developers or managers. as we wanted to focus on development practices and project issues, we focused on the personnel directly involved with the practical development issues in the projects. the respondents are outlined in the table in the previous subsection. in terms of experience, respondents , , , and were junior developers. respondents and , on the other hand, were senior developers. respondent was a junior data scientist. we analyzed the data in two phases. first, we utilized a grounded theory (heath [ ] ) inspired approach to code the transcripts quote by quote for each interview. this process was carried out iteratively as the list of codes was updated during the process. this approach was chosen due to the lack of existing studies on the current state of practice in the area. in the second phase, we utilized the commitment net model of abrahamsson [ ] to then further analyze and categorize the coded content. we utilized the model by focusing on the concerns and actions of the developers. the concerns and actions of each respondent were compared across cases in search of recurring concerns and actions between cases and respondents. by evaluating the relationships between the actions taken in development the development process and the concerns of the developers, we could better understand the motivation behind the actions. similarly, we could also see which concerns did not lead to any actions, pointing to a lack of commitment towards tackling those concerns. the data were then compared with the research framework again to evaluate how ai ethics were implemented in each project. actions were the emphasis here, as the focus of this study was on tangible implementation of ai ethics and how it was carried out in terms of tools, practices, or methods. however, we also highlighted interesting findings in relation to the mere concerns related to ai ethics. this section is split into four subsections. the first three feature the analysis split between the accountability, responsibility and transparency constructs. the final subsection summarizes the analysis. we highlight our findings as primary empirical conclusions (pecs). during the analysis, we use quotes from the interviews to elaborate on the topic at hand. however, it should be noted that the conclusions are not drawn merely based on these individual citations. the concerns of the developers related to responsibility were varied, but ultimately detached from practice as far as concerns related to ai ethics were considered. the concerns the developers discussed in relation to responsibility were simply very practical concerns related to internal project matters or delivering a high quality product: "responsibility on reporting and keeping the project on schedule" (r ) pec . developers feel most responsibility towards tackling problems related to software development, such as finding bugs, meeting project goals. on the other hand, as the interviews progressed, the developers did also express some concerns towards various ethical issues. however, these concerns were detached from their current work. they did not affect the way they worked, and the developers felt that these types of concerns were not relevant during development. the presence of concerns in the absence of actions to address those concerns pointed towards a lack of commitment on this front. "it is just a prototype" (r ) "i do my best" (r ) "but this is a prototype, an experiment, just to show people that you can do this type of thing. this doesn't really have any responsibility issues in it." (r ) pec . on a personal level, developers are concerned about the ethical aspects of product development. however, little is done to tackle these concerns. furthermore, it was evident that in none of the cases had the hypothetical effects of the system on the stakeholders been discussed. to give a practical example, a system potentially affecting memory illness diagnoses clearly has various effects on its potential users, especially when the test can be taken without supervision. yet, the developers of this particular tool also felt that their users would not be curious about the workings of the system. they considered it sufficient if the responsibility was outsourced to the user and it was underlined that the system does not make the diagnosis but simply advises doctors. the developers did not consider the potential harm of the system past the tangible, physical harm potential of the systems. for example, stress or other negative effects on users and other stakeholders were not considered. in all three cases, the respondents did not consider the system to have had any potential of causing physical harm, and thus did not consider the system to have any notable harm potential at all. "nobody wants to listen to ethics-related technical stuff. no five hour lectures about it. it's not relevant to the users" (r ) "i don't really understand what it [responsibility] has to do with product development. we developers are all responsible." (r ) "what could it affect… the distribution of funds in a region, or it could result in a school taking useless action… it does have its own risks, but no one is going to die because of it" (r ) pec . responsibility of developers is unclear. case a highlighted the potential importance of mathematical expertise. the team had internal mathematical capabilities that allowed them to develop their own algorithms, as well as to better understand third party components, in order to have achieve a higher standard of transparency. they utilized algorithms they were familiar with and which they understood on an in-depth level. thus, the team considered themselves to be able to understand why the system made certain decisions in certain situations. this underlines the importance of mathematical skills in preventing the birth of black boxes in ai development. "in that sense it's not really a black box as we can understand what's going on in there just fine, and we can show the nodes and what affects them. it's a very transparent algorithm." (r ) the other two cases utilized existing ai solutions. they did not have an in-depth understanding of the technologies they were utilizing, which resulted in their systems being (partially) black boxes. they understood any components created by the team but did not have a full understanding of the third party components they had used as a base. this presents problems for feature traceability. even though transparency of algorithms and data was not present in two of the cases, the developers in case b nonetheless acknowledged its potential importance however, as it was not considered a formal requirement in the projects, the managers did not devote resources towards pursuing it. even in case a, transparency was not produced as a result of ethical goals but out of business reasons. "we have talked about the risks of decision-making support systems but it doesn't really affect what we do" (r ) pec . developers recognize transparency as a goal, but it is not formally pursued. on the other hand, in relation to transparency of systems development, all three cases displayed transparency. by having formal decision-making strategies, they were able to keep track of higher-level decisions related to the system. through proper documentation, they were able to keep track of decisions made on the code level. version control also assisted in this regard, making it clear who made what changes and when in retrospect. there were thus various existing practices that produced transparency of systems development. two of the cases also acknowledged the effects of team size on transparency of systems development. they noted that, in addition to documentation practices, the small team size itself made it easy to keep track of the actions of individual developers even in an ad hoc manner. established se practices, such as code documentation and code review, support transparency of systems development. some aspects of accountability were clear points of focus in the projects, namely ones related to security in terms of general information security as well as data management. the respondents were aware of being in possession of personal data, given that they developed healthcare solutions, and were concerned with keeping it secure. they mentioned taking measures to keep the data secure from potentially malicious actors, and they were aware that they would have to take measures to act in accordance with laws and regulations in the area. however, in some cases they had not done so yet. "it's really important how you handle any kind of data, that you preserve it correctly, among researchers, and don't hand it out to any government actors. for example, many of the data packages have kind of interesting data and it can't get into the wrong hands. i personally can't see any way to harm anyone with the data we have though" (r ). "we haven't really paid much attention to the [data] safety aspects yet… it hasn't really been a main focus. there's probably a lot of things we have to take into account [eventually]" (r ). the ethical concerns they had in relation to accountability were in general largely related to existing areas of focus in software development. for example, error handling was one aspect of accountability the respondents were particularly concerned with. this was tied with their goal of making quality software, which they considered their responsibility as professionals. the respondents could, to this end, discuss what tangible practices they utilized to deal with error handling. pec . developers feel accountable for error handling and have the means to deal with it. however, error handling was largely considered from the point of view of writing code and testing it in a laboratory setting. i.e. the system was considered error free if there were no red lines in the code in the ide during development. only case company b discussed measures they had taken to monitor errors in use. furthermore, potential misuse (e.g. a prankster drawing a horizontal white line on the pavement to intentionally confuse autonomous vehicles) and error scenarios during the operational life of the system had not been actively considered in any of the case projects. "the calculations are made in the algorithms, so it doesn't really make mistakes" (r ) pec . product misuse and error scenarios are only considered during development. they are not considered in terms of the future operational life of the system out on the field. due to the nature of machine learning, ai systems learn as they are taught with new data or as they collect it themselves while operating out on the field. from this arises the potential issue of unexpected behavior as a result of machine learning. none of the respondents had made plans to tackle potential unexpected behavior during the operational life of their system, should such behavior arise. in only one of the projects was the possibility directly acknowledged: "we just put it up for end-users to test and note that this is still being developed" (r ). pec . developers do not have plans to deal with unexpected behavior of the system resulting from e.g. machine learning or the future expansion of the use context of the system. past the art constructs, we highlight some commonalities between the cases on a more general level while summarizing our findings. in none of the cases were ethics implemented by following a formal method or tool, nor were ethical issues considered directly as ethical issues. rather, any ethical issues tackled in the projects were tackled for practical reasons (e.g. error free software is beneficial from the point of view of customer relations). nonetheless, some of the ethical issues such as error handling and transparency of systems development were tackled in a systematic manner through existing software engineering practices such as code documentation and version control. on the other hand, though ethics were not taken into consideration on a project level, the respondents still exhibited some concern towards the potential socio-ethical issues in the systems. when prompted, they were able to come up with various negative effects the systems could have on different stakeholders. they considered these to be potential real issues, but did not have a way to address these concerns in the absence of tools, practices, and methods for doing so. moreover, they seemed to realize these potential issues only after being directly asked about them in the interviews. this also points to a lack of tools to aid in ethical analyses. in this section, we have collected all the primary empirical conclusions (pec) outlined in preceding analysis section into table . we relate each of these findings to existing literature and discuss their implications in this section. we classify each of these pecs based on their contribution into either novel findings, findings that (empirically) validated existing literature, or findings that contradict existing literature. many of our findings underline a gap between research and practice in the area. whereas research on ai ethics alongside various guidelines devised by researchers [ ] and practitioners [ , ] alike has discussed various ethical goals for ai systems, these goals have not been widely adopted out on the field. in this sense, we consider some of our findings (pecs , , , and ) to contradict existing literature. for example, extant literature has highlighted the importance of transparency of algorithms and data [ ] [ ] [ ] . without understanding how the system works, it is impossible to establish why it malfunctioned in a certain situation, which may e.g. be pivotal in understanding the causes of an accident that resulted in material damage [ ] . our findings point towards transparency being largely ignored as a goal (pec ). existing system components are utilized as black boxes, and developers do not see this as a notable problem (pec ). we consider pec to contradict existing literature in that existing literature has, on multiple occasions, highlighted the importance of transparency in ai systems. yet, out on the field, this importance does not seem to be recognized to the point where it would result in changing development practices. the situation is similar for tackling potential misuse of the systems, error handling during system operations, and handling unexpected system behavior (pec - ). these goals are included into the ieee ead guidelines [ ] . however, none of the case companies took any measures to address these potential issues. on a further note of transparency, however, the lack of emphasis placed on it is also curious in relation to feature traceability in se. for decades, understanding the inner workings of the system was considered key in any se endeavor. yet, in the context of ai systems, the long-standing goal of feature traceability seems to be waning. our findings point towards this being at least partially a result of a lack of mathematical understanding, as the one case company that considered their system to be fully transparent also noted that they fully understood the mathematics behind the algorithms they utilized. in using existing components in their systems, developers may not always understand the algorithms in these components. indeed, in this vein, [ ] noted that simply seeing the code is not enough if the algorithm is not understood, or the system is not understood as a whole. though we discovered various examples of ethics not being implemented, we also discovered that various existing and established se practices can be used to implement ai ethics. documentation, version control, and project management practices such as meeting transcripts produce transparency of systems development by tracking actions and decision-making (pec ). similarly, software quality practices help in error handling also in the context of ai ethics (pec ), although they do not specifically account for the errors autonomous systems may face while operating out on the field. while discussing responsibility with the respondents, we also discovered that most of their responsibility was related to producing quality software and meeting project requirements. this validates existing literature in the area of spi (e.g. unterkalmsteiner, [ ] ). notably, we also discovered that the developers had ethical concerns towards their systems, which is a novel finding in this context (pec ). little is currently known about the state of practice out on the field, although a recent version of the ead guidelines speculated about a gap in the area, which our findings support in relation to most aspects of ai ethics. despite ai ethics largely not being implemented, our findings point towards it partially being a result of a lack of formal methods and tools to implement it. in our data, the reason given by multiple respondents for not actively considering ethical issues was that they were developing a prototype. however, prototypes do influence the final product or service developed based by them, as shown by existing studies [ ] . ai ethical issues should be tackled during earlier stages of development as well, seeing as many of them are higher-level design decisions (such as how to carry out machine learning in the system [ ] ), which can be difficult to undo later. following this study, as well as a past case study [ ] , we suggest that future research seek to tackle the lack of methods and tooling in the area. though developers may be concerned about ethical issues, they lack the means to address these concerns. on the other hand, methods can also raise the awareness of developers in relation to ai ethics, creating concerns where there now are none. in creating these methods, we suggest exploring existing practices that can be used as is or tailored to implement ai ethics, as we have discussed here. given the amount of activity in ai ethics currently, with many governmental actors drafting their own ai ethics guidelines, likely followed by regulations, methods and tools will likely have practical demand in the future. thus, even if one barrier to implementing ai ethics is currently the fact that it is seldom considered a requirement on a project level, regulations and laws can force organizations to take ethics into account. this would inevitably result in a demand for methods in this area, as well as the birth of various in-house ones. finally, in terms of limitations, the most notable limitations of the study stem from the data and the research approach. the qualitative multiple case study approach always poses problems for the generalizability of the data. we acknowledge this as a limitation, although we also refer to eisenhardt [ ] in arguing in favor of qualitative case studies, especially in the case of novel research areas. ai ethics, as far as empirical data goes, is a novel area of research. moreover, the multiple case study approach adds some further validity to the data, as we do not base our arguments on a single case. nonetheless, another limitation in the data is also that all the cases were based on finland. for example, the implementation of ai ethics can be more of a focus in us-based companies, as much of the current discussion on ai ethics also originates from the us. one other limitation in the data is that the interviews were conducted in finnish. the constructs such as transparency may not carry the same connotations in finnish as they do in english. this is especially the case with accountability and responsibility, which may not translate in a straightforward manner. however, during the interviews, we sought to clear any misunderstandings related to the constructs with the respondents. the research framework can also be argued to be a limitation. as ai ethics is a currently active field in terms of theoretical discussion, the constructs in the area are constantly evolving. the art principles and ead chosen as a basis of the framework were, at the time of writing, some of the most prominent works in the area. the framework ultimately presents but one way of perceiving ai ethics. this paper furthers our understanding of the current state of practice in the field of ai ethics. by means of a multiple case study, we studied the way ai ethics is currently implemented in practice, if it is implemented at all, when it is not formally or systematically implemented in software engineering projects. our findings can be summarized through the following two key takeaways: • even when ethics are not particularly considered, some currently commonly used software development practices, such as documentation, support ead. this is also the case with focusing on information security. • while the developers speculate potential socioethical impacts of the resulting system, they do not have means to address them. thus, from the point of view of software engineering methods and practices, this highlights a gap in the area. while some of the existing common practices support the implementation of some aspects of ai ethics, there are no methods or practices that help implement it on a project-level. further studies on the topic should seek to assist in the practical implementation of ai ethics. singular practices and especially project-level methods are needed to bridge the gap between research and practice in the area. this lack of higher-level methods was also highlighted in a review of tools and methods in the area [ ] . open access this chapter is licensed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/by/ . /), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license and indicate if changes were made. the images or other third party material in this chapter are included in the chapter's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the chapter's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. ai : america's most promising artificial intelligence companies artificial intelligence in medicine artificial intelligence for law enforcement: challenges and opportunities industrial artificial intelligence for industry . -based manufacturing systems hidden technical debt in machine learning systems from what to how: an initial review of publicly available ai ethics tools, methods and research to translate principles in-to practices towards moral autonomous systems ethically aligned design: a vision for prioritizing human well-being with autonomous and intelligent systems, first edition flourishing ethics value-sensitive design value sensitive design: applications, adaptations, and critiques. in: van den hoven why machine ethics? incorporating ethics into artificial intelligence ethically aligned design of autonomous systems: industry viewpoint and an empirical study stop explaining black box machine learning models for high stakes decisions and use interpretable models instead the ethics of information transparency false positives, false negatives, and false analyses: a rejoinder to "machine bias: there's software used across the country to predict future criminals, and it's biased against blacks for a meaningful artificial intelligence: towards a french and european strategy german federal ministry of transport and digital infrastructure: automated and con-nected driving ethics guidelines for trustworthy ai iso/iec jtc /sc artificial intelligence responsible bots: guidelines for developers of conversational ai principles alone cannot guarantee ethical ai does acm's code of ethics change ethical decision making in software development? ai ethics in industry: a research framework ethics in artificial intelligence: introduction to the special issue commitment nets in software process improvement mastering the semi-structured interview and beyond: from research design to analysis and publication developing a grounded theory approach: a comparison of glaser and strauss seeing without knowing: limitations of the transparency ideal and its application to algorithmic accountability evaluation and measurement of software process improvementa systematic literature review minimum viable product or multiple facet product? the role of mvp in software startups building theories from case study research. acad key: cord- -istz iql authors: nan title: procedures to investigate waterborne illness date: - - journal: procedures to investigate waterborne illness doi: . / - - - - _ sha: doc_id: cord_uid: istz iql humanity could not survive without a reliably clean, safe, and steady flow of drinking water. since the early s when typhoid fever and cholera were frequently causes of waterborne illness in developed countries, drinking water supplies have been protected and treated to ensure water safety, quality, and quantity. having access to safe drinking water has always been one of the cornerstones of good public health. not only safe water is limited to drinking water, but recreational water can also be a source for waterborne illness—both from treated waters such as in swimming pools, whirlpools, or splash pads and from non-treated surface waters such as lakes, rivers, streams and ponds. recreational waters may cause illness not only from ingestion of pathogens, but also when in contact with eyes, ears, or skin. some pathogens in water can be acquired by inhalation of aerosols from water that is agitated or sprayed such as in humidifiers, fountains, or misting of produce. this poses a potential risk to those exposed, particularly if they are immunocompromised. humanity could not survive without a reliably clean, safe, and steady flow of drinking water. since the early s when typhoid fever and cholera were frequently causes of waterborne illness in developed countries, drinking water supplies have been protected and treated to ensure water safety, quality, and quantity. having access to safe drinking water has always been one of the cornerstones of good public health. safe water is not limited to drinking water, since recreational water and aerosolized water can also be sources for waterborne illness, from treated waters such as in swimming pools, whirlpools, or splash pads and from non-treated surface waters such as lakes, rivers, streams and ponds. recreational waters may cause illness not only from ingestion of pathogens, but also when in contact with eyes, ears, or skin. some pathogens in water can be acquired by inhalation of aerosols from water that is agitated or sprayed such as in humidifiers, fountains, or misting of produce. this poses a potential risk to those exposed, particularly if they are immunocompromised. often when an outbreak is first suspected, the source is not clear, i.e., food, water, animal contact. investigation is usually needed to find the common source. in some outbreaks the food may first be identified as the source, such as with produce, but the ultimate source could be contaminated irrigation water. investigators have to keep an open mind until laboratory and/or epidemiologic evidence links cases to the primary source. although we frequently think of waterborne illness originating from a microbiological agent, we should be aware that water may also be contaminated by pesticides, fertilizers, and other chemicals which may enter through industrial discharge, agriculture runoff, or deliberate contamination. waterborne illness acquired from microorganisms may be classified as: • toxin-mediated infections caused by bacteria that produce enterotoxins or emetic toxins that affect water, glucose, and electrolyte transfer during their colonization and growth in the intestinal tract; • infections caused when microorganisms invade and multiply in the intestinal mucosa, eyes, ears, or respiratory tract, or contact the skin; • intoxications caused by ingestion of water containing poisonous chemicals or toxins produced by other microorganisms manifestations range from slight discomfort to acute illness to severe reactions that may terminate in death or chronic sequelae, depending on the nature of the causative agent, number of pathogenic microorganism or concentration of poisonous substances ingested, and host susceptibility and reaction. the public relies on public health regulators to investigate and mitigate waterborne illness. mitigation depends upon rapid detection of outbreaks and a thorough knowledge of the agents and factors responsible for waterborne illness. public health and law enforcement agency officials should always be alert to the rare possibility of an intentional contamination of water supplies by disgruntled employees or terrorists. the purposes of a waterborne illness investigation are to stop the outbreak or prevent further exposure by: • identifying illness associated with an exposure and verifying that the causative agent is waterborne • detecting all cases, the causative agent, and the place of exposure • determining the water source, mode of contamination, processes, or practices by which proliferation and/or survival of the etiological agent occurred • implementing emergency measures to control the spread of the outbreak • gathering information on the epidemiology of waterborne diseases and the etiology of the causative agents that can be used for education, training, and program planning, thereby impacting on the prevention of waterborne illness • determining if the outbreak under investigation is part of a larger outbreak by immediately reporting to state/provincial/national epidemiologists in the instance of a bottled water outbreak, halting of distribution and sale of product and recall of product, some of which may already be in consumers' homes, are necessary to prevent further illness. as epidemiologic data accumulate, information will indicate the source of the problem, whether a municipal water treatment plant, bottled water manufacturing plant, or recreational water exposure, and suggest methods for controlling and preventing waterborne illness. this information will guide administrators in making informed decisions to provide the highest degree of waterborne safety. a flowchart, sequence of events in investigating a typical outbreak of waterborne illness (fig. ) shows the sequential steps, as presented in this manual, in investigating a typical outbreak of waterborne illness and illustrates their relationships. a description of each step is presented in this manual. can be recognized at any point during the outbreak investigation. if intentional contamination is suspected follow your notification scheme in emergency response plans (this could include law enforcement, emergency management and other government agencies) the primary purpose of a waterborne disease surveillance system is to systematically gather accurate information on the occurrence of water-related illnesses in a community, thus allowing development of a rational approach for the detection, control and prevention of waterborne illness. other purposes are to (a) determine trends in the incidence of waterborne diseases, (b) characterize the epidemiology of waterborne diseases, (c) gather and disseminate information on waterborne diseases, and (d) develop a basis for evaluating control efforts. it may be useful to coordinate this system with, or integrate it into a foodborne disease surveillance system. however, while the procedures are quite similar from an epidemiologic viewpoint, they may differ with respect to personnel or agencies involved. an effective disease surveillance system is essential for detection of disease caused by either unintentional or intentional contamination of food. an effective waterborne disease surveillance system consists of: • early reports of enteric and other illnesses that may be related to water exposure or consumption • coordinated effort between local and state public health partners, water utility and water recreation staff • systematic organization and interpretation of data • timely investigation of identified outbreaks or clusters of illness • dissemination of outbreak reports and surveillance summaries to all appropriate stakeholders many types of reporting systems may already exist at the local or state/provincial level, and these should be incorporated into a waterborne disease surveillance program. these include (a) mandatory (or voluntary) laboratory-or physician-based reporting of specific infectious diseases, (b) national-based surveillance systems such as calicinet (cdc ) or nors (cdc in the us, (c) physician office, hospital emergency, and urgent-care clinic medical records, (d) public complaints made to health agencies and/or local water utilities, (e) school illness and absentee records, (f) absentee records of major employers, (g) water treatment records kept by water utilities (e.g., turbidity, disinfection levels, occurrence of coliforms), (h) increased sales of antidiarrheal drugs and anti-nausea medications, and (i) source water quality data kept by environmental agencies (e.g., departments of natural resources and geological survey agencies). another type of surveillance mechanism that may supplement or enhance existing reporting systems is a daily log of illness and water quality complaints. agency contemplates initiation or development of a waterborne illness surveillance program, give top priority to identification of appropriate financial, political, strategic, and administrative support. then, identify a key person to create, implement, and manage the system. this person takes responsibility for: • reviewing the types of reporting systems that already exist in your agency or in other agencies that could be incorporated into a waterborne illness surveillance system • identifying the types of information that cannot be obtained from existing reporting systems but that need to be collected or addressed by the waterborne illness surveillance system • identifying ways to merge or integrate the data collected by existing systems with data gathered in the waterborne illness surveillance system • identifying collaborating agencies and staff • develop a mechanism to communicate and update all stakeholders (may be by blast e-mail or periodic conference calls) • providing training in surveillance methods for agency staff and other partners to enhance cooperation • assembling materials that will be required during an outbreak investigation • evaluating the effectiveness of the system. develop procedures to seek and record complaints about waterborne illnesses, water supplies, and water recreational sites. for example, list the telephone number of the waterborne illness investigation unit prominently on local and state public health and water utility websites. to be most effective, have this number monitored / by staff or an answering service. if possible, the utilization of social media such as facebook or twitter should be considered and monitored as many large municipalities (including drinking water utilities) and recreational facilities have an internet presence. if your agency has social media accounts, consider using this vehicle to further disseminate information regarding waterborne illness clusters or outbreaks. identify medical care facilities and practitioners and seek their participation. direct educational activities, such as newsletters and talks at meetings, to stimulate participation in the program. encourage water treatment utilities and operators of recreational water sites to report suspected complaints of waterborne illness to the appropriate local agencies. also, encourage private and hospital laboratories to report isolations of parasitic agents (e.g., giardia, cryptosporidium), viruses (e.g., norovirus and hepatitis a virus), bacteria (e.g., e. coli (pathogenic), salmonella, shigella, vibrio cholerae), and other agents that may be waterborne. develop a protocol for notification and coordination with agencies that might cooperate in investigational activities, including -h-a-day, -days-a-week contacts. a comprehensive contact list should be constructed and updated at least twice a year as individuals may change. notify and coordinate with state/provincial or district agencies, national agencies that have surveillance and water regulatory responsibilities, and other national and international health agencies, as appropriate. for example, it may be useful to find out the level of participation within a certain jurisdiction in national-level outbreak surveillance programs such as nors (cdc, ) or other national surveillance system. delegate responsibility to a professionally trained person who is familiar with epidemiologic methods and with the principles of water treatment and recreational water protection. this person will (a) direct the surveillance program, (b) take charge if waterborne and enteric outbreaks are suspected, and (c) handle publicity during outbreaks. delegate responsibility to others who will carry out specific epidemiologic, laboratory and on-site investigations. if an intentional contamination event is suspected, local and national law enforcement agencies will likely become the lead agency responsible for the investigation. with this in mind, it is critical to identify appropriate individuals and include them in communication and any practice drills that may occur. if a relationship has been established prior to any event, the investigation may run more smoothly. enlist help from a team of epidemiologists, microbiologists, sanitarians/environmental health officers/public health inspectors, engineers, chemists, nurses, physicians, public information specialists, and other (e.g., toxicologists) as needed. free flow of information and coordination among those participating in waterborne disease surveillance and investigation are essential, particularly when several different agencies are involved. water-related complaints are equally likely to be directed at health departments or water utilities but also perhaps to different jurisdictions. therefore, it is essential that these complaints be registered by an agency and that the information is rapidly shared within and perhaps outside of a particular jurisdiction as part of an integrated surveillance system. whenever possible, share the information with participating parties by rapid means such as e-mail and by calling / contact phone numbers. if an intentional contamination event is suspected, contact emergency response and law enforcement for their early involvement. select staff members who will participate in the waterborne disease surveillance program on the basis of interest and ability. inform them of the objectives and protocol of the program. emphasize not only the value of disease surveillance, but also the value of monitoring water quality and treatment performance. if possible, provide printed learning material that can be referenced later. encourage the use of epidemiologic information and approaches in routine disease surveillance and prevention activities. develop their skills so that they can carry out their role effectively during an investigation, and teach them how to interpret data collected during investigations. conduct seminars routinely and during or after investigations to update staff and keep agency personnel informed. train office workers who will receive calls concerning waterborne illnesses to give appropriate instructions. those who participate in the investigation will learn from the experience and often are in a position to implement improvements after completion of the investigation. assemble and have readily available kits with forms and equipment as specified in table a (equipment useful for investigations). restock and maintain kits on a schedule recommended by, and in cooperation with, laboratory staff to ensure their stability and sterility. verify expiration dates, and use kits before this date or discard and reorder. assemble a reference library on waterborne illnesses, investigation techniques, and control measures from reference books, scientific journal articles, manuals, and reputable internet sources (e.g., www.cdc.gov, www.who.int/en/, www.hc-sc.gc.ca/ index-eng.php, www.gov.uk/topic/health-protection/infectious-diseases); make it available to the staff in an easy-to-access format. (see further reading for suggestions). organize a multiagency team with representatives from public health agencies, regulatory agencies, and water utilities and with local political officials to review and exercise existing emergency response plans in the event of a large scale waterborne disease outbreak or other disaster likely to result in waterborne illnesses. local public health agencies have the primary responsibility for the restoration and protection of health of a community following an outbreak event or other emergency. emergency operational procedures should include the following: • an emergency notification list that includes phone numbers and e-mail addresses of key persons/agencies that need to be informed about possible outbreaks and that should receive emergency press releases. every state/province has an emergency management agency and depending upon the scale of the event, it may be useful to coordinate efforts. • clear guidelines for household water consumption following an event. for example, boil-water advisories or instructions to drink only bottled water. statements should be reviewed to ensure current relevance and updated to reflect the most current knowledge. • a plan for dissemination of information to the public; select a coordination point to which all news media and outside agencies will be directed, and designate one person or one telephone number as the contact. (more than one contact person can create confusion). • alternative drinking water sources to be used in cases of emergency and plans for the distribution of this water, if necessary. these include alternative munici-pal systems, bottled water supplies, portable filtration and/or disinfection devices and home treatment units. (special attention should be given to backup supplies for hospitals, nursing homes and other places where lack of safe water would be immediately life-threatening). • identification of specialty laboratories at the state/provincial and national level that are capable of performing (and willing to perform) procedures not routinely done at local laboratories (e.g., large volume water sampling and processing for pathogenic parasites and viruses, serotyping, electron microscopic examination of stool samples, molecular and immunodiagnostic tests for pathogens in environmental and clinical samples). one or more of these tests may be necessary to identify the causative agents in an outbreak and confirm their transmission route. • a plan to exercise procedure with tabletop exercises involving all pertinent partners on a regular basis and implement any necessary adjustments based upon review of after-action findings. notification of a suspected outbreak is often received by health authorities from a laboratory report or a family physician and can be documented on a log such as form a (foodborne, waterborne, enteric illness complaint report). public health investigators will then interview cases and persons at risk who are well (controls) to make epidemiologic associations to find a common source. from here a hypothesis can be formed. further investigation will involve: • collecting clinical samples and water samples • conducting an on-site investigation at the facility alleged to be responsible to determine the mode of contamination or process failure, e.g., low disinfectant level • characterizing the etiologic agents by laboratory analysis using various typing schemes. dna profiling or pulsed-field gel electrophoresis (pfge), of isolates from clinical and water samples to "fingerprint" and link strains of the etiologic agent among cases and to the source prompt handling and referral of water-related complaints, rapid recognition of the problem, and prevention of further illnesses are the foundations of a successful investigation. complaints of water problems are as likely to be reported to a water utility as to a health department. communication is essential between these agencies. this first contact with the public is a vital aspect of an investigation of a potential outbreak and needs to begin by public health professionals as quickly as possible, usually within hours, sometimes by putting less urgent activities aside. as indicated earlier, any action respecting a potential deliberate contamination of water will generate a specific approach to further action. upon receiving a complaint or an alert about a water supply or water exposure or illness potentially attributed to these sources, record the information on form a. alerts may be initiated by reports from physicians, laboratories, or from hospital emergency rooms. alerts may also include an increase in a particular pfge pattern from clinical isolates. an investigation may be initiated to determine if there is a common water exposure among patients with the pfge pattern. the pattern may be compared with similar pfge patterns in pulsenet databases to determine if there are similar occurrences of the pattern in water and clinical isolates nationwide or internationally, e.g., for food that might have been contaminated with water, bottled water. the form provides information upon which to decide whether an incident should be investigated. form a is not difficult to fill out and can be completed by a public health professional, a trained water utility staff member, or trained office worker. assign a sequential number to each complaint. if additional space is needed to record information, use the reverse side or attach additional sheets. always ask the complainant to provide names of other persons at the event, or using the water supply or recreational water under suspicion, whether or not ill, and names of any other persons who are known to be ill with the same symptoms. follow up by contacting these additional persons. emphasize to the persons making alerts or complaints the need to retain a sample of the suspect water and to save clinical specimens (vomitus and stool) from ill persons using a clean utensil in a clean jar or plastic bag and to seal tightly and label clearly with the name of the person and date, and store in a refrigerator (do not freeze). also consider family members not ill for case-control studies. advise complainants to collect a liter (quart) of water immediately, preferably in sterile containers but otherwise in jars that have been boiled or in plastic bags, or if this is not feasible, in other clean containers. tell the complainant to save any ice cubes or refrigerated water, either in their present containers or in unused plastic bags, in the refrigerator or freezer (if already frozen) where they are normally kept. instruct the ill person to hold all clinical specimens and water samples until the health agency evaluates the epidemiological evidence and arranges, if necessary, to collect them. if it is determined that the specimen or sample is not necessary, notify the complainant and advise on proper disposal of the material. unfortunately, the specific etiologic agent cannot be identified in a large proportion of waterborne outbreaks because water samples and clinical specimens (a) were not collected in an appropriate time-frame (not early enough during illness), investigate outbreaks (b) are too old, (c) are too small in volume, especially for giardia and viruses which require liters, (d) have not been examined for the appropriate agent. contaminants may be in the water system for only a short time, and concentrations of toxic substances and numbers of microorganisms may decrease significantly because of dilution or disinfection. if there is a cluster of cases, monitor reports from physicians, complaints about water, or records of laboratory isolation of enteric pathogens that may suggest outbreaks of disease or contributory situations. collect clinical specimens and water as soon as practicable according to the section obtain clinical specimens in this book. extract key information (see* and † entries) from form a and enter it onto form b (foodborne, waterborne, enteric illness and complaint log). record time of onset of the first symptom or sign of illness, number of persons who became ill, predominant symptoms and signs, whether ice or water was ingested, and the name of the water supply or recreational water alleged to have caused the illness, and whether a physician had been consulted, and/or had taken feces or emesis samples, and/or prescribed antibiotics. also, enter on form b names of the places or common gatherings (other than home) at which the stricken persons ingested water during the weeks before onset of illness (see table for an example). enter a code for the water source (e.g., community, non-community, individual well, bottled, stream/ lake, vended, or untreated) . under "history of exposures" column indicate whether the afflicted person had recent domestic or international travel, attended a child care facility, or had recent contact with ill persons or animals. under "comment" column, enter notations of type of agent isolated, results of specimen tests, places where water was consumed during travel, names and locations of restaurants or other foodservice facilities, and other pertinent information including hospitalization, occupation, or place of employment. at this phase of the investigation it will probably not be known whether the illness is waterborne, foodborne, or person-toperson spread. this log can be kept either in hardcopy or in electronic format. see table (below) as an example of a log. interpretation of table . entry -get further details on the patient's symptoms and seek other cases. the report of foreign travel suggests an infection that may have been acquired outside the country. follow-up of such cases may identify an outbreak of international scope. if so, inform state/provincial and national authorities concerned with surveillance of waterborne disease about the situation. entry -possibly food associated; alert food safety officials. entry -initiate investigation; the two cases of conjunctivitis suggest the possibility of a common-source outbreak associated with the motel pool. entry -initiate investigation; cases indicate an outbreak that has a common time-place association. entry -this could be related to entry , because this person reported swimming in the same pool. exposure history: dt domestic travel (out of town, within country); it international travel; cc child care; ci contact with ill person outside household or visitor to household; a an exposure to ill animal; c contact with ill person within household responsible for the investigation, if this was not done when the surveillance protocol was established. delegate sufficient authority and provide resources to the head investigator so that the investigation tasks can be accomplished effectively and efficiently. inform all outbreak investigative team members that any findings are to be reported to this delegated authority. a list of all team members and additional contacts such as administrative contacts, sanitarians/environmental health officers/ public health inspectors, local and regional contacts, physicians, clinical laboratories, or other persons who may become involved in outbreak investigations should be assembled. before beginning the investigation, check the supply of forms and the availability of equipment suggested in table a (equipment useful for investigations) and obtain any needed materials or additional equipment. general resource materials describing signs and symptoms, incubation times, and specifics regarding specimen collection and appropriate kits to be used should be maintained and readily available to those processing the initial calls, which may help to formulate the initial hypothesis. if the alert or complaint suggests a possible outbreak, inform laboratory personnel of the type of outbreak and estimated quantity and arrival time of clinical specimens and water samples collected. this information will give laboratory managers time to prepare laboratory culture media, prepare reagents, and allocate personnel. at a minimum, the laboratory should have six to eight stool culture kits on hand or readily available, since in many cases, stool specimens must be collected within h of onset of illness to isolate and identify certain pathogens (e.g., campylobacter spp., and salmonella spp.). consult laboratory personnel about proper methods for collecting, preserving, and shipping environmental samples and clinical specimens if such information is needed. obtain appropriate specimen containers and sample submission (chain of custody forms) from them. once the investigation is underway, the proper clinical specimens should be collected as soon as possible before patients recover and become less likely to submit specimens. all suspected waterborne outbreaks should be examined and a determination made regarding the feasibility of conducting a thorough investigation even if the time to collect proper clinical specimens has passed. an ill person or family member, physician, hospital staff member, or operator of a water utility or recreational site may report suspected cases of waterborne illness. whatever the source of the report, verify the diagnosis by taking a thorough case history and, if possible, by reviewing clinical information and laboratory findings. (this analysis can be further substantiated by detecting suspected etiologic agents in water). verification of the diagnosis is done in consultation with medical professionals. when a complaint involves illness, complete forms c - (case history: clinical data and case history: food/water history and common sources) either at the time of initial notification, during a personal visit, or during a telephone call to the person reported to be ill. use this same detailed interview approach with every person who has been identified in the initial complaint or alert, even though some may not have been ill. be aware that potential cultural and language barriers can make interviews difficult. a different interviewer may be needed to accommodate these barriers. continue this until sufficient information is obtained to decide whether there is, indeed, an outbreak of waterborne illness. from persons who are at risk of illness but who remained well, also obtain water and -hour food histories, inquire about recreational water exposure in past weeks, and information about their activities in common with the ill persons. information from these persons is as important to make epidemiologic associations as it is from the cases. when it is apparent that an outbreak has occurred and a specific event has come under suspicion, substitute forms d - (case history summaries: clinical data and case history summaries: water/laboratory data) for form c. form d can be used initially in many routine waterborne illness outbreak investigations where it is obvious that a common-source outbreak has occurred or when all of the ill persons consumed water together (e.g., drank from the same public system, consumed ice at an event) or recreated at the same place (e.g., swam in the same lake or used the same hot tubs). this will simplify recording, because most affected persons will give similar information. at this time, notify the district, state, or provincial epidemiologist about the outbreak. if a specific pathogen (e.g., norovirus, e. coli o :h , cryptosporidium spp.) has been identified as the etiologic agent, consider developing a form for recording relevant information. many state/provincial or national public health agencies have standard forms tailored to specific pathogens. include signs and symptoms of the illness and other clinical information, the etiology of the agent, and usual methods of transmission. computer programs (e.g., epi info™) can aid in the design of such standard forms. upon contact with the affected person, identify yourself and your agency and explain the purpose of the visit or call. a professional attitude, appropriate attire, friendly manner, and confidence in discussing epidemiology and control of waterborne illnesses are essential for developing rapport with affected persons or their families and in projecting a good image of the investigating agency. keep in mind that you are not interviewing someone you inspect or regulate, but that you are providing a service to the affected person. exhibit genuine concern for persons affected and be sincere when requesting personal and confidential information. communicate a sense of the urgency of the investigation, and emphasize that their participation will make a positive contribution for the control and prevention of waterborne illness. parental consent must be obtained before interviewing children under years of age. in some locations, consent from the affected person's physician may also be required. after asking open-ended questions about the person's food exposures and illness history, follow up with more specific questions to fill in the details and better ensure a thorough recall. base your level of communication on a general impression of the person being interviewed, considering information about age, occupation, education, or socioeconomic status. tact is essential. use either form c or form d, as appropriate, as a guide. state questions so that the persons who are being interviewed will describe their illnesses and associated events in their own words. try not to suggest answers by the way you phrase questions. fill in form c - (if appropriate) and take additional notes during the interview. ask specific questions to clarify the patient's comments. think questions through before conducting the interview. realize that people are sometimes sensitive to questions about age, sex, special dietary habits, ethnic group, excreta disposal, and housing conditions. nevertheless, any or all information of this type can be relevant. word questions thoughtfully when discussing these characteristics and habits. such information can often be deduced from observations. if doubt remains, confirm your guesses by asking indirect questions. information on recent travel, gatherings, or visitors may provide a clue to common sources or events that would otherwise be difficult to pinpoint. review known allergies, recent immunizations, recent changes in the patient's medical status, and similar information. remember that the agents associated with waterborne disease can also be spread by other means such as consuming food, person-to-person, visiting child care centers, animal-to-person in petting zoos, through walk-in-spray fountains, and pools for young children. as persons describe their illnesses, check boxes next to appropriate symptoms or signs on form c . do not ask about all symptoms or signs listed; however, ask about those marked with an asterisk if the ill person does not mention them. if there are questions, explain symptoms to the patient in understandable terms. the symptoms and signs in the first two columns of form c are usually associated with poisoning or intoxication, although some occur during infections. those in the third, fourth, and fifth columns are usually associated with enteric infections, generalized infections, and localized infections, respectively. those in the last column are usually associated with disturbance of the central nervous system. diseases in any category will sometimes be characterized by a few symptoms and signs listed in the other columns, and not all signs and symptoms occur for any one ailment or for all persons reporting illness. if an illness seems to fall into one of these categories, mention other symptoms in the category and record the patient's response. whenever possible, use physician and hospital records to verify signs and symptoms reported by patients. clinical data may strengthen or dismiss the possibility of waterborne illness. before contacting a physician or a hospital, become familiar with laws and codes relating to medical records to ensure that you have legal access to these records. legal release forms may be necessary to obtain some records. do not distribute names of patients, their other personal identities (e.g., address, phone number), or their clinical information to unauthorized persons. the entries begin with the day of illness, followed by the previous days. if the illness, however, began early in the day or before any of the listed meals, modify the entries on the form so that the -hour history can be completed in the space pro-vided on the form. if the incubation period is days to a week in duration, use additional copies of form c and modify day or day before subtitles. signs and symptoms will sometimes give clues to the transmission route by indicating the organ systems affected. if the early and predominant symptoms are nausea and vomiting, ask about the most recently ingested water or beverage within the past h. in these situations, suspect high-acid water supplies, carbonated beverages and fruit drinks, because these tend to leach metallic ions from water pipes and containers. if diarrhea, chills, and fever predominate, be suspicious of water and beverages ingested - hours before onset of illness for salmonellosis, shigellosis, and norovirus related gastroenteritis. if the incubation period averages - weeks, consider typhoid fever, cryptosporidiosis or giardiasis. diseases with incubation periods exceeding weeks (e.g., hepatitis a and e, amebic dysentery, or schistosomiasis) can be handled as special cases for which longer histories would be sought. others, such as chronic lead and arsenic poisoning, have incubation periods of variable durations and onsets so gradual as to be indeterminable. see table b (illness acquired by ingestion of contaminated water: a condensed classification by symptoms, incubation periods, and types of agents) for details on specific pathogens, table c (illnesses acquired by contact with water: a condensed classification by, symptoms, incubation period, and types of agents), and table d (illnesses acquired by inhalation of microorganisms aerosolized from water. a classification by symptoms, incubation period, and type of agent). other microorganisms not listed in tables b, c, and d that can be potentially spread by water include the bacteria klebsiella pneumoniae, mycobacterium avium complex, acinetobacter calcoaceticus, elizabethkingia meningoseptica, stenotrophomonas maltophilia, pseudomonas putida, serratia marcescens, protozoa isospora, microsporidium, algae schizothrix calcicola. these microorganisms are less frequently identified with waterborne illness, but they may become opportunistic pathogens, particularly for highly susceptible and immunosuppressed persons. further investigation is needed to confirm their role in the spread of waterborne diseases. gather information about all sources of water to which the patient(s) may have been exposed weeks before onset of illness. the water supply and the event that precipitated the illness might not be obvious. persons often have difficulty recalling exposure to all water sources including; ice or water ingested; aerosols and recreational water contact. therefore, if the person does not remember specific exposures to water, ask about the water consumed in usual or routine daily habits and the amounts ingested; exposure to recreational waters; and unusual exposures or events attended during this interval. this may stimulate recall of away-from-home water consumption or contact that was unusual. ask about other risk factors for enteric illness, such as contact with young children and child care centers, animal contact, ingestion of raw foods of animal origin, and usual food preference habits. for persons who have been traveling, ask them where (both cities and rural areas) they have traveled during the incubation period of suspected agents. determine if they drank water from any taps or pumps in rural areas they visited. ask whether unheated (or untreated) tap water or beverages containing unheated (or untreated) water or ice was ingested at restaurants, in hotels or at events in the places they visited. also, ask whether they ingested bottled water and, if so, the brand name. find out whether they drank water from streams, ponds, springs, or other natural water sources. if they did, ask if they observed any abnormal condition of the water such as algal growth, high turbidity or discoloration. ask if domestic or wild animals had access to the water. if they have skin or eye infections or generalized infections, ask them to name all swimming pools, water slides, beaches, lakes, ponds, or other chlorinated and nonchlorinated water courses where they swam, waded or bathed during their trip. also ask them whether they used any hot tubs, spas, whirlpools, or similar devices. this information sometimes provides clues to common sources or to events that otherwise would be difficult to discover. record the information on form c . in a protracted outbreak, or when investigating an outbreak of a disease with a long incubation period, expect recall to be poor. in this situation, obtain from ill persons and others at risk a listing of their water, ice, and beverage preferences and amounts usually ingested, or their purchases of these items within the range of the incubation period of the suspected disease. as a guide, draw up a list of either water, ice, and beverages that are commonly consumed by the affected group or those waters, ice, and beverages previously identified as vehicles of the suspected disease under investigation. summarize data from all copies of forms c - on form d. form d allows rapid review of all exposed persons (ill or not ill) and serves as a basis for analyzing the data. diagnosis of most diseases can be confirmed only if etiologic agents are isolated and identified from specimens obtained from ill persons. get specimens from the ill persons to confirm an etiologic agent. • in large outbreaks, obtain fecal specimens from at least ten persons who manifest illness typical of the outbreak • in smaller outbreaks, obtain specimens from as many of those ill and those at risk as practicable, but from at least two, and preferably ten, ill persons • try to collect specimens before the patient takes any medication. if medication has already been taken, collect specimens anyway, and find out the kinds and amounts of medicine taken and the time that each dose was taken • also get control specimens from persons with similar exposure histories that did not become ill obtain clinical specimens at the time of the initial interview during acute illness or as soon as practicable thereafter. even though this is not always possible, take specimens even after recovery because etiologic agents may remain in low populations or concentrations. if a disease has already been diagnosed, collect specimens as listed in table b . if a disease has not yet been diagnosed, choose kinds of speci-mens that are appropriate to the clinical features. laboratory information obtained from the first patients may be useful to physicians in the treatment of cases detected later. apart from the fact that people are more likely to cooperate while they are ill, some pathogens or poisonous substances remain in the intestinal tract for only a day or so after onset of illness. if the patient is reluctant to provide a fecal specimen explain that the specimen will be tested to identify the causative agent and compare it to any agent recovered from the water. if a disease has not yet been diagnosed, choose specimens that are appropriate to the clinical features. laboratory information obtained from the first patients may be useful to physicians in treating cases detected later. some pathogens (e.g., salmonella, parasites) may be recovered for weeks after symptoms have abated. if applicable for the disease under investigation, take specimens even after recovery because some etiologic agents may remain in low numbers, and changes in serologic titers can be detected. before collecting specimens, review table e (guidelines for specimen collection) and, if necessary, get additional instructions from laboratory personnel and seek their advice on how to preserve the stool specimens if you cannot deliver them to the laboratory immediately. many public health agencies have special fecal specimen kits. demonstrate to the patient how to use the materials in the kit, how to complete the form in the kit and how to mail it if you are not going to pick it up. if mailing specimens, make sure that you are aware of the regulatory requirements that may apply to the transport of infectious material. stool specimen containers for intestinal parasite examination are not suitable for bacterial or viral examinations because they ordinarily contain a preservative, such as formalin or polyvinyl alcohol. if an inappropriate transport medium is used, a specimen can be rendered unsuitable for laboratory examination. feces. if the patient has diarrhea or is suspected of having had an enteric disease, obtain a stool specimen (preferred specimen) or a rectal swab. instruct patients to provide you with their own specimens by one of the following means. . if practicable, give the patient a stool specimen container with a wooden or plastic spoon or a tongue depressor. a clean container available in the home (e.g., a jar, or disposable container that can be sealed) and a clean plastic spoon or similar utensil can be used if laboratory containers are not available. . label the specimen container with the patient's name age/date of birth and date of collection. . collect the stool specimen by one of the following methods: (a) put sheets of plastic wrap or aluminum foil under the toilet seat and push them down slightly in the center, but not so far as to touch the water in the bowl. sheets of paper can be tacked on the rise of a latrine and pushed down to form a depression in which to catch feces. take care to ensure that toilet cleaning chemicals and other microorganisms in the toilet bowl do not contaminate the fecal specimen. after defecating, use a clean spoon or other utensil to transfer about g of feces into a specimen container or other clean container. (b) defecate directly into a large clean dry container or bedpan. use a clean spoon or other utensil to transfer about g or the size of a walnut of feces into a specimen container or other clean container. (c) scrape feces off a diaper with a clean spoon or other utensil to transfer about g of feces into a specimen container or other clean container. . collect fecal swabs by twisting the cotton-wrapped end of the swab into the stool obtained in one of the ways described above. follow instructions given in table e . if necessary, use fecal-soiled toilet paper or cloth diaper and twist a swab into the top of feces. take care to ensure that there is no carryover of toilet paper as they are impregnated with barium salts which are inhibitory to some fecal pathogens. dispose of excess fecal material into the toilet and carefully wrap all soiled articles (e.g., by placing them inside two plastic bags) and dispose of in domestic waste. check that the specimen container is tightly sealed and properly labeled and place into a clean outer plastic bag (special zip lock bags for clinical specimens, if available). store the specimen in a cool place, preferably at °c to await pick-up or despatch. do not freeze. feces from rectal swabs. collect rectal swabs by carefully inserting the swab approximately . cm ( in) beyond the anal sphincter. gently rotate the swab. fecal matter should be evident on the swab. vomitus. if the person is vomiting or subsequently does so, arrange to collect vomitus. tell the patient to vomit directly into a sterile specimen container or a plastic bag. otherwise, transfer some vomitus from a clean receptacle into the container with a clean spoon. refrigerate, but do not freeze, this specimen until it can be picked up or delivered to the laboratory. blood. take blood if a patient has a febrile infection or when infectious agents are suspected (see tables b, c, and d) . blood specimens are collected for: • bacterial culture • detection of antibodies to specific agents • detection of certain toxins before collecting specimens, get additional instructions from laboratory personnel and seek their advice. blood should be obtained by an appropriately trained and accredited person (check appropriate laws). collect blood during the acute phase of illness, as soon as the febrile patient is seen (within a week after onset of illness) and, if comparing of serologic titers, again within weeks (usually - weeks later) during the convalescent phase. draw ml of blood (from an adult) or ml (from a child) or - ml (from an infant). if possible, collect the blood from the same patients from which stool specimens were obtained if both specimens are to be examined. label tubes and vials at every step of serum transfer. do not freeze whole blood because the resultant hemolysis interferes with serologic reactions. collect into a sterile syringe or evacuated sterile tube that does not contain anticoagulants. if practicable, centrifuge the blood at , rpm for min; pour off the serum into small screw-cap vials and store at approximately − °c. if the serum cannot be separated immediately, rim the clot with a sterile applicator stick and refrigerate approximately °c to get maximum clot retraction if the specimen is to be stored unfrozen overnight. if centrifugation cannot be done, store the blood specimens in a refrigerator until a clot has formed, then remove the serum and transfer it with a pasteur pipette into an empty sterile tube. send only the serum for analysis urine. instruct patients to collect urine in the following manner. clean the area immediately around the urethral orifice with a paper pad that has been pre-moistened with % tincture of iodine or other appropriate antiseptic. then begin to urinate into a toilet and collect ml (about oz) of midstream urine into a sterile bottle. use either a second antiseptic-moistened pad or an alcohol-moistened cotton ball or tissue to clean any drops from the top or side of the bottle. other instructions. follow applicable instructions given in table e . before or immediately after collecting clinical specimens, use waterproof permanent markers to label each container with the patients name, complaint number, case identification number, specimen number, date and time of collection, tests requested, and other appropriate information. tightly seal all containers. clinical specimen collection report for each specimen. complete form e (clinical specimen collection report). the complaint number, case identification (id) number, and specimen number must be entered on each report so that laboratory results can later be correlated with other data. on form c record the type of specimen collected, and submit both the specimen and a copy of form e to the laboratory. send a copy of the laboratory report to the patient's physician or call if urgent. if the patient/case or other household member collected any water, ice, or beverage as instructed during initial contact, label containers with the complaint/outbreak and sample numbers. proceed as instructed in table f (general instructions for collecting water samples for microbiological analysis) and complete form f (water/ice collection report) and/or forms g -g as applicable. record conditions of collection as called for on the forms. if a hypothesis associates the illness with water, caution these persons not to use the water source unless the water is first boiled and to discard all previously prepared ice and water-containing beverages until notified otherwise. develop a working case definition to classify exposed persons as either cases or non-cases. start with the most specific symptoms (such as diarrhea and vomiting) rather than broader symptoms such as nausea or malaise. for example in an outbreak of gastroenteritis, a case might be defined as a person from whose stool a specific pathogen was isolated. it may be a person who was at risk and developed diarrhea within a specified period of time. diarrhea will have to be defined, perhaps as three or more loose, watery stools during a -hour period. in some cases, a particular pathogen responsible for the outbreak might have been identified from clinical specimens. a case definition, which is developed later in the investigation, might include either a person having specific signs and/or symptoms within a period of time or a person from whom a specific pathogen was isolated. the ultimate case definition has a tremendous impact on the investigator's ability to make illness and exposure associations and to calculate probability of these associations. sometimes the first symptom or sign provides a clue to developing a case definition. information in tables b, c, d, g, and h can be useful in making case definitions. compare newly identified cases with the definition to see whether each is part of the outbreak. classify cases into categories: • a confirmed case is a person with signs and symptoms that are clinically compatible with the disease under consideration and for which there is either (a) isolation of an etiologic agent from (or otherwise identified in) an appropriate specimen from the patient, or (b) serologic evidence of a fourfold or greater rise in convalescent antibody titer. a confirmed case must also have possible exposure to the etiologic agent within the incubation period of disease. see table e . criteria for confirmation of etiologic agent responsible for outbreaks of waterborne illnesses for definitions of confirmed cases for specific waterborne diseases: • a presumptive case is a person with signs and symptoms that are clinically compatible with the disease under consideration, and for which there is laboratory evidence of infection (e.g., an elevated antibody titer but less than a fourfold increase), but the etiologic agent was not found in specimens from patients or no specimens were collected. a presumptive case must also have possible exposure to the etiologic agent within the incubation period of disease. • a suspected case is a person with signs and symptoms that are clinically compatible with the disease under consideration and history of possible exposure, but laboratory evidence is absent, inconclusive or incomplete. • a secondary case is a person who became infected from contact with a primary (outbreak-associated) case or from a vehicle contaminated by a primary case. onset of illness for secondary cases typically is one or more incubation periods after the outbreak-associated cases. it is not essential, however, to classify cases into these categories. do so only if it aids in developing a final case definition or in making comparative analyses of data. consider doing analyses using case definitions of both confirmed and combined confirmed, presumptive, and highly suspect cases, and compare the results. make a preliminary evaluation of the data collected as soon as possible. if you decide that there is an outbreak, use the information you have to develop a hypothesis about the causal factors. an outbreak is an incident in which two or more persons have the same disease, have similar clinical features, or have the same pathogen (thus meeting the case definition), and there is a time, place, or person association among these persons. a waterborne outbreak is traceable to ingestion of contaminated water or ice or to contact with contaminated water. a single case of either chemical poisoning or a disease that can be definitely related to ingestion of drinking water or contact with water can be considered an incident of waterborne illness and warrants further investigation. waterborne methemoglobinemia in an infant who resides in a rural area having a high concentration of nitrates in well water is an example of a single case of waterborne illness due to ingestion. a rare diagnosis such as primary amebic meningoencephalitis in a person who swam in a body of freshwater and inadvertently ingested the ameba, naegleria fowleri, through the nose is an example of a single incident related to water contact. sometimes it will be obvious from an initial report that an outbreak of waterborne disease has occurred simply because of the number of persons displaying certain signs and symptoms at or near the same time. many complaints, however, involve illness in only one or a few persons. it is often difficult to decide whether ingestion or contact with a particular water source and onset of illness was associated or coincidental. certain diseases that are highly communicable (e.g., shigellosis and epidemic viral gastroenteritis) may result in secondary infections from person-to-person spread or from subsequently contaminated food or water. however, if complaints are received from several persons who are associated with ingesting water or contact with water at the same place, water is likely to be involved. routine review of the log pertaining to potential waterborne illnesses for similar complaints can often be useful in detecting time, place or person associations. an investigation may also proceed based upon the suspicion of an intentional contamination of a water source. a time association exists if the time of onset of similar illnesses is within a few hours or days of each other. place associations exist when persons have ingested water from a particular single source, have swum in, worked in or otherwise been exposed to the same water, have attended the same event, or reside in an area common to all. person associations indicate a shared personal characteristic, such as being of the same age group, sex, ethnic group, occupation, social group, or religion. waterborne illnesses transmitted by a community water supply usually afflict persons of both sexes and all ages throughout the community. non-community water sources, such as bottled water, ice, water from individual wells, or water from areas of recreation should also be considered when making associations. keep in mind that water can contaminate foods during washing or freshening, and it can contaminate utensils and vessels that are used to handle or store foods. water may therefore be a source of contamination of another vehicle. also, water can be ingested as aerosols generated by shower heads, whirlpools, hot tubs, fountains, cooling towers, and irrigation devices. once some of these associations become obvious, question other persons who could be at risk because of their time, place, or person associations with the ill persons. from time, place, or person associations that have been established or suggested by the investigation, formulate hypotheses to explain (a) the most likely type of illness, (b) the most likely vehicle involved, (c) where and the manner by which the vehicle became contaminated, and (d) other possible causal relationships. the section "collection and analysis of data" describes calculations that can aid in the formation of these hypotheses. test hypotheses by obtaining additional information to support or reject them. if the hypothesis includes food contamination, the instructions given in the manual, procedures to investigate foodborne illness, might be useful. guidelines for confirmation of waterborne outbreaks are presented in table g and guidelines for confirmation that water is responsible for illness are presented in table h . if there is strong evidence to support a hypothesis that the outbreak is waterborne, take precautionary actions. the choice of action is dictated by the (a) suspected causal agent, (b) size of the water source, (c) availability of alternate water sources, and (d) expected use of the water. on the basis of available information, estimate the population at risk and engage any public relations staff with your organization to help inform all persons potentially impacted. when dealing with a microbiological contaminant or agent, consider issuing a boil-water advisory with water treatment guidelines (e.g., heating water in a covered container to a rolling boil for at least min and keeping it covered until use). other options that can be explored include chlorinators that can be installed in individual and non-community systems. for community and non-community supplies in which chlorine is already used, increasing the chlorine dosage and opening hydrants and taps to draw the super-chlorinated water through the whole system might be an option. increasing chlorine is sometimes not effective because the chlorine contact time is too short or super-chlorinated water does not reach some parts of the system. furthermore, chlorination is ineffective against cryptosporidium oocysts and requires a long contact time to kill other human pathogens like hepatitis a virus and giardia. for suspected chemical contamination contact a specialist for further assessment and remedial strategies, such as activated charcoal filters. as a last resort, shut off the contaminated system until the source of contamination is found and controlled. be cautious when you take this drastic measure, because it may do greater harm than good by causing lack of water for hospitals, nursing homes, or for firefighters to extinguish fires. if the water is shut off or the treatment facility or distribution system disrupted (as in the case of floods or other disasters), consider means to distribute water from an alternative source to healthcare facilities and homes. if an illness could have resulted from water contact, close the offending water source, post warning signs around it, and patrol the area. where there is a swimming pool, hot tub, spa, fountain, or whirlpool, evaluate the recirculation system and its operation. it may be that increasing disinfectant concentration by super-disinfection could resolve the problem. where there may be chronic operational problems, evaluate ph, disinfectant concentration, and bacteriological laboratory records. choose your course of action, including consultation with appropriate professional experts, depending on the contributing factors existing at the time of investigation. verify the effectiveness of these actions (e.g., boil-water advisory, superchlorination, provision of alternate water source) to protect public health by monitoring illness levels in the population to determine if the outbreak terminates. if the outbreak continues unabated, consider the possibility of other transmission routes. also, verify the effectiveness of repairs to the water system, super-disinfection, and other actions by closely monitoring the quality of the water supply or recreational water to determine if laboratory reports indicate that the water is now safe for consumption or contact. if there is a public health threat, work with any available public relations staff to announce the outbreak in the mass media so that the public who consumed or was otherwise exposed to the implicated water can be alerted to take appropriate action including seeking medical consultation or treatment. provide only objective factual information about the outbreak. coordinate among the investigating agencies to assure that a consistent and accurate message is delivered. it is easy for agencies to miscommunicate before and during a water crisis (see box , false alarm; box , the walkerton outbreak; box , the flint water crisis). it is often preferable to have one spokesperson for all agencies. do not release preliminary information that has not been confirmed. the person giving information about an outbreak should be well informed about the etiologic agent being investigated and prepared to deal with questions. if the health hazard warrants a public warning at the hypothesis stage, tell the public why emergency measures are being invoked and that subsequent information may be cause to modify the action. as the investigation proceeds and the etiologic agent is confirmed and contributory factors are identified, consider terminating emergency measures, and give advice on specific control and preventive measures. attempt to reach all segments of the population at risk; this may require communication in multiple languages. route all news releases or statements to all persons involved in the investigation. in situations involving large outbreaks or highly virulent or toxigenic etiologic agents, set up an emergency hotline for the public to call to ask questions. this is likely to occur if there is an intentional contamination event where there is high publicity and public concern. train staff to handle these calls in a consistent manner so that the advice is the same who gives it. faulty information derived from poorly tested hypotheses can lead to severe political, legal or economic consequences. an example of this occurred in sydney, australia, in when an apparent water contamination event was publicized for the public to take precautionary actions. the false alarm was costly because of rebates to water customers, additional water testing, and for hiring extra staff, as well as a loss of confidence in the facility (see box , false alarm). they may then be disseminated by the mass media with inappropriate interpretations of the public health significance. furthermore, this information may be used as an unrealistic base for water programs or water regulations because of either misinterpretations or pressure from misinformed consumer-advocate groups. all involved parties should follow a written protocol for cross-agency communication and release of information to the public. unreasonable delays are unacceptable. test hypotheses by obtaining additional information to either confirm or refute their validity. do this by case-control or cohort studies, additional laboratory investigations, and on-site investigations (e.g., laboratory reports of water testing). sydney water (a new south wales state-owned corporation) supplies million liters of water each day to . million properties in sydney and its outlying areas. the city has a large and complex catchment with nine major dams and several storage reservoirs. about , km of water main, almost pumping stations and many tunnels deliver water from four main river systems. the water is filtered through eleven treatment plants. seven are owned by sydney water and four are privately owned. these plants provide % of sydney's drinking water and one plant, prospect, provides up to %. in , the quality of sydney's drinking water came under acute review when giardia and cryptosporidium were found in the city's main water supply at the warragamba dam. initially, low levels of these parasites were first detected in the water supply on july, but these were within the acceptable health limits. in days following, much higher levels were recorded, and on july the first "boil water" alert (in which residents were instructed to boil their tap water before use) was declared for the eastern central business district of sydney. however, by late on july high readings were found in samples at the prospect filtration plant, in a reservoir and at a location further down the system, and a "boil water" alert was issued for the south of sydney harbour, and on july a sydney-wide "boil water" alert was issued affecting most of sydney's residents. on august the warning was discontinued. however, high levels were again found on august (the second event), although it was believed that most organisms would likely be dead. more positive readings were found on august , although at lower levels. further contamination was identified on august and an extended boil water alert was again declared. this was progressively lifted suburb by suburb until further contamination was reported on september (the third event). a -week alert was then instituted, which was finally lifted on september . it was determined that the parasitic contamination was caused by low-quality surface water entering the dam. this contaminated source was attributed to moderate rainfall in july, followed by heavy rainfall in august and september which caused intermittent supplies of the raw water to enter the dam. despite high levels of cryptosporidium (up to > , oocysts) and giardia (up to > cysts) being recorded in july and august, , no increase in human cryptosporidiosis or giardiasis was detected in the exposed population. the incident was highly publicized and caused major a public alarm because the number of people affected, the on and off boil water alerts, and the fact that the filtration plant had been advertised as one of the best in the world. the economic and political repercussions were extensive. the cost of the crisis to sydney water was estimated at a$ million which included $ million paid in rebates to customers, $ million in lost revenue, water testing and staff costs and at least $ . million for damages claims. these costs exclude those relating to improvements to the system and infrastructure. the lack of cases of cryptosporidiosis, giardiasis or other water-related health problems led to suggestions that the parasites were either not an infectious type, or not as extensively distributed. an inquiry after the event revealed the publicity as an exaggeration of fact, with australian water technologies, part of sydney water, severely overestimating levels of cryptosporidium and giardia present in the water, with the recorded levels exposed to consumers as not harmful to human health. the handling of the crisis by state-owned sydney water was heavily criticized, causing the resignation of both the chairman and the managing director, and bringing up issues of private vs. public ownership and scientific uncertainty. the eventual consequence of the state inquiry was the establishment of the sydney catchment authority in to assume control of sydney's catchments and dams, while sydney water maintained responsibility for water treatment and distribution and for sewage collection, treatment and disposal. if an outbreak investigation requires resources beyond your agency's capacity, request assistance from other health professionals. it is desirable to have a team including, if feasible, an epidemiologist, an engineer, a microbiologist, a sanitarian/ environmental health office/public health inspector, a chemist, a physician and others, to undertake a detailed waterborne illness investigation. such personnel can usually be provided by local, state/provincial, or national agencies concerned with health, environment, or agriculture, depending on the expertise needed. for events suspected to arise from intentionally contaminated food, contact emergency response or law enforcement agencies. continue to search for and interview both ill persons who have had time, place, or person associations with the identified cases (see the section on "make time, place, and/or person associations"). review recently received complaints in the water-related complaint log (form b). contact other nearby health agencies, hospital emergency rooms, elderly care centers, and local physicians to discover other epidemiologically related cases. call previously contacted persons to see whether they know anyone else who has become ill or had a common association suggested by data in the log. the illness you are investigating may be part of a larger multijurisdictional outbreak, and therefore communicate with adjoining local and state agencies to learn if they are seeing similar illnesses. state or provincial public health agencies can check reportable disease records and state/provincial public health laboratories can start looking for clusters in isolates that they are characterizing. for outbreaks where intentional contamination of water is suspected or confirmed, public health and law enforcement agency officials may conduct the investigation jointly. if it becomes apparent that an outbreak is associated with a specific water supply (source) or recreational water or event, use form d for recording information. at this stage of the investigation, interviews can be expedited by reviewing the event itself to stimulate each person's recall. ask about specific symptoms and signs that are known to be common to the syndrome, as well as, time of ingestion or contact with water and onset of illness. mention each source of water to which the person may have been exposed, and ask each person (whether a case and well persons at risk) which of the water sources had been ingested or contacted. the number of persons to be interviewed depends on the number exposed and the proportion of them who are probably affected; if fewer than persons were at risk, try to interview all of them; if several hundred are involved, interview a representative sample. be sure to obtain clinical specimens from these cases and well persons at risk (controls). it is more difficult to obtain positive results if symptoms from persons have ceased. there may be situations where self-administrated questionnaires are sent to cases and persons at risk. use either form c or form d or modified versions for this purpose. after questionnaires have been completed, summarize the data on form d. also, identify and interview secondary cases if they become apparent. because no two waterborne disease outbreaks are identical, the order of the expanded investigation may not always follow the outlined sequence of procedures. some investigative steps can usually be done simultaneously by different investigators. additional procedures may also be required. the principles and techniques described will suffice for most investigations. modify forms, if necessary, to accommodate the type and amount of information to be collected. make on-site observations. prove or refute hypotheses developed during the epidemiological portion of the investigation. focus on sources and modes of contamination and ways contaminants could survive and pass through water treatment. as applicable, conduct an on-site investigation of source (lakes, streams, areas around groundwater, etc.), treatment facilities, distribution lines, cross connections, water reservoirs, places of recreational water contact and/or sites at which aerosols were generated. such an epidemiologically focused investigation is quite different from sanitary surveys done during routine evaluations of water source sites, treatment plants or recreational water facilities. not all drinking water (even municipal and bottled water) is disinfected; so, it is important to identify whether the water source is treated and if so, how. some treatments (filtration, reverse osmosis, membrane treatments, riverbank filtration, and others) may not be complemented with a disinfection step. sanitary survey information can provide information about potential sources of contamination in the area of a usually pristine water source. microbiological records of a water supplier, particularly if any total coliform positive samples were found by the system in the last months, may help identify a contamination pathway. if significant matters relating to water quality are observed or otherwise identified during the investigation, note them and communicate them to those responsible for the water system and to the proper authorities. do not lose the focus and objectivity of the investigation by confusing matters of quality and aesthetics with factors related to contamination by, and survival of, infectious and toxic agents. use the haccp-system, also known as systems analysis, way of thinking in your investigation. contact the person with the highest responsibility for the operation and maintenance for the implicated water source, water treatment facility, and/or distribution lines. identify the types of records that ought to be reviewed during the investigation and their likely source. do not forget that the responsible authorities also can have records (about water quality, if there has been a change of municipal water supply, industrial water pollution, wastewater pollution). they can be good sources of information about recent pipe breaks and other water system issues that could be related. in many cases they will be aware of the potential for contamination upstream of source water intakes. if applicable, obtain water distribution maps and recent water quality reports from appropriate departments. if you are not familiar with the community in which the investigation is to be done, obtain maps of the area to locate streams, lakes, water treatment facilities, and other community features that might have a bearing on the investigation. check if there are water protection areas and their rules. get plans and specifications on design of treatment facilities from consulting engineers or state agencies that approve these facilities. contact weather bureaus, airports, radio/television stations, or newspapers for information on heavy rainfall, flooding, extremely low temperatures, droughts, or other unusual weather conditions that preceded the outbreak, if this information is unknown to investigators. contact police or fire departments about traffic accidents, which can be the source of the outbreak. review all background data pertaining to the suspect water. as information is gathered, record it on applicable parts of form g. discuss with laboratory personnel that a field investigation will be made, and get their suggestions regarding samples and specimens that should be collected (see tables e and f) . confer with them about special analyses, media, and sampling procedures; make arrangements for rapid transport of samples to the laboratory. the samples must maybe be transported at the right temperature. pick up appropriate forms and sample collection equipment (preferably preassembled in a kit-see table a ). the laboratory can probably help assemble this kit. during the investigation, identify factors that contributed to contamination and survival of the etiologic agents and perhaps also to their growth or amplification or another cause of the outbreak. identified factors and situations that have contributed to waterborne disease outbreaks include those listed in table . focus the investigation on the potential situations listed in table , as applicable. remember that other possibilities can occur. describe circumstances that contributed to contamination and that permitted the etiologic agent to survive so that it reached drinking, agricultural, industrial, or recreational water. also describe circumstances that allowed pathogenic bacteria or algae to multiply in the water. write your findings down on the back of form g (illustration of contamination flow) or on a separate sheet. continually update the listing in table with newly available data. introduce yourself (who you are, where you come from, who ordered you there) to the owner, resident, or persons in charge and state your purpose, when you arrive at the place of the suspected contaminated water source. emphasize that your visit is to confirm or eliminate suspicion that this water was a source of illness. tell him or her that a complete epidemiologic study is in progress and that other possible sources (such as food) will be investigated as well as operations of this site. explain that your investigation is not to fix blame but to identify the cause of the outbreak. emphasize that the findings can yield benefits related to the ability to identify needed improvements, to educate staff and to provide public support. try to create an atmosphere of cooperation. maintain an open mind and try to answer all questions. if you can not answer a question, tell the person that you will come back with an answer. come back to the person within or weeks even if you do not have any new information. give the person your phone number and e-mail address and tell the person to contact you if the person has more information later. privately interview key persons responsible for operating or repairing water facilities. do not forget to interview persons from other work shifts. identify persons who were working there at the likely time of contamination and have since left and interview them as well. ask questions to determine the flow of water and operations from intake through distribution through plumbing systems. ask about any changes in operation, unusual events in the watershed or repairs to the water facilities. ask if you can check records, both in paper form and on the computer (monitoring system), analyses of results, and/or incident reports. plant personnel may not describe water treatment or installations exactly as they existed at the time that a mishap occurred. they may fear criticism or punitive action as a result of their possible role in the causation of the outbreak. their descriptions should be plausible and should account for possible sources and modes of contamination and indicate possibilities for survival of pathogens. if a description does not contain all the information desired, reword questions and continue the inquiry. confirm accounts by private interviews with others knowledgeable of water treatment or operation of the facility. be alert for inconsistencies among the accounts told by different persons. seek resolution of discrepancies in accounts by watching actual procedures as they are being carried out, by taking appropriate samples, or by conducting experiments. a communicative working relationship between the plant management and the investigator influences plant workers' attitudes toward the investigative team. consider the position, feelings, and concerns of the manager and staff; defensive reactions are normal on their part. diagram each phase of the water system or situation under study on form g (illustration of contamination flow). insert special symbols and notes for all sites that might be involved in introducing contamination to the water or where contaminants might have survived treatment. record other information gathered on the appropriate parts of forms g - . review and collate appropriate information on quality control and operational records from the water utility and from responsible agencies. as applicable, obtain information on quality of untreated surface or groundwater from a local, state/ provincial, or national pollution control or geological survey agency. also, seek water distribution maps, well logs, descriptions of geological conditions and indices of groundwater quality from them. for surface water supplies, obtain information on upstream discharges and unusual events that may have affected raw water quality. get data on finished water quality in the distribution system from a local, state/ provincial water surveillance or regulatory agency. water suppliers also frequently have records of raw and finished water quality. review data on quality control tests (e.g., ph, chlorine residual, chlorine demand, bacteriological and chemical tests, turbidity, jar test data, incident reports) that are available. obtain data on cross connection control programs and sewer repairs from the water supplier or other local agencies (e.g., building inspectors, sewage departments). review files for data concerning potential sources of contamination for individual or semipublic water supplies (e.g., diagrams of septic tank systems, sewer line locations, well logs, small individual wastewater plants, accidental industrial pollution of water, traffic accidents involving chemicals, salting of roads or sawmills). check if they have any haccp-systems or water safety plan and, if so, how they monitor their ccps (critical control points) and if they are implementing control measures. ask them about haccp, to see if they understand the system and if results are documented. check if the haccp-system is validated (should be documented) and that they are conducting internal audits. get information on all aspects of normal operations as well as unusual events or conditions to determine whether such events were coincidental with the time of suspected contamination as determined from the epidemic curve. also, consider the time it takes for a contaminant in the raw water or treatment plant to reach households in the affected community. ask responsible persons for this information. compare data on heterotrophic plate and total coliform counts of raw and finished water leaving the treatment facility and of water in distribution lines. also, compare data on chlorine residuals within the plant with that in distribution and check, if they have, that the uv-light is functioning. review other test data (e.g., turbidity and chemical analyses) that may indicate a problem situation. identify locations and dates of sample collection. take photos, if it is allowed, of things you suspect are not right. go back more than one incubation period of the disease under investigation. record this information on form g (record review of on-site investigations, and test results prior to and during outbreak). photocopy appropriate records for confirmation and subsequent review and attach them to the record review form. be alert for evidence of falsification of records. while reviewing records, watch for evidence of the following: • potential contamination of groundwater systems because of proximity to septic tank systems, latrines, animals manure or landfills, industrial contamination of the water supply, small sewage plants, especially old and nearly forgotten ones, and recent heavy rain • high heterotrophic plate or coliform counts, or counts that exceeded the average (median) or typical count • sudden changes in water quality or operating practices that suggest the possibility of contamination or treatment failure • high turbidity, unusual odor, color, or taste, or high coliform counts in raw water, which can indicate potential overloading of the normal treatment process • high levels of ammonium, nitrate and nitrite, which can indicate organic and inorganic contaminants • low chlorine residuals in treated water or higher-than-normal amounts of chlorine used, which can indicate either a high chlorine demand or a sudden high level of contamination • a sudden drop in amount of disinfectant used, possibly indicating failure or interruption of a disinfection process. no functioning alarm system • a sudden change in the amount of a chemical (e.g., alum or ferric sulfate) used, suggesting equipment disfunction or inadequate coagulation or flocculation and thus poor filtration • lack of treatment chemicals if a more corrosive water supply is used (see box , the flint water crisis) • pump failures, draining of distribution lines or reservoirs, or massive pumping to fight fires, which can produce low pressures that can cause contamination through cross connections or back siphonage • repairs to water mains, wells or pumps where contamination could have been introduced record this information on form g or other appropriate form in the g series. as applicable, investigate the water source, treatment facility, distribution and plumbing systems, sites where water was contacted, and sites at which microorganisms amplified and aerosols disseminated. use forms in the g series as guides while observing facilities, gathering data, making measurements and collecting samples. google or bing maps or other similar resources' views of the watershed can be very helpful in identifying potential sources of contamination that you will need to investigate further. these maps can also facilitate your own map and diagram making on form g . the water source may be surface or ground or in some cases a combination of the two. verify this by observations at the site and by talking to the property owner or persons responsible for operation or maintenance of water supply or recreational facilities, as applicable. examination of "weather events" such as heavy rainfall may indicate a potential for surface water contamination (see box , the walkerton outbreak). when a surface water is either suspected or implicated as the source of a contaminated supply, get information about the watershed concerning possible sites of contamination of the suspected etiologic agent. this includes, but is not limited to (a) land use, (b) sewage effluent from treatment plants and septic tanks, (c) industrial plants that may be discharging toxic waste, (d) mining wastes, (e) landfill leachates, (f) slaughterhouse discharge wastes, (g) animal feed lots, (h) both domestic and wild animals that use the source water for drinking, (i) sludge disposal from sewage treatment plants or septic tanks (e.g., land spreading or lagoons), (j) storm water discharge. if this information is not available from records or persons familiar with the site, visit the site and observe possible sources of contamination and pollution (e.g., while traveling by foot, vehicle, boat, or helicopter, as applicable). record this information on form g (source and mode of contamination of surface water). diagram the surface water and sites of contamination on form g . note type and location of sources of contamination and their distances from the water. visit groundwater sources. using form g (source and mode of contamination of groundwaters) as a guide, question owner or operator and inspect groundwater installations to ascertain character of the land and surface and subsurface soil and water. when a well or improved spring is under consideration as the source of the contaminated supply, observe its location relative to possible sites of contamination and to whether its construction allows contaminants to reach the water. determine locations of all sewage outflows or disposal sites (e.g., septic tanks and absorption lines, cesspools, privies, and other sewage disposal facilities), gradients, and distances from the well or spring. determine the type of soil at the site. if the soil is limestone or fissured rock or if there is a high ground or perched water table, pollution may travel many miles. in this case, the search for sources of contamination may have to be expanded for a considerable distance from the well or spring. ascertain whether there were heavy rains, heavy snow melts, or sudden discharge in may, , many people in walkerton, a small ontario, canada, community of about , people, began to simultaneously experience bloody diarrhea and other gastrointestinal infections. on may - , torrential rain had unknowingly contaminated the town's water system, but operators failed to check residual levels for a period of several days, allowing unchlorinated water to enter the distribution system. however, the privatelyowned walkerton public utilities commission insisted there was no problem with the water despite other laboratory tests showing evidence of e. coli contamination. illnesses began about may , with the first death occurring on may and the seventh and last on may . by may , however, many more cases had been diagnosed, the infectious agent determined to be e. coli o :h , and contaminated well water was confirmed as the source of the e. coli; all this allowed the region's medical officer of health to issue a boil water advisory, warning residents not to drink the tap water. two days later, laboratory results identified the presence of campylobacter and e. coli o :h and dna testing showed that the contaminating source was a cattle farm a short distance from a well used for the water supply. by the time the outbreak was over, > were ill and had died. the people who died directly from drinking the e. coli-contaminated water might have been saved if the walkerton public utilities commission had admitted to contaminated water sooner. those in charge of the water utilities at the commission had no formal training in their positions, retaining their jobs through three decades of on-the-job experience. they were later found to fail to use adequate doses of chlorine, fail to monitor chlorine residuals daily, make false entries about residuals in daily operating records, and misstate the locations at which microbiological samples were taken. regulations state that water suppliers are required to treat groundwater with chlorine to sufficiently neutralize contaminants and sustain a chlorine residual of . mg/l of water after min of contact. had utility operators adhered to the protocol, the disaster most likely would have been averted. the operators knew that these practices were unacceptable and contrary to ministry of environment guidelines and directives; they eventually admitted falsifying reports and were sentenced to short jail terms. the ontario government was also blamed for not regulating water quality and not enforcing the guidelines that had been in place. the water testing had been privatized in october . an enquiry found that the water supply, drawn from groundwater, became contaminated with the e. coli o :h strain from manure from cattle on a farm washing into a shallow water supply well after heavy rainfall. the risk of contamination from farm runoff into the adjacent water well had been known since . key recommendations from the enquiry included source water protection as part of a comprehensive multibarrier approach, the training and certification of operators, a quality management system for water suppliers, and more competent enforcement, which were incorporated into ontario new legislation. the bottom line of the enquiry was that officials and municipal water facilities operators and managers across north america need to recognize public waters are a most valued but vulnerable public resource. investment in keeping them safe and secure needs to be a community top priority. from dams that could have resulted in flooding within the duration of the incubation period of the disease under investigation. obtain information on the depth of the well in reference to the ground water table from the owner or by referring to any available well logs on public file or from local drillers. observe well construction and get information about depth of casing, depth and method of grouting, and whether there is an underground discharge. observe whether there is an impervious well platform and whether the pump or casing seal was subjected to flooding. illustrate the situation by showing location of the well in this event is considered a disaster, still unfolding, initiated from a political decision to save money, and ending up with acute and chronic illnesses and deaths to residents of a michigan city, as well as high system remediation and health-related costs to the taxpayer. on april , , flint, genesee county, michigan, switched its water supply from detroit's system to the flint river as a cost-saving measure for the struggling, majority-black city on the recommendation of the state-appointed emergency manager. flint agreed to separate from the detroit water and sewerage department and go with the karegnondi water authority, including the decision to pump flint river water. this was to be an interim measure until a new pipeline from lake huron was constructed in to serve the region. soon after the switch, residents begin to complain about the water's color, taste and odor, and to report rashes and concerns about bacteria. in august and september city officials issued boil-water advisories after coliform bacteria were detected in tap water. in october , the michigan department of environmental quality (mdeq) blamed the cold weather, aging pipes and a population decline. in the same month a general motors plant in flint (continued) reference to possible sites of contamination on form g . note distances between the well and contamination sites and elevations. determine whether any pumps were out of order or had been repaired during the interval of concern. if priming of the pump was done, find out the source of the water used. record this information on form g . test hypotheses of modes of contamination by conducting a dye test and/or sampling the water. (see appropriate sections of this manual for directions.) collect samples of water from these sites and submit them for analysis of the suspected etiologic agent or for any physical, bacterial, or chemical tests that will provide evidence of contamination or movement of the contaminants. (see procedures for collecting water samples) record these results on forms g or g and i (laboratory results summary). when appropriate, confirm hypotheses by a dye or other tracer test. (see section on this subject). determine the means by which the etiologic agent survived treatment or was otherwise not eliminated or inactivated. consider the treatment process as a series of barriers placed between contaminants and consumption of the treated water. the operation of each barrier should be optimized. review available data for each step in the treatment process. records of well-maintained and properly calibrated continuous monitoring equipment will be especially valuable. look for failures in the barriers, which could include (a) lack of disinfection, (b) inadequate concentration of disinfectant or contact time, (c) interruption of disinfection, (d) inadequate filtration, (e) lack of corrosion inhibitors, which may follow inadequate pre-filtration treatments. in in flint, michigan excessive levels of lead were found in drinking water from corrosion of water distribution pipes (see box , the flint water crisis). corrosion inhibitor had not been added. also, look for possible introduction of contaminants within the treatment process, such as in treatment chemicals. stopped using municipal water, saying it was rusting car parts. on january , , the city announced that flint's water contained a high level of trihalomethanes, a byproduct from increased disinfection by the city. though this is in violation of the safe drinking water act, officials told residents with normal immune systems that they have nothing to worry about. in january , detroit's water system offered to reconnect to flint, waiving a $ million connection fee but the offer was declined by the emergency manager. by february, state officials continued to play down any water problems saying that the water was not an imminent "threat to public health." on february , parts per billion (ppb) of lead were detected in drinking water at a flint home and the federal environmental protection agency (epa) was notified. the epa does not require action until levels reach parts per billion, but science indicates that there is no safe level for lead in potable water. officials from epa and mdeq discussed the lead level in the sample, and epa found that the state was testing the water in a way that could profoundly understate the lead levels. on march , , a second testing detected ppb of lead in flint drinking water. a consultant group hired by flint, reported that the city's water met state and federal standards, and it did not specifically report on any lead levels. in may, tests revealed high lead levels in two more homes in flint. in july, an epa administrator told flint's mayor that "it would be premature to draw any conclusions" based on a leaked internal epa memo regarding lead. however, in september, flint was asked to stop using the flint water supply or consider corrosion control for it, because it was causing lead to leach from the water pipes and children had high levels in their blood. state regulators insisted the water was safe. nevertheless, on october , the governor of michigan ordered the distribution of filters, the testing of water in schools, and the expansion of water and blood testing after a briefing on the lead problems with the mdeq and federal officials. at the same time, flint city officials urged residents to stop drinking water. on october , flint reconnected to detroit's water system, and residents were advised not to use unfiltered tap water for drinking, cooking or bathing. on october , the director of mdeq reported that his staff had used inappropriate federal protocol for corrosion control, and soon after, the governor announced that an independent advisory task force would review water use and testing in flint. on december flint added additional corrosion controls, and soon after an emergency was declared. at the end of december, the task force found that the mdeq was accountable for its lack of appropriate action, and the director resigned. on january , , the governor asked the national guard to distribute bottled water and filters in flint, and president obama declared a state of emergency in the city and surrounding county, allowing the federal emergency management agency to provide up to $ million in aid. three days earlier the crisis expanded to include legionnaires' disease, because of a spike in cases, including ten deaths, after the city started using river water. on january , the michigan department of health and human services stated it did not have enough information to conclude that the increase in cases was related to the ongoing flint water crisis, although the. head of michigan's communicable disease division had said three months earlier that the number of legionella cases at that time "likely represents the tip of the iceberg." as of february , the number of reported cases was close to . a flint hospital official was surprised that michigan and local health agencies did not inform the public about the legionnaires' outbreak in genesee county in - until january ; the hospital earlier had spent more than $ , on a water treatment system and bought bottled water for patients. the source of legionella is not known but it was likely in the flint river, and possibly extensive flushing of flint's colored water, which had undesirable odors and tastes, by residents may have caused chlorine residual in the pipes to be washed away, leaving the pipes susceptible to growth of the legionella; in addition, aerosols from the extensive flushing from turned-on faucets might have led to close contact between the residents and the pathogen. the investigation of the cause of the illnesses continues with criminal charges laid against michigan departmental employees. observe treatment processes from the water inlet to the finished water discharge. diagram on form g the treatment process; insert notations of hazardous situations that were observed. collect samples of water at the inlet, after each phase of treatment that may have functioned suboptimally or failed, and at the outlet. test the samples for pathogens that cause a syndrome characteristic of that being investigated, for indicator organisms and for physical and chemical characteristics of the water, as appropriate to the situation. evaluate effectiveness of the disinfection process and resulting residuals. determine the type of disinfectant (e.g., gaseous chlorine, hypochlorite, chlorine dioxide, chloramine, ozone, ultraviolet irradiation) used and whether the disinfection treatment was adequate for the volume of water treated. determine, by talking to water treatment plant employees and reviewing records of the plant or regulatory agency, whether there were any interruptions of disinfection during the two weeks prior to the first onset date. determine contact time between the point of addition of the disinfectant and the first point of use. measure the chlorine residual, ph and temperature of the water just before it leaves the plant. observe the condition, operation, and maintenance of disinfectant dispensing equipment. review plant records to identify any sudden changes in disinfectant demand that causes temporary depletion of disinfectant residuals and allows survival of pathogens. review maintenance records for disinfectant dispensing equipment and quality assurance records for online analyzers. record this information on form g a (disinfection failures that allowed survival of pathogens or toxic substances). calculate disinfectant rate applied and usage (see formulae in form a). for example, to calculate disinfectant rate, if the flow rate is , , gal/day and the dosage is lb/day: the destruction of pathogens is dependent on (a) type and condition of microorganisms present, (b) type of disinfectant used, (c) concentration of available chlorine or other disinfectant, (d) contact time, (e) water temperature, (f) ph, (g) degree of mixing, (h) presence of interfering substances (which may be related to turbidity). utilize treatment records that provide small scale time resolution, such as online monitoring data, to determine whether the process was stable during the time period in question. daily averages may provide evidence of massive failures, but will not provide information about whether consistent treatment was being provided. in general, the relative effectiveness of microorganisms' resistance to free chlorine, from high resistance to low resistance, is as follows: • protozoan oocysts (i.e., cryptosporidium) • protozoan cysts (i.e., giardia, entamoeba histolytica) • viruses (hepatitis a virus, poliovirus) • vegetative bacterial cells (shigella, escherichia coli) protozoan oocysts are highly resistant to chemical disinfectants, but not to physical means such as uv light or ozone (gas). microorganisms within each group and strains among the same species differ somewhat in resistance. the state of injury induced by environmental impacts and selection of resistant strains influence survival. aggregation of microorganisms and/or close association with debris shield them to various degrees from lethal effects of disinfectants and attachment to surfaces such as pipe walls to form biofilms that protect organisms from inactivation by disinfectants. a measurement of microbiological inactivation by disinfectants is the ct value (ct calc ), which is the product of the free residual disinfectant concentration (c) in mg/l that is determined before or at the first user (customer) and the corresponding disinfectant contact time (t) in minutes (i.e., c × t). refer to table i (ct . values for inactivation of giardia cysts at different concentrations of disinfectants, temperatures, and ph values) and table i (ct values for inactivation of viruses at ph - , at different temperatures with different disinfectants for comparing disinfectant efficiencies). make residual measurements during peak hourly flow. for comparisons of ct values between the indicated ph, temperature, and concentration values, use linear interpolation. (for example, for free chlorine, °c, concentration mg/l, ph . = [ − = ; / = ; + ] = ). if no interpolation is done, use the ct . value at the higher temperature, at the higher ph and higher concentration. a simple ct calculation, for example, using a disinfectant concentration (c) at the basin effluent of . mg/l and a detention time (t) of min, is as follows: use this calculation for comparing to values in table i or j. the calculated ct value should be higher than the value stated in the table for specific conditions of disinfection, temperature, ph, and concentration (residual). in this situation, if the temperature of the water was °c, the ph and the concentration of chlorine mg/l, a ct value of would be needed for a . reduction of giardia cysts. the ct value of . would have been inadequate to meet the criteria and could explain the survival of the pathogen under investigation. microbial inactivation efficiencies vary considerably among different disinfectants and are influenced by the characteristics of the water and water temperature. tables i and j show that, in general, ozone is more effective than chlorine dioxide, which is more effective than free chlorine, which is more effective than chloramines. also, in general, longer contact time increases the degree of inactivation, and higher water temperatures as well as lower ph values increase rates of inactivation. rapid mixing of the disinfectant with water increases disinfection efficiencies, whereas dissolved organic matter reacts with and consumes the disinfectant and forms products that have weak or no disinfection activity. certain inorganic compounds and particulate matter also react with disinfectants. the ct value must be determined sequentially whenever a disinfectant is added to water. contact time (t) is the duration in minutes for water to move from the point of application of the disinfectant or the previous point of residual disinfectant measurement to the point where residual disinfectant concentration (c) is measured. it is measured from the first point of disinfectant application and from all subsequent applications until or before the water reaches the first user. determine contact time in pipelines by dividing internal volume of the pipe by the maximal hourly flow rate through the pipe. determine the flow rate from (a) plant records, (b) continuous monitoring device readings, (c) measurements at hourly intervals, or (d) if this sort of information is unavailable, measurements at expected high flow periods. use tracer studies to determine contact time within mixing basins and storage reservoirs. these values represent only % effectiveness because of short circuiting. chlorine, fluoride, and rhodamine wt (but not b) are commonly used tracer chemicals. contact time is usually measured by a step-dose method, but a slug-dose method is used where chemical feed equipment is not available at the designated point of addition or where such equipment does not have the capacity to provide the necessary concentration. (see appropriate epa literature for procedures, and consider getting engineering expertise if these matters are too complex.) estimate whether pathogens had been inactivated. to do this, divide the ct calc value by a value (ct x% ) resulting in a certain percentage inactivation (e.g., . % [ -log] or ct . for giardia cysts and . % [ -log] or ct . for viruses). this gives an inactivation ratio. see table i for ct . values for giardia and table j for ct . values for viruses. following is a sample calculation for data in table i when water temperature is °c, ph in a clearwell (reservoir for storing filtered water) is . , time (t) (either calculated or measured by dye test) is min, and the disinfectant used is chlorine: the desired ct value for . % inactivation of giardia for ph at °c is between and depending on concentration of disinfectant. in this case, the disinfectant measured at the clearwell outlet is . mg/l. therefore, the result, , is larger than the value, , required in the table; hence, these disinfection concentration (c) and time (t) conditions should result in a . % or greater inactivation of giardia cysts. for free chlorine, a -log inactivation of giardia cysts provides greater than a -log inactivation of viruses. the following example, using the data in table i , demonstrates a means to calculate the increased disinfectant dosage needed for a plant during the transition from summer to winter, when the water temperature fell from to °c, chlorine dioxide was the disinfectant used and the t value (calculated or measured) is min. using table i in this situation, the plant should have increased the chlorine dioxide concentration from . mg/l to . mg/l to maintain the same efficiency of disinfection. if this had not been done, it may explain the survival of pathogens in the water supply. the sum of these ratios gives the total inactivation ratio, which should equal or more to provide effective disinfection. make calculations and record information on form g a. the following example shows the way this is done. chlorine is added to three basins. chlorine concentration, contact time, temperature and ph are measured at these locations and recorded as shown in table . data from table i is combined to do the calculation. the resulting sum exceeds . . this ensures that the plant met the recommended or required ct. regulations may require that community and non-community public water systems that use surface water or water under direct influence of surface water meet a criterion (e.g., minimum of . % [ -log] removal and/or inactivation of giardia cysts and a minimum of . % [ -log] removal and/or inactivation of viruses of fecal origin that are infectious to humans). removal and/or inactivation of microorganisms may be accomplished by either filtration plus disinfection or disinfection alone, depending on the water source. water systems using chlorine with ct values that attain minimal level or inactivation of giardia cysts will result in inactivation of . % ( -log) of viruses. evaluate the prefiltration processes (e.g., coagulation, flocculation and sedimentation). coagulation is a process that uses coagulant chemicals and mixing, by which colloidal and suspended materials are destabilized and aggregated into flocs. flocculation is the process that enhances agglutination of smaller floc particles into larger ones by stirring. sedimentation is the process by which solids are removed by gravity separation before filtration. observe whether these processes reduce turbidity. calculate detention (transit) time within the settling tank and seek information about frequency and method of cleaning the tank. for example, if an -ft-deep sedimentation basin has a volume of million gal, and the plant flow rate is million gal/day, detention time in the basin is: (in your country you may want to calculate rates based on metric measurements) several different types of filtration may be used in water treatment facilities. these are conventional, direct (both conventional and direct are referred to as "rapid" filtration), slow sand filtration, and diatomaceous earth filtration. conventional filtration consists of a series of processes including coagulation, flocculation, sedimentation, and filtration. direct filtration consists of a series of processes including coagulation and filtration but excluding sedimentation. slow sand filtration is a process involving passage of raw water through a bed of sand at low velocity (usually less than . m/h), utilizing both physical and biological means to remove particles and microorganisms. in diatomaceous earth filtration, water is passed through a precoat cake of diatomaceous earth filter medium while additional filter medium is continuously added to the feed water to maintain the permeability of the filter cake. if done properly, each filtration method results in substantial particulate removal. when rapid sand filters have a head loss of about - ft, they require back washing. filters are backwashed by reversing the flow of the filtered water back through the filter at a rate between and gal/min/ft of sand-bed area. sometimes water jets at the surface aid in loosening and removing deposited material on the sand. observe an actual backwash and look for indications of short-circuiting or areas of the filter material that seem agglomerated or resist being cleaned by the flowing water. if backwash water is not discharged to waste, evaluate where it is released. slow sand filters eventually become clogged. when this occurs, a scraper or flat shovel is used to remove the top layer of clogged sand, and new sand (equivalent to the depth removed by scraping) replaces the old. test the effectiveness of filtration for each filter unit by observing capacity and filtering area relative to volume and turbidity of the filtered water. also, review turbidity, headloss, and filter rate record. look for anomalies, especially in the few hours after a filter is returned to service, and before the filter is backwashed. review criteria that cause a backwash to be initiated, and establish if these criteria were followed during the time preceeding the outbreak. determine the source of backwash water and the frequency of back washing of filters from records and head gauge readings. check whether the water used to back wash or clean filters came from an untreated source and determine the fate of the backwash water. in the case of illness due to chemical substances, evaluate types of chemicals used and condition, operation and maintenance of chemical feeding equipment. consider sampling backwash water for pathogens under investigation. review plant records for results of monitoring and be alert for changes that suggest treatment failure. record this information on form g b (source of contamination and treatment failures that allowed survival of pathogens or toxic substances.) data in table k (estimated removal of giardia and viruses by various methods of filtration), give a summary of expected minimal removal of giardia and viruses in well operated filtration systems. values can be subtracted from ct values required for disinfection. although contamination is likely to be associated with raw incoming surface water, look for bypass connections where raw or partly treated water can get into treated water. also look for common walls that separate treated and untreated water. consider the possibility that a contaminant was introduced in any of the treatment chemicals themselves, or as an act of sabotage. determine whether any flooding has occurred during the interval of concern. check absentee records for possible enteric illness of the water treatment plant staff. such illness may reflect either sources of contamination or victims. record this information on form g b. at domestic locations, evaluate treatment devices (such as chlorinators, filtration units, softening equipment) as described above, but modified to fit the situation under investigation. record observations and measurements on forms g a and g b, as applicable. the water distribution system can be complex, with multiple entrance points for treated water and different pressure zones in which water can enter but not leave. water flows in the direction in which it is being "requested," so can flow in different directions in the same pipes from one hour to the next. contaminated water can enter a potable water supply from a non-potable water supply when the two are directly connected. such interconnections are referred to as cross connections. to evaluate such situations, trace lines of the treated supply from the point of treatment or entrance into a building to points of use and associated plumbing. look for any interconnections of other water supplies, such as wells, waste lines or holding tanks for water intended for fire control. if cross connections are found, look to see whether backflow prevention devices are inserted between the lines and, if so, whether they are functioning properly. also, look to see whether there is an air gap between the water inlet and vessel or tank. evaluate the arrangement and operation of check valves on connections between the two water systems. review inspection report for backflow prevention devices. contaminated water can also enter a treated supply by siphonage from a contaminated vessel or sewerage to the potable water line having negative pressure. this is referred to as back siphonage. examine all water vessels to see whether they contain submerged inlets or hoses connected to water faucets, and if so, whether properly functioning vacuum breakers are in place. without proper air gaps or properly functioning vacuum breakers, there is a possibility of siphonage of water from plumbing fixtures in upper stories to lower stories when line pressure is negative. this may occur when faucets on lower floors are opened after the water supply valve has been turned off for repairs or when the supply line has had a sudden loss of pressure, as can happen with nearby heavy use of water (e.g., to fight fires or irrigate) or when pressure lines are broken. measure water pressure on upper stories of buildings to determine whether negative pressure occurs. (pressure losses may be transient and of very short duration.) interview building managers and residents about whether there were (a) any repairs of water service during the past month, (b) fires that occurred nearby, or (c) other situations that could have caused negative pressure in the water line. also, if appropriate, review fire and utility department records for information about these situations. get dates of line repairs to see whether they correlate with the time of incubation periods of early cases. measure chlorine residual (of chlorinated water systems) and take samples for microbiological tests at several strategic locations in the distribution systems. perform calculation on comparison of disinfectant residual. if a toxic chemical poisoning is under investigation, talk to home owner, building manager or maintenance staff about whether pesticides or other toxic compounds were sprayed with equipment connected to a hose or a sprinkler system. furthermore, interview building managers and residents about whether there are persons residing there who either are or recently were ill with diarrhea. they may represent sources of the etiologic agent or may identify victims. interview those identified about the onset of their illness and symptoms and examine their plumbing systems. record information obtained during the investigation of distribution and plumbing systems, and record related calculations on form g (source and mode of contamination during distribution and at point-of-use). evaluate implicated waters used for swimming, water skiing, bathing, clothes washing by hand, or agricultural activities, in a manner similar to that described under the section on investigation of surface water source. if the potential site of contact was natural surface water, determine whether the water is likely to be infested by parasites and look for the presence of snails (swimmer's itch). for swimming pools, measure the water's ph, chlorine residual, water temperature, and turbidity, if applicable. also, review pool records for previous information on these characteristics. high turbidity in pools, hot tubs, and spas is a sign of either poor filtration or inadequate disinfection. evaluate whether the resulting water would adequately protect those who swam or waded in it or had any physical contact with it. evaluate filter and chlorination equipment as described for water treatment. backwash filters and collect a sample to get an indication of microorganisms present on the filter (thus obtaining historical information). this approach has been useful for identification of pseudomonas aeruginosa. look for the presence of slime on tub, whirlpool, slide and pool surfaces, and collect some of this material for analysis for p. aeruginosa. if the answer is not obvious, ask ill persons whether they had puncture injuries or wounds or scrapes while immersed in water. record this information on appropriate parts of form g (contamination source and survival of pathogens or toxic substances for recreational waters). collect samples of the water (see section on "collect water samples"), and test them for pathogens and/or indicator organisms, as applicable. the agents listed in table d can multiply in water and if such water is aerosolized, they can be transmitted to human beings via the respiratory route. highly susceptible persons (e.g., the elderly, smokers, immunosuppressed individuals) are the usual victims. look for possible sites where water may have been or is being disseminated as aerosols. consider (a) air conditioning cooling towers and evaporative towers, (b) hot water systems (heaters and tanks), (c) shower heads, (d) faucets with aerators, (e) mist machines used to freshen fruits and vegetables in markets, (f) humidifiers, (g) nebulizers/respiratory therapy equipment, (h) whirlpools and spas, (i) dental drills and cleaners, (j) cooling water apparatus for grinders, (k) splash from hoses, (l) water pressure line breaks, (m) decorative water features, (n) outside misters, (o) other aerosol-producing devices. sample water from all suspect sites for legionella or other waterborne agents that may cause illness when inhaled. it is not possible to recognize by visual inspection the potential for water to be contaminated with legionellae. warm temperatures, especially those between °c ( °f) and °c ( °f), are conducive to growth of legionellae. additionally, stagnant water allows time for legionellae to multiply, especially in dead-end lines, reservoirs and hot water tanks, and in water trapped in shower heads and faucet aerators. if it is deemed appropriate or necessary to sample for detection of legionella in the environment, collect water samples from suspect sources. it is important to use a lab with proven expertise in isolating and characterizing legionella, such as those labs in the u.s. certified under the environmental legionella isolation techniques evaluation (elite) program. the centers for disease control (cdc) have a convenient form for recording case histories (http:// www.cdc.gov/legionella/downloads/case-report-form.pdf). it is not appropriate to sample air for detection of legionella hazards. it may, however, be appropriate to use micromanometers or smoke to trace direction of air flow to determine route of dissemination. micromanometers measure pressure differences, and flow can be assumed to travel from high to low pressure areas. smoke moves from areas of higher pressure to areas of lower pressure and is extremely sensitive to air currents. observe direction and spread of smoke movement. record this information on form g (contamination source and sites of amplification and aerosolization of pathogens). prior to the collection of samples, investigators should consult with the testing laboratory that will be used, to receive specific laboratory sampling instructions and sampling kits. sampling protocols for potable and non-potable sources are dependent on the specific etiological agent and the related analytical procedures performed by the testing laboratory. collect samples promptly to test for possible etiologic agents and for microorganisms indicative of fecal contamination. contaminants in water are in a dynamic state; their presence and quantity differ with time and place. see table f (general instructions for collecting drinking water samples) for guidance on collecting and shipping samples for viral, bacterial, and parasitic analyses. samples for bacteriological tests can be collected in one of three ways: (a) by letting a stream of water flow into a container or by submersing a container into a volume of water, (b) by passing a large volume of water through a filter, (c) by putting moore swabs (see table a for description) or similar absorbent materials in surface water or drains for a few days (see table f ). use bottles that have been cleaned, rinsed, and sterilized, or use sterile plastic bags to collect and store samples for bacteriological examination. for a chlorinated water supply, or when in doubt about the presence of residual chlorine, use bottles containing mg/l sodium thiosulfate to combine with any free chlorine in the sample and prevent lethal effects of chlorine on microorganisms in the sample. this compound will not interfere if used for non-chlorinated water. when collecting water samples, first try to get "historical" samples that might give an indication of the condition of the water at the time it was ingested by those who became ill. obtain historical samples from water in bottles in refrigerators, toilet tanks, hot water tanks (for chemical analyses only), fire truck reservoirs, storage tanks, and taps at seldom-used and dead-end locations, and from ice in refrigerators and commercial ice plants. direct the laboratory to test historical samples for pathogenic organisms or toxic chemicals, as well as indicator organisms, because these samples have a chance of still containing the etiologic agent, whereas samples collected during the investigation several days or weeks after the event may be of water that has been flushed free of contamination or has been significantly diluted. take samples from to points throughout the distribution system. sample dead-end locations if they are found. do not neglect to obtain raw water samples even though treatment is provided. this is important, as it suggests possible sources of contamination and reflects the effectiveness of treatment. compare these test results with records of results on previous samples of raw or treated water. before drawing a sample from a water tap, make sure the tap is connected to the supply to be tested. do not collect samples (other than for legionella) from hose connections, sprays, or swivel faucets; uncouple these connections or choose different outlets. it is unnecessary to flame outlets, as this does not improve the quality of the sample. first, ensure your hands have been thoroughly washed then take a line sample by allowing the water to run to waste for - min. adjust the flow of water so that the thiosulfate will not wash out of the bottle or bag (do not overfill-most laboratory bottles indicate a maximum fill line). keep sample containers closed until the moment they are to be filled. hold the bottle near the base, fill to the "fill line" or within an inch of the top without rinsing, and immediately replace the stopper or cap and secure the hood, if attached. if a whirl-pak™-type plastic bag is used instead of a bottle, hold the base, rip off the perforated top, open the bag by pulling the side tabs apart, grasp the end wires, and place the bag under the flowing water. remove the bag before it is completely filled and squeeze most of the air out; fold over the top of the bag several times and secure by twisting the end wires. take a source or a distribution line sample by opening the tap fully and letting the water run to waste for sufficient time to empty the service line (or if in doubt, for min) and proceed as above. collect samples from open shallow wells and step wells by dropping a clean wide mouth container on a string or rope into the well. allow the container to sink below the water surface and then pull it out of the well. pour contents into a sample jar or bag. collect samples from rivers, streams, lakes, reservoirs, springs, toilet tanks, and non-pressurized storage tanks by holding a ml sample bottle near the bottom and plunging it neck down to a depth of cm ( in) below the surface; turn it right side up, and allow it to fill. don a plastic disposable glove when small vessels used for drinking are sampled in this manner. when collecting these samples, move the bottle in a sweeping, continuous, arc-shaped motion, counter to stream flow or in a direction away from the hand. collect samples at locations approximately one-quarter, one-half, and three-quarters the width of the stream or water course. special apparatus can be used for sampling at various depths. samples can then be taken by positioning large bottles on a rod or pole at the desired depth and location before pulling their stoppers with a wire, string or thin rod. samples of bottom sediments are sometimes useful for the detection of certain pathogens. collect surface scum or regions containing dense particulate colored material when seeking cyanobacteria (blue-green algae). collect slime, if present, when seeking pseudomonas. if large amounts of water are needed, seek assistance and obtain specialized sampling equipment from agencies responsible for water quality. if possible, avoid wading when sampling bodies of water because wading often stirs up bottom sediments. if this is the only way to get a sample, however, wade against any current (e.g., upstream in creek or river) and keep moving forward until sample taking is completed. piers or similar structures, or the front end of a drifting or slow moving boat, make good sampling stations. concentration of bacteria by the use of swabs, filters, or by absorption, is particularly important when waterborne pathogens are sought. to concentrate bacterial pathogens from flowing water (e.g., streams, lakes, sewer lines, or drains), suspend moore swabs (or non-medicated sanitary napkins or non-medicated tampons if moore swabs are unavailable) for - days. these can be held in place by wire just below the surface or at other depths. if rodents are about, put moore swabs in wire baskets. after the sampling period, either put swabs or pads into a plastic bag and pack in ice, or put the swabs or pads directly into an enrichment broth for the pathogen sought. take or send these to the laboratory promptly. concentration of microorganisms can be increased by filtration with a variety of filters (e.g., membrane filters, cartridge filters, or other filter media). when membrane filters are used for pathogenic bacteria recovery, pass at least l of water (relatively free of turbidity) through a sterile . μm membrane filter. for viral analysis, use virus-absorbing electropositive cartridge filter to concentrate l or more water (see table f ). keep filters cool (but not frozen) and ship to a reference laboratory for further processing. for giardia cysts and cryptosporidium detection, collect samples by passing at least l water through a cartridge filter (see table f ). for inorganic chemical analyses, use l polyethylene containers. these should be new, or acid-washed if previously used. collect the water without flushing the lines, preferably in the early morning before water is used. for trace metal analyses, preserve one sample with ml of high-grade nitric acid to a ph of or less. this is particularly important whenever it is suspected that metals may have leached from water pipes or vessels. for organic chemical analysis, use l glass containers with teflon-lined caps. clean and rinse the containers with a good quality laboratory solvent and heat at °c for min. rinse the cap thoroughly with distilled water. fill the container so that there is a minimum of air space. for physical analyses, collect at least l, or other amounts requested by the laboratory. collect ice aseptically in sterile plastic bags or jars. use sterile tongs to collect cubes; sterile spoons for collecting chipped or crushed ice; and sterile chisel, hammer, or pick to chip block ice. put block ice or large chips into plastic bags. if legionella is sought, sample water at sites of any source that may have been aerosolized and send to a lab with proven expertise in legionella isolation and characterization, such those in the cdc elite program. this includes cooling towers, evaporative condensers, water heaters and holding tanks, humidifiers, nebulizers, decorative fountains and whirlpool baths (see section on investigating sites where aerosols are disseminated for a more complete listing). turn off fans of condensers before sampling; if this is not possible, wear a respirator. use ml to l polyethylene bottles that have had sodium thiosulfate added if the water to be tested has been chlorinated. for each sample, don disposable plastic gloves and collect the sample by inverting the bottle and moving it in a continuous arc away from the hand. measure and record water temperature. handle samples as described in table f . rub swab over faucet aerators and shower heads if these are considered as sources of aerosols. break stick and allow tip to fall in a tube containing - ml sterile water (not saline). investigators are often requested to test air to demonstrate the presence of legionella in aerosols. although legionellosis is an airborne disease, legionellae are susceptible to low humidity and become non-viable on drying. therefore, air sampling is an ineffective and inefficient way of determining whether a legionella hazard exists, and it can thus be misleading. label each container with sample number, date, time of collection, and your name or initials. complete the water/ice sample collection report, form f, for the first sample. list additional samples with sample numbers and other pertinent information on the back of the form. in those situations where the laboratory needs additional information, attach the appropriate g series forms. send the original form f and list with samples to the laboratory; retain a copy for your files. inform the laboratory of the type and number of samples and specimens; also, consult with the laboratory on methods to preserve and transport samples, if necessary, and on time of their arrival. if legal proceedings are anticipated, deliver sample personally to the analyst, or seal the sample container in such a way that it cannot be opened without breaking the seal. note on form f the method by which the bottle was sealed. maintain a chain-of-custody log to document the handling of the sample, and have the log signed and dated each time it changes hands. consult with state/provincial regulatory agency on complying with legal requirements for chain-of-custody procedures. recipient should record on the form whether the sample was sealed when the laboratory received it. if analysis cannot be done on the day of collection, chill water samples rapidly and hold them at temperatures at or below °c ( °f), but do not freeze, because populations of bacteria such as escherichia coli and of parasites decrease during frozen storage. hold ice samples frozen; if this is not possible, keep the temperature below °c h ( °f). investigators should consult with the testing laboratory that will be used to receive specific laboratory sample packaging, labeling, and transportation instructions as protocols are dependent on specific transportation regulations (iafta, tdgr) within each jurisdiction. ensure each sample is uniquely identified and labeled (as per the receiving laboratories requirements). many laboratories include barcode labels along with the sample containers within the sample collection kits. ensure that the correct label is affixed onto the correct sample container and that this information is transferred to the shipping manifest accurately (chain of custody form). specimens should be packed and the packages labeled according to applicable regulations governing transport of hazardous materials. generally, the transport of samples of water and ice intended for laboratory analyses are packed and shipped in a manner to ensure the sample does not change from the time of sampling to the time received by the testing laboratory and shipped using the most expeditious means (e.g., personal delivery or overnight mail). typically samples of water or ice are packed with refrigerant (ice packs, dry ice, etc.) in insulated and sealed containers (see table f ). several measurements are routinely called for during on-site investigations. brief instructions are given for those that are commonly done; nevertheless, follow manufacturer's instructions if these are available. color comparison kits are available for testing for free, combined and total residual chlorine. the diethyl-p-phenylenediamine (dpd) test is an example (see table a ). check instrument calibration regularly. use dry reagents, because the liquid forms are unstable. chlorine comparators can be used to test for bromine by multiplying the result by the factor . and to test for iodine by multiplying the result by the factor . . measure temperature. measure water temperature by immersing the sensing end of either thermocouples, transistors, or thermometers into the water. sometimes measurements need to be made at various depths; use thermocouples with wire leads of sufficient length for this purpose. calibrate temperature measuring devices periodically. measure ph. calibrate the ph meter as recommended by the manufacturer with at least two standard buffers (e.g., ph . or . ) and compensate for temperature, if the meter does not do it automatically, before each series of tests. remove a sample of water to be tested and immerse the ph electrode into the sample; record the reading. ph can also be measured by color comparators that employ color indicator solutions or discs. (ranges of ph color indicator solutions are bromophenol blue, . - . ; bromocresol green, . - . ; methyl red, . - . ; bromocresol purple, . - . ; bromothymol blue, . - . ; phenol red, . - . ; cresol red, . - . ; thymol blue, . - . ; and phenolphthalein, . - . .) in this case, water containing more than mg/l chlorine in any form must be dechlorinated with sodium thiosulfate before the ph indicator solution is added to prevent decolorization of the indicator. always report temperature at which the ph is measured. measure turbidity. nephelometric turbidity unit (ntu) is the usual standard unit, but other turbidity measurements (such as particle counts) are used. the ntu requires a nephelometer, which measures the amount of light scattered predominantly at right angles and absorbed by suspended particles (e.g., clay, silt, finely divided organic matter, inorganic matter, soluble colored organic compounds, and microscopic organisms) in the water sample. calibrate turbidimeters with a standard reference suspension. make turbidity measures on the day samples are taken. vigorously shake samples, wait until all air bubbles have disappeared, and then pour sample into turbidimeter tube. read directly from scale on instrument or from an appropriate calibration scale. pump chemical smoke into the air at the exit of the device suspected of releasing aerosols. observe the direction and spread of the smoke. otherwise, measure pressure differentials with a micromanometer. measure other attributes of water. follow instructions given by manufacturers or in standard reference books (see further reading). use fluorescein dye, lithium or other tracers in appropriate soils to determine the means by which contamination from sewage, industrial wastes, or other sites of pollution reached the water supply. fluorescein dye is particularly helpful in evaluating flow of contamination through fissured rock, limestone, gravel, and certain other soils. this dye is not readily absorbed or discolored by passage through these soils or sand, as are many other dyes, but it is discolored by peaty formations or highly acid (ph < . ) soils. make a concentrated fluorescein dye solution by mixing g of fluorescein powder into a liter of water. usually, / to l of this solution are sufficient for the test for up to , l of water. fluorescein dye is also available in liquid and tablet form. one tablet will dye approximately l (~ us gal). pour the calculated amount of fluorescein solution or put a sufficient number of fluorescein tablets into a receptacle at a point of potential pollution. usually this point will be located within yards and at a higher elevation than the water source under study. cesspools, latrines, distribution boxes, sink holes, borings, septic tanks, drains, manholes, toilets and plumbing fixtures are typical places to introduce the dye. if dye is poured into a plumbing fixture or dry hole or boring, add water to wash it down. the amount of dye to use varies with the distance the dye must travel, the expected time of the journey, the size of the aquifer or water channel, and the nature of the soil. take samples of the water when the dye is introduced into the test hole or fixture and then hourly for up to h to detect arrival and departure of fluorescein. if no dye is observed, repeat the test with twice the amount of dye. whenever possible, use a fluorescent light or fluorometer to analyze water samples for evidence of fluorescein. a fluorometer can be set up and calibrated, and a continuous recording can be made. this meter can detect fluorescein in concentrations of μg/l (ppb). fluorescein dye will temporarily color water, which discourages use of the water until the dye is sufficiently degraded or diluted. alternate tracers can be used if specific ion meters are available. the dye stains all it touches. methanol is a good solvent for the dye, and hypochlorite solutions decolorize it; both can aid in removing stains. abrasive soaps are useful for cleaning stained skin; fluorescein-stained clothing should be washed separately. appearance of dye in a water supply is conclusive evidence of seepage from the site where the dye was introduced. failure to detect dye, however, is not conclusive evidence that seepage did not or would not occur if more dye had been added or if weather conditions or subsurface flow had been different at the time of the test than during the outbreak event. illustrate source and direction of contaminated water flow as indicated by the dye test on form g . take photographs of sources of contamination and evidence of staining of the ground at the site or dye-stained color of the water. in situations where a single source of contamination is obvious or where multiple sources are readily apparent, dye studies serve little purpose. drinking water, however, is not the only source of water that may contribute to outbreaks. other sources of water that can contribute to outbreaks include water not intended for drinking, recreational water and water used in agriculture during harvesting and packaging. legionnaires disease is the pneumonia caused by the inhalation of contaminated water aerosol containing the bacteria legionella, with legionella pneumophila being responsible for % of all infections. it is also a common cause of healthcare associated pneumonia. legionella can replicate within free-living amebae in water, allowing it to resist low levels of chlorine used in water distribution systems. risk of infection is more common in warm and humid weather, when water droplets are able to drift further due to higher absolute humidity. fifty percent of all legionella outbreaks have been traced to cooling towers with l. pneumophila serogroup responsible for all cooling tower outbreaks. all aerosol generating devices, however, can be potential sources of legionella. some other sources of aerosolization that may have contributed to or be associated with outbreaks include: whirlpool displays, building's air conditioning systems, water spray fountains, public bath houses, vegetable misting systems in grocery stores, evaporative condensers, showerheads, humidifiers, air scrubbers, car washes, ornamental and decorative fountains, potting soil, respiratory therapy equipment, dental units, road asphalt paving machines, car windshield washer fluid and car air-conditioning systems. in the investigation of a legionella outbreak, (see box , the flint water crisis, which describes a likely legionella outbreak from a commercial water source) due to the varied sources, there is a need to use a broad investigative questionnaire and the collection of environmental data. environmental factors such as dry bulb temperature, relative humidity and wind rose data can provide information regarding drift evaporation, deposition (settling) and the size of the affected zone. although aerosol drift can carry legionella up to mi ( km), the risk of infection is usually highest within ft ( m) of the source. there are also air dispersion models that can be used to determine drift zone and the use of human activity mapping in the identification of potential sources. in general, e. coli and norovirus are the most common pathogens responsible for recreational waterborne outbreaks associated with non-treated water such as beaches and lakes. cryptosporidium, which is resistant to chlorination, is the most common pathogen resulting in outbreaks in treated water venues such as swimming pools and water spray parks. it should be noted that e. coli, the indicator of choice of recreational water samples, is not indicative for the presence of norovirus and giardia, cryptosporidium. e. coli can also be "naturalized" and have been found to survive and multiply in beach sand. beach water sampling results therefore may provide false positive or false negative results and may not be the best indicator for the presence or absence of pathogens. recreational waterborne outbreaks are not just traced to the ingestion of contaminated water (table c . illnesses acquired by contact with water: a condensed classification by, symptoms, incubation period, and types of agents). hot tub rash, or pseudomonas dermatitis/folliculitis commonly occurs in public hot tubs or spas such as those found in hotels. the rash is often a result of skin infection from the bacteria pseudomonas aeruginosa colonizing in the hair follicles after exposure to contaminated water. pseudomonas aeruginosa is an opportunistic pathogen that can survive within the biofilm on the tub surface or within the piping system. outbreaks can occur when there is a heavy bather load resulting in an increase in chlorine demand, which in turn reduces the effectiveness of the disinfectant to control the population of pseudomonas. blue-green algae or cyanobacteria bloom can occur in warm, slow-moving or still water. when conditions are favorable, mostly during hot summer weather, cyanobacteria populations may increase dramatically, resulting in a "bloom" as they rise to the surfaces of lakes and ponds. they resemble thick pea soup and are often blue-green in color. although blooms can occur naturally, water bodies which have been enriched with plant nutrients from municipal, industrial, and agricultural sources are particularly susceptible. some cyanobacterial species may contain various toxins, some are known to attack the liver (hepatotoxins) or the nervous system (neurotoxins); others simply irritate the skin. health effects from cyanotoxin exposure may include dermatologic, gastrointestinal, respiratory and neurologic signs and symptoms (table b . illness acquired by ingestion of contaminated water: a condensed classification by symptoms, incubation periods, and types of agents). water can also be an indirect cause of foodborne outbreaks by providing a media for the survival, transportation and the introduction of pathogens into food products. water used during production, including irrigation, pesticides and fertilizers application and washing, frost protection, harvesting, has long been recognized by food safety scientists as one of plausible and probable sources of the contamination of fresh fruits and vegetables. there have been many outbreaks from produce traced to pathogens being introduced by contaminated irrigation water. although harvested products are sometimes washed with chlorine solution, pathogens may still survive the process through internalization. e. coli o :h may migrate to internal locations in plant tissue and be protected from the action of sanitizing agents by virtue of its inaccessibility. experiments have also demonstrated that e. coli o :h can enter the lettuce plant through the root system and migrate throughout the edible portion of the plant. however, this claim has been refuted by others. salmonella and e. coli can also adhere to the surface of plants, and enter through stomata, stem and bud scars and breaks in the plant surface caused by harvesting and processing. water containing bacteria can be drawn into the produce if it is immersed in or sprayed with water that is colder than the produce itself. e. coli o :h may also use its flagella to penetrate the plant cell walls and attached to the inside of the plant. once attached, it may be able to grow and colonize the surface of the plant. the concerns are not just with bacteria. the present of norovirus in the hydroponic water can result in internalization via roots and dissemination to the shoots and leaves of the hydroponically grown lettuce. irrigation water may be contaminated from runoff from nearby domesticated animals and their lagoons, feedlots, ranches into rivers; from feral/domestic animals with direct access to creeks, ditches, rivers, ponds; from sewage flows into waterways and contaminated wells. in some parts of the world sewage contaminated water is preferred for irrigation despite a potential risk of transporting enteric pathogens, since it carries nutrients (n and p) for the plants. there is sufficient information to conclude that the application method of irrigation water to fresh produce can have an effect on the microbiological risks associated with the crop. in general, keeping water away from the edible parts of ready-to-eat crops that are consumed without cooking can result in a lowered risk of a foodborne outbreak. the least to more risky methods for irrigations for microbial contamination are: subsurface irrigation (buried soak hoses) < drip irrigation < indoor flood irrigation (hydroponics) < outdoors flood irrigation (water-filled furrows) < overhead irrigation (sprinklers). an outbreak of illness arising from exposure to water demands immediate epidemiological investigation to assess the situation, gather, evaluate, and analyze all relevant information, with the goal of ( ) halting further spread of this illness, and ( ) predicting, preventing, and/or attenuating future outbreaks. this twofold mandate of epidemiology is usually described as "surveillance and containment." at the commencement of an investigation, the unknowns usually outnumber the known facts. there is no substitute for prompt, thorough, and careful collection of interview data from ill and well persons who ingested or contacted the suspect water, attended a common event, or who were part of a group of persons where illness occurred. careful analysis of these data, particularly with reference to common patterns of "time," "place," and the characteristics of the persons involved, can often eliminate many vehicles, agents, and pathways quite early in the investigation, and focus on the remaining possible vehicles, routes, and agents. later, laboratory results may confirm the agent, the specific pathology, the route taken by the infection or toxic agent, and indicate what is needed to stop the spread, but early epidemiology can often be invaluable in predicting the outcome and taking preventive steps to contain the problem before the lab results are available. lessons can be learned from most outbreak investigations and are invaluable for increasing our understanding of these pathologies, and preventing their future occurrence. an outbreak is defined as either an unusually large occurrence of an expected illness at that time of year in that place, or the occurrence of a type of illness that does not usually appear at that season and location. the "time" factor should be studied immediately by plotting the onset time of each case on a time-based grid, to create the epidemic curve. although any number of cases can be involved, the minimum number for an "outbreak" to be declared is two associated cases, with special exceptions such as naegleria fowleri where, because of the severity and the possibility that cases may have been missed, a single case constitutes an "outbreak." although the epidemic curve is usually measured in hours or days, protracted exposure to agents in water may mean apparent sporadic cases linked to a common source over months or years. if an "outbreak" is suspected by a sudden increase of cases, determining who is to be categorized as a "case" is not necessarily a simple process. many people notoriously fail to report enteric illness for many reasons: embarrassment, lack of time, no clear idea which agency should be notified, mild self-treatable symptoms, or simply because they prefer not to make a fuss. they may therefore be incorrectly classified at least initially as "nonill." consider also that - % of the general population will have experienced some form of "upset stomach" in the last hours, regardless of exposure to the suspect item, and they may be incorrectly classified, at least initially, as "ill." to reduce the "false negatives" and "false positives" that are expected with self-reporting, the investigator needs to establish a working case-definition. a careful case definition categorizes people as "case" or "control" with the best accuracy possible within the time constraints and resources available. a case definition could be considered "too sensitive" if it classifies as a "case" a person who experiences: "… at least one episode of stomach cramps, nausea, vomiting, or diarrhea in the last hours." this would confuse subsequent analysis, and produce more false positives. similarly, a case definition could be considered "too specific" if it classifies as "not-ill" a person who had experienced only three episodes of diarrhea or vomiting, because they failed to satisfy a case definition requiring "…at least four episodes of vomiting or diarrhea in the last hours." should this last individual, having been declared as not fitting the case definition, be taken into the "notill" group, the error and subsequent analysis is confounded even further. a reasonable case definition therefore attempts to reduce both types of errors, and will depend upon the early indications of what the etiology may be. in the instance of a suspected salmonellosis, a case could be defined as "a person who was in good health before attending the event on monday may rd, and who experienced two or more of the following symptoms anytime up to midnight, sunday may th.: nausea, vomiting, stomach-cramps, diarrhea, headache, or fever." note that a case definition should include a place of exposure if known, a timeframe during which symptoms may have been experienced (salmonellosis has a range from to h. usually - h), and the additional footnote that the individual was not already symptomatic before the suspected "exposure." calculate the percentage of ill persons who manifest each symptom by dividing the number of persons reporting the given symptom by the number of cases ( for the example, table ) and multiplying the quotient by . the distribution of symptoms can be used to identify the most likely pathogen, and aids in requests to the laboratory for microbiological assays of samples and specimens. other symptoms (e.g., prostration, lethargy, weakness) may be included if deemed appropriate or helpful, but the six symptoms in table should always be included. headache, for instance, is associated with many viral infections (e.g., norovirus, rotavirus), but much less so with bacterial infections. fever is usually associated with an invasive bacterial infection (such as salmonellosis or campylobacteriosis), and is not usually seen in outbreaks of simple enteritis (such as with cholera). this information helps to determine whether the outbreak was caused by an agent that produced intoxication, an enteric infection, or generalized illness. in the example given, a predominantly diarrheal syndrome without much fever or headache tends to eliminate some of the viral infections (norovirus or rotavirus) or the host-adaptive/invasive serotypes of salmonella (e.g., s. dublin or s. choleraesuis). median onset time calculations may further reduce possible candidate etiologies. in historical investigations, or where no laboratory confirmation is possible, the symptom profile and onset times can sometimes predict the etiology of the outbreak within reasonable certainty. an epidemic curve (also called an onset curve or onset distribution) is a graphic illustration called a histogram that shows the distribution of the time of onset of first symptoms for all cases that are associated with the disease outbreak. paper printed with square "grid" lines will allow the investigator while on site to represent each case as a single "block." the horizontal axis is the sequence of intervals of time and date. the unit of time that defines the width of each interval depends on the characteristics of the illness under investigation. for example, intervals of days or weeks are appropriate for diseases with long incubation periods, such as cryptosporidiosis or hepatitis a. intervals of a day or half-day are appropriate for outbreaks of enterohemorrhagic e. coli strains or shigellosis, while single-hour, -h, or -h intervals will be more suitable for illnesses with shorter incubation periods, such as chemical poisonings. the vertical axis is always the actual count, or "frequency" of cases (blocks) stacked at each interval. it is often necessary to redraw the onset curve as more accurate information becomes available. if the illness is known, a rule of thumb is that the time interval used for each "block" on the x-axis should be no more than ¼ the incubation period of the disease under investigation. if the illness is not known, select an interval where the data produces a bell-shaped curve; not too flat and not too tall. construct this graph using time-of-onset data from forms c or d, employing an appropriate time scale. once all the onset times for the cases have been plotted on the histogram, determine the range as the interval between the shortest and longest incubation periods. in fig. a , the range is the day period from the th to th march. the median onset time is preferred to the mean because the latter is vulnerable to a few or even a single very small or very large value. the median on the other hand, is the midvalue of a list of all individual onset times, including duplicate entries, that are ordered in a series, from shortest to longest. if the series comprises an even number of values, the median is the mean of the two middle values. most standard reference texts on communicable diseases give onset times as median values. the mode is simply the interval having the largest number of observations. a distribution with a single "peak" is called a uni-modal distribution, while an outbreak with two peaks is called "bi-modal." subsequent modal peaks following the first may indicate either a "secondary wave" of cases or the exposure of other people at a later time. the shape of the epidemic curve helps to determine whether the initial cases originated from a single point-source exposure (such as water or food available for only part of a day), or from repeated exposures for a longer time, or even more gradual person-to-person spread. a point-source epidemic curve is characterized by a sharp rise to a peak, followed by a fall that is almost as steep ( fig. a ). an "explosive" outbreak of this type is common where a municipal water supply is the vehicle, affecting large numbers of people in a very short period of time, but without secondary cases occurring, or any evidence of onward spread within the community. propagated outbreaks are those in which the initial victims ("primary cases") manage to spread the agent to other people ("secondary cases") such as family members, patients, clients, or other contacts in crowded places through aerosols, personal contact, or contaminated water/food/utensils/surfaces, etc. propagation following a point-source exposure is demonstrated by a second increase in reported cases following the decline of the first cluster. sometimes this takes the form of a second "modal peak" separated by approximately one incubation period, but this distinction is soon lost. figure a shows no evidence of propagation; fig. b suggests that propagation may have taken place, although care must be taken to consider other explanations. in addition to ( ) true propagation, where the secondary wave can be expected to appear one incubation period after the first, secondary waves may be also explained by ( ) exposure to the same point source (e.g., food or water supply) at different, but specific times by other people; this might be a repeated offering of contaminated food or water at two or more mealtimes; ( ) a second pathogen (perhaps from the same unhygienic food or water source) which may have a different symptom profile and a different (incubation) time. slow propagation from the beginning of an outbreak with neither an obvious point-source, nor any distinctive "waves" separated by an incubation period as in fig. c , usually indicates one-at-a-time person-to-person spread through closecontact, poor personal hygiene, aerosol (e.g., influenza, or sars), or sexual transmission (e.g., hiv/aids). it can also be explained by (non-propagated) continuing exposure, for example drinking of contaminated surface water following a conflict, natural disaster or other breakdown of infrastructure. as such it is commonly associated with waterborne cholera, shigellosis, typhoid fever, or e. coli infection, and characterized by scattered cases which continue until the chain of infection is cut. slow, constant and/or intermittent exposure to persons over time to pathogenic microorganisms can also result from sewage run-off after a series of heavy rainfalls. in addition to revealing whether the outbreak was due to a single point-source, or had been spread steadily through the community by propagation in some way, another important objective in constructing the epidemic curve is to estimate the incubation period of the illness if it is not already known. with waterborne illness especially, the time of exposure may be further obscured because people usually drink water several times a day. hence, the incubation period cannot always be determined for each case, but the actual time of onset is usually available. the incubation period is the interval between exposure to food or water that is contaminated (with enough pathogens or with a sufficient concentration of toxic substances to cause illness), and the appearance of the first sign or symptom of the illness. each etiology is characterized by a typical incubation period (tables b, c, d, and g). individual onset times will vary due to immune factors, co-morbidities, the dose ingested, and other ingested materials, but the investigator can often make a rough estimate of the average incubation time by examining the aggregation of all onset times as an epidemic curve. the modal peak of a single "cluster" or distribution is the time interval in which most cases commence symptoms. in fig. a this occurs on march , and in fig. d that occurs at the double interval feb - th. where two separate modal peaks (a "bi-modal distribution") suggests secondary cases ("propagation"), then the distance between the first two modes is a good estimate of the incubation period. figure b shows about days between primary and secondary modal peaks, suggesting that the initial exposure is likely to have been days before the first mode. in fig. b this would be sometime on or near the th of the month. if the exposure point is known but the agent is not, then that estimation of the median incubation period will allow many etiologic agents to be excluded due to date of onset of symptoms: between march and april , count per day onset histogram for cases of shigellosis, march to april , illustrating slow spread through a community through either propagation (person-to-person spread via poor hygiene), or exposure by many people to a small well at different times (a non-propagated route) incubation periods that are clearly outside the range of times observed. the list of possible candidates can be further reduced by examining the symptom profile and other characteristics of the illness and suspect food or water vehicle. as time passes, the onset curve also provides an ongoing measure of the potential for propagation, and the incidence rate. all this information can be useful in deciding whether the illness in question is an infection or intoxication and thereby determining which laboratory tests should be requested (tables b, c, d, and g). note that not all water or foodborne illnesses listed in a standard reference such as the "control of communicable diseases manual" (apha ), are directly communicable person-to-person; many require a suitable substrate (food or drink) and adequate time/temperature combinations to attain sufficient numbers or the production of enough toxin to induce a pathological condition. an exposure time can sometimes be estimated from a clear, point-source, singleexposure onset distribution (fig. d ). it has no solid basis in statistics, but has sometimes been found to be useful in practice. the typical incubation periods for most foodborne and waterborne illnesses are readily available for comparison (e.g., control of communicable diseases manual, apha/cdc, ), and in this manual in tables b, c, d, and g. an incidence rate is the number of new cases of a specified disease reported during a given time period in relation to the size of the population being studied, multiplied by a constant, usually , to give percentages. thus new cases of e. coli o :h infection among the residents of a children's summer camp in july is an incidence rate of ( / ) × or ( . ) × = . % for that month. if several people have left and their state of wellness is not known, their impact should be expressed in the form of the possible range of values around the known incidence rate within the two extremes whereby they may all be well or they may all be ill. thus, where six children who were at the camp had departed around the time of the outbreak and their health is unknown, the range could be from a possible ( / ) × (or . %) if all of the six had been well, up to ( / ) × (or . %) if all had been ill. note that the "missing" six are added to the denominator only when we speculate that none were ill, whereas they are added to the numerator and denominator if we speculate that they might all have been ill. in this example, the overall incidence rate would be reported as " %, with a possible range from . to . %." depending upon the situation, it is often necessary to identify exposures which may be related to the illness, and to calculate an incidence rate for each such exposure. for example, in the summer camp illustration (above) it might be useful to enquire if gender, age, location, or some other attribute or activity increased the risk of becoming ill. this should not be interpreted automatically as implying that a given exposure would be associated with the outcome in any situation. by hypothesizing that gender was linked to the risk of illness, for example, does not imply that males are more vulnerable to the illness (the outcome) than females, but it can indicate that gender may have been related to the exposure, which in turn increased the risk. as an illustration, suppose that boys at the camp had been swimming, while the girls had gone on a nature walk. the boys may subsequently show increased incidence rate for e. coli o infection, not because they are more susceptible, but because of their activity. every proportion or percentage statement should be made with clear reference to the appropriate denominator used. incidence rates of waterborne illnesses are usually similar for both sexes at any given age group in the population, but differences in activities or dietary habits or susceptibility due to age or underlying health status can change the risk. the very young, the elderly and the immunocompromised can be at more susceptible, while in some instances, previously exposed populations may have developed a measure of immunity to an infection that may still cause more serious illness among visitors. a further complication arises where the "at-risk" population (perhaps residents at an institution, summer camp, or on a cruise ship) have generally consumed all the food and water for the extended period. careful interviewing of affected persons often uncovers one or more persons who entered the subject community shortly before becoming ill or who visited the community for a short time and became ill after leaving it. example: the south-west part of the county is served by three semi-private water systems. thirty cases of waterborne illness are being investigated in the area. when the numbers of cases are displayed for each water system, no clear grouping or clustering is evident, although the delta supply appears associated with about % more cases than the other two (table a) . however, when the analysis introduces the total population of persons who depend upon each water system (as denominators), a different scenario emerges. the incidence rates (expressed here as percentages) now allow a meaningful comparison (table b ). we can see that persons using the bravo system have roughly five times the risk of illness compared to people who are served by the other two systems. the use of the denominator is vital for most calculations. caution: numerous other factors may also explain the outbreak and these should be carefully examined. for example, the households using the bravo supply may be closer to an unhygienic corner store, drink from a cross-connected public water fountain, or their children may swim in a more polluted pond than the other communities. potential sources such as these should be eliminated before the water supply is announced as the source of the illness. sometimes a spot map may be useful in showing the location of the residence of each case, while on a larger scale, the rates of illness can be shown using city blocks, census tracts, townships, or other subdivisions. different colors or symbols to indicate cases with different time of onset periods (such as weeks) may help to support a hypothesis as to where contamination was introduced, inasmuch as the earliest cases tend to cluster around the point where contamination first occurred. the weakness of this procedure is that if the exposure had been at a restaurant, workplace, or school, plotting the relationship to the location of the home would not be useful. the investigation of waterborne or foodborne disease outbreaks invariably commences after both exposure and illness have happened. this is the classical "casecontrol" study, where a group of ill people ("cases") and a group of non-ill people ("controls") are compared in terms of their exposures. to measure the association between exposure and illness, the data are typically displayed in a × contingency table. table compares cases and controls in terms of their exposure to a suspected factor "x." the table is ready for analysis using odds ratio, as well as the chi-square or the fisher's exact tests where appropriate. one × table will be used for each possible exposure (e.g., each beverage, food, or other material). as many cases as can be identified and contacted, and as many non-ill people (controls) as can be found, should be interviewed as quickly as possible about their exposures to each suspect item. fading memories, the chance of obtaining stillavailable samples of implicated food or water, and the opportunity to obtain fecal specimens before the patient is started on the ubiquitous broad-spectrum antibiotics are all reasons for rapid response. case and control numbers do not have to be the same; the calculations compare ratios so equal numbers in each group are not needed. generally a : to : ratio of cases to controls is perfectly adequate. as interview data from cases and controls are accumulated, leading to formation of hypotheses about the source of the illness, human resources should be deployed in two additional essential tasks: ( ) tracking down and confirming the hypothesized source of the illness, and ( ) promptly issuing warnings to all affected groups about the possible risks from any source that is still accessible, with assurances that further bulletins will be issued as soon as confirmation is received. this precautionary principle is a vital component of risk management in modern public health. waiting for absolute confirmation before releasing warnings and advisories should not be an option in the twentyfirst century. the principle holds that while false alarms can be quickly forgiven, further illness should be avoided at the highest priority. failure to heed this step has contributed to needless suffering and severe damage to reputation, trust and credibility. a case-control approach is necessary because unlike the data in table b , we rarely have full information about all the attendees, and therefore the true incidence/attack rate is not available. very rarely, when all cases and controls are available for interview, we would have the true incidence rates for ill and for not-ill persons and this would allow a "retrospective cohort study" to be carried out. under such circumstances, and using table as an illustration, we could state that of persons exposed to item x, persons ( . %) had become ill compared to ill of not exposed ( . %). where incubation times are longer than a day, there is increasing likelihood that only a small proportion of the non-ill people will be available for interview, and on many occasions, not even all the ill persons can be contacted. the point here is that the investigator is usually working with sub-sets of the true cases and controls. the controls in table and possibly even the cases may have been drawn from larger groups, and therefore we cannot state the incidence rate, for example, as: "… of exposed were ill," because the " " had been artificially assembled, and may not resemble the true incidence at all. we can, however, use exposure rates, for example: "…of ill persons, ( . %) had been exposed to x," and, "…of who were not-ill, only ( . %) had been exposed to x." the overwhelming majority of waterborne or foodborne illness investigations are run as "case-control" studies (or to be more accurate, "case-comparison" studies, as very little true "controlling" is accomplished during the selection of the comparison group). a broadcasted invitation to all who might have been exposed to come forward, typically results in few non-ill persons volunteering information, because nonaffected individuals believe they have little if anything to contribute. this reduces validity even further, and more active recruitment is often necessary to convince them that their information is just as essential for the investigation as are the contributions from the less-fortunate attendees. let us examine a waterborne illness suspected as being due to the consumption of water bottled from a certain spring. you have found people who meet the case definition of illness, and another non-ill people in same neighborhood who report no symptoms at all, and who will be your controls. in table we display the data and ask the question: "is drinking this water related to the risk of illness?" whenever a × table appears, the first step is to calculate the odds ratio (or). an odds ratio tells us if there is a relationship (where or ≠ ), and the strength of the relationship (the or value itself). it also clearly indicates the direction of the relationship: was drinking or not-drinking the dangerous activity? this is easily determined by finding the dominant pair from (a × d) or (b × c). in the example above, (a × d) is greater, so cell "a" links the row "drank" with the column "ill," while cell "d" links "not drink" with "not-ill." this assumption is not as obvious as it may seem; the cause of the illness may have been whatever "other" thing was drunk by those who avoided spring water! it is important to clarify that the odds ratio yields the strength of the association, not the statistical significance. most or values (where many exposures are being assessed) will be close to . (= "no association"), while an or clearly exceeding . signifies a positive association between this exposure and illness, such that this exposure increased the risk of illness. an or < . is protective, meaning that exposure to this factor reduced the risk of illness compared to the other group. for example, an or of . means that the exposed group had only one-quarter the risk of illness compared to the non-exposed group. the non-exposed group therefore has a greater risk (by a factor of ). while this protective effect can be due to true therapeutic protection (e.g., exposure to antibiotics when you have an infection), it is frequently explained as "statistical" protection. as an example, consider an outbreak where everyone consumed only one of two possible types of bottled water. one source, a, contains a pathogen, and b does not. if the ill people were found to be five times more likely to have consumed type a (odds ratio = . ) then the not-ill would have five times the rate of consuming water b, and only one-fifth of the rate of choosing water a (or = . or %). this can also be read as the risk of illness for the non-exposed group, or as the risk of staying well by the exposed group. an easier way to interpret an or less than is to place over the or to reveal a value greater than , but clearly labeled "protective." the or is a ratio between numbers, and therefore not sensitive to the actual numbers of people in individual cells, an important consideration when the numbers of subjects are relatively small. this is illustrated by the common question: "how large does an odds ratio have to be before it is considered evidence of an association?" a popular response is "at least . ," but this must be considered with extreme caution. for instance, with very large studies, an or of . (barely more than . ) can be shown to be very highly significant statistically (p = . ), whereas in a small-n study, an or of even . may not achieve statistical significance. the odds ratio is certainly a useful measurement, and should always be used when a × table is encountered. it will quickly advise you ( ) that there is an association, ( ) the strength of that association, and ( ) the direction of the association, none of which are specifically measured by a test of statistical significance. unfortunately, it is not reliable with small cell sizes, and is unable to answer the question: "how likely is it that these numbers could happen just due to chance?" for this, we need to test the statistical significance. the best advice is to use the or (or relative risk where appropriate) together with a test of statistical significance. most online statistic calculators or laptop versions of sas, spss, epiinfo, etc. will give a selection of useful statistics (odds ratio, relative risk, several versions of chi-square, and fisher's exact test, both onetailed and two-tailed.) in keeping with all scientific enquiry, we begin by advancing the notion (the "null hypothesis") that there is no association between the exposure and the illness, and attempt to support that notion. if insufficient evidence is found to support the null hypothesis, we reject it and cautiously consider that an association may exist between the two variables. this can be described as a statistically significant association. two methods of testing are presented: the chi-square test (written χ and pronounced "ky"-square) for most × (or larger) tables, and the fisher's exact test (only for × tables) when chi-square is not valid due to the numbers in the cells being too small (the following sections give advice about this decision). the original data value in each cell we call the observed, or "o" value, and these are compared with the numbers that you would expect ("e" values) if there were no relationship at all; that is, if the variables were not related, and the data were arranged purely by chance (as stated by the null hypothesis). the chi-square test measures the difference between the o and e values. if they are close, we have to accept that there may be no real relationship; if far apart, we can reject the null hypothesis and cautiously declare that exposure and illness were probably related. numerous online statistical calculators can be used to yield ors, rrs, and chisquare values. if you prefer to do the calculation by hand, construct a × table as shown, with "observed" data, marginal totals, and the grand total. the expected "e" values are found from: to make sure the chi-square analysis is appropriate for your table, you must be sure that all "e" numbers are more than . the quickest way is to first calculate for the cell with the smallest e value; (this will be the cell with the smaller column total and the smaller row total.) in table , the smallest e value will be cell "d," and this is calculated as ( × )/ = . . as this is > , all other e values will be greater than this, so chi-sq. is valid. (note that the smallest e value did not coincide with the smallest o value). . for all four cells the sum (χ ) is: . + . + . + . = . an online statistical calculator will give you this same chi-square (χ ) value. to verify by hand whether the o vs. e difference is statistically significant, compare your chi-sq. value (for a × table only) with . . if your calculated value exceeds . , then this is unlikely to be due to chance, and thus you can begin to believe that this exposure did influence the risk of illness, and you can reject the null hypothesis. statistical results usually include a probability (p) statement. this is the probability that the null hypothesis ("no association") is correct. the . value is the minimum needed for statistical significance, where the p is less than % (p < . ). recall that the p is the probability that no real association exists between exposure and illness. by convention, if p > . (more than %) then the relationship is declared not statistically significant. where p = . or < . , then the relationship is statistically significant. the smaller the p value, (p < . , p < . , etc.) the more confidence you have that a relationship really exists. other critical values exist for assessing calculated chi-sq. values, from larger tables than × , and at more extreme levels of significance. a further chi-square calculation is shown as an appendix. where a table greater than × is found to have more than % of the cells with an e value less than , chi-square is not valid. the solution is to collapse either columns or rows to allow the e values to increase. for example in table a , two cells out of six ( %) have e values less than , but if "high dose" is merged with "medium dose" the resulting increase in observed (o) cell sizes is also reflected in greater e values, while the table becomes × (table b) . some outcome information has been lost, but the chi-square analysis can proceed. if, after trying to collapse cells and/or rows, a × table is reached still with an e value < , the fisher's test is indicated. this procedure is reserved only for × tables where one or more expected (e) values is less than , making the chi-square test not valid. our example is taken from an investigation into an outbreak of shigellosis presumed to be due to water from a well ( table ). the odds ratio has been calculated as ( × )/( × ) = . , meaning ill persons were six times as likely to have drunk well water compared to non-ill the "!" denotes a factorial, meaning that number multiplied by the next smallest number, and so on down to . (e.g.: ! = ) p persons. an attempt to use chi-square is prevented by at least one e value less than of . (cells c and d both show e values as ( × )/ = . ). the starting null hypothesis is "that no relationship exists." this is not quite the end of the calculation however. the goal is to calculate the probability of the original data occurring plus all more extreme probabilities. the original data have to be adjusted by increasing the "dominant" pair of cells by + and the others by − , while leaving the margin totals the same (table ) . because no zero has yet appeared in the matrix of cells, we continue to increase the "dominant" pair by + and obtain a zero. the next calculation is the last. (by convention, ! and ! = ) (table ) . no reference table is required. the total calculated probability ( . ) is exactly the probability that the null hypothesis ("that there was no relationship"), is correct: . %. by convention, for a result to be significant statistically, that probability (p) must be less than % (< . ), so in this instance we are not able to reject the null hypothesis and must conclude that the relationship could have occurred by chance alone more than % of the time. the odds ratio of . is explained as the number of times more likely it was for a shigellosis victim to have drunk well water than for a non-ill person. this increased risk would normally be impressive, but because of the small number of persons in the study, it has been found not to pass the test of statistical significance. a basic write up of the results might read: "a relationship exists between drinking well water and developing shigellosis. a shigellosis patient is six times more likely to have drunk water from the well compared to a non-ill person. this relationship is not statistically significant, however, and could have occurred by chance alone more than % of the time. the null hypothesis of no-relationship cannot be rejected." [ df, p > . , or: . , not statistically significant.] with the odds ratio (or) calculated for all the suspected exposures, and the chisquare test or fisher's exact test calculated for the strongest of these, all the results can be displayed in a composite table. earlier protocols for the investigation of waterborne and foodborne diseases encouraged the use of the "factor-specific attack rate table" (for example the "foodspecific attack rate table"), but where only a "convenience sample" of controls and cases are available, we are unable to derive valid incidence/attack rates. investigators are discouraged from using it as it may produce misleading results. the exposurerate table for cases and controls is preferred in all case-control studies, and compares the rates of exposure to each factor between both the ill and non-ill people. table displays six exposure factors from a hypothetical outbreak involving water contamination. exposure rates are calculated from both cases and controls. the "spring-water" data that we used for the odds ratio calculation example in table appears as the first exposure in table . the column headed "differences in exposure rates" subtracts the exposure rate among the non-ill from the exposure rate among the ill. [use: exp. rate (cases) minus exp. rate (controls), keeping the signs correct]. you are looking for a large positive difference to indicate the most likely culprit. the spring water shows the largest positive difference at + %. the odds ratio of . supports this, again the largest value, indicating that ill persons were times more likely to have drunk the spring water compared to non-ill persons in this group. hence both the large positive difference in exposure rates and the large odds ratio point to the spring water being the likely source of the illness, and it is certainly the strongest association between illness and any of the exposures shown. the chi-square value has also been added ( . ), as well as the associated p value. taken together, the evidence clearly points to this factor as the culprit. in those less-common circumstances in which all the ill and non-ill persons can be contacted for interview, the table can be rearranged to show attack rates (incidence rates) for each of the suspect factors (table ) . here, the column of "differences" shows the attack rate (exposed) minus the attack rate (non-exposed), (i e − i n ), and again a large positive difference will point to the culprit. this measure is called the attributable risk and for the spring water example we obtain + %, the largest value of all the risk factors. also, because of the availability of valid attack rates (incidence rates), the true relative risk (rr) is available, and can be substituted the p (probability) value is a statement of statistical significance. it indicates the probability that there is no relationship between the factor and the illness. so as the number becomes very small (as shown here) we can be increasingly satisfied that a real relationship does exist. see the statistical significance section for the correct way to calculate this ns = not significant the ("true") relative risk (also called the risk ratio) is only used when we have the true incidence data. it is calculated as the attack rate (exposed) over the attack rate (non-exposed), or i the p (probability) value is a statement of statistical significance. it indicates the probability that there is no relationship between the factor and the illness. so as the number becomes very small (as shown here) we can be increasingly satisfied that a real relationship does exist. see the statistical significance section for the correct way to calculate this ns = not significant for the odds ratio. the data in table shows the same data as table rearranged for easy comparison. values in the column of "differences" are not the same as for table and of course the relative risks are not the same as the odds ratios in table , but both of these results still point clearly to the suspect exposure. in both analyses, spring water is clearly the factor most strongly associated with illness. it is important to note that in both tables a high rate (exposure-or attack-) on the left side taken by itself is meaningless until it is compared with the rate from the right side of the table. this again underscores the importance of gathering complete data from the non-ill as well as the ill. an interesting phenomenon is visible in the second factor listed (soft drink). the or is listed as . , which is "protective," meaning that this factor is strongly associated with not being ill. it is the equivalent of or equal to . ( / . ), and the chi-square is seen as quite large, although not enough for statistical significance. this is sometimes seen where two factors are "in competition" with each other; if everyone had drunk one item, and the spring water was the contaminated source, then those drinking the other item would be strongly "protected" because they did not drink the spring water, and this shows clearly. all other factors have or values very close to . . most attack rate tables record some persons who did not ingest the suspect vehicle but who nevertheless became ill. plausible explanations are that (a) some people forget which beverages or foods they ingested; (b) some might have become ill from other causes; or (c) some may have exhibited symptoms with a psychosomatic rather than a physiological origin. it is also not unusual for the table to include some persons who ingested contaminated water or food but did not become ill. plausible explanations are that (a) organisms or toxins are not always evenly distributed in water or food and consequently some persons ingest small doses or perhaps none at all; (b) some persons eat or drink larger quantities than others; (c) some are more resistant to illness than others, and (d) some will not admit that they became ill, or fail to report it. whichever table is used, the combined totals for cases (ill) and controls (well) are fixed and should not change for each exposure unless there are "missing" responses from interviewees. while some procedure manuals include confidence limits around both rr and or, this may be omitted here as the use of the chi-square test or fishers exact test yield the statistical significance for both tables. illness caused by ingestion of waterborne toxicants and some pathogenic organisms can be dose-related in that the risk of developing symptoms, and their severity varies with the quantity ingested. where the suspect water is no longer available (for example, the well may have been quickly super-chlorinated to break the chain of infection before samples were taken), attack rates can be based on the amount of water usually drunk per day by each person. this is easily extended to other non-treated sources of water such as ice cubes, water-reconstituted fruit juices, and flavored crystals. a comparison of attack rates at various water intake levels may provide valuable evidence that water is, or is not, the vehicle responsible for the outbreak. for an example, see table . here, the entire group was people and we have interviewed them all, so we are justified in calculating the attack/incidence rates: in this example, the attack rate increased as the consumption of water increased, which suggests that the illness was directly related to water and the agent it contained. this is a trend established from the group as a whole, and an individual's experience may vary with factors such as (a) preferences of water ingestion, (b) intermittent contamination, (c) unequal distribution of the contaminant, or (d) varying susceptibility of individuals. these data can be compared with rates from persons who ingested no water, but only hot tea, hot coffee, soups, and/or other safe sources of liquids. if unheated water was indeed the vehicle, and the agent was a living biological agent, these persons should have attack rates showing no increase in risk of illness. (outbreaks from a toxic agent may be unaffected by chlorination, boiling, and some types of filtering.) the data can be displayed in a contingency table as follows for analysis using chi-square procedure (table ) . for this example, chi-square equals . and if calculated by computer or online, p will be shown as p = . . reference to form j confirms that for a × table ( df), the calculated chi-square ( . ) exceeds the critical value for statistical significance at the . level ( . ), allowing us to claim statistical significance at p < . . odds ratios are normally associated only with × tables, but here, the or can usefully be calculated on selective cells or groups of cells as long as you clearly explain the selection process. for instance, persons who were ill were . times more likely to have drunk three or more glasses of water per day compared to those who were well. for this calculation we collapse cells into a × table and crossmultiply: (a + c) × (f + h)/(b + d) × (e + g) = ( ) × ( )/( ) × ( ) = / = . . alternatively, because we have all people involved, we can compare the attack rates (ar) for each intake level, and observe the increasing attack rate as the intake increases: for five or more glasses/day, ar: %, for - /day, ar: %, for - / day, ar: %, and for < /day, ar: %. we might summarize as follows: "there was a relationship observed between the quantity of water consumed each day and the risk of illness. the incidence rate increased with the quantity consumed from % for < glasses/day to % for five or more glasses/day. this relationship is statistically significant. the null hypothesis of no association can be rejected." , df, p < . ] water as a vehicle can deliver pathogenic organisms in many ways beyond simply drinking a glass of water, or using a drinking fountain. investigators should be sure to ask about the preparation of ice-cubes, the mixing of fruit flavored crystal drinks, reconstituting concentrated orange juice, brushing and rinsing teeth, and washing hands, utensils, or containers. swimming or playing in muddy pools or even swimming pools have caused waterborne poliomyelitis, and naegleriasis, while swimming in saltwater inlets have allowed inadvertent infections from vibrio parahaemolyticus and v. vulnificus. unwashed plastic jugs containing poster paint residue have caused rapid illness when drink crystals are reconstituted in them, while refillable plastic containers and bottles have a long history of contamination from biological and chemical agents. in the late s, an increase of viral ear, nose, and throat infections among people who were using parkland next to a river was hypothesized to have been due to people waterskiing on the river and creating an aerosol. the river was the receiving body for effluent from a water treatment plant upstream. record all laboratory results on form i, laboratory results summary. compare epidemiological and statistical results with on-site observations, laboratory results and the information summarized on form i. the agent responsible for the outbreak can be determined by (a) isolating and identifying pathogenic microorganisms from patients, (b) identifying the same strain and/or pfge pattern or genetic sequence of pathogen in specimens from several patients, (c) finding toxic substances or substances indicative of pathological responses in specimens, or (d) demonstrating increased antibody titer in sera from patients whose clinical features are consistent with those known to be produced by the agent. when implicating the water as a likely (or presumptive) vehicle of transmission, ideally identification of a pathogen in samples of suspect water will correspond to the one found in clinical specimens from ill persons or that produces an illness that is compatible with the incubation period and clinical features of the ill who were exposed to the water. for organisms that are common in the gastrointestinal tract or that have multiple strains, compare strains isolated from ill persons with strains isolated from the suspected water. additionally, specific microbial markers (e.g., serotype, phage type, immunoblotting, plasmid analysis, antibiotic resistance patterns, restriction endonuclease analysis, nucleotide sequence analysis) or chemical markers identified by chromatography or spectrophotometry can be used for this purpose. for confirmation of water-related transmission, the same pathogen strains should be found in both the ill persons and the epidemiologically implicated water. however, due to the period of time that may have passed after the outbreak was actually reported, and to methodological issues, such as the need for concentrating pathogens in water samples, it is often unlikely that the outbreak-associated pathogen will be found in the water samples. laboratories frequently test water samples for indicator organisms, such as fecal coliforms, escherichia coli, or enterococci, rather than pathogens. the finding of these bacteria in high densities in the water may indicate contamination (from a fecal source) and implicate the water was a possible vehicle. however, the finding of increased indicators in water samples alone is insufficient evidence to confirm the water as the source of an outbreak. the probable source of contamination or the situation that allowed contamination to reach and survive in a water supply (e.g., water supply not disinfected or inadequately disinfected, inadequately filtered, or upstream to sewage or agricultural discharges; cross connection between sewerage and drinking water pipes; well improperly constructed; nearby septic tank system; or livestock in water supply) can often be identified, but the etiologic agent in the water may never be found. success in finding the etiologic agent is most likely where (a) the incubation period of the illness is short, (b) the agent is stable in water and the system is static, or (c) large amounts of the agent are being continually added to the water supply. try to recover and identify the specific agent whenever a water supply is suspected to be the vehicle of transmission, even if finding the etiologic agent is likely to be difficult and not considered practical for routine monitoring of water supplies. if water samples do not reveal a likely causal agent, clinical data as well as time, place, and person associations can cast strong suspicion on a water supply, particularly if indicator organisms are found in the water. tests other than those for pathogens, however, are frequently used to evaluate water supplies on a routine basis. organoleptic tests attempt to evaluate the total effect of all compounds present in water that can be measured by the senses of taste, smell, or sight. results cannot be expressed in terms of specific compounds present, and the measured qualities are usually a result of a mixture of compounds. these tests are often empirical and arbitrary, but changes in the physical qualities of water (such as ph, turbidity, color, odor, or taste) can indicate abnormalities of the water. outbreaks have occurred, however, when turbidity readings have met present standards and when water appeared and tasted good. chemical examination of water is useful for (a) detecting pollution (especially from industrial wastes and pesticides), (b) determining effectiveness of treatment processes, (c) evaluating the previous history of the water, (d) determining hardness, and (e) detecting the presence of specific toxins. results are usually expressed in milligrams per liter (mg/l = ppm, parts per million), or micrograms per liter (μg/l = ppb, parts per billion). historically, acute water-related outbreaks seldom involve chemical substances, so chemical tests are not requested routinely unless either (a) circumstances indicate possible chemical contamination or (b) clinical symptoms suggest chemical poisoning. flowing water in a distribution system can be monitored to determine chlorine residual. free available residual chlorine refers to that portion of the total residual chlorine remaining in chlorinated water at the end of a specific contact period that will react chemically and biologically as hypochlorous acid or hypochlorite ion. the reaction is influenced by ph and temperature. total or combined residual chlorine refers to chlorine that has reacted with ammonia or other substances and is not available for further reactions, as well as the free available chlorine. a chlorine demand exists in a chlorinated water until a free available residual is produced. a free available chlorine residual, e.g., mg/l ( ppm) or higher, maintained throughout the distribution system of a community supply is an indicator of safety from enteric bacteria but not necessarily from pseudomonads, viruses or parasites. outbreaks have occurred when chlorine residue levels have met present standards. analyses for microbial indicator organisms provide information on the microbiological quality of water and guidance as to its safety for consumption or contact. indicator organisms are easier to test for than pathogenic organisms, and some serve as a surrogate measure of fecal contamination in water. the absence of indicator organisms in the water, however, does not guarantee water safety; numerous outbreaks of water-related disease have occurred from water in which no indicator organisms were detected. evaluation of the safety of water should be based upon a combination of results of (a) an on-site study to identify sources and modes of contamination and means by which contaminants survived treatment and (b) appropriate laboratory analyses. microbiological results should be compatible with observed sources of contamination and/or treatment failures found during the investigation. although all natural waters contain bacteria, the number and kind vary greatly in different places and under different climatic and environmental conditions. the number of bacteria isolated and reported, however, often represents only a fraction of the total number present, for several reasons. colonies seen on agar plates develop from either single organisms or clusters or chains of organisms. heterotrophic bacteria represent only those that can use organic matter and grow at the selected temperature ( - °c) within - hours under aerobic/microaerophilic conditions in/on a defined medium when the standard test (spread plate, membrane filter or pour plate) is used. the hpc may also be done using different media under different incubation times/conditions. (higher counts are usually found when the longer incubation periods are used.) also, certain microorganisms are unable to grow aerobically either in or on the medium used. because of these variables, the terms total plate count (tpc), standard plate count (spc) and aerobic plate counts (apc) should not be used. hpcs serve as an index of changing sanitary conditions. in general, counts of good-quality well water are fewer than - colonies per ml. densities in surface water are higher, but quite variable, depending on water temperature, sources of pollution, amount of organic matter present, and soil that washes into the water. the sources of pathogens, toxic substances, or fecal contamination may not increase the hpc of a surface water sample as much as washings from soil. nevertheless, marked changes in the number or kind of microorganisms should be viewed with concern, at least until the reason for the change is discovered. heterotrophic plate counts greater than /ml and some specific antagonistic species may interfere with the growth or recovery of pathogenic or indicator organisms. some heterotrophic species are opportunistic pathogens that may pose a health threat to immunocompromised persons. the coliform group of bacteria comprises those from non-fecal environmental sources, and those from animal and human intestines, including escherichia coli. the environmental species of non-fecal bacteria are found in soil, on fruits, leaves, and grains, and in run-off water, especially after heavy rains. some of these species are capable of surviving in water longer than e. coli. furthermore, some coliform strains and can multiply on decaying vegetation in water, in biofilms in pipelines, or on pump packings, washers, and similar materials. therefore, finding coliforms may not be indicative of fecal contamination, although most water utilities have standards for coliforms in water. fecal coliforms are present in large densities in all human and animal feces, normally much higher than pathogens which are typically only present in infected persons and normally at lower levels. as such, high populations of fecal coliforms can indicate recent sewage pollution of water, but are not always indicative of pathogens present, particularly viruses and parasites. none of the coliform group, however persists as long as most viral or protozoan pathogens in water, and indicator bacteria described below (fecal streptococci and clostridium perfringens). typical chlorination or ozonation of water inactivates coliform bacteria. presence of the coliform group or even a high population of coliform bacteria is not proof that a treated water supply contains pathogens. however, coliforms can provide a warning that either the water treatment was inadequate or contamination occurred after treatment, and that some pathogens may be present. as mentioned above, under some conditions, pathogens may be present where there are few or no coliforms. furthermore, unlike coliforms, many parasites and viruses are resistant to normal levels of disinfectants. coliforms have little or no correlation with the presence of parasitic protozoa or pathogenic viruses. the standard test for the coliform group may be carried out by a membrane filtration technique, a multiple-tube fermentation technique (presumptive test, confirmed test, or completed test), or a presence-absence test. results of the membrane filtration technique are reported as colony forming units (cfu) per ml of water. results of the multiple-tube fermentation technique are reported as the most probable number (mpn) per ml of water. this is a statistical estimation of the total number present, but the actual number can fall within a considerable range. counts derived from these two methods are not necessarily the same, but they have the same sanitary significance. false-negative or false-positive results can also occur with the membrane filtration technique because of interfering background growth of nonfecal microorganisms. results of the presumptive test of the multiple-tube fermentation technique can be misleading, because other microorganisms frequently found in water also produce gas in laboratory media, and may thereby give false-positive results. also, especially in waters containing a large number of microorganisms, some coliforms present may produce gas slowly, leading to false-negative results. the presence of coliform bacteria is corroborated by means of the second phase of the multiple-tube fermentation technique, known as the confirmed test. positive results are usually considered confirmation of the presence of coliforms. a third phase of this test, known as a completed test, further ensures the correct identification of coliform bacteria. a simple modification of the coliform test is to analyze for the presence or absence of coliforms in a -ml drinking water sample. the "presence-absence (p/a) coliform test" allows for simple examination of a larger number of samples. when a positive sample is detected, it is advisable to measure coliform densities in repeat samples by one of the other methods to determine the magnitude of the contamination. thermotolerant coliform (fecal coliform). coliform bacteria will frequently grow at a relatively high temperature, . °c, unlike species or strains normally encountered in the environment, which usually have an optimal temperature near °c. this thermotolerant characteristic has been used in an attempt to separate coliform bacteria into those of so-called fecal and non-fecal origin. this test may provide better indication of fecal contamination than the coliform test, but it is however, unreliable. positive results are not proof that either organisms of fecal origin or pathogens are present. the number of thermotolerant coliforms is considerably lower than the number of total coliforms in contaminated water; therefore, the test is less sensitive for testing treated drinking water. furthermore, escherichia coli o :h , which has been implicated as causing water-related illness, does not grow well at . °c. escherichia coli. e. coli is common in feces of human beings, other mammals, and birds. it can also be found to grow naturally in the environment, specifically in tropical waters. comprised of the larger coliform group, its detection in water is a more definitive indicator of fecal contamination, compared to total or fecal coliforms. however, a positive test result does not identify if the fecal source is human or nonhuman. rather, the finding of e. coli in water serves as an indicator that fecal matter reached the water and provides a warning, but not proof, that pathogenic organisms may also be present. it should be noted that some strains of e. coli are pathogenic (see table b ). simple commercial p/a and quantitative tests have been developed to detect the presence of total coliforms and e. coli in hours by observing color changes and fluorescence of the media under daylight and uv light. such tests may be useful for field evaluation of microbiological water quality. another group of organisms, collectively known as fecal streptococci, is also used as an indicator of fecal contamination. enterococci (enterococcus faecalis, enterococcus faecium) are particularly used for testing recreational waters. like coliforms, enterococci are normal inhabitants of the intestinal tract of human beings and other animals. in human feces, they occur in considerably lower numbers than e. coli. some members of the group, such as e. faecalis, subsp. liquefaciens, however, have been associated with vegetation, insects, and certain types of soils. enterococci generally survive longer than coliforms in fresh water, and therefore the source of contamination may be distant in either time or place from the site where samples were obtained. their resistance is, however, less than that of clostridium perfringens, enteric viruses, and parasites. like e. coli, simple commercial p/a and quantitative tests have been developed to detect the presence of enterococci in hours by observing color changes under uv light, which may be useful for field evaluation of microbiological water quality. clostridium perfringens (sulfite reducing clostridia). c. perfringens is also of fecal origin, but it occurs in feces in much lower densities than e. coli and can also be found in soils. being a spore-former, it can survive for long durations in soil and water, and persist when all other bacteria of fecal origin have disappeared. therefore, it is a useful indicator of remote or intermittent contamination in wells that are not frequently examined by the coliform test; but, it is not, by itself, evidence of recent contamination. chlorine, in the concentration typically used in water treatment, does not inactivate all spores; and thus c. perfringens is not valuable in assessing the efficiency of chlorination for bacterial vegetative cells. its long persistence and its resistance to chlorine make this organism a potential indicator for viral and parasitic organisms that have similar resistance and disinfectant susceptibility. coliphage. coliphages, which are viruses that infect e. coli, are simpler to detect and enumerate, compared to other viruses, and are generally associated with fecal contamination. they have been considered as possible indicators of treatment effectiveness for human enteric viruses. coliphages are categorized into two groups: the somatic phages, which enter e. coli via the cell wall and the male-specific phages, which enter e. coli through the sex pili. the somatic and male-specific phages are common in sewage and the feces of human beings and other animals, but in lower densities than the common fecal indicator bacteria, fecal coliforms, e. coli, and enterococci. some strains appear to be more resistant to chemical disinfection than water-related pathogens or indicator bacteria. be aware of local standards for water distribution systems, private water systems, and recreational water. although drinking water standards, such as the total number of coliforms allowed in a water sample, vary from jurisdiction-to-jurisdiction, it is generally agreed that any fecal contamination (e.g. fecal coliforms, escherichia coli) render the water unacceptable for human consumption and may close down recreational bathing waters. there are numerous pathogens that can be transmitted by water, many of which are also able to cause respiratory symptoms, in addition to the classical gastrointestinal symptoms. for a comprehensive summary of waterborne pathogens see "american waterworks association manual of water supply practices, m waterborne pathogens, nd edition ( ) ." for several reasons, analyses for pathogens are not usually conducted during routine water testing, or are only conducted by specialized laboratories. first, tests for pathogens are pathogen-specific, expensive, and often difficult to perform because they may require specialized trained personnel. secondly, the etiologic agent of the outbreak is often unknown at the time of analysis; hence, many analyses would have to be done blindly. thirdly, pathogens are not always recovered because they are heterogeneously dispersed and diluted in the environment, and their numbers decline in water over time. as a result, they may be absent or present in low densities by the time samples are collected following an outbreak. fourthly, recovery efficiencies are often poor because microorganisms are stressed by disinfectants or the method is sensitive to interferences from the source waters environment, hence not easily recovered by routine methods. additionally, recovery efficiencies for viruses and protozoa may be poor because of the interferences of substances within the sample matrix with method reagents (concentrating l of water down to μl will also concentrate inhibitory chemicals and substances). finally, the time required for isolation and identification is often long, and the number of samples is usually too small to allow the investigator to have much statistical confidence in the results when pathogens are not found. negative results should be reported as "not detected" because they do not ensure that the water sampled was not the source of the pathogen. procedures used for many bacterial pathogens are qualitative because enrichment procedures are used. quantitative procedures (e.g., mpn) require considerable work and are less reliable than those used for coliforms because small populations may be present, and these may be unevenly distributed. despite these difficulties, pathogens that cause a syndrome similar to the one being investigated should be sought. see tables b, c, and d, for descriptions of the disease syndrome associated with the pathogens described in the following material. finding the same pathogen in specimens from patients and in water samples confirms water as a vehicle. summarize investigative data in a narrative report. describe in this report situations that led to contamination of the water and survival of etiologic agents up to the time of consumption. include all events that contributed to the outbreak to guide control and preventive measures. compare your data with the listings in table g (guidelines for confirmation of waterborne outbreaks) and table h (guidelines for confirmation of water responsible for illness), and criteria for confirmation of vehicle responsible for waterborne illness before assigning the etiologic agent and the vehicle. outbreak confirmation is based on (a) time, place, person associations, (b) recovery of etiologic agents from clinical specimens from cases and samples of water, and (c) identification of sources and modes of contamination and means by which pathogens or toxic substances survived treatment. all three of these, however, might not be found in any one investigation. complete form k (waterborne illness summary report). attach the narrative and the epidemic curve. also attach form d (case history summaries: water/laboratory data), all applicable parts of forms g, forms h, form i, and other data that will provide supplemental information to reviewers. send this report through administrative channels to the appropriate agency responsible for waterborne disease surveillance. make the final report as complete as possible, so that the agency can accurately interpret the results and develop a meaningful waterborne disease data bank. in the interest of continuing cooperation, give all participants in the investigation due credit and send each a copy of the report. also, send copies of the report through administrative channels to agencies (a) that have jurisdiction over the implicated water, (b) that initiated the alert, and (c) that participated in the investigation. those concerned with water sources, treatment and recreation, as well as with public health, should make every effort to ensure the complete investigation and reporting of waterborne diseases. without reliable, complete information, trends in waterborne disease incidence and causal factors of the disease are difficult to determine. good surveillance is essential for detecting and evaluating new waterborne disease hazards. the primary purposes of a waterborne disease investigation are to identify the cause, establish control measures, and take actions to prevent future illness. prudence may require some action before all the hypotheses regarding the water supply involved and the source of contamination are confirmed. frequently the local health authority will issue a boil water advisory if a microorganism is suspected to have contaminated the water. refer to "possible precautionary control actions" section for a discussion of these precautionary control measures. if these measures have not already been considered, consider them now. once control measures have been implemented, continue to monitor for disease to evaluate whether the measures were effective. in a waterborne event in sydney, australia (see box ) sydney water severely overestimated levels of cryptosporidium and giardia present in the water raising public alarm. boil water advisories were announced and rescinded several times. however, it is better to announce boil-water advisories than to have thousands ill, as has happened in the past, such as the cryptosporidium outbreak in milwaukee in . deficiencies in treatment must be corrected and defective parts of distribution systems must be repaired, beginning with those that either contributed to or had a high potential for contributing to the outbreak. the effectiveness of these efforts will be directly related to the thoroughness of the investigation. document the source and the manner of contamination and survival of the etiologic agent through the water treatment process. provide clear documentation of contributory factors, so that preventive measures taken will be specific to the problem. if previous sanitary surveys have revealed, or if subsequent ones reveal, that conditions which contributed to the outbreak are widespread, initiate a training and education program. these programs can be developed for water treatment plant or recreational water operators and employees, engineers, homeowners, or other appropriate groups. impress upon them the importance of proper construction and operation of facilities and proper protection, treatment, storage, and distribution of water. follow up with periodic inspections and surveys and verify by sampling, as appropriate, to determine whether faulty conditions have been corrected or allowed to be reintroduced. legal action may be necessary to ensure compliance with official standards and accepted sanitary practices. formulate solutions to problems found during outbreak investigations, and incorporate these into regulations for drinking, agricultural, industrial, domestic, and recreational waters. inform the public, through mass media and other means available to your agency, of hazardous conditions that can affect their water supply, but do so only after hypotheses are confirmed. the public must be told of any potential or actual harm that may result from ingesting or contacting contaminated water and must also be informed of measures that they can take and that official agencies are taking to correct these conditions. the water supply and recreational water facilities must be verified periodically to determine whether critical processes are being monitored and operated within limits of appropriate public health standards (see box , the walkerton outbreak). most waterborne illnesses are preventable, but prevention requires that those in the water treatment industry and in health and water-protection regulatory agencies be constantly vigilant to ensure that the hazards are understood and that questionable water treatment or delivery system construction or practices are avoided. examples investigation guidelines and investigative forms iafp manual, "procedures to investigate waterborne illness, rd ed"; copies of form c; one dozen copies each of forms e and f; two copies of form d and all parts of form g, epi-info software (cdc, atlanta). water sample bottles (bottles for chlorinated water should contain enough sodium thiosulfate to provide a concentration of mg of this compound per l of sample), plastic bags (whirl-pak ® type), ml, -l and -gal sized jars and jugs. sterile and wrapped sampling implements moore swabs (compact pads of gauze made from strips cm [ ft] by cm [ in.] tied in the center with a long, stout twine or wire-for sewer drain, stream or pipeline samples), fiberglass-epoxy bacterial filter cartridge, . μm; tongs, scoop or similar utensils for collecting ice. specimencollecting equipment (for human specimens from cases and controls) sterile containers (with lids) for stool specimens, bottles containing a bacterial preservative and transport medium, mailer tubes or styrofoam box, sterile swabs, rectal swab units, tubes of bacterial transport medium, stool preservative medium for parasites, phlebotomy supplies for blood specimens. kits for testing chemical disinfectants and ph dpd (n,n-diethyl-p-phenylenediamine) chlorine comparator with color disc for chlorine ( . ppm) and chlorine test papers; field-type ph meter or ph comparator with color disc or ph test papers; applicable ph indicator solutions and dpd reagent solution; dissolved oxygen testing unit. dye tracing study equipment fluorescein (yellow-green fluorescent) dye in powder form ( packages containing g each), in tablet form ( tablets), or in liquid form (prepared by mixing g in l of water); fluorometer; filters (primary and secondary) for use with fluorometer; sample holder for continuous sampling or individual sampling; fluorometer recorder. disinfectant and neutralizer . % w/v solution of calcium hypochlorite or . % household liquid bleach; % w/v sodium thiosulfate. virus filtration equipment for viruses and parasites b large plastic container for storing water sample prior to concentration; portable electric or gasoline powered water pump with quick disconnect brass or stainless steel plumbing adapters or hose couplings; two filter holders for -in. water filter cartridges fitted for adapters or couplings; portable water meter fitted for adapters or couplings; four lengths of fiber-reinforced garden hose fitted with adapters or couplings; one length of a strong-walled supply hose fitted with adapters or couplings; -in. prefilter ( μm nominal porosity wound polypropylene yarn filter with hollow perforated stainless steel core) cartridge filter; -in. virus absorbing filter pleated . μm porosity nylon membrane type (positively charged) for waters of ph values up to . , or pleated . μm porosity glass fiber membrane type (positively charged) for waters of ph value of . or lower (e.g., virosorb, -mds, amf/cuno meriden, pleated, . μm, glass filter); ml sterile, ph , % beef extract solution in gal wide-mouth screw capped autoclavable polypropylene container for each sample to be collected; stands to support filter holders during filtration; for parasites -in. polypropylene yarn-wound cartridge filter, . μm porosity (e.g., micro wynd ii™, amf/cuno; meriden, ct. . μm normal porosity). (continued) laptop or tablet, with software; thermocouples of varying lengths with either recording potentiometer, data logger, or digital indicator; devices to take samples below surface and sediment samples; chemical smoke kit and/ or micromanometer; occupational safety and health administration (osha) or equivalent approved respirator; sterile plastic gloves; plastic container liners for ice; waterproof marking pens; waterproof test tube rack; pencils, note pad; roll of adhesive or masking tape; labels; waterproof cardboard tags with eyelets and wire ties; flashlight; matches; test tube rack to fit tubes used; insulated chest or styrofoam container; packing material; camera with flash; spare batteries for all equipment; % ethyl alcohol; propane torch; refrigerant in plastic bags, liquid in cans, rubber or heavy plastic bags that can be filled with water and frozen; heavy-duty bags for ice, "canned ice," or cold-packs (blue ice). a assemble a kit to be kept in the agency responsible for investigating waterborne illness. it should include at least ten water sample bottles; ten -l, or gal jars or jugs; ten specimen collection containers or devices; and one each of the following supporting equipment and sterilizing equipment. date of sterilization should be marked. periodic resterilization or replacement of sterile supplies, media, or transport media is required to maintain the kit in a ready-to-use condition b similar equipment for sampling for either viruses or parasites may be available from national water, environmental, or health agencies how much to collect two rectal swabs or swabs of fresh stool from ten ill persons; samples from ten controls also can be submitted. whole stool is preferred if nonbacterial stool testing considered a fresh stool sample from ten ill persons; samples from ten controls can also be submitted. to enhanced detection, three stool specimens per patient can be collected > h apart as much stool sample as possible from ten ill persons (a minimum of ml of stool sample from each); samples also can be obtained from ten controls. a fresh urine sample ( ml) from ten ill persons; samples from ten controls also can be submitted. label each specimen in a waterproof manner and put the samples in sealed, waterproof containers (i.e., plastic bags). batch the collection and send in overnight mail to arrive at the testing laboratory on a weekday during business hours unless other arrangements have been made in advance with the testing laboratory. contact the testing laboratory before shipping, and give the testing laboratory as much advance notice as possible so that testing can begin as soon as samples arrive. when etiology is unclear and syndrome is nonspecific, all four types of specimens may be appropriate to collect c for more detailed instructions on how to collect specimens for specific parasites, please go to http://www.cdc.gov and search the website of key words d for more detailed instructions on how to collect specimens for viral testing, please go to http://www.cdc.gov and search the website of key words e the containers have been tested for the presence of the chemical of interest prior to use f unused specimen collection containers that have been brought in to the field and subjected to the same field conditions as the used containers. these containers are then tested for trace amounts of the chemical of interest table e (continued) isolation of agent from ill persons and from water and laboratory criteria for confirming etiologic agent as stated in table g . combination of on-site investigation, statistical evidence and laboratory analysis. (see entries below) presumptive vehicle on-site investigation demonstrating source and mode of contamination of water and survival of etiologic agent in water. also, desirable to have laboratory isolations from water of etiologic agent that causes syndrome similar to that observed during the investigation and other supportive epidemiologic data. if so, this might provide sufficient evidence for confirmation. or p-value for water < . when other epidemiologic data supports water hypothesis. also, desirable to have either laboratory isolations from water or on-site investigation that demonstrates source and mode of contamination and survival of treatment that supports the hypothesis. if so, this might provide sufficient evidence for confirmation. or odds ratio or relative risk for water greater than and the lower limit of the % confidence level greater than when other epidemiologic data supports the water vehicle hypothesis. also, desirable to have either laboratory isolations from water or on-site investigation that demonstrates source and mode of contamination and survival of treatment that supports the hypothesis. if so, this might provide sufficient evidence for confirmation. for calculation of data when all persons who may have been exposed to the suspect vehicle (but not all persons will have ingested every beverage/food) have been identified and interviewed (retrospective cohort) form j : chi-sq. analysis can be easily completed using on-line calculators or statistics programs such as epi-info. however, to confirm the result or to do the whole thing yourself, here are the steps: ill well totals step : create a x table as shown with observed data (o values) and marginal totals step : calculate odds ratio: (axd)/(bxc) = ( x )/( x )= . step . . chi-sq. (all four cells) = . + . + . + . = . step : compare your calculated chi-sq. value with the critical value to determine significance (table ) : begin at column p < . … your calculated chi-square value must meet or exceed the critical value to be considered statistically significant at that level. if you fail to meet or exceed the minimal value for p < . , the result is p > . , and the relationship is declared "not significant". step : summarize: exposure was related to illness. ill persons were eight times more likely to have been exposed to this factor than non-ill persons. this relationship is statistically significant. the probability of these data occurring by chance alone is less than . %. reject the null hypothesis of "no association." [odds ratio: . , % cl: . < or < . , chi-sq.: . , df, p < . ] form j : fisher's exact test can be easily completed using on-line calculators or statistics programs such as epi-info. however, to confirm the result or to do the whole thing yourself, here are the steps. ill well totals step step : calculate the probability directly... here, cell 'a' has smallest e value at . p = ! x ! x ! x ! = . ! x ! x ! x ! x ! step : the final probability (p) is the sum of all probabilities (in this case p + p + p ) or approximately . . step : summarize: exposure was related to illness. ill people were almost times more likely to have been exposed to this factor compared to non-ill people. the relationship is statistically significant. the probability of these data occurring by chance alone is less than . % (< . ). reject null hypothesis of "no association". [odds ratio: . , % cl: . < or < . , p = . ]. . when deciding which cells to increase by + , always multiply (a) × (d) and compare with (b) × (c). increase each cell of the pair with the higher product and decrease each cell of the pair with the smaller product, while keeping all marginal totals unchanged. . the final p is an "exact" p (probability) and may be reported as such (p = . ). in this example, it is also < . of course, and can be reported in this way if preferred. . the fisher's test is used when the chi-square test is invalid due to any "e" values < in a × table. in all other circumstances, chi-sq. is an excellent approximation for the fe test. . if original data include a zero in one of the cells, you will calculate only one p value. (the o.r. will be reported as "undefinable" but the direction of the effect will be very clear). . this p is calculated for a one-tailed fe test. it is adequate for this application. two-tailed fe test will require further calculation. . should a relationship not meet the critical value for significance (that is, p > . ), it is described as "not statistically significant". note that a relationship may be observed, but this result is telling you that it could have occurred by chance alone more than % of time if you were to repeat the analysis. that may still require further investigation, but from a statistical standpoint, it cannot be claimed as a statistically significant relationship. water treatment plant design, fifth edition american waterworks association. manual of water supply practices, m waterborne pathogens, second edition the flint water crisis confirms that u.s. drinking water needs improved risk management produce safety-what's going on here? national environmental health association neha-cert ep global health -division of parasitic diseases and malaria page last reviewed surveillance reports for recreational water-associated disease & outbreaks. page last reviewed on internalization and dissemination of human norovirus and animal caliciviruses in hydroponically grown romaine lettuce environmental protection agency technical guidance manual lt eswtr disinfection profiling and benchmarking environmental protection agency guidance manual for the compliance with filtration and disinfection requirements public water systems using surface water sources environmental protection agency. manual of individual and non-public water supply systems. epa no. epa no. water treatment manual: disinfection. environmental protection agency health canada risk analysis of the walkerton drinking water crisis algal bloom-associated disease outbreaks among users of freshwater lakes-us microbial resistance to disinfectants: mechanisms and significance. environ health perspect safe drinking water: lessons from recent outbreaks in affluent nations risk management for assuring safe drinking water ensuring safe drinking water: learning from frontline experience with contamination. american water works association cyanotoxin management and human health risk mitigation in recreational waters a massive outbreak in milwaukee of cryptosporidium infection transmitted through the public water supply private water supplies: technical manual good practice guide to the operation of drinking water supply systems for the management of microbial risk: research project two cases of keratosis follicularis squamosa (dohi) caused by swimsuit friction part two report of the walkerton inquiry: a strategy for safe drinking water public health inspector's guide to the principles and practices of environmental microbiology acute otitis externa: an update collect representative distribution system samples guidance on water supply and sanitation in extreme weather events. who regional office for europe effect of irrigation method on transmission to and persistence of escherichia coli o :h on lettuce transmission of escherichia coli o :h from contaminated manure and irrigation water to lettuce plant tissue and its subsequent internalization acknowledgments the committee and association thank and cite the following persons for chloramines refer to all forms of chloramine. the ct values may be assumed to achieve greater than . % inactivation of viruses only if chlorine is added and mixed in the water before addition of ammonia. if this condition is not met, the system must demonstrate by on-site studies or other information that it is achieving at least this much inactivation of viruses key: cord- - y yxlb authors: teles, pedro title: predicting the evolution of sars-covid- in portugal using an adapted sir model previously used in south korea for the mers outbreak date: - - journal: nan doi: nan sha: doc_id: cord_uid: y yxlb the new coronavirus covid- has spread very quickly worldwide, leading the world health organization (who) to declare a state of pandemic. one of the questions many policy makers, and governments are asking themselves is how the spread is going to evolve in time. in this study, i applied an adapted sir model previously used in south korea to model the mers outbreak, which is also caused by a coronavirus, to estimate the evolution of the curve of active cases in the case of the portuguese situation, using italian dara. i then construct five different scenarios for the evolution of covid- in portugal. in the out of control scenario, the number of active cases could reach as much as ~ , people on the th of april (out-of-control scenario). if the self-protective and control are taken in the same level as what was considered for the south korean model, this number could have be reduced to about cases (scenario ). considering that this scenario is now unrealistic, three other scenarios were devised. in all these scenarios, the government measures had a % effectiveness when compared to the measures in korea. but in scenario the transmission rate $beta$ was effectively reduced to %, in this scenario active cases could reach circa , people. in scenario , the transmission rate $beta$ was reduced to % of its initial value, in which the number of cases would reach a peak of ~ , people. and finally in scenario , $beta$ was reduced to %. in this scenario, the peak would be reached at about ~ , cases. this study shows the importance of control and self-protecting measure to bring down the number of affected people by following the recommendations of the who and health authorities. with the appropriate measures, this number can be brought down to ~ , - , people. hopefully that will be the case not just in portugal, but in the rest of the world. there is already abundant information on the new coronavirus and its spread worldwide [ , , ] , as well as the risks it poses to the population. the person infected with the severe acute respiratory syndrome coronavirus (sars-cov- ) [ ] may develop the disease called covid- , which manifests with mild to severe symptoms of fever, cough, shortness of breath and other signs [ ] . in the most severe cases, the infection can lead to the development of acute respiratory distress syndrome (ards) causing respiratory failure, septic shock, or multi-organ failure, and even death [ ] . there is yet a lot about this new coronavirus that is still unknown. studies suggest that the case fatality rate of the virus is of about . % in mainland china, but the authors suggest considering the range . - . % [ ] . however, this value seems to be much higher in italy [ ] , suggesting its strong dependence on demographics. in fact, the chinese center for disease control, released an analysis that showed that the case fatality rate ranged from % in children aged - years old to . % in those over [ ] , which implies that countries with a high number of elderly citizens, as is the case of italy and portugal, are more prone to having higher death rates. the quick spread of the virus in europe has led the who to declare europe as the new epicentre of the disease on the th of march of [ ] . the rapid growth of the number of active cases presenting severe symptoms has saturated the health services in most countries in the continent, especially in italy [ ] . it is yet unknown when the epidemic will reach an end, but governments throughout europe have implemented harsh measures to prevent and mitigate the spread of the virus. yet, as of today there are as many as , confirmed cases on the european continent, in territories, resulting in , deaths, and rising [ , ] . in portugal, the two first confirmed cases in the portuguese territory were announced on the nd of march, which puts the country slightly behind the curve in the outbreak in the european continent. as of today, there are confirmed cases, deaths, and recovered [ ] . also, the country is on lockdown since the th of march , and the portuguese parliament declared a state of emergency on the th of march . one of the questions many policy makers, and governments are asking themselves is how the spread is going to evolve in time. a timely idea of the amount of cases that will exist in a near future can allow governments and policy makers to act accordingly. in this study, i adapted a model of the sir type used in south-korea to model the evolution of the active cases of the mers outbreak in the country back in [ ] . although there are other models being used [ , ] , this model seemed most appropriate given that the mers and the sars-cov- are related illnesses, both provoked by a coronavirus strand, and with similar symptoms, although mers was much deadlier. in order to fit the parameters and given that there is still very little data in the case of portugal, i used the data of italy instead. this allowed me to fit the curve of current active cases in portugal with a model, which i then use, by implementing the control measure parameters predicted in the model to predict the future number of cases, in five different scenarios (the out-of-control scenario, a scenario in which measures were the same as in the original model (scenario ), a scenario where government measures are % as effective as those in south korea, and self-protective measures reduce the transmission rate by % (scenario ), a similar scenario but in this case the transmission rate was only reduced to % (scenario ), and a fourth scenario, similar to the two previous ones but in which the transmission rate was reduced to %. the model used is the model described in xia et al [ ] , which can be understood by the flow diagram shown in figure (which was taken from the paper, page ). in this model, s corresponds to the number of susceptible individuals; e, the number of exposed individuals; a, the number of asymptomatic infected cases; i, the total number of mild-to-severe infected patients. h, the number of hospitalized cases; r, the number of removed cases, and finally n, the total population of portugal. β is the transmission coefficient of the asymptomatic infected cases, β is the transmission coefficient of the symptomatic infected cases (mild infected person and severe patients) to the susceptible, β is the transmission coefficient of the hospitalized cases to the susceptible, σ − is the mean incubation period, λ − is the mean time between symptom onset to hospitalization, k − is the mean infectious period of asymptomatic infected person for survivors, k − is the mean duration for hospitalized cases for survivors, δ − is the mean time from hospitalization to death, γ is the clinical outbreak rate in all the infected cases. the time unit is day. the set of differential equations can then be written as: given that the available data for covid- is still very preliminary, the model was further adapted. the only parameters that were considered "known" were the mean incubation time, which was taken as σ − = . days from the literature (here using the median as equal to the mean) [ ] , and the mean infectious period of asymptomatic people, where a conservative estimate of k − = days was used. all other parameters were taken to be "unknown". furthermore, and because the fitting of the model was difficult to achieve, i took β = β = β = β as a first approximation, meaning that the mean transmission coefficient is the same independently of type and setting of the transmission. finally, unlike xia et al [ ] , i consider that the epidemic starts with only one person infected (i = ), being the rest of the values , except for s which is simply n- . see table for a breakdown of the different parameters of this model. the solving of the system of differential equations was performed using the mathematica code [ ] , which also allows for the use of fittable parameters, using the function "nonlinearmodelfit" [ ] . given that there is still very little data for portugal, the data for italy was used as proxy. this seems like the most reasonable approach (instead of using data from china or another asian country), given the cultural and health system proximity between the two countries. in order to determine the parameters λ and δ, i used the number of deaths, as reported by the italian ministry of health and available online [ ] . for the estimation of the value of k , the number of recovered was used. all data was taken until the th of march . after determining the values for these parameters, they were used to fit the curve of infected cases for portugal, where the values of β = β = β = β and γ were fitted to obtain a model. this model was then used to estimate the evolution of future cases in portugal, according to five different scenarios: • out-of-control scenario (nothing done, the virus is free to spread (out-of-control scenario); • scenario in which the government takes severe mitigating measures and the population adheres to selfprotecting measures equivalent to the original model (scenario ) • scenario where government measures are % as effective as those in south korea, and self-protective measures reduce the transmission rate by % (scenario ) • scenario where government measures are % as effective as those in south korea, and self-protective measures reduce the transmission rate by % (scenario ) • scenario where government measures are % as effective as those in south korea, and self-protective measures reduce the transmission rate by % (scenario ) . fitting of parameters λ and δ (italy). the number of deaths in italy was taken from [ ] , and the set of differential equations described in eq. fitted to obtain the best possible fit for parameters λ and δ. an . fitting of parameter k (italy). now, using the values for λ and δ found in . , parameter k was obtained with a new fit of eq. , but now to the number of recovered cases in italy, which again was taken from [ ] . the best possible fit for k gave an r value of . . the rest of the parameters are presented in table . as can be seen, in the case of recovered cases, the fit has not the same quality as the fit in . . this is further evidenced by figure , where a graphical representation of the fit is shown. after the two previous procedures, we now have all the parameters we need to fit eq. to the number of portuguese active cases until the th of march, in order to determine the value of β and γ. the number of portuguese active cases was taken from [ ], which is updated daily. the values previously obtained of parameters λ, δ, and k were used. as explained previously, because the fitting was difficult to obtain, as a first approximation, we consideredβ = β = β = β. the obtained values for β and γ are given in table . a graphical depiction of the fitted model is given in figure . in this scenario, the out-of-control scenario, in which the corona virus would be "free" to spread within the country would lead to a peak of , infected around the th of april . a scenario that will very likely be avoided given the strong containment measures implemented by the government. . discussion of the obtained values for λ, δ, k , β, and γ the fitting of these parameters was difficult to obtain. there is enough systematic error and lack of statistics to make the present results very unreliable. in order to obtain the parameters for λ, δ, and k , an ansatz value for γ had to be given. in this model, γ is originally defined as "the clinical outbreak rate in all the infected cases". in the cases of the fits of λ, δ, and k , the ersatz value used for γ had a very strong impact in the results of the other parameters. in fact, as it comes multiplied with σ in the transfer from compartment e(t) to compartments a(t) and s(t), i think the high variation in this value could very well be due to the huge uncertainty there is at the moment for the appropriate [ ] , although this number is probably an outlier. also, a case of an incubation period of days seems to have been confirmed by a recent study [ ] . the other parameters are somewhat less elusive. the obtained value for δ = . is % the value obtained by xia et al [ ] of . , s % the value obtained by xia et al [ ] of . , which shows the difference in case fatality rates between the sars-covid- ( . % currently for italy), and mers (estimated at %) which is %. this seems reasonable, although the case fatality rate of the sars-covid- is still difficult to ascertain. finally, from the obtained values it is also possible to determine a value for the basic reproduction number r , which here i take as being simply the value r = β k +k = . which demonstrates how strong the capacity for spreading of this particular virus is. in table , the final values of the obtained parameters are given. the paper by xia et al [ ] further presents an extra parameters to take into account control measures in time evolution of the epidemic. these parameters are meant to take into account two things: • isolation and monitoring measures taken by the government (parameters d , d , d , and d ); • self-protection measures taken by the population (parameters l , l , and l ). the way these parameters are introduced in the model are as follows: the l , l , and l parameters are basically multiplication factors for the transmission parameter β, so in our model we only consider one value for it as we did in the previous sections. the d , d , d , and d parameters are summed to the parameters of spread between the infected, asymptomatic and hospitalized cases, further stressing their connection to implemented government measures. the values provided by xia et al [ ] , when applied to the portuguese case, seem to provide a very unrealistic scenario, in which the values would immediately start to diminish. perhaps this made sense in the case of the mers epidemic, given that it was much more localised that the one provoked by this virus. as such, and for the lack of a better model, i devised four different scenarios in addition to the "out-of-control" scenario described in the previous section: • scenario in which the government takes severe mitigating measures and the population adheres to selfprotecting measures equivalent to the original model (scenario ) • scenario where government measures are % as effective as those in south korea, and self-protective measures reduce the transmission rate by % (scenario ) • scenario where government measures are % as effective as those in south korea, and self-protective measures reduce the transmission rate by % (scenario ) • scenario where government measures are % as effective as those in south korea, and self-protective measures reduce the transmission rate by % (scenario ) [ ] . in the second scenario i keep the % reduction in the transmission rate but diminish the efforts of the government by half. in the third and fourth scenarios i use % and % of the transmission rate respectively. the values for these scenarios are given in table . the day considered for the initiation of these measures is day corresponding to the th of march which is days after the government implemented the measures, so giving the virus another cycle of infection before the measures take effect. results are shown in figure . results show that measures can be effective in "flattening the curve", as it has come to be called this effect in recent times. in the first scenario the effectiveness of the control measures seems to be at a maximum, and a maximum of just about cases would be reached. this has proven to be an unrealistic scenarion given that as of today there are active cases in the country. in scenario , the maximum is shifted to the th of april, reaching a maximum number of , active cases in the country. in this scenario, the transmission rate has been cut to a half, but the government's measures effectiveness has been cut to a half of the value from the original model used in korea. in scenarios and , the measures of the government's effectiveness are kept at the same value, but the transmission rate is only cut to % and %, respectively. in scenario the number of infected woulf reach a peak of about , people, on the th of april, and finally in scenario , the peak would be reached at , cases, on the th of april. in the out-of-control scenario, the peak would be reached at about , people on the th of april. given the huge uncertainties concerning these numbers, and the current lack of knowledge of the ongoing epidemic, it is very hard to make sense of its evolution, even using well-established sir methods. the current work makes a series of assumptions which may or may not be proven correct in the future, including the incubation period of the virus, which is still not well-known. this proved to be a major source of uncertainty to fit the results, because it had a great influence in the other parameters, especially parameter γ, which seems to describe a probability of the person being exposed to the virus being symptomatic or not. instead this parameter seems to behave in this study as an indicator of the huge uncertainty of the value for the incubation period. finally, epidemiologists and pathologists will tell you that these parameters, unlike what is considered in this study, not only are not constant, but dependent on time, location, culture, and other factors. it is therefore particularly hard to model the current epidemic of covid- at this stage. also, this study takes into account the particular situation for one country (portugal), and we know that in globalised times, the likelihood that new foci of infections arise on a multi-country scale is also very high. although currently most government have implemented serious travel restrictions, it is now well-known exactly how this parameter could affect this model, which does not take that into account. in fact, one of the major issues with the sars-covid- virus is that, unlike the other sars, it seems to be much less contained locally, as is evident by the amount of countries afflicted. the amount of actual active cases is another clear source of uncertainty. this model takes the values of active cases and compares them with official confirmed numbers, which not only may be smaller than the actual cases, as are released at an administratively defined time, which probably does not correspond to something realistic. the author believes that the values obtained in this study should be taken qualitatively rather than quantitatively. one can think of the scenarios as defining two limits of a likelihood interval, and as such, the actual figure of maximum number of active cases in portugal will likely be in the interval , - , between the th- th of april, if the government and the people of portugal manage to keep implementing self-protective and control measures. this can perhaps serve to advise the competent authorities in taking the appropriate measures. it also serves to show the importance of control and self-protecting measures. it is possible to bring down the number of affected people by following the recommendations of the who and health authorities. without them, this model predicts that the figures of active cases would reach a staggering , people. it also shows that with the appropriate measures this can be indeed brought down, thus flattening the curve. hopefully that will be the case not just in portugal, but in the rest of the world. novel coronavirus ( -ncov) situation reports -world health organization coronavirus disease (covid- ) -research and statistics the species severe acute respiratory syndrome-related coronavirus: classifying -ncov and naming it sars-cov- epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study covid- : what is next for public health emerg infect dis why deaths from coronavirus are so high in italy, rachael rettner, livescience on march novel coronavirus pneumonia emergency response epidemiology teamexternal icon who director-general's opening remarks at the media briefing on covid- - the extraordinary decisions facing italian doctors, yascha mounk, the atlantic modeling the transmission of middle east respirator syndrome corona virus in the republic of korea xia a time-dependent sir model for covid- risk assessment of novel coronavirus covid- outbreaks outside china the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application mathematica, version dipartimento della protezione civile covid- italia -monitoraggio della situazione coronavirus incubation could be as long as days, chinese provincial government says -reuters presumed asymptomatic carrier transmission of covid- key: cord- -u qc ey authors: qi, chong; karlsson, daniel; sallmen, karl; wyss, ramon title: model studies on the covid- pandemic in sweden date: - - journal: nan doi: nan sha: doc_id: cord_uid: u qc ey we study the increases of infections and deaths in sweden caused by covid- with several different models: firstly an analytical susceptible-infected (si) model and the standard susceptible-infected-recovered (sir) model. then within the sir framework we study the susceptible-infected-deceased (sid) correlations. all models reproduce well the number of infected cases and give similar predictions. what causes us deep concern is the large number of deaths projected by the si and sid models. our analysis shows that, irrespective of the possible uncertainty of our model prediction, the next few days can be critical for determining the future evolution of the death cases (updated april ). the fast spread of covid- (nearly m infected cases till april nd, ) has caused wide concern. within the basic research community, quite a few mathematical and physical models have been proposed [ ] [ ] [ ] [ ] to study the evolution of the infected cases, aiming to make reliable predictions and to help the governments to make proper strategic preparedness and response plans. we deem it is of special importance to study the covid- spreading in sweden where, unlike other countries, the government is taking a rather relaxed strategy with no massive testing on suspected individuals and no strict lockdown in her most affected regions. we start by introducing the sir (susceptible-infectedrecovered) model which is widely used for virus spreading predictions [ , ] . it consists of a system of three time-dependent variables: • infected cases (number of total infected individuals at given time), i(t). • susceptible cases (number of individuals susceptible of contracting the infection), s(t). • recovered cases (cumulative number of recovered individuals), r(t). one has in total n = s(t) + i(t) + r(t). above quantities satisfy the following non-linear differential equations where λ is the transmission rate, β the recovery rate. they can be parametrized using known infection data. it should be straightforward to extend the models to include deceased cases in the form dd dt = νi ( ) and the exposed cases (individuals who are already infected but asymptomatic) if the recovery rate is very low during the pandemic time interval (as it is indeed the case for covid- upto now), we can well approximate the infected cases by with initial value i( ) = . for such si model, the solution can be derived analytically, this function is known as woods-saxon form in nuclear physics and is widely used describing nuclear potential and matter distribution. we can write it in a more general form by introducing one more parameter as for such si model, the solution can be derived analytically, where d describes the diffuseness. we apply above formula to study the reported cases in sweden as a function of time in fig. ii . we firstly assume that the death cases follow the same woods-saxon form where the three parameters can be fitted separately to reported data by taking into account the time interval between infection and death dates. the result is given in fig. . we should emphasize that the uncertainty in the model is very large due to the limited data available. we were very optimistic when we first derived the curve from data back by two days which was very different with modest increases, as can be seen in fig. . the above woods-saxon function seems to agree rather well with the data on reported covid- death cases from china where the pandemic period may be expected to be over. it may, however, not expected to work well within the late stage of the pandemic period when the total infected cases show a saturation behavior. therefore we insert eq. ( ) to eq. ( ) to see if we can get a better estimation on d. the integral of i(t) reads therefore, we can propose a second form for the evolution of d d(t) = a ln e t −t d the result is given in fig. where a modest increase is predicted. however, again, the data from the last two days show significant deviation from the predicted curve. new data from the next few days can be critical in pining down the uncertainty in the predicted behavior. we now include the recovery cases in above si model. there is no analytical solution but the evolution of the sir quantities can be done numerically. the result as of april is given in fig. what we can see from above simulation is that the recovery rate will remain very low during the expected pandemic time interval. instead we now include the reported death cases in above sir model by replacing the quantity r with d. the result as of april is given in fig. . the projected death cases are again very large and are more than . our simulations show that all si, sir, sid models describe well the reported infected cases show rather modest increase in the near future which is very promising. however, the projected deceased cases in both si and sid models are extremely high even though the uncertainty is astonishingly large. we deem it urgent to explore the uncertainty of our model. the new data from the future few days can be critical for confining the predicted curve on decreased cases. if the model is correct, one should worry that the infected cases in sweden may be much much higher than it is reported today and a massive testing on exposed and suspicious cases may be urgent. estimating the number of infections and the impact of non-pharmaceutical interventions on covid- in european countries a contribution to the mathematical theory of epidemics the mathematical theory of infectious diseases and its applications key: cord- -xndrlnav authors: granozio, fabio miletto title: comparative analysis of the diffusion of covid- infection in different countries date: - - journal: nan doi: nan sha: doc_id: cord_uid: xndrlnav the sudden spread of covid- outside china has pushed on march the world health organization to acknowledge the ongoing outbreak as a pandemic. it is crucial in this phase to understand what should countries which presently lag behind in the spread of the infection learn from countries where the infection spread earlier. the choice of this work is to prefer timeliness to comprehensiveness. by adopting a purely empirical approach, we will limit ourselves to identifying different phases in the plots of different countries, based on their different functional behaviour, and to make a comparative analysis. the comparative analysis of the registered cases curves highlights remarkable similarities, especially among western countries, together with some minor but crucial differences. we highlight how timeliness can largely reduce the size of the individual national outbreaks, ultimately limiting the final death toll. our data suggest that western governments have not unfortunately shown the capability to anticipate their decisions, based on the experience of countries hit earlier by the outbreak. italy is presently the hardest hit country. its death toll seems bound to rapidly overcome the chinese case. other western countries follow the same route. it is crucial in this phase to understand what countries presently lagging behind in the spread of the infection can learn from countries where the infection spread earlier. the first question we address is: which are the relevant numerical signatures to be monitored to check how effectively a country is acting, compared to other countries, in containing the infection? here we show that an answer to this question can be given not relying on specific epidemiological expertise, but based on a simple numerical analysis of public data available on the internet. it is widely acknowledged that comparison of curves from different countries is made difficult by the different ways the detection of the virus is addressed. in particular, the ratios of the tested population to the total population, among the countries addressed in this paper, range from about . /million in the case of south korea, to . /million for italy to less the /million in the case of usa . therefore, not only the real number of infected people might largely exceed the registered cases, but such ratio (registered/total cases) might change country by country. this difference is partly mitigated by two observations: -in the specific spirit of this work, we will compare countries in the same stage of the epidemic. considering the delay of the outbreaks (korea is grossly days ahead of italy and days ahead of the states, as will be discussed later in detail) italy is grossly following the same testing curve as korea while the usa lag behind by less than one order of magnitude. -we should assume that in advanced countries most symptomatic patients are counted among the registered cases within a few days. these are exactly the cases we mostly want to focus on. the hidden background of asymptomatic patients, though playing a role in determining the disease spread, is a less relevant datum in foreseeing the final death count. at the end of this analysis, remarkable similarities are found, especially among western countries, together with some minor differences. the extent and relevance of the observed similarities for the case of western countries will justify, ex post, the adopted approach. epidemiological curves are typically believed to follow the stochastic logistic model. nevertheless, this assumption cannot take into account situations in which the infected population reacts by drastic changes of its collective behaviour, thus changing the virus reproductive number, in the course of the outbreak. a general model for covid- diffusion would require knowledge of all the specific virus containment measurements adopted in each single country, their dates, and their quantitative effect on the reproductive number. this is so far beyond our present understanding. the choice of this work is to prefer timeliness to comprehensiveness. by adopting a purely empirical approach, we will limit ourselves to identifying different phases in the plots of different countries, based on their different functional behaviour, and to make a comparative analysis. for more complex approaches, the human data analysis time could easily exceed the obsolescence time of the dataset, which is of the order of a couple of days. the case of countries beyond the initial phase of the outbreak the source of data for this work is the csse covid- dataset . we analyse here the data of three of the countries that registered at the date of march the highest cumulative number of registered cases, i.e. china, italy, and south korea. we neglect iran, also because of the lack of information about the number of tested people. the three countries are at different stages of the outbreak. china exceeded the number of registered cases in the hubei province on january and presently reports few new cases per day. korea exceeded the number of registered cases on february and presently reports few new cases per day. italy exceeded the number of registered cases only a few days later but, in spite of a recent slowdown, the end of the exponential phase, if confirmed, is happening in the present days. the chinese plot shown in fig. a stops on february . this is due to the change of criterium adopted in the counting of infected patients performed in china on february . the reported data are fortunately widely sufficient for the purpose of this work. as for italy, last data are aligning to a linear curve, which might well be the inflection point, anticipating a smooth transition to a sublinear behaviour. the absolute number of the new daily cases in the country, about . on march , is still very high. by comparing the linear coefficient of the italian and korean blue curves, we observe in fact that the former exceeds the later by a factor . the comparison of the plots shows that, in spite of the extremely fast growth rate ( = . d, corresponding to a doubling time of one day) the rapid response of the korean society allowed to switch the growth to a slower rate before reaching registered infected people. this rapidity is confirmed by the observation that at the time when only infections were found, on february , the republic of korea had already tested over citizens . italy had instead registered cases by the time it reached the same number of tests on february . the perduring fast growth rate in italy rises major concerns and suggests that the cumulative final number of cases might exceed the chinese case. comparison between western countries. the italian case seems to correspond to the worst-case scenario among the ones analysed above. it suggests that while korea implemented a faster reaction than china, profiting of the lesson learned by the experience of the neighbour country, italy apparently showed a longer response time than both asian countries, in terms either of diagnosis, or of governmental decision, or else of change of individual habits. it is of great importance to verify how well the italian lesson was learned by other western countries. the plots reported in fig. a this timescale seems to be characteristic of the covid- "free expansion" in all these countries or, to state it more prudently, of the rate at which they are detected. we remind in this context that, in absence of large-scale screening programs, most infected people are tested after showing symptoms, i.e. about to days after infection. therefore, the registered cases curves map the history of the past behaviours of the infected population. we observe that, still at the date of march , the spanish evolution is correctly described by the red exponential curve. the us curve shows a minor deviation, which might well indicate a switch to phase # . france has switched to the second phase, with exponent  = . d. germany has also switched to the second phase, with exponent  = . d. the plot in fig. gathers all the curves above in the same plot, comparing them with the italian curve. among the possible ways to plot the data together, the most significant one, by far, was found to apply a relative shift in time, in order to "synchronize" the different starting times of the outbreak. we remark that, by normalizing the number of infected people to the overall population, the us plot would have been shifted backwards by - days. when plotted with the appropriate relative time scale (it reference, de, fr - d, es - d, us - d), the data show how early or late the different countries deviated from the red exponential "phase # " curve with  ~ . d, d ~ . d. the violet curve fitting the italian "phase # " is also shown. it can be qualitatively deduced that france, germany and probably the united states, on this particular conventional time scale, have switched to the violet curve grossly at the same time as italy did. spain is potentially running towards a worse scenario, although the last points hint to a possible alignment to the same violet curve, albeit a factor two above. the plot in fig. graphically highlights the importance of the early reactions. the numerical history of the outbreak in korea is compared to the hypothetical outbreak evolution (dotted lines) in case a two-day delay in the transition from the red to the violet curve, rigidly reflected in a twoday shift in the transition to the blue curve, would have taken place. according to the estimation in fig. , the transition to phase # would have taken place on march with an infected population of about . people, about , times higher than the actual number of registered cases at the real transition, happened on march st . the same scale factor would be applied today, within our hypotheses, to the actual infected population. we attempted an elementary, real-time analysis of the covid- diffusion data updated at march . timeliness was preferred to comprehensiveness. important information has been extracted by the data, but major caution is needed in deriving general and far-reaching conclusions. both the inhomogeneity in data acquisition rate in different countries and the huge background of undetected, presumably asymptomatic, infected patients, are two major sources of uncertainty. the criterion applied in the plot in fig. is highly instructive but, to some extent, arbitrary. with all due prudence related to the uncertainties above, we believe the present analysis is an excellent and timely starting point for further studies on the delayed effects on the curves of the response adopted by different countries. such response includes both individual changes of habits (hands hygiene, social distancing by own choice) and restrictions imposed by the governments (closing of schools, constraints to the mobility of citizens). the korean example clearly shows that early diagnosis of the first infected patients and timeliness in the response can largely reduce the size of the outbreak, ultimately limiting the final death toll. our data suggest that western governments have not shown the capability to anticipate their decisions based on the experience of countries hit earlier by the outbreak. our hope is that this work can contribute to triggering early and appropriate responses to the covid- pandemic. how many tests for covid- are being performed around the world? our world in data coronavirus cases: statistics and charts -worldometer quanti test per il coronavirus abbiamo fatto key: cord- - dj h authors: yan, donghui; xu, ying; wang, pei title: estimating the number of infected cases in covid- pandemic date: - - journal: nan doi: nan sha: doc_id: cord_uid: dj h the covid- pandemic has caused major disturbance to human life. an important reason behind the widespread social anxiety is the huge uncertainty about the pandemic. one major uncertainty is how many or what percentage of people have been infected? there are published and frequently updated data on various statistics of the pandemic, at local, country or global level. however, due to various reasons, many cases were not included in those reported numbers. we propose a structured approach for the estimation of the number of unreported cases, where we distinguish cases that arrive late in the reported numbers and those who had mild or no symptoms and thus were not captured by any medical system at all. we use post-report data for the estimation of the former and population matching to the latter. we estimate that the reported number of infected cases in the us should be corrected by multiplying a factor of . % as of apr , . the infection ratio out of the us population is estimated to be . %, implying a case mortality rate at . % which is close to the . % suggested by the who. with the quick spread at the global scale, the covid- pandemic has become one of the most tragic disasters in human history, with a worldwide confirmed cases of . million and death toll at k as of april , . rising trend of these numbers still remains in multiple countries right now. the most risky aspects about the coronavirus are the long incubation period and the existence of a large number of asymptomatic cases. these cause a substantial proportion of infected cases not tracked by medical systems. for better policy making and disease control, as well as to reduce the widespread speculations among the public about the extent of the disease spread, it is of significant interest to give an estimate on the missing counts. specifically, when the pandemic gradually becomes under control, the world is considering the resume of normal business. this requires a prudent assessment of the potential risk. inevitably, such an assessment would involve the estimation of the number of asymptomatic cases when such cases are still active. however, the task of estimating the number of those undocumented cases is very challenging, exactly because of the long incubation period and those asymptomatic cases. in this work, we will present a structured approach for such an estimation task and give an approximate estimate at the us national and state level. the remainder of this paper is organized as follows. in section , we will describe our approach. this is followed by a presentation of results in section . finally we conclude in section . statistically, the estimation of the number of unreported cases is related to the problem of inference with missing data [ ] or censored data [ ] . however, certain characteristics of the coronavirus epidemiology allow us to take a different approach. we adopt a structured approach, inspired by the diagnostic analysis of remote sensing studies [ ] where the errors in the land use classification were decomposed according to their sources. our approach is illustrated by figure . the missing counts in the reported numbers come from two sources. one is those cases for which, at the report date, the symptoms were not severe enough and the affected individuals would not test for infection; however, they would eventually visit some medical facility and test for potential coronavirus infection. we call such cases the type i cases, and the waiting period before the onset is termed as the incubation (or dormant) period. this is illustrated as the filled blue bars in figure . at the time of report, all such cases are still in dormant status thus are missing in the reported number. the second source of unreported cases are those who were infected but are either not aware of it or with symptoms too light to visit the medical facility, and later on recovered without any particular medical treatments. we call such cases the type ii cases. the type ii cases never show up in any reported numbers, thus leaving too little clue for estimation. but we cannot overlook such cases, be-cause the number of such cases could be potentially large and such individuals form an important infecting source. for the rest of this section, we will describe our method for the estimation of each of the two cases. the estimation of the number of type i cases is facilitated by a crucial observation. though not included in the reported number while in the dormant period, such cases would eventually be reported when the symptoms become so severe that the individuals have to seek medical treatments. by that time, those previously missed cases at the original report date (which was a few days ago) would be counted towards infected cases at some later report dates (though one would not know at which particular report date). such numbers should be included at the original report date but surface only several days later; for this reason we call them delayed counts. if there is a way to estimate such delayed counts or their total, then one can estimate the number of type i cases for the original report date. it will be instructive to consider a simple ideal case where all infected cases have a dormant period of days. in this ideal case, the numbers d , d , ..., d in figure are exactly the number of cases who were at their th , th , ..., st day of infection, respectively, when counted at the original report date. if we assume that the incubation period is days, then these are all the number of type i cases missed at the original report date but reflected perfectly later in the number of newly reported cases during the days time window following the original report date. so the total number of type i cases at the original report date can be calculated by their sum, the reality is, however, complicated. first, the length of the dormant period varies for individual cases. also, during the post-report time window, newly infected cases may arise and be reported. thus the number of newly reported cases at any particular day within this time window might be mixed, in the sense that it would include both cases that are infected both before (but were in dormant period) and after the report date. the former case will not pose a problem as anyway such cases would be counted towardsd type though cases infected at the same day may now contribute to different d i 's. the latter case is undesirable but could be corrected, to a certain extent, by the truncating effect when we only sum up the counts in the post-report time window up to a length of t days. that is, those cases with a dormant period extending more than t days post-report will be truncated and not included ind type , with the total count of such truncated cases being 'cancelled out' by the newly infected cases within the post-report time window of a properly chosen length t . this leads to an estimate for the number of type i cases aŝ where d i are now the number of cases reported at the i th day after the original report date. we can let t take a value around or slightly larger than the mean of the incubation periods. in the appendix, we give a justification on why our estimate,d type , would be a reasonable one. if we can keep track of the delayed estimated type through time, then we can get a time series which, upon smoothing, could be used to estimate the current missing type i counts. for such an estimation to be feasible, we have two requirements. one is that the daily reported counts through time would not change too abruptly. thus, our approach would not work well when the infection trend still rises very rapidly. during such a period, the safest strategy might be to strictly enforce social distancing. but as the overall situation is gradually under control, our estimation would apply. the other is knowledge of the duration of the incubation period. according to many studies [ , , ] , the incubation periods has a median of around - days. while further studies or data analysis is required to confirm this, we take t = in our estimation. additionally, it should be cautious that our estimation is valid assuming that the test of coronavirus is sufficiently carried out for the population of interest; insufficient test would render an underestimate of the number of type i cases. in figure , we plot the ratio of estimated type i cases w.r.t. the reported number of cases for connecticut (ct) and massachusetts (ma) since mar , . these two states were chosen as they are similar in many aspects, so we expect their ratio of type i cases out of reported cases would be similar. in figure , there is an initial difference in ratios of type i cases in these two states, which we attribute to the late response and the small number of cases tested in ct. later, these two states exhibit strikingly similar trend, which is quite xpected. we also explore the effect of using different values of t where and are used. again, initially the resulting estimation are fairly different, which indicates the rapid spread of coronavirus and the rapid rise of infected cases. gradually, the difference in the resulting estimations diminish, which implies that the choice of t = leads to a fairly stable estimation at late stages of disease spread. similar observation can be made for the estimation of type i cases in us. this is shown in the right panel of figure . the estimation of the number of type ii cases is extremely challenging, as there is barely anything observable. our main strategy in the estimation is based on the matching of population statistics-using what we see well to infer what is missing. when we group reported infection cases, we notice a significant discrepancy in the count statistics by age groups between reported cases and the us population. we expect that, while people in most age groups in the popu- lation have a similar chance of being infected, those type ii cases occur much more often in age groups - but rarely for people of age +. this is because people at age over typically have a relatively weaker immune system along with some pre-existing medical conditions. once they are infected with coronavirus, a slight symptom would prompt them to seek medical treatments. as a result, such cases are very likely to be discovered. thus reported counts about such age groups would be more accurate and can serve as a reference to correct counts for other age groups. on the contrary, cases for the - age group are easy to be overlooked or not noticed, unless their status is deteriorated. the reported counts for these age groups thus require a correction (termed as age correction). the age group of + is more vulnerable to infections, as they typically live in the senior centers or extended-care nursing facilities which, as a matter of fact, have a very high risk of infection. the case statistics for this age group would be very thorough, but many in this age group get infected simply because they share a very confined living space with many other equally vulnerable seniors, and the infection of any one (including staff) in a senior center will quickly spread to the rest (to certain extent, one may think of this as a party of many people during covid- ). so statistics in this age group would not be a reliable reference for population match, since people in other age groups have a very different mobility pattern (the infants interact with the world through their parents thus have a chance of infection not so different from the general population). the main assumption we use for population match is that all the people, with an age in the range - , have similar chance of being infected. as a result, the counts at different age groups would be proportional to their respective percentage in the population; we call such an approach population matching. let r pop and r case be the proportions of the reference group in the population and in the reported cases, and x pop and x corrected be the the respective proportions for the target group, respectively. then r case : r pop = x corrected : x pop , and the corrected percentage in the infected cases for the target group can be calculated accordingly. as we argue before, the case statistics for age groups - and - are reliable, but those for ages - are incomplete and consist of substantial missing data, and we will use the reliable portion of the data to infer or correct statistics about the incomplete part of the data. a simple calculation reveals that age groups, - and - , according to table , have a similar ratio of cases percentage: population percentage, i.e., . : . ≈ . : . . thus, we can pool counts from these two groups and obtain r case : r pop = ( . + . )/( . + . ) = . . this yields the corrected ratio as the bottom row of table . adding up numbers in the bottom row gives a total of . %, implying that we should expand the reported counts by . % in order for the reported case counts to match the population statistics across age groups. this gives the ratio of type ii cases over the reported cases. an interesting question is, will estimated counts of type ii overlap with that for type i cases? we claim that this will not, at least not significantly, so the addition of estimated counts for type i and ii cases is valid. the reason is that, type i cases still contribute to the reported numbers, at a delayed time though. these delayed cases can be thought of as a sample from the reported cases (assuming that the reported cases have a stable proportion when breakdown by age groups). the inclusion of type i cases will not change the age-breakdown proportions. thus, after the inclusion of type i cases, we still have the same age-breakdown proportions and thus require an age correction. we apply our approach to each of the states and the us. the data are available from wikipedia [ ] . due to the large variation of the population at different states, we calculate the ratio of missing cases out of the number of reported cases for individual states. the ratio for type i cases is shown in figure . due to the lack of reported case data for individual states by age groups, we use the overall estimate, which is . % according to discussions in section . , for the ratio of type ii cases for all the states. the overall ratio for type i cases for the us is estimated to be . %. combining with the . % ratio for type ii cases, this gives an estimated ratio of missing cases versus the reported number at . %. in other words, the reported number should multiply by a factor of . % to reflect the true number of infected cases. with the unreported numbers estimated, we can estimate the infection ratio, defined as the ratio of the number of infected cases out of the population. the overall infection ratio of the us is estimated to be . %, or . million, as of apr , . if we use the associated death toll at about k, then the case mortality rate is calculated as . %, which is close to the who suggested estimation of . % [ ] . the infection ratio for individual states are visualized as heatmap in figure . heavily hit states are ny, nj, ct, ri, ma, and la with infection ratio estimated at . %, . %, . %, . %, . % and . %, respectively, as of apr , . the trend of infection ratio and cases by time for these states is shown in figure . it can be seen that, except la, the infection ratio for all other five states are still rapidly increasing. nj shows a similar growing pattern as ny, while the three new england states, ct, ri and ma, are similar. we have proposed a structured approach for the estimation the number of infected cases not included in the reported number at a given date. we distinguish two types of 'missing' cases, those cases which were infected but are still during the dormant period and those asymptomatic cases which later self-recover without medical treatments. the number of these two types of cases are estimated by accumulating reported counts within a properly chosen post-report time window and by population matching. the reported number, as of apr , , of infected cases in us should be corrected by multiplying a factor of . %. the overall infection ratio of the us is estimated to be . %, with a case mortality rate of . % which is close to the recommended . % by who. our estimation can potentially be used for risk assessment. the infant age group may worth further consideration as people in this group are much less risky than other age groups as they interact with the rest of the world through their parents, so the number of cases for this group may need to adjust accordingly to reflect the true risk. denote the number of cases that were infected one day, two days and so on before the report date (for which we use n ). here we limit to type i cases as we can conveniently assume that type ii cases have an infinite incubation period. then the expected number of cases that are discovered during the time window of t days following the original report date is calculated as for simplicity, we would assume that all the en −i 's take a constant value n . we feel that this should not be too unrealistic as we would expect that the number of newly infected cases per day do not vary too much when the pandemic reaches a stable stage (those at the very far distant past would be small, but they carry a very small fraction of the total number so could be ignored). also, we abuse the notation a bit by using d . 's to also indicate the expected value of the associated random variable; the exact meaning will be determined by the context. then equation ( ) can be rewritten as under the same assumption, the number of new cases generated during the post-report time window of length t days is (t − i) · p (i − ≤ x < i) + n · p (x < t ) thus the total number of reported cases during the t days post-report time window is calculated as d a + d new = (t − ) · n + n · p (x ≤ t ) = t n − n · p (x > t ). assuming that random variable x has a finite mean, then we have p (x > t ) ≤ ex/t µ/t, implying that the estimated number of type i cases satisfies the actual number of cases that have accumulated but not being discovered before the report date consists of missing cases during the previous t days and those even earlier cases, which has an expected value ( ) indicates that the mean number of type i cases equals the product of the mean daily infected cases of type i and the mean length of the incubation period, which is consistent with the ideal case discussed in section . . let t = ( +ǫ)µ, then we have the following error bound for the estimated number of cases of type i |d type − d type | ≤ µn · max(ǫ, |ǫ − /t |). it follows that the relative error of the estimate satisfies |d type − d type | d type ≤ max(ǫ, |ǫ − /t |) = max(ǫ, |ǫ − /(( + ǫ)µ)|). for a given µ, one can pick ǫ to optimize the above bound. for example, when µ = , one can take ǫ = . to achieve a relative error bound of about %. incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china nonparametric estimation from incomplete observations the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data statistical analysis with missing data world health organization. coronavirus (covid- ) mortality rate covid- pandemic in the united states a structured approach to the analysis of remote sensing images in this appendix, we will give a justification on our estimation algorithm. we show that the error between our estimate,d type , of the number of type i cases and its actual value d type is small in expectation under reasonable assumptions about the distribution of the incubation periods.denote by random variable x the length of the incubation period, and for simplicity we further assume that x ≥ takes integer values. let n − , n − , ... key: cord- -a i vnjz authors: nason, guy p. title: rapidly evaluating lockdown strategies using spectral analysis: the cycles behind new daily covid- cases and what happens after lockdown date: - - journal: nan doi: nan sha: doc_id: cord_uid: a i vnjz spectral analysis characterises oscillatory time series behaviours such as cycles, but accurate estimation requires reasonable numbers of observations. current covid- time series for many countries are short: pre- and post-lockdown series are shorter still. accurate estimation of potentially interesting cycles within such series seems beyond reach. we solve the problem of obtaining accurate estimates from short time series by using recent bayesian spectral fusion methods. here we show that transformed new daily covid- cases for many countries generally contain three cycles operating at wavelengths of around . , . and . days (weekly). we show that the shorter cycles are suppressed after lockdown. the pre- and post lockdown differences suggest that the weekly effect is at least partly due to non-epidemic factors, whereas the two shorter cycles seem intrinsic to the epidemic. unconstrained, new cases grow exponentially, but the internal cyclic structure causes periodic falls in cases. this suggests that lockdown success might only be indicated by four or more daily falls in cases. spectral learning for epidemic time series contributes to the understanding of the epidemic process, helping evaluate interventions and assists with forecasting. spectral fusion is a general technique that is able to fuse spectra recorded at different sampling rates, which can be applied to a wide range of time series from many disciplines. what the impact of measures that came in on march will be". the measures that professor mclean referred to were the widespread uk social distancing and lockdown interventions made in the face of the covid- threat. at the time of writing, few countries have experienced in excess of days of covid- cases and most only have around days. professor mclean is correct in that many scientific inferences require longer time series than those currently available. however, we show that there are considerable and useful similarities in the underlying cyclic (spectral) behaviours of the numbers of new daily covid- cases for a range of different countries (see extended data figures). we use recent bayesian spectral fusion methods [ ] (regspec) to pool spectral information across countries, which provides significantly more accurate estimates of cyclic behaviour than provided by a typical spectral analysis of a single country alone. the bayesian principles underlying our fusion method handle mean that uncertainty is treated coherently, producing rational uncertainy assessment for our cycle (spectral) estimates. our methods produce cycle estimates using the equivalent of over nine hundred daily observations, compared to the fifty or so that a typical standard spectral analysis might use. using data [ ] from all of the countries we considered, our results show that transformed new daily covid- cases have three underlying cycles: one operating at a wavelength of . days, a second at . days and a third at . days, which we take to be a weekly effect. we conducted separate analyses for the uk and groups of countries with similar spectra and note some variation in those cycles. for some purposes it is not reasonable to compare or pool the number of new daily cases from one country to another [ ] . for example, different countries might use different definitions of the number of daily cases and they record cases through different national structures and this is even the case for countries with political, geographical or cultural similarities. however, as long as the method of recording cases is broadly unchanged over the period in question for a particular country, the spectral properties across countries are comparable. the transformed cases' spectrum quantifies the internal oscillatory structure within the series and is largely unaffected by the overall level of cases, the different start times of epidemics in different countries (phase) and country-specific internal delays due to reporting requirements (also phase). in addition, the demonstration of the presence three consistent cycles across all countries, with some variation, provides supporting evidence for the suitability of the transformed new daily cases as a target of analysis, and comparisons between and across countries, another topic of great current interest is to ascertain whether and how a lockdown will influence the number of new daily covid- cases. we consider this question for the group consisting of the uk, italy, france, germany, spain, switzerland, belgium and the netherlands. the number of days (with cases) be-fore lockdown is, on average, for this group of countries, and, after lockdown, is (except the uk, which started its lockdown later). the averages just quoted include allowance for a seven day incubation period. our analysis compares the spectral properties before and after lockdown. a spectrum based on about days worth of data would provide a very poor and highly uncertain estimate. however, our spectral fusion methods [ ] permit effective sample sizes for the group of days worth of data prior to the lockdown, and after, resulting in highly accurate spectral estimates for these periods. we learn that, after lockdown, the weekly cycle remains strong, but the cycles operating around . and . days become suppressed. this indicates that the weekly cycle is due, at least in part, to administrative recording effects, which are not effected by the lockdown, whereas the . and . day cycles might be related to virus dynamics, which is certainly affected by lockdown. the discovery of how the high-frequency cycles are disrupted by full lockdown suggests that they could be monitored during partial lockdowns. for example, if schools are reopened and the . and . day cycles do not reappear, then this might indicate the effectiveness of that strategy. given the similarity of the cycles across countries, this indicates that cases could be monitored and pooled across regions, over a short number of days to be fused into longer effective samples using the methods described here. a more difficult problem is that of forecasting transformed new daily covid- cases. such information would be of great interest, e.g., to those planning health provision over a short timescale. knowledge of the three cycles is helpful and we have had moderate success in forecasting daily cases. however, with individual country series, with smaller number of days, it is unrealistic to expect too much and, in particular, the transformed cycles experience both a degree of time-modulation and possible frequency changes. more useful perhaps, are not daily forecasts, but the knowledge that the number of cases will increase and decrease over a period of three/four days. this means that if one observes a decrease in the number of daily covid- cases after lockdown, that does not necessarily mean the peak has been reached, but is simply a manifestation of the / day cycles. hence, one might believe a lockdown strategy has been successful after a sustained decrease of at least four days. spectral analysis [ , ] of epidemics is not new, but most work has been carried out on epidemics observed over long time periods (seasons and years) using lengthy time series [ , , ] . recent work [ ] on covid- has applied popular autoregressive integrated moving average process [ , ] models to a single prevalence time series with a sample size of n = . however, conclusions derived from such analyses on a single series with such small sample sizes [ ] are questionable. for example, an autoregressive process of order one with parameter . , normally considered to be a strong signal, is only distinguishable from white noise [ ] approximately % of the time with sample size of n = ; basic simulation studies show the large number of possible different models that can fit such short series apparently well. this indicates that it is virtually impossible to tie down the correct model with such a small sample size. phenomenological sub-epidemic models [ , ] show much more promise and have been applied with some success to short-term forecasting of covid- cases in guangdong and zhejiang, china. these improve performance by using bootstrap methods on short case time series, but are still ultimately based on a parametric model of single series. our work is very different as it provides exceptionally accurate spectral estimates for a novel live epidemic that is still in its early days on short series, but reliably so by using recent bayesian spectral fusion techniques. [ ] . the nonparametric nature of our analysis also permits us to split case time series at a boundary (e.g. lockdown or other intervention) and analyse the two halves separately, still with very short series in each. this is perhaps harder to do with classical parametric models and to maintain consistency between the two halves. on the other hand, our method relies on good quality case series from different regions, which is again not always the case for all epidemics. we transformed the number of new daily covid- cases by applying a signed log transform to the first differences of the new case time series (see methods). the transformed number of new daily cases for countries are shown in figure each showing a distorted noisy, but characteristic sinusoidal trace. the estimated log-spectrum for the uk transformed new daily cases is shown in figure and for all other countries we analysed in the extended data figures. spectral estimates are commonly displayed on a logarithmic scale [ ] . spectral peaks can be observed at wavelengths of . , . and . days, respectively. although the peaks are visible, the credible intervals indicate that there is a fairly large degree of uncertainty, because this time series contains observations. a frequentist analysis, e.g. using the spectrum function in r [ ] , produces a similar result, but with even wider confidence bands. similar spectral analyses for each country indicate three similar spectral peaks, although not always as well-defined nor in precisely the same location. figure shows an estimate that is the result of coherently fusing spectra from countries, giving an an effective sample size of days. here, the clear spectral peaks have narrow credible intervals, due to the large effective number of days afforded by using countries together. the spectral peaks are located at wavelengths of . , . and . days. the peak around . days is observed in the spectral plots for individual countries and we interpret it to be a weekly effect. such a weekly effect could be produced by reporting artefacts (e.g. paperwork being delayed until monday, or carried out differently at the weekend) or due to the behaviour differences of people at weekends. all countries analysed have a + working week/weekend pattern, although not necessarily the same days of the week (the actual days for a weekend are a phase effect, which does not effect the spectrum). clustering spectra and groups of countries with similar spectra we next clustered our countries based on their spectrum, by calculating a dissimilarity between the spectra for each pair of countries, and then performing both a hierarchical cluster analysis and multidimensional scaling on the dissimilarity matrix. the scaling solution indicated that only two dimensions were required to encapsulate % of variation in the data. figure shows the resultant twodimensional solution. attaching a meaning to the scaling axes in figure is not easy. we hypothesise that axis might indicate how badly a country has been perceived to have been affected by the virus with australia, new zealand and sweden less so and those on the left of the plot considerably more so. however, germany is the obvious anomaly to this interpretation as, currently, it has perhaps been perceived to have handled the crisis well so far. table : spectral peaks for the three country groups in units of days. the peaks in the second and third rows have been arbitrarily labelled as peak a. and b. figure show the spectral estimates for the three groups of countries identified in figure , using the clustering techniques mentioned in methods. the peak frequencies for each of these groups is listed in table , which shows differences between them. however, each group possesses a possible weekly peak and higherfrequency peaks labelled a., of around three to four days, and b., around . days. many countries experiencing the covid- pandemic have instituted a lockdown procedure to dramatically reduce virus transmission. at the time of writing, these countries have observed new daily covid- cases for between and days. we assume that, on average, it takes about seven days for the virus to incubate, for a person to seek attention and then be tested positive for the sars-cov- coronavirus. for each country, the number of days prior to and after the lockdown ( , ) . for some of these countries the lockdown was applied over a period of two of three days and we took the median of these as the lockdown start date. the number of days before and after the lockdown are, in each case, too small to carry out anything other than the most simplistic time series to maintain statistical reliability. in particular, a spectral estimate in this situation would be subject to a high degree of uncertainty. however, figure shows our coherently fused spectral estimates [ ] across these countries before and after the lockdown period, making use of effective days prior to lockdown and days afterwards. the weekly peak is clearly visible in both estimates. the second and third peaks (labelled a. and b. in table ) are visible pre-lockdown, but have all but disappeared post-lockdown. the spectrum is flat in the location where peak a. was previously, and spectral power declines considerably, relatively, where peak b. was located previously. this result is particularly interesting as it suggests that peaks a. and b. have been disrupted by the lockdown. the weekly effect seems relatively unchanged by the lockdown, indicating that perhaps it was strongly driven by non-epidemic effects, such as recording/paperwork or bureaucracy caused by weekends. the post-lockdown spectrum is higher overall than the pre-lockdown spectrum, this is due to the larger variation associated with the larger number of cases identified during the progress of the epidemic. our transformation suppresses this variation, but does not remove it entirely. we have had varied success in forecasting daily cases using a sum of two timemodulated cosine waves model, described in methods, and more research is required. we used the nelder-mead [ ] optimisation routine built into r [ ] , with starting frequencies of . and . taken from our uk spectral estimate plots, and built the model on the transformed cases up to april th. after optimisation, the fitted model resulted in modified frequencies ofω = . ,ω = . , close to the starting frequencies (the other estimated parameters wereα = . ,α = . ,φ = − . ,φ = − . ,μ = . ,μ = − . ,p = . ,p = . ). figure shows transformed new daily uk cases, the model fit and forecasts. the model fit does not look too bad, many spectral peaks are being identified, but perhaps the amplitudes of them could be better matched. the untransformed forecasts for april th, th, th and th were , , and , all with approximate % confidence interval of ± . the actual number of cases for april th turned out to be . in this case, the forecast was good. however, the two-step ahead forecast of was wrongthe true value turned out to be on april th. we also used several stochastic forecasting methods based on autoregressive integrated moving average modelling and exponential smoothing, but nothing that we tried was particularly successful. the series is difficult as its amplitude/variance is not constant and we suspect that frequencies are changing over time (as, e.g., the lockdown plot figure indicated). however, rather than point forecasts, the general sinusoidal nature of the transformed cases suggests a further, perhaps more reasonable strategy. at this stage, the uk government and media are looking expectantly at the daily case numbers to try and detect a sustained downward trend in cases. excitement has been generated by a drop in cases two days in a row. this happened on april th with cases, followed by a drop to and then on april th and th and then, unfortunately, increasing to on the th. however, the general sinusoidal patten, with a wavelengths of about . and four days shows that we should only perhaps start believing that a downward turn is a downward trend after a sustained decrease of four days or more. however, caution needs to be applied here as there is no guarantee that the dynamics will remain unchanged. we analysed numbers of deaths using similar methods described here and found similar cycles. although we have not carried out a detailed analysis, if the number of deaths process can be approximated by a linear system [ , ] with the numbers of cases as input, then similar cycles are to be expected. a time series with a fixed sampling rate and length has a minimum and maximum (nyquist) frequency that can be observed. [ , ] although our spectral fusion methods [ ] provide more accurate estimates of the spectrum in the normal range (equivalent to having a larger sample size), they can not provide information on frequencies outside of the normal range. to estimate lower frequencies, we would need a genuinely longer series and, for higher frequencies, we would require cases more frequently than once a day, which are arguably not really necessary for any practical purpose. our analyses assume approximate stationarity and linearity for the transformed series, which is unlikely to be exactly true in practice. for example, in the uk transformed case series in figure , there are hints of the series oscillation speeding up over the last ten days. practically speaking, changes in the testing regime, recording practices, the lockdowns or other interventions will change the dynamics of either the pandemic itself or recording of it. ideally, it would be of interest to use methods for non-stationary time series [ , ] , but the current series available to us are far too short for such analyses. all computations were executed in r [ ] and packages that are mentioned specifically below. let y t , for t = , . . . , n c represent the number of new daily cases for n c days for country c. the spectral dynamics of the number of daily cases for different countries are all countries masked by the well-known and characteristic exponential increases (and decrease, for those countries that locked down and have now passed their peak). hence, we transform our number of daily cases series to reveal the spectral dynamics. after exploration [ ] the following transform was used for all series l t = sgn(d t ) log(|d t |), where the sign function sgn(x) is + , if x is positive or − , if x is negative, and d t = y t − y t− for t = , . . . , n c . the transform is easily inverted, which is essential for forecasting the number of daily cases. we use the regspec [ , ] bayesian spectral estimation method with a neutral white noise prior with prior variance of and all default arguments, except for a smoothing parameter of . , although the results are not sensitive to the latter. regspec straightforwardly enables the production of spectral estimates using multiple data sets, with each having different lengths and produces coherent credible intervals to properly ascertain the uncertainty inherent in the estimation process. regspec can also fuse spectra for multiple series recorded at different sampling rates, but we do not need to use this aspect of its functionality here as all our case time series are reported daily. however, if a country decided to release case numbers on some other sampling plan (e.g. every two days, or weekly) then regspec would be able to fuse the spectral estimates as described here. such a feature might be of use when dealing with reporting structures that are not equipped to provide daily reporting of cases or where weekly cases are thought to be more accurate. for example, this might apply to regions with fragile health or reporting systems or populations that are spread across widely dispersed geographical regions with poor communications. although the number of cases transformed time series show similar spectral behaviour, it is possible to observe closer similarities within certain subgroups of countries. we used unsupervised clustering and scaling techniques [ , ] to depict the relationship between different countries and suggest a clustering for them. first, for each country we produced a spectral estimate using regspec as mentioned above, and then formed a dissimilarity for each pair of countries by computing the euclidean distance between their spectral values (using the dist function in r [ ] ). classical multidimensional scaling was then used to produce an estimated configuration using the cmdscale function in r [ ] . for clustering we use hierarchical cluster analysis on the dissimilarity matrix we computed. it is well-known that dendrograms are sensitive to the input dissimilarity matrix, so we used the clusterwise cluster stability assessment by resampling method to produce a stable clustering [ ] . given the form of the transformed new daily cases we propose a model, m t , that is the sum of two time-modulated cosine waves, m t = m where i = , indexes the two waves and t = , . . . , n c . initial values for forecast model fitting we used α i = . , φ i = , µ i = . , p i = . , for i = , . for model evaluation we put more weight on getting later observations correct and use a residual weight vector w t = (t/n) where t = , . . . , n and n is the number of cases. for short term forecasting, we fit m(t) to the transformed daily cases by weighted least-squares using standard r [ ] optimisation functions and then extrapolate m(t), using recent weighted residuals to estimate the forecasting error. the number of daily covid- cases for countries can be found at the website of the european centre for disease prevention and control [ ] . spectral analysis and time series european centre for disease prevention and control, covid- cases worldwide should we sample a time series more frequently? decision support via multirate spectrum estimation (with discussion) we don't know if coronavirus deaths will peak this week spectra analysis for physical applications travelling waves and spatial hierarchies in measles epidemics seasonality and the persistence and invasion of measles the dynamics of measles in sub-saharan africa application of the arima model on the covid- epidemic dataset the analysis of time series: an introduction forecasting: principles and practice white noise testing using wavelets a novel sub-epidemic modeling framework for short-term forecasting epidemic waves short-term forecasts of the covid- epidemic in guangdong and zhejiang flexible procedures for clustering, r package version . - r: a language and environment for statistical computing (r foundation for statistical computing a simplex algorithm for function minimization locally stationary processes a test for second-order stationarity and approximate confidence intervals for localized autocovariances for locally stationary time series non-parametric bayesian spectrum estimation for multirate data an introduction to multivariate analysis the elements of statistical learning key: cord- - kiypige authors: huang, c.-c.; lai, j.; cho, d.-y.; yu, j. title: a machine learning study to improve surgical case duration prediction date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: kiypige predictive accuracy of surgical case duration plays a critical role in reducing cost of operation room (or) utilization. the most common approaches used by hospitals rely on historic averages based on a specific surgeon or a specific procedure type obtained from the electronic medical record (emr) scheduling systems. however, low predictive accuracy of emr leads to negative impacts on patients and hospitals, such as rescheduling of surgeries and cancellation. in this study, we aim to improve prediction of operation case duration with advanced machine learning (ml) algorithms. we obtained a large data set containing , operation cases (from jan to dec ) from a hospital. the data covered a broad variety of details on patients, operations, specialties and surgical teams. meanwhile, a more recent data with , cases (from mar to apr ) was also available to be used for external evaluation. we computed historic averages from emr for surgeon- or procedure-specific and they were used as baseline models for comparison. subsequently, we developed our models using linear regression, random forest and extreme gradient boosting (xgb) algorithms. all models were evaluated with r-squre (r^ ), mean absolute error (mae), and percentage overage (case duration > prediction + % & mins), underage (case duration < prediction - % & mins) and within (otherwise). the xgb model was superior to the other models by having higher r^ ( %) and percentage within ( %) as well as lower mae ( . mins). the total prediction errors computed for all the models showed that the xgb model had the lowest inaccurate percent ( . %). as a whole, this study applied ml techniques in the field of or scheduling to reduce medical and financial burden for healthcare management. it revealed the importance of operation and surgeon factors in operation case duration prediction. this study also demonstrated the importance of performing an external evaluation to better validate performance of ml models. it becomes more and more important for clinics and hospitals in managing resources for critical cares during the covid- pandemic. statistics show that approximately % of patients admitted to the hospital will need to be treated in the operation room (or) [ ] , and the average cost of or is up to , dollars per hour in the united states [ , ] . hence, the or is considered as one of the highest hospital revenue generators and accounts for as much as % of a hospital's revenue [ , ] . based on these statistics, a good or schedule and management is not only critical to patients who are in need of elective, urgent and emergent operations, but is also important for surgical teams to be prepared. owing to the importance of or, improvement of or efficiency has high priority so that the cost and time spent on or is minimized while the utilization of or is maximized to increase surgical case number and patient access [ ] . in a healthcare system, numerous factors are involved in affecting or efficiency, for example patient expectation and satisfaction, interactions between different professional specialties, unpredictability during operations, surgical case scheduling and etc [ ] . although the process of or is complex and involves multiple parties, one way to enhance or efficiency is by increasing the accuracy of predicted surgical case duration. over-or under-utilization of or time often leads to undesirable consequences such as idle time, overtime, cancellation or rescheduling of surgeries, which may implement negative impact on the patient, staffs and hospital [ ] . in contrast, high efficiency in or scheduling not only contribute to better arrangement for the usage of operating room and resources, it can also lead to cost reduction and revenue increment since more surgeries can be performed. currently, most hospitals schedule surgical case duration by employing estimations from surgeon and/or averages of historical case durations, and studies show that both of these methods have limited accuracy [ , ] . for case length estimated by surgeons, factors including patient conditions, anesthetic issues might not be taken into consideration. moreover, underestimation of case duration often occurs as surgeon estimations were usually made by leaning towards maximizing block scheduling to account for potential cancellations and cost reduction. furthermore, operations with higher uncertainty and unexpected findings during operation add difficulties and challenges into case length estimation [ ] . historic averages of case duration for a specific surgeon or a specific type of operation obtained from electronic medical record (emr) scheduling systems have also been used in hospitals. however, these methods have been shown to produce low accuracy due to large variability and lack of same combination in the preoperative data available on the case that is being performed [ ] . in order to improve the predictability, researchers utilized linear statistical models, such as regression, or simulation for surgical duration prediction and evaluation of the importance of input variables [ , , ] . however, a common shortcoming of these studies is that relatively lesser input variables or features were used in their models due to the limitation of statistical techniques in handling too many input variables. similarly, we combined categories for primary surgeon's id, specialty, anesthesia type and room number which had case numbers less than into the category of 'others'. in addition, since operation case duration can be related to the performance of surgeons and surgeons' performance is affected by their working time, we also analysed . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . figure . the workflow of model training for this study. the data set used for model training fall within the time range of jan , to dec , . from this data set, about % of the cases were excluded based on these criteria: patients with two or more surgical procedures performed at the same time, emergent and urgent cases, surgeons with age under , patients with age younger than , pregnant patients, procedure duration longer than hours or less than minutes and cases with missing value. the total number of cases included in the data set for model building was , . this data set was then split into training ( %) and validation ( %) subsets for model development. machine learning and linear regression models were developed on the training data set and validated on the validation data set using r-square and mean absolute error. percentage of cases with actual duration differences falling within % and minutes of predicted procedure duration was also computed. eventually, the models were further evaluated on the most recent surgical cases (from mar to apr , ) which were not included in the original data set for model training. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . surgical minutes performed by the same primary surgeons on the same day as well as within the last days, and the number of urgent and emergent operations prior to the case that was being performed by the same surgeon were included in the analysis. together, predictor variables were included for predictive model building in this study. these predictors can be categorised into groups: patient, surgical team, operation, facility and primary surgeon's prior events (see table ). model development and training we applied multiple ml methods for operation case duration prediction. operation case duration (in minutes) is the total period starting from the time patient entering into the or to the time exiting the or. historic averages of case durations based on surgeon-specific or procedure-specific from emr systems were used as baseline models for comparison in case duration prediction. at the beginning, we performed multivariate linear regression (reg) to predict operation case duration. however, when we looked at the distribution of operation case duration, it was observed to be skewing to the right ( fig. ) . we performed logarithmic transformation on operation case duration to reduce the skewness. the model built from log transformed multivariate linear regression (logreg) outperformed reg in all evaluation indexes. subsequent ml algorithms were also trained by using the log transformed case duration as the target. the first ml algorithm that we tested is random forest (rf), a tree-based supervised learning algorithm. rf uses bootstrap aggregation or bagging technique for regression by constructing a multitude of decision trees based on training data and outputting the mean predicted value from the individual trees [ ] . bagging technique is unlikely to over-fitting, in other words, it reduces the variation without increasing the bias. tree-based techniques were suitable for our data since they include a large number of categorical variables, e.g. icd code and procedure type, most of which were sparse. the number of trees that was set in study is . extreme gradient boosting (xgb) algorithm is the other supervised ml algorithm that was tested for comparison to rf. recently, xgb algorithm gains popularity within the data science community due to its ability in overcoming the curse of dimensionality as well as capturing the interaction of variables [ ] . xgb is also a decision tree-based algorithm but more computationally efficient for real-time implementation than rf. xgb and rf algorithms are different in the way of how the trees are built. it has been shown that xgb performs better than rf if parameters are tuned carefully, otherwise it would be more likely to over-fitting if the data are noisy [ , ] . we adopted -fold cross validation strategy to tune out the best . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . data-splitting strategy was used in the training for all the models to prevent over-fitting consequences. we randomly separated the data into training and testing subsets at a ratio of : . the training data were used to build different predictive models as well as to extract important predictor variables. the testing data were used for internal evaluation of the models.in addition to interval evaluation, external evaluation on all the models were performed using data from mar to apr , . surgeon-or procedure-specific calculated from emr were also evaluated on the same internal and external testing sets to ensure fair and uniform comparison across all models. data processing and cleaning as well as model development in this study were performed using r software. the packages "xgboost and "randomforest were used to implement xgb and rf algorithms in r [ , ] . r is the coefficient of determination, it represents the proportion of the variance for the actual case duration that is explained by predictor variables in our models. mean absolute error (mae) measures the average of errors between the actual case / . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . hand, the average model based on a specific procedure had lower percentage underage and overage compared to the surgeon-specific model. these differences were due to an extensive procedure classification in the procedure-specific model. however, the percentage underage was still quite high. since no other information is taken into consideration in the average model, except durations of operation cases happened in the past, prediction bias and low accuracy usually result from the average model. we first fitted the reg model by including all the input variables showed in table . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . when its performance is better on training set but poor on testing set. when we log transformed operation case duration and re-ran a regression model (i.e. logreg), the performance of logreg model improved and outperformed reg model. [ , ] . again in the logreg model, the results of all the evaluation metrics were close for training, internal and external training sets, so the model was not over-fitting. although performance of the logreg model was not bad, an assumption of linear performance of the xgb model was better than the rf model on training set but did not improve a lot compared to the rf model on internal and external testing sets. since xgb was more computing efficient than rf, the xgb model was chosen to be the best model and was used in subsequent analysis. in addition to the three key metrics, we studied inaccuracy of different models by using external testing set. we calculated the total prediction error (in minutes) and the corresponding inaccurate percentage for all the models. the results are reported in in fig. , we plotted scatter plots of actual versus predicted duration on the external testing set for the average models of surgeon-and procedure-specific, and the xgb model. a straight line indicating the theoretical perfect relationship, i.e. predicted and actual procedure duration are identical, was added as a reference in each scatter plot. the data points of the xgb models were aligned closer to the straight line. therefore, the xgb model showed a higher correlation between predicted and actual duration compared to the other two types of average model. fig. shows the density plot of differences between actual and predicted case durations for the two average models and the xgb models. it clearly demonstrates that the error distribution of xgb model was narrower and closer to . as a result, the xgb model is more accurate than the other models in predicting operation case duration. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . . density plot of differences between the actual operation case durations and predicted case durations obtained from the xgb model (light blue color) was narrower and centered more at than density plots of those obtained from the average models (pink and cyan colors). in the average models, previous operation case durations, either averaging for a specific surgeon (cyan color) or specific procedure (pink color), were used as predictions. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . how important the variable is in making a branch of a decision tree to be purer [ , ] . a higher wfg percentage indicates that the variable is more important. the result of the top important variables are shown in table . one thing worth noting is that of the top important variables are attributed to operation information. moreover, three of the features which we computed from surgeons' data (i.e. total surgical minutes performed by the surgeon within the last days and on the same day, and number of accurate prediction of operation case duration is vital in elevating or efficiency and reducing cost. this study not only helps to improve accuracy of or case prediction, it also has novelty in the following aspects. first, the data set used in this study contained more than , cases and more than different types of surgical procedures which set up a new benchmark for huge amount and large diversity. the maximal number of cases that had been used in other studies were in the range of , to , [ , ] . second, or events was modeled as dependent events instead of independent. to this end, we extracted some additional information from surgeons' data, e.g. previous . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint april as external testing data for model evaluation. fourth, though urgent and emergent surgeries were excluded from the data, number of urgent and emergent operations prior to the case that was being performed by the same surgeon was included as an input variable to account for its effect on operation case duration. currently, surgical cases at cmuh are scheduled according to estimates made by primary surgeons. however, surgeon estimates rely heavily on prior experiences of the surgeons and many factors beyond expectation will not be taken into consideration. since there is no formal record on surgeon estimates, we used averages calculated based on a specific surgeon or procedure type on the testing set to be our baseline models. the performance of these two average models, as reported in table , clearly showed that these models were poor in predicting operation case duration. they also tended to under-predict operation case duration according to their scatter plots of actual versus prediction and density plot of differences between actual versus prediction (see fig. and ). when feature variables ( table ) were included in our model development, r , mae, percentage underage, overage and within improved greatly compared to the baseline models. we applied minutes as tolerance threshold for percentage underage, overage and within because ± minutes is an acceptable periodic range in cmuh to be considered as accurately booking. to avoid having too stringent standard and to better compare our outcomes with other studies [ , ] , tolerance threshold of % was also applied. by using regression and ml approaches, we were able to decrease the total prediction error (table ) of operation case durations at cmuh. among all the models, performance of the xgb model was considered to be the best because it was more computing efficient and had the lowest inaccuracy. moreover, even though the results of evaluation metrics of the rf model were similar to the xgb model, the xgb model was still able to reduce the total prediction error in minutes from , to , minutes. in other words, the xgb model was able to save more than , minutes of idle or delay times than the rf model. since most ors usually have multiple cases scheduled per day, the total prediction error represents the cumulative effect of total or cases in the -month period of mar to april . this cumulative effect may eventually reflects a significant financial advantage in scheduling an additional operation case [ ] . this would also lead to a significant cost reduction and increment in revenue because ors are utilized appropriately and efficiently. it has been reported in the past studies that primary surgeons contributed the largest variability in operation case duration prediction compared to other factors attributed to patients [ , , ] . these studies provide evidence and rationale that more factors relating to primary surgeon should be added as input variables in the training of ml models. moreover, extensive feature engineering usually improve the quality of ml model which can be independent to the modeling technique itself. as a result, in addition to primary surgeon's identifier, gender and age, we computed previous working time and number of previous surgeries performed by the same primary surgeons within the last days and on the same day. we also counted the number of urgent and emergent operations prior to the case that was being performed by the same primary surgeon. these variables extracted from the data of primary surgeon were significantly (p < . ) correlated with operation case duration (see table in appendix). the correlation coefficients of these variables also revealed that an operation case duration performed by a primary surgeon may decrease as he or she becomes more familiar with the surgical procedure but may increase if his or her total surgical minutes are too long. although performing a surgery multiple times on different patients may help a primary surgeon to be more efficient in his or her next operation, long working time may also lead to lethargic and affect the primary surgeon's performance. in the methodology of data processing, for predictor variables which contained a lot . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . of categories, we grouped categories that had cases less than into a categories named 'others'. in addition to reducing data dimensionality for categorical features, this may aid in generalization of our model. this indicates that our model will still be able to predict case duration even for operations that are rare. moreover, our model can be applied to new primary surgeons, who are not included in the training set during model development, by setting their id as 'others' for case duration prediction. however, there is still a need to update our model after a while, for example, when the operation cases performed by a new primary surgeon has increased beyond a certain number. in terms of timing, we recommend updating the model annually by using operation cases performed in the most recent years as training data. one limitation in this study is that we selected predictor variables which could only be extracted from preoperative data. our ml model still needs to be improved in order to be able to predict surgical case duration dynamically. for example, blood loss during operation may affect case duration as an unexpected increase in blood loss may cause surgeons to take longer time to complete the surgery. therefore, it would be better if intra-operative data are incorporated during ml model development and prediction made by the ml model can be updated during operation. one common issue in all ml studies in predicting operation case duration, including our study, is that ml models were developed using data from a single site. these ml models have difficulties in generalization, since the surgical team, facilities and patient populations are different across entities. it has to be custom made for a given organization using training data containing its patients, procedures, surgeons, medical staffs, and the facility itself. as a result, the exact same ml model is not meant to and will not perform well when applied to another organization or hospital. the other interesting issue of applying ml or artificial intelligence in operation estimation is that medical technologies evolve fast. hence, how frequent should a ml or artificial intelligence model need to be updated still remains to be answered. the xgb model was superior in predictive performance when comparing to the average, the reg and the logreg models. the total inaccuracy of predicted outcomes of the xgb model was the lowest among the other models developed in this study. although the performance of the rf model was close to the xgb model, the xgb model was more computing efficiency than the rf model in which it took shorter time to complete the training process. the coefficient of determination (r ) was higher while percentages of under-and over-prediction of the xgb model built in this study were also lower than other ml studies [ , , ] . moreover, this model improves the current or scheduling method which is based on estimates made by surgeons at cmuh. we propose extracting additional information from operation and surgeons' data to be used as predictor variables for ml algorithm training since their importance was high in the xgb model. moreover, we validated the model types using an external testing set in additional to the internal testing set split from the original data used in model training. this helped us to validate and test the models in a more stringent and rigorous way. therefore, we suggest external evaluation should be used as a tool to better validate the predictive power of ml models in the future. appendix . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . table . correlation coefficient, standard error, t-value and p-value of predictor variables extracted from primary surgeons' data. these information were obtained from the log transformed multivariate regression (logreg) model. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint optimization and planning of operating theatre activities: an original definition of pathways and process modeling improving operating room efficiency: machine learning approach to predict case-time duration a comparative analysis of xgboost package 'randomforest' title breiman and cutler's random forests for classification and regression package 'xgboost' type package title extreme gradient boosting understanding costs of care in the operating room decrease in case duration required to complete an additional case during regularly scheduled hours in an operating room suite predicting the unpredictable: a new prediction model for operating room times using individual characteristics and the surgeon's estimate greedy function approximation: a gradient boosting machine factors that influence the expected length of operation: results of a prospective study surgical unit time utilization review: resource utilization and management implications surgical duration estimation via data mining and predictive modeling: a case study use of simulation to assess a statistically driven surgical scheduling system improving predictions of pediatric surgical durations with supervised learning the surgical scheduling problem: current research and future opportunities tree boosting with xgboost -why does xgboost win "every" machine learning competition? tree boosting with xgboost -why does xgboost win "every" machine learning competition? newer classification and regression tree techniques: bagging and random forests for ecological prediction operating room efficiency improved prediction of procedure duration for elective surgery decision tree methods: applications for classification and prediction. shanghai archives of psychiatry surgeon and type of anesthesia predict variability in surgical procedure times a machine learning approach to predicting case duration for robot-assisted surgery relying solely on historical surgical times to estimate accurately future surgical times is unlikely to reduce the average length of time cases finish late the authors would like to thank shu-cheng liu, jhao-yu huang and min-hsuan lu in providing feedback during the progress of this study. key: cord- -jdizyzbl authors: bertschinger, nils title: visual explanation of country specific differences in covid- dynamics date: - - journal: nan doi: nan sha: doc_id: cord_uid: jdizyzbl this report provides a visual examination of covid- case and death data. in particular, it shows that country specific differences can too a large extend be explained by two easily interpreted parameters. namely, the delay between reported cases and deaths and the fraction of cases observed. furthermore, this allows to lower bound the actual total number of people already infected. the unfolding covid- pandemic requires timely and finessed actions. policy makers around the globe are hard pressed to balance mitigation measures such as social distancing and economic interests. while initial studies [ ] predicted millions of potential deaths never findings hint at a much more modest outcome [ , ] . especially the case fatality rate (cfr) and the number of unobserved infections are crucial to judge the state of the pandemic as well as the effectiveness of its mitigation. yet, there estimates are plagued with high uncertainties as exemplified in the quick revisions even from the same institution [ , ] most studies are based on elaborate epidemic modeling either using stochastic or deterministic transmission dynamics. especially, the susceptible-infectedrecovered (sir) model [ ] forms a basic building block and has been extended in several directions in order to understand the dynamics of the ongoing covid- pandemic [ , , , ] . in this context, it has not only been compared with more phenomenological growth models [ ] , e.g. logistic growth, but also been used to quantify the effectiveness of quarantine and social distancing [ , ] . e.g. social distancing, can be easily included by replacing the infection rate parameter with a function allowing it to change over time. [ ] assumes one or several (soft) step functions where the infection rate drops in response to different measures after these had been implemented. such detailed modeling is required in order to capture and forecast temporal dynamics of the epidemic spreading. yet, substantial care is needed as to which parameters can be learned from the data and which cannot. indeed, i show here that sir type models -and others exhibiting similarly flexible growth dynamics -are non-identified with respect to the cfr and the fraction of observed infections. instead, a direct visual exploration of the data leads to valuable insights in this regard. in particular, much of the variability relating reported case and death counts can be explained by two easily interpreted parameters. furthermore, based on three simple assumptions a lower bound on the number of actual infections, including observed and unobserved cases, can be obtained. in turn, confirming recent estimates without the need of complex and maybe questionable modeling choices. covid- data are published by several sources, most notably the john hopkins university and the european center for decease prevention and control (ecdc). here, data from ecdc as available from https://opendata.ecdc. europa.eu/covid /casedistribution/csv are used. figure shows the total cumulative case and death counts of selected countries. these countries are among the eight most effected countries in terms of absolute and relative deaths . in the following, i will focus on relative counts as these are arguably more meaningful when comparing different countries -which could differ widely in terms of population size. assumption . death counts are more reliable than case counts. by assumption analysis will start from relative cumulative death counts d t in the following . furthermore, in order to facilitate country comparisons, dates are shifted relative to the first day that relative death counts exceed a threshold θ of , , or deaths per million inhabitants respectively, i.e. t = is defined such that d t ≥ θ for t ≥ and d t < θ for t < . figure shows the resulting time course of relative case and death counts. aligning dates in this fashion shows that several countries exhibit similar time courses, e.g. belgium and spain or china and south korea. as shown in the supplementary figure s the remaining country specific differences can be explained by differences in growth rates. re-scaling time according to the estimated doubling time indeed leads to a data collapse as complete as often observed in physical systems exhibiting scaling laws [ ] . here, these differences in the precise temporal dynamics of epidemic growth are not required. instead, the relation between relative death and case counts is considered. while relative death counts exhibit similar time courses the corresponding relative case counts c t are more variable when aligned in the same fashion, i.e. relative to the first day that d t exceeds a given threshold. as i will argue now, most of this variability can be explained with two readily interpretable parameters. there is a well defined country specific delay between reported cases and deaths. relative days since one death per mill. estimated cfrτ for varying delays τ ita figure : estimated cfr cfr τ for germany (left) and italy (right) using different delays of τ = , . . . , days. note that in each case, there exists a characteristic delay such that estimates are almost constant over time. further note that estimates for all delays will eventually converge to the same final value when enough data are available. figure suggests that relative case counts are not aligned as some countries, e.g. germany, systematically lead the counts reported in other countries, e.g. italy. such a difference could mean that individuals survive longer, e.g. due to differences in medical care, until they eventually. it could also just reflect reporting delays due to bureaucratic reasons. in any case, it is clearly the case that individuals die not immediately, but some days after they had been tested positive previously. this delay also needs to be taken into account when estimating the case fatality rate (cfr). commonly the cfr is defined as cfr = dt ct . not surprisingly this estimate is highly variable and changes systematically over time, especially at the beginning of an epidemic. the observation captured in assumption also explains the surprisingly low cfrs initially announced in austria and germany where reported death counts are simply some days older compared to other countries! thus, taking into account that individuals that had been tested positive will usually not die on the same day but after some delay τ (if at all), i define i.e. comparing current death with previous case counts. figure shows the cfrs estimated for germany and italy in this fashion, i.e. for different delays τ . the estimate using τ = rises over time simply reflecting that due to the reporting delay death counts have not yet caught up with the exponentially growing case counts. interestingly, for each country there exists a characteristic delay at which the estimated cfrs are essentially constant. thus, reflecting the hypothesized delay between reported cases and deaths. this delay can either be estimated by visual inspection or by fitting a linear model on each delay and picking the one with minimal absolute slope . figure shows the delays τ and corresponding cfrs cfr τ , i.e. the median cfr value at this delay, estimated for each country in this fashion. in order to fully relate the observed case with death counts an additional, and stronger, assumption is needed. assumption . the true case fatality rate is the same for all countries. while assumption ignores medical, demographic and other differences between countries, i believe it unlikely that the cfr is very different across different countries. in the end, its the same type of virus spreading in all countries. this suggests that differences in estimated cfrs simply reflect differences in the ability of countries to actually observe all infected individuals, i.e. due to more or less effective tracking and testing procedures. to illustrate this effect, a true cfr of % is assumed in the following. this is consistent with current knowledge and had also been used in other studies [ ] . just from the estimated values any cfr below the minimum of all estimates (about % found for austria and south korea) and above . % (which would imply an observed fraction above one for belgium) is compatible with the data. figure shows the country specific estimates of reporting delay, cfr and fraction of observed cases (assuming a true cfr of %) obtained in this fashion. in turn, figure shows the implied relative case counts when shifted by the estimated delays and scaled to reflect the unobserved fraction of cases for each country. notably, these implied counts all align nearly as good as the death counts in figure (right panel) even though the initial threshold was based on the deaths counts alone. the supplementary figure s shows that this holds also when re-scaling time according to the growth rate of deaths. overall, the collapse of implied case dynamics convincingly illustrates that the relation between case and death counts is fully and reliably captured by two parameters -compatible with three reasonable assumptions. in reality, an additional delay between an infection and its corresponding positive test result can be assumed. therefore, the fraction of observed cases will be even lower than obtained by the analysis above. unfortunately, assuming a sufficiently flexible model for the growth of the actual cases already the cfr and the fraction of observed cases, let alone an additional delay, are not jointly identifiable. the basic sir model [ ] , assumes that an infection unfolds when susceptible (s) individuals become infected (i) -which in turn infect further susceptible individuals. finally, infected individuals recover (r) (or die) and are no longer susceptible. in continuous time, the dynamics can be described by the following system of ordinary differential equations (odes): where n ≡ s t + i t + r t is constant over time. model parameters are • the infection rate β • and the recovery rate γ. in this model, the average time of infection is γ − giving rise to a basic reproduction number of r = βγ − . sir models and extensions are widely used in epidemic modeling. the have also been applied to the understand the dynamics of the ongoing covid- pandemic [ , , , ] . in particular, models including the possibility of unobserved cases or including a reporting delay have been developed. within the sir framework, both effects can be included in several ways, most easily by assuming that observed cumulative infections are simply a fraction α ∈ [ , ] of previous total infections i t + r t , i.e. α(i t−τ + r t−τ ). a more elaborate attempt instead considers more detailed dynamics of the form where a fraction α of infected individuals i t is observed (o t ) after an initial delay γ i . in any case, whether observed or not, individuals recover (or die) after an additional delay. in general, the infection rates β i , β o , β u could be different for initial infections and observed vs unobserved cases . in addition, mitigation measures, e.g. social distancing, can be easily included by assuming that β's are functions of time. e.g. αγ i i t . now assume a second model with α = > α which nevertheless exhibits the same dynamics with an additional time shift τ . by using a time varying β (t) such that we obtain exactly the same number of observed cases, i.e. o t−τ = o t . note that as α > α, we have that s t < s t−τ and s t is a sigmoidal function of time due to the sir dynamics. furthermore, when the population is large, i.e. n and s ≈ n the resulting β (t) is mostly driven by the drop in s t+τ as compared to the much smaller change in s t . indeed, figure shows the dynamics of the above model with β = . , γ i = γ r = , α = . starting from (n = , , , , ). in turn, assuming α = and τ = , the time varying infectivity β (t) is approximated by the best-fitting logistic sigmoid of the form β + (β − β )σ( t−τ t ). note that the number of observed cases is identical, just shifted by τ , whereas the final fraction of susceptible individuals is vastly different. indeed, in the first case the epidemic is stopped by group immunity whereas in the second case effective mitigation measures are imposed. correspondingly, police implications would be vastly different in the two situations even though they are observationally indistinguishable. instead of detailed modeling of epidemic dynamics, which is further complicated due policy actions requiring flexible models with delicately chosen parameters, the present analysis is based on visual inspection of the reported data. overall, relative case and deaths counts (observed for country c) seem to be related as follows: where a c r denotes the actual infections a fraction α c ∈ [ , ] is observed. a suitable reporting delay τ c can be estimated by visual inspection of the data, but again the fraction of observed cases α c and cfr cfr are not jointly identifiable if there exist sets of parameters such that a t−τ = αa t , as is the case for dynamic sir type models. in the end, any epidemic modeling implicitly or explicitly chooses a parametric form for the latent growth process a t and will not be identified if sufficiently flexible. yet, assumption three of a constant cfr across all countries allows to derive . a range of values consistent among all countries, . as well as recover the corresponding fraction of observed cases in each country. thereby, assuming a reasonable true cfr value, i.e. from the model implied range . % to % which is also consistent with current knowledge, and using the estimated delay, the actual case numbers can be reconstructed. figure shows the resulting actual relative infection counts across several countries. note that despite the simplicity of this analysis, the estimated numbers compare favorable [ ] . indeed, i would rather trust these even more as they do not rely on complex modeling assumptions but follow from visual inspection of the data. overall, i have illustrated that much of the variability between observed case and deaths counts between different countries can be explained by two parameters. namely, the reporting delay τ and the fraction of observed cases. especially the reporting delay exhibits crucial differences between countries and needs to be taken into account when comparing data and planning actions. in particular, containment is challenging when long incubation times are involved [ ] but a combination of case tracing and isolation policies could be effective [ , ] . thus, detailed epidemic modeling is certainly needed in order to judge the effectiveness of current mitigation measures across different countries [ , ] . on the other hand, important parameters need to fixed based on additional knowledge as they cannot be identified within sufficiently flexible models. in the end, data analysis and detailed modeling alone only gets us only that far and more extensive testing is urgently needed to obtain reliable knowledge about the current progression of the covid- pandemic. figure s : aligned data as in figure , but time is additionally re-scaled to match local growth rate of the epidemics. a data collapse by re-scaling time aligning the data as in figure still shows country-specific differences in the temporal course of epidemic spreading. much of this difference can be attributed to the speed at which the epidemic spreads in different countries. estimating the local growth rate of deaths d log dt dt by the three day running average of observed changes log d t+ − log d t , relative time, i.e. relative to the threshold of total deaths reached, is re-scaled to match local growth rates. figure s shows the resulting data collapse for d t and the corresponding c t dynamics. further, taking the estimated relation between cases and deaths via cfr and country specific delays into account an almost complete data collapse for the cases is obtained. not that as in the main text, data are aligned according to relative death counts only. furthermore, the temporal re-scaling is based on the estimated growth rate from the death counts as well. yet, shifting and scaling case data according to the estimated country specific delay and fraction of observed cases leads to an almost complete data collapse as well. as individual countries can be hard to identify in figures and , the ny times featured panel views where each country is highlighted above a background of all countries. here, i provide similar figures for relative death and case counts using a threshold of two deaths per million inhabitants. note that an sir model already includes a natural delay between infections and recovery (or death). indeed, the total number of cases is given by c t = i t + r t while the cumulative death toll is obtained as cfrr t , i.e. modeling that a fraction of individuals does not recover but dies instead. assuming that only a fraction α of cases is observed, the model is estimated with the following relative days since two death per mill. relative count figure s : details of aligned and adjusted case counts for threshold of two deaths per million. sampling distribution thus, observed daily changes are related to the model implement changes via an over-dispersed poisson aka negative binomial distribution. figure s shows the resulting estimates assuming β t = β + (β − β )σ( t−τ t ) and cfr = % . the sir model assuming a single change point in the infectivity, via the logistic sigmoid sigma(·) in β t reflecting the implementation of social distancing is clearly able to capture the epidemic dynamics. yet, parameter uncertainties, especially about the reporting delay can be large . bayesian estimates have been carried out using stan (full code available from my https://github.com/bertschi/covid repository) and using weakly informative broad normal or student-t prior distributions on all parameters. due to the non-identifiability derived in the main text either α or cfr needs to be fixed. the high uncertainty could also reflect that an sir dynamics is misspecified in that it corresponds to an exponential delay distribution. such additional model assumptions need to be carefully chosen in order to obtain meaningful parameter estimates. figure s : model predictions and estimated parameters from sir model fitted to data from italy (top) and germany (bottom). mitigation and herd immunity strategy for covid- is likely to fail. medrxiv inferring covid- spreading rates and potential change points for case number forecasts impact of nonpharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand estimating the number of infections and the impact of non factors that make an infectious disease outbreak controllable a retrospective bayesian model for measuring covariate effects on observed covid- test and case counts substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) fundamental principles of epidemic spread highlight the immediate need for large-scale serological surveys to assess the stage of the sars-cov- epidemic. medrxiv effective containment explains subexponential growth in confirmed cases of recent covid- outbreak in mainland china scaling, universality, and renormalization: three pillars of modern critical phenomena rational evaluation of various epidemic models based on the covid- data of china. medrxiv modeling the epidemic dynamics and control of covid- outbreak in china. medrxiv key: cord- -h h vd r authors: scabini, leonardo f. s.; ribas, lucas c.; neiva, mariane b.; junior, altamir g. b.; farf'an, alex j. f.; bruno, odemir m. title: social interaction layers in complex networks for the dynamical epidemic modeling of covid- in brazil date: - - journal: nan doi: nan sha: doc_id: cord_uid: h h vd r we are currently living in a state of uncertainty due to the pandemic caused by the sars-cov- virus. there are several factors involved in the epidemic spreading such as the individual characteristics of each city/country. the true shape of the epidemic dynamics is a large, complex system such as most of the social systems. in this context, complex networks are a great candidate to analyze these systems due to their ability to tackle structural and dynamical properties. therefore this study presents a new approach to model the covid- epidemic using a multi-layer complex network, where nodes represent people, edges are social contacts, and layers represent different social activities. the model improves the traditional sir and it is applied to study the brazilian epidemic by analyzing possible future actions and their consequences. the network is characterized using statistics of infection, death, and hospitalization time. to simulate isolation, social distancing, or precautionary measures we remove layers and/or reduce the intensity of social contacts. results show that even taking various optimistic assumptions, the current isolation levels in brazil still may lead to a critical scenario for the healthcare system and a considerable death toll (average of , ). if all activities return to normal, the epidemic growth may suffer a steep increase, and the demand for icu beds may surpass times the country's capacity. this would surely lead to a catastrophic scenario, as our estimation reaches an average of , deaths even considering that all cases are effectively treated. the increase of isolation (up to a lockdown) shows to be the best option to keep the situation under the healthcare system capacity, aside from ensuring a faster decrease of new case occurrences (months of difference), and a significantly smaller death toll (average of , ). although we have experienced several pandemics throughout history, covid- is the first major pandemic in the modern era. the last critical global epidemic occurred in and became known as the spanish flu. but, in , the reality was quite different. scientific and medical knowledge was much more limited, making it difficult to fight the disease. furthermore, the world was not globalized, the means of transport were not as agile as the current ones and the population was much smaller. the st century is marked by globalization and an intricate and intense social network, which connects in one way or another to everyone on the planet. the latter fact increases the danger that a local epidemic disease will rapidly evolve into a pandemic like what happened in wuhan, china, and now is all over the world. the form of propagation and contagion of the sars-cov- virus occurs by direct contact between individuals, through secretions, saliva, and especially by droplets expelled during breathing, speeching, coughing, or sneezing. the virus also spreads by indirect contact, when such secretions reach surfaces, food, and objects [ ] . besides, infected people take a few days to manifest symptoms, which can be severe or as mild as a simple cold. there is even a large proportion of infected people who remain asymptomatic [ ] . this makes it practically impossible to quickly identify the infected and apply effective measures to limit the spread of the disease. also, sars-cov- was discovered in december , which makes it very recently in the face of the current epidemic. little is known about the covid- disease, which appears to be highly lethal, with no drugs to prevent or treat. the concern is greater since direct (individual -individual) and indirect (individual -objects -individual) social relations are the means of spreading the disease. thus, the social interaction structure is the key to create strategies and guide health organizations and governments to take appropriate actions to combat the disease. one of the main concerns is overloading the health system. the first case in brazil was confirmed on february , a -year-old man who traveled to the lombardy region in northern italy. now, in the middle of may, there are more than , cases and , deaths in all states of brazil [ ] . the concern is even worse due to the country's social inequality, over % of the population relies solely on the public health system and this distribution is not uniform. according to [ ] , there are only hospital beds per , people in the north region while southeast accounts for hospital beds. the treatment of severe cases requires the use of respirators/ventilation in intensive care units (icu), and if simultaneous infections occur there will be no beds to meet the demand and a possibly large number of victims. thus, it is urgent to develop models and analyses to try to predict the evolution of the virus. also, as noted in figure , brazil is running towards being the next epicenter of the pandemic. it has already exceeded the number of cases in important countries such as germany, china, japan, italy, iran, south korea, and france (the rates consider the population size of each country and are on a logarithmic scale). [ ] ). it is possible to notice that brazil is surpassing countries such as italy, south korea, japan, and china, and it is reaching the relative number of cases in the united kingdom and france. as of the date of this study, the united states is the epicenter of the pandemic. since covid- presents a unique and unprecedented situation, this work proposes a specific model for the current pandemic. based on the classic epidemic model sir, also extended to sid [ ] , siasd [ ] and siqr [ ] , we propose a more realistic model to better represent the effects of the covid- disease by adding more infection states. the proposed approach also considers social structures and demographic data for complex network modeling. each individual is represented as a node and edges represent social interaction between them. the multi-layer structure is implemented by different edges representing specific social activities: home, work, transports, schools, religious activities, and random contacts. the probability of contagion is composed of a dynamic term, which depends on the circumstances of the social activity considered, and a global scaling factor β for controlling characteristics such as isolation, preventive measures, and social distancing. the proposed model can be used to analyze any society given sufficient demographic data, such as medium/big cities, countries, or regions. here we analyze in depth the brazilian data. the sir model is applied through the network using an agent model, and each iteration of the system is simulated using the -hour pattern, allowing us to understand the dynamics of the disease throughout the days. the results show the importance of social distancing recommendations to flatten the curve of infected people over time. this is currently maybe the only way to avoid a collapse of the health system in the country. the paper is divided as follows: section presents important concepts about complex networks, the sir model and its applications. section explains our proposed approach and sections and presents the results, discussion, and conclusions of the work. created from a mixture of graph theory, physics, and statistics, complex networks (cn) are capable to analyze not only the elements themselves but also their environment to find patterns and obtain information about the dynamics of a system. as most of the natural structures are composed of connected elements, graphs are suitable to analyze most of the real-world phenomena. over the past two decades researchers have been showing that many real networks do not present a random structure, and its emergent patterns can be used to understand and characterize a model [ , ] . complex network analysis has then been applied to sociology, physics, nanotechnology, neuroscience, biology, among other areas [ , ] . to start with a formal definition, a graph g is a set {v,e} where v is composed by n vertices (also known as nodes or elements) {v i , v n } and e is the set e(v i , v j ) of edges (or connections) among its elements. edges represents the relationships between two elements and its value can also represent the strength or weight of a connection if usually, applications with complex networks consist of two main steps: i) transform the real structure into a complex network, and ii) analyze the model and extract its features or understand its dynamics. one natural phenomenon that has a straight forward connection to a complex network in society. people are connected due to several aspects such as members of a family, religious groups, co-workers, members of the same school, or faculty, among other social relationships. therefore cns have been widely employed for social network analysis [ ] . extended from social interactions, the epidemic spread has also been studied by researchers in the last decades. in this context, one of the best known and widely used epidemic models in infectious diseases is the susceptible-infectedrecovered (sir) model, which is composed of three categories of individuals [ , ] • susceptible: the ones who are not infected but could change its status to a state to infected if in contact with a sick person combined with a probability β of contagion • infected: the ones that have the disease • recovered: usually after some time, a person recovers from the illness and it is not able to be infected again due to the immunity process (in this case, this is an assumption of the process). the recovery rate of infected people is aligned with a probability of γ also, the model can be described as where s, i and r represents the ratio of susceptible, infected and recovered people in the population, respectively. usually, the problem is solved with differential equations, however, agent-based techniques in networks can represent the nature of the spread of viral diseases in a more complex scenario. if a network is fully connected, meaning that e(v i , v j ) = { , ∀ i,j < i, j <= n }, equation fits the structure perfectly. however, in the real world, not everyone is connected and people only contract the disease if in contact with an infected individual or object. this is why a complex network approximates the dynamics of real viruses and can help us to understand the disease behavior. there are various approaches to represent people and society as networks, named social network analysis. small world networks [ ] can be used as a good approximation of the social connections. in , moore [ ] emphasized that the use of small-world networks, where the distance among two elements is usually small in comparison to the size of the population, showed a faster spread of the viral disease than classical diffusion methods. the approximation of real social phenomena was first explained by milgram [ ] in [ ] , the sociologist is the author of the well-known idea that there are up to six people separating any two individuals in the world, which reinforces the importance of analyzing the epidemic spread from a graph view. in [ ] , the authors used small-world networks to simulate a sir model, however, they considered that every contact with an infected person resulted in contamination, which is not realistic. therefore, other researchers improved the model over the years, adding new constraints to approximate the simulation to real scenarios [ ] . the sir model on networks works as follows: each node represents a person and, the elements are connected according to some criteria and the epidemic propagation happens through an agent-based approach. it starts from a random node, and for each time step nodes with the susceptible state can contract the disease from a linked infected node with a predefined probability. the same idea occurs with the recovered category. after a certain period, a node can recover or can be removed from the system (case of death) according to a certain probability. at the end of the evolution of a sir model applied to a network, the number of nodes in each sir category (susceptible, infected and recovered) can be calculated for each unit of time evaluated and then compare these data with real information, for example, the hospital capabilities of the health system. also, the probability of infection and recovery can be adjusted over time considering social distancing, hygiene, and health conditions. the proposed model extends the sir model to a more realistic scenario to achieve a better correlation to the covid- disease, since the model was created specifically for the disease, we named the model as complexvid- . our strategy is based on a multi-layer network to represent the brazilian demography and its different characteristics of social relationships. each layer is composed of a set of groups representing how people interact in a given social context. in the network, a node represents a person and the edges are the social relationships between persons, and they are also the means through which the disease can be transmitted. the virus spreads from an infected node to neighboring nodes at each iteration step ( step = day), according to a given infection probability. first, we describe how the layers are built based on social data from brazil. to define the different social relations, the first information needed is the age distribution so that groups such as schools and work can be separated. we consider the brazilian age distribution in relation to the total population in [ ] , details are given on table . this distribution is used to define an age group for each node, which is then used to determine its social activities through the creation of edges on different layers. in this approach, each network-layer represents a kind of social relationship or activity that influences the transmission of the covid- . in this way, it is possible to evaluate and understand what is the impact of each social activity in the epidemic propagation. basically, in this work, a network layer is represented by a set of edges connecting some nodes. the following social activities are considered, composing different layers: • home: in this layer, all people that live in the same residence are connected. • work: connects people that work in the same environment/company. • transport: this layer represents people that eventually take the same vehicle at public transports. • school: represents the social contact of students that belong to the same school class. • religious activities: connects people of the same group of some religious activity. • random: this layer represents activities of smaller intensity, such as indirect contact (through objects/surfaces). the first layer represents home interactions and is composed of a set of groups with varying size which are fully connected internally. these groups have no external connections, i.e. the network starts with disconnected components representing each family. to create each group, we consider the brazilian family size distribution for [ ] , the year with more detailed information on family sizes from up to members. we consider the probability of a family having sizes from to , therefore the probability of a family having persons is the sum of the higher sizes, the details of this distribution are given in table . the first layer is then created following the family size distribution and ensuring that each family has at least adult. figure (a) shows the structure of such a layer built for a population of n = . a large fraction of the population in any country needs to work or practice some kind of economic activity, which also means interacting with other people. thus, work represents one of the most important factors of social relations, which is also very important in an epidemic scenario. to represent the work activity we propose a generic layer to connect people with ages from to years, i.e. % of the total population in the case of brazil. there is a wide variety of jobs and companies, therefore it is not trivial to create a connection rule that precisely reflects the real world. here, we consider an average scenario with random groups of sizes around [ , ] , uniformly distributed, and internally connected (such as the "home" layer). an example of this layer is shown on figure (b), using n = . although the nodes of a group are fully connected, the transmission of the virus depends directly on the edge weights, which we discuss in-depth on section . . . collective transports are essential in most cities, however, it is one of the most crowded environments and plays an important role in an epidemic scenario also due to the possibility of geographical spread, as vehicles are constantly moving around. the third layer we propose represents this kind of transports, such as public transports, and includes people that do not possess or use a personal vehicle. in brazil the number of people using public transport depends on the size of the city, with . % in the capitals and . % in other cities [ ] , with an average use of around . hours a day . here we consider the average of the population between the two cases ( %), randomly sampled, to participate in the "transports" layer. random groups are created with sizes between [ , ] , uniformly sampled, and the nodes within each group are fully connected. this variation of sizes is considered to represent cases such as low and high commuting times, and also the differences between vehicle sizes. other factors such as agglomeration and contact intensity are discussed in section . . . this layer is illustrated on figure (c). schools are another environment of great risk for epidemic propagation. the proposed layer considers the characteristics of schools from primary to high school and how children interact. we consider that all persons from to years ( % of the brazilian population) participate in this layer, and the size of the groups, which represents different school classes, varies uniformly between [ , ] [ ]. this layer is illustrated on figure (d). brazil is a very religious country, in which by only around . % of the population claimed not to belong to any religion [ ] . . % claimed to be catholic and . % to be protestant, summing up to . % of the total population. here we consider that nearly half of these people ( % of the total population) actively participate in religious activities (weekly). the distribution of religious temple sizes is defined as a pareto distribution in the interval [ , ] . taking into account that wage distribution follows the pareto distribution approximately, we model real estate predominance according to their capacity. the assumption here is that building costs (for churches, offices, homes, etc.) have a linear relationship to their internal capacity, and thus any given capacity has a power-law relationship with the number of such buildings within a region. we consider a random layer to represent all kinds of contacts not related to the specific previous social layers. this includes small direct contacts (person-to-person) and indirect contacts (individual -objects -individual) that may happen throughout the week, such as random friend/neighbor meetings, shopping, and other activities that involve surface contacts. for that n new random edges are created, that can connect any node. on the one hand, this yields an average of random connections to each node, which can randomly connect any other node. on the other hand, the impact of this layer on the epidemic is smaller than the others, as it represents rapid contacts in comparison to the other activities described, thus its infection probability is smaller. in the following section we discuss the details concerning this aspect, deriving from the edge weights of each layer. in figure (f) an example of this layer is shown. the overall structure of social interactions in our model can be compared to the statistical analysis in [ ] , however here we introduce a more detailed model of social contacts with specific layers and connection patterns to better fit the particularities of a given country or city. unlike the traditional sir model, which consists of a single β term to describe the probability of infection, here we propose a dynamic strategy to better represent the real world and the new covid- disease. the idea is to incorporate important characteristics in the context of epidemic propagation according to each layer. firstly, to a given layer a fixed probability term is calculated to represent its characteristic of social interaction. for this, we considered local terms: the contact time per week, the average number of people close to each other (agglomeration level), and the total number of people involved in the respective activity. considering two nodes v x and v y , connected at group j of layer i, its edge weight is then defined by where t i represents the average weekly contact time on layer i, k i is the agglomeration level (average number of nearby people) and n ij represents the size of the group j in which the nodes participates on layer i. the first fraction represents the contact time normalized by the total time of the week ( * = ), and the second fraction represents the proportion among the local people closest to the total number of people on that activity group. the first part of the infection probability equation is multiplied by a β term, which scales the original probability. the β term is then the only parameter to tune the infection rates for the entire network, and the other properties are specific for the studied society, based on its population characteristics and the nature of the activities (layers). table shows these specific properties that we considered for the brazilian population, and how the infection probabilities are calculated for each layer. in the table, we have the following information: who or how many people are part of the activity represented by a layer (column "who", discussed in the previous section); contact time according to activity (column "time of contact"); the average number of people close to each other in each activity (column "nearest", represents the agglomeration level); the number of connections between people (column "group size"); the probability of infection (column "probability"). • susceptible: traditional case, it means that a person can be infected at any time. this is the initial state of every node. • infected -asymptomatic: people who do not show any symptoms ( % of the total cases of infection) and remain contagious for up to days (they may recover after days). this is the most dangerous case for the epidemic spreading because the person is not aware of its infection. • infected -mild: % of the cases, present mild and moderated symptoms with no need for hospitalization, remain contagious for up to days, and may recover after days of infection. • infected -severe: % of the cases, present strong symptoms, and need hospitalization, remain contagious for up to days. has a death rate of % and may recover after days. • infected -critical: present worst symptoms and remain contagious for up to days, need icu and ventilation, have a death rate of % and may recover after days. • recovered: people who went through one of the infection cases and overcame the disease, ceasing to contaminate and supposedly becoming immune. these nodes no longer interact with other nodes anymore and are therefore removed from the network. • dead: people who went through severe or critical cases and eventually died. these nodes are also removed from the network. estimates for the proportion of asymptomatic cases vary from % ( % confidence, [ . , . %]) [ ] to % ( % confidence, [ . , . %]) [ ] . considering the confidence intervals, here we roughly approximate it to an average of % of the total number of infected cases. however, it is very difficult to study asymptomatic cases due to several reasons, such as the lack of available tests and the difficulty in identifying potential cases, which would include every person who had contact with known symptomatic cases. some studies indicate that asymptomatic cases may remain contagious for up to days, with an incubation period of days [ ] , but the viral load may be smaller at the end of the infection. here we take an optimistic approach considering that they may recover (become immune and cease to contaminate) uniformly after days of infection, up to around days. as for the recovered nodes, we are considering that people become immune or at least acquire a long-term resistance to the virus, up to a maximum of days (limit of our simulations). however, this should be taken cautiously as these properties are not yet fully understood [ ] . the infection grows through the contact (edges) between infected and susceptible nodes, and the probability of being infected is the edge weight. if infection occurs, then one of the infection cases are chosen based on the probability described above ( %, %, % and %). this distribution plays an important role in the structure and dynamics of the network. the node structure of asymptomatic cases does not change during the simulation, except for the time it takes to cease contamination and recover. it means that as these persons are not aware of their contamination, they will remain acting normally on the network (according to the active layers and edge weights). their contagious time varies from to days after infection. concerning the other cases (mild, severe, and critical), we consider the incubation time of the virus, the recovery time, the contagion time, the death rates of each case, and the usual action taken by the infected person or health professionals at hospitals. various works [ , , ] point out that the average incubation period of covid- is around days, but some cases may take much less or more time. the official who report [ ] states that the average incubation time is around to days, with cases up to days. the results in [ ] show that the average shape of the incubation time follows a log-normal distribution (weibull distribution) with an average of . days and a standard deviation of . days. in this context, we consider the day when an infected person begins to show symptoms by randomly sampling from this distribution ( repetitions), with cases varying from to days. for mild cases, the nodes are isolated at home, maintaining the connections of the first layer, and then only % of the cases are diagnosed. considering the ratio of diagnosed cases, patients who are asymptomatic or with mild symptoms of covid- may not seek health care, which leads to the underestimation of the burden of covid- [ ] . moreover, our diagnosis rule is also based on the fact that ongoing tests in brazil are increasing more slowly than in most european countries and the usa (tests are being performed mostly on people that need hospitalization). if a given case is severe or critical, the patient goes to a hospital and is fully isolated, i.e. we remove all of its connections. this is a rather optimistic assumption, considering that these patients still may infect the hospital staff. concerning the time that patients usually stay at hospitalization/icu, the works [ , ] points to an average of days for all cases. for standard hospitalization, we considered a minimum of days and a maximum of days of stay, and for the icu/ventilation, a minimum of and a maximum of days of stay. the time of each case will depend on the day the symptoms start and the day of recovering/death. figure illustrates all the infected states and mechanisms described here. this configuration results in an overall lethality of %. it is important to stress that here we consider a maximum of days of infection time, which is the time frame based on most studies we have seen so far in the literature. we are still at the beginning of the pandemic and a better characterization of the long-term impact is very difficult. nonetheless, the available information allows to represent the most obvious features of the sars-cov- virus and to evaluate its main impacts on society. to simulate the reduction or increase of social distancing/quarantine, we remove/include some layers of the network, or change their edge weights. similarly to the approach on [ ] to improve home contact when in quarantine, we increase the home layer edge weights by % for each removed layer. to balance that we considered a smaller number of hours of contact in the base calculation for the home layer ( hours a day), also taking into consideration that this layer has full contact between people of the same family. when the home contacts are increased according to our approach of layer removal, the time/intensity of contacts may increase up to its double. for each experiment with the proposed model, we consider the average and standard deviation (error) of random repetitions to extract statistics of infection, death, and hospitalization time. due to the random nature of these networks, it is possible that extreme cases occur within the repetitions, i.e. when the infection starts at a node that is not capable of further propagation, leading the epidemic to end at few iterations. considering the real data we know that this is not the case, at least not for brazil, therefore we manually remove these networks and they are not considered for the average/error calculations. it is important to notice, however, that this rarely happens, in all our experiments we noticed a maximum of networks of this kind. due to time and hardware constraints, our simulation considers , nodes, and the results need to be scaled up by a factor of to match the brazilian population statistics. this factor was empirically found by approximating the model results in the number of reported cases in brazil. it is important to stress that for better statistics it should be considered the largest possible number of nodes to represent a population, i.e. the ideal case would be n = total country/city population. however, the computational cost of the simulation grows directly proportional to the number of nodes and edges of the network, and considering the critical situation of the moment at hand, , nodes are our limit to promptly present results of the epidemic dynamics. in the experiments when varying the social distancing, the same network is considered in each iteration, i.e. comparisons of including/excluding layers are made in the same random network. we considered the epidemic began on february , which is the day the first confirmed case was officially reported. it is important to emphasize that we made various optimistic assumptions throughout the model construction and simulation, such as to consider that people are behaving with more caution by reducing direct contact, wearing masks, and doing proper home/hospital isolation when infected. it is also important to notice that we are not considering the number of available icu/regular hospitalization beds for the death count, i.e. all the critical and severe cases are effectively treated. it is not trivial to estimate the direct impact of these numbers on the epidemic, however, this is an essential factor that directly impacts the number of deaths. here we focus on the impacts of different actions on the overall epidemic picture, such as the increase and reduction of cases, deaths, and occupied beds in hospitals. the social network starts normally, with all its layers and the original infection probabilities. the infection starts at a node with the closest degree to the average network degree and propagates at iterations of day (up to days). we consider an optimistic scenario, in which people are aware of the virus since the beginning, thus the initial infection probability is β = . . this represents a natural social distancing, a reduction of direct contacts that could cause infection (hugs, kisses, and handshakes), and also precautions when sneezing, coughing, etc. we empirically found that this initial value of β yields results with a higher correlation to the brazilian pandemic. a moderated quarantine is applied after days, representing the isolation measures applied on march by most brazilian states, such as são paulo [ ]. to simulate this quarantine we remove the layers of religious activities and schools and reduce the contacts on transports and work down to % of its initial value, i.e. β = . . the remaining activities on these layers represent services that could not be stopped, such as essential services, activities that are kept taking higher precautionary measures, and also those who disrespect the quarantine. we compare the output of the model in the first days with real data available from the brazilian epidemic (up to may ) [ , , , ] . the model achieves a significant overall similarity within its standard deviation. the greatest difference in the number of diagnosed cases at the last days may be related to the increase in the number of tests being performed in brazil, or yet, the constant decrease of isolation levels in the country (below % for most days of the past month) [ ] . we considered here a fixed isolation level around what was observed in the first days after the government decrees in brazil, but data in ref. shows that these levels are constantly changing. therefore, the number of diagnosed cases and deaths for the remaining simulation may be greater than the reported on this paper (see the "keep isolation" scenario in the next section). concerning the daily death toll, the average number of the proposed model is greater than the official numbers. this is somehow expected, considering that the underdetection rates may be greater in contrast to the fewer number of tests being performed. to better understand this, we analyzed the number of death in brazil from january to april , comparing cases between and , the results are shown in figure . it is possible to observe a clear increasing pattern after february , which is the day of the first officially confirmed case of covid- in brazil. this indicates that the real death toll for the disease may be significantly greater than the official numbers. [ ] , and world health organization (who) [ ] . the dotted lines represent the standard deviation, in the case of the real data the curve is the average over a -day window, and the solid lines the real raw data. the greatest average number of deaths produced by the proposed model may be related to underdetection (see figure ). [ ] . then the total death difference is compared to the covid- records of the who [ ] and the brazilian government [ ] data. the largest difference that appears right after the first confirmed case may indicate a significant underdetection of covid- cases. after the initial epidemic phase, we consider possible actions that can be taken after days (may ): a) do nothing more, maintaining the current isolation levels; b) stop isolation, returning activities to normal (initial network layers and weights); c) return only work activities, restoring the initial probability of the layer; or d) increase isolation, stopping the remaining activities in the work and transports layers (home and random remains). firstly, we analyze the impacts on the number of daily new cases and deaths, results are shown in figure . as previously mentioned, at the start of the covid- pandemic, brazil was performing a fewer number of tests by an order of magnitude, in comparison to other countries with similar epidemic numbers, therefore we considered as diagnosed only the severe and critical cases, which are pronounced subjects for testing, and % of the mild cases. the total infection ratio is discussed later. considering keeping the current isolation levels, the peak of daily new cases occurs around days after the first case (june ), with around , confirmed cases. after days (september ), the average daily cases is around , and it goes below daily cases after around days (october ). the peak of daily new deaths occurs around days (june ), with an average of deaths, and goes below new occurrences after around days (september ). it is important to stress that this is a hypothetical scenario where the isolation level remains the same from day to , which is hardly true in the real world where it is constantly changing [ ] . the total numbers after the last day ( ) account for , (± , ) diagnosed cases and , (± , ) deaths. when we consider the return of all activities after days, the number of cases and deaths grows significantly in an exponential fashion. the peak occurs at days (june ) with an average of , (± , ) new cases, and at days (june ) with an average of , (± , ) new deaths. although the peak of cases/deaths and the decrease of the numbers occur early, in this case, the final result is critically worse, with a total of , , (± , ) diagnosed cases and , (± , ) deaths. here it is important to notice that we considered that all the activities return after days and remain fully operational until the last day ( ). moreover, we do not account for the overloading of hospitals, which directly impacts the final death count. therefore, the number of deaths may be considerably higher. another possible scenario is the return of only the work layer, keeping reduced transports and no schools and religious activities, however, the pattern is similar to returning all activities, considering the growth time, peak, and decay time. the final numbers in this case are , , (± , ) diagnosed cases and , (± , ) deaths. if the isolation is strictly increased after days (lockdown), the infection and death counts drop significantly in comparison to the other approaches. moreover, the recovering time is much faster, as daily new cases stop earlier than the other scenarios. the peak of daily new cases happens around day (june ), and of daily new deaths around day (june ). the total numbers of diagnosed cases and deaths after day are, respectively, , (± , ) and , (± , ). considering the hospitalization time described in the scheme of figure it is possible to estimate the number of occupied beds for regular hospitalization (severe cases) and icu/ventilation (critical cases). we also show the difference between the cumulative growth of diagnosed and undiagnosed cases and recovered cases. the same approach as the previous experiment is considered (except for "return work") with possible actions after days (may ), results are shown in figure . the overall pattern of results is similar to the previously observed for the number of diagnosed cases and deaths. it is possible to notice that the number of undiagnosed cases is much higher than the diagnosed cases. this reflects the number of asymptomatic cases and the lack of tests for mild cases. in the worst scenario, which means ending the isolation, the total infected number may go above million cases. the recovered rate is directly proportional to the infected rate, as one needs to be infected to either die or become resistant to the disease. if the infected rate is high, so is the recovered rate, e.g. the scenarios of keeping or ending isolation, and a high recovered rate also helps in mitigating the epidemic propagation (natural immunization). however, increasing isolation decreases the propagation much faster than natural immunization, with a considerably smaller death toll. it is also possible to observe the differences at the start of effective recovering, i.e. when the recovered rate surpasses the infected rates, this is due to the early increase in isolation levels. the peak of hospitalization occupancy occurs around a week before the death peaks, in any scenario. in this case, icus are very important because critical patients are treated there, which represents the cases of higher death rates. within the "end isolation" setting, patients may occupy up to an average of , (± , ) regular beds and , (± , ) icu beds. these numbers are by far greater than entire brazil's capacity, as publicly-available and private icu beds sum up to , [ ] . even considering the better scenario, i.e. the lower bound of the standard deviation, the number of occupied icu beds may reach around , , which is also critical for brazil's capacity (almost times it's capacity). in this setting of "end isolation", the healthcare system would surely collapse. when the isolation levels are kept, the numbers are significantly lower. however, the occupancy of , (± , ) regular beds and , (± , ) icu beds is still critical for the brazilian health system. considering the creation of new provisional icu units and good patient logistics, the situation may still remain under control during the peak of hospitalization occupancy. however, the results show that the hospital occupancy is prolonged considerably in this scenario, and they may stay functioning around their maximum capacity for up to a month (with an average of occupied icu beds above , ). when increasing the isolation the peak of occupied beds is smaller, with an average of , (± , ) regular beds and , (± , ) icu beds. moreover, the shape of the curve throughout the days is different and the final numbers are considerably smaller. the peak also occurs around a week earlier and then decreases much faster. this scenario would be preferable as it has much more chances of not overloading the brazilian healthcare system, relieving the hospital occupancy considerably faster and, therefore, contributing to the reduction of the number of deaths. this work presents a new approach for the modeling of the covid- epidemic dynamics based on multi-layer complex networks. each node represents a person, and edges are social interactions divided into layers: home, work, transports, schools, religions, and random relations. each layer has its own characteristics based on how people usually interact in that activity. the propagation is performed using an agent-based technique, a modification of the sir model, where weights represent the infection probability that varies depending on the layers and the groups the node interacts, scaled by a β term that controls the chances of infection. the network structure is built based on demographic statistics of a given country, region, or city, and the propagation simulation is performed at time iterations, that represent days. here, we studied in depth the case of the brazilian epidemic considering its population properties and also specific events, such as when the first isolation measures were taken, and the impacts of future actions. brazil is a large and populated country with a wide variety of geographical location types, climates, and it also has a lengthy border with other countries to the west. it is a challenging setting for any epidemiological study. here we consider an average over all the country population, as we adjust the model output to match some statistics of the epidemic official reports. brazil is performing fewer tests in comparison to other countries at the same epidemic scale, however, it is known that testing for infection is always limited, either due to the low number of tests or to the velocity of infections which the testing procedure cannot keep up to. we then considered that only hospitalization cases and % of the mild cases are diagnosed. asymptomatic cases are not diagnosed and keep acting normally in the network, considering the active layers. regarding the isolation of infected nodes, we take some optimistic assumptions: mild cases (even those not diagnosed) are aware of its symptoms and isolate themselves at home. severe and critical cases are eventually hospitalized, and then fully isolated from the network (removal of all its edges). under the described scenario, the network starts with all its layers and β = . , representing that people are aware of the virus since the beginning (even before isolation measures). after days of the first confirmed case, the first isolation measures are taken where schools and religious activities are stopped and work and transports keep functioning at % of the initial scale (achieved further reducing the β term). different actions are then considered after days of the first case: keep the current isolation levels, increase isolation, end isolation returning all activities to %, or returning only the work activities. the results show that keeping approximately the current isolation levels results in a prolonged propagation, as we are near the estimated peak (around june ) with an average of , daily new cases and daily new deaths, and an average of , diagnosed cases (up to , million infected) and , deaths until the end of the year. in this scenario, hospitals may exceed its maximum capacity around june , but the efficient implementation of new icu beds and good logistic management of patients may still keep the situation under control. however, this is a very optimistic assumption, considering that our definition of "keep isolation" considers social isolation above % as registered at the beginning of the brazilian quarantine [ ] . the social isolation levels in brazil are constantly decreasing even when we are still in a state of moderated quarantine, and it is possible to observe average isolation below % in most days of the past month (middle of april to middle of may ). moreover, the results show that this prolonged scenario may cause hospitals to keep functioning at maximum capacity for up to a month. when analyzing other possible scenarios the situation may be considerably different. relaxing isolation measures from now on causes an abrupt increase in the daily growth of cases and deaths, up to times higher in comparison to the current isolation levels. even if only work activities return while schools, religion, and transport activities remain inactive/reduced, the impact is very similar to returning all the activities, with a possible number of above , million diagnosed cases (up to , million infected), and around , deaths until the end of the year. this is, again, a very optimistic assumption as we do not consider the hospital overflow to calculate the death toll. considering this aspect, icu beds may be fully occupied in early june, and around the middle of the month their demand may reach up to , beds, which is around times higher than the entire country's capacity. the other alternative, which is the increase of isolation levels (lockdown), appears to be the only alternative to stop the healthcare system from entering a very critical situation. in this scenario, the growth in the number of daily cases and deaths would be mitigated, and faster. as we are near the peak of new cases at current isolation levels, estimated to be between the beginning and middle of june, increasing the isolation levels does not cause a significant impact on when the peak occurs or its magnitude. however, the disease spreading and the occurrences of new cases decrease much faster in this scenario in comparison to any other scenario studied here, with a difference of months. moreover, the final numbers are considerably smaller, with an average of , diagnosed cases (up to . million infected) , deaths until the end of the year. although the proposed method includes various demographic information for the network construction, and an improved sir approach to covid- , it still does not cover all factors that impact the epidemic propagation. as future works, one may consider more information such as the correlation between the age distribution within the social organization and the clinical spectrum of the infection types (e.g. severe and critical cases are mostly composed of risk groups). another possible improvement consists of increasing n (number of nodes of the networks), e.g. using a value near the real population of the studied society, which we avoided here due to hardware and time constraints (graph processing is costly). another important point regarding the obtained results is related to the "keep isolation" scenario, which may be underestimated as we take various optimistic assumptions and also consider a fixed isolation level based on previously observed data, while most recent data shows that these levels are decreasing [ ] . therefore, during the network evolution, a possible improvement is the use of dynamic isolation levels to better represent reality. it is also possible to consider various scenarios for future actions, such as or more measures of increasing/reducing isolation. this may allow the discovering of new epidemic waves if social activities return too soon after the isolation period, such as what happened in with the spanish flu. portal da transparência -painel covid registral amib. brazilian intensive care medicine association: updated data on icu beds in brazil, , visited on - - infectious diseases of humans: dynamics and control incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china presumed asymptomatic carrier transmission of covid- the mathematical theory of infectious diseases and its applications emergence of scaling in random networks modeling and forecasting the covid- pandemic in brazil covid- in critically ill patients in the seattle region-case series demand for hospitalization services for covid- patients in brazil analyzing and modeling real-world phenomena with complex networks: a survey of applications complex networks: the key to systems biology data analysis and modeling of the evolution of covid- in brazil epidemic spreading with awareness and different timescales in multiplex networks impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand clinical features of patients infected with novel coronavirus in wuhan, china tabela -população residente, por religião tabela -domicílios particulares permanentes por situação e número de moradores ibge. pesquisa nacional por amostra de domicílios contínua trimestral: tabela -população, por grupos de idade instituto nacional de estudos e pesquisas educacionais anísio teixeira: dados do censo escolar: ensino médio brasileiro tem média de alunos por sala instituto de pesquisa econômica aplicada: sistema de indicadores de percepção social (sips) coronavirus resource center asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus (sarscov- ): facts and myths positive rt-pcr test results in patients recovered from covid- the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data the small world problem portal do covid- estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship, yokohama, japan epidemics and percolation in small-world networks scaling and percolation in the small-world network model covid- coronavirus data model studies on the covid- pandemic in sweden the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- )-china clinical characteristics of asymptomatic and symptomatic patients with mild covid- collective dynamics of 'small-world'networks world health organization -coronavirus disease (covid- ): situation report, world health organization -modes of transmission of virus causing covid- : implications for ipc precaution recommendations world health organization coronavirus disease (covid- ) dashboard clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study key: cord- -rvg ayp authors: ponce, marcelo; sandhel, amit title: covid .analytics: an r package to obtain, analyze and visualize data from the corona virus disease pandemic date: - - journal: nan doi: nan sha: doc_id: cord_uid: rvg ayp with the emergence of a new pandemic worldwide, a novel strategy to approach it has emerged. several initiatives under the umbrella of"open science"are contributing to tackle this unprecedented situation. in particular, the"r language and environment for statistical computing"offers an excellent tool and ecosystem for approaches focusing on open science and reproducible results. hence it is not surprising that with the onset of the pandemic, a large number of r packages and resources were made available for researches working in the pandemic. in this paper, we present an r package that allows users to access and analyze worldwide data from resources publicly available. we will introduce the covid .analytics package, focusing in its capabilities and presenting a particular study case where we describe how to deploy the"covid .analytics dashboard explorer". in a novel type of corona virus was first reported, originally in the province of hubei, china. in a time frame of months this new virus was capable of producing a global pandemic of the corona virus disease (covid ), which can end up in a severe acute respiratory syndrome (sars-cov- ). the origin of the virus is still unclear [ , , ] , although some studies based on genetic evidence, suggest that it is quite unlikely that this virus was human made in a laboratory, but instead points towards cross-species transmission [ , ] . although this is not the first time in the human history when humanity faces a pandemic, this pandemic has unique characteristics. for starting the virus is "peculiar" as not all the infected individuals experience the same symptoms. some individuals display symptoms that are similar to the ones of a common cold or flu while other individuals experience serious symptoms that can cause death or hospitalization with different levels of severity, including staying in intensive-care units (icu) for several weeks or even months. a recent medical survey shows that the disease can transcend pulmonary manifestations affecting several other organs [ ] . studies also suggest that the level of severity of the disease can be linked to previous conditions [ ] , gender [ ] , or even blood type [ ] but the fundamental and underlying reasons still remain unclear. some infected individuals are completely asymptomatic, which makes them ideal vectors for disseminating the virus. this also makes very difficult to precisely determine the transmission rate of the disease, and it is argued that in part due to the peculiar characteristics of the virus, that some initial estimates were underdetermining the actual value [ ] . elderly are the most vulnerable to the disease and reported mortality rates vary from to % depending on the geographical location. in addition to this, the high connectivity of our modern societies, make possible for a virus like this to widely spread around the world in a relatively short period of time. what is also unprecedented is the pace at which the scientific community has engaged in fighting this pandemic in different fronts [ ] . technology and scientific knowledge are and will continue playing a fundamental role in how humanity is facing this pandemic and helping to reduce the risk of individuals to be exposed or suffer serious illness. techniques such as dna/rna sequencing, computer simulations, models generations and predictions, are nowadays widely accessible and can help in a great manner to evaluate and design the best course of action in a situation like this [ ] . public health organizations are relying on mathematical and data-driven models (e.g. [ ] ), to draw policies and protocols in order to try to mitigate the impact on societies by not suffocating their health institutions and resources [ ] . specifically, mathematical models of the evolution of the virus spread, have been used to establish strategies, like social distancing, quarantines, self-isolation and staying at home, to reduce the chances of transmission among individuals. usually, vaccination is also another approach that emerges as a possible contention strategy, however this is still not a viable possibility in the case of covid , as there is not vaccine developed yet [ , ] . simulations of the spread of virus have also shown that among the most efficient ways to reduce the spread of the virus are [ ] : increasing social distancing, which refers to staying apart from individuals so that the virus can not so easily disperse among individuals; improving hygiene routines, such as proper hand washing, use of hand sanitizer, etc. which would eventually reduce the chances of the virus to remain effective; quarantine or self-isolation, again to reduce unnecessary exposure to other potentially infected individuals. of course these recommendations based on simulations and models can be as accurate and useful as the simulations are, which ultimately depend on the value of the parameters used to set up the initial conditions of the models. moreover these parameters strongly depend on the actual data which can be also sensitive to many other factors, such as data collection or reporting protocols among others [ ] . hence counting with accurate, reliable and up-to-date data is critical when trying to understand the conditions for spreading the virus but also for predicting possible outcomes of the epidemic, as well as, designing proper containment measurements. similarly, being able to access and process the huge amount of genetic information associated with the virus has proben to shred light into the disease's path [ , ] . encompassing these unprecedented times, another interesting phenomenon has also occurred, in part related to a contemporaneous trend in how science can be done by emphasizing transparency, reproducibility and robustness: an open approach to the methods and the data; usually refer as open science. in particular, this approach has been part for quite sometime of the software developer community in the so-called open source projects or codes. this way of developing software, offers a lot of advantages in comparison to the more traditional and closed, proprietary approaches. for starting, it allows that any interested party can look at the actual implementation of the code, criticize, complement or even contribute to the project. it improves transparency, and at the same time, guarantees higher standards due to the public scrutiny; which at the end results in benefiting every one: the developers by increasing their reputation, reach and consolidating a widely validated product and the users by allowing direct access to the sources and details of the implementation. it also helps with reproducibility of results and bugs reports and fixes. several approaches and initiatives are taking the openness concepts and implementing in their platforms. specific examples of this have drown the internet, e.g. the surge of open source powered dashboards [ ] , open data repositories, etc. another example of this is for instance the number of scientific papers related to covid published since the beginning of the pandemic [ ] , the amount of data and tools developed to track the evolution of pandemic, etc. [ ] . as a matter of fact, scientists are now drowning in publications related to the covid [ , ] , and some collaborative and community initiatives are trying to use machine learning techniques to facilitate identify and digest the most relevant sources for a given topic [ , , ] . the "r language and environment for statistical computing" [ , ] is not exception here. moreover, promoting and based on the open source and open community principles, r has empowered scientists and researchers since its inception. not surprisingly then, the r community has contributed to the official cran [ ] repository already with more than a dozen of packages related to the covid pandemic since the beginning of the crisis. in particular, in this paper we will introduce and discuss the covid .analytics r package [ ] , which is mainly designed and focus in an open and modular approach to provide researchers quick access to the latest reported worldwide data of the covid cases, as well as, analytical and visualization tools to process this data. this paper is organized as follow: in sec. we describe the covid .analytics , in sec. we present some examples of data analysis and visualization, in sec. we describe in detail how to deploy a web dashboard employing the capabilities of the covid .analytics package providing full details on the implementation so that this procedure can be repeated and followed by interested users in developing their own dashboards. finally we summarize some conclusions in sec. . the covid .analytics r package [ ] allows users to obtain live worldwide data from the novel covid . it does this by accessing and retrieving the data publicly available and published by two main sources: the "covid- data repository by the center for systems science and engineering (csse) at johns hopkins university" [ ] for the worldwide and us data, and the city of toronto for the toronto data [ ] . the package also provides basic analysis and visualization tools and functions to investigate these datasets and other ones structured in a similar fashion. the covid .analytics package is an open source tool, which its main implementation and api is the r package [ ] . in addition to this, the package has a few more adds-on: • a central github repository, https://github.com/mponce /covid .analytics where the latest development version and source code of the package are available. users can also submit tickets for bugs, suggestions or comments using the "issues" tab. • a rendered version with live examples and documentation also hosted at github pages, https: //mponce .github.io/covid .analytics/; • a dashboard for interactive usage of the package with extended capabilities for users without any coding expertise, https://covid analytics.scinet.utoronto.ca. we will discuss the details of the implementation in sec. . • a "backup" data repository hosted at github, https://github.com/mponce /covid analytics. datasets -where replicas of the live datasets are stored for redundancy and robust accesibility sake (see fig. ). one of the main objectives of the covid .analytics package is to make the latest data from the reported cases of the current covid pandemic promptly available to researchers and the scientific community in what follows we describe the main functionalities from the package regarding data accessibility. the covid .data function allows users to obtain realtime data about the covid reported cases from the jhu's ccse repository, in the following modalities: • aggregated data for the latest day, with a great 'granularity' of geographical regions (ie. cities, provinces, states, countries) • time series data for larger accumulated geographical regions (provinces/countries) • deprecated : we also include the original data style in which these datasets were reported initially. the datasets also include information about the different categories (status) "confirmed"/"deaths"/"recovered" of the cases reported daily per country/region/city. this data-acquisition function, will first attempt to retrieve the data directly from the jhu repository with the latest updates. if for what ever reason this fails (eg. problems with the connection) the package will load a preserved "image" of the data which is not the latest one but it will still allow the user to explore this older dataset. in this way, the package offers a more robust and resilient approach to the quite dynamical situation with respect to data availability and integrity. in addition to the data of the reported cases of covid , the covid .analytics package also provides access to genomics data of the virus. the data is obtained from the national center for biotechnology information (ncbi) databases [ , ] . table shows the functions available in the covid .analytics package for accessing the reported cases of the covid pandemic. the functions can be divided in different categories, depending on what data they provide access to. for instance, they are distinguished between agreggated and time series data sets. they are also grouped by specific geographical locations, i.e. worldwide, united states of america (us) and the city of toronto (ontario, canada) data. the time series data is structured in an specific manner with a given set of fields or columns, which resembles the following format: "province.state" | "country.region" | "lat" | "long" | ... sequence of dates ... one of the modular features this package offers is that if an user has data structured in a data.frame organized as described above, then most of the functions provided by the covid .analytics package for analyzing time series data will just work with the user's defined data. in this way it is possible to add new data sets to the ones that can be loaded using the repositories predefined in this package and extend the analysis capabilities to these new datasets. sec. . presents an example of how external or synthetic data has to be structured so that can use the function from the covid .analytics package. it is also recommended to check the compatibility of these datasets using the data integrity and consistency checks functions described in the following section. due to the ongoing and rapid changing situation with the covid- pandemic, sometimes the reported data has been detected to change its internal format or even show some anomalies or inconsistencies . for instance, in some cumulative quantities reported in time series datasets, it has been observed that these quantities instead of continuously increase sometimes they decrease their values which is something that should not happen . we refer to this as an inconsistency of "type ii". some negative values have been reported as well in the data, which also is not possible or valid; we call this inconsistency of "type i". when this occurs, it happens at the level of the origin of the dataset, in our case, the one obtained from the jhu/ccesgis repository [ ] . in order to make the user aware of this, we implemented two consistency and integrity checking functions: • consistency.check: this function attempts to determine whether there are consistency issues within the data, such as, negative reported value (inconsistency of "type i") or anomalies in the cumulative quantities of the data (inconsistency of "type ii") • integrity.check: this determines whether there are integrity issues within the datasets or changes to the structure of the data alternatively we provide a data.checks function that will execute the previous described functions on an specified dataset. data integrity. it is highly unlikely that the user would face a situation where the internal structure of the data or its actual integrity may be compromised. however if there are any suspicious about this, it is possible to use the integrity.check function in order to verify this. if anything like this is detected we urge users to contact us about it, e.g. https://github.com/mponce /covid .analytics/issues. data consistency. data consistency issues and/or anomalies in the data have been reported several times these are claimed, in most of the cases, to be missreported data and usually are just an insignificant number of the total cases. having said that, we believe that the user should be aware of these situations and we recommend using the consistency.check function to verify the dataset you will be working with. nullifying spurious data. in order to deal with the different scenarios arising from incomplete, inconsistent or missreported data, we provide the nullify.data function, which will remove any potential entry in the data that can be suspected of these incongruencies. in addition ot that, the function accepts an optional argument stringent=true, which will also prune any incomplete cases (e.g. with nas present). similarly to the rapid developments and updates in the reported cases of the disease, the sequencing of the virus is moving almost at equal pace. that's why the covid .analytics package provides access to good number of the genomics data currently available. the covid .genomic.data function allows users to obtain the covid 's genomics data from ncbi's databases [ ] . the type of genomics data accessible from the package is described in table . although the package attempts to provide the latest available genomic data, there are a few important details and differences with respect to the reported cases data. for starting, the amount of genomic information available is way larger than the data reporting the number of cases which adds some additional constraints when retrieving this data. in addition to that, the hosting servers for the genomic databases impose certain limits on the rate and amounts of downloads. in order to mitigate these factors, the covid .analytics package employs a couple of different strategies as summarized below: • most of the data will be attempted to be retrieved live from ncbi databases -same as using src='livedata'. • if that is not possible, the package keeps a local version of some of the largest datasets (i.e. genomes, nucleotides and proteins) which might not be up-to-date -same as using src='repo'. • the package will attempt to obtain the data from a mirror server with the datasets updated on a regular basis but not necessarily with the latest updates -same as using src='local'. these sequence of steps are implemented in the package using trycath() exceptions in combination with recursivity, i.e. the retrieving data function calling itself with different variations indicating which data source to use. as the covid .analytics package will try present the user with the latest data sets possible, different strategies (as described above) may be in place to achieve this. one way to improve the realiability of the access to and avialability of the data is to use a series of replicas of the datasets which are hosted in different locations. fig. summarizes the different data sources and point of access that the package employs in order to retrieve the data and keeps the latest datasets available. genomic data as mentioned before is accessed from ncbi databases. this is implemented in the covid .genomic.data function employing the ape [ ] and rentrez [ ] packages. in particular the proteins datasets, with more than k entries, is quite challenging to obtain "live". as a matter of fact, the covid .genomic.data function accepts an argument to specify whether this should be the case or not. if the src argument is set to 'livedata' then the function will attempt to download the proteins list directly from ncbi databases. if this fail, we recommend using the argument src='local' which will provide an stagered copy of this dataset at the moment in which the package was submitted to the cran repository, meaning that is quite likely this dataset won't be complete and most likely outdated. additionaly, we offer a second replica of the datasets, located at https://github.com/mponce /covid analytics.datasets where all datasets are updated periodically, this can be accessed using the argument src='repo'. in addition to the access and retrieval of the data, the covid .analytics package includes several functions to perform basic analysis and visualizations. table shows the list of the main functions in the package. description main type of output data acquisition covid .data obtain live* worldwide data for covid virus, from the jhu's ccse repository [ ] return dataframes/list with the collected data covid .toronto.data obtain live* data for covid cases in the city of toronto, on canada, from the city of toronto reports [ ] return dataframe/list with the collected data covid .us.data obtain live* us specific data for covid virus, from the jhu's ccse repository [ ] return dataframe with the collected data genomics covid .genomic.data c .refgenome.data c .fasta.data c .ptree.data c .nps.data c .np_fasta.data obtain genomic data from ncbi databases -see table in the reported data, this is mostly given by the province/city and/or country/region. in order to facilitate the processing of locations that are located geo-politically close, the covid .analytics package provides a way to identify regions by indicating the corresponding continent's name where they are located. i.e. "south america", "north america", "central america", "america", "europe", "asia" and "oceania" can be used to process all the countries within each of these regions. the geographicalregions function is the one in charge of determining which countries are part of what continent and will display them when executing geographicalregions(). in this way, it is possible to specify a particular continent and all the countries in this continent will be processed without needing to explicitly specifying all of them. reports. as the amount of data available for the recorded cases of covid can be overwhelming, and in order to get a quick insight on the main statistical indicators, the covid .analytics package includes the report.summary function, which will generate an overall report summarizing the main statistical estimators for the different datasets. it can summarize the "time series" data (when indicating cases.to.process="ts"), the "aggregated" data (cases.to.process="agg") or both (cases.to.process="all"). the default will display the top entries in each category, or the number indicated in the nentries argument, for displaying all the records just set nentries= . the function can also target specific geographical location(s) using the geo.loc argument. when a geographical location is indicated, the report will include an additional "rel.perc" column for the confirmed cases indicating the relative percentage among the locations indicated. similarly the totals displayed at the end of the report will be for the selected locations. in each case ("ts" or/and "agg") will present tables ordered by the different cases included, i.e. confirmed infected, deaths, recovered and active cases. the dates when the report is generated and the date of the recorded data will be included at the beginning of each table. it will also compute the totals, averages or mean values, standard deviations and percentages of various quantities, i.e. • it will determine the number of unique locations processed within the dataset • it will compute the total number of cases per case type • percentages -which are computed as follow: for the "confirmed" cases, as the ratio between the corresponding number of cases and the total number of cases, i.e. a sort of "global percentage" indicating the percentage of infected cases with respect to the rest of the world covid .analytics "internal" rsync/git -when a new release is push to cran "internal" scripts src="livedata" src="repo" src="local" https://github.com/mponce /covid analytics.datasets figure : schematic of the data acquision flows between the covid .analytics package and the different sources of data. dark and solid/dashed lines represent api functions provided by the package accesible to the users. dotted lines are "internal" mechanisms employed by the package to synchronize and update replicas of the data. data acquisition from ncbi servers is mostly done utilizing the ape [ ] and rentrez [ ] packages. for "confirmed" cases, when geographical locations are specified, a "relative percentage" is given as the ratio of the confirmed cases over the total of the selected locations for the other categories, "deaths"/"recovered"/"active", the percentage of a given category is computed as the ratio between the number of cases in the corresponding category divided by the "confirmed" number of cases, i.e. a relative percentage with respect to the number of confirmed infected cases in the given region • for "time series" data: it will show the delta (change or variation) in the last day, daily changes day before that (t − ), three days ago (t − ), a week ago (t − ), two weeks ago (t − ) and a month ago (t − ) when possible, it will also display the percentage of "recovered" and "deaths" with respect to the "confirmed" number of cases the column "globalperc" is computed as the ratio between the number of cases for a given country over the total of cases reported -the "global perc. average (sd: standard deviation)" is computed as the average (standard deviation) of the number of cases among all the records in the data -the "global perc. average (sd: standard deviation) in top x" is computed as the average (standard deviation) of the number of cases among the top x records a typical output of the summary.report for the "time series" data, is shown in the example in sec. . in addition to this, the function also generates some graphical outputs, including pie and bar charts representing the top regions in each category; see fig. . totals per location & growth rate. it is possible to dive deeper into a particular location by using the tots.per.location and growth.rate functions. these functions are capable of processing different types of data, as far as these are "time series" data. it can either focus in one category (eg. "ts-confirmed", "ts-recovered", "ts-deaths",) or all ("ts-all"). when these functions detect different types of categories, each category will be processed separately. similarly the functions can take multiple locations, ie. just one, several ones or even "all" the locations within the data. the locations can either be countries, regions, provinces or cities. if an specified location includes multiple entries, eg. a country that has several cities reported, the functions will group them and process all these regions as the location requested. totals per location. the tots.per.location function will plot the number of cases as a function of time for the given locations and type of categories, in two plots: a log-scale scatter one a linear scale bar plot one. when the function is run with multiple locations or all the locations, the figures will be adjusted to display multiple plots in one figure in a mosaic type layout. additionally, the function will attempt to generate different fits to match the data: • an exponential model using a linear regression method • a poisson model using a general linear regression method • a gamma model using a general linear regression method the function will plot and add the values of the coefficients for the models to the plots and display a summary of the results in the console. it is also possible to instruct the function to draw a "confidence band" based on a moving average, so that the trend is also displayed including a region of higher confidence based on the mean value and standard deviation computed considering a time interval set to equally dividing the total range of time over equally spaced intervals. the function will return a list combining the results for the totals for the different locations as a function of time. growth rate. the growth.rate function allows to compute daily changes and the growth rate defined as the ratio of the daily changes between two consecutive dates. the growth.rate function shares all the features of the tots.per.location function as described above, i.e. can process the different types of cases and multiple locations. the graphical output will display two plots per location: • a scatter plot with the number of changes between consecutive dates as a function of time, both in linear scale (left vertical axis) and log-scale (right vertical axis) combined • a bar plot displaying the growth rate for the particular region as a function of time. when the function is run with multiple locations or all the locations, the figures will be adjusted to display multiple plots in one figure in a mosaic type layout. in addition to that, when there is more than one location the function will also generate two different styles of heatmaps comparing the changes per day and growth rate among the different locations (vertical axis) and time (horizontal axis). furthermore, if the interactivefig=true argument is used, then interactive heatmaps and d-surface representations will be generated too. some of the arguments in this function, as well as in many of the other functions that generate both static and interactive visualizations, can be used to indicate the type of output to be generated. table lists some of these arguments. in particular, the arguments controlling the interactive figures -interactivefig and interactive.display-can be used in combination to compose an interactive figure to be captured and used in another application. for instance, when interactive.display is turned off but interactivefig=true, the function will return the interactive figure, so that it can be captured and used for later purposes. this is the technique employed when capturing the resulting plots in the covid .analytics dashboard explorer as presented in sec. . . finally, the growth.rate function when not returning an interactive figure, will return a list combining the results for the "changes per day" and the "growth rate" as a function of time, i.e. when interactivefig is not specified or set to false (which its default value) or when interactive.display=true. when is turned off, but interactivefig=true, the function will return the interactive figure, so that it can be captured and used for later purposes. trends in daily changes. the covid .analytics package provides three different functions to visualize the trends in daily changes of reported cases from time series data. • single.trend, allows to inspect one single location, this could be used with the worldwide data sliced by the corresponding location, the toronto data or the user's own data formatted as "time series" data. • mtrends, is very similar to the single.trend function, but accepts multiple or single locations generating one plot per location requested; it can also process multiple cases for a given location. • itrends function to generate an interactive plot of the trend in daily changes representing changes in number of cases vs total number of cases in log-scale using splines techniques to smooth the abrupt variations in the data the first two functions will generate "static" plots in a compose with different insets: • the main plot represents daily changes as a function of time • the inset figures in the top, from left to right: total number of cases (in linear and semi-log scales), changes in number of cases vs total number of cases changes in number of cases vs total number of cases in log-scale • the second row of insets, represent the "growth rate" (as defined above) and the normalized growth rate defined as the growth rate divided by the maximum growth rate reported for this location plotting totals. the function totals.plt will generate plots of the total number of cases as a function of time. it can be used for the total data or for a specific or multiple locations. the function can generate static plots and/or interactive ones, as well, as linear and/or semi-log plots. plotting cases in the world. the function live.map will display the different cases in each corresponding location all around the world in an interactive map of the world. it can be used with time series data or aggregated data, aggregated data offers a much more detailed information about the geographical distribution. the covid .analytics package allows users to model the dispersion of the disease by implementing a simple susceptible-infected-recovered (sir) model [ , ] . the model is implemented by a system of ordinary differential equations (ode), as the one shown by eq.( ). where s represents the number of susceptible individuals to be infected, i the number of infected individuals and r the number of recovered ones at a given moment in time. the coefficients β and γ are the parameters controlling the transition rate from s to i and from i to r respectively; n is the total number of individuals, i.e. n = s(t) + i(t) + r(t); which should remain constant, i.e. eq.( ) can be written in terms of the normalized quantities, although the ode sir model is non-linear, analytical solutions have been found [ ] . however the approach we follow in the package implementation is to solve the ode system from eq.( ) numerically. the function generate.sir.model implements the sir model from eq.( ) using the actual data from the reported cases. the function will try to identify data points where the onset of the epidemic began and consider the following data points to generate proper guesses for the two parameters describing the sir ode system, i.e. β and γ. it does this by minimizing the residual sum of squares (rss) assuming one single explanatory variable, i.e. the sum of the squared differences between the number of infected cases i(t) and the quantity predicted by the modelĨ(t), the ode given by eq.( ) is solved numerically using the ode function from the desolve and the minimization is tackled using the optim function from base r. after the solution for eq.( ) is found, the function will provide details about the solution, as well as, plot the quantities s(t), i(t), r(t) in a static and interactive plot. the generate.sir.model function also estimates the value of the basic reproduction number or basic reproduction ratio, r , defined as, which can be considered as a measure of the average expected number of new infections from a single infection in a population where all subjects can be susceptible to get infected. the function also computes and plots on demand, the force of infection, defined as, f inf ection = βi(t), which measures the transition rate from the compartment of susceptible individuals to the compartment of infectious ones. for exploring the parameter space of the sir model, it is possible to produce a series of models by varying the conditions, i.e. range of dates considered for optimizing the parameters of the sir equation, which will effectively "sweep" a range for the parameters β, γ and r . this is implemented in the function sweep.sir.models, which takes a range of dates to be used as starting points for the number of cases used to feed into the generate.sir.model producing as many models as different ranges of dates are indicated. one could even use this in combination to other resampling or monte carlo techniques to estimate statistical variability of the parameters from the model. in this section we will present some basic examples of how to use the main functions from the covid .analytics package. we will begin by installing the covid .analytics package. this can be achieved in two alternative ways: . installing the latest stable version of the package directly from the cran repository. this can be done within an r session using the install.packages function, i.e. > install.packages("covid .analytics") . installing the development version from the package's github repository, https://github.com/ mponce /covid .analytics using the devtools package [ ] and its install_github function. i.e. # begin by installing devtools if not installed in your system > install.packages("devtools") # install the covid .analytics packages from the github repo > devtools::install_github("mponce /covid .analytics") after having installed the covid .analytics package, for accessing its functions, the package needs to be loaded using r's library function, i.e. the covid .analytics uses a few additional packages which are installed automatically if they are not present in the system. in particular, readxl is used to access the data from the city of toronto [ ] , ape is used for pulling the genomics data from ncbi; plotly and htmlwidgets are used to render the interactive plots and save them in html documents, desolve is used to solve the differential equations modelling the spread of the virus, and gplots, pheatmap are used to generate heatmaps. lst. shows how to use the covid .data function to obtain data in different cases. # obtain all the records combined for " confirmed " , " deaths " and " recovered " cases # for the global ( worldwide ) * aggregated * data covid . data . allcases <-covid . data () # obtain time series data for global " confirmed " cases covid . confirmed . cases <-covid . data ( " ts -confirmed " ) # reads all possible datasets , returning a list covid . all . datasets <-covid . data ( " all " ) # reads the latest aggregated data of the global cases covid . all . agg . cases <-covid . data ( " aggregated " ) # reads time series data for global casualties covid . ts . deaths <-covid . data ( " ts -deaths " ) # read " time series " data for the city of toronto toronto . ts . data <-covid . data ( " ts -toronto " ) # this can be also done using the covid . toronto . data () fn tor . ts . data <-covid . toronto . data () # or get the original data as reported by the city of toronto tor . df . data <-covid . toronto . data ( data . fmr = " orig " ) # retrieve us time series data of confirmed cases us . confirmed . cases <-covid . data ( " ts -confirmed -us " ) # retrieve us time series data of death cases us . deaths . cases <-covid . data ( " ts -deaths -us " ) # or both cases combined us . cases <-covid . us . data () listing : reading data from reported cases of covid using the covid .analytics package. in general, the reading functions will return data frames. exceptions to this, are when the functions need to return a more complex output, e.g. when combining "all" type of data or when requested to obtain the original data from the city of toronto (see details in table ). in these cases, the returning object will be a list containing in each element dataframes corresponding to the particular type of data. in either case, the structure and overall content can be quickly assessed by using r's str or summary functions. one useful information to look at after loading the datasets, would be to identify which locations/regions have reported cases. there are at least two main fields that can be used for that, the columns containing the keywords: 'country' or 'region' and 'province' or 'state'. lst. show examples of how to achieve this using partial matches for column names, e.g. "country" and "province". # read a data set data <-covid . data ( " ts -confirmed " ) # look at the structure and column names str ( data ) names ( data ) # find ' country ' column country . col <-pmatch ( " country " , names ( data ) ) # slice the countries countries <-data [ , country . col ] # list of countries print ( unique ( countries ) ) # sorted table of countries , may include multiple entries print ( sort ( table ( countries ) ) ) # find ' province ' column prov . col <-pmatch ( " province " , names ( data ) ) # slice the provinces provinces <-data [ , prov . col ] # list of provinces print ( unique ( provinces ) ) # sorted table of provinces , may include multiple entries print ( sort ( table ( provinces ) ) ) listing : identifying geographical locations in the data sets. an overall view of the current situation at a global or local level can be obtained using the report.summary function. lst. shows a few examples of how this function can be used. # a quick function to overview top cases per region for time series and aggregated records report . summary () # save the tables into a text file named ' covid -summaryreport _ currentdate . txt ' # where * currrentdate * is the actual date report . summary ( savereport = true ) # summary report for an specific location with default number of entries report . summary ( geo . loc = " canada " ) # summary report for an specific location with top report . summary ( nentries = , geo . loc = " canada " ) # it can combine several locations report . summary ( nentries = , geo . loc = c ( " canada " ," us " ," italy " ," uruguay " ," argentina " ) ) a typical output of the report generation tool is presented in lst. . typical output of the report.summary function. this particular example was generated using report.summary(nentries= ,graphical.output=true,savereport=true), which indicates to consider just the top entries, generate a graphical output as shown in fig. and a to save text file including the report which is the one shown here.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~- # #### ts -confirmed cases --data dated : - - :: - - : : # #### ts -deaths cases --data dated : - - :: - - : : # #### ts -recovered cases --data dated : - - :: - - : : # #### aggregated data --ordered by confirmed cases --data dated : - - :: - - : : # #### aggregated data --ordered by deaths cases --data dated : - - :: - - : : # #### aggregated data --ordered by recovered cases --data dated : - - :: - - : : # #### aggregated data --ordered by active cases --data dated : - - :: - - : : * statistical estimators computed considering independent reported entries * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * overall summary * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * statistical estimators computed considering / / independent reported entries per case -type * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * a daily generated report is also available from the covid .analytics documentation site, https: //mponce .github.io/covid .analytics/. the covid .analytics package allows users to investigate total cumulative quantities per geographical location with the totals.per.location function. examples of this are shown in lst. . # totals for confirmed cases for " ontario " tots . per . location ( covid . confirmed . cases , geo . loc = " ontario " ) # total for confirmed cases for " canada " tots . per . location ( covid . confirmed . cases , geo . loc = " canada " ) # total nbr of confirmed cases in hubei including a confidence band based on moving average tots . per . location ( covid . confirmed . cases , geo . loc = " hubei " , confbnd = true ) # total nbr of deaths for " mainland china " tots . per . location ( covid . ts . deaths , geo . loc = " china " ) # ## # read the time series data for all the cases all . data <-covid . data ( 'ts -all ') # run on all the cases tots . per . location ( all . data , " japan " ) # ## # total for death cases for " all " the regions tots . per . location ( covid . ts . deaths ) # or just tots . per . location ( covid . data ( " ts -confirmed " ) ) listing : calculation of totals per country/region/province. in addition to the graphical output as shown in fig. , the function will provide details of the models fitted to the data. similarly, utilizing the growth.rate function is possible to compute the actual growth rate and daily changes for specific locations, as defined in sec. . . lst. includes examples of these. # read time series data for confirmed cases ts . data <-covid . data ( " ts -confirmed " ) # compute changes and growth rates per location for all the countries growth . rate ( ts . data ) # compute changes and growth rates per location for ' italy ' growth . rate ( ts . data , geo . loc = " italy " ) # compute changes and growth rates per location for ' italy ' and ' germany ' growth . rate ( ts . data , geo . loc = c ( " italy " ," germany " ) ) # #### # combining multiple geographical locations : # obtain time series data tsconfirmed <-covid . data ( " ts -confirmed " ) # explore different combinations of regions / cities / countries # when combining different locations , heatmaps will also be generated comparing the trends among these locations growth . rate ( tsconfirmed , geo . loc = c ( " italy " ," canada " ," ontario " ," quebec " ," uruguay " ) ) growth . rate ( tsconfirmed , geo . loc = c ( " hubei " ," italy " ," spain " ," united ␣ states " ," canada " ," ontario " ," quebec " ," uruguay " ) ) growth . rate ( tsconfirmed , geo . loc = c ( " hubei " ," italy " ," spain " ," us " ," canada " ," ontario " , " quebec " ," uruguay " ) ) # turn off static plots and activate interactive figures growth . rate ( tsconfirmed , geo . loc = c ( " brazil " ," canada " ," ontario " ," us " ) , staticplt = # static and interactive figures growth . rate ( tsconfirmed , geo . loc = c ( " brazil " ," italy " ," india " ," us " ) , staticplt = true , interactivefig = true ) listing : calculation of growth rates and daily changes per country/region/province. in addition to the cumulative indicators described above, it is possible to estimate the global trends per location employing the functions single.trend, mtrends and itrends. the first two functions generate static plots of different quantities that can be used as indicators, while the third function generates an interactive representation of a normalized a-dimensional trend. the lst. shows examples of the use of these functions. fig. displays the graphical output produced by these functions. # single location trend , in this case using data from the city of toronto tor . data <-covid . toronto . data () single . trend ( tor . data [ tor . data $ status == " active ␣ cases " ,]) # or data from the province of ontario ts . data <-covid . data ( " ts -confirmed " ) ont . data <-ts . data [ ts . data $ province . state == " ontario " ,] single . trend ( ont . data ) # or from italy single . trend ( ts . data [ ts . data $ country . region == " italy " ,]) # multiple locations ts . data <-covid . data ( " ts -confirmed " ) mtrends ( ts . data , geo . loc = c ( " canada " ," ontario " ," uruguay " ," italy " ) ) # multiple cases single . trend ( tor . data ) # interactive plot of trends # for all locations and all type of cases itrends ( covid . data ( " ts -all " ) , geo . loc = " all " ) # or just for confirmed cases and some specific locations , saving the result in an html file named " itrends _ ex . html " itrends ( covid . data ( " ts -confirmed " ) , geo . loc = c ( " uruguay " ," argentina " ," ontario " ," us " ," italy " ," hubei " ) , filename = " itrends _ ex " ) listing : calculation of trends for different cases, utilizing the single.trend, mtrends and itrends functions. the typical representations can be seen in fig. . most of the analysis functions in the covid .analytics package have already plotting and visualization capabilities. in addition to the previously described ones, the package has also specialized visualization functions as shown in lst. . many of them will generate static and interactive figures, see table for details of the type of output. in particular the live.map function is an utility function which allows to plot the location of the recorded cases around the world. this function in particular allows for several customizable features, such as, the type of projection used in the map or to select different types of projection operators in a pull down menu, displaying or not the legend of the regions, specify rescaling factors for the sizes representing the number of cases, among others. the function will generate a live representation of the cases, utilizing the plotly package and ultimately open the map in a browser, where the user can explore the map, drag the representation, zoom in/out, turn on/off legends, etc. # retrieve time series data ts . data <-covid . data ( " ts -all " ) # static and interactive plot totals . plt ( ts . data ) # totals for ontario and canada , without displaying totals and one plot per page totals . plt ( ts . data , c ( " canada " ," ontario " ) , with . totals = false , one . plt . per . page = true ) # totals for ontario , canada , italy and uruguay ; including global totals with the linear and semi -log plots arranged one next to the other totals . plt ( ts . data , c ( " canada " ," ontario " ," italy " ," uruguay " ) , with . totals = true , one . plt . per . page = false ) # totals for all the locations reported on the dataset , interactive plot will be saved as " totals -all . html " totals . plt ( ts . data , " all " , filename = " totals -all " ) # retrieve aggregated data data <-covid . data ( " aggregated " ) # interactive map of aggregated cases --with more spatial resolution live . map ( data ) # or live . map () # interactive map of the time series data of the confirmed cases with less spatial resolution , ie . aggregated by country live . map ( covid . data ( " ts -confirmed " ) ) listing : examples of some of the interactive and visualization capabilities of plotting functions. the typical representations can be seen in fig. . last but not least, one the novel features added by the covid .analytics package, is the ability of model the spread of the virus by incorporating real data. as described in sec. . , the generate.sir.model function, implements a simple sir model employing the data reported from an specified dataset and a particular location. examples of this are shown in lst. . the generate.sir.model function is complemented with the plt.sir.model function which can be used to generate static or interactive figures as shown in fig. . the generate.sir.model function as described in sec. will attempt to obtain proper values for the parameters β and γ, by inferring the onset of the epidemic using the actual data. this is also listed in the output of the function (see lst. ), and it can be controlled by setting the parameters t and t or deltat, which are used to specify the range of dates to be considered for using when determining the values of β and γ. the fatality rate (constant) can also be indicated via the fatality.rate argument, as well, as the total population of the region with tot.population. # read time series data for confirmed cases data <-covid . data ( " ts -confirmed " ) # run a sir model for a given geographical location generate . sir . model ( data , " hubei " , t = , t = ) generate . sir . model ( data , " germany " , tot . population = ) generate . sir . model ( data , " uruguay " , tot . population = ) generate . sir . model ( data , " ontario " , tot . population = , add . extras = true ) # the function will aggregate data for a geographical location , like a country with multiple entries generate . sir . model ( data , " canada " , tot . population = , add . extras = true ) fig.( ) , also raises an interesting point regarding the accuracy of the sir model. we should recall that this is the simplest approach one could take in order to model the spread of diseases and usually more refined and complex models are used to incorporate several factors, such as, vaccination, quarantines, effects of social clusters, etc. however, in some cases, specially when the spread of the disease appears to have enter the so-called exponential growth rate, this simple sir model can capture the main trend of the dispersion (e.g. left plot from fig. ). while in other cases, when the rate of spread is slower than the freely exponential dispersion, the model clearly fails in tracking the actual evolution of cases (e.g. right plot from fig. ) . finally, lst. shows an example of the generation of a sequence of values for r , and actually any of the parameteres (β, γ) describing the sir model. in this case, the function takes a range of values for the initial date t and generates different date intervals, this allows the function to generate multiple sir models and return the corresponding parameters for each model. the results are then bundle in a "matrix"/"array" object which can be accessed by column for each model or by row for each paramter sets. # read timeseries data ts . data <-covid . data ( " ts -confirmed " ) # select a location of interest , eg . france # france has many entries , just pick " france " fr . data <-ts . data [ ( ts . data $ country . region == " france " ) & ( ts . data $ province . state == " " ) ,] # sweep values of r based on range of dates to consider for the model ranges <- : deltat <- params _ sweep <-sweep . sir . models ( data = fr . data , geo . loc = " france " , t _ range = ranges , deltat = deltat ) # the parameters --beta , gamma , r --are returned in a " matrix " " array " object print ( params _ sweep ) as mentioned before, the functions from the covid .analytics package also allow users to work with their own data, when the data is formated in the time series strucutre as discussed in sec. . . . this opens a large range of possibilities for users to import their own data into r and use the functions already defined in the covid .analytics package. a concrete example of how the data has to be formatted is shown in lst. . the example shows how to structure the data in a ts format from "synthetic" data generated from randomly sampling different distributions. however this could be actual data from other places or locations not accesible from the datasets provided by the package, or some researchers may have access to their own private sets of data too. the example also shows two cases, where the data can include the "status" column or not, and whether it could be more than one location. as a matter of fact, we left the "long" and "lat" fields empty but if one includes the actual coordinates, the maping function live.map can also be used with these structured data. # ts data structure : # " province . state " " country . region " " lat " " long " dates . . . # first let ' s create a ' fake ' location fake . locn <-c ( na , na , na , na ) # names for these columns names ( fake . locn ) <-c ( " province . state " ," country . region " ," lat " ," long " ) # let ' s set the dates dates . vec <-seq ( as . date ( " / / " ) , as . date ( " / / " ) , " days " ) # data . vecx would be the actual values / cases data . vec <-rpois ( length ( dates . vec ) , lambda = ) # can also add more cases data . vec <-abs ( rnorm ( length ( dates . vec ) , mean = , sd = ) ) data . vec <-abs ( rnorm ( length ( dates . vec ) , mean = , sd = ) ) # this will names the columns as your dates names ( data . vec ) <-dates . vec names ( data . vec ) <-dates . vec names ( data . vec ) <-dates . vec # merge them into a data frame with multiple entries synthetic . data <-as . data . frame ( rbind ( rbind ( c ( fake . locn , data . vec ) ) , rbind ( c ( fake . locn , data . vec ) ) , rbind ( c ( fake . locn , data . vec ) ) ) ) # finally set you locn to somethign unqiue , so you can use it in the generate . sir . model fn synthetic . data $ country . region <-" mylocn " # one could even add " status " synthetic . data $ status <-c ( " confirmed " ," death " ," recovered " ) # or just one case per locn synthetic . data <-synthetic . data [ , -ncol ( synthetic . data ) ] synthetic . data $ country . region <-c ( " mylocn " ," mylocn " ," mylocn " ) # now we can use this ' synthetic ' dataset with any of the ts functions # data checks integrity . check ( synthetic . data ) consistency . check ( synthetic . data ) data . checks ( synthetic . data ) # quantitative indicators tots . per . location ( synthetic . data ) growth . rate ( synthetic . data ) single . trend ( synthetic . data [ ,] ) mtrends ( synthetic . data ) # sir models synthsir <-generate . sir . model ( synthetic . data , geo . loc = " mylocn " ) plt . sir . model ( synthsir , interactivefig = true ) sweep . sir . models ( synthetic . data , geo . loc = " mylocn " ) listing : example of structuring data in a ts format, so that it can be used with any of the ts functions from the covid .analytics package. the covid .analytics package provides access to genomics data available at the ncbi databases [ , ] . the covid .genomic.data is the master function for accesing the different variations of the genomics information available as shown in gtypes <-c ( " genome " ," fasta " ," tree " , " nucleotide " ," protein " , " nucleotide -fasta " ," protein -fasta " , " genomic " ) each of these functions return different objects, lst. shows an example of the different structures for some of the objects. the most involved object is obtained from the covid .genomic.data when combining different types of datasets. # str ( results ) list of $ refgenome : list of .. $ livedata : chr [ : ] " a " " t " " t " " a " ... .. $ repo : chr [ : ] " a " " t " " t " " a " ... .. $ local : chr [ : ] " a " " t " " t " " a " . ] " a " " t " " t " " a " ... .. .. -attr ( * , " species " ) = chr " severe _ acute _ respiratory _ syndrome _ coronavirus _ " .. $ local : list of .. .. $ nc _ . : chr [ : ] " a " " t " " t " " a " ... .. .. -attr ( * , " species " ) = chr " severe _ acute _ respiratory _ syndrome _ coronavirus _ " $ ptns : list of .. $ repo : chr [ : ] " yp _ " " yp _ " " yp _ " " yp _ " ... .. $ local : chr [ : ] " yp _ " " yp _ " " yp _ " " yp _ " ... : chr [ : ] " - - t : : z " " - - t : : z " " - - t : : z " " - - t : : z " ... : chr [ : ] " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " .. : chr [ : ] " homo ␣ sapiens " " homo ␣ sapiens " " homo ␣ sapiens " " homo ␣ sapiens " ... .. $ isolation _ source : chr [ : ] " " " " " " " " ... .. $ collection _ date : chr [ : ] " - " " - - " " - - " " - - " ... .. $ biosample : chr [ : ] " " " samn " " samn " " samn " ... .. $ genbank _ title : chr [ : ] " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ␣ isolate ␣ wuhan -hu - , ␣ complete ␣ genome " " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ␣ isolate ␣ sars -cov - / human / ind / gbrc / , ␣ complete ␣ genome " " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ␣ isolate ␣ sars -cov - / human / ind / gbrc a / , ␣ complete ␣ genome " " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ␣ isolate ␣ sars -cov - / human / ind / gbrc b / , ␣ complete ␣ genome " ... $ proteins : ' data . frame ': obs . of variables : .. $ accession : chr [ : ] " yp _ " " yp _ " " yp _ " " yp _ " ... .. $ sra _ accession : chr [ : ] " " " " " " " " ... .. $ release _ date : chr [ : ] " - - t : : z " " - - t : : z " " - - t : : z " " - - t : : z " ... .. $ species : chr [ : ] " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " .. : chr [ : ] " leader ␣ protein ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ] " " nsp ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ] " " nsp ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ] " " nsp ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ ] " ... $ sra : list of .. $ sra _ info : chr [ : ] " this ␣ download ␣ ( via ␣ ftp ) ␣ provides ␣ coronaviridae ␣ family -containing ␣ sra ␣ runs ␣ detected ␣ with ␣ ncbi ' s ␣ kmer ␣ analysis ␣ ( stat ) ␣ tool . ␣ " " it ␣ provides ␣ corresponding ␣ sra ␣ run ␣ ( srr ) ,␣ sample ␣ ( srs ) ,␣ and ␣ submission ␣ ( sra ) ␣ accessions , ␣ as ␣ well ␣ as ␣ biosample ␣ an " | _ _ truncated _ _ " the ␣ stat ␣ kmer ␣ analysis ␣ was ␣ performed ␣ via ␣ a ␣ two -step ␣ process ␣ with ␣ a ␣ -mer ␣ coarse ␣ database ␣ and ␣ a ␣ -mer ␣ fine ␣ database . ␣ " " the ␣ database ␣ is ␣ generated ␣ from ␣ refseq ␣ genomes ␣ and ␣ the ␣ viral ␣ genome ␣ set ␣ from ␣ nt ␣ using ␣ a ␣ minhash -based ␣ approach . ␣ " ... .. $ sra _ runs : ' data . frame ': obs . of variables : .. .. $ acc : chr [ : ] " err " " err " " err " " err " ... .. .. $ sample _ acc : chr [ : ] " ers " " ers " " ers " " ers " ... .. .. $ biosample : chr [ : ] " samea " " same a " " samea " " samea " ... .. .. $ sra _ study : chr [ : ] " erp " " erp " " erp " " erp " ... .. .. $ bioproject : chr [ : ] " " " " " " " " ... $ references : list of .. $ : chr " covid . analytics ␣ --␣ local ␣ data " .. $ : chr " / users / marcelo / library / r / . / library / covid . analytics / extdata / " listing : objects composition for the example presented in lst. one aspect that should be mentioned with respect to the genomics data is that, in general, these are large datasets which are continuously being updated hence increasing theirs sizes even more. these would ultimately present pragmatical challenges, such as, long processing times or even starvation of memory resources. we will not dive into major interesting examples, like dna sequencing analysis or building phylogenetics trees; but packages such as ape, apegenet, phylocanvas, and others can be used for these and other analysis. one simple example we can present is the creation of dynamical categorization trees based on different elements of the sequencing data. we will consider for instance the data for the nucleotides as reported from ncbi. the example on lst. shows how to retrieve either nucleotides (or proteins) data and generate categorization trees based on different elements, such as, hosting organism, geographical location, sequences length, etc. in the examples we employed the collapsibletree package, that generates interactive browsable trees through web browsers. # retrieve the nucleotides data nucx <-covid . genomic . data ( type = ' nucleotide ' , src = ' repo ') # identify specific fields to look at len . fld <-" length " acc . fld <-" accession " geoloc . fld <-" geo _ location " seq . fld <-" sequence _ type " host . fld <-" host " seq . limit <- seq . limit <- seq . limit <- # selection criteria , nucleotides with seq . length between and selec . ctr . <-nucx $ length < seq . limit & nucx $ length > seq . limit # remove nucletoides without specifying a " host " listing : example of how to generate a dynamic browsable tree using some of information included in the nucleotides dataset. some of these trees representations are shown in fig. . in this section we will present and discuss, how the covid .analytics dashboard explorer is implemented. the main goal is to provide enough details about how the dashboard is implemented and works, so that users could modify it if/as they seem fit or even develop their own. for doing so, we will focus in three main points: • the front end implementation, also know as the user interface, mainly developed using the shiny package • the back end implementation, mostly using the covid .analytics package • the web server installation and configuration where the dashboard is hosted the covid .analytics dashboard explorer is built using the shiny package [ ] in combination with the covid .analytics package. shiny allows users to build interactive dashboards that can work through a web interface. the dashboard mimics the covid .analytics package commands and features but enhances the commands as it allows users to use dropdowns and other control widgets to easily input the data rather than using a command terminal. in addition the dashboard offers some unique features, such as a personal protective equipment (ppe) model estimation, based on realistic projections developed by the us centers for disease control and prevention (cdc). the dashboard interface offers several features: . the dashboard can be run on the cloud/web allowing for multiple users to simultaneously analyze the data with no special software or hardware requirements. the shiny package makes the dashboard mobile and tablet compatible as well. . it aids researchers to share and discuss analytical findings. . the dashboard can be run locally or through the web server. . no programming or software expertise is required which reduces technical barriers to analyzing the data. users can interact and analyze the data without any software expertise therefore users can focus on the modeling and analysis. in these times the dashboard can be a monumental tool as it removes barriers and allows a wider and diverse set of users to have quick access to the data. . interactivity. one feature of shiny and other graphing packages, such as plotly, is interactivity, i.e. the ability to interact with the data. this allows one to display and show complex data in a concise manner and focus on specific points of interest. interactive options such as zoom, panning and mouse hover all help in making the user interaction enjoyable and informative. . fast and easy to compare. one advantage of a dashboard is that users can easily analyze and compare the data quickly and multiple times. for example users can change the slider or dropdown to select multiple countries to see the total daily count effortlessly. this allows the data to be displayed and changed as users analysis requirements change. the dashboard can be laucnhed locally in a machine with r, either through an interactive r session or in batch mode using rscript or r cmd batch or through the web server accessing the following url https://covid analytics.scinet.utoronto.ca. for running the dashboard locally, the covid .analytics package has also to be installed. for running the dashboard within an r session the package has to be loaded and then it should be invoked using the following sequence of commands, > library(covid .analytics) > covid explorer() the batch mode can be executed using an r script containing the commands listed above. when the dashboard is run locally the browser will open a port in the local machine -localhost:port-connection, i.e. http:// . . . . it should be noted, that if the dashboard is launched interactively within an r session the port used is -http:// . . . : -, while if this is done through an r script in batch mode the port used will be different. to implement the dashboard and enhance some of the basic functionalities offered, the following libraries were specifically used in the implementation of the dashboard: • shiny [ ] : the main package that builds the dashboard. • shinydashboard [ ] : this is a package that assists us to build the dashboard with respect to themes, layouts and structure. • shinycssloaders [ ] : this package adds loader animations to shiny outputs such as plots and tables when they are loading or (re)-calculating. in general, this are wrappers around base css-style loaders. • plotly [ ] : charting library to generate interactive charts and plots. although extensively used in the core functions of the covid .analytics , we reiterate it here as it is great tool to develop interactive plots. • dt [ ] : a datatable library to generate interactive table output. • dplyr [ ] : a library that helps to apply functions and operations to data frames. this is important for calculations specifically in the ppe calculations. the r shiny package makes developing dashboards easy and seamless and removes challenges. for example setting the layout of a dashboard typically is challenging as it requires knowledge of frontend technologies such as html, css and bootstrap to be able to position elements and change there asthetic properties. shiny simplifies this problem by using a built in box controller widget which allows developers to easily group elements, tables, charts and widgets together. many of the css properties, such as, widths or colors are input parameters to the functions of interest. the sidebar feature is simple to implement and the shiny package makes it easy to be compatible across multiple devices such as tablets or cellphones. the shiny package also has built in layout properties such as fluidrow or columns making it easy to position elements on a page. the library does have some challenges as well. one challenge faced is theme design. shinydashboard does not make it easy to change the whole color theme of the dashboard outside of the white or blue theme that is provided by default. the issue is resolved by having the developer write custom css and change each of the various properties manually. the dashboard contains two main components a sidebar and a main body. the sidebar contains a list of all the menu options. options which are similar in nature are grouped in a nested format. for example the dashboard menu section called "datasets and reports", when selected, displays a nested list of further options the user can choose such as the world data or toronto data. grouping similar menu options together is important for making the user understand the data. the main body displays the content of a page. the content a main body displays depends on the sidebar and the selected menu option the user selects. there are three main generic elements needed to develop a dashboard: layouts, control widgets and output widgets. the layout options are components needed to layout the features or components on a page. in this dashboard the layout widgets used are the following: • box: the boxes are the main building blocks of a dashboard. this allows us to group content together. • tabpanels: tabpanels allow us to create tabs to divide one page into several sections. this allows for multiple charts or multiple types of data to be displayed in a single page. for example in the indicators page there are four tabs which display four different charts with mosaic tab displaying the charts in different configurations. • header and title: these are used to display text, title pages in the appropriate sizes and fonts. an example describing these elements and its implementation is shown in lst. . ␣ table ' ) , h ( ' world ␣ data ␣ of ␣ all ␣ covid ␣ cases ␣ across ␣ the ␣ globe ') , column ( , selectinput ( ns ( " category _ list " ) , label = h ( " category " ) , choices = category _ list ) ) , column ( , downloadbutton ( ns ( ' downloaddata ') , " download " ) ) , withspinner ( dt :: datatableoutput ( ns ( " table _ contents " ) ) ) ) } listing : snippet of a code that describes the various features used in generating a dashboard. the ns(id) is a namespaced id for inputs/outputs. withspinner is the shiny cssloaders which generates a loading gif while the chart is being loaded. shiny modules are used when a shiny application gets larger and complicated, they can also be used to fix the namespacing problem. however shiny modules also allow for code reusability and code modularity as the code can be broken into several pieces called modules. each module can then be called in different applications or even in the same application multiple times. in this dashboard we break the code into two main groups user interface (ui) modules and server modules. each menu option has there own dedicated set of ui and associated server modules. this makes the code easy to build and expand. for each new menu option a new set of ui and sever module functions will be built. lst. is also an example of an ui module, where it specifies the desing and look of the element and connect with the active parts of the application. lst. shows an example of a server function called reportserver. this type of module can update and display charts, tables and valueboxes based on the user selections. this same scenario occurs for all menu options with the ui/server paradigm. another way to think about the ui/server separation, is that the ui modules are in charge of laying down the look of a particular element in the dahboard, while the sever is in charge of dynamically 'filling' the dynamical elements and data to populate this element. control widgets, also called input widgets, are widgets which users use to input data, information or settings to update charts, tables and other output widgets. the following control widgets were used in this dashboard: • numericalinput: a textbox that only allows for numerical input which is used to select a single numerical value. • selectinput: a dropdown that may be multi select for allowing users to select multiple options as in the case of the country dropdown. figure : screenshot from the "covid .analytics dashboard explorer", "mosaic" tab from the 'indicators' category. four interactive figures are shown in this case: the trends (generated using the itrends function), totals (genrated using the totals.plt function) and two world global representations of covid reported cases (generated using the live.map function). the two upper plots are adjusted and re-rendered according to the selection of the country, category of the data from the input boxes. • slider: the slider in our dashboard is purely numerical but used to select a single numerical value from a given range of a min and max range. • download button: this is a button which allows users to download and save data in various formats such as csv format. • radiobuttons: used to select only one from a limited number of choices. • checkbox: similar in purpose to radiobuttons that also allow users to select one option from a limited number of options. output control widgets are widgets that are used to display content/information back to the user. there are three main ouput widgets used in this dashboard: • plotlyouput: this widget output and creates plotly charts. plotly is a graphical package library used to generate interactive charts. • rendertable: is an output that generates the output as an interactive table with search, filter and sort capabilities provided out of the box. • valuebox: this is a fancy textbox with border colors and descriptive font text to generate descriptive text to users such as the total number of deaths. the dashboard contains the menus and elements shown in and described below: • indicators: this menu section displays different covid indicators to analyze the pandemic. there are four notable indicators itrend, total plot, growth rate and live map, which are displayed in each of the various tabs. itrend displays the "trend" in a log-log plot, total plot shows a line graph of total number, growth rate displays the daily number of changes and growth rate (as defined in sec. . ), live map shows a world map of infections in an aggregated or timeseries format. these indicators are shown together in the "mosaic" tab. • models: this menu option contains a sub-menu presenting models related to the pandemic. the first model is the sir (susceptible infection recovery) which is implemented in the covid .analytics package. sir is a compartmental model to model how a disease will infect a population. the second two models are used to estimate the amount of ppe needed due to infectious diseases, such as ebola and covid . • datasets and reports: this section provides reporting capability which outputs reports as csv and text files for the data. the world data subsection displays all the world data as a table which can be filtered, sorted and searched. the data can also be saved as a csv file. the toronto data displays the toronto data in tabular format while also displaying the current pandemic numbers. data integrity section checks the integrity and consistency of the data set such as when the raw data contains negative numbers or if the cumulative quantities decrease. the report section is used to generate a report as a text file. • references: the reference section displays information on the github repo and documentation along with an external dashboards section which contains hyperlinks to other dashboards of interest. dashboards of interest are the vaccine tracker which tracks the progress of vaccines being tested for covid , john hopkins university and the canada dashboard built by the dall lana school of epidemiology at the university of toronto. • about us: contact information and information about the developers. in addition to implementing some of the functionalities provided by the covid .analytics package, the dashboard also includes a ppe calculator. the hospital ppe is a qualitative model which is designed to analyze the amount of ppe equipment needed for a single covid patient over a hospital duration. the ppe calculation implemented in the covid .analytics dashboard explorer is derived from the cdc's studies for infectious diseases, such as ebola and covid . the rationality is that ebola and covid are both contagious infections and ppe is used to protect staff and patients and prevent transmission for both of these contagious diseases. the hospital ppe calculation estimates and models the amount of ppe a hospital will need during the covid pandemic. there are two analysis methods a user can choose to determine hospital ppe requirement. the first method to analyze ppe is to determine the amount of ppe needed for a single hospitalized covid patient. this first model requires two major component: the size of the healthcare team needed to take care of a single covid patient and the amount of ppe equipment used by hospital staff per shift over a hosptialization duration. the model is based off the cdc ebola crisis calculation [ ] . alhough ebola is a different disease compared to covid , there is one major similarity. both covid and ebola are diseases which both require ppe for protection of healthcare staff and the infected patient. to compensate the user can change the amount of ppe a healthcare staff uses per shift. that information can be adjusted by changing the slider values in the advanced setting tab. the calculation is pretty straightforward as it takes the ppe amount used per shift and multiplies it by the number of healthcare staff and then by the hospitalization duration. the first model has two tabs. the first tab displays a stacked bar chart displaying the amount of ppe equipment user by each hospital staff over the total hospital duration of a single patient. it breaks each ppe equipment by stacks. the second tab panel called advanced settings has a series of sliders for each hospital staff example nurses where users can use the slider to change the amount of ppe that the hospital staff will user per shift. the second model is a more recent calculation developed by the cdc [ ] . the model calculates the burn rate of ppe equipment for hospitals for a one week time period. this model is designed specifically for covid . the cdc has created an excel file for hospital staff to input their information and also an android app as well which can be utilized. this model also implemented in our dashboard, is simplified to calculate the ppe for a one week setting. the one week limit was implemented for two reasons, first to limit the amount of input data a user has to enter into the system as too much data can overwhelm and confuse a user; second because the covid pandemic is a highly fluidic situation and for hospital staff to forecast their ppe and resource equipments greater than a one week period may not be accurate. note that this model is not accurate if the facilitiy recieves a resupply of ppe. for resupplied ppe start a new calculation. there are four tab panels to the burn rate calculation which displays charts and settings. the first tab daily usage displays a multi-line chart displaying the amount of ppe used daily, ∆p p e daily . the calculation for this is a simple subtraction between two consecutive days, i.e. the second day (j + ) from the first day (j) as noted in eq. ( ) . the tab panel called remaining supply shows a multi line chart the number of days the remaining ppe equipment will last in the facility. the duration of how long the ppe equipment can last in a given facility, inversely depends on the amount of covid patients admitted to the hospital. to calculate the remaining ppe one calculates the average amount of ppe used over the one week duration and then divides the amount of ppe at the beginning of the day by the average ppe usage, as shown in eq. ( ), where t denotes the time average over a t period of time. the third panel called ppe per patient displays a multi line chart of the burn rate, i.e. the amount of ppe used per patient per day. eq.( ) represents the calculation as the remaining ppe supply divided by the number of covid patients in the hospital staff during that exact day. the fourth tab called advanced settings is a series of show and hide "accordians" where users can input the amount of ppe equpiment they have at the start of each day. there are six collapsed boxes for each ppe equipment type and for covid patient count. expanding a box displays seven numericalinput textboxes which allows users to input the number of ppe or patient count for each day. the equations describing the ppe needs, eqs. ( , , ) are implemented in the shiny dashboard using the dplyr library. the dplyr library allows users to work with dataframe like objects in a quick and efficient manner. the three equations are implemented using a single dataframe. the advanced setting inputs of the burn rate analysis tab are saved into a dataframe. the ppe equations -eqs. ( the back-end implementation of the dashboard is achieved using the functions presented in sec. on the server module of the dashboard. the main strategy is to use a particular function and connect it with the input controls to feed the needed arguments into the function and then capture the output of the function and render it accordingly. let's consider the example of the globe map representation shown in the dashboard which is done using the live.map function. lst. shows how this function connects with the other elements in the dashboard: the input elements are accessed using input$... which in this are used to control the particular options for the displaying the legends or projections based on checkboxes. the output returned from this function is captured through the renderplotly({...}) function, that is aimed to take plotly type of plots and integrate them into the dashboard. # livemap plot charts on the three possible commbinations output $ ts _ livemap <-output $ ts _ livemap <-output $ ts _ livemap <-output $ ts _ livemap <-renderplotly ({ legend <-input $ sel _ legend projections <-input $ sel _ projection live . map ( covid . data ( " ts -confirmed " ) , interactive . display = false , no . legend = legend , select . projctn = projections ) }) listing : example of how the live.map function is used to render the ineractive figures display on the dashboard. another example is the report generation capability using the report.summary function which is shown in lst. . as mentioned before, the input arguments of the function are obtained from the input controls. the output in this case is rendered usign the rendertext({...}) function, as the output of the original function is plain text. notice also that there are two implementations of the report.summary, one is for the rendering in the screen and the second one is for making the report available to be downloaded which is handled by the downloadhandler function. reportserver <-function ( input , output , session , result ) { output $ report _ output _ default <-rendertext ({ # extract the vairables of the inputs nentries <-input $ txtbox _ nentries geo _ loc <-input $ geo _ loc _ select ts <-input $ ddl _ ts capture . output ( report . summary ( graphical . output = false , nentries = nentries , geo . loc = geo _ loc , cases . to . process = ts ) ) } , sep = '\ n ') report <-reactive ({ nentries <-input $ txtbox _ nentries geo _ loc <-input $ geo _ loc _ select ts <-input $ ddl _ ts report <-capture . output ( report . summary ( graphical . output = false , nentries = nentries , geo . loc = geo _ loc , cases . to . process = ts ) ) return ( report ) }) output $ downloadreport <-downloadhandler ( filename = function () { paste ( " report -" , sys . date () ," . txt " , sep = " " ) } , content = function ( file ) { writelines ( paste ( report () ) , file ) } ) } listing : report capabilites implemented in the dashboard using the report.summary function. the final element in the deployment of the dashboard is the actual set up and configuration of the web server where the application will run. the actual implementation of our web dashboard, accessible through https://covid analytics.scinet.utoronto.ca, relies on a virtual machine (vm) in a physical server located at scinet headquarters. we should also notice that there are other forms or ways to "publish" a dashboard, in particular for shiny based-dashboards, the most common way and perhaps straighforward one is to deploy the dashboard on https://www.shinyapps.io. alternatively one could also implement the dashboard in a cloud-based solution, e.g. https://aws.amazon.com/blogs/big-data/running-r-on-aws/. each approach has its own advantages and disadvantages, for instance, depending on a third party solution (like the previous mentioned) implies some cost to be paid to or dependency on the provider but will certainly eliminate some of the complexity and special attention one must take when using its own server. on the other hand, a self-deployed server will allow you for full control, in principle cost-effective or cost-controled expense and full integration with the end application. in our case, we opted for a self-controlled and configured server as mentioned above. moreover, it is quite a common practice to deploy (multiple) web services via vms or "containers". the vm for our web server runs on centos and has installed r version . from sources and compiled on the vm. after that we proceeded to install the shiny server from sources, i.e. https://github.com/rstudio/ shiny-server/wiki/building-shiny-server-from-source. after the installation of the shiny-server is completed, we proceed by creating a new user in the vm from where the server is going to be run. for security reasons, we recommend to avoid running the server as root. in general, the shiny server can use a user named "shiny". hence a local account is created for this user, and then logged as this user, one can proceed with the installation of the required r packages in a local library for this user. all the neeeded packages for running the dashboard and the covid .analytics package need to be installed. lst. shows the commands used for creating the shiny user and finalizing the configuration and details of the log files. # place a shortcut to the shiny -server executable in / usr / bin sudo ln -s / usr / local / shiny -server / bin / shiny -server / usr / bin / shiny -server # create shiny user sudo useradd -r -m shiny # create log , config , and application directories sudo mkdir -p / var / log / shiny -server sudo mkdir -p / srv / shiny -server sudo mkdir -p / var / lib / shiny -server sudo chown shiny / var / log / shiny -server sudo mkdir -p / etc / shiny -server listing : list of commands used on the vm to finalize the setup of the shiny user and server. source: https: //github.com/rstudio/shiny-server. for dealing with the apache configuration on port , we added the file /etc/httpd/conf.d/rewrite.conf as shown in lst. . rewritecond %{ request _ scheme } = http rewriterule^https : / / %{ server _ name }%{ request _ uri } [ qsa , r = permanent ] listing : modifications to the apache configurations, specified in the file rewrite.conf. these three lines rewrite any incoming request from http to https. for handling the apache configuration on port , we added this file /etc/httpd/conf.d/shiny.conf, as shown in lst. . this virtualhost receives the https requests from the internet on port , establishes the secure connection, and redirects all input to port using plain http. all requests to "/" are redirected to "http:// . . . : /app /", where app in this case is a subdirectory where a particular shiny app is located. there is an additional configuration file, /etc/httpd/conf.d/ssl.conf, which contains the configuration for establishing secure connections such as protocols, certificate paths, ciphers, etc. the main tool we use in order to communicate updates between the different elements we use in the development and mantainance of the covid .analytics package and dashboard web interface is orchestrated via git repositories. in this way, we have in place version control systems but also offer decentralized with multiple replicas. fig. shows an schematic of how our network of repositories and service is connected. the central hub for our package, is located at the github repo htttps: //github.com/mponce /covid .analytics; we then have (and users can too) our own clones of local copies of this repo -we usually use this for development and testing-. when a stable and substantial contribution to the package is reached, we submit this to the cran repository. similarly, when an update is done on the dashboard we can synchronize the vm via git pulls and deploy the updates on the server side. in this paper we have presented and discussed the r covid .analytics package, which is an open source tool to obtain, analyze and visualize data of the covid pandemic. the package also incorporates a dashboard to facilitate the access to its functionalities to less experienced users. as today, there are a few dozen other packages also in the cran repository that allow users to gain access to different datasets of the covid pandemic. in some cases, some packages just provide access to data from specific geographical locations or the approach to the data structure in which the data is presented is different from the one presented here. nevertheless, having a variety of packages from which users can try and probably combine, is an important and crucial element in data analysis. moreover it has been reported different cases of data misuse/misinterpretation due to different issues, such as, erroneous metadata or data formats [ ] and in some cases ending in articles' retractions [ ] . therefore providing additional functionalities to check the integrity and consistency of the data, as our the covid .analytics package github repo -central repository https://github.com/mponce /covid .analytics shiny server, running on vm https://covid analytics.scinet.utoronto.ca local copies cran repo https://cran.r-project.org/package=covid .analytics local copies local copies github io -web rendering https://mponce .github.io/covid .analytics/ private instances figure : schematic of the different repositories and systems employed by the covid .analytics package and dashboard interface. does is paramount. this is specially true in a situation where the unfolding of events and data availability is flowing so fast that sometimes is even hard to keep track of all the changes. moreover, the covid .analytics package offers a modular and versatile approach to the data, by allowing users to input their own data for which most of the package functions can be applied when the data is structured using a time series format as described in this manuscript. the covid .analytics is also capable of retrieving genomics data, and it does that by incorporating a novel, more reliable and robust way of accessing and designing different pathways to the data sources. another unique feature of this package is the ability of incorporating models to estimate the disease spread by using the actual data. although a simple model, it has shown some interesting results in agreement for certain cases. of course there are more sophisticated approaches to shred light in analyzing this pandemic; in particular novel "community" approaches have been catalyzed by this too [ ] . however all of these approaches face new challenges as well [ ] , and on that regards counting with a variety, in particular of open source tools and direct access to the data might help on this front. r: a language and environment for statistical computing, r foundation for statistical computing r: a language for data analysis and graphics covid .analytics: load and analyze live data from the covid- pandemic the biggest mystery: what it will take to trace the coronavirus source animal source of the coronavirus continues to elude scientists a pneumonia outbreak associated with a new coronavirus of probable bat origin the proximal origin of sars-cov- bat-borne virus diversity, spillover and emergence extrapulmonary manifestations of covid- opensafely: factors associated with covid- death in million patients considering how biological sex impacts immune responses and covid- outcomes coronavirus blood-clot mystery intensifies using influenza surveillance networks to estimate state-specific prevalence of sars-cov- in the united states consolidation in a crisis: patterns of international collaboration in early covid- research critiqued coronavirus simulation gets thumbs up from code-checking efforts timing social distancing to avert unmanageable covid- hospital surges special report: the simulations driving the world's response to covid- covid- vaccine design: the janus face of immune enhancement covidep: a web-based platform for real-time reporting of vaccine target recommendations for sars-cov- social network-based distancing strategies to flatten the covid- curve in a post-lockdown world asymptotic estimates of sarscov- infection counts and their sensitivity to stochastic perturbation evolutionary origins of the sars-cov- sarbecovirus lineage responsible for the covid- pandemic an interactive web-based dashboard to track covid- in real time pandemic publishing poses a new covid- challenge will the pandemic permanently alter scientific publishing? how swamped preprint servers are blocking bad coronavirus research project, trainees, faculty, advancing scientific knowledge in times of pandemics covid- risk factors: literature database & meta-analysis coronawhy: building a distributed, credible and scalable research and data infrastructure for open science, scinlp: natural language processing and data mining for scientific text the comprehensive r archive network covid- data repository by the center for systems science and engineering covid- : status of cases in toronto database resources of the national center for biotechnology information ape . : an environment for modern phylogenetics and evolutionary analyses in r rentrez: an r package for the ncbi eutils api a contribution to the mathematical theory of epidemics the sir model for spread of disease: the differential equation model, loci.(originally convergence exact analytical solutions of the susceptible-infected-recovered (sir) epidemic model and of the sir model with equal death and birth rates devtools: tools to make developing r packages easier shiny: web application framework for r shinydashboard: create dashboards with 'shiny', r package version shinycssloaders: add css loading animations to 'shiny' outputs interactive web-based data visualization with r, plotly, and shiny, chapman and hall/crc, dt: a wrapper of the javascript library 'datatables', r package version dplyr: a grammar of data manipulation estimated personal protective equipment (ppe) needed for healthcare facilities personal protective equipment (ppe) burn rate calculator high-profile coronavirus retractions raise concerns about data oversight covid- pandemic reveals the peril of ignoring metadata standards artificial intelligence cooperation to support the global response to covid- the challenges of deploying artificial intelligence models in a rapidly evolving pandemic the r script containing the shiny app to be run should be placed in /etc/shiny-server and confiurations details about the shiny interface are adjusted in the /etc/shiny-server/shiny-server.conf file.permissions for the application file has to match the identity of the user launching the server, in this case the shiny user.at this point if the installation was sucessful and all the pieces were placed properly, when the shiny-server command is executed, a shiny hosted app will be accessible from localhost: .since the shiny server listens on port in plain http, it is necessary to setup an apache web server to act as a reverse proxy to receive the connection requests from the internet on ports and , the regular http and https ports, and redirect them to port on the same host (localhost). mp wants to thank all his colleagues at scinet, especially daniel gruner for his continous and unconditional support, and marco saldarriaga who helped us setting up the vm for installing the shiny server. key: cord- -uokr mjq authors: barnes, t. title: the shir model: realistic fits to covid- case numbers date: - - journal: nan doi: nan sha: doc_id: cord_uid: uokr mjq we consider a global (location independent) model of pandemic growth which generalizes the sir model to accommodate important features of the covid- pandemic, notably the implementation of pandemic reduction measures. this"shir"model is applied to covid- data, and shows promise as a simple, tractable formalism with few parameters that can be used to model pandemic case numbers. as an example we show that the average time dependence of new covid- cases per day from central and western european countries is in good agreement with the analytic, parameter-free prediction of the model in the models typically employed in epidemiology to follow the evolution of a pandemic [ ] , one begins by partitioning a total population of n individuals into a complete set of disjoint subsets, according to their medical histories. the simplest models of this type have only a few categories, such as ) the susceptible but as yet uninfected population s, ) the infected but not recovered population i, who can infect s, and ) the recovered population r, who can no longer infect s, and can themselves no longer be infected. first-order ordinary differential equations (odes) in time are assumed to describe the coupling between these groups. once the appropriate initial conditions are specified, these odes can be integrated, which gives predictions for the subsequent evolution of the group populations. in this example, given constant rates {r ij } for the two assumed transitions, s → i and i → r, the resulting odes for this simple "sir" model are ds/dt = −r s→i s di/dt = +r s→i s − r i→r i dr/dt = +r i→r i we will refer to these two rate coefficients as r s→i = r i and r i→r = r r . on adding these equations we find that so the total number of individuals is a constant, n . since these equations are linear and homogeneous, it is convenient to divide by n and solve for the fraction of individuals in each category, such as f s = s/n . r or * email: tbarnes@utk.edu f r can be inferred from the other two populations, using r = n − s − i, or equivalently f r = − f s − f i , so we need only solve the set ( ), we will assume that the entire population is initially in category s (susceptible but not infected or recovered), so that f s (t = ) = and f i (t = ) = . given these initial conditions we can solve the equations ( ) , which also imply f r through f r = − f s − f i , with the results the behavior of this system is just what one would expect from the dynamics described in the sir-type defining equations ( ) : the initial population of susceptibles (s) decays exponentially at the specified rate r i as they transition into infected (i); the infected fraction increases to a maximum [ ] , and then declines as it populates the final, recovered population (r). as t → ∞ one asymptotically approaches a state in which all of the population has transitioned to recovered, f r (t = +∞) = . as anticipated, at any intermediate time < t < +∞, f s (t) + f i (t) + f i (t) = . as a specific example, the time dependence predicted by this sir model is shown in fig. , for r i = . [days − ] and r r = . [days − ] (an infection rate of five times the recovery rate). two important modifications to this simple pedagogical sir model appear appropriate for a more realistic description of the covid- pandemic. one is that the rate of transitions from susceptible (s) to infected (i) should be proportional to the product of these two populations, since their interaction determines this rate. this modifies the second evolution equation for the population fraction f i (t) to this "second-order reaction kinetics" in the infection process is a standard assumption in epidemic models [ , ] . a second, more novel modification of the sir model is to incorporate the effects of a social response to a highprofile pandemic such as covid- . in this case there has been strong encouragement from governments and medical authorities to reduce the growth of the pandemic by implementing social distancing and related measures. in this shir model these actions reduce the susceptible population by transferring them to a new category of "hidden" individuals (h) who are not susceptible to infection, which is populated from the original group of susceptibles (s) through another rate process, the individuals in h are not only the physically sequestered; simply changing behavior, such as avoiding public assemblies, crowded schools and public transportation, implementing rigorous hygienic practices, and many other measures contribute to the continued reduction of the effective susceptible population fraction f s [ ] . we consider τ = /r h , the "social response time," to be a measure of how quickly a society responds to a developing pandemic threat. we shall subsequently find that there are interesting differences between countries in the fitted values of this parameter. the partner de for f s , similarly modified to include a second-order infection rate process as well as the new first-order social response transition term for s → h, is the final "recovery" de for dr/dt is unchanged from the sir model formula in ( ) . however since the r cases in practice include mortality as well as recovery, we will instead refer to the r population as "resolved" [ ] . collecting these results gives our complete set of shir model des, note that one recovers the three original pandemic des of kermack et al. [ ] (their eqs.( )) through the substitutions f (s,i,r) → (x, y, z)/n and (r i , r r ) → (κ, ℓ), and removing the "hidden population" of the shir model by setting r h = and f h = . we note in passing that the infected (and still infective) individuals (all those in box i) are also referred to in the literature as the "active" cases, numbering a(t). here, i(t) and a(t) are identical; any individuals in box i who are no longer infective are immediately reclassified as "resolved," and moved to box r. since ( ) is a nonlinear set of odes for the four population fractions f s,h,i,r , an exact analytical solution will not be possible, except in certain limits and approximations. however some important results can still be proven for this nonlinear system. one such result, obtained by adding the equations in ( ) , is that the sum of the four populations fractions f is a constant of motion. thus f h + f s + f i + f r = , or h + s + i + r remains a constant, n . another useful result is that the population fractions of the two groups h "hidden" and r "resolved" can be expressed simply in terms of the susceptible (s) and infected (i) fractions f s and f i , and our principle task will therefore be to solve the two coupled equations for f s (t) and f i (t), the second and third equations in the set ( ) . since the rate of increase of the infected fraction df i /dt is proportional to the product f i f s , a trivial solution of the model follows from an initial condition of no infections, f i (t = ) = ; this implies f i (t) = , i.e. that there are no infections at any later (or earlier) time. in this limit all that happens is that the initial fully susceptible population f s (t = ) = ; f h (t = ) = evolves into an increasingly hidden population, as a decaying exponential; in practice the fraction of infected individuals f i (t) will usually be much smaller than the fraction of susceptibles f s (t). this suggests that we use the no-infection limit ( ) for f s (t) as a first approximation in determining f i (t) in the small-f i (t) limit. with this substitution, we find that the increase in df i /dt, the fractional rate of new cases per day, will be for completeness we note that the rate of decrease of the "active" (still infective) population fraction f i (t) per day due to transitions from "infected" to "resolved" status is given by so the full de for f i (t) in this small-f i (t) limit is the formula for the fractional "new cases per day" (cpd) growth rate in the small-f i (t) approximation, eq.( ), is attractive for several reasons. first, it is easily compared to data, since there is copious information available from many countries regarding the number of new cases per day. (this quantity is simply n times the df (in) i /dt above.) second, since ( ) is a linear, homogeneous, first-order differential equation involving only f i (t), and the associated integral over time is tractable, we may solve for f i (t) analytically in this small-f i (t) approximation. in the early and intermediate stages of a pandemic in which the infected fraction still dominates the resolved fraction, we can ignore the assumed slower transition of infected to resolved by setting r r = , which gives lim s>>i>>r df i /dt = +r i e −rht f i . this relation is especially amenable to comparison with data, as it relates two observed quantities, the number of new cases per day (n df i (t)/dt) and the cumulative number of cases (n f i (t)), assuming that n f r (t) can be neglected. the shir model in this small-infectedfraction limit predicts that this ratio should be a decaying exponential in time, in the following section we will compare the expected time dependence of several pandemic models to covid- data, including the shir model prediction ( ) . we will follow this with more detailed shir-model calculations of the cumulative case numbers n f i (t) and especially the new cases per day (cpd), n df i (t)/dt, and will describe detailed fits of these functions to covid- data from a range of countries. here we will first discuss the time dependence predicted by two familiar dynamic models of pandemics, and will show how these models can be compared to covid- data. we will find that there are serious difficulties in applying these simple models to covid- . in this discussion we will consider only the cumulative number of cases as a function of time (here called p(t)), and the rate of appearance of new cases per day, dp/dt. these numbers are widely reported for covid- , and require little interpretation. one important point is that the number of cumulative cases to time t, p(t), is the sum of the infected i(t) and the resolved r(t) populations distinguished in the previous section; as a first, simplest model of the growth of a pandemic, one can assume that the rate of change of the number of cases dp/dt is proportional to the number of cases p, the solution of this differential equation is an exponential times the number of cases at some arbitrary initial time, this simple model clearly makes unrealistic assumptions, notably that there are infinitely many potential cases. it also neglects spatial dependence or other "local" aspects of the problem, as well as the effect of transitions from infected to resolved individuals who are no longer infective. this exponential model predicts that the ratio of new cases per day to cumulative cases should be a constant, in fig. we compare this expectation to the ratio of new cases reported per day (∆p/∆t) to the cumulative number of cases (p) for the uk, using data from ref. [ ] over the period mar - may . evidently this ratio is far from constant; it falls by about a factor of over the -day period shown. the simple exponential model can be improved through the introduction of a limit in the number of the population that can be infected, p max . one can assume that the infection rate is initially equivalent to the exponential model, but later in the pandemic is suppressed in proportion to the number of uninfected individuals remaining, p max − p. a simple de with these properties is the "logistic model," defined by the solution of this model, which is symmetric about p = p max / , is the inverse of an exponential plus a constant, translated by a t that is determined by the initial conditions; this logistic model can also easily be tested by comparison with data on the ratio of new cases per day to cumulative cases. in this case, the model predicts that this ratio should be a simple, linear function of p, so, when data on this ratio (y-axis) is plotted against p (x-axis), this model anticipates linear p-dependence, with an x-axis intercept (where dp/dt = ) at p = p max . in fig. we show an example of this plot for covid- data, using the usa cumulative cases and new cases per day data from ref. [ ] through july . although this ratio initially has some qualitative resemblance to the logistic model form ( ), (see fig. upper left), the more recent data (lower right) is clearly inconsistent with ( ), and cannot be extrapolated linearly to zero dp/dt. a study of the pandemic time dependence predicted by the logistic model shows another specific aspect of the model that makes it unrealistic for covid- ; the rate of new cases dp/dt predicted by this model is symmetric about the maximum, at the p(t) inflection point t = t . we shall see that in contrast the rate of new cases dp/dt observed in the covid- data is rather skewed, and has a faster rise to maximum than the subsequent decline. here we will test a third prediction for time dependence, which is the form predicted by the shir model of the previous section. there we noted that the infected fraction f i of the population is predicted to satisfy the differential equation in the limits of a small fraction of the population being infected (f i << ) and the resolved fraction being small relative to the infected fraction (f r << f i ). the existing covid- data suggests that these are both reasonable approximations in the early and intermediate stages of the covid- pandemic. the expectation ( ) can immediately be compared to data, since (df i /dt)/f i is just the ratio shown on the y-axis of fig. . the dotted line in the figure shows a decaying exponential fit of exactly the form ( ), which evidently gives a very good description of the data. the parameter values found in this fit are r i = . [days − ] and τ ≡ /r h = . [days] . motivated by the good agreement between the shir model prediction of a decaying exponential in time for (df i /dt)/f i and the covid- data evident in fig. , we will subsequently discuss shir model predictions in more detail, and will show fits of this model to covid- data from many european countries. this will follow a short discussion of some general aspects of mathematically similar models, which will be used in the detailed discussion of shir results. the results discussed above motivate the consideration of generalizations of the simplest "pure exponential" pandemic model, in which the constant λ of that model ( ) is replaced by an explicit function of time, for a given function λ(t), the defining differential equation ( ) gives the predicted growth of case numbers as formally this may be regarded as exponential growth in a new (nonlinear) time variable u, defined by du = λ(t)dt. since this is a model of the growth of a pandemic, the cumulative number of cases ( ) can only increase, or become flat when the pandemic has been completely halted, which occurs if and when we reach a time t f for which λ(t f ) = . accordingly we constrain λ(t) to be positive (pandemic ongoing, t < t f ) or zero (t = t f , pandemic halted). the inflection point of p(t) is of considerable importance, since this is the time of peak pandemic growth. the time t inf l of the inflection point is specified by the rate of change of case numbers dp/dt reaching a maximum; this occurs when the second derivative d p/dt is zero, on substituting the general solution p(t) from ( ) into this constraint, we find an equivalent definition of the in-flection point in terms of the proportional growth function λ(t), a. cumulative cases p(t) and cases per day (cpd) dp/dt(t) in sec.i.b. we introduced the "shir" model as a generalization of the sir model, with the effects of pandemic reduction measures incorporated through a "hidden" population (h) that migrates from the initial susceptible population (s) with a rate constant r h . in the limit of a small infected population fraction (f i << ) relative to the remaining fraction of susceptibles (f s ), and assuming that the resolved fraction f r can be neglected, we showed that the infected fraction satisfies a differential equation of the form where the shir growth rate function is a decaying exponential in time, the rate coefficients r h and r i can be interpreted respectively as a characteristic "social response time" τ = /r h for the implementation of pandemic reduction measures, and an initial condition (at some t = ) on the growth rate function λ(t); if we multiply the infected fraction f i by the total population n , and similarly scale the fractional new cases per day, we can compare the results for the cumulative cases p(t) and new cases per day dp/dt directly to the data as normally reported. given the form ( ), on solving ( ) we find that the predicted number of cases as a function of time in the shir model is a nested exponential, this may be simplified by replacing the t = initial condition λ( ) by an equivalent time shift which gives a simple three-parameter form for the general solution of the cumulative number of cases in the shir model, this function increases monotonically from p = at t = −∞ to p max at t = +∞, and has a single inflection point at t = t . this is an example of a gompertz [ ] curve, y = ab q x [ ] ; these are often encountered in problems in which a proportional rate of growthḟ /f is driven by an exponential. the rate of appearance of new cases per day (cpd) in the model, dp/dt, can be evaluated directly from p(t) above, and is this rate of growth is zero at t = −∞, increases to a maximum value at the p(t) inflection point t , and then decreases with time, approaching zero exponentially as t → +∞. dp/dt integrates to a finite number of cases p max as t → +∞. the maximum number of cases per day, at the time t of the p(t) inflection point, is given by the three parameters that specify a solution of the shir model, p max , τ and t , all have simple interpretations; they are respectively the height, width scale, and time shift of the pandemic profile p(t) (or of the rate of new cases, dp/dt). p max is by definition the maximum value of p(t), and gives the total number of cases, which is p(t) at t = +∞. the social response time τ sets the scale for all time-interval features of p(t) and dp/dt, since changing t only translates these functions. the time shift t is the time of the inflection point of p(t), this inflection point t may be considered the peak of the local pandemic, since the number of new cases per day estimated by the fit is then a maximum. for discussion purposes a convenient choice for t in ( ) and ( ) is t = , which places the inflection point of p(t) at t = . plotting p(t) or dp/dt against t in units of τ , normalized to their maximum values, gives a parameter-independent "universal profile" for each of these functions. the universal form for p(t), scaled by its maximum value p max , is shown in fig. . the inflection point of p(t) at t = is indicated, where both p( )/p max and its slope (in the dimensionless time variable t/τ ) equal e − . this last property implies that the total number of cases p max and the cumulative number of cases at the time of the p(t) inflection point (pandemic maximum), p(t ), are related by p max = e · p(t ) . this provides a simple estimate of the total expected cases p max from the number observed up to the pandemic peak, p(t ), which may already be known. some additional times of interest are those at which p(t) has reached %, %, % and % of the total cumulative cases; these are respectively (t − t )/τ = − . , + . , + . , and + . . the universal curve for dp/dt, the new cases per day, is shown in fig. , scaled by its maximum value of p max /eτ . the mean and variance of t for this distribution are < t >= γτ (γ is euler's constant) and σ = (π/ √ )τ . the skewness [ ] of dp/dt is √ ζ( )/π ≈ + . , a positive value indicating a more heavily weighted rhs. several additional interesting features of dp/dt are the fwhm, . τ (indicated in fig. ), the rise time of dp/dt from half-max to peak, which is . τ ; and the much slower decline of dp/dt from peak to half-max, which requires . τ . the asymptotic approach of p(t) to p max cases at large times is exponential, as is the (decreasing) rate of growth of new cases at large times, we note in passing that these results suggest an improved estimate of the asymptotic total number of cases p max which has accelerated convergence, although this improved behavior would likely be masked in practice by the background of sporadic cases. in this section we will show results from fitting the predicted early pandemic time dependence from the shir model as derived in sec.iiia to data for the confirmed covid- case numbers from many different countries. we will primarily consider fits of the new case numbers per day (cpd) to the shir model prediction, eq.( ). as an initial example we will show results for austria, including fits to both the cpd and the cumulative case numbers. following this we will give the results of shir model fits to the cpds reported by a representative set of western countries, and will compare and contrast these results. we will also discuss procedures for fitting more complicated datasets that show evidence for multiple infection sites, and will show examples of such fits. finally we will show how datasets from multiple countries can be combined, and will use this procedure to test the predicted shir model profile for new cases per day, displayed as a universal (parameter-free) curve. as a first application we will fit the three-parameter shir model to the data on the number of new daily covid- cases per day in austria, as reported on the worldometer website, ref. [ ] . austria was chosen because it represents one of the earliest covid- outbreaks in europe, so their data allows us to follow both the earlier and later stages of the pandemic. for this fit we will use the entire austrian cpd dataset from the initial website date of feb through may , comprising a nominal data points. (for most countries we consider, including austria, there are actually many "null" or zero entries in the early dates.) as a reminder, in the small fraction of infections limit assumed here one may solve the model for the cumulative case numbers of infected people p(t) and hence the rate of new cases per day dp/dt in closed form, given by eqs. ( , ) . the three free parameters in these functions are p max (total number of cases), τ (social response time), and t (the p(t) inflection point; time of the maximum cases per day). our common t = reference time in all these numerical fits and discussions is taken to be mar . the fits are all simple, unweighted leastsquares without data errors. the result of this fit for austria is shown in fig. . this is a surprisingly good fit to the full range of the cpd data, including the rapid initial rise after the early cases, the peak region, and the subsequent slower decline; all are reasonably well described by the model [ ] . the shir model parameters resulting from this fit to the cpd data from austria are given below. these and other fitted parameters are typically quoted to three-place accuracy in this paper, to allow numerical tests such as debugging of numerical routines and checking analytic results. there is evidently reasonable agreement between the shir model and the data with these parameters for the number of new cases per day, although there is considerable scatter in the data. the numerical value of the peak predicted cpd, p max /eτ , and the time of the peak, t inf l = t are indicated by a single large point in fig. . these values are respectively [cases/day] and . [days] (measured from t = on mar ), giving mar as the peak date for new cases per day in austria implied by this fit. the fitted value of the austrian "social response time," τ ≈ . [days], is of special note. this is the smallest value (hence the fastest social response) we have found in our fits to the covid- pandemic numbers from a large set of representative central and western european countries (see table i ). this suggests that austria deployed an especially rapid and effective response to this pandemic, which presumably had a strongly limiting effect on the total number of cases. a minor discrepancy between the model and data is evident at the early times in fig. that are characterized by small case numbers. (see times before about t = − [days] in the figure.) the number of early cases is clearly underpredicted by the fit. this may represent their growth from a small number of initial cases, closely monitored and hence developing rather slowly, which were evident before the primary pandemic contribution became dominant. we will note a similar, more prominent effect in the early data from denmark and norway at about the same date. an alternative approach would be to fit the cumulative number of reported cases as a function of time, which is typically reported together with the new cases per day. since one is the derivative of the other, these should give similar parameter values. of course the results will not be identical, because the model is not exact, and the cumulative cases data will give higher fitting weight to the later stages of the pandemic. the choice of which dataset to fit, cumulative cases or new cases per day, may be suggested by the subject of greatest interest; the peak of the pandemic is best determined by fitting the new cases per day, but the final number of cases will be best determined if constrained by the large total case numbers reported in the later stages of the pandemic. here as an example of the second fit we give the shir model results that follow from fitting the cumulative case numbers from austria. we again use a set of points of austrian data [ ] from the initial reporting date of feb through the fitting date, may . the shir model fit to the austrian cumulative cases data is shown in fig. evidently the shir model also provides a reasonably accurate description of the cumulative cases for austria. the parameter values resulting from the two fits, to cpd data ( ) and cumulative cases data ( ), are quite similar [ ] . the total case numbers p max differ from their mean by ± %, the fitted social response times τ next we will follow the same procedure described in the first austrian fit above, and will fit the shir model to the cpd data for each of a representative set of central and western european countries. for each fit, as discussed for austria, we have again used pts of daily new case numbers per day [ ] for the period feb - may as the only input data. this data fitted to the threeparameter shir model form for dp(t)/dt, ( ). this fixes the three model parameters p max (with units of [cases]), τ [days], and the inflection point t inf l = t [days] (measured from t = on mar ) separately for each country. the fitted parameter values for the entire set of central and western european countries considered here are given in table. i, together with the calendar date of the inflection point t , and the fitted peak number of new cases per day, which occurs at t . perhaps the most remarkable aspect of the shir model fits to central and western european countries in table. i is the wide range of values found for the "social response time" τ , and how it appears to correlate with national coronavirus policy. as τ sets the width of the pandemic peak, it is a measure of how long a country will have to endure the pandemic. (recall for example that the fwhm of the new cases per day, dp/dt, is about . ·τ .) the extreme cases are austria (τ ≈ . days) and sweden (τ ≈ days), over times longer than austria. the swedish cpd data and fit are shown in fig. . the very slow swedish response time is apparently the result of a rather controversial covid- policy pro- moted by the swedish state epidemiologist, a. tegnell [ ] , which did not impose the strict school closings, border controls, and restrictions on large gatherings that characterized the policies of other scandinavian countries. tegnell instead advocated a more open society during the pandemic, to promote herd immunity and a quick economic recovery. although the swedish policy was evidently successful in broadening the curve, their per capita number of cases is over twice that of denmark and nor-way, and the swedish fatalities per capita are larger by a similar amount. this argues that an aggressive national policy of minimizing the social response time τ , for example through contact tracing, extensive testing, rapid medical response and isolation of positive cases through quarantine, may be the most effective in reducing the total case and fatality numbers. it may also prove easier to sustain a strict policy over a short period of time than a more lax one over a longer period. the uk and dutch social response times τ are also quite large, and can also be correlated with their early national policies that promoted "flattening the curve" and developing herd immunity. to quote the dutch prime minister regarding covid- policy in a national address [ ] , (in translation) "... we can slow down the spread of the virus while at the same time building group immunity in a controlled way." in a national address [ ] the uk prime minister stated that "it is vital to slow the spread of the disease. that is the way we reduce the number of people needing hospital treatment at any one time." of course the argument that slowing the spread of the pandemic is advantageous because it "flattens the curve" is specious. this tacitly assumes that the total number of cases p max is constant, so a broader rate curve must have a lower mean. in practice there is instead evidence that a longer τ may result in more infections per capita, as seen in comparing sweden with denmark and norway. if so, flattening the curve by slowing the spread of the pandemic unfortunately increases the total number of cases and fatalities. this complicated and perhaps counterintuitive issue certainly merits careful future investigation. we have also carried out fits of the shir model to covid- data for three north american countries, canada, mexico and the usa. these three countries were treated as a separate exercise because of concerns that european and north american policies differed considerably, which might lead to very different fit parameters and pandemic curves. this was indeed found to be the case. most of the fits of the shir model to european countries described above were carried out in may , using -point worldometer coronavirus datasets [ ] covering the period feb - may . initially we used the same procedures and datasets for the three north american countries. this appeared satisfactory for canada and the usa, however the data for mexico showed that this country was still in the early stages of the pandemic, and had a very long social response time of about days, with a predicted pandemic peak in late july. for this reason we decided to carry out a fit to mexico incorporating later data, specifically a -point worldometer cpd dataset for the period feb - july , and have fitted the corresponding data for canada as well. recent developments in the usa have shown a dramatic departure from a single peak model, which suggests that the usa should be treated as a superposition of several more localized outbreaks. accordingly, here we quote shir model fit results for new york state alone, as a representative component of the usa with an effective social response. the cpd data in this case is available from mar , so we fitted a dataset covering the period mar - july , comprising data points. the results of these fits are given in table. of course each of the national pandemic datasets we are studying is in some sense the sum of multiple events, displaced in time and encountering special local conditions. in the usa for example the early data is dominated by events on the west coast, but these were superseded by the major outbreak involving new york city, and then by a smaller event in new jersey, and a larger number of local events in the midwest and south. fitting the data from many local outbreaks as a single event is clearly problematic. a series of local events separated in time but still overlapping significantly, if fitted as a single outbreak, could give a misleadingly large τ . separating the individual events will require accurate local data, and a more detailed investigation. despite this concern, the shir model does nonetheless allow a reasonably accurate fit to most of the national datasets we have considered. of the european countries we have discussed here, just two showed clear evidence of a more complicated pandemic history that could not be fitted as a single-peak event. these were denmark and norway. in both countries there was evidence of an early, short-lived outbreak, which led to about cases of covid- in each country, both during the period of - mar . in both countries this early outbreak was rapidly suppressed, presumably through contact tracing and quarantine. we found that the cpd data from denmark and norway could be described by using eq.( ) to represent two independent outbreaks, a short, early one, with a very short τ ≈ . [days], and a dominant second outbreak, with the more typical covid- parameters listed in table.i. the resulting two-peak fit for norway is shown in fig. [ ] . . the total cases predicted for denmark and for norway are simply the sum of the early and later peaks, thus . k and . k cases respectively. the idea of simultaneously fitting multiple countries to the shir model seems appealing, particularly as this model gives a good description of the case numbers from many different european countries. unfortunately there are complications with this procedure; individual countries vary considerably in the fitted values of the total cases p max , the characteristic social response time τ , and the local time of the pandemic peak, t . these differences suggest a scaling approach, in which we determine these parameters separately for each country in a shir model fit, and then translate (by t ) and scale (by p max and τ ) the datasets for each country separately. if the model and the data are both accurate, these translated and scaled datasets should provide points that fall on the universal curves shown in figs. and . of course there are indications that the covid- data itself is occasionally problematic, with considerable scatter, single-bin spikes, and in some countries a modulation with a -day period that may reflect a weekly reporting regimen. nonetheless it is of interest to generate this translated and scaled scatterplot, to see whether a common pandemic profile is indeed evident in the european data. this scatterplot is shown in fig. for the -point cpd datasets of all european countries in table. i. each national dataset was translated and scaled separately by its particular values of t , p max , and τ (as given in the table) before being added to this figure. the data from denmark and norway before mar was excluded from the plot, to suppress contributions from their initial early outbreaks. table. i, translated and scaled to fit on the universal plot for dp/dt, fig. . the (parameterfree) shir model prediction for dp/dt, eq.( ), is shown as a solid line in this figure. the scaled, centered universal curve for dp/dt is shown as a solid line in fig. , and is given by dp dt we can use this scatterplot to combine the data from the european countries we have considered, since they have now been superimposed through translating in time and scaling both axes. on binning in the scaled time variable (t − t )/τ , we can calculate the average and variance of the scaled cpd datapoints in each bin, which provides an average and error for dp/dt at that value of (t − t )/τ . as an example, we have used bins of width ∆(t − t )/τ = . , centered on t − t = , which gives the result shown in fig. . this appears approximately consistent with the parameter-free shir model result for dp/dt ( ), although there may be relatively minor discrepancies at onset ((t − t )/τ ≈ − ) and well after peak the europe-averaged covid- data for the new cases per day shown as points with errors in fig. can be used to calculate expectation values under this common covid- dp/dt distribution. some of these results are given in table. iii, where they are compared to theoretical values predicted by the shir model dp/dt, eq.( ). evidently the simpler expected values are in reasonably good agreement, notably the displaced value of the mean from the maximum. there is however a discrepancy in the cubic expected values, which are sensitive to the relatively less well determined wings of the distribution at larger |t − t |/τ . fig. . here for simplicity we abbreviate (t − t )/τ = x. we have shown that a shir (generalized sir) model and its associated differential equations give rather good closed-form results for the covid- data on new cases per day and cumulative cases, when solved under certain assumptions. these assumptions can be relaxed in future studies. one important assumption was to ignore the effects of the "resolved" population fraction f r . this quantity, which is certainly of interest in planning economic recovery, is simple to evaluate from the "infected" fraction we have discussed here; it is simply the integral in eq. . this can be evaluated analytically, together with the full de for f i , including the r r term, to accommodate transitions out of "infected" and into "resolved." the cumulative case numbers p(t) discussed in relation to covid- data should then be defined by p(t) = n (f i + f r ), i.e. "infected" plus "resolved," since f r is no longer assumed to be negligible. calculations of mortality rates are certainly of interest, and are implicitly included in the transition from the infected population i (or i s ) to the resolved population r. mortality can easily be treated separately, for example by specifying separate i → r rate parameters for mortality and for recovery. in the extended shir model of fig. , mortality would presumably only contribute to the combined rate for i s → r. the mortality rate coefficients may of course depend strongly on the procedures followed at each country's medical facilities. numerical methods can be used to extract shir model results for the full model, including the s − i quadratic infection term, and can test the importance of the "small fraction of infections" approximation used here. a straightforward generalization of the model could accommodate the effect of "asymptomatic" infected individuals on the dynamics of the covid- pandemic. recent antibody results from italy [ ] suggest that the asymptomatic cases are a large but not dominant fraction of all covid- cases. once better data on the number of asymptomatic cases becomes available, it may prove useful to extend the model to include this population. this group follows a progression s → i a → r, and while in the i a population presumably contributes to the infection of other individuals still in s. although adding this branch to the model may indicate that the fraction of resolved individuals f r is much larger than the shir model alone suggests, the pathway through symptomatic cases will remain as before. the most visible predictions of the model, for the number of symptomatic cases (now i s ), may not change significantly. a block diagram of this extended shir model is shown in fig. . finally, although we have primarily considered covid- in central and western european countries, largely because of an assumed similarity in standards for reporting data, there is extensive data available from many other countries which could be addressed using this type of model, undoubtedly with interesting results. in this paper we have introduced a generalization of the sir model in order to incorporate the effects of pandemic reduction measures. this "shir" model adds a rate process that allows transitions from the susceptible population (s) to a new "hidden" population (h), which we assume is not susceptible to infection. we have solved this model analytically in the limit of a small infected population fraction, and showed that the predicted time dependence of cumulative cases and new cases per day is in surprisingly good agreement with covid- data. (we primarily considered central and western european countries in this study.) the solution of the model with our approximations involves three free parameters; one is the "social response time" τ , which varies widely between countries, in a manner that correlates with their coronavirus policies. we are also grateful to e.s.swanson for assistance with calculations of expected values and errors in the shir model, and with the model block diagrams. dynamics of infectious diseases in this simple sir model the time at which fi is a maximum and that maximum value can be solved for analytically, and are respectively t = ln(ri/rr)/(ri − rr) and fi = (ρ/(ρ − ))(ρ − /(ρ− ) − ρ −ρ a contribution to the mathematical theory of epidemics protected groups similar to the "h" box of fig. have previously been considered in generalizations of the sir model. for example, the effects of vaccination are discussed using an sirv model [ ], and the sars model of lipsitch transmission dynamics and control of severe acute respiratory syndrome the use of "resolved" for the post-infected population r, the sum of deceased and recovered, was suggested by p.ardaury. this population is also referred to as "closed cases worldometer coronavirus updates on the nature of the function expressive of the law of human mortality, and on a new mode of determining the value of life contingencies from mathworld -a wolfram web resource skewness is a dimensionless property of a distribution we note in passing that a single "outlier" point in the austrian cpd data, new cases on mar , lies above the upper cutoff of cases per day in fig. . it was of course included in the fit. similarly, the norwegian cpd data includes an outlier of new cases on mar and a negative entry of - new cases on the cumulative "cas" data fit are much smaller than in the preceding new cases per day "cpd" fit. the cas parameter errors are likely underestimated, since the cas data points represent a running sum, and are therefore highly correlated. the cpd parameter errors are presumably more realistic national address british prime minister boris johnson coronavirus address suppression of a sars-cov- outbreak in the italian municipality of vo' key: cord- -twsy oq authors: nan title: siu abstracts date: - - journal: world j urol doi: . /s - - - sha: doc_id: cord_uid: twsy oq nan introduction and objective: th e bladder is generally considered an organ for voiding and storage of urine, with the urothelium serving as an impermeable barrier. recent discovery of aquaporins in the bladder urothelium in rodents and later on also in human challenges this notion of impermeability. upregulation of aquaporins in response to dehydration or bladder outlet obstruction and downregulation following transitional cell carcinoma has been shown. th is emphasize the need to better understand the function and distribution of aquaporins, as well as their role in bladder diseases. th e present study aims at establishing basic knowledge about the expression of aquaporin (aqp ) in the porcine bladder, related to gender and gestational age. th ree pregnant sows at , or days of gestation were sacrifi ced. fetuses were removed and necropsied. th e bladder was rapidly removed and whole wall tissue samples from the bladder dome was snap frozen in liquid nitrogen and stored at - c. genetic gender determination was performed and fetuses with uncertain gender determination were excluded. aquaporin mrna expression was analyzed using qpcr and β-actin was used as the reference housekeeping gene. results were compared using two-way anova. results: a total of samples were analyzed. gestational age was either (n= ), (n= ) or days (n= ). aquaporin was expressed in all samples. aqp mrna expression was increased in the fetal porcine bladder with increasing gestational age (p< . ). however, there was no signifi cant diff erence in aqp mrna expression between genders (p= . ). conclusion: expression of aqp in fetal porcine bladder is demonstrated with increasing expression during gestation. to our knowledge aquaporins in the porcine bladder tissue have not previously been studied. th is exciting new discovery contributes to the ongoing discussion on reviewing the dogma that the lower urinary tract has an impermeable barrier function. improved contractility of the long term bladder outlet obstruction induced bladder underactivity using growth factor expressing mesenchymal stem cells introduction and objective: as the underactive bladder is diffi cult to manage, a new method of increasing bladder contractility in patients with underactive bladder is desired. mesenchymal stem cells (mscs) can serve as vehicles for the gene, proliferate and differentiate into bladder smooth muscle cells to repopulate damaged bladder. th e other is that the exogenous hepatocyte growth factor (hgf) gene can provide complementary functions as angiogenesis and inhibition of fi brosis. th is study was performed to examine the recovery of the decreased bladder contractility in the long term bladder outlet obstruction (boo) models of rats using transplantation of hgf expressing human mscs (hgf-hmscs) into the bladder wall. introduction and objective: suddenly dropping to low environmental temperature, cold stress exacerbates lower urinary tract symptoms (luts) such as urinary frequency and urgency. th is study determined if transient receptor potential ankyrin (trpa ) channels could mediate the cold-stress induced detrusor overactivity in rats. materials and methods: twenty-four female -weeks sprague dawley (sd) rats were used. th is th congress of the sociÉtÉ internationale d'urologie -siu abstract book study used hc (tocris bioscience) as trpa channel antagonist. th ree days prior to cystometric investigations, polyethylene catheters were inserted into the bladder and abdominal cavity. cystometric investigations of the unanesthetized rats were performed at room temperature (rt, ± °c) for min. following, the rats were intraperitoneally injected with vehicle, . -(low dose), or . -(high dose) mg/kg hc (n= , in each). aft er min, the treated rats were exposed to low temperature (lt, ± °c) for min. during the cystometric investigations, the micturition parameters were recorded. introduction and objective: hypoxia-inducible factors (hif , hif and hif ) play a critical role in cellular and systemic responses to hypoxia by inducing a range of diverse genes involved in cell survival, they have also been implicated in development of renal cell carcinoma. we aimed to assess the eff ect of zinc and cobalt on hypoxia-inducible factor expression in immortalized human kidney cells. to cells in mcl). esr at the observed patient aft er the seventh transfusion decreased from initial mm/ hour to mm/hour. aft er the fourth transfusion of mononuclear fraction of peripheral blood at the patient the increase in the content of the total testosterone that allowed to reduce a dose of % of dermal gel of testosterone from . ml per day to . ml per day was observed. aft er the seventh transfusion of mononuclear fraction of peripheral blood because of normalization of production of testosterone the restored number of own leydig's cells an androgen -replacement therapy was cancelled. introduction and objective: ketamine use as a recreational drug is on a rapid increase in young people. many reports have shown that long-term ketamine abuse is liable to lead to lower urinary tract symptoms that resemble interstitial cystitis (ic). ic is a disease characterised by severe and chronic pelvic pain with frequency, urinary urgency, and nocturia in the absence of bacterial infection or other diseases. th is study evaluated the therapeutic eff ect of human umbilical cord blood derived mesenchymal stem cells (ucb-mscs) in a ketamine induced cystitis (kc) rat model. for kc rat models -weekold, female sprague-dawley rats were used. sham treatment (n= ) rats were assigned to the control group. th e rats in the kc group (n= ) and kc+m-scs group (n= ) were intravenously injected with ketamine at a dose of mg/kg for days a week over a duration of weeks. aft er one week, x ucb-mscs were directly injected into the submucosal layer of the anterior wall and dome of the bladder in kc+mscs group. th e cystometric parameters and immunohistochemical results (toluidine-blue, masson trichrome, tunel staining) were measured at one week following the intervention. results: most rats in the kc group exhibited irregular voiding frequency and decreased inter-contraction interval in comparison with the control group ( . ± . vs. . ± . seconds, respectively; p< . ). th e kc+mscs group demonstrated improvement in most voiding parameters to normal levels within week. a single injection of ucb-mscs signifi cantly increased the inter-contraction interval ( . ± . , p< . ) ( figure ). in immunohistochemical analysis, the bladders in kc group were characterized by mast cell infi ltration in toluidine-blue staining, fibrosis in masson trichrome staining and apoptosis in tunel staining which were signifi cantly ameliorated in the bladders in the kc+mscs group ( figure ). conclusion: th e injection of ucb-mscs restored the damaged bladder and associated pathologies including mast cell infi ltration, fi brosis and apoptosis in the kc rat model. stem cell therapy could be valuable treatment option for painful bladder conditions such as ketamine induced interstitial cystitis. mp- . , figure . introduction and objective: currently no markers are available to predict intravesical bacillus calmette-guerin (bcg) response. among the various markers under study survivin has good sensitivity in detecting bladder cancer cases and there has been very limited number of studies regarding survivin as a prognostic marker and predictive marker. prospective evaluation of urinary survivin levels as a potential prognostic and predictive biomarker in non-muscle invasive bladder cancer cases on intravesical bcg therapy was planned in this study. from august to august a total intermediate and high risk group patients of nmibc age ranging from to yrs (mean ) planned for intravesical bcg instillation were enrolled. recurrence and progression score were calculated by using eortc genitourinary scoring system and risk table. patient's urinary samples were taken, pre and post [ (t ), (t ) and weeks (t )], intravesical bcg instillation. urinary survivin expression was studied by elisa technique. results: out of patients, ( . %) had complete remission at months th e mean survivin levels in remission group (group i) was . +/- . which was signifi cantly less than those in recurrence group (group ii) mean . +/- . . pre and post bcg, there was a signifi cant decrease in the urinary survivin levels in group i when compared to group ii where there was a signifi cant rise in pre and post bcg urinary survivin levels (p value< . ). conclusion: low pre bcg urinary survivin level can be used as a useful predictive marker for achieving complete remission in nmibc patients with on intravesical bcg immunotherapy. also pre and post bcg urinary survivin levels act as a useful prognostic marker and can be used as an adjunct to cystoscopy. introduction and objective: th e natural resistance-associated macrophage protein (nramp ) gene modulates macrophage activation in a myriad of infectious and autoimmune diseases. its single nucleotide polymorphisms (snps) have been identifi ed to infl uence susceptibility to tuberculosis and response to bcg therapy in murine models. in this study, we evaluate the predictive role of nramp snps in the oncological outcomes of asian patients receiving intravesical regimes of bcg for nmibc. a total of nmibc patients who underwent post-transurethral resection intravesical regimes of bcg ( mg or mg) or bcg ( mg) with interferon alfa from to and deemed intermediate to high risk by the european organisation for research and treatment of cancer risk tables, were prospectively recruited. from these patients and a group of healthy controls, peripheral blood samples were stored and genomic dna purifi ed. a total of nramp snps were evaluated using high resolution melt analysis. th e corresponding results were verifi ed by dna sequence analysis. kaplan-meier and cox regression methods were used to analyze the data. introduction and objective: microscopic hematuria can indicate presence of underlying urological conditions. aua guidelines recommend evaluation algorithms for microscopic hematuria. population-based studies have focused on risk pools such as heavy smokers and elderly men. we evaluated whether men interested in self-managing their lower urinary tract symptoms (luts) with an over-the-counter (otc) product should be screened for microscopic hematuria to detect undiagnosed signifi cant conditions (including urothelial malignancy) causing hematuria. materials and methods: urine dipstick testing was conducted in men who preferred to self-manage luts using an otc product. urologic assessment was conducted by a urologist to determine conditions causing/contributing to the urinary symptoms for: men < years; and men ≥ years who had traces of glucose, leukocyte, and/or blood in urine; or had an aua symptom index score ≥ . men experiencing complete urinary retention, dysuria, extreme thirst, gross hematuria, or urethral discharge ("do not use" symptoms in this study) were also assessed. men ≥ years of age who did not meet any of these criteria did not undergo urologic assessment. introduction and objective: th is fi rst experience, pilot study, was aimed to evaluate the outcome of en-bloc bladder tumor resection using the plasma-button electrode in cases of papillary non-muscle invasive bladder tumors (nmibt) from the perspectives of surgical safety and effi cacy, perioperative morbidity, histological assessment and short-term oncologic outcome. a total of patients previously diagnosed by abdominal ultrasound, contrast ct and fl exible cystoscopy with papillary bladder tumors over cm in diameter were included in the trial. th e exclusion criteria consisted in solid sessile tumors, lesions located in bladder neck area and tumors involving the ureteral orifi ce. en-bloc tumor resection using the plasma-button approach was applied in all enrolled cases. th e tumor base was subsequently biopsied by standard single-wire loop resection and followed by plasma-button coagulation. th e fi rst follow-up cystoscopy was completed at months. results: all procedures were successfully performed leading to visually complete tumor ablation. th e mean tumor diameter was . cm (range between and cm). no obturator nerve refl ex adverse events or cases of bladder wall perforation were encountered. no signifi cant postoperative hematuria and re-intervention requirements were encountered in this series. th e mean catheterization period was . days (range to . days) and the mean hospital stay was . days (range to days). th e pathological analysis confi rmed the presence of detrusor muscle in the resected biopsy specimens for all enrolled patients, thus enabling for a reliable tumor staging to be established (all nmibt histology diagnosed patients). a single case of other site residual lesion was found during the fi rst evaluation cystoscopy, while no orthotopic recurrences were described. to reduce the overdiagnosis and overtreatment of insignifi cant tumors there is an urgent need for a specifi c test to detect clinically signifi cant prostate cancer (pca). using gene expression profi ling specifi c pca-biomarkers were identifi ed. eight promising biomarkers were selected and the diagnostic accuracy was tested in urine of an intent-to-treat cohort. th e aim of this study was to clinically validate the four-gene biomarker panel (hoxc , dlx , tdrd and hoxc ) using an independent prospective multicenter study cohort. in two independent prospective, multicenter studies (cohort : n= en cohort : n= ) urine was collected aft er digital rectal examination (dre) from men undergoing prostate biopsies based on an elevated serum psa level (≥ . ng/ ml) and/or suspicious dre. klk , hoxc , hoxc , tdrd and dlx mrna levels were measured using rt-qpcr. th e assay was validated according to miqe criteria, hence the test is a standardized laboratory developed test (ldt). results from cohort were used to develop models with (combinations of) the four genes based on the comparative ct method. th e chosen model was validated in cohort , i.e. a fully independent validation cohort. results: pca was identifi ed in % ( / ) and % ( / ) of men from the studies respectively. th e model with the combination of hoxc /dlx resulted in the highest average auc ( . ) and specifi city ( %) at ≈ % sensitivity, based on cohort . furthermore, hoxc and dlx were signifi cant in the logistic regression, in % and % respectively. th is model was independently validated for the diagnosis of pca with gleason score ≥ in prostate biopsies. using roc curve analysis hoxc /dlx outperformed pca in both cohorts (cohort auc= . vs. . ; cohort auc= . vs. . ). adding serum psa to the hoxc /dlx model resulted in an auc of . and . , respectively. th is study showed the promising results of a new urine test for the early diagnosis of clini-cally signifi cant pca using a model which combines hoxc with dlx . th ese results demonstrate that this model could be used to assess the risk of pca with gleason score ≥ and therefore could reduce the amount of unnecessary prostate biopsies. introduction and objective: curcumin contains mul-introduction and objective: a family history of prostate cancer is a well-recognized high risk factor for this disease. various models for an inherited risk for prostate cancer have been described, but to date traditional linkage and association studies have only identifi ed a small number of rare tumor suppressor genes and snps involved in prostate cancer risk and development. we performed whole exome sequencing on multiple participants (n= ) with prostate cancer from families with a signifi cant history of prostate cancer to potentially identify new prostate cancer susceptibility variants. exome variants were fi ltered against a range of parameters with a subset of variants chosen for validation by sanger sequencing and segregation analysis within their respective families. each prostate cancer participant met the following criteria for inclusion if: (i) they had a verifi ed diagnosis of prostate cancer, (ii) there were multiple cases of prostate cancers in the family, iii) pathology, diagnostic and treatment notes were available, and (iv) they were classifi ed as brcax mutation status. results: essential splice site, missense and stop lost variants were fi ltered against a recently published candidate gene list, leaving shared truncating variants and shared missense variants to be genotyped through all prostate aff ected (n= ) and unaff ected male participants (n= ). th ree missense variants demonstrated complete segregation and one missense variant demonstrated partial segregation with the prostate cancers. th ree truncating variants demonstrated complete segregation and three truncation mutations demonstrated partial segregation with prostate cancer. no segregating variants between the three families were shared. conclusion: ten truncating or missense variants showed either complete or partial segregation in our three familial prostate cancer families. of interest, we detected a cyp a and parp variant in our multicase prostate cancer families. th ese two variants have previously been reported to occur in other familial associated prostate cancer families, thereby, potentially adding to the evidence that these two variants may have a role in the risk and development of prostate cancer. another eight novel variants were detected that segregated with disease and warrants further investigation. th congress of the sociÉtÉ internationale d'urologie -siu abstract book were recorded. patients with diabetes, hypertension or known cardiovascular disease were excluded. introduction and objective: traditional methods of prostate cancer diagnosis in males with an elevated or rising psa have relied on outpatient trus biopsy using local anaesthetic and taking between - biopsies. trus biopsy is painful, associated with rectal bleeding in %, uti in % and urosepsis in up to % of patients. it is also has a poor sensitivity (< %) low accuracy rates of < % and a poor specifi city of < %. from we changed to template guided prostatic biopsy (tgpb) carried out transperineally under a general anaesthetic. to date we have carried out tgpb in patients with a positive biopsy rate of % (accuracy of %; and specifi city of %). th e procedure is painless, utis occurred in %, no sepsis and no rectal bleeding. because of the large numbers of biopsies taken % of patients had transient retention. in patients who had a previous -ve trus biopsy % had a subsequent +ve tgbp and patients having tgbp on the fi rst occasion for an elevated psa ( . - ) % had a positive biopsy. results: with the advent of tesla mri and mri fusion technology we have now progressed to mri fusion biopsy using real time ultrasound imaging and fusing the abnormal mri image to perform the biopsy (biojet fusion, global prostate solutions) . th is allows for even greater accuracy of the biopsy without taking large numbers of samples. to date we have achieved a +ve biopsy rate of % with an accuracy of > % (in patients). to date there have been no cases of uti, sepsis or retention. to determine the suitability of circulating tumour cells (ctcs) as prognosticating indicator and biomarker for delivery of precision medicine. patients were recruited and screened (n= ) as a part of admet (androgen deprivation th erapy and adjuvant metformin) trial. five millilitres of whole blood was collected from patients for ctc enrichment, enumeration and propagation. enrichment was performed using cd negative selection kit (rosettesep™). ctcs were identifi ed using immunofl uorescence imaging with antibodies against prostate specifi c antigen, cytokeratin, cd and nucleus. cells were propagated in customized stem cell solution with hypoxic conditions. results: at screening, of patients demonstrated circulating tumour cells with the mean number of (range - , ± ) . in all of the enriched samples, cells could be propagated temporarily with the peak population being reached at . weeks. cells were cultured in both d and d conditions and temporary organoids could be developed from of patients. polymerase chain reaction and immunofl uorescence imaging at weeks aft er culturing demonstrated characteristics consistent with prostate cancer cells. conclusions: circulating tumour cell technology remains a viable option as a means of providing biomarker information and tumour activity indicator in delivering precision medicine. firstly, enumeration can be used to help determine the response to a treatment. secondly, temporary culture and progression into development of organoids may be used to allow for downstream analysis and therapeutic decision. transcriptionally-targeted retroviral replicating vectors: a novel strategy for gene therapy of prostate cancer introduction and objective: while hematospermia is mainly associated with genitourinary infl ammatory disorders, there are very few studies for prostatitis associated hematospermia (pah) via robust prostatitis evaluation methods. for this reason, we evaluated the incidence of pah with systematic evaluation methods for prostatitis. we evaluated hematospermia patients from a single hospital over fi ve years. we classifi ed the patients into pah versus he-matospermia without evidences of prostatitis (hwp) by using a nih-cpsi (chronic prostatitis symptom index) questionnaire and expressed prostatic secretion studies. th congress of the sociÉtÉ internationale d'urologie -siu abstract book cant diff erence in patient's the quality of life impact (table ) . introduction and objective: chronic prostatitis/ chronic pelvic pain syndrome is a chronic pain disease with high prevalence rates and substantial health care costs. chronic prostatitis syndrome is a common urological condition that many clinicians fi nd diffi cult to diagnose and treat eff ectively. th e signifi cance and diagnostic value of semen analysis in bacterial prostatitis has been extensively debated and remains controversial. our objective was to investigate the diagnostic accuracy of semen and urine culture in the diagnosis and treatment outcome of bacterial prostatitis. th e present study is based on a retrospective analysis of a database of over patients (age range - years) who met the consensus criteria for bacterial prostatitis, % of whom had dysuria, % perineal discomfort, % had obstructive luts, % infertility of unknown etiology, % erectile dysfunction and % recurrent infection of the partner. segmented urine cultures and semen culture, were performed in all patients. treatment were started as per the culture report and culture negative patients were treated empirically with quinolones group of antibiotics. patients were followed-up for year to rule out disease recurrence. results: of the patients, had positive semen culture and had positive urine culture; had negative culture for both semen and urine. of the positive cultures % of the bacteria was gram-negative microorganisms (escherichia coli was the commonest specimen isolated) and % had signifi cant positive cultures for gram-positive microorganisms. patients with positive semen culture had % response to antibiotics and full recovery was noted from the symptoms prospective aft er the full course of the antibiotic and recurrence of the disease were noted in % of the patient aft er year follow-up. patients with urine positive cultures, % had response to antibiotic, but % recurrence were noted in year. patients with negative cultures, % had symptomatic relieve but all of them had recurrence in year follow-up. conclusions: th e diagnosis of chronic prostatitis is diffi cult due to the absence of typical clinical symptoms and specifi c ultrasonographic signs. our data support the usefulness of semen analysis in the diagnostic work-up of prostatitis patients. semen culture positive patient responded well to medications and recurrence rate was very minimal compared to urine positive and culture negative patients. in our clinical work-up, semenculture are considered the only tests necessary to diagnose bacterial prostatitis and also guide us through the treatment. (rc) has been shown to be a predictor of poor outcomes in patients with bladder cancer. change in muscle volume during neoadjuvant chemotherapy (nac) administration has not been well studied. our objective was to assess for psoas muscle volume (pmv) change during the period of nac therapy and to assess if such a change was a predictor of pathologic response or survival. mp- . , figure . introduction and objective: alternative approach to the radical cystectomy for muscle-invasive bladder cancer is radical transurethral resection (tur), followed by chemotherapy/ radiotherapy. objectives: primary end points of the study were os (overall survival) and dss (disease-specifi c survival). secondary endpoint -oos survival aft er salvage cystectomy. materials and methods: sixty eight patients with t bladder cancer were treated by 'complete' tur fol-lowed by chemotherapy / radiotherapy. th e follow-up ended in june . all patients were subjected to "safety" resection. patients who had no tumor (t ), or had non-muscle-invasive (t ) tumor were given the option of follow-up with cystoscopy and adjuvant therapy or immediate cystectomy. mostly elder patients are candidates for bladder sparing. th ose with invasive tumor on the safety resection were subjected to cystectomy- patients (control group). we used spss : xi-square and kaplan-meier for statistical processing. results: five years overall survival (os) in the bladder spared group was % (n- ), and % of the cystectomy group (n- ) -p= . . th e disease specifi c survival (dss) was % and % for the bladder spared and cystectomy group respectively (p= . ). th irty four percent ( patients) with preserved bladder developed recurrent tumors. a repeated tur was conducted. fift een percent ( ) of them were with invasive tumor and the action taken was cystectomy. fift y percent ( ) of the salvage cystectomy group and % of the immediate cystectomy group survived years. of the preserved bladder patients, ( %) necessitated dj stenting and ( %) pns. pns in the cystectomy group were ( %). haematuria occurred in patients with preserved bladder and in of the cystectomy group. th e statistical diff erence between both groups according to complications is p = . . infl ammatory conditions were more common in the bladder sparing technique- orchiepididymitis, urosepsis, pyelonephritis, compared to urosepsis and pyelonephritis in the cystectomy group. conclusion: bladder conservation and radical cystectomy for muscle-invasive bladder cancer appear comparable regarding the dss until the th year. cystectomy continues to be standard of care. radical tur is successful bladder-sparing strategy in selected patients with no residual tumor on retur and lower life expectancy. introduction and objective: bladder cancer occurs commonly in the elderly patients. in some circumstance, uremic patients developed bladder cancer. we considered patients who are aged more than years old, end stage renal disease (esrd) or poor performance status (eastern cooperative oncology group, ecog >= ) as fragile patients for operation. we conducted this study to assess radical cystectomy (rc) outcomes and chemotherapy use including neoadjuvant and/or adjuvant chemotherapy in the fragile patients in routine practice. all patients undergoing rc for bladder urothelial cancer in china medical university hospital from to were enrolled. patients' basic characters, surgical and pathology reports and treatment records were retrospectively collected. patients were stratifi ed into fragile and non-fragile group. pearson's chi-square test and student t-test were used to assess parameters of these two groups. results: we identifi ed patients. th ere were patients aged more than years old, patient are uremic status and patients were performance ecog: . total patients were stratifi ed into fragile group. th e sex and pathological staging were no diff erence in these two groups. major perioperative complications defi ned as clavien-dino grade or more were . % in fragile group and only . % in non-fragile group (p= . ). chemotherapy use rate was . % and . % in fragile and non-fragile groups (p= . ). th e -day morbidity rate of non-fragile and fragile group was . % and . %, respectively. th e day morbidity was no signifi cant between these two groups ( . % of non-fragile and . % of fragile groups). in fragile group, -day mortality rate was . % and -day mortality rate was . %. th ere was no -day mortality in non-fragile group. half the patients died within months in fragile patients and fi ft y percent of patients lived aft er years in non-fragile patients. conclusions: fragile patients received radical cystectomy had higher perioperative major complications rate and higher -day mortality rate. we off ered complications and morbidity rate in these patients who received radical cystectomy. in elderly, esrd or ecog>= patients, we need more cautious care to decrease complication and morbidity rate. introduction and objective: primary management of muscle invasive bladder cancer (mibc) is cystectomy (cx). all traumas, including major surgery like cx, induce a stress response (sr), which plays an important role controlling the human immune system. a widely used parameter for systemic surgical sr is measurement of serum levels of c-reactive protein (crp). th is prospective study aims to compare the introduction and objective: several prognostic models predicting survival of patients with metastatic urothelial carcinoma (uc) have been developed, however, of them, the fi rst model by bajorin in is still the most representative and widely-used. th e aim of this study was to validate three major prognostic models constructed based on phase and trials, by using a cohort of real-world patients. we reviewed patients with metastatic uc who received fi rst-line chemotherapy at our fi ve affi liate institutions between and . using this multi-institutional cohort, we validated the following models: the "bajorin model", a model consisting of visceral metastasis and performance status (j clin oncol ; : ) ; the "apolo model", a nomogram including visceral metastasis, performance status, albumin and hemoglobin (j natl cancer inst ; : ) ; and the "galsky model", a nomogram including leukocyte count, number of sites of visceral metastases, site of primary tumor, performance status and lymph node metastasis (cancer ; : ) . cox proportional hazards regression model was used for multivariate analysis. harrell's c-index was calculated for each model. conclusion: all models were demonstrated to have high external validities in real-world patients, and of them, the "apolo model" achieved the highest c-index in the present population. further studies with larger populations are needed for establishment of the next standard model. the impact of female gender on bladder cancer specifi c death risk after radical cystectomy: a meta-analysis of patients liu s, yang t, na r, jiang h, ding q introduction and objective: bladder cancer was one of the most commonly diagnosed cancers in the world. up till now, there has been no study summarizing current studies on gender disparity and bladder cancer outcomes aft er radical cystectomy. to perform a fi rst meta-analysis on the association between female gender and cancer-specifi c death risk aft er radical cystectomy. a comprehensive literature search of the medline and embase databases was conducted for relevant studies published till november, th . th e primary goal of our study was to investigate the impact of gender disparity on cancer-specifi c death risk aft er radical cystectomy in urothelial bladder carcinoma population. th e meta-analysis was performed by estimating the odds ratios (or) and confi dence intervals (ci) through a random eff ect approach. results: a total of studies were included in the meta-analysis with a total population of patients. th e baseline characteristics of the studies were described in table . female gender was associated with a worse survival (pooled or: . , % confi dence interval . - . ) compared with male gender aft er radical cystectomy. signifi cant (q= . , p= . ) statistical between-study heterogeneity was present, with . % of variance secondary to between-study diff erences (i : . %). sub-group analysis found the correlation was signifi cant in north american, european studies (or: . , % ci . - . and or: . , % ci . - . , respectively) and studies from larger size of samples (or: . , % ci . - . ). we also found studies adjusted for the key elements (t stage, n stage and grade) obtained positive correlation (or: . , % ci . - . ). introduction and objective: pathologic response after neoadjuvant chemotherapy for muscle invasive bladder cancer is used widely as a surrogate endpoint for overall survival. controversy persists, however, whether the absence of residual cancer (pt ) or the presence of only non-muscle invasive residual cancer (pt , ptis, pta) is the optimal surrogate endpoint. we aimed to assess survival dependent on these pathologic responses in a large multicenter patient cohort. we retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at contributing institutions from - . patients with ct - an m and eventual pn disease were selected for this analysis. estimated os was compared between pt and pt /pta/ptis patients. a multivariable cox proportional hazards regression model for overall mortality was generated to evaluate hazard ratios (hrs) for variables of interest (age, gender, number of cycles and type of chemotherapy regimen, surgical margin, and pt vs. pt /pta/ptis). conclusions: pt /pta/ptisn and pt n stage on the fi nal cystectomy specimen are strong predictors of survival in patients receiving nac and rc. we did not discern a statistically signifi cant diff erence in os when comparing these two endpoints. signifi cance of computer materials and methods: fift y patients were included in our study, of them presented with haematuria and a recent diagnosis of bladder carcinoma, and patients with a history of previous transurethral resection of superfi cial bladder cancer in their follow up period. th ey ranged in age years to years with a mean of . ; while male to female ratio was . : . th e main steps to perform virtual cyctoscopy incorporate proper bladder distention with air aft er draining the residual urine through foley's catheter and scanning the patient in both supine and prone positions. an excellent overview of the bladder masses was obtained in all cases and the results of virtual cyctoscopy and conventional one were comparable with excellent sensitivity rates of virtual cyctoscopy in detection, localization and morphology description of the bladder lesions at variable sizes. results: for detection of all lesions (n= ), virtual cyctoscopy alone showed sensitivity: . %, specifi ty: . % with two false positive and one false negative in comparison to conventional cyctoscopy which detected lesion while in axial ct alone the sensitivity: . %, specifi ty: % with false negative fi ndings. conclusion: ct virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than mm. optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images. is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis and local staging of prostate cancer (pca). diff erences in interpretation, expertise and application of mpmri may be responsible for the range of reported results. th is retrospective study aims to evaluate the diagnostic accuracy of mpmri in a cohort of patients from melbourne, australia, as compared to the gold standard of radical prostatectomy (rp). th is retrospective study was conducted in through the electronic patient records of a tertiary hospital and several private urology practices in melbourne, australia. patients having undergone rp had their records assessed for the presence of a pre-operative mri performed aft er st january which was then evaluated against the reference standard of a radical prostatectomy wholemount specimen. mri sequences typically included t weighted imaging, diff usion weighted imaging and dynamic contrast enhancement at t. mri reports were evaluated using the prostate imaging-reporting and data system (pi-rads) system. in our cohort the sensitivity and specifi city of mpmri for prostate cancer (pca) detection was found to be approximately - % and - % respectively. th e area under the curve for determining local stage was approximately . . conclusion: mpmri may have a useful role as an adjunct for prostate cancer diagnosis and directing management toward improving patient outcomes. staging information may be less reliable. a randomized prospective trial to assess the outcomes of mri/trus-guided prostate biopsy and traditional -core trus-guided prostate biopsy baco e , rud e , eri l , moen g , vlatkovic l , svindland a , eggesbø h , ukimura o introduction and objective: th e outcomes of magnetic resonance imaging (mri) and -dimensional transrectal ultrasound ( d-trus)-image-fusion-guided prostate targeted biopsy (mri-group) has not yet been compared with traditional -core trus-guided prostate biopsy (control-group) in a randomized control trial (rct) . th e aim of this study was to compare the prostate cancer (pca) detection rates (cdrs) and histopathological outcomes in the two groups. th is prospective rct included prostate biopsy (pb) naïve patients with suspicion for pca, where were randomized to mri-group and to control-group from / to / . in the mri-group, two tb of mri suspicious regions was followed by -core systematic random biopsy (rb). in the control-group, two tb towards palpable and/or trus-visible suspicious regions and -core systematic rb were performed. clinically signifi cant pca (cspca) on biopsy was defi ned as maximum cancer core length (mccl) ≥ mm of gleason score (gs) or any mccl of gs ≥ according to start criteria. cdr of all pca and cspca, and histopathological fi ndings were compared between the two groups. results: in the mri-and control-group cdrs were / ( %) and / ( %), (p= . ). cspca were detected in / ( %) in and / ( %) in control-group, (p= . ). tb (median cores/ patient) detected cspca in / ( %) in mri-and / ( %) in control-group (p= . ), respectively. concordance of gs on biopsy and radical prostatectomy specimen was / ( %, k = . ) in mri-and / ( %, k = . ) in the control-group (p< . ). upgrading of gs biopsy vs. gs-rp specimen was % in mri-group and % in control-group (p< . ). since the present study had a restricted cohort size, this may limit the generalizability of the results. no signifi cant diff erence in cdrs was found between the two groups. pca diagnosis can be achieved with few mri/trus-fusion guided prostate biopsy. gleason score on targeted biopsy was more accurate in the mri-group. introduction and objective: infection is a complication of trus prostate biopsy, despite the use of antibiotic prophylaxis. worryingly the rate of infectious complications following trus biopsy has been shown to be increasing. we aimed to determine the rate, severity, risk factors and microbiology resistance patterns associated with trus biopsy sepsis. as well the standard patterns of care surrounding trus prostate biopsy. a retrospective case-control study was conducted. using electronic coding all patients who presented to cabrini hospital with sepsis following a trus biopsy from to were identifi ed. validated cases were matched to controls in a ratio of : . eligible controls were required to have undergone a trus biopsy at the same surgical institution as the case and in the closest period of time. demographic, procedural and patient related data-points were recorded for all patients using hospital and urologist records. univariate logistic regression models were constructed and used to determine risk factors associated with infection. results: seventy-one cases developed sepsis following trus biopsy and were matched to controls. th e average rate of sepsis over the -year study period was . %. a sofa score ≥ was identifi ed in % of cases. we found a high prevalence of antibiotic resistant e. coli, with % of blood culture isolates classifi ed as multidrug resistant organisms. eight diff erent prophylactic antibiotic regimens were identifi ed. statistically signifi cant risk factors included previous antibiotic use and prior international travel within the six months prior to biopsy. th e addition of a penicillin antibiotic to standard fl uoroquinolone antibiotic prophylaxis was protective. conclusions: trus biopsy is an elective procedure and as such needs to be associated with minimal morbidity. th e patterns of care surrounding periprocedural variables for trus biopsies were non-uniform and diverse. a wide variety of diff erent prophylaxis regimens and bowel preparation routines were recorded. patients with risk factors for sepsis may represent a better target population for intervention with alternative preventative strategies. alternative preventative options include augmented prophylaxis, tailored prophylaxis or the tp biopsy approach either as a fi rst line biopsy modality or based on epidemiological risk factors. psa level) and pathological data was collected for all patients undergoing fi rst-time prostate biopsy with at least months follow-up, at music practices. from this overall cohort we identifi ed all patients whose pathology revealed multi-focal hgpin and/or asap (pre-malignant pathology) . for this subgroup, we examined the frequency of repeat biopsy across music practices and cancer detection outcomes. introduction and objective: nowadays overtreatment is recognisable challenge in pca management. overdiagnosis is possible reason for further overtreat-ment. we hypothesised that repeated prostate biopsies could not only help to cure but also harm patients with pca. consecutive patients who underwent biopsy for suspicious pca following at least one rebiopsy at single tertiary medical centre in - were included. age, initial and subsequent psa, drv, histology and biopsy features were recorded along with characteristics of subsequently diagnosed pca and chosen treatment approach. descriptive statistical methods were used for further analysis. results: basic characteristics were (mean±sd or frequency): age at initial biopsy ( . ± . years), time between initial/fi nal biopsy ( . ± . months), initial/ fi nal psa ( . ± . and . ± . ng/ml), drv (normal/suspicious . %/ . %), and number of initial/fi nal biopsy cores ( . ± . and . ± . ). initial/ fi nal histology was bph in ( . %)/ ( . %), infl ammation in ( . %)/ ( . %) and premalignant lesions in ( . %)/ ( . %) cases. finally, ( . %) pca were diagnosed ( by biopsy, by turp) performing biopsies aft er all. mean number of biopsies per patient was . in total and . to reach cancer positive histology; turp was performed in ( . %) patients. in ( . %) patients ≤ biopsy cores were cancer positive and in ( . %) patients gleason score was ≤ . gleason score ≥ was found in ( . %) cases. treatment with curative intention was held in cases (rrp , external radiotherapy ), no treatment (as/ww) in and hormonal therapy in patients. fourteen patients with minimal low grade cancer (≤ positive cores, gleason score ≤ ) underwent rrp ( % of all surgery cases). conclusion: repeated biopsy is important approach in pca diagnosis. however, based on our results we cannot exclude the risk of overdiagnosis and subsequent overtreatment with signifi cant impact on patients' quality of life, including radical surgery for low risk disease and early hormonal therapy in non-metastatic low-intermediate risk disease. th e study is retrospective, but potential bias became the advantage, since we could exclude prospective "self-control" within treatment decision making process. (siemens, munich, germany) and images were interpreted visually to evaluate uptake in biopsy districts of prostate gland. th e lesions suspicious for pca were submitted to additional targeted biopsies. introduction and objective: multiparametric mri (mpmri) and mri/trus-fusion-guided biopsy (tb) are advocated to detect index lesions and signifi cant prostate cancer (pc) within the prostate more exactly than systematic biopsies (sb) . th e aim of this study was to evaluate the detection accuracy of tumor foci by mp-mri and tb on radical prostatectomy (rp) specimen. we selected consecutive patients who were treated with rp for localized pc diagnosed by tb and/or transperineal saturation sb. on mpmri, all lesions were scored according to pirads. all lesions with pirads≥ underwent tb. on rp specimen, index lesion was defi ned as highest gleason score (gs) or highest tumor volume (tv). gs= + and tv≥ . ml or gs≥ + and tv≥ . ml were considered signifi cant. we performed spearmans correlation coeffi cient between mpmri and rp specimen and fisher's test between mpmri, tb and sb. introduction and objective: prostate biopsy is evolving to pre-biopsy multi-parametric mri (mp-mri), followed by systematic biopsy (sb) ± targeted biopsy (tb). mp-mri combined with trus-guided tb may increase detection rates of prostate cancer (pca), especially clinically signifi cant pca (cspca). however, few studies compare the detection rate of sb versus tb in the same cohort of men, as recommended by the standards of reporting for mri-targeted biopsy studies (start) consensus panel. th is study compares the diagnostic yield of sb and tb in a single cohort. th irty-three patients had a pre-biopsy mp-mri that identifi ed a target lesion. each patient then had a trus-guided sb and tb. th e cognitive fusion technique was used to perform the tb. results: among the patients, mean age was years; mean psa was . ng/ml. th e positivity rate for pca was % (n= ) for both sb and tb. th e positivity rate for cspca was % (n= ) for sb and % (n= ) for tb (p= . ). sb underdiagnosed cases ( %) of cspca that were detected through tb; tb underdiagnosed cases ( %) of cspca (p= . ) . th e positivity rate for sb and tb combined was % (n= ) for cspca (p= . ). conclusion: detection rates for pca using sb and tb were equal, but sb had a higher detection rate for cspca. combining tb with sb increased the rate of detection for cspca by %. tb alone was % more introduction and objective: active surveillance (as) has gained popularity with the intention of avoiding or postponing interventions in subjects with pca of low biological potential. unfortunately, several inclusion criteria have been proposed but many doubts still persist about their performance in predicting favorable disease. we aimed to assess the added value of biopsy factors, like maximum cancer length in a core (mcl), cumulative cancer length (ccl), cumulative length of positive cores (clpc), and percentage of cancer involvement in positive cores (cipc), to the prias criteria in patients who underwent radical prostatectomy (rp) but eligible for active surveillance (as). from january to december , consecutive subjects underwent rp. we identifi ed ( . %) patients who were eligible for as based on prias criteria: clinical stage t c or t , psa level of ≤ ng/ml, gleason score ≤ , psa-d of < . ng/ml and one or two positive biopsy cores. we calculated the diagnostic accuracy of biopsy factors in determining pathological confi rmed unfavorable disease. decision curve analysis (dca) were performed. explored, we examine the feasibility of monitoring low volume gleason sum (gs) + disease compared to gs + disease. introduction and objective: th e selection of prostate cancer patients for active surveillance (as) is based on the criteria for low risk according to protocols such as the national comprehensive cancer network (nccn) or european association of urology (eau) guidelines. we aim to compare pathological upgrading and upstaging rates between prostate cancer patients who met the above guidelines but underwent radical prostatectomy. we also aim to refi ne the selection criteria for our local population. a total of men were treated with rp at our tertiary center from to . seventy-three patients met the nccn criteria for active surveillance: ct -t a, prostate-specifi c antigen (psa) less than ng/ml, and biopsy gleason sum to . th irty-fi ve met the eau guidelines, which had additional criteria of: or less biopsy cores positive and % or less ca detected per core. results: of the patients who met the nccn criteria, ( . %) showed pathological upgrading (gleason > ) while ( . %) were upstaged (pt ). upgrading and upstaging fi gures for the patients meeting the eau guidelines were ( . %) and ( . %) respectively. analyzing the patients who met the nccn criteria, those who had % or more of the number of biopsy cores positive for prostate cancer had a far greater upgrading rate of . %, which was more than the . % (p = . ) seen in the other patients. psa density or percentage of individual core did not show any statistical diff erence in upgrading or upstaging. conclusion: a lower percentage of upgrading was seen in patients meeting the eau. upstaging fi gures were relatively the same. when counseling patients for active surveillance using the nccn criteria for low risk, we should exercise strong caution in patients with % or more of the number of biopsy cores positive for prostate cancer. biochemical recurrence rates in active surveillance candidates and the role of improving gleason grading introduction and objective: to evaluate prospectively the role of prostate-specifi c antigen (psa) density to predict gleason score upgrade in prostate cancer patients eligible for active surveillance (t /t , biopsy gleason score ≤ and psa ≤ ng/ml and ≤ positive biopsy cores). between january and november , among the patients who underwent more than core trans-rectal ultrasound guided biopsy, patients eligible for active surveillance under-went radical prostatectomy. using the modifi ed gleason criteria, tumor grade of the surgical specimens was examined and compared to the biopsy results. results: a tumor upgrade was noticed in ( . %) patients. extra-capsular disease and positive surgical margin was found in ( . %) and ( . %) patients, respectively. a statistical signifi cant correlation between the psa density and postoperative upgrade was found (p= . ); this is in contrast to the other studied parameters which failed to reach signifi cance, including psa, prostate volume, number of biopsy cores and number of positive cores. tumor upgrade was also highly associated with extra-capsular cancer extension (p= . ). th e estimated optimal cutoff value of psa density was . ng/ml , obtained by roc analysis (area under the curve . , p= . , % ci . - . ). conclusions: psa density represents a strong predictor for gleason score upgrade aft er radical prostatectomy in patients eligible for active surveillance. since tumor upgrade increases the potential for postoperative pathological adverse fi ndings and prognosis, psa density should be considered when treating and consulting patients eligible for active surveillance. surgical outcomes of south australian patients who have discontinued active surveillance plagakis s , o'callaghan m , , , moretti k , , foreman d , introduction and objective: active surveillance (as) is a recognized management pathway for patients with low risk prostate cancer (pca). diff ering protocols exist to identify suitable patients and manage their follow up. our study compares surgical pathology outcomes between patients who were initiated on, but discontinued, as and underwent radical prostatectomy (rp) with patients who received surgery immediately at the time of diagnosis. we also explore predictors of as discontinuation. our cohort comprised men diagnosed with pca from the south australian prostate cancer clinical outcomes collaborative database between - , aged - years, gleason score ≤ and psa ≤ . patients were stratifi ed into an immediate treatment group and an as group. to assess if as derivation rules aff ected outcomes, patients were sub-categorised according to enrolment criteria of university of toronto, prias and royal marsden protocols (with psa and gleason adjustment accordingly). all patients had a minimum of two years follow up. chi squared, logistic regression and cox proportional hazards modelling were used to compare outcomes between groups. results: forty-three ( %) patients in the as group underwent rp, compared with in the immediate treatment group. extra capsular extension and upgrading of histology at rp were more common in those managed by as compared to those receiving im-mediate surgery. th ese associations were supported by sensitivity analysis using prias and toronto criteria but not royal marsden selection criteria. as trended to being associated with unfavourable surgical pathology in multi-variable analysis, but this was only statistically signifi cant for prias ), p= . ). in all patients managed by as, sensitivity analysis suggested that the percentage of core positive at diagnosis is a signifi cant predictor of as discontinuation in those meeting the university of toronto selection criteria (hr . ( . - . ), p= . ). to determine if prias has increased rates of active surveillance (as) for patients with low-risk prostate cancer (pca). secondly, to determine whether urologists are operating on greater proportions of high-grade pca as a result of increasing as and what eff ect this has on surgical practice. prospective data was collected on patients from - (cohorts - , - ) who underwent trus biopsy by a urologist in geelong (n= ). positive trus biopsies (n= ) in both the pre and post prias cohorts were assessed to see if they met prias eligibility and whether they received as or active treatment (at). at patients were risk stratifi ed by gleason score and d' amico risk. data on post-prostatectomy staging, margin status and nerve-sparing techniques were collected. chi-squared test were used to calculate statistical signifi cance between cohorts. results: as increased between cohorts ( %, %, p= . ). before prias % ( / ) of patients eligible for as by prias criteria opted to undergo as compared with % ( / ) aft er the introduction of prias (p=< . ). th e relative proportion of high-grade pca (gleason score ≥ and d' amico high-risk) undergoing at increased from to % (p= . ) and to % (p= . introduction and objective: renal trauma is predominantly managed conservatively. trauma nephrectomy is reserved for patients who fail conservative or alternative management options. nephron sparing surgery is the cornerstone of renal preservation. our objective was to review the management of renal trauma at three tertiary facilities in queensland over a year period and compare these outcomes with current literature. a retrospective analysis was performed to fi nd the total number of renal traumas presenting to the princess alexandra hospital, royal brisbane and women's hospital and gold coast hospital, in queensland, australia. renal trauma patients were identifi ed using icd- codes (s . - ) and operative databases. patients requiring angioembolisation were obtained from radiological databases. we accessed the number of conservatively managed patients, trauma nephrectomies and angioembolisations for renal trauma. results: a total of renal traumas were identifi ed from june to june . six hundred and sixteen injuries were managed conservatively. th irty-three patients warranted acute exploration due to haemodynamic instability and resulted in nephrectomy in all cases. a trauma or general surgeon was the primary operator. fift een patients underwent angioembolisation for blunt renal trauma and patients for penetrating injuries. two patients proceeded to delayed nephrectomy for ongoing bleeding and for a ureteric stricture requiring nephrectomy aft er failed auto transplantation. th ese were performed by an urologist. th ere were further devascularised atrophic kidneys. seventeen of renal units were spared and of patients remained with functioning kidneys. all treated patients with angioembolisation were followed up with either mag renogram or ct triple phase and had functional kidneys at . years. conclusion: renal trauma is managed conservatively in most cases, consistent with the current literature. angioembolisation is an eff ective management option in selected patients with renal trauma. th is may prevent the need for trauma nephrectomy. in our cohort, patients requiring a trauma nephrectomy had predominantly grade iv and v injuries. general or trauma surgeons performed trauma nephrectomies in the acute setting of haemodynamic instability with rapid transfer to theatre. delayed nephrectomies were performed primarily by urologists in this cohort. introduction and objective: to review the contemporary management of traumatic extra-peritoneal bladder ruptures at an australian level one trauma centre. patients presenting with bladder injuries from july through to june were identifi ed using the traumanet database. th is was cross-linked with medical records and only patients with extra-peritoneal bladder rupture were included in the study. clinico-pathological data were collected from the database, medical records and health information services coding data. results: over the twelve-year study period, multi-trauma patients sustained an extra-peritoneal bladder rupture. of these patients, . % had a concurrent pelvic fracture and . % had co-existing intra-abdominal injury. a total of patients underwent operative repair for the bladder rupture and patients were managed conservatively with catheter drainage. of the patients managed operatively, % of cases were done at the time of another general surgical or orthopaedic operation and only two cases were done as a stand-alone repair. conclusion: extra-peritoneal bladder ruptures can be managed both conservatively and with operative repair. if operative repair is performed, it is usually done at the time of another operation for concomitant injury. management outcomes of major renal injuries following blunt trauma: changing concepts over years results: a total of / ( . %) of group i, and / ( . %) of group ii were treated non-operatively. diagnosis and grading in group i depended mainly on u/s, ivp and in some cases ct scan, while u/s and enhanced ct scan were mainly used for most of the group ii cases. in the total cohort, grade iii, iv and v renal injury were seen in ( . %), ( . %) and ( . %) patients respectively. open exploration was followed in ( . %) and ( . %) patients of group i and ii, with an overall exploration rate in / ( . %) of grade iv and v injury. th e incidence of nephrectomy have decreased from cases ( . %) in group i to cases ( %) only in group ii ( / kidneys were pathologic). double-j stenting and percutaneous drainage of urinoma was done in and cases, and chest-tube drainage to one patient with traumatic urinothorax in the conservatively managed group. outcomes were excellent, however in the non-operatively managed (grade iv-v) cases, / ( . %) normotensive patients had a non-functioning kidney within one year of follow up. conclusion: non-surgical management of high grade blunt renal injury can be safely undertaken and also recommended unless the patient is haemodynamically unstable. accurate grading is sometimes imprecise in multi-trauma patients, where instability is not always due to renal injury. drainage of extravasation is necessary to reduce morbidity. abdominal exploration does not mandate concomitant renal exploration, which is indicated in selected instances, otherwise it is an aggressive decision with a triple incidence nephrectomy rate. management of grade iv renal trauma: a revision of the aast renal injury grading scale is mandatory chiron p , hornez e , , boddaert g , dusaud m , bayoud y , molimard b , desfemmes f , durand x introduction and objective: th e aast (american association for the surgery of trauma) injury grading scale for renal trauma is currently the most important variable predicting the need for kidney repair or removal, for morbidity and mortality aft er blunt or penetrating injuries of the kidney. th e revision included the renal pelvis, the uretero pelvic junction and the segmental vascular injuries as grade iv, limiting grade v to severe hilar injuries. however, this revision does not permit the identifi cation of the group of patients who will require surgery because of hemodynamic instability due to grade iv renal injuries. th is study aims to propose an add-on for the grade iv of aast renal injury scale, in order to improve the management of these patients. we searched the following electronic databases: medline and scopus database. searches were not restricted by date, language or publication status. searches were last conducted in september . paediatric studies were excluded. results: seventy-one articles were found, were pertinent, including directly related to the topic. th ree risk factors were identifi ed to be associated with surgery for hemodynamic instability: peri-renal hematoma > . cm, intravascular contrast extravasation, medial renal laceration. presence of two or more of these criteria has been validated by others studies to predict the need for intervention. patients with > % devascularized fragments also present a poor prognosis and should be treated more aggressively. conclusion: th ese data should be incorporated into a future reassessment of the classifi cation, in order to better determine the need and time for surgery in grade iv renal traumas, generally leading to a nephrectomy. single panurethral reconstruction can be a surgical challenge. techniques include staged urethroplasty, augmented anastomosis with buccal mucosa graft (bmg) onlay via penile and/or transperineal, skin fl aps, or combinations of these. we report our experience of single stage modifi ed transperineal urethroplasty using a dorsal bmg in treatment of panurethral stricture. aft er obtaining irb approval, we performed a retrospective review of our urethral stricture database and identifi ed patients having undergone single stage transperineal urethroplasty using dorsal bmg as treatment of pan-anterior urethral stricture. patient characteristics, operative, and post-operative outcomes were studied. failure was defi ned as a need to any intervention during the follow-up period. results: th irteen patients underwent complete anterior urethra dorsal urethrotomy with dorsal bmg onlay between september and january . mean age was . years (sd: +/- . ). urethral stricture etiology was lichen sclerosis in patients ( . %), idiopathic in ( . %), hypospadias in ( . %) and infection in ( . %). previous treatments of dilatation and dviu were noted in patients ( . %) and previous urethroplasty in ( . %). mean operative time was . minutes (sd: +/- . ). mean estimated blood loss was . cc (sd: +/- . ). th ere were no intraoperative complications. early postoperative complications were buccal donor site bleed in patients ( . %) one treated with digital compression and other with hemostatic stitch, one patient ( . %) presented a perineal abscess and secondary urethroperineal fi stula. late complications was observed in patients who had postoperatory dribbling ( %). at mean follow up of . +/- . months, had recurrence ( . %) requiring dviu without new recurrence aft er a mean follow-up of . months (range - ) and one had meatal stenosis treated with dilatation ( . %) without recurrence aft er . month of follow-up. conclusion: in this small cohort, reconstruction of panurethral strictures may be safely and eff ective-introduction and objective: we present a novel technique for reconstruction of bulbo-membranous urethral strictures aft er surgery for bph with external sphincter sparing to preserve continence. anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. by meticulous dissection of this sheath we separated the muscle from the urethral wall preserving the sphincteric function. patients with bulbo-membranous strictures aft er turp or open prostatectomy (op) who failed dilation and/or internal urethrotomy were reconstructed with a bulbo-prostatic anastomosis with preservation of the fi bers of the external sphincter. th e bulbo-membranous junction is approached dorsally, the inter-crural space is opened on the midline and the bulb is mobilized only from one side, without detachment from the perineal body. th e bulbo-membranous junction and membranous urethra are exposed and secured with vessel loops. th e membranous urethra sheath is opened circumferentially, carefully refl ecting the circular muscle fibers until exposure of the urethral wall. gentle blunt proximal dissection allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis. results: from january to march we operated patients ( aft er turp and aft er op). all had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. mean age was years ( - ). fourteen patients have been treated with either dilation and/or dviu; seven were with a suprapubic tube. mean length of stricture was cm ( - . ) , mean time from surgery to reconstruction was months ( - ) and mean follow-up was months ( - ) . two patients were not evaluable due to insuffi cient follow up. of the remaining , twelve were completely dry or using one security pad ( . % success). th ere were two clavien complications (both scrotal hematomas) and no stricture recurrence. conclusion: excision and bulbo-prostatic anastomosis with sphincter sparing for strictures aft er surgery for bph is feasible and safe. our technique allows preserving continence in most patients. to our knowledge this technique has not been described before. a larger series and reproduction in other centers will help to validate its therapeutic role. introduction and objective: panurethral strictures are complex and extensive strictures that involve the penile and bulbar urethra. management of these patients is challenging. in the last two decades, oral mucosal graft s have gained widespread popularity as the most versatile substitute tissue for urethral reconstruction. th e aim of this paper to present the shortterm outcome of our experience in the use of oral mucosal graft s in one-stage urethroplasty in patients with panurethral strictures. materials and methods: between april and october , men were evaluated and had one-stage oral mucosa urethroplasty for panurethral strictures. results: th ere were patients age range of - years with a mean of . years. aetiological factors identifi ed were poorly treated urethritis ( . %), post-urethral catheterization ( %) and lichen sclerosis ( . %). th e commonest cause of catheter-associated panurethral strictures was part of intra-operative patient monitoring in ( %), following spinal cord injury ( %). preliminary suprapubic cystostomy was done in patients ( . %). graft length ranged from - cm with a mean of . cm. oral mucosa donor sites were buccal in ( . %), labial ( . %), combined buccal and labial ( . %) and ( . %) for combined buccal/lingual and buccal/labial/penile skin fl ap respectively. twenty eight patients ( . %) had satisfactory voiding on removal of the urethral catheter and subsequent follow-up whereas patients ( . %) experienced diffi culty. of these , one patient had bladder outlet obstruction due to benign prostatic hyperplasia which was the reason for previous repeated urethral catheterization that had resulted in the stricture. oral mucosa donor site complications were present in patients ( . %) and consisted mainly pain and numbness in the mouth. duration of follow-up ranged from - months and there was no mortality among the patients. conclusion: panurethral strictures are common in our practice mainly resulting as complication of prolonged urethral catheterization. urethral reconstruction by one-stage oral mucosa graft urethroplasty is feasible, has good outcome though it may be associated with minor donor site complications. larger number of patients and longer-term follow-up are needed to assess durability of the procedure. missed and delayed ureteral injuries in hasan sadikin hospital, bandung, indonesia introduction and objective: to review our experience with delayed and missed traumatic ureteral injuries. materials and methods: genitourinary trauma database was retrospectively reviewed from - . variables such as time to diagnosis, imaging modalitites, location of missed or delay injuries, management, duration of operation, length of stay and complications were noted. introduction and objective: traumatic urethral stricture as the result of straddle injury or pelvic fracture urethral injury (pfui) is associated with long term morbidity and reduce the quality of life. most patients will end with long life urethral dilatation even aft er endoscopic treatment. anastomotic urethroplasty at present is the answer of defi nitive treatment. general principles of urethroplasty are to defi ne healthy urethra above and below the site of surrounding fi brosis and to perform a spatulated end-to-end anastomosis. prior to the year of , most urethral stricture cases including traumatic anterior and posterior urethral stricture was managed mostly with direct vision internal urethrotomy (dviu) in our institution. we present our experience with transperineal anastomotic urethroplasty. to our knowledge this is the fi rst indonesian local centre report of the changing defi nitive treatment of traumatic urethral stricture in a series of patients. we retrospectively reviewed traumatic urethral stricture due to straddle injury and pfui that had been treated with urethral reconstructive surgery by transperineal anastomotic urethroplasty approach. th e data cases from january -december were analyzed; which were the age of patients, location, length of gap, previous operations, and treatments. th e clinical outcome was evaluated with urofl owmetry aft er , , , and months aft er the surgery. results: a total of patients came with traumatic urethral stricture to hasan sadikin hospital during , which consist of patients with pfui and patients with traumatic anterior urethral stricture due to straddle injury. th e median age was . and . for pfui and straddle injury, respectively. twenty four percent of pfui patients had distraction length > cm and % had distraction length < cm. meanwhile, % of straddle injuries had stricture length < cm and % had distraction length > cm. in order to achieve tension free of anastomotic urethroplasty, % of pfui patients underwent crural separation, % patients underwent inferior pubectomy and only one patient for supracrural re-routing. sixteen percent of patient of pfui are redo case urethroplasty. success rate aft er transperineal anastomotic urethroplasty of pfui cases was %, % for redo case pfui and % for straddle injury cases. mean q max rates at , , , and months aft er catheter removal of pfui patients was , , , and ml/s whereas for straddle injury patients was , , , and . conclusions: in short term follow up, transperineal anastomotic urethroplasty achieved a signifi cant good result for traumatic urethral stricture treatment at our institution. recurrence after urethroplasty in a tertiary care centre in sub-saharan africa: an analysis of preoperative factors introduction and objective: urethral strictures disease remains very common in sub-saharan africa but despite this, there are no available reconstructive urology trainings / fellowships outside the formal urology residency programmes of the region. we reviewed the outcomes of urethroplasties at a tertiary urology centre in nigeria, sub-saharan africa which typically off ers general urology service. preoperative independent predictors of recurrence post-urethroplasty were determined. th e records of a total of men who had urethroplasty for proven anterior urethral stricture disease between february and january were retrospectively analyzed. age, social status, aetiology of strictures, stricture location, length of strictures and type of urethroplasty were assessed. appropriate inferential statistics were performed to determine independent predictors of stricture recurrence. results: mean patient age was years (range to ) and majority of the patients were of low income status ( . %). iatrogenic strictures due to urethral instrumentations and catheterization ( . %) and post infl ammatory strictures ( . %) were more common. isolated penile and long segment peno-bulbar strictures accounted for over two-thirds of all patients ( . %). mean stricture length was . cm (range to cm). most patients had quartey's urethroplasty ( . %), others had buccal mucosal graft ( . %), orandi ( . %) and anastomotic bulbar urethroplasty ( . %). for a mean follow up of . ± months, the overall recurrence rate was . % with mean time to recurrence of . months. of the evaluated preoperative factors (age, p= . ; social status, p= . ; aetiology, p= . ; stricture location, p= . ; type of urethroplasty, p= . ; stric-ture length, p= . ), only stricture length (p= . ) was a signifi cant predictor of recurrence. roc analysis was done and stricture length > cm signifi cantly predicted recurrence (auc of . , p= . ). conclusion: stricture length > cm are a signifi cant cause of recurrence following urethroplasty in the setting of prevalent general urology practice in sub-saharan africa. th e introduction of formal reconstructive urology fellowship or training may help improve skills and outcomes. introduction and objective: males with hypospadias are likely at increased risk for future urologic complications as adults. however, it is unclear how childhood surgery modifi es this risk. th e purpose of this study is to describe the spectrum of adult presentations with hypospadias-related complications and examine the eff ect of childhood surgery on these complications. a retrospective chart review over a year period, from august -december , demonstrated adult patients who presented to an adult reconstructive urologist with urologic complications related to hypospadias. patients were divided into two groups: those with no prior hypospadias surgery (group , n= ) and those who underwent surgical correction as a child (group , n= ). charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required. results: overall, the mean age at presentation was . years old. meatal location was not statistically diff erent between groups and , respectively: glans ( . % vs. . %), subcoronal ( . % vs. . %), coronal ( . % vs. . %), distal penile ( . % vs. . %), midshaft ( . % vs. . %), and penoscrotal ( . % vs. . %). overall, luts ( . %) was the most common presenting complaint, followed by spraying ( . %), urethrocutaneous fi stula ( . %), recurrent uti's ( . %), and chordee ( %). comparison demonstrated group patients were more likely to present with luts ( . % vs. . %, p= . ) and recurrent uti's ( . % vs. %, p= . ). contrastingly, group patients presented more commonly with cosmetic dissatisfaction ( . % vs. . %, p= . ). urethral stricture disease was demonstrated in more patients who had previous hypospadias repair, than those who had not ( . % vs. . % p= . ). of these, strictures were signifi cantly longer in the previous surgery group ( . cm vs. . cm, p= . ). surgical intervention was required in . % of group and . % of group (p= . ). conclusion: correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent uti's, and subsequent luts, but improves patient satisfaction with cosmesis. follow-up of hypospadias repair patients should extend into adulthood, as a signifi cant portion of adult presentations ultimately require surgical intervention. introduction and objective: during male to female gender confi rming surgery with vaginoplasty, a space is created for the neovagina within the potential space between the prostate anteriorly, and denonvillier's fascia and rectum posteriorly. entry to this plane is challenging, and to date, the only surgical approaches to this space describe blunt and sharp dissection along the ventral surface of the urethra. th e likely trauma to perirectal vasculature muscle-laden connective associated with this approach may account for the observed recto-vaginal fi stula rate associated with vaginoplasty. we describe an alternative, never before published approach using a male urethral sound upon the apex of the prostate to enter this plane with sharp dissection in a reliable and effi cient fashion. we describe our surgical technique, wherein we use a male urethral sound during the dissection to help expose denonvillier's fascia over the apex of the prostate. we dissected a block of tissue containing prostate, denonvillier's fascia and rectum from human cadavers, to describe (using ihc) the location and relative abundance of blood vessels (factor viii ab.), nerves (nf & s- ab.), and connective tissue (h&e and masson's trichrome), to support the sharp surgical approach we describe over the traditional approach to this plane. we describe clinical outcomes and the recto-neovaginal fi stula rate utilizing this approach in our institutions. results: immunohistochemistry results showed that the sharp dissection we describe is associated with incision through signifi cantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. use of the sharp dissection we describe resulted in, at our institutions, a signifi cant decrease in recto-neovaginal fi stula in the peri-operative period. conclusion: th e surgical technique we describe for dissection of the plane between prostate and denonvillier's fascia during vaginoplasty is well supported by the anatomic studies we performed, and, is associated with lower morbidity. th is surgical approach and technique is also likely useful for gaining access to this same plane for repair of recto-vesical and recto-urethral fi stulas. introduction and objective: mitrofi noff procedure is commonly employed as bladder draining tool in patients who are unable to do clean intermittent self-catheterization through native urethera. it preserves renal function in small capacity and high pressure bladders and to improve quality of life. here we want to share our single centre experience of patients undergoing mitroffi noff procedure. a retrospective study of patients who underwent mitrofi noff procedure from january till december with a median age of (range = to ). twenty eight patients were males while female. indications for catheterizable stoma formation included neurogenic bladder in patients, small bladder in , bladder tumor in , uretheral stricture in one and interstitial cystitis in one patient. median follow-up was month to years. stoma was made from appendix in cases, from tapered ileum in cases and from ureter in cases. stoma location was lower right quadrant in cases, left lower quadrant in cases and at umbilicus in cases. augmentation accompanied by mitrofanoff was done in patients while mitrofanoff alone was done in patients. augmentation was done by using ileum in patients and cecum in one and illeocecum in one patient. data was entered from chart review and analyzed on spss. sixteen patients were analyzed in terms of complications and stoma revision. results: post-operative complications included uti in ( . %) patients, stones formed in ( . %), fistula was seen in ( . %) patient (augmentation cystoplasty + mitrofanoff ), stoma stenosis seen in ( . %), stoma revision done in ( . %). one female ( . %) patient had dribbling urine through urethera (incontinence), she underwent bladder neck closure. metabolic complications were not seen based on serum electrolytes follow-up records. we concluded that aft er mitrofanoff procedure renal function was preserved in most of the patients while no metabolic complications were seen in patients aft er undergoing mitrofanoff +bladder augmentation. stone risk was . % which was not very high. quality of patients was improved aft er mitrofanoff procedure. results: sesfm has higher porosity and larger pore size compared with bam (p< . ). at weeks, the presence of vesical calculus was evident in / rabbits. histological analysis showed that sesfm and bam promoted similar degree of urothelium regeneration (p> . ), and sesfm promoted a higher degree of smooth muscle and vessel regeneration compared to bam at each time point (p< . ). in addition, muscle strips supported by sesfm displayed higher contractile responses to carbachol, kcl, and phenylephrine compared with bam. at weeks, both matrices elicited similar mild acute and chronic infl ammatory reactions. conclusion: our results demonstrated that sesfm has greater ability to promote bladder tissue regeneration with structural and functional properties compared to bam, and with similar biocompatibility. introduction and objective: ureteral access sheaths (uas) can aid ureteroscopy by facilitating multiple passes of the ureteroscope, maximizing irrigation drainage, and reducing intra-renal pressures. however insertion of the access sheath may induce ureteral ischemia, cause iatrogenic ureteric injury, and could ultimately lead to ureteric stricture. in this study, we aim to evaluate the stricture rate following ureteroscopy both with and without the use of uas. we performed a retrospective chart review of consecutive ureteroscopies performed at our center (a tertiary referral center for endourology) between april and april to treat ureteric and renal calculi. th e primary outcome was the development of new hydronephrosis three months following successful ureteroscopy, not due to an obstructing stone. patients without follow-up renal ultrasound (us) or ct scan months post-ureteroscopy were excluded. data on age, sex, size of the stone, location of the stone, stone density, stone-free rate (sfr), time of the procedure, pre-op stenting, postop stenting, use of the uas, size of the uas, length of the uas, stone analysis, and imaging details were recorded. baseline and outcome variables were compared with anova and chi-square analysis where appropriate using spss statistical soft ware. results: a total of patients were eligible. a uas was used in ( . %) patients; ( . %) for renal stones and for proximal ureteric stones. th ere was no signifi cant diff erence in baseline or demographic data. none of the patients developed new hydronephrosis or developed a ureteric stricture, and none required endoureterotomy. conclusions: uas use during ureteroscopy for renal and ureteric stones is both safe and eff ective. even with routine use of . f and f uas, ureteric stricture rates are very low (zero in this series), suggesting that signifi cant ureteric injury is rare with proper technique and case selection. to evaluate the value of fl exible ureteroscopy for the treatment of the upper urinary tract calculi in children. a total of children, males and females, were identifi ed in this study. th e median age was . years, range months to years. among them, patients had the upper ureteral calculi ( with calculi in situ, with middle/fi stal ureteral calculi shift ing to upper ureteral aft er rigid ureteroscopic lithotripsy) and had renal calculi. ipsilateral mild to moderate hydronephrosis was found in all of the cases. four children had melamine-induced stones ( with upper ureteral calculi and with renal calculi). th e calculi were found on left side in cases, on right side in , and on both sides in (upper ureteral calculi). th e median stone size was . (range . to . ) cm. retrograde fl exible ureteroscopy and anterograde fl exible ureteroscopy in mini-percutaneous nephrolithotomy was performed. results: twenty eight cases were performed retrograde fl exible ureteroscopic procedure. one case was conversed to mini-percutaneous nephrolithotomy because the fl exible ureteroscope could not be inserted into the upper ureter. th e fl exible ureteral access sheath was failed to insert into the upper ureter in cases, and the fl exible ureteroscope was inserted into ureter directly. th e successful rate of stone search was % in cases. th irty cases were successfully performed in one stage. th e stones were successfully fragmented aft er two stages in two cases. th e success rate of stone fragmentation was . % with the holmium laser lithotripsy in one stage. th ree anterograde fl exible ureteroscopy with mini-percutaneous nephrolithotomy were successfully performed, and the stones were successfully found and fragmented aft er a single holmium laser lithotripsy. th e median operative time was (range to ) mins. th ere was no major perioperative complication. th e patients were discharged from hospital aft er a median of . days (range to ). double-j stent was removed aft er to weeks when no residual stones more than . mm in size were found. no recurred stones, no urethra stricture, no ureter stricture, no urinary incontinence and no vesicoureteral refl ux were found during the to -months follow-up. conclusion: flexible ureteroscopy is a safe and feasible method for the treatment of the upper urinary tract calculi in children. it is suitable for the stones in the pelvis and calyceal where the rigid ureteroscopy could not reach. introduction and objective: laparoscopic ureterolithotomy is an alternative to open ureterolithotomy for the primary treatment of large, impacted, proximal or mid ureteral stone. transperitoneal and retroperitoneal approaches are the basic techniques and each has its own advantages and disadvantages. th e aim of this study is to compare retroperitoneal versus transperitoneal laparoscopic ureterolithotomy in eff ectivity, pain scale and early complications. in this prospective comparison study from january to december , patients with proximal and mid ureteral stones underwent retroperitoneal laparoscopic ureterolithotomy or transperitoneal laparoscopic ureterolithotomy. th e randomization occurred on consecutive sampling on a : basis. groups and consisted of patients who underwent retroperitoneal laparoscopic ureterolithotomy and transperitoneal laparoscopic ureterolithotomy, respectively. demographic and clinical variable, operative time, length of stay, ureteral suturing, pain scale according to visual analog scale (vas) and early complications data were collected and analyzed. statistical analysis was performed with spss® version . using student t-test and mann-whitney u tests with p value< . considered statistically signifi cant. results: vas on day between the groups was statistically signifi cant, and was higher in group (p< . ). according to the clavien-dindo classification of surgical complication all the patients were in grade classifi cation. th e diff erences in operative time, length of stay, ureteral suturing, visual pain analog score on day , and early complications between the groups were not statistically signifi cant. ionising radiation is commonly used in urological practice in the form of fl ouroscopy. to date there is a relative dearth of information regarding patient exposure during the urological procedures and the subsequent risk of development of a lethal malignancy due to the radiation exposure. objectives: to determine the radiation exposure for a patient for the most commonly performed urological procedures and determine the lifetime additional risk of fatal cancer per procedure. data was collected prospectively in two institutions on endoscopic urological operations. procedures were classifi ed as retro-graphic, semi-rigid ureteroscopic (urs) and fl exible ureterorenscopic (furs). data collected included procure type and diffi culty, dose are product [dap (gy*cm )]). th e eff ective dose (ed) as measured in millisievert was determined from the dap by using the monte carlo calculation. results: a total of consecutive operations from two institutions were assessed. th e mean ed for all procedures in this study was . msev, irq ( . - . ). th e maximum ed was . msev. th e radiation exposure for all procedures was relatively small, for diagnostic retrographic procedures the median ed was . msev. for retrograde procedures that involved a stent insertion the median ed was . msev. th e median ed for all ureteroscopic surgeries was . msev, and the median ed for all furs procedures is . . th e fi ndings of this study are reassuring. endoscopic urological procedures appear to expose patients to relatively small radiation compared to other procedures requiring fl uoroscopy and a very low lifetime additional risk of fatal cancer per procedure. five during the follow no local recurrence was noted and two patients presented with distant metastasis. th e actual -year overall and cancer specifi c survival was . % and . %, respectively. on multivariable cox regression analysis, acci was the only factor associated with increased risk of overall mortality (hr . ; % ci ( . - . )). conclusion: rpn achieves excellent long-term oncological outcomes. age and comorbidities are associated with increased risk of overall mortality. to our knowledge, this is the fi rst series of long-term follow up aft er rpn reported to date. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short and long term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy (lpn) has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. it was reported that using barbed suture can reduce warm ischemia time during lpn. we designed a single blind randomized controlled trial to fi nd whether the barbed suture can materials and methods: from july to march , forty-six patients with renal score less than were enrolled for this study. patients were randomized into two groups: control and v-loc group. all patients were evaluated before surgery including performance status, asa score, liver and renal function, abdominal ct, lung function, and cardiac function etc. during the surgeries, standard ports were placed. aft er the renal artery was clamped by bulldog, tumor resection was performed using a cold scissor. th en the inner layer deep vessels and collecting system, and outer layer were sutured with v-loctm respectively in v-loc group. in control group, inner layer was sutured with - absorbable sutures, and the outer layer renal parenchyma was sutured with absorbable sutures. operative characteristics and complications were compared between groups. results: laparoscopic partial nephrectomy was successfully completed in all forty-six patients without open conversion. control and v-loc groups were equivalent in demographic and tumor characteristics. no signifi cant diff erence was seen between control and v-loc groups in operative time ( vs. min, p = . ), estimated blood loss ( vs. , p = . ), warm ischemia time ( vs. min, p = . ), and complication rate ( % vs. . %, p = . ). conclusion: lpn with v-loc sutures for renorrhaphy is safe and feasible. however, using v-loc suture for renorrhaphy doesn't show any superiority in patients with low and moderate complexity renal tumors in our randomized control trial. small th e local recurrence free survival was signifi cantly better in the combined us/ct-guided group than in the us-guided group (p= . ). recurrences were found in % with us/ct-group and in % in usgroup. th e overall complication rate was similar (us/ ct % versus us %) in both groups. th e mean percentage decrease in the estimated glomerular fi ltration rate (egfr) aft er the treatment was . ± . % with us/ct, compared to . ± . % mean decrease in egfr aft er treatment in the us-guided group (p= . ). conclusion: th e use of combined us/ct-guidance when performing renal rfa resulted in superior primary and short term outcome compared to the use of us-guidance alone in patients treated at the same institution. increased experience with rfa treatment probably also contributed to the results. introduction and objective: to present our initial experience in female patients undergoing transvaginal notes-assisted laparoscopic partial nephrectomy (pn). between august and january , a prospective analysis of the initial ten patients who underwent transvaginal notes-assisted pn was entered into an institutional review board (irb)-approved database. th e procedure was performed using two umbilical trocars and one trocar through the vaginal wall. th e main renal artery clamping, segmental renal artery clamping and unclamped pn were performed depending on the circumstances of the tumour. some perioperative parameters including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. sexual function was assessed with the female sexual function index (fsfi) questionnaire before and aft er surgery. th e cosmetic results were investigated by administering patient scar assessment questionnaire and scoring system (psaq). results: nine transvaginal notes-assisted pns were completed successfully. one patient with a right anterior upper-pole tumor was converted to radical nephrectomy because of persistent bleeding from the parenchymal defect. th e median (range) operating time was ( - ) mins and the median (range) estimated blood loss was ( - ) ml. th e median (range) warm ischaemia time (wit) was ( - ) mins. th e median (range) postoperative hospital stay was ( - ) days. all surgical margins were negative. eight patients completed the fsfi questionnaire, and analysis did not show diff erences in fsfi scores before and aft er surgery. th e better cosmesis results were confi rmed by the psaq score. transvaginal notes-assisted pn is a safe and feasible surgical procedure in the treatment of small renal mass with excellent cosmesis results. more prospective studies with long follow-up are needed to investigate the oncologic safety. introduction and objective: to analyze the complications of urologic transvaginal natural orifi ce transluminal endoscopic surgery (tv-notes), and to explore eff ective measures for its prevention and management. materials and methods: from may to february , a total of cases underwent tv-notes in our institute. intraoperative and postoperative complications were graded according to satava and clavien-dindo grade classifi cations system. th e major complications and their treatments were most importantly analyzed. results: among the tv-notes procedures, case conversion to open surgery and one case conversion to suprapubic-assisted laparoendoscopic single-site surgery (sa-less). th irty-one ( . %) patients had intraoperative complications, the minor and major was ( . %) and ( . %), respectively. th e intraoperative complications include cases of pneumoderm, cases of skin ecchymosis, cases of pleural damage, cases of liver injury, case of adrenal central vein injury, cases of spleen injury, cases of inferior vena cava injury, cases of renal veins injury, case of right iliac vein injury, case of bladder injury, case of renal collecting system injury, cases of colon injury, case of rectum injury. th e proportion of patients incurring minor and major postoperative complications undergoing tv-notes was . % (n = ) and . % (n = ), respectively. th e postoperative complications include case of adrenal crisis, cases of incision infection, cases of postoperative fever, cases of postoperative bleeding, case of the right external iliac artery thrombosis and case of urinary leakage. no intraoperative and postoperative deaths occurred. conclusion: tv-notes operation is safe and feasible surgical technique in urology, and does not increase the incidence of complications. but there is a potential risk of major complications occurring, which should be paid more attention to prevent. introduction and objective: knotless barbed suture, a relatively innovative type of suture, can eliminate knot tying, speed the placement of the sutures, and create the possibility of improved scar cosmoses. th e minimally invasive radical prostatectomy (mirp), as one of the earliest surgeries that adopted this advanced technique, was reported about diverse eff ects on the patients and the surgeons. our objective is to present the available evidence about the effi cacy and safety of barbed sutures in minimally invasive radical prostatectomy. we searched pubmed, em-base, and cochrane library for published studies and clinicaltrials.gov for additional information to identify randomized controlled trials (rcts) and cohort studies addressing the application of barbed and conventional sutures in mirp (until feb. ) . quality assessment was performed according to cochrane recommendations. th e data were analyzed using review manager (version . ), and sensitivity analysis was performed by sequentially omitting each study. hemi-pelvises, . % had the periprostatic plexus (ppp) as the largest vein of the dvc. th is was followed by the obturator vein (ov) ( . %), which originates from the lateral part of the plexus and runs laterally. next was the internal pudendal vein (ipv) ( . %), which originates lateral to the posterior part and runs postero-laterally. in the rp group, the dvc bunching stump was an average of . mm from the origin of the cavernous vein. no complications occurred while performing examinations. conclusion: d-ct pelvic venography depicted the dvc and its related veins in all cases. venous systems making up the dvc diff ered among patients. in . %, the main venous system was the ppp, which can be controlled by conventional dvc ligation technique. however, in the remaining % of hemi-pelvises, the ipv and the ov were the main venous systems. th ese will need wider ligation because of existing outside and to the back of pathways. we believe that a better understanding of dvc will lead to refi ned rp. introduction and objective: bladder pheochromocytoma and carcinoid tumors are rare neuroendocrine tumors of the bladder. presenting a series of cases of these rare bladder tumors which were managed laparoscopically. materials and methods: case was a years lady who presented with symptom of giddiness following micturition. ultrasound revealed a . cm bladder mass at the bladder base. twenty four hour urinary biochemical evaluation and mibg scan did not reveal any abnormalities. cystoscopy revealed a submucosal sessile mass above the trigone. on cystoscopic bladder distension a spike in blood pressure ( / ) was noticed which fell rapidly on emptying. patient underwent laparoscopic partial cystectomy aft er weeks of alpha blockade with phenoxybenzamine. case was a years old gentleman who presented with episodes of severe headache following micturition. despite antihypertensives his blood pressures were not under control. ultrasound revealed a cm bladder mass in the left lateral wall encroaching close to the left ureteric orifi ce. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent cystoscopy followed by laparoscopic partial cystectomy with left ureteric reimplantation. case was a years old gentleman a hypertensive who underwent an attempted turbt and subsequent hypertensive crisis and bleeding for a bladder mass in a peripheral hospital. he was stabilized and referred to our center for further management. ultrasound revealed a cm anterior wall mass. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent laparoscopic partial cystectomy. mri has shown to be accurate in diagnosing index tumours in prostate cancer. a variety of focal therapies has been explored in treating these lesions. th is study aims to compare the detection rate, grade and location of non-index lesions found in radical prostatectomy specimens with their initial mpmri. a prospective database of all men undergoing mpmri for suspicion of prostate cancer in our group practice was kept. ethics approval was obtained from epworth healthcare. of these men, all who had a -d summary diagram including pirads score for each mpmri and who then underwent radical prostatectomy were assessed. volumetric studies were performed for all prostatectomy specimens and compared to each corresponding mpmri -d summary diagram. analysis of non-index lesions was performed. conclusion: a signifi cant amount of patients who underwent radical prostatectomy in treatment for prostate cancer were identifi ed to have non-index tumours in their volumetric analysis. in our cohort of patients, the majority of low grade disease was undiagnosed on mpmri. however, a signifi cant amount of moderate grade non-index tumours were also missed on initial mpmri. th is questions the safety and appropriateness of focal therapy. ongoing research is warranted and we will continue to report our prospective mp-mri database as our experience with this modality grows. eligibility for active surveillance of prostate cancer and functional outcomes after prostatectomy shepherd a , , o'callaghan m , , introduction and objective: we aimed to compare the outcomes following radical prostatectomy (rp) of active surveillance (as) and non-as candidates. we hypothesised that as eligibility at diagnosis would be associated with favourable pathological, surgical and also functional outcomes. using a prospectively maintained database, all patients with a primary treatment of rp conducted prior to were identifi ed, including those who were initially eligible for as. men defi ned as eligible for as were those: diagnosed between and years of age; with gleason score ≤ ; psa ≤ ; clinical stage ≤ a; and with percentage of positive cores ≤ %. we compared the histopathological and functional outcomes of the two groups. results: of patients with a primary treatment of rp, met the criteria for as. pre-operative tumour characteristics of the patients meeting criteria for as were favourable compared with those ineligible (lower psas and less cancer in the biopsies; p< . ). functionally, the groups had similar pre-operative continence ( % vs. %) and potency rates ( % vs. %). histologic characteristics of the prostate specimen in patients qualifying for as were more favourable, with lower rates of positive surgical margins and extracapsular extension observed in this group (p< . ). following rp, at -, -and -month follow-up, there were no signifi cant diff erences in the proportion of men who were continent between as and non-as candidate groups ( months: % vs. %; months: % vs. %; months: % vs. %; p> . ). similarly, no signifi cant diff erences between groups were observed in the proportion of men who were potent at -and -month follow-up ( months: % vs. %; months: % vs. %; p> . ). aft er -month follow-up, however, potency appeared to be higher for the as candidates ( % vs. %; p= . ). were assessed pre-implant as well as at , , and months aft er seed implantation, and every months thereaft er. we evaluated clinical factors, including prostate volume (pv), neoadjuvant combined androgen blockade (cad), radiation dose to % of the prostate volume (d ), and to % of the urethral volume (ud ) to predict urinary disorders aft er brachytherapy using multivariate analysis. results: th e mean pre-implant ipss was . , with the greatest mean score of . at month aft er seed implantation. at , , , , and months, the mean ipss had decreased to . , . , . , . , . and, . respectively. th e mean pre-implant prostate volume (pv) was . g, followed by . g at months and . g at months aft er brachytherapy. in cases with pv more than g, d more than gy, and ud more than gy, ipss levels were signifi cantly high-er even years aft er treatment. on multivariate analysis, d more than gy (p< . ) and ud more than gy (p= . ) were independent predictors for ipss increases of more than points at years aft er brachytherapy. only d was an independent predictor at (p< . ) and years (p= . ) aft er brachytherapy. introduction and objective: metformin has been shown to be protective in prostate cancer (pc). we aimed to assess the eff ects of metformin on pc outcomes in men treated with external beam radiotherapy (ebrt) and/or androgen deprivation th erapy (adt). we also aimed to investigate the eff ects of metformin on the above outcome measures in type diabetic men with pc. th e outcome measures of time to biochemical failure (bf), metastasis, pc specifi c mortality and overall mortality were analysed in men on metformin using a competing risk model and a cox proportional regression model. a total of eligible cases, of whom were on metformin, were identifi ed with a median follow-up of . months. th ere were no diff erences in age, initial psa, gleason scores, t stage, d' amico risk or duration of adt between men who were on metformin and those not on metformin. treatment with metformin did not result in any apparent improvement in time to bf, time to metastases or overall survival but there was an increase of . fold in pc-specifi c deaths (p< . ) in men on metformin and adt when adjusted for cancer risk and co-morbidities. on a subgroup analysis of the men with type diabetes, similar fi ndings were seen with metformin being associated with a . fold increase in pc-specifi c deaths (p < . ). th ese adverse eff ects were lost in men on metformin and statins. conclusions: th e use of metformin did not improve time to metastases, time to bf or overall survival in men undergoing ebrt +/-adt for pc with curative intent. however, in type diabetic men on high doses of metformin there was an increased risk of pc-specifi c mortality. further studies are needed to investigate these fi ndings. th e objective of this study is to assess ire eff ects in prostate tissue and to correlate ire treatment planning with the d-histopathology of radical prostatectomy (rp) specimens that essential structures will be spared. sixteen patients, scheduled for rp, ire procedures were performed weeks before rp. ablation was performed according to two protocols: focal or extended ablation. th e electrode probes were inserted transperineally under ultrasound guidance. th e locations of the electrodes were used as input for the plannings soft ware. following rp, the specimens were processed into whole-mount sections, were histopathologically (pa) assessed and ablation zones were delineated. th e volumes of tissue alteration were determined by adding the delineated areas. th e planned and pa ablation volumes were compared using the pearson correlation coeffi cient. results: th e d volumes of the ablation zones follow the planned lesions volumes with a pearson correlation index r= . with a slope of . ( figure ). th e focally planned ablations results in a volumetric smaller histopathological ablation zone than predicted whereas the extended ablations result in volumetric larger ablation. pa showed sharply demarcated fi brotic and necrotic areas with mild infl ammation. th e urethra was aff ected by the ire treatment in nine mp- . , figure . correlation of ablation volumes t -weighted mri and ceus with h&e pathology (pa) mp- . , figure . scatterplot of planned ablation zone volumes compared with volumes in histopathology patients were observed throughout the neurovascular bundle in thirteen prostates and extended beyond the prostatic capsule in twelve cases. conclusion: ) ire in prostates results in sharply demarcated lesions with fi brotic and necrotic features, but may damage essential structures as urethra, capsule and nerves. ) th e actual ablation zones on d-histopathology follow reasonably the planned ablation zones. ) focal ablation protocols lead to a smaller ablation zone than extended ablation protocols. therapeutic all patients treated at our institution with primary pca t - , n , m were included provided they did not present with a long history of adt. patients were stratifi ed into groups according to their psa nadir occurring between - weeks following hifu. group a (n= : nadir < . ng/ml), group b (n= : nadir > . - ng/ml ng/ml), group c (n= : nadir > ng/ml). th e primary endpoint of our analysis was the onset of any salvage therapy other than hifu. repeat hifu can be performed without undue additional morbidity and is standardly not considered as salvage therapy but rather an adjuvant to the index hifu. multivariate analysis was performed to determine what predicts onset of salvage therapy. results: at inclusion: . % of patients were t and . % were t . outcomes are summarized in table . conclusion: group a (nadir < . ) showed % salvage treatment free survival without adt; preoperative high gleason, high initial psa and "no turp" were negative predictive factors for outcome; % of the patients had nd hifu treatments in follow-up; in case of salvage therapy most patients opted for adt. metastasis-free survival of % at and % at years excludes turp in pca as potential metastasis-inducing factor. combined "turp and hifu" showed its oncological effi cacy, postponing / avoiding classical salvage therapies (rad/adt) and their potential side eff ects. laparoscopic radical prostatectomy (lrp): changing trends in practice introduction and objective: we audited our lrp outcomes in order to evaluate outcomes and how our practice has evolved over the years. we evaluate pathological and margin status outcomes and determine whether there has been a shift towards treatment of higher risk disease and the impact of this practice on margin status. a total of patients underwent lrp performed by one surgeon at our institution from june to september . we divided the cohort into early period from - (group , n= ) and - (group , n= ). results: mean age was yrs. mean preoperative psa ( . ) and gleason score (gs, ) did not diff er between groups. however, preoperative stage ≥t c increased from ( %) to ( %) for groups and respectively. postoperatively, diagnosis of gs ≥ increased from ( %) in group to ( %) in group . similarly, % of group was staged as pt compared to % of group . th ere were more extracapsular extension in group ( %) compared to group ( %). overall positive surgical margin (psm) rate was % (group , % vs. group , %). when stratifi ed according to pathological stage, psm was identifi ed in more men with pt ( %) compared to pt ( %). th e commonest site of psm was at the apex. seminal vesicle invasion rate was similar ( %). results: mean operation time and length of hospital stay for rarp and lrp were . ± . min and . ± . min, and . ± . days and . ± . days, respectively (p = . and p = . ). aft er cases, the mean operation time for rarp was similar to lrp (less than h). positive surgical margins in localized cancer were seen in . % and . % of cases in rarp an lrp, respectively (p = . ). at postoperative months, sexual intercourse was reported in % and %, and pad-free continence in % and % in patients with rarp and lrp, respectively (p = . and p = . ). conclusion: previous large-volume experience of lrps may shorten the learning curve for rarp in terms of oncological outcome. additionally, previous experience with laparoscopy may improve the functional outcomes of rarp. introduction and objective: signifi cant prostate cancer is increasingly diagnosed in younger men. th is patient group has high expectations regarding oncological and functional outcomes at robotic radical prostatectomy (rarp). we reviewed a prospective database ( rarps) at a single tertiary referral centre and obtained erectile dysfunction rates/treatment and continence pre-and post-operatively, positive margins, metastases and death. median follow-up was years. male sprague-dawley rat aged weeks were used. a total of rats were divided into two groups. one group was used as a control and other group received intramuscular injections of testosterone propionate ( mg/kg) plus β-estradiol ( . mg/kg) for weeks to induce bph. th e prostate and genitourinary organ weights, histopathologic change and serum hormones were evaluated. we compared the eff ects of ldd ( mg/kg) with tamsulosin ( μg/kg) in intraurethral pressure responses induced by es of the hypogastric nerves. we performed western blotting for alpha a and d receptor of adrenergic nerve. results: bph-induced rats showed signifi cantly increased absolute prostate weight and prostatic index (prostate weight/body weight x ), increased testosterone, free testosterone and estradiol levels in the serum. histomorphology also showed that epithelial cell layers in the prostates of bph-induced rats were larger than control groups. ldd and tamsulosin signifi cantly inhibited the intraurethral pressure elevation induced by es of the hypogastric nerves. alpha d and alpha a adrenergic receptors in bph rat model were expressed more than control. ldd decreased expression of alpha d adrenergic receptor than control. conclusions: th is study suggested that ldd could be an alternative medicine to treat bph inducing lower urinary tract symptoms. does according to recent studies, atherosclerosis has a key role in the pathogenesis of bph. th erefore, we evaluate the correlation between prostate volume and intima-media thickness (imt) of carotid artery in diabetic bph. from january to august , patients with dm were analyzed, retrospectively. baseline characteristics and diabetic profi le were collected. mean intima-media thicknesses (imt) were collected using carotid doppler ultrasound. and prostate volume (pv) was measured by transrectal ultrasound. two groups were analyzed using lineal regression analysis. results: th e patients were classifi ed into group (n= , . %) and into group (n= , . %) based on the presence of bph. th ere were statistically signifi cant diff erences on bmi, waist circumference and hba c between the two groups (table ) . th ere is a signifi cant correlations between imt and pv and imt and transition zone (tz) (p= . , p= . , figure ). porting symptoms listed on the otc label as reasons for not using the product; traces of glucose, leukocyte, and/or blood in their urine; or an aua-si score ≥ . conclusion: pvp has demonstrated acceptable complication rates compared to traditional turp in treating bph in a cohort of men having a greater frequency of comorbidities and in those having to remain on oral anticoagulation. th is makes pvp an attractive alternative to turp in such men particularly if symptomatic relief and re-treatment rate in the longer term is demonstrated to be equivalent. prospective study of high-risk patients undergoing photovaporisation of prostate (pvp) without cessation of oral anticoagulants ow d , papa n , sengupta s , , lawrentschuk n , , , bolton d introduction and objective: greenlight laser photovaporisation of the prostate (pvp) is suggested to be safe to perform on high risk patients requiring surgical intervention in the management of benign prostatic hyperplasia (bph), where cessation of oral anticoagulation is not possible due to medical comorbidities. we prospectively evaluated the outcomes of patients who underwent pvp with ongoing oral anticoagulant therapy. materials and methods: between january and december , patients with ongoing oral anticoagulant therapy were treated with pvp. types of oral anticoagulants were recorded and perioperative outcomes were collected. th ese metrics included transfusion rate, duration of hospital stay and laser treatment variables. ninety-day readmissions also were recorded as were complications of treatment. results: sixty-two patients were treated by greenlight laser pvp while taking oral anticoagulants. out of this total, patients ( . %) were on warfarin while ( . %) had ongoing clopidogrel. th e remaining were either taking one or a combination of other (non-asprin) oral anticoagulants. nine out of ( . %) patients required readmission post pvp, and all of these readmissions were for management of complications related to haematuria. five of this group of patients ( . % of total cohort) had undergone pvp without cessation of warfarin, while of patients ( . % of total cohort) had undergone treatment without cessation of clopidogrel. th ree patients ( . %) required blood transfusion. conclusions: despite continuation of oral anticoagulants in these high risk patients, the readmission rate is low and transfusion rate is similar to what has previously been reported for conventional turp in patients without anticoagulation. greenlight laser pvp is a viable option for surgical management of bph in patients for whom cessation of oral anticoagulant therapy is contraindicated. introduction and objective: cystinuria is a rare, chronic condition characterised by recurrent urolithiasis. th e condition is due to a variety of genetic mutations in an amino acid transporter and accounts for between . - percent of urinary tract stones. cystine urolithiasis may be treated by preventative medical therapy or therapeutic urological intervention. it is the authors' experience that patients tend to shy away from long-term medical treatment, possibly due to a perceived lack of effi cacy or poorly tolerated side-eff ects. as with all chronic conditions, quality of life for cystinuric patients is expected to be diminished. sub-optimal medical therapy and the need for repeated urological intervention is expected to have a further impact on quality of life. th e authors seek to describe the natural history and quality of life in patients with cystine urolithiasis. th is in turn allows further improvements to the standard-of-care off ered to such patients. a cohort study was carried out involving participants recruited from a single surgeon's case mix. participants suff ering from cystinuria and related urolithiasis were invited to complete a questionnaire involving demographic information, use of medical treatment, surgical interventions and the sf- quality of life survey. attitudes towards the use of current and potential future medical treatments were also explored. results: fourteen participants completed the survey. th e sf- survey showed lower quality of life than the general public in of domains. th e mean interventional rate in patients with cystinuria was . procedures per patient. most patients reported previ-ous use of d-penicillamine and urinary alkalinisation medications, with most ceasing due to side-eff ects or lack of perceived effi cacy. conclusion: cystinuria is associated with a high rate of surgical intervention and lower quality of life than the general public. individuals with this condition report that medical management is either ineff ective or poorly tolerated. th ere is a need for further improvements in medical management of cystinuria, to reduce the rate of operative intervention. recommendations to guide clinical practice, based on patients' experience of cystinuria management can be made. dipstick results: a total patients were retrospectively reviewed for the ph results. th e mean diff erence in ph between spot urine value and the -hr collection values was . ± . ph. higher ph was associated with lower accuracy (p < . ). th e accuracy of spot urine samples to predict -hour ph values of < . was . %, . % for . to . and % for > . . samples taken more than days apart had only % the accuracy of more recent samples (p < . ). th e overall accuracy is lower than % (p < . ). infl uence of diurnal variation was not signifi cant (p = . ). conclusions: spot urine ph by dipstick is not an accurate method for evaluation of the patients with urolithiasis. patients with alkaline urine are more prone to error with reliance on spot urine ph. relationship is the fi rst lithotripter on the market with a unique design that allows for a dual focus system with the option of either a narrow or wide focal zone. ex vivo data on the slk-f lithotripter shows that the disintegration capacity and the renal vascular injury are independent of the focal diameter of the sw generator at the same peak positive pressure and disintegration power. th e objective of this study is to compare the single-treatment success rates of narrow and wide focal zones for the shock wave lithotripsy of renal stones. a total of patients with previously untreated radio-opaque solitary stone located within the renal collecting system, measuring at least mm, were randomized to receive narrow or wide focus lithotripsy while maintaining a constant overall energy level. patients were followed with kub x-rays and renal ultrasound at and weeks post lithotripsy to assess stone area and stone free status. urinary markers indicating the degree of renal cellular damage (microalbulin and beta microglobulin) were measured pre and post swl, hours post swl and days post-treatment. primary outcome was success rate, defi ned as stone-free or adequate fragmentation (sand and asymptomatic fragments <= mm) at months post-treatment. mp- . , figure . introduction and objective: despite being uncommon, infantile kidney stone remains a major health problem due to its higher recurrence rate and morbidity. th e parents usually notice that their infants have recurrent fever and failure to thrive of unknown origin. th ose patients comprise a big challenge for the urologist in management. th erefore, this study aimed to evaluate the outcome of shockwave lithotripsy (swl) in management of renal stones in infants. a retrospective analysis of prospectively collected data performed between january and december for infants underwent swl for single radio-opaque renal stones ≤ mm at a single stone center. swl was performed with dorneir s lithotripter with a maximum of shocks per session. a single session was indicated for each infant, but a second session was performed when satisfactory disintegration was not achieved. follow-up based on urinalysis, urine culture and sensitivity, plain x-ray kidney ureter bladder (kub) and abdominal ultrasonography (us) was carried out weeks post swl and monthly for successive months. multislice computed tomography (msct) was performed -months post-swl to confi rm the stone-free status. results: a total of infants, less than months of age were enrolled in this research. swl success was defi ned as absence of any residual fragments on msct months aft er the last session. stone free rate was . % aft er the fi rst swl session and reached % aft er the second session. rate of retreatment with second session of swl was . %. urinary tract infection (uti) was detected in . %, transient renal obstruction with low grade fever in . % of infants and no major complication had been recorded. conclusion: th e new generation of swl technology with a precise focal area seems to be safe and eff ective in management of kidney calculi in infants. stone introduction and objective: th e incidence of abdominal discomfort is frequent during pregnancy, but renal colic is infrequent. one of the main causes of renal colic during pregnancy is urolithiasis. managements of urolithiasis during pregnancy are hydration, antibiotics, ureteral stent insertion, percutaneous nephrostomy, and ureteroscopic stone removal. in this study, we assessed the reliability and stability of ureteral stent insertion to pregnant patients with renal colic. results: th e overall mean patient age ( years), male to female ratio ( . : ) and mean asa score ( . ) did not vary signifi cantly between years. admissions for elective renal stone procedures, adjusted for population, increased % over the study period. th is growth was entirely in the last years, corresponding with a -fold increase in the use of pyeloscopy (from to cases per year). from the fi rst to last year, there was a % reduction in eswl (from to cases per year) and a % increase in pcnl (from to cases per year). nephrolithotomy ranged from to cases per year. th ere has been an increase in the proportion of associated ureteric stent insertions from % to %. th e proportion of day-only admissions has decreased from % to %. th e average government assigned cost per admission has increased %. conclusion: victorian public hospitals have seen a rapid expansion in the use of pyeloscopy and laser for treatment of renal stones. th is corresponds with a signifi cant increase in admissions for elective renal stone treatment, relatively fewer day-case admissions, higher treatment costs and more associated stent isertions. introduction and objective: th is retrospective study assessed the semirigid ureteroscopy approach coupled with ballistic or ho:yag laser lithotripsy for the treatment of proximal ureteral stones. patients with a single lower calyceal stone with an evidence of a ct diameter between and cm were enrolled in this multicentric study. exclusion criteria were the presence of coagulation impairments, age less than or more than , presence of acute infection, presence of cardiovascular or pulmonary comorbidities. patients were randomized into three groups: group a: patients treated with swl; group b: patients treated with rirs; group c: patients treated with pcnl. patients were controlled with abdomen x-ray and ct scan aft er months. a negative x-ray or an asymptomatic patient with stone fragments less than mm big and a negative urinary colture were the criteria to assess the stone-free status. a statistical analysis was carried out to assess patients' data, success and complications rates, re-treatment rate and need for auxiliary treatment. radiotherapy is an eff ective and common treatment for the prostate cancer. however, there is still an historic deep rooted fear of its use due to the existence of late genitourinary toxicities such as the radiation cystitis. nowadays these toxicities may pose less of a threat due to the use of newer radiotherapy techniques and the reduction of radiation doses applied to the tissues adjacent to the tumor. th e objective of our study is to fi nd predictive factors and determine the cumulative incidence of overall and severe radiation cystitis. conclusion: radiation cystitis is a feared complication of the use of radiation therapy in prostate cancer which occurs infrequently, and the severe cases requiring hospitalization are very rare. th e characteristics of the tumor, purpose of radiotherapy used or radiation dose applied do not seem to infl uence the incidence of radiation cystitis. introduction and objective: th e aim of the study was to assess prognostic factors of biochemical and radiological disease progression (dp) in subgroup of lymph node (ln) positive prostate cancer (pc) pts. evaluation of detection rate of ga-psma pet/ct for biochemical recurrence after radical prostatectomy introduction and objective: prostate specifi c membrane antigen (psma) is overexpressed in more than % of all prostate cancers (pca). since the introduction of pet-imaging with gallium-labelled psma, this method is regarded as a signifi cant step forward in the diagnosis for recurrent pca. from the patients that were scanned for detection of recurrent pca aft er radical prostatectomy between august and december , were evaluable for retrospective analysis. patients underwent pet/ct aft er injection with the ga-hbed-psma. th e potential infl uence of psa-level, primary gleason score (gsc) and psa-doubling time (psa-dt) on the detection rate were evaluated. results: a total of ( %) patients had pathological fi ndings on the ga-psma pet/ct, with an average psa-level of . ng/ml (range . - ng/ ml). detection rates were %, %, % and % for psa-levels < . , . - , > - . and > . respectively. if recurrent pca was detected, oligometastatic disease ( metastasis or less) was most commonly seen ( %). th e detection effi cacy was signifi cantly infl uenced (p< . ) by higher gsc ( % and %, for gsc ≤ and ≥ respectively). for the patients that were evaluated for the infl uence of psa-dt on detection rate, no signifi cant diff erence was found (p= . ) for psa-dt < months and ≥ months (detection rate % and % respectively). conclusion: ga-psma pet/ct has a high detection rate compared to prior studies of conventional imaging modalities, especially in lower range psa-levels. further research is needed to determine to assess whether localization of small volume disease on ga-psma pet/ct can improve diagnostic algorithms and outcomes in patients with recurrent pca. introduction and objective: to assess long-term results of salvage pelvic lymph node dissection (plnd) in prostate cancer (pc) patients (pts) with biochemical recurrence aft er primary local treatment and confi rmed solitary lymph node (ln) metastases. results: a total of , abstracts were screened, full-text papers were considered, and articles were included ( rct, comparative studies, and case series). th is abstract focuses on the comparative studies. primary therapy was prostatectomy in , radiation therapy in , and studies included both therapies. diff erent defi nitions of recurrence were applied among mostly retrospective studies and the adt strategy oft en not specifi ed. factors associated with unfavorable outcomes (overall, pc-specifi c, or metastasis-free survival) included higher age, higher psa nadir, higher gleason score, higher psa-dt, and early start of adt at recurrence. contradictory results were reported on the role of the length of adt aft er ebrt, partly explained by a selection of high risk cases. most patients with disease relapse aft er primary therapy seem not to benefi t from adt while side eff ects are known to be harmful. selected highrisk patients (short psa doubling time, high gleason score) however may have benefi t, and early start of adt may be preferable in this group. an intermittent adt strategy in this setting may be feasible. a rct is indicated, although diffi cult to perform. a personalized approach is warranted, taking disease characteristics, side eff ects, and quality of life into account. adt may only be given in patients with pc recurrence who have high risk characteristics. introduction and objective: locally radio-recurrent prostate cancer (rr-pca) can off er a chance of cure albeit with potential morbidities. current salvage treatment options include radical surgery and minimally-invasive ablative modalities such as hifu and cryosurgery (s-cryo). current data suggests that s-cryo can achieve disease-free survival (dfs) rates up to % at years. however, the majority of data is based on retrospective analysis with mid-term follow-up and there is still paucity of data on longterm outcomes. th e aim of this study was to analyze morbidity and oncological outcomes, with median follow-up years, of s-cryo on rr-pca patients at an academic center. figure ). adverse events were similar between the treatment arms. figure . th ese analyses demonstrates that, during the fi rst year of treatment, men treated with degarelix had a reduced risk of disease-related adverse events. th ere was also a lower risk of death, likely due to the higher incidence of cv events in lhrh agonist patients. introduction and objective: androgen-deprivation therapy (adt) appears to increase cardiovascular (cv) morbidity and mortality in men with prostate cancer, particularly in those with a history of cv disease (cvd). however, the risk is lower with the gonadotropin-releasing hormone (gnrh) antagonist, degarelix, compared with lhrh agonists. here we evaluate regional diff erences in baseline cv status in men with prostate cancer treated with degarelix or lhrh agonists and their subsequent risk of cv events. th is was a pooled analysis of data from three phase studies with a duration > months. individual patient level data on baseline cv status and subsequent cv events over year were summarized by geographic region (usa/canada vs. europe). cv event data were compared using cumulative incidence functions (with all-cause mortality as the competing risk) and cox regression analyses. canada had more severe disease and a higher cv risk (p< . ) ( table ). in men with baseline cvd, cumulative incidence ( % ci) of a cv event was . ( . - . ) in usa/canada vs. . ( . - . ) in europe (p= . ). at baseline, cv status was similar in the degarelix and lhrh agonist groups (table ) . however, in those with baseline cvd, degarelix was associated with a lower risk of subsequent cv events vs. lhrh agonists in both regions (hazard ratio [ % ci]: . [ . - . ]; p= . ). conclusions: men in the usa/canada with prostate cancer and cvd and who were treated with adt were more likely to experience a cv event than their counterparts in europe. th is likely refl ects the greater severity of baseline cvd and higher cv risk in these patients. degarelix reduced the risk of cv events compared with lhrh agonists in both regions. introduction and objective: androgendeprivation therapy (adt) decreases bone mineral density and may increase skeletal complications in metastatic prostate cancer. however, lhrh agonists and gnrh antagonists have diff erential eff ects on follicle-stimulating hormone (fsh), which regulates bone resorption. th e current analysis compared the eff ect of lhrh agonists and the gnrh antagonist, degarelix, on serum alkaline phosphatase (salp), a marker of bone turnover, and the incidence of skeletal adverse events (aes). conclusions: degarelix suppressed s-alp more quickly and for longer than lhrh agonists. it also reduced bone pain and was associated with a lower incidence of fractures. collectively, these data indicate that degarelix provides better control of skeletal disease in men with metastatic prostate cancer, an eff ect that may be mediated by its diff erential eff ect on fsh. prognostic introduction and objective: testosterone (t) regulates nitric oxide synthase and is necessary to achieve an optimum response to pde inhibitors for erectile dysfunction. recently, tadalafi l was found to be eff ective for treating lower urinary tract symptoms (luts) secondary to benign prostatic hyperplasia (bph). we studied the relative importance of the t level in patients with luts and determined whether the t level predicts the response to tadalafi l mg once daily for luts/bph. aft er a -week washout period, men older than years without (n= , t level ≥ ng/dl) and with (n= , t level < ng/dl) hypogonadism were given tadalafi l mg once daily for weeks. we assessed its impact and the severity of luts/bph using the international prostate symptom score (ipss) and bph impact index (bii) and ipss quality-of-life (ipss-qol) subscores. safety was assessed using treatment-emergent adverse events. introduction and objective: diabetes has been reported as a major cause in patients who complain of erectile dysfunction and is frequent in the comorbidity of severe erectile dysfunction. also, patients with diabetes are oft en poor response to treatment for erectile dysfunction. in such patients, according to the mirodenafi l (mvix ) use of the odf (oral decomposition fi lm) mg and mg was to compare the therapeutic eff ects of the treatment period. of the patients with erectile dysfunction were enrolled in a patient with diabetes. and the patients were classifi ed into two groups by randomized double blind controlled trial. th e fi rst group was to take the mirodenafi l odf mg once a daily and the second group was to take a mg at least twice one week, depending on the need to have sexual intercourse. international index of erectile function- (iief- ), international prostate symptom score(ipss) were examined for each time of initial visit, weeks, weeks, weeks. th e questionnaire items of two groups were analyzed at each time point. total of patients were included in the study. th e patients who were taking once a daily were and the patients taking when needed were . th ere was no signifi cant diff erence between age, iief- score, and ipss of each groups on initial visit. ipss score and quality of life score was lowered gradually all aspects in the two groups. iief- score was a tendency to increase in all categories. in comparing the two groups at weeks, once a day group showed a signifi cantly higher score than the group taking when needed for the questionnaire of erection confi dence, erection times, iief- total score(p< . ). th ere was no diff erence between two groups at weeks, weeks. in addition, this study showed the similar therapeutic eff ect between the two groups at end point of continued treatment during the weeks. conclusion: aft er daily dose method weeks, at least twice weekly dosing method and daily dose method is determined to exhibit the same eff ect. th erefore, we think that it is possible to change the intermittent dosing from daily regimen aft er two months. introduction introduction and objective: phosphodiesterase inhibitors (pde i) are the established fi rst line therapy for most cases of erectile dysfunction(ed). it is estimated that - % of ed patients may drop out and discontinue the usage of these drugs. th is study aims to evaluate the patient perspective of discontinuation of on-demand tadalafi l mgm and switching to daily tadalafi l mgm for ed. th e study comprises men with median age years suff ering from ed of average . years duration. co-morbidities included: hypertension ( %), diabetes ( %), dyslipidemia ( %) and smoking ( %). th e primary indication for usage of on-demand tadalafi l mgm was ed. all the patients had used mgm tadalafi l on demand on more than occasions over the last months. results: th irty-eight out of men opted to discontinue on-demand mgm tadalafi l and switch to daily dose mgm tadalafi l. a detailed interview was conducted to identify the reasons for this switch over. th e salient factors were: ) unsatisfactory clinical response to on-demand dose ( %), ) adverse eff ects with on-demand dose ( %), ) concomitant improvement in luts ( %), ) economic factors-daily dose therapy is cheaper than on-demand ( %), ) freedom of spontaneous sexual activity with daily dose ( %), ) patient perception of daily dose as a long-term cure for ed ( %), ) combination of above factors ( %). overall % of patients planned to continue daily dose tadalafi l mgm. conclusion: daily dose tadalafi l mgm appears to be preferred by patients over on-demand mgm tadalafi l for ed treatment. and plateaued aft er two years. in % of men, iief-ef improved by category, in % by and in % by categories. five men remained within the same category despite slight improvements in score, man's score dropped from to changing from "no ed" to "mild ed". fift y six percent men achieved normal erectile function. conclusions: improvements in erectile function were clinically meaningful and signifi cant during the fi rst to years of t therapy and sustained during the full treatment duration. th ey were independent of obesity class. it may be necessary to continue t therapy for to years before an optimal response is achieved. hypogonadal conclusion: all changes were clinically meaningful and sustained for the full observation period, despite the fact that patients' age increased by years. t therapy seems to be highly eff ective in hypogonadal men with t dm, improving both erectile function and glycemic control. needle-free delivery of intracavernosal injections: proof of concept introduction and objective: intracavernosal injection is a well-established second line therapy for the treatment of erectile dysfunction (ed) and has shown very high success rates. despite this, intracavernosal injection is not a therapy suited to all patients for a number of reasons including needle phobia (trypanophobia), pain, and anxiety with self-needling. th e development of needle-free injectable devices has been heralded as a promising advance in the administration of certain vaccines and parenteral medications. initial research into the use of these devices in the delivery of intracavernosal injections however showed inferiority to needle-tipped injectors in terms of efficacy and pain scores. th e use of needle-free injection devices is not currently recognised for the administration of intracavernosal injections. it was the aim of our study to investigate the ability of contemporary needle-free injection devices to successfully deliver intracavernosal injections. two diff erent needle-free injection devices were used to inject . mls of methylene-blue solution into the corporal bodies of a number of australian brangus bullock penises; the bioject®ze-tajet™(spring-loaded fi ring system) and biojector® (pressurized co fi ring system) were used. both products are produced by bioject medical technologies inc., california, usa. all the available syringe depths were used for each device, and compared with the injection of the same volume of methylene-blue with an insulin syringe as a control. following injection, a cross-section of the penis was taken, and the depth of penetration observed macroscopically. results: despite the comparatively thicker and denser tunica albuginia of the bullock penis, the pressurized co device successfully delivered the solution into the corporal body, through the tunica. none of the syringes from the spring-loaded device penetrated the tunica. we have shown that contemporary needle-free injectable devices can in theory be used to administer intracavernosal injections successfully. th e bullock penis model may not be the ideal model for the human penis but we are currently in the process of performing human cadaveric experiments with these devices. needle-free injection devices may be very useful in the administration of intracavernosal injections in the future and extend the use of these therapies to a wider population of patients. penile linear shock wave therapy for poor responders to prior erectile dysfunction therapy ( ), ici with alprostadil ( ), vcd ( ) and muse ( ) . all these patients opted to discontinue these regimen due to unsatisfactory erectile improvement or side eff ects. th ese patients were treated with lswt by renova device with four weekly outpatient sessions without any analgesia or preparation. lswt was applied to four anatomical sites (right, left crura, and right, left corpus cavernosum) at shocks per minute, total shocks per session. patients were followed up at and months aft er the last session. results: at one month follow up statistically significant improvement in iief was recorded in patients ( %) from mean score of . at baseline to . .th e improvement was maintained at months .no side eff ect was noted. overall % patients expressed satisfaction with lswt irrespective of the clinical outcome. conclusion: lswt appears to be a safe and eff ective noninvasive, offi ce based therapy in the management of diffi cult to treat poor responders to prior treatment of ed. introduction and objective: hypogonadism and sexual dysfunction are common clinical presentation in male liver transplant candidate. th e aim of the study was to evaluate the eff ects of living donor liver transplantation (ldlt) on testosterone, sex hormone-binding globulin (shbg), free androgen index (fai) and erectile function in ldlt recipient. introduction and objective: penile size has been a source of major concern and anxiety to the male population since several years. diff erent methods for increasing penile size have been described in the literature, such as, pubopelvic liposuction, lipectomy, suspensory ligament dissection, z-plasty, v-yplasty and injections. combining some of these techniques may be more eff ective to improve the length of the penis. in this study, patients were underwent the combination of z-plasty and suprapubic lipectomy for increasing penile size. between and , patients who complained decreased penile size were underwent surgery. z plasty and suprapubic lipectomy were performed to each patient. informed consent was provided by all participants. th e outcomes were assessed based on the preoperative and postoperative penile length in the fl accid state at maximal stretch and patient-partner satisfaction. th e paired student t test was used for statistical analysis. results: median age of the patients was . ( - ) years. th e etiologies were congenital micropenis in ( %), concealed penis in ( %), previous penile surgery in ( %) and epispadias in ( %) patient. mean preoperative and postoperative penile lengths were . cm ( - cm) and . cm ( . - cm) respectively. th e mean increase in stretched penile length was . ± . cm (minimum . cm, maximum cm) (p< . ). th e patient and partner satisfaction rates were . % ( / ) and . % ( / ) respectively. only one postoperative complication was detected. th is was a wound infection at suprapubic incision site. conclusions: based on our results, the combining of the penoscrotal z-plasty and suprapubic lipectomy is a safety, eff ective and satisfactory procedure for lengthening of the penis in selected cases. corporal lengthening with infl atable penile implants : - ( ) ). recently, we have developed a new technique that combines key aspects of these approaches to create a minimally invasive, no-touch ("mint") technique for penile prosthesis insertion. we theorized that the mint technique would take advantage of the benefi ts that each of these established approaches off ered and therefore our aims were to assess feasibility, safety, post-operative hematoma and infection rate and percentage of patients cycling the prosthesis by weeks. th e principles of the mint technique involve a small infrapubic incision approach combined with a no-touch technique facilitated by using standard surgical drapes ( x clear non-adhesive drape and x ioban® drape) and an alexis® wound retractor. we present results for our fi rst consecutive patients undergoing primary prosthesis implantation from may -july with at least months follow-up. patients having revision surgery, or with complex surgery necessitating > incision were excluded. data was collected using a prospective database. results: average age (±sd) was . (± . ) years. median follow-up was . months. patients had one or more of the following etiologies for erectile dysfunction: vascular disease (n= ), post-radical prostatectomy (n= ), diabetes (n= ), peyronies disease (n= ), venous leak (n= ) and priapism fi brosis (n= ). seventy percent had used intracavernosal injections. implant used: coloplast titan (n= ), american medical systems (lgx; n = ), (cx; n = ). th e average (±sd) cylinder and rear tip extender length was . (± . ) and . (± . ) cms respectively. all operations were completed successfully and there were no peri-operative complications necessitating intervention or re-operation. th ere were post-operative hematomas (treated conservatively). sixty-fi ve percent could cycle prosthesis by weeks. th ere were no post-operative infections. conclusion: th e mint technique for penile implant surgery is a safe and feasible procedure with a zero infection rate in our fi rst patients. effi cacy and safety of botulinum th e initial number of patients to be recruited were twenty-six, but actual patient enrolment was eleven (six control and fi ve botulinum toxin a). all of the patients had a history of vulvar pain for more than six months despite proper medical treatments. patients were randomly assigned to two groups: control -saline injection, toxin -botulinum toxin a (meditoxin® injection, meditox, inc., korea). in both groups, areas of pain were mapped on the vestibule and injections were performed at fi ve sites to cover the entire painful area. th e dosage of each injection was - ml with a maximum cumulative total of ml. at baseline, two, four, and eight weeks aft er the injection, visual analogue scale (vas) and sf- questionnaires were scored. data was analyzed and p value was considered to be signifi cant at < . according to the mann-whitney test. results: th e mean age of patients was . ( - ) years old in the control group and . ( - ) years old in the toxin group. aft er breaking of the blinding, two of the toxin group had iu of botulinum injection, and the others had iu injections. two patients from the control group dropped out because of aggravated pain. th eir vas were and respectively at their drop-out point (baseline and , respectively). at week eight, vas was signifi cantly decreased in toxin group when compared with baseline (table ) . th ere were no drug related adverse reactions. introduction and objective: congenital anomalies of uro-genital system have increased globally as a consequence of higher maternal age at pregnancy and developments in assisted reproductive techniques in the last few decades. aim of the study was to determine the incidence of apparent congenital uro-genital anomalies in north indian newborns and factors associated with them. a prospective study was conducted to collect data of all newborns delivered at our institute between september and august . th e predetermined format included newborn's birth weight and gestational age, maternal age, parity and infertility treatment if any. newborns weighing less than gm or born before weeks of gestation were excluded from the study. results: th ere were , deliveries with , males and females. a total of apparent uro-genital congenital anomalies were recorded with an incidence of . per newborns. th e most common anomaly was cryptorchidism found in newborns, amongst others hypospadias was noted in , ambiguous genitalia in , congenital hernia/hydrocele in , exstrophy-epispadias complex in and prune belly syndrome in newborn. newborns weighing less than , grams had a higher proportion of anomalies ( . %) in comparison to those weighing over , grams having . % (p = . ). maternal age (> yrs), parity (> ) and infertility treatment were recorded in . %, . % and . % respectively and all were independently associated with increased risk of uro-genital anomalies (p= . ). conclusions: incidence of apparent congenital uro-genital anomalies was . %. infertility treatment, parity (> ) and maternal age (> years) were independently associated with increased risk of congenital uro-genital anomalies. comparison conclusions: double-breasting spongioplasty is very good method to decrease complications in hypospadias repair, so it is recommended an as interposing tissue in tipu. advantages of the double breasting spongioplasty are that avoiding of suture line and adding two layers of spongiosum over neourethra decreases the chances of urethral fi stula and gives cylindrical shape to neo-urethra. use stretched penile length (spl) is the standard measurement used in reconstructive penile surgery (rps), but is associated with high inter-rater variability, and is seldom reported. furthermore, ruler-based measurements require that all measurements be made intraoperatively; post-hoc measurements are diffi cult to impossible. we used a novel smartphone application to assess the correlation of post-op digital-photo based length measurements to intra-operative ruler measurements. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: intra-operative spl was measured in a consecutive series of pediatric patients undergoing rps who agreed to participate in this study. spl was measured intra-operatively (spl-io), and a picture was taken, with the ruler and from a true lateral view, as proof. a second digital picture was taken at the same time, with a reference object (obj) (object whose dimensions are known and constant). post-op, spl was later measured using the medmeasure! app for iphone and ios android, using the picture with obj, by two diff erent surgeons blinded to intra-op measurements. th e three diff erent measurements (intra-op spl (spl-io), and post-op using the app (spl-s -spl-s ) were then compared to assess overall correlation and correlation to ruler measurements using spss . statistical soft ware package. results: twenty consecutive patients underwent surgery for hypospadias (n= ), buried penis (n= ), epispadias (n= ) and circumcision accident (n= ). median age at surgery was months [ - ]. median penile spl-io was . cm [ . - . ]. when ruler-based measurements (spl-io) and app-photo based measurements were treated as independent measurements (students t test), there was no statistical diff erence between any of the three groups (p . - . ). even with spl-io measurements were treated as the gold standard, by bland-altman limits of agreement analysis, the correlation factor of spl-ip to spl-s & spl-s was > %. conclusions: when compared with intraoperative measurements, digital measurements using medmeasure! are reliable and precise, provided that the picture is taken from a true anterior-posterior or lateral view. because measurements are made based on captured images, a limitless number of length measurements (within the same plane as the reference object) can be made post-hoc. use of digital photography and this smartphone app has the potential to aid in surgical planning, improve documentation, and, facilitate clinical research. aseel's technique for distal penile and coronal hypospadius repair (simple, easy with less complications) introduction and objective: th is technique is modification of the old operation of arab that makes it very simple, easy to learn and even in cases of failure there will be no problem of redoing it or other operation because of the minimal tissue dissection. th is technique was applied in patients. first a transverse ventral incision is done parallel to the circumcision incision and cm proximal to the urethral meatus, figure ( ) . th en proximal and distal skin dissection is done, figure ( ). a longitudinal incision across the urethra plate extending through the meatus is done, figure ( ) and closed transversely that leads to urethral advancement, figure ( ). th en aided by skin hooks the distal skin edge is pulled downwards to create a roof for the advanced urethra, figure ( ) followed by closure of the skin incision, no catheter or stent is left , figure ( ). th is is a -minute operation and the patient is discharged as a day case. results: th irty-eight patients passed without complications and had loss of the skin stitches either partial in cases or complete in cases that were repaired by reapplication of the stitches, no meatal stenosis or fi stula were reported. th is is a very easy technique that can be applied as an outpatient or day case, and done in minutes, with no catheter or stent per urethra left or complications such as urethral meatus stenosis or fi stula formation. th e remained boys ( ) underwent transinguinal laparoscopy during ipsilateral herniorrhaphy. all data were collected prospectively. results: th e incidence of cppv confi rmed by transinguinal laparoscopy was . % ( / ). th e width of hernia sac and mother's age at birth were signifi cant risk factors in the univariate analysis. however, in the multivariate analysis the width of hernia (> cm) sac was only an independent risk factor for cppv (odds ratio . ; p= . ). th e laterality, type of hernia, age, preterm, low birth weight, twin, blood type, father's and mother's age at birth, and the type of delivery were insignifi cant. in this study the width of hernia sac was the independent risk factor for cppv. th is result suggests that the transinguinal laparoscopic examination is benefi cial for the detection of cppv in boys with this risk factor. however, it should be considered in the clinical practice that the one-third of boys with cppv has a narrowed width of hernia sac (< cm). low introduction and objective: traditionally bladder exstrophy complex is managed by staged repair, however now there is trend towards single stage repair. to achieve a satisfactory level of continence, secure abdominal wall closure and preservation of renal functions in patients with bladder exstrophy remains an elusive goal. objective of the study was to assess continence and functional outcome of single stage repair pediatric and adults. materials and methods: th irteen patients, boys and girls with classic bladder exstrophy were treated from to . aft er proper evaluation patients under went complete primary repair of exstrophy repair (ureteric re-implantation, bladder closure with or without cystoplasty, iliac osteotomy, neck reconstruction and epispadias repair). bladder and urethral plate was mobilized as single unit and bladder closure was done to create an adequate capacity bladder. epispadias repair was done by separating the two corpora; tubularization of urethral plate and ventral transposition of neo-urethra to create an orthotopic neomeatus. th en bilateral anterior iliac osteotomies were performed and external fi xators were applied to approximate the pubic symphysis which helps in sphincteroplasty. bladder neck was reconstructed using young dees technique and placed deep within the pelvis; sphincteroplasty was done followed by abdominal wall closure. voiding cysto-urethrography was obtained at months and at one year. continence was defi ned as dry intervals of hours or more. patients were followed-up at , , , months and annually. results: age of patients varied from days to years (mean . years). pre-operative symphyseal gap varied between - cm and post operatively the average diastasis was . cm with the range of cm to cm. in a follow-up period was months to years, patients had good results ( girl and boys) minor supra-pubic leak was present in patients which was managed conservatively, all being able to hold urine for - hours with no leaking at night. colo-cystoplasty was needed in cases with small bladder plate. overall continence rate was . % in single stage. two male incontinent patients were continent aft er second surgery. conclusions: single stage complete bladder exstrophy repair is safe and viable option for both pediatric and adult cases. augmentation enterocystoplasty is required in small bladder capacity cases. anterior iliac osteotomy with approximation of pubic symphysis improves continence and allows tension free closure of abdominal wall and sphincter. long wilms tumor (wt) represents approximately six to seven percent of all pediatric cancers and accounts for more than percent of all tumors of the kidney in the pediatric age group. recently some centers have explored the role of nephron sparing procedures in children with unilateral wilms tumors because of the concern about late occurrence of renal dysfunction aft er unilateral nephrectomy. we assessed the long-term renal functional outcome aft er parenchymal-sparing procedure for non-syndromic unilateral wilms tumor at our center. we retrospectively reviewed the records of all children with unilateral wilms tumor who had undergone nephron sparing surgery at our center. patient's long-term renal function, tumor recurrence, and survival, were determined from a review of each patient's medical record. results: a total of eight patients underwent partial nephrectomy (pn) and the remaining three with polar tumors underwent hemi-nephrectomy (hn) following chemotherapy. smaller tumor volumes were associated with not only preservation of renal function but also increase in egfr during the follow-up period. th e median preoperative egfr was ± . and median egfr at the last follow-up was . ± . . in properly selected children with non-syndromic unilateral wilms tumor, nephron sparing surgery provides excellent renal function preservation. introduction introduction and objective: hyperbaric oxygen (hbo) therapy, which increases the amount of oxygen dissolved in the blood and that carried to tissues, is used in the treatment of several disorders. hbo therapy may be a useful adjunctive treatment in the management of some of challenging conditions encountered in pediatric urology practice. in this paper, we report our experience on the use of hbo therapy in children with urologic problems. we reviewed our department's records to identify pediatric patients who received hbo therapy between and . all patients were evaluated at the department of underwater and hyperbaric medicine and informed consent was obtained from the patient or his parents. total number of hbo sessions was determined based on patient's clinical response to hbo therapy. results: eleven patients received hbo therapy during the study period. all of them were male. th e mean age was . ± . ( - years) . indications of hbo therapy were necrosis aft er hypospadias and epispadias repair, penile glans necrosis, circumcision caused penile skin necrosis, sickle cell crisis induced priapism, and testicular torsion. th e average number of hbo sessions was . ± . ( - ). nine patients ( %) healed aft er hbo therapy, but ( %) patients did not (table ) . . th e essential parameters of kegel exercise are duration of contraction and active relaxation, and, frequency of exercises. to date, exercise duration times could only be captured during in-clinic biofeedback. we hypothesized that a smartphone-based app that provides users biofeedback -and reports mean duration of contraction and relaxation, could help return to continence aft er rp. we designed/made a working prototype of such an app, and validated it. our novel app (ios) was programmed to allow users to record the duration of kegel active pfm contraction and relaxation. it also allows users to record urinary frequency, urgency, voiding, and leakage events, and number of pads used-on a daily basis. it contains a -q visual analog scale questionnaire that queries satisfaction (urinary, sexual, erectile), pain control, depression, sleep quality, and quality of life. data from the app can be "pushed" automatically by the user to a queryable custom database on a hipaa-secure server (ucsf). we provided the app to non-medical colleagues ( women/ men age - ) for evaluation. all completed mock kegel exercises using the app to measure contraction/relaxation duration, which were timed using a stopwatch. measured times were compared to duration times recorded in our database for each user. a -point likert scale was used to query the following items: ) user reported ease of use; ) privacy related anxiety related to use of such an app to submit study data wirelessly; and ) perceived usefulness of the app to improve kegel performance. results: th e pfm contraction and relaxation times recorded by the app within the wireless database disagreed with stop-watch measured duration times by mean +/-< second for all subjects. mean likert scores: . "overall ease of use" score = . (sd . ), "privacy related anxiety" score = . (sd . ), and "usefulness"= . (sd . ). conclusions: our novel smartphone app appears to allow users to accurately record key kegel exercise parameters: duration and progress. th e platform also allows collection of key patient data during daily life. a randomized controlled clinical study is warranted to further assess clinical utility, and, possible means to further enhance utility and research. safety and effi cacy of reduced dose of botulinum toxin-a for patients with detrusor overactivity place j, vyas l, watcyn-jones t, lupton b, miah s, darrad j, kumar v introduction and objective: th is prospective study was carried out to look at the response of a lower dose of botulinum toxin-a for treatment of symptoms of oab, its tolerability and side-eff ects. materials and methods: following due counselling and consenting, all newly diagnosed patients with confi rmed detrusor overactivity on uds (n= , with a mean age of . years (range= - )) were given iu of trigone-sparing, intra-detrusor botulinum toxin-a. of the total of patients, ( . %) were males and ( . %) were females. of this cohort, . % stopped anticholinergic medications because of lack of benefi t. th e rest ( . %) could not tolerate the side eff ects. th e procedure was performed in outpatient department using a fl exible cystoscope under local anaesthetic. th ese patients fi lled up a pre-treatment iciq-sf for oab as well as ui and follow-up scores at week , and . th e per-procedural pain score and follow-up urinary residual volumes were recorded. results: two ( . %) patients did not respond to the treatment at all. in the responders, average scores from the iciq-sf questionnaire fell from the pre-treatment level of . ( - ) to . ( - ) at week , . ( - ) at week and . ( - ) at week (p< . ). th e urgency incontinence scores fell from an average pre-treatment level of . ( - ) to . ( - ) at week follow-up. th e average daytime urinary frequency scores fell from . to . and nocturia scores fell from . to . . five patients went into urinary retention following intra-detrusor botulinum toxin-a injections. in the rest of the cohort, post void residuals remained largely unchanged with pre-procedure fi gure of . mls ( - ) to . mls ( - ) (p=ns). average pain score was . ( - ) on a scale of to . no symptomatic uti was found in post procedural patients. conclusions: th ese results albeit with a small number of cases, have suggested a signifi cant clinical response in over % patients with proven detrusor overactivity with a reduced dose of intra-detrusor botulinum toxin-a injections, thereby maintaining the clinical eff ectiveness of the drug and at the same time reducing the cost of delivery with possibly reduced incidence of urinary retention. prior to the initiation of intravesical onabotulinumtoxina treatment, all patients had an assessment of mid-stream urine for culture and sensitivity, renal tract ultrasound scan, subjective and objective assessments of symptoms (including iciq-ui and iciq-oab questionnaires) and conventional urodynamic study. all patients had proven overactive bladder. onabotulinumtoxina effi cacy and durability was assessed by subjective and objective assessments of symptoms. results: duration of effi cacy of onabotulinumtoxi-na injections is well maintained in the idoa group in comparison with noab group. th ese trends are shown in figure . four injections out of administered in total to the idoa group were unsuccessful ( . %) and brought no relief of symptoms to the patient. th ere were no unsuccessful treatments in the ndoa group ( / total injections administered). results: from the general practitioner's records, none of the non-traceable patients were on botulinum toxin-a treatment elsewhere. of the total number of traceable patients (n= ), ( %) stayed on mirabegron alone. of these % were satisfi ed ( / ). as a whole . % ( / ) were satisfi ed and continued with mirabegron only. one patient moved to combined mirabegron with an anticholinergic. of the patients on mirabegron iciq-sf scores fell from . ( - ) to . ( - ) at months. eighteen of ( %) patients progressed requiring botulinum toxin a treatment. side-eff ects included-palpitations ( ), vomiting ( ), rashes ( ), lethargy ( ) and yellow urine ( ) . th is study showed that % of patient with refractory oab symptoms awaiting fi rst or subsequent treatment with intra-detrusor botulinum toxin a injections will respond to mirabegron and % of these responders ( . % of total) are able to come off botulinum toxin a at months, reducing the burden of the waiting list; with a cost reduction mirabegron= £ vs cost of botulinum toxin a= £ /year/patient. th is is a small study but provides a medium-term option for patients on long waiting list for botulinum toxin a thereby helping to limit use of botulinum toxin-a for patients with detrusor overactivity. introduction and objective: patients that fail to achieve symptom improvements with sacral neuromodulation (snm) may benefi t from increased aff erent stimulation via tined lead placement at the pudendal nerve. we evaluated −year outcomes of chronic pudendal neuromodulation (cpn) in patients that had failed sacral neuromodulation (snm). adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. medical records were reviewed. outcomes were measured at , , and months with interstitial cystitis symptom/problem indices (icsi−pi), overactive bladder questionnaire (oabq) symptom severity (ss) and quality of life (qol), voiding diaries, and global response assessments (gra analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence introduction and objective: voiding dysfunction is common complication of midurethral sling surgery (mus) for stress urinary incontinence. however, the defi nition of post-mus voiding dysfunction is inconsistent in the literature. subjective feeling of slow stream, signifi cant postvoid residual (pvr), additional procedure for bladder emptying, or objective fl ow rates can be a yardstick of voiding dysfunction. in this study we retrospectively investigated the risk factors for post transobturator tape procedure (tot) voiding dysfunction applying various defi nitions in one cohort. four hundred fi ft een patients were evaluated who underwent tot. preoperative urodynamic study were performed and urofl owmetry and international prostate symptom score questionnaire were investigated pre and post-operatively. several postoperatively parameters representing voiding dysfunction were adopted for analysis. acute urinary retention requiring catheterization (aur), subjective feeling of voiding diffi culty during follow-up (vd), and signifi cant postoperative pvr greater than ml or more than % of voided volume (pvr) were adopted for categorization of the defi nition of voiding dysfunction. results: sixteen patients ( . %) required catheterization, ( . %) experienced post-operative voiding diffi culty, ( . %) and ( . %) showed low fl ow rate and signifi cant pvr. in the aur and vd category, concomitant co-operation and general anesthesia were signifi cant parameters, especially anteroposterior repair of vagina. older and menopaused patients complained subjective voiding diffi culty. th e patients in vd category showed lower fl ow rates and larger pvrs. patients in pvr category had old age and low preoperative fl ow rates. th e patients with vd tend to be prescribed alpha blocker during postoperative follow-up period. th ere were no signifi cant urodynamic parameters attributing for various voiding dysfunction categories. with logistic regression analysis aur, vd and pvr category had concomitant co-operation and preoperative retention history as risk factors. conclusion: several factors including preoperative voiding symptoms and intraoperative parameters such as co-operation may aff ect postoperative voiding dysfunction. th e diversity in clinical presentation underscores the importance of a high clinical suspicion with an appropriate diagnostic evaluation. subjective and objective voiding dysfunction should be evaluated aft er midurethral sling operation. introduction and objective: some have hypothesized that patients with lower functional bladder capacity (fbc) experience less improvement in symptoms after staged neuromodulation procedures. th erefore, we evaluated the impact of baseline fbc on generator implant rate and symptom changes. adults enrolled in our prospective observational neuromodulation study were evaluated. functional bladder capacity (fbc) was defi ned as average volume per void on day voiding diary. data were collected from medical records, and validated interstitial cystitis symptom/problem indices (icsi−pi) and overactive bladder questionnaire (oabq) symptom severity and health related quality of life (hrqol) domains, and examined with descriptive statistics, wilcoxon rank sum tests, logistic regression, and spearman correlation coeffi cients. results: of patients (mean age . ± . years; % female), most had urinary urgency/frequency with or without urge incontinence ( %) and a sacral lead placed ( %); % had the lead placed at the pudendal nerve. mean fbc at baseline was . ± . ml. among the , ( %) had ≥ % improvement in overall symptoms aft er lead placement with subsequent generator implant. baseline fbc was similar between implanted/not implanted patients (p= . ), however implanted patients had a median . % increase in fbc aft er lead placement compared to explanted patients whose fbc decreased by median . % (p= . ). logistic regression identifi ed a strong relationship between percent change in fbc aft er lead placement and generator implant (p= . ) but there was no relationship between baseline fbc (ml) and subsequent generator implant. at months, a lower pre-implant fbc weakly predicted a greater improvement in oab-q hrqol from baseline (p= . ; r = - . ). fbc (ml) at baseline, or percent change in fbc aft er lead placement, had no relationship with achieving at least % improvement in icsi−pi or oab−q symptom severity scores at months. conclusions: lower baseline fbc should not be a contraindication to neuromodulation since there was no impact on outcomes. improved fbc aft er lead placement may have contributed to overall improvements in symptoms leading to generator implant. improvement in fbc was equal to or greater than that seen in medical treatment trials for oab. introduction and objective: to present our preliminary experience with the sars (sacral anterior root stimulator) in spinal cord-injury patients with hyperactive bladder at our center. th e sars is an implantable electronic device that allows patients with spinal cord injury to assume voluntary control of micturition, defecation and erectile function. it involves a s -s dorsal (sensitive) rhizotomy and placement of electrodes around those roots, which are connected to a subcutaneous receiver antenna. by transcutaneous radiofrequency stimulation of that antenna the patient can selectively use stimulation programs to activate the diff erent functions: program for micturition, program for defecation and program for erection. results: between january and november nine sars implants (eight men and one woman) were performed in patients with spinal cord injury-related overactive bladder refractory to standard conservative treatment. average age was years and mean follow-up was months (range - ). bladder function: eight of the nine patients exhibit an increase of the bladder capacity and use the device - times daily, voiding - cc with ≤ cc residual urine. one of these patients showed de-novo postoperative stress incontinence due to sphincter incompetence that was solved with placement of a suburethral sling. th e ninth case had a poor compliance and low capacity bladder; despite sars, he failed to increase capacity and persisted incontinent so aft er months he underwent a continent urinary reservoir. voiding objectives were therefore achieved in / patients ( % success). defecation: all patients use the device once a day. erectile function: of the eight male patients, seven achieved erection with sars. however, this erection was not always reliable for intercourse; patients associate sildenafi l and eventually requested a penile prosthesis implantation. complications: th ere were no postoperative complications or failure of the internal components. one patient showed a transient s neurapraxia, which resolved spontaneously aft er months. conclusion: in selected spinal cord injury patients, sars is an excellent option for urinary and defecatory control, being also useful for erectile function in some of them. how to determine the complication rate of urolastic (vinyl dimethyl polydimethylsiloxane, pdms), a bulking agent for female stress urinary incontinence. twenty-eight females with stress urinary incontinence were treated with pdms. th e group mainly consisted of secondary patients (n= ), with extensive comorbidity. six patients had one previous surgical procedure for sui; nine underwent two procedures and ten received three or more interventions. an amount of . - . ml of pdms was injected at - positions paraurethrally at the midurethra. procedures were performed on the outpatient department, with local anaesthesia. th e clavien dindo score was determined aft er months, to assess the severity of the complications encountered. results: aft er six months, % ( / ) of the patients reported a % improvement, % ( / ) a - % improvement and % ( / ) a - % improvement, % ( / ) reported % improvement and % ( / ) was % improved. six patients ( %) had no improvement aft er six months, four of which had also not shown initial improvement. in one patient the implants were removed during surgery, so no follow-up was available. of twenty-eight patients treated, % ( / ) had no complications. in % ( / ) complications were seen, which were classifi ed following the clavien dindo-classifi cation. a score of i was appointed to % ( / ) of the patients. reasons were: implant-exposure, minor pain, anti-emetics use or de novo retention. th ree patients had a score of ii, because of more severe complaints of pain or urge. th ey were treated pharmacologically. in % ( / ) one or more implants were removed, mostly due to exposure, erosion or pain. removal under local anaesthesia was performed in % ( / ) of the patients and this resulted in a iiia-score. th ree patients ( %) had a iiib-score, which meant the implant(s) were removed under general anaesthesia. in the fi rst twenty-eight diffi cult to treat patients receiving pdms, in ten cases a clavien dindo grade ii-iiib is scored, mainly because of surgical removal of implants. in spite of the seemingly high complication rate, this remains a useful therapeutical option for female stress urinary incontinence. magnetic stimulation for stress urinary incontinence: a randomized, double-blind, sham-controlled trial introduction and objective: we conducted a multicenter, randomized, double-blind, sham-controlled trial to evaluate the effi cacy of magnetic stimulation (ms) for stress urinary incontinence (sui). a total of sui subjects were randomized : to active or sham ms for eight weeks (twice weekly). th e primary criterion for response was a reduction of points or more in the international consultation on incontinence questionnaire for urinary incontinence-short form (iciq-ui sf). th e secondary outcomes included objective (leakage of less than gram on -hour pad test) and subjective cure (a 'never' response to 'how oft en do you leak urine?), incontinence diary, pelvic fl oor muscle strength, urofl owmetry, patient global impression of improvement (pgi-i) and international consultation on incontinence questionnaire-lower urinary tract symptoms quality of life (iciq-lutsqol). results: using the primary criterion, ( . %) of subjects were treatment responders in the active group compared to ( . %) of subjects in the sham group (relative risk (rr) . , % ci . - . , p< . ). based on objective cure, ( . %) subjects in the active group were dry versus ( . %) subjects in the sham group (rr . , % ci . - . , p< . ). nineteen ( . %) in the active group and ( %) subjects in the sham group perceived themselves as dry (rr . , % ci . - . , p< . ). th e active group had greater reductions (p< . ) in incontinence frequency than the sham group. changes in pelvic fl oor muscle strength and urofl owmetry parameters were not statistically signifi cant between groups (p> . ). th irty-nine ( %) subjects in the active group reported signifi cant benefi ts (much/very much better) for pgi-i rating compared to ( . %) subjects in the sham group (p< . ). all item scores in iciq-lutsqol were not statistically diff erent (p> . ) except 'eff ect on friends' , 'smell' , feeling of embarrassment' and 'overall impact' in the active group. of all evaluable subjects, ( . %) of subjects in the active group and ( . %) of subjects in the sham group experienced adverse events (p= . ). conclusions: modifi ed tvt abbrevo is a simple, safe and eff ective procedure with comparable short-midterm cure rates to standard tvt abbrevo. th e modifi cations of avoiding the tunnelling device and groin exit helped to minimize the groin pain and analgesic requirements. evaluation of standard practice for artifi cial urinary sphincter implantation auckland dhb, auckland, new zealand; ucd medical center, sacramento, usa introduction and objective: th e artifi cial urinary sphincter (aus) has been available since and over this time it has established itself as the gold standard in management of post prostatectomy incontinence. th e successes, failures and diffi culties are well documented, however little is published regarding the standard implantation practice of the aus. our objective was to review the standard practice for implantation of the aus within a group of high volume implanters. aft er obtaining institutional review board ethical approval a web-based questionnaire was designed using survey monkey soft ware. an email was sent to the current members of the society of genitourinary reconstructive surgeons (gurs) explaining the aims of the confi dential questionnaire with a web link to the aforementioned questionnaire. all results were collected via survey monkey and were then analyzed. results: one hundred and twenty gurs members were contacted by email, members replied. th is group averaged aus placements a year (range to ). pre-operative assessment utilized routinely included pad weights in . %, pad numbers in . % and urodynamic studies in % of participants. additionally % of participants surveyed would routinely perform a cystoscopy in the pre-operative assessment ninety four percent of those surveyed used greater than one pre-operative antibiotic; most commonly gentamicin with either vancomycin or cefazolin. th e antibiotic most commonly utilized alone was levofl oxacin. post-operatively % continue antibiotics anywhere between hours and month, with % continuing intravenous antibiotics for a minimum of days. intra-operatively % have aus componentry prepared on a separate set up stand. th e single cuff aus, size . and . cm cuff were the most commonly placed cuff s, with the - cm reservoirs. radio-opaque contrast is used by % of participants in the aus reservoir. only % of participants would recommend a medical alert bracelet in the post-operative period, and % encourage pump traction. conclusion: despite a uniform technique recommended for the implantation of the aus by american medical systems in order to improve success and decrease complications, there is great heterogeneity in pre-operative assessment, surgical placement and post-operative management of the aus in a cohort of high volume implanters. patients presenting to a multi-disciplinary stone clinic were administered a survey. th ey were asked to elect a treatment modality from shock wave lithotripsy (swl), ureteroscopy (urs) or percutaneous nephrolithotomy (pcnl) for a hypothetical mm kidney stone. th e success rates ( % swl, % urs and % pcnl), morbidity and the risks associated with each treatment options were explained. patients were also to elect whether personal or doctors' decision of treatment is most preferred and the most important variable in deciding a choice of treatment modality. results: of the respondents with mean age . ± . , female/male ratio was : ( figure ). majority of the subjects ( %) elected urs as their treatment choice (table ) . previous experience with urs (p= . ) and pcnl (p= . ) impacted the choice of urs. th e respondents were equally distributed in their primary concern being success rate ( %) versus risks ( %) associated with the procedure of choice (p= . ). age and gender has no infl uence on treatment choice (p= . and p= . ) and on whether the primary concern is success or risk (p= . and p= . respectively). majority ( %) of the surveyed population would prefer the physician recommend the appropriate treatment. conclusion: th ough patients prefer the physician to recommend the appropriate treatment for a medium-sized renal stone, it is important for the physician to consider the patient's priorities of minimizing risk versus maximizing success. as such, majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. solo introduction and objective: sonography has been brought in percutaneous nephrolithotripsy (pcnl) as an adjunct to x-ray to restrict radiation exposure. th is study was designed to respond this question that "is sonography proper enough to supersede x-ray in pcnl under spinal anesthesia?" moreover, we investigated possible predictors of success. tract infection were excluded from study. th e intraand post-operative surgical outcomes were evaluated. results: th e mean age of the patients was . ± . years. mean stone size was . ± . cm. mean access and operative time were . ± . and ± . minutes respectively. superior calyx was selected for access in % of patients. th e patients were categorized in following groups; history of more than one section previously open stone surgery ( %), horseshoe kidney ( %), major lumbosacral deformity ( %), failed standard pcnl ( %), children under years old ( %), pregnancy ( %). th e primary complete stone free rate was %, and aft er ancillary procedures (urs, swl), raised to %. th e mean hemoglobin drop was . ± . gr/dl. transfusion needs in patients. signifi cant prolonged or delay hemorrhage was not shown in any cases. pneumothorax was detected in one patient that managed with chest tube insertion. visceral or solid abdominal organ injury was not occurred. conclusion: with some attention, the outcomes of ultrasonography-guided pcnl for challenging renal stones are comparable with standard fl uoroscopic approach, and in some situation, fl ank position contain benefi ts rather than standard prone position. study of ten cases of p.c.n.l in "previously operated kidney stone with incisional hernia" conclusions: p.c.n.l in incision hernia patient is a safe procedure with excellent results. c.t. urogram is necessary tool for puncture. st puncture in virgin fi eld (out of incisional hernia site) and avoiding colonic gas shadow on fl uoroscopy is key point. bowel injury is the concern -which should be taken care during puncture. daycare pcnl: now a reality! introduction and objective: pcnl as a therapy for renal stones is an established modality. th e use of holmium laser has led to miniaturisation of instruments and sheaths and has thus made the procedure less morbid. a stage has come for the patient to now leave hospital on the same day of the procedure. materials and methods: all cases were done under spinal anaesthesia and prone position. aft er placing a retrograde ureteric catheter, pcs was accessed through the appropriate calyx, and a french sheath with suction capability was used. holmium laser was the energy used. aft er fragmentation, clearance was achieved by a combination of suction and retrograde wash and confi rmed radiologically and visually. clots were fl ushed out through the sheath which was then removed having retained the guide wire. finger pressure on the puncture site achieved haemostasis. th e guide wire and the retrograde catheter were fi nally removed. no urethral catheter was kept. a total tubeless procedure in the real sense. all patients were counselled about haematuria and pain. results: from january to march , a total of cases are included comprising renal and upper ureteric stones. stone size ranged from . to . cms. age ranged from to yrs. th e m/f ratio was : . operative time ranged from to mins. th ere was no signifi cant blood loss. all patients received dose of a parenteral analgesic hrs post procedure, were ambulant hours postopt and were allowed oral liquids. patient had leak at puncture site lasting for hours .all had haematuria which cleared completely within to hours. all were off ered discharge on the same day without any major event. one patient had clot retention on the th po day requiring clot evacuation. conclusion: pcnl as a day care procedure has been achieved by the above described method. patient acceptance is fair though most showed apprehension of going home the same day aft er a major procedure. whether it can be accepted universally remains to be seen. initial experience in ultraminiperc we have reviewed our initial experience of ultra-miniperc-ump in patients. between june and march , total patients underwent ultra-miniperc. puncture and dilatation were done under fl uoroscopy in prone position. we used and fr ump amplatz. stones were fragmented by holmium laser and removed by whirlpool eff ect. post-operative stone-free status was confi rmed by ultrasonography and x-ray aft er week. results: mean patient age was years ( to years) and male to female ratio was . : . in % the procedure was bilateral simultaneous and in % in solitary kidney. stone locations were lower calyx ( %); upper calyx ( %), middle calyx ( %), renal pelvis ( %), upper ureter ( %) and rest were at multiple sites. calyx punctures were lower ( %), upper ( %), middle ( %) and multiple in rest. eight punctures were supracostal. mean operative time from puncture to amplatz removal was minutes (range to minutes). signifi cant bleeding (hb drop more than . gm/dl) was in %. all were managed conservatively without transfusion. dj stents were kept in patients. nephrostomy-tube was not kept in any patient. eleven percent of patients had minor complications like pleural eff usion ( %), uti-fever ( %), and mild hematuria ( %). all were managed conservatively. one patient required conversion to miniperc- fr track due to intraoperative poor vision. mean hospital stay was days ( - days). th ree patients required readmission for fever or clot colic. stone-free rate was %. eight percent had small fragments that were treated by oral hydrotherapy. two patients were treated by eswl. introduction and objective: a prospective randomized controlled study was executed to compare minipercutaneous nephrolithotomy (miniperc) and retrograde intrarenal surgery (rirs) in the management of renal stones larger than mm in a single session. between june and february , patients presenting with renal stones > mm were randomized to a miniperc or a rirs group in a ratio of : . randomization was performed by a biostatistician and opened to the surgeon at the time of the patient's admission on the day before surgery. patient and stone characteristics, perioperative outcomes, and complications were compared between the two groups. th e primary end point was "stonefree", which was defi ned as no residual stone or stones < mm on computed tomography within months postoperatively. results: th irty-fi ve patients (miniperc) and (rirs) were included in the fi nal analysis. th ere were no statistically signifi cant diff erences in stone size ( . ± . versus . ± . mm, p= . ) and stone number ( . ± . versus . ± . , p= . ) between the miniperc and rirs groups. laterality, mean hounsfi eld units, stone location, presence of staghorn stone, and stone composition were similar between the both groups (p> . ). miniperc and rirs had stone free rates of . % and . %, respectively (p= . ). operation time ( . ± . versus . ± . minutes, p= . ), hemoglobin drop ( . ± . versus . ± . g/dl, p= . ), and hospital stay ( . ± . versus . ± . days, p= . ) were similar between the two groups. pain visual analogue score at hour postoperatively ( . ± . versus . ± . , p= . ) and analgesic requirement ( . % versus . %, p= . ) were lower in the miniperc group. two patients in the miniperc group and in the rirs group had minor pelvic or ureter perforation. one patient in each of both groups had hypertension and urinary tract infection. miniperc and rirs are safe and feasible surgical options for managing renal stones larger than mm. rirs had a little higher stone free rates, but more immediate postoperative pain and higher analgesic requirement compared with miniperc. colonic perforation during percutaneous nephrolithotomy darabi mahboub m, aslzare m, shakiba b introduction and objective: percutaneous nephrolithotomy (pcnl) is the treatment of choice for large, extracorporeal lithotripsy failure stones and those in the inferior calyx. despite the development of new techniques and the increasing experience in recent decades, complications may still occur. colonic perforation is one of the most dangerous and rare complications of pcnl, which may lead to peritonitis and sepsis. we present our -year experience on the diagnosis and management of colonic perforation during pcnl. we retrospectively reviewed the data of pcnl procedures performed between may and august . preoperative and operative factors, such as age, sex, history of previous ipsilateral stone intervention, stone side, stone location, site of skin puncture and punctured calyx, were reviewed in patients with colonic injury. results: colonic perforation was found in patients ( males and females) and the mean age was . ± . years (range: to ). all injuries were retroperitoneal. th e left side was aff ected in patients and the right side was injured in cases. conservative management was the treatment planned for all patients. it included withdrawal of the nephrostomy tube outside the kidney to the colon as a percutaneous colostomy, insertion of a double-j ureteral stent, intravenous broad-spectrum antibiotics, bowel rest and total parenteral nutrition. under this conservative management, complete healing of the colon was achieved in all patients. early diagnosis and conservative management of colonic perforation can minimize patient morbidity and mortality and result in excellent healing of the fi stulous tract without any serious complications. colon materials and methods: during ten years, pnl procedures performed in our center. extraperitoneal colonic perforation complicated procedures. all cases were managed without any tube in the colon. we took a retroperitoneal drain through pnl tract and a double-j stent inserted in all cases. we reported the results of our cases that managed without colostomy tube. results: male to female ratio was / . th e diagnosis was established aft er nephrostomy tract dilation and nephroscope insertion before lithotripsy in two cases and in other cases, at the end of nephrolithotomy during amplatz sheath removal. conservative treatment was successful in all cases. mean hospital stay was / days. th ere wasn't any fever or other major complication. conclusions: it seems that management of retroperitoneal colonic perforation when diagnosed intraoperatively during tubeless pnl without colostomy tube is safe and eff ective. does intercostals nerve block and peritubal nerve block with bupivacaine reduce post-operative pain after percutaneous nephrolithomy? introduction and objective: to fi nd the most eff ective post-operative analgesia method aft er percutaneous nephrolithotomy (pcnl). in a prospective, -months duration study all patients undergoing pcnl (tubeless or with -f nephrostomy) were divided into groups. group (pcnl in fi rst- -months) had no intervention; group (pcnl between and months) received intercostal block (icb) with . % bupivacaine; group (pcnl in last -months of study) had peritubal track infi ltration (pti) with . % bupivacaine at end of procedure. visual analog pain scores and rescue analgesia requirements at , , and hours in the arms were compared. results: see table . conclusions: peritubular tract infi ltration with bupivacaine established its superiority over both intercostal block and standard pcnl for post-operative analgesia and rescue analgesic requirements. the post-operative fever was defi ned as body temperature above . within hospital stay. relationship between clinical factors and sirs or post-operation fever was assessed using logistic regression analysis. results: a total of male ( . %) and female ( . %) were enrolled in our study (table ) . forty-fi ve cases ( . %) developed sirs and fever was observed in cases ( . %). shock was observed in ( . %) cases. in univariate analysis, stone size (p = . ) and urine wbc (p = . ) were found to be the predictors of sirs. in multivariate logistic analysis, stone size (or= . , p= . ) and urine wbc (or= . , p= . ) were signifi cantly related to the development of sirs (table ). in univariate analysis, post-operative fever was found to be associated with the location of stones (p= . ), stone size (p= . ), urine wbc (p< . ) and albumin (p= . ). by multivariate logistic regression analysis, only stone size (or= . , p= . ), urine wbc (or= . , p= . ) and serum albumin (or= . , p= . ) were associated with post-operative fever (table ) . conclusion: patients with larger stone size and urinary tract infection before surgery might have higher risk of developing sirs and fever, while a normal serum albumin was found to be the protective factors of fever development. introduction and objective: perioperative hemorrhage owing to high vascularity in bph is the fearsome complication of turp that leads to clot retention, reoperation and oft en requiring blood transfusion. finasteride, a type α-reductase inhibitor, by interacting with vascular endothelial growth factor (vegf), reduces prostatic angiogenesis. microvessel density (mvd) is a histological measurement of angiogenesis and thus a marker of bleeding. we aim to determine the eff ect of two weeks preoperative fi nasteride therapy in reducing prostate vascularity in terms of mean microvessel density (mvd) and expression of vegf in prostate urothelium among patients of bph by comparing with controls. trial has been conducted in department of urology at shifa international hospital islamabad from jan to jan . total patients of benign prostatic hyperplasia (bph) planned for transurethral resection of prostate (turp) having prostate sized of more than grams on trans-abdominal ultrasonography were randomized into two groups each group having patients. th e finasteride group (group a) was prescribed oral mg of fi nasteride daily for weeks before surgery. th e control group (group b) didn't receive any drug. aft er weeks, turp was performed and prostate chips were sent for histopathological determination of mvd and expression of vegf. results: mean age . ± . years, ranging from minimum of years to years. th e mean prostate gland size was comparable in both groups ( ± . grams vs. . ± . grams). mean mvd in fi nasteride group was . ± . whereas in control group mean mvd was . ± . . when compared the mean mvd in both group, the mean mvd was signifi cantly low in fi nasteride group as compared to control group with a p= < . . similarly mean expression of vegf was % in fi nasteride group compared to % in control group. th is expression of vegf was also signifi cantly lower in fi nasteride group as compared to control group (p= . ). also mean mvd was clearly correlated with size of prostate gland and the correlation was found statistically signifi cant on pearson correlation test ( -tailed) with p= . . conclusion: finasteride reduces microvessel density and hence prostate vascularity with only week therapy and the mean mvd is clearly correlated with size of prostate. characteristics -alpha reductase inhibitor induced prostate volume reductions yun j , yang h , kim d , jeon y , lee c introduction and objective: benign prostatic hyperplasia develops in the transition zone of the prostate and α-reductase inhibitors ( -aris) reduce prostate volume. we investigated whether oral treatment with the -aris dutasteride and fi nasteride more significantly aff ected volume reduction in the transition zone or in the entire prostate. total prostate and transition zone volumes (tpv and tzv) were measured at baseline using a transrectal ultrasound (trus) and then at yr aft er the commencement of dutasteride ( . mg) or fi nasteride ( . mg). th e ratio of tpv to tzv was used to determine the transition zone index (tzi). volume reduction (%) was calculated as the ratio of volume reduction to baseline prostate volume. additionally, serum prostate specifi c antigen (psa) concentrations were measured at baseline and then at yr aft er the -ari were commenced. results: all of the patients (mean age, . yr ± . ; range, - yr) with clinical lower urinary tract symptoms suggestive of benign prostatic hyperplasia and who were -ari naïve were prescribed dutasteride ( . mg, . %, / ) or fi nasteride ( . mg, . %, / ) for more than yr ( . ± . mos). at baseline, the mean tpv, tzv, and tzi values were . ± . cm , . ± . cm , and . ± . , respectively. at yr aft er the commencement of the -ari, the mean tpv, tzv, and tzi were . ± . cm , . ± . cm , and . ± . , respectively. th e tzi value is not signifi cantly diff erent at yr compared with baseline (p > . ), while the tpv and tzv reductions are . ± . % and . ± . %, respectively; there is no signifi cant diff erence between the tpv and tzv volume reductions (p> . ). conclusion: th ese results show that prostate volume reduction induced by -aris occurs in the entire prostate universally, rather than in the transition zone specifi cally. russo g, favilla v, privitera s, castelli t, fragalà e, cimino s, morgia g introduction and objective: combination therapy with of -alpha reductase inhibitors ( -ari) and alpha-blockers (ab) is the gold standard for the treatment of moderate-severe secondary to benign prostatic hyperplasia (bph). several clinical trials have already analyzed the overall impact of the medical treatment of luts/bph on sexual sphere, but any one investigated the overall impact on erectile dysfunction (ed) and libido alterations (la). th e aim of this this systematic review and meta-analysis was to evaluate the impact of combination therapy on ed and la from randomized clinical trial (rct). we performed a search of the cochrane central register of controlled trials, pubmed, embase, cochrane database of systematic review, and web of science, until december . we conducted a meta-analysis to determine the impact of combination therapy ( ari + ab) in determining the onset of ed or la. a p value < . was used to denote the presence of heterogeneity. of the studies reviewed, only fi ve rct were included, involving participants. th e overall prevalence of erectile dysfunction was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. th e overall prevalence of altered libido was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. combination therapy ari + ab was found to be associated with increased risk of ed (or = . ; p < . ) and la (or = : ; p = . ) compared to monotherapy with ab. th e combination therapy was found to increase the risk of ed (or = . ; p = . ) compared to monotherapy with ari, but not the risk of la (or = : ; p = . ). analyzing the individual monotherapies, therapy with alpha-blockers signifi cantly reduces the risk of ed (or = . ; p < . ) and la (or = . ; p = . ) compared to treatment with ari. conclusions: combination therapy ari + ab is associated with a higher risk of ed. in addition, ari monotherapy has the same risk of the combination of having la. th ese results could be taken into account during the counseling therapy in patients with luts/ bph. mladenov b, mariyanovski v introduction and objective: bph bleeding is one of the common causes of gross hematuria in older men. -alpha reductase inhibitor ( ari) treatment has been showed to reduce prostate tissue microvascularity and to prevent bph-associated hematuria. alpha-blockers are oft en prescribed, where their eff ect on hematuria is not well evaluated. th e aim of this study was to investigate the impact and effi cacy of the current used drugs for bph for treatment and prevention of bph-caused hematuria. a total of men with median age of were enrolled for a period of years. all were presented with bph-caused macrospopic hematuria, diagnosed according to an adopted investigation protocol. detailed history was obtained, including usage of alpha-blockers and/or -ari prior to the hematuria episode. patients were released or immediately hospitalized and catheterized according to their status. all patients were followed up for year for recurrent bleeding and were divided into groups -with an alpha-blocker, -ari, or without therapy. in this study patients were sent home and treated conservatively, other with severe bleeding and/or clot retention necessitated catheterization and hospitalization. from patients ( %) were taking alpha-blockers, ( %) -ari, and ( %) had no medications for the bph prior to the hematuria. patients were followed up for recurrent bleeding for year in medication groups. were given alpha-blockers, - -ari and were released without medication for the bph. within year bph-bleeding occur respectively in , , and cases. th ere was a statistically signifi cant diff erence between the group with -ari therapy and the group without therapy (p= . ). no statistically signifi cant diff erence (p= . ) was found between the groups with an alpha-blocker and without therapy. in all cases with medication the hematuria episodes were lighter according to blood loss and/or hospital stay (in days) than the initial one. conclusions: according to our study, bph-associated hematuria can be eff ectively controlled and reduced with ari. although as per our data alpha-blockers have a positive eff ect on the intensity of the recurrent hematuria, much more signifi cant results in treating and controlling bph-bleeding are shown with -ari. effi overactive bladder syndrome (oab) is a common condition with a negative impact on quality of life. botulinum toxin is commonly used. despite the favorable outcomes seen using botulinum toxin a, the method of injection and side eff ects still need to be solved. our aim is to use botulinium toxin with simple method and check its safety and effi cacy. a total of patients with refractory oab were included in this study. inclusion criteria was refractory non neurogenic oab not responding to conservative management for at least months. aft er written consent, patients were randomly divided into two groups. group a ( patients) received botulinium toxin a unit intravesical instillation diluted in cc normal saline, group b ( patients) received placebo in the form of cc normal saline by the same method. patients were evaluated initially by history, physical examination, overactive bladder symptom score (oabss), quality of life symptom score (qolss), urine analysis, routine laboratory investigations, kub, pelviabdominal ultrasound and urodynamics. patients were followed up at one, and two month post instillation for effi cacy and safety by oabss, qol score, side eff ects and postvoid residual urine. introduction and objective: th e authors evaluate the safety and effi cacy of the prostatic urethral lift when performed in conjunction with a second procedure. in this retrospective study, patients underwent the prostatic urethral lift between january and november . sixteen patients received the prostatic urethral lift as a single procedure and the mean patient age for this group was years (range to ). in the remaining patients, a second procedure was performed in conjunction with the prostatic urethral lift . th ese procedures were: th ulium laser enucleation of the middle lobe, optical urethrotomy and bladder neck incision. results: in patients who were treated with the prostatic urethral lift as a single procedure the mean international prostate symptom score was . (range to ) and mean maximum urine fl ow rate was . mls- (range to ). th e average prostate volume was cc (range to ) and mean quality of life rating was . points (range to ). at months aft er the procedure, the mean international prostate symptom score improved by . points ( %), mean maximum urine fl ow rate by . mls- ( %) and mean quality of life rating by . ( %). th e improvements achieved in the combined procedures were greater than the patients who underwent the prostatic urethral lift as a single procedure. th ere was one case ( %) of postoperative moderate pelvic pain which was managed conservatively with a nonsteroidal anti-infl ammatory drug. a urinary tract infection occurred in one case ( %) and resolved aft er treatment with an antibiotic. th ere were no complications in the combined procedure cases. no patients reported any decline in erectile function, retrograde ejaculation or dysejaculation. conclusion: th e prostatic urethral lift is a safe and eff ective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia while preserving sexual function. in carefully selected patients, the performing the prostatic urethral lift in conjunction with a second procedure may achieve superior results with no major complications. evaluation . we sought to evaluate the effi cien-cy, safety and outcome parameters between green-light pvp and vit. data of xps cases were retrospectively collected from experienced surgeons at high volume greenlight xps centers. preoperative, operative and post-operative parameters were collected and compared between groups. pvp was defi ned as pure vaporization only while vit included techniques to incise into adenoma and allow tissue resection and removal. results: as summarized in table , men undergoing vit (n= ) had larger prostate size, higher ipss∕qol and retention preoperatively than those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs. . kj∕g), operative time was longer and had greater need for > fi bres. th ere were no diff erences in intra and post-operative adverse events. while no diff erences were observed in ipss∕qol at months post-operatively, more favorable qmax and pvr were observed at months, along with greater psa reduction, in the vit group. preoperative patient characteristics introduction and objective: to prospectively evaluate at two years, the quality of life (qol) and satisfaction of subjects randomized to either gl-xps or turp for luts/bpo. a total of patients at sites in european countries who were candidates for surgical relief of bpo were randomised : to undergo gl-xps or turp. subjects had ipss scores > and prostate volumes < mls. multiple self-administered patient questionnaires were assessed from baseline to years via: ) a general health status eq- d- l questionnaire (index score and visual scale); ) physical and mental health (sf- physical health and sf- mental health scores); ) erectile function and ejaculatory status (iief- questionnaire); ) urinary continence via oabq-sf symptoms, oabq-sf health and iciq-ui sf; ) overall satisfaction: willingness to undergo the procedure gain or ) recommend to a friend. table and subject satisfaction at years is shown in figure . conclusions: th ere is a statistically similar improvement in qol with gl-xps and turp at years. erectile function is not aff ected by gl-xps or turp and both result in a % risk of retrograde ejaculation at years. functional introduction and objective: technology for photoselective vaporisation of the prostate (pvp) has evolved in recent years. we report our early experience of pvp with the greenlight™ -w xps and assess our institutional learning curve for this technique. we performed a retrospectively analysis of our fi rst patients undergoing pvp using the greenlight™ -w xps over a twoyear period. data was collected on demographics, prostate volume, length of stay, time to trial of void, and complications. complications were graded according to the clavien classifi cation system. th e operative learning curve was analysed via various intra-operative lasering variables including the total delivered energy, total vapourisation time (vt), and vapourisation time/operation time (vt/ot). th e study population was divided into three consecutive equal groups and the three groups were compared. results: mean age was . mean length of stay was . days. mean prostate volume was cc. twenty-fi ve percent were on some form of anticoagulation. twenty-one percent were in-dwelling catheter-dependent preoperatively. th e median duration to removal of in-dwelling catheter was day. seventy-six percent had a successful trial of void on day . th e overall complication rate was %, the vast majority of which were clavien grade i or ii. th ere were no statistically signifi cant diff erences between the groups in terms of age or prostate size. over time, there was a statistically signifi cant decrease in ot and increase in vt/ot but no diff erences in complication rates, time to trial of void or length of stay as experience increased. conclusion: greenlight laser pvp using the -w xps is a safe and effi cient treatment option for benign prostatic hyperplasia, with minimal bleeding and low complication rates. our data suggests that a learning curve exists for this procedure in terms of intra-operative lasering variables with no statistically signifi cant increase in post-operative complications or length of hospital stay during this period. tillou x, le gal s, chahwan c, oitchayomi a, doerfl er a introduction and objective: to compare results of pvp (photoselective vaporisation of the prostate) in elderly patients to those observed in younger male patients taking into account the presence of an indwelling bladder catheter. we performed a review of our prospectively maintained database between december and march . a total of patients were operated for luts related to hbp. th ree groups were fi rst established to compare results of pvp in elderly male patients. we then analyzed the impact of an indwelling bladder catheter by comparing two groups of patients under and above year-old. results: th ere were no diff erences between groups for bmi, neurological disorder or hypertension history, aspirin treatment, ipss, qol and preoperative pvr (post void residual). patients above years old had statistically more heart diseases (p= . ) and had more anticoagulant treatments (p= . ). prostate volume increased with aging (p= . ), which resulted in an increased procedure time (p= . ) and an increased amount of energy delivered (p= . ). for postoperative outcomes, there were no diff erences between groups for bladder catheter removal time, ipss, qol, pvr, and surgical complications. postoperative qmax was statistically lower for patients above years old (p= . ) but with a decreased diff erence compared to preoperative measurements (p= . ). in the group without an indwelling catheter, postoperative catheter time was signifi cantly longer in patients over years (p= . ) with a greater pvr (p= . ). urofl owmetry and ipss voiding were signifi cantly improved in both groups without diff erences. th ere was no diff erence for early or late postoperative complications. for patients with an indwelling catheter, for all parameters studied, no statistically signifi cant diff erences were found except higher post-operative pvr in patients older than year-old. conclusions: pvp is an effi cient and safe procedure in elderly male patients despite more heart diseases and anticoagulant treatments. with or without a previous indwelling bladder catheter, functional outcomes were identical whatever age. introduction and objective: th e procedure of holep has steep learning curve and more than cases are needed for overcoming the curve. th e objective of our study is for identifying the detailed steps in improving skills during learning curve. total patients who underwent holep in single center were included in the study. th e operation was performed by surgeons who were experienced tur-p more than cases. patients were divided into groups. groups were initial cases (group ), mid cases (group ), and later cases (group ) in each surgeons. th e enucleation time, morcellation time, the amount of energy use, diff erential count of hemoglobin between pre-and post-operation, post-operative urofl owmetry parameter were compared between each group. especially, enucleation time was divided into diff erent steps, which was action time that was actual use of laser energy or dissecting prostate tissue using cystoscopy and identifi cation time was time for identifying anatomical structure without any procedure. results: mean ages was . years old and mean bmi was . kg/m . mean psa was . ng/ml and mean prostate volume was . cc. th ere were no signifi cant diff erences in baseline characteristics in preoperative data. aft er cases (group ), there was less use of laser energy, less time consuming for morcellation and identifi cation compared to group . identifi cation time was signifi cantly improved than group and more shortening feature as cases added but had no signifi cant diff erence. aft er cases (in groups ), there was more signifi cant diff erence in all operative parameter. especially morcellation time was signifi cantly improved aft er cases. th ere was no signifi cant diff erence in post-operative urofl owmetric parameters. conclusion: in initial experience, it seemed to be overcoming one step about identifying surgical anatomy in learning curve aft er cases. especially, cases were optimal cases for overcoming learning curve for morcellation. aft er cases, we did not overcome the learning curve but all operative parameter was improved. transrectal ultrasound as an intraoperative tool in the identifi cation of the plane of dissection during holep procedure introduction and objective: holmium laser enuclation of the prostate (holep) has been named since as the potential gold standard of treatment for bladder outlet obstruction as a consequence of benign prostatic hiperplasia. one of the most important steps during procedure is to identify the plane of dissection between the adenoma and periferic zone. in this study we demonstrated the utility of transrectal ultrasound in the identifi cation of this surgical plane during ho-lep for novel surgeons. materials and methods: previews informed concerned, we preform transrectal ultrasound during holep of patients, using the proved of the flex focus ultrasound system of bk medical, obtaining images of the prostate as a method to simplify the identifi cation of the surgical plane. we preformed holep as a standard method with storz endoscopic instruments using fr resectoscope with a kunts element and with the watts holium laser power suite from lumenis, we obtained images of the fi ve patients in real time with axial and sagital planes simultaneously, clearly helping the surgeon to identify the surgical dissection plane between the adenoma and the peripherical zone. conclusions: transrectal ultrasound could be a useful tool during the training of novel surgeons in holep technique. introduction and objective: th e aristolochia family of herbaceous plants has been used worldwide for traditional medicinal purposes for more than two centuries. th ese plants contain aristolochic acid (aa), a powerful nephrotoxin and human carcinogen, which, in susceptible individuals, causes chronic kidney disease and/or upper urinary tract urothelial carcinoma (utuc). bioactivation of aa yields a reactive intermediate that binds covalently with dna to form aristolactam (al)-dna adducts. in the urothelium, these adducts give rise to a unique mutational signature. as there are several reports of renal dysfunction in japan associated with the use of aa-containing chinese herbs, we hypothesize that a fraction of utuc cases in this country may result from past use of aristolochia herbs. patients with histologically confi rmed utuc who underwent nephroureterectomy in kyushu university aft er august were eligible for this study. informed consent was provided by each participant prior to surgery. surgical specimens of tumor and renal cortex were snap-frozen following nephroureterectomy. dna was isolated from renal cortex and analyzed for the presence of al-dna adducts using either mass spectrometry or a p-postlabelling method. dna isolated from matched tumor samples was subjected to mutational analysis of the tumor suppressor gene tp . results: th irty three utuc patients were enrolled in this study between august and march , males and females, with a mean age of years. al-dna adducts were detected in of renal cortex samples ( . %) analyzed; adduct levels were . and . per deoxynucelotides. sequencing analysis of tp in tumor dna revealed the absence of the unique mutational signature associated with aa. conclusion: aa exposure was confi rmed in two utuc patients; however, in these two cases, the mutational profi le of tp in tumor dna was not consistent with aa-induced carcinogenesis. further accrual and analysis of utuc cases are needed to estimate the prevalence of aa exposure in japan, to evaluate the role of aa exposure to utuc in this country, and to confi rm the public health implications of these fi ndings. preoperative introduction and objective: our aims are to assess the association between upper urinary tract urothelial carcinoma (uutuc) development and the polymorphisms in the aurora kinase a (aurka) phe ile (rs ) and survivin rs c>t genes. a total of patients with uutuc and hospital controls with bladder stones were recruited in this study. clinical records, demographic data, and possible confounding factors were collected using a standardized questionnaire. genotyping was determined using a real-time polymerase chain reaction using taqman probe. results: signifi cantly more controls than patients with uutuc drank alcohol and tea, but there were no diff erences in the frequencies of cigarette smokers and coff ee drinkers. aurka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, were associated with uutuc development (χ test and multivariate logistic regression) (χ = . , p= . ; crude or= . , % ci= . - . ; adjusted or= . , % ci = . - . ). stratifi cation analysis and multivariate logistic regression analysis showed that only the association between aurka phe ile gene polymorphisms and uutuc development were diff erentiated between those with and without the habits of smoking, tea drinking, or coff ee drinking. conclusion: our major fi ndings supported that aur-ka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, increase genetic susceptibility to uutuc. metastatic and has thereaft er stabilized around %. th ere was a regional variation in the proportion of patients who underwent cn between % and %. th e relative survival at fi ve years was % aft er cn compared to % in patients who did not undergo cn (p< . ). th e median age of the m patients who underwent cn was years compared to years in patients who did not undergo cn. tumor recurrence, aft er initial treatment with curative intention in primary m patients, was % aft er fi ve years. th e location of the metastases were: lung %, bone %, lymph nodes %, liver %, adrenal % and brain metastases in % of the patients. th irteen percent of the patients suff ered local recurrence in the renal fossa aft er nephrectomy. th e most common treatment for patients with a recurrence was oncological medical treatment ( %). metastasectomy was performed in % of the patients with recurrence and in % of the patients the surgery had a curative intention. conclusions: th e incidence of metastases in renal cell carcinoma in sweden is decreasing and is lower than in historical materials. th e patients with synchronous metastases who undergo cn have a signifi cantly better survival than patients who do not undergo cn, but constitute a highly selected group. recurrence after initial treatment with curative intention is treated surgically in % and oncologically in %. immediate introduction and objective: pretreatment characterization of renal masses (rm) remain suboptimal with overtreatment being a signifi cant concern. we examined the ability of preoperative clinical characteristics to predict histological features of rms. in the global renal mass study conducted by the clinical research offi ce of endourology society (croes), data were collected for consecutive patients with renal masses who underwent surgery for clinical stage i renal mass between - . based on surgical histology, tumors were categorized as benign, low aggressiveness cancer, and high aggressiveness cancer. we assessed the ability of clinical (patient gender, age, smoking history, bmi), laboratory (preoperative hemoglobin and c-reactive protein) and radiographic (tumor diameter, location, exophytic rate and enhancement) characteristics to discriminate between benign and cancer (low + high aggressiveness) and between highly aggressive tumors and others (benign + low aggressiveness cancer). multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a sub group of ct a tumor. th e performance of the models was consequently studied by calibration, nagelkerke's r , and discrimination (roc area under the curve). results: th e study cohort included patients with clinical stage i renal mass of which ( %) had ct a mass. benign lesions were found in ( . %), low aggressiveness tumors in ( %) and high aggressiveness tumors in ( . %). male gender, smoking history, increased tumor size, and lower exophytic rate were associated with malignancy and high aggressiveness features (all p-values < . ). models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of . ) and high aggressiveness tumors from benign and low aggressiveness tumors (bootstrap corrected c-index of . ). similar results were achieved in the ct a subgroup. th e c-index of tumor diameter as a single predictor of malignancy and high aggressiveness tumors in the entire cohort was . and . , respectively. conclusions: although older age, male gender, smoking history, increased tumor diameter and reduced exophytic rate are associated with malignancy and high aggressiveness of renal mass, models incorporating these characteristics have modest discriminating power, slightly better than the predictive ability of tumor size alone in clinical stage i tumors. could surgery be prevented in the management of small renal masses? introduction and objective: th e diagnosis, characterization and management of small renal masses (srms) remains an important clinical issue. a proportion of srms may be benign or have low malignant potential. th ese lesions could arguably be managed non-operatively. strategies such as renal mass biopsy may be valuable in reducing the rate of unnecessary surgery. we evaluated a large contemporary surgical series of resected srms in a tertiary center with a very low biopsy rate to determine the number of procedures that could have been prevented for benign and low malignant potential lesions. conclusion: sbrt is a safe and effi cacious modality and appears to be well-tolerated at the dose fractionation we have used, and its use correlates with improved survival in this cohort of patients with rcc. cyberknife can deliver complex treatment plans to multiple lesions while minimizing irradiation to the surrounding healthy tissue, thereby decreasing the risk of complications. cyberknife has the potential to be an excellent treatment modality for renal cancer patients with renal cell carcinomas or patients with bilateral renal cell carcinoma who refuse surgery or are medically inoperable. introduction and objective: th e introduction of the robotic surgical systems has changed the way both surgeons and patients view urological surgical procedures. we tested the same theoretical and tangible benefi ts for partial nephrectomy with tele-lap alf-x system. we review our technique of robot-assisted laparoscopic partial nephrectomy performed using a new robotic telesurgical device (alf-x) on swine large white/landrace model. we set up an operating theatre to test alf-x on partial nephrectomy procedure to be performed on swine large white/landrace in total anesthesia. th e console incorporates the following main components: an ergonomic seat, the laparoscopic teleoperation master (ltm) with haptic handles, a d-hd monitor, an eye-tracking system (ets), a keyboard and a touchpad, and one foot pedal. th e ets is an infrared-based eye tracking system that detects which point the surgeon is looking at. th ere was one surgeon placed at computer-console and one surgeon placed at the surgical table. a random decision on the kidney to be tested is performed before the operation. once the trocars are placed and the kidney isolated a period of warm ischemia is due to perform the partial nephrectomy on the lower or upper pole (random choice). th e haptic sensation can be used for palpation, pushing or pulling to estimate elasticity and consistency of tissues and controlling the tensility of the sutures when tying. low-cost disposable or reusable instruments were used. results: to date, we performed partial nephrectomy with alf-x robot on swine large white/landrace (pigs) models. th ree robot's arms were used. five partial nephrectomies were on the right kidney, while were on the left one. th e mean surgical time was . minutes (range - min). th e mean warm ischemia time was . min (range . - min). th e mean blood loss was . ml (range - ml). conclusions: according to these experimental experiences on pig models, we may assume that robot-assisted laparoscopic partial nephrectomy, using tele-lap alf-x system, is safe, feasible and reproducible procedure. moreover it off ers a good perception when instruments touch each other avoiding collision between robotic arms. we believe that robot-assisted tele surgery approach could be reasonable an innovative contribution in the near future also in humans. it also off ers a reduction of costs per intervention. preoperative chronic kidney disease to reduce the eff ects of selection bias and potential confounding factors, patients in non-ckd group were selected by propensity score matching. results: th e median age of all patients was . years (range, - years) and the median follow-up was . months (range, - months). comparisons of the propensity score-matched cohorts showed that t and n stages were more advanced and the tumor size was larger in the ckd than in the non-ckd group (p < . each). kaplan-meier analyses showed that recurrence-free survival (rfs), cancer-specifi c survival (css), and overall survival (os) were signifi cantly lower in the ckd group (p < . each). multivariate regression analysis showed that preoperative ckd status was an independent predictor of css and os in patients with rcc (p < . each). conclusion: preoperative ckd may be associated with more aggressive features and poorer prognosis in patients with rcc. rcc patients with preoperative ckd should be followed up frequently and carefully aft er nephrectomy. . ) were independent prognostic factors. bone-modifying agents (zoledronic acid and denosumab) were not associated with os. th e median os of patients receiving molecular-targeted therapy aft er diagnosis of bone metastasis was signifi cantly better than that of those who did not receive targeted therapy ( . vs. . months, p= . ). our study suggests that molecular-targeted therapy prolongs survival of rcc patients with bone metastasis. th us, molecular-targeted therapy, nephrectomy and surgery for bone metastasis should be considered for these patients. introduction and objective: ureteric stenting for urinary tract obstruction secondary to malignancy may off er a survival benefi t and buy time for oncological management. since the introduction of the ureteral stent symptom questionnaire (ussq), studies have revealed that up to % of patients with ureteric stents for benign conditions experience stent related symptoms that interfere with daily activities and reduce quality of life. our aim was to evaluate stent symptoms in patients with malignant obstruction and their impact on health related quality of life. patients with indwelling ureteric stents for malignant obstruction were identifi ed from the departmental stent register during a march to june . telephone interviews and face to face interviews at the time of stent change were conducted using the validated ussq. results were analysed according to the questionnaire scoring system. results: twenty patients with a mean age of years completed the ussq. of these patients - % reported bothersome urinary symptoms that included storage symptoms, incontinence and haematuria. fifty percent of patients experienced stent related pain in the fl ank ( / ), suprapubic ( / ) and groin area ( / ). fift y percent of these patients required regular analgesia and - % experienced pain interfered with activities and daily life. seventy percent of patients experienced diffi culty in performing physical activities, with a negative impact on social life. one out of patients reported sexual dysfunction. eighty fi ve percent experienced urinary tract infection (uti) with % having a uti most or all of the time and % requiring admission to hospital. mortality within one year of stent insertion was %. conclusion: ureteric stents are associated with signifi cant debilitating symptoms and reduced quality of life in patients with malignant obstruction. th is has signifi cant implications for management of cancer patients and patient counselling. ureteric stenting can prevent death from malignant obstruction, but may result in prolonged suff ering due to stent symptoms without benefi t in overall survival. introduction and objective: management pheochromocytoma laparoscopic was initially controversial because of the possibility of adrenergic discharge with the generation of the pneumoperitoneum. th e work of a proper medical preparation and anesthetic precise control obvious that circumstance and allows more precise surgery and a better image as it gives the laparoscopy to get with much less aggressive surgical removal. our goal is to present the preparation and the key points in its approach. we present -year-old male with recent diagnosis prostate cancer and high pressure treated with drugs. discovery of left adrenal mass of cm. in ct and mri and scintography with mibg suggestive focus of pheochromocytoma in the adrenal gland. twenty-four-hours urine: total catecholamines: . ug/ ( - ) adrenaline: . ug/ hours ( d- ); normetanephrines ug/ ( - ), metanephrines: ug/ ( - ). vanilvandelico . ug/ ( - ). preparing medical / anaesthetic consisted: entry days before surgery and control alpha-blockers with doxazosin every hours. treatment with beta-blockers with propranolol. expansion of intravascular volume with intravenous fl uid therapy hours before surgery. and control of blood glucose levels. intraoperatively crisis were treated with nitroprusiate. results: aft er adrenalectomy laparoscopic left with a length of minutes and adequate control pressure intraoperative the pathology diagnosis was of pheochromocytoma. postoperative attended without incident (clavien i) and went out hospital to the hours. th e presence a pheochromocytoma should not be a contraindication to laparoscopic approach of the adrenal gland in services experienced laparoscopic, and must be an exhaustive control of anesthetic, as well as a careful dissection of the gland trying to avoid excessive manipulation of the same. robotic assisted "davinci" adrenalectomy al-ansari a, younes n, al-rumaihi k, al-jalham k, gul t, badawi a, kamkoum h introduction and objective: adrenal mass could be challenging, especially when it is large in size or cystic, adrenal had short and variable vasculature, in addition to functional adenoma, adrenal surgery require minimal handling. robotic assisted adrenalectomy (ra) had been proven to be safe and eff ective. objectives: to describe robotic adrenalectomy (ra), to ensure a safe and eff ective removal of complex adrenal mass. we reviewed the record of consecutive patients who underwent ra performed by a single surgeon, between january and january , fi ve were right and fi ve were left , were solid and were cystic, none were functional adenoma patients position and port placement were similar to renal surgery, aft er control of the renal vein the gland was dissected, small arteries were clipped and the gland were removed. results: patients were females and males, age range between to years mean tumor size was . cm range ( . - cm), mean hospital stay was days, no perioperative complications, all masses were intact, one postoperative addisonian crisis pathology was benign cyst, adenoma, ganglionuroma, neuroendocine, adrenal hyperplasia, adrenocortical neoplasm of low malignant potential. conclusion: robotic adrenalectomy is safe and feasible in the management of complex adrenal mass. robotic materials and methods: th e girl was in a good general health and came walking to our out-patients department. she was admitted and her investigations reviewed. she had a right renal mass with cavo-atrial extension with an isolated embolus in the pulmonary artery. she was planned for a complete excision under cardio-pulmonary bypass with deep hypothermic circulatory arrest. under general anaesthesia, aft er establishing complete monitoring, she was opened by long midline laparotomy and mid-sternotomy. mid-sternotomy extension was done up-front in-view of the pulmonary embolus. an incision was made in the posterior peritoneum medial to the inferior mesenteric vein. th e right renal artery was dissected posterior to the left renal vein, ligated and divided. suddenly her end tidal carbon-di-oxide fell. th e video demonstrates the trans-esophageal echo-cardiography confi rming fragmentation of the cavo-atrial thrombus and its migration into the right ventricle and main pulmonary artery. th e patient was immediately put on cardio-pulmonary bypass. initially the venous return was low. she was rapidly cooled to degrees centigrade and aorta cross clamped just above the diaphragm. arterial infl ow was reduced to litre per minute to main blood fl ow to the brain. th e video demonstrates opening, clearing and repairing of the right atrium, right ventricle and main pulmonary artery in a step by step approach. th e branches of the pulmonary artery were cleared with fogarty's catheter. right radical nephrectomy was completed and ivc cleared and repaired. th e total circulatory arrest time was minutes. she was slowly re-warmed and taken off cardio-pulmonary bypass. results: her post-op recovery was uneventful. th e fi nal histo-pathology report showed a primitive neuro-ectodermal tumor. she received adjuvant chemotherapy for cycles and is well at months of follow-up. in an appropriate case pulmonary artery embolectomy along with excision of cavo-atrial tumor thrombus is acceptable in experienced centers. an up-front mid-sternotomy should be contemplated in patients where the risk of embolisation of tumor thrombus is high. a total of consecutive patients who underwent a turbts were identifi ed from january to february by a single surgeon at our institution. we excluded patients as they had a known history of bladder cancer that previously underwent treatment. via rigid cystoscopy, tumors were resected en bloc using a polypectomy snare with electro-cautery and retrieved transurethrally. following turbts, the base of the tumor was either biopsied and fulgurize or a formal turbt was performed. results: nineteen consecutive patients (median age , range - ) underwent an initial turbts for the initial staging and management of bladder tumor. median number of tumors found was (range - ). median tumor size was cm (range cm- cm). median follow-up was months (range - months). tumors sites were: posterior wall, trigone, lateral wall, anterior wall. immediate aft er snaring of the tumor, patients underwent biopsy and fulguration while underwent a turbt in the same operative setting. patient from the turbt group experienced an obturator refl ex. muscle was visualized on of pathology specimens. patients required subsequent redo procedure to obtain muscle for tissue diagnosis and staging. recurrence occurred in patients (median . months, range . - months). conclusion: turbts is a feasible technique for pedunculated bladder tumors. it provides a bloodless fi eld with maximal visibility for the surgeon and may be an adjunct in turbt. dilep-diode laser ( nm technical aspects for overcoming the holep learning curve omori y, matsumoto s, matsumoto s introduction and objective: holep is an excellent surgical procedure and alternative to turp and open prostatectomy for bladder outlet obstruction due to benign prostatic hyperplasia. it has been widely accepted and performed, for its safety and eff ectiveness. however, it may not be considered an option for the majority of worldwide urologists, because of its steep learning curve. our objective is to help beginners and operators who are interested in learning holep to get familiarized with it, and feel confi dent about opting for this procedure. in this video we demonstrate a case of holep using watt holmium laser in a -year-old male with ml prostate. th e operative fl ow is described as follow: ) downward dissection of the left lobe and longitudinal incision; ) downward dissection of the right lobe and longitudinal incision; ) enucleation of the medium lobe; ) lateral side dissection of the both lobes; ) o' clock incision and bladder neck ablation at between and o' clock ) diagonal longitudinal incision of apical lobes; ) enucleation of the both lobes; ) hemostasis; ) morcellation. results: in this video operative time was min (enucleation time: min) and resected tissue weight was g. our procedure has some modifi cations compared to the surgical technique from original procedure of gilling, separating lobes and dissecting in a retrograde fashion. conclusion: holep is a safe and eff ective surgical procedure. we hope our procedure will become the reference for beginners and urologists who are wishing to master it, but are worried about methods and complications. and also we hope holep will become the new gold standard for the treatment of benign prostatic hyperplasia. to obliterate the circular fi bers of bladder neck to the level of proximal urethra, carefully avoiding the external striated sphincter. laser power is reduced to w to prior to vaporization of any pseudomembranous trigonitis, which is commonly found in pbno or recurrent cystitis cases. results: laser vaporization is successful in relieving voiding diffi culties. th is procedure opens the bladder neck and allows for optimal post-operative urine fl ow. th e patient had improvement in both objective and subjective voiding functions immediately aft er treatment. during -months follow-up urofl owmetry, the maximum fl ow rate increased from to ml/s. th e postvoid residual urine decreased from ml to less than ml. conclusion: primary bladder neck obstruction in female can be eff ectively and safely treated with laser photoselective vaporization of the bladder neck. bilateral retroperitoneal laparoscopic nephrectomy using mm instruments introduction and objective: laparoscopy has become the standard nephrectomy approach. it has been shown that th e retroperitoneal approach is comparable to the transperitoneal approach when it comes to safety and results, even more, it can present advantages in selected patients, as in patients with prior abdominal surgery. th e use of mm instruments is gaining acceptance as a safe way to improve aesthetic results and minimize abdominal wall trauma while maintaining the principles of standard laparoscopy. we present the case of a -year-old woman with a history of radical hysterectomy and radiotherapy, aft er which she presents: ) bilateral ureteral obstruction that produces terminal renal insuffi ciency, and, ) vesico-vaginal fi stula, refractory to conservative treatment. th e decision is made to perform a bilateral retroperitoneal laparoscopic radical nephrectomy as a defi nitive treatment of the vaginal fi stula and as preparation for the kidney transplant. results: th e right nephrectomy is performed fi rst. classic retroperitoneal technique is used, using mm trocars (with an mm trocar to create the retroperitoneal space). on the left side, a previously produced nephrostomy catheter tract is used to insert a mm trocar. no relevant intraoperatory complications were observed. preoperative haemoglobin was g/l and the postoperative was g/l aft er transfusion of one bag of packed red blood cells. th e only postoperative complication was the infection of the mm left side trocar tract (where the previous nephrostomy catheter was placed). th e total hospital stay was days. th e pathological anatomy for both kidneys was: chronic pyelonephritis with extended interstitial fi brosis and tubular atrophy. conclusions: retroperitoneal laparoscopic nephrectomy is an effi cient and safe approach, comparable to transperitoneal laparoscopic nephrectomy, and even superior to this one in patients with previous abdominal surgery. th e use of mm instruments (in this case in a combined fashion), allows performing the surgery in a safe way, with superior aesthetic results. pure aft er complete mobilization of the renal artery three hem-o-lok clips were applied and the artery was transected. th e ivc was isolated upwards as far as possible, and intraoperative laparoscopic ultrasound was employed to identify the extent of the thrombus. aft er the inferior vena cava ivc was blocked using tourniquet loops above and below the thrombus and the contralateral renal vein was blocked, the ivc was opened and the tumor thrombus was extracted entirely. th e ivc was stitched with a running - polypropylene suture. th e specimen was extracted in an endoscopic extraction bag through a gibson incision. results: from february to june , fi ve patients underwent pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy. th e mean patient age was yr ( - yr). th e mean operative time was min ( - min), and the mean estimated blood loss was ml ( - ml). th e mean length of tumor thrombus was . cm ( - cm). with a mean follow-up of . mo ( - mo), one patient was identifi ed lung metastasis four months postoperatively. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short-and long-term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. however, higher complexity tumors are associated with more resection of normal tissue, a longer warm ischemia time, and postoperative morbidity, especially entirely endophytic hilar tumor. in order to reduce normal tissue resected during laparoscopic partial nephrectomy for entirely endophytic hilar tumor, we develop a novel technique to deal with the higher complexity tumors. subject is a -year-old female with t a clear cell carcinoma with a diameter of . cm. th e tumor is entirely endophytic hilar tumor. renal nephrometry score is . she underwent laparoscopic partial nephrectomy in retroperitoneal approach. standard ports were placed. th e surgeon opened gerota's fascia and dissects along the renal capsule mobilizing the kidney from within gerota's fascia. th e resection line was marked using the laparoscopic ultrasound probe. aft er the renal artery was clamped by bulldog, tumor enucleation was performed using a cold scissor. one incision above the tumor was made, and careful dissection was performed to approach the tumor. th e tumor was completely mobilized outside its margin. th en the inner layer renal parenchyma and collecting system was sutured with - absorbable sutures and the outer layer renal parenchyma was sutured with absorbable suture. results: th e procedure was successfully accomplished without open conversion and transfusion. th e operative time was min, and the estimated blood loss was ml. th e warm ischemia time was min. histology revealed that the tumor was chromophobe renal cell carcinoma, and the surgical margin was negative. conclusion: laparoscopic partial nephrectomy for entirely endophytic tumor is challenging. tumor enucleation with one resection line can reserve more normal renal tissue during the procedure. more cases are needed to evaluate the effi ciency of the technique. introduction and objective: laparoscopic adrenalectomy by posterior approach carries high recovery and shorter operative time. children with metastatic high risk neuroblastoma arising from the suprarenal gland should undergo local surgical excision of the primary tumor before further intensifi cation of chemotherapy and possible bone marrow transplantation. herein, we report a video of left laparoscopic adrenalectomy showing the diff erent steps of the procedure. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: a . -year-old boy with left metastatic suprarenal neuroblastoma, received chemotherapy according to high risk european protocol. child positioned in prone position, fi rst trocar at the tip of the last rib by open introduction, two mm trocars one in costovertebral angle and the other is lateral. balloon development of the space, gerota fascia opened, the upper pole of kidney identifi ed, mass dissected, suprarenal vein is clipped during dissection, extraction in bag. results: oral feeding is begun aft er hours, discharge from hospital in the second day postoperatively, rapid convalescence, rapid resumption of chemotherapy. conclusion: laparoscopic adrenalectomy using posterior approach gives direct access to the adrenal gland, no peritoneal violation, rapid intestinal movement recovery, short hospital stay and rapid recovery. all advantages that might facilitate the early start of adjuvant chemotherapy in children with neuroblastoma, however, oncological outcome should be proven by long-term follow-up, larger number of patients, and good selection of small tumor facilitates surgical extirpation. introduction and objective: robotic multiplex partial nephrectomy (rmxpnx) is minimally invasive partial nephrectomy for three or more tumors in a single kidney. rmxpnx has been previously shown feasible with excellent preservation of renal function. we present our technique of off -clamp robotic transperitoneal multiplex partial nephrectomy in the treatment of multifocal and hereditary renal tumors. a prospectively maintained database was retrospectively queried to identify all patients who underwent rmxpnx from to . rmxpnx is defi ned a resection of or more masses from a single kidney. patients underwent rmxpnx when the largest tumor reached cm in size. tumors were excised using enucleation techniques. from the data of eligible patients, a representative patient was identifi ed and surgical video was edited to demonstrate the important aspects of the surgical technique. results: th e patient is a -year-old white male with von hippel lindau diagnosed with bilateral multifocal renal tumors with several tumors > cm in size. he underwent bilateral robotic multiplex partial nephrectomy separated by weeks with no operative complications. th irty fi ve tumors were excised from the right kidney. fift y two lesions were then resected from the left kidney. his preoperative creatinine was . and at year postop from bilateral multiplex partial nephrectomies his creatinine is . . in the hands of an experienced surgeon, off -clamp robotic transperitoneal multiplex partial nephrectomy is feasible, safe and eff ective in the treatment of multifocal and hereditary renal tumors. th is technique provides exceptional renal functional preservation and decreases technical diffi culty of reoperation. louie-johnsun m introduction and objective: th e advantages of minimally invasive laparoscopic surgery are well documented. as there are few urological emergencies suitable for a laparoscopic approach, the increased use of robotic surgery for elective procedures that can be performed equally as well laparoscopically threatens the acquisition of skills that can be transferred from these elective procedures (e.g. laparoscopic radical prostatectomy, pyeloplasty and partial nephrectomy) to emergency cases. in emergency situations, a robotic approach may not be feasible or practical. we highlight this with three recent cases. materials and methods/results: a video presentation of three of our recent urological emergency cases managed successfully laparoscopically which includes: ( ) a -year-old girl with neurogenic bladder presenting with urinary peritonitis aft er spontaneous rupture of an augmentation cystoplasty: laparoscopic adhesolysis and repair of perforated augmented bladder. ( ) an -year-old woman with intraoperative mid ureteric injury during laparoscopic right hemicolectomy: laparoscopic ureteroureterostomy and insertion of ureteric stent. ( ) a -year-old woman with ureterovaginal fi stula post laparoscopic hysterectomy: laparoscopic ureteric reimplantation with psoas hitch and insertion of stent. conclusion: despite the increasing use of robotic surgery in urology we encourage the continued training and dissemination of advanced laparoscopic skills in the elective setting to allow for the advantages of laparoscopy to be transferred to the less common urological emergency setting. robotic ureteric catheter placement; ) port placement with patient in lateral position; ) bowel mobilization; ) localization of lower calyx by intra-operative ultra sound probe; ) lower segmental nephrectomy; ) anastomosis (ureterocalicostomy) with - v-lock sutures over a pre placed f ureteric catheter and drain placement; ) changing of ureteric catheter to dj-stent on rd day post-operatively. results: th e procedure was completed successfully without any intra operative complications in all the cases. mean operative time was ± minutes and analgesic requirement of ± milligram of tramadol. none of the patients required blood transfusion. urethral catheter was removed on th and drain on th post-operative day and stent aft er weeks. one patient had clavien grade (pyrexia) complication. conclusions: robot-assisted laparoscopic ureterocalicostomy for secondary upjo is safe and feasible in expert hands. apart from the short recovery times, early mobilization, decreased analgesic requirements; robotic approach provides the added advantage of technical ease and precision of suturing. laparoscopic dismembered pyeloplasty for upjo in pelvic ectopic kidney apollo bgs hospital, mysore, india introduction and objective: renal ectopia is a rare anomaly and may be associated with pelvic ureteric junction obstruction (pujo). we report such a case with an ectopic pelvic kidney (l-type) with pujo and its successful laparoscopic management. th rough this report we emphasize the importance of adequate preoperative imaging and intraoperative details to avoid mishaps. a -year-old male was admitted with complaints of right-side lower abdominal pain of a dull aching type lasting months. ultrasonography revealed left pelvic kidney. th ese fi ndings were confi rmed with an intravenous pyelogram, which showed the left kidney low lying in the pelvic region with features of hydronephrosis and upjo. ct angiography revealed no crossing vessel as the cause of pujo. results: th e patient was taken up for transperitoneal laparoscopic pyeloplasty under general anesthesia. aft er creation of the pneumoperitoneum and with the ports in place, dissection was started and the dilated pelvis could be visualized through the peritoneal window. th e peritoneum was incised and the dilated pelvis on the left side was reached. aft er further dissection, the classic anderson-hynes dismembered laparoscopic pyeloplasty was done by using - vicryl. minimal excision of the redundant pelvis was required and because the kidney was not mobilized, nephropexy was not required. care was taken to avoid injury to the right ureter, which was coursing in close proximity to the left renal pelvis. preoperatively placed stent was retained and repositioned during the pyeloplasty. estimated blood loss during the procedure was around ml, and the procedure was completed in minutes without any intraoperative complications. th e patient could tolerate oral feeding on the evening of the same day. conclusion: th e upjo in ectopic pelvic kidneys presents a large spectrum of presentation. th e laparoscopic approach provides good surgical exposure, and operative times are compared to those of laparoscopic procedure in anatomically normal kidneys. laparoscopic we present laparoscopic radical cystectomy (lrc) and intracorporeal orthotopic ileal neobladder with two isoperistaltic aff erent limbs. a -year-old male patient with recurrent urothelial bladder carcinoma. ct demonstrates bulky bladder tumor in right lateral wall. lrc and intracorporeal urinary diversion were performed. six trocars were used in the procedure. aft er lrc and extended pelvic lymph node dissection were accomplished, a cm ileal segment cm proximal to the ileocecum was harvested, of which a cm proximal ileal segment was moved to anastomose with the end of the harvested segment which was right isoperistaltic aff erent limb. th en cm ileal segment was detubularisated leaving cm intact proximal ileum for left isoperistaltic aff erent limb. th e harvested ileal segment was symmetrically folded with identical limb lengths. th e posterior wall of the neobladder was sutured, and ileoureteral stents were delivered into the two isoperistaltic limbs and passed up the ureter and coiled into the renal pelvis, and one foley catheter was delivered into the neobladder at the same time. bilateral ureteroileal anastomoses were performed in a continuous manner respectively. th e anterior wall of the neobladder was closed and the posterior urethra was anastomosed with the neobladder. we have performed cases with this technique. all procedures were completed without open conversion. th e mean operative time was min with a blood loss of ml. th e construction time of the neobladder was min. th e time to orally allow was postoperative day in all. th e mean hospital stay was d. foley catheter and dj stents were removed on postoperative day . no major complication was occurred. conclusion: laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with two isoperistaltic limbs were a safe and feasible for experienced laparoscopic surgeons. however, more cases and long follow-up were required to evaluate the function of the novel neobladder. all in this video, we wanted to share our robotics augmentation ileosistoplasty experience in -year-old male patient with a diagnosis of neurogenic bladder. an -year-old male patient treated with clean intermittent catheterization and anti-cholinergic therapy for neurogenic bladder. bladder capacity was detected cc, the irregularities in the bladder contour and left grade vur was detected in control video urodynamics. so we decided to implement robotic augmentation ileocystoplasty to the patients. results: th e transperitoneal approach is performed by using veress needle to access the peritoneal cavity. th e abdomen was insuffl ated using co and trocars placed under direct vision ( of camera port ( mm), of da vinci ports ( mm) was placed and of mm and of mm assistant ports were placed). a cm segment of ileum with mesentery was incised with about cm proximal from the ileocecal valve and this segment was suspended. intestinal anastomosis was performed with - vicril and - monocril sutures and created a u-shaped ileal pouch. th e bladder was released from the surrounding tissue. about cm, longitudinal incision was made to the bladder. a single-j catheters were placed to the left ureter and bladder for the left ureteral catheter and cystostomy. th e bowel prepared for bladder augmentation and it was sutured with . pds with wate tight anastomosis. operation was terminated by placing the drainage catheter. introduction and objective: although their numerous indications make double-j stents frequently preferred in the armamentarium of the urological practice, serious complications can arise, if they are not used correctly. in endourological surgeries, due to type and stuff of material the breakage or fracture risk of the equipment is more. th ere are various types of surgical procedures for the removal of the foreign bodies. shock wave lithotomy (swl) and ureteroscopy (urs) are the fi rst step in the removal encrusted ureteral stent. th is report presents a case of successful forgotten ureteral stent removal by means of fl exible ureterorenoscope (furs) and fl uoroscopic imaging. a -year-old male patient was admitted to our clinic with the complaint of recurrent urinary tract infection. in his medical history he said that he had an open kidney stone surgery in and aft er months d-j catheter removal had been performed. aft er radiologic imaging it is determined that there are two d-j catheter pieces in the right kidney collecting system. furs and removal of foreign body was performed successfully. postoperative fi rst day patient discharged with no complication. results: various materials and coatings have been developed to avoid ureteral stent complications such as encrustation and infections. th e incidence of encrustation increases with the duration that the stent remains in place. th ere are numerous types of removal techniques for foreign body removal, however furs seems to be the better one with the minimal postoperative rates. our technique was performed easily and in a short surgery time. conclusion: flexible urs modifi ed with fl uoroscopy has particular advantages for treating encrusted ureteral stents. th is procedure is least invasive and is thus considered to be most suitable surgery for encrusted ureteral stents or foreign body materials in the kidney. results: we outline strategies to prevent diffi culties with urethro-ileal anastomosis during rarc iucd neobladder formation. furthermore we off er some key technical points that can be benefi cial in overcoming challenging urethro-ileal anastomosis. conclusions: due to the technically complex nature of rarc icud neobladder formation, the awareness of potential pitfalls during each step of the process is essential. issues and solutions discussed in this video provide a valuable resource for clinicians performing this procedure. robotic in this video we present a patient presenting with concomitant renal neoplasm and a large calculus in the renal pelvis that what was managed with robotic pyelolithotomy at the time of partial nephrectomy. results: aft er exposure of kidney the ureter was identifi ed. th e renal pelvis was exposed and pyelolithotomy was performed. aft er this hilum was clamped and partial nephrectomy and renorrhaphy followed. th e warm ischemia time was minutes. th e procedure was completed without any complications. patient was discharged on the second postoperative day. conclusions: although uncommon, the presence of concomitant stone and renal neoplasm can make the decision of optimal patient care more challenging. using robotic platform simultaneous management of both conditions can be accomplished in appropriately selected cases. single introduction and objective: female epispadias is a rare congenital anomaly and is classifi ed, into vestibular, subsymphyseal, and retro-symphyseal. historically treatment consists of staged repairs with urethral and vulvar reconstruction in fi rst stage followed by bladder neck reconstruction at a later age. in addition, staged procedures require multiple sessions of surgery and anesthesia, and are associated with relatively higher morbidity. recently single stage perineal urethroplasty has been used for epispadias repair. objective of the study is to evaluate the results of single-stage perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female epispadias. we treated patients with severe female epispadias since to . age varied from to years (mean years). perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in cases. th e urethral plate and bladder neck was mobilized from the surrounding tissue till bladder neck. a urethral mucosal strip of about to mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and tubularized over a f catheter. urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neo-meatus with corporoplasty, sphincteroplasty, and genital reconstruction. results: all patients were satisfi ed and happy about cosmesis. of the patients, were fully continent with a dry interval of to hours, one of them had occasional night wetting was put on anticholinergic. one was partially continent with dry interval of hours required anticholinergic. conclusions: perineal urethroplasty with double breasting of urethra, from inside the bladder neck to the neomeatus, resulted in continence in most cases because it increased the urethral and bladder neck resistance, as well as bladder capacity, all were important factors in continence. we advocate this procedure as a fi rst choice in all patients with female epispadias, because it is simple, safe, and eff ective for continence. single we had partial penile disassembly to have the advantage of both technique. so objective of the study was to evaluate the functional and cosmetic outcome of single stage partial penile disassembly repair in isolated male epispadias. a retrospective analysis of cases of primary epispadias repair, performed during july to july at our institution. patients were classifi ed on the basis of type of epispadias, urinary incontinence, presence/degree of chordee and penile rotation. exstrophy epispadias complex and secondary repair were excluded. surgical technique: penile de-gloving with mobilization of urethral plate from ventral to dorsal aspect with preservation of blood supply at both ends, distally up to the level of midglans and proximally up to pubic symphysis with division of penopubic ligament to lengthen the penis and position the urethra ventrally. tubularization of urethral plate followed by spongioplasty, corporoplasty with medial rotation of corporeal bodies (without any corporotomy) and glanuloplasty with meatoplasty to bring the meatus ventrally. skin cover with rotation of ventral fl aps and z-plasty when required. results: age of the patients varied from months to years with a mean of years. forty patients ( %) had excellent cosmetic outcome while three patients ( %) had minimal residual chordee/torque but didn't require any surgery in a follow-up to - years. all seven partially incontinent patients in the study group achieved continence aft er surgery. none of the patients developed complications like fi stula or stricture. all the patients in the post pubertal group reported normal erections and successful ejaculations aft er the surgery. post-operative follow-up ranged from - years with a mean of years. conclusions: th e technique incorporates all the benefi ts of cantwell ransley repair, needs less extensive dissection than total penile disassembly. both functional and cosmetic results are good with low complication rate. spongioplasty reconstructs near normal urethra and corporoplasty with spongioplasty also helps in prevention of urethral fi stula. introduction and objective: to introduce a unique technique, single port laparoscopic assisted extraperitoneal closure of patent processus vaginalis using j shaped bended spinal needle. materials and methods: a . -mm -degree laparoscope was inserted through an umbilical incision. th e scope could view both inguinal ring. j shaped bended g spinal needle was inserted just mm lateral to the internal inguinal ring. th e needle was introduced to the extraperitoneal space over the vas deferens and spermatic vessels, injecting of saline for the preperitoneal hydrodilation. a - polyester suture was threaded through an g spinal needle. same - polyester suture was threaded through a g spinal needle from the tip. along the guidance of the suture and g needle, j shaped bended g spinal needle was reintroduced to extraperitoneal space. g spinal needle traveled through the upper margin of internal ring, g needle tip was pulled out of the initial g needle punctured opening. - polyester suture was pulled outside from the g needle tip and then g needle is also withdrawn. aft er all these procedure, internal inguinal ring was completely encircled and tied extracorporeally. th e knot was buried in the subcutaneous area within the punctured needle hole. results: sixteen children underwent laparoscopic transcutaneous extraperitoneal (lte) repair of hydrocele by using j shaped bended spinal needle. all patients were discharged on the same day aft er surgery without any complication. during a mean follow-up period of months (range - mo), no recurrence has been observed except fi rst cases. th is lte technique is simple, fast, safe and cosmetic procedure for pediatric hydrocele. robot assisted laparoscopic ureteral reimplantation for girl and boy patients: differences and similarities introduction and objective: nowadays robot assisted laparoscopic extravesical ureteral reimplantation is getting famous and in the literature is being an alternative for gold standard open surgery. in our clinic we have performed ralur procedures in our clinic for vesicoureteral refl ux and ureterovesical stricture and with this video-abstract we would like to share our experience on ralur in girl and boy patients; diff erences and similarities of procedure. we have performed ral-ur cases in our clinic between july -april for pediatric and adult patients. technique: all procedures have been performed under general anesthesia. nasogastric tube and urethral catheter placed to all patients. for all procedures -port confi guration is used: two robotic mm trocar, one mm camera trocar and one mm (including mm cover) assistant trocar. following docking robotic working arms of robot is placed. in all procedures one monopolar curved scissors, one needle holder and one maryland bipolar forceps is used as the working arms. all procedures performed transperitoneally and extravesically. in the working area of the procedure girls have more structures compared to boys. uterus, fallopian tubes and ovaries are the risky structures for girls while the vas deferens in boys. as seen in the video fallopian tubes, uterus and vas deferens are extraperitoneal organs, but ovary is intraperitoneal organ. we create a peritoneal window to reach the retroperioneal space and to dissect the ureter. dissecting the ureter we have been very careful not to harm vas deferens in boys and fallopian tubes in girls. protecting this structures we open one peritoneal window in boys and two windows in girls to fi nd and to work with the distal part of the ureter. vessel tape is used to hang the ureters. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. aft er that the ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion (if necessary). aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed (if necessary). following detrusorotomy, mucosa is cut for the anastomosis (if necessary). before the ureterovesical anastomosis f nelaton or a dj catheter was placed inside the ureter (if necessary). ureterovesical anastomosis is made with a - monocryl suture (if necessary). in the cases that ureter and mucosa are not cut, realignment suture is used. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum to close the peritoneal window one line and two lines in boys and girls, respectively. results: ralur procedure has been used successfully in girls and boys by considering the anatomical differences. bleeding was minimal in all patients. all patients discharged at the nd or rd postoperative days. conclusion: while using ralur procedures in pediatric patients, surgeon must be aware of the anatomy. mistakes during the procedure may damage the reproductive system components. performing this procedure in children, compared in adult patients, there are diffi culties due to the small size of the abdominal cavity. with the appropriate trocar placement this problem can be solved. robot assisted laparoscopic left ureteral reimplantation for ureterovesical stricture introduction and objective: extravesical robot-assisted laparoscopic ureteral reimplantation (ralur) for vesicoureteral refl ux (vur), ureterovesical strictures (uvs) and ureteral pathologies are alternative to the gold standard open repair in the literature. with this video presentation we want to share our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique for a -year-old boy patient who is the youngest patient received this intervention in turkey. we have performed ral-ur procedure for adult and pediatric patients in our clinic. th is patient explained in the video was a -yearold boy who has had recurrent infections due to this condition. when the patient applied to our clinic he had already grade left ureterohydronephrosis. we performed left sided ralur procedure for this patient. technique: th e davinci si system was used via a transperitoneal approach. we used a port confi guration for the procedure; one -mm trochar for optic, two -mm trochars for robotic working arms and one -mm trochar for assistance. th e patient was placed in a modifi ed trendelenburg (approximately °) position. aft er docking the robotic arms, the ureter is identifi ed closed to the vas deferens. th e ureter is dissected distal to the vas and tented up with a tape. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. a cm detrusorotomy is performed". aft er that left ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion. aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed. before the ureterovesical anastomosis f nelaton catheter is placed thorough urethra and bladder inside the left tailored ureter. following this application nelaton catheter is binded to the urethral catheter. ureterovesical anastomosis is made with a - monocryl suture. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum and fi nished the procedure. foley catheter, nelaton catheter and drain are left at the end of the procedure. rectourethral fi stula is a morbid complication that can occur post trauma, radical prostatectomy, radiation, or pelvic surgery. th e management of these cases can be challenging and might require multiple procedures to achieve cure. th e use of omentum fl ap between the rectum and the urethra is recommended for its potential benefi ts in prevention of fi stula recurrence. we aim to illustrate the feasibility and safety of a new laparoscopic surgical technique for interposition of omentum in patients with complex pelvic fractures urethral injury (pfui) and rectourethral fi stula (ruf). we performed prospective case series of patients with pfui and ruf from september till october . th e initial approach is perineal with continued dissection until urethral transaction. laparoscopic team mobilises omentum and enters retroperitoneum lateral to bladder. a tvt needle is passed from perineum hugging the posterior wall of pubic symphysis and enters peritoneal cavity. th is tract is dilated and omentum transposed in to perineum. th is omentum is used as interposition between urethral anastomosis and rectum. th e clinical outcome was considered a failure when any instrumentation was needed or the recurrence of ruf. th congress of the sociÉtÉ internationale d'urologie -siu abstract book results: median age is years (range - ). all patients had complex pfui with ruf. th ey all had an attempt of perineal anastomotic urethroplasty with ruf repair that failed outside our center and were referred to us subsequently. all the patients had supra pubic catheters and of the three patients were passing urine through the rectum and the urethral meatus. one of the patients had a loop colostomy that was closed during the fi rst failed surgery. no intra-operative or post-operative complications occurred. patients were discharged home on post-operative day . all patients had the urethral catheter removed aft er weeks. th ree-month follow-up shows no fi stula recurrence with good urine fl ow. conclusion: using our new technique of laparoscopic omentoplasty for interposition of omentum in patients with ruf post pfui is a viable and safe option. th is allows us to perform a perineal surgery with the benefi t of omental interposition using a minimally invasive technique. further studies with larger number of patients as well as longer follow-up would be needed. introduction and objective: to test the hypothesis that a new surgical technique using elaborated perineal anastomotic urethroplasty combined with laparoscopic omentoplasty for patients with complex and prior failed pelvic fracture urethral defect repair was feasible, safe, and eff ective. we performed a prospective, observational, stage a study to observe treatment outcomes of combined perineal and laparoscopic approach for urethroplasty in patients with pelvic fracture urethral defect at a single center in pune, india, between january and february . complex and redo patients with pelvic fracture urethral defect occurring aft er pelvic fracture urethral injury were included in the study. anterior urethral strictures were excluded. th e primary study outcome was the success rate of the surgical technique, and the secondary outcome was to evaluate feasibility and safety of the procedure. th e clinical outcome was considered a failure when any postoperative instrumentation was needed. results: fift een male patients with a median age of years were included in the study. seven patients were adolescents ( - years) and patients ( . %) were adults ( - years). th e mean number of prior urethroplasties was . (range, - ). all patients underwent elaborated bulbomembranous anastomosis using a perineal approach with inferior pubectomy combined with laparoscopic mobilization of the omentum into the perineum to envelope the anastomosis and to fi ll the perineal dead space. of patients, ( . %) were successful and ( . %) failed. one adolescent boy years old developed a recurrent stricture months aft er the procedure and was managed using internal urethrotomy. median follow-up was months (range, - months). conclusion: combining a laparoscopic omentoplasty to a membranobulbar anastomosis for complex and redo pelvic fracture urethral injury is successful, feasible, safe, and with minimal additional morbidity to the patient. th e technique has the advantage of a perineal incision and the ability to use the omentum to support the anastomosis. dorsal results: buccal mucosal graft urethroplasty was done in all the patients with the graft being harvested from the buccal mucosa of the oral cavity. postoperative evaluation was done with voiding cystourethrogram at the time of catheter removal during the th postoperative week. mean peak urinary fl ow rate increased from . ml/sec to . ml/sec with normal fl ow curve stabilised at months to a mean of . ml/sec. patients were followed at , , and months in the fi rst year and then monthly thereaft er with urofl owmetry and ultrasonogram. mean follow-up period is around months. two patients required urethral dilatation for recurrence of symptoms. none of the patients developed stress urinary incontinence during follow-up. conclusions: female urethral stricture disease is under diagnosed and bmg urethroplasty is underutilised. our study adds to the limited evidence base, that bmg urethroplasty can be done safely with good results in females. a introduction and objective: ureteral fi stula's treatment oft en includes long and complex surgical and endoscopic therapies and represent a challenge for the urologist oft en with disappointing results. uventa® stent placement could represent a new option of conservative treatment for ureteral fi stulas. materials and methods: uventa® self-expanding ureteral stent are able to restore urinary fl ow in ureteral stenosis and to facilitate the closure of ureteral fi stulas thanks to its triple layer structure made of two layers of metal mesh with interposed a ptfe membrane. uventa® stents are available in diff erent lengths and diameters, and allow the coaxial overlap of the ends of multiple stents, providing a lumen of large caliber able to ensure the proper urinary fl ow and the possibility of further endoscopic procedures. we show the case of -year-old man that in september , undergone to pelvic surgery for an adenocarcinoma of the sigma in advanced stage. th e postoperative period revealed a urinary leakage, dealt initially in conservative way by the general surgeon. due to unsatisfactory results, the patient was then evaluated by the urologist and subjected to bilateral ascending pyelography highlighting the presence of a high fl ow left ureteral fi stula in pelvic tract; he case was managed immediately with bilateral ureteral stenting prior to placement of a uventa® stent. th e subsequent step was a retrograde pyelography through the left stent, used to identify the site of the ureteral fi stula. aft er hydrophilic guidewire positioning and mono-j stent removal, the delivery system of the uventa® stent is advanced coaxially to the guidewire under radiologia control. once reached the desired position the stent is released from its delivery system whit pull-back technique playing a uventa® stent fr x cm allowing its simultaneous self-expansion. th e next ureteroscopic control has shown the need to placement of an additional uventa® stent to complete fi stula's coverage. following the insertion of a hydrophilic nitinol guidewire a new uventa® stent fr x cm has been positioned further in order that the ends of the two stent's overlap for a length of at least cm. results: intraoperative retrograde pyelography showed that the stent have eff ectively excluded the fi stula. th e absence of contrast medium leakage was also documented by retrograde cystography performed after days from stents positioning. conclusions: in our experience, the application of uventa® stent has proven to be an eff ective option in the conservative treatment of minimally invasive ureteral fi stulas. robotic we performed fi ve robotic ureteroplasties using a buccal mucosal onlay between september and march . th e graft was procured by our otolaryngology colleague (jcl). th e graft onlay was performed using - pds suture and stent was placed robotically. stent was left in place for - weeks, and imaging repeated aft er removal. results: table describes each case and the outcomes observed. th e three patients who have undergone stent removal and reimaging had complete success and resolution of obstruction. th ere were post-operative complications, and none were higher than grade iii (table ) . table shows the demographic and perioperative variables of the patients undergoing this procedure. conclusion: our technique of robotic buccal mucosal ureteroplasty is safe and eff ective. we believe this is a relatively simple technique which is easily replicated. long-term data will be important to prove the validity of this procedure. primary endoscopic realignment of rupture urethra introduction and objective: pelvic fracture urethral injury (pfui) is more common in india and subcontinent. th ere is no consensus on the initial management of this injury. th ere are two schools of thoughts in all cases of suspected or confi rmed urethral rupture: a) initial supra-pubic catheterization (spc) followed by urethral reconstruction of inevitable stricture; and b) realignment of urethra. we demonstrate method of primary endoscopic realignment of rupture urethra and review the literature comparing these two procedures. a /m-presented with retention of urine and bleeding per urethra. he had sustained pelvic trauma when he was crushed between a tank and a wall. aft er initial resuscitation he had x ray pelvis, ct abdomen, rgu. he then underwent spc under ultrasound guidance. on th day aft er spc he underwent primary endoscopic realignment of the rupture urethra. we have shown a technique and reviewed the relevant literature emphasizing advantages of realignment. results: we used a two endoscopes technique one each from the spc route and per-urethral route. intra-operative contrast study was done to see extent of injury and also to see possible patency and continuity of the urethra. additionally methylene blue study was also done. a ptfe guide wire (gw) was passed from below. at the fi rst site of the gw from above it was apparent that further manoeuvers such as "going for light" would not be required. th e gw was carefully pulled in suprapubically. a silicon foley catheter ( f) was gently passed perurethrally over it. th e position of catheter was confi rmed suprapubically. patient had no major or minor complication. catheter was placed in for weeks and removed. post catheter removal patient voided well. th ese results correlated well with other studies in the literature. conclusion: ) technically not a challenging procedure. ) low risk and low complication rate. ) one failure of procedure does not preclude further attempts. ) adequate experience and instrumentation are essential. ) level evidence in favor of this approach over spc alone and further urethroplasty. neourethra with penile skin flap after total amputation of the penis kulkarni s, joshi p, batra v, sharour w, hunter c, surana s, kulkarni j introduction and objective: urethral carcinoma is a rare oncological entity. th e standard treatment for invasive urethral squamous cell carcinoma is radical penectomy, prostatectomy, cystectomy and ileal conduit. in our technique, we describe a palliative surgery that avoids the ileal diversion and perineal urethrostomy through the use of dorsal penile skin tubularization. th is video represents a detailed, step-by-step technique for retro auricular graft harvesting that we have found facilitates resident and general urologist teaching. ears were prepped and draped. th e grafted was areas were marked bilaterally. diluted lidocaine with epinephrine was injected subcutaneously. th e graft was harvested using sharp scissors. donor site was closed in two layers with minimal aesthetic changes. conclusions: our technique to harvest retroauricular graft is a simple and reproducible. it is useful in patients with lack of bmg. th is step-by-step video could be a useful resource for residents and general urologist who wish to learn an alternative graft . hand combined antegrade and retrograde intraureteric surgery in re-implanted ureter introduction and objective: we review a case of re-implanted ureter complicated with stricture and stone impaction. a -year-old gentleman was following the urology department at hmc. between the year until he was managed by the same urology team for his multiple urological complaints. diff erent open and endourological approaches were conducted. at the year of , this gentleman was complaining of colicky pain due to a cm impacted stone in the left lower ureter, sessions of eswl failed to break it. ivu showed left ureteric stricture, cystoscopy with trial of ureteroscopy was unsuccessful because the left ureteric orifi ce couldn't be identifi ed, so left percutaneous nephrostomy access inserted and followed by antegrade fl exible ureteroscopy, small opening found at the lower part of mid ureter and opened widely by laser, then followed by antegrade double j stenting. retrograde rigid ureteroscopy french identifi ed the stone at mid ureter in a later session and fragmented by laser. a double j stent was reinserted and removed later with smooth recovery. results: management of stones, in the male urethra, is a challenge, more so in a reconstructed urethra. th e dilemma always is whether it is worth incising an otherwise normal or reconstructed urethra, to extract a calculus, especially in this minimally invasive era. th e point to note is the 'painting' technique used to powder the stone, rather than fragmenting the stone into large fragments, which are then diffi cult to remove. high frequency and low energy laser setting is the order of the day. conclusion: laser lithotripsy using a high frequency low energy setting, is a good option for urethral calculi in a reconstructed urethra. retrograd introduction and objective: uretery duplication is a most common congenital anomaly of upper urinary system. th e incidence of it, in autopsy and intravenous pyelography (ivp) series, is . % and - % respectively. it is two-fold more frequent in women than men. retrograde intrarenal surgery (rirs) is a new technology in stone surgery with the fl exibility and most eff ective visualing. in patients who suff er from kidney or uretery with ureter duplication, rirs become the best surgery choice with its advantages. in this case, we present a patient who have the symptoms of kidney stone and ureter duplication. a -year-old male patient applied our clinic with the left fl ank pain. in his intravenous pyelography (ivp) and computerized tomography, it was clearly seen left ureter duplication of which both ureteropelvic junction and duplicated ureters obstructed by two kidney stones. other laboratory tests were normal. rirs surgery was performed the patient successfully. postoperative fi rst day patient was discharged without any complication. results: ureter duplication is a rare congenital anomaly of upper urinary system but the rarest thing is that the obstruction of both duplicated ureters with upj by kidney stones. in our case this kind of case successfully treated by rirs. in this surgery a new technique of access sheet entering for rirs was applied. to our knowledge it is the fi rst case in literature. surgical procedures in patients with urinary tract abnormalities are more diffi cult than the normal anatomy. th e development of new technologies is changing approach to such cases. rirs fi eld of use is gradually increasing in urologic practice. rirs in is a preferable method in duplicated ureter with stone formation. a introduction and objective: nephron-sparing surgery is now the standard of management of small renal mass and is increasingly performed for larger and more challenging lesions. th e aim of this study is to report our experience with robotic partial nephrectomy (rpn) and lapascopic partial nephrectomy (lpn) in patient's surgical outcome (blood loss, wit los renal function, complication). ( )) aml (rpn ( ) lpn ( )), oncocytoma (rpn ( ) lpn ( )) and simple cyst (lpn ( )). th e positive surgical margin rate were both % in rpn and lpn group. th e decline in glomerular fi ltration rate at the last available follow-up was similar in both groups. laparoscopy training at home guijarro a, ascencios j, morales s, huertas j, fernández b, navarro f, paniagua p introduction and objective: th e increasing use of laparoscopic surgery makes training fundamental to acquisition of the basics techniques of endourology. unfortunately, laparoscopic fi eld requires high ability and a long learning curve so it's needed simulators to practice. traditional pelvitrainers improve the laparoscopic skills of a trainee but don't simulate the real conditions of the human body. we present a homemade training surgical model that may help to achieve the skills needed and simulates the abdominal space. it is called simulated environment for laparoscopic training (selt). we have developed a laparoscopic training system based in a simulated environment. we modifi ed a dummy who represents a human trunk, this model it easy to fi nd in hardware stores. th en, we performed several orifi ces in order to place traditional laparoscopic ports in pelvic surgery disposition and two additional for our camera. inside the dummy we placed three screws and developed another hole for attaching a cork panel. also, we used a wardrobe fl ashlight as lighting system. as optical system we have used a inch tablet or a photographic camera linked to the tv. finally, for reproducing a vesicourethral model we use two balloons in order to create an anastomosis between them. final price for the selt model, excluding optical system and disposables (we used discarded ports) was euros, what is signifi cantly lower than the commercial pelvitrainers. time needed for installing all the devices is about minutes. results: th e level of simulation is high, it is more realistic, being harder and diffi cult than "traditional" pelvitrainers. th e degree of movements is limited by the real placement of the ports, distance until exercise is similar and we have to be able to work without results: nine patients underwent tmc left pyeloplasty. th ere were female and male patients with age ranging from - years .operating time ranged from - minutes with mean of minutes. per-operative blood loss was minimal ranging from - ml. return of bowel movement was within - days. all patients were discharged within days and drain removed with - days. two patients were discharged on nd day but drain was removed on rd day in outdoor. follow-up of patients showed improvement in their pain status and ivu showed no re-stricture or stenosis. our last patient is yet to come for the fi rst follow-up. conclusion: tranmesocolic approach for left puj obstruction is feasible and seems to have low morbidity with shorter hospital stay. comparison with colon-refl ecting pyeloplasty and larger number of cases are needed for better statistical evaluation. transperitoneal conclusion: th e overall cdr ( %) for our cohort was comparable to results from mri in-gantry biopsy. in volumes > cm , the cdr was % which was signifi cantly higher than that achieved by historical trus controls. th is study reinforces the benefi t of fusion biopsy in prostates in all volumes, but this utility is further enhanced in large volume glands without the potential toxicity associated with increased number of biopsies. fusion mim-transperineal fusion biopsy has the greatest impact in the biopsy naive population results: during the above mentioned period patients underwent radical prostatectomy. in ( . %) cases erp was preceded by mpmri and psm was detected in of them ( . %). in the majority of patients ( / ; . %) with positive margins pca was locally advanced or gleason score was greater than . th e margin was focal in ( . %) cases. th e most frequent location of psm was the prostate apex. it occurred in patients ( . %) and in of them the right side was involved. in ( . %) patients psm was detected in a location in which mpmri did not reveal the presence of pca. in of them, cancer invaded periprostatic tissues. macroscopic evaluation of the specimen performed directly aft er the erp indicated the possibility of psm presence only in patients but in both cases histological evaluation of the prostate specimen revealed extensive psm. the peri-prostate fat seen on mri. prostate volume was calculated using (height x width x length x π)/ . peri-prostatic fat density was then calculated using peri-prostatic fat volume/ (peri-prostatic fat volume + prostate volume). peri-prostatic fat ratio was calculated using (peri-prostatic fat volume / prostate volume). intervention includes cryoablation, brachytherapy, prostatectomy, external beam radiation with or without androgen deprivation therapy. results: a higher periprostatic fat density is signifi cantly associated with a higher gleason score, p= . , odds ratio . . a higher periprostatic fat ratio is also associated with a higher gleason score, p= . odds ratio . .patients with a higher prostate fat density (p= . , odds ratio . ) and higher peri-prostatic fat ratio (p= . , odds ratio . ) was also more likely to undergo intervention for prostate cancer (table ). psa has no correlation between periprostatic fat and periprostatic fat ratio. a higher prostate fat density and fat ratio is signifi cantly associated with a higher gleason score and a higher likelihood of patient undergoing an intervention for prostate cancer. peri-prostatic fat density and fat ratio may be an important risk factor in diagnosing patients higher grade prostate cancer. laparoscopic . th e mean urinary ph among the diabetics was . ± . and among the non-diabetics was . ± . , which was signifi cantly lower (p< . ). conclusions: th ere is a strong association between type diabetes and uric acid stone formation. th ere is also a strong association between diabetes mellitus, bmi, and also with lower urinary ph. the most patients ( %) were discharged on good condition while one patient died post-operatively. majority of patients ( %) stayed in the ward more than days post operation, the long-term post-operative outcome is yet to be assessed. conclusion: usd in our local setting seem to aff ect people of low social economic status whose daily activities in the fi elds, livestock keeping etc. mean survival; therefore longer stay in the hospital has a detrimental economic impact. outdated diagnostic, treatment equipment and technology lead to prolonged hospital stay. th ere is a need therefore for administrators and urologists in tanzania to improve quality of management of usd by acquiring aff ordable equipment and technologies. percutaneous nephrolithotomy in an ambulatory setting introduction and objective: percutaneous nephrolithotomy (pcnl) is the gold standard for the surgical management of large renal stones. various modifi cations have been done over a period of time to bring down the morbidity of this procedure. ambulatory pcnl (a-pcnl) aims at short hospital stay which is less than hours with faster recovery aft er pcnl. th is study aimed at exploring the feasibility and safety of short stay ambulatory pcnl. : th e number of pcnl procedure done at our institute annually ranges between - . hence, carefully selected patients with single renal calculus, size< cm, bmi < kg/m , favorable anatomy, no medical co-morbidities and moreover patients staying within a radius of km to the hospital with a supportive well informed family were given the option of a-pcnl. a total of patients underwent a-pcnl from april to june . all patients underwent totally tubeless pcnl with single puncture, amplatz size < f, minimal saline irrigation and puncture site infi ltration with . % bupivacaine. postoperatively narcotic analgesics were given; catheter was removed in the post-operative ward and patient was discharged within hrs. patients were explained regarding the complications of the procedure and need for homecare management. results: ten out of patients had insignifi cant post-operative period. one patient returned aft er hrs with loin pain which was evaluated and managed with injectable nsaid. another patient had hematuria which resolved aft er hours with conservative management. introduction and objective: chronic kidney disease (ckd) is associated with increased cardiovascular (cv) disease, independent of other risk factors. it is unclear whether anaemia develops in the setting of nephrectomy induced ckd, and whether it leads to an increased risk of cv morbidity. we assessed the impact nephrectomy has on renal function and evaluated our cohort for the presence of anaemia in relation to ckd stage and cardiac specifi c morbidity. pre-operative, post-operative, and yearly creatinine, hb and hct (up to years) was collected from nephrectomy patients between and . th e cohort was stratifi ed by cardiac risk factors and the prevalence of anaemia was stratifi ed by each ckd stage. we collected all-cause mortality and cv morbidity and mortality data. statistical tests were two-sided. where data was non-normally distributed median values and non-parametric tests were used. results: th e eff ect of nephrectomy on renal function is immediate (pre-operative vs. post-operative cr: p= . ) but not progressive (post-operative vs. -year cr: p= . ). elderly patients, patients with ≥ risk factors, bmi≥ or hypertension had signifi cantly higher post-operative cr (p= . ; p= . ; p= . ; p= . ). advanced age and mild ckd were important risk factors for ckd stage progression. th e prevalence of anaemia increased as ckd stage increased. at one year, the prevalence of anaemia was highest in ckd- patients ( . %), compared to ckd- ( . %) and ckd- ( . %) patients. fift een percent of patients experienced a new cv event; % of these patients were anaemic. conclusion: nephrectomy leads to immediate renal function deterioration but with no progression over time. th e clinical impact of nephrectomy is especially important in elderly patients and in patients with mild pre-operative renal impairment. th e prevalence of anaemia is more common in patients who have a higher ckd stage aft er nephrectomy, and may be a key risk factor for cv morbidity in nephrectomy patients. we believe that it is important to be able to predict who will progress to clinically signifi cant ckd, in order to optimise comorbidities and aggressively treat complications of ckd, such as anaemia. renal results: urological complication were observed in . % of all transplants. in an early phase we found that . % of patients showed problems related to the ureterovesical suture (loosening of the suture or attaching the double-j stent in the suture). suspicion of leakage with the formation of a urinoma was noted in . % of cases. more frequent were the late urological complications: hydronephrosis was seen in . % of cases. when further analyzing this group we discovered a distal ureteral stenosis in . % of all transplants. persistent hydronephrosis was resolved by reimplantation ( . %), permanent nephrostomy ( . %) or placement of a double-j stent ( . %). a large group of late complications consisted of infectious pathology. th us . % suff ered from complicated urinary tract infections which slightly more than a quarter of this population presenting with hydronephrosis. recurrent urinary tract infections without complications were found in . % of transplanted patients. conclusion: currently, the urological team mainly plays a role in the pre-and post-operative phase of renal transplantation. given the signifi cant compli-cations associated with the ureterimplantation performed during kidney transplantation, we advocate a place for the urologist in the perioperative phase as well. since the majority of the complications could be related to refl ux pathology, we propose a ureterimplantation with anti-refl ux mechanism. and october , patients were prospectively randomised into two groups. all patients presented with a simple renal cyst underwent ultrasonographic aspiration and injection of a sclerosing agent. in group , patients had the cyst injected with eo, and in group , were treated with ae. one injection was used in cysts of < ml and two injections were used in larger cysts. complete and partial success were defi ned as complete cyst ablation or a > % reduction in cyst volume with symptomatic relief, respectively. patients were followed up using semi-annual ultrasonography and computed tomography for years. results: sclerotherapy was technically successful in all patients. th ere was no signifi cant diff erence in cyst volume between the groups. aft er years of follow-up there was complete symptomatic relief in both groups, and the overall radiological success rate was % of both groups, at % complete and % partial in group , and % complete and % partial in group . th e frequency of transient complications in the form of microscopic haematuria was % and %, and of low-grade fever was % and % in groups and , respectively. a composite outcome parameter, known as "trifecta", has been recently proposed as measure of the surgical quality for partial nephrectomy (pn) procedures. we aim to validate the value of "trifecta" as a predictor of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive pn. we retrospectively reviewed records of consecutive cases of minimally invasive (laparoscopic and robotic) pn performed for ct renal masses in centres from usa and europe from to . inclusion criteria consisted of availability of a renal scan obtained within two weeks prior to surgery and follow-up renal scan - months aft er the surgery. trifecta was defi ned as a combination of negative surgical margin, zero perioperative complications and warm ischemia of less than minutes. th e primary endpoint of the study was to compare the degree of ipsilateral renal function preservation in relation to achievement of trifecta. renal function preservation was defi ned as a proportion of post-operative to pre-operative split renal function assessed by mag renal scan. a multivariable linear regression model was used to determine the independent value of several factors (surgical modality, charlson comorbidity score, achievement of trifecta, r.e.n.a.l score) to predict ipsilateral split function preservation. th e logic was that pnet is chemo-responsive and remaining are not. results: a total of patients were identifi ed. th e various histo-pathologies are shown in table . group had and group had patients. mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( %) and left -sided in ( %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( . %) and left -sided in ( . %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . one of these was diagnosed pre-operatively by a biopsy and had received chemotherapy with partial tumor shrinkage. remaining received adjuvant chemotherapy. of relevance is that the youngest patient in group was years whereas the oldest patient in group was years. in patients with renal tumors and venous thrombus who are younger than years, pre-operative biopsy should be contemplated. in patients with a diagnosis of pnet, neo-adjuvant chemotherapy can be studied. introduction and objective: th e use of nephrectomy in emergency is increasingly rare due to the improved critical care urinary sepsis and development of radio-embolization. few series have been reported on this subject. th e aim of our study was to evaluate current indications, morbidity and mortality and results of nephrectomies performed in our hospital in emergency. a single-center retrospective study was conducted from january to december . twenty patients were operated in emergency from total nephrectomy. results: nine women and men with a mean age . ( . to . ) were treated for sepsis on emphysematous pyelonephritis or renal abscess, trauma with haemorrhagic shock, acute bleeding on renal tumours with haemorrhagic shock. one patient required critical care for multiple organ failure. th e time between the initial care and surgery was . days ( . - ). ten patients were referred to the emergency room by their physician and by a peripheral hospital. all these nephrectomies concerned native kidneys ( left kidneys). surgical approach was a lumbotomy for patients and a median laparotomy for patients. one patient died of multiple organ failure following urinary sepsis. one patient required dialysis following nephrectomy. th e mean follow-up aft er surgery was . months ( . to . ). conclusion: th e nephrectomy in emergency remains anecdotal. uncontrolled urinary sepsis were the main indications. th e identifi cation of populations at risk of progression to septic shock is essential for faster and reduced mortality in sepsis care. experiences of adrenalectomy for the incidentally discovered adrenal masses introduction and objective: a diagnosis of urinary tract obstruction (upjo) results in a functionally signifi cant impairment of the urinary transport from the renal pelvis to the ureter. options for the surgical management of upjo include ureteral stent placement, balloon dilation (antegrade, retrograde or cutting balloon), endopyelotomy, and open or laparoscopic pyeloplasty. however, in some cases, surgery is not eff ective, or too invasive for a particular patient. we herein report ten cases of treatment using bethanecol chloride. we retrospectively reviewed the record of patients, men and women, aged - years (mean . ) whose diagnosis was upjo ( cases of hydronephrosis on the left , on the right). th e chief complaints were back pain ( cases) and urinary tract infection ( cases). one patient had no complaint. all patients took mg of bethanecol chloride times a day for two weeks. aft er two weeks, kidney condition was evaluated using ultrasonography. results: five cases of hydronephrosis decreased or disappeared. five cases showed no improvement. among the latter, one had pyelonephritis, two had received laparoscopic pyeloplasty (one of whom had a non-functioning kidney and a pyelonephritis), and another had a non-functioning kidney. guzman martinez-valls p, sanchez rodriguez c, doñate iñiguez g, maluff torres a, honrubia vilchez b introduction and objective: we present man -yearold, hypertensive, diagnosed incidentally of intrathoracic renal ectopia during a constitutional syndrome study. intrathoracic renal ectopia is a very rare fi nd, with an incidence of less than of every , , which mainly aff ects left kidney since the liver protects the right diaphragm from pressure changes. a literature review of incidence, source, clinic, diagnostic and treatment of this type of renal ectopia occurs and we present the case diagnosed in our service. : chest x-ray shows a mass back in mediastinum so it was decided to ask for tomography computer (ct) that shows a hernia left postero-lateral difragmatic with promotion to the thoracic cavity of upper pole and half of the left kidney. since the patient is asymptomatic and the hernia is extrapleural does not need repairing surgical treatment. annual checks will be. intrathoracic renal ectopia is a very uncommon, usually asymptomatic, fi nding oft en diagnosed incidentally and which does not usually require treatment. surgical ( ), non-clamp zero ischemia ( ). th e average blood loss was ml (range ml - ml) and patients ( %) required blood transfusion. postoperatively patients ( %) had surgical complications: severe haemorrhage requiring emergency completion nephrectomy ( ), post-operative urinoma formation requiring ureteric stenting ( ), pneumothorax requiring tube thoracostomy ( ) . early day mortality occurred in one patient with pre-existing stage chronic kidney disease who died of acute on chronic renal failure. th e r.e.n.a.l. score of those with and without surgical complications was . and . respectively. th e complication rate of low (score - ), intermediate (score - ), and high (score - ) r.e.n.a.l. category was . %, . % and % respectively. statistically, blood loss, transfusion rate and surgical complication rate were not signifi cantly associated with medical co-morbidity, r.e.n.a.l. score or mode of ischemia, although more complex mass apparently resulted in more surgical complications. our study suggested that partial nephrectomy is a safe operation with acceptable bleeding risk and low complication rate. further larger scale study is needed to analyze the correlation of complications with renal mass complexity. introduction and objective: th e sound of running water has been eff ectively used for toilet training during the toddler period. however the eff ect of the sound of running water (srw) on voiding function for adult male with lower urinary tract symptoms (luts) has not been evaluated yet. to determine the eff ect of the srw on urination of male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of the srw played by mobile application. a statistically pre-calculated numbers of consecutive male patients with luts were prospectively enrolled between march and april , excluding patients with hearing impairment, disability for movement, neurologic disease, urology deformity, and recent history of urinary tract infection or urethral stricture. urofl owmetry with pvr measured by bladder scan were randomly performed once a week for two consecutive weeks with and without srw in a completely sealed room away from exterior noise aft er pre-checking bladder volume scanned to be more than cc. th e srw was played with river water sound among relax melodies recorded in the smart-mobile application. results: th e mean age of enrolled patients and their mean ipss were . ± . years (range: - ) and . ± . . all patients have not been prescribed any medications including alpha-blocker or anti-muscarinic agents in the last three months. a signifi cant increase in mean peak fl ow rate (pfr) with srw was detected in comparison with pfr without srw ( . ml/s vs. . ml/s, p = . ). however, there were no diff erences in other urofl owmetric parameters including pvr. materials and methods: over a two-year period, men underwent lumbar spinal fusion by a single neurosurgeon. we excluded men with previous prostate or urethral surgery, a history of urinary retention, men taking alpha-blockers or fi ve alpha-reductase inhibitors, and men with prolonged hospital stay, leaving men evaluable. all men left the operating room with a foley catheter in place and were given a void trial on the day of anticipated discharge. twenty-three men were unable to void aft er eight hours and had their foley catheters replaced; they were discharged next day with an appointment for urologic follow-up. th ese men were compared to successful voiders with respect to comorbid medical conditions, age, surgical placement of hardware, operative time, lumbar level, multiple level fusion, and surgical approach. results: using multivariable analysis, successful postoperative voiders were compared with men who failed the initial voiding trial. only insulin-dependent diabetes mellitus (p-value less than . ) and multiple lumbar level surgery (p-value less than . ) were predictive of initial postoperative failure of voiding trial. conclusion: men scheduled to undergo lumbar fusion who have insulin-dependent diabetes or who will require multiple level intervention may benefi t from preoperative initiation of alpha blockade at the time of scheduling, as well as an inpatient postoperative urologic consultation. introduction and objective: heart rate variability (hrv) is a tool to measure autonomic nervous function, however there is no evidence that it is able to defi ne sympathetic hyperactivity in men with luts. we suppose that luts is diff erent between sympathetic hyperactive and hypoactive patients. th erefore we measured their hrv, divided luts patients into two groups, sympathetic hyperactive group and sympathetic hypoactive group according to the lf/hf ratio, and then compared their clinical situations. a total of symptomatic luts patients (ipss> ) and healthy volunteers were enrolled. all subjects had no disease which can aff ect autonomic nervous system, such as diabetes, hypertension and so on. electrocardiographic signals were obtained from subjects in resting state and calculated the hrv indices with spectral analyses. we divided luts patients into two groups by lf/hf ratio . which was mean value in healthy volunteer and compared the diff erence of clinical characteristics, ipss, psa and trus results. th e parameters were compared by independent sample t-test using spss version . results: th ere was no diff erence in age, serum psa and volume of prostate. th e comparative results of pa-rameters of hrv between groups (mean ± standard error) are in the table . conclusions: as most investigators believe that lf and hf represent sympathetic and parasympathetic nervous system activity, respectively, our results may suggest that luts patients with relatively sympathetic hypoactivity suff er from nocturia more than those with sympathetic hyperactivity. we suggest that the imbalance of the autonomic nervous system activity may be a factor that evokes varieties of symptoms in men with luts. introduction and objective: women presenting with urogenital pain oft en have lower urinary tract symptoms (luts). pelvic fl oor dysfunction and hypertonicity is thought to contribute to these symptoms. physical therapy and myofascial release are eff ective for both conditions, suggesting a common underlying pathophysiology. we aim to investigate the association among pelvic fl oor tone, luts, and pelvic organ distress. th ere was a tendency of lower hemoblobin decrease in ari group, however, this results was not statistically signifi cant. th ere were also no significant diff erences in improvement of ipss, qol and urodynamic fi ndings between the two groups. conclusion: preoperative use of ari does not compromise, but rather increase the effi ciency of surgery. th e use of ari is not a contraindication to th ulium laser vapoenucleation. age-specifi c relationships between lower urinary tract symptoms and late-onset hypogonadism symptoms in the japanese general population introduction and objective: aging is known to aff ect sexual, psychological and physiological functions including lower urinary tract symptoms (luts). recent data suggested that severity of luts was associated with that of late-onset hypogonadism (loh) in elderly men. however, information on the association in young adults is limited. in this study, we evaluated the relationship between luts and loh symptoms in young and middle-aged adults. results: th e mean ages of the patient and control groups were . ± . years and . ± . years, respectively (p= . ). th e mean ifsf-total and all of the ifsf sub scales (except pain) in the patient group were signifi cantly lower than those of the control group. th e mean udi- score of the patients was signifi cantly higher than the controls (p= . ). th e mean iiq- scores of the patients was higher than controls, however this increase was not statistically signifi cant (p= . ). introduction and objective: sav is one of the core components of hippo pathway, and this pathway plays a role for cell proliferation, apoptosis and migration through regulation of yes-associated protein (yap ). yap is known as an oncogenic protein in many human cancers, but only a few studies demonstrated that yap acts as an oncogene in renal cell carcinoma (rcc). in our previous study, we identifi ed sav was downregulated in high grade clear cell renal cell carcinoma (ccrcc) cases compared with low grade ccrcc cases and re-expression of sav inhibited rcc cell proliferation in vitro. to evaluate a role of sav in vivo, we created a murine xenograft model of human rcc. a total of -o cells with stable sav re-expression (sav - ) and control cells (control) were subcutaneously injected into the fl anks of mice, respectively. th ese two cell lines were also injected into subrenal capsule. tumor size, histological appearance and proliferation rate were evaluated. furthermore, transcriptome analysis was performed using a whole-genome microarray, in order to identify functional pathway by ingenuity pathway analysis (ipa) soft ware. to explore whether the identifi ed pathway was involved in hippo signaling pathway, western blotting was performed using antibodies against downstream proteins. in addition, the luciferase reporter assay was performed to explore whether the promoter activity is regulated by hippo signaling. results: tumors injected with sav - showed a decrease of tumor size and growth rate, compared with those of control. by immunohistochemical analysis, it was shown that re-expression of sav caused yap to localize in the cytoplasm. pathway analysis revealed that tgfβ signaling was found to be inhibited in tumors with sav - . in sav re-expression cells, protein levels of tgfβ were lower than those in control cells. when yap and tead were introduced, reporter activity of tgfβ promoter was increased. attached to a linear motion stage with a stepper motor. shaft buckling was determined by measuring the peak force to compress a cm section of the shaft a distance of cm. lubricity was measured by extracting each wire through simulated tissue at a constant speed, measuring average force over a second period. tip fl exibility was determined by isolating the distal cm portion of each guidewire and measuring the peak force required to compress a distance . cm while securing the tip in a small hole in a wooden block. perforation force was evaluated by stabilizing each wire in the dilator of a ureteral access sheath and measuring peak force required to perforate aluminum foil. up. , table . th e results showed that kh- protected tm cells against h o -induced oxdidative stress in a dose-dependent manner. it improved signifi cantly both the decline of semen parameters and decrease of testicular weight of androgen-defi cient rats at a dose of mg/kg. also it inhibited the activities of aromatase with and then increase the serum testosterone levels. conclusion: th ese results suggested that the aromatase inhibitory activity of kh- may contribute to the improvement of serum testosterone levels in androgen-defi cient male rats. introduction and objective: although several theories have been suggested, the pathophysiology of interstitial cystitis/bladder pain syndrome (ic/bps) is unclear. disruption of the bladder epithelial barrier is an important pathophysiologic theory of ic/bps, and uroplakin is known to have an important role in the bladder epithelial barrier. th e change in expression of uroplakin subtypes in the bladder could be related to ic/bps. we investigated the change in expression of uroplakin ib and iii in the bladders of patients with ulcerative ic/bps. bladder tissue samples were obtained from patients with ulcerative ic/bps who were treated with augmentation ileocystoplasty. samples for the control were obtained from normal bladder tissue apart from the malignant lesions of patients with bladder cancer who needed radical cystectomy. a voiding diary, the pain visual analogue scale (vas), and the o'leary-sant interstitial cystitis symptom index (icsi), and problem index (icpi) were used to assess patients with ic/bps before operation. expressions of uroplakin ib and iii were compared between the ulcerative ic/bps and control groups by immunofl uorescence staining and western blotting. results: in total, patients with ic/bps (mean age . ± . years, women and men) were evaluated. th e mean symptom duration was . ± . years. preoperative voiding frequency, nocturia, and functional bladder capacity documented in the voiding diary were . ± . , . ± . , and . ± . ml (mean ± sd), respectively. pain vas score, icsi, and icpi were . ± . , . ± . , and . ± . (mean ± sd), respectively. th e mean anesthetic bladder capacity was . ± . ml. immunofl uorescence staining showed that uroplakin ib and iii were localized in the urothelium. in western blot analysis, immunoreactive bands indicating expression of uroplakin iii were signifi cantly increased in the ic/bps group compared with the control group. however, uroplakin ib expression was not diff erent between the ic/bps and control groups. green fl uorescence protein cassette, and the infectivity of kshv was assessed using fl ow cytometry. to investigate viral replication, the levels of expression of representative kshv latent and lytic proteins were analyzed by immunofl uorescence assay. in addition, cell cycle and proliferation following kshv infection was analyzed. finally, cdna microarray was performed to identify gene changes by infection of kshv in bc. results: four bc cell lines, except rt , showed levels of infection similar to or higher than those of hu-vecs. infectivity of kshv in tccsup and huvec cells was similar, but t , , and ht- cells showed signifi cantly higher infectivity than huvec. our tested kshv-infected bc cells were latently infected by kshv. interestingly, a subset of kshv-infected bc cells showed higher brdu incorporation and proliferation rate than non-infected cells. furthermore, in soft agar colony formation assay, the numbers and sizes of colonies of kshv-infected cells were signifi cantly greater and larger, respectively, than non-infected cells. cdna microarray analysis showed that many proliferation and cancer development-related genes were simultaneously up-regulated in kshv-infected cells. introduction and objective: bladder cancer (bca) is the second common genitourinary tumor, and especially muscle-invasive bca (mibc) is poor prognosis. th erefore, it is important to clarify the mechanism of invasion in mibc is useful for the strategy of appropriate treatment. previously, we have showed hgf-met signaling is correlated with invasion in bca cells. here, we investigate the eff ects of met inhibitor, cabozantinib (xl ), in bca cells to investigate the significance of met upregulation in rt , , j , t , um-uc- cells, we conducted western blot analysis. next, we examined eff ect of cabozantinib on proliferation and invasion abilities using mtt and matrigel invasion assays. invasion assays were performed by the xcelligence system. moreover, to investigate biological function of hgf-met signaling, we analyzed gene expression profi le and real time pcr of cells which cultivated with or without hgf stimulation. . th e mechanical properties of scaff olds were measured to compare tensile strength between two types. for in vitro cell study, scaff olds were seeded with human fi broblast cell at x cells and were cultured for up to weeks. th e ability of these scaffolds to support fi broblast cell growth was also investigated in vitro. results: d strand-deposited scaff olds were characterized by sem images and porosity measurement. sem images showed the surface morphology of pcl scaff olds. th e young's modulus of °pcl was . ± . mpa, and °pcl was . ± . mpa, respectively. human fi broblast cells covered well the surface of the scaff olds. immunofl uorescent staining of α-er-tr on fi broblast cells/scaff olds confi rmed that the cells remained viable and proliferated throughout the time course of the culture. th is is a preliminary study to investigate the possibility of using d bioprinting technique for tissue engineered tunica albuginea. introduction and objective: aft er - years at people the decrease in a pool of pluripotent stem cells resulting in insuffi ciency of replenishment of cellular structure of cambial zones and, as a result, to incomplete replacement of the perishing old cells is observed. in reply surrounding epithelial and endothelial cells, and also the macrophages, attracted with death of old cells, stimulate cells division of growth zones by the cellular growth factors (pechersky a.v. et al., ) . to patients aged from till years with a cancer of a kidney, bladder, prostate gland of a stage of t -t the chemotherapy or target therapy was carried out. to patients of - years for restoration of regeneration it was carried out from to transfusions of mononuclear fraction of peripheral blood, same-gender and blood types with recipients. results: in month aft er carrying out chemotherapy or target therapy aft er development of a leukopenia in patients the level of the basic fi broblast growth factor (bfgf) increased on average by . times, at patients from them the increase in level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had an increase in the human epidermal growth factor (human egf) on average by . times. in - months aft er the last transfusion of mononuclear fraction of peripheral blood the maintenance of hemopoietic cells predecessors of cd + in peripheral blood increased on average by . times (at patients with to - cells in mcl). at patients the level of the basic fi broblast growth factor (bfgf) decreased on average by . times, at patients from them reduction of level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had a reduction an human epidermal growth factor (human egf) on average by . times. decrease in levels of cellular growth factors naturally brought at all patients in a buccal epithelium to decrease in an expression of p on average by . times, at the rd of them to decrease in an expression of bcl- on average by . times. excess stimulation of mitotic activity at people years are more senior it is possible to lower to normal level by means of restoration of number of a pool of pluripotent stem cells by transfusion of mononuclear fraction of the peripheral blood from young donors of - years of one with the recipient blood types and a sex. mashhadi r to compare the expression rate of sex steroid hormone receptors of estrogen (er), progesterone (pr) and androgen (ar) in normal urothelium and urothelial bladder cancer (ubc) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival. we evaluated the clinical data and tumor specimens of patients with patho-logically confi rmed primary ubc with normal healthy controls. both patients and controls selected from list of subjects who have been referred to sina urology clinic, and had a minimum of one year follow-up duration. data collected from medical cords. for evaluation of expression, immunohistochemistry was performed on paraffi n-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. presence of at least % positive cells defi ned as positive expression. results: none of the control subjects showed ar expression, while % of the patients were ar-positive. er/pr expressions were observed in . %/ and . % of the cases and in . % and . % of the controls, respectively. a statistically signifi cant correlation was found between ar expression and tumor stage and grade (p < . ). ar-positive patients showed a signifi cantly poorer prognosis than ar-negative cases (log-rank test, p = . , hazard ratio = . ; % confidence interval: . - . ). conclusion: ar expression was signifi cantly associated with higher grade and poorly diff erentiated tumors with unfavorable outcome. ar expression test might be useful as a diagnostic tool for determining the malignancy and outcome of ubc patients. park s, park w, yoon s introduction and objective: previous researchers consider interaction roles of ampk and ros as a regulator of cancer cell apoptosis and cancer invasiveness in hypoxia and oxidative stress. th e aim of this study was to fi nd out the other aspect of invasion and cell death mechanisms as a new treatment option in urothelial cancer. we performed western blot analysis to determine association between ampk regulator (compound c, aicar) and ros scavenger (nac and tempol) as cytotoxic eff ectors. using gelatin zymography to measure mmp- , activity, we evaluated the cancer invasion. pathway activation analysis was also determined by western blot. cell survival was investigated by mtt analysis. results: ros scavenger like nac and tempol treated cells showed no change of expressions of phospho-ampk. aicar, compound c and tempol treated cells showed no change of mmp- and mmp- expressions. however, nac treated cells showed decreased expressions of mmp- and mmp- . ai-car and compound c treated cells with or without added nac and tempol showed no change of mtor and phospho-mtor expressions. aicar treated cells only showed decreased expression of phospho-p s k. compound c and tempol treated cells did not showed statistically any change in cell counts. however, aicar and nac treated with or without added compound c and tempol showed increased cell death signifi cantly. conclusions: activator of ampk and ros scavenger like nac decrease t invasion activity and increase t cell death. so, we demonstrate that the cytotoxic mechanism of bladder cancer remains to be further investigated. epigenetic bladder cancer is still one of common human malignancies which some environmental agents play important role in the process of carcinogenesis, such as aromatic amines or chronic arsenism, and easy to be recurrent and progressive despite of therapy. it is continuing to search some novel genetic or epigenetic biomarkers and to investigate their signifi cance in bladder urothelial carcinoma. doc- /dab (diff erentially expressed in ovarian carcinoma- /disabled- ) interacting protein (dab ip), a novel family of ras gtpase-activating protein family, is a potent tumor suppressor gene. th e objectives of this study are to explore the prognostic values of dab ip expression and the possible regulatory mechanism in superfi cial bladder cancer. with irb consent and patient permit, eight human urothelial cancer cell lines and superfi cial bladder cancer tissues were available for exploring dab ip expression using western blotting and immunohistochemical staining, respectively. th e prognostic signifi cance of dab ip expression in term of recurrence and progression were analyzed with log-rank test. aft er treated with demethylizing agents trichostatin a (tsa) and -aza ' deoxycytidine (aza) separately and together, urothelial carcinoma cell lines were then tested with dab ip mrna expression using quantitative rtpcr. data mining was also done using published mrna diff erential array (dataset gse ). th irty patients with non-muscle invasive bladder cancer and agematched healthy controls were included in the study. peripheral blood samples were obtained from the patients before transurethral resection of bladder tumor (turbt), twenty days aft er the operation (fi rst control) and at the end of intravesical immunotherapy (second control). vegf- , mmp- , es and tsp- were measured by enzyme-linked immunosorbent assay (elisa). th e mean marker levels of the patients and controls were statistically compared. th e mean marker levels of the patients before turbt, in the fi rst and second control were also compared. results: th e mean age of the patients ( females and males) and controls ( females and males) were found to be . ± . and . ± . , respectively (p= . ). although the mean vegf and mmp levels in the patients before turbt were signifi cantly higher than the controls (p< . and p< . , respectively), there were no diff erences between the mean es and tps- levels (p= . and p= . , respectively). th e wegf- and mmp- levels signifi cantly decreased aft er turbt (p< . and p< . , respectively). th ese reductions continued aft er intravesical immunotherapy, but these diff erences between fi rst and second control were statistically insignifi cant. th is study showed that elevated angionenic factors in the patients with bladder cancer decreased aft er the treatment. we think that vegf and mmp may be used for the follow-up and therapy of non-muscle invasive bladder cancer. prognostic results: nitrose oxide level and bfgf expression were signifi cally elevated in patients with urothelial carcinoma associated with chronic bladder infection, normal urothelium showed low levels of no and low expression of bfgf. conclusion: th e association of elevated levels of nitrose oxide and over-expression of bfgf indicated that the angiogenic peptide bfgf had been modulated by nitrose oxide. th ese results would indicate an anti-angiogenisis target therapy in urothelial carcinoma associated with chronic bladder infection. the relationships between increase of serum creatinine and recurrence of nonmuscle invasive bladder cancer after transurethral resection of bladder tumor introduction and objective: while impaired renal function had a negative impact on the prognosis of invasive bladder cancer by infl uencing stage of tumor and selection of treatment modality, the relationships between the change of renal function and prognosis of non-muscle invasive bladder cancer (nmibc) have not yet been studied. preliminarily, we investigated the impact of increased serum creatinine and recurrence of nmibc. a total of patients who underwent transurethral resection of bladder tumor (turbt) with minimum follow-up of months were divided into two groups based on with (n= ) or without recurrence (n= ). th e changes of serum creatinine from the preoperative baseline to the time of recurrence were evaluated (Δ creatinine). for subjects without recurrence, serum creatinine was measured at months aft er turbt. th e impact of variables including characteristics of host (age, sex, past medical history, bmi, and smoking history), tumor (location, size, and grade), and laboratory data on recurrence of nmibc were then analyzed. tsai y , jou y , tsai y , liu b , lin h , wei c , chen s , tsai h , tzai t introduction and objective: bladder cancer is a common human malignancy and exhibits a life-long risk of disease recurrence and progression. it is continuing to search some simple, innovative biomarker to monitor the disease status in order to diminish the suff ering during cystoscopic follow-up. th e metabolite of tryptophan aft er indoleamine , -dioxygenase (ido) digestion, -hydroxyanthranilic acid ( -haa) is conventionally thought to be a potential biomarker for bladder cancer occurrence. th e aim to study is to investigate the diagnostic potential of an integrated a -haa-based biosensor for urothelial carcinoma of the upper tract and urinary bladder. human urothelial cancer cell lines and human urothelial carcinoma tissues as well as adjacent benign tissues were available for exploring ido expression, including western blotting and immunohistochemical staining. patients who received urological surgery were enrolled for urine -haa testing using an integrating biosensor for -haa. some of urine specimens were investigated with high performance liquid chromatography (hplc) assay. results: from western blotting assays, eight human urothelial carcinoma cell lines exhibited more ido expression than the immortalized cell sv-huc. both of urothelial carcinoma of urinary bladder and upper urinary tract exhibited more ido immunoreactivity than those of the adjacent benign bladder, ureteral or cortical tissues (chi-square test, p= . ). th ere is a moderate correlation for urine -haa measurement based on between hplc and the biosensor assays (r = . , p= . ). besides, the -haa content within the cultured media of tccsup and bftc measured with biosensors signifi cantly increased with incubation time (p < . ). finally, patients with urothelial carcinoma of bladder and upper tract have higher urine -haa levels than those without recurrence or benign urological disease, such as bph, or hernia (unpaired t-test, p= . ), except for urolithiasis. conclusion: th e integrated biosensor exhibited a modest accuracy in urine -haa detection. both of urothelial carcinoma of urinary bladder and upper tract exhibited higher ido expression and its metabolite -haa in urine. how a cancer spreads: public awareness of genitourinary cancer introduction and objective: patients' perceptions of disease can aff ect the diagnosis and treatment of the disease. it is diffi cult to give a defi nite answer to the questions; "can genitourinary cancers be spread around during coitus or in public bathtub?". doctors know that there is no evidence that cancers can be spread in this way, however many people don't know that. th e objective of this study was to investigate the public awareness of genitourinary cancer. one hundred and forty nine patients who have visited outpatient department of urology completed a self-administered questionnaire from june to july . th e questionnaires included epidemiologic information about age, gender, residential area, level of education and yearly income and the questions whether prostate cancer and bladder tumor could spread out during coitus or bathing. returned responses to questions were analyzed. results: a total of of ( %) patients completed the questionnaires. mean age was years, and ( %) men and ( %) women were included. th e residential area were metropolitan in ( %), urban in ( %), and suburban in ( %), respectively. th e level of education were middle school graduates in ( %), high school graduates in ( %), and college graduates in ( %), respectively. th e yearly incomes were under , dollars in ( %), , ~ , in ( %), and over , in ( %), respectively. seventeen ( %) and ( %) patients answered that they thought that bladder tumor could spread during coitus and bathing, respectively. likewise ( %) and ( %) patients answered that they believed that prostate cancer could spread during coitus and bathing, respectively. moreover, young patients (< years) reported that they have the opinions that coitus spreads prostate cancer ( %) and bladder tumor ( %). of college graduates, % and % reported that they thought coitus spreads prostate cancer and bladder tumor, respectively. conclusion: a signifi cant proportion of patients believed that prostate cancer and bladder tumor could spread during coitus. furthermore, even young and highly educated people also tended to have this misbelief. protoporphyrin we evaluated the feasibility of photodynamic diagnosis of bladder cancer by spectrophotometric analysis of voided urine samples aft er extracorporeal treatment with -aminolevulinic acid (ala). further, we investigate the protein that plays a key role in increased accumulation of protoporphyrin ix in bladder cancer cells. sixty-one patients with bladder cancer, confi rmed histologically aft er the transurethral resection of a bladder tumor, were recruited as the bladder cancer group, and outpatients without history of urothelial carcinoma were recruited as the control group. half of the voided urine sample was incubated with ala, and the rest was incubated without treatment. intensity of the samples at the excitation wavelength of nm was measured using a spectrophotometer. th e diff erence between the intensity of the ala-treated and ala-untreated samples at nm was calculated for photodynamic diagnosis of bladder cancer. immunohistochemistry was used to estimate the expression of peptide transporter , hydroxymethylbilane synthase, ferrochelatase, atp-binding cassette , and heme oxygenase- in samples from patients who underwent transurethral resection of bladder tumors. th e correlation between the expression of each protein in cells from resected bladder specimens and accumulated protoporphyrin ix in bladder cancer cells in voided urine was evaluated using pearson's correlation analysis. results: th e area under the curve was . . sensitivity and specifi city of the method were % and % respectively. th e expression of peptide transporter (p < . , r = . ), heme oxygenase- (p < . , r = . ), and ferrochelatase (p < . , r = . ) was correlated with the accumulation of protoporphyrin ix in bladder cancer cells in voided urine. we demonstrated that protoporphyrin ix levels in urinary cells treated with ala could be quantitatively detected by spectrophotometer in patients with bladder cancer. th e expression of ferrochelatase plays a key role in the accumulation of protoporphyrin ix in photodynamic diagnosis of bladder cancer. assessment of visual inspection as a tool to determine pelvic drain fluid type following radical cystectomy crozier j, papa n, lawrentschuk n introduction and objective: following radical cystectomy, patients generally spend a period of days under observation on a urology ward. during that time, staff closely monitor pelvic drain output to assess for the possibility of a urine leak. we aim to investigate the ability of medical and nursing staff to correctly identify pelvic drain fl uid type using visual inspection alone. investigators collected a series of de-identifi ed images showing pelvic drain fl uid in patients post radical cystectomy. th e fl uid type in each image was confi rmed by measuring creatinine level. investigators then attended a victorian public hospital urology meeting and a victorian gp conference. attendees were invited to participate in a study. present staff included consultant urologists, urology registrars, urology residents, urology nurses, medical oncologists, radiation oncologists, general practitioners and medical students. participants were then provided with a survey. th ey were asked to indicate their level of experience working on a urology ward, the number of years since graduation from their primary medical or nursing degree. participants were then shown the series of pelvic drain fl uid images on a project. th ey were asked to correctly identifying the fl uid type in each image. using the survey, participants had the option of choosing either urine or peritoneal fl uid. results: all groups poorly identifi ed fl uid type. no individual staff group was signifi cantly better at identifying fl uid type. level of experience on a urology ward and years since graduation do not infl uence ability to determine fl uid type. conclusion: visual inspection of pelvic drain fl uid is a poor determinant of fl uid type. chang y, hsiao p, chen g, lee s, huang c, wu h, yang c, chang c introduction and objective: muscle invasive bladder urothelial cell carcinoma occasionally mixed with squamous diff erentiation. we conducted this study to investigate the incidence and treatment outcome of bladder urothelial cell carcinoma with squamous component. we enrolled patients muscle invasion bladder cancer who received radical cystectomy with bilateral pelvic lymph node dissection during to . patients' characteristics, chemotherapy record, and pathological report were retrospectively reviewed. th e following endpoints were assessed: overall survival (os) and recurrence-free survival (rfs). response of neoadjuvant chemotherapy subgroup was also analyzed. all survival data were analyzed by the kaplan-meier method using a log-rank test and multivariate analysis was carried out using a cox proportional hazards regression model. results: it was very clear that more than one third of these cases coming from the south of saudi arabia ( . %). th e bilharzia infestation found in ( . %) of the cases most of them are the southern patients. th e t staging turn to be high in most of our cases ( . % are t b). squamous cells carcinomas was also a striking feature of our result and found in ( . %). lymph node involvement found in one fourth of these cases ( . %). a total of ( . %) had local or lymph node recurrence and ( . %) got distant metastasis. around % ( cases) of our result showing that these cases having high grade and around % ( cases) had a hydronephrosis upon presentation. bladder cancer as a cause of death because of its advancement or recurrence account for ( . %) of deaths happened in these cases. th e survival of these cases severely aff ected by the fact that cases ( . %) could not know there survival status because they stop to show up in our institute for follow-up in spite the fact that there are some of them followed for more than years. arabia showing that the bilharzia infestation is quit high especially in the south and the squamous cell cancer is not as low as we expected. finding of hydronephrosis, lymph node involvement, high t and high recurrence in high percentage of our cases indicating that the bladder cancer aggressiveness behavior is not changing over years. introduction and objective: th is is an observational retrospective study utilising long-term patient follow-up for years (ys). to determine the survival and quality of life in women with age range - years, who had been treated for carcinoma of the bladder with radical cystectomy with preservation of genital organs. materials and methods: study included women patients with invasive urothelial carcinoma of the bladder treated with genital sparring radical cystectomy during the period from to . th ey had orthotopic ileal neobladder. follow-up included recurrence-free survival, metastases-free survival, overall survival, continence, and sexual function. results: overall survival up to - ys was in / women ( . %). survivors up to ys were in / ( . %). survival from to ys was in / patients ( . %). tumours stage of t were / patients, t were / patients, and t a were / patients. tumour grade was g in / , g in / , and g in / . age range of - ys were patients, range of - ys was patients, range of - ys was patients. continence was good in / patients; three patients / needed cic. sexual function tested by fsfi over< - was ( . %). conclusion: th e study provide evidence of safety and effi cacy of radical cystectomy with sparing of genital organs in women aged to with low grade, low stage invasive urothelial carcinoma of the bladder. oncological outcome for - years was good; continence and sexual function were very good. th is procedure should be considered when surgical approach appears to be feasible. tan w, sherer b, nehra a, deane l introduction and objective: radical cystectomy for bladder cancer has been the surgical gold standard for decades. increasingly, experience with robotic assisted techniques has become more common in select centers. in the majority of instances, the urinary diversion has been performed extracorporeally and with the use of stents. herein, we report our center's initial experience with robotic radical cystectomy and stentless totally intracorporeal urinary diversion. a retrospective review of the medical records of all patients undergoing robotic cystectomy and intracorporeal diversion was conducted at rumc from - . specifi cally, attention was focused on perioperative parameters. results: a total of patients were identifi ed (male= , female= ) in the sample. four patients underwent intracorporeal ileal conduit reconstruction and one patient underwent totally intracorporeal ileal neobladder reconstruction. no patients received a pre op bowel preparation, post op pca or epidural and all were allowed oral intake early. no patient received a transfusion for operative blood loss. one patient was readmitted for dehydration. see table for details. conclusion: robotic assisted radical cystectomy with stentless intracorporeal diversion is safe and feasible. eliminating bowel preparation, pca and epidural, and incorporating early refeeding and ambulation may result in a shortened length of stay. a rigorous post-operative plan to optimize return of bowel function, permit rapid reintroduction of diet without restrictions and facilitate early ambulation is critical in improving outcomes for this patient population. computed up. , table . and hypermethylation of these two gene promoters. in order to investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status in urine samples of bladder cancer patients. methylation of the tested genes in urine sediment dna was detected in the majority of cases that were hypermethylated in tumor samples ( . %) and the frequencies were . % . % and . % for apc, rarβ and survivin, respectively. our results indicate that methylation of apc, rarβ and survivin gene promoters is a common fi nding in patients with bladder carcinoma. th e ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancer. usefulness of the all cases were followed for over year. th e procedure is ) point marking; ) circular incision; ) level incision; and ) specimen retrieval using a needle electrode in accordance with the ukai's method. we investigated pathological fi ndings (margin situation), operation time, complications and recurrence. results: it is possible to diagnose the precise pathological fi ndings by turbo. we judged the width and depth ew in sequential section. th ere were few complications during and aft er the operation. operation time of turbo ( - min) was longer than conventional turbt. urethral catheter holding period and hospitalization period aft er turbo was the same as turbt. turbo is a relatively safe procedure even for beginners. twenty cases had a recurrence in cases. eleven cases had a recurrence in under year, but the same place recurrence was cases. th ere were few cases of same place recurrence in under year among margin-negative cases. th erefore we judged that ew-negative cases had no residual cancers. conclusion: turbo is a safe and useful procedure that provides precise pathological fi ndings with minimal complications. second tur is not necessary for turbo. turbo has a possibility to be gold standard of the treatment for non-muscle invasive bladder cancer (nmibc). the risks of bladder-preserving bacillus calmette-guérin therapy in high-grade non-muscle-invasive bladder cancer continuous physical activity has many eff ects on human body. it doesn't only strengthen the skeleton or muscles; it also affects cardiovascular system, nervous system and etc. in this research we wanted to fi gure out if continuous physical activity (cpa) eff ects the lower urinary tract symptoms in retired military offi cers or not. th is is a retrospective study. retired offi cers attending to urology clinic for annual prostate control and not using any drugs for prostate were enrolled in this study. aft er the patients' permission were taken for the study they were asked for cpa or not and their international prostate symptom scale (ipss) answers were compared. results: th ere were patients in cpa group and patients in non-cpa group. th e mean age is ( - ) in cpa group and . ( - ) in non-cpa group. answers of questions in ipss: incomplete emptying (p= . ), frequency (p= . ), urgency (p= . ), and straining (p= . ) were detected statistically rare in cpa group (table ) . although they were not statistically signifi cant, intermittency (p= . ), weak stream (p= . ) and nocturia (p= . ) were rare in cpa group too (table ) . in order to maintain a better lower urinary tract function, elderly men should continue their physical activity aft er retirement. conclusions: th e number of nocturia episodes was signifi cantly and linearly correlated with ipss total score, voiding, storage, qol and nih-cpsi voiding scores. however, other risk factors, including bmi, body fat percentage, blood pressure, bun, creatinine, lipid panel, ck, t , free t , prostate-specifi c antigen, serum testosterone levels, urine fl ow (assessed using urofl owmetry) and prostate size (assessed using transrectal ultrasound and digital rectal examinations) were not associated with the number of nocturia episodes, despite an a priori assumption that they all infl uence nocturia risk. risk results: symptom prevalence increased to . %, and the mean international prostate symptom score increased by . points during years. aft er adjusting for confounders, smoking history of ≥ pack-years was an independent risk factor for symptom deterioration and storage sub-symptoms, compared with non-smokers ( . and . odds, respectively). physical activity had a protective eff ect for voiding sub-symptoms. high daily protein intake exacerbated the storage symptoms. however, alcohol intake was not associated with symptom deterioration. conclusions: th e symptom prevalence among elderly men living in a suburban area increased to . %, and the international prostate symptom score increased by . points during years. smoking history, physical activity, and protein intake were associated with symptom deterioration. however, there was no signifi cant association with alcohol intake and symptom deterioration. russo g, castelli t, urzì d, privitera s, fragalà e, favilla v, cimino s, morgia g introduction and objective: a signifi cant amount of epidemiological evidences have underlined an emerging link between mets, benign prostatic enlargement (bpe) secondary to benign prostatic hyperplasia (bph) and related lower urinary tract symptoms (luts). we aimed to assess the connections between lower urinary tract symptoms (luts) related to benign prostatic enlargement (bpe) and metabolic syndrome (mets) with its components. is increased prostatic urethral angle related to lower urinary symptoms in male without prostatic obstruction? introduction and objective: th e prostatic urethra is a bent tube, and the clinical signifi cance of the prostatic urethral angle (pua) was recently reported. we investigated the statistical signifi cance of an increased pua on the international prostate symptom score (ipss), with luts/bph. a prospective analysis was made of patients ( . ± . years) with luts and/or bph. patient underwent an evaluation including the ipss, psa, transrectal ultrasonography, urofl owmetry, and measurement of post-void residual. pua were measured by cystourethroscopy ( figure ). in order to minimize the eff ect of prostate, patients with prostatic obstruction under cystourethroscopy were excluded. th e minimum pua degree of symptoms change was constructed as a predictor of the eff ect of medication. all patients received tamsulosin . mg during the fi rst weeks and . mg during the next weeks. results: th e psa, prostate volume and pua were . ± . ng/ml, . ± . ml and . ± . °, respectively. th e area under the roc curve was . at the degrees with a sensitivity of . % and a specifi city of . %. comparing a higher pua (over degree, group a) with a lower pua (under degree, group b), patient with a higher pua had a longer luts period (p= . ), an improvement of symptoms aft er medication (p= . ) and an increase of average fl ow rate (p= . ). however, there was no signifi cant diff erence in age, psa, post-voided volume between the two groups. conclusion: pua showed signifi cantly correlated with the improvement of ipss, the eff ect of medication, and urofl owmetry. our fi ndings suggest that pua under cystourethroscopy may be one method to assess the presence of luts in men and help in the treatment of individuals by better predicting their likely classifi cation from ipss, urofl owmetry, and prostate volume. however, further studies are needed to explore the mechanisms and the eff ects of pua under cystourethroscopy. introduction and objective: th e prevalence of lower urinary tract symptoms increased with age. it is known that irritable bladder symptoms such as urinary frequency, urgency, nocturia increased with age in many studies. recently it was reported that vascular calcifi cation was one of the cause of lower urinary tract symptoms. we studied to evaluate the association between lower urinary tract symptoms of vascular calcifi cation in the abdominal ct using by agar score. th e records were obtained from a retrospective database who underwent abdominal ct due abdominal pain, hematuria. sex, age, height, weight, prostatic size, calcifi cation of aorta and internal iliac artery, amount of subcutaneous fat and visceral fat in the umbilicus level, international prostate symptom score, overactive symptoms score and urofl owmetry were assessed. calcifi cation of aorta was estimated from renal artery bifurcation to iliac artery bifurcation level. and internal iliac artery calcifi cation was calculated from bifurcation of iliac artery to bladder. we scanned each subject of . cm interval on the ct scan. th e calcifi cation of blood vessels was measured as agar score using abdominal ct aft er our explaining about each contents of nih-cp-si and iief- , the paper was checked by volunteers in person, and then we collected it. th e subjects were limited to - s korean male. we analyzed the collected questionnaires, and considered men who have perineal and/or ejaculatory pain or discomfort and a total nih-cpsi pain score of ≥ as having prostatitis-like symptoms, and categorized to four groups by iief- score, mild ( - ), mild-moderate ( - ), moderate ( - ), severe ( - ). results: an average age of volunteers was years old ( - ). th e iief- category was divided to fi ve groups. among total volunteers, persons were chronic prostatitis like symptom patients ( . %), and whose nih-cpsi average of pain score, voiding score, quality of life score and total score were . ± . , . ± . , . ± . , and . ± . , respective-up. , figure . ly. th ere were a little correlations among pain score, voiding score, quality life score, but not signifi cant. an average of total iief- scores in chronic prostatitis like symptom patients was . ± . , it was signifi cantly lower than absent group. th ere were all negative correlations of between iief- and pain score (t=- . , r = . , p= . ), voiding score (t=- . , r = . , p= . ), qol score (t=- . , r = . , p= . ), and total score (t=- . , r = . , p= . ). conclusion: th e higher total nih-cpsi score, especially pain score plays a larger role, adversely aff ects erectile function of chronic prostatitis like symptom patients in - s korean male. a antimuscarinic agent is the mainstay of treatment, but it have side eff ects such as dry mouth, constipation. th ese eff ects resulted in cessation of medication in many cases. th e authors therefore assessed the impact of side eff ects on health-related quality of life (hr-qol) through an analysis of questionnaires. th is study was designed to investigate the patients' satisfaction by quality weight (utility weight) of health status as aff ected by the side eff ects of oab medications in tertiary hospitals in korea. patients who had oab symptoms lasting longer than months and side eff ects aft er any antimuscarinic treatment fi lled in the eq- d. th e questionnaire and vas score for two diff erent health statuses, presence or absence of side eff ects, were analyzed. quality weight was calculated using the score of ed- d health status. results: one hundred patients were enrolled. th e most prevalent side eff ect was dry mouth ( %), followed by constipation ( %). twenty-eight percent of the patients had dry mouth and constipation concurrently. most of the patients with side eff ects tried to overcome these side eff ects ( %), but % desired a change in medication, and % stopped medication altogether. fift y-fi ve patients replied that they consider side eff ects to be an important factor in deciding on the continuation of medication. th e quality weight of eq- d without side eff ects was . , while the quality weight with side eff ects was . (p= . ). th e vas score was in patient without side eff ects and in those with side eff ects, supporting the results of quality weight assessment. th e same trend was observed when stratifi ed according to age and sex. as for the overall distribution of ed- d, the patients with side eff ects were less healthy in terms of daily life, pain/discomfort, and anxiety/depression. introduction and objective: treatment of men with large prostates is challenging with greater risk of complication and retreatment. while photo-vaporization (pvp) has been well described for greenlight w-xps, vapor resection techniques have been described to help improve tissue resection, including vapour-incision techniques (vit). we sought to evaluate the effi ciency, safety and outcome parameters between greenlight pvp and vit specifi cally for men with prostate volumes > . among xps cases retrospectively collected from experienced surgeons at high-volume greenlight xps centers, had large prostates. preoperative, operative and post-operative parameters were collected and compared between groups. results: as summarized in table , men undergoing vit (n= ) had comparable preoperative parameters to those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs . kj/g), operative time was longer and there was greater need for > fi bres. th ere were no diff erences in intra-and day post-operative adverse events. both vit and pvp demonstrated comparable marked improvements in ipss/qol at months post-operatively. however, despite greater urinary retention and pvr preoperatively, men with vit demonstrated signifi cantly lower post-operative pvr and greater qmax at moths. no signifi cant diff erence in retreatment rates was noted between vit and pvp follow-up. conclusions: both greenlight pvp and vit techniques can be safely used to treat men with large prostates. both techniques off er signifi cant and durable relief of symptom relief with comparable complication rates at years. longer follow-up is necessary to assess durability. open within two years, one-hundred patients were prospectively randomized into two equal groups. all patients underwent tvp whereas rb was used in group- . rb is a balloon fi xed to -way foley catheter tip by blaster strip making it air tight. we placed it in the rectum opposing prostate and infl ate (pressure controlled) for min. hemoglobin (hg) levels have been assessed pre-and postoperation. blood transfusion, amount of saline for irrigation, catheter duration, hospital stay, and rectal complain were recorded. follow-up was and -mo, postoperatively. results: enucleated adenoma weight was gm in g- and gm in g- . th ere is signifi cant diff erence between both group for hg-loss within fi rst h post-operative and total hg-loss . gm in g- and . gm in g- (p, . ) and . gm vs. gm (p, . ) respectively. also there is signifi cant diff erence between both group in relation to the saline/l for irrigation ( . vs. . l), catheter duration ( . vs. . day), and hospital stay ( . vs. . day), with favorable results to the rb group. blood transfusion was in g- and one in g- . th ere is no rectal complain. conclusion: rb infl ation post-tvp is simple and safe procedure without operative technique, reduces post-operative blood loss, blood transfusion incidence, saline for irrigation, and shortens the catheterization period and hospital stay, without rectal complication. conclusion: th ough this was not a head-to-head study and there were a number of dissimilarities in the study design, we demonstrated a non-inferiority of our study and a signifi cantly shorter median length of catheterization, time until stable health, and hospitalization relative to the goliath study. introduction and objective: th ulium laser enucleation of the prostate (th ulep) has been introduced as a minimally invasive treatment for benign prostatic obstruction (bpo). th e aim of the study is to assess what are the intraoperative key points and possible complications of the morcellation procedure aft er th ulep. to assess whether this events have any eff ect on hospitalization length. a cooperation between the university of milan and moscow was settled. prospective study that analyzes events that prolonged the morcellation process aft er completing thullium laser enucleation procedure in a group of consecutive patients was performed. events related to the morcellation procedure were recorded. patients' hospitalization length were evaluated aft er discharge only considering patients that were not re-admitted because of a surgical related issue. statistical analysis was performed by the student t and chi-square test and logistic regression analysis. for all statistical comparisons signifi cance was considered at p< . . results: mean age was . years. five groups of reasons for prolonged morcellation were recorded. bladder suction with wall damage, bleeding due to "ex vacuo" fast empting, suction problem, morcellation impairment and prolonged morcellation time due to enlarged prostate. each group of issues was related to a signifi cant prolonged operative time (p< . ). th e table shows the key points rate and their correlation with a prolonged hospital stay. a statistical significance between the event and the prolonged hospital stay found only for bladder suction. conclusions: issues related to the morcellation procedure aft er laser enucleation of the prostate (th ulep) causes prolonged hospitalization length only in the case of bladder suction. other events, even if related to a slower operative time, do not mean a prolonged hospitalization. suprapubic cystostomy makes turp more effective and safer introduction and objective: a recent survey found turp the commonest performed procedure in bph, despite the rising popularity of laser prostatectomy. th e reasons for popularity in laser are ease of performance, lesser complications, and good results. it is the complications factor that makes it look attractive. th e onus is therefore to make turp safer. th is is more applicable in india, where the cost of laser excludes - % of patients. numerous innovative procedures have been tried to make turp safer. continuous outfl ow has been described as innovation, the means to achieve it not described. introduction and objective: prophylactic peri-vesical drain placement during suprapubic prostatectomy remains a widespread surgical practice. however the surgical technique of suprapubic prostatectomy has signifi cantly improved and as such the contemporary role of prophylactic surgical drains needs reevaluation. it has been traditionally assumed that prophylactic drains helps prevent fl uid collection (blood, serum, urine) which if not drained can lead to surgical wound complications. th is paper investigates the incidence of surgical wound complications aft er a series of suprapubic prostatectomy done without placement of surgical drains but in the context of modifi cations to the surgical technique. prostatic hyperplasia (bph) were operated upon between and -all using a modifi ed suprapubic prostatectomy technique that includes meticulous dissection, hemostatic suturing that covers the main areas of anatomic distribution of the urethral arterial branches of the inferior vesical artery, non-placement of drains and suprapubic catheter, and also routine irrigation of the surgical wound with normal saline among other modifi cations. pre-and post-operative blood hemoglobin levels, prostate specimen weights and presence of surgical wound complications if any were recorded. th e main outcome measure was to determine the presence of early surgical wound complication defi ned as clinical evidence of hematoma/ seroma, infection, drainage or wound dehiscence. results: th e mean age of the patients was . (range of to years). th e mean prostate weight was . gm-(range of to gm). th e mean hemoglobin diff erence was . mg/dl (range of . mg/dl to . mg/dl). on a minimum days observation of the surgical wounds, there was only one case of superficial wound infection ( . %) that healed with wound dressing. th ere was no mortality and none of the patients received blood transfusion. in the context of an improved surgical technique, suprapubic prostatectomy for bph can be safely performed without the placement of prophylactic peri-vesical drain. non-placement of prophylactic surgical drains in this series was not associated with increased wound complication rate. effects of detrusor underactivity conclusions: according to detrusor activity, there were not diff erent in diff erences between preoperative or postoperative ipss. abnormal detrusor contractility (esp. dua) cannot be a contraindication for tur-p, and turp should be a defi nite therapeutic option in abnormal detrusor activity. geavlete p, dragutescu m, multescu r, georgescu d, geavlete p introduction and objective: th is long-term retrospective study aimed to analyze the re-intervention necessities aft er bipolar plasma vaporization of the prostate (bpvp) in patients with medium sized benign prostatic hyperplasia (bph). materials and methods: th ere were followed patients who underwent bpvp for prostates sized between and ml. th e re-intervention rates were analyzed during a follow-up period of at least months. results: additional interventions consisted of immediate reoperation for secondary hematuria, endoscopic re-intervention for urethral stricture or blad-der neck sclerosis and transurethral resection of the prostate (turp) for residual bph bulk. endoscopic hemostasis during hospitalization was required in cases ( . %) and in discharged patients in other cases ( . %). during the follow-up period, patients ( . %) with bladder neck sclerosis underwent the plasma vaporization approach. urethral stricture was diagnosed in patients ( . %), of them receiving internal optical urethrotomy while urethroplasty was performed in cases. residual adenoma was present in patients ( . %), thus requiring and secondary turp. conclusion: bpvp is a valuable endoscopic treatment alternative for medium size bph cases with higher effi ciency and a satisfactory rate of reoperation. diode laser nm for the treatment of bph: long-term comparison of the enucleation vs. vaporization introduction and objective: to report -years follow-up results of clinical trial comparing diode laser enucleation of the prostate (dilep) with diode laser vaporisation of the prostate (dlvap). a total of consecutive patients were included in the prospective study who had received laser treatment for bph. patients were assigned to two groups based on the type of procedure: to dilep group and to dlvap group. patients with a history of neurogenic bladder dysfunction, chronic prostatitis or bladder cancer were excluded from evaluation. standard follow-up examinations were performed in both study groups in predefi ned time points (in the perioperative period, at month and month , and month , and then every year). primary endpoints included: lower urinary tract symptoms (luts) as measured by the international prostate symptom score (ipss), urinary fl ow rates and post-void residual urinary volume. complications were assessed. an additional endpoint was to review video records to precisely determine the timeframes for individual surgical procedures and to plot the learning curve. results: all the remaining patients had undergone the -year follow-up assessment. measurements were performed at , , , , , , and months. th ere were no statistically signifi cant differences in baseline characteristics between the two groups. no signifi cant intraoperative and early postoperative bleeding was observed. hospital stay aft er surgical intervention covered day that was equal to average time of urethral catheter indwelling. th e improvement rates, calculated based on the ipss scores at years aft er surgery, were . % and . % in the dilep and dlvap group, respectively. th e results indicate signifi cant decrease in severity of luts. th e sustained treatment eff ect was in favor of dilep intervention group. also treatment effi cacy was better in the dilep group compared to the dvlap group, as regards the maximum urinary fl ow rate (qmax). th e diff erence was statistically signifi cant. conclusions: diode laser enucleation and vaporisation of the prostate are low-risk minimally-invasive treatment option of treatment of patients with bph. both methods may be safely performed even in high risk and patients on ongoing oral anticoagulation. treatment eff ects are better and more sustained with laser enucleation than with laser vaporization of the prostate. dilep is a true endourological alternative to turp. changes in urination according to the sound of running water using a mobile phone application introduction and objective: th e sound of running water (srw) has been eff ectively used for toilet training during toddlerhood. however, the eff ect of srw on voiding functions in adult males with lower urinary tract symptoms (luts) has not been evaluated. to determine the eff ect of srw on urination in male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of srw played by a mobile application. eighteen consecutive male patients with luts were prospectively enrolled between march and april . urofl owmetry with pvr measured by a bladder scan was randomly performed once weekly for two consecutive weeks with and without srw in a completely sealed room aft er pre-checked bladder volume was scanned to be more than cc. srw was played with river water sounds amongst relaxed melodies from a smartphone mobile application. results: th e mean age of enrolled patients and their mean international prostate symptom score (ipss) were . ± . years (range: - ) and . ± . , respectively. all patients had not been prescribed any medications, including alpha-blockers or anti-muscarinic agents, in the last months. th ere was a signifi cant increase in mean peak fl ow rate (pfr) with srw in comparison to without srw ( . ml/s vs. . ml/s, respectively, p = . ). however, there were no diff erences in other urofl owmetric parameters, including pvr. th e study showed that srw from a mobile phone application may be helpful in facilitating voiding functions by increasing pfr in male luts patients. th is study aims to analyse how bladder outlet obstruction index (booi) and bladder contractility index (bci) aff ect surgical outcome for bph patients who were treated homium laser enucleation of the prostate (holep). we classifi ed the patients, who were treated holep and observed more than months, into group i (booi≥ and bci≥ , n= ), group ii (booi≥ and bci< , n= ), group iii ( <booi< and bci≥ , n= ) and group iv ( <booi< and bci< , n= ) based on urodynamic study result. patient's characteristics including volume of prostate, psa, ipss, maximum urinary fl ow rate and residual urine volume compared in each group. and we also compared ipss, maximum urinary fl ow rate, residual urine volume before and months aft er surgery. results: th ere was no signifi cant diff erence comparing age, psa, ipss, maximum urinary fl ow rate and residual urine volume among each group. th e prostate volume, ranked in ascending order of group, are as follows: . ± . ml, . ± . ml, . ± . ml and . ± . ml, it had signifi cantly disparity between group i and iii (p= . ), group i and iv (p= . ), and group ii and iv p= . ). using repeated measure anova, we found that ipss, maximum urinary fl ow rate and residual urine volume were signifi cantly improved within group in each group aft er surgery except ipss storage subscore between group ii and group iii and residual urine volume. and the degree of improvement among each group was not diff erent (table ) . th e incidence of aur ( . %) and bph-related surgery ( . %) were low in ct group. in comparison of baseline age, psa, and pv according to switch of medical therapy, baseline pv was signifi cant diff erence in both groups, respectively (p= . , p= . ). conclusion: th ere was more mt than ct in initial treatment. however, there was more switch of medical treatment type in initial mt in real-world clinical practice over -year follow-up. th e incidence of bph progression events was high in initial mt group. th e initial use of ct is recommended in patients with luts and bph. relationship between bladder wall thickness and lower urinary board the antarctic research vessel "shirase" on their way home and approximately two months aft er returning to japan. we analyzed the data of members of the winter party who had responded to the questionnaires more than times before departure and during their stays in antarctica. results: compared to before departure, the mean scores for all of the questionnaires decreased during their stays in antarctica, from . to . points for ipss, from . to . points for oabss, and from . to . points for psqi, but the mean volume voided per micturition increased from to ml. in regard to the amount of change in ipss scores over the same period, a signifi cant diff erence was noted between members with a pre-departure score ≥ points and members with a pre-departure score < points (- . vs. . , p = . ). th is study is the fi rst to report the urinary status of people in a polar environment investigated with questionnaires and voiding logs. we initiated this study under the assumption that one's urinary status would deteriorate in a polar environment, but our fi ndings indicated that urination and sleep tend to improve in antarctica. management of male luts: a southeast asia regional survey on practice patterns and perspectives results: responses were obtained from urologists from centres with size ranging from to patients per week. referral patterns diff er across the region -in hong kong, singapore and malaysia, patients prefer or are required to consult a general practitioner before seeking urologist care. common investigations that respondents proposed included urofl owmetry ± post-void residual volume measurement ( %), psa ( %), urinalysis ( %), voiding diary ( %), physical examination ( %) and trus-biopsy ( %). however, only urinalysis and symptom scores are essential investigations recommended consistently in major international guidelines. whether urofl owmetry should become an essential investigation in sea remains debatable. luts secondary to bph/bpo ( %) and oab ( %) were the two most common diagnoses for the case scenario, and correspondingly, alpha-blocker ( %) and antimuscarinics ( %) were the two predominant treatments suggested by respondents. nocturnal polyuria is a common cause of nocturia especially amongst elderly, yet relatively few urologists ( %) considered this condition as a main diagnosis. respondents felt that there was a paucity of large-scale epidemiology studies on luts in sea, and on the natural history of the disease. more education on the proper evaluation and diagnosis of luts is needed for both gps and urologists in the region. results from this sea survey revealed variations in urologists' practice patterns and guideline recommendations, and pointed to the needs for further research and education in luts. female urethral prolapse: bhalla v , attri a , bhalla s introduction and objective: urethral prolapse means the protrusion of the distal urethra through the external urethral meatus. female urethral prolapse is a rare condition that has bimodal distribution aff ecting postmenopausal women and prepubertal girls. female urethra has two layers of smooth muscles inner longitudinal layer and outer circular which remain adherent to each other by strong connective tissue. separation of these two layers with episodic increase in intra-abdominal pressure leads to complete urethral prolapse. birth trauma during prolonged vaginal delivery, perineal tears, debility, malnutrition and periurethral bulking agent injections have been implicated in postmenopausal group. we present two postmenopausal female patients of urethral prolapse having similar clinical presentation aged years and years respectively. th ey presented with symptoms of blood spotting of undergarments and voiding diffi culty with dysuria of acute onset. on physical examination a doughnut-shaped erythematous infl amed mass was seen protruding from external urethral opening. th e evaluated parameters included pop-q grade, international prostatic symptom score (ipss), overactive bladder questionnaire (oab-q), international consultation on incontinence questionnaires short form (iciq-sf), maximum fl ow rate (q-max), and residual urine volume (ru). we evaluated them before and , , year aft er surgery. results: pop-q grade before surgery tended to be high in elderly group without signifi cance. anatomical cure at year aft er surgery (%) of non-elderly and elderly was and %, respectively. a tendency to having poor scores was observed in elderly group concerning preoperative ipss, iciq-sf and oabss; however they did not attain signifi cance. th ese three parameters improved in both groups aft er surgery; however, the percent improvement was signifi cantly poor in elderly group. th e maximum fl ow rate before surgery was signifi cantly low in elderly group and was still low aft er surgery. th e residual urine volume did not show signifi cant diff erence in each group before and aft er surgery. in the observation period of year, de novo oab and mesh extrusion were observed in elderly group with a signifi cant frequency. conclusions: th ough the anatomical cure was not age specifi c, age apparently aff ected on the outcome of tvm especially in the percent improvement of luts. autologous materials and methods: ten women with sever and complicated stress urinary incontinence secondary to the bladder neck and urethral trauma or congenital epispadias (with or without extrophy) underwent transurethral injection of autologous muscle derived cells. a second injection was performed according to the assessment of patients, months aft er the fi rst treatment session. all patients were followed at one week, , and months aft er injection by physical examination (cough stress tests), one hour pad test and iiq- score. multi-channel urodynamic study and maximal urethral closure profi lometry (mucp) was performed before and months aft er the last treatment session. cough stress test, one hour pad test and urofl owmetry were repeated at months aft er the last injection. in each visit the severity and incidence of complications was recorded. results: all patients completed the study and were followed for months. th ree patients were cured; four and three of patients were improved and failed to the treatment respectively. th ere were no major adverse events related to the treatment. conclusions: according to our clinical results, in a limited number of female patients, muscle derived cell therapy is a minimally invasive and safe procedure in the treatment of patients with severe and complicated sui. th e cure rate is not high, though it may be considered as an option beside other treatment modality. are we evaluated the eff ect of patient position and bladder fi lling status on the q-tip angle for urethral hypermobility. we measured the q-tip angle in the supine position and at a ° angle in a reclining position in patients during bladder emptying and then repeated the measurements while fi lling the bladder, usually - ml. we defi ned urethral hypermobility as the urethral angle straining or coughing minus that at rest > °. results: all female patients (mean age, ± years; range, - ) who complained of urinary incontinence were assessed using the q-tip angle. th e pelvic organ prolapse quantifi cation stages of all patients were ≤ stage . mean q-tip angle with an empty bladder was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). mean q-tip angle during the fi lling bladder state was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). th e urethral hypermobility rate during the bladder emptying state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e relative positive ratio of the reclining to the supine position is . . th e urethral hypermobility rate during the bladder fi lling state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e positive rate was higher in the ° reclining position during bladder emptying than that in the other position during bladder fi lling. conclusion: th e outcome of the q-tip angle measurement and the rate of urethral hypermobility changed in relation to patient position. th e reclining position during bladder emptying increased the q-tip angle, resulting in positive urethral hypermobility. rotational th ere was no mortality from the surgical procedure, whereas pain and catheter blockage was main complication. all patients were followed at , , and weeks respectively. our success rate was %. vesicovaginal fi stula is the most common urogenital fi stula. obstructed labor and its complications are still the leading cause of its development, whereas iatrogenic fi stula is also up-coming warning for all health care professional. the effi cacy of combination therapy of alpha blocker with anticholinergic in adult women with overactive bladder introduction and objective: overactive bladder (oab) is associated with symptoms including urgency, with or without urge incontinence, usually with frequency and nocturia. anticholinergics are mainly used for the treatment of patients with oab, especially women. other than anticholinergics, alpha blockers have been shown in several clinical reports to be useful in treating detrusor overactivity caused by neurological diseases. th e aim of the study is to evaluate the effi cacy of alpha blocker in combination with anticholinergics to treat women suff ering from oab. th is prospective study enrolled female patients with oab. patients have been randomised into two groups. th e interventions for the -week treatment period included solifenacin daily for the group and combination of both solifenacin and tamsulosin daily for the group . at baseline and weeks aft er treatment, patients completed a -day bladder diary, international prostate symptom score (ipss), quality of life (qol) index, overactive bladder symptom score (oabss), maximum fl ow rate (qmax) and postvoid residual urine volume (pvr). results: a total of women were randomised and completed this study (group ; , group ; ). statistically signifi cant improvements in terms of urgency and frequency were observed in both groups at weeks aft er treatment as compared with baseline (p< . and < . ), while no inter-group diff erence was observed between the two groups. although group showed improvement of ipss voiding subscore, qol and qmax than group but not statistically signifi cant (p= . , p= . , p= . ) . no signifi cant diff erence was observed in terms of toxic events between the two groups. conclusion: th e combination of alpha blocker and anticholinergic for weeks was noninferior to anticholinergic alone in effi cacy, and there was no evidence of benefi t of alpha blocker in treating female oab. further studies are needed to assess the role of combined therapy of alpha blocker and anticholinergic in the treatment of female oab. conclusion: advancement of cystoscopy will continue undoubtedly. th is report emphasizes the key people whom contributions will always be a corner stone in the fi eld of urology. "gleason" in a nutshell unusual urogenital disorders introduction and objective: to present some aspects of unusual urogenital disorders, congenital malformations, and syndromes, sometimes occurring in eminent personalities or having been described by famous scientists. th e review of historical sources and biographies of famous suff erers and the study of modern medical literature about all these rare urogenital diseases. results: penile deformities such as hypospadias (the most known representative was henry ii of france - , suff ering also from chordee) and the rare epispadias (respectively the most known was the byzantine emperor heraclius, - ) were recorded by historians because of the infertility consequences or the bizarre urination habits (heraclius needed protective measures to avoid getting wet). historians also were attracted by spectacular and dramatic urological emergencies, such as fournier gangrene, known by the case of the prominent suff erer herod. referring to famous researchers, françois gigot de la peyronie ( - ), founder of the royal academy of surgery of france, described the homonymous disorder ( ), consisting of penile deformity due to induration of the corpora cavernosa of the penis. th e above disease, called also induratio penis plastica (ipp) is one of the extraordinary urogenital problems together with the strongly psychologically and non-physically induced syndromes koro (genital retraction syndrome) and castration anxiety (the latter described by freud). belief that genitals have disappear and fear of damage or loss of the penis characterize them both. much of the research has been done on the two above topics, although still relevant today. conclusions: unusual urological disorders are broadly known when happening on famous personalities or when described by famous physicians or when attract the common opinion as extraordinary events (called mirabilia by historians). koutsiaris e , drettas p , oikonomou a , poulakou-rebelakou e , rempelakos a introduction and objective: th e loss of a testis represents a psychologically traumatic experience in males of any age. testicular loss is commonly the result of torsion, trauma, infection or malignancy. th e patients who experience orchiectomy request the implantation of an artifi cial testis for psychological or cosmetic reasons. testicular prostheses are one of the most commonly implanted devices and we present the evolution of these devices. review of the medical literature regarding the history of testicular prostheses and the various materials that have been used during the decades. results: th e fi rst testicular prosthesis was an alloy of molybdenium, cobalt and chromium and was used in . during the s, other materials were used such as plexiglass and polyethylene without much success. it was then suggested by the scientifi c community that the ideal testicular prosthesis should not produce any infl ammatory reaction and that should be also made by a proven non carcinogen material. it was also suggested that the material of the prosthesis should also resist mechanical press and take and hold the desired form. as a result, solid silicone rubber prostheses were introduced and used in the s. th e demand for more natural feeling implants lead to gel fi lled silicone devices appearing in . in , fi rmer silicone coated prosthesis became the "gold" standard. in the us in , the food and drug administration (fda) halted the use of gel fi lled breast implants due to the risks of autoimmune disorders and the possibility of tumor development. as a consequence, in there was a voluntary withdrawal of silicone gel fi lled testicular prostheses and replacement with saline fi lled prostheses. nowadays both silicone and saline fi lled testicular implants are used worldwide which are safe and eff ective. conclusions: testicular prostheses reduce the psychological impact that results from loss or absence of a testicle and should be off ered to male patients of any age. introduction and objective: we investigated population-based management trends of urinary stone disease in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the recent years in a korean population. we conducted this retrospective study by reviewing the medical records of patients diagnosed with acute ureteric colic in the emergency room and in the urology outpatient from january to december . nine hundred patients were diagnosed with ureteric stone and all of them underwent ultrasound as the primary imaging modality. sensitivity, specifi city, positive and negative predictive value in determining the size, position of the stone in the ureter by ultrasound has been documented. results: out of patients, there were males ( %) and females ( %). age range was - years. our study found that color doppler ultrasound with twinkling sign, diagnosis was made with confi dence in cases ( . %). sixty-fi ve patients who failed the ultrasound, the stones were confi rmed by helical ct, failure to detect the stone was mainly due to poor visualization (due to bowel gases and obesity) and smaller size of stone. right side stones were seen in ( . %) patients while left side stones were seen in ( . %). stones were detected bilaterally in cases ( . %). th e range of stones size was - . mm. th ere were ( . %), ( . %) and ( . %) upper, middle and lower ureteral stones. conclusion: th ere is no doubt that spiral ct is superior in the demonstrating of ureteral calculi. th e present study emphasized that utilization of color doppler ultrasound with twinkling in trained hands can provide an excellent alternative modality with high sensitivity and specifi city in diagnosis of acute ureteric colic and with confi dence can be used as fi rst imaging modality, hence we could avoid high cost, higher radiation dose and high workload. contemporary imaging practice patterns following ureteroscopy for stone disease cleveland clinic, cleveland, usa introduction and objective: routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. however, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. we sought to identify post-ureteroscopy imaging practices amongst experienced urologists. a redcap questionnaire was sent to urologists in north america. th e questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors infl uenced these preferences. th e likelihood of altering clinical practice and the desire for specifi c imaging guidelines were also assessed. th e interquartile range (iqr) was utilized as a measure of median consensus, with a lower iqr denoting increased agreement. results: th ree hundred twenty two urologists completed the questionnaire. th e mean number of years in practice was ± ; % of respondents performed more than ureteroscopic stone procedures monthly. routine postoperative imaging was obtained by % of participants as follows: us ( %), kub ( %), ct ( %), ivp ( %), and kub + us ( %). urologists who did not routinely image patients were more concerned about cost ( % vs. %, p= < . ), radiation exposure ( % vs. %, p= < . ), and diagnostic inaccuracy of us ( % vs. %, p= < . ). th ese urologists were also less likely to have completed an endourology fellowship ( % vs. %, p= < . ). th e most compelling predictors of obtaining postoperative imaging were post-op pain and fever (median , iqr ), residual stones (median , iqr ), ureteral perforation (median , iqr ), and presence of a solitary kidney (median . , iqr ). conclusions: currently, about % of urologists who regularly perform ureteroscopic stone procedures obtain post-op imaging. imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever. introduction and objective: ct scans expose patients to ionizing radiation which is associated with risks of secondary malignancy. we sought to evaluate the performance of reduced dose ct scans in patients evaluated for renal colic in the emergency room. up. , figure . introduction and objective: intraoperative exposure to ionizing radiation is a growing concern for the safety of both patient and or staff . eff orts to reduce the amount of radiation during ureteroscopic procedures oft en result in decreased image quality. lessray™ is a device used to digitally enhance images obtained from a c-arm using a low-dose pulse setting allowing for reduction in radiation dose while maintaining image quality. a randomized prospective trial of patients was performed comparing ureteroscopic cases for unilateral obstructing ureteral stones using standard fl uoroscopy compared to lessray™. patient demographics, stone parameters, and operative characteristics were recorded in addition to total radiation dose, total fl uoroscopy time and images obtained ( (table ) . a statistically signifi cant reduction in radiation exposure to the surgeon was also noted (p = . ). image quality was not compromised and no conversion from less-ray™ to standard fl uoroscopy was needed in any case. a nearly threefold reduction in patient radiation exposure was achieved using the lessray™ digital enhancement device compared to standard fl uoroscopy. th is novel technology has not previously been used in urologic surgery and off ers a promising alternative to standard fl uoroscopy while ameliorating risks to both the patient and surgeon. bilateral results: in the cases of cn patients, accepted retroperitoneal laparoscopic cyst unroofi ng, accepted retroperitoneal laparoscopic partial nephrectomy, patient with a preoperative diagnosis of cystic renal cell carcinoma, the maximum diameter of cm and located in the center of the kidney got retroperitoneal laparoscopic radical nephrectomy. one patient recurred yrs later aft er retroperitoneal laparoscopic cyst unroofi ng, and underwent open partial nephrectomy at last. six mestk patients underwent retroperitoneal laparoscopic radical nephrectomy and accepted retroperitoneal laparoscopic partial nephrectomy. twelve cases were followed up for months to years, no recurrence. conclusion: cn and mestk are rare benign tumors of the kidney. preoperative misdiagnosis is high. multi-cystic lesions with no mural nodules should take cn/mestk into consideration, especially when the lesions convex to the pelvis, should be highly suspected for cn diagnosis, and to assess the possibility of partial nephrectomy. cyst unroofi ng for cn has recurrence risk. the value of -t multiparametric mri for detecting prostate cancer of t stage introduction and objective: th e objective of this study was to prospectively determine the value of -t multiparametric (mp) mri with pelvic -phased array coil for prostate cancer of t stage. december , patients underwent -t mpm-ri with pelvic -phased array coil, transrectal ultrasound-guided biopsy and radical prostatectomy for adenocarcinoma. mr images were evaluated by three experienced radiologists with regard to extracapsular extension and seminal vesicle involvement and compared with whole-mount histopathological sections as a gold standard. we estimated the sensitivity, specifi city, positive, and negative predictive value and overall accuracy of mpmri for t disease. introduction and objective: prostate cancer (pca) imaging has undergone a revolution in the past fi ve years with the rise of multiparametric magnetic resonance imaging (mri) for cancer detection and the evolution of positron emission tomography-computed tomography (pet-ct) for staging. initially, choline pet-ct was considered the new standard for detecting metastatic disease where biochemical recurrence (bcr) occurs aft er primary treatment, but a newer agent based on prostate-specifi c membrane antigen (psma) has emerged. despite the reported promising results with this novel imaging modality few reports correlating psma pet-ct with pca histology have been documented. we present the case of a fi t year old gentleman, where psma pet-ct was used to accurately detect pca pelvic lymph node (ln) metastasis in the setting of bcr following primary radiation treatment. results: th e positive psma pet result was confi rmed with histological examination of the involved pelvic lns following robotic-assisted laparoscopic pelvic ln dissection (plnd). larger studies are required to document accurately the role of psma pet-ct but it is likely it will usher in a new era of surgical and even radiation treatment of oligometastatic disease, aiming for cure or prolonged deferring of systemic treatment. introduction and objective: imaged guided radiotherapy has been shown to improve the outcome of pelvic radiotherapy, notably with prostate gold seed fi ducials. lipiodol has been utilized for radiotherapy bladder fi ducials, but can be technically diffi cult to inject as discrete fi ducial markers, particularly in the post-prostatectomy setting. th e objective is to investigate contrast agent/tissue glue mixtures as radiotherapy bladder fi ducials with respect to deliverability and visualisation for radiotherapy verifi cation. two radiopaque contrast agents, lipiodol and urograffi n were investigated. th ese were mixed with a three tissue glues: histoac-ryl™, tisseel™ and glubran™. to simulate the clinical procedure, the mixtures were injected ex-vivo into the submucosa of fl uid fi lled pigs' bladders using a cystoscope and williams needle. th e aim was to produce a small, medium and large fi ducial. th e bladders were transferred to a pigs' pelvis to provide realistic tissue densities for radiotherapy imaging. visualisation of the pelvis was performed in accordance with radiotherapy procedures. th e initial imaging was done on a radiotherapy ct simulator. radiotherapy verifi cation was performed by radiation therapists using widely accepted protocols including cone beam ct (cbct) and kilovoltage (kv) & megavoltage (mv) d planar images. results: delivery: urograffi n glue mixtures were diffi cult to deliver as it polymerized rapidly in the catheter. consequently it was only possible to produce a single fi ducial. th e lipiodol glue combinations were all deliverable. visibility: th e urograffi n glue combinations were only able to produce a single fi ducial that was visible on ct and cbct but were not visible with kv or mv verifi cation. all of the lipiodol glue combinations produced multiple fi ducials that could be satisfactorily visualised on ct and cbct. lipiodol with either hystoacryl or glubran produced visible fi ducials on kv imaging, however the lipiodol tisseel combinations could not be seen. no combination produced suffi cient contrast with mv planar imaging. introduction and objective: th e fl exible urethrocystoscopy is a procedure that is performed routinely in urology for monitoring bladder tumors and diagnosis in patients with lower urinary tract symptoms and hematuria. th e aim of this study is to analyze whether the use or not of antibiotic prophylaxis is indicated in this outpatient procedure. prospective nonrandomized observational study in which patients were divided into two groups: -group : patients with prophylaxis with ciprofl oxacin mg h before urethrocystoscopy; -group : patients without antibiotic prophylaxis. prior to inclusion in the study absence of urinary tract infection is checked by urine culture obtained three days before the procedure. indication of cystoscopy, cystoscopy results, presence of comorbidities, urine culture aft er days, urinary symptoms over the next seven days were analyzed. statistical analysis with spss . with signifi cance diff erences p≤ . . results: th e mean age of patients in group was . ± . years versus . ± . years in group (p= . ). no diff erences in the percentage of men / women included among the groups. fourteen percent of patients in group had bacteriuria compared with % in group , no signifi cant diff erence. in the multivariate analysis, it appears that neither age, diabetes, smoking, lower urinary tract symptoms or immunosuppression were associated with the onset of bacteriuria between groups. conclusion: th e use of ciprofl oxacin prophylaxis in fl exible cystoscopy is not indicated in our health area, because does not diminish the presence of urinary tract infection or bacteriuria. minimal inhibitory concentrations for a novel anti-bacterial peptide eluting urethral catheter introduction and objective: catheter associated urinary tract infection is a serious prevalent medical problem. several strategies have been developed to suppress the seemingly inevitable ascent of foreign pathogens through the urethra. th e primary strategy has been to coat the surface of the catheter with repellant agents, such as silver alloy hydrogels or anti-biotics. anti-bacterial peptides, such as human beta defensing (hbd- ) or cathelicidine are naturally produced peptides from the urothelium, acting to inhibit bacterial attachment and infi ltration as part of the innate immunity of the host. we have recently been able to engineer anti-bacterial peptide elution through gelatin coated catheters. th is study investigates the effi cacy of this strategy in deterring common uti pathogens. materials and methods: e. coli and p. aeruginosa, bacteria commonly associated with uti, were inoculated in tryptic soy broth, and then were aliquoted into each well of plates. anti-bacterial peptides, either recombinant hbd- or cathelicidine, were diluted and added to each well at increasing concentrations, where microorganisms were exposed for hours or for the indicated times following antimicrobial challenge and determination of the planktonic mics. bacteria were then enumerated by serial dilution plating. time-kill studies were performed. bactericidal activities of the antimicrobial agents were defi ned as a log decrease in the cfu/ml over hours relative to cell counts in the starting inoculum. results: th e standard inoculant of e. coli and p. aeruginosa commonly required an mic of μg/ml hbd- , and μg/ml for cathelicidine. time kill studies estimated bactericidal eff ect for hbd- on e. coli and p. aeruginosa both at hours, while for cathelicidine it was and hours, respectively. conclusion: th e current study demonstrates the efficacy and feasibility of a controlled release elution of anti-bacterial peptides, hbd- and cathelicidine, in inhibiting growth of common uti pathogens. the conclusion: co-infections of ng with ct appear less frequently. and mpcr method is rapid and accurate for identifi cation of stp. th e mpcr should be conducted in advance prior to antibiotic treatment as well as it will be better to give suitable antibiotics rather than empirical combination antibiotics for ng with ct in patient with urethritis. introduction and objective: th e prevalence of multi-drug resistant extended-spectrum beta-lactamase-producing (esbl) bacteria in normal gut fl ora in the australian community is increasing. current prophylactic antibiotic regimes for trans-rectal ultrasound (trus) prostate biopsies do not have activity against esbl organisms leaving some men at risk of esbl sepsis. our objective is to determine the prevalence of esbl in gut fl ora in northern tasmanian men and to identify risk factors for colonisation. patients were recruited into two groups. group were volunteers from the urology pre-operative clinic or the general community. group were men undergoing trus prostate biopsies. all patients were assessed via an enrolment questionnaire for the presence of known esbl risk factors. further procedural data were collected for those who had trus biopsies. all patients were assessed for esbl via a faecal culture, prior to any antibiotic prophylaxis. fisher's two-tailed test was used for comparative analysis. patients with ic/pbs were assessed with the o'leary-sant interstitial cystitis index score and global response assessment questionnaire prior to commencing treatment. assessment with these questionnaires was performed aft er treatments ( weeks) and again aft er treatments ( weeks). assessment end points were pain, urgency, symptom score and problem score. results: data was collected on patients, female and male. six patients had failed rimso- dimethyl sulphoxide (dmso) % w/w treatment prior. at baseline the mean pain score was . , urgency score . , symptom score . and problem score . . aft er weeks the mean pain score fell to . , urgency score to . , symptom score to . and problem score to . . at weeks the global response to treatment was %. nocturia was the fi rst symptom to improve with urgency and pain following. no side eff ects were noted no was reported during instillation and all patients tolerated the treatments. conclusion: ic is a diffi cult disease to treat. it requires a multimodal approach. we found that intravesical chondroitin sulphate reduced pain, urgency and o'leary-sant symptom and problem scores in patients with ic/pbs. all patients tolerated the treatment and no side eff ects were reported. introduction and objective: extended spectrum beta-lactamase (esbl) producing enterobacteriaceae are an increasing concern in an era of antibiotic resistance as they cause infections ranging from community acquired urinary tract infection (uti) to life threatening sepsis. we retrospectively reviewed the incidence and antibiotic susceptibility profi le of all esbl producing enterobacteriaceae at a university hospital in the united kingdom. patient gender, age and catheter specimen were assessed as risk factors. patient age, gender and specimen type were recorded in the database. urine samples received from outside our institution (including community isolates) were excluded from the analysis. urine was processed by calibrated loop sampling on to chromogenic clear media (oxoid ltd, basingstoke, uk). a positive culture was defi ned as ≥ cfu/ml except for samples from children and pregnant women where a cut-off value of > cfu/ml was used. susceptibility testing was performed by bsac (british society of antimicrobial chemotherapy) disc diff usion testing and reported for ampicillin, co-amoxiclav, piperacillin-tazobactam, carbapenems (ertapenem, meropenem), nitrofurantoin, pivmecillinam, trimethoprim, cephalexin, fosfomycin, third generation cephalosporins (ceft riaxone, ceft azidime) quinolones (norfl oxacin or ciprofl oxacin), aminoglycosides (gentamicin, amikacin) and others. cultures of more than two organisms (heavy mixed growth) were considered contamination and excluded. other exclusion criteria included missing data such as gender, age or susceptibility results, age < years old or an unusual specimen type such as an ileal conduit, nephrostomy, prostatic secretion, bag specimen or a suprapubic aspirate. results: our initial database included , samples which was reduced to , samples from , unique patients aft er exclusion criteria were applied. causative organisms were found to predominantly be e. coli, enterococcus, klebsiella, pseudomonas and proteus species. th e proportion of causative organisms was largely stable across the ten year period. antibiotic resistance was demonstrated to have increased, particularly across fi rst line agents. male gender and catheter use were associated with multi-resistance. in the modern era of antibiotic resistance we demonstrate that antibiotic resistance in hospital urinary tract infections is increasing. our results may be used to guide empirical treatment of hospital urinary tract infection. chronic pyelonephritis is a risk factor for renal dysfunction after urinary diversion in bladder cancer uehara s , , murao w , otsuki h , shimizu t , yoshioka t , , fujio k okayama university, okayama, japan; abiko toho hospital, abiko, japan introduction and objective: several reports showed that acute pyelonephritis is a risk factor for renal dysfunction in bladder cancer aft er urinary diversion, but the impact of chronic pyelonephritis fer renal dysfunction was unclear. materials and methods: from to , patients underwent radical cystectomy in our institute. among those patients, who showed hydronephrosis (more than grade ) or did not have enough data were excluded in this retrospective study. finally patients were enrolled. th e urinary diversions were divided into types: ileal neobladder (ib), ileal conduit (ic), ureterocutaneostomy without stent (uc) and ureterocutaneostomy with stent (ucws). ureteral stents were indwelled because of the ureteral stenosis aft er ureterocutaneostomy. because the cases of ucws generally showed pyuria and bacteriuria, ucws was determined as the chronic pyelonephritis model, and the estimated serum creatinine-based glomerular fi ltration rate (egfr) was calculated and compared with other urinary diversion. results: median follow-up period was . months (range - months) and median egfr was . ml/ min/ . m before surgery and . ml/min/ . m at the last follow-up. th e median decrease of egfr during the period between pre-surgery and the last follow-up in ib, ic, uc and ucws was . , . , . and . ml/min/ . m respectively. renal function was signifi cantly impaired in ucws cases than other urinay diversion. conclusion: chronic pyelonephritis may be a risk factor for renal dysfunction aft er urinary diversion. to avoid the renal dysfunction, ureteral stents should not be indwelled permanently. comparison of antibiotic susceptibility of escherichia coli between community-acquired and post-biopsy acute prostatitis introduction and objective: th e etiology of acute prostatitis aft er transrectal-ultrasound-guided-prostate-biopsy (pbx-ap) seems to be diff erent from that of community-acquired acute prostatitis (ca-ap). recent studies suggested that pbx-ap should be considered a separate category of prostatitis, distinct from spontaneous acute prostatitis. th us, we aimed to compare antibiotic susceptibility of escherichia coli between ca-ap and pbx-ap. of , patients who underwent transrectal-ultrasound-guided-prostate-biopsy, a total of patients had pbx-ap. in among these, escherichia coli was isolated on urine or blood culture. in of the patients with ca-ap, escherichia coli was identifi ed on urine or blood culture test. th us, a total of patients with ca-ap (n = ) or pbx-ap (n = ) caused by escherichia coli were included in this retrospective study. we compared demographic variables, data on clinical laboratory tests or transrectal ultrasound and antibiotic sensitivity data between the two types of prostatitis. results: in comparison to the ca-ap group, the pbx-ap group showed signifi cantly higher incidence of bacteremia and lower count of white blood cell. th ere was no signifi cant diff erence between the two, regarding to other clinical or laboratory parameters including age, body mass index, serum psa, prostate volume and percentage of patients with ebsl-positive escherichia coli. th e percentages of patients with quinolone-resistant escherichia coli in the ca-ap and pbx-ap groups were . % and . %, respectively, while those with nd or rd cephalosporin-resistant escherichia coli were . % - . % and . % - . %, respectively (table ). in both groups, the percentage of patients with amikacin-resistant escherichia coli were . %. our data suggest that a combination therapy of cephalosporin and amikacin can be recommended for treatment of pbx-ap while quinolone alone may be a feasible treatment option for ca-ap. the effectiveness of prostatic massage in treating chronic prostatitis (cp) tanabalan c, panah a, kabir m, masood j, pati j, nargund v introduction and objective: we review the eff ectiveness of prostatic massage under general anaesthesia (ga) for persistent symptoms aft er failure of antibiotic therapy. th e mainstay of treating cp is empirical antibacterial therapy with varying results. prostatic massage has been used to treat cp with mixed results. retrospective study of patients that were seen in urology outpatient clinics from june to july with symptoms of chronic prostatitis. all patients had a full clinical evaluation and urinary samples were sent for culture/microscopy on their visit. patients were treated initially with a course of -aminoquinolone and doxycycline in combination with lifestyle advice. if initial antibiotic therapy failed and no abnormal results detected in the work-up, a prostatic massage was off ered. th is involved a rigid cystoscopy followed by a -minute prostatic massage under anaesthesia. post-operatively patients received a further course of antibiotics. patients were followed up aft er the procedure and were assessed for improvement in symptoms. a total of patients ( %) commented on an improvement in some or all of their cp symptoms for a mean length of time of . (range . to . weeks). mean psa was . (range . to . ). one bladder tumour and one urethral stricture were detected on cystoscopy with one prostate cancer following prostate biopsies. if voiding urinary symptoms present men were given an alpha-blocker, there was no signifi cant improvement in pain symptoms post-operatively between the two groups (p= . ). th ere were no adverse eff ects from having the procedure with no complications noted. prostatic massage under ga is a safe and eff ective therapy in the treatment of refractory cp in select patients. th e issues of long-term surveillance and assessment of response to treatment remains a challenge. th ere seems little role for alpha-blockers, psa testing and mri prostate in the management of cp. oral antibiotic therapy and lifestyle modifi cations should remain as a fi rst-line treatment option. th e eff ect of stress, lifestyle and ethnicity has not been demonstrated in this study and further research will need to be undertaken. intravesical hyaluronic acid and chondroitin sulfate therapy for interstitial cystitis and painful bladder syndrome shin b, hwang e, chung h, kim s, jung s, kang t, park k, kwon d introduction and objective: damage to the urothelial glycosaminoglycan (gag) barrier layer may underlie the pathogenesis of several chronic bladder pathologies, including interstitial cystitis/painful bladder syndrome (ic/pbs). th is study evaluated the eff ect of intravesical hyaluronic acid (ha) in ic/pbs. twenty patients received intravesical ha mg and chondroitin sulfate (cs) g (ialuril®) in ml saline solutions once weekly for weeks, once every weeks for the next month, then once every month for the next months. results: a signifi cant improvement in urinary symptoms was evident on voiding diaries (number of voids and mean void volume; p= . and . , respectively). th e interstitial cystitis symptom index and interstitial cystitis problem index resulted in a significant improvement in both scores (p= . and . , respectively). th e storage symptom score (ipps) decreased from . to . (p= . ). th e quality of life to urinary symptom reduced from . to . (p= . ). th ere was no statistical signifi cant change in the voiding symptom score of ipps aft er ialuril instillation (p= . ). conclusions: th is promising experience seems to offer an additional therapeutic option in patients with refractory ic/pbs. prevention of surgical site infection: new approach alexander e , , hulda t , edna d introduction and objective: until the middle of the th century, when ignaz semmelweis and joseph lister became the pioneers of infection control by introducing antiseptic surgery, most wounds became infected. in cases of deep or extensive infection this resulted in a mortality rate of - %. most surgical site infections (ssi) are superfi cial, but even so they contribute greatly to the morbidity and mortality associated with surgery. th e aim of this study is to fi nd out rate of surgical site infection by single change of wound dressing. th e study is prospective in two hospitals (ba regional hospital, tophill hospital in kumasi). surgically clean cases are selected for operation. wounds are not opened till the seventh day or when soaked. window is left for wound inspection. results: results are shown in table . table , patients with diff erent surgical conditions were operated. average post-surgery change of dressing was days. ssi= / ( . %). single post-surgery change of dressing is eff ective ssi prevention method. effects of semen cuscutae on the fertilization ability in varicocele-induced rat introduction and objective: th ere is no specifi c medication to improve the sperm motility and count yet. th is study aimed to evaluate the favorable eff ects of purifi ed fl avonoid, semen cuscutae extract (sce) against oxidative stress injuries and other homeostatic imbalances in reproductive organs in adolescent rat with varicocele and to develop the new herbal medication to treat the male fertility. materials and methods: seventy-two rats were divided into groups: control (ctr) + hydroxypropyl-methyl cellulose (hpmc) (ctr + hpmc), ctr + mg/kg sce and ctr + mg/kg sce, varicocele (vc) + hpmc, vc + mg/kg sce and vc + mg/kg sce. in ctr group, they were started with medication for days from weeks aft er environmental stabilization. for the vc groups, they were given medications for days aft er weeks of operation. blood was collected before sacrifi ce for the testosterone test. sperm motility, daily sperm production (dsp), sperm count, and sperm transit time were calculated. th e seminiferous tubules were graded according to johnsen scoring. th e mrna expression of glutathione peroxidase (gpx ) and . nmol/mg protein, respectively) than vc group ( . ± . u/mg protein and . ± . nmol/mg protein, respectively). also, the testosterone, johnsen score were signifi cantly increased in the dose of mg/kg sce group than other groups. th ese results suggest that purifi ed fl avonoid semen cuscutae extract could be an alternative medicine for the infertility patients by inhibition of oxidative stress by favorable mechanisms. the relationship between pregnancy rate and semen quality improvement after varicocelectomy varicocele is the most common cause of male infertility and is generally correctable via surgery. in some reports, pregnancy rates were improved aft er varicocelectomy in male patients with poor semen quality. th e aim of this study was to determine the relationship between semen improvement and pregnancy rate. patients who underwent microsurgical varicocelectomy from jan. to jun. were enrolled. all patients had history of infertility (> year) and confi rmed varicocele on physical examination. th e abnormality of semen analysis results was based on who guidelines. varicocelectomy was performed in patients with poor semen quality in a series of two semen analysis where the female partner was normal in spontaneous pregnancy, as evaluated gynecologically. microsurgical varicocelectomy was performed by single surgeon. follow-up semen analysis was performed months aft er operation. improvement in semen quality was defi ned as > % improvement in total motile sperm compared with pre-operation semen analysis. pregnancy rate, method of pregnancy, and time to pregnancy were investigated. results: a total of male patients were included in this study, ( . %) in the improvement group (ig) and ( . %) in the non-improvement (nig). th e pregnancy rate was % ( / ) in the ig group and % ( / ) in the nig group; there was no significant diff erence between groups. pregnancy methods between the two groups were similar (table ) . introduction and objective: to review the learning curve, complications and outcomes of the fi rst cases of microsurgical vasectomy reversal performed in a developing country. th e fi rst dedicated service in male infertility microsurgery in south africa was established in . between january and december , a total of patients underwent microsurgical vasectomy reversal by a single surgeon (amir d zarrabi). mean patient age was years (range to ), mean age at vasectomy years (range to ), mean number of children for the male partner . and mean age of the female partner years (range to ). th e mean time interval between vasectomy and reversal was . years (range . to . ). five patients had previous failed vasectomy reversals and in patients the indication for reversal was post-vasectomy pain syndrome. a total of % of patients travelled from other countries for their surgery. results: mean surgical time per testicular unit was . minutes (range to ) and total operative time minutes (range to ). sperm motility (intra-operative light microscopy) was good in . %, average in . % and poor in . %. vasovasostomy was required in . % of testicular units and vaso-epididymostomy in . %. in patients sperm was harvested at the time of reversal for cryopreservation. complications occurred in % of patients and were managed conservatively in all but , who required an additional surgical procedure. for patients with adequate follow-up the overall surgical success rate was %. mean post-operative sperm count was . million. nine pregnancies and live births have been recorded during the limited follow-up. comparing the fi rst cases with the last cases revealed no signifi cant diff erences in surgical time, complications or patency rates. th e mean post-operative sperm count was % higher for the last cases. although microsurgical vasectomy reversal is technically demanding and requires specialized equipment and instruments, it can be successfully implemented in a developing country. infl uence of unilateral iatrogenic torsin on contralateral testis in rat, prepubertal and postpubertal introduction and objective: th e present study was conducted to investigate the infl uence of hemicastration and age at hemicastration on the subsequent contralateral testis. sixty-four wistar-derived male rats divided randomly in groups. group named immature intervention, group immature control, group mature intervention and group mature control. in group , rats hemicastrated at days of age (prepubertal). in group , sham surgery (midscrotal incision) was done at same age. in group , rats hemicastrated at days of age (postpubertal) and in group sham surgery was done at same age. twenty days aft er fi rst surgery, in intervention groups contralateral orchiectomy was done and in control groups random orchiectomy (left or right) was done. blood sampling for evaluation of serum testosterone was performed just before second surgery. results: testis weight and the mean testicular weight per g of body weight was greater in hemicastrated rats. th ese parameters was greater in prepubertal group than postpubertal hemicastrated rats. th ere was no appreciable diff erence in serum testosterone levels in groups. our research demonstrated that hemicastration resulted in compensatory hypertrophy of the remaining testis and it decreased as the animals aged. hemicastration does not lead to reduction in serum testosterone levels and remaining testis can retrieve a normal serum testosterone level. role of antibiotic in the treatment of semen hyperviscosity: a single institution study introduction and objective: th e prevalence of semen hyperviscosity is estimated to be between - % and can lead to male factor infertility both in vivo and in vitro. semen is composed of fl uids secreted by the male accessory glands, which contain proteins essential to the coagulation and liquefaction of semen. hypofunction of the prostate or seminal vesicles causes' abnormal viscosity of seminal fl uid. hyperviscosity can impair normal sperm movement in the female reproductive tract, and can lead to decreased sperm count. multiple factors have been predicated which result in the development of semen hyperviscosity, of this infection is considered to be one of the main contributor. aim of the study was to predict the eff ect of antibiotic in the treatment of hyperviscosity. th is is a single institution study, patients (age range - years) were recruited who were diagnosed with semen hyperviscosity (failure to liquefy aft er min). medical, sexual, and family history were documented. all the patients semen were kept for culture and they all got levofl oxacin for days and patient who had positive culture were changed to appropriate antibiotics. all the patients underwent repeat semen analysis aft er weeks. results: seventy seven percent patient had previous history of prostatitis, % patient had past history of sexual transmitted diseases. seventy fi ve percent patient are suff ering from infertility, of this % patient had a family history. th irty seven percent patients had positive culture and of this only % patient had liquefaction post treatment. culture negative patients, % patient had liquefaction post treatment. conclusions: semen hyperviscosity is associated with infertility and exact cause is considered to be multifactorial, of this infection is considered to be the main factor. in our study we did found that most of the patients has infection but antibiotic treatment even for culture positive patients showed minimal eff ect. treatment with antibiotic along to treat hyperviscosity cannot be considered curative since in our study the eff ect was only %. further research is needed to better understand the contributors to semen hyperviscosity and the treatments that can be used for infertile males with hyperviscous semen. modifi ed microsurgical subinguinal varicocelectomy: bundle ligation technique hong y, lee s, choi k, park d, hong j introduction and objective: microsurgical varicocelectomy has become the gold standard because of low recurrence and postoperative complication rate. during the procedure, isvs should be carefully dissected, cut and suture-ligated one by one. however, it is not easy to divide all isvs in a horizontal line, which can result in some uncertainty whether every single isv was divided or the same vein was unnecessarily divided multiple times. th erefore, we have developed a modifi ed technique, so called bundle ligation technique (blt), to make the procedure more reliable and simpler. a total of cases of microsurgical subinguinal varicocelectomy performed from to were grouped as conventional varicocelectomy (cv, n= , age: ± . ) and blt (n= , age: ± . ). mean follow-up time was . ± . months. blt is a simpler procedure because isvs are ligated as a whole, however, it is possible only aft er dissecting and securing the testicular artery fi rst. we compared operation time, resolution of palpable varicocele or pain, recurrence rate and complications. results: mean operation time was . ± . in cv group and . ± . in blt group (p= . ). resolution rates months aft er surgery were . % (cv) and . % (blt) in each group. recurrence aft er surgery during the mean follow-up time was . % (cv) and . % (blt). th e aim of the study is to evaluate the eff ect of hbo on the level of sperm dnaf and on the content of reactive oxygen species (ros) in semen. th e study included men with idiopathic infertility, the level of sperm dnaf was above % and the content of ros in the sperm was above . mv/sec. in the main group (n= ) sessions of hbo were performed and in vitro fertilization (ivf) was carried out months later. in the control group (n= ) ivf was performed without preceding hbo. th e age of patients ranged from to years (median - . years). sperm dnaf was determined by tunel, the level of ros in semen was studied by chemiluminescence. th e assessment was made at the time of entry into the study and aft er months (in the main group - months aft er hbo). in the main group, average sperm dnaf aft er hbo decreased from . ± . % to . ± . % (p< . ), the median level of ros in semen decreased from . mv/sec to . mv/sec (p< . ), whereas in the control group of patients these fi gures have remained almost at the same level - . ± . % and . ± . % (p> . ), . mv/sec and . mv/sec (p> . ). pregnancy resulting from ivf occurred in . % ( / ) of the cases in the study group and in . % ( / ) -in the control group (p< . ). conclusion: hbo is an eff ective method to reduce the number of sperm with dnaf, which can potentially lead to an increased fertility in patients with idiopathic male infertility. to evaluate the natural history and growth kinetics between sporadic clear cell renal cell carcinoma (ccrcc) and ccrcc in von hippel-lindau disease (vhl). we reviewed patients with sporadic ccrccs and patients with vhl ccrccs all confi rmed by delayed surgery aft er at least months active surveillance. th e growth rate was calculated. th e growth kinetics between sporadic and vhl ccrcc were compared. th e initial tumor diameter and pathological grade were reviewed, and their correlation with the growth rate were analyzed. results: th e mean growth rate of sporadic ccrcc was . cm/yr (range, - . cm/yr). th e mean growth rate of vhl ccrcc was . cm/yr (range, . - . cm/yr). th e growth rate of vhl ccrcc was lower than that of sporadic ccrcc (p= . ). for vhl ccrcc, the initial tumor diameter aff ect the growth rate (r= . , p< . ), while the pathological grade not (p= . ). for sporadic ccrcc, the pathological grade aff ect the growth rate (p< . ), while the initial tumor diameter not (r=- . , p= . ). conclusion: th e growth kinetics of vhl ccrcc is more indolent than that of sporadic ccrcc. for ccrcc with aggressive growth kinetics, its growth rate might correlates with the pathological grade, for those with slow growth kinetics, the growth rate might correlates with the initial tumor diameter. effects of trpm silencing on the proliferation, migration, and invasiveness of renal cell carcinoma (rcc) cells proliferation, migration, and invasiveness of human rcc following trpm knockdown. we constructed sirna sequences targeting the trpm gene and then transfected them into rcc cells mediated by liposome. th e potency of nm trpm sirnas was detected trpm mrna measurement by rt-pcr. th e eff ect of trpm sirna on cell viability was determined by wst- assay. cell motility and invasiveness were evaluated by wound healing assays and a matrigel migration and invasion assay. transfected rcc cells were cultured in eagle's minimum essential media supplemented with % fetal bovine serum. all measurements were done hours aft er trpm blocking. results: trpm sirna weakly inhibited the gene transcription of trpm . it was for nothing in the proliferation of human rcc cells. compared with vehicle control, the migration and invasion of human rcc cells were suppressed signifi cantly by trpm sirna until aft er hours. in addition, although protein levels of mmp- were not changed signifi cantly, we found that the protein levels of matrix metalloproteinase (mmp)- were diminished markedly by trpm sirna. th ese results suggest that trpm may have a role in the rcc progression including migration and invasion through upregulation of mmp . role of tnf-and cd in resistance to sunitinib treatment in clear cell renal cell carcinomas introduction and objective: tumor necrosis factor-α (tnf-α) was originally reported as a cytokine to induce apoptotic cell death and cachexia. recent studies have indicated that tnf-α also enhances tumor progression by inducing epithelial-mesenchymal transition (emt). tnf-α is also known as a modulator of cd expression, which belongs to cancer stem cell marker in several cancers. in this study we clarifi ed the signifi cance of tnf-α as well as cd in clear cell renal cell carcinomas (ccrccs). protein expression of tnf-α and cd was examined by immunohistochemistry in primary ccrccs, untreated metastatic ccrccs, and metastatic ccrccs treated with sunitinib, and its association with the clinicopathological parameters and prognosis was analyzed. involvement of tnf-α in emt and induction of cd was analyzed by comparing expression of emt-related genes and cd , and migration and invasion in cultured ccrcc cell lines. results: tnf-α and cd were predominantly expressed in carcinoma cells of high-grade ccrccs with positive correlations with primary tumor stage and distant metastasis. th ere was a positive correlation between tnf-α and cd expression, and elevated expression of tnf-α and cd was a poor predictor of prognosis. tnf-α enhanced migration and invasion of ccrcc cells together with down-regulation of e-cadherin expression and up-regulation of matrix metalloproteinase and cd expression. tnf-α also up-regulated the expression of tnf-α itself in ccrcc cells. twenty-fi ve patients were treated with sunitinib for metastasis, and the patients with cd -high tumors showed a shorter time to treatment failure compared to those with cd -low tumors. furthermore, residual carcinoma cells in the sunitinib-treated metastatic ccrccs were strongly positive for cd , and the cd expression was signifi cantly higher in tumors from the sunitinib-treated patients than in those from untreated ones. conclusions: tnf-α seemed to play an important role in progression of ccrccs by inducing emt, and suggested that tnf-α-induced cd might be involved in the resistance to sunitinib treatment. although further experimental studies on the relations between cd expression and cancer stem cells in ccrccs are needed, our data suggest that therapy targeting tnf-α and/or cd may provide a clue for improving the prognosis of patients with sunitinib-resistant ccrcc. introduction and objective: th e aim of this study was to investigate the relationship between the immunohistochemical expression of hypoxia-inducible factor- α (hif- α) with histological parameters such as tumor size; presence of tumor necrosis and hemorrhage; nuclear grade and pathological stage in patients with clear cell renal cell carcinoma (ccrcc). specimens from cases of rcc patients treated with radical prostatectomy were formalin-fi xed, paraffi n embedded, and stained with h&e. additional sections from each case were stained for hif- α. hif- α immunohistochemical expression was estimated as negative ( ), weak positive (+ ), moderate positive (+ ), and intense positive (+ ). th e statistical package "in stat " was used for data processing. results: immunohistochemical expression of hif- α in crcc was signifi cantly higher than in normal kidney tissue at statistically signifi cant level (hif- α: x -test = . , p= . ). a positive non-signifi cant correlation was found between hif- α and the tumor nuclear grade (r= . , p= . ); between hif- α and presence of hemorrhage (r= . , p= . ); whereas, a negative non-signifi cant correlation of a very weak scale was observed comparing hif- α and tumor size (r = - . , p= . ); hif- α and pathological stage (r=- . , p= . ), as well as hif- α and tumor necrosis (r=- . , p= . ). conclusion: our data showed heterogeneity in angiogenic activity, which might have an impact on biological behavior and anti-angiogenic, anti-vegf therapy of ccrcc patients. th is study suggests that there should be taken more than one tissue biomarkers into the consideration in predicting the biological behavior of ccrcc. introduction and objective: clear cell renal carcinoma (ccrcc) is the most frequent rcc subtype and is characterized by high mortality of %, due to late diagnosis and distant metastases found in % of rcc patients. although the involvement of vhl (von hippel-lindau), hif a (hypoxia-inducible factor -alpha) and vegf-a (vascular endothelial growth factor a) genes in development and progression of ccrcc is widely analyzed, our objective was to perform the common study of those factors in clinical samples of matched tumor-normal kidney biopsies of ccrcc cases. materials and methods: vhl, hif a and vegf-a mrna levels in samples were assessed by quantitative polymerase chain reaction (qpcr); rna was extracted from matched tumor-normal (t, c) kidney samples of ccrcc patients (mean age . ± . , median age ); ccrcc cases were characterized by local or distant metastasis; sunitinib was administrated to patients. vhl, hif α and vegf-a proteins were localized in matched tumor-kidney tissue of patients with the use of immunohistochemistry (ihc). molecular data was statistically calculated with clinical and follow-up data. introduction and objective: to identify tissue biomarker that are predictive of the therapeutic eff ect of sunitinib in treatment of metastatic clear cell renal cell carcinoma (mcrcc). our study included patients with mcrcc; these were selected from patients who received sunitinib in our hospital between the years - according to inclusion criteria of the study. patients were stratifi ed into two groups based on their response to sunitinib treatment; non-responders (progression), and responders (stable disease, regression). th e eff ect of treatment was measured by comparing imaging studies performed before the initiation of treatment with those done between rd and th months of treatment. histological samples of tumour tissue and healthy renal parenchyma, acquired during surgery of the primary tumour, were examined with immunohistochemistry to detect tissue biomarkers (mtor, p , vegf, hif , hif , caix). th e comparison between the two groups of patients was based on comparing the average levels of biomarker expression in both tumour tissue, as well as in healthy renal parenchyma. results were evaluated using student's t-test. results: when considering the results of the group of responders, statistically signifi cant diff erences in marker expression in tumour tissue versus healthy parenchyma were found for mtor ( %/ . %;p= . ), p ( %/ . %;p= . ), vegf ( . %/ %;p= . ) and caix ( %/ . %;p= . ). as for the group without response (non-responders), a statistically signifi cant diff erence was also evident in p a vegf expression in tumour versus healthy tissue ( %/ . %;p= . resp. . %/ %;p= . ). in the responders, a further signifi cant diff erence was found in the frequency of high expression (more than %) between tumour tissue and healthy parenchyma in vegf ( %/ %;p= . ) and caix ( %/ %;p= . ). caix shows high levels of expression in the tumour tissue, in both of the evaluated groups. when comparing the expression levels in the same type of tissue, between the group of responders and non-responders, no signifi cant diff erence in any biomarker was found. conclusion: a signifi cantly higher expression of vegf in crcc in comparison to healthy parenchyma, can predict a better response to sunitinib. on the other hand, the high expression of vegf in healthy renal parenchyma can predict worse response to treatment. the impact of preoperative retrograde pyelography before radical nephroureterectomy for upper urinary tract urothelial carcinoma on intravesical tumor recurrence song p , ko y , choi j , moon k , jung h , kim t introduction and objective: despite its diagnostic role in identifi cation of upper urinary tract urothelial carcinoma (uut-uc), approach to ipsilateral ureteral potentially aggravates spread of tumor, as reported in preoperative ureteroscopy before nephroureterectomy. we thus assessed the impact of preoperative retrograde pyelography (rgp) on intravesical recurrence aft er radical nephroureterectomy for uut-uc. of a total of patients who underwent nephroureterectomy for uut-uc from january to june in our institution, patients who did not undergo preoperative ureteroscopy were selectively enrolled. computed tomography and urine cytology as a basic diagnostic modality were performed in all subjects. th e impact of preoperative rgp and the other variables (age, sex, operating time, clinicopathological factors, and hematological factors) on intravesical recurrence were analyzed by multivariate cox regression model. during a mean follow-up period of . months, ( . %) patients had intravesical recurrence aft er rnu, and subjects ( . %) underwent preoperative rgp. th e mean duration from preoperative rgp to rnu was . ± . days and mean interval of intravesical recurrence was . ± . months. multivariable analysis showed that rgp and pathologic stage over t were independent factors for intravesical tumor recurrence (p= . and p= . , respectively, table ). regarding the duration from preoperative rgp to rnu, no signifi cant diff erence was observed between the recurrence group and the non-recurrence group (p> . ). as with preoperative ureteroscopy, our data demonstrated that preoperative rgp is an independent factor associated with intravesical recurrence of uut-uc aft er rnu. introduction and objective: axitinib which is tyrosine kinase inhibitor is standard nd-line treatment for metastatic renal cell carcinoma (mrcc). th e neutrophil-to-lymphocyte ratio (nlr), an index of systemic infl ammation, is associated with outcome in several cancer types. to assess the relation of pretreatment nlr with progression-free survival (pfs) and overall survival (os) of patients treated with axitinib. twenty-two patients with mrcc were treated with axitinib between october and january . patients were stratifi ed in two groups with nlr > (group a: n= ) vs. < (group b: n= ). pfs and os were estimated using kaplan-meier method. results: median os and pfs were . and . months, respectively. median os was . and . months in group a and group b, respectively (p= . ). median pfs was . and . months in group a and group b, respectively (p< . ). multivariate analysis showed that nlr > was an independent predictor of os (hr . . ; p= . ). in patients with mrcc treated with axitinib, pretreatment nlr might be an independent predictor for the outcome. th e aim of this study was to evaluate whether preoperative neutrophil-to-lymphocyte ratio (nlr) predict the prognosis in patients with upper urinary tract urothelial carcinoma (uu-tuc). a cohort of patients diagnosed with uutuc from to at tokyo metropolitan tama medical center was enrolled in this retrospective study. log-rank test and cox proportional hazards regression models were used for univariate and multivariate analyses. results: on univariate analysis, pathologic t stage, grade, lymphovascular invasion, c-reactive protein (crp) level, and nlr were signifi cantly associated with recurrence-free survival (rfs) and cancer-specifi c survival (css). th e rfs rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e css rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e multivariate cox proportional hazards regression models showed that the nlr could be an independent predictor for rfs and css. based on the results of multivariate analysis, the scoring model was developed. rfs and css rates at years were as follows: risk factor, . % and . %, respectively; risk factor, . % and . %, respectively; risk factors, . % and . %, respectively; risk factors, . % and . %, respectively; and risk factors, . % and . %, respectively. conclusion: th e preoperative nlr is an independent prognostic predictor. th e model based on the nlr and pathologic factors can be useful in clinical practice. clinicopathological outcome of small cell carcinoma of upper urinary tract: one starting point, diverging paths lu k, wang h, lin v, yu t introduction and objective: primary small cell carcinoma of upper urinary tract (uut-scc) is an extremely rare disease entity with distinct histological and biological behavior, representing less than . % of urinary tract tumor. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about uut-scc and the current knowledge of this disease is based on case reports or small series. our aim of study was to characterize the patients with uut-scc and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with small cell carcinoma of upper urinary tract followed at e-da hospital, kaohsiung city, taiwan be-tween january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: six patients with primary uut-scc were identifi ed, consisting of arising from renal pelvis and from upper ureter. th e median age at diagnosis was years with male-to-female ration of : . th e most common presenting symptoms were painless gross hematuria, followed by fl ank pain. th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers and cytokeratin helped establish the diagnosis. in of cases, scc coexisted with urothelial carcinoma. surgery was standard treatment given to all patients. of all cases, of patients received chemotherapy, including one receiving neoadjuvant chemotherapy and administering adjuvant chemotherapy. overall median survival was months. conclusion: primary small cell carcinoma of the upper urinary tract is characterized by an aggressive clinical course with early metastatic spread and relatively short overall survival. although high response rate to cytotoxic chemotherapy, its duration of response is limited and the prognosis remains dismal. as there is no standard of care for patients with uut-scc, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic approach for this high-risk lethal disease. prognostic introduction and objective: th e aim of this study was to evaluate the impact of body mass index (bmi) on survival in patients with non-metastatic renal cell carcinoma (rcc) treated with radical or partial nephrectomy. between june and july , patients with rcc underwent radical or partial nephrectomy at two hospitals. among these patients, patients with lymph node or distant metastasis were excluded. th us, the medical records of the remaining patients ( men and women, mean age of . years) were retrospectively reviewed. th e median follow-up duration was months (range to months). th e patients were classifi ed into groups according to their bmi based on the asia-pacifi c criteria for obesity: normal ( . to < kg/m ), overweight ( to < kg/m ), and obese (≥ kg/ m ). th e prognostic signifi cance of various clinicopathological variables including bmi was analyzed using univariate and multivariate analysis. results: of the total patients, patients ( . %) were categorized as normal, ( . %) as overweight, and ( . %) as obese. forty-six patients ( . %) developed local recurrence or distant metastasis and patients ( . %) died of disease during the follow-up period. in the univariate analysis, bmi, tumor size, t stage, fuhrman's nuclear grade, coag-ulative tumor necrosis, and lymphovascular invasion were signifi cant predictors of recurrence-free survival. also, bmi, tumor size, t stage, fuhrman's nuclear grade, and lymphovascular invasion were signifi cant predictors of cancer-specifi c survival. in the multivariate analysis, bmi (p= . ), tumor size (p= . ), t stage (p< . ), fuhrman's nuclear grade (p= . ), and lymphovascular invasion (p= . ) were independent predictors of recurrence-free survival. also, bmi (p= . ), tumor size (p= . ), t stage (p= . ), and lymphovascular invasion (p= . ) were independent predictors of cancer-specifi c survival. our results suggest that bmi is an independent prognostic factor for recurrence-free and cancer-specifi c survival in patients with non-metastatic rcc treated with radical or partial nephrectomy. th ese fi ndings indicate that bmi could be an eff ective tool for predicting recurrence or survival in patients undergoing nephrectomy for non-metastatic rcc. phase i/ii study of multipeptide-based cancer vaccine ima after single-dose cyclophosphamide in japanese patients with advanced renal cell cancer hongo f , ueda t , nakamura t , naya y , okihara k , tamada s , schoor o , singh-jasuja h , nakatani t , miki t introduction and objective: ima is the fi rst therapeutic vaccine for renal cell cancer (rcc) consisting of multiple tumor-associated peptides (tumaps) confi rmed to be naturally presented in human cancer tissue. objective was to assess the safety and tolerability of ima vaccination. in this phase i/ii study in japan, we treated a total of japanese patients with advanced rcc with human leukocyte antigen a (hla-a)* + subjects in - . each of the vaccinations consisted of an i.d. injection of gm-csf ( μg) followed within - minutes by an i.d. injection of ima ( μg of each peptide). th e vaccine therapy was a monotherapy, i.e. no other anti-tumor therapies were concomitantly administered during the study course. no treatment with either anti-cancer agents or immunosuppressants was allowed within weeks before entering the trial. patients were to receive vaccinations in the fi rst weeks of treatment (induction period) followed by further vaccinations at weeks intervals for up to weeks (maintenance period). th e primary endpoint was safety and tolerability. th e secondary endpoints were pfs, os, immunogenicity. results: no treatment-related serious adverse events (saes) or deaths were observed during the study period. at follow-up at months, all cases were assessed for treatment response. ten percent of patients had partial response (pr), % with stable disease (sd), % of patients had progressive disease (pd). median pfs was . months and median os was . months. among all patients analyzed for t-cell response, fi ve showed vaccine-induced (vi) t-cell responses against at least one hla class i-restricted tumap and two patients with responses to multiple tumaps. interestingly, two of the immune responders were of hla-a* phenotype, a hla suballele rarely occurring in europe and us but common in japan. we evaluate the patients who underwent robot-assisted laparoscopic partial nephrectomy (ralpn), laparoscopic partial nephrectomy (lapn), or open partial nephrectomy (opn) in terms of perioperative outcomes. all patients with ct a renal masses who underwent ralpn (n= ), lapn (n= ), or opn (n= ) between november and may at our institute were compared in terms of perioperative outcomes, including the mean operative time, ischemia time, estimated blood loss, change in the estimated glomerular fi ltration rate (egfr), surgical margins, and complications. intraoperative and early postoperative data were collected retrospectively. conclusion: ralpn was signifi cantly associated with shorter ischemia time. any methods of partial nephrectomy preserved renal function at three months postoperatively and showed good oncological outcomes. laparoscopic nephrectomy: does patient obesity affect outcome? introduction and objective: th e prevalence of obesity worldwide is increasing, up to % of men and % of women are now obese. th ere are various means to assess obesity, waist circumference (wc) has emerged as a superior determinant of obesity and then body mass index (bmi). th is study evaluates wc on the outcome of laparoscopic nephrectomy. data was obtained on consecutive patients. a wc of > cm for women and > cm for men is considered obese. data collected includes age, gender, asa score, wc, anaesthetic duration, operative approach, surgery duration, blood loss, renal function, complication rate and duration of hospital stay. overall, patients underwent laparoscopic nephrectomy, were male and female. seventy three ( . %) patients had wc above normal for their gender. mean anaesthetic duration was longer in obese patients . minutes vs. . minutes, (p= . ). operative duration in obese patients was also longer, . minutes vs. . minutes, (p= . ). th ere was no diff erence between groups for conversion, number of ports, intra-operative complications, blood loss, or post-operative complications. however, obese patients had a longer in-patient stay; . days versus . days. conclusion: laparoscopic nephrectomy is safe in obese patients. however, obese patients should be warned that their obesity may be associated with increased anaesthetic and surgical ties and prolonged recovery. the long-term oncologic results of radiofrequency ablation for small renal tumors sung g , bae y , kim s introduction and objective: th e aim of this study was to retrospectively evaluate the long-term oncologic results of radiofrequency ablation (rfa) of small renal masses (srms). : th e patients who had been followed over years aft er percutaneous or laparoscopic rfa for small renal mass were included in this study. a total of patients and renal tumors were included. th e follow-up study included physical examination, chest radiography, creatinine, and contrast-enhanced ct or mri. recurrence was defi ned as contrast enhancement aft er months or lesion growth at subsequent imaging or viable cancer cells on follow-up biopsy. results: th e mean tumor size was . cm and the mean follow-up period was . months. technical success was achieved in / renal tumors ( . %). repeated rfa was necessary in tumors due to incomplete ablation. th e overall complication (oc) occurred in . % of which the low-grade complications accounted for . % of oc. a relevant deterioration of renal function aft er rfa was very rare. th e -year local recurrence-free survival rates, cancer-specific survival rates, and overall survival rates are %, . %, and . % respectively. conclusion: rfa is considered useful treatment for selected patients with srms and also for nephron-sparing. our long-term follow-up results suggest excellent therapeutic outcome with rfa, while achieving eff ective local tumor control. introduction and objective: endoscopic approach of the terminal ureter was proposed as a complementary fi rst step in nephroureterectomy with perimetal cystectomy in order to obviate the low abdominal incision. we aimed to establish the value of a novel method of endoscopic distal ureteral management: pluck technique using bipolar plasma vaporization. during the last years, we performed nephroureterectomy involving plasma-button uretreal desinsertion by bipolar vaporization in upper urinary tract transitional cell carcinoma (uuttcc) cases (pta - cases; pt - cases; pt - cases; pt - cases). th e tumor was pyelocaliceal in cases, ureteral in cases and both ureteral and pyelocaliceal in cases. th e follow-up protocol included cystoscopy with urinary cytology, abdominal ultrasound and ct. th e mean follow-up period was months (range to months). results: all procedures were successfully completed. th e mean duration of the endoscopic procedure was minutes. in cases, aft er the completion of the nephroureterectomy, endoscopic haemostasis of the desinsetion area and margins was necessary. th e postoperative complications' rate was . %: cases of hematuria, one imposing endoscopic approach and another treated conservatively. during the follow-up period, patients presented bladder recurrences, had renal fossa tumor and had secondary lymphnode invasion. th e disease-specifi c mortality rate was %. conclusion: th e endoscopic detachment of the terminal ureter using bipolar plasma vaporization as part of one-step nephroureterectomy is a safe and eff ective method. mid-term evaluation demonstrated good oncologic outcomes. th congress of the sociÉtÉ internationale d'urologie -siu abstract book introduction and objective: we thought that combining open and laparoscopic surgery for partial nephrectomy would be less invasive than open method, easier and expend shorter time to clamp renal artery than pure laparoscopic approach. and combining approach would lead to introduce pure laparoscopic approach safely from open method. we reviewed the records of patients with renal mass treated with partial nephrectomy from to at our hospital. a total of patients underwent partial nephrectomy. of these, patients underwent pure laparoscopic procedures. seventy-seven patients underwent combining method, and two patients of these with solitary kidney and one patient with chronic nephritis were excluded. we compared these two groups in terms of perioperative outcomes, including the mean operative time, ischemic time, change in the glomerulofi ltration rate (egfr), and adverse events. conclusion: th is nonrandomized, comparative study suggests that pure laparoscopic approach had longer cold ischemic time but lower postoperative egfr change. complication rates were almost equivalent for both approaches. th erefore, we might shift safely to pure laparoscopic approach through the combined approach in the way of partial nephrectomy. nephron th irty-four ( . %) had bilateral suspected malignant tumors and were used as material for this study. twenty-fi ve were men and were women. results: eighteen patients ( %) had the same type of tumor in both kidneys. ten of them had clear cell carcinoma and had papillary renal cell cancer. four patients had bilateral oncocytomas. in patients ( %) the lesions diff ered between the kidneys (table ). in all patients only one kidney was operated on one occasion. in two patients treated with radical nephrectomy (rn) over years ago for renal cancer the subtype of the fi rst tumor was unknown. ten patients were treated with nss -nss, with rn -nss, with nss -rn, with nss -observation and with nss -radiofrequency ablation. two of the patients had von hippel-lindaus disease and one had birt-hogg-dubé syndrome. conclusion: bilateral renal masses were found in % of the patients in a material of patients treated with nss. over % of them had the same type of tumor on both sides but % of these were benign. th e combination of diff erent malignant and benign lesions occurred in %. th ese fi ndings are strong arguments for tumor biopsy before surgery is decided. preoperative oita red cross hospital, oita, japan introduction and objective: approximately % to % of patients who underwent total nephroureterectomy for upper urinary tract (uut) urothelial carcinoma (uc) developed recurrence in the bladder during the follow-up period. last year, we presented a risk factor for intravesical recurrence aft er laparoscopic radical nephroureterectomy (lrnu) in patients with uut-uc in siu congress. th is time, we will report the result of analysis of a multi-center study. a total of patients with uut-uc received lrnu between january and december in oita university hospital and affi liated institutions that were enrolled in this study. patients with concomitant bladder cancer or a history of bladder cancer were excluded from this study. postoperative cystoscopy and urine cytology were performed every months for to years, and postoperative intravesical recurrence was evaluated pathologically. th e signifi cance of each variable was analyzed univariately by log-rank test. multivariate analyses by cox proportion hazards regression model was used to estimate simultaneous eff ects of multiple risk factors. statistical signifi cance was defi ned as a p value of < . . results: median follow-up aft er lrnu was months (range - ). of the patients, postoperative intravesical recurrences were shown in / ( %). average time to fi rst intravesical recurrence was . months. in univariate analysis, there were two signifi cant risk factors of intravesical recurrences. one was for patients who did not receive postoperative adjuvant chemotherapy (p= . ). th e other was for patients with preoperative positive urine cytology indicating class iv and v (p= . ). multivarite analysis revealed that preoperative positive urine cytology indicating class iv and class v was a signifi cant risk factor for intravesical recurrence (hr . % ci . - . p= . ). in this multi-center retrospective study, preoperative positive urine cytology was a significant risk factor for intravesical recurrence. th erefore, adjuvant chemotherapy such as intravesical instillation therapy can be eff ective to prevent intravesical recurrence in patients with preoperative positive urine cytology. retroperitoneal laparoscopic nephron-sparing surgery for complicated renal cysts introduction and objective: to evaluate the feasibility, effi cacy and safety of laparoscopic partial nephrectomy for complex renal cystic lesions. a retrospective cohort study on clinical data of patients with complex renal cystic lesions treated by laparoscopic partial nephrectomy from may to april in peking university th ird hospital. according to the bosniak classifi cation, cases were lesions of grade iif, were grade iii, and were grade iv. th e mean diameter of cystic lesions was ( . ± . ) cm, and lesions were larger than . cm. results: all procedures were performed through retroperitoneal approach and successful. th e mean operative time was ( . ± . ) min, ranged from min to min, and the mean renal warm ischemia time was ( . ± . ) min, ranged from min to min. blood loss in operations was from ml to ml, and the mean was ( . ± . ) ml. th e postoperative hospital stay was ~ days, and the mean was ( . ± . ) day. postoperative pathological results included simple renal cysts ( . %), cases of adult cystic nephroma ( . %), mixed epithelial and stromal tumor ( . %), cases of renal cell carcinoma with cystic change ( . %), and multilocular cystic renal cell carcinoma ( . %). th e results showed . % of cystic lesions of grade iif, . % of grade iii and . % of grade iv were malignant. in the follow-up ranged from to months (median months), there was no case of recurrence. conclusion: th e diff erentiation between benign and malignant renal cystic lesions before surgery remains diffi cult. according to the bosniak classifi cation, radiological diagnostic fi ndings are standard but still limit to the accuracy to determine the dignity of pathological entity. laparoscopic partial nephrectomy is feasible to treat complex renal cystic lesions, and is a safe and eff ective minimally invasive option. introduction and objective: th e aim of the study was to evaluate the value of metastasectomy in patients with metastatic renal cell carcinoma (mrcc) in the targeted therapy era. we reviewed the medical records of patients who presented with mrcc and received no systemic therapy before enrollment. of them, underwent complete metastasectomy followed by targeted therapy (complete metastasectomy group), underwent partial metastasectomy followed by targeted therapy (partial metastasectomy group), and treated with targeted therapy alone (non-metastasectomy group). we estimated progression-free and overall survival using kaplan-meier curves. a cox proportional hazards regression model was used to estimate the prognostic signifi cance of metastasectomy. results: clinicopathological variables did not diff er among the groups except for history of nephrectomy, bone metastasis, number of metastatic sites, and time from diagnosis to treatment. th e median progression-free survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p = . ). karnofsky performance status (hr . , p < . ), cell type (hr . , p = . ), sarcomatoid or rhabdoid features (hr . , p < . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), lactate dehydrogenase (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ) were independent predictors of progression-free survival. th e median overall survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p < . ). complete metastasectomy (hr . , p = . ) was an independent predictor of overall survival, along with age (hr . , p = . ), karnofsky performance status (hr . , p < . ), sarcomatoid or rhabdoid features (hr . , p = . ), bone metastasis (hr . , p = . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), hemoglobin (hr . , p = . ), neutrophil (hr . , p = . ), corrected calcium (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ). conclusion: complete metastasectomy performed before targeted therapy signifi cantly increased overall survival in patients with mrcc. if surgically resectable, aggressive metastasectomy should be considered. guideline results: prominent international guidelines and strategies varied signifi cantly in relation to follow-up practice. th e mode and frequency of radiological imaging was signifi cantly diff erent across the guidelines for low and intermediate risk disease. although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics. th is information raises questions regarding the follow-up practice in australia due to both the lack of guidelines and the fi nancial. introduction and objective: nephrectomy is the cornerstone therapy for renal cell carcinoma (rcc) and its continued refi nement through research may enhance patient outcomes. medical registries are used domestically and internationally to aid research, assess trends and help guide future practice of many medical disciplines. th ere is currently no national australian nephrectomy registry. th is review aimed to explore possible defi ciencies within the australian rcc nephrectomy fi eld and through assessment of literature from established registries, determine if a national nephrectomy registry is appropriate and justifi ed to address these issues. a pubmed search identifi ed records pertaining to rcc nephrectomy in australia. a similar search identifi ed records relating to established nephrectomy registries internationally as well as other surgical registries of clinical importance. th ese records were reviewed to address the stated aims of this article. results: australian rcc nephrectomy fi eld lacks population-based data: resulting key issues identifi ed ) diffi culty benchmarking individual and institutional outcomes; ) small sample sizes and reduced power of studies; ) assessment of regional and nationwide outcome trends: diffi cult to achieve and oft en done years in retrospect with no ongoing monitoring; ) care centralisation debate: can small volume centres provide comparable outcomes to high volume centres? ) best practice guidelines: patterns of adherence to existing protocols is uncertain; and ) limited platform for large scale prospective studies -restricting potential research. review of established international registries demonstrated the registry model can eff ectively address issues comparable to those identifi ed in the australian literature. a centrally held, de-identifi ed national nephrectomy registry could provide a means of ad-dressing defi ciencies identifi ed in the australian rcc nephrectomy fi eld. th e model is supported by evidence from comparable international examples and will provide population-based data needed for studies at the institutional, regional and national level. th e development of a confi dential and non-threatening escalation policy to be implemented should trends in the data emerge is a future possibility. scope exists for possible integration with current or future registries/ databases to develop a more encompassing urological, cancer or surgical registry. need remains for continued exploration of the feasibility and practicalities of initiating such a registry. new technologies of identifi cation of renal artery in retroperitoneal laparoscopic renal surgery hao y, xiao c, liu y, ma l introduction and objective: th e objective of this study was to evaluate the feasibility of a new method to identify renal vessels during retroperitoneal laparoscopic nephrectomy. a total of patients underwent transperitoneal radical laparoscopic nephrectomies from january to august . in the fi rst consecutive patients (group ) we located renal artery with the standard technique; in the last consecutive patients (group ) the medial arcuate ligament (mal)-psoas muscle fat complex was used as an anatomic landmark to identify renal vessels. comparative analysis was carried out between the two groups, including mean hilar exposure time, mean blood loss, duration of hospital stay, conversion rate and complication rate. no diff erences were noted in gender, age, mean body mass index, tumor side and size of the lesions in the two groups (p> . ). mean hilar exposure times were . ± . minutes in group versus . ± . minutes in group (p< . ). mean blood loss was . ± . ml in group versus . ± . ml in group (p< . ). no signifi cant diff erences were detected regarding duration of hospital stay, complication rate and conversion rate between the two groups (p > . ). no complications and no recurrence of disease at ct evaluation were recorded neither in group nor in group . conclusion: radical laparoscopic nephrectomy in use of the mal-psoas muscle fat complex as an anatomic landmark is technically feasible and safe. in conclusion, the mal-psoas muscle fat complex can serve as an objective and belt-and-braces anatomic landmark for the identifi cation of the renal vessels in retroperitoneal laparoscopies. kalpinskiy a, alekseev b, kaprin a, nyushko k, vorobyev n, vokach d introduction and objective: th e aim of our study is to evaluate the results of percutaneous radiofrequency ablation (rfa) of renal tumors in elderly patients with severe comorbidities and a high risk of surgical intervention. th e aim of this study was to evaluate the expression of cd and microvessel density (mvd) in clear cell renal cell carcinoma (ccrcc) as well as the relationship between mvd and possible prognostic markers like tumor size, degree of tumor necrosis and degree of tumor hemorrhage. expression of cd was detected in patients with ccrcc and cases with benign kidney tissue using immunohistochemical staining. th e mvd was studied by weidner's method. results: th e expression of cd in the clear cell renal cell carcinoma (ccrcc) ( . (ds± . ), varied from to .) were signifi cantly higher than the expression of cd in the benign kidney tissue, as the control group, was . (ds± . ) (u= , p< . ). th e mvd values marked by cd were negatively correlated with degree of tumor necrosis (r=- . , p= . ), tumor size (r=- . , p= . ), but no association was found between mvd values and degree of tumor hemorrhage (r=- . , p= . ) in crcc. our results show that mvd in crcc were signifi cantly higher than mvd in the benign kidney tissue. th ere was a negative non signifi cant correlation between the mvd and presence of tumor necrosis as well as between mvd and tumor size. on the other hand, there was no correlation between mvd and degree of tumor hemorrhage in ccrcc. conclusion: expression of hif- α and vegf in crcc was signifi cantly higher than in normal kidney tissue. th e expression of hif- α and vegf may be responsible for angiogenesis in ccrcc, however these angiogenic factors play an important role in the prognosis of ccrcc patients. transvaginal hybrid notes nephrectomy in a low resource setting firaza p, lorenzo e, bardelosa j, reyes e, patron n introduction and objective: hybrid notes decreases the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure notes especially in the absence of angulated instruments. th e patients are , and -year-old females with complaints of recurrent fl ank pain and urinary tract infection due to an obstructed non-functioning kidney. materials and methods: materials used include standard laparoscopic instrumentations and a endoscope. under general anesthesia the patient was placed in a lithotomy position with the aff ected side up at degrees. veress needle was initially inserted thru the umbilicus and was later replaced with a mm laparoscopic port with additional mm port also inserted at the aff ected lower quadrant site. pa-tient was then positioned in a steep trendelenberg and mm port was inserted thru the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the endoscope. nephrectomy proceeded despite noted severe adhesions and the kidney was placed in the specimen retrieval bag. th e vaginal port site was enlarged to cm for extraction of the specimen. th e vaginal wound was repaired using running - absorbable sutures. results: th ree cases of transvaginal hybrid notes nephrectomy were successfully completed. th e median operative time was minutes (range: - ). th e mean estimated blood loss was ml for the three cases. median renal dimensions (cm) were as follows: craniocaudal . (range: . - ), laterolateral . (range: - . ), and anteroposterior . (range: . - . ). th e patient resumed regular diet as early as day post operatively. drain was removed prior to discharge. th e mean date of discharge was rd day post-operatively. th ere were no noted surgical complications according to clavien-dindo grading system. conclusion: hybrid notes transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced post-operative pain and early recovery. however, the view was challenging because it was from the pelvis. th e left side procedure proved to be more diffi cult due to the gonadal vein obstructing the view, which is usually larger in young females. introduction and objective: to summarize our clinical experiences of laparoendoscopic single-site surgery (less) in urology. results: all procedure underwent successfully using single trocar x cone (storz) without any major complications. early recovery with minimal scar is the hallmark of less surgery. duration of time ( - mns), blood loss ( - ml), mobilization ( - hrs), hospital stay ( - days). no intraoperative complication without any conversion to other surgery (multi port laparoscopic surgery) and uneventful post-operative period was the fi nal outcome. introduction and objective: th e use of fl exible cystoscopy to study bladder is usually perform in urology departments using diff erent types of lubricant to reduce pain. th e objective is to compare the use of lubricant gel with lidocaine versus lubricant gel without anesthetic in fl exible cystoscopy in terms of pain and tolerability. materials and methods: seventy two patients are divided in two groups in this observational not randomized study. group : patients with lidocaine gel % and group : patients with lubricant gel without anesthetic. th e main variables analyzed are score in visual analogue scale (vas) and score in spanish pain questionnaire (spq). t-student test and chi-square test are used to compare diff erences using spss program and signifi cant statistical diff erences is considered p≤ . . results: mean age of patients in group is . ± . years and . ± . years in group (p= . ). th e distribution according to sex was men: women in group and men: women in group (p= . ). th e main pain score in vas was . ± . in group versus . ± . in group (p= . ). in the spq, the current intensity value was . ± . in group versus . ± . in group (p= . ), and the total intensity value was . ± . in group versus . ± . in group (p= . ). th e cost of gel with lidocaine is . euro and gel without anaesthetic . euro. conclusion: th e use of lidocaine gel do not produce benefi t in the fl exible cystoscopy and expensive the procedure. new laparoscopic surgery using water filled laparo-endoscopic surgery systems introduction and objective: urologist usual operated under water fi lled condition, such as transurethral surgery, percutaneous renal surgery. however, laparoscopic surgery was done under co . water fi lled condition has several merits. water pressure is suppressing venous bleeding and prevent from co embolism in venous injury condition. to keep water temperature as same as body temperature was useful to avoid low body temperature. simultaneous observation of ultrasound image from the surface of the body and laparoscopic view is possible during surgery. th us we conduct to develop the water fi lled laparo-endoscopic surgery systems (wafles). first problem is dispersion of blood aft er bleeding. it interrupts the laparoscopic view. we solved this problem to control the fl ow of irrigation, aff ording the continuous observation of bleeding point and it is easy to control the bleeding by vessel sealing system or coagulation. second problem is managing fl oating organs such as intestine or nets. th ese are disturbed the operating view and space. to keep the operating space, we use sheath and single port devices. however, obtaining wide view was still hard in the water because fl oating organs disturb the fi eld. to solve this problem, we use -d tracking navigation system. results: using young male pig, we performed partial nephrectomy and radical cystectomy using this new system. wafles is now developing. we will be present the update of this research soon. comparison of safety, effi cacy and cosmetic outcomes between standard laparoscopic live donor nephrectomy and mini-laparoscopic donor nephrectomy: a randomized clinical trial introduction and objective: th is study was conducted to compare safety, effi cacy and cosmetic outcome between standard laparoscopic live donor nephrectomy (sldn) and mini-laparoscopic donor nephrectomy (mldn) in a randomized clinical trial. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. mldn: six to eight centimeters pfannenstiel incision was made slightly above pubis symphysis and millimeters trocar was fi xed through exposed fascia using open technique. five mm port was placed under direct vision at the umbilicus for camera insertion and two . mm ports were placed in subxiphoid and paraumbilical area. sldn: ten mm port was placed at umbilicus using open access technique for camera insertion. five mm trocar for grasping and mm trocar for vascular clipping were placed at subxiphoid and paraumbilical areas under direct vision, respectively. th e second mm trocar was placed in suprapubic area. cosmetic appearance was assessed three months aft er surgery by using the modifi ed patient scar assessment questionnaire (psaq). conclusion: our experience in this study revealed that peri and postoperative fi ndings were comparable between sldn and mldn but mldn has signifi cant better cosmetic appearance than standard laparoscopic approach. qiu m, ma l, lu j introduction and objective: to report our experience and outcomes with retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty for the repair of ureteropelvic junction obstruction (upjo). we performed retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty between june and december . ureter was found in the lower pole of the kidney psoas front, then ureteropelvic junction stenosis was dissociated. ureter was cut at about cm distal ureter beyond the part of stenosis, then stenosis was resected. posterior wall was continuous sutured, and double j tube was antegrade placed. at last, anterior wall was continuous sutured. patient characteristics and perioperative outcomes were analyzed. perioperative parameters including operative time, estimated blood loss, postoperative length of hospital stay, and complication. results: th e procedure was successfully accomplished in all patients, and no patient required conversion to open surgery. th e mean operation time was . min ( - min), mean estimated blood loss was ml ( - ml), mean postoperative length of hospital stay was . d ( - d), and mean time of keep drainage tube was . d ( - d) . patients were followed up for ~ months (average . months). eighteen cases were followed up in years, and an- renal cyst ( ) other patients were followed up for - years. th e total remission rate was . %. conclusion: retroperitoneal laparoscopic dismembered pyeloplasty is a safe and effi cacious procedure for upjo in a long time follow-up. positioning-related complications of robot-assisted radical prostatectomy (rarp) in a steep trendelenberg position with physique fixation appliance by the negative pressure takeda h, nakano y, narita h introduction and objective: because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (rarp) has become the primary treatment option in prostate cancer. rarp, however, necessitates patients to be placed in a steep trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. our study aims to study the prevalence and demographic predictors of these positioning complications. we included patients who underwent rp from to using data extracted from our hospital database. all patients (n= ) had trendelenberg position with physique fi xation appliance by the negative pressure, hug-u-vac and film dressings. positioning complications (skin, eye, nerve, compartment syndrome/rhabdomyolysis) were identifi ed using patient-level diagnosis and procedural international classifi cation of disease, th edition, clinical modifi cation codes. we analyzed body pressure by portable interface pressure sensor. results: positioning complications occurred in . % of cases with shoulder complications contributing the most to this frequency. rubefaction occurred in cases, without bedsore. having positioning complications not increased a patient's odds of having increased age, bmi, operation time, body pressure, insignifi cantly. conclusion: th e steep trendelenberg position used in rarp was not shown to be associated with patient positioning-related complications in this sample. physique fi xation appliance by the negative pressure is safety and useful. evaluation of nasogastric tube (ngt) suction for evacuation of large bladder blood clot introduction and objective: blood clot formation in the urinary bladder can be caused by many etiologies such as postoperative bleeding, tumor bleeding, radiation cystitis and etc. acute urinary retention may disclose and a large three way catheter with irrigation is placed conventionally to prevent further formation of blood clot and manually remove the blood clot. when this failed an endoscopic procedure takes place to con-trol the bleeding and to relief the bladder. urologists may fi nd it diffi cult to remove a large, thick and bulky clot using ellik evacuator. here we introduce using nasogastric tube as an alternative to procure a safe and effi cient way to remove these bothersome clots. aim: to introduce a novel method to successfully remove large, troublesome blood clots during cystoscopy. we prospectively perform blood clot evacuation on patients within month (september -february ) in hasan sadikin hospital. th e patient, preoperatively have at least ½ of bladder volume with blood clot using ultrasonography. a fr ngt inserted into the bladder through the resectoscope sheath fr and connected to suction unit with a mmhg negative pressure. a calibration of the ngt tip does not exceed more than cm from the cystoscopy beak was made. backward and forward movement was set in motion during the procedure to facilitate blood clot removal. cystoscopy evaluation was performed in the end of the procedure to evaluate any complication. a total cystoscopy time, ngt suction time, and the volume of blood clot were documented. results: a total patients was all successfully managed with this method without any complications such as bladder laceration/perforation. th e mean age was years old with male predominance. most common etiologies of blood clots retention were postoperative bleeding ( %). th e average time for clot removal time was ( - ) minutes. th e average volume of blood clots removed was grams. conclusion: evacuation using ngt suction is eff ective, safe and an effi cient way to remove of large bothersome clot. learning curve assessment of robot-assisted radical prostatectomy in the oncological and functional outcomes takeda h, nakano y, narita h introduction and objective: th is study aims to compare the oncological, safety and functional outcomes between fi rst-step rarp and second-step rarp. th e study was conducted on a total of patients having undergone robot-assisted radical prostatectomy from to . th e fi rst patients (group ) were compared with the second (group ) to evaluate the learning curve eff ects. results: both groups were similar with respect to age, prostate-specifi c antigen level, body mass index, gleason score, and distribution of the clinical stage. th e operative time was minutes for group , and minutes for group (p= . ). individual times of various stages of the procedure (dissection of the seminal vesicles, entering the extraperitoneal space and dissection of the endopelvic fascia, incision of the bladder neck, division of the prostatic pedicles and preservation of the neurovascular bundle, and urethrovesical anastomosis) decreased signifi cantly over time. estimated blood loss was ml for group , ml for group . th e length of stay was . days for group , . days for group . positive surgical margin rates were % for group , % for group . while one patient in group had biochemical recur-rence, no patient in group had biochemical recurrence. continence rates at months were . %, and . % in groups and . conclusion: surgical, oncologic, and functional outcomes of rarp improve with increasing experience. outcomes similar to the published series by high-volume centers could be achieved aft er to rarp cases. possibility of d modeling and intraoperative navigation during procedures in the retroperitoneal space introduction and objective: application of d modeling allows you to get more information about the spatial imaging of the disease. intraoperative navigation in the retroperitoneal space is an innovative minimally invasive procedure, the surgeon improves orientation in retroperitoneal space. we present the method of intraoperative navigation based on virtual simulation during videoendoscopic partial nephrectomy for kidney's tumors. special computer program has been developed, that created three-dimensional image of operative space on the basis of preoperational tomographic data of a concrete patient. we used hardware-soft ware complex (hsc) for virtual modeling of the surgery zone. th e complex consists of a pc, original soft ware and mechanical d digitizer. th e hsc allowing to form virtual d model of a patient according to the results of tomography examination. th e original method of matching the system of coordinates of a virtual model with the patient was off ered. th e procedure was conducted under the conditions warm ischemia, aft er mobilization of the kidney, partial nephrectomy was performed by observing the image of d organ model agreed with the video image of the kidney tumor. th e method was originally performed for the patients with small renal tumors, who needed in surgical treatment, their average age was . (in the range from to ) years, men - ( . %), women - ( . %). size of the tumors were . ( . - . ) cm, they were located in the lower poles of the kidneys. average time of an operation performed with the use of the computerized choice of the surgical approach was . ( - ) minutes. warm ischemia time was . ( - min). th ere were no complications during the operation and in the post-operative period. th ere were no cases of positive surgical margins. conclusions: usage of the introduced computer program allows the surgeon to determine compliance with the contours of the d models of the body shown in the video monitor. th e technique provides additional possibilities for the surgeon in selecting borders in partial nephrectomy. th is method is particularly perspective for teaching beginner surgeons, it can help them acquire skills in minimally invasive surgery. possible impact of continuous drainage after minimally invasive partial nephrectomy introduction and objective: postoperative management of partial nephrectomy without drain placement is common, but the specifi c eff ects on patients are unclear. we investigated the impact of no drain placement aft er minimally invasive partial nephrectomy (mipn). we retrospectively studied consecutive patients who underwent laparoscopic and robotic partial nephrectomy at a single academic center. th e study group included evaluable patients without drain placement. th e quantity of postoperative fl uid collection in the perirenal space was calculated using computed tomography. th e pre-and postoperative serum concentrations of total protein and albumin, in addition to neutrophils, lymphocytes, monocytes numbers and c-reactive protein (crp) levels in the blood were compared. results: drain was placed in ( . %) patients who underwent mipn. th e remaining ( . %) patients were not provided with drain placement. although the average total quantity of fl uid discharged from the drain was ml, the average fl uid remaining in the perirenal space was not signifi cantly diff erent with or without drain placement ( . ml vs. . ml, p= . ). decrease in serum total protein and albumin with drain placement was signifi cantly greater than without drain placement (total protein; . % vs. . % p< . and albumin; . % vs. % p= . ). no drain placement also caused markedly greater decreases in lymphocytes and monocytes than drain placement, while neutrophils and crp were not different. a mipn population was necessary by design, which may limit the ability to generalize these results. conclusion: analysis of the quantity of fl uid collection showed little need for routine drain placement. no drain aft er mipn prevents serum protein loss and might aff ect wound-healing immune responses. initial experiences of laparoscopic radical cystectomy introduction and objective: simultaneous treatment of bilateral lesions is an interesting application of laparoscopy. our goal was to present our experience with simultaneous bilateral laparoscopic pyeloplasty using three midline ports in two adult patients. two adult patients (one male and one female) underwent bilateral laparoscopic dismembered pyeloplasty in one session. one of the patients had horseshoe kidneys. a -mm trocar was placed through the umbilicus, and two -mm trocars were placed midline - cm superior and inferior to the umbilicus. results: intra-and postoperative periods were uneventful. operation time was and minutes in the fi rst and second patient, respectively. obstruction was relieved in both patients bilaterally on a -month follow-up. conclusions: simultaneous bilateral laparoscopic pyeloplasty using three midline ports is safe and feasible in adult patients with bilateral ureteropelvic junction obstruction. introduction and objective: radical cystectomy is considered to be the most eff ective treatment for patients with muscle-invasive bladder cancer. most urinary diversions are performed extracorporeally because of complex procedure time consuming. however, with the development of minimally invasive radical cystectomy techniques, increasing attention has been focused on intracorporeal urinary diversions, including both ileal conduit and orthotopic neobladder. we reviewed cases of laparoscopic radical cystectomy with intracorporeal ileal conduit in our medical center. ten patients with bladder cancer who underwent laparoscopic radical cystectomy and intracorporeal ileal conduit were retrospectively reviewed. with the cystoprostatectomy and lymphadenectomy completed, a - cm segment of ileum was identifi ed cm from the ileocecal junction. division of the isolated segment of bowel and the mesentery was performed using the endo-gia stapler. ileo-ileal continuity was reestablished by creating a generous side-to-side anastomosis with endo-gia stapler. th e left ureter was passed to the right side of the abdomen. aft er placement of single-j stent, the ureters were spatulated and the ureteroileal anastomis was performed with a running suture. results: laparoscopic radical cystectomy and intracorporeal ileal conduit were performed successfully in all ten patients from jan to dec . th e mean operating time was min ( - min), and the mean ileal conduit construction time was min ( - min). th e mean blood loss was ml ( - ml), and no patient received transfusion. th e time to orally allow was postoperative day ( - ). th e mean hospital stay was d. no major complication occurred. results: all the procedures were successfully completed without additional trocars except for one patient who was immediately converted to suprapubic-assisted laparoendoscopic single-site surgery (sa-less) nephrectomy for rectal injury during the placement of the zou-port. in our initial cases, tri-port was used. in the subsequent procedures, zou-port was used. th ere were no other intraoperative complications occurred. postoperative complications included a right external iliac artery thrombosis in one patient who underwent pure transvaginal notes simple nephrectomy. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes renal cyst decortication. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes nephrectomy. th e mean visual analog scale (vas) pain score was . (range - ) on postoperative day . th e mean time for ambulation was . (range - ) d. th e mean time for oral feeding was . (range ~ ) d. th e mean postoperative hospitalization stay was . (range ~ ) d. during the to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed well. th ere was no scar on the abdominal wall. th ere was no retrograde infection of pelvic and abdominal cavity, umbilical hernia, or uterine prolapse. conclusion: th e application of zou-port in pure notes transvaginal eff ectively reduces the diffi culty of operation and avoids the abdominal and pelvic organ injury, which is worthy of clinical application. lower ureter stricture. all the cases presented only one abdominal scar before surgery, including cases with the history of caesarean section, cases with the history of birth control surgery, cases with the history of appendectomy, cases with the history of inguinal hernia repair, cases with the history of ureterolithotomy, one case with the history of bladder lithotomy, and cases with the history of laparotomy surgery. th e mean length of scar is . ( . to . ) cm. under general anesthesia, the patients were positioned in lithotomy with aff ected side elevated at °. two trocars ( mm or mm) were introduced into abdominal cavity from the incisions at the right and left medial margin of umbilicus. a -or -mm trocar was inserted into the abdominal cavity through the abdominal scar under the direct vision. our technique for the transabdominal scar-assisted u-less is similar to that of standard laparoscopy, using conventional operating apparatus placed in the umbilical trocars, under direct vision achieved by a fl exible-tip ° laparoscope placed through the trocar at the abdominal scar. th e specimen was placed inside a homemade bag and removed under direct vision through an extended incision at the abdominal scar. to explore the application of three-dimensional ( d) laparoscopic technique in hybrid transvaginal notes nephrectomy. a total of female patients underwent hybrid transvaginal notes nephrectomy using d laparoscopy system. th ose included cases of hydronephrosis, cases of renal empyema, and cases of renal atrophy. th e median age was (range to ) years, and body mass index was . ( . ~ . ) kg/m . all patients were with unilateral disease and normal contralateral kidney. th e perioperative data including operative time, estimated blood loss, and surgical outcome were analyzed. results: th e procedures were successfully completed. th e median operative time was ( to ) mins. th e median estimated blood loss was ( to ) ml. th e patients were recover ambulation on postoperative day to , and tolerated diet on postoperative day to . th e patients were discharged on postoperative day to . th ere were no intraoperative or postoperative complications. during the -to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed up well. th ere were two hidden umbilicus scars. and p= . , respectively). mean incision length was shorter ( . vs. . cm, p< . ) and the scar satisfaction score was higher ( . vs. . , p= . ) in ldn with fl ank incision group. th e postoperative pain scores were higher (p= . ) in ldn with fl ank incision group but analgesic requirements were similar in both groups (p= . ). conclusion: ldn with fl ank incision had cosmetic satisfaction and comparable graft function, although challenging to the surgeon with longer warm ischemia time and higher postoperative pain. the effect of caudal block on postoperative analgesia in robotic assisted laparoscopic prostatectomy: a prospective study in a national referral centre introduction and objective: caudal block is widely used in paediatric surgery. it provides satisfactory postoperative pain relief in lower abdominal operations with minimal complications. th is pilot study explores its eff ect on postoperative pain control and its safety in patients who underwent robotic assisted laparoscopic prostatectomy (ralp). from to , consecutive patients were randomised into groups of patients. th e intervention group received caudal block using ropivacaine immediately aft er operation, while the control group only received analgesia consisting of paracetamol, nsaids, and opioids. both groups were assessed using verbalised pain scores in recovery room, and , , , , hours aft er the operation. additional analgesic requirements were recorded in the intervention group. opioid-related adverse events and the time to passage of fl atus were also recorded. introduction and objective: th e dorsal venous complex (dvc) ligation and vesicourethral anastomosis (vua) are the most challenging parts during laparoscopic radical prostatectomy (lrp). th is study will introduce a unique technique without any knots for the dvc ligation and vua using the unidirectional single running self-retaining suture. th is study is to examine the eff ectiveness of our knotless laparoscopic radical prostatectomy compared with the conventional technique. materials and methods: from december to december , lrp were separated into groups: group of knotless lrp and group of conventional single-knot lrp. during knotless lrp, the dvc is sutured using a - / circle self-retaining suture with bites at the same place, and the vua is performed with a -cm - / circle barbed self-retaining suture with one needle driver. retroperitonoscopic pyeloplasty is a feasible approach in the management of pelviureteric junction obstruction with a crossing vessel. anterior transposition using the posterior approach demands a good experience. herein, we present a case with complex vascular anatomy representing a real surgical challenge for a retroperitonoscopic approach. in the period from - , cases with a crossing vessel were operated by a single surgeon using both transperitoneal and retroperitoneal approaches. we report here a y old girl with left sided pelviureteric junction obstruction presenting with recurrent loin pain. lateral retroperitoneal laparoscopic approach was used with trocars; mm optic trocar and two mm working trocars. th e pelviureteric junction was tightly pushed anteriorly and close proximity to complex crossing vessels. dissection from the crossing vessels was performed followed by anterior transposition of the pelviureteric junction and a diffi cult anastomosis was performed with antegrade dj insertion. smooth postoperative recovery, no leakage, dj is removed aft er . month; follow-up ultrasound revealed decompression of the pelvis with no recurrence of the symptoms during the follow-up period. conclusion: retroperitonoscopic lateral approach is feasible for the management of pelviureteric junction obstruction with crossing vessel even in the most diffi cult cases in well trained hands. robotic assisted laparoscopic reimplantation for iatrogenic ureteral injury franklin a, jones c, pokala n, cummings j introduction and objective: ureteral injuries are a source of morbidity in pelvic surgery. robotic approaches to these injuries have been proposed. we reviewed our experience with this approach to examine the outcomes in patients undergoing robotic assisted laparoscopic reimplantation (ralr) for iatrogenic ureteral injury. oncological outcomes of robotic prostatectomy in the victorian public sector basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , murphy d , , , , introduction and objective: following the installation of the davinci s at peter maccallum cancer centre in , we aim to report medium-term oncological outcomes of patients undergoing robot-assisted radical prostatectomy (rarp) and to identify factors that act as predictors for biochemical recurrence (bcr) and oncological failure (of). a prospective cohort of consecutive men who underwent rarp in a single victorian public hospital were followed up for a median time of . and . months for bcr and of respectively. of was defi ned as bcr (psa≥ . ng/ml) or the start of adjuvant therapy. however, longer-term data is still required to better evaluate oncological success. functional outcomes of robotic prostatectomy: the victorian public sector experience basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , declan murphy d , , , , introduction and objective: to report medium-term functional outcomes of men aft er undergoing robotic assisted radical prostatectomy (rarp). furthermore, the impact of the procedure on quality of life will also be analysed. a cohort of consecutive men who underwent rarp in a single victorian public institution was assessed post-operatively for continence and potency status. a 'prostate cancer research survey' that was distributed pre-operatively and at , , , and months post-rarp, in combination with hospital medical records were utilized to collect data. th e following validated questionnaires were included in the survey: expanded prostate cancer index composite for clinical practice (epic-cp), sexual health inventory for men (shim) and prostate cancer related quality of life scale (pcar-qols). th e latter primarily evaluated the impact of surgery on quality of life. results: utilising hospital medical records, of the ( %) men that had follow-up post-operatively, % ( / ) were fully continent at months using a zero pad defi nition and % ( / ) were continent using a zero or security pad defi nition. of those who completed the epic-cp questionnaire, preoperatively (n= responders), . % and . % were continent using a zero and security pad defi nition respectively. at -months (n= responders), . % of patients were fully continent using zero pads per day and . % of patients were continent using none or security pad per day. regarding erectile function, shim scores were available for men pre-rarp, of which % were considered to be potent. of this subset of men, only %, % and % are considered post-operatively potent at , and -months. none of the patients that were pre-operatively impotent regained their erectile function at months. sexual confi dence was the facet of life that was most impacted by rarp. other quality of life subdomains showed no signifi cant diff erences aft er robotic prostatectomy. conclusion: th ere has been satisfactory recovery of continence post-rarp, however, erectile dysfunction still remains an important adverse sequela of surgery. overall, robotic prostatectomy has been successfully implemented in the victorian public sector with satis-introduction and objective: to compare patterns of care and perioperative outcomes of robotic prostatectomy to other surgical approaches, and create an economic model to assess the viability of robotic prostatectomy in the case-mix public health funding system. we retrospectively reviewed all radical prostatectomies (rp) performed for localised prostate cancer in victoria, australia, between july and april from the victorian admitted episode dataset (vaed), a large administrative database that records all hospital inpatient episodes in victoria, australia's second most populous state. patterns of care, length of hospital stay (los) and blood transfusion rates (btr) were compared by surgical approach. we then created an economic model to evaluate the incremental cost of robotic assisted radical prostatectomy (rarp) over open radical prostatectomy (orp) and laparoscopic radical prostatectomy (lrp) incorporating the cost off set from diff erences in length of hospital stay and blood transfusion rates. th e economic model constructs estimates of the diagnosis related group (drg) costs of orp and lrp, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these drg costs to obtain a drg cost per day which can be used to estimate the cost off set associated with rarp in comparison with orp and lrp. economic modelling was performed around a base-case scenario, assuming a -year robot lifespan and robotic cases performed per fi nancial year, and one and twoway sensitivity analyses performed for the -arm da vinci shd, si and si dual surgical systems (intuitive surgical ltd, sunnyvale, ca, usa). both situations present a challenge to the surgeon contemplating a radical prostatectomy for prostate cancer, due to surgical access and anomalous vascular and ureteric anatomy. open radical prostatectomy has been reported in transplant recipients, but very little has been described using a robot-assisted laparoscopic approach. a case series will be described, illustrating the challenges and techniques required to successfully perform transperitoneal robot-assisted radical prostatectomy in patients with a congenital pelvic kidney or renal transplant within the pelvis. operations were performed using the da-vinci surgical system. we will describe a series of patients between and who underwent transperitoneal ro-bot-assisted radical prostatectomy, including patients with a congenital pelvic kidney and a redo renal transplant within the pelvis. prostatectomy was performed using a partial nerve spare in all cases, and pelvic lymph node dissection was not performed. th ere was a mean console time of minutes with a mean estimated blood loss of ml. histopathology confi rmed gleason sum - disease confi ned to the prostate with no extraprostatic extension or seminal vesicle invasion (pt c), and surgical margins were free of tumour in all cases. th e tumour volume ranged from . to . cubic centimetres. th e psa became undetectable postoperatively and remained undetectable without further therapy. careful perioperative review of imaging and placement of ports under direct vision was essential in avoiding complications. stay suture is applied at glans. circumcision incision is applied leaving at least mm tissue of inner mucosal collar. penile skin is denuded down to the penoscrotal junction. minor degree of chordee is corrected by this procedure. a fr feeding tube in the urethra adds to identify the distal urethra which is just underneath the skin in these case, which removed at the end of procedure. mucosa is defi cient ventrally and is replaced by a triangular patch of skin. th is skin patch is excised and mucosal edges are approximated in the midline. th is simple maneuver gives glans penis an upward tilt and meatus appears almost on the tip of glans. redundant preputial skin is excised and mucocutaneous approximation is done with / pds. no dressing is required. we operated cases of glanular hypospadias between december and january . mean age of children was . ± . years. all cases were day cases. th ere was no need for catheterization and dressing. we used temporary dressing for mild bleeding immediate post op in cases only which were removed in recovery room. th ere was no immediate post-operative complication like urinary retention, severe pain, fever or urinary tract infection. th ere was no complication of meatal stenosis in follow-up ( - month follow-up). urine stream was good and cosmesis was satisfactory to parents. we had low complications in our set up and success of glanular hypospadias by our technique was good in terms of good urine stream and cosmesis. conclusions: th e goal of modern hypospadias surgery is a functional neourethra that appears to be normally circumcised penis. tubularized incised plate urethroplasty is a widely applicable technique for distal hypospadias repair. but our current series shows that modifi ed tubularized incised plate technique has low complication rate and excellent cosmetic results superior to tubularized incised plate urethroplasty for primary distal hypospadias repair. however, these results must be further evaluated by comparison study of large series. the impact (catalona, ) was performed in patients. occult metastatic disease was found in two patients ( groins) at the time of diagnosis and subsequently developed in patients during follow-up. th erefore, a total of ( %) of the patients developed metastatic disease. conclusions: current management protocols place moderately diff erentiated t penile scc without vascular invasion in a low risk group for lymph node metastases. for this reason a primary option for these patients expectant approach is currently recommended. our experience has shown that patients in this group are really at higher risk for metastatic disease, and we suggest early modifi ed groin dissection instead of expectant observation. introduction and objective: penile cancers are rare. in ghana, they account for less than % of all genitourinary cancers. data on penile cancers in ghana is scanty. we report on cases of penile cancers seen over the last years at the komfo anokye teaching hospital (kath). th e aim of the study was to describe the clinicopathological presentation and the mode of treatment of penile cancers in our setting. th is was a retrospective study of histologically confi rmed cases of penile cancers seen at kath from january to december . information gathered included age, the clinicopathological features and mode of treatment using a structured proforma. results: th ere were cases of histologically confi rmed penile cancers over the period. th e age range was from - years with a median age of years. eight were uncircumcised and were married. in only one did the lesion not originate from the glans penis rather aff ecting the base and upper part of the left of hemi-scrotum. in patients, the lesion was restricted to the glans penis, it had involved the distal penis in , midshaft in , proximal penile in and base of penis in one of whom had auto amputation. all were squamous cell carcinoma with majority being moderately well diff erentiated ( %). seven had ulcerative lesions and were caulifl ower-like. majority were advanced (t ) involving the corpora ( %). only one patient reported with a t lesion. eleven patients ( . %) had lymph node involvement and two had distant metastasis at presentation. only one patient had a penile sparing surgery with of them having partial penectomy at various levels with ure-throstomy at the stump ends. one had total penectomy with suprapubic urinary diversion whiles the one with auto amputation had radiotherapy as the primary treatment. eleven of the patients had lymph node dissection. four had adjuvant radiotherapy. conclusion: most patients present with advanced disease making any hope of achieving a functional and cosmetically acceptable penis aft er treatment impossible. further education is needed to ensure early detection and treatment. how does partial penectomy due to penile cancer affect the sexual life? even though the high incidence of penile cancer in brazil, the sexual life of its patients, as well as their partners, has never been evaluated before. th e aim of this study is to evaluate erectile function in patients who underwent partial penectomy due to penile cancer, describe the socio-demographic and clinical data as well as to assess the patient's partners' sexual function. we performed a prospective analysis in patients between and at pernambuco state cancer hospital in brazil. th e sample consisted of patients who were submitted to partial penectomy for the treatment of penile cancer. control group included volunteer couples from the general population with similar socio-demographic features. th e assessment of erectile function and female sexual dysfunction were evaluated with iief- and fsfi respectively. results: th e prevalence of erectile dysfunction (ed) in the group of individuals subjected to partial penectomy was . %, including severe ed in %, moderate ed in %, mild-to-moderate in %, mild ed in . %, and no ed in . % of the participants. th e prevalence of ed in men of the control group was . % and was typically characterized as mild ed (p < . ). between partners of partial penectomy and control groups, % and % reported sexual dysfunction, respectively (p = . ). a comparative analysis of the risk factors for the ed showed that there were not diff erences between both groups (body mass index (bmi); tabagism; diabetes; hypertension; dyslipidemia and hypogonadism). conclusion: th e actual incidence of erectile dysfunction in patients submitted to partial penectomy for penile cancer is . %. comparative analysis between patients who underwent partial penectomy and general population showed a higher dysfunction rate in addition to more severe ed. in despite of that, their partner's sexual function was similar between the analysed groups. the introduction and objective: androgens are essential for the development and growth of the genitalia. th ey regulate the erectile physiology by multiple mechanisms. several studies have examined associations among sex hormones' serum levels, erectile function and sex drive. we sought to identify a protocol for using testosterone in men with erectile dysfunction and late-onset hypogonadism (loh). during a -month period, men with erectile dysfunction who presented to the andrology clinic were selected. th ey underwent a complete physical examination and fi lled out the international index of erectile function- questionnaire. serum luteinizing hormone (lh) and testosterone levels were evaluated. patients received a single intramuscular injection of mg testosterone. th ereaft er, serum levels of lh and testosterone were measured weeks later. results: th e mean age was years old. aft er treating patients with testosterone, ( %) showed improvement in loh symptoms including libido, loss of energy, irritability and quality of life. th e mean international index of erectile function was and . , prior to and aft er treatment respectively. mean serum testosterone levels before and aft er treatment were . and . ng ml_ respectively (p = . ). mean serum lh revealed a signifi cant decrease aft er the study (p = . ) ( . and . ng ml_ , before and aft er the study respectively). our fi ndings suggested that testosterone replacement therapy improves libido and loh symptoms in individuals with almost normal or lower limit normal value of serum testosterone levels. does l-carnitine therapy add any extra benefi t to standard inguinal varicocelectomy in terms of deoxyribonucleic acid damage or sperm quality factor indices: a randomized study to evaluate if addition of l-carnitine therapy to standard varicocelectomy adds any extra benefi t in terms of improvement in semen parameters or deoxyribonucleic acid (dna) damage. one hundred patients enrolled in this study and were randomly divided into groups ( patients in each group). in group , standard inguinal varicocelectomy and, in group , standard inguinal varicocelectomy plus oral antioxidant therapy (oral l-carnitine, mg times a day) were performed for months. for all patients, routine semen analysis and dna damage test of spermatozoa (by methods of terminal deoxynucleotidyl transferase dutp nick end labeling and protamine damage assay) were performed at baseline and at and months postoperatively. results: in both groups, the improvement in semen analysis parameters and dna damage was observed, but there was not any statistically signifi cant diff erence between the groups in these parameters, although the slope of improvement in dna damage was slightly better in group (that was not statistically signifi cant). we observed that addition of mg of l-carnitine orally daily to standard inguinal varicocelectomy does not add any extra benefi t in terms of improvement in semen analysis parameters or dna damage. serum uric acid as a risk predictor for erectile dysfunction introduction and objective: testicular torsion is one of the few urological emergencies that require prompt diagnosis and treatment, since its delay leads to testicular ischemia inevitably leads to testicular necrosis and atrophy. we aimed to determine the pattern of presentation and early outcome of patients with testicular torsion managed at kcmc. th is was a hospital based descriptive retrospective and prospective study involving patients who were managed for testicular torsion between january and january . eighty three ( %) were at the age of years with a mean . and a standard deviation of . . results: left side was more aff ected by . %. th irty two ( . %) patients arrived at kcmc within six hours from the onset of symptoms. scrotal pain was the main complaint. seventy two ( %) patients were misdiagnosed at the peripheral health facilities and treated empirically with antibiotics. ninety six point nine percent of those with more than degrees of rotation and duration of arrival to kcmc beyond six hours were found with missed torsion compared to . % of those with a degree of rotation less than and less than six hours on arrival to kcmc (p-value . ). orchiectomy of the aff ected testis and fi xation of the viable was the mostly adopted treatment option by . %. eighty four percent of our clients had fi rm and smooth testis at follow-up of three months with % having atrophic testis at three months in both groups (retrospective and prospective arms). conclusion: testicular torsion aff ects more young adolescent males. all patients with testicular torsion presented with scrotal pain. most patients arrived to kcmc hospital beyond six hours majority of them being treated empirically with antibiotics at the peripheral health facilities. missed torsion is a common sequel to our patients outcome at three months is promising by having viable testis. ho:yag laser ablation for ulcerative interstitial cystitis tokyo women's medical university aoyama hospital, tokyo, japan introduction and objective: in cases of ulcerative interstitial cystitis are usually treated by tur or by electrocautery, resulting in improvement of pain. efficacy of electrocautery using laser remains unclear because of a very few number of case reports. we treated this time ulcers of interstitial cystitis by cautery using ho:yag laser to evaluate its effi cacy as well as safety. materials and methods: eight cases with hunner's ulcers whose pains were hardly controlled aft er drug therapy and/or hydrodistention were treated with ho:yag laser. patients were evaluated with interstitial cystitis symptom index (icsi), interstitial cystitis problem index (icpi), international prostate symptom score (ipss), quality of life (qol) index and a visual analog pain scale (vas) at base line, one, three and six months post operatively. statistical analysis was performed using the paired t test, in which p< . was considered statistically signifi cant. results: patients were all females aged to years. half of them were treated more than two times. scores obtained by the questionnaire survey were improved aft er the laser therapy. scores of icsi, icpi, ipss, qol index and vas were statistically signifi cantly decreased at one and three months. only vas was statistically signifi cantly decreased at six months. th ere was no severe complication associated by the therapy. conclusion: ho:yag laser therapy for ulcerative interstitial cystitis is effi cacious at least for three months. also this treatment is safe for aged patients. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. a narrow urethral plate can be diffi cult to properly locate intraoperatively, particularly in panurethral strictures. our objective is to assess the value of intraurethral injection of mb during urethroplasty. th ere is cc of mb ( mg/ ml) diluted in cc of normal saline. th e mb is gently injected retrograde into the urethra. a penile clamp is applied for minutes to increase the contact time of the mb with the urethra. th e urethroplasty commenced and the urethra was opened. th e impact of the mb on the anatomy of the urethra was by subjective assessment of a single surgeon (s.b.k.). results: a total of consecutive cases were prospectively evaluated from - . precise staining of the narrow lumen was successfully observed in ( %). in these cases, the diseased urethral strictured portion of the urethra was subjectively stained blue with mb. th e grossly normal appearing urothelium remained pink and did not take up signifi cant mb stain. in ( %) cases minimal or no staining was observed. extravasation in to the spongiosa was seen in ( %) cases. in ( %) cases there was dense staining distal to the narrow lumen. th ere were no known allergic complications. conclusion: normal urothelium does not appear to be stained by mb. mb readily stains diseased and strictured urotheilum. intraurethral injection of mb is a useful tool in urethroplasty. it helps in delineation of stricture and identifying lumen. it guides us to the exact area of urethra to be augmented. it is a simple, non-costly and non-invasive tool. in our high volume tertiary referral unit, it is now standard to inject methylene blue in urethra immediately prior to urethroplasty. demography, preoperative imaging and surgical outcome in penile fracture results: condition was occurred in . % of patients during an abnormal sex such as masturbation, aggressive sex and also taghaandan. all patients except one that refused intervention were treated surgically. only four cases involved bilateral corporal injury. two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury that all were repaired primary. urine analysis was performed for . % of patients. gross hematuria was seen in one and microscopic in two patients of urethral injury and did not see in others. retrograde urethrogram were not taken of patients with urethral injuries. diagnostic cavernosography or magnetic resonance imaging was not used in any of the patients. cystoscopy was performed in case of gross hematuria with complete urethral transection. no complications occurred in the patients in early follow-up. we are interested in that report entire result of this study such as longterm surgical outcome at congress. conclusion: based on islam promotion for early and inexpensive marriage, avoiding from abnormal sex can signifi cantly decrease penile fracture. in addition, we recommended immediate surgical exploration and repair of tunica albuginea without any preoperative diagnostic imaging. introduction and objective: cowper's glands are two exocrine glands, which are located in the perineal pouch between the fascia layers of the urogenital diaphragm. th ey excrete pre-ejaculate into the urethra to lubricate it and neutralize acid to enable sperm to pass through the urethra. th e glands form two ducts that are . to cm long. although anatomic variations exist, the majority of ducts combine to make one confl uent passage that opens at the posterior part of the bulbar urethra. cowper's gland collecting ducts dilatation is called syringocele, an uncommon and under-diagnosed anomaly in adults. in pediatric patients there are . % and . % found on autopsy studies. we are presenting case of an adult -year-old male, whose symptoms were unrecognized by many physicians, even experienced urologists. th e patient had diff erent treatments with antibiotics and other diff erent medications without success. results: th e patient's chief complaint was dribbling aft er voiding few drops of urine when smiling, coughing, sneezing, crouching and any kind of eff ort. he received treatment as an outpatient by family physician and dermatologist. a bulging on the perineum was found by palpation, hard to elastic consistency, walnut size formation in the corpus spongiosum, easily movable from the perineal skin. urethroscopy was performed and the fi nding in the bulbar urethra was a cystic formation, gray to white color with very thin blood vessels. it fi lled the lumen of the bulbar urethra, but with pressure very easily passed the urethra and verumontanum to the bladder. voiding and retrograde urethrography showed fi lling defects in the bulbar urethra. th is cystic formation was fi xed to the fl oor of the urethra. an incision and deroofi ng of the cystic wall by resection was done. th e patient aft er this procedure was without dribbling aft er voiding. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. th ere are diff ering opinions regarding the management of short atraumatic bulbar strictures. some favor augmentation with buccal mucosal graft (bmg) while others favor excision and primary anastamosis (epa). th e divergence of opinion is unifi ed toward epa in the face of signifi cant spongiofi brosis. our objective is to determine if mb can be used to assess the degree of spongiofi brosis in short atraumatic bulbar strictures. we term the procedure methylene blue spongiography. five cc of methylene blue ( mg/ml) is diluted in cc of normal saline. th e dissection for the urethroplasty continues until the bulbar urethra is exposed. th e location of the stricture is identifi ed. insulin needles are inserted in three locations. one needle is placed in the sponge proximal to the stricture. another needle is placed in the sponge at level of stricture. th e third needle is placed in the sponge distal to the stricture. large atraumatic clamp is place at the most proximal extent of the bulb to limit the confounding blood fl ow from the bulbar artery. methylene blue is gently injected via distal needle. th e two remaining needles are then observed for mb effl ux. presence of mb effl ux in needle proximal to stricture implies a defi ciency of signifi cant spongiofi brosis and urethral transection with epa is not performed. absence of effl ux of methylene blue in proximal needle implies signifi cant spongiofibrosis and epa is performed. we performed mb spongiosography in short bulbar idiopathic strictures. mean length of the stricture was . (range to . ). in ( %) cases methylene blue was seen across the stricture and transecting urethra was avoided. in ( %) cases where no mb went across primary excision and anastomosis was performed. no patients had adverse reaction or complication of methylene blue. conclusions: methylene blue spongiography can be performed to guide the method of urethroplasty performed. it is a simple, cost eff ective, and time effi cient method to further evaluate the degree of spongiofibrosis. effi . th e allium bulbar urethral stent is a fully covered, self-expandable, large caliber metal stent, specially designed for the treatment of bulbar urethral strictures. th e indwelling time for the stents was planned to be months. all men underwent an internal uretrotomy procedure followed by an endoscopic stent placement. progressive decreasing of the urinary peak fl ow rate, recurrent urinary infection and stent migration were the early removal criteria. th e success criteria aft er the stent removal were: no evidence of stricture on urethrogram or endoscopy, urinary peak fl ow greater than ml/sec and no recurrent urinary tract infection. results: five stents were replaced since very early migration not more than one month period. none of the patients reported discomfort at the stent site. five patients complained of mild urinary incontinence which was resolved aft er stent explantation. all stents were removed very easily without any complication to months (mean . months) aft er implantation. follow-up period was meanly months ( to ) after stent explantation. clinical success was achieved in patients ( %). conclusion: based on our results, temporary placement of allium bulbar urethral stent, for management of the recurrent urethral strictures, is noninvasive, safe and eff ective procedure. the impact of testicular loss on the psychopathology we also compared the results of long-term treatment group and short-term treatment group. th is study showed that cases of long-term continuous administration of doc consisting of or more cycles among patients of castration-resistant prostate cancer (crpc) treated with doc from october to september at our institution, retrospectively. nineteen patients who had treated with doc or less cycles were defi ned as short-term dose group, and both groups were compared. doc was administered every to weeks at to mg/m , and was treated with prednisolone at mg/day as a general. results: th e median number of treatment cycles was (range to ), and the median age of patients was (range to ) years old. th e median psa levels at start of doc based chemotherapy was . (range . to . ) ng/ml. th irteen cases ( %) showed a decrease in psa levels and cases ( %) showed a decrease in psa levels of % or more, the -year survival rate of long-term dose and short-term dose group were % and %. adverse eff ects of grade or lower consisted of leukocytopenia in % and thrombocytopenia in %, stomatitis and general fatigue in some cases, however, grade or higher were not observed in long-term dose group. in multivariable analysis of parameters, long-term treatment was related to psa levels at start of treatment and alp levels. pattern of use of androgen deprivation therapy in prostate cancer: an italian multicenter cross-sectional analysis introduction and objective: androgen deprivation therapy (adt) for prostate cancer (pca) is widely used with diff erent indications, however, some discrepancies exist between clinical practice and the recommendations of the international guidelines. th e aim of this cross-sectional study was to evaluate patterns of use of adt in patients with pca in italy. we also aimed to measure the adherence of adt prescriptions to the recommendations of the eau guidelines. materials and methods: th e choice study was an italian multicenter cross-sectional studying conducted from december to january on patients treated with adt for pca (fi rst prescription or renewal of therapy). th e project involved radiotherapy departments and urology centers. inclusion criteria were: age ≥ years, previous diagnosis of pca and current adt. at baseline all the following information were included: charlson comorbidity index (cci), clinical stage, psa level at the time of the diagnosis, total prostate volume and gleason score; gleason score and pathological stage from radical prostatectomy (rp) when available. we subdivided the cohort into three risk categories for each treatment group, based on d' amico classifi cation. patients were categorized according to primary treatment into rp, radiotherapy (rt), rp + rt and adt only. radiotherapy comprised external beam therapy and brachytherapy. adt included bilateral orchiectomy, gnrh agonists or anti-androgens. th ree geographical areas were considered: northern, central and southern italy. adt change (adt-c) was defi ned as any modifi cation of therapy between previous adt and treatment prescribed aft er enrolment. the prevalence and outcomes of pt disease after neoadjuvant hormonal therapy plus radical prostatectomy in high-risk prostate cancer introduction and objective: to identify the prevalence and clinical outcomes of pt disease following neoadjuvant hormonal therapy (nht) and radical prostatectomy (rp) in high-risk prostate cancer. we retrospectively included patients who had received nht and rp for the treatment of high-risk prostate cancer. we classifi ed the patients into two groups, the pt group and the non-pt group depending on whether a residual tumor was observed or not. we identifi ed cases ( . %) with pt disease aft er reviewing all slides of the patients. th ere was no recurrence of disease in the pt group during a median follow-up of months. among the patients in the non-pt group, biochemical recurrence (bcr) developed in patients ( . %), with the median time to bcr being months. conclusions: among the patients with high-risk prostate cancer, we found cases that showed a pathologic complete response aft er nht and no recurrence of disease during the follow-up, which means that the androgen-deprivation therapy could potentially eradicate high-risk prostate cancer. th is is one of the largest studies demonstrating the prevalence of pt disease and its outcomes aft er nht among patients with high-risk prostate cancer. introduction and objective: in metastatic castration-resistant prostate cancer (mcrpc), data are limited regarding optimal combinatorial or sequential use of available treatments. p - (stride; nct ) is an ongoing, randomized, open-label, phase study evaluating concurrent vs. sequential administration of the androgen receptor inhibitor enzalutamide (enz) with the autologous cellular immunotherapy sipuleucel (sip-t). fift y-two patients (pts) with asymptomatic or minimally symptomatic mcrpc were randomized : to receive sip-t infusions with enz starting weeks before (n= , concurrent arm a) or weeks aft er (n= , sequential arm b) sip-t initiation. th e primary endpoint is peripheral t cell proliferation response to pa , the sip-t immunizing antigen. secondary endpoints include interferon (ifn)-γ elispot and humoral immune responses to pa and prostatic acid phosphatase (pap), product release parameters (total nucleated cell count, cd + cell counts, and antigen presenting cell activation [as measured by cd upregulation]), cytokine production, and adverse events (aes). results through week are described. results: pa -specifi c t cell proliferative response was signifi cantly elevated at all post-baseline time points (p< . ) and was sustained through week , including a > -fold increase at week in both arms. th is pa -specifi c response was observed in nearly all pts, . % in arm a vs. . % in arm b. both arms showed a signifi cant and sustained increase in humoral responses to pa and pap as well as ifn-γ elispot response to pa . sip-t product parameters were similar between arms. cytokines indicative of immune activation (such as ifn-γ, interleukin- , and tumor necrosis factor-α) were also elevated in both arms. aes were observed in % (arm a) and % (arm b) of pts. th e incidence of grade ≥ aes was similar between arms. materials and methods: tur specimens without hormonal use ( cases), specimens aft er three weeks of chlormadinone acetate (cma) ( cases), specimens aft er average six months of dutasteride ( cases), and specimens two weeks aft er initial use of degarelix ( cases) were studied using he and immunohistochemical staining with prostate specifi c antigen (psa), prostatic stem cell markers such as cd , cd , and vimentin. results: specimens treated with cma showed acinar dilatation and atrophy of glandular cells. specimens treated with dutasteride showed marked decrease of gland and increase of fi bromuscular tissue. specimens treated with degarelix showed prominent decrease of gland and glandular cells. psa was stained all of the prostatic glandular cells in all specimens. cd was stained at basal cells in normal prostatic tissue without hormones, however in hormone treated specimens, basal cells elongate and some glandular cells were also stained by cd , especially in cma treated specimens. cd was stained in many glandular cells without special patterns. vimentin was stained in all mesenchymal interstitial cells and a part of basal cells, and not stained in glandular cells. conclusion: elongation of basal cells and increased sensitivity to cd in glandular cells, especially treated with cma, were thought to the result of emt of prostatic glandular cells. th ree weeks use of cma might be a good model to observe emt of prostatic cells among these three hormone models, presumably because six months use of dutasteride is long enough to alter the structure of prostatic tissue, and degarelix has strong apoptotic activity to prostate cells in a short period. aryl plays an important role in normal physiologic responses such as development, cell cycle regulation, and immune function in various tissues. th e strong nuclear ahr expression was observed in the invasive phenotype and an elevated nuclear ahr expression was associated with a poor prognosis of human prostate. on the other hand, the ahr defi ciency results in a smaller volume and in increased susceptibility to prostate tumors in mouse model. in the present study, we investigated ahr expression and its role in the growth and invasiveness of human prostate cancer cells. we checked ahr proteins expression in prostate cancer cell lines and in human prostate cancer specimens by immunoblotting and immunohistochemistry respectively. we used a small interfering rna targeting ahr, constitutive active ahr expression vector, and ahr agonist and antagonist were used to moderate its expression and signaling to examine growth and invasion in prostate cancer cells. introduction and objective: androgen deprivation therapy (adt) has been increasingly used in patient with prostate cancer (pca). it has been considered that adt is associated with greater risk of incident cardiovascular disease (cvd). th e one of the reason is that hyperlipidemia was caused by adt may contribute to greater cvd risk. but the evidence remains inconclusive and sometimes contradictory. in our present study, we investigated an eff ect of adt on arterial atherosclerotic changes assessed by cardio-ankle vascular index (cavi) in pca patients. th e present study was participated in patients with prostate cancer before initiate adt. we recorded and statistically analyzed the data of the patients before adt and at months, months, and months aft er adt. and the patients' arterial atherosclerotic changes was evaluated by cavi at baseline. correlation between the degree of infl ammation and gleason score in prostate cancer patients alexandrescu e, geavlete p, georgescu d, geavlete b introduction and objective: hypothesis regarding the involvement of infl ammatory processes in prostate cancer has been the subject of several recent studies. chronic infl ammation generates the appearance of morphological changes of atrophic type, lesions located predominantly in the periphery of the gland, as well as prostate cancer (pca). th e aim of the study was to assess the possible infl uence of associated infl ammation on the gleason score in pca patients. results: th e gleason score - was detected in patients ( . %), score - in patients ( . %) and score - in patients ( . %). cases of aggressive disease (gleason score - ) were detected by prostate biopsy, while high-grade infl ammation has been mostly associated with pca cases incidentally detected by turp. no signifi cant correlations were found between the presence and degree of histologically proved infl ammation and the gleason score or the presence of pca. identifi cation of n -methyladenosine methylated mrnas in prostate cancer pang k , , cumberbatch m , , catto j , introduction and objective: rna methylation is a common epigenetic event in oncogenesis, and the most common form is the methylation of n -adenosine (m a). th e recent identifi cation of > , m a-methylated human mrnas from > human genes point towards novel epigenetic mechanisms. however, the distribution of m a in the prostate transcriptome is unknown. we aimed to predict the mrnas susceptible to m a-methyation in primary prostate cancer (pca) and castrate-resistant pca (crpc), and identify the functions of these mrnas. th e aim of this study was to assess the contribution of multiparametric mri and pca in pre-decision of initial biopsy in patients with serum psa level - ng/ml and normal digital rectal examination. th e study is planned as prospective and single-centered. patients whose serum psa level - ng/ml with normal digital rectal examination scheduled for initial prostate biopsy were included in the study between february and march . each patient underwent multiparametric mri (diff usion, spectroscopy, dynamic-contrast, t ) one week prior to biopsy. th e lesion seen at least in two mri was accepted as multiparametric mri lesion. twenty to thirty ml initial urine samples were taken aft er minutes prostate massage for pca examination before biopsy. pca score over was considered as signifi cant. guided biopsies were taken according to lesions seen in multiparametric mri. patients with high psa levels were separated into two groups as high pca scores and normal pca scores. each group, then, was separated into two groups due to mri results as lesion positive and negative. tumor incidence and positive predictive values were calculated in patients with high psa and pca scores with positive multiparametric mri lesion. tumor incidence and negative predictive value were also calculated in patients with high psa level but low pca score with negative multiparametric mri lesion. up. , figure . a biopsy-induced hemorrhage was defi ned as a case in which a subject complained of bleeding from the rectum and excretion of blood clots was confi rmed. we categorized signifi cant rectal bleeding into two grades for hemostasis management, including mild and severe. when the bleeding was classifi ed as mild, we inserted the gelatin sponge into the participants in either group b or reinserted it into those participants in group a. if the bleeding could not be stopped by this approach, we additionally used index fi nger pressure for ten minutes or more to promote hemostasis. in the severe cases, an endoscopic clipping was performed to control the bleeding because arterial bleeding was suspected. a blood test and a questionnaire survey, and pain related to biopsy was performed before and aft er biopsy. th e diff erence in background factors between groups a and b was assessed. to identify the independent predictive factors for rectal bleeding for all participants, background factors, including insertion of a gelatin sponge into the rectum were analyzed by logistic regression analysis. results: signifi cantly fewer patients in group a required hemostasis aft er biopsy compared to group b ( ( . %) vs. ( . %), p= . ). th e results of blood tests performed before and aft er biopsy and the results from the questionnaire did not diff er signifi cantly between the two groups. in multivariate analysis, only "insertion of a gelatin sponge into the rectum" emerged as a signifi cant predictor of hemostasis. our results suggest that the tissue elastic modulus of prostate cancer may increase with an increase in the gleason score and that the diff erence in the stiff ness between low-grade lesions and prostate hyperplasia may be slight. th ese basic fi ndings will contribute to the development of quantitative elastography technique. the results: th e median ipss was , the mean psa was . ng/ml; the mean size of prostate was . cc. of the total subjects, prostate cancer was detected in ( . %) patients. among subscores refl ecting specific luts, the nocturia was only symptom score predict the cancer detection. th e detection rate of patient with nocturia more than time a day was . %, but the cancer detection rate of patient without nocturia was only . %. at multivariate analysis adjusting infl uence of covariate of age, psa, prostate size and transitional zone size, frequency and nocturia scores were the two only factor predicting cancer detection. at the roc curve analysis measuring the benefi t of the additional consideration of the severity of nocturia and frequency, the additional consideration induced . % prediction accuracy elevation (from . to . ). conclusions: men with frequency or nocturia have lesser chance of prostate cancer detection rate than the men without luts. however, the infl uence of these storage symptoms seems not strong enough to change current consensus of indication to biopsy the prostate. routine in the discontinuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e median Δegfr at baseline, , , and months in the continuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e continuing group decreased months later. however, the renal function in the discontinuing group had a tendency to improve at months aft er treatment insignifi cantly. th ere was not statistical signifi cant diff erence in various factors between discontinuing group and continuing group. conclusions: it was possible that the recovery of testosterone was associated with the improvement of the renal function. it has been reported that the discontinuation of adt recovered the level of testosterone. namely, the discontinuation of adt for prostate cancer might revive the renal function. th erefore, it was suggested that intermittent adt might recover the renal function. introduction and objective: as more and more patients are getting diagnosed as carcinoma of prostate (cap), we would like to look into how prostate cancers are presented at the early age of forties and how they were treated. as cap is more popularised in the media, more and more people are asking gps for psa measurements. introduction and objective: irreversible electroporation (ire) is a novel ablative therapy for prostate cancer, with reported advantages of sparing surrounding essential structures. th ese properties could potentially help to reduce or avoid side eff ects. th e objective is to determine quality of life outcomes (qol) and side-eff ects of ire treatment. sixteen patients planned for radical prostatectomy (rp), were asked to participate in the study. all patients underwent an ire treatment one month before rp, using a focal or extended ablation protocol. th e safety was measured by the number of adverse events graded by the common terminology criteria for adverse events (ctcae). to determine qol validated questionnaires (expanded prostate cancer index composite (epic), the fi ve-item version of the international index of erectile function (iief- ) and international prostate symptom score (ipss)) were used. results: five developed a urinary retention (ctcae grade ) solved by an indwelling catheter or self-catheterisation. two patients developed a urinary tract infection (ctcae grade ), one progressed to urosepsis (ctcae grade ), both resolved without sequelae. mild haematuria (ctcae grade ) was noted in ten patients, spontaneously resolved within days. five patients experienced temporary incontinence with duration of - days, three suff ered from total incontinence and needed pads and pelvic fl oor training (ctcae grade ). two patients reported mild hematospermia, lasting one and thirty days. ipss showed no signifi cant diff erence between baseline (average of (avg) ± ) and four weeks postoperatively (avg ± ). iief showed no signifi cant diff erence between baseline (avg ± ) and four weeks postoperatively (avg ± ). epic outcomes, shown in figure , were not signifi cantly diff erent at baseline, one and four weeks aft er ire, regardless of the used ablation protocol. conclusion: ire treatment for prostate cancer is safe and shows only adverse events that lie within the range of what was expected and shows promising rates of genito-urinary functional preservation. introduction and objective: mri-guided transurethral ultrasound ablation (tulsa) is a novel minimally-invasive technology for treatment of prostate cancer aiming to provide local disease control with low morbidity. th e ultrasound device generates conformal volume of thermal ablation, shaped precisely to the prostate using real-time mri thermometry feedback control. aim of this prospective, multi-national phase i study is to determine safety and feasibility of mri-guided tulsa. biochemical recurrence (bcr) was defi ned using phoenix criteria (psa nadir + ng/dl) and positive biopsy in the treated area was considered recurrence. we compared the perioperative and oncologic outcomes following fc in patients with gs vs. gs ( + ) at initial trus biopsy. th e complications were reported using the clavien-dindo classifi cation. we found patients with gs and with gs ( + ). clinical and operative characteristics were similar (table ) . th e mean follow-up was . (± . ) months. th ere was no signifi cant diff erence noted between gs vs. gs in the biopsy recurrence ( % vs. %, p= . ) and bcr rates. th ere were complications in ( . %) patients. all were low grade, except two patients who had iii b complications (table ) . conclusion: th e perioperative and oncologic outcomes of fc -hemiablation for unilateral, organ confi ned pca appears to similar between gs and gs ( + ) disease. pentafecta in the evaluation of surgical results after open radical prostatectomy de la rosa h, rios s, martinez n introduction and objective: "pentafecta" has been used to evaluate the oncological and functional results in patients with prostate cancer treated with minimal invasive radical surgical techniques. in this study we evaluate, with this quality tool, the outcomes in a group of patients undergoing open radical prostatectomy. we analyzed retrospectively the database of surgeries performed at the urology department of the military hospital of guadalajara and the clinical fi les of patients with localized prostate cancer treated with radical prostatectomy. we describe the patients' characteristics including the charlson comorbidity index (cci) and identify the parameters that conform pentafecta as well as the variables that can infl uence the oncological and functional results using the fisher´s exact test. results: fift y four patients were treated with radical prostatectomy between and , fi nding in their fi les a minimum of months of follow-up. seven patients were discarded of the study because they undergo laparoscopic radical prostatectomy, and more because missing information at their fi les. th e average age was ( - ) and the cci average was . ( . - . ). mean operative time was min ( - ) and intraoperative bleeding cc ( - ). th e presence of potency, continence, biochemical recurrence-free survival, negative surgical margins and no perioperative complications were %, %, %, % and % respectively. seven ( %) patients achieved pentafecta, and patients ( %) failed to achieve. statistical analysis confi rmed the surgeon's experience as the only factor associated with achieving pentafecta. conclusions: th e fi rst cause of failure to achieve pentafecta in our study group was impotence, second were positive surgical margins and third surgical complications mainly intraoperative bleeding. pentafecta is a useful tool for objective assessment of oncological and functional outcomes of patients treated with open radical prostatectomy. plasma introduction and objective: hepatocyte growth factor (hgf) is a well-known multifunctional growth factor, the amount of evidence has accumulated suggesting that the hgf/met (hgf receptor) signaling axis is involved in cancer progression. macrophage stimulating protein (msp) is also known as a growth factor which activates not only macrophages but also cancer cells and osteoclasts through the activation of the specifi c receptor d' origine nantais (ron). hgf and msp are secreted as an inactive single-chain precursor (pro-hgf, pro-msp), which lacks biological activity and, therefore, requires proteolytic activation for conversion to an active two-chain form by hgf activator (hgfa). although, there have been reported a lot of study for hgf/met signaling with castration-resistant (cr) pc and bone metastasis, the report for examination of plasma protein is rare. in addition, msp/ron signaling axis is not well evaluated in pc. here, we analyzed the associations between pc progression and plasma levels of hgf and a closely related molecule, msp. conclusion: dehydroepiandrosterone (dhea) concentrations in blood were examined by newly developed ultra-sensitive quantifying method, lc-ms/ms. we confi rmed that low serum dhea levels in men with prostate were related to high gleason score and advanced clinical stage. th ese results suggest that serum dhea level may be useful as a prognostic factor in men with prostate cancer. introduction and objective: androgen/androgen receptor (ar) signal is known as a powerful driver of prostate cancer (pca) progression. previously we reported the limitation of prostate-specifi c antigen (psa), which is an ar-regulated protein, at diagnosis as a prognostic biomarker of pca. paradoxically pca patients with low psa < . ng/ml had a more advanced stage of cancer compared with those with psa between . and ng/ml. although serum total testosterone (tt) has also been reported as a pca prognostic biomarker, its usability is still controversial. we examine the potential and the character of tt as a biomarker, comparing to psa. serum tt level of patients who underwent prostate biopsy at kanazawa university hospital between and were measured and pca-specifi c survival (pcass), overall survival (os), and the correlation between tnm stage and tt level were analyzed. results: of total biopsied patients, were diagnosed with pca. median tt was . ng/ml (range: . - . ). when patients were divided into groups according to their tt at diagnosis, patients with tt < and ≥ ng/ml had worse pcass than those with ≤ tt < , ≤ tt < , and ≤ tt < ng/ml. os in patients with tt < and ≥ ng/ml also was worse than that in other groups. moreover, tt < and ≥ ng/ml showed worse pcass even in patients with advanced stage (t or n or m ). higher tnm stage was observed in patients with tt < and ≥ ng/ml than those with ≤ tt < ng/ml. low tt level has been reported as a predictive biomarker indicating worse outcomes in pca patients. th is study showed not only low but also high tt level may indicate poor prognosis. th ese data are consistent with our previous studies showing low psa (< . ng/ml) also might indicate poor prognosis as well as high psa. although poor prognosis of high tt and high psa strongly depends on androgen/ar signal, poor prognosis of low tt and low psa patients may be due to other signals than androgen/ar. usefulness of psa as a marker of prostate cancer in men treated with dutasteride takeda h, nakano y, narita h introduction and objective: to analyse whether the use of treatment-specifi c criteria for repeat biopsy maintains the usefulness of prostate-specifi c antigen (psa) level for detecting prostate cancers. th is study was a retrospective investigation to assess the eff ects of dutasteride on psa in asymptomatic men aft er negative st biopsy and on repeat prostate biopsy decision. th e usefulness of psa was evaluated using biopsy thresholds defi ned by three times consecutive rises and . ng/ml up in psa from nadir (the lowest psa level achieved while in the study) in the dutasteride group. prostate cancer pathological characteristics were compared. results: of men, (dutasteride) underwent at least one prostate biopsy during the study and were included in the analysis. mean follow-up (month) was . , ipsa was . ng/ml, mean prostate volume(cc) was . , psad was . ng/ml/cc. nine of ( %) were detected prostate cancer, % ( / ) of gleason and % ( / ) of gleason - cancers were detected in the dutasteride group. in the study, the incidence of gleason and gleason - cancers generally increased with greater rises in psa. sensitivity of psa kinetics with dutasteride was high as usual. conclusion: using treatment-specifi c biopsy thresholds, the present study shows that the ability of psa kinetics to detect prostate cancer is maintained with dutasteride in men with a previous negative biopsy. biopsy decisions based on three times consecutive increased and . ng/ml psa measurement from nadir in the dutasteride group are useful, indicating the importance of confi rmation of psa measurements. our goal was to develop a fi t-for-purpose assay that could be performed on rna from diagnostic needle biopsies, and provide improved risk stratifi cation in early-stage pca. to date, development and validation studies have included > , patients from four academic centers. in these studies, archival tissues were assayed following prospectively designed protocols with pre-specifi ed methods and statistical analysis plans. results: feasibility and development studies confi rmed gene expression and identifi ed genes whose expression was predictive of clinical recurrence, biochemical recurrence (bcr), prostate cancer death, and adverse pathology (ap) at surgery in the face of tumor heterogeneity and multifocality. analytic validation studies showed that the assay provided robust, reproducible results over a wide range of rna inputs, diff erent operators, instruments, and reagent lots. th e fi rst clinical validation study established gps as an independent predictor of ap in men with nccn verylow to intermediate-risk pca. exploratory analyses showed that gps is a robust predictor of ap despite inter-observer diff erences in pathologic grade and stage assessment. a second clinical validation study in a racially diverse population confi rmed the assay as a predictor of ap and validated the assay as a strong predictor of bcr (hr/ gps units= . ; p< . ). gps was also signifi cantly associated with metastatic disease (hr/ units= . ; p= . ). other exploratory analyses showed that the assay can predict ) likelihood of clinical recurrence aft er bcr, regardless of salvage therapy, and ) tumor aggressiveness when assessed in adjacent normal-appearing tissue. all four gene groups contribute to the predictive value of the assay. conclusions: th e development program for the assay addressed challenges of small sample size, tumor heterogeneity, multifocality, and biopsy under-sampling. validation in two large contemporary cohorts of men with pca in two prospectively designed studies provides level ib clinical evidence for gps as a predictor of ap. clinical and therapeutic implications of neuroendocrine prostate cancer: a long winding road to cure lu k, wang h, lin v, yu t introduction and objective: primary neuroendocrine cancer of prostate is an extremely rare variant of prostate cancer, comprising . % to % of prostate malignancies. th is entity encompasses various clinical contexts, ranging from the de novo small cell carcinoma (scc) to a treatment-emergent transformed phenotype that arising from typical adenocarcinoma (ad) of the prostate. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about neuroendocrine prostate cancer and the current knowledge of this disease is based on case reports or small series. our purpose was to characterize the cases treated at a tertiary academic center and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with neuroendocrine prostate cancer followed at e-da hospital, kaohsiung city, taiwan between january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: among prostate cancers, six patients were identifi ed with primary neuroendocrine prostate cancer, comprising from de novo mixed variety (scc and ad) and from transformed phenotype (pure scc). th e median age at diagnosis was . years. th e most common presenting symptoms were obstructive symptoms (weak stream, incomplete empty and urine retention). th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers, and prostate specifi c antigen (psa) helped establish the diagnosis. overall median survival was months from diagnosis of neuroendocrine prostate cancer/ prostate small cell carcinoma. conclusion: primary neuroendocrine prostate cancer is characterized by an aggressive clinical course with relatively short lifespan. although high response rate to cytotoxic chemotherapy, overall prognosis is poor. as there is no standard of care for patients with neuroendocrine prostate cancer, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic strategy. association th e mean duration for the side eff ect to occur was months (range - months), the mean duration between the onset of side eff ect and beginning of hbo therapy was months (range - months). th e patient with both hemorrhagic proctitis and cystitis completely recovered, and the remaining patients had improvement of side-eff ects. conclusion: hbo therapy can be a choice of treatment for radiation induced side-eff ects. a treatment trend of the prostate cancer in japanese provincial hospital introduction and objective: th e prostate cancer patients can choose various treatment options for cancer. however, the choice is limited by a diff erence in the scale and/or the location of each medical institution. we examined a treatment trend of the prostate cancer in our japanese provincial hospital. we evaluated patients who had a diagnosis of prostate cancer between and . th ey were classifi ed four groups, cases of the middle-aged generation (range - years old), cases of the early advanced-aged generation (range - ), cases of the middle advanced-aged generation (range - ) and cases of the latter advanced-aged generation (range -). we sorted each groups using the d' amico risk classifi cation system. in the middle-aged generation, patients, except for metastatic cases, underwent radical prostatectomy or radiotherapy. in the early advanced-aged generation, of low-very high risk group patients ( %) chose radical prostatectomy or radiotherapy. on the other hand, in the same generation, of intermediate risk group cases ( %) were treated with hormonal therapy. in the middle advanced-aged generation, only of low-very high risk group patients ( %) underwent radical prostatectomy or radiotherapy, which was fewer compared with the early advanced-aged generation. th at means, they oft en chose hormonal therapy. in the latter advanced-aged generation, all patients, except for cases, were treated with hormonal therapy. th e cases belong to the low-intermediate risk group, chose watchful waiting (psa monitoring). introduction and objective: robot-assisted radical prostatectomy (rarp) has emerged as an excellent treatment option for men with localised prostate cancer. as with other surgical treatment options, urinary incontinence remains a signifi cant side eff ect of the procedure and has been associated with weak pelvic fl oor muscle (pfm) strength. we aimed to assess pfm strength preand post-rarp, its relevance to incontinence and relevant predictors of poor outcomes post-op. we conducted a retrospective analysis of a prospectively collected database of men undergoing rarp by urologists over a -month period. each man had a pelvic fl oor strength assessment pre-operatively and at week and weeks post-operatively. pfm strength was recorded as strong (grade ), moderate (grade ) or weak (grade ). continence rates were recorded at weeks post-op, with continence defi ned as no requirement for pads or continence aids. basic demographic data and histological data were also collected. introduction and objective: urethral trauma is reported to occur in . % of patients undergoing catheterisation but, in practice, seems to be more common than this. we have investigated its incidence retrospectively and prospectively and have evaluated a new approach to catheterisation to reduce the incidence of catheter-related trauma and its consequences, which has led to the development of a novel urethral catheterisation device (ucd) produced by urethrotech™. a total of patients being catheterised for cardiac surgery were reviewed retrospectively and studied prospectively to determine the incidence of urethral trauma due to urethral catheterisation. one hundred similar patients were then studied prospectively to trial a ucd to see if it reduced the incidence of trauma. ( ) lavh ( ) myomectomy ( ) lap. ovarian cyst excision ( ) ( ) nephrectomy ( ) ileal ureter substitution ( ) ureterolithotomy ( ) angioembolization ( ) urs c d-j stent ( ) ureteroneocystostomy ( ) ureteroureterostomy ( ) . hospitalization ( notes. none had documented consent and none had been counselled about potential complications. one hundred and forty-six were successfully catheterised. four ( . %) required a suprapubic catheter for traumatic and unsuccessful urethral catheterisation. no other adverse events were recorded. seventy-four consecutive patients were studied prospectively aft er counselling and consenting. th e incidence of urethral trauma was out of ( . %). five had urethral or perineal pain and urethral bleeding ( . %) and ( . %) additionally required a suprapubic catheter. having developed a practice of passing a urethral catheter over a guide wire in patients undergoing reconstructive urethral surgery in our unit we subsequently trialled the urethrotech™ ucd for routine urethral catheterisation. th is ucd was used for catheterisation in consecutive patients without complications. we conclude that urethral catheterisation has a signifi cant risk of trauma -ten times the reported incidence -and to reduce that risk the catheter should be passed over a guide wire, as with the ure-throtech™ ucd, as is the practice for passing catheters and similar tubes into other anatomical structures. th is should particularly apply in high risk patients, such as those being catheterised for cardiac surgery who are about to be heparinised, and in higher risk circumstances such as when catheterisation is being performed by junior medical or nursing staff . results: mean age at the time of transplantation was . ± . years with male to female ratio of . : . etiology of esrd included renal parenchymal diseases ( %), o vesicoureteric refl ux ( %) and o vesicoureteric refl ux due to posterior urethral valve ( %), urolithiasis ( %) and neurogenic bladder ( %). pre-transplant bilateral nephroureterectomies were performed in patients, augmentation ileocystoplasty with mitrofanoff conduit in patients while posterior urethral valve fulguration in patients. mean serum creatinine post-transplantation was . mg/dl and . mg/dl at week and months respectively. surgical complications occurred only in two patients; one developed lymphocele while other presented with febrile uti due to ureteric refl ux in the early postoperative period and was managed by doing a new ureteral reimplantation. th e mean graft and patient survival rates at one year were % and % respectively. one patient lost her graft at months which was turned out case of hyperoxaluria. acute rejection was seen in ( %) patients. all of these were successfully reversed with pulse therapy. none of the patients developed cytomegalovirus (cmv) infections or lympho-proliferative disease. symptomatic urinary tract infections aft er transplantation occurred in ( %) patients including pyelonephritis in ( . %) patients. two of these patients with pyelonephritis had prior bladder augmentation. ureteric stenosis is a well recognised major urological complication of renal transplantation. following initial antegrade decompression, defi nitive treatment options include long-term ureteric stenting, endoscopic stricture dilatation/division or ureteric re-implantation. th ere is minimal current data in the literature to help guide patient choice. we aimed to characterise the outcomes following management of ureteric stenosis at a large european regional transplant centre. a retrospective cohort study was performed for all patients following renal transplantation who required treatment for ureteric stenosis between august and august . case identifi cation was via a prospectively maintained database on all renal transplant patients and international classifi cation of disease procedure codes. results: of renal transplants performed during the study time period, patients developed ureteric stenosis requiring intervention ( . %). eleven patients underwent initial open ureteric re-implantation, had endoscopic management and had longterm ureteric stents. mean length of time between elective stent changes was . months (range - months). one patient opted for open re-implantation aft er a period of stenting with a good outcome. one experienced graft failure due to non-compliance with immunosuppression, otherwise renal function was preserved. of the patients having open re-implantation only one experienced re-stenosis -managed with long-term ureteric stenting and . % had satisfactory renal function at follow-up. two patients received successful balloon dilatation and patient had upper tract stenosis managed with pyeloureteroplasty. all patients have experienced no decline in graft function since. endoscopic, open reconstruction and long-term stenting can all provide satisfactory outcomes for the majority of renal transplant patients aff ected by this problem. medium-term graft function was well preserved. in recent years approximately half of patients have proceeded to open re-implantation. surgical and clinical factors impact the choice of treatment. however, patient choice also plays a significant role. th is study has provided up to date information to aid counselling patients. further prospective study is warranted to assess what variables infl uence patient choice and cost effi ciency of open re-implantation versus long-term ureteric stenting. the angiogenic mechanisms of endothelial progenitor cells in kidney transplantation patients introduction and objective: th e blood fl ow blocking during kidney transplantation oft en results in renal ischemic injury. in this process, endothelial cells and endothelial progenitor cells (epcs) are activated to participate in angiogenesis. epcs and endothelial cells participate in angiogenesis and tissue repair through diff erent signaling pathway. prostaglandin e (pge ) is a kind of metabolites of arachidonic acid, and is a mediator of infl ammation and ischemia. pge took part in angiogenesis and epcs diff erentiation according to our previous study. in this study we will demonstrate the angiogenic function of epcs of kidney transplantation patients and reveal the molecular mechanisms of angiogenesis. materials and methods: epcs from peripheral blood aft er kidney transplantation were isolated by density-gradient centrifugation. facs was used to identify the epcs. th e aa metabolites pge in epcs cultured medium was measured by liquid chromatography-tandem mass spectrometry (lc-ms/ms). q-pcr and wb were used to detect the expression of endothelial markers in human umbilical vein endothelial cells (huvecs) cultured with epcs conditional medium. tube formation assay was performed to elucidate the angiogenic ability of huvecs. results: epcs from kidney transplantation expressed c-kit and cd by facs analysis. multiple types of aa metabolites was detected in the conditional medium by lc-ms/ms and pge was increased to more than -fold aft er kidney transplantation. huvecs cultured with conditional medium highly expressed cd and ve-cadherin and also formed more tubes compared with control. huvecs given pge had the same biological characteristics like the conditional culture. conclusion: pge paracrine of epcs from kidney transplantation enhanced the capacity of angiogenesis in huvecs. graft survival, proteinuria and kidney growth: challenges between pediatric and adult deceased kidney donation basiri a , , , zare s introduction and objective: th e presence of widening discrepancy between supply and demand of donor and recipient in the fi eld of renal transplantation, has led us to compare the graft and patient survivals, post transplantation complications, rate and severity of proteinuria secondary to hyperfi ltration injury and the kidney growth of recipients who underwent transplantation from pediatric (group ) and adult deceased donors (group ). each groups contains patients. outcome measures included, patient and graft survivals, quality of graft function as assessed by serum creatinine (scr) and estimated gfr (egfr), surgical complications, proteinuria that was detected by routine urinalysis and then confi rmed by a -h urine protein > mg, and kidney length that measured by early and following ultrasonography. results: th e mean donor age in groups and were . (range . to y/o) and ( to y/o) respectively. th e nine kidneys ( %) from pediatric donors (group ) were off ered en-block. mean follow-up was month (range to ). th ere were no statistical differences in the incidence of dgf between two groups ( % versus %) (p= . ). group had a slightly higher incidence of acute rejection than group ( versus %), but the diff erence was not statistically signifi cant (p= . ). one year's graft survival were similar between two groups ( % and %). serum cre-atinine (scr) and estimated gfr (egfr) th ere were no statistically diff erences between two groups ( . versus . mg/dl and versus cc/min respectively) (p= . ). th e incidences of surgical complications that required surgical intervention (urinary leakage, ureteral stenosis, lymphocele, vascular thrombosis) were similar in both groups ( versus %) (p= . ). development of proteinuria was not diff erent between two groups ( % versus %) (p= . ). early kidney length within one week was signifi cantly lower in group than in group ( ± mm versus ± mm) (p< . ), but the rate of increase of kidney length in group was signifi cantly greater than group ( ± mm versus ± mm) (p< . ) under follow-up period. conclusion: although in this study, median-term outcomes and complications of single and en-block kidney transplantation from pediatric donors are acceptable and same as those from older donors. but assessment of functional and hemodynamic adaptation of small pediatric kidneys in adult recipients and subsequent hyperfi ltration eff ects requires the study with more cases and greater follow-up periods. george a, singh c, devasia a introduction and objective: th e need for vascular access for hemodialysis (hd) increases with the increasing number of patients with end stage renal disease (esrd) requiring hd, with increasing life span, and with more available facilities especially in developing countries. when the usual accesses (radiocephalic and brachiocephalic) have been utilised or failed, a ptfe graft is usually considered. we present here a 'bridging' option of a basilic vein transposition, as a doable, cost eff ective procedure before av graft ing. patients with end stage renal disease were included. th ey all either had poor cephalic veins at the wrist and cubital fossa, or had previously used and failed fi stulae. anasthesia: regional block (local anaesthetic). technique: th e basilic vein was exposed using three small incisions: cm above cubital fossa, mid arm (medial aspect), and upper arm (medial aspect up to axilla). th e vein was completely freed off surrounding structures, tributaries tied, distal end ligated, patency ensured and vein delivered out of the uppermost incision. using a tunneller, the vein was rerouted subcutaneously, anteriorly to reach the cubital fossa incision. th e brachial artery was identifi ed and looped. arteriovenous anastomosis was done using 'o' prolene, continuous sutures. (images in the poster). results: out of a total of venous access surgeries done during the study period, seven basilic vein transpositions were done. all had pre-operative doppler evaluation to assess size and patency of veins. all fi stulae created were functional at the time of discharge. th e fi stula is used for hemodialysis at - weeks, when the fi stula matures (arterialization of the vein implying good/suffi cient fl ow for dialysis). one patient needed exploration for a venous thrombus, hours later, which was removed with a venotomy and th congress of the sociÉtÉ internationale d'urologie -siu abstract book using a fogarty catheter. subsequently with anticoagulation for hours, the fi stula continued to function and is being used for access. th e second patient had exploration on the th post-operative day for evacuating a subcutaneous hematoma. th e fi stula is patent and will be used once it has matured. five of the seven done were uneventful and are being used for hemodialysis access. conclusion: basilic vein transposition, is the preferred option of vascular access over a ptfe graft , as it is cost eff ective, autologous and doable under regional anaesthesia. retrospective results: a total of renal transplants have been performed since . th e transplants were performed via an extraperitoneal approach with a modifi ed lich-gregoir ureteric anastamosis in most cases. jj-stents were not routinely used. th irty two urological complications were noted in transplants ( %). th ere were boys and girls with ages ranging from . to . yrs (mean . ). th e most common complication was vesico-ureteric refl ux (vur) occurring in patients ( %). all those with vur presented with recurrent urinary tract infections and bladder dysfunction was present in % (none were augmented). vur was managed successfully with reimplant in six and submucosal injection of defl ux in three; eight patients were managed conservatively. post-operative urine leaks occurred in patients ( %) and were managed with reimplant in two, uretero-ureterostomy in one, jj-stent in one and conservatively in two. ureteric stenoses presented in patients ( %) with hydronephrosis and worsening renal function and were managed initially with either percutaneous nephrostomy or jj-stent placement. surgical management was performed in four patients (three reimplants and one uretero-ureterostomy); two patients were managed conservatively with transient jj-stent placement. th ree patients ( %) developed unexplained hydronephrosis -one with worsening renal function due to chronic rejection and two with stable renal function. loss of graft occurred in patients ( %) as a direct result of their urological complication. th ere were deaths -two due to chronic rejection and one due to overwhelming sepsis immediately post uretero-ureterostomy for ureteric stenosis. conclusion: urological complications following paediatric renal transplantation are common and can cause signifi cant morbidity and even mortality. vur was the most frequently observed and, if presenting with recurrent utis, can be managed successfully with surgery. other urological complications observed included urine leaks, ureteric stenoses and unexplained hydronephrosis. kidney transplantation in abnormal bladder: analysis of outcome kumar a, gulia a, chauhan u, sharma a, yadav r, dassi v introduction and objective: kidney transplantation in abnormal bladder is a challenging situation and associated with poor outcome. we have analyzed outcome of our data of last years. materials and methods: from to , patients who had abnormal bladder had undergone kidney tx. average age at the time of transplant was years. average age at bladder reconstruction was years. four patients had neurogenic bladder who were practicing cic, using native urethra and one had appendix as a mirofenof procedure. two patients had bilateral nephrectomy for grade vur and their lower ureters were used for augmentation and other two had ileocystoplasty. four patients of grade vur refl ux had subsequent transplant in the bladder. four patients with puv had bladder augmentation and mitrofenof procedure due to poor compliance. one child with puv had augmentation by stomach patch when he was year old. one patient had cystectomy in the past and ileal conduit reconstruction where transplant ureter was implanted. all patients had very trabeculated and thick bladder during ureteric reimplantations. all patients had extravesical ureteroneocystostomy with stents. urethral catheter was kept on average of days. no patients had any ureteric leak or stricture in postoperative period. all four patients with cic through native urethra had recurrent uti in the postoperative period and required long-term chemoprophylaxis. one patient who had ileocystoplasty before transplant, died due to sepsis just before his transplant. incidence of uti was % in this group. six patients also had pyelonephritis, which was controlled by injectable antibiotic. rejection rate was % in this group in fi rst month which was higher than our normal bladder group. average serum creatinine was . mg% at months and . mg% at year which was high than normal bladder population. average follow-up is . years where serum creatine was . mg%. mean hospital admission was . times. conclusion: kidney transplant in abnormal bladder is a good option but long-term results are inferior. recurrent uti and pyelonephritis are still a troublesome problem. various techniques and procedures are required to overcome these diffi cult situations. analysis of results: th e mean operative time, warm ischemia time and blood loos were minutes, . minutes. ml respectively. th ere were major complications including hemorrhage and injury to organs like bowel, spleen and pancreas. fourteen of these patients required exploration to control bleeding or repair. two patients were explored for adhesive obstruction. th ere were minor complications which were managed conservatively. one patient died in immediate postoperative period due to slippage of a single hemolock clip. all patients have adequate vascular and ureteric length. th ere were cases of multiple vessels. th ere were two urinary fi stulae and one ureteric obstruction. mild atn was noticed in patients. no graft was lost. hospital stay was . days. operative time has also come down to from minutes. th e average cost of the laparoscopic donor nephrectomy is us$ . conclusion: lap donor nephrectomy is a safe and minimally invasive procedure. it is a cost eff ective procedures even for the developing country. prostate carcinoma in solid organ transplant recipients tillou x , guleryuz k , bouvier n , belin a , chiche l , bensadoun h , doerfl er a introduction and objective: improvements in immunosuppression and anti-infection drugs in solid organ transplantation have led to a signifi cant survival increase for patients and graft s. prostate cancer (pc), being the most common tumor in men and given the increasing number of old male recipients, should show an increasing incidence in solid organ transplant recipients (sotr). th e aim of this study was to analyze retrospectively our liver (ltr), kidney (ktr) and cardiac transplant recipients (ctr) treated for a pc. between january and december , we found pc in male sotr ( %): pc in ltr, in ktr and in ctr. a ge at diagnosis was . ± . ( . - . ) years old and the interval from transplantation to diagnosis was . ± . ( . - . ) months. mean psa level was . ± . ( . - ) ng/ml. clinical stages were t , t and t in respectively , and patients. diagnosis was suspected during screening, because of prostatitis or bone pain in respectively , and patients. th ree pc were discovered aft er prostate transurethral resection. results: th irty-one patients ( ktr and ltr) with a localized disease underwent radical prostatectomy (rp). histological fi ndings were pt c and pt tumors, with positive surgical margins. gleason score (gs) was in case, in cases, in cases and in case. one patient with positive pelvic lymph nodes was given hormonotherapy. another had a biochemical recurrence at months and was treated with salvage radiotherapy. with a mean follow-up of . ± . ( . - . ) months, two ktr died from kp, and years aft er hormonotherapy and rp respectively. conclusions: prevalence of pc in sotr remains controversial, even though a signifi cant increase can be expected in the coming decades. it is therefore recommended to systematically screen male transplant recipients aft er years of age because outcome is much better if pc is diagnosed and treated early. radical prostatectomy is feasible in ktr as well as in ltr. conservative introduction and objective: conservative surgery results in the transplanted population remain unknown because they are only presented in small series or case reports. our objective was to study renal conservative surgery for kidney graft renal cell carcinomas (rcc) in a multicenter cohort. nephron sparing surgery (nss), radiofrequency ablation (rf) and cryoablation (ca) were studied. iiib) . none of the patients treated by radiofrequency ablation or cryoablation had complications. th e mean time of follow-up was . months ( . - ). fift y-nine ( . %) patients had a functional kidney graft , without dialysis and no long-term complications. specifi c survival was % at the last time of follow-up. conclusion: nss has proven its effi ciency for treatment of small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis. cryoablation and radiofrequency ablation seem to be alternative therapies that can be chosen with good results, in selected patients. ureteric implantation into introduction and objective: conventional technique recommends ureteric anastomosis to the bladder during kidney transplantation in patients with bladder augmentation. we report our experience of kidney transplantation in augmented bladders with the transplant ureter implanted into the bowel portion of the cystoplasty. a total of patients (mean age, . years (range - years), female, deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon between and was reviewed. following standard arterial and venous anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous pds / anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a size fr dj stent. a second layer of bowel plication was performed around the anastomosis to prevent refl ux using interrupted / vicryl sutures. chart review was performed to evaluate the short-term urological and kidney function outcomes. results: th e cause of renal failure was bilateral vesicoureteric refl ux in patients, posterior urethral valve with refl ux nephropathy in patients, tuberculosis of the urinary tract with infl ammatory ureteric stricture in patient, and lumbosacral agenesis with neurogenic bladder in patient. bladder reconstruction was performed at a median duration of months ( - months) before transplantation. gastrocystoplasty was performed in patients, while the colon and/or ileum were used in the remaining patients. all reconstructed bladders except had a mitrofanoff created for clean intermittent self-catheter drainage aft er transplantation between to x / day. aft er surgery, th e dose fi nding study, toxicokinetics of human bone marrow-derived mesenchymal stem cells, and study deciding timing and number of cell injection were conducted in order. results: from the dose fi nding study, × was selected as dose per an injection of human bone marrow-derived mesenchymal stem cells. from the toxicokinetics of human bone marrow-derived mesenchymal stem cells, days was selected as interval between repeat treatments. in the third study, the ratio of maximal intracavernous pressure to mean arterial pressure was signifi cantly lower in the control group than in the sham group ( . % vs. . %, p< . ). immediate single injection of human bone marrow-derived mesenchymal stem cells ( . %, p= . ) signifi cantly improved erectile function compared to that in the control group, whereas delayed single injection ( . %, p= . ) showed marginally signifi cant improvement. all histomorphometric changes were signifi cantly improved in the up. , figure . immediate or delayed single injection groups than in the control group. repeat treatments did not provide any incremental eff ect on recovery of erectile function and histomorphometric changes. conclusion: intracavernous injection of × human bone marrow-derived mesenchymal stem cells results in recovery of penile erection along with histomorphometric changes in a rat model of cavernous nerve injury, even when treatment was delayed by weeks following cavernous nerve injury. any incremental eff ect aff orded by repeat treatments remains to be undefi ned. relationship between metabolic syndrome, erectile dysfunction and hypogonadism abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: a strong association between erectile dysfunction (ed) and metabolic syndrome (ms) and hypogonadism was determined. aim of the work: to investigate the relationship between (ms), (ed) and the incidence of hypogonadism. th e correlation between hypogonadism and the metabolic risk factors was also determined. a total of patients with ed were included in the study, patients meet the criteria of ms were estimated. ed was classifi ed based on iief- domain score and the relation between severity of symptoms and the number of metabolic risk factors was determined. th e incidence of hypogonadism in ms patients was determined and the correlation between hypogonadism and metabolic risk factors was identifi ed. introduction and objective: peyronie's disease (pd) is a fi brotic disorder aff ecting the tunica albuginea of the corpora cavernosa. erectile dysfunction (ed) due to pd may be secondary to the penile deformity and the resultant changes in the hemodynamic parameters. th e aim of this study is to defi ne color doppler duplex ultrasound (cddu) characteristics in pd, with specifi c attention to describing the presence and etiology of ed in these patients. introduction and objective: th e cause of peyronie's disease (pd) is unknown. th e most accepted causative theory is trauma to tunica albuginea. because prevalence varies ( . - %), the potential for contributory cofactors have been proposed. we hypothesized that metabolic syndrome and other comorbidities may be found at higher rates in pd. retrospective chart review of patients presenting to a men's health clinic with a variety of complaints: erectile dysfunction (ed), premature ejaculation (pe), premarital checkup, small penis, decreased libido, lower urinary tract symptoms (luts) were screened for pd. variables collected: presence/absence of diabetes mellitus (dm), hypertension(htn), dyslipidemia (dl), body mass index (bmi), total testosterone (t), penile peak systolic velocity (psv) and end diastolic volume (edv), smoking, and glycosolated hemoglobin level (a c) in patients with dm. results: a total of patients, with a mean age of years (range - ) were analyzed. pd incidence ranged widely within individual clinics ( - %, average %). hypertension, bmi, t level, total number of comorbidities, low psv, abnormal edv, and mean a c were not associated with the presence of pd. th congress of the sociÉtÉ internationale d'urologie -siu abstract book diabetes was associated with pd (p= . ) and dm patients had a % higher incidence. patients with the highest a c levels (> . ) had an increased incidence of pd [or . (p= . , ci . - . )]. increased age was correlated with pd (p= . ); for each year of life, the likelihood increases by an or of . (~ % per year) (p= . , ci . - . ). dyslipidemia (p= . ) and smoking (p= . ) were associated with - % lower incidences of pd. conclusion: peyronies disease is found in about % of patients seen for other complaints. diabetes, particularly poorly controlled diabetes, is associated with an increased incidence. several other clinical factors appeared noncontributory. a decreased incidence of pd in smokers and patients with dyslipidemia is seen, but does not necessarily refl ect a protective role, but likely increased levels of erectile dysfunction in these groups--patients with inability to achieve erection are unlikely to complain of peyronies' disease. further research into the interaction of pd and dm are warranted. kim j, park j, chae j, oh m, park h, kim j, moon d introduction and objective: limited data are available concerning sexual behavior of korean men. th is study aimed to perform the national sex survey and to collect the basic data for establishment of the prevention strategies of sexually transmitted infections (stis) and hiv/aids. th is is a national survey performed on a sample of , individuals ( , men and , women) aged - years old. th e online surveys were carried out on a national scale in south korea. subjects were randomly selected from resident registration. a structured questionnaire was developed which elicited information concerning: demographic information, information on their sexual behavior, sexual identity, prostitution, experience of stis, and experience of sex education. results: th e majority of the subjects were either married or living with a partner. mean number of sexual intercourse is . ± . times a month. mean sexual satisfaction score using visual analog scale is . ± . . eighty-four percent had a fi xed sex partner; . % ( . % of men; . % of women) had experience through a speed dating or prostitution; . % of men and . % of women were sexually attracted to the same gender only, . % of men and . % of women were sexually attracted to both gender; . % of participants had the experience of the stis. only . % of the respondents had received sex education in the past year. we performed the national sex survey according to the nationwide distribution of population. it would be useful for establishment of the prevention strategies of stis and hiv/aids. to control stis and hiv/aids, powerful policies containing sex education and medical services will be needed. the introduction and objective: erectile function evaluated by international index of erectile function- (iief- ) tends to decrease in aging, obesity and hypogonadism, but the importance of body composition is unclear. in the present study, we evaluated associations between iief- , body composition and testosterone level (tt) in middle-aged men. design was a population-based cross-sectional study in middle-aged men. between march and september , police officers aged - years who had participated in a health examination were included. total , men underwent a detailed clinical evaluation using the validated international index of erectile function- (iief- ) questionnaires and body composition (measured by bioelectrical impedance analysis). weight, body mass index (bmi), waist-hip ratio (whr), and serum testosterone level were also established. results: data from men were analyzed. th e median age was . years, and median value of iief- score was . th e iief- score was inversely associated with age, whr, and body fat percentage (bfp) (r=- . ; p< . , r=- . ; p< . , r=- . ; p= . , respectively), and positively associated with body muscle percentage (bmp) and body skeletal muscle percentage (bsp) (r=- . ; p= . , r=- . ; p= . , respectively). testosterone level had no correlation with iief- score (p= . ). using logistic regression analyses, age, whr, bfp, and bsp predict moderate to severe erectile dysfunction (ed) in univariate analysis. age, whr, and bfp were independent predictive factors for moderate to severe ed in multivariate analysis (p< . , or . , % ci . - . ; p= . , or . , % ci . - . ; p= . , or . , % ci . - . , respectively). our data showed that erectile function in middle-aged men was closely associated with whr and bfp than with testosterone level and body muscle percentage. however, whr was identifi ed as a negative predictive factor for ed. further studies for the unique form of obesity pattern in korean men will be needed. in order to estimate the magnitude and outline the main components of adult male genital organs "dysmorphophobia" in greece, we surveyed the beliefs of men about parameters potentially aff ecting their sexual performance and activity as they relate with self-perceptions regarding adequacy of their external genitalia image. herein, we present preliminary results of this questionnaire based cross-sectional study. a specially designed self-administered questionnaire, consisting of demographic characteristics and main outcome measure questions aiming at defi ning whether and how beliefs regarding men's sexual image adequacy aff ect their sexual confi dence and function (answers scored - ), was fi lled in by males (aged - ) who consulted a single urology clinical setting, for symptoms unrelated to genital area pathology. statistical analysis was performed using spss- , p< . . results: th e majority of subjects ( . %) were highly satisfi ed of their sex organs image, while only one in seven ( . %) reported moderate to low levels of satisfaction. small penile size in the fl accid state was the most frequent ( . %) complaint followed by small erect penis dimensions ( %). in one out of two men ( . %), sex image inadequacy impression was based on self-assessment, in . % on sexual partner comments and in only . % on expert medical examination. nine out of ten men ( . %) considered external genitalia appearance the most signifi cant determinant of a man's sexual confi dence with . % believing they strongly fulfi l this requirement, while most of them ( . %) were highly satisfi ed with their whole body image. in only one in ten men ( . %) the impression of the sexual partner regarding sex image aff ects signifi cantly his sexual performance. most men ( . %) argued against resorting to surgical techniques to improve their sex image, % considered this option imperative for their well-being, while one in four ( . %) would consider surgery if a spectacular cosmetic result was guaranteed. various statistically signifi cant correlations between demographic and main outcome measures variables were recorded. conclusions: symptoms of genital organs dysmorphophobia, are expressed by one in seven men of the general population, in most cases complaints focus mainly at small penile size, while most frequently impression of inadequate sex image originates from self-assessment and negative sexual partner's comments. th e majority of men consider genital image a strong determining factor for sexual performance, while very few experience sexual relationships difficulties due to feelings of genital inadequacy. only a small minority of men would be strongly willing to undergo external genitalia surgery, which they consider imperative treatment for sexual image inadequacy. abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: metabolic syndrome is a public health problem associated with increased incidence of erectile dysfunction (ed). erectile dysfunction in patients with metabolic syndrome is diffi cult introduction and objective: erectile dysfunction (ed) and lower urinary tract symptom/ benign prostatic hyperplasia (luts/bph) has common pathophysiology. and phosphodiesterase type inhibitor (pde -i) partially reverses the prostatic tissue contraction, and increases cyclic guanosine monophos- phate to show antiproliferative eff ects in the prostatic smooth muscle cells and consequently, voiding symptoms were suggested to be improved. however, there was no defi nite mechanism of the eff ectiveness of pde -i on luts/bph. some previous study has reported the hypothesis which is pde -i improve the blood fl ow rate of prostate and it may improve the luts. in present study, by transrectal ultrasonography (trus), evaluated the change of blood fl ow rate of prostate aft er pde -i administration. materials and methods: total patients were included in this study. among enrolled patients, patients had once daily administrated mirodenafi l (mvix®, sk chemical, korea) mg for week, other patients had administrated placebo daily. peak systolic velocity (psv) and end diastolic velocity (edv) were estimated by trus at before medication and a day aft er last administration. results: baseline characteristics were no signifi cant diff erence between two groups. in mirodenafi l group showed . cm/sec increase of psv and placebo group showed . cm/sec increase of psv (p= . ). moreover, mirodenafi l group showed . cm/sec increase of edv and placebo group showed . cm/sec decrease of edv (p= . ). once daily administration of mirodenafi l mg showed improvement of blood fl ow rate of prostate. factors predicting outcomes of penile rehabilitation with udenafi l mg following radical prostatectomy introduction and objective: udenafi l is a selective phosphodiesterase type inhibitor (pde i) made available in recent years for the treatment of erectile dysfunction (ed). penile rehabilitation using pde is following radical prostatectomy (rp) has been advocated; however, there are no previous reports on the role of udenafi l for potency recovery aft er rp. herein, we evaluated independent predictors of potency recovery in rp patients who underwent penile rehabilitation with udenafi l mg. between january and december , a total of patients underwent rp at a single institute. among them, men were enrolled in a penile rehabilitation program using udenafi l mg every other day. uni-and multivariable cox regression analyses were used to determine independent predictive factors for potency recovery. results: th e overall potency rate was . % during the mean follow-up of . months. on the multivariate cox analyses, preoperative international index of erectile function (iief)- scores (hazard ratio [hr], . ; p = . ), alcohol consumption (hr, . ; p = . ), and gleason biopsy score (hr, . ; p = . ) were independent preoperative predictors for potency recovery. among post-rp variables, the use of robotic procedures (hr, . ; p = . ) and pathologic stage (hr, . ; p = . ) were significantly associated with potency recovery. conclusion: th is study identifi ed predictive factors for the recovery of potency in patients undergoing penile rehabilitation with udenafi l following rp. our results provide physicians with useful information for counseling rp patients and selecting optimal candidates for penile rehabilitation. introduction and objective: androgen replacement therapy (art) effi cacy on late-onset hypogonadism (loh) has been widely investigated in western countries; however, it remains controversial whether art can improve health and prolong active lifestyles. we prospectively assessed long-term art eff ects on the physical and mental statuses of aging men with loh in japan. of volunteers eligible patients > years with loh were randomly assigned to either the art (n= ) or the control groups (n= ). art was conducted with intramuscular injection of testosterone enanthate mg each time every four weeks up to times. th e primary endpoint was health-related quality of life assessed by questionnaires. secondary endpoints included glycemic control, lipid parameters, blood pressure, waist circumference, body mass index (bmi), body composition, muscular strength, bone mineral density (bmd), international prostate symptom scores (ipss), international index of erectile function (iief)- scores, and serum prostate-specifi c antigen levels. th e safety and tolerability of long-term art were also examined in these populations. results: fift y-two weeks aft er the initial treatment, art signifi cantly aff ected the role physical subdomain of the short form- health survey (sf- ) scale (p = . ). art was also associated with signifi cant decreases in waist circumstance (p = . ) and serum triglyceride (tg) (p = . ) and with signifi cant increases in whole-body and leg muscle mass volumes (p = . and . , respectively), serum hemoglobin (p < . ), ipss voiding subscore (p = . ), and the second question on iief- (p = . ). th ere was no signifi cant deference between the groups in terms of bmi, bmd, isometric handgrip strength, serum fasting blood sugar and hemoglobin a c, serum psa, and the incidence of sever adverse events. conclusion: long-term art for patients with loh have the benefi cial eff ects on role physical subdomain of the sf- scale, serum tg, waist circumstance, muscle mass volume, voiding subscore of ipss, and the second question of iief- . we hope our study will contribute to the future development of this area. introduction and objective: hyperoxaluria is characterised by a high urinary oxalate level. super-saturation of urine with oxalate will lead to nucleation, aggregation and the formation of calcium oxalate crystals leading to renal calculi. patients with hyperoxaluria are at increased risk of recurrent urolithiasis. objectives: to analysis the interventions and outcomes of new patients with enteric and dietary hyperoxaluria referred to a metabolic stone clinic. an analysis of patients with hyperoxaluria was performed. data examined included; age, sex, metabolic abnormalities, malabsorptive syndromes, previous treatments, stone composition, medical and life style interventions. all patients had or more hr collections of urine performed at median of months apart. twenty-four-month follow-up was performed to assess need of further stone treatment. results: a total of patients were identifi ed for study. twenty-fi ve were male, were female. th e median age is years, iqr ( - ). first median urinary oxalate level is . mm, iqr ( . - . ). patients that reduced their oxalate intake and increased their fl uid intake were signifi cantly less likely to need further long-term stone treatment. th e arr of increased urinary output and decreased urinary oxalate on the need for further stone surgery is th congress of the sociÉtÉ internationale d'urologie -siu abstract book . %, ci (- . - . ) . th e rrr for the need of stone surgery is . %, ci (- . - . ) . th e nnt to prevent one patient needed further stone treatment is . , ci ( . -- . ) . conclusion: hyperoxaluria is important cause of recurrent stone formation that requires management in a dedicated metabolic stone clinic. compliance with fl uid, dietary and medical management is limited. in compliant patients, urine parameters and stone recurrence rates can be altered. clinical using specifi c diagnosis codes from billing data, patients were identifi ed that met criteria for urosepsis secondary to an obstructive ureteral calculi. data was analyzed in the following areas: demographics, admitting hospital of origin, duration of admission before transfer, need for higher level of care, need for invasive procedures, and length of hospital stay. results: using the screening criteria patients were identifi ed. th e average age was ; % were female versus % male. patients transferred from an outside hospital made up % of the patients and overall hospital admission lasted . days. of the patients transferred % went to the icu for an average duration of . days. of the transferred patients % needed vasopressor/ionotropic therapy, and % required intubation. overall, over % needed urologic intervention; % had ureteral stent placement and % underwent nephrostomy tube placement. patients admitted from the ed made up % of the patients and had an average admission of . days. of these patients % went to the icu for an average of . days. only % and % needed vasopressor/ionotropic therapy and intubation respectively. also, % had ureteral stent placement and only % had a nephrostomy tube placed. conclusion: urospesis in the setting of an obstructive ureteral stone is a medical emergency that merits urgent relief of the obstruction. once this condition is identifi ed, any facility without the resources for prompt intervention should transfer these patients immediately to a center with these capabilities. th is is supported by our data, as transferred patients on average had a longer icu and hospital stay, and needed more aggressive interventions. clinical signifi cance of ureteral wall thickness adjacent to the stone in abdomen-pelvis ct in the patients treated with extracorporeal shock wave lithotripsy park m, yeo j, cho d introduction and objective: although, ivp was standard diagnostic tool for years, the use of abdomen-pelvis ct (apct) without contrast, particularly in an acute setting, is becoming increasingly common. th is study was planned to know the clinical signifi cance of ureteral wall thickness adjacent to the stone in apct in the patients treated with extracorporeal shock wave lithotripsy (eswl). : th e data of patients who took ap-ct to diagnose ureter stone and were treated with eswl was reviewed. aft er maximum zoom of the ap-ct image showing the longest diameter of stone, the ureteral wall thickness adjacent to the stone was measured by same physician. th e baseline characteristics of patients, the parameters related to ureter stone and effi cacy of eswl were investigated. th e correlation between ureteral wall thickness and those parameters was statistically analyzed. th en, the patients were divided into two groups by the median value of ureteral wall thickness and the diff erence of those parameters between two groups was also investigated. additionally, cut-off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was determined. in simple correlation analysis, bmi, stone length at kub, stone diameter in ct, number of eswl, and time to stone removal showed signifi cant positive correlation with ureteral wall thickness. th e median value of ureteral wall thickness was . mm and the patients were divided into two groups. in comparison of baseline characteristics between two groups, group ii showed more incidence of pyuria than group i and stone burden at kub and ct also showed statistical diff erence between two groups. in comparison of effi cacy of eswl, group ii showed more number of eswl and longer time to stone removal than group i. th e cut off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was . mm. conclusions: in addition to actual size of stone, ureteral wall thickness of ct also aff ects the treatment effi cacy of eswl. especially, the ureteral wall thickness greater than . mm has an impact on the results of the eswl. the introduction and objective: th e treatment of large volume bladder stones by current equipment continues to be a management problem in both developing and developed countries. ah- stone removal system (srs) invented by us is primarily used to crush and retrieve bladder stones. th is study evaluated the safety and effi ciency of transurethral cystolitholapaxy with srs to treat the large volume bladder stone. materials and methods: srs, which was invented by aihua li in , composed by endoscope, continuous-fl ow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. a total of patients with bladder stones were performed by transurethral cystolitholapaxy with srs since . th ese patients were divided into four groups by the stone size. fift y nine patients with stone size < cm were in group a, patients with stone size from to . cm were in group b, patients with stone size from to . cm were in group c, and patients with stone size ≥ cm were in group d and the largest stone was . cm. results: characteristics of patients and stone removal time in variable size were evaluated. to patients with single stone, stone size was . ± . cm and the operating time was . ± . min in group a. stone introduction and objective: eswl has emerged as a primary modality of treatment for solitary renal calculi in modern era. th e size of calculus is a major factor for consideration before subjecting a patient to eswl procedure. stone size less than two centimetre is considered ideal for eswl. other factors like obesity, position of calculus, renal infundibular anatomy and stone composition etc. also determine clearance rates. given a choice patients in india still prefer one time clearance by pcnl than multiple eswl sittings for similar sized calculus. our study reiterates the benefi ts of eswl in developing world with multivariate data supporting it. th e objective of this study was to evaluate the feasibility and safety of minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus aft er radical cystectomy urinary diversion. a total of patients underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy from january to august . th ere were cases that were diagnosed urinary stones aft er bricker urinary diversion of radical cystectomy, case of studer orthotopic ileal neobladder, and case of cutaneous ureterostomy. th ere were cases with left side calculi and cases with right side ones, including renal calculus, ureteral calculus and ureterointestinal anastomotic calculus. th e upper urethral calculi were identifi ed by urinary tract ultrasound and the multiplanar ct. all of cases underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy. th e ureteral stent was indwelled for weeks routinely. th e kidney ureter and bladder x-ray or a ct scan was examined weeks aft er the procedure to evaluate the clinical outcomes. any residual calculus larger than mm was taken as signifi cant. results: th e combined lithotripsy was carried out successfully in all the cases. th e mean operative time was ( ± . ) min. th e nephrostomic catheter was removed days aft er the surgery. th e average blood loss was less than ml. no residual calculus was found during the weeks' follow-up. th e average follow-up was months. one case had recurrent calculus months aft er the fi rst procedure, which was successfully managed by the fl exible ureteroscopy again. minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus secondary to urinary diversion aft er radical cystectomy is technically feasible introduction and objective: th e main goal of any intervention for urolithiasis is complete stone removal in order to achieve a stone free status. complete stone removal assures resolution of the immediate adverse outcomes of the stone disease, and prevents possible long-term complications such as pain, obstruction and stone growth. percutaneous nephrolithotomy is an eff ective procedure which is being considered as the gold standard in the treatment of large/complex renal calculi. reported stone free rates are up to %, probably refl ecting the level of experience, stone properties and equipment employed in the procedure. it is well established that higher incidence of residual fragments increases the complication rates and needs further interventions. th e main reason for failure of complete radiolucent stone clearance is inability to visualize the residual stones either by nephroscope or by fl uoroscopy. th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, will help to increase stone free rate. materials and methods: between sept. and sept. intraoperative ultrasound was used in cases of large complex radiolucent renal stones. results: it showed stone free rate % in patients, false negative in patients ( %) and there was diffi cult scanning in patients ( %). conclusions: th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, it will help to increase stone free rate. intravenous acetaminophen decreases sedation requirements during extracorporeal shockwave lithotripsy conclusion: th ere is benefi t in pre-operative administration of intravenous acetaminophen in reducing the dose requirements of sedative analgesic for satisfactory pain control during the procedure of swl under conscious sedation. introduction and objective: while most of the bleeding associated with pcnl can be managed conservatively, few need angioembolisation. th ere are diff erent technical methods of embolisation with risk of varying degree of parenchymal damage. we present case of ultrasonography guided embolisation. materials and methods: right lower calyx pcnl was performed successfully in year female with mm renal stone in solitary kidney. she came back on th postoperative day with gross hematuria, with cm by cm clot in renal pelvis and mm arterio-venous fi stula at pcnl puncture site. patient was managed with iv higher antibiotics, strict bed rest, blood transfusion and iv tranexamic acid. but her renal function deteriorated (creatinine- . mg/dl). one haemodialysis was done and patient was explored by sub costal approach, with idea of removal of blood clots and suture ligation of av fi stula. renal pelvis was opened and clots were removed. during operation av fi stula was located with doppler usg and deep suture by - vicryl was attempted to close av fi stula, but due to oedematous kidney suture closure was not possible. so under usg guidance gauze lumber puncture needle was inserted into av fi stula, its position was confi rmed by saline jet on real time usg and cc histoacryl tissue adhesive (monomeric n-butyl- -cyanoacrylate) was injected into av fi stula. intraoperative embolisation of av fi stula was confi rmed by colour doppler. results: renal functions became normal in hours and patient was discharged on th postoperative day. aft er days ivp was done which demonstrated normally excreting whole kidney, showing successful superselective embolisation in solitary kidney. conclusions: usg guided procedure avoids the side eff ects of contrast media in case of acute renal failure. it avoids hazards of radiation and complications of angiographic catheterisation. th e main importance of this procedure is preserving maximum renal tissue, especially in case of renal insuffi ciency and in solitary kidney. th is procedure gives a new vision to do percutaneous usg guided embolisation by thin gauze needle without need of angiography, iv contrast, radiation and minimum morbidity. ultrasound th ree pregnant women in the th, th and th week of pregnancy presented with a symptomatic large renal stone in the fi rst and multiple renal stones in the second and third which were unresponsive to conventional medical therapy. th ey required defi nitive stone treatment. th e operations were done in nov , jun and feb . data was gathered prospectively. all steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and amplatz sheath placement were performed under ultrasonography guidance. tract was dilated with single shot technique. th e fi rst two procedures were performed in supine position and the third procedure was performed in lateral fl ank position. results: two patients were stone-free postoperatively and one patient had only an asymptomatic mm residual stone. th ey were discharged on the nd postoperative day and had an uneventful postoperative course. no fever, bleeding or renal colic was noticed during postoperative hospitalization. th e fi rst two patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist aft er their birth. th e third patient was followed until week of pregnancy without any obstetric complication. conclusion: ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. supine or fl ank ultrasound guided percutaneous nephrolithotomy can be off ered to pregnant women in whom conservative measures fail to the patient's well-being. introduction and objective: acute ureteral obstruction in pregnancy may result in severe pain, hematuria and serious complications like upper urinary track infection with consecutive sepsis. th e ureteral stenting has been usual in recent years. we evaluated the usefulness of ureteral stenting for ureteral obstruction with symptoms in pregnancy. fift y-three pregnant women participated in this study. abdominal ultrasonography, serum creatinine levels, white blood cell (wbc) counts, urinalysis and urine culture were done in all patients. of these pregnant women, women were treated by ureteral stenting because of not improving with conservative management (positioning, analgesia, antibiotics, etc.). th ey were completely followed-up to removal of ureteral stent. results: of these pregnant women, women who were treated by ureteral stenting, experienced signifi cant relief of pain at least for days. in abdominal ultrasound, patients ( %) had resolution of hydronephrosis. twelve of patients ( %) continued to have problems post-therapeutically irritative voiding symptoms with dysuria, urgency, frequency, and hematuria, but patients experienced relief of symptoms for days. a patient was taken remove of stent due to continuous complaint irritative voiding symptoms. aft er delivery, patients were taken ivp. of patients, were normal fi nding with ivp. four patients were diagnosed ureter stone (upper , mid , lower ). th ree patients were treated by extracoporeal shock-wave lithotripsy for the stone in upper and lower urinary tract. a patient was treated ureteroscopic lithotripsy. conclusions: since the ureteral stents were usually placed without any major problems and well tolerated with only minor and short post-therapeutic discomfort. we concluded that the ureteral stenting was a simple, safe and eff ective method of internal upper tract drainage in case of symptomatic ureteral obstruction during pregnancy. safety introduction and objective: to evaluate objective and subjective outcomes of retrograde intrarenal surgery (rirs) for the treatment of radiopaque - mm renal calculi. a retrospective analysis was performed for patients who underwent rirs to treat renal calculi sized with - mm between april and december . operative and postoperative data were collected for each patient such as stone burden, stone location, number of sessions, and auxiliary procedures. th e term of follow-up was one year at least. surgery was usually performed under general anaesthesia. flexible ureteroscopy with ureteral access sheath and holmium-yag laser were employed. patients were evaluated with simple radiography, abdominal ultrasonography, or ct without contrast. surgery success was determined as stone free rate (sfr) at three months aft er last session. re-treatment rates were also calculated. results: mean age was . ± . years old. th e highest-frequency location was pelvis ( %). single stones were described in % of patients although multiple urolithiasis were detected in the %, mainly located in the lower calyceal. average surgery time was . ± . min. th e auxiliary procedure rate and the re-treatment rate were . % and . %, respectively. th e overall sfr and sfr aft er a single session were . % and . %, respectively. although no serious complications were noted in all of patients (above clavien-dindo classifi cation level iii), clavien level i to ii complications were identifi ed in two-patients ( . %). all these patients were successfully treated conservatively. conclusion: our fi nding suggest that rirs represents a valuable treatment option of - mm radiopaque renal calculi for selected patients. rirs would be also a good therapeutic alternative to extracorporeal shock wave lithotripsy (eswl) and percutaneous nephrolithotomy (pnl). rirs should be considered as fi rst line treatment. prospective analysis is required to be corroborated these fi ndings. ureteroscopic lithotripsy for extremely old patients yoshioka t , uehara s , otsuki h , shimizu t , murao w , fujio k , kikuchi h , fujio k , wada k , araki m , ebara s , watanabe t , nasu y introduction and objective: one of the biggest problems in st century is an aging society. in , the number of old people (≥ years old) in japan was , , . th at is about % of all japanese population. japanese society is becoming not an "aging" society, but an "aged" society, and we have to prepare for this society. on the other hand, upper urinary stone is a common disease, and oft en occurs not only young people but also aged people. however, there are no standard treatments for aged patients of upper urinary stones, especially extremely old patients who are more than years old. in this study, we investigate the safety and effi cacy of ureteroscopic lithotripsy of upper urinary calculi for these patients. between january and october , ureteroscopic lithotripsy (urs) underwent in abiko toho hospital. of these cases, cases are for the extremely old patients (≥ years old). we retrospectively reviewed gender, age, body mass index (bmi), american society of anesthesiology (asa) physical score, stone size, reasons for operation (whether symptomatic or not), operative duration, and stone free rate (sfr) of all cases. all data were reviewed by one urologist, and asa physical scores were evaluated by one anesthesiologist. results: all cases were bedridden female. mean age was . (range to ), bmi was . kg/ m^ (range . to . ), asa physical score was . (range to ). cases had preoperative complicated pyelonephritis, and out of these cases were indwelled preoperative unilateral ureteral catheters. mean stone size was . mm (range . to . ), and operative duration was . minutes (range to ). postoperative complication was pyelonephritis (clavien grade ), and sfr was % ( / cases). in all cases, postoperative unilateral ureteral catheters were indwelled, and were withdrawn weeks later. th ere have been no recurrent stones and/or pyelonephritis (median observation time: . months). conclusion: although sfr was low, urs for extremely old patients can prevent recurrent complicated pyelonephritis even on infected stones. th ere were . % of patients who had a single urinary stone and . % (n = ) had or more. one hundred and nine stones were treated. sixty-three percent of stones were intrarenal. th ere were ( . %) postoperative complications: two stage clavien classifi cation infections (prostatitis at day and two pyelonephritis hours aft er the procedure); three stage b complications (two renal colics requiring ureteral stenting hours aft er discharge and symptomatic perirenal urinoma hours aft er discharge). th ere was one intraoperative complication ( . %): a ureteral wound with contrast leakage. th e rate of transfer to conventional hospitalization was . %. stone size infl uenced the stone-free status and the need for more than one sessions (p < . ). th ere was a signifi cant correlation between operative time and stone size above mm (p= . ). conclusions: flexible and rigid ureteroscopy are safe and effi cient procedures for upper urinary tract stones, and can easily be carried out in an outpatient introduction and objective: renal stone disease is one of commonest urological disorders. pakistan is located in stone belt region with high incidence of urolithiasis. th ere have been innovations and improvement in stone treatment modalities. eswl is one of them. here we share experience of single centre in terms of stone free rate and effi cacy in adults. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. number of shocks per session for kidney and for ureter. energy level for kidney is set at and for ureter at . rate of shock wave delivery is shocks/minute. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: yolk-sac tumor (yst) is formed almost % germ cell tumors of infant and children. yst is the most common type of testis tumors in prepubertal period, but adult pure yst is extremely rare. in this case we aim to share our surgical experience with an adult pure yst in the right testis. a year-old man was referred to our clinic from cardiovascular surgery department for right testicular mass which is detected during the evaluation of his deep vein thrombosis. th e patient stated having a slowly progressive increase in size of his right gonad. th ere is no history about testicular trauma or epididymoorchitis. physical examination revealed a painful right testis which was uniformly increased in size and presented a smooth surface. usg showed a volumetric increase in the right testis. mass size was detected as . x . x cm, which was characterized by cystic components in heterogeneous echogenicity. serum chemistry revealed a marked increase in afp while β-hcg and ldh levels were within the normal limits. results: a right radical inguinal orchiectomy was performed. during the orchiectomy, because of the invasion to scrotum skin, scrotum skin was removed. th e surgical specimen was rigid, its surface was smooth and necrotic areas were observed ( figure ). pathologic examination revealed a pure yst with positive spermatic cord, tunica albugea, tunica vaginalis and scrotum skin invasion and in light microscopy tumor cells with large hyperchromatic nuclei arranging concentrically around a small vessel were seen (schiller-duval or glomeruloid body). metastasis of lung adenocarcinoma to the testis is an extremely rare occurrence and very few cases have been reported to date. th e authors aim to review the current literature in regard to incidence, clinical manifestation, sources of primary tumour and mechanism of metastasis, in addition to retrospective ten year review of testicular pathology at a single institution. we report an unusual case of a -year-old non-smoking australian gentleman who presented with a six month history of cough and dyspnoea. a physical examination, complete laboratory and radiological work up was performed. a palpable left testicular mass was identifi ed, ct scan revealed multiple bilateral lung nodules and mediastinal lymphadenopathy, however testicular tumour markers were negative. th e patient underwent a radical left inguinal orchidectomy and endobronchial hilar lymph node biopsy with bronchial washings. medical records and pathology results for patients undergoing radical orchidectomy over the past ten years at our institution were obtained and analysed. results: histopathological examination of the left testis and lung biopsy revealed features of a moderately to poorly diff erentiated adenocarcinoma, with morphological and immunohistochemical appearances consistent with lung origin. th e prognosis is extremely poor. a total of patients underwent radical orchidectomy at our institution between january and february . th e mean patient age was ( - ). histopathology is summarised in table . cur-up. , figure . th congress of the sociÉtÉ internationale d'urologie -siu abstract book rent literature review confi rms testicular metastases are rare and may be discovered incidentally at autopsy or following diagnostic orchidectomy. autopsy series revealed testicular metastases in . to . % of specimens. th e most common primaries, excluding lymphoma and leukaemia, include prostate, melanoma, sarcoma, gastrointestinal tract, kidney and lung, with most testicular metastases being a fi nal manifestation of widespread tumours. conclusions: testicular metastases from lung adenocarcinoma origin are scarcely encountered in clinical practice and may create a diagnostic dilemma by mimicking primary testicular neoplasms. extensive pathologic evaluation and specifi c immunohistochemical staining is essential. in patients presenting with a testicular mass, the diff erential diagnosis must include metastatic carcinoma. by . on average compared to only . by non-users (p= . ). many of these fi ndings were only present with recent vge; heavy users from high school and middle school did not show similar trends (table ; figure ). conclusion: th is study shows that subjects with heavy vge perform better on the da vinci skills simulator than subjects who report no vge. th e improvements seen with recent vge are not apparent if stratifying for frequency of use during high school and middle school. th ese fi ndings may have important implications for the future of surgical training. 'virtual urology clinic': a feasibility study in a busy uk teaching hospital introduction and objective: urology is an advancing surgical specialty with a parallel increase in demands from health service commissioners to meet national targets and patients' needs. th is has been refl ected on the outpatient urology service with a rising burden and delays in patients' outpatients' assessments. in our busy tertiary unit, we estimated a total of overdue outpatient appointment (by months or more). th us we designed this virtual clinic feasibility study aiming to: prioritise patients according to their clini- cal needs, enhance their care and decrease the burden by assigning patients to our novel computer based follow-up models. we used the hospital information system to identify one urologist overdue appointments (by months or more). all included cases had thorough review of their medical notes, investigations and treatment before being stratifi ed according to their diagnosis then assigned one of outcomes: urology, cancer nurse specialist (cns) and gp follow-up. results: a total of cases were reviewed in this virtual clinic over a period equivalent to full working days. even though they were all waiting to see one urology cancer surgeon, only % had a primary diagnosis of cancer with the rest being diagnosed with a benign urological condition. th e clinical investigator recommended for only % of all patients to have a urology follow-up with % and % discharged to the gp and computer based follow-up respectively. all patients received a letter explaining the procedure of this clinic along with a tailored management plan. th ere was an evident gap between the dynamic changes in service provision with new available tools and our current practice. th is virtual clinic allowed bridging this gap by categorising the urological priorities and utilising existing resources such as our novel computer based follow-up models. over the last year more than patients' visits have been registered on our computer based clinic which is potentially a cost eff ective model. patients' perspectives of accessibility introduction and objective: patients undergoing major lower abdo/pelvic operations are oft en catheterised (idc) at the start of the procedure to monitor urine output and decompress the bladder to avoid bladder injury. early removal of urinary catheters aft er surgery has been associated with a decrease in urinary tract infections though increasing failure of trial of void (tov), thus being discharged with idc or prolonged admissions. th e aim of this study is to determine the optimal time for tov. th is is a retrospective study looking at patients undergoing abdominal or pelvic procedures due to colorectal/pelvic pathology in the townsville base hospital surgical unit from jan -dec . pre-procedure idc and the deceased were excluded. data was collected from the operating theatre database (ormis). results: out of the total, were female while male, abdominal and pelvic procedures. sixteen male patients had documented prostatic history which include bph, prostate cancer and prostatitis post radiation. four were discharged with an idc failing tov. fift y-seven percent of the patients had their catheters removed on day post-op; . % on day , % on day , . % on day and % > days. th ree patients developed a urinary tract infec-tion (uti) ( . %). patients with good pre morbid function and female tend to pass their trial of void on day post op for pelvic procedures. th e majority of patients had comorbidities and failed tov on day . th ere was no signifi cant diff erence between day and day in uti rates (increasing day onwards). conclusions: idc's should be removed in a timely manner to reduce complications, balanced with monitoring fl uid balance. we proposed that patients should have tov on day , due to increased rates of failed tov day in patients with comorbidities and no diff erence in uti rates between days and . th e limitation of this study is the lack of documentation of preoperative urinary function. to further this study, we can analyse the data to state diff erences between bladder dysfunction as well as tov in groups with various comorbidities. international urology journal club on twitter: a growing educational forum introduction and objective: urologists use urinary and thoracostomy drainage collection systems regularly. pleural and urine fl uid pools at the bottom of dependent loops of both thoracostomy and urinary drainage tubing systems, respectively. we hypothesized that fl uid pooled in a dependent loop ) diminishes the expected negative pressure-head delivered to the pleural space by a chest-tube, and ) obstructs antegrade catheterized urine drainage. we created an ex-vivo thocacostomy tube model, and, performed two separate clinical trials to test our hypothesis. a pleur-evac chest drainage system was connected to - cmh o wall-suction. a digital pressure transducer was connected to the drainage tubing close to the insertion of connection to a chest-tube. model: to simulate dependent loops observed in hospital patients, we created , , and cm-high dependent loops (distance between the bottom of loop and the highest-point en-route to the drainage box). th e pressure close to the (blind-ending) chest-tube was measured as the drainage tube was fi lled in ml. increments. fitted linear regression of pressure and loop-height was performed. clinical trials # . pressure within the drainage tube was measured in six icu patients with thoracostomy tubes in place following cabg surgery. clinical trial # : we performed early-morning hospital icu bedside bladder-scan us on patients with an indwelling urinary catheter and clear urine, to assess for un-drained residual urine. results: with an empty dependent loop, thoracostomy tube pressure equaled the suction pressure (- cm h o). pooled of fl uid within the dependent loop diminished proximal negative pressure (p< . ) in a volume (i.e. loop-height) dependent fashion. th e net range of proximal drainage tube pressure ranged from - to + cmh o. in icu patients, an identical relationship between loops and chest-tube pressure was observed. bladder scan of catheterized ward patients revealed high urine residuals (mean ml) with a dependent loop present, and ~zero residual when no loop present. conclusions: th oracostomy-tube negative-pressure is steadily diminished as a dependent loop fi lls with fl uid. th e resulting air-lock opposes antegrade drainage. th e weight of the fl uid column accounts for positive thoracic pressures, and could account for why many patients fail water seal trials. similarly, urinary tubing dependent-loops result in air-locks that prevent gravity dependent drainage. th oracostomy and urinary drainage tubing should always be positioned without dependent loops. single incision mid-urethral sling (miniarctm) and tension-free vaginal tape (tvt) procedure in women with stress urinary incontinence (sui) at months. a total women with sui were randomized to receive miniarc and tvt. th e primary outcomes were objective and subjective cure rates at a -month follow-up visit. objective and subjective cure of sui were defi ned as a negative cough stress test and absence of self-reported sui symptoms. cure rates of the two groups were compared at -month follow-up. results: a total of ( %) of women originally included in the study (miniarc: , tvt: ) were evaluated at -month follow-up. th ere were no signifi cant diff erences found in demographic and clinical preoperative parameters. objective cure rates for miniarc and tvt groups were % and % while subjective cure rates were % and %. th ere was no statistically signifi cant diff erence between groups (p> . ). conclusions: our -month randomized clinical trial showed that miniarc single incision sling is not inferior to tvt procedure with respect to objective and subjective cures at -month follow-up. introduction and objective: male sui is a debilitating and challenging problem to manage. insertion of transobturator sling off ers less invasive treatment than aus insertion. published data demonstrate cure rates of % but are limited by short follow-up. th e aim of our study was to report long-term outcomes for male transobturator slings for sui with a mean year (minimum year) follow-up. a single-centre retrospective audit of outcomes in male patients who underwent transobturator sling insertion for sui. follow-up was conducted via telephone or in outpatient clinic. incontinence was classifi ed as mild (≤ pads/day), moderate ( - pads/day) or severe (≥ pads/day). classifications post-surgery were: cured -dry; improved -≤ pads/day and ≥ % less pad use; failure -no change or worsened. results: in patients with mild/moderate incontinence, / patients (= . %) were cured/improved with tot. success rates were poor in severely incontinent patients, regardless of radiotherapy history ( %; n= ). of 'cured'/'improved' patients, ( . %) maintained that degree of continence for the duration of follow-up. one patient was lost to follow-up. th ree patients reported a later decline in continence; patients had had previous pelvic radiotherapy. one patient had progression of underlying prostate cancer. conclusion: durable success rates of . % are achievable in men with mild/moderate sui who have not had pelvic radiotherapy. pelvic radiotherapy may play a role in delayed failure of tots with % of patients with mild/moderate sui who were initially cured/improved declining in the second or third year aft er surgery. the mesh wallstent (urolume) in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury dept. of surgery, div. of urology, king saud university faculty of medicine, riyadh, saudi arabia introduction and objective: to evaluate the longterm effi cacy and safety of the urolume stent for the treatment of detrusor sphincter dyssynergia (dsd) in spinal cord injured (sci) patients. twenty-four spinal cord injured patients with neurogenic bladder and dsd associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (vcmg) were retrospectively reviewed. twenty-one patients had cervical level injury whilst had a thoracic injury. eleven patients were on clean intermittent catheterization (cic) and with indwelling foley's catheter. all patients underwent urolume stent insertion according to standardized protocol. follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months aft er insertion, and a follow-up vcmg at six months. residual urine volume, autonomic dysrefl exia, catheter need, and presence of bladder stones and hydronephrosis were compared before and aft er treatment. post-operative patient and physician satisfaction, complications and re-obstruction rates were also analyzed. paired t-test is used and p value < . was taken as signifi cant. results: th e twenty-four patients had a mean (range) follow-up of . ( . - ) years. th e mean age was introduction and objective: at present, sacral neuromodulation (snm) with interstim® therapy is indicated for non obstructive urinary retention and overactive bladder, including urinary urge incontinence and signifi cant symptoms of urgency-frequency alone or in combination, in subjects who have failed or could not tolerate more conservative treatments and do not have any neurological disorder. th ere are also reports of the use of interstim® in the treatment of chronic pelvic pain and other conditions. we report our experience with the use of this device in patients with post-traumatic brain injury damage without anatomical anomalies and with severe urinary voiding dysfunction who had failed intensive medical and behavioral therapies. materials and methods: from november to november , patients underwent interstim® placement ( male and female). all had severe voiding dysfunction secondary to post-traumatic brain injury damage; ten of them had also defecatory disturbances ( a chronic constipation and fecal incontinence). th e main goal was to evaluate the improvement of the urinary symptoms and the second goal the improvement of the intestinal symptoms. success was defi ned as a ≥ % improvement in any of the two variables evaluated. results: with a mean follow-up of months, / patients reported ≥ % improvement in their urinary voiding symptoms ( %), in these patients urinary frequency decreased from to episodes per day, mean voided volume increased from cc to cc, incontinence disappeared in of patients and urgency disappeared in all patients. of patients with intestinal disturbances, showed a signifi cant improvement ( %). one patient showed a clavien iii complication (seroma and partial dehiscence of the surgical wound managed with conservative surgical treatment). conclusion: snm in post-traumatic brain injury patients is an eff ective and safe option for urinary and defecatory dysfunction when other conservative therapies have failed. to our knowledge the use of inters-tim® in this scenario has not been reported previously. a larger series and a longer follow-up are needed to validate this indication. introduction and objective: th ere were some reports that in the patients who have stress incontinence (sui) with detrusor underactivity, voiding symptoms aggravated aft er mid-urethral sling operation (mus). we report our experiences of mus cases on the patients who have sui with detrusor underactivity. conclusion: urethral sphincter and bladder function worsen immediately aft er rarp and recover over time. th e bladder storage function aft er rarp returns to almost the same level before rarp, the voiding function improves compared with the condition inserted into the rabbit bladder through the urethra and saline solution is infused using a disposable syringe into the bladder through the end cap. conventional cystometry was performed and the intravesical pressure was measured by prototype intravesical pressure sensor at the same time. we also evaluated the biocompatibility of ecofl ex® by checking changes in the levels of macrophages, macrophage migratory inhibitory factor, and infl ammatory cytokines in the bladder tissue and urine. cape town, south africa th congress of the sociÉtÉ internationale d'urologie -siu abstract book and urgency incontinence are signifi cantly detected luts in children with vur the -gene genomic prostate score assay: initial commercial experience of , patients th congress of the sociÉtÉ internationale d'urologie -siu abstract book th congress of the sociÉtÉ internationale d'urologie -siu abstract book pelvic strength physiotherapy percutaneous treatment of bladder stones in children: -year experience; is blind access safe? extirpative treatment of upper urinary tract urothelial carcinoma: an -year comprehensive review paik l th e overall complication rate was %. no hydronephrosis were seen thought the follow-up period. stricture rate was low, only one patient ( %) at one year, and none at years had urethral stricture. patients ( %) required re-stenting due to stent migration ( patients, %), or stricture ( patient, %), all of which happened during the fi rst year of surgery. patients ( %) required alpha-blockers to control bladder neck dyssynergia post operatively. stents ( %) were removed due to exacerbation of autonomic dysrefl exia symptoms (n = ); encrustation and stone formation (n = ). overall, % of patients and % of physicians felt there was improvement in urination at year. conclusions: th e treatment of detrusor sphincter dyssynergia in spinal cord injured patients with urolome stent is safe and eff ective sacral neuromodulation with interstim® therapy for urinary voiding dysfunctions in post-traumatic brain injury patients: a new therapeutic indication? hospital pablo tobon uribe, medellin, colombia th congress of the sociÉtÉ internationale d'urologie -siu abstract book between pre-and post-operative qmax abstract book before rarp; however, the urethral sphincter func male ( . %) ( %) . ** introduction and objective: we evaluated the clinical eff ect of alternative fl utamide therapy for metastatic prostate cancer that relapsed aft er initial maximum androgen blockade (mab), and investigated the relationship between the eff ectiveness of alternative fl utamide therapy and the eff ectiveness of initial mab. and december , patients with metastatic prostate cancer that relapsed aft er initial surgical or medical castration along with bicalutamide for mab were treated with fl utamide therapy ( mg daily). importantly, patients who had discontinued bicalutamide because of adverse events were excluded.results: of the patients treated with alternative fl utamide therapy, prostate-specifi c antigen (psa) levels decreased by > % (group a) in patients ( %), by - % (group b) in patients ( %), and by - % (group c) in patients ( %), but increased by > % in patients ( %). th e median duration of response was . , . , and . months for groups a, b and c, respectively. th e duration of response for patients ( %) was more than months. aft er alternative fl utamide therapy, decreased psa levels of > % were achieved in of patients ( %) with mab nadir psa levels of < . ng/ ml, in of patients ( %) with mab nadir psa levels of . to ng/ml, and in of patients ( %) with mab nadir psa levels of > ng/ml. during the observation period there were no severe side eff ects.conclusion: approximately % of patients with metastatic prostate cancer who relapsed aft er mab with bicalutamide achieved a decrease in their psa level with no severe side eff ects. th e nadir psa level during mab, however, was not a predictor for the eff ectiveness of alternative fl utamide therapy. th us, alternative fl utamide therapy is a reasonable treatment option for metastatic castration resistant prostate cancer. nevertheless, changing to another therapy should be considered in patients who achieve decreases in psa levels of < % with alternative fl utamide therapy, as the duration of response was relatively short in these patients. association of renal function and androgen deprivation therapy with prostate cancermasuda h, kanesaka m, sugiura m, hou k, araki k, kojima s, naya y introduction and objective: we evaluated the change of renal function by androgen deprivation therapy (adt) and examined the association of the occurrence of renal dysfunction and concomitant diseases. between january and april , patients who could measure estimated glomerular fi ltration rate (egfr) at pretreatment, , and months were evaluated retrospectively. all of them were diagnosed prostate cancer by prostate biopsy pathologically and had taken adt for at least months. we assessed the renal function of prostate cancer patients by using the egfr and investigated the time-independent change rate of the egfr (Δegfr) aft er adt. th e Δegfr was calculated by (post treatment egfr-pretreatment egfr)/pretreatment egfr × ). univariate and multivariate logistic analyses were carried out to identify clinical covariates signifi cantly associated with the risk factors for renal dysfunction at months later.results: th e incidence of the renal dysfunction at months was % ( / ). th e mean Δegfr at , , months were - . %, - . % and - . %, respectively (p= . ). th e incidence of the renal dysfunction at months was signifi cantly associated with the renal dysfunction at month (p< . ), at months (p< . ), hypertension (p= . ) and dyslipidemia (p= . ). th e renal dysfunction at pretreatment with adt did not aff ect the renal function months later (p= . ). th e renal dysfunction at months (odds ratio [or] . , p= . ), renal dysfunction at months ([or] . , p= . ), hypertension ([or] . , p= . ) and hyperlipidemia ([or] . , p= . ) were independent predictors of the renal dysfunction at months in the multivariate analysis.conclusions: it was suggested that the renal dysfunction with adt occurred relatively early. th e earlier renal dysfunction may cause the renal dysfunction at months later. so, when the treatment of adt began, it was thought that an examination of periodical renal function was necessary. th e present results suggested that it was necessary to control the blood pressure and lipid for receiving adt with prostate cancer. immune (pc) and isolated lymph node metastases aft er curative therapy are usually treated with an anti-androgen therapy. th e choline pet-ct is the method of choice in diagnostic of the recurrent psa. controver-sial in the latest debate is the oncological eff ectiveness of the local salvage therapy of isolated lymph node metastases. th e aim of this study is to compare the oncologic outcome of the salvage lymphadenectomy (la) alone versus the la in combination with adjuvant radiotherapy (ar) and androgen deprivation therapy (adt).materials and methods: th erefore we randomized patients with biochemical recurrence of a pc (psa: ≥ , ng/ml) aft er curative local therapy and detection of at least one lymph node metastasis. we applied two treatment arms. a (n= ): single la; b (n= ): la plus ar/adt (bicalutamide) over years. we determined the biochemical recurrence-free survival (bfs) and the time-to-treat (ttt) until complete androgen blockade. conclusion: compared for both treatment arms, the combination of la plus adt/ar is superior to la alone. however, both methods are to be seen as individual decisions in highly selected patients. th e oncological long-term eff ectiveness is questionable. stem cell transformation of prostatic cells after hormonal therapy we reviewed consecutive patients who underwent transperineal mri-trus fusion target biopsy followed by conventional transrectal systematic core biopsy between july and mar in our institution. in all patients, t low region was detected by prostate mri image and target biopsy was conducted for region of interest (roi) of the mri image utilizing biojet system. baseline characteristics and pathological outcome were analyzed.results: in analyzed cohort, mean age was . ± . years, median initial psa was . ng/ml (range, . - . ), median prostate volume (pv) was . ml (range, . - . ) , and median volume of roi was . ml (range . - . ). of patients, prostate cancer was detected in ( %) patients by target biopsy and ( %) patients by systematic biopsy. patients with positive biopsy was likely to be higher psa than men with negative biopsy (p= . ). median roi/pv was not signifi cant between them ( . vs. . : positive vs. negative, p= . ). cancer detection rates per core between target and systematic biopsy were . and . %, respectively (p= . ).regarding pathological results, mean gleason score of target biopsy was . compared with . of systematic biopsy, although which is not statistically signifi cant (p= . ).conclusion: mri-trus fusion target biopsy is gradually spreading in japan, since its higher cancer detection rate compared with conventional systematic biopsy. in our institution, substantial detection ability of prostate cancer by mri-trus fusion target biopsy was confi rmed, which encouraged future clinical trial for prostate focal therapy. multiparametric introduction and objective: sepsis has always been a concern in the traditional transrectal ultrasound (trus) guided biopsy of the prostate. however, rates of sepsis following trus biopsy have shown to be increasing around the world in addition to the emergence of multiresistant organisms found in rec-tal fl ora. as a result, our practice of seven urologists has switched to transperineal (tp) biopsy. we aim to determine the rate of hospital re-admission in our patients undergoing tp biopsy. an ethics approved prospective database of all men undergoing tp biopsy at our practice has been kept including antibiotics used as well as re-admission for infection. introduction and objective: robot-assisted radical prostatectomy (rarp) has become one of standard treatments for localized prostate cancer. however, a feasibility of rarp in elderly patients has not been clear yet. we performed a comparative analysis of peri-surgical / oncological outcomes for younger and elder patients underwent rarp. we reviewed and compared our initial consecutive patients who underwent rarp from / to / for peri-surgical outcomes, including surgical times, blood loss, complications, pathological fi ndings, continence recovery, and oncological outcomes stratifi ed by age less than and over years.results: in our cohort, men were age less than and men were ≥ . preoperative parameters (age, psa, gleason score) were similar in both younger and elder groups. operative time (mean: vs. minutes) and estimated blood loss were similar in both groups. one of elder patients ( . %) needed transfusion. peri/post-operative complications in both groups appeared to be minimal with no cases of intra-operative open conversion. one of younger patients needed a surgical settlement for port site herniation. surgical positive margin rates in organ-confi ned (pt ) disease were also similar ( . %, younger vs. . %, elder). continence at months was % in elder patients as opposed to % in younger patients. biochemical recurrences in short follow-up period (median vs. months) were observed . % in elder patients as opposed . % in younger patients.conclusions: in our study, although urinary continence recovery in elderly patients might show a short delay, rarp in elderly patients was relatively safe and yielded good oncologic results. rarp is feasible eve in elderly patients. quality in the fi rst study, community-based urologists ordering at least assays from / to / participated. clinicopathologic data, the gps and treatment were abstracted from medical records of gps patients and a clinically similar baseline group. th e proportion of men recommended and pursuing active surveillance (as) before and aft er the availability of the gps were computed. in the second prospective study, urologists at centers (academic and community) recorded tr on pre-and post-gps questionnaires, including changes in treatment intensity.results: fift een urologists completed the chart review study on men ( gps; baseline). th e relative increase in tr for as was %, ( % baseline, % gps; absolute diff erence of %). gps pts chose as more than baseline pts ( % gps; % baseline, absolute increase of %, relative increase of %). of men recommended as, % of gps and % of baseline pts chose it. in men in the prospective study, the relative increase in recommendation for as was % and absolute tr increase for as was also % ( % to %). % of tr changed post-gps and tr modality and/or intensity occurred in % of men ( decreased; increased; equivocal).conclusions: both studies, conducted with diff erent methodologies, demonstrate that use of gps provides meaningful change in tr and decisions in men with newly diagnosed pca and results in a net increase in recommendation and/or adoption of as. in the chart review study, tr changes appear to underestimate changes in actual treatment received and more gps patients than baseline patients were assigned to as supporting the clinical utility of gps in the initial assessment and management of men with low risk pca. comparison we prospectively evaluated in patients with clinically localized prostate cancer, the possible association between hce (≥ . mmol/l) and aggressive prostate cancer. pre-operative serum cholesterol levels (ch), triglycerides (tr), were prospectively assessed in men treated consecutively with radical prostatectomy from feb. to oct. . th e results were related to patient specifi c and clinico-pathologic data.results: patients with hce (n= ) had a more aggressive grade gleason score (gs) ≥ b, p< . )), a locally more advanced stage (≥pt a, p< . ), and lymph node metastasis (n+, p< . ). hce was also associated more frequent with a positive surgical resection margin (r , p< . ). in multivariate regression analysis hce is associated with a high-risk pc (hr . , % ci . to . , p < . ) -adjusted for psa, dre, age and poor biopsy score (gs ≥ ).conclusion: th e results indicate that hca is associated with high-grade and metastatic disease in men diagnosed with clinically localized pc. our fi ndings suggest that ch can be used as an additional predictive marker in therapy. conclusion: th e incidence of bs-positive tumours is low in men being staged for radical treatment except in high-risk disease. pelvic/prostate mpmri alone cannot be relied upon to exclude bone metastases in this group. hyperbaric oxygen therapy for radiation induced side-effects introduction and objective: to evaluate the effi cacy of hyperbaric oxygen (hbo) th erapy for prostate conclusions: in our japanese provincial hospital, the comparatively young patients chose a treatment according to treatment algorithm. however, according to aging, the patients tended to choose hormonal therapy regardless of algorithm. as for one of the reasons, it is thought as follows: even if the patients chose operation or radiotherapy, it may be diffi cult to visit the institutions that have such a treatment because public transport does not develop in our prefecture. nurse-led telephone follow-up for prostate cancer surveillanceturner b, tanabalan c, nargund v, pati j, wells p introduction and objective: we review the patients' experience of a nurse-led, telephone follow-up service for men with 'stable' prostate cancer, to measure satisfaction and quality. th e telephone follow-up service is based on the premise that psa measurement can be used as a surrogate for outpatient attendance. telephone follow-up service serves to reduce the number of patients attending hospital appointments. th is has led to increased clinic capacity and reduced waiting times, ensuring urgent care is available for patients who need it. a nurse-led, protocol based telephone follow-up service was set up for patients deemed to have 'stable' disease. questionnaires were sent to all patients. survey was voluntary and anonymous. we addressed a variety of aspects of the service, including time, duration and content of the telephone appointments, patients' preference for type of follow-up (telephone vs. hospital follow-up) and overall satisfaction with the service.results: response rate of %. reported high satisfaction with telephone follow-up ( % were either satisfi ed or very satisfi ed). majority of patients found the length of the conversations to be 'just right' ( %) with a lesser majority expressing that the calls were always at times convenient to them ( %) and that they were always called when they were told they would be called ( %). patients felt that the information given to them over the phone was always easy enough to understand ( %) and the majority felt that they always had the opportunity to ask questions during the conversations ( %). when asked whether they would prefer telephone follow-up or hospital follow-up, % of respondents reported that they would prefer telephone follow-up, citing convenience, time and privacy as the reasons for their preference. twenty-one percent of patients would prefer hospital follow-up, reporting ease of understanding, not liking the telephone and preference for face to face contact.conclusions: telephone follow-up relieves pressure on the outpatient department, increases capacity, reduces waiting times and brings care closer to home. patients perceive the service as a valuable addition to their care and report high levels of satisfaction with the service. prostate ' th e target sample sizes of australasian trials 'currently recruiting' ranged from to men (median= ), the majority of trials investigating medical and radiation oncological interventions. five of the trials 'currently recruiting' were recorded as single-centre studies in new south wales, victoria and queensland. of the remaining trials, % (n= ) were recorded as international, industry sponsored, multi-centre studies with australian and/ or new zealand recruitment sites.conclusion: australasian prostate cancer clinical trial activity (though likely under-recognised in this study, due to trial registration limitations) represents a relatively small fraction of international eff ort. continued investment will ensure that the talented and world-leading scientists and medical professionals across both nations can tackle the big challenges in prostate cancer through working collaboratively. assessment modifi ed laparoscopic intravesical nonrefl uxing ureteral reimplantation with psoas hitch using a submucosal tunneling introduction and objective: we aimed to study the safety and effi cacy of the cystoscopy-assisted nonrefl uxing ureteral reimplantation technique using sub-mucosal tunneling during laparoscopic ureteroneocystostomy (unc) with a psoas hitch in patients with distal ureter stricture aft er gynecologic surgery. we reviewed six female patients who underwent gynecological surgeries. all patients showed persistent postoperative distal ureter stricture or obstruction. th ese patients underwent laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute.results: th ey had corrective surgery at an average of . weeks aft er ureteral injury. th e short-term success was confi rmed either by voiding cystourethrography (vcu) or by diuretic isotope renal scan (mag- ) conducted months aft er the operation. none of the patients showed evidence of postoperative stricture at the reimplanted site and refl ux on either mag- renal scan or vcu. none of the patients showed major or minor complications during follow-up. it is safe and feasible to perform the laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture. upper ureteral injuries were more frequent in the urological surgery group than in the non-urological surgery group ( % vs. . %). complications or serious injuries were more frequent in the urological surgery group. th ere were no signifi cant diff erences in the mean durations of hospitalization and indwelling times between the groups. conclusion: th e occurrence of a ureteral injury during urological surgery is an infrequent but serious complication may occur. urologists should pay attention to the potential for ureteral injury, especially during a ureteroscopic ureterolithotomy for the treatment of an upper ureter stone. reducing the risks of trauma due to urethral catheterisation mundy a, yim i, tamini a, roberts n conclusion: isolated ureteric trauma can be managed successfully using minimally invasive endoscopic and radiological approach. a pcn initially helps in minimizing extravasation and ureteral wall edema subsequently facilitating stent placement. medium-and long- university of sydney, sydney, australia introduction and objective: urethral stricture is a common urological presentation for obstructive lower urinary tract symptoms. th e treatment of choice for a durable outcome is usually substitution urethroplasty using buccal mucosal graft . graft failure is not uncommonly encountered. we present the mediumand long-term outcomes of ventral buccal mucosal graft urethroplasty using spongio fl ap technique. a retrospective review of a single surgeons experience was reviewed for a period of years. data was collected from medical records, surgeon's notes and operation reports. inclusion criteria included reconstruction of anterior urethral stricture using bm graft positioned ventrally and graft support using spongio fl ap technique. patients who were lost to follow-up were excluded from analysis. graft patency was defi ned as having a lumen greater than fr. th is was assessed via cystoscopic examinations at , and months intervals post procedure.results: a total of male patients identifi ed with age ranging from to years and mean age of years. average length of bm graft used was . cm. total of ( %) achieved long-term successful outcome. of these ( . %) patients had successful outcomes with no further interventions, and ( . %) required gentle urethral dilatation at fi rst cystoscopy and subsequently achieved long-term patency. sixteen ( . %) of this cohort formed recurrent stricture at initial cystoscopy, and ( . %) of patients formed urethral stricture formed delayed stricture, despite the initial cystoscopic examination and urethral dilatation.conclusion: ventral buccal mucosal graft urethroplasty using spongio fl ap technique has very good short-term and long-term graft patency outcomes. outcome of paediatric kidney transplantation: single center experience nawaz g, jamil i, athar khawaja m, muhammad s, shohab d, ur rehman a, ali khan i, khan a, hussain i, akhter s introduction and objective: renal transplantation is the treatment of choice for children with end-stage renal disease (esrd) because in addition to making them off dialysis it also improves growth and development of the child. about - % of children have a lower urinary tract dysfunction due to congenital or acquired genitourinary anomaly as the etiology of esrd and they need a diversion or augmentation procedure prior to transplantation. we aim to deter-mine the outcome of paediatric renal transplant at year in term of graft survival and complications. we retrospectively reviewed the record of consecutive children underwent living related renal transplant between jan to jan . all were primary renal transplants and had living related renal donors. patient characteristics, causes of esrd and pre transplant surgical procedure were recorded. patients with lower tract abnormalities as cause of renal failure underwent reconstructive procedure prior to transplant. induction immunosuppression consisted of triple therapy with antithymocytic globulin (atg), prednisone and mycophenolate mofetil (mmf). cyclosporine was introduced when creatinine came down to > % of normal. all patients were treated as cmv positive with either acyclovir or ganciclovir and received daily dose of trimethoprim-sulfamethoxazole as prophylaxis for pneumocystis carnii pneumonia aft er transplantation. post transplant surgical and medical complication, graft and patient survival were recorded.conclusion: ureteric implantation into the bowel portion of augmented bladders appears safe in this population of patients with previously reported increased risk of ureteric complications and urinary tract infections aft er transplantation. transition of cavernous function after radical prostatectomy materials and methods: study subjects were ed patients with a history of rp (median age: ). intervals between rp and examination diff ered among patients (range: to months). we also performed doppler penile ultrasound examination using intracavernous injection of micrograms of prostaglandin e . we adopted an infusion rate of less than ml/min at mmhg of intracavernous pressure as the normal cavernous function limit for dicc.results: arterial velocity in ultrasonic examinations showed a tendency to decrease. cavernous function aft er rp clearly diff erentiated according to phospho-diesterase inhibitors (pde is) response ( figure ). in the pde is responder patient group ( cases), the rate of normal cavernous function was % at month, months, and months, but the rate increased to % at months, and % at months. a diff erent transition was seen in the pde is non-responder patient group ( cases). in this group, the rate of normal cavernous function was also % at month. however, from here, the rate increased to % at months, and then aft er this point, it decreased to % at months. sixteen -week-old sprague-dawley rats were induced diabetes by a onetime intraperitoneal injection of streptozocin ( mg/ kg). one week later, the diabetic rats were randomly divided into groups including a normal control, dm control and two uu treated group ( , and mg/kg/d). th e latter rats were fed uu by intragastric administration for weeks. aft er weeks, penile hemodynamic function was evaluated by measuring the intracavernosal pressure aft er electrostimulating cavernous nerve. we measured nitric oxide (no) and cyclic guanosine monophosphate (cgmp) activity. endothelial nitric oxide synthase (enos) and neuronal nos (nnos) protein expression was determined by western blot. masson's trichrome staining was also assessed.results: serum glucose level in dm +uu group was signifi cant lower than in that of the dm control groups. maximum intracavernosal pressure in dm control rats decreased signifi cantly compared to normal control rats and increased signifi cantly compared to untreated dm rats aft er uu supplementation. dm + uu group had signifi cantly increased no and cgmp level compared with the dm control group. decreased activity and expression enos and nnos were found in the dm groups compare with normal control group. decreased enos and nnos in diabetic rats were improved by uu administration. decreased the cavernous smooth muscle to collagen ratio was improved in dm + uu groups in the masson's trichrome staining.conclusions: uu eff ectively ameliorated erectile function in a streptozocin induced diabetic rat model of erectile dysfunction. you d , jung s , jang m , kim b , lee c , song g , choi k , shin h , suh n , kim y , ahn t , kim c the etiology and management of erectile dysfunction (ed) in patients with metabolic syndrome (ms). eighty-six patients suff ering from erectile dysfunction and metabolic syndrome were included in the study, patients were classifi ed based on iief- domain into three groups: mild ed (n= ), moderate ed (n= ) and severe ed (n= ). th ese patients were treated using upgraded regimen protocol (changing of the life style for months, on demand use of pde- inhibitors for months, chronic dosing with long acting pde- inhibitors for months and combination therapy of pde- inhibitors and intracavernosal injection for months) re-evaluation of the patients was done at the end of each stage by (iief-ef, waist circumference and laboratory investigations).results: aft er months of lifestyle modifi cation there was increase in the iief-ef but this change was not signifi cant the overall improvement was ( %), aft er on demand pde- inhibitors for months( . %) of patients with mild ed were improved, ( %) with moderate ed and ( . %) with severe ed were improved. non-improved patients in each group aft er on demand pde- inhibitors received pde- inhibitors chronic dosing for another months then re-evaluated ( . %) of patients with mild ed were improved, ( . %) with moderate ed and ( . %) with severe ed were improved, combination therapy in the form of tadalafi l mg daily and pge μg on demand were off ered to patient whom reported failure of pde- inhibitors chronic dosing patients with mild symptoms reported the maximum improvement ( %), patients with moderate symptoms reported fair improvement ( . %); however patient with severe symptoms reported no improvement at all.conclusion: pde inhibitors should be considered as the fi rst line phamaco-therapy in treatment of ed in metabolic syndrome patients. non-responders to pde inhibitors may have a benefi t from daily dosing of long acting pde- inhibitors. combination therapy of pde- inhibitors chronic dosing associated with intracavernosal injection of pge may play a role as a salvage therapy aft er failure of monotherapy. following this upgraded regimen case with ms and ed can have overall successful results in . %. comorbidity of premature ejaculation and erectile dysfunction: are they inseparable in chinese adult men?tang y, yang j, jiang x introduction and objective: premature ejaculation (pe) and erectile dysfunction (ed) are usually regarded as a symbol of incompetence. but in china for the inconsistent defi nitions of pe, some of them cannot correctly distinguish pe from ed. th erefore, to fi nd out the real relationship between pe and ed, a detailed investigation was implemented. were enrolled. all the subjects were evaluated by the face-to-face questionnaires of premature ejaculation diagnostic tool (pedt) and the international index of erectile function (iief- ). a professional urologist was invited to measure their lengths of penis and volumes of testes. all the data were analyzed by spss version . soft ware.results: a total of men aged from to years ( . ± . ) were categorized into lifelong pe (lpe) ( men), acquired premature ejaculation (ape) ( men), variable pe (vpe) ( men) and subjective pe (spe) ( men), respectively. th ere was no signifi cant diff erence among the four pe subtypes except for the ielts and the iief- . th e self-estimated ielt of spe was signifi cant longer than that of other subtypes, and the similar case could be seen in iief- . th e highest percentage was found in ape ( . %) for chronic prostatitis (cp) and in lpe ( . %) for ed.conclusion: vpe was the most common subtype, next ape, thirdly spe and the least one is lpe. consistent with the previous reports, we found that the incidence of cp in ape was the highest among all the four subtypes of pe, and cp was a signifi cant risk factor of ape but not for other subtypes. th ere has always been controversial about the relationship between pe and ed. th e results from our multinomial logistic regression analysis showed that ed was not only associated with pe, but also could be regarded as a risk factor of pe. introduction and objective: depression oft en overlapped with late-onset hypogonadism (loh) syndrome. clinically, many loh patients who have depressive symptom were treated with testosterone replacement therapy (trt). however, treatment efficacy of trt for these patients is unclear. in this study, we aimed to identify characteristics of loh patients on trt who had medical history of ongoing mental health treatment for depression syndrome. we reviewed consecutive patients who visited men's health clinic and underwent trt in our institution during june and december . prior to trt, patients received a physical examination and full hormonal evaluation including free testosterone (ft), lutenzing hormone (lh), and follicle-stimulating hormone (fsh). th e aging males' symptoms (ams) score was also evaluated. trt was conducted by mg monthly testosterone injection. effi cacy of trt was noted when diff erential of ams score between pre-and post-treatment was more than points. in the entire cohort of patients, the mean age was . ± . years and pre-trt ams score was . ± . . pre-trt ft, lh, and fsh were . ± . ng/ml, . ± . miu/ml, and . ± . miu/ml, respectively. of total patients, cases ( . %) had diagnosis of depression by psychiatrist and ongoing mental health treatment. patients with positive medical history of mental health treatment were found to be younger ( . vs. . years, p = . ), higher pre-trt ams score ( . vs. . , p < . ), lower lh ( . vs. . %, p = . ), and lower fsh ( . vs. . %, p = . ) compared to patients with negative medical history of mental health treatment. effi cacy of trt was greater in men who have mental treatment history ( . vs. . %, p = . ) based on ams improvements. while, there were no signifi cant diff erence in ft ( . vs. . ng/ml, p = . ), trt duration ( vs. days, p = . ), and trt discontinuation rate ( . vs. . %, p = . ) between two groups.conclusion: even though, loh patients who had diagnosis of depression and underwent medical treatment such as antidepressant, trt can be feasible approach for those patients. majority of those loh patients underwent mental health treatment at the same moment with trt, which may not harm treatment effi cacy of trt. the effect on blood flow rate of prostate in daily administration of mirodenafi l mg for benign prostatic hyperplasia patients: randomized paroxetine is the most eff ective ssris. in few studies, tramadol has been used to treat pe. considering the high incidence of pe in men and lack of consensus on its treatment, we decided to compare the therapeutic eff ects of tramadol, paroxetine and placebo in the treatment of primary pe. in this randomized, double-blind, placebo-controlled clinical trial, patients were randomly divided into groups. one group was treated with tramadol mg, the other group took paroxetine mg and the third group was treated with placebo. before starting treatment and aft er weeks, patients were asked to measure their average intravaginal ejaculation latency time (ielt) and fi ll the pep (premature ejaculation profi le) questionnaire. aft er collecting the data, they were recorded in spss version and were analyzed.results: patients in the groups in baseline characteristics, including mean age, ielt and pep were similar at the beginning of the study and there was no clinically signifi cant diff erence in the groups (p> . ). a total of patients completed the study period. at the end of the th week, the mean ielt and average of pep scores increased in all groups. th ese changes in tramadol group were signifi cantly higher than the paroxetine and placebo groups (p< . ). th ere were no signifi cant diff erences in terms of side eff ects between the groups. th e results showed that despite an increase in mean ielt and pep scores in all groups, the rate of improvement in tramadol group was considerably more than the other groups. th us, tramadol may be considered as an appropriate alternative therapeutic for long-life pe. the effi cacy and safety of tadalafi l mg once daily for the treatment of erectile dysfunction related to the vascular causes after robot-assisted radical prostatectomy: -year follow-updong-a university hospital, busan, south korea; jeil hospital, ulsan, south korea introduction and objective: to evaluate the effi cacy and safety of tadalafi l mg once daily use in the treatment of erectile dysfunction (ed) based on the vascular cause aft er robot-assisted radical prostatectomy (rarp). th e study retrospectively evaluated patients who underwent rarp and had a penile rehabilitation by tadalafi l mg once daily use at our medical center. th e patients were surveyed based on the abridged fi ve-item version of the international index of erectile function (iief- ) questionnaire, which was self-administered before the surgery, and at months, year and years aft er the surgery. th e patients were classifi ed into the tadalafi l group (n= ) and the non-tadalafi l group (n= ). each group was then classifi ed depending on the nerve-sparing (ns) procedure: bilateral ns and unilateral ns. additionally, patients who underwent a penile color-duplex u/s study to evaluate the cause of erectile dysfunction were also analysed.results: at months, year, and years, the total iief score of the tadalafi l group and that of the non-tadalafi l group were . ± . vs. . ± . , . ± . vs. . ± . , and . ± . vs. . ± . , respectively. statistically signifi cant improvements (p< . ) were observed in the tadalafi l group for all domains of iief- score, while in the non-tadalafi l group there was no signifi cant improvement in any of the domains at and years. fift y three patients had a penile color-duplex u/s study. arteriogenic and venogenic ed was seen in patients ( . %) and patients ( . %). fift een patients ( . %) showed unremarkable fi ndings. venogenic ed patients had little response compared to arteriogeinc ed patients by tadalafi l mg once daily use ( % vs. . %). th e overall side eff ects were hot fl ushing in . %, headache in . %, and dizziness in . %. in ed patients aft er ns ralp, a once daily dosage of tadalafi l mg was well tolerated and signifi cantly improved ef compared with the non-tadalafi l group until two years. but in the venogenic ed patients, response to a once daily dosage of tadalafi l mg was relatively limited compared to the arteriogenic ed patients. effects of long-term androgen replacement therapy on the physical and mental statuses of aging males with late-onset hypogonadism (earth): a randomized phase trial in japan introduction and objective: to determine the role of stone density and skin-to-stone distance (ssd) by non-contrast computed tomography of the kidneys, ureters and bladder (ct-kub) in predicting the success of extracorporeal shock wave lithotripsy (eswl). we evaluated patients who received eswl for renal and upper ureteric calculi measuring - mm, over a month period. mean stone density in hounsfi eld units (hu) and mean ssd in millimeters (mm) was determined on pre-treatment ct-kub at the ct workstation. eswl was successful if post-treatment residual stone fragments were ≤ mm.results: e wl success was observed in . % of the patients. mean stone densities were ± and ± hu in e wl successful and failure groups, respectively; this was statistically signifi cant (p < . , student's t-test). mean ssd were . ± . and . ± . cm in eswl successful and failure groups, respectively, this was not statistically signifi cant.conclusions: th is study shows that stone density can help in predicting the out-come of eswl. we propose that stone densities < hu are highly likely to result in successful eswl. conversely, stone densities > hu are less likely to do . th is should be accounted for when considering eswl. assessment th is prospective study was conducted upon children with mean age . ± . years. patients underwent retrograde intrarenal surgery (rirs) under general anesthesia as monotherapy. th e procedure was initially started by the semi-rigid ureteroscope (storz . f) and holmium laser and was completed by the fl exible ureterorenoscope (fl ex x ) for other parts of the stone which were not accessible by the semi-rigid ureteroscope. ureteral access sheath was not used and only hydrodilation was performed. patients were evaluated preoperatively by ultrasound and plain x-ray of the abdomen and pelvis. pre-intervention sterilization of urine was performed in all patients using culture guided antibiotics. follow-up lasted for months.results: stone-free rate aft er a single session treatment was % and % aft er second session. mean operative time was . ± . minutes. th e mean fl uoroscopy exposure time was . ± . seconds. mean hospital stay was . ± . days. all patients had jj stent inserted. no major complications (clavien iii-v) occurred. none of the children received blood transfusion. th ree patients needed a second session of rirs, patient required a pnl session.conclusions: retrograde intra renal surgery using combined semi-rigid and fl exible ureteroscope off ers eff ective and safe option for treatment of medium sized renal stones children with comparable results to shock wave lithotripsy (swl) and percutaneous nephrolithotomy (pnl). introduction and objective: calcium stones are associated with osteoporosis and manifested mainly by elevated fasting urinary calcium/creatinine ratio. th e objective of this study is to demonstrate the presence of abnormal metabolism of calcium and calciuria in women with osteoporotic fracture with no previous-ly known renal lithiasis compared to women without osteoporosis and without renal lithiasis. eighty-seven women were included in the study and divided into two groups: group : postmenopausal women with osteoporotic fracture and without renal lithiasis; group : postmenopausal women without osteoporosis and without history of renal lithiasis. th e following parameters of phospho-calcium metabolism were analyzed: calciuria h, oxaluria h, uricosuria h and citraturia h. th e presence of hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia was compared between the two groups. statistical signifi cance was determined as p≤ . . results: th e mean age was . ± . years in group and . ± . years in group (p = . ). women in group had higher levels of serum alkaline phosphatise (p< . ) and fasting urinary calcium/ creatinine ratio (p< . ) than women in group . th e percentage of women with hypercalciuria in group ( %) was higher compared to women in group ( . %) and statistically signifi cant (p = . ). th ere were no statistically signifi cant diff erences in the percentage of hyperoxaluria, hyperuricosuria and hypocitraturia between the two groups. th is paper has the limitations of cross sectional study in a unique center and with a low number of patients. dept. of urology, ulster hospital, dundonald, uk introduction and objective: bladder stones are more common found in children from developing countries. open cystolithotomy or transurethral cystolithalopaxy are the traditional treatment but a percutaneous approach has been advocated. we present our experience with percutaneous cystolithotomy in children with bladder stones without any ultrasonic or fl uoroscopic guidance. from april to october , a total of children ( boys and girls) with a mean (range) age of . ( - . ) years underwent percutaneous cystolithotripsy (pccl). th e mean (range) stone diameter was . ( . - ) cm. one hundred thirty-eight children ( %) had a solitary stone while nine ( %) had more than one stone. th e main component of the stones were calcium oxalate in patients ( . %).results: all children were stone-free aft er one pccl; no recurrent stones developed. th e mean (range) pccl procedure time was . ( to ) min and intraoperative blood loss was scant. perioperative complications were few. th e mean (range) hospital stay was . ( - ) days.conclusions: blind access pccl (without any ultrasonic or fl uoroscopic guidance) is a facile and safe approach for removing stones in the pediatric bladder stones. advantages include the lack of ionizing radiation, no need for opacifi cation by iodine contrast media and low relative cost. we recommend this minimally invasive technique for management of large bladder stones (larger than cm) in children. to our knowledge, this is the largest single center series re-ported on percutaneous cystolithotripsy of endemic bladder stones in children. retrograde intrarenal surgery (rirs) in an unusual kidney ( ), polycystic kidney ( )]; who underwent rirs for stone management was evaluated. stone size was less than mm in all the cases. bleeding being the commonest complication, hemoglobin drop was measured to fi nd out the blood loss. all patients were assessed by x-ray and usg on the fi rst postoperative day and month follow-up. th e other parameter of focus was operative time, hospital stay, stone free rate and the auxiliary procedure. th e auxiliary procedure was divided as (staged, follow-up ( month) or other-pcnl/swl) so that stone free was the main target for the patients. conclusion: urolithiasis occurs in an abnormal kidney, indeed challenging, but rirs can also be performed successfully. proper handling of instrument can increase the longevity of the instrument for cost eff ectiveness. although complete stone clearance cannot be achieved, but meritorious achievement is less morbidity, early recovery, minimal bleeding with less complication. th us, rirs can be performed effi ciently, effi caciously and successfully in an unusual kidney with prior exposure of rirs. value of intraoperative ultrasound in decreasing of the risk of residual radiolucent stone post-pcnl al shareef j, aboelmagd m introduction and objective: hemorrhage is the most concerning complication aft er tubeless percutaneous nephrolithotomy (pcnl). we compressed the access tract of the kidney with oxidized regenerated cellulose (surgicele) aft er pcnl to facilitate homeostasis for tubeless pcnl. since april to september , pcnl was performed at our hospital. all patients received one stage procedure with metal dilator. aft er the end of stone extraction, the access tract was cauterized and an f foley catheter was inserted to the renal pelvis through the working sheath then infl ated and gently retracted. th e working sheath was withdrawn to the renal capsule and the access tract of the renal parenchyma was packed with surgicele and compressed with small sized dilators through the working sheath for minutes. a bloodless tract usually could be obtained in nearly every patient and all patients underwent tubeless modifi cation. th e results of these patients were analyzed with retrospective chart review.results: th e age of these patients ranged from to (mean . ) years old. th e average stone size was . ( . - . ) cm and the average operation time was . ( - ) minutes. th e target stones had been removed in all patients and the overall stone free rate was . %. th e postoperative blood transfusion rate was . % with no patient underwent angiographic intervention or other management for severe hemorrhage. postoperative fever was noted in . % patients and sepsis was noted in . % patients. th is study was designed to evaluate the adverse eff ects of swl on the metal devices for spine fi xation and the hemoclips for hemostasis. a total of cases who underwent swl for treatment of upper ureteral and renal stones were investigated. th eir ages were from ~ years (mean . ± . ). male patient was one and female patients were . th e piezolith (wolf, germany) was used as the lithotripter. th e metal devices were hemoclips for cholecystectomy in one, and pedicle screw in fi ve patients and bone cement (polymethylmethacrylate) in one patient for spinal fi xation through l to s . th e locations of the stones were the kidneys in and the upper ureter in patients and their sizes were from . cm to . cm (mean, . ± . ) . th e numbers of the swl were . ~ . times (median, ) . th e distances between the stones and metal devices were . ~ . cm (mean, . ± . ). th ey were followed-up for . ~ . months ( . ± . ). th e complications were investigated in terms of pain, fever, damage of the devices (change of morphology and location in simple x-ray fi lm and their function). no patient showed fever and pain in sites of the devices requiring medication, injection or other management during or aft er swl. one patient was admitted for acute colick fl ank pain with tenderness in costovertebral angle caused by acute ureteral obstruction by a crumbled small piece of the stone. th ere was no complication concerning with the eff ect of the swl on metal devices. even though swl is one of the safe treatment modality in various clinical fi elds, it can't be said that swl is always safe without complication. however, it can be said that it would be safe when it being done following the instruction. a prospective study to identify risk factors of pleural injury during percutaneous nephrolithotomy a total of patients with renal/upper ureteric stones, undergoing pcnl between january and june were evaluated for pleural injury. an erect chest x-ray antero-posterior view on inspiration was done within -hours of pcnl. th e patients were divided into groups a and b depending on whether they developed or did not develop pleural injury. patient-, stone-, renal-and procedure-related factors were compared between the two groups. patients with any known disease of lungs or pleura, patients undergoing simultaneous bilateral pcnl, relook nephroscopy, concomitant other procedures such as endo-pyelotomy or retrograde ureterorenoscopy were excluded from study. tract dilatation up to -f was done using alken metal dilators and an amplatz sheath was placed into system. nephroscopy was done with rigid nephroscope and stones were fragmented with pneumatic lithoclast.results: pleural complications occurred in patients ( %). out of patients, had supra-costal puncture and ( . %) developed pleural injury; patients had infra-costal puncture and pleural injury occurred in ( % on multivariate analysis, only low bmi and mean age < -years was associated with higher risk of pleural injury. th e limitation is the small number of patients (as pleural injury is not common a very large number is needed to show signifi cance).conclusions: higher incidence of pleural injury was noted in patients with low bmi and younger age. large multicenter study can provide a true picture. flexible and rigid ureteroscopy in th e success rate was defi ned as radiopacities less than mm on plain fi lm at one month follow-up aft er the fl exible ureteronoscopic procedure. our tips included: tip , moving technique, refers to move the lower pole stones to the upper pole or middle pole depending on the convenient site for fragmenting the stones with the escape basket. if the stones were large or the lower pole orifi ce is narrow, we fragmented the stones into two or more pieces, trapped and moved the stones into the convenient pole. tip , holding technique, refers to hold the stones in the renal pelvis and insert a laser fi ber through the escape to fragment the stones. tip , sheath technique, refers to extract the large stones and pull the stones to the sheath distal side, the stone was too large to pull out, a laser fi ber was inserted though the escape, fragmented the stones. all the videos were recorded.results: overall success rate was . %. th e success rate in the renal pelvis stone, upper pole, middle pole and lower pole was %, . %, . %, . % respectively. th e operating time was . minutes on the average. th ree patients had fever over °c aft er the procedures. no urosepsis occurred.conclusion: our tips are feasible in the treatment of kidney stones with fl exible ureteronoscopy. satisfactory success rate, shortening operating time, less fl exible ureteronoscopy consuming and less complication were obtained in the procedures of fl exible ureteronoscopy with escape. ureteroscopic introduction and objective: patients with underlying diseases, especially in old-aged, the urinary tract obstruction with the ureter stone would progress to the severe condition like renal failure or sepsis. prompt urinary diversion like percutaneous nephrostomy or removal of the stone via ureteroscope is necessary for these patients. however, most of them have poor general conditions to endure regional or general an-esthesia. so, we tried to implement the ureteroscopic removal of stone (urs) without anesthesia for the patients with ureter stone who were in septic conditions or severe urinary tract infections (uti). fift een patients ( males and females) included this study and all of them had serious problems like sepsis, heart problems or lung problems which were diffi cult to endure anesthesia. most of them were inserted pre-operative percutaneous nephrostomy catheter (pcn) due to impending septic shock. all of the stones were impacted in the ureter and urs were successfully performed with painkiller like pethidine mg iv. success rate of stone removal, pain perception during operation using a visual analog pain scale were done. results: th e mean age of the patients was . (± . ). th e position of the stones was as follows; upper ureter, mid-ureter and lower ureter stones. and there was no patient that had to stop the operation because of intolerable pain. th e mean of vas (visual analogue pain scale) was . (± . ). overall success rate was %. however, % of cases were unable to fi nd the impacted calculi but stone debris and blood clots. th e general condition of the patients except one was improved quickly aft er operation and discharged aft er . (± . ) days.conclusion: most obstructive uropathy due to calculi was in serious conditions to need immediate procedures and urs were safely and successfully performed under intravenous analgesics. in some of female patients, urs is well-tolerated even without analgesics. prompt urs procedure with intravenous analgesics can recover these conditions with minimal morbidity. geavlete p, georgescu d, multescu r, geavlete b introduction and objective: percutaneous nephrolithotomy (pcnl) is nowadays a widely practiced procedure. despite the good stone-free rates, it still has a specifi c morbidity. our goal was to describe the complications of this method on a signifi cant series of patients. between january and january , patients (age between and years) underwent pcnl ( procedures). we used f rigid nephroscopes and f fl exible ones ( procedures). th e mean follow-up period was months (range to months).results: intraoperative incidents were encountered during procedures ( . %): losing the percutaneous traject ( cases), poor visibility due to bleeding and imposing the termination of the procedure ( cases) and descendant stone fragments' migration imposing antegrade ureteroscopic removal ( cases). th e overall complications' rate was % ( cases): signifi cant bleeding requiring blood transfusions ( cases), emobolisation ( cases) nephrectomy ( cases) or open surgical hemostasis ( cases), sepsis ( cases), fever ( cases), pyelocaliceal perforations ( cases), hemoperitoneum ( case), persistent lumbar uri-nary fi stulae requiring retrograde jj ureteral stenting ( cases) and extra-renal stone fragments migration ( cases). however, the majority of these complications were minor. th e mortality rate related to pcnl procedures was %.conclusion: according to our experience, pcnl is a safe and eff ective technique. most of the intraoperative incidents or complications are minor and easy to solve. however, an adequate training is imperative in order to reduce the associated morbidity. is spinal anesthesia adequate for percutaneous nephrolithotomy? introduction and objective: to evaluate the adequacy of spinal anesthesia in terms of patient and surgeon satisfaction and convenience during percutaneous nephrolithotomy. patients who were candidates for percutaneous nephrolithotomy and operated by two endourology fellows during july -september were enrolled. spinal anesthesia was performed using an injection of . mg/kg bupivacaine . % in the intrathecal space; no opium (fentanyl) agent was used. all procedures were performed with the patient in the prone position. access was achieved by fl uoroscopic guidance, and the tract was dilated using a single-stage technique. anestheisa duration was defi ned from injection of anesthetic medication to fi xation of nephrostomy tube. operation duration was defi ned from start of cystoscopy to fi xation of nephrostomy tube. patient pain and satisfaction during operation and surgeon satisfaction was measured by an ordinal likert-type scale and collected by an examiner blinded to the study objectives.results: a total of patients (mean±sd age, . ± . years; male) were enrolled during the study period. th e mean±sd of anesthesia and operation duration were . ± . and . ± . minutes respectively. severe pain causing signifi cant discomfort to the patient and surgeon was observed in patients ( %). in three patients the operation was prematurely terminated because of excessive pain and/ or agitation of the patient. mild-moderate pain was observed in eight patients ( %). vomiting and headache was observed in another two patients. the african : our experience of stenting ureters in outpatients without screening or ga introduction and objective: to review ureteric catheters/dj stents placed under local anaesthetic, with antibiotic coverage, without the use of screening, at groote schuur hospital (gsh) over the last years. a prospectively collected database exists from july until present. all patients signed informed consent and received pre-procedural oral antibiotics. a post-procedural abdominal kub radiograph was obtained to ensure correct placement. demographic data and variables (stent/catheter, indication, side, success/failure -including reasons for failure) were collected. patients were asked to subjectively rate the level of pain at the end of the procedure.th e data has been collected and tabulated into an ex-cel® worksheet.results: a total of procedures (average . per year) were performed with age range from to years (average: . years). th e average time taken was minutes (median: minutes). th e shortest procedure recorded was minutes, and longest was minutes (with a failure). th e failure rate totals . % and further inspection shows that . % of failures were with bilateral stents, . % right sided and . % left sided. stated diff erently, % ( / ) of bilateral stents failed, . % ( / ) of right sided stents failed, and . % ( / ) left sided stents failed. th ere was a success rate of . % with stenting under local anaesthetic. th e average subjective pain score was . , which is tolerable. sivalingam et al ( , urology : - ) showed the average cost for stenting under general anaesthetic was almost times more expensive than under local. th eir local group had a failure rate of . %, which was lower than our . %, but we had a larger group ( in years vs. in years).conclusion: flexible cystoscopy and stenting under local anaesthetic without screening is useful and feasible, with minimal morbidity, discomfort and failures. it can be practiced as a cost eff ective, offi ce-based procedure and is suitable for the third world environment. introduction and objective: urolithiasis is an ancient disease with global distribution and is an important health problem all over the world. th ere are diff erent results for stone clearance rate in diff erent renal and ureteric locations aft er eswl. here we share our experience of the comparison of stone free rates and complications in diff erent renal locations. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: tubeless percutaneous nephrolithotomy (pcnl) for staghorn calculi has been reported to be safe and eff ective in select patients. although outpatient pcnl has been recently been shown to be safe and eff ective in a series of patients, it requires further study before urologists embrace same day discharge following pcnl. th e objective of this study is to report our early experience in treating staghorn calculi with pcnl on a completely outpatient basis, assessing its safety and effi cacy. a review of all outpatient tubeless pcnl cases between march and may at two canadian centres was performed, including collection of preoperative, intraoperative and postoperative data. strict preoperative, intraoperative and postoperative criteria were used in the selection of candidates for outpatient pcnl: no intraoperative complications including signifi cant bleeding or collecting system perforation; postoperative hemodynamic stability; adequate pain control; reliable patient with supportive family.results: fift y patients underwent ambulatory pcnl during the study period. staghorn calculi were treated in patients including cases of bilateral staghorn calculi, resulting in a total of staghorn renal units treated by ambulatory pcnl. all patients were discharged home uneventfully - hours postoperatively. th ere were no major postoperative complications, emergency room visits, hospital readmissions or deaths. th e stone-free rate was %, with of the renal units being stone-free at follow-up.conclusion: th is small series represents the largest series of ambulatory pcnl for staghorn calculi to date. in very carefully selected patients, pcnl for staghorn calculi on a completely outpatient basis appears safe and may be feasible. further research on ambulatory pcnl for staghorn calculi is required prior to widespread adoption by urologists. introduction and objective: th e most diffi cult aspect of percutaneous nephrolithotomy (pcnl) is frequently the renal puncture. most are performed under fl uoroscopic control. parallax, the assessment of the displacement of an object when viewed along two lines of sight, is the concept which allows the surgeon to gauge the d relationship of the needle to the kidney from a d fl uoroscopic image. whilst most urologists appreciate successful access correlates with both kidney and stone images moving in unison on rotation of the c arm (or "reverse parallax"), confusion oft en arises with unsuccessful attempts in relating how to amend the puncture with the radiological fi ndings. we create a model to describe visual observation of parallax. by way of a short video we outline how it can be implemented seamlessly into routine pcnl.results: visualization of the theory followed by its application in theatre clearly demonstrates a failsafe technique to allow operators to reliably detect when their puncture needle is deep or superfi cial to the stone.conclusions: parallax, as an adjunct to routine fl uoroscopy during pcnl, allows the operating urologist to rapidly gauge depth of needle in relation to the collecting system in diffi cult access scenarios. familiarity with this technique is important to minimize radiation exposure, ensure satisfactory access to the collecting system and improve operating times. the signifi cance of non-enhanced compute tomography for renal colic has been overestimated in absence of pyuria kim t , ahn s , kang j , kim j , myung s , moon y , kim k , chang i introduction and objective: th e study was undertaken to compare clinical utility in patients undergoing non-enhanced computed tomography (nect) and intravenous urography (ivu) in patient with classic symptoms of renal colic without evidence of urine infection and to determine the clinical importance. th is was a retrospective observational analysis of all adult patients between and . all nect and ivu were reviewed and categorized as the cause of symptoms. non-urolithiasis cause were further categorized as "acutely important", "follow-up recommended", and "other unimportant cause". full record review blinding to imaging fi nding was underwent including demographics, diagnosis, and management. we compared stone characteristics on imaging study, and demographic, exact diagnosis, and management methods between nect and ivu groups.results: a total of , patients were available inclusion criteria and ( . %) patients were underwent ivu and patients were nect. th e incidence of nect was . % at , but . % at . nect group was older ( . ± . vs. . ± . years old, p< . ), less hematuria in urine analysis ( . vs. . %, p< . ) and more admit ( . vs. . %, p< . ) than ivu group. urinary stones were detected ( . %) patients. nect group showed higher proportion of renal stone, mid ureteral stone and multiple stones ( . vs. . %, p< . , . vs. . %, p< . , . vs. . %, p< . , respectively), and smaller stone ( . ± . vs. . ± . mm, p< . ), and more radiolucent stone ( . vs. . %, p< . ) comparing to ivu group. th e incidence of urolithiasis more than mm were no diff erence between nect and ivu groups ( . vs. . %, p= . on radiologic fi nding, and . vs. . %, p= . on full chart record). moreover, the incidence of "acutely important" among non-urolithiasis cause was similar between nect and ivu groups on full record review ( . vs. . %, p= . ) . th e incidence of the active management including surgery and extracorporal shock wave therapy (eswl) were not diff erence between nect and ivu group ( . vs. . %, p= . ).conclusions: nect is a rapid and accurate diagnosis test for suspected renal colic, and nowadays almost renal colic patients in our hospital underwent nect in ed. however, it did not show better advantage for the detection of clinically signifi cant urolithiasis and acutely signifi cant cause of renal colic in patient with renal colic and absence of pyuria. from january to july we reviewed the scrotal ultrasound images of all patients diagnosed with leydig cell tumor and treated with conservative surgery (group a). we considered only patients that were fi rst diagnosed at one of the participating centers. we create a random homogenous control group of patients (group b), in term of age and presentation, diff erent from the group a just for the defi nitive malignant histology. all the images were collected and we analyzed ultrasound features of the lesions classifi ed in terms of length, us lesion homogeneity, shape, presence of hypervascularization. th e collected data were analysed by an online regression (student's t-test, chi-square test, and logistic regression analysis).results: th irty fi ve patients with leydig cell tumor underwent conservative surgery at our centers. a random group b of patients was also considered. pa-tient mean age was . years (range to ) for the fi rst group and . years for the second one (range to ). patients presented either with a palpable testicular nodule ( patients group a, . % - patients . % group b) or a nodule diagnosed by ultrasound ( patients group a, . % - patients . % group b). mean ultrasound size was . cm and . cm for the two groups respectively (range . to . cm and . to cm). both groups had hypervascularization of the lesions with no signifi cant diff erences. patients presenting with lct (group a) had an homogenous ultrasound intralesional aspect and the shape is defi ned with an elliptic or spheroid mold while patients from group b had dis-homogenous intralesional aspect and non-defi ned margins (p> . ).conclusion: although most focal lesions will be malignant and require an orchiectomy, recognition of the benign entity may be challenging. in a small lesion mainly not palpable the presence of a well-defi ned shape with an homogenous intralesional ultrasound aspect do correlate with a lct. adult testicular pure yolk-sac tumor the association of torsion with testicular cancer: a retrospective study introduction and objective: testicular torsion is a medical emergency that usually requires surgical exploration of scrotum to allow reperfusion of the aff ected testis. nonetheless, such surgeries can be frequently resulted in orchiectomy due to tissue ischemia and necrosis. however, testicular malignancy has been anecdotally reported with the association of torsion in the surgical specimens and the literature remains scant on the association of torsion with testicular tumors. th is retrospective study was set to explore the association of torsion with testicular cancer in cases of testicular torsion undergoing orchiectomy during scrotal exploration. a chart review was performed for patients who admitted to our clinic and had a diagnosis of testicular torsion between january and february . data of patients' characteristics, the laterality of the torsion, time and type of intervention and pathological examination were recorded. results: overall, patients with a diagnosis of testicular torsion were identifi ed. th e mean age was . years (ranges from to years). all the patients had unilateral intravaginal testicular torsion aff ecting the left side in cases ( . %) and on the right side in cases ( . %). manual detorsion was successful in patients ( . %) all of whom underwent bilateral testicular fi xation surgery within hours via scrotal incision. twenty-six ( . %) patients underwent emergency surgery with a testicular detorsion and fi xation surgery in ( . %) cases (bilaterally in and right-sided in ) and orchiectomy in ( . %) cases ( in right side and in left side). th e type of incision was scrotal in cases, inguinal in cases and unspecifi ed in surgeries. pathological examination of specimens revealed ischemia and necrosis in cases, while patients underwent testicular removal via inguinal incision had malignancy including seminoma and malign mixed germ cell tumor.conclusion: our retrospective study, as the largest case series in the current literature, showed the association of intravaginal torsion with testicular cancer to be . %. further high-level evidences are needed to establish the optimal incision type in testicular torsion cases with surgical exploration to avoid scrotal violation resulted from suboptimal approaches. wong l , , dickson b , catton c , yap s , , alkasab t , van der kwast t , hamilton r , jewett m st vincent 's hospital, melbourne, australia; princess margaret hospital, toronto, canada; university of california davis, davis, usa introduction and objective: paratesticular sarcoma (pts) is an uncommon disease and the literature is mostly confi ned to small case series with short follow-up. herein we present an update on our institution's experience in the management of patients with pts. fift y-one men with pts at princess margaret cancer center, between and were identifi ed from retrospective chart review. important relevant clinical pathological variables were collected with study endpoints being local recurrence, metastasis and overall survival. univariate analysis of variables associated with survival end points was performed with cox proportional hazards regression.results: median follow-up of our cohort was . years (iqr . - . ) with a median overall survival of . years. at presentation . % (n= ) of men had localized disease. interval completion hemiscrotectomy (performed aft er initial unplanned diagnostic surgery) was done in men, in which % (n= ) had residual disease present. local recurrence (lr) occurred in patients ( . %). median time from diagnosis to lr was months. univariate analysis showed presence of positive margins at diagnostic surgery (hr . , p= . ) and upfront/ completion hemiscrotectomy (hr . , p= . ) to be signifi cant variables. at last follow-up, / men ( . %) with lr were alive and disease free, developed metastatic disease with pts-related mortalities, and deceased of other cancer type. metastasis was present in men ( . %), with median time to metastasis mo, and median to from metastasis to death . mo. at last follow-up, . % (n= ) of the patients were deceased with cases attributable to pts. on univariate analysis, there were no significant variables for metastatic disease, and age (hr . , ci . - . , p= . ) and non-localized disease at presentation (hr . , p= . ) were signifi cant for overall survival.conclusion: in our cohort of pts patients with median years follow-up, aggressive treatment of local recurrence ( . %) resulted in good disease free survival for of men. completion hemiscrotectomy, particularly for positive margin disease, may decrease local recurrence. a rare case of testicular metastasis from primary lung adenocarcinoma: case report and ten-year review of testicular pathology at a single institution demkiw s , jackett l , goad j , wong l introduction and objective: health care websites provide a valuable resource of health information to online consumers, especially patients. offi cial surgical and medical society websites should be a reliable fi rst point of contact. th e primary aim of this study was to quantitatively assess medical and surgical society websites for content and highlight the essential features required for a high-quality, user-friendly society website. twenty specialty association websites from each of the regions, australia, uk, canada, europe, and the usa were selected for a total of websites. medical and surgical specialities were consistent across each region. each website was systematically and critically analysed for content and usability.results: th e average points scored per website was . out of . of the total (n= ) websites, scored at least out of points and scored out of . as well, % ( . / ) of the websites had an infor-mation tab for patients on their respective homepages while % ( . / ) had download access to patient information. a minority of the websites included different forms of multimedia such as pictures and diagrams ( . / , %) and videos ( . / , %). we found that most society websites did not meet an adequate standard for delivery of information. half of the websites were not patient accessible, with the primary focus being for health professionals. as well, most required logins for information access. specialty health care societies should create patient-friendly websites that would be benefi cial to all online consumers. application materials and methods: students were selected by sampling in pbl group (n = ) and pbl-ebm group (n = ), and the two groups received clinical teaching of urology by pbl and pbl-ebm model respectively. at the end of the study, each student received objective and subjective evaluation.results: th ere was no signifi cant diff erence in results of the baseline on evidence-based medicine between two groups (p> . ), but the percentage of high-recommended-level research evidence obtained by the students in the pbl-ebm group was signifi cantly higher than that in pbl group (p< . ). and questionnaire showed more students in pbl-ebm group believed that this teaching model improved their ability of comprehensive analysis and application of medical evidence, and developed their skills in solving problem and obtaining information on various subjects (p< . ).conclusions: th e model of problem-based learning combined with evidence-based medicine is feasible and eff ective in clinical teaching of urology and optimize the outcomes from pbl education. by the pbl-ebm model teaching, students improve the ability to advantage in managing evidence from medical studies, analyzing and solving problem, obtaining and applying medical information. incidence (dvt) or pulmonary embolism (pe), is recognized as one of the most serious complications of surgery. in urologic surgery, this has not been well reported thus the objective of this study is to access the risk factors for the development of vte among patients undergoing major pelvic surgery for prostate and bladder cancer in an australian tertiary referral center. consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a fi ve-year period ( - ) were identifi ed. patient variables, types of surgery, types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.results: an overall incidence of vte was . %. patients undergoing radical cystectomy were more likely to suff er a vte event compared to patients having radical prostatectomy. in this cohort, the risk factors for vte include, prolonged operative time of greater than hours, lymph node dissection (lnd) and patients requiring blood transfusions.conclusion: patient undergoing major pelvic uro-oncologic surgery have a % risk of developing vte. risk factors identifi ed in this study should be used to guide the use of early and prolonged thromboprophylaxis. optimal trial of void after idc insertion for pelvic surgery th am c , ho p introduction and objective: in , we pioneered the fi rst international twitter-based journal club (#urojc) to discuss urology articles on a monthly basis with diverse global participation. since that time, this model of an international twitter-based journal club has been adopted by several other medical specialties including general surgery, respiratory medicine and nephrology. th e objective of this study is to examine the development of the urology journal club into an innovative and thriving forum for exchange of ideas, information and opinions since its conception two years ago. monthly twitter analyses such as number of users, tweets and impressions for the journal club were obtained via a third-party service called symplur using the hashtag #urojc. qualitative analysis was also performed of each individual tweet to assess for relevance to the discussion. comparisons were made between data from the fi rst and second year of operation of the journal club, including the number and geographic location of participants, as well as the quantity and quality of tweets.results: see table for summary statistics. th e total number of unique users of #urojc almost doubled from year one to year two. th e mean number of total participants increased by seven per month, and mean number of total countries represented increased by three per month. while the number of tweets per month also increased from year one to year two, the proportion of content-relevant tweets remained stably high at approximately %. meanwhile, there was a greater degree of participation from authors of the study being discussed over time. journal club continues to draw robust participation from a global audience, and serves as a benchmark for twitter-based journal clubs in other specialties. th e majority of tweets are relevant to the content of the article, providing a novel forum to discuss new research fi ndings with a global audience. prognostic impact of perinephric fat stranding on computed tomography in ureteral urothelial carcinoma introduction and objective: ureteral urothelial carcinoma causes gradual ureteral obstruction. perinephric fat stranding is defi ned as linear areas of soft tissue attenuation in the perinephric space, which can result from any acute process or injury to the kidney. we analyzed the prognostic impact of perinephric fat standing as well as secondary signs of upper urinary obstruction on the oncologic outcomes of patients with ureteral urothleial carcinoma. a total of patients who were evaluated by abdominal-pelvic computed tomography (ct) preoperatively and were diagnosed with ureteral urothelial carcinoma aft er nephroureterectomy conducted between january and december were enrolled in this retrospective study. we analyzed the association between oncologic outcomes and clinical-pathologic fi ndings, including secondary signs of upper urinary obstruction on preoperative ct such as hydronephrosis grade, perinephric fat stranding, renal enlargement, kidney density diff erence, renal cortical thinning, periureteral fat stranding.results: preoperatively patients ( . %) had perinephric fat stranding on preoperative ct. multivariate analysis showed that perinephric fat stranding, higher pt stage (≥ t ), lymph node involvement of cancer, and positive surgical margin were independent prognostic factors of cancer-specifi c survival (p = . , p = . , p < . and p = . , respec-tively). and perinephric fat stranding, higher pt stage (≥ t ), lymphovascular invasion, and lymph node involvement of cancer were identifi ed as independent prognostic factors of recurrence-free survival in ureteral urothelial carcinoma (p = . , p = . , p = . and p = . , respectively).conclusion: perinephric fat stranding on preoperative ct in ureteral urothelial carcinoma was found to be an independent prognostic factor of disease recurrence and cancer-specifi c mortality. our fi ndings indicate that immediate radical surgery and adjuvant therapy should be considered in patients with perinephric fat stranding preoperatively. lower increased urinary tract malignancy in end-stage renal disease (esrd) has been reported. however, little is known in chronic kidney disease (ckd). th is study is designed to explore the association between ckd and upper urinary tract urothelial carcinoma (uut-uc). health insurance database, we included ckd patients between january and december . th e non-ckd controls were selected with the ratio : and frequency matched with gender, age group and index date. chi-square test and t-test were used to inspect sociodemographic information and comorbidities. logistic regression analysis was used to calculate hazard ratio (hr) and % confi dence interval (ci). a year-old man with a strong family history of various cancers presented with haematuria and was subsequently found to have a mass in the right pelviureteric junction suggestive of urothelial carcinoma. work-up confi rmed the diagnosis without evidence of metastatic disease and the patient went on to have an open transperitoneal nephroureterectomy. laparoscopic approach was initially attempted but abandoned due to dense adhesions thought secondary to previous open bowel resection for colorectal cancer. a fl ank incision was used; there were no specifi c operative complications and the specimen was easily retrieved without manipulation or rupture. post-operative recovery was unremarkable and histological analysis of the tumour revealed a non-invasive high-grade papillary urothelial carcinoma at the right pelviureteric junction with clear resection margins. approximately months post-operatively the patient re-presented with a rapidly enlarging mass at the fl ank incision. imaging demonstrated a circumscribed hypodense mass within the muscle layers at the site of the scar and biopsy revealed poorly diff erentiated carcinoma. surgery to excise the mass was subsequently performed and immunohistochemical analysis revealed a lack of staining for msh .results: abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma is rare, with only one case reported previously. given patient's previous history of colorectal cancer, strong family history and immunohistochemical fi ndings are highly suggestive of lynch syndrome. incisional site tumour recurrence following surgery for urological malignancy is a very rare complication, with only a handful of case reports existing, mostly relating to port-site metastasis following laparoscopic surgery. wound recurrence following open surgery is an extremely uncommon but recognised event, more frequent in certain gynaecological and general surgical malignancies. ls involves inherited defects in the dna mismatch repair system, resulting in predisposition to a number of malignancies. urologists should consider the possibility of lynch syndrome in any patient with de-novo upper tract urothelial carcinoma, and strongly recommend genetic testing where patients meet the amsterdam ii criteria or are diagnosed under the age of . prognostic ) developed recurrent bladder cancer within years aft er nephroureterectomy, and the median interval between surgery and intravesical recurrence was . months (range to months). multifocal tumors, native aristolochic acid nephropathy and distal ureter invasion were determined as risk factors for intravesical recurrence by univariate analysis. however, by multivariate analyses, multifocality (hazard ratio = . , % ci = . - . , p = . ) and native aristolochic acid nephropathy (hazard ratio = . , % ci = . - . , p = . ) were identifi ed as independent predictors for the development of recurrent bladder cancer aft er surgery for uut-uc in renal transplant recipients.conclusions: th e incidence of intravesical recurrence aft er laparoscopic nephroureterectomy for uut-uc in renal transplant recipients is high, and most subsequent bladder cancers recur within years aft er surgery. tumor multifocality and native aristolochic acid nephropathy are signifi cant independent risk factors in developing initial intravesical recurrence aft er laparoscopic surgery for primary upper urinary tract urothelial carcinoma aft er renal transplantation.introduction and objective: transient urinary incontinence may occur in up to % of patients aft er holmium laser enucleation of the prostate (holep). however, there are few published data concerning the factors associated with de novo urinary incontinence (ui). th e aim of this study was to investigate the associated factors of de novo ui aft er holep. our study included patients who underwent holep. enrolled patients were divided into two groups according to the presence of ui. independent t test was used to compare between two groups. logistic regression was performed to analyze a correlation between de novo ui and other factors such as age, prostate volume, retrieved tissue weight, operative time, and the fi rst post-void residual (pvr) urine volume immediately aft er removing postoperative urethral catheter. urethral catheter was removed aft er bladder instillation with a ml normal saline via urethral catheter, and pvr urine volume was estimated immediately aft er the fi rst postoperative self-voiding. all defi nitions of ui corresponded to recommendations of the international continence society.results: aft er holep, patients ( . %) had de novo ui, most of which resolved within - months; had stress ui, had urgency ui, and had mixed ui. age and pvr urine volume were signifi cantly higher in ui group than non-ui group ( . ± . vs. . ± . years; p = . , . ± . vs. . ± . ml, p < . ). in a logistic linear regression analysis, only pvr urine volume was an independent predictor of de novo ui aft er holep. th e most optimal cut-off value of pvr urine volume for predicting de novo ui was defi ned as . ml in the receiver operating characteristics curve analysis (sensitivity, . %; specifi city, . %; auc, . ; p < . ).conclusion: about one-third of patients might undergo de novo ui following holep, and most of them might have been resolved within - months. high pvr urine volume aft er removal of postoperative urethral catheter is associated with de novo ui aft er holep, and could be used a practical tool to predict postoperative de novo ui. concomitant transurethral and introduction and objective: stress urinary incontinence is a common medical problem among women. th e urethral closure complex and/or the support mechanisms are responsible for incontinence in the majority of patients. several surgical procedures with diff erent degrees of invasiveness and outcomes have been reported to treat the problem. although many are reasonably eff ective, a general trend towards study of natural and biocompatible tissues is emerging over popular synthetic materials. here we report our experience with injection of autologous adipose-derived stem cells to the periurethral region as a new method of stress urinary incontinence treatment. ten women with symptoms of stress urinary incontinence were treated by injections of autologous adipose-derived stem cells into the periurethral region via transurethral and transvaginal approach under urethroscopic observation. th is report presents the short-term outcome of the patients. th e outcome measured by pad test results, iciq-sf scores and qmax.results: th e mean age of the participants was . ± . years. urinary incontinence signifi cantly decreased through the fi rst two, and weeks aft er the injection therapy. th e diff erence was signifi cant in pad test results (p< . ) and iciq-sf scores (p< . ), especially comparing results between and weeks and among and weeks, but not for and weeks compared to each other. surprisingly, qmax showed improvement aft er the study period (means . vs. . ; p= . ). th is study showed that injection of the autologous adipose-derived stem cells to periurethral region is a safe, yet shot-term eff ective treatment option for stress urinary incontinence. further studies with longer follow-up are needed to confi rm its longterm effi cacy. sparc sling system for treatment of female stress and mixed urinary incontinence in the elderly sung l, noh c, chung j, yoo j introduction and objective: th e aim of this study was to investigate the safety and effi cacy of the suprapubic arch (sparc) sling procedure for the management of urinary incontinence in elderly versus younger women. a total of women underwent the sparc procedure for female urinary incontinence. of these patients, were classifi ed younger women (sui, . mui, ) and (sui, . mui, ) were elderly (more than year). th e preoperative evaluations included a complete medical history, a female bladder questionnaires, urogynecological examination and urodynamic test with valsalva leak point pressure (vlpp). th e main outcome measures were perioperative morbidity, postoperative sui, persistent or de novo urge incontinence, postoperative complication and voiding dysfunction. th e objective and subjective success rate were evaluated by visual analogue score and global patient impression questionnaire at , , months. th e mean follow-up period was ± mo (range, - mo).results: th e incidence of sparc related morbidity was similar in both groups. for the operation outcome results, in younger group ( patients) there were cases of cure ( . %), cases of improvement ( . %), and cases of fail ( . %) and in elderly group ( patients) there were cases of cure ( . %), cases of improvement ( . %), a case of fail ( . %) (p> . ). th e operation satisfaction rate of patients was . % in the younger group and . % in the elderly group (p> . ). a total of patients ( . %) would like to recommend the sparc procedure to others. th e objective success rate and operation satisfaction rate of the younger group did not diff er from elderly group. no severe intraoperative or postoperative complications occurred in both groups.conclusions: th e sparc procedure is eff ective and off ers a satisfactory cure rate without signifi cant morbidity in elderly women. validity introduction and objective: urinary incontinence secondary to surgery or trauma is a debilitating condition for the patient, and for the urologist a diffi cult situation to manage. because of the complexity of reconstructive surgical techniques and the cost of the prosthetic devices used, there is a need for a simple procedure. aims: we here in report our experience in managing urinary incontinence secondary to sphincteric incompetence in patients using a modifi ed bulbar urethral sling procedure over a period of years. results: all patients were continent postoperatively, with only mild stress leakage in the erect posture in two patients, during a mean follow-up of . months (range - months) and required one or some time two pads per day to remain continent during the daytime. one patient required clean intermittent catheterization for a short period postoperatively. conclusions: th e male bulbourethral sling procedure using a polypropilene mesh is economical and safe but further experience is needed to establish this procedure as an alternative for the treatment of male urinary incontinence. investigation of a teikyo university, tokyo, japan; juntendou university, tokyo, japan introduction and objective: th is study compares the safety and benefi ts of administering anticholinergic agent propiverine hydrochloride in combination with adrenergic alpha- receptor antagonist silodosin (sp group) as therapy for patients diagnosed with benign prostatic hyperplasia with overactive bladder, as opposed to administering silodosin alone (s group). th is study included male patients aged or above who had an international prostate symptom score (i-pss) of or more, an overactive bladder, a qol index of or greater, an overactive bladder syndrome score (oabss) of or more along with an oabss urgency score of or greater, and a maximum urinary fl ow rate of < ml/s. at random, patients were assigned to the sp group, and to the s group. th e sp group was administered mg/day of silodosin along with mg/day of propiverine hydrochloride and the s group mg/day of silodosin only, for weeks respectively. i-pss, qol index, oabss urofl owmetry results, and residual urine were evaluated prior to therapy and , , and weeks post-therapy.results: th ere were no statistically signifi cant diff erences in patient background between the two groups. statistically signifi cant improvements were seen in i-pss total score, qol index, and oabss weeks post-therapy, but there were no statistically signifi cant diff erences between the two groups. both groups refl ected statistically signifi cant improvements in i-pss storage symptom scores and voiding symptom scores, but there were no diff erences between the two groups. analyzing by prostate volume, among those with lower prostate volume (average . ± . mm ), the sp group showed a statistically signifi cant improvement in i-pss total score and oabss as compared to the s "monotherapy" group. no serious side eff ects were shown in either group.conclusion: among benign prostatic hyperplasia patients with overactive bladder, those treated with silodosin alone showed statistically signifi cant improvements in both storage and voiding symptoms, as did those additionally treated with propiverine hydrochloride. results were even more benefi cial when both silodosin and propiverine hydrochloride treatment were used for patients with lower prostate volumes. the effi cacy and safety of fesoterodine in vulnerable elderly patients with overactive bladder takeda h, nakano y, narita h introduction and objective: we evaluated the efficacy and safety of fesoterodine in medically complex vulnerable elderly patients with overactive bladder. in this -week, patients were community dwelling men and women years old or older. patients with oab had scores of less or more on the ves- by nccn (vulnerable elders survey). we evaluated the changes of each parameter before and to weeks aft er the administration of fesoterodine mg per day. th e overactive bladder symptoms score (oabss), ipss were used as a subjective questionnaire for overactive bladder symptoms. we compare between vulnerable elderly group and no-vulnerable elderly groups. statistical comparisons before and aft er the administration were made using the wilcoxon signed-rank test. to examine the relation between oabss and ipss, spearman's testing was used for correlations between independent variables and p< . was considered statistically significant. safety evaluations included self-reported symptoms and post-void residual volume.results: a total of patients were enrolled (mean age . years, . % age years or greater). th e vulnerable elderly patients had high rates of comorbidities, polypharmacy and functional impairment. at week both group had insignifi cantly greater improvements in oabss (p= . ) and ipss (p= . ). adverse eff ects were generally similar.conclusions: fesoterodine improved overactive bladder symptoms not only in no-vulnerable elderly patients, but also in vulnerable elderly patients. the effectiveness and tolerability of fesoterodine mg in "real world" outpatient clinical settings the benefi cial effect of a combination of solifenacin and mirabegron on oab patients persu c, paraianu b, nita g, geavlete p introduction and objective: th e development of a new drug class intended for the treatment of oab patients opened a new and promising era for our patients. th e current study aims to evaluate the eff ects of a combination therapy using an antimuscarinic and mirabegron. we designed a prospective study including oab patients with or without wet episodes. treatment was started with two months of solifenacin mg, then mirabegron mg was added for the next two months. th e patients were evaluated using a bladder diary for three consecutive days at the end of each treatment period. we compared the total number of voidings, the number of urgency episodes and the number of urge incontinence episodes. th e statistical analysis included only the patients who fi nished the whole four month period. a total of fourteen female sprague-dawley® rats weighing - g were used, which were randomly divided into two groups. both the experimental group and the control group, fourteen rats were inserted intrathecal catheter in the spinal l -s segment. seven days later, all rats were catheterized through the bladder dome for saline-fi lling cystometry. in experimental group, seven rats were given intrathecal diff erent concentration ketanserin ( . - . mg/kg) dose-response curves for ketanserin were followed by doi ( . mg/kg) test.in control group, seven rats were given intrathecal normal saline. all rats were intravascularly perfused with % paraformaldehyde aft er the completion of the urodynamic recordings. th e l -s spinal cord were removed and pathological sections and immunohistochemical staining were made. meanwhile, we observed and recorded the distribution of -ht a receptors in the spinal motor neuron. results: th irty-four patients were included in the study. twenty-four of them completed the follow-up. twenty-one were female and were male with an average age of . years ( - years). detrusor sphincter dyssynegia was the most common abnormal urodynamic fi ndings in these patients. th ere was an improvement in bladder capacity, detrusor and sphincter action following de-tethering surgery.conclusion: urodynamics should be considered as a part of preoperative evaluation in all patients with primary tethered cord syndrome to decide the urological aspect of management. urinary bladder reinnervation with creation of a "somato-autonomic" refl ex pathway in rabbits -s ) and detrusor muscle (recipient, s -s ) were located. aft er their resection, intradural anastomosis of donor root to the recipient distal root stub was performed. th ose roots whose stimulation elicited the largest response were always selected. aft er - months (mean months), the artifi cial refl ex arc's function was examined (to date in rabbits). under general anaesthesia, skin segments l -s were peripherally stimulated and then the spinal root above the anastomosis was stimulated. detrusor response was measured using an emg strip electrode and intravesical pressure (pves) monitoring and sphincter response using an emg needle electrode. a root sample from under the anastomosis was resected for histology.results: electromyography confi rmed detrusor response to peripheral skin stimulation in ( %) animals and sphincter response in ( %). five ( %) animals displayed elevated intravesical pressure (pves) up to cm h o. root stimulation induced detrusor and sphincter emg response in ( %) and ( %) rabbits, respectively, and ( %) animals displayed increased pves up to cm h o. micturition was not induced in any animals. with confi rmed detrusor contraction (emg, elevated pves), external sphincter activity was never inhibited. somatic-to-autonomic anastomosis creation was histologically confi rmed in all samples. hind limb paresis occurred in ( %) animals and spinal lesion in ( %).conclusion: lumbar-to-sacral-nerve rerouting is a technically manageable method with donor root fibres verifi ably joining recipient roots. only in a limited percentage of cases, however, can the method achieve positive functional results, i.e. demonstrable detrusor contractions and elevated intravesical pressure. physiological micturition without detrusorsphincter dyssynergia as described in the literature did not occur in our experiment. development in this study, we evaluate the effi cacy of the prototype intravesical pressure sensor integrated into a catheter-like tube and in the rabbit and biocompatibility of ecofl ex® as a packing materials in the rats. th e catheter type wireless pressure sensor is manufactured by direct inserting the prototype sensor into the port split from the feeding tube between the sensor and the port so the tube could hold the bladder pressure. th e tip of the tube is results: th e measured resonance frequencies and the pressure data converted from those signals were compared to the reference pressure data obtained from a conventional cystometry. th e scale factor of the sensor to correlate the prototype sensor resonance frequencies to the reference pressure data is - . kpa/ mhz (=- . mhz/kpa), comparable to the result of its in-vitro measurement, a pressure responsivity of - . mhz/kpa. increased macrophage activity and mif in the bladder were revealed in the early phase aft er implantation of ecofl ex®. however, decreased macrophage activity and mif in the bladder were observed in the later aft er implantation. furthermore, decreased infl ammatory cytokines were also observed at that time. in this study, we demonstrated the feasibility of the catheter type which is non-invasive method and easy to apply to patients in actual examination. further investigation to overcome the limitation of the prototype intravesical pressure sensor is necessary for the application to the real life practice. in addition, ecofl ex is biocompatible materials for the implanted medical devices in the bladder. introduction and objective: urethral pressure profi le (upp) is a primary method for evaluating urethral continence function in human beings. however, upp recording in female rat, a widely used animal model, has been challenging because of the animal's small body size. th is study reports a novel method for recording upp in female rats. seventeen anesthetized female rats were studied. leak-point pressure (lpp) data of rats were included; the other rats were excluded due to animal die or abnormal urogenital organ. upp curves were recorded using a modifi ed method of water-perfusion catheter system, with the lateral hole facing -, -, -, -o' clock positions respectively in a randomized sequence. lpp, functional urethral length (ful), and maximum urethral close pressure (mucp) were the analysis parameters. in the era of aging society, an easy-to-use screening tool for voiding dysfunction refl ecting to activity of daily life is much-needed. bladder diary (frequency volume chart) is gold standard to check urine storage status, but diffi cult for elderly to measure and record all the time. urofl owmetry is useful to check voiding status, but limited to clinics or hospitals. we developed a portable device, p-urofl owdiary®, which records every urine fl ow with bladder diary at home. we elucidate the feasibility and the usefulness of this device. materials and methods: p-urofl owdiary® records voiding time and date, length of voiding, voided volume, fl ow rate and self-evaluation of every urination for a couple of days with gravimetric determination method. th e device consists of a disposable urine cup, a load cell and the circuit board on which microcomputer, clock, acceleration sensor, audio guidance, bluetooth and sd card mounted. self-evaluation of every urination is recorded by pushing one of the four buttons on the body-side, which represent "very good", "good", "bad" and "very bad". th e data in sd card are analyzed using the dedicated soft ware. accuracy of the measurement has been approved in a comparative study of the device and an existing urofl owmeter. th e infl uences of hand shaking are canceled by acceleration sensor and are smoothed by the soft ware.results: th e feasibility study were done under the approval of irb of nara medical university. first semester study in healthy volunteers focused on user-friendliness. th e results were almost acceptable except for female volunteers, especially in elderly. th e urine volume and peak fl ow rate as well as self-evaluation were linearly related in volunteers who measured multiple sessions. a clinical trial in patients with voiding dysfunction is in operation in seven institutions, and summarized data will be reported.conclusion: p-urofl owdiary® is light and small and easy-to-use at home even in elderly. although its practical usefulness as voiding diary have been proved, the usefulness as urofl owmetry and self-evaluation of every urination is not clarifi ed yet. however, p-urofl owdiary® seems to be a useful tool for screening of voiding dysfunction as well as assessment of therapeutic performance. to determine the continence position and the contributory factors in the female canine urethra. materials and methods: by using adult female dogs, we determined the continence function of each mm intervals of the urethra when we excluded these segments by progressively inserting a fr catheter and recording the abdominal leak-point pressure (alpp). th e urethral pressure profi le (upp) and alpp were determined before and min aft er occlusion of the abdominal aorta. each urethra specimen was split into segments averagely and the histological components were determined. th e relationship between the histological components and the urodynamic parameters were analyzed.results: th e striated muscle confi ned to the distal / urethra. th e anatomic structure of the proximal / urethra was found to be quite homogenous, which surrounded by circular smooth muscle. th e connective tissue constituted with abundant collagen fi bers and vascular plexus was most voluminous in the distal / urethra, and relatively richer near the bladder neck. upp had pressure zones: high pressure zone corresponding to the distal / urethra and low pressure zone corresponding to the proximal / urethra. alpp decreased sharply when exclusion progressed over the distal / urethra. alpp and mucp decreased about % and % aft er occlusion of aorta, respectively. th e distribution of the urethral pressure or pressure change is in accordance with the location of the striated muscle sphincter; there is no linear correlation with any other particular tissue component in the diff erent urethral segments.conclusion: th e strongest continence function locates at the distal / urethra with striated muscle layer; the remaining / proximal urethra lacking striated muscle has only weak continence function. striated muscle is the predominant contributory factor to continence and the other components like vascular sinusoids, smooth muscle, collagen fi bers are minor contributory factors. urodynamics in children: a -year experience persu c, mirciulescu v, geavlete p introduction and objective: urodynamics, in the modern defi nition of the term, developed rapidly from a state of the art gadget into an extremely useful tool in the armamentarium of the modern practitioner, who is no longer accepting the clinical exam as the mainstay of the diagnosis, but requires more and more in-depth data from paraclinical investigations.our study aims to review the particular aspects of the urodynamic examination in children. we retrospectively reviewed the data from our archive in patients aged less than years old, examined in our department in the last years. for analysis purposes, patients were divided into two groups, less than years old and more than years old, considering that compliance during the examination improves greatly with age. a total of children were evaluated, in the fi rst group and in the second. we noticed changes in the procedure over time, due to the lack of standardization.results: th e main conditions behind the urinary symptoms were spina bifi da, myelomeningocele, cerebral palsy, spinal cord injury, frontal dementia. children with chronic conditions showed a signifi cantly better compliance during the examination, providing "cleaner" traces and shorter examination times. in cases ( %), the results of the exam were considered unreliable. in the fi rst group, sensations are recorded in only cases ( %), the other traces are marked as pain or crying. in the second group, the sensations are reported by children ( %). in six cases ( %), more than one examination was available, and the intra-individual variability was higher than in adult patients. urodynamics in children is a challenging, yet useful investigation, which requires both a state-of-the-art equipment and dedicated and highly professional staff . th e main question when thinking about urodynamic testing in children is not whether it can be done, but if it is really needed for the management of the patient, keeping in mind not only the benefi ts but also the potential harm that it can do. the underactive bladder syndrome: a single center experience persu c, geavlete p introduction and objective: detrusor underactivity (uab syndrome) is defi ned as a contraction of reduced strength or duration, leading to obstructive symptoms of the lower urinary tract. our study aims to review our clinical experience with such cases. we reviewed the electronic fi les of the patients diagnosed with uab aft er urodynamics in the past years. our review focused on the referral diagnosis and other associated conditions, as well as on the symptoms reported by the patient during history taking or the examination itself. we tried to correlate symptoms with the parameters obtained during urodynamics. th e initial treatment offered was also recorded.results: a total of patients ( males, females) were analyzed. th e most common referral diagnosis was bladder outlet obstruction ( pts - %), followed by oab syndrome ( pts - %) and other conditions ( pts - %). most patients reported signifi cant dysuria ( pts - %), sensation of incomplete voiding ( pts - %) and the need for straining in order to void ( pts - %). other reported symptoms include recurrent utis ( pts - %), urgency ( pts - %), frequency ( pts - %) and urinary incontinence ( pts - %). th e initial treatment consisted of self-catheterization ( pts - %), α blockers ( pts - %), suprapubic cystostomy ( pts - %), double voiding ( pts - %) and neurostimulation ( pts - %).conclusion: th e most common causes for uab include neurogenic conditions and obstructive symptoms associated with aging. th ere are no specifi c symptoms to support this diagnosis but some might suggest it stronger than others. urodynamic evaluation is mandatory to assess the parameters of this condition. underactive bladder: clinical features, urodynamic parameters, and treatmenthoag n, gani j introduction and objective: underactive bladder is a complex clinical condition that remains poorly defi ned in the available literature. we aim to determine its prevalence among those with voiding dysfunction, presenting symptoms, risk factors, urodynamic fi ndings, and treatment undertaken. a retrospective chart review was conducted on consecutive urodynamic studies performed for voiding dysfunction between and , to identify patients with detrusor underactivity. underactive bladder was defi ned as bladder contractility index less than . charts and urodynamic tracing were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken.results: th e prevalence of underactive bladder in this series was % ( / ). average age was . (range - ). women represented . % ( / ) of patients. th e most common reported symptoms were: urinary urgency ( . %), weak stream ( . %), straining ( . %), nocturia ( . %), and urinary frequency ( . %). prior pelvic surgery and prior back surgery was noted in . % and . %, respectively. most common management was intermittent self-catheterization at . %, followed by observation/conservative treatment at . %, and sacral neuromodulation at . %.conclusion: underactive bladder is common, yet precise diagnosis and treatment remains nebulous. th ere exists signifi cant overlap in symptoms compared to other bladder disorders, and urodynamic evaluation is useful in determining those patients with impaired detrusor contractility. th is will help prevent mismanagement of these patients with surgery or medical therapy that may worsen their condition. th ere remains much work to be done to better understand this condition, and establish optimal management for patients. what is the relationship between the size of a patient's medical notes and their fitness?birring a, jelski j, burns-cox n introduction and objective: assessment of patients' co-morbidities is necessary when considering treatment options. comorbidity tools exist but aren't always used outside of studies. clinicians may infer a patient's fi tness from the size of their notes. th is is particularly apparent in multidisciplinary meetings when the patient, and sometimes the referring clinician, is absent. we aim to establish if any correlation exists between the thickness and weight of medical notes and patient comorbidity. th ickness and weight of medical notes was measured for consecutive patients admitted to a urology/surgical ward. comorbidity was assessed using the charlston comorbidity index (cci).results: mean (and range): age ( - ) years; thickness . ( . - . ) cm; weight ( - ) g; cci . ( - ). male to female ratio : . pearson's correlation (r) between thickness and cci was . (p= . ). th e correlation between weight and cci was . (p= . ). regression analysis showed, an . cm increase in thickness gives in a -point increase in cci (p= . ); and a g increase in weight gives a -point increase in cci (p= . ).conclusion: th ere is a statistically signifi cant relationship between the thickness and weight of a patient's notes and their cci (p= . ), but the strength of this relationship is extremely weak (r= . and . ). on average, an . cm or kg diff erence in size has only a -point diff erence in cci. th is change may reduce the -year survival of a patient by as little as %. size of notes is a highly misleading indicator of fi tness. patients should have a formal comorbidity assessment before deciding treatment options.did you know? siu academy... the endorsed event programme allows approved webcasts from high-quality meetings around the world to be presented and shared on the portal.off ers a wide range of content eligible for selflearning cme credits non-accredited content is eligible for self-learning credits. contact your national accreditation body to fi nd out how. navigate the portal to its full potential by using the top and bottom panels. this allows you to narrow down your search by selecting the type of content, topic, sub-topics and labels to fi nd exactly what you are looking for. what's trendingthe what's trending page gives you an overview of featured content and the most recent material at a glance. the "rate & comment" feature allows you to share your feedback on every piece of material available on the portal. share exciting new content with colleagues through facebook and twitter at the click of a button.www.siu-urology.orgregister today! siu academy reaches over , users.are you one of them?siu members span over countries and represent the full spectrum of clinicians and investigators from all the urological subspecialties, including established academic and non-academic urologists, as well as physicians undergoing full-time training in urology.siu membership gives you an equal voice in this influential organization. we believe that each member can contribute the knowledge and experience needed to forge valuable links between urologists, and between developed and developing nations. by working together, our members carry on the tradition of creating positive change in a changing world. as a new member, you will be a partner in the one urological association dedicated to creating sustainable educational projects and providing and improving urological resources worldwide.members are able to vote for siu leadership, organize siu-endorsed educational activities, become involved in the congress scientific programme, as well as contribute to various siu academy programmes. we strive to make each member feel valued, respected, and supported.the siu network, both virtual and live, is an unparalleled pool of global contacts. siu brings urologists together. key: cord- -x f ahr authors: nistal, manuel; paniagua, ricardo title: non-neoplastic diseases of the testis date: - - journal: urologic surgical pathology doi: . /b - - - - . - sha: doc_id: cord_uid: x f ahr nan testicular biopsy infertility and chromosomal anomalies other syndromes associated with hypergonadotropic hypogonadism secondary idiopathic hypogonadism hypogonadism secondary to endocrine gland dysfunction infertility secondary to physical and chemical agents infertility in patients with spinal cord injury orchitis histiocytosis with testicular involvement non-neoplastic diseases of the testis manuel nistal, ricardo paniagua chapter embryology and anatomy of the testis embryology sexual differentiation is the result of complex genetic and endocrine mechanisms that are closely associated with the development of both the genitourinary system and the adrenal glands. formation of the bipotential gonad and, subsequently, of the ovaries and testes, depends on gene expression in both sex and autosomal chromosomes. testes secrete steroid and peptidic hormones that are necessary for the development of inner and outer male genitalia. these hormonal actions are mediated by specifi c receptors that are transcriptional regulators. alteration of these genetic events leads to sexual dimorphism involving the inner and outer genitalia, and can also hinder the development of other organs. chromosomal gender is established at fecundation with formation of an egg with either a xy (male) or a xx (female) karyotype. each chromosomal constitution initiates a cascade of genetic events leading to the development of female (ovaries) or male (testes) gonads (gonadal gender). hormonal secretions from the ovaries or testes are essential for the development of external genitalia (phenotypic gender). the relationship between the individual and the environment determines the social gender. there are multiple genes involved in the formation of the undifferentiated gonad. the two most important for the proper formation of the bipotential gonad are wt (wilms' tumor gene) and nr a ( fig. - ). wt contains exons located on chromosome p , with two alternative splicing loci in introns and . intron splicing can lead to the inclusion or exclusion of three amino acids (kts: lysine, threonine and serine), giving rise to kts+ or kts− isoforms. an adequate kts+/kts− balance is crucial for normal expression of the gene. translation of this gene may generate up to isoforms with several zinc-fi nger domains. this gene is expressed mainly in the kidneys and gonads, and mediates the transition from stroma to epithelium and morphogenetic differentiation (inhibits those genes that encode proliferative factors and activates those that enhance epithelial differentiation). wt gene anomalies lead to a wide variety of phenotypes; deletions are associated with minimal genitourinary alterations and predisposition to develop wilms' tumor. [ ] [ ] [ ] missense heterozygous mutations give rise to denys-drash syndrome (complete or partial xy gonadal dysgenesis, renal disease of early onset with diffuse mesangial sclerosis, and wilms' tumor (omim ) ). loss of the kts+ isoform accounts for frasier's syndrome ( xy gonadal dysgenesis, renal disease of late onset and absence of wilms' tumor (omim )). nr a gene product is termed sf- (steroidogenic factor ). the gene has seven exons in chromosome q . , and is expressed in the urogenital ridge that forms the gonads and adrenal glands. sf- promotes the expression of the anti-müllerian hormone (amh) and joins elements that regulate upstream the amh gene. sf- is fi rst detected in the developing sertoli cells of sex cords, but later is mainly localized in leydig cells. a heterozygous deletion causes a female phenotype in patients with xy, adrenal failure during the fi rst weeks of extrauterine life, persistence of normal müllerian structures, and gonads consisting of poorly differentiated tubules embedded in abundant connective tissue. these patients do not respond to hcg stimulation. in xx patients, ovarian development is not modifi ed by sf- mutations, and they present with adrenal failure only. lim- is another gene involved in the formation of the bipotential gonad and kidneys. it was recently identifi ed in mice that bore homozygous deletions and presented alterations in both organs. fgf- (fi broblastic growth factor ) has also been related to gonadal development. both gonosomal and autosomal genes mediate the progression of the bipotential gonad toward testicular differentiation. the signal is triggered by the sry gene on the distal portion of the short arm of the y chromosome (sexdetermining region of the y chromosome; yp . ), also called tdf (testis determining factor gene). this gene stimulates the differentiation of sertoli cell precursors and germ cells, is responsible for the production of the anti-müllerian hormone, and regulates other genes of the downstream cascade. these are either activated or inhibited by other genes in such a way that dozens of genes are involved in testicular differentiation. the sry gene contains a single exon that encodes a amino acid protein whose central part ( amino acids) encodes a dna-binding domain termed hmg (high mobil- ity group). immunohistochemical studies have demonstrated expression of the sry gene in the nuclei of both sertoli cells and germ cells, suggesting that this gene acts in somatic cells of genital ridge and germ cells. sry works with the amh promoter gene and also regulates steroidogenic hormone expression. sry mutations produce pure gonadal dysgenesis (swyer's syndrome) or true hermaphroditism; the karyotype of patients with the male phenotype lacking y chromosome is either xx sry+ ( %) or xx sry− ( %), and all have male external genitalia, testes, azoospermia and no müllerian structures. some xx srypatients have sox- duplication. following discovery of the sry gene, the knowledge about genes involved in gonadal formation advanced experimentally with knockout mice and the study of human syndromes. now, there are numerous reported genes (including sox- , sox- , dax- , lhx- , lim- and dmrt- ) that encode associated transcription factors. sox- and sox- (sryy box and or sry hmg-box gene ) are related to autosomal genes. sox- is on chromosome q , q , and is expressed after sry expression in the same cell type (the pre-sertoli cell). this gene is also essential for the development of the cartilaginous extracellular matrix. in the mouse gonad, sox- inhibits testicular development or sertoli cell marker expression, and the gonad acquires an ovarian pattern. sox- haploinsufficiency (loss of a functional allele) causes camptomelic dysplasia (a syndrome characterized by abnormal formation of cartilage) and a xy constitution with female phenotype, , whereas sox- duplication results in xx patients with male phenotype. sox- is other cofactor in amh regulation and acts by protein-protein interaction with sf- . experimental models show that sox- dysfunction results in replacement by sox- expression via a feedback mechanism. dax- (dosage-sensitive sex-reversal, adrenal hyperplasia, x-linked) gene is involved in the development of testes, ovaries, and adrenal glands. dax- , on x chromosome, is expressed during ovarian formation and inhibited by sry during testicular formation. duplication of the dax- region in xp results in xy gonadal dysgenesis. , conversely, dax- mutations decrease gene expression, resulting in absence of adrenal cortex and hypogonadotropic hypogonadism; testicular determination is normal. deletions in chromosomes p and q are associated with the female phenotype in xy individuals. chromosome p deletions are also associated with facial malformations, premature closure of the frontal suture, hydronephrosis, and delayed development. deletions of two genes (dmrt and dmrt ) on chromosome p . may be found in xy females. terminal deletions in chromosome q are associated with genital malformations, multiple phenotypic anomalies, and mental retardation. in the fourth week of gestation, the urogenital ridges appear as two parallel prominences along the posterior abdominal wall. these give rise to two important pairs of structures: the genital ridges arising from the medial prominences, and the mesonephric ridges from the lateral prominences. the genital ridges are the fi rst primordium of the gonad and stand out as a pair of prominences about the midline. in - -day embryos, each genital ridge is lateral to the aorta and medial to the mesonephric duct ( fig. - ) . the celomic epithelium forming the genital ridges grows as cordlike structures to create the primary sex cords. immediately beneath the celomic epithelium there are several mesonephric ductuli and glomeruli ( fig. - ) . the origin of the gonadal blastema results from the junction of two cell types: epithelial cells from the celomic epithelium and mesenchymal cells from the mesonephric region, , although experimental data are confl icting. one of the earliest effects of sry expression is induction of mesonephric cell migration toward the genital ridge. , histochemical studies revealed that an early event is also disruption of the celomic epithelium basal lamina, permitting the migration of these epithelial cells inside the gonad. if chromosomal constitution is xy, these cells give rise to sertoli cells. cells derived from the celomic epithelium are recognized by their pale cytoplasm, large size, embryology and anatomy of the testis the rete testis originates from mesonephric remnants of sex cords that are in continuity with the seminiferous cords. the connection between the testis and the mesonephros becomes progressively thinner ( fig. - ) . the testis has a round transversal section, and remains located between two suspensory ligaments: the cranial and the caudal, the latter of which gives rise to the gubernaculum. the development of the urogenital tract begins at the stage of the undifferentiated gonad, with the appearance of two different pairs of ducts: the wolffi an and the müllerian. the wolffi an ducts are formed in the mesonephros in the third week of gestation, when the cranial region of the segmented intermediate mesoderm gives rise to pairs of tubules (the nephric tubules) that are metamerically arranged. these tubules form the pronephros. on each side of the body, the tubules converge to form a longitudinal duct that opens in the celomic cavity. in the fourth week, the pronephros disappears and is replaced by another tubular system (derived from the intermediate mesoderm, which is not segmented) that forms the mesonephros. the medial ends of the mesonephric tubules do not open to the celomic cavity but are connected to glomeruli at one end and the wolffi an duct at the other. at the end of the second month of gestation, the mesonephros is replaced by the metanephros or defi nitive kidney. however, in the male, the most caudal mesonephric tubules and the wolffi an duct persist. the former give rise to the ductuli efferentes, and the latter forms the ductus epididymidis, the ductus deferens, the seminal vesicle, and the ejaculatory duct. both müllerian ducts originate from a longitudinal invagination of the celomic epithelium in the anterolateral aspect of the genital ridge. the cranial end of each duct is a funnel that opens in the celomic cavity. each duct runs parallel and lateral to the respective wolffi an duct and, as they pass caudally, the müllerian duct crosses over the wolffi an duct and lies medial to it. finally, the two müllerian ducts fuse into the uterovaginal duct. this elongates caudally up to the posterior and ovoid euchromatic nucleus. the cells of mesonephric origin are darker and have a mesenchymal pattern. initially, the genital ridges are devoid of germ cells. in the third week, primordial germ cells appear in the extraembryonal mesoderm lining the posterior wall of the yolk sac near the allantoic evagination. they are ovoid, measuring - µm in diameter, and are easily detected histochemically by a high content of alkaline phosphatase. the nuclei are spherical and possess one or two prominent central nucleoli. the cytoplasm contains mitochondria with tubular cristae, lysosomes, microfi laments, lipid inclusions, numerous ribosomes, and abundant glycogen granules. attracted by chemotactic factors, the primordial germ cells migrate along the mesenchyma of the mesentery and reach the genital ridge by - days. the seminiferous cords arise from the gonadal blastema. , many germ cells reach the seminiferous cords, but some degenerate during migration. the seminiferous cords are delimited from the stroma by a basement membrane and lose their connection to the celomic epithelium, which reduces its depth to one or two cell layers only. the intercordal mesenchyma, composed chiefl y of cells that migrated from the mesonephric stroma, differentiate later into myoid cells, leydig cells, fi broblasts, and blood vessels. up to the sixth week, the gonads appear similar, although the incipient testes have more numerous blood vessels, more abundant stroma, and a higher total dna content, suggesting more rapid growth. sertoli cells arise from somatic sex cord cells. these cells differentiate at the end of the seventh week from the somatic cells in the cords, develop adherent junctions between them and a basal lamina on the other cord surface, and begin to express amh. in the eighth week, leydig cells differentiate from the intercordal gonadal blastema, and immunohistochemical detection of β-hsd is apparently the fi rst step in this process. leydig cell development peaks during the th week, and numbers subsequently decrease progressively. aspect of the urogenital sinus, forming the müllerian tubercle. the wolffi an ducts terminate at either side of this tubercle. the remaining structures of the male genital system are derived from the urogenital sinus. epithelium with endodermal origin forms the prostate, the urethra, and the bulbourethral and periurethral glands. the primitive urogenital sinus derives from the cloaca, a structure that appears at the end of the fi rst month and which consists of a dilation of the terminal portion of the primitive posterior intestine. the cloaca is closed by the cloacal membrane. in the third week, mesenchyma proliferates in the outer aspect of the cloacal membrane to form the cloacal folds and the cloacal eminence. in the sixth week, the cloacal folds enlarge to form the genital (or urethral) tubercle. external to the genital folds, another mesenchymal thickening develops into the genital prominences or genital swellings. in the fi fth week, a septum forms, dividing the cloaca into two compartments. the anterior compartment is the primitive urogenital sinus that is covered by the urogenital membrane. the posterior compartment is the anorectal canal, covered by the anal membrane. the primitive urogenital sinus then divides into two new compartments: superior and inferior. the superior compartment is the vesicourethral canal that later forms the urinary bladder and the urethra. the inferior compartment is the defi nitive urogenital sinus that will develop later according to the gender. the development of the male genital system is directly infl uenced by the action of multiple hormones, including anti-müllerian hormone (amh), dihydrotestosterone (derived from testosterone), and the pituitary hormones folliclestimulating hormone (fsh) and luteinizing hormone (lh) . amh (müllerian inhibitory substance; mis), secreted by the sertoli cells, is a glycoprotein polymer consisting of two identical kda subunits linked by disulfi de bonds. [ ] [ ] [ ] it belongs to the tgf-β family and is synthesized as a amino-acid precursor protein with proteolytic cleavage at amino acids from the c terminal. cleavage is necessary to activate the hormone. amh is encoded by a . kb gene that comprises fi ve exons and is located on the p . region of chromosome . amh is secreted by somatic cells only in both sexes: sertoli cells in males and granulosa cells in females. it is detected by - weeks of gonadal development ( - weeks of gestation), probably as soon as germ cells make contact with pre-sertoli cells, a week before the müllerian ducts lose their responsiveness. , amh is at high concentration in the second trimester, but drops precipitously in the third trimester. levels rise again during the fi rst year after birth, are detectable during infancy and childhood, and fi nally drop defi nitively to undetectable levels at the onset of puberty. the secreted amount of amh is inversely correlated to the degree of sertoli cell maturation. amh regulation is incompletely understood. its expression is controlled by steroidogenic factor (sf- ), also called ad bp, which is an orphan nuclear receptor that acts as a transcriptional regulator of all steroidogenic genes. amh regulates sry expression, which in sertoli cells is detected immediately before amh expression. during puberty, amh is negatively regulated by androgens. amh acts on the testis, genital tract, and extragenital structures. it causes involution of the ipsilateral müllerian duct. action begins at the caudal testicular pole and progresses rapidly. in adults, remnants of the müllerian ducts include the appendix testis at the cranial end and the prostatic utricle (verumontanum) at the caudal end. amh also stimulates development of the tunica albuginea, formed by insertion of mesenchyma between the celomic epithelium and primordial sex cords. this mesenchyma is also the origin of collagenized connective tissue, with deposition of collagen fi bers in several layers that parallel the testicular surface. amh also hinders the entry of spermatogonia in meiosis. the best-known function of amh in the extragonadal system is the maturation of fetal lungs. testosterone is synthesized by the leydig cells. these fi rst appear among the sex cords in the eighth week of gestation, and their number increases to million per pair of testes by the th week, occupying about % of the testicular volume ( fig. - ). the relative number of leydig cells decreases from the th to the th week, owing to rapid enlargement of the testis during this period. however, the absolute number of leydig cells remains constant. from the th week to birth, the number of leydig cells decreases to million per pair of testes. testosterone synthesis begins after the th day of gestation. testosterone secretion is regulated by hcg and lh concentrations. hcg peaks between weeks and and drops markedly thereafter; hcg-dependent testosterone is the most important determinant of genital differentiation. wolffian duct differentiation occurs only as a response to the testosterone secreted by the ipsilateral testis. this secretion stimulates differentiation of the ductus epididymidis, ductus deferens, and seminal vesicle. anomalies in androgen synthesis lead to incomplete masculinization and cryptorchidism. dihydrotestosterone (dht) derives from testosterone by the action of the enzyme α-reductase and is responsible for differentiation of the prostate and the development of the external genitalia, male urethra, penis and scrotum. it induces fusion of the labioscrotal folds in the middle plane to form the scrotum and the middle scrotal raphe. the urethral folds become fused to form the penile urethra. the genital tubercle enlarges to form the glans penis. an ectodermal invagination of the glans tip forms the terminal portion of the urethra. the urogenital sinus gives rise to the urinary bladder, prostatic urethra, and prostate. the initial effects of dht (labioscrotal fusion) occur on approximately day ; the urethral groove is closed on about day ; and the external genitalia are completely developed by week . the actions of these hormones occur at precise moments in development. failure in the amount or timing of secretion or in the responsiveness of target tissues causes most of the malformations found in intersex conditions. fsh and lh both play an important role in the last months of gestation. lh appears in the fetal circulation during the th week and peaks by the th, decreasing progressively and slowly thereafter until birth. lh chiefl y regulates androgen production during the second half of fetal life. fsh is an essential mitogen for sertoli cells that reach the highest mitotic ratio at the end of fetal life ( fig. - ) . , testicular descent testicular descent is the result of hormonal and mechanical actions that are not fully understood. three steps are recognized: nephric displacement, transabdominal descent, and inguinal descent. in nephric displacement, the gonad detaches from the metanephros in the seventh week of gestation. transabdominal descent occurs in the th week and consists of the displacement of the testis towards the deep inguinal ring. inguinal descent occurs between the seventh month and birth. clinically, the term testicular descent often refers only to this last step, in which the testis passes from the abdominal cavity to the scrotum. testicular descent is directed by the gubernaculum testis, a structure that appears in the sixth week as an elongate condensation of mesenchymal cells extending from the genital ridge to the presumptive inguinal region. , at this level in the abdominal wall, the gubernaculum cells persist as a simple mesenchyma while the remaining abdominal wall cells differentiate into muscle. these mesenchymal cells give rise to the inguinal canal. thus, the testis lies on a continuous column of mesenchyma limited by the cranial testicular ligament in the upper pole and by the plica gubernaculi that joins the testis to the future scrotal region in the inferior pole. the periphery of this mesenchymal tissue is invaded by the processus vaginalis, which develops from a peritoneal pouch that grows into this mesenchyma. once the inguinal canal and the plica gubernaculi are formed, development slows. in the seventh month the processus vaginalis undergoes active growth, the cremasteric muscle develops from the mesenchyma outside the processus vaginalis, and the distal end of the gubernaculum enlarges markedly. gubernacular enlargement occurs from the th to the th weeks of gestation period and is caused by hyperplasia, hypertrophy, and the absorption of a great volume of water by the glycosaminoglycans of the matrix. the tissue is reminiscent of wharton's jelly of the umbilical cord. by this time, the testis-epididymis complex is pear-shaped and its largest component is the gubernaculum. the testis and epididymis slide through the inguinal canal behind the gubernaculum. simultaneously, development of the processus vaginalis is completed and the gubernaculum begins to shorten, the epididymis develops further, and the testicular blood vessels and vas deferens lengthen. testicular descent is a complex process integrating several essential factors, including normal function of the hypothalamopituitary-testicular axis, normal development of abdominal musculature, gubernaculum and the processus vaginalis, , and a testis with normal endocrine function. the critical role of normal hormonal function is supported by clinical and experimental observations: destruction of the hypophysis in laboratory animals impedes testicular descent; anencephalic fetuses usually have undescended testes; many cryptorchid patients have transitory neonatal hypogonadotropic hypogonadism; and some undescended testes descend after treatment with human chorionic gonadotropin or gonadotropin-releasing hormone. adequate intra-abdominal pressure is another requisite. , in the prune-belly syndrome, bilateral cryptorchidism is associated with urologic malformations and absence of the abdominal wall musculature. in a variant of this syndrome, termed pseudo-prune-belly syndrome, there is a positive correlation between the development of the abdominal wall musculature and testicular descent. development of the processus vaginalis also plays a critical role in testicular descent. this structure grows within the gubernaculum; if it is partially replaced by fi brous tissue, the testis will follow other directions in its descent and end in an ectopic location. if fi brous tissue completely replaces the gubernaculum, the processus vaginalis and cremasteric muscle fail to develop fully, and descent of the testis is mechanically blocked. the hormonal requirements for testicular descent are not clear. the most important factor in transabdominal descent is the androgen-independent peptide insulin-like factor (insf- ), a member of the relaxin-insulin family that is produced by fetal leydig cells. this peptide stimulates gubernaculum cells to initiate gubernaculum swelling, a necessary step for the initiation of testicular descent. mutations in insl- gene or its receptors lgrb- (leucine-rich repeatcontaining g protein-coupled receptor ) or great (g protein-coupled receptor affecting testicular descent) interfere with transabdominal descent and cause cryptorchidism. , amh and androgens are also involved in the gubernaculum swelling reaction; androgens also facilitate regression of the cranial suspensory ligament. uncertainty exists regarding the mechanism of inguinoscrotal descent and its hormonal control. androgens and the genitofemoral nerve are two factors strongly implicated in these processes. the role of androgens on the gubernaculum is very limited, because this structure has neither muscular cells nor androgen receptors at the time of testicular descent. androgenic effects are explained by the hypothesis of the genitofemoral nerve. androgens appear to act on the nucleus of the genitofemoral nerve in the spinal cord rather than directly on the gubernacula, producing masculinization of the neurons that form this nucleus (these neurons are much more numerous in males than in females) and secreting great amounts of calcitonin gene-related peptide (cgrp). in rats, cgrp causes rapid rhythmic contractions of the gubernaculum and it has been suggested that the gubernaculum might have embryonic cardiac muscle cells. however, it is also possible that cgrp acts on the cremasteric muscle that develops within the gubernaculum and is innervated by the genitofemoral nerve. this hypothesis is supported by the observation of neurogenic atrophy of this muscle in cryptorchid patients. other factors involved in testicular descent are estrogens and epidermal growth factor (egf). during the fi rst trimester of gestation, mothers of cryptorchid infants have free estradiol serum concentrations that are signifi cantly higher than those of controls. experimental studies have shown that estradiol diminishes gubernacular swelling and stabilizes müllerian ducts. it has been proposed that estradiol inhibits the cell proliferation that causes gubernaculum swelling. , egf may facilitate testicular descent throughout the placental-gonadal axis. maternal egf levels increase just before fetal masculinization occurs. the placenta has an elevated concentration of egf receptors, and placental stimulation by egf might stimulate hcg production, which may also stimulate fetal leydig cells to produce androgens; hypothetically, these and/or other factors may determine testicular descent. after birth, the gubernaculum and processus vaginalis regress. the gubernaculum is replaced by fi brous tissue that forms the scrotal ligament. the cephalic segment of the processus vaginalis atrophies after testicular descent. an exaggerated resorption of the processus vaginalis with pulling up of the testis may induce a testis that had descended normally to ascend, resulting in cryptorchidism. from birth to puberty the testis is a dynamic structure, an important consideration in interpreting biopsies from children. all testicular components undergo waves of proliferation and differentiation prior to puberty. three waves of germ cell proliferation occur: during the neonatal period, infancy, and puberty. the last gives rise to complete spermatogenesis. there also are three waves of leydig cell proliferation (fetal, neonatal, and pubertal); the last corresponds to the pubertal wave of germ cell proliferation. the testis at birth the newborn testis has a volume of about . ml and is covered by a thin tunica albuginea from which the intratesticular septa arise. these divide the testis into lobules containing the seminiferous tubules and testicular interstitium ( fig. - ) . the seminiferous tubules measure - µm in diameter, with no apparent lumina, and are fi lled with sertoli cells and germ cells. sertoli cells are the most abundant, with - cells per tubular cross-section ( fig. - ) . they form a pseudostratifi ed cellular layer and have elongated to oval nuclei with darker chromatin than that of mature sertoli cells, as well as one or two small peripheral nucleoli. the cytoplasm contains abundant rough endoplasmic reticulum, several golgi complexes and numerous vimentin fi laments, and expresses inhibin b (fig. - ) . no specialized intercellular junctions appear between sertoli cells, but desmosome-like junctions are present between sertoli cells and germ cells. two types of germ cell are present at birth: gonocytes and spermatogonia. gonocytes are usually located near the center of the tubules, with voluminous nuclei and large central nucleoli. gonocyte migration is probably facilitated by cell adhesion molecules such as p cadherin, which is expressed by sertoli cells of immature testes. spermatogonia are mainly located on the basal lamina, and possess smaller nuclei and less cytoplasm than gonocytes; the nucleoli are peripheral and very small. at birth, most spermatogonia correspond to the adult type a (see discussion on the adult testis below) ( fig. - ) . the testicular interstitium contains fetal leydig cells that resemble adult leydig cells but lack reinke's crystalloids ( fig. - ) . , additionally, mast cells, macrophages, and hematopoietic cell are present. the fi rst wave of testicular development occurs during the neonatal period and involves germ cells and leydig cells. these changes are caused by a signifi cant increase in secretion of both fsh and lh during the third postnatal month. - testicular weight and volume increase. lh stimulates the leydig cells to produce testosterone, , which stimulates the transformation of gonocytes to spermatogonia of the ad type ( fig. - ) . afterwards, some of these in some normal testes at this age, meiotic primary spermatocytes and round spermatids are observed ( fig. - ). this spermatogenic attempt fails and many degenerate germ cells may be present. , the testis continues to produce amh (by sertoli cells) and inhibin b. amh modulates the number and function of leydig cells by regulating differentiation of their mesenchymal precursors and the expression of steroidogenic enzymes. inhibin b plays a role in fsh inactivation during infancy. the cause of this second wave of germ cell proliferation is unknown; there is no elevation of fsh or lh serum concentrations between months and years of life. after the sixth year, there is a slight increase in adrenal androgens, but testicular testosterone levels increase only after the th year. , by the third year, most leydig cells have degenerated: from a peak of about million at birth, only remain by the age of years. at this age, testosterone levels embryology and anatomy of the testis divide to form ap spermatogonia (see discussion on the adult testis below). six months after birth, gonocytes are absent, coinciding with the loss of fetal germ cell markers (placental alkaline phosphatase and c-kit). paraganglia are often observed in epididymides and spermatic cords from newborns. this is not surprising, as paraganglia are the main source of catecholamine before birth ( fig. - ) . the testis in infancy from the sixth month to approximately the second half of the third year of life, the testis is in a resting period; this quiescence is broken by the second wave of germ cell proliferation. the number of ap spermatogonia increases, and b spermatogonia (derived from ap spermatogonia) appear. are similar to those of girls, and most androgens are of adrenal origin. at about years of age, the third and defi nitive wave of spermatogenesis begins, coinciding with a signifi cant elevation of lh. this is followed by additional increases in the level of this hormone between and years of age. lh induces fi broblast-like leydig cell precursors to differentiate into mature leydig cells. by the end of puberty, the population of leydig cells per testis has risen to about million. leydig cells secrete androgens, which, together with the rise in fsh between and years of age, cause sertoli cell maturation, germ cell development, and the appearance of tubular lumina ( fig. - ) , increasing the size of the testes between the ages of . and . years of life. at . years, before the testis reaches adult size, spermatozoa are present, secondary sex characteristics are completely developed, and the epiphyses close. testicular biopsy in children is useful for diagnosing those with ambiguous genitalia, a history of leukemia or lymphoma whose testes underwent a rapid enlargement, or precocious testicular maturation of unknown cause. in other situations, the value of testicular biopsy is less established. for example, the value of biopsy of cryptorchid testes during orchidopexy is controversial. evaluation of biopsies of the prepubertal testis should involve the assessment of several features, including tunica albuginea thickness, mean tubular diameter, and the number of germ cells, sertoli cells, and leydig cells. the most frequent anomalies of the tunica albuginea include thin, poorly collagenized tunica albuginea with abnormal tubules typical of testicular dysgenesis (see the section on male pseudohermaphrodites with müllerian remnants, below); well-collagenized tunica albuginea containing ectopic seminiferous tubules, a frequent fi nding in cryptorchidism; and poorly collagenized tunica albuginea containing ovocytes characteristic of true hermaphroditic ovotestes. the mean tubular diameter is an excellent indicator of the development of the seminiferous epithelium. in the prepubertal testis, tubular diameter depends principally on the sertoli cells and thus indicates whether they are adequately stimulated by fsh. tubular diameter varies throughout, being smallest in the end of the third year of life, slowly enlarging up to years of age, and rapidly enlarging thereafter up to years ( fig. - ) . the most frequent abnormality in the prepubertal testis is a low mean tubular diameter. this is seen in undescended testes as well as in hypogonadotropic or hypergonadotropic hypogonadism. in the latter, the lesion results from anomalous sertoli cell responsiveness to fsh. there are three levels of severity of low tubular diameter: slight tubular hypoplasia (up to % reduction in relation to the diameter normal for the age); marked tubular hypoplasia (from % to % reduction); and severe tubular hypoplasia (more than % reduction). many testicular biopsies show malformed seminiferous tubules that vary from straight or branched tubules up to ring-shaped. these are megatubules formed by either tight spiral or bell-shaped tubules. the presence of these malformations suggests the child will be infertile in adulthood. diffuse increase in mean tubular diameter may be unilateral or bilateral. unilateral increase is found in monorchidism (compensatory testicular hypertrophy) and some testes that are contralateral to cryptorchid testes. most frequently, diffuse enlargement occurs with benign idiopathic macroorchidism or macroorchidism associated with fragile x chromosome, familial testotoxicosis, hypothyroidism, or different forms of precocious puberty. focal increases in mean tubular diameter are usually associated with precocious maturation of the seminiferous epithelium layers, and occur at the periphery of some sertoli cell and leydig cell tumors. germ cells can be counted in two ways: calculation of the number of cells per tubular cross-section, or determination of the tubular fertility index. the former counts the number of germ cells in a light microscopic fi eld and divides this by the number of cross-sectioned tubules in the same fi eld. in the fi rst months of postnatal life the normal testis has two germ cells per cross-sectioned tubule. this number drops to . at the end of the fi rst year and to . at the end of the third year. the number of germ cells increases to . cells at the age of - years, which coincides with the appearance of spermatocytes in some tubules. the tubular fertility index refl ects the percentage of tubular sections containing germ cells. in newborns, % of tubular sections contain at least one germ cell. from birth to years this decreases to %, followed by a progressive increase to % at puberty. if the numbers of gonocytes and spermatogonia are calculated separately, it is possible to determine when the transformation of gonocytes to spermatogonia occurs. the most accurate measure is calculation of total germ cell numbers per testis. this is more diffi cult because it requires morphometric assessment of intratubular volume and careful clinical measurement of the three axes of the testis. congenital decrease of germ cells occurs in numerous conditions, including trisomies , , and , some forms of primary hypogonadism such as klinefelter's syndrome, anencephaly, many cryptorchid testes, and in patients with posterior urethral valves and severe obstruction of the urinary ducts. an increased number of germ cells may be seen at the periphery of germ cell tumor, gonadal-stromal tumor, and paratesticular sarcoma. at the periphery of leydig cell tumor, seminiferous tubular cellular maturation may be complete. three levels of severity of germinal hypoplasia are recognized: slight (tubular fertility index > ), marked (tubular fertility index between and ), and severe (tubular fertility index < ) ( fig. - ). marked and severe germinal hypoplasia is usually associated with marked or severe tubular hypoplasia, in most cases resulting from tubular dysgenesis. it also is useful to determine whether the seminiferous tubules devoid of germ cells are randomly distributed. if they are grouped, they probably belong to the same lobule or group of lobules that never will develop normally. other germ cells observed are multinucleate or hypertrophied spermatogonia and gonocyte-like cells; these latter may require immunohistochemical studies to exclude intratubular germ cell neoplasia. the number of sertoli cells per tubular cross-section varies during childhood as a result of slow proliferation from years to years and the redistribution of sertoli cells as the seminiferous tubules become longer and broader. the pseudostratifi ed cellular pattern characteristic of sertoli cells at birth changes slowly to a columnar pattern at puberty . testicular biopsies may reveal hypoplasia or hyperplasia of sertoli cells; hyperplasia is usually pronounced and a sign of tubular dysgenesis, often detected during the fi rst year of life or the beginning of puberty. some biopsies reveal one or several tubular sections containing sertoli cells with eosinophilic and granular cytoplasm that is positive to cd and α -antitrypsin. these oncocytic changes are the result of lysosomal accumulation. calculation of leydig cell numbers during childhood is diffi cult because at this age the population is scant. semi-thin sections or immunohistochemistry to detect testosteronecontaining cells may be helpful. selection of the appropriate denominator to express the leydig cell population is another problem. the most frequent measures are leydig cell number per tubular section, per unit area, or total number per testis. low numbers of leydig cell are observed in undescended testes, hypogonadotropic hypogonadism, some variants of male pseudohermaphroditism caused by a defect in the lh receptor, and in anencephalic fetuses. high numbers of leydig cells occur in congenital leydig cell hyperplasia, triploid fetuses, variants of precocious puberty, several syndromes such as leprechaunism and beckwith-wiederman syndrome, and in most male pseudohermaphroditisms. an apparent increase in loose connective tissue is found in patients with marked tubular hypoplasia; in addition, disordered thick fusiform cell bundles are seen in patients with androgen insensitivity. other alterations include the presence of excessively developed lymphatic vessels (lymphangiectasis), focal hematopoiesis, leukemic infi ltration, and the presence of cells similar to those of the adrenal cortex (tumors of the adrenogenital syndrome). embryology and anatomy of the testis the adult testis is an egg-shaped organ that hangs in the scrotum from the spermatic cord, the retroepididymal surface, and the scrotal ligament. mean weight in caucasian men is . ± . g for the right testis and ± . g for the left. mean testicular diameter is . cm (range, . - . cm) for the longest axis and . cm (range, . - . cm) for the shortest. [ ] [ ] [ ] [ ] testicular volume varies from to ml. the tunica albuginea and interlobular septa make up the connective tissue framework of the testis. the tunica albuginea consists of three connective tissue layers and an outer surface covered by mesothelium. from the outer to the inner layers, the amount of collagen fi bers decreases while the number of cells increases. the fi bers and cells in the two outermost layers form planes parallel to the testicular surface; cell types include fi broblasts, myofi broblasts, and mast cells. myofi broblasts are more numerous in the posterior portion of the testis. the thickness of the tunica albuginea increases with age from - µm in young men to more than µm in elderly men. it acts as a semipermeable membrane that produces the fl uid of the vaginal cavity. the presence of many contractile cells showing high concentrations of gmp suggests that the tunica albuginea undergoes impulses of contraction and relaxation. these cells might regulate testicular size and favor the transport of spermatozoa into the epididymis. the innermost layer, the tunica vasculosa, consists of loose connective tissue containing blood and lymphatic vessels. the interlobular septa consist of fi brous connective tissue with blood vessels supplying the testicular parenchyma. the interlobular septa divide the testis into approximately pyramidal lobules with their bases at the tunica albuginea and vertices at the mediastinum testis. each lobule contains two to four seminiferous tubules and numerous leydig cells. adult seminiferous tubules are - µm in diameter and - cm long. the total combined length of the seminiferous tubules is about m (range, - m). they are highly convoluted and tightly packed within the lobules. the seminiferous tubules comprise about % of testicular volume. the tubular lining of germ cells and sertoli cells is surrounded by a lamina propria (tunica propria) ( fig. - ). sertoli cells are columnar cells that extend from the basal lamina to the tubular lumen, with - cells per crosssectioned tubule. they are easily identifi ed by their nuclear characteristics. the nucleus is located near the basal lamina and has a triangular shape with indented outline, pale chromatin, and a large central nucleolus ( fig. - ). charcot-böttcher's crystals and lipid droplets often are visible in the cytoplasm. [ ] [ ] [ ] [ ] ultrastructurally, sertoli cells have characteristic nucleoli, plasma membranes, and cytoplasmic components. the nucleolus has a tripartite structure with a round fi brillar center, a compact granular portion, and a three-dimensional net composed of intermingled fi brillar and granular portions. [ ] [ ] [ ] the plasma membrane has two types of intercellular junction which develop at puberty: junctions between adjacent sertoli cells, and junctions between sertoli cells and germ cells. the inter-sertoli cell junctions are tightjunction complexes. the adjacent cytoplasm has numerous actin fi laments and parallel-arranged smooth endoplasmic reticula cisternae. in adjacent plasma membranes there are adhesion molecules, including connexin- . between the plasma membrane and the adjacent endoplasmic reticulum cisterna there are many molecules, including those required for actin fi lament anchorage, vinculin, zonula occludens- , plakoglobin, and radixin. the inter-sertoli cell junctions are the morphologic basis for the blood-testis barrier and divide the seminiferous epithelium into two compartments: the basal compartment (which contains spermatogonia and newly formed primary spermatocytes) and the adluminal compartment (which contains meiotic primary spermatocytes, secondary spermatocytes and spermatids). these junctions permit each compartment to have its own microenvironment for spermatogenic development. [ ] [ ] [ ] the sertoli cell-germ cell junctions persist from the primary spermatocyte stage through spermatozoon release. these junctions are desmosomes and gap-type junctions. the adhesion among sertoli cells and germ cells is mediated by n-cadherin. these junctions have also occasionally been observed between spermatogonia. sertoli cell cytoplasm contains abundant smooth endoplasmic reticulum, elongated mitochondria, annulate lamellae, lysosomes, residual bodies, glycogen granules, microtubules, vimentin fi laments around the nucleus , actin fi laments in both inter-sertoli cell junctions and ectoplasmic specializations that surround germ cells, lipid droplets in amounts that vary with the seminiferous tubular cycle, charcot-böttcher crystals (structures several micrometers long, formed of multiple parallel laminae of protein), and scant rough endoplasmic reticulum and ribosomes. the number of sertoli cells decreases with age, from about million per testis in young men to million in men over years. , there is a positive correlation between the number of sertoli cells and daily sperm production. sertoli cells are the target of fsh , and androgen action ( fig. - ) . in adulthood, they produce testicular fl uid through an active transport mechanism, and synthesize multiple products to ensure the nutrition, proliferation and maturation of germ cells, to stimulate other cells such as leydig cells and peritubular cells, and to contribute to hormonal regulation (inhibin secretion) (table - ). the transport of small molecules (< - da) such as pyruvate, lactate, and probably choline from the sertoli cell, to germ cells occurs through gap junctions. large or small soluble molecules are transported by proteins that are synthesized by the sertoli cell, and include androgen-binding protein, transferrin, ceruloplas-embryology and anatomy of the testis min, sulfated glycoproteins, α -macroglobulin, and γ-glutamyl transpeptidase. activin and inhibin are sertoli cell-secreted proteins that induce the proliferation and differentiation of germ cells. whereas activin stimulates fsh production and, subsequently, spermatogonial proliferation, inhibin b inhibits fsh secretion, and is an important marker of spermatogenesis. other sertoli cell secretions are interleukins, mainly il- , and growth factors such as transforming growth factor-β (tgf-β), insulin growth factors and (igf- and igf- ), and seminiferous growth factor (sgf) or stem cell factor (scf). some of these growth factors, such as tgf-α, tgf-β, and igf- , are involved in the regulation of leydig cell function. other secreted substances include clusterin, the steroid -α- -pregnen- -one ( hp), and prostaglandin d synthase (table - ) . sertoli cells are also involved in migration of differentiating germ cells towards the tubular lumen. this movement leads to a continuous remodeling of the plasma membrane and requires synthesis of several proteases, including urokinase, tissue-type plasminogen activator, cyclic protein , collagenase iv, other metalloproteins, and several antiproteases, such as cystatin c, tissue inhibitor of metalloproteinase type , and α -macroglobulin. the sertoli cell also regulates germ cell apoptosis by the production of fas-ligand, which binds to the fas-ligand receptor (apo- , cd ) in germ cell plasma membranes. in addition, sertoli cells possess receptors for several factors such as the nerve growth factor (ngf) produced by spermatocytes and young spermatids, emphasizing the complexity of the sertoli cell-germ cell relationship. sertoli cells also produce some steroid hormones (estradiol and testosterone) and several components of the seminiferous tubule wall, including laminin, type iv collagen, and heparin sulfate-rich proteoglycans. the germ cells of the adult testis include spermatogonia, primary and secondary spermatocytes, and spermatids . spermatogonia there are two types of spermatogonia: a and b. type a are about µm in diameter, rest on the basal lamina, and are surrounded by the cytoplasm of the adjacent sertoli cells. the nuclei of type a spermatogonia are spherical, contain several peripheral nucleoli, and have four different patterns: ad (dark), ap (pale), al (long), and ac (cloudy). , the cytoplasm of these spermatogonia contains a moderate number of ribosomes, small ovoid mitochondria joined by electron-dense bars, and lubarsch's crystals. these are several micrometers long and are composed of numerous - nm parallel fi laments intermingled with ribosome-like granules. ad spermatogonia are thought to be stem cells in spermatogenesis. some of them replicate dna and, during replication, acquire the al pattern. afterwards, they divide to make another ad (maintaining the stem cell reservoir) and an ap spermatogonium. during replication, ap spermatogonia become ac and then divide to form two type b spermatogonia. [ ] [ ] [ ] type b spermatogonia are the most numerous, and their contact with the basal lamina is less extensive than that of ultrastructural studies show coarse chromatin masses in which synaptonemal complexes and sex pairs may be present. the nucleolus acquires a peculiar appearance, with segregation of the fi brillar and granular portions. associated with the nucleolus is the round body that contains proteins but no nucleic acids. in the pachytene spermatocyte, homologous chromosomes are completely paired, and on electron microscopy the chromatin masses appear larger and less numerous than in the zygotene spermatocyte. in the diplotene spermatocyte, paired homologous chromosomes begin to separate and remain joined by the points of interchange (chiasmata); neither synaptonemal complexes nor sex pairs are observed. the diakinesis spermatocyte shows maximal chromosome shortening and the chiasmata begin to resolve by displacement towards the chromosomal ends. the nuclear envelope and the nucleolus disintegrate. the spermatocyte completes the other phases of the fi rst meiotic division (metaphase, anaphase and telophase), forming two secondary spermatocytes; the fi rst meiotic division lasts days. secondary spermatocytes are haploid cells, smaller than primary spermatocytes, and show coarse chromatin granules and abundant rough endoplasmic reticulum cisternae. these cells rapidly undergo the second meiotic division and within hours give rise to two spermatids. the newly formed spermatids differ from secondary spermatocytes, having smaller nuclei with homogeneously distributed chromatin. spermiogenesis the transformation of spermatids into spermatozoa is called spermiogenesis. during this process pronounced changes occur in the nucleus and cytoplasm. the nucleus becomes progressively darker and elongated. the cytoplasm develops the acrosome and fl agellum, the mitochondria cluster around the fi rst portion of the spermatozoon tail, and the remaining cytoplasm is phagocytosed by sertoli cells. , by electron microscopy, there are four tran-sient stages of spermatid development: golgi, cap, acrosome, and maturation. these correspond to those defi ned by light microscopy of nuclear morphology: sa, sb, sb , sb , sc, sd and sd . , these phases may be grouped as early (or round) spermatids that comprise the stages with round nuclei (sa and sb), and as late (or elongated) spermatids that comprise the stages with elongated nuclei (sc and sd). mature spermatids (sd ) are the spermatozoa that are released into the tubular lumen (spermiation). all the germ cells derived from the same stem cell remain interconnected by cytoplasmic bridges that ensure synchronous maturation during the spermatogenic process. cycle of the seminiferous epithelium at fi rst glance, the arrangement of the germ cells in the seminiferous tubules appears disorderly. however, closer study reveals that these cells are grouped into six successive associations, designated i-vi. in contrast to other mammals, in humans the volume occupied by each association is small, so that several associations may be observed in the same tubular cross-section. stereological studies have shown that the successive associations are organized helically along the length of the seminiferous tubule. , [ ] [ ] [ ] each association persists for a specifi c number of days (i, . days; ii, . days; iii, day; iv, . days; v, days; and vi, . days), and each successively transforms into the following one. finally, at the end of association vi, the cycle is repeated; the spermatogenic process requires . cycles. because each cycle lasts . days, the transformation of spermatogonium into spermatozoon takes days (fig. - ) . the succession of different associations probably depends on cyclic sertoli cell activity. cyclic changes in the mitochondria, rough endoplasmic reticulum, golgi complex, lysosomes, and lipid droplets have been reported. [ ] [ ] [ ] this cyclic activity is probably regulated by germ cell signals. the yield of human spermatogenesis is lower than that of embryology and anatomy of the testis the six different germ cell associations of the seminiferous tubules and the sequence of spermatogenesis. completion of spermatogenesis requires more than four cycles and lasts for approximately days. each association is indicated by roman numerals with its corresponding duration. ad: dark type of a spermatogonia; ap: pale type of a spermatogonia; b: b spermatogonia; i: interphase primary spermatocyte; l: leptotene primary spermatocyte; z: zygotene primary spermatocyte; p: pachytene primary spermatocyte; ii: secondary spermatocyte (only in stage vi). s a , s b , s b , s c , s d , and s d represent the progressive stages of spermatid differentiation into spermatozoa. most mammalian species, including primates, with maximal cell degeneration occurring at the end of meiosis. the seminiferous tubule is surrounded by a µm thick lamina propria (tunica propria) consisting of a basement membrane, myofi broblasts, fi broblasts, collagen and elastic fi bers, and extracellular matrix. , the basement membrane measures - nm in thickness, and displays three layers: lamina lucida (beneath the sertoli cells), lamina densa (basal lamina), and lamina reticularis (a discontinuous layer containing fi bers). the basal lamina contains laminin, type iv collagen, entactin (nidogen), and heparan sulfate. external to the basal lamina there are fi ve to seven layers of fl attened, elongated peritubular cells that have important secretory functions (table - ) . the cells forming the three to fi ve innermost layers are myofi broblasts containing numerous actin, myosin, and desmin fi laments. these cells play an important role in the rhythmic tubular contractions that propel spermatozoa toward the rete testis. , the two outermost cell layers consist of fi broblasts without desmin fi laments, and with less actin and myosin than the myofi broblasts. collagen fi bers are present among the peritubular cells and are abundant between the basal lamina and the peritubular cells. elastic fi bers are located mainly at the periphery of peritubular cells. because elastic fi bers appear at puberty, their absence in adults is a sign of tubular immaturity or dysgenesis. the extracellular matrix contains proteoglycans and fi bronectin. in addition, the tubular wall contains capillaries and leydig cells. these are very similar to the interstitial leydig cells and are named peritubular leydig cells. the most important functions of myofi broblasts are contraction of seminiferous tubules and control of sertoli cells. myofi broblasts have α and β adrenergic and muscarinic receptors. contractility depends on several factors produced in the testis (endothelin- , vasopressin, oxytocin, and tgf-β) and prostaglandins. relaxation can be facilitated by the no/cgmp system because myofi broblasts are also able to synthesize nitric oxide. sertoli cell control by myofibroblasts is facilitated by the production of p-mod-s, which activates aromatase activity, inhibin production, and the secretion of androgen-binding protein and transferrin. the interstitium between the seminiferous tubules contain leydig cells, macrophages, neuron-like cells, mast cells, blood vessels, lymphatic vessels, and nerves, accounting for - % of testicular volume. the most numerous connective tissue cells are fi broblasts and myofi broblasts. the former are also known as interstitial dendritic cells or cd -positive stromal cells. they display a network around the seminiferous tubules and leydig cells, and also form the outermost layers of the tubular wall. this distribution begins in fetal life. some of these cells are in contact with typical macrophages, so it has been suggested that they might be involved in immune surveillance. myofibroblasts, in addition to their presence in the inner layer of the tubular wall, are numerous in the tunica albuginea. leydig cells are distributed single or in clusters, and form about . % of testicular volume. most are in the testicular interstitium, although they may also be found in the tubular tunica propria, mediastinum testis, tunica albuginea, epididymis, and spermatic cord. extratesticular leydig cells are usually seen within or near nerve trunks. [ ] [ ] [ ] leydig cells have spherical eccentric nuclei with one or two eccentric nucleoli and prominent nuclear lamina. the cytoplasm is abundant, eosinophilic, and contains lipid droplets and lipofuscin granules (residual bodies) ( fig. - ). reinke's crystalloids are found only in the leydig cells of adults and, although it was believed that these crystals were present exclusively in humans, they have also been observed in the wild bush rat. reinke's crystalloids are up to µm long and - µm wide, consisting of a complicated meshwork of nm fi laments with a trigonal lattice arrangement. depending on the plane of section, three basic aspects of this lattice can be discerned. frequently, the crystalloids display pale lines, con- sidered to be potential planes of cleavage. the fi laments are grouped into nm-wide hexagons visible on cross-section. in some areas there are aggregates of electron-dense, rodshaped structures. some leydig cells contain other types of paracrystalline inclusion, the most common of which consists of multiple parallel-folded laminae. leydig cells contain abundant well-developed smooth endoplasmic reticulum, pleomorphic mitochondria with tubular cristae, lysosomes, and peroxisomes. leydig cells react with antibodies to s protein and neuron-specifi c enolase. leydig cells immunoreact to lh receptors, -β-hydroxysteroid dehydrogenase ( -β-Ηsd), relaxin-like factor, inhibin, and ghrelin. relaxin-like factor, also known as insulin-like factor (insf- ), is a peptide that is involved in testicular descent and can be found in serum. its concentration is a maker of the leydig cell functional status. as occurs with testosterone, insf- production is associated with that of lh. leydig cells immunoreact with calretinin, a kda calcium-binding protein that has a buffering effect to avoid abnormal increases in intracellular calcium. calretinin is a more sensitive marker than inhibin, albeit less specifi c ( fig. - ) . leydig cells also contain vegf and its two receptors (flt- and kdr), and endothelin and its two receptors (α and β). vegf and endothelin are involved in paracrine and autocrine control of leydig cells. leydig cells near seminiferous tubules show immunoreactivity for glial fi brillar acid protein (gfap) (fig. - ). the demonstration of several substances that are characteristic of nerve cells, such as substance p, neurofi lament triplet proteins (nf-l, nf-m and nf-h), and the ultrastructural observation of microtubules, intermediate fi laments, and clear and dense core vesicles, qualifi es leydig cells for inclusion within the family of the diffuse endocrine system or paraneurons. , leydig cells of the adult testis originate from fi broblastic precursor cells at puberty under lh stimulation. experimental studies in rats have shown that adult leydig cells differentiate from peritubular cells (myofi broblasts and blood capillary pericytes). precursor leydig cells are reminiscent of neural stem cells because they express nestin and eventually acquire properties of neurons and glial cells. the human testis contains about million leydig cells. this number decreases with age: the testes of -year-old men contain about half as many as those of -year-old men. [ ] [ ] mitotic fi gures are seen occasionally in normal leydig cells. leydig cells are the target cell of lh, in response to which they produce testosterone and other androgens necessary for the maintenance of spermatogenesis and many structures of the male genital tract, as well as other tissues such as bone, muscle, and skin. [ ] [ ] [ ] [ ] testosterone acts on the sertoli cells, either directly or via the p-mod-s factor secreted by the myofi broblasts in the tunica propria. [ ] [ ] [ ] leydig cells also secrete numerous non-steroidal factors, including oxytocin, which acts on myofi broblasts and stimulates seminiferous tubule contraction; β endorphin, which inhibits sertoli cell proliferation and function; egf, which regulates spermatogenesis; and other factors with less known actions, such as angiotensin, pro-opiomelanocortin, and α-melanotropic stimulating hormone (table - ) . together with sertoli cells, peritubular cells, and endothelial cells, leydig cells produce nitric oxide, which has a relaxing effect on smooth muscle. leydig cells are associated with cholinergic and adrenergic nerve fi bers. varicosities containing synaptic vesicles in the proximity of leydig cells and nerve endings in direct contact with leydig cells have been reported, although the functional signifi cance of this innervation is unknown. , macrophages, neuron-like cells, and mast cells macrophages are a normal component of the testis - and can be classifi ed into two groups: resident and activated. resident macrophages are an essential cell type of the testicular interstitium (about % of interstitial cells in mouse testis). in young adult men, there is one macrophage per - leydig cells, and this number increases with age. macrophages are closely related to leydig cells and play a role in proliferation and differentiation of leydig cell fi broblastic precursors. interaction between macrophages and leydig cells is an example of paracrine function. in the rat, testicular macrophages produce -hydroxycholesterol ( -hc) and express -hydroxylase, which transforms cholesterol into -hc. , activated macrophages produce interleukins and (il- and il- ), tumor necrotizing factor-α (tnf-α), and transforming growth factor-α (tgf-α). immunohistochemical techniques have demonstrated neuron-like cells in the testicular interstitium. these cells are an important source of intratesticular cate-cholamines, which appear to be increased in some disorders such as the sertoli cell-only syndrome, and hypospermatogenesis. mast cells are a normal component of the testicular interstitium, where they are often found near blood vessels. their number increases in several diseases. the testis is supplied by the testicular artery, which arises from the abdominal aorta. in the spermatic cord, the testicular artery gives rise to two or three branches that obliquely penetrate the tunica albuginea testis and to multiple branches that run along the intralobular septa of the testis. these centripetal arteries lead to the mediastinum testis. along their course, the centripetal arteries give off branches that abruptly reverse direction; these are called centrifugal arteries. at puberty, both the centripetal and the centrifugal arteries develop a pronounced spiral architecture. , the centrifugal arteries develop additional branches in the testicular interstitium, giving rise to arterioles and capillaries that form intertubular plexuses, some of which are apposed to the tunica propria. , capillaries are of the continuous type, except for the seminiferous tubule capillaries, which are partially fenestrated, and their endothelial cells are similar to those of brain capillaries, with scant pinocytosis, intercellular junctions of the fascia adherens type, and low permeability. the mediastinum testis is poorly vascularized. the inner two-thirds of the testicular parenchyma is drained by veins that follow the interlobular septa to the mediastinum testis (centripetal veins). the outer third is drained by veins that lead to the tunica albuginea (centrifugal veins). both centripetal and centrifugal veins join to form the pampiniform plexus, which drains the testis via the spermatic cord. lymphatic vessels are poorly developed in the testis and limited to the tunica vasculosa and interlobular septa, where they accompany arterioles and venules. prelymphatic vessels have been reported in the interstitium and probably drain interstitial fl uid into the true interlobular lymphatic vessels. efferent innervation of the testis is mainly supplied by neurons of the pelvic ganglia, where contralateral and bilateral neural connections occur. postganglionic nerve fi bers enter the testis via the pelvic nerves, extend throughout the tunica vasculosa, and follow the interlobular septa to reach the interstitium. these nerve fi bers end in the wall of arterioles, the wall of seminiferous tubules, and the leydig cells. adrenergic nerve fi bers innervate the tunica albuginea and the blood vessels of the tunica vasculosa. peptidergic nerve endings are uncommon. afferent nerve endings form corpuscles similar to those of meissner and pacini in the tunica albuginea. the rete testis is a network of channels and cavities that connects the seminiferous tubules with the ductuli efferentes. differences in the confi guration and size of channels and cavities distinguish three portions of the rete testis: septal (intralobular), composed of the tubuli recti; mediastinal, composed of a network of interconnected channels; and extratesticular, composed of dilated cavities (up to mm in diameter) termed the bullae retis. the tubuli recti are short tubules ( . - mm long) that connect the seminiferous tubules to the mediastinal rete, although some seminiferous tubules may connect directly to the mediastinal rete, principally those in the central region of the testis. the tubuli recti are lined by cuboidal epithelium. there are approximately tubuli recti (or their analogous seminiferous tubule segments). the tubuli recti in the cranial, central, and anterior testis are perpendicular to the mediastinal rete testis channel into which they drain, and those in the caudal testicular region are parallel to their respective channels. the transitional segments between the seminiferous tubules and the tubuli recti are formed by modifi ed sertoli cells. the epithelium of the mediastinal rete testis consists of fl attened cells interspersed with small areas of columnar cells. both cell types have single centrally located cilia and numerous microvilli on their free surfaces, and contain keratin and vimentin fi laments. there are interdigitations between adjacent cells. the epithelium rests on a basal lamina, surrounded by a layer of myofi broblasts and a more peripheral layer of fi broblasts and collagen and elastic fi bers. the rete channels and cavities are traversed by the chordae rete, columns from µm to µm long and from µm to µm wide, arranged obliquely to the long axis of the cavity. the chordae consist of fi brous connective tissue with fi broblasts and are covered by fl attened epithelium; the widest contain capillaries. the rete testis probably has the following functions: damping differences in pressure between the seminiferous tubules and ductuli efferentes; reabsorption of protein and potassium from tubular fl uid; and, occasionally, phagocytosis of spermatozoa. anorchidism refers to the absence of one (monorchidism) or both testes (testicular regression syndrome). monorchidism is estimated to occur in about . % of cryptorchid testes, % of the testes that are impalpable in physical examination, or in males. bilateral anorchidism occurs in approximately in males. monorchidism the hormonal pattern in prepubertal patients with monorchidism does not differ from that of normal children, whereas children lacking both testes have elevated levels of gonadotropins and fail to respond to stimulation with hcg. [ ] [ ] [ ] although the hcg stimulation test is often positive in children with bilateral cryptorchidism, it is negative in some children with bilateral intra-abdominal cryptorchidism and this further complicates the differential diagnosis between anorchidism and cryptorchidism. for unknown reasons, the left testis is more frequently absent ( . %) than the right. in such cases the contralateral scrotal testis undergoes compensatory hypertrophy and its volume increases to more than ml. compensatory hypertrophy has also been reported in association with abdominal cryptorchid testis. the absence of testicular parenchyma should be confi rmed before diagnosing monorchidism. at exploration, the fi nding of a vas deferens ending near or in a hypoplastic epididymis is not suffi cient for the diagnosis of monorchidism. the only acceptable fi nding is blind-ending spermatic vessels. if inguinoscrotal exploration fails to identify these vessels, intra-abdominal exploration is required to insure against an undescended testis and avoid the development of a testicular tumor. all remnants found at exploration should be removed. testicular regression syndrome testicular regression syndrome refers to a variety of conditions, including agonadism, anorchidism, testicular agenesis, rudimentary testes, hypoplastic testes, and embryonal testicular dysgenesis. each of these syndromes shares a complete absence or involution of both testes but differ in the time of testicular disappearance during development. the most frequently observed are swyer's syndrome (see discussion on gonadal dysgenesis below), true agonadism, rudimentary testes, bilateral anorchidism, vanishing testes syndrome, and leydig cell-only syndrome (table - ) . true agonadism ( xy gonadal agenesis syndrome) patients with true agonadism have ambiguous external genitalia, fusion of the labia, and a short vagina, refl ecting very early testicular regression (between the eighth and th weeks of embryonal development). the internal genitalia consist of a uterus and two uterine tubes, although both müllerian and wolffi an derivatives may be absent. no gonads (not even in an ectopic location) are found. patients are phenotypically girls, and the male gender may be discovered only at the time of referral for other symptoms. both sporadic and familial cases with associated extragenital anomalies have been reported. in some cases the cause is a heterozygous mutation of wt . in most familial cases inheritance is either recessive autonomic or x-linked, and the cause seems to be either unknown anomalies in the wt gene or known anomalies in other genes involved in development. a sry molecular defect has never been observed. agonadism may be associ-ated with several syndromes, including those of pagod (hypoplasia of lungs and pulmonary artery, agonadism, omphalocele/diaphragmatic defect, dextrocardia), kennerknecht, seckel, and charge. rudimentary testes syndrome patients with rudimentary testes have a normal male phenotype. müllerian remnants are absent and wolffi an derivatives usually are found. the testes are cryptorchid and very small, less than . cm long. seminiferous tubules are few ( fig. - ). the testicular regression occurs between the th and th weeks of gestation. this syndrome has been reported in several members of the same family, suggesting genetic transmission, but this is not a constant feature. , congenital bilateral anorchidism congenital bilateral anorchidism occurs in in newborns. the patients have male external genitalia, but the internal genitalia consist only of normal wolffi an derivatives without müllerian derivatives, suggesting that the testes were present and functionally active up to approximately the th week of gestation. patients have male external genitalia with hypoplasia of both the scrotum and penis. the karyotype is the normal male. the disorder may be associated with other malformations, such as anal atresia, rectourethral and rectovaginal fi stula, and urinary exstrophy. patients diagnosed at adulthood have male phenotype, androgen insuffi ciency symptoms, and elevated levels of both fsh and lh. , familial incidence in some cases suggests sry gene mutation, but this has not been confi rmed. , vanishing testes syndrome this term refers to the disappearance of one or both testes between the last months of intrauterine life and the beginning of puberty. [ ] [ ] [ ] as testicular regression occurs after the seventh month, exploration fi nds the vas deferens in the inguinal canal or high in the scrotum; it may be accompanied by the epididymis and, less frequently, by testicular remnants consisting of small groups of seminiferous tubules ( fig. - ). patients lacking both testes develop hypergonadotropic hypogonadism after puberty, with gynecomastia, infantile phallus, hypoplastic scrotum, and impalpable prostate. the condition is usually secondary to a perinatal scrotal torsion, although rarely there is a genetic cause. , leydig cell-only syndrome patients with leydig cell-only syndrome have agonadism without eunuchoidism and a normal male phenotype, although meticulous surgical exploration fails to fi nd testicular remnants. study of serial sections from the spermatic cord reveals clusters of leydig cells. detection of testosterone in spermatic vein blood indicates that these ectopic leydig cells are functionally active and synthesize testosterone in amounts suffi cient to induce a rudimentary male phenotype but insuffi cient to support the complete development of secondary sex characteristics. the morphology of spermatic cord remnants is similar in monorchidism and testicular regression syndrome occurring after the th week of gestation. [ ] [ ] [ ] grossly, a small, fi rm mass is found at the end of the cord ( fig. - ). histologic examination reveals vas deferens, epididymis, or small groups of seminiferous tubules in - % of cases. vas deferens is the most constant fi nding ( %), followed by epididymis ( %) and seminiferous tubules ( - %). the spermatic vessels are abnormally small in % of cases. , areas of dystrophic calcifi cation, hemosiderin deposition, and giant cell reaction may be found within the mass in place of the testis. other fi ndings include arterial and venous vessels ( %), fat ( %), and nerves that may resemble traumatic neuroma ( %). the minimal requirement to diagnose vanishing testis is to fi nd either a vascularized fi brous nodule with calcifi cation or hemosiderin, or a fi brous nodule with cord elements. it has been proposed that removal of the testicular nubbin in this syndrome may not be required because the percentage of seminiferous tubules is very low and the presence of germ cells low, and thus the probability of a tumor is minimal. , the general recommendation is scrotal exploration as a fi rst step, reserving laparoscopy for cases in which either the atrophic remnant cannot be identifi ed during scrotal exploration or has a patent vaginal process. the histologic fi ndings suggest that most cases of unilateral and bilateral anorchidism are produced during the fetal period after the testis has inhibited the müllerian ducts and induced differentiation of wolffi an duct derivatives. two hypotheses account for the disappearance of the testes: primary anomaly of the gonad; and atrophy secondary to a vascular lesion such as thrombosis or intrauterine torsion. the presence of macrophages with hemosiderin and dystrophic calcifi cation supports the latter. absence of one testis may be associated with malformations of the urogenital system, such as absence of the kidney, cystic seminal vesicles, and ipsilateral renal dysgenesis. , this clinical term refers to diverse conditions (klinefelter's syndrome, hypogonadotropic hypogonadism, rudimentary testes syndrome, bilateral cryptorchidism, etc.) that share small testicular size. , a peculiar case is presented by some patients with kenny-caffey syndrome: short stature, cortical thickening and medullary stenosis of long bones, delayed closure of anterior fontanelles, hypoparathyroidism, and several ocular alterations. fsh serum levels are elevated, but only in some cases, whereas lh and testosterone are normal. adult testes are small, with seminiferous tubules showing complete but diminished spermatogenesis. leydig are hyperplastic. unlike patients with the rudimentary testes syndrome, microorchidism patients have a normal-sized penis and no epididymal or prostatic atrophy. polyorchidism is a rare condition, with approximately reported cases. , it was fi rst described in a postmortem study in , and the fi rst case treated surgically and confi rmed histologically was reported in . although three testes are the most common, four testes have been reported in six patients, [ ] [ ] [ ] [ ] [ ] and fi ve in one case but without histologic confi rmation. age of diagnosis varies from newborn to years, with a mean of years. testicular duplication is usually an incidental fi nding during surgery for inguinal hernia, cryptorchidism, or testicular torsion, but has also been detected in patients with infertility or unexplained fertility after bilateral vasectomy. the extra testis is often intrascrotal ( %) and less frequently inguinal ( %), abdominal, or retroperitoneal ( %). , duplication is three times more frequent on the left than on the right. high-resolution ultrasound is the appropriate diagnostic technique. , testicular maldescent ( %), inguinal hernia ( %), hydrocele, varicocele, and contralateral cryptorchidism are the most frequently associated anomalies. [ ] [ ] [ ] testicular torsion ( %) and testicular cancer ( . %) are occasional complications. although the extra testis may be histologically normal, - usually it is not, , and displays lesions such as sertoli cell-only tubules, hypospermatogenesis, or maturation arrest. the lack of spermatogenesis has been attributed to the anomalous location of the testis and the absence of communication between the testis and excretory ducts. the embryologic origin of polyorchidism remains uncertain, and the following have been proposed to account for the variety of fi ndings in different cases ( fig. - the clinical differential diagnosis of polyorchidism includes most of pathologic conditions that enlarge the scrotum and spermatic cords: spermatocele, hydrocele, cysts and tumors of the spermatic cord, crossed testicular ectopia, adrenal cortical ectopia, and splenogonadal fusion. orchidectomy used to be the treatment of choice for all atrophic and non-scrotal testes. today, most surgeons undertake fi xation of the testis to the scrotal pouch and the re-creation of a 'simple testis' if it is permitted by the anatomical condition and malignancy has been precluded. this treatment may allow spermatogenesis as well as additional psychologic and cosmetic benefi ts. intrascrotal rhabdomyosarcoma, testicular teratoma, and seminoma have been reported in patients with polyorchidism. , macro-orchidism may be uni-or bilateral and be associated with chromosomal anomalies or endocrine alterations. an increase in the testicular parenchyma occurs in several conditions, including congenital leydig cell hyperplasia, compensatory hypertrophy, benign idiopathic macroorchidism, bilateral megalotestes with low gonadotropins, fragile x chromosome, and the testicular hypertrophy observed in juvenile hypothyroidism. congenital leydig cell hyperplasia is uncommon and may be diffuse or nodular. the diagnosis of diffuse leydig cell hyperplasia requires quantifi cation of leydig cells by morphometry, using normal newborn testes as controls ( fig. - ). nodular leydig cell hyperplasia is characterized by the presence of non-encapsulated leydig cell nodules in the mediastinum testis, adjacent testicular parenchyma and connective tissue among the ductuli efferentes ( fig. - ) . the differential diagnosis of nodular leydig cell hyperplasia includes intratesticular adrenal rests and bilateral leydig cell tumor. except for patients with adrenogenital syndrome, intratesticular adrenal rests are rare. these rests are encapsulated, with the exception of the adrenogenital tumors, and consist of radially arranged cells with vesicular nuclei and small nucleoli displacing the rete testis or seminiferous tubules. leydig cell tumors may be bilateral, poorly circumscribed, and surrounded by testicular parenchyma, features making it diffi cult to distinguish from leydig cell hyper-plasia. however, leydig cell tumors are rarely congenital, whereas those occurring at infancy often induce precocious maturation of the adjacent seminiferous tubules and early macrogenitosomia. leydig cell hyperplasia is caused by large quantities of hcg entering the fetal circulation. diabetic mothers, particularly those with hypertension, may develop hyperplacentosis; the resulting edema in the placental villi alters the vascular permeability and allows the passage of hcg to the fetus. congenital leydig cell hyperplasia decreases rapidly during the fi rst months of postnatal life, after maternal human chorionic gonadotropin is gone. combined diffuse and nodular leydig cell hyperplasia occurs in several malformative syndromes, such as beckwith-wiederman, leprechaunism, triploid fetuses, fetuses with rh isoimmunization, and in several complications of pregnancy. compensatory hypertrophy has been observed in monorchidism, cryptorchidism ( fig. - ) , varicocele, and after testicular injury. hypertrophy persists and may increase during childhood and puberty, but ceases thereafter; the hypertrophied testis then becomes normal or remains slightly enlarged. , the degree of hypertrophy is determined by three factors: the volume of the remaining testicular parenchyma, the age at which the injury occurred, and the functional ability of the descended testis. compensatory hypertrophy results from an alteration in the hypophyseal hormonal feedback mechanism, followed by an increase in secretion of fsh, evidence that the contralateral testis is normal. in monorchidism, the testis is initially normal. when a % reduction of testicular mass occurs (probably before birth), the endocrine feedback changes and the resulting secretion of fsh (before or immediately after birth) causes accelerated growth of the contralateral testis. in cryptorchidism, the reduction in testicular mass is less severe than in monorchidism, and the scrotal testis may also be abnormal, inducing a lesser compensatory hypertrophy. compen- satory hypertrophy develops between birth and years of age, and the testis may reach a volume twice normal when the other testis is absent. some prepubertal and pubertal patients have pronounced unilateral or bilateral [ ] [ ] [ ] testicular hypertrophy in the absence of other pathologic fi ndings. this probably results from hormonal receptivity in the testicular parenchyma. morphometric studies have shown that the testicular enlargement is chiefl y due to an increase in the length of the seminiferous tubules, although increases in tubular diameter and sertoli cell numbers have also been observed. elevated fsh serum levels, reported in some cases, or hyperactive fsh receptors might be the cause of the excessive sertoli cell proliferation and the lengthening and thickening of seminiferous tubules. [ ] [ ] [ ] in addition, leydig cell hyperplasia and defi cient spermatogenesis are frequent fi ndings in adult life. as the development of the two testes may be asynchronous during puberty, some unilateral macroorchidisms may represent cases in which these differences are unusually exaggerated. about % of adults with fertility problems have enlarged testes, with volumes over ml, and low levels of fsh, lh, testosterone, prolactin, and estradiol. despite the important hormonal changes, sperm concentrations and total numbers of spermatozoa are higher than normal. low fsh levels may be attributable to increased inhibin secretion because the number of sertoli cells is elevated in these testes, but no explanation for the reduction in the other hormone levels has been found. fragile x chromosome is the best-known form of inherited mental retardation, with an incidence of in males and in females. in addition to facial dysmorphia (large ears, prognathism, high forehead, and arched palate), macroorchidism (martin-bell syndrome) is often an associated fi nding. [ ] [ ] [ ] [ ] [ ] the impaired gene (fmr gene) is mapped to xq , which is genetically fragile. the gene alteration is due to a lengthening of a trinucleotide cgg repeat that results in fmr gene silencing. if the cgg sequence is repeated fewer than times, the disorder is considered a premutation and males show no symptoms; if the number of repetitions exceeds , mutation is complete and all show the disorder. [ ] [ ] [ ] in men with this syndrome, the average testicular volume is more than ml (four times greater than normal). the penis also is larger than normal, and both anomalies are apparent in infancy. the scrotum is also enlarged and prematurely pigmented. this precocious genital development is diffi cult to explain because the hypothalamopituitary axis is normal, but it may be caused by increased sensitivity to stimulation by fsh. testicular biopsies from adults may be normal or show interstitial edema and hypospermatogenesis ( fig. - ) . usually, there is normal testicular parenchyma with focal reduced spermatogenesis and sertoli cell hyperplasia ( fig. - ) or tubules containing only immature sertoli cells. morphometry indicates that testicular enlargement is chiefl y the result of lengthening of seminiferous tubules. the low number of spermatids is attributed to atrophy caused by compression of the seminiferous epithelium by marked increase in intratubular fl uid. meiotic anomalies have been excluded. the fragile x syndrome is second in frequency only to down's syndrome as a cause of mental retardation. [ ] [ ] [ ] however, this chromosomal anomaly is not always associated with mental retardation or macroorchidism, and there are men with fragile x syndrome who are otherwise normal. the terms 'fragile x-negative martin-bell syndrome' or 'mental retardation-macro-orchidism' refer to x-linked (mrmo) or xlmr+mo patients who have the martin-bell syndrome phenotype but do not present the fragile x site. the gene responsible for this disorder is mapped to xq -q . starts. , , the etiopathogenesis has been explained by three hypotheses: an increase in gonadotropin secretion caused by trh stimulation of gonadotropic cells; , a direct tsh effect on the testis due to the structural similarity between tsh receptors and fsh receptors present in the testis; and a lack of steroid hormones that are required for testicular maturation (in their absence, sertoli cell proliferation is excessive, giving rise to testicular enlargement). [ ] [ ] [ ] [ ] precocious puberty precocious puberty is defi ned by onset of secondary sex characteristics at a chronologic age that is below the mean middle age for the population. for practical purposes, this is considered to be before years of age in girls and years in boys. the incidence is estimated at between in and in , with a female:male ratio higher than : . in boys, the fi rst symptom is rapid testicular enlargement followed by growth of pubic and axillary hair, enlargement of the penis, and acceleration of skeletal growth. according to hypothalamopituitary-gonadal axis function, precocious puberty can be classifi ed into three groups: central or gonadotropin-dependent, which results from the activation of this axis; peripheral or gonadotropinindependent, mediated by sex steroid hormones secreted by the testis or adrenal glands; and a mixed group that fi rst appears as peripheral precocious puberty and thereafter, because of the secondary response of the hypothalamus, becomes gonadotropin dependent. other possible causes of precocious puberty are hypoprolactinemia, pituitary tumor, and alteration of testicular steroid metabolism. central precocious puberty (cpp) central precocious puberty, also known as true precocious puberty, is isosexual. it is the most common form of precocious puberty in girls and accounts for more than % of cases in boys. the age of presentation is between and years. the cause is only known in % of cases; most are related to lesions in the central nervous system, whereas the others are usually idiopathic. lesions in the central nervous system that causes cpp share alterations of specifi c areas, including the posterior hypothalamus (eminencia media and tuber cinereum), mammillary bodies, the bottom of the third ventricle, or the pineal gland. testicular hypertrophy appears associated with fsh-secreting pituitary adenoma, hyperprolactinemia, hypoprolactinemia, and hypothyroidism. , the most frequent association of testicular hypertrophy is with hypothyroidism. children with hypothyroidism often show testicular enlargement without virilization. about % have macroorchidism, most have elevated fsh levels, and half have increased lh levels. , testosterone levels are normal during infancy. the response of fsh and lh to gnrh is altered and no pulsatile lh release occurs ( fig. - ). testicular biopsies before puberty show an accelerated development of the testis with pubertal maturation of seminiferous tubules but not leydig cells. testicular biopsies in untreated adults show tubular and interstitial hyalinization with few leydig cells. , testicular size in this type of macroorchidism diminishes as soon as the substitutive therapy • hereditary diseases as neurofi bromatosis and tuberous sclerosis. children with type i neurofi bromatosis often have also optic pathway tumors. • cerebral irradiation, as occurs in hypothalamopituitary selective irradiation, prophylactic irradiation in children with acute lymphoblastic leukemia, and irradiation of cerebral tumor that is far from the hypothalamopituitary region. the diagnosis of central precocious puberty is easy if the hormonal fi ndings show elevated gonadotropin levels (both basal values and in response to gnrh), associated with high testosterone levels and an increase in either lh/fsh ratio or in lh and fsh values after stimulation with gnrh agonists. however, in some cases it is necessary to measure nocturnal lh secretion to fi nd secretion pulses before a dynamic test can reveal the pubertal pattern. knowledge of the etiology in males has improved with the use of ct and mri. , one of the most important contributions of these techniques is the fi nding of a high number of hamartomas in children with precocious puberty. [ ] [ ] [ ] these lesions, also known as gangliocytomas, consist of abnormally located neurons and glial cells. lesions are usually multiple, small, and located on the hypothalamus between the anterior part of the mammillary body and the posterior part of the tuber cinereum. these neurons contain lhrh-positive neurosecretory granules, suggesting that this hormone can be released into the blood draining the hypophyseal portal system and reach the gonadotropic cells. precocious puberty owing to cerebral tumors usually occurs with advanced stage of the tumor, preceded by cerebral symptoms such as hydrocephaly, papillary edema, or psychic alterations. the same occurs when precocious puberty results from cerebral infl ammation or cerebral malformation. although pineal gland tumor is rare in children, % produce precocious puberty, principally in boys. this tumor is usually a teratoma or non-parenchymatous tumor that destroys the pineal gland, hindering its antigonadotropic action and initiating puberty. in contrast, pinealocytederived tumor secretes great amounts of melatonin that delay the onset of puberty. peripheral precocious puberty (ppp) peripheral precocious puberty is also known as precocious pseudopuberty. it may be caused by a primary testicular disorder, a lesion in other endocrine glands, or hormonal treatment. primary testicular disorders causing precocious pseudopuberty include familial testotoxicosis, functioning testicular tumor, excessive aromatase activity, or leydig cell hyperplasia with focal spermatogenesis. the principal secondary anomalies include adrenal cortical anomaly (congenital adrenal hyperplasia, virilizing tumor of the adrenal, and nelson's syndrome), and lesion secondary to hcg-secreting tumor (hepatoblastoma accounts for half of precocious pseudopuberty cases, and testicular germ cell tumor and the tumors of the retroperitoneum, mediastinum, and pineal gland are responsible for the other half of cases). familial testotoxicosis: gonadotropin-independent precocious puberty (gipp) or familial male-limited precocious puberty (fmpp) familial testotoxicosis is a form of male sexual precocity characterized by early differentiation of leydig cells and the initiation of spermatogenesis in the absence of stimulation by pituitary gonadotropin. this is a primary testicular abnormality with autosomal dominant inheritance. , ultrastructural studies confi rm an adult leydig cell pattern and complete spermatogenesis, although many spermatids are abnormal. the cause of familial testotoxicosis is a constitutive activating mutation of the lh receptor gene. this gene comprises exons and has been mapped to p . hormonal measurements show elevated serum levels of testosterone, and low levels of dihydroepiandrosterone sulfate, androstenedione, -hydroxyprogesterone, gonadotropin-releasing hormone (grh), and lh, as well as absence of a pulsatile pattern. in addition, serum levels of inhibin b appear elevated before the normal age of onset of puberty. in some patients, a mutation in lh receptor induces leydig cell adenoma. precocious puberty secondary to functioning testicular tumor a syndrome of precocious puberty can be the result of different tumors, including leydig cell tumor, sex cord tumor, adrenal cortex virilizing carcinoma, and extratesticular hcg-secreting germ cell tumor. leydig cell tumor may cause precocious puberty. the testis is enlarged owing to tumor growth and maturation of the seminiferous tubules adjacent to the tumor; such maturation results from androgen secretion by tumor cells (fig. - ) . in most cases, the contralateral testis is not enlarged. , sex cord tumor with annular tubules and large cell calcifying sertoli cell tumor may give rise to precocious pseudopuberty that is isosexual (development of musculature and axillary and pubic hair) and heterosexual (gynecomastia). this precocious testicular maturation and the development of the tumor itself cause testicular enlargement. it has been suggested that tumor cells stimulate leydig cells to produce androgens that are aromatized to estrogens by the tumor cells themselves, thus accounting for the clinical symptoms. these tumors are frequently observed in peutz-jeghers syndrome , and carney's complex. most infants with adrenal cortex virilizing tumors have small testes, but some cases of testicular hypertrophy have also been observed. testicular development in these cases is attributed to adrenal androgenic action on seminiferous tubules. in untreated (or maltreated) congenital adrenal hyperplasia, both testes can be enlarged because they contain growing masses of adrenal cortex-like cells. a similar condition is observed in nelson's syndrome. testicular enlargement is modest in paraneoplastic precocious pseudopuberty secondary to hepatoblastoma or extratesticular hcg-secreting germ cell tumor, although nodular or diffuse precocious maturation has been occasionally reported. precocious pseudopuberty secondary to excessive aromatase activity biosynthesis of c estrogens from c androgens occurs by three consecutive oxidative reactions that are catalyzed by an enzymatic complex known as estrogen synthetase or aromatase. this complex has two components: p arom (a product from the cyp gene located on p . ), which joins c substrate and catalyzes the insertion of oxygen in c to form c estrogens; and nadph-cytochrome p reductase, a ubiquitous fl avoprotein that conveys reducing equivalents to any form of cytochrome p it meets. aromatase is in the endoplasmic reticulum of estrogensynthesizing cells and expressed in placenta, ovarian granulosa, sertoli cells, leydig cells, adipose tissue, and several central nervous system regions, including the hypothalamus, amygdala, and hippocampus. excessive aromatase causes excessive conversion of androgens to estrogen, and is a heterogeneous genetic disorder with an autosomal dominant inheritance. the disorder leads to heterosexual precocious pseudopuberty with gynecomastia in males, and to isosexual precocity and macromastia in females. ultimately, patient stature is short because of the potent ability of androgens to accelerate epiphyseal closure. most males are fertile and have normal libido. generally, the inhibitory estrogenic effect on testicular function is less than that observed with estrogen-producing tumors or in patients treated with exogen estrogens. excessive aromatase caused by p mutation induces alterations in both males and females. in females lacking estrogens owing to desmolase defi ciency, excessive aromatase leads to pseudohermaphroditism and progressive virilization at puberty; conversely, pubertal development is normal in males. in children, fsh and lh levels and gonadotropin response to gnrh are normal, suggesting that the role of estrogens in pituitary regulation is weak during infancy. in both genders, epiphyseal closure is delayed and a eunuchoid habitus results. adult males have small testes, severe oligozoospermia, and complete asthenozoospermia; fsh and lh levels are high, testosterone levels are normal, and serum estrogen levels are very low. all patients with excessive aromatase have short stature, with continuing linear growth into adulthood, unfused epiphyses, osteoporosis, bilateral genu valgum, and eunuchoid proportions. the testes show macroorchidism with normal testicular consistency in some cases, and are small with severe oligozoospermia and % immotile spermatozoa in other cases. a syndrome similar to that of excessive aromatase production is found in patients with estrogen resistance caused by disruptive mutations of the er gene. these patients show macroorchidism, elevated testosterone levels, and increased levels of fsh, lh, estradiol, and estrona. precocious pseudopuberty secondary to leydig cell hyperplasia with focal spermatogenesis this entity can present with clinical symptoms similar to those of a functioning leydig cell tumor; this is a precocious pseudopuberty with ipsilateral testicular enlargement. the testes contains hypertrophic leydig cell nests in association with normal spermatogenesis. no tumoral mass is seen. leydig cells do not contain reinke's crystalloids and do not compress the seminiferous tubules. there is a clear delimitation between tubules with spermatogenesis and infantile immature tubules. the differential diagnosis between this entity and leydig cell tumor with precocious pseudopuberty is based on the histological pattern. open excisional testicular biopsy is recommended; if there is leydig cell tumor, or the diagnosis by frozen section is not conclusive, removal is advisable. there are no data to suggest that this hyperplasia might develop into leydig cell tumor. mixed precocious puberty the best known form is the mccune-albright syndrome (mas), characterized by the association of 'coffee and milk' pigmentary lesions in the skin, bone lesions (polyostotic fi brous dysplasia), enlarged testes, prepubertal size of the penis, and absence of pubic and axillary hair. although testicular enlargement is usually bilateral, unilateral macroorchidism may be the fi rst symptom. an interesting fi nding is that the onset of testicular maturation is induced by the testis itself, which produces steroid secretion due to autonomous hyperfunction of sertoli cells without evidence of leydig cell involvement. this secretion causes early maturation of the hypothalamopituitary-testicular axis and, subsequently, true precocious puberty. serum levels of testosterone are low, but those of inhibin b and amh are abnormally increased. this syndrome is caused by mutations that activate the gnas- gene, which encodes the α subunit of the trimeric g-protein. because mutations are lethal in the uterus, those subjects producing amh bear a mosaicism chromosomal constitution for this defi ciency. a testis is ectopic when it is in a location outside the normal path of descent. unlike cryptorchid testes, ectopic testes are nearly normal in size and are accompanied by a spermatic cord that is normal or even longer than normal, and by a normal scrotum. testicular ectopia is classifi ed according to location; [ ] [ ] [ ] [ ] [ ] in decreasing order of frequency, the major types are: • interstitial or inguinal superfi cial ectopia. this is the most frequent form and may be confused with inguinal cryptorchidism. after passing through the outer genital opening, the testis ascends to the anterosuperior iliac spine and remains on the aponeurosis of the major oblique muscle. these testes often are more nearly normal histologically than are cryptorchid testes. • femoral or crural ectopia. after passing through the inguinal canal, the testis lodges in the high crural cone in scarpa's triangle. • perineal. the testis is located between the raphe and the genitocrural fold. • transverse or crossed ectopia. both testes descend through the same inguinal canal and lodge in the same scrotal pouch. each possesses its own vascular supply, epididymis, and vas deferens. in addition, there is ipsilateral hernia. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] between % and % of patients with this ectopia have persistent müllerian duct syndrome [ ] [ ] and show a high incidence of testicular germ cell tumor. • pubopenile ectopia. the ectopic testis is on the back of the penis near the symphysis pubis. • pelvic ectopia. the testis is in the pelvis, usually in the depth of douglas' cul-de-sac. • other unusual testicular ectopias include retroumbilical, craniolateral to the inner inguinal opening between the outer and inner oblique muscles, and subumbilical. rarely, the testis and its spermatic cord may protrude through a defect in the scrotal skin, a condition called testicular exstrophy. the term testicular dislocation refers to testes that secondarily disappear from the scrotum and lodge around the superfi cial inguinal ring, within the inguinal ring, or inside the abdominal cavity as a result of testicular trauma. the formation of canalicular and intra-abdominal dislocation requires the presence of previous inguinal hernia. testicular fusion is a rare anomaly characterized by fusion of the testes to form a single structure, usually in the midline. each has its own epididymis and vas deferens. this anomaly is often associated with other malformations, such as fusion of the adrenal glands or horseshoe kidney. cystic dysplasia of the testis is a congenital lesion characterized by cystic transformation of an excessively developed rete testis that may extend to the tunica albuginea of the opposite pole. to date, fewer than cases have been reported. , the seminiferous tubules may be dilated and atrophic; this is more evident after puberty. ultrasound images are characteristic. , cysts arise in the septal and mediastinal rete testis ( fig. - ); they are interconnected and contain acellular, eosinophilic, periodic acid-schiffpositive material. they are lined by cuboidal cells that resemble those of the normal rete testis. [ ] [ ] [ ] the connective tissue between the cysts is scant and histologically similar to the interstitial connective tissue. there may be small groups of cysts limited to the region of the mediastinum testis, or cysts extending throughout the entire testis. in extensive cases, residual seminiferous tubules occupy only a small crescent beneath the tunica albuginea and the testis is grossly spongy. cystic dysplasia occurs in normally descended and cryptorchid testes in children and adults, and may affect one or both testes. in adults, the residual parenchyma often shows complete tubular sclerosis or hypospermatogenesis with intratubular accumulation of spermatozoa and leydig cell pseudohyperplasia. in most cases the epididymis is altered. the head of the epididymis is small and contains few ductuli efferentes with irregular, usually dilated lumina. the ductus epididymidis is dilated, has an atrophic epithelium, and thick connective tissue replaces the muscular layer ( fig. - ) . testicular cystic dysplasia is frequently associated with severe anomalies of the urinary system. renal agenesis, [ ] [ ] [ ] [ ] renal dysplasia, hydroureter, and urethral stenosis have been reported ipsilateral to cystic dysplasia. the clinical differential diagnosis should consider all cystic testicular lesions impairing prepubertal testes, including epidermoid cyst, cystic teratoma, juvenile granulosa cell tumor, testicular lymphangiectasis, and simple cyst of the testis. the presence of ipsilateral renal anomalies during ultrasound exploration provides an important diagnostic clue. previously, orchidectomy was the treatment of choice, but testis-sparing surgery is now recommended. , the etiology and pathogenesis of cystic dysplasia are uncertain. given that the rete testis is a mesonephric derivative and most of the associated renal malformations are apparently caused by failure in the induction of renal blastema by the mesonephros, cystic dysplasia is considered to be the result of an abnormal mesonephros. during childhood, the normal rete testis has no lumina, and these form during puberty. the adult rete testis is a conduit for the passage of tubular fl uid and spermatozoa and also actively reabsorbs part of this fl uid while adding ions, proteins and steroids to it. malfunction of the rete testis cells may cause the formation of excessive fl uid of abnormal composition, resulting in a condition morphologically similar to cystic dysplasia of the rete testis induced in fowl by sodium intoxication or the administration of the saltretaining hormone deoxycorticosterone acetate. gonadoblastoid testicular dysplasia refers to an abnormally differentiated testicular parenchyma beneath the tunica albuginea. the anomaly consists of large tubular or nodular structures within a dense stroma, reminiscent of ovarian stroma ( fig. - ). each structure is composed of three cell types: cells with vesicular nuclei and vacuolated cytoplasm; cells with hyperchromatic nuclei; and germ cell-like cells. the former two types are arranged at the periphery, forming a pseudostratifi ed epithelium. the third type resembles fetal spermatogonia and are fewer in number. these structures contain eosinophilic, periodic acid-schiff-positive material, similar to call-exner bodies ( fig. - ). there may be continuity between these structures and normal seminiferous tubules. the differential diagnosis includes conditions showing anomalous seminiferous tubules at the gonadal periphery, including testicular dysgenesis and gonadoblastoma. testicular dysgenesis also presents tubular or cord-like structures, but these are differentiated (some form true seminiferous tubules) and may also be present within a poorly collagenized tunica albuginea; patients with testicular dysgenesis are male pseudohermaphrodites with müllerian remnants. gonadoblastoma usually appears in a streak gonad or dysgenetic gonad and contains granulosa-sertoli cells and germ cells that are similar to those of dysgerminoma or seminoma; these cells are absent in gonadoblastoid testicular dysplasia. several cases with this disorder have been reported in patients with walker-warburg syndrome. , this disorder refers to the presence, in an adult testis, of one or several foci of infantile (immature) seminiferous tubules. each group of tubules appears well delimited but unencapsulated. nodule size varies from microscopic to mm. on section, each nodule is distinguished by its whitish color. sertoli cell nodule is found in most adult cryptorchid testes, regardless of when the testes descended. it is also present in % of normal scrotal testes in some series, and is an occasional fi nding in males with idiopathic infertility. the seminiferous tubules have a prepubertal diameter and may be anastomotic. the epithelium is columnar or pseudostratifi ed, devoid of lumina, and usually consists only of sertoli cells ( fig. - ). the cells have elongated hyperchromatic nuclei with one or several peripherally placed small nucleoli. the interstitium varies from scant to well collagenized. leydig cells are usually absent in these areas and, if present, their numbers are low. study of serial sections reveals continuity between some of these tubules and normal tubules. sertoli cell nodule changes with advancing age. the sertoli cells produce large amounts of basal lamina that protrudes inside the hypoplastic tubules. in transverse and oblique sections, these protrusions might be misinterpreted as intratubular accumulations of basal lamina material ( fig. - ). this material can undergo calcifi cation to form microliths. immunohistochemical study reveals two basic components of the basal lamina (collagen iv and laminin), confi rming its extracellular origin; the protrusions consist mainly of laminin, whereas collagen iv delimits the outer profi le of the seminiferous tubules. so, while the amount of collagen iv is uniform around the tubules, the depth of laminin varies within the same tubule. tubular hypoplasia is assumed to be a primary testicular lesion, and refers to the presence of seminiferous tubules that are unable to undergo pubertal development despite the same hormonal stimuli of adjacent normal tubules. this dysgenesis includes immature sertoli cell pattern, low inhibin secretion, absence of androgen receptors, and lack of maturation of peritubular myoid cells that fail to synthesize elastic fi bers. the presence of hypoplastic zones in a testicular biopsy is an adverse prognostic sign for fertility. the differential diagnosis includes tubular hamartoma in androgen insensitivity syndrome, sex cord tumor with annular tubules, and mixed atrophy of the testis. tubular hamartoma in androgen insensitivity syndrome is multiple, similar to the hypoplastic zones of tubular hypoplasia; however, the sertoli-like cells of hamartoma have spherical nuclei (rather of elongated nuclei), form a cuboidal epithelium, and contain numerous leydig cells among the tubules (see androgen insensitivity syndrome, below). sex cord tumor with annular tubules may present with multiple foci of intratubular neoplasia, similar in distribution to that of hypoplastic zones; however, sex cord tumor appears in undescended testes, and in patients with peutz-jeghers syndrome, and consists of cuboidal or spherical cells that express cytokeratins that are not expressed in hypoplastic tubules. it is possible that hypoplastic tubules contain some germ cells that may be spermatogonia or gonocytes. there are scant spermatogonia that fail to display signs of maturation or proliferation. also, some of the tubules contain intratubular undifferentiated germ cell neoplasia that usually also appears in the adjacent, non-hypoplastic seminiferous tubules. the histologic picture is similar to that of gonadoblastoma, but such a tumor can be easily excluded because it arises in malformed gonads (gonadal dysgenesis and testicular dysgenesis) characteristic of intersex stages, unlike patients with tubular hypoplasia. congenital testicular lymphangiectasis is characterized by abnormal and excessive development of lymphatic vessels in the tunica albuginea, mediastinum testis, interlobular septa, and testicular interstitium. [ ] [ ] [ ] ultrastructurally these dilated vessels are similar to normal lymphatic capillaries, although some are markedly dilated and the testicular interstitium is slightly edematous ( fig. - ). testicular lymphangiectasis occurs in both cryptorchid and scrotal testes; in one of the latter cases, the patient had noonan's syndrome. the disease does not seem to affect the seminiferous tubules, and low numbers of spermatogonia and reduced tubular diameters are observed only in cryptorchid testes. the epididymis and spermatic cord are not affected, and congenital testicular lymphangiectasis is not associated with pulmonary, intestinal, or systemic lymphangiectasis. during fetal life, lymphatic vessels are visible only immediately beneath the tunica albuginea and in the interlobular septa. during childhood, the number and size of the septal lymphatic vessels decreases; by adulthood they are inconspicuous. in lymphangiectasis, the septal lymphatic vessels are large and often massively dilated. testicular lymphangiectasis occurs only in the childhood testis, suggesting that these dilated vessels undergo involution at puberty or that pubertal development of the seminiferous tubules masks the lymphangiectasis. one exceptional case of epididymal lymphangiectasis, with dilated epididymal blood vessels, was reported in a -year-old man. the vessels distort the architecture of the ductuli efferentes, which in turn become irregularly dilated by mechanical compression. other hamartomas of the testis include hamartoma of the rete testis and smooth muscle hamartoma. hamartoma of the rete testis is a disordered proliferation of tubular structures in a loose connective tissue. cystic transformation of the rete testis associated with proliferation of smooth muscle cells and abundant myxoid stroma was reported in a -year-old man. smooth muscle hamartoma is located in the inferior testicular pole, the cauda of the epididymis, and the proximal segment of the vas deferens ( fig. - ) , and is similar to that reported in the digestive and respiratory tracts. , smooth muscle hyperplasia also occurs in the androgen insensitivity syndrome, forming nodules up to cm in diameter. the muscular proliferation is located in the lower testicular pole, and involves the tunica albuginea and adjacent soft tissues. this infrequent fi nding has been observed in newborns and consists of gonadal blastema in otherwise normal testes. the blastema is located in the vicinity of the upper testicular pole, near the implantation of the caput of the epididymis, displays a crescent shape, and extends throughout the depth of the tunica albuginea and the adjacent testicular parenchyma. the blastema consists of epithelial cords of cells or solid masses in continuity with the mesothelium (fig. - ). these cells are intermingled with others that are larger, with pale cytoplasm, vesicular nuclei, and prominent nucleoli. the blastematous epithelial cells display immunoreactivity for vimentin, laminin, type iv collagen, and cytokeratin; the expression of the latter in the most superfi cial cells is similar to that of mesothelial cells and decreases in intensity in the deeper cells. this suggests that these may be pre-sertoli cells. the cord-like structures are delimited by laminin and type iv collagen. the second larger cell type is immunoreactive for placenta-like alkaline phosphatase (plap) on the surface, suggesting that it is related to the gonocyte. leydig cells have not been observed among the cords of gonadal blastema. the differential diagnosis of gonadal blastema ectopia is with ovotestes. the small size of the gonocytes distinguishes them from ovocytes, which are several times larger. in addition, no intersex condition is observed. the presence of seminiferous tubules within the tunica albuginea is rare and usually an incidental histologic fi nding. ectopic tubules are present in approximately . % of pediatric autopsies and . % of adult autopsies. the lower inci- dence in adults may be explained by proportionally less sampling. the lesion ranges from microscopic size to a few millimeters in diameter, and may be visible as minute bulges in which multiple small vesicles protrude through a thin tunica albuginea. histologically there are groups of seminiferous tubules in the tunica albuginea, sometimes accompanied by leydig cells. in children, the ectopic tubules appear normal ( fig. - ), whereas in adults they are usually slightly dilated, although some may be hyalinized. serial sections reveal continuity with the intraparenchymatous seminiferous tubules. ectopia of the seminiferous tubule is probably congenital, although it has been found in elderly men. it does not appear to be the result of trauma. the malformation probably arises in the sixth week of gestation, when the primordial sex cords have formed and are branching toward the gonadal surface, and the developing testes is covered by only one to three layers of celomic epithelium. later, the tunica albuginea forms around the sex cords and under the celomic epithelium. failure of insertion of the tunica albuginea between the sex cords and celomic epithelium may entrap seminiferous tubules. ectopia differs from testicular dysgenesis, a distinctive form of male pseudohermaphroditism with müllerian remnants. numerous features, characteristic of ectopic seminiferous tubules, distinguish it from other conditions, including normal thickness and collagenization of the tunica albuginea, absence of interstitial tissue resembling ovarian stroma (characteristic of testicular dysgenesis), and clear delimitation of the tunica albuginea and testicular parenchyma (see discussion on male pseudohermaphroditism with müllerian remnants, below). in a unique case, there were multiple clusters of seminiferous tubules in the wall of a hernia sac that accompanied an undescended testis removed from an adult man. the ectopic tubules were not surrounded by tunica albuginea and were similar to those in cryptorchid testicular parenchyma with only dysgenetic sertoli cells. leydig cells occur normally in the testicular interstitium (interstitial leydig cells) and in the wall of the seminiferous tubules (peritubular leydig cells). however, clusters of leydig cells are often observed in other locations in the testis, or in the epididymis or spermatic cord. ectopic leydig cells may be found in the interlobular septa, - rete testis, tunica albuginea, [ ] [ ] [ ] or within hyalinized seminiferous tubules. , [ ] [ ] [ ] intratubular leydig cells are found only in tubules with advanced atrophy and marked thickening of the tunica propria, including the tubules in adult cryptorchid testes, those of men with klinefelter's syndrome, and in some other primary hypogonadisms ( fig. - ). immunohistochemical studies suggest that the endocrine function of these leydig cells is low. several theories have been offered to account for these ectopic cells, including in situ differentiation, migration from the testicular interstitium, and trapping of peritubular leydig cells in the tunica propria during its thickening. leydig cells are commonly found in the epididymis and spermatic cord; , of autopsies had such foci. extratesticular leydig cells usually form small groups within or adjacent to nerves ( fig. - ) . , the occurrence of ectopic leydig cells in the albuginea, epididymis, or spermatic cord may account for the rare cases of leydig cell tumor in these paratesticular structures. ectopic leydig cells should not be misinterpreted as tumor cells (infi ltration or metastasis) when malignancy of a testicular leydig cell tumor is suspected. other rare forms of ectopia are found within and outside the testis. intratesticular ectopia includes adrenal cortical ectopia, osseous and adipose tissue heterotopia, and ectopia of the ductus epididymidis. extratesticular ectopia includes splenic ectopia (splenogonadal fusion), hepatic ectopia (hepatotes- adrenal cortical ectopia may be important in two conditions that develop tumoral masses: adrenogenital syndrome and nelson's syndrome. tumors in adrenogenital syndrome appear in . % of patients with congenital adrenal hyperplasia, appearing as bilateral testicular masses of synchronous growth. these tumors consist of well delimited but non-encapsulated yellow nodules, several centimeters long, composed of large microvacuolated cells. the cause seems to be prolonged stimulation by elevated acth secretion. the differential diagnosis includes leydig cell tumor. the diagnosis of tumors in adrenogenital syndrome is supported by a family or personal history of salt-lost syndrome or hypertension, demonstration of β-hydroxysteroids (a specifi c marker for adrenal cortex) in spermatic vein blood, or a rapid positive response of tumor to corticoid treatment. nelson's syndrome occurs in patients who, after adrenalectomy for treatment of cushing's syndrome, develop an acth-secreting pituitary adenoma. these patients may develop testicular tumor growth similar to that in adrenogenital syndrome. most nelson's syndrome tumors do not respond to dexametasone treatment. cartilaginous heterotopia may be found in the caput of the epididymis and has been attributed to metaplasia of metanephric rests. osseous heterotopia (testicular osteoma) is a metaplasia occurring in areas of the testicular parenchyma with fi brosis or ischemia. adipose metaplasia is frequent in undescended testis, elderly men, and those with cowden's syndrome ( fig. - ). groups of tubular formations that resembles the epididymis have been reported inside the testicular parenchyma in testes with marked tubular atrophy, and probably represent a rare form of metaplasia. testicular descent is not always complete at birth, and about . % of full-term newborns have incompletely descended testes. most of these descend within months, and only . % of infants have incompletely descended testes months after birth. spontaneous testicular descent is exceptional after the fi rst year. in recent decades, a signifi cant increase in the incidence of cryptorchidism has been detected. only % of patients with impalpable testes are actually devoid of testes. other causes include true cryptorchidism, testicular ectopia, and retractile testes. true cryptorchidism includes abdominal, inguinal, and high scrotal testes that cannot be moved to the scrotum. ectopic testes are those located out of the normal path of testicular descent; the most frequent site is the superfi cial inguinal pouch. other rare locations of ectopia include the abdominal wall, the upper thigh, the perineum, and the base of the penis. retractile testes may be moved to the scrotum at exploration and account for about one third of undescended testes. patients with true cryptorchidism account for about % of cases of empty scrotum. these testes most frequently are found in the inguinal canal or upper scrotum; arrest within the abdomen is less frequent. cryptorchidism is slightly more frequent on the right than the left, and in approximately % of cases is bilateral. there is a family history of cryptorchidism in % of cases. the cryptorchid testis is usually smaller than the contralateral one, and this difference is often discernible at months of age. one-third of cryptorchid testes are soft. several conditions are predictive of high risk of cryptorchidism, including increased maternal age, maternal obesity, pregnancy toxemia, bleeding during late pregnancy, and smoking, tallness, subfertility antecedents, cesarean birth, low birthweight, preterm newborn, twin birth, hypospadias and other congenital malformations, and children born from september to november, and in may and june. , of these associations, low birth weight seems to be the most important. there are two types of cryptorchidism: congenital and acquired. this cryptorchidism is caused by anomalies in anatomic development or hormonal mechanisms involved in testicular descent (described above). impalpable undescended testes are infrequent because the transabdominal phase follows the simple mechanism of relative movement of the testis, whereas displacement of the ovary is more complex. conversely, palpable undescended testes are more frequent because the second phase of testicular descent is more complex. unilateral cryptorchidism may be caused by androgen failure, which leads to either an ipsilateral lesion in the development of genitofemoral nerve neurons or a defect in cgrp release that hinders normal migration of the gubernaculum. a normally descended testis may become cryptorchid and locate even in the abdominal cavity. two categories of acquired undescended testis have been described. the postoperative trapped testis is a normally descended testis that leaves the scrotal pouch after surgery owing to an inguinal hernia or hydrocele. [ ] [ ] [ ] this iatrogenic cryptorchidism occurs in . % of children after herniotomy. adherence of the testis or the cremasteric muscle to the surgical incision causes testicular ascent when the incision heals and undergoes retraction. spontaneous ascent from unknown causes. various mechanisms have been proposed, including inability of the spermatic blood vessels to grow adequately, anomalous insertion of the gubernaculum, failure in reabsorption of the vaginal process , and failure in postnatal elongation of the spermatic cord. , the spermatic cord measures - cm at birth and reaches - cm at years of age. this growth does not occur if the peritoneal-vaginal duct has become a fi brous remnant. the cause might be a defect in postnatal cgrp release by the genitofemoral nerve. , , pathogenesis the most frequent fi ndings in congenital and acquired cryptorchidism at infancy are decreased germ cell numbers and diminished tubular diameter. , there are multiple causes of testicular maldescent, including anatomical anomalies of the gubernaculum testis, hormonal dysfunction (hypogonadotropic hypogonadism), mechanical impairment (insuffi cient intra-abdominal pressure, short spermatic cord, underdeveloped processus vaginalis), dysgenetic (primary anomaly of the testis), and heredity. most cryptorchidism appears to be caused by either a defi cit of fetal androgens or an excess of maternal estrogens. androgen insuffi ciency seems to be slight and transient because anomalies other than hypoplasia of the epididymis are not seen. elevated maternal estrogens level could cause diminution of fsh secretion by the fetal pituitary, inducing low müllerian-inhibiting hormone production that would hinder testicular descent. three mechanisms seem to be involved in the process: • primary testicular anomaly. cryptorchid testes may bear an anomalous germ cell population, as suggested many years ago. more than % of cryptorchid patients have a marked decrease in the tubular fertility index, in the normal testis there is transient formation of spermatocytes at - years of age. this meiotic attempt is probably an androgenic event that does not occur in cryptorchid testes and agrees with the characteristic low numbers of spermatogonia in the prepubertal age. prepubertal testes undescended testes are usually smaller than the contralateral ones. this difference is already significant at months of age. , although there have been a number of biopsy studies in the fi rst years of life, there is no agreement about the severity of damage or the time of its onset. , , based on the tubular fertility index (tfi) and mean tubular diameter (mtd), most testicular biopsies from cryptorchid testes of children can be classifi ed into one of three groups: • type i (testes with slight alterations). the tubular fertility index is higher than , and the mean tubular diameter is normal or slightly (< %) decreased. approximately % of cryptorchid testes are in this group ( fig. - ). • type ii (testes with marked germinal hypoplasia). tubular fertility index is between and , and mean tubular diameter is - % lower than normal. the spermatogonia are distributed irregularly and most are in tubular sections that are grouped in the same testicular lobule. these testes comprise approximately % of cryptorchid testes ( fig. - ). • type iii (testes with severe germinal hypoplasia). tubular fertility index is less than , and mean tubular diameter less than % of normal. many of the spermatogonia are giant with dark nuclei (fig. - ). these testes often contain ring-shaped tubules, induced by increased temperature. testes with type ii or iii lesions bear variable degrees of dysgenesis that, in addition to germ cells, involve sertoli cells, peritubular myofibroblasts, and leydig cells. the dysgenesis of these other cell types is evident only after puberty. in about % of cases the contralateral scrotal testis also has histologic lesions of variable severity. this fi nding supports the hypothesis of a bilateral defect in many cases of unilateral cryptorchidism. microdeletions in the long arm of the y chromosome are present in % of patients with corrected unilateral cryptorchidism who present with azoospermia or severe oligospermia. these fi ndings are similar to those observed in patients with azoospermia or severe idiopathic oligospermia. unilateral cryptorchidism with a normal contralateral testis could be due to an end-organ failure. in cryptorchidism secondary to spontaneous ascent, lesions are similar to megatubules (with or without eosinophilic bodies or microliths) ( fig. - ) , and focal granular changes in the sertoli cells ( fig. - ). the testicular interstitium is wide and edematous. these comprise about % of cryptorchid testes. about % of tests with type i lesions show many multinucleated spermatogonia (with three or more nuclei) ( fig. - ). the seminiferous tubules of testes with types ii or iii lesions have a thickened lamina propria during childhood and, at puberty, sertoli cell hyperplasia. patients with bilateral cryptorchidism have a higher incidence of type ii and iii lesions than those with unilateral cryptorchidism. type i lesions are comparable to those seen in experimental cryptorchidism; normal testes in which lesions were those of congenital cryptorchidism, whereas in cryptorchidism secondary to herniotomy, germ cell depletion is slight and becomes important only after years of age. adult testes most pubertal and adult cryptorchid testes have anomalies in all testicular structures. the seminiferous tubules have decreased diameters and defi cient spermatogenesis. in decreasing order of frequency, the most common germ cell lesions are tubules with sertoli cell and spermatogonia-only pattern; tubules with sertoli cells (dysgenetic) only; tubular hyalinization; and mixed atrophy. the lamina propria has scant elastic fi bers and increased collagen fi bers. sertoli cells are present in increased numbers and do not mature normally except in tubules with germ cells (fig. - ). , often, groups of tubules containing only sertoli cells with a prepubertal pattern (very small diameter and total absence of maturation) are present and are considered hypoplastic, dysgenetic, or hamartomatous. areas of apparent leydig cell hyperplasia are frequent, and many of these cells contain vacuolated lipid-laden cytoplasm ( fig. - ). the rete testis is hypoplastic in most cases and is lined by columnar epithelium with rare areas of fl attened cells. cystic dilation is common, and adenomatous hyperplasia has been found in some cases. near the rete testis, the testicular parenchyma frequently contains metaplastic fat. in some cryptorchid testes, several tubular segments are destroyed by infl ammation that probably has an autoimmune cause (focal orchitis). epididymal tubules are poorly developed and peritubular tissue is immature. blood fl ow is associated with testicular histology. for example, testicular volume, histologic pattern, and testicular artery resistive index are lower in undescended testes than in controls, and testicular artery resistive index is inversely proportional to testicular histology score in undescended testes. there is also an apparent correlation between testicular size, spermiogram, and hormone levels. assuming that a signifi cant reduction in testicular size (> ml) is only observed in . % of cases, and that serum levels of fsh, lh, and testosterone are normal, an inverse correlation is seen between fsh and testicular volume, sperm concentration, sperm motility, and normally shaped sperm. in addition, there is a direct relation between testicular volume and sperm concentration, sperm motility, and normally shaped sperm. these fi ndings indicate the cause of tubular impairment in young men operated on in childhood for cryptorchidism. obstructed testes are located in the superfi cial inguinal pouch (denis-browne pouch) and are considered ectopic by some authors and cryptorchid by others. , histologic studies reveal that most obstructed testes bear the same lesions as true cryptorchid testes. type i lesions are observed in half, type ii in more than one-third, and the remainder show type iii lesions. the higher proportion of type i lesions suggests a better prognosis than in true cryptorchid testes. some authors assume that retractile testes are normal and exclude them from studies of cryptorchidism. , however, these testes may present important lesions and many consider them to be a form of cryptorchidism. [ ] [ ] [ ] retractile testes may not always be movable to the lower scrotum ( - mm from the pubic tubercle) and in % of cases are smaller than scrotal testes. approximately % of retractile testes remain high after age years, when cremasteric activity declines. retractile testes have a % risk of becoming ascending or acquired undescended testes. the risk is higher in boys younger than years, or when the spermatic cord is tight or inelastic. during childhood, tubular diameter and tubular fertility index decrease. adults with retractile testes that descended spontaneously but late may be fertile or infertile. usually there is germ cell atrophy that varies in severity from lobule to lobule. regular examination of retractile testes is advisable during childhood and, if complete testicular descent does not occur, orchidopexy is indicated. most cryptorchid patients have a patent processus vaginalis, and - % have a hernia sac, although most hernias are not clinically visible. urologic anomalies are present in . % of patients, the most frequent being hypospadias, complete duplication of the urinary tract, non-obstructive ureteral dilatation, kidney malrotation, and posterior urethral valves. cryptorchidism is more frequent in patients with microcephaly, myelomeningocele, bifi d spine, omphalocele, gastroschisis, micropenis, and imperforate anus. cryptorchidism may appear isolated or associated with congenital anomalies, endocrine dysfunction, chromosomal disorders, or intersex conditions. thus, cryptorchidism is found in the kallmann, prader-willi, klinefelter, noonan, smith-lemli-opitz, aarskog-scott, rubinstein-taybi, prune belly, and caudal regression syndromes, anomalies of the androgen receptor, absence of anti-müllerian hormone, charge association, and trisomies , , and . sperm excretory duct anomalies occur in - % of cryptorchid patients, , and are classifi ed into three types: • ductal fusion anomalies ( % of cases). these consist of anomalous fusion of the caput of the epididymis to the testis or segmental atresia of the epididymis and vas deferens. this is chiefl y associated with intraabdominal or high scrotal cryptorchid testes. • ductal suspension anomalies ( % of cases). the caput of the epididymis is attached to the testis, whereas the corpus and the cauda of the epididymis are separated from the testis by a mesentery. a variant consists of an excessively long cauda of the epididymis that descends along the inguinal duct to the scrotum. • anomalies associated with absent or vanishing testes ( % of cases). cryptorchidism is part of the testicular dysgenesis syndrome. this consists of abnormal testicular development that predisposes to cryptorchidism, hypospadias, spermatogenetic alterations, and testicular cancer. the association of these disorders with cryptorchidism has been corroborated by numerous clinical, epidemiological and genetic studies. the least severe form of this syndrome is a defect in spermatogenesis; the most severe is testicular cancer. a constellation of histologic lesions is common in the testes of men with testicular dysgenesis; these lesions include sertoli cellonly pattern, mixed atrophy, hypoplastic tubules (sertoli cell nodules), microlithiasis, malformed tubules, granular changes in sertoli cells, nodular leydig cell hyperplasia, and intratubular germ cell neoplasia. it is assumed that there is a prenatal development of the lesions as a result of several genetic, environmental, or endocrine disruptor factors that would interfere with the estrogen/androgen ratio. [ ] [ ] [ ] [ ] the main complications of cryptorchidism are testicular cancer, infertility, testicular torsion, and psychological problems. approximately . % of -year-old males have cryptorchidism, and about % of testicular cancer patients had cryptorchidism. the risk of testicular cancer in cryptorchid males is four to times higher than that of the general population. testes with elevated number of multinucleated spermatogonia seem to have a higher risk of cancer and adulthood. about % of biopsies in children contain cells similar to those seen in undifferentiated intratubular germ cell neoplasia, and these cells may evolve toward germ cell tumor ( fig. - ). the most frequent tumor in undescended testes is seminoma. , regardless of timing, orchidopexy does not reduce the risk of cancer, although it facilitates early detection as the intrascrotal testis is palpable. one in fi ve testicular tumors arises in properly descended testes contralateral to cryptorchid testes, suggesting that there is a primary bilateral testicular anomaly in cryptorchidism. intra-abdominal testes also have a higher incidence of tumors. infertility infertility is the most frequent problem caused by cryptorchidism. in a series of patients with infertility, nearly % had cryptorchidism. infertility is infl uenced by several factors, including bilaterality, number of germ cells, location and size of the testis, and age at time of orchidopexy. the most important risk factors are bilaterality and germ cell number. only % to % of men with bilateral cryptorchidism have normal sperm counts ( million/ml or more). the highest sperm counts occur with testes in the superfi cial inguinal pouch. patients with bilaterally impalpable testes are usually azoospermic. fertility rates in unilateral cryptorchidism vary from % to %. the number of germ cells per cross-sectioned tubule is the most important prognostic factor. patients with no increase in inhibin b during the postoperative period usually have a low number of spermatogonia per cross-sectioned tubule and a low tubular fertility index. in unilateral cryptorchidism, fertility depends on the number of spermatogonia in the contralateral testis. however, if the number of germ cells per cross-sectioned tubule in the cryptorchid testis is lower than % of normal, the risk of infertility is %. in bilateral cryptorchidism the risk of infertility rises from % to % when one or both testes have less than % of germ cells per cross-sectioned tubule. neither the preoperative location of the testis in patients with unilateral cryptorchidism nor the small size of the testis at the time of orchidopexy is relevant for fertility. [ ] [ ] [ ] an important fertility factor is the permeability of sperm excretory ducts. the age at orchidopexy may also infl uence fertility, although this has not been proven. in patients over years of age orchidopexy does not enhance fertility. , benefi t of testicular biopsy in patients with cryptorchidism testicular biopsies of infantile testes at orchidopexy are useful for determining baseline germ cell status and whether surgery should be completed with hormonal treatment. however, even if biopsy supplies important data, it is not considered a routine procedure. even in the best cases when the number of spermatogonia is nearly normal, spermatogenesis may never occur owing to defi cient spermatogonium development during childhood, failure of spermatogenesis at puberty, and, if complete spermatogenesis occurs, this might be associated with obstruction of sperm excretory ducts. in childhood, the chance of a biopsy fi nding an occult cancer or precancer is low because intratubular germ cell neoplasia is not diffusely distributed throughout the testis. testicular biopsy is recommended in patients with intra-abdominal testes, abnormal external genitalia, or abnormal karyotype. the situation is different in adults because intratubular germ cell neoplasia is present in - % of cases and is diffuse. , when intratubular germ cell neoplasia is detected in a child, further examination of the testis and rebiopsy after puberty are recommended. in adults, if intratubular germ cell neoplasia is unilateral orchidectomy should be performed, but if it is bilateral, radiation may be used to eradicate the neoplasia while maintaining leydig cell function. testicular microlithiasis (tm) is characterized by the presence of numerous calcifi cations diffusely distributed throughout the testicular parenchyma. the number and size of the calcifi cations often is great enough to be detected radiographically or by ultrasound. isolated microliths have been reported in undescended testes, prepubertal klinefelter's syndrome, male pseudohermaphroditism, and otherwise normal children and patients studied for other diseases. in adults, microliths are frequently observed in cryptorchid and ex-cryptorchid testes, seminiferous tubules located at the periphery of germ cell tumor, infertile patients, [ ] [ ] [ ] and in some patients complaining of orchialgia , or testicular asymmetry. testicular microlithiasis occurs in . % of cryptorchid testes and is slightly more common in prepubertal than adult testes. in adults, it usually is diagnosed when men seek help for infertility, pain, or testicular asymmetry. microlithiasis has been observed in . - % of testicular echographies of different disorders. , in infertile patients the incidence is slightly higher. microlithiasis is present in % of testis having a malignant tumor. ultrasound studies reveal two types of microlithiasis: classic tm, in which the number of microliths is fi ve or more; and limited tm, when there are fewer than fi ve microliths ( fig. - ). the incidences of tm in these studies are lower than % in infants, . % in the general population aged between and years (bilateral in % of patients showing microliths, . - . % in patients with other disorders, , , - from . % to % in subfertile patients, . % in ex-cryptorchid testes, and more than % in adult testes with germ cell tumors). , - several cases of testicular microlithiasis have also been observed in infant testes with germ cell tumor or gonadal stroma tumor. , the incidence is higher in whites than in blacks. pain is the most common clinical symptom in patients without a palpable testicular mass, and has been attributed to dilation of seminiferous tubules secondary to obstruction by microliths. microliths are made by hydroxyapatite, according to x-ray diffraction studies and raman spectroscopy. in the prepubertal testis, microliths are surrounded by a double layer of sertoli cells and measure up to µm in diameter. when they are very large, the seminiferous epithelium may be destroyed and the microlith is surrounded by peritubular cells (fig. - ). testes with microliths have subnormal mean tubular diameters and tubular fertility index. in adult testes with microliths there is incomplete spermatogenesis. some seminiferous tubules with microliths are cystically dilated (fig. - ). microliths arise as extratubular eosinophilic bodies that mineralize and pass into the tubular lumina. microlithiasis may be a disorder of the tunica propria. also, testicular microlithiasis is occasionally associated with pulmonary microlithiasis and with calcifi cations in the parasympathetic nervous system. , the association of microlithiasis and testicular cancer is controversial. , although the development of testicular cancer has been observed in several patients whose testicular microlithiasis had been previously diagnosed by ultrasound studies, [ ] [ ] [ ] [ ] [ ] it is also thought that patients with testicular microlithiasis not associated with other disorder do not require any follow-up. when microlithiasis is associated with infertility the incidence of cancer varies according to the unilaterality or bilaterality of microlithiasis: subfertile patients with unilateral microlithiasis show no intratubular germ cell neoplasia, whereas this is present in % of those with bilateral microlithiasis. the risk of malignancy is higher in classic than in limited tm. the nexus between microlithiasis and cancer does not seem to be the predisposition of one disorder towards the other but rather the predisposition of both to develop in abnormal testes. this may also explain the association between microlithiasis and infertility. yearly ultrasound examination, perhaps with testicular biopsy, is recommended in those with testicular microlithiasis associated with cryptorchidism, infertility, atrophic testes, or contralateral testis bearing germ cell tumor. microlithiasis also occurs in the rete testis or sperm excretory ducts. epididymal rupture and extravasation of microliths into the interductal tissue may cause a histiocytic reaction resembling malakoplakia ( fig. - ). the disorder is asymptomatic and not associated with testicular cancer. gonadal dysgenesis refers to disorders characterized by amenorrhea and streak gonads in phenotypically female patients. in adults, streak gonads are elongated masses of fi brous tissue resembling ovarian stroma ( fig. - ). they may contain hilar cells and rete or epithelial cords with variable degrees of maturation, and may result from failure in gonad formation, failure of gonadal differentiation to ovary, or failure of gonadal differentiation to testis. some streak gonads contain a few ovocytes or primordial follicles, but all germ cells disappear at puberty. patients with streak gonads have a hypoplastic uterus and fallopian tubes. four types of gonadal dysgenesis have been described: xy pure, xx pure, x , and mixed. xy gonadal dysgenesis (swyer's syndrome) is characterized by female phenotype, absence of turnerian stigmata, and female external genitalia, sometimes with fused labia majora, a hypertrophic clitoris, and hypospadias. the breasts develop at puberty. sexual infantilism persists in adulthood, and eunuchoidism and amenorrhea appear. these patients have elevated serum gonadotropin levels and low serum estradiol. there are two types of gonadal dysgenesis: complete and incomplete. patients with the complete type have female external genitalia and classic streak gonads, although cases with ovarian tissue have been reported. the cause is unknown in about % of cases, and is due to alterations in the sry gene in the remainder (a mutation in - % of cases, and a sry deletion as a result of an aberrant x/y interchange in - %). the consequence of failure is very early gonadal alteration (sixth to eighth week of gestation). with the subsequent absence of müllerian inhibiting factor, testosterone, and dihydrotestosterone, a female phenotype develops. patients with incomplete xy gonadal dysgenesis have ambiguous external genitalia and variable degree of development of the müllerian and wolffi an structures. although they have streak gonads, testicular development is usually observed. this gonadal dysgenesis does not seem to be caused by sry alterations. these fi ndings suggest that in the fi rst type ovarian differentiation was canceled, and that in the second type testicular differentiation failed. the fi rst is similar to the gonad of x turner's syndrome, whereas the second resembles the gonad of mixed gonadal dysgenesis. the clitoromegaly may be caused by androgens secreted by hyperplastic leydig cells in the streak gonad. some patients with xy gonadal dysgenesis present with extragonadal anomalies and multiple syndromes, including camptomelic dysplasia and renal disorder, myotonic dystrophy and terminal renal disease, without facial anomalies or short stature, renal insufficiency and wilms' tumor (denys-drash syndrome), the combination of cleft palate, micrognathia, kyphosis, scoliosis, and clubfoot (gardner-silengo-wachtel syndrome or genitopalatocardiac syndrome), pterygium multiple syndrome, graves' disease, , and congenital universalis alopecia, microcephaly, cutis marmorata, and short stature. , most cases are sporadic, although the syndrome has been reported in several members of the same family, [ ] [ ] [ ] [ ] and several forms of inheritance (x-linked, autosomal recessive, and male-limited autosomal dominant) have been proposed. in addition to infertility, patients with xy gonadal dysgenesis have a high risk of germ cell tumor. this risk is about % in the fi rst decade of life, and - % overall, [ ] [ ] [ ] [ ] and, thus, prophylactic gonadectomy is recommended. patients with xx gonadal dysgenesis have normal stature, female phenotype, well-developed external genitalia, and hypoplastic ovaries rather than streak gonads ( fig. - ). the anomaly is usually detected when patients present with primary amenorrhea or infertility. this syndrome is sporadic and familial, and it may be linked to recessive autosomal inheritance. , patients have no predisposition to gonadal neoplasia. associated somatic anomalies such as neurosensory hearing loss (perrault's syndrome) are rare. some familial cases have shown a balanced translocation of the x chromosome (from the long arm to the short arm) , or between chromosomes and . because the development of ovarian follicles requires fsh, mutations have been sought in the fshr gene. mutations have been detected in familial cases and also in unrelated patients, , whereas other patients have shown no mutations in this gene. the incidence of tumors in these patients is very low, and the most common is dysgerminoma. [ ] [ ] [ ] this is one of the most common chromosomal anomalies (from / to / in female newborns), although % of zygotes with this karyotype are aborted in the fi rst stages of embryonal development. patients with xo gonadal dysgenesis have characteristic stigmata of turner's syndrome, including short stature, pterygium coli, lymphedema, and cardiac malformations. the external genitalia are female and infantile; the gonads are typical streak gonads. today, turner's syndrome is defi ned by the combination of physical features and the complete or partial absence of one of both x chromosomes, frequently associated with mosaicism. turnerian stigmata may be classifi ed into four groups: skeletal anomalies such as cubitus valgus, shortening of the fourth metacarpal and madelund's deformity characteristic of leri-weill dyschondrosteosis; soft tissue anomalies such as webbed neck, low posterior hair line, and puffy hands and feet; visceral anomalies such as aortic coarctation, horseshoe kidney, polycystic kidney, urethral stenosis and vesicourethral refl ux; and miscellaneous anomalies such as nevus pigmentosus. during embryonic life, these gonads show normal germ cell numbers up to the third month, when germ cell proliferation ceases. , ovogenesis stops in meiosis i, usually before the pachytene stage. the cause seems to be generalized meiotic pairing errors with the start of an apoptotic mechanism to avoid the formation of abnormal gametes. massive apoptosis of ovocytes occurs between the th and the th weeks. surviving germ cells disappear throughout fetal life, and their numbers at birth are usually low ( fig. - ). patients with mosaicism have fewer anomalies than pure x individuals; % have menstruation (compared to % of pure x patients), and % have breast development (compared to % of pure x patients). in - % of x patients the sry gene is demonstrable by in-situ hybridization. it has been proposed that patients with sry expression should undergo gonadectomy, because this gene is also a marker of gonadoblastoma. these patients may develop gonadoblastoma, dysgerminoma, and mixed germ cell tumor. , mixed gonadal dysgenesis is characterized by the presence of a streak gonad and a contralateral testis (often cryptorchid) or streak testis (see discussion on male pseudohermaphroditism with müllerian remnants, below). true hermaphroditism is a disorder of gonadal differentiation characterized by the presence in the same individual of both testicular and ovarian tissue. this condition is rare and usually diffi cult to diagnose, so only % of male hermaphrodites are diagnosed before age . failure to recognize this disorder may lead to surgical intervention for hernia repair or orchidopexy. most hermaphrodites raised as males display symptoms for the fi rst time at puberty because of breast development ( % of hermaphrodites have some degree of gynecomastia), periodic hematuria (if they have a uterus ending in the urinary tract), or cryptorchidism. hermaphrodites raised as females initially present with irregular menstruation or clitoromegaly. true hermaphroditism should be suspected in all children with ambiguous sex characteristics ( fig. - ). the gonads of these patients are ovotestes, ovaries, or testes, with all possible combinations. true hermaphroditism can be ( ) unilateral, if there are both testicular and ovarian tissues (forming one ovotestes or two separated gonads) on one side, and a testis or an ovary in the other side; if there is no gonadal tissue in this latter side, unilateral hermaphroditism is incomplete; ( ) bilateral, if testicular and ovarian tissues are present on both sides of the body; and ( ) alternate, if there is a testis on one side, and an ovary on the other side. ovotestis is the most frequent gonadal type in true hermaphroditism. it is more frequent on the right side and is located in the abdomen ( % of cases), labioscrotal folds, inguinal canal, or the external inguinal ring. the ovotestis has a bilobated or ovoid shape ( fig. - ). in the bilobated ovotestis the testis and ovary are connected by a pedicle, whereas in the ovoid ovotestis the ovarian tissue forms a crescent capping the testicular parenchyma. the proportion of ovary to testis varies widely ( fig. - ). at adulthood, the ovarian follicles mature and corpora lutea or corpora albicantia may be seen. the seminiferous tubules rarely develop complete spermatogenesis. the interstitium usually contains leydig cells. ovotestis is associated with a fallopian tube in % of cases, and with a vas deferens in the remainder. if the patient has ovotestis/ovary, a completely developed uterus is present. if the patient has bilateral ovotestis ( %), uterine agenesis is frequent (fig. - ). the testis of hermaphrodites is most often on the right side ( %) and is located anywhere from the abdomen to the scrotum. these testes have low tubular fertility indices during childhood. after puberty, the seminiferous tubules remain small, often containing only dysgenetic sertoli cells, similar to the tubules of cryptorchid testes. incomplete spermatogenesis has been reported, but complete spermatogenesis is exceptional. the ovary of hermaphrodites is most frequently on the left side ( %) and usually is hypoplastic with few primordial follicles. however, in occasional patients the ovary is histologically and functionally normal. the most frequent karyotype is xx ( %), followed by several mosaicisms ( %) which, in decreasing order of frequency, are xx/ xy, xy/ xxy, x / xy, xx/ xxy. the xy karyotype is the least common ( %). there is variation in the incidence of some karyotypes around the world. mosaicism is found in . % of european cases, but in only % of north america cases. conversely, most african true hermaphrodites ( %) have xx karyotype. the karyotype xy is rare and its frequency is similar in europe, asia, and north america. , most cases are sporadic, and families with several affected members also have xx males. this fi nding suggests that both genetic anomalies are alternative forms of a single genetic defect. the following mechanisms , have been proposed to explain the occurrence of testicular parenchyma: true hermaphroditism xx, a hidden mosaicism with a cell line having a y chromosome; transfer from a y chromosome fragment (including sry gene) to the x chromosome; autosomal mutation of variable penetrance; and x-linked mutation coupled with rare x inactivation or x mutation that permits testicular differentiation in the absence of sry. some xx hermaphrodites with sry-negative leukocytes are positive for this gene in dna from the testicular parenchyma in the ovotestis. over pregnancies in true hermaphrodites have been reported, in contrast to the exceptional cases of paternity. ovules may arise from the ovotestes or the ovary. management of true hermaphroditism depends on the patient's age at the time of diagnosis, the nature and location of the gonads, and the developmental stage of the external genitalia. although bilateral castration may be justifi ed in order to avoid the risk of neoplasia, gonadal preservation may be desirable until adulthood. in this case, if the patient is raised as a girl, puberty will occur spontaneously and there is a small chance of fertility. however, the high risk of malignancy (estimated at . %) should be taken into account. the most frequent tumors are gonadoblastoma, dysgerminoma, and yolk sac tumor. the risk of cancer may be reduced if some precautions are taken, including removal of the testis if it has not descended and surveillance of the residual gonad with periodic ultrasound studies, especially in cases of chromosomal mosaicisms. normal male development requires adequate differentiation of the testes in the fetal period, synthesis and secretion of testicular hormones, and proper response of target organs to these hormones. anti-müllerian hormone produced by sertoli cells inhibits the development of müllerian derivatives that would otherwise form the uterus and fallopian tubes. testosterone produced by leydig cells stimulates differentiation of the wolffi an ducts into male genital ducts. the conversion of testosterone into dihydrotestosterone by the enzyme α-reductase ensures the development of male external genitalia. alterations in these processes may cause male pseudohermaphroditism. androgen synthesis defi ciencies these autosomal recessive syndromes are characterized by an error in testosterone synthesis that results in incomplete or absent virilization. cholesterol is the source for the synthesis of androgens, estrogens, and other steroid hormones through multiple steps. first, the steroidogenic acute regulatory protein (star) generates cholesterol into mitochondria; star gene mutations cause congenital lipoid adrenal hyperplasia. second, within mitochondria, the cholesterol sidechain cleavage enzyme p scc transforms cholesterol into pregnenolone; a disorder in this enzyme is rare because it is highly lethal in embryonic life. third, pregnenolone undergoes α-hydroxylation by microsomal p c ; defi ciency in α-hydroxylase causes female sexual infantilism and hypertension. fourth, -oh-pregnenolone is converted into dhea by , -lyase activity of p c . the ratio of , -lyase to α-hydroxylase activity of p c determines the ratio of c to c steroids produced. the ratio is regulated by at least three factors, including the electrondonating protein p oxidoreductase (por), cytochrome b , and serine phosphorylation of p c . mutations in por are present in the antley-bixler skeletal dysplasia syndrome as well as a variant of polycystic ovarian syndrome. figure - shows the enzymes involved in the abovementioned steps. the enzyme β-hydroxysteroid dehydrogenase transforms dhea to androstenedione, and the enzymatic complex called aromatase transforms androstenedione into estrone and testosterone into estradiol. in some patients cholesterol synthesis is also impaired, and congenital adrenal hyperplasia is superimposed on androgen defi ciency. defi cient testosterone synthesis may result from abnormalities in the enzymes involved in pregnenolone formation (congenital lipoid adrenal hyperplasia), including β hydroxysteroid dehydrogenase, αhydroxylase, , -desmolase, and β-hydroxysteroid dehydrogenase ( fig. - ). congenital lipoid adrenal hyperplasia is the most severe form of congenital adrenal hyperplasia. the disorder is characterized by a defi cit in steroid hormone synthesis in the adrenal cortex and gonads, producing a female phenotype with severe salt-loss syndrome. conversion of cholesterol to pregnenolone requires the enzymes α-hydroxylase, , desmolase, and α-hydroxylase. failure of any of these leads to defi cits in cortisol, aldosterone, and testosterone. the enzymatic defect is usually is caused by a defi cit in the steroidogenic acute regulatory (star) protein; in other cases, the defi cit is in p ssc. the mitochondrial protein star promotes cholesterol transfer from the outer to inner mitochondrial membrane, where cholesterol serves as a substrate for p scc and initiates steroidogenesis. more than different mutations in the star gene have been identifi ed. as a result, cholesterol is not converted to pregnenolone, which is required for the synthesis of mineralocorticoids, glucocorticoids, and sex hormones. the disorder is rare in most countries, but is common in japan, korea, and the arabian countries. , patients usually present with salt-losing crisis in the fi rst months of life. , in most cases, males have female or ambiguous external genitalia and a blind-sac vagina, hypoplastic wolffi an derivatives, absence of müllerian structures, and cryptorchidism. the adrenals usually appear enlarged and contain lipid accumulations, , but these diminish with age and the adrenals shrink. in the testes, lipid accumulations may be present or absent in leydig cells , , [ ] [ ] [ ] [ ] [ ] or sertoli cells. an -year-old child had partially hyalinized seminiferous tubules with sertoli cell-only pattern. the testes of pubertal patients are usually normal for age. , intratubular germ cell neoplasia has been reported in one case. most patients die from adrenal insuffi ciency. survivors have female phenotype and require the administration of glucocorticoids, mineralocorticoids, and gonadal steroids. β-hydroxysteroid dehydrogenase defi ciency patients with this defect have two main problems: salt-loss syndrome produced by reduced aldosterone secretion, and incomplete virilization. at puberty, virilization increases and gynecomastia develops. , the enzyme bhsd catalyzes the conversion of - βhydroxysteroids such as pregnenolone, -hydroxypregnenolone, and dehydroepiandrosterone into respectively - β-ketosteroid, progesterone, -hydroxyprogesterone, and androstenedione. there are two bhsd genes located on the p -p region of chromosome . the type i gene is expressed in the placenta, kidney, and skin, whereas the type ii gene bhsd is expressed only in the gonads and adrenal glands. complete absence of the bhsd gene is lethal; therefore, most reported cases have only partial bhsd deficits. [ ] [ ] [ ] it is assumed that these defi cits account for % of cases of congenital adrenal hyperplasia. the classic form of salt-losing bhsd defi cit is diagnosed in the fi rst months of life because of insuffi cient aldosterone synthesis and subsequent loss of salt. the other bhsd defi cit, without salt loss, is due to mutations in the type ii bhsd gene and its diagnosis may be delayed until puberty. severe forms of bhsd defi ciency are associated with defi cits in aldosterone, cortisol, and estradiol. symptoms may vary widely, as enzymatic activity in the adrenal gland is not the same as in the testis. most patients show salt loss and adrenal crisis; they have incomplete masculinization and may develop spontaneous puberty and gynecomastia. , , patients with mild forms have normal genitalia and normal mineralocorticoid levels. some patients have only hypospadias or micropenis. the testes are smaller and softer than normal. α-hydroxylase defi ciency the cause of defi cits in the enzymes α-hydroxylase and , -lyase are mutations of the cyp gene that encodes cytochrome p c . the cyp gene is located on chromosome q -q , and different mutations have been described. p c catalyzes the α-hydroxylation of pregnenolone to ohpregnenolone and of progesterone to α-oh-progesterone. this enzyme also catalyzes , -lyase activity, transforming oh-pregnenolone to dhea. the classic form of αhydroxylase defi cit is caused by severe defi ciencies in cyp ; less severe defects give rise to the isolated , -lyase defi cit. α-hydroxylase defi cit impairs the synthesis of both cortisol and testosterone. low cortisol levels stimulate acth secretion, causing hypersecretion of aldosterone precursors and the development of hypokalemic hypertension and male pseudohermaphroditism in males. patients usually have hypospadias and develop gynecomastia at puberty. the enzyme , -desmolase cleaves the side chain of -hydroxypregnenolone and hydroxyprogesterone to form dehydroepiandrosterone and androstenedione, respectively. varying degrees of , desmolase defi ciency are seen, resulting in varied development of external genitalia, ranging from female phenotype to virilization with microphallus, bifi d scrotum, and perineal hypospadias. in childhood, the testes contain reduced numbers of spermatogonia (figs - , - ) . , the cause may be mutations in one of the genetic loci encoding p c , fl avoprotein or or b . β-hydroxysteroid dehydrogenase defi ciency this enzyme transforms androstenedione into testosterone and also converts estrone into estradiol. the enzymatic defects are sexlinked. most patients have female phenotype at birth and are raised as girls, but at puberty undergo virilization. one or both testes may be cryptorchid or are located in the labia majora. normal spermatogenesis has never been observed. the most common testicular patterns are hypoplasia or absence of germ cells and leydig cell hyperplasia. the germ cell injury was initially attributed to cryptorchidism, but it is now thought to be a primary testicular lesion because even very young patients lack germ cells. this defi cit is due to mutations in the hsd b gene located on q . , leydig cell hypoplasia this variant of male pseudohermaphroditism is defi ned by insuffi cient testosterone secretion and the following characteristics: predominance of female external genitalia; absence of male secondary sex characteristics at puberty; absence of uterus and fallopian tubes and the presence of epididymis and vas deferens; xy karyotype; lack of response to human chorionic gonadotropin stimulation; absence of an enzymatic defect in testosterone synthesis; and small undescended testes that are gray and mucous on section. [ ] [ ] [ ] [ ] age at diagnosis varies from months to years. the syndrome is sporadic and familial. , the best-known cause of leydig cell hypoplasia is inactivating mutation of the lh receptor in these cells. [ ] [ ] [ ] during fetal life, there is an inadequate response to placental hcg initially and to pituitary lh subsequently. phenotypes vary widely according to the presence of complete or partial loss of receptor function. these changes range from male pseudohermaphroditism with female external genitalia (type i of leydig cell hypoplasia) to male phenotype with micropenis, hypospadias, pubertal delay, and primary hypogonadism (type ii of leydig cell hypoplasia). in type i hypoplasia, the testes contain small seminiferous tubules with sertoli cells, spermatogonia, and thickened basement membranes. leydig cells are rare or absent, in contrast to leydig cell hyperplasia seen in other types of male pseudohermaphroditism, such as those arising from defects in androgen synthesis or androgen action on peripheral tissues. , leydig cell hypoplasia accounts for low serum testosterone levels, lack of virilization, and lack of spermatogenesis. the absence of müllerian derivatives suggests a normal function of sertoli cells, which synthesize müllerian inhibiting factor. in type ii hypoplasia, adult testes show maturation arrest of spermatogonia and a few incompletely differentiated leydig cells. , resistance to androgen stimulation is the cause of several syndromes with phenotypes varying from complete testicular feminization to normal male. , these syndromes are caused by partial or complete lack of response of the target organs to androgens due to the absence, diminution, or impairment of androgen receptors or postreceptor anomaly. the gene for the androgen receptor is located on the x chromosome (xq -q ), and x-linked transmission occurs in two-thirds of cases. the karyotype is usually xy, but xxy and several mosaicisms have been observed. these syndromes affect : - : newborns. the diverse phenotypes associated with androgen insensitivity may be classifi ed as: complete androgen insensitivity syndrome (cais) or testicular feminization syndrome; partial androgen insensitivity syndrome (pais) or partial testicular feminization syndrome, which includes the syndromes of lubs, gilbert-dreyfus, reifenstein, and rossewater; and mild androgen insensitivity syndrome (mais), infertile men with light androgen insensitivity, and kennedy's disease. complete androgen insensitivity syndrome (complete testicular feminization syndrome) this form of male pseudohermaphroditism is characterized by female phenotype with testes. complete testicular feminization syndrome is rarely diagnosed during childhood except in patients who present with hernia, inguinal tumor, or with a family history of pseudohermaphroditism. primary amenorrhea is the principal presentation in adults. the testes may be in the abdomen, inguinal canal, or labia majora, and during the fi rst year of life may be normal histologically except for reduced tubular diameter and low tubular fertility index. after the fi rst year, decreased germ cell numbers become evident and the few remaining spermatogonia are concentrated in clusters of seminiferous tubules. the testicular interstitium contains numerous spindle cells arranged in bundles, and during the fi rst year of life has leydig cells with abundant eosinophilic or vacuolated cytoplasm. at puberty, patients have female external genitalia, a short blind-ended vagina, feminine breast development; and scarce pubic and axillary hair. serum testosterone is at the normal male level and lh is markedly increased. in adults, the testes vary in size from small to large, are tan-brown, and contain small seminiferous tubules without lumina which usually contain only sertoli cells. , in one-third of patients both sertoli cells and spermatogonia are present. ultrastructurally, sertoli cells lack charcot-böttcher crystals and annulated lamellae; inter-sertoli cell specialized junctions are not well developed, and in cryofracture studies the arrangement of membrane particles has an immature pattern. leydig cells are abundant, but few contain reinke's crystalloids. often, there are areas resembling ovarian stroma in the testicular interstitium. in about two-thirds of cases the testes contain grossly visible white nodules that stand out from the surrounding testicular parenchyma (figs - , - ). histologically, the nodules consist of clusters of small seminiferous tubules with immature sertoli cells, hyalinized lamina propria, numerous leydig cells, and an absence of elastic fi bers ( fig. - ) . these have been referred to as sertoli-leydig cell hamartoma. about % of testes have sertoli cell adenoma, sometimes very large, consisting of tubules resembling infantile testis but lacking in germ cells and peritubular myofi broblasts. no leydig cells are present between the tubules (figs - , - ). other benign tumors include sertoli cell tumor (large cell calcifying sertoli cell tumor and sex cord tumor with annular tubules), leydig cell tumor, leiomyoma, and fi broma. approximately % of cases have small cystic structures closely apposed to the testes, and about % of patients have thick bundles of smooth muscle fi bers resembling myo- metrium near the testis. true myometrium has been demonstrated in only one case. hypoplastic fallopian tubes are present in about one-third of cases. in about % of patients the epididymis and vas deferens are rudimentary; the only explanation for this is residual activity of the mutated androgen receptor. approximately % of testes from patients with testicular feminization syndrome develop cancer. the frequency increases with age, but tumors rarely appear before puberty. these tumors include intratubular germ cell neoplasia ( fig. - ) , several types of germ cell tumor, , and sex cord tumor. thus, the gonads should be removed immediately after puberty. partial androgen insensitivity syndrome (partial testicular feminization syndrome) the phenotype of patients with partial testicular feminization varies from normal female to normal male. the disorder includes four classic syndromes: lubs' syndrome, characterized by partial fusion of labioscrotal folds, a defi nitive introitus, clitoromegaly, pubic and axillary hair, and poor breast development; gilbert-dreyfus syndrome, characterized by progressively greater male phenotypic features that include small phallus, hypospadias, incomplete development of wolffi an derivatives, and gynecomastia; reifenstein's syndrome, characterized by hypospadias, weak or absent virilization, testicular atrophy, gynecomastia, azoospermia, and infertility; and rosewater-gwinup-hamwi syndrome, characterized by infertile men whose only abnormal feature is gynecomastia. mild androgen insensitivity syndrome spermatogenesis requires high levels of intratesticular testosterone. a minor form of androgen insensitivity may be observed in some patients with male phenotype who present with infertility. the frequency of androgen resistance among azoospermic and oligozoospermic men is estimated at about % or lower. , some patients have lost exon or mutated exons or . kennedy's disease kennedy's disease (spinal and bulbar muscular atrophy, sbma) is an x-linked recessive disorder of the adult male , characterized by loss of motor neurons in the spinal cord and brain stem and associated with less important loss of sensory neurons and atrophy caused by skeletal muscle denervation. , disease onset around years of age includes muscular weakness, cramps, and fasciculations. in most cases the male reproductive system is impaired. [ ] [ ] [ ] the testes may be normal in the initial stages of the disease, and many patients are fertile; however, with progression, there is onset of secondary testicular atrophy and gynecomastia. testosterone levels are decreased in some cases. the disease results from mutations in the fi rst exon of the androgen receptor (ar) gene. the smba gene, located on xq - , has expansion of a repetitive cag sequence in exon a. the number of cag repeats is (range, - ) in control men and more than in men with kennedy's disease. , [ ] [ ] [ ] [ ] this disorder is a variant of male pseudohermaphroditism caused by a lack of the enzyme α-reductase with failure of conversion of testosterone to dihydrotestosterone. in patients with the xy karyotype there are two isoenzymes: isoenzyme is encoded by the gene srd a, located on p , and isoenzyme is encoded by the gene srd a on p . most reported cases result from defects in srd a . many mutations in different exons have been reported. [ ] [ ] [ ] [ ] [ ] during childhood, patients have a clitoriform penis, bifi d scrotum, urogenital sinus, and testes in the inguinal canal or labioscrotal folds (fig. - ) . müllerian derivatives are absent. at puberty they acquire the male phenotype, with development of the penis and scrotum. adults have erections, ejaculations, and normal libido, scant body hair and a thin beard, a very small prostate, and lack of temporal hairline recession (male pattern baldness). serum levels of fsh, lh, and testosterone are increased, but dihydrotestosterone is decreased. , the disorder is autosomal recessive and has been observed in many consanguineous families from the dominican republic. this group of male pseudohermaphrodites is characterized by the presence of müllerian derivatives and unilateral or bilateral testicular dysgenesis. these two features depend on anti-müllerian hormone gene mutations and end-organ insensitivity. [ ] [ ] [ ] [ ] in normal development, anti-müllerian hormone is responsible for inhibition of the ipsilateral müllerian ducts and collagenization of the tunica albuginea. patients with defi cient secretion of this hormone may also have androgen defi ciency. three variants of defective müllerian duct regression have been reported: mixed gonadal dysgenesis, dysgenetic male pseudohermaphroditism, and persistent müllerian duct syndrome. mixed gonadal dysgenesis (asymmetric gonadal differentiation) is characterized by the presence of a testis on one side of the body and a streak gonad on the other. if the gonads are intra-abdominal, the labioscrotal folds may appear as either normal labia or empty scrotal sacs (fig. - ). in the former, the syndrome cannot be recognized in the newborn unless a peniform clitoris is present. if the gonad is descended, it is usually a testis. müllerian derivatives such as fallopian tubes are usually associated with streak gonad ( % of cases), but may also be associated with testicular tissue ( %). ipsilateral to the testis there is one epididymis and one vas deferens. on the contralateral side, no gonad or a streak gonad and a fallopian tube are present. a hypoplastic uterus and a poorly developed vagina are frequent fi ndings. this syndrome accounts for about % of intersex conditions. some patients are raised as males, although their external genitalia are usually ambiguous as a result of fetal virilization. the penis is clitoriform, and the urethra opens in the perineum. most have cryptorchid testes and are raised as girls, becoming virilized at puberty. infertility is a common symptom. the etiology is heterogeneous: one-third of patients have turnerian features, in accordance with the presence of the x / xy karyotype in more than % of patients. other observed karyotypes are xy and x / xyy. approximately % of patients have one y chromosome. mutation in the sry gene has not been found. the testes can show two different patterns: testicular dysgenesis and streak testis. testicular dysgenesis is characterized by a tunica albuginea that varies in width and is reminiscent of ovarian stroma by the storiform distribution of cells and fi bers; there are also malformed seminiferous tubules (fig. - ) that are small, usually lack lumina, and contain only immature sertoli cells. in adults, spermatogenesis has been observed occasionally. the testicular interstitium contains increased numbers of leydig cells. streak testes are complex gonads in which testicular dysgenesis is associated with a fi brous streak. most of the gonad consists of a testis showing the characteristic lesions of testicular dysgenesis. in a pole of the gonad, or in continuity with it, there is a fi brous streak whose structure may correspond to any of the varieties mentioned above (fig. - ). this peculiar gonad can also be observed in some dysgenetic male pseudohermaphrodites as well as in the persistent mül- lerian duct syndrome. in these cases, the streak contains no ovocytes. light microscopy indicates a wide spectrum of testicular lesions, ranging from those of patients with xy pure gonadal dysgenesis to true hermaphroditism. differentiation of the ovocyte-containing streak testis and ovotestis remains controversial. , the testes in mixed gonadal dysgenesis are incapable of müllerian duct inhibition and allow complete differentiation of wolffi an derivatives, virilization of external genitalia, and, in most cases, testicular descent. the risk of germ cell neoplasia reaches % in the third decade of life, usually beginning with gonadoblastoma. the testes should be removed after puberty. dysgenetic male pseudohermaphroditism is a disorder of sexual differentiation characterized by bilateral dysgenetic testes or streak testis, persistent müllerian structures, and cryptorchidism. this syndrome is considered a variant of mixed gonadal dysgenesis ( fig. - ) . , the karyotype may be xy or x / xy, and turnerian stigmata may be present. the uterus and fallopian tubes are present and both are usually hypoplastic (fig. - ). the testes show lesions characteristic of testicular dysgenesis, with few germ cells during childhood (fig. - ) . in adults, spermatogenesis is poorly developed and the testicular interstitium shows leydig cell hyperplasia. about % of patients develop gonadoblastoma. persistent müllerian duct syndrome has many names, including male with uterus, tubular hermaphroditism, persistent oviduct syndrome, and hernia uteri inguinalis. it is a rare form of pseudohermaphroditism, with müllerian derivatives in an otherwise phenotypically normal male, and is the most characteristic form of isolated anti-müllerian hormone defi ciency. the molecular basis of this syndrome is heterogeneous. three hypotheses have been proposed, including a defect in anti-müllerian hormone synthesis, caused by mutation in the anti-müllerian hormone gene ( % of cases); resistance of target organs to this hormone, caused by mutation in the receptor ii for this hormone ( % of cases); and failure in the action of this hormone immediately before the eighth week of gestation ( % of cases). although the external genitalia are male, one ( % of cases) or both testes ( % of cases) are cryptorchid. the syndrome usually also includes inguinal hernia contralateral to the undescended testis, with a uterus and fallopian tubes within the hernia sac (figs - , - ) . several cases with transverse testicular ectopia and persistent müllerian duct structures have been reported. , patients usually have inguinal hernia, but others have cryptorchidism, infertility, and testicular tumor. in childhood, the testes have a low tubular fertility index and decreased tubular diameter. in adults, the tunica albu- ginea is variably thickened, contains connective tissue resembling ovarian stroma, and may contain tubular structures -alterations typical of testicular dysgenesis. the seminiferous tubules are usually atrophic and hyalinized. tubules with reduced spermatogenesis or patterns suggesting mixed atrophy (seminiferous tubules with spermatogenesis intermingled with sertoli cell-only tubules) have also been reported. the leydig cells appear hyperplastic. azoospermia or oligozoospermia are common, and paternity is exceptional. the syndrome is sporadic or familial, with autosomal recessive or x-linked inheritance. , these patients have a higher risk of testicular tumor than that attributed to cryptorchidism, and all types of germ cell tumor have been observed. , other forms of male pseudohermaphroditism of the dysmorphic syndromes associated with incomplete virilization of external genitalia, the best-known are those of rsh, denys-drash, wagr, opiz, camptomelic dysplasia, atr-x, gardner-silengo-wachtel, meckel, branchioskeletal-genital, down's, and other trisomies. rsh (smith-lemli-opitz) syndrome is a malformative recessive autosomal syndrome caused by mutations in the gene encoding for -dehydrocholesterol reductase (dhcr ), responsible for the synthesis of cholesterol from its immediate precursor -dehydrocholesterol. [ ] [ ] [ ] the disorder is common in europe and rare in other countries. the most severe form is lethal before birth. fetuses show postaxial oligodactyly (instead of polydactyly) and sometimes severe hydrops. non-lethal forms are characterized after birth by severe growth failure; a semi-obtunded state; absence of psychomotor development; microcephaly; congenital cataracts; peculiar facies; broad anteriorly rugose alveolar ridges with cleft palate, edema of the nape of the neck, and unilobulate lungs; male pseudohermaphroditism or female external genitalia in ,xy patients; postaxial polydactyly of the hands and feet; congenital heart defects; and renal anomalies. hepatic and renal insuffi ciencies are frequent. the less severe forms in the male have genital anomalies ( %) varying from normal genitalia to severe hypospadias with or without cryptorchidism, and numerous small anomalies whose collection characterizes the syndrome. most patients also show mental retardation and severe behavioral problems. the dhcr gene maps to chromosome q - . its product is a microsomal, membrane-bound protein. many different missense, nonsense, and splice-site mutations as well as duplications and deletions have been reported. [ ] [ ] [ ] [ ] [ ] [ ] prenatal diagnosis is possible by relating ultrasound and cytogenetic studies and carrying out a biochemical analysis in the second trimester in those pregnant women who have low levels or no conjugated estriol. in denys-drash syndrome, male pseudohermaphroditism is associated with nephroblastoma and renal insufficiency. the pseudohermaphroditism is usually either mixed gonadal dysgenesis, dysgenetic male pseudohermaphroditism, xy pure gonadal dysgenesis, or true hermaphroditism. the most common nephropathy is diffuse mesangial sclerosis. most patients have mutations in the wt- gene, which is expressed in the genital ridge in the sixth week of gestation and gives rise to either streak gonads or testicular dysgenesis, but, if a delay in testicular determination occurs, normal testes are formed. the term wagr syndrome refers to wilms' tumor, aniridia, genital anomalies, and mental retardation. prevalence is estimated at between . % and % of wilms' tumor patients. the syndrome is related to the syndrome of denys-drash and that of frasier (a variety of ,xy gonadal dysgenesis). , all have in common mutations in the wt- gene located on chromosome ( p ). wt- product is a transcription factor expressed in different tissues that participates in embryogenesis and cell differentiation. mutations lead to the production of an anomalous protein that causes alterations in renal function, gonadal anomalies, and the loss of tumor suppressor function. six variants of alleles have been described: isolated wilms' tumor, mesothelioma, isolated diffuse mesangial sclerosis, denis-drash syndrome, frasier syndrome, and wagr syndrome. frasier syndrome is caused by mutations in the donor zone of the intron link, with the subsequent loss of the +kts isoform (the patient has an imbalance in kts isoforms), whereas large deletions or loss of genetic material that comprises the wt- gene and other contiguous genes (pax or an) lead to the wagr syndrome. , patients with opitz's syndrome are mainly boys with hypertelorism and, in the severe forms, unilateral or bilateral lip cleft, laryngeal cleft, severe dysphagia with more or less life-threatening aspiration, hypospadias and, occasionally, imperforate anus. the most important internal anomalies are those in the tracheobronchial tree, cardiovascular system (defects in cardiac septation), and gallbladder, with a subjacent defect of the developing embryonal ventral midline. the syndrome is genetically heterogeneous and consists of two entities that were described as different in the past: ados, or autosomal dominant opitz syndrome or g syn- drome with a mutated gene that maps to q . ; and xlos, or x-linked opitz syndrome or bbb syndrome with a mutated gene that maps to xp . . , camptomelic dysplasia is an autosomal dominant syndrome with multiple osseous malformations. patients have xy karyotype and external genitalia that are ambiguous or female. gonadal histology varies from testes to dysgenetic ovaries with primary follicles. the cause is a haploinsufficiency of sox , located on q. the incidence of gonadoblastoma is low. atr-x syndrome is characterized by mild α-thalassemia, mental retardation, facial dysmorphism, and hypospadias. , the disorder is x-linked, and is caused by mutation in the art-x gene (synonymous xnp, hx ). testicular biopsy to diagnose infertility began in the s, , and most of the diagnostic terms used today were created then. these terms are usually descriptive and, except for a few (normal testes, sertoli cell-only tubules, tubular hyalinization, for example), do not specify the degree of tubular abnormality that is evaluated by each pathologist subjectively. the terms maturation arrest and hypospermatogenesis have been applied to biopsies in more than % of cases of infertility, - but the criteria for these vary widely among pathologists. two forms of maturation arrest have been described: spermatogenic arrest, and spermatocytic arrest, or its equivalent, meiotic arrest. true spermatogenic arrest is rare because germ cell maturation usually does not arrest at the level of a defi ned germ cell type. to avoid confusion the term irregular hypospermatogenesis has been proposed for testicular biopsies with decreased numbers of germ cells, subclassifi ed as slight, moderate, or severe. however, this diagnosis is of little help to clinicians. the reported frequency of spermatocytic (meiotic) arrest in infertile men varies from % to . % and is present in one or both testes of about % of oligozoospermic or azoospermic patients. if observed in only one testis, the contralateral testis may show histologic changes ranging from normal spermatogenesis to hyalinized tubules. disorganization of the seminiferous tubular cell layers is another frequent diagnosis in testicular biopsies, , , but this term is rejected by many pathologists. actual disorganization of the seminiferous tubular cells is unlikely and has not been demonstrated in ultrastructural studies. in most cases, the apparent disorganization is an artifact induced by handling or fi xation. , the term tubular blockage was introduced by meinhard and co-workers for testes with at least % of seminiferous tubules devoid of a central lumen and showing spatial disorganization of germ cells. this morphology was found in % of testicular biopsies from infertile men, mainly those with obstructive azoospermia. although this appearance can result from improper fi xation, the accumulation of sertoli cells and immature germ cells in the centers of tubules suggests a specifi c lesion, a variant of germ cell sloughing. diagnostic confusion decreased the interest and trust of urologists and andrologists in the study of testicular biopsies. subsequent studies attempted to correlate semen spermatozoa concentration with testicular size and biochemical fi ndings such as serum levels of fsh, and testicular biopsies were undertaken in only a limited number of oligozoospermic and azoospermic patients. , , however, these studies were also discouraging because fsh was found to correlate poorly with numbers of spermatozoa in the semen but better with numbers of spermatogonia in the seminiferous tubules, and normal numbers of spermatozoa can be produced by relatively small testes whereas some large testes have no spermatogenesis. in recent years, serum levels of inhibin b have been shown to have a positive correlation with spermatozoon numbers and serum fsh level. , the development of morphometry caused a resurgence of interest in biopsies. many semiquantitative , - and quantitative [ ] [ ] [ ] [ ] [ ] [ ] studies were carried out. the greatest achievements of these studies were enhancement of the reproducibility of results and better evaluation of the reversibility of lesions. morphometry emerged as the best method to objectively evaluate the seminiferous tubular cells. the scoring method of johnsen, estimation of the germ cell/ sertoli cell ratio for each germ cell type, and calculation of germ cell number per unit length of seminiferous tubules are reliable and useful. several methods are available to evaluate the leydig cell population, including the mean number of cells per seminiferous tubule and per cell cluster; the mean number of leydig cell clusters per seminiferous tubule; the ratio of leydig cell area to seminiferous tubule area; and the ratio of leydig cells to sertoli cells. these methods have shown that the appearance of leydig cell hyperplasia described in many conditions is false, and that true leydig cell hyperplasia is extremely rare. optimal interpretation of testicular biopsies depends on the surgical technique by which the tissue sample is taken, the care and delicacy with which the specimen is manipulated, and proper fi xation and processing of the tissue. the size of the biopsy should not be greater than a grain of rice: that is, no diameter should be greater than mm. this amounts to about . % of testicular volume (normal volume is approximately ml). the biopsy should be bilateral because in more than % of patients the fi ndings differ between the testes. at the time of biopsy, the testicular axes should be measured as the basis of quantitative studies. the tissue should be taken opposite to the rete testis through a - mm incision in the tunica albuginea. this parenchyma herniates through the incision and can be carefully snipped off. if only light microscopy is to be performed, the specimen should be fi xed in bouin's fl uid for hours. if electron microscopy is indicated, a small biopsy fragment should be fi xed in glutaraldehyde-osmium tetroxide or a similar fi xative. to perform meiotic studies, testicular biopsy should be processed by air-drying or surface-spreading methods. the examination of testicular biopsies includes qualitative and quantitative evaluation of the testis and correlation between the biopsy and spermiogram. light microscopy immediately reveals whether the lesion is focal or diffuse. if focal, the percentage of tubules showing each lesion (sertoli cell-only, hyalinization, tubular hypoplasia, etc.) should be calculated. it is useful to evaluate elastic fi bers with a special stain because this highlights groups of small tubules that may be missed with hematoxylin and eosin. a minimum of cross-sectioned tubules should be studied (this is usually possible when fi ve or six histological sections are available). the diameter of each tubule should be measured, and the number of spermatogonia, primary spermatocytes, young spermatids (also called round spermatids or s a + s b spermatids), mature spermatids (also called elongated or s c + s d spermatids), sertoli cells, and, in some cases, peritubular cells counted. the presence of tubular diverticula, the most frequently observed lesions are sertoli cell-only tubules, tubular hyalinization, alterations in spermatogenesis in either the adluminal or the basal compartments of seminiferous tubules, and mixed tubular atrophy. sertoli cell-only syndrome includes all azoospermias in which the seminiferous epithelium consists only of sertoli cells. to better understand this syndrome, it is necessary to consider the morphological and functional changes induced in the sertoli cell by hypophyseal gonadotropin secretion during puberty. during childhood, sertoli cells are pseudostratifi ed and their nuclei are dark, small, and round or elongated, with regular outlines and one or two small peripherally placed nucleoli. the cytoplasm lacks specialized organelles. adult sertoli cells have characteristically pale, triangular nuclei with irregular, indented outlines. the nucleoli are large and have tripartite structures. the cytoplasm contains abundant smooth endoplasmic reticulum and specialized structures, including annulate lamellae, charcot-böttcher crystals, and specialized junctional complexes with other sertoli cells. the pubertal increase in length and width of the seminiferous tubules replaces the infantile pseudostratifi ed pattern with a simple columnar distribution. five variants of the sertoli cell-only syndrome are identifi ed by sertoli cell morphology, the degree of development of the seminiferous tubules, and the presence or absence of interstitial lesions. these variants are designated by the appearance of the predominant sertoli cell population: immature sertoli cells, dysgenetic sertoli cells, adult sertoli cells, involuting sertoli cells, and dedifferentiated sertoli cells (fig. - ) . each type is associated with other tubular and interstitial alterations (table - ) . the most frequent types of sertoli cell-only syndrome in infertility patients are dysgenetic sertoli cells, adult sertoli cells, and involuting sertoli cells. the clinical manifestations are similar, including normal external genitalia, welldeveloped secondary male characteristics, azoospermia, elevated serum fsh level, normal or elevated serum lh level, and normal or slightly low testosterone. these clinical and histologic features were long thought to constitute a single syndrome, del castillo's syndrome, but recent ultrastructural, histochemical, immunohistochemical, and cytogenetic studies have shown that this results from a variety of syndromes that may have primary or secondary causes (table - ) . [ ] [ ] [ ] [ ] [ ] some patients with the adult or dysgenetic sertoli cellonly syndrome variants have a few spermatozoa in their spermiograms. this discrepancy between oligozoospermia and the biopsy histology is caused by the presence of some seminiferous tubules with complete spermatogenesis elsewhere in the testicular parenchyma. sertoli cell-only syndrome with immature sertoli cells sertoli cells in adult testes with this variant of sertoli cell-only syndrome have an immature prepubertal appearance with pseudostratifi cation. the number of cells per cross-sectioned tubule is greater than normal. other tubular and interstitial features suggest immaturity, including small tubular diame-ters (< µm), tubules lacking central lumina, thin lamina propria lacking elastic fi bers, and interstitium lacking mature leydig cells. [ ] [ ] [ ] this syndrome is caused by a defi ciency of both fsh and lh which begins in childhood and is responsible for the lack of maturation of the sertoli cells, tubular walls, and interstitium. subsequently, there is no renewal or differentiation of germ cells, and these eventually disappear. when these patients are treated with hormones, the biopsy may show some degree of spermatogenesis or thickening and hyalinization of the tubular basement membrane. sertoli cell-only syndrome with dysgenetic sertoli cells dysgenetic sertoli cells begin pubertal differentiation but variably deviate from normal maturation, so that the morphology of dysgenetic sertoli cells differs among tubules and even among sertoli cells within the same tubule. nuclei usually have both mature features (pale chromatin and a centrally located, tripartite nucleolus) and features of immaturity (ovoid or round shape; regular outline; and small, dense chromatin granules) (fig. - ) . in addition to vimentin, sertoli cells immunoexpress anti-müllerian hormone (amh) and cytokeratin . immunoreaction to these two substances is assumed to be a sign of immaturity, as under normal conditions it is not detected after puberty. other signs of immaturity are poor development of the hematotesticular barrier and the absence of tubular lumina. tubular lumina are very small or absent in most dysgenetic sertoli cell-containing tubules, because the ability to produce testicular fl uid is greatly reduced. sertoli cell numbers per cross-sectioned tubule are very high, and mean tubular diameter is lower than µm. the tubular walls have few elastic fi bers, and most tubules show a variable degree of tunica propria hyalinization. completely hyalinized tubules are frequent. the testicular interstitium contains a variable number of leydig cells (normal, decreased, or apparently increased), many of which are pleomorphic with abundant paracrystalline inclusions. , most patients have normal or slightly subnormal testosterone level and elevated levels of fsh and lh. this syndrome can be observed in men with cryptorchid testes, at the periphery of germ cell tumors, in men with idiopathic infertility, and in men with y chromosome anomalies. sertoli cell-only syndrome with mature sertoli cells in this variant, most sertoli cells appear mature but are present in increased numbers ( ± . per cross-sectioned tubule). the seminiferous tubules have small diameters, but are still larger than in the two variants described above, and central lumina are visible. the cytoplasm contains abundant vacuoles that communicate with the tubular lumina ( fig. - ). the lateral cell surfaces have many unfolding and extensive specialized junctions with other sertoli cells (from the basement membrane to the apical cytoplasmic portion). lipid droplets, usually derived from phagocytosis of spermatid tubulobulbar complexes and dead germ cells, are scant. vimentin fi laments are abundant in the basal and perinuclear cytoplasm. the lamina propria is normal or slightly thickened. leydig cells are normal. serum testosterone level is normal or nearly normal, and fsh and lh levels are elevated. [ ] [ ] [ ] this syndrome is probably caused by failure of migration of primordial germ cells from the primitive yolk sac to the gonadal ridge. this failure may be due to a deletion in the azfa region in yq or a mutation in the genes that encodes c-kit or its ligand (stem cell factor), responsible for migration, proliferation, and survival of germ cells. testes with this variant of sertoli cell-only syndrome have numerous changes. sertoli cell nuclei may have lobulated shapes with irregular outlines, coarse chromatin granules, and inconspicuous nucleoli. seminiferous tubules have central lumina, decreased diameters, and variable thickening of the basement membrane (fig. - ) . elastic fi bers are present in normal or diminished amounts. leydig cells are variably involuted. this syndrome may be a primary disorder or secondary to irradiation or cytotoxic therapy, such as cancer chemotherapy or treatment for nephrotic syndrome. it is not usually possible to determine the etiology from the biopsy fi ndings alone. changes in the tubular walls are more pronounced in patients with a history of cyclophosphamide treatment, combination chemotherapy, or radiotherapy. the testicular interstitium may be fi brotic in patients treated with cis-platinum or cyclophosphamide. some syndromes with involuting sertoli cells, mainly those associated with decreased number of elastic fi bers, probably express a primary testicular anomaly with involuting and dysgenetic sertoli cells within the same tubule. the presence of immature-appearing sertoli cells in the tubular wall is thickened and contains elastic fi bers, increased amounts of collagen fi bers, and elevated numbers of peritubular cells as a result of tubular shortening. mean tubular diameter is markedly decreased to less than µm. the testicular interstitium contains few leydig cells, and these appear dedifferentiated or contain an increased amount of lipofuscin. this variant has been observed in surgical specimens from patients receiving androgen deprivation therapy for prostatic cancer, estrogen treatment for transsexuality, and cancer chemotherapy with cis-platinum. there is a correlation between the degree of sertoli cell dedifferentiation and the dose and timing of treatment with estrogens or anti-androgens. brief treatment induces germ cell loss and inconspicuous sertoli cell changes; long-term treatment causes pronounced sertoli cell changes, including initial nuclear rounding followed by nuclear elongation and the development of dark chromatin masses. eventually, the nuclei come to resemble those of infantile sertoli cells, including pseudostratifi cation. at the same time, the tubules become hyalinized and peritubular cells increase whereas leydig cells disappear. , estrogens act on the pituitary by inhibiting lh secretion, and on leydig cells. the action of gonadotropin-releasing hormone agonist analogs is only on the pituitary, whereas cis-platinum acts only on the testis. the most common causes of tubular hyalinization include dysgenetic hyalinization, hormonal defi cit, ischemia, obstruction, infl ammation, and physical or chemical agents. the differential diagnosis is given in table - . dysgenetic hyalinization dysgenetic hyalinization is a diffuse lesion in which most tubules are uniformly hyalinized (fig. - ) . tubules lack seminiferous tubular cells and have a reduced number of peritubular cells. the few preserved tubules usually contain only sertoli cells, although rarely a few with spermatogenesis are present. dysgenetic hyalinization is seen in klinefelter's syndrome, testes that remain cryptorchid through puberty, and some hypergonadotropic hypogonadisms associated with myopathy. focal lesions are seen in mixed atrophy of the testis. tubular hyalinization is pronounced in klinefelter's syndrome, and from infancy the seminiferous tubules are small, containing reduced numbers of sertoli cells and few or no spermatogonia. at puberty, the dysgenetic sertoli cells fail to infertility mature and soon disappear. the tubules collapse, giving the appearance of phantom tubules. peritubular cells fail to differentiate and their number is low. they form a discontinuous ring around the hyalinized tubules and are incapable of synthesizing elastic fi bers and other components of the lamina propria. dysgenesis also involves the interstitium: leydig cells exhibit a characteristic adenomatous pattern, although their total number is decreased. the morphology of the leydig cell is not uniform, and there are shrunken, normal, and large forms. most contain reduced amounts of lipofuscin granules and lipid droplets. reinke's crystalloids are uncommon, and paracrystalline inclusions are abundant. in spite of the hyperplastic adenomatous appearance of the leydig cells, testosterone secretion is markedly decreased, and the resulting hypogonadism is the most important clinical feature of klinefelter's syndrome. tubular hyalinization in the cryptorchid testis is also dysgenetic. however, in contrast to the atrophic collapse seen in klinefelter's syndrome, cross-sections of the hyalinized tubules in cryptorchidism are targetoid. this results from the arrangement of the peritubular cells into two layers, suggesting an atrophic process that has evolved over a longer period than in klinefelter's syndrome, or a lower degree of dysgenesis. elastic fi bers are diminished. in the interstitium leydig cells appear hyperplastic, forming large aggregates, although their absolute numbers are decreased. leydig cell pleomorphism is less intense than in klinefelter's syndrome. many leydig cells have abundant vacuolated cytoplasm. whereas tubular hyalinization in klinefelter's syndrome is secondary to the effect of pubertal gonadotropin secretion on dysgenetic tubules, tubular hyalinization in cryptorchidism probably results from the effect of increased temperature on the dysgenetic tubules. however, other mechanisms are also involved in cryptorchid tubular hyalinization, including obstruction of sperm excretory ducts (anomalies in these ducts are frequent in cryptorchidism) and ischemia (principally in testes that could only be incompletely descended by surgery). hyalinization caused by hormonal defi cit hormonal defi cit causes diffuse tubular hyalinization, although the tubules may be recognized for a time as cellular cords surrounded by hyaline material. sertoli cell, a few spermatogonia, and rare primary spermatocytes may be identifi ed in these cords. when hyalinization is complete, only the elastic fi bers in the lamina propria indicate the structure of the previously normal adult testis. peritubular myofi broblasts decrease in number and form a ring at the periphery of the lamina propria. leydig cells disappear as hyalinization progresses, and the few that remain have pyknotic nuclei and shrunken cytoplasm with abundant lipofuscin granules. this process manifests clinically as postpubertal hypogonadotropic hypogonadism and is usually caused by a lesion in or near the pituitary, such as pituitary adenoma, craniopharyngioma, and trauma to the cranial base or sella turcica (see discussion on hypogonadotropic hypogonadism in this chapter). ischemic hyalinization ischemic atrophy is usually caused by torsion of the spermatic cord, vascular injury during inguinal surgery, polyarteritis nodosa, and severe arteriosclerosis. except for cases caused by torsion of the cord, these patients usually are not referred to infertility clinics. torsion of the spermatic cord often is not listed as a cause in large series of infertile patients. however, follow-up of men with torsion reveals marked alteration in their spermiograms. several hypotheses have been offered to explain the low number of sperm produced by the contralateral normal testis; the most promising include response to the release of antigens by the ischemic testis, and primary lesions of the contralateral testis (see discussion on testicular torsion in this chapter). testicular anoxia caused by torsion rapidly produces severe lesions that are irreversible without adequate treatment. eight hours after torsion, there is intense hemorrhagic infarction of the seminiferous tubular cells. chronic anoxia leads to tubular hyalinization and loss of leydig cells (fig. - ) . testicular atrophy secondary to inguinal hernia surgery occurs in . - . % of patents in the fi rst repair, and in . - % in surgery for recurrent hernia. atrophy is most fre- postobstructive hyalinization obstruction of sperm excretory ducts may cause atrophy of seminiferous tubules. in order to produce tubular hyalinization, the obstruction must be close to the testis because the ductuli efferentes in the caput epididymis absorb about % of tubular fl uid and protect the testis from excessive intratubular pressure. obstructive tubular hyalinization is usually focal and secondary to varicocele and other disorders involving dilation of the channels of the rete testis. these may be congenital, as in epididymis-testis dissociation, or acquired, as in rete testis dilation secondary to epididymal atrophy caused by arteritis, arteriosclerosis, or androgen insuffi ciency. obstructive tubular hyalinization also occurs in the seminiferous tubules at the periphery of the testis in patients who have had orchitis. obstructive hyalinization has a mosaic distribution: lobules of completely hyalinized tubules are intermingled with lobules of normal tubules (fig. - ). the diameter of the hyalinized tubules is not as small as in other causes of hyalinization, and the tubules occasionally contain sertoli cells. in the centers of many of the tubules there is a small lumen or vacuole, the latter in the cytoplasm of a residual sertoli cell. the lamina propria is thick and contains hypertrophic peritubular cells and abundant extracellular material. finally, the peritubular cells dedifferentiate and only fi broblasts remain. the interstitium contains a normal number of leydig cells forming small clusters, some of which are among hyalinized tubules. this is not seen in other patterns such as ischemic hyalinization. in addition, dilated veins with eccentrically hyalinized walls can be seen in testes associated with varicocele. this lobular pattern of tubular atrophy causes a peculiar ultrasound image which has been described as a striated pattern. , postinfl ammatory hyalinization many infections of the testis cause irreversible lesions in the seminiferous tubules. in bacterial infection the epididymis is usually involved, resulting in obstructive azoospermia. in viral infection the testis is often affected, even without symptoms. two types of viral orchitis often cause infertility, including mumps orchitis and coxsackie b orchitis. tubular atrophy caused by viral infection has a mosaic topography in which hyalinized and normal tubules are intermingled. in fully hyalinized tubules, the only recognizable cells are peritubular cells that form an incomplete, peripheral ring around the hyalinized material. the presence of elastic fi bers in these tubules distinguishes this from dysgenetic hyalinization. leydig cells form clusters of variable size, but their total number is normal. in bacterial infection the pattern of tubular hyalinization is variable. tubular atrophy of unknown etiology may be caused by an autoimmune response. this appears to occur in hypogonadism associated with disorders in other endocrine glands, such as addison's disease associated with gonadal insufficiency; adrenal-thyroid-gonadal insuffi ciency; and the association of diabetes, hypogonadism, adrenal insuffi ciency, and hypothyroidism. the testicular lesions are morphologically similar to those seen in the seminiferous tubules at the periphery of germ cell tumor and in testes with burn-out germinal cancer. in the initial stages of hyalinization associated with germ cell neoplasm, the tubules are small, contain intratubular germ cell neoplasia and dedifferentiating sertoli cells, and the lamina propria is infi ltrated by macrophages, lymphocytes, and plasma cells. in the fi nal stages, the intratubular cells have degenerated, the infl ammation has disappeared, and the seminiferous tubules are replaced by areas of hypocellular or acellular fi brosis (fig. - ) . it should be noted that autoimmune hyalinization is not the most common type of hyalinization associated with testicular tumors: the obstructive, ischemic, and dysgenetic variants are more common. radiation and a wide variety of chemicals cause tubular hyalinization. lengthy cancer chemotherapy combined with infertility radiotherapy invariably causes hyalinization. children's testes are more sensitive to radiation than those of adults. radiation for testicular leukemia frequently causes tubular hyalinization. in addition, radiation induces dense interstitial fi brosis and loss of peritubular cells, obscuring the borders between the interstitium and the tubules. this makes the tubules hard to see in hematoxylin-eosin-stained sections. leydig cells are atrophic and decreased in number. ischemia secondary to radiation-induced vascular injury also contributes to hyalinization. in tubular hyalinization associated with cancer chemotherapy, in addition to the direct toxicity of drugs on seminiferous tubular cells (see discussion on sertoli cell-only syndrome with involuting sertoli cells in this chapter), nutritional defi ciencies cause hypogonadotropic hypogonadism. , histophysiological studies have distinguished two compartments in the seminiferous tubules: basal and adluminal. the blood-testis barrier separates these, and each contains different cell types with diverse hormonal and nutritional requirements. on this basis, lesions may be classifi ed as involving only the adluminal compartment or both the basal and the adluminal compartments. the following discussion of spermatogenic lesions uses this new concept of tubular pathophysiology, conserving as much as possible of the classic terminology. this category includes all infertile testes with normal numbers of spermatogonia per cross-sectioned tubule, normal or decreased numbers of spermatocytes and young spermatids, and variable numbers of adult spermatids. a descriptive term for this disorder is immature germ cell sloughing. a few immature germ cells are normally found in the lumina of the seminiferous tubules, a fi nding that correlates with their presence in the ejaculates of fertile men. when these cells make up more than % of the cells in the ejaculate, it is abnormal and the result of premature sloughing of spermatids and, in some cases, of spermatocytes. , some authors have attempted to establish a correlation between the number of sloughed immature germ cells and the severity of lesions of the seminiferous tubules using light and electron microscopy. lesions in the adluminal compartment are classifi ed according to the most abundant type of germ cell whose maturation is arrested and which then sloughs: young spermatids, late primary spermatocytes, or early primary spermatocytes ( fig. - ) . young spermatid sloughing young spermatid sloughing is present when the ratio of elongated (s c + s d ) spermatids to round (s a + s b ) spermatids is lower than normal. the implication of this pattern is that many round spermatids are incapable of further differentiation and are sloughed ( fig. - ) . late primary spermatocyte sloughing in this condition, spermatogenesis develops normally up to the level of interphase primary spermatocytes, and these are present in normal numbers. afterwards, these spermatocytes degenerate without achieving meiosis and slough into the tubular lumen. all types of spermatid are greatly reduced in number. when biopsies of these testes are not properly fi xed, the seminiferous tubules may have a target-like appearance, with numerous cells in the lumen. this appearance sometimes has been referred to as tubular blockage. another descriptive term, spermatogenic arrest, also has been applied to this morphology. the latter term is inadequate in most cases, because some spermatids are present, and the number of primary spermatocytes is usually not increased as would occur if the transformation of spermatocyte into spermatid were blocked (fig. - ). late spermatocyte sloughing is a more accurate term for this condition and is preferred. primary spermatocyte sloughing occurs at the pachytene or diplotene stage of meiosis. early primary spermatocyte sloughing this lesion is characterized by the presence of a normal number of spermatogonia and decreased numbers of primary spermatocytes (fig. - ). the seminiferous tubules may contain a few spermatids. the term early primary spermatocyte sloughing does not necessarily imply an early meiotic lesion, which is quite rare. , rather, it refers to the sloughing of newly formed spermatocytes. the sertoli cells may show vacuolation of the apical cytoplasm as an expression of germ cell loss. this lesion is more severe than that in testes with late primary spermatocyte sloughing, and is considered to result from failure of the sertoli cells to maintain the adluminal compartment. etiology the mechanisms causing adluminal compartment lesions can be classifi ed into obstructive and nonobstructive. obstruction is present in more than % of cases, and is characterized by variability of involvement among lobules and the presence of at least two of the following abnormalities: enlargement of tubular diameter and a lumen with remarkable differences among lobules; sertoli cells with adherens germ cells protruding into the lumen, giving an indented outline; intense apical vacuolation of sertoli cell cytoplasm; accumulation of spermatozoa in the lumen of some tubules; or number of spermatids s c + s d is higher that that of s a + s b (see testicular lesions resulting from obstruction of sperm excretory ducts). the three levels of severity of adluminal compartment lesions emphasized by the terms young spermatid sloughing, later primary spermatocytes sloughing, and early primary spermatocyte sloughing, depend on the degree (total or partial) of obstruction and the level of sperm excretory duct obstruction: as the obstruction gets nearer to the testis, the greater the severity. obstruction may be extratesticular (epididymis, vas deferens, and ejaculatory ducts) or intratesticular (rete testis or any level of the seminiferous tubule length). the most frequent causes of extratesticular excretory duct obstruction are vasectomy, infl ammation (epididymitis, prostatitis), mucoviscidosis (congenital bilateral absence of vas deferens), and testis-epididymis dissociation. rete testis obstruction. varicocele is the most frequent cause of obstruction of the rete testis. more than % of testes with varicocele patients also often have spermatozoa with characteristically elongated heads with thin bases. initially, abnormalities are confi ned to the testis ipsilateral to the varicocele, but eventually both testes are affected, although abnormalities are more severe in the ipsilateral testis. elevated pressure in the pampiniform plexus is transmitted to the veins within the testes, principally to the centripetal veins that cross the testicular mediastinum and drain most of the testicular parenchyma ( fig. - ). the dilated centripetal veins compress the intratesticular sperm excretory ducts, explaining the mosaic distribution of the tubular lesions. seminiferous tubule obstruction. obstruction at the level of the seminiferous tubules can be dysgenetic or post-orchitic. a dysgenetic cause may be suspected in specimens with a mosaic distribution of lesions and seminiferous tubules with small diameters, thickened lamina propria, and an unusual seminiferous tubular cell layer consisting of cuboidal sertoli cells and spermatozoa that clog the lumina (fig. - ) . the diagnosis is confi rmed if study of serial sections demonstrates continuity between these tubules and those with conserved spermatogenesis. the structure of seminiferous tubules has been observed with scanning microscopy at such points of continuity. , tubular stenosis appears to be due to a primary anomaly of sertoli cells and peritubular cells. post-orchitic obstruction should be suspected in cases of tubular atrophy with a mosaic pattern without dysgenetic tubules or varicocele. some patients have a history of orchitis associated with parotiditis; in others the only fi ndings are oligozoospermia and small testes. testicular biopsy, sampling only the testicular periphery, reveals only the consequences of obstruction, lesions similar to those observed with varicocele. however, some postinfl ammatory changes should also be present, including hyalinized tubules, dilated tubules lined by cuboidal sertoli cells, or complete spermatogenesis. occasionally, there is modest perivascular or peritubular infl ammation and angiectasis. , about % of testes with lesions in the adluminal compartment have no obstruction, and most have primary anomalies of germ cells. this claim is supported by the following: pronounced decrease of germ cell type when the preceding type is greatly increased in number; normal correlation between the number of mature spermatids in biopsy and number of spermatozoa in the spermiogram; and the presence of numerous malformed germ cells in the adluminal compartment. decrease in the number of a germ cell type may be so important that spermatogenesis is arrested, with subsequent azoospermia. in some cases, maturation arrest is only partial and results in severe oligozoospermia. this maturation arrest is observed mainly in primary spermatocytes and young spermatids. primary spermatocyte sloughing may also be owing to meiotic anomalies ( fig. - ). the observation of increased numbers of spermatocytes arrested in preleptotene-leptotene or, more frequently, pachytene suggests the diagnosis. the lesion is always bilateral. spermatocytes arrested in pachytene are usually increased in size and later degenerate. in addition, some spermatids have large, diploid, spherical, hyperchromatic nuclei. the anomaly does not always affect all spermatocytes, and then a higher number of spermatids are produced. young spermatid sloughing not associated with obstruction may be due to either meiotic anomalies or defective spermiogenesis. the former gives rises to the appearance of many multinucleate, polyploid, hyperchromatic young spermatids. in the second cause, young spermatids are incapable of transforming into mature spermatids, and only round spermatids appear in the ejaculate. lesions in the basal and adluminal compartments of seminiferous tubules are the most frequent histological fi ndings in testicular biopsies from infertile men. these testes may be classifi ed into two major subgroups: hypospermatogenesis and spermatogonial maturation arrest ( fig. - ) . hypospermatogenesis: types and etiology hypospermatogenesis is defi ned as a reduced number of spermatogonia and primary spermatocytes, with primary spermatocytes outnumbering the spermatogonia. most seminiferous tubules contain few spermatids. about % of patients with hypospermatogenesis have focal tubular hyalinization. two variants of hypospermatogenesis have been quantitatively distinguished: pure hypospermatogenesis, and hypospermatogenesis associated with sloughing of primary spermatocytes. pure hypospermatogenesis is defi ned as a proportionate decrease in the number of all types of germ cell. the number of spermatogonia per cross-sectioned tubule is less than and usually more than . the number of primary spermatocytes is equal to or higher than that of spermatogonia. the number of round spermatids is higher than that of primary spermatocytes, and the number of elongated spermatids is similar to that of spermatogonia ( fig. - ) . hypospermatogenesis associated with primary spermatocyte sloughing is characterized by two features: low numbers of spermatogonia and primary spermatocytes (with spermatocytes more numerous than spermatogonia), and degeneration and sloughing of many primary spermatocytes. the remaining spermatocytes give rise to the few spermatids observed in the tubules (fig. - ) . etiology of hypospermatogenesis. hypospermatogenesis may result from hormonal dysfunction, congenital germ cell defi ciency, sertoli cell dysfunction, leydig cell dysfunction, infertility androgen insensitivity, exposure to chemical or physical agents, and vascular malfunction. hormonal dysregulation. although complete spermatogenesis may be observed in men with low levels of fsh and lh, the production of a normal number of spermatozoa requires normal gonadotropin levels. hypospermatogenesis has been reported in patients with abnormal pulsatile secretion of fsh and lh, low gonadotropin secretion, biologically inactive gonadotropins, mutation in the gonadotropin β subunit, inactivating mutation of fsh receptor gene, hyperprolactinemia, and adrenal and thyroid dysfunction (see discussion on hypogonadisms secondary to endocrine gland dysfunction in this chapter). congenital germ cell defi ciency. biopsy of cryptorchid patients after orchidopexy reveals that spermatogonia proliferation is decreased and germ cell development is insufficient in adulthood even if the number of spermatogonia was normal in infancy. is it likely that this poorly understood primary anomaly of germ cells is present in some cases of hypospermatogenesis. sertoli cell dysfunction. for many years, primary germ cell defi ciency was considered the most common cause of hypospermatogenesis; today, it is known that sertoli cell failure is the cause of many cases of germ cell defi ciency. this conclusion is based on several fi ndings. sertoli cells in many infertile patients are markedly abnormal, with an increase in the number of glycogen granules and acid phosphatase activity; a decrease in the number of lipid droplets; and alterations in the cytoskeleton, the nucleus, and cytoplasmic organelles. in some cases sertoli cells have abnormal maturation, with elongated nuclei containing coarse clumped chromatin instead of triangular-shaped nuclei with pale chromatin. anomalies in sertoli cell fsh receptors may be present in idiopathic oligozoospermia associated with elevated levels of fsh. serum inhibin b concentration may be used as a marker to estimate sertoli cell function. leydig cell dysfunction. testosterone synthesis by leydig cells is necessary for normal spermatogenesis, and abnormal leydig cell function is a frequent fi nding in idiopathic oligozoospermia. [ ] [ ] [ ] leydig cell dysfunction should be suspected when the cells appear diffusely hyperplastic. patients have elevated serum lh level with depletion of rapid-release testosterone, revealing a lack of early response of leydig cells to gonadotropin-releasing hormone stimulation. the ratio of testosterone to lh in the plasma indicates the degree of leydig cell dysfunction. decreased ratio with normal testosterone level suggests compensated dysfunction. patients with a ratio of less than : and normal other parameters may have complete spermatogenesis. androgen insensitivity. some patients with severe oligozoospermia or azoospermia have a defect in androgen receptor responsiveness, similar to that in reifenstein's syndrome. [ ] [ ] [ ] the abnormality may arise from a genetic defect in the eight exons that code for this receptor, mapped to xq - , or from post-translational errors. , this defect is also referred to as infertile male syndrome and mild androgen insensitivity, and the patients have male phenotype with somatic features of slight androgen defi cit. histologically, the testis is similar to that observed with leydig cell dysfunction or mixed atrophy, although the mechanism causing the leydig cell hyperplasia is quite different (fig. - ) . peripheral resistance to testosterone action alters regulation of the hypothalamohypophyseal-testicular axis, and lh and testosterone levels are elevated. androgen insensitivity causes between % and % of all cases of severe oligozoospermia or azoospermia. in such cases spermatogenesis improves with the administration of tamoxifen citrate, clomiphene citrate, or androgen therapy. , calculation of the index of androgen insensitivity can be helpful: plasma lh (miu/ml) × plasma testosterone levels (ng/ml). in patients with androgen insensitivity, the index is higher than (normal is about ). physical and chemical agents. the number of chemicals implicated in infertility increases daily. a detailed history is invaluable in evaluating these patients. the same is true of physical agents such as prolonged exposure to heat, ionizing radiation, or microwave radiation. etiology of hypospermatogenesis associated with primary spermatocyte sloughing. most testes with primary spermatocyte sloughing have varicocele, and this is commonly associated with infertility. [ ] [ ] [ ] [ ] varicocele is found in % of the general population, and is present in - % of infertile men. the mechanism by which varicocele affects fertility is unknown. clinical varicocele may occur without a testicular lesion (or only phlebectasis), and subclinical varicocele may be associated with severe spermatogenic lesions. increased testicular temperature , and compression of intratesticular sperm excretory ducts by dilated veins are the most plausible mechanisms. in other cases, primary spermatocyte sloughing results from anomalies of primary spermatocytes and spermatids, suggesting a meiotic anomaly. finally, in some patients the cause may be the presence of involuting sertoli cells. spermatogonial maturation arrest spermatogonial maturation arrest is a disorder defi ned by the presence of fewer than spermatogonia per cross-sectioned tubule and even fewer primary spermatocytes. spermatids are usually absent. there have been attempts to correlate the etiology of spermatogonial maturation arrest with the sertoli cell type present. immature sertoli cells are characteristic of hypogonadotropic hypogonadism and some syndromes with androgen insensitivity (fig. - ) . mature sertoli cells, if their presence is unilateral, are observed in varicocele, epididymitis, and ipsilateral testicular traumatism, but if they appear in both testes the etiology is unknown. involuting sertoli cells are usually present bilaterally; some cases are idiopathic, whereas others are associated with a history of alcoholism or chemotherapy. dedifferentiated sertoli cells are found in spermatogonial maturation arrest caused by gonadotropin inhibition in treatment with estrogen, -releasing hormone agonist, or anti-androgen. mixed atrophy is a descriptive term for the coexistence, in the same testis, of tubules containing only sertoli cells and tubules with complete or incomplete spermatogenesis. this disorder includes patchy failure of spermatogenesis and partial del castillo's syndrome. the extent of sertoli cell-only tubules varies widely. tubules with spermatogenesis may be normal or partially atrophic. tubular hyalinization is occasionally seen (fig. - ) . mixed atrophy is more common than suggested by the literature, and many cases are included under other diagnoses, such as 'hypospermatogenesis with a severe germ cell depletion in such a way that some sertoli cell-only tubules are seen,' and 'sertoli cell-only syndromes with focal spermatogenesis.' serial sections from testes with mixed atrophy reveal that the two different types of tubule are grouped according to their histologic pattern, suggesting that the distribution is by testicular lobules. in cases of mixed atrophy, the percentage of tubules with spermatogenesis, the degree of spermatogenic development in the tubules, and the type of sertoli cell present should be reported. correlation of the fi rst two with the spermiogram gives an indication of prognosis, and the sertoli cell types identifi es the nature (primary or secondary) of the lesion. mixed atrophy (probably primary) is observed in idiopathic infertility, cryptorchidism (even if orchidopexy was done at infancy, in both the cryptorchid and the contralateral descended testis), retractile testes, macroorchidism, intravaginal torsion of the spermatic cord (in both twisted and contralateral testis), and chromosomal anomalies such as down's syndrome, /xyy karyotype, /xx karyotype, infertility giant y chromosome, klinefelter's syndrome with chromosomal mosaicism, partial androgen insensitivity, and some male pseudohermaphrodites. secondary mixed atrophy may be seen in patients undergoing chemotherapy, corticoid therapy, or in those with a history of viral orchitis. in addition to anomalies in the seminiferous tubules, examination of the biopsy should include a description of the morphology of the germ cells. giant spermatogonia are a normal component of the seminiferous epithelium. these cells may be altered spermatogonia in the s or g phases of the cell cycle. they rest on the basal lamina and have pale cytoplasm and an ovoid nucleus measuring at least µm in diameter. the frequency of these cells in normal and infertile men is about . cells per cross-sectioned tubules, although their number is usually higher in mixed atrophy. these cells should not be mistaken for intratubular germ cell neoplasia; they are also present in normal numbers in tubules at the periphery of germ cell tumor ( fig. - ). multinucleate spermatogonia are a common fi nding in cryptorchid testes that were surgically corrected, infertile patients, and old men. nuclei of both ad and ap spermatogonial types may be seen within the same cell. normally, spermatogonia are present only in the transition zone between the seminiferous tubule basal layer and the tubuli recti. dislocated spermatogonia have been found throughout the testis in old age, in infertile patients with a variety of lesions, after long-term estrogen therapy, and in seminiferous tubules with intratubular germ cell neoplasia. megalospermatocytes are large primary spermatocytes arrested in the leptotene stage ( fig. - ) that exhibit asynapsis of chromosomes. joined by cytoplasmic bridges, they form small groups. these cells may be clones of synchronously degenerating spermatocytes. they are frequently found in elderly men and are a non-specifi c fi nding in infertile patients. the presence of spermatids with multiple nuclei (from to ) is frequent is old age. similar cells with fewer nuclei have also been reported in infertility due to cryptorchidism, hyperprolactinemia, and idiopathic infertility ( fig. - ). there are at least four teratozoospermic syndromes that may be easily identifi ed by testicular biopsy, although in most the diagnosis previously relied on morphologic study of the spermiogram: ( ) round-headed spermatids (characteristic of spermatozoa lacking acrosomes) (fig. - ) , ( ) s c + s d spermatids with a very elongated head (characteristic of varicocele) (fig. - ) , ( ) macrocephalic s c + s d spermatids whose dna content suggests an anomaly in the fi rst meiotic division, and ( ) s c + s d spermatids with voluminous eosinophilic cytoplasmic droplets (syndrome of spermatozoa with short thick fl agella or fi brous sheath dysplasia). in some patients, s a + s b spermatids rest in these initial phases of spermiogenesis and eventually become sloughed in the tubular lumina. in other testes there are macrocephalic s c and s d spermatids with anomalous dna content, suggesting an anomaly in the fi rst meiotic division. ultrastructural study of spermatozoa is sometimes necessary to determine the cause of male infertility. a number of mor-phologically abnormal spermatozoa are present in all semen samples, including those from fertile men, but abnormal spermatozoa are very numerous in infertile patients. ultrastructural study is advised in all cases of asthenozoospermia, in teratozoospermia when the number of spermatozoa showing the same morphological anomaly is high, and in cases with apparently normal spermatozoa that fail to fertilize in vitro. the classifi cation of ultrastructural anomalies in spermatozoa is based on light microscopy fi ndings of lesions in the head and tail. anomalies of the spermatozoal head these are defi ned by changes in the shape of the head, and usually involve both the nucleus and the acrosome. some anomalies, such as pear-shaped, candle-shaped, or egg-shaped heads, , are regarded as minor variants of normal. more signifi cant abnormalities are the elongated, microcephalic, macrocephalic, and crater-defect forms. the most frequent abnormal head shape is elongated with a narrow base (tapered head spermatozoa). this anomaly is frequently associated with varicocele. microcephalic spermatozoa have spherical (globozoospermia) or irregularly shaped heads. the former have spherical nuclei with poorly condensed chromatin and lack acrosomes, postacrosomal sheaths, and a nuclear ring (fig. - ). most cases are sporadic, but this lesion was also reported in two pairs of infertile brothers. , microcephalic spermatozoa with irregularly shaped heads have small and irregularly shaped acrosomes that usually are not in contact with the nucleus. this anomaly may be congenital, as in aarskog-scott syndrome, or secondary to heat exposure or hashish smoking. in both types of microcephaly loss of connection between the acrosomal vesicle and the spermatozoal head is attributed to a defi ciency in basic proteins of the sperm perinuclear theca that promotes nuclear envelope organization and adhesion of the acrosomal vesicle. acrosin is reduced or absent in spermatozoa lacking acrosomes and those with small acrosomes. motility may be infertility normal. the occurrence of aneuploidy and disomy of sex chromosomes , in some cases should be evaluated before performing intracytoplasmic sperm injection (icsi). the cause of round-headed spermatozoa might be the lack of golgi-associated protein known in male mice as golgi-associated pdz-and coiled-coil motif-containing protein (gopc). this protein is principally localized in the trans-golgi region in round spermatids, and its loss produces globozoospermia. the primary defect consists of an inability of acrosomal vesicles to fuse to each other to create the acrosome. macrocephalic spermatozoa (macronuclear spermatozoa) have enlarged, irregularly shaped heads and defi cient chromatin condensation. there are two types (multiple tails , and afl agellate), both of which have abnormal dna content (many are tetraploid), suggesting a meiotic anomaly. , irregularly shaped spermatozoa are characterized by irregularity in the shape of the nucleus or acrosome. in the crater defect syndrome, there is invagination of the nuclear envelope in which the acrosome penetrates. the tail is morphologically normal, and motility is only slightly reduced. in spermatozoa with spoon-shaped nuclei, the defect is probably genetic. other anomalies include double-headed spermatozoa with two nuclei sharing a single acrosome. anomalies in the spermatozoal tail spermatozoal tail anomalies are classifi ed as generalized anomalies of the tail or anomalies in defi ned tail components, such as the connecting piece, the axoneme, or the periaxonemal structure. generalized anomalies in the tail cytoplasmic remnants. the presence of cytoplasmic droplets is normal during spermiogenesis. an elevated number of spermatozoa with cytoplasmic droplets in semen is associated with premature sloughing of spermatozoa, as occurs in varicocele, and should not be misinterpreted as spermatozoa with excess residual cytoplasm. these spermatozoa are very often abnormal and the residual cytoplasm may be located around the intermediate piece or surrounding the head. these spermatozoa also have other fl agellar anomalies. bent tail. a bend in the tail may occur at the level of the connecting piece or the intermediate piece. in bends of the connecting piece, the tail is laterally implanted and forms an angle with a nucleus that displays a thin base. bends of the intermediate piece are associated with cytoplasmic droplets, malposition of mitochondria, and loss of the parallel arrangement of the dense outer fi bers. coiled tail. spermatozoa with a coiled tail are a frequent fi nding in centrifuged semen, but they may also be a true abnormality. these spermatozoa have a perinuclear cytoplasmic remnant containing a fl agellum that is coiled around the nucleus and along the middle or principal pieces (fig. - ). this is frequently associated with abnormalities of the periaxonemal structures. tail stump (short-tail spermatozoa). the presence of many spermatozoa with short, thick tails in semen represents a well-defi ned teratozoospermic syndrome. ultrastructural examination reveals hypertrophy and hyperplasia of the fi brous sheath, hence this syndrome has also been termed 'fi brous sheath dysplasia.' additional axonemal malformations, including absence of the central pair of microtu-bules ( fig. - ) and, less frequently, lack of dynein arms, are observed in % of cases. about % of patients have respiratory disease, such as rhinosinusitis, bronchitis, and bronchiectasis from an early age. similar fi ndings have been reported in the cilia of the upper respiratory tract, and thus a relationship between fi brous sheath dysplasia and immotile cilia syndrome has been assumed. clinical presentation may be sporadic or familial. the cause of fi brous sheath dysplasia and the subsequent lack of motility in these spermatozoa is probably related to the occurrence of deletions in akap and akap genes, as well as the absence of akp protein in the fi brous sheath. multiple tails. the presence of more than two tails is associated with macrocephalic spermatozoa. sperm tail agenesis. teratozoospermia with % sperm tail agenesis has been reported in patients with a high degree of consanguinity. these spermatozoa also have defects in chromatin condensation and residual cytoplasmic droplets. anomalies of the connecting piece anomalies of the connecting piece are classifi ed as acephalic spermatozoa, defi cient organization of the connecting piece, and separation between the head and the tail. acephalic spermatozoa are known as 'pin-headed,' although they lack a true head; the small cephalic knob-like thickening is actually a cytoplasmic droplet with a variable degree of mitochondrial organization giving rise to a variable degree of motility. this anomaly is due to an early failure in spermiogenesis. it may be familial in some cases. , spermatozoa with defi cient organization of the connecting piece have narrowing at this level, with loss of alignment of the head and fl agellum axes. spermatozoa with a separated head and fl agellum, known as decapitated and decaudated spermatozoa, are also the result of an anomaly in spermiogenesis, but the separation between heads and tails can occur during spermiation or at any level of the sperm excretory ducts. , anomalies in axoneme abnormalities of the axoneme are classifi ed as numerical anomalies, microtubular ectopia, and immotile cilia syndrome. the most common numerical anomalies are the absence of one or both microtubules of the central pair and complete lack of the axoneme. spermatozoa lacking the central microtubule pair also lack the central sheath and are immotile, although they are normal by light microscopy. familial cases have been reported. this anomaly may be associated with ciliary dyskinesia. immotile cilia syndrome (primary ciliary dyskinesia) refers to patients having low mucociliary clearance associated with otitis, sinusitis, bronchitis, bronchiectasis, and immotile spermatozoa. most patients have the same defect in the axoneme and cilia of the respiratory mucosa. the frequency of this syndrome is estimated at between in and in men. clinical symptoms consist of reduced clearance of ciliary mucus in the airway, with onset at infancy. in order to prevent the later development of bronchiectasis, ultrastructural study of the respiratory mucosa is advisable if other disorders have been excluded, including cystic fi brosis, allergy and other immune disorders, α antitrypsin defi ciency, and cardiovascular and metabolic diseases. the most frequent anomalies of this syndrome are the absence of microtubule doublets and peripheral junctions, the central microtubule pair, the outer dynein arms, the central junctions, the two dynein arms, and the inner dynein arm plus the peripheral junctions ( fig. - ) . spermatozoa lacking the two dynein arms or the peripheral junctions are immotile. reduced motility is seen in spermatozoa with only one dynein arm. kartagener's syndrome is a variant of the immotile cilia syndrome characterized by the classic triad of situs inversus, bronchiectasis, and chronic sinusitis. the syndrome has autosomal recessive inheritance and is found in - % of patients with situs inversus. anomalies in periaxonemal structures periaxonemal abnormalities include mitochondrial sheath defects, malposition of the annulus, alteration in number, shape, or length of the outer dense fi bers, and absence, thickening, or disruption of the fi brous sheath. , many cases of asthenozoospermia, present in % of infertile men, may be attributable to defi cient mitochondrial function, possibly caused by mutations in their dna. abnormalities of the dense fi bers are associated with deficient motility. abnormalities of the fi brous sheath include, in addition to the abovementioned dysplasia of the fi brous sheath, absence of the fi brous sheath, and redundant fi brous sheath material associated with a defi cit or lack of mitochondria. the three defects are probably inherited. the incidence of intratubular germ cell neoplasia (igcn) in infertile patient is . % in england, . % in spain, . % in germany, and . % in denmark. a higher risk occurs in patients with severe oligozoospermia (fewer than million spermatozoa per milliliter), azoospermia associated with unilaterally or bilaterally diminished testicular volume, a history of testicular maldescent, , or unilateral testicular cancer. the cells of igcn are located in seminiferous tubules with decreased tubular diameter and lacking spermatogenesis. these cells are large and have pale cytoplasm and large and irregularly outlined nuclei, with one or several prominent nucleoli. they stain intensely with periodic acid-schiff and express placenta-like alkaline phosphatase, c-kit, and the cell adhesion molecule cd . a reduction in the number or absence of leydig cells is infrequent in infertility, and only occurs in hypogonadotropic hypogonadism secondary to lh defi cit and in patients infertility with biologically inactive lh. leydig cell hyperplasia is very common, and has been observed in klinefelter's syndrome, cryptorchidism, male pseudohermaphroditism, minor androgen insensitivity, infertility secondary to leydig cell dysfunction, varicocele, after treatment with αreductase inhibitors or non-steroidal anti-androgens, and in some elderly men. such hyperplasia may give rise to hypoechoic or hyperechoic images that may be misdiagnosed as tumor. there is a close relationship between testicular dysfunction and elevated mast cell numbers in the testis. an increase in interstitial and peritubular mast cells occasionally occurs in infertile patients. , this increase is higher than that observed in infl ammatory or neoplastic process. daily administration of ketotifen, an antihistamine-like drug with a mast cell-stabilizing effect, signifi cantly improves the spermiogram parameters in some patients. for effective therapy, it is important to know whether or not the azoospermia or oligozoospermia is the result of obstruction. , obstructive azoospermia and oligozoospermia azoospermia caused by obstruction is usually easily diagnosed, but this determination is more diffi cult with oligozoospermia. obstruction of the ductal system should be suspected when there are more than mature spermatids (s c + s d ) per cross-sectioned tubule and fewer than million spermatozoa in the spermiogram (fig. - ) . , obstructive azoospermia is implicated in . - . % of cases of male infertility. obstruction is classifi ed as proximal, distal, and mixed, according to the distance from the testis to the point of obstruction in the ductal system. proximal obstruction obstruction is considered proximal when the lesion lies between the seminiferous tubules and the distal end of the ampulla of the vas deferens. epididymal obstruction, principally of the caput-corpus transition zone, accounts for % of cases. rarely, there is a defective connection between the rete testis and epididymal ductuli efferentes. because the seminal vesicles are normal, men with proximal obstruction have a normal volume of semen (the testicular contribution to semen is about % of the total volume). when obstruction is in the cauda of the epididymis, epididymal markers, including carnitine, glycerophosphorylcholine and α-glycosidase are low. the nearer the obstruction is to the caput of the epididymis, the higher the level of these markers. distal obstruction distal obstruction is located between the ampulla of the vas deferens and the junction of the ejaculatory ducts and urethra. these patients present with sacral, perineal, or scrotal pain on ejaculation. rectal examination often reveals enlarged seminal vesicles. the volume of semen is low and consists of watery fl uid that fails to coagulate. seminal vesicle secretions are lacking. the concentration of prostatic secretions, such as acid phosphatase and citric acid, is increased owing to the lack of semen dilution. vasography may help in diagnosis, as higher segments fail to fi ll. transrectal ultrasonography is the most accurate imaging modality for the diagnosis of ejaculatory duct obstruction. needle aspiration of seminal vesicle fl uid may show spermatozoa that have entered the seminal vesicles by refl ux. mixed obstruction mixed obstruction refers to lack of patency of the vas deferens or the epididymis and alterations in the ejaculatory ducts or seminal vesicles (low ejaculate volume, and absence of fructose). the most frequent cause is mucoviscidosis. one-third of patients with congenital bilateral absence of the vas deferens have agenesis or hypoplasia of the seminal vesicles. the cause of epididymal obstruction in patients with anomalies of the prostate-vesiculo-deferential junctions is diffi cult to determine. etiology of obstructive azoospermia obstructive azoospermia may be caused by congenital or acquired lesions. congenital azoospermia the most frequent anomalies associated with congenital azoospermia are testis-epididymis dissociation, epididymal malformation in cryptorchidism, bilateral absence of the vas deferens, congenital unilateral absence of the vas deferens associated with pathology of the contralateral testis or its sperm excretory ducts, seminal vesicle agenesis, and ejaculatory duct obstruction (table - ) . agenesis of all mesonephric duct derivatives. agenesis of all mesonephric duct derivatives is a rare disorder that gives rise to varied anatomical anomalies, depending on the stage of embryonic development at which the mesonephric duct derivatives disappear. if failure occurs before the fourth week the ipsilateral kidney and ureter are absent, although the testis may be present, or there may be other renal anomalies. if failure occurs in the fourth week, and the ureteral bud is already formed, the ureter and kidney may develop normally. if failure occurs between the fourth and the th weeks, there is a variable constellation of anomalies that most frequently include normal development of the testis and globus major and hypoplasia of the other excretory duct segments, or agenesis of an excretory duct segment (epididymis, vas deferens, or seminal vesicle). epididymal anomalies. the most frequent epididymal anomalies are absence of the epididymis, testis-epididymis dissociation, defective connection of the vas deferens and epididymis, epididymal cyst, and anatomical abnormalities of the epididymis. complete absence of the epididymis is frequent in monorchidism and anorchidism. the epididymis is replaced by a small mass of cellular connective tissue with abundant blood vessels at the blind end of the vas deferens. partial absence of the epididymis is more frequent than complete absence. absence of the corpus of the epididymis gives rise to a characteristic malformation called bilobated epididymis. this varies from simple strangulation to complete separation of the caput and cauda. these anomalies are often associated with absence of the vas deferens. testis-epididymis dissociation is found in % of cases of obstructive azoospermia and is usually associated with cryptorchidism. defects in connection between the ductuli efferentes and the ductus epididymidis are rarely complete. in the incomplete form, some of the fi ve to ductuli efferentes in the epididymis are short and end blindly. epididymal cysts usually arise from blind-ended ductuli efferentes and contain spermatozoa. these spermatoceles retain their epithelial lining, although it becomes atrophic ( fig. - ). spermatozoa may be obtained from these cysts. some epididymal cysts arise from embryonic remnants, do not contain spermatozoa, and are lined by columnar or pseudostratifi ed epithelium. wolffi an cyst, unlike müllerian cyst, is immunoreactive in the apical border of epithelial cells with cd . cyst lined by clear cells with or without papillae raises concern for von hippel-lindau disease. large epididymal cyst requires removal and must be excised with great care to avoid damaging the ductuli efferentes and resulting in obstruction. epididymal cyst is present in about % of males, and the incidence is high ( %) in those exposed to diethylstilbestrol during gestation. the incidence of epididymal cyst in those with hepatorenal polycystosis is similar to that in the general population. anomalies in epididymal confi guration, altering its shape and location, are frequent in men with cryptorchidism and uncommon with descended testes. the most common malformations are elongated epididymis, angulated epididymis, and free epididymis. elongated epididymis is found in approximately % of undescended testes. the length of the epididymis may be several times that of the testis, and, in abdominal or inguinal cryptorchidism, the epididymis extends several centimeters below the testis. angulated epididymis is characterized by a long epididymis that has a sharp bend in the corpus with or without stenosis. with free epididymis, all or part of the epididymis is unattached to the testis. the most common variant is epididymis with free cauda. vas deferens anomalies. the most frequent anomalies are of the vas deferens are congenital absence, segmental aplasia, ectopia, duplication, diverticula, and crossed dystopia. congenital absence is defi ned as unilateral or bilateral absence of either the whole vas deferens or only a segment. obviously, azoospermia occurs with bilateral absence. the frequency of this malformation varies among populations. at autopsy, the prevalence is . %, but the clinical incidence infertility is - . % in infertile men and - % in patients with obstructive azoospermia. unilateral complete absence is three times more frequent than bilateral absence, and absence of only a segment is even more frequent. the affected segment may be absent or reduced to a fi brous cord. absence of the vas deferens may be associated with other malformations of the sperm excretory ducts or urinary system. the most frequent malformations of the excretory ducts are absence of the ejaculatory ducts ( % of cases) and, less frequently, absence of the seminal vesicles. about % of patients with bilateral absence of the vas deferens have partial aplasia of the epididymis. the most frequent malformations of the urinary system are absence of the ipsilateral kidney and other renal anomalies. complete or partial absence of the vas deferens occurs frequently in patients with cystic fi brosis. persistent mesonephric duct consists of the ureter joined to the vas deferens, forming a single duct that opens in an ectopic orifi ce between the trigone and the verumontanum. this malformation may be associated with cystic transformation or absence of the seminal vesicle. the kidney may be normal or dysplastic. anomalies of seminal vesicle and ejaculatory duct. the most frequent anomalies are agenesis of the seminal vesicles or ejaculatory ducts, cyst of the seminal vesicle, and ectopic opening of the ureter into the seminal vesicle. the last is the most common and often is associated with ipsilateral renal dysplasia. acquired azoospermia infl ammation and trauma are the main causes of acquired azoospermia. epididymitis is a frequent cause; chlamydia trachomatis , and escherichia coli are the most common infectious causes in developed countries. infections with neisseria gonorrheae and mycobacteria are also implicated, and non-specifi c epididymitis is important. apart from elective vasectomy, the most frequent traumatic causes of azoospermia are surgical accidents during herniorrhaphy in chidren, orchidopexy, varicocelectomy, hydrocelectomy, deferentography, and removal of epididymal cyst. obstructive azoospermia may also result from blockage of the ejaculatory ducts following transurethral resection, or as a result of chronic urethral catheterization. lesions of the testis and epididymis may result from obstructed sperm excretory ducts, depending on the location, origin (congenital or acquired), and duration of the obstruction. location of obstruction obstruction at the level of the ampulla of the vas deferens, seminal vesicles, or ejaculatory ducts does not usually cause signifi cant lesions in the testis or epididymis. more proximal obstruction at the level of the vas deferens, epididymis, or testis-epididymis junction usually causes severe lesions in both the sperm excretory ducts and the testicular parenchyma. obstruction of the vas deferens causes increased pressure within the ductus epididymis. as a result, epididymal lumina dilate, the epithelium atrophies, and fl uid containing few spermatozoa and some spermiophages accumulates in the lumen (fig. - ) . the most dilated epididymal segment is the caput. the ductuli efferentes often become cystically dilated and fi lled with spermatozoa and macrophages. from reabsorption and lysosomal degradation of this protein-rich fl uid, the epithelium accumulates lipofuscin granules or aquires apical eosinophilic granules (paneth cell-like change). rupture of the vas deferens gives rise to microgranulomas and ceroid granuloma (fig. - ). macrophages and lymphocytes are often present in the intertubular connective tissue. the most frequent testicular lesions in proximal obstruction involve the adluminal compartment, and are the result of the negative effect of hydrostatic pressure on the seminiferous tubular cell layers and, in particular, on the sertoli cell (figs - - - ) . etiology of obstruction obstruction secondary to congenital absence of the vas deferens usually causes little testicular injury, mainly dilation of the seminiferous tubules and an increase in the number of mature (s c + s d ) spermatids. lesions resulting from vasectomy are more important. increased intraluminal pressure in the epididymis may give rise to pain (late post-vasectomy syndrome). testicular lesions depend on the surgical technique used: they are slight if the proximal end of the vas deferens is not ligated or sperm granuloma forms at the site of vasectomy. the spermatogenic rhythm in the testis is slower than before vasectomy, and lesions characteristic of testicular obstruction develop, including thickening of the lamina propria and fi brosis of the interstitium. , in testicular obstruction secondary to herniorrhaphy in infancy, testicular lesions are mild. testicular lesions may be important if the epididymis is damaged by hydrocelectomy, and consist mainly of primary spermatocyte sloughing. in addition to these lesions, hyalinized tubules may be observed when obstruction is caused by infl ammation. in acquired obstruction the testicular lesions worsen with time. obstruction in the caput of the epididymis leads to disappearance of all germ cells in the adluminal compartment of seminiferous tubules. the tubules become dilated and sertoli cells appear vacuolated. testicular alterations after vasectomy may not be related to the duration of the obstruction but rather to the initial injury, and may disappear with time as the intraluminal pressure decreases. however, if a signifi cant amount of time has elapsed after vasectomy, the possibility of attaining a normal spermiogram with vasovasostomy is very low. vasal patency is restored in most cases of reanastomosis, but paternity rates are markedly lower ( - %) than normal ( %). some azoospermic patients have testicular biopsy with minimal histologic abnormality or minor tubular dilation without detectable excretory duct obstruction. these fi ndings are characteristic of two main conditions: young's syndrome, and alterations in spermatozoal transport. young's syndrome young's syndrome is defi ned by the following constellation of fi ndings: azoospermia, sinusitis, bronchitis or bronchiectasis, and normal spermatozoal fl agella. the incidence is probably higher than that recorded in the literature, and young's syndrome should be suspected in all patients with obstructive azoospermia without a history of epididymitis or scrotal trauma. these patients have a lesion at the junction of the caput and corpus of the epididymis that gives the epididymis a characteristic gross appearance. the caput of the epididymis is distended, the ductuli efferentes contain yellowish fl uid and numerous spermatozoa, and the remaining epididymal segments are normal. the ductus epididymidis is blocked by thick fl uid. young's syndrome should be distinguished from other causes of infertility also associated with chronic sinusitis and pulmonary infections, including ciliary dyskinesia and cystic fi brosis. ciliary dyskinesia consists of morphological, biochemical, and functional alterations in cilia and fl agella, and includes infertility several diseases such as the immotile cilia syndrome, kartagener's syndrome, and miscellaneous syndromes characterized by imperfectly defi ned abnormalities of cilia and fl agella. in young's syndrome, sinusitis and pulmonary infections develop in childhood and stabilize or improve in adolescence; in other conditions, the pulmonary damage increases with age and the cilia and fl agella are ultrastructurally abnormal. alterations in spermatozoon transport normally, spermatozoa detach from the sertoli cells and are transported through the intratesticular and extratesticular excretory ducts, where they are stored, mainly in the cauda of the epididymis, and fi nally released from the corpus by ejaculation or eliminated by phagocytosis. only about % of spermatozoa are ejaculated. whereas the release of spermatozoa from the corpus is intermittent, their transport through the sperm excretory ducts is continuous. transport is accomplished by the myofi broblasts in the wall of the seminiferous tubules and ductuli efferentes and the smooth muscle cells in the wall of the ductus epididymidis and vas deferens. these cells cause peristaltic contraction, propelling spermatozoa along the length of the epididymis in a mean of days (range, - days). the walls of the seminiferous tubules and extratesticular excretory ducts are under hormonal and neural control. the myofi broblasts in the seminiferous tubules have oxytocinic, α -β-adrenergic, and muscarinic receptors. unmyelinated nerve fi bers penetrate the tubular lamina propria, pass among the myofi broblasts, and end near the sertoli cells. along their length these nerve fi bers have varicosities containing sympathetic vesicles. the ductus epididymis is innervated by sympathetic adrenergic nerve fi bers that end among the smooth muscle cells. several hormones, including oxytocin, endothelin- , vasopressin, and prostaglandins, act on the musculature of the ductus epididymis. the peristaltic contractions begin in the caput and propagate toward the cauda. the frequency and amplitude of contractions vary from region to region, being higher in frequency near the caput and of maximal amplitude in the initial portion of the cauda. the progressive increase in amplitude parallels the progressive increase in thickness of the muscular wall and the requirement for greater force to propel the fl uid as it becomes progressively more viscous with a higher concentration of spermatozoa. the distal portion of the cauda is unusually at rest because it is the main reservoir of spermatozoa between ejaculations. several times daily, vigorous contractions of the distal cauda impel the spermatozoa from the cauda toward the vas deferens. several drugs that favor contraction of the muscular wall (α blocking and f α prostaglandins) have been successfully used in the treatment of alterations in the spermatozoon transport. knowledge of the incidence of chromosomal abnormalities in male infertility has progressed in parallel with advances in technology: karyotypic studies in peripheral blood, meiotic and chromosomal studies of testicular biopsies, analysis of chromosomes in spermatozoa, and analysis of dna in blood and spermatozoa for the detection of chromosome y deletions. the incidence of chromosomal anomalies in infertile men is . - . %, whereas in the general population it is lower than . %. the frequency of chromosomal abnormalities increases with the decrease in number of spermatozoa in the ejaculate. klinefelter's syndrome genetic and clinical aspects klinefelter's syndrome is characterized by an abnormal number of x chromosomes and primary gonadal insuffi ciency. the original description was of a man with eunuchoidism, gynecomastia, small testes, mental retardation, and elevated level of serum gonadotropins. the frequency of this syndrome varies according to the population studied: in to in surviving newborns; in patients in mental institution; . in infertile men; and % of patients who are azoospermic. in % of cases, the karyotype is xxy. the remaining % have chromosomal mosaicism with at least two x chromosomes. the most common are xy/xxy, xy/xxxy, xx/ xxy, xxy/xx/xy, xy/xo/xxy, xx/xxy/xxxy, and xxxy/ xxxxy. the xxy lesion is due to non-disjunction in sex chromosome migration during the fi rst or second meiotic division of the spermatocyte or ovule, or during the fi rst meiotic division of the zygote. study of the xg antigen in blood revealed that the extra x chromosome is from the mother in % of cases. advanced maternal age increases the incidence of children with the xxy karyotype. in xxy patients, the most common clinical fi ndings are: • eunuchoid phenotype with increased stature. the increased height is due to a disproportionate lengthening of the lower extremities. the ratio of span to height is less than . • incomplete virilization. this is variable and ranges from normal development to absence of secondary sex characteristics. • gynecomastia, usually bilateral, present in % of patients. • mental retardation. other commonly associated conditions include chronic bronchitis; varicose veins; cervical rib; kyphosis; scoliosis or pectus excavatum; and a high incidence of hypothalamic, hypophyseal, thyroid, and pancreatic dysfunction. the external genitalia usually are normally developed. the testes are usually less than . cm long, although in some cases of chromosomal mosaicism they are of normal size. the incidence of cryptorchidism is low in xxy patients but increased in mosaicism. supernumerary x-chromosome material is associated with a reduction of gray matter in the left temporal lobule, a fi nding correlated with verbal and language defi cits. histologically, the testes show the classic picture of tubular dysgenesis with small hyalinized seminiferous tubules lacking elastic fi bers and pseudoadenomatous clustering of leydig cells (figs - , - ). most biopsies show some tubules with a few sertoli cells. these cells may be dysgenetic (pseudostratifi ed distribution of nuclei that are dark and elongate and contain small peripherally placed nucleoli in tubules without apparent lumina). sex chromatin may only be observed in dysgenetic sertoli cells. this suggests that either there is testicular mosaicism of the x chromosome, or that both x chromosomes are heterochromatinized. in mosaicism, sertoli cell-only tubules may be more numerous than hyalinized ones. the reduced testicular volume gives an appearance of leydig cell hyperplasia, although quantitative studies have shown that the total number of leydig cells is lower than normal. many of the leydig cells are pleomorphic and some are multivacuolated. immature fi broblast-like leydig cells may be present. the abnormally differentiated leydig cells have nuclei with coarse masses of dense chromatin, deep unfolding of the nuclear envelope, multiple paracrystalline inclusions instead of reinke's crystalloids, multilayered concentric cisternae of smooth endoplasmic reticulum, large masses of microfi laments, and scant lipid droplets. sex chromatin is apparent in - % of leydig cells. leydig cell function is insuffi cient and androgen levels are less than % of normal. basal fsh and lh are markedly increased. , , in a few patients the testicular damage is less severe, with some tubules showing spermatogenesis and less prominence of leydig cells. exceptionally, complete spermatogenesis and even paternity have been reported. the xy/xxy karyotype is the most frequent variant of klinefelter's syndrome with chromosomal mosaicism. in this condition, the clinical abnormalities may be attenuated. gynecomastia is present in % of cases, compared to a frequency of % in men with the xxy karyotype. azoospermia is found in % of cases ( % in xxy men). the testes are larger and spermatogenesis is more developed in men with xxy ( fig. - ) . patients with the xxy karyotype who have spermatozoa in seminiferous tubules are bearers of xy spermatogonia and also of xxy spermatogonia, whereas those who have no spermatozoa have xxy spermatogonia only; these xxy spermatogonia may include some spermatozoa with x or y chromosomal complement, elevated numbers of both xy and xx spermatozoa, and also a high frequency of spermatozoa with disomy; this could be an important risk for gonosomy and also for trisomy . genetic counseling is advisable in patients seeking intracytoplasmic sperm injection therapy. genetic diagnosis before implantation of the zygote or prenatal diagnosis have been recommended, except for parents who assume the risk of gonosomy. the incidence of the xxyy karyotype is estimated to be . per live births. [ ] [ ] [ ] [ ] this karyotype may be associated with aggressive character, antisocial behavior, more severe mental retardation, and a higher frequency of congenital malformations than the xxy karyotype. men with the xxyy karyotype also have characteristic dermatoglyphics with an increase in arches, a decrease in total fi nger ridge count, and ulnar triradiuses associated with changes in the hypothenar region. concentric lamellae of smooth endoplasmic reticulum in leydig cells are a characteristic fi nding (fig. - ). men with the xxxy or xxxyy karyotype often have skeletal malformations, principally radioulnar synostosis, and cryptorchidism. in addition to the characteristic symptoms of xxy klinefelter's syndrome, men with the xxxxy karyotype have other abnormalities, including severe mental retardation, hypoplasia of external genitalia, cardiac malformations, radioulnar synostosis, microcephaly, and a high arched palate. association of klinefelter's syndrome with malignancy patients with klinefelter's syndrome have a higher incidence of malignancy than the general population. the association was fi rst discovered with breast carcinoma, which had an incidence times greater than in the general male population, and is related to hormonal stimulation. although testicular germ cell tumor is rare in these patients, extragonadal germ cell tumor is - times more frequent than in the general population. most occur in the mediastinum (about %) and are less frequent in the pineal gland, central nervous system, and retroperitoneum. the most frequent types are teratoma and choriocarcinoma; embryonal carcinoma and seminoma are rare. [ ] [ ] [ ] the extragonadal origin of germ cell tumors has been attributed to abnormal germ cell migration from the yolk sac. the high incidence has been attributed to elevated hormone levels and chromosomal anomaly. in a patient with the xy/xxy chromosomal mosaic and bronchogenic carcinoma, cultured xxy fi broblasts transformed three times more frequently when exposed to sv virus than did fi broblasts from normal men. other tumors reported in patients with klinefelter's syndrome (lymphoma, leukemia, bronchogenic carcinoma, urothelial carcinoma of the bladder, adrenal carcinoma, prostatic adenocarcinoma, testicular leydig cell tumor, and epidermoid cyst) do not appear to have a higher incidence than in the general population. [ ] [ ] [ ] [ ] occurrence of klinefelter's syndrome in childhood early identifi cation of this syndrome is possible with systematic cytogenetic study of newborns with positive sex chromatin or mental retardation. several clinical symptoms suggest klinefelter's syndrome. initial symptoms include decreased muscle tone, delayed speech, and poor language skills with an increased incidence of reading diffi culties and dyslexia. later, there may be recognition of mental retardation, psychiatric problems, excessive stature for age, disproportionately long legs, micropenis, and small testes. [ ] [ ] [ ] [ ] androgen defi ciency is an early fi nding. testicular biopsy reveals scant or absent germ cells. quantitative studies indicate that the number of germ cells in xxy fetuses is signifi cantly lower than in normal xy fetuses. the seminiferous tubules have reduced diameter, particularly those devoid of germ cells. the number of sertoli cells per cross-sectioned tubule is reduced. megatubules, ring-shaped tubules, and intratubular eosinophilic bodies are common (fig. - ) . in some cases of klinefelter's syndrome associated with down's syndrome, tubular hyalinization is observed in childhood. the interstitium is wide and contains few leydig cell precursors. if one testis is undescended, its histology does not differ from that of the contralateral testis. the testicular pattern remains constant through childhood. at puberty, before maturation of the tunica propria occurs, the seminiferous tubules rapidly hyalinize and leydig cell precursors differentiate into leydig cells. association of klinefelter's syndrome with precocious puberty although precocious puberty is not a characteristic fi nding in klinefelter's syndrome, karyotyping in older boys with mental retardation, gynecomastia, small testes, and precocious puberty is advisable. in most cases, the cause of precocious puberty is a hcg-secreting germ cell tumor in the mediastinum. infrequently, precocious puberty is idiopathic, and only in isolated cases is there a hamartoma in the third ventricle. klinefelter's syndrome is often associated with pituitary disorders such as panhypopituitarism or incomplete hypopituitarism. defi cits in fsh, lh, or both , have been reported. the cause of this association is unknown, and diverse etiologies such as trauma, immunologic disorders, and genetic defi ciencies have been postulated. alternatively, it may be due to exhaustion of pituitary gonadotropin-secreting cells after years of gonadotropin-releasing hormone stimulation. in patients defi cient in both gonadotropins, testicular biopsy shows diffuse tubular hyalinization and a marked reduction in or absence of leydig cells. the histological picture is similar to that of hypogonadotropic hypogonadism occurring after puberty, except for the presence of isolated tubules containing only dysgenetic sertoli cells and absence of elastic fi bers in the hyalinized tubular wall (fig. - ) . biopsy of patients with a defi cit only in fsh is similar to that of the dysgenetic sertoli cell variant of the sertoli cell-only syndrome, although some hyalinized tubules are present. the testicular biopsy of patients defi cient only in lh resembles that of men with classic xxy klinefelter's syndrome. xx males the xx karyotype may be present in three phenotypes: male phenotype, including normal external genitalia; male pseudohermaphrodites, with a variable degree of ambiguity in external genitalia, ranging from hypospadias to micropenis; and true male hermaphrodites. xx males with male phenotype and normal external genitalia men with the xx karyotype having male phenotype and normal external genitalia have clinical features similar to those of klinefelter's syndrome, including small testes, small or normal penis, azoospermia, gynecomastia, and minimal development of secondary sex characteristics. however, these men have harmonious body proportions, normal or slightly low stature, and normal intelligence. the incidence of xx males varies from : to : live births, accounting for about . % of infertile men. , males with xx karyotype have hypergonadotropic hypogonadism with elevated serum levels of fsh and, to a lesser degree, elevated lh, with normal or slightly decreased testosterone. familial cases have been reported. during childhood, biopsy of xx males reveals decreased numbers of germ cells. , biopsies from adults show one of three patterns: histology similar to that of xxy men, including diffuse tubular hyalinization with prominent leydig cells; sertoli cell-only tubules; , and both patterns intermingled with less prominent leydig cells. the last is the most frequent ( fig. - ) . ultrastructural studies reveal an increase in intermediate fi laments, absence of annulate lamellae in sertoli cells, absence of reinke's crystalloids, and abundance of intracytoplasmic and intranuclear paracrystalline inclusions in leydig cells. xx males with ambiguous external genitalia some patients with the xx karyotype have ambiguous external genitalia or hypospadias and are assumed to have a variation of male pseudohermaphroditism. these males, together with true hermaphrodites, may be found in the same family, suggesting that both disorders are different manifestations of the same genetic defect. the origin of xx males may be diffi cult to determine. however, as testicular differentiation requires genes located on the y chromosome, xx males have been classifi ed by cytogenetics as those having the sry gene, those lacking the sry gene, and xx/xy mosaicism. males with the sry gene comprise % of xx males. it is likely that this occurs when the genetic material from infertility the short arm of the y chromosome is translocated to the x chromosome. during paternal meiosis, the homolog pseudoautosomal regions of chromosomes x and y interchange the terminal portions of their short arms, giving rise to an x chromosome with the sry gene but lacking the azoospermia factor. [ ] [ ] [ ] [ ] [ ] [ ] alternatively, the sry region may be inserted in an autosome. most xx patients who are sry positive have a normal male phenotype. about % of xx males are sry negative and most have ambiguous genitalia. some patients have a normal male phenotype and only infertility. although sry is assumed to be the most important regulator factor of testicular determination, these patients may have mutation of one of the downstream non-y testis-determining genes. [ ] [ ] [ ] [ ] about % of xx males have xx/xy mosaicism or other karyotype with the chromosomal complement y. in these cases, detection of the specifi c dna sequences of y chromosome may be diffi cult because this chromosome may be only in some tissues and in a small number of cells. xyy syndrome the xyy syndrome was fi rst described in in the father of a girl with down's syndrome. the only clinical fi ndings were excessive height and pustular acne. study of other cases suggests that these men are predisposed to a psychopathic personality and antisocial behavior, although most have a normal personality and are socially adapted. the incidence of xyy patients is estimated to be . % of the general population, . - . % of men in prison, and . % of sexual homicide criminals. the extra y chromosome originates from non-disjunction during the paternal second meiotic division. in the past decade, many cases have been diagnosed prenatally. from birth, the patients have weight, stature and cephalic circumference above mean values and a higher risk for delayed language and/or motor development. about % of children have psychological and psychiatric problems such as autism; although their intelligence is normal, many patients are referred to special education programs. as adults, they have normal external genitalia and secondary sex characteristics. fertility is reduced, although many have been fathers. usually, testicular biopsy reveals mixed atrophy characterized by tubules with spermatogenesis associated with sertoli cell-only tubules (fig. - ) . , those tubules with spermatogenesis may show normal spermatogenesis or have lesions in the adluminal or basal compartments. in these tubules, many xxy spermatocytes degenerate during meiosis. about % of pachytene cells have three sex chromosomes. the number of normal spermatozoa in the ejaculate is low. there is a high incidence of both yy and xy spermatozoa and disomy . the variability in germ cell development is apparently due to elimination of germ cells that could not pair their sex chromosomes during the fi rst or second meiotic divisions or, later, during the round spermatid stage. spermatocytes that succeed in forming trivalent chromosomes are initially viable. the ultimate trivalent chromosome segregation yields aneuploid and euploid cells in equal numbers. sertoli cell-only tubules are attributed to either spermatogonial damage by substances released from degenerated spermatocytes or absence of testicular colonization by primordial germ cells. these men have normal serum levels of testosterone and lh. the latter may be slightly increased in xyy men with severe spermatogenic alterations. xyy men with mosaicism ( xyy/ xy) have a higher risk of fathering children with hyperdiploid chromosomal constitution, and spermatozoa should be studied genetically to evaluate the risk of intracytoplasmic sperm injection. men with three and four y chromosomes have been reported. men with the xyyy karyotype are tall and have normal male phenotype, slight mental retardation, azoospermia and, during childhood, frequent infections of the upper respiratory tract. testicular biopsy shows sertoli cell-only tubules, severe hyalinization of tubular basement membrane, and diffuse leydig cell hyperplasia. the chromosomal complement of parents can be normal. men with xyyyy also have no signifi cant phenotypic abnormalities (except for cases of chromosomal mosaicism). slight mental retardation, infertility, and antisocial behavior are the most signifi cant clinical fi ndings. rarely patients have facial dysmorphism and various skeletal abnormalities. the y chromosome is essential for gender determination and spermatogenesis, and abnormalities often lead to infertility. the relationship between y chromosome abnormalities and infertility is best understood in azoospermic men with alterations in yq , the distal region of the euchromatic part of the long y arm, the location of a male fertility gene complex called azoospermia factor. infertility may result from deletion of any of four subregions in which the azoospermia factor has been divided (azfa, azfb, azfc and azfd). , the best-known y chromosome genes involved in spermatogenesis are rbm. daz, dffry, cdy, smcy, and zfy. six different partial deletions of this region have been found in azoospermic patients (table - monocentric deleted yq chromosome partial deletion of the distal portion of the yq euchromatic region is associated with azoospermia owing to loss of the azoospermia factor. these men have normal external genitalia except for small testes, normal testosterone and lh serum levels, and increased fsh serum level. the most frequent histological fi nding is sertoli cell-only pattern, although many other patterns have been reported. the number of leydig cells is normal or increased. these fi ndings suggest that the azoospermia factor is required for early spermatogenesis. if the breakpoint of yq is proximal to the centromere, patients are short because the gene that controls stature is close to that for the azoospermia factor. dicentric yq isochromosomes sterility is frequent in men with dicentric yq isochromosomes. this anomaly is usually associated with a x cell line. the proportion of this line varies between patients and between cell types (fi broblasts or lymphocytes). when the point of breakage and fusion of the two y chromosomes is in the distal region yq , and the second centromere is inactivated, the y isochromosome is normal in size but does not stain with quinacrine, and thus is called non-fl uorescent y chromosome (ynf). as the breakpoint is in the yq region, the azoospermia factor function is altered. development of external genitalia varies from ambiguous to normal, and is probably related to the extent of xo present. testicular biopsies are similar to those of men with monocentric deleted yq chromosomes (fig. - ) . , ring y chromosome men with ring y chromosomes have normal male phenotype, azoospermia, and, in some cases, short stature. most have mosaic karyotype with a x line. in some cases, testicular biopsy resembles that of men with monocentric deleted yq chromosome, but in others there is premeiotic arrest of spermatocyte maturation. this is attributed to diffi culty in pairing the x and y chromosomes during meiosis. many patients have deletion of some azf regions. , y/y translocation chromosome patients with this anomaly have small soft testes and primary spermatocyte maturation arrest owing to defective pairing of the x and y chromosomes. the karyotype may be mosaic with a x line. translocation of y chromosome to x chromosome most frequently this translocation is cytogenetically undetectable, and patients present with infertility and are found to have xx karyotype. the phenotype is similar to that of men with klinefelter's syndrome except for shorter stature, absence of mental retardation, and smaller teeth. testicular biopsy shows sertoli cell-only pattern. men with cytogenetically detectable translocations have short stature, small testes, tubular hyalinization, and prominent clustered leydig cells similar to klinefelter's syndrome. autosomal translocation of y chromosome translocation of the distal heterochromatic portion of the y chromosome to the short arm of an acrocentric chromosome occurs occasionally. the most frequent are translocations to chromosomes , , , , and . the fertility of these men depends on the point of breakage. , if this occurs in the yq heterochromatic region, the patient has a male phenotype and is fertile. if the point of breakage is in the yq region, the patient is infertile and has small testes. seminiferous tubules may show only sertoli cells, spermatogenetic arrest in early stages of meiosis, or an infantile pattern. , interstitial microdeletion in yq yq microdeletion is the most frequent congenital cause of infertility. the frequency of y chromosome microdeletion in infertile patients varies widely ( - %). in azoospermic men, the frequency is between % and %. in oligozoospermic males the incidence drops. most microdeletions are in the azfc subregion. , testicular biopsy shows only sertoli cells, maturation arrest, or mixed atrophy. there is no correlation between site of azf subregion alteration and histological pattern. there is no exact correlation between genotype and phenotype, but most microdeletions in azfa are associated with azoospermia, most microdeletions in azfb are associated with maturation arrest, and most microdeletions of azfc are associated with spermatid maturation arrest or mixed testicular atrophy. partial deletion of azfc has a mild effect on fertility. external genitalia in xy patients with duplication of distal xp vary from male, ambiguous, to female, and gonadal dysgenesis is frequent. if the patient has male genitalia, these are usually hypoplastic with hypogonadotropic hypogonadism and, frequently, multiple congenital anomalies and mental retardation. males with translocation of the x chromosome to an autosome may have disturbed spermatogenesis with subfertility or infertility. , xxx males show mental retardation, gynecomastia, normal stature, hypoplastic scrotum, a well-confi gured but small penis, small testes, and poorly developed pubic hair. serum testosterone levels are very low. seminiferous tubules appear severely hyalinized. xxx males result from an abnormal x-y interchange during paternal meiosis and x-x non-disjunction during maternal meiosis. there have been many reports on the relationship between autosomal anomalies and infertility, although the causes are not fully understood because the same anomaly is associated with infertility in some patients but not in others. robertsonian translocations are found in . % of infertile men ( . % higher than in the normal population) and are more frequent in oligozoospermic than in azoospermic men. the most frequent translocations are ; and ; . the incidence of reciprocal translocations in infertile patients is . % ( . % in the general population) and increases to . % in patients with azoospermia or severe oligozoospermia. the most frequent in infertile men are ; and ; . paracentric and pericentric inversions (except for the pericentric inversion of the heterochromatic region in chromosome ) are eight times greater in infertile patients ( . %) than in the general population. the highest risk for infertility occurs in the pericentric inversion of chromosome . , the most common testicular lesions in men with autosomal anomalies are spermatogonial maturation arrest, primary spermatocyte sloughing sometimes associated with hypospermatogenesis, and sertoli cell-only pattern. the only autosomal anomaly with prolonged survival is down's syndrome. in addition to trisomy of chromosome and the characteristic appearance, patients with down's syndrome usually have cryptorchidism, small testes, hypoplasia of the penis and scrotum, and hypospadias. adults have oligozoospermia or azoospermia secondary to primary testicular defi ciency. levels of fsh and lh are elevated, but testosterone is normal or slightly diminished. isolated cases of paternity have been reported. , in utero, there is marked delay in germ cell development. histologic studies of prepubertal testes at autopsy reveal decreased tubular diameter and tubular fertility index. eosinophilic bodies or microliths may be present in some tubules (fig. - ). adult testes have defi cient spermatogenesis and mixed atrophy, with some tubules showing complete spermatogenesis and others containing sertoli cellonly pattern. hypergonadotropic hypogonadism is found in several myopathies (myotonic dystrophy and progressive muscular fig. - prepubertal testis in down's syndrome. there are megatubules, ring-shaped tubules, and small tubules. germ cell number is very low in all these tubules. eosinophilic bodies or microliths are present in some tubules. dystrophy) and dermopathies (bloom's, rothmund-thomson, werner's, cockayne's, and tay's syndromes), with testicular histology that resembles that of klinefelter's syndrome. hypogonadism is also observed in noonan's syndrome, cerebellar ataxia (with milder testicular lesions), and a miscellaneous group of syndromes with variable histological fi ndings. myotonic dystrophy accounts for approximately % of men with muscular disorders, and about % have testicular atrophy. the estimated incidence is in live births. the abnormality involves the distal muscles of the extremities. in addition, patients may have premature baldness, posterior subcapsular cataracts, cardiac conduction defects, impotence, gynecomastia (rarely), and dementia (at later stages). myotonic dystrophy is an autosomal dominant inherited disease with variable penetrance. two loci are associated with the disease phenotype: dm in q . , and dm in chromosome . mutation in dm results in a serine/threonine protein kinase defi ciency that causes expansion of a ctg repeat (from to several hundred repeats) located on the ′-untranslated region of the dystrophy myotonic-protein kinase gene. the number of repeats is positively correlated to severity of the disease and negatively correlated to age of clinical onset. [ ] [ ] [ ] dm is caused by a mutation in q . of the znf gene and accounts for cctg-repeat expansion (from to repeats) in intron of this gene. the common clinical symptoms are due to gain of function of rna mechanism in cug and ccug repeats altering cellular function, including alternative splicing of various genes. the severity of the disease increases in the successive generations. the number of ctg repeats is not associated with male subfertility. hypogonadism is hypergonadotropic in most cases and is not related to the number of ctg repeats. testicular lesions probably begin late because % of patients are fathers. testicular biopsy shows different degrees of severity, ranging from nearly normal to fully hyalinized seminiferous tubules, with the number of leydig cells varying from increased to decreased. in some patients the hypogonadism is hypogonadotropic, and the testes show an infantile pattern. infertility may be the fi rst symptom of myotonic dystrophy. progressive muscular dystrophy is a multisystemic x-linked disease. it is usually associated with gonadal atrophy caused by a defective locus in chromosome . patients rarely live more than years. the incidence is approximately in live births. in both duchenne and becker forms the cause is a defect in the dystrophin gene. , bloom's, rothmund-thomson, and werner's syndromes are caused by a homozygous defect in human receq helicases in chromosome . of the fi ve members of this gene family (recq , blm, wrn, recq , and recq ), three produce autosomal recessive inherited diseases. mutations of blm have been identifi ed in patients with bloom's syndrome, wrn has been shown to be mutated in werner's syndrome, and mutations of recq have been associated with rothmund-thomson syndrome. , despite the close genetic origin of the three syndromes, symptoms are very different. bloom's syndrome is characterized by short stature, narrow face with prominent nose, facial 'patchy' skin color changes that become more marked with sun light exposure, and increased susceptibility to respiratory diseases, cancer and leukemia. severe oligozoospermia and azoospermia are common. leydig cell function is conserved. rothmund-thomson syndrome presents with poikiloderma, juvenile cataracts, sparse hair, short stature, skeletal defects, dystrophic teeth and nails, and hypogonadism. these patients are predisposed to cancer and osteogenic sarcoma. werner's syndrome (progeria) is characterized by short stature, prematurely graying hair, baldness, cataracts, atrophy and calcifi cation of muscle and fat, wrinkling of the skin, keratosis, osteoporosis, telangiectasis, atheroma, diabetes mellitus, gynecomastia, and hypergonadotropic hypogonadism. the lifespan of fi broblasts and other cells is shortened in this syndrome. the mutation is in the recq helicase gene. cockayne's syndrome is a rare autosomal recessive neurodegenerative disorder. signs and symptoms include infantile failure to thrive, short stature, poorly developed trunk, premature aging, neurological alterations, retinitis pigmentosa, optic atrophy, cataract, deafness, microcephaly, micrognathia, photosensitivity, delayed eruption of primary teeth, congenital absence of some permanent teeth, partial macrodontia, atrophy of the alveolar process and caries, limited articular movements in elbows, knees, and fi ngers, abnormally small eccrine glands, and hypergonadotropic hypogonadism. it may be caused by two gene mutations: cnk (ercc ) and ercc , located respectively on chromosomes and , and causing two variations of cockayne's syndrome, including cs-a, secondary to a ercc mutation, and cs-b with ercc mutation. cs-b patients have hypersensitivity to ultraviolet light secondary to a dna repair defect. tay's syndrome (trichothiodystrophy) has two presentations: ibsd (ichthyosis, brittle hair, impaired intelligence, short stature) and ibisd (photosensitivity, ichthyosis, brittle hair, impaired intelligence, short stature). in both forms, patients have decreased fertility. one case of hypergonadotropic hypogonadism has been reported. noonan's syndrome is characterized by multiple malformations reminiscent of turner's syndrome, including short statute, pterygium coli, and cubitus valgus, although there is normal male karyotype. the disease has an incidence of in to in live births and autosomal dominant inheritance, with sporadic occurrence in about % of cases. a locus for dominant forms has been mapped to q . . mutation in ptpn (protein-tyrosine phosphatase, nonreceptor-type ) accounts for half of cases, although similar germline mutations also cause leopard's syndrome and certain pediatric hematopoietic malignancies. cryptorchidism is present in about % of cases and is usually bilateral. during childhood, testicular biopsy shows a low tubular fertility index. puberty is often delayed, and, at adulthood, hypogonadotropic or hypergonadotropic hypogonadism occurs. ultrastructural studies reveal morphologic anomalies in germ cells. although spermatogenesis is generally impaired, some patients have been fertile (fig. - ) . cerebellar atrophy may be associated with hypogonadism. patients are infertile and have moderate ataxia without endocrine disorder. infertility is due to morphological abnormalities of spermatozoa caused by decreased expression of map (the most important microtubule-associated protein), and a defect in erythroid ankyrin. , many other syndromes also present with primary hypogonadism. the best known are alström's, weinstein's, borjenson-forssman-lehmann, marinesco-sjögren, richards-rundle, robinow's, and silver-russell syndromes. hypogonadotropic hypogonadism or hypogonadism of hypothalamo-hypophyseal origin is classifi ed according to whether the hypothalamo-hypophyseal failure occurs before or after puberty. eunuchoidism, present only in the former group, is the basis of the distinction. the most frequent types of hypogonadism caused by hypothalamo-hypophyseal failure are those caused by a defi cit of gonadotropinreleasing hormone, bioinactive fsh and lh, defi cit in growth hormone, those associated with prader-willi syndrome, and laurence-moon-rozabal-bardet-biedl syndrome. the onset and maintenance of the hypothalamo-hypophyseal-gonadal axis is due to pulsatile gonadotropin-releasing hormone (gnrh) secretion by neurons of the nucleus arcuatus hypothalamus, with release into the pituitary portal system and subsequent stimulation of gonadotropinreleasing hormone receptors on the surface of gonadotropinsecreting cells. the gnrh gene is located on q . patients with gnrh defi cit have partial or complete absence of gnrh-induced pulsatile lh secretion, and normalization of pituitary and gonadal secretions after exogenous gnrh administration. imaging studies of the hypothalamo-hypophyseal region are normal. clinical symptoms vary with age at presentation (congenital or acquired) and severity (complete or partial defi cit). clinical presentations include delayed puberty, idiopathic hypogonadotropic hypogonadism (isolated gonadotropin defi cit), kallmann's syndrome, isolated fsh defi cit, and isolated lh defi cit (fertile eunuch syndrome). constitutional delayed puberty is assumed to be a minor form of gnrh defi cit, and is characterized by delayed sexual maturation in otherwise healthy males. patients are short and usually have a family history of delayed puberty. puberty usually begins at - years of age and progresses over years. if a -year-old boy has not begun pubertal changes (testicular enlargement, growth in height, and development of secondary sex characteristics), delayed puberty should be suspected. simple pubertal delay that is overcome naturally in a short time without treatment must be distinguished from hypogonadotropic hypogonadism. the latter should be suspected when any of the following symptoms are present in the patient or his family: a midline defect, anosmia, or pubic hair without testicular development. hormone assays may also assist in diagnosis. if a patient between and years old has prepubertal gonadotropin levels, he probably has hypogonadotropic hypogonadism. a variant of hypogonadotropic hypogonadism, isolated gonadotropin defi cit is characterized by defects in the synthesis or release of fsh and lh; other hypophyseal functions are normal. patients have eunuchoid phenotype, with small testes and penis, scanty body hair and beard, a high-pitched voice, and poorly developed muscles. presentation may be sporadic, autosomal dominant, autosomal recessive, or xlinked. the cause might be a mutation in the gnrh receptor gene. patients have very low levels of fsh, lh, testosterone, and estrogen. clomiphene citrate treatment fails to stimulate hormonal secretion. pulsatile administration of gnrh is useful to promote both androgen production and spermatogenesis. the lh-leydig cell-testosterone axis is normal in most cases, but normalization of the fsh-sertoli cell-inhibin axis is not achieved in all cases. basal inhibin levels higher than pg/ml and absence of cryptorchidism are favorable predictor factors for the acquisition of normal testicular size and acceptable spermatogenesis. testicular biopsy reveals an immature pattern. the seminiferous tubules have neither lumina nor elastic fi bers (fig. - ). sertoli cells are immature, and no differentiated leydig cells are seen. spermatogonia are rare. in some patients the pattern is similar to that of sertoli cell-only testes with immature sertoli cells. hypogonadism associated with anosmia is also known as maestre de san juan, kallman, abnormalities include olfactory bulb agenesis, cryptorchidism, mental retardation, color blindness, facial asymmetry, nerve deafness, epilepsy, shortening of the fourth metacarpal, tarsal navicular fi brous dysplasia, familial cerebellar ataxia, diabetes mellitus, hyperlipidemia, gynecomastia, cleft lip, maxillary or palate, unilateral renal aplasia, and cardiovascular abnormalities. the syndrome may be xlinked or autosomal. the gene for the x-linked form is mapped to xp . and may have different mutations (termed kal-x, kalig- , and admlx), complete deletion, and point mutations. this gene encodes the protein anosmina- , which is similar to other nerve cell adhesion molecules and is involved in axonal growth and development. kal protein, secreted by mitral cells, permits the passage of olfactory neurons into the olfactory bulbs and is lacking in kallmann's syndrome. this failure also inhibits migration of neuroblasts from the olfactory epithelium to the hypothalamus to form gnrh-secreting neurons. the autosomal dominant presentation (occurring in % of cases) is due to loss of function of fi broblastic growth factor receptor (fgfr ). interaction between kal and fgfr is required for neuronal migration. patients are classifi ed into two groups according to the partial or complete absence of gnrh. partial absence of gnrh is diagnosed by the presence of spontaneous pulses of lh, fsh, and testosterone during a -hour period. complete absence is diagnosed by the absence of spontaneous pulses of lh, fsh, and testosterone during a -hour period. these patients show an increase in fsh only after gnrh administration. testes are histologically infantile; the tubules have a small diameter, lack lumina, and contain immature sertoli cells and isolated spermatogonia. the interstitium is wide and consists of acellular connective tissue with no recognizable leydig cell precursors (fig. - ). autopsy studies in patients with anosmia and hypogonadism reveal agenesis of the olfactory bulbs that may be partial or complete and unilateral or bilateral, together with an apparently normal hypophysis and normal or hypoplastic hypothalamus. this syndrome is the least severe form of holoprosencephaly-hypopituitarism complex, a spectrum of developmental anomalies associated with impaired midline cleavage of the embryonic forebrain, aplasia of the olfactory bulbs and tracts, and midline dysplasia of the face. testicular seminoma has been reported in a patient with anosmia with hypogonadotropic hypogonadism. this rare syndrome is characterized by azoospermia or oligozoospermia in normally virilized patients with normal sexual potency. serum levels of lh and testosterone are normal, but fsh levels are very low or undetectable. the clomiphene stimulation test gives variable results. the gnrh test induces a normal response only of lh. mutations in the fsh-β gene are exceptional. , testicular biopsy shows maturation arrest at the spermatocyte level, hypospermatogenesis, or partial sertoli cell-only pattern. gonadotropin treatment increases spermatozoal numbers in most cases, and fertility may be induced. isolated lh defi ciency, also known as pasqualini's or fertile eunuch syndrome, , is characterized by hypogonadism secondary to lh defi cit with preservation of spermatogenesis. patients have eunuchoid habitus, small testes, decreased libido, female distribution of pubic hair, and a high-pitched voice. other frequent fi ndings include gynecomastia, anosmia, ocular lesions, and pituitary tumor. fsh level is normal, but lh and testosterone levels are very low. mutations in the lh-β subunit gene and the gnrh receptor have been reported. the clomiphene test is usually negative, and gnrh stimulation increases lh and, to a lesser degree, fsh. testicular biopsy shows seminiferous tubules with normal or slightly decreased diameters and complete spermatogenesis; however, the number of all germ cell types is below normal. leydig cells are rare or absent (fig. - ) . maintenance of spermatogenesis in the absence of leydig cells and serum testosterone can only be explained by assuming the occurrence of testosterone secretion suffi cient for spermatogenesis but not to be detectable in the blood. in addition to adequate hypothalamic function, spermatogenesis requires that fsh and lh are biologically active. lh is a heterodimer, composed of two subunits: α (common to fsh and lh) and β (specifi c for lh). the genes for the β subunit are on q . . if both alleles are mutated for this subunit, the lh produced in biologically inactive although it may be detectable in standard hormone assay. homozygous patients have elevated serum level of lh and low testosterone levels, lack of puberty, and infantile testes. heterozygous patients are only infertile. patients with mutation in the β subunit of the fsh gene are oligozoospermic or azoospermic. activating and inactivating mutations of gonadotropin receptor genes have been reported. activating mutation of the lh/human chorionic gonadotropin receptor gene causes familial precocious puberty (see discussion on familial testotoxicosis, below). inactivating mutation of this gene causes male pseudohermaphroditism (see discussion on leydig cell hypoplasia in this chapter). inactivating mutation of the fsh receptor gene produces only mild spermatogenetic lesions, emphasizing the relative value assumed for fsh in spermatogenesis. activating muta-tion of this gene gives rise to spermatogenesis even in the absence of pituitary function. patients with isolated growth hormone defi cit and those with resistance to growth hormone action may have delayed puberty and hypogonadotropic hypogonadism. some patients with spermatogenetic maturation arrest or idiopathic oligozoospermia have a relative defi cit of growth hormone. this hormone probably acts on the testis by stimulating local secretion of insulin-like growth factor- , which cooperates with testosterone. prader-willi syndrome is characterized by hypogonadism, obesity, muscular hypotonia, mental and physical retardation, and acromicria. other frequent fi ndings include strabismus and non-insulin-dependent diabetes mellitus. the incidence is estimated at between in and in newborns in live births, and is higher in males. patients have low serum levels of lh, testosterone, estradiol, and inhibin b, and high levels of fsh. these hormonal fi ndings suggest the occurrence of a mixed form of central (low lh) and peripheral (low inhibin b and high fsh) hypogonadism. the penis and testes are hypoplastic, and cryptorchidism is present in about % of cases (bilateral in % of cases) (fig. - ). during infancy and childhood, the testes have reduced tubular diameters; adults have an infantile pattern. this syndrome is caused by an anomaly of chromosome , usually in the p - band. other chromosomal anomalies include robertsonian translocations, reciprocal translocations, small supernumerary metacentric chromosomes, and partial deletion of the long arm of chromosome . this syndrome is a pleiotropic disorder characterized by obesity, infantilism, short stature, diabetes insipidus, mental retardation, retinitis pigmentosa, polydactyly, and syndactyly. it is more frequent in males than in females. men with this syndrome are infertile, and about % show hypogonadism. the testes are prepubertal, the scrotum is hypoplastic or bifi d, and the penis is small. cryptorchidism is found in % of males, and is bilateral in %. at least genes responsible for this syndrome have been cloned, and it is probable that additional genes are involved. the function of the products of these gene is to mediate and regulate microtubule-based transport processes. , hypogonadotropic hypogonadism associated with dermatologic diseases several dermatopathies are associated with hypogonadotropic hypogonadism, including ichthyosis and johnson's neuroectodermic syndrome. most cases of ichthyosis associated with hypogonadism are x-linked. about % of these patients have cryptorchidism, small testes, micropenis, and high risk of testicular cancer. the cause is a defective microsomal enzyme, steroid sulfatase, causing the accumulation of cholesterol sulfate that hinders sloughing of the cornifi ed layer of the epidermis. the gene responsible for this enzyme is mapped to xp , . some of these patients also have anosmia or hyposmia owing to involvement of the neighboring genes, causing a contiguous gene defect. johnson-mcmillin neuroectodermic syndrome is a rare autosomal dominant disorder characterized by alopecia, hypogonadotropic hypogonadism, anosmia or hyposmia, deafness, prominent ears, microtia and/or atresia of the external auditory meatus, and a pronounced tendency to dental caries. hypogonadism associated with ataxia is rare. most patients are the offspring of a consanguineous marriage. inheritance is autosomal recessive. the most frequent syndromes are louis-bar's syndrome (ataxia-telangiectasia) and friedreich's ataxia. ataxia-telangiectasia is the most common inherited ataxia and is characterized by cerebellar ataxia that starts in infancy and develops progressively; mucocutaneous telangiectasis; anomalies of the immune system that cause pulmonary infection; hypersensitivity to ionizing radiation owing to impairment of dna repair; and a high risk of lymphoid neoplasia. the gene responsible is on q -q . . this ataxia results from inactivation of the a-t mutated (atm) kinase, a critical protein kinase that regulates the response to dna double-strand breaks by selective phosphorylation of a variety of substrates. friedreich's ataxia is a neurodegenerative disorder characterized by degeneration of dorsal root ganglia and spinocerebellar tracts. hypertrophic myocardiopathy is also observed in many of these patients. the incidence is estimated at in children. it is caused by defects in the gene encoding frataxin, a protein required for vesicular traffi c in cell and synaptic transmission. about % of patients are homozygous for an unstable trinucleoid (gaa) expansion in intron of stm on q . the normal gene has up to or triplet repeats, whereas patients with this ataxia carry to more than gaa triplets. the normal gene has seven to gaa repeats, whereas the mutated gene has over repeats. the extent of the expanded allele is directly proportional to the severity of disease, early onset of disease, and development of cardiac abnormalities. other ataxias associated with hypogonadism are kearns-sayre, boucher-neuhauser, and gordon-holmes syndromes. hypogonadotropic hypogonadism may also be present in carpenter's, biemond's, fraser's, and moebius' syndromes, and in patients with mental retardation. maintenance of spermatogenesis requires the harmonious cooperation of several endocrine glands and proper functioning of other tissues. symptomatic endocrinopathy is present in only . % of infertile men, but over % of infertile patients have abnormalities in their endocrine studies. hypogonadism may be present in disorders involving the hypothalamus-hypophysis, thyroid, adrenals, pancreas, liver, kidney, and gastrointestinal tract, and may be associated with aids, chronic anemia, obesity, lysosomal and peroxisomal diseases, and neoplasia. hypogonadotropic hypogonadism can also be found in some (usually women) who perform rigorous sports (long-distance runners, swimmers, dancers, and rhythmic gymnasts). hypopituitarism hypogonadism may result from destruction of the hypothalamus or hypophysis by primary or secondary hypothalamic tumor; granulomatous disease ( fig. - ); fracture infertility of the cranial base; radiotherapy for malignancy of the nasopharynx, central nervous system, or the eye orbit; pituitary adenoma and cyst; aneurysm of the inner carotid artery; and chronic and nutritional disease. many of these processes cause panhypopituitarism with varied symptoms. clinical manifestations of hypogonadism in patients with pituitary lesions vary according to time of onset (childhood, or after puberty). in prepubertal hypopituitarism the testes retain an infantile appearance into adulthood, and there is rarely proliferation of spermatogonia and the development of primary spermatocytes. biopsy shows variable hyalinization of tubules. in postpubertal hypopituitarism the appearance ranges from complete spermatogenesis to tubular hyalinization ( fig. - ) . the presence of elastic fi bers in tubular walls indicates that pubertal maturation occurred before the development of hypopituitarism. leydig cells have pyknotic nuclei and retracted cytoplasm with abundant lipofuscin. in some patients, recovery of spermatogenesis occurs after administration of human chorionic gonadotropin. there are cases in which pituitary adenoma secretes both fsh and lh, inducing testosterone hypersecretion and an elevated sperm count. fsh-secreting pituitary adenoma associated with large testes and increased serum inhibin concentration has been reported. hyperprolactinemia prolactin inhibits gnrh secretion and hence fsh and lh secretion. in addition, prolactin has a direct inhibitory effect on androgens in target tissues. in men, hyperprolactinemia causes impairment of spermatogenesis, impotence, loss of libido, and depressed serum testosterone. some patients seek treatment because of oligozoospermia and infertility. hyperprolactinemia is also associated with dysfunction of prolactin receptors. spermiograms usually show oligozoospermia and an elevated level of fructose, although not all males with hyperprolactinemia have subnormal testicular function. testicular biopsy reveals variable testicular atrophy. the most frequent lesion is in the tubular adluminal compartment, with degenerative changes in the apical cytoplasm of sertoli cells, sloughing of young spermatids, and increased lipid droplets in leydig cells. in boys, two different conditions associated with abnormal prolactin secretion have been reported: hyperprolactinemia, testicular enlargement, and primary hypothyroidism; and prolactin defi ciency, obesity, and enlarged testes. infertility caused by thyroid gland malfunction is rare but reversible. it accounts for about . % of male infertility testicular function is impaired more by hypo-than by hyperthyroidism. patients with hyperthyroidism may have gynecomastia, impotence, and infertility. levels of fsh and lh serum are normal or increased, with elevated sex hormonebinding globulin, increased testosterone concentration, reduced non-sex hormone-binding globulin-bound testosterone, and little or no change in free testosterone. , in graves' disease there is a pronounced inhibition of gonadal steroidogenesis. in patients with hyperthyroidism, spermatozoa may be normal or reduced in number, and in both cases progressive motility is low. prepubertal hypothyroidism may impair testicular function by causing precocious or delayed puberty. in delayed puberty, hypothyroidism leads to hypogonadotropic hypogonadism, with testes showing incomplete maturation arrest and, in severe myxedematous hypothyroidism, hydrocele. in experimental hypothyroidism, testicular enlargement is frequently associated with increased spermatid production. primary hypothyroidism in adults causes hypergonadotropic, hypogonadotropic, or normogonadotropic hypogonadism, but testicular function is rarely impaired and patients are usually infertile. the cause of testicular damage is decreased gonadotropins or hyperprolactinemia. children with hypothyroidism usually have precocious pseudopuberty. about % of infertile patients reportedly have subclinical adrenal dysfunction, but the true incidence is probably lower. adrenal disorders most frequently associated with infertility are adrenal hypoplasia, adrenal hyperplasia, and adrenal carcinoma. congenital adrenal hypoplasia with hypogonadotropic hypogonadism is an x-linked recessive disorder that gives rise to adrenal insuffi ciency in the fi rst months of life. in later presentations, patients have cryptorchidism and delayed puberty. the responsible gene, dax on xp , is expressed in the adrenals, testes, pituitary, and hypothalamus. the resulting hypogonadism may be either pure or mixed (hypophyseal and testicular). in the last case, hypogonadism is partial. testicular biopsy from one adult with adrenal hypoplasia showed an apparent primary lesion, including tubules with dysgenetic sertoli cells and others with spermatogonial maturation arrest in associated with hypertrophy and hyperplasia of leydig cells. infertility is frequent in patients with minor forms of congenital adrenal hyperplasia. those with defi ciency of hydroxylase or β-hydroxylase usually have complete spermatogenesis but with reduced numbers of all germ cells. the characteristic histologic fi nding is decreased numbers of leydig cells. [ ] [ ] [ ] [ ] in untreated patients, the testes become enlarged by 'tumors' of the adrenogenital syndrome that consist of cells similar to adrenal cortical cells ( fig. - ). [ ] [ ] [ ] [ ] adrenal cortical carcinoma adrenal carcinoma is often associated with excessive secretion of several hormones, causing hyperaldosteronism, cushing's syndrome, virilization, or feminization. virilizing tumors in infancy have their own characteristics, which differ from those of the same adult tumors as the infantile form may be associated with other disorders, such as hemihypertrophy and beckwith-wiederman syndrome, may be included in the spectrum of 'families with cancer predisposition' (mutations in p gene), and produce precocious pseudopuberty syndrome. in adults, adrenal carcinoma may cause marked spermatogenic depletion owing to the conversion of large amounts of dehydroepiandrosterone produced by the tumor into estrogen. feminizing tumor in infancy causes gynecomastia and pubic hair development. feminizing tumor presents more striking clinical characteristics, including progressive loss of secondary sex characteristics and feminization due to elevated estrogen. testicular atrophy results from the inhibitory effect of estrogen on pituitary gonadotropins. similar symptoms may be observed in patients with prostatic carcinoma treated with estrogens ( fig. - ) and in other conditions with excessive estrogen production, such as sertoli cell or leydig cell tumor. patients with cushing's syndrome or diseases that require long-term corticoid therapy, such as ulcerous colitis, rheumatoid arthritis, or asthma, have reversible reduction of fertility. the explanation for this is that most testicular receptors for corticoids are in leydig cells, and thus glucocorticoids are powerful inhibitors of testosterone synthesis. alterations in the carbohydrate, lipid and protein metabolism characteristic of diabetes mellitus involve the genital system, although most diabetic patients are fertile. gonadal impairment depends on the type of diabetes and the time of disease onset (infancy and childhood, puberty, or adulthood). , testicular lesions in newborns with diabetic mothers are discussed in the section on congenital anomalies of the testis. puberty may be delayed in diabetic patients, although the cause is unknown. other gonadal alterations appear at puberty, and diabetic men who have not been adequately treated may be infertile and have sexual dysfunction. serum levels of fsh, lh, and testosterone are decreased. spermiograms reveal low numbers and poor motility of spermatozoa. prolactin levels are increased and testosterone levels low or near normal. the seminiferous tubules have reduced diameters, thickening of the lamina propria, and alterations in the adluminal compartment. these consist of degenerative changes in the sertoli cell apical cytoplasm and sloughing of immature germ cells. the major lesion is in the interstitial connective tissue and leydig cells. small interstitial blood vessels show diabetic microangiopathy characterized by enlargement and duplication of the basal lamina, pericyte degeneration, and endothelial cell alterations. the number of fi broblasts infertility and the amount of collagen and ground substance in the interstitial connective tissue are increased. leydig cells are decreased in number and show increased amounts of lipid droplets and lysosomes, accounting for the reduced function of these cells. the tubular lesions are attributed to low serum testosterone, probably owing to defi cient leydig cell stimulation by insulin (or a decrease in insulin-dependent fsh) and abnormal carbohydrate metabolism of sertoli cells. sexual dysfunction is present in more than half of patients and consists of impotence, decreased libido, disorders of intercourse, and retrograde ejaculation. the causes of impotence are multiple, including microangiopathy and macroangiopathy, hormonal defi ciencies, psychological factors, and autonomic neuropathy affecting the parasympathetic system. neuropathy is probably chiefl y responsible for erectile failure in diabetic men. alterations in sperm excretory ducts may be associated with diabetes. the most frequent are enlarged seminal vesicles and calcifi cation of both seminal vesicles and vasa deferentia. calcifi cations are found in the muscular layers and display a concentric arrangement (fig. - ). although cystic fi brosis (mucoviscidosis) was recognized as a disease prior to , its effects on the male genital system were not recognized until the s. this may be explained by improvements in medical care during childhood, allowing the survival of many patients to adulthood, and the recognition of cystic fi brosis in patients who had been diagnosed with chronic bronchitis and hepatic or digestive dysfunction. in the us, cystic fi brosis is the most lethal congenital disease, with a prevalence of in children, and a carrier status of in white men. lesions in sperm excretory ducts involve (in decreasing order of frequency) the vas deferens (congenital bilateral absence, unilateral absence), ejaculatory ducts (bilateral obstruction), epididymis (diffuse or segmental hypoplasia), and seminal vesicles (incomplete development). thus, it appears that most patients with cystic fi brosis have infertility due to obstruction. , histologic studies in children, even at an early age, reveal that the vas deferens and ductus epididymis are absent or reduced to small ductuli with reduced or absent lumina and thin, poorly muscular walls (fig. - ). the testes are normal during childhood, but show hypospermatogenesis and spermatid malformations by adulthood. the spermiogram is characteristic of obstructive azoospermia, with acid ph, decreased semen volume and fructose concentration, and increased citric acid and acid phosphatase. the disease is a genetic disorder with autosomal recessive inheritance. the impaired gene (cystic fi brosis gene) is on chromosome ( q ), and encodes a protein termed cystic fi brosis transmembrane regulator (cftr). alterations in this protein cause cystic fi brosis. although more than mutations of this gene have been identifi ed, the most frequent mutation in caucasians is d-f , responsible for % of cases. congenital bilateral obstructive azoospermia secondary to bilateral absence of the vas deferens, even in the absence of other symptoms, is often a forme fruste of cystic fi brosis. before initiating treatment for infertility, the possibility that the patient is a carrier of the cystic fi brosis gene should be evaluated. malformation of the genital system plays the most important role in infertility in cystic fi brosis. the lesions begin in the th week of gestation, when the wolffi an duct forms the sperm excretory ducts. variable penetrance of the cystic fi brosis gene accounts for the diversity of malformations affecting different regions of the male genital system. the liver has a primary role in metabolism, detoxifi cation, and excretion of sex steroid hormones. chronic hepatic failure damages the hypothalamo-hypophyseal-testicular axis, and subsequently all related endocrine glands. hypogonadism is frequent in the fi nal stages of severe chronic liver diseases, including alcoholism, non-alcoholic liver disease, and hemochromatosis. the association of testicular atrophy with gynecomastia and hepatic cirrhosis is well known and is referred to as silvestrini-corda syndrome. , alcohol has a direct toxic effect on leydig cells. acute alcoholic intoxication suppresses serum testosterone in voluntary non-alcoholic men and laboratory animals. chronic alcohol ingestion, even in the absence of cirrhosis, causes hypogonadism, with symptoms of leydig cell failure, including testicular atrophy, infertility, decreased libido, impotence, and reduced size of the prostate and seminal vesicles. chronic alcoholic patients with cirrhosis also have symptoms of hyperestrogenism, including gynecomastia, female escutcheon, and female fat distribution pattern. most chronic alcoholic men, with or without cirrhosis, have signifi cant testicular lesions. the seminiferous tubules have reduced diameters, thickened lamina propria, and decreased or absent germ cells. leydig cells are reduced in number and contain abundant lipofuscin granules ( fig. - ). the epididymis becomes atrophic, mainly in the ductuli efferentes, owing to androgen deprivation. the epithelium of the rete testis becomes cuboidal or columnar due to estrogens. the spermiogram correlates with the variability of histologic fi ndings, usually showing a marked reduction in the number and motility of spermatozoa and an increase in the percentage of morphologically abnormal spermatozoa. , about % of patients initially have an increase in serum testosterone; with advanced disease, testosterone level decreases. the initial increase is due to an elevation in sex hormone-binding globulin concentration and reduced testosterone metabolism by the liver. serum estrogen level also increases owing to increased conversion of testos-terone into estrogen in peripheral adipose and muscular tissue. non-alcoholic liver disease impairs gonadal function according to the severity of the disease. patients have decreased levels of total and biologically active free testosterone. hormonal alterations are not as severe as in alcoholic patients, emphasizing the direct action of alcohol on leydig cells. in α -antitrypsin defi ciency testicular function and fertility are conserved; only in advanced stages of the disease do minor biochemical alterations occur. in alagille's syndrome (intrahepatic biliary duct hypoplasia), hypogonadism is associated with cholestasis, frequent vertebral, cardiac, and facial malformations, and mental retardation. hypogonadism is manifest by small testes, delayed puberty, and, in adults, lack of germ cell development. hereditary hemochromatosis is the most frequent genetic disease in the northern hemisphere and results from excessive iron absorption and accumulation in multiple tissue and organs, leading to cirrhosis, diabetes, hypogonadism, and arthralgia. four types of hereditary hemochromatosis have been reported. type , the most frequent, is caused by mutation in the hfe gene (c y), leading to increased intestinal absorption of iron, supersaturation of iron deposits, and damage in multiples organs. the type i hereditary hemochromatosis gene (hfe) is located on the short arm of chromosome , , is present in - % of hemochromatosis patients with northern european ancestry, and its protein product is mainly expressed in the epithelium of lieberkühn crypts. this protein interacts with the transferrin receptor, reducing its affi nity for iron-bound transferrin; therefore, hfe becomes a negative regulator of transferrinbound iron uptake. type gene is a juvenile form that expresses before the age of years in both sexes, and is associated with severe cardiomyopathy and hypogonadism. the type hemochromatosis locus is on chromosome q , but this gene has not yet been isolated. , type is on chromosome q , impairs the transferrin receptor, and its consequences are similar to those of type receptor defect. type is autosomal dominant, on q , and affects the basolateral iron carrier ferroportin , resulting in iron deposition in macrophages. types , , and have recessive autosomal inheritance and show a similar distribution pattern of iron deposits. in these three types, alteration of gonadal function has also been reported. iron homeostasis depends on many genes that act in a coordinated manner, and their exact function is not well known. it is assumed that normal individuals absorb - mg/day of iron, whereas homozygous patients with hereditary hemochromatosis absorb up to - mg/day. once iron deposits become saturated (cells of liver, pancreas, hypophysis, heart, adrenals, and gastric mucosa), the toxic effects of iron cause dysfunction of the liver (cirrhosis and cancer in - % of patients), the pancreas (diabetes in % of patients), the heart (myocardiopathy), musculoskeletal system (arthritis), and hypophysis (hypogonadism) (fig. - ) . hypogonadism may be the fi rst sign of disease when it starts in adult life. with age, hypogonadism becomes hypogonadotropic, with low serum levels of testosterone, lh, and fsh in more than % of patients, except if early treatment is initiated. the most frequent fi ndings are testicular atrophy with diminished tubular diameter, tubular wall thickening, a progressive decrease in spermatogenesis, and increased lipofuscin granules in leydig cells. the cause of these testicular disorders might be preferential deposition of iron in gonadotropic cells. iron deposits are not observed in the testis. hypogonadism decreases after aggressive therapy. polycystic renal disease in adults is a dominant autosomal disorder that appears with in frequency in the general population. patients with this disease comprise % of end-stage renal failure cases. infertility is common, even before the beginning of renal insuffi ciency. oligoteratozoospermia and necrospermia are frequent fi ndings. , serum levels of fsh, lh, prolactin, testosterone, and estradiol remain normal for a long time before the onset of renal insuffi ciency. the causes of spermiogram alterations have been related to partial obstruction of ejaculatory ducts (based on fi nding cystic dilations in seminal vesicles in % of patients) or seminal vesicle cyst. the incidence of these two disorders in patients with polycystic renal disease is very high compared to andrological patients without this disease ( . %). chronic renal insuffi ciency is associated with disturbed endocrine function in the pituitary, thyroid, parathyroids, and testes. the associated sexual dysfunction consists of erectile impotence, diminution of libido and semen volume, oligozoospermia or azoospermia, and infertility. in children, skeletal development and puberty are delayed. hormonal studies reveal elevated levels of fsh, lh, and prolactin, but testosterone levels are low. testicular biopsy shows seminiferous tubules with reduced diameters and reduced or absent germ cells (fig. - ) . , the interstitium contains a normal number of leydig cells and increased numbers of macrophages. additionally, patients with chronic renal insuffi ciency due to glomerulonephritis have thickening of the tubular lamina propria and decreased number of leydig cells. patients with end-stage renal disease who undergo dialysis show calcifi cations in several organs and tissues, including the male genital system (epididymidis, tunica albuginea, and cavernous tissue) in % of cases, and, in isolated cases, calcifi cation of the testicular parenchyma and microlithiasis. elevated serum levels of phosphorus, increased calciumphosphorus product, severe hyperparathyroidism secondary to other disorders, older age, and prolonged time on dialysis contribute to this disorder. uremic calcifi cation is a cell-mediated process in which elevated levels of tgf, vitamin k-dependent proteins such as osteocalcin and atherocalcin, and defects in calcium-regulatory proteins such as fetuin are implicated. when these patients are dialyzed, accumulations of urate and oxalate crystals are deposited in the rete testes and ductuli efferentes. these crystals are deposited beneath the epithelium and often sloughed into the lumen. reactive changes in the rete testis, including cystic transformation, are frequent (see disorders of the rete testis). the cause of gonadal dysfunction is unclear and probably involves several factors, including impaired testicular steroidogenesis, reduced clearance of pituitary hormones, and secretory defects of the pituitary and hypothalamus. dialysis does not improve testicular function. the response to renal transplantation is not immediate and is related to the glomerular fi ltration rate. patients with rates lower than ml/min develop atrophy of the seminiferous tubular cells. hypogonadism is a frequent fi nding in men with celiac disease, and results in clinical symptoms in - % of untreated patients. celiac disease causes infertility in some cases. spermiograms show reduced motility and numerous morphologic anomalies in spermatozoa. hormonal studies show elevated serum fsh levels in more than % of men with celiac disease. lh also is increased in more than % of these men. the response of fsh and lh to gnrh stimulation is excessive. the cause of this pituitary derangement is unknown. sperm anomalies are not always corrected by a gluten-free diet. studies in patients with ulcerative colitis and regional enteritis reveal a low sperm count, impaired motility, and ultrastructural alterations, including nuclear pleomorphism and chromatin malcondensation and decondensation. zinc defi cit may be responsible for these alterations in crohn's disease. the alterations apparently are related to the extent of the intestinal lesions and the severity of symptoms. patients with ulcerative colitis treated with salazopyrine, mesalazine or fasalazine present with signifi cant impairment of spermatogenesis and subfertility. spermiogram parameters improve when treatment ceases. more than % of hiv-infected men have hypogonadism, which can be observed even in those whose viral replication is under control and show normal numbers of cd lymphocytes. patients frequently develop 'early andropause,' marked by dysregulation of the hypothalamopituitary-testicular axis. hypogonadism is more frequent in hiv-infected men with wasting syndrome, and therefore these patients should undergo screening for hypogonadism and, if necessary, physiologic androgen replacement therapy. [ ] [ ] [ ] [ ] the incidence of hypogonadism in males with aids is estimated to be %. , according to autopsy studies this increases to % in the - months prior to death. histological studies reveal that % have complete but quantitatively abnormal spermatogenesis, and the remainder have spermatocytic arrest or sertoli cell-only pattern. patients with chronic anemia requiring multiple transfusions develop iron deposits in the pituitary and polyglandular insuffi ciency, with atrophy of the thyroid, adrenals, and testes ( fig. - ) . the most frequent conditions are βthalassemia and sickle cell anemia (see fig. - ) . β-thalassemia is an autosomal dominant disease with three types: thalassemia trait (heterozygous β-thalassemia), intermediate thalassemia, and major β-thalassemia. the cause is mutation in the β-globin gene resulting in ineffective erythropoiesis, hemolysis, and anemia. nearly % of patients with major thalassemia have delayed puberty, [ ] [ ] [ ] and % have hypogonadotropic hypogonadism. gonadal dysfunction persists in most patients after healing of the thalassemia. sickle cell anemia is an autosomal recessive disorder with a constellation of fi ndings resulting from abnormal synthesis of hemoglobin, with over % of hemoglobin being type a. most patients have hypogonadotropic hypogonadism. the majority of people in developed countries are currently overweight, and the incidence of obesity seems to be increasing. infertility is frequently associated with obesity. very obese males have increased levels of serum estradiol and decreased levels of free testosterone and inhibin b. testosterone reduction is not followed by a compensatory increase in gonadotropins, resulting in hypogonadotropic hypogonadism. , testicular abnormalities begin with the adluminal compartment and later involve the basal compartment; also, there are leydig cell atrophy, cuboidal metaplasia of the rete testis, and epididymal atrophy. there are three types of autoimmune polyglandular insufficiency syndrome. type i is defi ned by the presence of at least two of three characteristic features: addison's disease, hypoparathyroidism, and chronic mucocutaneous candidiasis. the aire gene (autoimmune regulator), responsible for type l disease, is on q . , , and the disorder is recessive autosomal. hypergonadotropic hypogonadism is frequent. patients with type i syndrome have antibodies against many autoantigens, intracellular enzymes including the p side-chain cleavage enzyme, α-hydroxylase , and -hydroxylase, glutamic acid decarboxylase , aromatic l-amino acid decarboxylase, tyrosine phosphataselike protein ia- , tryptophan hydroxylase (tph), tyrosine hydroxylase, and cytochrome p a . type ii autoimmune polyglandular syndrome is characterized by the presence of diabetes mellitus, hyperthyroid- infertility ism, hashimoto's thyroiditis, addison's disease, vitiligo, alopecia, pernicious anemia, and hypogonadism (listed in decreasing order of frequency). type iii syndrome includes thyroiditis, diabetes mellitus, pernicious anemia, and vitiligo or alopecia. about % of patients have hypogonadism owing to autoimmune destruction of the testis or pituitary gonadotropin-secreting cells (fig. - ) . , there are at least four diseases caused by metabolic deposits in lysosomes or peroxisomes associated with testicular alterations, including fabry's disease, adrenal leukodystrophy, wolman's disease, and cystinosis. fabry's disease is an x-linked metabolic disorder characterized by intralysosomal deposits of globotriaosylceramide (gb ) owing to α-galactosidase defi ciency. clinical symptoms begin with painful neuropathy and progressive renal, cardiovascular, and cerebrovascular dysfunction. all endocrine glands may accumulate gb as a result of welldeveloped vasculature and low rate of cell proliferation. testes and sperm excretory ducts are always damaged. some alterations, including those of endothelial cells, smooth muscle cells, and fi broblasts, are non-specifi c; others, such as those of myofi broblasts, leydig cells, and epididymal epithelium, are specifi c (figs - , - ). spermatogenesis is defi cient. enzyme replacement therapy with recombinant human α-galactosidase eliminates existing glycosphingolipid deposits and blocks new ones, and is thus recommended for implementation as soon as possible after diagnosis. [ ] [ ] [ ] adrenoleukodystrophy (adrenal testicular myeloneuropathy) this disorder is caused by mutation in the adrenoleukodystrophy gene on xq . mutation at this site produces three peroxisomal diseases: adrenoleukodystrophy, adrenomyeloneuropathy, and addison's disease. adrenoleukodystrophy is characterized by progressive demyelinization of the central nervous system, usually in children and young adults, often with adrenal insuffi ciency and testicular failure. peroxisomal β-oxidation is defi cient and, as a result, very long-chain fatty acids accumulate inside peroxisomes in many tissues, causing the signs and symptoms of the disease. , adrenomyeloneuropathy begins at a later age (about years) with progressive paraparesis, peripheral neuropathy, and adrenal cortical failure. males usually have gonadal dysfunction with oligozoospermia or azoospermia and hypergonadotropic hypogonadism. testicular atrophy develops slowly, the seminiferous epithelium disappear, and leydig cells contain characteristic cytoplasmic lamellar inclusions, with similar inclusions in adrenal cortical cells and cerebral cells. wolman's disease is a rare inherited lysosomal disease characterized by a defi cit in acid lipase/cholesteryl ester hydrolase. the genetic mutation has been mapped to q . -q . . complete enzymatic defi ciency (wolman's disease) causes death in infancy as a result of the accumulation of cholesterol esters and triglycerides in numerous organs such as the liver, adrenal cortex, and intestines. partial defi ciency is known as cholesteryl ester storage disease, and the testis accumulates triglycerides and cholesterol in leydig cells and, to a lesser degree, in interstitial macrophages. delayed disruption of spermatogenesis by this storage disease probably accounts for the frequent lack of fertility problems in men with this disease. early treatment of children with wolman's disease by transplantation of umbilical cord blood-derived stem cells may successfully restore acid lipase level in some. cystinosis is an autosomal recessive metabolopathy characterized by alterations in cystine transport from the lysosomes to the cytosol that results in intralysosomal accumulation of cystine. there are several genes responsible, all on chromosome p . cystine storage occurs in all body tissues. deposits in the renal parenchyma cause the main complication of cystinosis, namely renal insuffi ciency (nephropathic cystinosis). patients also develop hypergonadotropic hypogonadism. testicular involvement may be massive, with interstitial macrophages fi lled with cystine crystals that are visible by polarized light. niemann-pick disease consists of a heterogeneous group of inherited recessive autosomal diseases characterized by deposition of lipids in macrophages and other tissues. there are four reported types (a, b, c, d). the most common, type a, results from excessive storage of sphingomyelin owing to a mutation in the acid sphingomyelin gene that encodes a lysosomal hydrolase, located on p . - region. interstitial macrophages in the testes have wide eosinophilic, granular cytoplasm. ultrastructural studies reveal a large number of lysosomes fi lled with laminate bodies. physical and chemical agents may impair testicular function by direct action on the pituitary, the testis, or the sperm excretory ducts. in the pituitary, damage to gonadotropic cells may be caused by estrogen. in the testes, gonadotoxic agents may selectively impair a select cell type, but later, global dysfunction occurs. for example, there is direct toxicity to sertoli cells by phthalates used as plasticizers, nitroaromatic compounds intermediate in the production of dyes and explosives, and γ-diketones used as solvents. direct toxicity on spermatogenesis is seen wtih ionizing radiation. many drugs that impair epididymal fl uid or spermatozoon transport damage sperm excretory ducts, with subsequent loss of fertility. the relationship between infertility or subfertility and certain professions or exposures to environmental agents is well known. adverse effects of the following agents on spermatogenesis has been demonstrated: organic solvents such as chlorinated solvents, aromatic solvents and varnishes, degreasers, thinners, and adhesives; this is also the case with carbon disulfi de exposure; pesticides such as ddt, linuron, and polychlorinated biphenyls; heavy metals such as lead, cadmium, mercury, and copper; industrial wastes such as dioxins and ethylene dibromide; phthalates and polyvinyl chloride; oral contraceptives; exposure to radiation or high temperature; and recreational drugs and doping. there is also a long list of potentially harmful agents that disrupt testicular function. carbon disulfi de is used as a solvent in the production of rayon. continuous exposure is toxic to the nervous system, and causes a decrease in spermatogenesis and libido and an increase in fsh and lh serum levels. , dibromochloropropane dibromochloropropane is used as a soil fumigant to control nematodes. lengthy exposure causes oligozoospermia, azoospermia, increased fsh and lh levels, and y-chromosome non-dysjunction. of the two natural forms of lead, organic and inorganic, the inorganic form is more dangerous. exposure to inorganic lead by workers in smelting, battery, and stained-glass plants causes direct spermatogenic damage. patients have asthenospermia, teratozoospermia, and oligozoospermia. , oral contraceptive manufacture workers in pharmaceutical plants using synthetic estrogens and progestins develop hyperestrogenism with gynecomastia, decreased libido, and impotence. neonatal exposure of males to diethylstilbestrol may induce cryptorchidism, testicular hypoplasia, epididymal cyst, and severe anomalies in semen production. there is increasing evidence to suggest that estrogen-like effects are produced by a variety of naturally occurring estrogens (so-called phytoestrogens) and numerous synthetic compounds such as phthalates, pesticides, and polychlorinated biphenyls. the principal methods of contact with potential endocrine-disrupting compounds is dietary ingestion of milk, fi sh, meat, fruits and vegetables, or environmental exposure. the increasing incidence of cryptorchidism, hypospadias, testicular cancer, and poor semen quality may be related to the negative infl uence of environmental factors on the testis during fetal life. the term 'testicular dysgenesis syndrome' has been proposed to designate this constellation of putative syndromes. estrogen exposure in utero may disrupt development of the testes and the entire male reproductive tract. estrogen may hinder fsh secretion by the fetal pituitary, and also interfere with subsequent sertoli cell proliferation, and hence the secretion of amh required for the regression of müllerian ducts. persistence of müllerian derivatives is associated with lack of testicular descent. changes in amh secretion may also account for altered germ cell proliferation during fetal life. exposure to high concentrations of estrogen might compromise testosterone production as well as masculinization of external genitalia (hypospadias) and inguinal descent of the testis (cryptorchidism). abnormal development of sertoli cells and low germ cell numbers could cause diminished spermatozoon production and infertility. marijuana decreases sperm density and motility and increases the number of morphologically abnormal spermatozoa. cocaine induces apoptosis in the rat testis ( fig. - ). about % of injection drug users have low serum testosterone levels. consumption of more than g alcohol per day adversely affects spermatogenesis in two-thirds of patients. women smoking more than cigarettes per day have fertility problems, neonatal and perinatal mortality, miscarriage, and congenital malformations. abuse of anabolic steroids by athletes causes hypogonadotropic hypogonadism and transient azoospermia. ionizing radiation causes alterations in spermatogenesis and hormonal regulation of the testes. some patients recover fertility a few years after exposure. the effects of non-ionizing radiation are less severe; however, reduced libido and reduced numbers of spermatozoa have been reported in men exposed to microwaves. heat normal intratesticular temperature is - °c, about - °c lower than core body temperature. conditions causing higher testicular temperature, such as varicocele and cryptorchidism, also cause testicular damage, with decreased numbers of spermatozoa and an elevated percentage of sper-matozoa with abnormal forms and low motility. , primary spermatocytes at the end of the pachytene stage are most sensitive to heat. the mechanism by which heat produces testicular lesions is unknown; hyperthermia affects the activity of enzymes such as ornithine decarboxylase and carnitine acetyl transferase, both necessary for metabolism and proliferation of the seminiferous tubular cells. the synthesis of dna and rna by germ cells also depends on temperature. dna synthesis by spermatogonia and preleptotene primary spermatocytes is higher at °c than at °c. rna and protein synthesis are normal at temperatures between °c and °c, but decrease markedly at °c. testicular trauma is especially frequent among athletes. trauma results in a wide variety of lesions, including contusion with or without hematocele, rupture, dislocation, and eventually spermatogenetic alteration that may lead to infertility. dislocation involves the displacement of one or both testes to a non-scrotal location , such as the inguinal canal, abdominal cavity, acetabular area, or distant locations such as the perineum, subcutaneous tissues, or superfi cial to the outer oblique fascia. , spermatogenetic recovery by orchidopexy has been successfully performed up to years after bilateral traumatic dislocation. sexual dysfunction is found in - % of patients who are treated for cancer. testicular cancer, hodgkin's disease, and leukemia are the most frequent malignancies during the reproductive years. therefore, preservation of fertility requires careful selection of less gonadotoxic therapeutic regimens; if paternity is planned, cryopreservation of semen before treatment may be considered. the most destructive treatments for gonadal function are radiation therapy and alkylating agents. the testicular parenchyma is one of the most radiosensitive tissues of the body, and the germ cells are the most radiosensitive cells of the testis. experimental irradiation of volunteers with a single dose revealed that late spermatogonia (ap and b) are more radiosensitive than early (ad) spermatogonia. ap and b spermatogonia may be destroyed with doses as low as . gy ( gy = rad), whereas ad spermatogonia tolerate doses higher than gy. type a spermatogonia, spermatids, and spermatozoa are respectively , , and times less radiosensitive than b spermatogonia. doses higher than gy produce a sertoli cellonly pattern. leydig cells tolerate up to gy and sertoli cells up to gy, although sertoli cells show ultrastructural alterations and increased phagocytosis of germ cell remnants after low doses of radiation. even with optimal protection, the contralateral testis absorbs from . to . gy in adjuvant therapy for rectal cancer or when the opposite testis is irradiated, a dose suffi cient to cause temporary azoospermia. likewise, irradiation of iliac or inguinal lymph nodes for hodgkin's disease or other forms of lymphoma exposes the testes to about gy. restoration of testicular function is time-dependent, requiring at least years. fertility in thyroid cancer patients who received radioiodine- ( i) therapy decreases briefl y, but infertility is not permanent. electromagnetic radiation from cell phones impairs spermatozoon motility according to one study. prepubertal testes also are sensitive to radiation therapy. patients treated for wilms' tumor may have delayed puberty and, at adulthood, oligoospermia or azoospermia with elevated levels of fsh; this fi nding suggests that leydig cells are also damaged. a special case is that of children with acute lymphoblastic leukemia involving the testis. radiotherapy with doses of - gy, either alone or with chemotherapy, causes irreversible damage to the seminiferous tubules and leydig cells. these patients develop azoospermia and hypogonadotropic hypogonadism with low serum testosterone ( fig. - ). widespread use of cytotoxic chemotherapy has created a number of adverse side effects, including gonadotoxicity. combination chemotherapy makes it diffi cult to ascertain which specifi c agent is responsible for azoospermia and leydig cell dysfunction. comparative studies of chemotherapy for acute lymphoblastic leukemia, extragonadal solid tumors, hodgkin's disease, ewing's sarcoma, and other soft tissue sarcomas in children and pubertal boys have shown that alkylating agents cause the most severe testicular damage. alkylating agents destroy the seminiferous tubular cells and induce tubular atrophy, shrinking the testis and increasing fsh serum concentration. these agents also impair leydig cell function, causing low testosterone, normal or elevated serum levels of lh, and an exaggerated response of lh to gnrh administration. testicular damage may be increased by combination with other agents (fig. - ). cyclophosphamide appears to be responsible for the greatest number of permanent or temporary cases of azoospermia after chemotherapy. this agent acts directly on the spermatogenic stem cells, and recovery depends on the number of surviving cells. in children, cyclophosphamide reduces seminiferous tubule diameter and germ cell numbers; in the residual spermatogonia nuclei are enlarged. puberty may progress, even during treatment, and the adult testis may show a sertoli cell-only pattern. in adults, cyclophosphamide treatment may cause irreversible testicular damage. administered alone, a dose of mg/m produces permanent azoospermia in % of men. if cyclophosphamide is administered with doxorubicin, vincristine, dacarbazine, or dactinomycin (drugs that alone do not cause azoospermia), doses of mg/m cause azoospermia in % of patients. fludarabine, used for the treatment of chronic lymphocytic leukemia, produces testicular damage with diminution of ejaculate volume, oligozoospermia, increase in serum levels of fsh and lh, and decreased testosterone level. dna in spermatozoa is markedly abnormal, an effect that persists for several months. procarbazine, used to treat hodgkin's disease, causes permanent azoospermia in % of patients, even when not combined with alkylating agents. patients treated with a combination of cyclophosphamide and procarbazine in the copp protocol (cyclophosphamide, vincristine, procarbazine, and prednisone) do not recover spermatogenesis even if the cyclophosphamide dose does not exceed mg/m . chemotherapy without both alkylating agents and procarbazine, such as the abvd (dexorubicin, bleomycin, vinblastine and dacarbazine) or vbm (vinblastine, bleomycin and methotrexate) regimens, produces reversible azoospermia in % of patients. the alternating use of mopp (mechlorethamine, vincristine, procarbazine and prednisone) and fig. - testis from a -year-old patient who, at the age of years, underwent surgery followed by radiotherapy for paratesticular rhabdomyosarcoma. the testicular biopsy shows post-irradiation lesions, including germ cell aplasia and peritubular and interstitial fi brosis. abvd treatments causes testicular dysfunction in % of patients, but spermatogenesis recovers in %. patients with germ cell cancer who received chemotherapy with bep regimens (cisplatinum, etoposide, and bleomycin) become azoospermic - weeks after starting treatment. when the total doses reaches mg/m , infertility is irreversible; at lower dosages, fertility might be recovered over a period of about ( % of patients) to ( %) years, although a high percentage of spermatozoa with dna abnormalities persists. an important consideration in patients with testicular cancer or hodgkin's disease is the existence of testicular dysfunction before treatment. in some series dysfunction is present at diagnosis in more than % of patients; its cause is unknown. proposed mechanisms include primary germ cell defi ciency, release of toxic substances by tumor cells, and alteration in the hypothalamo-hypophysealtesticular axis. sexual function is often lost in patients who undergo bilateral retroperitoneal lymph node dissection for nonseminomatous testicular cancer. up to % lose antegrade ejaculation, although libido, erection, and orgasm are normal. loss of antegrade ejaculation results from the removal of or injury to sympathetic ganglia and the hypogastric nervous plexus during surgery. unilateral surgery, especially if the left side is not operated on, reduces this complication. , hypospermatogenesis sometimes occurs after surgery for rectal cancer, perhaps due to vascular compromise. spinal cord injury is a frequent fi nding, with more than cases annually in the us, mostly in young adults. fertility is impaired in % of males with spinal cord injury. the major sexual dysfunctions in these patients are the lack of erection and ejaculation and poor semen quality. [ ] [ ] [ ] [ ] [ ] [ ] failure of ejaculation occurs in % of patients. semen may be obtained by means of vibratory stimulation of the penis or electroejaculation in more than %, but its quality is low, with increased numbers of dead spermatozoa, markedly low motility, and reduced fertilization rate. [ ] [ ] [ ] possible explanations include genitourinary tract infection, endocrine anomaly, and impaired spermatogenesis. recurrent infection occurs in - % of patients. compared to controls, a signifi cant increase in the numbers of neutrophils and macrophages occurs, with a marked increase in the production of reactive oxygen species. , this fi nding and the presence of elevated cytokine levels are assumed to be involved in pathogenesis. endocrine anomalies are transient, and hormonal levels return to normal after a few months. more than % of patients have abnormalities of the adluminal compartment of the seminiferous tubules, with variable degrees of immature germ cell sloughing; in % of patients the number of mature spermatids per cross-sectioned tubule is less than (normal > ). possible etiologies include an increase in testicular temperature due to vascular dilation, or an alteration in scrotal thermoregulation secondary to impaired sympathetic innervation from prolonged wheelchair restraint; alteration in sperm transport secondary to nerve injury, resulting in sperm stagnation in seminal vesicles, a hostile environment that normally is devoid of spermatozoa; and abnormal composition of seminal fl uid, causing deterioration of spermatozoa that in the epididymis and ductus deferens had good motility. more than % of patients with spinal cord injury have brown-tinged semen in some ejaculations. although the cause is unknown, it might be related to seminal vesicle dysfunction. when spermatozoa cannot be obtained by electroejaculation or vibratory stimulation, vasal aspiration or testicular biopsy are recommended. most patients have at least a few mature spermatids in some seminiferous tubules; therefore, testicular sperm extraction followed by intracytoplasmic sperm injection is a reasonable consideration in azoospermic patients. infectious agents may reach the testis and epididymis through blood vessels, lymphatics, sperm excretory ducts, or directly from a superfi cial wound. infection transmitted through the blood mainly affects the testis and causes orchitis, whereas infection ascending through the sperm excretory ducts usually causes epididymitis. acute infl ammation is accompanied by enlargement of the testis or epididymis. the tunica albuginea is covered by a fi brinous exudate, and the testicular parenchyma is yellow or brown. bacterial infection may cause abscess. in some cases the infection begins to heal, with the deposition of granulation tissue and fi brosis; in others, the infection may persist as an active process for a long time, resulting in chronic orchidoepididymitis. the most frequent causes of viral orchidoepididymitis are mumps virus and coxsackie b virus. other viral infections that occasionally cause acute orchitis include infl uenza, infectious mononucleosis, echovirus, lymphocytic choriomeningitis, adenovirus, coronavirus, bat salivary gland virus, smallpox, varicella, vaccinia, rubella, dengue, and phlebotomous fever. subclinical orchitis probably occurs during other viral infections (fig. - ) . before vaccination was commonly used, mumps orchidoepididymitis complicated - % of adult mumps cases and was bilateral in - % of cases. nevertheless, miniepidemics still occasionally occur. , as expected, the incidence remains high in countries where vaccination is not obligatory. in about % of cases of mumps orchitis the epididymis is also involved, but epididymal involvement alone is rare. clinical symptoms of orchitis usually appear - days after symptoms of parotiditis, but orchitis may also appear without parotid involvement. testicular involvement is multifocal, and consists of acute infl ammation of the interstitium and seminiferous tubules. the tubular lining is destroyed, and eventually only hyalinized tubules and clusters of leydig cells remain. with time, the testes shrink and become soft. if the infection is bilateral the patient is usually infertile, with severe oligozoospermia or azoospermia, although biopsy may reveal the presence of mature spermatids in some tubules, allowing sperm extraction for paternity. if only one testis was affected, the sperm concentration may be normal or slightly decreased and fertility is maintained. occasionally the testicular damage is so severe that testicular endocrine function is impaired, causing hypergonadotropic hypogonadism, with low testosterone levels and regression of secondary sex characteristics. mumps orchidoepididymitis is infrequent in childhood. most bacterial orchitis is associated with bacterial epididymitis. orchitis secondary to suppurative epididymitis caused by escherichia coli is most common. on light microscopy, the tubules are effaced by intense acute infl ammation. chronic orchitis with microabscesses is caused by e. coli, streptococci, staphylococci, pneumococci, salmonella enteritidis, and actinomyces israeli. , in some cases of chronic bacterial orchitis, the testis contains an infl ammatory infi ltrate consisting of numerous histiocytes with foamy cytoplasm (xanthogranulomatous orchitis) (fig. - ) , similar to that of idiopathic granulomatous orchitis but lacking intratubular giant cells. rarely, as in whipple's disease, large numbers of bacilli are present in histiocytes in the interstitium, vascular walls, and seminiferous tubules. the most frequent complications of pyogenic bacterial orchidoepididymitis are scrotal pyocele and chronic draining scrotal sinus. small fragments of testicular parenchyma may be eliminated through the scrotal skin, known clinically as fungus testis. another complication is testicular infarct, resulting from compression or thrombosis of the veins of the spermatic cord, in the scrotal neck, or the superfi cial inguinal ring. most cases of chronic orchidoepididymitis are associated with granulomas in the testis. specifi c causes may require special stains, cultures, or serologic tests, and include tuberculosis, syphilis, leprosy, brucellosis, mycoses, and parasitic diseases. in sarcoidosis and idiopathic granulomatous orchitis, the agent is unknown. the incidence of tuberculous orchidoepididymitis declined after the development of effective antibiotics, but it has recently undergone a resurgence among people who have emigrated from countries with a high incidence of the disease and the increasing population of immunologically compromised patients. most cases of tuberculous orchidoepididymitis are associated with involvement elsewhere in the genitourinary system. tuberculous epididymitis is usually the result of ascent from tuberculous prostatitis, which in turn is often secondary to renal or pulmonary tuberculosis. the pattern of spread is different in children: more than half have advanced pulmonary tuberculosis, and the testis is infected through the blood. more than % of patients with renal tuberculosis develop tuberculous epididymitis, and orchitis occurs in approximately % of patients with genital tuberculosis, usually secondary to epididymal tuberculosis. it has been suggested that some cases of tuberculous orchidoepididymitis are sexually transmitted. tuberculous orchidoepididymitis occurs mainly in adults: % of patients are older than years, and % are over years. the signs and symptoms may be mild, consisting only of testicular enlargement and scrotal pain. in such cases, fever is infrequent and constitutional symptoms may be absent. histologically, there are typical caseating and noncaseating granulomas that destroy the seminiferous tubules and interstitium (figs - , - ). in immunosuppressed patients, the granulomas consist of epithelioid histiocytes and a few lymphocytes with rare giant cells. acid-fast bacilli tend to be more numerous in immunosuppressed patients. similar lesions may be observed in orchidoepididymitis caused by bacillus calmette-guérin, which is usually used for intravesical instillation in patients with vesicular urothelial carcinoma. syphilis syphilitic orchitis may be congenital or acquired. in congenital orchitis, both testes are enlarged at birth. the histological fi ndings are similar to those of the interstitial orchitis of acquired syphilis. if diagnosis is delayed until puberty, the testis often shows retraction and fi brosis. in adults, acquired orchitis is a complication of the tertiary stage of syphilis and has two characteristic histologic patterns: interstitial infl ammation and gumma. early in the disease, patients with interstitial orchitis have painless enlargement. grossly, the parenchyma is gray with translucent areas. histologically, plasma cells are abundant. the infl ammation begins in the mediastinum testis and testicular septa, later extending through the parenchyma as the seminiferous tubules lose their cellular lining and undergo sclerosis. initially, the arteries show an obliterans type of endarteritis. small gummas may be observed. eventually, the infl ammation subsides and is replaced by fi brosis. the epididymis is usually not affected. gummatous orchitis is characterized by the presence of one or several well-delineated grossly gray-yellow zones of necrosis. histologically, ghostly silhouettes of seminiferous tubules are visible within the gumma, surrounded by infl ammation consisting of lymphocytes, plasma cells, and scattered giant cells. in most cases spirochetes may be demonstrated histochemically with warthin-starry silver stain, but the most specifi c diagnostic technique is genetic testing. the testis may be infected in patients with lepromatous or borderline leprosy. frequent involvement of the testis in lepromatous leprosy results from the low intrascrotal temperature that promotes growth of the bacilli. orchitis is usually bilateral, although the degree of involvement may differ between the testes. occasionally, testicular involvement may be the sole indication of the infection, and the diagnosis may be made by testicular biopsy. the histologic fi ndings in the testis vary with the duration of the infection. initially, there is perivascular lymphocytic infl ammation and interstitial macrophages that contain numerous acid-fast bacilli. later, the seminiferous tubules undergo atrophy, the leydig cells cluster, and blood vessels show endarteritis obliterans. finally, the testis is replaced by fi brous tissue with a few lymphocytes and macrophages containing acid-fast bacilli. most patients with lepromatous leprosy are infertile, even if the orchitis was clinically mild. , brucellosis brucellosis is common in some parts of the world, including the middle east. , orchitis occurs in some patients and may be the fi rst sign of disease. brucellosis should be suspected when testicular enlargement occurs in patients with undulating fever, malaise, sweats, weight loss, and headache. occasionally this may mimic testicular tumor. histologically, there is a dense lymphohistiocytic infl ammation with occasional non-caseating granulomas in the interstitium. the seminiferous tubules are infi ltrated by infl ammatory cells and undergo atrophy. diagnosis is made by clinical and laboratory fi ndings, including blood culture, the bengal rose test, and high brucella agglutination titers, , or by real-time polymerase chain reaction assay of urine. sarcoidosis is a systemic granulomatous disease of unknown etiology that preferentially affects young black adults. the genitourinary tract is involved in only . % of clinical cases and % of autopsy cases. fewer than cases of primary epididymal involvement have been reported, and about of these also involved the testis. , isolated testicular involvement is exceptional. , , testicular sarcoidosis is usually unilateral and nodular. it is often asymptomatic and found at autopsy. the testis contains non-caseating granulomas similar to sarcoid granulomas at other locations. before diagnosing testicular sarcoidosis, other granulomatous lesions should be excluded, including tuberculosis, sperm granuloma, granulomatous orchitis, and seminoma. seminoma often has an intense sarcoid-like reaction, and examination of multiple histologic sections may be necessary to fi nd diagnostic foci of seminoma. an association of mediastinal sarcoidosis and testicular cancer has been reported. genital involvement of sarcoidosis may be the cause of intermittent azoospermia that benefi ts from corticoid therapy. malakoplakia is a chronic infl ammatory disease that was initially described in the bladder and subsequently in many other organs. the testes (alone or together with the epididymis) are involved in % of cases involving the urogenital system. , grossly, the testes are enlarged and have a brown-yellow parenchymous discoloration, often with abscesses. malakoplakia causes tubular destruction that is associated with a dense infi ltrate of macrophages with granular eosinophilic cytoplasm that often contains michaelis-gutmann bodies (fig. - ) . , the differential diagnosis includes idiopathic granulomatous orchitis and leydig cell tumor. infl ammation in idiopathic granulomatous orchitis includes intratubular multinucleate giant cells; in malakoplakia it is diffi cult to identify the tubular outlines, and giant cells are usually absent. leydig cell tumor is not usually associated with infl ammation, but may contain mononucleated or binucleated cells with abundant eosinophilic cytoplasm. reinke's crystalloids are identifi ed in up to % of cases of leydig cell tumor but absent in malakoplakia, and michaelis-gutmann bodies are absent. fungal orchitis is rare; most cases are associated with blastomycosis, coccidiomycosis, histoplasmosis, and cryptococcocis. the genital tract may be involved in widespread blastomycosis. in decreasing order, the organs most frequently affected are the prostate, epididymis, testis, and seminal vesicles. grossly, there often are small abscesses that may have caseous centers. fungi measuring - µm in diameter with double refringent contours are present in the giant cells in granulomas and stain positively with periodic acid-schiff and methenamine silver stains. coccidioidomycosis is endemic in california, the southwestern united states, and mexico, and may present as epididymal disease after remission of systemic symptoms. the granulomas are similar to those of tuberculosis and contain - µm sporangia with endospores that stain with periodic acid-schiff. dissemination of histoplasmosis and cryptococcosis frequently occurs after steroid therapy and may give rise to granulomatous orchitis with extensive necrosis. histoplasma capsulatum measures - µm in diameter and may be demonstrated with silver stain. cryptococcus is identifi ed by its thick wall that stains with mucicarmine. most parasites that reach the genital tract, such as phyllaria and schistosoma, are in the spermatic cord, and testicular lesions are secondary to vascular injury. testicular infection has also been reported in patients with visceral leishmaniasis, congenital and acquired toxoplasmosis ( fig. - ) , echinococcus infection, and orchitis due to trichomonas vaginalis. idiopathic granulomatous orchitis is a chronic infl ammatory condition of older adults (mean, . years). the most prominent clinical symptom is testicular enlargement, suggesting malignancy. most patients have a history of scrotal trauma, % have symptoms of urinary tract infection with negative cultures, and % have sperm granuloma in the epididymis. an autoimmune etiology has been suggested. the testis is enlarged, with a nodular cut surface and areas of necrosis or infarction. there are two histologic forms, according to whether the lesion is predominantly in the tubules (tubular orchitis) or the interstitium (interstitial orchitis). in tubular orchitis, germ cells degenerate and the sertoli cells have vacuolated cytoplasm and vesicular nuclei. plasma cells and lymphocytes infi ltrate the walls of the seminiferous tubules, forming concentric rings. multinucleated giant cells are present in the tubular lumina and sometimes in the interstitium (fig. - ). vascular thrombosis and arteritis are common. in interstitial orchitis, the infl ammation is predominantly interstitial. ultimately, tubular atrophy and interstitial fi brosis prevail in both forms, which may arise from different immune mechanisms. tubular orchitis histologically resembles experimental orchitis caused by injection of serum from animals with orchitis, whereas interstitial orchitis resembles orchitis produced by the transfer of cells from immunized animals. the differential diagnosis of idiopathic granulomatous orchitis is infectious orchitis caused by bacteria, spirochetes, fungi, or parasites. a useful clue in the tubular form is the presence of giant cells within seminiferous tubules. the occurrence of focal lymphoid cell infi ltrates in the testicular interstitium is common in infertile patients, , patients who have undergone surgery for bilateral inguinal hernia, vasectomized patients who developed post-infection obstruction, after testicular piercing, and cryptorchidism. infl ammatory infi ltrates usually involve the seminiferous tubules, and this suggests the disorder is due to an immunologic response (fig. - ). pseudolymphoma is a benign reactive process with a lymphoid cell proliferation so intense that it may be mistaken for lymphoma. testicular pseudolymphoma consists of infl ammatory infi ltrates with numerous lymphocytes and plasma cells that partially or totally destroy testicular parenchyma. , the differential diagnosis includes lymphoma, various forms of orchitis, and seminoma. the diagnosis of lymphoma may be excluded by the lack of atypia and polyclonal nature of the infl ammation. syphilitic orchitis also contains a plasma cell-rich infl ammatory infi ltrate, but pseudolymphoma does not have other characteristic features of syphilitic orchitis, such as endarteritis obliterans; spirochetes cannot be demonstrated by special stains. the lack of granulomas or signifi cant numbers of macrophages, together with the negative results of specifi c histochemical stains, also helps to exclude idiopathic granulomatous orchitis, tuberculosis, leprosy, sarcoidosis, and fungal infection. finally, although the presence of a prominent infl ammatory infi ltrate and, in many cases, numerous lymphoid follicles, may suggest the diagnosis of seminoma, the presence of seminoma cells should be easily demonstrated with best's carmine stain, periodic acid-schiff, or placenta-like alkaline phosphatase. the term plasma cell granuloma refers to a reactive process characterized by the presence of polyclonal adult plasma cells that are absent in testicular plasmacytoma. sinus histiocytosis with massive lymphadenopathy (rosai-dorfman disease) is a benign proliferation of macrophages that uniquely contain numerous lymphocytes in their cytoplasm. the disease was reported in a kidney and testis of a patient in remission from malignant lymphoma in association with monoclonal iga gammopathy, and in a second patient with diabetes mellitus who had been previously treated for pulmonary tuberculosis. increased numbers of interstitial macrophages may also be observed in more than two-thirds of autopsies from adult patients, but the cause is unknown. one condition associated with this disorder is treatment with hydroxyethylstarch plasma expander. in this lesion, the interstitial macrophages stand out by virtue of their large size and multivacuolated cytoplasm, suggesting thesaurosis. there is no evidence of mucin glycoproteins, proteoglycans, starch, lipids, glycogen, or foreign body material. most patients have no clinical symptoms other than pruritus and persistent erythrema. epididymitis nodosa is a proliferation of small irregular ducts whose epithelium lacks the characteristic features of the epididymal epithelium. the disorder is associated with infl ammation and fi brosis, similar to vasitis nodosa. in several tissues, including the testis, amiodarone is concentrated up to times its plasma level, causing testicular atrophy and increased serum levels of fsh and lh in some patients. the incidence of epididymitis during amiodarone therapy varies from % to %, , and more than cases (in several cases involvement was bilateral) have been reported, although there are probably many others. , the disorder may occur at any age. when amiodarone dosage is reduced to mg/day the epididymitis heals within a few weeks. autopsy studies show focal areas of fi brosis and lymphoid cell infi ltrates not related to infection. recognition is important to avoid unnecessary antibiotics or aggressive surgery. this term describes a lesion located in the epididymal head characterized by non-infectious necrosis with polypoid masses of infl amed granulation tissue in peripheral ductal structures. granulomas containing multinucleated giant cells present within efferent ductuli or form sperm microgranulomas with ductal neoformation similar to that of epididymitis nodosa. the cause is unknown, but may result from ischemia. the terms 'testicular calculus' and 'stone in the testis' have been used to describe a lesion characterized by the presence of nodular testicular calcifi cation that is not related to ischemia, orchitis, vasculitis, hematoma, or tumor. , the testicular arteries may be affected by systemic disorders such as schönlein-henoch purpura, wegener's disease, , kogan's disease, behçet's disease, relapsing polychondritis, rheumatoid arthritis, and dermatomyositis, but the most frequent involvement is with polyarteritis nodosa. approximately % of patients with polyarteritis nodosa have testicular or epididymal involvement, but only - % are diagnosed during life. rarely, testicular or epididymal polyarteritis nodosa is the fi rst manifestation of the disease. in these cases the symptoms may suggest orchitis, epididymitis, testicular torsion, or tumor. [ ] [ ] [ ] the testis usually shows arterial lesions in different stages of evolution, including fi brinoid necrosis, infl ammatory reaction, thrombosis, or aneurysm. the parenchyma initially has zones of infarction ( fig. - ). histologic and immunohistochemical fi ndings similar to those of polyarteritis nodosa may occasionally be observed in the testis or the epididymis without lesions elsewhere; this condition is referred to as isolated arteritis of the testis and epididymis, and differs from classic polyarteritis by a lack of vascular thrombosis, aneurysm, or infarct. the etiology of isolated arteritis is unknown, but the prognosis is excellent. the histologic fi ndings of necrotizing arteritis in the testis or epididymis should be followed by clinical, hematologic, and biochemical studies to exclude systemic arteritis. , torsion of the spermatic cord is the most frequent cause of testicular infarct, followed by trauma, incarcerated inguinal hernia, epididymitis, and vasculitis. spermatic cord torsion is a surgical emergency. if repair is delayed more than hours, testicular viability is usually compromised. this disorder may appear at any age, but the other testicular and epididymal lesions peaks of maximal incidence are the perinatal period and puberty. factors that predispose to testicular torsion are anatomical anomalies in testicular suspension and abnormal position of the testis. many men with testicular torsion have an abnormally high refl ection of the tunica vaginalis, giving rise to the deformity known as 'bell-clapper.' other anomalies include elongated mesorchium, separation between the epididymis and testis, and absent or very elongated gubernaculum. the frequency of testicular torsion is higher in cryptorchid and retractile testes than in normal testes. there are two classic anatomic forms of testicular torsion: high (supravaginal or extravaginal) and low (intravaginal). each appears at a different age. extravaginal torsion typically occurs in infancy and childhood, whereas intravaginal torsion is more frequent at puberty and adulthood. neonatal torsion is bilateral in - % of cases. most torsion observed on the fi rst of life is intrauterine. pubertal and adult torsion causes testicular pain that may radiate to the abdomen or other sites. about % of patients have a previous history of pain or swelling in one or both testes. the differential diagnosis includes all causes of acute scrotum. , torsion causes hemorrhagic infarction of the testis ( fig. - ). in old neonatal torsion, the histological fi ndings are so advanced that only collagenized tissue containing calcium and hemosiderin deposits is seen. in adults, three degrees of histological lesion may be distinguished. degree i ( . % of adult twisted testes) is characterized by edema, vascular congestion, and focal hemorrhage. seminiferous tubules are dilated, with sloughed immature germ cells, apical vacuolation of sertoli cells, and dilated lymphatic vessels. degree ii ( . % of testes) has pronounced interstitial hemorrhage and sloughing of all germ cell types in the seminiferous tubules. the lesion is more severe in the center of the testis, and thus biopsy might provide erroneous information (fig. - ). degree iii lesions ( % of testes) are characterized by necrosis of the seminiferous tubular cell layers. there is often a correlation between the time interval of torsion and the degree of the histologic lesion. degree i appears in torsion of less than hours' duration, degree ii in torsion of between and hours, and degree iii in torsion of more than hours. nevertheless, there are some exceptions that could probably be related, among other factors, to the number of twists in the torsed spermatic cord (degrees of testicular rotation). the testicular salvage rate, defi ned as testicular growth and development that refl ects the age of the patient and the contralateral testis, is around % in all cases of testicular torsion. testes that do not bleed into the albugineal incision within minutes are assumed to be non-viable and should be removed. little attention has been paid to intermittent testicular torsion. early orchiopexy may save these testes, but after surgery, the testis becomes small and excessively mobile, and most have the bell-clapper deformity. seminiferous tubules are devoid of germ cells and have hyalinized walls. some adults with untreated testicular torsion develop lipomembranous fat necrosis of the spermatic cord. patients seek help for pain in the high scrotum. at this level, there is a small nodule that corresponds to remnants of the twisted testis. the epididymis and proximal spermatic cord characteristically contain fat necrosis (fig. - ) . adults with prior spermatic cord torsion often consult for infertility. the mechanism causing spermiogram alteration is controversial, and three hypotheses have been proposed: • autoimmune process. it has been suggested that the ischemic injury breaks the blood-testis barrier, and antigens released from the necrotic germ cells activate macrophages and lymphocytes in the interstitium, stimulating the formation of antibodies against these antigens. these antibodies that enter in the blood circulation may presumably damage the contralateral testis. • alterations in microcirculation. after testicular torsion, blood fl ow decreases in the contralateral testis, causing an increase in the characteristic products of hypoxia, such as lactic acid and hypoxanthine. intense apoptosis involving mainly spermatocytes i and ii has been observed. long-term effects are yet unknown. • primary testicular lesions. many twisted testes have lesions that cannot be formed in a few hours, such as hypoplastic tubules, microlithiasis, and focal spermatogenesis. in addition, more than half of biopsies of the contralateral testis show marked spermatogenetic lesions. these fi ndings suggest that torsion occurs in testes with congenital lesions. trauma and lesions of the vessels of the spermatic cord may also cause testicular infarct. ischemic atrophy is a risk of inguinal surgery, including herniorrhaphy, varicocelectomy, hydrocelectomy, and descent of cryptorchid testis ( fig. - ). the incidence of atrophy after inguinal herniorrhaphy varies from . % in primary herniorrhaphy to . % after surgery for recurrent herna, depending on the diffi culty and extent of the hernia. atrophy occurs in some cases of thrombosis of the vena cava or spermatic artery. focal infarction of the testis is associated with polycythemia, sickle cell disease, trauma, , and laparoscopic inguinal hernia repair. focal infarction may also be spontaneous. clinical symptoms of testicular infarct mimic testicular tumor. color doppler ultrasound reveals the diagnosis in most cases. cystic malformation of the tunica albuginea and testicular parenchyma was fi rst described in the th century, and was long considered rare and mainly present in the tunica albuginea. , with the systematic use of ultrasonography, the incidence of cysts has been found to be much higher: non-neoplastic cysts are found in . % to . % of testes. , cyst of the tunica albuginea is usually an incidental fi nding in patients in the fi fth or sixth decade of life. it is located in the anterolateral aspect of the testis and may be unilocular or multilocular, ranging from to mm and containing clear fl uid without spermatozoa. the cyst may be embedded within the connective tissue of the tunica albuginea, protrude from the inner surface of the tunica albuginea into the testicular parenchyma, or protrude from the outer surface forming a blue lump in the tunica albuginea. the epithelium lining the cyst may be simple columnar or stratifi ed cuboidal, and is supported by a thin layer of collagenized connective tissue. the columnar epithelium usually includes some ciliated cells, and the cuboidal epithelium is composed of two layers of non-ciliated cells (fig. - ) . cyst of the rete testis is identifi ed by a distinctive epithelial lining of areas of fl attened cells intermingled with areas of tall columnar cells. spermatozoa are frequently found within the cyst, and hence the cyst is also called intratesticular spermatocele. it may be associated with cystic transformation of the rete testis and multiple epididymal cysts. rete testis cyst is not always attached to the rete and may be found at a distance. simple cyst of the testis constitutes the remaining intraparenchymal cyst. it is usually lined by cuboidal epithelium and contains no spermatozoa. , simple cyst ranges other testicular diseases from nm to mm in diameter. , the disorders occurs at any age, from months to years, with a bimodal distribution with peaks at month and years. it may occur bilaterally, and may present as two cysts in the same testis. origin of the three types of testicular cyst is uncertain. previously, traumatic and infl ammatory origins were attributed to tunica albuginea cyst, but most now believe that they are derived from embryonal remnants of the mesonephric ducts , or mesothelial cells embedded in the tunica albuginea during embryogenesis. , , simple cyst of the testis may also have a mesothelial origin, but it is possible that some arise from ectopic rete testis epithelium. these cysts are unrelated to epidermoid cyst, differing in the ultrasonographic , and histologic features (see discussion on cystic dysplasia and testicular tumors in the section on hamartomatous testicular lesions). ultrasound studies indicate that testicular cyst has little potential for growth. , currently, excision is recommended only in children when the cyst may impair testicular development. dysgenesis of the rete testis is characterized by inadequate maturation and persistence of infantile or pubertal characteristics in adults. this disorder is frequent in undescended adult testes. the lesion involves the rete testis segments referred to as septal, mediastinal, and extratesticular. there is poor development of the cavities and their epithelial lining, which becomes cuboidal or columnar instead of fl attened with areas of columnar cells. the lumina of the rete testis cavities may be completely absent (simple hypoplasia) or, conversely, undergo microcystic dilation (cystic hypoplasia). in a few cases, the rete testis develops papillary, cribriform, or tubular formations (adenomatous hyperplasia). the epithelium of the rete testis is usually fl attened, with scattered areas of columnar cells. in estrogen-treated patients, those with chronic hepatic insuffi ciency, functioning tumor that secretes estrogens or human chorionic gonadotropin, and other disorders that are described as hyperplasia of the rete testis it may undergo diffuse transformation into tall columnar epithelium. except for the latter group, metaplasia of the rete testis seems to be an estrogen-dependent process, and estrogen receptors are present in the rete testis epithelium. acquired cystic transformation of the rete testis is common, and its incidence increases with age and associated disorders. ultrasound ultrasound , and magnetic resonance studies reveal characteristic images that may suggest malignancy. the lesion has three forms: simple, associated with epithelial metaplasia, and with crystalline deposits. simple cystic transformation consists of dilated cavities with normal epithelium. it results from obstruction of the epididymis or the initial portion of the vas deferens due to ischemia (aging men); compression by epididymal and spermatic cord tumor, or by congestive veins in varicocele; infl ammation in patients with previous epididymitis; malformation (testis-epididymis dissociation, malformed epididymis and absence of the vas deferens); or iatrogenic causes (surgery for epididymoectomy or removal of epididymal cyst) (fig. - ) . cystic transformation with epithelial metaplasia is a frequent fi nding at autopsy. its development is probably due to the concurrence of sperm excretory duct obstruction and conditions involved in increased serum estrogen levels, such as chronic liver insuffi ciency. another possible cause is infl ammation involving the rete testis. cystic transformation with crystalline deposits has also been called cystic transformation of the rete testis secondary to renal insuffi ciency. it is a bilateral lesion of adult testes characterized by the concurrence of three fi ndings: cystic transformation of the rete testis, cuboidal or columnar metaplasia of its epithelium, and the presence of urate and oxalate crystalline deposits that may be recognized by polarized light. the lesion is pathognomonic of dialyzed patients with chronic renal insuffi ciency. crystalline deposits are initially formed beneath the epithelia of the rete testis and ductuli efferentes; later they protrude into the lumina, where they are fi nally released. infl ammation is absent or slight, although a few giant cells and small fi brotic areas are often seen (figs - , - ). this lesion is characterized by diffuse or nodular proliferation of tubular or papillary structures that are derived from the rete testis and are observed in cryptorchid or normally descended testes. cases have been reported in newborns, children, and adults. adenomatous hyperplasia in newborn and infantile testes consists of enlargement of the mediastinum testis by cordlike or tubular structures derived from the rete testis. the lesion may extend up to one-third of testicular volume. despite excessive development of the rete testis, the normal connections with seminiferous tubules and efferent ductuli remain. presentation may be unilateral or bilateral. unilateral presentation is associated with cryptorchidism or vanishing testis. bilateral cases may also present with bilateral renal dysplasia. efferent ductuli may show luminal dilation and irregular outlines. the etiopathogenesis might be similar to that of cystic dysplasia of the testis. adenomatous hyperplasia in adults is usually an incidental fi nding at autopsy, in cryptorchid testes, or in testes with germ cell tumor. the rete testis epithelium forms nonencapsulated nodular outgrowths or a diffuse pattern. nodule size may be large enough to suggest tumor. the epithelium consists of cuboidal cells with ovoid nuclei, deep nuclear folds, and peripheral nucleoli. atypias and mitotic fi gures are lacking (fig. - ) . the ultrastructure and immunophenotype of the epithelium are similar to those of the normal rete testis. spermatozoa may be seen inside the cavities in some cases, suggesting that such a proliferation is connected with the seminiferous tubules. most of the testes show a certain degree of seminiferous tubular atrophy. in incidental autopsy cases the etiology is unknown, although it may be related to hormonal or chemical agent effects. [ ] [ ] [ ] in cryptorchid testes and with many testicular tumors, the most probable cause is a primary anomaly that is part of the testicular dysgenesis syndrome. adenomatous hyperplasia should be distinguished from three entities: rete testis pseudohyperplasia, which appears in atrophic testes; primary rete testis tumor; and metastasis of adenocarcinoma. in pseudohyperplasia, lesions are focal, microscopic, and usually located in the septal rete, although the mediastinal rete shows few or no alterations. benign rete testis tumor such as adenoma (solid and papillary variants) fig. - changes in the rete testis associated with dialysis. dilation of the rete testis and initial portion of the ductuli efferentes can be observed. crystalline structures, mainly rhomboidal in shape, accumulate inside and outside the tubules. other testicular diseases and cystoadenoma are isolated and focal, whereas rete testis hyperplasia is diffuse. adenocarcinoma of the rete testis is a tumor that displays numerous mitotic fi gures and infi ltrates adjacent structures. metastasis of prostatic adenocarcinoma may be excluded because these metastases alter the rete testis architecture and are immunoreactive for prostatic acid phosphatase and psa. this reactive lesion is characterized by the presence of intracytoplasmic accumulation of hyaline eosinophilic globules in the epithelial cells of the rete testis. the epithelium may be hyperplastic, but does not contain mitotic fi gures or nuclear atypia. the globules are up to µm in diameter ( fig. - ). this lesion is associated with tumor and infl ammatory processes occurring near the mediastinum testis, and can be observed in association with % of mixed testicular germ cell tumors, % of seminomas, and % of non-germ cell testicular tumors, such as epididymal tumor that infi ltrates the testis (adenomatoid tumor). yolk sac tumor infi ltrating the rete testis may closely resemble this type of rete testis hyperplasia. positive immunoreactions for α-fetoprotein and placenta-like alkaline phosphatase, as well as nuclear atypia, are helpful to distinguish germ cell neoplasia from this rete testis hyperplasia. this lesion, described as nodular proliferation of calcifying connective tissue in the rete testis, is characterized by the presence of multiple nodules that originate from the rete testis lining and subjacent connective tissue, protruding into the channels of the rete testis. these consist of cellular connective tissue covered by several layers of a fi brin-like material, which in turn is covered by rete testis epithelium. the nodules may be totally or partially calcifi ed (fig. - ). the lesion is an incidental fi nding at autopsy in patients with impaired peripheral perfusion. selective location of the lesion in the walls of the cavities and chordae rete testis is probably related to poor vascularization of these structures. the etiopathogenetic mechanism may be anoxia, necrosis, fi brin deposition, proliferation of connective tissue, or dystrophic calcifi cation. the intracavitary growth of the lesion might be due to the lower intracavitary pressure and also to the stiff structure of the mediastinum testis. the molecular basis of male sexual differentiation homozygous deletions in wilms'tumours of a zinc-fi nger gene identifi ed by chromosome jumping isolation and characterization of a zinc fi nger polypeptide gene at the human chromosome wilms' tumor locus wt- is required for early kidney development germline mutations in the wilms' tumor suppressor gene are associated with abnormal urogenital development in denys-drash syndrome donor splice-site mutations in wt are responsible for frasier syndrome expression of steroidogenic factor and wilms' tumour during early human gonadal development and sex determination a mutation in the gene encoding steroidogenic factor- causes xy sex reversal and adrenal failure in humans apparently normal ovarian differentiation in a prepubertal girl with transcriptionally inactive steroidogenic factor (nr a /sf- ) and adrenal cortical insuffi ciency genetic control of gonadal differentiation, baillière's single-copy dna sequences specifi c for the human y chromosome sex determination and the y chromosome gonadal differentiation: a review of the physiological process and infl uencing factors based on recent experimental evidence the human sry protein is present in fetal and adult sertoli cells and germ cells molecular basis of mammalian sexual determination: activation of müllerian inhibiting substance gene expression by sry autosomal xx sex reversal caused by duplication of sox- campomelic dysplasia and autosomal sex reversal caused by mutations in an sry-related gene functional analysis of sox and sox during sex determination in the mouse autosomal sex reversal and campomelic dysplasia are caused by mutations in and around the sryrelated gene sox similar gene structure of two sox a genes and their expression patterns during gonadal differentiation in a teleost fi sh, rice fi eld eel (monopterus albus) sex determination: a tale of two sox genes the molecular genetics of human sex determination x-p duplications with and without sex reversal the role of folliclestimulating hormone in controlling sertoli cell proliferation in testes of fetal rats age-retated variation of folliclestimulating hormone stimulated camp production, protein kinase c activity and their interactions on the rat testis the embryology of testicular descent the gubernaculum during testicular descent in the pig fetus the gubernaculum during testicular descent in the human fetus hyperplasia and hypertrophy of the gubernaculum during testicular descent in the fetus incidence of cryptorchidism the role of a non-androgenic testicular factor in the process of testicular descent in the dog mechanism of testicular descent the gubernaculum testis hunteri, testicular descent and maldescent role of the gubernaculum and intraabdominal pressure in the process of testicular descent testicular descent and cryptorchidism: the state of the art in the insulin- gene: lack of a genetic basis for human cryptorchidism transabdominal testicular descent is disrupted in mice with deletion of insulinlike factor receptor a novel circulating hormone of testis origin in humans testicular descent ii. ontogeny and response to denervation of calcitonin gene-related peptide receptors in neonatal rat gubernaculum prenatal androgen blockade with fl utamide inhibits masculinization of the genitofemoral nerve and testicular descent cremaster muscles obtained from boys with an undescended testis show signifi cant neurological changes maternal hormone levels in early gestation of cryptorchid males: a case-control study the endocrinology of testicular descent expression of estrogen receptor esr and its -kda variant in the gubernaculum testis expression of references children and adults spermatic and peripheral plasma concentration of testosterone and androstenedione in prepubertal boys pituitary testicular axis during puberal development development of leydig cells in the normal human testis. a cytological, cytochemical and quantitative study a quantitative morphology study of human leydig cells from birth to adulthood testicular volume during adolescence. cross-sectional and longitudinal studies testicular volumes of adolescent clinical measurement of the testes in boys and men testicular histology in fetuses with the prune belly syndrome and posterior urethral valves proliferation of sertoli cells during development of the human testis assessed by stereological methods hyperplasia and the immature appearance of sertoli cells in primary testicular disorders granular transformation of sertoli cells in testicular disorders a quantitative morphological study of human leydig cells from birth to adulthood congenital leydig cell hyperplasia morphologic anomalies in triploid liveborn fetuses objective measurement of testicular volume by ultrasonography: evaluation of the technique and comparison with orchidometer estimates ethnic differences. variation in human testis size testicular size: the effects of ageing, malnutrition, and illness testicular size: assesment and clinical importance studies of the participation of the tunica albuginea and rete testis (ta and rt) in the quantitative structure of human testis postnatal development and differentiation of contractile cells within the rabbit testis the tunica albuginea of the human testis is characterized by complex contraction and relaxation activities regulated by cyclic gmp histology of the normal testis a method for determining the relative total lenght of the tubules in the testis the fi ne structure of sertoli cells in the human testis some observations on the fi ne structure of the sertoli cell in the human testis on the morphology of the human sertoli cell organization and morphogenesis of the human seminiferous epithelium the mammalian spermatozoon ultrastructural observations on nucleoli and related structures during human spermatogenesis ultrastructure of the nucleus of human sertoli cells in normal and pathological testes cell-cell communication in the testis the fi ne structure of the monkey (macaca) sertoli cell and its role in maintaining the blood-testis barrier electron microscopic observations on the structural components of the blood testis barrier sertoli cell junctions: morphological and functional correlates morphological and functional evidence for sertoli-germ cell relationship the testis evidence that vinculin is codistributed with actin bundles in ectoplasmic ('junctional') specializations of mammalian sertoli cells changes in the lipid inclusion/ sertoli cell cytoplasm area ratio during the cycle of the human seminiferous epithelium fine structure of the sertoli cell of the human testis testicular involution in elderly men: comparison of histologic quantitative studies with hormone patterns multinucleate sertoli cells in aged human testes infl uence of age on sperm production and testicular weights in men localization of folliclestimulating hormone (fsh) immunoreactivity and hormone receptor mrna in testicular tissue of infertile men role of fsh in male gonadal function androgen receptor distribution in adult human testis the paracrine role of sertoli cells on leydig cell function receptormediated endocytosis of testicular transferrin by germinal cells of the rat testis regulation of inhibin production in the human male and its clinical applications human testis cytosol an ovarian follicular fl uid contain high amounts of interleukin- -like factor(s) cell interactions during the seminiferous epithelial cycle quantitative differences between variants of a spermatogonia in man the ultrastructure of the four types of human spermatogonia decrease in the number of ap and ad spermatogonia and the ap/ad ratio with advancing age quantifi cation of cell types throughout the cycle of the human seminiferous epithelium and their dna content normal and abnormal spermatogonia in the human testis development of the endoplasmic reticulum during human spermatogenesis kinetics of the germinal epithelium in man atlas of human spermatogenesis ultrastructural features of human spermiogenesis morphogenetic factors infl uencing the shape of the sperm head the fi ne structure and development of the neck region of the mammalian spermatozoon morphogenesis and fate of the residual body in human spermiogenesis the phagocytic function of sertoli cells. a morphological, biochemical, and endocrinological study of lysosomes and acid phosphatase localization in the rat testis renewal of spermatogonia in man ultrastructural observations on the differentiation of spermatids in man further observations on the numbers of spermatogonia, spermatocytes and spermatids connected by intercellular bridges in the mammalian testis evidence of a wave of spermatogenesis in the human testis computeraided threedimensional reconstructions of the arrangement of primary spermatocytes in human seminiferous tubules the cycle of the seminiferous epithelium in man morphometrical analysis of sertoli cell ultrastructure during the seminiferous epithelial cycle in rats stage-specifi c signals in germ line differentiation control of sertoli cell phagocytic activity by spermatogenic cells changes in the lipid inclusions/ sertoli cell cytoplasm area ratio during the cycle of the sertoli cell of the human seminiferous epithelium interaction between germ cells and sertoli cells in the testis apoptosis of male germ cells, a generalized or a cell typespecifi c phenomenon? ultrastructure and function of the lamina propia of mammalian seminiferous tubules the peritubular tissue in the normal and pathological human testis: an ultrastructural study basement membrane regulation of sertoli cells the lamina propia of vertebrate seminiferous tubules: a comparative light and electron microscopic investigation contractile cells in human seminiferous tubules peritubular myoid cells of human and rat testis are smooth muscle cells that contain desmin-type intermediate fi laments elastic tissue in the limiting membrane of the human seminiferous tubules the biology of myofi broblasts evidence for contractility of the human seminiferous tubule confi rmed by its response to noradrenaline and acetylcholine agerelated variations in seminiferous tubules in men. a stereologic evaluation distribution and role of cd -positive stromal cells and myofi broblasts in human normal testicular stroma giant interstitial cells and extraparenchimal interstitial cells of the human testis morphological relationship between testicular nerves and leydig cells in man sertoli cells and leydig cells in man ultrastructure of leydig cells in human ageins testes neuron-specifi c enolase-like inmunoreactivity in human leydig cells relaxin-like factor: a highly specifi c and constitutive new marker for leydig cells in the human testis ghrelin and reproduction: a novel signal linking energy status and fertility a novel circulating hormone of testis origin in humans calretinin is expressed in the leydig cells of rat testis calretinin, a more sensitive but less specifi c marker than α-inhibin for ovarian sex cord-stromal neoplasms: an immunohistochemical study of cases barrier properties of testis microvessels the leydig cell of the human testis -a new member of the diffuse neuroendocrine system sertoli and leydig cells of the human testis express neurofi lament triplet proteins isolation of human leydig cell mesenchymal precursors from patients with the androgen insensitivity syndrome: testosterone production and response to human chorionic gonadotropin stimulation in culture progenitor cells of the testosterone-producing leydig cells revealed attrition of the human leydig cell population with advancing age effect of ageing on the volume, structure and total leydig cell content of human testis stereological analysis of leydig cell ultrastructure in aged humans multinucleate leydig cells in normal human testes mitosis in adult human leydig cells leydig cell numbers, daily sperm production and serum gonadotropin levels in ageing men agerelated change in numbers of other interstitial cells in testes of adult men: evidence bearing on the fate of leydig cells lost with increasing age testosterone and spermatogenesis. identifi cation of stage-specifi c, androgen-regulated proteins secreted by adult rat seminiferous tubules regulation of the semininiferous epithelium changes in surface area and number of leydig cells in relation to the stages of the cycle of the human seminiferous epithelium actions of the testicular paracrine factor (p-mod-s) on sertoli cell transferrin secretion througout pubertal development diaphragmatic hernia in denys-drash syndrome sex reversal and diaphragmatic hernia in phenotypically female sibs with normal xy chromosomes clinical expression and sry gene analysis in xy subjets lacking gonadal tissue pagod syndrome: eighth case and comparison to animal models of congenital vitamin a defi ciency familial occurrence of agonadism and multiple internal malformations in phenotypically normal girls with ,xy and ,xx karyotypes, respectively: a new autosomal recessive syndrome low birth-weight, microcephalic malformation syndrome in a ,xx girl and her ,xy sister with agonadism: third report of the kennerknecht syndrome or autosomal recessive seckel-like syndrome with previously undescribed genital anomalies agonadism in a ,xy patient with charge association the syndrome of rudimentary testes: occurrence in live siblings identical twins discordant for the 'rudimentary testes' syndrome rudimentary testes syndrome revisited congenital anorchism: diagnostic and therapeutic aspects congenital bilateral anorchia: clinical, hormonal and imaging study in cases pcr analysis and sequencing of the sry sex determining gene in four patients with bilateral congenital anorchia is bilateral congenital anorchia genetically determined? the vanishing testis syndrome. indications for conservative therapy the vanishing testis the vanishing testis is the vanished testis always a scrotal event? bilateral anorchia: discordance in monozygotic twins an analysis of the genetic factors involved in testicular descent in a cohort of male patients with anorchia report of cases with discussion of etiology and pathogenesis hyperplasia of spermatic cord nerves: a sign of testicular absence signifi cance of testicular biopsies in cryptorchidism in children human monorchism: a clinicopathological study of unilateral absent testes in boys testicular regression syndrome a pathological study of cases testicular regression syndrome: a clinical and pathologic study of cases laparoscopic and histologic evaluation of the inguinal vanishing testis histological evaluation of the testicular nubbin in the vanishing testis syndrome ureteral ectopia into cystic seminal vesicle with ipsilateral renal dysgenesis and monorchia renal and testicular agenesis in a patient with darier's disease findings: small testicles klinefelter's syndrome diagnosed three years after surgery for mediastinal teratoma kenny-caffey syndrome and microorchidism polyorchidism: case report and review of literature polyorchidism: sonographic and magnetic resonance image fi ndings a case of supernumerary testis polyorchidism presenting as retractile testes polyorchidism: evaluation by mr polyorchidism: an unusual case polyorchidism: a strange anomaly with unsuspected properties bilateral double by testis: evaluation magnetic resonance imaging one man with fi ve testes: report of case triorchidism with normal spermatogenesis: an unusual cause for failure of vasectomy abdominal polyorchidism: a case report and review of the literature ultrasound of polyorchidism: case report and literature review sonographic features of polyorchidism polyorchidism: case report and literature review polyorchidism discovered as testicular torsion associated with undescended atrophic contralateral testis. a surgical solution revisión y aportación de un nuevo caso polyorchidism discovered as testicular torsion polyorchidism with normal spermatogenesis polyorchidism with normal spermatogenesis polyorchidism with normal spermatogenesis and equal sized testes. a theory of embryonal development testiculo supernumerario. comunicación de un caso y revisión de la literatura polyorchidism: case report and review of the literature polyorchidism: a case report polyorchidism: report of a case polyorchidism in a newborn: case report and review of the literature polyorchidism: a case report and review of the literature polyorchidism and seminoma in a child a case of polyorchidism with testicular teratoma signifi cance of testicular size measurement in andrology. ii correlation of testicular size with testicular function congenital leydig cell hyperplasia evidence in favor of the mechanical (intrauterine torsion) theory over the endocrinopathy (cryptorchidism) theory in the pathogenesis of testicular agenesis compensatory hypertrophy of testicle in unilateral cnyptorchidism impact of varicocele on testicular volume in young men: signifi cance of compensatory hypertrophy of contralateral testis plasma lh and fsh response to lrh in boys with compensatory testicular hypertrophy followup of boys with unilateral compensatory testicular hypertrophy testicular volume during adolencence unilateral testicular hypertrophy: an apparently benign occurrence without cryptorchidism benign bilateral testicular enlargement benign macroorchidism in a pubescent boy idiopathic macroorchidism macro-orchidism: light and electron microscopic study of four cases idiopathic benign bilateral testicular enlargement in a pubertal boy: a case report and review of literature macroorchidism: a case report endocrine and spermatological characteristics of patients with bilateral megalotestis the fragile x premutation: new insights and clinical consequences a marker x chromosome a pedigree of mental defect showing sex-linkage x-linked mental retardation associated with macroorchidism inherited congenital normofunctional testicular hyperplasia and mental defi ciency. a corroborative study x-linked mental defi ciency megalotestes syndrome xlinked mental retardation with macroorchidism and the fragile site at xq or familial-x-linked mental retardation with a marker x chromosome and its relationship to macroorchidism a recognizable syndrome of sex-linked mental retardation, large testes and marker x chromosome gonadal function in men with the martin-bell (fragile x) syndrome spermatogenesis in two patients with the fragile x syndrome. i. histology: light and electron microscopy spermatogenesis in two patients with the fragile x syndrome x-linked mental retardation and an x-chromosome marker population incidence and segregation ratios in martin-bell syndrome study of a family with a fragile site of the x chromosome at xq - without mental retardation testicular size in fetal fragile x syndrome a family with mental retardation, variable macrocephaly and macroorchidism, and linkage to xq -q testicular enlargement and elevated serum inhibin concentrations occur in patients with pituitary macroadenomas secreting follicle stimulating hormone juvenile hypothyroidism with testicular enlargement hipotiroidismo y maduración testicular precoz thyroid hormone and male gonadal function sexual maturation in juvenile hypothyroidism hypothalamic-pituitary gonadal axis in boys with primary hypothyroidism and macroorchidism thyroid hormones: their role in testicular steroidogenesis male hypogonadism in hypothyroidism: a study of six cases macroorchidism and testicular fi brosis associated with autoimmune thyroiditis juvenile hypothyroidism and precocious testicular maturation acquired hypothyroidism with muscular hypertrophy and precocious testicular enlargement regulation of gonadotropin-releasing hormone (gnrh) gene expression in hypothalamic neuronal cells hypothyroidism-induced macroorchidism: use of a gonadotropin-hormone agonist to understand its mechanism and augment adult stature a potential novel mechanism for precocious puberty in juvenile hypothyroidism high neonatal triiodothironine levels reduce the period of sertoli cell proliferation and accelerate tubular lumen formation in the rat testis, and increase serum inhibin levels increased numbers of sertoli and germ cells in adult rat testes induced by synergistic action of transient neonatal hypothyroidism and neonatal hemicastration tri-iodothyronine directly affects rat sertoli cell proliferation and differentiation neonatal hypothyroidism causes delayed sertoli cell maturation in rats treated with propylthiouracil: evidence that the sertoli cell controls testis growth central precocious puberty. an overview of diagnosis, treatment, and outcome precocious puberty precocious puberty sexual precocity precocious puberty caused by a suprasellar arachnoid cyst. analysis of cases the endocrine spectrum of arachnoid cysts in childhood growth, puberty and hypothalamicpituitary function in children with suprasellar arachnoid cyst aspects étiologiques cliniques et biologiques des pubertés précoces d'origine centrale precocious puberty following severe head trauma precocious puberty after traumatic brain injury endocrine disorder as the only sign of chronic 'nonhypertensive' hydrocephalus precocious puberty after hypothalamic and pituitary irradiation in young children precocious and premature puberty associated with treatment of acute lymphoblastic leukaemia endocrine function and morphological fi ndings in patients with disorders of the hypothalamopituitary area: a study with magnetic resonance the radiological approach to precocious puberty mr imaging features in hypothalamic hamartoma: a report of three cases and review of literature boys with precocious puberty due to hypothalamic hamartoma: reproductive axis after discontinuation of gonadotropinreleasing hormone analog therapy etiology of central precocious puberty in males: the results of the italian study group for physiopathology of puberty hypothalamic hamartoma: a source references of luteinizing-hormone-releasing factor in precocious puberty mixed germ cell tumour of the pineal region: a case report hcg-secreting pineal teratoma causing precocious puberty: report of two patients and review of the literature puberty without gonadotropins: a unique mechanism of sexual development gonadotropinindependent familial sexual precocity with premature leydig and germinal cell maturation (familial testotoxicosis): effects of a patent luteinizing hormone-releasing factor agonist and metroxyprogesterone acetate therapy in four cases testicular changes in gonadotropin-independent familial male sexual precocity. familial testotoxicosis gonadotropin-independent precocious puberty due to luteinizing hormone receptor mutations in brazillian boys: a novel constitutively activating mutation in the fi rst transmembrane helix activating mutations in the lh receptor gene: a human model of non fsh-dependent inhibin production and germ cell maturation mutational analysis of the luteinizing hormone receptor gene in two individuals with leydig cell tumors tumor de células de leydig con pseudopubertad precoz leydig cell tumor in a child with spermatocyte maturation and no pseudoprecocious puberty an aromatase-producing sex-cord tumor resulting in prepubertal gynecomastia sertoli cell tumour in a boy with peutz-jeghers syndrome carney complex: the complex of mixomas, spotty pigmentation, endocrine overactivity, and schwannomas virilising adrenal cortical tumours in children virilizing adrenal cortical carcinoma with hypertrophy of spermatic tubules in childhood bilateral testicular tumours in congenital adrenal hyperplasia: a continuing diagnostic and therapeutic dilemma hepatoblastoma presenting as isosexual precocity. the clinical importance of histologic and serologic parameters gonadotropin-secreting pineal teratoma causing precocious puberty the p gene superfamily: updated listing of all genes and recommended nomenclature for the chromosomal loci human aromatase: cdna cloning, southern blot analysis, and assignment of the gene to chromosome familial hyperestrogenism in both sexes: clinical, hormonal, and molecular studies of two siblings the aromatase excess syndrome is associated with feminization of both sexes and autosomal dominant transmission of aberrant p aromatase gene transcription aromatase defi ciency caused by a novel p arom gene mutation: impact of absent estrogen production on serum gonadotropin concentration in a boy aromatase defi ciency in male and female siblings caused by a novel mutation and the physiological role of estrogens effect of testosterone and estradiol in a man with aromatase defi ciency estrogen: consequences and implications of human mutations in synthesis and action primary testicular abnormalities causing precocious puberty leydig cell tumor, leydig cell hyperplasia, and adrenal rest tumor focal lobular spermatogenesis and pubertal acceleration associated with ipsilateral leydig cell hyperplasia mccune-albright syndrome in a boy may present with a monolateral macroorchidism as an early and isolated clinical manifestation macroorchidism due to autonomous hyperfunction of sertoli cells and g(s)alpha gene mutation: an unusual expression of mccune-albright syndrome in a prepubertal boy mccune-albright syndrome in a male child: a clinical and endocrinologic enigma anomalies of the testicle preperitoneal ectopic testis: a case report ectopia epidídimo-perineal testículo ectópico perineal perineal testicle crossed ectopic testis: a case report and review of the literature crossed ectopic testis. case report and review transverse testicular ectopia crossed ectopic testis with common vas deferens crossed testicular ectopia detected by laparoscopy transverse testicular ectopia: a case report crossed testicular ectopia in association with double incomplete testicular descent two rare genital abnormalities: crossed testicular and scrototesticular ectopia transverse testicular ectopia associated with persistent müllerian duct syndrome. a case report the persistent müllerian duct syndrome: a rare cause of cryptorchidism mixed germ cell tumor after bilateral orchidopexy in persistent müllerian duct syndrome with transverse testicular ectopia two rare cases of ectopic testes subumbilical ectopic testis exstrophy of the testis testicular dislocation after scrotal trauma cystic dysplasia of the testis: a unique anomaly studied by microdissection cystic dysplasia of the rete testis. case report cystic dysplasia of the rete testis associated to cryptorchidism: a case report cystic dysplasia of the testis: sonographic and pathologic fi ndings cystic testicular lesions in the pediatric population the human rete testis the rete testis in man: ultrastructural aspects the mammalian rete testis. a morphological examination cystic displasia of the testis: light and electron microscopic study of three cases cystic dysplasia of the testis associated with multicystic dysplasia of the kidney ectasia of the rete testis with ipsilateral renal agenesis cystic dysplasia of the testis cystic dysplasia of testis coffi n cm. cystic testicular lesions in the pediatric population cystic dysplasia of the testis with ipsilateral renal agenesis. a case report and review of the literature conservative managemet of cystic dysplasia of the testis testicular cystic dysplasia: evaluation of new cases treated without surgery cystic dysplasia of rete testis associated with ipsilateral renal agenesis. case report fetal gonadoblastoid testicular dysplasia gonadoblastoid testicular dysplasia in walker-warburg syndrome fetal gonadoblastoid testicular dysplasia: a focal failure of testicular development frequency of so-called hypoplastic or dysgenetic zones in scrotal and otherwise normal testes androgen receptor expression in sertoli cells as a function of seminiferous tubule maturation in the human cryptorchid testis congenital testicular lymphangiectasis congenital testicular lymphangiectasis in noonan's syndrome congenital testicular lymphangiectasis in children with otherwise normal testes macromicroscopischeskoe is sledavanie vnutriorgannoi limfaticheskoi sistemy muzhskoi polovoi zhelezy [macro/ microscopic study of intraorgan lymphatic system of male gonad in man distribution and fi ne structure of the lymphatic system in the human testis lymph vascular system of the interstitial tissue of the testis as revealed by electron microscopy epididymal lymphangiectasis tumors and cysts of the paratesticular region complex multilocular cystic lesion of rete testis, accompanied by smooth muscle hyperplasia, mimicking intratesticular leydig cell neoplasm smooth muscle hyperplasia of the testicular adnexa clinically mimicking neoplasia. clinicopathologic study of sixteen cases myoepithelial hamartoma of the small bowel: report of a case focal muscular hyperplasia of the trachea ectopic seminiferous tubules in the tunica albuginea of normal and dysgenetic testes pseudocysts of the tunica albuginea: benign invasion by testicular tubules development of the testis from birth to puberty testosterone immunoexpression in human leydig cells of the tunica albugiena testis and spermatic cord. a quantitative study in normal fetuses, young adults, elderly men and patients with cryptorchidism giant interstitial cells and extraparenchymal interstitial cells of the human testis the infi ltrative activity of leydig cells relation of leydig cells in the human testicle to the tubules and testicular function a histological study of extraparenchymal leydig-like cells Über die zwischenzellen des hodens zur pathologischen anatomie der leydig zelle leydig cells within the lamina propria of seminiferous tubules in four patients with azoospermia ectopic leydig cells in seminiferous tubules of an infertile human male with a chromosomal aberration leydig cells within the spermatogenic seminiferous tubules immunohistochemical and quantitative study of interstitial and intratubular leydig cells in normal men, cryptorchidism, and klinefelter's syndrome Über das verhalten von hoden und nebenhoden bei angeborenem fehlen des ductus deferens, zugleich zur frage des vorkommens von zwischenzellen in menschliche nebenhoden sur l'existence de glands sympathicotropes dans l'ovaire et le testicule humains; leur rapport avec la glande interstitielle du testicule zur ultrastrusktur der leydigzellen im funiculus spermaticus des menschen histogenesis of human extraparenchymal leydig cells presentación de un caso y revisión de la literatura testicular lipomatosis in cowden's syndrome age-related epididymis-like intratesticular structures: benign lesions of wolffi an origin that can be misdiagnosed as testicular tumors male reproductive disorders in humans and prenatal indicators of estrogen exposure. a review of published epidemiological studies testicular cancers occurring in brothers with cryptorchism anatomical, morphological and volumetric analysis: a review of cases of testicular maldescent risk factor patterns for cryptorchidism and hypospadias cryptorchidism: a registry based study in sweden on some factors of some possible etiological importance maternal and neonatal risk factors for cryptorchidism risk factors for cryptorchidism and hypospadias abnormalities of testicular descent surgical outcome of orchidopexy ii. trapped and ascending testes iatrogenic cryptorchidism resulting from hernia repair iatrogenic ascent of the testis: an under-recognized complication of inguinal hernia operation in children iatrogenic ascent of the testis: an underrecognized complication of inguinal hernia operation in children testicular descent and ascent in the fi rst year of life late presentation of cryptorchidism: the etiology of testicular re-ascent ascent of the testis: fact or fi ction incomplete disappearance of the processus vaginalis as a cause of ascending testis undescended testis: congenital or acquired? spontaneous ascent of the testis acquired undescended testis does proximal genitofemoral nerve division induce testicular maldescent or ascent in the rat? association between testicular microlithiasis, testicular cancer, cryptorchidism and history of ascending testis the ascending testis and the testis undescended since birth share the same histopathology elevated placental estradiol: a possible etiological factor of human cryptorchidism histologic observations in cryptorchidism: the congenital germinal-cell defi ciency of the undescended testis histologic classifi cation of undescended testes cytophotometric dna quantifi cation in human spermatogonia of cryptorchid testes early postnatal testicular maldevelopment in cryptorchidism hormonal treatment of cryptorchidism -hcg or gnrh -a multicentre study busereline treatment of cryptorchidism: a randomized, double-blind, placebo-controlled study abnormal germ cell development in cryptorchidism anatomical, morphological and volumetric analysis: a review of cases of testicular maldescent impact of early orchidopexy on testicular growth effi cacy of orchiopexy by patient age year for cryptorchidism clinical and histopathologic evaluation of operated maldescended testes after luteinizing hormonereleasing hormone treatment bilateral prepubertad testicular biopsias predict signifi cance of cryptorchisism-associated mixed testicular atrophy, and allow assessment of fertility multinucleated spermatogonia in cryptorchid boys: a possible association with an increased risk of testicular malignancy y chromosome microdeletions in cryptorchidism and idiopathic infertility an unusual subset of cryptorchidism: possible end organ failure ascent of the testis in children impaired germ cells in secondary cryptorchid testis after herniotomy elastic fi bers in tunica propria of undescended and contralateral scrotal testes from cryptorchid patients hyperplasia and the immature appearance of sertoli cells in primary testicular disorders focal orchitis in undescended testes: discussion of pathogenetic mechanisms of tubular atrophy undescended testes in adults: clinical signifi cance of resistive index values of the testicular artery measured by doppler ultrasound as a predictor of testicular histology testicular function in men treated in childhood for undescended testes histologic lesions in undescended ectopic obstructed testes is a testis located at the superfi cial inguinal pouch (denis browne pouch) comparable to a true cryptorchid testis? histologic maldevelopment of unilaterally cryptorchid testes and their descended partners anatomical, morphological and volumetric analysis: a review of cases of testicular maldescent les testicules oscillants. forme degradée de cryptorchidie? infertility in adult males with retractile testes changes in the volume and histology of retractile testes in prepubertal boys the retractile testis retractile testis -is it really a normal variant? bilateral retractile testes -subsequent effects on fertility effect of cryptorchidism and retractile testes on male factor infertility: a multicenter, retrospective, chart review epididymal anomalies associated with hydrocele/hernia and cryptorchidism: implications regarding testicular descent congenital deformities of the testis and epididymis signifi cance of epididymal and ductal anomalies associated with undescended testis insulin-like factor gene mutations in testicular dysgenesis syndrome: clinical and functional characterization testicular dysgenesis syndrome: possible role of endocrine disrupters ethnic differences in occurrence of tds -genetics and/or environment? granular changes in sertoli cells in children and pubertal patients erythropoietin may reduce the risk of germ cell loss in boys with cryptorchidism early orchiopexy: prepubertal intratubular germ cell neoplasia and fertility outcome testicular cancer and cryptorchidism cryptorchidism and testicular neoplasia testicular maldescent and infertility histology of testicular biopsies taken at operation for bilateral maldescended testes in relation to fertility in adulthood semen analysis in patients operated on for impalpable testes fertility in cryptorchidism: an overview in paternity and hormone levels after unilateral cryptorchidism: association with pretreatment testicular location no relationship of testicular size at orchiopexy with fertility in men who previously had unilateral cryptorchidism fertility potential: a comparison of intra-abdominal and intracanalicular testes by age groups in children surgical mangeament of undescended testis: retrospective study of potential fertility in cases orchiopexy and infertility: a critical long-term retrospective analysis the importance of mini-puberty for fertility in cryptorchidism cryptorchidism: aspects of fertility references and neoplasms. a study including data of , consecutive boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism experience of screening for carcinoma-in-situ of the testis among young men with surgically corrected maldescended testes distribution of carcinoma-in-situ in testes from infertile men carcinoma-in-situ of the testis: aneuploid cells in semen cryptorchidism and testicular neoplasia testicular microlithiasis: sonographic features with pathologic correlation testicular microlithiasis in a child with torsion of the appendix testis testicular microlithiasis occurring in a postorchidopexy testis microcalcifi cations in testicular malignancy: diagnostic tool in occult tumor? testicular microlithiasis with sterility testicular microlithiasis in male infertility microlitiasis testicular asociada a infertilidad painful testicular lithiasis testicular microlithiasis: diagnosis associated with orchialgia idiopathic testicular microlithiasis. ultrastructural study testicular microlithiasis in a uk population: its incidence, associations and follow-up testicular microlithiasis is associated with testicular pathology testicular microlithiasis -a possibly premalignant condition the prevalence of testicular microlithiasis in an asymptomatic population of men to years old testicular microlithiasis: prevalence and tumor risk in a population referred for scrotal sonography testicular calcifi cation and microlithiasis: association with primary intra-testicular malignancy in , patients testicular microlithiasis, a premalignant condition: prevalence, histopathologic fi ndings, and relation to testicular tumor seminal profi le of subjects with testicular microlithiasis and testicular calcifi cations bilateral testicular microlithiasis predicts the presence of the precursor of testicular germ cell tumors in subfertile men testicular nicrolithiasis and cryptorchidism: ultrasound analysis after orchidopexy testicular microlithiasis. a benign condition with a malignant association testicular microlithiasis: a review and its association with testicular cancer testicular microlithiasis heralding mixed germ cell tumor of the testis in a boy signifi cance of testicular microlithiasis yolk sac tumor and testicular microlithiasis testicular microlithiasis in children: sonographic features and clinical implications identifi cation of seminiferous tubule aberrations and a low incidence of testicular microliths associated with the development of azoospermia raman spectroscopic analysis identifi es testicular microlithiasis as intratubular hydroxyapatite testicular calcifi cation in a -year-old boy the origin of testicular microliths testicular microlithiasis in children with bilateral cryptorchidism pulmonary alveolar microlithiasis with involvement of the sympathetic nervous system and gonads testicular microlithiasis and concomitant testicular intraepithelial neoplasia increased risk of carcinoma in situ in patients with testicular germ cell cancer with ultrasonic microlithiasis in the contralateral testicle testicular carcinoma in a patient with previously demostrated testicular microlithiasis testicular microlithiasis and subsequent development of metastatic germ cell tumor detection of testicular microlithiasis by sonography the interval of development of testicular carcinoma in a patient with previously demonstrated testicular microlithiasis surveillance of testicular microlithiasis? results of an uk based national questionnaire survey testicular microlithiasis: us follow-up testicular microlithiasis as a predictor of intratubular germ cell neoplasia microlithiasis of the epididymis and the rete testis three novel sry mutations in xy gonadal dysgenesis and the enigma of xy dysgenesis cases without sry mutations a novel postzygotic nonsense mutation in sry in familial xy gonadal dysgenesis mutations in sry and wt genes required for gonadal development are not responsible for xy partial gonadal dysgenesis pathology of ,xy pure gonadal dysgenesis: absence of testis differentiation associated with mutations in the testis-determining factor xy gonadal dysgenesis: genetic heterogeneity based upon clinical observations, h-y antigen status and segregations analysis chronic renal disease, myotonic dystrophy, and gonadoblastoma in xy gonadal dysgenesis renal failure with xy gonadal dysgenesis: report of the second case a syndrome of chronic renal failure and xy gonadal dysgenesis in young phenotypic females without genital ambiguity atypical presentation of denys-drash syndrome in a female with a novel wt gene mutation molecular analysis of frasier syndrome: mutation in the wt gene in a girl with gonadal dysgenesis and nephronophthisis frasier syndrome: a rare syndrome with wt gene mutation in pediatric urology xy siblings with inadequate virilization and cns defi ciency testicular dysgenesis and mental retardation in two incompletely masculinized xysiblings analysis of the testisdetermining gene sry in patients with xy gonadal dysgenesis the gardner-silengo-wachtel or genitor-palato-cardiac syndrome: male pseudohermaphroditism with micrognathia, cleft palate, and conotruncal cardiac defects xy gonadal dysgenesis associated with a multiple pterygium syndrome phenotype xy pure gonadal dysgenesis: a case with graves' disease a case of gonadal dysgenesis, breast development, graves' disease, and low bone mass alopecia universalis congenita, xy gonadal dysgenesis and laryngomalacia: a novel malformation syndrome alopecia congenita universalis, microcephaly, cutis marmorata, short stature and xy gonadal dysgenesis: variable expression of el-shanti syndrome syndromal (and nonsyndromal) forms of male pseudohermaphroditism familial ovarian dysgerminomas (swyer syndrome) in females associated with a new familial syndrome of xy gonadal dysgenesis with anomalies of ectodermal and mesodermal structural familial xy gonadal dysgenesis familial xy gonadal dysgenesis xy gonadal dysgenesis: genetic heterogeneity based upon clinical observations, h-y antigen status and segregations analysis the x linked recessive form of xy gonadal dysgenesis with high incidende of gonadal cell tumors: clinical and genetic studies the relationship of neoplasia to disorders of abnormal sexual diferentiation xy gonadal dysgenesis: evidence for autosomal dominant transmission in a large kindred gonadoblastomas in patients with xy gonadal dysgenesis familial ,xx gonadal dysgenesis pure gonadal dysgenesis xx and xy: observations in fi fteen patients gonadal dysgenesis in a patient with an x; translocation: case report and review gonadal dysgenesis, intra-x chromosomal insertion, and possible position effect in an otherwise normal female ovarian dysgenesis with balanced autosomal translocation a novel mutation in the fsh receptor inhibiting signal transduction and causing primary ovarian failure a novel loss of function mutation in exon of the fsh receptor gene causing hypergonadotropic hypogonadism: clinical and molecular characteristics no evidence of mutations in the follicle-stimulating hormone receptor gene in mexican women with ,xx pure gonadal dysgenesis dysgerminoma and gonadal dysgenesis in a ,xx female with no evidence of y chromosomal dna dysgerminoma with syncytiotrophoblastic giant cells references arising from ,xx pure gonadal dysgenesis familial dysgerminoma associated with , xx pure gonadal dysgenesis prenatal and postnatal prevalence of turner's syndrome: a registry study the distribution of chromosomal genotypes associated with turner's syndrome: livebirth prevalence and evidence for dismissed fetal mortality and severity in genotypes associated with structural x abnomalities or mosaicism primary ovarian failure turner syndrome and female sex chromosome aberrations: deduction of the principal factors involved in the development of clinical features turner's syndrome the anatomy and histology of xo human embryos and fetuses principles of reproductive embryology mammalian muts homologue is required for chromosome pairing in meiosis accelerated germ cell apoptosis in sex chromosome aneuploid fetal human gonads sex chromosomes and sexlinked genes gonadal mixed germ cell tumor combined with a large hemangiomatous lesion in a patient with turner's syndrome and ,x/ ,x, + mar karyotype gonadoblastoma and turner syndrome a review of cases with observations on testicular histology and function true hermaphroditism presenting as bilateral gynecomastia in an adolescent phenotypic male aetiological diagnosis of male sex ambiguity: a collaborative study seminoma in a xx true hermaphrodite with positive h-y antigen. a case report the gonads of human true hermaphrodites true hermaphroditism. clinical morphological and cytogenetic aspects true hermaphroditism: geographical distribution, clinical fi ndings, chromosomes and gonadal histology true hermaprhoditism: clinical features, genetic variants and gonadal histology hormonal and molecular genetic fundings in , xx subjects with sexual ambiguity and testicular differentiation familial xx males coexisting with familial ,xx true hermaphrodites in same pedigree partially delected sry gene confi ned to testicular tissue in a ,xx true hermaphrodite without sry in leukocytic dna pregnancy in a woman with a y chromosome after removal of an ovarian dysgerminoma preservation of gonadal function in true hermaphroditism das syndrom des pseudohermaphroditismus masculinus bei kongenitaler nebennierensiden-hyperplasie ohne androgenüberproduktion a novel compound heterozygous mutation in the steroidogenic acute regulatory protein gene in a patient with congenital lipoid adrenal hyperplasia molecular and structural analysis of two novel star mutation in patients with lipoid congenital adrenal hyperplasia a novel mutation l p of the steroidogenic acute regulatory protein gene in three unrelated patients of swiss ancestry with congenital lipoid adrenal hyperplasia mutations in the steroidogenic acute regulatory protein (star) in six patients with congenital lipoid adrenal hyperplasia disorders of androgen synthesis -from cholesterol to dehydroepiandrosterone a genetic isolate of congenital lipoid adrenal hyperplasia with atypical clinical fi ndings phenotypic variations in lipoid congenital adrenal hyperplasia abnormal sex differentiation prenatal diagnosis of congenital lipoid adrenal hyperplasia targeted disruption of the mouse gene encoding steroidogenic acute regulatory protein provides insights into congenital lipoid adrenal hyperplasia an autopsy case of congenital lipoid hyperplasia of the adrenal cortex gonadal development and grown in ,xx and ,xy individuals with p scc defi ciency (congenital lipoid adrenal hyperplasia) new developments in congenital lipoid adrenal hyperplasia and steroidogenic acute regulatory protein zur morphologie und genese der kongenitalen nebennierenrindenhyperplasie beim männlichen scheinzwitter the testicular lesion and sexual differentiation in congenital lipoid adrenal hyperplasia congenital adrenal lipoid hyperplasia due to defi cient cholesterol side-chain cleavage activity ( , -desmolase) in a patient treated for years congenital lipoid adrenal hyperplasia in a eight-year-old phenotype female gonadal histology with testicular carcinoma in situ in a -year old ,xy female patient with a premature termination in the steroidogenic acute regulatory protein causing congenital lipoid adrenal hyperplasia unusual steroid pattern in congenital adrenal hyperplasia: defi ciency of β-hydroxydehydrogenase pubertal boy with the β-hydroxysteroid dehydrogenase defect characterization of two novel homozygous missense mutations involving codon and of type ii β-hydroxysteroid dehydrogenase ( βhsd) gene causing, respectively, nonsalt-wasting and salt-wasting βhsd defi ciency disorder disorders of sexual differentiation congenital adrenal hyperplasia due to point mutations in the type ii β-hydroxysteroid dehydrogenase gene molecular basis of congenital adrenal hyperplasia due to β-hydroxysteroid dehydrogenase defi ciency detection and functional characterization of the novel missense mutation y d in type ii β-hydroxysteroid dehydrogenase ( βhsd) gene of a female patient with nonsalt-losing βhsd defi ciency nonsalt-losing congenital adrenal hyperplasia due to β-hydroxysteroid dehydrogenase defi ciency with normal glomerulosa function defects of the testosterone biosynthetic pathway in boys with hypospadias abnormalities of adrenal steroidogenesis in chilean boys with micropenis mutation of proline to arginine in the meander region of cytochrome p c causes severe alpha-hydroxylase defi ciency localization of the human cyp gene (cytochrome p ( alpha)) to q . by fl uorescence 'in situ' hybridization and simultaneous chromosome banding a novel point mutation in p c (cyp ) causing combined alpha-hydroxylase/ , -lyase defi ciency towards a unifying mechanism for cyp mutations that cause isolated , -lyase defi ciency alpha-hydroxylation defi ciency in man endocrine studies in male pseudohermaphroditism in childhood and adolescence desmolase defi ciency male pseudohermaphroditism consistent with - desmolase defi ciency pitfalls in characterizing p c mutations associated with isolated , -lyase defi ciency severe ,xy virilization defi cit due to β-hydroxysteroid dehydrogenase defi ciency ketosteroid reductase defi ciency in an adult patient without gynecomastia but with female psychosexual orientation absent spermatogenesis despite early bilateral orchidopexy in -ketoreductase defi ciency substitution mutation c y causes β-hydroxysteroid dehydrogenase defi ciency novel insertion frameshift mutation of the lh receptor gene: problematic clinical distinction of leydig cell hypoplasia from enzyme defects primarily affecting testosterone biosynthesis leydig cell hypoplasia: a cause of male pseudohermaphroditism leydig cell hypoplasia causing male pseudohermaphroditism: diagnosis year after prepubertal castration leydig cell hypofunction resulting in male pseudohermaphroditism a case of male pseudohemaphroditism associated with elevated lh, normal fsh and low testosterone possibly due to the secretion of an abnormal lh molecula inherited male pseudohermaphroditism due to gonadotropin irresponsiveness a clinico-genetic investigation of leydig cell hypoplasia naturally occurring mutations of the luteinizing hormone receptor gene affecting reproduction leydig cell hypoplasia due to inactivation of luteinizing hormone receptor by a novel homozygous nonsense truncation mutation in the seventh transmembrane domain biological effect of a novel mutation in the third leucine-rich repeat of human luteinizing hormone references receptor familial incomplete male pseudohermaphroditism, type i. evidence for androgen resistance and variable clinical manifestations in a family with the reifenstein syndrome quantitative receptor defects in families with androgen resistance; failure of stabilization of the fi broblast cytosol androgen receptor leydig cell hypoplasia determining familial hypergonadotropic hypogonadism male pseudohermaphroditism resulting from leydig cell hypoplasia the syndrome of testicular feminization in male pseudohermaphrodites the molecular bases of androgen insensitivity molecular basis of androgen insensitivity the androgen insensitivity syndrome (testicular feminization). a clnicopathologic study of cases a case of complete testicular feminization and xxy karyotype morphometry and histology of gonads from twelve children and adolescents with the androgen insensitivity (testicular feminization) syndrome testicular carcinoma in situ in children with the androgen insensitivity (testicular feminization) syndrome síndrome de feminización testicular completa inmunohistochemical and ultrastructural study of sertoli cells in androgen insensitivity androgen receptor gene mutation associated with complete androgen insensitivity syndrome and sertoli cell adenoma residual activity of mutant androgen receptors explains wolffi an duct development in the complete androgen insensitivity syndrome bilateral testicular tumors in androgen insensitivity syndrome puberty in subjects with complete androgen insensitivity syndrome familial male pseudohermaphroditism with labial testes and partial feminization: endocrine studies and genetic aspects altered hypothalamic-pituitarytesticular function in incomplete testicular feminization syndrome etude d'un cas familial d'androgynoïdisme avec hypospadias grave, gynécomastie et hyperoestrogénie hereditary familial hypogonadism familial gynecomastia androgens and fertility variable androgen receptor levels in infertile men frecuency of androgen insensitivity in infertile phenotypically normal men analysis of the transactivation domain of the androgen receptor in patients with male infertility evidence for partial deletion in the androgen receptor gene in a phenotypic male with azoospermia preserved male fertility despite decreased androgen sensitivity caused by a mutation in the ligand-binding domain of the androgen receptor gene progressive proximal spinal and bulbar muscular atrophy of late onset. a sex-linked recessive trait founder effect in spinal and bulbar muscular atrophy (sbma) x-linked recessive bulbospinal neuronopathy: a clinicopathological study x-linked recessive bulbospinal neuronopathy: a report of ten cases x-linked spinal and bulbar muscular atrophy of late onset. a separate type of motor neuron disease? a family with adult spinal and bulbar muscular atrophy, x-linked inheritance and associated testicular failure androgen receptor gene mutations in x-linked spinal and bulbar muscular atrophy meiotic stability and genotypephenotype correlation of the tricucleotide repeat in x-linked spinal and bulbar muscular atrophy the length and location of cag trinucleotide repeats in the androgen receptor n-terminal domain affect transactivation function abnormal androgen receptor binding affi nity in subjects with kennedy's disease (spinal and bulbar muscular atrophy) molecular pathology of the androgen receptor in male (in)fertility steroid alpha-reductase defi ciency in man. an inherited form of male pseudohermaphroditism identifi cation of missense mutations in the srd a gene from patients with steroid alpha-reductase defi ciency deletion of steroid alpha reductase gene in male pseudohermaphroditism steroid alpha-reductase defi ciency molecular study of the alpha-reductase type gene in three european families with alphareductase defi ciency alpha-reductase gene mutations in three unrelated patients of greek cypriot origin: identifi cation of an ancestral founder effect a novel frameshift mutation in the alpha-reductase type gene in korean sisters with male pseudohermaphroditism testosterone and epitestosterone metabolism of single hairs in patients with alpha-reductasedefi ciency male pseudohermaphroditism due to alpha-reductase defi ciency male pseudohermaphroditism due to steroid alpha-reductase defi ciency persistence of müllerian ducts in male pseudohermaphroditism, and its relationship to cryptorchidism anti-müllerian hormone and intersex states anti-müllerian hormone, the jost factor the persistent müllerian duct syndrome: a rare cause of cryptorchidism hermaphroditism with atypical or 'mixed' gonadal dysgenesis. relationship to gonadal neoplasm mixed gonadal dysgenesis penoscrotal hypospadias and coarctation of the aorta with mixed gonadal dysgenesis molecular analysis of sry gene in patients with mixed gonadal dysgenesis dysgenesis of testicular and streak gonads in the syndrome of mixed gonadal dysgenesis. perspective derived from a clinicopathologic analysis of twentyone cases clinical and pathologic spectrum of ,xy gonadal dysgenesis: its relevance to the understanding of sex differentiation dysgenetic male pseudohermaphroditism morphometry and histology of gonads from children with dysgenetic male pseudohermaphroditism testicular pathology in ,xy dysgenetic male pseudohermaphroditism: an approach to pathogenesis of testis cancer hernia uteri inguinalis beim manne persistence of müllerian derivatives in males persistent müllerian duct syndrome. review and report of cases familial persistent müllerian duct syndrome persistent müllerian duct syndrome in a man with transverse testicular ectopia persistent müllerian structures in infertile male male pseudohermaphroditism with persistent müllerian and wolffi an structures complicated by intraabdominal seminoma persistence of müllerian derivatives in males familial persistent müllerian duct syndrome variants of the anti-müllerian hormone gene in a compound heterozygote with the persistent müllerian duct syndrome and his family diffuse intratubular undifferentiated germ cell tumor in both testes of a male subject with a uterus and ipsilateral testicular dysgenesis testicular tumor in patient with persistent müllerian duct syndrome a case of bilateral seminoma in the setting of persistent müllerian duct syndrome rsh/smith-lemli-opitz syndrome: mutations and metabolic morphogenesis atypical case of smith-lemli-opitz syndrome: implications for diagnosis genetic disorders of cholesterol biosynthesis in mice and humans frequency gradients of dhcr mutations in patients with smith-lemli-opitz syndrome in europe: evidence for different origins of common mutations prenatal death in smith-lemli-opitz/rsh syndrome antenatal manifestations of smith-lemli-opitz (rsh) syndrome: a retrospective survey of cases levels of unconjugated estriol and other maternal serum markers in pregnancies with smith-lemli-opitz (rsh) syndrome fetuses syndromal (and nonsyndromal) forms of male pseudohermaphroditism mutations in the delta -steroid reductase gene in patients with the smith-lemli-opitz syndrome molecular cloning and expression of the human delta -sterol reductase mutations in the human sterol delta reductase gene at q - cause smith-lemli-opitz syndrome smith-lemli-opitz syndrome is caused by mutations in the -dehydrocholesterol reductase gene opitz syndrome: a multiple congenital anomaly/mental retardation syndrome due to an inborn error of cholesterol biosynthesis mutation analysis and description of sixteen rsh/smith-lemli-opitz syndrome patients: polymerase chain reaction-based assays to simplify genotyping recognition of smith-lemli-opitz syndrome (rsh) in the fetus: utility of ultrasonography and biochemical analysis in pregnancies with low maternal serum estriol a syndrome of pseudohermaphroditism, wilms' tumor, hypertension and degenerative renal disease association between wilms' tumor and gonadal dysgenesis glomerulonephritis associated with male pseudohermaphroditism and nephroblastoma twenty-four new cases of wt germline mutations and review of the literature: genotype/phenotype correlations for wilms' tumor development nephrogenic rests in wilms' tumor patients with the drash syndrome frasier syndrome, part of the denys drash continuum or simply a wt gene associated disorder of intersex and nephropathy? frasier syndrome: a rare syndrome with wt gene mutation in pediatric urology mutation in the pax gene in twenty patients with aniridia wagr syndrome: a clinical review of cases the g syndrome of multiple congenital anomalies the bbb syndrome: familial telecanthus with associated congenital anomalies mig , a novel opitz syndrome gene product partner, is expressed in the embryonic ventral midline and co-operates with mid to bundle and stabilize microtubules xlinked opitz g/bbb syndrome: identifi cation of a novel mutation and prenatal diagnosis in a korean family genetic study of sox in a case of campomelic dysplasia molecularclinical spectrum of the atr-x syndrome a new detection method for atrx gene mutations using a mismatch-specifi c endonuclease prenatal diagnosis of atr-x syndrome in a fetus with a new g>t splicing mutation in the xnp/atr-x gene testicular biopsy, its value in male sterility testicular biopsy. further studies in male infertility interpretation of testicular biopsy testicular biopsy in the evolution of male infertility testicular causes of infertility pretesticular causes of infertility a quantitative approach to the classifi cation of hypospermatogenesis in testicular biopsies for infertility testicular biopsy for infertility: a review of sixty-eight cases with a simplifi ed histologic classifi cation of lesions testicular biopsy in azoospermia: a review of the last ten years. experience of over cases posttesticular causes of infertility histopathology and ultrastructure of meiotic arrest in human spermatogenesis refl ections on testicular biopsy testicular biopsy in evaluation of male infertility testicular biopsy in the study of male infertility. its current usefulness, histologic techniques, and prospects for the future testicular biopsy of azoospermic men with vas deferens malformation using two different techniques ultrastructural studies on testicular biopsies from eighteen cases of hypospermatogenesis serum and seminal gonadotropins in normal and infertile men: correlations with sperm count, prolactinemia, and seminal prolactin the relationship of biopsy evaluations and testicular measurements to overall daily sperm production in human testes the relationship between germinal cells and serum fsh levels in males with infertility inhibin b as a serum marker of spermatogenesis: correlation to differences in sperm concentration and follicle-stimulating hormone levels danish men inhibin b is a better marker of spermatogenesis than other hormones in the evaluation of male factor infertility the correlation between sperm count and testicular biopsy using a new scoring system testicular biopsy score count -a method for registration of spermatogenesis in human testes: normal values and results in hypogonadal males statistical study of a semiquantitative evaluation of testicular biopsies a method for quantitative analysis of human seminiferous epithelium quantitation of the cells of the seminiferous epithelium of human testis employing sertoli cells as a constant quantifi cation of human seminiferous epithelium. iii histological studies in infertile men with normal chromosome complements quantifi cation of human seminiferous epithelium. . histological studies in men with numerical and structural autosomal aberrations quantifi cation of human seminiferous epithelium. i histological studies in twenty-one fertile men with normal chromosome complements quantitative analysis of the seminiferous epithelium in human testicular biopsies, and the relation of spermatogenesis to sperm density quantifi cation of the human sertoli cell population: its distribution, relation to germ cell numbers, and age related decline quantitation of leydig cells in testicular biopsies of oligospermic men with varicocele a method for the quantifi cation of leydig cells in man seminiferous tubule hypercurvature: a newly recognized common syndrome of human male infertility branching of seminiferous tubules associated with hypofertility and chronic respiratory infection morphological and histometric study on the human sertoli cells from birth to the onset of puberty sertoli cell types in sertoli-cell-only syndrome: relationships between sertoli cell morphology and aetiology pathophysiological observations of sertoli cells in patients with germinal aplasia or severe germ cell depletion. ultrastructural fi ndings and hormone levels morphological evidence for two types of idiopathic 'sertoli-cell-only' syndrome enzyme histochemical studies on the pathological changes in human sertoli cells behaviour of glycogen and related enzymes in the sertoli cell syndrome hypoplasia túbulo intersticial difusa (hipogonadismo hipogonadotrópico) leydig cell differentiation induced by stimulation with hcg and hmg in two patients affected with hypogonadotropic hypogonadism the fi ne structure of the immature human testis in hypogonadotrophic hypogonadism hyperplasia and the immature appearance of sertoli cells in primary testicular disorders immunohistochemical detection of immature sertoli cell markers in testicular tissue of infertile adult men: a preliminary study maturation phenotype of sertoli cells in testicular biopsies of azoospermic men the human blood-testis barrier in impaired spermatogenesis reversion of the differentiated phenotype and maturation block in sertoli cells in pathological human testis leydig cell types in primary testicular disorders ectopic testis and the undescended testis: a histological comparison short arm dicentric y chromosome in a sterile man: a case report intermediate fi laments in sertoli cells urinary gonadotropins in the sertoli-cell-only syndrome impaired leydig cell function in vitro in testicular tissue from human males with 'sertoli cell only' syndrome testicular fsh and hcg receptors in sertoli-cell-only syndrome syndrome produced by absence of the germinal epithelium without impairment of the sertoli or leydig cells azfa deletions in sertoli cell-only syndrome: a retrospective study sertoli cell only syndrome in return of spermatogenesis after stopping cyclophosphamide therapy evidence for testicular impairment after long-term treatment with a luteinizing hormone-releasing hormone agonist in elderly men effects of estrogens on the testis of transsexuals: a pathological and immunocytochemical study response of the human testis to long-term estrogen treatment: morphology of sertoli cells, leydig cells and spermatogonial stem cells depressed testosterone release from testicular tissue in vitro after withdrawal of oestrogen treatment in patients with prostatic carcinoma tubular hyalinization in human testes the peritubular myofi broblasts in the testes from normal men and men with klinefelter's syndrome. a quantitative, ultrastructural, and immunohistochemical study laminin, type iv collagen, and fi bronectin in normal references and cryptorchid human testes. an immunohistochemical study testicular atrophy as a sequela of inguinal herniorrhaphy testis epididymis, and spermatic cord in elderly men. correlation of angiographic and histologic studies with systemic arteriosclerosis primary testicular lesions in the twisted testis infl ammation and infestation of the testis and paratesticular structures quantitative testicular biopsy in congenital and acquired genital obstruction the peritubular myoid cells in the testes from men with varicocele. an ultrastructural, immunohistochemical and quantitative study striated pattern of the testicle on ultrasound: an appearance of testicular fi brosis clinical importance of a unilateral striated pattern seen on sonography of the testicle suppressive effects of , -dibromo- - -chloropropane on human spermatogenesis signifi cance of testicular exfoliation in male infecundity laboratory manual for the examination of human semen and semen-cervical mucus interaction zytologische klassifi kation in reifer keimzellen im luftgetrockneten ejakulatanstrich beim spermatologische syndrom der vermehrten desquamation von zellen der spermatogenese (vdzs) transformed spermatocytes constituting the ejaculate of an infertile man studies on the differentiation of round cells in the human ejaculate diagnostic value of differential quantifi cation of spermatids in obstructive azoospermia seminal cytology in the presence of varicocele the pathophysiology of varicocele in male infertility obstruction of the tubuli recti and ductuli efferentes by dilated veins in the testes of men with varicocele and its possible role in causing atrophy of the seminiferous tubules scanning electron microscopic study on the shape of infertile seminiferous tubules: a hypothesis of pathogenesis of idiopathic male infertility the histopathology of acute mumps orchitis an azoospermic man with a double-strand dna break-processing defi ciency in the spermatocyte nuclei: case report association of three isoforms of the meiotic boule gene with spermatogenic failure in infertile men abnormal germ cell exfoliation in semen of hypogonadotrophic patients during a hcg treatment altered luteinizing hormone pulsatility in infertile patients with idiopathic oligoasthenozoospermia differential effect of luteinizing hormone-releasing hormone infusion on testicular steroids in normal men and patients with idiopathic oligospermia molecular heterogeneity of serum follicle-stimulating hormone in hypogonadal patients before and during androgen replacement therapy and in normal men men homozygous for an inactivating mutation of the folliclestimulating-hormone (fsh) receptor gene present variable suppression of spermatogenesis and fertility klassifi zierung tubulärer hodenatrophien bei sterilitätabklärungen testicular ultrastructure in infertile men ultrastructure of the nucleus of human sertoli cells in normal and pathological testes evaluation of the ultrastructural changes in the human sertoli cell in testicular disorders and the relationship of the changes to the levels of serum fsh abnormality of testicular fsh receptors in infertile men signifi cance of inhibin in reproductive pathophysiology and current clinical applications placebo-controlled trial of high-dose mesterolone treatment of idiopathic male infertility impaired leydig cell function in infertile men: a study of idiopathic infertile men and proven fertile controls leydig and sertoli cell function in normal and oligospermic males: a preliminary report leydig cell function in infertile men with idiopathic oligospermic infertility androgen insensitivity as a cause of infertility in otherwise normal men the frequency of androgen receptor defi ciency in infertile men malignant sex cord stromal tumor in a patient with the androgen insensitivity syndrome a new point mutation of the androgen receptor gene in a patient with partial androgen resistance and severe oligozoospermia the use of clomiphene citrate in the treatment of azoospermia secondary to incomplete androgen resistance evidence for a partial deletion in the androgen receptor gene in a phenotypic male with azoospermia androgen insensitivity and male infertility frequency of androgen insensitivity infertile phenotypically normal men improvement of spermatogenesis after treatment with the antiestrogen tamoxifen in a man with the incomplete androgen insensitivity syndrome a controlled comparison of the effi cacy of clomiphene citrate in male infertility pregnancy after hormonal correction of severe spermatogenic defect due to a mutation in androgen receptor gene occupational exposures associated with male reproductive dysfunction ultrastructural surface characteristics of seminiferous tubules from men with varicocele signifi cance of testicular size measurement in andrology. ii. correlation of testicular size with testicular function deterioration of semen parameters over time in men with untreated varicocele: evidence of progressive testicular damage quantitative evaluation of testicular biopsies in varicocele testis biopsy in subfertile men with varicocele testicular changes in subfertile males with varicocele classifi cation of several types of maturational arrest of spermatogonia according to sertoli cell morphology: an approach to aetiology prostate cancer. primary hormonal treatment focal atrophy of the seminiferous tubule in the human testis quantitative and ultrastructural study on germinal epithelium in testicular biopsies with 'mixed atrophy proliferation and functional maturation of sertoli cells, and their relevance to disorders of testis function in adulthood return of spermatogenesis after stopping cyclophosphamide therapy the frequency and morphology of 'giant spermatogonia' in the human testis seminiferous tubule involution in elderly men pattern of compartmentation in human seminiferous tubules showing dislocation of spermatogonia dislocated type-a spermatogonia in human seminiferous tubules intercellular bridges between megalospermatocytes in the human testis megalospermatocytes in the human testis exhibit asynapsis of chromosomes megalospermatocytes: indicators of disturbed meiosis in man multinucleate spermatids in aging human testes unusual incidence of binucleate spermatids in human cryptorchidism testicular and epididymal pathology spermatogenetic arrest with inhibition of acrosome and sperm tail development recent advances in human sperm pathology anomalies morphologiques du spermatozoide humain. propositions pour un système de classifi cation morphologische studien an abnormen spermatiden und spermatozoen des menschen classifi cation of abnormalities in human spermatids based on recent advances in ultrastructural research on spermatid differentiation morphology of spermatozoa in fertile man with and without varicocele on round headed human spermatozoa morphogenesis of round headed human spermatozoa lacking acrosomes in a case of severe teratozoospermia sperm acrosome defects in a patient with aarskog-scott syndrome failure of differentiation of the nuclear-perinuclear skeletal complex in the round-headed human spermatozoa human sperm acrosin activity with relation to semen parameters and acrosomal ultrastructure chromosome aneuploidy in the spermatozoa of two men with globozoospermia sperm chromosome aneuploidy analysis in a man with globozoospermia round head' sperm defect. ultrastructural and meiotic segregation study lack of acrosome formation in mice lacking a golgi protein human infertility due to production of multiple-tailed references spermatozoa with excessive amounts of dna multi-tailed spermatozoa in a case with asthenospermia and teratospermia human spermatozoa with large heads and multiple fl agella: a quantitative ultrastructural study of cases chromosomal analysis of spermatozoa with normal-sized heads in two infertile patients with macrocephalic sperm head syndrome crater defect in human spermatozoa ultrastructural study of human binucleate spermatids ultrastructural abnormalities of human spermatozoa cytoplasmic droplets: the good, the bad or just confusing? absence de la paire centrale du complexe axonemique dans une tératospermie avec fl agelles courts et épais asthenozoospermie totale avec anomalie ultrastructurale du fl agelle dans deux frères stériles dysplasia of the fi brous sheath. an ultrastructural defect of human spermatozoa associated with sperm immotility and primary sterility tail stump spermatozoa: morphogenesis of the defect. an ultrastructural study of sperm and testicular biopsy gene deletions in an infertile man with sperm fi brous sheath dysplasia multi-tailed spermatozoa in a case with asthenospermia and teratospermia sperm tail agenesis in a case of consanguinity ultrastructural study of the decapitates sperm defect in a infertile man morphogenesis of the decapitated and decaudated sperm defect in two brothers acephalic spermatozoa and abnormal development of the head-neck attachment: a human syndrome of genetic origin sperm structure and its relevance to infertility decapitated and decaudated spermatozoa in man, and pathogenesis based on the ultrastructure assisted reproduction for infertile patients with + immotile spermatozoa associated with autosomal dominant polycystic kidney disease spermatozoa and cilia lacking axoneme in an infertile man lack of dynein arms in immotile human spermatozoa diagnostic approach to primary ciliary dyskinesia: a review primary ciliary dyskinesia: a review anomalies of lateralization in man: a case of total situs inversus stiff-tail-oder mittelstück-syndrom pour development of outer dense fi bres as a mayor cause of tail abnormalities in the spermatozoa of asthenoteratozoospermic men human mtdna haplogroups associated with high or reduced spermatozoa motility male infertility and mitochondrial dna carcinoma in situ in testicular biopsies from men presenting with infertility carcinoma in situ of the testis in infertile men. a histological, immunocytochemical and cytophotometric study of dna content early testicular cancer in severe oligozoospermia carcinoma-insitu of the testis: possible origin from gonocytes and precursor of all types of germ cell tumours except spermatocytoma male subfertility. continuing diagnostic and therapeutic measures testicular cancer risk in boys with maldescended testis: a cohort study seminoma discovered in two males undergoing successful testicular sperm extraction for intracytoplasmic sperm injection screening for carcinoma in situ of the contralateral testis in patients with germinal testicular cancer the incidence of seminoma and expression of cell adhesion cd in cryptorchid boys and infertile men a novel androgen receptor mutation resulting in complete androgen insensitivity syndrome and bilateral leydig cell hyperplasia leydig cell hyperplasia mimicking testicular neoplasm increased mast cells in the limiting membrane of seminiferous tubules in the testes of patients with idiopathic infertility testicular mast cell heterogeneity in idiopathic male infertility mast cells in testicular lesions ketotifen improves sperm motility and sperm morphology in male patients with leukocytospermia and unexplained infertility an attempt to explain occurrence of patent reproductive tract in azoospermic males with tubular spermatogenesis quantitative analysis of testicular biopsy: determination of partial obstruction and prediction of sperm count after surgery for obstruction correlation between spermatozoon numbers in spermiogram and seminiferous epithelium histology in testicular biopsies from subfertile men alpha- , -glucosidase activity and the presence of germinal epithelium cells in the semen for differential diagnosis of obstructive and nonobstructive azoospermia ejaculatory duct obstruction in subfertile males: analysis of patients paratesticular cysts with benign epithelial proliferations of wolffi an origin von hippel-lindau disease prevalence of epididymal, seminal vesicle, prostate, and testicular cysts in autosomal dominant polycystic kidney disease congenital anomalies of the vas deferens, epididymis, and seminal vesicles etiologic factors in consecutive cases of male infertility male fertility and positive chlamydial serology. a study of fertile and subfertile men relationship of bacteriologic characteristics to semen indices in men attending an infertility clinic treatment of bacterial urinary tract infections: presence and future relationship of azoospermia to inguinal surgery coarse granular cytoplasmic change of the epididymis. an immunohistochemical and ultrastructural study histology of the epididymis in men with obstructive infertility quantitative testicular biopsy in spinal cord injured men: comparison to fertile controls some gross observations of the epididymides following vasectomy: a clinical study chronic testicular pain following vasectomy quantitative pathologic changes in the human testis after vasectomy. a controlled study consequences of vasectomy: an immunological and histological study related to subsequent fertility the status of vasectomy reversals a fi fteen-year study of alterations in semen quality occurring after vasectomy reversal surgical treatment of male infertility young's syndrome: obstructive azoospermia and chronic sinopulmonary infections respiratory tract disease and obstructive azoospermia obstructive azoospermia: respiratory function tests, electron microscopy and the results of surgery varicose axon bearing 'synaptic' vesicles on the basal lamina of the human seminiferous tubules oxytocin mediates the estrogendependent contractile activity of endothelin- in human and rabbit epididymis comparison of the effectiveness of placebo and alpha-blocker therapy for the treatment of idiopathic oligozoospermia screening for abnormalities of chromosomes x, y, and and for diploidy in spermatozoa from infertile men participating in an vitro fertilization-intracytoplasmic sperm injection program cytogenetic study of subfertile men: incidence and clinical features syndrome characterized by gynecomastia, aspermatogenesis without aleydigism and increased excretion of follicle-stimulating hormone infertility in the klinefelter syndrome control of meiotic process klinefelter syndrome endocrine features of klinefelter's syndrome clinical and diagnostic features of patients with suspected klinefelter syndrome clinical and therapeutic experiences with klinefelter's syndrome brain morphology in klinefelter syndrome: extra x chromosome and testosterone supplementation their fi ne structure in three cases of klinefelter's syndrome dimorphism in sex chromatin pattern of sertoli cells in adults with klinefelter'ssyndrome: correlation with two types of 'sertoli-cell-only' tubes leydig cell counts in chromatin-positive klinefelter's syndrome quantitative and ultrastructural study of leydig cells in klinefelter'ssyndrome etude en microscopie électronique de references la cellule de leydig dans la maladie de klinefelter en périodes pre, per et postpubertaires testicular function in klinefelter's syndrome testosterone and δ androstenedione in the saliva of patients with klinefelter's syndrome fine structure of spermatogenesis in klinefelter's syndrome spermatogenesis in klinefelter's syndrome pdg in ,xxy klinefelter's syndrome patients risk of trisomy in offspring of patients with klinefelter's syndrome a new chromosome constitution in klinefelter's syndrome a male with xxyy chromosomes do the xxyy males have a characteristic phenotype? genetics and endocrine fi ndings in a xxyy male dermatoglyphics associated with the xxyy chromosome complement ultrastructure of leydig cells in klinefelter's syndrome with xxyy karyotype primary amentia and microorchidism associated with an xxxy sex-chromosome constitution ,xxxxy syndrome with diabetes mellitus a child with chromosomes carcinoma of the male breast in association with klinefelter's syndrome male breast cancer klinefelter's syndrome and breast cancer seminoma in klinefelter's syndrome with xxy, s+ karyotype klinefelter's syndrome and mediastinal teratoma extragonadal germ cell tumor in the retrovesical region associated with klinefelter's syndrome: a case report and review of literature primary mediastinal embryonal carcinoma in association with klinefelter's syndrome the malignant potential of the dysgenetic germ cell in klinefelter's syndrome simian papovavirus transformation of cells from cancer patient with xy/xxy mosaic klinefelter's syndrome isolated primary aldosteronism in a patient with adrenal carcinoma and xy/xxy klinefelter's syndrome acute leukemia following a malignant teratoma in a child with klinefelter's syndrome hematologic malignancies and klinefelter syndrome. a chance association? prostate cancer in klinefelter syndrome during hormonal replacement therapy the prepubertal testicular lesion in chromatin-positive klinefelter's syndrome (primary micro-orchidism). as seen in mentally handicapped children mental development in polysomy x klinefelter syndrome ( ,xxy; ,xxxy): effects of incomplete x inactivation klinefelter syndrome is a common cause for mental retardation of unknown etiology among prepubertal males growth and body proportions in boys and men with klinefelter's syndrome disorders of sex differentiation klinefelter syndrome klinefelter syndrome and its variants: an update and review for the primary pediatrician early androgen defi ciency in infants and young boys with ,xxy klinefelter syndrome klinefelter's syndrome in a ten month old mongolian idiot síndrome de klinefelter's xxy en el periodo prepuberal. estudio de ocho observaciones natural history of seminiferous tubule degeneration in klinefelter syndrome klinefelter syndrome and mediastinal germ cell tumors central precocious puberty in ,xxyy klinefelter syndrome variant a case of klinefelter's syndrome with acquired hypopituitarism klinefelter's syndrome with hypogonadotropic hypogonadism chromatinpositive klinefelter's syndrome with undetectable peripheral fsh levels a case of hypogonadotrophic hypogonadism with an xy/xxy chromosome mosaicism klinefelter's syndrome with hypogonadotrophic hypogonadism xxy klinefelter's syndrome with low fsh and lh levels and absence of leydig cells a case of xx-male syndrome x/ xx boy with hypospadias: case report xx sex chromosomes in a human male. first case xx sex reversal, palmoplantar keratoderma, and predisposition to squamous cell carcinoma: genetic analysis in one family analytic review: nature and origin of males with xx sex chromosomes leydig cell ultrastructure in an xx male varón con cariotipo xx ultrastructure of testicular biopsy from an xx male le testicule chez l'homme , xx: a propos d'une observation ultrastructural ultrastructure of the testis in an xx male with normal plasma testosterone sex determination and sex reversal: genotype, phenotype, dogma and semantics clinical case of the month. a male with ,xx karyotype x-y chromosomal interchange in the etiology of true hermaphroditism and of xx klinefelter's syndrome a possible etiology of the infertile xx male subject deletion mapping of the testis determining locus with dna probes in xx males and xy and x dic (y) females dna hybridization study using yspecifi c probes in an xx-male localization of the sex-determining region-y gene in xx males xx male: clinical, hormonal/ genetic fi ndings a comparative genomic hybridization study in a ,xx male an xx male with the sexdetermining region y gene inserted in the long arm of chromosome deoxyribonucleic acid and cytological detection of y-containing cells in a xx hypospadic boy with polyorchidism xx males without sry gene and with infertility sry-negative ,xx male with normal genitals, complete masculinization and infertility genotype-phenotype correlations in xx males and their bearing on current theories of sex determination a regulatory cascade hypothesis for mammalian sex determination: sry represses a negative regulator of male development xx sex reversal with partial duplication of chromosome arm q clinical, hormonal and cytogenetic evaluation of ,xx males and review of the literature xyy human male xyy chromosome abnormality in sexual homicide perpetrators the xyy syndrome: a follow-up study on boys testicular function in xyy men quantifi cation of human seminiferous epithelium. ii. histological studies in eight , xyy men persistence of two y chromosomes through meiotic prophase and metaphase i in an xyy man from spermatocytes to spermatozoa in an infertile xyy male sex chromosome pairing and male fertility the role of unpaired sex chromosomes in spermatogenetic failure evidence for an association between univalent y chromosomes and spermatocyte loss in xyy mice and men meiosis in xyy men pituitary gonadotrophins and -ketosteroids in patients with the xyy syndrome analysis of the sex chromosome constitution of sperm in men with a ,xyy mosaic karyotype by fl uorescence in situ hybridization a male subject with y chromosomes ( ,xyyy): a case report triple-y syndrome following icsi treatment in a couple with normal chromosomes: case report xyyyy. a case report tetrasomy y by structural rearrangement: clinical report human y chromosome function in male germ cell development (review) defi ning regions of the ychromosome reponsible for male infertility and identifi cation of a fourth azf region (azfd) by ychromosome microdeletion characterization of novel genes in azf regions localization of factors controlling spermatogenesis in the nonfl uorescent portion of the human y chromosome long arm severe oligozoospermia resulting from deletions of references azoospermia factor gene on y chromosome yq deletion and failure of spermatogenesis yq deletion with short stature, abnormal male development, and schizoid character disorder fish characterization of a dicentric yq (p . ) isochromosome in an azoospermic male the y chromosome, part b. clinical aspects of y chromosome abnormalities short arm dicentric y chromosome with associated statural defect in a sterile man four new cases of dicentric y chromosomes meiotic studies on a subfertile patient with a ring y chromosome mosaic ring y chromosome in two normal healthy men with azoospermia ring (y) in two azoospermic men the y chromosome part b: clinical aspects of y chromosome abnormalities an abnormal terminal x-y interchange accounts for most but not all cases of human xx maleness cytogenetic, molecular and testicular tissue studies in an infertile ,x male carrying an unbalanced (y; ) translocation: case report unique t(y; )(q ; q ) reciprocal translocation with loss of the heterochromatic region of chromosome in a male with azoospermia due to meiotic arrest: a case report y; autosome translocations and mosaicism in the aetiology of ,x maleness: assignment of fertility factor to distal yq ll characterization of a (y; ) translocation by dna hybridization genome analysis: from sequence to function submicroscopic delections in the y chromosome of infertile men y-chromosome deletions in idiopathic severe testiculopathies prevalence of y chromosome microdelections in oligospermic and azoospermic candidates for intracytoplasmic sperm injection y-chromosome microdeletions and recurrent pregnancy loss molecular scanning of yq (interval ) in men with sertoli-cellonly syndrome y chromosome variants and male reproductive function a duplication of distal xp associated with hypogonadotrophic hypogonadism, hypoplastic external genitalia, mental retardation, and multiple congenital abnormalities the behavior of sex chromosomes in two human xautosome translocations: failure of extensive -inactivation spreading icsi and the transmission of xautosomal translocation: a threegeneration evaluation of x; translocation: case report xxx male: a clinical and molecular study chromosome complements in sperm from three men heterozygous for reciprocal translocations and a review of the literature analysis of sperm chromosome complements from a man heterozygous for a pericentric inversion of chromosome an excess of chromosome breakpoints in male infertility unbalanced chromosomal translocation associated with sertoli-cell-only histology urological manifestations of down syndrome hormone profi les and contralateral testicular histology in down's syndrome with unilateral testicular tumor down syndrome and male fertility: pcr-derived fi ngerprinting, serological and andrological investigations successful pregnancy and delivery from frozen-thawed embryos after intracytoplasmic sperm injection using round-headed spermatozoa and assisted oocyte activation in a globozoospermic patient with mosaic down syndrome maturation delay of germ cells in fetuses with trisomy results in increased risk for the development of testicular germ cell tumors down syndrome in the male. reproductive pathology and meiotic studies hypogonadism due to primary testicular failure correlation between ctg trinucleotide repeat length and frequency of severe congenital myotonic dystrophy size of the unstable ctg repeat sequence in relation to phenotype and prenatal transmission in myotonic dystrophy relationship between parenteral trinucleotide ctg repeat length and severity of myotonic dystrophy in offspring myotonic dystrophy: clinical and molecular parallels between myotonic dystrophy type and type infl uence of sex of the transmitting parent as well as of parental allele size on the ctg expansion in myotonic dystrophy (dm) ctg amplifi cation in the dm pk gene is not associated with idiopathic male subfertility correlations between individual clinical manifestations and ctg repeat amplifi cation in myotonic dystrophy increasing infertility in myotonia dystrophica curschmann-steinert. a case report dystrophin characterization in muscle biopsies from duchenne and becker muscular dystrophy patients dystrophin, its interactions with other proteins, and implications for muscular dystrophy cloning of two new human helicase genes of the recq family: biological signifi cance of multiple species in higher eukaryotes positional cloning of the werner's syndrome gene chromosomal breakage in human spermatozoa, a heterozygous effect of the bloom syndrome mutation recql -defi cient cells are hypersensitive to oxidative stress/ damage: insights for osteosarcoma prevalence and heterogeneity in rothmund-thomson syndrome cockayne's syndrome with unusual retinal involvement (report of one family) eccrine sweat gland anatomy in cockayne syndrome: a possible diagnostic aid cockayne's syndrome: a case report. literature review trichothiodystrophy associated with photosensitivity, gonadal failure, and striking osteosclerosis mapping a gene for noonan syndrome to the long arm of chromosome noonan syndrome and related disorders: genetics and pathogenesis testicular biopsy and hormonal study in a male with noonan's syndrome purkinje cell degeneration associated with erythroid ankyrin defi ciency in nb/nb mice ataxia and male sterility (ams) mouse. a new genetic variant exhibiting degeneration and loss of cerebellar purkinje cells and spermatic cells molecular structure of the human gonadotropin-releasing hormone receptor gene gonadotropin-releasing hormone defi ciency in the human (idiopathic hypogonadotropic hypogonadism and kallmann's syndrome): pathophysiological and genetic considerations algunos aspectos del eunucoidismo hipogonadotrópico complete hypogonadotropic hypogonadism associated with a novel inactivating mutation of the gonadotropin-releasing hormone receptor synchronization of augmented luteinizing hormone secretion with sleep during puberty predictors of outcome of longterm gnrh therapy in men with idiopathic hypogonadotropic hypogonadism hypogonadism due to secondary testicular failure falta total de nervios olfatorios con anosmia en un individuo en quien existía una atrofi a congénita de los testículos y miembro viril the genetic aspects of primary eunuchoidism la dysplasie olfacto-génitale polysialic acid facilitates migration of luteinizing hormonereleasing hormone neurons on vomeronasal axons mechanisms of disease: insights into x-linked and autosomal-dominant kallmann syndrome mutations in fi broblast growth factor receptor cause kallmann syndrome with a wide spectrum of reproductive phenotypes pulsatile gonadotropin-releasing therapy in male patients with kallmann's syndrome or constitutional delay of puberty hipogonadismo hipogonadotrópico con anosmia electron microscopic studies of testes in kallmann syndrome seminoma in hypogonadotropic hypogonadism associated with anosmia (kallmann's syndrome) clinical and hormonal features of selective follicle-stimulating hormone (fsh) defi ciency due to fsh βsubunit gene mutations in both sexes human fsh β subunit gene is highly conserved isolated folliclestimulating hormone defi ciency in men: successful long-term gonadotropin therapy síndrome hipoandrogénico con gametogénesis conservada: clasifi cación de la insufi ciencia testicular hypoandrogenic syndrome with spermatogenesis a syndrome of eunuchoidism with spermatogenesis, normal urinary fsh, and low-normal icsh ('fertile eunuchs') fertile eunuch syndrome with the mutations (trp arg and ile thr) in the β subunit of luteinizing hormone the fertile eunuch variant of idiopathic hypogonadotropic hypogonadism: spontaneous reversal associated with a homozygous mutation in the gonadotropinreleasing hormone receptor hypogonadism caused by a single amino acid substitution in the β subunit of luteinzing hormone fsh β gene mutations in a female with partial breast development and a male sibling with normal puberty and azoospermia gonadal function and response to growth hormone (gh) in boys with isolated gh defi ciency and to gh and gonadotropins in boys with multiple pituitary hormone defi ciencies ein syndrom von adipositas, kleinwuchs, kryptorchismus, und oligophrenie nach myotonieartigen zustand in neugeborenenalter hypothalamic and gonadal components of hypogonadism in boys with prader-labhart-willi syndrome cryptorchidism in the prader-willi syndrome síndrome de prader-willi a fi fth locus for bardet-biedl syndrome maps to chromosome q bardet-biedl syndrome: an emerging pathomechanism of intracellular transport an atypical contiguous gene syndrome: molecular studies in a family with xlinked kallmann's syndrome and xlinked ichthyosis johnson-mcmillin syndrome: report of a new case with novel features a single ataxia telangiectasia gene with a product similar to pi- kinase ataxiatelangiectasia and related diseases the friedreich's ataxia gene encodes a novel phosphatidylinositol- -phosphatase -kinase friedreich ataxia: detection of gaa repeat expansions and frataxin point mutations endocrine evaluation of infertile men idiopathic hypogonadotropic hypogonadism in a male runner is reversed by clomiphene citrate endocrine function after spontaneous infarction of the human pituitary acquired hypogonadotropic hypogonadism presenting as decreased seminal volume gonadotropin-secreting pituitary adenoma with concomitant hypersecretion of testosterone and elevated sperm count. treatment with lrh agonists testicular enlargement and elevated serum inhibin concentrations occur in patients with pituitary macroadenomas secreting follicle stimulating hormone the impotent couple: low desire immunohistochemical detection of prolactin and its receptors in human testis ultrastructural lesions in testes from hyperprolactinemic men infl uence of serum prolactin on semen characteristics and sperm function return of gonadal function in men with prolactin-secreting tumors serum levels of free and bound testosterone in hyperthyroidism testicular function in hyperthyroidism graves'autoimmune serum inhibits gonadal steroidogenesis. development of a leydig cell bioassay to identify broad spectrum anti-endocrine autoantibodies male hypogonodism in hypothyroidism: a study of six cases male reproductive function in relation with thyroid alterations testicular dysfunction in men with primary hypothyroidism; reversal of hypogonadotropic hypogonadism with replacement thyroxine primary hypothyroidism and human spermatogenesis serum hormones and seminal parameters in males with thyroid disturbance thyroid function and puberty prepubertal diagnosis of x-linked congenital adrenal hypoplasia presenting after infancy x-linked adrenal hypoplasia congenita and hypogonadotropic hypogonadism: report on new mutation of the dax- gene in two siblings x-linked adrenal hypoplasia congenita: a mutation in dax expands the phenotypic spectrum in males and females genotyping of congenital adrenal hyperplasia due to -hydroxylase defi ciency presenting as male infertility: case report and literature review male infertility due to congenital adrenal hyperplasia: testicular biopsy fi ndings, hormonal evaluation, and therapeutic results in three patients adrenal rest tumors of the testes bilateral testicular adrenal rests in a patient with -hydroxylase defi cient congenital adrenal hyperplasia infertility caused by bilateral testicular masses secondary to congenital adrenal hyperplasia ( -hydroxylase defi ciency) elevated -hydroxyprogesterone and testosterone in a newborn with β-hydroxysteroid dehydrogenase defi ciency. n eng l congenital alfa-hydroxylase defi ciency: a clinico-pathologic study bilateral tumors of the testis in -alpha hydroxylase defi ciency without adrenal hyperplasia estrogen secreting adrenal adenocarcinoma in an -month-old boy: aromatase activity, protein expression, mrna and utilization of gonadal type promoter diabetes mellitus/male infertility growth, puberty, and fi nal height in children with type diabetes insulin-dependent diabetes affects testicular function by fshand lh-linked mechanisms semen characteristics and diabetes mellitus: signifi cance of insulin in male infertility interstitial compartment pathology and spermatogenic disruption in testes from impotent diabetic men autonomic neuropathy and sexual impotence in diabetic patients: analisis of cardiovascular refl exes mutation analysis for heterozygote detection and the prenatal diagnosis of cystic fi brosis cftr gene mutations and male infertility infertility in male patients with cystic fi brosis anomalies du sperme, des defferents et de l'epididyme dans la mucoviscidose a mutation in the second nucleotide binding fold of the cystic fi brosis gene cystic fi brosis in infertility: screening before assisted reproduction: opinion autosomal recessive hereditary congenital aplasia of the vasa deferentia in four siblings congenital bilateral absence of the vas deferens. a primary genital form of cystic fi brosis congenital mesonephric defects in male infants with mucoviscidosis genital abnormalities in male patients with cystic fi brosis la reviviscenza mammaria nell'uomo affecto da cirrosi del laennec sulla c.d. reviviscenza della mammella maschile nella cirrosi epatica (nota preventiva) hypogonadism in alcoholic liver direase: evidence for a double defect effect of chronic alcoholism on semenstudies on lipid profi les alterations of testicular morphology in alcoholic disease differential binding of testosterone and oestradiol to isoforms of sex hormone binding glolulim: selective alteration of estradiol binding in cirrhosis group for liver diseases. serum testosterone concentration in men with alcoholic cirrhosis: background for variation sexual function and testosterone levels in men with nonalcoholic liver disease testicular function and fertility in men with homozygous alpha- antitrypsin defi ciency hereditary hemochromatosis haemochromatosis and hla-h a novel mhc class -like gene is mutated in patients with hereditary haemochromatosis clinical and molecular aspects of juvenile hemochromatosis in saguenay juvenile hemochromatosis locus maps to chromosome q juvenile hemochromatosis a -year-old patient with decreased libido and erectile dysfunction as initial manifestations of hemochromatosis endocrine complications of genetic hemochromatosis hypogonadism in hereditary hemochromatosis the anterior pituitary in hemochromatosis reversibility of hypogonadotropic hypogonadism in a patient with the juvenile form of hemochromatosis polycystic kidney disease and infertility: case report and literature review infertility in adults with references polycystic kidney disease male infertility and adult polycystic kidney disease are associated with necrospermia seminal vesicle cysts and infertility in autosomal dominant polycystic kidney disease clinical relevance of scrotal and transrectal ultrasonography in andrological patients testosterone esters advance skeletal maturation more than growth in short boys with chronic renal failure and delayed puberty discordant elevation of the common alpha subunit of the glycoprotein hormones compared to β subunits in serum of uremic patients the pituitary testicular axis in men with chronic renal failure pathology of endocrine organs in chronic renal failure. an autopsy analysis of patients calcifi cation of the epididymis and the tunica albuginea of the corpora cavernosa in patients on maintenance hemodialysis novel insights into uremic vascular calcifi cation: role of matrix gla protein and alpha- -heremans schmid glycoprotein/fetuin cystic transformation and calcium oxalate deposits in rete testis and efferent ducts in dialysis patients gonadal dysfunction in uremic men. a study of the hypothalamo-pituitarytesticular axis before and after renal transplantation pathogenesis of endocrine abnormalities in uremia hypothalamic-pituitary function in uremia zinc defi ciency in men with crohn's disease may contribute to poor sperm function and male infertility sperm nucleomalacia in men with infl amatory bowel disease the effects of sulphasalazine on human male fertility potencial and seminal prostaglandins mesalazineinduced reversible infertility in a young male sulphasalazine and -aminosalicylic acid in long-term treatment of ulcerative colitis: report on tolerance and side-effects testosterone replacement for hypogonadism: clinical fi ndings and best practices hiv-associated hypogonadism hypogonadism and wasting in the era of haart in hiv-infected patients prevalence of hypogonadism among men with weight loss related to human immunodefi ciency virus infection who were receiving highly active antiretroviral therapy loss of lean body mass and muscle mass correlates with androgen levels in hypogonadal men with acquired immunodefi ciency syndrome and wasting effects of hypogonadism and testosterone administration on depression indices in hiv-infected men gonadal hormone levels in injection drug users endocrine disorders in men infected with human immunodefi ciency virus testicular pathologic changes and the pituitary-testicular axis during human immunodefi ciency virus infection adrenal and testicular function in boys affected by thalassemia italian working group on endocrine complications in non-endocrine diseases. impact of long-term iron chelation therapy on growth and endocrine functions in thalassaemia pubertal evaluation of adolescent boys with β-thalassemia major and delayed puberty prevalence of growth and puberty failure with respect to growth hormone and gonadotropins secretion in βthalassemia major growth and puberty and its management in thalassaemia spontaneous and gnrhprovoked gonadotropin secretion and testosterone response to human chorionic gonadotropin in adolescent boys with thalassaemia major and delayed puberty inhibin b in men with severe obesity and after weight reduction following gastroplasty obesity and reproductive disorders: a review obesity, fat distribution and infertility mutational analysis of the autoimmune regulator (aire) gene in sporadic autoimmune addison's disease can reveal patients with unidentifi ed autoimmune polyendocrine syndrome type l autoimmune regulator (aire) gene on chromosome : implications for autoimmune polyendocrinopathycandidiasis-ectodermal dystrophy (apeced) any more common manifestations of endocrine autoimmunity adrenal and gonadal autoimmune diseases identifi cation by molecular cloning of an autoantigen associated with addison's disease as steroid alphahydroxylase two different cytochrome p enzymes are the adrenal antigens in autoimmune polyendocrine syndrome type i and addison's disease prevalence and clinical associations of defi ned autoantibodies in autoimmune polyendocrine syndrome type i polyglandular autoinmune syndromes isolated gonadotrope failure in the polyglandular autoimmune syndrome endocrine dysfunction in patients with fabry disease testicular and epididymal involvement in fabry's disease safety and effi cacy of recombinant human alpha-galactosidase a replacement therapy in fabry's disease fabry disease, an underrecognized multisystemic disorder: expert recommendations for diagnosis, management, and enzyme replacement therapy enzyme replacement therapy and renal function in patients with fabry disease putative x-linked adrenoleukodystrophy gene shares unexpected homology with abc transporters gonadal mosaicism in a family with adreno-leukodystrophy. molecular diagnosis of carrier status among daughters of a gonadal mosaic when direct detection of the mutation is not possible x-linked adrenoleukodystrophy: role of very long-chain acyl-coa synthetases adrenal and testicular function in patients with adrenoleukodystrophy or adrenomyeloneuropathy the testis in adreno-leukodystrophy in situ localization of the genetic locus encoding the lysosomal acid lipase/cholesteryl esterase (lipa) defi cient in wolman disease to chromosome q . -q . enfermedad de wolman. estudio anatomopatológico de dos observaciones autopsy report of an adult case with a long-standing subclinical course complicated by accelerated atherosclerosis and liver carcinoma successful treatment of wolman disease by unrelated umbilical cord blood transplantation pituitary-testicular function in nephropathic cystinosis lysosomal diseases environmental infl uences on male reproductive health occupational exposures associated with male reproductive dysfunction semen quality in fertile us men in relation to geographical area and pesticide exposure semen quality of workers occupationally exposed to hydrocarbons semen quality in workers exposed to carbon disulfi de compared to a control group from the same plant endocrinologic studies in men exposed occupationally to carbon disulfi de y-chromosomal nondysjunction in dibromochloropropane exposed workmen inorganic lead exposure in battery and paint factory: effect on human sperm structure and functional activity reproductive ability of workmen occupationally exposed to lead endocrine and reproductive dysfunction in men associated with occupational inorganic lead intoxication occupational exposure to synthetic estrogens: some methodological problems association of diethylstilbestrol exposure in utero with cryptorchidism, testicular hypoplasia and semen abnormalities altered semen quality in relation to urinary concentrations of phthalate monoester and oxidative metabolites current use of pesticides in poland and the risk of reproductive disorders the environment and male fertility: recent research on emerging chemicals and semen quality exposure to exogenous estrogens in food: possible impact on human development and health testicular dysgenesis syndrome; an increasingly common developmental disorder with environmental aspects environmental infl uences on male reproduction effects of delta- -tetrahydrocannabinol, the primary psychoactive cannabinoid in marijuana, on human sperm function in vitro effect of cocaine on germ cell apoptosis in rats at different ages effect of chronic alcoholism on male fertility hormones and semen quality effect of smoking on semen parameters of men attending an infertility clinic concomitant abuse of anabolic androgenic steroids and human chorionic gonadotrophin impairs spermatogenesis in power athletes the infl uence of radiation on fertility in man gonadal function in workmen with long term exposure to microwaves effects of artifi cial cryptorchidism on sperm morphology spermatogenic arrest in men with testicular hyperthermia the effect of hyperthermia on ornithine decarboxylase activity in different rat tissue effects of l-acetylcarnitine (lac) on the post-injury recovery of mouse spermatogenesis monitored by fl ow cytometry. recovery after hyperthermic treatment the role of carnitine in spermatozoa metabolism. substrate induced elevations in the acetylation state of carnitine and coenzyme a in bovine and monkey spermatozoa in vitro temperature sensitivity of dna, rna, and protein synthesis throughout puberty in human testis traumatic dislocation of testes and bladder rupture report of new cases and review of the literature traumatic dislocation of testis traumatic testicular dislocation a review of cases restoration of spermatogenesis by orchiopexy years after bilateral traumatic testicular dislocation sexuality and fertility in long-term survivors of testicular cancer fertility and pregnancy after treatment for cancer during childhood or adolescence male gonadal dose in adjuvant -d-pelvic irradiation after anterior resection of rectal cancer. infl uence to fertility recovery from aspermia induced by low-dose radiation in seminoma patients aspermia following lower truncal irradiation in hodgkin's disease testicular function in eight patients with seminoma after unilateral orchidectomy and radiotherapy paternity after irradiation for testicular cancer gonadal function in patients with differentiated thyroid cancer treated with ( )i effects of electromagnetic radiation from a cellular phone on human sperm motility: an in vitro study development of the seminiferous epithelium during and after treatment for acute lymphoblastic leukemia in childhood gonadal effects of cancer therapy in boys the effects of different cumulative doses of chemotherapy on testicular function impact of cyclophosphamide on long-term reduction in sperm count in men treated with combination chemotherapy for ewing and soft tissue sarcomas sertoli cell inactivation by cytotoxic damage to the human testis after cancer chemotherapy leydig cell dysfunction and gynaecomastia in adult males treated with alkylating agents testicular and sperm dna damage after treatment with fl udarabine for chronic lymphocytic leukaemia . van den berg h, furstner f, van den bos c, behrendt h. decreasing the number of mopp courses reduces gonadal damage in survivors of childhood hodgkin disease effects of the chemotherapy cocktail used to treat testicular cancer on sperm chromatin integrity sperm integrity pre-and postchemotherapy in men with testicular germ cell cancer testicular dysfunction in hodgkin's disease before and after treatment posttreatment fertility in patients with testicular cancer. part sexual function after bilateral retroperitoneal lymph node dissection for nonseminomatous testicular cancer sexual dysfunction and electroejaculation in men with spinal cord injury: review infertilty in the spinal cord injuried male reproductive biology of paraplegics: results of semen collection, testicular biopsy and serum hormone evaluation auto-immunity to spermatozoa and quality of semen in men with spinal cord injury histological and hormonal testicular changes in spinal cord patients male fertility and sexual function after spinal cord injury current trends in the treatment of infertility in men with spinal cord injury spermatogenese bei patienten mit traumatischer querschnittähmung deep scrotal temperature and the effect on it of clothing, air, temperature, activity, posture and paraplegia neurological correlations of ejaculation and testicular size in men with a complete spinal cord section leukocytes in semen from men with spinal cord injuries leukocyte subtypes in electroejaculates of spinal cord injured men infl ammatory cytokine concentrations are elevated in seminal plasma of men with spinal cord injuries testis biopsy fi ndings in the spinal cord injured patient seminal vesicle aspiration in spinal cord injured men: insight into poor sperm quality sperm motility from the vas deferens of spinal cord injured men is higher than from the ejaculate brown-colored semen in men with spinal cord injury mumps orchitis: report of a mini-epidemic mumps orchitis mumps -an underestimated disease mumps orchitis among soldiers: frequency, effect on sperm quality, and sperm antibodies mumps orchitis: symptoms and treatment possibilities pathology of mumps orchitis successful testicular sperm extraction and fertilization in an azoospermic man with postpubertal mumps orchitis infl ammation of the testis, epididymis, peritesticular membranes and scrotum orchitis and testicular abscess formation caused by non-typhoid salmonellosis disseminated actinomycosis presenting as a testicular mass. a case report primary testicular actinomycosis mimicking metastatic tumor xanthogranulomatous funiculitis and orchiepididymitis: report of cases with immunohistochemical study and literature review tuberculous epididymitis occurring years after renal tuberculosis tuberculous epididymitis as a cause of testicular pseudomalignancy in two young children tuberculous epididymo-orchitis. diagnosis by fi ne needle aspiration tuberculous epididymo-orchitis. a case report epididymo-orchitis caused by intravesically instillated bacillus calmette-guérin: genetically proven using a multiplex polymerase chain reaction method gumma of testis lepromatous leprosy presenting as orchitis clinicopathological study of testicular involvement in leprosy genital manifestations of tropical diseases human brucellosis in northern saudi arabia epididymoorchitis due to brucellosis in central anatolia brucellar orchiepididymitis in acute brucellosis brucella orchitis: a rare cause of testicular enlargement orquioepididimitis brucelosa: a propósito de un caso rapid diagnosis of brucella epididymo-orchitis by realtime polymerase chain reaction assay in urine samples epididymal sarcoidosis sarcoidosis with bilateral epididymal and testicular lesions sarcoidosis presenting as a testicular mass sarcoid of the testis genitourinary involvement of systemic sarcoidosis confi ned to testicle seminoma and sarcoidosis: an unusual association intermittent azoospermia associated with epididymal sarcoidosis ueber einschlüsse in blastumoren a case of malacoplakia of the epididymis associated with trauma epididymo-testicular malacoplakiaa case report an unusual case of malakoplakia involving the testis and prostate testicular malacoplakia septate junctions between digestive vacuoles in human malakoplakia genitourinary tract involvement with systemic mycosis coccidioidomycosis of the epididymis and testis cryptococcal epididymoorchitis complicating steroid therapy for releasing polychondritis schistosomal epididymitis alveolar echinococcosis with involvement of the ureter and testes idiopathic granulomatous orchitis: pathologic study of one case experimental allergic orchitis in mice. histopathological and immunological studies immunological phenomena observed in the testis and their possible role in infertility immunocompetent cells in human testis in health and disease sympathetic autoimmune orchitis testicular obstruction: clinicopathological studies hypoechoic lesion found on testicular ultrasound after testicular piercing focal orchitis in undescended testes: discussion of pathogenetic mechanisms of tubular atrophy pseudolymphoma of the testis plasma cell granuloma of the testis: unusual localization testicular plasmacytoma: report of a case and review of the literature sinus histiocytosis with massive lymphadenopathy (rosai-dorfman disease): report of a patient with isolated renotesticular involvement after cure of non-hodgkin's lymphoma rosai-dorfman disease of the testis: an unusual entity that mimics testicular malignancy persistent erythema and pruritus, with a confl uent histiocytic skin infi ltrate, following the use of a hydroxyethylstarch plasma expander epididymitis nodosa. an epididymal lesion analogous to vasitis nodosa amiodarone in testis and semen testicular dysfunction with amiodarone use non-infectious epididymitis associated with amiodarone therapy amiodaroneinduced epididymitis: report of a new case and literature review of cases amiodarone-induced sterile epididymitis recurrent bilateral amiodarone induced epididymitis amiodarone induced epididymitis in children amiodarone-induced epididymitis granulomatous epididymal lesion of possible ischemic origin a stone in the testicle testicular calculus orchitis mimicking testicular torsion in henoch-schönlein's purpura wegener's granulomatosis involving the urogenital tract testicular infarction in a -year-old boy with wegener's granulomatosis cogan's syndrome: cases and a review of the literature recurrent epididymo-orchitis in patients with behçet's disease isolated polyarteritis nodosa of the male reproductive system testicular mass as presenting symptom of isolated polyarteritis nodosa testicular lesions of periarteritis nodosa, with special reference to diagnosis polyarteritis nodosa presenting as acute orchitis: a case report and review of the literature isolated epididymal vasculitis limited polyarteritis nodosa of the male and female reproductive systems: diagnostic and therapeutic approach polyarteritis nodosa masquerading as a primary testicular neoplasm. a case report and review of the literature testicular vasculitis: implication for systemic disease torsión del cordón espermático. a propósito de nuevos casos. revisión de la literatura controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations prenatal testicular torsion: ultrasonographic features, management and histopathological fi ndings torsion of the testis testicular torsion in a -year-old man testicular torsion: simple grading for histological evaluation of tissues damage primary testicular lesions in the twisted testis torsión testicular antes de horas late postoperative results in males treated for testicular torsion during childhood testicular tissue bleeding as an indicator of gonadal salvageability in testicular torsion surgery intermittent testicular torsion lipomembranous fat necrosis in three cases of testicular torsion immunologic aspects of testicular torsion: detection of antisperm antibodies in contralateral testicle ipsilateral and contralateral testicular biochemical acute changes after unilateral testicular torsion and detorsion increased apoptosis in the contralateral testes of patients with testicular torsion as a factor for infertility unilateral testicular torsion: abnormal histological fi ndings in the contralateral testis. cause or effect? testicular injury. late results of semen analyses after orchiectomy testicular atrophy as a sequela of inguinal hernioplasty cooper's ligament repair for adult growing hernias spontaneous thrombosis of left spermatic vein: report of cases postsurgical focal testicular infarct localised infarction of the testis acute segmental testicular infarction: differentiation from tumour using high frequency colour doppler ultrasound observations on the structure and diseases of the testis cysts of the testicle tunica albuginea cyst: rare testicular mass high-resolution sonography of scrotal contents in asymptomatic subjects the high incidence of benign testicular tumors testicular cysts. us fi ndings benign intrascrotal lesions sonography of benign intrascrotal lesions cysts of the testicular parenchyma and tunica albuginea efferent ductule cyst of tunica albuginea simple cyst of the rete testis intratesticular spermatocele simple cyst of the testis: case report and review of literature congenital simple cysts of the testis: a hitherto undescribed lesion intratesticular cysts testicular cysts: differentiation with us and clinical fi ndings simple testicular cyst: a rare cause of scrotal swelling in infancy bilateral intratesticular cysts. a specifi c entity cysts of the tunica albuginea (cysts of the testis) cysts of the tunica albuginea testis nonneoplastic cystic lesions of the tunica albuginea: an electron microscopic and clinical study of cases cysts of the tunica albuginea: report of cases and review of the literature cysts of the tunica albuginea: a report of cases with a review of the literature high resolution ultrasonography in the diagnosis of simple intratesticular cysts simple testicular cyst diagnosed preoperatively by ultrasound surveillance strategy for intratesticular cysts: preliminary report simple cysts of the testis in children: preoperative diagnosis by ultrasound and excision with testicular preservation rete testis dysgenesis. a characteristic lesion of undescended testes estrogen receptor alpha has a functional role in the mouse rete testis and efferent ductules cystic transformation of the rete testis tubular ectasia of the rete testis: an ultrasound diagnosis cystic ectasia of the rete testis pronounced cystic transformation of the rete testis. mri appearance the diversity of reproductive tract abnormalities in males with cystic fi brosis postsurgical changes in the testis: a diagnostic dilemma acquired cystic transformation of the rete testis secondary to renal failure adenomatous hyperplasia of the rete testis adenomatous hyperplasia of the rete testis. a review and report of new cases displasia quística del testículo: anomalia en la diferenciación del parénquima testicular por probable fallo en la conexión entre los conductos de origen mesonéfrico y los cordones testiculares adenomatous hyperplasia of the references rete testis: report of two cases glandular changes in the rete testis: metastatic tumour or adenomatous hyperplasia? [letter tumors and cysts of the paratesticular region adenomatous hyperplasia of the rete testis. a clinicopathologic study of nine cases primary testicular lesions are associated with testicular germ cell tumors of adult men adénome du rete testis adenocarcinoma of the rete testis: case report, ultrastructural observations, and clinicopathologic correlates infarcted adenomatoid tumor: a report of fi ve cases of a facet of a benign neoplasm that may cause diagnostic diffi culty rete testis hyperplasia with hyaline globule formation. a lesion simulating yolk sac tumor nodular proliferation of calcifying connective tissue in the rete testis: a study of three cases key: cord- - k zaqsy authors: wick, w. david title: stopping the superspreader epidemic: the lessons from sars (with, perhaps, applications to mers) date: - - journal: nan doi: nan sha: doc_id: cord_uid: k zaqsy i discuss the so-called superspreader epidemic, for which sars is the canonical examples (and, perhaps, mers will be another). i use simulation by an agent-based model as well as the mathematics of multi-type branching-processes to illustrate how the ss epidemic differs from the more familiar uniform epidemic (e.g., caused by influenza). the conclusions may surprise the reader: (a) the ss epidemic must be described by at least two numbers, such as the mean reproductive number (of"secondary"cases caused by a"primary case"), r , and the variance of same, call it v ; (b) even if r > , if v >>r the probability that an infection-chain caused by one primary case goes extinct without intervention may be close to one (e.g., . ); (c) the ss epidemic may have a long"kindling period"in which sporadic cases appear (transmitted from some unknown host) and generate a cluster of cases, but the chains peter out, perhaps generating a false sense of security that a pandemic will not occur; (d) interventions such as isolation (or contact-tracing and secondary case isolation) may prove efficacious even without driving r below one; (e) the efficacy of such interventions diminishes, but slowly, with increasing v at fixed r . from these considerations, i argue that the ss epidemic has dynamics sufficiently distinct from the uniform case that efficacious public-health interventions can be designed even in the absence of a vaccine or other form of treatment. abstract i discuss the so-called superspreader (ss) epidemic, for which sars is the canonical example (and, perhaps, mers will be another). i use simulation by an agent-based model as well as the mathematics of multi-type branchingprocesses to illustrate how the ss epidemic differs from the more-familiar uniform epidemic (e.g., caused by influenza). the conclusions may surprise the reader: (a) the ss epidemic must be described by at least two numbers, such as the mean reproductive number (of "secondary" infections caused by a "primary" case), r , and the variance of same, call it v ; (b) even with r > , if v r the probability that the infection-chain caused by one primary case goes extinct without intervention may be close to one (e.g., . ); (c) the ss epidemic may have a long "kindling period" in which sporadic cases appear (transmitted from some unknown host) and generate a cluster of cases, but the chains peter out, perhaps generating a false sense of security that a pandemic will not occur; (d) interventions such as isolating primary cases (or contact-tracing and secondary-case isolation) can be efficacious even without driving r below one; (e) the efficacy of such interventions diminishes, but slowly, with increasing v at fixed r . from these considerations, i argue that the ss epidemic has dynamics sufficiently distinct from the uniform case that efficacious public-health interventions can be designed even in the absence of a vaccine or other form of treatment. this is a mathematical-modeling paper about certain types of epidemics and corresponding public-health interventions, other than by vaccines or drugs. my desire is to communicate the main points to a wider audience then just my fellow math-modelers: in particular, infectious-disease doctors and public-health officials, who are charged with responding to, and, if possible, halting, a future epidemic of a deadly disease. so i have chosen to relegate the mathematical and computational details to appendices (which are meant to be accessible to anyone with some background in math modeling or computer science, with no prerequisites.) i also eschew the usual introduction/methods/results/discussion format and adopt the form of an essay, because i believe the flow of the argument will be easier for the general reader to follow. to begin, recall sars, the acronym for "severe acute respiratory syndrome," an atypical form of pneumonia caused by a coronavirus that generated a gobal pandemic in . the large-scale spread of sars began on february of that year, when a professor of medicine in guangdong province, china, who had been treating patients with pneumonia, traveled to hong kong and checked into the metropole hotel downtown. for reasons still unclear, the professor passed the virus on to about a dozen persons staying at the hotel. then the professor, feeling unwell, checked himself into the teaching hospital and told the staff that he had a dangerous infectious disease and should be isolated, which the staff accomplished. (the professor died of the disease in hospital.) when another patient from the hotel cluster arrived at the hospital, the staff made a medical mistake (administering an expectorant or performing aspiration), and subsequently every doctor, nurse, medical student, and orderly who entered the room- or more-developed sars. this was the first "superspreader" (ss) event of the epidemic. more such events followed: + infected on a plane to beijing, at a hospital in vietnam, and so forth. but the godzilla of all known ss events occurred at an apartment complex in hong kong called the amoy gardens, where a sick person visited for one night and generated + secondary cases. virologists eventually traced the source of sars to bats, with an intermediate host, the civet cat, which was sold in live-animal markets in guangdong province. the final toll (november to july , , the date of the last known case) was: countries, including canada and the united states, affected; cases; and deaths. (thus the case mortality for sars was around percent; compare to the two percent estimated for the flu.) the pandemic is thought to have been brought under control by introduction of better hospital procedures for rapidly isolating cases; most clusters were "nosocomial" (occurring in, and specific to, a medical setting) with few secondary clusters, beyond those mentioned above, occurring in the community. as i write, a new disease caused by a different coronovirus, called the middle east respiratory syndrome (mers) virus, has appeared and generated cases in saudi arabia, jordan, qatar, and other countries of the arabian penninsula (at this time, all cases outside the region have occurred in persons who had recently visited the middle east). a steady drumbeat of sporadic cases ( since september , as of july ), some generating small ss events (mostly nosocomial), have been reported to the world health agency (and can be followed on the listservice of the international society for infectious diseases called promed-mail). the current estimate of mers case mortality is a frightening percent (but "case mortality" has a denominator problem: the "cases" are hospitalized patients, and we do not as yet know how many milder cases are occurring in the community). sars, mers, and (in one theory) hiv all represent a different kind of epidemic than usually treated in textbooks (particularly those that emphasize modeling). i will refer to a "superspreader epidemic," sse for shorthand. much of the conventional wisdom about epidemics does not apply to the sse case. next, i informally describe models for an sse, leaving details about software implementation and mathematical issues to appendices. the approbathrooms had floor drains that were supposed to be isolated by u-traps, but these only function if filled with water; but no one had told the residents to regularly dump a gallon of water on their bathroom floors. studies of transmission of hiv between an infected and an uninfected partner in a long-term relationship found very low transmission rates; e.g., one transmission in , unprotected sex acts. this gave rise to the theory that hiv is an ss epidemic; the candidates for the superpreaders are: (a) persons in the primary retroviral-infection period that lasts a few weeks, who have a thousand times the level of virus in blood and semen found in chronically-infected patients; and (b) cases like "patient zero," the canadian airline attendant with an impressive rolodex of sexual partners in many cities, described in 'randy shilts's book, and the band played on. priate kind of model is called a "stochastic multi-type branching-process." the adjective "stochastic" refers to random events, as in a dice game; in computer terms, when simulating the model the program makes calls on the random number generator, abbreviated rng (supplied with your operating system), when making updates. the "branching-process" was introduced by mathematicians in the s to describe, among other things, epidemics. (other applications include demographic population growth and nuclear chain-reactions.) in a branching-process, some entity produces a (random) number of "offspring" at some rate, not depending on the number of other entities existing, for some (also possibly random) reproductive period; the offspring, which may be of various types, can generate descendants in a similar manner. (the particular sort of branching-processes i use may differ from the kind described in math texts, however; see the appendices for the details.) mathematical biologists also introduced a deterministic model of epidemics dubbed "sir," for susceptible-infected-recovered, appropriate to describe a measles or influenza epidemic. here i am interested in interventions that bring the disease to a halt before it establishes an epidemic, so the susceptible population can be regarded as fixed. (by the time a moderate fraction of the population of a major city or country had sars or mers, the pandemic would long since have been declared by who and, given the modern phenomenon of "jet spread," airport closures and international panic would soon follow.) in addition, as the reader will understand from the results described below, a deterministic model of an sse is totally inappropriate. this is true for much of biology, despite the widespread use of deterministic equations, called by the ancient acronym "odes" whose significance nobody recalls, by mathematical biologists; see my book, [ ] . now we come to the famous "r ," also called the basic, or mean, reproduc- full disclosure: in march of , the author and two colleagues sent a paper to science proposing a stochastic branching-process model of the sars epidemic, concluding that the epidemic could be controlled by rapid isolation of infected patients if r was not too large. science rejected the paper, with the sole reviewer's comment being: "the model looks right, the conclusion looks right, but it doesn't penetrate!" in fact, the outcome of the epidemic was as we predicted. later that spring, science published papers from two modeling groups; one used odes, [ ] , which is absurd, and another, [ ] , a model like the authors', with similar conclusions. the latter group had access to case incidence data from hong kong, which our group lacked (we derived our model from published accounts, mostly in newspapers and on who and cdc websites). later, the present author fit a stochastic model to the hong kong data, see [ ] , chapter , in order to derive disease transmission parameters and demonstrate a new fitting technique. tive number of the virus, which was historically the original "tipping-point." it is defined as the average number of secondary cases caused (infected directly by) a primary case, in the absence of any treatment or intervention. as we will see, that number of secondary infections should be thought of as a random variable, so it has a variance as well as a mean; to uphold tradition, i denote it by v . now we must carefully distinguish two epidemic scenarios, which i will call the "uniform" (or poisson) and the superspreader (ss) epidemics. in the former, the number of secondary cases of a primary case (assumed for this discussion to have a fixed infectious period) is a poisson random variable, which is the name given in probability theory for the number of events in a random but constant-rate accrual process, like the number of hits inside the ring by a darts-player of little skill. the poisson random variable is characterized by v = r and a (super-exponential) fall off beyond the mean; e.g., if r = , the probability of the primary case producing secondary infections is infinitesimal. models in which such accruals have larger variances are said to possess "extra-poisson variation" (epv). what could be the meaning of this epv? the more-infectious case-i will also refer to this person as a superspreader-might have a special biological ability to spread the infection (perhaps through vomiting, diarrhea, or just a deep cough), or might be situated in some place that facilitates transmission (e.g., in a crowded icu, but not in isolation; on a plane; or visiting the amoy gardens). the simplest example, that i use throughout this paper for illustrations, is an epidemic model with two types of infected persons, each making a poissondistributed number of secondary cases. the person of type one has an average number of secondary cases of r l (the subscript meaning lower-value), and the type-two person, r h (high-level); these occur with probabilities p l and p h , so the population average is: for instance, suppose r l = . and r h = . , with p l = . and p h = . ; then r = . , while (easy computation) v = . . mathematicians proved in the s that a branching-process with r > can grow, while one with r ≤ eventually dies out. but it is often overlooked that a branching-process with r > can nevertheless go extinct. the outcome of a branching-process with r > (mathematicians use the phrase, "supercritical") is dichotomous: either heading for infinity or destined to die out, with certain probabilities. for instance, the process with the r's above plus assumptions about incubation periods, infectious periods, etc., resulting in various models; (see the appendices) will disappear eventually with probability p e in the range . - . . for the uniform case, r l = r h = . , p e is about . . as a rule, p e increases with increasing v for fixed r . this is easy to understand: the most probable "index" (epidemiology jargon for initial) case is a low-infectivity patient, and, although one or more secondary cases might follow while the patient remains infectious (even if r l < ), the infection-chain is likely to die out unless preserved by the appearance of a superspreader. see table for some illustrative examples. the simulation technique i used is described in appendix one, and the parameters are listed there in table a . i also included results in the table from an exactly-solvable model, meaning explicit formulas exist for extinction probabilities (see appendix two), called the markov case. i included it to satisfy mathematicians and to check the software, by comparing probabilities from repeated simulations to exact answers; but it has a feature that renders it dubious for use in biology. the markov case is the model in which all waiting times-times to end of the incubation period; to end of the infectious period; and to generate the next secondary case-have exponential distributions (see appendix two for the explanation of why the famous "markov property" requires exponential distributions for all waiting times). but only for the last mentioned is this a realistic choice: the exponential law was derived from physics, where it represents radioactive decay; but people are not atoms. for applications i assumed, pending more data, normal distributions for the incubation and infectious periods (conditional on non-negativity, of course). for these models, simulation must be used to compute probabilities (for reasons spelled out in appendix two). so the last column in the table represents the biologically more-realistic case. the reason that the entries in this column are the smallest in the rows is that the markov case has more epv; see appendix two. next consider mers, for which (as i write) another sporadic case apparently shows up on average every three days. (a "case" means laboratoryconfirmed in hospital, which may represent the very sick and potential superspreaders; there are probably more cases appearing in the community.) let "sp-int" stand for the average interval between appearances of sporadic infections. sp-int is hard to estimate, because it is difficult to distinguish sporadic from secondary cases; e.g., if in a family a father and two children become infected and the father becomes ill first, should the children be counted as secondary cases, or were they exposed to the same external source of virus and so additional sporadic cases? thus sp-int might be considerably larger than three days. the law for first-time-to-a-bernoulli-event gives: e.g., if p e = . and sp-int is days, the mean initiation time is days (but it could be much longer). because of the dichotomy and the tendency of most infection-chains to go extinct, the sse with large epv seeded by sporadic cases can be very surprising. for instance, figure shows an epidemic with r's as in the example above; for several months the epidemic seems indolent, then around days, it takes off. figure shows another epidemic with parameters from the last row (most extreme case) of the table; nothing exciting happens for a year, which might cause premature optimism among public-health officials; then comes disaster. (rerunning with the same parameters but different "seeds" for the rng, the timing of the pandemic in the figures is highly variable.) note that no spontaneous modifications, genetic or otherwise, are assumed in the virus for these simulations; disease parameters are fixed. the patterns are entirely due to epv and chance. now to interventions. neither vaccines nor therapeutic drugs currently exist for human coronaviruses; considering that the sars virus has disappeared while mers remains contained, and the enormous cost of developing, testing, and licensing a new vaccine or drug, this unfortunate situation is likely to persist. therefore, let us explore other interventions that could prevent an sse pandemic by these viruses. the interventions are restricted to isolation of cases, preventing some secondary infections. the intervention might be primary: rapidly isolating an infected patient in hospital in a negativepressure room and requiring all attendant personel to wear gowns and p masks, hopefully decreasing the patient's infectious period; or secondary: tracing contacts of the primary case and getting as many as possible to go into isolation at home, thus diminishing secondary infections. the secondary intervention has one advantage over the primary: it can be instigated even if laboratory tests are delayed beyond the lifetime, or infectious period, of the patient, which may be a consideration early in the epidemic. both interventions have the same effect: decreasing the effective "r" of the patient. an interesting special case, which i will refer to as the "ss intervention" (ssi), limits the intervention to high-infectivity cases. possible scenarios where the ssi is effective might include: ss patients are sicker and usually hospitalized, while low-infectivity cases remain in the community; and where ss patients can be detected by some physiological or virological measurement. in most discussions of interventions in infectious-disease epidemiology, it is assumed that an efficacious intervention is one that drives r below one. i argue that, for the sse, the proper quantity to look at is not r but the extinction probability of the infection-chain, which i have denoted by p e . thus the goal of the intervention must be to increase p e ; indeed, i define intervention-efficacy (ie) by: where p e,i stands for the extinction probability in the presence of the intervention. thus ie = . if the intervention drives p e,i all the way to one, and zero if p e,i = p e . of course, if the intervention should push r below one, then ie will be one, but ie could be, e.g., . even with an r still greater than one after the intervention is active (as we will see below). ie depends on both r and v , as we will see. if the reader is dubious about this redefinition of efficacy, consider (a) the disease introduced into cities. if, e.g., p e = . while p e,i = . (efficacy, percent; these numbers are not implausible, see table ), the effect of the intervention is to spare cities on average from a local epidemic. more convincing, perhaps, is to think about (b): the time before the epidemic takes off in a given region, for the sporadically-appearing disease. in the scenario in table fourth row, the epidemic takes off in a few months, but with the intervention increasing p e to the value in the last row, it takes roughly a half-year-perhaps enough time for epidemiologists or veterinarians to find and eliminate the source of the virus. i therefore explored efficacy for such interventions through simulating an sse epidemic with ssi's of various efficiencies (at lowering r h ). see figures and . efficacy is partially mediated by decreasing the effective (withintervention) r , which in any case remains above one in the figures. note that, for a high-v epidemic, even an intervention with efficiency in the - percent range can be quite valuable. i next asked whether it is easier or harder to stop an epidemic with a large v (equivalently here, large r h ) than an epidemic with a smaller value, at fixed intervention. the question is hard to answer through introspection or analysis. on the one hand, a larger r h should mean that the ssi intervention is more relevant; on the other hand, the explosive nature of case growth suggests the intervention would have to be larger. one thought suggests that efficacy should be an increasing function of r h , the other that it should be decreasing. see figures and : in fact, efficacy in the models does diminish with increasing r h at fixed intervention efficiency, but falls off remarkably slowly. as of august , mers has not generated a pandemic after months of sporadic cases. the obvious explanation is that r is less than one-but that could be an illusion; recall figure ! in july , a group of epidemiologists published in lancet, [ ] an estimate, based on cases (there were more as of july but the authors culled some due to ambiguities), of r as about . , which i used for the lower figure (r l ) in the simulations. however, they made an "occam's razor" simplifying assumption which may have biased their analysis. despite being critical of the authors' methodology, i agree with their conclusion that r of mers is currently less than one. (the best fit in my model-class to the cluster-data reported in [ ] had r = . ; r l = . ; r h = . ; normal periods; and sp-int = days. i.e., an sse but not a pandemic. see appendix three.) whatever the truth may be, in two ) saudi arabia has a population of million, so this represents less than an eight percent increase; however, these pilgrims will be congregating in a few sites where there may be increased opportunity for viral transmission from infected cases, possibly locally raising r and, more likely, v . also at present the source of the sporadic cases is under investigation, with reports of a related virus in a bat (not found in the middle east, however), and antibodies to coronaviruses in camels (but not in saudi arabia, and without recovery of a virus; because of cross-reactivity the latter report may be noise). the situation is too uncertain to make definite predictions about a mers epidemic at this time. here is a summary of my conclusions about the ss epidemic and interventions, based on the modeling exercise. first, it is better not to be complacent about an often-fatal disease occurring at low frequency and generating small clusters of secondary cases. despite appearances, it may represent the "kindling" phase of a future pandemic-which may develop even in the absence of genetic modification in the pathogen increasing transmission rates to or among humans (as occurred a decade ago in sars; but an event, given the current state of genetics, which nobody can predict). second, the sse has very different dynamics from more uniform epidemics caused by, e.g., influenza or measles; remarkably, this permits the design of interventions which are not available in the latter cases. for instance, because the superspreader is rare and possibly detectable, a specifically targeted intervention may at least delay the onset of a pandemic long enough to allow epidemiologists to locate and eliminate the source of sporadic infections. even detection after the end of a superspreader's infectious period can be efficacious (through contact-tracing). finally, for my fellow math-modelers: the story related here is an instance of the important role played by heterogeneity, and stochasticity, in biology. (for other examples, see my books [ ] and [ ] .) a desire for simplicity in modeling is not an excuse for overlooking these possibilities. the model is of "agent-based" type, which means that the characteristics of each case are stored separately in computer memory. the descriptors of each case are: infectious status (in incubation period, so not infectious; or infectious); infectious type; and some integers assigned at creation for identification purposes (including the index of the primary, if a secondary case; and an indentifier for cluster). in addition, for each case some floating-point numbers are stored: when a case is created in the incubation phase, a predicted (clock) time for entering the infectious phase; once in the latter, the time of creation of a secondary case (updated when that event occurs); and the time of death or end of infectious period. because of the agent-based modeling, these times can be generated with any desired distributions. for the time-of-next-secondary-case, an exponential random variable is appropriate (consistent with the assumption that the infections caused in a fixed period have a poisson distribution). but an exponential random variable is a poor choice for the other waiting times (time-to-infectivity and to death or end-ofinfectious period), because the exponential law has no memory. conventional mathematical models assume that all waiting times are exponentials, because the markov property then holds, permitting mathematicians to write down and solve equations for quantities like extinction probabilities; see the math appendix for discussion. however, the convenience of mathematicians should not be a determining element in science. i assumed that the waiting times other than for secondary infections had normal distributions (conditional on being non-negative). the simulation starts by filling in the characteristics and times for the index case (and, for the sporadic scenario, a conjectured time for the appearance of the next sporadic case). then the smallest waiting time is found; the corresponding changes are made, including creation of a new case and its characteristics and waiting times if the event is a sporadic-or secondaryinfection. the clock time is moved forward to this event time. at subsequent iterations the program runs through all the stored waiting times looking for the next one; then performs those changes, etc. in other words, the process is simulated in the most straightforward manner, with no mathematical approximations whatsoever except for the belief that the rng provides truly random digits (about which john von neumann made his famous joke: "anyone who believes a computer can generate a random variable is living in sin"), which is unlikely to cause trouble here. when computing extinction probabilities, the process was run until either extinction occurred, incident (incubation or infectious) cases existed on a single day (after which i assumed extinction was unlikely), or the clock time reached four years. , samples were used in simulations. table reports the comparisons of the solvable (markov) case with simulations of same; rerunning some cases with , repetitions, even the third decimal came out right. table a reports the parameters used. when more data about, e.g., mers, becomes available, it will be interesting to fit the model in order to estimate parameters; a convenient method was introduced in my book [ ] , chapter . the program was written in the c programming language, runs on anything, and is available from the author by request. (but if the reader is interested in modeling the sse, it is always better to write your own program then rely on somebody else's.) i am an ex-mathematical physicist. so why the resort to programming the laptop? my motivation is simple: i intend to use the model to make predictions about mers and other ss epidemics, once transmission parameters become available. in my philosophy, the proper goal of any scientist is to make predictions for future experiments or observations, because that is ultimately the only way to be sure that you are not modeling moonshine. so marc kac's fabled advice for mathematical physicists ("mutilate, mutilate until you can solve the equations") cannot be accepted. i may need to employ all sorts of peculiar distributions taken from empirical data. however, it is useful to solve even an unrealistic scenario because it provides a formula to compare to the output of the software for that case, helpful to allay the suspicion that the results in this paper are due to bugs or numerical issues. the markov case is the model in which all waiting times-times to end of the incubation period; to end of the infectious period; and to generate the next secondary case-have exponential distributions. as pointed out in the text, only for the last mentioned is this a realistic choice. but it is required by the markov property ("the future and the past are independent, given the present") because only the exponential is memoryless: provided τ is an exponential random variable: p [ τ > t ] = exp(−λ t). with the exponential for incubation and infectious periods, the number of secondary cases of a primary case is actually geometric rather than poisson, with a larger variance (so this case has epv even even without multiple types). it is, of course, the markov property that makes it easy to derive equations for probabilities associated to stochastic processes. here is a simple (non-rigorous?) derivation of the extinction probabilities for the markov version of the ss epidemic without sporadic cases. let ex stand for the event: extinction of the infection-chain; p k for probabilities generated by the process begun by a type-k case; and r k for the corresponding extinction probability, so: r k = p [ extinction probability given one initial case, type k ] then by conditioning on the first secondary case, if there is one: where γ k is the rate of generating secondary cases by a primary case of type k and ρ is the reciprocal of the time-to-end of the infectious period. thus we obtain a quadratic system, easily reduced to a single quadratic for the two-level case of the text (below). however, the reader may doubt whether this is rigorous. there is another (long-winded but fully rigorous) approach for the markov case, which is to note that it is identical to a markov birth-and-death compartmental jump process. here we have to distinguish incubation and infectious stages for each type; call the respective compartments (populations) x k and y k . the rates of jumps for this process are: next given numbers < r k < and < s k < introduce the momentgenerating function (mgf): where e denotes expectation. differentiating using kolmogorov's forward equation (just a consequence of jumps occurring at given rates): now make the substitutions: r k ∂/∂r k −→ x k and s k ∂/∂s k −→ y k to obtain the pde: solve this system by the method of characteristics; that is, define functions of time r k (t) and s k (t) to satisfy the ode system: now note that φ is a function of r = {r k }, s = {s k } and t and from the above φ(r(t), s(t); ) = φ(r( ), s( ); t). also from its definition, if we take as initial conditions x k = and y k = so setting the right-hand sides of the odes, ( ), equal to zero to find the fixed point gives the required extinction probabilities. the resulting equations are the same as ( ). for the two-level case, these equations are, using r k = γ k /ρ: which after a little algebra yields the quadratic: this is solved for ψ (taking the negative sign in the quadratic formula and rationalizing the numerator) by: note that if the extinction probabilities r and r are less than one, ψ is negative and vice versa; hence that is the case if and only if r > . given ψ, r and r can then be found from ( ); p e = r , r , or p r + p r , depending on how you choose the initial condition. (the third is the realistic case.) we used these results to reproduce tables and figures from the text, comparing to output obtained by implementing exponentials for all waiting times and repeating the simulations. why can't we use the informal argument for the general case (without requiring everything to be exponential)? because there were several hidden assumptions in deriving ( ). for one, in ( ) we used the exponential integral: which in a non-exponential case would have to be done numerically. worse, in ( ) there was a concealed use of the markov property; i erased conditioning as follows: p [ ex | first secondary case is of type j, at time τ ] = p [ ex | first secondary case is of type j ] , reasoning that the time of creation of the first secondary infection was not informative about the time left in the infectious period, which invokes the memorylessness of the exponential law, or just the markov property. in a non-markov case, that time would be informative, so one would have to evaluate that conditional probability as stated somehow, and ( ) becomes a system of integral equations which would have to be solved on the computer by discretizing the time, solving matrix equations, then letting the discretization interval shrink, controlling for numerical error, etc. relative to simulating the process on a fast computer, it doesn't seem worth the effort. appendix : the lancet transmission paper, [ ] the lancet authors, breban et al., based their analysis on certain caseclusters (epidemiologically-linked cases), which they summarized in a table (the scenarios concern how the authors interpreted the clusters in terms of sporadic vs. secondary cases): table b . distribution of cluster sizes size scenario scenario converting from numbers of clusters to frequencies: in their mathematical appendix, the lancet authors begin by citing a paper in plos by others [ ] who showed how to use branching-processes and bayesian methodology to estimate r from cluster data, allowing for some extra variance in reproductive number, namely by assuming a certain distribution (called the "negative binomial") that interpolates between poisson and geometric. in my terminology, those two cases represent the uniform epidemic with either fixed or exponential infectious period-so much smaller epv than allowed in my two-level model (which in fact has three free parameters, see last paragraph). the lancet authors apply bayesian analysis to the plos authors' distribution but reject it as unable to resolve both parameters (r and a dispersion parameter affecting v ) because the latter "could be very large, even ." it is here that they abused poor occam and retreated to an analysis using poisson and estimating a single parameter, r . of course, with this assumption the big cluster in the last row must include tertiary, etc., cases, because a cluster of secondary cases of one primary case, with an r of . , is virtually impossible. here are simulated cluster frequencies under some models described in the text ( , simulations, each run to cases, per model; a "cluster" consists of the tree generated by a sporadic primary case): not surprisingly, the uniform (poisson) model with r = . has difficulty fitting the big cluster of cases in the last line of tables b/c; indeed, it appears as if models b-d can be rejected, say by a fisherian p-value test. this suggests that what happened in the lancet authors' bayesian fitting procedure is that their single-type, poisson likelihood settled for fitting the small clusters and ignored the the big one. which could render their logic circular (r is less than one because, in a model with no higher-infectious types and ignoring one data point . . . r comes out less than one). however, does that mean the authors' conclusion is wrong? to answer that question, i utilized the nknn method (advertised in my book [ ] ) to search for best-fitting models in my model-class. this venerable method selects among various theories, given samples from each, that best explains a given data-set; it is commonly used in pattern-recognition. (it reduces to maximum likelihood in the limit of infinitely-large samples from each theory; i.e., if you have an infinitely-fast computer to perform the simulations.) here the samples were , simulated epidemics, and corresponding clusterfrequencies, from models chosen at random with . < r l < , < r h < , and r l < r < min(r h , . ), with , repetitions. the data-set was column one of table c . the search turned up excellent fits for the frequency data (smallest sum-of-squares, . ): on the basis of this result, i must agree that r < for mers at present. note however that the good fit of table e to table c is attained because an ss model reproduces the big cluster in the last row of the latter. the lancet authors' choice to limit their model-class to a poisson distribution for secondary cases ruled out this possibility-a superspreader, multiple-levels, epidemic model, but with r less than one-a priori. on the other hand, "fitting" a three-parameter model to data consisting of seven frequencies cannot be recommended either. now a bit of preaching about modeling traps. when you have a model with free parameters and a data-set, there are two ways to delude yourself. methods like bayesian analysis, possible if you have an explicit likelihood, or my nknn method, which works for anything provided you can simulate fast enough, will generate a "best-fitting model." if some parameter (like the plos authors' dispersion parameter) fluctuates so much that it can't be pinned down, you can choose to omit it-i.e., mutilate the model in order to be able to "estimate the parameters." or you can keep the troublesome parameter and let the software choose a "best model." either way, the model selected may be false; but you won't discover that until more data arrives. in my book, [ ] , i labeled these two pitfalls the "simple-is-best trap" and the "etch-a-sketch trap" and argued that the modeler is required to steer between these two hazards, like odysseus sailing between skylla and charybdis. fall in the first, and your parameter estimates will be wrong or biologically unintelligible; fall in the other, and your model can "explain" anything (which karl popper decried as not science). ultimately, the best approach is to make a prediction-even when it fails, you will have learned something. (unfortunately, on the basis of the data thus far available, making a prediction about mers is impossible.) interhuman transmissibility of middle east respiratory syndrome coronavirus: estimation of pandemic risk inference of r and transmission heterogeneity from the size distribution of stuttering chains transmission dynamics and control of severe acute respiratory syndrome. science transmission dynamics of the etiological agent of sars in hong kong: impact of public health interventions fitting non-linear, stochastic models to data in war in the body: the evolutionary arms race between hiv and the human immune system and the implications for vaccines key: cord- -xmry xj authors: hsieh, chung-han title: on control of epidemics with application to covid- date: - - journal: nan doi: nan sha: doc_id: cord_uid: xmry xj at the time of writing, the ongoing covid- pandemic, caused by severe acute respiratory syndrome coronavirus (sars-cov- ), had already resulted in more than thirty-two million cases infected and more than one million deaths worldwide. given the fact that the pandemic is still threatening health and safety, it is in the urgency to understand the covid- contagion process and know how it might be controlled. with this motivation in mind, in this paper, we consider a version of a stochastic discrete-time susceptible-infected-recovered-death~(sird)-based epidemiological model with two uncertainties: the uncertain rate of infected cases which are undetected or asymptomatic, and the uncertain effectiveness rate of control. our aim is to study the effect of an epidemic control policy on the uncertain model in a control-theoretic framework. we begin by providing the closed-form solutions of states in the modified sird-based model such as infected cases, susceptible cases, recovered cases, and deceased cases. then, the corresponding expected states and the technical lower and upper bounds for those states are provided as well. subsequently, we consider two epidemic control problems to be addressed: one is almost sure epidemic control problem and the other average epidemic control problem. having defined the two problems, our main results are a set of sufficient conditions on a class of linear control policy which assures that the epidemic is"well-controlled"; i.e., both of the infected cases and deceased cases are upper bounded uniformly and the number of infected cases converges to zero asymptotically. our numerical studies, using the historical covid- contagion data in the united states, suggest that our appealingly simple model and control framework can provide a reasonable epidemic control performance compared to the ongoing pandemic situation. at the time of writing, according to the world health organization, the ongoing covid- pandemic, caused by severe acute respiratory syndrome coronavirus (sars-cov- ), had already resulted in more than thirty-two million cases infected and more than one million deaths worldwide; see [ ] , and even worse, the pandemic seems to be "showing no clear signs of slowing down" in many countries. to this end, governments are persistently striving to control and slow down the spread of covid- ; e.g., minimizing the contact rate by consulting non-pharmaceutical intervention mechanisms such as lock-downs and social distancing or relying on some pharmaceutical interventions such as enhancing medical treatments, and developing possible cure or remedies. with this motivation in mind, the focal point for this paper, as a preliminary work, is to understand how the disease spreads and how it would be possibly controlled. the remainder of the paper is organized as follows: in section we describe the preliminaries involving the details of our modified sird-based epidemiological model. then two problem formulations for epidemic control: almost sure epidemic control problem and average epidemic control problem are stated. subsequently, in sections , detailed analyses on our epidemiological model are provided. in sections and , using a linear epidemic control policy, we provide sufficient conditions on feedback gain so that the epidemic can be properly controlled in either expected value sense or almost sure sense. next, in section , we describe a simple model parameter estimation approach and illustrate its use via numerical examples involving historical covid- data from the united states, the country among those with a relatively high confirmed cases in the middle of . the control performance is also discussed. finally, in section , we provide some concluding remarks and promising directions for future research. in the sequel, we take k to be the index indicating the day number and u(k) ≥ to be the corresponding abstract epidemic control policy implemented by governments. we view that the large values of u(k) correspond to enhanced medical treatments or stringent non-pharmaceutical interventions such as mandating social distancing with wearing the masks. the smaller values of u(k) might correspond to diminished medical treatments or relaxation of the rules. in the analysis to follow, we assume that the epidemic control policy u(k) is causal ; i.e., it only depends on the past and current information that is available at hand-not the future. for k = , , . . . , let s(k) be the number of susceptible cases at the kth day, i(k) be the infected cases at the kth day and r(k) be the recovered cases at the kth day, and d(k) be the deceased cases at the kth day. take n (k) be the underlying human population at the kth day satisfying n (k) = s(k)+i(k)+r(k). as mentioned in section , many infected individuals may go undetected or asymptomatic [ ] and the effectiveness of a control policy u(k) may be uncertain at the time, we introduce two uncertainty quantities: the uncertain rate of infected cases which are undetected or asymptomatic, call it δ(k), and the uncertain effectiveness rate of control, call it v(k), in our model to follow. now, with initial values s( ) := n ( ) := s , i( ) := i > , and r( ) = d( ) = , we consider a discrete-time stochastic epidemiological model with uncertainties described by where d i (k) is the death rate for infected cases satisfying d i (k) ∈ [ , d max ] with d max < for all k. we assume that the sequence d i (k) are independent and identically distributed (i.i.d.) random variables. in addition, we assume that both of δ(k) and v(k) are i.i.d. random variables with arbitrary distribution but known bounds ≤ δ(k) ≤ δ max and < v min ≤ v(k) ≤ v max ≤ , respectively. if v(k) = , it corresponds to the case where the control policy is extremely effective. on the other hand, if v(k) ≈ , it corresponds to an extremely ineffective case; i.e., the people are not disciplined and may be unwilling to follow the medical advise for masks or social distancing; see also a discussion in section . . in the sequel, we assume further that i δ max < s ; and v(k), δ(k), and d i (k) are mutually independent. for the sake of notational convenience, we also take the shorthand notations δ : remark on the epidemiology model. as a preliminary work, while we allow uncertainties on both infected cases i(k) and control u(k), our epidemiological model assumes that u(·) can interact with the infected cases instantaneously without any time delay. the action with delay is left for future work; see also section . it is also worth mentioning that, if one considers a linear control policy u(k) = ki(k) with constant k ≥ , then a basic reproduction ratio of sorts, call it r (·), can be obtained as follows: for k ≥ , where β(k) := δ(k)(s(k) + i(k)))/s(k) is the infectious rate and γ(k) := v(k)k is the recovery rate. if r (·) > , the number of infected cases is expected to increase; if r (·) < , then the infected cases decrease. finally, we should mention that, in terms of the terminology in systems and control theory, the epidemiological dynamics described by equation ( ) is indeed an uncertain linear time-varying system. this observation is useful in the following sections to follow. in this subsection, we introduce the first epidemic control problem, which we call the almost sure epidemic control problem. that is, given the modified sird model , we seek a control policy u(·) which assures the following conditions hold: (i) the ratio of infected cases converge to zero with probability one; i.e., remarks. the results related to this almost sure epidemic control problem is discussed in section when a linear control policy of the form u(k) = ki(k) with pure gain k ≥ for all k ≥ is applied. while almost sure epidemic control policy, if exists, can be a good candidate to mitigate the pandemic. however, in practice, some potential issues remain. for example, in some cases, the cost for implementing an almost sure epidemic control policy may be still too expensive in practice; see remark . . in section . to hedge this issue, we now introduce our second epidemic control problem which we call the average epidemic control problem aimed at controlling the "expected" infected cases and "expected" deceased cases. to address the issue raised in previous subsection, we consider the second epidemic control problem which we call the average epidemic control problem aimed at controlling the "expected" infected cases and "expected" deceased cases. rigorously speaking, given the modified sird model , we seek a control policy u(·) which assures the following conditions hold: remark. similar to the previous remark, the results related to this average epidemic control problem is discussed in section when a linear control policy of the form u(k) = ki(k) with k ≥ for all k ≥ is applied. in this section, to understand the contagion process and the evolution of the epidemic, we assume that there exists a control policy u(·) which assures that infected cases i(k), susceptible cases s(k), recovered cases r(k) and deceased cases d(k) are all nonnegative for all k with probability one. the analytic expression for infected cases, susceptible cases, recovered cases, and deceased cases are provided. the results obtained in this section are useful for the subsequent sections to follow. in the sequel, we use a shorthand notation for integer k ≥ k ≥ . we mention here that Φ(k, k ) is a state transition function for infected cases from day k to k. the reader is referred to [ ] for detailed discussion on this topic. we may sometimes write Φ i (·, ·) instead of Φ(·, ·) to emphasize that the function is related to the infected cases. the following lemma characterizes some useful properties of the function. proof. to prove part (i), we let f (k) := + δ(k) − d i (k). since δ(k) ∈ [ , δ max ] and d i (k) ≥ for all k ≥ k ≥ , we have − d max ≤ f (k) ≤ + δ max for all k with probability one. note that the upper and lower bounds are nonnegative. hence, a straightforward multiplication leads to the desired inequality and the proof of part (i) is complete. to prove part (ii), with the aid of the fact that δ(k) and d i (k) are i.i.d. in k and are mutually independent, we obtain having proved lemma . , we are now ready to characterize the infected cases i(k). given i > , the infected cases at the kth day is described by for k ≥ . moreover, the expected infected cases satisfy proof. since the infected cases dynamics ( ) is a linear time-varying system, the solution i(k) and its corresponding proof are well-established; hence we omitted here and refer the reader to any standard textbook in system theory; e.g., see [ ] . to complete the proof, we must show that the expected infected cases can be characterized by the form described in the lemma. using lemma . and the fact that v(k) ≥ v min and are i.i.d., we observe that note that u(i), as assumed in section , is causal; i.e., it only depends on the information available up to the ith day. in addition, according to equation ( ) , the state transition function Φ i (k, i + ) = as seen later in the next section, if one adopts the linear feedback policy of the form u(k) = ki(k), then the solution i(k) described in lemma . can be greatly simplified. the following lemma gives a closed-form expression for the susceptible cases s(k). with s( ) = s > , the number of susceptible cases at the kth day is given by using lemma . , we obtain in this subsection, we characterize the solution of recovered cases and some of its useful properties. with r( ) = , the recovered cases at the kth day is given by for k ≥ . proof. while the proof is simple, for the sake of completion, we provide a full proof here. we first recall that r( ) = by assumption on initial condition. to complete the proof, we proceed a proof by induction. begin by noting that for k = , the recursion on r(k) tells us that to complete the proof, we now show the desired expected recovered cases and its bounds. for which is desired. it is readily seen that r(k) is increasing in k since u, v are nonnegative. the number of deceased cases and its expectation are provided in this subsection. for k ≥ . moreover, the expected number of death is bounded by proof. with d( ) = , we begin by recalling that the deaths dynamics ( ) is given by d(k + ) = d(k) + d i (k)i(k) for k ≥ . an almost identical proof as seen in lemma . leads to to complete the proof, we take expectation on equation and, with the linearity of expectation and the fact ≤ d i (k) ≤ d max , the desired inequality follows immediately. if there are low or no medical supports, i.e., u(k) ≈ , or the medical treatments are lacking or extremely ineffective, due to the reasons such as the people are not disciplined or unwilling to follow the medical advise to wearing masks or social distancing; i.e., v(k) ≈ , then it is readily verified that the susceptible cases, infected cases, recovered cases, and deceased cases become consistent with the intuition, the equation ( ) above tells us that the recovered cases r(k) are close to zero approximately. on the other hand, the infected cases i(k) and the deceased cases d(k) are both increasing monotonically; i.e., an "outbreak" is seen. to mitigate the pandemic, in this paper, we consider a class of linear epidemic control policy of the form u(k) := ki(k) for k ≥ where k ≥ is the feedback gain which represents the degree of the epidemic control effort on providing medical treatment or mandating the non-pharmaceutical interventions. in the sequel, we sometimes call the linear epidemic control policy above as linear feedback policy or just linear policy for the sake of brevity. as mentioned in section , our objective of this section is to address the almost sure epidemic control problem using the linear control policy. we begin with discussing the control of infected cases in the almost sure sense. the following lemma is useful for deriving one of our main results: theorem . . . then the infected cases dynamics becomes therefore, the product of f (i) is also nonnegative which implies that i(k) ≥ for all k with probability one. to complete the proof of part (i), we note that for any k ∈ [ , −dmax vmax ], the infected cases satisfy to prove part (ii), an almost identical proof as seen in part (i) applies. that is, if k < ( − d max )/v max , then i(k) > for all k with probability one. according to part (ii) of the lemma above, we see that if k < ( − d max )/v max , then the infected cases i(k) is strictly positive for all k with probability one. said another way, the infected cases can not be eradicated at any time. however, as seen in the next theorem, the ratio of the infected cases can go down to zero asymptotically for some k. then we have (i) lim k→∞ i(k)/i = with probability one. (ii) the controlled infected cases are upper bounded uniformly; i.e., i(k) < i for all k with probability one. if k = δmax vmin , then i(k) ≤ i . proof. to prove (i), we observe that as defined in the proof of lemma . . with the assumed inequalities and feedback gain δmax vmin < k < −dmax vmax , it is readily verified that < f (i) < for all i = , , . . . , k − . to show the limit of the ratio i(k)/i is zero with probability one, we write we also note that the logarithmic function above is well-defined for k within the assumed range. hence, now, since f (i) are i.i.d., by the strong law of large number (slln); e.g., see [ ] , we have as k → ∞ with probability one. now, using the fact that the logarithmic function is strictly concave, jensen's inequality yields where the last inequality hold by the monotonicity of logarithmic function. hence, log( +δ−kv) ≤ for any k ≥ δ max /v min ≥ δ/v. therefore, e[log f ( )] < , which implies that lim k→∞ i(k)/i → and the proof for part (i) is complete. to prove (ii), we must show that the i(k) is upper bounded by the initial infected cases i . as seen in the proof of part (i) of lemma . , we have, for all k, where the last inequality holds by using the assumed fact that k ≥ δmax vmin . in practice, since the medical resource is limited, it is natural to put additional constraints on the feedback gain such as k ∈ [ , l] with l ≥ being the constant which corresponds to the maximum allowable medical resources to be used. hence, other than the sufficient condition , for any δ max < vmin( −dmax) vmax , one might require k to satisfy however, one should note that the set k might be an empty set. to see this, we consider l = , v min = v max = . and δ max = . and d max = . . then it is readily verified that the condition δ max < vmin( −dmax) vmax but k = ( , )∩[ , ] = ∅. if k = ∅, it tells us that the infected cases does not converge to zero asymptotically and the epidemic is uncontrollable. if this is the case, one should put whatever they can to suppress the disease; e.g., by putting k := l for possible l ≥ . on the other hand, given the fact that the higher feedback gain would cause a higher consumption on medical/economical resources, one should choose the lowest feedback gain which is nonzero. hence, an immediate "sub-optimal" choice would simply be as follows: if δ max ≤ v min we take k * := δ max /v min with the aim that i(k) ≤ i can be guaranteed at least. on the other hand, if δ max > v min , we take k * := l. or, we can write it in a more compact way as follows: provided that δ max < vmin( −dmax) vmax where {δmax≤lvmin} and {δmax>lvmin} are the indicator function; see [ ] for a detailed discussion on this topic. as seen later in section , the k * above will be adopted to test the epidemic control performance using historical data. in this subsection, the recovered cases r(k), susceptible cases s(k), and deceased cases d(k) under linear control policy are discussed. the analysis of recovered cases is simple. we begin by recalling lemma . and write r(k) = k− i= v(i)u(i). now, by taking linear control policy u(k) = ki(k) with gain ≤ k ≤ ( − d max )/v max , we have r(k) ≥ for all k with probability one and where the last inequality holds by using lemma . . for k = , , . . . , ⌊s /(i δ max )⌋ with probability one where ⌊z⌋ is the floor function satisfying ⌊z⌋ := max{n ∈ z : n ≤ z}. proof. similar to the proof of lemma . , recalling that s(k+ ) = s(k)−δ(k)i(k), a straightforward inductive calculation leads to using lemma . , the desired form of solution follows immediately. to complete the proof, we note that thus, via a lengthy but straightforward calculations, it is readily verified that s(k) ≥ for k ≤ ⌊s /(i δ max )⌋ with probability one. remark. while the lemma above tells us that s(k) ≥ holds up to k ≤ ⌊s /(i δ max )⌋, we should note that the initial cases s = n ( ) are often far larger than the denominator i δ max . hence, without loss of generality, in the sequel, we deemed that s(k) ≥ for sufficiently large k. the next lemma indicates that the deceased cases under the linear control policy. for all k ≥ with probability one. proof. we begin by recalling that d(k) = k− i= d i (i)i(i) for all k ≥ . hence, using lemma . , we have note here that the assumption k ≤ ( − d max )/v max assures i(k) ≥ for all k with probability one; hence the inequality above is well-defined. to complete the proof, with the aid of sum of geometric series, we have which completes the proof. with the aids of theorem . and lemma . , we see that if we take linear feedback policy with constant gain; i.e., u(k) = ki(k) and assuming that δ max < v min ( such that infected cases i(k) ≤ m d for all k with probability one. therefore, the almost sure epidemic control problem is solved. while the almost sure epidemic control policy, if exists, can be a good candidate to mitigate the pandemic, some potential issues remain in practice. that is, recalling remark . . in section , it tells us that, in some cases, the almost sure epidemic control policy, while exist, may not be possible to implement. to address this, as mentioned in section , we now move to our second epidemic control problem which we call the average epidemic control problem. in this setting, the aim now becomes to control the "expected" infected cases and "expected" deceased cases in this section, we provide our results on control of epidemics in the sense of expected value. we begin with discussing the control of expected infected cases. the lemma below provides an useful analytical expression for the expected number of infected cases. proof. the proof is straightforward. we begin by noting that, for any linear policy u(k) = ki(k) with gain k ∈ [ , ( − d max )/v max ], i(k) ≥ for all k with probability one and i(k) = k− i= ( + δ(i)−d i (i)−kv(i))i . since δ(k), d i (k) and v(k) are i.i.d in k and are mutually independent, taking the expected value on the i(k) above yields and the proof is complete. with the aid of the lemma above, we are now ready to provide our second main result. proof. the idea of the proof is similar to the one used in theorem . . however, for the sake of completeness, we provide our full proof here. we begin by assuming that δ < ( −dmax)v vmax and δ−di v /v max , it implies that i(k) > for all k with probability one. now, according to lemma . , we have where note that hence, log( + δ − d i − kv) < for any k > (δ − d i )/v and the logarithmic function is welldefined for k within the assumed range. therefore, we have log e[f ( )] < , which implies that lim k→∞ e[i(k)]/i → and the proof for part (i) is complete. to prove part (ii), we fix k and simply note that, with the assumed assumptions on δ and k and the fact that d i (·) ≥ , it is readily verified that e[i(k)] ≤ i , which completes the proof of part (ii). to prove part (iii), take k = (δ − d i )/v and substitute it back into the equation , we obtain e[i(k)] = i for all k and the proof of part (iii) is complete. similar to remark . . , to accommodate the practical considerations, we fix l ≥ and require due to the limited available medical resources, it is reasonable to choose a "sub-optimal" k in the sense of minimizing the potential use of medical resources. for example, we let {δ≤lv} and {δ>lv} be the indicator functions and consider provided that δ < v( −dmax) vmax to be our choice of feedback gain for controlling of epidemics in the sense of expected value. note that k * > δ−di v for d i > ; hence, the theorem above applies. this usage of k * will be also seen later in section . where the last inequality holds by using lemma . . the next lemma states the expected susceptible cases. we begin by recalling that lemma . tells us that s(k) ≥ for stage k = , , . . . , ⌊s /(δ max i )⌋. now using the facts that δ(k) are i.i.d. in k, and δ, d i and v are mutually independent, we have using the geometric series, we conclude which completes the proof. for k ≥ , any linear feedback control policy of the form u(k) = ki(k) with ≤ k ≤ ( − d max )/v max yields the expected deceased cases proof. the proof is similar to lemma . . using lemma . and the fact that v(k), d i (k), and δ(k) are independent, we have it is easy to verify that d i (i) and ( + δ(j) − d i (j) − kv(j)) are independent for all j = , . . . , i − ; hence, we have using the geometric series, the equality above reduces to which is desired. for u(k) = ki(k), one can readily verify that with the aids of theorem . such that expected deceased cases e[d(k)] ≤ c d for all k. therefore, the average epidemic control problem is solved. in the next section to follow, we provide an illustrative example using historical covid- data to demonstrate our epidemic control performance. we now illustrate the application of our control methodology on the epidemiological model using historical data for year available in https://ourworldindata.org/coronavirus, which contain the number of daily confirmed cases, denoted by c(k), and daily reported deaths, denoted by d(k) for k = , , . . . , n − for some fixed integer n . to study the epidemic control performance, there are various way to estimate the uncertain parameters; e.g., one can consult "standard" approach such as minimizing the least-square estimation error to obtain the "optimal" parameters δ, d i and v; e.g., see [ , , ] . however, for the sake of simplicity, we now provide a simple "mean-replacing" approach to estimate the uncertain rate of infected cases δ(·) and the death rate d i via the available data of confirmed cases and the number of reported deaths. that is, we begin by recalling that the deceased cases satisfy d(k + ) = d(k) + d i (k)i(k). for k = , , . . . , n − , given the confirmed (infected) cases c(k) and reported deaths d(k) and taking c(k) := i(k) and d(k) := d(k), we obtain then, the estimate of death rate d i (k), call it d i , is defined by having found d i , we can now estimate the remaining two uncertain quantities δ(k) and v(k). to this end, assume that the adopted epidemic control policy is linear of the form u(k) = ki(k) with k := ; i.e., we ideally assumed that government had put all available resources to control the pandemic. now, setting c(k) := i(k), d i := d i (k), and replacing v(k) by its mean v, we obtain with the aid of equation ( ), the estimate of δ(k), call it δ, is given by having obtained the estimates δ and d i , we then ready to apply the epidemiological model and use it to compare it with the available data; see next subsections to follow. using the data from the start of the epidemy, over a horizon starting from march , to september , , we obtain the estimates δ with δ max := δ ≈ . and d i := d max ≈ . . in addition, we take l = and assume that the effectiveness rate of control v(k) follows a uniform distribution with v min = . and v max = . ; i.e., % to % effectiveness rate on control. observe that hence, theorem . does not apply. however, we can still choose a suboptimal feedback gain discussed in section . . ; i.e., this means that, if the infected cases can not be well-controlled in almost sure sense, governments should put whatever they can to suppress it; here, we see a · l% feedback gain is applied. the epidemic control performance is shown in figure where the black solid lines depict the confirmed cases c(k) and reported deaths d(k) from historical covid- data in the united states. the other thinner lines with various colors depict the epidemic control performance, in terms of c(k) and d(k), under the linear policy u(k) = kc(k) with k := l. interestingly, the figure also tells us that if l = is possible, it may yield, in average, a lower confirmed cases. with the aid of equations and , we obtain the estimates d i ≈ . and δ := δ ≈ . . similar to the previous example, we again assume that v(k) follows a uniform distribution with v min = . and v max = . ; hence the average v = . . it is readily verified that our estimates satisfy hence, theorem . applies if we take the control policy above tells us that the government may need to bring in extra medical resources to achieve k > . the corresponding epidemic control performance is shown in figure where the confirmed cases is on the top panel and the deaths is on the bottom panel. in the figure, we see a downward trend occurs on the confirmed cases and the saturated deaths as time increases. the figure shows, with y-axis in log-scale, the epidemic control performance comparison where the black solid lines are the reported confirmed cases (top) and reported deaths (bottom). this preliminary work has been done in the urgency of the ongoing covid- pandemic, with the mind of providing a simple yet explainable epidemiological model with a rigorous study on the effectiveness of a linear epidemic control policy class. consistent with the existing literature on epidemic modeling and control, this paper considers a modified stochastic sird-based model. we analyzed the model and considered two epidemy control problems: one is the almost sure epidemic control problem and the other is the average epidemic control problem. then, for both of two problems, with linear control policy, we show sufficient conditions on feedback gain so that the epidemy is deemed to be "well-controlled" in the sense that infected cases goes down to zero asymptotically, and both infected cases and deceased cases are upper bounded uniformly. subsequently, we provide a simple data-driven parameter estimations and show some promising numerical results using historical covid- data in the united states. based on our work to date, two important directions immediately present themselves for future work which described in the next subsections to follow. it is possible to extend our analysis to involve multi-population epidemics. to illustrate this, below we consider only the infected cases dynamics. fix m populations, then for each population i = , . . . , m, we write with limited medical resource for some u max > and the overall infected cases are it is also possible to consider the case where the control policy is with delay effect; i.e., u(k −d) with delay timed; see also [ ] for a discussion on handling the time delay considerations in a class of positive finance systems. another possible research direction would be to take the economic budget into play. as seen in remark . . , the idea of minimizing the expenditure induced by implementing control policy may lead to a version of "optimal" choice for feedback gain k. in particular, one can even consider the budget dynamics and carry out the optimization. specifically, let b(k) be the available medical budget at the kth day which satisfies b(k + ) = b(k) + p(k)u(k) where p(k) is the price to pay per control policy at each stage, which can be modeled as a random variables with finite support. then, it is readily verified that for k ≥ . from here, there are many possible directions to pursue. for example, one can consider a optimization problem which minimizes the expected budget cost and infected cases; i.e., one might seek to find a sequence of k which solve inf k e[βb(k) + γi(k)] for some constants β and γ. data-driven methods to monitor, model, forecast and control covid- pandemic: leveraging data science, epidemiology and control theory some discrete-time si, sir, and sis epidemic models, mathematical biosciences infectious diseases of humans: dynamics and control the mathematical theory of infectious diseases and its applications a data-driven control-theoretic paradigm for pandemic mitigation with application to covid- a modified sir model for the covid- contagion in italy linear system theory and design a time-dependent sir model for covid- with undetectable infected persons fitting dynamic models to epidemic outbreaks with quantified uncertainty: a primer for parameter uncertainty, identifiability, and forecasts probability: theory and examples probability and random processes for electrical and computer engineers the mathematics of infectious diseases, siam review on positive solutions of a delay equation arising when trading in financial markets containing papers of a mathematical and physical character robust and optimal predictive control of the covid- outbreak substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov- ) how control theory can help us control covid- world helth organization, weekly epidemiological and operational updates key: cord- -doi w tb authors: seto, christopher; khademi, aria; graif, corina; honavar, vasant g. title: commuting network spillovers and covid- deaths across us counties date: - - journal: nan doi: nan sha: doc_id: cord_uid: doi w tb this study explored how population mobility flows form commuting networks across us counties and influence the spread of covid- . we utilized -level mixed effects negative binomial regression models to estimate the impact of network covid- exposure on county confirmed cases and deaths over time. we also conducted weighting-based analyses to estimate the causal effect of network exposure. results showed that commuting networks matter for covid- deaths and cases, net of spatial proximity, socioeconomic, and demographic factors. different local racial and ethnic concentrations are also associated with unequal outcomes. these findings suggest that commuting is an important causal mechanism in the spread of covid- and highlight the significance of interconnected of communities. the results suggest that local level mitigation and prevention efforts are more effective when complemented by similar efforts in the network of connected places. implications for research on inequality in health and flexible work arrangements are discussed. the coronavirus disease pandemic has dramatically impacted societies globally, with over million confirmed cases and over , covid- deaths worldwide at the time of this writing (hopkins, ) . consequently, a growing body of research seeks to understand the social and demographic predictors of this disease at the community level, identifying local etiological factors such as age structure , population density (sy et al., ) , and racial composition of the residents (millett et al., ) . in addition to local factors, equally important it is to understand the role of social contacts within and across communities, such as the extent to which the movement of people between communities facilitate the transmission of this infectious disease. one important type of such movement is commuting for work, a routine mobility activity that millions of people in the us engage in, typically on a daily basis (mckenzie, ) . many of the local and state level mitigation and prevention policies have involved some form of social distancing recommendations to "flatten the curve", in recognition that close physical proximity among people (in the regular course of their daily activities such as in the workplace, at church, or in school) can contribute significantly contributor to the spread of this disease. research on the transmission of this disease across space, between places such as work areas and residential areas is still in its infancy, yet important evidence is starting to emerge. for instance, (bai et al., ) analyzed inter-county commuting flows in the state of new york and found that "community spreader" counties were characterized by high commuting flows to and from other counties. these findings are consistent with prior research focused on the spread of other infectious diseases which finds that commuting is an important mechanism through which as of . . diseases may be transmitted to new populations. for example, (xu et al., ) linked road traffic among chinese cities to the incidence of influenza a (h n ) during the pandemic. understanding how exposures to coronavirus in an area's commuting network affects local cases and deaths is important in guiding thinking and policy in support of remote working schedule and other flexible work arrangements. because many types of jobs do not permit remote work, certain populations, often underpaid and socioeconomically vulnerable minority groups, are disproportionately affected both at work and at home by increased risk of exposure to this disease. moreover, these same groups are further disadvantaged disproportionately by school closures and the need to find alternative arrangements for the care of school age children and other dependents. we contribute to the extant literature on the social and spatial dynamics of covid- by analyzing population across united states (us) counties which we consider to be linked via a network of commuting ties. we assess the extent to which county rates of covid- deaths and cases are predicted by covid- cases in linked counties, controlling for relevant structural and sociodemographic characteristics and spatial contiguity. we leverage methodological strategies from computational statistics to assess model fit and estimate significance while accounting for spatial and network dependencies within the data. our findings demonstrate that commuting networks are an important determinant of the spread of covid- , as measured by deaths and confirmed cases. we analyze a population of all us counties. data on total number of covid- confirmed cases and total number of covid- deaths are drawn from a database maintained by usa facts , which is updated daily and contains counts by county and state. we utilize -level mixed effects negative binomial models, analyzing covid- cases and deaths of county-time periods (n= , ), nested within counties (n= , ), nested within states (n= , includes dc). these models are implemented using the menbreg command in stata (statacorp, ). negative binomial models are well suited to predicting overdispersed count outcomes (osgood, ) , making them well suited to this research application. we incorporate state-level random intercepts to account for cross-state variation in covid- outcomes which may have been driven by statelevel policy differences (e.g., different masking requirements and enforcement of business lockdowns) and county-level random intercepts to account for unmeasured variation across counties in covid- susceptibility and response. county-time periods, our first-level units of analysis, are based on the number of new covid- cases and deaths for a given county within a given two weeks. within each county are nested ten of these county-time periods, ranging from april st to august th, . we use total county population (based on the american community survey -year population estimates) as an exposure term for all models, making the model coefficients interpretable as population rates. all models are estimated using huber-white robust standard errors. as a result of the network and spatial interdependencies which we hypothesize to exist among counties, conventional, analytic tests of statistical significance may fail to produce accurate confidence estimates (lesage, ) . instead, we utilize a permutation testing, a flexible, simulation-based approach (breiman, ; graif et al., ) . for each predictor, we conduct permutations in which the values of the predictor are randomly permuted across all observations, breaking any association with covid- mortality rates. each permuted dataset is used to calculate model error, generating a distribution of what model error would look like if the predictor had no effect. the observed error is then compared to this distribution in order to assess the contribution which the predictor makes to model fit. a relatively low proportion of permuted cases which produced a lower error than that which was observed shows a significant contribution to model fit. in these permutation tests, we use mean arctangent absolute percentage error (maape) to capture average model error. maape is computed by averaging the arctangent of the ratio of error to observed value for each observation, as shown in equation . maape has the advantage of capturing error as a percent, making it less sensitive to outliers than mae, while also being robust to observations for which the true value of y is (an advantage over mape) (kim & kim, ) . ( ) we used data on intercounty commuting, used to construct a weighted average of networklagged covid- exposure, were drawn from the lehd origin-destination employment statistics (lodes) dataset, which is publicly available from the u.s. census bureau (us census of -lehd) (graif et al., ; kelling et al., ) . this measure was created according to equation , where a given home county (h) is connected to w work counties. ℎ− represents the number of commuters from county h who commute to county w, while ℎ− represents the total number of outgoing commuters from county h. an additional measure of covid- exposure was also created based on spatial proximity using average rate of confirmed cases of all (queen) contiguous counties (e.g., equation for a county which borders b counties). we incorporate a temporal lag into the construction of these measures by using cases from the prior two-week time period. we also incorporate measures capturing network and spatial change in covid- cases from the prior to current time period which use identical weighting (equations and ). finally, we control for each county's own covid- case rate during the prior weeks. we used the rubin-neyman causal inference potential outcomes framework (rubin, ) to estimate the causal effect of each of the county-level characteristics, including economic disadvantage, percentage of population over the age of , etc. (see table for details), on the number of deaths by covid- in that county. to estimate the causal effects, we applied the wellestablished weighting procedure in causal inference by following a two-step mechanism: first, we weight each data sample so as to adjust for the effect of confounding and generate a weighted population that we can consider "as if randomized." second, we perform a weighted regression where we regress total number of deaths by covid- against county-level characteristics. we repeated this two-step procedure for each county-level characteristic separately, each time designating a characteristic as "treatment," and estimated the causal effect of that characteristic on total number of deaths by covid- . we used the following state-of-the-art weighting methods for causal inference from observational data. each of the three methods that we applied use a different methodology for computing the weights (in the weight model). (i) covariate balancing propensity score weighting (cbpsw): propensity score is defined as the probability of receiving the treatment given the covariates and is used in estimating the causal effect of binary treatments on outcomes. propensity density is its counterpart for coping with continuous treatments. cbpsw was recently proposed and it estimates the weights based on the propensity score (for binary treatments) and propensity density (for continuous treatments) while maximizing covariate balance between the treated and controlled via an additional balancing constraint in the optimization (fong et al., ; ratkovic, ) (ii) inverse probability of treatment weighting: this method weights each of data samples proportionate to the inverse of the propensity score (robins et al., ) . (iii) super learner: this method offers a doubly robust estimate of causal effects computed through an ensemble of propensity score estimators (pirracchio et al., ; van der laan et al., ) . the methods that we have used have been shown to be reliable, effective, and efficient in estimating causal effects from observational data in various applications , . the weighted outcome regression model determines the causal effect of each county level characteristic on deaths by covid- through statistical hypothesis testing. we tested for the null hypothesis that each such causal effect is zero. a statistically non-significant p-value would determine a non-significant causal effect. a statistically significant p-value shows a significant causal effect and the degree (and sign) of the causal effect is determined by the magnitude (and sign) of the estimated coefficient for the treatment in the outcome regression model. we used . as the statistical significance level. research has indicated that communities that have lower socioeconomic status can have more preexisting health conditions, lower access to healthcare, lower access to high-speed internet that could enable remote work, and are less able to engage in social distancing during the covid- pandemic (chiou & tucker, ; weill et al., ) . for these reasons, several sociodemographic controls are included in the analyses. these measures were drawn from the - american community survey (acs) -year estimates. note that these measures are county-level attributes, i.e., considered to be invariant over time for the two-week time periods defining the level-one units. economic disadvantage was measured as the first principal component produced following an analysis of unemployment rate, median income, percent in poverty, percent female-headed households, percent college graduates, percent owner-occupied housing units, and percent vacant housing units (eigenvalue = . ). we also include the percent of residents of years or older, as well as binary indicators of whether the county is above average regarding ( ) percent non-hispanic white, ( ) percent non-hispanic black, and ( ) hispanic. finally, we include a measure of the percent of the county with urban residence, as measured in . table shows descriptive statistics for all measures described above. table displays coefficient and standard error estimates from multilevel negative binomial models predicting total deaths and total confirmed cases using the full analytic sample. results from these models are consistent with prior literature and theoretical expectations. as shown, the commuting network-based measures are robust predictors of both total deaths and total cases. this is true for both the network measure based on confirmed cases at the prior time period and the network measure capturing change in cases from the prior time period. note that, when these network measures are taken into account, spatial contiguity is not a strong predictor of covid- spread across counties. estimated coefficients for other measures are also consistent with extant research and our expectations. economic disadvantage, concentration of racial/ethnic minority groups, and urban population are associated with higher rates of covid- cases and deaths, while a higher concentration of non-hispanic white population is associated with lower covid- cases and deaths (tai et al., ) . population percent aged years and older is negatively associated with cases, but positively associated with deaths (le couteur et al., ) . as expected, a county's case rate at the prior time point is a strong predictor of cases at the current time point. the permutation test results shown in table provide further support for these findings. the p-values shown in table we conducted several tests to assess how findings changed with alternative model specifications. in order to better separate network effects from possible unmeasured spatial confounders, we re-estimated the models using network measures based on ( ) only contiguous counties and ( ) only non-contiguous counties. tables and show estimates from these models (respectively). as shown, the network effects persist in both cases, further supporting our finding that commuting networks matter for the spread of covid- beyond spatial proximity. notes: exposure = county race-specific population - , acs -year estimates; nhb = non-hispanic black; ***p < . ; ** p < . ; * p < . ; † p < . to aid our causal inference, we also conducted several analyses using different weighting strategies on a cross-sectional version of our data in which outcomes are cumulative counts of a county's cases or deaths, and network and spatially lagged measures are based on these cumulative counts. results from these models are shown in table . as shown, these alternative model specifications produced substantively similar results with regard to the commuting network effects, offering further support for our conclusions. results of all of the causal effect estimators consistently show that the percentage of population over the age of and economic table . negative binomial models (with state and county random intercepts) predicting covid- outcomes across time periods based on network, spatial, and time lagged cases. network based on only non-contiguous counties. total confirmed cases beta se beta se network lagged confirmed case rate (tn- ) . *** (. ) . *** (. ) Δ network lagged confirmed case rate (tn- -tn) . (. ) . *** (. ) spatially lagged confirmed case rate (tn- ) . *** (. ) . *** (. ) Δ spatially lagged confirmed case rate (tn- -tn) . *** (. ) . *** (. ) confirmed case rate (tn- ) . *** (. given the growing research suggesting that vulnerable populations are less able to work remotely and engage in physical distancing during this pandemic, our results also indicate the acute need for work level protections, such as providing paid sick days, increasing minimal wages, providing health safety equipment to essential workers, to assisting with childcare for working parents who have to work while the schools are closed or in remote mode. these necessary provisions will not only help save the lives and health of workers who cannot afford to socially distance themselves from their work environments, but they have the great potential to spillover and improve the fates of whole communities that their workers go back home to. as expected, an area's socioeconomic disadvantage contributed to both higher death rates and cases relative to the local population. the area's concentration of whites was associated with a protective effect against both infection cases and covid- deaths. the concentration of minorities, both above average share of hispanics and non-hispanic blacks was associated with higher rates of confirmed cases, consistent with a large body of work that has documented the many challenges associated with covid- risk that burden minority communities, including the higher likelihood to be in frontline occupations and in other low paid occupations that have little flexibility and cannot be easily be transitioned to remote work format. these data come with several limitations. the analytical focus was on counties in part due to restrictions regarding the covid- data availability across the country. to the extent that the data access and granularity expands in future months, analyses at more local levels will be very valuable. still, analyses on other important transmittable diseases like influenza have examined place-to-place transmission patterns for geographic units as large as states and counties (bozick & real, ) with important lessons that have inspired further research. the network measures used in this study were limited by the data access constraints to information updated on an annual basis, and thus they do not capture the fast-occurring changes during this ongoing pandemic. while these measures captured the commuting network prior the pandemic, those links have likely been weakened by layoffs or remote work transitions. still, the information on the covid- rates within the commuting network was captured as it changed over time. given that the pandemic likely contributed to weakening rather than strengthening preexisting commuting links across places, the fact that nevertheless we still see strong effects suggests to us that adjustments in the future to these data to reflect the rapid changes in employment status will likely reveal even stronger effects of commuting exposures to covid- . many businesses across the country have restricted their employment during the covid- pandemic, some have even closed temporarily or permanently, while others allowed employees to work remotely for the purpose of "social distancing" and in the hope of "flattening the curve" (bartik et al., ) . understanding how these mobility changes and restrictions contribute to containing the covid- transmission is an important next step for future research. moreover, it is known that some population groups are more likely to be in occupations (e.g., health care providers, grocery workers, bus drivers, meatpacking workers) that have been on the frontlines in the fight against covid- , unable to comply with social distancing recommendations and policies. understanding how workplace networks and risk transmission differentially affect disadvantaged and minority populations is of great importance in future research. importantly, also understanding the types of workplace connections and other social network-based distancing strategies that can work best to contain the pandemic risk without further isolating the most vulnerable populations and communities is essential. mapping the intercounty transmission risk of covid- in the impact of covid- on small business outcomes and expectations social network-based distancing strategies to flatten the covid- curve in a post-lockdown world the role of human transportation networks in mediating the genetic structure of seasonal influenza in the united states random forests social distancing, internet access and inequality demographic science aids in understanding the spread and fatality rates of covid- covariate balancing propensity score for a continuous treatment: application to the efficacy of political advertisements network spillovers and neighborhood crime: a computational statistics analysis of employment-based networks of neighborhoods neighborhood isolation in chicago: violent crime effects on structural isolation and homophily in inter-neighborhood commuting networks coronavirus resource center covariate balancing propensity score modeling the social and spatial proximity of crime: domestic and sexual violence across neighborhoods fairness in algorithmic decision making: an excursion through the lens of causality algorithmic bias in recidivism prediction: a causal perspective a causal lens for peeking into black box predictive models: predictive model interpretation via causal attribution a new metric of absolute percentage error for intermittent demand forecasts covid- through the lens of gerontology spatial econometrics. in handbook of research methods and applications in economic geography who drives to work?: commuting by automobile in the united states assessing differential impacts of covid- on black communities poisson-based regression analysis of aggregate crime rates improving propensity score estimators' robustness to model misspecification using super learner marginal structural models and causal inference in epidemiology causal inference using potential outcomes: design, modeling, decisions stata statistical software: release population density and basic reproductive number of covid- across united states counties the disproportionate impact of covid- on racial and ethnic minorities in the united states super learner social distancing responses to covid- emergency declarations strongly differentiated by income impacts of road traffic network and socioeconomic factors on the diffusion of pandemic influenza a (h n ) in mainland china key: cord- - cpe x authors: moustakas, aristides title: ranking the explanatory power of factors associated with worldwide new covid- cases date: - - journal: nan doi: nan sha: doc_id: cord_uid: cpe x disease spread is a complex phenomenon requiring an interdisciplinary approach. covid- exhibited a global spatial spread in a very short time frame resulting in a global pandemic. data of new covid- cases per million were analysed worldwide at the spatial scale of a country and time replicated from the end of december to late may . data driven analysis of epidemiological, economic, public health, and governmental intervention variables was performed in order to select the optimal variables in explaining new covid- cases across all countries in time. sequentially, hierarchical variance partitioning of the optimal variables was performed in order to quantify the independent contribution of each variable in the total variance of new covid- cases per million. results indicated that from the variables available new tests per thousand explained the vast majority of the total variance in new cases ( . %) followed by the governmental stringency index ( . %). availability of hospital beds per k inhabitants explained % extreme poverty explained . %, hand washing facilities . %, the fraction of the population aged or older explained . %, and other disease prevalence (cardiovascular diseases plus diabetes) explained . %. the percentage of smokers within the population explained . % of the total variance, while population density explained . %. patterns of infectious diseases across spatial and temporal scales are fundamental for understanding their dynamics and for designing eradication strategies [ , ] . disease spread is a complex phenomenon and requires an interdisciplinary approach spanning from medicine to statistics and social sciences [ ] . covid- exhibited a global spatial spread in a relatively very short time frame resulting in being characterized as a pandemic by the world health organisation [ ] . to date there is no known anti-viral treatment or vaccine against covid- [ ] . therefore the available options against the virus are the characteristics of the immune system and health status of each individual, the health system of the country that the individual has access to, the social behaviour of the other individuals forming the society, public interventions of movement or public campaigns, and testing [ ] [ ] [ ] . thus, there are relatively few options to be employed in order to diminish the spread of the disease. this scarcity of options makes quantifying the factors associated with disease spread more important and ranking the relative contribution of each factor on covid- spread may facilitate diminishing it [ ] . analysis so far has often been dominated either on a one-at-a-time factor analysis (e.g. new cases per testing effort or total cases per age structure) or on a country basis analysis (e.g doubling time in one country in comparison to other countries). while such comparisons are straightforward and comprehensive, from a statistical perspective they are examining one factor at a time and masking underlying characteristics within countries under a variable 'country' [ ] . this results in a hidden burden of the underlying factors regarding disease spread and causality is often discussed in a speculative manner. admittedly the problem is complex due to the large differences across the potential underlying factors across countries. a small variance implies that the mean contains virtually all of the information, while a large variance implies that more information than the mean is present [ ] . when examining several countries together and across time, quantifying the variance may be more informative than the mean [ ] . variance is introduced both by space, there are large e.g. climatic differences between locations on the same date, as well as by temporal e.g. climatic or behavioural changes within locations in seasons [ ] [ ] [ ] . the potential effect of economic, epidemiological and public health, or governmental interventions may become clearer when the contribution of these factors into new covid- cases are analysed accounting for the fact that they derive from different countries as well as in different time snapshots [ ] but in a way that the effect of each factor can be quantified in conjunction with the effects of other factors. to that end methods that can account for both spatial and temporal autocorrelation [ ] in the data of new covid- cases but can quantify the effect of each epidemiological, economic, public health, and governmental intervention are key to our understanding of how the disease spreads in populations worldwide [ , ] . in this study spatio-temporal worldwide data of new covid- cases form the "our world in data" database [ ] were analyzed using computational statistics. the spatial replicate of the dataset included over countries time replicated for each country across a period of ≈five months. data driven analysis was performed in order to quantify the optimal variables in cases where several candidate variables were available. during the data driven variable selection, the fact that data derived from different countries and were time replicated was accounted for by nesting the variance of time within the variance of country and treated as random effects [ , ] . the percentage of the total variance explained by each epidemiological, economic, public health, and governmental intervention variables associated with covid- new cases was quantified using hierarchical variance partitioning [ , ] thereby ranking the relative contribution of the variance of each factor on new covid- cases worldwide. the objective was to quantify epidemiological, public health, economic, and governmental intervention factors associated with covid- spread worldwide. new covid- cases per million per country per time step were used a proxy of disease spread. new cases per million in each country was chosen instead of new cases per country as this estimator is less biased by the total population of each country -countries with higher populations are more likely to produce higher new cases or total but the number may be relatively low in comparison to the total population pool. data regarding new covid- cases per million from the "our world in data" database were analyzed. the dataset was last accessed on / / and the download location is https://github.com/owid/covid- data/tree/master/public/data. the data derive from the european centre for disease prevention and control (ecdc), an eu agency with the aim to strengthen europe's defense against infectious diseases. the ecdc collects and aggregates data from countries around the world. the most up-to-date data for any particular country is therefore typically available earlier via the national health agencies than via the ecdc. this lag between nationally available data and the ecdc data is not very long as the ecdc publishes new data daily; typically this time lag is at the level of some hours and less than a day. the ecdc collects compiles and harmonizes data from around the world in a consistent way which allows us to compare what is happening in different countries. the spatial replicate of the dataset comprised of countries while the temporal replicate spans from / / to (including) / / . the variables included: from the available variables male and female smokers were averaged as 'smokers'. we employed generalised linear mixed effects models (lme; [ ] ) with new covid- cases per million as the dependent variable. as the dataset contained several potential indexes of testing, population density, or age structure within each country, initial analysis was conducted in order to select the most informative index of each. we initially sought to quantify the most parsimonious data driven index of testing which included the fixed effects of (i) news tests (ii) total tests (iii) new tests per thousand (iv) total tests per thousand (v) new tests smoothed, (vi) new tests smoothed per thousand. this was achieved by fitting six lmes with new cases per million as the dependent variable and six lmes with i -vi as the single independent variable. the random effect structure of each lme included the nested variance of time within each country (random~country/time). doing so the fitted lmes accounted for both temporal and spatial autocorrelation in the time replicated data deriving from different geographic locations [ , ] . lmes were fitted with maximum likelihood (ml) estimation to allow comparisons between models with different fixed effects and selecting the lme that exhibited the lowest akaike (aic) value [ , ] . here and throughout the analysis, there were , data points in the analysis but there were variables with missing values at some time steps or at some countries. missing values were omitted from the statistical analysis. therefore aic values are compared between models fitted with different fixed effects but also with potentially different sample sizes. similarly, lmes with new cases per million as the dependent variable and the fixed effects of (i) population or (ii) population density, and the nested random effects of time within country were fitted with ml and compared against aic values to select the optimal data driven population index. regarding age structure of the population within each country, the available variables were (i) median age of the population, (ii) the percentage of the population aged or older, and (iii) the percentage of the population aged or older. the analysis proceeded by selecting the ml fitted lme with the lowest aic between the three available age population structure variables. all three fitted lmes contained the random effects of time nested within country. regarding economic status of the population within each country, the available variables were (i) gdp per capita, and (ii) percentage of the population under extreme poverty. the analysis proceeded by selecting the ml fitted lme with the lowest aic between the two available economy status variables. the two fitted lmes contained the random effects of time nested within country. having selected the optimal index of testing, population density and age structures the analysis proceeded with the following variables: ( ) population density, ( ) new tests per thousand, ( ) governmental stringency index, ( ) percentage of the population aged > , ( ) percentage of the population under extreme poverty, ( ) cvd death rate, ( ) diabetes prevalence, ( ) percentage of smokers, ( ) percentage of the population with access to hand washing facilities, and ( ) hospital beds per k inhabitants within each country as independent variables. hierarchical variance partitioning (hvp) statistical modelling was implemented to account for the contribution of each data driven epidemiological, economic, public health, and governmental intervention explanatory variable to the total variance of new covid- per million cases [ , ] . hvp is a statistical framework that is capable of handling correlated independent variables, whilst providing a reliable ranking of predictor importance of each variable [ ] . variance partitioning is calculated from the akaike (aic) weights of each explanatory variable and it is based upon the number of times that a variable was significant in all possible combinations of the explanatory variables. the hvp function produces a minor rounding error for hierarchies constructed from more than nine variables [ ] -the available data driven variables were . to check if this error affects the inference from an analysis, the analysis was repeated several times with the variables entered in a different order [ ] . the analysis resulted in changes in the derived results when the order of the variables was changed. the analysis proceeded by creating a new variable that merged together other disease related variables: other diseases variable= (cvd_death_rate + diabetes_prevalence) plus the other remaining eight variables resulting in a total of nine variables. there is no known statistical bias in hvp when or fewer variables are used [ ] . the optimal data driven index for explaining new cases per million from the ones available regarding testing was new cases per thousand as fitted by lmes and selected against the lowest aic value (table a) . new tests per thousand smoothed could not be fitted as the lme did not converge (table a) . the optimal data driven population index for new cases per million was population density (table b ). the optimal data driven index for age structure within the population was the percentage of the population within each country aged or older (table c ). the optimal aic selected lme regarding the economic status of the population within each country in relation to new covid- cases per million was extreme poverty (table d) . results from hvp indicated that total tests per thousand explained . % of the total variance of new cases per million, while governmental stringency index explained . % (fig. , table ). availability of hospital bed per k inhabitants explained % (fig. , table ). extreme poverty explained . % of the total variance of new cases per million, hand washing facilities . %, the fraction of the population aged or older explained . %, other disease prevalence (cardiovascular diseases plus diabetes) explained . % (fig. , table ). the percentage of smokers within the population explained . % of the total variance of new covid- cases per million, while population density explained . % (fig. , table ). the best model fit regarding new covid- cases per million and the economic status of the country where the new cases are recorded indicated that extreme poverty was a better predictor of new cases than gdp per capita. it is thus the poorest individuals within each country impacted rather than poor countries. from the data available, the fraction of the population aged or older explained optimally new cases per million and not median population age. total tests per thousand and not new tests or new tests smoothed or other available indexes is a better predictor of new cases per million, perhaps unsurprisingly as the number of new cases is already normalized by the population and thus the number of tests also normalized by the population explains better the pattern. the latter also applies for population density instead of total population as the best available predictor of new cases per million. summing up, from the data-driven analysis it is evident that new covid- cases per million are best explained by extreme poverty prevalence within each country as well as by the fraction of the population older than , thereby indicating association of the spread of the disease with the poor and older. results from variance partitioning of the data-driven selected epidemiological, public health, economic, and governmental intervention variables explaining covid- new cases per million across countries through time, indicated that the vast majority of new cases per million are explained by the number of tests conducted. the number of new tests per thousand explains over % of the total variance through time and countries and thus the message regarding the efficacy of testing against covid- spread is strong, at least form the results derived here. the efficacy of testing has been highlighted as the best strategy against other diseases too across humans, agriculture, and wildlife [ , , , ] . it therefore seems that the optimal strategies against covid- spread should include high number of tests both to suspicious cases as well as random population testing. would increasing the number of tests result in detecting more covid- cases? lost covid- cases are not uncommon [ , ] . from a statistical perspective, variance partitioning does not provide information on the sign of the effects (positive or negative) it simply shows in how many cases this variable could not be excluded from the final optimal statistical model in explaining new covid- cases. the slope between new tests per thousand inhabitants and new cases per million vary between countries (fig. a) . indeed there are countries where the slope between new cases per million and new tests per thousand are positive indicating that testing more would actually result into identifying more cases (fig. a) ; [ ] . however, there are also countries with a negative slope between new tests -new cases' indicating that testing frequency is saturated (fig. a) . overall, using data from all countries and time steps, the relationship between testing and new cases is positive indicating that worldwide more tests would result in identifying higher number of new cases (fig. b) . therefore the efficacy of testing has not been saturated. the second best variable in explaining new covid- cases per million was the governmental stringency index. the governmental stringency index contains several measures taken by governments including school closures, national and international movement restrictions, public gathering and public events restrictions, exiting home restrictions as well as testing policies and financial measures [ ] . to that end testing policy is in part contained in the stringency index as a weighted percentage of the overall index. however the relationship between stringency index and new tests per thousand is very weak with both r and slope close to zero: linear regression (new_tests_per_thousand) = . + . (stringency_index), s = . , r = . %, p< . . therefore of the available governmental measures summarized in the stringency index, testing frequency can be treated independently. in general, countries increased their level of stringency as their number of confirmed covid- cases raised, however there is significant variation in the rate and timing of this relationship [ ] . another study indicated that in the early and accelerating stages of the pandemic, many citizens across countries viewed their governments' response as insufficient [ ] . in general the status of the infection spread and policy implementation influence restrictions uniformly across every countries [ ] . given the overall large effect of testing on new cases, it has been investigated whether there exists a testing frequency for covid- such that the shutdown could have been avoided [ ] . the study concluded that indeed there is an optimal testing frequency such that lockdown and thus governmental stringency may not be deemed necessary [ ] . the test against covid- is known to be imperfect but not precisely known [ ] and testing strategies to surmount this problem have been proposed [ ] . the availability of hospital beds per k inhabitants, hand washing facilities, the effect of covid- in the older people as well as prevalence of other diseases and smokers have been highlighted [ , , ] and this study confirms their importance. environmental factors have also been reported to play an important role in covid- dynamics [ ] however this study did not explore their relative contribution. table . data driven variable selection in cases where several candidate variables were available. variable selection was conducted by fitting lmes with new covid- cases per million as dependent variable and the candidate explanatory variables as single fixed effect variables and the variance introduced time nested within the variance of countries as random effects. models were fitted with ml to allow comparisons between lmes fitted with different fixed effects. the optimal model is bolded and italicized in each case. abrupt events and population synchrony in the dynamics of bovine tuberculosis synchrony, waves, and spatial hierarchies in the spread of influenza interdisciplinary public health reasoning and epidemic modelling: the case of black death: the case of black death world health organization. director-general's opening remarks at the media briefing on covid- - no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid- infection ethical and legal considerations in mitigating pandemic disease: workshop summary growth rate and acceleration analysis of the covid- pandemic reveals the effect of public health measures in real time new insights of emerging sars-cov- : epidemiology, etiology, clinical features, clinical treatment, and prevention effect of non-pharmaceutical interventions to contain covid- in china. . . little introduction to machine learning with applications in information security analysis of variance-why it is more important than ever. the annals of statistics effective transmission across the globe: the role of climate in covid- mitigation strategies. the lancet. planetary health temperature and latitude analysis to predict potential spread and seasonality for covid- using social and behavioural science to support covid- pandemic response the consequence of ignoring a level of nesting in multilevel analysis analysis of epidemics using spatio-temporal autocorrelation clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study. the lancet risk factors for severity and mortality in adult covid- inpatients in wuhan covid- ) -the data random-effects models for longitudinal data mixed-effects modeling with crossed random effects for subjects and items hierarchical partitioning. the american statistician coupling models of cattle and farms with models of badgers for predicting the dynamics of bovine tuberculosis (tb) variation in government responses to covid- . blavatnik school of government working paper mixed-effects models in s and s-plus model selection and multimodel inference data-driven competitive facilitative tree interactions and their implications on nature-based solutions. science of the total environment multiple regression and inference in ecology and conservation biology: further comments on identifying important predictor variables a spatially explicit impact assessment of road characteristics, road-induced fragmentation and noise on birds species in cyprus estimating and modelling bias of the hierarchical partitioning public-domain software: implications in environmental management and conservation regional and temporal characteristics of bovine tuberculosis of cattle in great britain. stochastic environmental research and risk assessment covid- epidemic in switzerland: on the importance of testing, contact tracing and isolation. swiss medical weekly internationally lost covid- cases quantifying undetected covid- cases and effects of containment measures in italy global behaviors and perceptions in the covid- pandemic international comparison of behavior changes with social distancing policies in response to covid- how often should people be the accuracy of covid- tests opensafely: factors associated with covid- -related hospital death in the linked electronic health records of million adult nhs patients. medrxiv covid- : what has been learned and to be learned about the novel coronavirus disease the role of environmental factors on transmission rates of the covid- outbreak: an initial assessment in two spatial scales. available at ssrn key: cord- -d cf ms authors: gupta, sourendu title: epidemic parameters for covid- in several regions of india date: - - journal: nan doi: nan sha: doc_id: cord_uid: d cf ms bayesian analysis of publicly available time series of cases and fatalities in different geographical regions of india during april is reported. it is found that the initial apparent rapid growthin infections could be partly due to confounding factors such as initial rapid ramp-up of disease surveillance. a brief discussion is given of the fallacies which arise if this possibility is neglected. the growth after april is consistent with a time independent but region dependent exponential. from this, r is extracted using both known cases and fatalities. the two estimates are seen to agree in many cases; for these cfr is reported. it is seen that cfr and r increase together. some public health implications of this observation are discussed, including a target doubling interval if medical facilities are to remain adequate. sars-cov- is a virus which has newly entered the global human population [ ] . as this host-parasite system evolves towards an equilibrium, its epidemiology has been studied extensively, but with some conflicting results [ , ] . the true extent of its penetration into the population is as yet open to question [ ] , since testing is fairly restricted in most countries. nor is the progression of the disease, covid- , or its method of spread completely clear [ ] . since the virus is already so widely established, it seems unlikely that it will be totally eliminated soon. so it is important to extract basic epidemiological parameters as cleanly as possible. india has managed to geographically contain the spread of the covid- epidemic with the nation-wide lock-down which started on march, . at the end of april the proportion of identified cases in india as a whole was a few tens per million, with - orders of magnitude more in hot spots. even if this were wrong by an order of magnitude, it would still mean that the epidemic remains at an early stage in india. this, combined with the lock-down, presents an opportunity to examine the growth of the epidemic in multiple isolated regions which implement essentially the same policy with regard to testing. this study examines the heterogeneity in the growth rate of the disease, in several ways. first, the doubling intervals, τ , of the cumulative number of identified cases, c(t), and the cumulative number of fatalities, d(t), is examined. from τ it is possible to extract the basic reproduction rate, r , within epidemic models. marked heterogeneity are observed. after this the correlation between the case fatality ratio, cfr, and r is studied. epidemic data, especially at the beginning is never clean. the public health system has to gear up for disease surveillance. the continuing recurrence of cholera epidemics [ ] , the spread of dengue and chikungunya [ ] , the successful surveillance and elimination of nipah [ ] and zika [ ] , show that india has a mixed record on epidemic surveillance. in addition to a possible lag between the beginning of the epidemic and its surveillance, there could be a problem of incomplete surveillance during the time the health service ramps up. any examination of data has to allow for the identification of confounding factors such as these. for the covid- surveillance data, there are further cautionary remarks. the icmr guidelines for testing [ ] specify that only symptomatic cases should be tested using rrt-pcr. this part of the policy has been unchanged since the middle of march. depending on the fraction of cases which are symptomatic, this could miss the actual prevalence of the disease in the population. estimates of the fraction of asymptomatic infections range as high as % [ ] , implying that, in this extreme case, the testing policy can never reveal more than % of the cases. the social stigma attached to covid- [ ] also means that some fraction of infections may be cryptic. there are uncertainties in the statistics of fatalities also. it has been reported that in europe and the us the number of fatalities due to covid- may have been underestimated by a factor of - . indian cities have fairly complete registries of deaths, so miscounting of covid- fatalities could come mainly from mistaken or incomplete reports of the cause of death. for larger regions, say districts and whole states, where most deaths happen at home and death certificates are not common [ ] the errors in counting fatalities may be significantly larger, and hard to estimate at this time. one point about the quality test that is developed here is that absolute numbers are not as important for it as the check that fatalities and identified cases are independently tracing the same rate of growth of the epidemic. this is expected at the beginning of the epidemic, when all epidemic models become linear, and the growth of generic measures is driven by the maximum eigenvalue of the linearized models. however, in the extraction of the cfr, the absolute counts do matter. in spite of the uncertainties, the correlation of cfr and r holds important lessons for public health in the inevitable later stages of this epidemic in india, and the middle and low income countries of the world. data has been extracted from official sources where possible. for ahmedabad city, the data is made publicly available by the municipal council of the city [ ] . this well-organized site corrects data retrospectively for up to about days. for chennai city, the data has been collected from daily tweets by the municipal council [ ] . for indore city, the data was collected from daily bulletins of the chief medical and health officer and the collection is available for public use [ ] . for mumbai city the data has been collated from the daily tweets by mcgm [ ] into a publicly available site [ ] . for pune district the data was collated from the daily tweets by the district authority [ ] and the collection is publicly available [ ] . for delhi and all other states, the data was taken from the publicly available collection at covid india [ ] . this site corrects data retrospectively for over a week. only data on the cumulative number of identified cases, c(t), and the cumulative number of known fatalities, d(t), are used in this analysis. for this work data collection stopped on may , , and retrospective corrections made after this are not included. the unquantifiable parts of the errors in the counts of cases and fatalities due to covid- were discussed in the previous section, along with the reasons why their estimates need not be included in this analysis. however, there is another part of the errors in the daily counts of cases and fatalities which come from backlogs of tests or hospital records. these shuffle a fraction of the numbers from one day to another, and therefore cause errors in the daily counts. as long as the number of facilities keep pace with the growth of the epidemic, these errors remain proportional to the number of cases and fatalities. since the wait time for hospital beds for covid- cases has remained roughly constant during the period of study, this argument is expected to hold. in view of this, of % of the reported values of c(t) and d(t) are assigned as errors. the specific fraction, %, was chosen to in order to cover the long range fluctuations visible in the time series (for example in those visible on days and of figure ). it has been seen that official reports and independent estimates of these number are generally within this range. at such an early stage in the infection, it is reasonable to assume exponential growth, i.e., doubling every τ days. within this assumption one can check how well the lock-down is working by letting the doubling interval become time dependent. the simplest function to try is a linear change in τ , i.e., and a similar set of three parameters for c(t). note that τ has dimensions of time, whereas τ is dimensionless. a fitting form with constant doubling interval was also used; this is denoted τ , dropping the subscript. the fitting procedure follows the methods of [ ] , with gamma distributions used as prior probability distribution functions (pdfs) for τ and c . the additional parameter τ is allowed to take positive and negative values, by letting the prior pdf to be a gaussian. for all these distributions, the widths are taken large enough that the posterior distribution is insensitive to the choice of priors. the appendix contains details of the relation between a time varying doubling interval and time variation of the basic reproductive rate r . this requires choosing a model of the epidemic. using the seir model, and the median interval between the appearance of symptoms and the time of fatalities, t = . days [ ] , one has when a constant τ is used, one can set τ = in the above formulae and write r and τ instead of r and τ . exactly the same procedure is followed for fits to the time series for d(t). estimates of the median values of the parameters, along with interquartile ranges (iqr) and % credible intervals (cri) are quoted for the doubling intervals as well as r . the analysis of the time series for c(t) and d(t) lead quite naturally to the case fatality ratio, cfr. this is defined as the ratio cfr = d(t)/c(t). ( if c(t) is underestimated, then cfr is overestimated, and conversely, when d(t) is underestimated, then cfr is also underestimated. this was regulated using a bayesian estimator. since the outcome is binomial, the prior pdf used is a beta distribution with α = and β = . these choices make the posterior distribution insensitive to doubling or halving the values of the priors. the posterior distribution is of the same form with α = + d(t) and β = + c(t) − d(t), with t taken to be the final day of the analysis. since c(t) and d(t) are both large, the following approximations for the median, µ, and standard deviation, σ, may be used: iii. results the time series of c(t) and d(t) is shown for the example of delhi in figure . of the regions that we analysed, most cities show an initial rapid growth followed by a tempered growth. the exceptions are ahmedabad and chennai among cities, and the states of gujarat, kerala, and west bengal. note that day one is taken to be march , , which is days after the beginning of the national lock-down. since t = . days, it might be expected that the growth rate of cases in the pre-lock-down period could manifest itself in that of fatalities until around day . in case of a successful lock-down, d(t) could then show an initial exponential growth, tempered after day . the initial data for fatalities in delhi, indore, mumbai and pune can indeed be described by an exponential. however, the doubling interval in pune turns out to be half of that in mumbai, although the average population density of mumbai is about times larger than the average in pune city. the ansatz of eq. ( ), i.e., a linearly varying doubling interval, was also examined for urban regions. the results are collected in table i . in most locations the initial doubling interval seems to be between half and day and two days. when converted to r , one obtains extremely high values, far in excess of what has been quoted in the literature. certainly r could vary from place to place, since it depends on infectivity of the virus as well as the social networks in each location, and the latter may change from one place to another. however, τ for pune is one third that of mumbai, when mumbai has six times the average population density. the wrong dependence of the doubling time for fatalities on population density, together with the observation that c(t) shows a growth till the same date, supports the idea that there could be a more parsimonious explanation for this common period of growth. this is discussed in the next section. at the moment, any statistical evidence for a gradual slowing of the growth rate of the epidemic is hidden due to some confounding factors. in view of this, the analysis was continued with a constant doubling interval, τ , applying it to the period after day or . for this part of the analysis data was from three states, namely gujarat, kerala, and west bengal, was also used. from figure , one sees that this simpler model provides as good a description of the data as the model of eq. ( ). furthermore, this yields more realistic values of r implies that during the lock-down each of these places has seen a location dependent constant doubling interval. the values of τ , along with inferred values of r , are collected in table ii . these are the primary results of this analysis. it was noted that the number of known cases, c(t), is definitely missing cases among those who have not been tested. this could include a possibly large, fraction of asymptomatic and non-critical or pre-symptomatic cases [ , ] . however, india's disease surveillance mechanism has concentrated on identifying critical cases and contact tracing, which could be a good tracer of the growth of epidemics. if this reasoning is correct, then, during the early growth of the epidemic, one should be able to obtain reliable doubling intervals from the cumulative counts of test positives [ ] . the results of this analysis are also given in table ii . the two independent estimates of r agree well enough that a closer look reveals interesting patterns. the scatter plot in figure of r obtained in two different ways shows several interesting patterns. first, there seem to be two groups of outbreaks. most regions have r below . among the regions that we studied, ahmedabad and gujarat were a separate group, which saw a faster epidemic growth, with r above . finally there is kerala, a different outlier, whose doubling intervals are longer than t , and therefore with very low values of r . the case of kerala merits a separate remark. the cumulative number of fatalities reached at the end of the period of study. with such low counts of fatalities the assumption of exponential growth cannot be well tested. the counts of total infections was larger, and supported the hypothesis of exponential growth over the period studied. second, one sees that most estimates lie close to the diagonal line. if the data was perfect, and the epidemic grew steadily, the estimates would lie exactly on this line. with this requirement we can separate the regions into two groups. one consisting of ahmedabad, chennai, delhi, gujarat, and west bengal are, within statistical uncertainties, on this line. the second group, with indore, kerala, mumbai, and pune, are not. this could indicate some issues with the data. on the other hand, if the data is as good as the other regions, then the fact that they are off the diagonal line should be understood. kerala, which is the only region which lies below the diagonal, is perhaps seeing a lower growth in new cases than fatalities, which could be indicative of a gradual slowing down of the epidemic. due to the lag by t , fatalities would see the slowing down later. conversely, the regions which lie above the diagonal (namely indore, mumbai, and pune, and, possibly, chennai) could be seeing an increased growth in infections, not yet visible in fatalities because of the same time lag. whether these scenarios are true, or the data quality is not dependable, should be known to the health agencies now, and would become visible to the public later. when there is a statistically significant difference between the doubling interval determined by c(t) and d(t), then the ratio gives a time-dependent cfr. this is usually understood to be a transient phenomenon. in view of this, the analysis was restricted to ahmedabad, chennai, delhi, gujarat, kerala, and west bengal, i.e., the regions which lie on the diagonal line of figure , and therefore are seeing a steady growth of identified cases as well as fatalities. the case fatality ratios for these regions are plotted against the r inferred from d(t) in figure . the most obvious trend is that for the group of three cities there is an overall trend towards smaller cfr with decreasing r . this is also true of the two states. however, the cfr for states is displaced upwards from that for cities. both trends have strong implications for the public health outlook and will be discussed further in the next section. counts of known cases and fatalities of covid- from five cities (ahmedabad, chennai, delhi, indore, and mumbai), one district (pune), and three states (gujarat, kerala and west bengal) was investigated in this work. in two of the groups, there was one case each where the epidemic was not severe at the end of april (chennai among cities, and kerala among states). the others were known hot spots. kerala is special because the number of fatalities is too low for statistical tests to be meaningful. there are strong regional heterogeneity in the course of the epidemic, indicating the necessity of looking at its spread at extremely local scales in order to check and control it. the time series both of known cases and fatalities in four out of the six urban centers showed a rapid rise for about days after the lock-down. this was followed by a much slower growth. since fatalities track cases with a delay of . days on the average, the early part of this data could track the growth in the time before the lock-down. however, it turns out that the data grows faster in less dense urban areas. moreover, this hypothesis is not tenable for the growth in the number of known cases. a possibility which resolves these difficulties is that this rapid rise of numbers in the early days tracks the rapid improvement of disease surveillance rather than the epidemic. the fact that the positive cases in kerala does not show such a rapid initial growth is consistent with reports that the state activated disease surveillance after the first infections came from abroad [ ] . this could also be true of ahmedabad and gujarat, two other centers which show no such initial increase, since the state had passed through the surveillance challenge of zika virus in recent years [ ] . due to this confounding factor, it is not possible to use the data until april or to make any statistically valid measurement of the growth of the epidemic before the lock-down. neglecting this leads to multiple fallacies, which i remark on next. the apparent slowing down of the growth in later stages may be falsely interpreted as a transition to polynomial growth. as shown in eq. (a ) and eq. (a ), this is equivalent to a time dependent doubling interval. it has been discussed in the previous subsection that this leads to highly unlikely properties of the covid- epidemic. the same apparent slowing down of the growth rate in india has also been interpreted within the homogeneous sir model with constant, time invariant, parameters [ ] . in such a simple model the time dependence can only come from early evolution towards herd immunity. this gives rise to the unlikely conclusion that herd immunity will be reached for covid- while % of the population remains susceptible. a misrepresentation of data also arises when "instantaneous doubling intervals" or similar measures of exponential growth are constructed using c(t) for one day, or averaged over small windows of time [ ] . this shows a spurious gradual slowing of growth during the first three weeks of the lock-down. in later weeks these estimates are also plagued by spurious effects which result when delayed reports are dumped into cumulative numbers on one day instead of being assigned to correct past dates. these appear as evidence of local spurts or slumps in growth. evidence of retroactive corrections from [ ] shows that delays of as much as ten days may occur. when these artifacts are averaged over a moving window, this gives the mistaken appearance of peaks and troughs, and may put erroneous pressure to change policies. due to the reasons discussed in the previous subsections, the period after april or constitutes the base data for the main part of this analysis. as shown in figure a constant growth rate in each locality during the the lockdown models the data as well as a growth rate which changes linearly with time. this is also the most parsimonious hypothesis about the growth of the epidemic. the observed doubling interval, and the derived quantity r , fall into three groups (see table ii and figure ). several geographical regions have r less than . kerala has r ≃ . (a doubling interval larger than t , the interval from the emergence of symptoms to death). gujarat and ahmedabad have r higher than . since this is the growth rate during the lock-down, population density effects are unlikely to be the major determinant of r . it would be worthwhile to consider the role of individuals with extremely large number of contacts in this context, or a significant tail of the distribution with small number of contacts, but still above three. five regions pass the following data quality test-the value of r obtained from the growth of fatalities and cases are equal. this does not mean that the number of cases is correctly counted. rather it indicates that the effort to find the cases requiring critical care, and tracing their contacts has successfully resulted in tracking a constant fraction of all infected persons. it may miss, for example, a large fraction of asymptomatic cases. for the five geographical regions which pass the quality test described in the previous section, a further study was performed. the dependence of the case fatality ratio, cfr (i.e., the ratio of the observed number of fatalities and cases) on r was investigated. although the number of cases identified may be much smaller than the actual number of cases, the chance that cases are identified in these five regions are expected to be similar, since the rate of testing is about the same. a positive correlation between r and cfr is observed. one possible reason for this is that with lower r the number of critical cases grows slower, giving medical practitioners time to figure out good practices which prevent critical care patients from progressing to fatality. deeper studies of this factor, comparing case data from different regions, is called for in future. it is possible that this is one of the most positive, and least discussed, outcomes of the lock-down. another possibility may also be conjectured. careful maintenance of social distancing, necessary to reduce r , results in evolutionary pressure on the virus. lock-down and similar methods force the virus to evolve in a direction which maximizes its ability to reproduce, which it can do if the disease becomes less critical or asymptomatic, and the chances of fatality decrease. it would be interesting to compare different regions across the globe for changes in the serial time and cfr. at the observed rate of growth, and with the current rate of testing, more than . % of the population in hot spots will begin to test positive for infections in about a month. a constant rate of growth of infections means that the number of hospital beds will also grow at the same rate, for as long as the epidemic is growing. even if the rate is slowed down heavily, as it is already in delhi, mumbai, and chennai, the demand for hospital facilities will keep on growing, as long as the epidemic grows. this demand is already beginning to outstrip resources in the larger cities. the mean interval between the start of symptoms and discharge was estimated to be . days [ ] . this means that unless the doubling interval is kept above days (= . / ln ), the demand on hospitals will keep rising. of the places we studied, only kerala has begun to approach this break-even point. cfr is currently small, partly because medical facilities have been able to cope with the rate of growth. if the number of cases exceeds the capacity of the medical system, cases which might have recovered will be harder to treat. inevitably in such cases cfr will climb. it is useful to note that in figure the statewide figures for cfr are higher than those for cities. this is a reflection of the relative paucity of medical services outside cities, and is a pointer to what might happen when the number of infections rises beyond the sustainable capacity of hospitals. i thank rahul banerjee, prahlad harsha, d. indumathi, and r. shankar for sharing collated data on various cities. i thank jayasree subramanian for providing me with the reference [ ] . in this form of the equation time is measured in units of the case resolution time. this equation assumes that the fraction of susceptible persons is close to unity, and the fraction of persons in any other compartment is very small. as argued before, this is a reasonable assumption to make. the cumulative number of infections is then found by integration. there is no closed form result for the general case. if only the linear term in the expansion of r is retained, then the function erfi is defined through the integral it is possible to use an expansion for t ≪ t , which gives the form i(t) = i( ) λ e λ t + ǫ( − λ t + λ t ) + o(ǫ ) (a ) where the notation λ = r − , and ǫ = r /(λ t ) are introduced. the imaginary part vanishes exponentially. this is easy to match to the phenomenological form i(t) = i( ) t/(τ +τ t/t ′ ) = i( ) t/τ − ln τ where an artificial expansion parameter t ′ is introduced. it is set to unity after expansion. matching these two expansions is accurate only when λ t is large. then the phenomenological parametrization of eq. (a ) can be connected to the parameters of (non-autonomous) evolution equations for the epidemic. note that t and t ′ are both regularization scales, in the sense of a renormalization group, whose numerical value need not be specified. in order to change units of time to days, it is necessary to choose a model of the epidemic. if one uses the seir model, then the unit of time would be the median interval between the appearance of symptoms and the time of fatality or recovery, whichever is earlier. this quantity, t = . days [ ] . if one instead uses the sir model, then it is appropriate to choose the unit of time to be the median interval between the beginning of the infection and the earlier of the time of fatality or recovery. this is t + t , where t is the median pre-symptomatic period, t = . days. here the conversion is made within the seir scheme. this gives when a constant τ is used, one can set τ = in the above formulae and write r and τ instead of r and τ . evolutionary origins of the sars-cov- sarbecovirus lineage responsible for the covid- pandemic changes in contact patterns shape the dynamics of the covid- outbreak in china effect of non-pharmaceutical interventions to contain covid- in china first antibody surveys draw fire for quality, bias coronavirus disease (covid- ): a literature review identification of burden hotspots and risk factors for cholera in india: an observational study emergencies preparedness, response who, zika virus infection -india, emergencies preparedness, response strategy for covid testing in india global covid- case fatality rates ministry of health and family welfare, government of india, addressing social stigma associated with covid- undated advisory nationwide mortality studies to quantify causes of death: relevant lessons form india's million death study amdavad municipal corporation, covid- website greater chennai corporation, official twitter page collection of press releases by praveen jadiya, chief medical and health officer municipal commission of greater mumbai, health department, official handle district information office, pune, official twitter account covid- india api estimates of the severity of coronavirus disease : a model based analysis inferring epidemic parameters for covid- from fatality counts in mumbai estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship estimation of the asymptomatic ratio of novel coronavirus infections (covid- ) coronavirus: surveillance is the key, kerala shows the way singapore univ. of tech. and design, data driven innovation lab, predictive monitoring of covid- coronavirus (covid- ) cases our world in data in this appendix the unit of time will be taken to be the inverse of the mean rate of fatality of the infected. in these units, r is the average number of new infections caused by an infected person. r depends on the infectivity of the virus, as well as an average degree of the contact network. as a result, it may be affect by public health policies, such as a lock down. say a policy measure has a time scale is t . due to this, r may become time-dependent, and one may write a taylor series expansionone may introduce this into a typical epidemic model equation, to obtain di dt = (r − )i, which gives log i(t) i( ) = t r − + key: cord- - d eq y authors: nan title: espr date: - - journal: pediatr radiol doi: . /s - - - sha: doc_id: cord_uid: d eq y nan prof. michael riccabona undertook his medical school & university training at the university of innsbruck, tirol, austria, completing his md at karl franzens university in graz, austria. following an internship in neurology, surgery and internal medicine he then specialized in paediatrics at the dept. of paediatrics, university hospital in graz. there he took charge of the paediatric radiology and sonography sections at university hospital in graz, as associate professor of paediatrics. in he additionally started to specialise in radiology, becoming associate professor of radiology in -then taking charge of the subsection of paediatric sonography at the dept. of radiology, university hospital in graz, where in march he was appointed full univ. prof at the medical university graz, austria. he has a distinguished academic career and written over papers, more than chapters and several textbooks, and is a very popular international speaker, delivering numerous lectures at many high profile scientific meetings. he is an active member of several reputable international societies, has been chair of the paediatric ultrasound section of the austrian ultrasound society since , and president of the society of german speaking paediatric radiologists ( ) ( ) ( ) ( ) ( ) ( ) ( ) . he is a constant source of inspiration within his subspecialist areas of interest in ultrasound and abdominal radiology in children. he has been course director at several important meetings and served as president of espr in graz in and as lead of the paediatric subcommittee at ecr in . he has provided inspirational leadership as chair of the espr task force on uroradiology since writing state of the art guidelines and procedural recommendations to facilitate standardised best practice for imaging within paediatric uroradiology. he has been a reviewer for many international journals. he has on-going active roles in postgraduate education for medical colleagues from eastern europe, including basic ultrasound education and refresher courses, and workshops. michael riccabona is very deserving of honorary membership of espr, which reflects his seminal role within paediatric radiology in europe and his tireless dedication working for the good of children. & to discuss how to optimally adapt the various imaging techniques minimising radiation exposure and risks during diagnostic imaging in children. & to consider common restrictions, challenges, and possible solutions in paediatric radiology within the different settings in different countries, regions, continents and clinical scenarios -discussing all these aspects with colleagues, and to mingle with experts from all over the world learning from each other and fostering networking in paediatric radiology to try to grant optimal imaging for all children. an application for the rd annual meeting as well as for the th post graduate course has been submitted to the eaccme® for cme accreditation of this event. the eaccme is an institution of the uems (www.uems.net). the number of cme points will be announced at the espr congress website. each medical specialist should only claim those hours of credit that he/she actually spent in the educational activity. certificates of attendance will be available in the espr myuserarea after the meeting. the answers right away is: yes we can and we constantly have to. it is part of human nature to recognize problems and to find solutions. we define ideals but we also face reality. being aware of the gap in between we are constantly driven to improve. this overview will highlight some milestones and disputes throughout the years of development in the use of plain x-ray imaging. it will hint on scientific literature and sources of information. and it will hint on some swiss contributions as the espr meeting will be held in davos, switzerland. fighting the glow not the fire - years of x-ray imaging development and improvement: in the beginning of the clinical use of x-ray imaging, there was great enthusiasm in its potential without knowing the unfavorable dangers of uncontrolled use of x-ray. the dangers were recognized and the 'beast' was tamed and domesticated. in respect to radiation protection, the most significant achievements took place in the first half of that development. throughout the recent decades, some further considerable steps in dose reduction took place mainly by the improvement of film-screen systems and the recent introduction of computed (cr) and digitized radiography (dr). even if the early computerized x-ray imaging brought a slight increase in patient doses (which was overcompensated later on by direct digital radiography) a whole new world of further advantages launched the digital era in which we live today. as we all know new dangers arose with these techniques as the uncontrolled distribution of images and thereby confidential patient data over hospital departments and across borders throughout. also, the risk of an evitable overexposure in digital radiography is a significant issue. throughout the process of taming the radiation and controlling it, today's doses are attained within the lowest range of the danger scale. this range still is perceived as a black box within which we do not exactly know which concept reflects the potential harm best. the linear no-threshold model [lnt] is acknowledged as the concept which most reliably supports the idea of radiation protection. other concepts partly oppose the linear idea and question the relevance of that dose range because there lie so much greater health benefits in the appropriate use of diagnostic x-rays. several scientists even propagate the idea that very low levels are producing health benefits instead of physical harm [hormesis model]. nevertheless, the lnt model is widely accepted as the most helpful in the context of diagnostic radiology. some recent studies were able to support the idea of potential harm at very low dose levels as they were able to prove the induction of attributable cancers in the pediatric age group. so today we are fighting the glow, not the fire. as trained medical professionals we are fully aware of the fact that there is only little potential harm to the patient by using x-rays in the current state of the art. but on the other hand, we also have to be aware of the fact that our patients and their parents still fear the fire. one of our main tasks, therefore, is to explain the risks and benefits to the patients and their advocates and to educate the public. developed straight from the first radiographic technique's digital radiography today is state-of-the-art in plain d-imaging. throughout the last decade, it has replaced cr and conventional radiography in many institutions. in the united states of america, one of the most developed healthcare systems, healthcare authorities propagate incentives to abolish cr and older imaging systems by making them financially unattractive. the market is fully concentrated on the spread of dr systems. momentarily there are no real milestones but many refinements of existing systems such as tomosynthesis, dual energy subtraction and advanced auto-stitching, fluoroscopy capability, basic angiography applications and -d cone-beam ct images are made available. combinations of these features can be found in some recently designed x-ray machines. grid-less imaging software can reduce patient dose significantly. concerning detectors, there are cr retrofit systems which will support the easy upgrade of existing systems to dr capability. wireless detectors with large internal storage, different sizes and high resolutions of microns are available. dr is becoming a part of the system in the current era of full digitalization of our lives and big data, digital radiology is a cornerstone of our healthcare systems. ris and pacs as part of integrated healthcare (ihs) systems are widely disseminated. at the next step, all accessible data will be used for analyses. the major vendors of imaging systems, as well as pacs suppliers and independent companies, offer readymade software tools for reports and evaluations of all kind. the doses from different x-ray sources can be screened internally and be used for optimization purposes. they also can be sent to remote servers for dose monitoring, comparison and optimization in multi-hospital health care provider settings or to comprehensive databases like the american college of radiology dose index registry, cancer registries, or for central billing. has everything been invented? many technologies have been declared dead before a new transformation appeared. this was the case for example with single slice ct before the invention of spiral ct by willi kalender, germany and peter vock, switzerland in . often the plain x-ray image was meant to be needless or redundant as newer technologies like ct or mri approached. but it still is of value because of different reasons as the low dose, high availability, well known and easy interpretation to name a few. there are some new and sophisticated techniques on the way like the "smart x-ray source" which uses coherent beams of x-rays from an array of micronsized point sources, developed by scientists at the massachusetts institute of technology (mit). the developers promise less radiation, less weight of the equipment and a far better soft tissue resolution. another promising approach is phase contrast x-ray imaging which has the potential to reduce the dose up to / of the actual value. it also has its strengths in additional soft tissue information as recent experimental publications show (paul scherrer institute switzerland) e. g. in functional evaluation of lung fluid (munich, germany). functional imaging of the lungs can also be achieved without any radiation as the development of the known concept of electrical impedance tomography highlights. this functional imaging method usually is not within the modality spectrum of radiologists. dose control and reduction -local -regional -international the most effective measures to achieve significant dose reductions in your own department are still the same strategies which are based on the "eternal rules" as we know them from our teachers: avoiding unnecessary exposures by strictly controlling the appropriateness of a referral. justification is a shared responsibility between radiologists and clinicians. there are many tools available for justification like the appropriateness criteria, guidelines or rules (like wrist or ankle rules) of several national societies and different study groups. the process of optimization is mainly in the hands of the technicians. as many studies show, the proper collimation still has the greatest effect on dose reduction. other important factors are the positioning of the patient and the shielding of radiosensitive organs which are not relevant for image interpretation so that they may be covered by lead shields. the proper use of the grid in bigger children can now partially be replaced by software solutions. in digital radiography, a profound knowledge of postprocessing possibilities is mandatory as well as the active control of the exposure indices. dose limitation procedures should be regularly checked in a team-based approach to avoid overexposure by less experienced staff or "exposure creep". existing standards should be actively used to guarantee a constant satisfactory image quality. in , the image gently campaign released a safety checklist for performing digital radiography examinations on pediatric patients which is easily applicable to every radiology service. organizational improvements: at regional and national level, efforts should be made to check for best practice use in the departments and to compare and discuss imaging strategies. the establishment of national and international dose reference levels helps to keep the overall doses low and to protect the population from unnecessary overexposure. the pidrl project prepared the "european diagnostic reference levels for pediatric imaging" as part of the eurosafe project. momentarily the results of pidrl-workgroup are harmonized with international organizations. the european guidelines on drls for paediatric imaging can be accessed as a preliminary final for workshop drafts on the internet. on a worldwide basis, the world health organization has published a fundamental information brochure concerning radiation risks and the communication of health professionals and patients. health care professionals have a shared responsibility for communicating risks and benefits of imaging procedures to patients, especially in the case of pediatric patients. the document "communicating radiation risks in paediatric imaging-information to support health care discussions about benefit and risk" is intended to serve as a tool for health care providers, to communicate known or potential radiation risks associated with pediatric imaging procedures and to support risk-benefit dialogue in health care settings. as said before we are fighting the glow, not the fire. the paper of the swiss pediatric oncology group stirred a broad discussion. among other issues, there was a question if it shouldn't be a logical consequence to transfer kids from areas with higher background radiation to safer areas. the author's answers were clear: that swiss health authorities better concentrate their efforts more effectively and with greater benefit for more people by supporting prevention "toward modifiable environmental factors leading to larger numbers of deaths from several causes, such as exposure to radon, air pollution, and second-hand tobacco smoke". this leads to the conclusion that we as medical radiological professionals do have the obligation to make every effort to prevent our patients and personnel from harm of the usage or non-usage of radiation. as health specialists, we also should support the fields of prevention with broad mass effects as far as we have the opportunity. and as human beings, we are summoned to do so in respect to other beings, to our environment and to the resources we all share. radiation protection and quality improvement is just a small part of it all, but it is our field -and 'yes we can'. "communicating radiation risks in paediatric imaging. freely available at the who homepage." computed tomography: are we doing enough? e. sorantin; graz/at summary: already in the alara principle was publishedbut the implementation is still far from complete. according to the surveys of the ec tender project "pidrl -european diagnostic reference levels for paediatric imaging" the most frequent computed tomography (ct) examinations in children are, in descending order, head/neck, chest and abdomen thus counting for about % of all pediatric ct's. therefore it makes sense to optimize these examinations first. surveys of the "international atomic energy agency (iaea)" in countries have shown, there is considerable lack of organizationeg in about % of facilities protocols for children were missing, indication based protocols available only in %, ctdi values for head and chest two to five times of those for adults. all of these simple facts indicate we are not doing enough for radiation protection in pediatric ct. actions to lower dose in ct can be categorized in organisational, optimization and alternatives. the interdisciplinary implementation of international guidelines for ct in minor head trauma with trauma surgeons could serve as an example of organisational actions. for dose optimization knowledge about dose relevant factors according the "imaging chain" is mandatory as well as adjusting kv to pediatric needs. dose influence on image quality must be known, by exploiting the fact, that, if all ct parameters are kept constant but hte slice thickness is just halve there must be an increase in noisein particular about two times more. therefore if a standard examination is reconstructed at half slice thickness and image quality is still appropriate the amount of waste radiation is in the range of %. therefore if the next examination will be reduced with eg % mas setting less will be for sure in appropriate quality and the process can be started again. after a couple of examinations the optimal dose will be reached. thus the "half slice thickness" approach is easy to do, does not need special equipment or human resources and will help to find the appropriate dose. the third point is alternatives -ultrasound and mri being the candidates in the first row. new, radiation free, techniques like electrical impedance tomography and others are already developed and can be expected to be release soon. take home points: & we are not doing enough for ct dose savingeven more than years after release of alara principle & dose saving actions can be categorized inthe subtasks organisation, optimization and alternatives & "the half slice thickness approach" is an easy to do technique to elaborate the optimal dose on an particular ct machine. prenatal thoracic mr l. alamo; lausanne/ch the generalization of screening us has considerably increased the detection of congenital anomalies in utero. in the last years, important technological advances and especially, the development of fast heavily t -weighted sequences has led to an increasing use of prenatal mri as additional diagnostic imaging method. mri is increasingly used for evaluation of thoracic pathology, including tumours and vascular malformations as well as anomalies of the diaphragm, the lungs and more recently, even of the foetal heart: -thoracic tumours and vascular malformations: the diagnosis of a congenital tumor during pregnancy involves a tremendous emotional impact for a family. the most frequently observed thoracic tumours are teratoma, myocardial rhabdomyoma and exceptionally, pleuropulmonary blastomas. mri may provide relevant additional information concerning the origin of the lesion and its real anatomical extent. -diaphragmatic pathology: congenital hernia is by far the most commonly reported foetal diaphragmatic anomaly. the large field of view and the multiplanar possibilities of mri may help to clarify the position of the herniated organs and to evaluate the severity of lung hypoplasia, considered the most important parameter for predicting outcome. other rare pathologies include eventration, paralysis and diaphragmatic lung sequestrations. -lung anomalies: congenital lung abnormalities are a heterogeneous group of pathologies consisting of isolated bronchopulmonary or vascular anomalies or a combination of both of them. congenital pulmonary airway malformation, bronchopulmonary sequestration and bronchial atresia are the most often observed pathologies but they present significant overlap imaging findings. mri allows accurate information concerning the location and extension of the lesion and the volume of the normal and abnormal lung. -heart pathology: the evaluation of the foetal heart remains extremely difficult because of its small size and high rate of battements. the unpredictable foetal motions during data acquisition and the absence of a foetal ecg signal to synchronize data acquisition are additional problems. in the last years, different approaches have been made to overcome these challenges. radiologists should know the typical imaging findings of the thoracic pathology most often observed in foetuses. prenatal mri may provide additional relevant information in a wide spectrum of congenital thoracic anomalies, but in general, it should only be performed if it is considered that additional results might influence the management of the pregnancy and/or the therapeutic approach. therefore, it is important to know the right indications for mri and to recognize the limits of the method. interruptions during embryogenesis of the muellerian or wolffian ducts result in various, potentially complex genitourinary abnormalities of a wide spectrum or combinations. multiple imaging modalities are employed to evaluate patients with these abnormalities. ultrasound is the frontline imaging modality. mr imaging is mostly reserved for complex cases and may incorporate an mr urography, too. other imaging modalities are less frequently used or provide only ancillary information. this presentation will demonstrate the utility of ultrasound and mr imaging, in particular, in the routine diagnostic imaging of patients with the wide spectrum of muellerian and wolffian duct abnormalities. & mr imaging is reserved for more complex cases. neonatal hepatic tumors and vascular malformations d. pariente, s. franchi-abella; le kremlin bicêtre/fr neonatal hepatic tumours and vascular malformations are rare but imaging plays a key role in diagnosis and treatment. the most frequent hepatic tumour is haemangioma (fig ) which often is asymptomatic but may be complicated by cardiac failure, coagulopathy or compartment syndrome. the differential diagnosis mainly includes hepatoblastoma, hematoma (fig ), abscess, mesenchymal hamartoma, choriocarcinoma in the solitary form and metastatic neuroblastoma, cirrhosis, neonatal leukemia in the multifocal form. pertinent biological data are alpha-fetoprotein (but level may be normally high in neonate), betahcg, and urinary catechol amines. hepatic vascular malformations are rarer and include intra or extra porto-systemic shunts (pss), arterio-portal fistula or complex mixed forms. intrahepatic pss may be associated with haemangioma and regress in most cases rapidly (fig ). on the contrary the extrahepatic pss which are located below the portal vein, should be urgently closed to avoid occurrence of agenesis of the portal vein. the best imaging modality is us which must be performed with high frequency probes and colour doppler to identify hepatic vessels and assess patency, direction of flow, abnormal communication. mri and ct with contrast injection may also be useful. hepatic mass in a do neonate with increased crp and afp. us showing a hyperechoic mass with thrombosis of the left portal vein (black arrow) and a track (white) extending to the mass: hematoma due to malposition of an umbilical vein catheter. hemangioma of antenatal diagnosis on d . the mass is composed of a large anterior vascular lake corresponding to a porto-systemic shunt and a tissular hyperechoic part. the infant has remained asymptomatic. intrahepatic porto-systemic shunt between the left portal branch of segment (white arrow) and the left hepatic vein (black arrow) in a neonate. at months of age this shunt has completely resolved. haemangioma is the most frequent hepatic tumour in the neonate and is often asymptomatic with spontaneous resolution. levels of alphafetoprotein are physiologically high in the neonate, and can be misleading. hepatic hematoma can be secondary to traumatic delivery, to coagulation disorders or to umbilical vein catheterization. intrahepatic porto-hepatic shunts are the most frequent vascular malformations and regress in most of the cases in the first year of life. us with colour doppler remains the best imaging modality in the neonatal period. imaging in crohn disease: state of the art in diagnosis, prognosis and followup n. colavolpe, a. aschero, b. bourliere-najean, c. roman, f. khachab, h. pico, m. kheiri, g. gorincour, c. desvignes, p. petit; marseille/fr summary: during the past years the inflammatory bowed diseases (ibd) have increase in frequency ( ). less than twenty-five percent of them occur in children of less than years ( ) and crohn's disease (cd) is twice as frequent than ulcerative colitis (uc) in the pediatric age group. specific phenotypic and genotypic subtype of ibd occur in younger children. early onset (eo) pediatric ibd (before years of age) represent % of childhood ibd ( ) . uc and undetermined colitis are more frequent in this age group. eo cd showed a more frequent isolated colonic and upper gastrointestinal involvement than later-onset disease where locations are predominantly colic and terminal ileum later on childhood. some pediatric ibd specificities exist than can interfere with the imaging findings: -cd can be limited to the terminal ileum or to the colon in up to % of children ( ) . isolated jejunal involvement is reported to occur in - % of children. this location is more frequent in the youngest and is more at risk of complicated course of disease ( ) . for auvin et al. ( ) the small bowel is involved in % of cases with less involvement of the terminal ileum than in the adult population. -uc: the classical contiguous alteration of the bowel wall from the rectum to the caecum is inconstant. a macroscopic rectal sparing is reported from et % and the absence of continuous disease from rectum to caecum (caecal patch) described in % of children. transmural inflammation may be present in severe form as well as terminal ileitis without granulomata (backwash ileitis) ( ) . in order to assess these pathologies, and more specifically cd small bowel locations which are difficulty explored by others modalities, small bowel follow-through, barium enema, ultrasound, computed tomography and mr imaging have been widely used. among them, mr-enterography has gained worldwide acceptance due to multiple factors including: a high contrast resolution, a multiplanar ability, an absence of radiation, the possibility to explore in the same exploration the whole bowel and the extra-bowel diseases (perianal fistulae, sacroiliac joint, biliary tract), the ability to compare of side by side consecutive studies in a reproducible manner, a more easily understood exploration by the clinicians than ultrasound, and first of all for its performances. in order to technically harmonize this exploration a recent consensus statements on mre protocol has been published by the esgar and the espr societies ( ) . preparation: -depending on their age children must not have solid oral intake from to hours prior to the examination to reduce bowel wall motility. morning mr appointment is more favorable for this purpose. no gasless fluid restriction is recommended but is reabsorbed too quickly to distend enough the small bowel. none hyperosmolar non absorbable solution is superior to another. its ingestion must start to minutes prior to mre. the recommended volume is ml/kg with a maximum up to ml/kg. explanations long before the mre concerning the importance of such absorption and the use of a refreshed product mixed with aromatized flavors will facilitate the child's participation. -the use of spasmolytic agents is optional. however, there are recommended in adults by multiple societies including esgar ( ) , the society of abdominal radiology ( ) and the acr (www.acr.org/ quality-safety/standards-guidelines). but, mre without antiperistaltic agents result has reached a high diagnostic confidence and excellent agreement with ct enterography for the presence of cd ( ) . if used, they need to be administered immediately prior to motion sensitive sequence (t w dynamic enhanced sequences). if the pictures obtain with these medications are of better quality, there is no evidence that they change the final diagnosis and the children's therapeutic management ( ) . the use of these products increase the length of the exploration and their side effects are frequent (nausea > vomiting) which balance their visual benefice ( ) . if a spasmolytic agent is used, the recommended first line spasmolytic agent is i.v. hyoscine butylbromide ( . mg/kg i.v). the recommended second line agent is i.v. glucagon, . mg (< . kg) and mg (> . kg), given as a slow infusion with i.v. saline at an infusion rate at ml/s. -no rectal enema is needed. -exploration can be performed either at . tesla or testla. more chemical shift and susceptibility artifacts are present with the latter. prone position has been demonstrated to allow better small bowel distension than the supine one with reduction of the peristaltism but without better lesion detections ( , ) . large multi-elements coils are needed to cover with high resolution from the perineum up to the left colonic flexure. sequences: both morphologic steady state free precession gradient echo and d -t -weighted images are needed in the axial and coronal planes. fat saturation in one of this plane is recommended and maximal slice thickness of mm is required. nowadays, non-enhanced then enhanced d t -fat saturation weighted sequences are mandatory. slice thickness does not exceed mm. enhance sequence need to be acquired at the portal phase of injection. however, in recent studies the need for gadolinium has been questioned when dwi is added to the morphologic sequences. dwi sequences have been considered optional ( , ) but we consider their place essential in pediatric practice. they must be done with high b values, from up to in the coronal and axial planes with to mm contiguous cut in free breathing. axial plane is less prone to artefact than the coronal plane. interestingly enough shenoy et al ( ) report in pediatric patients that dwi does not perform as well as standard mre for detection of active crohn disease but the combination of dwi and mre increases imaging accuracy for determining disease activity compared with either technique alone. seo et al ( ) in young adults said that dwi mre was noninferior to contrast-enhanced mre for the evaluation of inflammation in cd. based on the exploration of cd adult and pediatric population, dwi proved to be efficient and would avoid gadolinium injection ( ) . sirin et al. ( ) report in children that dwi revealed lesions that were not detectable with mre done with gadolinium injection. finally, respectively dubron et al. ( ) in children and neubauer et al ( ) in children and young adults demonstrate better performance of dwi than gadolinium enhanced imaging. like the existing mr protocols for suspected appendicitis ( ) it will not be surprising to see fast mr ibd explorations becoming an alternative to emergency us as already proposed ( ) . this fast mr limited to a morphologic t sequence in two planes associated with dwi sequences will allow a positive diagnosis and the ibd work up. apart from bowel obstruction and its spontaneous bowel distension one of the limiting factors will be the need for an oral water agent uptake in a potential surgical patient. however, it has been published in the adult literature than an oral or rectal preparation was not necessary to rule out uc ( ) nor a cd ( ) . the other limiting factor is the length of exploration. mre can be shorten especially if the patient's positioning is easy to do (dorsal decubitus) ( ) and if there is no need for injection, either for spasmolotytic agent and for gadolinium chelates. the suppression of the iv line, the absence of potential side effects (nausea, vomiting) of paralytic agents and the decreased of repeated long apneas with no loss of significant information will be strong progresses toward the holy grail. -positive diagnosis, disease activity, prognosis and follow-up: mre has a better accuracy to detect inflammation for the small bowel than for the colon ( ) . one of its goal is to try to accurately identify features of active inflammation vs fibrotic disease. this is of paramount importance since the former may respond to medical treatment and the latter may need surgical resection. however, inflammation and fibrosis are associated within the same bowel segment and progress in a parallel way making the goal difficult to reach ( ) ( ) ( ) . in their study based on the analyze of children operated for cd strictures, barkmeier et al. ( ) report than strictures demonstrating > cm upstream dilatation with associated feces sign were highly associated with transmural fibrosis. the most severely fibrotic strictures were associated to the greatest amount of inflammation and there was no significant correlation between stricture length, mural thickness, degree of post-contrast enhancement (arterial and delayed venous phases), diffusion-weighted imaging apparent diffusion coefficient, pattern of post-contrast enhancement, or normalized t -weighted signal intensity and histological fibrosis or inflammation scores. however, correlation with histological specimens of cd done on a other series s ( ) (suppl ):s -s pediatr radiol demonstrated that the enhancement ratio of the wall is positively correlated with disease chronicity due to a possible increasing microvessels permeability and inversely correlated to acute disease ( ). on the other hand, several authors have tried to correlate the adc values to cd activity. fibrotic tissue does not restrict diffusion and presents a decrease of signal at high b values and high adc values whether acute inflammation shows decrease adc values. variable thresholds from . x - mm /s to . x - mm /s have been proposed to separate active vs non active disease ( ) . however, others authors have reported low adc value of fibrosis compare to histology ( ). even if promising results have been published with high correlation with the crohn disease endoscopic index of severity ( ) , adc measurements are associated with sever limitation factors including sample size overlap between the bowel wall and its atmosphere, lack of reproducibility between mri-units and mri-vendors, non-standardized sequence b-values parameters ( ) . two mre scores are available to quantify the activity of cd. one is using gadolinium injection ( ) and the other dwi ( ) . due to the complexity of the formula, both are difficult to use in daily practice and have not been evaluated in paediatric practice. interestingly enough if a simplify mre paediatric protocol appears to become a reality, us stays a good imaging challenger and ( ). in a recent meta-analysis, based on adult and pediatric series, calabrese et al ( ) reported that bowel us showed . % sensitivity and . % specificity for the diagnosis of suspected cd, and % sensitivity and . % specificity for initial assessment in established patients with cd. bowel us identified ileal cd with . % sensitivity, . % specificity, and colon cd with . % sensitivity, . % specificity, with lower accuracy for detecting proximal lesions. the absence of abnormal thickness wall would have a negative predictive value, high enough to exclude the need for further exploration, especially when cd is concerned ( , ). concordance between us and mre have been variably reported from excellent ( ) to just correct ( ). rosembaum and al ( ) report that the us findings present in children operated for cd include: bowel wall thickness above . mm (mean, . mm) and an increased frequency of loss of mural stratification and fibrofatty proliferation. others us technologies are used in children to better approach the disease activity. it includes, hydrosonograpy using specific oral agents (mannitol, sorbitol, polyethylene glycol, etc…), contrast-enhanced ultrasound and dynamic contrast-enhanced ultrasound (nowadays, contrast agent is offlabel in children) ( ) and elastography ( ). their enthusiastic results and their efficiency to assess disease activity need to be confirmed ( ). in conclusion, as we suspected years ago ( ), mre has dramatically modified our approach of pediatric ibd especially when considering its orientation toward a less invasive exploration and the increasing importance of dwi imaging. a cost benefice between mre and us remains to be done on this increasing disease. heterotaxy and isomerism c. lapierre; montreal/ca summary: objectives: to review the classification of visceroatrial situs to describe the associated cardiac and non-cardiac anomalies to illustrate typical findings in fetuses, neonates and children to discuss the surgical consideration and the long-term follow-up in these patients abstract: by definition, the type of situs is determined by the relationship between the atria and the adjacent organs. anatomically, the atrial chamber differentiation is based on the morphologic aspect of the atrial appendages, earlike extensions of the atria. three types of situs exist: solitus (normal), inversus (mirror image) and ambiguus. a single type of situs is present in a patient. when the situs is neither solitus nor inversus, it is referred to as situs ambiguus or heterotaxy. heterotaxy may manifest with various abnormal visceroatrial configurations that are associated with cardiac (in - % of cases) and extracardiac anomalies such as splenic abnormalities, biliary atresia and intestinal malrotation. two subsets of situs ambiguus are well-recognized: right isomerism (asplenia) and left isomerism (polysplenia). in heterotaxy, the venoatrial connections are frequently abnormal. left isomerism is usually indicated by bilateral bilobed lungs, interruption of the ivc and multiple spleens. the more likely found cardiac anomalies are: pulmonary or aortic stenosis, isolated atrial and ventricular septal defects, cardiac arrhythmia due to sinus node dysfunction as well as pulmonary veins that drain into both the right and the left atria. in the presence of right isomerism, bilateral trilobed lungs, a large symmetric liver, and absence of the spleen are frequently observed. at the cardiac level, patients are more likely to have a common atrioventricular defect, a double outlet right ventricle and pulmonary stenosis. total anomaly of the pulmonary venous return and absence of coronary sinus will always be present in right isomerism. heterotaxy can be diagnosed with high accuracy by prenatal echography. a diagnosis should be suggested in the presence of congenital heart disease, visceroatrial heterotaxy and interruption of inferior vena cava with azygos continuation for left isomerism or abnormally closed juxtaposition of inferior vena cava and descending aorta in right isomerism. the mortality in fetuses is high in the presence of heart block and hydrops whereas the cardiac anomalies influence the long-term outcome. as discussed in the literature, the clinical outcomes and long-term prognosis in these patients are relatively poor when compared with non-heterotaxy patients. the risk factors are cardiac (underlying anatomy and arrhythmia risk) and non-cardiac. based on the cardiac anatomy, one of the main determinants is left versus right isomerism. with right isomerism, the cardiac malformation is more severe and an univentricular correction is more frequent. another predictor of mortality is pulmonary vein stenosis/obstruction. whatever the severity of cardiac lesions, the postoperative or discharge mortality is higher in patients with heterotaxy. prenatal diagnosis seems not improve the survival. extracardiac anomalies also contribute to the increased morbidity and mortality. three of the more challenging entities are respiratory, immunologic and gastrointestinal. recurrent respiratory infections, failed extubation or chronic respiratory failure are frequently observed in patients with heterotaxy. recent studies revealed an association between heterotaxy and primary ciliary dyskinesia which can explain the increased postoperative respiratory complications. the spleen is important for the bacterial clearance. patients with asplenia or polysplenia are thought to have "functional asplenia". so, they are at risk for sepsis and severe bacterial infection. the incidence of intestinal malrotation is high, approximately % to %. observation versus prophylactic ladd procedure and screening for asymptomatic intestinal malrotation are a growing area of debate. the trend seems to go along conservative management and surveillance of malrotation. bronchopulmonary malformations, such as congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital lobar emphysema (currently known as congenital lobar overinflation [clo] ), are common congenital lung diseases. these conditions are detected prenatally, usually in the second trimester, in countries where obstetric sonography is routinely performed. the malformations are seen as hyperechoic images with respect to normal fetal lung parenchyma, with a mass effect and homogenous appearance or with coexisting cysts. the lesions usually decrease in size along gestation. a residual mass is seen on postnatal chest radiography, the first imaging technique performed, in only % of cases. cpam and bps are predominantly located in the posterior lower chest and can be identified postnatally on ultrasound using a small vector probe and a subcostal and subxiphoid approach. potential feeding arteries can be visualized using color or power doppler. based on clinical and sonographic findings, the differential diagnosis between congenital lung malformations and tumors such as neuroblastoma, type i pleuropulmonary blastoma, and myofibroblastic tumor will be discussed. postnatal management and imaging of newborns with congenital lung malformations is controversial, particularly in asymptomatic patients (approximately % of cases). chest radiography is mandatory at birth and chest ultrasound is also recommended to confirm the prenatal diagnosis. computed tomography (ct) or magnetic resonance imaging (mri) using angiographic techniques should be performed some months ( months) after birth in asymptomatic patients. these techniques are also recommended in symptomatic newborns and before surgery to characterize the arterial supply and venous drainage in cpam and bps, as ultrasound is limited in this regard. in premature infants, sonography complements radiography in the study of prematurity-related lung diseases such as respiratory distress syndrome and its pulmonary complications (eg, pneumothorax), in predicting bronchopulmonary dysplasia, and in diagnosing transient tachypnea of the newborn when clinical and radiographic features are inconclusive. the main ultrasound finding in these conditions is visualization of numerous "b-lines", vertical narrow-based hyperechoic bands extending from the pleural surface to the end of the field of view, representing what is currently known as "sonographic interstitial syndrome". b-lines are artifacts originating from variations in the air-fluid relationship of the lung and are better seen using high-frequency linear probes . use of sonography for follow-up of these patients will reduce the number of the chest plain films performed, and therefore, the amount of radiation exposure in this vulnerable population. for proper interpretation of the sonographic findings in these conditions, the radiologist should be familiar with current related terms, such as lines a, lines b, comet tail artifact, interstitial-alveolar syndrome, septal syndrome, and white lung. trauma is the leading cause of mortality and morbidity in children after the first year of life. motor vehicle accidents are the leading cause of death from unintentional injury in children up to the age of . of these cases, the abdomen is the fourth most commonly injured area. in pediatric patients non-operative management of these injuries predominate, hence the importance of early radiologic assessment for appropriate clinical follow-up. anatomically, compared to adults, childrens' abdomens are more square, less muscular and with less intraperitoneal and subcutaneous fat to absorb impact. the diaphragm is more horizontal causing downward displacement of the liver and the spleen outside the protective casement of the ribs. the pelvis is smaller and hence the bladder is displaced upward, also resulting in more vulnerability to this organ. the organ surface area is larger in children and they have a smaller body mass-hence more force applied per-unit of body surface area. the ribs are flexible, and although we see fewer rib fractures, this results in more internal damage. physiologically, children maintain hemodynamic stability longer, often presenting with only mild tachycardia, even when in severe hemodynamic shock. decrease in blood pressure may not be evident before the loss of % blood volume. nevertheless, bleeding is less severe and operative intervention is rarely performed. mechanics of blunt abdominal trauma include organ compression from seat belt injury with the presence of erythema, ecchymossis or abrasion on the abdominal wall increasing the likelihood of internal organ injury ( % likelihood of injury). other common mechanisms include pedestrian-car collisions( % with intra-abdominal injuries), falls ( % with intra-abdominal injuries), or handle bar injuries ( % with intraabdominal injuries). after the child arrives in the hospital, a trauma algorithm is initiated. generally, for the unstable patient, algorithms are similar and require a rapid atls protocol, followed by a fast ultrasound to confirm free fluid prior to operation. in stable patients, institutional algorithms vary greatly between countries and in different centers. some rely solely on mechanism to determine the need for fast vs ct (not complete ultrasound), others will rely on clinical exam (in a conscious patient with reliable exam) and blood work to determine the need for imaging (ct or us) and others may chose to perform an initial us and complete the exam with a constrastenhanced us during work hours. in the literature many management prediction rules exist based on the history, physical examination, mechanism of injury and are supplemented by blood work and/or intial imaging. most are based on retrospective reviews, with only a few controlled clinical trials. however, the validity of these studies is limited because of different populations, institutional policies and variable radiological practices in terms of when imaging is performed, which modalities are most beneficial and which are less valuable, all the while, considering the utilization of the least irradiating techniques. a representative sample of such algorithms will be discussed. routine and extensive initial trauma panels are not required according to a number of studies. abdominal ultrasound and urinalysis together have been found to confirm % of all intra-abdominal injures, in some studies. serial haemoglobins/hematocrit is valuable for determining ongoing s ( ) (suppl ):s -s pediatr radiol blood loss and assists clinical surveillance. electrolyte abnormalities are uncommon in children unless severe shock is present (metabolic acidosis). liver function tests are elevated in most cases of blunt abdominal trauma, hence, are often performed for its high sensitivity, to avoid ct if the liver panel is negative. imaging, however, is needed for grading of the potential liver injury if the liver panel is positive. abdominal xray is not useful in blunt abdominal trauma, and is usually normal. ultrasound has an important role in the pediatric community, as a sensitive and non-irradiating modality. however, this sensitivity is dependent on the type of ultrasound performed (fast vs. complete abdominal ultrasound vs. contrast-enhanced ultrasound) but also on the qualifications and experience of the performing physician. a meta-analysis of fast in pediatrics demonstrates that it has a sensitivity of % (grade i-ii evidence) for identifying hemoperitoneum. a negative fast is not sufficient to rule out intra-abdominal trauma. one prospective observational trial demonstrasted that % of patients without free fluid on fast (performed by formally trained pediatric truama surgeons demonstrated at least grade iii liver or splenic injuries on ct). we know that pediatric ultrasound is operator-dependent, and generally an ultrasound performed by the skillful hand of a pediatric radiologist is more sensitive than that performed by surgeons or by adult radiologists. furthermore, we know that the benefits of contrast-enhanced ultrasound in pediatric trauma exist-highly accurate in visualising lesions, hence avoiding non-contributive ct imaging, however, the feasibility of providing -hr contrast-enhanced ultrasound by a qualified radiologist is resource intesive: both structurally and with respect to personnel. published indications for abdominal ct in stable pediatric patients included suspected mechanism of blunt abdominal trauma, significant fluid resusitation without apparant blood loss, hemoglobin < mg/l without obvious blood loss, multisystem trauma and unreliable abdominal exam. one series with children undergoing ct for blunt abdominal trauma demonstrate postive findings in ( %), of which all solid organ injuries and % of hollow viscus injuries were identified on ct. however, ct has its limitations: it was found to identify gastrointestinal perforation in only % of patients with known perforation, but with findings of free fluid, wall thickening and/or bowel dilatation. it is also less accurate in identifying pancreatic trauma, with normal scans in - % of children with pancreatic trauma. again, findings of pancreatic trauma can be non-specific: free fluid or, less commonly, thickening of the gerota's fascia, presence of mesenteric fluid or of fluid between the pancreas and the superior mesenteric vein. when and where to perform ct depends on the imaging algorithms established by individual centers. generally, unstable patients with very high grade visceral injuries are taken to surgery. the stable patients are treated with non-operative management. the literature on angiographic embolization in pediatric blunt trauma is limited to case series that demonstrate a limited utility in hemodynamically stable patients with ongoing blood loss or for the definitive treatment of traumatic pseudoanevryms. a dialogue with the interventional radiologist is imperative in such cases. common imaging findings and pitfalls will be illustrated with case examples. in conclusion, a child's anatomy and physiology must be taken into account when determing the level of urgency and appropriate imaging work-up in blunt abdominal trauma. imaging of these patients cannot follow a standard algorithm as institutions vary with respect to types of personel, training, frequency of trauma, emergency department trauma protocols and availability of an in-house pediatric radiologist. ultrasound and ct have their advantages and disadvantages with associated pitfalls that the pediatric radiologist must recognize to provide an optimal diagnostic workup with minium irradiation. take home points: a child's anatomy and physiology must be taken into account when determing the level of urgency and appropriate imaging work-up in blunt abdominal trauma. imaging of pediatric abdominal trauma cannot follow a standard algorithm as institutions vary with respect to types of personel, training, frequency of trauma, emergency department trauma protocols and availability of a pediatric radiologist. ultrasound and ct have their advantages and disadvantages with associated pitfalls that the pediatric radiologist must recognize to provide an optimal diagnostic workup with minium irradiation. sport injuries d. jaramillo; miami, fl/us the growing skeleton has unique vulnerabilities to acute and chronic injuries due to sports. the practice of intensive sports during puberty and adolescence has led to a great increase in the incidence of sportsrelated injuries. during the growth spurt of early adolescence, the physis becomes weak, and is the site of fractures and avulsions (particularly in the apophyses) and of physeal widening due to repeated stresses, such as the wrist in gymnasts or the proximal humerus of baseball pitchers. both lesions can result in growth arrest. the chondro-osseous junctions of the ossifying epiphyses and apophyses are also vulnerable to avulsions, and the avulsed fragment may be entirely cartilaginous and not visible radiographically (such as in the patellar sleeve fracture). repeated trauma to epiphyses or round bones can lead to osteonecrosis (panner's disease) but more often to osteochondritis dissecans (ocd). in adolescents, ocd occurs most frequently in the medial femoral condyle, the capitellum of the elbow and the talar dome. juvenile ocd has a better prognosis than the adult form. when the skeleton begins to mature, there are fractures unique to partially closing physes such as the triplane and tillaux fracture. some sturctures have propensity to unique injuries during adolescence. a stress on the anterior cruciate ligament (acl) can lead to a tibial eminence avulsion in puberty ( figure) , an incomplete acl tear in early adolescence or a complete acl tear later. meniscal tears are almost always vertical and often involve large meniscal fragments that can flip. patellar dislocations often result in osteochondral injuries. this review will cover the main types of sports-related injuries and the imaging modalities used to diagnose them. year-old with pain and popping sensation during a fall on a football game. ap radiograph is normal & it is important to take into account the specific sport in order to anticipate subtle injuries that may be difficult to detect. a. c. offiah; sheffield/uk the radiographs obtained when inflicted injury is suspected are collectively termed the "skeletal survey". a full skeletal survey should be performed in all children below years of age in whom abuse is suspected. the investigation is not complete until follow-up skeletal imaging has been performed in the to days following the initial survey. children below one year of age should also receive a ct brain. neurological imaging in older children will depend on the clinical scenario. ct chest/abdomen is indicated when visceral injury is suspected. in terms of imaging in suspected abuse, espr has adopted the rcr guidelines. in the absence of a history of significant trauma, fractures highly specific for abuse in pre-ambulatory children include rib, metaphyseal and diaphyseal fractures. simple linear skull fractures have a relatively low specificity for abuse. the combination of subdural haemorrhage, retinal haemorrhage and diffuse cerebral oedema/encephalopathy (the so-called, "triad") suggests shaking. whereas the presence of a skull fracture implies impact. visceral injury often results from direct blunt trauma and may therefore be accompanied by anterior and/or costochondral rib fractures. the posterior rib arcs are protected by soft tissue and posterior rib fractures result from compressive/squeezing forces rather than direct trauma. the dating of fractures has a subjective element and it is more important to recognise that fractures are in different stages of healing, rather than to assign a definite age/age range to the injuries. the major differential diagnoses are accidental trauma and osteogenesis imperfecta. if rickets is the cause of the fractures, then radiology and/or biochemistry will show evidence of rickets. a low vitamin d level, in the absence of rachitic features, is not the cause of fractures. close liaison between radiologists and paediatricians is vital and any siblings/children in the same household who are below years of age should also receive a skeletal survey. remember that the presence of injury does not always mean abuse and that the absence of injury does not always exclude abuse. scoliosis may be primitive, structural, particularly during adolescence; during this period, careful follow-up is mandatory, because worsening is frequent. clinical examination with evaluation of a hump (gibbosity) with a scoliometer is mandatory, with also neurological assessment. beside radiography, additional tools have been developed to avoid xray exposure: "spinal mouse", back surface topography systems, ultrasound and other computer-assisted systems. but scoliosis can also be secondary, and imaging is important to find a cause and adapt management. among the etiologies, radiologist must recognize spine malformations, dysplastic and neuromuscular scoliosis. in addition, scoliosis may also be in relation with a primitive lesion, tumor-related or not, whether the initial disease could be within the spinal canal, spinal or paravertebral. imaging studies lies first on pa and lateral full spine x-rays, if possible with a low dose device (flat panel, slot-scanning system), keeping in mind that follow-up with repetitive exposures may be necessary. reproducible measures of different curvatures help to assess the overall static spine and the importance of scoliosis with cobb angle. the assessment of axial rotation can be obtained through d simulations, with frontal and axial views (see figure) . morphologic evaluation of the s ( ) (suppl ):s -s pediatr radiol spine is mandatory: if a secondary scoliosis is suspected, the research to etiology needs to perform ct or mri, depending on the clinical signs and the results of plain x rays evaluation. similarly, these explorations are useful in the preoperative assessment when surgical treatment is necessary. girl scoliosis, pa and lateral views with eos®, d simulation, coronal and axial views take home points: clinical evaluation is always the first step in subject with suspected scoliosis radiation burning is quite low with new devices, but repetitive exposures for follow-up need to carefully respect justification for x-rays exposures new tools are available to appreciate d spinal deformation and evaluate prognosis and surgical procedures ct and/or mri are useful in presurgical assessment and to look for etiologies in suspected secondary scoliosis malformations of the spine and spinal cord a. rossi; genoa/it summary: embryology and classification: spinal cord development occurs through three consecutive periods: (i) gastrulation ( nd gestational week): the embryonic disk is converted from a bilaminar into a trilaminar arrangement, with formation of the intervening mesoderm; the notochord is laid down along the midline, identifying the craniocaudal embryonic axis; (ii) primary neurulation ( th - th day): under the induction of the notochord, the midline ectoderm specializes into neural ectoderm. the initially flat neural plate progressively bends and folds until it fuses in the midline to form the neural tube. the primary neural tube produces the uppermost / of spinal cord; (iii) secondary neurulation ( th - th day): a secondary neural tube is laid down caudad to the termination of the primary neural tube. retrogressive differentiation of the secondary neural tube results in the tip of the conus medullaris and filum terminale. defects in one of these three embryological steps produce spinal dysraphisms, characterized by anomalous differentiation and fusion of dorsal midline structures. spinal dysraphisms may be categorized clinically in two subsets: open and closed spinal dysraphisms. in open spinal dysraphisms (osd) the placode (non-neurulated neural tissue) is exposed to the environment through a cutaneous defect along the child's back. osd include myelomeningocele, myelocele, hemimyelomeningocele and hemimyelocele, and are associated with a chiari ii malformation. myelomeningocele is by far the most common of these forms; the placode protrudes through a posterior defect and is elevated above the skin surface due to concurrent dilatation of the subarachnoid spaces. closed spinal dysraphisms (csd) are covered by intact skin, although cutaneous stigmata usually indicate their presence. two subsets may be identified based on whether a subcutaneous mass is present. csd with tumefaction comprise lipomas with dural defect (lipomyelocele and lipomyelomeningocele), meningocele, and myelocystocele. lipomas with dural defect are more common; they are differentiated from one another based on the position of the cord-lipoma interface, that lies within the spinal canal in lipomyelocele, and outside the spinal canal (ie, into a meningocele) in lipomyelomeningocele. csd without tumefaction comprise complex dysraphic states (ranging from complete dorsal enteric fistula to neurenteric cysts, diastematomyelia, dermal sinuses, caudal agenesis, and spinal segmental dysgenesis), bony spina bifida, tight filum terminale, filar and intradural lipomas, and persisting terminal ventricle. the most complicated forms (complex dysraphic states), including diastematomyelia, caudal regression, and segmental spinal dysgenesis) are related to faulty gastrulation. diastematomyelia (literally, split cord) is caused by failure of midline notochordal integration, resulting into two separate hemineural plates. caudal agenesis and segmental spinal dysgenesis are related to defective notochordal formation, characterized by absence or hypoplasia of a segment of the notochord, in turn resulting into absence or hypoplasia of a corresponding segment of the spinal cord. functional neuroimaging of cns is a fast advancing field with frequent new developments in scanner's hardware, protocols, clinical indications, and post-processing techniques. for radiation safety reasons in the case of children, functional neuroimaging is mostly based on mr techniques especially designed to focus on the assessment of functional tissue characteristics, such as neuronal activity (fmri),, metabolism (mrs) and perfusion (dsc perfusion, asl). pediatric coils with multiple elements, multiple slice excitation, d spectroscopy, d asl, reduced fov (zoom) and improved motion compensation techniques are important tools available to meet the permanent challenges of pediatric mr functional imaging: fast motionless acquisitions and increased resolution. functional mri (fmri) reveals brain activation during performance of behavioral tasks, based on the blood oxygen level dependent (bold) mri signal, which is modulated by neural activity via a process of neurovascular coupling. for children, especially of younger age unable to follow a task, resting-state fmri (rfmri) can be performed and correlates brain areas with similar spontaneous fluctuations in the bold signalthereby enabling estimates of 'functional connectivity.' main clinical applications of fmri are the delineation of eloquent cortex near a space-occupying lesion and the determination of the "dominant hemisphere" for language. intense research is conducted in the areas of language organization and development, brain plasticity, and neurobehavioral disorders (e.g. adhd). magnetic resonance spectroscopy (mrs) is a noninvasive mr technique, that detects intracellular metabolites, and may provide neuroimaging biomarkers of normal biological and pathological processes or response to a therapeutic intervention. although the main field of application of mrs is the brain tumors, it has also been of particular ( ) (suppl ):s -s pediatr radiol usefulness in assessing ischemic or traumatic brain injury and neurometabolic disorders. perfusion mr imaging methods detect signal changes that accompany the passage of a tracer through the cerebrovascular system. a less invasive approach is arterial spin labeling (asl) that uses arterial water as an endogenous tracer to measure cbf and thus it is more suitable for pediatric studies. mr perfusion is applied in the evaluation of brain tumors, neurological diseases and developmental disorders. functional neuroimaging clinical applications are expected to expand greatly in the future due to the increasing availability of their techniques, as well as the continuous advancements in the field of pediatric research. good knowledge of these techniques will become more necessary for an effective clinical practice and will enhance the role of radiology in the healthcare system. functional neuroimaging advanced techniques based on mri allow us to study complex cns processes such as cerebral perfusion (dsc, asl), metabolic activity (mrs) and brain activation (fmri). functional neuroimaging techniques already have significant clinical pediatric applications and assisted by recent advances in mr technology are expected to become even more powerful in the near future. kidney: perfusion, excretion, obstruction k. darge; philadelphia/us the functional imaging of the urinary tract entails the evaluation of the renal perfusion and excretion. in this complex process the sites of the main abnormalities could be pre-renal, renal parenchymal, renal pelvicalyceal or post-renal or even a combination at different sites. functional mr urography (fmru) is an advanced tool that not only allows the exquisite morphological depiction of the urinary tract, but also makes it possible to generate comprehensive functional data. these provide information about the function of the kidney as well as the excretion of urine from the renal parenchyma into the pelvicalyces and ureter. the functional results are mainly divided into two groups: . transit timesthese are recorded in minutes and a side comparison gives idea how much time it takes for the contrast to go through the renal parenchymathe longer the more abnormal in general. . differential renal functionsthese can be based on the enhanced renal parenchymal volume or the patalk number generated from this area and provides in percentage the split renal function. this presentation will discuss in detail the functional aspect of mr urography and demonstrate its utility in routine pediatric uroradiologic imaging. in chronic childhood lung disease (e.g. cystic fibrosis) global pulmonary function tests (pft) can be normal although lung damage is already present. moreover, in comparison to imaging, pft is challenging in young children. thus, cross-sectional imaging became more important in the past two decades. regarding morphological evaluation, multidetector computed tomography (mdct) serves as the most sensitive and reproducible modality. for functional evaluation perfusion/ventilation scintigraphy remains the reference standard. although the individual radiation burden by a single chest ct has decreased significantly in the past, radiation doses can cumulate considerably when repeated examinations are performed in a longterm follow-up. pulmonary mri exists as an alternative method, especially for paediatric patients. however, standard h+mr sequences do not demonstrate small airway disease due to inherent limitations of low signal and rapid t * signal decay of lung tissue. for comprehensive diagnosis, functional mri offers the unique possibility to measure regional ventilation and perfusion, and mapping relaxation times and diffusion. focussing on research applications, a variety of methods are available for these purposes. in this context, ventilation imaging using inert fluorinated gas indicates to overcome the limitations of the expensive setting necessary for imaging with hyperpolarized noble gasses. regarding lung perfusion, dynamic contrast-enhanced mri (dce-mri) is the most established method in clinical practice. however, especially in children, techniques that are completely non-invasive and do not require i.v.-contrast agents administration or gas inhalation could be promising to achieve broad acceptance. concerning non-invasive methods, ventilation can be assessed by sequences with ultra-short echo times (ute), perfusion by arterial-spin-labeling (asl) and both by fourier decomposition mri (fd-mri). in conclusion, pulmonary mri offers both, the assessment of morphology and the unique possibility to measure regional ventilation and perfusion, and mapping relaxation times and diffusion. new mr techniques that are completely non-invasive are now available. however, further scientific evaluation is needed. ibd and related arthropaties d. jaramillo; miami, fl/us musculoskeletal diseases affect about % of patients with crohn's disease and are the most frequent extra-intestinal manifestation of inflammatory disease. the articular manifestations of inflammatory bowel disease (ibd) are one of the seronegative arthritides, although they have a lower incidence of hla -b than other seronegative arthritis such as ankylosing spondylitis. there are manifestations in the joints of the extremities, and findings in the pelvis, especially in the sacro-iliac joints, and spine. involvement of the extremities occurs in about % of patients with ibd related arthropathies, are more common with crohn's disease, and can have either manifestations related olygoarticular jia, or can have symmetrical involvement of smaller joints. the axial manifestations include ankylosing spondylitis and sacro-iliitis. sacroilliitis is typically bilateral (figure) and often has radiographic as well as mri abnormalities. enthesitis, tenosynovitis and dactylitis can occur with ibd just as they occur with other arthritides. it is important to differentiate ibd related arthritis from septic arthritis due to extension of an enteric fistula. deceased bone mineral density is a common finding in inflammatory disease. it occurs as a combination of malabsorption of vitamin d due to intestinal involvement and the effects of therapy, particularly corticosteroids. insufficiency fractures of the spine, sacrum and extremities can mimic the symptoms of arthritis. finally, ibd can be associated with chronic non-bacterial osteomyelitis, although this association is relatively rare. this review will illustrate several of the skeletal manifestations of ibd, focusing on the arthropathies. juvenile idiopathic arthritis (jia) can be defined as an arthritis of unknown cause occuring in children younger than years and of at least weeks duration. juvenile spondyloarthritis (jspa) is a subset of jia and is characterized by enthesitis (inflammation at the attachment of tendons, ligaments and the joint capsule), arthritis and an increased risk of axial disease. there is also a strong association with human leukocyte antigen b . jspa accounts for approximately - % of juveniles arthritis cases in europe and is the most common form of juvenile arthritis in asia. the condition is associated with significant long-term morbidity, high health-care costs and poorer outcomes compared with other forms of juvenile arthritis as well as its adult counterpart. up to % of patients continue to be at risk of developing ankylosing spondylitis (as) during the disease course. recognizing spondyloarthritis (spa) in children is challenging, particularly early in the course of disease, as the signs and symptoms at disease onset differ from those seen in adults. jspa typically presents with hip and lower limb arthritis in conjunction with enthesitis. inflammatory back pain as a presenting symptom is less common. as a consequence, jspa may be missed or confused with other juvenile arthritides and patients often experience prolonged delays in diagnosis. currently there is no single diagnostic or classification system that is representative of the jspa population. according to the international league of associations for rheumatology (ilar) classification system, most childhood spa's are classified as enthesitis-related arthritis (era), psoriatic arthritis or undifferentiated arthritis. recent studies indicate that there are two clinical phenotypes of era: those with early axial disease often associated with hip arthritis in addition to peripheral arthritis; and those who follow a more peripheral disease course with arthritis and enthesitis and do not develop axial disease. the ilar classification system places patients with both axial and peripheral involvement into the era subtype, and does not specifically address children who meet the criteria for as. the correct approach to the classification of era is uncertain, and this issue is confusing to both pediatric and adult rheumatologists. unlike other categories of juvenile arthritis, jspa affects boys more often than girls, and peak age of onset is early adolescence. enthesitis is a defining characteristic of jspa. it is more common and affects more sites in the paediatric population compared with the adult one. the most commonly tender entheses are the insertions of the patellar ligament at the inferior patella, plantar fascia at the calcaneus, and the achilles tendon. arthritis in jspa is typically asymmetrical, oligoarticular (< joints) and involves predominantely the weightbearing joints. isolated hip joint arthritis may be the presenting feature and predicts early axial disease. involvement of the small toe joints is common in jspa but rare in other forms of jia. midfoot arthritis and tarsitis (inflammation of the intertarsal bones, overlying tendons, entheses and soft tissue) is highly suggestive of spondyloarthritis. in adults, inflammatory back pain typically heralds the onset of sacroiliitis, whereas children seldom present with symptoms of axial disease. however, according to several studies, sacroilitis can be asymptomatic in jspa and only detectable by imaging. other axial manifestations in jspa are inflammation of the lumbar apophyseal joints and interspinous ligaments, corner lesions of the spine and other sites of axial enthesitis-osteitis including the various ligamentous and muscular attachments of the pelvis. extraarticular manifestations of jspa are highly associated with axial disease and include acute anterior uveitis, bowel inflammation, psoriasis, and cardiac disease. clinical diagnosis of jspa can be difficult and the role of imaging may be more critical than in adult disease. the major goal of imaging in jspa is to identify children with early signs of axial disease, as this group is at the greatest risk for progression to as. the presence of axial disease in spa has also major implications for treatment decisions, since traditional firstline therapies appear to have minimal effectiveness in the management of axial inflammation. in addition, recent studies in adults suggest that earlier initiation of biologic agents (anti-tnfs) may slow radiographic progression. x-rays are not sensitive to acute inflammatory changes and will only show advanced disease in the sacroiliac joints. for these reasons plain radiographs are not useful in children or adolescents. ultrasound is a non-invasive, non-ionizing and relatively inexpensive technique that can be performed in a clinical setting. it is emerging as a valid diagnostic tool in spa and can be used to visualize peripheral synovitis, tendonitis and enthesitis, but the method is heavily operator-dependent and there does not yet exist a clear definition for the diagnosis and grading of enthesitis in children. secondary changes (calcifications, enthesophytes) have been observed much less in children compared with adults. there is a need for better consensus on abnormal ultrasonographic findings that define enthesitis lesions and standardization of methods. magnetic resonance imaging (mri) is a radiation free and sensitive imaging modality for detection of synovitis as well as cartilage and bone destruction. mri of the sacroiliac joints is increasingly obtained for early detection of inflammatory changes, as it shows active inflammatory (bone marrow edema, osteitis, enthesitis and capsulitis) and structural (erosions, subchondral sclerosis, subchondral fatty change and bony ankylosis) lesions of sacroiliitis long before radiographic changes become evident. in adults, mri has become the gold standard imaging modality for detecting arthritis and enthesitis. consensus definitions of lesions indicating pathology on mri are now incorporated into diagnostic criteria for adult with spa. in children and adolescents there is no gold standard mri technique and it is therefore not clearly defined whether changes s ( ) (suppl ):s -s pediatr radiol seen in the sacroiliac joints are pathologic or part of normal maturation in the growing skeleton. the use of contrast enhanced imaging for the detection of active sacroiliitis on mri in jspa is a major controversy. synovial enhancement can be detected without accompanying bone marrow edema in children, and it can be argued that contrast should be administered in order not to miss the diagnosis. some authors argue that contrast administration does not change or add substantially to the mri findings made on non-enhanced scans. certainly, given the risks associated with gadolinium administration, contrast should be used with caution. perhaps the use of contrast agents should be limited to selected cases when high stir signal in the joint is the only finding in order to confirm the presence of synovitis, and when the differential diagnosis includes etiologies such as infection or tumor. the development of new mri techniques has made it possible to perform whole body mri scans (wbmri) that allow assessment of the full range of affected entheses and joints. there is limited data on the utility of wbmri in the pediatric population. it is worth noting that edema-like changes seen in the marrow of healthy children is an important potential pitfall to consider during interpretation and further studies are required in order to establish specific reference standards for mri of the pediatric skeleton. diffusion-weighted imaging (dwi) offers a new approach to detect inflammation. inflammation produces an increase in the apparent diffusion coefficient (adc) of water molecules in affected tissues. several studies in adults and a few recent studies in children have demonstrated that adc is elevated in sacroilitis versus controls and that diffusion scores correlates well with stir images. dwi is promising as a potential biomarker of disease activity in jia and presents a novel approach to contrast-free imaging of synovitis. however, further studies are needed before it can be implemented in clinical practice. jspa is distinct from adult spa and manifests more frequently as peripheral arthritis and enthesitis. symptoms involving the spine and sacroiliac joints often occures later in this population. clinical diagnosis of jspa can be difficult, and imaging therefore plays an important role in the diagnostic workup of disease. identifying early signs of axial disease has major implications for treatment decisions and mri of the sacroiliac joints is increasingly obtained for early detection of inflammatory changes. however, mri criteria for sacroilitis in children are lacking. a major controversy in imaging of sacroilitis in jspa is the use of contrast, as children can have sacroilitis without accompanying bone-marrow edema. dwi presents a novel approach to contrast-free imaging of synovitis but further studies are needed before it can be used in clinical practice.wbmri has been shown to be more sensitive than clinical examination in the assessment of both disease activity and extent, but there is limited data on wbmri in children. normal variants in the growing skeleton may mimic pathologic changes and potentially cause overdiagnosing and -staging of disease. hence, there is an urgent need to establish specific reference standards for mri of the pediatric skeleton and to develop a gold standard mri technique for the axial skeleton in children and adolescents. juvenile idiopathic arthritis o. olsen; london/uk summary: juvenile idiopathic arthritis (jia) is common (about : , children). diagnosis and classification are based on clinical criteria. these criteria are in flux depending on ) contemporaneous knowledge about aetiology and ) available treatment options. radiology has currently no role in establishing the diagnosis. the clinical classification rests on whether the child has few joints affected (oligo jia), many joints (poly jia), has a condition similar to adult spondyloarthritis (entesitis-related arthritis) or other clinical presentations (systemic-onset jia, psoriatic jia, etc). radiology can potentially assess expressions of jia, such as synovitis, tenosynovitis, systemic manifestations and permanent damage caused by inflammation. it is therefore thought to play a part in gauging the disease activity. the clinical care aims at optimising the child's everyday function, reducing acute symptoms (pain, swelling, joint restriction), allowing normal growth, minimising long-term sequelae (joint deformity) and minimising adverse effects of medical treatment. medical treatment in jia is systemic (immuno-modulation) and local (steroid injection to joints and tendon sheaths). both modes of therapy may to some degree be guided by imaging. however, there currently is no evidence that any form of whole-body imaging is efficacious for guiding treatment. this means that, in principle, indication for imaging should be ) specific clinical questions, e.g. uncertainty regarding active inflammation at specific sites, or ) a high pre-test likelihood of inflammation at a site which is difficult to assess clinically and where imaging offers reasonable accuracy. one example of the latter are the temporo-mandibular joints where destruction is frequently seen at an early stage, often without prior symptomatic warning. there is one fundamental challenge for imaging research in jia: what is the reference standard? for lack of anything better, a standardised clinical examination is often used as 'ground truth'. the dilemma is obvious. if clinical examination is reliable and accurate, then why bother with imaging? but we think imaging offers an improvement, then we cannot use an inferior method to set the standard. this problem is not unique to jia. as is often the case, radiology in jia is all about: knowing your clinicians (i.e. the pretest likelihood for disease) being technically eloquent (e.g. using high-resolution us probes, not delaying post-contrast mri acquisitions) knowing what is normal (e.g. normal undulations in the articular surface, focal bone marrow signal variation) not being dogmatic about individual observations or measurements interpreting your findings in a clinical context the lecture will demonstrate similarities and differences among joints and modalities in children with variable-severity jia. the following points will be made: focal areas in the bone marrow with high signal (t ) and corresponding enhancement are often seen in healthy children. in isolation, these do not signify active inflammation. active synovitis in children often is not associated with (much) effusion the combination of synovial thickening with hyperaemia (us)/abnormal contrast enhancement (mri) and surrounding softtissue swelling suggests active inflammation, however there is (yet) no established system for quantifying hyperaemia/enhancement focal pits in the carpal bones do not represent erosions unless there is an associated cartilage defect radiographs are useful for detection of destructive abnormality in mri, scan fairly soon after injecting contrast. gadolinium physiologically leaks into the synovial fluid making it difficult to delineate the synovium a few differential diagnoses to keep in mind when there is mass-like swelling within or adjacent to a joint: vascular and neoplastic lesion, pigmented villonodular synovitis, synovial chondromatosis, lipoma arborescens. synovial inflammation is not always primary. even when there is an established diagnosis of jia, do consider that it may be secondary to biomechanical abnormality (erosion, osteochondral lesion, deformity). focal areas in the bone marrow with high signal (t ) and corresponding enhancement are often seen in healthy children. in isolation, these do not signify active inflammation. active synovitis in children often is not associated with (much) effusion the combination of synovial thickening with hyperaemia (us)/abnormal contrast enhancement (mri) and surrounding soft-tissue swelling suggests active inflammation, however there is (yet) no established system for quantifying hyperaemia/enhancement focal pits in the carpal s ( ) (suppl ):s -s pediatr radiol bones do not represent erosions unless there is an associated cartilage defect radiographs are useful for detection of destructive abnormality in mri, scan fairly soon after injecting contrast. gadolinium physiologically leaks into the synovial fluid making it difficult to delineate the synovium pulmonary manifestation of connective tissue disorders c. m. owens; london/uk summary: connective tissue diseases are an important cause of morbidity and mortality in children with very varied presentations. nomenclature is confusing and a more appropriate descriptive term would be "multisystem inflammatory disorder +/-autoimmunity". it is important for the radiologist to be aware of the protean radiological appearances and clinical manifestations. take home points: different patterns of diffuse lung disease (eg, desquamative interstitial pneumonia, non specific interstitial pneumonia, lymphocytic interstitial pneumonia, organising pneumonia, diffuse alveolar damage) may be present in several forms of collagen vascular disease, (and indeed other rheumatological conditions such as jia) including scleroderma, systemic lupus erythematosis, juvenile dermato and polymyositis, sjogren's syndrome and mixed connective tissue disease. these will be discussed in detail with illustrations for thin section high resolution ct with histopathological correlation. the clinical presentation, prognosis and response to therapy vary depending on the histological pattern of diffuse lung disease, as well as on the underlying collagen vascular disease. whole body imaging in children: sonography, ct, mri, nuclear medicine -what and when? r. a. nievelstein; utrecht/nl there are several (benign and malignant) disease processes in children that frequently involve more than one organ system or body region. diagnostic imaging of children with such multifocal or multisystem diseases has been quite challenging, often requiring a combination of different imaging techniques for a whole body coverage. the recent technical developments in computed tomography (ct), magnetic resonance imaging (mri) and nuclear medicine (nm) have changed the role of imaging in these children revolutionary. in the past, imaging techniques have been mainly used as a tool to detect the cause of illness and to assess the extent of disease spread before, during and after therapy (i.e. structural imaging). but nowadays, it has also become possible to use imaging techniques to gain information on the biological behavior of diseases before and during therapy (i.e. functional imaging). plain radiography, ultrasonography (us) and computed tomography (ct) have been the structural imaging techniques of choice for many decades, more recently supplemented by functional imaging techniques like single-photon emission tomography (spect) and positron emission tomography (pet). a major disadvantage of most of these techniques is the use of ionizing radiation, which may be associated with induction of second cancers later during life. this small but not negligible health risk is of particular concern in children as their tissues are more radiosensitive than adults and they have more years ahead in which cancerous changes might occur. that is why there is an increasing interest in the use of alternative imaging techniques that do not use ionizing radiation. with mri it is nowadays possible to acquire images with a high spatial resolution and excellent soft tissue contrast throughout the body, which makes it an ideal radiation-free tool for the detection of pathology, especially in soft tissue, parenchymal and bone marrow locations. moreover, recent technological advances have resulted in fast diagnostic sequences for whole-body mr imaging (wb-mri), including functional techniques such as diffusion weighted imaging (dwi). as a result, wb-mri has become a clinically feasible imaging modality for diagnosis and follow-up of multifocal and multisystem diseases in children. in this scope, the recent development of integrated pet/mri systems is very interesting, combining the superior structural imaging of mri with the functional (molecular) information of both imaging techniques while decreasing the radiation dose. traditionally, whole body imaging techniques have been mainly used for oncological indications, such as staging of malignancies, and monitoring of the effectiveness of therapy. however, whole-body imaging techniques are increasingly used for the diagnostic imaging of other benign multisystem diseases and indications, including chronic recurrent multifocal osteomyelitis (crmo), rheumatological diseases, neuromuscular diseases, neurofibromatosis type , generalized vascular malformations, multifocal osteonecrosis after intensive chemotherapy, fever of unknown origin, and post-mortem imaging. finally, these imaging techniques may be used for the screening of children with a cancer predisposition syndrome. during this lecture, imaging protocols and indications of the different whole body imaging techniques will be discussed with a focus on their clinical application in children with benign and malignant multifocal or multisystem diseases. ( ) (suppl ):s -s pediatr radiol appearances is important for any radiologist involved in child imaging, because we have an important role in characterizing the lesions and guiding purposeful and minimally invasive but successful diagnostic procedures. most head and neck masses in children are benign and have an inflammatory, infective, vascular or congenital cause (cf. special presentation on vascular malformations). malignant lesions are less common, however, early diagnosis is paramount as many of these cancers are readily treatable and often curable. differential diagnosis is guided by patient age, clinical presentation, tumour localisation, and imaging characteristics. while some masses such as (epi-)dermoids, fibromatosis colli and swollen lymph nodes including atypical mycobacterial infections (mott) may be readily diagnosed by clinical inspection und ultrasound, others present special diagnostic challenges. fibromatosis, for example, is a benign lesion with an often complex and potentially destructive local spread. some malignant lesions tend to be localised such as the embryonal rhabdomyosarcoma, while others may be part of a systemic disease such as lymphoma and langerhans cell histiocytosis (lchc). in case of a suspected malignancy, patients should be referred to a specialized centre which will be able to provide the full spectrum of multidisciplinary evaluation and treatment according to the guidelines of an international oncology study group. this is also important for image guided or surgical biopsies as long term outcome and survival of many of the young patients are directly associated with these initial diagnostic and therapeutic strategies. with its excellent spatial resolution in the near field, ultrasound is the method of choice for all superficial masses. an experienced paediatric radiologist will be able to identify most of the benign lesions and in other cases will be able to guide further diagnostic decisions. tumours in the midline require thorough workup to exclude an encephalocele or a dermal sinus with connection to the intracranial space. high resolution mri is required if such an extension cannot be ruled out by ultrasound or if a tumour is larger than the transducer's scan area. soft tissue tumours in the deeper parts of face and neck as well as tumours of osseous origin are also best delineated by mri. in lesions adjacent to the skull base contrast enhanced and fat saturated mr images with high spatial resolution are of utmost importance to completely depict the tumour's extension through the foramina and along the meninges (fig. ) . ct can provide additional information on the involvement of osseous structures. embryonal rhabdomyosarcoma. high resolution mri with fat saturation after contrast injection depicts the tumour's extension through the foramen ovale (long arrow) and along the meninges (short arrows). skull base and face lesions are less frequent in children than in adults. symptoms may be subtle or unspecific. depending on their localization, clinical findings may be common (nasal obstruction, otitis…) or more disturbing (cranial nerves palsies, exophthalmos, vision loss …). clinical history and physical examination findings are important to reduce the spectrum of differential diagnosis, but imaging data are the key features to determine the nature of these lesions. ct and mri play an important role in diagnosis, treatment survey and surgery planning of skull base and face lesions. skull base and face bone lesions are either intrinsic lesions of the bone or secondary to soft-tissue tumors or pseudo tumors invasion. this lecture will focus on bone intrinsic lesions, and include soft-tissue and pseudo tumors only as differential diagnoses. computed tomography plays the role for skull base and face of plain radiograph for long bones. therefore, the same semiology may be used to determine if the lesion is slowly or rapidly growing, aggressive or looks benign. helical ct allows reconstructions with both soft-tissue and bone algorithms as well as multiplanar reformations. it gives a good visualization of the anatomy of the skull base and allows a good depiction of the bone architecture. ct is first used for the initial work up of the disease but also for surgery and therapeutic planning (endoscopic sinus surgery with navigation). however, ct analysis may be challenging in children due to growth changes: normal process of pneumatization according to age, sutures not yet fused has to be recognized. some variations in pneumatization must not be mistaken for pathology: asymmetrical pneumatization of the petrous apex and arrested pneumatization of the sphenoid mimicking intraosseous lesion are the most common. both ct and mr imaging are complementary: most preferably, contrast-enhanced mr is associated with non-contrast high resolution ct. mri allows a good delineation of bone involvement of skull base lesion due to bone marrow changes, whether ct can fail to detect subtle extension within the bone. in addition to t and t weighted sequences, the use of specific sequences and/or techniques such as fat-saturation, diffusion, dynamic-contrast-enhanced sequences, and mr angiography helps to characterize the lesions. t spin echo sequence is mandatory to appreciate bone marrow infiltration in adults and older children. but when red bone marrow has not yet be replaced by fatty bone marrow, in young children, this can be challenging. it is useful to know the bone marrow fatty conversion of the skull base chronology. cranial mr can also be associated to whole body mr to look for multifocal or metastatic disease. epidemiologic data concerning bone tumors of the skull base are scarce due the rarity of these lesions. they can be classified according to their location within anterior, middle or posterior cranial fossa or classified according to their origin: osteogenic (osteoblastoma, osteoma, osteosarcoma...), chondrogenic (chondroma, chondrosarcoma), fibrous ( fibrous dysplasia, fibro-s ( ) (suppl ):s -s pediatr radiol osseous lesions..), notochord (chordoma), hematopoietic (leukemia, histiocytosis ), vascular (hemangioma), neuro ectodermic ( ewing sarcoma) or unknown origin (aneurysmal cyst, giant cell tumor). the aim of this presentation is to draw attention to skull base growth changes that can mimic pathology and to describe the imaging specificities of the most common bone tumors of the skull base and face in children. because conflicted nomenclature can cause confusion, accurate diagnosis and classification of these anomalies is important for proper clinical evaluation and management. many of these patients require multidisciplinary care, consequently the usage of a correct nomenclature across all disciplines is a sine qua non. the international society for the study of vascular anomalies (issva) classification, updated in , offers a comprehensive classification accepted by many subspecialities. this approach/ classification has facilitated correct communication for all medical subspecialties involved in the care of these complex vascular anomalies. pediatric radiologists play a critical role in evaluating these patients since the majority present during childhood. in this presentation, we present a state of the art mri imaging protocol with exemplary cases of the most common types of vascular anomalies in the pediatric trunk and extremities, using the current issva classification. in addition, we discuss the common syndromes associated with vascular anomalies such as klippel-trenaunay and lumbar syndrome. genetic skeletal disorders (gsd's) are a heterogeneous group of syndromes characterized by an intrinsic abnormality in growth and (re-)modeling of cartilage and bone. a large sub-group of gsd's may have additional involvement of other structures/organs beside the skeleton, such as the central nervous system (cns). cns abnormalities have an important role in long-term prognosis of children with gsd's and should consequently not be missed. sensitive and specific identification of cns lesions while evaluating a child with a gsd requires a detailed knowledge of the possible associated cns abnormalities. here, we will present and discuss a pattern-recognition approach for identifying relevant neuroimaging findings in gsd's guided by the obvious skeletal manifestations of gsd. in particular, we will discuss which cns findings should be ruled out for the various gsd. to facilitate this diagnostic approach the multiple gsd are classified based on the pattern of skeletal involvement ( . abnormal metaphysis or epiphysis, ) abnormal size/number of bones, ) abnormal shape of bones and joints, and ) abnormal dynamic or structural changes). skeletal involvement is defined in accordance with online mendelian inheritance in man. the spectrum of co-existing cns involvement is extracted from an extensive literature search. selected examples will be shown based on prevalence of the diseases and significance of the cns involvement. cns involvement is common in gsd's. a wide spectrum of morphological abnormalities is associated with gsd's. early diagnosis of cns involvement is important in the management of children with gsd's. this pattern-recognition approach aims to assist and guide physicians in the diagnostic work-up of cns involvement in children with gsd's and their management. not infrequently the correct radiological differentiation of skeletal and/or central nervous system findings secondary to non-accidental injury versus inherited genetic and/or metabolic disorders may be challenging. imaging findings may be non-specific, can result in incorrect diagnosis and subsequently inadequate patient management or initiation of faulty treatment. the diagnostic work-up of children suspected of non-accidental injury or genetic/metabolic disorders requires a multi-disciplinary approach involving many key players including physicans of various disciplines, nurses, psychologists, social workers and many more. a proper and detailed medical history and physical examination of the patient, collection of the relevant family history, a metabolic and genetic work up, a detailed interview of care givers, friends and family are essential for the correct and comprehensive evaluation of imaging findings. in the current session, various exemplary and possibly confusing cases will be interactively discussed with the audience by a panel of experts (susan blaser, thierry a.g.m. huisman and andrea superti-furga). goal is to offer a case based approach to challenging patients with discussion of the best diagnostic approach including differential considerations. the zikv is transmitted mainly by the bite of female aedes aegypti and aedes albopictus mosquitoes. other forms of transmission, including through sexual intercourse, blood transfusion, and neonatal, are currently under evaluation, although more elements are still needed to assess the real importance of these transmission routes . the course of the zikv infection is self-limited. so far, no specific symptoms have been attributed to the disease, and a wide variety of manifestations ranging from absent to mild symptoms (in % of cases) have been described. when symptoms are present, they may lead to a misdiagnosis of other bacterial and viral infections, especially other arboviroses in endemic areas. the most frequently reported symptoms are mild fever, cutaneous rash, fatigue, arthralgia/myalgia, and conjunctivitis. dizziness, malaise, edema of the extremities, anorexia, retro orbital pain, photophobia, gastrointestinal disorders, sore throat, cough, sweating, and lymphadenopathy have also been reported. infection by the zikv in adults may be associated with autoimmune complications such as guillain-barré syndrome . the laboratory diagnosis of zikv infection is based on the demonstration of the virus in the urine and blood using real-time reverse transcription polymerase chain reaction (rt-pcr). the main limitation of this diagnostic method is a false-negative result after the viremia is resolved. the serological diagnosis of the disease is limited due to cross-reactivity of the zikv with other viruses of the flavivirus genus, especially those causing dengue and chikungunya. physicians should be aware of this fact when the diagnosis of zikv infection relies solely on serological results. the diagnosis is also possible by igm measurement in serum, urine, or cerebrospinal fluid using enzyme-linked immunosorbent assay (elisa) . the prevention against zikv infection is similar to that of other arboviroses, including vector control and mosquito bite prevention. the first major zikv epidemics were reported in the french polynesia in and . at that time, some neurological changes were observed in neonates of infected pregnant women but were not associated with a maternal-fetal transmission of the virus. the growing increase in the number of cases and the severity of the infection specific to this subpopulation then led to the evidence of a congenital disease . in brazil, the situation became alarming with the report of a high number of infected individuals in the second half of , . the brazilian ministry of health attributed to congenital zikv infection the -fold increase in cases of neonatal microcephaly in the northeastern part of the country, particularly in the state of pernambuco. this led the world health organization (who) to declare the zikv infection a "public health emergency of international concern" in february . the main challenge for radiologists practicing in regions of endemic zikv infection is to become familiarized with findings of congenital zikv infection in perinatal imaging studies; this is particularly important for the prenatal screening of pregnant women , . the diagnosis of zikv infection in the fetus by neuroimaging is based on prenatal ultrasound (us), especially in the third trimester, and complemented with magnetic resonance imaging (mri). postnatal imaging was obtained by transfontanellar us, ct or mri. the main imaging findings on ct are microcephaly, an exuberant external occipital protuberance, rectification of the frontonasal angle, and a redundant scalp skin. three-dimensional ( d) reconstruction of al skull permits a better evaluation of these findings and enhances the parents' understanding of the disease. moreover, ct scan data may yield a d virtual physical model that can maybe obtained from ct scan data and printed onto using thermoplastic acrylonitrile butadiene styrene . the aim of this study was to describe the perinatal imaging findings in cases of congenital zikv infection. we studied mothers diagnosed with zikv infection from october to november . they had all presented a maculopapular rash and fever during the first or second trimester of pregnancy, and their neonates presented neurological defects that were attributed to intrauterine transmission of the zikv. the maternal diagnosis of zikv infection was confirmed by serology (n= ) or rt-pcr (n= ). all patients were torch (toxoplasma, rubella, cytomegalovirus, herpes simplex) negative. prenatal us was performed every weeks after the first imaging findings, and fetal mri was obtained in all cases. microcephaly was considered present when the infant's head circumference was two standard deviations below the mean value for age and sex or below the second percentile. postnatal imaging follow-up was obtained in all cases by transfontanellar us, ct or mri. we found several cns malformations, including lissencephaly, pachygyria and/or polymicrogyria, cerebral atrophy (panel ), enlarged cisterna magna with abnormalities of the corpus callosum, ventriculomegaly, brainstem hypoplasia, malformation of the cortical development, and cortical and/or periventricular calcifications mainly in the junction between the cortical and subcortical white matter (panel ). the skull of the infants had a collapsed appearance, with overlapping sutures and redundant skinfolds (panel ). craniofacial disproportion was easily identifiable, and arthrogryposis was identified in one case. similar neurological findings were observed in the infected patients and seemed to differ from findings of other infectious diseases. the finding of microcephaly in neonates with congenital zikv infection seems to be only the tip of the iceberg, as several cns malformations have been identified in connection with the disease. in brazil, a spectrum of imaging findings associated with congenital zikv infection has been observed. such findings are useful in helping radiologists to identify suspected cases of the disease. panel : prenatal ultrasound ( weeks) shows calcifications (arrows) and microcephaly. axial and sagittal t shows relative smoothness of the brain surface (arrows) and assymmetric colpocephaly. panel :ax t -wi multiple cortical-subcortical fronto-parietal hyperintense foci (arrows) and markedly hypointense on swi. sagittal t : dysgenesis of the corpus callosum, with dilation of the posterior horns of the lateral ventricles (colpocephaly). pre-and postnatal imaging in zika virus: where are we? early insights into zika's microcephaly physiopathology, from the epicenter of the outbreak: a case for teratogenic apoptosis of central nervous system. p. jungmann; recife/br early insights into zika's microcephaly physiopathology, from the epicenter of the outbreak: a case for teratogenic apoptosis of central nervous system. in mid-october , intense interaction among surgical pathology and fetal medicine specialists from university of pernambuco was only focused on the dramatic and non explained ultrasonographic (us) findings and hopelessness due to lack of explanations on the odd us discoveries on the first gestational cases of zika's microcephaly. this is the field of our history of a physiopathological hypothesis on zika virus (zikv) related microcephaly when it first struck pernambuco state (pe), northeast brazil, the place that has been at the front line of the global response to the microcephaly and responsible for a large amount of data from affected children. the outbreak onset came with a sudden increase in microcephalic newborns being reported in pe state from august (panel, fig. ) . zikv was previously thought to cause a relatively mild disease, but was recently accepted to lead to severe and diverse neurologic conditions in s ( ) (suppl ):s -s pediatr radiol some children born from infected mothers and in adults . the scientific community is actively trying to uncover the extent of these disorders but little has been reported on the early days of the outbreak when doctors were approaching the unknown. while evidence that zikv is related to microcephaly in newborns is accumulating, the mechanisms of how the virus affects the fetus is still uncertain. in the outbreak onset we had to face daunting challenges to search the cause of microcephaly and the emotional toll on the families. we took a very early approach from microcephalic fetuses on gestation and microcephalic babies on clinical follow-up from different pe areas, evaluated between october and december in oswaldo cruz hospital, to propose the early physiopathologic hypothesis that, a viral-related brain developmental disruption could be the basic neuropathogenesis in zikv babies instead of a direct injurious process due to viral insult followed by active inflammation. the eight pregnant women were all in the rd gestational trimester and had had normal us follow-ups till week th . crucially, we were facing a temporal-geographic association of cases presenting an unanticipated pattern of us alterations. because of their late alarming findings they were re-examined and the us scans revealed sudden encephalic alterations after th gestational week. such devastating us clustering images were not seen here before, but are now considered as part of the "congenital zika syndrome". we observed late appearing severe dysmorphic encephalic changes in out of fetuses, including small skull, small brain, sub arachnoidal space enlargement, ventricular dilation, brain calcifications of varied shape and distribution, inclined frontal bone, progressive decline of head growth potential, early fontanels closure and redundant scalp (panel, figs. a, b). we had no clues on the causes and mechanisms responsible for this phenotype of severe alterations. thus, we had no explanation to offer to patients, in particular, or to the medical community. both as physicians and human beings, we were committed straightaway to continue the study of these victims of an unknown medical tragedy, engaging our expertise in fetal imaging and immunopathology. from beginning october, the first microcephalic babies were referred to the upe pediatric infectology service for initial investigation. strikingly, the newborns exhibited "healthy" appearance, excluded the microcephaly itself and motor sequels. we then looked for csf analysis of the microcephalic babies. for that, we obtained from dr. patricia travassos, a csf specialist at upe, a cohort of csf samples that have been studied for signs of meningitis or encephalitis. about % ( cases) of the csf analyzed looked normal for any signs of central nervous system ongoing inflammatory responses (panel, fig. ). the babies had been examined by outpatient clinic dr angela rocha, from the upe hospital infectology reference center that have stated that although small, the babies were near to full term gestation ( - weeks gestation), had good apgar scores and variable degrees of microcephaly and neurologic impairments, i.e. contractures, spasms, irritability and in some retinal macular atrophy. during the follow-up, the babies were cared at home, breastfeeding, gaining weight and having routine vaccines. none of them expressed signs of ongoing inflammatory reaction in the cns (panel, fig. ) or alterations on peripheral blood count and other routine laboratory tests up to months of age. despite the striking neurological phenotype, % of the babies were negative for torch agents, no deaths were recorded. furthermore only in january , the first evidence associating zikv to microcephaly from rt-pcr test on amniotic fluid was reported . astonishingly, a particular kind of physiopathological process linked to fetal brain development was arising without clinical manifestation of inflammatory reactions or necrotic processes in these babies. unfortunately, no necroscopic samples of affected brain tissues were available to us to monitor the presence of putative neural dysgenesis and the very nature of brain calcifications background offering histological support for our hypothesis. nevertheless, with this restricted dataset we hypothesized that whatever the etiologic agent involved in these cases, its physiopathologic mechanism must trigger the cellular death programthe apoptotic process -at a particular development window on the cns, assuming clinically that the agent was not encephaalitogenic but silently tertogenic. if not, the clinical outcome of affected babies would not be so mild as far as signs of inflammation on cns was concerned. consequently, the inflammation-free clinical status of patients suggested us that a massive enhanced apoptotic cell death during the window of telencephalic expansion was the most probable physiopathologic process operating this microcephaly phenotype, with no direct direct lytic brain lesion or significant necrosis due to usual injury. furthermore, knowles and penn stated that this window is very active to select the "fittest" neural cells by a constitutive apoptotic pathway. we so hypothetized that during this developmental time window, the "fit or not fit" status of the rapid, transient amplifying neural progenitors cells facing zikv, would heavily shift the selective process toward the self-elimination of virusbearing cells through apoptotic pathways. thus, zikv-enhanced constitutive apoptotic mechanisms would lead a massive loss of developing telencephalic neuronal precursors and, consequently, provoking losses of dividing cells and the arrest of further brain development. this could be particularly inferred by the absence of the characteristic morphology of late stages structures of neocortex, according with our us images of zikv microcephalics in gestation. similar processo could also be inferred to neurocrest derivatives as deformities in the viscercrany always accompany the cephalic malformation. our initial understandings based on clinical examination on the field, when no specific laboratory test, necroscopic data or experimental evidence on the disease causality were available, conducted our physiopathological approach to the "apoptosis hypothesis" for zika microcephaly that is now gaining strong support. in february, mlarkar et al showed clear connection between zikv and microcephaly, presenting cns histopathologic analyses, revealing remnants of neural germinative matrix, intense gliosis, alterations in cortical ribbon, calcifications in gray and white matters without associated necrosis, encephalitis or meningitis and the presence of the virus, further supporting neurodevelopmental arrest. similar results were showed by driggers et al . the ct scans from microcephalic babies from hazin at al , have added details of brain development arrest with no radiological signs of brain destruction or active inflammation. finally, experimental models have provided a body of evidence f or neuroprogenitors permissiveness to zikv and viralinduced apoptotic process. tang et al demonstrated by icq that the zikv infection of cortical neural progenitors attenuates their growth and increases caspase- activation, calling for an apoptotic process. this finding was corroborated by the up regulations of caspase- genes by rna sequencing. nowakowsky et al demonstrated that zikv may hijack axl protein as an entryway to infection. interestingly, axl is highly abundant on the surface of neural stem cells but not on differentiated neurons in the developing brain. recently, cugola et al demonstrated that zikv was able to cause cns congenital brain dysgenesis upon vertical transmission in mice. in parallel, human brain organoids infected by zikv show a reduction of proliferative zones and disrupted cortical layers, so targeting cortical progenitors and inducing apoptotic cell death with impaired development. for babies born with zikv-related microcephaly, the many expected consequences besides the evolving congenital neurosequels, are the unanticipated pattern of persistence of zikv in cns host cells, unsafe maintenance of neuron genome stability on remaining arrested populations, implying risks for brain tumors, risks for impaired adult type neuron wiring and neuron survival in an affected neuronal circuitry. in brief, evolve life with a wide vulnerable brain. the outbreak of zikv in the americas will eventually decline as herd immunity increases, but the world remains at risk of further waves of infection in affected countries and spread into new territories . while experimental studies will be carried out to fully understand the pathophysiology of zikv infection in the developing fetus, our findings provide a coherent and testable physiopathological hypothesis for cns teratogenic phenotype linked to zikv congenital infection, which may be critical for the clinical care of pregnant mothers and their babies before and after birth. take home points: fetal dysmorphisms detected by ultrassonographic and mri images in congenital zika syndrome are late findings, usually after the th gestational week and requires acurate analyses. clinically, zika's virus microcephaly is an infectiuos congenital condition that is not encephalitogenic but primarily teratogenic on the nervous system. the most important process leading to zika's virus microcephaly is pathologically induced apoptosis in telencephalic neuroprecursosrs cells and neurocrest precurssors cells. viral induced autophagy and low antiviral responses during the fetal period are linked to zika virus persistence in the central nervous system of affected new borns and babies a. vossough; philadelphia/us summary: susceptibility-weighted imaging (swi) has proven to be a valuable mr imaging sequence in a variety of applications. pediatric imaging has also immensely benefitted from this technique. in this presentation we will review pediatric neuroimaging applications in trauma, arterial and venous vascular disorders, hypoxic-anoxic injury, congenital malformations, congenital heart disorders, neoplasms, and pediatric degenerative disease. use of swi in pediatrics other than demonstrating hemorrhage and calcification will be reviewed. challenges in the clinical use of swi in pediatrics, interpretive pitfalls, and sources of clinical misinterpretation of swi will also be explored. we will also briefly present ongoing research and clinical use of swi in pediatrics and potentials for future collaborative investigations. & swi is highly sensitive in detection of susceptibility effects on mri. & in many cases, but not all, swi processing can differentiate between calclium and blood products. & quantitation information can also be obtained from swi with further processing. state of the art imaging of the single ventricle d.m. biko; philadelphia/us there are many congenital heart defects that result in a functional single ventricle. this may be functional or anatomical as a result of a dysfunctional valve or absent or ineffective pumping chamber. the repair of single ventricle physiology most often involves a staged reconstruction due to changing physiology ultimately resulting in a total cavopulomonary connection or fontan procedure. to appropriately image the single ventricle throughout its stages of palliation, familiarity with the physiology of the various steps in surgical palliation of the single ventricle is essential although echocardiography is a mainstay of cardiac imaging, cross sectional imaging has a vital role in the evaluation of the single ventricle. the role of ct angiography is mostly for anatomic evaluation. although it is fast and has high spatial resolution for evaluation of vasculature, ct has lower temporal resolution than mri and is unable to quantify flow. ventricular performance along with quantification of flow can be performed with mri. systemic to pulmonary collateral flow, which has been shown to result in adverse outcomes after fontan, can be quantified. valvular insufficiency and myocardial scarring can also be assessed. additionally, high anatomic vascular detail can be obtained with mri, particularly with the recent investigational use of the blood pool agent ferumoxytol. mri also has the ability to assess the lymphatics either through non-contrast t weighted imaging and/or dynamic contrast mr lymphangiography as lymphatic pathology may play a role in postsurgical hemodynamics in single ventricle patients. this lecture will focus on the use of ct and mri in the evaluation of the single ventricle particularly concentrating on the developing use of mri for anatomic and physiologic assessment. take home points: in single ventricle physiology, there is only one effective pumping chamber. familiarity with the physiology of the various steps in surgical palliation of the single ventricle is essential in imaging this disorder ct angiography provides high anatomic detail but limited in its assessment of physiology since it cannot quantify flow and has lower temporal resolution than mri. mri can evaluate ventricular performance, quantify flow and valvular insufficiency, and assess myocardial scarring. high anatomic vascular detail can also be obtained with mri particularly with the emerging investigational use of ferumoxytol. with non-contrast t weighted mri and/or dynamic contrast mr lymphangiography, lymphatic evaluation can be performed which may play a role in post-surgical hemodynamics in single ventricle patients. neuroimaging in head trauma m. argyropoulou, g. alexiou; ioannina/gr summary: objective: head trauma in children is one of the most common reasons for visiting emergency department. however, only a small portion of patients will have a traumatic brain injury. patients with moderate or severe head trauma should undergo ct scan, however, a debate exists for the indication and yield of neuroimaging for minor head trauma. we performed a systematic literature review on the accuracy of symptoms and signs in children with minor head trauma in order to identify those with severe intracranial injuries. materials: a systematic literature search of medline ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was performed to identify studies assessing the diagnosis of intracranial injuries in children. the authors independently performed critical appraisal and data extraction. results: we identified studies that evaluated the performance of findings for detecting intracranial injury using the reference standard of neuroimaging or follow-up examination. mechanism of injury, multiple vomiting episodes and decline in gcs score were more commonly associated with severe intracranial injury on ct. normal variations in the amount of joint fluid, ganglion cysts, bone marrow edema, and bony depressions that resemble erosions are frequent in the wrists of children. the results of a follow-up of a healthy cohort aged - will be presented. the cohort was examined twice with mr of the wrist, and the second time also with a cartilage sequence for better visualization of the bony depressions. knowledge of these normal variations is important because they can resemble disease. bone marrow edema, joint fluid more than mm, and bony depressions that can resemble erosion are frequent findings in the normal wrist. take home points: bone marrow edema, joint fluid more than mm, and bony depressions that can resemble erosion are frequent findings in the normal wrist. these findings can not be attributed to dissease without additional findings of synovitis. a cartilage sequence can be of use in the differentiation between true erosions and bony depressions. mri scoring of the wrist in patients with jia-current status and future perspectives c. nusman; amsterdam/nl the wrist is a frequently affected joint in patients with juvenile idiopathic arthritis. due to recent improvements in treatment strategies, permanent damage is not that common anymore. also, imaging has been playing a key role in monitoring the disease activity in the wrist of jia patients. the past years lots of efforts have been made to improve the assessment of acute and permanent changes of the jia wrist. requisites and recommendations for the mri protocol to use for of the jia wrist are available in literature. currently, the features of scoring the jia wrist are synovitis, tenosynovitis, bone marrow edema and bone erosions. the repeatability of the above-mentioned scoring features proved to be acceptable. recent studies showed that the appearance of the wrist in healthy children can mimic pathology. therefore, construct validity of the scoring features needs to be assessed by comparing wrists of healthy children with the wrists of jia patients. & construct validity of the scoring features needs to be assessed by comparing wrists of healthy children with the wrists of jia patients a novel radiographic scoring system for permanent hip involvement l. tanturri de horatio , p.l. di paolo , s.c. shelmerdine , p. toma , k. rosendahl ; rome/it, london/uk, approximately - % of children with jia, particularly those with systemic onset disease, will have hip-involvement within - years after disease onset. as scoring systems for radiographic changes in children with hip involvement are lacking, we aimed to examine the reliability of potential markers and suggest a novel scoring system. a set of hip-radiographs from children with jia and clinical hipinvolvement: seen at the outpatient clinic at great ormond street hospital (gosh), london, and seen at ospedale pediatrico bambino gesù, rome, was used. all hip radiographs were scored in a blinded fashion, once by an experienced paediatric radiologist and a paediatric radiologist with minor experience in musculo-skeletal imaging in rome, and twice by an experienced radiologist and a research fellow in bergen/ london. radiographic findings suggestive of ) destructive change (bone erosion, flattening of the femoral head, squaring of the femoral head contour, presence of sclerosis, joint space height, and ) growth abnormality (length and width of the femoral neck, varus/valgus deformity, the ccd angle and the trochanteric-femoral head height) were assessed. assessment of erosions of the femoral head, femoral neck and the acetabulum showed moderate to good agreement for the same reader. the inter-reader agreement was, however lower. there was a high to moderate ( ) (suppl ):s -s pediatr radiol agreement for the assessment of femoral head flattening using the mose' circle. the measurements of femoral neck length and width, the ccd and trochanteric-femoral head lengths were precise, with % limits of agreements within - % of the mean. we have identified a set of relative robust radiographic findings suggestive of growth abnormalities and destructive change in children with hip-jia, and suggested a novel scoring system. x-ray of a years-old jia patient with severe chronic hip involvement. x-ray of a years-old boy with growth abnormalities on hips (bilateral coxa magna). in jia hip involvement is often a predictor of a severe disease course. radiographic findings vary according to mode of onset and age: in younger children the initial findings may be developmental rather than destructive while children with later onset jia may have destruction/narrowed joint space as the first feature. several of the commonly used radiographic findings for chronic hipchange are inaccurate. we have identified a set of relative robust radiographic findings suggestive of growth abnormalities and destructive changes in children with hip-jia, and suggested a novel scoring system. bone age assessment -statement from the msk task force k. rosendahl; bergen/no summary: age assessment is an important, yet complex and challenging issue that authorities may need to perform to determine whether an individual is an adult or a child in circumstances where their age is unknown. there is currently no method which can identify the exact age of an individual and there are concerns about the invasiveness and accuracy of the methods in use, namely analysis of documentary evidence, interviews, physical or other form of medical examination such as imaging. the main imaging methods include carpal, collar bone and dental examinations. whilst many countries make use of these methods they do not apply them in the same way and often use different combinations and/or order. one of the main reasons for this is the fact that age assessment procedures remain to a large extent determined by national legislation, with procedures evolving through national jurisprudence (ref.: european asylum support office (easo age assessment practice in europe)). the ethical and legal aspects of using bone age to determine age will be addressed in a statement from the msk task force. the ethical and legal aspects of using bone age to determine age will be addressed in a statement from the msk task force. & the application of drls should be the responsibility of all providers of x-ray imaging. this means that drls should also be applied to imaging performed outside the radiology department. & the physical quantity used to establish drls should be an easily measurable quantity, usually directly obtainable from the x-ray equipment console, obtained either by manual recording or preferably by automatic recording and analysis. organ doses and effective dose are not considered feasible as a drl quantity because these cannot be easily determined. the ultimate mission of eurosafe imaging is to support and strengthen medical radiation protection across europe following a holistic, inclusive approach. most common imaging procedures in children and their contribution to collective dose e. sorantin , c. granata ; graz/at, genova/it summary: several countries have released "diagnostic reference levels (drl)" for imaging procedures using ionizing radiation. unfortunately those drl differ in types of procedures and granularity as well as information about the proportion of pediatric patients within the different examinations are sparse. therefore an more evidence based approach seems to be feasable -meaning releasing drl first for frequent and radiation burdened examinations. therefore a survey within europe was conducted and a questionnaire was sent to key persons of the european society of pediatric radiology (www.espr.org) as well to members of a large academic, interdisciplinary, international network within the ceepus programme (central european exchange programm for university studieswww.ceepus.info). alltogether centers were contacted and an response was received from ( . .%). from one center only frequencies for interventional radiology was sent. plain films: most frequent procedures are extremities ( . %), followed by chest films ( . %) -both account together for more than ¾. flouroscopy: voding cysto urethrography (vcu) . %, followed by upper gastro intestinal (gi) series with . % -again representing / of those examinations. computed tomography: head & neck . %, chest . %, abdomen . % -together almost %. interventional radiology and cardiac interventions: only limited data available and procedures quite hardly standardize and comparable. it seems adviseable, that only a few procedures are suitable for drl like peripheral insertion of vascular lines, occlusion of ductus arteriosus botalli or stent implantation for coarctation. in order to estimate the contribution to the relative collective dose all values were normalized to a chest xrays ( . ) and the following numbers could be calculated: abdominal plain film . , skull . , ct head . , ct chest . , ct abdomen . . the most frequent imaging procedures using on ionizing radiation are: in plain films extremities and chest xrays in flouroscopy vcu and upper gi series in ct head, chest and abdomen therefore eu wide drl should be released for those examinations. as it could be expected chest ct is the main contributor to the collective dose. since the espr abdominal (gi and gu) imaging task force has changed its name and agenda, extending from initially only genitourinary queries to also other abdominal imaging topics, new projects have been added such as for example imaging in anorectal and cloacal malformations, imaging in paediatric inflammatory bowel disease (ibd, a joint project with esgar), or paediatric abdominal ceus applications. results of these new projects will be presented in the upcoming talkshoping that again (as the last procedural recommendations and proposed imaging algorithms) our proposals and recommendations will help to standardise paediatric imaging, to reduce radiation burden, and to facilitate comparable imaging data for future research. other topics in this session are a proposal for a more standardised approach to gastrointestinal ultrasonography, and considerations on gadolinium applications in children in the light of new observations (i.e., gadolinium deposit in tissue even in children with normal renal function). the work goes ononly achievable with active participation of interested and competent members. many interesting topics for either recommendations or joint research are on the list such as addressing late decompensating pujo or specific imaging needs in ibd in early childhood; other new ones may be proposed by any task force member. thus all espr members are invited to join the group, work with us and share their expertise. ( ) (suppl ):s -s pediatr radiol contrast enhanced us in childhood -applications in children: literature review and results from the questionnaire c. bruno; verona/it in adults, following the characterization of focal liver lesions, several applications of contrast-enhanced ultrasound (ceus) have emerged in the last two decades, since second-generation contrast agents have been introduced and approved for use in most european countries. from many points of view, children represent an ideal population for ceus, because of the absence of radiation exposure and of need of sedation. moreover, due to the small body size many anatomical targets in children can be adequately explored with high-frequency ultrasound, obtaining images with higher spatial resolution than in adults. however, to date comparatively few data on pediatric ceus are available. although very rare and usually mild, possible adverse effects of contrast agents probably limit their use in many centers. in addition, the intravenous administration of ultrasound contrast agents in children is still off-label in europe, which makes informed consent necessary in every case. finally, for unclear reasons information on this topic does not flow easily. & from the comparison between the data available, similar or better results are likely to be obtained with ceus in children than in adults, and some specific pediatric indications might be proposed. imaging in ibd-joint recommendation statement with esgar f.e. avni , m. napolitano , p. petit ; brussels/be, milan/it, marseille/fr the first joint esgar/espr consensus statement on the technical performance of cross-sectional small bowel and colonic imaging ( ) objective: to develop guidelines describing a standardized approach to patient preparation and acquisition protocols for magnetic resonance imaging (mri), computed tomography (ct) and ultrasound (us) of the small bowel and colon, with an emphasis on imaging inflammatory bowel disease. methods: an expert consensus committee of members from the european society of gastrointestinal and abdominal radiology (esgar) and european society of paediatric radiology (espr) undertook a six-stage modified delphi process, including a detailed literature review, to create a series of consensus statements concerning patient preparation, imaging hardware and image acquisition protocols in pediatric and adult patients. the delphi process is constructed as follow: step questionnaire construction to includes all contents relevant to the guideline and set up of working groups; step questionnaire completed by all committee member, step literature search; step draft consensus produced by each wg based on the literature review and questionnaire responses; step committee members indicate agreement or otherwise for each individual draft consensus; step acceptance of agreed statements (more than % of members), face to face meeting to modify statements without agreement. committee members indicate agreement or otherwise for each modified consensus statement and final consensus statements. the questionnaire was split into four broad topics, each of them treated by a subgroup including in each of them a pediatric radiologist: ( ) patient preparation for mre/mr enteroclysis/cte/ct enteroclysis, ( ) mre/ mr enteroclysis technique and sequence selection, ( ) cte/ct enteroclysis technique, and ( ) enteric us patient preparation and technique. after an extensive literature research each member were instructed to always base their statements on the retrieved literature wherever possible, and to this end graded the strength of retrieved relevant publications from i (high) to v (low) using the criteria of the oxford centre for evidence based medicine ( ) during their review process. if no relevant literature was available for a particular item, members used expert opinion to construct the consensus statements. the pediatric guidelines were based on the opinion of pediatric radiologists and adult radiologists who have experience in pediatric practice. & it is recommended that children aged - should not eat any solid & it is recommended that the use of a spasmolytic agent is optional. unlike adult practice, the use of spasmolytic prior to mre is considered optional in paediatric patients and use is likely dependent on the age of the patient, with older children more likely to tolerate spasmolytic injection. there are data supporting the benefits of glucagon on image quality, at the expense of prolonged imaging time and precipitation of nausea in just under half of paediatric patients ( , ) . however, high diagnostic accuracy can also be achieved without spasmolytic ( ) . & it is recommended that children aged over years should be nil by mouth for carbonated and milk beverages for - h. ingestion of still water or non-carbonated fruit juice is recommended. & it is recommended that for dedicated colonic evaluation, a standard protocol without specific modification is used. & use of a spasmolytic agent is not recommended. & the use of i.v. us contrast is not recommended. & it is recommended that scan coverage should include an abdominal and pelvic examination, including the liver. there are no specific recommendations as to the use of hydro us in the paediatric patient as practice is not well developed. if oral contrast is given prior to us, it would seem sensible to follow the recommendations for mre in the paediatric population & it is recommended that if ct scanning is used in the paediatric population, no specific preparation is usually required although administration of positive oral contrast could be considered; for example, prior to percutaneous drainage of abscesses. limitations: there is little evidence in the literature to ascertain all these proposals. the recommendations were mainly based on expert opinion. no recommendations have been proposed for children before years of age. especially the benefice of mre under sedation ( ) in the younger compare to us doppler need to be explored. contrast media application is essential for a number of mri studies in children. there is some evidence that gadolinium-based contrast agents (gbca) are well tolerated in infants and children. the risk of adverse reaction is no higher in children than in adults. there are only few data available about pharamakokinetics in children, especially for the use of gbca in neonates. age-adapted reference values of the glomerular filtration rate (gfr) have to be used to identify children with a potential risk. in the past few years there was some attention toward the potential cellular toxicity of gadolinium and its role in the development of nephrogenic systemic fibrosis (nsf). there were only few children identified with proof of nsf. but, particulary renal insufficiency, poor hydration, acidosis and inflammation increase the risk for nsf. because the cases of nsf have been observed with linear componds the guidelines ( ) (suppl ):s -s pediatr radiol from the esur and the espr and others propose to avoid linear compounds and to prefer macrocyclic gbca. in the past year several studies have described observations about possible gadolinium retention in the brain; hyperintense brain structures in native t weighted sequences were verified -globus pallidum and dentate nucleaus -also in children undergoing multiple mri examinations with gbca application. so, repeated mr investigations within a short time should be avoided -the cumulative dose of gbca should be recorded. consider all these points, the benefit of a contrast-enhanced study should be weighted against the potential risks before administering a gbca for each child separately. but, never deny a child an indicated cemri study. use single dose application ( . - . ml/kg body weight), improve renal function and hydration, balance acidosis -and ask your pediatric nephrologist íf necessary. gadolinium-based contrast agents are safe. macrocyclic compounds should be used in children. avoid contrast media in neonates and be careful in infants. identify risk factors. avoid repetivite application. procedural recommendation: how to perform pediatric gastrointestinal us m.l. lobo , m. riccabona ; lisbon/pt, graz/at summary: ultrasound (us) is the first imaging modality applied in the investigation of abdominal complaints in children, and an increasingly valuable imaging tool in the assessment of the gastrointestinal (gi) tract in neonates, infants and children. a comprehensive us examination is a critical first-step to optimize the potential of us diagnostic yield in many paediatric gi conditions. using proper high resolution transducers and graded compression technique is an essential part of gi us examination. a methodical and systematic analysis is crucial to facilitate a thorough evaluation of the bowel segments as complete as possible: follow bowel in a cross section, complete by longitudinal and oblique views. for some bowel sections filling is essentialsuch as stomach for gastroesophageal reflux and pyloric function, and distensibility and size of the colon by enema (e.g. for query microcolon). modern us methods are valuable, but not a pre-requisite. proper documentation of abnormal size of the gi tract segments, their luminal content, peristalsis, bowel wall characteristics and its surroundings, as well as local tenderness should be noted. a proposal for recommendation on how to perform paediatric gastrointestinal us will be presented for public discussion. & careful and dedicated us examination is crucial to obtain maximum anatomic and functional information in many gastrointestinal disorders in children. & systematic and methodical analysis helps to assess the bowel as complete as possible. & satndardization of us technique is essential to optimize us diagnostic capabilities and to allow for comparable examinations wich is essential to improve future evidence-based knowledge. hominid evo-devo: reconstructing the evolution of human development c. zollikofer; zurich/ch from an evolutionary biologist's perspective, modern humans represent the only surviving species of a group of highly specialized "bipedal great apes". they evolved more than seven million years ago in africa and managed to spread over the entire globe. in this talk, i will trace the history of our species with an emphasis on key developmental innovations that underlie major evolutionary innovations. why are we born with brains that have the size of adult great ape brains? and why do we grow up so slowly and get so old? i will highlight how advanced biomedical imaging methods help addressing these questions, and show how combined fossil, clinical and great ape data yield surprising insights into the evolution of our development. to present our experience with innovative imaging in pediatric interventional radiology. imaging technologies presented will include: . use of bubble contrast (lumeson) for indicatons including; complex pleural effusion and abdominal collection assessment pre and post therapy, primary g tube placement, renal perfusion pre and post rena artery angioplasty, vascular patency during central venous line placement, vascular malformation therapy and biliary tube assessment. . intravascular us (ivus) in arterial intervention pre and post angioplasty and venous thrombolysis intervention. . optical coherence tomography pilot study assesssment for renal artery intervention -validation in normal subjects. currently this imagng which uses laser light technology to assess vascular mural detail at the micron level, is only validated in coronary artery intervention in adults. . mr overlay -a technology that fuses mr imaging with low dose fluoroscopy and can faciltate biopsy of mr positive/ct negative lesions in the ir suite. focus will be on bone lesion biopsy and vascular malformation therapy. critical structures to be avoided can be outlined on the mr and transposed onto the fluoroscopic image during biopsy. in our experience this technology has promise in the pediatric setting with significant dose reduction when compared to ct. . mr fusion and i guide fusion technology enables an mr positive/ct negative lesion that would require ct guided imaging to be biopsed, using low dose c -arm ct, with fusion of the ct and mri images performed using landmarks, facilitating fluoroscopically guided biopsy in the ir suite. critical landmarks/structures to be avoided can be outlined on the ct or mr and transposed onto the fluoroscopic image during biopsy path planning and orchestration. focus will be on bone lesion biopsy. . color parametric flow related imaging in vascular interventionthis software enables time to peak opacification of arterial or venous contrast to be color coded in time and can provide adjunctive information for assessent of perfusion change during vascular intervention such as renal artery angioplasty, dialysis access intervention and cerebral embolization. . mr guided intervention -this focus will be on the initial development of an mr interventional program and our initial experience with mr arthrography. discussion will also involve the use of this modality for vascular malformation sclerotherapy and other msk interventions such as biopsy and nerve injections. . high frequency us imaging-focus will be on the use of a mhz us probe in the ir suite for various indications including visualization of smaller targets such as neonatal central venous access, superficial vascular malformation therapy and thyroid fine needle biopsy. . participants will become more familiar with exisitng and emerging innovative imaging technologies for pediatric intervention. participants will learn about the various indications and limitations of these technologies. . participants will gain insight into the process of introducing new imaging modalities into their pediatric interventional practice. increasing evidence supports the notion that autism spectrum disorder is associated with anomalies of brain function and connectivity. it is also evident that there are atypicalities in development/maturation of brain systems. particular promise arises from findings of atypical electrophysiology -indexing brain neuronal activity in real time. in particular, this talk will address a characteristic electrophsyiologic signature of delayed auditory evoked response latency (at~ ms). this, and related timing anomalies, have been proposed as biomarkers for asd -with candidate use for diagnosis, prognosis, stratification and therapy monitoring. progress along each of these axes will be discussed. however, to justify the term "biomarker", we demonstrate converging evidence from spectrally-edited (megapress) mrs and diffusion-mri. mrs offers insights into neurotransmitter levels, especially gaba and glutamate, imbalance of which may be associated with anomalous electrophysiologic oscillations in the gamma band. diffusion offers insights into the white matter of the brain (auditory pathway will be illustrated) and an interpretation of diffusion parameters as an index of central conduction velocity will be offered. combining these mechanistic measures with the spectrospatio-temporal capabilities of magnetoencephalography (meg), this talk will present a state of the art review of multimodal biomarker development in asd. take home points: meg captures brain activity in space and time as well as showing sensitivity to activity at different frequencies (where, when and what) delays in cortical neuronal response latency are evidence in asd atypical coupling between diffusion evidence of conduction velocity and timing of cortical responses in shown in asd oscillatory activity is atypical in asd (elevated "noise", decreased "synchrony") diminished inhibitory neurotransmitter (gaba) levels are shown in asd disturbance of teh typical coupling between gaba and gamma-band oscillations in development leads to anomalous adult oscillatory activity (taken to index local circuit function). multimodal and longitudinal approaches may be required to tackjle the complex and heterogeneous landscape of asd the paediatric radiologist can play an important role in establishing vascular access in paediatric patients ranging from neonates to teenagers. a breadth of knowledge and skills are needed to deal with changing body morphology and varied pathology in this age range. some of the skills particular to performing and managing vascular access in children will be discussed. different devices which can be placed, their indications, advantages and disadvantages will be reviewed. choice of access vessel is important in children, because there are known long term complication such as central venous stenosis and thrombosis, which can have a huge impact for future venous procedures or potential creation of an arteriovenous fistula of the arm for dialysis. preserving venous access sites is a ( ) (suppl ):s -s pediatr radiol key responsibility especially in children with complex medical and surgical co-morbidities. because vascular access in children has associated morbidity it's important to manage and maintain devices that are placed. the risk of infection when repairing or exchanging a broken line will be highlighted. image guided biopsy is a very frequent procedure in pediatric patients. they range from random organ parenchyma for the diagnosis of medical disease up to tumor biopsies for histopathology analysis. different imaging modalities can be used for guidance as well as different biopsy devices and needles. ultrasound guidance is the most common modality used for this purpose in the pediatric population. the success of this procedure depends on multiple factors: from pain control up to choosing the correct device and area to sample. the radiologist performing the procedure also needs to be familiar with the potential complications of the intervention, how to prevent them and how to manage them. the intention is to perform the safer procedure as possible, obtaining the best quality of sample. the goal of this lecture is to present in a didactic way technical tips to perform safe and effective image guided pediatric biopsies, which may be applicable to different groups of operators, ranging from general pediatric radiologists performing occasional biopsies up to pediatric interventional radiologists. the objectives will be: to identify the safest approach to different types of biopsies; to describe ways to obtain the better quality of sample as possible; to demonstrate the use of different approaches in challenging clinical scenarios; to illustrate new devices currently used in specific applications; to discuss potential complications and its management and to show imaging modality integration applied to biopsy planning an performance. image guided biopsy is a frequent procedure in pediatric patients. a pre-procedure planning is fundamental in the success of the intervention. the operator must be aware of the aims of the biopsy and based on this choose the best approach, device and site for sampling. preparation and competency to manage complications is mandatory. pediatric interventional oncology: big cases in little people m. heran; vancouver/ca summary: the pediatric patient presents unique challenges in diagnosis and management of oncologic disorders. interventional radiology (ir) has a prominent role in the care of these children, with improvements in imaging and equipment offering better and safer options to traditional diagnostic and therapeutic procedures. as cancer can involve any organ system, consultations to the ir service can involve any part of the body, and can be non-vascular and vascular, simple and complex. the most common ir procedures in the pediatric oncology patient are enteric tube placement/change, vascular access, and percutaneous image-guided tissue/organ biopsy. however, with the explosion of interventional oncology in the adult setting, the variety and complexity of ir in pediatric oncology has begun to increase as well. ir techniques, such as thermal ablation, transarterial pharmacotherapy, and preoperative embolization, are now increasingly discussed in multi-disciplinary conferences as complementary or primary modes of treatment of oncologic disorders or related diseases/complications. however, although the principles of these diagnostic and therapeutic ir procedures remain essentially the same in their translation from adults to children, well recognized differences in pediatric physiology and metabolism, as well as the range in weight, size, and age of children, result in a practical question of "how do we do this?" the aim of this presentation is to provide an overview of the role of ir in the pediatric oncology patient, and to highlight areas of research and innovation. vascular anomalies encompass a spectrum of disorders including vascular tumours and vascular malformations. incorrect nomenclature and misdiagnoses resulting in inappropriate treatment are commonly experienced by patients with vascular anomalies. the currently accepted method for classification of vascular anomalies is straightforward and clinically relevant. vascular malformations can be divided into high flow lesions such as arteriovenous malformation or low flow lesions such as venous or lymphatic malformations. in children, a diagnosis can often be made with the history, examination and ultrasound. the classification of vascular anomalies will be briefly reviewed with examples of commonly encountered pathologies. a multidisciplinary team approach to the management of these conditions is vital. paediatric radiologists can play a key role not only in diagnosis but also in management, principally by injection sclerotherapy of low flow lesions and embolization of the much rarer arteriovenous malformation. many sclerotherapy agents are available with sodium tetradecyl sulphate the most commonly used for venous malformations and doxycycline for lymphatic malformations. different sclerotherapy agents have different characteristics and uses which will be covered. symptomatic relief is often achieved with treatment but multiple treatment episodes may be needed to achieve the desired outcome. ensuring the child and family understand this is vital to ensure they are satisfied with the management of the condition. contrast media is commonly used during imaging in children whatever their age and whatever the pathologic conditions. still, youngest patients are vulnerable and unstable. therefore, in neonates and infants the use of s ( ) (suppl ):s -s pediatr radiol contrast media should be carefully evaluated and customized putting in balance the risk versus the benefit of its use. when using contrast media in neonates and infants, several features should be highlighted: -prematures and neonates have rather immature kidneys and some contrast media might be difficult harmful -the thyroid gland in prematures may be (transitorily) depressed by iodinated contrast media -the use of high osmolar contrast may induce a fluid shift and dehydration especially in premature and neonates -most contrast media are used off label; almost none has obtained the authorization to be used in neonates. -there are very few studies evaluating the short and long term adverse reactions in neonates and infants below the age of two. fortunately these reactions seem very rare in these age groups. -using contrast extends the duration of the examination and the need for sedation different types of techniques will potentially need ingestion, instillation or injection of contrast media: ) opacification of the entire gi tract pre-and post-operatively ) retrograde uretro-cystography ) contrast enhanced ct ) contrast enhanced mr imaging ) contrast enhanced us ) angiography furthermore, different types of contrast media can be used to achieve these purposes ) barium (sulfate) ) iodinated water-soluble contrast media (hyper-, iso-or hypoosmolar) remarks regarding opacification of the upper gi tract: -the upper or lower gi tract should be opacified using water soluble contrast in the immediate postoperative period or whenever a bowel perforation is suspected. -air can be used to confirm esophageal atresia and duodenal atresia -barium should be preferred in case of t-e fistula -either barium or water soluble iodinate contrast can be used in order to opacify (sub)obstructed upper gi tract remarks regarding the opacification of the lower gi tract -iodinated iso/hypo osmolar contrast should be used to opacify the colon in case of obstruction -a higher osmolarity iodinated contrast can be used in case of suspected meconium ileus or plug; still this contrast should be used diluted and under close clinical surveillance and adequate hydration. -in some more specific cases, for instance whenever hirschprung disease or a stenosis post nectotizing enterocolitis are suspected, barium enema can be used remarks regarding ct scan -contrast enhancement may help for the global assessment of various pathologies especially in case of cardio-vascular malformations or for the evaluation of abdominal masses. any iodinate contrast among those available is acceptable in neonates. higher osmolality contrast allows to inject a lower volume -injected volumes of . ml/kg seem adequate using - gauge needles -power injectors are acceptable as long as adequate catheters can be used -allergic or side effects are very rare and should be managed similarly to adults. remarks regarding mr imaging -the use of gd chelates in neonates remains controversial as there is no data available on the long term effects of gd injected so early in life -gd should be used only when enhancement may provide additional information compared to the non-enhanced study (cns infections, tumors, cardiovascular imaging, abdominal tumors, uro-mr imaging...) -only gd with low nsf risk should be used -gd should not be used in children with renal failure remarks regarding contrast enhanced us -little is known about the use of ce-us in neonates -indications seem equal to older children -there are very few side or allergic effects -doses suggested are . ml/year of age children present varied histological types of brain tumours. it's now possible to combine different information and image techniques to improve the diagnosis of paediatric brain tumours. the multimodal approach has increased the diagnostic specificity and permits, in most cases, the pre-operative differentiation between low and grade tumours. children with low grade lesions, and in particular the less accessible tumours, would benefit the most from avoiding biopsy. in addition, preoperative spinal mri evaluation to rule out drop metastases should be performed in patients with suspected high grade tumours. in general paediatric brain tumours are less necrotic, i.e. aggressive tumours in paediatric patients tend to be more hypercellular and homogeneous. because of its ready availability and speed, computed tomography ( ) (suppl ):s -s pediatr radiol (ct) is the first investigation generally performed for a suspected brain tumour. ct can rule out haemorrhage or calcifications, but can also be used to evaluate tumour cellularity. a hyperdense tumour on ct reflects hypercellularity and is very often high grade. medulloblastoma are, for example, typically hyperdense on ct scans and paediatric low-grade astrocytomas are almost always hypodense. mri plays a major role in the evaluation of brain tumours. in conventional mri, the "general aspect" is the single most important parameter in predicting high-grade tumours in children. the same does not hold true for low-grade tumours, of which only % can be predicted using the general aspect. in our previous study, hyperintensity on t -w and the lack of diffusion changes were the most important single parameters with % positive prediction. embryonic tumours, such as medulloblastoma or pnet have high tumour cellularity with consequent very low adc and hypo/isointense t compared to the cortex. adc values derived from dwi have been shown to be decrease in highly cellular tumours. adc values cannot reliably be used in individual cases due to the substantial overlap between tumour types previously described in the literature. nevertheless, adc has a higher predictive value in children and increases the accuracy of preoperative differentiation between low grade and high grade paediatric tumours. the cut-off values for differentiating between low and high grade paediatric brain tumours are . x mm /s and . x mm /s for minimum adc and average adc values, respectively. perfusion with relative cerebral blood volume (rcbv) is considered a marker of angiogenesis and is helpful in distinguishing high and low grade tumours. however, perfusion can be difficult to perform in small children; small catheters with manual injection are therefore used in such cases (or, as an alternative, arterial labelling). it should however be taken into account that choroid plexus tumours can have high rcbvs resulting from highly leaky capillaries. mr spectroscopy (mrs) shows the metabolic profile of the tumour. high grade tumours show elevated choline (cho) -reflecting increase in cell membrane turnover -and decreased n-acetylaspartate (naa), which represents a neuronal marker. the absolute values of the mrs peaks are not used by us; we favour to normalize the signal intensities of metabolites to their values in contralateral brain tissue. mrs is helpful not only as guidance for stereotactic biopsy (cho hot spot) but also for determining whether the tumour is high or low grade. as a rule of thumb, a % increase of cho when compared to the contralateral brain tissue is highly suggestive of a high-grade tumour. however, in children, increased cho levels can also be found in pilocytic astrocytoma; in this case the typical aspect with cystic component and location can suggest the diagnosis, despite the mrs result. therefore, in children, high cho levels do not necessarily imply the presence of a malignant tumour. task based functional mri (fmri) can be used for pre-operative localization of the eloquent cortex together with the identification of the language and somatomotor function. in the future, small children who are unable to cooperate will probably profit from resting-state fmri. pet mri has the advantage of integrating structural mr imaging with physiologic pet. take home points: take home points although the histology of paediatric brain tumours is diverse, their general morphological aspect on mri has a very high diagnostic reliability. unlike adult grade iv brain tumours, malignant paediatric brain tumours are less necrotic, but are highly cellular with high nuclear-to-cytoplasmic ratios. adding information on signal intensities on t w and dwi further increases the diagnostic accuracy of conventional mri. the solid areas of high-grade tumours are iso-or hypointense on t w and hyperintense on dwi, whereas low-grade tumours show inverse signal characteristics. advanced mr techniques (perfusion and spectroscopy) provide important biological information which can be used to correctly identify grading (high vs. low) and to guide biopsy. in children high cho levels, although suggestive, do not necessarily mean a malignant tumour. experience with central review of paediatric renal tumours g. khanna; st louis/us summary: central imaging review of pediatric renal tumors has been performed in children's oncology group since . to date, more than cases of pediatric renal tumors have been centrally reviewed real time by the study radiologists. the mean time for central review was < days. discrepancies between local and central risk stratification were identified for detection of bilateral disease and pulmonary metastasis. in addition, central archiving of images has created a rich repository of cases for future research. the role of imaging in detection of key diagnostic features in pediatric renal tumors will be reviewed. the diagnostic performance of imaging for staging, detection of vascular invasion and tumor rupture will be discussed. real time central review of imaging is feasible in pediatric oncology wilms tumor remains the most common pediatric renal malignancy, followed by renal cell carcinoma cystic nephroma typically presents as a bosniak lesion, and has high association with dicer- mutations is there a role for dwi in nephroblastoma? a.s. littooij; utrecht/nl wilms tumour or nephroblastoma is the most common malignant renal tumour in children. ultrasound is usually the first line investigation. mri of the abdomen is often performed to further delineate the tumor and its surroundings. the addition of diffusion-weighted imaging (dwi) to the standard mri protocol may enable subtype characterisation and allows assessing treatment response beyond necrosis and volume change. overall, the survival rate in patients with nephroblastoma is relatively good and the current focus is on finding biomarkers to further improve outcomes while reducing therapy-related side effects in these children. therefore, identifying low-or high-risk type nephroblastoma might be relevant for treatment planning. diffuse anaplastic nephroblastoma and extensive blastema in residual tumour after preoperative chemotherapy may require more intensive treatment. the limited available literature suggest a linear relation between adc values and subtypes nephroblastoma at histopathology. furthermore, the addition of dwi to the standard mri protocol may detect lesions (e.g. nephrogenic rests of nephroblastomatosis) that remain undetected at post contrast t -weighted images. unfortunately, there is a considerable heterogeneity in acquisition techniques and methods of adc measurements. nephroblastoma often contains areas of necrosis and/or hemorrhage that can demonstrate very low adc values and consequently mimic highly cellular portions of tumours. therefore these areas should be excluded from further analysis. this lecture will highlight the potential additional benefit and limitations of dwi in children presenting with renal tumour. significantly lower radiation exposure even in comparison to low-dose pet/ct, (b) the higher diagnostic accuracy as compared to pet/ct even when using diagnostic contrast-enhanced ct, (c) the unique possibility to combine distinct mr-inherent contrasts (e.g. dwi) with specific pettracers (e.g. cu-labeled antibody imaging) for the evaluation of novel targeted therapies, and (d) the opportunity to stage local and systemic tumour burden within a single and highly resolved examination. on the other hand, many circumstances are challenging the extensive use of pet/mri in children. in general, the availability of pet/mri systems is low, particularly for children. thus, only a few sites in europe have experience with this technique in children, and therefore the generated scientific evidence is limited. moreover, whole-body-mri is still not a broadly adopted method for the combined assessment of local disease extent and whole-body staging, potentially replacing other whole-body modalities like the bone scan. in this context, especially the detection of pulmonary metastases is biased also against pet/mri. finally harmonized sequence protocols and specific recommendations for trace dosage are not available for pet/mri. in conclusion, further efforts are needed to keep the promises of pet-mri in the daily practice. common artefacts in paediatric mri-how to recognise, avoid or take advantage of them c. kellenberger; zurich/ch summary: while mri is a robust and radiation free imaging technique for assessing anatomy and pathology of most tissues and organs throughout the body, it is inherently prone to artefacts as no other imaging modality is. mri artefacts may impair image quality potentially leading to difficulties or errors in interpretation, but in some instances can contribute diagnostic information. main sources of image degradation are motion, disturbances of the local magnetic field and other factors inherent to image acquisition. strategies to reduce effects from various kinds of motion and adjustment of sequence parameters for eliminating artefacts will be discussed. & understanding the origin and effects of artefacts encountered in paediatric mri is essential for modification of mri protocols, so that artefacts and associated errors can be avoided. & for safely and successfully imaging children with implants and devices, the composition, location and functionality of the foreign body needs to be known. injuries to the central nervous system in abusive head trauma are responsible for the primary cause of morbidity and mortality in infants. neuroradiology has an important role in diagnosis but also in depicting injury and extent of brain damage of poor outcome. computerized tomography (ct) and magnetic resonance imaging (mri) are the primary imaging techniques. ct is usually performed in the acute phase while mri is performed the following days after injury. some injuries are better identified on mri such as diffuse axonal injury and cerebral edema with susceptibility and diffusion weighted images. abusive head trauma (aht) is the primary cause of morbidity and mortality in infancy, especially during the first year of life. aht is clinically characterized by a triad consisting of subdural hematoma, retinal hemorrhage and encephalopathy caused by brain swelling ( ). the most common mechanism responsible for brain damage is thought to be caused by whiplash shaking injury explaining that abusive head trauma is also referred as shaken baby syndrome. impaction, compression and penetrating injury are also possible mechanisms as well as strangulation. however because of the variability of types and severity of injury, clinical symptoms vary from subtle to severe such as alteration of consciousness or coma ( ) . the most common symptoms include vomiting, seizure, lethargy, poor feeding and apnea of which vomiting and respiratory pauses are non-specific ( ). poor feeding, irritability or lethargy is also nonspecific signs. however apnea and/or retinal hemorrhages seen in children with brain injury are strongly associated with inflicted trauma ( ) . in contrast to acute injury some children may manifest with increased head circumference related to chronic subdural hematomas. neuroimaging is therefore playing a crucial role to assess infants and children with a suspicion of abusive head trauma. computerized tomography (ct) and magnetic resonance imaging (mri) are the primary imaging techniques. ct is performed for the initial evaluation in cases with acute symptoms to look for hemorrhagic intracranial injury as subdural hematoma. mri is more often performed in the following days to further evaluate brain injury and to look for spine and spinal cord damage ( , ) or in the presence of normal or equivocal ct findings ( ) . however brain mri may be the first option in children presenting with increased head circumference. recently the study from flom et al showed the high sensitivity of mri for intracranial hemorrhage in well appearing infants at risk for abusive head trauma suggesting mri as a screening tool with pulse sequences (axial t , axial gradient recalled echo and coronal t weighted inversion recovery) ( ) . ct is generally performed without intravenous contrast injection with d volume rendering (vr) reconstructions for identification of fractures. in some cases postcontrast images are also obtained specially to rule out deep venous thrombosis especially when children present with nonspecific clinical symptoms. mri protocol should include axial t , t * or susceptibility weighted images, coronal t images, diffusion or diffusion tensor images, and postcontrast dt images including mip reconstructions to evaluate the venous structures. mr venography can also be performed. susceptibility-weighted images are usually preferred because they allow the depiction of smaller hemorrhagic dai lesions and greater number of lesions compared to gre t ( ) . it was also reported by colbert et al ( ) that the presence of micro-hemorrhages alone was useful for outcome prediction in abusive head trauma with significant poor long-term outcome. the sensitivity and specificity of microhemorrhages was also higher than the other clinical (such as retinal hemorrhages and glasgow coma scale score) and other imaging findings for prediction of outcome. diffusion tensor imaging (dti) measurements were reported in abusive head trauma by imagawa et al: decreased axial diffusivity related to axonal injury with consequent reduced mean diffusivity did correlate with poor outcomes ( ) . magnetic resonance spectroscopy (mrs) is usually not part of the standard protocol. however aaen et al ( ) showed that n-acetylaspartate/creatine and/or nacetylaspartate/choline ratios were decreased significantly in the corpus callosum, frontal white matter, parieto-occipital white matter, and parietooccipital gray matter in children with poor outcomes. this study mentioned above also reported that the prediction of outcome was accurate in % of patients by using a logistic regression model that include age, initial glasgow coma scale score, presence of retinal hemorrhage, lactate on mrs, and mean total n-acetylaspartate/creatine. functional mri, ( ) (suppl ):s -s pediatr radiol volumetry may be performed in long-term follow up of victims of child abuse. physical abuse is associated with altered emotion with greater activation in the salience network in response to negative stimuli, that includes amygdala, thalamus, putamen and anterior insula ( ) . increased responsiveness of the right amygdala to fearful and angry faces (negative stimuli) and structural changes as reduced hippocampal volume, are reported by dannlowski et al ( ) . impaired attention was also reported in patients with childhood abuse ( ) with reduced activation during attention tasks in the left hemispheric ventral and dorsolateral prefrontal regions. intracranial injuries include extracerebral hemorrhages and parenchymal damage as brain swelling and ischemia, venous infarction, diffuse axonal injury, contusions and intraparenchymal hematomas ( , ) . extracerebral hemorrhages subdural hematoma is a characteristic finding of inflicted traumatic brain injury, is generally multifocal and most commonly seen along the posterior interhemispheric scissure, over de convexities at the vertex level and/ or in the posterior fossa ( ) ( ) ( ) . subdural hematomas are most likely bilateral but may be unilateral. all locations are related to disruption of bridging veins. the identification of bridging vein rupture allows the diagnosis of traumatism in relation to acceleration/deceleration, rotational and shearing forces due to violent shaking ( ) . a mixed density appearance of subdural hematomas is frequent but is also seen in accidental traumatic brain injury ( ) ( ) ( ) . indeed this feature is often present in the very early hours following trauma and is thought to be secondary to early sedimentation of blood clots and supernatant serum. tubular high density is often seen on non-contrast ct over the convexities in abusive head trauma. this ct feature is related to a clot secondary to venous disruption ( , ) that can end up in thrombophlebitis. this tubular high density was reported more recently as tadpole sign ( ) and lollipop sign ( ) respectively seen in and % of abusive head trauma. this appearance is strongly associated to inflicted trauma and much less frequent in accidental trauma ( out of cases ( , %) of accidental trauma in our experience). associated venous infarction is reported in % of cases of abusive head trauma ( ) and often located in the parieto-occipital region, unilaterally at the site of venous disruption of bridging veins. subdural hemorrhages, when multiple, in the convexity and interhemispheric, or in the posterior fossa were found significantly associated with abusive head trauma in the meta-analysis reported by kemp et al ( ). in addition subdural hematoma, cerebral ischemia, skull fracture, retinal hemorrhage and intracranial injury were significantly associated with abusive head trauma in the review from piteau et al ( ). subarachnoid hemorrhages (sah) and epidural hematomas are also found in inflicted trauma and are not considered discriminant-imaging features. however epidural hemorrhages, isolated skull fracture and scalp swelling were reported as significantly associated with accidental traumatic brain injury ( ). sah in shaking injury is usually caused by tears of the vessels within the pia and arachnoid predominantly in the interhemispheric fissure and high convexity ( ). parenchymal injury parenchymal injury include brain swelling and ischemia, venous infarction (discussed above), diffuse axonal injury related to rotationallyinduced shear-strain injury with different inertia for grey and white matter due to their different specific gravities, contusions seen in deceleration trauma with friction between the skull and brain, and in blunt trauma and intraparenchymal hematomas related to lacerated vessels. brain swelling/ischemia may be related to increased blood volume (congestive swelling), increased presence of water in the nervous tissue, and the combination of both. increased water in the nervous tissue may manifest as vasogenic edema located in the white matter due to extravasation of plasma like fluid related to incompetent blood-brain-barrier and as cytotoxic edema located in the grey matter, related to ionic imbalance. cerebral edema can be recognize on ct within the hours following injury as loss of gray-white matter differentiation and decreased attenuation of grey and white matter. cytotoxic and vasogenic edema are better characterized on mri with diffusion-weighted imaging. brain swelling and edema occur early after trauma with consequent underestimation of subdural hematoma. therefore imaging should be repeated (ct or mri) especially when neurologic symptoms change rapidly. brain swelling/ edema may also involve the posterior fossa and is better identified on brain mri. two frequent patterns have been reported in abusive head trauma ( ). diffuse supratentorial brain swelling (infarction) involving the cortex and white matter was reported in % of cases and is considered as severe hypoxic-ischemic injury with poor outcome ( ). watershed infarction was reported in % of cases and considered a less severe form of hypoxia-ischemia. apparent diffusion coefficient (adc) values are strongly associated with poor neurodevelopmental outcomes in the acute phase (within days) especially basal ganglia, thalamus, brainstem, cerebral cortex, cerebellar vermis, cerebellar cortex and mean total brain ( ). during the early phase up to month adc values in fewer regions (basal ganglia, thalamus, brainstem and corpus callosum) were associated with poor outcome. when patients with and without parenchymal lesions are compared, the detection of diffuse lesions during the first months as well as beyond months is significantly associated with severe developmental outcome ( ). late mri (beyond months after injury) also showed that recovery depends on the extent of brain damage. patients with diffuse lesions show more severe motor and intellectual impairments and are more likely to have blindness and epilepsy than patients with focal or hemispheric lesions ( ). diffuse axonal injury (dai) is related to shear-strain injury of small medullary veins and was reported in % of cases of abusive head trauma ( ). it is encountered in trauma with sudden acceleration-deceleration associated with rotational angular forces and in shaking-impact trauma. the lesions may be hemorrhagic or non hemorrhagic (related to axonal swelling). dai is most often located in the subcortical white matter at the gray-white matter junction, corpus callosum, basal ganglia, brainstem and internal capsule. if the lesions are large enough and hemorrhagic dai may be seen on ct. however dai is usually better identified on mri with susceptibility and diffusion weighted images. the detection of changes in the basal ganglia or brainstem during the first days as well as during the first month after injury is significantly associated with poor long-term outcome in survivors ( ). the presence of intraparenchymal brain micro-haemorrhages detected on swi in children with abusive head trauma correlates with significantly poor long-term neurologic outcome ( ) contusion is also reported in abusive head trauma and is seen in blunt trauma with impact with or without contrecoup contusion. contusions are located at the surface of the brain (crest of gyri) and may be pial and haemorrhagic (disruption of cortical arteries). they are also found in the frontal and temporal regions related to impact of the brain on the roof of the orbit, middle cranial fossa and sphenoid wing. white matter tears are also seen in the frontal and temporal area related to the vulnerability of unmyelinated and soft white matter in infants. skull fractures are seen in blunt impact and are less frequent than long bones and rib fractures in non-accidental trauma. the most common site is the parietal bone (because of bulging of parietal bones below year of age). the fracture may be linear as in accidental trauma. radiologic features significant for inflicted trauma are multiple fractures, bilateral fractures and fractures that cross suture lines ( , ). focal underlying brain damage can be seen such as subdural hematoma and hemorrhagic contusion. hypoxic-ischemic encephalopathy is seen in strangulation injury with involvement of the territories of the internal carotid artery related to their anatomic vulnerability. neuroradiology (ct and mr) is crucial for the diagnosis of trauma, to predict outcome when showing edema and hypoxic-ischemic injury. this presentation will present an update on post mortem mri (pmmr) with relevance to clinical developments over the last years. in particular, reference will be made to diagnostic accuracy of pmmr across different body parts, the current limitations of post mortem mr, and protocol development at different field strengths. imaging correlates of post mortem interval are also being investigated. maceration (autolysis within intrauterine fluid) and perimortem hypoxic brain changes caused difficulties in image interpretation, which more advanced and quantitative techniques may be able to address. jawad take home points: below g, . -t pmmr shows a significant reduction in diagnostic yield, compared with conventional autopsy, and therefore its clinical usefulness in this setting will depend on individual circumstances. t pmmr performs better than . t particularly < weeks gestation, and particularly for the chest, heart and abdomen. diffusion characteristics in different fetal brain areas are multifactorial, with maceration the strongest predictor in most areas. international pm ct protocols c.y. gerrard , o.j. arthurs ; albuquerque, nm/us, london/uk the european society of pediatric radiology (espr) taskforce and the international society of forensic radiology and imaging (isfri) pediatric working group have combined efforts to establish best practice standards for performing perinatal and pediatric post mortem computed tomography (pmct) examinations. use of pmct in the investigation of pediatric death has increased significantly in the past decade. due to quick acquisition times and the ability to acquire thin slice, high detailed images of the whole body, ( ) (suppl ):s -s pediatr radiol many hospitals and forensic institutes have implemented pmct into daily practice. however, there lack an overall standardization of how cases are triaged and the acquisition methods when comparing institutes using pmct. in an effort to address inconsistencies in acquisition parameters, post processing, and case selection, pmct protocols were compiled from international institutes and centres currently performing pediatric imaging. this paper will describe both the uniform and divergent elements of image acquisition and procedural uses identified among the participating centres. the outcome is to provide a single source of information that can guide already established and new centres on the best practice standards for implementing pediatric pmct. take home points: describe how pediatric post mortem computed tomography (pmct) has increased in utility over the past decade. identify the differences in acquisition methods for clinical computed tomography versus post mortem computed tomography. discuss the overall consensus of case triage and scan acquisitions when comparing institutes in aggregate. provide comprehensive statement of best practice standards for pediatric pmct. post mortem imaging research: updates and future proposals o.j. arthurs; london/uk paediatric and perinatal post mortem imaging is a new and rapidly growing field, and the post mortem imaging taskforce was founded in graz at espr . the pmi taskforce aims to help reach consensus and guidance regarding imaging protocols and the potential yield of post mortem ultrasound, ct and mr. the key priorities are the themes of collaboration, image acquisition, best practice guidelines, training and education, raising awareness and access to imaging. this presentation will give updates on the latest developments in perinatal and paediatric imaging, with particular focus on where the pmi taskforce can help. in particular, protocol development is underway, and the espr meeting acts as an opportunity for collaborative working and network development, to facilitate best clinical practice and welcome new members. arthurs oj et al., espr post mortem imaging task force: where we begin. pediatr radiol ( ) ; : - take home points: post mortem imaging is an exciting sub-specialty which requires a combination of in depth fetal medicine, perinatal autopsy and pediatric imaging knowledge to help shape and grow the clinical and research arena. dedicated personnel have an opportunity to create the evidence-based behind a growing clinical service, with clear benefits to patients, families and referring clinicians. abstracts appear as submitted to the online submission system and have not been checked for correctness and completeness. sequences, are an emerging tool for evaluating intracranial vessel disease. improved survival due to emended treatment protocols results in an increasing number of long-term medulloblastoma survivors who experience delayed treatment effects. microbleedings, developement of cavernomas, vasculitis and atherosclerotic lesions are cerebrovascular structures affecting sequelae of the applied radiochemotherapy. this study evaluates radiation-induced intracranial vascular changes. twenty-two long-term pediatric medulloblastoma survivors (mean age . years, range - years; mean years after primary radiochemotherapy . years, range - years) underwent mri. the scan protocol included precontrast -dimensional time of flight (tof)magnetic resonance angiography (mra), precontrast d t -and d t -vwisequences and postcontrast d t -vwi-sequences of the medium and large intracranial arteries. vessel wall thickening, contrast enhancement and luminal narrowing were analyzed. additionally precontrast t -, t -swi and t -weighted images of the supra-and infratentorial brain were acquired. results: vwi-sequences: vessel wall changes could be found in ( %) and patients ( %) of the right and left ica, respectively. for the ba ( %) patients revealed vessel wall changes; for the left and right va ( %) patients were detected with vessel wall changes, respectively. in the tof angiography no alteration of the ica, ba or vas could be identified. in total vessel wall changes for the vertebrobasilar system and the icas could be found in ( %) patients. swi-sequences: all patients ( %) revealed swi lesions, the smallest lesion measuring less than mm, the biggest up to mm. sixteen patients ( %) were presented with lesions > mm, suspicious for cavernomas. to ensure quality of life in long term childhood medulloblastoma survivors, monitoring of long-term effects, like vascular changes after rct is gaining in importance. high resolution mri, including swi and vwisequences could be used here for. this study images, asymptomatic vessel wall alterations in former childhood medulloblastoma patients through vwi sequences and micro bleedings through swi sequences. vessel wall alterations, revealing rct induced arteriosclerosis, can lead to symptomatic intracranial stenosis which is associated with ischemia, furthermore micro bleedings and cavernomas can lead to intracranial hemorrhage. however further studies are needed to standardize mri sequence protocols to ensure a high standard follow up protocol, detecting clinically still asymptomatic vascular changes. fast "black-bone" mr imaging in evaluation of craniofacial abnormalities: comparison with high resolution ct z. habib, a. talib, c. parks, s. avula, l.j. abernethy; liverpool/uk to evaluate the feasibility and diagnostic value of a fast field echo, "black bone" mri sequence in children with craniofacial abnormalities. a fast "black bone" mri sequence has been used in addition to standard brain mri in children (mean age months, age range months to years and months) referred to the supra-regional craniofacial surgery unit at alder hey children's hospital, liverpool, uk. a subgroup of of these patients with complex craniofacial abnormalities additionally had high resolution volume ct performed at the same visit. "black bone" mr imaging was performed on philips ingenia t and . t scanners, using a d fast field echo sequence (tr= . ms, te= . ms, flip angle ). this sequence can be performed with an acquisition time of less than minutes. the "black bone" sequences were assessed for accuracy in evaluating the patency of the sagittal, coronal and lambdoid sutures, and, where applicable, were compared with high resolution ct. the fast "black bone" mri sequence was shown to be technically feasible in all cases. the resultant images successfully demonstrated both patent sutures, which were confidently seen, and prematurely fused sutures which were confidently not seen. visualisation of patent sutures was found to be further enhanced by the use of minimum intensity projection. in the subgroup of patients with complex craniofacial abnormalities, comparison with high resolution volume ct confirmed good sensitivity for patency of cranial sutures. there was complete agreement in out of sutures assessed. the "black bone" mr images were also found to produce good-quality surface-rendered images and were also suitable for -d printing of models for pre-operative planning. fast "black-bone" mri has proven to be technically feasible and to demonstrate cranial suture patency with good agreement with high resolution ct. additionally "black-bone" mri can be used to produce good quality surface-rendered images and -d printed models for surgical planning. main symptom of mucopolysaccharidosis type iva (mps iva) is progressive systemic skeletal dysplasia. this is routinely monitored by cerebral and spinal mri. the vascular system is generally not in the primary focus of interest. in our population of mps iva patients we observed vessel shape alterations of the vertebrobasilar arteries, which has not been described before materials: mri-datasets of patients with mps iva acquired between and were eligible for retrospective analysis of the vertebrobasilar arteries. the vessel length and angle of the basilar artery (ba) and both vertebral arteries (va) were analyzed. a deflection angle between °and °in the vessel course was defined as tortuosity, less than °as kinking. the results were compared to an matched control group of patients not suffering from mps. the deflection angle [°] of the va and ba was significantly decreased in the majority ( %) of mps iva patients (fig. ) mps iva is associated with significantly increased tortuosity of vertebrobasilar arteries. therefore the vascular system of mps iva patients should be monitored on routinely basis, as vessel shape alterations had been associated with dissections, leading to a higher risk of cerebrovascular events. in the pediatric population, intraspinal cysts (arachnoid or neurenteric cysts) are rare lesions mainly located in the thoracic region, whose acute onset is not well described in the literature. ( ) (suppl ):s -s pediatr radiol we present a series of four children seen in the last two years as spinal cord emergencies and discuss the clinical aspects, imaging diagnosis, and management approaches, particularly in the emergency setting. a comparison of our cases with those reported in the literature is also provided. as in other types of spinal cord lesions, mr imaging is the diagnostic procedure of choice, because of its potential to demonstrate the exact location and extent of the cyst and its relationship to the spinal cord, valuable information for planning surgical treatment. this is a retrospective review of cases of pediatric intraspinal cyst occurring in boys and girl, aged to years, treated at our institution between and . onset was sudden in all cases and mimicked transverse myelitis or infarction. all our affected patients had no preceding history of trauma and presented with signs of spinal cord compression-back pain and less commonly abdominal pain-followed by weakness. all patients underwent emergent mr imaging, including t , t , t *, d ciss, diffusion imaging and enhanced t sequences, mainly in the sagittal and axial planes. in each sequence, mr imaging showed a well-defined cystic lesion with signal intensity similar to cerebrospinal fluid, and secondary spinal cord compression that was severe in most cases. blood remnants were not visualized within or around the arachnoid cyst in any patient, which correlated with the absence of trauma antecedents. three of the four cysts were located in an anterior position relative to the spinal cord, and only one was located posteriorly; this latter had an associated subdural effusion. none of our patients had an associated neural tube defect. all patients were urgently treated with cyst wall fenestration or resection. the symptoms improved in all except one patient, whose symptoms did not abate, but ceased to progress. a prompt emergent diagnosis with mr imaging is important, as the symptoms can resolve if surgical treatment is performed before the spinal cord becomes irreversibly damaged. urgent surgery is essential in these cases, particularly if progressive neurological dysfunction develops over the course of spinal cord compression. the outcome following surgical fenestration or excision is excellent in most cases. nevertheless, a long-term imaging follow-up is recommended to detect possible recurrence. the objective of this study was to evaluate the usefulness of multiparametric quantitative mri model for myelination quantification in children. twenty-two children (age range: - , days) were scanned with multiparametric quantitative mri. total volume of myelin water fraction (mwf) (msum), the percentage of msum within the whole brain parenchyma (mbpv), and the percentage of msum within intracranial volume (micv) were obtained. mwf values of brain regions were acquired by drawing regions of interests. the values were fitted to representative models of myelin maturation. spatiotemporal pattern of mwf mapping was visually assessed. values of msum, mbpv, and micv well fitted to a developmental model of myelination. mwf of brain regions well fitted to a developmental model with high r values: pons (r = . ), middle cerebeller peduncle (r = . ), genu of corpus callosum (r = . ), splenium of corpus callosum (r = . ), thalamus (r = . ), frontal white matter (wm) (r = . ), parietal wm (r = . ), temporal wm (r = . ), occipital wm (r = . ), and centrum semiovale (r = . ). mwf mapping followed the known spatiotemporal pattern of myelination. multiparametric quantitative mri is a useful tool for mwf quantification in children. retinoblastoma is the most common intraocular tumour of childhood. it is a highly malignant. retinoblastoma is curable. if detected while still confined to the globe and if there are no metastatic risk factors, the child will nearly always survive following appropriate treatment. our aim is to assess diagnostic accuracy of preoperatively performed magnetic resonance (mr) imaging for detection of tumor extent in patients with histopathologically proved retinoblastoma. local ethics committee approval and informed consent were required for reviewing of patients' images and records. fifty-eight eyes in girls and boys with retinoblastoma (mean age at diagnosis was months ± . ) were reviewed on unenhanced t wi, t wi, and gadolinium-enhanced t -weighted mri with and without fat suppression. mri parameters such as anterior chamber hyperintensity, involvement of choroid, ciliary body, optic nerve, sclera, orbital fat, and pineal gland were determined. maximum tumor diameter was measured and correlated to metastatic risk factors. imaging and pathologic findings were compared. choroidal invasion was suspected with mr imaging in / eyes; findings were false-positive in eyes and false-negative in two (accuracy, . %; sensitivity, . %; specificity, %). mr imaging findings were true-positive in of eyes with proved prelaminar optic nerve invasion ( % sensitivity) and false-positive in ( . % specificity, . % accuracy). postlaminar optic nerve invasion was correctly detected in eyes; eyes were false positive, in other eyes, this metastatic risk factor was missed (accuracy, . %; sensitivity, . %; specificity, %). of nine eyes with histologically proven scleral invasion, eyes were true positive . in the other eyes, scleral involvement was missed on mri (accuracy, %; sensitivity, . %; specificity, %).extraocular fat invasion was suspected on mri in / eyes. of these, findings were truly positive in eyes ( %) and in eye ( %) was incorrect (false positive) (accuracy, . %; sensitivity, %; specificity, %).anterior chamber hyperintensity on t -weighted mr images obtained after contrast agent administration correlated well with main mri and histolopathology findings. tumor size (assessed in our study by the maximum diameter in mm) was statistically associated with postlaminar optic nerve invasion (ρ=. ) and choroidal invasion (ρ=. ). mr imaging shows promising role for tumor staging and detection of metastatic risk factors. tumor diameter, measured with mr imaging, is associated with postlaminar optic nerve and choroidal involvement. patterns of the cortical watershed continuum of term gestation hypoxic ischaemic injurythe "wish-bone sign" a. chacko , s. andronikou , s. vedajallam , j. thai ; east london/za, bristol/uk objective: background partial-prolonged term hypoxic ischaemic injury (hii) involves the cortical and subcortical watershed zones of the brain, which are visually difficult to conceive. new innovative methods of demonstrating watershed cortical atrophy using flattened maps of the brain surface gives added insight into distribution of the watershed zone by demonstrating the entire brain surface. aim determining and validating patterns of hii sustained at birth in term infants using cross-sectional mri and the innovative mercator and scroll map views of cortical surface anatomy, to define the distribution of the watershed zones in children with partial-prolonged injury. one hundred paediatric mri brain scans with an mri and clinical diagnosis of chronic term hypoxic injury were read by radiologists independently. all sites of abnormality were recorded and patterns classified. ( ) (suppl ):s -s pediatr radiol patients with partial-prolonged and combined patterns were evaluated using mercator and scroll map reconstructions, generating schematics of the watershed zone. predominant patterns of disease were partial-prolonged and acuteprofound types. the watershed zone was demonstrated, on the derived maps, representing a continuum of involvement in the shape of a 'wish-bone' extending bilateral from frontal lobes to posterior parietal lobes in band-like fashion along the para-falcine cortex and intersected by another band of atrophy in the peri-rolandic regions extending along peri-sylvian cortices. this is defined in schematics as a visual aid. predominant patterns of injury in term hypoxic ischaemic injury are described and quantified, with the 'wish-bone sign' introduced to describe the typical distribution pattern of partial-prolonged hii in the watershed zone. correlation of brain edema degree and biochemical parameters in pediatric posterior reversible encephalopathy syndrome with hematologic/oncologic diseases t. akbas , s. ulus , b. karagun , t. arpaci , c. kalayci , b. antmen ; adana/tr, istanbul/tr posterior reversible encephalopathy syndrome (pres) often associated with hypertension is characterized by typical transient parietooccipital predominantly brain edema on magnetic resonance imaging (mri) with neurological symptoms such as seizures, headache and visual disturbances. even if endothelial dysfunction, increased blood-brain barrier permeability and hyper-hypoperfusion remain as controversial mechanisms to explain, the pathophysiology of pres is unremain. the aim of our study was to investigate the correlation between brain edema degree on mri and serum biochemical parameters such as lactate dehydrogenase (ldh), albumin (alb), creatinine, uric acid (ua) and urea. a total of pediatric hematology and oncology patients ( male, female, aged - , mean age: years months) diagnosed with pres during treatment and after hematopoietic stem cell transplantation (hsct) were included in this retrospective study. underlying diseases were beta thalassemia (n: ), aplastic anemia (n: ), acute lymphoblastic leukemia (n: ), acute myeloid leukemia (n: ), lymphoid leukemia (n: ) and burkitt's lymphoma (n: ). pres was seen after undergoing hsct in patients. the brain edema degree according to specified anatomical regions on fluid attenuation inversion recovery (flair) mri sequence was scored by two radiologists blinded to patients' records. the levels of serum biochemical parameters at onset of symptoms were correlated with score of brain edema degree on mri. serum ldh concentration was statistically correlated with the score of brain edema degree (spearman's rho correlation, r= . , p= . ). no relationship was found between other biochemical parameters and the score of brain edema degree. our results suggest that increased serum ldh as a marker of endothelial dysfunction is the main biomarker for development of brain edema in pediatric pres patients under treatment and after hsct with underlying hematologic and oncologic diseases. objective: gadolinium based contrast agents (gbcas) have been associated with increasing signal intensities in deep brain nuclei on unenhanced t -weighted brain imaging. until now, most studies have been performed in adults, while results on pediatric patients are sparse. therefore, the aim of this study was to evaluate if there is any difference between signs of gadolinium retention in pediatric and adult patients. in this irb-approved, single center retrospective study, we extracted all patients with at least contrast-enhanced mris archived on pacs between - . all patients with gadobenate dimeglumine only enhanced mris were reviewed. seventy-six pediatric patients with the most injections and adult patients with the most injections were included in the final evaluation. therapies were documented. t signal intensity measurements for the initial and last unenhanced brain mris were performed for dentate nucleus, pons, globus pallidus and thalamus. signal intensity ratios for dentate-to-pons (dnp) and globus pallidus-to-thalamus (gpt) were calculated and correlated with number of injections and time interval as well as therapy. differences between adults and pediatrics were assessed. mean age for the pediatric group was . years compared to . years in the adults. no significant difference was found for gender distribution ( vs. % females) and follow up time ( . vs. years). there was no difference concerning the signal intensities on first and last mri in children and adults (p= . / . , respectively). for each additional year of follow-up the change in ratio increases by . for adults but only . for peds (p= . ). comparing therapies, in children a statistically significant difference between patients with and without former radiation was found (p< . ) while there was no difference in adult patients with and without therapy (p= . ). children and adults show a similar increase in t signal in deep brain nuclei ascribed to gadolinium deposition. in children, radiation and chemotherapy) seem to have a higher influence on gadolinium deposition. this correlation cannot be found in our adult cohort, indicating therapies have no (additional) influence. kearns-sayre syndrome (kss) is a rare mitochondrial dna-deletion syndrome characterized by early onset (< years), progressive external ophthalmoplegia and pigmentary retinopathy, often associated with cerebellar ataxia, muscle weakness, bilateral sensorineural hearing loss and cardiomyopathy. pyramidal symptoms may be present in kss, but they are poorly reported in the literature. through this case series, we aim to evaluate the concordance with the imaging patterns proposed by literature, correlating them with clinical and laboratory data, and to investigate possible microstructural damage with diffusion tensor imaging (dti) and magnetic resonance spectroscopy (mrs). we evaluated eight patients ( - years of age) with genetically confirmed diagnosis of kss. all pts. were studied with t/ . t mri. in / pts. the study was completed by mrs and in / by dti imaging with reconstruction of cortico-spinal tracts (cst) using a -rois approach. a t-test comparative study between mean fractional anisotropy (fa) of cst in the kss patients with dti and a group of healthy controls was performed. cst reconstruction in a patient suffering from kss (images a-c), compared to an healthy control (images d-f). the dti study showed significantly reduced fa values, pointing out a possible microstructural damage. the disease showed an mr pattern of mixed white and gray matter signal abnormality, with periventricular and/or subcortical white matter hyperintense lesions, which in / patient presented a "tigroid pattern" (fig. ) three patients displayed a disease extension to the cervical spinal cord. (fig. ) dwi images demonstrated restricted diffusivity in almost all lesions (fig. ) , with persistence of low adc values. mrs study documented a high lactate peak in / pts. and a naa reduction in / pts; an increment of gsh was noted in one patient (fig. ) . the t-test comparative study of cst showed a significant reduction of mean fa value in kss patients compared to healthy controls (p= , ). involvement of the spinal cord (a-c, yellow arrows). comorbidity was suspected in "a" (myelitis). below (d-f): pale nuclei (d, green arrows) and subcortical white matter (e) alterations. right image displays the "tigroid pattern" (purple arrow). mrs showing the presence of a gsh peak, which may suggest an augmented antioxidative activity within the encephalic tissue. below: dwi hyperintensity in many regions of the brain in patients suffering from kss, due to diffusion resctriction. the integration of neuroimaging with clinical data can implement the diagnosis of mitochondrial diseases such as kss. according to our experience, comorbidities can delay the achievement of a correct diagnosis. the finding of an altered signal in the spinal cord of / pts. may suggest a new possible localization of the disease, while in one patient was referable to myelitis (fig. , a) the evidence of a "tigroid patter" in should be taken in count in the differential diagnosis with lysosomal disorders. the presence of a prominent gsh peak may represent an augmented antioxidant activity, which may correlate with a more favorable outcome. an involvment of cst can be speculated even if pyramidal symptoms are poorly represented in kss. remotely distractible, magnetically controlled growing rod (mcgr, fig. ) system has been developed to allow for gradual lengthening on an outpatient basis. this allows for safe spinal lengthening with continuous neurologic monitoring and real-time feedback by the patient. this study aims to evaluate retrospectively our ultrasound (us) geometric method and his accuracy compared with the plain radiograph (gold standard) for assessing mcgr distractions. this is a retrospective study that includes patients with early-onset scoliosis undergoing multiple consecutive distractions after mcgr implant. the rods length was measured for with us, for each distraction ( -months interval), and compared with plain radiograph follow-up ( -year interval). all patients included were treated with dual-rod systems. distraction length was monitored by a senior radiologist with us at each visit, one rod at a ( ) (suppl ):s -s pediatr radiol time, before and after magnetic lengthening, with our geometric measurement method (fig. ) . low-dose upright two-projections radiograph were taken immediately after surgery and at -year intervals and measured by two radiologists ( and years of experience respectfully) (fig. ) . we compared measurements with the wilcoxon signed-rank test. from january to october , a total of patients ( females and male), which diagnoses included mitochondrial encephalopathy syndrome (n= ), spina bifida (n= ), ataxia of unknown cause (n= ), juvenile idiopathic scoliosis (n= ) and trisomy (n= ), with a mean of distractions per patient (standard deviation [sd] ± , ), were recruited. fifty distractions for each system ( measurements in total) were performed, targeting different lengths of distraction (from - . mm to + . mm) on each occasion. a total of sets of plain radiographs were taken. from these, sets of data points were used for correlation analysis. the mean distracted length per year on plain radiographs was , mm (sd ± , mm) and the mean distracted length on us per -months interval was , mm (sd ± , mm). excellent correlation was observed between radiographic and ultrasound measurements. in particular, correlation between rx measurements and ultrasound was excellent both for junior ( . <p< . , w= ) and senior radiologist (p< . , w= , ). there were no rod's breaches identified neither in ultrasound or radiographs in this series. the measured changes in rod length between the two imaging modalities were highly correlated. thus, ultrasonography is at least as accurate as radiographs in measuring changes in rod length. our geometric measurement method adds reproducibility to an effective, non-ionizing and lowcost procedure for monitoring distraction of mcgr in children population. refuting child abuse denialistshealing rickets is clearly different from child abuse metaphyseal fracture a.e. oestreich; cincinnati/us objective: child abuse denialists, who testify against the diagnosis of child abuse, often claim that radiographic findings generally recognized by pediatric radiologists as likely due to abusive trauma are instead a consequence of rickets, including healing rickets. in particular, bucket handle transverse bony density at metaphyses are declared by some denialists to be identical to the pattern of healing rickets. i demonstrate by reviewing the details of these different patterns that this is an incorrect declaration. additionally, concave distal ulna margins alone are not a sign of rickets. rickets is radiologically distinct from classic metaphyseal fractures. i reviewed medicolegal documents and published articles by several well known physicians who claim that certain children suspected of having suffered child abuse instead demonstrate rachitic bone disease. their statements and images in support of their opinions are critically reviewed and contrasted with known examples of rickets, including healing rickets. at the physeal region of long bones in rickets, the zone of provisional calcification (zpc) is not calcified and the normal metaphyseal collar shaftward from that zone is not maintained. in metaphyseal fractures from abuse, the zpc and collar are maintained. in early healing rickets, the zone of provisional calcification calcifies first, giving a transverse calcification separated from the already ossified metaphysis. this calcification is different from a bucket handle fracture pattern without signs of rickets. moreover, concave distal margin of the ulna without other signs of rickets is seen in about % of normal infants. repeatedly, denialists have testified against the diagnosis of child abuse, claiming rickets in the absence of radiographic evidence -i critique one well known child abuse is a serious diagnosisclaiming by denialists of an alternate diagnosis, such as rickets, when radiographically no rickets is present, should be refuted. a clear understanding of the differences between abuse fractures and rickets is obligatory. when no rickets is seen at other growth sites, including seeing the presence of zones of provisional calcification, rickets is not present. simultaneous multi-slice turbo spin echo: a -fold time-saving alternative to conventional tse in mr imaging of the pediatric knee s. benali, a. gholipour, p.r. johnston, s.d. bixby; boston/us objective: simultaneous multi-slice (sms) is a novel iteration of parallel imaging in mri that reduces acquisition time at least two-fold over conventional turbo spin echo (tse) acquisitions. the aim of this study is to determine whether -dimensional ( d) sms tse can replace conventional d tse in imaging of the knee in pediatric patients without compromising diagnostic quality. this was an irb-approved retrospective study. subjects included all pediatric patients referred for routine -tesla mri of the knee between october through december . mri examination consisted of institutional basic protocol with both traditional t tse and sms t tse in axial and sagittal planes with fat suppression. two anonymized study folders were created for each subject, one containing all basic sequences (basic exam), and one in which t tse sequences were substituted with t sms sequences (sms exam). two pediatric radiologists independently and blindly reviewed each study and noted presence or absence of pre-determined abnormalities (table ) . discrepancies between radiologists were settled by consensus. qualitative assessment was performed using a likert scale to evaluate edge blurring, contrast resolution, image noise, and flow artifact. thirty-five subjects comprised the study population (mean age . years, range - , female, male). diagnostic performance was assessed by comparing findings (table ) from basic exam to sms exam based on absolute agreement and cohen's kappa statistic. for all findings, the proportion of absolute agreements between basic and sms exam was > . for reader , > . for reader , and . for consensus between readers. kappas for consensus reads were . on all structures (p< . , lower % confidence limit > . ). for reader , kappas were . for / structures (p< . ) and . for pcl. for reader , kappas were . for / structures (p< . ) and . for cartilage defects. paired t-test was used to compare mean likert scores for image quality characteristics. for both readers, sms was preferred for flow artifacts whereas tse was preferred for the three remaining image quality characteristics (p< . ). our primary assessment suggests that sms t tse is comparable to standard tse in terms of diagnostic performance in the evaluation of the pediatric knee despite modest decrease in overall image quality. the -fold decreased acquisition time of sms is a significant advantage which is felt to offset the mild decrease in image quality, particularly as it increases the likelihood that children will tolerate the examination without motion. mri for sacroiliitis in children: panel findings and inter-observer evaluation using standardised reporting k.e. orr , m.j. bramham , s. andronikou ; plymouth/uk, bristol/uk there is little evidence regarding mri for diagnosing sacroiliitis in children with juvenile idiopathic arthritis (jia). the limited literature presents varied opinions but no published recommendations for standardisation of reporting. axial disease in jia responds poorly to conventional first-line treatments but identifying these children using history and examination findings is unreliable. standardised mri reporting ( ) (suppl ):s -s pediatr radiol may improve diagnosis and selection of patients in whom newer biologic treatments are indicated. the aim was to use a standardised reporting proforma based on published definitions for recording mri findings in suspected sacroiliitis to evaluate inter-observer agreement and determine the reliability of findings according to specific sequences. ninety-nine sacroiliac joint mris ( joints) were included, were initial examinations and were follow-up mris. the age range was between . and . years (mean age . years). three readers retrospectively reported all mris using the standardised proforma. 'reader ' was the study group panel while readers and were specialist paediatric radiology consultants working in the united kingdom. readers were blinded to additional clinical information and other imaging. inter-reader variation was evaluated for the presence of bone marrow oedema, erosions, effusions, ankylosis, sclerosis and enhancement, as well as the presence or absence of sacroiliitis. the quality of mri examinations was evaluated, including presence and adequacy of sequences performed and alignment of the coronal/oblique studies. mri findings were correlated with clinical details and final diagnosis. there is significant variability in sacroiliac joint mri protocols. refinement of these to include only necessary sequences based on inter-reader reliability and reinforcement of good positioning will improve reporting and result in universal standardisation. there is inconsistency in current reporting practice of sacroiliac joint mri in children but increasingly, clinicians rely on imaging to select patients with sacroiliitis and guide appropriate treatment. using a standardised reporting proforma may improve the quality and consistency of reporting. ultrasound-guided steroid tendon sheath injections in juvenile idiopathic arthritis s. peters, d.a. parra; toronto/ca objective: juvenile idiopathic arthritis (jia) is the most common chronic rheumatic disease in childhood. tenosynovitis is one of the manifestations of jia, which can explain the absence of response to treatment when adjacent joints are injected. steroid injection is one of the treatment options for tenosynovitis and it has been shown to be effective in the literature. utilizing ultrasound (us) guidance for injections into tendon sheaths has shown clinical advantage to conventional blind injections in the adult rheumatoid arthritis population. the aims of this study are to: (a) identify tendon sheaths most commonly treated in our patient population with jia referred for steroid injections; (b) describe technical aspects of the procedure; (c) characterize sonographic appearance of tenosynovitis in jia; (d) assess agreement between clinical request and sites injected. this was a year single-center retrospective study ( may -april in which we recruited patients with jia referred by rheumatology for us-guided tendon sheath injections. we collected patient demographics, clinical assessment information, sonographic appearance of the tendons and technical aspects of the intervention from the procedure records. we collected data from visits of patients ( % female, mean age years months) with a total of injections. the ankle region was most commonly injected ( %), specifically the tendon sheaths of tibialis posterior ( %), peroneus longus ( %) and brevis ( %). % of the procedures were performed under general anesthesia and triamcinolone hexacetonide was used in % of the injections. an "out of plane" approach was used in % of the interventions and the mhz "hockey stick" us probe was preferred for guidance ( %). we found minor intra-procedure complications without sequelae. the majority of treated sites ( %) showed peritendinous fluid and sheath thickening on us. other findings were increased color-doppler signal and echogenic peritendinous fluid. a strong agreement between clinical request and sites injected was observed and most patients required one visit ( %). us-guided tendon sheath injections are used frequently to treat patients with jia. it is a safe intervention with a high technical success rate. the ankle region, specifically the medial compartment, is the area most commonly injected in this cohort of patients. the most common sonographic finding is peritendinous fluid and sheath thickening. these findings might assist radiologists and rheumatologists to characterize and more effectively manage tenosynovitis in patients with jia. to evaluate the accuracy of the software for automatic bone age (ba) estimation based on deep learning technique, and to validate the feasibility of this system in clinical practice. the software for automatic ba estimation was developed based on deep learning technique using , left hand radiographs and estimated ba of each radiograph based on greulich-pyle method. ba estimation was done for left hand radiographs of consecutive patients ( months - years; boys and girls) in three methods: ( ) ai bone age (assessed by the software), ( ) ai-assisted ba (assessed by two radiologists with the assistance of the software), ( ) gp atlas-assisted ba (assessed by two radiologists with only gp atlas but the software). the reference ba was determined by two radiologists by consensus. the accuracy of the estimated ba by each method was assessed using concordance rate (%), pearson's correlation analysis, the root mean square error (rmse), and bland-altman plot. reading time for ba estimation by each method was evaluated. ai bone age showed % of concordance rate, and a significant correlation with reference ba (r = . , p< . ). the bland-altman plot of agreement between the reference ba and ai bone age showed the mean difference of - . years ( % limit of agreement, ± . years). rmse was . years. in reviewer , concordance rates were same between both gp atlasassisted ba and ai-assisted ba ( %), and rmse of ai-assisted ba ( . ) was slightly lower than that of gp atlas-assisted ba s ( ) (suppl ):s -s pediatr radiol ( . ). in reviewer , concordance rate was slightly higher in aiassisted ba ( %) than gp atlas-assisted ba ( %), and rmse was almost the same ( . in ai-assisted ba, . in gp atlasassisted ba). the reading time was reduced . % in reviewer and . % in reviewer . the software for automatic ba estimation based on deep learning technique showed high accuracy and may enhance work efficiency in ba estimation by allowing radiologists to save reading time and to improve accuracy. temporomandibular joint mri findings in adolescents with primary disk displacement in comparison to those in juvenile idiopathic arthritis j. bucheli, d. ettlin, c. kellenberger; zurich/ch to investigate potential differences of morphology and degree of inflammation in temporomandibular joints (tmjs) affected by primary anterior disk displacement (add) and juvenile idiopathic arthritis (jia). in adolescents ( female, age ± y), contrast enhanced magnetic resonance images (fig. a) of tmjs with add were retrospectively compared to those of age-and gender-matched controls with jia. morphology of articular disk and bony structures were described. osseous deformity and inflammation were qualitatively scored with progressive -grade scales and compared between groups with mann-whitney-u test. mandibular ramus length, measured on gradient echo minimum intensity projection images (fig. b) , was compared between groups and to normal values with independent samples t-test. in the add-group, / disks were dislocated anteriorly and showed thickening of the posterior band ( / ). in contrast, tmj disks of jia patients were mainly flattened (n= ) and/or centrally perforated (n= ) and rarely dislocated (n= ). tmjs with add showed similar overall grades of inflammation (p= . ) and osseous deformation (p= . ) as tmjs in the jia group. while erosions were frequent in both groups (add / ; jia / , p= . ), the mandibular condyle (p< . ) and glenoid fossa (p< . ) were less flattened in tmjs with add. in add tmjs, bone marrow oedema was less frequent (p= . ) and grades of joint enhancement slightly lower (p= . ), but presence of synovial thickening (p= . ) and degree of effusion (p= . ) were not significantly different between groups. mandibular ramus length was not significantly different (p= . ) between groups, but in both groups clearly decreased compared to mean normal values (p< . ). articular disks in tmjs affected by jia are rarely dislocated. surprisingly, tmjs with primary add show considerable inflammatory change including condylar erosions. still, chronic systemic inflammation in jia joints results in considerable higher deformity of the mandibular condyle and the temporal joint surface. observation of the mostly preserved normal shape of the temporal bone may help differentiating primary add from jia. retrospective magnetic resonance imaging (mri) study of consecutive jia patients ( female, median age y) with at least two consecutive tmj mri examinations ≥ y apart and no csi. degree of tmj inflammation was determined on t -weighted and contrast-enhanced t weighted fast spin echo images (fig. a) , and degree of osseous deformity on gradient echo images (fig. b) by progressive -grade scales ( - ). change of respective grades was assessed with wilcoxon test. mandibular growth was determined by ramus length change and compared to normal values. over a median period of . y (interquartile range, . - . y), degree of tmj inflammation improved (p< . ) with decrease in frequency of grade ( . % to %) and grade ( . % to . %). inflammatory grades improved both in patients with (n= , p= . ) and without (n= , p= . ) systemic disease modifying medication. the degree of osseous deformation slightly improved (p= . ), with decrease in frequency of grade ( . % to . %) and grade ( . % to . %), and increase of grade ( % to . %). overall growth rates of mandibular ramus (median, . mm/y) were not significantly different from normal growth rates (p= . ) (fig. c) . growth rates of tmjs from patients only receiving non-steroidal anti-inflammatory drugs (median, . mm/y) were not significantly different (p= . ) compared to patients treated with systemic disease modifying drugs (median, . mm/y). in patients with systemic treatment of jia, both the degree of tmj inflammation and osseous deformity as seen on mri improved at midterm follow-up. normal growth of the mandibular ramus was maintained. these results are in contrast to those from an earlier cohort treated with csi, in which on average deformities deteriorated and growth was impaired. objective: pediatric ileocolic intussusception, ici, is a common abdominal condition for which pediatric radiologists are asked to attempt emergency pneumatic reduction. because of the high success and low complication rates of pneumatic reductions, radiologists are able to make several attempts at reduction in stable patients if the initial enema attempt is unsuccessful. we have observed patients with successful reductions with rather long periods between initial symptoms of ici and performance of the air enema. we hypothesize that successful pneumatic reduction rates are independent of length of symptoms and in stable patients, repeated reduction attempts can be performed with the expectation of successful reduction. we performed an irb-approved retrospective review of all ici with a pneumatic reduction attempt between - at xxx. clinical, imaging and surgical data was reviewed. time to enema was defined as the time from first symptom to first air enema attempt. linear and second order polynomial statistical analysis was performed to assess the relationship between time to enema and enema outcome. results: ici were identified in patients. air enema was successful in ici, %. the mean time to enema was . hours, range - hours with sd of . hours for successfully reduced ici and . hours, range - hours with sd of . hours for unsuccessfully reduced ici. surgical resection was required in patients with ischemic bowel including one with an irreducible meckel's diverticulum as lead point. there was no correlation between time to enema and successful reduction, fig . no patient with a successful pneumatic reduction of a ici required subsequent bowel resection. conclusions: air enema for ici can be safely performed despite prolonged time to enema with the anticipation of a successful reduction. the lack of correlation of pneumatic reducibility and time to enema suggests that in surgically cleared patients with ici, the pneumatic reduction attempt may not be a true emergency and that repeated attempts at reduction are safe. additionally, though our numbers are small, they suggest that an ici is reducible or not from the beginning and do not "become irreducible" with prolongation of the time to enema. evaluation of splenic stiffness measurements for the diagnosis and the follow-up of portal stenosis after paediatric liver transplantation c. escalard , a. dabadie , s. chapeliere , d. pariente , c. adamsbaum , s. franchi ; le kremlin-bicêtre, paris/fr, la timone, marseille/fr to report our preliminary findings about the role of splenic and hepatic supersonic shear-wave elastography (sswe) in the diagnosis and followup after treatment of portal stenosis in paediatric liver graft recipients. all paediatric liver recipients with portal stenosis treated by the interventional radiology procedure, and who underwent splenic and hepatic sswe pre and post interventional procedures, were retrospectively reviewed. demographics, data about the portal stenosis (delay post transplantation, clinical presentation, initial radiological findings, hemoglobin and platelet counts), ir procedure performed, clinical and ultrasonographic follow-up and spleen stiffness pre and post ir procedure were collected. four patients were included, median age , years (range , months to years) and median delay post transplantation , years (range month to . years). two patients presented with anemia, associated in one case with progressive splenomegaly. one patient had liver test abnormalities, and one had decreased portal flow found on systematic doppler followup. spleen stiffness was elevated pre-procedure in all patients, from to kpa (normal < kpa), and liver stiffness was normal or mildly elevated in all. portal stenosis was successfully treated by ir in patients. spleen stiffness decreased rapidly, ranging from to % (figure ) . however, the size of the spleen remained unchanged. in the last patient, angioplasty of the portal stenosis failed leading to portal thrombosis. spleen stiffness increased on the subsequent ultrasound ( figure ). mr elastography (mre) is a novel imaging technique that provides a non-invasive evaluation of liver fibrosis. the standard sequence used for this purpose on a siemens scanner has been gradient echo (gre). we also implemented echo planar imaging (epi) available as a work-in-progress (wip). our aim is to compare the liver elastogram values between gre and epi in children. after consent from both research and referred clinical subjects, a dedicated mre of the liver was performed on a t mr scanner (magnetom® skyra, siemens) with a pediatric mechanical driver over the right upper quadrant. an axial t blade with fat saturation, coronal t vibe dixon and axial diffusion weighted imaging (dwi) were obtained. elastograms were obtained using both standard gre and epi, in the axial plane. for the gre sequence, different slices were selected and each scanned sequentially. the epi sequence incorporated different slices in just one series. images were post-processed placing regions-of-interest (roi) and measuring the stiffness in kilopascals (kpa). for each sequence and each slice the mean stiffness and then the average of the means was calculated. a spleen elastogram was simultaneously generated, without changing the mechanical driver location, and the mean stiffness was also calculated. increased stiffness was defined as > . kpa in the liver and > . kpa in the spleen. we focused on a technical comparison between the sequences without clinical or histological correlation of findings. we included subjects that had elastogram measurements of liver and of them spleen stiffness on both gre and epi sequences. mean liver stiffness on gre was . (sd+/- . ) and on epi was . (sd+/- . ), with a pearson's correlation of r= . (p< . ). increased liver stiffness was found in / ( . %) of the cases in gre and / ( %) of the cases in epi. mean spleen stiffness on gre was . (sd+/- . ) and on epi was . (sd +/- . ) with a pearson's correlation of r= . (p= . ). epi reported consistently higher values than gre in both liver and spleen stiffness. our preliminary data shows a moderate to high correlation between gre and epi sequences; however, the epi values were higher in both liver and spleen. in the future, larger studies are needed to validate these thresholds and patterns among different sequences. were also reviewed if done. patient's medical & surgical treatment, and clinical progress were also reviewed. active telephone follow-up days after cevus was performed. results: patients giving a total of pelviureteric units were referred for vus study during the study period, with age ranging from month to years old. no contrast-related complication was encountered. except cases with failed catheterization, were investigations of urinary tract infection (uti), antenatal hydronephrosis and congenital anomalies etc., and remaining were follow up studies of known reflux. of all cases of uti, refluxing units were picked up by vus, ranging from grade i to v. of the refluxing units diagnosed by cevus, were missed on mcu, among which were high grade refluxes (grade iii to v) requiring treatment; whereas cevus only missed one grade i refluxing unit detected by mcu. besides, one grade iv refluxing unit identified on vus was under graded by mcu to grade i. regarding patient outcomes, one patient with mcu-missed refluxing unit presented with breakthrough uti on follow up. two refluxing units that were missed on mcu but detected on cevus demonstrated scarring on dmsa. conclusion: cevus is shown to be more sensitive in detecting vesicoureteric reflux than mcu. the fact that mcu-missed refluxes detected by cevus were associated with breakthrough urinary tract infection and scarring on dmsa indicated that the extra sensitivity brought by cevus did translate to clinical significance. difficulty in visualizing low-grade reflux is a potential limitation of this technique. with favourable diagnostic performance and safety profile, cevus can be further applied in this community in the era of radiation reduction. percutaneous transbiliary needle or forceps biopsy in hepatic masses with biliary dilatation a. dabadie , s. franchi , d. pariente ; la timone, marseille/fr, le kremlin-bicêtre, paris/fr hepatic masses with biliary dilatation are rare in children and mainly include rhabdomyosarcoma of the biliary ducts, but also other masses or pseudo-masses compressing the hepatic hilum. in these patients histological diagnosis of the lesion as well as temporary biliary drainage are warranted. the objective of this study is to report our experience in percutaneous transbiliary biopsy performed simultaneously and using the same access as the percutaneous biliary drainage in children with hepatic mass obstructing the biliary ducts. children presenting with a hepatic mass causing biliary obstruction, with need for biliary drainage, were considered candidates for percutaneous transbiliary biopsy of the lesion performed at the same time. the biopsy was performed under ultrasound guidance, through a sheath introduced in the dilated biliary system, using a semi-automatic gauge needle or the transluminal biliary biopsy forceps set (cook medical, bloomington, usa). between and , four patients were included, three females and one male, median age . years (range . - . ). all presented with jaundice and were diagnosed with a hepatic mass with secondary biliary obstruction. percutaneous transbiliary biopsy was performed in all patients using the gauge needle. in one patient, the biopsy did not demonstrate any tumoral cells and a second biopsy was performed using the forceps device through the same biliary access. the samples deemed adequate for analysis by the pathology department in all patients, however the samples were larger when using the needle. a retrospective -prospective study included patients of both sexes ( , +/- , y), in a two-year span. patients were divided into two groups according to the used diagnostic method (positivegroup a on us and a on mri, with intestine mural thickness above mm, and negativegroup b on us and b on mri, with mural thickness below mm). overall sensitivity and specificity of us and mri in diagnosing ibd was calculated in comparison to pathohistological (ph) findings. us examination showed an average intestinal mural thickness of . ± . mm and . + . mm in group a ( patients) and group b ( patients) respectively. mri examination showed an average intestinal mural thickness of . ± . mm and , + , mm in group a ( patients) and group b ( patients) respectively. out of patients from group a, ( %) had irregular mural architecture, contrary to group b in which mural architecture irregularities have not been observed. in groups a and b ( . %) and ( . %) patients had irregular mural architecture respectively. average length of affected intestinal segment on us and mri was mm and mm respectively. five patients from group a and four from group a had signs of fibrosis. color doppler showed hyperemia in and patients of group a and a respectively. transmural signs of inflammation were found in % of patients on us, and . % of patients on mri. average longer diameter of mesentery lymph nodes measured by us and mri was . ± . mm and . ± . mm, respectively. overall sensitivity of us and mri was . % and . % respectively. both us and mri showed a specificity of %. us and mri are reliable and compatible methods in diagnosing ibd, with mri being slightly more accurate. us is an extremely valuable and widely available imaging modality in every-day clinical work, both in diagnosing and follow-up of therapy effects in children with ibd. findings in percutaneous transhepatic cholecysto-cholangiography in neonates and young infants presenting with conjugated hyperbilirubinemia d.a. parra, s. peters, j. amaral; toronto/ca objective: conjugated hyperbilirubinemia is a concerning finding in neonates and young infants, biliary atresia (ba) being one of the main diagnostic considerations. ba is a rare disease characterized by fibrosis of the biliary tree. the obliteration of the biliary system leads to cholestasis and ultimately liver parenchymal injury, cirrhosis and death. an early diagnosis of ba along with a kasai portoenterostomy operation significantly improves the long-term prognosis. percutaneous transhepatic cholecysto-cholangiography (ptcc) is one of the options described in the diagnostic algorithm of ba. the aims of this study are to: (a) describe ptcc findings in patients with conjugated hyperbilirubinemia; (b) identify the abnormal patterns encountered that justify further investigations; (c) analyze technical aspects of the procedure. this is a year single-center retrospective study ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in which we recruited patients with the diagnosis of cholestasis (less than months old) referred for ptcc. we collected patient demographics, clinical information, findings in ptcc, post-procedure management and long term clinical outcome. eigthy-nine patients were referred for ptcc in the study period. the procedure was technically feasible and successfully performed in patients ( % male, mean age . months). forty-one had a pre-procedure hida scan suggestive of ba. fifty-nine patients had an ultrasound-guided biopsy in conjunction with the ptcc and in all of them the cholangiography was performed through a needle placed using ultrasound guidance in the gallbladder. % ( ) of the patients had a normal ptcc. abnormal patterns encountered were: ) variable degrees of hypoplastic bile ducts seen in %; ) atretic gallbladder without demonstration of communication with bile ducts seen in %; and ) gallbladder communication with a cystic structure not communicated with the biliary ducts (cystic biliary atresia) seen in %. the most common diagnosis in the abnormal group was ba ( %). alagille's syndrome, alpha- antitrypsin deficiency and progressive familial intrahepatic cholestasis were other diagnoses in this group. no complications related to the procedure were observed. ptcc is a safe and effective option in the diagnostic algorithm of patients presenting with cholestasis early in life. visualization of the gallbladder is fundamental to perform the procedure. the majority of studies were normal in our patient population preventing further invasive investigations. three types of abnormal ptcc patters were encountered, with ba being the most common diagnosis in this group of patients. to evaluate the additive role of shear wave elastography in the sonographic distinction of biliary atresia from other causes of neonatal/ infantile cholestatic liver disease. neonates and infants with clinical and biochemical diagnosis of cholestatic jaundice were enrolled in our study after obtaining informed written consent from the parents. grey scale, doppler and shear wave elastographic findings were recorded after hours of fasting using aixplorer® ultrasound system (supersonic imagine, aix en provence, france). sedation was not needed during the study. for obtaining elastographic values, linear transducer ( - hz) was used and after image stabilization a q-box measuring mm was placed in the most homogenous vessel free area. the mean of three elastographic values were recorded. hida scan, liver biopsy, intra-operative cholangiogram and histopathological evaluation of resected specimens was done wherever feasible and clinically indicated. the prospectively obtained elastographic values were retrospectively evaluated. eleven of patients included in our study were proven to be biliary atresia (ba) by intra operative cholangiogram and histopathological reports. the diagnosis in the remaining patients included other causes of infantile cholestatic jaundice like infantile choledochal cyst, neonatal idiopathic hepatitis, progressive familial intrahepatic cholestasis, abernathy malformation, cmv hepatitis etc. the elastographic values of ba and non-ba patients were compared. six of infants were younger than days which included four patients with ba and their elastographic values ( . ± . kpa) were significantly different from that of non-biliary atresia ( ± kpa) in the same age group (p value < . ). similarly, for patients aged > days also we had a significant difference (p value < . ) in elastographic stiffness between ba ( . ± kpa; n= ) and non-ba ( . ± . kpa; n= ) groups. the mean echogenic area anterior to right portal vein (earpv) was . ± . mm in ba and . ± . mm in non-ba group (p value < . ). the mean gall bladder (gb) length was . ± . mm in biliary atresia group in contrast to . ± . mm in the rest (p value < . ). the roc plot for earpv and gb length gave a youden index cut off value of > . mm (sensitivity . & specificity . %) and < . cm (sensitivity & specificity . %) respectively. infants with biliary atresia have a significantly higher elastographic value when compared to age matched patients with other causes of neonatal cholestasis. we expect to validate the findings in our ongoing study with a larger sample size. to retrospectively define in a large pediatric population the association between testicular microlithiasis and testicular neoplasia. retrospective multicenter study of scrotal ultrasounds performed between january and april in subjects < years of age. all unique subject scrotal ultrasound reports from each institution were reviewed for mention of microlithiasis. for subjects with serial exams, the most recent exam performed was included in the analysis. all exams mentioning microlithiasis were reviewed by site-specific investigators to confirm the presence of ≥ punctate calcifications in the testicle on a single image. the presence of testicular germ cell and stromal tumors were determined for subjects with and without microlithiasis through review of institutional pathology and imaging databases. the risk of testicular neoplasia in the context of microlithiasis was expressed in terms of odds ratios with (a-or) and without adjustment (u-or) for fixed study site (institution) effects by logistic regression. the study population included , unique subjects with confirmed microlithiasis in , ( . %). mean subject age was . ± . years for subjects with microlithiasis and . ± . years for subjects without (p< . ). one hundred thirty-nine subjects ( . this large, multicenter study confirms that there is a significant, strong association between testicular microlithiasis and testicular neoplasia, particularly malignant germ cell tumors. children with microlithiasis have approximately x greater odds of having a malignant germ cell tumor than children without microlithiasis. this reinforces the need for a large prospective study assessing the risk of developing testicular neoplasia in children with incidentally identified diffuse microlithiasis. do adc-values reflect renal function or obstruction in children with uretero-pelvic-junction obstruction? p. grehten, a.c. eichenberger, c. kellenberger; zurich/ch the use of diffusion weighted imaging (dwi) in renal mri is increasing. in adults as well as in infants a positive linear correlation between adcvalues and glomerular filtration rate has been demonstrated. the aim of our study was to assess whether renal dwi can provide information on the grade of urinary tract obstruction or renal function in children with uretero-pelvic-junction (upj)-obstruction. retrospective analysis of children (age . +/- . y) with unilateral upj-obstruction who underwent pre-and postoperative mri at . t and normal controls (age . +/- . y). functional mr-urography and multiple b-value dwi were part of the mr-protocol. renal adc-values were correlated to measures of obstruction and function, and compared between obstructed and non-obstructed kidneys and between pre-and postoperative studies. no correlation was found between mean parenchymal, cortical or medullary adc-values and calyceal transit time (ctt), renal transit time (rtt) and measures of differential renal function (%parenchymal s ( ) (suppl ):s -s pediatr radiol volume, vdrf, pdrf). there was moderate correlation with absolute parenchymal volume and total kidney volume, and low correlation with pelvic volume. adc-values showed high correlation with age and patient's weight. adc-values normalized for age or weight showed low correlation with rtt and ctt, but no correlation with functional measures. adc-values were not significantly different between obstructed and contralateral normal kidneys (p= . - . ) or between pre-and postoperative studies (p= . - ). renal adc is dependent on age and weight in young children and does not correlate with differential renal function. for assessing urinary tract obstruction with adc normative values need to be established. to determine the level of knowledge and awareness of medical staff, medical students and parents concerning possible risks associated with ionizing radiation. a prospective study has been conducted at children's hospital, center for adult's radiology, and medical faculty, by filling out two anonymous questionnaires (questionnaire medical staff and medical students, questionnaire parents of the children exposed to x-ray based procedures), and it included participants. statistical analysis was performed using the spss . . the majority of examinees assessed their knowledge about ionizing radiation as moderate. knowledge level was statistically significantly higher only in the group of medical students who passed the course of radiology, in comparison to the group of those who have not attended the course yet. only % of radiologists and up to . % of pediatricians, pediatric surgeons and anesthesiologists are informed about "image gently" campaign. up to % of radiologists, and up to % of clinicians, both specialists and residents, are aware of alara principle. over % of medical doctors think that diagnostic radiology procedures are very often performed unnecessarily among children, while only . % of parents share this opinion. most of the radiologists and clinicians consider it necessary to inform parents about potentially harmful effects of ionizing radiation, but even though - % of clinicians claim they do inform parents in every-day clinical practice, over % of parents affirm that they had never been informed about effects of ionizing radiation before diagnostic procedures were performed on their children. only % of pediatric surgeons and pediatricians, but . % of radiologist and % of anesthesiologists are concerned that informing parents about ionizing radiation would cause problems in every-day work. nearly % of parents claimed that they would not refuse to expose their child to x-ray based diagnostic procedure, after the given information about potential harmful effects. over % of radiologists and less than % of pediatric surgeons and pediatricians support the initiative to calculate the total effective dose child was exposed to during hospitalization, and place it on the discharge list. between % and % of pediatricians and pediatric surgeons greatly underestimated the effective doses in ct and fluoroscopy procedures. there are - % of clinicians who are aware that ct increases the risk of carcinoma development. this study showed that general knowledge about ionizing radiation, potential risks and effective doses in pediatric population is poor, and that organized education is required. fluoroscopy in pediatric radiology -how important is an individual impact to radiation exposure of children? j. lovrenski, i. varga; novi sad/rs to determine whether there are differences between different pediatric radiologists and radiology residents in exposure of pediatric population to ionizing radiation during fluoroscopy procedures. a retrospective study has been conducted at the regional children's hospital, and included all the diagnostic fluoroscopy examinations performed within a one-year period. the fluoroscopic data along with the names of pediatric radiologists/radiology residents performing these examinations were retrieved from the evidentiary notebooks, and included: dose-area product (dap), skin dose, and fluoroscopy time. there were radiologists (r -r ), and radiology residents (r -r ) involved in fluoroscopic examinations. we found all the fluoroscopic findings in the hospital's data base, which enabled a differentiation between positive and negative findings. statistical analysis was performed using the spss . . a p-value less than . was considered statistically significant. a total of fluoroscopy procedures in children (mean age , y, males and females) have been performed within a one-year period, most of which were voiding cystourethrograms (vcug) - , and an upper gastrointestinal (gi) series - examinations. radiology residents and radiologists carried out and examinations respectively. duration of fluoroscopy procedures performed by residents (av. . s) was statistically significantly shorter in comparison with duration of fluoroscopy examinations performed by radiologists (av. s). dap and skin dose did not show statistically significant difference between these two groups, as well as the number of positive and negative fluoroscopic findings in groups of examinations performed by radiologists and radiology residents. mean dap value ranged from . μgym (r ) to . μgym (r ) when performing vcugs, and from . μgym (r ) to . μgym (r ) for upper gi series. mean skin dose ranged from . mgy (r ) to . mgy (r ) for vcugs, and from . mgy (r ) to . mgy (r ) for upper gi series. mean fluoroscopy time ranged from . s (r ) to . s (r ) for vcug, and from . s (r ) to . s (r ) for upper gi series. statistically significant difference was shown only between radiologists r and r for dap and skin dose values in performing vcug, and for fluoroscopy time in performing an upper gi series. for all examinations dap and skin dose were statistically significantly higher in the group of positive fluoroscopic findings. this study has shown that exposure of children to ionizing radiation during fluoroscopy procedures significantly depends on radiologist/ radiology resident and the nature of fluoroscopic finding. to evaluate image quality and radiation exposure of non-contrast pediatric chest ct with automated tube voltage selection (atvs), in combination with automated tube current modulation (atcm). non-contrast chest ct scans of children ( male and female; mean age, . ± . years) were analysed retrospectively with regard to radiation exposure and image quality before and after the implementation of an automated tube voltage selection. correlations of volume ct dose index (ctdi vol ) and the effective diameter (edm), before and after the implementation of atvs were compared, and confidence intervals related to the change in correlations with and without atvs were determined using fisher's z-transformation. image quality was assessed by mean signal-difference-tonoise ratios (snrs) in the aorta and in the left principal bronchus with the independent samples t-test. subjective image quality was rated by two pediatric radiologists and a general radiologist on a point scale. agreement between the readers was assessed using weighted kappa coefficients. a p< . were considered significant. automated tube voltage selection, in combination with an automated tube current modulation, resulted in optimization of scan protocols, homogeneity of image quality, and reduction of radiation exposure for pediatric patients. advantages and disadvantages of cone beam ct for pediatric interventions l. dance, r.b. towbin, d. aria, c. schaefer, r. kaye; phoenix/us objective: illustrate the advantages and disadvantages of cone beam ct (cbct) as an alternative to conventional ct guidance and an adjunct to angiography. there is a steep learning curve to optimize utilization of cbct. we found that cbct reliably identifies high-contrast lesions. however, the lower dose and decreased penetration of cbct resulted in poorer visualization of low-contrast lesions. also cbct can be degraded by streak artifact from hardware or dense contrast. the relatively narrow field of view can be restrictive for peripherally located lesions in larger patients. however, the anatomic display is adequate for guidance in most instances. these findings are illustrated in a series of cbct-guided cases including pulmonary nodule localization, osteoid osteoma ablation, abc sclerotherapy, renal av fistula embolization, and liver lesion biopsy. the advent of cbct as an adjunct modality in the ir suite has significantly decreased the use of conventional ct guidance and significantly decreased the radiation dose in children. we have found cbct to be a practice changer. the aim of this study is to review our local drl in pediatric fluoroscopy and to compare them to values proposed by pidrl guidelines and recent international litterature. data were prospectively collected on consecutive procedures ( total) performed from january to december on different fluoroscopy units (siemens iconos r , luminos drf). of each procedure patients data (name, weight and birth date), examination-data (kind of procedure, date, dap [cgy*cm ], total fluoroscopy time, number of images) were recorded. data from micturating-cystourethrography(mcu), barium meal/swallow(bs) and most commonly performed procedures were divided into weight-groups (< kg, - kg, - kg, - kg) and of each one th-percentile was calculated. data were compared to europeandrl and recent literature data (by age:newborn, -, -, years old). weight-groups are considered a representative sample if at least -patients per procedure-type and per patient-group are included. our local-drl for mcu are (< kg), ( - kg), ( - kg) and ( - kg). they results to be lower than pidrls values ( , , , ) but higher if compared to a previous local survey of ( , , , ) . bs data are (< kg), ( - kg), ( - kg); these data are lower than that of a previous local survey of ( , , ) . the update of local-drl is helpful in daily practice to identify (and solve) critical issues such as incorrect technique or poor practice with new flat-panel equipment. pidrl guidelines: a review of local drl for pediatric head, thorax and abdomen ct in a italian referral center a. magistrelli, v. cannatà, e. genovese, m. cirillo, r. lombardi, p. toma; rome/it the aim of this study is to review our local drl in pediatric ct and to compare them to values proposed by pidrl guidelines and recent international litterature. data were prospectively collected on consecutive procedures ( total) performed from january to june on a somatom definition flash siemens. of each procedure patients data (name, weight and birth date), examination-data (kind of procedure, clincal question, date, ctdivol / and dlp / ) were recorded. ctdivo/dlp from head ct were divided into age-groups (< weeks, weeks- y, - y,≥ y) and of each one th-percentile was calculated. ctdivol/dlp from thorax (chest, cardiovascular ct angiography) and abdomen+pelvis ct examination were divided into weightgroups (< kg, - kg, - kg, - kg,> kg) and of each one th-percentile was calculated. data were compared to europeandrl and recent literature data. weight-groups are considered a representative sample if at least patients per procedure-type and per patient-group are included. our local drl are substantially lower than that proposed by pidrl guidelines. specifically ctdivol/dlp for chest ct are / (< kg), , / ( - kg), , / ( - kg), , / ( - kg), , / (> kg) respectively. for cardiovascular ct angiography are , / (< kg), , / ( - kg), , / ( - kg), , / ( - kg), , / (> kg). while for abdomen+pelvis ct are , / (< kg), , / ( - kg), , / ( - kg), , / ( - kg), , / (> kg). data for trunk sere not collected. for head ct local drl are higher in age-group and but lower in other age-group if compared to routine head ct pidrl ones. the update of local-drl allowed us to identify (and solve) some critical issues such as incorrect technique. drl-curve in optimization of pediatric body ct r. seuri , p. laarne , a. nikkola-sihto , k. nygaard bolstad , m.s. perhomaa , a. thilander klang , k. rosendahl , j. ruohonen , e. tyrvainen ; helsinki/fi, tampere/fi, seinäjoki/fi, bergen/no, oulu/fi, gothenburg/se, kuopio/fi objective: diagnostic reference levels (drls) in medical imaging represent valuable tools to study dose optimization in clinical practice. this is particularly important in pediatric computed tomography (ct) as the number of the examinations in many institutions is low. drls are typically given as a percentile point, usually as % or rd quartile of the observed distribution of patient dose. in pediatric practice drls are often given for each age-or weight group separately. we present continuous drl-curve as a feasible way to compare dose levels in pediatric body ct. during - a selected group of nordic hospitals collected dose values (ct dose index by volume, ctdi vol , and dose-length product, dlp) from pediatric body ct examinations on children aged - years. the dose values were imported into a dynamic excel table, previously established by the radiation and nuclear safety authority in finland, stuk (fig ) . the stuk-table includes a graphic presentation of a continuous drl-curve presented as a function of body weight, and the program automatically calculates a dose curve and compares it to the established reference level (fig ) . the dose values were easily exported to the excel tables, and the graphic presentation and comparison with an established drl-curve was clear and readily understandable for both radiologists and radiographers. in some of the institutions included in the present study, the weight of the patient was not recorded routinely. this represents a challenge for the use of the drl-curves provided by stuk. the drl-curves provided by stuk were feasible for clinical practice. the automatic calculation of the dose curve and graphic presentation were helpful to interpret the results. the drl-curve also allows relevant comparison even with a smaller number of patients. fifty randomly selected ct chest studies performed over years to assess diffuse lung disease were included in the study sample ( females, males; mean age . years + . years), comprising disorders. two pediatric radiologists and a pediatric radiology fellow blinded to the results of the cts evaluated four subsets of complete chest cts ( slices, every third slice, every other slice, and all images below the thyroid) and compared the subsets with the entire chest ct, interpreted as the control. accuracy of evaluating the primary diagnosis and determination if significant diagnoses were missed in the reduced slice ct subsets were rendered. we assume linear distribution of dose across the anatomy to estimate dose reduction on reduced slice subsets. most significant findings were present on all reduced slice ct subsets. all relevant findings were present in % of subthyroid, % of every other slice, % of every rd slice, and % of regional slice subsets respectively. excluded findings included small foci of ground glass opacity, consolidation, focal mosaic attenuation, and linear parenchymal bands; peribronchial thickening, dextrocardia vs dextropositioning, tree-in-bud opacities, extent of mild bronchiectasis. with the exception of consolidation in of the studies, these findings were not thought to inhibit diagnostic assessment. the underlying diagnosis was correctly identified in most of the subsets: % subthyroid and every other slice, % every rd slice, and % of regional slice subsets. dose is significantly decreased by using any of these methods. while some findings are excluded with increasing gaps between slices, equivalent diagnostic information can be provided on reduced slice ct and can serve as a viable strategy to reduce lifetime radiation dose to children and young adults with diffuse lung disease imaged for routine follow-up. as findings are missed with larger gaps, this strategy should be used with caution in patients presenting with acute symptoms . to extrapolate the significance of early diagnosis which will compliment to treatment planning and management. case presentation: types a and b niemann-pick disease are lysosomal storage disorders that result from deficient acid sphingomyelinase activity and lead to the accumulation of sphingomyelin, primarily in tissues of the reticuloendothelial system. type b niemann-pick disease manifestations are hepatosplenomegaly, excess bleeding and bruising, growth retardation, and recurrent respiratory infections. features of hrct include thickened peribronchovascular and interlobular septal thickening, ground-glass opacities. the intermixed regions could be characterized as showing crazy paving, although this is not the predominant pattern. type b niemann-pick disease should be added to the list of clinical entities that can demonstrate crazy paving. our patient is a sevenyear old girl, presented with dry cough and fever. physical examination revealed hepato splenomegaly. radiological work up included abdominal ultrasound examination, which showed mild hepatosplenomegaly. chest radiography revealed diffuse reticulonodular infiltration in both lungs. chest hrct was done for more comprehensive evaluation which showed multilobar bilateral peribronchovascular interstitial thickening and interlobular septal thickening with ground-glass opacities and crazy paving appearance. no honeycomb pattern was seen. no sizable pulmonary nodule or sizable mediastinal lymphadenopathy was seen. no pleural effusion was seen. finding were indicating extensive pulmonary intestitial disease. a corroborative analysis along with lab tests and genetic studies revealed the diagnosis of type b niemann pick disease. . the spectra of hrct features including crazy paving pattern may be encountered; though not frequent. hence should be included in the differential diagnosis of crazy paving pattern. blast from the past: lemierre's syndrome in adolescents with sore throat o. kvist; stockholm/se a minor ailment such as a sore throat could prove to be a severe disorder known as lemierre's syndrome. this syndrome mostly affects previously healthy adolescents and young adults and in its classical form should meet four diagnostic criteria; primary infection of the oropharynx, septicemia, clinical-or radiographic evidence of thrombosis of the internal jugular vein (ijv) plus secondary metastatic abscesses. the infection is caused by fusobacterium necrophorum, a species of obligate anaerobe bacteria forming part of the normal human flora. the syndrome should be suspected in any patient with pharyngitis, cervicalgia and pulmonary symptoms. the incidence of lemierre's syndrome decreased dramatically after the introduction of antibiotics but has, of unknown reasons, increased over the past years. we will present four patients diagnosed with lemierre's syndrome in our department during the last years. the purpose of this case report is to raise awareness of this "forgotten disease". of the four patients diagnosed with lemierre's syndrome two fulfilled all criteria while two fulfilled out of . (table ). the first two presented at the emergency department with one week's history of a sore throat, left sided cervical lymphadenopathy, erythematous tonsils, leukocytosis and elevated crp. in both cases the clinical condition deteriorated and they were referred to the icu. one developed ards and required initiation of ecmo. in both patients, chest ct revealed multiple pulmonary consolidations with cavitations, findings consistent with septic emboli (image , and ). incidentally ct-neck revealed thrombosis in the left ejvand ijv (image ). ultrasound of the neck veins confirmed the finding (image and ). blood cultures taken on admission later proved positive to f. necrophorum. the third and fourth case, with similar clinical histories but with a less aggressive development, had positive blood cultures but no thrombosis and vice versa. (table and all four patients recovered and could be discharged with oral antibiotics and anticoagulants. unique teaching points: in conclusion, lemierre's syndrome is less common today thanks to antibiotics but may still occur in previously healthy adolescents and may lead to a fatal outcome. the pediatric radiologist should be aware of typical findings like septic emboli in the lungs and thrombosis in the ijv. unicameral bone cyst associated with secondary aneurysmal bone cyst of clavicle i. dasic, g.j. djuricic, s. ducic; belgrade/rs objective: aneurysmal bone cyst (abc) accounts for , % of all bone tumors. they are benign but locally destructive lesion of the bone characterized by presence of spongy or multiloculated cystic tissue filled with blood. abcs are metaphyseal, excentric, bulging, fluid-filled and multicameral, and may develop in all bones of the skeleton. most common locations include the proximal humerus, distal femur, proximal tibia, and spine. clavicle is a very rare site for aneurysmal bone cyst with only few cases reported in literature. a -year-old boy reported to the university children's hospital for detailed examination of swelling of right shoulder. - days before admission parents noticed tumefaction of right shoulder. there was no history of trauma or fever. physical examination revealed tumefaction of the right shoulder, in projection of acromial end of clavicle, measuring approximately x cm, which was tender and fixed. the swelling was not hot to the touch, and there was no skin discoloration over that area. regional lymph nodes were not palpable. (fig. a) x-ray revealed osteolytic, expansible lesion in the lateral end of clavicle and there was no pathological fracture. (fig. b) laboratory analyzes were within normal limits. blood cultures remained sterile. chest x ray and abdominal ultrasound were normal. computed tomography (ct) revealed a thinwalled multiloculate lesion in lateral end of right clavicle. (fig. a) there was no extension in the soft tissues on magnetic resonance imaging (mri). mri shows the multiloculate cavities and fluid levels. (fig. b) . the open biopsy was done. histopathological examination confirmed the secondary aneurysmal bone cyst on the field of simple bone cyst of clavicle. the clavicle is an uncommon site for bone tumors. review of literature shows clavicle accounts for less than % of all bone tumors. the patient with an aneurysmal bone cyst generally presents with pain and swelling, which may vary in duration from weeks to several years. up to % of bone tumors occur in less than years of age with peak incidence in second decade. radiologically, lesion is lytic and may have a soap-bubble appearance with ballooned distension of the periosteum. the differential diagnosis for aneurysmal bone cyst include giant cell tumor, chondromyxoid fibroma and telangiectatic osteosarcoma. distinction from telangiectatic osteosarcoma is difficult because the conditions have overlapping clinical and radiologic features. the differentiation is made from the histologic features. imaging of glomus tumor of liver in a child (case report) n. tewattanarat, j. srinakarind, j. wongwiwatchai, p. komvilaisak, s. areemit, p. ungarereevittaya, p. intarawichian; khonkaen/th objective: glomus tumors occur preferentially in subcutaneous tissue of fingers and toes, but extremely rare in visceral organs. most cases of the tumors are diagnosed in adults. several cases of glomus tumors in liver have been reported in adults. a literature review, no case of glomus tumor in liver in children was published. therefore, we present clinical, imaging findings of the first case of pediatric patient with glomus tumor in liver and also histopathological features. a previously healthy year-old-girl was admitted with a twoweek history of progressive dyspnea on exertion and vomiting. family history was unremarkable. physical examination revealed hypertension and smooth and firm mass at epigastrium. systolic apical murmur on heart examination was noted. liver function test ( ) (suppl ):s -s pediatr radiol showed elevated cholesterol ( mg/dl). other laboratory tests (complete blood count, blood chemistry, renal and liver function test, coagulation test, hepatitis profiles and alpha-fetoprotein) were within normal limits. echocardiogram found mitral and tricuspid regurgitation and poor left ventricular systolic dysfunction. abdominal mri demonstrated a -cm well-defined exophytic hypervascular mass with intratumoral hemorrhage at segment / b of the liver. there were no other suspicious lesions in other organs. the biopsy was done and revealed glomus tumor. patient underwent preoperative embolization and the liver mass revealed decreased size to -cm after -month follow up with ultrasound. after that, exploratory laparotomy with left lateral segmentectomy was performed. the pathological results showed dilated vascular channels surrounded by uniform neoplastic cells, uniform with round nuclei, fine chromatin, inconspicuous nucleoli, and pale eosinophilic cytoplasm, and well-defined cytoplasmic border. no mitotic figures and necrosis are identified. immunohistochemical (ihc) staining of tumor was positive for cd , smooth muscle actin (sma) and h-caldesmon. others ihc including ae /ae , heppar , cd , desmin and myogenin were negative. from these findings, the tumor was finally diagnosed as glomus tumor of uncertain malignant potential due to deep location and large size. primary glomus tumor is a rare entity of liver tumor diagnosed in children. however, it should be considered in the differential diagnosis of a hypervascular liver mass. most of these tumors are benign, however tumor in liver have malignant potential due to deep seated position. therefore, tumor removal with pre-operative embolization should be considered. brain mri in a pediatric patient with linear scleroderma en coup de sabre m. mortilla, a. rosati, e. canale, c. filippi; florence/it objective: linear scleroderma "en coup de sabre" (ecds) is a rare subset of localized scleroderma. affected individuals typically have a characteristic atrophic skin lesion involving the fronto-parietal scalp. the disease usually has a benign course but rare neurologic symptoms can be seen associated: the most common described is epilepsy. intracranial mri findings described in the literature include: focal brain atrophy, calcifications and t -hyperintense white matter lesions that may demonstrate contrast enhancement. white matter lesions and calcifications are found in the cerebral hemisphere ipsilateral to the skin abnormality. in the literature only a few pediatric cases have been described. a yrs. old girl was hospitalized at our institution for evaluation of a lesion of the frontal skin associated to a history of febrile seizures and mri alterations. she presented febrile seizures at the age of on april . on january parents noted a frontal cutaneous lesion that was defined as "linear scleroderma, port-wine stain type". on november she performed an mri at another institution showing a diffuse white matter alteration in the left emisphere with focal lesions with high susceptibility and mild contrast enhancement. she was addressed to immunosuppresive therapy with steroids and methotrexate, with steroids stopped after months. a clinical cutaneous improvement was noted. on july a second mri showed a worsening of the findings. we describe a case of a little girl with ecds with no neurologic deficits or symptoms that shows extensive and progressive neuroradiologic alterations. only a few pediatric cases have been described, but it has to be known that also in absence of symptoms, patients with linear scleroderma should be screened with mri to look for cns involvement in this immune disease. brain mri can also be used to monitor the progression of the disease and the response to therapy. mals is a vascular compression syndrome which symptoms can overlap chronic functional abdominal pain. in mals the proximal part of the celiac artery is compressed by the too low located median arcuate ligament during expiration resulting in hemodynamically significant symptoms. we report two cases with mals diagnosed primarily by ultrasonography. case -year-old girl was admitted to tartu university children's clinic (tucc) due to recurrent acute epigastric pain episodes with nausea and loss of appetite during years. previous analyses were normal, abdominal uss and gastroscopy did not show any abnormalities. she was referred to paediatric radiology department for doppler us (dus) which showed narrowed proximal celiac artery (ca) with turbulent flow, increased peak-systolic and end-diastolic velocities on deep inspiration and expiration, and positive ca deflexion angle on expiration. superior mesenteric artery (sma) was markedly widened, indicating possible collateral blood-supply due to severe ca stenosis. according us findings mals was suspected. abdominal mra showed proximal ca kinking, stenosis and poststenotic dilatation and confirmed diagnosis. during dsa collateral blood-supply from sma via pancreaticoduodenale arcade (pda) was seen. laparoscopic release of mal resulted in relief of patient's symptoms, she has been pain-free for two years. case -year-old girl applied to tucc due to recurrent abdominal pain episodes for - years. usually, pain occurred - times per week about minutes after the start of intense cycling training or competitions, and passed about minutes resting in squat position. mild mid-epigastric bruit was audible at physical examination. dus showed two-fold increase in expiratory peak-systolic and enddiastolic blood flow velocities compared to inspiratory velocities which indicated to the hemodynamically significant worsening of ca compression by mal during expiration. mra showed proximal ca compression, upward angulation and poststenotic dilatation. preoperative ct-angiography depicted collateral supply via pda. during laparoscopic surgery ca was released by transecting mal and surrounding fibrous tissue. after surgery the girl has been pain-free for one year except single pain episode during intense competition. the diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have other clearly established etiology. colour doppler us should be the first choice imaging method. to confirm diagnosis in pediatric patients abdominal mra is preferred in our institution, but as mra may still have a tendency to movement artifacts and inadequate spatial resolution for smaller blood vessels, in these two cases mra was followed by cta or dsa. understand the unique predilection of infantile malignancies to metastasize and present as skin-based masses, most commonly lymphoma/leukemia. case presentation: an otherwise healthy day old male presented to dermatology with a pedunculated, friable red glabellar mass (centered between the eyes). first noticed as a flat, bluish lesion at days, its subsequent rapid growth led to an emergency department visit where dermatology diagnosed a hemangioma and initiated propranolol treatment. despite this, the mass continued to grow rapidly, encroaching upon the patient's right eye. the patient was admitted for further workup. an elevated beta hcg, anemia ( . mg/dl), and thrombocytopenia ( , ) suggested an alternate diagnosis. an mri and ultrasound led to a percutaneous biopsy; pathology was consistent with choriocarcinoma. pet ct found fdg-avid glabellar, liver and lung lesions. maternal and placental testing was negative for choriocarcinoma. ultrasound demonstrates a hypoechoic hypervascular mass. mri brain demonstrates cutaneous confinement of the solid avidly enhancing glabellar mass. ct shows a peripherally enhancing liver mass with a masslike area of consolidation in the right lung. initial pet/ct demonstrated fdg avid liver and lung metastases with a small focus of residual activity at the glabella consistent with incomplete resection. follow-up pet/ct showed astoundingly rapid re-growth of the glabellar mass and enlargement of the hepatic and pulmonary masses just days later demonstrating the extremely aggressive nature of this cancer. month follow-up pet/ct showed significantly decreased size and activity of the metastases consistent with a treatment response. in a series of infants with cutaneous metastases, the following diseases presented with cutaneous involvement (ordered most to least common): leukemia, langerhans cell histiocytosis, neuroblastoma, rhabdoid tumor, rhabdomyosarcoma, primitive neuroectodermal tumor, choriocarcinoma, and adrenocortical carcinoma. pathology slides ( ) (suppl ):s -s pediatr radiol unique teaching points: considered one of the fastest growing tumors, infantile choriocarcinoma classically presents with hepatomegaly, anemia, failure to thrive, and precocious puberty between days and months of life. left untreated, the disease is usually fatal within weeks of presentation. a solitary cutaneous metastasis can be mistaken for infantile hemangioma both clinically and radiographically. atypical mri appearance is one important clue that can suggest an alternative diagnosis. pet/ct may be useful for staging and follow-up. a rare case of ovarian juvenile granulosa cell tumor associated with ollier's disease -generalised mesodermal dysplasia p. joshi; pune/in to demonstrate a rare case of mesodermal dysplasia -association of ovarian granulosa cell tumour with enchondromatosis case presentation: two year month old girl presented with precocious puberty i.e thelarche. left hand radiograph showed the radiological age corresponding to chronological age, suggestive of peripheral precious puberty. the patient subsequently underwent a sonography which revealed a pelvic mass probably arising from the right ovary ? sex cord stromal tumour. a mri of the abdomen and pelvis confirmed the pelvic mass and revealed multiple bone lesions in the right hemipelvis -on the side of the tumour she was later operated. hpe of pelvis mass revealed juvenile granulosa cell tumour. ultrasound pelvis images reveal a solid pelvic mass, probably ovarian in etiology mri pelvis also reveals multiple bone lesions unique teaching points: the aim of the poster is to create awareness about this association. the bone lesions should not be mistaken for metastasis juvenile granulosa cell tumour of the ovary (jgct) is a well-known sexcord stromal ovarian neoplasm. ollier's disease is a rare, non hereditary mesosermal dysplasia consisting of multiple enchondromas. the association of granulosa call tumour with asymmetric ipsilateral hemiskeletal distribution may indicate generalised mesodermal dysplasia as there is also association of jgct with maffucci's syndrome, other dysplastic conditions such as microcephaly, facial asymmetry,' and potter's syndrome. review of literature showed previous cases of juvenile granulosa cell tumor associated with enchondromatosis, three associated with maffucci's syndrome, and the rest with ollier's disease goldbloom's syndrome is a paediatric idiopathic disease characterized by transient bone marrow oedema with recurrent crisis of bone pain, periosteal hyperostosis, fever, increased inflammatory markers and dysproteinaemia. a case series of wbmr studies in goldbloom's syndrome is reported and differential diagnosis discussed. case presentation: a -year-old female girl was admitted to our paediatric department because of daily crisis of bone pain of the lower limbs, associated with fever spikes, limping and nocturnal awakenings. no history of trauma was reported. laboratory tests showed mild anaemia (hb . g/dl), thrombocytosis (plt /mmc), increased inflammatory markers (ers mm/h, crp mg/dl), high streptolysine o and dnase-b antibody levels (aso iu/ml and adn-b ui/ml, respectively). throat swab was positive for group a β-haemolytic streptococcus (gas). unusual dysproteinaemia, characterized by hypoalbuminemia ( . g/dl) with increased a , a and g globulinaemia, was noted. x-ray examinations of both legs resulted normal. wbmri showed markedly delineated, high and homogeneous hyper-hypointensity respectively in stir/t of the distal tibialperoneal meta-diaphysis of both legs (fig a,b). distal metaphysis of femur, humerus, radius-ulna and proximal tibia were also homogeneously mildly hyperintense on stir sequences bilaterally (fig a). bone biopsy revealed signs of chronic inflammation. infectious and neoplastic diseases were ruled out and the diagnosis of gs with dysproteinaemia seemed conceivable. steroid treatment was started in association with indomethacin, leading to a prompt resolution of the clinical picture within a few days. the follow-up stir total body mri, performed after months, showed the complete resolution of bone oedema. (fig a,b) the sock sign is a pathognomonic whole-body magnetic resonance imaging (wbmri) feature of goldbloom's syndrome (gs).it is a well marked, symmetric, homogeneous and high bone marrow hyperintensity, localized both at the distal tibial and peroneal meta-diaphysis, which looks like a pair of socks. objective: left ventricle hypoplasia is generally thought as a part of hypoplastic left ventricle syndrome or aortic hypoplasia. it is estimated that about - ml/m left ventricle volume is needed in order to support systemic circulation. less than that volume generally precludes biventricular repair. however conditions associated with severe preload decrease such as total anomolous pulmonary venous return (tapvr) should be considered in the differential diagnosis. tapvr presenting as hypoplastic left ventricle syndrome is presented in this study. six month old female patient admitted to emergency service with symptoms of fever, dyspnea and coughing. emergency staff started intravenous antibiotic theraphy and from medical records learned that she has been followed for partial anomolous pulmonary venous return (papvr) and atrial septal defect (asd). lung x-rays revealed pulmonary edema. echocardiography was performed and revealed very small left ventricle, papvr and mm wide asd. ecg gated cardiac ct was requested with the prediagnosis of hypoplastic left ventricle syndrome. ct images revealed dilated right cavities, very small left ventricle, pulmonary edema, tapvd and peritoneal fluid plus hepatomegaly. we then retrospectively searched our archive and found she was diagnosed as papvr when she was days old. all the cavities that time, were normal sized. according to these we confirmed our diagnosis as tapvr and hypoplastic appearing cavities due to reduced preload and right chamber dilatation due pulmonary overcirculation. surgical team decided to perform corrective operation and they confirmed our diagnosis unique teaching points: small left ventricle cavity in an infant need not to be due to intrinsic hypoplasia. whenever we experience such a situtation we should search for other reasons of pseudohypoplasia in order to give a chance for corrective surgery instead of palliative procesures. we present a case report of kimura disease, a rare benign chronic inflammatory disease that involves the deep subcutaneous tissues and lymph nodes of the head and neck. we report the case of a thirteen year old male who presented with a right sided facial mass which had been present for two years but had enlarged rapidly in the preceding three months. us and mr were interpreted locally as an arteriovenous malformation. review of these examinations and catheter angiography performed at this quaternary referral centre favoured a vascular tumour. subsequent percutaneous biopsy demonstrated angiolymphoid hyperplasia with eosinophilia and blood tests showed a serum eosinophilia, consistent with kimura disease. us shows a mass consisting of scattered heterogenous foci within the fat with multiple large feeding vessels. contrast enhanced mri demonstrated a solid, homogenously enhancing, mass with multiple vascular flow voids from the right external carotid artery branches. catheter angiography showed tumour blood supply from branches of the right transverse facial artery and distal right ima. the dominant supply arose superficially from the transverse facial artery. kimura disease is a rare chronic inflammatory disorder of unknown aetiology that involves the deep subcutaneous tissues and lymph nodes of the head and neck region, most common in asian men in the third decade and sporadic in the non-asian population. the histopathological and biochemical characteristics are eosinophilic lymphfolliculoid granuloma, increased eosinophils in the peripheral blood and increased ige levels. whilst ultrasound and mri are effective imaging modalities, imaging alone does not allow confident differentiation from malignant lesions and biopsy is necessitated. kimura disease has a benign indolent course with an excellent prognosis following surgical excision although local recurrence has been reported. increased naa: is it surely canavan disease? e. varga, p. barsi, g. rudas; budapest/hu leukodystrophies are a group of rare genetic, metabolic diseases that affect the central nervous system, mainly the brain. each type of them is caused by a specific gene abnormality that leads to abnormal development or destruction of the white matter of the brain. the differential diagnosis are made on the basis of clinical and neuroradiological signs. there are some diseases which show typical changes on mr spectroscopy. we present a case of a year-old boy, who has been investigated due to somatomental retardation and muscle dystrophy since his six months of age. his perinatal period was normal except of a nystagmus visible from his birth. the child has muscle dystrophy, spastic quadriparesis, contractures, scoliosis, truncal hypotonia and ataxia and mental retardation. we started examinations to find out the background pathology of his idiopathic encephalo-myopathy. the brain mri showed a bilateral, symmetrical white matter signal alteration, which referred to some kind of metabolic ( ) (suppl ):s -s pediatr radiol disease. the mr spectroscopy revealed decreased cholin and increased naa levels, which are typical of canavan disease. despite of this, the clinical aspects and the location of the involved brain areas were more typical of pelizaeus-merzbacher disease (pmd). the pmd is a genetic disorder, which is originated of the mutation of the proteolipid protein gene (plp ) located on long arm of x-chromosome (xq - ) . this gene has an impact on growth of the myelin sheath. various types of mutations (deletion, duplication, point mutation, insertion) of plp gene lead to various severity of clinical picture. all form of mutations show decreased naa level on spectroscopy, except the duplication of plp gene. in connection with our case, we present briefly the clinical and neuroradiological differences between the two entities. magnetic resonance imaging findings in medium-chain acyl-coenzyme a dehydrogenase (mcad) deficiency l. talamanca, d. narese, m.c. rossi espagnet, l. pasquini, d. longo; rome/it we report serial brain magnetic resonance (mri) in a patient with medium-chain acyl-coenzyme a dehydrogenase (mcad) deficiency who developed acute encephalopathy. a -months-old girl was admitted in the emergency department of our hospital with sudden onset of acute encephalopathy with drowsiness. baseline laboratory investigations revealed severe hypoglycemia, hyperammonemia, hyperchloremic metabolic acidosis and hyperuricemia. the patient was treated with glucose solution infusion that resulted in a gradual resolution of symptoms. the first brain mri, performed within hours of onset of symptoms showed bilateral symmetric restricted diffusion on diffusion-weighted imaging (dwi) in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter; the adc map showed reduced diffusivity (fig ) . the second mri, at hours after the onset, revealed bilateral and symmetric hyperintensity on t -weighted images in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter. dwi showed restricted diffusion in both globus pallidus (fig ) . a single voxel h-mrs study performed by placing a roi in the right nucleus lenticularis revealed increased values of gaba and glutamine (fig ) . a further mri was performed weeks after the first neuroimaging and indicated widespread atrophy and the appearance of a hyperintense signal in t -wi in both globus pallidus while dwi did not reveal any remarkable signal abnormality. single-voxel mrs of the same region showed a normalization of gaba and glutamine values. brain mri showed bilateral symmetric restricted diffusion on diffusionweighted imaging (dwi) in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter; the adc map showed reduced diffusivity the second mri, at hours after the onset, revealed bilateral symmetric restricted diffusion on diffusion-weighted imaging (dwi) in both globus pallidus. a single voxel h-mrs study performed by placing a roi in the right nucleus lenticularis revealed increased values of gaba and glutamine. mcad is an enzyme of the mitochondrial b-oxidation of fatty acids, an essential source of energy for cells during stress. mcad deficiency is the most common genetic disorder of fatty acid oxidation. the clinical manifestation of the disorder is typically precipitated by stress due to fasting, vomiting, fever or muscular exertion and occurs in the majority of cases before the age of with the onset of acute hypoketotic hypoglycemia. clinical features of this decompensated state include seizures and lethargy proceeding to coma and death in the absence of prompt treatment with intravenous dextrose infusion. mcad deficiency usually appears in an acute form and has high morbidity and mortality rates; early diagnosis is therefore extremely important in order to promptly begin treatment and obtain a complete recovery from symptoms. mr can play a significant role in the early diagnosis of the decompensated state of the disease; in our case dwi revealed the presence of lesions with a bilateral symmetric topographic distribution that strongly suggested a metabolic disease leading to acute encephalopathy. a full-term male neonate ( days old) with external perineal anomalies was referred to our hospital. the physical perineal examination revealed a bifid scrotum containing palpable testis and a normal configured penis located at the bottom of the bifid scrotum. two soft masses of and cm respectively, divided from a cutaneous notch, were located below the bifid scrotum and on the right of the midline. the rear biggest mass was normal epithelized, instead the other one was a rugged pigmented mass, which resembled the scrotum (figure ). there were no additional abnormalities of the external genitalia. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content. a mild hydrocele in the right scrotum and a sliding testis on the left side were also revealed. us examination showed a hyperechoic solid tissue, corresponding to the rear biggest perineal mass. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content (figure ) . a mild hydrocele in the right scrotum and a sliding testis on the left side were also revealed. mri also confirmed two perineal peduncolar masses: the biggest and posterior one, was made up by homogeneous fatty matter without contrast-enhancement after intravenous gadolinium injection (figure ). the patient underwent excision of perineal masses and no complications occurred in the surgery. the histopathological examination of the perineal masses revealed two areas with different histological features: the first one was characterized by the presence of smooth muscle bundles dispersed in the dermal collagen, instead the other contiguous area showed abundant mature adipose tissue in the deep dermis and hypodermis ( figure ). at last the rugged swelling mass was definitively diagnosed as as without testis tissue inside, and the rear mass was diagnosed as lipoma. the physical perineal examination revealed a bifid scrotum containing palpable testis. two soft masses of and cm respectively, divided from a cutaneous notch, were located below the bifid scrotum. us examination showed a hyperechoic solid tissue, corresponding to the rear biggest perineal mass. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content mri confirmed the presence of two perineal peduncolar masses: the biggest and posterior one, was made up by homogeneous fatty matter without contrast-enhancement after intravenous gadolinium injection. neonates presenting with perineal masses are uncommon. these anomalies can occur isolated or more rarely in combination with other abnormalities such as uro-genital or ano-rectal anomalies or with contiguous subcutaneous tumors. when perineal masses are found, with prenatal diagnosis or during a newborn physical examination, it is important to look for any associated congenital anomalies or subcutaneous tumors by using imaging. to describe and emphasize the significance of the "half-moon" sign in pelvic mri. a -year-old adolescent, karate athlete, was submitted with left hip pain, decreased range of movement and asymmetry in thigh circumference. markers for infection or inflammation were negative. frog-leg radiograph was negative for hip effusion, slipped epiphysis and equivocal for a left trochanteric abnormality. mri demonstrated a half-moon pattern of bone marrow edema at the left intertrochanteric area and at the major trochanter, surrounding an apophyseal low-intensity lesion. ap radiograph and limited ct confirmed the presence of a lytic lesion with sclerotic margins, containing calcified chondroid matrix. chondroblastoma was histologically confirmed following excision. mri, coronal stir sequence, demonstrates semilunar-shaped hyperintense area abutting the growth plate and the cortex of the femoral neck, consistent with the half-moon sign. note edema surrounding an apophyseal low-intensity lesion and soft-tissue edema. ct confirms a typical apophyseal lesion with sclerotic margins containing chondroid matrix. unique teaching points: "half-moon" sign refers to a semilunar shape of bone marrow edema at the intertrochanteric area of the hip with its base located at the cortex of the femoral neck. this distribution differs from the distribution of edema in metaphyseal and metaphyseal-equivalent osteomyelitis. "half-moon" sign has been described in patients with stress fractures and osteoid osteomas. to our knowledge, this is the first case of chondroblastoma exhibiting this sign. whenever the "half-moon" pattern of edema is identified at pelvic mri scans, a thorough search for an occult fracture line or a nidus corresponding to an osteoid osteoma or a chondroblastoma is mandatory. mr elastography (mre) is a noninvasive imaging technique that quantitatively measures liver stiffness and provides an estimate of the degree of fibrosis. our aim was to evaluate the feasibility of performing mre using both gradient echo (gre) and echo planar (epi) sequences on siemens scanners. a dedicated mre of the liver was performed on a t mr scanner (magnetom® skyra, siemens) with a pediatric mechanical ( ) (suppl ):s -s pediatr radiol driver (courtesy of mayo clinic) over the right upper quadrant. an axial t blade with fat saturation, a coronal t vibe dixon and axial diffusion weighted imaging (dwi) were obtained. elastograms were obtained using both an axial standard gre and a works in-progress (wip) epi sequence. for the gre sequence, different slices were selected and each scanned sequentially. the epi sequence incorporated different slices in just one series. images were post-processed placing regions-of-interest (roi) and measuring the stiffness in kilopascals (kpa). for each sequence and each slice the stiffness mean was measured and then the average of the means was obtained. a spleen elastogram was simultaneously generated, without changing the mechanical driver location, and mean stiffness was also calculated. based on cutoffs in the literature, values were considered abnormal if liver stiffness > . kpa and spleen stiffness > . kpa. our initial experience shows that mre is feasible on siemens scanners using both gre and epi sequences. epi sequences are a promising addition to standard gre. prone versus supine ultrasound positioning for evaluation of urinary tract dilation (utd) in children c. maya , y. gorfu , e. dunn , k. darge , s. back ; philadelphia/us, addis ababa/et objective: ultrasound (us) is used in the initial evaluation and surveillance of utd in children. utd classification systems, including the multidisciplinary consensus, assess anterior-posterior renal pelvic diameter (aprpd) and calyceal dilation. there is currently no consensus regarding optimal patient positioning-prone versus supine-during us assessment of utd. this study was performed to determine if there is a significant difference in the measurement of the aprpd, presence of calyceal dilation, or resulting utd consensus score obtained between supine and prone positions. two raters retrospectively reviewed renal bladder ultrasounds of patients with utd of one or both kidneys. technically adequate ultrasound examinations of orthotopic kidneys that were imaged in both supine and prone positions were included. those with renal anomalies or prior surgery were excluded. aprpd measurements, as well as central and peripheral calyceal dilation, were documented in both prone and supine positions. a postnatal utd consensus score was assigned to each kidney based only on these features. kidneys ( left) in subjects had utd in either the supine or prone position. mean age was . years (range: . - . y). female to male ratio was : ( / ). the interclass correlation (icc) of the aprpd between raters was . and . in the supine and prone positions respectively (ps< . ). central calyceal dilation was found in / supine kidneys and / prone kidneys by rater and / supine and / prone kidneys by rater (kappa . ). peripheral calyceal dilation was found in / supine kidneys and / prone kidneys by rater and / supine kidneys and / prone kidneys by rater (kappa . ). as such the results are presented as one. the aprpd tended to be greater when prone with a strong correlation between prone and supine measurements ( . , p< . ). the mean difference between supine and prone aprpd was . mm (p< . ). in kidneys, calyceal dilation was seen in the prone position and not supine while kidney had central calyceal dilation only when supine. the utd score differed between supine and prone in / kidneys, with all but one higher when prone. in other kidneys, the aprpd differed between positions however concurrent calyceal dilation resulted in no change in utd class. as a screening tool, performing ultrasounds in the prone position may help identify more kidneys with utd. further research is needed to determine if these differences are clinically significant. during the evaluation of magnetic resonance enterography (mre), diffusion restriction (dr) has been utilized as a marker for bowel inflammation, but in our practice we commonly see dr in otherwise normal segments of jejunum. the purpose of this article is to assess the dr in normal loops of jejunum on mre and to determine if there is a correlation between dr and luminal distention, age, magnet field strength, and bowel segment location. a retrospective analysis of subjects with a normal mre and normal clinical work up (based on available clinical history, endoscopy reports, serum white blood cell count and inflammatory markers, and stool samples) was performed. the abdomen was divided into quadrants. if available, loops of jejunum were randomly chosen in each quadrant. two radiologists independently evaluated these same loops of jejunum for the following: luminal distension, wall thickness, and enhancement pattern. additionally, the loops were then evaluated for the presence or absence of dr. inter-rater reliability was determined. disagreement was resolved by consensus. presence or absence of dr was correlated with luminal distension, age, magnet field strength ( . versus tesla), and abdominal quadrant. one hundred ninety-seven loops of jejunum were evaluated in patients. not all subjects had jejunal loops in all quadrants. sixteen subjects ( %) had jejunal loops with dr for a total of loops. one loop had increased wall thickness and another increased enhancement but both did not demonstrate dr. no other loops demonstrate increased enhancement or wall thickening. for the presence or absence of dr, inter-rater reliability was fair (kappa= . ). there was no correlation between the presence/ absence of dr in relation to luminal distension, age, magnet field strength, or quadrant location. of the subjects who had a single loop with dr, a nd loop with dr was found in %. year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. a. coronal haste demonstrates the craniocaudal position of the axial diffusion sequence for reference (line). year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. b. axial diffusion weighted seqeunce (b= ) shows diffusion restriction within loops of jejunum (arrow) within the anterior abdomen. year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. c. corresponding adc map demonstrates low signal within the jejunal wall consistent with diffusion restriction (arrow). diffusion restriction in normal loops of jejunum on mre was present in % of patients. if dr is seen in an otherwise normal segment of jejunum, this can be considered non-pathologic. a patient with a loop of jejunum with dr is likely to have an additional loop of jejunum demonstrating dr. there is no correlation with dr of normal jejunum with luminal distension, magnet field strength, or patient age. our data may help reduce overestimation of disease burden when clinically applied. imaging findings in the newborn with meconium peritonitis that require surgery p. caro dominguez , a. zani , a. daneman ; cordoba/es, toronto/ca objective: meconium peritonitis is a rare condition caused by an in-utero bowel perforation resulting in spillage of meconium into the peritoneal cavity and subsequent calcification. the role of prenatal and postnatal imaging is to identify infants who require surgery. the aim of this study was to evaluate the role of postnatal imaging in meconium peritonitis and to correlate the radiologic and sonographic patterns with the need for surgery. imaging studies in infants with meconium peritonitis performed between and at our institution were reviewed separately by a pediatric radiologist, a pediatric radiology fellow and a pediatric surgeon. patients were divided in a surgical and a non-surgical group. clinical, surgical and pathology reports were reviewed to validate the diagnosis. statistical analysis: comparisons between sonographic and radiographic findings and patterns in the surgical and non-surgical groups were performed using unpaired t-test and chi-square. during the study period, there were infants with meconium peritonitis managed at our institution. in the ( %) who needed surgery, the most frequent surgical findings were idiopathic perforation, jejunal and ileal atresia. ultrasound identified more cases with hepatic calcifications, meconium pseudocyst, ascites and pneumoperitoneum than radiography and radiography more cases of small bowel obstruction. ascites identified with ultrasound (p= . ) [fig ] and bowel obstruction [fig ] diagnosed either with ultrasound (p= . ) or radiography (p= . ) were associated with the need for surgical intervention. one third of children with meconium pseudocysts ( / ) [fig ] , did not require surgery. diffuse peritoneal or hepatic calcifications as an isolated postnatal finding were not associated with the need for surgery. both radiography and ultrasonography give valuable information to the surgeon to take the decision for surgery. dilatation of bowel loops and ascites detected postnatally with radiography and/or ultrasound require surgical intervention in children with meconium peritonitis. interestingly, a large proportion of infants with meconium peritonitis can be managed conservatively. . - . ) . those included had complete fmru analysis, dti (b= and b= , directions), and upjo configuration in at least kidney. cases with motion artifact (n= ), post-pyeloplasty (n= ) or duplex collecting systems (n= ) were excluded. pelvicalyceal dilation grade (pcd), corticomedullary differentiation (cmd), and functional parameters were included. pyeloplasty following fmru was recorded. dti tractography was reconstructed using a fractional anisotropy (fa) and an angle threshold of . and °, respectively (figure ) . user-defined regions-of-interest (roi) of the renal parenchyma, excluding the collecting system, were drawn to quantify dti parameters: mean fa, apparent diffusion coefficient (adc), tract length and tract volume. the relationships between dti quantitative parameters and fmru parameters were analyzed. age and adc (roi) (p< . , r = . ), tract volume (p< . , r = . ) and tract length (p< . , r = . ) were positively correlated. age and fa (roi) (p< . , r = . ) were negatively correlated. there was a correlation between fmru parenchymal volume and tract volume (p< . , r = . ), but median volumes were higher on dti (tractography= . cm vs. fmru= . cm ; p< . ). of the children, had pyeloplasty, had nephrectomy, were managed conservatively and was lost to follow-up. fa was significantly lower in kidneys that went on to have pyeloplasty in comparison to those without pyeloplasty, but the %ci and the iqr overlapped (table ) . the adc, tract length and tract volume were similar between these groups (table ) . there was no difference between the adc of fa values in kidneys with and without pcd or cmd (p> . ). linear hierarchical regressions controlling the age did not show a significant relation between adc and cortical or renal transit times (p> . ), but lower fa values were related to a higher renal transit time (p< . , r = . ). table . quantitative dti parameters between kidneys with and without pyeloplasty following fmru. renal adc, fa, tract volume and tract length change with age but tractography overestimates renal parenchymal volume. there was a tendency towards a lower fa in kidneys that went on to pyeloplasty. otherwise, none of the quantitative parameters evaluated in this study differentiated degrees of upjo. echo-enhanced voiding urosonography (eevus) has become an important imaging tool in urodiagnostics; however, it has been observed that during eevus the premature destruction of ultrasound contrast agent microbubbles might occur. the purpose of this study was to evaluate the possible causes of contrast vanishing during investigations and propose the protocol to avoid false negative results. eevus was performed in children from april to december . sonovue mixed with saline solution in a plastic bottle is applied by continuous flow through the urine catheter. the collected data according to the protocol in this prospective study was completed in children, aged from weeks to . years. the protocol included general patient information, indication for eevus, duration of eevus in minutes, and the presence of vesicoureteric reflux. extensive data about sonovue were recorded: charge number, expiration date, time since opening, amount of initially administered contrast (ml sonovue/ml saline solution), grading of the initial contrast opacification of the bladder, the need for immediate readministration of contrast (dose), grading of contrast opacification during examination, and the need for readministration of contrast later in the course of the examination (dose). in addition, the data regarding bladder (ratio real/predicted bladder volume, wall thickness, ureter dilatation), saline solution, the size of urine catheter (french), and the type of antibiotic prophylaxis were collected. child observation included grading of crying and muscle stiffness. normal contrast opacification of urinary tract during examination was found in / children, while in / ( . %) the contrast opacification was insufficient. in / ( . %) microbubble destruction occurred during the first minute, in ( . %) in minutes, and in in minutes after the beginning of contrast administration. the reason for unsatisfactory contrast opacification at the beginning of the eevus is probably due to small urine catheter size ( % of children with fr catheter had insufficient opacification compared to . % with fr in whole cohort), time since the contrast is opened (more than hours in children), and insufficient bladder emptying at the beginning of the procedure. the reason for microbubble destruction later in the course of the examination is bladder overfilling in combination with increased muscle stiffness and strong crying, which led to increased bladder pressure. there was no correlation between the type of antibiotics and microbubble destruction. we should be aware of possible false negative vur results during eevus caused by premature microbubble destruction. patients with fontan-type palliation of univentricular congenital heart disease have elevated central venous pressure due to their passive pulmonary flow. the altered circulation has a negative impact on several visceral organs, and these patients have chronic liver congestion. they are at risk of developing hepatic fibrosis and cirrhosis with potential malignant transformation. these changes can occur from only a few years after fontan palliation, making early detection and grading of major importance. the patchy pattern of hepatic changes makes liver biopsy an unreliable diagnostic tool. magnetic resonance imaging (mri) t mapping has been suggested as a technique for non-invasive assessment and quantification of hepatic fibrosis/cirrhosis. the aim of this study was to compare two different t mapping sequences of the liver in adolescents with fontan palliation, and in healthy controls. materials: adolescents ( - y) with fontan circulation and young healthy adults ( - y) were included as a part of an ongoing national population-based study. all underwent mri ( . tesla) pre-and post-gadolinium contrast, including two types of t mapping of the liver. a d t volumetric interpolated breath-hold examination ( d vibe) sequence with dual flips with b correction and a modified look-locker inversion recovery (molli) sequence. t relaxation times (ms) were measured by placing five standardized circular regions of interest (roi) in the mid-section of the liver and one in the spleen (fig ) . statistical analysis was performed comparing measurements pre-and post-contrast, between sequences, and patients and controls. there was a significant difference in the measurements between molli and d vibe with increased values for the latter. within each sequence there were small, but significant regional differences in relaxation times (table ). the same pattern was seen in pre-and post-contrast images in both groups. there were significantly increased native t times on both sequences in all regions in the fontan group as compared to the controls, but not post contrast. t relaxation times differ between the t mapping sequences, molli and d vibe, pre-and post-contrast. t mapping of the liver revealed significantly increased native t times in adolescents with fontan palliation compared to healthy slightly older controls. these findings suggest hepatic fibrosis/cirrhosis, but may also represent a component of congestion. diagnostic accuracy of ultrasound, computed tomography and wedge portography in the work-up for mesenterico-rex bypass in children with extrahepatic portal hypertension s. toso, r. breguet, m. annoshiravani, s. terraz; geneva/ch to identify the diagnostic accuracy of ultrasound (us), computed tomography (ct) scan and portography (wedge hepatic vein portography or direct portography) in the pre-operative work-up of mesenterico-rex bypass performed for extrahepatic portal hypertension in children. we conducted a retrospective analysis of pre-operative imaging for mesenterico-rex bypass in our tertiary hospital over the last years. we analyzed all patients between the ages of - years, with extrahepatic portal hypertension necessitating surgical treatment that underwent us, ct and portography. three reviewers independently analysed the patency of the left portal vein, mesenteric vein, splenic vein and the presence of communication between the left and right portal vein on preoperative imaging with correlation to surgical findings. statistical analysis of diagnostic accuracy was performed. eleven patients underwent mesenterico-rex bypass for portal hypertension secondary to portal vein thrombosis. two patients had partial liver transplant. ct with ultrasound correlation was sufficient in responding to the preoperative criteria in % ( / ) cases. portography was useful in the % ( / ) cases where ct could not respond to preoperative criteria, in particular the presence of left-right communication. there was good inter-rater correlation for each modality and good correlation of findings between modalities. in the majority of cases the use of ultrasound and ct is sufficient for preoperative planning for mesentrico-rex bypass. portography is mandatory in cases with large intra-hepatic cavernoma, where the left-right communication could not be confirmed on ct. contemporaneous clinical data was reviewed where available, and a clinical decision on disease severity and activity on a likert scale made with and without imaging. fifty-three patients underwent mre and bowel us in the specified timeframe ( male; median age . years, range - years). twenty patients had sufficient contemporaneous clinical information to be analysed. inter-observer variability for the imaging scores was assessed using bland-altman plots. where variability was beyond pre-determined limits, the studies were consensus reviewed. mean scores were used for the studies within accepted limits of variability. there was no significant difference between total mre and us scores (wilcoxon signed-rank test z= . , p= . ). at the bowel segment level, there was no significant difference between the mre and us segment scores for the ileum and terminal ileum (wilcoxon-signed rank test, z= . , p= . ), but significant differences were present between the imaging scores for other bowel segments, with mre identifying more abnormalities. there is a significant positive correlation between mre and clinical consensus scores (spearman's rho= . , p= . ) and between us and clinical consensus scores (spearman's rho = . , p= . ). imaging caused a refinement to the original clinical assessment in of the cases, with jejunal and ileal disease the most common reason for 'upgrading' a score and absence of any detectable abnormality on us and mre the most common reason for 'downgrading' a score. we found good agreement between mre and us for total patient imaging scores, ileal and terminal ileal scores. both mre and us scores correlated well with the gold standard clinical consensus, with imaging altering the original clinical decision in % of cases. although us detected fewer abnormalities than mr, it correlates marginally better with the clinical consensus, suggesting it is at least equally clinically valuable. background: differentiating between acute osteomyelitis (om) and acute bone infarct (bi) in children with sickle cell disease (scd) is a challenge for clinicians and radiologists, particularly when blood cultures are negative. although bone aspiration is the gold standard test for om diagnosis, it is an invasive procedure and infrequently performed. magnetic resonance imaging (mri) has shown a potential role in differentiating between acute bi and acute om. the goal of this case series is to evaluate the utility of fluid signal on unenhanced fat-suppressed (fs) t -weighted mr sequence in distinguishing acute bi and om in children with scd. methods: we reviewed a total of children with scd admitted with long bone pain during the one -year study period - attributed to either an acute bi or an acute om. twelve of patients with available bone aspiration, blood culture, and mri data were evaluated for fluid signal, marrow signal and other criteria. of patients, nine patients were diagnosed as acute bi and two patients had acute om and one with coexisting bi and om. the diagnosis was based on the fluid signal on t unenhanced t fs mr images as compared to aspiration cytology in which eight of nine patients with bi had hyperintense fluid signal on non-contrast t fs mr images while one of two patients with om demonstrated hypointense fluid signal. the last patient was diagnosed as a probable coexisting lesion (om&bi) based on a giant well demarcated hypointense marrow signal with an extraosseous hyperintense fluid signal. in acute bi, an abnormal hyperintense subperiosteal or paraosteal fluid signal is frequently observed on unenhanced t -fs weighted images. this finding was present in the majority of cases in our study population regardless of age, sex or site in the appendicular skeleton. mri fluid signal characteristic on unenhanced t fs shows promise as a criterion to differentiate between acute bi and om. role of mri to assess skeletal age in pediatric celiac disease s. bernardo, m. martino, a. laghi, e. tomei; rome/it objective: coeliac children are often subject to weight loss and lower somatic growth rate, compared to healthy children of the same age. the purpose of this study was to asses the feasibility of magnetic resonance imaging (mri) of the hand and the wrist to assess skeletal age and growth delay. we enrolled in our study coeliac children ( males and females) affected by histological proven coeliac disease, with a chronological age ranged between years and month and years and months (mean age of years, +/ years and months standard deviation). a single mri sequence (t d se, acquisition time: minute seconds) of the hand and wrist in coronal plane was performed of each patient to estimate the skeletal age. patients' data were compared with a population of normal subjects. the preliminary results showed a delay in skeletal age in children affected by coeliac disease in , % of the simple study, with a delay of maturity of . years (+/- , years of sd). only children showed advance mri skeletal age when compared to normal subjects. mri of hand/wrist to assess skeletal age may be considered as a reliable indicator of somatic growth. mri, without radiation exposure, can be an used as a diagnostic tool in skeletal delay. it could play an important role in the follow up of coeliac children, after glutenfree diet. the prevalence of metaphyseal injury and its mimickers in otherwise healthy children under two years of age p. eide, Å. djuve, r.e. gjøsaeter, k.f. forseth, a. nøttveit, c. brudvik, k. rosendahl; bergen/no objective: metaphyseal lesions in infants and toddlers are believed to have a high specificity for inflicted injury, however, normal metaphyseal irregularities may mimic pathology and lead to overdiagnosis. during the period - all children between and years, seen at the a&e department in bergen (bergen legevakt) due to an injury, and who had radiographs taken, were included. data on previous injury, age, sex and injury mechanism were drawn from the medical notes and pacs archive. all radiographs were reviewed by two researchers and an experienced paediatric radiologist, registering the following: number, site and type of fractures, signs of healing (yes, no), bone structure (normal, pathological) and metaphyseal appearances (shape (normal, metaphyseal collar, metaphyseal irregularity), injury). the study was approved by the institutional review board. six hundred one children ( girls) between and months of age (mean . months) were included, of whom ( girls) had a total of fractures. one hundred eight of the fractures ( . %) involved the forearm, followed by leg-fractures ( / , . %) and fractures to the clavicle ( / , . %). one epiphyseal separation and one metaphyseal lesion (without a history of trauma) were seen. one thousand three hundred twenty metaphysis were analysed, of which ( . %) were defined as either irregular ( / , . %) or demonstrating a metaphyseal collar ( / , . %). metaphyseal lesions with a history of trauma did not occur in otherwise healthy neonates and infants under years of age, indicating that this type of fracture has a particular mechanism. metaphyseal irregularities are frequent, particularly around the knee, and should not be mistaken for clms to evaluate whether mri might be used for age estimation, based on greulich-pyle (gp) atlas criteria. . tesla mri of the left hand was conducted in adolescents, and subjectively evaluated by two blinded radiologists. for sequence optimization, coronal mri sequences (t tirm, t vibe- d-we, and t se) and a left hand x-ray were compared in ten patients (eight male, two female; mean age, . years). the ages of healthy volunteers ( s ( ) (suppl ):s -s pediatr radiol male, female; mean age, years) were assessed from coronal t vibe- d-we. bland-altman plots, intraclass correlation coefficients (icc), and logistic regression models were calculated. coronal t vibe- d-we achieved the best image quality. the correlation between estimated patients' ages on x-ray and mri was high. icc showed high inter-observer agreement ( . for x-ray, . for mri). the estimated age of the healthy volunteers tended to be older than their chronological age. the probability of overestimation was higher in girls than in boys. coronal t vibe- d-we of the left hand is feasible for skeletal age estimation by gp criteria with a high readers' agreement. the likelihood of overestimation of healthy children makes it necessary to develop a new hand atlas representing changes since the s. to assess the relationship between the radiographic findings of metabolic bone disease (mbd) and serum biochemical markers in preterm infants. preterm infants in our neonatal intensive care unit between january and september were included. two readers retrospectively reviewed the wrist radiography for grading according to mbd severity. we recorded the levels of alkaline phosphatase (alp) and phosphorous (p) immediately after birth, on the same day of the first wrist radiography (alp-s, p-s), the highest alp levels before the first wrist radiography (alp-hb) and during follow-up (alp-h), and the lowest p levels before the first wrist radiography (p-lb) and during follow-up (p-l). patients were subdivided into four groups according to mbd severity determined by wrist radiography for the first analysis, and were divided into two groups according to mbd presence for the second analysis. one-way analysis of variance with a tukey multiple comparison and the student's t-test were used for statistical comparisons in the two analyses, respectively. a receiver operator characteristic (roc) curve was constructed to determine the optimal cut-off values of the biochemical markers for the radiological prediction of mbd. of the patients, , , , and infants were classified into grades , , and , respectively. in the first analysis, alp-s, alp-hb, and alp-h were significantly different between grades - and - (all p< . ). plb was significantly different between grades and (p= . ) and p-l was significantly different between grades and or (p< . or p= . ). in the second analysis, alp-s, alp-hb, alp-h, p-s, p-lb, and p-l were all significantly different between the two groups (p< . ). the roc curve of alp-h showed the largest area under the curve values ( . , % confidence interval= . - . ; p= . ) for detection of a radiographic change. the optimal cut-off value of alp-h was . u/l, and the sensitivity and specificity were . % and . %, respectively. the first wrist radiography was obtained at . ± . weeks after birth, and alp-h was measured at . ± . weeks after birth. the cut-off value of alp for the prediction of abnormal radiological changes in wrist radiography was determined to be was . u/l. our findings indicate that the highest alp level at around . weeks after birth could be a valuable predictor of radiological mbd in preterm infants, including those with very low and extremely low birth weights. quantitative grading of tmj synovitis in children with jia-influence of mr-coil, timing after contrast-injection and location of measurements on joint-to-muscle enhancement ratio a. hamardzumyan schmid, c. kellenberger; zurich/ch objective: assessment of signal intensity ratio between joint space and longus capitis muscle on contrast-enhanced mri has been proposed as reliable method across different mr-scanners and protocols for grading temporomandibular joint (tmj) arthritis in juvenile idiopathic arthritis (jia) with a cut-off of . for diagnosing synovitis. the aim of this study was to investigate potential influences on such enhancement ratios (er). retrospective evaluation of contrast-enhanced mr-studies of tmjs in girls with jia (age . ± . y) obtained at two occasions with two different coils on a . t scanner. joint-to-muscle er were calculated from signal intensity measurements in different joint compartments, muscles and sequences obtained with varying delay after contrast-injection, and compared with paired sample t-test. er of tmjs without synovitis (n= ) and tmjs with synovitis (n= ), determined by qualitative criteria, were compared to er reported in the literature. superior and inferior joint space to longus capitis muscle er for normal tmjs ( . ± . ; . ± . respectively) exceeded . in all but one case (figure) and for tmjs with synovitis ( . ± . , . ± . ) were significantly higher than in cases with synovitis from the literature ( . ± . , p≤ ). the same er were higher when obtained with dual-ring coil ( . ± . ; . ± . ) than with multichannel surface coil ( . ± . ; . ± . ; p≤ . ). while er to longus capitis muscle were higher than those to pterygoideus muscle for both coils (p≤ . ), er to pterygoideus muscle did not differ between coils (p> . ). not considering the timing of the scan, er to pterygoideus muscle were highest in the inferior joint space ( . ± . ), followed by the anterior joint recess ( . ± . ) and superior joint space ( . ± . ). comparing images acquired immediately after contrast injection to later images (median delay min, range - min), pterygoideus muscle er in the superior ( . ± . to . ± . ) and inferior ( . ± . to . ± . ) joint space increased substantially (p< . ), while er in anterior recess showed no significant increase ( . ± . to . ± . , p= . ). conclusion: joint-to-muscle er are clearly dependent on ) the signal profile of the mr coil with muscles located further away from the coil providing higher er, ) the time of image acquisition after contrast-injection with later obtained images providing higher er, and ) where the joint signal intensity is measured. as these factors need to be accounted for, the described normal and pathologic ranges of joint to longus capitis muscle er cannot be generalised for every mr-system and imaging protocol. integration of d c-arm ct images with navigational software provides real-time fluoroscopic guidance during percutaneous interventions in the interventional radiology (ir) suite. a trajectory, drawn from skin entry point to the target lesion on the d c-arm ct data, is overlaid on intraprocedural fluoroscopy for real-time needle guidance. this study describes our experience with syngo iguide (siemens) needle guidance software in a range of clinical applications in the pediatric ir suite, including technical success, radiation dose and procedure time. in this irb approved study, all percutaneous interventions performed in the ir suite using syngo iguide over a -year period were included. cases were classified by procedure type; for each type, mean effective radiation dose (msv) was estimated using pcxmc program (v . . . , stuk) and procedure times were evaluated. forty-five patients ( male, female; mean age: ± years) underwent iguide-assisted interventions including: bone biopsies - / ( pelvic, lumbar, and lower extremity), intra-articular steroid injections - / ( sacroiliac, and temporomandibular joint), lumbar punctures - / , percutaneous catheter placements - / (cecostomy, and chest tube placement) and bone biopsy with radiofrequency (rf) ablation - / . iguide was used in particular for the cecostomy procedure due to high sub-hepatic cecal pole position, and in the chest tube procedure due to the presence of loculated pneumothoraces. all procedures were technically successful. the diagnostic bone biopsy rate was . %. the mean estimated dose and procedure times for each procedure type are listed in table . sonography of neonatal spine (sus) is a simple, non-invasive, quick, relatively inexpensive method to evaluate lumbar spine anomalies in infants less than months of age. unossified posterior neural arches allow beam penetration to obtain high-resolution images of the intra-spinal contents. sus is carried out at the bedside, does not utilize radiation & requires no sedation. linear array transducers with extended field-of-view permit diagnostic sensitivity equal to mri. factors affecting mri resolution like patient movement, pulsation & vascular flow do not affect sus. we use sus as first-line screening test in neonates with lumbosacral cutaneous stigmata & spinal dysraphism (sd) associated syndromes. this was a prospective study approved by the institutional ethics committee. thirty five children (age range of to years) with clinically suspected and complicated pulmonary tb were enrolled in the study. lung mri and ct scan was performed in all the patients. the sensitivity, specificity, positive predictive value (ppv), and negative predictive value (npv) of lung mri in detection of radiological findings that were considered highly suggestive or diagnostic for tb, were calculated, with ct as the standard of reference. lung mri performed equivalent to ct in detection of pleural effusion, mediastinal/hilar lymphadenopathy and lung cavitation with sensitivity and specificity of %. agreement between ct and mri in detection of each finding was almost perfect (k: . - ). lung mri was found to be comparable to ct scan for detecting various radiological abnormalities which were highly suggestive for tuberculosis. being a radiation free imaging modality, it has the potential, particularly in children, to replace chest radiographs and ct scan in the coming years. to evaluate differences of myocardial strain assessed by feature tracking using ssfp cardiac mri sequences between pectus excavatum (pe) patients and healthy volunteers. in this prospective study, cardiac mri was performed in pe patients (with a pathologic haller-index above . ) and healthy volunteers ( males and females, respectively; age range - years) including short-and long-axis cine-ssfp sequences on a t scanner. post-examination analysis included standard cardiac volumetry with measurements of the biventricular ejection fractions (ef). additionally, manual biventricular contouring by an experienced radiologist, and subsequent automated strain assessment using dedicated software (circle cvi ®) was performed. longitudinal, radial, and circumferential peak systolic strain and strain rates were analyzed for both ventricles. left-ventricular ef was normal in all patients. five pe patients had a normal right-ventricular ef, in pe patients rvef was slightly impaired ( - %), all healthy volunteers had a normal rvef. compared with healthy volunteers, pe patients showed a significantly higher apical left-ventricular strain (radial: ± . vs. ± %, p< . ; circumferential: - . ± . vs. - . ± %, p= . ) and strain rate (radial: . ± . vs . ± . s - , p< . ; circumferential: - . ± . vs. - . ± . s - , p= . ). mid right-ventricular strain (radial: . ± . vs. . ± . %, p= . ; circumferential: - . ± . vs. - . ± . %, p= . ) and strain rate (radial: . ± . vs. . ± . s - , p= . ; circumferential: - . ± . vs. - . ± . s - , p= . ), as well as apical right-ventricular strain (radial: . ± . vs. . ± . %, p= . ; circumferential: - . ± . vs. - . ± %, p= . ) and circumferential strain rate (- ± . vs. - . ± . s - , p= . ) were also significantly higher in pe patients than in healthy volunteers. left-and especially right-ventricular radial and circumferential strain and strain rate increased from the bases to apices in pe patients. longitudinal strain and strain rate did not differ significantly between pe patients and healthy volunteers. myocardial strain assessed by cardiac mri differs significantly between pe patients and healthy volunteers. as the chest wall deformity usually leads to a compression of the basal parts of the ventricles, higher values of myocardial strain in the mid and apical ventricles in pe patients might indicate a compensation mechanism to enhance especially right ventricular output against sternal compression. to determine the normal range of the haller index (hi) value, and its dependence on the age, sex, and respiratory phase. evaluate the possibility of reduction of the effective dose (ed) of ionizing radiation using a single-slice ct scan technique. the retrospective-prospective study included patients (av. y, sd y). it consisted of parts. the prospective study included evaluation of ct scans performed by single-slice technique in patients with pectus excavatum both in inspiratory and expiratory phase, without topogram. hi was measured in each patient in both respiratory phases. in retrospective study, ct scans of the chest in children without pectus excavatum were analyzed to determine normal range of hi values depending on the age ( - y, - y, - y, - y) and gender. the retrospective study also included the analysis of another ct scans in patients who were operated or diagnosed with pectus excavatum. in the latter group of patients the average value of ed of ionizing radiation was calculated, and the values were compared with the average ed obtained using low-dose ct examinations applied in the new protocol (single-slice technique). the normal value of hi was . ± . . a significant positive correlation between age and value of hi was found. older patients had higher hi ( - y: . ± . , - y: . ± . ). results of mann-whitney test did not demonstrate any difference between gender in the observed group, however girls had generally higher hi in all age groups. in the group of patients who were operated/diagnosed with pectus excavatum, hi was . ± . . the average value of hi in inspirium in children with diagnosed deformity was . ± . , while in expirium it was . ± . . only / ( %) patients had hi value over . (a boundary value for surgical treatment) during inspirium, while / ( %) patients had it in expirium, which showed statistically significant difference (p= . ). single-slice ct technique during the inspiratory and expiratory phase showed average ed of . msv, which is an equivalent of chest xray. it reduced ed more than times in comparison with low-dose whole chest ct. the value of haller index increases with the age and in expiratory phase. we propose the single-slice ct technique without topogram in expiratory phase, as a sufficient and reliable technique in evaluation of haller index and preoperative preparation. mps iva is a lysosomal storage disorder caused by a deficiency of nacetylgalactosamine-sulfatase. main symptom is a systemic skeletal dysplasia. affection of the vascular system has not been described yet. our goal is the analysis of the vascular system in patients with mps iva, based on the example of the aorta. in a retrospective study, patients with mps iva were included. the aorta in its course from th thoracic vertebrae to th was analyzed on the basis of craniospinal mr and ct examinations. to describe the course of the aorta, the area around the vertebral body was devided into equal parts (fig. ) . high buckled arteries in relation to the length of the affected aortal part were indicated as aortal kinking, and a moderate twist in relation to the length of the affected aortal part as aortal tortuosity. results: twelve of patients had an aortal kinking, of patients an aortal tortuosity, of these had moderate and strongly tortuous aortae. seven patients had a normal aortal course, couldn't be analyzed. one patient revealed both, aortal kinking and tortuosity. this study reveals the occurrence of aortic tortuosity in patients with mps iva. we suggest that this complication could be due to glycosaminoglycane deposition in the aortic intima, which may be s ( ) (suppl ):s -s pediatr radiol associated with an increased vulnerability of the vascular wall. we conclude that the examination of the vascular system should be included in regular follow-up protocols. lung ultrasound in the diagnosis and follow-up of pneumonia in children -is it really as reliable as chest x-ray? s. balj-barbir, j. lovrenski, s. petrović; novi sad/rs to investigate the role of lung ultrasound (lus) both in the diagnosis and follow-up of pneumonia in children. a prospective study was carried out in the regional children's hospital, and included children (av. . y, sd . y) with clinically suspected pneumonia, in whom initial lus and subsequent chest x-ray (cxr) were performed within h. the final diagnosis of pneumonia at discharge was used as a reference test to determine the reliability of lus, cxr, clinical and laboratory findings in the diagnosis of pneumonia. children with pneumonia formed a study group, while the control group consisted of children without diagnosed pneumonia. lus finding of subpleural lung consolidation was considered a diagnostic sign for pneumonia. the children with lus signs of pneumonia were followed-up until complete resolution of the lus findings. there were from one to five follow-up lus examinations performed. a final diagnosis of pneumonia was confirmed in / ( . %) patients, and / ( . %) were hospitalized (av. . , sd . hospital days). in diagnosis of pneumonia lus, cxr, auscultation, elevated crp, and tachypnea showed sensitivity of . %, . %, %, % and . %, and specificity of %, %, %, % and % respectively. lus detected lung consolidations in of children with final diagnosis of pneumonia, and in / patients lus showed air-bronchogram (figures , ) . lus was superior to cxr in the detection of lung consolidations smaller than mm. interstitial lung changes were detected by lus in / ( . %) patients, and by cxr in / ( %). lus and cxr detected pleural effusion in / ( . %) and / ( . %) patients respectively. mcnemar's test showed no statistically significant difference, and cohen's kappa coefficient showed almost perfect agreement ( . ) between us diagnosis of pneumonia and final diagnosis of pneumonia. during the follow-ups, moderate to substantial agreement between lus and clinical evaluation of the course of the disease was obtained (k= . - . ). in children with complete clinical and incomplete us regression of pneumonia, consolidations of less than mm were the most prevalent finding. the average time period until complete resolution of the lus findings was . ± . days. children with us detected pulmonary consolidations larger than mm were statistically significantly longer hospitalized than others. lung ultrasound in the diagnosis of pneumonia in children is just as reliable as radiography, and should be included in the standard diagnostic protocol. the latest uk nice guidelines for childhood tb contact screening require that a chest x-ray (cxr) be requested only when mantoux or igra testing is positive or if there is a documented reason e.g. clinical concern. nice clarifies the role of cxr in determining treatment choice. we aimed to review cxr referral and treatment in the current climate of european migrant screening. retrospective review of paediatric referrals to the infectious diseases clinic for tb contact screening of whom had cxrs, from october to august and correlation with the medical notes. a panel of paediatric radiologists independently interpreted radiographs in the clinical context of tb contact screening and a majority decision was reached. of patients referred to the infectious diseases unit, underwent cxr in addition to a mantoux and igra test. of those cxr's, were reported as having features of pulmonary tb but only / ( %) were treated as active tb. eighteen of the ( %) cxr's which were reported as having no features of pulmonary tb, were treated as active tb. of those , only / ( . %) had a clearly documented reason. review of the radiographs (mean age years) by the panel of radiologists noted that all were of readable quality, radiographs were in keeping with a diagnosis of tb, were inconclusive and were normal. the diagnosis of tb was based on lymphadenopathy in and ( ) (suppl ):s -s pediatr radiol milliary nodules in . parenchymal abnormality was seen in patients [one was the milliary] and effusion was seen in . this correlated well with the initial radiology reports of duty radiologists. of the who underwent cxr, referral information was available in . ( . %) of these had been appropriately referred because of a +ve mantoux/igra. only out of ( . %) of those who had cxr despite a -ve mantoux or igra, had a documented reason. according to nice guidelines, % of cxr reported positive for tb were not treated for active tb. this may represent a lack of clarity regarding the definition of 'latent tb'. furthermore, only a third of the % of patients who received treatment despite negative radiographs had a documented reason. the current migrant crisis requires clarity of x-ray definitions of latent tb to avoid the % under-treatment and % overtreatment identified in our population. is there really no cardiac problem for performing sports Ö.İ. koska, p. bayindir, h. alper; izmir/tr objective: sudden death in young is a rare condition excluding known anomalies and sudden infant death sydrome; but its consequences are devastating because they are so unexpected. % of them occur in a context of sports event. everyday parents of millions of children admit hospitals in order to get permission for participating in sports events. and after physical examination and ecg, physicians are expected to decide such an important issue. however there are a number of silent reasons that may lead to child to sudden death. altough we don't perform ct scans for such indications, we have encountered several cases with abnormalities that can lead to sudden child death and while reporting an examination, awareness of these devastating conditions may be usefull. we searched our database from . . to . . in order to see how often we diagnosed such a silent reason from the ct images that are performed for some reasons. as our center is a tertiary center we have performed cardiac ct examinations in that period that are mainly for excluding or defining complex cardiac anomalies. in order to prepare a pictorial review of unexpected but ct detectable sudden cardiac death reasons, we excluded congenital heart diseases (namely obstructive, shunting or complex anomalies) and ecg detectable arrhytmic diseases. the non arrhytmic, non traumatic reasons for sudden cardiac death excluding congenital heart diseases in the papers are: hypertrophic cardiomyopathy (cmp) (% ), some coronary artery path and origin anomalies (mainly abnormal left coronary artery from pulmonary artery (alcapa), and interarterial path)(% ), increased cardiac mass (% ), dilated cmp (% ), marfan disease (% ), myocarditis (% ), ischemic heart disease (% ). we detected examinations according to our inclusion criteria and selected one cases of each; rca path anomaly, alcapa, dilated cmp, hypertrophic cmp, subaortic discrete membrane and increased cardiac mass for presentation although sudden cardiac death is rare in young children it is a so devastating condition that it must be taken into account for every situation. awareness of silent conditions and active search of them may protect professionals from medicolegal issues and unpleasent results. to describe the spectrum of chest ct scan findings of pulmonary involvement in childhood langerhans cell histiocytosis (lch) and propose a simple scoring system to evaluate the profusion and distribution of the main lung lesions. one hundred forty-six chest ct scans of the pediatric patients with pulmonary lch enrolled in the french national database for lch until april , could be retrospectively and independently reviewed by pediatric radiologists. for each ct scan a semi-quantitative analysis was performed for nodular opacities and cystic abnormalities. the chest was divided in fields (upper, medium and lower field of the left and the right lung) and for each field, both for the nodules and the cysts the score was =no lesion, = lesions involving up to % of the parenchyma, = - %, = - % and =more than %. of patients evaluated at diagnosis, patients ( %) presented with nodules, patients ( %) presented with cysts and patients ( %) presented a combination of both nodular and cystic lesions. on the initial ct scan, median nodules total score was and median cysts total score was . during subsequent ct scans almost the same percentage of patients with nodules ( patients, %) was found but we observed an increase number of patients with cysts ( patients, %), median nodules total score was and median cysts total score was . the distribution of nodules and cysts was symmetric in the upper, medium and lower fields with an involvement of costo-phrenic angles in % of the cases. patients with pneumothorax ( patients, %) had a higher cysts median score ( ) than patients without pneumothorax ( ). we found alveolar condensation in patients ( %). none of them showed signs of infection at bal examination or any improvement after a treatment with a standard antibiotic therapy while they did show regression under the lch standard regimen of chemotherapy. we proposed a score for semiquantitative analysis of distribution and profusion of nodular and cystic lesions on chest ct scans that can be a useful tool in pediatric population to monitor lung involvement. we found a significant correlation between pneumothorax and a high cysts median score. alveolar condensation could be considered as a possible manifestation of plch in children. lung bases involvement was found in % of the cases, representing an important different imaging feature from adult plch. high resolution computed tomography for chronic small airway disease in hiv infected adolescents a.-m. du plessis , s. andronikou , h. zar ; cape town/za, bristol/uk early treatment with antiretroviral therapy (art) and decline in infected infants due to prevention of mother-to-child transmission has resulted in an increase in the population of hiv-infected adolescents. pulmonary disease is common among them. cxr is considered insensitive and terminology inconsistent. therefore, despite concerns related to radiation dose in paediatric patients, high resolution computed tomography (hrct) is the modality of choice for the evaluation of small and large airway pathology, prominent in chronic pulmonary disease. hrct findings are used for prognosis, treatment decisions and defining anatomic extent of bronchiectasis for surgical intervention. the aim of this paper is to demonstrate the spectrum, frequency and extent of airway pathology in hiv-infected adolescents using hrct. a nested sub study was undertaken within the cape town adolescent antiretroviral cohort (ctaac); a prospective, descriptive cohort study of hiv-infected adolescents on art and age matched hiv-s ( ) (suppl ):s -s pediatr radiol negative controls. hrct was performed on patients who demonstrated abnormal lung function (defined by forced expiratory volume in second (fev ) of < % and/or low lung diffusion capacity (dlco)). single phase, contrasted multi-detector volume acquisitions were performed from the thoracic inlet to the diaphragms at full inspiration and image data postprocessed to yield thin ( , mm) and thicker slice images ( mm). three mm slices at cm intervals were performed in full expiration. three radiologists interpreted the c t scans independently, with strict imaging definitions, and a majority decision was generated for each finding. ages of patients ranged from between to years with a mean of , . there were females and males with a ratio of : , . bronchiolitis obliterans was seen in % of patients and bronchiectasis was demonstrated in %, % of which was classified as severe (involving either an entire lobe or more than % of at least lobes). there was an absence of lymphadenopathy (a sign of primary tuberculosis (tb)), lymphocytic interstitial pneumonitis (lip) and post tuberculous apical architechtural distortion. miliary tb was identified in a single patient. ground glass was seen in % and consolidation in %. the majority of hiv infected adolescents with poor lung function demonstrated bronchiolitis obliterans strongly emphasizing the use of hrct for confirming small airways disease. hrct was also useful for demonstrating extent of associated bronchiectasis in %. hrct allows classification of patients into those with diffuse small airways disease requiring medical management and those with local disease requiring surgery. background: chronic recurrent multifocal osteomyelitis (crmo) is an autoinflammatory paediatric non-infectious bone disease. presenting symptoms are non-specific, prolonging diagnosis, and leading to deformity, morbidity and unnecessary procedures. imaging is critical to diagnosis, with whole-body mri (wbmri) commonly used in all stages of care. in our institution, a baseline whole-body coronal stir sequence is routinely obtained. aim: to determine lesion distribution and extent on baseline wbmri via retrospective panel review of all patients clinically diagnosed with crmo, and to determine any patterns of involvement that could facilitate earlier radiological diagnosis. method: all patients diagnosed with crmo since december using published bristol criteria were identified and baseline whole body mris reviewed. the reviewing radiologists were blinded to the original report and previous investigations. each mri was reviewed for focal lesions consistent with crmo. the extent of metaphyseal and epiphyseal lesions was categorized into involvement of thirds of the width of the structure. the wbmri of forty children ( girls, boys), averaging years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were reviewed by the panel using a majority decision rule. three hundred three lesions were recorded, averaging . lesions ( - ). the tibia was most affected ( lesions), most commonly the distal tibial metaphysis ( lesions in patients, bilateral). rib, metatarsals and distal femoral epiphyseals lesions were common. humeral, hand and skull lesions were few. complete metaphyseal involvement, the 'smouldering physis', was most prevalent within the proximal and distal tibial metaphyses. although ranked seventh, the reportedly more common clavicular lesions were the site of the most florid lesions, demonstrating bone expansion and periosteal reactions. two clear patterns of involvement emerged. in patients with clavicular lesions, fewer overall lesions were observed (average . ), mainly affecting the axial skeleton and feet. patients with tibial involvement had a higher number of overall lesions (average . ), but few lesions outside the lower limbs. only four patients had a both clavicular and tibial lesions. twelve vertebral lesions and four cases of spodylo-discitis were identified; two at t / level, one at t / level, and one involving both t / and t / . our series of cases of crmo with baseline wbmri, one of the largest in the published literature, identifies the common sites that should be interrogated for involvement. this study also demonstrates potential as-yet undescribed patterns of skeletal involvement that can be used to aid radiological diagnosis and highlights a non-infective cause for spondylo-discitis. hepatic hemangiomas (hh) are the most common benign vascular tumors encountered in the pediatric population. two main types have been described congenital and infantile, which both display distinct clinical courses and biological features. hemangioendothelioma in differential diagnosis of hh is controversy. recent literature suggests that congenital hepatic hemangiomas present in a focal form, whereas infantile hepatic hemangiomas present in either a multifocal or diffuse form. the goal of this study is to evaluate the features associated with focal and multifocal hh. the records of patients diagnosed with a hepatic hemangioma at a tertiary pediatric hospital from to were reviewed. we divided our series into groups: focal or multifocal including diffuse form. clinical endpoints are: age of diagnosis, presence of cutaneous hemangioma, alpha-fetoprotein, thrombocytopenia, cardiac insufficiency. imaging endpoints were echogenicity on us (hypoechoic, hyperechoic or mixed), vessels density on color doppler (< ; - , > cm ). presence of calcifications, venous lakes, visible vessels and aortic tapering were assessed on us, ct-scan, mr and angio. treatment and outcome were analyzed. univariate and bivariate analysis were done. this study included focal ( m, f) and multifocal ( m, f) hh. antenatal diagnosis was done in focal and multifocal hh. focal lesions were associated with the presence of cutaneous hemangiomas (p< . ) and calcifications (p< . ). no other variable was significant. conservative management was decided in focal and multifocal hh. steroids (focal: , multifocal: ), steroid-interferon (focal: , multifocal: ), propranolol-steroid (focal: , multifocal: ) and surgery in one focal form. complete regression was observed in most lesions (focal: n= , multifocal n= ), whereas incomplete regression < % was observed in patients (focal: n= , multifocal: n= ) and patients in the focal group with the pathology diagnosis of hemangioendothelioma. hepatic hemangiomas demonstrate a wide range of radiological features, with important overlaps in focal, multifocal or diffuse forms. focal and multifocal hh can be seen in congenital hemangioma, infantile hemangioma or hemangioendothelioma. the association of cutaneous infantile hemangioma in the focal group confirmed that the focal lesion can be seen in infantile hemangioma. however, calcifications are more frequent in focal hh which is described in congenital hemangioma or hemangioendothelioma. ( ) (suppl ):s -s pediatr radiol symptomatic and asymptomatic meckel's diverticulum in the pediatric population -a retrospective analysis of imaging findings with histopathologic correlation n. abu ata, r. cytter-kuint, j. bar-ziv, i. hadas-halpern; jerusalem/il objective: though meckel's diverticulum (md) is a relatively common gastrointestinal anomaly, many of the symptomatic and most of the asymptomatic md's are often missed on abdominal imaging. our purpose is to describe the radiologic appearance of symptomatic and asymptomatic md in the pediatric population and to correlate the radiologic findings with histopathology. a retrospective analysis of all children diagnosed with md between / - / and had relevant imaging (n= ) was done. imaging studies-ultrasound (us), computed tomography (ct) and magnetic resonance imaging (mri) were retrospectively reviewed and evaluated for visualization of md in symptomatic and asymptomatic patients. findings were compared with the preoperative radiology report and the pathology specimen. symptomatic group (n= ): mean age . ± years, nineteen males. md presented with abdominal pain in patients, small bowel obstruction (sbo) in patients, gastrointestinal bleeding or anemia in patients and intussusception in cases. md was identified in preoperative reports ( . %) and retrospectively identified in more cases (overall patients, . %). in cases, an inflamed or perforated md were found. in cases, mucosal lining resembling gastric folds was seen. inverted meckel and prominent tissue surrounding the diverticula were seen in patients. in a single case md was misdiagnosed as a duplication cyst. asymptomatic group (n= ): mean age . ± , eight males. md was not mentioned in any of the original reports and only md's were identified retrospectively ( . %). no mucosal abnormality or irregularity were noted. histopathology: ectopic gastric mucosa was found in / ( . %) of the symptomatic patients vs. / ( . %) in the asymptomatic group. all patients with sonographic appearance of gastric mucosa had gastric mucosa in pathology (specificity- %, positive predictive value- %). md has a variety of radiologic appearances. it can be detected in most of the symptomatic patients but is almost undetectable in asymptomatic patients. heterotopic gastric mucosa is more common in the symptomatic group. inflamed gastric mucosa may have a typical appearance resembling a small stomach, a sign that was not described before and has both high specificity and high positive predictive value for gastric mucosa within a meckel diverticulum. preliminary results on dna damage from ct irradiation in pediatric patients i. dilevska, e. nagy, w. schwinger, e. sorantin; graz/at the increased radiation sensitivity in children, compared to adults, is a well-recognised fact in the pediatric radiology community. the high-dose irradiation induced dna damage has been well established, however the dosages that are clinically used in everyday ct procedures are so low, that it remains unclear how this severely affects the dna and can induce cancer in the long run. the aim of this study is to assess the effects of lowdose ionizing radiation from ct in children by establishing a standardization curve ranging from the high to the low, medically significant ctdi values. this is done by measuring the phosphorylation of the h ax histone (γh ax), which is considered a biomarker for quantification of radiation induced dna double-strand breaks (ddsbs). the detection of the γh ax histone was done by two methods: immunofluorescence microscopy (im), which is an established method for detection and quantification of this histone and the new, promising flow cytometry technique (facs). for this study, leucocyte samples ("buffy coats") were provided by the local transfusion department and these samples were irradiated with a clinical ct scanner (aqilionone, tmse) with values ranging from , to , mgy ctdi. afterwards the samples were processed with both methods. for the immunofluorescence, twostep immunostaining was used with two different antibodies and the cell and foci counting were done on an olympus xc microscope, while the facs staining was done with a one-step antibody and the samples were measured on a navios flow cytometer (beckman coulter). comparable results were detected with both methods, with a good correlation between the facs and im, with a linear incline (r > . ) in the high and in the low dosages from , to . mgy ctdi. however, in the samples irradiated with doses below . mgy ctdi, there seems to be less phosphorylated h ax than in the native samples. two possible explanations arise: a) low dose irradiation initiates repair that extends to ddsbs occurring naturally or b) low dose irradiation doesn´t cause phosphorylation of this histone, but affects other dna damage and repair pathways. the preliminary findings show that the facs analysis can be used as a valid replacement method for the labor-intensive if method in the higher dosages. however more analysis should be done to establish its accuracy in the lower regions since underlying mechanisms are not clear yet. a. turkaj , g. cicero , e. sorantin , r. coroiu ; graz/at, mesina/it, cluj-napoca/ro there is only little information available regarding imaging procedures in the trauma setting of pediatric patients. such data can serve as a rational basis for running pediatric trauma units. the purpose of the paper is to investigate the number, types and distribution of imaging procedures in a tertiary pediatric trauma center serving children of about . million inhabitants with approximately . children. all trauma-caused admission to the emergency room and their imaging procedures were analyzed retrospectively occurring within a period of months. a cohort of patients (m:f= . : ) were analyzed. patients were grouped according to age into the following categories: neonates, infants, middle childhood, early adolescence, late adolescence. imaging procedures were classified into plain films, us, ct and mri. furthermore, the time of admission was noted and categorized in time slots : - : , : - : , : - : and : - : . referral cause was divided in domestic accidents, motor-scooter-bicycle accidents, car accidents, sport injuries, falls from height and others. the average age was . ± . years, aligned in the following age-groups neonates ( %), infants ( %), middle childhood ( %), early adolescence ( %), late adolescence ( %). a total of imaging procedures were performed, of which plain films ( %), us ( %), ct ( %) and mri ( %). there was a statistically significant difference of imaging procedures due to age in particular in us and ct. regarding the timeslots: : - : ; patients ( %), : - : ; patients ( %), : - : ; patients ( %), : - : ; patients ( %). domestic accidents were the leading referral cause with cases ( %) prevailed age groups were infants and middle childhoods corresponding for more than %. motorscooter/bicycle accidents accounted for cases ( %) of which most were early and late adolescence (more than %), s ( ) (suppl ):s -s pediatr radiol sport's accidents ( . %) equally shared among middle childhood, early and late adolescences. car accidents ( . %) cases and fall from height ( , %) did not show any prevalence according to the age groups. for the first time detailed data about imaging procedures at the emergency room for pediatric patients are now available. over half of the admissions ( %) occur outside regular work hours thus representing a challenge for the staff in duty and this fact should be considered in working schedules. due to strict interdisciplinary developed diagnostic pathways the number of ct examinations was reasonable low. head ct in a regional children's hospital without mri -effective doses and justification of clinical indications j. lovrenski, n. milenković; novi sad/rs to calculate effective doses (ed) for pediatric head computed tomography (ct), to determine the most common referral diagnoses, and the share of normal and pathological ct findings. a retrospectiveprospective study comprised all the children with performed ct examination ( -slice scanner) within a one-year period. pediatric ct protocols were used. the values of ed for head cts were calculated based on the two different models (shrimpton's and icrp publication ). average ed for different age groups was expressed as the number of chest x-rays (cxrs) ( cxr . msv). the most common non-traumatic referral diagnoses for head cts were determined, as well as percentage and type of pathological ct findings. a share of pathological ct findings was also determined for trauma as a referral diagnosis. head cts were represented with ( %) in total number of ct examinations within a one-year period. the different calculation models have shown the difference in ed values of up to . %. eds for head cts were equivalent of ( years of age and older) to (younger than months of age) cxrs for one sequence of scanning. the most common non-traumatic referral diagnoses for head cts were: loss of consciousness, epilepsy, headache, convulsions, and vertigo. in this group of patients, % of completely normal ct findings were found. pathological findings in this group consisted of the patients with the most common non-traumatic referral diagnoses were as follows: cortical atrophy ( patients), arachnoid cyst ( ), ischemia ( ), porencephalic cyst ( ), agenesis of the corpus callosum ( ), chiari malformation -type i ( ), open-lip schizencephaly ( ), and tumor of the posterior cranial fossa ( ). most common incidental, extracerebral pathology discovered included sinusitis and otomastoiditis. in patients with trauma as referral diagnosis, the share of pathological ct findings was . %. it is necessary to get clinicians familiar with the extent of ionizing radiation that children are exposed to during the head ct examinations. a more careful selection of children for head cts is necessary in an every-day clinical practice, especially for patients with non-traumatic referral diagnoses. diffuse and symmetric diffusion restriction involving the white matter of the brain in patients with neonatal seizures j.-y. hwang , y.j. lee , y.-w. kim ; yangsan-si, gyeongsangnam-do/ kr, yangsan-si/kr this study aimed to evaluate magnetic resonance (mr) imaging findings in patients with neonatal seizures focused on the diffuse white matter lesions on diffusion weighted image (dwi) in addition to clinical manifestations. a total of neonates aged less than -week old underwent brain mr imaging for evaluation of neonatal seizures between november and december . among them, patients showed diffuse and symmetric pattern of high signal intensity on dwi. clinical, laboratory, and mr images were analyzed retrospectively. nine patients were males and three patients were females. patient age was . ± . days (range, - days). all the patients were born at full term. the most frequent month of the hospital visit was march (n= ) and january (n= ). eight patients showed generalized clonic seizure and four patients showed partial clonic seizure. stool viral test was performed in nine patients. among them, five patients were positive for the rotavirus and one patient was positive for the astrovirus. nine patients underwent cerebrospinal fluid analysis, however, all showed negative results. mr imaging was performed at . ± . days after onset of seizures. diffuse and symmetric diffusion restriction were distributed along the cerebral white matter tracts and both thalami (fig ) accompanied with high signal intensity on either t -weighted images or on the fluid-attenuated inversion recovery (flair) sequence. multiple foci of high signal intensity on t -weighted images at the centrum semiovale that was affected on dwi were also observed. follow-up period was . ± . months (range, . - . months) and developmental delay was encountered in three patients. six patients underwent follow-up mr imaging at the age of . ± . months (median, . months; range, . - months). five patients showed volume loss in cerebral white matter on both sides of the brain and four patients showed high signal intensity of the periventricular white matter on either t weighted images or flair sequences (fig ) . myelination delay was not observed in follow-up mr images. diffuse and symmetric diffusion restriction involving the cerebral white matters can be seen in patients with neonatal seizures on mr imaging. our study shows that rotavirus is commonly encountered, but not exclusively detected in these patients. nevertheless, viral infection-associated encephalopathy should be considered when a patient is presented with characteristic clinical and mr findings. whole body mri on diagnosis and follow-up of neurofibromatosis type d. grassi, v. tostes, e. caran, h.m. lederman; sao paulo/br demonstrate that whole body mri is effective on showing neurofibromatosis type involvement of different regions of the body not known by the clinicians. review of patients with neurofibromatosis type (nf ) who underwent whole body mri throughout their follow-up with the majority of them had only brain and spine imaging studies. it was possible to demonstrate that whole body mri provides an overview of nf systemic manifestations and neurofibroma's extension beyond the clinic expectation. despite being rare, sarcomatous degeneration was suspected when there was any difference on the characteristics of the neurofibromas. whole body overview where its possible to see the neurofibroma's extension in right cervical region, scoliosis and multiple plexiform neurofibromas. only the biggest neurofibroma was detected by clinical exam. however it is possible to identify two others neurofibromas. whole body view of multiple plexiform neurofibromas. whole body mri is a radiation-free exam and it is useful on the diagnosis of nf and on patient's follow-up. it provides an overview of the systemic s ( ) (suppl ):s -s pediatr radiol involvement and neurofibroma's extension beyond the clinical expectation. during patients follow up, it could also show tumor's characteristics modification, which was considered as a possible sarcomatous degeneration. accuracy of non-radiologists and lay-persons for identifying children with cerebral cortical atrophy from 'mercator map' curved reconstructions of the brain s. vedajallam , a. chacko , s. andronikou , e. simpson , j. thai ; east london/za, bristol/uk objective: background: communication of cortical brain atrophy in children with term hypoxic ischaemic injury (hii) to parents and the legal fraternity contesting compensation rights can be very difficult using text and standard cross-sectional images. when demonstrating the cortex in hii, a single image of the brain surface, much like the way a map of the earth is derived from a globe, can be generated from curved reconstruction of coronal magnetic resonance imaging (mri) scans i.e. a mercator map. lay people's ability to identify abnormal scans from such maps without prior training requires evaluation before routine use. aim: to determine the sensitivity and specificity of lay people in detecting abnormal brain scans through review of mercator flat-earth maps of the brain, without prior training. ten mercator map images were provided to participants with a distribution of hii, cortical dysplasia and reported normal. participants were required to identify abnormal scans. sensitivity and specificity overall and for sub-groups were derived by averaging true positives and negatives; false positives and negatives. the results show a strong ability for lay-people to identify normal versus abnormal mri brain studies using mercator maps. the sensitivity and specificity in this group is % and % respectively. non-radiologist physicians and radiographers performed slightly better than lay people as expected. radiologists of course had very high sensitivity and specificity of % and %. the mercator map is therefore a viable tool in the communication of complex mr imaging to the lay-person. safety and efficacy of sphenopalatine ganglion blockade in childreninitial experience l. dance, c. schaefer, d. aria, r. kaye, r.b. towbin; phoenix/us objective: sphenopalatine ganglion (spg) blockade is known to be a safe and effective migraine headache treatment among adults. this paper will report the initial experience in the pediatric population with spg blockade. one hundred thirty-three procedures were performed in patients ages to from february through november . pre-intervention headache scores were recorded on a scale of to . the procedure was performed supine with neck in hyperextension. anesthesia of the bilateral nares was accomplished with lidocaine spray and gel. contrast was injected using a sphenocath confirming catheter position. % lidocaine was injected. patients remained supine with neck in hyperextension for minutes. post-intervention headache scores were recorded. mean pre-treatment score of . decreased to . post-treatment (Δ . , % ci . - . , p< . ). there were no complications. spg blockade is a safe and effective treatment for migraine headaches in children which results in decreased reliance on intravenous drug therapy. orbital masses represent a spectrum of benign and malignant lesions in children that can be challenging to diagnose and treat. imaging plays an important role in diagnosis, due to a potentially limited clinical examination and risks associated with biopsy. mr imaging is a powerful tool for imaging the orbit, due to the excellent tissue contrast it provides. yet conventional mri has a limitation in discriminate the benign from malignant lesions. diffusion-weighted imaging (dwi) is non-invasive rapid technique uses the water diffusibility to produce contrast among different kinds of tissues. our propose was to assess the role of dwi and calculated apparent diffusion coefficient (adc) values in characterization of the pediatric orbital masses regarding benignancy or malignancy. one hundred and thirty patients with recently diagnosed orbital masses and who underwent preoperative conventional mri and dwi were included in this study. the orbit was divided into six compartments: the eye globe, retroocular fat, optic nerve, lacrimal system, bony boundaries and extra-ocular muscles. the average adc obtained from each tumor was compared with the histopathological diagnosis determined from subsequent surgical sample. seventy girls and sixty boys with orbital masses were included in this study. their age was ranged from month to years. the globe is the seat of lesions in / cases, optic nerve in / case. seven cases have lesions in the lacrimal gland. forty-five of cases was diagnosed as having benign masses & of cases have malignant lesions. there is a statistically significant difference between the mean adc value of the benign lesions ( . ± . x - mm /s) and the mean adc value of the malignant lesions ( . ± . x - mm /s) (p< . ). the optimal adc cutoff value that was determined for discrimination between these lesions is: . x - mm /s), with sensitivity of . % and specificity of %. using conventional mri alone in predicting benign and malignant lesions has the sensitivity of % and specificity of % with % positive predictive value and % negative predicative value. combining dwi and conventional mri has increased accuracy, as the sensitivity and specificity were %, % respectively with % positive predictive value and % negative predicative value. ( ) (suppl ):s -s pediatr radiol adc values provide an accurate, sensitive, fast, and non-invasive mean of characterization of pediatric orbital tumors. a priori tumor characterization is useful in timing and treatment planning for orbital tumors. utiliy of resting state fmri in children for preoperative language mapping l.-m. leiber, m. delion, a. ter minassian; angers/fr to assess if resting state fmri is able to detect language eloquent areas in childrens. six children, from to years old suffering from brain lesions were enrolled in this study. they underwent mri with one dt morphology session and three minutes fmri sessions, including one resting state fmri and two language task induced activity fmri sessions. analysis was performed using a generalized linear model for the first one and a spatial independent component analysis approach for the two others. language maps were compared with cortical mapping obtained by intraoperative direct stimulation. language network was identified systematically by resting state session but not by task induced activity sessions. moreover, in two of the six patients, resting state fmri was able to detect eloquent areas found during intraoperative cortical mapping that were not present in task induced activity sessions. resting state fmri appears superior to task induced activity fmri in detecting language eloquent areas. is sclerotherapy an effective treatment option for ranulas or thyroglossal duct cysts in children? d. aria, l. dance, c. schaefer, r. kaye, r.b. towbin; phoenix/us to assess the utility of sclerotherapy in the treatment of ranulas and thyroglossal duct cysts materials: from - , patients varying in age from months to years were referred to the ir department for sclerotherapy. of the patients, had a diagnosis of ranula while had the diagnosis of thyroglossal duct cyst by either mr, ct, or us. sclerotherapy treatments were performed with standard sclerosing agents, i.e. sotradecol % foam, absolute ethanol, and bleomycin. in the subset of patients with ranulas, sclerotherapy was commonly performed in accordance with salivary (submandibular and/or sublingual) gland botox injection or ethanol ablation. -gauge or f sheathed needles were used for us-guided access to the lesions, with ranula sclerotherapy being performed after placement of side-hole drainage catheters ( - f) due to their increased viscosity. the preferred sclerosing agent was injected with dwell times ranging from mins to hours. salivary gland injection/ablation was performed under usguidance using a -gauge needle with volume injection targeted centrally within the gland or in the portion of the gland abutting the ranula. after treatment, all patients were scheduled for follow-up ultrasounds at a minimum of weeks to assess lesion response or residual disease. a total of sclerotherapy treatments were performed. of the patients, were lost to follow-up after single sessions for ranula and thyroglossal duct cyst. the other patients all had follow-up ultrasounds after each of the remaining sclerotherapy sessions. four of these patients showed initial improvement with either decreased size of lesion or lesion resolution while the other showed no improvement with either stable or increased size on initial follow-up. the patients who initially showed promising response unfortunately had recurrence on follow-up imaging and ultimately, demonstrated no favorable response to sclerotherapy after subsequent treatments regardless of whether treatment was combined with ethanol/botox salivary gland injection. in summary, all patients who were successfully followed show no appreciable response to treatment for ranula or thyroglossal duct cyst. despite the emergence of clinical requests for sclerotherapy of ranulas and thyroglossal duct cysts, in our case series, sclerotherapy has not proven to be an effective treatment option using our current drug regimen. role of the susceptibility-weighted imaging (swi) in the neuroimaging of term newborns g. rudas, e. varga, p. barsi, l. kozák, Ü. méder; budapest/hu objective: susceptibility-weighted imaging (swi) was introduced in the neonatal neuroimaging only a few years ago. we can find only a few publications about its advantages and disadvantages. according to our experience, swi is extremely useful not only for detecting bleedings but for the diagnosis of other diseases as well. during the last year we had mri examinations on term newborns ( - days of life) and the swi gave additional information in cases. we used a t philips insignia scanner. in the case of the questionable hypoxic-ischemic-encephalopathy ( cases) and the metabolic diseases ( cases) we could find increased signal intensity in the cortex; in the case of stroke we could find the thrombus itself in cases; the avm were much clearer using the swi in cases; at the pvl in cases we could visualize the cysts better using swi; in the case of congenital heart disease ( cases) and in the case of sinus thrombosis ( ) we could find microbleedings and/or dilated veins; in cases the position of the lateral ventricle drain or shunt was much clearer using the swi. the swi gave important additional information in / ( %). the swi is a strongly recommended new sequence at the mri examination of the term newborns' brain. a disadvantage of swi is that it requires ca. three minutes examination time (in contrast to t * which is only minute long). mechanical birth-related trauma: imaging of the "accidents of birth" a. chaturvedi, j.g. blickman; rochester/us objective: . to discuss definition, incidence and risk factors leading to "mechanical birth-related trauma" and compare these with existing literature. offer an organ-system based classification scheme encompassing the varied manifestations of birth-related trauma and describing the implications on care decisions. materials: the hospital imaging department database was searched for neonates who presented with history of difficult/traumatic birth at our obstetric center between january , -june , . search software used was primordial customised radiology solutions, san mateo, ca. the search terms used were "macrosomia", "shoulder dystocia", "instrumental delivery", "malpresentation", "cephalopelvic disproportion", "forceps" and "vacuum". initial and follow-up imaging and clinical data on these neonates was reviewed and compiled by two board-certified pediatric radiologists. the relevant literature was reviewed and findings compared. organ-system based classification scheme for birth-realted trauma. in our study, mechanical trauma of birth was seen to manifest within different organ systems, which have been listed below in the order of occurrence within our sample. injuries to the skull (sutural overlap, dents and fractures), scalp hemorrhages (subgaleal hematoma, cephalhematoma, caput). intracranial intraand extra-axial hemorrhages (subdural, subarachnoid, epidural, intraparenchymal). clavicle fractures neonatal brachial plexus injury. sternocleidomastoid hematomas. adrenal hemorrhages. cervical spinal cord contusions. schematic diagram depicting intra-and extracranial hemorrhages by location. -year-old with history of calvarial fracture at birth-fracture did not heal but enlarged secondary to leptomeningeal entrapment at the fracture sitean entity called "growing fracture" or "leptomeningeal cyst". multiple newborn organ systems can be injured from mechanical trauma of birth. our numbers compare favourably with the existing literature. mechanical birth-related trauma can occur simultaneously with hypoxic-ischemic birth injury. although most of these injuries spontaneously and completely resolve, long-term complications can be seen in some cases. few of these injuries are life-threatening. imaging plays a crucial role in diagnosis and follow-up, and can assist in decision making as well as in counselling the parents. ewing sarcoma of tibia in an infant girl a. seehofnerova, j. skotáková, i. Červinková; brno/cz objective: ewing sarcoma (es) is the second most common primary bone malignancy in children. it histologically originates from neuroectodermal tissue and consists of small round blue cells. ewing tumour family is very close to primitive neuroectoderm tumour (pnet) family with diverse stage of differentiation, ewing sarcoma being less differentiated. approximately % of the cases occur between ten and twenty years of age with slightly higher prevalence in male gender. nine-month-old caucasian girl presented to local surgery department after she had wedged her lower leg in a bed. the right lower leg was swollen and painful. she was initially diagnosed with a ligament injury and underwent standard treatment. oedema gradually disappeared, but swelling and pain increased after three weeks. she also suffered from a fever of . °c ( . o f). at that point x-ray of her right lower leg was performed with report describing pathologically changed structure of tibia and she was referred to our university centre. ( ) (suppl ):s -s pediatr radiol we made a second reading of the plain film, reporting sclerotic heterogeneous bone structure of the right tibial diaphysis and distal metaphysis, onion-like periosteal reaction with sunburst spiculation and cortical bone destruction. her laboratory results were: crp . mg/l, ld . μkat/l, nse . μg/l, ferritin μg/l. crp has been raising for a week to mg/ l, then decreased to normal level. differential diagnosis was established as a primary bone malignancy (especially es) or, less likely, an osteomyelitis. mri revealed pathological signal of bone marrow of diaphysis of the whole tibia with cortical scalloping and periosteal spiculated apposition. epiphyses were spared. dorsal cortical bone was interrupted with extraosseal spread of the process. intraosseal part enhanced heterogeneously, whereas extraosseal component enhanced almost homogeneously after contrast medium administration. total size of the tumour was assessed as x . x mm ( . ml) . adjacent muscles were oedematous with post-contrast enhancement. there were also few enlarged lymph nodes in popliteal region. results from the biopsy confirmed ews with positive ews/fli gene. tumour was assessed as a localized disease, enneking iib. patient underwent chemotherapy according to aews doc protocol and a knee-exarticulation with no traces of tumour in resection lines. nowadays she is in the first complete remission. x-ray: ap view mri: etw _tse postcontrast, sagittal view, pre-treatment mri: etw _tse postcontrast, sagittal view, after initial treatment unique teaching points: ewing sarcoma belongs to common primary bone tumours in children but is a very rare unit in infants. despite the age predilection it is necessary to consider this diagnosis even in children younger than one year of age. scimitar syndrome together with pulmonary sequestration and horseshoe lung: congenital pulmonary venolobar syndrome b.e. derinkuyu, h.n. Özcan, y. tasci-yildiz, h g. cınar, u.a. orun; ankara/tr objective: congenital pulmonary venolobar syndrome (cpvls) comprises of a spectrum of pulmonary developmental anomalies. the main components of cpvls are hypogenetic lung partial anomalous pulmonary venous return, absence of pulmonary artery, pulmonary sequestration, systemic arterialization of lung, absence of inferior vena cava. minor components of cpvls include tracheal trifurcation, eventration and partial absence of the diaphragm, phrenic cyst, horseshoe lung, esophageal and gastric lung, anomalous superior vena cava, and absence of the pericardium. in this case presentation, we present a baby with scimitar syndrome, pulmonary sequestration, horseshoe lung and right aberran subclavian artery. a month-old girl was admitted to our hospital with the suspicion of scimitar syndrome from a different hospital. she did not have any symptoms. the physical examination was unremarkable. on plain radiograph, the baby had dextrocardia. there was a doubtful tubular structure with the shape of scimitar and a nodular radioopacity behind the heart (figure ). transthoracic echocardiography demonstrated the dextrocardia, atrial septal defect and the right pulmonary artery hypoplasia. afterwards, the ct angiography was done for confirmation of scimitar syndrome and other accompanying abnormalities. on the ct angiography, there was a partial anomalous pulmonary venous return to the suprahepatic inferior vena cava known as scimitar syndrome. besides this, there was a right pulmonary extralobar sequestration in the lung base. the arterial supply was arising from the celiac trunk, while the venous drainage was going directly to the inferior vena cava. therefore, the right lung was hypoplastic of which the tongue of the right pulmonary parenchyma passing between the aorta and heart, appearing confluent with the left lung in a horseshoe configuration. there was dextrocardia and right aberran s ( ) (suppl ):s -s pediatr radiol subclavian artery. the patient was subjected to catheterization and angiography for treatment. on plain radiograph, the baby had dextrocardia. there was a doubtful tubular structure with the shape of scimitar and a nodular radioopacity behind the heart unique teaching points: the term cpvls is an umbrella to a group of pulmonary parenchymal and vascular anomalies that may present in combination. mdct is a helpful diagnostic tool in the preoperative evaluation for delineation of the components of this syndrome. congenital pulmonary venolobar syndrome refers to a wide spectrum of pulmonary developmental anomalies that may appear single or in combination. the main components of congenital pulmonary venolobar syndrome are hypogenetic lung (including lobar agenesis, aplasia, or hypoplasia), partial anomalous pulmonary venous return, absence of pulmonary artery, pulmonary sequestration, systemic arterialization of lung, absence of inferior vena cava, and accessory diaphragm. in this case presentation, we describe a child with scimitar syndrome, bilateral sequestration, hypogenetic lung (single lobed left lung) and right aberran subclavian artery. an year-old syrian girl was admitted to our hospital with the history of heart defect. she did not have syncope or ciyanosis whereas she has easy fatigue and palpitation. on plain radiograph the anomalous draining vein was seen as a tubular structure paralleling the right heart border in the shape of a turkish sword ("scimitar") ( figure ) . transthoracic echocardiography demonstrated the scimitar vein as well as large patent ductus arteriosus (pda), atrial septal defect and left pulmonary hypoplasia. afterwards, the ct angiography was done for confirmation of scimitar syndrome and other accompanying abnormalities. on the ct angiography, there was a partial anomalous pulmonary venous return to the suprahepatic inferior vena cava known as scimitar syndrome. besides this, there was a bilateral intralobar pulmonary sequestration in the lung bases. the arterial supply of the right side was arising from the celiac trunk, while the left side feeding artery was originating directly from the descending aorta. therefore, the left lung had a single lobe with single pulmonary vein draining to left atrium. there was a large pda and right aberran subclavian artery. the patient was subjected to catheterization and angiography for treatment. the right sided anomalous draining pulmonary vein and the feeding artery of the right sequestration were closed in the first session. the procedure was completed without any complication. afterwards, the closure of the feeding artery of the left pulmonary sequestration and the pda were planned in the next sessions. on plain radiograph the anomalous draining vein was seen as a tubular structure paralleling the right heart border in the shape of a turkish sword ("scimitar") unique teaching points: congenital pulmonary venolobar syndrome comprises a heterogeneous group of uncommon abnormalities that may occur in combination. diagnosis of congenital pulmonary venolobar syndrome can be confirmed by ct angiography that allows detailed evaluation of vascular, tracheobronchial, and pulmonary parenchymal abnormalities with a single short, noninvasive procedure. neck infection disclosing diagnosis of congenital fourth branchial arc anomaly in a girl h.n. Özcan, z. aycan, b. ardıclı, m. haliloglu; ankara/tr objective: congenital branchial arc anomalies are rare entities. herein, we describe the imaging findings of acute suppurative infection of the neck caused by fourth branchial fistula in a child. case presentation: an -year-old girl presented to our pediatric emergency department with fever, left sided neck swelling and redness. her complaints were started five days ago. on her physical examination, there was a x cm, stiff, painful mass lesion with redness on the left side of the neck. blood count and thyroid function tests were in normal range; however, c-reactive protein level and erythrocyte sedimentation rate were elevated. neck ultrasonography revealed diffuse soft tissue swelling, a hypoechoic mass consistent with abscess in the left thyroid lobe and perithyroid tissue. the left lobe of the thyroid gland had poorly defined margin and a focus of air. contrast-enhanced neck mr imaging demonstrated an abscess in the left thyroid and perithyroid tissue ( figure ) and enhancement of the soft tissue plane around the left pyriform fossa (figure ). barium swallow revealed the sinus tract originating from the left pyriform sinus apex. the patient was operated after antibiotic treatment and sinus tract was surgically excised. the aim of this report is to describe three cases of right kidney wilms' tumor with cavoatrial tumor extension, referred to our institution between january and september . case presentation: three children, two girls ( and years old) and one boy ( years old) were admitted at the emergency service with cardiac failure symptoms; the latter had also liver failure. echocardiography showed right atrial thrombus in all three patients, as an extension of massive obstructive thrombosis of the inferior vena cava (ivc). abdominal ultrasonography revealed in all patients a right renal mass, associated to right renal vein thrombosis that extended to the ivc and to the right hepatic vein. contrast enhenced computed tomography confirmed findings. patients were treated primarily with chemotherapy before surgery, with partial regression of the thrombus in two patients and no response in one. ( ) (suppl ):s -s pediatr radiol unique teaching points: wilms' tumor is the most common renal malignancy in children and its intravascular extension is a well-recognized event. incidence of tumor extension to inferior vena cava (ivc) is reported to be of - % and intra-atrial extension of , - , %. it occurs most commonly in tumors located in the right kidney (probably due to the shorter path of the right renal vein compared to the left one). this complication does not directly influence the prognosis of malignancy, but the degree of intravascular extension determines technical surgical strategy and increases difficulty of the surgical procedure, especially when there is intracardiac involvement, which increases morbidity. several classifications have been proposed in the adult age group, but due to the similarity of the degree of intraoperative difficulty, the same classifications are used in children. pritchett et al. ( ) described the relation between thrombus and hepatic vessels: level i -intrahepatic intravascular extension; level iiintrahepatic extension; and level iii -suprahepatic or atrial extension. staehler et al. ( ) proposed a different classification that was posteriorly modified and detailed by daum ( ) : stage i -small extension (thrombus size within ivc < cm); stage iilarge thrombus (> cm within the ivc), but still below the hepatic vessels; stage iii -thrombus extending to the level and above the hepatic vessels; stage iv -intra-atrial thrombus. a year old boy presented with a soft tissue mass in his forearm which appeared to have grown quickly in size over a period of three to four months. physical examination demonstrated a welldefined mass in the dorsal aspect of the forearm with no pulsatile bruit. intial differentials included a vascular anomaly or a sarcomatous lesion. the patient proceeded to have an ultrasound examination which revealed a very well-defined heterogenous subcutaneous mass, mostly solid in substance. the lesion measured . cm x . cm x . cm (transverse x length x depth). there was no evidence of muscle invasion. prominent internal arterial vascularisation was demonstrated and the mass was classed as inderminate in nature. subsequent mr findings demonstrated a mass with t signal isointense to muscle, hyperintense t signal and marked homogenous enhancement. small foci of intralesional t hyperintensity and larger areas of t * gradient hypointensity were noted, in keeping with small areas of intralesional blood. vessels were seen to extend from the subcutaneous fat into the lesion. the mass slightly distorted the underlying extensor muscles and tendons of the forearm but there was no deep extension across the fascia. findings deemed the lesion to be more malignant in nature. the patient underwent incisional biopsy and histological findings confirmed a diagnosis of angiomatous fibrous histiocytoma. these tumours are rare soft tissue tumours which most commonly occur in children, adolescents and young adults. while it is rare, there is a potential for local recurrence and metastasis. therefore, it is essential to identify these tumours where possible or at least consider them as a differential for a soft tissue mass in a child. the surgeon commented that the imaging findings and report were essential in making the initial decision about whether to perform an incisional or excisional biopsy as the best treatment for the tumour is wide surgical excision with clearance of margins. unique teaching points: angiomatous fibrous histiocytomas are rare lesions with potential for recurrence and metastasis and therefore should be identified and managed appropriately as a malignant tumour. they are often confused as soft tissue haemangiomas or complex haematomas. it is very important to be aware of the presentation and imaging findings, remembering this form of tumour as a key differential for a soft tissue mass. nasopharyngeal anlage tumor in a neonate with the initial presentation of respiratory difficulty: correlation between imaging and clinicopathologic findings p.-s. tsai, d.-c. lin, s.-l. shih; taipei/tw the etiologies of nasal or nasopharygeal obstruction are variable in neonates. the respiratory symptoms are varied in these cases. mass lesions in nasal cavity or nasopharynx are extremely rare during the neonatal period. however, we must keep it in mind when respiratory problems occur in the neonatal period. here, we report a case presenting with sleep apnea resulting from nasal obstruction by a rare benign salivary anlage tumor in nasopharynx and discuss the imaging findings as well as clinicopathologic characteristics. the -day-old female infant had loud breathing sound, slow feeding and sleep apnea since birth. nasal endoscope and laryngoscope disclosed a polypoid tumor in nasopharyngeal cavity with a stalk connecting with posterior nasal septum. further magnetic resonance imaging (mri) revealed a lobulated mass about . cm in greatest diameter occupying posterior nasal cavity to the nasopharynx that was intermediate signal intensity on t -weighted/t -weighted images and heterogeneous gadolinium enhancement. the patient then received endoscopic resection. the tumor was shown locating in nasopharyngeal cavity and having a stalk from posterior nasal septum, partially occluding the choanae as well. resected tissue fragments displayed tan and whitish in color grossly. microscopic examination demonstrated duct-like structures and mesenchymal elements in a nodular pattern which are typical features of salivary gland anlage tumor. until now, there is no tumor recurrence for four years. unique teaching points: "salivary gland anlage tumor (sgat)" was firstly introduced in a report by dehner et al in . the tumor that has histologic resemblance to the developing salivary gland, is believed to be a hamartoma originating from minor salivary gland rather than a true neoplasm. congenital sgat displays male predilection and is a rare cause of neonatal airway obstruction. the mass is usual in the midline and attached to the posterior nasal septum or posterior nasopharygeal wall by a delicate pedicle. favorable results with simple excision are obtained. once massrelated airway obstruction is established, further examination with computed tomography (ct) or mri is helpful in anatomic evaluation, size measurement, characteristics definition and intracranial involvement. if mass induced airway obstruction is suspected in a neonate and sgat is considered based on imaging studies, invasive procedure should be careful due to the potential of tumor dislodgement from its fine pedicle resulting in complete airway obstruction. the association of intussusception with malrotation is referred to as waugh syndrome. [ ] malrotation occurs in approximately in live births. [ ] the incidence of malrotation amongchildren with intussusception is %. we hereby present a case report of waugh's syndrome associated with midgut volvulus. case presentation: a month old male child reported to the emergency department with the clinical history of vomiting, abdominal distension, bloody mucoid stools and incessant cry. routine blood examination revealed hb: . gm%, tlc: /cu mm, plt- . lac/cu. mm. ultrasound (us) examination was performed and it revealed dilated fluid-filled small bowel loops with moderate amount of free fluid, right iliac fossa showed bowel within bowel appearance suggestive of target/pseudo kidney sign of bowel intussusception. no pathologic lead point was identified. transverse ultrasound image through the upper abdomen showed superior mesenteric vein noted to the left of the superior mesenteric artery hence malrotation should be considered. in view of surgical emergency non contrast enhanced ct was done and axial image showed target/sausage shaped soft tissue density mass it had alternating areas of low and high attenuation due to bowel wall and mesentry. on emergency laparotomy patient was found to have intestinal malrotation with duodenojejunal junction on the right of the midline and mid gut volvulus in clockwise direction. intussusception with terminal ileum (gangrenous), caecum, appendix, whole of ascending colon, transverse colon were telescoping into descending and sigmoid colon. the volvulus was derotated and the in tussusceptum was reduced. the gangrenous terminal ileum and appendix was resected and ladd's procedure was done, a diverting ileostomy was created. the patient recovered uneventfully after which an ileo-colonic anastomosis was created transverse ultrasound shows a mass with a swirled appearance of alternating hypoechoic and hyperechoic "bowel-within-bowel" appearance (target sign) unique teaching points: on ultrasonography multiple, concentric, target like appearance of wall layers of invaginated segments (target sign) on axial scan, as well as pseudokidney sign (sandwich sign) on longitudinal scans were accepted as diagnostic criteria for intussusception. [ ] it can assess the relative positions of the smv and sma which are mostly abnormal in malrotation. upper gastrointestinal contrast study is the imaging reference standard for diagnosis of malrotation with or without volvulus. abnormal position of the duodeno-jejunal junction. spiral, "corkscrew" or z-shaped course of the distal duodenum and proximal jejunum, and location of the proximal jejunum in the right abdomen. [ ] a high degree of clinical suspicion and radiologist's awareness of this entity is helpful in guiding the surgeons towards diagnosis and prevention of morbidity and mortality. a rare case of epidermal naevus syndrome p. joshi; pune/in to acquaint the radiologists with the entity of epidermal nevus syndromes (enss) which are a group of rare complex disorders characterized by the presence of skin lesions known as epidermal nevi associated with additional extra-cutaneous abnormalities, most often affecting the brain, eye and skeletal systems case presentation: this one and a half year old child was referred to us for neuroimaging. he had multiple hairy naevi over his face, limbs including the palms, since birth, associated with blackish discolouration of his entire trunk. unique teaching points: epidermal nevi are overgrowths of structures and tissue of the epidermis, the outermost layer of the skin. the different types of epidermal nevi can vary in size, number, location, distribution and appearance. neurological abnormalities that can be associated with enss can include seizures, cognitive impairment, developmental delays and paralysis of one side of the body (hemiparesis). skeletal abnormalities can include abnormal curvature of the spine, the term "epidermal nevus syndrome" has generated significant controversy and confusion in the medical literature. originally, the term was used to denote a disorder that was actually several different disorders erroneously grouped together. in the recent past, the term was used to denote a specific disorder now known as schimmelpenning syndrome. however, the term epidermal nevus syndrome could be correctly applied to several different disorders. therefore, the umbrella term "epidermal nevus syndromes" now represents a group of distinct disorders that have in common the presence of one of the various types of epidermal nevi. however, there is so far no general agreement how to classify the types of this diverse group of disorders, adding to the confusion within the medical literature. these disorders are quite different from one another and are not "variants" of each other as is sometimes mistakenly stated in the medical literature. in the future, as the genetic molecular basis of these disorders is better understood, the classification may change or expand. bilateral axillary lump in a newborn diagnosed as hematoma h.n. Özcan, u. aydingoz, m. haliloglu; ankara/tr objective: most birth traumas are self-limiting and have a favorable outcome. injuries to the infant that result from mechanical forces during the birth process are not uncommon. they occur most commonly on head and neck after vaginal breech delivery. however, soft tissue hematomas can be rarely seen after caesarian section (c/s). herein, we describe imaging findings of a newborn with bilateral axillary lump diagnosed as hematoma. case presentation: a -year-old woman was admitted to an outside hospital at weeks' gestation for c/s due to prior caesarean operation. it was her fourth pregnancy (g p ). the pregnancy was unremarkable and she had normal ultrasounds at gestation. there was no history of trauma or fall during antenatal period. according to the c/s reports, the process of operation was uneventful any undue prolongation and without having used any other instrumentation. the weight of the female baby was . kg at birth. on the rd postnatal day, her mother noticed a left axillary swelling, then admitted to a tertiary children's hospital. her physical examination revealed, bilateral axillary asymmetry with a fluctuant, nontender swellings. there was no redness or discoloration of the skin. there was no clinical feature suggestive of trauma or bleeding diathesis. a superficial ultrasonography showed solid heterogeneous, hyperechogenic masses x mm in the left axillary region and x mm in the right side. doppler study did not reveal any flow in the masses. contrast enhanced mr imaging demonstrated, bilateral axillary mass lesions with fluid levels and smooth contours (figure and ) . t w images demonstrated hyperintense component suggesting hemorrhage. after the administration of the gadolinium-based contrast material, lesions showed peripheral enhancement (figure ) . a diagnosis of hematoma was entertained. the child was managed non-operatively. she was monitored clinically and radiologically. follow-up ultrasounds scan revealed significant regression of the swellings. unique teaching points: soft tissue hematomas can be rarely seen in newborns. the formation of axillary hematoma on the background of c/s is a rare complication, which, to the best of our knowledge, has not been previously reported. ultrasonography and mr imaging readily depicts hematoma and aids in the differential diagnosis. colorectal carcinoma (crc) is extremely rare in pediatric age, with an estimated annual incidence of approximately case per million individuals. the majority of reported cases occur in adolescence, while the incidence is further lower for children under years. the distribution between males and females is not equal, with higher prevalence in males (ratio of : ). the etiology in children is unclear as these tumors are often sporadic and not linked to a preexisting adenomatous polyp, unlike adults. predisposing factors such as familial polyposis of the colon, other polyposis syndromes, ulcerative colitis and familial multiple cancer syndromes were reported in % of cases. advanced stage at diagnosis, aggressive histologic subtypes (poorly differentiated, signet ring and mucinous adenocarcinoma) and poor survival are the hallmarks of pediatric crc. case presentation: a -year-old male presented with a history of dyspeptic symptoms (recurrent epigastric-right flank colic pain and heartburn) for the last eight months, without evidence of irregular bowel function. after a prior diagnosis of esophagitis secondary to a gastroesophageal reflux disease, physical and laboratory examinations revealed anorexia, progressive body weight loss, microcytic iron deficiency anemia and positive fecal occult blood test. during an emergency access, abdominal ultrasound identified rounded target liver lesions and circumferential heterogeneous mural thickening of the ascending colon. contrast-enhanced computed tomography scan (cect) demonstrated a marked circumferential wall thickening of the ascending colon and cecum with a longitudinal extension of mm and thickness of mm; the mass contained lowdensity areas and calcifications. furthermore hypovascular hepatic lesions along with lymph node metastases containing calcifications were identified. no lung metastases were found. histopathological analysis confirmed the diagnosis of metastatic colon adenocarcinoma. after chemo-and radio-therapy, only the hepatic lesions showed reduction in size and number. the patient subsequently underwent right hemicolectomy. one month after surgery he is in a rigorous follow-up through ultrasonographic evaluation of pleural effusion and ascites and cect. unique teaching points: crc, although rare, should be suspected in children presenting with unexplained persistent abdominal pain, progressive body weight loss and positive fecal occult blood test. ultrasound imaging can be appropriate in the preliminary detection of abnormal bowel wall thickening, lymph node and liver metastases; cect is mandatory to confirm the radiological diagnosis and complete the staging. to increase awareness of this rare syndrome and its varied presentation in order to facilitate its early diagnosis and treatment to prevent poor prognostic outcomes. case presentation: lemierre syndrome is a rare disease characterized by an initial infection of the head and neck leading to the development of a septic thrombophlebitis which has a propensity to spread and involve the jugular and facial veins. this progressive infection then leads to the development of metastatic septic emboli to the respiratory tract. we present the case of a year old boy who attended with a week history of fever and a cough. initial imaging on admission demonstrated a large left sided hydropneumothorax with multiple cavitating lesions throughout the lung parenchyma in addition to thrombosis of some of the segmental pulmonary veins. the hydropneumothorax was surgically drained and the patient was transferred to the paediatric intensive care unit after further deterioration with the development of a broncho-pleural fistula. following a short course of antibiotics there was no clinical or radiological improvement and sputum cultures grew coliform organisms which raised suspicion for a more distant source. when pus was noted to be discharging from the left ear, a contrast enhanced ct of the head and neck revealed a left mastoiditis with multiple cerebral abscesses and occlusive thrombi in the left jugular vein, transverse venous sinus, sagittal and straight sinuses. following this diagnosis antibiotic therapy was modified and targeted at anaerobes, which was vital in assisting the patients recovery and successful discharge home. unique teaching points: clasically the majority of lemierres syndrome begins in the oropharynxinvolving the palantine tonsils and peritonsillar tissue often presenting with fever, sore throat and neck pain. our case demonstrates an atypical presentation with sepsis and respiratory symptoms as a result of the septic emboli which delayed diagnosis. we have learnt from this case the importance of considering lemierres syndrome in patients presenting with signs of a respiratory infectionin particular cavitating pulmonary lesions-that have not improved with conventional therapy and to have a low threshold to investigate the head and neck as a potential source of infection. when the working hypothesis of meningitis could not help e. kovacs , n. pinter , g. balázs , a. machovitsch , a. arany , z. liptai , l. fonyad , p. benke ; budapest/hu, amherst/us objective: neuroinfection still represents a diagnostic challenge in the everyday practice, where clinical evaluation, imaging, laboratory and pathological workup and treatment goes hand in hand under the pressure of time. we summarized a case in which, despite the extensive multilateral collaboration the battle was lost, to bring attention to the possible causes. a two year old, previously healthy female was taken to the emergency department for altered state of consciousness and fever. she also suffered from gingivitis. the unconscious child underwent an emergency ct scan: hydrocephalus with signs of raised intraventricular pressure was detected. subsequently mri of the head and spine was performed, and showed signs of diffuse leptomeningeal enhancement with basal predominance. multiple dwi restricted parenchymal lesions with basal predominance were also found. repeated csf and blood tests did not reveal any causative organism, although the gradually increasing crp suggested infection. two weeks after the onset of symptoms a follow up mri study showed extensive cerebral and spinal swelling with no focal lesion. the child passed away three days later due to cardiac failure. autopsy and neuropathological evaluation could not reveal the cause of the disease, which was identified only weeks after the child died, by culturing sputum and csf. unique teaching points: an overview of the clinical and radiological presentation of meningitis basilaris is carried out. attention is given to the circumstances, when tuberculotic infection should be suspected, and antituberculotic treatment should be started, even before the confirmation of the presence of mycobacteria can be obtained. to describe the clinical, laboratory and mri findings of chronic nonbacterial osteomyelitis(cno) in a patient with a negative radiograph and emphasize useful imaging findings, including an unusual radial pattern of edema in both femoral heads. case presentation: a -year-old adolescent, was referred with progressive debilitating hip pain and inability to walk since days, that was unsuccessfully treated with non-steroidal anti-inflammatory drugs. during hospitalization he developed fever up to ο with normal full blood count and smear, elevated esr ( mm/h) and crp ( . mg/dl), positive serologic markers for streptococcus (asto) and ebv and received antibiotics with relative good response. blood cultures did not grow any pathogens, the rest of serology was negative for acute infection, tuberculin skin test was negative and immunological investigation was unremarkable. pelvic radiographs were negative. mri showed a symmetric pattern of bone marrow involvement around both triradiate cartillages, at both femoral heads and ( ) (suppl ):s -s pediatr radiol major trochanters. complementary evaluation of tibial areas with a limited protocol disclosed asymptomatic involvement of tibial epiphyses and apophyses. a radial pattern of edema was seen at the femoral heads with alternating stripes of involved and uninvolved areas. clinical course and imaging appearances were highly suggestive of cno. rapid clinical improvement occurred during hospitalization while a repeat mri months later showed complete resolution of hip findings and the patient was free of any symptoms or signs. coronal stir sequence at presentation showing the radial pattern of bone marrow edema (arrowheads) alternating with stripes of normal marrow (*) at both femoral epiphyses. note hyperinense edema (arrows) around triradial cartillages. coronal stir sequence showing the predilection of bone marrow edema symmetrically around triradial cartillages (arrows) and at major and minor trochanters (arrowheads). coronal stir sequence at -months follow-up shows resolution of edema. unique teaching points: cno is a not well known chronic autoinflammatory bone disorder affecting primarily children and adolescents. positive serology for streptococcus or other infectious agents has been previously reported as in our case and may be a triggering factor. striking mri findings with a negative radiograph may occur at initial stages. symmetrical distribution of non-specific bone marrow edema around epiphyses and apophyses is highly suggestive of the diagnosis in the appropriate clinical setting and following exclusion of suppurative bone infections as well as bone or hematologic malignancies. the radial pattern of edema in our patient is unusual and considered to comply with the direction of main trabecular systems in femoral heads. in / chest cts, nodules (median size . mm) were detected. display mode a with mm mip yielded the best interreader variability (κ= . ) and the highest sensitivity ( . %) compared to mode b and c (κ= . , sensitivity . % and κ= . , sensitivity . %, respectively). perifissural nodules were detected in all subgroups. conclusion: mip improves the detection of pulmonary nodules in chest cts of young children, but overall interreader agreement is only fair. nodules, including perifissural nodules, occur in children with and without malignancy. images were subsequently read and interpreted by board-certified radiologists and nuclear medicine physicians in communal reading. in case of identifying suspicious lesions in cect additional imaging (mri) or biopsy was performed. compared to pet/ct employing only low dose ct (ldct), the use of cect resulted in the identification of additional suspicious lesions in patients. furthermore the use of cect allowed us to qualify lesions as benign/ physiologic which in pet/ldct were identified as suspicious and lesions suspect for metastases or tumor. in those patients who received combined integrated fdg pet/ct including both ldct and cect the ctdi ranged in between , - . mgy (n= . mgy) and the dose length product (dlp) ranged in between . - mgy *cm (n= . mgy *cm) specificity was significantly higher combining pet and ct compared to stand-alone ct and pet. our study showed that the acquisition of cect in combined integrated pet/ct leads to an increased specificity and thus represents an essential component of a good fdg pet/ct in pediatric oncology. in assessment of lymph nodes, inflammatory foci and liver lesions diagnostic contrast enhanced ct is essential. comparison of the detectability of ubos in neurofibromatosis type i patients with proton density-weighted and flair sequences in t mri l. porto, s. lescher, n. hillenbrand; frankfurt/de objective: neurofibromatosis type (nf ) is an autosomal-dominant congenital disease. in nf patients, significant numbers of so-called unidentified bright objects (ubos) can be found in brain imaging, with predilection sites at the basal ganglia and the dentate nucleus. ubos seem to develop at a very early age, contrary to other criteria leading to diagnosis. the detection of ubos might therefore prove helpful in the early diagnosis of nf , complementing the clinical diagnosis based on criteria of the "national institutes of health consensus development conference". the aim of the study was to investigate whether the detectability of ubos increases at t by comparing proton density-weighted images (pdw) with fluid-attenuated inversion recovery (flair) sequences. a total of nf patients ( male, female, between and years old, mean age . years) were examined by a t magnetic resonance scanner. the presence of ubos was evaluated on pd-w and flair images by evaluators ( experienced neuroradiologists, junior radiologist and student in his final year). detectability was rated by a three-point scoring system for dedicated regions: lesions which were "well defined/detectable", "suspicious" or "detected after a second look". the wilcoxon signed-rank test was used for comparisons between the raters. the level of significance was p< . . significantly more lesions were marked as "well defined/detectable" in the pd-w sequence compared to flair (p< , for all four evaluators together, as well as for each evaluator separately). in particular, pd-w proved to be superior for detecting ubos located in the medulla oblongata (p= , ) dentate nucleus (p= , ) and hippocampal region (p= , ), regardless of the level of the raters' experience. this is the first study that compares flair and pd-w at t for the diagnosis of ubos in nf . significantly more ubos are detected in the pd-w compared to flair sequences, especially for the infratentorial regions. as ubos occur at very early stages of the disease in patients with suspected nf , pd-w might aid an early diagnosis in these patients. assessment of radiation doses from diagnostic imaging in the followup of paediatric oncology patients p. logan , r. harbron , k. mchugh ; london/uk, newcastle-upon-tyne/uk objective: previous literature ( , ) has suggested paediatric oncology patients accumulate a large radiation burden as a consequence of routine diagnostic imaging examinations during therapy. we retrospectively looked at the effective doses from routine ct and nuclear medicine in three cohorts of children, namely patients with hepatoblastoma, wilms' tumours and rhabdomyosarcoma (rms). of note, in our centre we rely on repeated mris of the primary site for many tumours. effective doses (e), in millisieverts (msv), were estimated using the ncict dose estimation tool (lee et al ) , based on details specific to each procedure: patient age, scan region, scanner type and ct dose index (ctdi -an indicator of radiation exposure recorded at the time of each scan). doses for general radiography were estimated using pcxmc v . monte carlo simulations, assuming standard exposure factors and field size. there were patients in total ( hepatoblastoma, wilms', rms). there were boys. the mean age was years months (ranging from days - years months). the mean and median cumulative effective doses from ct for the whole cohort were . msv and . msv respectively. four patients in the wilms' cohort had a dmsa nuclear scintigram ( . - . msv), no hepatoblastoma patient had any nuclear medicine imaging, and patients with rms received a bone scan ( - . msv) or a pet scan (approximately msv). cumulative radiation doses from routine radiological investigations in paediatric oncology can be kept in a much lower range than reported in the literature ( , ). in our institution, the followup of solid intra-abdominal tumours with mri, with additional ct or nuclear medicine only when clinically justified, has resulted in a significantly low radiation exposure in these patient cohorts. mri of the primary tumour site should be implemented as a replacement for ct imaging when there is no significant detriment to the diagnostic information obtained. ( ) (suppl ):s -s pediatr radiol mri-based evaluation of multiorgan iron overload is a predictor of adverse outcomes in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation f. zennaro , d. zanon , r. simeone , g. boz , f. degrassi , m. gregori , g. schillani , c. boyer , n. maximova ; nice/fr, trieste/it objective: iron overload is associated with poor clinical outcomes in patients undergoing allogeneic hematopoietic stem cell transplantation (hsct). although the effects of hepatic and cardiac siderosis on patient outcomes have been extensively studied, less is known about the effects of siderosis in other organs. the medical records of consecutive pediatric patients who underwent allogeneic hsct in our institute from to were retrospectively reviewed. mri was used to measure iron concentrations in the liver, spleen, pancreas and bone. these patients were divided into two groups, with non-elevated (< μmol/g; group ) and with elevated (> μmol/g; group ) liver iron concentration (lic) at baseline. in group , only two patients had normal iron concentrations in all organs. none of the patients of group presented with pathological iron concentrations in only two organs. comparisons of baseline data with results of the first follow-up mri performed - months after hsct, showed a general worsening of iron accumulation. in group , none of the patients showed complete absence of iron overload in a single organ. in group , none of the patients showed a total absence of siderosis involving fewer than three organs. this study confirms the correlations between iron overload and the risks of transplant-related complications, such as transplant related mortality, sinusoidal obstruction syndrome, infections, pancreatic insufficiency, and metabolic syndrome, in transplant recipients with systemic siderosis. another important finding of this study was the close correlations between pre-transplant bic and times to neutrophil and platelet engraftment (p< . each). ( ), ganglioneuromas (gn, ) and ganglioneuroblastoma (gnb, ), examined by t mri were retrospectively grouped according to tumor entity, risk factors (bone marrow metastasis, mycn amplification or p deletion) and therapeutic regime (observation versus chemotherapy). dw (b values , and ) and conventional mri images (t , t pre and post contrast) were analyzed for tumor size, relative si-and absolute adc-values at baseline (base; no therapy), and after (fu ) and (fu ) months. adc values in nb were lower than in gnb and gn ( . * - mm /s versus . * - mm /s; p< . ). there was a tendency towards lower adc values in tumors with risk factors (n= ) versus no risk factors (n= ) at baseline, which did not reach statistical significance (p= . ). during follow-up shrinkage of tumor volume was noted (baseline ml, fu ml, fu ml; p< . baseline vs. fu ; p= . baseline vs. fu ). in the observation group, tumor adc values rose without relapse ( . * - to . * - mm /s). only in eventually relapsing tumors adc values tended to decrease further ( . * - to . * - mm /s, p= . ), despite initial reduction in tumor size. to establish inter and intra-observer variability in the radiological detection and assessment of pulmonary nodules at diagnosis in children with wilms tumours. a test set of ct thoraxes at diagnosis from patients enrolled in the multicentre 'improving population outcomes of renal tumours of childhood' (import) study in the uk were assessed. five radiologists ( chest, paediatric) from different centres ( uk, netherlands) completed a scoring sheet for nodule assessment on the same studies on two occasions, months apart. the readers were blinded to patient respiratory symptoms, the original radiology reports and also that they were scoring identical cases. descriptive statistics, modified bland altman graph and fleiss kappa scores were used for statistical assessment. in total, different pulmonary nodules across the ct thoraces at both rounds were scored by at least one reader. ( %) were seen by at least one reader in round and ( %) in round , ( . %) nodules were seen by at least one reader in both rounds. only ( %) nodules were scored by all readers in round , ( %) by all readers in round , and ( %) nodules by all readers in both rounds. of the nodules seen in the first round, were measured to be > mm in at least one dimension and of these, were classified as malignant by all readers. the limits of agreement for mean difference in nodule size in anterior-posterior, transverse and longitudinal measurements were ± . mm, ± . mm and ± . mm respectively. the fleiss kappa scores ranked from poor to fair agreement for nodule border smoothness ( . ), nodule shape ( . ), solidity ( . ) and impression of malignancy ( . ). within the same readers for both rounds, nodule detection rates of agreement were between . - . %. the average intra-reader percentage of observed agreements for nodule border smoothness, shape, solidity and impression of malignancy were . %, . %, . % and . % respectively. conclusion: detection and characterisation of pulmonary nodules on ct thorax shows both intra-and inter-observer variability. this has important implications for the interpretation of metastatic disease at presentation. fever without a focus is defined as febrile illness without an initial obvious cause or localizing signs. our aim is to assess the diagnostic value of whole-body mri (wb-mri) in the diagnostic work-up of children with fever without a focus. we retrospectively searched for subjects who underwent wb-mri for fever without a focus. a total of children (m= , f= ), mean age . years (range: . - . ) were included. / ( . %) subjects were immunosuppressed and / ( . %) subjects were hospitalized at onset of fever. the reference standard was based on positive cultures, biopsy or surgery. when this was not possible, a probable diagnosis was made based on clinical follow-up or serology. initially, the wb-mri images were reviewed independently by pediatric radiologists blinded to all clinical information. at the end of each case the final diagnosis and the diagnostic category ( categories: a. normal, b. infection, c. oncologic, d. rheumatologic, e. miscellaneous) was recorded. this was followed by a consensus read for comparison with the reference standard. for statistical analyses all subjects were treated as fever without a focus. results: reference standard: the diagnostic category of the reference standard was as follows: infectious / ( . %), oncologic / ( . %), rheumatologic / ( . %), miscellaneous. / ( . %). even after extensive work-up in / ( . %) no clear cause for the fever was found table . wb-mri: wb-mri diagnosed the cause of fever without a focus in / subjects ( . %) ( table ). in subjects ( . %) wb-mri results were falsely positive ( jia and myositis), and in the remaining subjects no imaging findings compatible a cause of febrile disease were found. interobserver agreement was fair (kappa . ). in children with fever without a focus wb-mri provided the diagnosis in in almost a quarter of the cases. given the multiplicity of causes of fever without a focus, some of them not possible to visualize on mr imaging, wb-mri may be considered in routine imaging practice when evaluating pediatric patients with fever without a focus. to compare linear measurement/volume to direct volumetric measurements using dimensional( d) post-processing software. for this irb approved study initial diagnostic ct or mr exams in patients( mo- yr) with solid tumors were reviewed by radiologists and technologists. radiologists recorded measurements in axes in their routine method, described tumor shape (sphere, ellipse, cone) and surface texture (smooth, almost smooth, or mildly, moderately, markedly irregular). three technologists individually, and radiologists by consensus, used d processing software (intellispace portal, philips, cleveland, oh) to directly measure tumor volume. tumor volume (v) was calculated from linear measuments using the following equations: sphere v= / πr , ellipsoid v= πr or πr , conicalv= πr or πr , and cuboid v=(xyz). inter-reader variability in tumor measurement in all tumors and for tumors divided by surface characteristics was assessed amongst radiologists and technologists, and radiologist consensus using coefficient of variation (cov). tumor shape analysis was reported as sphere, ellipse, cone, and surface texture smooth, almost smooth, mildly irregular, moderately irregular, markedly irregular. inter-reader variability of as much as , cc above to cc below the mean tumor volume was found when using radiologist determined linear measurements, with standard deviation (sd), range . - . inter-reader variability amongst technologist derived volumes was considerably less, range cc above to cc below the mean, with sd, range . - . cov analysis shows a greater degree of variation in tumor volume calculated from linear measurements [smooth( %), almost smooth( %), mildly( %), moderately( %), markedly( %) irregular] than direct volume determination [smooth( %), almost smooth( %), mildly( %), moderately( %), markedly( %) irregular]. variation was significant only for tumor with irregular surface texture [smooth (p= . ), almost smooth (p= . ), mildly (p= . ), moderately (p= . ), or markedly (p= . ) irregular]. variation in linear/volume measurements in very irregular tumors. light blue=middle % tumor volume measurements by pediatric radiologists. whiskers mark limits of range. ▲♦ • markers =measurements by technologists. note broad degree of variation. ( ) (suppl ):s -s pediatr radiol variation in linear/volume measurements in almost smooth tumors. light blue=middle % tumor volume measurements by pediatric radiologists. whiskers mark limits of range. ▲♦ • markers =measurements by technologists. note narrow degree of variation. both graphs show the same informationthe % relative variation in tumor volume measurements determined by dimensional linear measurements ( pediatric radiologists) v. volumetric processing (technologists & consensus group). radiologist generated measurements are subjective and unreliable. variation in measurement technique leads to differences in calculated tumor volume which significantly over or under estimate volume in tumors with irregular texture and is not significant in smooth tumors. quail-quantitative mri-based evaluation of pancreatic iron overload in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation f. zennaro , m. gregori , f. degrassi , e. cattaruzzi , y. diascorn , c. boyer , n. maximova ; trieste/it, muggia/it, nice/fr objective: iron overload (io) is a relatively common but often neglected transplantrelated complication and has been associated with poor prognosis in patients undergoing allogeneic hsct for hemato-oncological disease. pancreatic io is frequent among patients with transfusion-dependent anemias, but is uncommon among patients with hematologic malignancies. the causes of pancreatic io and the potential effects of pancreas iron deposits on transplant outcomes or on the risk of developing significant late effects in long-term hsct survivors have not been yet determined. our institute routinely uses magnetic resonance imaging (mri) with various gradient-recalled-echo (gre) sequences to quantitatively measure the iron concentration in abdominal parenchymal organs in all pediatric patients before and after allogeneic hsct. this study retrospectively analyzes the correlations of pancreas io with the type of conditioning regimen and pretransplant liver iron concentration (lic) in pediatric patients who underwent allogeneic hsct in our transplant unit over the last years. we enrolled patients, age - years. pre-transplant mean lic was , μmol/g (normal values μmol/g). ( %) patients had mild liver io and ( %) had moderate or severe io. pretransplant mean pancreatic iron concentration (pic) was , μmol/g, whose only ( %) had mild pancreatic io and none had severe io. post-transplant mean lic was , μmol/g, only one patient had mild liver io but patients ( %) had moderate or severe io. post-transplant mean pic was , μmol/g, ( %) patients had moderate or severe io. mean pre-transplant pancreatic volume was , cm , while mean post-transplant pancreatic volume (evaluated days after transplantation) was , cm . ( , %, p< , ) patients with post-transplant moderate or severe pancreatic io underwent tbi-based conditioning. mean reduction of pancreas volume in tbi group was , cm (p< , ). no pancreatic volume reduction was observed in chemotherapy-based group. all patients with pancreatic io have had exocrine pancreatic insufficiency and ( , %) patients have had metabolic syndrome. volume reduction well correlate (mean , %, p< , ) with pancreatic io. this study confirms that pancreatic iron overload is not so rare in patients with hematologic malignancy underwent allogeneic hsct, with increased risk of metabolic syndrome and total deficit of exocrine pancreatic activity, but not of endocrine activity. iron overload monitoring allows for chelation therapy optimization. mr is fast, reproducible and more reliable compared to serum ferritin and transfusional history and allows a multi organ evaluation. pulmonary tb is common in south africa, with many children affected. diagnosis can be challenging and chest x-ray remains fundamental for diagnosis. interpretation is difficult and shown to have wide inter-reader variability. no study however has compared cxr findings and interreader agreement between ambulatory and hospitalised patients. this study compares the frequency of cxr changes, as well as interreader agreement in ambulatory compared to hospitalised children with suspected tb. from nolungile clinic and red cross children's hospital respectively was done. each sample contained % proven tb and % negative controls. two paediatric radiologists and one paediatrician served as blinded, independent readers for the database using standardised ticksheets. our study demonstrated no significant difference in lymphadenopathy, but an increase in parenchymal change in the hospitalised group. we otherwise showed similar results to literature regarding finding frequency, but poor inter-observer agreement. if the least expert reader were removed, results were comparable with available literature. this highlights the need for development and study of explicit cxr criteria for lymphadenopathy to improve the value of cxr for paediatric tb in all settings. lung ultrasound in pediatric pneumonia -why is it necessary to use the additional trans-abdominal approach? j. lovrenski; novi sad/rs objective: to emphasize the need of lung ultrasound (lus) technique modification, which enables detection of pneumonia in children not visualized by using solely the standard trans-thoracic approach. a prospective study was carried out in the regional children's hospital, and comprised a -year period. the inclusion criterion was us finding of pneumonia detected by trans-abdominal, and not with trans-thoracic approach. lus examinations were performed using a combined, trans-abdominal and trans-thoracic approach. longitudinal, transversal (intercostal), and oblique sections were used. trans-abdominal examination included transhepatic and trans-splenic approach. the ultrasound probe was angulated from the most anterior to the most posterior sections while examining the lung bases by trans-abdominal approach. a pneumonia-positive lus finding included subpleural consolidation with air-bronchogram, or with an adjacent area of interstitial/ alveolar-interstitial edema. lus was always performed before the other diagnostic modalities (chest x-ray (cxr) and computed tomography (ct)), if they were indicated by pediatrician or radiologist. within a -year period in children (mean age . y, sd . y) the pneumonic focus was discovered using the trans-abdominal approach, while the trans-thoracic approach showed a normal lus pattern. all the children had the clinical symptoms of pneumonia (fever and cough, with or without dyspnea/tachypnea). the auscultatory finding was positive in children. cxr was performed in three children, showed a right-sided pneumonia in two, and was negative in one patient. one child had a contrastenhanced chest ct, which confirmed a left-sided pulmonary base abscess detected during lus examination by trans-splenic approach only (figures , ) . apart from pulmonary symptoms, there has not been any other associated diseases found, apart from otitis media in two children. each child responded to the antibiotics treatment with resolution of infection and us signs of pneumonia. in this oral presentation we will explain and give anatomical and technical reasons for pneumonia-positive us findings within lung bases, that remained undetected by the trans-thoracic approach. left-sided abscess abutted on the spleen (s), and was detected by trans-splenic us approach. it did not contact the pleural surface approachable by trans-thoracic ultrasound (black semi-lunar mark). l-liver. conclusion: trans-abdominal (trans-hepatic and trans-splenic) approach should become an inseparable part of each lus examination, along with a standard trans-thoracic approach. this modification of technique is expected to result in a further increase of lus sensitivity in diagnosing pneumonia. is thoracic ultrasound really competitive to computed tomography in children -a two-year retrospective study j. lovrenski, k. antolović; novi sad/rs to compare diagnostic accuracy of thoracic ultrasound (us) and computed tomography (ct) in children. a retrospective study was conducted in the regional children's hospital, and comprised a -year period. the inclusion criteria were: chest ct performed within h after the us examination of thorax, and us and ct examinations in the same patient performed by different pediatric radiologists. all us examinations were performed using a combined transabdominal-transthoracic approach. ct examinations were done ( ) (suppl ):s -s pediatr radiol according to the body mass based pediatric ct protocols. each hemithorax was analyzed separately in terms of comparison between us and ct findings. statistical analysis included the calculation of sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of ultrasound in diagnosis of pulmonary pathological entities. out of children with chest ct, of them (mean age , y, sd , y) fulfilled the criteria to enter the study group. lung us showed sensitivity, specificity, ppv and npv in diagnosis of pleural effusion: %, , %, %, %; lung consolidation: %, %, %, %; lung abscess: %, %, %, %; and interstitial lung disease: %, %, %, %, respectively. within hemithoraces multiseptation of pleural effusion was observed by us only. air bronchogram within lung consolidation was observed in hemithoraces both by us and ct examinations. necrotic areas within pulmonary consolidations were detected by us in hemithoraces, which was later confirmed by ct examination. lung abscesses were diagnosed in hemithoraces by both us and ct. two small lung abscesses filled with air ( hemithorax) and bronchiectasis ( hemithoraces) were detected only by ct examinations. other pathological findings detected both by us and ct examinations were: congenital pulmonary airway malformation (cpam) ( hemithorax), pulmonary sequestration ( hemithorax), partial pneumothorax ( hemithoraces), hidropneumotorax ( hemithorax), inflamed pneumatocele ( hemithorax), hydatid cyst ( hemithorax), pericardial effusion ( patients), soft tissue masses of thoracic wall with initial bone destruction ( patients), and lymphomas ( patients) (figures - ) . in one patient us and ct revealed cysts and an extremely dilated bronchus within lung consolidation (pathohistological finding: cpam type combined with subsegmental bronchial atresia, and extensive bronchopneumonia). us examination, unlike ct, could not differentiate between eventration of the left hemidiaphragm and diaphragmatic hernia in one patient. to determine and compare the accuracy of frontal cxrs alone and 'combination frontal-lateral' set of cxrs for diagnosing lymphadenopathy in children with tb using patients with confirmed tb and controls without tb, and to compare findings in hiv-infected and hiv-uninfected children. a total of children (ie: children with gene xpert confirmed tb and control patients admitted with lower respiratory tract infections), which were part of a larger south african study, who had both frontal and lateral cxrs, were included. three qualified radiologists read the cxrs in separate sittings one month apart (one for the frontal x-ray alone and one for the 'combination frontal-lateral' cxrs) for the presence of lymphadenopathy. odds ratios and % confidence intervals were calculated to determine the presence of lymphadenopathy using a consensus reading on the frontal cxr and frontal-lateral cxr combination according to the final diagnosis of tb. inter reader agreement was determined using the kappa statistic. lymphadenopathy was reported in ( %) patients on the frontal cxr alone and in ( %) patients on the frontal-lateral cxr combination. ( %) of the patients with lymphadenopathy on the frontal cxr alone were gene xpert positive versus ( %) of the patients with lymphadenopathy on the frontal-lateral cxr combination. in all patients, the consensus reading using a frontal-lateral cxr combination resulted in a -fold increase (or , ; % ci , ) in calling lymphadenopathy compared to using a frontal cxr only in the gene xpert positive group, the consensus reading using a frontal and lateral cxr combination resulted in a fold increase (or , ; % ci , - , ) in calling lymphadenopathy compared to a frontal cxr only. overall inter reader agreement for all readers when evaluating for lymphadenopathy was 'fair' on both the frontal cxr (k= , ) and the frontal-lateral cxr combination (k= , ). the addition of a lateral view to the standard frontal cxr increased the rate of calling lymphadenopathy. however, the accuracy of diagnosing lymphadenopathy on chest x-ray as a marker for tb was poor. this poor accuracy was further hampered by only 'fair' inter reader agreement for the presence of lymphadenopathy on chest x-ray. dynamic d ct imaging in children has significant advantages over routine ct scanning, bronchography and bronchoscopy for diagnosing trachebronchomalacia because it can be performed during free breathing without anaesthesia or invasive airwayaccess.itcanalsodemonstratevascularcausesoftracheo-bronchomalaciain the same sitting. the technique is currently performed in paediatric center in the uk. we aimed to report pitfalls encountered while setting up a dynamic d ct imaging service for children and report the findings of studies performed. materials: dynamic d ctscanning was introduced after installation of a large array ( slice) ct scanner, applications specialist training and review of the literature. imaging parameters in use by greenberg and colleagues (arkansas children's hospital, usa) were applied. referral indications, pitfalls encountered, quality of scanning and imaging findings/diagnoses were reviewed and enumerated. results: nineteen paediatric dynamic d ct scans ( females, males; days - years months; mean months) were performed over months. the first studies were performed without ivi contrast due to lack of experience and subsequent studies were performed with contrast ( figure major pitfalls included initial failure to perform contrasted studies for simultaneous evaluation of vessels, initial failure to withdraw the endotracheal tube, patient motion under care of nurses and clinicians, failure to appreciate the value of imaging the full lung volume while trying to keep dose length product to a minimum and failure to appreciate that collapse of the airway is often in the ap plane and not appreciated on coronal slab projections -rotating d volume rendered images is a requirement ( figure ). additional obstacles were initial clinician and radiologist lack of support after early failures and colleague concerns regarding the radiation dose. objective: diagnosis of pulmonary tuberculosis (ptb) in children relies on chest radiography, however there is wide inter-observer agreement in detecting lymphadenopathy, the hallmark of ptb. paediatric airways are pliable, thus detection of airway compression may be a more objective criterion for the presence of lymphadenopathy. thus the objctive was to assess the usefulness of airway compression on chest radiographs for diagnosis of ptb in children. chest radiographs of children admitted to red cross children's hospital with suspected ptb were read by two readers according to a standardised format and a rd when there was disagreement. radiographs of children with definite ptb were compared to those with lower respiratory tract infection (lrti) from another cause. the prevalence and location of airway compression was evaluated. findings were correlated with hiv status and age. inter-observer agreement was assessed using kappa statistic. . % in older children (or . ; %ci . - . ). no association with airway compression and hiv infection was found. inter-observer agreement ranged from . - . . eighteen-month-old male patient diagnosed with ptb; hiv negative. majority agreement of airway compression at lmb indicative of lymphadenopathy. left upper lobe opacity is in keeping with a ghon focus. there is a strong association between airway compression on chest radiographs and confirmed ptb, particularly in infants, irrespective of hiv status. however, clinical use is limited by poor inter-observer agreement. paediatric ultrasound-guided biopsies in a tertiary oncology centre: five years experience n. parvizi, m. smedley, s. chakraborty; oxford/uk objective: histological diagnosis is almost always essential to guide appropriate therapy for children diagnosed with cancer. tissue can either be obtained by surgical/open or image-guided percutaneous biopsy. the aim of this study is to assess the safety and diagnostic accuracy of ultrasound-guided biopsies in a tertiary oncology referral centre. a retrospective analysis of clinical data, imaging findings and histological diagnosis of patients aged to years between january and december was carried out. a total of ultrasound-guided biopsies were performed in our institution on patients. most of the biopsies were performed in theatre with the patient under general anesthetic and with an -gauge spring-loaded core biopsy needle with a minimum of two cores per patient. in % of lesions the needle biopsy was diagnostic. the single nondiagnostic case did not have sufficient material to make a full diagnosis and a surgical biopsy was required. eighty-two of the biopsied lesions were malignant and were benign. in no cases was a repeat biopsy required. the vast majority of the biopsies were performed within one week of request with over half performed within days. all biopsies were performed without complication and in the majority of cases the patients were discharged the same day or following an overnight stay. ultrasound-guided percutaneous biopsy is an accurate and safe technique in order to acquire tissue from suspected malignant lesions in children. these can be performed instead of or in addition to open biopsy and will often result in a shorter hospital admission and recovery time. the role of imaging in the diagnosis of thymoma in paediatric patients with myasthenia gravis j. adu, t. a. watson; london/uk thymomas are exceedingly rare tumours in the paediatric age group, with only very few cases having been reported in the literature. thymomas are commonly associated with myasthenia gravis (mg), with thymectomy being potentially curative. ct is the mainstay imaging modality for thymoma diagnosis in the adult population. while, chemical shift mr imaging can be helpful to distinguish thymoma from other anterior mediastinal abnormalities. currently, there is no consensus on the imaging pathway for children with mg with suspected thymoma. our aim is to review the imaging of patients who were referred to our institution for management of mg, and suggest an imaging pathway in cases where thymoma is suspected. we performed a retrospective search of the local pacs system of cases between and using the search terms "thymoma" and "myasthenia gravis" in the clinical indication for the study and the body of the final report. forty-three cases were identified using the search criteria. eight cases were excluded owing to an absence of cardiothoracic imaging. / of all cases ( %) had chest x-rays (cxr's), of these / ( %) were normal. the three remaining patients who had abnormal cxr's went on to have ct scans, which confirmed an anterior mediastinal mass (amm) in all three cases. / of all cases ( %) had cross-sectional imaging (mri / cases, ct / cases). of those, / of cases ( %) had normal studies. specifically, all mri studies ( % of cases) were normal, while only / ct scans ( %) demonstrated an anterior mediastinal abnormality. / of all cases ( %) had both cxr and cross sectional studies. / of these cases ( %) had a normal ct or mri. in the remaining three cases, the amm was clearly demonstrated on both cxr and the crosssectional imaging. in our series, radiography, ct and mri studies were normal in the vast majority of cases. however, given that thymectomy is potentially s ( ) (suppl ):s -s pediatr radiol curative, it is appreciated that clinicians may still be keen to radiologically investigate paediatric patients with myasthenia gravis. cxr is not an efficacious imaging modality in this context, as patients with a normal cxr may be falsely negative, and patients with an abnormal cxr may undergo cross-sectional imaging regardless. we propose that mri should be used as first line investigation for patients in this population. this approach will negate the need for ionizing radiation, maximize diagnostic yield, and facilitate surgical planning if deemed clinically appropriate. increased risk of venous thrombosis of the arm with multiple peripherally inserted central catheters insertion in paediatric patients r. gnannt , n. waespe , j. donnellan , k. liu , l. brandao , b. connolly ; zurich/ch, toronto/ca objective: peripherally inserted central catheters (piccs) are associated with superficial and deep venous thrombosis of the arm. the impact on the incidence of developing a thrombosis of the arm when inserting a subsequent picc remains unclear. the purpose of this study was to analyze the incidence of deep, upper limb thrombosis of repeated upper limb piccs in children. the study population included all patients who underwent their first successful arm picc insertion between january and december . subsequent ipsilateral arm piccs were included in the analysis. patients were followed until march or until any alternative central venous line insertion (jugular, femoral, saphenous or umbilical vein lines -because of their thrombogenic effect). for each picc insertion the following data were collected: date of insertion and removal, weight of the patient, type of picc ( . fr, . fr, fr, fr, fr), left or right arm, and vein cannulated (basilic, brachial, cephalic). all symptomatic deep and superficial thrombosis of the arm were correlated with the picc database. four thousand one hundred thirty-eight piccs were inserted. applying inclusion and exclusion criteria, piccs remained for analysis. first, nd , rd , and th picc insertions in the same arm were identified in , , and patients, respectively. in total there were upper body deep symptomatic thrombotic events diagnosed with ultrasound. a st , nd , rd , and th picc insertion was associated with / (incidence . %), / ( . %), / ( . %), and / ( . %) thrombotic events, respectively. an increasing hazard ratio was seen with higher numbers of picc insertions, which was significant when comparing the st with the rd picc insertion in the same arm (hr . , ci % . - . , p= . ). after excluding any confounder, double lumen piccs were associated with a significantly higher risk of thrombosis than single lumen (or . , ci . - . , p= . ). repetitive picc insertions in the same arm are associated with an increased risk of thrombosis. double lumen piccs are associated with a higher risk of thrombosis compared to single lumen lines. diagnostic performance of lung ultrasound for the detection of community acquired pneumonia in children j.a.m. stadler , s. androunikou , h. zar ; paarl/za, bristol/uk, cape town/za objective: chest radiographs (cxr) are considered the first line imaging modality when investigating cases of suspected community acquired pneumonia (cap) in children. however, cxr interpretation is limited by moderate sensitivity and specificity and poor inter-and intra-rater reliability and expose children to potentially harmful ionizing radiation. point-of-care lung ultrasound (lus) has been proposed as alternative to cxr for diagnosis of pneumonia in children and some published data suggest accuracy and reliability as good as or better than cxr. most of these studies however, were performed in in-hospital settings creating a bias for selceting more severe disease and consequently more overt radiological findings. the mean age of children in most of these studies were also well above one year, while the highest incidence and risk of complicated pneumonia occurs during the first year of life. the purpose of our study was to assess the diagnostic performance of lus for the diagnosis of pneumonia in both hospitalised and non-hospitalised children in an age group representative of the most at risk segment of the population. we performed a lus on children who presented with clinical signs consistent with the who case definition for childhood pneumonia. one hundred of these patients also had chest radiographs performed as part of routine clinical care. inter-rater reliability (irr) between a general practitioner and an expert paediatric radiologist were assessed for the interpretation of lus findings consistent with pneumonia. where radiographs were available concordance between lus and cxr findings of pneumonia were also assessed. results: seventy-four hospitalised and non-hospitalised clinically defined pneumonia cases were included with a median age of . years. our general practitioner reported lus findings consistent with pneumonia in / ( %) compared with / ( %) by the paediatric radiologist. substantial overall agreement between the reporters was found with an overall agreement proportion of . and kappa= . . agreement for the presence of lung consolidation or for a normal scan was also substantial with kappa of . and . respectively. agreement on the finding of interstitial syndrome was moderate with kappa= . . agreement was higher in hospitalised than in non-hospitalised cases with kappa of . and . for the respective categories. results showing concordance between lus and cxr findings are pending. conclusion: lus shows substantial irr for the diagnosis of pneumonia in children. irr are higher for the detection of consolidation or for no pathology than for interstitial syndrome. irr also appears to be lower in clinically less severe disease. 'white-out' on plain chest radiograph-a late presentation of congenital diaphragmatic hernia a. fagan , c. stewart , k. halliday , s. rao , d.t. chang kwok ; peterborough/uk, lincoln/uk, objective: awareness of the limitations of plain radiograph and computed tomography in diagnosis of late presentation of congenital diaphragmatic hernia. case presentation: a year old boy presented with a day history of pyrexia, vomiting and respiratory distress. he was haemodynamically stable, and had no audible air entry over his upper left thorax with occasional wheeze over the left base. he had bronchiolitis previously but did not require ventilatory support. he was otherwise well with unremarkable antenatal scans. initial chest x-ray showed a large air collection with fluid or soft tissue density within the left hemi-thorax and mediastinal shift to the right. repeat x-ray (figure ) demonstrated the nasogastric tube below the diaphragm. complicated pneumonia was suspected but as the findings were atypical a non-contrast ct was performed. this was interpreted as showing a large hydropneumothorax. (figure ) . a chest drain was inserted which drained only a small volume of fluid, and a repeat chest film showed no change. ct chest and abdomen with oral and intravenous contrast revealed a bochdalek diaphragmatic hernia (figure ) . fortunately the chest drain had not entered the herniated stomach. the hernia was surgically corrected and the child recovered well. ( ) (suppl ):s -s pediatr radiol bochdalek is the most common congenital diaphragmatic hernia (cdh). it is often diagnosed on prenatal ultrasound, with mri used for confirmation. cdh which is not diagnosed in the perinatal period may be asymptomatic and imaging findings can be confusing. postnatal x-ray typically shows an opacified hemi-thorax with or without gas bubbles. there can be mass effect with mediastinal shift. the position of an ng tube can be helpful in localising the stomach, but in this case the infradiaphragmatic position of the tube gave false reassurance. in neonates, the position of an umbilical venous catheter may demonstrate abnormal location of the liver. computed tomography generally demonstrates a posterolateral defect (foramen of bochdalek), which is located on the left in % of cases. ct is useful for excluding lung masses or bronchopulmonary foregut malformations, which may appear similar to cdh on x-ray. ct can also identify anatomical abnormalities associated with cdh. late presenting cdh is often misdiagnosed as pleural effusion or pneumothorax. there are other case reports published where chest drains were inserted before cdh was diagnosed. it is important to keep cdh in mind as a potential cause of unilateral hemithorax opacification, even in previously asymptomatic older children. ct with oral contrast can be useful in diagnosis. ovarian tuberculosis with peritoneal dissemination mimicking ovarian tumor with peritoneal seeding d. grassi, v. tostes, a. duarte, s. abib, h.m. lederman; sao paulo/br consider tuberculosis (tb) as a differential diagnosis whenever the case enrolls in an endemic region. case presentation: female, years old adolescent, who presents with abdominal pain and weight loss. abdominal sonography was performed in a public family practice location and bilateral ovarian masses were detected. she was referred to an oncology pediatric facility for further investigation. abdominal mri and chest ct were performed where dissemination through the peritoneal and mesenteric lymph nodes could be detected; chest ct was normal. the patient underwent surgical intervention for diagnosis and on pathology the findings in the bilateral ovarian masses were secondary to tb involvement. sonography showing bilateral pelvic masses. t -weighted coronal overview bilateral ovarian masses. unique teaching points: whenever a case enrolls in an endemic region of tuberculosis, it is important to consider it as a possible differential diagnosis. in this case, the initial presentation mimicked ovarian tumor with mesenteric seeding. however, only after surgical approach was possible to diagnose ovarian tuberculosis with mesenteric lymph nodes and peritoneal involvement. retrospectively, patient's uncle was discovered as having pulmonary tb. langerhans'-cell histiocytosis with thoracic involvement in infant and young child: ct findings s.-l. shih , k. tsai , w. huang , f.-s. yang ; taipei/tw, taitung/tw the purpose of the study was to evaluate the ct changes of thorax in the patients with langerhans'-cell histiocytosis. the -month-old female infant presented with generalized hemorrhagic macular rash over the skin for months. the laboratory findings showed hemoglobin . gm/dl (normal . ~ . gm/dl). the chest radiograph showed bilateral reticulonodular infiltration. high-resolution computed tomography (hrct) of chest showed multiple cystic-like lesions ( - mm) in the right middle and bilateral lower lobes. the pathological report was langerhans'-cell histiocytosis after skin biopsy from upper chest. then she was on scheduled chemotherapy. she was in remission after one-year treatment. the y m-old girl presented with fever for months. the physical examination revealed hemorrhagic-macular rash over the skin in the anterior chest wall and hepatosplenomegaly. the laboratory findings revealed albumin . g/dl (normal . - . g/dl) and hemoglobin . g/dl (normal . - . g/dl). hrct of chest showed multiple cystic-like lesions ( - mm) in the bilateral lower lobes with left pleural effusion as well as multiple osteolytic lesions in the vertebral bodies of t , t , t and t . the pathological report was langerhans'-cell histiocytosis after skin biopy from anterior chest wall. then she was on scheduled chemotherapy. she was doing well years after treatment. the y m-old girl presented with yellowish discoloration of skin for one month. the laboratory findings revealed direct/total bilirubin . / . mg/dl (normal . - . / . - . mg/dl), got iu/l ( - iu/l) and gpt iu/l ( - iu/l). the chest radiograph revealed enlargement of upper mediastinum. the ct scan of chest and upper abdomen showed punctuate calcification with heterogeneous enhancement in the upper mediastinum and several minute cysts in the lower lobes of lung (hrct) as well as dilatation of bilateral intrahepatic bile ducts in the liver. the pathological report was langerhans'-cell histiocytosis after biopsy from thymus and liver. then she was on scheduled chemotherapy and got initial response. unique teaching points: langerhans'-cell histiocytosis affecting the lungs and thymus may be in isolation or as part of a multiorgan disease. the pulmonary changes on ct scan may not have corresponding respiratory symptoms. ct scan of thorax may have multiple minute cysts ( - mm) in the lungs, pleural effusion, calcification in the thymus and osteolytic lesions in the thoracic spine. case of fungal infection of the soft tissue in a child with acute myeloid leukemia (ultrasound aspects of diagnosis) i. begun, s. kondaurova; minsk region/by objective: early diagnosis of fungal infections of the tissues is essential for a successful and complete recovery. we describe a clinical case of fungal infection of the soft tissue in a child with acute myeloid leukemia (aml). ultrasound were made for the characteristics of the structural changes in the area of interest to perform biopsies followed by bacteriological culture studies. case presentation: patient k., years old, diagnosed with aml, from which after a course of induction chemotherapy with neutropenia about weeks on the skin of the foreskin appeared removable hard white coating. cultures of plaque it possible to establish the presence of fungi of the genus trichosporon spp. after days, there were hyperemia, compaction and ulceration of the glans penis, which led to extensive tissue defects. with help ultrasound were determined the structural deformation of the glans penis with the pronounced around changed tissues vascularization. after days in the rear surface projection of the left thigh and the lateral surface of the left calf were defined erythematous papules which progressed to ulceration with central black scab. by standard ultrasound were visualized: subcutaneous nodal education oval , х , sm on hip and echogenic skin thickened portion having an average degree of severity of dorsal acoustic shadow on the lower leg (weakening of the signal behind scab). in cultures of biopsies of subcutaneous foci were revealed fungi of the genus trichosporon spp too. the patient received the combination treatment (intravenous liposomal amphotericin b and surgical rehabilitation of lesions of glans and corpus cavernosum of penis). after the stabilization of patient state the treatment of the underlying disease was continued. unique teaching points: for some patients, lesions of superficial tissues may be the only sign of systemic fungal infections, and rapid recognition of these lesions may contribute to early diagnosis and treatment. ultrasound examination in such a situation naturally becomes an main imaging tool and by choice method. the scanning high-resolution of foci of the thigh of the patient k. in grayscale made possibility to determine the configuration consisting of the central echogenic focus surrounded by a hypoechoic rim (fig. ) with peripheral changes in the type of "infiltrative" according by the active fungal infection at the exit of cytopenia. duplex and triplex ultrasound scanning were indicating to the perifocal vascularization with low level vascular resistance around of the affected area (see fig. - ) . to increase knowledge and awareness of rare cases and diseases in order to be able to better manage and treat patients in the future. case presentation: an -month-old female was presented to our hospital with abdominal distention that increased in the past months associated with low-grade fever, loss of weight and mild respiratory distress. abdominal ultrasonography revealed an enlarged liver with multifocal hypoechoic lesions scattered all over the liver (fig ) . a ct scan with iv contrast (mri was not available at that time in our district) revealed severe hepatomegaly with the presence of multiple, variable in size, hepatic hypodense lesions which had peripheral (ring) enhancement after contrast injection in the arterial phase (fig ) . progressive centripetal filling in portal phase is seen and in the delayed images many of the lesions were completely filled (fig ) . reduction in the aortic caliber (mid-aortic syndrome) below the level of celiac branch was noted. a diagnosis of hemangioendothelioma was made although liver biopsy was not done due to fear of hemorrhage. alternative diagnosis to infantile hemangioendothelioma in this age group is hepatoblastoma, mesenchymal hamartoma and metastatic neuroblastoma. the patient was transferred to another city to a hospital with pediatric oncology department for follow up and treatment. unfortunately the lack of experience and knowledge of such rare cases led to mismanagement and delayed treatment and after less than months the patient was brought back to our hospital to the pediatric icu due to deterioration of her status due to congestive heart failure. unfortunately the patient died shortly afterwards. hemangioendothelioma is twice as common in girls and can have complications due to high output chf secondary to arteriovenous shunting hemangioendotheliomas tend to involute spontaneously without therapy over a course of months to years. they are followed with sequential ultrasounds. medical therapy is reserved for severely symptomatic lesions (e.g. anemia, consumptive coagulopathy, high-output chf) and includes high-dose steroids or alpha-interferon. in cases of failed medical management, surgical resection should be performed. if partial hepatectomy is not technically achievable, transarterial embolization should be used either as definitive therapy or as a temporizing measure until liver transplantation is possible. the sad outcome of this case was mainly due to mismanagment due to lack of medical experience and knowledge of such rare cases so we suggest that such rare cases should be catalogued in a national data bank for future consultation and teaching purposes. fatal outcome of acute gastric dilatation causing acute abdomen compartment syndrome in a child: a case review c.s. yoon; seoul/kr to describe and review presumed acute abdominal compartment syndrome in a child. case presentation: a years and months old boy was admitted to emergency room due to abdominal distention. he suffered abdominal pain and vomited since yesterday after lunch. on physical examination, his abdomen was rigid and distended. body temperature is . °c. the white cell count was increased ( , /μl). esr is mm/hr and c-reactive protein was . mg/l. creatinine was increased ( . mg/dl). amylase and lipase were increased ( u/l and u/l respectively). prothrombin time was prolonged ( . sec). plain abdomen radiograph shows markedly distended stomach with air-fluid level (fig. ) . first trial of nasogastric tube insertion was failed due to kinking of tube at gastroesophageal junction. contrast-enhanced abdomen ctscan shows marked distensionofstomachwithlargeamountoffoodmaterialsandintraluminalairwith prominent external compression in the duodenal rd- th junction. esophageal air distention is also markedly noted with l-tube insertion. no opacification of large vessel with contrast media, without contrast enhancement of spleen, pancreas and left kidney is noted (fig. ) . prob. markedly compressed and poorly defined lower abdominal aorta with faintly visible both common iliac arteries and femoral arteries. after ctscan, nasogastric tube exchange was performed due to poor drainage of gastric fluid. about cc of gastric fluid was drained. however, sudden cardiac arrest of the patient was developed. although vigorous cardiopulmonary resuscitation was performed, the patient was died. ( ) (suppl ):s -s pediatr radiol unique teaching points: acute abdomen compartment syndrome is a very serious and lifethreatening disease. as soon as possible, rapid diagnosis and adequate treatment are necessary for good prognosis. delayed diagnosis and treatment may result in fatal outcome. pleuroperitoneal fistula in a pediatric patient with primary hyperoxaluria type w.p. chu; hang hau/hk to illustrate the imaging features of pleuroperitoneal fistula in a pediatric patient suffering from primary hyperoxaluria type case presentation: an -year-old girl with the history of primary hyperoxaluria type was repeatedly admitted to the hospital for recurrent right pleural effusion despite chest drain insertion. the right pleural fluid was transudative in nature and the microbiological cultures for bacteria and mycobacterial species were negative. the radiographic examination [ figure ] showed moderate right pleural effusion a n d f e a t u r e s o f o x a l o s i s i n c l u d i n g b i l a t e r a l c o r t i c a l nephrocalcinosis and generalized increased in bone sclerosis. delayed planar images of the peritoneal scinitigraphy [ figure ] obtained and hours after injection of technetium- m suphlur colloid found diffuse tracer activity at the right hemithorax, suggestive of pleuro-peritoneal fistula. the patient subsequently required thoracoscopy and surgical decortication at the right hemithorax and renal transplantation. primary hyperoxaluria is due to defective glyoxylate metabolism and results in increased synthesis of oxalic acid. cortical nephrocalcinosis and diffusely increased bone sclerosis are characteristic radiographic features. pleuroperitoneal fistula is unusual in patients without peritoneal dialysis. possible cause in this patient is increased intra-abdominal pressure related to portal hypertension and cirrhosis. osteosarcoma with pulmonary intra-arterial tumor embolism metastasis a. alzaher, f. alzaher; dammam/sa objective: osteosarcoma rarely invade the veins and small number of cases has been reported with venous invasion at the presentation. however, to our knowledge, no case has been reported with venous invasion and isolated distal metastasis as intra-arterial pulmonary embolisms. we are presenting a case of pediatric pelvic osteosarcoma with venous invasion and pulmonary arterial tumor embolisms as isolated distant metastasis at the presentation. the purpose of this case report is to describe the rare presentation of distant metastasis as isolated pulmonary arterial embolism that might be overlooked radiological. additionally, such tumor embolism might cause respiratory symptoms and differentiating tumor emblism from pulmonary thromboembolism is crucial to avoid the unnecessary anticoagulation. case presentation: fourteen year old boy who presented with months history of right hip and lower limb pain after trauma. this was associated with lower limb swelling. the plain radiography showed right pelvic iliac bone aggressive mass, along with lobulated, soft-tissue components, extensive areas of osseous matrix, and malignant periosteal reaction. the patient could not tolerate the mri and ct scan was performed and it showed that the mass was invading the right external and internal iliac vein with imaging appearance was most consistent with osteosarcoma. patient staging was then carried on with mri under anesthesia and chest, abdomen and pelvic ct scan. the unenhanced and iv contrast enhanced chest ct scan showed multiple beaded expansion of sub segmental pulmonary arteries with soft tissue destinies and calcification suggestive of intra-arterial pulmonary tumor embolisms. there was no isolated pulmonary nodule or any other site of distant metastasis. unique teaching points: we present this case to increase the awareness of isolated intra-arterial pulmonary tumor embolisms as osteosarcoma metastasis especially with the present of venous invasion. additionally, such condition might be with respiratory symptoms and differentiating the tumor embolism from pulmonary thromboembolism is crucial to avoid the unnecessary anticoagulation. case presentation: a -year old boy with acute myelodysplastic syndrome presented with recurrent, acute severe anemia (hemoglobin g/dl) and melena. his past history was significant for bone marrow transplant twice followed by graft-versus-host-disease of intestines, bilateral lung transplants for bronchiolitis obliterans, renal failure, scleroderma and acute pancreatitis. ct angiography performed previously did not identify active extravasation. several days before, upper gi endoscopy had demonstrated ulceration of the greater curvature of the gastric wall that was initially treated with epinephrine injection and surgical clip placement. at the time of referral, endoscopic interventions were unsuccessful leading to progressive clinical deterioration. a decision was taken to proceed to angiography to isolate the arterial source of hemorrhage, with an intention to embolize, if feasible. catheter angiography via transfemoral fr access revealed a left gastric artery pseudoaneurysm with active extravasation into the gastric lumen through the ulcer. after selecting the feeding pedicle of the left gastric artery with a microcatheter, the pseudoaneurysm was embolized using % nbca in lipiodol, resulting in complete angiographic obliteration of the bleeding source. on repeat cbc hours post-procedure, the hemoglobin had increased from to g/dl. the patient remained hemodynamically stable in the intensive care unit. there is no evidence of bleeding recurrence days later. unique teaching points: catheter angiography can define the bleeding source with greater accuracy than cta in children. there should be a low threshold to perform catheter angiography, with an intention to proceed to treatment. nbca embolization is a feasible and effective option for treatment of acute gi bleeding in children. case presentation: an infant born by cesarean section at weeks of gestation, after nonreassuring cardiotocoghraphy, with meconium aspiration at birth, severe hepatocellular failure with hyperbilirubinemia, signs of hemorrhage, edema, ascites, hypoglycemia, increased ferritin values, and lactic acidosis was referred for ultrasound and magnetic resonance. both examinations showed signs of liver cirrhosis with portal hypertension; in addition, on t -weighted images and gradient-echo images, the signal intensity of the liver and the pancreas was lower than that of the spleen and skeletal muscle, a finding consistent with abnormal iron deposition in those organs. a biopsy of the lower lip confirmed the diagnosis of neonatal hemochromatosis. unique teaching points: although the diagnosis may be suspected clinically, it must be confirmed by demonstrating the generalized iron overload affecting, among other organs, the salivary glands, liver and pancreas, with sparing of the reticuloendothelial system. the underlying cause may be associated with an an alloimmune mechanism; thus, intravenous immunoglobulin during gestation is administered in selected cases to prevent the severity of neonatal hemochromatosis. diagnosis is then crucial not only for management of the affected infant, but also for prevention in the future offspring. fishing for the answer -a rare case of paediatric exogenous lipoid pneumonia secondary to fish oil aspiration h. moodley, d. white, g.d. baker; johannesburg/za objective: lipoid pneumonia is a rare condition caused by the intrapulmonary accumulation of endogenous or exogenous fat containing substances. in the acute exogenous form secondary to aspiration of oil, it is important to make the diagnosis and remove the causative agent to prevent or arrest the progression of pulmonary fibrosis. radiopathological findings usually prompt the diagnosis, as aspiration of mineral oils is usually unnoticed due to the lack of reactive airway symptoms and patients present with vague chronic respiratory symptoms. case presentation: we present the clinical, radiological and pathological correlation of exogenous lipoid pneumonia in a -month-old male patient with recurrent respiratory tract infections. a ct chest demonstrated an extensive crazy paving pattern of the dependent lung segments bilaterally. the lung biopsy findings of occasional intra -alveolar macrophages with larger ( ) (suppl ):s -s pediatr radiol foamy cytoplasmic vacuoles, raised the possibility of an exogenous lipoid pneumonia secondary to aspiration. on further history, the patient was found to have been fed fish oil by his mother, confirming the diagnosis. unique teaching points: the rare diagnosis of exogenous lipoid pneumonia can be confirmed on ct chest by measuring the hounsfield units in the most hyperdense components of consolidation (typically - to - hu). histopathological confirmation can be obtained provided that the specimens are not embedded in paraffin. the possible role of visual evaluation of dwibs in childhood renal masses based on our five cases e. varga, g. rudas; budapest/hu objective: nowadays, the diffusion-weighted mri has a great importance not only in the differential diagnosis and follow-ups of childhood renal tumors, but in the early detection of recurrence of the disease as well. the dwibs with appropriate b-values and the adc calculation can be helpful in distinguishing between benign and malignant processes. however, the adc calculation is a time consuming method and in addition, there are cases when we cannot use this technique, but we can still apply the visual evaluation of diffusion. case presentation: between - , we had cases in which the visual assessment of dwibs was the best method which helped to make the appropriate therapeutic decisions. left kidney of an infant with nephroblastomatosis was removed because of an arising wilms tumor. , years later, in the contralateral kidney, a small area of diffusion restriction appeared on the dwibs in one of the cystic residual lesions, but the anatomic sequences haven't showed any changes comparing with the previous examinations. in another patient with beckwidt-wiedemann syndrome, the follow-up ultrasound examination showed a little bulging of the surface of the left kidney. accordingly, the mri showed a barely distinguishable nodule, but the dwibs referred to a wilms tumor. in a -month-old child, more nodules were visible in both kidney on the dwibs than on other sequences. with the help of visual evaluation of dwibs, we were able to detect the malignant lesion easily and quickly, among a lot of cystic and solid nodules of the kidneys in a seven years old patient with sclerosis tuberosa. an -month-old infant was followed with a benign cystic renal disease and a new small solid nodule was found on the last ultrasound examination. instead, the visual assessment of dwibs indicated a multilocular cystic wilms' tumor. unique teaching points: the diffusion-weighted mri is suitable for differentiate benign and malignant renal lesions in children. the dwibs (with appropriate b-values) and the adc calculation are very sensitive methods in pediatric oncoradiology. the adc calculation is a long process andas our cases demonstrated -we cannot apply in every cases. the visual evaluation of dwibs is a time saving method which is spared from limitations of adc histogram-based assessment, so it may become very useful in the everyday practice. we can use it in the differential diagnosis and follow-ups of childhood renal tumors and we can detect the recurrence of the malgnancy very early and easily. mr urography in a -years-old female with unusual urinary dribbling m.c. terranova, c. tudisca, d. narese, g. li voti, s. salerno; palermo/it objective: congenital anomalies of kidney and urinary tract (cakut) occurs in up to . % of infants, and clinically they can range from asymptomatic patients, in which anomaly is detected incidentally even in adulthood, to ante-natal or post-natal mortality due to bilateral kidney agenesis or acute renal failure. dmsa renal scintigraphy is considered gold standard, for evaluation of those cases electable for surgery, in order to assess renal function, depict and locate ectopic kidney and guide surgical management, but has the important limit of radiation exposure and may undetect poorly functional renal moieties. the advent of modern magnetic resonance technics proven to be able to assess anatomical malformations and renal function, overcoming the limits of dmsa scintigraphy, may be used as a valid alternative, especially in vulnerable pediatric population. we herein describe a case of a young girl with small left renal bud and ectopic ureter, draining in vagina, discovered by mr and undetected by previous dsma scintigraphy. case presentation: a years old girl was referred for continuous urinary dribbling, after starting toilet training, with normal bladder voiding pattern, unrelated to any physical and psychological events, and no history of urinary tract infections. physical examination revealed vaginal septa and micturition training was practiced, with no symptoms improvement. abdominal us study was performed, reporting empty left renal fossa and hypertrophic right kidney; no ectopic kidney nor sign of urine stasis or other urogenital anomalies were detected, and dmsa renal scintigraphy was planned. it depicted only normal right kidney radionuclide uptake but no evidence of left renal or ectopic renal tissues activity. patient then underwent mr evaluation for suspected genito urinary malformation, that revealed a small cystic formation, with a slight cortex, at the level of the iv lumbar vertebra -that represented the left immature renal bud -supplied by a short fluid-filled tubular structure, located postero-medially to the bladder -that configured the left ectopic ureter, draining in left vaginal wall. bladder was normal, and regularly connected with the right orthotopic ureter (fig ) . pre-surgical cystoscopy and vaginoscopy, followed by left ascending urethrogram were performed, confirmed previous mr findings, and patient underwent successfull laparoscopic left nephron-ureterectomy. unique teaching points: mr urography has proven to be a rapid, safe, radiation free, systematic diagnostic tool especially in the evaluation of poorly functioning renal systems, and of collecting system, bladder and ureteral abnormalities, overcoming the limits of conventional imaging technics agenesis of the dorsal pancreas: case report c. lanza, g. pieroni, l. amici, a. giovagnoni; ancona/it objective: agenesis of the dorsal pancreas (adp) is a rare malformation. since and until , cases have been reported. majority of the patients with this anomaly are asymptomatic or associated with abdominal pain, hyperglycemia, diabetes mellitus, and acute or chronic pancreatitis. case presentation: we present a case report of a -year-old girl with adp, diagnosed incidentally during radiological evaluation for abdominal pain. she was hospitalized in the pediatric department for recurrent abdominal pain for the past months. there was no history of nausea, vomiting or trauma. biochemical investigations showed a normal random serum glucose, serum amylase levels slightly increased ( u/l; reference value - u/l) and slightly elevated serum pancreatic lipase levels ( u/l; reference value - u/l). the day after serum amylase levels decresed up to u/l and lipase levels to u/l. us revealed increased -size pancreatic head with normal contour and echotexture with no parenchymal calcification or duct dilatation. the body and the tail of the pancreas were poorly visualized. mr imaging examinations revealed only a partial visualization of the pancreas: the pancreatic head and the uncinate process were visualized with defined margins with peripancreatic fat stranding, but the distal neck, body, and tail of the pancreas were absent. on mrcp, the dorsal pancreatic duct of santorini and the minor duodenal papilla could not be visualized. the ventral pancreatic duct of wirsung and the common bile duct were normal and clearly visualized. these findings were compatible with complete adp, eliminating the need for ercp. unique teaching points: the clinical presentation of dpa varies greatly ranging from incidental detection on x-ray, surgery or autopsy through to the development of a ductal adenocarcinoma of the pancreas. abdominal pain and diabetes are the most frequent clinical manifestations reflecting exocrine and endocrine insufficiency as most of the islands of langerhans are located in the tail of the pancreas. there have also been reports of an increase in the size of the remnant pancreas and recurrent acute pancreatitis as a form of presentation. diagnosis requires confirmation of the absence of the neck, body and tail of the pancreas and duct of wirsung using endoscopic retrograde cholangiopancreatography (ercp) or mrcp. one hundred four mr images of foetal cns with a us suspicion of acc were retrospectively reviewed. foetal mri was performed at . t magnetom avanto (siemens, erlangen, germany) without motherfoetal sedation. polymicrogyria, lissencephaly, schizencephaly, subependymal heterotopias and migration disorders were evaluated. cortical findings were compared to three types of acc (complete agenesis, partial agenesis and hypoplasia). genetic tests were collected. postnatal mri or foetopsy for diagnostic confirmation were collected. on foetuses, fetal mri was able to detect cortical malformations in cases even in early gestational ages (< gw). the mean gestational weeks (gw) at mr diagnosis was (range: - gw). mr imaging found / polymicrogyria, / lissencephaly, / schizencephaly, / subependymal heterotopias and / neuronal migration disorders. / had complete acc, / had partial acc and / had cc hypoplasia. statistically significant correlations (p< . ) between complete acc, focal polymicrogyria and cortical dysmorphism affecting frontal lobes were found. fetal cns mri can detect cortical development malformations in complex acc, providing further information for the clinician to assess the severity of perinatal outcome. mri is a useful tool in improving obstetrical genetic prenatal counselling to predict pregnancy and foetal prognosis. clinical signs of the neonatal lymphatic flow disorder (nlfd) are a combination of the congenital chylothorax, chylous ascites and body edema. it can present as neonatal chylothorax (nc), neonatal chylous ascites, or congenital lymphatic dysplasia (cld). the prenatal appearance of lymphangiectasia has been described as nutmeg lung. the purpose of this study is to describe prenatal and postnatal imaging features and outcomes of neonates with nlfd. materials: this is a retrospective case series of neonates in our institution that had pre-and postnatal lymphatic imaging and nlfd. all patients had prenatal imaging (fetal mri and us) and underwent postnatal dynamic contrast mr lymphangiography (dcmrl) with a three-dimensional ( d) t space. conventional lymphangiography (cl) when performed was also reviewed. six patients with nlfd were identified ( with nc and with cld). one patient had congenital heart disease. nutmeg lung was seen in all patients on fetal mri and patients on fetal us. / patients had pleural effusions, / had ascites and / had body wall edema prenatally. postnatal mri with d t space revealed soft tissue edema in the upper chest and neck ( / patients), mediastinal edema ( / patients), interstitial lung edema ( / patients), retroperitoneal edema ( / patients), and ascites ( / patients). dcmrl demonstrated lymphatic flow to the pleural space ( / patients) and to the abdominal cavity ( / patients) and dermal backflow ( / patients). cl was performed in patients, all of which had collateral lymphatic flow to the lung. lymphatic intervention was performed in patients, lipiodol injection for patients with nc and thoracic duct embolization (tde) for patient with cld. mean hospital duration in the first months of life was days (range - ) for nc and days (range - ) for cld. all patients with cld died after months of age due to respiratory distress including the patient that had tde and both with findings of dermal backflow. the pleural effusions in the patients with nc resolved post lipiodol injection and in the other patient with nc it resolved with conservative therapy. conclusion: nlfd is a disorder that can be recognized on prenatal and postnatal imaging. in this small series, nutmeg lung was present in all patients with nlfd and may be easier to recognize with fetal mr than us. dermal backflow on dcmrl suggests a poor prognosis. both prenatal and postnatal imaging may guide treatment and interventions in nlfd. fetal mri and postnatal ct scans of prenatally diagnosed bpms from patients with available histology were analyzed retrospectively. the fetal mri and ct images were reviewed by two radiologists blinded to histological findings. specific diagnosis was assigned based on predetermined criteria. the accuracy of fetal mri was evaluated. the agreement rate in fetal mri diagnosis between two radiologists was %. an overlap of % in fetal mri and histopathological diagnosis was reached. when comparing fetal mri and postnatal ct examinations, the agreement of the results was also %. the least matching histological diagnosis was bronchopulmonary sequestration (bps). fetal mri is very accurate in characterizing the bpm spectrum and provides important information on lesion type and structure when compared with histology. with relatively small number of patients high correlation between prenatal mri and postnatal ct was reached. therefore, further investigation with more patients is needed. we hypotethise that fetal mri in late pregnancy could in the future replace early (neonatal) ct examinations if fetal mri provides sufficient inforfmation for clinical management. real time virtual sonography: a new integrated approach for the evaluation of fetal cerebral pathologies? s. bernardo, a. antonelli, v. vinci, m. saldari, c. catalano, l. manganaro; rome/it objective: real-time virtual sonography (rvs) is a new technique that uses magnetic navigation and computer software for the synchronized display of real-time us and multiplanar reconstruction mri images. the purpose of this study was to evaluate the feasibility and ability of rvs to assess the main cerebral pathologies in fetuses with suspected us anomalies. materials: this is a prospective study. fusion imaging (hitachi hi vision ascendus) was offered to patients undergone fetal mri for a us suspicion of cerebral pathology. the mri image dataset acquired was loaded into the fusion system using a cd support and displayed together with the us image. both sets of images were then manually synchronized and images were registered. the possibility to record the images in a video format allowed, however, the possibility to re-evaluated the examination. results: rvs was technically possible in all cases. data registration, matching and fusion imaging were performed in minutes at the beginning and in less than - minutes after practice. the ability of rvs imaging to assess the main anatomical sites and fetal anomalies was evaluated and compared with standard us and mri images. the principal application of rvs was the study of midline, cerebral gyration and vascular malformations because it also allowed adding a real time doppler signal on mri images. fusion imaging helped the diagnosis in %. in the / cases of encephalic pathology, fusion imaging improved the diagnosis; in the other cases mri was superior to us even using the rvs. this is a preliminary study on the feasibility and practical use of a fetal mri-us real-time fusion imaging. both techniques are complementary but still independent and the retrospective synthesis of these exams allows optimal analysis of fetal cerebral anomalies. this technique has many advantages especially on the pedagogic plan. however, rvs is currently limited to the research area. role of foetal mri in the evaluation of ischaemic-haemorrhagic lesions of the foetal brain s. bernardo, a. antonelli, v. vinci, m. saldari, c. catalano, l. manganaro; rome/it the aim of this study was to define the role of fetal magnetic resonance imaging in the evaluation of cerebral ischaemic-haemorrhagic lesions and the extension of parenchymal injuries. from september to december we performed fetal mri of cerebral region in foetuses with suspected abnormalities on ultrasound or cmv infection and toxoplasma serum conversion. fetal mri was performed with a . -t magnet system without materno-fetal sedation. fetal mri detected ischaemic-haemorrhagic lesions in / fetuses, revealing a % pathology incidence. mri confirmed the diagnosis in / cases with us suspect of ischaemic-haemorrhagic lesions associated with ventriculomegaly. in / cases with us findings of cerebellar haemorrhage, mri confirmed and provided additional information regarding the parenchymal ischaemic injury. in / cases with us suspect of ventriculomegaly (n= ), corpus callosum agenesis ( ), cerebellar vermis hypoplasia ( ), holoprosencephaly ( ), spina bifida ( ) mri detected ischaemic and haemorrhagic lesions unidentified at us examination. in / fetuses with us suspicion of intracerebral tissue space-occupying lesion, mri modified the diagnosis to extra-axial haematoma associated with dural sinus malformation. results were compared to fetopsy or after-birth follow up. fetal mri is an additional imaging modality in the diagnosis of cerebral ischaemic-haemorrhagic lesions and it is useful in providing further information on the extension of parenchyma injury and associated abnormalities and in improving delivery management. the contribution of mid-trimester virtual autopsy with mr imaging a. d'hondt, n. d'haene, j. rommens, m. cassart, f.e. avni; brussels/be the aim of the study was to assess the potential contribution of fetal virtopsy (post-mortem mr imaging (pm-mri)) in the second trimester of pregnancy. during a one-year period, post-mortem mr imaging (pm-mri) was performed in all fetuses who died in utero or whose pregnancy was interrupted due to major malformations. the study was performed in agreement with the local ethical committee. fetuses of < weeks that underwent obstetrical ultrasound and pm-mr were included. mr imaging examination was performed on a . tesla magnet with a standardized protocol. the findings on pm-mri were compared to obstetrical sonographic findings (and to pathology when available). we have analyzed separately the findings in the central nervous system and those in the rest of the fetus (chest, abdomen and skeleton). the results were classified in three categories according to the diagnostic accuracy: ultrasound>pm-mri, ultrasound=pm-mri and pm-mri>ultrasound. the us and pm-mri data of ten fetuses were analyzed. their gestational age ranged from . - weeks and their bodyweight ranged from - g. for the cns malformation: pm-mri offered a better diagnostic accuracy than us in cases ( %) (e.g. agenesis of the corpus callosum and holoprosencephaly). in cases ( %) us offered the same information than pm-mri. there was no case where us was more accurate than pm-mri. for the rest of the body malformations: pm-mri offered a better diagnostic accuracy in cases ( %) (e.g. heterotaxy anomalies or vertebral segmentation anomalies). in cases ( %), us offered the same information as pm-mri. there were cases ( %) where us showed major malformations that were not diagnosed on the pm-mri (two cases of cardiac malformation). post mortem mr imaging is more accurate than obstetrical ultrasound in detecting major malformations in the cns as well as in the rest of the body. the present exceptions are cardiac malformations. the examination offers an easy evaluation of the deceased fetus. it provides, in most cases, important additional information. diffusion coefficient and perfusion fraction parameters correlate with gestational age in normal human in vivo placenta: a preliminary study a. antonelli, m. guerreri, s. bernardo, s. capuani, c. catalano, l. manganaro; rome/it to investigate the potential of diffusion parameters derived from a biexponential analysis as marker to evaluate the perfusion quality of normal in vivo placenta. eighteen normal pregnancies, fulfilling the study inclusion criteria, have been analysed at . t magnetom avanto (siemens, erlangen, germany) without mother-foetal sedation. dw imaging was collected using seven b values: , , , , , , (s/mm ). three regions of interest (rois) have been considered -central (c), peripheral (p) and umbilical (u) regions. a bi-exponential model was used to obtain perfusion fraction (f), pseudo-perfusion (d*) and apparent diffusion (d) coefficients. pearson test was performed to investigate correlation between diffusion parameters and gestation weeks (gw), body mass index (bmi) and basal glycaemia (bg). the average values on all rois were d= . ± . • - (mm /s), d*= . ± . • - (mm /s), f= . ± . • - , in good agreement with the literature. in the c roi, a positive correlation (p< . ) was observed between f and gw. after gw in the p roi a positive correlation between f and gw (p< . ) and a negative correlation between d and gw (p< . ) were found. no correlation was found between d, d*, f, bmi and bg. conclusion: the f increase reflects normal placenta perfusion physiology. on the other hand, the decrease of d highlights placental parenchyma maturation becoming more fibrotic during late gestational age. bi-exponential model provides more and useful information about placental morphological changes compared to mono-exponential diffusion model. to demonstrate the diagnostic value of fetal mri in the detection of fetal central nervous system (cns) impairment in prenatally echocardiographic diagnosed congenital heart diseases. we retrospectively examined fetuses between gestational weeks and gestational weeks who performed a fetal mri in our institution after a second-line ultrasonography, between april and october . fetal heart and cns studies were performed with a . tesla magnet (siemens magnetm avanto) without maternal sedation. prenatal findings were compared to fetopsy results, fetal mri after gw or postnatal mri. in our sample of cases, / had interatrial septal defect (iasd),intervertricular septal defect (ivsd), and atrioventricular canal defect (cavc), / had cardiac rhabdomyomas, / had hypoplastic left heart syndrome and hypoplastic aorta, / had transposition of the great vessels, / had fallot tetralogy, / had aorta coartation and / had intracardiac masses of uncertain significance. magnetic resonance imaging was able to detect cns impairment: we recognize / corpus callosum (cc) dysgenesis ( / cc hypoplasia, / complete cc agenesis, / partial cc agenesis), / ventriculomegalies or hydrocephalus, / subtentorial anomalies (dandy-walker, vermian hypoplasia and vermian malrotation) and / gyration anomalies. due to the high risk of cns involvement in prenatal congenital heart diseases, it is essential to suggest an mri study of the evolving fetal brain especially in complexes forms that suggest a syndromic background. fetal mri of the cns is mandatory in the study of congenital heart disease due to the high rate of encephalic anomalies associated, particularly in iasd, ivsd and cavc. first experiences and diagnostic utility of micro-ct for fetal autopsy j.c. hutchinson , x. kang , s.c. shelmerdine , m. cannie , v. segers , n. sebire , j. jani , o.j. arthurs ; newcastle upon tyne/uk, brussels/ be, london/uk perinatal autopsy remains poorly accepted by parents, despite yielding information that affects the management of future pregnancies in around % of cases. microcomputed tomography (micro-ct) has shown promising results in the examination of ex-vivo fetal organs, and may provide diagnostic imaging in cases where traditional autopsy is challenging, and s ( ) (suppl ):s -s pediatr radiol existing post mortem imaging techniques (ct and mri) provide insufficient diagnostic resolution. our objective was to examine whole fetuses non-invasively using micro-ct, and compare the findings with standard autopsy as the gold standard. in this ethically approved double blinded study, terminated fetuses or miscarriages underwent iodinated micro-ct examination followed by conventional autopsy. images were acquired using a nikon xth st microfocus-ct scanner with individual specimen image optimisation. forty indices normally assessed at perinatal autopsy were evaluated for each imaging dataset by two independent reporters and a consensus report produced. autopsies were performed blinded to the imaging findings by one of two perinatal pathologists. we examined fetuses, with a gestational age range of - gestational weeks. / indices were non-diagnostic ( %), but there was agreement for / diagnostic indices (overall concordance of . % ( % ci . , . %). in seven out of eight fetuses ( . %), the same final diagnosis was made following micro-ct examination and autopsy examination; in one case, micro-ct was non-diagnostic. ten false negatives indices included a vsd, laryngeal anomaly, ambiguous genitalia and incomplete bowel rotation, none of which changed the overall diagnosis. three apparent false positives on micro ct were a cloacal anomaly, incidental cystic neck lesion and thymic atrophy, which were not detected at autopsy. micro-ct of early gestation whole fetuses can provide highly accurate datasets with three-dimensional renderings of complex disease processes. this approach confirms the potential of this technology for non-invasive examination of small fetuses. investigation of perinatal body organ diffusion-weighted post mortem mri s.c. shelmerdine , m. cheryl , j.c. hutchinson , n. sebire , o.j. arthurs ; london/uk, southampton/uk objective: diffusion weighted magnetic resonance imaging (dwi) uses water molecule diffusion to generate mr contrast images, and can reveal microstructural or functional changes in tissues, quantified by measuring the apparent diffusion coefficient (adc). the application of dwi to the post mortem setting is appealing as it does not require the administration of an exogenous contrast agent. a recent pilot study of paediatric cases suggested that lung adc values at pm mri may be a useful marker of post mortem interval (time since death; pmi) which has forensic relevance, but other body organs have not been comprehensively evaluated. the aim of this study was therefore to evaluate the relationship between pmi and body organ adc values in a larger cohort of subjects across a wider gestational range in the setting of perinatal death. whole body perinatal postmortem mri with dwi sequences were performed at . t, with b values of , , mm /s. mean adc values were calculated from regions of interest (rois) placed in the lungs, myocardium, spleen, renal cortex, liver and psoas muscle. the values were measured by two independent readers, correlated against gestational age and post mortem interval (pmi) using the pearson product-moment correlation coefficient. bland-altman plots were created, and the limits of agreement used to assess the inter-observer agreement of mean adc values. results: eighty fetal deaths and stillbirths were imaged with mean gestational age . weeks (range: - weeks). the mean pmi was . days (range - days). there was a weakly positive correlation between pmi and mean lung adc (r = . ) and spleen adc (r = . ). no correlation was found with between adc and pmi for the other body organs. there was reasonable inter-observer agreement between the two readers, with mean adc difference . mm /s (+/- . mm /s). perinatal lung and splenic adc values show a mild increase with increasing pmi. together with other imaging parameters, this may be useful to evaluate organ-specific changes which occur in the post mortem period, particularly in a forensic setting. further research is needed to understand the organ-specific changes which occur in the post-mortem period. usefulness of combined grey-scale and color doppler ultrasonography(us) findings in the evaluation of acute pyelonephritis in children k. lee, j.h. lee; anyang/kr objective: us diagnosis of apn in children can give a valuable information to the clinicians for the early treatment. but the problem of us in the diagnosis of apn is wide range of sensitivity, which is - %. the purpose of this presentation is to evaluate the usefulness of grey-scale us and color doppler us in the diagnosis of acute pyelonephritis in children. from march to february , children( kidneys), boys and girls, aged weeks to years (mean age, . months) underwent kidney us as an initial diagnostic tool for acute pyelonephritis and follow up dmsa scintigraphy within a week. criteria for acute pyelonephritis on grey-scale image were focal/diffusely increased/decreased echogenicity or loss of corticomedullary differentiation. on color doppler sonography, the criterion was decreased color flow. we classified the us diagnosis of apn into categories. definite, suggestive, possible and normal. when above two grey-scale us criteria and color doppler us criterion are seen, we classified it as 'definite'. when one of greyscale us and color doppler us finding are seen, it was classified as 'suggestive' of apn. 'possible' apn was abnormal finding either on grey-scale or color doppler us. 'normal' was no abnormal findings on grey-scale and color doppler us. we compared above findings with dmsa scan, which is considered as gold standard for diagnosing apn. statistical analysis was performed on all kidneys. the overall sensitivity of our study was %( / ) and specificity was %( / ). the positive predictive value for each definite, suggestive, possible groups were %, %, and % respectively. the negative predictive value for normal group was %, which means the false ppv was %. the p-value of the definite and suggestive was statistically significant, but the possible was statistically insignificant. in the diagnosis of apn in children, abnormal us finding either on greyscale or color doppler us is not optimal. abnormal us findings both grey-scale us and color doppler us showed good association with dmsa scan and statistically significant. combined grey-scale and color doppler us findings can give a more reliable information in the diagnosis of apn in children. the greater degree of gastric and/or duodenal wall thickening and increased echogenicity are helpful sonographic features in differentiating congenital duodenal anomalies from malrotation. our findings confirm the superiority of us vs ugi for evaluation of duodenal obstruction in neonates and evaluation of gastric and duodenal wall must be added to the constellation of other features to be assessed on us examinations. a measure of renal morphology as an indicator for potential renal failure a.c. eichenberger, p. grehten, c. kellenberger; zurich/ch this study introduces a measure of renal morphology, herein labelled split renal volume (srv), that should be applied as an indicator for potential renal failure and eventual surgical treatment of obstructive uropathy in children. current practice applies dynamic contrast enhanced functional renal imaging (fri) with complex post-processing methods. fri generates a measure of split renal function (srf). reduced values of srf under % are currently considered to be an indicator for surgical treatment. this retrospective study compares the accuracy of srv with the accuracy of srf as methods for assessing potential renal failure. materials: srv is a quotient of volumetric measurements. total renal volume is described by the sum of parenchymal volume and intra-renal collecting system volume. srv is designated in this study as the quotient of two ratios: first, the ratio of total renal volume to parenchymal volume of the left kidney; and second, the ratio of total renal volume to parenchymal volume of the right kidney. twenty-two children were studied: (age . ± . y) with unilateral asymptomatic intrinsic uretero-pelvic-junction obstruction (upjo), and normal controls (age . ± . y). all subjects underwent mr urography at . t, which provided estimates of srf and srv for each of the examined kidneys. the sensitivity and specificity of both srf and srv for predicting surgical management were determined by comparing the indicators with an expert review panel's decision to operate. the panel was blinded to values of srv. results: when a cut-off value of % for srf was used, the resultant sensitivity and specificity of srf for the detection of kidneys at risk were found to be % and %. the values of srv ranged between . and . . it was found that a value greater than . indicated kidneys at risk. when the cut-off value of . for srv was used, the resultant sensitivity and specificity of srv for the detection of kidneys at risk were both %. in this small population, srv proved to be % accurate and is superior to srf for detecting kidneys at risk of failure due to obstruction. routine application of srv promises to simplify mr urography by obviating dynamic contrast enhanced imaging studies. further prospective studies are necessary in order to select an optimal cut-off value of srv. factors that can distort the dj flexure mimicking malrotation v. bhalla , s. mohan , k.a. bradshaw , m. thyagarajan ; stoke-on-trent/uk, birmingham/uk to highlight the varied radiological appearances and position of the duodenal-jejunal flexure in children and to discuss its importance in assessing for malrotation materials: retrospective analysis of the multiple fluoroscopic examinations performed in the assessment for malrotation over the past years in a busy tertiary centre results: the classic position of the dj flexure is to the left of left pedicle of l and at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views. however variations of the normal location can appear, particularly on frontal views, in the upper gi series that can mimic malrotation which has shown to be more common in neonates. we present cases with examples to illustrate the variability in position due to various causes and its implications in the diagnosis of malrotation and volvulus. our case mix includes patients with excessively distended stomachs, large bowel obstruction, renal pelvic dilatation, repeated naso-jejunal and gastro-jejunal tube insertion and in patients post liver transplantation. malrotation and its assessment have serious management and prognostic implications. this presentation demonstrates that the imaging features can be varied, and knowledge about factors distorting the position of the dj flexure is vital in the accurate management of neonates presenting with bilious vomits. retrospective study of prospectively collected data performed at a single tertiary paediatric institution over a . year period. a total of consecutive patients, aged < years, were reviewed who underwent native renal biopsy. all biopsies were performed within the interventional radiology department. all patients had renal disease requiring a renal biopsy for diagnosis. outcome measures include technical success, early and late complications and the adequacy of histological samples. in addition, age, body weight, glomeruli number, histological data, number of cores, size of the biopsy needle, use of co-axial needle and the rate of tract embolisation/plugging were recorded. results: from september to april , patients (mean age: . years +/- . ; range . - . years) underwent native renal biopsy. one hundred ninety-one patients were < years of age. nine hundred forty-six patients ( . %) had a biopsy of the right kidney, patients ( . %) had a biopsy of the left kidney and patient ( . %) had a biopsy of a horseshoe kidney. five hundred fifteen patients were female ( . %). seven hundred sixtynine patients ( . %) had the procedure performed under general anaes-thetic and of patients ( . %) had the procedure performed under local anaesthetic (+/-sedation/entonox). mean number of passes of the core biopsy needle through the renal capsule was . . a gauge core biopsy needle was used in % of the patients. . % of the patients had three or less passes of the biopsy needle though the renal capsule. the overall complication rate was . % (n= ). . % (n= ) of patients had a non-diagnostic biopsy. fifty-five patients underwent a post biopsy ultrasound due to clinical concerns. twenty patients developed perinephric haematoma ( were treated conservatively; one underwent embolisation and subsequent nephrectomy). four patients developed arteriovenous fistulas. two patients developed post procedure infections (one at the skin site and one a perinephric collection). histology results were reviewed in all patients. the mean number of glomeruli obtained was . (range - ). glomerulonephritis was the most common histological diagnosis (n= ; . %) conclusion: renal biopsy is an extremely useful diagnostic tool for renal disease. there is no published data of this size assessing the outcome of native renal biopsies in the paediatric population. jr usa a. lassrich germany j. sauvegrain france c. fauré france a. giedion switzerland e. willich germany r. astley united kingdom ringertz sweden d.g. shaw united kingdom r. lebowitz usa b. lombay hungary pena spain gold medallists london/united kingdom the dutch group of paediatric radiologists, the hague/the netherlands g. stake ringertz (espr) & d. kirks (spr) chicago/united states future espr meeting italy european courses of paediatric radiology (ecpr) genoa/italy (neuroradiology) r.fotter, graz/austria (abdomen) brussels/belgium (thorax) j-n. dacher paediatric musculoskeletal imaging) references: . -stellungnahme-lnt-modell.pdf [internet]. [zitiert an evaluation of paediatric projection radiography in ireland contrast imaging -> application -dectris background ionizing radiation and the risk of childhood cancer: a census-based nationwide cohort study best practices in digital radiography communicating radiation risks in paediatric imaging kinderradiologie-besonderheiten des strahlenschutzes diagnostic imaging and ionizing radiation -canadian nuclear safety commission epidemiology without biology: false paradigms, unfounded assumptions, and specious statistics in radiation science (with commentaries by inge schmitz-feuerhake and christopher busby and a reply by the authors) european guidelines for ap/pa chest x-rays: routinely satisfiable in a paediatric radiology division? eurosafe imaging together -for patient safety image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography hostens j, u. a. in-vivo dark-field and phase-contrast x-ray imaging safety commission cn. linear-non-threshold model optimisation of paediatric chest radiography optimizing digital radiography of children radiation exposure in diagnostic imaging: wisdom and prudence, but still a lot to understand radiation shielding for diagnostic radiology strahlenhygienische aspekte bei der röntgenuntersuchung des thorax the image gently pediatric digital radiography safety checklist: tools for improving pediatric radiography the standardized exposure index for digital radiography: an opportunity for optimization of radiation dose to the pediatric population gastroenterology and radiology records were searched to identify ibd patients with colonic strictures. all patients underwent an mre within months of colonoscopy. the following colonic parameters were evaluated: bowel wall thickening with luminal narrowing, pre-stenotic bowel dilatation, bowel wall enhancement, and diffusion restriction (if performed). colonoscopy and operative notes were correlated. results: fourteen patients met the inclusion criteria, one with colonic strictures. bowel wall thickening with luminal narrowing at the site of the reported stricture was present in all cases. pre-stenotic bowel dilatation (> . cm) proximal to the reported stricture was present in / cases. using luminal narrowing and prestenotic dilatation as criteria for diagnosis of a colonic stricture, / cases were therefore positive on mre. when comparing to colonoscopy, mre diagnosed colonic strictures in / cases ( %). in the six patients who had surgery, mre accurately diagnosed colonic strictures in / cases ( %). conclusion: mre is not the primary modality for colonic evaluation, yet diagnosing colonic pathology on mre, particularly strictures, may be beneficial for the referring gastroenterologist in the assessment of these patients. potential strictures on colonoscopy did not agree with mre in all cases, but when correlating with surgery % of colonic strictures were accurately diagnosed in a small subset. although mre is not optimized for the evaluation of the colon, colonic strictures can be recongnized in children with crohn's disease.disorders of sexual differentiations in neonates: standardized sonographic evaluation and proposal of a reading grid h. lerisson, e. amzallag -bellenger, f.e. avni, m. cartigny; lille/fr to propose a systematic and structured sonographic approach in neonates with disorders of sexual differentiation (dsd) materials: review of the us pelvic, external genital and adrenal findings in consecutive patients with clinical suspicion of dsd evaluated in the neonatal period. the us survey included: the uterus (absent or visible -with or without hormonal impregnation), the vagina (absent or present (complete or partial)), the gonads (ovaries, testis or unsetermineddysgenetic ) as well as the adrenals (normal, too small or enlarged). the us conclusions were correlated with the endocrinological and genetical work-up of each patient results: twenty cases of dsd have been included us had correctly identified the presence of a uterus in patients. there was one false positive case; among the patients did not show the physiological hormonal impregnation. the vaginal anomalies were correctly evaluated. the gonads were defined correctly as normal testis in patients, normal ovaries in and dysgenetic gonads in . they could not be visualized in patients. adrenals were considered normal in patients (one false negative), hypertrophied in and small in one patient. to compare hepatic d shear wave elastography ( d swe) in children between free-breathing and breath-hold conditions, in terms of measurement agreement and time expenditure. a cohort of children ( . ± . years) who underwent standardized d swe between may and october were retrospectively evaluated. liver elastograms were obtained under free-breathing and breath-hold conditions and time expenditure was measured. median stiffness, interquartile range (iqr), and iqr/median ratio were calculated based on , six, and three elastograms. results were compared using pearson correlation coefficient, intraclass correlation coefficient (icc), bland-altman analysis, and student's t. median liver stiffness under free-breathing and breath-hold conditions correlated strongly ( . ± . kpa vs. . ± . kpa; r= . , p< . ). time to acquire elastograms with free-breathing was lower than that with breath-holding ( . ± . sec vs. . ± . sec, p< . ). results for median liver stiffness based of , six, and three elastograms demonstrated very high agreement for free-breathing (icc . ) and for breath-hold conditions (icc . ). hepatic d swe performed with free-breathing yields results similar to the breath-hold condition. with a substantially lower time requirement, which can be further reduced by lowering the number of elastograms, the free-breathing technique may be suitable for infants and less cooperative children not capable of breath-holding. abstract: pelvi-ureteric junction obstruction (pujo), classified into intrinsic and estrinsic is one of the most frequent urological diseases affecting the pediatric population. extrinsic causes include the presence of crossing vessels, kinks or adhesions. in cases with extrinsic obstruction of puj, colour doppler ultrasound (cd-us) can detect the presence of crossing vessels. in presence of crossing vessels pyeloplasty or vascular hitch can be performed. the aim of the study is to analyze the sensitivity of cd-us and magnetic resonance urography (mru) in visualizing crossing vessels in extrinsic pediatric hydronephrosis in order to decide the correct diagnostic pathway and evaluate in the pre-operative phase which surgical technique and approach (open, laparoscopic or robotic) is the ideal to be performed. a retrospective review of medical records for patients who underwent surgical treatment for hydronephrosis from august to february was performed. a descriptive statistical analysis was performed. the presence of crossing vessels at surgery was considered the gold standard. the sensitivity was calculated for both the imaging techniques as a measure of accuracy, evaluating the ratio between the positive cases divided by the those with aberrant vessels identified at surgery. results clinical charts were reviewed. crossing vessels identified at surgery were ( , % of pujo). the median age was higher in the group with crossing vessels compared to the group without crossing vessels (p< , ). the sensitivity of cd-us was higher compared to mru ( , % vs , %). before the surgical time knowing which technique and approach have to be managed in hydronephrotic patients with crossing vessels could be very important. according to our preliminary datacollection cd-us has got a higher sensitivity and could be the gold standard technique. study limitations include the absence of specificity, positive and negative predictive values. in the future it could be useful to perform a double blind trial in which children with moderate-severe hydronephrosis will be subjected to both imaging techniques to evaluate not only the sensitivity, but also the specificity, the positive predictive value and the negative predictive value conclusion: conclusions in the pre-operative phase, cd-us could be sufficient for the surgeon to discern between pujo with the presence or the absence of crossing vessels, as it has a higher sensitivity and lower costs compared to mru.urosonography -nonradiant alternative for voiding cystourethrography o.m. fufezan, c.a. asavoaie, s. tatar; cluj-napoca/ro voiding cystourethrography (vcug) was considered the gold standard in the diagnosis and monitoring of vesicoureteric reflux (vur). this method is invasive due to the radiation exposure. in the present the diagnosis of vur can also be established by contrast ultrasound examination, also known as voiding urosnography (vus). the authors will present the role of vus in the diagnosis and grading of the vur and the role of patient position in the detection of vur. the infants and children with congenital anomalies of the urinary tract and/or urinary tract infection have been evaluated with vus. iatrogenic vur, neurogenic bladder and urogenital sinus anomalies were excluded. the presence and the degree of the vur were evaluated. vus has been performed using a protocol similar to the one used for vcug. in conditions of sterile urine, . ml sonovue and saline solution have been introduced into the bladder until voiding started. the patients were examined both in a supine and an upright position and the following structures have been scanned: urinary bladder, distal part of the ureters and both pelvicaliceal systems during bladder filling, during and after voiding. the visualisation of the ultrasound contrast agent in the upper urinary tract represented a positive vur diagnosis. the grading of the vur has been established based on the same criteria as in vcug. sixty five patients ( renal units), ages between weeks and years were evaluated (median age ± sd: years ± years and months) through vus. vcug was performed in patients in a maximum of hours after vus. vur has been identified in patients ( . % renal units). a high vur grade (iv-v) was identified in . % of renal units. for the patients investigated with both methods, the results were concordant in patients. in two patients vur has not been identified by vcug, but was detected during vus. the upright position (in addition to decubitus) revealed vur in renal units in which the reflux was not detected in decubitus. conclusion: vus is extremely useful and reliable in diagnosing and grading vur in pediatrics. the changing of the patient position during examination can improve vur detection.new sonographic features useful in differentiating congenital duodenal anomalies from malrotation: gastric and duodenal wall thickening and hyperechogenicity p. caro dominguez , s. hameed , a. zani , r. moineddin , o.m. navarro kunstmann , a. daneman ; cordoba/es, london/uk, toronto/ca the clinical and plain radiographic differentiation of congenital duodenal anomalies (atresia, web, stenosis) and intestinal malrotation is not always clear. although sonography has been documented as an important diagnostic tool to differentiate these two entities, its role is still not widely appreciated. the purpose of this study was to assess the sonographic features of the gastric and duodenal wall in a large series of neonates with congenital duodenal obstruction as these have not been reported previously. neonates who had surgically proven congenital duodenal anomalies or malrotation were identified from the surgical database in a tertiary pediatric hospital in a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . those with an ultrasound performed within hours of surgery were included in the study. imaging was retrospectively and independently reviewed by two readers in chronological order blinded to final diagnosis. a wall thickness of ≥ mm of a distended loop was considered abnormal. hyperechogenicity was recorded when the wall of the stomach or duodenum was brighter than liver or splenic parenchyma. imaging findings in the group with congenital duodenal anomalies was compared to the group with malrotation using fisher's exact test. one hundred eight neonates were included in the study, with a congenital duodenal anomaly, with malrotation ( with volvulus) and with both. ugi was performed in neonates who had us. the correct diagnosis was provided only by us in of these newborns ( %), only by ugi in ( %), by both in ( %) and by neither in ( %). ugi was performed in children with malrotation and volvulus, eight were diagnosed only by us, four only by ugi and nine by both. the gastric and/or duodenal wall was significantly thicker and more hyperechoic in neonates with congenital duodenal anomalies than those with malrotation (p< . ) [fig , table ]. conversely an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum and the whirlpool sign were found more commonly in neonates with malrotation than those with congenital anomalies (p< . ). key: cord- -gtmpd t authors: bento, ana i.; nguyen, thuy; wing, coady; lozano-rojas, felipe; ahn, yong-yeol; simon, kosali title: information seeking responses to news of local covid- cases: evidence from internet search data date: - - journal: nan doi: nan sha: doc_id: cord_uid: gtmpd t the novel coronavirus (covid- ) outbreak is a global pandemic with community circulation in many countries, including the u.s. where every state is reporting confirmed cases. the course of this pandemic will be largely shaped by how governments enact timely policies, disseminate the information, and most importantly, how the public reacts to them. here, we examine informationseeking responses to the first covid- case public announcement in a state. by using an eventstudy framework, we show that such news increases collective attention to the crisis right away, but the elevated level of attention is short-lived, even though the initial announcements were followed by increasingly strong measures. we find that people respond to the first report of covid- in their state by immediately seeking information about covid- , as measured by searches for coronavirus, coronavirus symptoms and hand sanitizer. on the other hand, searches for information regarding community level policies (e.g., quarantine, school closures, testing), or personal health strategies (e.g., masks, grocery delivery, over-the-counter medications) do not appear to be immediately triggered by first reports. these results are encouraging given our study period is relatively early in the epidemic and more elaborate policy responses were not yet part of the public discourse. further analysis will track evolving patterns of responses to subsequent flows of public information. the first confirmed case of covid- in the u.s. occurred in washington state on january . since then the virus has spread across the country ( , ). there are confirmed cases in every state and the vast majority are not connected to international travel ( ) , indicating that the virus has been circulating for several weeks before the first positive test ( , ) . slowing the transmission of the virus will help reduce the burden of the disease, save lives, and reduce strain on the health care system ( , ) . in the absence of a vaccine, the main strategies for reducing transmission involve sanitation and handwashing, disciplined social distancing, quarantines, and school and workplace closures ( ) . these non-pharmaceutical interventions (npis) are not disease-specific, yet they are effective and powerful ways to control transmission ( ), as shown by earlier epidemics ( ) and the steady decline of covid- cases in china ( ) . to be successful, npis require people to voluntarily undertake behavioral changes that may be personally costly. this is particularly true in countries with deeply rooted norms about personal freedom and reluctance to impose mandatory policies. in settings where restrictions on the free movement of residents are less strictly enforced, it is especially critical for public officials to know whether and for how long statements from leaders motivate individuals to efficiently seek and absorb specific information as officials put their communication strategies in place. such coordinated actions are needed at the first signs of community spreading and cannot be guided through traditional polling methods. because the extent of the epidemic is likely to be underestimated at this stage, it is crucial to know how much the early case announcements induced heightened collective attention and information-seeking behavior. to provide rapid information to guide policy making, we use internet search data in an event-study design to examine how collective attention and information seeking behaviors respond to state government announcements of first covid- cases. we highlight changes in search patterns occurring in the days leading up to and following first case announcements in a state ( , ). our results display poisson coefficients and confidence intervals for the days leading up to the first case announcement, and up to the days following it. the vertical axis measures the differential percentage change in search frequency as states approach the first case announcement. in figure depicts the event study estimates of the effects of initial announcements on overall coronavirus search. searches for "coronavirus" increased by about % ( % ci: % to %) on the day immediately after the announcement but quickly decreased back to the baseline level in less than a week or two (figure ). there was no observable trend in the search behavior in the days leading up to the announcements, suggesting the first "local" case indeed heightened the collective attention to the pandemic. however, the increased level of information-seeking faded within two weeks, even though many announcements of school closures or other mitigation strategies followed, suggesting that increased attention is only short-lived. this is consistent with no observable trend in the sense of urgency prior to the local announcement. figure shows the event studies of internet search for (i) symptoms and treatments, (ii) hand sanitizer and diagnostic tests, (iii) coordinated responses, and (iv) narratives that undermine public responses. news of the first covid- case in a state leads to a % increase in searches for "coronavirus symptoms" but did not increase searches for coronavirus treatment options. the second row shows searches for "hand sanitizer" increasing % immediately after first case announcements, and unlike in the previous two cases, the search activity remains high for the remainder of the observable period. however, the announcements did not induce searches for nearby coronavirus testing opportunities, at least in the period under study. the third row suggests that first case announcements did not induce search for community level policies (quarantines, school closures, and coronavirus testing), or more elaborate personal health strategies (face masks, grocery delivery, overthe-counter medications). the final row examines how first case reports affect searches about the credibility of the epidemic. there is no indication that government confirmation of the first case increased or reduced searches for coronavirus hoaxes and overreactions; one might have expected official news to reduce concerns about false news. our results suggest that first state covid- case announcements do lead to a widespread increase in the extent to which people seek out internet information about the epidemic. we find that announcements of first cases had the biggest effect on searches for basic information about the virus and its symptoms, suggesting that people attempted to educate themselves about covid- and its effects. however, first case reports do not lead to a differential increase in searches involving large scale non-pharmaceutical interventions (school and workplace closures) that will likely have important consequences for everyday life. this may be because first cases are reported relatively early in the epidemic and many of these more serious mitigation strategies were not yet part of public discourse. finally, although one might expect official news to reduce concerns related to false messages, we do not find much indication that state announcements of first covid- cases affect searches questioning whether the epidemic may be a hoax. overall, our analysis of internet search data suggests that government information disclosure does help focus public attention on the crisis. our evidence also indicates people seem to mainly react by seeking information on what they can and should do in response to the epidemic. this provides actionable evidence for those designing the next stages of public information strategies for the covid- crisis and future threats to public wellbeing. samples. our analysis is based on a balanced daily panel of covid- related search intensity data in us states and d.c. between january , and march , (n= regions x days). we collected the data using a restricted-access google health trends application program interface (api) account ( ) . measures. the outcome variables measure the daily share of all google queries in a state that correspond to a particular term during our study period. we multiply the shares by million and round to the nearest integer to make the measure more interpretable. we collected data on the timing of the first covid- case announcements from media reports in each state; see supplement table . all states reported their first case by march , . data analysis. we estimated poisson models in an event-study ( ) framework to examine the effect of the first covid- case announcements on searches. in the model we use, the expected number of searches per million is: !, is an indicator variable set to if the first case of state i was announced k days ago. the reference category was one day prior to the first case announcement and we created single indicators !, , for any ≥ and !, , for any ≤ − .. we controlled for state fixed effects to allow for time invariant differences in search patterns by state, and for date fixed effects to account national trends. standard errors allowed for heteroskedasticity and clustering at the state level. we performed regression analysis using stata, version . (statacorp). data availability. state news data and code are available here ( ) . the search data for this study are available from google trends, but are restricted in use; researchers may apply to google trends api for access. limitations. although the eventual failure of google flu trends suggested that building and maintaining a complex model for a long period of time is difficult ( ), internet search volume has been shown to be a good proxy for many socio-economic behavioral indicators, such as automobile sales ( ) or dietary patterns ( ) . moreover, the major issues with search query data -long-term drift and representation bias across geographic regions -does not come into play in our study because we focus on relative change in a short time window surrounding the government announcements. an interactive web-based dashboard to track covid- in real time the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak coronavirus is already here. blocking travelers won't prevent its spread nextstrain: genomic epidemiology of novel coronavirus (hcov- modeling infectious diseases in humans and animals impact of non-pharmaceutical interventions ( npis ) to reduce covid- mortality and healthcare demand public health interventions and epidemic intensity during the influenza pandemic the parable of google flu: traps in big data analysis. science ( -. ) predicting the present with google trends from cookies to cooks: insights on dietary patterns via analysis of web usage logs enhancing feature selection using word embeddings: the case of flu surveillance. th int. world wide web conf an empirical evaluation of accounting income numbers author ( s ): ray ball and philip brown published by : blackwell publishing on behalf of the institute of professional accounting , graduate school of business covid- googletrends project author contributions: flr and ks collected the data; flr, tn, ks, aib, and cw analyzed data; and aib, flr, tn, ks, yya, and cw contributed to the writing of the paper. the authors declare no competing interest. key: cord- -sizuef v authors: nan title: ectes abstracts date: - - journal: eur j trauma emerg surg doi: . /s - - -y sha: doc_id: cord_uid: sizuef v nan the gertality-score: a feasible and adequate tool to predict mortality in geriatric trauma patients introduction: a large number of prediction models and subsequent outcome scores for trauma mortality have been developed over the last decades. however, feasible scoring systems for the severely injured geriatric patient are lacking. the aim of this study was to develop a new mortality prediction model for severily injured geriatric patients. materials and methods: the german trauma registry was utilized and all geriatric individuals (c years) admitted between and with an iss [ ] c were included. patient and trauma characteristics, diagnostics, therapy and outcome data were gathered. the specific odds of all variables for mortality were calculated. relevant variables were added to the novel gertality-scoring system. subsequently, this score as a sole predictor for mortality was compared with the geriatric trauma outcome score , iss, patient's age and max ais. results: a total of . trauma patients with a mean age of years were included. based on the univariable analysis, the following five variables were included in the gertality-score: age c years, pbrc-transfusion requirements from admission to ward, asa-score c , gcs b , ais c . the values of a given parameter are added to reach the total gertality-score (range - points). the auc found in the novel gertality-score was . , whereas the geriatric trauma outcome score had an auc of . . conclusions: the novel gertality-score is a simple and feasible scoring system that enables an adequate prediction of the probability of mortality in severely injured geriatric patients by using only five specific parameters. references: . champion hr, et al. the major trauma outcome study: establishing national norms for trauma care. j trauma. ; : - . . zhao fz, et al. estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. j palliat med. ; ( ) : - . the longer the better! 'extending thawed plasma shelf life to days' introduction: major bleeding is one of the most common causes of death after severe polytrauma. one of the most recent interventions that aims for bleeding control is resuscitative balloon occlusion of the aorta (reboa). this study aims to compare macro-and microcirculatory changes of intraabdominal organs and the lower extremity during the use of reboa. materials and methods: six pigs were anesthesized and received a median laparotomy. the reboa catheter (reliant balloon, medtronic) was inserted via the inguinal artery and occluded in zones , and . the occlusion of the reboa was vizualized with fluoroscopy. the balloon was inflated for min per zone. during this time the local microcirculation was measured with oxygen to see (o c, lea). between each zone the balloon was deflated for min. blood pressure was measured at the carotis artery and the femoral artery. results: baseline values of microcirculation differ significantly among organs. the flow rate is significantly higher in intraabdominal organs (colon . a.u., stomach . a.u.) compared to the extremity ( . a.u., p \ . ). blood pressure measured at the carotic artery increased significantly after inflation of the balloon (p \ . ). this increase depends on the zone of inflation (increase of ? mmhg in zone compared to baseline). the increase of blood pressure after inflation in zone is comparable to the baseline value. the colon is most sensitive to changes of microcirculation whereas the stomach and the extremity are most robust. conclusions: reboa is a new device to control for massive bleeding. different organ systems react differently to the same occlusion of the aorta. the systemic blood pressure does not mirror the local microcirculation of the abdominal organs. during emergency resuscitation with reboa these changes should be kept in mind. none of the authors have any conflicts of interests to declare. investigation of coagulopathies and its relevance with mortality and transfusion rates using thromboelastography in trauma patients introduction: fibrinolysis shutdown after injury is a common and lethal coagulopathic phenotype. patients with polytrauma, especially those with brain hemorrhage, require delayed initiation of prophylactic or therapeutic anticoagulation despite a measurable hypercoagulable state. to understand and modulate the post-trauma coagulation milieu, we assess patients with daily thromboelastography(teg). we hypothesized that persistently high clot strength and low dissolution is associated with thrombotic adverse outcomes in severely injured patients. materials and methods: adult patients with blunt or penetrating injuries admitted to the icu of a level i urban trauma center from jan-jul were included. adverse outcomes were defined as death, ventilator-free-days (vfd) = , acute lung injury (ali), acute kidney injury (aki), and venous thromboembolic events (vte). we assessed trends of clot dissolution (fibrinolysis, ly %) and strength (maximum amplitude, ma) in the first icu days using linear mixed models to account for repeated measures and missing observations. ly % was box-cox power-transformed to approximate normality. significance for pairwise comparisons at each time was adjusted by false-discovery-rate. results: patients: median age -years, % female, iss (iqr - ), % blunt mechanism, median icu days . overall, % developed one or more of the following; %vfd = , %ali, %aki, %vte, %death. ly was persistently lower in patients with adverse outcomes compared to those without (interaction time*adverse_outcomes p = . ), with fdr-adjusted significant differences at icu days and (fig ) . conversely, ma did not differ significantly by adverse outcome status(interaction time*complications p = . , fig ) . conclusions: low clot dissolution, not clot strength, is associated with adverse outcomes in severely injured trauma patients. additional work is underway for earlier identification of sd phenotypes and strategies to mitigate impaired fibrinolysis. introduction: angioembolization (ae) is can be both diagnostic and therapeutic in management of a hemodynamically unstable trauma patient. however, patients who would benefit from ae typically require emergent surgery for their injuries. the critical decision of transferring a patient to the operating room versus the interventional radiology suite can be bypassed with the advent of intra-operative angioembolization (ioae) . while the ability to perform such an intervention was previously limited by the availability of costly rooms termed raptor (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using c-arm digital subtraction angiography (dsa) is a comparable alternative. this case series aims to establish the feasibility and safety of ioae. materials and methods: we conducted a retrospective anlaysis of all trauma patients at our level trauma centre who underwent ioae with a concomitant surgical intervention from january to april . results: a total of patients ( . % male, . ± . years, . % blunt) underwent ioae using the c-arm dsa. all but one patient underwent exploratory laparotomy, . % of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopaedic). either gelfoam ( . %), coils ( . %), or a combination of both ( . %) were used for embolization. internal iliac embolization was performed in . % of cases ( . % bilateral) and five patients ( . %) required hepatic embolization. ae was successful in all but one case, inferior vena cava filters were placed in . % of cases, and . % of patients required a second ae. the -day mortality was . %. conclusions: our results suggest ioae is a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control. introduction: partial resuscitative endovascular balloon occlusion of the aorta (reboa) is a new concept of aortic occlusion to reduce the ischemic injuries below the occlusion level. it is, however, difficult to determine when the occlusion is partial in a clinical setting. end-tidal carbon dioxide (etco ) is a product of aerobic metabolism and its production is reduced during ischemia and anaerobic metabolism. the aim of this study was to investigate if etco is a good predictor of the degree of aortic occlusion during normovolemia and hemorrhagic shock in a porcine model. methods: nine pigs, - kg, were anesthetized and surgically prepared. then, gradual zone aortic occlusion by %, % and % was induced, during first normovolemia and then controlled hemorrhagic grade iv shock. hemodynamic/respiratory variables, blood gases, aortic/mesenteric blood flow, blood pressure of common femoral artery and etco were measured continuously. oxygen consumption and carbon dioxide production were calculated for each timepoint for correlation measurement to different methods for partial occlusion determination. background: acute appendicitis is one of the most common surgical emergencies worldwide. the aim of this meta-analysis of randomized controlled trials was to compare the safety and efficacy of antibiotic treatment versus appendicectomy as the primary treatment for patients diagnosed to have acute appendicitis. methods: a systematic online search was conducted using the following databases: pubmed, scopus, cochrane database, the virtual health library, clinical trials.gov and science direct. only randomized controlled trials (rcts) that compared antibiotics treatment (a) versus surgical treatment (s) as primary treatment of appendicitis were included. results: eight rcts with . patients were included: in the antibiotics group and in appendicectomy group. higher rate of treatment success was noted in appendicectomy group . % versus only . % in the antibiotics group (p \ . ) (fig. ). follow up period for recurrence was one year in all studies and the recurrence at year was reported in . % ( / ) of patients treated with antibiotics and . % ( / ) of them underwent appendicectomy. moreover, rate of overall were . % in a group and . % in s group (odd ratio . [ . - . ], ci %, p-value: . ) (fig. ) . a longer length of hospital stay was reported among antibiotics group ( . ± . in a group versus . ± . in s group, p . ). conclusions: appendicectomy has significantly higher efficacy rate but higher complications rate when compared to antibiotics treatment. most of the studies included in this meta-analysis conveyed a high risk of bias, hence more well-designed rcts are recommended. introduction: post-operative adhesions are associated with increased risk of morbidity and mortality. up to date no effective measures has been introduced to decrease intra-abdominal adhesions following laparotomy. oxiplex-ap gel has been used in extra-abdominal surgical procedures to prevent adhesions. in the current study oxiplex-ap was tested in a mural animal model to investigate its efficacy in reducing post-surgical intra-abdominal adhesions. materials and methods: forty rats subjected to laparotomy were randomly divided into groups of . a serosa injury was made on the small intestine and three different treatments were applied: simple suture, simple suture ? oxiplexap, and oxiplex-ap only; the last group received no treatment of the injury before closure of the abdomen. all animals were kept alive for days, and a second laparotomy was done to measure the intra-abdominal adhesion by the nair classification. results: at second look laparotomy a significant difference in adhesion was noticed between the simple sutures and simple suture ? oxiplex-ap were the latter had developed less adhesions. there was also a trend towards less adhesion development between the simple sutures and oxiplex-ap only group, with less adhesions in the latter. conclusions: the use of oxiplex-ap was associated with decrease adhesion formation in the current animal model particularly without suturing. further investigations into these findings are needed. introduction: emergency abdominal surgery is known to result in high morbidity and mortality. furthermore, evidence suggests that unplanned admissions to the intensive care unit (icu) are associated with higher in-hospital mortality than those patients with planned icu admissions . the aim of the study was to describe the patient population who required an unplanned admission to icu following emergency laparotomy at the royal melbourne hospital. materials and methods: a single-centre retrospective observational study was performed using prospectively collected data between and . patients who underwent an emergency laparotomy and experienced an unplanned icu admission were included. patients who underwent a trauma laparotomy were excluded from the study. results: emergency laparotomies were performed. of these, ( . %) required an unplanned admission to icu. fourty-two patients ( %) were female, and patients ( %) were aged years and above. sixty-three ( %) were admitted due to single organ dysfunction (clavien-dindo iva). the median time to icu admission was days in patients classified to have experienced clavien-dindo iva, while it was days in patients who experience multi-organ dysfunction (clavien-dindo ivb). thirty-seven patients ( %) were admitted to icu due to complications classified as cardiopulmonary. conclusions: recognising that emergency laparotomy is a high risk procedure, with the elderly patients accounting for the majority of unplanned icu admissions, it is imperative to utilise risk stratification methods to guide optimal peri-operative management. this should result in improved utilisation of critical care resources and overall patient outcomes. introduction: the way of reconstruction following intestinal resection in the emergency settings is still controversial. the question which is better between hand-sewn and stapled anastomosis in trauma and emergency surgery occasionally arises; however, there have been few reports comparing these methods. materials and methods: a record-based retrospective study was performed to compare hand-sewn with functional end-to-end anastomoses in trauma and emergency operations from october to october in one of the largest trauma and emergency centers in japan. the patients who had intestinal resection with functional endto-end or hand-sewn anastomosis in an emergency surgery were included. the patients who had covering ileostomy or colostomy, or who underwent surgery as an elective operation were excluded. the primary outcome is the rate of complication associated with anastomosis. the statistical analyses were performed using a chi introduction: injuries are the fourth leading cause of death in europe. laparotomy is the standard treatment for penetrating abdominal wounds. because of the morbidity and the high rate of negative laparotomies, the nonoperative treatment is effectively developing. the aim of this study is to analyze the complications and the quality of life of the patients after laparotomy for this kind of wounds. materials and methods: a retrospective cohort of patients was studied between and at the laveran military teaching hospital in marseille. one hundred and eighty-six trunk gunshot or stab wound were recorded, including abdominal wounds. thirtyfour patients were managed by laparotomy and included in this study. the patients and their referring general practitioners were contacted to complete missing data and the sf- quality of life score. results: among the patients included, the average age was years and most of them were men. the indication for laparotomy was mainly based on the hemodynamic instability, then according to the results of the computed tomography in case of suspicion of specific lesions: bowel injuries, major vascular injury, mesenteric or mesocolic vascular injury, diaphragmatic injury and intraperitoneal bladder rupture. only laparotomies were negatives. eleven complications after laparotomy were found ( , %), including early (within the days) and late. no complication was found after negative or non-therapeutic laparotomies. the quality of life of the patients after one year is similar to those of the general population. conclusions: the most common indication for laparotomy for abdominal penetrating trauma is hemodynamic instability. the rate of laparotomy complications for penetrating abdominal trauma is similar to those of scheduled surgeries. the quality of life after this care remains unchanged. these results may insist on the fact that the ''gold standard'' treatment for penetrating abdominal injury remains the laparotomy objectives: splenic artery embolization (sae), a routinely used adjunct in the non-operative management (nom) of splenic injuries(si), was widely adopted in trauma about two decades ago. we examined complications that occurred with this modality at a level trauma center over a recent -year period and compared this to the prior years. methods: patients who had sae for si between - were identified. sae complications were noted. splenic abscess, splenic infarction and contrast-induced renal insufficiency were considered major complications. coil migration, fever and pleural effusions were regarded ''minor'' complications. the results were compared with data from a prior study examining similar indices at the same trauma center between and . fishers exact test was used for comparison. results: there were patients admitted with si in the recent period, of which ( %) underwent immediate splenectomy. sae was performed in ( . %) of the patients who underwent nom. of these sae patients, % had a contrast blush and . % were either aast grade or . five sae patients ( . %) had splenectomy for continued bleeding. the overall complication rate was . %. major complications occurred in patients ( . %) and minor in patients ( . %). embolization location in the splenic artery was proximal in . %, distal in . % and in both in . %. there was no association between complications and coil location by logistic regression. differences between the two periods shown in table . conclusion: sae continues to be a useful adjunct in nom of si and has seen increased utilization. complications continue to occur,although fewer minor complications were noted in the second period. no association between embolization location and complications was noted in the recent period. judicious utilization of sae is imperative given the complications that continue to be noted from this procedure. the effect of the time spent in the emergency department on the mortality rates and cause of death in patients who underwent emergent laparotomy introduction: the purpose of this study was to a) examine the effect of the time spent in the emergency department (ed) on hypotensive patients in need of emergent laparotomy and b) to determine the mortality rates and cause of death in these patients. materials and methods: between - , patients were included ( men and women, mean age . years) who underwent laparotomy less or equal to min from ed admission. of the patients, (group ) had a systolic blood pressure (sbp) greater than mmhg and had a sbp less or equal to mmhg. all patients had abdominal injuries with an injury scale score (iss) between and . the in-hospital mortality represented the primary outcome, while secondary outcomes included cause of death and time to death. results: in this study both groups spent a median of min in the ed, but the time from the ed to the operating theatre was shorter in the group ( min versus min). in total, the mortality rate was %, but in the group the mortality was %. the sbp on arrival in the ed was strongly associated with the risk of death. furthermore, we observed significant positive correlation between the probability of death and the time spent in the ed, with an increase of probability of death equal to . % per minute spent in the ed. in both groups the hemorrhage was the commonest cause of death ( %). the results of this study indicate that, in patients with abdominal injuries requiring emergent laparotomy, the probability of death is proportional to both extent of hypotension and the length of time spent in the ed. especially, in patients who were presented with a sbp inferior of equal of mmhg, this probability increased as much as % for each min. despite many advances in trauma surgery, half of hypotensive patients are going to die in the first h. introduction: injury to the pancreas may lead to significant morbidity and mortality. we studied the prevalence of pancreatic endocrine and exocrine functions and evaluated the morphological regenerations in pancreas following partial pancreatectomy. materials and methods: patients with pancreatic trauma were recruited ambispectively from january to december . endocrine functions were assessed at the time of admission and at months follow up with g oral glucose tolerance test (ogtt), serum insulin and c-peptide levels, hba c estimation and exocrine functions were assessed with faecal elastase test. pancreatic volumetry was done with imaging studies at -and -months post discharge. results: twenty patients were studied with a median age of years at the time of injury. all the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus requiring insulin on follow up. patients ( %) were found to have prediabetes by american diabetes association (ada) criteria. patients ( %) had pancreatic exocrine insufficiency. pancreatic volume increment, from mean pancreatic volume of . cm to . cm , was noted in partial pancreatectomy patients. conclusions: overt endocrine and exocrine insufficiency is rare in pancreatic trauma patients. but subsets of patients are biochemically predicted to have higher risks of endocrine dysfunction and exocrine insufficiency. hence, while dealing with pancreatic trauma patients, one should remember the possible metabolic disorders associated and the need for specific investigations. pancreatic volume increment is a new finding which opens up more opportunities for further research. hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal, hospital de santo espírito da ilha terceira, orthopedics and traumatology, angra do heroísmo, portugal introduction: rope bullfights are traditional events in the azores islands, where a bull is set on the streets, arrested by a rope on its neck. around events happen every year and it is already part of the island's touristic attractions. inevitably, every year, people get injured either from direct trauma with the bull or from falls when trying to escape from the animal. the aim of this study was to characterize the type of injuries that occur in these bullfighting events, as to their incidence, mechanism of injury, anatomical affected area and severity. materials and methods: we prospectively registered all cases of injured people who suffered any type of trauma during rope bullfights and received emergency therapy in the local hospital, between and . results: patients recured to the emergency department, . % female, with mean age of . years. regarding the mechanism of injury, . % occured due to direct trauma to the animal while in the remaining . % resulted from falls during escape or handling of the rope. the most commonly affected anatomical areas were the limbs ( . %) followed by the head and neck ( . %) and thorax ( . %). in , % of the cases, patients suffered from multiple traumas. in . % of the cases the treatments performed were wound care, wound closure and/or symptomatic therapy. in total, patiens were hospitalized, patients required interventions in the operating room ( closed fracture reductions and exploratory laparotomy with splenectomy) and patients were hemodynamically unstable upon admission (hypovolemic shock due to splenic fracture and cet). conclusions: the rare articles published describe the mechanisms of injury associated with bullfights in spanish centers and injuries resulting from wild cow accidents in indian cities. this is the first local descriptive study on the prevalence of traumatic injuries associated to this specific type of rope bullfights. introduction: the two-stage splenic rupture is seldom, its risk is unpredictable and a precise diagnosis of a ct and/or mri imaging unexpectable or unexcludable. generally, and due to our experience and current literature a two-stage rupture occurs within one week after trauma. though dramatic courses after two or three weeks are known. therefore, it is suggested to perform a prophylactic angioembolization in (still) hemodynamically stable patients. materials and methods: a retrospective study in a level-one trauma centre of switzerland did analyse all patients that underwent a prophylactic angioembolisation after an explicit diagnose by ct and/or mri of a splenic parenchymal lesion after trauma between and . further inclusion criteria were hemodynamical stability (sys rr [ mmhg) and missing indication for immediate laparotomy. results: patients ( f, m) with an average age of ± years underwent preemptive angioembolisation after traumatic lesions of the spleen. the ais abdomen was in and in patients. besides a splenic injury patients did also have a kidney injury. the overall iss was ± points. patients suffered additional thoracic or head trauma. in patients the angioembolisation was performed on admission, in on the st, in at the nd and respectively in the rd and th day of. in case an uncomplicated selective embolization of a main duct of the splenic artery was performed. in patients the trouble-free proximal embolization of the splenic artery was done. the average stay was ± . days. no deaths or complications seen due to angioembolisation or splenic rupture. there were no complications or operative introduction: traumatic abdominal wall hernias (tawhs) are uncommon, and the optimal management is debated. tawhs most often result from blunt trauma and are associated with severe intraabdominal injuries. our institutional protocol mandates primary repair only if the patient undergoes laparotomy for other reasons and is without mesh. since , primary repair of lumbar hernias included bone anchors when indicated. we wanted to describe the tawh patients treated operatively during initial hospitalization focusing on injury mechanism, diagnosis, associated injuries, operative techniques, early complications and outcomes. materials and methods: we performed a retrospective, descriptive cohort-analysis of data from the institutional trauma registry from - . all operatively managed tawhs were identified based on ais codes, ncsp codes and relevant key words. results: of the identified patients, ( %) were women. median age was years (range - ). median iss was and patients had iss [ . injury mechanism was blunt except for one explosion. patients ( %) had been in a mvc, and of these ( %) had seat belt injuries. of these patients had a disruption of the muscle from the iliac crest, and one had a hernia through a fractured iliac wing. bicycle falls and fall from height had hernias in the anterior abdominal wall. two meshes were placed, with no known complications. bone anchors (twinfix Ò , mm) were used in patients. no recurring hernias were identified in the patients with routine follow-up ( - months) . conclusions: surgery for tawh is uncommon in our institution. tawh is often associated with severe torso injuries and primary repair is only done when laparotomy for other reasons is indicated. primary suture of the muscle, including use of bone anchors seems to be adequate treatment, as we have identified no recurrences. a longterm follow-up study is warranted for operated and non-operated patients with tawh. a comparison of sub-specialty operative adolescent patient outcomes in adult and pediatric trauma centers introduction: adolescent trauma victims may be treated at either an adult (atc) or pediatric trauma center (ptc). these centers have different resources, surgeon training and overnight in-house coverage. it is not known how outcomes compare with regards to the very small subset of patients that actually undergo a surgical trauma intervention. we hypothesized that presentation to a ptc would yield increased mortality when subspecialty intervention was required and that this would be most pronounced at night when in-house attending coverage is absent at all state ptcs. materials and methods: a review of the pennsylvania trauma outcome study (ptos) database was performed to capture patients aged - who underwent any non-orthopedic trauma surgery. cohorts were created for cranial, thoracic, abdominal or vascular surgery from - . trauma centers were divided as adult level (atc ), adult level (atc ) or pediatric (ptc). groups were created based on time of arrival with am- pm being dayshift and : pm- am being night shift. age, race, mechanism of injury, vital signs, gcs, iss, los and mortality were evaluated. ancova was utilized to control for iss variation. spss was used for all analyses. results: patients met initial criteria. atc s saw more minority patients and more males than other center types. atc s saw an overall older cohort ( . years vs . years in atc and . years in ptc, p \ . ). despite this age difference, presenting systolic blood pressure was lowest at the atc s ( . mmhg vs . mmhg at atc and . mmhg at ptc, p \ . ). iss and triss and overall mortality were not different and this included when grouped by day or night shift. of note, trauma thoracotomy was more likely to be performed at night in adult centers. hospital length of stay was significantly lower for atc ( . days vs . in atc vs and . in ptc). conclusions: adult and pediatric trauma centers see different patients. operative trauma cases are surprisingly low at our state's ptcs and trauma thoracotomy was more likely to be performed at night in atcs than ptcs. broader study is needed to uncover differences in operative care and outcomes. treatment of dislocation of the patella as a result of sports injuries in children. forecast and consequences in adulthood k. furmanova , o. loskutov , a. naumenko medinua clinic and lab, ortopedics, dnepr, ukraine introduction: dislocations of the patella with a rupture of the medial patellofemoral ligament (mpfl) account for - % of acute injuries of the knee joint [ , ] . inadequate therapeutic tactics of these injuries in childhood and youth, as a result of sports injuries, are fraught with complications in the form of the instability of the knee joint, residual deformities and contractures in patients in adulthood [ , ] . materials and methods: in the period from to cases of rupture of mpfl among children aged - years who were involved in sports were observed. the examination included conducting a clinical examination, axial radiography with flexion of the joint at angles of °and °, mri of the knee joint. results: in . % ( cases) the integrity of the mpfl(with a reduced number of sutures) was restored using a yamamoto suture, and in cases ( . %), the autoplasty of the mpfl was performed. excellent medium-term ( years) clinical and functional results according to the ikdc scale were noted in . % of cases, good in . %, satisfactory in . %. in patients ( . %) there was a relapse of dislocation after performing an mpfl suture during the first year after surgery mainly due to noncompliance with the recommendations. conclusions: injury to the knee joint with the patella dislocation in childhood and adolescence, associated with a sports injury is an indication for surgical treatment in order to adequately restore the integrity of the mpfl and prevent disabling complications. our yamamoto suture technique is more optimal for treating young patients with instability of the patella and is recommended for widespread use in pediatric orthopedists due to its undeniable clinical advantages. osteotomy with a defect cm placed cm below tibial plateau. types of fixation have been simulated: plate fixation of only a medial pillar, plate fixation of only a lateral pillar, plate fixation of both pillars, and locking intramedullary nailing. results: in case of plate fixation of only a medial pillar, the injury to an interosseal membrane causes an expressed valgus deformation at axial loading, leading to a reasonable ( . mpa) overload of the fixator in the osteotomy area. the use of a lateral plate leads to excessive loading on an external pillar, while the medial pillar remains unsupported. this causes overloads of the fixator in the osteotomy area ( . mpa). the double plate fixation is typical of the lowest extent of bone fragments displacements ( . mm) . this is a super-rigid type of osteosynthesis, able to cause a stress-shielding syndrome in the adjacent bone. it has been estimated that the method of im nailing is an optimal fixation method, with minimum loading of the fixator ( . mpa) and the best distribution of changed elastic strains in the bone-implant system. conclusions: the mathematical simulation demonstrates that fixation by a medial plate is possible only if support functions of the ligament system and interosseal membrane remained intact. if an injury is a high-energy one, nailing is preferable. introduction: treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. grafts are necessary to support bone healing. a well-established allograft is demineralized bone matrix (dbm) prepared from donated human bone. a recent development is a new fibrous demineralized bone matrix (f-dbm) with a high surface-to-volume ratio. in this study we examine toxicity of an innovative dbm fibers preparation. materials and methods: f-dbm was transplanted to a mm, platestabilized, femoral critical-size-bone-defect of mm in sprague-dawley (sd)-rats (n = ). healthy animals were used as control. after months histology, hematological analyses as well as serum biochemistry was performed. were measured as indicators of free radical exposure. there were no significant differences between the control group and animals receiving f-dbm. hematology as well as biochemistry did not differ between operated animals and control. histologically no evidence of damage to liver and kidney and a good bone healing could be observed in most cases. conclusions: taken together, these results provide evidence for no systemic toxicity of the bone allograft. i have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. • i hereby confirm that my abstract is based on previously unpublished data and that i own the rights to the written summaries of research or observations presented in the abstract, or that i have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. • in submitting an abstract i hereby agree that the copyright of my abstract is transferred to the european society of trauma and emergency surgery. • i hereby confirm that i will present my abstract at the congress in case it is accepted. sponsor: german institute for cell and tissue replacement (dizg, gemeinnützige gmbh), berlin, germany. intramedullary nailing through suprapatellar approach in distal tibia fractures: a retrospective study evaluating clinical and radiographic results d. bustamante recuenco , a. gómez , j. m. pardo garcía , e. garcía , p. castillón , p. caba doussoux hospital de octubre, madrid, spain, madrid, spain, hospital mutua terrasa, orthopaedics, barcelona, spain introduction: distal tibia fractures (dtf) can be operated either by intramedullary nailing (imn) or by orif with plates. the current literature shows a higher rate of malalignment and consolidation delay with imn when compared to plates. in these studies, an infrapatellar approach for the imn is performed. recent studies show a better alignment in dtf treated with imn by suprapatellar approach, though functional and biological outcomes have not been analyzed yet. our goal is to assess the clinical and radiographic results of the treatment of dtf with imn using a suprapatellar approach. materials and methods: a two-center retrospective study was performed, collecting the cases with dtf treated with suprapatellar imn from / to / . results: a total of patients were obtained, with a mean age of . years. the average follow-up was months. % of the fractures were ao type a, presenting the remaining % intra-articular involvement. patients presented complications, corresponding in of them to superficial infections. as for clinical results, complete mobility in the knee and ankle was obtained in almost all cases. at the radiographic level, a total of % ( ) of distal malalignment cases were detected, defined as more than °deviation from normal axis in the coronal and sagittal planes. most of the fractures consolidated in a period of - months. there were cases of delayed consolidation, from which developed pseudoarthrosis. conclusions: intramedullary nailing through a suprapatellar approach for dtf offers good clinical and radiographic results, with low rates of malalignment and lack of consolidation. more studies are required to compare the results obtained with other fixation methods for these fractures. reference: avilucea fr, triantafillou k, whiting ps, perez ea, mir hr. suprapatellar intramedullary nail technique lowers rate of malalignment of distal tibia fractures. j orthop trauma. ; ( ) : - . the clinical consequences of follow-up radiographs in ankle fractures are unclear and indications for these radiographs are seldom well-defined. routine radiographic imaging in the follow up of patients with an ankle fracture adds to treatment costs, although retrospective studies dispute its usefulness. the aim of this study was to assess if a protocol with a reduced number of routine radiographs would lead to cost savings, without compromising clinical outcomes. materials and methods: a multicentre randomized controlled trial was conducted. patients were randomly assigned in a : ratio to usual-care (consisting of routine radiography at one, two, six and twelve weeks) or reduced-imaging (radiographs only obtained for a clinical indication at six and twelve weeks). functional outcome was assessed using the omas and aaos ankle questionnaires, quality of life was measured with eq- d- l and sf- questionnaires. other outcome measures included complications, pain, the number of radiographs, health perception and self-perceived recovery. costs were measured with self-reported questionnaires results: the study group consisted of participants, of which ( %) received operative treatment. patients in the reduced-imaging group received median radiographs, whilst patients in the usual care group received median radiographs (p \ . ). omas, aaos scores, quality of life, pain, health perception and self-perceived recovery did not differ between groups. we observed complications in the reduced imaging group. this did not differ significantly from the usual care group ( complications p = . ). a significant reduction in radiographic imaging costs was observed (-€ per patient, % ci - to - ). overall costs per patient were comparable ( [ % ci - to ]). conclusions: implementation of a reduced imaging protocol in the follow up of ankle fractures leads to cost savings and more importantly does not lead to worse functional outcomes. results after percutaneous and arthroscopically assisted osteosynthesis of calcaneal fractures w. grün , m. molund , f. nilsen , a. stødle oslo university hospital, orthopaedic department, ullevål, oslo, norway, Østfold hospital, orthopaedic department, grålum, norway introduction: operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. during the last years there has been a trend towards less invasive fixation methods. percutaneous and arthroscopically assisted calcaneal osteosynthesis (paco) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. materials and methods: we conducted a clinical and radiographic follow-up of patients with calcaneal fractures treated by paco with a minimum follow-up of year. there were sanders ii and sanders iii fractures. the mean follow-up period was . months (sd . ). our primary outcome was the american orthopaedic foot and ankle society (aofas) ankle-hindfoot score. secondary outcomes were the calcaneus fracture scoring system (cfss), the manchester-oxford foot questionaire (moxfq), the visual analog scale (vas) for pain and the incidence of complications. radiographs were obtained to evaluate the reduction of the fractures as well as the presence of subtalar osteoarthritis. results: the median aofas score was (range, - ), the cfss score ( - ), the moxfq score . ( - . ). the vas pain score was ( - . ) at rest and . ( - . ) during activity. the böhler angle improved from mean . degrees (sd . ) preoperatively to . degrees ( . ) postoperatively. however, the follow-up radiographs showed subsidence of the fractures and a böhler angle of . degrees ( . ). % of the operated feet showed signs of posttraumatic subtalar osteoarthritis. there were no wound healing complications. two patients were reoperated with screw removal due to prominent screws. conclusions: our results suggest that paco gives good clinical results and a reduced risk of complications in selected calcaneal fractures. prospective longterm studies will be necessary to better evaluate the potential advantages and limitations of paco. with the nascent state of microsurgical services in the region the application of negative pressure wound therapy (npwt) has proven to be very helpful. an improvised npwt has made it locally available to patients. this report aims to show how this has improved the management of open fractures of the lower limb in a resource restricted setting. materials and methods: a -month review of cases of lower limb open fractures managed at a regional trauma centre in nigeria was done. the type of wounds were classified based on region and need for soft tissue coverage. results: a total of cases were reviewed approximately % of these case were gustilo and anderson type iii. of these had npwt as part of their management. some of the benefits of observed were; reduced frequency of wound dressings, and shorter time to optimize wound for closure. conclusions: the locally improvised npwt has proven to be an affordable and cost-effective tool in the management of open lower limb fractures. it remains an invaluable alternative of care in the absence of microsurgical skills and patented device with are far from reach owing to financial constraints. references: . hussain a, singh k, singh m. cost effectiveness of vacuum assisted closure and its modifications: a review. isrn plast surg. ; : - . . isiguzo c, ogbonnaya i, uduezue a. modification of negative pressure wound therapy in the economically constrained region: a preliminary report. vol. , nigerian j plast surg. joytal printing press; . p. - . . mba u, nevo a. challenges of limb salvage in a resource limited environment: case report and review of literature. niger j plast surg. ; ( ): . . novak a, wasim sk, palmer j. the evidence-based principles of negative pressure wound therapy in trauma and orthopedics. open orthop j. ; : - . introduction: lower extremity vascular trauma may result in limb loss or mortality. this study examined outcomes of lower extremity vascular trauma (levt) and potential associations to amputation/mortality. materials and methods: a retrospective cohort study of patients (n = ; limbs) with levt between and in a single trauma center. only patients requiring a vascular procedure were included. data were extracted from the swedish vascular registry (swedvasc) and the swedish trauma registry (swetrau). results: mean age ± years; men % ( / ); trauma mechanism % ( / ) blunt and % ( / ) penetrating. % of patients underwent preoperative cta; % of patients ( / ) were transferred to hybrid operating room. arterial injury was present in / limbs ( %) and venous injury in / limbs ( %). the most frequently injured artery was popliteal artery ( / ; %) followed by superficial femoral artery ( / ; %). most common vascular operative procedure was arterial bypass/interposition graft ( / ; %). a vascular shunt was used in % of cases ( / ). fasciotomy was performed in % ( / ) of limbs. four patients were lost to follow-up after less than five days. there were eleven limbs ( / ; %) amputated within -day postoperative follow-up. all amputations were caused by blunt trauma. % ( / ) of arterial injuries below-the-knee led to amputation. thirty-day mortality rate was . % ( / ) . univariate analysis showed that fractures (p \ . ), soft tissue injury (p \ . ), multiple injuries (p = . ), and blunt mechanism (p \ . ) were associated with amputation and mortality after levt. conclusions: this study showed that amputations after levt are caused by blunt trauma. also levt combined with fractures, soft tissue injury, or multiple injuries increased the risk of amputation and mortality. multi-center study enabling multivariate analysis to adjust for potential confounding factors is imperative to confirm these findings. incidence, treatment and financial burden of tibial plateau fractures in belgium between and describe the incidence, evolution in management and financial burden of tpf in belgium between and . we compare national data with data from uz leuven (uzl), the largest university hospital in belgium. materials and methods: this study includes all tpf treated in belgium between and . we identified . tpf, of which fractures were treated in uzl. despcriptive statistics were used to analyze the data. results: the annual incidence increased from . to . / , /y. an increase in number was true for both operatively treated patients (otp) and non-operatively treated patients (notp), but was more pronounced in the latter ( % vs. % increase). the rate of surgery (ros) decreased from . % to . %. the mean ros for uzl was . %. the total financial burden in belgium increased with %, mainly driven by increasing costs in otp. hospitalisation rates for notp decreased from % to %, as day hospital admission occured more commonly. the mean hospitalisation cost was € , for otp and € , for notp. costs for uzl inpatients were € , and € , . nursing days accounted for % of the cost in otp and % in notp. the mean los was . days for otp and . days for notp. uzl patients had a mean los of . and . days. conclusions: tpf are associated with increasing hospital related healthcare costs. as nursing days determine the majority of the financial burden, measures should be taken to avoid prolonged los. introduction: rotational malalignment (rm) is a common postoperative complication after intramedullary (im) nailing of tibial shaft fractures. computed tomography (ct) is commonly used for detection of malrotation, however reliability is frequently questioned. the purpose of this study is to evaluate the intra-and inter-observer reliability of low-dose protocolled bilateral postoperative ct-assessment of rotational malalignment after im nailing of tibial shaft fractures. materials and methods: a total of patients were prospectively included with tibial shaft fractures that were treated with imn in a level-i trauma center. all patients underwent postoperative bilateral low-dose ct-assessment (effective dose of . - . mgy) as per hospital protocol. four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. the intra-class coefficient (icc) was calculated to evaluate intra-and inter-observer reliability. the intra-and inter-observer reliability was categorized according to landis and koch. results: intra-observer reliability for quantification of rotational malalignment on postoperative ct after imn of tibial shaft fractures was excellent with . ( % ci = . - . ). the overall inter-observer reliability was . ( % ci = . - . ), also excellent according landis and koch. discussion and conclusion: first, bilateral postoperative low-dosesimilar radiation exposure as plain chest radiographs-ct assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following imn of tibial shaft fractures and it allows for early revision surgery. second, it may contribute to our understanding of the incidence, predictors, and clinical relevance of postoperative tibial rotational malalignment in patients treated with imn for a tibial shaft fracture, and facilitates future studies on this topic. the trauma emergency laparotomy audit (tela) t. collaborators , m. marsden , p. vulliamy , r. carden , o. najiuba , n. tai , r. davenport tela collaboration, natric, n/a, united kingdom, queen mary university of london, centre for trauma science, london, united kingdom introduction: mortality for shocked trauma patients undergoing emergency laparotomy remains unchanged for years. the tela study aimed to describe the contemporary peri-operative management and patient outcome following abdominal injury. materials and methods: a prospective multicentre observational study of all patients undergoing emergency abdominal surgery within h of injury was performed in the uk and ireland for six months from the st january . shock was defined as the receipt of blood transfusion, with clinical or biochemical evidence of hypoperfusion. results: the study included patients from hospitals, of whom ( %) were shocked and received a median of units red blood cells. shocked patients were more likely to have a blunt mechanism of injury ( % vs %, p \ . ) and had a % mortality ( / ). half of these deaths occurred in the operating room (or). patients that died were more severely injured (injury severity score (iqr - ) vs (iqr - ), p = . ) and had a greater degree of shock at hospital arrival (base deficit . (iqr . - . ) vs . ( . - . ) , p \ . ). processes of care were equivalent or better among non-survivors, with a higher proportion of patients that died undergoing laparotomy within min of arrival in the emergency department ( % vs %, p = . ) and a lower proportion receiving crystalloid in the or ( % vs %, p \ . ). however, delays to achieving definitive haemorrhage control and delivering balanced blood transfusion ratios were observed among both survivors and non-survivors. conclusions: damage control resuscitation principles are followed most closely in patients that die. despite better processes of care, in shocked patients died in this study justifying the continued search for novel therapeutic approaches. pre-operative temporary haemorrhage control and pharmacological mitigation of the effects of shock may be productive avenues of research to improve patient outcomes. introduction: tranexamic acid (txa) has been shown to reduce mortality in bleeding trauma patients, with greater effect if administered early. normally administered intravenously, txa can also be administered intramuscularly, which could be advantageous in low resource and military settings. intramuscular use has only been tested in healthy patients, and it is likely that shock will reduce intramuscular uptake. materials and methods: in a prospective experimental study norwegian landrace pigs ( - kg) utilised in a surgical course in haemostatic emergency surgery were subjected to various abdominal and thoracic trauma. after h of surgery the pigs were injected with mg/kg txa either intravenously or intramuscularly. blood samples were drawn at , , , , , , and min. the samples were centrifuged and analysed with liquid chromatography-mass spectrometry (lc-ms/ms). results: preliminary results from animals in the intramuscular and animals in the intravenous group. mean plasma concentration with sd of txa as a function of time is shown in figure . plasma concentration in the intramuscular group was near ug/ml min after administration, and rose above ug/ml after min. conclusions: plasma concentrations reported to inhibit fibrinolysis in vitro is - . ug/ml ( , ) . if this extrapolates to the clinical situation intramuscular administration would yield plasma levels within the lower end of therapeutic range after min. in ongoing haemorrhagic shock plasma concentrations of txa after intramuscular administration were considerably lower than after intravenous administration, but within therapeutic range . introduction: fallowing laparoscopic cholecystectomy(lc), patients suffer from postoperative pain, especially in the abdomen. intraperitoneal local anesthesia (ipla) reduces pain after laparoscopic cholecystectomy(lc). acute cholecystitis(ac)-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent lc with ipla application. the aim was to determine the postoperative analgesic efficacy of high-volume lowdose intraperitoneal bupivacaine in urgent lc. materials and methods: fifty-seven patients, american society of anesthesiologists(asa) physical status i or ii were randomly assigned to receive either normal saline(group a) or intraperitoneal bupivacaine(group b) at the beginning or at the end of the surgery in urgent lc. the primary outcome was the scores of postoperative pain by visual analogue scale score (vas) after surgery. results: postoperative vas scores at st and th hours were significantly lower in group b than group a (p \ . ). postoperative vrs scores at st, th and th hours were significantly lower in group b than group a (p \ . , p: . , p: . ). anelgesic use was significantly higher in group a at st postoperative hour than group b (p \ . ). shoulder pain was significantly lower in group b than in group a (p \ . ). patient satisfaction was significantly higher in group b than in group a (p \ . ). conclusions: high-volume low-concentration intraperitoneal bupivacaine instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and analgesic consumption in comparison to control group in urgent lc. introduction: in-hospital resuscitative thoracotomy is an established procedure for patients with penetrating cardiac injuries. the survival rate is dismal in patients with cardiac arrest prior to admission. prehospital resuscitative thoracotomy (prt) was introduced by the london hems with the highest published survival rate of %. we aimed to identify the number of patients who could potentially benefit from prt in our major trauma center catchment area. materials and methods: data from to were collected from the institutional trauma registry and electronic records. we included patients [ years, with penetrating cardiac injury, or penetrating chest trauma and cardiac arrest, or penetrating chest trauma and sbp \ mmhg. commonly used criteria for prt are tamponade with cardiac arrest lasting \ min at the time of ambulance arrival and with [ min remaining transportation time to hospital. results: cardiac injury was found in of included patients. of these , arrived at the hospital with signs of life and survived. of the patients who died had tamponade. criteria for prt were not met in of patients with tamponade. two patients could have been eligible for prt. one patient was found in oslo with cardiac arrest lasting min. the patient had multiple stab wounds to the chest and had several perforations of the right atrium, not technically manageable in a prehospital setting. the second patient was injured outside our primary catchment area and arrested with prehospital personnel present. prt was performed and the tamponade relieved, but compression of the aorta was necessary. the patient was declared dead shortly after hospital admission. conclusions: in years in a population of . million, two patients met london hems criteria for prt. prt was performed in one patient who was declared dead shortly after hospital admission while one patient suffered from injuries which are unmanageable in a prehospital setting. isolated tissue injury leads to fibrinolytic shutdown, tpa resistance and alterations in clot structure in a porcine model introduction: trauma-induced coagulopathy includes a spectrum of hypo-to hypercoagulable phenotypes with differing levels of fibrinolysis and tpa sensitivity. fibrinolysis shutdown is associated with increased late mortality and shown in small animal studies to be driven by tissue injury. utilizing a novel method of clot structure analysis, we hypothesize that isolated tissue injury provokes fibrinolysis shutdown, tpa resistance and is associated with altered clot structure resulting in enhanced clot stability. materials and methods: all male pigs (n = ) underwent anesthesia, intubation, femoral artery cannulation and mini-laparotomy. tissue injury (n = ), was inflicted with bilateral chest wall muscular cutdowns and bilateral femoral fractures using a captive bolt pistol. mean arterial pressure was maintained at [ mmhg. timed blood samples analyzed using tpa challenged and citrated native teg to evaluate tpa resistance and fibrinolytic shutdown respectively. after mm punch biopsy induced splenic injury, clot was collected, washed, and chemically fractioned by strong cation exchange chromatography. tandem mass spectrometry and bioinformatic analysis were used to evaluate clot structure and factor xiiia cross-linking patterns and covalently associated proteins. results: tissue injury pigs showed increased tpa resistance (change tpa-teg ly : - . % vs - . % p = . ) and a trend of fibrinolytic shutdown evidenced by teg compared to control (fig. ) . splenic clot structure analysis demonstrated altered clot structure (fig. ) and identified elevated levels of protease inhibitors such as alpha macroglobulin and alpha antiplasmin at h post tissue injury compared to baseline. conclusions: in a porcine model, isolated tissue injury provokes fibrinolysis shutdown and tpa resistance resulting in altered clot structure with an increased incorporation of anti-protease proteins resulting in enhanced clot stability. there is a high incidence of rotational malalignment after intramedullary nailing of tibial shaft fractures: a prospective cohort series of patients n. j. bleeker amsterdam medical centre, flinders university, department of orthopedics and trauma surgery, amserdam, netherlands introduction: intramedullary nailing (imn) is the treatment of choice for most tibial shaft fractures due to its minimalistic surgical approach, superior fracture healing, and rapid recovery. however, an iatrogenic pitfall is rotational malalignment (rm). the aim of this prospective cohort study was to determine the incidence of rm and to evaluate the efficacy of protocolled bilateral postoperative computed tomography (ct) assessment of rotational tibial alignment. materials and methods: between and we prospectively included patients ( male ( %)), with a mean age of years, with a unilateral tibial shaft fracture. as per hospital protocol, patients underwent a routine low-dose bilateral postoperative ct to assess rm. forty-two patients ( %) suffered open injuries; ( %) were involved in a multi-trauma sustaining more than one injury. according to the ao/ota classification, there were simple ( %), wedge ( %), and complex fractures ( %). fracture location within the tibial shaft varied with six patients ( %) being within the proximal third, ( %) middle third, and ( %) distal third. there were segmental ( %) fractures that involved more than one third of the tibia. results: fifty-five patients ( %) had post-reduction rm including patients ( %) between °- °, seven patients ( %) with a rm between °- °, and two patients ( %) with a rm greater than °w hen compared to the uninjured side. of the patients with rm, the tibia was externally malrotated in patients ( %). three patients ( % of cohort or % of those with rm) underwent revision surgery to correct the rm as detected on ct scan. conclusions: this study reveals a high incidence of rm following tibial nails ( %) with a surprisingly low revision rate ( % of those with rm). a subsequent study should aim to assess clinical relevance of rm in terms of functional outcome and gait analysis. for now ctrotational-profiling provides a platform for early recognition and correction of rm secondary to tibial imn. level of evidence: therapeutic level ii -prospective cohort study. materials and methods: the tarn database was analysed retrospectively to quantify the number of trauma team activations, patients with major trauma (mt), causes of injury, and subspecialty-specific trauma procedures. crude and risk-adjusted mortality rates, observed to expected (o/e) mortality ratio, and risk-adjusted rates of survival from mt were also calculated. results: the number of trauma team activations has risen by a factor of . the predominant injury mechanism that resulted in mt was a fall from less than m. there has been a fivefold increase in the overall number of trauma surgical procedures. orthopaedic surgeons have performed % of trauma procedures, followed by neurosurgeons, oral and maxillofacial surgeons, and visceral trauma surgeons. the rate of trauma laparotomies per consultant fluctuated between . and . per month. a fall from less than m, road traffic accident and a fall from more than m were the three leading causes of death from mt. the overall o/e mortality ratio was . . conclusions: aintree trauma profile has significantly changed since . this change highlights the potential need for a review of how mt services are offered at aintree to reduce the o/e mortality ratio. this may be achieved through more co-ordinated provision of trauma care, prevention, audit and research programmes. the role of visceral trauma surgery should be reconsidered within the context of the surgical patients' needs and demands, and fundamental requirements of the profession. inter-hospital variation in surgical intensity for trauma admissions: a multicenter cohort study l. moore , m. p. patton , i. farhat , p. a. tardif , c. gonthier , a. belcaid , f. lauzier , a. turgeon , j. clément université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, introduction: guidelines for trauma patients are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. we aimed to assess inter-hospital variation in surgical intensity for trauma patients and identify determinants of surgical intensity. materials and methods: we conducted a retrospective multicenter cohort study based on the trauma centers of an inclusive canadian provincial trauma system. we included adults admitted for major trauma between and . analyses were stratified for orthopedic (n = , ), neurological (n = , ) and thoracoabdominal surgery (n = ). surgical intensity was quantified with the number of surgical procedures during the first h. inter-hospital variation was assessed with the intra-class correlation coefficient (icc) from multilevel poisson regression models. relative risks (rr) were generated to identify determinants. results: moderate inter-hospital variation was observed for orthopedic surgery (icc = . %, % confidence interval [ci]: . - . ) whereas variation was low for thoracoabdominal surgery (icc = . %, % ci: . - . ) and neurosurgery (icc = . %, % ci: . - . ). level iv centers had similar surgical intensity for thoracoabdominal injuries (rr: . , % ci: . - . ) but lower intensity for orthopedic injuries (rr = . , % ci: . - . ) than level i/ii centers. during the study period, we observed a decrease in intensity for neurosurgery (rr for (rr for - versus . , % ci: . - . ) and thoracoabdominal surgery (rr = . , % ci: . - . ). conclusions: the observed inter-hospital variation in risk-adjusted surgical intensity suggests that there may be opportunities for quality improvement in surgical care for injury admissions. a better understanding of how surgical intensity influences clinical outcomes is needed to inform quality improvement activities. pre-hospital injury diagnosis a. easthope , m. marsden , g. grier barts and the london medical school, london, united kingdom, royal london hospital, centre for trauma science, london, united kingdom introduction: accurate pre-hospital diagnosis of a patient's injuries may improve care by facilitating effective intervention at the scene and reducing time to definitive treatment in hospital . we sought to assess the diagnostic accuracy of injuries by london's air ambulance (laa) clinicians and identify conditions in which clinical accuracy may deteriorate. materials and methods: a retrospective review was undertaken of all patients conveyed to the royal london hospital by laa from october for six-months. pre-hospital injury scores, coded using the abbreviated injury score (ais) were compared to hospital discharge ais. patient outcomes were evaluated in the case of underscored injuries. results: during the study period patients were seen and met eligibility. mean clinical sensitivity and specificity was % and % respectively. chest injury identification was most sensitive ( %) and pelvic injury least sensitive ( %). the relative risk (rr) of underscored injuries to the chest, abdomen and pelvis increased with decreasing glasgow coma scale (gcs) peaking at . (iqr . - . ). the average accuracy of injury identification was % with a negative predictive value of %. no overt patient morbidity resulted from a missed, or under-scored injury. all missed injuries were subsequently identified in the emergency department. conclusions: the pre-hospital diagnosis of injuries has reasonable sensitivity and excellent specificity. accurate pelvic injury diagnosis is more challenging than chest or abdomen. with decreasing gcs, the risk of missing injuries increases. clinicians should be aware of the potential for error when treating trauma patients with impaired conscious levels. comorbidities, injury severity and complications predict mortality in severe thoracic trauma: a retrospective analysis from the norwegian national trauma registry of epidemiology, clinical factors and risk factors for mortality of patients with thoracic injuries. materials and methods: adult patients treated for severe thoracic trauma (injury severity ais c ), between and at haukeland university hospital were included. data were extracted from ( ) the haukeland university hospital local trauma registry, and ( ) the norwegian trauma registry. additional data on comorbidities and complications was collected from patient records. the factors age, gender, comorbidities [charlson comorbidity index (cci)], anticoagulant use, injury severity [revised trauma score (rts)], [injury severity score (iss)] and complications [clavien-dindo scale (cds)] were analyzed for being predictive of in-hospital mortality. multivariate logistic regression analyses with backward selection methods were used. results: data of patients were analyzed, of which ( %) patients died. median iss was in the non-survivors (iqr , ) and (iqr , ) in survivors (p = . ). data of patients were used in the risk factor for mortality analysis. two or more comorbidities measured by cci (or: . , p = . ), injury severity measured with the rts (or: . , p = \ . ), and grade c complications on the cds (or: . , p = . ) were significant predictors for mortality. conclusions: severe comorbidities significantly decreased the chances of survival after thoracic trauma. injury severity was also found to be a significant predictor of mortality. physiological injury severity, measured by rts, appeared to be a stronger predictor of mortality than iss after thoracic trauma. finally, severe complications led to considerably higher risk of mortality following thoracic trauma. the psychosocial impact of e-bike accidents and changing values of older patients in the netherlands, a qualitative study s. berben , l. vloet , e. c. t. tan , m. edwards , , a. brants , , , g. olthuis , , , , a. oerlemans , , , , f. haverkamp , , introduction: the mechanical impact of e-bike accidents, increasingly used by older persons, has shown to be higher compared to regular bike accidents. however, the psychological impact of e-bike accidents in older trauma patients, their experiences in emergency and follow-up care, and the possible change in values and beliefs in response to the accident is still unknown. materials and methods: we used a qualitative design and included older patients ( ? years) with a variety of (severe) injuries, who were admitted to the emergency department after an e-bike accident (n = ) and their relatives (n = ). they were interviewed within one month (t ) and after three months (t ) of the date of accident. interviews were transcribed verbatim and analyzed via a thematic analysis approach using an ethical perspective. results: many patients required (in)formal care after hospital discharge. in general patients were satisfied with the provided emergency surgical care, although some patients reported limited and insufficient information on rehabilitation and homecare support. the analysis yielded impaired physical condition, anxiety, increased vulnerability and dependency of care givers as psychosocial impact. freedom impairment, shifting relational autonomy, and confrontation with vulnerability and mortality were reported changes in values. central values as mobility and freedom, vitality and health, social participation and recreation were put under pressure and needed to be negotiated again after the accident in order to decide whether to use the e-bike again. conclusions: follow-up information of surgeons and emergency physicians after initial hospital care for older trauma patients with an e-bike accident shows room for improvement, with more specific consideration for the psychological impact of trauma and changes in values after e-bike accidents. eur j trauma emerg surg. . https://doi.org/ . /s - - - . traumatic subaxial cervical fractures: functional prognostic factors and survival analysis introduction: the main goal of this study is to identify the risk factors for poor functional outcomes and to analyze the overall survival (os) and complications rate in patients with traumatic cervical spinal cord injury (sci) and subaxial cervical fracture (sacf) treated with open surgical fixation. materials and methods: the authors retrospectively reviewed sixtyfive consecutive patients from one single center with traumatic unstable sacf and associated sci treated surgically between and . we exclude cervical fractures with concomitant severe head injury, brachial plexus injury, lumbar plexus injury, superior or inferior limb fractures and patients who were lost during the followup period. statistical analysis using a chi square test, student's t-test and logist regression were used to identify factors associated with poor functional outcomes after surgical treatment. os analyses were performed using kaplan-meier curves. results: the -year survival rate was . %. four patients died in the first days after surgery and , % need a reoperation. the median time from injury to surgery was . days. the complication rate was %, being respiratory failure the most common one. preoperatively, % had an asia \ c. about % of the patients with asia between a-d had improve one or more asia grades. logistic regression analysis show that older age, sacf above c , asia \ c pre-surgery and long time from injury to surgery were related with poor prognosis. the os rate was higher in patients with neurological improvement, without signs of neurogenic shock at presentation and in sacf bellow c . conclusions: our results suggest that sacf should be treated as soon as possible in order to improve the os rates and functional outcomes. older patients, lower asia at presentation and sacf above c are related with worst functional outcomes. introduction: compression fractures of multilevel vertebral bodies are common in children. due to segmental plasticity, several adjacent vertebral bodies are compressed to a lesser degree at each body. plain ap and lateral x-ray is the first diagnostic examination in the emergency department (ed), but a proper diagnosis is often delayed or missed. materials and methods: this is a retrospective, monocentric study in children falling on their back who showed up at the orthopedic ed, between december and september . nine children ( f, m) with an average age of . years were included. trauma occurred playing games and doing sports in all cases. all children were subjected to x-ray, followed by mri scans for doubtful findings on the plain x-ray or persistent mild pain (t , t , t -stir sequences). results: cuneiform vertebral fracture or vertebral body height reduction was diagnosed with x-ray in five vertebrae while mri showed fractures in vertebrae including compression and edema of adjacent vertebrae in the t -stir sequence. therefore only . % vertebral fractures have been detected by plain x-ray. the injured vertebral bodies were so distributed: t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , l n = , l n = , s n = , s n = . the most involved spine section was between t and t with fractures. conclusions: vertebral fractures are not always related to hyperflexion or forward hinging mechanism. mri showed vertebral compression fractures and the t -stir sequence showed edema as post-traumatic evidence that had not been detected by x-ray. in absence of a radiologically visible lesion, the persistence of pain should be investigated by performing mri scans. the middle thoracic spine level appeared to be the most involved one in pediatric vertebral fractures. introduction: occipitocervical fixation (ocf) is an effective surgical method to treat various craniovertebral junction (cvj) pathologies. a rigid fixation achieved from ocf displaces other techniques of cvj stabilization unfortunately during procedure deep and wide wound is performed. aim of this study is to share our experience in ocf and lately performed percutaneous ocfs with intraoperative ct guided navigation system. materials and methods: of patients who underwent ocf were performed percutaneously. o-arm ct scans were used to illustrate and measure radiologic parameters. screws were implanted in c lateral masses ( ) , isthmus of c ( ) and c pedicles ( ) and assessed according gertzbein robbins (gr) in modification of bredow classification from a to e. results: a total screws were implanted, of them was performed in open surgery and percutaneously. outcome in gr classification for screws implanted in open surgery was: a ( , %), b ( , %), c ( , %), d ( , %) and e ( , %) while in percutaneous: a ( , %) and b ( , %) . in open surgery one screw was revised. conclusions: percutaneous occipitocervical fusion seems to be a good option to achieve desirable effect in cervical pedicle screws implantation. during procedure whole nuchal muscles are preserved. ct guided surgery and microscope view are necessary to perform percutaneous ocf. introduction: studies have found higher risk of traumatic deaths in rural areas in norway combined with a paradoxically decreased prevalence of severe, non-fatal injuries ( ) . this study investigates the risk of fatal and non-fatal injuries among all adults in norway in the period - . materials and methods: all traumatic injuries and deaths among persons with residential address in norway from - were included. data was collected from the norwegian patient registry and the norwegian national cause of death registry. all cases were stratified according to six groups of centrality based on statistics norway's classification of centrality . mortality-and injury rates was calculated per , inhabitants per year. results: the mortality rate differed significantly according to the levels of centrality (p \ . ). the mortality rate in the most urban group ( ) was . and in the most rural group ( ) . . the lowest mortality rate was found in centrality group ( . ). there was an increased risk of death between centrality group and group with a relative risk of . (ci: . - . , p \ . ). the most common cause of death was transport injuries, self harm, fall injury and other external causes. the highest urban-rural gradient was seen in transport injuries with a relative risk of . (ci . - . , p \ . ) comparing group to group . group had the lowest risk of nonfatal injuries ( ) and group the highest ( ). the risk of nonfatal injuries increased with higher grade of rurality, comparing group and revealed a relative risk . (ki . - . , p \ . ). conclusions: the more rural the higher risk of traumatic deaths and non-fatal injuries. transport injuries had the highest urban-rural gradient. references: . bakke hk, hansen is, bendixen ab, morild i, lilleng pk, wisborg t. fatal injury as a function of rurality-a tale of introduction: virtual fracture clinics (vfcs) are an alternative to conventional fracture clinics for management of musculoskeletal injuries. they have been shown to be a safe and effective model for upper and lower limb injuries. there is limited data to support their use for specialist thoracolumbar fracture follow-up. materials and methods: lean methodology including process mapping was applied to identify a safe virtual alternative for the pathway. first cycle analysis of consecutive referrals to a traditional specialist thoracolumbar fracture clinic. second cycle analysis of consecutive referrals six months after introduction of a vfc. results: mean time to first outpatient review in first cycle was days. referrals led to booked outpatient appointments and were missed ( % non-attendance). % of referrals had or more scheduled appointments. / were ao type a - and all of these received non-operative treatment. / were ao type a or b and of these received non-operative treatment. patient received operative stabilisation (ao type b). process mapping identified two pathways-virtual review with advice letter and physiotherapy referral (outcome a-ao type a - ) or face to face review (outcome b-ao type a or b). mean time to outpatient review in second cycle was days. / received outcome a. / ( %) made a telephone call for advice and only / ( %) asked for a face to face appointment. / received outcome b and all were discharged after one visit. patients in cycle required operative stabilisation. statistically significant reduction in number of scheduled face-to-face reviews ( versus ; p \ . ) and mean time to first review ( days versus days; p \ . ). conclusion: virtual thoracolumbar fracture clinics are a safe and clinically effective alternative to traditional fracture clinic models. lean methodology can be uses to extend virtual clinic pathways to specialist trauma clinics. treatment prognosis of cases of fragility fracture of pelvis m. yoshida fujita health universityhospital, emergency, aichi, japan introduction: the number of cases of fragility fracture of pelvis in the elderly has been increasing in recent years, but there are still not enough reports of surgical treatment as a treatment method, but there is still no certainty how to treat. so we investigated prognosis of cases of fragility fracture of pelvis. materials and methods: subjects were fragility fracture of pelvis treated at a single center from april to april , males, females, average age ± . years. only cases that had ct scan were included. we examined rommens classification, the presence of injury, presence of hip implants, functional prognosis, and -year mortality. results: the breakdown of rommens classification is type ia cases, ib cases, iia cases, iib cases, iic cases there were cases of iiia, cases of iiic, case of iva, cases of ivb, and cases of ivc. surgical treatment was indicated in cases ( . %) (iic case, iiia cases, ivb cases, ivc cases) there were cases ( . %) with no injury mechanism and cases ( %) with hip implants. cases ( %) were able to follow up for more than year including telephone surveys, and . % of them did not recover to functional level before injury. the one-year mortality rate was . %. conclusions: in the cases studied here, cases ( . %) were indicated for surgery. the prognosis and mortality rate are almost the same as those reported overseas, and as with proximal femoral fractures, there is a possibility that it may be greatly involved in adl decline in the elderly. we think that further study is needed in the future. conclusions: patients with a femoral neck fracture who received a hip hemiarthroplasty and used anticoagulation had no significant longer delay to surgery and had a higher mean loss of hemoglobin points. as a clinical consequence of this, more packed cells were supplemented. also more postoperative hematomas were found in the population with anticoagulation. no differences were found in mortality rates at -days and one year. results: on all eight patients the easy-approach was applied without adverse events. in four cases the plate osteosynthesis was done completely endoscopically with excellent results for the patients regarding pain relief and scar development. in the remaining four cases the endoscopic stabilization was not performed for the following reasons: in the first overall case primarily only the endoscopic approach was planned. in the fourth overall case, ventilation showed high end-expiratory co -levels after endoscopic situs preparation, so we converted to the open plating. in the fifth overall case, the easyapproach was applied to evacuate a retrosymphyseal hematoma in a patient with a stable pubic rami fracture. in the eighth overall case, the anterior pelvic ring injury was a bilateral multifragmentary pubic rami fracture in combination with a disruption of the symphysis. after endoscopic situs preparation with clipping of the corona mortis vessel, reduction of the displaced symphysis could not be done endoscopically. conclusions: we demonstrated that the endoscopic plate osteosynthesis of the anterior pelvic ring is feasible with existing standard laparoscopic instruments. the evaluation of the easy-approach in the clinical setting is going on, while the development of suitable reduction tools is one major goal of future studies. introduction: retrograde intramedullary pubic ramus screw fixation is less invasive method and biomechanically stable compared to the plate fixation. the purpose of this study is to examine the feasibility of screw insertion using computed tomography (ct). materials and methods: we analyzed sixty ct data ( cases in male and female each). by using ct analyzing software, the virtual column with . mm diameter was inserted so that we analyzed the feasibility of the screw insertion. and the intramedullary diameter of the pubic ramus at the parasymphyseal area, base, and acetabulum were measured. results: the virtual . mm diameter screws could be inserted in % ( / ) in male and . % ( / ) in female. the cause that screws insertion was impossible was penetration to the hip joint in all cases. the screw inserting point was . mm and . mm from the medial border of the pubic symphysis and . mm and . mm from the upper border of the pubic symphysis in male and female respectively (p [ . ). the intramedullary diameter of pubic ramus was . mm, . mm and . mm at parasymphyseal area, . mm, . mm and . mm at the base of pubis, and . mm. . mm and . mm at the acetabulum in male, female who had the screw corridor and female who didn't have the screw corridor respectively. the diameter of the pubic ramus of the female who didn't have the screw corridor was significantly small compared to male and pubic ramus in three measuring points (p \ . ). , % of the screws were revised. there were no neurovascular or urologic complications. radiographic nonunion was observed in % with a minimum follow-up of months, this correlated with a peri-implant infection (p . ), operation [ months after trauma (p . ) and non-significantly with implant loosening (p . ). there was no correlation of nonunion with patient's age, the fracture mechanism or a non-excellent reduction. in total, . % of the patients were re-operated, in . % a re-osteosynthesis was conducted. conclusions: retrograde trans-pubic screws show good clinical results with lower or similar complication rates compared to alternative methods as plate fixation or external fixator. fracture union did not depend on fracture mechanism or age. hence, this minimal-invasive method is especially attractive in elderly patients with an ffp. because it is an internal fixation of the superior pubic ramus with relative stability, an anatomic open reduction is not necessary to achieve fracture union. the need for extraperitonal pelvic packing -finally confirmed to be vanishing? introduction: the presence of cerebral venous thrombosis (cvt) is increasingly recognized in traumatic brain injury (tbi), but its complication rate and effect on outcome remains undetermined. in this study, we characterize the complications and outcome-effect of cvt in tbi patients. materials and methods: in a retrospective, case-control study of patients included in the oslo university hospital trauma registry and radiology registry from - , we identified patients with cvt (cases) and without cvt (controls). groups were matched regarding abbreviated injury severity (ais) head region score - . cases were identified by ais or icd-code for cvt and a ct/mr venography confirmed to be positive for cvt, whereas controls had no ais or icd-code for cvt and a ct/mr venography confirmed to be negative for cvt. risk of mortality was assessed using multivariate logistic regression adjusting for initial gcs, iss and rotterdam score. results are also reported for subgroups according to cvt location ( fig. introduction: the aims of this prospective cohort study were (i) to identify trajectories of recovery in patients with mild traumatic brain injury (mtbi) during the first two years after trauma and (ii) assess patients and injury characteristics for these trajectories. materials and methods: all adult trauma patients with mtbi (aisseverity or and an injury severity score \ ) who were admitted to a hospital in a region of the netherlands from august to november were asked to complete questionnaires. the questionnaires could be completed at week, and , , , and months and included the euroqol- -d for health status, including a cognition dimension, the hospital anxiety depression scale (hads-d and hads-a for symptoms of depression and anxiety respectively) and the impact of event scale (ies) (for post-traumatic stress symptoms). latent class trajectory analysis was used to determine trajectories of recovery in latentgold . , patient and injury characteristics of the classes were assessed in ibm spss . . results: a total of patients ( % of total) completed at least one follow-up questionnaire. the number of classes (trajectories) ranged from for cognition to for depression. poor recovery classes of cognition and health status consisted of mostly females, patients with low education, higher age, longer length of stay at the hospital and frail patients. the class with full recovery consisted of young patients, with most recovery occurring during the first six months after injury. patients who reported poor health status before injury scored significantly lower health status after injury and showed no recovery over time. conclusions: different recovery patterns were present in patients with mild traumatic brain injury. especially frail elderly patients who reported poor health status before injury have poor outcome up to months after injury. post-concussive symptoms in children and adolescents with traumatic brain injury: a center-tbi study introduction: acute respiratory is associated with high morbidity and mortality. in addition, its etiologies are heterogeneous and the outcome depends on the underlying cause. the aim of the present study is to analyze, whether the mortality of posttraumatic ards is affected ( ) over time, ( ) attributable to geographic distribution, ( ) related to the used definition and ( ) introduction: many factors of trauma care have changed in the last decades. this review investigated the effect of these changes on overall and cause-specific mortality in polytrauma patients admitted to the intensive care unit (icu). moreover, changes in trauma mechanism over time and differences between continents were analyzed. materials and methods: a systematic review of literature on overall mortality in polytrauma patients admitted to the icu was conducted. overall and cause-specific mortality rates were extracted as well as the trauma mechanism of each patient. linear regression on changes in overall and cause-specific mortality rates was performed. results: thirty studies, which reported mortality rates for , observed patients, were included and showed a decrease of . % in overall mortality per year ( fig. ). brain-related death has become more common over the years, whereas multiple organ dysfunction syndrome (mods), acute respiratory distress syndrome and sepsis became less prevalent (fig. ) . mods was the most common cause of death in north america and brain-related death was the most common in asia, south america and europe (fig. a) . penetrating trauma was most often reported in north and south america and asia (fig. b) . conclusions: overall mortality in polytrauma patients admitted to the icu has been decreasing as a result of the improvements in trauma care. a shift from mods to brain-related death could be observed. more research on preventative measures for the latter is required to ensure a further decline in mortality. moreover, we have shown geographical differences in cause-specific mortality, which may provide learning possibilities between similar trauma centers resulting in improvement of trauma care introduction: aim of the current study was to assess an association between trauma patient volume of the intensive care unit and inhospital mortality. materials and methods: from data of the japan trauma databank, this retrospective cohort study selected adult (c y) trauma patients hospitalized in the intensive care unit with the injury severity score of c . after applying a multiple imputation on all the study variables, a logistic regression generalized estimating equation after adjustment for age, sex, mechanism of trauma, and the injury severity score as covariates and hospitals as a cluster assessed an association between quartile of patient volume in intensive care unit and hospital mortality. introduction: quality and content of early fracture hematoma (fh) dictate the healing process in long bone fractures. different reaming protocols for intramedullary nailing (imn) are available. however, the impact of reaming strategies on immune cell characteristics of early fracture hematoma is unclear. we hypothesized that the application of reaming irrigation and aspiration (ria) techniques optimizes cellular content of fracture hematoma. materials and methods: twenty-four pigs underwent standardized femur fracturing. then, animals were exposed to different protocols of imn. group a underwent no reaming prior to imn. group b was treated with conventional reaming plus imn and group c composed of animals treated with ria and subsequent nailing. fracture hematoma was collected h after reaming. fh-immune cells were isolated and studied by flowcytometry. cell viability was tested by annexin-v-labelling. neutrophil activation was determined by mac- /cd bcell surface expression levels, whereas fcyriii/cd -receptor expression was utilized to investigate neutrophil maturation. results: all animals survived the observation period. propertions of white blood cell subtypes in fh did not differ between conditions. however, the percentage of viable fracture hematoma immune cells was significantly higher in the ria-group, compared with conventional reaming (respectively mean . % vs. . %, p = . ). additionally, both neutrophil cd -expression (- %) and cd bexpression (- %) were significantly lower in those animals treated with ria compared with the conventional reaming condition. conclusions: this experimental study reveals that reamed irrigationaspiration (ria) prior to imn is associated with increased immune cell viability and less neutrophil senescence/activation in early fracture hematoma. this underlines the important role of imn in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma. introduction: the study and determination of the traumatic pattern in bicyclists-delivery employees. the recording of personal protective equipment and evaluation of the selection criteria of their self protection. materials and methods: a total of patients ( men and woman) with mean age of . years ( - years) were included over a study period from january to march . twenty-one patients admitted to the hospital with a total of injuries treated operatively, whereas injuries were treated conservatively. we recorded and evaluated the use of adequate personal protective equipment of these delivery employees. results: the mean hospitalization time was . days ( - days) . a total of thoracic injuries, traumatic brain injuries, spine injuries, lower extremity injuries and upper extremity injuries were recorded. surgical treatment concerned patients with upper extremities and patients with lower extremities injuries and the anatomic regions involved were the distal radius ( ), pelvic ring injury ( ), femoral fractures ( ), tibial plateau fractures ( ), patella fractures ( ), diaphyseal tibial fractures ( ), and ankle fractures ( ) . conclusions: the lack of an adequate personal protective equipment due to their low financial status in combination with the absence of driving professional education among workers in this category of delivery employees results in lower extremity injuries with the majority requiring hospitalization and surgery. further investigation is needed, as well as constant training and setting right criteria for the pursuit of such employment. results: a total of nine rct's ( patients) and the sixteen observational studies ( patients) were included. the pooled nonunion rate did not differ significantly between both treatment groups (risk difference: %; or . , % ci . - . ). more patients treated with nailing required re-intervention (risk difference: %; or . , % ci . - . ) with shoulder impingement being the most predominant indication. more patients treated with pate fixation developed radial nerve palsy compared to nailing (or . , % ci . - . ). notably the absolute risk difference is small ( %) and during follow-up the palsy resolved spontaneously in the majority of patients. nailing lead to a faster time to union (mean difference: . week, % ci . - . ), lower infection rate (risk difference: %, or . , % ci . - . ) and shorter operation duration (mean difference: min, % ci . - . ). functional scores were comparable in both groups (standardised mean difference: - . , % ci - . to . ). there was no difference between effect estimates form observational studies and rct's. conclusion: there appears to be no difference between plate fixation and nailing for humeral shaft fractures with regard to non-union rate and functional outcome. patients treated with plate fixation have a higher risk for infection and radial nerve palsy, but lower risk for reintervention. the absolute differences, however, are small. nailing does differ significantly from plate fixation in terms of shorter operation duration and time to union. the pooled estimates from randomised clinical trials did not differ significantly from estimates obtained from observational studies. post-traumatic complications are more often after medial clavicle injuries compared to lateral clavicle injuries introduction: medial clavicle injuries (mci) are widely unexplored, especially in contrast to lateral clavicle injuries (lci). current research concerning mci assumes a higher severity of mci, e.g. concerning concomitant injuries. our aim is to evaluate by big data analysis if these rare injuries would also lead to a higher number of post-traumatic complications. materials and methods: we focused on the mci subgroup consisting of medial clavicle fracture and sternoclavicular joint dislocation. the lateral clavicle fracture and the acromioclavicular joint dislocation were summarized to the subgroup of lci. the midshaft clavicle fracture was analyzed for comparison. the data are based on icd- codes of all german hospitals as provided by the german federal statistical office. anonymized patient data from to were evaluated. the retrospective analysis addresses the fracture healing in dislocation, delayed union and non-union. results: the proportion of all patients suffering from complications was . %, which were attributed to one of the three post-traumatic complications. each complication rate for the single injury and the single complication was rather low with a maximum of %. mci were more likely to be affected by post-traumatic complications than lci with a ratio of . to . times (p \ . ). the midshaft clavicle fracture was similarly frequently affected by complications with . % of all complications as the mci ( . %). the lci accounted for the smallest proportion at . %. conclusions: we proved that mci are more often associated with post-traumatic complications than injuries of the other parts of the clavicle. this is another hint that mci appear to be more complex than lci. this could be due to a missing standard procedure and the higher number of concomitant injuries in mci. further representative clinical studies are required since miscoding is a frequent issue in research concerning clavicle injuries, especially in a big data analysis. quantification of trauma center accessibility using gis-based technology introduction: there is no generally accepted methodology to asses trauma system access and optimal geographical trauma center distribution. the goal of this study is to determine the influence of trauma center(tc) distribution during high and low traffic density using geographical-information-system(gis)-technology. methods: using arcgis-pro, we calculated differences in transport time (tt) and population coverage in seven scenarios with , , or tcs during rush [r]-and low traffic [l] hours in a densely-populated region with tcs in the netherlands (fig. ) . results: in the seven scenarios, the population that could reach the nearest tc within (\) min, varied between - % ( fig. ) in the three-tc-scenario, roughly % of the population could reach the nearest tc \ min in [r] and [l] . the hypothetical scenarios with two geographically well-spread tcs showed similar results as the current three-tc-scenario. in the one-tc-scenarios, the population reaching the nearest tc \ min decreased by - % in both [r] and [l] compared to the three-tc-scenario. in the three-tcscenario the average tt increased with about . min to almost min in [r] , in comparison to min during [l] (fig. ) . similar results were seen in the scenarios with two geographically well-spread tcs. in the one-tc-scenarios and the geographically close two-tcscenario the average tt increased by - min [l] and - min [r] in comparison to the three-tc-scenario. conclusion: this study shows that a gis-model for trauma center access offers a quantifiable and objective method to evaluate trauma system configuration in areas with different geography and demography. applying this technology to one of the most densely populated areas in the netherlands shows that the transport time from accident to trauma center would remain acceptable if the current situation with three trauma centers would be changed to a scenario with two geographically well-spread centers. classifying posttraumatic stress disorder courses in physical trauma patients: an observational prospective cohort study introduction: the aim was to identify different courses of posttraumatic stress disorder (ptsd) in physical trauma patients. then, to examine whether these classes could be characterized by sociodemographic, clinical, psychological, and personality outcomes. methods: patients completed the impact of event scale-revised (ies-r), m.i.n.i.-plus after inclusion, , , , and months after injury to examine different courses. the hospital anxiety and depression scale, neo-five factor inventory, state-trait anxiety inventory-trait, and the whoqol-bref were completed after inclusion only. latent class analysis, chi square tests, and anova were performed to analyze the aims. results: in total, patients were included. the mean age was . (sd = . ) and % were male patients. the ies-r (see figure ) and the m.i.n.i-plus had five classes ( : moderately, : little bit, : worse, : none, : quite a bit of ptsd symptoms). patients in class are diagnosed with ptsd (cut-off score c ). on both questionnaires, patients (proportion & %) in class or , scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety compared to the other classes over months after trauma. lower scores on all domains, except for social domain on the ies-r, were found compared to the other classes (ies-r; physical domain: class vs. (mean ± sd): . ± . vs. . ± . , p-value = \ . ). psychological and personality outcomes were significantly different on all courses. also, patients in class or were younger compared to the other classes (ies-r; class vs. : . ± . vs. . ± . , p-value = \ . ). no medical outcomes for ptsd were found. conclusions: about % suffer from ptsd symptoms months after trauma. different courses were defined by sociodemographic, psychological, and personality characteristics. professionals can, short after trauma, recognize patients at risk for ptsd when they focus on these characteristics. then, an intervention can be offered. six meter, the criterion for severe adult trauma to falls from heights in cdc field triage needs to be lowered introduction: trauma is one of major public health care issue which is costly to society. differences vary from region to region, but blunt trauma accounts for a large part of the total trauma, and the rates of the falls from heights among the blunt trauma is getting higher. it is serious that falls from heights is often accompanied by severe multiple trauma. therefore, authors studied the relationship between the height of the fall/other related factors and outcomes including hospital stay/mortality. materials and methods: retrospective cohort study of the adult falls-from-heights patients visited a regional trauma center for years (from . . to . . ). results: of total patients, the number of d.o.a patients were . the height from falls of the deceased patients was statistically significantly higher than that of the survived patients. ( . ± . m vs. . ± . , p \ . ) the auc of the roc curve of the height from fall to mortality was . . (figure) the sensitivity of . m was . % and . m was . %, respectively. the traumatic brain injury, pelvis fracture, visceral organ injury, age, and the height from fall were statistically significant risk factors in multivariate analysis for mortality (p = \ . , . , , , . , and . respectively). conclusions: the height from the fall is closely related with mortality. we think the current height for the severe fall injury in cdc field triage for trauma is high and needs to be lower to . introduction: operative management of severe trauma is a team effort, requiring excellent communication skills. surgeons, anesthesiologists and nurses need to coordinate effectively in order to ensure an excellent clinical outcome. the definitive surgical trauma care (dstc), definitive anesthesia trauma care (datc) and definitive perioperative nurses trauma care (dpntc) courses provide an excellent opportunity to train efficient teamwork. we aimed to study the impact of the joint dstc-datc-dpntc courses in candidates' perceptions and skills in perioperative communication. materials and methods: study population of candidates ( surgeons, anesthesiologists and nurses) participating in a joint dstc-datc-dpntc course in coimbra, portugal. median age of years (range - ). female gender in ( %) of cases. all participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. postcourse survey on several aspects of peri-operative communication, with responses on a likert scale. participants were also asked which aspects of intraoperative communication they valued the most. statistical analysis with spps, . (wilcoxon signed rank test, significance with p-value \ . ). results: all participants responded to the survey. results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments (p \ . ). postoperative team debriefing was also valued as highly relevant. closed-loop and direct, by-name communication were highly rated (p \ . ). self-reported communication skills improved significantly during the course (p \ . ). conclusions: joint training in the dstc-datc-dpntc courses provides a unique opportunity to improve candidates' self-awareness and skills in intraoperative communication. a public health approach to knife related trauma in liverpool: a geospatial study r. shellien , n. misra , , j. germain , m. whitfield aintree university hospital, emergency general surgery and trauma unit, liverpool, united kingdom, liverpool john moores university, public health institute, liverpool, united kingdom introduction: liverpool is a city that has undergone recent rapic socioeconomic change. despite reductions in overall deprivation, incidents of stabbings have increased by % in the last years. this study will describe the trend in knife crime, drawing on governmental data and policies to conclude the reasons behind the trend. materials and methods: a retrospective cohort study of patients presenting to north-west ambulance service (nwas) with a penetrating injury in liverpool between and . data collected included patient demographics, geography and timing of incidents and correlation to datasets of multiple indices of deprivation and knife crime prevention outreach education programmes. results: incidents of stabbings have increased by % between and . victims were more likely to be males ( %) between the ages of and ( %). the peak rate was between : - : ( . %) and trough between : - : ( . %). there is a spike in incidents of stabbings of - year olds from : to : , correlating with school closure. there appears to be statistically poor correlation between deprivation of lower super output areas and stabbings (r = . , . and . for , and respectively). however, when the data is split into larger areas, middle super output areas (msoas), deprivation appears to be a further risk factor. this study has identified certain geographical areas as high risk. conclusions: this study allows for targeted public health interventions at populations most at risk of knife trauma, including geographical mapping of high-risk areas, so that interventions can be distributed appropriately. references: ministry of housing, communities and local government ( government ( , government ( , introduction: trauma teams treat complex patients with injuries posing significant resuscitative and management challenges. effective teamwork is essential to optimise patient outcomes and improve survival, with failure contributing to adverse events [ ] . the role of multidisciplinary (mdt) trauma training has been demonstrated by the military operational surgical training course (most) [ ] . it is imperative that civilian trauma training adopts similar methodology to optimise team work. materials and methods: the three-day multidisciplinary trauma course comprised cadaveric-based skills teaching supplemented by lectures and real-life scenario discussion. delegates were senior surgical and anaesthetic registrars and consultants, alongside trauma team leaders (ttl), scrub staff and operating department practitioners (odp). pre-and post-course questionnaires assessed perceptions of multidisciplinary trauma simulation and confidence in specialty specific skills. results: all delegates reported mdt simulation clarified each role, including their own, in the trauma team. post-course, scrub staff and odps felt confident gaining intraosseous access (p \ . ), surgical delegates had improved confidence performing all skills (p \ . ), with anaesthetists and ttls more confident in haemorrhage control and performing resuscitative thoracotomy (p \ . ). conclusions: mdt trauma training improves team understanding of role and effectively teaches skills. mdt courses with experienced faculty are one way of improving mdt trauma team function. further careful evaluation is required to assess performance of trauma teams in real scenarios. introduction: despite a dramatic rise in youth knife crime, the factors associated with it remain underexplored, especially in the critical pre-college years, which hinders effective counter-knife carrying interventions. the current research is the first to addresses this deficit. materials and methods: british male school students (mean age = . , sd = . ) coming from four different schools completed a short -min survey. they indicated their standing on a number of dimensions (school-adapted and shortened-scale-based predictors) derived from theories of violence, developmental psychology and related research (i.e. violence acceptance, need for respect, belief in self-defence, belief in a just world, narcissism, psychopathy, impulsivity, sensation seeking, and need for closure). results: for perceived knife harmfulness (i.e., the knife's assumed value in inflicting injury and death)-the total variance explained by the model was . %, r = . ; f( , ) = . . the only statistically significant predictors were: right-wing authoritariamism (b = . , p = . ) and need for respect (b = . , p = . ). the other factors were not statistically significant. for the perceived value of knife defence (i.e., its assumed defensive worth in violent confrontations) -the total variance explained by the model was . %, r = . ; f( , ) = . , pviolence acceptance (b = . , p = . ), followed by need for closure (b = . , p = . ), narcissism (b = . , p = . ) and psychopathy (b = . , p = . ). conclusions: this study provides evidence for future knife-carrying prevention interventions, such as talks in schools or social media videos, to focus more on how to increase self-esteem, stimulate empathy for and better understanding of other people, and approach problems from multiple (rather than just two) perspectives, emphasizing the ultimate superiority of the human intellect over brute force. introduction: the physician's response unit (pru) is a novel service that operates from the royal gwent hospital's emergency department (ed), in newport, south wales. it involves an emergency medicine consultant and a paramedic responding to calls in a rapid response vehicle. their aim is to treat and, hopefully, discharge patients at the scene, reducing ed admissions. the pru can also refer patients on to other departments, e.g. the medical assessment unit, allowing patients to bypass the ed. methods: the author spent six weeks out in the pru and in the ed to observe and speak to patients. to assess whether ed admissions were reduced, the dispositions of patients seen by the pru were recorded on a daily log sheet. the service users' satisfaction with the pru was evaluated using simple questionnaires. this included both patients and paramedics, who can request the pru for support with a patient. results: the pru saw patients during the project's timeframe. % (n = ) of these patients were discharged at scene, while % (n = ) were sent to the ed. % (n = ) of patients asked described the care they received from the pru as equal to or better than care they have received previously. % (n = ) of patients rated their overall satisfaction with the pru as / . conclusions: the pru is very well received by both patients and paramedics and has been shown to reduce the number of patients attending the ed. this system excellently implements the principles of prudent healthcare introduction: in germany reducing alcohol related harms in youth is still a priority, because adolescents and young adults still have the highest accident risk in road traffic. therefore, the p.a.r.t.y.-project aim to increase awareness of alcohol and risk-related issues. the purpose of this study was to analyse the risk behaviour of adolescents before and after a prevention project in two different hospitals in germany. materials and methods: during a one-day prevention project, young people within the age of to years got an overview of the route an accident victim go through from the ambulance until the rehabilitation. before and after the prevention day, a structured written survey was completed by the adolescents. results: students participated in the p.a.r.t.y. program between and . the gender distribution of the participating students were balanced. the average age of the adolescent was years. according to the program, the risk assessment and risk behaviour improved through the project significantly (\ . ). the evaluation of the students' satisfaction was rated as good. the majority of students prefer to repeat the project day after years. conclusions: the prevention program shows that the program increase for short-term the awareness for risk related trauma in youth. nevertheless, long-term studies are necessary to receive data regarding the long-lasting effect. references: the present study is funded by the ministry for energy, infrastructure and digitization of the country mecklenburg-vorpommern, germany. development of a claims-based risk adjustment model for trauma introduction: duodenal injury is rare. the diagnosis requires a high index of suspicion which might result in delayed treatment. there is limited data on the delayed diagnosis group, especially high grade duodenal injuries. the purpose of this study is to determine the characteristics and outcomes of delayed high grade duodenal injuries. materials and methods: charts of all patients from - who had history of small bowel injuries are reviewed. the inclusion criteria were age between - years old, diagnosis with duodenal injuries at least grade with delayed operation at least h after injuries. baseline characteristics and postoperative outcomes were recorded. results: of the small bowel injuries, ( %) were duodenal injuries. the overall mortality was %. delayed diagnosis more than h with at least grade of duodenal injuries were cases. the overall in-hospital mortality rate of the delayed group was . % ( / ) who had concomittent hemorrhagic shock and low initial systolic blood pressure. cases ( . %) were diagnosed within h and had better outcomes without leakage. they could step diet within days and had shorter length of hospital stay (mean = days). patients ( . %) presented with delayed diagnosis more than h (the maximum was h after injuries). all these patients had anastomosis leakage and need reoperation. they had initial low level of serum albumin (mean . mg/dl), high white blood cell count, low serum bicarbonate and presented with preoperative acute kidney injury. conclusions: delayed diagnosis and surgical treatment of high grade duodenal injuries lead to poor outcome. low initial blood pressure associated with mortality and delayed treatment more than h had higher morbidity. references: gary sa, frederick am, charles sc, et al. delayed diagnosis of blunt duodenal injury: an avoidable complication. acs meeting. ; ( ) : - . routine follow-up imaging has no advantage in the non-operative management of blunt splenic injury in adult patients modality. the aim of this study was to investigate the incidence and time to failure of nom as well as to evaluate the relevance of follow-up imaging. materials and methods: all adult patients with bsi admitted to our level i trauma center, including two associated hospitals, between / / and / / were retrospectively analyzed. demographic data, injury severity score, splenic injury grade, modality, results and consequences of follow-up imaging were retrospectively analyzed. results: a total of patients with a mean age of . ± . years ( - years) met inclusion criteria. patients ( . %) underwent immediate intervention. patients ( . %) were treated by nom. failure of nom occurred in patients ( . %). failure was significantly associated with active bleeding (or . , % ci . , . , p = . ) , and liver cirrhosis (or , % ci . , . , p = . ) . patients ( . %) in the nom-group received followup imaging by ultrasound (us, n = ) or computed tomography (ct, n = ). in cases, routine imaging examinations were conducted ( us and ct scans) without prior clinical deterioration. ( . %) of these imaging results revealed no new significant findings. every failure of nom was detected following clinical deterioration. conclusions: to our knowledge this study includes the largest monocentric patient cohort undergoing ultrasound as first-line followup imaging modality in the nom setting of bsi in adult patients. the results indicate that a routine follow-up imaging, regardless of the modality, has no therapeutic advantage. indication for radiological follow-up should be based on clinical findings. if indicated, a ct scan should be used as preferred imaging modality. the association between bmi and mortality of renal injuries in adult trauma patients introduction: the role of body mass index (bmi) on solid organ injuries remains debatable. while some studies have shown no association between bmi and hepatic or splenic injuries, others have reported that severe hepatic injuries were more common in pediatric patients with bmi [ . the aim of this study is to examine the association of bmi and mortality, as well as any significant differences between operative vs. non-operative management. materials and methods: this was a retrospective study using the american college of surgeons-trauma quality improvement program database to identify all adult patients (ages to \ ) with traumatic renal injuries. the primary analysis showed a different pattern of mortality between patients with bmi \ and those with bmi c kg/m . then, the study population was divided into patients with bmi \ and those with bmi c kg/m . multivariable logistic regression was conducted to assess any association of mortality with age, gender, bmi, and injury severity score (iss). results: adult trauma patients were identified. a greater proportion of males ( . %) and females ( . %) had bmi \ kg/m (p = . ). the average age of patients with bmi \ kg/m was . (sd = . ) years which was significantly younger than that in patients with bmi c kg/m , . (sd = . ) years (p = . ). patients with bmi \ kg/m were found to have a significantly higher mortality rate of . % vs. . % in patients with bmi c kg/m (p = . ). however, there was no significant difference in type of operative or nonoperative management between patients with bmi \ vs. bmi c kg/m . after multivariable logistic regression, mortality was associated with age, bmi and iss. no effect modification of sex was observed in the relationship of mortality and bmi. conclusions: adult patients with renal injuries and bmi \ kg/m have significantly higher rates of mortality compared with adult patients with renal injuries and bmi c kg/m . introduction: trauma is an ever-evolving surgical discipline. trauma remains a major source of global mortality. the operative and non-operative options for trauma patients has steadily increased. the development of trauma protocols, advancement in transport to trauma centres and radiological techniques has seen a shift in trauma surgery caseload. observing and understanding this shift from operative management to an increasing non-operative management of trauma cases will better prepare the acute medical team in this setting. materials and methods: prospective trauma registry data was collected and analysed retrospectively. patients presenting to a tertiary referral hospital between jan to dec with an injury severity score of [ were reviewed. patients who were transferred to another facility for management were excluded. the demographic data and surgical outcome data were collected and analysed. trend analysis of the operative cases performed for each specialty. results: major trauma patients presented to the john hunter hospital between january to dec . there was a non-statistically significant increase in the number of presentations ( pt in vs in , p = . ). there was a decreasing rate of operations performed for trauma patients ( % in vs % in , p \ . ). there was an increasing rate of orthopaedic surgery cases and operative time compared to other specialties ( in vs in , p \ . ). general surgical major trauma operating cases noted a significant decline over the study time ( in vs in , p \ . ). conclusions: there is a sizeable shift in the caseload of different surgical specialties in regard to major trauma patients over the course of years from to . orthopaedics has seen a significant increase in operative caseload and surgical time required to adequately manage major trauma presentations. the workload and experience of general surgical teams will likely be affected by these changes. the distribution of resources needs to be reflected in the changing work demands of each surgical subspecialty. traumatic internal hernia with delayed small bowel strangulation after pelvic ring injury hospitalization, follow up abdomen ct checked. there was no other specific change than increased thigh hematoma. eight days after hospitalization, ct was re-examined due to abdominal pain with abdominal distraction. an ct showed peritonitis with pneumoperitoneum and small amount of ascites. small bowel herniation through right pubic bone fracture site with ischemic change also noted. diagnosis: diagnosis was traumatic pelvic hernia with delayed small bowel strangulation. therapy and progressions: an emergency operation was performed. ileal loop was hernitated and perforation was found. emphysematouns change and fluid collection was exsited at perineal area and left high. after small bowel loop segmental resection, wound vac was applied at thigh area. comments: traumatic pelvic hernia is rare. diagnosis is challenging in the acute setting and often delayed due to lack of awareness. when diagnosed, efforts should be made to look for other serious injuries as traumatic pelvic hernia usually associated with concomitant intraabdominal injuries. the optimal management of traumatic hernia should be individualised based on the mechanism and severity of injury, presence of concomitant injuries, size of defect, and presence of incarceration. delayed treatment may read to fatal outcomes. careful inspection of the patient is important. references: vincent k, cheah sd. traumatic abdominal wall hernia-a case of handlebar hernia. med j malaysia. ; ( ): - . angio-embolization in pediatric trauma patients with blunt splenic injury: a systematicreview t. nijdam , r. spijkerman , l. hesselink , t. hardcastle , l. leenen , f. hietbrink umc utrecht, traumasurgery, utrecht, netherlands, inkosi albert luthuli central hospital, trauma, durban, south africa introduction: non-operative management (nom) for children with blunt splenic injury (bsi) is nowadays a commonly used treatment in pediatric trauma departments. in adult trauma departments the addition of splenic angio-embolization (sae) is suggested to decrease the failure rate of nom in high grade splenic injuries. however, the use of sae in pediatric trauma departments is very uncommon and it is unknown if sae is of additional value in pediatric trauma patients. therefore, the aim was to analyze the available literature on sae in pediatric trauma patients with bsi. materials and methods: a literature search was performed to find eligible studies that analyzed sae in pediatric patients with bsi. the primary outcome was failure of treatment in these patients. secondary outcomes were the success rate of sae, length of stay and mortality. the relative risk (rr) was calculated to compare primary outcome between study groups. results: in total studies were identified through the search, a total of studies matched our inclusion criteria and were selected for this review. studies included a total of . pediatric patients, of whom underwent sae. patient age ranged from &lt; year to years, mean age was . years. both injury severity score and spleen injury grade were higher in the sae group compared to the nom group. failure rate of sae was %. no spleen related morality was observed in the sae group. conclusions: the literature suggests that sae might be of added value in a very selective group of pediatric trauma patients with high grade splenic injures. however, since limited evidence is available concerning the use of sae in pediatric trauma patients with bsi, no firm conclusions can be drawn about safety and effectiveness. introduction: the management algorithms for trauma have changed with the development of specialised trauma centres. the aim of this study was to review the management and outcomes of patients with traumatic small bowel (sb) and colonic injuries. material and methods: patients treated for sb and colonic injuries between - at aintree university hospital (liverpool) were identified using the prospective trauma audit and research network database. the management and outcomes of the patients included were analysed. results: patients sustained sb and colonic injuries. there were ( . %) sb injuries and ( . %) colonic injuries ( patients had a sb and colonic injury). patients ( . %) of injuries were due to knife stabbing wounds, ( . %) patients were due to gunshot wounds, and ( . %) patients were due to road traffic accidents/ blunt blows. damage control surgery was performed in ( . %) patients. colonic injuries included ( . %) haematomas and ( . %) perforations. a resection and stoma (rs) procedure was performed in patients ( . %), primary repair (pr) in patients ( . %) and resection with anastomosis (ra) in patients ( . %). sb injuries included ( . %) haematomas and ( . %) perforations. pr was performed in ( . %) cases and ra in ( . %) cases. the overall complication rate after sb and colonic injury was % ( patients) with a significant complication rate ( patients, p value = . ) for patients undergoing rs in colonic trauma. the -day mortality rate was . % ( patient). conclusions: pr in sb and colonic injuries appears safe. in our dataset, rs appeared to have a higher complication rate. our study highlights that such injuries are uncommon with a high complication rate. surgeons need to provide individualised treatment. introduction: nowadays, patients with high grade bsi are preferably treated using spleen preserving treatments (spt). it is assumed that patients with low grade bsi treated with spt have a good splenic function after recovery. however, there is no consensus on splenic function after high grade bsi. in several institutions, asplenic/hyposplenic infection prevention protocol will be executed in all patients who had spt after high grade bsi, where other institutions evaluate splenic function first. scintigraphy is believed to be the best flow/activity test to approximate splenic functionality. the aim of the study was to analyze whether spleen injury grade is associated with diminished splenic function. secondarily, we aimed to evaluate whether splenic function testing is necessary in pediatric patients after bsi. material and methods: a retrospective study was performed from january to january . in our institution patients with bsi grade iv of v are assumed hyposplenic and will receive a splenic function test. we included all patients with a minimum follow-up test period of days. all tests were analyzed by the radiology specialist. for each patient we furthermore collected clinical data, including the date of trauma, gender, age, mechanism of injury, ais of splenic injury and iss. results: patients consisted of male and female, with a median (iqr) age of . ( . - . ) . median iss was . ( - . ) and the median spleen ais was ( ) ( ) . nom was used in patients, sae in five patients and two patients were treated with surgical mesh technique. the median follow-up time of all performed tests was ( - ) days. a total of patients ( %) had a grade iv or v splenic injury. scintigraphy was utilized to test most patients. a total of out of patients had an adequate splenic function, including all sae patients. conclusions: even high grade splenic injuries show adequate splenic function in the follow-up of pediatric trauma patients after bsi. therefore routine diagnostic follow-up by scintigraphy is not necessary in this specific patient group. evaluation of abdominal injuries treated at stavanger university hospital: occurrence, severity and mortality j. w. larsen , k. søreide , , j. a. søreide , , k. tjosevik , k. material and methods: retrospective evaluation of data recorded prospectively in the hospital's trauma registry between january and december . patients with abbreviated injury scale (ais) code for abdominal injury were included. descriptive analyzes are presented for demographic data, injury type, mechanism, and severity, as well as -days mortality. results: a total of patients with abdominal injuries were included ( . % of all trauma patients). % where men. median age was . the injury mechanism was blunt in %. transport accidents were the most frequent cause of injury ( %). median iss was , and median niss . overall -days mortality was . %, with a median trauma injury severity score (triss) of , . multiple abdominal injuries were recorded in % of the patients. % had associated injuries in other body regions, most frequently in the thoracic region ( . %). solid organ injury occurred in % of the patients, with liver injury ( %), splenic injury ( %), and kidney injury ( %) encountered most frequently. an ais score c was found in % of liver injuries, % of splenic injuries, and in % of patients with kidney injuries. hollow viscus injuries were found in % of the patients. injuries to the small intestine ( %) and colon ( %) were most frequent. abdominal vessel injuries were encountered in %, and % of these had an ais score c . conclusions: abdominal injuries are dominated by solid organ injuries following blunt injury mechanism and are often associated with concomitant thoracic injury. patients who dies within days from admission are characterized by a low probability of survival shown by triss. pancreatic trauma management in a third level centre a. gonzález-costa , r. gracia-roman , s. montmany-vioque , a. campos-serra , r. lobato-gil , c. zerpa-martin , f. j. garcía-borobia , p. rebasa-cladera , s. navarro-soto management. the aim of the study is to review the management and describe the most frequent complications of pancreatic trauma in our centre. material and methods: observational study with prospective collection of data, from march to march . inclusion criteria: trauma patients older than admitted to the emergency department who were admitted to icu or died before admission. demographic data has been collected, also vital signs, iss, mechanism of action, mortality, complications, and lesions. results: between and , polytraumatic patients were registered. only had pancreatic trauma ( . %). the male: female ratio was : ; with an average age of . years (sd . ) . mean iss of . (sd . ), mean ais of . (sd . ) and mortality of . % ( patients). the most frequent pancreatic lesion was at the head of the pancreas ( patients; . %), followed by body-tail ( patients; . %) and two patients with full section ( . %). . % of patients were treated with non-operative management. five patients required urgent surgery ( %), requiring corporocaudal pancreatectomy in cases and drainage in patients. an embolization of a gastroduodenal artery aneurysm was performed in patient. respiratory complications were the most frequent. patients developed a pancreatic fistula ( . %), although in surgical patients this complication was much higher ( % in our series). one of them required puestow pancreaticojejunostomy and patient developed necrotizing pancreatitis ( . %). conclusions: pancreatic trauma is very uncommon. its management can be difficult, depending on the degree of injury (aast), with a high rate of complications. therefore, combined management and monitoring by the surgery and intensive care team will be very important. introduction: the aim of this retrospective study was to evaluate and compare the clinical outcomes of conservative versus surgical treatment in a series of patients with liver injury. material and methods: between - , there were included patients. according the treatment chosen, the patients were subdivided in two groups. non-operative management was considered in hemodynamically stable patients. the failure of conservative treatment was defined as need to resort to operative management after a period of strict monitoring when the reason was related to the liver or associated injuries or need for late angioembolization. all hemodynamically unstable patients were subjected surgical treatment. results: conservative treatment was selected for patients and only in of them was failed due to associated delayed bleeding and small bowel injury. patients underwent emergent surgery which included packing, lobectomy and splenectomy. operative findings revealed grade iii liver injuries in % and grade iv in %. pneumonia, sepsis and ards were the most frequently associated complications. the overall mortality rate was . %. in patients of conservative group, non-surgical treatment failed with surgery being required. the mortality in the group of patients who underwent emergent laparotomy on admission was of patients. conclusions: conservative treatment of blunt traumatic hepatic injuries is applicable in patients presenting hemodynamic stability with mild hepatic injuries and it could be successful even in high graded injuries with low morbidity and mortality. surgical treatment is indicated in grade v injuries. nevertheless, failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality. with the trend towards more conservative management strategies, surgeons' exposure to laparotomies for blunt injuries in rtas has decreased. the aim of this study was to examine surgeons' exposure to laparotomies following blunt trauma which remains important to maintain low patient morbidity and mortality rates. material and methods: data was collected for adult patients admitted to mater dei hospital (malta) following rtas with ctproven intrabdominal injuries between january and january . results: patients ( ( . %) males vs. ( . %) female (p value \ . ), mean age = . years) were included in the study. patients ( . %) were car occupants whilst patients ( . %) were pedestrians. ( . %) patients had single intraabdominal organ injury, whilst ( . %) had multiple intraabdominal organ injuries. the -day mortality rate was . % ( patients). liver injuries occurred in ( . %) patients, splenic injuries occurred in ( . %) patients, kidney injuries in ( . %) patients and other organs were injured in ( . %) patients. conservative management was followed in ( . %) patients, angioembolisation was utilised in ( . %) patients and operative management was performed in ( . %) patients during the -year period. this resulted in trauma laparotomies following rtas per year. conclusions: only a minority of patients require operative management after rtas. surgeons in small countries have limited exposure to complex rta's. in view of the low exposure to emergency laparotomies following rtas, changes to our local training programme was done. trauma courses, lectures and fellowships in eu have been implemented to maintain surgical skills to an optimal level. references: european commission, annual accident report. european commission, directorate general for transport june . case history: a year old female presented to the accident and emergency department h post colonoscopy with complaints of left sided abdominal pain. this colonoscopy was requested under a -week wait for a history of chronic diarrhoea. this was a complete and uneventful examination ath the time, with random colonic and ileal biopsies taken. she attended a ? e with left sided abdominal pain increasing in severity. clinical findings: she was found to have an exquisitely tender abdomen, experienced more in the left upper quadrant. she was clinically shocked with a marked hypotension and tachycardia. investigation/results: a ct of her abdomen and pelvis showed free fluid within the abdomen and pelvis, with active bleeding and large haematoma adjacent to the spleen. the grade of splenic injury however was not commented upon by the reporting radiologist. interventional radiological embolism was considered but unfeasible as patient not stable haemodynamically. diagnosis: she was diagnosed with a splenic injury post-colonoscopy, with internal bleeding and haemodynamic instability. therapy and progressions: she underwent an emergency splenectomy overnight and was transferred to the intensive care unit for postoperative care. she recovered well, was stepped down to ward level care and was discharged with post splenectomy protocols, including all necessary vaccinations. comments: splenic rupture post-colonoscopy is a very rare event, with less than cases reported worldwide since . however, it still should be considered as a cause of a ? e presentation in patients with upper abdominal pain and haemodynamic instability after recent colonoscopy. we wanted to present this rare case to the international audience of estes congress to raise awareness of this rare complication. clinical findings: hemorrhagic shock and consciousness disorder were observed. her abdomen was distended, and she was intubated in the emergency room. investigation/results: ct revealed massive intra-abdominal bleeding. diagnosis: massive intra-abdominal bleeding due to hepatic laceration. therapy and progression: damage control surgery (dcs) and transcatheter arterial embolization (tae) were performed. she was transported to a hybrid operating room. she experienced cardiac arrest before operation. cardiopulmonary resuscitation was immediately initiated, resulting in the return of spontaneous circulation. laparotomy with perihepatic packing (php) was performed, but she experienced two more episodes of cardiac arrest during operation. then, tae was performed for right hepatic artery extravasation. after physiological function restoration, including rewarming, coagulopathy correction and hemodynamic stabilization in the intensive care unit. she gradually became hemodynamically stable. however, incomplete hemostasis was obtained at second-look laparotomy h later. because of bleeding, we repeated php. we performed cholecystectomy and abdominal closure after confirming complete hemostasis ( h post-accident). she was discharged ambulatory without neurological deficit (day ). comments: prognosis of traumatic cardiac arrest is generally poor, and survival without considerable neurological deficit is very rare. we reported a surviving patient with severe hepatic laceration. sharing of strategies and tactics, such as blood transfusion, tae, trauma team approach to surgery, early decision of dcs improves outcome of patients with severe abdominal trauma. references: resuscitation. ; : - . introduction: the spleen is the most commonly injured organ after blunt trauma. non operative treatment (nom) of splenic injuries has gained wide acceptance. transcatheter embolization of the splenic artery is considered a useful adjunct in aast lesions c without active bleeding. we report a retrospective review of all patients admitted to a level trauma center with blunt splenic injury from to and compare their treatment and outcome with a previous series from to , when angioembolization was performed only in case of contrast blush at ct scan. patients and results: from to june , patients with blunt splenic injuries were admitted to the ed of a level university hospital in milan, italy. men to female ratio was : ,the mean age . ± years (range - ), and the iss ± . (range - ). eight patients ( . %) underwent emergent splenectomy due to hemodynamic instability. of the stable patients treated with nom, those with aast lesions c (n = ) were submitted also to angiography and to embolization of the spleen ( %), either proximally ( ) or distally ( ). two nom failed, and the patients were submitted to splenectomy or distal embolization. the median hospital stay was . ± . days. the total spleen salvage rate was %. no associated abdominal injuries were missed in the nom group. in the previous series of patients (mean age . ± . years, range - , #:$ = : , iss ± , range - ), underwent emergency splenectomy ( %), and ( %) were treated conservatively, with only embolization ( , %) in case of aast c at ct scan. failure of nom were , and the spleen salvage rate . %. liver injury following multiple cardiopulmonary resuscitations case history: this is a case of a year old woman who presented to the emergency department (ed) due to worsening dyspnea complicated by two lengthy cardiac arrests. after the first resuscitation and return to spontaneous circulation (rosc), echocardiography was done and showed severely dilated right ventricle with strain, suggestive of massive pulmonary embolism, for which rtpa was given. arrest occurred again, and post rosc, heparin was started and the patient was transferred to the icu. extracorporeal membrane oxygenation (ecmo) was initiated but complicated by severe hemodynamic instability and a third cardiac arrest, so cardiopulmonary resuscitation (cpr) was performed till rosc and massive transfusion protocol was started for suspected intraperitoneal bleeding. clinical findings: after ecmo cannulation, abdominal distention was noted with a severe drop in hemoglobin and an increased intraabdominal pressure ( mmhg). abdominal bedside ultrasound showed significant amount of dense free fluid. the decision for an urgent exploratory laparotomy was made and the patient was taken to the operating room. therapy and progressions: deep liver laceration over the right hepatic dome with rupture of the capsule and an estimated hemoperitoneum of l were found intra-op. controlling the bleeding was difficult due to the laceration site and the patients coagulopathic status, so packing was done and the patient was transferred to icu for correction of the coagulopathy and re-evaluation in h. the liver was unpacked after h, bleeding sites were cauterized and sutured and the liver was wrapped with a mesh with an attempt for a tamponade effect. the patient's stay in icu was complicated with kidney injury requiring chronic dialysis but otherwise recovered well. comments: liver injury is a rare but serious complication after cpr that should be considered in case of persistent hemodynamic instability along with bedside findings. this case is intriguing due to the right sided liver injury with no overlying rib fractures. blunt renal trauma after electrical injury: a series of curious events. a. nixon , e. falidas , d. davris , a. botou , g. sofos chalkida general hospital, department of surgery, chalkida, greece case history: a yr old patient was referred to the emergency department (ed) of our hospital from a primary health center after sustaining an electrical injury ( v ac). the patient experienced loss of consciousness (loc) and promptly fell to the ground in a supine position. the patient arrived approximately h after the incident. clinical findings: vital signs: bp: / mmhg, hr: bpm. the patient's major complaint was left flank and abdominal pain. no obvious thermal injuries were observed or any other signs of external trauma. a left abdominal mass developed which was evident on physical examination. in addition, examination of urine revealed gross hematuria. investigation/results: ekg monitoring documented sinus tachycardia without evidence of cardiac arrhythmias. fast indicated the presence of a massive retroperitoneal hematoma. the fast exam indicated the left kidney as the probable source of hemorrhage. the initial hematocrit (hct) from the primary health facility was % while results from the ed recorded a hct of %. diagnosis: grade v renal trauma. therapy and progressions: a massive transfusion protocol was initiated. the patient underwent an emergency laparotomy and a left nephrectomy was performed. subsequent imaging did not reveal other injures. comments: the history of electrical injury could have misdirected investigation efforts towards cardiogenic shock. this case suggests that even in the absence of a high energy impact, sustained hemodynamic instability should always be attributed to hemorrhagic shock until disproven. in addition, the management of grade v renal trauma in blunt injury remains a controversial topic, however we believe that in cases of class iv shock, surgical management is imperative. case history: y.o. female with a history of chagas' disease of years duration and esophageal involvement in the last few months. she's admitted for a first endoscopic balloon dilatation due to dysphagia, which is performed according to protocol, and a tear of the mucosa layer is observed during it. clinical findings: she's stable for the first h but with continuous thoracic pain of moderate intensity according to the gi specialist. on the second day there's a general worsening of the patient's condition, with dyspnea, fever, desaturation and tachycardia. results and diagnosis: she develops leukopenia and elevations of acute phase reactants, and a ct scan reports a distal esophageal perforation with free extravasation of contrast in the mediastinum and bilateral pleural effusions. therapy and progressions: emergency surgery is performed through a midline supraumbilical laparotomy which shows peritonitis around the epigastric area. after opening the hiatus, a very long transmural esophageal tear with devitalized tissues and severe contamination are observed. a trans-hiatal esophagectomy was decided and, given the hemodynamic stability, a gastroplasty is performed and brought up to the neck without anastomosis, along with a terminal cervical esophagostomy and feeding jejunostomy. the patient did well in the postop period. we were able to do the esophagogastric anastomosis in the neck days later, during the same admission. comments: the surgical technique in esophageal perforation depends mainly on the time elapsed since the perforation, and on the condition of the patient. esophagectomy is sometimes unavoidable, and a gastroplasty can be brought up to the neck at the same time in selected cases, with reconstruction of the upper gi tract during the same admission. introduction: the spleen is one of the most frequently injured abdominal organ. the anatomy of the lesion defines the degree according to aast, ranging from grade i to v in increasing complexity. the diagnosis of splenic trauma may be difficult, as % of patients may show no signs or symptoms at primary survey. the approach involves two main strategies: conservative or surgical. the strategy should take into account four aspects: hemodynamic status, anatomy of the lesion, associated injuries and organizational structures of the evaluation site. this study aims to evaluate the type of approach performed on different degrees of splenic trauma during years in a portuguese trauma center. material and methods: we conducted a retrospective study including all patients diagnosed with splenic trauma during a period of seven years. by consulting the patient's clinical files we evaluated and compared: demographic data, trauma kinetics, degree of splenic injury and the approach taken as well as morbidity and mortality. results: of the patients studied, most were male with blunt trauma. in patients the inicial approach was surgery and in the option was conservative treatment. in grade iii or iv lesions conservative treatment failed in % of patients. patients in whom the surgical approach was first chosen had predominantly grade iv lesions, with total splenectomy being the preferred approach. in grade iii lesions, the option was mainly conservative surgery of the spleen. conclusions: the initial approach of splenic trauma results essentially of the experience of emergency teams and support structures for surveillance and intervention (intervention radiology and -h operating room availability). the attempt to try conservative strategy is increasing over time. introduction: for decades, helicopter emergency medical services (hems) contribute greatly to prehospital trauma patient's care by performing advanced medical interventions on scene. unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable. these cancellations contribute to overtriage and provide additional costs to society. an earlier study showed a cancellation rate of % in our trauma region. however, little empirical knowledge exists about reasons for cancellations for different mechanisms of injury (moi) and type of dispatch. this study aims to examine the current cancellation rate in our trauma region over a -year period. additionally, insights in cancellation reasons for different moi and type of dispatch are evaluated. methods: a retrospective study was performed, using data derived from the hems database of trauma region north west netherlands, between april st and april st . information regarding patient's characteristics, date and time of day, moi, type of dispatch, and cancellation reason were compared. results: in total, , patients were included. hems was cancelled in . % of dispatches. the majority of dispatches ( . %) were cancelled because the patient was physiologic-and neurologically stable. dispatches simultaneously activated with ems were cancelled . % of times, compared to . % when hems assistance was additionally requested by ems on scene. no differences were found between dayand night-time dispatches. trauma related dispatches were cancelled more frequently compared to non-trauma related dispatches. conclusions: this study found a considerable-and increased cancellation rate compared to previous research. an explanation for this finding could be better adherence to dispatch protocols. furthermore, a great variety in cancellation rates was found among different moi's. therefore, continuous critical evaluation of hems triage is important and dispatch criteria should be adjusted if necessary. case history: two separate cases of high speed road traffic collision. the first is years old female without significant past medical history. the second is years old male who had short extremitis due to history of spastic quadriplegic cerebral palsy alongside congenital kyphosis and postural scoliosis. clinical findings: on examination the first patient was hemodynamically stable with soft abdomen and bruising over the left pelvic area. the second patient had left side neck and right side chest bruises; furthermore, he was tachycardic with normal blood pressure, but he was generally pale, getting clammy and significantly sweaty. investigation/results: fast scan for both patients showed free fluid in the abdomen and ct scan was uncertain of the source in the first patient. in the second, a large mesenteric haematoma was evident on ct with contrast extravasation with corresponding significant drop in hemoglobin and raised lactate levels. diagnosis: case : hemodynamically stable blunt abdominal trauma. case : hemodynamically unstable blunt abdominal trauma. therapy and progressions: the first patient was managed conservatively initially but worsened overnight with a drop in haemoglobin and increase in lactate mandating emergency laparotomy. hemoperitoneum and cm of ischaemic bowel with tear in the mesentery was found. she had an uneventful recovery after resection and primary anastomosis. the second patient underwent immediate emergency laparotomy. there was evidence of hemoperitoneum ( l) and similar mesenteric tear with ischemia involving cm of the terminal ileum. resection with end to end anastomosis was done. patient was then transferred to itu; however, he developed chest infection which prolonged hospital stay. comments: hemodynamic instability is a major factor in mandating urgent exploratory laparotomy in bat and bucket-handle injury is not uncommon following road traffic accidents. introduction: incisional hernias are one of the most common complications post-abdominal surgery, affecting between - % of patients undergoing a laparotomy. a number of risk factors are associated with their development such as age, bmi, type of surgery and co-morbidities. these risk factors also affect their levels of recurrence which is why the technique undertaken to repair these is of such interest. the primary purpose of this meta-analysis was to examine which repair technique is associated with the lowest level of recurrence whilst a secondary aim was to examine whether the frequency of common complications was dependent on the type of repair utilised. material and methods: this systematic review and meta-analysis was conducted by both co-authors. the following information sources were utilised; cochrane/embase/google scholar/pubmed/scopus. in relation to the eligibility criteria-papers that were published from onwards and in the english language were included with any length of follow-up. study selection was as per the inclusion/exclusion criteria below and only cohort studies/rcts/systematic reviews/ meta-analyses and case control studies were included. inclusion criteria: abdominal incisional hernias, all types of repairmesh/open/laparoscopic/sutured repair/primary repair etc. in terms of the exclusion criteria-any hernia repair that was not incisional was excluded. results and conclusions: in terms of the primary question posed by this repair, meta-analysis shows that there is a significant difference between open vs laparoscopic technique and recurrence rates in relation to the primary question posed by this paper whilst the use of mesh impacts negatively on post-operative wound infection rates. this invites an interesting debate on the merits of each technique whilst demonstrating the need for a multicentre randomised controlled trial. laparoscopic approach in penetrating abdominal trauma: case study and review of the literature b. vieira , v. taranu , a. silva , d. galvão , a. soares hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal introduction: laparoscopy(ls) has greatly improved surgical outcomes in many elective abdominal procedures. the use of ls in acute care is becoming widely accepted. however, a number of safety issues have limited its application in abdominal trauma. notwithstanding with the reports and studies of the past decade proving its safety and accuracy, ls is slowly replacing the need for exploratory laparotomies. case report: a yo male sustained with penetrating stab wound on the left flank. he was hemodynamically stable. ct confirmed intraperitoneal positioning of the knife, without free fluid or air nor any evidence of organ injury. an exploratory ls was performed and confirmed the intraperitoneal positioning of the knife. abdominal exploration revealed a jejunal transfixating lesion about m from treiz's angle that was manually closed. the patient maintained a favorable po evolution and was discharged on the thpo day. discussion/conclusion: a number of concerns have limited the use of ls in abdominal penetrating trauma. initially, it resulted in high rates of missed injury, mainly of the small bowel, generating considerable criticism. the development of systematic abdominal explorations in ls, as described by choi and kawahara, resulted in a rate of missed injuries close to zero. moreover, direct visualization using ls has shown superior specificity and sensitivity in identifying peritoneal penetration, hollow viscus injuries and diaphragmatic lesions when compared to ct. in the case reported here, ct didn't show any image suspected of perfuration such as free air or fluid, and yet ls showed a small bowell injury. besides its advantages as a diagnostic tool avoiding negative laparotomies in more than % of the cases, thanks to evolving techniques and improved practice, it may also be therapeutic and allow safe definitive treatment for many types of injuries as described here. method: this is a monocentric retrospective study from a database entered prospectively. all patients admitted to the university hospital in nice with splenic trauma between / / and / / were included. the primary endpoint was performing splenectomy as a failure of a nom. results: patients were included in our study. the majority of splenic lesions were severe grades, that is to say greater than . in total, splenectomies were performed urgently, i.e. % of patients; angio-embolizations were performed, i.e. % of patients with a success rate greater than %; . % of patients who had not anterior angio-embolization required secondary splenectomy; . % of the patients who had anterior angio-embolization required secondary splenectomy. in the patient group with successful angio-embolization, the mean age was years vs . years in the nom failure group (p = . ). a decrease in hemoglobin between admission and h after admission was found in the nom failure group compared with the successful embolization group (p = . ). conclusion: hemoglobin monitoring in the hours following admission of a patient with splenic trauma may be an important factor in the surveillance of hemodynamically stable patients. prospective studies could confirm these results. missed ureteric injuries in gunshot injuries of the abdomen: how to avoid? introduction: traumatic ureteral injuries are uncommon. penetrating rather than blunt trauma is the most common cause of ureteral injuries. the aim of this study is to make a strategy to avoid missing ureteric injuries in gunshot injuries of the abdomen. material and methods: patients were operated in our hospital in years period. all patients were managed according to atls guidelines. for stable patients, full radiological work up was done, while hemodynamically unstable patients were shifted to or immediately for laparotomy and exploration. all patients demographic and clinical data were recorded these include :patient age, sex, mechanism of injury, hemodynamic state on arrival to the rr, anatomical site of gunshot injury, associated injuries, ureteric injuries detected early or late, early repair, delayed presentation and morbidly associated with delayed discovery. results: ureteric injuries were found in patients out of patients who underwent laparotomy for gunshot injuries had ureteric injury in an incidence of . %. ureteric injuries were missed in the first laparotomy in patients. associated injuries of other abdominal viscera include; colon injuries affecting ascending and descending colon in all the patients. conclusions: ct and pyelogram are the modalities of choice in stable patient but in unstable patients the early recognition of ureteric injuries depends on high index of suspicion leading to surgical exploration of the ureter along its course. case history: we present a case of a year old man, who was injured by his agricultural machine in the abdomen. clinical findings: he was transferred in the emergency department and he was hemodynamically stable. he had several traumas in his abdominal wall. from the largest one, in the left iliac fossa, omentum, transverse colon and loops of the small intestine were protruded out of the abdominal wall. the small bowel was ischemic and ruptured. investigation/results: computed tomography investigation, revealed small amounts of liquid and air in the abdominal cavity. diagnosis: the patient was immediately operated. the destroyed loop of the small bowel was resected with the use of a stapler and the field was washout. then with a midline incision the abdomen was opened. there were no other injuries inside the abdomen cavity. there was an extensive injury with a creation of a large gap in the anterolateral abdominal wall. it was impossible to identify the left rectus abdominis muscle as also the lateral muscles (external and internal oblique and transversus abdominis). therapy and progressions: a side to side entero-enteric anastomosis was created and a meticulous observation and washout of the abdomen were performed. for the closure of the abdominal wall a double-sided mesh from polypropylene coated with silicone on one side ( cm) was placed and the operation was completed. all the other wounds of the abdominal wall were closed with loop nylon stitches no . a closed suction drain was placed above the mesh. the patient had a very good postoperative course. he was dismissed from the hospital after days in a very good condition. comments: the usage of mesh was very useful for the reconstruction of the abdominal wall. there is no conflict of interest. strategy shift from damage control surgery to primary radical surgery improve the outcome of blunt hepatic injury involving inferior vena cava introduction: the diagnosis of abdominal trauma is a real challenge even for surgeons experienced in trauma. clinical findings are usually unreliable, and abdominal examination is made up of various factors. diagnostic tools that help the attending physician make critical decisions, such as the need for laparotomy or conservative treatment, are mandatory if we propose a favorable outcome. material and methods: the study was performed in the clinic i surgery, the county clinical emergency hospital craiova, between - and analyzed a number of abdominal traumas hospitalized, investigated and treated in the clinic. the methods of paraclinical diagnosis are evaluated comparatively, the study analyzing the evolution and the tendencies during the studied period, from , to . results: the study allowed an evaluation of the diagnosis and treatment methods compared to the data in the literature. conclusions: thus ct scan remains the standard criterion for detecting solid organic lesions. in addition, a ct scan of the abdomen may reveal other associated lesions. fast ultrasound is an important and valuable alternative for diagnosing abdominal trauma, especially for patients who are hemodynamically unstable and cannot be mobilized. there is a tendency in the treatment of abdominal trauma, as evidenced by the literature data on the use of conservative versus surgical treatment for a larger number of cases introduction: antiplatelet agents and anticoagulant drugs are widely used in prevention of cardiovascular incidents, which poses a challenge in surgical emergencies. the drafting of a multidisciplinary protocol for the treatment of pharmacological induced coagulopathy in patients who require urgent surgery standardizes management and increases patients' perioperative safety. material and methods: aims of the study were to describe the results from the protocol implementation. a retrospective study was conducted by examining reports of every patient presenting pharmacological induced coagulopathy and undergoing emergent surgery, recorded in our center from to inclusive. different algorithms used were explained and data such as need of transfusion, reintervention rate and perioperative complications were analyzed. results: data from patients were analyzed, median age of , ( %) men. patients ( %) used anticoagulant drugs. fresh frozen plasma transfusion and/or prothrombin complex concentrates were used according to the guideline. ( %) patients used antiplatelet agents. % of them underwent a delayed h surgery directly. tirofiban therapy was established in patients on dual therapy due to medium-high risk of cardiovascular event. regarding surgical approach, ( %) were laparoscopic, ( %) open and conversion occurred in ( %) cases, but only of them due to intraoperative hemorrhagic complication. only cases of postoperative hemorrhagic complications led up to reintervention and only one isolated case of thrombotic complication was reported. finally, ( %) mortality cases were reported, but none was caused by hemorrhagic nor thrombotic complications. conclusions: establishment of a guideline on management of pharmacological induced coagulopathy in emergent surgery is crucial in all surgical emergency units and has proven to be effective and safe. introduction: digestive haemorrhage is a frequent pathology. most of the episodes are self-limited, but in some cases massive haemorrhage occurs, leading to a % mortality rate. severe problems occurs when endoscopic treatment is not effective, requiring emergent surgery with poor prognosis. the aim of this study is to evaluate the implementation of interventional radiology techniques on short-term results. methods: a retrospective descriptive study was performed reviewing patients who underwent radiological embolization after failure of endoscopic conventional treatment between - in our hospital. a total of patients were included. results: patients were male. cases were from lower gi track and were from the upper gi with a similar death rate between them, with a higher rebleeding rate in upper gi ( . % vs . %). % of the arteriographies did not show any bleeding site, of them developed a new bleeding episode. overall patients who undergo embolization, urgent surgery was avoided in of the patients diagnosed as upper gi haemorrhage and in of the patients diagnosed as lower gi haemorrhage. patients died, those death occurred later on the recovery of the acute bleeding episode and embolization, all of them related to patients comorbidities. conclusions: arterial embolization has become an important tool in order to treat massive haemorrhages of the gastrointestinal tract. it seems to decrease the mortality and morbidity rate, but some complications can be associated such as rebleeding or bowel ischaemia. massive transfusion protocol with early administration of platelet and fresh-frozen plasma along with packed red cells in the initial phase of resuscitation is associated with improved outcomes introduction: massive transfusion (mt) in a ratio of : : (prbc:platelet:ffp) is the standard of care in hemorrhaging trauma patients. the aim of our study was to compare the outcomes of patients who receive near balanced resuscitation (nbr) compared to unbalanced resuscitation (ubr) during the initial phase of resuscitation. material and methods: we performed a -year analysis of the acs-tqip. all adult patients (age [ ) who received mt (defined as transfusion of prbc c units in -h) were included. patients were stratified into two groups: nbr defined as prbc:platelets:ffp in : [ . : [ . and ubr ( : \ . : \ . ) in the first h of resuscitation. primary outcome measure was mortality. secondary outcome measures were complications, and hospital length of stay. propensity matching was performed to match the two groups. results: a total of , patients received mt. mean age was ± years, median iss was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . overall h mortality was . %. only % patients received nbr while % received ubr in the first -h. using propensity score matching, patients were matched for demographics, ed vitals, iss, ais and injury parameters. patients who received nbr in the early resuscitation phase had lower mortality ( % vs. %, p = . ), lower overall complications ( % vs. %, p = . ), with no difference in hospital length of stay ( days vs. days, p = . ) compared to the ubr group. conclusions: only one-third of patient receiving massive transfusion receive prbc, ffp and platelet in a ratio closer to : : in the initial -h and they have lower mortality and complications compared to patients with unbalanced resuscitation. material and methods: the goal is to assess mtp strategies in level- trauma centres in the netherlands and compare these with each other and (inter) national guidelines. a trauma surgeon or anaesthesiologist involved in compiling the mtp in each level- trauma centre in the netherlands and dutch ministry of defence was approached to share their mtp and comment on their protocol in a survey or oral follow-up interview. results: all eleven level- trauma centres responded. content of the packages and transfusion ratio (red blood cells/plasma/platelets) was : : , : : , : : , : : , : : , : : , : : and : : . tranexamic acid was used in all centres and an additional dose was administered in eight centres. fibrinogen was given directly (n = ), with persistent bleeding (n = ), based on clauss fibrinogen (n = ) or rotem Ò (n = ). standard coagulation monitoring are used in all centres, but most hospitals use also rotational thromboelastometry (rotem Ò ) (n = ), thromboelastography (teg Ò ) (n = ) or both (n = ). all centres used additional medication for patients using anticoagulants, but its use was ambiguous. conclusions: mtps in dutch level trauma centres differs from (inter) national guidelines in transfusion ratio and additional medication, which could be explained by misinterpretation of the : : ratio, changes in components and following an outdated dutch national guideline. whether these differences in mtps actually leads to different patient outcomes will follow from data that is currently being collected. this study is sponsored by the dutch ministry of defence. anastomotic bleeding after colorectal surgery: incidence, management and complications introduction: postoperative anastomotic bleeding (pab) is a frequent minor complication ( - %) that usually resolves by a conservative approach. hemodynamic instability and anemization may develop requiring urgent management. the aim of our study is to describe pab and its treatment. material and methods: observational retrospective cohort study of patients with pab collected between july and september . pab was defined as an episode of lower gi bleeding after colorectal surgery with at least one anastomosis. characteristics of patients, surgery, length of hospital stay, morbidity and mortality, and management of pab were reviewed. results: a total of ( . %) patients with pab was collected. median age was of years (iqr - ), with a median estimated asa grade of . the most common procedure was a right hemicolectomy ( %), followed by sigmoidectomy ( %). % of surgeries were laparoscopic. only cases were converted to an open approach. % of patients had the first episode of pab during the first h after surgery, while % after the third postoperative day. pab was treated conservatively in % of the cases. the remaining % required urgent endoscopic management identifying the bleeding through the anastomosis line, using clips in patients and hemospray in patient to control it. no complications were recorded after endoscopic treatment. just case required surgical reintervention. a total of ( %) patients required blood transfusion with a median of (iqr - . ) units. length of hospital stay was . days. no mortality related to pab was registered. conclusions: pab is a mild complication after colorectal surgery. most of the patients respond to conservative management. urgent endoscopic treatment seems to be effective and safe to control pab even during the first postoperative day. introduction: hemorrhagic shock and associated reperfusion injuries are davastating situations during the treatment of polytrauma patients. the aim of this study was to analyze and compare alterations of the local circulatory changes of various body regions during hemorrhagic shock and after fluid resuscitation. material and methods: this study was conducted on male pigs. they suffered a standardized polytrauma including femoral fracture, blunt thoracic trauma and liver laceration. further, the suffered a hemorrhagic shock for h (aimed map mmhg). fluid resuscitation with three times drawn blood volume after hemorrhagic shock. retrograde nailing for femoral fracture and chest tube in case of pneumothorax liver packing. measuring circulation at liver, colon, stomach, and extremity. results: inclusion of animals. local circulation at the extremity decreased significantly compared to baseline values during hemorrhagic shock ( . a.u. versus . a.u., p \ . ). after resuscitation the flow rate at the extremity was comparable to baseline values. the stomach was least sensitive to hemorrhagic shock, whereas the oxygen delivery rate at the colon decreased during shock phase and remained decreased during fluid resuscitation (p \ . ). conclusions: different body regions react differently to hemorrhagic shock. the colon appears to be most vulnerable to changes based on hemorrhage. the delayed improvement of circulation in liver, colon, and extremities may represent a trigger for systemic hyperinflammation and subsequent sirs and sepsis. none of the authors have any conflicts of interest to declare. massive transfusion in penetrating trauma: the search for a specific prediction system introduction: prediction systems of massive transfusion (mt) were developed from cohorts with a small proportion of penetrating trauma. some of them required laboratory tests. we aimed to evaluate abc score and to identify independent predictors of mt in a cohort of torso penetrating trauma (tpt) material and methods: adults with tpt, managed in a level-i trauma center, who received one or more packed red blood cells (prbc), were included. variables obtained during the evaluation in the trauma bay were registered prospectively. the ability to predict mt was evaluated with simple, multiple logistic regressions and roc curves. results: we included patients; . % were male, and . % received fire-arm wounds. twenty-one ( %) received mt. mt patients were intubated more frequently in the pre-hospital, had lower sbp, higher hr, lower gcs, and received more frequently vasopressors (p \ . ) when compared with the no-mt patients. trauma mechanism, number or localization of the wounds, and positive fast could not discriminate mt (p [ . ). hypotension, tachycardia, and alteration of the glasgow coma scale or its motor response behaved as independent predictors of mt. models created with these variables showed better discriminative ability than abc score, with adequate goodness to fit. conclusions: prediction models of mt, based on heart rate, systolic blood pressure, and neurologic alteration outperformed abc score in a tpt cohort. introduction: rectus sheath hematoma presents with abdominal pain and anterior abdominal wall mass. it can be followed conservatively and rarely causes mortality ( ) . in this study we aimed to review rectus sheath hematoma cases consulted to our department and to present our management. material and methods: the data of patients admitted with rectus sheath hematoma between and was collected using hospital database. treatment modalities, demographic data and complications were reviewed retrospectively. results: all the cases presented with abdominal pain and/or with a palpable abdominal mass. . % of the patients (n = ) were receiving anticoagulant therapy at the time of admission. the mean inr value was . . patients were followed up with es&ffp transfusion and conservative treatment. patients not eligible for conservative care underwent inferior epigastric artery embolization and hematomas in patients were evacuated via a percutaneous drainage catheter. patient went through laparotomy for an infected hematoma and one patient underwent laparotomy plus packing. the patient who had laparotomy plus packing died due to intraabdominal hematoma and sepsis. conclusions: rectus sheath heamatoma is a rare cause of acute abdominal pain. the patients diagnosed early and have suitable indications can be treated conservatively ( ) . rectus sheath hematoma should be considered in the differential when a patient with a history of anticoagulant drug use presents with acute abdominal pain in order to prevent unnecessary surgery and complications. introduction: an early delivery of blood products when massive transfusion protocols (mtp) are triggered is mandatory to improve trauma patients survival. scores predicting massive transfusion (mt) have already been described ( ) . the aim of our study is to compare scores for predicting mt and identify the best trigger for mtp. material and methods: multicentric retrospective study from the trauma registry of the spanish surgeons' association. severe trauma patients (injury severity score [iss] c ), admitted to different level trauma centers, from january to september were included. demographic and clinical information was recorded, and predictive scores for mt were assessed. results: patients were included. medium age was . ± . years, ( . %) were male. median iss was (iqr ). in % of the patients a mt (defined as c units of packed rbc) was necessary, while a mtp was triggered in . %. surgery was performed in . %. the overall mortality was of . %. predictive scores for mt were compared: gap (glasgow coma scale, age, systolic blood pressure), shock index (si), assessment of blood consumption (abc) and mabc (modified abc). auroc for gap was . ± . , si . ± . , abc . ± . and mabc . ± . , showing differences between gap (the worst score) and the others, p \ . . no differences were found between si, ab and mabc. best cut-off points were calculated. si c . better predicts mt with a sensitivity %, specificity . %, positive and negative predictive values . % and %. conclusions: si, abc and mabc are all good scores for predicting mt in our population. appealing by its simplicity, we recommend si as the best trigger for mtp. protocols should be standardized to improve the accuracy of mtp activation for trauma patients. introduction: the prevalence of knife-related offences is rising in the uk. successful management of trauma patients requires the co-ordinated response of specialist services, including transfusion. we aimed to assess the impact of knife-crime on transfusion support within a uk adult major trauma centre (mtc). material and methods: retrospective review of patients admitted to a uk mtc following knife injuries resulting from interpersonal violence during a three-year period (may -april ). source material included electronic patient records, tarn database and massive transfusion protocol (mtp) logbook. patient characteristics, resource utilisation including transfusion, mtp activation and outcome were collated. results: patients were identified, ( %) were male. median age was years. ( %) were under the age of . patients ( %) presented with circulatory compromise (sbp \ ). patients ( %) had attended our hospital previously for violencerelated trauma. % arrived at hospital between h to h. ( %) required one or more surgical procedures. median length of stay was days. patients ( %) received blood transfusion. median units transfused were prbc, ffp, platelets (atd). mean component use was pbrc (range - ), . ffp ( - ), platelets . ( - ), cryoprecipitate . ( - ). annual mtp activations increased from to during the study period (total ). stabbings accounted for . % of these ( patients), of which ( %) were transfused. conclusions: knife crime presents a burden to blood transfusion, accounting for a quarter of mtp activations. patients typically present out of hours with implications for service planning and delivery. patient profile together with repeat healthcare attendance and surgery requiring transfusion has implications for red cell allo-immunisation. we recommend timely baseline blood grouping and triage to optimise the safe use of rhd positive cellular components. introduction: spontaneous intramural small bowel hematoma is a very rare complication of anticoagulant therapy. nowadays, the prevalence is increasing due to the widespread use of computerized tomography and the increasing number of patients receiving anticoagulant therapy. material and methods: patients admitted to our center between january and june and treated with the diagnosis of intramural hematoma were retrospectively evaluated. results: the median age of the patients was years ( - ) and ( %) were male. at the time of appeal, warfarin intoxication was present in cases ( %) and the median inr was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . one patient had known factor deficiency. diagnosis was made by computerized tomography in all cases. one intramural hematoma was localized in the duodenum ( . %), nine in the jejunum ( %), and five in the ileum ( . %) six patients ( %) had ileus findings. all patients underwent fresh frozen plasma replacement due to high inr levels and bleeding. median tdp transfusion was units ( - ). only patients ( %) required erythrocyte suspension replacement. all cases were followed up conservatively and there was no need for intensive care. the median hospital stay was ( - ) days. conclusions: due to the limited number of studies in the literature with a large number of cases, retrospective evaluation of singlecenter cases may be helpful. spontaneous intramural small bowel hematoma should be considered in the elderly population under warfarin therapy who present with abdominal pain, especially if inr values are above therapeutic limits spontaneous regression is seen in the majority of cases. non operative management and correction of coagulopathy with fresh frozen plasma replacement is the preferred approach. references: abbas ma, et al. spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. arch surg. ; ( ) : - . pre-hospital decision-making: identifying the challenges assessing and managing traumatic haemorrhage and coagulopathy m. marsden , r. bagga , k. gillies , r. lyon , s. kellett , r. davenport , n. tai expert pre-hospital clinicians in making decisions about the diagnosis and treatment of patients with major haemorrhage and suspected tic. methods: semi-structured interviews were conducted with senior pre-hospital consultants from london's air ambulance and air ambulance kent, surrey and sussex. interviews probed clinicians on how they make decisions relating to the pre-hospital assessment of major haemorrhage and tic and subsequent blood product transfusion. the interviews were analysed using descriptive thematic analysis. results: all clinicians agreed that identifying and treating major haemorrhage was vital. half of the clinicians reported making no conscious assessment for tic and six reported tic should be managed in a hospital setting. four broad themes were identified: collation of information, weighing utility of different approaches, influence of experience and evaluation of unknowns. collating information from multiple sources drove clinical decision-making. decisions on blood product transfusion were made after weighing potential benefits (e.g. improve microvascular perfusion) against harms. clinical experience was reported as key to nuance clinical assessment, detect subtle signs and identify patterns. uncertainty complicated clinical decision-making in two domains; incomplete knowledge of a patient's injury and uncertainty of best clinical practice. conclusion: the pre-hospital identification and treatment of major haemorrhage was recognised as challenging and fundamental. necessity of pre-hospital tic diagnosis and treatment divided opinion. identifying these four themes allows for a greater understanding of the factors involved in making these decisions and will guide the creation of more accurate decision support tools to aid pre-hospital clinicians. nothing to declare. introduction: massive transfusion (mt) is defined as the administration of c packed red blood cells (prbc) in h. alternative definitions have been proposed; however, there is little understanding about the discriminative ability of different mt definitions with regards to mortality and multiorgan failure (mof). we aim to assess and compare the discriminative ability of different definitions of mt concerning mortality and mof. material and methods: we included patients who arrived to the emergency department and required trauma team activation at a level i trauma center in the city of cali, colombia between - . demographics and trauma characteristics were evaluated. the following mt definitions were measured: units of blood products in h (t ), u prbc in (t - ), u prbc in h (t - ), prbc in h (t - ), the combination of t - and t (t-combi), prbc in h (t - ), prbc in h (t - ) and units of prbcs in min. the operative characteristics were calculated for each definition. mof was defined as a sofa score of c points. results: we included subjects, . % male. trauma mechanism was penetrating in . %. the median and interquartile range (iqr) of age was years iqr ( - ) and of iss ( - ). lesions were located in the torso in . % of patients, and . % had a positive abc score. a total of ( %) received at least unit of prbc. tables and presents the operative characteristics of definitions of mt with respect to mortality and mof, respectively. conclusions: although all definitions showed an association with higher odds with the outcomes of interest, none of them showed an accurate diagnostic capacity regarding mof and mortality. thus, we advise caution when relying on the classical definition of mt ([ rbc units in h) to guide the flow of care of severely injured patients. trauma and coagulation: trends in coagulation factors in the severely injured trauma patient introduction: trauma-induced coagulopathy (tic), affects about - % of the major trauma patients. in the past, tic was considered as a consequence of the coagulation factors' dilution after a highvolume colloid administration. today tic is seen as a phenomenon that can arise after trauma; the first event is the c-protein activation by the tissue damage and hypoperfusion, resulting in the subversion of the hemostatic process. material and methods: the patients of the pilot study ''trauma and coagulation'' run in irccs san raffaele scientific institute have been reviewed and analyzed using a suite of experimental coagulation factors including rotem parameters, activated protein c (apc), thrombomodulin, endothelial protein c receptor, thrombin-antithrombin complex (tat), plasminogen activator inhibitor (pai- ), seselectin, interleukin- (il- ), interleukin- (il- ), d-dimer (xdp), antithrombin iii (atiii), and prothrombin fragment f ? (f ? ). new patients have been enrolled to validate the results of the pilot study. results: there is a statistically significative correlation between clinical scores of severity of trauma and risk of massive transfusion (iss, abc and tash) and some of the experimental coagulation factors analyzed. case history: to evaluate the role of negative pressure wound-care systems applied to the pleural cavity in case of severe acute empyemas and frail patients not amenable to conventional surgery. clinical findings: we report the case of a yrs old male critically ill patient suffering from complications of cardiac surgeries who developed a severe right empyema with broncho-pleural fistula through the site of a previous pulmonary hernia. investigation/results: we review the actual indications of negative pressure therapy in thoracic surgical emergencies especially in septic patients unfit for surgery. in our case the repeated application of negative pressure with dedicated dressings through the initial thoracotomy was the chosen damage control approach because of the sepsis and poor conditions. diagnosis, therapy and progressions: air leaks were later found to originate from a subsegmentary branch of middle lobe bronchus. subsequent video-assisted debridement procedures followed by negative pressure therapy managed to ( ) control the infection, ( ) reduce the thoracotomy incision into a thoracoscopic access and ( ) heal the pleural cavity, restoring eventually better general conditions of the patient. the closure of the bronchial fistula required further procedures after the acute phase when sepsis was overcome. comments: negative pressure systems can be applied to the pleural cavity with many advantages in selected critically ill patients. they allow to contain, treat and resolve infections both of chest wall and pleural cavity in case of severe empyemas reducing also wound pain and eliminating the need of chest drains. air leaks may also be managed by negative pressure therapy with adequate indications and particular attention to its settings. references: sziklavari z. mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. eur j cardiothorac surg. . flail chest: the renaissance of rib osteosynthesis c. leite , a. oliveira , a. lemos , b. barbosa , c. casimiro centro hospitalar tondela-viseu, general surgery, viseu, portugal case history: we present the clinical case of a male patient of years old. injury mechanism: fall from his own height over the right hemithorax. clinical findings: rib fractures with flail chest and significant displacement of bone edges. symptoms: intense thoracic pain. diagnosis: rib fractures with flail chest. therapy and progressions: multimodal analgesia. on the th day, he presented a tension pneumothorax. after adequate intercostal drainage, the pneumothorax relapsed. on the th day, he underwent a right posterolateral thoracotomy, open reduction and internal fixation of ribs with plates and screws and intercostal drainage. evolution: he received respiratory kinesiotherapy and was discharged on the th pos op day. follow-up at st and th months, without functional impairment and with preservation of quality of life. comments: rib fracture is the most common injury in the setting of thoracic trauma and is associated with a higher morbimortality. in the last years, positive pressure mechanical ventilation was the first line treatment of respiratory insufficiency caused by rib fractures. however, severe complications associated with prolonged mechanical ventilation, have elicited the rising implementation of open rib reduction and internal fixation techniques. the most consensual indications are: flail chest with fracture of at least ribs, significant displacement of bone edges or uncontrolled pain. rib osteosynthesis is a simple method but requires clinical experience in thoracic approaches and handling of specific instruments and material. its implementation in non-ventilated patients reduces the need for mechanical ventilation, pain, length of stay and allows preservation of quality of life. yokohama city university medical center, advanced critical care and emergency center, yokohama, japan, saiseikai yokohama-shi nanbu hospital, department of surgery, yokohama, japan, yokohama city university, department of general surgery, yokohama, japan, yokohama city university, department of emergency medicine, yokohama, japan introduction: although americans and europeans report emergency room thoracotomy (ert) is of value in penetrating trauma patients, most of ert is performed for blunt trauma in japan. after the establishment of the local government-directed major trauma center in the city of yokohama, the unexpected trauma survivor rate increased in the single center study. we report our experience in ert and surveyed the effect of the establishment. material and methods: patient characteristics (backgrounds, mechanism of injury, indication for ert, anatomic injuries, interventions and survival) of those who underwent emergency thoracotomy compliant with the guideline of western trauma association, between october and september were analyzed. results: fifty-eight patients ( males) underwent emergency thoracotomy. median age was . ( - ) years. fifty-seven were performed for blunt trauma ( %) and only for penetrating injuries. twenty-three patients presented with cardiac arrest on arrival, while thirty-five had deep and refractory hypotension. overall, survival rate improved from ( / ) to % ( / ) (p = . ) after the establishment of the trauma center. of patients presenting with cardiac arrest, only one survived. conclusions: the establishment of major trauma center seemed to affect the survival rate of the patient edt was performed. introduction: more than % of polytrauma events involve chest injuries. one third of these patients sustain thoracic instability due to serial rib fractures. thanks to numerous innovations in implant development several approaches currently exist for surgical rib stabilization (srs). however, no consensus exists regarding patient selection for srs to date. material and methods: retrospective single center cohort analysis in trauma patients. serial rib fracture was defined as three consecutive ribs confirmed by chest ct. cohort includes patients that were treated conservatively and patients that underwent srs by plate osteosynthesis. demographic patient data, trauma mechanism, injury pattern, injury severity score (iss), glasgow coma scale (gcs) and hospital course were analyzed. two matched pair analyses stratified for iss ( pairs) and gcs ( pairs) were performed to minimize selection bias. results: the majority of patients was male ( %) and aged ± years. serial rib fractures were located left/right/bilateral in %/ %/ % of cases. other thoracic bone injury included sternum ( %), scapula ( %) and clavicula ( %). visceral injury consisted of pneumothorax ( %), lung contusion ( %) and diaphragmatic rupture ( %). average iss was ± . . overall hospital stay was . and icu stay . days. in hospital mortality was %. srs did not improve hospital course or postoperative complications in the complete study cohort. however, patients undergoing srs had significantly reduced gcs ( . ± . vs . ± , ; p = . ). matched pair analysis stratified for gcs showed a reduced need for blood substitution and shorter icu stays ( vs days; p = . ) including shorter respirator time ( vs h; p = . ) and reduced in hospital mortality ( vs %). conclusions: patients with serial rib fractures and simultaneous severe cerebral injury benefit from surgical rib stabilization. tracheal and bilateral recurrent laryngeal nerve disruption injury secondary to accidental strangulation by dupatta case history: year old female brought to trauma emergency with a/h/o accidental strangulation injury with dhupatta at farm field while working with thresher machine after h of injury. patient had severe dyspnoea, dysphagia, paining neck clinical findings: primary survey revealed threatened airway with extensive surgical emphysema, rr- /min, spo - % on high flow oxygen mask, hemodynamically stable, and had no neurological deficits. patient was immediately intubated, however ventilation could not be maintained and surgical emphysema worsened hence immediate tracheostomy was established. investigation/results: computed tomography (ct) head and ct angiography of neck with venous phase study of neck and chest with ct esophagogram revealed complete disruption of cricotracheal junction with extensive cervical and upper thoracic surgical emphysema and no other injuries. diagnosis: disruption of trachea from cricoid cartilage with crushed trachea with loss of approximately cm, cricoid and thyroid cartilage fracture, complete avulsion of bilateral recurrent laryngeal nerves and serosal tear of esophagus. therapy and progressions: neck exploration with debridement of tracheal margins and anastomosis between trachea and cricoid cartilage with repair of cricoid, laryngeal cartilage and esophageal serosal repair was performed. comments: post-operatively patient underwent fibreoptic bronchoscopy and revealed paramedian location of vocal cords. at present patient is with tracheostomy tube in situ undergoing speech therapy and is able to generate comprehensible sounds. further laryngeal framework surgery is being planned. introduction: emergency resuscitative thoracotomy (ert) is a lifesaving procedure in selected patients and it is often considered a controversial ''last chance'' method of resuscitation. objectives of ert are to resolve pericardial tamponade, to repair heart injuries, to perform an open cardiac massage, to cross-clamp the aorta to redistribute blood flow to the myocardium and brain, to control intrathoracic bleeding and air embolism in the bronchial venous system. outcome mostly in blunt trauma is believed to be poor. material and methods: we retrospective reviewed patients c years who underwent ert at san camillo-forlanini hospital (rome, italy) between january and september with traumatic arrest for blunt or penetrating injuries. results: of ert, ( . %) were for blunt trauma, ( . %) were for penetrating trauma. . % of patients were male. the collectively reported overall survival was % (n = ). when including erts designated as done in the emergency department for blunt mechanism, only patient survived ( . %). survival after erts for penetrating trauma was % ( of ). conclusions: our experience suggests that ert is a technique that should be utilized for patients with critical penetrating injuries. the reported outcome after ert in european civilian trauma populations is favorable with an overall survival of %. multicenter, prospective, observational data are needed to validate the modern role of ert in blunt or penetrating trauma. references: narvestad jk, et al. emergency resuscitative thoracotomy performed in european civilian trauma patients with blunt or penetrating injuries: a systematic review. eur j trauma emerg surg. ; ( ) case history: an -year-old male driving a car collided with a wall at a speed of km/h and was brought to a hospital near the scene. he was diagnosed with right multiple rib fractures and hemopneumothorax, and transferred to our emergency center for definitive care. clinical findings: the patient's consciousness was clear and his heart rate, blood pressure, respiratory rate, and o saturation (room air) on arrival were /min, / mmhg, /min, and %, respectively. subcutaneous emphysema was identified on the right side of his chest and his right breathing sound decreased on auscultation. there was no tenderness and rebound on abdominal examination. investigation/results: an enhanced whole-body computed tomography scan revealed a small disruption on the right diaphragm behind the sternum and free air in the abdomen. diagnosis: the diagnosis was right traumatic diaphragmatic injury, sternum fracture, and right multiple rib fractures with pneumohemothorax. there was free air in the abdomen but without evidence of perforation of the digestive tract as there was no finding of peritonitis on physical examination. thus, pneumoperitoneum from the thorax was strongly suspected. therapy and progressions: laparoscopic observation revealed a . cm-length of disruption on the diaphragm in the right sternocostal triangle. this was covered with falciform ligament using extracorporeal knot tying method because there was little seam allowance in front of the disruption on the sternum side, and direct suture was not possible. prognosis was good following surgery, and the chest drain was removed on postoperative day and the patient was discharged on postoperative day . comments: laparoscopic repair of the diaphragm using extracorporeal knot tying method is often used for retrosternal (morgagni) hernias. however, the method was also useful in this case because the diaphragmatic injury occurred in the sternocostal triangle. rib fractures associated with pneumo-and/or hemothorax; does everyone need a chest tube? v. snartland , p. a. naess , c. gaarder , m. hestnes , p. majak , , faculty of medicine, university of oslo, oslo, norway, oslo university hospital, department of traumatology, oslo, norway, oslo university hospital, trauma registry, oslo, norway, oslo university hospital, department of cardiothoracic surgery, oslo, norway introduction: pneumo-and/or hemothorax are often seen in trauma patients with rib fractures (rfs). standard treatment for pneumothorax (ptx), hemothorax (htx) and hemopneumothorax (hptx) is tube thoracostomy (tt). however, a non-operative approach can be applied in selected patients. we wanted to assess our practice in patients with rib fractures and associated ptx, htx or hptx. material and methods: all adult patients (c years) with rf, admitted by a trauma team at oslo university hospital in were identified retrospectively and those with associated ptx, htx or hptx were then included in the study. patients who underwent tt prior to arrival and those who died were excluded. spss v was used for statistical analysis. results: of the patients with rfs, a total of patients had ptx, htx or hptx. fifty-one percent ( / ) of these patients were treated with tt and % ( / ) of the patients underwent tt within h after arrival. the presence of opacification (p \ . ), chest wall deformity (p \ . ) and pneumothorax size (p \ . ) were significantly higher on chest x-ray in the tt group compared to the nonoperative group. intubation at arrival was also significantly more common in patients treated with tt (p \ . ). there was no difference in the presence of subcutaneous emphysema between the groups. the tt group was sicker than the non-operative group (had a significantly lower systolic blood pressure, a lower gcs and a higher lactate on arrival). oxygen saturation, heart rate, respiratory rate, ph and hemoglobin did not differ significantly between the groups. conclusions: in trauma patients with rf concurrent ptx, htx or hptx should be suspected. in our study only half of these patients were treated with tt, and % of tubes were inserted within h after admission. size of the ptx, radiological presence of opacification and deformity of the chest wall should be addressed when choosing treatment strategy. introduction: emergency department thoracotomy (edt) is a potentially life-saving surgical procedure performed in the emergency department (ed) in patients presenting with cardiac arrest following penetrating thoracic trauma. however, it is not clear if all surgeons are prepared or motivated to perform this procedure. furthermore, not all institutions are equipped, either in terms of logistics or team training, to perform edt. our purpose was to perform a pilot study in a cohort of polish surgeons of various specializations, in order to ascertain who would and who would not (and why) perform edt in their departments. material and methods: study population of surgeons ( specialists, residents) from various hospitals in poland, mean age: - years, . % men, . % women. study respondents were asked to fill in a questionnaire on the indications and motivation to perform edt in their clinical practice. results: most respondents (n = , %) correctly recognized the indications to perform edt. however, only ( %) declared they would perform it. the reasons for not performing edt were: lack of team training ( . %); lack of equipment ( %); lack of motivation among ed personnel ( . %); the ed is not prepared ( . %); the respondent is not prepared ( %). only participants ( . %) declared that their institutions had the edt protocol. conclusions: this survey demonstrates that, although most surgeons agree on the indications for edt, the level of preparedness in its execution is lacking. the main reasons are the lack of team training, the lack of equipment and the lack of motivation among ed personnel. other relevant reasons were the lack of preparation of either a surgeon or a department. these results demonstrate that improvements in institutional logistics as well as in team and individual training can translate into improved care. we strongly advise the performance of a pan-european survey on edt to address other unrecognized issues. mediastinum widening: how to manage it? a. gonzález-costa , r. gracia-roman , s. montmany-vioque , m. s. santos-espi , r. lobato-gil , m. pascua-solé , a. campos-serra , a. luna-aufroy , p. rebasa-cladera , s. navarro-soto parc tauli hospital universitari, trauma and emergency general surgery department, sabadell, spain, parc tauli hospital universitari, esofagogastric general surgery department, sabadell, spain, parc tauli hospital universitari, angiology and vascular surgery, sabadell, spain case history: a -year old male was admitted to our emergency department as a polytrauma code, because of a gunshot wound in the neck. clinical findings: his airway was compromised with expansive cervical hematoma. intubation was difficult. he was hemodynamically unstable with cervical bleeding, in which manual compression was applied. results: chest x-ray showed mediastinal widening without pneumo or hemothorax. diagnosis: urgent sternotomy while maintaining manual compression on the cervical bleeding, followed by left antero-lateral cervicotomy. injuries: section of left jugular vein and left carotid artery, lesions of unnamed vein. free cervical chylous fluid. left pleura and pericardium were opened without identifying major injuries. therapy and progressions: jugular vein was repaired with continuous suture and carotid artery with patch sutured. unnamed vein was sectioned between ligatures. thoracic duct was ligated. after surgery, ct scan showed cervical and mediastinal hematomas without signs of active bleeding, and correct permeability of the vessels, with no cranial lesions. the patient was admitted to the intensive care unit. tracheostomy was performed. fibrobronchoscopy, fibrogastroscopy and esophagogastricoduodenal discarded airway and esophageal lesions. he presented the following complications: • small mediastinal collection • right diaphragmatic paralysis. • paralysis of vi left cranial nerve (mononeuritis of vascular origin). the patient was discharged on the th postoperative day. comments: in this kind of trauma is essential the airway management with intubation when necessary. it is important that mediastinal widening visualized in the chest x-ray in a traumatic patient, should be an indication of surgery. in our case, it was essential to start it with sternotomy while maintaining manual neck compression, and in a second time, perform the cervical approach since that prevented the patient from suffering a greater blood loss. background: clavicular fracture is very common in childhood. otherwise, the medial third of the clavicle is the less affected. the current report describes a new pattern of clavicular injury, in which a medial third clavicular fracture and posterior sternoclavicular joint (scj) dislocation occur together in a skeletally immature patient. clinical findings: an -year-old boy sustained a direct impact to his left shoulder resulting from the fall of a sofa. at admission, he complained of severe pain in the clavicular and shoulder associated with functional limb impotence. physical examination revealed deformity of the proximal third clavicle, with swelling and tenderness to palpation along the medial left clavicle. no signs of skin pression or neurovascular impairment were found. the anteroposterior radiograph of the left clavicle showed a fracture of the proximal third shaft and an asymmetry of the scj. computed tomography confirmed the association of a greenstick fracture of the proximal third clavicular shaft, accompanied by a mild posterior scj dislocation. therapy and progressions: the left limb was immobilized with a sling during weeks, after which physical therapy was initiated to improve range of motion using active and gentle active-assisted exercises. at the months medical consultation, he presented asymptomatic, with good bone healing, full range of motion of the shoulder and absence of relevant aesthetic deformity. comments: in the immature skeleton, scj dislocation and epiphyseal fracture of the proximal clavicle are very rare entities due to the multiple strong ligaments that stabilize the scj. trauma in the proximal third of the clavicle typically results in fractures in the region of the physis and only more rarely culminate in dislocations of the scj. these injuries warrant a high index of suspicion, and early ct scanning is recommended. although treatment may be conservative, in situations of major displacement, surgery should be considered. use of rib fracture scoring systems in a uk major trauma unit: a retrospective audit and lessons learnt introduction: rib fractures are detected in % of trauma patients [ ] . significant morbidity and admission to intensive care units (itu) is common [ ] . rib fracture scores do not have strong validity as a predictor, but are a useful screening tool to identify patients at higher risk, of morbidity. the aim of this study was to audit the use of rib fixation scores in a single major trauma centre. material and methods: a retrospective audit of trauma patients with rib fractures presenting to a single major trauma centre over a -year period subsequently admitted to itu was performed. demographics, length of itu stay, rib fracture score (rfs) and ribscore were recorded and comparisons made between patients who had surgical rib fixation and those who did not. results: patients with traumatic rib fractures were admitted to itu over -year, of whom had rib fixation. mean age of patients undergoing surgery was compared to in the non-surgical cohort. average rfs was higher in the surgical cohort ( vs ; p = \ . ), as was average ribscore ( vs ; p = \ . ). incidence of flail segment was higher in surgical cohort ( % vs %; p = \ . ), as was number of rib fractures ( vs ; p = \ . ) and incidence of st rib fracture ( % vs %, p = \ . ). rib fractures treated surgically had a longer itu stay ( . days vs . ; p = \ . ). conclusions: surgical rib fixation patients were older and had longer itu stay. higher rib fracture scores correlated with need for surgical intervention. this highlights the need for careful patient selection for rib fixation, as they appear to fall in a more vulnerable patient demographic. there is a need for a score combining ribscore and rfs, ensuring the nature of fractures and presence of flail segments are interpreted in the context of patient age, to ensure this vulnerable patient group undergoes surgical fixation only when necessary. jichi medical university, shimotsuke tochigi, japan case history: an -year-old female individual hurt her back while walking during a hospital rehabilitation program after experiencing a brain stroke. her hemoglobin level gradually decreased to . g/dl on the th day after injury. a non-enhanced abdominal ct scan revealed a burst fracture of the lumbar spine. the patient was brought to our emergency center for a thorough examination. clinical findings: her vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , and bt: . . her back presented a severe kyphotic spine. the palpebral conjunctiva was anemic and there were no injuries on her surface. no abnormalities were detected upon auscultation of the thorax and no tenderness and rebound was detected upon physical examination of the patient's abdomen. investigation/results: hemoglobin level was . g/dl and lactate . mmol/l on arrival. an enhanced chest and abdominal ct scan revealed a burst fracture of the th lumbar spine, a large hematoma around it, and a pseudoaneurysm of the lumbar artery. diagnosis: a pseudoaneurysm of the lumbar artery and a burst fracture of the th lumbar spine was diagnosed. therapy and progressions: the angioembolization of the lumbar artery was abandoned because the distance between the abdominal aorta and the aneurysm was \ mm. endovascular aneurysm repair (evar) was finally performed. after the successful completion of the surgery, the patient was discharged on the th day after evar. comments: slight injury caused the fracture of the lumbar spine, possibly yielding pseudoaneurysm of the lumbar artery. such pseudoaneurysms are rare and employing evar for its treatment is equally rare. blunt lumbar artery injury may be a differential diagnosis for the elderly patients who present burst spine fractures with extreme anemia or shock, even if it results from a minimal injury. case history: a year old co-driver was hit by another car on her side. air rescue found the patient with gcs and right tension pneumothorax. oral intubation, decompression with chest tube and transportation to the nearest level one trauma center was undertaken. clinical findings/investigation/results: on presentation in the emergency room the patient was hemodynamically instable with free fluid in efast-sonography and a haemoglobin of . g/dl. she was immediately taken to the operation room where laparotomy was performed. liver rupture and right diaphragm rupture was found. diagnosis: right hilar bronchial disruption. therapy and progressions: despite packing of the liver the patient remained instable. due to continuous bleeding from diaphragm rupture side right anterolateral thoracotomy was performed. bronchial disruption close to the hilus was detected leading to total pneumonectomy. after surgery the patient recovered under intensive care. six weeks after initial trauma the patient presented with ileus. a gastric tube was placed without complications. chest x-ray was performed showing intrathoracal displacement of the gastric tube. in an emergency operation the insufficient bronchus trunk was covered with an intercostal muscle flap. comments: this case shows the rare necessity of total pneumonectomy after blunt chest trauma and its typical complication with insufficiency of the bronchial trunk. after total pneumonectomy surgery covering the bronchial trunk should be performed as soon as possible to prevent insufficiency. in these patients gastric tubes should only be placed under endoscopic vision. because of the high complication rate total pneumonectomy should only be performed as a last resort procedure in the context of damage-control surgery. introduction: multiple rib fractures continue to be a challenging problem as the associated pain leads to a compromise in respiration. proper analgesia is required for physiotherapy, and to prevent development of respiratory failure. ultrasound-guided serratus plane block (spb) has recently been described as a regional anesthetic technique to provide analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. material and methods: from sept we applied the serratus plane block for pain control in patients with multiple rib fractures. we administered . - . % bupivacaine solution with easypump for - days, the infusion rate was ml/h. after admission we measured pulmonary function of patients and recorded the forced vital capacity (fvc). we repeated the test after the catheter insertion on the - - days. in our control group ( patients introduction: rib fractures are the most frequent injury after blunt thoracic trauma. it is very important to choose the most appropriate interventions to minimize or prevent complications. but who will benefit most of those interventions remains a challenge. material and methods: a retrospective study with a prospective data collection from march to december . there have been included all traumatic patients older than years old, that were admitted to the icu or who were died before the admission and had a plain chest radiograph (cxr) and thoracic or thoraco-abdominal scan (ct scan) in the first h. demographic data has been collected, vital signs, iss, mechanism of action, need of ventilation or intubation, lesions, complications, cause of death. a total of cxr were reevaluated by one general surgeon (one of the authors) and one radiologist, who were blinded to the results of the subsequent chest ct scan, the written radiology report and the patient's outcome. rib fractures, pneumothorax, hemothorax, pulmonary contusion, laceration and atelectasis were described. results: attending to the number of fractures, the kappa between the radiologist, the surgeon and the ct report is very low: surgeon-ct k = . , radiologist-ct k = . , and radiologist-surgeon k = . . both radiologist and surgeon under-diagnosed rib fractures. we tried to predict respiratory failure and pneumonia using the number of fractures, and scores (chest trauma score, ribscore and rib fracture score). results are shown on the table. conclusions: plain radiography seems not to be a good diagnostic method for rib fractures. both radiologists and surgeons under-diagnosed rib fractures. scores based on radiography seem un-useful given that this under-diagnoses rib fractures; but with a precision of % by the surgeon evaluating cxr and using a score like rfs perhaps it is enough to decide which patients require a ct scan or more specific treatment in the icu. surgical experience of traumatic diaphragm injury in a single regional trauma center for years introduction: this study is a retrospective review of the experience with the management of traumatic diaphragm injury in our trauma center from to . material and methods: we identified a total of patients with the traumatic diaphragm injury coded from the institutional trauma registry. we reviewed the radiographic finding of radiologists and the electronic medical record (emr). results: the mean of injury severity score (iss) was . ± . . except for case, the plain chest x-ray was evaluated in the patients before surgery, only patients were revealed positive finding for diaphragm injury (n = / , %). the computed tomography (ct) was performed for patients, the positive finding was . % (n = / ). according to the clinician impression before surgery, the diagnosis for diaphragm injury was showed . % (n = / ). approaches were laparotomy in patients ( . %), thoracotomy in ( . %), thoracoscopy in ( . %), laparoscopy in ( . %), open conversion after thoracoscopic or laparoscopic exploration in ( . %), median sternotomy in ( . %). the occurrence of herniation was ( . %). the mean of the calculated rupture size in the operation field was . ± . cm. in our study, the herniated peritoneal organ was observed in more than cm size rupture of the diaphragm. patients were performed surgical management of diaphragm rupture after h. conclusions: without herniation of organs, the radiologic evaluation was difficult to detect diaphragm injury. and, detect of diaphragm injury with herniation of organ, the injury of the diaphragm was predicted a larger than cm. case history and clinical findings: a -year-old man presented to the emergency room with a single self-inflicted left chest gunshot wound at the level of nd rib. on arrival patient was conscious, with systolic blood pressure mmhg and heart rate bpm. extremities were pale, cold. jugular veins distended. investigation/results: fast scan was negative. chest radiograph revealed a metal foreign body with the size of mm at the projection of heart. a ct scan of chest and abdomen demonstrated bullet inside the dorsal wall of the left ventricle and blood in pericardium and left pleural cavity (figs. , ) . therapy and progression: patient was taken to the operation room for median sternotomy. due to severe deterioration of patient's condition, ml of blood was aspirated from the pericardium prior to sternotomy. during subsequent pericardiotomy ml of blood was evacuated. main pulmonary artery wall gunshot injury was detected above the pulmonary valve. the wound was sutured, after which the hemodynamics stabilized. cardiac surgeon was consulted about the air gun bullet inside the myocardium. it was decided that removal of the bullet is not indicated. the patient was observed in the icu for the next h, later transferred to the thoracic surgery ward. the postoperative course was uneventful. an echocardiogram demonstrated a perforation of the anterior leaflet of mitral valve with a mild to moderate regurgitation, otherwise no abnormalities. patient was discharged on day . patient has been followed up on an annual basis for the last years. patient's exercise tolerance and cardiac function according to repeated echocardiography remains unchanged with no evidence of dyskinesia or other abnormalities. bullet is retained in the same location (fig. ) . comments: this case illustrates a successful management of usually lethal injury of main pulmonary artery and reflects that retained myocardial foreign body does not necessarily cause any complications. profile of penetrating chest injuries in hostile environment: a three year study introduction: penetrating chest injuries are one of the leading causes of death and major morbidity in operations involving high energy weapon systems. this study aimed at assess the profile of penetrating chest injuries suffered during armed combat operations in a hostile environment over a three year period. material and methods: a retrospective and prospective, non-randomized study designed to assess the profile of chest injuries in armed combat operations over years. all patients with penetrating chest injuries were included in the study. results: there were trauma cases out of which patients suffered penetrating chest injuries. the age range of patients was - years and all were male. a total of casualties were brought dead ( . %). there were lung injuries and two diaphragmatic injuries. thoracotomy was required in patients ( . %) and intercostal chest drainage (icd) in patients ( . %). average blood loss was ml and duration of hospital stay ranged from to days. conclusions: ballistic injuries to the chest are frequently fatal due to injuries to the heart, major vessels and tracheobronchial tree. prompt and efficient pre hospital treatment, expedient evacuation to a surgical facility and swift management by critical care specialists and surgeons can be instrumental in reducing mortality and morbidity. the cornerstone of management is bedside intercostal chest drain insertion as a formal thoracotomy is seldom needed. penetrating chest injuries can be managed by general surgeons with training in thoracotomy and repair of intra-thoracic structures does the number of a-or low symptomatic but intervention requiring complications justify regularly chest x-ray controls after less than rib fractures? c. deininger , , f. wichlas , , s. deininger , v. hofmann , university hospital of salzburg, orthopedics and traumatology, salzburg, austria, universitätsklinikum salzburg, klinik für orthopädie und traumatologie, salzburg, austria, universitätsklinikum salzburg, universitätsklinik für urologie und andrologie, salzburg, austria introduction: fractures of less than ribs may still cause delayed complications ( ) . the aim of this retrospective study is to determine whether standardized control imaging in a-or low symptomatic patients reveals a significant number of intervention requiring complications and therefor should be recommended. material and methods: all patients with less than rib fractures presenting in our emergency department after any trauma mechanism in the study period of years ( - ) and available for follow up were included retrospectively in the study. results: we included patients in this study, ( . %) of which were male, female ( . %), with a median age of . ± . years. in patients ( . %) rib was affected, in patients ( . %) , the fractured ribs being true ribs ( - ) in cases ( . %), false ribs ( - ) in cases ( . %) and both in cases ( . %). the affected thorax half was the left side in cases ( . %), the right side in cases ( . %) and both thorax halves in cases ( . %). the trauma mechanisms were falls at home, traffic accidents, sporting accidents, work accidents, fighting related and minor trauma in ( . %), ( . %), ( . %), ( . %), ( . %) and ( . %) cases, respectively. the median follow up time was ± days. patients ( . %) required delayed intervention: case of hemopneumothorax and cases of pneumothorax all treated with chest tube. conclusions: planned chest x-ray controls seem not to be necessary. symptom triggered reappearance for patients after rib fractures in hospitals seems to be sufficient and more economical compared to regularly re-imaging ( ) is computed tomography a first line modality in stable blunt chest trauma elderly patients? a. becker , , y. berlin , , d. hershko , emek medical center, department of surgery a, afula, israel, technion-israel institute of technology, haifa, israel, emek medical center, surgery, afula, israel introduction: adult older, patients aged [ years, represent up to - % of all trauma patients admitted to the trauma centers. chest trauma in older patients have been recognized to strongly influence mortality. the estimated of % mortality and pneumonia rate for these patients was observed ( , ) . based on low diagnostic accuracy of cxr, interpretation difficulties due to aging chest wall deformities, we hypothesized that ct chest should be the first imaging modality in stable elderly blunt chest trauma patients. patients and methods a retrospective analysis of all blunt trauma admissions at emek medical center between - years was performed in order to identify patients with blunt chest trauma. only stable trauma patients with abbreviated injury score (ais). results: among patients that met inclusion criteria, there were ( %) patients aged - years old and ( %) patients aged c . in the first group of patients ( - ), had ct chest on arrival. in the second group of patients (aged c ), there were ( . %) patients with missed injuries. in this group, patients who had ct chest on arrival, of ( . %) patients had missed injuries. eleven of ( %) patients who had no ct chest on arrival, diagnosed with missed injuries (p- . ). readmission rate in the first group of patients ( - ) was of ( %) who had ct chest on arrival, and of ( %) who had cxr on arrival only (p- . ). in the second group (c ), readmission rate was of ( . %) patients with ct chest on arrival, and of who had cxr on arrival only ( %) (p- . ). conclusions: based on our study result we conclude that ct chest should be a first imaging tool in stable elderly patients with blunt chest trauma. no disclosures. efficacy and safety of small-bored tube thoracotomy for chest trauma: large-bored chest tubes will no longer be needed introduction: tube thoracostomy drainage is an important treatment for traumatic pneumothorax and hemothorax. traditionally, largebored chest tubes have been recommended for successful drainage and prevention for clogging by clots. however, there is little evidence that large-bored tubes are more effective than smaller ones. in consideration of invasiveness, in our emergency room (er), we use fr chest tube for all trauma patients when chest thoracotomy is indicated. the aim of our study is to investigate the efficacy and safety of small-bored tubes for chest trauma patients. material and methods: we conducted a retrospective observational study. we included the adult patients ([ years old) who had undergone tube thoracostomy with fr chest tubes for chest trauma during the years from october to september in our er. the patients with cardiopulmonary arrest on contact or on arrival were excluded. we evaluated tube-size related complications defined as obstruction and worsening of pneumothorax/hemothorax due to ineffective drainage. results: there were eligible patients, % were male, mean age was . and the average injury severity score was . (± . ). sixty-six tube thoracostomies were performed by emergency physicians and were performed by thoracic surgeons. the average duration of tube placement was . days (± . ). there were not any tube-size related complications nor any patients who required additional tube insertion. case history, clinical findings: different stable hemodynamic cases with thoracoabdominal penetrating trauma and negative fast evaluation were enrolled in study. subsequent hemo/pneumothorax was managed initially by tube thoracostomy. investigation/results: hence laparoscopic investigation is an effective method for evaluation of diaphragmatic injuries in thoracoabdominal penetrating trauma, patients underwent diagnostic laparoscopy. in case , classic approach was done by open technique mm port insertion in sub umbilical. two mm ports inserted in lower abdomen at the level of midclavicular line. then mm port was added in subxiphoid area and by introducing zero-degree camera through it a better exposure was obtained. in case , mm sub umbilical port, mm port in subxiphoid and another mm working port at the level of umbilicus and right midclavicular line were applied. a -degree camera used. exposure, working space and exploration maneuvers were much easier to perform in compare with case . in case , port placement was identical to case but zerodegree camera was used. due to poor exposure, subxiphoid port was replaced by a mm one and used for camera insertion, then an acceptable exposure was obtained. in case , port placement of case was used by using -degree camera which resulted in a great exposure. diagnosis, therapy, progressions: patients tolerated the operation well and underwent appropriate management according to their intra operation findings; post-op courses passed without any complications. comments: in patients with suspicious diaphragmatic injury and according to available facilities in our centers, in unilateral injuries we suggest that a mm port in subxiphoid area can be used instead of contralateral midclavicular mm port. in bilateral injuries, if enough exposure doesn't achieve, a mm port in subxiphoid can be added. in absence of degree cameras, mm port use in subxiphoid can give surgeons better exposure. hemodynamic instability in patients with extremity injuries: motor vehicle accidents and shot wounds vs. explosions a. mahamid , i. ashkenazi hillel yaffe medical center, hadera, israel introduction: we previously reported that hemorrhagic instability (hs) was a complication of extremity injuries in as many as of of patients treated in one medical center following explosions. the objective of this study was to evaluate whether the prevalence of hs in patients with other high energetic injuries such as motor vehicle accidents and shot wounds (mva/sw) is different or not. material and methods: victims following mva/sw with extremity injuries and hs treated in one medical center during were identified with the aid of the national trauma registry and the center's blood bank. hs was defined as tachycardia (pulse [ /min) and/or hypotension (systolic pressure \ mmhg) in need of blood transfusions to reverse instability. patients in whom hs could be attributed to injuries other than the extremity injury were excluded. these were compared to patients treated following bomb explosions ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) conclusions: the proportion of patients in need of blood transfusion is much higher in patients whose extremity injury was caused by an explosion. the relative risk for hs is almost times higher in these patients. new technologies in soft tissue wound management limit reconstruction complexity and enhance recovery introduction: large soft tissue losses are associated with infection, increased morbidity and mortality, increased costs and poor outcome functionality. the purpose of this study was to evaluate the efficacy of a combination treatment of combined topclosure Ò tension relief system (trs) and administration of regulated oxygen and antibiotic irrigation negative pressure-assisted wound therapy (roi-npt) in the treatment of patients suffering from significant soft tissue loss. patients with open abdomen, large infected wounds, and extensive soft tissue loss treated with trs and roi-npt. results: full wound closure was achieved in [ patients treated without skin grafts or flaps. primary failure was successfully followed with secondary closure with the same system. the trs system allowed early postoperative physiotherapy with good to excellent functional results. limitations and complications will be discussed. . trs is a novel device for stretching, and securing wound closure, applying stress relaxation and mechanical creep for primary closure of large skin defects that otherwise would have required closure by skin grafts, flaps or tissue expanders. . irrigation may accelerate the evacuation of infectious material from the wound and may provide a novel method for antibiotic administration. . supplemental oxygen to the wound reverses reduced o levels in the wound's atmosphere inherent to the conventional negative pressure-assisted wound therapy restricting vacuum use in anaerobic contamination. moris topaz is the inventor and patent holder of the topclosure Ò and vcarea Ò . attendees' perceptions about tourniquet safety use aboard, easiness of application, and preference among four devices tested assessed. material and methods: the descriptive study design assessed employing a post-seminar survey, participants' perceptions of tourniquet safety use, application easiness, and preference among the four devices tested (cat, sam-xt, swat-t, and rats). the first two variables measured on a one-to-ten scale (being ten the easiest or safest, and one the least easy or least safe), while preference was measured by frequency count, with only one device to select as the preferred. frequencies and percentages for categorical variables and averages calculated and compared using the anova test (p \ . ). results: a total of sailors, ( %) females, and ( %) males, aged between and , participated in the workshop and completed the survey. the mean for the perception of safety regarding onboard usage was . . as for application easiness, cat and sam-xt ranked equally high ( . ), followed by swat ( . ) and rats ( . ), and the only statistical difference found was for rats (p \ . ). cat was reported as preferred by participants ( %), followed by sam-xt ( %), swat-t ( %), and rats ( %). conclusions: jse crewmembers (non-medical personnel) considered safe the use of tourniquets on board. of the four devices assessed, cat and sam-xt were regarded as equally easy to use and rats the least of all. cat was reported as preferred by almost three out of every four respondents. introduction: surge capacity is the ability to manage the increased influx of critically ill or injured patients during suddenly onset crisis, like a mass-casualty incident (mci) or disaster. during such an event all ordinary resources are activated and used in a systematic, structured and planned way. there are, however, situations where conventional healthcare means are insufficient and additional resources must be summoned. this study investigates the possibility of using community resources such as primary health care centers, nonmedical professionals and non-standardized facilities together with educational initiatives to increase surge capacity in a flexible manner. purpose: to investigate the possibility of an increased and flexible surge capacity during a crisis, disaster or mass casualty incident (mci) by examining the main components of surge capacity (sc) (staff, stuff, structure, and system) in the västragötaland region of sweden. method: this thesis uses a mixed methods research approach with an explanatory sequential design. a literature search was performed by using standard search engines utilizing relevant keywords, questionnaires and semistructured interviews were used for data collection from primary health care centers, dental and veterinary clinics, schools, hotels and sports facilities to determine capabilities, barriers, limitations and interest to be included in a flexible surge capacity system. results: preliminary findings indicate that there is interest, capacity and capability in the investigated municipalities to partake in a fscplan: primary healthcare centers can be toned up with drills and exercises, civilians can be educated in advanced first aid procedures (immediate responders) and focused leadership (scene management), schools, hotels and sports facilities can be prepared with advanced first aids kits and be used as alternative care facilities. these alternatives together represent the concept of flexible surge capacity. conclusion: flexible surge capacity can be a possible approach to create extra resources in disaster situations, mci's, or whenever supporting infrastructure is not intact. new educational initiatives, drills and exercises, laymen empowerment and organizational and legal changes might be needed to realize a flexible surge capacity. introduction: a hospital may need partial or total evacuation because of internal or external incidents, such as in natural disasters and or armed conflicts. an evacuation aims either to transport a large number of patients to other medical facilities or to prepare enough space to receive a large number of victims. despite many publications and reports on successful and unsuccessful evacuations, and lessons learned, there is still no standardized guide for such an evacuation, and many hospitals lack the proper preparedness. we aimed to analyze the preparedness of hospitals for a total evacuation by looking into some key parameters necessary for a successful performance. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. eleven questions were sent to representatives from euand non-eu countries. results: our findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the eu or other non-eu countries included in this study. some countries did not respond to our questions due to the lack of relevant guidelines, instructions, or time. conclusions: hospitals are exposed to internal and external incidents and require an adequate evacuation plan. there is a need for a multinational collaboration, specifically within the eu, to establish a standardized evacuation plan. references: nero c, Ö rtenwall p, khorram-manesh a. hospital evacuation; planning, assessment, performance and evaluation. j acute dis. ; ( ): - . introduction: the importance of and the need for medical management during any armed conflict is a fact. many medical achievements have been accomplished due to wars and armed conflicts. the world is, however, divided into countries with and without related military healthcare services. there is a need for joint structure with the civilian in the former, while in the latter the civilian healthcare is responsible for offering services to the military. this study aims to identify the needs of military healthcare system and military medicine as an independent specialty. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. relevant professionals were asked about the pros and cons of having established military healthcare. the data was collected and analyzed. results: although our findings indicate a need for military medicine/ healthcare as a professional specialty, the organizational divisions between military and civilian healthcare systems seems to be changing. the current security issues worldwide, the pattern of injuries and resource scarcity indicates a need for improved collaboration and maybe a fusion between these entities. conclusions: new security threats, modern technology, the pattern of medical injuries, and the lack of adequate surge capacity may indicate a very close collaboration between military and civilian healthcare systems. such a close collaboration may develop to fusion and a total defense healthcare system that can act both in peace and during conflicts. references: ringel js. the elasticity of demand for health care. a review of the literature and its application to the military health system. https://apps.dtic.mil/docs/citations/ada khorram-manesh, a. facilitators and constrainers of civilian-military collaboration: the swedish perspectives. eur j trauma emerg surg. . https://doi.org/ . /s - - - . alternative methods of mandibular comminuted fracture fixation in severe maxillofacial injured patients introduction: severe maxillofacial injuries refer to significant facial trauma with communitive bony fractures and soft tissue loss. they result in violent trauma as firearm injuries (wartimes injuries, terrorist attack, suicide attempt) and high velocity motor vehicle accidents. the initial management consist of fighting hemorrhage, fighting asphyxia, wounds debridement and suture, and fractures stabilization, especially mandibular fracture stabilization. our study aims to share thoughts on the alternative methods of comminuted mandibular fracture fixation within the context: kind of injury, multitrauma patients, mass-casualty situation, precarious situation or hostile environment. material and methods: based on our experience (clinical cases), on senior surgeons questioning and on medical literature data, we sought to identify, to evaluate and to compare the different available methods to stabilize comminuted mandibular fractures in severe facial injured patients. results: open reduction and stable internal fixation (using macro plate), external pin fixation and closed reduction with maxillomandibular fixation are the methods of treatment which are the most classically used and described. however, some methods using kirschner wires are reported: in cross extrafocal pinning ( fig. ) , external fixation and handmade splints. all these methods differ in their complexity of use, in their availability, and in their possibilities to treat one kind of mandibular fracture or another. conclusions: the stabilization method of comminuted mandibular fracture will be choose depending on material availability, on surgeon's abilities, on the time available (mass-casualty situation) and on the patient's overall condition. even if stabilization methods using wires are less commonly used, they appear to us to be useful in the initial management of the severe maxillofacial injured patient with comminuted mandibular fracture, especially in austere conditions. causes of combat casualties' death at medical treatment facilities (mtf) in modern conflicts: russian experience i. samokhvalov , v. badalov , k. golovko , t. suprun , v. chupriaev material and methods: data including mechanism of injury, physiologic and laboratory variables, staged surgical treatment and cause of death were obtained from the combat trauma registry of the kirov military medical academy war surgery department. the combat trauma registry includes russian wounded in military conflicts over the past decades, of them ( . %) dead of wounds (dow) at the mtf. results: . % of the total dow number died at the role ii field medical units, . % died at the forward military role iii hospitals, and . % died at the role iv hospitals. the causes of dow patients delivered to the mtf were nonsurvivable traumatic brain wound ( . %), life-threatening consequences of injuries-mainly massive blood loss due to external and internal bleeding and acute respiratory failure ( . %), as well as the late septic complications ( . %). terms of death depended on the cause of dow. so for nonsurvivable traumatic brain injuries, they amounted to . ± . days, for lifethreatening consequences of wounds- . ± . days, and in the development of complications- . ± . days. conclusions: there is a high mortality rate among the combat casualties delivered to mtf in modern asymmetric warfare ( . %). moreover, half of these patients ( . %) die at role ii field medical units mostly from nonsurvivable injuries and from acute irreversible blood loss that occurred at the prehospital stage. the main cause of hospital combat mortality is severe septic complications of combat trauma. in consideration of the present counterterrorism practices, prevention and initial treatment for primary blast injury by shock waves constitute a particularly urgent subject because blast injuries and gunshot wounds account for the majority of terrorism deaths. in japan, due to strict ethical standards in animal experiments, there is no appropriate animal model of blast injury. we established an original small animal model of blast injury using a laser-induced shock wave at the national defense medical college (ndmc). however, since the experiments were conducted using only small animals, such as mice and rats, it was necessary to establish a medium-sized animal model aimed to test the applicability in human patients in the long term. correspondingly, we established a blast tube, which was authorized globally as a shock wave-generating device that causes blast injury based on air pressure differences, in the ndmc research institute using the budget of advanced research on military medicine of japan in . this allowed us to conduct scientific studies on blast injury using mediumsized animals. in this presentation, we will introduce the structure and function of the blast tube installed in the ndmc and present some of the results of our research thus far. this research is financially unfortunately, even if hospital and their staff are an essential key for successful response to mcis, the plan are seldom well-known and, above all, exercises are quite neglected at local and national levels. due to mci rarity, simulation exercises are the only way to achieve proficiency in mci response. therefore, we tested an original mci training system (macsim Ò ) adapted to the pemaf of a large university hospital in milan (italy). material and methods: the original mci training format called macsim-pemaf (emergency plan for massive influx of casualties)was developed for the italian society for trauma and emergency surgery (sicut) in . it uses macsim Ò , a simulation tool scientifically validated for training and assessment of healthcare professionals in mci management. between and the course was held for the emergency department staff of a single university hospital of milan (italy) (foundation cà granda-ospedale maggiore policlinico). macsim Ò was used to reproduce the hospital resources, with different mci scenarios. during the simulation the participants had the opportunity to test the local pemaf, in adjunct to their knowledge and skills. course effectiveness was evaluated by a pre-and post-course self-assessment questionnaire. results: macsim-pemaf was tested in seven courses, for a total of participants. pre-and post-test questionnaires showed a significant improvement in hospital staff self-perception of knowledge and skills in mci management. on a - scale, the improvement value was from . ± . to . ± . (p \ . ). conclusions: macsim-pemaf is a useful tool to test single hospital pemaf. it is versatile enough to adapt to specific realties, mimicking different traumatic scenarios. participants, acting in their usual professional roles, can increase their self-perception to be able to respond to a mci with in-hospital resources. introduction: emt are field health facilities, specifically structured to operate in case of disaster, where local healthcare resources are insufficient. there are types of emt. ''emt regione piemonte'' is the first italian emt to be certificated by who. it's a type , meaning that more than triage and stabilization of emergency cases it's provided with an icu, a / working operation room, a test lab, radiological and ultrasound devices. it can admit up to inpatients. cyclone idai made landfall on / / in the district of dondo in mozambique. it brought torrential rains and strong winds and had heavy impacts on the city of beira and surrounding areas resulting in loss of communication and access. in addition important damage and destruction to shelter, settlements, health and wash facilities occurred. on / italian government approved the aid mission, from march st to th three italian military aircraft transported the medical staff and the boxes containing the hospital to maputo and then in beira. on / , the hospital began working, treating an average of patients and performing - surgeries per day, involving mozambican staff who immediately well integrated with the italian colleagues. results: days of activities. surgeries ( orthopaedic, general surgery, gynaecology, plastic surgery). . % of the cases related to cyclone. mean tiss: ( - ). mean age ( - ) females, males. types of anaesthesia: % locoregional, % general, % analgosedation. conclusions: our first experience in a mass casualties' scenario showed how important is to refresh team skills through periodic drills. the leadership is of paramount importance to keep the team united and to support collaboration with other nations' teams and with the local population. adaptability and open-mindedness are fundamental. emts do not arrive in loco immediately so that longer periods of mission and integration with local medical staffs should be programmed. introduction: in utrecht, the netherlands, a worldwide unique major incident hospital is continuously standby to receive multiple victims during mass casualty events. each year, different types of mass casualty events are simulated with a varying number of victims, to train command and control under extreme circumstances. in utrecht, on march th , a terrorist opened gunshot fire in crowded public transport. the aim of the study is to compare our experiences in simulation versus reality. material and methods: an internal evaluation was performed by questionnaires completed by participants and an external evaluation was performed by interviews. results: all five victims were brought to the major incident hospital, of whom two were dead on arrival, one died seven days after due to multiple organ failure and two survived after multiple surgical procedures. all victims arrived within min after the major incident hospital was activated. a sufficient number of medical staff was alarmed for these five victims, however, since the event occurred during office hours, at least a double amount of staff showed up. among some medical staff on commanding key positions fear arose about their own safety and of relatives outside the hospital. this was exaggerated by incomplete and incorrect provided information from the scene. although medical care of the victims was not affected at all, occasionally the anxiety negatively influenced the command and control structure. conclusions: the combination of anxiety and a surplus of awaiting and benevolent curious medical staff resulted in occasional insufficient performance of the existing command and control structure, despite proper training. however, simulation of fear in a training is very difficult. nowadays, with the increasing threat of terror attacks, one should be aware of the influence of fear and anxiety on personnel, even with low numbers of victims. ethic and law issues during mass casualties management operations in foreign countries introduction: mass casualties incidents occur even more frequently during the last years globally. international help in order to manage them, when needed and asked, has to take into consideration special aspects of ethics and local law status in order to successfully fulfill its expectation. purpose: to demonstrate the ethic and law issues that arise during mass casualties management operations in foreign countries. material and method: literature review from recent management operations in syria, iran and sub saharan africa. results: during such operations a lot of ethical and law issues arise. the knowledge of ethics and laws in the country that these take place is essential and critical for the successful result of them. special care must be taken for the management of women, children and dead people. traditions and religion status of the local populations also must be taken into consideration and actions must take place in accordance to respect of the local authorities and social conditions. conclusions: mass casualties management operations in foreign countries is a challenging mission. ethic and law issues arise and must be taken into consideration for the success of the mission. western surgical experience is one thing, but surgical practice in countries in conflict zones is another. the pathologies are different, the thermal conditions are often difficult and the follow-up of the patients is fundamentally modified. humanitarian surgery is becoming more professional and most organizations are setting up a training program for new surgeons embarking on the humanitarian adventure. international committee of the red cross (icrc) has implemented an onboarding-surgeon experience, before to become a fully icrc surgeon. i hereby present my personal onboarding experience in south sudan: how to learn a new type of surgery, how to come with an helicopter to collect patients in the bush and then, how much you learn about yourself. conflict of interest: i only represent my own experience and i do not represent icrc. surgical clinical reasoning during the war in the period between and , i was the head of operating rooms and icu at the clinic for orthopedic surgery and traumatology, in sarajevo. working in the operating room whose walls are shaking because of the sniping and shelling was not remembered by any other generation of surgeons. there were around traumatized citizens of sarajevo. thousands of injured, dying patients were seeking for help from a small number of surgeons. the duty of a surgeon working in the war conditions, without water, electricity, medicines, or heat, is not easy at all, and there were a lot of difficult situations. for example, one day, operated children were again wounded by direct shelling on the walls of pediatric department of our clinic. after we re-operated the children, we also operated the injured nurses. th may, , th february, , and th august, were the most painful experiences in the surgical treatment of disaster in the center of sarajevo, with a large number of massively traumatized patients. while you were helping one casualty, others were pulling our arms or legs. while you were helping one patient, others were dying in the cramp of pain. during the war, a series of traumatic events happened. above many thousands of them, i admitted a -year-old girl, severely injured, with traumatic lower leg amputation of the leg, and severe injuries of the thigh, pelvis, and neck. we operated on her through the night. during the surgery, she received whole blood transfusions. following the surgery, she was stabilized on pediatric department of our clinic. one day, i saw her mother brought her a gift, immensely valuable in those days, a small canister of pure water. in the , one girl approached me, and asked me if i remembered her. i remembered the canister of pure water. she was happy to show me how she can walk now, and told me she lives in canada and works as a university assistant. i was more than happy to see her walk proudly, as she was leaving. she injury pattern of earthquake in athens, greece: the panic-effect introduction: earthquakes are devastating events. greece is known to be in the first place of seismicity in europe and sixth worldwide. lately, a . richter earthquake shook the greek capital, and fortunately no substantial construction damage was sustained. the aim of the study is to evaluate the classification and severity of all injuries, as well as the type of orthopedic surgical procedures performed, in addition to the role that panic plays on the occurrence of these kind of trauma material and methods: prospective case-series study, conducted in the emergency department of our hospital after the july th, earthquake. the study included patients treated by our department, who sustained injuries in their attempt to run away from the scene. age range was from to years old (mean . y.o), were female and were male. results: a total of injuries reviewed. upper extremities were involved in of all cases, lower extremities in and one patient suffered minor head trauma. four patients required hospitalization and all of them underwent surgical treatment. open reduction and internal fixation performed in patients ( calcaneus fracture and olecranon fracture), patient underwent intramedullary nail fixation (tibial shaft fracture) and external fixation was applied to another (distal tibia fracture). six patients were conclusions: panic is an independent contributing factor in natural disaster associated trauma. prior education, preparedness and combined team effort are clearly needed, in order to reduce the incidence of these injuries. regardless of age, panic may result in various types of fractures, even in cases there are no substantial construction damages after an earthquake. digital and analogue record system for mass casualty incidences at sea: results, reliability and validity introduction: mistriage may have serious consequences for patients in mass causality incidences (mci) at sea. therefore, an exercise was conducted to compare the reliability and validity of an analogue and tablet based recording system for triage of sample patients. material and methods: volunteers were asked to triage with the start-algorithm (black, red, yellow and green) patients in a given time using an analogue and tablet based system. triage score distribution and agreement between the two triage methods and a predefined standard were reported. the present study assessed the triage results as well as the reliability through cronbachs alpha and kappa. for testing of validity and internal consistency, the sensitivity, specificity and predictive value was measured. results: forty-eight participants completed a total of triages. while the number of triaged patients in the given time was significantly higher with the analogue system compared to the digital system (p-value . , t-test), the validity measured with the cronbachs alpha and unweighted cohens kappa was higher with the digital system. for each triage category, higher values were gained with the digital system. the sensitivity, specificity and predictive value for the digital system was higher than for the analogue system. conclusions: this study gives reliable and valid results comparing a digital versus an analogue triage system for a mci at sea. significant differences could be found for the number of triages and the number of under triage. the results of the study show that the used digital system has a slightly higher reliability and validity than the analogue triage system. references: the present work is part of the project improved emergency treatment and organization in the event of a mass casualty of casualties at sea (venomas), planned within the framework of the research network ''kompetenz und organisation für den massenanfall von patienten in der seeschifffahrt'' (kompass) and funded by the federal ministry of education and research (grant number: n ). predicting outcome for extremity wounds in pediatric casualties of war introduction: during the early s, the international committee of the red cross (icrc) implemented the red cross wound classification (rcwc) for penetrating wounds. wound grades of , and describe the amount of kinetic energy transferred to the tissue (low, high and massive, respectively). currently, this classification system mostly serves as a descriptive tool, but it is hypothesized it could also support clinical decision making. the aim of this study is to assess whether the wound grade of a pediatric patient's extremity wound correlates with patient outcomes. material and methods: this study included pediatric patients (age \ years), who have been treated by the icrc for conflictrelated extremity injuries between and . the correlation of the following variables with the wound grade were analyzed: number of surgeries required, length of stay, and in-hospital mortality. results: the study cohort consisted of pediatric patients. the higher the wound grade, the more surgeries were performed per patient (p \ . ), with a mean of surgeries per patient if they had a wound grading of . there were no significant differences in mortality rates between any of the wound grades, which were . % ( / ), . % ( / ) and . % ( / ) for wound grade , and respectively. pediatric patients with wound grade were hospitalized for the longest period (mean . days), followed by wound grade (mean . days) and wound grade (mean . days; all with p \ . ). conclusions: the wound grade of pediatric patients' extremity wounds appears to correlate with some patient outcomes, but not with mortality. grading of extremity wounds according to the rcws could support clinical decision making in pediatric patients. introduction: during the last few decades, french armed forces have regularly deployed in asymmetric conflicts. surgical support for casualties of these conflicts occurs in nato role and medical treatment facilities (mtf); definitive surgical care occurs in france following a strategic medical evacuation. the aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or non-exclusively brain injuries. material and methods: this descriptive study is a retrospective analysis of the surgical management of french casualties performed in role or mtf in afghanistan, mali, niger, djibouti and the central african republic between january and december . results: one hundred patients were included. forty had fragment wounds. the most severe lesions were of the head, neck or thorax. the average injury severity score (iss) was . (ic % . - ). damage control procedures were performed. thirty patients died with a mean iss of (ic % - ); deaths were considered as preventable deaths. the most frequent surgical procedures in the mtf were digestive (n = ) and thoracic surgery (n = ). thirty patients needed second-look surgery in france; eleven had severe complications. no patient died following medical evacuation to france. conclusions: results from this study indicate that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. introduction: telemedicine has been applied to disasters and extreme environments for more than years, however, despite the many lessons learned so far, telemedicine is still not a common part of the immediate disaster response. for this reason, a review of the literature was conducted to investigate whether telemedicine technology can be used to address medical and non-medical needs in extreme environments. material and methods: this systematic review included studies published in the period - , originating from literature search bases medline, scopus, cinahl and pubmed. the case of neemo project were studied so to evaluate the diagnostical and surgical care of the patients regarding the emergency response in a remote and constricted area, with limited human medical resources and using the telecommunications and telerobotic technologies. results: the majority of the included studies have highlighted the importance of telemedicine interventions in extreme environments, stressing that it is a viable solution to health care provision. in addition, it has been found that telemedicinal technology provides the possibility of virtual collaboration between healthcare professionals with various specializations. projects neemo , , engaged to eliminate the challenges of telesurgery. conclusions: future studies such as large multicentre randomized trials will have to be conducted that will lead to safe conclusions on the usefulness and efficiency of telemedicine applications in extreme environments. introduction: tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage. the optimal tourniquet type and effectiveness of non-commercial devices is unclear, and the aim of this study. material and methods: this prospective observational cadaverbased study was performed using a perfused cadaver model with a standardized superficial femoral artery injury bleeding at ml/ min. five devices were tested: cat (combat application tourniquet), rats (rapid application tourniquet system), swat-t (stretch, wrap, and tuck tourniquet), a triangle bandage and a stick and a leather belt. volunteer medical students with no prior clinical tourniquet experience participated. each student underwent a practical hands-on demonstration of each of the tourniquets, prior to the test. using a random number generator, they then placed all tourniquets in random order. outcomes measures included time to hemostasis, total time to secure devices, estimated blood loss (ebl) and difficulty rating. a one-way anova repeated measures was used to compare efficacy between the tourniquets in achieving the outcomes. results: participants' mean age was ± . years and ( %) were male. all participants were able to stop the bleeding with of the tourniquets. with the rats there was a % failure rate. among the five types of tourniquets, time to hemostasis and ebl were not statistically significantly different (p [ . ). the swat-t required the longest time to be secured ( . ± . ), while the belt was the fastest ( . ± . ; p \ . ). conclusions: all five tourniquets, including the non-commercial devices, were effective in achieving hemostasis. a standard leather belt was the fastest to place and able to stop the bleeding. however, it required continuous pressure to maintain hemostasis. nevertheless, in an emergency setting where commercial devices are not available, improvised tourniquets may be an affective lifesaving bridge to definitive care. hospital preparedness for mass gathering events and mass casualty incidents in matera, european capital of culture for introduction: mass casualty incidents (mci) may occur during mass gathering events (mge). lack of preparedness of health system increases mortality. education and training are crucial. hospital mci plans are mandatory in italy, but they are poorly known. on , matera was declared italian host of european capital of culture for : the local hospital decided to revise the hospital plan for massive influx of injured (pemaf) and to start a program to train the staff. material and methods: the pemaf was reviewed through simulations that involved all the staff. a partnership with mrmi-italia (italian chapter of the international association medical response to major incident and disaster-mrmi&d) leaded to the support of experts and to the organization of residential courses based on the macsim Ò (mass casualty simulation) simulation tool. educational capacity of the residential events was tested through a self-assessment tool. results: alert, coordination and command sequences were defined. all the available resources were recorded and the functional areas identified. the communication network was improved. documentation and registration system was prepared. standard operational procedures (action cards) were created for the key positions. residential educational events of macsim-pemaf were organized. the educational capacity was tested through self-evaluation: knowledge of participants resulted improved. conclusions: mge are a great opportunity for the hosting community but they also represent an increased risk of mci. preparedness is mandatory for health system. the format macsim-pemaf seems to be adequate to review the existing plans and transfer skills to attendants. introduction: the cruise industry is facing a constantly growth of infectious diseases. some of them are reaching the extent of mass casualty incidences (mci), which are overwhelming the capacity of the local rescue system. our aim was to improve the ability to act in a mci due to an infectious emergency regarding the situation at sea/in the port. hamburg, as one of the largest ports in europe, was chosen for analysis. material and methods: the collaborative project ''adaptive resilience management in the port'' (armihn) is funded by the german federal ministry of education and research. scenarios due to an infectiological emergency were developed together with the university central department of occupational medicine and maritime medicine and the hamburg port health center in hamburg, germany. these scenarios were specified with all key stakeholders in the port. the organizational structure of the current emergency management was analyzed and a new concept was developed. results: for the ship and the port, emergency strategies dealing with mass casualties of injured persons are available. nevertheless, current concepts regarding this special situation of an infectiological mci were missing. we developed a new concept, which based on the models concerning mass casualties of injured persons. for this purpose, emergency surgeons can be recommended as experts regarding coping with a major emergency and for developing adaptive training concepts. conclusions: new operational concepts coping with mci of infectious patients were developed. in a second step, an emergency plan and a training concept for relevant stakeholders in the port will be developed. these will be evaluated in a full exercise in the port of hamburg and tested for their suitability. the results will be transferred to comparable infrastructures to cope with a major case incident with infected people in the port area. emergency surgeons should be involved in these steps due to their expertise. the work was funded by the german federal ministry of education and research ( n ). no further significant relationships. war surgery training, the use of swine model in military simulation center introduction: due to the international instability, our forces are deployed in many place and our military surgeons have to deal with ballistics trauma and improvised explosive devices related trauma. in order to be well prepared and effective in these isolated situation, the val de grace school (our military health service academy) provide a years course to train the young surgeon. this year surgical courses ended with war trauma surgery simulation on a swine model. material and methods: this use of the swine alive model is incorporated in the cesimco (military surgical simulation center) and also use for the training of our fully registered surgical team. this laboratory responds to all civilian authorizations and ethical considerations as enacted by european rules (felasa). results: the aim of this presentation is to show the different procedures and the teaching provided in this structure to improve surgical skills in war condition. all procedures are approved by the ministry in charge of the animal experimentation and respond to the animal welfare regulation. the number of swine used in these teaching is reduced to the minimum. we think that this animal model and its use in military forward surgical facilities, is the end point of the years military surgical course provided by the val de grace school. conclusions: this model is actually the most reliable and ethically acceptable teaching procedure we've found. during these teaching the students have to deal with open trauma and hemorrhagic lesions in damage control situation. we try to follow the different type of war related lesions observed in french military in order to stick to the reality of the field. this teaching is now mandatory before being deployed as a military surgeon on field. case history: -year-old male, previously healthy, admitted to the er due to shotgun injury to the right hip. during transport, the bleeding open wound was covered, two iv catheters were introduced, and saline and painkillers were administered. on admission, the patient was conscious, eupneic and normotensive, with a gcs score of . clinical findings: after the primary survey and exclusion of cranial, thoracic and abdominal lesions, the limb injury was addressed, showing a cm oval-shaped wound. the right leg was shortened and externally rotated. pulses were present but the patient referred calf and foot hypoesthesia. investigation/results: x-rays showed a comminuted pertrochanteric fracture and the presence of metallic foreign bodies. diagnosis: open right pertrochanteric fracture. therapy and progressions: initially, the wound was covered, and iv antibiotics and supportive therapy were given. in the or, irrigation, surgical debridement, and foreign body removal were performed, followed by orif with one dall-miles cable and a cephalomedullary femoral long nail. after surgery, the patient maintained lower limb hypoesthesia and had plantar flexion and foot dorsiflexion grade motor deficit. during follow-up, soft tissues recovered uneventfully and bone healing successfully occurred. full weight-bearing was tolerated at weeks post-op but the neurological deficits persisted despite physiatric treatment. electromyography confirmed severe partial lesion of the sciatic nerve. comments: generally, clean wound, fracture stability, restoration of circulation and skin closure of neurovascular structures are a priority and should be a reason for delayed nerve repair. introduction: despite mass casualty incidents (mci) are becoming a common concern, particularly regarding the care of paediatric victims, pure paediatric trauma centres (ptc) are still rare in europe. the purpose of this study is to assess the capacity of the hospitals in the metropolitan area of milan in case of mci involving the paediatric population, with focus on the pre-impact planning phase. material and methods: relevant literature and existing guidelines were reviewed by the representatives of four referral centres for the management of either trauma or paediatric patients. minimum standard requirements of care of paediatric trauma and consequently the maximal surge capacities for each hospital were defined based on the severity of injuries and personnel/equipment availability. results: overall, the four hospitals are able to treat patients with the highest priority (t ), to patients with intermediate priority (t ), and patients with deferrable priority (t ). severely injured patients \ years old should be preferentially transported to the hospitals with paediatric expertise, whereas patients between to years of age can be managed in multi-speciality structures. conclusions: in case of mci it is not always possible to rely on the availability of a ptc. hospitals with paediatric trauma care expertise can work in synergy with ptcs, or offer an alternative if there is no ptc, and should therefore be included in disaster plans for mci involving paediatric victims. case history: we present a case of a -year-old male with a proximal radius and ulna gunshot fracture associated with a complete lesion of the brachial artery, which was urgently repaired by grafting in his native country. a partial proximal radius excision was also performed. three months later, after soft tissue recovery, the ulna fracture was fixed with a dcp plate plus iliac crest bone graft. at months follow up x-rays showed hardware loosening, so the plate was removed and an external fixator was implanted. in this situation the patient attended to our clinic months after the initial injury. clinical findings: findings included proximal pin purulence, an elbow varus deformity and a limited joint motion: flexion °, extension °, supination/pronation °. investigation/results: x-rays and ct scan showed proximal ulna pseudoarthrosis. diagnosis: proximal ulna pseudoarthrosis after a gunshot fracture. therapy and progressions: a two-stage procedure was performed. initially we performed a wide debridement and external fixator removal. an ulna nail combined with gentamicin and vancomycin pmma spacer was implanted. s. aureus was identified in intraoperative cultures. in a second stage, year after, the nail and spacer were removed and a vascularized fibula graft with saphenous loop was implanted and fixed with a va-lcp plate. the central band of the interosseous membrane was repaired with a prosthetic device. currently, the patient presents full flexion range, hyperextension of °, active pronation of °and supination of °. x-rays show graft consolidation. comments: gunshot fractures are complicated lesions with significant soft tissue damage and high risk of vascular and nervous injury. a thorough study and initial systematic approach is mandatory in order to avoid later complications. introduction: the purpose of our study was to independently analyze pediatric trauma data, especially that of preschool-aged children, including demographics, injury patterns, the associated mechanism of injury, and outcomes, at a single institution in korea to gain a better understanding of current trends in non-regional trauma centers. material and methods: we conducted a retrospective review of preschool-aged children with trauma, who presented to the emergency department a single center between march and december . results: overall, there were pediatric patients who experienced trauma admitted during this study period. the frequency of admissions was similarly high in all seasons except winter. falls were the most common mechanism of injury at all ages, except , , and years of age, according to comparative analysis by age and mechanism. the most common place of trauma at - years of age was at home, and outside the home at the age of years or older. the most common injury region was to an extremity ( . %). mean injury severity score was ± . , and the mean hospital stay was . ± . days. conclusions: although mortality from trauma is low in pediatric patients, we must continue to improve treatment outcomes for children. it is unlikely for a hospital to have a pediatric trauma specialist, such as a pediatric orthopedic surgeon or plastic surgeon, due to manpower constraints. in order to further improve the outcome of treatment with insufficient resources, it is necessary to recognize agespecific characteristics. question: the new safety situation in europe and the lessons learnt civilian events of damage show that hospitals have to be prepared for mass casualties. the shift of the operational mode to ''emergency medicine'' have to be planed and practiced. the reporting tool for this is the hospital action plan (hap) that every hospital should have. the efficiency of the existing plan is already proven in different largescale exercises. in germany the legislator obligates the hospitals to enable there staff to properly perform the different tasks of the hap. in addition, the have to develop and evaluate proper training and exercises. goal of this study was to establish along the hap of a level one trauma center an modular mass casualty training (manv ) that would help to analyze the tasks to face and to deepen the existing structures of communication. method: we set a scenario with casualties and evolved the different shifting phases of the trauma center (alarming-, mobilization-, constitution phase). setting the concept of training outside the regular service period we took in account that there will be a lack of resources and material. we did not exercise in a large-scale but trained in small groups modular. we also did a screen adaption of the hap of the trauma center to have a mind set for the staff and a starting point to the scenario. to teach our operative procedure we simulated our '' columns concept'' (medical, personal and infrastructure) to the staff. specific to the different task groups (medical doctors, technicians, nurses) we exercised and the different sectors (er, triage, or, command etc.) and the necessary shifts of the different hospital sectors when a mass casualty occurs. before and after we did a query of the staff to see how much impact the modular exercise would have on the hap-knowledge of our staff. results: we were able to simulate realistically an identical mass casualty scenario to different staff groups of our hospital. knowledge about the hap increased significant from to % after the trainings. % of the staff see a clear improvement of information about the hap. also, the specific shifting-phases and the enrolment of the plan to move in an ''emergency medicine mode'' understand % better. % of the staff fell now a much better preparedness than before. % think that through modular exercises and small group training the communication in between working groups improved. conclusion: we could manage to improve a significant increase of knowledge about the hap in our staff. all the small group modular training in the different sector can be easily but together in large-scale exercise and other teams like police, military or fire-department can easily be added. introduction: dstc course focusses on surgical skills for trauma care. it is designed to teach surgical techniques for the definitive treatment of severe trauma. currently, it has evolved into an international trauma team course. our objective was to assess faculty members' opinion regarding course content, educational methods, and incorporation of non-technical skills. material and methods: a descriptive study was designed using an anonymous online survey issued from may to august , . senior international faculties' opinion from countries assessed. the survey inquired views of courses content, duration, adequacy of hands-on practice, need for updates, and usefulness of incorporating non-technical skills to the course. results: from the surveys issued, were ( %) answered. the course content was valued as very satisfactory by %; % were very satisfied or satisfied with courses educational method. % considered the time devoted to lectures, case discussions, and skills lab very adequate or adequate. course duration ( days) was valued suitably by % of responders. the inclusion of non-technical skills was considered as very important by %, important %, of some importance %, of little importance by %, and unimportant by %. this result reflects the insufficient sense of significance, among some, of the importance of trauma team dynamics. course content updates were seen as convenient by % of the surveyed population, suggesting them at least every - years. conclusions: dstc international faculty response to the online survey tool was inadequate, receiving % of the targeted study population. of the assessed faculty, most were satisfied with course content, duration, and educational methods. the surveyed population lacked a uniform perception of the importance of incorporating nontechnical skills. introduction: dstc is an iatsic course emphasizing on teaching surgical skills for trauma care. in many countries, it is an essential course focused on the ''second hour'' beyond atls and teamwork. initially centered on the surgeon, it currently seems to be adopting a trauma team training (ttt) model, incorporating the anesthetist to the program (ds-datc). our objective was to review this changing trend in three countries: spain, portugal, and brazil. material and methods: a descriptive study was designed by faculty from the three countries examining course records and analyzing its evolution during the last five years. number and types of courses delivered in each country from to reported, and the proportion of dstc to ds-datc scrutinized. frequencies and percentages calculated for categorical variables and the proportion of course types also determined. results: during the -year studied period, dstc courses were issued: ( %) in spain, ( %) in brazil, and ( %) in portugal. a total of ( %) ds-datc courses in the three countries, and the percentage of total delivered in each country was as follows; spain ( %), portugal ( %) and brazil ( %). overall ds-datc to dstc ratio was : , detailed as follows: portugal : , spain : , and introduction: thailand is a disaster-prone country with a high dependency on tourism. it has been affected by both natural and manmade emergencies. the thai emergency healthcare system consists of emergency physicians working at hospitals and prehospital levels, emphasizing their essential role in emergency management of any incident. we aimed to investigate the thai emergency physicians' level of preparedness by using tabletop simulation exercises and three different scenarios. material and methods: using the lc (three level collaboration) method, two training sessions were arranged for over thai emergency physicians, who were divided into three groups of prehospital, hospital, and incident command staff. three scenarios of a terror attack and explosion, riot and shooting, and high building fire were discussed in the groups. results: our findings indicate that the initial shortcomings in command and control, communication, coordination, and the ability of situation assessment increased in all groups step by step and after each scenario. new perspectives and innovative measures were presented by participants, which improved the whole management on the final day. conclusions: tabletop simulation exercises increase the ability, knowledge, and attitude of thai emergency physicians in managing major incidents in strategic, tactical, and operative managerial levels, and should be included in their professional curriculum. introduction: non-operative management of traumatic injuries has led to decreased surgical exposure for trauma trainees [ ] . while simulation using cadavers may improve exposure to damage control techniques, tissue handling realism is variable depending on embalmment and perfusion techniques [ ] . objective: to evaluate the feasibility of perfused thiel cadaver use for trauma surgery simulation. material and methods: thiel cadavers were cannulated in the ascending aorta and right atrium to create a left-to-right perfusion system. a magnetic pump was used to achieve a pulsatile flow with a gelatin-based solution, aiming for a flow of l/min. peripheral circulation was improved with arteriovenous fistulas (carotid-jugular, femoro-femoral and brachio-brachial). a left common iliac vein injury was performed laparoscopically through the sigmoid mesentery. the surgical trainee was blinded to the initial injury and assisted by a staff surgeon. results: a trauma laparotomy was performed. the small bowel was eviscerated and all four quadrants were packed with gauze. a left, expanding zone iii hematoma was detected. the left sigmoid colon was mobilized to achieve proximal control of the left iliac vessels. the left common iliac vein was actively bleeding and ligated according to damage control principles. the left ureter was uninjured. the sigmoid mesentery was closed, without active bleeding. the remaining of the abdominal cavity was explored without other injuries. time from laparotomy to closure was min. tissue handling and circulation dynamics were highly realistic due to thiel embalmment and pulsatile perfusion. conclusions: pulse-perfused thiel cadavers represent a realistic simulation option for surgical trainees. widespread implementation may provide accurate simulation for lifesaving procedures rarely performed in an era of non-operative management of traumatic injury. a new concept of intra-operative performance monitoring and self-assessment in hepato-pancreato-biliary surgery and other surgical specialties s. kharchenko , , m. yanovsky colmar civil hospital, university of strasbourg, department of general surgery, colmar, france, hepato-biliary institute henri bismuth, paris, france, interceg, kharkiv, ukraine introduction: currently, the majority of learning curve studies for surgical interventions associated with simple chronometric estimation in a whole: from incision to closure. a selective approach for step-bystep time fixation of all hpb interventions (hepatectomy, others) or other surgical specialties can bring a new vision of correlation between intra-operative timing and the clinical outcome. material and methods: every operation can be divided into step items so standardized worldwide, for example, planned or urgent laparoscopic cholecystectomy e.g. incision to port placement, exposure, dissection to cholangiography, cholangiography, extraction, closure. results: the prototype named chronoi of infrastructure for automated monitoring (simulator of time tracking activities, web-service for request processing, database and knowledge base collection subsystems, learning curve representative and analytics software) is designed and to be implemented. individual self-assessment is available in a real-time fashion. the learning curve changes are shown per procedure. up to our knowledge, we can firstly in the world describe the surgeons, incl. in hpb, as speedy, standard or nonstandard depending on the surgeon's ''individual speed'' in operative performance. it's to be documented in their e-logbooks according to the current fellowship standards or practice re-certification. conclusion: the intra-operative monitoring and worldwide standardization give a new vision of the surgical practice in hpb surgery meaning an introduction of monitoring-based clinical outcomes (timing with morbi-mortality or other). only new trials will approve the role of the presented concept in hpb surgery as well as in general, emergency and trauma. introduction: the management of patients victims of war weapons and collective emergencies represents a major public health issue in france, but also abroad. terrorist events in recent years on the national territory have highlighted the need for training the population and caregivers in the management of these injuries. because of his experiment in the domain, the french military medical service (fmms) was requested to cooperate with the french prehospital teams in order to improve knowledge and teaching in this area. today, a continuing medical education, easily available and free access is needed in this area. material and methods: development of video podcasts (infographics) of a few minutes on the theme of management of patients victims of war weapons and collective emergencies. the working group ensures the production and quality of educational messages. production is provided by the communication establishment of defense. the broadcast is displayed on the channel you tube of the fmms. results: the title of the traum'cast podcast is the contraction of trauma and podcast. twelve episodes are scheduled on a -weeks rhythm. the podcast program is as follows: conclusion: fmms knowledge and experiment in managing patients victims of war weapons is unique. teaching can take various forms, theoretical, practical, academic, or through publications. traum'cast is a major innovation in the dissemination of this knowledge and each episode focuses on a specific skill. traum'cast will highlight the applicability of military medicine concepts in a civilian environment. traum'cast will be translated in an english version. project was supported by grants of french ministry of defense (innovation department). splenectomy in current surgical practice: a tricky and elusive procedure for the surgical resident? introduction: splenic rupture and oncologic resections are the most common indications for splenectomy, but technical expertise is progressively being taken over by non-operative and more conservative approaches. material and methods: retrospective review of all total splenectomies performed between february and january at an italian academic hospital, assessing demographics, diagnosis, operating surgeon, surgical approach, complication rate, postoperative critical care admission, and -day mortality. results: over years, consecutive splenectomies were performed by different surgeons, of whom surgical trainees, with unplanned (i.e. emergency/iatrogenic injury) and planned (i.e. benign/malignant disorders) procedures and an average of . and . procedures per year respectively. over the study period, only surgeons performed at least procedures and only performed at least procedures. laparoscopy was performed in . % of cases, predominantly during planned procedures, with an overall . % conversion rate mostly related to technical difficulties (i.e. spleen dimension, difficult vascular visualization). overall major postoperative complication rate (clavien-dindo c ) was . %, slightly higher in emergency procedures although not significantly different ( . % vs. . %, p = . ). reintervention rate was . %, due to hemorrhage in more than half of cases. overall -day mortality rate was . %, with elective -day mortality rate of . % (p = . ). conclusions: splenectomy may be required ever more rarely but potential risks are not irrelevant. competence for surgical trainees should be achieved elsewhere (e.g. simulated/cadaveric training case history: an year old femal patient underwent changing of the components of the tha because of aseptic loosening. due to circumstances the surgeon decided to implant a cemented femoral component. the procedure was without any significant abnormalities. the first postoperative radiograph was planned after recovery-as usual. the x-ray imaging showed a misplaced femoral component. therefore a ct-scan was performed additionally and the malposition of the cemented femoral component was confirmed. the patient had to undergo another surgery-removing of the cemented femoral component and implantation of a new well placed one. therapy and progressions: after prompt resuscitation, an emergency laparotomy was performed and an anastomotic leak was found, requiring re-do ileo-ileal anastomosis. postoperative course was complicated by intra-abdominal collection treated by antibiotics alone (clavien-dindo grade ). the patient was discharged on th pod. at pathological report, segmental absence of intestinal musculature (saim) was diagnosed. the revision of past specimens confirmed the same finding. comments: usually recognized in neonates/premature infants, saim is generally an incidental finding in adults [ ] , often undiagnosed and more frequently described in the colon [ ] . in such scenario, main differential diagnosis is ischemia. etiology is unclear and can be classified as either primary/congenital or secondary. the former is characterized by acute onset of symptoms, whereas in the latter a longer history of intestinal symptoms is usually present [ , ] . most authors agree upon a congenital pathogenesis. generally, saim is associated with hollow viscus perforation and treated with surgical resection. contrary to our experience, no recurrence of intestinal perforation has been reported [ ] virgen del rocío university hospital, general surgery, seville, spain, hospital regional de málaga, general surgery, málaga, spain, hospital de estella, general surgery, navarra, spain, hospital gregorio marañón, general surgery, madrid, spain, complejo hospitalario de jaen, general surgery, jaen, spain introduction: specific training in the management of trauma patients is essential for surgeons. training through courses in this area (atls, dstc, musec) directly impacts the care of these patients. the aim of this study is to know the specific training in trauma care of spanish surgeons. materials and methods: a national survey has been sent to all member surgeons of the spanish surgeons association. it has evaluated their degree of participation in emergency surgery acute care, and therefore the possibility of attending trauma patients, their participation in the initial care at their hospital, as well as their specific training in this area. results: the survey has been completed by surgeons from spanish regions, and most surgeons who responded were from catalonia and andalusia. ( . %) of those surveyed take calls for the ed. only ( . %) report having a hospital registry of trauma patients. . % of surgeons answer that in their hospital the general surgeon is not involved in the initial care of trauma patients. . % have taken the atls course, . % the dstc course, and . % the musec course (or another course on e-fast). despite this, . % consider the atls course should be mandatory during residency, and . % of those surveyed consider trauma care in their hospital as very bad or deficient. conclusions: according to this survey, specific training in trauma care is still deficient in spain and with many aspects that can be improved. only % of those surveyed have received specific training in definitive surgical management of severe trauma. despite this, a large percentage of surgeons take calls for the ed routinely, and face the challenge of managing these patients. exploring team leaders' decision-making challenges in civilian and military complex trauma introduction: in the nordic countries professionals may work in both civilian and military trauma care. timely and effective decisionmaking in complex trauma is essential in improving survival benefits. the mindset and management priorities differ among medical professionals, and correlate with different experience levels. trauma leaders are usually senior surgeons with extensive experience and well-developed decision-making skills. simulation training has been shown to be effective in practicing decision-making. the aim of this study is to explore the team leaders' decision-making challenges in complex trauma care and structure them with the activity theory framework (at). material and methods: video recordings at a trauma center in johannesburg and live observations of complex trauma training in gothenburg focusing on team leaders' decision-making challenges were analyzed and systemized using the at. results: the team leaders' activities were mapped onto the main elements of at ( fig. ) whereby the decision making challenges were classified into six categories (table ) . conclusions: the at framework may benefit and inform the design of educational interventions by structuring key issues of complex activities. introduction: trauma is one of the main causes of mortality worldwide and prevention stands out as one of the main ways to modify its incidence. a prime example of such initiatives is the prevent alcohol and risk-related trauma in youth program (p.a.r.t.y.). it aims to raise awareness of the population most at risk for trauma, young people from to years. the study objective was to evaluate the program impact on students' knowledge and behavior. material and methods: a quantitative, uncontrolled intervention cohort study was conducted through the responses of the p.a.r.t.y. in and . data collection occurred through the application of a questionnaire to participating and non-participating students of public schools in the city of campinas, after a few months of participation in the program. results: among answers, . % were male, . % between and years, and . % program participants. time between participation and answers was . (± . ) months. regarding the first conducts when facing traffic trauma, . % of those who participated chose the correct answer, against . % of those who did not. about the first care while the service does not arrive, . % of the first group answered correctly, compared to . % of the second. concerning about the service that should be called in the event of a trauma, . % of participants would call correctly against . % of non-participants. in questions related to traffic laws, . % of participants opted for the correct answer as to what should be done in the face of a running over, against . % of non-participants. conclusions: students who had participated in the program had a higher rate of correct answers, a few months after the event, compared with students who did not attend. thus, it is concluded that there is a impact over the time caused by it. introduction: currently, intraosseous (io) devices are necessary for the resuscitation of severe trauma patients. however, opportunities to learn io device insertion are limited for residents. the aim of this study was to conduct a simulation of io device insertion for residents and to evaluate its effectiveness. material and methods: in this simulation, residents inserted io needles into the sternum of pigs under general anesthesia with the instructor's guidance. comprehension tests and questionnaires about satisfaction level and self-efficacy were conducted before and after the simulation. the objective evaluation was the io access success rate, and the subjective evaluation was obtained from points on comprehension tests and questionnaires. results: thirty-six residents participated in this study. just one resident had successfully obtained io access clinically. success rate of establishing io access in the simulation was %. the rate of test completion was % and that of questionnaire with survey response was %. the comprehension test results improved from . ± . to . ± . (mean ± standard deviation, p = . ) out of points. the questionnaires concerning satisfaction level changed from . ± . to ± . (p \ . ) out of points. the questions specifically concerning self-efficacy dramatically increased from . ± . to . ± . (p \ . ) out of points after the simulation. conclusions: the simulation in this study improved the knowledge, satisfaction level, and self-efficacy of the residents for io access. the success rate of confirmation of io access in this study was %. this experience may positively affect their clinical performance in trauma care. case history: case . a -year-old white man presented to the ed complaining of intense abdominal pain and vomiting. he referred at least two previous episodes with associated fever which resolved spontaneously. case . a years old white man consulted at the ed for intense abdominal pain, nausea, anorexia and constipation for the last h. none history of abdominal surgery were registered. clinical findings: in both cases, the abdomen was distended without bowel sounds. investigation/results: case . abdomen xr: distended small bowel loops localized at the right side. ct scan: an encapsulated cluster of dilated small bowel loops into the ascending mesocolon. case . ct scan: an encapsulated nonrotated small bowel in the right side of transverse mesocolon and mesenteric vascular pedicle displaced. diagnosis: intestinal obstruction secondary right paraduodenal hernia therapy and progressions: emergency midline laparotomy that evidenced a rpdh which was reduced before closing the mesentery defect. the postoperative was uneventful. comments: paraduodenal hernias are a type of internal hernia and a rare cause of intestinal obstruction accounting for about . % of all hernias. right paraduodenal hernias are far less common than left ones. symptoms of paraduodenal hernias are nonspecific. preoperative diagnosis of pdh by imaging techniques is difficult. contrastenhanced ct scan is highly recommended as the most specific method of diagnosis for pdh. with the increased use and improved enhancement of ct scans, paraduodenal hernias currently can be diagnosed preoperatively. this advancement in diagnostics coupled with increasing experience and facility of general surgeons in using laparoscopic techniques has led to the initiation of laparoscopic repair of internal hernias. case history: a -year-old female patient who goes to the emergency department due to vomiting and abdominal pain. since the accident, the patient reported post-prandial discomfort and gastroesophageal reflux, as well as self-limited abdominal cramps. clinical findings: soft, depressible abdomen. bowel sounds on left hemithorax. investigation/results: cxr: right hemidiaphragm elevation. lab test: leukocytosis. thorax and abdomen ct: right anterior diaphragmatic hernia and passive atelectasis secondary to ascent of dilated small intestine and colon. diagnosis: intestinal obstruction secondary post trauma diaphragmatic hernia. therapy and progressions: emergency laparotomy due to symptoms compatible with intestinal obstruction secondary to incarcerated diaphragmatic hernia. it is right diaphragmatic chronic rupture chronic with omental incarceration, antrum, small bowel and ascending colon with reversible signs of suffering. chelotomy and content reduction, herniorrhaphy with loose spots with non-absorbable material are performed. endothoracic drainage is left removed at h. the postoperative course is uncomplicated. comments: trauma events should be considered in the diagnostic process to avoid delayed treatment. case history/clinical findings: we present a -year-old male patient with a history of large pelvic mass in the rectum-prostate space under study, since months. he were admitted into the emergency unit, days after the mass biopsy, with fever up to °c and rectorrhagia. the patient rapidly developed septic shock with hemodynamic instability and elevation of acute phase reactants. abdominal ct was performed: pelvic mass of . . cm, of heterogeneous content, with areas of blood density. we decided doing an emergency surgical exploration of this mass as the only suspected origin of infection. investigation/results: in the surgical exploration the mass was protruding on the anterior rectum wall. the mass was drainaged with an output of ml of purulent material mixed with clots and necrotic tissue. foley no. probe was placed inside the cavity. in the postoperative period, the patient showed significant hematochezia, so he was reoperated performing hemostasis and rectal tamponade. it was effective and a new foley catheter was replaced at h. when the purulent drain gave way, the catheter was removed and the patient evolved favorably. diagnosis: cytology analysis: mesenchymal type lesion, morphologically and immunophenotypically compatible with gist (gastrointestinal stromal tumor). ihq profile: cd , dog , c-kit positive. therapy and progressions/comments: the complications of gist are usually acute abdomen due to peritonitis secondary to perforation or hemorrhage. however, the formation of intratumoral abscesses is very inusual, although is described in the literature. emergency surgery is often necessary due to the significant affectation of the general condition of the patient and the difficulty of the diagnosis. fournier's gangrene (fg) is a surgical emergency defined by an obliterating endarteritis of the subcutaneous tissue arteries of infectious etiology, with progressive necrotizing fasciitis of the perineal, abdominal, thoracic or lower limbs, which can lead to multiorgan failure. a years old woman was admitted in our er presenting with a week worsening vulvar pain. clinical exam showed vulvar and mons venus erythema, without lesions, bp was / mmhg and she had a fever of . °c. blood work showed leukocytosis ( . /ll), neutrophilia ( . /ll) and crp of mg/ l. past medical history of obesity, right thp and total thyroidectomy. vulvar cellulitis was the initial diagnosis and empirical atb was implemented. on d , due to an evolution into septic shock and spread of an emphysematous inflammatory process to the right thigh and buttock, the diagnosis of fg was made. during emergent surgery we observed extensive fascial and tissue necrosis from the asis and suprapubic region to the proximal third of the right thigh and perineum. extensive necrosectomy, drainage of purulent exudate and transversostomy were performed. empirical second-line broad-spectrum atb was started. she underwent new necrosectomies and surgical debridements on po days and and needed icu stay for days. daily dressing changes were performed with povidone iodine and later with octenidine. microbiology sample showed polymicrobial infection with gram positive and negative organisms as well as anaerobes, thus confirming the diagnosis of fg type i of vulvar origin. after surgical and hd stabilization, the patient underwent plastic reconstructive surgery, with local flaps and partial skin graft. the postoperative period was uneventful and the outcome was great. introduction: appendicitis is not uncommon in the elderly but may often be mis-diagnosed [ ] . the aim of this study was to explore the specific traits and treatments of this group in a swedish context to better understand where to optimize the management. material and methods: all acute appendectomies registered in the southern general hospital registry between january and june constituted the cohort (n = ). patients were stratified into two groups; c and \ years of age. significances were computed with pearsons chi and anova. results: the older group made up % of the study population (n = ). the elderly population was female to a larger extent (or . , p \ . ), triaged higher in the emergency department (p \ . ) and had higher asa classifications (p \ . ). the elderly were also perceived as sicker at the time of decision for surgery, expressed as having higher priorities for surgery (p \ . ). no significant difference between the groups in time from arrival to decision for surgery was found, nor for the time from arrival to surgery. there was a higher rate of perforations in the elderly group ( . % vs . %, p \ . ), twice the length of hospital stay (p \ . ) but no significant differences in complication rates ( . vs . %, p = . ). twenty-eight day mortality rate was % in the younger group and . % in the older group (p \ . ). conclusions: this study shows that an elderly group of appendicitis patients are more frail and more acutely sick when presenting to the hospital. in spite of higher priority for surgery, the elderly experience longer hospitalization and higher mortality rate, but not more complications. the findings are consistent with antecedent research. introduction: existing evidence points towards the notion that patients undergoing emergency surgery receive a poorer consenting quality when compared to their elective counterparts. with , cholecystectomies in england a year, cholecystectomy is one of the most frequently performed procedures both in the emergency and elective settings. however, to date, no studies have explored the relationship between consenting quality and the setting of cholecystectomy. we aimed to measure the quality of informed consent (ic) for patients who underwent emergency vs elective cholecystectomy. material and methods: the final review included the analysis of ic forms completed between - . percentage proportions were calculated to demonstrate the degree of completeness of consenting against a total of components of information. binary regression was utilised for subgroup analysis. results: patients undergoing emergency surgery were more likely than elective patients to be warned of severe perioperative complications such as cardiac disorders ( . % vs . %, p = . ), fluid collection ( . % vs . %, p = . ), and infected bile spillage ( . % vs . %, p = . ). elective patients were more likely to be counselled about the risk of less serious side effects of cholecystectomy such as diarrhoea ( . % vs . %, p = . ). patients in asa - group were more likely to be counselled about the occurrence of pulmonary embolism. interestingly, patients were more likely to receive a patient information leaflet if they were females and under . conclusions: the results of this study demonstrate multiple inconsistencies in the level of disclosed information to patients undergoing cholecystectomy. the results suggest that the consenting physicians make assumptions regarding the information that the patient would like to receive based on patient demographics and clinical factors, highlighting the need for more consistent consenting procedures. acute calculous cholecystitis and the timing of cholecystectomy: advocating early surgery i. moutsos , r. lunevicius liverpool university hospitals nhs foundation trust, general surgery, liverpool, united kingdom introduction: cholecystectomy cures acute calculous cholecystitis (acc) in nearly all patients and, according to nice, augis, tokyo and wses guidelines, should be conducted at the earliest opportunity, within days of the diagnosis. the present audit aimed to measure whether the care of patients with acc meets the standards of best practice and to assess whether early cholecystectomy was a more beneficial and safer intervention as compared to delayed cholecystectomy. material and methods: a ''snapshot'' sample of patients operated on between / and / with an index admission diagnosis of acc was reviewed. the selected patients were divided into three subgroups according to the timing of their surgery: - (early), - , and[ days. the other measures used in this audit were the rates of conversion to open surgery, subtotal cholecystectomy (stc), perioperative complication-specific morbidity, secondary interventions, and admission to intensive therapy unit (itu). results: nine patients ( %) underwent early cholecystectomy-laparoscopic (n = ) or primary open (n = ); of the other patients-delayed laparoscopic cholecystectomy. the rates of stc were similar in both subgroups- . % ( / ) vs . % ( / ). delayed cholecystectomy was related to five side effects: higher rates of postoperative collections (three patients, . %), external bile leak (one patient, . %), ercp ( . %), emergency re-operations (two patients, . %), and admission to itu ( . %). they all occurred in the delayed [ weeks surgery subgroup of patients. conclusions: although no significant associations were found when comparing early to delayed cholecystectomy, this analysis shows that postoperative morbidity, the rates of secondary interventions and admissions to itu were higher when surgery was delayed. this audit advocates that early cholecystectomy should become a standard of practice as per national and international guidelines. esophagopericardial fistula following primary repair for chronic esophageal ulceration presenting with pericardial tamponade: a case report and outline of management and treatment case history: a -year-old man with chronic esophageal ulcerations presented with substernal pain, fever, and shortness of breath. a radiograph revealed a right pleural effusion and pneumomediastinum consistent with an esophageal perforation (fig. ). he underwent a right thoracotomy, primary esophageal repair with intercostal muscle flap buttress, and gastrojejunostomy feeding access. a post-procedural gastrograffin study demonstrated an anastomotic leak (fig. ) . a right thoracostomy drain was placed for diversion. the patient was discharged home and returned days later. clinical findings: he presented with substernal pain, hypotension, and fatigue. thoracic computed-tomography (ct) revealed a pneumopericardium and an esophagopericardial fistula (epf) manifesting as pericardial tamponade (fig. ) . diagnosis: epf. therapy and progressions: the patient underwent a subxiphoid pericardial window and mediastinal drain placement for decompression. an esophagogastroduodenoscopy revealed an exposed right atrium, thus precluding esophageal stenting. sepsis and antibioticassociated clostridium difficile colitis complicated his post-operative course. once resolved, the patient underwent a partial esophageal resection, epf ligation, and esophagogastrostomy. the postoperative gastrograffin study did not demonstrate an anastomotic stricture or leak. the patient tolerated a regular diet and was discharged home. comments: esophagopericardial fistula is a rare clinical entity most often caused by benign disease. prompt diagnosis and treatmentpericardial decompression and fistula ligation-is critical. due to wide use of proton pump inhibitors and development of interventional radiology (ir), causative reasons are changing. introduction: secondary peritonitis yields high morbidity and mortality rates. besides rapid source control, adequate antimicrobial therapy is essential to improve outcomes. thus initial empiric therapy has to take suspected germ spectrum as well as possible resistance rates into account. microbial selection and resistances may pose problems during prolonged administration of antibiotics. however, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified. material and methods: intraabdominal swabs from consecutive patients from to requiring intensive care due to secondary peritonitis were evaluated retrospectively. patient characteristics and outcomes, germ spectrum and resistance rates were collected. changes over the course of therapy and development of resistance as well as influences on the clinical course were analyzed. introduction: complicated intra-abdominal infections (c-iai) represent challenging diseases with high mortality rates. depending on different selection criteria and therapy strategies the reported mortality rates vary between . and %. usually a distinction between community (cap) and hospital acquired peritonitis (hap) is made. hap can further be classified as postoperative peritonitis (pop) or non-postoperative peritonitis (hap-non-pop). we conducted a retrospective analysis of patients with c-iai requiring intensive care therapy. material and methods: all patients with c-iai requiring surgery and intensive care treated at the danube hospital in vienna from to were retrospectively analyzed. a total of patients where included into the study and grouped as cap, hap-non-pop or pop. for each group comorbidity and patient characteristics, source and cause of infection, hospital and icu stay, apache ii, saps ii and sofa-scores, mortality and outcome were calculated and compared to each other, using fisher exact test or mann-whitney-u-test. results: a total of c-iai were treated, consisting of . % cap, . % hap-non-pop and % pop. concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in pop. the postoperative (source control) apache ii and saps ii values did not differ between cap and pop (apache ii mean: cap . , pop . ) whereas both were significantly higher in hap-non-pop (apache ii mean: . ). mortality rates were not significantly different in cap and pop ( . % vs. . %): however, hap-non-pop was complicated by a nearly doubled death rate ( . %). conclusions: although patients with pop are described to have a higher mortality in the literature, this could not be shown in our study. postoperative survival was comparable between cap and pop patients. hap-non-pop demonstrated a significantly higher mortality. acute appendicitis and acute diverticulitis presenting concurrently treated surgically and conservatively clinical findings: on examination the abdomen was soft but there was tenderness and guarding in the right iliac fossa and suprapubic region. her observations were stable on admission and she was afebrile. investigation/results: laboratory tests demonstrated a wcc . ( /l) and crp of . (mg/l). urinalysis was normal. a ct of the abdomen and pelvis with intravenous contrast demonstrated acute appendicitis with non-perforated sigmoid diverticulitis (fig. , fig. ). diagnosis: concurrent acute appendicitis and non-perforated sigmoid diverticulitis. therapy and progressions: the patient underwent a laparoscopic appendicectomy. intraoperative findings included a retrocaecal inflamed appendix and diverticulitis in the pelvis which was not disturbed. there was no pus in the pelvis. she recovered well postoperatively and was discharged home to complete one week of oral antibiotics the following day. the histology demonstrated acute appendicitis. comments: there are very few reports in the literature of concurrent appendicitis and sigmoid diverticulitis despite these two pathologies being amongst the most common presentations of abdominal pain. this case demonstrates the value of cross sectional imaging, ct imaging is a helpful diagnostic tool and is highly sensitive and specific for both diverticulitis and appendicitis.the challenge in this case is balancing the two differing managements of these two conditions. most cases of diverticulitis are managed conservatively with dietary modification and antibiotics. operative management is only usually considered if there are associated complications such as intraabdominal perforation. this is in contrast to appendicitis where the standard treatment is to undergo surgery. references millions of people die from major trauma annually. - % of these deaths are due to exsanguination, with nearly half dying prior to hospital arrival. when properly managed, these deaths are preventable. this paper summarizes data relating to the extent of hemorrhage as a cause of mortality in the traumatic arena. an overview of the pathophysiological steps occurring during massive bleeding and their clinical implication is presented. a variety of treatment options, both historical and current, is then discussed, including vascular occlusion methods and hemostatic dressings, along with their limitations and complications. finally, woundclot, a new hemostatic gauze, is introduced, which not only requires no compression when it is applied, but allows the first responder to rapidly and effectively treat more than one casualty within seconds. additionally, it is adaptable to a wide array of clinical applications, both traumatic and surgical, including situations where vascular occlusion methods are not practical or are contraindicated. i am the clinical research administrator for core scientific creations treating acute colonic diverticulitis with extraluminal pericolic air; a multi-centre retrospective cohort study background: since the emergence of acute care surgery as an entity encompassing trauma and emergency general surgery there have been several studies evaluating patient outcomes noting a higher unexpected survivorship and expedited operative times, shorter hospital stays, and fewer complications for patients undergoing procedures such as appendectomy; however, these superior outcomes have not been demonstrated across the array of emergency surgical cases. the aim of this investigation is to determine whether patients operated on by acute care surgeons in a trauma center benefit from the trauma model of in-house availability, earlier availability of surgical care, and care dictated by evidence-based protocol. we examined our health care system's data to determine if trauma centers were to able to provide more timely care with improved outcomes, by focusing on truly emergent general surgery cases. this was examined by identifying and quantitatively comparing time to operative intervention, need for re-operation, hospital length of stay, duration of stay spent in intensive care unit, and patient disposition at time of discharge. methods: this is a retrospective cohort study. patients presenting with emergency general surgery conditions (incarcerated hernia, perforated viscus, sbo, necrotizing soft tissue infection) who underwent surgery within h of presentation were selected. outcomes were compared between patients presenting to our two trauma centers versus our two non-trauma centers. n = results: at this time we are nearing the finalization of our data interpretation. we are examining mean time to operation, los, icu los, need for re-operation, and disposition at discharge. discussion: although our data analysis is not complete we feel that the results of our data will shed valuable and needed light onto the care delivered to emergency general surgery patients by surgeons in this increasingly complex population. anastomosis leakage after hartmann removal, with conservative treatment at the beginning but after, bad evolution, a surgery was performed with colostomy and vac system. patient. after h, he develop a compartmental syndrome and a vac system was applied. investigation/results: patient. after the first change the distance between the two layers was cm and botulinum toxin was applied. pat. the distance between the two layers of abdomen was cm and botulinum toxin was applied. patient. the distance between the two layers was cms and toxin was applied. unfortunately, he suffered from a hepatorenal syndrome and died. diagnosis: open abdomen with distance between the two layers: cm, and cm. therapy and progressions: we have added botulism toxin with doses of units in each side of abdominal wall. patient. three changes after, the abdomen wall was closed. months later, the abdominal wall is ok. patient. a reduction of % was got. comments: the use of open abdomen in patients suffer from septic shock or after an abdominal compartment syndrome often poses a challenge in the abdomen closure. we have developed a protocol, dividing our patients according to the distance between the two layers in two group: more than cm or cm or less. in the first group ([ ), we present our first cases in our protocol. conclusions: botulinum toxin can make easier abdomen closure when the distance between the two layers is more than cms incidentally discovered splenic peliosis in a patient with no comorbidity clinical findings: a -year-old man with no comorbidities visited our emergency medical center based on a complaint of chest pain. the chest and abdomen radiographs, electrocardiogram, and cardiac markers showed no abnormalities; therefore, he was discharged from the hospital. two months later, he returned to our hospital with abdominal pain and distension. he was hemodynamically stable, and there were little tenderness and rebound tenderness on his abdomen, although he complained a slight abdomen discomfort investigation/results: no abnormalities were found on the laboratory examinations, including complete blood cell count, cardiac markers, and coagulation profile. an abdomen computed tomography revealed multiple hemorrhagic cysts on spleen with moderate amount of hemoperitoneum. diagnosis: ruptured splenic peliosis with hemoperitoneum. therapy and progressions: laparoscopic splenectomy was done because recurrent rupture of hemorrhagic cysts was strongly anticipated. on histologic examination, the blood-filled cysts were welldemarcated, distributed in red pulp congestion. no vascular-endothelial cells were observed, and normal lining cells were disappeared in the wall. comments: a peliosis is a rare disorder characterized by widespread, blood-filled cystic cavities within the parenchymatous organs. the liver is the most commonly involved organ, and an isolated splenic peliosis is extremely uncommon. patients are often asymptomatic; therefore, early recognition and withdrawal of offending agents is crucial. in cases with the rupture of surface lesions, which can occur spontaneously or by the minor trauma, prompt surgical management is necessarily required. splenectomy offers the advantage of a definite histological diagnosis with the complete elimination of the risk of recurrent hemorrhage. introduction: despite an evident success and advantages of endoscopic surgery, the discussion on reasonability of endoscopic surgeries in children with acute appendicitis is still going on. purpose: to assess the effectiveness of laparoscopic techniques for treating appendicular peritonitis in children. material and methods: children with appendicular peritonitis were operated in our hospital ( ) ( ) ( ) . they aged - years ( ± . ); . % of boys, . % of girls. appendicular peritonitis was registered in . % cases of acute appendicitis. three ports were used for the approach: appendectomy was performed by the ligature technique with roder loop. results: laparoscopic surgery is indicated in all forms of appendicular peritonitis, except appendicular abscess stage , and total abscessing peritonitis. in appendicular abscess stage , we perform a puncture and drainage under ultrasound control. - months later appendectomy is made. total abscessing peritonitis is an indication for laparotomy. laparoscopic surgery in patients with peritonitis has the following stages: diagnostic laparoscopy; sanation of the abdominal cavity by the aspiration of purulent exudate; ligature appendectomy; in diffuse and combined peritonitis a pelvic aspiration drainage is made. in appendicular abscess stage , we additionally put the aspiration drainage in the cavity of destructed abscess. conclusions: laparoscopic technique applied for surgeries in children with acute appendicitis has considerably improved outcomes introduction: nighttime emergency surgery is associated with increased postoperative morbidity and mortality [ ] , and delayed appendectomy due to acute appendicitis is not linked to a higher rate of postoperative complications (pc) [ ] . the aim of this study was to determine whether appendectomy on-call (oc) was associated with higher risk of pc. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . two patients underwent major thigh amputation. negative pressure wound therapy and hyperbaric oxygen therapy were used in and patients, respectively. three patients died (mortality rate = %). conclusions: the mortality and major amputation rates ( % and %, respectively) were lower than those reported previously. in this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. material and methods: a systematic search in pubmed/medline, embase, cinahl and central was performed. the primary outcomes were mortality and amputation. these outcomes were related to the following time related variables ( ) time from onset symptoms to presentation; ( ) time from onset symptoms to surgery; ( ) time from presentation to surgery; ( ) duration of the initial surgical procedure. for the meta-analysis, effects were estimated using random-effects meta-analysis models. results: a total of studies ( patients) were included for qualitative analysis, of which patients died ( . %). a total of studies ( nsti patients) were included for the different quantitative analyses performed. mortality was significantly lower for patients with surgery within h after presentation compared to when treatment was delayed more than h (or . ; % ci . - . ). surgical treatment within h resulted in a % mortality rate compared to % when surgical treatment was delayed more than h. also, surgery within h reduced the mortality compared to surgery after h from presentation (or . ; % ci . - . ). patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. none of the time related variables assessed reduced the amputation rate. conclusions: average mortality rates reported remained constant (around %) over the past years (fig. ) . surgical debridement as soon as possible lowers the mortality rate for nsti with almost %. thus, a sense of urgency is essential in the treatment of nsti. altemeiers procedure in an emergency setting case history: three patients with irreducible incarcerated rectal prolapsed were referred to our department for treatment. all patients were female and their age was , and years old. all patients suffered from severe co-morbidities. clinical findings: all patients presented with incarcerated rectal prolapse. in one patient there was macroscopic evidence of mucosal necrosis, whereas the other two patients had evidence of ischemia. the former patient was febrile whereas the latter did not exhibit signs or symptoms indicative of sepsis. investigation/results: blood panels demonstrated leukocytosis and elevated levels of c-reactive protein (crp) in all patients. apart from routine imaging upon admission (e.g. chest radiography), no other imaging modalities were performed. diagnosis: irreducible incarcerated rectal prolapse. therapy and progressions: initially manual reduction of the prolapsed was attempted without success. all patients were evaluated as high risk surgical candidates. altemeier's procedure was selected as a safer alternative to an abdominal approach. all patients were successfully discharged after resumption of bowel function. comments: incarcerated rectal prolapse is a rare clinical condition. initial management involves manual reduction of the prolapse. when this is not feasible, urgent surgical management is mandatory. in patients with severe co-morbidities, altemeir's procedure is a safe and effective treatment when performed by an experienced practitioner. introduction: treatment options for sigmoid volvulus are decided by its severity. uncomplicated cases are usually treated by endoscopic detorsion followed by elective surgery and complicated cases or cases can't be detorsioned are treated with emergency surgery. in this study we aim to review a single center experience in long term management of sigmoid volvulus cases. material and methods: data of the sigmoid volvulus cases between - were collected using hospital database. files of patients were reviewed for treatment modalities, demographic info and complications. patients were dropped from the study due to inadequate long term follow-up. results: were men and were women. mean age was , . endoscopic detorsion was attempted in cases. success rate was % (n = ). of these patients were followed up with elective surgery. patients with complicated cases and unsuccessful detorsion patients were managed by emergency surgery. hartman procedures, anterior resections, left hemicolectomies, subtotal colectomy and transverse loop colostomies were done. a stoma was created in cases. patients had their stoma created in the primary surgery and an additional of stomas were created due to anastomosis leakage. mortality rate in the first days was % (n = ) in patients with a stoma (n = ). asa and charlson co-morbidity scores were exceptionally high in the mortality group. in the remaining patient group, stoma closure rate was . %. conclusions: endoscopic detorsion is a powerful and highly successful management option in uncomplicated cases when done by an experienced staff. emergency surgery shouldn't be delayed in complicated cases or after unsuccessful detorsion attempts. introduction: esophageal perforation has high mortality rates when not treated aggressively. treatment options are conservative approach, endoscopic intervention and surgery. purpose of this study is to review cases of esophageal perforation in a single center and to evaluate types of diagnosis and treatment options. material and methods: using hospital database we collected data of patients diagnosed with esophageal perforation between - . we reviewed treatment modalities, demographic data and complications. patient was removed from the study due to insufficient long term data. results: were female and were male. average age was . . average time between the onset of symptoms and admission was . days. the most common etiology was iatrogenic (n = ) followed by consumption of corrosive substances in patients, spontaneous perforation in patients, esophageal tumour in patients and foreign body ingestion in patients. patients were treated surgically, patients were treated with endoscopic stenting and patient was treated with surgery following stenting. patients were managed conservatively with antibiotherapy. average time in intensive care was . days and average hospital stay was . days. mortality was seen in patients treated with surgery and patients treated with stents. conclusions: esophageal perforations are mainly iatrogenic but also can be caused by multiple reasons. especially in cases developed after endoscopy, rapid intervention can be a significant factor that can decrease both mortality and morbidity rates. introduction: spontaneous rupture of liver tumors (rlt) is a rare but potentially life-threatening condition. damage control techniques, namely perihepatic packing (php), is a resource for the most physiologically compromised patients, with more stable patients undergoing transarterial embolization (tae) or immediate resection. decision algorithm depends on patient status, available resources and liver function. the authors present their center experience in managing rlt and propose a management algorithm. material and methods: eighteen consecutive patients who underwent surgery for rlt in our department (january -october ). inclusion criteria: spontaneous rupture and evidence of intraperitoneal bleeding. fourteen patients were male. mean age of . years ( - ). thirteen patients ( %) presented in hemorrhagic shock. mean tumor size was . cm ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . most frequent pathological diagnosis were: hepatocellular carcinoma in cases ( %); adenoma in three cases ( %); metastases in two cases ( %); liver sarcoma in one case ( . %). median of seven units transfused by patient ( - ). statistical analyses with spss tm version . results: six patients ( %) needed immediate surgery (php in three and resection in three). five ( %) underwent urgent ([ h and \ h) and seven ( %) delayed ([ h) resection. hepatectomy was performed on all (fifteen minor and two major) but one patient php only. eight patients ( %) underwent tae prior to resection, two of them ( %) between php and hepatectomy. median length of stay days . major morbidity in three patients ( %); mortality in three patients ( %). number of transfused units associated with increased risk of complications (p = . ). conclusions: rupture of liver tumors is a severe complication. although hepatic resection, with or without preoperative tae, should be considered gold standard, damage control techniques such as php are the only option for physiologically compromised patients (fig. ) . seasonal variability of cellulitis: a five year retrospective cohort study introduction: it is commonly purported that the incidence of cellulitis is highly seasonal but there is little empirical evidence supporting this assertion. this year retrospective cohort study set out to identify whether there is a statistically significant relationship between an increase in temperature and incidences of cellulitis. as a corollary to this proposition, length of hospital stay for cellulitis was examined in relation to the level of inflammatory markers upon admission and micro-organism identified on culture. material and methods: this is a year retrospective single centre cohort study of all patients admitted with cellulitis to tallaght university hospital from to inclusive. the patient cohort was identified via the use of a prospectively managed database of all surgical admissions and corroborated via examination of clinical chart records. dates of admission were correlated with the average temperature of dublin as provided by the meteorological office of ireland. site of infection, inflammatory markers and the prevalent micro-organism were also identified whilst the length of admission was extrapolated from hipe (hospital inpatient enquiry) records. results: there were admissions for cellulitis with cases of necrotising fasciitis. there was a statistically significant (p \ . ) relationship between temperature and cellulitis with admission peaking in late summer/autumn. age correlated significantly with readmission. furthermore, the level of crp had a statistically significant prognostic value as an independent predictor for the length of hospital stay with a high level resulting in a prolonged admission. conclusions: there is a statistically significant relationship between a rise in temperature and the incidence of cellulitis. furthermore age is an independent risk factor for re-admission with same whilst inflammatory markers at time of admission can be used as a prognostic marker for length of stay. case history | clinical findings: a -year-old female patient, with history of type ii diabetes, high blood pressure and major depressive syndrome, was admitted in the emergency room department complaining of abdominal pain. based on the patient's history and physical examination, a presumptive diagnosis of renal colic was initially made. however, after days, the patient showed signs of fever, aggravated abdominal pain and vomiting. investigation/results | diagnosis | therapy and progressions: a ct scan showed the presence of a radiopaque foreign body near the duodenum, the presence of air bubbles outside the intestinal lumen and an hepatic abscess. we agreed to perform a laparoscopy, drainage of hepatic abscess and fish bone removal after successfully identification. after days, the laboratory findings showed persistent leukocytosis and raised cpr, which led to a second ct scan with maintenance of the hepatic abscess. the decision was to perform a percutaneous drainage. after the second drainage, the patient had an uneventful recovery. comments: foreign body ingestion into the gastrointestinal (gi) tract is rare and typically accidental in adults. most ingested foreign bodies pass through the gastrointestinal tract without the need for any intervention. gi perforation is rare and can occur at any site. surgical intervention is required in less than % of the cases. fish bones are the most commonly ingested objects. preoperative diagnosis, when possible, is made with ct scan, identifying a linear high-density structure. high level of suspicion is of paramount importance. in cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation. reports of hepatic abscess secondary to fish bone perforation has been limited to isolated case reports in the literature. case history: description of two cases of appendicular goblet cell carcinoid tumors, which debuted as acute appendicitis. patient a was a -year-old woman with a -h evolution of classic symptoms of acute appendicitis. patient b was a -year-old female that consulted for chronic abdominal pain in rlq that recently increased pain intensity and fever. clinical findings: patient a had pain and defense in rlq without a fever. patient b had a chronic painful fluctuating mass in rlq, with fever over °c. investigation/results: patient's a lab test showed leukocytosis and us findings of acute appendicitis. the patient's b ctscan showed an intra-abdominal abscess fistulized to the abdominal wall, along with formation of a phlegmonous mass related to appendicular plastron. diagnosis: the anatomopathological reports for both patients were informed as appendicular goblet cell carcinoid tumor. therapy and progressions: both underwent laparoscopic exploration. after appendicectomy in patient a, when the diagnosis of gcct was made, the case was discussed at our mdt meeting and a right hemicolectomy was indicated and performed shortly after. in the patient b a right hemicolectomy was performed in the initial surgery due to the magnitude of tissue involvement. currently, both are receiving chemotherapy with xelox without signs of recurrence or tumor spread on follow up. comments: the gcc is a rare entity of appendicular tumors with a less favorable prognosis than the appendicular pure neuroendocrine tumors. it behaves like a low-grade adenocarcinoma and often presents as disseminated disease. therefore, sometimes surgical treatment with appendicectomy is not enough, needing the right hemicolectomy to avoid recurrence. this is recommended for tumors [ cm, pt or t and higher grade histology. introduction: among the post-pancreatoduodenectomy complications post pancreatoduodenectomy hemorrhage (pph) is the least common complication, but severe form may be life-threatening without an urgent treatment. late pph are more likely due to a complex physio-pathological pathway secondary to different etiologies. the understanding of the etiology and such a pathway could therefore be of great interest to guide the treatment of potential lifethreatening late severe pph. results: during the aforementioned period patients underwent pd, of whom ( . %) developed pph. early pph was reported in one patient ( . %) with severe bleeding from the gastric stapler line. late pph were reported in of these patients ( . %). the most common causes were bleeding from a vascular pseudoaneurysm reported in patients of which, one had mild and had severe hemorrhage and bleeding from gastro-enteric anastomosis marginal ulcer in patients, all with mild hemorrhage. no etiology was fond in patients with mild hemorrhage. a significant association was found between the severity of late hemorrhage and the vascular pseudoaneurysm as a cause of bleeding (p \ . ). all pseudoaneurysm bleeding occurred in cases complicated by a postoperative pancreatic fistula (popf) with a significant statistical association (p \ . ). conclusions: the most common cause of pph was bleeding from a vascular pseudoaneurysm, most of them were severe bleeding with late presentation and all were associated with a popf. in these cases, early detection by cta is mandatory, allowing an urgent treatment by angiography of such a bleeding vascular complication following pd. ventral hernia in hostile situation introduction: there is no consensus about the benefit or harm derived from adding a mesh hernioplasty at the same time as an urgent intraperitoneal surgery for another cause. the use of a prosthesis in contaminated fields is controversial, but suture repair has a high risk of recurrence. the main objective has been to analyze the impact of the simultaneous repair of uncomplicated midline hernias at the same time as emergency surgery for another cause, in relation to the presentation of complications, the surgical site infection rate (isq) and recurrences. material and methods: retrospective, observational study of all urgently operated patients (surgery open and laparoscopic) in the period between - who underwent a simultaneous midline primary ventral hernioplasty. the background, circumstances of the surgery and postoperative complications during the first month and long term through the basis of prospective data of emergency surgery and complications of our surgery department. results: a total of patients ( female) met the inclusion criteria with a mean age of . years (sd = . ), average bmi of . kg/ m (sd = . ). the most frequently performed interventions were: appendectomy ( . %); cholecystectomy ( . %); and lysis of adhesions ( . %). the . % of all interventions were performed by laparoscopic approach. they presented associated peritonitis in . % of the cases. the . % of patients presented some complication, in . % surgical site infection ( . % organ space). during the followup three recurrences were detected ( . %), no patient has presented chronic infection related to the use of prostheses. conclusions: in our series the simultaneous performance of hernia repair of the midline in the context of emergency surgery for another cause has been safe and not associated with long-term complications and low recurrence rate. the open abdomen: our experience introduction: ''open abdomen'' refers to a solution in which the abdominal content is left deliberately exposed under a temporary cover for a variable amount of time. since this method has been used more and more for the treatment of severe intra-abdominal infections. starting from the s the concept has been also applied in trauma surgery. material and methods: between / we have treated patients with this technique. in cases the etiology was traumatic, in the remaining cases the abdominal pathology was inflammatory. in the last years we also started to use it in some cases of treatment of surgical complications. the techniques we used were different and changed during the time. at the beginning of the experience we've completed drainages of the abdominal cavity according to mickulizt, laparostomies with mesh, bogota bags. these techniques have been abandoned since the negative pressure therapy came out. we started with the barker vacuum pack ( cases), followed by the vac (vacuum assisted closure) and ab thera kci Ò ( patients) systems and in the last three years we used the cnp suprasorb Ò of lohmann and raucher ( patients case history: year old lady presented at the a&e with few days history of constipation, faeculent vomiting, abdominal distension and pain in the lower abdomen. she had hysterectomy many years ago through a lower midline incision. her urgent ct scan of the abdomen and pelvis confirmed an incarcerated right obturator hernia containing a small bowel loop causing bowel obstruction. clinical findings: elderly, frail patient with mild tachycardia, distended abdomen and lower abdominal tenderness with guarding in the left iliac fossa. per rectal examination was unremarkable. investigation/results: inflammatory markers were raised, lactate, liver and kidney function was in normal limits with only mild hypokalaemia and hyponatraemia. ct abdomen and pelvis confirmed small bowel obstruction at the mid ileal level due to right obturator hernia. diagnosis: incarcerated right obturator hernia causing small bowel obstruction. therapy and progressions: patient was taken to the operating theatre for urgent laparotomy. dilated small bowel loops and incarcerated right obturator hernia was found with proximal ileal loop in it. after blunt stretching and dilatation of the obturator foramen, the involved ileal loop was reduced. it was deemed viable, therefore no bowel resection was required. the defect at the right obturator foramen was closed with suture. post-operatively the patient was transferred to the intensive care unit for further management. comments: obturator hernias are a rare type of pelvic hernias. their real incidence is unknown but it is thought to be less than % of all hernias worldwide and due to its non-specific symptoms and late diagnosis, they require bowel resectional surgery in nearly % of the cases. howship-romberg sign is helpful in diagnosing such a hernia, but the ultimate diagnostic choice is ct scanning which is the only way to find this condition early and avoid bowel ischaemia. case history: a -year-old woman without previous medical history presented to the emergency department with abdominal pain and dysphagia associated with nausea, vomiting and absolute constipation. during previous months, she reported having ingested hair. clinical findings: abdominal examination revealed a distended abdomen with rebound tenderness and tinkly bowel sounds. investigation/results: ct-scan showed a distended stomach with a mussel-shaped, heterogeneous and non-enhancing mass. an esophagogastroduodenoscopy revealed hair inside the lower esophagus and the stomach. diagnosis: high intestinal obstruction due to a gastric trichobezoar. therapy and progressions: the patient underwent laparotomy, gastrotomy and trichobezoar removal (fig. ) . the postoperative period was uneventful and she was discharged home on the th pod with a psychiatric evaluation scheduled. comments: bezoars are rare conditions consisting of compacted material that is unable to pass through the gastrointestinal tract. this condition usually involves the stomach; rarely, it can extend into the small bowel and even the colon, giving the so-called rapunzel syndrome. bezoars could be composed by vegetable material (phytobezoars), hair (trichobezoars), drugs (pharmacobezoars), or other materials. , a trichobezoar is the result of trichotillomania, trichophagia or other psychiatric disorders. always consider bezoars in differential diagnosis. introduction: the effectiveness of different step-up approaches is increasingly evaluated but results are controversial. we assessed the results of a standardized step-up approach protocol in the treatment of acute severe necrotizing pancreatitis, with a special focus on patient stratification to obtain an early identification of those deserving a more aggressive strategy. matherials and methods: this is a retrospective analysis of patients with acute severe pancreatitis over a period of years. the variables taken into account were: etiology and severity of the disease, sepsis, organ failure, hemodynamic stability, treatment, los, morbidity, mortality. since , patients with infected necrosis underwent a standardized step-up approach: percutaneous drainage only; percutaneous and endoscopic procedure; surgery. the results were compared with the standard care delivered from to . results: among patients, ( . %) were identified as affected by severe necrotizing disease. overall mortality was . %. the initial management was non operativein all patients. mortality in the step-up group was % ( / ) vs % ( / ) in the standard care group. conclusion: a standardized step-up approach protocol offers better results than standard care in the management of acute severe necrotizing pancreatitis. however, a better stratification of patients. introduction:the appendix stump closure in complicated appendicitis has been widely practiced in different ways such as metal clip, hem-o-lok clip, endoloop and endostapler. the treatment of complicated appendicitis with necrosis and perforation of the appendix base is controversial. we aimed evaluate the efficacy of laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and base perforation. material and methods:from january to october , we evaluated consecutive patients who underwent a laparoscopic partial caecum resection in complicated appendicitis with necrosis and perforation of the appendix base. partial caecum resection was performed with the endostapler to close the appendix base at ileocaecal junction. results:the laparoscopic partial caecum resection with endostapler was used in % . of the cases. the mean operative time was . ± . min. there were necrosis of appendix base in , perforation of appendix base and diffuse peritonitis in , perforation of the appendix base and localized peritonitis in of the patients. the wound and intra-abdominal infection rates were . % and . %, respectively. there were no operative complications and the conversion rate was . %. the average length of hospital stay was . ± . days. there was no leakage on the stapler line. conclusions:the laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and perforation of the appendix base, is a safe and effective technique. introduction: the term ''''volvulus'''' comes from the latin ''''volvere''''meaning twist. if left unattended, sigmoid volvulus can compromise the blood supply of the involved segment,leading to ischemia,gangrene,perforation and death. the mainstay of sigmoid volvulus management has been through proctoscopic or colonoscopic decompression when feasible, followed by surgery either during the same admission or electively. the aim of our study is to identify patients which can benefit of immediate surgical approach and prognostic factors associated with failure of conservative/endoscopic treatment. materials and methods: charts of patients admitted for sigmoid volvulus to our institute were retrospectively analysed. we revised ct scan images and laboratory tests of all the patients to identify risk factors for conservative treatment failure. results: patients underwent surgical procedures; in cases after a failure of an initial conservative approach; patients were managed with endoscopic approach only. elective surgery was performed in patients. case history: we report a -year-old male case presenting left hand middle finger pain after pressured paint gun shot in volar proximal phalanx clinical findings: on physical examination swelling and tenderness on the volar side of the hand was observed (fig. ) investigation/results: pain was remarkably more intense with passive finger extension. distal nerurovascular status was unscathed. there was no fracture reported on radiography. leukocytosis and acute phase reactants rise was observed on laboratory examination diagnosis: after physical, radiological and laboratory examination the diagnosis of acute flexor tenosynovitis was made. therapy and progressions: open debridement and irrigation following bruner incisions on middle finger was undertaken within h of injury. paint impregned in tissues could be observed in subcutaneous tissue, palmar fascia and flexor tendon sheath. paint affected tissues samples were analysed in microbiology laboratory (fig , ) after checking nerurovascular indemnity, g drainage was left in deep tissues and skin suture was performed with - monofilament non absorbable suture. the patient followed days intravenous antibiotical therapy followed by weeks oral treatment. he attended physiotherapy program postoperatively, reporting no functional disability or wound complications after weeks. comments: chemical flexor tenosynovitis is an important emergency which must be correctly diagnosed and treated due to quick progression and potential morbidity if not treated effectively ( ) in our experience, case was managed by open debridement and irrigation but different treatments can be followed depending of patientsclinical situation, such as iv antibiotics with serial examinations or percutaneous drainage. it should also be noted that australia does not have a specific subspecialty in emergency surgery. the acute surgical unit at the tch was set up in in order to provide a dedicated acute unit to service the ever increasing demand acute surgery. previous model was that the acute surgical service was integrated into the elective work. additional beds were provided to the unit including the positions of a dedicated director and chief nurse. the achievement of the unit has been the decreased time to theatre, less after-hours operating, standardised treatment approaches, and dedicated emergency surgery medical staff. the difficulties have included clinician engagement, competing resources with elective surgery, emergency surgical presentations increasing by - % each year, and the unit''s beds being used for non-acute patients as the hospital approaches regular %. the acute surgical unit has evolved into a specialised acute care that enables rapid assessment and treatment of patients with staff dedicated with skills in this area. treating pyogenic liver abscesses secondary to diverticulitis in a patient using immunosuppressants for crohns disease by performing a sigmoid colectomy introduction: pyogenic liver abscess (pla) formation due to microbial contamination of the liver parenchyma is often seen secondary to intra-abdominal infections. pla formation due to crohn''s disease (cd) is a rare complication and not well-documented in current literature. as symptoms often mimic a cd exacerbation, diagnosis is often delayed and severe disease may develop. optimal treatment for this group of patients remains debatable. case presentation: a -year-old man was admitted to the hospital with a -week history of overall malaise, fever and night sweats. patient''s history solely stated a -year treatment of cd that was stable over the past period with infliximab and azathioprine. investigations and treatment: biochemical analysis revealed a c-reactive protein of mg/l and a white blood cell count of . /l. an abdominal ct scan showed multiple abscesses in the right lobe of the liver and a thickening of the wall in the transition of the descendent colon to sigmoid. the patient''s immunosuppressants were paused, intravenous antibiotics were administered and a percutaneous drainage of the biggest pla was performed. however, the clinical condition of the patient did not improve. colonoscopy and pet-ct scan did not reveal any other sites of infections. as patient remained septic and previous imaging revealed mild diverticulitis rather than active cd, an emergency hartmann''s procedure was performed. hereafter, the patient recovered rapidly and the plas resolved completely. conclusion: diverticulitis of the sigmoid colon should be considered as causative pathology in patients presenting with multiple pyogenic liver abscesses and a history of crohn''s disease that is in full remission with immunosuppression. when the abscesses exceed cm in size and are multilocular, resection of the inflamed colon can be a treatment option of value. clinical findings: epigastric pain and recent episode of hematemesis. pain at deep palpation of the epigastrium, no signs of peritoneal irritation investigation/results: abdominal x-ray and ct showing a large right sided strangulated paraesophageal peh, with pneumatosis of the gastric wall diagnosis: right sided strangulated peh therapy and progressions: emergent laparotomy. peh reduced, ischemic portion of the stomach recovering viability. closure of diaphragmatic defect with non-absorbable suture, reinforcement of lower esophageal sphincter with round ligament (ligamentum teres hepatis) and anterior partial fundoplication (dor). postoperative course uneventful, patient discharged on th pod. comments: peh are mediastinal displacements of abdominal organs, most often the stomach, associated with laxity or a hole in the phrenoesophageal membrane, large enough to allow the gastric fundus to herniate. because the stomach is attached to the gastroesophageal junction, it tends to rotate around its axis leading to organoaxial volvulus. occurrence and size increases with age. peh account for - % of all diaphragmatic hernias. in patients without prohibitive operative risk, they should be surgically corrected, avoiding the risk of acute and potentially life-threatening complications when emergent surgical repair is required. the risk of developing these complications is less than %/yr and associated mortality rate is approximately %. case history: patient was a previously healthy -year-old female with an unremarkable past medical history, non-smoker with a high body mass index (bmi [ ). she first presented to a level medical facility with acute left upper leg pain and swelling. one week prior to this she had a progressive cough, swinging fever, and malaise. clinical findings: patient was transferred to our hospital haemodynamically unstable, acidotic, hypoxemic and delusional. tachypnea and oliguria were present. she continued to deteriorate clinically with pyrexia (t , oc), resistant shock, and toxaemia. on examination her left leg was found to be paresthetic below the femoral-inguinal fold. investigation/results: abg samples showed lactic acidosis with a ph of . and lactate of . mmol/l. hypoxia and hypocapnea were present.her biochemical profile showed acute kidney injury (aki) with raised creatinine kinase (cpk) and serum creatinine (cr) . . chest x-ray illustrated bilateral lung infiltrations (ards image). diagnosis: patient was urgently referred to a ct scan of the left femur with i.v. contrast for suspected necrotising fasciitis. ct findings highlighted a deep muscular femoral abscess with multiple regional fluid collections and necrotizing inflammation from the femur diaphysis to the patella. therapy and progressions: the patient was immediately transferred to or for emergency surgical exploration and debridement. almost the entire anterior compartment of the femur was necrotic and hence an extensive excision of the dead tissues and packing with npwt was performed. comments: severe snm can cause marked systemic toxic effects, namely, the streptococcal toxic shock syndrome (stss). stss secondary to snm is a life-threatening host response to gas superantigens with a mortality rate as high as %. clinical findings: patient had a diffusedlty tender abdomen and had not passed flatus proceeding his admission to the a ? e department and was vomiting. investigation/results: ct abdomen showed small bowel dilatation with abrupt cut-off point proximal to the icv diagnosis: a diagnosis of small bowel obstruction was made based on the clinical and ct findings. therapy and progressions: patient was taken to theatre for laparoscopy ? -proceed and a 'slipped' bowel lopp was noted within the peritoneal flap that had been created a week prior during the original hernia repair. the 'v lock'' suture line was found to be loose which is thought to have led to this complication. the bowel loop was reduced, deemed viable and an internal hernia repair was performed. post-operative period was unremarkable and the patient was discharged day posy-operatively. comments: during lap tapp hernia repair, there are currently at least options avaiable for peritoneal flap closure; (sutures, tackers and glue.) suregons prefernce prevails over the chosen approach. when sutures are chosen, most surgeons prefer the self-locking v-lock stitch. by adopting this technique, meticulous periotneal closure is impoartan, as loose suturing of the peritoneum can lead to post operative complications of internal herniation and small bowel obstruction, as described in this case. a multi-centre prospective study would be welcomed, to compare efficacy and safety of all types of peritoneal closure devices. introduction: peer review assessment of medical treatment has been shown to be a robust way of improving quality of care in trauma in our institution and globally. in we introduced regular morbidity and mortality meetings at the department of gastrointestinal surgery. severe complications (revised accordion classification [ ) after surgery were identified on a weekly basis, evaluated and data included in a local quality registry with the aim of revealing suboptimal surgical quality and continuously improving our results. material and methods: retrospective analysis of collected data from the described quality registry. all adult patients who had undergone gastrointestinal surgery in were assessed. results: of surgical procedures performed, % were emergency procedures. a total of % ( / ) experienced a severe complication after surgery and % ( / ) required reoperation. in the group of upper gastrointestinal surgery [n = ( %)] % were emergency procedures. anastomotic leak (al) was identified in % ( / ) undergoing thoraco-laparoscopic esophagectomy and in % ( / patients) after gastrectomy. of laparoscopic cholecystectomies, % were emergency procedures with % ( / ) reoperation. of hernia repairs, % required reoperation. in the group of lower gastrointestinal surgery [n = ( %)] % were emergency procedures. al was diagnosed in % of colonic resections and % of patients after rectal resection. in emergency colorectal resections(n = ) there were no al. of appendectomies, patients ( %) required reoperation. the most frequent cause of reoperation was revision of stoma ( ), followed by reoperation for al ( ), abscess ( ), and wound dehiscence ( ). patients died after surgery of which were emergency surgical patients. conclusions: systematic assessment of all severe complications helps reveal surgical procedures which can be improved but also to identify surgical procedures with low complications rates. plans are being developed to improve the quality of the identified procedures. all surgical departments should have regular and thorough assessment of their activity. acute surgical patients operated by emergency surgeons has less risk of post-operative complications and mortality d. gumaa east kent hospitals university nhs foundation trust, general surgery, ashford, united kingdom introduction: in england and wales, we perform over , emergency laparotomy every year. days mortality rate is around - %. in our study we are trying to demonstrate if have dedicated emergency surgery service will make a difference in the outcome of emergency laparotomy. material and methods: retrospective study on prospectively collected data from nela database done in a large district general hospital. all patients over years old who underwent emergency laparotomy for acute surgical condition between november and january were included in the study. mortality and post-operative complications were the primary outcomes. results: total of patients were included in the study, operations were performed by emergency surgeons (es). days mortality rate was %, while it was . % for the none emergency surgeons group (nes) post-operative complications were . % compared to % for patients operated by nes. there was shorter itu stay with average of . days, while the itu stay for the other group was . days, but the es group had higher chance of unplanned return to theatre. . % of the patients went back to theatre compared to % of the other group. reasons of unplanned return to theatre was mainly post-operative collection or wound dehiscence. conclusions: emergency surgeons has better outcomes when they perform emergency laparotomy, may be because they perform higher number of laparotomy compared to their peers. emergency surgery has been a growing subspeciality recently, and with no doubts having surgical emergency units has improved the patient's care around uk. the advantage of g over g of prophylactic cefazolin in surgical site infections in trauma surgery below the knee introduction: the rate of surgical site infections(ssi) after foot/ankle surgery remains high, despite the implementation of antibiotic prophylaxis ( ) . recently guidelines suggest a single dose of g instead of g of cefazolin for implant surgery, this decision is largely based on pharmacokinetic studies ( ) . however, the clinical effect of this higher dose has never been investigated in this region. this retrospective cohort study therefore investigated the effect of g compared to g of prophylactic cefazolin on the incidence of ssis in foot/ankle surgery. material and methods: all patients undergoing trauma-related surgery of the foot, ankle or lower leg between september and march were included. primary outcome was the incidence of a ssi. ssis were compared between patients receiving g and g of cefazolin as surgical prophylaxis. results: a total of patients received g and patients received g of cefazolin. the groups did not differ in gender, age, weight, co-morbidities or intoxications. the overall number of ssis was ( . %) in the g group and ( . %) in the g group. corrected for the confounders ''age'', ''smoking'' and ''blood loss'' this was not statistically significant (p = . ). conclusions: even though the decrease in ssi rate from . to . % was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality and healthcare costs. research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing ssis in foot/ankle surgery. introduction:right-sided colonic diverticulitis (rd) is much rarer than left-sided (ld) and subsequently, controversies concerning the most appropriate treatment remain unsolved. our experience let us believe that mild rd can benefit from an outpatient management. material and methods: we performed a single center retrospective comparative study in which we included all our diverticulitis patients that were treated as inpatient in our unit. we divided in two groups:rd and ld group. the ld group was created by randomization from a prospective ld patients database. results: we included rd and ld patients treated in our unit from july to july . median age was . in rd and . in ld, with a . % of females in rd vs . % in ld. asa classification was significantly lower in rd (asai: . % vs %, asaii: . % vs , , asaiii: vs . %, asaiv: vs . % p = . ). the presence of neumoperitoneum in ct scan was significantly higher in ld . % vs . % p = . ) surgery was performed in . % of the left-sided diverticulitis compared to of the rd group (p = . ). antibiotics of third line (imipenem and meropenem) were only required for ld ( vs . % p = . ). length of hospital stay was significantly shorter (p = . ) in rd ( . ± . ) than in ld group ( . ± , ) conclusions: in our series, patients with right diverticulitis had fewer perforations in the ct scan, they required lower spectrum antibiotics and did not required any surgical treatment with a shorter length of hospital stay. we consider that mild right diverticulitis could benefit from an outpatient treatment with oral antibiotic following similar recommendations to those followed for mild ld patients. when surgery should not be immediate, a night of hospitalization in a specialized environment is performed and surgery deferred overnight. in some selected patients, a return home is possible with a scheduled emergency surgery the next day. the pa.r.c.o.ur protocol is set up in the surgical emergencies of the university hospital of lille after a suitable medical treatment and enlightened information. this retrospective study assesses whether this deferred surgical management allows a return home on the day of the operation. methods: between / / and / / , records of patients operated for an abscess, appendicitis, cholecystitis or symptomatic inguinal hernia were reviewed. patients who did not have criteria for immediate surgical management (peritonitis, occlusion, sepsis, cellulitis, intravenous treatment need) agreed to return to their home for an os the next day. results: / % interventions were performed in os and allowed a return home at day , within a median time of h [iqr - ]. conclusions: the pa.r.c.o.ur protocol makes it possible to reserve the availability of the entire technical platform (operating rooms and beds) to the most serious pathologies with a failure rate of %. the medico-economic benefits, the efficiency in the management of the beds and the satisfaction of the patient and medical staff of this protocol must be evaluated prospectively. a years old woman was admitted in our er presenting with a h sharp epigastric and ruq pain, fever, nausea and vomiting, hd stable. the patient had a past medical history of tachyarrhythmia, open-angle glaucoma and lower limb venous insufficiency. her past surgical history included an hysterectomy and bilateral salpingooophorectomy, appendectomy and left inguinal hernioplasty. during clinical examination, signs of peritoneal irritation were present. ct scan revealed a small pneumoperitoneum in the luq and multiple small and large bowel diverticula, without free peritoneal fluid. blood work showed mild leukocytosis and neutrophilia. we performed an urgent exploratory laparoscopy in which dozens of small intestine diverticula were found, increasing proximally in number. one of them, cm distally from the treitzs angle, showed signs of perforation, with a small abscess and surrounding fibrin. the affected bowel was externalized through a cm laparotomy for segmental resection and a manual double-layer terminoterminal jejunojejunostomy was performed. in the perforated jejunal diverticulum, a mm cod fishbone was identified as the cause of the perforation. the histopathological examination of the extracted cm tissue sample, found several diverticular structures of the muscular wall, one of which with a mm perforation and a granulocytic infiltrate with serosa involvement. complicated cases of small bowel diverticulosis are best managed by segmental resection surgery. despite being quite rare, every surgeon should be aware of such acute abdomen presentation. asymptomatic cases benefit from a watch-and-wait approach. case history: a -year-old female consulted to the emergency department for a h epigastric pain. it was accompanied by nausea without vomiting. clinical findings: the patient was hemodynamically normal and the abdomen was soft with minimal distention. investigation/results: x-rays showed large gastric dilation. the abdominal ct scan showed mesenteric axial gastric volvulus with minimal free fluid. suddenly, the patient presented diffuse abdominal pain with diaphoresis, mucocutaneous pallor, hypotension and tachycardia. diagnosis: a gastric volvulus with gastric ischemia was suspected. broad-spectrum antibiotic therapy and resuscitation measures were started. emergency surgery was indicated. therapy and progressions: a decompressive gastrostomy, gastric reduction and devolvulation, transverse colon resection due to ischemia and splenectomy were performed. after h, she required total gastrectomy and right hemicolectomy due to ischemia secondary to severe septic shock associated with disseminated intravascular coagulation. comments: the gastric volvulus is an uncommon entity, being the mesenteric-axial type so rare. there are very few cases described whose manifestation is accompanied by hypovolemic shock secondary to splenic laceration, which occurred due to the great gastric distention. early diagnosis is the key to start treatment as quickly as possible, due to high mortality the main mechanism of death is usually vascular involvement, perforation and multiorgan failure. results: we analyzed , pediatric ogis, and . % of pediatric cases occurred in the - age group, . % in - , . % in - , and . % in - . the average age of the cohort was . years and . % of cases occurred in boys. racial distribution revealed . % of cases in caucasians, . % in african americans, and . % in hispanics. most ( . %) cases were documented in the southern united states. of our , cases, . % underwent vitrectomy, . % underwent enucleation, and . % developed endophthalmitis. the rate of endophthalmitis development after ogi was highest ( . %) in the asian/pacific islander group. the average length of stay for the entire cohort was . days, and the average cost per day was $ , . . table contains a breakdown of our statistics. conclusions: as documented in the nis, ogi occurs more commonly in boys than in girls at a ratio of approximately : . the rates of vitrectomy and enucleation are higher in boys. we noted a higher of rate of enucleation in asian/pacific islanders and african americans. the plurality of ogis occur in the - age group; this age group also has the highest relative rate of enucleation. with respect to location, ogis occurring in the western united states had the highest average cost per day of inpatient stay. autologous tissue from intramedullary channel parietes for femur nonunions management introduction: a reamer-irrigator-aspirator (ria) method is deeply reliable for getting high volumes of bone graft/mscs. high rates of successful outcomes have been reported after the use of ria bone fragments to cure non-unions. material and methods: being supported by histomorphological examination of the material acquired while drilling intramedullary channels of patients with femur nonunions ( -hypertrophic, oligotrophic), we have discovered that nevertheless, expressions of the dystrophy and necrosis in bone tissue and marrow in pseudoarthrosis areas depend on time since fracture occurrence, the microscopic study of the material cm above and below a fracture line has demonstrated ordinary structures of bone tissue and marrow in all cases. introduction: this study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (pmfs) involving \ % of the articular surface treated with or without screw fixation. material and methods: among patients with ankle fractures and pmfs who underwent surgery between march and february , with type pmfs involving \ % of the articular surface were included. of these patients, underwent screw fixation for pmfs and lateral and/or medial malleolar fracture fixation (group a) and underwent internal fixation for malleolar fractures without screw fixation for pmfs (group b). ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (ct). clinical outcomes were determined using the american academy of orthopaedic surgeons foot and ankle questionnaire, short form- , and american orthopaedic foot & ankle society scale. results: nonunion was not noted in either group. however, we detected union with a step-off of mm or more in cases from group b. with regard to ankle joint alignment, case in group a and cases in group b showed mild asymmetry of the medial and lateral clear spaces on ct at months. clinical outcomes at and months after surgery were better in group a than in group b. conclusions: screw fixation of pmfs was effective for fracture healing and maintaining ankle alignment. additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with pmfs involving\ % of the articular surface. references: level ii, prospective comparative study. how accurate can gaps and step-offs be determined in acetabular fracture treatment? introduction: the assessment of gaps and steps in acetabular fractures is challenging. studies evaluating the value of various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. this study aimed to assess the inter-and intraobserver variability of gap and step-off measurements using pelvic radiographs, intraoperative fluoroscopy and computed tomography (ct). material and methods: sixty patients, surgically treated for acetabular fractures, were included. five observers measured the gap and step-off on all the pre-and postoperative pelvic radiographs and ct scans. intraoperative fluoroscopy images were reassessed to determine the presence of gaps and/or step-offs. the inter-and intraobserver variability were calculated for the measurements using pelvic radiographs or ct scans. kappa was calculated for the intraoperative fluoroscopy assessment. results: for the preoperative displacement, the intraclass correlation coefficient (icc) was . (gap and step-off) using pelvic radiographs, and . (gap) and . (step-off) using ct scans. for the postoperative displacement the icc was . (gap) and . (step-off) using pelvic radiographs and . (gap) and . (step-off) using ct scans. the average kappa for the intraoperative gap and/or step-off assessment using fluoroscopy was . (- . to ) both for the inter-and intraobserver assessment. conclusions: there is little agreement between the observers regarding the measurements of the preoperative displacement, the presence of gaps and step-offs intraoperatively and the measurements of the postoperative displacement. a possible explanation for this is that the acetabulum has a three-dimensional spherical shape with multiple fracture lines and fragments going in different directions. single radiographic or ct-based gap or step-off measurements do not seem to be representative for the fracture characteristics, therefore the use of d measurements should be considered. introduction: long-term intake of glucocorticoids leads to pathologic changes in bone and cartilage tissues. material and methods: to understand how to prevent the occurrence of the pathology, we studied the use of vitamin d, vitamin e and a combination thereof on the background of the intake of prednisolone, . mg/ g of body weight. the experiment involved male rats of wistar linear breed. the animals were months old and weighted . ± . g. the experiment included series of animals, rats in each, namely: the first group-intact animals; the rest of the animals received prednisolone, . mg/ g of body weight. the rats of the third series received additionally iu of vitamin d . the animals from the fourth group also received . iu ( . mg) of vitamin e. results: long-term administration of prednisolone to the experimental animals has caused significant structural and functional disorders in their bone and cartilage tissues. they can be construed as simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated its ability to promote restoration of histomorphologic features of bone and articular cartilage in proximal femur epiphysis and epiphyseal cartilage of proximal femur epimetaphysis in animals with simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated a better effect on the background of the glucocorticoid-induced osteochondropathy, compared to the vitamin d alone. conclusions: preventive administration of the vitamins d and e while treatment with prednisolone leads to avoidance of the majority of pathologic changes, resulting otherwise from glucocorticoid-induced osteochondropathy. konyang university hospital, orthopaedic, deajeon, south korea introduction: the purpose of this study was to evaluate clinical, radiological and functional outcomes of patients had osteochondral autograft harvested from the ipsilateral femoral head for a femoral head defect after posterior hip fracture dislocation material and methods: this study was approved by irb at our institution. a retrospective chart review of a prospectively performed operation was performed at two university hospital between march , , and june , . all fracture was classified by the ao/ota classification. we included the patients had minimum months of follow up periods. ten displaced head fractures were addressed through posterior surgical dislocation and two patients had no posterior dislocation was operated using smith-peterson approach. an osteochondral graft was harvested from inferior non-weight bearing articular surface and grafted to osteochondral defect. all patients were full weight bearing by months results: we had femoral head fracture dislocation. patients were excluded due to lost to follow up. twelve of with type i/ii pipkin fracture dislocation with the articular defect and reduced within h of injury was identified for review. the patients were followed up for a mean of . months. there was no osteonecrosis. decreased joint space was identified in two patients. all fractures achieved union. the mean harris hip score of last follow up was . ( - ) one patient who operated using the smith-peterson approach had femoral nerve palsy. conclusions: the clinical and radiological results after treatment of femoral head fracture dislocation with articular defect by osteochondral autograft harvested from its own non-weight bearing articular surface show good outcomes. hospital universitario fundacion jimenez diaz, madrid, spain, hospital universitario de octubre, madrid, spain, hospital universitario la paz, madrid, spain introduction: preoperative computerized tomography scan provides important information about ankle fractures associating posterior malleolus, helping us distinguishing fractures affecting distal tibiofibular joint. the aim of our paper is to describe our series of patients suffering an ankle fracture with posterior malleolus involvement. methods: fifty-two consecutive patients, with ankle fracture involving posterior malleolus were evaluated prospectively. all of them were assed with a preoperative ct scan, demographic data, fracture mechanism, surgical approaches, posterior malleolus size measured classification and treatments were analyzed. results: most frequent posterior malleolus pattern according to bartonicek classification was type ii, twenty-two patients ( . %). an alternative surgical approach was performed in thirty-three patients ( %) as a consequence of information provided by ct scan. no statistical differences were observed when measuring posterior malleolus in conventional x-rays or ct scan. analysis of variance showed a p value less than . when comparing pm size and haraguchi and bartonicek classifications. discussion and conclusion: ct scan is required to perform an adequate preoperative study of ankle fractures involving posterior malleolus, using this information to provide a better outcome to our patients. effect of atorvastatin and losartan on gene expression and cell count in a rat model of posttraumatic joint contracture of the knee-a blinded and randomized animal study introduction: myofibroblasts have been associated with increased posttraumatic joint contracture, which has a massive impact on articular function. atorvastatin and losartan have shown to reduce the proliferation of cardiac, hepatic and pulmonary myofibroblasts. the aim of this study was to evaluate the effect of atorvastatin and losartan on gene expression, cell count and collagen deposition in the posterior joint capsule , and weeks after trauma in a rat model of posttraumatic joint contracture of the knee. material and methods: posterior capsular injury and kirschner-wire immobilization of the knee were performed in sprague-dawley rats. atorvastatin, losartan, or placebo was administered daily orally. the rats were sacrificed at either (n = ), (n = ) or (n = ) weeks after initial surgery. rats euthanized at week had their k-wire removed at week , followed by a remobilization period of another weeks. the results were evaluated via qpcr and immunohistochemistry. results: losartan reduced the number of myofibroblasts in comparison to the control at week and , whereas atorvastatin lowered myofibroblasts only at week (p \ . ). atorvastatin reduced the collagen deposition at week , whereas losartan had no effect on collagen deposition. losartan decreased gene expression of connective tissue growth factor (ctgf) at week and of tgf-b at week . clinical findings: positive anterior drawer test, grade iii valgus instability, and a palpable gap below the patella were assessed. no neurovascular alterations were found and ankle-brachial index scored [ . . investigation/results: initial immobilization with a splint was performed. radiographs showed a high patella with no other lesions. mri revealed a complete rupture of the patellar tendon and a complex multiligamentous injury with complete anterior cruciate ligament (acl) tear, avulsion of distal medial colateral ligament (mcl), and a complex rupture of both meniscus. diagnosis: knee dislocation with patellar tendon rupture. therapy and progressions: definitive treatment was performed days after the initial lesion, with arthroscopic resection of the posterior horn of the external meniscus and reconstruction of the acl with posterior tibial tendon allograft, as well as open repair of the patellar tendon and the internal meniscus, with subsequent mcl distal reinsertion. immediate partial weight-bearing with an extension orthosis was allowed. the patient is currently progressing with rehabilitation. comments: knee dislocation is a rare injury, and most cases are due to highenergy trauma. concomitant rupture of the patellar tendon is very unusual, and most cases are described in the context of open injuries. surgery is mandatory in order to restore full stability of the knee, with either one intervention or a staged surgery, including repair of the collateral ligaments and the patellar tendon followed by arthroscopic reconstruction of the cruciate ligaments. postoperative management consists on early rom restoration and weight-bearing as tolerated. introduction: apophyseal anterior inferior iliac spine (aiis) fractures are rare injuries. they most commonly occur in athletes in adolescence period. because the ossification of pelvis is not completed, apophyses are the weakest part of musculo-tendinous unit during this period, thus avulsion fractures are more frequent than muscle ruptures. aiis avulsions are the result of sudden and forceful contraction of rectus femoris muscle concentrically or eccentrically. material and methods: we report a clinical case of a aiis avulsion fracture in a young male football player, after being misdiagnosed as muscle strain. results: our patient was treated with conservative treatment including bed rest, analgesia, using crutches and toe-touch weight bearing, progressing to full weight bearing as tolerated and nonsteroidal anti-inflammatory drugs. at follow-up, he showed relief from his pain and mechanical symptoms and regained full range of motion and returned to his previous levels of activity. conclusions: diagnosis requires careful attention to the physical examination and imaging. in this case, the fracture was managed successfully with a conservative approach. good results and return to previous levels of activity can be achieved with conservative treatment. when misdiagnosed as a simple strain, the late diagnosis may cause chronic pain with decreased sportive performance in the future. therefore, a carefully taken anamnesis and physical examination with comparative anterior-posterior pelvic x-rays are needed not to miss avulsions in adolescents; also in some instances, more advanced scanning methods must be considered. introduction: the problem of meniscus damage in children is due to unsatisfactory treatment results, which is associated with the frequent execution of meniscectomies. amount of unjustified meniscectomies and the incidence of osteoarthritis can be reduced if menisci are repaired. material and methods: during the period january -august children with injuries of the meniscus were treated in morozov children's clinical hospital. children underwent meniscus repair by suturing using three techniques: ''all inside'', ''inside out'' and ''outside to inside''. meniscus suture decision was made taking into account the assessment of the severity of the damage. the period from the moment of injury wasn't taken into account. the technique of meniscus suture was determined depending on the location and type of damage. we met children with damage to the discoid meniscus who underwent partial resection and meniscus suture. children underwent a meniscectomy due to severe traumatic and degenerative changes. children had mri of the knee after months and x-ray after months. results: children achieved a satisfactory functional result; operated children are at the rehabilitation stage. we faced a complication-limitation of flexion in the knee joint in child. in all children on the control mri, the absence of synovitis, the safety of the reconstructed meniscus contour and the decrease in the intensity of the hyperechoic signal in the gap zone in dynamics are determined. conclusions: the introduction of a technique for repair meniscus integrity in the daily practice of an arthroscopist makes it possible to reduce the number of meniscectomies, which will reduce the number of unsatisfactory treatment results for this pathology and prevent the development of early osteoarthritis of these, children revealed a fracture-dislocation of the patella. in children, a tangential fracture of the lateral condyle of the femur was noted. in children, the dislocation was repeated. we met children with bilateral damage. all children with complete damage to the medial patellofemoral ligament, fracture-dislocation of the patella and dysplastic dislocation were performed tendon plastic using the quadriceps femoris tendon. the technique includes: transplanting a graft quadriceps tendon graft without cutting off the patella. next, the transplant is subfascial carried out in the medial direction and is fixed with a bio-integrated screw in the femur. results: the rehabilitation period was months. % of children have a satisfactory result (there is a limitation of flexion in the knee joint to °). % have an excellent clinical result: the full range of motion in the knee joint, the absence of pain and a return to sports. none of the operated children had relapses of dislocation. conclusions: it is recommended to consider the technique of tendon plasty of the medial patellofemoral ligament using the quadriceps femoris tendon as a method of choosing the treatment for patellar dislocation in children. case history: a -year-old boy who was injured while playing baseball. he was playing as a catcher and was bumped into the runner, therefore his ankle got twisted. he was immediately taken to the hospital. clinical findings: x-ray the distal tibial epiphyseal growth plate was irregular. although the ankle joint was not dislocated. in the ct, the proximal fibular fragment was caught behind the posterior edge of epiphysis of the distal tibia and was trapped there. investigation/results: the patient must be operated in order to repair the ankle. but the reduction of the entrapped distal tibia epiphysis was not easy without open. diagnosis: we diagnosed with bosworth like fracture. therapy and progressions: reduction was not easy, however we performed it by the pulling the fibula towards to outside, pulling out the curled anterior tibiofibular ligament, and then pushing into the tibia. we performed screw fixation after reduction of distal tibial epiphysis. furthermore, we fixed the fibula with plate. we made him to do range of motion exercise and toe touch gait from next day, and full weight bearing from weeks. we removed the implant months after the surgery. he did well subsequently, and at years after injury, he had normal function of the ankle, and normal x-ray. and he has returned to sports without pain. introduction: judo is the most popular martial art in the world and the first martial art recognized since as an olympic sport. worldwide, the international judo federation has registered countries with about million judo practitioners. like martial arts, judo mainly involves grip and throwing techniques. the competition rules in judo have been subject to constant adjustment and optimization in recent years. injuries prevalence is an important factor in the contact martial arts. material and methods: a prospective cohort study of all registered international athletes ( ) at three different european judo contests in germany were accomplished with the aim to investigate the injury rate as well as the pattern of injury. the age of the athletes ranged between and years. injury incidence rates were calculated per athlete-exposures (iirae) and per min of exposure (iirme). independent variables were sex and weight division. subgroups were compared by calculating the injury incidence rate ratio. results: severe injuries by judo tournaments are rare. the most frequently injured regions were the hand and head. the fights of the main block are riskier than the finals. the incidence of injury in heavyweight division differed with lightweight competitors. the risk of injury for female and male competitors differed slightly. conclusions: further studies are needed to determine a judo specific injury patterns and factors especially in the pre-competitional phase. investigation of prevention-strategies like the adaptation of competition rules etc. makes sense. does garden''s classification of femoral neck fracture match between orthopedic specialist and clinical resident? t. inoue , s. inoue , t. muraoka prefectural miyazaki hospital, orthopedics, miyazaki, japan introduction: garden''s classification is the most popular classification of femoral neck fractures. femoral neck fracture should be operated^ h; however poor agreement make waiting time longer because it takes more time to prepare implants and biological clean room. we investigate the agreement of the garden''s classification (non-displacement type or displacement type) between clinical resident and orthopedic specialist. material and methods: the examiner are a clinical resident ( nd year) and an orthopedic specialist ( th year). the subjects were cases of femoral neck fractures treated at our hospital between january and december . first, the examiners classified them into a non-displacement type and a displacement type (test ). second, the examiners studied the literature about unclassifiable type. third, the examiners classified cases month later once more (test ). finally, we compared the first test with the second test using the agreement (the number of matched patients/total) and kappa coefficient. results: the test showed that the agreement and kappa coefficient were . % and . . the test showed agreement was . %, . . the intra-observer agreement of clinical resident was . % and kappa coefficient was . . the orthopedic specialist was . %, and kappa coefficient was . . at test , cases did not match. cases of those were unclassifiable type, which were valgus type with medial fracture line. with slight displacement, agreement will get lower; some doctors consider it displacement type. conclusions: unclassifiable type makes us confused. it makes agreement better to discuss about unclassifiable type. introduction: the aim of this retrospective study was to describe the profile of missed hand and foot fractures in multitrauma patients and to elucidate risk factors for the delayed diagnosis. material and methods: from to , there were included patients. missed fractures were defined as fractures, which were not diagnosed during primary and secondary survey. patients were assessed for age, sex, glasgow coma scale, injury severity score, and length of stay in hospital (los). timing of hand or foot diagnosis related to admission date (measured in days) was noted. results: overall, . % of patients had a delayed diagnosis of hand fracture, . % ha a delayed diagnosis of foot fracture. the mean gcs for patients with delayed diagnosis was , whereas patients with diagnosis the day of admission had and mean gcs of (p \ . ). patients with delayed diagnosis had a mean iss of . versus . for those diagnosed the day of admission (p \ . ). furthermore, patients with delayed diagnosis had a mean los of . days, whereas those diagnosed at the time of admission had a mean los of days (p \ . ). concerning delayed diagnosis hand fractures, metacarpal and phalangeal fractures were the most common injuries overall ( . % and . %, respectively). concerning delayed diagnosis foot fractures, metatarsal fractures ( cases) and calcaneus fractures were the most common injuries overall, followed by talus fractures and toe fractures. conclusions: this study revealed that with a decreased gcs and increase in iss, polytrauma patients are increasingly at risk for delayed diagnosis of hand and foot fractures with a concomitantly increased los. as a delayed diagnosis has significant impact on the final functional outcome, correct and careful primary, secondary and tertiary survey is essential. introduction: the aim of this study was a) to determine the methods of hemorrhage control currently being used in clinical practice and b) to analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. material and method: between and , we included trauma patients with pelvic fractures (group ). a similar retrospective examination was performed on a number of trauma patients without pelvic fractures (control group). there were collected injury severity score (iss), the highest abbreviated injury scale (ais) score in each anatomic region and methods of pelvic hemorrhage control. there were also recorded hospital lengths of stay (los) and in-hospital mortality. results: the average follow-up was -months. the average iss in group and group was respectively . and . . in both groups the commonest mechanism of injury was motor vehicle crash ( . %). in group , angioembolization and external fixator placement were the commonest used method of hemorrhage control. patients underwent diagnostic angiography with contrast extravasation noted in patients. patients with pelvic fracture had a mean hospital los of . days. the overall in-hospital mortality rate of patients with pelvic fractures was . %, while in group the overall in-hospital mortality was . %. age, shock, severe head injury and increasing iss, are all significantly associated with mortality in the pelvic fracture group. conclusions: the findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient's clinical status. in healthier patients with unstable pelvic fractures, the mortality rate was similar to that of patients with stable fracture patterns. introduction: various percutaneous screw placement for pelvic and acetabulum fractures is often difficult because of complex anatomical morphology, however, it becomes very beneficial to set enough fixation stability if we can insert the long screws. d-ct navigation system for the screw placement is beneficial for precise screw insertion. we investigated the accuracy of screws with d-ct navigation. material and methods: our retrospective case series were assessed by the accuracy of screws with d-ct navigation for pelvic and acetabulum fractures. twenty-six patients who sustained pelvic fractures and thirteen patients who sustained acetabular fractures were included in this study and . mm cortical screws or . mm cannulated screws were inserted with d-ct navigation. we investigated the number of screws and screw positions which is measured by postoperative ct scan and classified by smith criteria. results: we inserted tits (transiliac-transsacral) screws and is (iliosacral) screws for pelvic fractures. of screws ( . %) were placed in correct position (grade or ). screw for s lesion was placed in incorrect position. meanwhile we inserted antegrade pubic screw, anterior column screws, posterior column screws and infra-acetabular screws. of screws ( . %) were placed in correct position (grade or ). screws were in incorrect position and they were all cortical screws. and there was no complication related to screw insertion. conclusions: our study highlights that d-ct navigation system reduced the malposition rate of screw insertion for pelvic and acetabular fractures. however, we sometimes had difficulty in inserting tits screw for s lesion and cortical screw for acetabular fractures. we assumed that this was caused by narrowness of s corridor and flexibility of drill or inserting cortical screws in wrong position manually. we should pay much more attention even using d-ct navigation. is operative therapy still warranted for dislocated acetabular fractures in elderly patients? introduction: the incidence of acetabular fractures in elderly patients is increasing. there is no consensus about the right treatment for the impaired elderly patient with an acetabular fracture. the aim of study was to investigate acetabular fractures in the elderly patient and the risk of a secondary tha. material and methods: a retrospective study was performed from till in the radboudumc nijmegen. all patients with an acetabular fracture were reviewed. they were divided into two groups, younger than and or older. ct scans were used for classification according to letournel and for the quality of the reduction according to matta. there was a follow-up of minimal years. results: in total, patients attended at the radboudumc with an acetabular fracture, of which were years or older. in the younger group, patients received surgery and elderly patients. according to matta, an anatomical reduction was achieved in % of the young patients and % of the elderly patients. imperfect reduction was achieved in % of the younger patients and % of the elderly patients. thirteen percent of younger group and % of the older group needed a tha based due to the posttraumatic arthritis, the younger group after months and the older group after months on average. one younger patient with anatomical reduction needed a tha, none of the elderly patients. twenty-three percent of the younger patients and % of the elderly patients, all with a poor reduction, needed a tha. age, the complexity of the fracture and the quality of the reduction were important factors leading to a secondary total hip arthroplasty. conclusions: elderly patients are two times more likely to need a secondary total hip arthroplasty. after an anatomical reduction, the risk is very low, even in the elderly. surgery for dislocated acetabular fractures is a good option when there is a possibility for a good reduction. references: letournel e. matta jm. introduction: in japan, as a definition of basicervical fractures of the proximal femur, a fracture line is placed into and out of the joint capsule of the hip joint. however, in fact there are various fracture types.we classified these fracture types based on treatment methods and reported on these results. material and methods: cases of proximal femoral fractures treated in our hospital from january to december . basicervical fractures occurred in cases ( . %). all cases diagnosed with x-ray and d-ct, and observed for months or more after surgery. results: there are two types of basicervical fractures: the fracture line exists around the just inside of the intertrochanteric part: normal type(n type); cases ( . %), and fracture line exists subcapital at ventral side, the coronal plane in the center of the neck and the trochanteric fossa at the dorsal part: coronal shear type(c type); cases ( . %).c type was further classified by treatment method depending on existence of posterolateral fragment and anterior wall fracture. c type without comminution ( part:c- type) was cases ( . %). with posterolateral fragment ( part:c- type) was cases ( . %), with posterolateral fragment and anterior wall fragment ( part:c- type) was cases ( . %).n type and c- type were treated by sliding hip screw (shs) with anti-rotation screw. c- type: shs with trochanteric stabilizing plate, c- type because of the bony contact area is very small: hemi-arthroplasty with calcar replacement was performed. cut out occurred in cases of c- type and case of c- type, but others obtained union.. one case of c- type occurred peri-prosthetic fracture intraoperatively. conclusions: we classified cases of basicervical fractures, and according to its classification, treatment method was decided and good clinical results were obtained. strategies aimed at preventing chronic opioid use after trauma: a scoping review c. cô té , m. berube université laval, faculty of nursing, québec city, canada, chu de quebec research center, université laval, trauma, emergency, critical care medicine, québec city, canada introduction: a high incidence of chronic opioid use (up to %) has been documented after trauma. solutions are urgently needed considering the importance of this public health issue. we aim to identify strategies to prevent chronic opioid use in the trauma population and to assess their level of evidence. material and methods: we initiated a scoping review of literature to identify research articles and guidelines on preventive strategies. several databases and websites of trauma were searched. strategies were classified according to their types and targeted trauma populations. the level of evidence was summarized according to an adaptation of oxford center for evidence-based medicine classifications and strategies effectiveness. results: close to items have been screened until now from which studies - and one guideline were found eligible. two studies - combined education with mandatory limit of opioid prescriptions (level iii) in the orthopaedic trauma population and the other study used tailored physical training after whiplash injury (level i). findings showed reduction of opioid use or complete weaning at and weeks after trauma, however the effect was not maintained beyond weeks. guidelines on orthopaedic trauma made the following recommendations: prescribe the lowest effective dose for the shortest period (strong, high-quality evidence), avoid long-acting opioids in the acute setting (strong, moderate-quality evidence), and prescribe precisely (avoiding ranges of dose and duration) (strong, low-quality evidence). conclusions: chronic opioid use is an important issue in trauma patients. findings highlighted the need for more research to reduce the burden associated with chronic opioid use in this population. references material and methods: we analyzed clinical cases: men- and women- , mean age years. trauma circumstances: habitual trauma- cases, traffic accident- , precipitation- , sport- , aggression- . for cohort analize schatzker classification was used: especially type i was meet in cases, ii- , iii- , iv- , v- , vi- ; close, open. for paraclinic examination were used x-ray and ct. surgical management consisted of: close reduction, internal fixation- cases ( -percutaneus canulated screws arthroscopic assisted, -external fixator), open reduction, internal fixation- cases. bone graft was done in cases. results: postoperative follow up was performed at , , , weeks. patients were evaluated according to the lysholm knee scoring scale, obtaining an average score of points. bone healing was achieved in a period of between to weeks. postoperative complication developed in cases. results were depending on the stability of osteosynthesis, precocity, rightness of functional reeducation and patient compliance. conclusions: favorable functional results and less complication were met in cases of individual approach of surgical management, a good choice of implants and minimally invasive surgical techniques. fractures of the shoulder processes-a case report case history, clinical findings and diagnosis: -year-old male, low-speed motorcycle crash with subsequent polytrauma. he presented with right shoulder pain, swelling and pain to the touch. articular ct revealed a type i fracture of the coracoid base, type iii acromion fracture and scapular body fracture without displacement. results, therapy and progressions: he was submitted to surgical treatment days later. a superior ''sabercut'' approach with open reduction and osteosynthesis of the coracoid process was performed with a cancellous screw and washer and fixation of the acromion with k-wires and tension band wire. fracture of the scapular body followed a conservative treatment. immediate postoperative period was uneventful and he presented with favourable evolution in the subsequent -week, -week and -month follow-up. at present time, at -month follow-up, maintained anatomical reduction in radiological control, complete arm abduction and no limitation with efforts. comments: conservative treatment is generally indicated for all shoulder body fractures without displacement. fractures of the coracoid or acromion with [ cm displacement are described as an indication for surgical treatment. fractures of the acromium without displacement may follow conservative treatment with sling immobilization. surgical fixation can be achieved with screws, plate and screws or tension band wire. although controversial, surgical treatment for coracoid fractures is preferred, especially in active young patients with open reduction and fixation with screws or, if necessary, with plate and screws. the treatment applied in the present case, all approaches described in the literature as being effective and with good results, is in agreement with the options described in the literature and constitutes a corroborative example of its efficient results. case history: a -year-old male, hand worker, attended to our emergency department after a traffic accident complaining about pain and swelling in his left wrist. initial radiographs revealed an isolated dorsal dislocation of the lunate that went unnoticed. two and a half months later he was referred to our clinic. clinical findings: findings included dorsal wrist deformity and pain. he presented a decreased passive wrist flexion and extension range of motion, with normal finger tendinous function. investigation/results: plain x-rays showed persistence of the lunate dorsal dislocation without any associated injuries. diagnosis: chronic isolated dorsal dislocation of the lunate therapy and progressions: open reduction was performed using a dorsal approach. the scapholunate, lunotriquetal and scaphocapitate spaces were stabilized with a compression screw and kirschner wires respectively. the patient persisted with pain and functional limitation after the surgery, showing an insufficient reduction of the scapholunate space on the x-ray. nine months after the initial surgery, he developed a purulent fistula on the ulnar edge of the carpus. after it was resolved, a total wrist arthrodesis was performed using the mannerfelt technique. at the months follow up, he was clinically stable, consolidation of the arthrodesis was documented and he had returned to his previous normal activities. comments: isolated dorsal dislocation of the lunate is a rare lesion. the delay in the diagnosis of carpal dislocations is frequent. this compromises the final outcome of reconstructive techniques and the risk of residual instability, hence increasing the risk of chronic pain associated with posttraumatic osteoarthritis. in the case of chronic lesions, treatment with palliative techniques such as proximal carpectomy or joint arthrodesis should be taken into consideration. references: siddiqui n., sarkar s. isolated dorsal dislocation of the lunate. open orthop j. ; : - is ultrasound-guided regional anesthesia safer than landmark technique? one-hospital experience introduction: according to the literature the application of ultrasound (us) in performing regional anesthesia had a significant impact on patient safety by increasing the success rate [ ] . in a donated ultrasound device became available in the institute of emergency medicine, chisinau, republic of moldova. due to lack of equipment both us guided and landmark techniques have been performed. the aim of this study was to analyze the two methods of performing regional anesthesia, in order to estimate the potentials benefits of of us guided techniques (succes rate and doses). results: the bivariate analysis showed that, out of anesthetics in lmg, a number of were reported as unsuccessful, compared with a number of in usg. the v test with corrections for continuity did not determine significance (test value . , df = , p = . , effect size = . ), rr being . ( % ci . - . ). linear regression for dose (lidocaine) modeling, in patients included in the research, showed a decrease of the dose by mg in lmg, the confidence interval being quite wide ( % ci -. , -. ). that is, the actual decrease is within the limits of and mg. conclusions: the tendency towards higher failure rate in successfully performing an us guided regional anesthesia and relative ''uncertain'' decreasing of dosage are in contradiction with the international statistical data. this in turn evidenced probable deficiencies in the training of the practitioners in field of ultrasound guided techniques in our country. the prospective research to confirme/infirme these results and estimate the complication rate follows. references: . barrington mj, uda y. did ultrasound fulfill the promise of safety in regional anesthesia? current opinion in anaesthesiology ; ( ) results: average age years old ( - ).all were active labour patient. the most frequent mechanism was high energy trauma (traffic accident), of who presented gustilo grade iiib open fractures operated in the country of origin. most frequent pattern of fracture was -c. ( cases) and -c. ( cases). initial conservative treatment was performed in of the cases. one persistent pseudoartrhosis with osteosynthesis material failure. in every case, preoperative ct and early surgical intervention were carried. in cases, an additional procedure was associated at the radioulnar distal joint. in all cases consolidation occurred. one patient required reintervention for persistent pseudoarthrosis. average consolidation time months ( ) ( ) ( ) ( ) ( ) ( ) ( ) .average follow-up of months ( - ). average active joint balance: flexion °( °- °), extension °( °- °), pronation °( °- °), supination °( °- °). average dash . ( - . ).force reduction greater than % compared to contralateral in of the cases. radiological parameters:radial height . mm ( - ),radial inclination °( - °),volar angulation . °( . °- °), ulnar variance . mm ( ) ( ) ( ) ( ) ( ) . conclusions: malunion of the distal radius is an uncommon and severe complication with increasing incidence that requires early and personalized surgical treatment to achieve the correction of the deformity, preserving mobility acquiring consolidation with acceptable functional results case history: isolated ulnar translocation of the carpus is unusual. when the translation occurs without injury of the radius, ulna or carpal bones are often misdiagnosed. early diagnosis is key, to avoid further complications such as redislocation of the carpus ( ). clinical findings: in our case a young male patient suffered a high energy motorcycle accident. he had no a b c d problem investigation/results: the ulnar translation of the left carpus was evident but comparison x-rays were taken on both wrist for further evaluation. the distance between the line, drawn through the axis of the radius and the center of the capitate bone was measured bilaterally. the results were . mm vs . mm. diagnosis: isolated, open ulnar translocation of the radiocarpal joint, dumontier type i, was diagnosed. treatment: the primary treatment was debridement, reposition and fixation with ex fix. after the wound healing on th days we made reconstruction. volar approach was used, we re-reponate the carpus and fixated the position with two mm smooth kirschner wires. the radioscaphocapitate and long radiolunate and radioscaphoid ligaments were reattached to the volar margins of radius using mitek mini anchors. we put the ex fix and left the bended wires percutaneously. after weeks the ex fix and the k wires were remove. wrist motion exercises were initiated under supervision of physiotherapist. comments: after weeks the wrist was in good alignment, the flexion-extension were - , the deviations were - °. the radiographic signs of this injury are unusual and often misdiagnosed. it can be useful to compare with contralateral x-rays. the radiolunate and radioscaphocapitate ligaments is considered crucial in prevention of ulnar translation. in our opinion the radiolunate arthrodesis can be reserved for failed ligament repairs. introduction: within the orthopaedic paediatric population, there is a distinct paucity of literature in regard to post-operative paediatric analgesic regimes. supracondylar humeral fractures account for % of all paediatric limb fractures and there has been a marked divergence in recent literature concerning the most appropriate choice of analgesia for this cohort with recent studies recommending the routine inclusion of an opioid agent post-operatively on prescription. opioids have deleterious side effects pertinent to paediatrics. in our institution, patients'' only receive a prescription for acetaminophen and nsaids upon discharge. our study assessed postoperative analgesic satisfaction rates in all paediatric patients who underwent crpp for supracondylar humeral fractures in our institution from january to december . material and methods: this is a retrospective multi-surgeon case series of all paediatric patients who underwent crpp from january to december . patient data was extrapolated from theatre records and clinical charts. for each patient, all analgesic agents given were identified, the dosage, route and frequency of administration in addition to the length of their hospital stay and time from injury to operation. following discharge, patients'' guardians were contacted retrospectively and a questionnaire was administered which ascertained the efficacy and duration of analgesia used by the patient postoperatively. results: fifty patients were identified for inclusion within the study who met the inclusion and exclusion criteria. there was a % satisfaction rating amongst the responders with the analgesic regime recommended-acetaminophen & nsaids. conclusions: in stark contrast to papers which we discuss throughout our paper, our study conclusively demonstrates that opioid prescriptions are not required upon discharge for supracondylar fractures within a paediatric population case history: a -year old man suffered an isolated injury of his right hand in a motorcycle accident. clinical findings: the patient presented with a swollen hand, a subtotal amputation of the middle finger at the level of the middle phalanx and lacerations to the other fingers (fig. ) . investigation/results: after excluding injuries to other body regions, radiographs and a ct of the hand were performed (fig. ) . diagnosis: closed fracture dislocation of cmc joints from ii. to v. finger, comminuted fracture of the middle phalanx of the middle finger, closed fracture of the proximal phalanx of the middle finger, other lacerations to the iv. and the v. finger. therapy and progressions: urgent open reduction and internal fixation (orif) with k wires of the cmc joints. exploration of the middle finger reviled heavy contamination and comminution of the phalanx, with injury to one neurovascular bundle. a phalangectomy with acute finger shortening was performed with creation of a new ip articulation (distal to proximal phalanx) (fig. , ) . progression after the surgery was uneventful. there was no sign of infection. the shortened finger was sufficiently perfused and the patient reported a sense of touch. k wires were removed after weeks and physical therapy was started. the patient has limited rom in his neo ip joint with minimal pain (vas - ) (fig. ) . comments: middle phalangectomy of the hand was described in the literature only in two papers which report treatment of chronical or congenital diseases. the authors propose this method as an alternative to amputation in selected trauma cases. results: patients ( m, f, mean age y) with fractures were included. kidney-tpl, lung-tpl, liver-tpl, heart-tpl, kidney/pancreas-tpl. all patients got treated with at least two immunosuppressive drugs. cause of accident: . % sports/leisure, % work/household, . % traffic accidents, % without trauma. the operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. patients were hospitalized for an average duration of . days and were also examined by the particular organ specialists. osteosynthesis: in % primary operative fracture treatment, in % two-step procedure. plates distal radius and ulna [healing period (h) conclusions: the fracture healing was possible but significantly delayed. the wound healing took longer. the immunosuppressive therapy may be responsible for these problems. the rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing. introduction: the prevalence of fragility fractures of the pelvis (ffp) increases, including in up to % a lesion of the posterior pelvic ring. an operative therapy is indicated in cases of prolonged or immobilizing pain or in a displaced dorsal fracture. methods: patients suffering an ffp treated with a minimal-invasive trans-sacral bar through s from to were included. the patients or their relatives were contacted to ask about mortality, the present mobility and place of residence. % of all patients still alive could be included in follow-up. results: females and males with a mean age of . ± . years ( - ) were included. concomitant stabilization of the anterior pelvic ring was performed in %. . % underwent an operative revision ( % evacuation of hematoma, % peri-implant infection, % hardware removal-combinations possible). the trans-sacral bar was removed in one case due to malpositioning. the length of stay was ± days. at discharge, % were mobile on the ward, % in their room, % for transfer to sitting position and % were bedridden. % were discharged to their home, % in geriatric rehabilitation unit, the remaining to other rehabilitation or to a nursing home. during follow-up, mortality was %, one patient died during hospital stay. the patients died in average ± weeks after discharge. after a follow-up of ± weeks, % lived at their home, thereof one-third with assistance. % needed a walking aid, % were mobile without walking aid, % were bedridden or only mobile to sitting position. conclusion: the trans-sacral bar in s is a valuable minimal-invasive stabilization method to recover mobility in elderly with an ffp. a relatively long in-hospital stay could be explained by the initial trial of conservative treatment and due to intra-and inter-departmental cogeriatric services. the high mortality and need for assistance reflects this geriatric, multi-morbid patient collective. case history: a -years-old woman was admitted in the emergency room after being run over by a bus. clinical findings: at the emergency room, she was conscient and hemodynamic stable. head, thoracic or abdominal trauma were excluded. the patient presented with an open wound in left popliteal area with massive bleeding with exposure of gastrocnemius and soleus muscles and achilles tendon investigation: radiologic images didn't show any fracture. a limb angiography showed complete perfusion of the leg, without any lesion on major arteries. diagnosis: open aquilles tendon avulsion through the popliteal fossa therapy and progressions: the patient was taken to the operating room. we approach the popliteal area and found a small laceration of popliteal vein, which was sutured with prolene / . then, we reference the achilles tendon, and tunneled the posterior face of the leg, and passed the tendon through the tunnel. a distal approach, above the insertion of achilles tendon was done, and two suture anchors preloaded with sutures were inserted in the medial and lateral sides of the calcaneal tuberosity, then we did an krackow suture. we also did a fasciectomy on the lateral side of the leg, to prevent compartmental syndrome. the patient was put in a posterior cast with of flexion for weeks. the immediate post-operative time was in an intermedia unit care, to control possible multiorgan failure. in days, she was discharged to orthopedics nursery. due to the degloving of subcutaneous tissue, she evolved with some blisters which made her stay inpatient about weeks. after some time, she developed some areas of skin necrosis, which needed some intervention by plastic surgery with skin graft. now, she has skin completely healed, some loss of strength in the leg, with loss of plantarflexion, and is under prolonged rehabilitation program. therapy and progressions: she was rushed into the or and submitted to external fixation of the humerus and bones of the forearm, debridement, and primary closure of the forearm and hand. successive dressings and debridement was maintained and, at th postoperatory day(po) the external fixator of the left humerus was removed and a nailing was performed as well as an osteosynthesis of the clavicle fracture with anatomical plate. at thpo the external fixator of the forearm bones was removed and an open reduction and internal fixation of the radius with lcp plate and closed reduction and internal fixation of the ulna with an anterograde ten nail was performed. at thpo, she underwent an autologous skin graft of the forearm and hand wounds. good clinical evolution of the wounds and fractures, all of which evolved to consolidation, although m fracture malunion was verified as well as deficit of thumb abduction and extension of rd- th fingers. uefi of / . comments: the approach of polytrauma patients should be sequential, according to the atls protocol, preserving life, limb and function. treatment of these lesions is complex and, if poorly managed, can be associated with high morbidity, as most patients combine severe and contaminated lesions, extensive skin loss, open fractures, postoperative infection. a sequential approach is required, which involves injury assessment, infection prevention, soft tissue treatment and fracture stabilization. introduction: pelvic fractures, though rare ( - %), are often associated with high mortality ( - %). the factual outcomes in polytrauma patients with the additional burden of pelvic fractures are unknown. the purpose of this study is to provide an in-depth analysis of pelvic fractures in seriously injured patients. material and methods: this is a retrospective analysis of prospectively maintained trauma registry from to . we included all trauma patients with iss c . group i, which had an additional burden of pelvic fractures, was compared with group ii, consisted of patients without pelvic fractures. a double-adjustment propensity score match (psm) analysis was utilized to minimize confounding and unbiased estimation of the impact of pelvic fractures. . ± . , asmd = . ).patients in group i had higher number of genitourinary surgery (p = . ), exploratory laparotomy (p = . ). therequirement of angio-embolization was similar in between two groups (p = . ). while there were no difference in mortality (or . , % ci . - . , p = . ), group i had higher odds of severe sepsis (or . % ci . - . , p = . ) and ventilator-associated pneumonia (or . , % ci . - . , p = . ) conclusions: pelvic fractures in polytrauma patients did not translate into higher mortality. however, there was an increased risk of sepsis and vap. evidence-based management at tertiary care specialized centers can further enhance the outcomes. investigation/results: ap pelvis x-ray reveals a complex left proximal femur fracture with neck and trochanteric extension. a ct-scan was obtained and showed a complex fracture pattern with subcapital and trochanteric extension. blood analysis showed a hemoglobin of . g/dl. diagnosis: therapy and progressions: at admission, patient refused erythrocytes'' concentrate transfusion and was hospitalized for pain control and hemodynamic stabilization. despite alternative measures such as intravenous iron supplementation and erythropoietin, hemoglobin values remained lower than . g/dl, thus preventing any surgical procedure. at day , patient finally decided to accept packed red blood cells and was then transfused. at day and with a hemoglobin of . g/dl, the patient was finally submitted to a total hip arthroplasty with an uncemented revision femoral stem. at day , the patient initiated the rehabilitation protocol with hospital discharge at day with a hemoglobin of . g/dl. comments: proximal femur fractures arise as one of the major problems of present traumatology. comorbidities frequently prevent surgical treatment within the golden hour (first h) and thus limiting the postoperative results. in this particular case, a timely surgical approach would have made it possible to try a more conservative procedure with femoral osteosynthesis. the surgical delayed due to low hemoglobin values limited the surgical options and forced a more aggressive procedure. routine versus on demand removal of the syndesmotic screw; a multicenter randomized controlled trial on functional outcome introduction: syndesmotic injuries are common, being present in approximately - % of surgically treated ankle fractures . one of the most commonly used ways of fixation is the syndesmotic screw (ss). traditionally, this screw is removed after - weeks as it is thought to hamper ankle function and cause pain. however, a recent study showed that implant removal does not always result in improvement of functional outcome . with the relatively high complication rate of implant removal in mind, retaining sss could be beneficial. we therefore aimed to investigate the effect of retaining the ss on functional outcome. material and methods: in this multicenter rct, patients were randomized between routine and on demand removal (upon patients request). the primary outcome was functional outcome at months after ss placement, measured by the olerud-molander score (omas) with a non-inferiority limit of points ( % power, a = . ). secondary outcomes include quality of life, range of motion, complications and costs of ss removal. results: a total of patients were randomized, of which for routine removal and for on demand removal. the mean age was years old and % was male. follow up of all participants will be completed in march . results of the primary outcome analysis are therefore not yet available, but will be at the conference. conclusions: if on demand removal of the ss is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. this means that patients will not have to undergo a secondary procedure, resulting in fewer complications and subsequent lower costs. introduction: treatment options for pertrochanteric fractures of the hip are extra-or intramedullary fixation. the aim of this study is to identify risk factors for the development of complications: varus deformity, neck shortening, revision and cut-out. material and methods: retrospective cohort study in which radiographs of patients with pertrochanteric fractures, treated at the uz brussel between and , were reviewed. fracture type, type of the device, cut-out and revision where noted. measurements for the centrum-collum-diaphyseal angle (ccd) of the two hips, impaction, tip apex distance (tad), parker''s ratio were realized. statistical analyzes were made with logistic and multiple linear regression analyzes. results: patients were included. bmi (p = , ), type of osteosynthesis (p = , ), dhs ? plate (p = , ), short nail (p = , ) and the tad (p = , ) are independent risk factors for the development of varus deformity after consolidation. for impaction are bmi (p = , ), short nail (p = , ), long nail (p = , ) and fracture type a (p = , ) independent risk factors. we identified a marginal statistical significant risk factor for cut-out: tad (p = , ). conclusions: , % of the patients had varus deformity after consolidation. the risk of varus deformity rises with a higher bmi and a higher tad. the risk for this complication was higher when using a nail. neck impaction was shown more together with a high bmi and less in fracture type a and with the use of a short or long nail. in the prevention of cut-out, it is important to keep the tad low. case history: -year old female with previous distal femoral plating ( years ago) and ipsilateral proximal femoral nailing ( months ago) presented with a diaphyseal femur fracture. clinical findings: extremity was swollen, painful, neurocirculatory intact, no shortening or external rotation was seen. she was unable to lift her leg. scars showed no sign of infection. investigation: x-ray revealed a spiral fracture including distal pfna locking screw, unhealed proximal femur fracture without loss of reduction, protruding pfna blade and a healed distal femoral fracture. diagnosis: peri-implant fracture classification proposed by the singapore group presented a discrepancy between nail type subtype b and plate type subtype. by simplification, we disregarded the distal (healed) fracture to choose the first option. therapy: firstly, the distal femoral plate was removed as the preoperative simplification dictated. secondly, pfna distal locking screw was removed and the pfna blade shortened. after open reduction cerclage wires were applied. a long lcp plate was initially fixed through the plate and pfna locking hole, adjusted in line, fixed proximally with screws through a locking attachment plate and cerclage, distally locking screws were used. comments: distal femoral callus prevented the use of a long nail. as the proximal fracture was not yet healed, we avoided full implant removal. as the pfna was unstable, fixation through the plate and pfna distal locking hole enabled implant coupling to strengthen the construct. the plate covered the entire bone to bridge the possible loci minori left by the plate removal and minimize stress risers. background: we have been reported the usefulness of intra-medullary antibiotics perfusion (imap) and intra-soft tissue antibiotics perfusion (isap) for suppressing open fracture and bone infection. imap and isap was a method of antibiotics delivery with the continuous administration of high-dose aminoglycosides. however, the best dose was not obviously. the purpose of this study was to evaluate translation of aminoglycosides from imap or isap. as follows: males and females, average age was . years old, intramedullary nails and plates. one dialysis patient was including. we measured concentration of gentamicin from imap, isap and in blood, outflow. results: average administration concentration of all cases was . lg/ml. average blood concentration of all cases was lg/ml and outflow concentration were . lg/ml. average blood and outflow concentration of each dosage were shown as follows: lg/ ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml, lg/ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml. in dialysis patient case, lg/ml administration lead concentration of blood as . lg/ml, outflow as lg/ml. side effect were not observed. discussion: local antibiotic administration using imap and isap showed increasing blood concentration depend on administration dose. under lg/ml administration dose showed safe blood concentration(\ lg/ml). on the other hand, lg/ml administration dose achieve trough concentrations over - times of minimum inhibitory concentration. furthermore, we need to pay attention for administration dose in dialysis patient case. conclusion: lg/ml administration dose achieved safe and effective local concentration. introduction: distal radius fractures and supracondylar humerus fractures are two of the most common fractures seen in children. most can be treated with non-operative treatment but a small number require operative reduction and surgical stabilisation, often with percutaneous kirschner wires. this study aims to identify whether an early review is required before planned removal of the wires. materials and methods: retrospective review of paediatric patients undergoing surgical reduction and stabilisation with percutaneous kirschner wires for upper limb injuries. data collected over threemonth period (june-august ). number and type of outpatient reviews, imaging episodes and clinical interventions recorded. results: consecutive patients with mean age years (range - ). distal radius fractures and supracondylar humerus fractures. patients transferred to another unit. / patients received a week check and then a second review where the wires were removed. mean time to first outpatient review . days (sd . ). at initial appointment all patients had a change of cast and a satisfactory radiograph. mean time to second outpatient review was . days (sd . ). at the second appointment / patients had the wires and cast removed and subsequent satisfactory radiograph. / required a further period of casting. / had a third appointment. / required formal physiotherapy after cast removal. there was one transient anterior interosseous nerve palsy after supracondylar fracture stabilisation. clinical union of the fracture and good functional outcome was seen in all cases. conclusion: the initial outpatient review at - weeks allows a lighter weight cast to be applied but in this series the radiograph taken after the cast was changed did not alter management. our findings support a cast change alone at weeks and then clinician review with radiographs at the time of wire removal. introduction: the aim of this study was to describe surgical technique, report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. methods: the study comprised patients who were treated with open reduction and internal fixation (orif) of a scapular fractures between september and july . surgical indications were as follows: medial/lateral displacement greater than mm; shortening greater than mm; angular deformity greater than °; intraarticular step-off greater than mm and double shoulder suspensory injuries (including fracture of clavicle, coracoid or acromion with displacement greater than mm). all patients underwent x-ray examination (true ap, y scapular view) and computed tomography (ct) scans. fractures were classified according to the revised (ao/ota) classification system. functional outcome were measured using the constant-murley score. results: seven patients had glenoid fossa fracture, six patients had scapular body fracture and one patient had acromion process fracture. all glenoid fossa and scapular body fractures were exposed via the judet approach. eleven of patients were reviewed with constant-murley score at the final follow-up examination, three patients were lost for follow-up. the mean follow-up after injury was months ( - months). we found in four patients infraspinatus muscle hypotrophy. mean constant-murley score was . (± . ) for injured arm and . (± . ) for uninjured arm. mean score between injured and uninjured arm was . (± . ) which is excellent functional outcome according to grading the constant-murley score. conclusions: open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in reliable union rate and good to excellent functional outcome. introduction: the aim of this study was to evaluate clinical and radiological results of intramedullary radius and ulna nails in treatment of adult forearm fractures. methods: the retrospective study included patients who were treated with intramedullary nailing of forearm fractures between january and september . the medical records and radiographic images of all patients, taken preoperatively and postoperatively, were reviewed. fractures were classified according to the ao/ota classification system by reviewing the radiographs. we analayzed time to union, union rate, clinical outcome and complications. results: primary intramedullary osteosynthesis were performed in patients with forearm diaphyseal fractures. the average time to union was months (range, - months) in primary osteosynthesis cohort. secondary intramedullary osteosynthesis were performed in four patients following removal of plates and screws due to pseudoarthrosis. the average time to union was months (range, - months) in secondary osteosynthesis cohort. overall union rate was , % in forearms with fractures or pseudoarthrosis of the radius, ulna, or both bones, which were treated with intramedullary nail with compression screw. overall complications were one nonunion, one postoperative rupture of the extensor pollicis longus tendon and one postoperative transitory radial nerve palsy. conclusions: intramedullary nailing of adult forearm fractures is a safe and effective treatment option that results in reliable union rate and good to excellent clinical outcome. key words: forearm fractures, intramedullary nailing, biological fixation, union rate results: transverse or short oblique fractures of the middle third of the humeral shaft were treated using a retrograde approach. spiral fractures of the middle third of the humeral shaft were treated through the antegrade approach. comminuted fractures of the proximal third of the humeral shaft were treated mostly through the antegrade approach. comminuted fractures of the distal third of the humeral shaft were usually treated using the retrograde approach. whenever possible, we prefer retrograde insertion because the approach through the shoulder joint is avoided. reduction with retrograde nailingnis easier because upper arm was placed on the radiolucent operating table extension. interlocking screw insertion by freehand techique is also easier to perform because there is no danger of radial nerve injury. nonunion was found in eight patients ( , %). there were five patients ( , %) with postoperative transitory radial nerve palsy that fully recovered within months. conclusions: the choice of approach to the medullary canal depends on the fracture type and the fracture site. therefore, antegrade nailing should be performed for proximal third humeral shaft fractures and complex middle third humeral shaft fractures, while retrograde nailing should be perforemd for distal third humeral shaft fractures and simple transvese or short oblique middle third humeral shaft fractures. keywords: humeral shaft fractures, intramedullary nailing, radial nerve palsy, nonunion the diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail i. kostic , m. m. mitkovic clinical center nis, university hospital, orthopaedics and traumatology, nis, serbia, university of nis, serbia, orthopaedics and traumatology, nis, serbia introduction: in this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. material and methods: between and , patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. all patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. results: the time that elapsed from injury to intramedullary nailing ranged from to months (mean months).open intramedullary nailing was unavoidable in cases ( , %), while closed nailing was performed in patients ( , %). all patients were followed up in average period of years postoperative (range - years), and ( , %) patients achieved a solid union within the first months. conclusions: in conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. percutaneous figure of suture as a novel technique for treating closed tendinous mallet injuries following failed splinting therapy. t. eltantawy , a. yousif , k. maheshwari , a. hartpinto bedford hospital, plastic surgery, bedford, united kingdom introduction: mallet injuries are common injuries affecting the hand. majority of them are managed using conservative method, however a small percentage of patients that do not do well on conservative treatment need an operative intervention. we wish to evaluate the efficacy of percutaneous figure of suture as a new technique for treating closed tendinous mallet injuries resistant to splinting therapy, as a minimally invasive treatment option. material and methods: we present a case series of patients who had persistence of more than degree extensor lag, despite splinting minimally for weeks. all of these were treated with a percutaneous figure of suture placed across the dorsum of dipj, which provided splinting for further weeks. this technique provides fixation for the dipj in hyperextension position by going through the periosteum on both sides and was done under local anaesthesia. results: the mean age of our patients was years, with a single digit involved in all patients. all the five cases had nearly fully straight dipj with less than °extensor lag following weeks of percutaneous stitch placement. there was no further recurrence with mobilisation or overlying skin necrosis. conclusions: percutaneous figure of suturing technique can be an effective, minimally invasive and safe technique to treat closed tendinous mallet injuries not responding well for conservative splinting. introduction: osteosynthesis of pertrochanteric fractures (pf) is a frequently performed procedure in orthopaedic trauma care. dynamization of the osteosynthesis during fracture healing can lead to dynamization of the lag screw. which can cause debilitating complaints. a spontaneous femoral neck fracture (sfnf) after implant removal was seen in patients over a month period. based on these cases we evaluate the different aspects of the pathophysiological and mechanical mechanisms of lag screw dynamization, complaints and complications in pf healing. material and methods: pubmed search on incidence of chronic pain, gait impairment associated with dynamization of osteosynthesis, risk factors for dynamization and complications after implant removal. based on research data preventive recommendations are suggested. results: literature describes complaints as reduced mobility, gait impairment and chronic pain in association with lag screw dynamization. an important risk factor is the ao-classification of pf, a type fractures are significantly associated with more dynamization and the onset of trochanteric pain and gait disturbances. partial implant removal can reduce complaints in the majority of symptomatic patients, and induce symptoms in % of asymptomatic patients. literature study shows a sfnf after lag screw removal with an incidence of %, affecting mostly vulnerable elderly patient resulting in a high mortality rate. risk factors associated with an increased risk of this complication are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant. most importantly the removal itself, a sfnf with the implant in situ is very uncommon. conclusions: the clinical indications for implant removal in healed pf are not well established, and should be restricted to specific cases. after removal, partial weight bearing and good patient counselling is extremely important. replacement with shorter lag screw should be considered. metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with a spray on their surface of hydroxyapatite and % silver v. protsenko , a. abudayeh , v. chornyi , y. solonitsyn institute of traumatology and orthopedics of nams of ukraine, onco-orthopedics, kiev, ukraine, bogomolets national medical university, kiev, ukraine introduction: surgical intervention in the case of pathological bone fracture against the background of metastatic lesion involves performing osteosynthesis. for more effective integration of the metal plate with the bone, a material based on bioactive glass was sprayed on their surface. bioactive glass-based material is an osteoinductive and osteoconductive biomaterial that integrates quickly with bone, forms a bone-ceramic complex, and is transformed into bone over time. material and methods: metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with spraying on their surface of hydroxyapatite and % silver was performed in patients. the functional result of the operated limb was calculated on the msts scale. evaluation of pain was performed on the scale of r.g. watkins. the quality of life of patients was evaluated using the eortc qlq-c system. the evaluation of the integration of the plate with the bone was performed by radiological examination and by osteoscintigraphy. results: postoperative complications were found in ( , %) patient, recurrence of metastatic tumor was noted in ( , %) patients. the functional result of the operated limb after metal osteosynthesis was , %. the degree of pain decreased from , % to , %. the quality of life of patients after metal osteosynthesis improved from to points. x-ray examination revealed the formation of callus within a shorter timeframe, as evidenced by the more intense accumulation of radioisotope during osteoscintigraphy. introduction:the aim of this study was to evaluate the results in patients who had heal intertrochanteric fracture but did not receive adequate mobilization and rehabilitation support. material and methods:sixty patients over years old age were included in our study. the rehabilitation emphasized pain relief, muscle strength, range of motion, endurance, balance challenges, and proprioceptive enhancement for all patients. it started postoperative first day and was delivered twice a day by the physical therapist until discharge. patients were discharged on average . days ( - days) after surgery. the mobilization of patients was evaluated with the parker and palmer mobility scoring system, the clinical evaluation was performed with the haris hip scoring and daily living activities were evaluated with the barthel life index before and at the end of the fracture. results: female male patients were included in our study. the mean age was , ( - ) years and the mean follow-up period was , ( - ) months. patients had a type, patients had a type intertrochanteric femur fracture. in the last follow-up, all patients had fracture union. patients' mobility, daily life activity and clinical evaluations were found to be statistically significantly worse in the last control than before surgery. conclusions:the success of the surgical treatment and the union of the fracture after fixation are not sufficient for the successful mobility,daily life activity,and clinical results.the success in the functional results are significantly related with the ambulatory ability.although early mobilization and rehabilitation support are important in intertrochanteric femur fractures after surgery,the continuity of mabilization and rehabilitation support after hospital discharge is more important.the rehabilitation which administered by the patient''s ralations after hospital discharge is not sufficient.therefore,the importance of home-based rehabilitation is increased. the prognostic value of the hip screw position in trochanteric fractures i. gárgyán , î csonka , t. ecseri university of szeged, department of traumatology, szeged, hungary introduction: in our study, we analyzed one of the hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. according to the classification of the swiss association for ostheosynthesis (ao), we focused on -a and -a fractures, the incidence of which increases by ageing. material and methods: between and , we analyzed the data of patients. all of the fractures were stabilized with intramedullary nails. patients received stryker gamma Ò , whereas patients' fractures were solved with synthesis pfna Ò nail. in all cases, closed reduction method was used with fluoroscopy on an extension table. the surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. data were collected using gepacs software and statistical analysis was done with ms excel. results: cut-out occurred in cases ( , %): out of that ( . %) were left sided and were ( , %) right sided. ( . %) patients were treated with gamma nail, and in ( , %) cases pfna nail was used. the average tad-index was mm. conclusions: according to recommendations of the tad-index value, when using dynamic hip screw, it should be mm or lower. the average index value was mm which was equal in the complicated and non-complicated groups. our study shows that the cutout is independent from the tad-index value, thus this recommendation cannot be applied for intramedullary nails. oita university hospital, acute trauma, emergency, and critical care center, yufu, japan, oita university, orthopaedic surgery, yufu-city, oita, japan introduction: dome impaction fragments (difs) in acetabular fractures are typically accompanied with anterior column fragments and recognized as the gull sign on plain radiographs. meanwhile there are some difs which do not fit into typical difs. the aims of this study were to define atypical dif and describe tips for diagnosis and intraoperative visualization. material and methods: this study was a retrospective case review. we defined atypical difs as the fragments which were independent of anterior column fragments and did not show the gull sign on plain radiographs. from jan to july , there were patients of acetabular fractures, and patients ( . %) had difs. among them, patients ( . %) were identified as the cases with atypical difs. all of them were male. the ages were from to . results: the atypical difs were not obvious on x-rays (fig. ) . all three atypical difs were located at posteromedial weight bearing zones of the acetabulum. case and were displaced in accordance with posterior column fragments, and were visualized clearly on the sagittal view of ct images (fig. ) . case was impacted posteriorly into a posterior part of the ilium as a free fragment, and well visualized on ct sagittal and coronal views. anterior intrapelvic approach was chosen in all patients to treat atypical difs. the iliac oblique view was useful to visualize the atypical difs intraoperatively in case and . in both cases, the reverse gull sign appeared after reduction of posterior column fragments (fig. ) . in case , the inlet view was useful to visualized the atypical dif intraoperatively.the fragments were reduced and fixed with supra-acetabular screws (fig. ) . results: we found prospective two to years after acetabular osteosynthesis , % complications. avn of the femoral head was present in , % of the hips reduced within h and , % of the hips reduced more than h after the injury [p = , ; = , ; or = ( % ci = , - , ) ]. post-traumatic oa of the hip we found in , % (fig. ) infections we found in , % ( deep, superficial), iatrogenic nerve palsy in ( , %), traumatic nerve palsy in , % ( ), dvt in , % ( ) , and ho in , % ( ) cases. in one case ( , %) revision surgery was done. conclusions: acetabular fractures are followed with complications. some complications depend on surgery, meanwhile others cannot be affected on (type of fracture, impaction of acetabulum, injury of the femoral head, dislocation of femoral head). good knowledge of acetabular anatomy, surgical technique, experienced surgical team, early surgery, anatomical reduction and stable orif, early mobilization, can significantly influence excellent/good functional outcomes and reduce possibility for complications. introduction: reduction is one of the important factors in surgical treatment of femoral trochanteric fractures. in this study, postoperative reduction status was examined and the relationship between this reduction status and unsatisfactory cases was investigated. material and methods: cases of femoral trochanteric fractures over years treated with pfna-ii were investigated. postoperative reduction status was evaluated in ap and lateral view of x-ray and ct. anatomical reduction means medial or anterior cortex is reduced anatomically (abbreviation am and aa). intramedullary reduction means medial or anterior cortex of proximal fragment is inside the shaft (im, ia). extramedullary reduction is medial or anterior cortex of proximal fragment is overlapped to cortex of shaft (em, ea). unsatisfactory cases were ununited cases until months and excessive sliding cases over mm. reduction status of these cases was evaluated. results: postoperative status was classified with combination of medial and anterior reduction status. so there are nine groups and number of each group are as follows; im-ia: case, im-aa: cases, im-ea: case, am-ia: cases, am-aa: case, am-ea: cases, em-ia: cases, em-aa: cases, em-ea: cases. non-united cases until months were cases. reduction status of non-united cases were; im-ia: cases, im-ea: cases, am-ia: cases, am-aa: cases, em-ia: cases, em-aa: cases. there was no case in extramedullary reduction of anterior cortex. excessive sliding of blade over mm was cases. there was also no case of extramedullary reduction of anterior cortex in these cases ( cases were cut out). conclusions: our results show there are no ununited cases and excessive sliding cases in extramedullary reduction of anterior cortex. this means extramedullary reduction of anterior cortex is important to reduce unsatisfactory results in surgical treatment of femoral trochanteric fractures. male injured open lateral condyle fracture of femur by to be bitten by a pig. after months from initial debridement, i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after months from bone transplantation, i confirmed bone union and two . mm diameter osteochondral grafts and . mm diameter osteochondral graft were transplanted for the chondral defect lesion. case ; seventy year old male injured open lateral condyle fracture of femur by traffic accident. after months from first debridement, i confirmed the bone defect (size cm( ) cm in depth) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. and simultaneously two mm diameter osteochondral grafts were transplanted for the chondral defect lesion. case ; year old male injured open lateral condyle fracture of femur by traffic accident. i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after month from bone transplantation, he had undergone autologous chondrocyte implantation. investigation/results: at last follow-up, average flexion angle of knee was degrees. in all cases, lysholm knee scoring scale was good. diagnosis: large traumatic osteochondral defect of the weightbearing articular surface of the knee comments: treatment of large traumatic osteochondral defect of the weight-bearing articular surface of the knee is a difficult condition to treat. combination of bone transplantation and osteochondral autograft transfer or autologous chondrocyte implantation is useful strategy for the injury. references: tegner y., lysholm j., clin orthop relat res., , - , pr treatment of double tension band wiring method with ai wiring system for transcondylar distal humeral fractures m. uchino hakujikai memorial general hospital, orthopaedic surgery, tokyo, japan introduction: as ai wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. we review the treatment of transcondylar distal humeral fractures with ai wiring system in geriatric patients. patients and methods: were identified as receiving this surgery. all patients were female and their mean age was years. they were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for japanese orthopedic score. results: union rate was %. the mean arch of motion was °at latest follow-up. the complications were detected cases which were temporary ulnar palsy for cases and hardware failure for case. the average of functional outcome was points ( / ). conclusion: tension band wiring of transcondylar distal humeral fractures with ai wiring system provides stable fixation for osteoporotic bone and tiny fragment. introduction: the purpose of this study was a comparative evaluation of the complications related to the treatment of trochanteric fractures using -screw proximal femoral nail (pfn) versus proximal femoral anti-rotational blade nail (pfna). material and methods: a retrospective review was conducted between march and march . the study included patients treated surgically for trochanteric fractures. the mean age was , ± , ( - ) years. patients were treated by pfn ( patients, , %) or by pfna ( patients, , %). implant related complications were the primary objectives. infection and revision surgery were also recorded. results: complications were observed in ( . %) patients in pfn group and ( , %) patients in pfna group (p = . ). screw backout (n = ) and cut-out (n = ) occurred in , % patients treated with pfn. in the pfna group, cut-out occurred in , % (n = ) of cases. infection (n = ) represented , % in pfna patients and , % (n = ) in pfn group. there were no statistically significant differences in both groups considering implant-related complications (p = , ) and infections (p = . ). revision surgery was performed in ( , %) patients. soft tissue problems are more likely in fractures due to high energy impact than low energy type fractures. high energy type present with horizontal fractures of tibia and fibula (i.e. on the same level), whereas in low energy type tibia fractures they present with spiral or oblique fracture patterns often associated with concomitant fractures of the posterior rim of the distal tibia (i.e. volkmann's triangle). posterior malleolus fractures occur regularly but are often missed and seen only on ct scans obtained either for preoperative planning or to verify postoperative rotation. in literature these mostly undisplaced fractures are treated with screw fixation mostly from anterior. but is this really necessary? material and methods: we retrospectively analysed consecutive tibia shaft fractures operatively treated over the past years at our regional hospital analysing the fracture pattern. results: out of patients with tibia shaft fractures patients presented with a posterior rim fracture of the tibia. no routine stabilisation of the volkmann fragment was performed, in all cases the posterior rim fragments healed uneventful. angles of °and above seem to present themselves with a concomitant fracture of the posterior malleolus. they are mostly undisplaced and the trauma mechanisms is low energy and torsion. none out of the patients had known osteoporosis. conclusions: low energy and torsion-type tibia fractures with an angle of [ °seem to have an accompanying undisplaced fracture of the posterior malleolus. these fractures are usually undisplaced and do not need to be addressed. as a consequence there seems to be no need to actively rule them out with ct scans prior to surgery. concomitant ankle fractures including posterior rim fractures should be addressed like isolated ankle fractures. the dangers of bouncing: a prospecive cohort study of injuries associated with trampolines and bouncy castles over a month period in a paediatric population. introduction: within the orthopaedic paediatric population, there is an increasing incidence of presentation of fractures associated with both trampolines & bouncy castles. whilst this phenomenon has been depicted frequently within the media in recent years given the dramatic upsurge in trampoline and bouncy castle usage, there have been few studies documenting either the incidence of fractures associated with either. materials and methods: this was a prospective cohort study conducted within our institution over a month period june to august inclusive . all paediatric patients who sustain a fracture and present to the national childrens'' hospital are referred to the orthopaedic department either whilst as an inpatient or as an outpatient depending on the assessment of the severity of injury. a standardised mixed questionnaire was given to all parents''/guardians which recorded the type of injury, type of trampoline/bouncy castle, inherent awareness of safety precautions governing the usage of either and application of same was recorded. the type of fracture was corroborated via examination of x-ray in addition to the recording of any complications via examination of clinical chart records. results: there were patients who sustained a fracture directly related to the usage of either a trampoline or bouncy castle for which the majority required operative intervention. there was wide variability in the nature of injuries recorded; supracondylar/radial fractures were the most common whilst more complex injuries such as an open fracture of the femur was rarer. conclusions: awareness and application of necessary safety precautions was low ( %) amongst parents'' supervising parents''/guardians highlighting the need for greater public awareness of same. furthermore, the incidence of severe injury relating to usage of trampolines/bouncy castles is not uncommon highlighting the high risk activity that trampolining is. introduction: conventional plate fixation (pf) of distal fibular fractures in elderly patients is associated with a high risk of wound and implant related complications. intramedullary fixation (imf) using a fibular nail is a minimally invasive alternative to pf that provides superior biomechanical strength and allows immediate full weight-bearing postoperatively. aim: to compare the postoperative complications of minimally invasive intramedullary nail fixation to conventional pf for lauge-hansen supination external rotation type fractures in patients aged years or older treated in a single geriatric trauma unit in the netherlands. methods: a retrospective cohort study was performed including unstable ankle fractures in patients aged years or older treated with either imf or pf between january to january . the primary outcome measure was the total number of wound related complications. results: a total number of patients were included with a mean age of . years (range to ). the imf-cohort (n = ) had a significantly higher mean age ( . versus . years, p = . ) and charlson co-morbidity index ( . versus . , p = . ) compared to the pf-cohort (n = ). the total number of postoperative complications was lower after imf ( %) compared to pf ( %), although this relative difference was not statistically significant (p = . ). all complications observed in the imf-cohort were wound related but demanded no debridement or implant removal. wound related complications did not differ significantly from pf ( % versus %, p = . ). no implant related complications, hospital-acquired complications or mortality were observed after imf. conclusion: despite the higher mean age and co-morbidity status of patients treated with a minimally invasive intramedullary nail, the total number of postoperative complications was lower after imf compared to pf. this technique might be a promising alternative in a selected group of patients. the authors declare that they have no commercial associations that might pose a conflict of interest. no funding or other compensation was received for the research, authorship or publication of this article. gustilo type ii and gustilo type iii fractures. the treatment protocol was external fixation at admission and definitive osteosynthesis with plate at ± days. a single approach to the tibia was performed in patients, and a combined anterior and posterior approach was used in . the incidence of complications was %: cases of poor soft tissue evolution, of which were infections. patients evolved to nonunion. osteoarthritis appeared in % of patients ( . % grade ), and only one patient needed arthrodesis. . % had a valgus ldta (\ °) and . % a varus deformity ([ °). we found a significant relationship between the history of open fracture and the development of complications (p \ . ). we found no relationship between the incidence of complications and the approach. conclusions: tibia ao c fractures have a high percentage of complications and evolve to well-tolerated osteoarthritis. open fracture seems to significantly influence the poor postoperative outcomes of these patients. clinical findings: a -year-old male, who suffers a closed chest trauma with pneumothorax, right pulmonary contusion and poor pneumoperitoneum. also a grade iiia open fracture of the right femur, with a cm bone defect. investigation/results: upon arrival at the hospital, he needs orotracheal intubation, as well as blood transfusion with red blood cell concentrates. external fixator is placed on the right femur. diagnosis: a iiia grade diaphyseal open fracture of the right femur with cm bone defect, bearing external fixator with one broken proximal pin and positive culture for s maltophila in the distal pin. therapy and progressions: antibiotic treatment and medical optimization are performed, cemented intramedullary nailing (t -stryker) with antibiotic (vancomycin-tobramycin), as well as cement spacer with antibiotic (masquelet's first stage) in the defect area. in second time, withdrawal of spacer and contribution of ria autograft of contralateral femur and allograft respecting membrane. the patient begins the protected weight bearing with two crutches immediately, without using them months after the surgery. bone consolidation without pain or limitation after year. comments: the induced membrane technique is a simple and effective technique for the reconstruction of segmental bone defects and can be used as a first time technique together with the initial stabilization, leaving the defect ready for graft delivery in the second time. introduction: carpal metacarpal dislocation is a rare entity that accounts for less than % of all carpal injuries. dorsal dislocations are the most common and occur most frequently after violent trauma in young individuals and are easily overlooked and may lead to longterm sequelae. material and methods: we present the case of a carpal metacarpal dislocation from d to d . male, years old, no relevant personal history. brought to the emergency service after a motorcycle accident with projection. he had a symphysis pubis diastasis, a distal radius fracture on the right wrist and a fracture of the left forearm bones. no other apparent injuries associated. at week , he presented edema and dorsal deformity of the left hand associated with limited finger movements. neurovascular assessment was normal. the radiological evaluation showed a carpal metacarpal dislocation from m to m . it was an unstable reduction so open reduction was performed, with debridement of fibrous material, until exposure of the articular surfaces, and reduction and fixation with k wires of the three metacarpals (from d to d ). similarly, m was stabilized with a k-wire due to clinical instability observed intraoperatively. results: it is necessary to reduce and stabilize these lesions to avoid vasculonervous compression and skin distress. open reduction is indicated in irreducible cases allowing debridement and excision or os of small osteochondral fragments and fixation of associated fractures. conclusions: combined dislocation of multiple metacarpals is a rare lesion that compromises the functional prognosis of the hand in the absence of adequate treatment. instability and post traumatic arthrosis are among the sequelae of this lesion. identify the lesion to allow the appropriate treatment usually leads to good results. case history: -year-old suffered direct trauma to his right hand after falling off his bicycle. clinical findings: on physical examination showed edema and bruising from the base of the thumb and thenar eminence, tenderness over the cmc joint and functional disability speacialy in pincer grasp. no neurovascular injuries investigation/results: the x-ray revealed a comminuted fracture of the base of the thumb metacarpal. diagnosis: we identifed a rolando fracture. therapy and progressions: on the day after the trauma, he was submited to open reduction and osteosinthesis with lateral-palmar plate and screws, through radiopalmar aproach of the thumb base. intra operatively no dorsal fragments werefound to be left undisplaced. two months after surgery, the patient went back to the hospital for sudden pain and inability to extend the thumb. clinically with rupture of the long extensor of the thumb. on the x-ray, the fracture was aligned. the latero-lateral tenorrhaphy with kessler suture was preformed and intraoperatively a bony spicule was identified in the proximal stump of the tendon, which was removed. months after the initial trauma, the patient has a consolidated neck and no limitation of the mobility of the thumb. comments: rollando fracture is relatively rare in adolescents. the aim of treatment should be exact reduction usually with open technics. the main complications are stifness and early arthrosis. there are also records of conflicts with the plates and even rupture of the extensor tendon, so the radiopalmar placement of the plate was chosen. nevertheless, the rupture occurred due to conflict with an unidentified bone fragment during surgery causing an unexpected complication in this case. the immobilization necessary after tenorrhaphy could have caused joint stiffness, but in this case the teenager fully recovered after physical therapy case history: periprosthetic and periimplant femoral fractures are an increasingly frequent pathology. in many cases they are a challenge with limited or too aggressive therapeutic options. it is important to investigate new approaches that increase the arsenal of the orthopedic surgeon. the recently described mipo (minimally invasive plate osteosynthesis) approach for the medial aspect of the femur may seem like a dangerous procedure because of the anatomical structures that run along the medial aspect of the thigh, but it is a viable and useful option in selected cases. clinical findings: we present the case of a -year-old patient with a total hip replacement who presented a first periprosthetic vancouver b fracture of the femur that was treated with a lateral blocked plate. subsequently the patient presented a second supracondylar femur fracture below the first plate (vancouver c). investigation/results: after thinking over the possible therapeutic options, we decided to treat our patient by means of the medial femoral mipo approach with a long medially placed blocked plate, managing to stabilize the fracture and superimpose the plate on the previous implants without the necessity of removing the previous lateral plate. diagnosis: periprosthetic and periimplant supracondylar left femoral fracture. therapy and progressions: we used the surgical technique of the medial femoral mipo approach as described by apivatthakakul . comments: we consider that the medial femoral mipo approach is a useful therapeutic tool to consider. it seems a safe and low-invasive option for the resolution of cases in which the lateral mipo approach is not a feasible option. references: c. jiamton y t. apivatthakakul, « the safety and feasibility of minimally invasive plate osteosynthesis (mipo) on the medial side of the femur: a cadaveric injection study » , injury, vol. , n.o , pp. » , injury, vol. , n.o , pp. - » , injury, vol. , n.o , pp. , nov. . posterior knee dislocation with neurovascular injury associated-a case report case history, investigation and diagnosis: a -year-old male was brought in after h following a heavy straw bale fall. he presented with a posterior knee dislocation that had already been reduced and an open wound in the popliteal fossa. the limb was flushed and pale on the extremity, with absence of the pedis and posterior tibial pulses. stability tests revealed unstable knee in all axes. an anterior shoulder dislocation was diagnosed and reduced. therapy and progressions: an emergent surgery was performed, involving a transarticular external knee fixation and a femoro-popliteal bypass above the knee (angiogram revealed a stop sign at the level of the interarticular popliteal artery). he developed circulatory shock and was admitted to the intensive care unit. on the stpostoperative day(po) was diagnosed a compartment syndrome that was treated with fasciotomies. these incisions showed a slow but progressive evolution, that required vacuum dressings and underwent autologous skin graft on the thpo day. the external fixator was removed on the stpo day and rehabilitation was started. on a -month follow-up, the patient had a good evolution of the wounds, but a knee with valgus and anteroposterior laxity and severe complete peroneal, tibial and sural neurological injury, confirmed with electromyography, and neuropathic pain. introduction: isolated iliac wing fractures represent only a small part of all pelvic fractures. these fractures are associated with severe injuries, but are considered benign. the literature lack information about the function and quality of life of these patients. our objective was to evaluate the long-term effects of isolated iliac wing fractures. material and methods: patients with pelvic fractures treated at oslo university hospital, ullevaal, in the time period - , were extracted from the local fracture registry. patients were registered in this period. a search was also made in the hospital''s administrative electronic database for patients registered with diagnose code s . in icd- in the same period. patients were identified. in total, patients had an isolated iliac wing fracture, and these were invited to a follow-up examination, including proms (eq- d- l and majeed score), clinical examination, and pelvic x-ray. results: nine patients agreed to participate in the study, median years after the fracture (range - ). all of them were injured from high energy trauma, with mean niss , (range - ) . four of the fractures were open, and seven of the patients had associated injuries. five were treated with internal fixation. the mean eq- d vas was (range - ). five patients reported pain, one of them related to the pelvic fracture. the mean majeed score was (range - ). seven patients had sensory deficit in the lateral thigh. one patient had difference in range of motion between the two hips. the x-rays showed healed fractures in all the patients. eight of them showed ectopic ossification. conclusions: our study confirms previous studies that isolated iliac wing fractures are results of high energy trauma with severe associated injuries. however, the majority of this group of patients seem to have a good general state of health, which is in accordance with the general assumption of the injury as a benign one. fenton's syndrome-a case report of a common underdiagnosed entity case history: a right handed -year-old male, construction worker, was admitted in our emergency department, after a meters fall. the authors report a case of fenton's syndrome in a politrauma scenarium. clinical findings: both right elbow and left wrist were painful, swollen and with a remarkable restriction of the range of motion (rom). patient also reported lower back pain. no neurovascular injuries were detected. investigation/results: x-ray and ct scan confirmed a fracture of a lumbar vertebra, fracture of the right olecranon and, on is left wrist, a carpal fracture-luxation mayfield of both scaphoid and capitate associated with rotation of the last one proximal pole-fenton''s syndrome. diagnosis: this syndrome is an atypical presentation of perilunate fracture dislocation and, therefore, difficult to diagnose. few reports were found in literature. after an open reduction of the fractures, a definitive fixation with headless herbert screws was achieved. percutaneous kw and immobilization of the wrist were performed to further stabilization of the lunotriquetral joint. weeks later consolidation was noted. a decrease of °in extension and flexion were detected when compared with the contralateral wrist. grip strength test was similar on both hands. osteosynthesis of the right olecranon was also realized. comments: a careful neurovascular assessment is important. although it is rare, injuries of median nerve were already reported associated to this complex fractures. open reduction and osteosynthesis are necessary due to the great instability and the risk of nonunion and osteonecrosis of the rotated proximal segment. introduction: intramedullary nailing has been popularly applied for the femoral shaft fractures. the current study aimed to analyze the femur geometry for development of implant design with dimensional skeletonization. material and methods: we acquired computed tomography (ct) images of both femur reviewed in a single center from to . the total participants were enrolled and they were divided into subgroups according to age (decades) and gender. each subgroup included persons, respectively. these images are used to produce d samplings. with the skeletonization, we obtained the geometry parameter; ( ) femur shaft length from the tip of the greater trochanter to the bicondylar line, ( ) the minimum diameter of the medullary canal and its location, ( ) anteroposterior (ap) diameter and lateral diameter of the entire femur, ( ) radius of curvature (roc) of the femur (bowing). we compared all parameters according to sex and age. results: the average age of the participants were . years (range - years) and the number of each gender was exactly same. the femur length was . ± . mm (range, . - . mm) and the femur shaft length was . ± . mm (range . - . mm), both of them were longer in male (p = . , \ . ). the minimum diameter of the medullary canal was . ± . mm (range . - . mm). the roc was . ± . mm (range . - . mm) . the rate of the minimum diameter less than mm and mm was . % and . %, respectively. the rate of roc with less than mm and mm was . % and . %, respectively. conclusions: this geometry analysis showed that there are mismatch problem between the current nail and the medullary canal in . % and the roc of the femur was smaller than that of the current nail systems ( - mm). the result indicates potential mismatch problem in clinical cases and the problem can be resolved with newly designed nail system. the study was funded by national reserach foundation of korea (nrf- r d a b ). safe zone of the infracacetabular screw: virtual mapping of three-dimensional hemipelvises for quantitative anatomic analysis introduction: an infra-acetabular screw can provide increased stability in fixating acetabular fracture. we conducted this study to define the incidence of the safe corridor for infra-acetabular screw and to determine the correlation between the safe corridor and other demographic factors such as age, sex and height. material & methods: pelvis computed tomography (ct) of participants was extracted with evenly age-and sex-allotted. virtual three-dimensional ( d) model was generated. a search was performed to find the maximum-with corridor connecting two points. the entry and exit point was displaced in the template. the maximum diameter of each corridor was measured in automatic procedure. a minimum mm corridor diameter, sate corridor, was defined as a cutoff for placing a . mm cortical screw in clinical setting. all data were presented as mean and range or mean and standard deviation. two-sample t test and regression analysis were used to compare difference between groups based on sex, age, and height. results: among hemipelvis, hemipelves ( . %) satisfied a minimum safe corridor diameter of mm. when divided into a subgroup by the patient's gender, the incidence of the safe corridor of a male group was statistically higher than a female group ( . % vs . %), with the mean corridor diameter of . mm ( % ci, . ) and . mm ( % ci, . ), respectively (p \ . ). in correlation analysis, only the height showed a positive correlation with the diameter of the safe corridor of a total population (r = . ; p \ . ). conclusions: the study provided the safe corridor was found in % of male and % of female, and the taller had the higher incidence of the safe corridor. the patient''s height was correlated with the corridor diameter of the infra-acetabular screw, whereas the patient''s age did not correlate with the corridor diameter. introduction: femoral neck fractures in middle-aged and older patients represent one of the most common orthopedic conditions. osteosynthesis, as a primary treatment option for femoral neck fractures has shown to have successful outcomes. however, this is not the case for old fractures. the purpose of this study was to evaluate the outcomes of treatment of femoral neck fractures in which cementless total hip arthroplasty was indicated. the aim of our study was to analyze the prosthetic failure, i.e., the reasons for unsuccessful outcome, in order to suggest the indications for primary osteosynthesis which could guide the femoral neck fracture management. material and methods: a total of patients were analyzed in this study, with femoral neck fracture treated with osteosynthesis. reviewing the radiological findings, as well as the course of the treatment, we set up the criteria, on the basis of which we could advice the immediate implantation of total hip prosthesis for the femoral neck fracture. results: old fractures, varus deformity of the femoral head and neck, dislocation, as well as the comminuted fractures, are all factors affecting the surgical outcomes of osteosynthesis. additionally, medical and technical equipment of medical institution, personnel competence, and minutious surgical technique affect the treatment outcomes. introduction:proximal ulnar fractures are usually osteosynthesized by means of angle stable plate osteosynthesis. despite good functional results of this procedure, complications such as high access morbidity and disruptive osteosynthesis material with a high rate of material removal are described. the aim of our study was the development of a new locking nail and test setup for comparison with a plate osteosynthesis on artificial bones. material and methods: in our biomechanical laboratory, a jupiter b fracture of the proximal ulna was standardized on sawbones and stabilized by means of the newly developed nail or anglestable posterior plate osteosynthesis. a servopneumatic testing machine, the specimens were flexed under a cyclic load ( - n) in the physiological range of movement of the elbow from °to °.the maximum elastic deformation of the specimens and the loosening of the implants were evaluated after test cycles. results: the primary stability of the constructs at the anterior cortical bone after nail osteosynthesis was significantly greater ( . ± . mm) than in the angle-stable plate osteosynthesis ( . ± . mm, p \ . ).after passing through the test cycles, both implants showed a low loosening rate. in the area of the anterior cortex, the locking nail showed a significantly lower rate of loosening (nail . ± . mm, plate . ± . mm, p \ . ). at the dorsal cortex, there were no differences between plate and nail in both series of measurements. conclusions: intramedullary implants provide biomechanical benefits in fracture stabilization. good biomechanical results have already been shown in the literature after nailing olecranon fractures . nevertheless, due to the complex anatomy and the resulting difficult implantation technique, ulnar nails could not prevail in practice. the presented nail allows a safe stability with simple surgical technique. introduction: adequate treatment of tibial plateau fractures is crucial to minimize patient disability, development of posttraumatic arthritis and subsequent need for a total knee arthroplasty (tka). however, due to the complexity of the fracture, adequate reduction cannot always be achieved which could result in the early conversion to a tka. in this study we introduce a quantitative d fracture assessment method and investigate whether it could help to identify patients that are at risk of conversion to a tka. material and methods: we retrospectively included patients, who were treated for a tibial plateau fracture between and . patients developed severe posttraumatic arthritis and underwent conversion to a tka. from all patients, d models were created using the pre-operative ct-scans. for each patient, the d gap area between the fracture lines, representing an innovative combined gap and step-off measurement in d, was determined in order to quantify the displacement (figure ). roc curve analysis was performed to determine a critical cut-off value for the d gap area. kaplan-meier survival curves were created to assess the association between d fracture anatomy and risk on a tka at follow up. results: a critical cut-off value of mm was found to give highest combined sensitivity and specificity for d gap area and the risk of tka at follow-up. kaplan-meier survival curves showed . % knee survival (no tka) at year follow up in the group with a gap area of \ mm , whereas in the group with a gap area of c mm a knee survival of . % was found. at year follow up knee survival was . % and . %, respectively, for the two groups (\ mm and c mm ). conclusions: we developed an innovative method to quantify the amount of displacement in d. pre-operative d fracture assessment could be used as an addition to the current fracture classification methods to help identify patients who have a high risk on conversion to tka at follow-up. introduction: soft tissue sarcomas (sts) in the anterior compartment of the thigh are frequent. the extent of quadriceps resection is controversial. the aim of the present study is to communicate our results in complete quadricectomies due to high-grade sts. material and methods: we present sts, in stage iiib of the ajcc, with a mean craniocaudal diameter of cm ( - ). there were women and men, with a mean age of years ( - ). six were undifferentiated pleomorphic sarcomas, myxofibrosarcoma and clear cell sarcoma. in every case, total quadricectomy was performed with wide margins. posterior reconstruction with local muscle transfers was performed, expect for the younger patient, who received a vascularized contralateral vastus lateralis transplant. in all cases, complementary radiotherapy was indicated, and in patients adjuvant chemotherapy. results: three patients required friedrich due to necrosis of the edges of the surgical wound. one patient died months after the intervention as a result of multiple metastasis, and two due to medical complications after week and months, respectively. the average follow-up time for the rest was months , with no local recurrence. as for functional outcomes, mean msts score was ( - ), with deficit of active knee extension in most of them. the functional result of the patient with the vascularized muscle transplantation was excellent. all of them were satisfied with the results of the treatment. conclusions: quadricectomy provides good functional and acceptable cancer results, although it is not exempt from complications in frail patients. vascularized muscle transplantation, though complex, can improve functional results, especially in younger patients. introduction: operative treatment is a valuable option in displaced proximal and/or middle one-third diaphyseal humeral fractures. although plate osteosynthesis is preferred to intramedullary nailing, surgery can be complicated by radial nerve palsy. a helical plate could avoid this high-impact complication. to date there is however a lack of published evidence in literature, although recent asian case reports show promising results. material and methods: we retrospectively reviewed patients who were treated with open reduction and internal fixation with a helical plate consecutively from october until august at az groeninge, kortrijk. a deltopectoral approach was used in combination with a distal anterolateral incision, whether or not in continuity. a self-molded long philos plate was used in the first patients, while in our last patients the a.l.p.s plate (zimmer Ò ) was used. standard radiographs were obtained pre-and postoperatively. we retrospectively searched for complications, e.g. radial nerve palsy, infection and/or loosening. in autumn , patients were reassessed. patient''s general health status was evaluated using the eq- d- l score. constant-murley scores and dash scores were used for evaluating shoulder function and disability measures consecutively. results: all humeral fractures consolidated at months. there were no radial nerve palsies due to surgery. one plate was removed after year due to a late infection. with a minimum follow up of year, the mean dash score was ( - ) and the mean constant-murley score was ( - ). the dash score was inversely proportional with the constant-murley score and patient''s general health status. conclusion: a helical plate avoids neurological complications with similar healing rates and good to excellent shoulder function at year follow up in the treatment for proximal and/or middle one-third diaphyseal humeral fractures. the use of antibiotic-impregnated cancellous bone grafts in onestage surgery for chronic orthopaedic infection: preliminary clinical results k. dendoncker , g. putzeys , az groeninge, tissue bank, kortrijk, belgium, az groeninge, orthopaedic center, kortrijk, belgium introduction: the use of cancellous bone allografts is an established technique in reconstructive orthopaedic surgery. unfortunately, its use is generally avoided in the presence of a local infection. antibiotic impregnated cancellous bone grafts has shown its effectiveness as an local antibiotic delivery system [ ] [ ] [ ] . in this clinical study, we report our first personal experience with the use of vancomycin-impregnated cancellous bone grafts in one-stage surgery for periprosthetic joint infections (pji) and fracture-related infections (fri). material and methods: between december and march nine patients were treated during a one-stage surgery with vancomycinimpregnated cancellous bone grafts, containing g vancomycin per cc bone. regular clinical, laboratory and radiographic follow-ups were performed for at least months after surgery. results: the procedures included revision of pjis (hip and humerus) and fris (tibia, femur and clavicula). one tibia required further revision because of recurrent infection and one hip has an uncertain infection state, however the remaining patients stayed free from infection during a follow-up of at least months. interestingly, in one patient the vancomycin concentration could be determined in the drainage fluid from the wound. radiographic examination revealed no signs of osteolysis or loosening, good incorporation of the bone graft and progressive consolidation. conclusions: within the limits of the study, the use of vancomycinimpregnated cancellous bone grafts in one-stage surgery to treat pji and fri yielded positive outcomes in terms of clinical, laboratory and radiographic follow-up. this technique might offer new treatment strategies in often devastating injuries. references: . putzeys g., et al. orthopaedic proceedings. ; -b:supp_ , - . with the modified arthroscopic approach (group b). the prospective follow-up included the lysholm score, the subjective questionnaire of the ikdc score and the specifically extended oak score for clinical evaluation. the rolimeter Ò was used to test the translational mobility of the knee joint. the statistical significance level was set at %. results: the follow-up was . ± . months and . ± . months postoperatively in group a and b, respectively. the subjective scores were tested. group a and b achieved a mean lysholm score of . ± . and . ± . points respectively. in the subjective ikdc assessment, group a achieved . ± . points and group b . ± . points. the clinical oak score was . ± . points in group a and . ± . points in group b. the following values could be recorded for the stability of the posterior cruciate ligament: the side difference in the rear drawer test was . ± , mm in group a and . ± . mm in group b. in the reversed lachman test, a difference of . ± . mm and . ± . mm was measured in group a and b, respectively. all values mentioned were comparable between the two evaluated groups. conclusions: the results of the two surgical techniques were comparable. therefore the arthroscopic approach is the preferred method in our institute. simple correction technique of femoral malrotation after pfn-a osteosynthesis of trochanteric fracture k. pavotbawan , p. stillhard , c. sommer kantonsspital graubünden, department of trauma surgery, chur, switzerland introduction: malrotation after intramedullary nailing in femoral shaft fractures are well known. but malrotation after nailing of trochanteric fractures is an underestimated problem. during surgery the axial alignment can easily be evaluated by fluoroscopy in both planes. but the torsional alignment is difficult to assess especially with the patient placed on the traction table. in literature a malrotation after pfna is described in up to % of the cases. a revision with replacement of the blade, especially in patients with poor bone quality, may result in a reduced stability. to our knowledge there is no publication till to date to give a treatment pathway for this problem. we developed a rather easy technique to derotate a malrotated femur after pfna fixation. material and methods: the basic idea is to leave the usually well placed blade insitu in the femoral head, just rotating the distal main fragment around the nail. therefore, a small u-shaped osteotomy with a chisel is performed in the femoral cortex just anterior of the entry site of the blade. the length (l) of this osteotomy can be calculated, following the formula: l = d x p x a/ (d = diameter of femur, a = angle of malrotation). then the distal locking bolt is removed, the leg derotated and finally locked again. the procedure is controlled by two schanz''screws separately inserted in both main fragments angulated to each other in the angle ''a''. results: since patients were detected with a clinically relevant femoral malrotation. all patients had an internal malrotation from to degrees confirmed and measured by ct scan. all of them were successfully revised in the above described technique - days after initial fixation. conclusions: first, we believe that malrotation after trochanteric fracture fixation is an underestimated problem. and second our method is a simple salvage procedure for malrotated trochanteric fractures after pfna, leaving the blade in situ in the femoral head. optimal intramedullary nailing for trochanteric fractures: the importance of distal locking screw and reduction position t. waki , t. yano , k. ito , s. matsushima akashi medical center, orthopaedic surgery, akashi, japan introduction: distal locking issue for trochanteric fractures is still controversial. therefore, the purpose of this study was to investigate the complications between distal unlocked group and distal locked group. further, the relationships were evaluated between these complications rates and their reduction positions after operation. material and methods: operations were performed for trochanteric fracture (ao a ?a ) from to . of these, patients with f/u periods [ month were . gamma im nailing system (stryker) was used for all patients. patients (unlocked group) from to operated without distal locking screw. patients (locked group) from to operated with distal locking screw. we retrospectively analyzed those patients who suffered complications such as delayed healing and postoperative periimplant fractures and cut-out of the lag screw. further, in lateral view of their radiographs, we evaluated the position of the proximal fragment compared with distal fragment. the reduction positions were divided into groups: anterior (subtype-a), neutral (subtype-n), and posterior (subtype-p). results: in unlocked group, complication was shown in patients (complication group). delayed healing was shown in / ( . %) in unlocked group and / ( . %) in locked group. peri-implant fracture was shown in / ( . %) in unlocked group and / ( %) in locked group. cut-out of the lag screw was shown in / ( . %) in unlocked group and / ( . %) in locked group. in complication group, subtype-p was more than non-complication group. conclusion: in the current study, higher number of complications was seen in the distal unlocked group. and, our study showed the reduction position might be associated with post-operative complications. we concluded that nailing without distal locking screw might be dangerous and subtype-p should be avoided. introduction: heterotopic ossification (ho) after acetabular fracture surgery has been one of the common complications and often limits function with the range of motion severely. surgical resection is challenging and only effective treatment for established ho. we herein report four cases who underwent surgical resection and mobilization for ho after acetabular fractures surgery. material and methods: four cases with severe ho after acetabular fracture surgery were included in this study. the mean age at operation was years old, and all patients were males. in judet-letournel classification, there were three cases classified as posterior wall fracture, and one case as transverse and posterior wall fracture. two of four cases were combined with posterior dislocation of the hip. in all cases, the first operation was performed using with the kocher-langenbeck (kl) approach. results: surgical resection of ho was performed using with the kl approach at . months (range - months) after the first operation. the median operating time and intraoperative bleeding were respectively . h and ml. intraoperative d navigation was used in one case. as postoperative complications, one case developed sciatic nerve palsy and another case sustained the iatrogenic femoral neck fracture. all cases have no recurrence with a follow-up of . years after the surgical resection. conclusions: surgical resection is the only treatment for symptomatic ho. but that requires preoperative planning and must be performed carefully because the extent of resection is still controversial and that may develop severe complications such as nerve palsy and iatrogenic fractures. by using navigation, we can determine the extent of resection easily and operated safely. case history: -year-old male, previously healthy, turned to the hospital after a motorbike crash, resulting in high energy direct trauma of the right wrist. clinical findings: upon admission, cranial, thoracic, abdominal and other traumatic injuries were excluded. the patient presented with pain, swelling and visible deformity of the right wrist and hand, hypoesthesia of the th finger, and no perfusion deficits. investigation/results: x-rays showed volar perilunate carpal dislocation with associated comminuted scaphoid fracture, radial styloid avulsion, and metacarpal phalangeal dislocation of the th digit. under sedation, closed reduction of the metacarpal phalangeal joint was accomplished, and reduction of the carpal dislocation was attempted unsuccessfully. the wrist was temporarily immobilized in a cast and taken to the or. diagnosis: transcaphoid-transradial-styloid-perilunate volar dislocation therapy and progressions: surgical treatment comprised loose bodies removal, reduction of the perilunate dislocation, orif of the scaphoid using a herbert screw, and stabilization of the carpal rows using two percutaneous kirschner wires. after surgery, a thumb spica cast was applied. post-operatively, neurovascular status was normal. at weeks, x-rays showed signs of bone healing, the cast and k wires were removed, and physical therapy was initiated. at months, scaphoid fracture consolidation was achieved. the patient remained with a mild deficit in wrist extension but reported no pain nor important limitation in daily living activities. comments: perilunate injuries with displacement or dislocation usually require surgery. persistent instability is a described complication, often progressing to secondary post-traumatic arthritis of the wrist and carpus, termed scapholunate advanced collapse. introduction: this study was conducted to study the patient characteristics, classification, treatment, complications and functional outcome of operatively treated displaced intra-articular calcaneal fractures (diacf) in a level trauma center in the netherlands material and methods: patients with an diacf, classified as sanders c and operatively treated with percutaneous screw fixation (psf) or open reduction and internal fixation (orif) between january and december were identified. pre-and postoperative radiological assessment was performed. functional outcome, range of motion and change in footwear were evaluated with the use of the american orthopaedic foot & ankle society (aofas) score and the maryland footscore. general health and patient satisfaction was assessed using the short form- (sf- ) and the visual analogue scale results: in total, patients with an operatively treated diacf were identified. patient with diacf completed the questionnaires. there were males and females, mean age at trauma was years. average follow up was years. were classified as sanders type , and as respectively type and . were joint depression and were tongue-type fractures. there were no differences in sanders classification between the group treated with orif and psf. for orif and psf there were ( - %), ( - %) and ( - %) for respectively sanders type , and fractures. mean aofas, mfs, sf- and vas was ( - ), ( - ), ( - ) and ( - ) for respectively orif and psf. mean pre-and post-bohler angle was ( - ) and ( - ) for respectively psf and orif. underwent an ankle arthrodesis. surgical site infection and deep infection occurred in ( , - %) and ( , - %) in respectively psf and orif conclusions: long-term comparison shows no significant differences between orif and psf in treatment of sanders fracture type, bohler angle reduction, on functional outcome or complication rates introduction: the prevalence of hand injury in the pediatric population is attributed to their curiosity, limited fear of pain and diminuted motor coordination. the seymour fracture, which was first reported by seymour in , represents a transverse extra-articular open fracture of the distal phalanges associated with nail bed injuries. the fracture includes salter-harris type i and ii fractures as well as juxta-epiphyseal injuries. material and methods: the aim of this report is to present a case of a seymour fracture in a young boy and describe the injury mechanism associated with misuse of the newly emerging vehicle, the hoverboard. results: our patient was treated promptly and provided with appropriate management following the standard of care in our hospital for such injuries: disimpaction and repair of the nail bed, reduction of the fracture, and k-wire fixation across the distal interphalangeal joint. the patient was discharged with a volar slab and was prescribed an oral antibiotic. the patient recovered well with no major deficits. conclusions: the timely recognition and management of seymour fractures is crucial. the surgical treatment has good results however, conservative management can be an option in some specific cases. antibiotics are always required. we report a case of a fracture pattern resulting from the improper use of an hoverboard. although improper use was a factor, design fault also plays a role in causing the injury. hoverboards are a new transport technology that has been introduced in recent years. because of the number of injuries that have resulted from hoverboards, they should be used in the most controlled way possible to prevent any unnecessary injuries. case history: we report the case of a years old male from bangladesh, with months of progressively increasing pain, limited range of motion and swelling on his left knee, with kg of weight loss and inguinal lymph nodes. clinical findings: knee radiography and mri of the knee demonstrated a voluminous soft tissue mass surrounding the distal femur with intraarticular and posterior extension. a toracic-abdominal-pelvic ct showed supra and infradiaphragmatic lymph nodes. c-reactive protein level was , mg/dl. investigation/results: the clinical picture suggested a lymphoproliferative syndrome. a biopsy was performed, revealing cm of purulent material. synovial fluid had leucocytes/ul, % of polymorphonuclear cells, % of mononuclear cells and undetectable glucose. acid-alcohol resistant bacilli test and pcr test for mycobacterium tuberculosis were positive. diagnosis: mycobacterium tuberculosis knee arthritis therapy and progressions: the patient was treated with polytherapy consisting on rifampin, isoniazid, pyrazinamide and ethambutol. months later, the patient reports no pain, and tumor size has decreased. comments: mycobacterium tuberculosis infection is not a common disease in developed countries. however, the incidence in europe is increasing due to immigration. even though the lung is the most affected organ, osteoarticular tuberculosis represents around % of extra-pulmonary cases. tuberculosis simulates several diseases. because of non-specific symptoms and radiological signs, it can be difficult to diagnose. in a patient with chronic knee pain and limited range of motion, tuberculosis infection should be kept in mind, among other differential diagnoses, such as fibromatosis, pigmented villonodular synovitis or soft tissue sarcomas. clinical findings: the patient presented with a valgus deformity of the knee, the medial femoral condyle protuding on the medial side of the knee. neurovascular status was intact. investigation/results: xray revealed lateral dislocation of the knee. mri revealed mcl, pcl and acl rupture. diagnosis: knee dislocation (kd) grade iii (schenck). therapy and progressions: the patient underwent emergent closed reduction. neurovascular status was intact after resuction. due to important oedema and blisters, the lower limb was immobilized with a brace to allow for skin surveillance. after weeks, the brace was replaced by a long leg cast for more weeks. after months, the patient maintained residual pain, rom - / and minor instability. comments: kd are unusual injuries, associated with high energy trauma, therefore they often result in disruption of at least major ligaments and associated injuries, from soft tissue to vascular structures. emergent reduction is mandatory, and definitive treatment can be conservative, or early/late surgical repair/reconstruction of the ruptured ligaments. there is a lack of large prospective clinical studies comparing the different types of treatment. even so, data tend to associate early surgical treatment with better functional outcomes, though there is no statistic evidence supporting its improvement of the range of motion or stability. long term complications most frequently include residual pain, instability or rigidity. rarely the knee returns to its pre-injured state, independently of the treatment used. references: dwyer, t., et al. ( ) . outcomes of treatment of multiple ligament knee injuries. the journal of knee surgery, ( ), - . advising a reduction after a fracture of the distal radius, reliability with and without use of expert based criteria introduction: distal radius fractures (drf) are common, however many aspects of its management remain subject of debate . this study assessed the interobserver reliability of surgeons concerning the recommendation for a reduction and the improvement of expert based criteria for reduction. material and methods: we sent out surveys to members of the science of variation group. the first survey divided participants in groups, each rated - radiographs of drf. resulting in rated fractures by participants. each observer indicated whether they would advise a reduction or not. the second survey randomized participants ( surgeons) to either receive or not receive criteria for reduction and participants indicated if they would recommend reduction. results: the reliability for advising a reduction was poor, kappa . ( % ci . - . ). multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the change of recommending a reduction by % (beta . , % ci . - . p \ . ). criteria for reduction did not increase interobserver reliability for recommending reduction (no criteria kappa . % ci . - . vs. criteria . % ci . - . ). the likelihood of recommending a reduction was higher in the group using the criteria ( . vs . , p = . ). conclusions: poor interobserver reliability is associated with greater practice variation. dorsal angulation is the main drive for recommending a reduction. the liberal use of the criteria in combination with a specific focus on dorsal angulation leads in our opinion to less variation in treatment recommendation for distal radius fractures. this is something future study could assess for distal radius fractures in actual practice introduction: the number of pertrochanteric hip fractures increases proportionally to the increase in life expectancy. currently, the most used treatment in these fractures is the antegrade nailing. suffering a second fracture in the same femur around an antegrade nail is an uncommon complication, but it has a great impact on the patient. the aim of this study is to describe the type of perinail femoral fractures observed in our center, the treatment performed and the medium-term results. material and methods: between and , patients presented a perinail femoral fracture. were women and one was male, with an average age of . initial fractures were classified according to the ao classification: were a , were a and were a . of them were synthesized by short pfn-a (synthes), with short pfn (synthes) and with gamma (stryker). the average time since osteosynthesis of the proximal femur fracture and the perinail fracture was . years ( month- years). results: of the peri-implant fractures occurred at the level of the nail tip or the distal locking screw. the remaining fractures occurred in the distal femur. these supracondylar fractures and of the fractures at the level of the nail tip were synthesized with a va condylar plate (synthes), overlapped with the nail. in the rest of the fractures around the tip of the nail, the short nail was removed and replaced by a long pfn-a nail. one of the patients died in the immediate postoperative period. two patients died during the first year. in the rest of the patients, a complete consolidation of the fracture was observed, and their previous baseline situation was recovered. conclusions: peri-implant femur fracture is a rare but very severe condition, which requires good surgical planning, and is not without complications. gamagori city hospital, department of orthopedics, gamagori, japan, nagoya daini redcross hospital, department of orthopedics, nagoya, japan introduction: hip fracture is a leading worldwide health problem for the elderly. a missed diagnosis of hip fracture on radiography leads to a dismal prognosis. the application of a computer-aided diagnosis (cad) system using artificial intelligence (ai) to detect hip fracture can potentially improve the accuracy and efficiency of hip fracture diagnosis. material and methods: cad system using ai was trained using cases, plain frontal pelvic radiographs (pxrs) between and from each institution. the accuracy, sensitivity, falsenegative rate, and area under the receiver operating characteristic curve (auc) were evaluated on independent pxrs. the authors mixed resnext as classification algorithm and ssd as object detection algorithm to train cad system. results: the algorithm achieved an accuracy of . %, a sensitivity of . %, a false-negative rate of %, and an auc of . for identifying hip fractures. the visualization algorithm showed an accuracy of . % for lesion identification. conclusions: our cad system using ai not only detected hip fractures on pxrs with a low false-negative rate but also had high accuracy for localizing fracture lesions. the cad system using ai might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. medical faculty university of nis, orthopaedic surgery, nis, serbia, clinical center nis, orthopaedic and traumatology clinic, nis, serbia, orthopaedic word of medical center, cuprija, serbia introduction: bone reconstruction and limb lengthening usually refers to application of ilizarov or other ring external fixation devi-ces . we present here series of posttraumatic reconstruction and limb lengthening, by the use of new concept of d unilateral external fixation device. material and methods: as a clinical material, we present series of patients with different posttraumatic deformities ( ) and limbs discrepancy ( ) as a result of severe traffic accidents and wars. all patients have been treated by specially designed unilateral d external fixation system. that system is not bulky and it is more comfortable in comparison to ring fixators. procedure is relatively simple, so patients handle the device by themselves. during biomechanical testing, it was found that stability of this device is similar to ring systems. the last version of the device includes computer program and two sensors. results: all deformity corrections have been achieved successfully. sliding graft procedure has successfully been performed in all patients with bone defect reconstruction from to cm. in one patient with complex deformity and shortening, correction couldn''t be achieved during one procedure, so additional operations, by the use of the same system have been performed and correction completed. superficial pin tract infection rate was . % and we didn''t have deep infection. there were no other complications including dvt, joint stiffness, neurovascular injuries. conclusion: unilateral external fixation device with balanced d stability provides the same success of bone reconstruction and limb lengthening as ring fixators, but it is more comfortable and more easy for handling. references: treatment principles in bone reconstruction and limb lengthening of the lower extremity. olesen uk, nygaard t, kold sv, hede a. ugeskr laeger. nov ; ( ) at this moment author has licence agreement with the producer of external fixation devices. all patients were classified into the isolated hip fracture and the concomitant fracture. we analyzed these patients'' characteristics such as age, gender, bone mineral density (bmd), body mass index (bmi), korean version of mini-mental state examination (mmse-k), injury mechanism, and length of hospital stay. results: the most common site of upper extremity fracture was distal radius fracture of patients ( . %), followed by proximal humeral fracture of ( . %). concomitant fractures occurred on the same side in patients ( . %). the mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p \ . ). mean preinjury mmse-k was . in isolated hip fracture and . in concomitant fracture patients (p \ . ). mean length of hospital stay was statistically significant different between two groups (p \ . ). according to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture. conclusions: we found a . % prevalence of concomitant hip and upper extremity fractures. it was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. in addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation. on the other hand, the amount of bleeding was ml in group e and ml in group l, and there was no significant difference between the two groups. poor cases on postoperative images were % in group e and % in group l, and the joa hip score was . (groupe) and . (group l). in clinical results is significantly improved in group l. conclusions: the treatment results improved significantly in group l. as the number of experienced cases increased from these results, the reduction accuracy and treatment results improved, so experience was considered important for improving the treatment results of acetabular fractures. the additional value of the weight-bearing and gravity stress radiograph in determining stability of isolated type b ankle fractures introduction: the goal of the current study is to investigate whether the weight-bearing and gravity stress radiographs have additional value in determining stability in isolated type b fibular fractures. this in order to make the important distinction between fractures that need surgical treatment and fractures that can be safely treated conservatively. material and methods: patients with an isolated type b ankle fracture, without medial or posterior fracture, and a medial clear space (mcs) \ mm on the regular mortise radiograph were included. in the emergency room, a gravity radiograph was performed (in accordance with out protocol). within week, an additional mri scan was made. at this moment, in patients a weight-bearing radiograph was performed too. the mcs measurements of these regular mortise, gravity and weight-bearing radiograph were compared with the mri findings. the mri scan was set as reference standard to detect injury of the deltoid ligament in order to determine (in)stability. results: mean mcs on mortise radiograph was . mm (range . - . ); in ( . %) patients the mcs was [ mm and in patients ( . %) the superior clear space (scs) was [ mcs ? mm. in ( . %) patients, the scs [ mcs ? mm. on the gravity stress radiograph, . % of the patients had a mcs [ mm. the weight-bearing radiograph showed a mcs [ mm in ( . %) patients. in ( . %) patients, the mri showed a complete rupture of the deltoid ligament. in ( . %) patients a partial rupture was seen. patients ( . %) received surgical treatment. in all conservatively treated patients, no secondary dislocation occurred and there was no need for postponed surgical treatment. conclusions: the gravity stress view has a tendency to overestimate the mcs. thus, potentially too many stable fractures are incorrectly diagnosed instable and receive unnecessarily surgical treatment (with additional costs and risks). the weight-bearing radiograph, on the contrary, does not overrate the medial injury and can safely be used in the decision making process of treating conservatively and weightbearing (for example by using a brace) introduction: the purpose of this study was to identify the effect of the intravenous iron supplementation on demand of perioperative blood transfusion and post-operative hemoglobin recovery in geriatric hip fractures. material and methods: a retrospective cohort study was performed on patients who underwent surgery with proximal femoral nail for hip fracture and age years old or older between jan and may in a single center. the participants were divided into groups according to preoperative intravenous iron supplementation (iron isomaltoside, monofer Ò , pharmacosmos, holbaek, denmark); group (n = ) with monofer mg before surgery and group (n = ) without monofer. transfusion was preformed when the hgb was less than mg/dl). primary endpoint was incidence of perioperative transfusion. secondary endpoints were various hemoglobin (hgb) levels. results: the average age of the participants were . years old, and average body mass index (bmi) was . . demographic data including age, sex, bmi, comorbidity (charlson comorbidity index) of each group showed no difference. the complications from intravenous iron administration were not occurred. the preoperative hgb was . mg/dl (group . ± . vs, group . ± . , p = . ). the hgb at the postoperative day was . mg/dl (group . ± . vs group . ± . , p = . ). the average hgb at the postoperative month was . mg/dl (group . ± . vs group . ± . , p = . ). transfusion rate was . % ( / ) and the rate showed no difference between groups ( . % vs . %, p = . . the recovery of hgb between postoperative month and preoperative state showed statistically difference (group . vs group -. , p = . ), and iron supplementation group had more recovery. conclusions: intravenous iron supplement before the hip fracture surgery in elderly helped to recover hgb at postoperative month. comminuted subtrochanteric femur fractures-our experiences introduction: subtrochanteric femoral fractures account for approximately % of all the hip fractures and their treatment represents a challenge because of the short proximal fragment and highenergy forces. material and methods: a total of patients with subtrochanteric, highly comminuted fractures, were included in this study, with age range from to years. the mechanism of injury in all patients was high-energy trauma. in each case we applied a long gamma nail (limma lto) without focus opening. results: in all patients, good clinical and radiologic results were accomplished, in addition to early weight-bearing, without shortening of the legs, or consequences on the state of the hip and morbidity in general. conclusions: although the comminuted subtrochanteric femur fractures represent a challenge for the orthopedic surgeons, osteosynthesis using long gamma nail without the focus opening provides outstanding results. introduction: this study analyzed the association between the postoperative reduced position obtained on using short femoral nails (sfns) and the amount of sliding after fixation in unstable trochanteric fractures. material and methods: this retrospective study included patients with unstable trochanteric fractures with posterolateral support deficiency who underwent osteosynthesis with sfns and were followedup for months or longer. the study included men and women with a mean age of . years at the time of fracture. closed or open reduction was performed to achieve anatomical to medial type position on frontal view and anatomical to extramedullary type position on lateral view, followed by fixation with sfns. immediately and extramedullary type in patients immediately after surgery. three months after surgery, the reduced position worsened from the anatomical to intramedullary type in patients. according to the reduced positions at months after surgery, the mean amount of sliding was . mm in patients with intramedullary type, . mm in those with anatomical type, and . mm in those with extramedullary type. the amount was larger in those with intramedullary type than in those with anatomical and extramedullary types. moreover, excessive sliding was observed in patient with intramedullary type. conclusions:to prevent excessive sliding by ensuring anteromedial bony support in unstable trochanteric fractures with posterolateral support deficiency, open reduction should be aggressively performed to overcorrect to the extramedullary type when reduction performed on a traction table results in either anatomical or intramedullary type positioning. in this paper, we report patient previously studied for osteomyelitis caused by high-energy missile trauma, in . that study involved a total of patients with osteomyelits, divided into two groups, according to the treatment protocol applied. the group included patients treated using classic surgical methods, including debridement, curretage, forage, perfusion drainage and sequestration. the group included patients treated using recommended surgical methods and used pmma antibiotic beads. years after, we tried to contact all of the patients, for the purpose of follow-up. however, only patient was available for analysis. among patients we followed-up, were treated using recommended surgical protocol, while the remaining patients were treated using classic surgical methods. we present the patients' general status, as well as the local surgical status and radiographic analysis, years after. we obtained long-term results of both treatment protocols applied. from the group , patients developed chronic recurrent osteomyelitis, while only one patient from the group developed such condition. introduction: the aim of this study was to evaluate the treatment results using anterior subcutaneous internal fixation(infix) for the pelvic fractures and to consider an improvement strategy for the complications. material and methods: from to , pelvic fractures were enrolled. there were two males and females. the average age was years. there were fragility fractures and five high energy fractures. our operative procedure was as below: the connection between screws and rod was just above the fascia of the sartorius muscle. the connection bar was pre-bended before the operation using the initial axial ct scan. we assessed bone union, additional fixation, the distance between the femoral artery and connection rod (dar), the distance of protruded bar lateral to the connection (dpb), and complications. results: bone union achieved in out of cases. there was one nonunion and three early deaths because of medical complications. seventeen out of cases required additional posterior fixations. the average dar was . ( . - . mm) , and the dpb was . ( - ) mm. thirteen out of cases ( . %) had complications. there were seven lateral femoral cutaneous nerve (lfcn) symptoms ( required implant removal (ir)), two infections ( required ir), one hematoma (ir), one irritation (ir), one heterotopic ossification, one loosening (re-operation). there were no femoral vessels and nerve-related symptoms. to release lfcn and surrounding soft tissues decreased the nerve symptoms. conclusions: to connect the screws, and the rod just above the sartorius fascia could avoid major vessels and nerve complications, and also irritations. although this study found a high complication rate of infix, to release the lfcn and around soft tissue could decrease the complications. introduction: several studies have reported that posterior or anterior tilt increases the risk of reoperation in undisplaced femoral neck fractures (garden i/ii) after internal fixation performed using nonangular stable devices such as pins and multiple screws. however, to the best of our knowledge, there is limited research involving angular stable devices. the present study aimed to investigate the clinical outcomes in undisplaced femoral neck fractures after internal fixation using angular stable devices. material and methods: this retrospective study included patients (mean age, . [range, - ] years) who underwent internal fixation using angular stable devices between january and january . undisplaced femoral neck fractures with garden alignment index (gai) b °(posterior tilt angle c °) or gai b °( anterior tilt angle c °) were included (posterior: , anterior: ) in this study. patients were followed up for at least months (mean, . months). we analyzed the preoperative and last-followed gai on lateral radiographs, non-union, and late segmental collapse (lsc). results: among the patients, non-union was identified in ( . %) and lsc was observed in ( . %). the mean preoperative gai was . °(range, °- °), and the mean last-followed gai was . °( °- °). the overall complication (non-union and lsc) rate was . % ( / patients). among patients with gai c °, lsc occurred in ( . %). conclusions: in undisplaced femoral neck fractures, preoperative posterior c °is a risk factor for postoperative complications even when internal fixation is performed using angular stable devices; thus, primary arthroplasty may be considered. case history: the patient is a -year-old female who had undergone lumpectomy at the age of when she was diagnosed with breast cancer. she had antiresorptive drug therapy for bone metastasis, since years after the lumpectomy. she fell down from standing height and was diagnosed as right femoral subtrochanteric fracture. her femur was fixed with short femoral nail. she complained left hip pain at age .she complained left hip pain from july . clinical findings: she could walk with crutch.rom of left hip was normal. investigation/results: breast surgeon took mri and there was metastasis in the proximal part of femur. he thought the cause of pain was this metastasis. however, there was fracture line at the height of lesser trochanter when she visited our department. diagnosis: atypical fracture was strongly suspected, however, fracture line was little higher as normal atypical fracture. therapy and progressions: osteosynthesis with long femoral nail was performed months after first visit to our department because of increasing pain. pathological findings were metastasis and fracture. after surgery, radiation to femur was performed. she can walk without pain by crutch and fracture line is almost disappeared on months after surgery. comments: atypical femoral fractures (affs) are recently observed as a complication of antiresorptive drugs for bone metastasis. however, there were metastasis and atypical fracture in this case. introduction: in the present study we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (ct), in complex tibial plateau fractures, treated with an illizarov frame. materials and methods: this retrospective case series covers the period from - to - . forty-four patients with a mean age of years (range - years), with a complex intrarticular proximal tibia fracture were included. fracture types iii to vi according to schatzker's classification were included. the majority were closed injuries, apart from cases (a gustilo anderson type a and a type ). all patients were placed on a fracture table. a mini-open reduction of the articular surface was followed by application of a knee spanning illizarov frame. post-operatively all patients were subject to ct of the injured knee. outcomes were measured using the american knee society score. results: mean outpatient follow up was of at least months (range of - months). mean time for fracture consolidation . weeks (ranging from to weeks). according to the degree of postoperative articular surface depression patients were grouped as follows: had under mm, had - mm and over mm of depression. those with less than . mm of collapse had % chances of an excellent result according to akss. on the contrary, those with more than . mm of articular surface collapse had % chances for low scores and functional results. the achievement of a mechanical axis within °of the contralateral limb was positively correlated with good functional results but did not have a correlation with the akss. conclusions: complex tibial plateau fractures may be treated successfully with mini open reduction and the application of an illizarov frame. post-operative ct denotes the exact degree of displacement of the articular surface, which is prognostic regarding outcome. postoperative x-rays may be misleading, since they can underestimate articular surface collapse. introduction: a new trauma center building was constructed in march , and the process from the trauma bay to the operation room is faster. we hypothesized that this process improved the survival rate of trauma patients in need of trauma laparotomy. material and methods: the new trauma center separates the trauma bay from the emergency room, and the trauma team exam patients initially. it also has a separate operation room that is always available for emergency surgery. therefore, the decision to perform laparotomy and time to operation has been shortened. from january to december , trauma patients who underwent emergency laparotomy were included. those younger than years, who had delayed operation, underwent surgical observation, delayed admission by patient, or underwent angiography first were excluded. patients were dichotomized to the before-trauma-center (bc) and after-traumacenter (ac) groups, and their characteristics and clinical outcomes were compared. results: of patients, were included in the bc group and were included in the ac group. the times from admission to operation introduction: acute care is a growing worldwide burden with increasing visits to the emergency department (ed). the acute care system in the netherlands is almost overloaded and costs are increasing. almost % of ed visits have surgical disease. there is no nationwide acute care surgery (acs) model implemented yet, and resources and infrastructure are organized differently in almost every hospital. this study provides an overview of the existing systems nationwide, and basis for a national uniform model. material and methods: an online survey was distributed through the dutch surgical society and sent to all dutch hospitals. after sending a reminder, the survey was closed and results were analyzed. results: thirty-two hospitals ( %) participated in the survey. in % a surgeon (trauma, vascular or gastro-intestinal) was assigned as consultant and responsible for ed admissions, emergencies in-house, and in some cases also emergency surgeries. % of hospitals have an ed observation unit (edou). a dedicated emergency surgery operating room (esor) is available in % ( / available in %), and used efficiently in % primarily due to the following challenges: elective surgery scheduled at esor ( %), necessary stop of esor when elective programs are delayed ( %). in hospitals without an esor, the emergency surgeries are scheduled in between elective surgeries resulting in extending programs into the evening. finally, % of respondents was familiar with acs, with % being positive about exploring options of implementing such a model in our country, and % of the respondents opts for more focus on acs in surgical residency. conclusions: in the netherlands the organization of acute care varies. the main common bottleneck is the logistics around the or. implementation of a dedicated esor and unconditional availability / of this or seem to be the most important factors for optimal efficiency. although there needs to be more focus on acs in general, implementing a uniform model nationwide seems challenging at this moment. trauma team activations (tta) at an european trauma center: cases analyzed s. saar , , e. lipping , h. vospert , r. volmer , h. k. laas , j. lepp , k. g. isand , p. talving , north estonia medical centre, division of acute care surgery, tallinn, estonia, university of tartu, tartu, estonia, north estonia medical centre, tallinn, estonia introduction: the north estonia medical centre (nemc) is the largest trauma center in estonia with evolving capabilities. however, studies scrutinizing trauma team activations (tta) are currently lacking. thus, we initiated an investigation to document tta profile and outcomes. material and methods: all tta patients admitted to the nemc between / and / were retrospectively identified. data collected included demographics, injury severity score (iss), management, hospital length of stay (hlos), and in-hospital outcomes. primary outcome was -day mortality. results: overall, patients were included. mean age was . ± . years and . % were male. penetrating and blunt trauma accounted for . % and . % of the cases, respectively. non-ground level falls were the predominant mechanism of injury constituting . % of the admissions. mean iss was . ± . and . % of the patients were severely injured (iss [ ). blood alcohol level (bal) was positive at . %. a total of . % of the patients had an emergent operation. mean hlos was . ± . days.overall -day mortality and mortality of severely injured patients was . % and . %, respectively. conclusions: the current investigation documents comparable outcomes with established european trauma facilities [ , ] . blunt injury patterns predominate, however, high penetrating trauma incidence for european settings was noted. high rate of positive bal in tta patients warrants national preventive measures. introduction: the acute care surgery (acs) model was initially developed as a dedicated service for the provision of high quality / non-trauma emergency surgical care. after implementation in the united states (us), the model has been adopted in several variations around the world.in this systemic review we investigated which components are essential for a potential uniform acs model, by giving an overview of the current available acs models worldwide and their state of implementation. material and methods: a literature search ( - ) was conducted using pubmed, medline, embase, cochrane library and web of science databases following the prisma guidelines. all relevant data of acs models were extracted from included articles. results: sixty-five articles describing acs models in different countries were included in this review. the majority consist of a dedicated surgical service, providing non-trauma emergency surgical coverage, with daytime on-site attending coverage by an attending surgeon who is cleared from elective duties, and / in-house resident coverage. emergency department coverage and access to an acute care operating room varied widely across countries. critical care is fully embedded in the original us model as part of the acute care chain (acc), while in most other countries it is still a separate unit. while in most european countries acs is not a recognised specialty yet, there is a tendency towards more structured acute care, with training and separation from elective practice. conclusions: acs is gradually implemented worldwide. however, large national and international heterogeneity exists in the structure and components of the model. critical care is still a separate unit and specialty in most systems while it is essential to be part of the acc in order to provide the best peri-operative care of the physiologically deranged patient. universal acceptance of one global acs model seems challenging, however a global consensus on essential components would benefit any healthcare system. introduction: the recent financial crisis in greece is coped mainly with reformations towards cost effectiveness and rationality in the management of public expenses. the goal of the study is to evaluate the cost and time effectiveness in the management of the surgical patients admitted in emergency department (ed). methods: for a period of h/day in consecutive days, surgical cases presented in the ed of a tertiary university hospital of athens were followed. inclusion criteria were need for laboratory tests or imaging examinations or an immediate resuscitative intervention. data recorded regarding demographics, vitals, critical time points, disease and management. physician related data and cost of examinations were also collected. case severity was calculated by early warning score [ ] . results: she average waiting time for each patient was min and the average total time until final decision was : h. blood tests costs reached an average of , € per case and imaging an average of , €. the striking finding was that only one out of patients was of medium clinical risk, while all the others were of low. thus, substantial symptoms and clinical findings were lacking and as the ''tertiary care'' character of the hospital was mandating conclusive diagnosis, exams were ordered. this approach absorbs time and funds putting at risk the very few severe cases which are the target population for the magnitude of the facility. the current study indicates that the use of a tertiary hospital as a primary health care center by the public, is disorganizing the system, and increase the cost in time, funds, and preventable morbidity and mortality. a pre-hospital triage and management of the low severity cases system is pending to be established in our environment and becomes top priority in an era of prolonged financial crash. for years, surgical emergencies in ecuador have been managed without significant standardization. scarce numbers of specialists, lack of a constant presence of full-time teaching faculty versed in emergency surgery and lack of continuity with surgical trainees led to variability in clinical and surgical decision-making. to address these issues, the regional hospital vicente corral moscoso (hvcm) adapted and implemented a model of ''trauma and acute care surgery'' (tacs) to the reality of cuenca, ecuador. a cohort study was carried out, comparing trauma and acute care surgery patients exposed to the ''traditional care model'' before the implementation of the tacs model. variables assessed included: surgical wait times, number of hospital visits, number of surgical interventions, number of surgeries performed per surgeon and inhospital mortality. higher mortality was found in the traditional care model (rr of . , p b . ) compared to the tacs model. we observed a statistically significant decrease in surgical wait time ( . - . h for emergency general surgery, . - . h for trauma, p b . ). lengthof-stay decreased in trauma patients ( - days p b . ). the total number of surgical interventions increased ( , . - , . , p b . ) ; by extension, the total number of surgeries performed per surgeon also increased ( . - . , p b . ) . the implementation of tacs model in a typical resource-restrained, tertiary care hospital in latin america had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients, and length-of-stay in trauma patients. we also noted a statistically significant decrease in mortality. while cost could not be objectively evaluated with the available data, savings to the overall system and patients can be inferred by decreased mortality, length-ofstay and surgical wait times. to our knowledge, this is the first implementation of an tacs model that has been described in latin america. introduction: traumatic injuries constitute one of our major public health challenges. the most effective means to reduce the impact trauma has on individuals and society is primary injury prevention, reducing the incidence of traumatic events, which relies on detailed knowledge of risk factors. the aim of this study is to facilitate targeted injury prevention through improved data collection and analysis on impairing substances as risk factors for traumatic injuries. material and methods: idart is a national prospective observational study including analyses of the toxicological profile of all patients c year of age admitted via trauma team activation to any norwegian trauma hospital (n ) during a month study period. residual blood from routinely drawn blood samples at trauma admission is analyzed for alcohol, illegal and psychoactive drugs. toxicological data will be linked to clinical data from the national trauma registry. results: the study period started march st, , and during the first months patients were included from trauma hospitals. more than % of the included patients tested positive for psychoactive substances according to preliminary data. data on the prevalence of different psychoactive substances disaggregated by mechanism of injury, demography and geography from the month study period will be presented. conclusions: the idart study will provide a detailed descriptive analysis on the prevalence of alcohol, illicit and medicinal drug use among all patients admitted to a norwegian hospital with suspected severe injury. subgroup analyses will include prevalence of alcohol and other substances in subgroups analyses on patient and injury characteristics and geographical variations. analyses will aim to identify high risk groups according age, gender, circumstances of the injury, geographical location and type of psychoactive substance. the dutch nationwide trauma registry: the value of capturing all acute trauma admissions m. driessen , l. sturms , l. leenen lnaz/umcu, trauma surgery, nijmegen, netherlands introduction: twenty years ago the dutch government decided to reform the trauma care system and designated level regional trauma centers (rtcs). these centers, in collaboration with ambulance services and regional hospitals, have managed to set up regionalized inclusive trauma systems. moreover, they set up the dutch national trauma registry (dntr) as a quality evaluation and epidemiology resource. in this resource all acute hospital admissions were included, in order to measure the hospital and prehospital processes and outcomes. in the current study we demonstrate its current status and compare it with national trauma registries from the uk and germany. material and methods: the dntr includes all injured patients treated at the ed of % of all hospitals in the netherlands within h after the trauma followed by direct admission, transfer to another hospital or death at the ed. a representative descriptive analysis of extracted data from is demonstrated. results: between and a total of , trauma cases have been registered in the dntr. hospital participation has increased from % up to %. in alone, a total of . patient were included, % concerned males, the median age was years. % of all admissions had an iss c , of which % was treated at a rtc. from this cohort, in comparison, only % and % of the dntr patients met tr-dgu or tarn inclusion criteria. particularly children, elderly and patients admitted at non rtcs are not captured in the tr-dgu or tarn. also, part of iss c and fatal cases do not meet tr-dgu or tarn inclusion criteria. conclusions: the dntr has evolved into a comprehensive wellstructured nationwide population-based trauma register, with an annual number of , cases being entered in the database the dtr has grown to be one of the largest trauma databases in europe. the registry enables studies on the injury burden and quality and efficiency of the entire trauma care system encompassing all traumareceiving hospitals. introduction: trauma mortality is not distributed evenly. rural areas have higher incidence rates of trauma mortality than urban areas. the rural northern part of the nordic countries have common challenges with sparsely populated areas, long distances, and an arctic climate. the aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the nordic countries over a fiveyear period. material and methods: in this retrospective cohort we used the cause of death registries and collated all deaths from to with an external cause of death (icd- , v -y , except y - and t - ). the study area was the three northernmost counties in norway, the four northernmost counties in finland and sweden and the whole of iceland. we used % confidence intervals (ci ) to test for differences between the countries. results: there were deaths in the study area during the -year period. low energy (le) trauma constituted % and high energy (he) trauma % of deaths. northern finland had the highest incidence for both high energy trauma and low energy trauma. iceland had the lowest incidence for high-, and low energy trauma. iceland had the lowest prehospital share of deaths at % and the lowest incidence of injuries occurring in a rural location. the incidence rates for he trauma death was , / . /year in northern finland, , / . /year in iceland, , / . /year in northern norway and , / . /year in northern sweden. conclusions: there were significant and unexpected differences in the epidemiology of trauma death between the countries. the differences suggest that a comparison of the trauma care systems and preventive strategies in the countries is required. the diurnal and seasonal relationships of pedestrian injuries secondary to motor vehicles in young people introduction: there remains a significant morbidity and mortality in young pedestrians that are hit by motor vehicles, even in the era of pedestrian crossings and speed limits. the aim of this study was to compare incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. we hypothesised that injuries in young people would be more prevalent during dusk and dawn and during autumn and winter. material and methods: data was reviewed from patients in the - year old age group in the trauma audit and research network (tarn) national database, who had been involved as a pedestrian in a motor vehicle accident between and . the incidence of injuries, their severity (using the injury severity score [iss]), hospital transfer time and mortality were analysed according to the hours of daylight, darkness and seasons. results: . % of injuries occurred during time of darkness post sunset, while . % occurred during daylight. the incidence of injuries in motor vehicle accidents, in absolute terms, was highest during - , with a second peak at - . the greatest injury rate (number of injuries/hour) occurred during - and - with respective rates of . and . injuries scoring an iss over occurred . % at - and a further . % until . mortality was greatest during - involving out of the total deaths. autumn was the predominant season and lead to . % of injuries, with a further . % in winter. this demonstrated a clear difference to . % and . % in spring and summer. conclusions: we have identified a relationship between reduced daylight and the frequency and severity of pedestrian trauma in young people suggesting that reduced visibility may play a significant role which could be addressed through a targeted public health approach to implement change. enhancing cost effectiveness in a system in crisis: a , patient study a. tsolakidis , c. christou , p. smyrnis , a. prionas , a. tooulias , g. tsoulfas , v. n. papadopoulos aristotle university of thessaloniki, st department of surgery, papageorgiou general hospital, thessaloniki, thessaloniki, greece introduction: to date, there is no national trauma database in greece. the goal of our study is to record and evaluate trauma management at our university hospital as well as to measure the associated healthcare cost, while laying out the foundations for a national database. material and methods: retrospective study of trauma patients (n = , ) between and . demographic information, injury patterns and severity, outcomes and cost were recorded. results: the proportion of patients that were transferred to the hospital by the national emergency medical services was , %, whereas ( %) of our trauma patients did not meet the us trauma field triage algorithm criteria. over-triage of trauma patients to our facility ranged from . to . %, depending on the criteria used. ( . %) of our patients received operative management and % ( ) of them had postoperative complications. an iss [ was seen in ( %) of our patients and their mortality was , %. the overall non-salary cost for trauma management was . . euros. the cost resulting from the observed over-triage ranged from . to . . euros. furthermore ( . %) of our patients underwent at least one ct scan that did not show any significant traumatic lesion. the cost of hospitalization of these patients was . euros. conclusions: the prehospital triage of trauma patients in the greek national health system is ineffective, with significant over triaging, leading to excessive costs. appropriate use of criteria for diagnostic procedures and algorithms may lead to a, much-needed, reduction of these costs. introduction: in japan, there are emergency and critical care centers nationwide (one center for approximately every , people), and a system is in place to accept local critically ill patients h a day, irrespective of whether their conditions are intrinsic or extrinsic. however, manpower and medical care systems differ depending on the emergency and critical care center, and the establishment of a system for consolidating severe trauma patients has been particularly problematic. material and methods: this study examined cases where the patient had some sign of life when encountered by ambulance teams of the cases of traffic accident deaths that occurred in chiba prefecture between and . thirteen emergency and critical care center representatives in chiba prefecture met to verify each case based on data from the police, fire department, and medical institutions. the cases were classified into ( ) preventable trauma death (ptd) cases, ( ) suspected ptd cases, and ( ) non-life-saving cases; the problems (causes of ptd) in each case were examined. result: there were cases ( %) of ptd and suspected ptd. sixty-eight of these cases were transported to emergency and critical care centers. the most common cause of death was bleeding, accounting for cases and the locations where the problems that caused ptd occurred were outside of the hospital (n = ) and in the hospital (n = ). the problems that occurred in the hospital (including duplications) include circulatory management (n = , %), the treatment plan (n = , %), delay of lifesaving surgery (n = , %), and delay of diagnosis (n = , %). most of these occurred in the initial emergency care room. conclusion: this study clarified that ptd still occurs in relation to bleeding control in the current trauma care system in chiba prefecture. it is vital to establish a national ''trauma center'' and to thoroughly consolidate trauma cases to eradicate ptd. analysis of the impact of the implementation of a trauma team in a trauma center from an upper-middle-income country introduction: trauma teams (tt) improve the care process and the outcomes. a multidisciplinary tt was conformed in september to achieve a rapid response by specialists in emergency medicine, trauma surgery, diagnostic imaging services, and blood bank in a level i trauma university hospital in southwestern colombia. objective: to evaluate the impact of a tt implementation in terms of times of attention and mortality. material and methods: retrospective study. all the patients with the highest level of tt activation treated in the months after the tt implementation were included. the subjects triaged to the trauma center in the months pre tt were taken as controls. four hundred sixty-four patients were included, before the implementation of the tt (btt) and after (att). demographic data, trauma characteristics, times to tomography, and trauma surgery and mortality were recorded. the analysis was made on stata , Ò . categorical variables were described as quantities and proportionscontinuous variables as mean and standard deviation or median and interquartile range (iqr). categorical variables were compared by chi or fisher's test. continuous variables with student's t or wilcoxon-mann-withney. a multiple logistic regression model was created to evaluate the impact on mortality if being treated att, adjusted by age, trauma severity, and physiologic response on admission. results: the time from admission to the ct scan was min (iqr - ) in the btt group and min (iqr - ) in the att group, p &lt; . . the time to trauma surgery was min (iqr - ) in the btt group and min iqr - ) in the att group, p &lt; . . mortality in the btt group was . % and . % in the att group. adjusted or was . ( . - . ) p = . conclusions: the implementation of a multidisciplinary trauma team associated with a reduction of the times to tomography and surgery and with a decrease in mortality risk. no prediction of an unfavourable outcome after surgical treatment of chronic subdural hematoma patients using machine-learning l. riemann , a. younsi , c. habel , j. fischer , a. unterberg , k. zweckberger university hospital heidelberg, neurosurgery, heidelberg, germany introduction: chronic subdural hematomas (csdh) are expected to become the most frequent neurosurgical disease by the year . although often perceived as a ''benign'' condition, considerable rates of mortality and poor outcome have been reported. we therefore evaluated factors associated with an unfavorable outcome after surgical treatment of csdh patients by developing a predictive model using machine-learning. material and methods: consecutive patients treated for csdh with surgical evacuation between and at a single institution were retrospectively analyzed. potential demographical, clinical, imaging and laboratory predictors were assessed and a decision-tree predicting unfavorable outcome (gos - ) was subsequently developed using the classification and regression tree (cart) algorithm. out-of-sample model performance was evaluated using repeated cross-validation (fivefold with repetitions). results: eligible patients were analyzed. median age was (iqr - ) years and % were males. mortality rate was . % and rate of unfavorable outcome was . %. the developed decision-tree to predict unfavorable outcome had splits and included the following clinical variables (in descending order of calculated importance): gcs, comorbidities, hb, and age. after cross-validation, the following model performance metrics were obtained: a model accuracy of . ( . - . ), sensitivity of . ( . - . ), and specificity of . ( . - . ). conclusions: gcs, comorbidities, hb, and age were identified as the most important clinical predictors for an unfavorable outcome in csdh patients after surgery. the developed model was simple and still displayed a high accuracy and very high specificity, the sensitivity was however rather low. our results might help clinicians to better assess the prognosis in patients with csdh. introduction: in most developing countries access to tertiary care neurosurgical setup is uncommon. majority trauma including neurotrauma & medical conditions requiring emergency neurosurgical interventions present to a general surgeon. this study is an attempt to highlight the importance of emergency neurosurgery as a skill amongst general surgeons & also focus on the challenges in managing such cases in austere environments material and methods: this study was a retrospective analysis of progressively collected data of trauma patients with a specific focus on head injuries & emergency neurosurgical interventions for both traumatic & non traumatic indications in a level trauma centre in a semi urban area over a period of years from august to september results: a total of patients of trauma were analysed out of which were head injuries. road traffic accidents accounted for nearly % of head injuries. atypical trauma especially in rural setup e.g. train collision, animal related causes were also seen. males accounted for majority (m:f = . : ). mean age was yrs. patients had imaging findings suggestive of severe head injury. acute sdh was the commonest post traumatic finding and mca territory infarct in non traumatic group. patients underwent emergency neurosurgical intervention with a survival of %. factors associated with poor outcome were delayed presentation (p \ . ), sdh with diffuse axonal injury. alcohol consumption was a significant factor. conclusions: emergency neurosurgery is an essential skill for general surgeons. performing such cases in a low resource environment in absence of modern day facilities for imaging, icp monitoring & powered equipment presents a significant challenge. general surgeons should be able to perform operative interventions with basic handheld instruments. operative management whenever indicated should be done & helps improve outcomes. head trauma in polytraumatized patient. analysis of risk factors and neurological prognosis b. castro , , , m. morote gonzález , , , l. cebolla , , , a. sada , , , l. seisdedos , , , , , j. gil , c. rey valcárcel , , f. j. turégano fuentes , , c. tristan , c. ruiz moreno hgugm, surgery, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospitall, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospital, madrid, sri lanka introduction: severe trauma is one of the most frequent causes of death and disability and traumatic brain injury (tbi) in polytrauma is the main cause of death and disability in survivors. the aim of this study is to analyze mortality associated to tbi in the last years, prognostic factors associated with it and neurological outcomes in survivors with tbi. methods: retrospective observational study that includes risk factors and functional neurologic evaluation in polytrauma patients attended in gregorio marañon hospital between - . inclusion criteria were severe trauma patients (iss c ) with a tbi and abnormal ct of the head. we analyzed mortality trend in two periods : - and - , and neurological evolution and outcome at discharge with functional scores (ramkin scale and gos) in the second one. results: from to , severe trauma patients were admitted, ( , %) with brain or central nervous system injuries visible on head ct. median age was ' ; . % were men. the global mortality of the cohort has been , %, . % of them for neurological causes. ischemic heart disease, anticoagulation, abnormal pupils or eye opening, the need for surgery, shock, gos, iss, niss, cranial ais are significant associated with higher mortality (p \ , ).the mortality rate due to neurological causes decreases in the second period from , to , %, this descent being statistically significant (p = , ). between and , % patients died from cnsi, and , % of tbi survivors had a vegetative status at discharge, , % had major disability, and , % had a good neurological recovery. conclusions: mortality due to tbi decreased in the last years, but this improvement after tbi was at the expense of a high rate of vegetative status and great disability, showing the need for continuous research in this area. introduction: severe traumatic brain injury (tbi) constitutes one of the most frequent causes of intensive care unit admissions and is a major cause of death and disability among young people. decompressive craniectomy (dc) is a life-saving measure used to relieve intracranial pressure (icp). this procedure is related with low mortality rates and poor functional outcomes. the aim of this study is to analyze the survival rates and prognostic factors related with functional outcomes after dc for severe tbi. material and methods: retrospective, single center study of patients with severe tbi in whom a dc was performed between the years and . demographic features, clinical parameters, radiological findings and clinical outcomes were included in the study. for the statistical analysis we used anova, chi-square, kaplan meyer, cox regression and logistic regression. a p value of less than . was considered to indicate statistical significance. results: the mean initial glasgow coma scale was , ± , and the mean initial motor response (imr) was , ± , . the mean icp after dc was , ± , . the -day survival after dc was %. twenty percent of the patients improve ate least point in the glasgow outcome scale (gos) between and months after surgery. twelve patients improve from unfavorable gos to favorable gos. at -month follow-up, % of the patients has gos [ . younger age, high irm a post-operative icp were the factors significantly associated with a higher chance of outcome improvement. conclusions: dc is useful for the management of refractory intracranial hypertension related to severe tbi, and in selected patients is associated with good functional outcomes. introduction: antiplatelets and anticoagulation, commonly referred to as antithrombotic therapy, are frequently used in patients c years. the use of antiplatelets and anticoagulation are associated with increased incidence of intracranial bleeding ( , ) . there are two research questions addressed in this study: ( ) does preinjury antithrombotic therapy affect survival in elderly patients with tbi? ( ) are direct oral anticoagulants (doacs) associated with better survival than vitamin k antagonists (vka) in tbi patients on anticoagulation? materials andmethods: retrospective cohort study based on data extracted from the oslo tbi registry. included in the study are tbi patients c years admitted to ouh with cerebral-ct showing signs of acute trauma (hemorrhage, fracture, vascular injury) in the time period - . the impact of age, comorbidity, antithrombotic medication and antithrombotic reversal protocol for survival will be explored. results: the patient inclusion is ongoing. preliminary data will be presented at the st ectes in april . the estimated number of tbi patients c years with cerebral-ct showing signs of acute trauma in the study period is * . in this patients group, the expected preinjury use of antiplatelet and anticoagulation medication is * % and * %, respectively. conclusions: the knowledge regarding impact of preinjury antithrombotic therapy on survival in elderly tbi patients is clinically relevant, and may improve patient management in the acute phase of injury. references: introduction: traumatic acute subdural hematoma (asdh), especially the large ones in need of surgical evacuation, is associated with high mortality. contemporary population-based series of surgically treated asdh are sparse. the two main aims of this single-center study from oslo university hospital (ous) were to estimate incidence of surgery for asdh in the population of helse sør-Øst, and estimate in-hospital and -month survival of these patients. treatment of tbi at ous adheres to the brain trauma foundation guidelines, with icp controlled therapy and evacuation of asdh when gcs \ and hematoma volume c cm or midline shift c mm or hematoma width [ mm. the goals of tbi treatment for adults have been to maintain icp \ mmhg and cerebral perfusion pressure (cpp) c mmhg. methods: from . . all patients with traumatic brain injury (tbi) with positive head ct, admitted to ous, living in helse sør-Øst ( . million inhabitants) and having a norwegian social security number, have been included in our approved tbi-quality register. included in the present study are all patients with asdh undergoing evacuation of the hematoma within days of trauma. the following data were extracted from the register; demographic variables, date of injury and trauma mechanism, severity of head injury according to hiss grade, rotterdam ct score, surgical procedures, multitrauma, glasgow outcome scale at discharge and date of death. results: asdh patients were operated in the -year period - , % males, mean age was years ( - ), the most frequent trauma mechanism was falls ( %), % were under influence of ethanol, % had severe tbi and % had multitrauma. the incidence of surgically treated asdh in helse sør-Øst was / . /year. in-hospital and -month mortality was . % and %, respectively. conclusion: the presented data for incidence and mortality will be compared with earlier reports. age-related difference in impacts of coagulopathy in patients with isolated traumatic brain injury: an observational cohort study w. takayama , a. endo , y. otomo tokyo medical and dental university hospital of medicine, trauma and acute critical care, tokyo, japan background: age and trauma-induced coagulopathy (tic) have been reported to be the predictors of poor outcome following traumatic brain injury (tbi). whether the impact of brain injury induced coagulopathy on outcomes have age related differently is unknown. objectives: we evaluated the age-related difference in the impact of tic on outcomes in patients with isolated tbi. methods: a retrospective observational study was conducted in two tertiary emergency critical care medical centers in japan from to . the patients with isolated tbi [head abbreviated injury scale (ais) c , and other ais \ ] were included. we evaluated the impact of coagulopathy (international normalized ratio c . , and/or platelet count \ /l, and/or fibrinogen b mg/dl) on the outcomes [glasgow outcome scale-extended (gos-e) scores, inhospital mortality and ventilation free days (vfd)] in both group using univariate and multivariate models. furthermore, we visualized the impact of coagulopathy on gos-e according to age, by using a generalized additive model. results: of the patients studied, they were divided based on their age: non-elderly group (n = , - years) and elderly group (n = , age c years). although, in the multivariate model, age and coagulopathy were significantly associated with lower gos-e, in-hospital mortality and shorter vfd in the non-elderly group, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. the correlation between coagulopathy and lower gos-e decreased with age after round years old. conclusions: in patients with isolated tbi, impact of coagulopathy on functional and survival outcomes was lower in geriatric patients. no difference in mortality between isolated tbi and polytrauma with tbi: it is all about the brain introduction: despite improvements in trauma and critical care mortality caused by traumatic brain injury (tbi) remains high. [ ] as polytrauma is naturally associated with increased mortality, this study compared mortality rates in isolated tbi (itbi) patients and polytrauma patients with tbi admitted to icu. material and methods: a -year retrospective cohort study included both consecutive trauma patients with itbi with ais head c (ais of other body regions b ) and polytrauma patients with ais head c admitted to a level-i trauma center icu. patients \ years of age, injury caused by asphyxiation, drowning, burns and transfers from and to other hospitals were excluded. patient demographics, shock and resuscitation parameters, denver multiple organ failure scores and acute respiratory distress syndrome (ards) data were collected. [ ] data is shown as medians with interquartile ranges. p-values \ . were statistically significant. results: a total of patients were included. the median age was ( - ) years, ( %) patients were male, median iss was ( - ). seventy-nine ( %) of all patients died. polytrauma patients developed more often ards ( % vs % p = . ) but had similar mods rates ( % vs % p = . ). polytrauma patients stayed longer on the ventilator ( vs. days p b . ), longer in icu ( vs. days p b . ) and longer in hospital ( vs. days p b . ). there was no distinction in in-hospital mortality of itbi and polytrauma patients ( % vs. % p = . ). tbi contributed to all deaths in itbi patients and all but three deaths ( %) in polytrauma patients. conclusions: tbi was the main cause of death in both groups. there was no difference in mortality rates between polytrauma patients with tbi and itbi patients, even though polytrauma patients were more severely injured. references: [ ] dewan mc et al. estimating the global incidence of traumatic brain injury. j neurosurg. ; ( ): - . no significant relationships or conflict of interests. how modeling the brain ventricles could help brain trauma understanding ( ). in pathological cases as in hydrocephalus, or in brain trauma, it is likely that each patient's ventricle structure has an impact on the way they behave. for instance, a shock wave may turn out differently according to the ventricle's shape. this can explain why for a same shock, the clinical translation is not the same. the aim of the study is to implement a finite element model of the cranio-cerebral system and to analyse the impact of a trauma simulation. material and methods: this is amonocentricretrospective study from . the database contains ct scans of healthy patients. we used itk-snap software to segment the ventricles and matlab to implement the model. results: the mean volume of the total ventricles is ml (sd = ). the median is ml (table ) .to identify the correlation between the parameters acquired we performed a pearson test. we found multiple significant correlations and one of the most relevant one is between the ventricular volume and the width of the third ventricle ( table ). showing that the total ventricular volume is statistically correlated to the width of the third ventricle is clinically interesting. we could potentially simplify our analysis of the ventricular system in head trauma by measuring less coordinates and yet come up to an accurate prognosis. the ventricle volumes are used as neuroimaging marker of brain changes in health and brain trauma. to our knowledge, it is the first time they are studied in vivo on ct-scan. this study and the existing correlations are relevant for the configuration of the finite element model on going. it can surely help the comprehension of the interaction between the structural parts of the cranio-cerebral system during brain trauma. (excitatory-glutamate, and inhibitory-c-aminobutyric acid, gaba), is crucial for the normal cerebral functioning. gaba concentrations vary in different cerebral zones [ ] responsible for different cerebral tasks. in this study, [gaba] is measured in the posterior cingulate cortex (pcc) of children with acute mtbi. material and methods: acute mtbi patients (\ h since injury, . ± . y.o) and healthy controls ( . ± . y.o). mri scanner philips achieva t was used. standard mri protocol for tbi revealed no pathological lesions in brain of any subject. magnetic resonance spectroscopy (mega-press [ ] ) was applied to obtain gaba signal without macromolecules. spectroscopy voxel is demonstrated on fig. . intensities of gaba, glutamate ? glutamine, creatine and water signals were calculated in gannet program [ ] . absolute concentrations were calculated. mann-whitney was used to reveal the statistical significance of between-group differences. results: typical gaba spectrum processing in gannet is demonstrated on fig. . no changes in glx were found. the values of [gaba] in pcc are demonstrated on fig. : the increase in gaba is not statistically significant. conclusions: this is the first study of [gaba] in pcc of children with acute mtbi. the result of current work disagrees with our previous study, where gaba was increased (p \ . ) in the anterior cingulate cortex of children with mtbi [ ] . this indicates to a necessity of further data collecting in order to reveal any [gaba] alterations in various cerebral loci. this would help to identify the causes of an inhibition/excitation imbalance and to predict possible dysfunctions of cns following mtbi. results: tnaa and naag concentrations along with stable naa concentration were found to be reduced in patient group. reduced asp and elevated mi concentrations were also found. the main finding of the study is that tnaa signal reduction in wm after mild traumatic brain injury is associated with the drop of the naag concentration rather than of naa one, as it was thought previously. this highlights the importance of separation of these signals at least for wm studies to avoid misinterpretations of the results. naag plays an important role in its selective activation of the mglur receptors, thus providing neuroprotective and neuroreparative function immediately after mtbi. it might have potential for the development of new therapy strategy for patients with injuries of various severity. introduction: traumatic brain injury (tbi) is globally recognized as a major health and socioeconomic issue. however, reported numbers vary and often represent subgroups. the number of hospital-admitted tbi has an important impact on hospital resources. thus, the monitoring of hospitalized tbi patients is needed. in , oslo neurosurgical tbi registry was established and includes patients admitted to oslo university hospital (ouh) with traumatic intracranial injury identified by neuroimaging. the aim is to introduce the registry; describe the patient group and volume. material and methods: descriptive study from oslo neurosurgical tbi registry. results: patients from south-east region were included in - (population million). mean age was years (sd ), % were males. most frequent cause of injury was falls ( %), increasing with age. % was influenced by alcohol at time of injury. preinjury antithrombotic therapy was common ( %). most of the patients had multiple pathologies on ct caput, e.g. simultaneous cranial fracture, sdh, tsah and brain contusion (four most frequent). accompanying injuries were found in %. % was transported to ouh directly form accident scene. % was classified as severe tbi upon arrival ouh, % was intubated, and trauma team was activated in %. median annual and monthly numbers of cases were (range - ) and (range - ), respectively. no clear change in case load between years and months, except a slight decline in march. admission rate peaked during the weekend. patients were continuously admitted throughout day and night, [ % between : and : . conclusions: patients included in the registry were older than those included in previous tbi studies. the numbers of cases admitted were stable across the months and years. however, the majority of patients were admitted during weekends and nights; thus handled by duty staff. relationship between brain-body temperature difference and neurologic outcomes in patients with severe head trauma introduction: brain is one of the most vulnerable organ to temperature. the association between core body temperature(ct) and neurologic outcomes in patients with post-cardiac arrest, severe head trauma and stroke has been reported. there were few reports comparing brain temperature(bt) with ct and peripheral temperature(pt). we investigated the association of differences among bt, ct and pt with neurologic outcomes in patients with severe head trauma. material and methods: we retrospectively reviewed data for patients with severe head trauma who underwent monitoring intracranial cerebral pressure(icp), bt, ct and pt simultaneously between january and december . results: we evaluated patients with a median age of years (range - years). glasgow outcome scale(gos) at discharge were as follows: good recovery(gr) , severely disabled(sd) , vegetative state(vs) , death(d) . table showed the average values of icp, cerebral perfusion pressure(cpp), bt, ct, pt, differences between each temperature (bt-ct, ct-pt, bt-pt) and gos in each patients. there was remarkable difference between bt and ct in the dead patient, whereas less differences were found in the other alive patients. we found greater difference between bt/ct and pt in the vs patients than gr patients. conclusions: greater differences between bt/ct and pt can be related to poorer neurologic outcomes introduction: minor head traumas are difficult to assess even with guidelines, hence head cts are often requested. as head cts are increasingly accessible, the demand on the radiology department often exceeds its capacity. there has been an increase in head cts at the oslo emergency department (oed), norway. the scandinavian guidelines for initial management of head injuries in adults (sg) is standard practice in the oed when assessing patients with head trauma.the aim of this study is to assess the number of patients with traumatic brain injury, evaluate guideline compliance and false negative initial reports by junior radiologists. material and methods: a consecutive cohort of patients from jan-june who received a head ct at oed due to minor head trauma was assessed. data was gathered from the ct request form, radiology report and ct images. the data points analyzed were: type of trauma, gcs, anticoagulants, loss of consciousness, nausea and vomiting, positive traumatic ct findings, and number of head cts within a year period. results: intracranial bleeds were reported in ( %) patients, ( . %) required neurosurgical intervention. skull fractures were reported in ( . %) patients, however no intracranial bleeds were present. it was impossible to assess guideline compliance because % of the referrals lacked adequate clinical information. ten bleeds were missed, however no further action was needed. % received more than head cts in years conclusions: head injury guidelines can improve clinical practice and reduce unnecessary ct scans; thus minimizing radiation exposure. based on the low number of positive findings, we hypothesize that sg compliance can be improved at oed. compliance was not assessable for nearly half of the patients, due to vital clinical factors missing. implementation of a standardized ct referral form based on the sg and educating junior ed doctors may decrease the number of unnecessary head cts. introduction: to date, there is no ideal allograft that provides local antibiotic release. along with this, existing fillers are expensive material, which complicates their application in practice. all this leads to the need to look for new ways to solve this problem. material and methods: gentamicin was used as an antibacterial drug because of its wide spectrum of action and thermal stability. for the study, staphylococcus aureus attc was used as a microbial strain. the antibiotic release from the studied materials was determined by equilibrium dialysis over the entire observation period. gentamicin antibiotic concentration was determined by hplc. results: an allograft impregnated with an antibiotic, prepared according to the marburg system in the area of the subcortical part of the bone, suppresses the staphylococcus aureus attc strain twice as much as perossal. when comparing bone allografts impregnated in various ways, the longest release time showed a perforated allograft.a bone graft impregnated with an antibiotic by incubation showed a % longer release time compared to perossal granules (p \ . ).when in vitro incubation of the antibiotic gentamicin with the drug ''perossal'', the dissociation rate is more than % in the first two days. when the antibiotic gentamicin with a bone allograft is incubated in vitro on the second day, dissociation into the extracellular space makes up more than % of the drug from the previously bound (p \ . ), which also indicates a longer release time from the bone allograft. conclusions: in vitro, a bone allograft impregnated with an antibiotic is able to reversibly bind the antibiotic gentamicin and gradually release it over a period of days. the use of a bone allograft impregnated with an antibiotic suppresses the growth zones of staphylococcus aureus strains. references: rudenko a., impregnation of the bone allograft: comparison of heads coloring. european journal of trauma and emergency surgery (suppl) p. acute appendicitis and pregnancy: from incidence to modern management: literature review and proposal for consensus estes experts guidelines a. l. bubuianu , a. mihailescu , g. pokusevski tameside general hospital, general/emergency surgery, ashtonunder-lyne, united kingdom introduction: acute abdominal pathology during pregnancy has historically been a challenging decision for the emergency surgeon, that had to deal with patients at same time. acute appendicitis has probably the highest prevalence of all. early involvement of the gynaecological team was considered paramount and the ongoing debate laparoscopic versus open intervention, has been more recently challenged by case reports where antibiotics alone have been a successful strategy. material and methods: literature review has been conducted by the investigating team, using the following search algorithm: reviewers screened pubmed portal to conduct a thorough search of the most important medical databases, cochrane's library, medline and embase. case reports and low quality case series have been excluded from the literature review. results: there is currently no general consensus in regards to operative strategy in acute appendicitis during pregnancy, but most authors described safety of laparoscopic intervention in the first trimesters and favoured open approach in a mother closer to term. the antibiotic treatment alone can only be considered in presumed early appendicitis, where there are no features of pending perforation, presence of phlebolith or established peritonitis and should be done under the close monitoring of experienced general surgeons. conclusions: an expert consensus is required in first instance, (set of questions submitted to audience at end of presentation for their expert opinion) regarding optimal treatment strategy in acute appendicitis during pregnancy, followed by a multicenter prospective randomised control trial, which we are hopeful to engage with help of numerous european hospitals where estes members activate. introduction: deep tissue pressure injuries (dtpi) are complex and difficult to treat. the higher prevalence is observed in paraplegic and elderly populations. primary closure of large, stage- dtpis is rarely feasible and flap closure is customarily applied. presented is a technique using tension relief system (trs; topclosureÒ tension relief system) and regulated oxygen and irrigation negative pressure wound therapy (roi-npt; vcareaÒ) to facilitate simple primary wound closure of dtpis. methods: large, stage- dtpis were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of trs and roi-npt. results: details of the closure of consecutive large dtpis in patients is presented. immediate primary closure was achieved in cases, while three others were closed over - days. surgery time ranged between . and h and hospitalization between and days. following a median follow-up of months (range - months), all wounds healed with one late recurrence. post-operative wound infection observed in one patient was successfully treated with systemic antibiotics. minor skin damage inflicted by the tension sutures at the anchoring sites healed spontaneously. gradual return to partial loading of the operated area was enabled within - weeks and full weight-bearing was achieved within - weeks. introduction: chronic pain is a disabling condition affecting - % of trauma patients. considering the burden of chronic pain, interest in interventions to prevent this disorder after trauma has grown. a descriptive review of literature was undertaken to assess the evidence on these interventions. material and methods: medline, cinahl and cochrane library databases were searched to identify interventional studies published up to august . websites of injury, critical care and pain organizations were also consulted to retrieve relevant guidelines. the literature search used combinations of medical subject headings and keyword under the themes of pain, trauma, surgery and preventive interventions. results: many knowledge syntheses relevant to the population of trauma published between and were found. low to moderate level of evidence was reported for pharmacological interventions such as the administration of ketamine, neuropathic pain medication and multimodal analgesia. local or regional nerve block in the presence of factures was associated with a high level of evidence. very low to low evidence was described for nonpharmacological interventions including cryotherapy and early mobilization. finally, psychological interventions were associated with a low to moderate level of evidence and multimodal pain management interventions (pharmacological and non-pharmacological) with a high level of evidence. conclusions: research is still needed to define the role of interventions to prevent chronic pain in trauma patients. thus far, multimodal pain management interventions involving multidisciplinary team management appear to be the most promising. implementing such interventions could reduce the negative consequences associated with chronic pain. introduction: chronic use of opioids has been documented % of trauma patients. accordingly, the tapering opioids prescription program in trauma (topp-trauma) was developed. the aim of this study was to assess the feasibility of topp-trauma and explore the efficacy of topp-trauma in reducing opioid use. material and methods: a -arm pilot rct was conducted in patients presenting a high risk for chronic opioid use. we aimed to recruit participants to receive either topp-trauma or an educational pamphlet. topp-trauma comprised educational and counseling sessions. the feasibility assessment of topp-trauma was based on the ability to provide its components. the morphine equivalent dose (med) per day as well as pain intensity and pain interference with activities were measured at and weeks following discharge. results: preliminary findings based on data collected in participants showed that counseling sessions were most frequently needed to completely taper opioids. sessions attendance reached %. nearly % of eligible patients accepted to participate and an attrition rate of % was found. even though the experimental group consumed a higher med h prior to hospital discharge compared to the control group ( . vs . ), its med/day intake was lower at weeks ( . vs . ) and weeks ( vs . ). these self-reported data were validated by the total med delivered by participants'' pharmacy at both time points ( . vs . at weeks; . vs . at weeks). minimal mean score differences were observed in both groups with regard to pain intensity and interference with activities. conclusions: data collected until now provided evidence on the feasibility of topp-trauma and on the program potential efficacy. challenges that will require to be addressed in future rct include the acceptance to take part in the study and participants' drop out. introduction: head preserving surgical treatment for ao-type b fractures with little to no dislocation consists of three canullated screws or a dynamic hip screw (dhs). there is a new alternative: the femoral neck system (fns). the fns has some advantages over dhs. the anti-rotation screw provides extra rotational stability because of the diverging design. furthermore, the incision is smaller in fns and only one locking screw is necessary for plate fixation. we present the first results of this new surgical fixation of femoral neck fractures with fns. material and methods: during the period of november until october , all patients with femoral neck fractures treated with fns, were included in this prospective single center cohort study. patient characteristics, fracture classification (ao, garden, pauwel), perioperative parameters and postoperative complications were registered. patients were allowed to mobilize based on the principle of permissive weightbearing. follow up was planned after weeks and weeks. primary outcome measure was cut-out rate within months. results: twenty-four patients with a femoral neck fracture (ao-type b) were surgically treated with fns. median age was , (range - ). median operation time was mins (range - ). mean duration of in hospital stay was days (range - days). twentytwo ( , %) patients completed the regular follow up of weeks. one patient ( %) had a reoperation due to a cut-out. during follow up one patient developed a wound-infection ( %) which was treated with intravenous antibiotics conclusions: femoral neck system as surgical treatment for femoral neck fractures shows promising first results. low cut-out rate, limited operation time, low mortality and short duration of in-hospital stay make this device a possible alternative for dhs of canullated screws. definitive conclusions should be made after studying long term results in larger cohorts. references: none. new personalized approach to enteroatmospheric fistulas using d bioprinting device introduction: enteroatmospheric fistula is a challenge for surgeons. it presents a great clinical variability. this diversity means that, despite having tried multiple devices and techniques to achieve local control of the intestinal effluvium over the rest of the wound, there is currently no technique that can solve this problem in all patients. d printing is a novel therapy that allows the customization of the devices according to the needs of each patient. the aim of this study is to describe the technique of manufacturing a custom device designed by bioscanner imaging and manufactured using a d printer for use in the management of enteroatmospheric fistula. we describe our initial results. materials and methods: we present four patients with enteroatmospheric fistula. the intestinal segment involved, the dimensions of the wound, the intestinal debit and the size of the exposed intestinal surface are substantially. all require an average of - daily cures by the nurse. after obtaining images of each fistula with a bioscanner, a personalized device was designed and made by a d printer. the polycaprolactone device was placed including inside the fistulous orifices and surrounding it with npwt in order to accelerate the healing of the wound to ostomize the fistula or achieve its definitive closure. results: four devices with different designs have been manufactured. the wound remained isolated from the intestinal contents after placement, favouring the granulation of the surrounding tissue with npwt and thus avoiding contamination of the wound. the system remained without leaks for an average of h, reducing the need for daily cures, improving patient comfort and avoiding complications. conclusions: the use of a manufacturing model using d bioprosthesis printing in order to create a personalized device that fits the characteristics of the patient's wound is feasible and offers promising results in the management of enteroatmospheric fistulas. new approaches in bone tissue engineering: innovative scaffold design for principle unlimited size bone substitutes introduction: in bone tissue engineering (bte), autologous boneregenerative cells are combined with a scaffold for large bone defect treatment. microporous, polylactic acid scaffolds showed good healing results in bone defects in small animals. transfer to large animal models, however, is challenging and not easily achieved simply by upscaling the design. increasing diffusion distances has a negative impact on cell survival and nutrition supply. this can lead to cell death and ultimately implant failure.this approach focuses on scaffold architectures, that meet all the requirements for a modern bone substitute. biological-functional, porous subunits in a loadbearing, compression-resistant frame structure characterise the innovative design. an open, macro-and microporous internal architecture provides optimal conditions for oxygen and nutrient supply in the inner areas of the implant by diffusion. material and methods: during the design process, prototypes (temple (figure a) , grid (figure b) , onion (figure c)) were dprinted (fused filament fabrication) using polylactic acid (pla). -after incubation with saos- (sarcoma osteogenic) cells for days (measurements on days , , and ), cell morphology, distribution and survival (fluorescence microscopy, ldh-based cytotoxicity assay), metabolic activity (mtt test) and osteogenic gene expression were determined. results: all designs not only showed cell colonization, but cells also sustained their ability to differentiate (already after days) and to divide. the open, hierarchical-structured design, with its innovative porous structure, provides a good basis for cell settlement and proliferation. the modular design allows easy upscaling and offers potential solutions to previous limitations scaffold developement in bone tissue engineering. references: the value of d reconstructions in determining post-operative reduction in acetabular fractures: a pilot study introduction: in patients with acetabular fractures, the reconstructed three-dimensional ( d) model of the contralateral acetabulum could be used as a mirrored template for the anatomic configuration of the affected joint. this has not been validated. material and methods: computer tomography (ct)-scans of twenty patients with unaffected acetabula were used. the symmetry of the generated d models was evaluated through; ( ) mirroring of the acetabulum; ( ) initial rough matching; ( ) automatic optimisation of the matching via surface-based matching; ( ) calculation of distances between surfaces by evaluating the euclidean (straight-line) error distance between the closest points between left and right. the percentages of surface-points of the left and right acetabulum with a distance smaller than . , . , . and . mm were calculated and evaluated, in relation to matta's criteria, for acetabular fracture reductions. the analysis was performed using the mirrored left acetabulum matched onto the right original structure (left mirrored to right original; ''lm ro'') and the right mirrored to left original (rm lo). to determine the inter-observer agreement the procedure was repeated by a second assessor for the first ten patients. results: patients had a mean ± sd age of . ± . years, % was male. the mean distance deviation was less than . mm in all comparisons. the calculated distances in . % of the surface points of the left and right acetabulum were below the tolerance threshold of . mm, based on matta's anatomical reduction critera (table ). absolute differences between assessors were\ . mm per patient with an overall moderate agreement of %. conclusions: d reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. the next step will be to investigate these results in patients with reduced acetabular fractures. : matta, j. ( ).j bone joint sur am. : - pr minimally invasive plate osteosynthesis technique for distal humeral fracture: a cadaveric study v. hofmann , c. deininger , t. freude , f. wichlas university hospital salzburg, orthopedics and traumatology, salzburg, austria introduction: in our study we want to evaluate the feasibility of minimally invasive plate osteosynthesis (mipo) technique for distal humeral fracture using anatomically precontoured double plate osteosynthesis. material and methods: eight elbows from four thiel fixed cadavers were included. on unfractued cadavers we tested the minimally invasive approach with two separate incisions, one at the lateral and one at the medial epicondylus. the preformed plates were inserted directly into the bone on sides and fixed with percutaneous screws. then we created an ao type a and c fracture. the reduction was performed under x-ray control and stabilized with k-wires. then we also inserted the plates in mipo technique. in the case of an intraarticular fracture, an olecranon osteotomy was additional performed in a minimal invasive way to control the distal humeral joint surface. after finishing reduction and fixation the approach were extended to control the fracture alignement, position of the plates and to expose the ulnar nerve. results: the plate position was satisfactory and we could not detect any major soft tissue damage or ulnar nerve injury by using the minimally invasive plate osteosynthesis technique. in the extraarticular fractures, reduction was achieved with k-wires and was acceptable in all cases. the intra-articular fractures were controlled by an additional olecranon osteotomy using the mipo technique with a good view on the joint surface of the distal humerus. conclusions: the findings of the present study show that mipo technique in distal humerus fracture is feasible and save especially for ao type a fractures. in ao type c fractures the olecranon osteotomy provided enough visibility to evaluate the distal humeral joint surface. the surgical technique is demanding, and care must be taken not to injure the ulnar nerve. never the less it is an effective surgical treatment method and an alternative option to open techniques. correlation between pelvic incidence and acetabular orientation in anteversion and inclination-an analysis based on a d statistical model of the pelvic ring introduction: the pelvic ring is a complex bony structure with a central role for the human''s mobility building the connecting part between the upper body and the lower extremities. pelvic incidence and acetabular orientation are two important parameters used in the description of pelvic anatomy and are of central importance for understanding the biomechanical interaction of spine, pelvis and hip joints. the objective of the study was the analysis of a potential correlation between pelvic incidence and acetabular orientation. material and methods: a d statistical model of the pelvic ring consisting of individual ct scans of european adults without bony pathologies was used to analyse pelvic incidence and acetabular orientation in anteversion and inclination. an additional analysis on the correlation between those parameters was performed using the software spss. results: a slight positive correlation between pelvic incidence and acetabular anteversion could be shown (r = . ; p = . ) as well as a strong positive correlation between anteversion and inclination (r = . ; p \ . ). pelvic incidence and acetabular inclination showed none statistically significant correlation (r = . ; p = . ). conclusions: the results of the study might contribute to a better understanding of the biomechanical interaction between the axial skeleton and the lower extremities and deliver valuable information concerning preoperative planning in orthopaedic and trauma surgery of the lumbar spine, the pelvis and the hip joints like for example reconstructive surgery after trauma, operative treatment of congenital or acquired deformities or total joint arthroplasty. references: boulay et al., ''pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminarystudy. '' anat res int. ; : . doi: . / . epub . introduction: the majority of distal clavicle fractures (dcfs) are displaced fractures and are prone to delayed-or non-union. there are several options for surgical reconstruction, open reduction and fixation or hook plate, but in patients with a comminuted or small fracture they are known to have a high complication and failure rate, and secondary surgery for removal is often necessary. we hypothesize that resection of the distal fracture fragment and subsequent stabilization with the lockdown device, is an alternative for selected patients with dcfs. methods: eleven patients with a comminuted dcf were treated with a lockdown device. data on pain and range of motion were documented and the constant shoulder score (css), oxford shoulder score (oss) and nottingham clavicle score (ncs) were assessed at one year follow-up. results: eight patients underwent surgery within weeks, compared to patients where the surgery was delayed ([ weeks) due to persisting pain and delayed-union. none of the patients had postoperative complications. in months after treatment, patients were complaint-free. one patient had hardware removal due to pain at the site of the screw head. four patients were assessed after one year follow-up. the mean pain score was . . the mean flexion , °, abduction , °, exorotation °and extension °. the css had a mean of . , oss . and the ncs a mean of . conclusions: all patients had a good short-term clinical outcome and hardware complications did not occur. we are the first to describe the use of the lockdown device in dcfs. this device is not dependent on fracture healing and secondary surgery is not necessary, therefore it can be an alternative in the treatment of dcfs. a larger series and longer follow-up is necessary to confirm this conclusion. in this ongoing study, the remainder seven patients will be included and presented at the estes. moore type i tibial head fractures are one of the most challenging fractures to treat. material and methods: we performed the following approaches on eight thiel fixed cadavers: the anterolateral (with an osteotomy of the tuberculum gerdyi, a subcapital fibula-osteotomy and an osteotomy of the tuberositas tibia), the medial approach (with submeniscal arthrotomy and a dissection of the medial collateral ligament) and the posterior approach with a submeniscal athrotomy. the reachable borders of the articular joint surface have been marked by a k-wire. the visual joint surface has also been radiographically documented by inserting k-wires into the tibia head. finally the results have been photo documented on the exarticulated joints. results: the reachable areas of the articular surface have been defined and documented. the combination of the subcapital fibulaosteotomy and the submeniscal arthrotomy showed the most increase in accessibility to the articular surface in the dorsal part. an additional osteotomy of the tuberculum gerdyi increased the vision on the entire lateral and anterior articular surface. the submeniscal arthrotomy, at the medial approach, has not a good view on the surface. the posterior approach showed only a limited view on the lateral and medial articular surface at the dorsal part. none of the surgical approaches sufficiently visualizes the intercondylar region. conclusions: a fracture-specific approach strategy is critical for the preoperative planning of complex tibia-head fractures. subcapital fibula osteotomy is the most efficient surgical approach to reach the posterior and lateral articular surface. for the anterior articular surface, the best overview was achieved by an osteotomy of the tuberculum gerdyi. it was not possible to see and control the intercondylar region with any approach. introduction: osteosarcoma (os) is the most common bone carcinoma in humans. at the time of the first diagnosis are already in about % metastases present. the current treatment strategies include above all radical surgical resection and chemotherapy. in the search for alternative therapy methods. treatment with cold atmospheric plasma (cap) shows promising prospects. at the cellular level, this leads to various cellular mechanisms and finally to induction of anticancerogenic effects such as growth inhibition, apoptosis, and changes in the cell-cell interactions. the impact of cap on the integrity of the cell membrane of os cells, however, is unknown. material and methods: suspended cells from two human osteosarcoma cell lines (u -os, mnng) were treated for s, s, and s with cap. cell proliferation was determined after h, , , , and h using casy cell counter. dye loss assay was performed by using fluorescein diacetate (fda). this was followed by indirect treatment with cap for s. in the cell-free supernatant was determined by tecan multireader the dye emission. flow cytometry assay was used after cap treatments and incubation with fda. the mean fda fluorescence intensity of individual cells in the flow cytometer was measured. results: cell kinetics showed significant inhibition of cell proliferation in both cell lines after cap treatment. the assays for determination of the dye level showed a significantly increased membrane permeability of both cell lines after cap treatment. the significant effect on the membrane integrity correlated with treatment duration. conclusions: this confirms a modulating influence of cap on the functionality of the cell membrane and may support the anti-proliferative effect of the cap treatment. thus, cap is a promising therapy option, especially for chemotherapy-resistant entities introduction: osteosarcoma (os) is the most common bone cancer in humans. standard therapy includes radical surgical resection and chemotherapy, but due to strong toxic effects, new treatment options are urgently needed. currently, there is a discussion about expanding the oncological therapy spectrum and treat with cold atmospheric plasma (cap). it is a reactive ionized gas rich in radicals, photons, and electromagnetic rays. its biological effects are primarily mediated by reactive oxygen and nitrogen species (rons). due to its low temperature, cap is suited for medical applications. in vitro studies have shown the antitumoral effect of cap also for pancreatic cancer, melanoma, ovarian, breast, and colon cancer. material and methods: human os cell lines u -os and mnng/ hos were used. proliferation assay. the growth of cap-treated cells was examined using a casy cell counter. caspase / assay. following cap treatment, the activities of caspase- and caspase- were measured using a specific substrate peptide coupled with a fluorescent dye (cellevent tm ). single-cell gel electrophoresis comet assay. dna damage after cap treatment was identified using alkaline microgel electrophoresis. dna migration was measured using comet score software. the percentage of tail dna was used to indicate the relative fluorescence intensity of the head and tail. tunel assay. after cap treatment tunel analysis was performed. results: the results revealed that the cap treatment of os cell lines leads to significant inhibition of cell growth. subsequently, the activation of caspases and the induction of apoptotic dna fragmentation was demonstrated. the treatment of os cells with cap leads to an induction of apoptosis and a reduction of cell growth. introduction: extra peritoneal packing (epp) is a quick and highly effective method to control pelvic hemorrhage. we hypothesized that this procedure may be as safely and efficiently performed in the emergency room (er) as in the operating room (or). methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . material and methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . results: patients were included in our study, in the er-epp group and in the or-epp group. the mean injury severity score (iss) was . ± . . following epp, hemodynamic stability was successfully achieved in of patients ( . %). a raise in the mean arterial pressure (map) with a median of mmhg (mean . ± . , p = . ) was documented. all patients who did not achieve hemodynamic stability after epp had multiple sources of bleeding or fatal head injury and eventually succumbed. the overall mortality rate was . % ( / ) with no difference between the or and er-epp groups. patients who underwent epp in the er showed higher change in map (p = . ). no differences were found between er and or epp in the amount of transfused blood products, surgical site infections and length of stay in the hospital. however, patients who underwent er epp were more prone to develop deep vein thrombosis (dvt): % ( / ) vs % ( / ) in er and or-epp groups respectively (p = . ). conclusions: epp is equally effective when performed in the er or or with similar surgical site infection rates but higher incidence of dvt. level of evidence: retrospective cohort study, level iv. introduction: application of supraacetabular schanz screws is usually performed under image intensifier guidance. the aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre-and intraoperative fluoroscopy can be avoided. material and methods: insertion of the supra-acetabular schanz screws was performed in human adult cadavers. with cadavers placed in supine position, the anterior superior iliac spine (asis) was palpated. starting from this landmark, cm were measured in a distal and cm in the medial direction. at this point, a cm long oblique skin incision was performed. through this approach, mm schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of °to distal as well as °to medial. combined obturator oblique-outlet views (cooo) were taken bilaterally to prove the screw position. six of the specimens underwent a d-ctscan. images were evaluated concerning correct screw positioning. skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (lfcn) or to the joint capsule were evaluated. results: during radiographic evaluation of the cooo-scans ( specimens) and the d-scans ( specimens), the schanz screws were placed inside the supra-acetabular corridor in all specimens ( / ). during dissections, no intracapsular screw placements or lfcn lesions were found. conclusions: using our technique, all schanz screws could be sufficiently inserted without intraprocedural x-ray imaging. references: . karaharju, e. and p. slätis, external fixation of double vertical pelvic fractures with a trapezoid compression frame. inhury, . : p. - . . mears, d. and f. fu, external fixation in pelvic fractures. orthop clin north am, . : p. - . . mears, d. and f. fu, modern concepts of external skeletal fixation of the pelvis. clin orthop, . : p. - . pr epidemiology of self-inflicted major trauma r. stoner , n. misra , l. mason aintree university hospital, liverpool, united kingdom introduction: in the united kingdom, severely injured patients are taken directly to a major trauma centre (mtc). whilst deliberate self harm (dsh) is a known mechanism for this, there is limited prior research. - % of major trauma is thought to be self inflicted , . our aim was to describe the epidemiology of presentation to our mtc resulting from dsh. material and methods: retrospective review of patient records in our mtc for adult trauma team activations between / / and / / . data was collected on patient demographics, location type, injury severity score (iss), mechanism of injury and mortality. results: episodes of dsh made up . % of all trauma cases, involving patients; . % re-attended. z-scores show no change in incidence over time, but significant variability month by month, with / months [ sd from mean. mean patient age years (range - ). . % were male. . % came from residential location and . % from prison. most common mechanism was penetrating trauma ( . %). in-hospital mortality was % ( . % in males vs . % in females, chi p = . ). conclusions: this is the largest review of self inflicted trauma cases in a uk mtc, with a similar incidence to prior studies. there was no observed correlation with season or trend over time. mortality was higher in male patients, in keeping with national statistics on suicide, whilst dsh in females was linked to less severe injury; severity is related to mechanism of injury. injury from self stabbing/cutting was most common in patients from residential locations, whilst hanging was more common in prisoners. this study identifies preventable risk factors for major self inflicted injury. introduction: the distribution of trauma deaths was classically described following a trimodal pattern. during the last decade improvements in trauma care as damage control resuscitation (dcr) have minimized resuscitation injury. we hypothesized that the implementation of dcr in severely injured trauma patients is associated with less mortality and modifies mortality pattern. material and methods: we performed a -year ( - ) retrospective cohort analysis of all severely injured trauma patients (niss c ) who underwent surgery at our level trauma center. since , dcr was implemented including damage control surgery, minimizing crystalloids and increasing the use of blood products. our patients were stratified into two phases: pre-dcr ( - ( ) and post-dcr ( . results: a total of patients were identified. there were patients ( . %) in the pre-dcr group and patients ( . %) in the post-dcr group. mean age ( . vs . , non significant (ns)), mechanism of injury (blunt trauma: . % vs . %, ns) and shock on admission ( . % vs . %, ns) were similar between groups. there is a significant reduction in the rate of overall mortality ( . % vs . %, p \ . ). while early deaths from traumatic brain injury ( . % vs . %, ns) and hemorrhage ( . % vs . %, ns) are alike, mortality secondary to multisystem organ failure (msof) is lessened ( . vs . %, p \ . ). conclusions: dcr has helped in reducing overall mortality and mortality due to msof in our severely injured trauma patients. introduction: the mangled extremity severity score (mess) was constructed as an objective quantification criterion for limb trauma. a mess of or greater than was proposed as a cut-off point for primary limb amputation. opinions concerning the predictive value of the mess vary broadly in the literature. the aim of this study was to evaluate the applicability of the mess in a contemporary civilian central european cohort. material and methods: all patients treated for extremity injuries with arterial reconstruction at two centres between january and december were assessed. the mangled extremity severity score (mess) and the amputation rate were determined. results: seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. the mean mess was ). seventy-three percent of all patients ( / ) had a mess b and % ( / ) of c . eight patients ( %) underwent secondary amputation. patients with a mess c showed a higher, but statistically not significant secondary amputation rate ( . %; / ) than those with a mess b ( . %; / ; p = . ). the area under the roc curve was . (ci . ; . ). conclusions: based on these results, the mess seems to be an inappropriate predictor for amputation in civilian settings in central europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft tissue traumas. introduction: in polytrauma victims the acute respiratory distress syndrome (ards) is a major cause of morbidity and mortality. it presents a complex pathophysiology that is characterized by pulmonary activated coagulation and reduced fibrinolysis. due to the fact that the pulmonary endothelium is considered a key modulator of ards and that tpa in plasma is predominantly synthesized and secreted by vascular endothelial cells, we hypothesized that the time courses of serum tissue-type plasminogen activator (tpa) and its main inhibitor, the plasminogen activator inhibitor type- (pai- ), might indicate a clinical approach to preventing ards in polytrauma victims. material and methods: twenty-eight consecutive polytraumatized patients with concomitant thoracic trauma, age c years, iss c , who were directly admitted to our level i trauma center, were evaluated. blood samples were taken initially and on day , , , , , , and during hospitalization. luminex multi-analyte-technology was used for analysis of tpa and pai- antigen levels. results: both levels were particularly high at admission. although they significantly declined within three and seven days, respectively, they remained elevated throughout three weeks. throughout this observation period mean tpa antigen levels were higher in polytrauma victims suffering ards than in those without ards, whereas mean pai- levels were higher in polytrauma victims sustaining pneumonia than in those without pneumonia. noteworthy, in each patient, who developed ards, the tpa antigen level raised up to the onset of the syndrome and declined afterwards. conclusions: the development of ards has to be expected in a polytrauma victims if the tpa antigen level continues to rise after admission. potentially, in patients with a low risk of excessive bleeding the onset of the syndrome might be prevented by the timely administration of recombinant profibrinolytic proteins. motocross is a dangerous business: small bowell perforation case report case history: a year-old male, previously healthy, was admitted to the ed after being involved in a motorcross accident. he suffered blunt abdominal trauma. clinical findings: at admission, patient presented pale but haemodinamically stable. physical examination was unremarkable except for an evident abdominal wall hematoma and abdominal guarding over the left quadrants. investigation/results: abdominal ultrasound showed an intestinal loop with decreased peristalsis with a small amount of liquid adjacent (fig ) . due to the patient's haemodynamic stability, ct scan was performed (fig . ) which showed liquid in the left flank and iliac fossa, but without an identifiable intrabdominal lesion. diagnosis: the patient was admitted to the operating theatre with acute abdomen. therapy and progressions: intraoperatively fecal peritonitis was evident from a cm-hole on the antimesenteric border of the jejunum, the enterotomy was closed and profuse lavage was done; the abdominal wall closed without drainage. the patient went through an empirical antibiotic cycle. liquids per os were started on the first postoperative day and the patient progressed without issues. he was discharged at the th postoperative day. the remaining follow-up was uneventful. comments: small bowel perforation after blunt abdominal trauma is rare. sbmi has a high morbidity and mortality that increase with delayed diagnosis; however, clinical and radiographic signs of perforation are often absent, like in the case presented. ct is considered the gold-standard. in our specific situation, the small bowel perforation did not produce any pneumoperitoneum in a young patient with very good physiologic status that kept him hemodynamically stable. the prognosis of pelvic injury is closely related to the severity of vascular injury rather than the complexity of bony fracture y. wu , c. hsieh , c. fu chang gung memorial hospital, trauma and emergency surgery department, taoyuan city, taiwan introduction: pelvic injuries are among the most dangerous and deadly trauma. although complex pelvic fractures are often associated with vascular injuries, it is still unclear regarding the impact of the severity of vascular injury to the outcome of patients. we hypothesized that, in addition to the complexity of bony fracture, the severity of pelvic vascular injury plays a more decisive role to the patients'' outcome. material and methods:medical records of patients with pelvic fracture in a single trauma center between jan and dec were retrospectively reviewed. those who had an abbreviated injury scale (ais) c other than pelvis were excluded. based on ct results, the type of pelvic fracture was classified according to young-burgess classification, and the severity of vascular injury were recorded as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling or extravasation). the patient demographics, clinical parameters, and outcome measures were compared between the groups. results: among the patients, severe vascular injury were noted in patients. patients with severe vascular injuries had significantly increased amount of red blood cell transfusion (rbct) ( . vs. . units, p = . ), longer icu stay (is) ( . vs. . days, p = . ) and total hospital stay (hs) ( . vs. . days, p = . ) compared to minor vascular injuries. on the other hand, those with complicated pelvic fracture (lc type ii/iii, apc type ii/iii, vs and combined type) had similar amount of rbct and is compared to that of simple pelvic fracture (lc type i, apc type i) except a longer hs ( . vs. . days, p = . ). conclusions: our results indicated that the severity of vascular injury is more closely correlated to the outcome of patients with pelvic fractures than the type of bony fracture does. in addition to the type of bony fracture, the grade of vascular injury should be considered as an important part of pelvic injury classification. associated abdominal injuries do not influence reduction quality in operatively treated pelvic fractures-a multicenter cohort study from the german pelvic registry results: . patients with pelvic injuries were treated during this period. . % had a concomitant abdominal trauma. the mean age was . ± . years. comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger ( . ± . vs. . ± . years; p \ . ). both, complication rates ( . % vs. . %; p \ . ) and mortality ( . % vs. . %;p \ . ) were significantly higher. in the subgroup of acetabular fractures, the time until definitive surgery of the pelvis was significantly longer in the group with the combined injury ( . ± . vs. . ± . days; p \ . ) . the grade of successful anatomic reduction did not differ between the two groups. conclusions: patients with a pelvic injury have a concomitant abdominal trauma in about % of the cases. the clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. however, the quality of the postoperative results is not influenced by a concomitant abdominal injury. a. martins rangel , r. pozzi , j. alfredo cavalcante padilha , s. sardinha , f. eduardo silva , d. teixeira rangel heat, trauma center, são gonçalo, brazil f.f.c., male, years old, was admitted to the trauma center about h after a stabbing wound in the neck. upon examination the patient was mechanically ventilated and hemodynamically stable, with an exposed sectioned trachea, which had a tracheostomy tube applied. the penetrating injury itself was mostly allocated in zone ii. he had a ct angiography and was referred to the or for surgical treatment. the cervicotomy found that both the external and internal right jugular veins had been injured alongside the sternocleidomastoid, sternohyoid and homohyoid muscles, the thyroid cartilage, just above the vocal cords, which had exposed the anterior larynx and the epiglottis the right anterior jugular vein and smaller tributaries of the right internal jugular vein, were ligated; a tracheostomy was performed and the thyroid cartilage and anterior laryngopharyngeal wall were reconstructed with the epiglottis implantation, sternoid, homohyoid and sternocleidomastoid muscle sutures, after which the platysma was closed but not the skin, left to secondary healing. patient was extubated within h, discharged from icu on the fifth postoperative day. thickened oral diet was introduced on the th day, and by the th day he was discharged without the tracheostomy tube, with a normal diet. comments: the cervical region is an area susceptible to serious injury due to the presence of vital structures, with massive hemorrhage, airway obstruction, cervical spine injuries and cerebral ischemia as the leading causes of death. initial management of penetrating injuries follows the principles of trauma care with airway control initially. references: bhatt nr-penetrating neck injury from a screwdriver: can the no zone approach be applied to zone i injuries? bmj yan wang-penetrating neck trauma caused by a rebar-a case report. medicine ( ) introduction: annually, approximately , people decease as a result of a fall in the netherlands, according to the statistics netherlands. the aim of this study is to evaluate the demographic parameters, fall characteristics and resulting injury patterns of this group in the region of amsterdam. methods: all patients deceased as a result of injury due to a fall in the period july st until july st in the region of amsterdam were included. data were collected from the database (formatus) of the department of forensic medicine (public health service amsterdam). results: during the study period , patients deceased after a fall. the mean age was years ( - years) and % was male. a psychiatric disease was diagnosed or suspected in % of the population of which cognitive impairment, including dementia, was encountered in most of the cases ( %). the majority of the falls happened at home ( %) or at nursing facilities. a minority ( . %) was work related. over % of the falls was from standing position, . % was not from standing position of which . % regarded falls from stairs, the majority was male. multitrauma patients accounted for . % of the population. from the remaining , patients, . % sustained one or more injuries to the pelvis or extremities. central nervous system (cns) injuries were described in . % of the patients. mortality was in . % of the cases due to primary cns injury, . % was due to complications of which clinical deterioration ( . %) and infection ( . %) were the most common. conclusions: in the region of amsterdam the majority of deaths due to a fall regards the geriatric population. fall from standing position and mortality due to complications, mainly clinical deterioration, accounted for the majority of deaths. intervention to prevent falls and thereby complications need more awareness to reduce mortality. results from a multidisciplinary blunt splenic injury protocol introduction: the majority of splenic injuries are currently managed non-operatively. failure of non-operative management includes grade iv or v splenic injury or vascular abnormalities that are suitable for embolization. the primary indication for operative management of blunt splenic injury is hemodynamic instability. in our center, the last twenty splenic injuries, admitted during two years, were not managed according to published guidelines. ten patients ( %) underwent splenectomy, being unstable only of them ( % of the whole sample). material and methods: staff from anesthesiology, interventional radiology and trauma surgery came up with a joint protocol. grade iii splenic injury non-operatively management, including fluid responsiveness (achieving shock index (ht/bp) below . after a bolus of colloids) and, focus placed only on hemodynamic stability instead of on vascular abnormalities are our principal modifications regarding already published protocols. results: seventeen patients with blunt spleen trauma were admitted after starting up our protocol. six ( grade iii, grade ii and grade i) splenic injuries were successfully managed non-operatively. prophylatic embolization was performed in five patients: were grade iv spleen trauma and were grade iii spleen trauma with vascular abnormalities. one grade iii splenic trauma was embolized due to a pseudoaneurysm detected in ct scan performed h post injury. five grade v spleen trauma required urgent surgery. of them presented with shock index [ . . conclusions: our multidisciplinary protocol has helped in improving outcomes in blunt splenic injuries. we have achieved an almost full compliance to our protocol. case history: -year old male experienced severe blunt trauma after a bus accident. clinical findings: he is found alert (gcs = ), hemodynamically stable and with a patent airway. he presented catastrophic lower left limb where tourniquet was applied. gram of tranexamic acid (txa) and ml of crystalloids were administered. he was intubated in the site of injury and transfered to our center, being always hemodynamically stable. on hospital admission he was normotensive (bp = / mmhg, sinus rithm ppm), shock index \ . . he suffered uneventfully amputation of the limb with no need for blood products transfusion. his past medical history was only pertinent for hypertension. investigation/results: following urgent damage control surgery, ct scan was performed where acute bilateral pulmonary embolism was diagnosed. diagnosis: asymptomatic acute bilateral pulmonary embolism therapy and progressions: during icu stay, the patient kept hemodynamically stable. endotracheal tube is removed one day later and he is successfully transfered to the ward three days later. comments: hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tpa). in contrast, when shock and hypoperfusion occur, activation of the protein c pathway and endothelial tpa release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. it can be inferred that a patient presenting with severe tissue injury without shock is at high risk of perioperative thrombosis and txa might not be administered. ( ) . it signifies high energy force, representative of severe overall trauma. study reported mortality of blunt pelvic trauma to reach . - % ( ) . injury severity score (iss), hypotension, head injury, posterior fracture & haemorrhage have been implicated ( ) . however, there is a paucity of data in developing countries. this study identifies the problem burden, management outcomes and factors predicting mortality. material and methods: patients had pelvic trauma, retrospectively from jan to dec and prospectively from may to april . patients was included after excluding less than years and coagulation disorder results: majority were males ( . %),with a mean age of . . mechanism was rti ( . %) followed by fall from height ( %), railway accidents ( . %). mean iss & rts was . and . respectively. associated injury were long bone fractures ( . %), chest injuries ( . %).head injury ( . %). lateral compression ( . %), was the most common followed by anteroposterior compression ( %) & combined ( . %).majority underwent operative intervention ( . %) for pelvis or associated injury. the mortality rate was . % secondary to haemorrhagic shock ( . %) and sepsis ( . %). the factors were male gender, age, iss, rts, head injury, unstable pelvis. however, no association with haemoglobin, long bone fracture, and massive transfusion protocol was found conclusions: our study showed a mortality of . % which is comparing with previous study introduction: the number of patients admitted to oslo university hospital (ouh) due to bicycle trauma is increasing. we aimed to identify possible predictors of serious and fatal bicycle injury. material and methods: the ouh trauma registry was searched for patients treated for bicycle trauma between and . data extraction included putative predictors of serious and fatal injuries, defined as iss c and death within days, respectively. univariate analyses were performed and reported as odds ratios (or). p \ . was regarded as statistically significant. results: bicyclists were admitted, % were males, median age was years (range - ). injury mechanisms were single bicycle crash in %, collision with a motorized vehicle in %, bicycle vs. bicycle in % and others in %. serious injuries were seen in % and . % died. predictors for serious and fatal bicycle trauma are presented in figure . conclusions: we identified age c , high comorbidity and loss of consciousness (gcs b ) as predictors for both serious and fatal injury after bicycle trauma. single bicycle crash was the most common cause of serious bicycle injury in our trauma center. diagnosis, investigation and results: all case reports represent polytrauma patients with clinical worsening and admission to the icu, with subsequent development of acute respiratory distress syndrome (ards) refractory to primary measures. therapy and progressions: different mechanisms led to the development of ards in the different cases. on a primary approach, standard measures such as curarization, recruitment maneuvers, prone positioning and peep increase were applied whenever possible. an absence of improvement led to an almost inevitable need of extracorporeal membrane oxygenation (ecmo) rescue therapy. all patients responded positively to this treatment without major complications and were eventually discharged from the icu. comments: ards is a major cause of respiratory failure in polytrauma patients. among the many therapeutic options, ecmo emerges as a powerful tool as rescue therapy in respiratory failure refractory to all other measures, being the present case reports corroborative examples of its efficiency. introduction: nowadays when cities are improving fast and significantly, including transportation system, even more we encounter with high energy trauma . still the most vulnerable on the roads are pedestrians. material and methods: the analysis of the data collected prospectively from january to october was performed including the mechanism and diagnosis of polytrauma, patient demographics and the main outcomes. results: in total, patients were assessed according to the polytrauma protocol. the median age of the cohort was years (iqr - ), male patients, . % vs. . % females, p = . . the most frequent mechanism was a pedestrian struck by a vehicle in . % cases, and falling from a height of over m in . %. of those patients who had musculoskeletal injuries, in . % the trauma mechanism was a fall from a height and in . % pedestrians were struck by a vehicle, . % of patients who fell from a height and . % of those struck by a vehicle suffered visceral injuries. the most common cause of neurotrauma was a fall from a height in . %, and pedestrians involved in car accidents in . %. from the whole cohort, patients were not saved, resulting in a . % mortality rate. most patients ( ) who died had iss [ . the mortality reached . % among pedestrians struck by a vehicle and . % among patients who fell from a height of over m. conclusions: the most common mechanism in the cohort was a pedestrian struck by a vehicle, followed by falling from a height, with a predominant involvement of male patients. similarly, the most frequent cause of musculoskeletal injuries and visceral injuries was falling from a height and pedestrians struck by a vehicle, demonstrating an important direction for polytrauma prevention. introduction: recent reviews of uk trauma data show altering demographics. patients are increasingly older and sustain lower energy injuries, with falls \ m being the most common ( ) . material and methods: data collected over years in a major trauma centre was used to calculate injury specific admission rates, case fatality rates and injury specific mortality attribution. data on patient age, footwear, lighting, alcohol intoxication and previous admissions were collected in falls \ m resulting in mortality. results: patients sustaining falls \ m represented % of admissions and % of mortalities. all falls represented % of admissions and % of mortalities. case fatality of falls of \ m and [ m was . % and . %. all fall case fatality was . %. this was significantly higher than the case fatality of stabbings ( . %) and rtas ( . %). in falls \ m causing fatality, mean patient age was . years. % of patients aged - were under the influence of alcohol when falling, with % aged - , but only % patients aged - . % aged - who died when falling were wearing slippers. this increased to % in those aged - , and % aged - . % of falls occurred under daylight/full light. % of patients aged - who died after falling had been admitted to hospital within the last year, although this increased to % in those aged - , and % aged - . conclusions: falls were the most common cause for hospital admission, had the highest case fatality of injury mechanisms and caused the most patient mortality. alcohol intoxication was associated with falls in younger patients who died after falling, but this was less common in older patients. wearing slippers was less common in the young but significantly associated with fatal falls in older patients. these results offer a range of therapeutic targets when developing fall prevention strategies. introduction: the treatment of splenic lesions is determined by the hemodynamic situation, the degree of injury and the presence of bleeding. arterial embolization has expanded the indications of the conservative treatment. retrospective observational study on splenic traumatism and its therapeutic options. material and methods: a total of patients with splenic injury have been treated at our centre between and . patients were hemodynamically stable: were embolized and received a conservative treatment. patients were hemodynamically unstable: had a good response to the resuscitation treatment so they were embolized, but there was one patient who deceased because of other causes. from these patients, patients received splenectomy. results: the main objective of this study is to review the management of the trauma patient with splenic injury. of the total of patients with splenic trauma, average iss of , underwent splenic embolization, underwent urgent splenectomy and were treated with conservative treatment. the embolized, were hemodynamic unstable at arrival but responded to the fluid therapy, had a splenic lesion grade iv, a grade iii, grade ii and another a grade i. the success rate of embolization was % in the embolized patients. patient died, only one of them in the embolization group and was not related to the splenic trauma nor embolization, were in the urgent splenectomy group due to severity of trauma, died before receiving any treatment and in the conservative treatment group due to other complications. conclusions: patients who respond to volume or are hemodinamically with high-grade lesions, arterial embolization would be less aggressive treatment options with excellent results. haukeland university hospital, surgical unit/ regional traumacenter, bergen, norway, norwegian university of science and technology, trondheim, norway, haukeland university hospital, physical and rehabilitation medicine, bergen, norway, university of bergen, bergen, norway, st olavs hospital, physical and rehabilitation medicine, trondheim, norway introduction: during the past decades acute trauma care has improved through the development of highly specialized trauma centres and teams. since patients are considerable young when being affected, trauma may lead to life-long physical, cognitive and emotional constraints interfering with an independent self-determined life ( , ) . in , a revised national plan for the treatment of trauma patients in norway was published ( ) . the plan emphasizes the importance of rehabilitation and the need for early interdisciplinary rehabilitation. this study will examine in which extent patients receive rehabilitation in early phase after trauma as recommended in the norwegian national plan. in addition we will examine what follow-up patients receive after trauma, quality of life, functional level and use of health care and next-of kin resources. material and methods: patients admitted to regional trauma center in mid-or western norway in with niss c are recruited to participate. data will be collected from national trauma register, the norwegian patient register, the municipal patient and user register, data from statistics norway, the electronic patient record (epj) and the patient/relatives questionnaire. discussion: the results will be useful in the preparation of patient courses that comply with strong recommendations in the national trauma plan, ensuring equal treatment and raising awarness about rehabilitation for trauma patients. introduction: diaphragmatic lesions involve wounds and rupture of the diaphragm, through penetrating wounds or thoraco-abdominal trauma. their incidence is - %. the diagnosis may be late, despite the technical advances made by medical imaging. the choice of surgical approach and technique is still controversial. mortality is usually related to the associated injuries. the present paper analyzes the incidence of diaphragmatic lesions that occur in thoraco-abdominal trauma, their epidemiology, diagnosis and treatment. material and methods: we performed a retrospective study over a -year period ( - ) , in the surgical units of the emergency county hospital of braila, including all patients diagnosed with diaphragmatic lesions. results: during the study period, patients had thoracic-abdominal trauma. there were cases of blunt trauma and thoracic-abdominal trauma. our study involved cases of diaphragmatic injuries ( . %), by road accident and by white weapon. the sex ratio was : . the average age was years. chest radiography was a contributory preoperative diagnosis in cases. the diaphragmatic wound was on the left side in cases, and its average size was cm. the surgical procedure involved the reduction in the abdomen of the herniated viscera and the monoplane suture of the diaphragm by nonabsorbable ''x'' points in all cases. chest aspiration was the rule. there was only one death in a complex polytrauma case. case history: we report the one case which performed tae, angioplasty, thoracotomy, laparotomy and preperitoneal pelvic packing (ppp) in the hybrid emergency room (h-er). the patient was male in the s, who was riding on his motorcycle and fell from a m height. clinical findings: he was in shock state. diagnosis: we scanned cect and diagnosed subdural hematoma, traumatic subarachnoid hematoma, lt hemopneumothorax, lung contusion, multiple costal bone fracture, intercostal artery injury, splenic injury (gradeiii), pelvic bone fracture. therapy: we inserted the drainage tube to the hemopneumothorax and did the tae for the pelvic bone fracture and splenic injury. after tae, he was in still shock state. the bleeding volume from the lt drainage tube increased, so trauma surgeons did the emergency thoracotomy and thoracic endovascular aortic repair (tevar) for intercostal artery injury. we suspected he also had abdominal compartment syndrome due to recanalization of tae, and they performed the emergency laparotomy and did ppp for the pelvic bone fracture. comments: we install an ivr-ct system in our trauma resuscitation room in october . we named it h-er, as it enables us to do all examinations (sonography, ct and fluoroscopy) and treatments (ir, operation) required for trauma in a single room. we have to perform prompt diagnosis and treatment, especially in cases of severe polytrauma cases. a retrospective study proved that the h-er had shortened the time of ct initiation and emergency procedure and that lead to improve mortality ). h-er is a novel trauma resuscitation room to do all treatments required in the only one room for severe traumatic patients introduction: according to the previous advanced trauma life support (atls) guidance, the early assessment of trauma patients with haemorrhage were classified upon the vital signs. recently, national trauma registry analyses suggested to extend the assessment criteria with the base deficit (bd), referring to the metabolic status. our objective was to investigate the relevance of bd and to explore new prognostic factors in the early assessment of the severely injured. material and methods: our study included patients registered between . . and . . on our emergency ward for whom the trauma team was activated. they were grouped into severity groups (i-iv) according to either the vital signs (classical) or the extended criteria with bd. the data were extracted from medical documentations of the early phase of treatment. as primary outcome, we compared the -h mortality rate of the patient groups. we studied the need for massive transfusion and intensive care unit care as secondary outcomes. results: according to the classical assessment, % of the patients were assigned to group i (lowest risk for haemorrhagic shock) and % to group ii. the remaining % were grouped into groups iii and iv (higher risk). with taking bd into consideration, % were reassigned to a higher risk group; however, this change affected only groups i and ii. the -h mortality changed only in group i ( . % vs . %; p = . ). bd did not affect the need for massive transfusion. in groups i and ii, . % of the patients, in groups iii-iv % needed intensive care unit treatment. conclusions: bd is an effective prognostic factor in the early assessment of trauma patients. however, compared to the vital signbased evaluation, it provides extra informaton only in less severe cases. according to our findings, it may help to assess the need for the administration of blood products. grants: nkfi k ; ginop- . . - - - ; efop- . . - - - . complejo hospitalario de jaén, servicio de cirugía general y del aparato digestivo, jaén, spain, complejo hospitalario de jaén, servicio de anestesiología y reanimación, jaén, spain case history: years old male, with history of hypertension and dyslipidemia, suffered a backhoe accident and was admitted in a regional hospital. on initial assesment he presented contusion and two laceration wounds in left chest and in lumbar region. body ct informed subcutaneous emphysema and left rib fractures from th to th, left hemidiaphragm edema, laminar left pneumothorax and contusive lung. posterior lumbar hematoma and no intra-abdominal free fluid. laceration wounds were partially sutured, with drainages through the wounds clinical findings: he was transferred to our emergency department, presenting dyspnea, tachycardia, sweating, painful luq and left hemithorax worsening with breathing investigation/results: reviewed by our radiologist, tc images showed herniation of abdominal organs into the chest diagnosis: traumatic hernia in left costophrenic recess. multiple rib fractures therapy and progressions: the hernia contents (left colonic flexure and omentum) were reduced and defect closed with primary repair in emergency surgery. rib fractures treated by osteosynthesis.on th pod left renal artery dissection and renal infarction were evidence in a new ct. comments: diaphragmatic injuries are caused by blunt or penetrating thoraco-abdominal trauma. potentially life-threatening due to the herniation of abdominal organs and severe associated lesions. clinical suspicion is important as prompt diagnosis and treatment are necessary for good outcomes. in our case, the initial clinical assessment was incorrect and the transfer put the patient in danger as an emergency surgery should have been performed before transfer. this enhances the importance of a correct initial management of polytrauma patients. introduction: the fractures of the calcaneus account for about - % of all fractures of the human skeleton. the majority of these fractures ( %) are intra-articular and surgical intervention is a widely accepted way of treatment material and methods: the aim of this study was to evaluate the results of open reduction and internal fixation for di-afc.in a period of years ( - ) patients ( patients with bilateral fractures) with age range from to years old, were treated surgically using the lateral extensile approach. follow-up was - years. the results were evaluated based on x-ray parameters (calcaneal morphology, bohler''s and gissane''s angles), active range of motion, footwear problems and time needed to return to work. the sf- health survey was used for outcome assessment. results: fracture mean healing time was , weeks. the outcome was excellent in cases, good in cases and poor in cases. the complications were malposition of fixation in patients, superficial wound slough in patients, reflex sympathetic dystrophy in patients, deep infection in patients who were treated with antibiotics and metalwork removal following union of the fracture. one patient resulted in metal breakage with consequent pseudarthrosis. finally one patient developed chronic osteomyelitis and is under treatment. the treatment with open reduction and internal fixation for di-afc is indicated, provided that the restoration of calcaneal shape, alignment and height is achieved. long term functional results with mild pain, few alterations in activities of daily living or work, and essentially no footwear problems, can be expected from a properly performed open reduction and internal fixation. extraperitoneal rectal injury in emodinamically unstable patient treated after dcs with external traction applied in an endorectal balloon r. somigli hospital, general and emergency surgery, pistoia, italy case history: a -year-old man was crushed between two vehicles while he was working. he arrived in er hemodynamically unstable, so he underwent to emergency surgery. clinical findings: at rectal examination there was evidence of almost complete antero-lateral anorectal laceration. at abdominal examination there was evidence of anorectal full-thickness laceration and urethra full laceration. investigation/results: no diagnostic was required in preop because of patient instabilty. diagnosis: pelvic fracture with hemodynamic instability, severe rectal injury and complete prostatic urethra transection. therapy and progressions: el, lateral colostomy, pelvic paking, cistostomy and hip external binder. damage control surgery was performed. on pod second look was carried out and an almost complete extraperitoneal rectal injury was found during pelvic depaking. properitoneum was drained and a baloon probe was introduced in the rectum to allow the proximal rectal flap to advance to the distal rectum. stomal washes were performed with no rectal leak and rectal baloon traction mantained for days. radiological and endoscopic check haven't shown any leak and a good mucosal reconstruction. mri no sphincteral anatonical defects. waiting for emg before stoma reversal. comments: the optimal managment for extraperitoneal rectal injuries remains controversial. an approach with lateral colostomy and conservative treatment of rectal lacerations with rectal trac-tion baloon, could represent a safe treatment alternative in those cases with sphincter preservation, with a lower risk of complication. exploring differences between iss and niss scores for -day mortality in adult and elderly trauma patients in a norwegian national trauma cohort m. introduction: injury severity score (iss) and new injury severity score (niss) with a threshold over is commonly used to define severe injury and to define the study population in trauma registrybased studies for both adult and elderly trauma patients ( ) . for elderly patients (c years) this might be unreasonably high and might lead to exclusion of significantly injured elderly with increased risk of mortality. the aim of this study was to assess whether there were significant differences in -days mortality between adults and elderly trauma patients for different frequently used iss and niss thresholds material and methods: the norwegian trauma registry was interrogated to identify all adult (c years) trauma patients included in the registry from january through december . data were dichotomized to age groups ''adult'' and ''elderly'' ( - and c respectively) with -days mortality as primary endpoint. mortality rates were assessed for iss and niss thresholds of [ , [ and [ . we applied descriptive statistics and chi-squared test for comparisons. results: patients with available information about age, -days mortality and iss and niss scores were included in the analysis, of which patients were - years old and patients were c years. adult and elderly patients died, giving overall mortality rates of . % and . % respectively. for iss and niss [ there was a significantly higher -days mortality in elderly trauma patients ( . % and . % respectively) than adult patients ( . and . % respectively) (p \ , ), as for all other iss and niss thresholds tested. conclusions: this study demonstrates that elderly trauma patients has a significantly higher mortality risk than adult trauma patients at all iss or niss-thresholds analysed. this group has a significant mortality even at iss and niss above . introduction: the trauma tertiary survey (tts) is a widely accepted tool in the prevention of missed injury. existing literature on its effectiveness focusses on multitrauma patients. this study investigates the yield of the tertiary survey in trauma who are admitted for tts, without having any significant injury. material and methods: a single center retrospective cohort study was performed in a level ii trauma center. trauma patients without any clinically significant injury at the primary and secondary survey were included. the primary outcome was missed injury found during tts (type ). secondary outcomes were missed injury found after tts but during admission (type ), mortality and hospital length of stay [ days. results: from included patients, patients ( . %) had a type missed injury. alcohol consumption was associated with an increased risk for type missed injuries (odds ratio = . , % ci: . - . ) . a type missed injury was only found once, it concerned the only case of trauma related mortility. out of nonoperated patients, ( . %) were admitted for more than two days. these patients were significantly older ( vs. years, p \ . ) and had a higher asa classification, - vs. - ( . % vs. . %, p \ . ). conclusions: tts showed missed injuries in only . % of trauma patients who had no clinical significant injury found during primary and secondary survey. high costs of admission, together with a low yield found for this study's population the cost benefit of hospitalizing these patients is for discussion. future research should therefore focus on the identification of predictors of a positive tertiary survey. references: . advanced trauma life supportÒ student course manual. . keijzers, et al., the effect of tertiary surveys on missed injuries in trauma: a systematic review. . enderson et al., the tertiary trauma survey: a prospective study of missed injury. the -h rule in the emergency department and its association with surgical mortality in one public hospital in israel: retrospective study i. ashkenazi hillel yaffe medical center, hadera, israel introduction: in order to improve patient treatment the -h rule in the emergency department (ed) was introduced in many countries as well as in israel. within four h, patients attending the ed must be seen, treated, and a decision must be reached whether these patients are to be admitted or discharged. though a popular performancebased measure, whether the -h rule in ed is associated with a decrease in mortality is controversial. the primary objective of this study was to evaluate the association between time in the ed and surgical mortality in one public hospital in israel. material and methods: included in this retrospective study were patients admitted to the ed of hymc during . patients dying on the first day were excluded. . results: included in this study were , patients. of these, , ( . %) patients were hospitalized and the rest were discharged. overall, patients died. general surgery accounted for , patients of which died ( . % of hospital deaths; . % of all surgical patients; . % of patients hospitalized in general surgery). internal medicine together with general surgery and orthopedic surgery accounted for . %, . % and . % of the mortalities observed in patients with decisions made within - h, in patients with decisions made beyond h and in all the patients respectively. forty-five patients with decisions made within h died compared to with decisions made beyond h. these represent . % and . % of all surgical patients in the ed (whether hospitalized or discharged) and . % and . % of those hospitalized. conclusions: general surgery is the second largest contributor to hospital morality. in both absolute terms and relative terms, mortality was not increased by delays in decisions made beyond h. the adoption of this performance-based measure should be questioned. introduction: trauma is an important cause of mortality [ , ] . researchers are looking for optimal death/survival predictive models in trauma population. one way is to validate traumatic scores for different medical systems [ ] . the aim of our study was to validate the new injury severy score (niss) in severe trauma ( introduction: the international classification of diseases-based injury severity score (iciss) has been proposed as a reliable tool to measure trauma system performance especially in countries where a trauma registry has not been yet established. the purpose of this study is to assess the predictive capability for in-hospital mortality of iciss with international and adjusted survival risk ratios (srrs) in greek trauma population. material and methods: this single center, retrospective cohort study was conducted in a greek tertiary care hospital between january to december . the trauma population was defined as hospitalized patients with a principal hospital discharge diagnosis in the range icd- s -t . duplicated injury icd codes, readmissions, transfer to another hospital and missing data were excluded. the primary outcome was in-hospital mortality. adjusted srrs was calculated from patients with multiple injuries and the following two iciss scores were evaluated: multiplicative-injury (iciss) and singleworst-injury (swi). the models were assessed in terms of their discrimination, measured by receiver operating curve (roc) analysis and calibration measured using calibration curves. results: a total of patients were included in the study. median age was ± years and mortality rate was , %. based on international srrs, the area under the curve was , ( % ci . - . ) for iciss-multiplicative and , ( % ci . - . ) for iciss-worst injury. both modes had statistically significant better performance with adjusted greek srrs (aur = , % ci . - . and aur = , % ci . - . , respectively). conclusions: this analysis has demonstrated the validity iciss model for in-hospital mortality prediction in greek trauma population. further research is warranted to confirm the performance of iciss using a sufficiently sized sample to define national srrs. introduction: the occurrence of intra-abdominal abscesses is the most serious post-operative infective complication after appendectomy. a significant amount of research has been conducted in an attempt to identify those patients at greatest risk. pct is initially described as an early, sensitive and specific marker for sepsis associated with bacterial infection. we hypothesize that pct could serve as a predictor of the development of intraabdominal abscess and postoperative infective complication material and methods: the present study is a prospective, single centre, observational cohort study involving patients undergoing emergency appendectomy. all patients admitted to the acute care surgery ward for appendicitis were screened for study eligibility. pct poc samples will be obtained preoperatively (t ) and post procedure (t ) at h (t ), h (t ), and days (t ) post procedure. the primary objective of this study was to assess the diagnostic accuracy of point-of-care testing for pct in identifying post appendectomy abscess. the secondary objective was to determine the diagnostic accuracy in identifying any infective complication conclusions: we expect the incidence of abscess and infective complication to be increased in the pct elevated group compared with the control group. previous investigations indicate the overall morbidity related to infective complication is approximately - % of patient undergoing laparoscopic appendectomy. our pilot study revealed that the incidence could be as high as % in patients with prolonged elevated pct levels. introduction: hand trauma is a common cause for attendance to the accident and emergency (a&e), accounting for nearly - % of all patients . it is essential that accurate treatment and management is done as the implications of mismanagement are long term, which may lead to disability, loss of work and income, livelihood, and even psychological issues . the presence of a specialised hand surgeon is essential for management of these injuries , but in the a&e setting it is not always possible to have such specialised care and there is a need for an efficient triage system. materials and methods: we did an audit in our department and found a delay in the referral of patients from a&e to our trauma clinic, which was quite expected due to a high patient inflow. we devised a trauma pathway for the a&e, known as the d-system which outlines for them till what day from trauma is a particular hand patient safe to be sent to the hand clinic or who needs an urgent referral to a higher trauma centre, based on urgency of need of intervention. the pathway is in the form of a simple flowchart, which is easy to understand even for junior members of the team. we intend to do another audit after implementation of the pathway to assess change in practice. conclusion: it is essential to have simplified pathways for non-specialist areas in order to streamline treatment and offer the best care, in the limited availability of resources, especially at smaller hospitals. our aim is to develop one such system and assess it's effective in delivering better care. introduction: a quantitative method for measuring trauma severity has many potential applications. the intent of this study was to evaluate the accuracy of the mgap score and its components in prediction of in-hospital mortality versus the accuracy of the revised trauma score rts at a trauma center. material and methods: this study included patients with trauma. data regarding age, mechanism of injury, systolic blood pressure, glasgow coma score and respiratory rate were collected at trauma center of alberto torres hospital. mgap and rts scores were calculated, and their accuracy to predict survival/death outcome. results the study included patients, ranging in age from to years, % male. from the total sample, patients who suffered from penetrating trauma and patients who suffered from blunt trauma were observed. in the comparison of the scores, rts and mgap, there was no significant superiority in any of them for predicting the outcome -which in our study was hospital discharge or death -even when compared by trauma mechanism. the gcs proved to be a very sensitive criterion in both scores, especially in patients with traumatic brain injury, totaling patients in our statistical analysis, of which , % had a negative outcome. rts was slightly superior than mgap in patients classified by the score as high chance of mortality, with % versus % of assertiveness. conclusions: up to the moment, there is no evidence to support the superiority of one of the analyzed scores as a predictor of mortality in the patients evaluated. although the rts score is more widely used in trauma centers, the application of the mgap score is more feasible in pre or in-hospital care of polytrauma patients, since it does not use respiratory rate in its parameters. validation of d-dimer for screening for venous thromboembolism in pelvic and lower extremity trauma patients t. uehara , , t. noda , t. yumoto , n. kobayashi , a. nakao , t. ozaki okayama university, emergency healthcare and disaster medicine, okayama, japan, okayama university, orthopaedic surgery, okayama, japan, okayama university, musculoskeletal traumatology, okayama, japan, okayama university, emergency and critical care medicine, okayama, japan, okayama saidaiji hospital, okayama, japan introduction: venous thromboembolism (vte) is a life-threatening complication after major trauma patients. we previously reported that the patients with higher injury severity score (iss) and lower extremity trauma had high risk for vte. additionally, high d-dimer levels (cut-off d-dimer value, . lg/ml) on day were useful for screening for vte in major trauma patients. we validated d-dimer levels for vte screening for patients with pelvic and lower extremity trauma. material and methods: a retrospective study was undertaken between april and august at the okayama university hospital. patients with pelvic or lower extremity trauma were included (median iss, ). we collected following data; age, sex, iss, the number of operation times, value of d-dimer in screening, incidence of vte and use of anticoagulants. results: eleven patients showed high d-dimer levels in screening, furthermore, six patients were diagnosed vte using contrast-enhanced computed tomography. symptomatic pulmonary embolism was not occurred. patients with vte had undergone orthopaedic surgeries two or more times. fourteen patients received therapeutically or prophylactic anticoagulation therapies. conclusions: measurements of d-dimer levels after pelvic or lower extremity trauma patients were useful for screening of incidence of vte. direct oral anticoagulants were convenient for treatment to vte. trauma patients often needed several times of surgeries, heparin was also useful in perioperative period. introduction: early assessment of the clinical status of severely injured patients is crucial for guiding surgical treatment. several scales are available to differentiate between risk categories. we compared four established scoring systems in regard to their predictive abilities for early versus late in-hospital complications. methods: database from a level i trauma center. the following four scales were tested: the clinical grading scale (cgs; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mcgs), the polytrauma grading score (ptgs), and the early appropriate care protocol (eac; covers acid-base changes). admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. results: in total, severely injured patients were included (mean age, . ± years; mean iss, . ± . points; incidence of pneumonia, . %; incidence of sepsis, . %; death from hem. shock, . %; death from multiple organ failure (mof), . %; mortality rate, . %). istinct differences in the prediction of complications, including mortality, for these scores (or ranging from . to . ). the ptgs demonstrated the highest predictive value for any late complication (or = . ), sepsis (or = . , p = . ), or pneumonia (or = . , p = . ). the eac demonstrated good prediction for hemorrhage-induced early mortality (or = . , p \ . ), but did not predict late complications (sepsis, or = . and p = . ; pneumonia, or = . and p = . ) cgs and mcgs are not comparable and should not be used interchangeably (krippendorff a = . ). conclusion: our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid-base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). none of the authors have any conflicts of interest to declare. mortality rate related to trauma mechanisms in trauma center at alberto torres hospital from january to july r. p. pereira , r. adriana martins , j. a. c. padilha , f. e. silva , , d. rangel alberto torres hospital, trauma center, são gonçalo, brazil, federal university of rio de janeiro, niterói, brazil introduction: to demonstrate the healthcare services of the trauma center of rio de janeiro based on epidemiological data and on the specificity of the type of initial care delivered to multiple trauma patients, comparing the mortality rate at the second peak of death with the worldwide literature. materials/methods: retrospective study extracted from ''ct heat'' database. polytraumatized patients of both sexes were included and the mortality rate was calculated taking into account the second peak of death from trauma, gender, age and primary mechanisms of injury. discussion: the data collected show % mortality in the second peak, with firearm projectiles ( %) followed by traffic accident and fall as the primary causes of death. conclusion: because of the structural and health care profile of this trauma center, it was possible to reach the desirable mortality rate according to the worldwide literature (less than %). introduction: trauma patients are sometimes in critical condition upon arrival and need aggressive treatments to survive. despite all efforts many end up dying. it seems necessary to try to identify those patients with a very high risk of death to avoid futile treatments. the aim of our study was to develop a simple clinical tool to predict mortality in trauma patients that can be easily calculated in the ed. material and methods: we analyzed data from all trauma patients arriving at a spanish trauma hospital from june to june . patient demographics, physiologic trauma scores, vital signs, and glasgow coma scale (gcs) were recorded. our primary outcome was mortality. logistic regression analysis (lra) was performed using three variables (age, shock index (si), and gcs) to determine the appropriate weights for predicting mortality. using them, we constructed a simple score to calculate mortality. results: patients were studied. the mortality rate was . %. our score was constructed using weights derived from lra for age [ y ( points), si [ ( points) , and gcs conclusions: our score is easy and quick to calculate and could be a useful tool to predict mortality using early available parameters upon arrival in the ed. acknowledging the ethics involved in this topic, this score could sort out patients with a very high risk of death and in whom aggressive therapeutic measures could be limited early or withdrawn in agreement with family members references: haider a, et al ( ) ( ) ( ) states the average cost for an a&e attendance and non-elective inpatient stay is £ and £ , respectively highlighting the importance for schemes to reduce hospital admissions. assess impact of ambulatory care, surgical emergency assessment unit (seau) and ''emergency surgeon of the week'' (esw) on hospital admissions for surgical referrals (gp/ a&e). material and methods: retrospective analysis of prospectively collected data of hospital admissions from the patient centre database before and after implementation of seau (in november ) and esw (in november ), including the units'' activities. emergency general surgeon followed : (monday-thursday, - ) rota based at seau. results: since ( months), seau has reviewed (new ; follow ups ) patients. surgical admissions (sa) pre and post implementation seau were * and */month respectively, a drop by %. esw helped a further drop by another % to */month. % of new referrals were admitted and overall % of all patients reviewed were admitted. juniors (st /st ) and seniors (st - /staff grades/consultants) admitted % and % of the referrals respectively. uss and ct were performed in dedicated seau slots. % attending seau were likely to recommend the unit to friends or relatives. conclusions: in the face of unprecedented demand for hospital beds (more so in the winter), ''emergency surgeon of the week'' based at seau could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained nhs. surgical emergencies, an educational and medico-economic challenge introduction: surgical emergencies are a frequent reason for consultation in the emergency department and are responsible for significant morbidity and mortality. our study aims to present the number of patients admitted for a surgical emergency in a french level trauma-center and the volume of patients operated in emergency depending on the different specialties. method: we conducted a retrospective, single-center study of the hospital emergency department (uas) of the university hospital center of nice between january and december . we studied the volume represented by surgical emergencies according to the different specialties. results: the emergency department welcomed , patients, of which , surgical emergencies patients accounted for % of the total activity; patients were operated on urgently, which represents % of all surgical procedures in our hospital. conclusion: surgical emergencies are an important part of the activity of our hospitals. an academic definition is difficult to achieve. a regional organization is needed for the management and optimal care of these patients. the creation of regional centers, as for the trauma centers, seems indispensable, especially for the most serious patients, allowing both a better medico-economic and educational management of surgical emergencies. introduction: every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last years, however, % of patients admitted to an icu will die during their admission ( ) . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover ( ) . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction ( ) . material and methods: a checklist was created to review to score the handover. this was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing handovers on the icu. results: there is a notable discrepancy in the quality of handovers of new patients. this is true of handovers between doctors, nurses and a combination of the two. % (n = ) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight ( %, n = ), their height ( %, n = ), whether the patient has previously been admitted to an icu ( %, n = ) and whether the patient has any allergies ( %, n = ). conclusions: the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. introduction: bowel resection for acute mesenteric ischaemia (ami) in elderly is associated with significant morbidity and mortality, and increasing age and frailty are associated with increased risk. this study aims to assess the short-term outcomes for elderly patients undergoing surgery for ami, and to assess the accuracy of surgical risk calculators in this population, to determine their utility in preoperative discussions. introduction: intertrochanteric femoral fracture of the super-elderly is often difficult to treat because good surgery does not always lead to good functional prognosis. we investigated the factors affecting the functional prognosis in patients with intertrochanteric fracture over years old. material and methods: cases of intertrochanteric fracture over years old who had undergone surgical treatment at our hospital between december and september were examined. nine men and women, age at injury ranged from to years, with a median of years. the average postoperative follow-up period was . months. for these cases, the mobility was classified into independent walking, assisted walking (cane, walker), wheelchair, bedridden, and the transition of pre-and postoperative mobility was analyzed. the significance test was performed using the mann-whitney u test, and p \ . was considered significant. results: by fracture type, when jensen classifications i and ii were stable, iii, iv, and v were unstable, mobility of unstable type was significantly reduced (p = . ). when the waiting period for surgery is divided by the median of days, there was no difference in mobility reduction between groups of less than days and groups of more than days (p = . ). although there was no significant difference in the presence or absence of preoperative rehabilitation intervention (p = . ), there was a tendency for less decline in mobility when preoperative rehabilitation intervention was performed. conclusions: in the treatment of this fracture, early surgical treatment after injury is recommended, but in the case of very elderly people, waiting is often required due to existing diseases and poor general condition . this study suggests the importance of preoperative rehabilitation intervention during the waiting period for surgery to prevent disuse disorders. references: . kelly-pettersson et al. waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: a cohort study international journal of nursing studies ( ) - . older patients with traumatic shock exhibited lower pulse pressure compared with younger patients; an analysis of nationwide trauma data base in japan introduction: the study purpose was to assess the effect of age on the relationship between pulse pressure (pp) and systolic blood pressure (sbp) in patients with traumatic shock. material and methods: in this retrospective cohort study using nationwide trauma data base in japan from april to may , trauma patients years of age and older with sbp \ mmhg were selected. patients with severe traumatic brain injury (the abbreviated injury scale on head [ ) and cardiac arrest (hr = and sbp \ mmhg) were excluded. linear regression analysis assessed association between pp and sbp interacted by age group dichotomized as \ or c years old. results: during the study period, patients were included. the linear regression analysis indicated the significant association between pp and sbp in overall population (ec, estimated coefficient = . %ci [ . , . ], p \ . ). association between pp and sbp was significantly interacted by the age group (ec = . %ci [ . , . ] introduction: high rates of trauma in south africa (sa) predominantly affect the youth, yet the geriatric population is not exempt. in addition to inherent challenges of age, elderly trauma patients are further compromised by resource constraints. we aimed to assess injuries and outcomes in elderly patients admitted to a tertiary trauma unit in sa. material and methods: a retrospective record review was done of all patients years and older, admitted to the trauma unit over an -month period. injury severity score (iss), mechanism of injury (moi), in-hospital complications and length of hospital stay were documented. results: patients (mean age: years; % female) were included with mean iss of . the most frequent mois included nontraumatic falls ( %), falls from height ( %), motor-vehicle collisions ( %), pedestrian vehicle collisions ( %), and blunt injuries ( %, % intentionally inflicted). eighty patients ( %) experienced at least one in-hospital complication. the mortality rate was %. the mean length of hospital stay was days. conclusions: despite the known vulnerablities of the elderly, the mortality rate and isss of this cohort were relativley low. however, when compared to first world literature, intentionally inflicted injuries and certain preventable mois (e.g. fall from height and pedestrian vehicle collisions) were common, [ ] [ ] introduction: the majority of new colorectal cancer is diagnosed in people [ years, yet the elderly are less likely to undergo curative surgery. chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. conversely, frailty is a strong predictor of poor outcomes following surgery and presents an opportunity for patient optimisation. the aim of this systematic review is to assess the available evidence between frailty and outcomes in patients of all ages undergoing surgical resections for colorectal cancer. material and methods: pubmed was searched for articles reporting outcomes for patients deemed frail undergoing elective or emergency colorectal cancer resection up until august . the primary outcome was mortality ( and day). secondary outcomes; length of stay, readmission, reoperation & post-operative complications. results: studies identified, studies were deemed eligible for inclusion. study types, frailty assessments & outcomes measured were variable. despite this heterogeneity, categorisation of ''frailty'' was associated with higher rates of post-operative mortality, complications, readmission, and length of stay. conclusions: based on current evidence, frailty is a strong predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. standardisation of frailty assessment and measure of outcomes is needed for more robust analysis. accurate risk stratification of patients will allow us to make informed treatment decisions and identify patients who may benefit from prehabilitation and intensive tailored post-operative care. introduction: pneumatosis intestinalis (pi) and hepatic portal venous gas (hpvg) are two radiological findings associated with a broad range of medical conditions. pi can be primary ( % of cases),usually with a benign course, or secondary ( % of cases),which results from obstructive or ischemic gastrointestinal diseases. only a minority of pi is associated to free abdominal air. in literature there is no consensus on radiological and biochemical markers of favourable outcome nor on treatment options-medical or surgical. we tried to identify prognostic markers in a series admitted to a single university hospital. material and methods: the medical records of patients with pi and/or hpvg admitted to ospedale maggiore policlinico (milan, italy) in the period - were collected the ct scan were reviewed by a single radiologist. results: mean age was . ± years ( - ). pi was primary in , % of the patients (n = ), and secondary in , % (n = ). at ct, pi was associated to portal gas in patients ( %) ( dead, alive) and to free air in patients ( %) ( dead, alive). linear or rounded gas collections were equally distributed in primary and secondary pi. the colon was involved in patients ( %), followed by the small intestine in ( , %),and the stomach (n = ). in patients serum lactate was [ , and died. leucocytosis (wbc [ , /mm ) was present in patients ( alive).four patients had peritonitis and abdominal tenderness. laparotomy was performed in primary (alive) and secondary pi ( deaths).in two patients it was diagnostic; in and associated to right or left colectomy, in to ileal resection and in to other procedures.surgery was judged futile in patients; all died a few hours after emergency department access. conclusions: we could not found any relationship between clinical, biochemical and radiological findings and outcome of pi. mesenteric and portal gas is a ominous finding, but did not reach significant value. successful transcatheter arterial embolization for a giant pseudoaneurysm of gluteal muscle due to ground level fall in elderly woman with direct oral anticoagulants t. kadoya , r. nakama , k. arakawa , t. ogura , k. kase saiseikai utsunomiya hospital, department of emergency medicine and critical care medicine, utsunomiya, japan, saiseikai utsunomiya hospital, department of radiology, utsunomiya, japan case history: a 's year-old woman using apixaban fell on the ground and was transferred to previous hospital. magnetic resonance imaging was taken and she was diagnosed as gluteal hematoma. she was treated conservatively but hemoglobin (hb) level was gradually decreased. although she was administered red blood cell as needed, anemia progressed. contrast-enhanced ct showed expanding hematoma of gluteal muscle. she transferred our hospital for advanced treatment including surgery on th day on hospital. clinical findings: vital signs were stable on arrival at our hospital. extensive subcutaneous hematoma was found in the right thigh and gluteal lesion. investigation/results: laboratory test showed that hb . g/dl and normal coagulation status. contrast-enhanced ct showed a giant pseudoaneurysm inside the gluteal muscle. therapy and progressions: angiography showed a giant aneurysm of peripheral branch of internal iliac artery. we performed transcatheter arterial embolization (tae) for it by gelatin sponge. after tae, there was no complication and progressive anemia was stopped. she was transferred to another hospital for rehabilitation six days after tae. comments: increase use of direct oral anticoagulants in elderly people could induce severe hemorrhagic trauma by minimal mechanism. tae is minimal invasive and safety procedure for such trauma case. introduction: the number of elderly people will increase during the next few decades. more importantly, the number of people aged or above are projected to increase % in developed countries. in spain, people over age were . % of the population in , and this will increase to . % in . that has implications in the health services and in the management of trauma patients. material and methods: we did a retrospective cohort analysis of trauma patients c y.o. admitted to our level i trauma center during the time-period of - . demographic data, icu care, and mortality were assessed. results: trauma patients c y.o. were admitted during that period. this is a % increase compared with the number of patients admitted during the previous decade ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . mean age was . ± . years, and median new injury severity score (niss) was (interquartile range to ). % were male. the mechanism of injury was % falls, and % pedestrian runovers. patients were admitted to icu, with median niss of and mortality rate of %. among severely injured trauma patients (niss c ) the hospital mortality rate of those c years was %, much higher than in the age group of - years ( %), with a significant difference (p \ . ). no differences mortality rates between - years and youngers with the same niss. conclusions: the geriatric trauma patient population is on the rise worldwide. this should be taken into account in our trauma centres in order to be able to adapt and try to improve trauma care in these patients. introduction: frailty is a geriatric syndrome which has been considered as a risk factor in the elderly, increasing adverse events in terms of global health, as hospitalization, increase of falls, need of institutionalization, and mortality. the aim of this study is to evaluate relationship between frailty, and the presence of major complications in the postoperative course of patients older than years undergoing emergency surgery. material and methods: prospective, longitudinal, cohort study, using four different scales of frailty as a predictor of risk for short-term adverse events, for patients during the postoperative course of emergency surgery (may -september ). the sample is categorized according to four frailty scales (clinical frailty scale, frail score, trst and share-fi) . we analyze the variables regarding diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first days. clavien-dindo classification was used in order to graduate the severity of complications. results: patients were included with a mean age of , years (sd , ) . , % of the simple are women. frailty prevalence ranges, according to the frailty scales, from , % to %. median hospital stay was days ( iqr , ) . all four frailty scales show statistical differences to predict major complication in our simple. trst and frail scales show the strongest measure of association (or , and , , respectively). the frail phenotype, is also related to an increased of mortality, and frail scale is the frailty scale with largest or (or = , ).only frail show association with longer hospital stay ([ days), and reoperation rate. conclusions: frailty represents a predictive marker of major complications and mortality, for patients older than years undergoing emergency surgery. frail score, shows the strongest relationship with mortality and complications. introduction: age has been identified as a predictor of trauma mortality [ ] and it is known that even low energy trauma may cause severe injuries in the elderly [ ] . the aim of this study was to explore how the elderly trauma patients, and the care thereof, differ from the younger ones in a swedish context. material and methods: the swedish trauma registry (swetrau) was used. consecutive recorded trauma cases that presented at one level ii trauma hospital during december -august were included (n = ). patients were stratified into groups; those c and those results: in the c years group, sex distribution was more even (female . vs . %, p \ . ), physical status according to pretrauma asa classification was higher (mean . vs . , p \ . ) and the trauma mechanism was predominantly low-energy (falls from no height) as opposed to the conclusions: the trauma among elderly swedish patients are more often of low energy compared to the younger population. in spite of this, the elderly are more severely injured, require more surgical interventions, and their short term mortality is increased -fold. measures aimed at prevention of low energy trauma of the elderly are therefore much needed. introduction: there are intramedullary or extramedullary methods in internal fixation od trochanteric fractures. seldynamisalbe internal fixator with two sliding screws (sif), as an extramedullary method, and gamma nail (gn), as an intramedullary method, are in routine trochanteric fractures treatment at our institution for last two decades. material and methods: health related quality of life and hip function were assesed at least two years after surgery, in the series of patients with a surgically treated ao a or a fracture type. there were two groups of patients: group treated by sif and group treated by gn. examination had been performed using sf- test, with its physical component score (pcs) and mental component score (mcs), and harris hip score (hhs) tests. results: in sif group, mean pcs was , , mean mcs was , and mean hhs was , . in gn group mean pcs was , , mean mcs was , and mean hhs was , . there was no significant difference regarding all these parameters between the groups of patients (p [ , ). there was correlation between all evaluated parameters, both in groups of patients particularly and in all patients (p \ , we identified undertriage in , % ( / ). falls from own height ( - m) was found in patients with iss [ , / ( %) of them was found to have been undertiaged (p . ). we found an association between gcs \ and undertriage (p = . ). % ( / ) falls between - m and % ( / ) of these without trauma team. falls between - m , % ( / ) without trauma team. all with fall [ m had trauma team. mortality was % ( / ), no association between height of fall and mortality (p . ). undertriage was not associated with increased mortality (p = , ). median age in mortality group was years versus years in surviving group (p \ . ). in univariate analysis there was association between prehospital bp \ (p . ), gcs \ (p \ , ), iss (p \ . ), prehospital rr [ , rts \ (p \ . ) asa score [ (p \ . ) and mortality. conclusions: we found significant undertriage in the geriatric trauma population with fall injuries. gcs \ and low energy falls was associated with undertriage but not with mortality. laparoscopic direct repair of an incarcerated spigelian hernia c. bergamini , v. iacopini , r. de vincenti , a. bottari , g. alemanno , p. prosperi aou-careggi, emergency surgery, firenze, italy spigelian hernia occurs through a defect in the anterior abdominal wall adjacent to the semilunar line. it is in itself very rare and more over it is difficult to diagnose clinically. it has been estimated that it constitutes . % of abdominal wall hernias. the majority of patients present with symptomatic incarceration of preperitoneal fat or intraabdominal viscera. radiographic studies are beneficial in confirming the diagnosis. the high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed. the spigelian hernia has been repaired by both conventional and laparoscopic approach. laparoscopic management of spigelian hernia is well established. most of the authors have managed it by transperitoneal approach either by a direct repair or by placing the mesh in intraperitoneal position or raising the peritoneal flap and placing the mesh in extraperitoneal space. there have also been case reports of management of spigelian hernia by total extraperitoneal approach. we present the case of an obese eighty-four y.o patient. complaining for a sudden onset abdominal pain in the right low quadrant, mimicking an appendicitis. the ct scan demonstrated a typical picture of a spigelian hernia containing an intestinal loop. the loop showed classical signs of parietal wall ischemia. the video describes the surgical laparoscopic approach of this case which was able to confirm the diagnosis e to reduce the loop into the abdomen. the loop initially appeared diffusely ischemic, but after the intra-abdominal reduction some signs of vitality started to be noticed. however, they were incomplete; thus the loop was resected. the hernia defect was successively repaired in a direct way because of the small caliber (\ cm of diameter) and the possible contamination coming from the intestinal resection. post-operative course was particularly benign and the patient was discharged on the seventh post-operative day in good health. introduction: trauma audit & research network (tarn) data shows older persons falling from standing height and sustaining significant injury has become the commonest trauma presentation in england and wales . we aimed to assess whether frailty predicts poor outcomes in the elderly. material and methods: retrospective database review of tarn eligible patients [ years old admitted in a week period with documented rockwood clinical frailty score . age, injury severity score (iss), length of stay (los) and mortality were noted. the inhospital mortality group was sub-analysed. logistic regression was performed (stata v ), odds ratios and % ci reported. results: older age was associated with higher cfs in the patients studied. increasing cfs was associated with increased overall mortality (cfs - vs cfs - or . ; % ci . - . ), decreased likelihood of pre-hospital trauma alert and increased length of stay (cfs - stayed days more than cfs - ). all deaths had cfs [ and head or chest injury. adjusting for age and cfs those with chest injury were . times more likely to die (or . %ci . - . ). mortality in those with rib fracture was times higher in cfs - vs cfs - (or . %ci . - . ). conclusions: increasing age and cfs (especially - ) are associated with poor outcomes in elderly trauma, thus cfs is a useful prognostic tool in severely injured elderly patients. chest injuries are a major cause of mortality in this group, especially with increasing frailty. major trauma centres must develop practice management guidelines to appropriately manage these patients. introduction: major trauma causes activation of the complement system, which plays a key role in development of systemic inflammatory response syndrome and multiple organ failure. complement is known to be activated early after trauma , but the relationship between outcome and the extent of complement activation during the first critical hours after injury is unknown. we hypothesized that complement activation in the first hours after trauma displays a highly dynamic pattern which is associated with outcome. material and methods: complement activation was assessed by plasma terminal c b- complement complex (tcc) using elisa in a prospective cohort of trauma patients. samples were obtained at admission, after , , and h, and daily in the intensive care unit. the extent of complement activation was assessed as area under the concentration curves - h after injury (tcc-auc - ). the relative contribution of complement activation, base excess (be) and new injury severity score (niss) to outcome was analyzed by multivariable analyses. results: niss and be were associated with tcc-auc - in bivariate analyses (spearmans rho (p) was respectively , (p = . ) and - . (p = . )). in multivariable analyses, niss and initial tcc alone predicted % of the variability in ventilatorfree days (vfds), whereas initial tcc and tcc-auc - predicted %. tcc auc - alone contributed with % to the model. tcc-auc - was also significantly higher in patients deceased at day ( . ; . - . (median; quartiles) vs. . ; . - . , p = . introduction: massive transfusion protocols [mtp] have been widely adopted for the care of bleeding trauma patients but their actual effectiveness is unclear. this study aims to conduct an updated meta-analysis to evaluate the effect of implementing an mtp on the mortality of trauma patients. material and methods: medline, pubmed, google scholar and cochrane library databases were systematically searched for relevant articles published from january , to july , using a combination of key words and additional manual searching of reference lists. three reviewers independently screened the articles for potential inclusion. eligible articles were original articles in english, included trauma patients and compared mortality outcomes before and after institutional implementation of a mtp. primary outcomes were h and overall mortality. results: nineteen studies met inclusion criteria, analyzing outcomes from , trauma patients. there was a wide range of outcome and process indicators utilized by the different authors. mtps significantly reduced over-all mortality, pre-mtp- . % and post-mtp . % [or . ( . - . )] for trauma patients. -h mortality was not significantly reduced [or . ( . - . )]. conclusions: the institution of an mtp has a significant over-all mortality reduction for trauma patients. we encourage that researchers use standard nomenclature and indicators, provide more details regarding protocols and patient populations and incorporate advances in the management of bleeding trauma patients in all future mtp studies. introduction: when resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized with good outcomes for penetrating trauma patients. however, evidence that these concepts apply well to the management of blunt trauma is lacking. this study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. material and methods: in this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival \ . . patient's characteristics, examinations, severity and administrated therapies were compared between survivors and non-survivors. data are described with median ( - % interquartile range) or number. results: thirty patients were included and median injury severity score in survivors vs non-survivors was ( - ) vs ( - ) (p = . ), with no significant difference in probability of survival. despite no significant difference in injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. total blood transfusion amount administered within h after admission was significantly higher in survivors ( [ conclusions: vasopressor administration and high-dose use for hemorrhagic shock following severe blunt trauma are significantly associated with increased mortality. although the transfused volume of blood products tends to be increased, early termination of vasopressor should be considered. all authors have no significant relationships with regard to this study. early amplitudes of citrated functional fibrinogen in thromboelastography to predict massive transfusion introduction: this study aims to evaluate the role of early amplitudes of the thromboelastography measure of citrated functional fibrinogen (cff) to predict massive transfusion (mtx) defined as transfusion of c of any blood products within an hour of arrival to a major trauma centre. material and methods: trauma patients c years requiring activation of the major haemorrhage protocol with teg performed on a tegÒ s hemostasis analyser were eligible for inclusion. exclusion criteria were arrival [ h after injury, pregnancy, bleeding disorder or anticoagulant use. patient demographics and transfusion requirements were obtained from medical notes. teg manager was accessed to extract amplitudes at min (a ), min (a ) introduction: hyperfibrinolysis, remains a significant characteristic of acute traumatic coagulopathy induced mortality. s a , a cell surface protein, when shed creats an occult hyperfibrinolytic subtype. annexin a (a ), a multicompartment protein that co-localizes with s a and contains a tissue plasminogen activator (tpa) binding site has been shown to enhance tpa activity -fold and thus behaves as marker of hyperfibrinolysis. we hypothesize that increased concentrations of a in blood will enhance tpa fibrinolysis. material and methods: blood was collected from ( ) healthy volunteers. recombinant a in concentrations , , , , , lg/ ml was added blood and then combined with tpa ng/ml. samples were assessed using thromboelastography (teg). blood samples were collected from trauma activations from -current at a single, urban, level- trauma center. samples were assessed using a combination of rapid, citrated native and tpa challenge teg. a levels were established via proteomic analysis. results: a - (lg/ml) significantly increased tpa mediated ly % vs tpa alone (a ? tpa [ - ] median . % vs tpa . % p \ . ). a without tpa had no significant effect on ly % and was similar to the lysis of control (a lg/ml . % vs control . % p = . ). a - (lg/ml) significantly increased r time from control and tpa alone (control normalized to vs a median . -fold increase in minutes p \ . and tpa . -fold decrease vs a median . -fold increase p \ . ). rapid teg for patient vs patient in our ongoing study was . % vs . % and . % and . % respectively on tpa challenge teg. proteomic analysis of a relative activity found a . -fold a activity in patient compared to patient . conclusions: exogenous cell free a significantly increases tpa mediated fibrinolysis measured by teg. preliminary data from our ongoing trauma study evaluating a levels and hyperfibrinolysis coincide with our in vitro study. introduction: massive transfusion protocol can be activated to mobilize the blood products resource in a timely and effective manner. blood products, however, are still wasted or overused. we aimed to study what proportion of patients who met the abc criteria for massive transfusion received or more units packed rbc (prbc). material and methods: a retrospective study all level i trauma patients admitted with arrival systolic blood pressure of or less (july to may ) was recruited. transfusion was complied with stts. all clinical and laboratory findings, and management procedures were populated from the data registry. results: of admitted trauma patients met the inclusion criteria. of patients who where admitted with hypotension, of patients ( . %), who met the abc criteria for receiving or more prbc were stabilized with or units. in other words, stts enabled us to save units of prbc. arrival data, i.e. blood pressure (cut of point: mmhg and p value: . ), shock index (cut of point: . and p value: . ) and pulse rate (cut of point: beat/min and p value: . ) were significantly different in patients prescribed or more units prbc. after initial resuscitation, blood pressure (cut of point: mmhg and p value: . shock index cut of point: . and p value: . ), pulse rate(cut of poinan beat/min and p value: . ) presence of pelvic fracture, positive fast,and base deficit [ were significantly different in the group received or more units prbc. conclusions: massive transfusion protocol with abc criteria may lead to wasted or overused blood products.consideration of dcr continuation strategy complied with stts along with the findings of this study has resulted in a refined protocol characterized by more effective and efficient blood product resource allocation. references: -chang r, holcomb jb. optimal fluid therapy for traumatic hemorrhagic shock. critical care clinics. jan ; ( ) case history: we present the clinical case of a female patient of years old who had been taking aspirin. mechanism of injury: a fall from her own height, resulting in head trauma. clinical findings: dysphonia and stridor, having underwent an immediate orotracheal intubation. investigation/results: she had a head ct done that was normal; and a cervical column and neck ct that showed a large retropharyngeal hematoma, without an associated vertebrae fracture. diagnosis: large retropharyngeal hematoma. therapy and progressions: she was admitted to the intensive care unit for mechanical ventilation. on nd day, she underwent a surgical tracheostomy. on th day, underwent weaning from mechanical ventilation. on h day, was transferred to the ent ward, had the tracheostomy tube removed and was discharged from hospital. comments: a hematoma in this potential space may constitute an immediately life threatening emergency due to airway compromise. in , thomas et al found only cases described in the literature since . the most common cause is the blunt cervical trauma (in % of the cases). other causes are the cervical hyperextension injury, cervical vertebrae fracture, cough, sneeze, strain, blunt head trauma, swallow a foreign body, retropharyngeal infection, carotid artery aneurism, internal jugular vein puncture, metastatic disease, coagulopathy, anticoagulants, etc. in the setting of trauma, the mechanism of injury generally permits explaining the presenting injuries. in this case, the clinical severity expressed by the patient seemed to be disproportional to the resultant injury. however, the presence of haemorrhage contributing factors associated with the existence of fascial spaces in the neck, should warn us of the possibility of formation of deep cervical hematomas that may cause an occult airway obstruction. case history: a -year-old male with a personal history of consumption of alcohol, cannabis, smoked cocaine and heroin. he was found in decubitus position and in a situation of cardiac arrest. the last time he was seen in his baseline situation was h before. after performing cpr and administration of naloxone and flumacenyl, sinus rhythm was achieved. clinical findings: h after admission, increased tension was observed in left leg, thigh and gluteal region. absence dorsalis pedis, tibialis posterior and popliteal pulse was observed in a doppler examination. investigation/results: intracompartmental pressure measurement revealed a result of mmhg in the deep posterior compartment and mmhg in the superficial (diastolic bp mmhg). at admission k levels were . meq/l, creatinine . mg/dl and ck u/l. diagnosis: opioid-related compartment syndrome. therapy and progressions: urgent fasciotomies of the leg and thigh were performed h after diagnosis with a posteromedial and anterolateral approach in the first case and with a lateral approach in the latter. herniation and signs of poor viability in all the compartments were observed. after the surgery, he persisted with anuria and a ck peak of , u/ l, which was next normalized. debridements were performedfor the next days. subsequently, after the isolation of p. stutzeri and mucor in the wound and the absence of signs of vitality, a supracondylar amputation was performed. after, hemodynamic status improved. weeks after the amputation it was possible to withdraw hemodialysis, which he had required since admission. comments: opioid misuse is a topic of growing interest. recent works have reported a worse prognosis in the case of opioid-related compartment syndrome. a high level of suspicion is necessary to make a prompt diagnose in these patients. introduction: the pelvic binder is a mechanical device designed to compress instable pelvic ring fractures and minimize dead space in order to limit blood loss. it is generally recommended to apply a pelvic binder if an unstable injury is suspected and the patient presents with a ''c-problem''. the effectiveness remains questionable though. material and methods: a total of trauma patients between and were retrospectively evaluated regarding instable pelvic injury. patients were admitted with a pelvic binder applied. the correct application was evaluated using ct scout. four groups were generated: group with correct pelvic binder application, group with incorrect placement, group with no pelvic binder at time of admission, group with pelvic binder applied in er. total outcome was determined based upon iss, age, preclinical time, time to ct, shock index, hemoglobin at admission, survival rate, administration of blood products as well as total hospital and icu days. results: % of all pelvic binders were applied incorrectly. patients ( %) suffered an instable pelvic fracture. patient survival was not influenced by the preclinical application of a pelvic binder ( % group vs. , % group , p = , ). no significant statistical difference was found for total icu days , vs. , , p = , ; total hospital days , vs. , , p = , ; rbc transfusion , vs. , , p = , ; iss , vs. , , p = , . conclusions: the correct application of a pelvic binder seems to pose problems preclinically. while the need to minimize blood loss is crucial, our collective did not benefit from this device. additionally, survival rates of the patients that suffered an instable pelvic fracture were unaffected. the iss remains the strongest predictor of total patient survival in pelvic trauma. trauma resuscitation times in a level trauma center in the netherlands: a prospective overview introduction: in trauma, time is considered to be an important factor influencing patient's outcome. in the first hour after injury, appropriate care has the greatest effect on trauma patient's survival. previous research showed that measuring in-hospital trauma resuscitation times, contributes to insights and improvement of the resuscitation process. however, despite developments of atls guidelines, no recent empirical knowledge regarding resuscitation times exists. the aim of this study is to examine in-hospital trauma resuscitation times in a level trauma center in the netherlands. material and methods: a prospective study was performed in level trauma center amsterdam umc location vumc, between may and august . trauma patients, aged c , presented during daytime at the trauma resuscitation room were included. information regarding patient's characteristics, trauma-and injury type, handover duration, duration till start of diagnostics and intervention, total resuscitation time, patient's disposition and survival were compared. results: in total, patients were analyzed. motorized traffic accident ( %) and blunt injury ( %) were the most common mechanism-and injury types. median prehospital to in-hospital handover time was . min (iqr . ) . median duration till start of diagnostics and intervention were . (iqr . ) and . min (iqr . ) respectively. median total resuscitation time showed to be . min (iqr . background: terrorist attacks and civilian mass casualty events are frequent, and some countries have implemented tourniquets for uncontrollable extremity bleeding in civilian settings. we summarized current knowledge on the use of pre-hospital tourniquets in civilian settings to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. methods: using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, we searched medline (ovid), embase (ovid), cochrane library, and epistemonikos in january . all types of studies that examined the topic in a pre-hospital setting published after january , , were included. the protocol was registered in prospero (crd ). results: among screened records, studies were identified as relevant. due to a lack of relevant civilian studies, military studies were also included. the studies were highly heterogeneous, with low quality of evidence. most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. conclusion: the data suggest that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage is probably associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects. the effect of venous infusion by emergency medical service personnel on the prognosis of severe traffic accident patients: a nation-wide study in japan y. katayama , t. kitamura , , t. hirose , y. nakagawa , t. shimazu osaka university graduate school of medicine, department of traumatology and acute critical medicine, suita, japan, osaka university graduate school of medicine, environmental and population science, suita, japan introduction: in japan, the law of paramedic was revised in , and it became possible for paramedic in japan to secure an infusion route before cardiac arrest for severe patients. however, the effect of this treatment on the prognosis of severe trauma patients has not been assessed. we assessed this effect on the prognosis of severe traffic accident patients with using population-based ambulance record and nation-wide hospital-based trauma registry in japan. material and methods: this study was a retrospective observational study and the study periods was years between january to december . we linked the nation-wide hospital based trauma registry (jtdb) and the population-based ambulance record in japan in case. in this study, we included the traffic accident patients with iss score more than and excluded cardiopulmonary arrest patients on the arrival of ems on the scene and missing data cases. the main outcome was cardiopulmonary arrest on hospital arrival. mcnemar's test and conditional logistic regression analysis were used to assess the association between the securing a infusion route by ems personnel and the primary outcome after one-to-one propensity score matching for securing a infusion route or not. results: traffic accident patients were eligible for analysis and patients were dripped by ems personnel. after one-to-one propensity score matching, the proportion of cardiopulmonary arrest on hospital arrival were . % ( / ) in patients dripped by ems personnel and . % ( / ) in patients not dripped by ems personnel, respectively (p = . ). the adjusted odds ratio for securing a infusion route was . [ % confidence interval; . - . , p = . ]. conclusions: in this study, there was no association between the securing a infusion route and outcome of traffic accident patients. the association between trauma patient characteristics and adverse laboratory values: which patient characteristics are most predictive? introduction: in more than countries worldwide, laboratory testing is protocol driven since when it was included in the practice guideline of the advanced trauma life support course (atls). however, it is not clear yet which patient characteristics are associated with unfortunate laboratory values. the aim was to create an overview of the characteristics that were associated with adverse laboratory values. material and methods: this cohort study was performed at amsterdam umc, location amc (level trauma center), including patients during a period of years. data concerning age, gender, asa scores, injury severity scores (iss), glasgow coma scores (gcs), mechanism of injury, type of injury (blunt or penetrating) and the presence of helicopter emergency medical services (hems) were obtained. the hematology panel included hemoglobin, hematocrit, mcv, leucocyte and thrombocyte values. the coagulation panel included inr, pt, aptt, fibrinogen and d-dimer values. other panels include arterial blood gas, kidney and liver panels. the association between trauma patient characteristics and laboratory values were determined by using binary and multinomial logistic regression. results: a total of patients were included, consisting of predominantly men ( %) with a mean age of years old. an increase in age and iss was correlated with abnormal laboratory values (p = . ). additionally, male gender, iss [ , blunt trauma and the absence of hems was associated with a deviation in laboratory values (p \ . ). other patient characteristics did not show a significant correlation with adverse laboratory values. case history: a -year-old man presented with a classic case of pituitary apoplexy with a history of headache, nausea and vomiting. clinical findings: he was found to have a sellar and suprasellar mass with internal cystic and hemorrhagic component consistent with a pituitary macroadenoma. investigation/results: he underwent transsphenoidal sugery for a pituitary macroadenoma. because the tumor was invaded to left cavernous sinus, we left small portion of the tumor. eighth day after surgery, he underwent gamma-knife surgery (gks) for residual tumor. after two weeks, he complained of left ptosis. we considered the rd nerve palsy to be a post-radiation reaction at first. after months, the symptoms had been continuous and mri showed increased size of cystic lesion involving left cavernous sinus. diagnosis: ct angiogram demonstrated a saccular aneurysm at left distal ica. endovascular coil embolization was performed. therapy and progressions: after months of the intervention, the rd nerve palsy was partly improving. comments: our case report emphasizes the necessity of cerebrovascular imaging before surgery for pa. mr angiography/ct angiography is not currently obligatory in patients with pituitary adenoma, but in cases with the symptoms of displacement of the neuro-vascular structures it can be of great value. even in patients without such presentations, it may be helpful to evaluate the vascular involvement. case history: a -year-old boy during the preparation for a fishing session was pierced to the left orbitary region by a high-speed spearfishing steel. clinical findings: upon arrival the patient was conscious and responsive with a gcs of , he followed commands appropriately and there were no motor of sensory deficits. investigation/results: plain skull radiographs showed the spear crossing the skull from the left orbit to the posterior part of the parietal bone. diagnosis: the patient was immediately intubated to prevent involuntary movement of the foreign body. ct scan showed the fracture of the left orbitary roof where a centimetres long metallic object crosses the cerebral parenchyma of the left hemisphere and perforates the left parietal skull. therapy and progressions: under direct visualization via transorbital approach the foreign body was removed together with bone fragments, hemostasis was done and orbitary roof repaired. serial cranial ct scan showed progressive reduction of frontal and parietal hematoma. the movement of the eye improved after a few days, normalizing with the regression of periorbital edema. upon discharge at th postoperative day the patient had a gcs score of , no motor deficit and minimal visual loss. comments: penetrating injury of the skull and brain are relatively uncommon events, representing about , % of all head injuries. orbital roof is relatively thinner part of the skull that can provide easy access to projectile objects, which can penetrate into cranial cavity and damaging the brain parenchyma. the principles of treatment are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection though debridement of all contaminated and necrotic tissue and at the same time preservation of as much nervous tissue as possible. multitraumapatients whith severe head injury (ais ‡ ) are more quickly carried out ct scan on than a patient without severe head injury v. giil-jensen , k. andersen , t. k. helle haukeland univercity hospital, sugical department, bergen, norway, haukeland univercity hospital, ambulance service, bergen, norway introduction: trauma patients who are prone to severe head injuries during trauma may profit from obtaining a rapid clarification of the injury magnitude when using ct examination. in the case of a delayed ct examination, the consequence of the head injury could be more extensive. in this study, we wanted to see if those with severe head injury (ais c ) received a faster ct survey than those who had no severe head injury. material and methods: retrospective registry study of severely injured patients (iss [ ) which had been hospitalized as a trauma patient at haukeland university hospital in the period - . in the study, we have excluded all patients entered as multitrauma but who have iss \ and all patients who have not defined ct time. it turns out that over half of the patients lacked the registration of accurate time for the ct survey in the national trauma register. the number is still considered large enough to find a result. results: patients were received as multitraumatic at haukeland university hospital during the period. of these, was severely injured. of these, patients had severe head injuries and they again had head injuries as the only serious injury (ais c ). median time from arrival receipt to start ct, for this group was min. in the control group that was severely injured but without severe head injury is the same time min. there was patients in the control group. conclusions: for the patients in this study who had severe injuries (n: ), the median time from the arrival in the emergency department to the ct starts was min shorter for severe head injuries than for the group without severe head injuries. introduction: the patients with severe traumatic brain injury (stbi) who needs surgical intervention often experience acute traumatic coagulopathy (atc). earlier transfusion with high blood product ratios (plasma, platelets, and red blood cells via : : ratio) is recommended for severely injured patients. however, recommended blood product ratio for stbi is still controversial. material and methods: we retrospectively reviewed successive adult stbi who underwent surgical treatment in our hospital between january and december . we have transfused plasma aggressively to maintain blood fibrinogen above - mg/dl. we evaluated the total amount of transfusion and mortality. we exclude cases administered fibrinogen concentrate. results: patients were enrolled. the amount of transfusion for h is rbc . units, ffp . units, pc . units . stbi with severe other trauma needs higher ratio of plasma. discussion: tissue injury of stbi causes severe coagulopathy and : : transfusion was thought to be insufficient for stbi in order to maintain fibrinogen. we agressively transfused plasma but we achieved fibrinogen value above only in % of stbi with severe other trauma. agressive plasma transfusion had limitation for hyperfibrinolysis so we expect other product, for example fibrinogen concentrate. introduction: traumatic brain injury (tbi) remains a leading cause of hospital admission and mortality amongst trauma patients. intracranial hemorrhage (ich) can occur with tbi and presents a severe complication. low complication tolerance in developed countries and uncertainty on actual risk cause excessive diagnostics and hospitalization, considered unnecessary and expensive. methods: tbi cases indicated for cranial computer tomography (ct) according to international guidelines, at our level i trauma center between - were retrospectively included. multivariate logistic regression was performed for ich, progression and mortality predictors. results: tbi patients (m: . ; age at trauma: . ± . ), were included. ct was performed in . %, skull fracture diagnosed in . %, ich in . %, ich progression in . %. in patients \ a, chronic alcohol consumption (p = . ) and neurocranial fracture (p \ . ) were significant ich risk factors in a multivariate analysis. in patients between - a, chronic alcohol consumption (p \ . ) and skull fracture (p \ . ) revealed as significant ich predictors. in patients [ a, age (p = . ), anticoagulation (p = . ) and neurocranial fracture (p \ . ) were significant risk factors for ich, age (p = . ) was an independent risk factor for mortality. late onset ich only occurred in cases with at least of factors: age [ , anticoagulation, neurocranial fracture. overall hospitalization might have been reduced by . % via low risk cases. conclusions: triggered by decreasing error tolerance, international guidelines for mild tbi focus on safety maximization. repeated ct in initially ich negative cases should only be considered in high risk patients. non-ich cases aged \ years do not gain safety from observation or hospitalization. recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics. references: to be added by the authors. evaluation of low-value clinical practices in acute trauma care: a multi-center retrospective study l. moore , k. soltana , j. clément , a. turgeon , î mercier , r. krouchev , p. a. tardif , s. bouderba , a. belcaid université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, université-laval, québec, canada, introduction: low-value clinical practices have been identified as one of the most important areas of excess healthcare spending and are associated with adverse health outcomes. the objectives of this study were to estimate the frequency low-value practices in injury care and assess inter-hospital variations. material and methods: we identified low-value clinical practices from internationally recognized clinical guidelines. we conducted a population-based retrospective cohort study using data from an inclusive canadian trauma system ( - ) to calculate frequencies and assessed inter-hospital variations with intra-class correlation coefficients (icc). results: we identified low-value practices of which could be measured and validated using trauma registry data. the three lowvalue clinical practices with the highest absolute and relative frequencies were pelvic x-rays in hemodynamically stable patients with a negative physical exam for pelvic injury ( . %), head ct in adults with minor head injury who were negative on a validated clinical decision rule ( . %) and chest x-ray in hemodynamically stable patients with a normal physical exam ( . %). we observed high inter-hospital variation for surgical management of penetrating zone ii neck injury without hard signs (icc = %), and moderate variation for head ct in adults with minor head injury who were negative on a validated clinical decision rule (icc = . %). conclusions: we have developed and validated algorithms to evaluate nine potentially low-value clinical practices using trauma registry data. highest frequencies were observed for imaging in the emergency department and the highest inter-hospital variation was observed for inappropriate surgical management. these data can be used to advance the agenda on low-value care for injury admissions. dysfunction of functional connectivity between default mode network and cerebellar structures in patients with mtbi in acute stage. rsfmri and dti study introduction: mild traumatic brain injury (mtbi) occupies one of the first places in children injuries. among all brain networks at the resting state, the default mode network (dmn) is the most widely studied network. the aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mtbi using rsfmri. material and methods: mr negative participants were studied in age from to years (mean age- . years). group of patients consisted of children with mild traumatic brain injury in acute stage. age-matched healthy volunteers comprised control group. all studies were performed at phillips achieva . t mri scanner using -channel head coil. fmri data were processed using functional connectivity toolbox conn. seed-based analysis was performed in order to reveal disturbances in functional connectivity. statistical processing was performed using statistica . results: dti analysis didn't show any changes in values of apparent diffusion coefficient (adc) and fractional anisotropy (fa) between two groups (see fig. ). no statistically significant differences in correlation strength between dmn parts were observed in two groups (see fig. ). intergroup seed-based analysis revealed statistically significant (p \ , ) difference in neural correlations between dmn parts and vermis (cerebellum structural part): positive link in control group and negative link in group of patients. conclusions: one of the most common symptoms of mtbi is dizziness as a result of impaired movements coordination. vermis as an essential cerebellum part plays an important role in the vestibuloocular system which is involved in the learning of basic motor skills in the brain. vermis aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together.our results show that mtbi appears to be a possible reason of connectivity malfunction in normal-appearing vermis. references: predictors of developing post-traumatic endophthalmitis introduction: h magnetic resonance spectroscopy ( h mrs) allows to study structural and metabolic brain disorders in various pathological conditions in vivo. non-invasive method determines its advantage for use in children in serious condition with acute cerebral injuries. this determined the purpose of the study: to identify criteria of irreversible brain damage based on the h mr spectra analysis in comatose children with acute traumatic brain injury (tbi) or anoxia. material and methods: patients ( months- years) were examined in the acute period of severe cerebral injury (gcs score - ): six were in acute and subacute period of severe tbi, one patient was examined on the seventh day after drowning, and one-a day after acute cerebral blood flow (hemorrhage). all patients died in - days after the study. control group included healthy children aged from to years. single voxel h mrs and d h mrs was performed on t scanner. h spectroscopic voxel (te/tr = / ms, voi = cm , nsa = ) was oriented on mri intact areas: cortex of frontal, parietal and occipital lobes (fig. ) , thalamic nuclei (fig. ) , cerebellum, brainstem (fig. ) . for d h mrs a spin-echo point-resolved spectroscopy (press) sequence was used (te/tr = / ms) with the spectroscopic voi of cm on frontal lobes. results: in all spectra lactate (lac) signal, dominating all other signals, was detected. n-acetylaspartate (naa) was reduced by % and creatine/phosphocreatine (cr)-by %. conclusions: h mrs is a non-invasive prognostic method in patients with acute cerebral brain damage in coma. the cause of patients' death is the shift of cerebral glucose metabolism to an anaerobic type, as evidenced by the accumulation of lac. disturbance of energy metabolism causes a decrease of cr and a decrease in the neuronal marker naa. the combination of these patterns in acute cerebral injury, regardless of etiology indicates irreversible brain tissue damage. introduction: scalds and contact burns are the most common burn injuries both in children and adults. data are conflicting regarding which type of burns are more severe. we compared scalds, contact, and flame/fire burns at our burn center to determine which type were more likely to result in full thickness injuries and prolonged length of stay (los). material and methods: we conducted a structured retrospective medical record review of all patient admissions to a regional burn unit over a -year period between and . data included demographic, clinical, and specific burn characteristics. the association between patient predictor variables and outcomes (full thickness burns, los) was explored using chi-square and stepwise logistic regression. results: there were , patients with either scald (n = , %), fire/flame (n = , %) or contact burns (n = , %). burn depth was not available for cases ( %). mean (sd) age was ( ), % were male. mean (sd) total body surface area (tbsa) was ( )%. % of burns contained areas of full thickness injury. patients with scalds were younger than those with contact or fire burns ( ± vs. ± vs. ± years respectively, p \ . ). the percentage of burns that were full thickness by etiology were contacts ( %), fire/flame ( %) and scalds ( %); p \ . . after adjusting for age, location, and tbsa, scalds were less likely to result in full thickness injuries than contact burns (odds ratio . , %%ci, . - . ). adjusting for multiple testing, univariate analysis (as well as the multivariate analysis) showed no difference in % rd degree burns between fire and contact burns, but scalds were significantly lower than each of those. los for scalds ( ± ) and contact burns ( ± ) was significantly shorter than for fire/flame ( ± days, p \ . ). conclusions: while less common, contact and flame burns were more likely to result in full thickness injuries than scalds. references: epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (rocket); a multicenter prospective observational case series introduction: the aim of this study is to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from fireworks. material and methods: a multicenter, prospective, observational case series performed in the southwest netherlands trauma region, which reflects % of the netherlands and includes a level i trauma center, a burn center, and an eye hospital. all patients with any injury from consumer fireworks, treated at a dutch hospital between december , and january , , were eligible for inclusion. exclusion criteria were unknown contact information or insufficient understanding of dutch or english language. the primary outcome measure was injury characteristics. secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma. results: out of patients agreed to participate in this study. the majority was male (n = ; %), % were children \ years, and % were bystanders. injuries were located to the upper extremity or eyes and were mostly burns (n = ; %) of partial thickness (n = ; %). fifteen ( %) patients were admitted and ( %) patients needed surgery. the mean total costs per patient were € , ( % ci € , to € , ). patient-reported quality of life and functional outcome was not significantly different during follow-up compared with pre-trauma. conclusion: the most common injuries afflicted by consumer fireworks were burns, mostly located to the upper extremity, and eye injuries. fireworks can result in severe injuries, for which ( %) patients needed hospital admission and ( %) patients needed surgical treatment. although some injuries resulted in permanent disability, year after trauma it in general did not have major or longlasting impact on patients'' self-reported quality of life or functional abilities. persistent inflammation, immunosuppression and catabolism syndrome after polytrauma: a rare syndrome with major consequences. l. hesselink , r. spijkerman , r. hoepelman , l. koenderman , l. leenen , f. hietbrink umc utrecht, trauma surgery, utrecht, netherlands, wilhelmina children's hospital, center for translational immunology, utrecht, netherlands introduction: more severely injured patients survive the critical first phase after trauma nowadays. a substantial portion of these patients require long-term critical care support and suffer from recurrent infections. this clinical condition fits in a syndrome referred to as ''persistent inflammation, immunosuppression and catabolism syndrome'' (pics). the aim of this study was to investigate the incidence of pics and clinical outcomes of trauma patients with pics in a level one trauma center. material and methods: all trauma patients c years admitted to the intensive care unit (icu) for c days between and , were included. patients with isolated neurological injuries were excluded. pics patients were identified by icu stay c days, c infectious complications and increased catabolism. infectious complications included infections during hospitalization and readmissions due to an infection. increased catabolism was defined as weight loss [ %, a body mass index. results: of the , polytrauma patients, patients had an icu stay c days. after exclusion of patients with isolated neurological injuries, patients were included. of these patients, developed pics. pics patients sustained infectious complications on average (compared to in the non-pics group, p \ . ) and . % of the pics patients developed sepsis. also, pics patients had a longer hospital stay (mean of days versus days, p \ . ) and sustained more surgical procedures (mean of versus per patient, p \ . ). infectious readmissions occurred until years after the initial trauma. conclusions: patients who develop pics experience long-term inflammatory complications that lead to frequent readmissions and surgical procedures. therefore, despite its low incidence, this clinical condition forms a burden on patients and a substantial financial burden on society. hyperbilirubinemia as a risk factor of the trauma icu patient introduction: hyperbilirubinemia is common in the intensive care unit (icu). hyperbilirubinemia has been considered as a risk factor of the icu patient. hyperbilirubinemia can have various causes. the hyperbilirubinemia has never been studied for the trauma icu patient. the aim of this study is to elucidate the incidence and effects of the hyperbilirubinemia for the trauma icu patient. material and methods: retrospective review of the trauma icu patients from . . to . . . initial bilirubin serum level, h bilirubin level, day bilirubin level, highest bilirubin level, overall morbidity and mortality and other clinical variables were identified and evaluated. the patients who have highest bilirubin level c . mg/dl were defined as hyperbilirubinemia group. results: a total patients were enrolled in this study. hyperbilirubinemia above serum bilirubin c . mg/dl were appeared in patients. the mortality of the hyperbilirubinemia group was higher than the other group ( . % vs . %, p = . ). the icu stay of the hyperbilirubinemia group was longer than the other group ( . day vs . day, p = . ). the hyperbilirubinemia group had more incidences of pneumonia, acute kidney injury, and sepsis than the other group ( . % vs %, p = . / . % vs . %, p = . / % vs %, p \ . ). conclusions: the hyperbilirubinemia is a risk factor of the trauma icu. if the hyperbilirubinemia is appeared, the cause of the hyperbilirubinemia should be evaluated and make an effort to correct hyperbilirubinemia for the each cause of the hyperbilirubinemia. case history: we present the clinical case of a male patient of years old. injury mechanism: a firework burst on his right forearm. clinical findings: injury: a large area of carbonization of the muscles of the flexor compartment. signs and symptoms: intense pain in the hand and forearm with local oedema and tension. diagnosis: deep burn of the forearm. therapy and progressions: surgical debridement and fasciotomy of this compartment; followed by deferred and progressive primary closure by means of rubber bands that were tightened as the oedema diminuished-shoelace technique. evolution: discharged from hospital on the th pos op day; follow-up at rd and th month without functional impairment, with a good healing evolution. comments: deep burns that reach the subfascial planes of the limbs, increase the pressure in the muscular compartments, and may progress to a compartment syndrome. there is no specific cutoff value of pressure for this diagnosis; consequently, the final decision to proceed with a fasciotomy relies on the clinical experience. surgical debridement and fasciotomy may result in large wounds, sometimes difficult to close. grafts and flaps result in another wounds and carry a risk of pain, infection, scar shrinking and necrosis. the diagnosis of a limb compartment syndrome is almost always a clinical one and requires a high index of suspicion so as to the fasciotomy is done in time. the shoelace technique is a simple, reproducible and cost-effective method of deferred closure of a large wound, preserving functionality and resulting in a good final cosmesis. references: johnson ls et al, management of extremity fasciotomy sites prospective randomized evaluation of two techniques, am j surg. . the use of propranolol in the management of acute thermal burn injury: evaluation of the effect of fixed dosages in african patients c. jac-okereke , i. onah , esut teaching hospital, surgery, enugu, nigeria, national orthopaedic hospital, enugu, nigeria introduction: propranolol has been shown to improve outcomes in burn patients. its effects are achieved at doses that reduce the heart rate by - %. africans have a different propranolol pharmacogenetic profile as compared to other races. there is paucity of literary works on the use of propranolol in africans with burns. in our study, we explored the effectiveness of fixed dosages of propranolol in nigerian patients. material and methods: this was a prospective comparative study of adult burn patients; two test groups received propranolol mg/day and mg/day respectively. the average daily pulse rate prior to and after the administration of propranolol were compared. results: patients in the control group had no effective reduction in their pulse rate. patients who received propranolol at a dose of mg/day had a reduction c %. no adverse events were observed. conclusion: it is important to establish the effective dosage of propranolol in burn patients of african-descent and explore its potential benefits in their treatment. although we cannot draw strong case history: the authors present in their paper three cases of blunt abdominal injury caused by seat belt in car accident. in the first two cases there was no diagnostic problem thanks to clear clinical finding. in the third case there was no clinical correlation and even repeated auxiliary examinations did not indicate the need for surgical intervention of the abdominal cavity. clinical findings: case no. -male y. old, haemodynamic stability, thoracic an abdominal pain, fast positivity, on ct free fluid in abdominal cavity, small spleen laceration, positivity of peritoneal symptomatology. case no. -male y. old, haemodynamic stability, bilateral hypogastric pain without peritoneal symptomatology, fast with small perihepatic fluid, on ct fluido-pneumoperitoneum. case no. -female y. old, haemodynamic stability, thoracic pain, massive oedema on the right side of the neck and supraclavicular area, without abdominal symptomatology. fast with small subhepatal fluid collection- mm, ct scan with large neck haematoma and fracture of st rib, apical pneumothorax- mm. intraabdominal only subhepatal fluid stripe- mm, suspected of small hepatic laceration. after days the clinical status rapidly changed, during h peritoneal symptomatology occured. on control ct scan fluido-pneumoperitoneum was detected. investigation/results: all patients underwent surgical procedure diagnosis: bowel mesenteric injury therapy and progressions: the first patient underwent ileo-caecal and hartmann resection, by the second patient was small intestine and col. sigmoideum resection needed, and the last one underwent ileal resection and npwt. comments: despite the current diagnostic methods blunt abdominal injuries, unlike the penetrating ones, can present a certain diagnostic problem especially when they are accompanied by other serious conditions such as manifest chest injuries. introduction: patients with hypertension and peritonitis must undergo a laparotomy. in isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. to miss a hollow viscus organ lesion, that would need an operative procedure, is a constant fear. it is the aim of this study to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions. material and methods: data of over ' inpatients of a levelone-trauma centre between and were analysed. only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. significant predictors were detected in bi-and multivariant analysis. results: of the patients with an average age of ± years % (n = ) had a splenic-, % (n = ) a liver-and % (n = ) a kidney rupture. the total iss was ± points. in patients ( %) a hollow viscus injury could be found (stomach n = , small bowl n = , colon n = , rectum n = ). injuries of the thorax ( %), the extremities ( %), the head ( %), the vertebra column ( %) and the pelvis ( %) were diagnosed as concomitant injuries. due to multivariant analysis neither age, gender, heart frequency at admission, gcs, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion. conclusions: clinical parameters taken at admission are not useful to predict hollow viscus injuries. the ct-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first min after trauma. repetitive clinical examination is necessary. in doubt a diagnostic laparoscopy or even laparotomy has to be performed. introduction: a heavy abdominal trauma is associated with a high morbidity and mortality. it is the aim of this study to show injury patterns in the abdomen and concomitant injuries in polytraumatized patients as well as to identify risk factors of the decease. material and methods: data of over ' inpatients of a level-one trauma centre between and were retrospectively analysed. only patients with a relevant abdominal trauma (ais abdomen c ) were included. the ais score was determined either with a contrast enhanced computed tomography or intraoperatively. significant risk factors were detected in bi-and multivariate analysis. results: patients with an averaga age of ± years were included. % (n = ) had an ais abdomen of , % (n = ) of and % (n = ) of . the overall iss was ± points. the mechanism of injury was mainly blunt ( %). a splenic rupture was present in % (n = ), a liver rupture in % (n = ) and a kidney rupture in % (n = ). hollow viscus injuries were present in % (small bowl n = , colon n = , stomach n = , rectum n = , bladder n = ). concomitant injuries were determined in % of the patients. of these % were diagnosed a thoracic injury, % injuries at the extremities, % head injuries. % spinal injuries and % pelvic injuries. the mortality was % (n = ). a liver rupture (p = . , or . ), pelvic injuries (p = . , or . ), age (p = . , or . ), hypotension (systolic blood pressure \ mmhg) (p = . , or . ) and a low gcs at admission (p \ . , or . ) were determined to be significant risk factors. conclusions: in our trauma department life threatening abdominal traumata are treated about every days. lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. due to our experience we recommend the use of an early ct-scan as thereby the injury severity can be fast and precisely assessed. case history: a yo female was tranferred to our icu on day of a severe acute necrotizing alchoolic pancreatitis with mof. crrt with cytosorb was immediately started. on day after onset (dao ) an acs with a new organ failure (lung) showed up. open abdomen (oa) and tac with mesh-mediated/npwt got a temporary improvement. clinical findings: on dao (oa ), reopening of the mesh entailed a sudden fascial retraction of cm. a new larger mesh was positioned. on dao (oa ) the fascial defect measured both on ct slices and in or was cm. provision of a longterm oa was done. therapy and progressions: a new fascial traction device (fas-ciotensÒ, germany) was positioned on dao (oa ), with a continuous traction weight of - kg. revision was scheduled any - days, according to clinical needs, including combined anterior and retroperitoneal necrosectomy. progressive traction allowed to get a cm fascial gap under traction on dao (oa ). anterior cst was thus performed and fascia primarily closed. completion of necrosectomy was done through the bilateral lumbar incisions and npwt. comments: early fascial closure is a goal in oa. mesh-mediated traction/npwt is the most effective strategy, but primary fascial closure is sometimes impossible. the duration of oa is a key point. fasciotensÒ allowed to overcome the failure of mesh-mediated option and avoided fascia retraction in a longterm oa. it was quickly managed by the nurse staff, allowed a easier access to the abdomen and a proper positioning of the protective film. its effectiveness in this demanding case makes it an interesting option for shortening fascial closure in septic oa too. background: small bowel obstruction (sbo) caused by intra-abdominal adhesions is one of the main surgical emergencies. in most of the time, adhesions are created by previous abdominal surgeries. without any severity signs, the medical treatment is first proposed to avoid superfluous surgery. we noticed that the failure of medical treatment is frequently seen in patients previously operated of appendicectomy. the purpose of this study is to determine the eventual relation between a previous appendicectomy and failure of medical treatment in sbo. methods: we conducted a retrospective data collection using a diagnostic code for bowel obstruction in patients who have consulted in emergency from . . to . . at the salengro university hospital in lille. using the administrative database, patients were identified. we excluded all children, patients with wrong diagnosis and those whose outcome was not known. finally, patients with sbo on intra-abdominal adhesions confirmed on ct-scan were reviewed. the patients were separated in two groups. the group (g ) included patients who required surgical management during hospitalization ( patients) and group (g ) patients with successful medical treatment ( patients). we compared the rate of previous appendectomy in these two groups using a pearson's chi-squared test. in a second step, we tried to find out if there were others factor associated with failure of medical management. results: there was significant difference between the two groups with a higher rate of appendectomy in the surgical management group g (p = . ). this difference was even more pronounced if appendectomy was the only surgical history. in the subgroup analysis of patients with previous appendicectomy, the laparoscopic approach or laparotomy didn't influence the outcome of the management of the sbo. conclusion: this study shows the difference between the two groups of sbo, with more surgery sanction in the group of patients previously operated of appendicectomy. perhaps because this surgery involves the very distal part of the small bowel and decrease the efficiency of a proximal nasogastric aspiration. these results should not change the initial management of sbo by medical treatment in absence of severity signs. however, knowing this data, we have to consider that a history of appendicectomy is a risk factor of failure of medical treatment in this situation. introduction: diaphragmatic injuries are a rare consequence of closed thoraco-abdominal trauma that could be difficult to detect due to paucity of clinical signs and frequent erroneous interpretation of radiological images. the overall incidence of diaphragmatic injury is , - , % in blunt trauma. if the injury is not recognized it could lead to considerable risk of late morbidity and mortality. this study reviews our years experience in the management of this patients. material and methods: a retrospective review of trauma registry of our tertiary referral centre was performed. preoperative, intraoperative and postoperative data were analysed to assess determinants of mortality, morbidity and effect of therapeutic delay by univariate analysis models. penetrating injuries were excluded from the study. results: over years patients with diaphragmatic injury due to blunt trauma were identified: had a simple laceration of the diaphragm without hernia, had acute and chronic diaphragmatic hernia. the mean patient age was years (range -- years). overall mortality was %. the site of injury was the left diaphragm in cases, the right diaphragm in cases and bilateral in case.the hernia content was stomach ( ), colon ( ), spleen ( ), liver ( ), omentum ( ) and multiorgan ( ). all acute patients were managed with primary suture repair via laparotomy except for two patients that required additional thoracotomy; chronic patients were treated laparoscopically in cases ( , %), in which a synthetic or a biosynthetic mesh was used to reinforce the suture. higher morbidity and mortality was seen in multiple associated injuries, head injuries associated, right diaprhagm injury, age [ years and treatment delay [ h. conclusions: delayed treatment of diaphragmatic injuries could be dramatic: it is importnat not to misinterpreter the radiological findings and to reassess the patient mantaining a high level of suspicion of these injuries. trauma opposing vector forces resulting in distal avulsion of internal oblique muscle: a case report p. spada , p. fransvea , g. altieri , m. di grezia , v. cozza , g. pepe , a. la greca , g. sganga fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy case history: abdominal muscle injuries after blunt trauma are rare but increasingly recognized. here we report a case of blunt trauma resulting in a complete disinsertion of the distal part of the internal oblique muscle. case report: y.o. male, was involved in a roll over motor vehicle accident. primary survey was carried out according to atlsÒ approach with good response. he had a seatbelt sign. according to the dynamic of the trauma he underwent a ct. diagnosis: a ce-mdct revealed complete disinsertion of the oblique muscles of the left abdomen from their iliac insertion, with herniation of adipose tissue and hematoma of the soft tissues without active blushing. no other traumatic injuries were identified. therapy progressions: a conservative treatment of the hematoma of the left abdominal wall was adopted. the patients was then ischarged from hospital after days. no late complications were observed. comments: the overall incidence in all traumatic admission is . - . %. a deep knowledge of vector force involved in trauma and their influence in the specific anatomical changes of the abdominal wall muscle can lead to suspicious of this rare injuries even if no other lesion are detected. in our opinion this trauma case is useful in reminding us to look for it because the radiologist or a no well experienced trauma surgeon may miss it fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy introduction: the best and correct management of patients with open abdomen (oa) is nowadays still unclear. our algorithm consists of using an intra abdominal negative pressure wound therapy device plus an early medial mesh mediated fascia traction (''step by step'' procedure). the aim of this study was to asses outcomes of this algorithm technique based on patient conditions and open abdomen technique performed. materials and methods: we performed a retrospective analysis of patients treated with open abdomen technique from / / to the / / . variables taken into account were: initial diagnosis, open abdomen technique used, number of surgical interventions, abdominal wall closure technique, length of stay in the icu, inhospital morbidity and mortality rates. we collected also data on the post-operative development of incisional hernias and entero-atmospheric fistula. results: / of open abdomen were done after trauma. in the remaining cases open abdomen was done for non-traumatic disease. patients have been treated following our algorithm (with negative pressure wound therapy abthera device and step by step approach with medial mesh mediated fascia traction). in this group fascial retraction was significant lower and definitive direct abdominal wall closure rate was statistically higher. conclusion: an early fascia traction mediated with a mesh lead to an earlier fascia closure with a lower need of mesh positioning for definitive closure; the rate of post incisional hernia is similar among the two groups references: case history: a year old male presented in the er with malaise, fatigue and loss of appetite. he was recently hospitalised due to a peritonsillar abscess and during investigations he was first-diagnosed with non-hodgkin lymphoma. his medical and surgical history were otherwise unremarkable. clinical findings: on admission the patient was febrile and tachycardic (hr bpm) but remained hemodynamically stable (bp: / mmhg). clinical examination revealed abdominal distention and rebound tenderness in the right abdomen. investigation/results: blood tests were significant for leukocytosis (wbc: . /ll-neut: %), acute kidney injury (urea: mg/dl, cr: . mg/dl), elevated crp ( mg/l) and ldh ( iu/l), hyponatremia (na: mmol/l) and hypoalbuminemia. chest and abdominal x-rays were non-diagnostic, while abdominal ultrasound showed increased air presence along the medial line. investigations concluded with an abdominal ct scan that revealed pneumoperitoneum, small bowel distention and multiple enlarged mesenteric lymph nodes. diagnosis: the patient was transferred to the or for an explorative laparotomy. he was diagnosed with ileo-cecal intussusception causing bowel ischemia and perforation at the ileocecal valve. enlarged lymph nodes were observed along the mesentery. therapy and progressions: the affected ileus and colon were removed and a subtotal colectomy with end ileostomy was performed. the pathology report confirmed infiltration of the dissected bowel and lymph nodes by lymphoma cells. the patient continued treatment in the icu. he was discharged on the th postoperative day. comments: intussusception is rare in adults and, contrary to children, is highly associated with malignancies. resection without reduction has been advocated-wherever possible-in order to ensure better oncological outcomes. introduction: emergency surgeries are oftenly related to contaminated/infected fields, where the implantation of non reabsorbable meshes for reconstruction of the abdominal wall may not be recomendable. we aim to evaluate the results of polyvinylidenfluoride (pvdf) meshes used for complicated ventral hernia in the acute setting material and methods: retrospective analysis of patients with vh undergoing emergency surgery on which a pvdf mesh was required, in a third level hospital (november -september ). we analyzed early and late postoperative complications and -year recurrence rates. association between grade of contamination, mesh placement and infectious complications and recurrences was investigated using binary and multiple regression. results: we collected patients with a mean age of '' years, mean bmi of '' kg/m and mean cedar index of '' . '' % of patients had a grade - ventral hernia according to rosen''s index. concomitant procedures included al least one organ resection in '' % of surgeries and previous contamined mesh explantation in '' %. a pvdf mesh was placed using an intraperitoneal onlay mesh (ipom) technique in '' % of cases and an interposition location in '' %. readmission rate was '' %, one-month recurrence '' % and recurrence after a year '' %. overall mortality rate was . %. risk of recurrence was related with patients with a rosen score over (p \ . ) and also with postoperative ssi (p = . ). higher recurrence rates were not found regarding the pdvf meshes placement. postoperative seroma and hematoma rates were '' % and '' %. enteroatmospheric fistula rate was '' %. conclusions: pvdf prosthesis seems to be an useful material for complicated ventral hernia repair, specially in the acute setting, showing similar recurrence and infectious complication (fistula, chronic mesh infection, surgical site infection) rates with regard to different prosthesis used in the literature. operative vs non-operative management in liver trauma patients in a uk major trauma centre conclusions: the airs can predict the histologic severity and the intra operative findings in patients with a high clinical suspicion of aa. airs could be useful to reduce negative appendectomy and predict the postoperative stay to evaluate the deformity progression in spine injuries (dorsal, dorsolumbar, lumbar) managed by internal fixation. introduction: there continues to be controversy surrounding the management of thoracolumbar burst fractures. numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. material and methods: patients with spinal injury (dorsal, dorsolumbar, lumbar) were included. all patients had dorsal, dorsolumbar, lumbar spine injuries managed with posterior short segment pedicle screw fixation and were followed up for at least one year after surgery. preoperative, post operative and follow up lateral radiographs were examined for cobb''s angle, anterior wedge compression angle and upper and lower adjacent intervertebral disc heights anteriorly, middle and posteriorly. results: at final follow up, the mean improvement in cobb''s angle post operatively was . °. the mean loss of correction of cobb''s angle was . °with sd of . °compared to post operative. the mean improvement in anterior wedge compression angle was . °post operatively. the mean loss of reduction in anterior wedge compression angle was . °with sd of . °. the increase in cobb''s angle was statically significant (r = . , p = . ) with the loss of reduction of anterior wedge compression angle at follow up and loss in intervetebral disc height at upper intervetebral disc anteriorly only(r = . , p = . ). the mean period at which sitting and standing was initiated was . months and . months respectively and mean periods for which brace was used was . months. conclusions: pedicle screw fixation is good but related to loss in reduction of anterior wedge compression angle and decrease in upper intervertebral disc height anteriorly. references: p. l. sanderson:short segment fixation of thoracolumbar burst fractures without fusion. introduction: with the newly implemented ao upper cervical spine classification system a modern, pragmatic system has been established. to what extent the simplification is helpful or whether an adjustment of the new ao classification may be discussed, forms the question of this work. material and methods: retrospective analysis of upper cervical spine injuries with ct/mri diagnostics presented to trauma surgeons with several years' experience to do classification and suggest treatment. results: the classification according to the known systems showed a relatively good agreement in the exact classification and therapy. the classification according to the new ao upper cervical spine was simple and consistent but revealed different treatment recommendations for two subtypes (iii type a and iii type b). conclusions: the new ao upper cervical spine classification system leads to a simplification. uncertainties remain with the most frequent fractures on the upper cervical spine, the c fractures. these will be managed under iii type a. however, just these injuries require completely different treatment concepts. further adaptation is required for type iii b because there uncertainties regarding the therapy also remain. case history: a -year-old woman, on treatment with acenocoumarol due to atrial fibrillation, and interatrial communication, suffered a compression fracture of the vertebrae l to l after a lowenergy trauma. due to poor pain control, she underwent a percutaneous transpedicular kyphoplasty, with no intraoperative complications. clinical findings: during the immediate postoperative period, she developed dysarthria and claudication of barré in her right upper limb. investigation/results: an angio-ct scan was performed, showing endovascular material in the left middle cerebral artery (mca) and within the lungs, compatible with cement emboli. mri showed cortico-subcortical ischemic areas in mca territory. cement-embolism stroke after percutaneous kyphoplasty therapy and progressions: conservative treatment was chosen due to the high number of emboli and the favorable evolution of the patient, with resolution of the neurologic symptoms in h without sequelae. days later, she suffered a transient ischemic attack, with no changes in the ct-scan compared to the previous images, which also solved with no residual deficits. one month after this episode, the patient died due to a spontaneous cerebellar hemorrhage related to acenocoumarol overdose. comments: kyphoplasty is a safe technique performed to treat vertebral compression fractures in elderly patients, with good clinical results and a low complication rate. its main complications are related to the leakage of cement from the vertebral body, usually well tolerated. other complications are exceptional, such as cerebral strokes, cardiac perforation, or death. the present case, although infrequent, shows us the need to assess the risk-benefit balance when operating fragile patients, as life-threatening complications may happen in these procedures. references: . marden fa, putman cm. cement-embolic stroke associated with vertebroplasty. ajnr am j neuroradiol. nov; ( ): - . survival rate and application number of total hip arthroplasty in patients with femoral neck fracture: an analysis of clinical studies and national arthroplasty registers g. hauer , a. heri , s. klim , p. puchwein , a. leithner , p. sadoghi medical university of graz, department of orthopaedics and trauma, graz, austria introduction: total hip arthroplasty (tha) is an increasingly popular treatment option for fractured neck of femur (nof) [ , ] . the aim of this study was to systematically review all literature on primary tha after fractured nof to calculate an overall revision rate. furthermore, we wanted to compare primary tha implantations after fractured nof between different countries in terms of tha number per inhabitant. material and methods: all clinical studies on tha for femoral neck fractures between and were reviewed and evaluated with a special interest on revision rate. revision rate was calculated as ''revision per component years'' [ ] . tha registers were compared between different countries with respect to the number of primary implantations per inhabitant. results: twenty-two studies showed a mean revision rate of . % after ten years. we identified eight arthroplasty registers that revealed an annual average incidence of tha for fractured nof of . per , inhabitants (table ) . conclusions: we found similar annual numbers of thas for fractured nof per inhabitant across countries. revision rates in clinical studies are higher compared to registry data [ , , ] . the results of this analysis can be used to rank present and future national tha numbers within an international context. early clinical predictors of pneumonia in patients with acute spinal cord injury without bone injury: a retrospective study t. sakamoto , s. kanezaki , n. notani oita university, oita, japan introduction: pneumonia is still significant complication that associates with mortality and duration of hospitalization in patient with acute spinal cord injury without bone injury (sciwobi). the purpose of this retrospective study is to clarify early clinical predictors of pneumonia in patients with sciwobi. material and methods: we reviewed the medical records of patients with sciwobi who admitted between january and november . spearman's rank-correlation coefficient was used to test the relationship between each parameter. multiple logistic regression analysis was performed to determine the factors that influenced pneumonic morbidity. results: a total of patients with acute sciwobi, who were evaluated for neurological impairment within h after injury, were reviewed. pneumonia occurred in patients ( %), seven patients injured at c and four at c . according to spearman's rank method, asia motor score, beginning period of nutrition, ventilator use, neurological level of injury (nli) ] c , low prognostic nutritional index (pni) were correlated with onset of pneumonia. logistic regression found ventilator use to be most predictive of pneumonia (odds ratio [or] = . , % confidence interval [ci] . - ), followed by nli ] c (or . , % ci . - . ), beginning period of nutrition (or . , % ci . - . ), pni (or . , % ci . - . ). conclusions: in addition nli, low pni increases the risk of pneumonia. we consider that improving nutritional status, especially early initiation of enteral nutrition, decrease the incidence of pneumonia. bicycle-related cervical spine fractures e. helseth , j. ramm-pettersen , s. f. eng , i. naess , m. mejlaender-evjensvold , h. linnerud oslo university hospital, neurosurgery, oslo, norway introduction: the incidence of traumatic cervical spine fractures (cs-fx) in the norwegian population is / , /year, and % of these injuries are bicycle-related ( , ) . materials and methods: prospective cohort study of all bicyclerelated cs-fx in the south-east norwegian population ( . million) in the time period - . the data were retrieved from our quality control database for traumatic cs-fx in south-east norway. in the database all cs-fx patients (c (occipital condyle) to c /th ) are prospectively registered. results: during the four-year study period patients with bicyclerelated cs-fx were registered, ( %) were males, and mean age was years (range - ). the cs-fx was located in the upper cervical segment (c -c ) in ( %) patients, lower cervical segment (c -th ) in ( %), and at both segments in ( %). the most common fx subtype was c -fx. spinal cord injury secondary to cs-fx was registered in patients ( %). fracture stabilization was achieved with open surgery in ( %), external immobilization with a stiff collar alone in ( %,) and without treatment in ( %). conclusions: severe bicycle-related cervical spine injuries are not uncommon. the increasing political desire to move commuting from motorized vehicles to bicycles warrants a heightened focus on road safety. introduction: the need for cervical immobilization is predicted by the atls, the standard of care in trauma since , because cervical trauma is a important cause of disability. however, its discontinuation was linked to x-rays, a fact that has been changed thanks to the development of two algorithms that assess the severity of cervical trauma: the canadian c-spine rule (ccr) and the national emergency x-radigraphy utilization study (nexus). material and methods: this study aims to compare the reduction values in the number of ct scans required after the application of both algorithms in a level- trauma center and to verify the degree of adherence of residents in the use of each. cohort study with randomized application by residents of the algorithms in all patients suffering from blunt trauma with cervical collars who were admitted from august to october . the conducts had their frequencies analyzed to obtain an inference about the efficacy of each method in the abstention of x-rays and case resolution, in addition to verifying if the indicated conduct was followed by the resident, inferring on the confidence in the algorithm. results: cases were evaluated during this period, of which were by the ccr algorithm and by the nexus. the indication rate for ccr imaging was . % and nexus was . %, showing no statistical difference between them (p = , ; ci = %). in the evaluation of the effective conduct, which evaluated the reliability of the algorithm, there was no disagreement between them (p [ , ; ci = %). conclusions: neither method demonstrated superiority to the other in reducing the indication of imaging exams and its uses had equal adherence by resident physicians. panacek case history: a year old lady presented with severe neck pain following a fall and cervical hyper-extension injury. she had previously undergone anterior cervical discectomy and fusion at c / with placement of artificial interbody bone graft. postoperatively, the patient reported an excellent clinical outcome and later imaging confirmed interbody fusion. clinical findings: on examination, the patient was neurologically intact but reported severe mid-cervical neck pain with reduced range of movement. investigation/results: imaging included ct and mri of the whole spine diagnosis: imaging revealed an unstable hyper-extension injury of the cervical spine. a fracture extended through the caudal end of the fused graft-vertebral interface at c / with disruption of the posterior elements. therapy and progressions: given the severity of the injury surgery was recommended. the patient underwent uneventful c -t posterior instrumentation and fusion with excellent outcome (follow up two years). comments: this is the first report of a cervical spine fracture through the site of an anterior cervical discectomy and fusion. it is hypothesised that the fused cervical segment resulted in increased stress at the fused caudal graft-vertebral interface during hyper-extension, this combined with reduced tensile strength at the graft-vertebral interface resulted in this unusual transverse fracture pattern. the clinician should be aware that patients presenting with cervical spine trauma in the context of previous cervical spine surgery are prone to greater mechanical forces. there should be a high index of suspicion for serious injury prompting thorough assessment and investigation. pr s -screw-fixation: computer aided study prevent unguided missile r. krassnig , w. pichler , e. viertler , a. schwarz , r. wildburger , g. hohenberger auva rehabilitation clinic tobelbad, tobelbad, austria, boldin und pichler og, graz, austria, medical university graz, graz, austria, auva unfallkrankenhaus, graz, austria, medical university graz, orthopaedics and trauma, graz, austria introduction: transiliosacral screw fixation of unstable dorsal pelvic ring fractures is not much present neither in literature nor in practice. in cause of the complex anatomy and the varying narrow safe bony corridors its a demanding procedure. limited information is available on optimal placement and the geometry of safe zones for screw insertion in the pelvis. material and methods: d-reconstructions of consecutive ct scans of polytraumatic injured patients ( female, male) were the basis to insert two virtual cad bolts (representing screws) into the first two sacral segments as performing during screw fixation. results: in s the narrowest point was reached after a mean of . mm respectively . mm, depending on the selected way of measurement. for s the mean distance to the tricky constriction area amounted to . mm, respectively . mm. the average height in s measured . mm and the average width . mm. according, the average height for s was . mm and the average width . mm. the measurement results didn't show a significant difference between male and female pelvis bones for any distance of interest. conclusions: an optimal screw position is very important, because in the areas of bony narrowing are the exit points of the sacral nerves, which exit through the foramina anteriorly and posteriorly. damage to this nerve structures can cause severe long-term consequences such as numbness or paralysis. knowledge of predefined distances may aid in preoperative planning, decrease operative and radiation times and may prevent unguided missiles. clinical findings: there were absent breath sounds on the right side of the thorax, ultrasound showed an extensive pleural effusion. a chest tube was inserted and l of bloody-milky fluid was drained. investigation/results: ct scan showed fractured c -c and th -th vertebral bodies, fractured lateral osteophytes of th - and probable injury of the thoracic duct at th - level. pleural effusion analysis showed raised cholesterol and triglyceride levels. diagnosis: traumatic chylothorax; fractures th -th , th -th , c -c therapy and progressions: patient was kept on ventilatory support for days. primarily she was treated with total parenteral nutrition followed by no fat and hypolipidemic diet. the chest tube was removed after days. she was discharged in stable condition the following day. at the month check-up she was stable and eupnoic. comments: traumatic chylothorax caused by blunt chest trauma is extremely rare. there are hypotheses that injuries to the thoracic duct are caused by hyperextension of the spine or by increased thoracic/ abdominal pressure (seat-belt injuries). in our case, chylothorax probably resulted from fractured lateral osteophytes. patients are usually successfully treated with pleural drainage and total parenteral nutrition. if there is no improvement after weeks or if drainage exceeds . l/day or l/day for more than days, thoracic duct ligation should be considered. conservative treatment resulting in t-l or lumbar kyphosis can worsen the quality of life of the patient whereas traditional open surgery may be an overtreatment in some cases, considering blood loss, possible complications, hospital stay and delayed functional recovery. in this setting, a good option can be a percutaneous minimally invasive surgery. the advantages of percutaneous pedicle screw fixation are: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter hospital stay and easier implant removal after bone union. limitations such as inability to achieve direct spinal canal decompression can be dealed by combination with open techniques. the objective of this study was to report the results of ppsf on these fractures and the technical problems we had to overcome. methods: patients are included, treated with percutaneous transpedicular fixation and stabilization with minimally invasive technique from december to october . patients were males, females; average age was , years (range from to ). in all cases, system pathfinder-nxt (zimmer) was used. results: most of the patients presented an early post-operative mobilization with amelioration concerning pain and a low complication rate. limitations in mobilization were mainly due to coexistent injuries, polytrauma or non-reversible neurological deficit. conclusion: ppsf is a reliable and safe procedure which does not replace the open technique but adds to treatment options by restoring a good sagittal alignment similar to those reported for open surgery. removal of hard material is advocated after fracture healing to preserve the lumbar spinal mobility and avoid zygapophyseal joint osteoarthritis. critical surgery within the first hour of presentation: is it a feasible intervention for better trauma care outcomes in low and middle income countries? introduction: in low and middle-income countries (lmic) golden hour care concept is almost nonexistence due to resource constraints. in this study, we analyzed one novel concept of critical surgery within the first hour of admission as a possible intervention which could be applied in the existing scenario in these countries without much resource requirement. material and methods: a retrospective analysis of a prospectively maintained data registry under a project named titco (towards improved trauma care outcome) was done. registry data from a level - trauma centre in india were analyzed from october to september . all patients who admitted and underwent critical surgical interventions within the first hour of presentation were analyzed. these patients were divided into two groups depending upon primary presentation or referred from another facility. statistical analysis was done between these two groups to compare the outcome. results: sixty-one ( . %) patients were directly admitted from the site of the incident whereas forty-five ( . %) were transferred from other hospitals for surgical needs. the median time from injury to presentation for primary patients was min with interquartile range (iqr) of . in the referred patient median time gap between the injury to our center (not referring center) was min with iqr of . this difference was statistically significant. major outcome indicators in the form of median icu and total stay, as well as mortality, were not significantly different conclusions: proposed concept might be a useful hospital-based intervention in existing trauma system in lmic to improve the outcome of injured patients along with improving prehospital services. oslo university hospital, ullevål, orthopedic department, oslo, norway, extrastiftelsen, oslo, norway introduction: it is well-known that physical activity is good for us. although the skeletal muscle is the main organ which is directly affected, exercise affects the whole body. the mechanisms responsible for these beneficial effects are gradually becoming known to us through extensive research. this might make it easier for physicians to prescribe exercise as a therapy equally and even more beneficial than drugs regarding effect and risk profile. the aim of this thesis was to review the current literature on the molecular mechanisms of exercise-induced health benefits. material and methods: a search in medline and embase resulted in articles. they were sorted by title and abstract, then by reading the full text. relevant articles from the reference-lists were included. sources were found outside of the search. results: when we exercise, the skeletal muscle is subjected to several mechanical and chemical stimuli, which in turn activate a set of kinases and phosphatases. these are molecules that regulate transcription-factors and co-activators, and this leads to adaption of the muscle-cells. i addition, the muscle secretes a number of proteins called myokines, which conduct the effect of exercise to other organs and tissues. some lead to increased cerebral neuroplasticity, hypertrophy and angiogenesis (bdnf, vegf and igf- ). several interleukins have also been identified as myokines, and they mediate an anti-inflammatory effect which is favorable in the prevention and management of conditions like atherosclerosis and type diabetes. lastly, we found that exercise leads to epigenetic changes, altering the genetic expression in several types of tissues. some studies suggest that the epigenome is affected by exercise even before we are born, giving babies born to physically active mothers a favorable epigenetic expression. conclusions: we should use this knowledge to support the implementation of physical activity in treatment and preventive health care. impact on undertriage and mortality after changing from a twotiered to one-tiered trauma team activation protocol costs. prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increase rtw rates. evaluation of long-term follow-up and consequences of gunshot and stab wounds in a french civilian population introduction: the data concerning long-temr follow-up of patients and consequences of gunshot wound (gsw) and stab wound (sw) are almost inexistent in the literature. in finland, a study showed that % of patients with trunk wounds died secondarily from alcohol-related or violent problems [ ] , highlighting the secondary importance of long-term care for these patients. the main objective of our study was to analyze the hospital and posthospital follow-up of patients with gsw or sw and to evaluate late complications and the consequences of these traumas. material and methods: from january to january , patients were hospitalized for gsw or sw management in laveran military hospital. hospital data were collected via informatic patient file and post-hospital data via a telephone questionnaire with the general physician (gp). results: median hospital follow-up was days . seventy-six patients had a follow-up visit with their gp ( %). median follow-up was mois . twenty-four patients were totally lost to follow-up ( . %). global follow-up identified patients with longterm consequences ( . %), psychiatrics and organics. seventeen cases of recurrence were found ( . %). high iss, age, gsw and gp identified in patient medical file were significantly linked to long-term consequences occurrence. conclusion: this study showed a high number of long-term consequences occurrence among patients with gsw or sw. however, the extra-hospital follow-up seems insufficient. it is therefore imperative to strengthen the compliance and adherence to the care network of these patients. awareness and involvement of medical, paramedical teams and gp role seems essential to screening and management of these consequences. introduction: focused assessment with sonography for trauma(-fast) is an effective tool for assessments of severely injured patients, especially in the settings of helicopter emergency medical service(hems) because of limited devices and time. the objective of this study is to investigate accuracy of trauma ultrasound in helicopter emergency service compared with enhanced ct scan. material and methods: we investigated the trauma patients in years which was demonstrated fast and delivered to the advanced critical care center in gifu university by hems. accuracy of the fast was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. results: patients were included in this criteria. there were and patients in which we found fluids in thoracic or abdominal cavity by enhanced ct scans and ultrasounds in hems, respectively. sensitivity and specificity, positive predictive value, negative predictive value, accuracy were . , . , . , . , . . if we limited the data for abdominal fluids, each data were . , . , . , . , . . in the patients of negative fast with positive ct, no patient died due to hemorrhage in thoracic or abdominal cavity. conclusions: it has been reported that sensitivity of fast in hems was lower compared with in er. in the settings of prehospital trauma care, advantages of portable ultrasound could be limited because of peculiar environments. and also, the thoracic or abdominal fluids could increase with time by organ injuries and it causes fast negative in acute phases.in this series, we could not find cases which has possibility of death because of negative fast and might influence the treatment. repeated fast or careful assessment of patients based on the other findings could be beneficial. references: the sensitivity of fast in hems was low and demonstrating fast for several times could be effective to detect the thoracic or abdominal hemorrhage. pre-hospital trauma care in switzerland and germany: do they speak the same language? los angeles county ? usc medical center, department of surgery, divison of acute care surgery and surgical critical care, los angeles, united states introduction: field amputation can be life-saving for entrapped patients requiring surgical extrication. under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. the aim of this study was to determine the optimal saw for a field amputation. material and methods: this was a prospective cadaver-based study. four saws (gigli, hand pruning, electric oscillating and reciprocating) were tested in human cadavers. each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula). the time required for each saw to cut through the bone, the number of attempts, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. univariate analysis (fisher's exact and kruskal-wallis or mann-whitney u-test) was used to compare the outcomes between the different saws. results: the fastest saw was the reciprocating followed by oscillating ( . [ . - . ] sec vs . [ . - . ] sec, p = . ). the number of attempts required to amputate ( . [ . - . ] , p = . ) and the amount of slippage ( . [ . - . ], p = . ) were highest with the pruning saw. the reciprocating saw had the worst proximal bone cut quality ( % poor, p = . ) and the largest blood splatter ( . [ - ] , p = . ). the physical space required to perform an amputation ranged from cm with the oscillating to cm with the reciprocating saw. overall, the oscillating saw outperformed the others in number of attempts, slippage and quality of bone cut and physical space requirements, and was the second fastest ( table ) . conclusions: the speed, precision, safety, space required, as well as the highly adjustable blade in the oscillating saw make it ideal for a field amputation. a gigli saw is an excellent backup for when electrical tools cannot be used or fail. impact of air medical transport on the survival of major trauma patients in thailand e. surakarn , w. siriwanitchaphan bangkok hospital headquarters, bangkok trauma center, bangkok, thailand introduction: air medical transport is an alternative mode of interfacility transfer for injured patients who required a higher level of trauma care in thailand. this study assessed the impact of air medical transport on the survival of major trauma patients transferred from local hospitals to a tertiary care hospital. material and methods: trauma registry of - was reviewed. major trauma patients transferred by air ambulance were identified. injury severity score (iss), predicted mortality and actual survival to hospital discharge were studied and compared between two subgroups, the seriously injured patients (iss - ) and the severely injured patients (iss [ ) . the predicted mortality was calculated from the probability of survival (ps) of trauma and injury severity score (triss). results: there were major trauma patients (iss [ ) transferred by air ambulance in five years period. patients were severely injured (median iss = ), and patients were seriously injured (median iss = ). the range of flight time was - min. the overall survival rate was . %. the predicted mortality in the severely injured group was cases ( . %), but the actual mortality was nine ( . %), . % lower than predicted mortality. the predicted mortality in the seriously injured group was one case ( . %), while the actual number was two ( . %). the eleven deaths in this study were eight cases of severe traumatic brain injury(tbi) patients, two cases of massive bleeding with subsequent multi-organ failure and one drowning. conclusions: air medical transport significantly improved the survival of severely injured patients who need higher level of trauma care. severe tbi and the presence of multi-organ failure associated with unfavorable outcomes. however, a detailed analysis of the trends and epidemiology of rtis affecting the most vulnerable children in qatar, under years of age, has not been conducted. this study's primary objective of is to describe the epidemiology of rtis and deaths in young pediatric patients in qatar. material and methods: data, for all young pediatric [under years] victims of rti''s and rti deaths from january , , through december , , from the trauma registry of the hamad trauma center [htc], the national level trauma referral center of qatar, was analyzed. this data was correlated and compared with data from the hamad general hospital mortuary and vital statistics data from the qatar ministry of development planning and statistics, the vital statistics annual bulletin, for the years - . results: the htc attended to patients, under years, with severe rtis and in-hospital rti deaths were reported during the study period. males made up . % of the injured and % of fatalities.the average age of the injured was years and for fatalities was it was . years. the rti incidence rate per , for both sexes, under years, has been unchanged ( in and in ) . the road mortality rate, per , , has decreased significantly, from . in to . in . since , the proportion of pre-hospital deaths has been increasing, - %, and the in-hospital death rates has been reduced to %. conclusions: rapid improvements in pre and in-hospital post-crash care in qatar have resulted in marked reductions in in-hospital deaths for young children with rtis. the emergence of pre-hospital road deaths of under ''s must be made a priority for road safety in qatar. the implementation of proven prevention programsshould be fast tracked in order to directly address this issue. introduction: despite improving survival of patients in prehospital traumatic cardiac arrest (tca), initiation and/or discontinuation of resuscitation of tca patients remains a subject of debate among prehospital emergency medical service providers. the aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with tca. methods: twenty-five semi-structured interviews were conducted with experienced ambulance nurses, hems nurses and hems physicians individually, followed by a focus group discussion. participants had to be currently active in prehospital medicine in the netherlands. interviews were encoded for analysis using atlas.ti. using qualitative analysis, different themes around decision making in tca were identified. results: the causes of bleeding were grouped into several categories.the most frequent cause with cases in a row is attributed to diverticular bleeding,other causes of bleeding were angiodysplasia,post polypectomy bleeding,gist tumor,rectal ulcers and inflammatory disease.no case presented mortal or serious complications,secondary to the procedure. only cases presented a mild complication: focal mucosal ischemia of the embolized intestinal segment that was resolved with conservative treatment.lesions in charge of bleeding in those cases in which the angiographic treatment failed,were:ulcer in cases,a case of bleeding after endoscopic polypectomy, a case of diverticular bleeding and bleeding secondary to a coagulation disorder.among these patients, the definitive treatment was the following: -a second angiographic treatment was effective in the case of bleeding due to coagulation disorder. -a case of self-limited bleeding. -surgical treatment was the definitive treatment in both cases of bleeding in the context of and patient with bleeding after polypectomy. we have not observed a significant relationship neither the type of lesion or its location with the probability of failure of the angiographic treatment. nor do we observe a significant relationship between the type of material used for embolization and the risk of treatment failure. comments: our data show that angioembolization is an effective and safe technique to treatment lgi bleeding. references: clin endosc . endoscopic therapy for acute diverticular bleeding introduction: the use of resuscitative endovascular balloon occlusion of the aorta (reboa) as adjunct for temporary hemorrhage control in patients with major torso hemorrhage is increasing. specifications and characteristics of available aortic occlusion balloons (aob) are diverse. in order to minimize the risk of failure and complications it is important to choose a device that fits the requirements per medical situation. the aim of this study is to provide guidance in the choice of an aob in a specific situation. material and methods: aob were assessed for characteristics and different properties of each are outlined. the bending stiffness was measured with a three-point bending device. results: although all aob tested are small caliber devices ranging from (er-reboa tm ) to french (codaÒ ), some need large bore access sheaths up to french (fogarty Ò and lemaitre tm ) or even insertion via surgical cut-down (equalizer tm ). the bending stiffness of the aob varied from . n/mm (± . sd) with the codaÒ to . n/mm (± . sd) with the russian prototype. guidewire-free devices are generally stiffer than over-thewire catheters. the tokai rescue balloon tm showed kinking of the shaft at low bending pressures. the er-reboa tm , fogarty Ò , lemaitre tm , reboa balloon Ò , and rescue balloon tm are the only catheters with external length marks to assist blind positioning. the only aob using a non-compliant balloon is the reboa balloon Ò . conclusions: specifications of available aob are diverse. in resource-limited settings, reboa should be performed with a rather stiff device that can be placed without wire and fluoroscopy, such as the er-reboa tm , fogarty Ò , and lemaitre tm . of these aob, the er-reboa tm is the only catheter compatible with a small french sheath. use of non-compliant balloons without real-time fluoroscopy is not advised given the potential risk of aortic rupture. when fluoroscopy is available, a guidewire can be considered. case history: year old male patient presenting with an initially uncomplicated pertrochanteric fracture, treated by an intramedullary nailing system (figs. and ) . days after the operation and mobilization without any adverse events the patient was readmitted. clinical findings: massive swelling, hematoma and pain. investigation/results: sudden fall of hb values down to , g/dl, ct scans showed the lesser trochanter located directly to the deeper femoral artery after mobilization (fig. ) . diagnosis: perforation of the deep femoral artery and several veins by the dislocated lesser trochanter therapy and progressions: blood transfusion, intraoperative cardiopulmonary resuscitation, several revision surgeries to stop the bleeding by oversewing the deep femoral artery and ligation of the veins, removal of the lesser trochanter fragment (fig. ) . admission to intensive care unit. subsequent plastic coverage. comments: according to literature, bleeding complications and injuries of the deep femoral artery can occur even several days after an initially uncomplicated pertrochanteric hip fracture. besides acute life-threatening bleeding, false aneurysm can occur ( ) ( ) ( ) . even if those late complications are very rare, the consequence for the patient can be devastating. these rare cases show the clear obligation to a thorough follow up treatment and regularly dressing changes. investigation/results: arterial colour doppler of the popliteal artery showed hypoechoeic contents and narrowed lumen. biphasic flow was seen in both popliteal and posterior tibial arteries. diagnosis: popliteal artery injury with delayed repair therapy and progressions: two incision and four compartment fasciotomy was done under regional block the next day which revealed a non contractile posterior compartment. superficial and deep muscles of the posterior compartment had doubtful viability. left distal sfa to infragenicular popliteal artery bypass graft was placed on day post injury. blood flow was established upto the ankle and foot, confirmed on check angio. however, foot drop of the patient persisted. after appearance of a healthy granulation tissue at the wound site ( days), a split thickness skin graft was placed to give coverage with % uptake of the graft. comments: blunt popliteal artery injury has been reported to result in amputation rates of nearly - %.the importance of a detailed vascular examination of a blunt trauma patient is emphasized as a limb can be salvaged if timely intervention is done. in this case even with an unfavourable mess score. case history: a healthy -year-old male, with no history of interest, suffers a high-energy trauma as a water bottle rushes over his left knee. clinical findings: go to the emergency room with pain and functional impotence in the left knee, with its anatomical deformity. knee x-ray pa and l are performed and the distal pulses that are present are taken. ankle-brachial index [ . . closed reduction is performed in emergencies under sedation and control x-ray is requested, aiming at correct reduction. it was decided to keep under observation for - h before discharge from hospital to schedule regulated ligament reconstruction surgery after studying with mri. therapy and progressions: at h of evolution after the accident and after having reduced the dislocation, the patient who has the leg with a temperature equal to the contralateral is reassessed, however, there is no palpable dorsal pedis pulse or posterior tibial palpation in the affected leg. it is decided to urgently request an angiotc and it is objective thrombosis of popliteal artery. vascular surgeon is contacted and emergency surgery is decided. a by-pass is performed with vena safena. diagnosis: traumatic knee dislocation and popliteal artery injury comments: in the st century, complementary tests in diagnosis are becoming increasingly important. however, in this case we want to management of aseptic tibial nonunion anastasios g. c. reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. can we expect an optimum result? results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion management of tibial non-union using reamed interlocking intramedullary nailing the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre pelvic trauma: wses classification and guidelines damage control orthopaedics in unstable pelvic ring injuries references: beuran, m. trauma scores: a review of the literature glasgow coma scale, age, and arterial pressure (mgap): a new simple prehospital triage score to predict mortality in trauma patients. critical care medicine. champion hr. a revision of the trauma score proximal femoral nail antirotation versus gamma nail for intramedullary nailing of unstable trochanteric fractures. a randomised comparative study results of the femur fractures treated with the new selfdynamisable internal fixator (sif) dhs helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures the hypermetabolic response to burn injury and interventions to modify this response racial differences in propranolol enantiomer kinetics following simultaneous i.v. and oral administration propranolol dosing practices in adult burn patients the hypermetabolic response to burn injury and modulation of this response: an overview. wound heal south africa management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience blunt traumatic abdominal wall hernias: a surgeon's dilemma blunt traumatic abdominal wall hernias: associated injuries and optimal timing and method of repair traumatic abdominal wall herniation: case series review and discussion trauma patients with open abdomen: do they differ from others? a single center experience h. fagertun , a. seternes department of circulation and medical imaging, trondheim, norway introduction: treatment with open abdomen is demanding for patients, staff and hospital. a multidisciplinary approach is mandatory. the aim of this study was to compare trauma patients with open abdomen (oa) and patients treated with oa for other reasons, regarding outcome and resources spent. material and methods: retrospective study of patients treated with oa in a tertiary hospital in norway. ten were trauma patients vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy-a systematic review prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique thoracic-abdominal trauma with diaphragm lesions n. vlad , i. streanga , a. morar , i st. spiridon'' hospital iasi. we have analyzed clinical data, trauma mechanism, pathology of the lesion, time trauma-diagnostic, associated lesions, treatment, and follow-up. results: there have been patients ( men, women), mean age . location of diaphragmatic tears has been on the left hemidiaphragm ( cases), on the right hemidiaphragm ( cases), or bilateral ( cases). the trauma mechanism has been blunt ( cases) or penetrant ( cases). all patients had associated visceral lesions and had been operated right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literaturereview traumatic diaphrag-matic ruptures: clinical presentation, diagnosis and surgicalapproach in adults traumatic rupture of the diaphragm: experiencewith patients % ( / ) were aast grade or . in the total group, median age was years, . % were male and . % were blunt injuries. median iss in the nom group was and in the om group. median iss for those with grade or injury was . . % ( / ) underwent nom, compared to . % ( / ) of those with aast grade or . for each mmhg increase in systolic blood pressure, patients with grade or injury were % less likely to have an operation (or . , p = . ) and for each beat increase in heart rate intra-operative grade i was revealed in patients ( , %), grade ii in ( , %), grade iii in ( , %) grade iv in ( , %) and grade v in ( , %). histologic finding of catarral appendicitis was found in ( , %) patients, ( %) had phlegmonous appendicitis and ( , %) had gangrenous appendicitis. the airs difference was statistically significant with histological findings quality of publications regarding the outcome of revision rate after arthroplasty swedish hip arthroplasty register annual report joon yung lee: risk factors for failure of nonoperative treatment for unilateral cervical facet fractures in , patients were included in the trauma registry. median iss was and patients had an iss [ . of these patients / ( %) were undertriaged with a mortality of / ( %). the total mortality in was , % ( / ). i , median age was years for the patients with no tta vs years for those patients who did receive a tta (p \ . ) prognostic factors for medical and productivity costs, and return to work after trauma: a prospective cohort study l results: a total of trauma patients ( % of total study population) responded to at least one follow-up questionnaire. mean medical costs per patient (€ , ) and mean productivity costs per patient (€ , ) varied widely. prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the icu. prognostic factors for rtw were high educational level, male gender, low injury severity swiss and german (pre-)hospital systems, distribution and organisation of trauma centres differ from each other [ , ]. it is unclear if outcome in trauma patients differs as well. therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both german-speaking countries. material and methods: the traumaregister dguÒ (tr-dgu) was between - and - were included if they required icu care or died. trauma pattern trauma care in germany trauma systems in europe practical assessment of different saw types for field amputation: a cadaver-based test study these themes were: factual information (e.g., electrocardiography rhythm)educational programs and future guidelines. references: rosemurgy as, prehospital traumatic cardiac arrest: the cost of futility blunt vertebral vascular injury in trauma patients: atlsÒ recommendations and review of current evidence treatment-relater outcomes fron blunt cerebrovascular injuries. importance of routine follow-up arteriography provided the catheters used for this study. no other support was provided diagnosis: the probe had perforated the ivc wall. therapy and progressions: open repair was performed through a xifopubic laparotomy and the cattel-braasch maneuver to expose the ivc (fig. ). a retroperitoneal hematoma was observed anteriorly to the infrarenal ivc, without active bleeding. the ivc was dissected out sufficiently to permit proximal and distal vascular control (fig. ), the probe was then removed and the laceration on the infrarenal ivc closed with a running suture. the postoperative course was uneventful. comments: to our knowledge this is the first reported case of symptomatic ivc laceration by an ice probe during ca. references: enriquez a. use of intracardiac echocardiography in interventional cardiology complications of catheter ablation for atrial fibrilla iatrogenic percutaneous vascular injuries: clinical, presentation, imaging, and management vascular complications during catheter ablation of cardiac arrhythmias: a comparison between vascular ultrasound guided access and conventional vascular access false aneurysm of the profunda artery resulting from intertrochanteric fracture. a case report profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments. a case report with major thoraco-abdominal vascular injuries (aorta, inferior vena cava and main branches). data on demographic, clinical status and imaging was recorded. descriptive and kaplan meir survival analysis was performed. results: patients were included. median age was years (iqr - ), ( . %) were male. aorta was the most frequently damaged vessel ( , %) the median iss was (iqr - )interventional procedure. overall mortality was %, with % of deaths during the first hour, . % in the first h and . % afterwards. median survival was days (ic - ). we compared survival curves in periods abdominal vascular trauma. trauma surg acute care open history: popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. a thirty one year old pathologies. references: natsuhara, k.m. et al, what is the frequency of vascular injury after knee dislocation knee dislocation and vascular injury: -year experience at a uk major trauma centre and vascular hub can vascular injury be appropriately assessed with physical examination after knee dislocation? introduction: this retrospective cohort study investigated the prevalence of and risk factors for preoperative venous thromboembolism (vte) in patients with a hip fracture and a delay of [ h from injury to surgery. material and methods: this observational study included patients with a hip fracture surgically treated at university hospital. patients underwent indirect multidetector computed tomographic (mdct) venography for preoperative vte detection after admission. overall vte risk and median time from injury to ct scan were calculated. age, sex, fracture type, time from injury to ct scan, body mass index, preinjury mobility score, previous anticoagulation treatment, previous hospitalization for vte, varicose veins, and medical comorbidities were considered potential risk factors. results: the prevalence of preoperative vte was . % ( of patients). the mean time from injury to ct scan was . days. the delay from the time of injury to ct scan averaged . days for patients who developed preoperative vte, compared with . days for patients who had not developed vte. in the adjusted models, female sex, subtrochanteric fracture, pulmonary disease, cancer, previous hospitalization for vte, and varicose veins were risk factors for vte. the final multivariate logistic regression analysis introduction: vertebral compression fractures constitute a large percentage of traumatic injuries of spine. the initial management plays an important role in the final outcomes. the present study aims to study the profile of vertebral injuries in rural & semi urban population & to analyse the role of level two hospitals in initial management of vertebral injuries. material and methods: this study was a retrospective analysis of progressively collected data of patients presenting with vertebral injuries in a level two hospital catering to semi urban & rural population in india. the initial presentation along with the age & sex profile was noted. etiological factors leading to compression fractures were noted. any neurological deficit either at the time of admission or transfer to a tertiary care neurocentre was noted as per asia scale. initial management was carried out in accordance with the atls guidelines. results: a total of out patients admitted with complaints of back pain were diagnosed to have compression fractures of the spine. the mean age was . years. male: female ratio was approx : . the lumbo sacral spine region was the most comply affected region. two patients were incidentally detected to have vertebral fractures as a result of metastatic malignancy. a due note was made regarding patients who had deteriorated during the transfer in terms of neurological deficit & evidence of spinal shock. conclusions: road traffic accidents contribute a significant portion of vertebral trauma . smaller hospitals & general surgeons have an important role to play in terms of initial stabilisation of such patients particularly the ones presenting with neurogenic shock. a good initial management has sigificant bearing on outcomes. analysis of risk factors for tracheostomy in cervical spinal cord injury without bone injury n. notani , s. kanezaki , t. sakamoto , h. tsumura oita university, orthopaedic surgery, yuhu, oita, japan introduction: there are many cases that require tracheostomy in the acute phase of cervical spinal cord injury, and various risk factors have been reported so far. however, there has been no report on cervical spinal cord injury without bone injury. the aim of this study is to evaluate risk factors for tracheostomy in patients with cervical spinal cord injury without bone injury. material and methods: we conducted a retrospective observational study. patients who were treated for cervical spinal cord injury without bone injury in our hospital were divided into groups: tracheostomy (tc) group and no tracheostomy (no tc) group. we compared variables, including age, sex, asia impairment scale (ais), neurological level of injury (nli), injury severity score (iss), vital signs, blood gas analysis, tracheal intubation, chest complication, smoking history between two groups. results: there were patients in tc group, and patients in no tc group. on univariate analysis, there were significant differences in age, ais a, tracheal intubation, nli ] c . on multivariate analysis, nli ] c was an independent predictor of tracheostomy. conclusions: in this study, we demonstrated that nli ] tc could be useful to predict tracheostomy in patients with cervical spinal cord injury without bone injury. case history: many fractures of the articular processes of the cervical spine are associated with displacement and instability, approximately % of all traumatic cervical spine injuries involve isolated fracture of the articular processes non-displaced or minimally displaced. [ ] this case demonstrates a isolated facet fracture of the cervical spine with c radiculapathy treated with minimally invasive spine surgery techniques clinical findings: a -year-old male was admitted to the neurosurgery department due to severe neck pain (vas / ). the pain radiating to the right upper extermity along dermatome c . neck and trunk rotation worsened the pain. investigation/results: furthermore, physical examination revealed hyperaesthesia in the right index finger without muscle weakness. ailments suddenly appeared weeks earlier after getting up in the morning. imaging demonstrated isolated, unilateral fracture of the right superior articular process of c diagnosis: imaging demonstrated isolated, unilateral fracture of the right superior articular process of c therapy and progressions: the patient was treated by microsurgical c decompression and fusion of c - under navigation guidance. intraoperative ct scans were performed to evaluate sufficient bone removal.after the surgery, the neck and upper extremity pain subsided. the patient had returned to his usual job and sport activities. comments: this case illustrates the value of the navigation and intraoperative ct in the evaluation of bony decompression, anatomy and location of implants. navigation minimized iatrogenic injury resulting in reducing postoperative complications like chronic pain, kyphotic deformity and muscular atrophy.introduction: resuscitative endovascular balloon occlusion of aorta (reboa) is a technique initially developed in the military for trauma patients injured in combat . recently, there has been much debate on its role in civilian trauma cases in controlling non-compressible torso haemorrhage (ncth) . this review aims to provide an update on current literature on the outcomes and concerns of this procedure. material and methods: a systematic literature search according to prisma guidelines was performed over the period of january to august across embase, medline and cochrane databases. patient characteristics, mechanism and severity of injury, survival rates and post-reboa complications between survivors and non-survivors were compared. results: a total of studies were included in this review. % and % of the reboa cases were penetrative and blunt cases respectively. the survival rates ranged from to % across the studies. systolic blood pressure (sbp) was significantly elevated post-procedure, from . to . mmhg in the survivor group (p \ . ) and . to . mmhg in the non-survivor group (p = . ). the injury severity score (iss) was lower in the survivor group ( . vs . ; p \ . ) whereas their glasgow coma scale (gcs) was higher ( . vs . ; p = . ). the survivors also had a shorter duration of aortic occlusion ( . vs . min; p = . ). common complications noted following the procedure include renal injury, lower limb ischaemia and thrombosis. conclusions: pre-reboa sbp, iss, gcs and duration of aortic occlusion were found to be associated with survival. complications directly due to the procedure were difficult to ascertain. a prospective study in a multiple trauma centre is needed for further evaluation of the indications, feasibility and complications involved in reboa. references: introduction: traumatic vertebral artery injury (vai) is a wellknown complication of cervical spine injury and often causes posterior circulation stroke. we report preventive effect of acute phase endovascular intervention for traumatic vai. material and methods: all patients with cervical spine injury were surveyed with post-contrast computed tomography for vai. when vai was diagnosed, the affected vertebral artery (va) was occluded with endovascular intervention before spine reduction and fixation. brain ischemic lesion was evaluated before and after the treatment. results: forty-one patients with vai associated with cervical spine injury underwent endovascular intervention. the affected va was occluded with endovascular coils before cervical spine reduction and fixation in patients, and after treatment in one patient. va stenting was done for another two. six presented new brain infarctions after spine surgery. of these, two had endovascular intervention after spine reduction. out of patients who had endovascular embolization before spine reduction, four had newly developed infarctions after spine surgery, of which two were symptomatic. there were no complications related to the endovascular procedure. conclusions: in conclusion, endovascular embolization for traumatic vai before spine reduction and fixation was found to be effective to prevent symptomatic brain infarction. introduction: the use of drug coating balloons (dcb) in primary or secondary angioplasty for peripheral vascular disease is a new tendency. the use of paclitaxel decelerates the growth and hyperplasia of neo-intima tissue which can cause re-stenosis and total occlusion in the spot of pta is a very promising technique in long lasting results of balloon ptas. purpose: to demonstrate our experience and results of the technique of dcb pta with the use of drag coating balloons. material and method: in the period between march and september , patients with sfa lessions were treated with pta with dcb for acute limb ischemia. were males and females. mean age was , y.o (± . ). patients were examined pro operationally and immediate post operationally in abi difference and their post operational follow up included measurement of abi and u/s triplex scan on the st, rd, th and th month(where chronically available) after pta. results: the mean immediate post operative increase of abi was , (± , ). were chronically available the increase of abi remained to , in the months follow up, , in the months and , in the th month follow up while patency of the artery treated remained in all patients. of the patients suffered from acute complications during or short after the pta ( with peripheral embolization and with retroperitoneal hematoma) which were treated immediately and left no consequences. conclusions: the use of dcb for pta in acute ischemia is a quite new, promising technique for maintaining patency of treated arteries for long time post operative period. the medium time results from its use in our clinic seem to be satisfactory. jichi medical university hospital, tochigi, japancase history: a -year-old male hit his neck hard against the fence. thereafter, he experienced difficulty in breathing and severe neck pain. he was brought to the emergency center by ambulance. clinical findings: his vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , spo : ( lo ). significant neck edema and tracheal deviation were noted. inspiratory stridor was not heard with no signs of retracted breathing or subcutaneous emphysema. investigation/results: an enhanced ct scan of the neck revealed tracheal deviation and compression with ruptures of the left thyroid lobe. a large hematoma and arterial extravasation from a branch of the inferior thyroid artery were noted. diagnosis: rupture of the left thyroid lobe and injury around the distal portion of the left inferior thyroid artery. therapy and progressions: after securing the airway by intubation, angiography of the neck was performed; extravasation from a branch of the left inferior thyroid artery was suspected. angioembolization was continued for hemostasis using gelatin sponge. neck edema improved in the intensive care unit. following extubation on the hospital day , the patient was discharged on the th day with no complication. comments: thyroid injury due to blunt neck trauma is rare and surgical intervention such as hemithyroidectomy is generally prescribed. the patient''s condition, in this case, improved by angioembolization without any invasive surgical procedures. catheter procedure may, thus, be effective for hemostasis on thyroid injury after the confirmation of airway placement. introduction: the indication for resuscitative endovascular balloon occlusion of the aorta (reboa) is hemodynamically unstable patients in life-threatening hemorrhage below diaphragm. it was unclear that the difference of indications for reboa affects mortality in trauma.material and methods: this study used data from the japan trauma data bank (jtdb) ( - ), a nationwide trauma registry, to describe the epidemiology of reboa. adult trauma patients used reboa were included. patients were excluded if they had cardiac arrest at the scene or dead on arrival, or had an unsurvivable injury of any region of the body as defined by the abbreviated injury scale. patients were classified by whether patients had indications for reboa. the indications for reboa were defined by indications for hemostasis to intraabdominal, retroperitoneal, pelvic or extremity hemorrhage. the indications were decided by the delphi method with the cooperation of experts in trauma for this study. the contraindications were defined by brain injury needed intervention and hemorrhage above diaphragm. the logistic regression was used to assess the mortality after adjustment for injury severity score. as a sensitivity analysis, a generalized linear mixed model with random effects of a facility was performed. results: of , patients registered in the jtdb, patients underwent reboa. had indications for reboa and underwent reboa without indications. the physiological variables were similar, but the consciousness was worse in the no-indications group. injury severity of brain and chest were higher in the no-indications group. the indications group had . % and the no-indications group had . % contraindications for reboa. the mortality was similar ( . % versus . %, or . , %ci . - . ). a sensitivity analysis showed the same result as the primary analysis (or . , %ci . - . ). introduction: most incident first responders have a primary nonmedical role, but are frequently the only professionals initially at the scene. early hemorrhage control via advanced techniques such as resuscitative endovascular balloon occlusion of the aorta (reboa) can save lives. training first responders these techniques has therefore the potential to improve outcomes. this study evaluates the ability to train quick response team fire fighters (qrt-ff) to gain percutaneous femoral artery access and place a reboa catheter, using a comprehensive theoretical and practical training program. material and methods: six qrt-ff participated in the training. sof medics from a previous training served as control group. a formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and reboa catheter placement. key skills were: ( ) preparation of an endovascular toolkit, ( ) achieving vascular access in the model and ( ) placement and positioning of the reboa catheter. results: qrt-ff had significantly better baseline knowledge of surgical anatomy (p = . ) compared to medics. they also scored significantly better on using endovascular materials (p = . ), performing the procedure without unnecessary attempts (p = . ) and overall technical skills (p = . ). the median time from start to reboa inflation was : min for qrt-ff and : min for medics. procedure times improved in all qrt-ff and of the medics in a second attempt of gaining vascular access and reboa placement. conclusions: our comprehensive theoretical and practical training program proves suitable for percutaneous femoral access and reboa placement training of qrt-ff without prior ultrasound or endovascular experience. repetition reduces procedure times. training in the use of advanced hemorrhage control techniques such as reboa, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in out-of-hospital settings. prytime medical tm devices, inc. provided the reboa access task trainer (ratt) and the catheters used for this study. no other support was provided.the authors declare that there are no conflicts of interest that could inappropriately influence (bias) their work. introduction: angioembolization (ae) has become an important component in the management of bleeding from severe pelvic fractures. timely availablity of ae is required for both, level and trauma centers. the aim of this study was to assess the utilization of this procedure in level and trauma centers and effect on oucomes. material and methods: retrospective, -year ( - ) study using the the american college of surgeons tqip database, including adult patients with isolated severe pelvic facture (ais [ ] [ ] [ ] . patients who underwent laparotomy or preperitoneal packing within h from admission were excluded, operative management for bleeding control between and h was considered as failure. univariate analysis was used to compare patients in level vs centers, multivariate regression analysis was performed to determine factors predictive for mortality and overall complications.results: patients ( in level ; in level centers) met the criteria for inclusion. overall, ( . %) underwent ae, with a trend toward higher ae rate in level centers ( . % vs . %, p = . ). no significant differences were observed in timing and failure rate of ae between the levels. particulary in the ae subgroup there was a significantly lower blood product utilization in the first h in level i centers (prbc . vs . units, p = . ; plasma . vs . units, p = . ). mortality and overall complication rates were similar. table the level of trauma center was not a predictive factor for mortality (or . , p = . ) and overall complications (or . , p = . ). conclusions: in isolated severe pelvic fractures, there was a trend toward higher ae rate and significantly lower utilization of blood products in level centers. there were no significant differences in mortality or complications. the ae subgroup in level centers had a higher blood products use without outcome benefit, suggesting more restrictive transfusion policy may be considered. portal vein thrombosis after distal splenopancreatectomy: successful recanalization using fogarty balloon catheter case history: intraoperative lesion of smv during distal splenopancreatectomy is repaired using peritoneal patch harvested from anterior abdominal wall clinical findings: postoperative increase in serum lactate and d-dimer without signs of peritonitis prompts bedside doppler us showing no blood flood within portal vein (pv) investigation/results: ct angiography is performed suspecting acute mesenteric ischemia, but no abnormal bowel enhancement/ thickness is seen despite complete pv thrombosis. anticoagulation with unfractioned heparin is started, but clinical conditions deteriorate diagnosis: at reintervention, bowel is viable, so the surgeon performs fogarty balloon catheter thrombectomy successfully reestablishing blood flow within pv. no intestinal resection is required therapy and progressions: pv patency is regularly evaluated with us. anticoagulation with low molecular weight heparin is prosecuted for months and then suspended since no recurrence is recorded meanwhile comments: pv thrombosis is uncommon but can follow injury to portal venous axis during surgery. anticoagulation with heparin should be started as soon as the diagnosis is made and maintained for at least - months postoperatively to prevent recurrence. patients with persisting/worsening symptoms - h after initiation of anticoagulation, or those with peritonitis who are poor surgical candidates may be considered for interventional radiological treatment. otherwise, surgical intervention is required and may encompass resection of necrotic bowel. thrombectomy and/or balloon dilation/vascular stent placement may be helpful in recently developed pv thrombosis since risk of recurrence seems to be decreased references: acute mesenteric ischemia: guidelines of the world society of emergency surgery (world j emerg surg ); mesenteric venous thrombosis (j clin exp hepatol ); contemporary management of acute mesenteric ischemia in the endovascular era (vasc endovascular surg ) key: cord- - jatvium authors: han, yuanyuan; jiang, mao; xia, da; he, lichao; lv, xin; liao, xiaohua; meng, jie title: covid- in a patient with long-term use of glucocorticoids: a study of a familial cluster date: - - journal: clin immunol doi: . /j.clim. . sha: doc_id: cord_uid: jatvium clusters of patients with novel coronavirus disease (covid- ) have been successively reported globally. studies show clear person-to-person transmission. the average incubation period is – days, and mostly – days. however, in some patients, this period may be longer. here, we report a familial cluster of covid- where a -year-old woman with long-term use of glucocorticoids did not develop any symptoms within the -day quarantine period but was confirmed with covid- by tested positive of antibody on day after she left wuhan. almost at the same time, her father and sister were diagnosed with covid- . the results suggest that the long-term use of glucocorticoids might cause atypical infections, a long incubation period, and extra transmission of covid- . in december , a novel pneumonia resulting from sars-cov , named coronavirus disease (covid- ), emerged in wuhan [ , ] . due to the high viral contagiousness and transmission during the presymptomatic phase [ , ] , covid- progressively spread throughout china and has since become a global health issue [ ] . in china, wuhan city, the capital of hubei province, became the center of a covid- outbreak [ ] . in an effort to prevent a covid- epidemic, wuhan and its surrounding cities in hubei province were locked down on january rd. however, a tremendous number of patients who were still in their incubation period traveled across china before the lockdown date due to chinese new year, resulting in the widespread transmission of covid- . hunan province is adjacent to hubei province. by march th, , a total of confirmed cases had been reported in hunan, most of which showed familial clustering. the average incubation period for covid- is reported to be to days, and most patients show symptoms within . days [ , ] . to stop the spread of the disease, public health officials in hunan placed those who may have been from wuhan and exposed to covid- under quarantine for days. however, the incubation period may be longer in some patients. here, we report on the last covid- familial cluster in hunan province, which was hospitalized on february . the disease was not confirmed until days after the index patient had returned from wuhan. on february th, a new covid- case was confirmed in the fourth people's hospital of yiyang. in following the patient's epidemiological history, it emerged that this was a familial cluster. afterward, we further collected the clinical data of the patient's family members, including epidemiological history, laboratory examinations, lung cts, pathogen results, treatment course, and recovery. all the clinical data were collected from the fourth people's hospital of yiyang, and all the epidemiological histories of the patients were gathered from the patients themselves; these data were further confirmed by the local centers for disease control. all the information used in this article was approved by the patients. the home quarantine involved in our article was completely implemented according to the announcement released by the national health commission of the people's republic of china (http://www.gov. cn/zhengce/zhengceku/ - / /content_ .htm.accessed march ). influenza a and b viruses and respiratory syncytial virus were tested by the xpert xpress flu/rsv assay (genexpert system, cepheid, sunnyvale, ca, usa) according to the manufacturer's instructions [ ] . the igg/igm of chlamydophila pneumoniae and mycoplasma pneumoniae were also tested using the seromp kit (savyon diagnostics, ashdod, israel). the sars-cov nucleic acid test was conducted via real-time rt-pcr according to the protocol of the nucleic acid kit (kangwei century biotechnology company, china). the sars-cov antibody kit was used to test for specific igm and igg antibodies (guangzhou wonfo biological technology co, ltd., china) via colloidal gold immunochromatography. five cases were detected in our research, all of whom were from the same family. we defined the case numbers from case to case , and their epidemiological and clinical characteristics are presented in fig. . case and case are the parents of case , case is the younger sister of case , and case is the husband of case . case is a wuhan-settled -year-old female. she has a more than -year history of systemic lupus erythematosus (sle) and has been taking oral prednisone ( . mg/d) since her diagnosis. she had not taken hydroxychloroquine or other immunosuppressive drugs. on january th, , she spent h dancing and singing in a room and one of her partners was later diagnosed with covid- . in the following days, she had no contact with any confirmed or suspected patients. she returned to her parents' home in yiyang on january th and after that never went out. because of the severity of covid- , hunan province carried out a 'level one response to major public health emergencies' on january . therefore, case was placed under home quarantine and observation for days. during the isolation period, she felt good and had no fever, cough or shortness of breath. therefore, she was released from quarantine on february th. just a day later, however, case began to have a mild cough, nasal congestion, and runny nose, but no fever. she paid little attention to her symptoms and did not seek further medical help. these symptoms improved days later. on february th, she was admitted to hospital for screening because of her father's (case ) diagnosis of covid- . her routine blood examination was abnormal, with a white blood cell (wbc) count of . * ^ /l, hemoglobin concentration of g/l, and platelet count of * ^ /l. her erythrocyte sedimentation rate (esr) was mm/h, which was above normal. il- was normal. the sars-cov nuclei acid test from nasopharyngeal swabs was negative, but her igm and igg antibodies were positive. mycoplasma pneumoniae and chlamydia pneumoniae antibodies were negative. lung ct ( fig. a, b) showed multiple lesions in both lungs. these results supported the diagnosis of covid- . hence, she was given antiviral treatment, including . g bid of abidol orally and million iu of interferon nebulization. nasopharyngeal swab virus nucleic acid tests were performed again on february th and march rd, both of which were negative. on march th, her lung ct (fig. c, d) worsened, and ground-glass opacity changes were found in the right upper lung. she was given extra piperacillin sodium tazobactam sodium ( . tid), and then glycyrrhizin ( mg qd). her ct showed improvements and she was discharged on march th. case is an -year-old male who has been living in yiyang for many years. he has a history of prostate cancer and coronary heart disease. he had been living with his eldest daughter (case ) since she returned from wuhan and had not gone out since then. he developed a paroxysmal dry cough and anorexia on february st. in the beginning, he did not get treatment. on february th, the symptoms aggravated with a fever ( . °c) and shortness of breath. influenza a and b viruses were negative. his chest ct (fig. e ) was abnormal with bilateral ground-glass opacities. his symptoms did not improve even after treatment with piperacillin-tazobactam ( . g q h), ambroxol, ribavirin ( mg q h), and oseltamivir ( mg bid). the sars-cov nucleic acid test was positive by both nasopharyngeal swabs and sputum on february th. his hemoglobin ( g/l) and lymphocytes ( . * ^ /l) were below normal, and his d-dimer ( . mg/ml), creactive protein ( mg/l), esr ( mm/h), il- ( . pg/ml) were above normal. his arterial blood gas showed a po of mmhg and a fio of %. therefore, he was diagnosed with severe covid- and admitted to the intensive care unit with support treatments including high fluids, oxygen, interferon, lopinavir-ritonavir and ribavirin for anti-viral therapy, linezolid, meropenem and fluconazole for anti-inflammation, and albumin, gamma globulin, steroids ( mg/d) and recovery plasma ( ml * ) to improve his immune system. his virus nucleic acid tests were retested on march nd and march th, with both showing negative. on march rd, his igm and igg specific antibodies were positive. repeat blood gas on march th showed a po of mmhg and a fio of %. his lung ct (fig. f) showed that his inflammation lesions were absorbed and ground-glass opacities were improved. case is a -year-old female from yiyang. she also had close contact with her elder sister (case ). she developed a fever ( . °c) and inappetence on february th. three days later, she was taken to a hospital. laboratory examination showed a wbc of . * ^ /l, creactive protein of . mg/l, and fibrinogen of . g/l. influenza a and b were negative. lung ct (fig. g) showed multiple patchy highdensity shadows on both lungs. on february th and february th, the nasopharyngeal swab was negative for sars-cov . after treatment, the symptoms disappeared. hence, she was discharged on february st and placed under home quarantine. since her father (case ) was diagnosed with covid- on february th, she was admitted to the hospital again for further screening. this time, her sars-cov nucleic acids and specific igg and igm antibodies were positive. the esr was . mm/h. antiviral therapy was given with interferon and lopinavirritonavir. on march nd, her repeat viral nucleic acid test was still positive. the nasopharyngeal swab was negative twice, respectively on march th and march th, with simultaneously improved lung ct (fig. h ). case and case were the other two family members but were excluded from covid- . remarkably, case , who developed fever, was diagnosed with malignant lymphoma according to the result of her bone marrow puncture. the ongoing outbreak of covid- , starting in december , has quickly become a sweeping and unprecedented global challenge. because covid- can spread from person to person [ , ] , a major challenge in controlling the disease is recognizing and quarantining potential infectious sources as soon as possible [ ] . as li reported, the median incubation period is - . days and the th percentile of the distribution is . days [ ] . unfortunately, covid- patients can be infective before the disease onset and maintain infective ability during the convalescent phase [ , , ] . according to cao's report [ ] , the shortest observed duration of viral shedding was days, whereas the longest was days. however, to date, no article has reported what kind of patients have a longer viral shedding time. in the family we report here, the index patient, case , was from wuhan and had contact with covid- patients before she returned to yiyang city. the other family members were from yiyang and had never left yiyang, nor did they have contact with any other covid- patients. it is most likely that case was the infective source in this family. by further examining their epidemiological data, we find that the incubation period of covid- and the shedding duration of sars-cov might be extremely long in this case. the index patient did not develop atypical symptoms (including a mild cough and a runny nose) until days after she had returned from wuhan. remarkably, case was immunocompromised due to her long-term use of oral prednisone, which might explain why she did not develop typical symptoms at first and why she had a longer duration of viral shedding. in summary, it is important to recognize potential patients who might have no or only mild symptoms. therefore, we highly recommend that all people with an exposure history be strictly quarantined, and for immunocompromised people with long-term use of glucocorticoids, this time should not be limited to days. we declare no competing interests. a novel coronavirus from patients with pneumonia in china sars-cov- is an appropriate name for the new coronavirus clinical characteristics of asymptomatic infections with covid- screened among close contacts in nanjing a family cluster of sars-cov- infection involving patients in nanjing, china cdc covid- response team, update: public health response to the coronavirus disease outbreak -united states the deadly coronaviruses: the sars pandemic and the novel coronavirus epidemic in china a familial cluster of infection associated with the novel coronavirus indicating potential person-to-person transmission during the incubation period the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application saliva as a diagnostic specimen for testing respiratory virus by a point-of-care molecular assay: a diagnostic validity study first known person-to-person transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) in the usa a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia transmission of -ncov infection from an asymptomatic contact in germany clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study we thank huanxing sun (yale university school of medicine, new haven, usa) and lingzhong meng (yale university school of medicine, new haven, usa) for reviewing and checking the wordings of the manuscript. all authors also gratefully acknowledge relevant medical workers and local centers for disease control. key: cord- -gxqg t authors: diouf, massamba; ndiaye, babacar mbaye title: logistic growth model and modeling of factors for community case transmission date: - - journal: nan doi: nan sha: doc_id: cord_uid: gxqg t in this article, we analyze the spread of cases resulting from community transmission of covid- in senegal in order to identify statistical associations. the identification and knowledge of the factors associated with this community transmission can be a decision support tool to limit the spread of the disease. we estimate parameters and evaluate the growth factor, community rate, weekly increase and daily difference, and make forecasting to help on how to find concrete actions to control the situation. in december , the outbreak of covid- associated with a new coronavirus was a significant event. the ensuing spread prompted the world health organization to declare a pandemic on march , , after it was considered a health emergency of global concern [ ] . the whole world is thus facing an unprecedented health crisis from the coronavirus with the number of people affected which is gradually increasing with more than , , confirmed cases for nearly , deaths at the end of august [ ] . less affected by the pandemic compared to other continents, africa is still resisting with a covid- death toll reaching nearly , deaths while confirmed cases have exceeded , , (august , ) according to the african control center and disease prevention [ ] . this progression of the disease in this zone raises concerns as well among the governors as among the health experts with regard to the living conditions of the communities, the insufficient resources to face this type of threat and the noted failures. in some health systems in africa. in senegal, at the start of the epidemic, the government declared a state of emergency with several health, economic and security measures taken to reduce the spread of covid- . then in the face of socio-economic stress, an easing followed by the lifting of restrictive measures seems to give a boost to the disease with the meteoric increase in incident cases. from march to april, the number of cases was . in the period from may-june, people sick with the coronavirus increased by , . from july to this work was completed with the support of the nlaga project. arxiv: . v [q-bio.pe] nov august, the number of cases in senegal increased by , . this progression affecting almost all the health districts of all the regions of the country results for the most part from the resurgence of cases resulting from community transmission. these community cases are characterized by their difficulty in tracing to identify the source of contamination, but also by the limited possibilities for identifying and isolating the various associated contacts. during the three periods described above, the number of community cases among people positive for the coronavirus in senegal was for the first two-month period, for the second two-month period and for the third two-month period july-august . this development reflects an epidemiological situation including the magnitude and seriousness with regard to the consequences related to lethality and other impacts of all kinds, remain worrying. the determinants and/or variables linked to this form of transmission are not sufficiently documented in senegal. therefore, the identification and knowledge of the factors associated with this community transmission can constitute a decision support tool to limit the spread of the disease, on the one hand through targeted actions, to control the epidemic and its externalities on the other hand. the objective of this work is to model the variables potentially involved in the spread of cases resulting from community transmission of covid- in senegal in order to identify statistical associations. in our previous articles [ , , , , ] , we try to forecast the pandemic for senegal using the sir, stochastic sir and machine learning. here, we give forecasting pandemic size of community cases for senegal and daily predictions using the logistic model. we assume that the model is a reasonable description of the epidemic. full daily reports are available in [ ] . first, we collect the pandemic data from [ ] , from march , to september , . then, we propose a logistic growth model for forecasting. variables such as community rate, growth factor, daily difference (daily variations) and weekly increase (number of cumulative cases per week) were defined to better understand the dynamics of the development of community cases in senegal. the article is organized as follows. in section , we present some data analysis followed by the logistic growth model for forecasting in section . finally, in section , we present conclusions and perspectives. the simulations are carried out from data in [ ] , from march , , to september , . the numerical tests were performed by using the python with panda library [ ] , and were executed on a computer with the following characteristics: intel(r) core-i cpu . ghz, . gb of ram, under unix system. according to daily reports, we first analyze and make some data preprocessing before simulations. the cumulative numbers of confirmed and community cases are illustrated in figure , which shows a progression of community cases as a function of the total number of confirmed cases. it seems to mean that the increase in confirmed cases correlates with the increase in community cases. figure shows the variation in the number of community cases with the various institutional measures taken since the declaration of the index community case on march , ; as well as the religious events that occurred during this period. the restriction of barrier measures has helped stabilize community cases (rbp, july , from figure ) , with a slight increase followed by a decrease. the aid al kabir (tabaski, july , ) intensively increases the cases, because during this period people mix from house to house. this increase in cases has prompted the government to strengthen barrier measures (renbm, august , ). this increase in cases has prompted the government to strengthen barrier measures (renbm, august , ). that made it possible to reduce the transmission. in managing the pandemic, controlling movement is a sure way to limit the spread. this is why slogans urging everyone to stay at home were widely shared on social media to persuade more. first, let's define the community rate. community rate = number of community cases number of confirmed cases × the community rate (per day) is given by figure , and it's average and median values in table . the analysis of figure shows a variable evolution of the rate with extreme the growth factor is the factor by which a quantity multiplies itself over time. the formula used is: every day's new community cases new community cases on the previous day remark . . • a growth factor constant at indicates there is no change in any kind of cases. • a growth factor above indicates an increase in corresponding cases. • a growth factor above but trending downward is a positive sign, whereas a growth factor constantly above is the sign of exponential growth. the growth factor for community cases is given by figure , and it's average and median growth factors in table . the two largest growth peaks ( and ) are reached in may and july. the daily difference for community cases is given by figure . the greatest variations are obtained between the end of july and the beginning of august (period of after aid el kabir). the curve and the histogram for the weekly increase in number of community cases are illustrated in figures and , respectively. we see that week was fatal for community cases, which corresponds to the period after aid el kabir. in this section, we a perform forecast with the logistics model ( [ , , ] ) to predict the final size of coronavirus epidemy, for community cases in senegal. the logistic model is a data-driven phenomenological model. thus its predictions are as good as useful data are and as good as it can mimics epidemy dynamics. it's in a way mimic both epidemy spreading and its control i.e. prevention measures. when daily predictions of epidemic size begin to converge, we can say that epidemy is in control. in mathematical epidemiology, the epidemic dynamics can be described by the following variant of logistic growth model: where c is an accumulated number of community cases, r > infection rate, and k > is the final epidemic size (of community cases). if c( ) = c > is the initial number of cases then the solution of ( . ) is: where a = k−c c . when t , assuming k c , and therefore a . we have the natural growth: when t −→ ∞ the number of community cases follows the weibull function: the growth rate dc dt reaches its maximum when d c dt = . from this condition, we obtain that the growth rate peak occurs in time: lna r at this time the number of cases is c p = k and the growth rate is dc dt p = rk to answer the question about doubling time ∆t, i.e., the time takes to double the number of cases we solve c(t + ∆t) = c(t) for ∆t . result is the first term represents initial exponential growth, then ∆t increases with t. when t −→ t p = lna r , i.e., when c −→ k , then ∆t −→ ∞. for c ≥ k doubling time lost its meaning. for more details for the logistic growth model, see [ , , ] . in senegal, the first case of coronavirus appeared on march , . but the first community case was detected on march , . first, we collect the pandemic data from [ ] , from march , , to september , . then, we perform a forecast with the logistics model to predict the final size of coronavirus epidemy, for community cases. the size will be approximately ∓ cases ( table ). the estimated coefficients are given in table , and that the peak of the epidemic was on august , . it seems that the epidemic in senegal is in the ending stage (see figures and ). the short-term forecasting is given in table where we see that the discrepancy of actual and forecasted number of cases is within %. however, actual and predicted daily new cases are scattered and vary between % to %. on september , , the actual number of cases was , and the daily number of cases was . prediction in table is cumulative cases and daily cases. the errors are . % and . %, respectively. these extensive statistical analyzes allow us to make predictions about the future of the pandemic in senegal. in the first phase of the response (at the national level), the emphasis was more on government actions, the involvement of health professionals, and uncompromising communication. then, with the increase in cases of so-called community transmission, the epidemic entered its active phase with an increasing incidence in society. this worrying situation has led to the strengthening of various measures: the state of emergency with a curfew, the prohibition or restriction of interurban travel, gatherings but above all barrier gestures such as wearing a mask. this context of restriction, like everywhere in the world, has caused a gloomy economic environment in senegal forcing the state to readjust measures. an easing of restrictions is announced first and then, a little later, the lifting of institutional measures, without first giving the necessary guarantees and support for the response strategy at the global level. decisions that seemed to help boost the spread of the pandemic nationally with areas, initially free from the disease, which recorded their first cases of covid- . despite these considerations, religious events like the eid feast have taken place during this critical period. the festival of eid or sacrifice of the sheep, in senegalese sociology is a symbol and a pillar of stability and solidarity. the individuals preferentially celebrate it in a family or in the community. it is a time of exchanges of civilities, prayers in communion and sharing meals. this could facilitate the breaking of the barrier measures against the spread of covid- . moreover, one to two weeks after the july celebration of this holiday in senegal, the rate of contamination of the disease has almost tripled with all the affected regions and the resurgence of cases resulting from community transmission. this situation further prompted the state to make the general wearing of masks compulsory in public places, commerce, transport, schools and universities. wearing a mask remains a beneficial measure for many countries and reduces contamination by limiting the projection of postilions (especially in public). this fact seems to contribute to the control of the disease in senegal which, since the beginning of september, has been in a downward dynamic. according to an optimistic estimate, the pandemic in senegal will end soon, while for most countries of the world, the blow of the anti-pandemic will be no later than the end of the year. novel coronavirus ( -ncov) strategic preparedness and response plan for south east area region world health organisation coronavirus disease outbreak visualization and machine learning for forecasting of covid- in senegal impact of contamination factors on the covid- evolution in senegal analysis of the covid- pandemic by sir model and machine learning technics for forecasting comparative prediction of confirmed cases with covid- pandemic by machine learning, deterministic and stochastic sir models impact studies of nationwide mea-sures covid- anti-pandemic: compartmental model and machine learning richards model revisited: validation by and application to infection dynamics west africa approaching a catastrophic phase or is the ebola epidemic slowing down? different models yield different answers for liberia mathematical epidemiology: past, present, and future, infectious disease modelling minisère de la santé et de l'action sociale key: cord- - w t x authors: booss-bavnbek, bernhelm; krickeberg, klaus title: dynamics and control of covid- : comments by two mathematicians date: - - journal: nan doi: nan sha: doc_id: cord_uid: w t x we are asking: why are the dynamics and control of covid- most interesting for mathematicians and why are mathematicians urgently needed for controlling the pandemic? first we present our comments in a bottom-up approach, i.e., following the events from their beginning as they evolved through time. they happened differently in different countries, and the main objective of the first part is to compare these evolutions in a few selected countries with each other. the second part of the article is not"country-oriented"but"problem-oriented". from a given problem we go top-down to its solutions and their applications in concrete situations. we have organized this part by the mathematical methods that play a role in their solution. we give an overview of the main branches of mathematics that play a role and sketch the most frequent applications, emphasising mathematical pattern analysis in laboratory work and statistical-mathematical models in judging the quality of tests; demographic methods in the collection of data; different ways to model the evolution of the pandemic mathematically; and clinical epidemiology in attempts to develop a vaccine. since the covid- pandemic is not over it may appear to be premature to draw some conclusions. however, it may be, as well, just in time to recapitulate some lessons we as mathematicians should have learned and are urged to apply now. thus we are asking: why are the dynamics and control of covid- most interesting for mathematicians and why are mathematicians urgently needed for controlling the pandemic? we shall first present our comments in a bottom-up approach, i.e., following the events from their beginning as they evolved through time. they happened differently in different countries, and the main objective of this first part is to compare these evolutions in a few selected countries with each other. still, there are some general features, which we present separately as we are used to do in mathematics. they include the history of certain epidemics which have influenced the reactions of people in many countries, and some basic mathematical tools. in addition there is a common factor, which one of the present authors (kk) has defined on the th march in an e-mail to a german health office: "the extension and evolution of covid- in various countries and regions reflects the state of their health systems. this was for instance already very obvious in the case of ebola." it is in fact the public health component of the health system that plays a crucial role. the second part of the article is not "country-oriented" but "problem-oriented". from a given problem we go "top-down" to its solutions and their applications in concrete situations. we have organized this part by the mathematical methods that play a role in their solution. here is an example where specially much mathematics is needed: to develop a vaccine and the strategy for applying it without loosing sight of basic ethical principles. in the following the gentle reader may consult when necessary the book [kpp] for the basic concepts of epidemiology. demography as a mathematical subject area was already developed centuries ago well beyond its elementary beginnings. for a long time it remained the only mathematical tool in the study of the evolution of infectious diseases. here is a famous early example. in china, india and europe one tried to confer immunity against smallpox by infecting individuals slightly so they would contract a mild form of the disease and be immune afterwards. some of them died by this procedure but in the swiss mathematician daniel bernoulli showed by a demographical approach that the procedure would increase life expectancy if applied to everybody [di ] . nowadays evaluating the costeffectiveness of a public health measure is being done widely; it is based on methods of mathematical economy. the th century saw the discovery of microorganisms as pathogens of many diseases and their study by mainly microbiological methods. the mathematical tools for following up an epidemic remained essentially demographical well into the th century. a few physicians suggested that every epidemic ends because there are finally not enough people left to be infected, which is a naïve predecessor to the mathematical-epidemiologic concept of herd immunity (see sect. ). nevertheless even the abundant literature on the influenza pandemic of - , wrongly called spanish flu, discusses only two possible ways for its ending: better clinical treatment and mutations of the pathogen. seen from a virological viewpoint the spanish flu was an extreme form of the so-called seasonal influenza. the virus which causes them can be one of a large variety, its genus being denoted by a, b, c or d, where some of them include several species. a is the most serious one; is has subtypes a(hxny), x = ,..., and y = ,..., , where x and y represent proteins on the surface of the virus. the strategy for controlling the "normal" seasonal influenza epidemic is widely known even among laymen: identify the strain of the virus in autumn, develop a vaccine as fast as possible, and vaccinate people thought to be at risk. nevertheless the number of infections and of deaths by a seasonal influenza can be as high as those by some of the pandemics to be described now. the spanish flu was due to a(h n ). pictures from that time show people wearing masks that resembled those used now. in the years - another "digression" from seasonal influenza occurred, called the asian flu and caused by a(h n ). it started in china and then became a pandemic, passing from neighbouring states through the uk and the usa. estimations of the number of cases vary around millions and of the number of deaths around millions. its beginnings looked much like those of the spanish flu but towards the end a vaccine became available, a predecessor to the ones being used now routinely against the seasonal flu. the hong kong influenza of - , generated by the virus a(h n ), had similar characteristics and will not be described further. parallel to the entering the scene of these and other epidemics, and partly motivated by them, basically new mathematical tools of public health emerged in the first part of the th century, preceded by a few studies in the late th . they were twofold. the first tool was called a "statistical-mathematical model". its aim is the study of the influence of factors, also called determinants, on the health of people. such factors may for instance be a lack of hygiene or a polluted environment. a factor can also be a preventive or curative treatment by an immunization or a drug, respectively; in that case the main objective of a study is to estimate the efficacy of the treatment. sampling plans are statistical-mathematical models of a different but related kind. they form the basis of sample surveys, which are being done in profusion about covid- , too, and not always very illuminating. the second tool is called "mathematical modelling of the evolution of an epidemic", or briefly "mathematical modelling". there are two kinds of it. first, one may aim at the epidemic curve, which is the cumulated number of cases up to a moment t as a function of covid- booß-bavnbek &krickeberg, august t . in that case mathematical modelling serves to estimate or predict this curve under various assumptions on the infectivity of infected subjects. early predecessors are presented in [fin] , see figure ; the question whether the infectivity remains constant or decreases played already a role. refined versions are still being used, in particular for covid- (sect. ). early numerical simulation of an epidemic curve by j. brownlee, , discussed in [fin] second, one may build so-called compartmental models (sect. ). the first one, for measles, was published in by p.d. en'ko; see [di ] . around the year compartmental models for malaria appeared. then in the s new models for the evolution of measles in closed populations were defined and intensively studied. they became very influential because they displayed already many basic features that reappeared later in mathematical models of epidemics in other and more complex settings. such tools found many applications. dealing with large epidemics mathematically was no longer a matter of demography alone, although that continued to be the main tool for estimating number of cases and deaths. statistical-mathematical models were employed to estimate the efficacy of antiviral drugs, for instance against hiv-infections, and the efficacy of various immunizations including those against forms of influenza. mathematical modelling of epidemics was used in planning strategies to eradicate smallpox, poliomyelitis, measles and perhaps others. the first articles on modelling influenza epidemics appeared in the scientific literature. planning a vaccination strategy involves both statisticalmathematical and mathematical models [hal] . these roads to progress may have produced a general feeling of success in dealing with epidemics. then in the period from to a few events occurred that evoked memories of previous pandemics and undermined such believes. in finally another zoonotic influenza appeared, popularly called bird flu and in scientific language highly pathogenic avian influenza (hpai). the main pathogen was an a(h n ) influenza virus. it had been known long ago but reached a peak in the years - . whether there existed an airborne transmission from poultry to humans was a hotly debated question with obvious economic consequences. the bird flu spread widely over the whole world but the number of known human cases remained small, just over . in addition to various forms of influenza and the epidemics generated by the corona virus sars-cov- , sars-cov- or mers-cov, other epidemics occurred. it is instructive to compare them with those just mentioned, applying in addition mathematical yardsticks. we shall restrict ourselves to ebola epidemics. their most widespread outbreak was the western african ebola virus epidemic from to , which caused , cases and , deaths. there is a fundamental difference in the evolution of a case of influenza or sars-cov- or sars-cov- on the one hand and of an ebola case on the other, which leads to a basic difference in their mathematical modelling (sects. and ). a carrier of an influenza or corona virus can transmit it to other persons well before the first symptoms appear, that is well before the end of the incubation period. a subject infected by ebola will become infective only around the end of the incubation period. he (if it is a man) could then be immediately isolated together with his latest contacts in order to avoid further extension of the infection, provided that there is a health service nearby to do it. therefore ebola did not spread to countries that have a sufficiently dense primary health care network but it caused much suffering in countries that do not have it. the strategy of who to control the epidemic was wrong. it insisted on drugs and the search for a vaccine (which became available only in december ) but neglected primary health care. for the present purpose it would even have been most useful to rapidly train village health workers and "barefoot doctors" as it had been done decades ago. only very few countries profited from the experiences of these premonitory years to prepare much in advance for a possible, and probable, new outbreak of an epidemic. some others took appropriate measures only at the first signs of covid- , and many started planning when the epidemic had almost reached its zenith. we shall sketch some examples. for simplicity we shall always describe the result of the strategy of a country by indicating its cumulated numbers of confirmed cases and deaths around the st june . regarding the reliability of these data see sects. and . we begin with those that had planned early. , the year after the sars-epidemic outbreak, the government established the national health command center (nhcc), which was to prepare the country for a possible new epidemic. from on it was headed by the popular minister of health, chen shih-chung, who had studied dentistry at the taipei medical college. the vice-president of taiwan from to , chen chien-jen, had been minister of health from to after having studied human genetics, public health, and epidemiology at the national taiwan university and the johns hopkins university in the usa, followed by research. thus decisions about the control of covid- were taken by politicians competent in matters of health including public health. taiwan counts million inhabitants and many of them travelled from and to china. from the st december on when who was notified of the epidemic in wuhan all incoming flights from there were checked, followed by controls of passengers arriving from anywhere. an "action table" was produced in the period th january to th february , which listed measures to be taken. the public obtained daily revised clear information by all existing means. "contact tracing", which means repeated followup of symptomatic persons, of confirmed cases and of all of their contacts, was rapidly established on the basis of the electronic health insurance card that everybody has. the virological pcr-tests used (sect. ) were already available and quarantines well organised. in late january rules about the wearing of masks were edited; a sufficient supply existed already. as a result confirmed cases had been found and deaths recorded up to the st june. the vietnamese strategy resembles the taiwanese one in almost all aspects, with the exception of contact tracing. a steering committee to deal with new epidemics existed within the ministry of health. it put into effect its plan right after the rd january when the first infected persons arrived at vietnamese airports, among them a vietnamese returning from the uk. all schools were closed on the th january, and since the st february everybody entering vietnam must spend two weeks in quarantine. other measures were imposed or relieved in accordance with the evolution of the epidemic, for instance a limited confinement or the wearing of masks. the ministry of health issued regular precise and clear information for the entire population by all available means including smartphones. in addition there is a personalized information system by so-called "survival guides" given to everybody. every survival guide defines three categories of persons: f : a confirmed case; f : suspected to be infected or having had contact with an infected person; f : having had contact with a person in f . each person is expected to find the category to which it belongs. the survival guide then provides printed information about what she or he must do as a function of her or his category, for example to submit to a test. only pcrtests are being used. in contrast to taiwan contact tracing does not use electronic tools. it is being done by the population itself, aided by the survival guides, together with a large number of well-trained members of the health services, for example university lecturers. at the end of vietnam had , , inhabitants. on the st of june there had been confirmed cases and deaths. these data are based on a strong demographic section of the "general statistical office" and on several health information systems [kkr] and can hardly be contested. the preceding sketch of control measures in taiwan and vietnam has shown us the three main components of their epidemiologic side: contact tracing; lock-down, that is physical, or social, distancing in the wide sense including quarantine and border controls; wearing of masks. we may call this the "surveillancecontainment strategy". in addition there is the medical-clinical side, from primary health care such as general practitioners up to large hospitals. its state is crucial to the number of deaths caused by the virus sars-cov- . in contrast to taiwan and vietnam it seems that all other countries of the world were unprepared at the end of december . a few of them took fairly systematic and strict measures that covered the entire population as soon as the first cases had declared themselves. for a quick overview see figure . this was for example true for china at the end of january , for slovakia and greece on the th and th february, for austria on the th march and for denmark on the th march. an alternative danish strategy, based on rigorous contact tracing and quarantine, but not implemented until now was argued for in [sia] . regarding the results the turbulent evolution in china is well known. in denmark, with a population of . million, about , cases had been confirmed and deaths recorded, and the corresponding figures for austria are . million people, , cases and deaths. the confrontation of slovakia, a country of around . million inhabitants, with greece, which counts . million people, is particularly striking because it makes visible the role of their physicians and hospitals. in slovakia there were , confirmed cases and deaths. the corresponding data for greece are , and . the relatively much higher number of fatalities in greece, in spite of equally early reaction and almost the same number of cases per number of inhabitants, is no doubt due to the catastrophic state of its medical-clinical system caused mainly by the debt crisis from on. next we pass to a group of countries that reacted late and not systematically, applying the various measures in a haphazard way and only to part of the population. here are some of them with their numbers of inhabitants in million, cumulated numbers of confirmed cases and numbers of fatalities: the relatively low number of deaths in germany reflects mainly a sufficient medical-clinical system that could readily adapt itself to the epidemic. the opposite was true in france. there, about , hospital beds had been eliminated in the period between and . an arbitrary strict "confinement" not determined by epidemiologic reasoning was imposed on the th march. finally there are countries that decided to do nothing, at least for a long while. their motivation, or pretext, was above all a belief in herd immunity (sects. this overview of strategies confirms that, as said in the introduction, the results depend indeed heavily on the state of public health. note that nowadays in every language of the world the concept "public health" is designated by a literal translation or a slight modification of this expression. for instance in danish it is "folkesundhed", that is, "health of the people". in this second part we shall sketch the scientific and in particular mathematical principles involved in the study of successive stages of the pandemics. in short: sect. : discovery of the new virus, basic properties, testing for its presence in a person. and : data on the evolution of covid- in a population. : attempts at analysing mathematically and predicting such an evolution by representing it by an epidemic curve. : the analogous for a representation by a compartmental model. : trying to stop the epidemic by a vaccine. : what to learn and what to do? after the often-depicted outbreak in late december of cases of pneumonia of unknown aetiology around wuhan, in the course of january chinese scientists identified a new virus as the pathogen. they followed the usual procedures, i.e., they determined the load of common respiratory pathogens in the patients. they found none of them in abundance. they suspected sars-cov but could not find it either. then they investigated all kinds of viral load that had a slight similarity (coincidence in a number of genomes) with sars-cov and detected a novel virus which displayed abundant virions in respiratory specimens from patients. electron microscopy and mathematical pattern analysis [mum, pev] showed that it belongs to the same species as sars-cov- and mers-cov (sect. ); hence the name sars-cov- . starting with this work in china a large number of publications about the peculiar properties of the pathogen and the ways it is acting have appeared. on the virological side its genetic sequence was determined. the new virus is believed to have zoonotic origins but human to human infection was rapidly established. the combination of sars and influenza features, that is intensive respiratory inhibition of patients and rapid transmission, make covid- , the disease caused by sars-cov- , particularly dangerous. for further work see [and] . in the clinical context, several periods in the evolution of a case were determined (see their definition in [kpp, sect. . ]): the median incubation period is . days; the mean latency period is . days, i.e., in general the infectious period starts indeed before the prodromal phase. we have discussed the implications in sect. by comparison with ebola. the mean length of the infectious period is days for mild and asymptomatic cases; for severe and critical cases this period lasts on the average days and ends only by recovery or death. the manifold applications to the control of the pandemic of both their virological and their clinical characteristics will appear in sects. , , and . their study is still active and may even reverse former results; this happened for example recently about so-called cross-immunities. however, in this article we shall only treat applications to the basic element of well-designed control strategies, namely testing for infections. the first step of a test programme is to define the target population. who will be tested? subjects who had a contact with infected people? or those who complain about symptoms? or everybody coming from a region where cases exist? see the example of vietnam in sect. . next, what will be the objective? to discover the presence of the virus or that of some kind of antibodies? depending on the objective there exist virological and serological tests. the usual virological test is called the pcr-(polymerase chain reaction) test. dozens of serologic tests of varying quality have been and still are developed and even offered in some countries to the general public. recall that the characterization of a test with a given target population and a given objective is a classical subject of clinical epidemiology [kpp, sect. . ] . coming back to the fundamental role of testing in control strategies we only remark that in poor countries or in rich countries with inattentive public health officials, the target population was often determined by the shortage of test kits and by the influence of institutions that required them for themselves. this is classical medical statistics, which gives for a specific disease the number of cases and deaths together with the when and where and a few additional data such as sex, age and sometimes profession of the subjects. in principle the methods for finding the number of confirmed cases and of fatalities by covid- are the same as for any other disease. they fluctuate widely between countries. both the diagnosis of a case of a disease and the description of the cause of a death may be relatively correct or most unreliable. in particular finding a correct diagnosis for somebody who complains about acute health problems depends very much on the local contact tracing methods and on the state of the clinical-medical system. an additional difficulty arises form the existence of asymptomatic forms of the disease, that is, subjects infected by sars-cov- who display no symptoms. in sect. we have mentioned vietnam, which uses its normal demographic and health information systems [kkr] . it includes in its statistics asymptomatic cases found by contact tracing. other countries obtain their morbidity and mortality data from a "health reporting system". such a system is partly based on sampling methods from various sources, for example hospitals and local health offices. in germany the robert koch-institute, a central institute mainly devoted to infectious diseases, reports on the results for covid- . in the usa the johns hopkins university plays a similar role. still other countries use data from health insurance offices. however, many countries have neither a health information system nor a health reporting system, or they do not use it for covid- . a host of alternative methods is being employed. for example france counts only hospitalized confirmed cases and only deaths which happen in a hospital or in a retirement home that is connected with a medical structure. summing up we may say that morbidity data and to a lesser degree mortality data for covid- that one finds in various periodic publications are fairly unreliable, with very few exceptions. the sources are not always clearly indicated. an important alternative idea is to compare the present situation with that in years past. speaking again naïvely we assume that the present higher case frequencies and death tolls, and only these, are the result of covid- . given the diagnostic difficulties mentioned above this idea is mainly applied to fatalities and hardly to nonlethal cases. thus in the method of "excess mortality" we only measure how many more deaths by any cause happened this year than in the corresponding period in the past. for the uk we have for instance quoted in sect. the figure of , deaths up to the st june as supplied by the national health service. by contrast the national statistical office advanced about , deaths as excess mortality! fig. estimated number of infections on lock-down day and excess mortality for selected countries. reproduced from [fit] , permission granted by finally, here is an interesting idea based on the most classical form of a statistical-mathematical model. a graphic in the paper [fit] (see figure ) shows for every one of selected countries the point in the plane whose coordinates are, respectively, the estimated number of infections per million inhabitants on lockdown day and the excess mortality. a short glance convinces us that they are positively correlated. a simple regression analysis based on this graphic would allow us to estimate one of these values by the other one for any other country, too. it goes in several directions beyond classical health statistics, all of them relevant to covid- , too. firstly, sample surveys are conducted instead of using the data from the entire "target population". they have for example been used to study the influence of social factors on the evolution of various aspects of the disease. in particular the factor "to be an immigrant or to descend from them" was thoroughly investigated in some countries. secondly, more types of data about cases and deaths are collected, for example about morbidity and mortality by age groups. thirdly, data sets are not only being registered and perhaps published but also transformed and interpreted in various ways. here, standardization is the best-known procedure. a fictitious example would be the number of fatalities by covid- in denmark if denmark had the same age structure as vietnam and in each age group it had the same covid- mortality as in the same age group in vietnam. in sect. we shall meet statistical-mathematical models as a basic mathematical tool in developing a preventive treatment of covid- . with their help one studies in a clinical trial the influence of various factors on some outcome variable e of interest. here the idea of "controlling" for the influence of another factor, which might be a "confounder" in the study of the action of e , plays a role. it looks as if most demographers on the one hand, and most clinical epidemiologists on the other, ignore that the mathematical procedure of standardizing is the same as that of controlling for a confounder [kpp, lesson ] . a mathematician will not be astonished, though! we have mentioned this classical concept in sect. ; see [kpp, sect. . ]. let c be an epidemic, v a geographical region, t a moment of time which may be that of the first case of c in v , and f(t) for t ≥ t the number of observed and reported cases of c that had declared themselves in v before or at the instant t . then f is called the epidemic curve of c in v . in particular it needs to be said whether unconfirmed cases are included or not. measuring f(t) as the time t goes along is the task of the relevant demographic services (sects. and ). this process is therefore subject to all the deficiencies listed there. to get some knowledge about f for various regions v is of course one of the main concerns of the population of a country invaded by c . such knowledge is equally vital for health authorities who attempt to control c . however, much more knowledge is desirable. what can we learn about the mechanism of c by observing f(t) ? this was already the subject of the papers described in [fin] ; see sect. . in particular, is there a way to predict aspects of the future evolution of f , having observed the values f(t) for a while? answers to these questions are generally given by modelling f , that is by making certain assumptions about its shape and by estimating certain parameters in it. a very large number of papers was published about this issue. some of them use extrapolation methods known from mathematical economy. a recent survey on basic ideas and techniques can be found in [krm] where a model is described in terms of an integro-differential equation. we shall restrict ourselves to a discussion of an application, namely the so-called basic reproduction number r . it appears constantly in popular publications. to define it let us look at a subject s that is infected at a time t* ≥ t . let µ(s, t*) be the number of all subjects infected by s after t* in the form of secondary, tertiary etc. infections. then r is the average of µ(s, t*) over all s . thus it depends on t*. it is precisely this dependence in which people are interested: a value less than is looked upon as predictor of the extinction of c after t*. in the case c = covid- , values as high as . had been estimated in the beginning, that is, for t* close to the time of the first outbreak of c. the article [sia] presents an interesting factorisation of r in order to compare different approaches to control the size of it. we have sketched their historical origin in sect. . we distinguished between two ways of mathematically modelling the evolution of an epidemic. models of the first kind (sect. ) represent the temporal evolution of the number of subjects in a certain state, for instance the state "to be infected". by contrast, compartmental models also represent changes of this state at some moments in the form of transitions of a subject from one compartment to another one. the sir-model, which we designated in sect. as "intensively studied in the s", is particularly simple and has served as a paragon for many others, in particular for those applied to covid- . it involves three compartments: s are the susceptible, not yet infected subjects, i the infected ones, and r consists of subjects removed by recovery with immunity or death. the transitions between compartments are described by differential equations for the numbers s(t), i(t) and r(t) of subjects in the compartments as a function of time t . they involve certain parameters such as transition probabilities from one compartment to another one. under various assumptions the resulting system of differential equations for s , i and r can be solved explicitly or numerically. a first important application is to estimate the basic reproduction number r defined in sect. . it can be expressed by the basic parameters. secondly, it turns out that the limit s∞ of s(t) for t →∞ is strictly positive, which means that a certain part of the population will never be infected. this led to the concept of herd immunity, which, however, gave rise to much confusion among people who thought they had something to say about the matter. after the outbreak of covid- many more involved compartmental models were defined and analysed. their parameters represented among other features the underlying control strategy to be used. there was for instance the "do nothing" strategy and also the "mitigation" strategy, which consisted of the less stringent components of the "surveillancecontainment strategy" defined in sect. . in the much discussed paper [fer] neil ferguson and collaborators described the shape of the function i, that is the number of infected subjects, for the "do nothing" strategy. from the value on it increases, reaches a maximum, decreases and finally reaches at a certain moment thappy . this had apparently motivated the countries uk, usa, sweden and brazil to adopt this strategy for too long, ignoring that ferguson predicted (see figure ) about , deaths caused by the epidemic in the uk and . million in the usa before extinction at the moment thappy. expected deaths caused by the epidemic for the do-nothing strategy, reproduced from [fer] with permission of school of public health, imperial college london at present compartmental models play hardly any practical role, mainly because they contain too many unknown parameters. some parameters such as infectivity are estimated with the help of a model of the epidemic curve, which seems to be a not very successful detour. it will hardly surprise that several pharmacological companies have started a run for developing curative and preventive treatments of various ailments, which sars-cov- may inflict on a person. up to now no curative treatment was found. there are only the wellknown methods to be used in the treatment of non-specific aspects of a case such as reducing pain, facilitate breathing or shorten the time to recovery by a antiviral drug. we shall therefore restrict ourselves to preventive treatments, that is, to immunizations. the objective of an immunization by a vaccine against a covid- connected health deficiency needs to be defined in the same way as for any other infectious disease. first the target population needs to be determined: whom do we intend to protect? next, what are the health deficiencies we want to prevent? for how long is the preventive effect to last? this is a particularly important aspect of the vaccine but is usually suppressed when a new one is announced. for instance the measles vaccination remains lifelong active in most subjects. for covid- the company which tries to develop the vaccine may be satisfied with a few months, hoping that sars-cov- will have disappeared after that. finally the efficacy needs to be found, which represents the part of the target population actually protected. it may also be defined in epidemiologic terms by regarding as "exposed" all subjects that had not obtained the treatment. then the efficacy is the "aetiological fraction among the exposed subjects". nowadays there is general agreement that the process of developing a vaccine against an infectious disease needs to run along a well-defined common line [kpp, lesson , and hal] . this ought to hold for covid- , too, and we shall therefore recall it here. first, one or several substances are selected which, for some reasons whatsoever, usually virological ones, look like possible candidates for a vaccine. each of them needs to be submitted to a "clinical trial" in order to explore its most important properties. such a clinical trial consists of three "phases" i, ii and iii. phase i deals with various mainly pharmacologic aspects such as side effects for various possible dosages. statistical-mathematical models are the essential tools of the phases ii and iii. phase ii aims at providing a first idea of the efficacy of the selected vaccine. thus a relatively small target population is built artificially. here two basic problems arise. the first is the definition of the outcome variable of interest. often only the "immunogenicity" is being studied, which means the formation of antibodies, but not protection against the disease. it is a particularly complex and manifold problem in the case of covid- . secondly, the target population needs to include among the vaccinated subjects a sufficient number of people who would attract the disease when not vaccinated. since covid- morbidity in the entire population of a country is small, such a group must be constructed by "challenge", that is, by infecting its members artificially. they are usually volunteers and their risk of dying is small except in the age groups where the lethality by the disease is high, that is, in the case of covid- , for old people. faced with this ethical problem the usa used, for various previous infectious diseases, prison inmates whose terms were shortened as a reward. there was a time when vietnam, while developing a certain vaccine, sent its samples for the phase ii trial to the usa to be tested in this way because vietnamese ethical standards forbade all kinds of challenge. there are usually several phase ii trials in order to select the potential vaccine to be finally studied in a phase iii trial. this is a field trial in the sense that a sample of subjects is drawn from the entire population of interest, for instance from among all inhabitants of a country within a certain age group. the outcome variable is not immunogenicity but protection against the disease in the sense of the desired efficacy. the size of the sample is determined beforehand by the precision of the intended estimate of the efficacy. as noted above the decision about the duration of the trial is a crucial element. if high efficacy during the first two weeks after vaccination is considered sufficient, the trial may be stopped after two weeks; this philosophy underlies the vaccinations against the seasonal influenza. if we are interested in its efficacy during the first ten years after vaccination, it must last ten years. this has, in addition to other problems, caused the long delay in developing an ebola vaccine (end of sect. ). we hope that it will not be glossed over by those who are trying to sell a covid- vaccine very soon. the pandemic has functioned like a magnifying glass. in some places, it showed a basically well-functioning society. in other places it revealed scandals and intolerable social inequalities. in particular it reflected the state of a country's public health system. the present article aimed at describing the role of mathematics in the pandemic. as said above there are two parts to this "outlook". let us take up the first one, namely: what can be learnt from the epidemic? in sect. we gave an overview of the main branches of mathematics that play a role. then the sects. - sketched the most frequent applications; their titles and their order correspond vaguely to the branches of mathematics concerned. thus there were mathematical pattern analysis in laboratory work and statistical-mathematical models in judging the quality of tests; demographic methods in the collection of data; different ways to model the evolution of the pandemic mathematically; and clinical epidemiology in attempts to develop a vaccine. in this way the article aimed at clarifying the potential role of mathematics in making decisions. on the one hand it turned out that in practise the role of epidemic curve or compartmental models is much more restricted than advertised in many publications. decisions based on them may even have disastrous consequences, for instance those based on the mathematical concept of herd immunity. thus blind trust in mathematical arguments is unjustified. on the other hand denying the existence of a valid mathematicalscientific foundation for a control strategy is just as detrimental. it was done in denmark with the "tracing and lock-down" strategy by a report of an "expert group" of health academics and officials, which reflected the interests of medical, industrial and governmental circles. this comment leads us to the second part of our "outlook", namely: what to do in the future? the authors of the present article started it in early may by "since the covid- pandemic is not over ...". while we are finally finishing our work in the middle of july, it is still not over! it is even very active but has taken a largely different form. hence it seems natural to analyse its present characteristics in the light of the facts we have described in the sections - above and to ask ourselves: which lessons can we draw regarding the control strategies to be applied now? covid- does no longer surge from a single source. it reappears in small or large regions of many parts of the world, which may be of various forms and extensions: a single home for the elderly in france, two districts in germany, a large city like beijing, an entire province in spain, or a whole country like new zealand. we shall call them "nests" to distinguish them from "clusters", which denote certain discrete sets of people. a precise follow-up of the evolution of cases in these nests meets with the manifold difficulties explained in sects. and and will not be repeated here. a first natural question to ask is, then: why do "active" nests persist and reappear? sect. presented three components of successful control strategies: contact tracing; lock-down; masks. while contact tracing continues reluctantly, lock-down and wearing masks were widely abandoned, often as a result of governmental policies seeking popularity. next, what should be done? in the sections , and we have explained, using in particular mathematical arguments, in how far the strategies of control treated there suffer from serious drawbacks. this leaves us with the combination of two measures: inside a nest a rigorous lock-down such as social distancing and preventing larger assemblies of people; at its borders: closing them or only allowing passage when combined with quarantine. for example new zealand regarded as a single nest has taken such rigorous measures. as a result there are now no new cases, except two cases around the th july in "managed isolation facilities". other nests will act similarly, we hope. the proximal origin of sars-cov- the first epidemic model: a historical note on p.d. en'ko daniel bernoulli's epidemiological model revisited impact of nonpharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand. mrc centre for global infectious disease analysis john brownlee and the measurement of infectiousness: an historical study in epidemic theory the risks of lifting lockdowns prematurely are very large design and analysis of vaccine studies principles of health information systems in developing countries key to public health a novel deterministic forecast model for covid- epidemic based on a single ordinary integro-differential equation pattern theory. the stochastic analysis of real-world signals an introduction to bioinformatics algorithms alternative corona strategy: we can beat the infection down for the count with quarantine and tracing of infectors the authors: bernhelm booß-bavnbek born in , studied mathematics from to at bonn university. research, teaching and practical work first in econometrics and operations research and then in geometric analysis and membrane processes of cell physiology professor at several universities in europe and outside; research, teaching and practical work first in mathematics and then in epidemiology and public health. much of this was done in developing countries key: cord- -yao v authors: carneiro, carlos b.; ferreira, i'uri h.; medeiros, marcelo c.; pires, henrique f.; zilberman, eduardo title: lockdown effects in us states: an artificial counterfactual approach date: - - journal: nan doi: nan sha: doc_id: cord_uid: yao v we adopt an artificial counterfactual approach to assess the impact of lockdowns on the short-run evolution of the number of cases and deaths in some us states. to do so, we explore the different timing in which us states adopted lockdown policies, and divide them among treated and control groups. for each treated state, we construct an artificial counterfactual. on average, and in the very short-run, the counterfactual accumulated number of cases would be two times larger if lockdown policies were not implemented. the evolution of the covid- has been posing several challenges to policymakers. decisions have to be made in a timely fashion, without much undisputed evidence to support them. being a new disease, and despite the enormous research effort to understand it, estimates of the transmission, recovery and death rates remain uncertain. nevertheless, these are key pieces of information to assess potential pressures on the health system capacity, as well as the need of a lockdown policy and its intensity if implemented. not surprisingly, similar regions have implemented different strategies regarding lockdowns. the leading example in the media is the looser social distancing policy in sweden versus strict policies in its scandinavian peers. by informally comparing the evolution of the pandemics in sweden and denmark (or norway), many commentators argue that several covid- cases and deaths in sweden would be avoided in the short-run were a strict lockdown in place. aiming to provide a quantitative assessment on the short-run effects of lockdowns, this paper takes this exercise seriously in the context of us states. given that the timing us states adopted lockdown policies differs among them, we adopt techniques based on synthetic control (sc) approach of abadie and gardeazabal [ ] and abadie et al. [ ] to assess the impact of lockdowns on the short-run evolution of the number of cases and deaths in the treated us states. more specifically, we consider an extension of the original sc method called artificial counterfactual (arco) which was put forward by carvalho et al. [ ] . due to the nonstationary nature of the data, the correction of masini and medeiros [ ] is necessary. our results point to a substantial short-run taming of the cumulative number cases due to the adoption of lockdown policies. on average, for treated states, the counterfactual accumulated number of cases, according to the method adopted here, would be two times larger were lockdown policies not implemented. a key feature of our approach is that it is purely data-driven. in the beginning of the crisis, the majority of papers written by economists to evaluate the effectiveness of lockdowns relied on epidemiological models for analysis, including the most recent ones that incorporate behavioral responses. these models are hard to discipline quantitatively. many calibrated parameters remain uncertain, and models that incorporate behavioral responses need time to mature and agree on a reliable set of ingredients and moments to be matched. model-free approaches like ours or medeiros et al. [ ] should complement policy discussions or forecasting exercises based on those models, especially from a quantitative point of view. there are related papers using state or county level us data. at least one of them, , uses a synthetic control approach but it is restricted solely to california. other papers, such as brzezinski et al. [ ] , and sears et al. [ ] , use variations in the timing of statewide adoption of containment policies, and difference-in-differences models to document substantial reductions in mobility and improvements of health outcomes. the key identification assumption in these papers is that variations in the timing are random after controlling for covariates. brzezinski et al. [ ] also consider an instrumental-variable approach. fowler et al. [ ] and grassi and j. sauvagnat [ ] follow similar empirical strategies but at county level, and also find substantial reductions in cases and fatalities in counties that adopted stay-at-home orders and state-mandated business closures, respectively. our analysis, that rests on alternative identification assumption and method, should be seen as complementary. as the pandemic evolves, and more data become available, we expect more related empirical evidence to be consolidated. the paper is organized as follows. section describes the data, while section presents the empirical strategy. the results are discussed in section . finally, section concludes the paper. additional results are included in the appendix. data on covid- (confirmed) cases are obtained from the repository at the johns hopkins university center for systems science and engineering (jhu csse). we consider the cumulative cases for a subset of the us states and the district of columbia. instead of using the chronological time across the states, we consider the epidemiological time, which means that the day one in a given state is the day that the first covid- case was confirmed there. the econometric approach adopted here relies on the fact that some states adopted a lockdown strategy (the treatment), whereas others did not adopt social distancing measures (control group) and are used to construct the counterfactual. lockdown strategies include a mix of state-wide non-pharmaceutical measures aiming to limit social interactions, such as restrictions on nonessential activities and requirements that residents stay at home. containment policies. see, for example, atkeson [ a] on the uncertainty regarding estimates of the fatality rate. there are also related papers for other countries. for example, fang et al. [ ] for china. the timing of those policies at each state were obtained, and double checked, in several press articles, e.g., https://www.businessinsider.com/us-map-stay-at-home-orders-lockdowns- - and https://www.nytimes.com/interactive/ /us/coronavirus-stay-at-home-order.html. in this section, we describe how we assign states to control and treatment groups, and then, describe the method used to construct the counterfactuals. aiming to balance control and treatment states, and at the same time obtain enough observations to estimate properly the model before the lockdown policy was implemented, we divide us states into three groups. for a state to be included in the analysis, a state-wide lockdown policy must be established at least twenty days after the first case. we assume that whenever an individual becomes infected, it takes an average of ten days to show up as a confirmed case in the statistics. hence, the in-sample period used to estimate the synthetic control ("before" the lockdown policy) for each treated state (to be defined below) is the number of days between the tenth day after the first confirmed case and the tenth day after the lockdown strategy was implemented. we choose to start the in-sample from the tenth day as a way to smooth the initial volatility of the data. we adopt a criteria that a state must have at least twenty observations in the in-sample period to be included in the analysis. this criteria excludes states that adopted a state-wide lockdown strategy too early, such as connecticut, new jersey, ohio, among others. these are the unmarked states in table , which reports the dates of the first case and lockdown policy, as well the difference in days between them, and also helps visualize the three groups of states. the remaining states must be divided into treated and control groups. the idea is to find a synthetic control for each of the treated states. the group of potential controls should consist of states that adopted a lockdown policy too late (or never adopted), such that counterfactuals are not contaminated by lockdown policies implemented in those states. at the same time, and for a similar reasoning, the lockdown strategies adopted in treated states must be in place during the period of analysis. this assumption is motivated by the incubation period of the virus. according to the world health organization, the "[...] the incubation period for covid- , which is the time between exposure to the virus (becoming infected) and symptom onset, is on average - days, however can be up to days." see https://www.who.int/docs/default-source/coronaviruse/situation-reports/ -sitrep- -covid- .pdf. in the appendix a. , table a . shows the reopen dates for the treated states. fortunately, there are horizons that can balance both goals: enough states to build the synthetic controls and a relative extensive period to construct the counterfactuals. in particular, we restrict the analysis up to the th epidemiological day. this figure accommodates at least ten control states to build the synthetic controls, at the same time it maximizes the out-of-sample days to run the counterfactuals. in this sense, our analysis concerns the very short-run impact of lockdowns, up to nearly three weeks. the treated states are marked in blue in table , and include twenty states: alabama, colorado, florida, georgia, kansas, kentucky, maine, maryland, mississippi, missouri, nevada, new hampshire, new york, north carolina, oregon, pennsylvania, rhode island, south carolina, tennessee, and texas. the potential control states are marked in red, and include ten states: arizona, arkansas, california, illinois, iowa, massachusetts, nebraska, north dakota, south dakota, and washington. nonetheless, due to the lack of variation within the in-sample period, we exclude four states from this control pool as we explain below. importantly, oklahoma, utah and wyoming only implemented partial lockdowns (not reported in the table). therefore, they are hard to classify as either treated or control states. we opt to exclude them from the analysis. figure illustrates the empirical strategy, which is formalized in the next subsection. it plots the evolution of (log) cumulative cases along the epidemiological time. the first vertical dashed line represents the tenth day after the first confirmed case. the in-sample period is represented in between the first and second vertical dashed lines, which mark the tenth day and the following twenty days, respectively. similarly, the out-of-sample period is in between the second and third vertical dashed lines, which mark the th and th epidemiological day, respectively. blue lines represent the treated states, whereas the red ones the potential control states. the turning points from blue full-to dashed-lines represent the days lockdowns were implemented (plus ten days) in treated states. note that new york is clearly an outlier among the treated states, exhibiting a huge amount of cases (more on that below). we use the red lines to build synthetic controls for each full blue-line up to the turning point, and then construct counterfactuals by simulating the synthetic controls forward up to the th day. the idea is to compare them with the blue dashed-lines that capture actual cases. as figure highlights, some states display lack of variation within the in-sample period. just to give an example, washington had had only one confirmed case for the first days since its first confirmed covid- infection. hence, we exclude it from the control group. for similar reasons, we also exclude arizona, illinois, and massachusetts from the control pool. the analysis ended up relying on six control states. we propose a two-step approach using the artificial counterfactual (arco) method introduced by carvalho et al. [ ] with the correction of masini and medeiros [ ] to estimate the number of cases for each us state. let = , , . . . , represents the number of days after the first confirmed case of covid- in a given state. define as the natural logarithm of the number of confirmed cases days after the first case of the disease in this specific treated state, and as a vector containing the logarithm of the number of reported cases for control states also days after the first case has been reported as well as a logarithmic trend: log( ). the inclusion of the trend is important to capture the shape of the curve. the model is estimated as follows. we use the weighted least absolute and shrinkage operator (wlasso) as described in masini and medeiros [ ] to select the control states that will be used to estimate our counterfactual. the goal of the lasso is to balance the trade-off between bias and variance and is an useful tool to select the relevant peers in an environment with very few data points:̂︀ = arg min where = | , |, = , . . . , − , and = . is, for each state, the number of days from the first reported case until the lockdown plus ten extra days, and > is the penalty parameter which is selected by the bayesian information criterion (bic), in accordance with medeiros and mendes [ ] . the weight correction in the lasso is necessary in order to control for the nonstationarity of the data; see masini and medeiros [ ] for a detailed discussion. the counterfactual for = + , . . . , is computed aŝ︀ we also report % confidence intervals based on the resampling procedure proposed in masini and medeiros [ ] . we are interested in examining the effects of lockdown policies not only on the number of cases, but also on the number of deaths. however, we cannot implement the strategy described above because there is not enough variation in deaths for the in-sample period. some states, for instance, implemented a state-wide lockdown policies before the first confirmed death. thus, we propose an alternative method. we consider a counterfactual state for the number of deaths based on the counterfactual estimated for the number of cases. this is not straightforward as in the traditional synthetic control method because the arco methodology described above includes an intercept in the estimation, which is measured in the log of the number of cases, and not only a convex combination of other states. intuitively, the methodology described above chooses a combination of states that is at a fixed distance from the treated unit at the in-sample period and not a convex combination of states that matches exactly the actual number of cases. the intercept controls for all time-invariant characteristics that define the counterfactual. then, we proceed as follows. let be the number of accumulated deaths in state at the day . also, let be the vector of estimated coefficients for the state as in ( ) and used to construct the counterfactual for cases. in addition, let be a vector of the number of deaths for all states in the control pool at time . we define the counterfactual number of deaths in that state as: = −¯+¯ ( ) where¯is the day that state implemented the lockdown policies. that is, we maintain the weights estimated above and adjust the intercept so that the counterfactual series for deaths matches the number of actual observed deaths in the beginning of the quarantine. for the sake of exposition, we relegate the results on cumulative deaths to appendix a. . to illustrate how the method works, figure presents the arco counterfactuals for the states of alabama, colorado, and maine. the timing of the policy intervention ( + ) corresponds to the lockdown date plus ten days. the counterfactual analysis makes it clear the importance of lockdown policies in mitigating the acceleration of the number of covid- confirmed cases in the treated states. as shown in figure a , for example, our results point to a substantial increase in the number of cases in alabama if it had not adopted an early lockdown. similarly, figures b and c reveal the same behavior for the cumulative curves in the other selected states. counterfactuals are constructed with the estimated weights and cumulative cases of the six states that compose the control group. these weights are reported in table a . in appendix a. . in appendix a. , we present similar counterfactual plots for the remaining treated states. in order to assure that the proposed methodology is producing proper counterfactual analysis, we generate placebo results by producing a "synthetic control" for each control state using the remaining control states as control pool. results are displayed in figure , which shows the ratio of the estimated counterfactual cumulative cases to the actual ones for treated states except new york (black lines), and non-treated states (red lines). we assume that the epidemiological day of the placebo intervention is = , marked by the vertical dashed line, which is the median (and the mean) timing of the policy interventions in the treated states. it is reassuring that for half of the placebo counterfactuals the ratios fluctuate around one, whereas for the majority of treated states ratios grew above one at some point (likely around the actual timing of policy intervention). the latter result means that lockdown policies were effective to tame the spread of the virus, whereas the former suggests that results are not driven by chance. regarding south dakota, the only placebo counterfactual that reached a ratio well above one, by using google mobility data (described in appendix a. ), we show that mobility in residential areas increased whereas mobility in outdoor areas decreased substantially once compared to the period before the pandemic (see figures a. and a. in appendix a. ) . this is suggestive that south dakota's population endogenously decided to stay more at home, and avoided environments prone to the risk of contamination. at the time, a proper lockdown policy was not necessary, and south dakota's non-conformity to the placebo test does not seem to invalidate our approach. in contrast, for nebraska and california, the counterfactuals are pointing to a smaller number of cases than the actual ones, which goes against finding that lockdowns were effective to reduce cases of covid- . the case of california is quite emblematic, as the number of cases during the estimation window remained very small and with very low variation. however, the number of cases started to grow at a fast rate much after the cut-off date. the state of nebraska displays a similar pattern. to gauge the quantitative impact of lockdown policies, for each state, whether treated or control used as placebo, we compute the ratio of the counterfactual estimated comulative cases ("without" a lockdown strategy in place) to actual ones on the th epidemiological day, which is the last day used to compute the counterfactual. table reports the mean and median of the ratios across states, whereas table a . in appendix a. reports these ratios for each state. the first row corresponds the case in which controls are used as placebos, whereas the second considers the treated states only. as we discuss below, new york is clearly an outlier, whose ratio reached an implausible value of . as reported in table a . . hence, our preferred specification is displayed in the third row which excludes new york from the pool of treated states. we also compute other two versions of these ratios using the lower bound (lb) and upper bound (up) of the % confidence interval in the numerator. the ratios are clearly above one for the treated units, whether new york is excluded or not. according to our preferred specification, counterfactual estimates suggest that the number of cases would be nearly two times larger were lockdown policies absent. again, it is reassuring that among the controls used as placebo, these average ratios remain around one. regarding the effects of lockdowns on cumulative deaths, we present the results for all treated states in appendix a. . for some states, the counterfactual cumulative deaths exhibit similar patterns to those regarding cumulative cases. but, for many other states, they are not statistically significant at least for the first days after the policy implementation. one possible explanation is that there is a delay between cases and deaths, as the latter is a consequence of the former. hence, deaths only show up in the official statistics days after cases. perhaps, if we could estimate counterfactuals for longer periods, the synthetic accumulated deaths would further decouple from the actual ones. in addition, since weights on the controls are estimated considering the (log) cumulative number of cases, the counterfactuals for cumulative deaths are arguably noisier. as discussed above and presented in table a . in appendix a. , we obtain an implausible ratio (of counterfactuals to actual cumulative cases) of . to new york. this section puts a lens on this state. in particular, figure displays the estimated cumulative number of cases for new york "without" lockdown, as well as extrapolations of the cumulative number of cases based on the mean and median growth rate of the last ten days of the in-sample period. as reported in table , among the treated states, new york was the fastest one to react to the pandemic, and established a state-wide lockdown policy only days after the first case. figure extrapolates the last in-sample observations by using both the observed mean and median growth rates for the last ten days, which yields a similar pattern to the result obtained by applying the synthetic control approach. due to the progression of the virus, particularly in new york city, the in-sample observed rates are quite high once compared to other states as illustrated in figure , which can be explained not only by the dynamics of the city but also by its high population density. hence, new york is clearly an outlier and might not be amenable to our synthetic control approach, which justifies reporting results excluding new york above. in this paper, as opposed to most of the early and incipient literature on the lockdown effects during the covid- crisis, we conisder a purely data-driven approach to assess the impact of lockdowns on the short-run evolution of the number of cases and deaths in some us states. also, as opposed to some recent papers that use a difference-in-difference approach, we adopt a variant of the synthetic control approach, arco, due to carvalho et al. [ ] and masini and medeiros [ ] . on average, according to the synthetic controls, the counterfactual accumulated number of cases would be two times larger were lockdown policies not implemented in treated states. in the first two columns of table a . we show the date of the first confirmed case in every treated state we analyze and its reopen date (plus ten days), whenever available at the time we started to circulate this paper. in the third column, we show the difference (in days) from the first confirmed case and the reopen date plus ten days. these figures illustrate why we had to limit our sample size to only epidemiological days. for example, if we had used days in our analysis, we would have to exclude alabama and maine from our treated states, given that they would not be in a state-wide lockdown in the last days of the out-of-sample period. we report in the first seven rows of table a . the coefficients estimated by the lasso model for each treated state for the + in-sample period. the last two rows display the mean and the median (across the out-of-sample period) of the ratio between the actual cumulative cases and the counterfactual cases for every state. with only two exceptions (missouri and nevada), every state has an out-of-sample mean and median of the observed-to-predicted ratio below one. this means that, on average, the realized cumulative cases were smaller than the counterfactual, which highlight that lockdowns had a meaningful impact on slowing down the covid- spread in these states. table a . reports the ratio of the counterfactual cumulative cases to the actual ones on the th day after the first confirmed case in each state. it also reports the lower and upper limits of the % confidence interval. among the treated states, the ratio is larger than one in of them. for missouri and nevada, there is no evidence on the effectiveness of lockdown policies. for mississipi and south carolina, the impacts of lockdowns are only modest. note that new york is clearly an outlier, with such ratio around . . we discuss this case in the main text. in contrast, among the non-treated states, we obtain ratios close to one for three out of six cases. we assume that the cut-off of the placebo intervention is = , which is the median (and the mean) timing of the policy interventions in the treated states. as discussed in the main text, south dakota, which displays a ratio well above one, experienced a large reduction in outside mobility even without official lockdown measures. california and nebraska, which display ratios below one, had very few covid- confirmed cases during the period before the cut-off. in this section, in figures a. -a. , we report the counterfactual estimates for cumulative deaths based on the methodology described in section . . as we discuss in the main text, although for some states, the counterfactuals exhibit similar shapes to those regarding cumulative cases, for many other states, they are not statistically significant at least for the first days after the policy implementation. we know that lockdowns affect the covid- dynamics by imposing social distancing and mobility restrictions. to help understand the results described in this paper, we analyze the mobility data available at google mobility reports (https://www.google.com/covid /mobility/). google mobility data show how visits and length of stay at different places change compared to a baseline, before the outbreak of the pandemic. in particular, the baseline is the median value, for the corresponding day of the week, during the five weeks between january rd and february th . in order to understand how the population in each group (treated and control states) is behaving during the covid- crisis, we compute the median of mobility changes across our sample period, i.e. the days following the tenth day after the first confirmed case in each state. also, the data concern mobility changes for six categories, being five of them related to outdoor activities. namely, grocery & pharmacy, transit stations, parks, retail & recreation, and workplaces. the remaining one concerns indoor activities, namely, residential. hence, to capture an idea of outdoor mobility changes, we aggregate the aforementioned five categories into a single one defined as the median of the original five categories. in contrast, mobility changes in residential areas capture indoor mobility changes. the two boxplots in figures a. and a. present the median of mobility changes in all analyzed states both in residential and in outdoor areas, respectively. we report results for treated and control states separately. regarding mobility changes in residential areas, on average, residents from every state analyzed spent more time in these areas after the pandemic outbreak. however, those from treated states spent even more time indoor. nevertheless, there are outliers. for instance, residents from south dakota spent a lot more time in residential areas than before the pandemic, which helps understand the results found for this state in the placebo test. we found similar results for mobility changes in outdoor areas. clearly, residents from treated states remained in outside areas less often than residents from controls (always compared to the period before the pandemic). in new york, for example, there was a % decrease of outdoor mobility. once more, south dakota is an outlier for the control group, reinforcing the thesis that its population voluntarily decided to stay more at home. indeed, residents from south dakota spent almost % less time in outside areas, while those from the median state for the control group spent nearly % less. the economic costs of conflict: a case study of the basque country synthetic control methods for comparative case studies: estimating the effect of california's tobacco control program pandemic, shutdown and consumer spending: lessons from scandinavian policy responses to covid. working paper, university of copenhagen a simple planning problem for covid- lockdown how deadly is covid- ? understanding the difficulties with estimation of its fatality rate what will be the economic impact of covid- in the us? rough estimates of disease scenarios an seir infectious disease model with testing and conditional quarantine covid- infection externalities: trading off lives vs. livelihoods. working paper the covid- pandemic: government vs. community action across the united states. working paper arco: an artificial counterfactual approach for high-dimensional panel time-series data when do shelter-in-place orders fight covid- best? policy heterogeneity across states and adoption time the macroeconomics of epidemics human mobility restrictions and the spread of the novel coronavirus ( -ncov) in china the effect of stay-at-home orders on covid- cases and fatalities in the united states. working paper did california's shelter-in-place order work? early coronavirus-related public health effects costs and benefits of closing businesses in a pandemic optimal mitigation policies in a pandemic: social distancing and working from home the effect of social distancing measures on intensive care occupancy: evidence on covid- in scandinavia. working paper counterfactual analysis with artificial controls: inference, high dimensions and nonstationarity ℓ -regularization of high-dimensional time-series models with nongaussian and heteroskedastic innovations short-term covid- forecast for latecomers. working paper villas-boas. are we #stayinghome to flatten the curve? working paper key: cord- - f ofdsc authors: alsaied, tarek; aboulhosn, jamil a.; cotts, timothy b.; daniels, curt j.; etheridge, susan p.; feltes, timothy f.; gurvitz, michelle z.; lewin, mark b.; oster, matthew e.; saidi, arwa title: coronavirus disease (covid‐ ) pandemic implications in pediatric and adult congenital heart disease date: - - journal: j am heart assoc doi: . /jaha. . sha: doc_id: cord_uid: f ofdsc the corona virus disease ‐ (covid‐ ) is a recently described infectious disease caused by the severe acute respiratory syndrome corona virus with significant cardiovascular implications. given the increased risk for severe covid‐ observed in adults with underlying cardiac involvement, there is concern that patients with pediatric and congenital heart disease (chd) may likewise be at increased risk for severe infection. the cardiac manifestations of covid‐ include myocarditis, arrhythmia and myocardial infarction. importantly, the pandemic has stretched health care systems and many care team members are at risk for contracting and possibly transmitting the disease which may further impact the care of patients with cardiovascular disease. in this review, we describe the effects of covid‐ in the pediatric and young adult population and review the cardiovascular involvement in covid‐ focusing on implications for patients with congenital heart disease in particular. corona viruses are important pathogens that can infect humans and animals. at the end of , a novel corona virus was isolated in wuhan, a city in china, as a cause of a cluster of severe cases of pneumonia and acute respiratory distress syndrome . the virus rapidly spread around china and the world. on march th , covid- was declared as a pandemic by the who and the virus has infected hundreds of thousands of patients and thousands of health care providers , . while children in general seem to have milder or even asymptomatic forms of the illness, there is little to no data in children with chronic medical conditions, specifically heart and lung disease , . the knowledge and experience in caring for patients with covid- is rapidly evolving and thus it is crucial for all health care providers to be aware of the potential impact of covid- on patients with congenital heart disease (chd). covid- is particularly important for cardiac team members for the following reasons: -covid- has higher morbidity and mortality in adult patients with acquired cardiac disease. -covid- may affect and impact the cardiovascular system. -covid- may cause symptoms that mimic symptoms of cardiovascular disease like cyanosis and shortness of breath commonly seen in forms of worsening cardiac disease. -cardiac care team members are at risk for acquiring covid- and may play a role in spreading the disease between patients and in the society at large. -patients with chd are known to have higher risk for complications with viral illnesses , . -covid- may stretch our health care system and our resources which may impact the care of patients with cardiovascular disease. based on the covid- pandemic trends it is expected that many of the cardiovascular care team members will be exposed to patients with covid- in the coming weeks and months. in anticipation of the spread of covid- many hospitals and cardiology practices have this article is protected by copyright. all rights reserved changed their care models and policies to accommodate the care of patients impacted by covid- and prevent the spread of the disease. the objective of this review is to explore the current knowledge about covid- potential effects on the cardiovascular system in the pediatric cardiology and adult chd population. in addition, we will review the prevention practices and the impact on the health care team wellness. due to the emergent and evolving nature of covid- we reviewed the published literature in medline through pubmed and critically assessed early reports using a search for covid- and sars-cov- in medrxiv and biorxiv from january st until march rd . we had personal communications with multiple organizations around the world caring for children and adults with chd and we reviewed social media reports from leaders in the field of congenital cardiology. in addition, the websites of the health organizations including who and cdc were reviewed to provide up to date numbers and infection control recommendations. a congenital cardiology email list serve was initiated on the th march to facilitate discussion and share experiences and ideas on topics such as: strategies to manage outpatient clinic, inpatient service, procedure prioritization, screening, telemedicine and dealing with staff illness and school closures and we share some thoughts and information from physicians on the frontline of care of patients with covid- . sars-cov belongs to the coronaviridae family. as a group this family has a single strand rna genome . the viral rna closely resembles the rna of two bat corona viruses ( % identical) . the hypothesis is that the bat is likely the primary source of the virus although the this article is protected by copyright. all rights reserved mechanism of transfer from bat to human is still unclear (i.e. whether it was through direct transmission or whether there was an intermediate host) , . the virus is also closely related ( % identical) to the sars corona virus which was responsible for an outbreak in china in [ ] [ ] and % identical to the middle east respiratory syndrome corona virus that caused an outbreak in the arabian peninsula in [ ] [ ] [ ] . importantly the virus enters the cells using the angiotensin converting enzyme (ace- ) , . sars-cov spike protein binds to the ace- and the virus enters the cells through endocytosis , . ace- are expressed on the surface of epithelial cells within the alveoli and small intestine which explain the respiratory and gastrointestinal symptoms associated with the disease , . ace is a membrane bound protein that is also expressed in vascular endothelium, renal tissue and cardiovascular tissue . ace converts angiotensin i to angiotensin while ace- deactivates angiotensin . angiotensin stimulates lung injury and ace- serves a role in lung protection as it deactivates angiotensin . viral binding to ace- deactivates the protective role of ace- and that may contribute to severe lung injury seen with covid- , . more than . million cases of covid- have been confirmed worldwide with more than , deaths attributed to covid- according to the who website as of / / , . of these cases , cases were reported from china where the disease peaked between mid-january and early february , , . the initial patients had worked or visited a seafood "wet" market in wuhan that sold live animals and was closed subsequently for infection control , . human to human spread subsequently became the main source of transmission , . the disease then spread around the world initially through patients travelling from china followed by local transmission . as of april rd , there were , confirmed cases in the united states and over , deaths due to covid- according to the centers for disease this article is protected by copyright. all rights reserved control and prevention (cdc) website . transmission is thought to occur mainly via respiratory droplets produced during talking, coughing or sneezing similar to other corona viruses and similar to the influenza virus . transmission from asymptomatic individuals or patients in the incubation period has been documented , . the virus can also stay viable in aerosols up to . hours and can stay for hours to days on surfaces, especially plastic and stainless steel . in adult patients the incubation period is up to two weeks with a median of - days [ ] [ ] [ ] . more than % of infected individuals will remain asymptomatic or develop mild pneumonia . about % of patients will develop severe pneumonia and another % of patients will develop critical disease with respiratory and multi-organ failure and shock . fever is the most common symptom reported in most adult patients followed by fatigue and dry cough , . other symptoms include myalgia, anorexia, dyspnea, loss of sense of taste and smell (anosmia) and less commonly rhinorrhea, headache and sore throat [ ] [ ] [ ] . gastrointestinal symptoms including diarrhea and nausea have also been reported in up to % of patients , . the median time to hospital admission is days from the start of symptoms . according to the who, recovery happens in two weeks in mild cases and in up to weeks in severe cases , . the median time from symptoms to death in severe cases is estimated to be between - days . estimating case fatality rate is challenging and is evolving depending on the testing policies in each country and the age and risk profile of the infected patients. the rates reported range from . % up to . % , - . this article is protected by copyright. all rights reserved while the severity and mortality due to covid- is higher in older patients, the virus can also infect children and young adults , . overall only % of the reported cases from china were in individuals younger than years and less than % were younger than years , . fortunately, the disease in children is reported to be milder than adults although severe cases with multi-organ involvement have been reported , . a nationwide case series from china included pediatric patients with covid- . of those, had positive testing while the rest had highly suspicious clinical picture . severe disease with hypoxia was reported in % of the cases while a total of patients had critical disease with acute respiratory distress syndrome or multi-organ failure and one death was reported in a year-old . compared to older children, infants had a high risk for severe disease . another study looked at all the cases tested and treated at the wuhan children's hospital which is the only hospital to test and treat children in wuhan for covid- . of patients tested, ( . %) were confirmed to have sars-cov infection at a median age of . years. of these % were asymptomatic and only % were febrile at some point during the illness. during the course of the admission only of patients required intensive care unit and mechanical ventilation and all had preexisting conditions (intussusception, leukemia on maintenance chemotherapy and hydronephrosis). one month old patient died but the patient also had intussusception with multi-organ failure . the data on cardiovascular involvement with covid- is evolving . covid- may result in cardiac injury through multiple potential mechanisms, including: . cardiomyocyte injury due to an acute and severe inflammatory response as seen during a cytokine storm this article is protected by copyright. all rights reserved a recent meta-analysis evaluated the prevalence and effect of preexisting cardiovascular disease in patients with covid- . the study evaluated patients and reported the prevalence of hypertension, cardiac and cerebrovascular disease, and diabetes to be %, % and % respectively . studies from china and italy consistently show that preexisting cardiovascular disease increase the risk of mortality in patients with covid- , . the mechanism for increased risk of mortality is likely multifactorial including older age in patients with cardiac morbidities and altered immunologic response due to age and diabetes , . a population with potentially increased risk is patients with heart transplantation due to immunosuppression and two case reports describe covid- in heart transplant patients [ ] [ ] [ ] . one patient had mild disease while the other had severe disease. both patients were successfully treated with steroids, intravenous immunoglobulins and antibiotics and both survived without rejection , . multiple cardiovascular sequelae are reported in patients with covid- which may lead to or exacerbate cardiac disease . myocardial injury evidenced by elevated troponin is common in covid- especially in patients with severe disease , . arrhythmia is also commonly seen in covid- patients and while nonspecific, palpitations are one of the presenting symptoms in % of the patients , , . arrhythmia was noted in % of a group of hospitalized adult patients in china and was more common in the icu setting . there remains uncertainty about the specifics of the type of arrhythmia and there are no data in children. arrhythmia could be related to stress, inflammation and metabolic abnormalities but the development of new malignant arrhythmias should raise the suspicion for an underlying myocarditis , . myocarditis is a significant contributor to mortality in up to one third of cases with severe covid- and was the primary cause of death in % of the patients . autopsy found evidence this article is protected by copyright. all rights reserved of fulminant myocarditis with inflammatory mononuclear infiltrates in the myocardial tissue in some cases although the prevalence and risk factors for myocarditis are yet to be described . heart failure was reported in up to % of patients with covid- with a high prevalence of mortality . whether this is due to unmasking of pre-existing left ventricular dysfunction or new onset of cardiomyopathy due to myocarditis remains unclear . finally some severe cases may progress to cardiogenic shock and extracorporeal membranous oxygenation support may be considered in these cases although the prognosis is poor with % mortality in one report , . population chd affects up to % of the general population and remains the leading cause of infant mortality due to congenital malformations this article is protected by copyright. all rights reserved summarized in table . in addition to the cardiac morbidity, many patients with chd also have other organ involvement including chronic lung disease, cirrhosis and renal disease which may also increase the risk of covid- . we want to emphasize that there is very limited evidence to make firm recommendations and that these are based on the experience with previous viral diseases , . of note cardiovascular morbidities like diabetes and hypertension may also increase the risk of covid- in pediatric patients similar to that seen in adult patients. additionally, diabetes, hypertension, and acquired cardiovascular disease may coexist in adults with chd, potentially further increasing their risks. it is also important to note that many symptoms of covid- may mimic symptoms of worsening cardiac conditions in the chd population. symptoms such as shortness of breath, palpitations and fever are commonly seen in endocarditis which is a major concern in patients with chd . the same symptoms can also be seen in heart failure decompensation due to a viral illnesses and these considerations should be kept in mind during the covid- pandemic. aspirin is commonly used in the pediatric and adult population with chd for its antiplatelet effects at a low dose of - mg/kg/day . there is an association between the use of aspirin and the development of reye syndrome, a rare form of hepatic encephalopathy, in young children taking high dose aspirin for kawasaki disease who have concurrent infection with influenza or varicella , . there are no reports of reye syndrome in patients on low dose aspirin typically used with chd or with covid- . due to that we currently do not stop aspirin in children or adults with chd and covid- . this article is protected by copyright. all rights reserved there is no convincing evidence that nsaids are harmful in covid- although some clinicians suggested a possible negative impact if used early in the course of the disease for fever . the who and the european medicines agency currently approve the use of ibuprofen and nsaids in covid- , . the british congenital cardiac association suggested avoiding nsaids to treat fever in covid- . the ace- is used by the virus for cell entry . at this point there is insufficient data to suggest that ace-i/arb could affect the course of covid- , . ace-i/arbs suppress angiotensin ii or blocks its effect on its receptor. this is a positive effect to blunt the pulmonary inflammatory response and may result in upregulation of ace- which can be a positive effect for the same reason but at the same time carries the potential risk of increasing sars-cov- entrance to the alveolar cells . in the chinese data the rate of hypertension was significantly higher in patients who died post covid- . whether this is because of the older age and multiple comorbidities in the patients with hypertension or if it has any relationship to the ace-i/arbs use is unclear , . it is our practice currently not to stop ace-i/arb in patients who have covid- as stopping these medications could have harmful effects. the acc, american heart association and the heart failure society of america issued a statement recommending not adding or removing these medications for patients who are taking these medications if diagnosed with covid- and to follow an individualized approach . this article is protected by copyright. all rights reserved coagulation cascade abnormalities and disseminated intravascular coagulation (dic) are reported in patients hospitalized with severe covid- disease , , . we suggest continuing anticoagulation in mild cases with monitoring from the prescribing physician. adjusting anticoagulation can be done as needed in cases of severe covid- . there is no data to suggest any interaction of covid- with these medications and we suggest continuing these medications and adjusting as needed by the prescribing physician. the interaction between covid- treatments and the cardiovascular system are previously reviewed in jacc . several medications are under active investigation to treat covid- . antiviral medications being trialed include ritonavir/lopinavir which can cause qt prolongation . ribavirin, another antiviral being investigated, and ritonavir/lopinavir can also interact with anticoagulants , . remdesivir, an investigational antiviral medication used to treat ebola virus, is being trialed and although cardiovascular toxicities have not been reported, among patients one developed hypotension and cardiac arrest after the loading dose , . chloroquine and hydroxychloroquine, antimalarial agents, have been shown in vitro to have inhibitory activity on sars-cov due to increasing cellular endosomal ph and thus preventing the viral endocytosis into the cells , [ ] [ ] [ ] . this medication has been trialed in vitro and has been shown to be effective. however, there is limited human data to support effectiveness in humans , . one small study treated patients who were asymptomatic or had mild covid- with hydroxychloroquine in combination with azithromycin and showed a significant decrease in viral load in treated patients . the results should be taken with this article is protected by copyright. all rights reserved caution as the medication was previously tried in cases of influenza, hiv and zika virus and showed effectiveness in vitro without any positive effect in humans . of note these agents have qt prolonging effects which should be taken into consideration especially when combined with hypokalemia, hypomagnesemia, myocarditis or other qt prolonging medications. this includes azithromycin, another commonly used antibiotic in respiratory infections with qt prolonging effects that is being trialed in covid- infections , . this would be of particular concern in patients in an intensive care unit setting where a variety of qt affecting medications and physiologic conditions might put patients at risk of myocardial hypersensitivity and arrhythmia risk. a list of these medications can be found at https://www.crediblemeds.org/. screening all patients entering a health care facility for covid- symptoms including fever and respiratory symptoms, travel and exposure to covid- cases is essential for early identification of potential covid- patients and to allow care team members to wear appropriate personal protective equipment (ppe) (figure ) . screening may be through the phone before the patient arrives and should employ the use of interpretation services when needed. non-urgent cardiac visits should be rescheduled for a later date, particularly if the patient has viral symptoms without concern for possible worsening cardiovascular disease. urgent cardiac visits with symptomatic patients (or if asymptomatic but with a high-risk exposure) should include the use of a facemask by the patient and ideally a separate waiting rooms . any caregiver entering the room for a confirmed or suspected covid- case should wear a gown, gloves, eye protection and a respirator (e.g. n ). when the supply of respirators is limited a facemask is an acceptable alternative for routine interaction but a respirator this article is protected by copyright. all rights reserved (preferably a powered or controlled air purifying respirator) should be worn for any aerosol generating procedures . these procedures include intubation, cardiopulmonary resuscitation, and manual ventilation before intubation , . transesophageal echocardiography (tee) has been included on this list; but the data is currently unavailable as to whether the risk of aerosolization during tee is similar in both the setting of the paralyzed and intubated patient as opposed to the sedated patient without cuffed intubation who might be expected to gag or cough during the procedure. in light of this data gap, a conservative approach should be employed. during this pandemic, patient to provider, provider to patient and provider to provider transmission represent major challenges. it is important to know that . % of the cases reported from china were of healthcare team members suggesting that health care providers are at a significantly increased risk of contracting covid- , . this emphasizes the need for selfprotection by all providers. this is especially a challenge in cases where ppe are limited and in emergent interventions such as cardiopulmonary resuscitation; providers should prioritize following ppe guidelines and should limit exposure. similarly, elective and nonessential visits and procedures should be postponed. in the chd settings, these include non-urgent cardiac surgeries, cardiac catheterization, tee and electrophysiological procedures. office visits can be postponed or scheduled through phone calls or telemedicine. telemedicine technologies limit the patient and provider exposure while still allowing for patient care . teams must go through the exercise of considering unintended consequence to delayed access to care for the patient and put into place safeguards in their strategy. the duration of the corona virus pandemic is uncertain and therefore requires frequent reassessment of care plans. specific definitions of urgent versus non-urgent should be created so that schedulers and care providers this article is protected by copyright. all rights reserved are in alignment. the definition of non-urgent should include the concept that "delay of a certain duration unlikely to result in patient harm". other strategies may include limiting the number of team members with exposure to suspected cases by allowing phone and chart review consults in patients admitted to the hospital. most congenital cardiac centers hold weekly multidisciplinary conferences to discuss the cases and all team members including cardiologist, surgeons and anesthesiologists attend these conferences. due to the requirement of social distancing to limit viral transmission management, and teaching conferences should be limited and virtual meetings should replace in person meetings (figure ) . in addition, many hospitals are implementing staff screening strategies for symptoms and taking temperature for all employees and is assigning those staff non-essential for patient care to work remotely during these times. as age is a risk factor for severe disease, decisions must be made as to whether to restrict older physicians and care team members to work in settings with lower potential for exposure. in addition to the physical risks this is a stressful time for the care team members and it is important to keep provider wellness in mind. resources can be found on the american college of cardiology website and other professional societal websites . during this time of "physical" distancing it is important to maintain "social connectivity" by supporting each other through our professional societies, our teams and our personal support networks. this has become increasingly via available video communication enterprises , . new information is emerging every day on covid- . it is important to continue to follow the guidelines from the who, the cdc, your local health department, hospital and practice. it is also crucial to make this information easily available and accessible in real time and utilize data visualization tools to allow smooth transformation of the data to the public. in addition, social distancing has limited trainee education. online education is now accessible and this article is protected by copyright. all rights reserved resources from the acc virtual national meeting will be available free of charge. efforts to make other recorded material available for all providers are ongoing. finally technology allows virtual meetings with video communications and conferences to allow for fellows teaching and continue to make multidisciplinary discussions accessible to all care team members. while data are emerging on covid- effect on the cardiovascular system, there are several areas where further research is needed. identifying high risk patients among children and adults with chd is a priority. furthermore, studies to understand the mechanisms of cardiovascular involvement in covid- will facilitate the efforts to discover treatment options. in addition, several trials are ongoing searching for identification of the significance of the infection in patients with chd, treatments and post exposure prophylaxis. an example is a collaboration effort between the adult congenital heart association and the international society for adults with congenital heart disease in order to better understand the impact and burden of covid- on adults with chd in the united states and globally. during these trying times of covid- pandemic, cardiovascular team members will play a central role in controlling the disease. patients with chd are likely to become increasingly affected with covid- and may have more grave outcomes than other populations during the pandemic due to their perturbed physiologic state and co-morbidities. infection control processes are crucial. continuing research and education about the disease may provide us with insights to alleviate morbidity and mortality in the near future. includes simple native lesions (isolated small asd or vsd, mild isolated pulmonary stenosis) or repaired lesions (ligated or occluded pda), repaired asd or vsd without residual shunting or chamber enlargement. repaired or unrepaired lesions including avsd, aortic or mitral valve disease and coarctation of the aorta, anomalous pulmonary venous return, alcapa, aaoca, ebstein, tof, ps (moderate or greater), vsd with moderate or greater shunt. cyanotic congenital heart defect (unrepaired or palliated, all forms), double-outlet ventricle, fontan procedure, iaa, single chd: congenital heart disease. this article is protected by copyright. all rights reserved theoretical concern for reye syndrome although the only reports were at high doses used in kawasaki disease in the setting of influenza or varicella. no reports with covid- . suggest continuing aspirin. theoretical concern due to potential upregulation of ace- . no data to support an interaction with the disease. suggest continuing the medication. covid- may cause dic and coagulation cascade abnormalities in severe cases. suggest continuing the medication in mild cases and adjust as needed in severe cases. some clinician suggested worsening course of the disease if given early. there is no data to show any association of nsaids with the course of the disease. the who does not recommend avoiding nsaids. there is no information to suggest any harmful effect in covid- patients thus it is reasonable to continue these medications. this article is protected by copyright. all rights reserved clinical features of patients infected with novel coronavirus in wuhan, china world health organization declares global emergency: a review of the novel coronavirus (covid- ) who director-general's opening remarks at the media briefing on covid- - covid- (coronavirus) american academy of pediatrics bronchiolitis guidelines c. updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection frequency and consequences of influenza vaccination in adults with congenital heart disease a pneumonia outbreak associated with a new coronavirus of probable bat origin genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding burden of middle east respiratory syndrome coronavirus infection in saudi arabia characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention evidence of the covid- virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms composition and divergence of coronavirus spike proteins and host ace receptors predict potential intermediate hosts of sars-cov- exploring the pathogenesis of severe acute respiratory syndrome (sars): the tissue distribution of the coronavirus (sars-cov) and its putative receptor, angiotensin-converting enzyme (ace ) a crucial role of angiotensin converting enzyme (ace ) in sars coronavirus-induced lung injury ace receptor expression and severe acute respiratory syndrome coronavirus infection depend on differentiation of human airway epithelia good ace, bad ace do battle in lung injury, sars an invited commentary on "world health organization declares global emergency: a review of the novel coronavirus (covid- )": emergency or new reality? a commentary on "world health organization declares global emergency: a review of the novel coronavirus (covid- ) epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid- ) during the early outbreak period: a scoping review covid- in the shadows of mers-cov in the kingdom of saudi arabia aerosol and surface stability of sars-cov- as compared with sars-cov- transmission of -ncov infection from an asymptomatic contact in germany a familial cluster of infection associated with the novel coronavirus indicating potential person-to-person transmission during the incubation period the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application clinical characteristics of coronavirus disease in china loss of sense of smell as marker of covid- infection aao-hns: anosmia, hyposmia, and dysgeusia symptoms of coronavirus disease clinical characteristics of hospitalized patients with novel coronavirusinfected pneumonia in wuhan, china accessed / / . who director-general's opening remarks at the media briefing on covid- - incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response -novel coronavirus ( -ncov): estimating the case fatality rate -a word of caution updates on covid- in korea clinical features in pediatric covid- a review of coronavirus disease- (covid- ). indian journal of pediatrics sars-cov- infection in children a -day-old female infant infected with covid : presenting with pneumonia, liver injury, and heart damage county teen's death may be coronavirus related. here is what we know epidemiological characteristics of pediatric patients with coronavirus disease in china cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease (covid- ) pandemic prevalence and impact of cardiovascular metabolic diseases on covid- in china electrophysiology and adult congenital heart disease: advances and options. progress in cardiovascular diseases similarity in case fatality rates (cfr) of covid- /sars-cov- in italy and china association of lymphopenia with risk of mortality among adults in the us general population inflammatory mechanisms linking obesity and metabolic disease first cases of covid- in heart transplantation from china covid- : yet another coronavirus challenge in transplantation epidemiological and clinical characteristics of heart transplant recipients during the coronavirus outbreak in wuhan, china a descriptive study cardiac troponin i in patients with coronavirus disease (covid- ): evidence from a meta-analysis. progress in cardiovascular diseases clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan, china clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study preparing for the most critically ill patients with covid- : the potential role of extracorporeal membrane oxygenation the total correction of congenital heart disease in infants. annual review of medicine congenital heart defects in the united states: estimating the magnitude of the affected population in detection of covid- in children in early january in wuhan, china aha/acc guideline for the management of adults with congenital heart disease: executive summary: a report of the american college of cardiology/american heart association task force on clinical practice guidelines aha/acc guideline for the management of adults with congenital heart disease: a report of the american college of cardiology/american heart association task force on clinical practice guidelines vulnerable groups with congenital heart disease diagnosis and management of noncardiac complications in adults with congenital heart disease: a scientific statement from the american heart association endocarditis in congenital heart disease: who is at highest risk? anti-platelet agents in pediatric cardiac practice reye's syndrome developing in an infant on treatment of kawasaki syndrome kawasaki disease with reye syndrome: report of one case. zhonghua minguo xiao er ke yi xue hui za zhi covid- : ibuprofen should not be used for managing symptoms, say doctors and scientists ema gives advice on the use of non-steroidal anti-inflammatories for covid- are patients with hypertension and diabetes mellitus at increased risk for covid- infection? hfsa/acc/aha statement addresses concerns re: using raas antagonists in covid- abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia teicoplanin: an alternative drug for the treatment of coronavirus covid- ? effect of ketoconazole and diltiazem on the pharmacokinetics of apixaban, an oral direct factor xa inhibitor a randomized, controlled trial of ebola virus disease therapeutics a systematic review on the efficacy and safety of chloroquine for the treatment of covid- aminoquinolines against coronavirus disease (covid- ): chloroquine or hydroxychloroquine of chloroquine and covid- : . . interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid- ) in healthcare settings the outbreak of covid- : an overview accessed / / . . ways to address physician stress during covid- pandemic understanding social media: opportunities for cardiovascular medicine this article is protected by copyright. all rights reserved sources of funding: none. this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved key: cord- -e x z rh authors: cruz, christian joy pattawi; ganly, rachel; li, zilin; gietel-basten, stuart title: exploring the young demographic profile of covid- cases in hong kong: evidence from migration and travel history data date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: e x z rh this paper investigates the profile of covid- cases in hong kong, highlighting the unique age structure of confirmed cases compared to other territories. while the majority of cases in most territories around the world have fitted an older age profile, our analysis shows that positive cases in hong kong have been concentrated among younger age groups, with the largest incidence of cases reported in the – age group. this is despite the population’s rapidly aging structure and extremely high levels of population density. using detailed case data from hong kong’s centre for health department and immigration department, we analyze the sex and age distribution of the confirmed cases along with their recent travel histories and immigration flows for the period january to april . our analysis highlights hong kong’s high proportion of imported cases and large overseas student population in developing covid- hotspot areas such as the united kingdom. combined with community action and targeted and aggressive early policy measures taken to contain the virus, these factors may have contributed to the uniquely younger age structure of covid- cases in the city. consequently, this young profile of confirmed cases may have prevented fatalities in the territory. recent research has highlighted the importance of a demographic approach to understanding covid- transmission and fatality rates. the experience in hong kong shows that while an older population age structure may be important for understanding covid- fatality, it is not a given. from a social science perspective at least, there is ‘no easy answer’ to why one area should experience covid- differently from another. the hong kong special administrative region of the people's republic of china (hereafter hong kong) is a city and special administrative region of china in the eastern pearl river delta by the south china sea. in , hong kong had roughly . million people in a , -square-kilometre ( square miles) territory while in kowloon, where more than three in ten residents reside, population density is at , persons per square kilometer. this makes it one of the most densely populated territories in the world [ ] . apart from being a rapidly aging society [ , ] , hong kong is also a migration destination. for the period to , the net migration number was , or a net of four in-migrants per , of the population [ ] . hong kong faces the challenge of infectious diseases as a consequence of various factors, including high population density, increasing environmental pollution, high migration inflows and outflows, the emergence of new infections as well as the changing lifestyle and behavior of its residents [ , ] . the most recent significant outbreak was the severe acute respiratory syndrome (sars) outbreak which reached hong kong in march [ ] . based on world health organization (who) data until july , , a total of , sars cases had been identified in the territory, of which people died of the disease [ ] . at that point, it was largely believed that hong kong was unprepared to be one of the epicenters of the sars epidemic. from this recent experience, did hong kong learn from the hard lessons of the past? the who officially declared the novel coronavirus infections (hereafter covid- ) outbreak as a pandemic on march , , after it had spread to more than countries and resulted in tens of thousands of cases within a few months. in hong kong, however, the first case was reported on january , . in early february, the government was strongly criticized for policy responses related to a variety of issues, including the legality of, and access to face masks; border closure; medical fees and quarantine policy [ ] . during this early period, unfavorable comparisons were made with other regional governments (especially macau and singapore) who appeared to be managing the crisis more effectively [ , ] . however, by the time of writing in june , new cases being reported in hong kong-especially local transmissions-are very rare [ ] . that this has occurred without the general lockdown policies seen in other parts of the world is even more remarkable. our study includes an examination of the age and sex distribution of the covid- confirmed cases in hong kong and an exploration of how the different measures to combat this outbreak resulted in a relatively low number of cases and deaths. specifically, as demographers, we wished to explore the extent to which insights from demographic science could assist in explaining the nature of the hong kong experience of covid- . in this paper, we highlight the potential impact of the young profile of the confirmed cases on the total number of mortalities and the effect of early, aggressive policy measures including travel bans, enforced quarantines and contact-tracing imposed by the hong kong government as early as january , in containing the spread of the covid- . data on confirmed covid- cases were taken from the centre for health protection (chp) of the hong kong department of health. we assessed the age and sex distribution of the confirmed cases, discharge status (discharged, hospitalized or died) and type of transmission. we obtained the data regarding cumulative cases by age group from january to april , , which allowed us to determine the age group that registers the highest number of confirmed cases over time. daily migrant inflows and outflows data was retrieved from the hong kong immigration department showing arrivals at each border checkpoint into hong kong broken down by citizenship status. in addition, we retrieved detailed archived datasets pertaining to the travel histories of confirmed covid- cases, which are updated on an almost daily basis by the chp. we excluded travel histories pertaining to domestic travel (buses, trains and ferries) and a small number of journeys pertaining to outbound from hong kong. we linked travel histories to confirmed case identifications (ids) in order to examine the age structure and timing of cases where the apparent source of infection was not in hong kong (i.e. not a community infection). these include cases with a travel history from countries with widespread infection or where infection from a confirmed case who traveled occurred. by doing so, we highlight the importance of returnee hong kong residents from overseas hotspots on the relatively young age structure of confirmed cases during the second wave in march . we also gathered data on policy measures implemented by the hong kong government in order to highlight the possible impact of major border closures and quarantine arrangements imposed by the hong kong government in reducing further numbers of imported covid- infections. we also utilized secondary data for comparative demographic analyses from the hong kong census and statistics department, united nations population division and the chinese center for disease control and prevention. compared with the aging hong kong population [ ] , the covid- confirmed cases have an entirely different distribution. fig shows [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . less than a tenth ( . %) are aged and over. this age distribution of the local covid- confirmed cases does not fit the general profile of other territories wherein the infections are more concentrated among those in the older age groups. although, of course, this may be related to testing patterns by age, rather than true differences in incidence. the who coronavirus disease situation report shows that as of april , , there were a total of , confirmed cases with reported information on age and sex coming from countries, territories and areas; of these confirmed cases, the median age for males is (interquartile range, iqr: - ) years and for females (iqr - ) years [ ] . examples of territories with an older profile of confirmed cases are mainland china where the majority of confirmed cases ( . %) as of february , belong to the older age groups, at least years old [ ] , and the philippines wherein as of march , , the majority of the confirmed cases are in the age group and older [ ] . there is also an imbalanced sex ratio among the covid- confirmed cases in hong kong with a higher proportion of male cases, representing % of the total. the number of male cases outnumbered females in almost all age groups, except in the - age group where they made up only % of cases. for all other age groups, male cases were between to % of the total; an exception was for those aged under of which % of cases were male, however, the total number of cases at this age was extremely small ( out of the total , cases). this sex profile with a higher prevalence of male cases is similar to the outbreaks in other territories [ , ] the youngest confirmed cases in hong kong were two males under one-year-old while the oldest confirmed case is a -year-old female. nearly half of the , confirmed cases ( . %) had already been discharged from the hospital as of april , . in short, covid- confirmed cases in hong kong were found primarily among the working and school-age groups, and to a certain degree, among men. by april , , almost three months after the first reported case on january , , four deaths among confirmed covid- cases were reported in hong kong. three such deaths were over years old (two males and one female) while the fourth was the case of a -year old male. it is possible that this young age structure of confirmed cases in hong kong contributed to the extremely low numbers of fatalities compared to other territories. a large proportion of hong kong's confirmed cases were 'imported'. three in five confirmed cases ( . %) have travel history from countries with widespread infection or were directly infected by a confirmed case who travelled; hence, they are considered cases with imported transmission (see fig ) . two-fifths of these imported confirmed cases ( . %) are young adults in the age group - years old. the proportion of imported versus local cases differs significantly based on age group. nine in ten of the confirmed cases in the - age group ( . %), the group with the largest incidence of covid- , were in fact imported. in contrast, . % of cases aged - and less than half of those in other age groups are considered imported. most of hong kong's cases in the younger age groups occurred in a second wave of infections during march. before march , , the age group with the highest frequency of covid- cases was - followed closely by the and over age group (see fig ) . however, after march , the number of new cases in hong kong sharply increased, most of these being imported cases in younger age groups. this timing of these imported cases is similar to that experienced by china wherein the imported cases more than doubled starting from march , , mostly coming from countries with high outbreak of covid- infections like the united kingdom (uk), united states of america (usa) and spain [ ] . however, age-specific data about imported cases is not available in china. analysis of the travel histories of hong kong cases suggests that the majority of imported cases in the - age group may be hong kong residents who are studying or working abroad. the travel history data collected and archived by the chp over the study period was matched to case numbers from the case data to study the travel history and age profile of all known imported cases. the data collected by the chp contains the travel histories of all confirmed covid- cases up to fourteen days before the case was reported and formed part of attempts of the government to track and trace the movements of all newly reported cases. this is done in order to contact and isolate anyone with whom they had close contact in the days before the onset of symptoms, including those whom they may have sat close to on flights. of the covid- cases with an overseas travel history tracked by the chp, . % were imported from the uk, . % from the usa and . % each from qatar, canada and switzerland. by far the largest age group with a travel history was those aged - with cases, of which the majority were from the uk ( . %), . % from the usa, and . % to . % each from switzerland, qatar and the netherlands. the next largest group with travel histories was those aged - with cases, nearly half of these coming from the uk ( . %). we are not able to ascertain the employment or other characteristics of these cases. hong kong has a large population of mobile residents who hold citizenship or permanent residency but work, study or are retired overseas. according to the by-census, just under , permanent residents of hong kong were deemed 'mobile', meaning they had spent between one to three months in the city of the previous six [ ] . in , the largest population of mobile residents was those aged - , with a total of , most of whom were registered as students. we were not able to obtain the country of temporary overseas residency from the census data. the next largest population of mobile residents were those aged and over ( , ) who were mostly registered as retired, while a further , were aged to mostly employees or retirees. in addition, according to the by-census hong kong is home to a sizable number of non-permanent residents; many of these residents may return to their home countries on a regular basis for study, work, or family visits. the largest groups of non-chinese nationals were filipinos ( , ) and indonesians ( , ), most of whom work as domestic workers on temporary foreign-worker permits. hong kong was also home to , british citizens, almost , americans and , citizens from south asian countries (india, nepal and pakistan), while a further , hong kong chinese were registered as being domiciled overseas in [ ] . the large increases in newly confirmed cases in the younger age groups, the majority of which were imported, occurred from march , onward (fig ) . this was in tandem with a large increase in confirmed cases and deaths throughout multiple countries in europe, usa and canada. on march , , the hong kong security bureau had announced a 'red outbound travel alert' ('red ota') for the schengen area, announcing a mandatory -day home quarantine for all arrivals from the schengen area. this was followed by a 'red ota' for ireland, united kingdom and the usa on march , with the announcement of home quarantine arrangements for all travelers from the three states to begin four days later (see s table for a full timeline of policy events). fig shows the arrivals into hong kong over the period from january to april , . most arrivals were hong kong residents travelling via the airport. on february , , all land and sea border points were closed except for two control points-the shenzhen bay control point and hong kong-zhuhai-macao bridge. daily arrivals into the city fell dramatically after the end of the chinese lunar new year holidays at the end of january , and took another dramatic fall after the home quarantine arrangements for all arrivals from china were put into place on february , . arrival numbers followed a relatively steady pattern at under , per day until dropping off sharply from march , , when the new -day home quarantine arrangements were put in place for all arrivals into the city, regardless of whether or not they were residents. from march , , all non-residents were barred from entering the city except for nationals of macau, taiwan or mainland china. these border closures and sharply lower inbound-travel movements together with hong kong's aggressive policy of testing, contact-tracing and quarantine of confirmed cases and their close contacts (see s table) undoubtedly contributed to the sharp decline in newly confirmed cases during the month of april [ ] . on april , , hong kong recorded its first day without a confirmed case, from a peak of more than cases per day in late march. social distancing and rapid population behavioral changes also likely played a role, with measures such as wearing masks, working from home and school closures leading to an estimated . % reduction in seasonal influenza incidence [ ] . the containment of a severe local outbreak of covid- in hong kong thus far, and the very high incidence of confirmed cases in younger age groups mostly among hong kong residents returning to the city from overseas hotspot areas, have surely contributed to the very low number of fatalities in the city-state, with only four deaths reported by april , out of , confirmed cases. one death occurred in the years and over age group, out of twelve total cases. in italy, china and south korea, vastly higher case fatality rates were recorded for those in the older age groups; as at march , case fatality rates for those above years old were at . % in italy and . % in south korea [ , ] . this paper takes a social scientific approach to illustrate the particularities of covid- outcomes in hong kong up until now. the paper is a simple, descriptive analysis of the available data on hand. a recent paper highlighted the importance of a demographic approach to understanding covid- transmission and fatality rates [ ] . the paper suggested that 'the age structure of a population may help explain differences in fatality rates across countries and how transmission unfolds.' fig shows the full population pyramid for hong kong in . observing the discrepancy in the shapes of the pyramids in figs and , it is clear the experience from hong kong suggests that age structure alone is not a universal factor in shaping transmission and fatality rates. despite having more than . % of the population and over and an extremely high population density, a package of policies designed to contain the virus spreading from younger imported cases and becoming a sustained local outbreak ensured that case and mortality numbers stayed low. a further difference between hong kong and other settings characterized by higher rates of infection (and fatality) is the lower levels of distribution of residential care and support among older persons. there is strong evidence that people living in residential/nursing homes are particularly vulnerable to not only infection and its rapid spread, but to severe covid- infection and fatality [ ] [ ] [ ] ; so much so that the who referred to care home infection and fatality rates as an "unimaginable human tragedy" [ ] . in a study of official data in ten countries, deaths in care homes account for between - % of all deaths [ ] -although international comparison is difficult because of differences in cause of death reporting as testing procedures. in common with other parts of the world, the hong kong government has issued guidelines to support residential care homes in preventing infection [ ] , as well as offering other support in terms of provision of personal protective equipment (ppes) and infection protection services [ ] and a switch to online care support for those who would ordinarily visit day care centers [ ] . there may thus be institutional reasons for the low levels of transmission among older people. the size and percentage of the older population resident in care homes differs widely around the world [ ] . in the uk, where a high percentage of infections and fatalities have occurred in care homes [ , ] , it is estimated that around . % of the population aged over is resident in care homes [ , ] . in addition, a further . % of that population receive care support in their own homes, including from carers making multiple home visits in a day-potentially another area of risk for infection [ , ] . in contemporary hong kong, meanwhile, the proportion of over s in residential/nursing homes is estimated to be around . % [ , ] . these lower rates of care home residence may have contributed to lower overall transmission and fatality numbers among the elderly by creating lower opportunities for sustained local spread within the elderly population. low-income migrant workers, an already neglected group in terms of health and other support mechanisms during this pandemic [ ] , represent a further group often characterized by communal living. highly elevated transmission rates have been seen in some settings where such migrant workers often live in cramped, unsanitary conditions [ ] . in singapore, for example, over half of the purpose-built and factory-converted dormitories have been affected [ ] ; a factor held primarily responsible for the 'second wave' of infections in the city-state. it has been estimated that some % of all cases have been linked to such dormitories. compared to singapore, such 'dormitories' are rare in hong kong. perhaps the primary, related housing issue in hong kong is 'subdivided housing'; home to up to , poor, urban individuals [ ] and sometimes referred to as 'coffin houses' because of their very small sizes [ ] . while often characterized by poor hygiene, low environmental [ ] and safety standards [ ] , it appears that policy measures in hong kong, which succeeded in stemming local transmission chains, meant these quasi-communal units were not left exposed to rapid covid- transmission. a final possible factor mentioned by dowd et al. [ ] concerns the possibility that 'intergenerational interactions, co-residence, and commuting may have accelerated the outbreak in italy through social networks that increased the proximity of elderly to initial cases.' this would be derived from a mechanism whereby the younger population most susceptible to initial infection [ ] transmit to the elder population through such contact. in hong kong, multi-generational residence is common [ ] , where around % of those aged and over live with their adult children [ ] -much higher than in italy (or, indeed, any other setting in europe or north america characterized by high transmission rates) [ ] . the extremely high population density of hong kong coupled with short distances and highly efficient transport systems means that there is a high degree of residential proximity as well regular contact between older parents and their children. a further dimension of intergenerational, intrahousehold interaction involves migrant domestic workers, who increasingly operate a major means of care support within the household. there is little evidence in hong kong that such workers were responsible for transmission within the household. as such, the hypothesis suggested for italy appears inconsistent with the hong kong case at least. the general quality of population health data in hong kong is generally accepted to be high, not least because of the centralized healthcare system in the territory. furthermore, in this case a very high degree of health surveillance and monitoring was in force throughout the period. this analysis relied heavily on secondary data for both the information on the confirmed cases and travel histories. given this, there are possible concerns for under diagnosis and under reporting especially during the start of the outbreak until before its first peak as have also been observed in other countries [ ] . the unique age and sex distribution of the cases in hong kong may also be affected by testing patterns. there may, of course, have been unreported and/or asymptomatic cases in hong kong which will have escaped our analysis. however, there is no current consensus on such rates of asymptomatic infection and, therefore, how one might either estimate or correct in the hong kong case [ ] . finally, the challenge of ascertaining primary cause of death and the role played by covid- interacting with other factors [ ] [ ] [ ] is not a significant issue in hong kong given the very small number of deaths. a major limitation is that the spread of covid- has not yet ended. any observations of a 'case in progress' are prone to future, unexpected changes which will change the narrative already described. of course, by the time this paper is published it is eminently possible that events have taken a turn for the worse and a third wave of infections occur. despite this, hong kong has clearly demonstrated a capacity to control both the transmission and fatality of covid- until this point. as of june , there have been no covid- ascribed deaths since march , . furthermore, as of april , , hong kong has reported no new cases for the sixth time in ten days [ ] , and there were just five cases of local transmission in the month of may. from the start of may, public facilities began to reopen, some border restrictions were lifted, and civil servants returned to work in their offices. as of mid-june, public facilities such as beaches, libraries, museums, swimming pools have largely reopened, as have the last group of commercial leisure/entertainment facilities (karaoke lounges, nightclubs, bathhouses and party venues). clearly, much more research is required to concretely establish both the epidemiological and social factors contributing to the hong kong experience. the data which will allow such analysis will only come on stream in the future. at this point more complex statistical analysis will be able to be performed. furthermore, it will then become possible to link data on transmission and fatality through to other clinical and vital records (including the planned census in ). such data will also need to be complimented by survey data and qualitative research to provide a broader sense of the hong kong context. policy interventions, institutional systems, household and living arrangements each played a role in a complex, interwoven way. however, we must not overlook the role played by the community itself who, through behavioral change and increased vigilance, appear to have been equally instrumental in shaping hong kong's covid- experience. it may be in this way that the greatest lessons of sars have been learned [ ] . supporting information s table. timeline world population prospects: the revision the population problem in pacific asia remeasuring ageing in hong kong sar; or "keeping the demographic window open prevention and control of communicable diseases in hong kong. government printer the sars epidemic in hong kong: what lessons have we learned? who. cumulative number of reported probable cases of sars. in: who [internet reasons hongkongers are angry about the gov't response to the coronavirus macau's last covid- patient recovers, with no new cases for a month why did singapore have more coronavirus cases than hong kong? in: south china morning post another day of no new covid- cases in hong kong situation report- . world health organization the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- )-china demographic research and development foundation, inc. (drdf). covid- and the older filipino population: how many are at risk? uppi/ drdf research brief weekly assessment of the covid- pandemic and risk of importation-china population by-census impact assessment of non-pharmaceutical interventions against coronavirus disease and influenza in hong kong: an observational study. lancet public health the epidemiological characteristics of novel coronavirus diseases (covid- demographic science aids in understanding the spread and fatality rates of covid- death toll in uk care homes from coronavirus may be , , study estimates. financial times number of deaths in care homes notified to the care quality commission, england. in: office for national statistics mortality associated with covid- outbreaks in care homes: early international evidence. international longterm care policy network unimaginable human tragedy" in europe's care homes, says who. japan times guidelines for residential care homes for the elderly or persons with disabilities for the prevention of coronavirus disease (covid- ) (interim) online day care keeping elderly hongkongers active during isolation nursing homes in nations: a comparison between countries and settings how big is the problem in care homes? bbc office for national statistics kong ngo shows care homes they can stop keeping elderly in restraints. south china morning post the neglected health of international migrant workers in the covid- epidemic migrant workers in cramped gulf dorms fear infection current situation on migrant workers in dormitories-home thematic report: persons living in subdivided units tiny affordable housing in hong kong air and hygiene quality in crowded housing environments-a case study of subdivided units in hong kong a brief discussion on fire safety issues of subdivided housing units in hong kong social contacts and mixing patterns relevant to the spread of infectious diseases solidarity, ambivalence and multigenerational co-residence in hong kong. contemporary grandparenting: changing family relationships in global contexts living arrangements and older people's labor force participation in hong kong intergenerational co-residence during later life in europe and china level of underreporting including underdiagnosis before the first peak of covid- in various countries: preliminary retrospective results based on wavelets and estimating the extent of asymptomatic covid- and its potential for community transmission: systematic review and meta-analysis. medrxiv pathological findings of covid- associated with acute respiratory distress syndrome autopsy in suspected covid- cases case-fatality rate and characteristics of patients dying in relation to covid- in italy we would like to thank the academic editor and reviewers for their helpful and constructive suggestions. we would also like to thank professor stéphane helleringer for his comments on an earlier draft. the authors have declared that no competing interests exist. key: cord- -o e na authors: nan title: scientific session of the th world congress of endoscopic surgery, jointly hosted by society of american gastrointestinal and endoscopic surgeons (sages) & canadian association of general surgeons (cags), seattle, washington, usa, – april : poster abstracts date: - - journal: surg endosc doi: . /s - - - sha: doc_id: cord_uid: o e na nan purpose: to evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (sils-tep) of incarcerated inguinal hernia. patients and methods: clinical setting a retrospective analysis of patients undergoing sils-tep for incarcerated hernia from may to august at kinki central hospital was performed. exclusion criteria sils-tep was contraindicated for the following conditions in our hospital: a history of radical prostatectomy; a small indirect inguinal hernia in a young patient; and unsuitable for general anesthesia. surgical procedure laparoscopic abdominal exploration through a single, . -cm, intraumbilical incision was performed. the incarcerated hernia content was gently retracted from the hernia sac into the abdominal cavity. in some cases, simultaneous manual compression on the incarcerated hernia from the body surface was required. if no bowel resection was needed, a standard sils-tep using mesh was performed following laparoscopic abdominal exploration and incarcerated hernia reduction. if bowel resection was required, inguinal hernia repair using mesh was not performed to avoid postoperative mesh infection, and two-stage sils-tep was performed - months after the bowel resection. results: fourteen patients ( men, women) with irreducible inguinal hernias, including with unilateral hernias and with bilateral hernias, underwent surgery. the patients' median age was years (range, - years), and median bmi was . kg/m (range, . - . kg/m ). of the patients, had acute incarceration, and had a chronic irreducible hernia. seven patients with acute incarcerated hernias underwent emergency surgery, and two of the seven patients needed singleincision laparoscopic partial resection of the ileum, followed by two-stage sils-tep. twelve patients, excluding two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by sils-tep. one case of chronic incarceration out of the twelve patients who underwent sils-tep after hernia reduction required conversion to kugel patch repair. the median operative times were min (range - min) for unilateral hernias and min (range - min) for bilateral hernias. the median blood loss was minimal (range - ml). the median postoperative hospital stay was day (range - days). the median follow-up period was months (range - months). a seroma developed in % ( / ) of patients and was managed conservatively. no other major complications or hernia recurrence were noted during the follow-up period. conclusions: sils-tep, which offers good cosmetic results, could be safely performed for incarcerated inguinal hernia. objective: introduction of mis in pediatric age group has been proved feasible and safe. there is considerable evolution with introduction of a number of invovation in mis pediatric inguinal hernia repair. high ligation of sac is the basic premise of surgical repair in pediatric inguinal hernias. there are different mis techniques broadly grouped into intracorporeal or intracorporeal with extracorporeal component namely the suturing. every techniques has its own complications. the main objective of our study was to focus on different anatomical pointers which can lead inadverent complications mainly bleeding and recurrence. methods and procedures: prospective review of hernias ( male and female) ( months- years) performed laparoscopically between september and june . under laparoscopic guidance, the internal ring was encircled extraperitoneally using a - non-absorbable suture and knotted extraperitoneally. data analyzed included operating time, ease of procedure, occult patent processus vaginalis (ppv), contralateral inguinal hernia, complications, cosmesis and recurrence. results: sixteen right ( %), left ( %) and bilateral hernia ( %) were repaired. five unilateral hernias ( . %), all left, had a contralateral ppv that was repaired (p= . ). mean operative time for a unilateral and bilateral repair were . ( - ) and . min ( - min) respectively. one hernia repair still recurred ( . %) even with all precautions and another had a post operative hydrocoele ( . %). one case ( . %) needed an additional port placement due to inability to reduce the contents of hernia completely. because of our techinique we could not find any adverent peroperative bleeding. there were no stitch abscess/granulomas, obvious spermatic cord injuries, testicular atrophy, or nerve injuries. conclusion: the results confirm safety, efficacy and cost effectiveness of laparoscopic inguinal hernia repair. during our per-operative analysis we focus to address the anatomical landmark to minimize future recurrence and peroperative surgical complications. we identified and named a point as j. point at the tip of triangle of "doom". that is most important point to address peroperatively. there is high chance of recurrence if that point is not encircled well or inadequately circled because of fear of iliac vessels injury. we aslo concluded that 'water dissection technique' is effective techniques in un-experienced hand and in early stages of laparoscopic hernia repair to prevent inadvertent iliac vessels injury. medstar georgetown university hospital, georgetown university school of medicine, introduction: incisional hernias following abdominal surgery can be associated with significant morbidity leading to decreased quality of life, increase in health care spending and need for repeat operations. patients undergoing gastrointestinal and hepatobiliary surgery for malignant disease may be at higher risk for developing incisional hernias. identifying these risk factors for incisional hernia development can help decrease occurrence. this will be the largest multi-institutional study looking at incidence of symptomatic hernia rates for major abdominal operations including colectomy, hepatectomy, pancreatectomy, and gastrectomy. methods and procedures: an irb-approved retrospective study within the medstar hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures performed across hospitals between the years of to . all patients were identified using icd- and icd- codes for relevant procedures and then subdivided into either having benign or malignant disease. exclusion criteria comprised of patients who had concomitant organ resection, or those undergoing organ transplant. data validation was performed to verify the accuracy of the data set. the rate of symptomatic incisional hernia rates (ihrs) were determined for each cohort based on subsequent hernia procedural codes identified and repairs performed. descriptive statistics and chi squared test were used to report ihrs in each group. results: during this -year span, a total of , major abdominal operations were performed at all institutions, comprising of , colectomies, , hepatectomies, , pancreatectomies, and gastrectomies. malignancy was the indication for surgery in , ( . %) colectomies, ( . %) hepatectomies, ( . %) pancreatectomies, and ( . %) gastrectomies. ihr in each cohort for benign vs malignant etiologies, respectively, are as follows: ( . %) vs ( . %) in colectomy (p= . ), ( . %) vs ( . %) in hepatectomy (p= . ), ( . %) vs ( . %) in pancreatectomy (p= . ), and ( . %) vs ( . %) in gastrectomy (p= . ) patients. conclusion: symptomatic incisional hernia rates following major gastrointestinal and hepatobiliary surgery ranges from . to . %. there was no significant increase in hernia rates in patients undergoing surgery for malignancy. patients undergoing colectomy for benign disease had a high incidence of symptomatic ihrs. introduction: prosthetic infections, although relatively uncommon, are a major source of cost and morbidity. the study aimed to evaluate the influence of mesh structure including the polymer type and mean pore size on bacterial adherence in a mouse model. methods: three commercially available hernia meshes were included in the study. for each mesh type, a cm square was surgically placed intraabdominally in mice. one mouse served as a control while an enterotomy was made in the subsequent mice to introduce a bacterial load onto the mesh. after hours the meshes were harvested. the inoculated meshes were then plated on agar plates and bacterial counts were counted after hours. the bacterial counts were compared between the various mesh types. results: the mean bacterial adherence was increased in the large pore mesh was colonies, for the small pore mesh was colonies, and in the biologic mesh group it was colonies. conclusions: through the use of a mouse model, the influence of mesh type and pore size on bacterial adherence was evaluated. meshes that have larger pores with a lower prosthetic load and the biologic mesh interestingly had lower early bacterial colonization after hours following an enterotomy. further evaluation with a longer incubation time could be helpful to determine the effect of bacterial colonization of mesh. hrishikesh salgaonkar, raquel maia, lynette loo, wee boon tan, sujith wijerathne, davide lomanto; national university hospital, singapore laparoscopic repair of groin hernias is widely accepted approach over open due to lesser pain, faster recovery, better cosmesis and decreased morbidity. however, there is still debate on its use in large inguino-scrotal hernias, recurrent hernias and history of lower abdominal surgery anticipating adhesions and difficulty in dissecting extensive hernia sac. retrospective analysis of prospectively collected data was done of patients undergoing laparoscopic repair of large inguino-scrotal, incarcerated groin hernia, recurrent cases after open or laparoscopic repair and history of previous lower abdominal surgery. between january to july , patients with large inguino-scrotal hernias, recurrent hernia, history of lower abdominal surgery, incarcerated femoral hernia underwent laparoscopic inguinal hernia repair. patient characteristics, operating time, surgical technique, conversion rate, complications and recurrence up to months recorded. patients had large inguino-scrotal hernia, recurrent hernia ( previous open, previous lap) , history of lower abdominal surgery ( lscs, appendectomy, prostatectomy, midline laparotomy), incarcerated femoral hernia, meshoma removal. patients underwent total extraperitoneal (tep) repair, transabdominal pre-peritoneal (tapp), needed conversion to open. mean operation time was min for unilateral and min for bilateral hernia. seroma formation seen in patients, minor wound infections treated conservatively. we conclude that the laparoscopic approach can be safely employed for the treatment of complex groin hernias; surgical experience in laparoscopic hernia repair is mandatory with tailored technique in order to minimize morbidity and achieve good clinical outcomes with acceptable recurrence rates. mesh fixation in ventral incisional hernia is a topic of ongoing debate. permanent and absorbable tacks are acceptable and widely used methods for mesh fixation. the purpose of this study was to compare outcomes of permanent tack fixation versus absorbable when used alone or with suture fixation in laparoscopic incisional hernia repairs. a retrospective review of all patients undergoing laparoscopic ventral hernia using tack fixation (absorbable/permanent) alone or in conjunction with suture fixation was queried from the ahsqc database. outcome measures included hernia recurrence rate, pain, quality of life, wound related issues, and hospital length of stay. propensity match scoring was performed to compare patients undergoing tack only fixation versus tack and suture fixation with a p-value of . considered significant. a total of patients were identified after propensity match scoring with who underwent repair with permanent tacks alone or with sutures and who underwent repair with absorbable tacks alone or with sutures. following matching there were no differences in bmi, age, hernia width/length, or baseline pain/ quality of life. there were no significant differences found in outcome measures including recurrence rates, pain and quality of life outcomes at days, months, and year, surgical site infection (ssi), and postoperative length of stay (p[ . ). there was a significant increase in any post op complication in the permanent tack fixation group compared to the absorbable tack fixation group ( % vs %, p. ) which is likely due to the increase in surgical site occurrences noted in the permanent tack fixation group ( % vs. %, p. ). based on this large data set, there are no significant differences in postoperative outcomes in permanent versus absorbable fixation in laparoscopic hernia repair except in surgical site occurrences. further study is needed to evaluate but at the present time, there is no convincing evidence that one type of fixation is superior to another in laparoscopic ventral hernia repair. introduction: inguinal hernia repair is the most common procedure in general and visceral surgery worldwide. laparoscopic transabdominal preperitoneal mesh hernioplasty (tapp) has been also popular surgical method in japan. single incision laparoscopic surgery is one of the newest branches of advanced laparoscopy, and its indication has been spread to not only simple surgery such as cholecystectomy, but also complex surgery. we report our experience with single incision laparoscopic tapp (s-tapp) for japanese patients with inguinal hernia. case description: a consecutive series of patients ( male, female) who underwent s-tapp during june to september in a single institution. twenty eight of the patients had bilateral inguinal hernia. the mean follow-up was days. the average age of the patients was . ± . years. establishment of the ports: a -mm vertical intra-umbilical incision is made for port access. one -mm optical port and two -mm ports were placed side-by-side through the umbilical scar. surgical procedure: the procedure was carried out in the conventional fashion with a wide incision in the peritoneum to achieve broad and clear access to the preperitoneal space, and an appropriate placement of polypropylene mesh ( dmaxtm light, bard) with fixation using the tacking device (absorbatack®, covidien). the hernia sac is usually reduced by blunt dissection, or is ligated and transected with ultrasound activated device. the peritoneal flap is closed by one suture with - pds and the - tacks using absorbatack®. discussion: in one patient, we encountered a large sliding hernia on the right side having sigmoid colon as content of the sac, which required conversion to the conventional laparoscopic procedure. there were nine recurrence cases after surgery of laparoscopic or anterior approach, and two cases after prostatectomy. there was no intra-operative complication. the mean operative time was . ± . min, and blood loss was minimum in all cases. the average postoperative stay was . ± . days. there was one recurrence case ( . %) months after the surgery. there was no severe complication after the surgery, but there were seromas ( . %) and one hematoma ( . %). two patients had blunt tactile sense in the area of the lateral femoral cutaneous nerve ( . %), which improved in two months. conclusion: our results suggest that s-tapp is a safe and feasible method without additional risk. moreover, cosmetic benefit is clear. however, further evaluation for postoperative pain and longterm complications compared to standard laparoscopic tapp mesh hernioplasty should be required. manuel garcia, md, daniel srikureja, md, marcos j michelotti, md, facs; loma linda university health introduction: prosthetic mesh use has become standard practice during ventral hernia repair to reduce the risk of recurrence. the ideal mesh is macro-porous which favors rapid cellular ingrowth and tissue integration, has limited tissue reactivity, low profile and weight, and has high tensile strength to add resilience to the repair. additionally, the material is expected to have good handling characteristics. currently, there is a wide variety of options for mesh. biosynthetic material (poliglycolic acid/trimethylene carbonate -pga/tmc) has been shown to behave well in terms of early vascularization and ingrowth as well as adequate long term tissue generation. gore® synecor® biomaterial is a composite mesh including two layers of absorbable biosynthetic material (pga/tmc) with one tridimensional non-absorbable macro-porous knit of dense ptfe mesh. it has shown good vascularization and ingrowth at days in animal examination. however, there is still no evidence of long term behavior of this mesh in human tissue. we present the first histologic analysis of this mesh year after placement in a human. objective: to perform a histologic analysis of the gore® synecor® biomaterial one year after placement in the human body. methods: after incidentally finding incorporated gore® synecor® mesh in a patient with prior ventral hernia repair year ago, during open bilateral inguinal hernia repair, a sample of mesh was taken and sent to pathology lab for analysis. tissue healing, vascularization, and ingrowth of the composite mesh were analyzed. results: histologic findings significant for a biomaterial consistent with a knitted ptfe material surrounded by mature fibrovascular tissue and foreign body inflammation consistent with expected healing response for this time frame. no evidence of any other biomaterial (pga/tmc) or evidence of infection. conclusion: gore® synecor® biomaterial has shown to be well integrated into appropriately healed tissue, with pronounced vascularization and ingrowth. the pga/tmc layers have been seen to be completely absorbed and replaced by collagen. these findings, in a human months sample, replicate what had been shown in animal specimens. method: from to , patients came to hospital with renal paratransplant hernia. they were evaluated for this study. the following data were collected from their records: age, gender, weight, age at graft rejection, surgical complications, treatment method and the treatment results with composite ptfe mesh. results: for laparoscopic repair of incisional hernia after renal transplant, the median interval between kidney transplantation and developing of incisional hernia was (range to ) days. predisposing factors were obesity, age over fifty years, and female gender. in six patients, hernia was large, and the repair was performed with using composite ptfe mesh. one patient had developed serous collection in surgical site, which was managed successfully with multiple punctures. hernia recurrence or infection was not noted in these patients during to months follow-up periods. conclusion: incisional hernia is not a rare entity after kidney transplantation. predisposing factors, such as obesity, age over years, and female gender have a role in its development. repeated surgeries in kidney recipients can increase the risk of incisional hernia. managing this complication by laparoscopic approach is a safe and effective method. sujith wijerathne, raquel maia, hrishikesh salgaonkar, wee boon tan, lynette loo, davide lomanto; national university hospital, singapore introduction: a femoral hernia is a less common type of hernia. it is estimated to account for less than % of all abdominal wall hernias. only about in every groin hernias are femoral hernias. they are found more commonly in females due to wider shape of pelvis. laparoscopy by offering magnification and better vision provides us the opportunity for clear visualization of the myopectineal orifice. laparoscopy seems to be a safe and feasible approach for femoral hernia repair in an asian population. case description: between and , consecutive patients with femoral hernia who underwent laparoscopic hernia repair were prospectively studied. patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured. discussion: total of femoral hernias were repaired, on right and on left groin. this included patients with bilateral and unilateral hernia. concomitant obturator hernia were found. there were male and female patient. no conversion was reported. one patient had injury to bowel at the mm port entry site, without contamination, identified and managed immediately. patients developed seroma, all were managed conservatively except one who needed aspiration. peri-port bruising was noticed in patients and patients had hematoma. one patient with hematoma underwent excision of the organised hematoma. of the hematoma patient was on aspirin pre-operatively. no wound infection, chronic groin pain or recurrence was documented during follow up till date. conclusion: laparoscopic repair offers accurate diagnosis and simultaneous treatment of both inguinal and femoral hernia with minimum morbidity and good clinical outcomes. better visualisation and magnification gives us an opportunity to identify occult hernias which can be repaired during the same setting, thereby reducing the chance of recurrence and possible need for second surgery. laparoscopic repair has become the procedure of choice for the treatment of the majority of groin hernia at our institution. introduction: totally extraperitoneal (tep) repair that does not require peritoneal incisions is a good procedure that involves minimal visceral damage. however, balloon-or camera-assisted blunt dissections that are performed in a haphazard manner do not follow precise dissection of the fascia layer. furthermore, they have a disadvantage in that they are difficult to understand anatomically. we therefore developed a novel preperitoneal approach to resolve this issue. methods: a -mm trocar is inserted into the rectus abdominis sheath cavity after a small incision is made below the umbilicus and the posterior rectus sheath is exposed. a -mm trocar is inserted cm towards the pubic bone from the umbilicus. using forceps from this position, narrow branches that enter the posterior rectus sheath from the inferior epigastric vessels are dissected, thereby broadly exposing the anterior surface of the posterior rectus sheath. the third mm-trocar is inserted near the lateral margin of the rectus abdominis. on the outside, local anesthetic is injected beneath the posterior rectus sheath and the preperitoneal cavity is separated in fluid so that the peritoneum is not injured during posterior rectus sheath incision. a small incision is made to the posterior rectus sheath or attenuated posterior rectus sheath at one finger width higher than the expected upper margin of the prosthetic mesh. due to the effects of local injection, a sharp incision to the fascia can be made with an electric scalpel. utilizing this mechanism, the posterior rectus sheath aponeurosis and the lining transverse fascia and superficial preperitoneal layer are individually identified. once the preperitoneal cavity is reached, the peritoneal margin is determined in the lateral direction, and the peritoneum that is pulled due to pneumoperitoneum is separated from the preperitoneal fascia on the outside from the cranial side towards the deep inguinal ring. on the inside, the pneumoperitoneum pressure pushes the peritoneum inferiorly, leading to enlargement and increased visibility of the posterior rectus sheath deep fascia, which is dissected one layer at a time from the outside. the umbilical prevesical fascia is dropped inferiorly, and the dissection of the preperitoneal cavity necessary for mesh deployment is performed. results: by individually dissecting each fascia using emphysema through pneumoperitoneum and enlargement through local injection, the method for reaching the preperitoneal cavity could be successfully completed by following the dissection of the fascia layer without proceeding with the operation blindly, thereby resulting in the elimination of intraoperative bleeding and postoperative hematoma. introduction: in the field of abdominal wall reconstruction, the utility of drain placement is of debatable value. we present outcomes evaluating drain placement vs no drain placement at the time of robotic transversus abdominis release (rtar) technique with placement of mesh in the retromuscular position, a currently understudied subject. methods: retrospective review of a prospectively maintained hernia patient database was conducted identifying individuals who received either drain placement or no drain placement during abdominal wall reconstruction via the rtar technique from august to june at a single high volume hernia center. perioperative data and postoperative outcomes between the two groups are presented with statistical analysis for comparison and quality of life (qol) measures assessed using the carolina comfort scale. results: thirty-five patients were identified for this study, of which had drains placed intraoperatively in the retromuscular position at the conclusion of rtar (drn) and underwent rtar without the placement of draining devices (nd). the drn cohort had a mean bmi, defect area, mesh area, and operative time of . , cm , cm and minutes, respectively, compared to . , cm , cm , and minutes in the nd group. all cases utilized medium weight macroporous polypropylene synthetic implantable mesh materials in both the drn and nd subgroups. there were no reported postoperative complications, including no development of hematoma, seroma, or surgical site infections in either group. hernia recurrence was not identified in either the drn or nd cohorts through a mean follow up of days ( . months). there were no statistically significant differences in postoperative qol outcomes. conclusion: our series review suggests that the use of intraoperative drains may not afford any benefits with the rtar technique when mesh is placed in the retromuscular position. additional postoperative management associated with drain care may be unnecessary. surg endosc ( ) :s -s background: appendectomy is one of the most common operations performed during emergency surgery. although laparoscopic appendectomy (la) has become the treatment of choice, there is still a debate regarding the use of la for treating complicated appendicitis. in this retrospective analysis, we aimed to clinically compare la and open appendectomy (oa) for treating complicated appendicitis. methods: we retrospectively identified patients who underwent an operation for complicated appendicitis at our hospital; these patients were operated on between and july . [editor ] in total, patients underwent conventional appendectomy and patients were laparoscopically treated. outcomes included operation time, blood loss, length of hospital stay, and postoperative complications. logistic regression analysis was performed to analyze the concurrent effects of various factors on the rate of postoperative complications. objective: small bowel perforation has conventionally been dealt with open exploration, which frequently leads to many wound-related complications. wound infection is the major reason for increasing morbidity in these patients and delay recovery. laparoscopic surgery has various benefits over open surgery like, smaller wound, lesser pain and faster recovery. the aim of this study was to relay the advantages of minimally invasive surgery (mis) to patients with small bowel perforation to decrease postoperative wound complications and duration of hospital stay. methods: it is a retrospective study, including patients with small bowel perforation from to . of these , had traumatic etiology, had typhoid-related perforation and the remaining had a duodenal perforation. of them were male, and the average age was . years. only patients who presented within hours of perforation were included in the study. laparoscopic exploration was done on introducing camera from -mm infraumbilical port after intraperitoneal carbon dioxide insufflation. the remaining two -mm working ports were then introduced depending on the site of perforation once identified. the perforations were then repaired using intracorporeal single-layer suturing using polydioxanone - suture. the peritoneal cavity was given thorough lavage and abdominal drain placed in the pouch of douglas. fecal contamination was found in all the patients. a total of patients underwent conversion to open surgery due to inability to find the site of perforation laparoscopically. of the operated patients, patients developed port-site infection, and there were no major postoperative complications in the -week follow up period. conclusion: we conclude from our study that laparoscopic intervention in early small bowel perforation is a safe approach with favorable outcomes, especially with regards to wound complications, that are a major factor in increasing the morbidity in such patients postoperatively. laparoscopic approach leads to early discharge and recovery postoperatively. with the emerging era of laparoscopic surgery, leading to its easy accessibility, more patients can advantage from this technique when they arrive in emergency with intestinal perforation. s surg endosc ( ) :s -s introduction: pneumatosis intestinalis (pi), or gas in the bowel wall, can be seen on various imaging modalities. the pathophysiology behind pi is unclear. one theory proposes a mechanical cause (e.g. small bowel obstruction) while another proposes a bacterial etiology. management of pi in adults is difficult as often there is a benign clinical course. however, when paired with specific clinical features such as hepatic portal venous gas (hpvg) on imaging, the course of management changes as the suspicion of bowel ischemia increases. hpvg alone has been associated with a high mortality rate and a poor prognosis. management in this case becomes surgical. case presentation: we present a case of -year-old latino male who presented to the emergency room with abdominal pain and altered mental status. focused physical examination revealed a non-rigid abdomen, no rebound tenderness, no guarding, and diffuse tenderness only to deep palpation. ct scan of the abdomen and pelvis demonstrated moderate portal venous gas in the right and left hepatic lobes, an upper midline dilated small bowel loop with pneumatosis intestinalis, and a moderately distended stomach with gas and fluid. laboratory studies revealed metabolic acidosis and a lactic acid level of . mmol/l. due to these findings, bowel ischemia was suspected, and the patient was taken to the operating room for a diagnostic laparoscopy. the laparoscopy was converted to an exploratory laparotomy due to extensive adhesions. intraoperatively, there was no small bowel compromise and no identifiable transition point. extensive lysis of adhesions and repair of iatrogenic enterotomy were performed. patient tolerated the procedure well, clinically improved, and was discharged from the hospital. discussion: this case illustrates the difficulty in management of a patient with pneumatosis intestinalis and, specifically, hepatic portal vein gas seen on ct imaging. hpvg has traditionally been a harbinger of morbidity and mortality, but exploratory laparotomy revealed only diffuse abdominal adhesions and the absence of bowel ischemia despite high clinical suspicion. background: ventral hernia repair is one of the most common surgical procedures facing the general surgeon. there is little consensus as to the best surgical technique for complex scenarios. often these patients have complicating co-morbid conditions such as radiation therapy, that has an inevitable effect in the abdominal wall structures, which can lead to non-traditional repairs. case report: we present a case of a year-old female who underwent a tah/bso and right hemicolectomy which was complicated by wound dehiscence. she underwent primary repair and adjuvant whole pelvis radiation for her squamous cell carcinoma. subsequently, the patient developed acute obstructive symptoms do to a stricture within her small bowel and a large ventral hernia measuring cm with non-reducible abdominal contents below the level of the fascia more prominent in the suprapubic area. the patient's bmi was . . various considerations are important in planning a surgical repair in a previously irradiated field with loss of domain which include, minimal dissection, and the use of an atraumatic surgical techniqueque with either external oblique release or transversus abdominis muscle release (tar). we chose a a tar, as it provides wider myofascial release and dissection below the arcuate line towards the space of retzius and bogros allowing for a larger sublay mesh placement. also it avoids the need of skin flaps reducing the risk for wound complications in under-perfused tissue. the tar was performed successfully and there were no intraoperative and postoperative complications. her follow-up at months revealed no wound complications or hernia recurrence. conclusion: for patients with compromised tissue and loss of domain a tar technique may be useful when reconstructing complex abdominal wall hernias. it provides the core principals of hernia repair such as primary fascial closure, wide mesh overlap, and finally it provides a reliable approach for the under-perfused tissue without need of skin and soft tissue flap creation. outcomes in the management of cholecystectomy patients in the setting of a new acute care surgery service model: impact on hospital course larsa al-omaishi, bs, william s richardson, md; ochsner medical clinic foundation introduction: the acute care surgery (acs) model, defined as a dedicated team of surgeons to address all emergency department, inpatient, and transfer consultations, is quickly evolving within hospitals across the united states due to demonstrated improved patient outcomes in the non-trauma setting. the traditional model of call scheduling consisted of one senior attending and one senior resident on call per -hour shift. attendings were responsible for consults, previously scheduled operations, as well as clinic time. multiple recent studies have shown statistically significant improvements in several parameters of patient care by using acs including but not limited to . time from emergency department to surgical evaluation . time from surgical evaluation to operating room . operative time . percent laparoscopic . length of hospital stay . intra-operative complications (blood loss, perforation rates) . post-operative complications (fever, infection, redo) . cost. one study demonstrated a statistically significant cost savings for the acute care surgery model with respect to appendectomies, but not cholecystectomies. study design: a retrospective analysis of patients who underwent cholecystectomy in the setting of non-traumatic emergent cholecystitis was performed to compare data from two cohorts: the traditional model and the acs between january , and dec , at ochsner medical center, a -bed acute care center in new orleans. parameters gathered included . time from emergency department to surgical evaluation . time from surgical evaluation to operating room . operative time . percent laparoscopic . length of hospital stay . intra-operative complications (blood loss, perforation rates, conversion to open) . post-operative complications (fever, infection, redo). demographics were also collected including age, weight, height, ethnicity, asa, etc. inclusion criteria included: age[ and having undergone cholecystectomy between jan , and december , . exclusion criteria included choledocholithiasis, gallstone pancreatitis, ascending cholangitis, gangrenous cholecystitis, septic complications precipitating further procedures and delays, or researcher discretion. results: patients were initially identified as having undergone cholecystectomy within the allotted time period [ - , - , - , - ] . were excluded due to one of the reasons above. median patient age was years old and the average patient encounter was . days. conclusion: the acs model is better suited to manage emergent non-traumatic cholecystectomies than the traditional call service at our institution, as evidenced by several parameters. s surg endosc ( ) :s -s he nailed it background: nail guns are powerful tools and are widely used. injuries with these devices may be devastating due to the significant force they can deploy. patients and methods: we herein report a first case of a self inflicted abdominal injury with a nail gun. results: a year old male with history of coronary artery disease, type dm and early signs of dementia attempted to refill a nail gun. he lodged the device against his right abdomen while the air hose was still attached and then accidently fired nails into his abdomen. after he unsuccessfully tried to pull the nails out he drove himself minutes to our emergency room. he was hemodynamically stable on arrival; pain control was achieved, antibiotics were given and he received tetanus immunization. ct-scan showed the two foreign bodies penetrating from the ruq with one reaching the transverse colon. on emergency laparoscopy, the nails were found to have penetrated the thick omentum and the puncture site of one nail into the colon was identified. the omentum was resected off the colon and the right colon was completely mobilized. no additional injuries were found. the entrance area of the nails was then used to create a loop colostomy. the postoperative course was initially uneventful but the patient developed a severe posttraumatic inflammatory reaction of the fat tissue in the right upper quadrant and had to be readmitted for pain control and antibiotics were again administered. he recovered and was discharged with a plan for laparoscopically assisted colostomy closure after weeks. discussion: to the best of our knowledge this is the first reported isolated colonic injury by a nail gun. given the tremendous force of the device with unknown collateral damage to the surrounding tissue it was decided to manage the accident with a laparoscopic assisted colostomy using the entrance point of the nails for fecal diversion. introduction: it is difficult to diagnose obturator hernias by routine physical examination. obturator hernias are frequently complicated by ileus and the diagnosis is often first made from abdominal ct. obturator hernias are difficult to reduce, and often necessitate emergency surgery. they are common in elderly people, and they often had bad general condition. so it was high in the death rate. at our hospital, we first attempt to reduce the hernia from the body surface under ultrasonographic guidance. after relieving the strangulation, we perform radical operation electively in patients who are for possible for surgery under the general anesthesia. we perform laparoscopic repair for obturator hernias. obturator hernias are often complicated by other types of hernia. in these cases, we perform total repair. herein, we present a review of the patients who underwent surgery for obturator hernia at our hospital. methods: we review the data of cases of obturator hernia encountered by us from february to december . we performed total repair in three of the cases. however, it is difficult to procure a mesh that would be adequate for all the defects (inner inguinal ring, femoral ring, obturator). no single mesh can fit, because the inguinal and pelvic curves present opposing curves near the obturator. therefore, we placed two pieces of mesh available at our hospital ( d max [bard] and onlay sheet of kugel patch [bard] ) together in the patientswe could successfully cover all the defects using these two pieces of mesh and could fit the mesh to the pelvic shape by devising an appropriate connection between the meshes. results: we reviewed a total of operated cases for obturator hernia. the hernia was bilateral in cases, and complicated by other hernias in cases. we first determined the appropriate approach for the repair. we performed total repair in cases. they were no complications and no cases of recurrence. conclusion: our approach to the repair of obturator hernias was very useful. we can use the exact area and shape of the mesh needed in individual patients by this method. we show the method of shaping the mesh to fit the pelvic form. demin aleksandr, do, ajit singh, do, noman khan, do; flushing hospital introduction: internal hernias are known complications that are well documented to involve peterson's defect. in bariatric patient's post gastric bypass there is a high index of suspicion for internal hernias as well as a low threshold to operate. there have been some debates around the closure of the potential peterson's space with several studies advocating closure versus some which show that there is no difference in the rate of symptomatic internal hernias. we present a case of an unusual cause of small bowel obstruction due to internal hernia caused by a cecal volvulus. it is an atypical presentation however the patient was triaged and brought to the or within hours of admission. although it is rare there have been reports of internal hernias caused by other structures like congenital bands or natural potential spaces. there have been reports of unusual presentations of the cecum herniating through the foramen of winslow. the anatomical rearrangements after bypass create potential areas where an internal hernia can occur. in this case a bowel resection was undertaken due to the anatomical variation of the cecal bascule and cecal volvulus due to high rate of recurrence of this cecal pathology. majority of internal hernias do not require bowel resection especially when detected earlier and prompt surgical exploration is undertaken. mortality as direct consequence internal hernia is extremely rare. however late diagnosis of internal hernias can lead to catastrophic gut loss and may require lifelong tpn and/or visceral transplantation or autologous reconstruction. conclusion: careful history and physical of our bariatric patient can elicit the signs and symptoms of internal hernias and prevent the morbidity and mortality that can come with the complications of this condition. unusual presentations and causes are reason for prompt diagnosis and complete exploration. shingo ishida , naotsugu yamashiro , satoshi taga , koichi yano ; shinkomonji hospital, shinmizumaki hospital symptomatic cholelithiasis is common disease performed with laparoscopic cholecystectomy (lc). we will hesitate to operate if the patient is pregnant in the third trimester. pregnant patients undergoing laparoscopic surgery have been reported increasingly. however, most case reports are confined to patients in the first and second trimester. we report a patient who underwent lc in the third trimester and review the relevant literature. a -year-old woman in the third trimester ( w d) of pregnancy was seen in the emergency department of our hospital with a history of upper abdominal pain. there was no problem in the course of pregnancy. the result of the examination proved to be attack of gallstone colic. she was hospitalized the same day and underwent lc the next day. the base of pregnancy uterus was cm above the navel. we needed to consider the surgical approach, for example inserting the first trocar under left hypochondrium. operative duration was minutes. she complained abdominal distension at postoperative day (pod) and but there was no abnormality in the fetus. she was discharged on pod . after that she gave birth to a healthy baby. lc in third trimester of pregnancy was safely performed with obstetrics back up. weekday or weekend hospital discharge: does it matter for acute care surgery? ibrahim albabtain , roaa alsuhaibani , sami almalki , hassan arishi , hatim alsulaim ; kamc, background: hospitals usually reduce staffing levels over weekend. this raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk for adverse events post-discharge. the aim of this study was to assess the outcomes of common acute care surgery procedures for patients discharged over weekend, and identify the key predictors of early readmission. methods: this retrospective cohort study was conducted at a tertiary care hospital between january and december . surgical procedures included were cholecystectomy, appendectomy, and hernia repairs. patients' demographic, co-morbidities, complications, readmission and follow-up details were collected from the electronic medical records. predictors and post-operative outcomes associated with weekend discharge were identified by multivariable analysis using univariable and multivariable logistic regression models controlling for potential confounders. results: a total of patients were included. overall median age was years (iqr: , ). the majority of patients were female (n= , . %). patients ( . %) underwent a cholecystectomy, ( . %) an appendectomy, and ( . %) hernia repairs. weekend discharge was . % vs. . % of weekday discharge. patients discharged during weekend were younger ( . vs. , p-value. , mean) . post-discharge -day follow-up visits were significantly lower in the weekend discharge subgroup ( . % vs. . %, p-value . ). overall, -day readmission rate was . % (n= ), and did not differ between those of weekend and weekday discharge (or= . , % ci . - . ). conclusions: patients discharged on weekends tended to be younger in age and less likely to have chronic diseases. patients discharged over the weekend were less likely to follow up compared to weekday discharge patients. however, the readmissions rate did not differ between the two groups. intrauterine device (iud) migration out of the uterine cavity is a serious complication. its incidence in the us has been reported to be about . % annually. previously published systematic review supports the use of laparoscopic surgery for elective removal of migrated iucds from the peritoneal cavity. we present the safety and efficacy of the laparoscopic approach to this complication in the acute care setting. depicted is an otherwise healthy year old female with no previous surgical history who presented to the ed with worsening abdominal pain for one week with no associated symptoms. on physical exam, patient was non toxic. abdomen was moderately distended with guarding and rebound tenderness to palpation, no rigid. patient had been seen shorlty prior to ed admission by her obgyn and recent work up with abdominal/pelvic x-ray and ultrasound has revealed a misplaced iud in the transverse position (side ways). pregnancy test was negative. based on patient clinical presentation and recent radiologic findings, we decided to proceed with diagnostic laparoscopy. after systematic review of cavity, the foreign body was found to be incorporated within the greater omentum. we procceded, laparoscopically with omentectomy+foreign body removal. there were no perioperative complications, patiet was discharged on the following day. the use of laparoscopy in elective iud retrieval within in the abdominal cavity has been considered standard of care in surgical management to date. this poster demonstrates its use as an effective approach for safe removal of intra-abdominal foreign bodies also in the acute setting. symptomatic inguinal and umbilical hernias in the emergency department: opportunity lost? andrew t bates, md, jie yang, phd, maria altieri, chencan zhu, bs, salvatore docimo, jr., do, konstantinos spaniolas, md, aurora pryor, md; stony brook university hospital introduction: patients with symptomatic inguinal and umbilical hernias often present to the emergency department (ed) when their symptoms change or increase, usually not requiring emergent surgery. however, little is known about how often these patients present prior to eventual repair and whether they undergo surgery at the initial presenting institution. the aim of this study was to assess the clinical flow of patients presenting in the ed for inguinal and umbilical hernia. methods: all patients presenting to eds in new york state from to with symptomatic inguinal and umbilical hernias were identified using the new york state longitudinal hospital claims database (sparcs). patients were followed for records of hernia repair and subsequent inpatient and outpatient visits up to . results: , patients presenting to the ed for symptomatic inguinal hernia were identified. . % ( , ) of ed presentations resulted in inpatient admissions. , ( . %) had repair later and their average time from ed presentation to inguinal hernia repair was (± ) days. . % of patients who did not have subsequent surgery had only one ed visit. of those that underwent interval repair, . % had only one ed visit prior to surgery. for those patients with only one ed visit before repair, . % had repair at a different hospital, as opposed to . % if multiple ed visits were made. , umbilical hernia patients presenting to the ed were identified. . % ( , ) resulted in inpatient admission. , ( . %) had interval repair, with the average time from ed presentation to umbilical hernia repair being (± . ) days. % of patients who did not record of later repair presented to the ed once. of those patients who underwent repair, . % did so after one ed visit. for those patients with only one ed visit before repair, . % had repair at a different hospital, as opposed to . % if multiple ed visits were made. conclusion: a majority of patients with symptomatic inguinal and umbilical hernias that present to the ed do so once with no subsequent follow-up or repair. for those patients that undergo interval repair, a significant portion willnopt for surgery at other hospitals. a significant proportion of patients with acutely symptomatic inguinal/umbilical hernias who undergo interval repair after a previous ed visit, will opt for definitive surgery at another hospital facility. this represents a missed opportunity for continuity of care for providers and healthcare systems. nikhil gupta, dr, himanshu agrawal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: peritonitis is the inflammation of the serous membrane that lines the abdominal cavity and the organ contained therein and is one of the most common infections, and an important problem that a surgeon has to face. reproducible scoring system that allows a surgeon to determine the severity of intra-abdominal infections are essential to prognosticate the patient. this study was done to compare apache ii scoring and mpi score to assess prognosis in perforation peritonitis. methods: all patients admitted with hollow viscus perforation from st november till st march was included in the study. it was a cross sectional observational study. apache ii and mannheim peritonitis index (mpi) scoring systems were calculated in all the patients in order to assess their individual risk of morbidity and mortality. the outcome variables were studied postoperatively -post-operative wound infection, wound dehiscence, anastomotic leak, respiratory complications, duration of hospital stay, need of ventilator support and mortality. the inferences were drawn with the use of appropriate tests of significance. results: the study comprised of patients. neither apache ii nor mpi could predict postoperative wound infection. the mean apache ii score of subjects included in the study was . ± . with range of to and the mean mpi score of subjects included in the study was . ± . with range of to . apache ii was able to predict postoperative respiratory complications, post-operative need for ventilatory support, hospital stay duration and mortality while mpi was able to predict post-operative wound dehiscence, post-operative respiratory complications, post-operative need for ventilatory support and mortality. neither apache ii nor mpi could predict postoperative anastomotic leak and postoperative wound infection. conclusion: mannheim peritonitis index is a useful and simple method to determine outcome in patients with peritonitis. mpi is comparable to apache ii in assessing the prognosis in perforation peritonitis and can well be used in emergency setting in place of apache ii scoring when time is a definite constraint. microrna- and the prognosis of human carcinomas: a systematic review and meta-analysis chengzhi huang, mengya yu; guangdong general hospital (guangdong academy of medical science) muhammad nadeem , julian ambrus, md , steven schwaitzberg, md , john butsch, md ; university at buffalo, introduction: mitochondria is a small energy producing structure of a cell. mitochondrial myopathy (mm) is mixed disorder clinically, which can affect various systems besides skeletal muscle. mm starts with muscle weakness or exercise weakness. mm patients have decreased skeletal muscle mitochondrial function than the healthy person, because of weakened intrinsic mitochondrial function and decreased mitochondrial volume density. no one has studied the mm role in gerd and constipation so far. this study is aimed to see effects of mm on the gastrointestinal system specifically gastroesophageal reflux disease (gerd), gall bladder issues, and constipation. methods: between may and june , mm diagnosed patients at buffalo general hospital were included in this retrospective study. we assessed their demeester score for gerd and wexner's constipation questionnaire for constipation. demeester score[ and constipation score[ were set points for gerd and constipation respectively. data was analyzed by using spss version . mitochondrial enzymes were assessed by using their muscle biopsy report. results: out of ( . % female, . % male) mitochondrial myopathy patients, . % and . % were suffering from gerd and constipation respectively. . %, . % and . % patients had gall bladder issues, obstructive sleep apnea (osa) and fatigue respectively. mm gerd patients ( . % female, . male) had mean demeester score . (sd: . ) more than normal although . % patients were on gerd medications and . % patients had nadh cytochrome c reductase, cytochrome c oxidase and citrate synthase abnormal mitochondrial enzyme in mm associated gerd but . % mm patients had abnormal cytochrome c oxidase enzyme only. mm along with constipation had mean wexner's constipation score . (sd: . ) more than the normal although . % were taking enema, medications or digital assistance. % patients had cytochrome c oxidase and nadh cytochrome c reductase enzymes were abnormal in those patients. . % mm associated gall bladder issues patients had cytochrome c oxidase abnormal. . % mm associated gerd and constipation patients had gall bladder issues. conclusion: in this present study, we found that mm had effects on gastrointestinal system causing gerd, constipation and gall bladder issues. gerd, constipation and gall bladder problems are common in mm patients even patients are taking medications for gerd and constipation. cytochrome c oxidase, citrate synthase and nadh cytochrome c reductase are the most commonly impaired mitochondrial enzyme in mm patients and mm associated gerd, constipation and gall bladder issues patients. objectives: gulf war illness (gwi) is a chronic, multisymptom illness marked by cognitive and mood dysfunction and disrupted neuroendocrine-immune homeostasis affecting % of gw veterans. after + years, useful treatments are lacking and its cause is poorly understood, although exposures to pyridostigmine bromide and pesticides are consistently identified among the strongest risk factors. previous work in our laboratory using an established rat model of gwi identified persistent elevation of microrna- (mir- ) levels in the hippocampus whose gene targets are involved in cognition-associated pathways and neuroendocrine function, suggesting that mir- inhibition is a promising therapeutic approach to improve the complex symptoms exhibited by gwi. the purpose of this study was to identify broad effects of mir- inhibition in the brain by profiling the expression of genes known to play a critical role in synaptic plasticity, glucocorticoid signaling, and neurogenesis in gwi rats administered a mir- antisense oligonucleotide (mir- inhibitor). methods and procedures: nine months after completion of a -day exposure regimen involving gw-relevant chemicals and stress, rats underwent intracerebroventricular infusion of mir- inhibitor (n= ) or scrambled negative control oligonucleotide (n= ) and were implanted with -day osmotic pumps delivering . nmol/day. intranasal delivery of oligonucleotides was performed on additional rats (n= per group; daily for days) to determine whether mir- inhibition is achievable using a noninvasive procedure. hippocampi were harvested and quantitative pcr arrays were used to profile the expression of focused panels of genes important for ) synaptic alterations during learning and memory, ) signaling initiated by the glucocorticoid receptor (known mir- target), and ) neurogenesis. hippocampi were also analyzed by quantitative pcr to examine expression levels of endogenous mir- . results: upregulation ([ . fold change, p. ) of synaptic plasticity genes, glucocorticoid signaling genes, and neurogenesis genes was observed in the hippocampus of gwi rats infused with mir- inhibitor compared to scrambled control, consistent with a significant reduction (p\ . ) in mir- levels detected in rats receiving mir- inhibitor. altered gene expression and a reduction in mir- levels were not observed in rats after intranasal delivery. conclusion: mir- antagonism in the hippocampus upregulates the expression of several downstream targets involved in synaptic plasticity, glucocorticoid signaling, and neurogenesis and is a promising therapeutic approach to improve cognition, emotion regulation, and neuroendocrine dysfunction in gwi. further testing is being pursued to discover the optimal dose for intranasal administration to test viability of this option for ill gw veterans. nikhil gupta, dr, ananya deori, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi background: the ultrasonic dissector, commonly known as the harmonic scalpel, has been in use for achieving haemostasis in surgery for almost yrs. its advantages in breast surgery, especially in the dissection of axilla, have been a matter of debate as previous studies have shown inconsistent results. this study compares the outcomes of the ultrasonic dissector in axillary dissection with that of the conventional electrocautery. methods: patients who were undergoing mrm and bcs with axillary dissection from november till march were included in the study. patients were randomized into two groups, group a undergoing axillary dissection with ultrasonic dissector and group b with electrocautery. the operative time, intra-op bleeding, post-op pain, post op drain volume, hospital stay and any other complications were noted in the two groups. results: the numbers of patients in both groups were each. group a had a significantly shorter operative time, both for axillary dissection ( . min vs. . min, p. ) and the total duration ( . vs. . min, p= . ). the blood loss was significantly less in group a, as measured by the mop count. there was significant reduction in the total post-op drainage volume, which resulted in fewer days of drain in-situ and the total number days stayed in the hospital. there was no significant change in the post-op complications such as haematoma, seroma, flap necrosis, oedema, etc. conclusion: with the use of ultrasonic dissector, the operative time, blood loss and the axillary drainage was significantly reduced. the axillary drainage in turn, reduced the hospital stay. there was no significant difference in terms of complications like haematoma formation, seroma formation, skin flap necrosis or oedema. for the statistical analysis, χ or fisher's exact tests to compare proportions and the nonparametric mann-whitney u test for analysis of values with abnormal distribution were used. discussion: the study included patients. all preoperative laboratory indicators were elevated. the laboratory tests do not demonstrate any statistical significance between these two groups. the group of the patients without stones in the cbd diagnosed by ioc was also divided in patients with diameters. ?mm and with diameters≥ . ?mm of the cbd. also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significant difference. all patients underwent ioc. ioc showed stones in / patients ( . %) . a comparison of patients with and without stones at ioc showed similar mean times from hospitalization to surgery ( . background: housed in a high volume tertiary referral center, our division receives a large amount of transfers and referrals from outside institutions for patients who require completion cholecystectomies. in this study "completion cholecystectomy" refers to patients that meet one of three criteria: . previous subtotal cholecystectomy, . previously aborted cholecystectomy, or . previous cholecystectomy with incidental finding of cancer on pathology. traditionally, exploration of a reoperative field in the right-upper quadrant mandates an open approach due to dense adhesions and inflammation. over the past few years, we have found that robotic-assisted surgery has allowed us to perform these completion cholecystectomies in a minimally invasive fashion. methods: case logs and operating room billing logs were reviewed from to to identify all robotic-assisted cholecystectomies performed at our institution. review of all reports identified completion cholecystectomies. all additional variables including demographics, operative variables, and postoperative outcomes were determined from manual chart review of all consultation notes, operative reports, anesthesia records, progress notes, discharge summaries, and postoperative office visits. results: of the identified robotic-assisted completion cholecystectomies, patients had a previous subtotal cholecystectomy, patients had an aborted cholecystectomy, and patients had an incidental finding of t gallbladder carcinoma on pathology. fifteen patients ( %) underwent preoperative ercp either for choledocolithiasis or to determine biliary anatomy. average time from original procedure was months with . % of previous procedures performed in an open approach. average or time was . minutes, average ebl was . cc, and average length of stay was . days. one patient ( . %) was readmitted within days for nausea that resolved with antiemetics. three patients ( . %) had minor postoperative complications (clavien-dindo grade or ) which resolved with pharmacologic therapy. no patients suffered a -day mortality. all cases were completed in minimally invasive fashion without a conversion to an open procedure. conclusions: although rare, completion cholecystectomies present a challenging surgical scenario. although traditionally performed in an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion cholecystectomy. we feel that the robotic approach offers certain advantages in a hostile, reoperative field which allows us to perform these procedures in a minimally invasive fashion with no conversions to an open procedure to date. previously limited to case reports, this report of procedures represents the largest case series of robot-assisted completion cholecystectomies to our knowledge. s surg endosc ( ) :s -s background: percutaneous cholecystostomy tube (pct) has been used as a bridge treatment for grade ii-iii moderate to severe acute cholecystitis (ac) to "cool" the gallbladder down over several weeks and allow the inflammation to resolve prior to performing interval cholecystectomy (ic) and removal of the pct, often laparoscopically. the aim of this study was to assess the impact of timing of ic after pct on operative success and outcomes. methods: a retrospective review of electronic medical records of patients who were treated for ac with a pct, and subsequently underwent ic at our institution between january to december was performed. the patients were divided into three groups (n= each), based on the duration of the pct prior to ic, and these groups were comparatively analyzed. a comparative sub-analysis of clinical outcomes between patients who underwent surgery within the first week vs. third week or later after pct was also performed. results: a total of patients met the study criteria. each group had patients. there were no statistically significant differences between the groups in regards to age, gender, bmi, imaging findings, and indications for cholecystostomy tube placement. overall, there was no statistically significant difference in outcomes between performing ic within the first weeks, - weeks and [ weeks after pct placement. the length of stay, overall morbidity, clavien-dindo grade of complications and mortality were similar between the time intervals. however, a sub-analysis showed that patients who underwent ic within the first week of pct placement had statistically significant higher mortality rate (p= . ) compared to those who underwent ic[ weeks of pct placement. the two patients who died in our sample had ic within a week after pct placement. even though there was a statistically significantly higher morbidity rate in those who had ic[ weeks after pct, the clavien-dindo grade of these complications was lower than. conclusion: delaying ic to [ weeks after pct placement for ac is not associated with any improvement in patient morbidity, length of stay or rate of conversion from laparoscopic to open cholecystectomy. cholecystectomy within the first week of pct placement is associated with higher mortality rate than after weeks likely due to associated sepsis. introduction: the effect of intraoperative bile spillage during laparoscopic cholecystectomy (lc) on operative time (or time), length of stay (los), postoperative complication rates, and day readmission rates was analyzed. laparoscopic cholecystectomy is the gold standard operation for gallbladder disease in the united states. number of studies have shown that same day discharge in elective laparoscopic cholecystectomy is feasible and safe. bile spillage during this procedure can be a common occurrence in teaching institutions, however, data on the effects of operative outcomes is lacking. methods: this is a retrospective study analyzing all of the laparoscopic cholecystectomies performed at the brooklyn hospital center (tbhc), both emergent and elective, from to . patient data was collected on demographics, comorbidities, bile spillage, operative findings, complications, los, and day readmission rates. statistical analysis was performed using imb spss statistics v. . covaried analysis of variance (ancova) was performed on continues variables and significance levels were calculated. pearson's chi square significance level was calculated for all binomial variables. results: of the patients who underwent lc during this time period, intraoperative bile spillage was encountered in patients. interestingly, bile spillage was significantly more likely to be seen in elective cases over acute cases ( . % vs . %, p. ). there was a statistically significant increase in or time in cases where intraoperative bile spillage was encountered vs. cases where no bile spillage was encountered ( vs. min, p= . ). there was a significant increase in rate of conversion to open procedure when bile spillage was encountered ( . % vs. . %, p. ). drain placement rates increased, not surprisingly, when bile spillage was encountered ( . % vs. . %, p. ). there was no statistically significant difference in los between cases with bile spillage and cases without ( . days vs. . days). there was no significant increase in complication rate or day readmission rates. conclusions: intraoperative bile spillage significantly increases or time, conversion to open procedure, and drain placement. however, there was no significant effect observed of intraoperative bile spillage on length of stay, complication, and day readmission rates. thus, intraoperative bile spillage appears to have little clinical significance on surgical outcomes. however it may have an impact on overall healthcare costs. larger prospective studies evaluating the effect of intraoperative bile spillage on los, or time, complication rates, and day readmission rates are needed to analyze these effects further. tariq nawaz, md; rawalpindi medical university study design: prospective and observational study. place and duration: from january, to july . surgical unit ll, holy family hospital, rawalpindi. patients and methods: thousand patients with a diagnosis of cholithiasis were included. exclusion criteria are patient younger than year and older than year. calot's triangle dissection was done meticulously. cystic artery and hepatic artery anomalies and variations were observed and analyzed on spss . results: the age varies from to years. on the basis of distributional variation the cystic artery was single in % cases, branched in % cases and absent in % cases. on positional variations the cystic artery was superomedial to the cystic duct in % cases, anterior in % cases, and posterior in % cases and low lying in % of the cases. on the basis of length variation results showed that ( %) cases had a normal cystic artery. a short cystic artery was found in ( %) cases and a long cystic artery was present in ( %) cases. other arterial variations are of hepatic artery i.e moynihan's hump ( %) and and right hepatic artery present in calots triangle in % conclusions: for the safety of laparoscopic cholecystectomy one should be well aware of the anatomical variations of the cystic and hepatic artery. keywords: cholelithiasis, cholecystitis, laparoscopic cholecystectomy. as small as it gets: micro-invasive laparoscopic cholecystectomy using only two mm trocars and a needle grasper background: the majority of surgeons use four ports including for laparoscopic cholecystectomy (lc). multiple efforts have been made to reduce number and size of ports. left upper quadrant (luq). patients and methods: of lcs performed from / - / , ( %) were done using three instruments including cases in which trocars and the teleflex needle grasper were used. in cases only two mm trocars were (left upper quadrant (luq) and umbilicus) with the minigrasper being placed between the two. the gallbladder (gb) serosa was incised on both sides and a window was created behind the gb midportion and widened towards fundus and infundibulum. cystic artery (ca) and cystic duct (cd) were dissected out obtaining the critical view and after the last fundus adhesion was cut, ca and cd were secured with clips or endoloop. results: median age of women and men was . (range . - . ) years. lc was done for acute cholecystitis (n= ), chronic cholecystitis (n= ), biliary dyskinesia (n= ), choledocholithiasis (n= ). three patients had an ercp with bile duct clearance prior to the lc. in one case a keith needle was used to suspend the gb fundus for better exposure. twelve patients had additional procedures together with their lc (wedge liver biopsy ( ), lysis of adhesions ( ) , umbilical hernia repair ( ) , mesenteric/lymphnode biopsies ( ) . median or time was (range - ) minutes. the specimen was removed through the luq port site in patients. there were no vascular or bile duct injuries in this series. % of cases were done as outpatient procedures, % of patients required hours observation only three patients were hospitalized for medical reasons. conclusion: in selected cases with either small stones or biliary dyskinesia, lc with only two mm ports and a needle grasper is possible. the teleflex minigrasper can completely replace a port based grasper. introduction: the standard treatment for lithiasic acute cholecystitis remains the laparoscopic cholecystectomy despite the timing of surgery is still controversial. the aim of this prospective study is to evaluate the advantages and limitations of early laparoscopic cholecystectomy in a district hospital. methods and procedure: all patients undergoing laparoscopic cholecystectomy at the surgical department of "carlo urbani" hospital in jesi (italy) from may to september were consecutively enrolled. clinical data such as gender, age, bmi, comorbidity, previous abdominal surgery, previous acute cholecystitis were collected. subsequently, the patients were arranged in two groups according to the timing of intervention (early versus elective surgery). for each group, we compared data concerning surgery, such as operative time, intraoperative and postoperative complications, length of hospital stay and cost analysis. results: this study is a part of an ongoing research. so far, we collected laparoscopic cholecystectomies. ten ( %) of them were admitted with acute cholecystitis and were operated during the hospital stay (group a). group b included patients scheduled for elective surgery (n= ; %). the two groups were comparable with respect to clinical data. conversion to open approach was performed in cases, all of them in group b. mean surgical time was . ± . minutes in group a and . ± . minutes in group b (p= . ). no significant differences in intraoperative and postoperative complications rates were seen in the two groups, just a few in both of them. mean overall length of hospitalization was . ± . days in group a and ± . days in group b (p= . ), whereas the difference in length of postoperative hospitalization was not statistically significant. due to the extended hospitalization for group a, the cost increase as compared to group b was statistically significant, too. conclusions: early laparoscopy is comparable to delayed laparoscopy in terms of postoperative hospitalization and complications in the management of acute cholecystitis. a longer hospital stay among patients scheduled for immediate surgery may be associated with a more time-consuming diagnostic work-up before surgery. however, in future research we expect to enhance our cost analysis with more data regarding the costs incurred in the first hospitalization reserved to nonoperative treatment of group b inpatients with acute cholecystitis. s surg endosc ( ) introduction: with improvements in healthcare access and technology, admissions of octogenarian population with acute cholangitis (ac) are increasing. octogenarians are vulnerable to inferior outcomes. there is no study to evaluate factors predicting outcomes of ac in octogenarians. the aim of our study is identify factors predicting outcomes, and to evaluate the quick sequential organ failure assessment (qsofa) score and tokyo guidelines (tg ) severity grading for octogenarian patients with ac. methods: a retrospective review of octogenarian patients admitted with ac from january to december was performed. demographic profile, clinical presentation and discharge outcomes were studied. systemic inflammatory response syndrome (sirs), qsofa and tg severity grading scores were calculated. mortality is defined as death within days of admission or in hospital mortality. statistical analysis was performed using spss version . results: there were a total of patients admitted for ac, of which ( %) were octogenarians. majority (n= , %) were female, with a mean age of (range - ) years. majority were secondary to gallstones (n= , %), and ( %) were due to malignancies. ( %) and ( %) patients fulfilled sirs and qsofa criteria of severity respectively. ( %) and ( %) of patients had a tg severity grading of moderate and severe respectively. nine ( %) patients required inotropic support in the emergency department (ed) and ( %) patients were admitted to critical care unit (ccu). ( %) patients underwent endoscopic retrograde cholangiopancreatography (ercp) and ( %) underwent percutaneous transhepatic biliary drainage (ptbd) for biliary decompression. patients underwent index cholecystectomy. length of stay was . (range - ) days and -day mortality of %. multivariate analysis performed showed that an abnormal glasgow coma score (p= . ) and malignancy (p. ) predicted -day mortality. the use of ed inotropic support predicted ccu admission (p= ). a positive blood culture (p= . ), presence of malignancy (p. ), use of ed inotropes (p= . ), and index cholecystectomy (p= . ) predicted a longer length of stay. qsofa (p. ) and tg severity grading (p= . ) were predictive of -day mortality. sirs criteria did not predict -day mortality. conclusion: reduced consciousness and malignancy predicted -day mortality in octogenarian patients with ac. qsofa and tg severity grading system is superior to sirs criteria in predicting mortality of octogenerians with ac. our group has performed needlescopic grasper assisted silc (nsilc) to overcome these problems. we evaluate the technical feasibility, safety and benefit of nsilc versus three-port laparoscopic cholecystectomy (tplc). methods and procedures: this prospective randomized control study was conducted to compare the advantages if any between the nsilc and tplc. one hundred and forty eight patient were randomized into two groups, with one group underwent n slic ( patients) and a control group underwent tplc ( patients). basic information about the patient and diagnosis was collected. the surgical outcome that was composed with critical view of safety (cvs) time, major procedure time and total operation time, and the comparison of postoperative complication was made. result: nsilc group was consisted of male ( . %) and female ( . %), and tplc group was consisted of male ( . %) and female ( . %) (p= . ). the average age of nsilc group was . ± . years old, and tplc group was . ± . years old (p= . ). cvs time of tplc group was shorter than silc group (nsilc: . ± . min, tplc: . ± . min, p= . ), major procedure time (skin incision to gb removal from liver bed) of tplc group was shorter than nsilc group (silc group: . ± . min, tplc: . ± . min, p= . ). however, there was no significant difference in postoperative complication (nsilc: , tlc: , p= . ). conclusion: although cvs time, major procedure time, and operation time of silc were longer than tplc, overall clinical results were similar. nsilc is feasible and safe surgical procedure in patient with benign gallbladder disease. introduction: management of malignant biliary obstruction not amenable to surgery is usually by means of ercp or pthc. however, on occasions, these routes are not accessible and the alternate decompressive technique of percutaneous cholecystostomy (pc) has to be adopted. the aim of this study was to evaluate the efficacy and outcomes of pc in a highly selected series at a tertiary referral center. methods: we retrospectively reviewed all patients that had undergone pc from to . data collected included baseline demographics, comorbidities, details of pc placement and management, etiology of mbo, and post-procedure outcomes. the charlson comorbidity index (cci) was calculated for all patients at the time of pc. results: four hundred and eight patients underwent pc placement of which patients including ( %) males and ( %) females, with malignant biliary obstruction. the mean age at the time of pc placement was . ± . years of age, and the mean cci was . ± . for all patients. of mbo in all patients was due to pancreatic malignancies (n= ), cholangiocarcinoma (n= ), primary hepatic malignancies (n= ), secondary hepatic tumors (n= ), and ampullary carcinoma (n= ). pc tube complications were reported in ( %) patients. mean number of tube exchanges was . ± . . mean duration from pc tube placement to death was ± . days. total deaths were recorded. conclusion: pc placement appears to be a viable option in mbo in elderly and frail patients. in this cohort, pc may be a potential definitive management to improve quality of life. melanie boyle, daivyd palencia, philip leggett; houston northwest medical center background: there are very few studies assessing the relationship between gastroesophageal reflux and biliary disease. this is surprising as they share presenting symptoms as well as risk factors, particularly obesity. our group previously produced a review of patients in our practice who had undergone some type of reflux procedure. conclusions showed that the prevalence of gallbladder disease in our severe reflux population is much higher compared to that found in the general population. our goal of this study is to expand on that data to include a larger sample size to investigate the incidence of biliary disease in our reflux population and decide if this should influence our pre-operative algorithm for anti-reflux surgery patients. methods: we expanded on our previously performed retrospective review of patients that underwent laparoscopic fundoplication for reflux disease. we previously reviewed data from to . we are now looking at data from to . our expected sample size will include approximately patients, of which have currently been reviewed. our previous study included only . the surgery preformed was either a toupet or nissen fundoplication, and one underwent a dor. demographic data, imaging studies, and pathology results were reviewed. results: we looked at whether each patient who underwent antireflux surgery had a prior cholecystectomy either remotely or recently, underwent concomitant cholecystectomy, or had no biliary disease in their workup. the groups had similar age and were predominantly women. we once again demonstrated that the prevalence of gallbladder disease in our severe reflux population is much higher than the general population. when approaching a patient with gastroesophageal reflux disease, attention should be paid to gallbladder symptomatology as well. we recommend that it may be beneficial to include gallbladder ultrasound in pre-operative workup for antireflux surgery so that concomitant cholecystectomy can be performed if indicated. steven schulberg, do, jonathan gumer, do, matt goldstein, vadim meytes, do, george ferzli, md; nyu langone hospital -brooklyn introduction: acute cholecystitis is a common surgical disease with roughly , cholecystectomies performed in the us annually. the current dogma revolves around the " hour rule" advocating early cholecystectomy if within the window, and if beyond hours, conservative treatment and interval operation. in patients beyond the hour window, as well as with multiple comorbidities, advanced age, and other complicating factors, cholecystostomy has become an acceptable treatment as a bridge to interval cholecystectomy. while this has become an appropriate treatment modality, it does not come without its own set of complications. we aim to evaluate the rate of complications in our institution. methods: this is a retrospective review of all patients at our institution who underwent cholecystostomy placement between and . we evaluate the comorbidities, readmission rate, overall rate of complication associated with cholecystostomy tubes, and eventual definitive cholecystectomy. results: our cohort includes patients, % of whom were male, with a mean age of . we had an overall complication rate of . %, including tube dislodgements, leaking tubes, and misplaced tubes. all cause readmission rate was % and only % of patients who had cholecystostomy drains underwent interval cholecystectomy. conclusion: there has been much interest in treatment of acute cholecystitis in patients with multiple comorbidities. in review of our data, a surprisingly large number of patients had mechanical complications involving the cholecystostomy drain. in an era focused on decreasing readmission rates and their associated costs, drains carry a high risk of malfunction which will in turn, lead to increases in these two metrics. while there is more work to be done in the evaluation of early cholecystectomy versus cholecystostomy in this subgroup of patients, we suspect that early cholecystectomy in the medically optimized patient will lead to reduced length of stay and hospital costs as well as increased patient satisfaction. does selective use of hepatobiliary scintigraphy (hida) scan for diagnosis of acute cholecystitis, following equivocal nondiagnostic gallbladder ultrasonography, affect outcomes fahad ali, ba, amir aryaie, md, eneko larumbe, phd, mark williams, md, edwin onkendi, md; texas tech university health sciences center introduction: acute cholecystitis (ac) is diagnosed by characteristic gallbladder ultrasonographic findings (high specificity, low sensitivity). hepatobiliary scintigraphy (hida) may be needed to confirm ac (higher sensitivity and specificity). the aim of this study was to assess the impact of the current selective use of hida scan for sonographically equivocal cases of ac on outcomes. methods: a retrospective chart review of patients treated for ac at our institution ( / to / ) was performed. patients were divided into groups: the ultrasound only group (us-only) and the ultrasound-hida group (us-hida). timing of us and hida, and intervention for ac since presentation to emergency room (er), and their impact on outcomes were analyzed. ac severity was graded per the tg -tokyo guidelines. results: a total of patients were analyzed. the groups were statistically similar with regards to age, body mass index, asa class ii, iii and iv, extent of leukocytosis at presentation and liver functions test levels at presentation. in the us-only group, diagnostic ultrasound was obtained sooner, [median of (interquartile range, iqr . - . ) hours] from presentation to the er compared to the us-hida group, ) hours], p= . . hida was obtained after a median delay of . (iqr . - ) hours from a nondiagnostic ultrasound. majority of patients ( %) in the us-only group had mild (tg grade i) to moderate (tg grade ii) ac, while % of the us-hida group had moderate (tg grade ii) to severe (tg grade iii) ac (p= . ). despite this, more patients in the us-hida group ( %) had a "normal" non-diagnostic ultrasound compared to the us-only group ( . %), p. . seven patients in the us-hida group had no intervention due to normal hida scan ( ) , ac misdiagnosis due to liver cirrhosis ( ) , and severe medical comorbidities ( ) . more patients ( %) in the us-only group underwent laparoscopic cholecystectomy, compared to % in the us-hida group (p= . ). between the two groups, there was no significant differences in -day morbidity, mortality and reoperations. however, the length of stay was longer by a median of . days in the us-hida group (p= . ). conclusion: patients with moderate to severe ac are more likely to need hida scan due to a "normal" non-diagnostic ultrasound, have a delay in diagnosis, not have intervention for ac due to severe medical comorbidities and have lower chance of laparoscopic cholecystectomy. the length of hospital stay is significantly longer for these patient by a median of . days. introduction: benign gallbladder disease is commonly treated with laparoscopic cholecystectomy (lc). gallbladder cancer (gbc) is a rare malignancy characterized by high invasiveness and poor survival. in our institution, all gallbladder specimens are routinely sent to pathology, to rule out gbc. the purpose of our study was to assess the efficacy for routine histopathology of gallbladder specimens after cholecystectomy (cly) for all gallbladder disease. methods and procedures: after obtaining approval from our institutional review board, a retrospective review was conducted on all patients who underwent cly from june of to may were included in the study. the data obtained include gender, age, american society of anesthesiologist score (asa), body mass index (bmi), comorbidities, length of stay (los), radiological imaging and pathology results. independent t and chi-square tests were performed using ibm® spss® software. results: there were cly performed at our institution, of which ( %) were lc. females composed of ( %) patients and the median age was . ( %) gallbladder specimens were found to be cancerous. ( %) gallbladder specimens were benign. majority ( %) were chronic cholecystitis, ( %) were acute cholecystitis and ( %) were gangrenous cholecystitis. ( %) were found to be acalculus cholecystitis and ( %) were cholelithiasis. ( %) were found to be adenomyositis, and other. conclusion: in our institution, less than % ( ) of all gallbladder specimens were found to be cancerous. it would decrease cost and work load if gallbladder specimens are selectively sent to pathology. emanuel a shapera, md we sought to determine clinical factors associated with recurrent cholangitis in two las vegas community hospitals to aid providers in management of this disease. methods and procedures: retrospective, multi-center study. over ercps were analyzed between and . patients were identified as having multiple ( ) admissions for cholangitis per tokyo criteria. univariate and multivariate analysis was conducted. results: patients with a significantly (p. ) higher albumin level on admission ( . ) were discharged home more often than patients discharged to a facility or hospice ( . ). on multivariate analysis, non-home discharge was associated with lower albumin level at admission (p= . ) and greater maximum temperature prior to decompression (p= . ). increased hospital stay was associated with lower albumin level at admission (p= . ). a majority ( / ) of recurrent episodes involved stent placement, exchange or removal. patients ( %) had either biliary malignancy, gallbladder or both. blood cultures were drawn in % of all episodes and positive in %, e coli being the most common pathogen isolated. all patients had low hdl levels ( - , mean ) . conclusions: high fevers and poor nutritional status was associated with increased length of hospital stay and fewer home discharges. tumors, gallbladders and malfunctioning stents contribute substantially to morbidity. close follow up for indicated gallbladder removal, stent management and nutritional optimization is critical to reduce the burden of this disease. we compared the surgical method in neonate choledochal cyst between oec and lec. the perioperative and surgical outcomes that were reviewed included age, operative time, postoperative hospital stay, time to diet, and surgical complications. the patients were followed up for months (range, - months) . results: there was no difference in range of bile duct excision and manner of roux-en-y hepaticojejunostomy between oec and lec groups. there was no intraoperative complication in both groups and no open conversion in the lec group except one case which was ruptured choledochal cyst. the median age of oec and lec groups were days (range, - ) and . days (range, and median body weight at the time of operation were . kg (range, . - . ) and . kg (range, . - . ) , respectively. the median operative time was minutes (range, - ) in oec and . minutes (range, in lec groups and there was no significant difference between oec and lec groups (p= . ). intraoperative bleeding was minimal in both groups. the postoperative hospital-stay, time to start diet, and time to return to full feeding had no significant differences in both groups. after discharge, of ( %) oec patients experienced readmission due to cholangitis and ileus, while there were none in the lec group. conclusions: this study revealed that lec had better prognosis compared to oec. lec provided an excellent cosmetic result. so we suggest lec could be the treatment of choice for neonatal choledochal cyst. this is a small series, therefore future studies will have to include a larger number of patients and evaluate long-term follow-up. keywords: choledochal cyst, laparoscopy, neonate. laparoscopic narrow band imaging for intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma: a preliminary study yukio iwashita, hiroki uchida, teijiro hirashita, yuichi endo, kazuhiro tada, kunihiro saga, hiroomi takayama, masayuki ohta, masafumi inomata; oita university faculty of medicine introduction: determining tumor invasiveness before operation is one of the most important unsolved issues in the management of gallbladder cancer. we hypothesized that the assessment of irregular vessels on the gallbladder wall may be useful for detecting subserosal infiltration. we present an initial report on the clinical usefulness of laparoscopic narrow band imaging (nbi) for the intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma. methods: thirteen patients with gallbladder cancer were included in this study. patients with tumors located in the liver bed and those with definitive invasion observed on computed tomography findings were excluded from this study. gallbladders were observed using nbi and the microvasculature was evaluated. according to previous reports of endoscopic nbi, we defined four findings as positive: vessel dilatation, tortuousness, interruption, and heterogeneity. the nbi findings were compared with postoperative pathological findings. the study protocol was approved by the institutional review board of the oita university. results: the serosal surface of the tumor site and its microvasculature were successfully observed in all patients. laparoscopic nbi detected at least one abnormal finding in seven patients, and postoperative pathology showed subserosal infiltration accompanied by vessel invasion. on the contrary, six patients with no positive nbi findings showed mild or no subserosal infiltration and no vessel invasion. conclusions: our study indicated that laparoscopic nbi may be useful for diagnosing subserosal infiltration accompanied by a vessel invasion. shuichi iwahashi, mitsuo shimada, satoru imura, yuji morine, tetsuya ikemoto, yu saito, hiroki teraoku; department of surgery, tokushima university introduction: laparoscopic cholecystectomy (lap-c) is the standard operation for the benign diseases. we have reported reduced port lap-c (rpl-c) was safely and comparable method to sils-c and conventional lap-c (sages ) . in this time, we examined the utility of rpl-c containing the post-operative adverse event. procedures: the adjustment is the benign illness including the cholecystolithiasis, and advanced obesity and the cases of the inflammation remaining have been excluded. the incision is put and cut open the abdomen to the umbilical region, and camera port was inserted. we used mm flexible scope. mm forceps for holding of the gallbladder bottom and left hand of operator were inserted directly with no port. methods: rpl-c has been introduced in this department since july, . we performed cases of lap-c, containing sils-c and american style conventional lap-c, and we performed rpl-c has been performed already cases. we compared the patient background and the operation factor between rpl-c, sils-c, conventional lap-c. operators were young surgeons, they were not specialists of gastroenterological surgery or endoscopic surgery. results: the difference was not admitted in the age, gender, the physique, and the disease, and the difference was not admitted in hospital stay after the operation (rpl-c:sils-c:conventional lap-c= . ± . days: . ± . days: . ± . days) and the amount of blood loss (rpl-c:sils-c:conventional lap-c= . ± . ml: . ± . ml: . ± . ml) and operation time (rpl-c:sils-c:conventional lap-c= ± min: ± min: ± min). and surgical wound after rpl-c was cosmetically acceptable. regarding as the post-operative adverse event, there were no patients of bile duct injury. conclusion: in the patients on reduced port lap-c, there were no bile duct injuries of postoperative adverse event. reduced port lap-c is safely for young surgeons and comparable method. introduction: acute cholangitis is an ascending infection of the biliary tree secondary to obstruction and can be severe if proper intervention and treatment are not performed in a timely fashion. the most common management of cholangitis with ductal obstruction due to choledocholithiasis is intravenous hydration, empiric antibiotic therapy, endoscopic retrograde cholangiopancreatogram (ercp) with sphincterotomy and stone extraction with or without stent placement, followed by a delayed laparoscopic cholecystectomy. we present the case of a patient with blood clot obstruction of a common bile duct (cbd) stent after ercp with sphincterotomy and stone extraction. case presentation: a year old male presented to the emergency department with jaundice, right upper quadrant abdominal pain, truncal pruritis, nausea, vomiting, and fever. biochemical analyses and liver profile demonstrated an elevated white blood cell count, hyperbilirubinemia, and elevated liver enzymes consistent with cholestasis. biliary ultrasound demonstrated multiple gallstones and dilation of the cbd with a distal obstructing calculus. he proceeded to ercp where biliary cannulation was achieved, sphincterotomy performed, and a large amount of sludge and pus was drained. an mm stone was removed from the cbd by balloon sweep with completion cholangiogram demonstrating no filling defects. a stent was then placed in the cbd with adequate flow. following the procedure, the patient continued to have increasing hyperbilirubinemia. a repeat ercp revealed a large blood clot and continued bleeding at the previous sphincterotomy that resolved with epinephrine injection. the former stent was visualized in the proper position, removed with a snare, and found to be fully occluded with blood clots. after retrieval of additional clots, a new stent was placed with adequate return of bile. the patient recovered with resolution of his symptoms and hyperbilirubinemia with laparoscopic cholecystectomy. discussion: cholangitis is characterized by charcot's triad of right upper quadrant abdominal pain, fever, and jaundice due to an ascending bacterial infection of the biliary tree coinciding with obstruction of biliary flow most commonly from gallstones. cholangiography via ercp with associated sphincterotomy, stone extraction, and stenting is both diagnostic and therapeutic. while debated by endoscopists, stent placement has shown to reduce recurrent biliary complications, decrease length of hospital stay, and lessen morbidity. although pancreatitis is the most common cause of hyperbilirubinemia post-ercp, stent occlusion secondary to stones or blood clots should be considered to effectively treat patients. proper hemostasis is important in any procedure and close patient follow-up should be performed to prevent further complications. sarrath sutthipong, md, panot yimcharoen, md, poschong suesat, md; bhumibol adulyadej hospital background: choledochal cyst (cc) is a rare disease, characterized by dilatations of the extra-or/ and intrahepatic bile ducts. ccs occur most frequently in asian and female populations. cc is associated with biliary lithiasis and considered at risk of malignant transformation. todani's classification dividing cc into types is the most useful in clinical practice. the current standard treatment is complete cyst excision with roux-en-y hepaticojejunostomy and cholecystectomy for the extrahepatic disease (todani type i and iv). in this report we present our experience using a total laparoscopic technique to treat adult patients with cc in -year period. methods: a retrospective review of the records of the patients above years who underwent laparoscopic cyst excision and roux-en-y hepaticojejunostomy in our hospital between january and may was carried out. the data included the clinical presentation, investigation, perioperative details and complication. the type of cc was classified according to todani's classification. results: seven cases of cc were reviewed, females and male with mean age years (range - years). these included cases of todani type ib and cases of type a. the predominant symptoms were chronic abdominal pain and jaundice. a case of both pancreatitis and cholangitis were also seen. investigations included ultrasound with mrcp in cases and ercp in case. the mean operative time was hours and minutes ( hours minutes to hours range) with mean intraoperative blood loss ml (range - ml). all the resected specimens showed chronic inflammation. malignancy was not seen in any patients. the early postoperative complications included bile leakage with intra-abdominal collection in patients, which were managed conservatively (evidenced by clinical status and imaging study), re-operation was not required. the median duration of hospital stay was days (range - days). there was no perioperative mortality. all patients were followed up at , , and months postoperatively, late complication were not detected during each visit. conclusion: in our opinion, laparoscopic cyst excision and hepaticojejunostomy could offer more feasible and safe methods of treatment for ccs in adult patients with potentially less postoperative morbidity, a shortened length of stay and a lower blood loss when compared to the preferred open approach. however, we would need to study this on a larger sample of patients to report the efficacy and safety of laparoscopic approach. endoscopic trans-papillary gallbladder drainage (etgbd) in acute cholecystitis: a single center experience arun kritsanasakul, chotirot angkurawaranon, jerasak wannapraset, thawee rattanachu-ek, kannikar laohavichitra; rajavithi hospital background: surgery is the mainstay of treatment for cholecystitis, however, it may not be safe or feasible in some circumstances such as severe cholecystitis or cholecystitis in extremely high-risk patients. gallbladder drainage may be an appropriate alternative or a bridging option prior to cholecystectomy. endoscopic trans-papillary gallbladder drainage (etgbd) has been proposed as a modality that is feasible and effective in cholecystitis. objective: the primary outcome of this study is to evaluate the effectiveness of etgbd. the secondary outcome is to evaluate the safety, early experience outcomes, and complications of this procedure. methods: retrospective medical records review between january -december from a single tertiary referral hospital center, rajavithi hospital, bangkok, thailand. a total of patients who was diagnosed with cholecystitis and underwent etgbd. the procedure was performed at the endoscopic suite under light sedation via total intravenous anesthesia. the patient demographic data and procedures were collected. the technical success of etgbd was defined as decompression of the gallbladder by successful cystic duct stent placement. the clinical success was defined as resolution of symptoms and/or improved laboratory data or ultra-sonographic findings. results: a total of patients underwent etgbd. among these patients, were high risk for surgery due to age or comorbidity, had concomitant jaundice and was failure of medical treatment. both technical and clinical success of etgbd was achieved in of cases ( %). the two patients that did not achieve technical success were due to failure to cannulate guidewire through cystic duct and the other had trans-cystic guidewire perforation that needed surgical intervention. there were two intra-operative complications ( %). one was the patient who had trans-cystic guidewire perforation and another had anesthesia-related complication (hypoventilation requiring endotracheal intubation). there were no -day mortality. conclusion: endoscopic trans-papillary gallbladder drainage is an alternative treatment modality for patients with cholecystitis who are at high-risk for surgery and or those who are unsuitable for percutaneous gallbladder drainage. the technique is feasible, however, careful case selection and high endoscopic skill is needed. julia f kohn, bs , alexander trenk, md , woody denham, md , john linn, md , stephen haggerty, md , ray joehl, md , michael ujiki, md ; university of illinois at chicago; northshore university healthsystem, northshore university healthsystem introduction: subtotal cholecystectomy, where the infundibulum of the gallbladder is transected to avoid dissecting within a heavily inflamed triangle of calot, has been suggested as a method to conclude laparoscopic cholecystectomy while avoiding common bile duct injury. however, some case reports have suggested the possibility of recurrent symptoms from the remnant gallbladder. this retrospective case series reports a minimum of two-year follow-up on patients who underwent subtotal cholecystectomy within one four-hospital system. methods: a retrospective chart review database containing randomly selected cholecystectomies, all of which occurred between and , was reviewed to identify all instances of subtotal cholecystectomy. charts for these patients were reviewed through / , including any documentation from other providers, including primary care. results: six patients who underwent subtotal cholecystectomy with a remnant of infundibulum left following surgery were identified. surgical approach and the choice to perform subtotal cholecystectomy were dependent on the attending surgeon; all decisions were made intraoperatively. there was an average of months of follow-up for these patients within our institution. discussion: this case series adds six cases to the literature surrounding long-term outcomes in patients who underwent subtotal cholecystectomy. although one patient was lost to follow-up, no patient had recurrent biliary colic or other complications arising from the remnant gallbladder. this may be encouraging to surgeons who feel that subtotal cholecystectomy with an infundibular remnant is the safest way to proceed with cholecystectomy in patients with severe inflammation. objective: this study aims to evaluate the utility and efficiency of icg as an alternative to routine intraoperative cholangiogram in patients undergoing cholecystectomy. introduction: common bile duct injury is an uncommon, but serious complication associated with laparoscopic cholecystectomy. current guidelines state that when used routinely intraoperative cholangiogram (ioc) can decrease biliary injury, however it is not routinely used due to increased time of operation, and inaccessibility of equipment. indocyanine green (icg) has been found to be effective for identification of biliary anatomy during cholecystectomy, however has not yet been widely adopted. we aim to assess if icg is able to overcome the obstacles of ioc, while still effectively assessing biliary anatomy. methods: we performed a retrospective analysis of laparoscopic cholecystectomies performed in a single institution from january to september . elective and emergent cases were included. we stratified patients into icg and non-icg groups. patients who had concomitant procedures performed were excluded. we analyzed patient demographic information, as well as bmi, asa classification and comorbidities in both groups. our primary outcome was operation time (skin to skin), and laparotomy conversion rate. secondary outcomes were effectiveness of icg in visualizing biliary anatomy, and cost. results: patients were included in our study, in the non-icg arm and in the icg arm. both groups were similar in background. there were no statistical differences in patient demographics, asa classification, bmi, or comorbidities. there was no statistical difference in operation time ( . vs . minutes; p. ) or conversion rate ( . vs %; p. ). icg was able to delineate biliary anatomy in % of the patients. the cost of a mg/vial kit of icg is approximately $ . conclusion: the use of icg does not increase operating time during laparoscopic cholecystectomy. icg is an inexpensive and effective tool used to delineate biliary anatomy without the inherent burden and limitations of ioc. benefsha mohammad, md , michele richard, md , steve brandwein, md , keith zuccala, md ; danbury hospital, danbury hospital department of gastroenterology, introduction: obesity is a prevalent issue in today's society, which has increased the number of gastric weight loss surgeries. this presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ercp). in gastric bypass patients, traditional ercp via the mouth in these patients is technically more challenging, requiring a longer endoscope with a reported success rate of less than %. a solution is laparoscopic assisted ercp (la-ercp) via gastrostomy. this minimally invasive technique has become increasingly more prevalent and safe. we present our experience with la-ercp at our teaching community hospital in a large cohort of patients. methods and procedures: retrospective chart review was performed on all patients with a history of prior laparoscopic gastric bypass surgery who underwent la-ercp from april to april . the procedure was performed by two different general surgeons and one gastroenterologist. a pursestring suture and transfacial stay sutures were used to bring the gastric remnant to the abdominal wall. a gastrostomy was then created and accessed by the duodenoscope to perform the ercp. biliary sphincterotomy, papillary or biliary dilation, lithotripsy, stent placement, and/or stone removal were performed as indicated. we observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital re-admission and bile leak. results: thirty-two patients met inclusion criteria. six patients were male and twenty-six were female, with mean ages of (std dev ) and years (std dev ), respectively. indications for la-ercp included suspected choledocholithiasis ( / ), cholangitis with choledocholithiasis ( / ), acute pancreatitis ( / ), abdominal pain with abnormal lft ( / ), cholangitis with cholecystitis ( / ), and bile leak ( / ). la-ercp was successfully performed in all thirty-two patients. biliary cannulation, sphincterotomy and stone extraction were performed on / patients, and one patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. one patient developed acute pancreatitis with elevated pancreatic enzymes which resolved after conservative treatment. one patient required a second la-ercp for stent replacement due to a persistent bile leak. the median length of stay was days (range - days). conclusions: la-ercp is a safe and feasible alternative to open surgery, and can be safely implemented at community hospitals with adequately trained providers. obesity is a growing burden on society, increasing the incidence of weight loss surgery. our large study proves that in this minimally invasive era, la-ercp provides gastric bypass patients a safe alternative with less pain and increased satisfaction. ahmed elgeidie, elsayed adel; gastrointestinal surgery center background: endoscopic sphincterotomy (es) is an effective therapeutic procedure for common bile duct (cbd) stone clearance but it carries a substantial risk of recurrent stones at long-term outcome. aim of the study: to evaluate the rate of cbd stones recurrence after primary complete endoscopic clearance, and to identify the risk factors of recurrence. methods: between january and december , patients with cbd stones who underwent successful es and complete stone clearance were studied retrospectively. recurrent cbd stone, was defined by the confirmation of the presence of cbd stone at least months after previous complete cbd stone clearance by es. the risk factors for recurrent cbd stones and mean time interval between initial es and stone recurrence were analyzed. results: in total, patients we included. the median follow up period was months. recurrent cbd stones appeared in / ( . %) patients after a median time interval of ( - ) months following es. stone recurrences were observed on multiple occasions in patients ( . %). on the univariate analysis, the significant risk factors related to recurrent cbd stone were male sex (p= . ), previous history of cholecystectomy (p= . ) multiple cbd stones (p= . ), large cbd stone (p= . ) the presence of periampulary diverticulum (p= . ) and stone crushing using mechanical lithotripsy (p= . ) conclusion: recurrence of cbd stones is an identified long-term risk after es and stone clearance. background: laparoscopic cholecystectomy during advanced pregnancy is challenging due to the limited intraabdominal space. patients may be at increased risk for developing trocar site hernia. case report: a year old hispanic female in her th week of pregnancy came to the er with acute right upper quadrant pain. due to lack of accessibility she had poor prenatal care. she had mildly elevated amylase but normal lfts and ultrasound showed some gallbladder wall thickening suggestive for acute cholecystitis and no dilated biliary duct. fetal ultrasound was normal. she was admitted to the hospital and started on antibiotics, obstetrics was consulted. her amylase peaked at [ u/l but then normalized and indication for laparoscopic cholecystectomy was made. mrcp and ercp were not performed as it was assumed that the patient had passed a stone. five mm trocars were placed in the luq and the umbilicus and a teleflex minigrasper between the tow. the uterus was found at the umbilical level. the gb was pulled out and the serosa was incised on both sides and a window was created behind the gb midportion and widened towards infundibulum and fundus. there was gb wall thickening and edema. the critical view was obtained and the cystic artery and duct were clipped and divided. the common bile duct appeared normal and no ioc was done. the specimen was retrieved through the luq port site using a mm endobag after dilatation to . cm due to the presence of two large stones. the port site fascia was closed using a suture passer. the postoperative course was uneventful and both mother and baby were well at the two weeks follow up. discussion: in case of biliary pancreatitis during pregnancy, lc should be performed and if ultrasound shows a normal biliary system and amylase/lipase normalize, mrcp/ercp and ioc may be avoidable to protect the baby. lc with two ports is feasible during pregnancy. removal of the specimen through a lateral abdominal wall site may help prevent an umbilical port site hernia in this patient population. s surg endosc ( ) :s -s introduction: splenic abscess is a rare, potentially lethal condition, with autopsy studies showing incidence rates between . - . %. mortality rates ranging from to % making early diagnosis and prompt intervention vital. several case reports have documented post surgical splenic abscess, most notably after laparoscopic sleeve gastrectomy. to the best of our knowledge, there has not been any reported cases of splenic abscess arising after laparoscopic cholecystectomy. it is important to remember this disease process for expeditious targeted treatment in future cases. case presentation: a year-old female with past medical history significant for cholilithiasis, hypertension, and hyperlipidemia presented to the emergency department (ed) with a chief complaint of abdominal pain for two days. labs and imaging were obtained which confirmed the diagnosis of choledocholithiasis and pancreatitis. ercp was performed which showed a . cm stone causing obstruction, with several other smaller filling defects. the stones were removed after sphincterotomy. post procedurally, the patient underwent an uncomplicated laparoscopic cholecystectomy on hospital day (hd) # . post operatively, the patient had persistent leukocytosis peaking at . thousand on postoperative day (pod) # . a ct scan was performed which showed a rim-enhancing splenic collection measuring . . cm suggestive of an abscess. interventional radiology was consulted and aspirated ml of purulent fluid. cultures grew out klebsiella pneumoniae and enterobacter cloacae complex, and the patient was discharged home on zosyn. discussion: laparoscopic cholecystectomy has become the cornerstone in treatment of symptomatic biliary colic and acute cholecystitis. of the many recognized complications of laparoscopic cholecystectomy, splenic abscess has not yet been reported in current literature. the nonspecific signs and symptoms of splenic abscess make clinical diagnosis difficult. the classic triad of fever, palpable spleen and left upper quadrant pain are only seen in about two-thirds of patients. ct scan has been shown to be the most sensitive imaging modality for diagnosis of splenic abscess. current treatment options for splenic abscess are broken down into two subsets: percutaneous and surgical intervention. percutaneous treatment includes image guided aspiration with or without placement of drainage catheter. surgical intervention can be either laparoscopic or open and includes drainage of abscess with splenectomy or splenic conservation. the best treatment option remains unclear, and there is lacking prospective data demonstrating which modality is superior. introduction: laparoscopic subtotal cholecystectomy is widely accepted as a safe alternative to the conventional laparoscopic cholecystectomy in case of acute cholecystitis with frozen calot's triangle. the remnant stump of the gallbladder may be either sutured or looped. however, there are limited studies comparing the outcomes of the two techniques. the present study is aimed at comparing loop and suture closure of the gall bladder stump. methods: a retrospective analysis of our prospectively maintained database revealed that between january and december . patients underwent laparoscopic subtotal cholecystectomy for acute cholecystitis, chronic cholecystitis or empyema gallbladder with frozen calot's triangle. the decision to use endoloop or sutures for stump closure was made intra-operatively after dividing the gallbladder through the infundibulum. a no. sized drain was kept in all the cases. the patients were discharged with drain in situ, and were reviewed on post-operative day during which an ultrasound was done and drain removed if the progress was satisfactory. the intra-operative and post-operative data between the two groups were recorded and analyzed. results: endoloop closure was performed in patients and suture closure using . ethibond was done in patients. three patients from the sutured group had post operative bile leak among which one patient underwent endobiliary stenting. the other were managed conservatively while the drain had to be retained for weeks. two patients in the endoloop group were detected to have retained stone in the remnant gallbladder cuff among which one had recurrent cholecystitis requiring laparoscopic completion cholecystectomy. none of the patients had bile duct injury or surgical site infection. mean post operative stay was . + . days, did not significantly vary between the groups. suturing needed more surgical expertise and had prolonged operative time than endoloop ( + min versus + min, p= . ). conclusion: suture or loop closure of the remnant gallbladder after subtotal cholecystectomy are equally effective. suturing the stump may be associated with increased incidence of biliary leak while endoloop may have higher incidence of retained gallstones. the choice between the two may be made intra-operatively based on the surgeon's expertise and preference. background and aim: in recent years, due to the spread of laparoscopic cholecystectomy, bile duct injury as its complication has been reported at a certain frequency. current surgical treatments include ) suturing and closing the injured part laparoscopically during surgery, ) transitioning to laparotomy and closing the suture, ) inserting a tube such as t-tube under the laparotomy, ) bile duct-intestinal anastomosis under the laparotomy, etc. are taken into consideration. regardless of which treatment method, it is not a definite ideal treatment. we have developed a bioabsorbable material (caprolactone: lactic acid ( : ) polymer reinforced with polyglycolic acid fiber and designed to be absorbed in about weeks). at this conference, we would like to talk about the current state and problems of development of minimally invasive therapy for biliary damaged area using bioabsorbable materials we developed. method: in order to overcome the problem of the current bile duct injury cure method, we have been developed, a) a method of closing a perforation part endoscopically from the luminal side of a bile duct (a covered stent using a bioabsorbable material in the damaged part), b) develop a method of closing the biliary duct injury under the laparoscope from the outside of the bile duct (adhering the bioabsorbable sheet to the bile duct perforation using a biocompatible adhesive). results: experimental results of suturing the bioabsorbable material in the biliary duct in surgery of laparotomy were able to regenerate the bile duct without stenosis in the damaged area. however, various adhesives were tried to bond the sheet of this bioabsorbable material and the native bile duct under the endoscope, but at the moment, there is no glue that will allow the sheet to be adhered readily and reliably where there is moisture to a certain extent. a tool for delivering the sheet from the bile duct into the injured part is under development and good results are obtained at present. conclusion: it is possible to regenerate the bile duct without constriction using a bioabsorbable material. it is difficult to laparoscopically adhere to the injured part of the bile duct, but we hope that it will be possible in the near future to develop further adhesives. s surg endosc ( ) , - kg/m (c) and more than kg/m (d). we made a . -cm longitudinal skin incision within the umbilicus. a wound retractor and a surgical glove were applied at that incision. we used the three -mm ports technique. after retracting the gallbladder upward, the cystic duct and artery were divided and identified using pre-bending forceps through the flexible port and laparoscopic coagulating shears (lcs). the cystic artery was dissected using the lcs and the cystic duct was also dissected after clipping. the gallbladder was freed from the liver bed using the lcs, and the specimen was retrieved from the umbilical wound. results: there were conversions to open laparotomy in cases ( . %) and requirement of additional ports in ( . %). the mean age (years), operation time (min), blood loss (ml) and postoperative hospital stay (days) in group a, b, c and d were . , . , . and . (p= . [), . , . , . and . (p= . ), . , . , . and . (p= . ) , and . , . , . , and . (p= . ), respectively. there was a significant difference in age only. the complications were bile duct injury in one case ( . %) and pneumothorax in two ( . %). conclusion: obesity had no influence of surgical outcomes for performing silc. introduction: recent studies have reported mixed outcomes when comparing surgeon case volume and laparoscopic cholecystectomy (lc) outcomes. formal minimally invasive surgical training (mist) has been shown to be associated with shorter post-operative length of stay (los), but no difference in major adverse events such as bile leak, bile duct injury, intra-abdominal abscess formation, and death. we aim to determine -day rates of major adverse events after lc in a university hospital setting, to identify significant associated risk factors, and to determine if mist or surgeon volume are associated with differences in los and major adverse events. methods: we conducted a single-center retrospective review of , cholecystectomies performed over a seven-year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . characteristics and outcomes were compared using chi squared or rank sum tests. multivariable regression modeling was used to determine independent associations with the two main outcomes, major adverse events and los. results: we identified , adults who underwent lc during the study period, with a median age of , and % women. about % (n= ) of patients had a los[ day and . % (n= ) were re-admitted within the first days after surgery for any reason. within days of lc, . % (n= ) of patients suffered from one or more major adverse events. this includes . % (n= ) of patients with bile duct injury, . % (n= ) of patients with bile leak, . % (n= ) of patients with intra-abdominal abscess, and . % (n= ) of patients died for reasons related to their procedure or post-operative recovery. table shows the characteristics of the patients and procedures with a comparison of the patients with an adverse event versus those without one. in univariate analysis, high annual surgical volume ( + cases/year) and procedure urgency were found to be significant predictors of adverse events and los, however, mist was not. in multivariable analysis, controlling for significant univariate predictors, urgent or emergent cases were associated with a -fold increase in odds of an adverse event (or= . introduction: laparoscopic cholecystectomy is an extremely common procedure in the united states, with over , cases performed annually. despite the procedure's overall safety, there has been some evidence that tobacco use is associated with increased risk of wound infection after lc. this retrospective chart review sought to examine whether tobacco use is associated with increased complications following laparoscopic cholecystectomy within a high-volume healthcare system. methods: after irb approval, of approximately , cholecystectomies performed within one four-hospital system between and were randomly selected, and patient charts were retrospectively reviewed. pre-, intra-, and postoperative data were collected, including all complications within days. tobacco use cohorts were defined as follows: never, former (any historical tobacco use), and current (active tobacco use within year of surgery) per the acs nsqip surgical risk guidelines. following preliminary data analysis, multivariable logistic regression models were generated to identify whether tobacco use was predictive of outcomes of interest. of the cases analyzed, patients ( . %) were never smokers; . % were former smokers, and . % were current tobacco users or had quit less than months prior to surgery. there were surgical site infections, one wound dehiscence, one port site hernia, three common bile duct injuries, and medical complications requiring prolonged hospitalization or readmission within days. current tobacco users were significantly more likely to undergo urgent surgery (following emergency admission or direct admission to the hospital) than former or nonsmokers. however, there was no difference between cohorts for prolonged duration of surgery, conversion to an open procedure, surgical site infection, wound dehiscence or hernia, common bile duct injury, or other medical complication. there was no significant difference between cohorts when all postoperative complications were pooled. conclusions: there does not appear to be a significant difference in -day surgical outcomes or complications in active tobacco users vs. former or non-users. although studies in other surgical settings have indicated a possible reduction in complications if patients abstained from smoking prior to surgery, this may not be beneficial in laparoscopic cholecystectomy. moreover, as current tobacco use appears to be associated with higher rates of urgent surgery, these patients may not be able to stop smoking prior to an elective procedure. prospective studies to further clarify whether there is any benefit towards tobacco cessation prior to lc may be valuable. , [ , [ respectively ( - ) , cyfra were . , . , . respectively ( - . ) . afp and cea were negative. as for this patient, he is of high risk of hepatobiliary system diseases. introduction: thymoma is one of the rare tumor entity benign or malignant arsisng from the epithelial cells of thymus gland, frequently associated with neuromuscular disorder myasthenia gravis. so, we are presenting this rare case of thymoma with myasthenia gravis in our institute. methods: we operated a single patient of thymoma in a case of myasthenia gravis by video assissted thoracoscopic approach. results: operative time- min, intraoperative blood loss − ml, post operative analgesia requirement in form of nsaids is for days, no ventilatory support required post operatively, with follow up reduction in achr ab from nmol/l to nmol/l and reduction in symptoms in form of reduced ptosis. conclusion: thoracoscopic thymectomy is feasible and safe in terms less operative time, less post operative pain and analgesia requirement and no post operative ventilatory support requirement. carter c lebares, md, stanley j rogers, md; ucsf background: duodenal fistulas are uncommon but morbid complications of acute necrotizing pancreatitis. if percutaneous drainage fails, surgical correction via roux-en-y diversion or pancreaticoduodenectomy can be required. while self-expanding metal stents have been tried, complications like migration and perforation have limited such use. endoscopic transmural stents have successfully treated fistulas of the stomach, particularly post-sleeve gastrectomy. here we present a case of endoscopic transmural stents used to treat a non-resolving duodenal fistula following acute necrotizing pancreatitis. methods: under general anesthesia, using a standard adult gastroscope, the fistula was identified in the second portion of the duodenum (fig. ) . a flexible-tipped guide wire was used to identify the fistula tract and two fr cm double pigtail biliary stents were deployed ( fig. ) with positioning verified under fluoroscopy. two weeks later these were removed and a single stent deployed into the visibly smaller tract (fig. ). two weeks after that, the single stent was removed and contrast medium was injected under fluoroscopic visualization, demonstrating resolution of the fistula (fig. ) . case: this patient is a year old woman with hypertension and congenital hearing loss who underwent a cholecystectomy for biliary colic and subsequent ercp with sphincterotomy for retained stone. this was complicated by acute pancreatitis which progressed to severe necrotizing pancreatitis with infected retroperitoneal necrosis. percutaneous drainage yielded initial improvement but a persistent moderate collection ( cc per day) lead to the identification of a fistula in the second part of the duodenum. repositioning and exchange of percutaneous drains over weeks did not hasten resolution. endoscopic transmural pigtail stents were tried after visualization of a large ( - mm diameter) fistula tract. stents were utilized as described in methods, with a total of three endoscopic interventions, at week intervals, resulting in resolution of the fistula as evidenced by contrast injection into the duodenum under fluoroscopy and subsequent ct scan with oral contrast. the patient's symptoms resolved and she was tolerating a normal diet. she remained thus at month follow-up. conclusion: this case demonstrates the benefit of endoscopic transmural stents for the resolution of duodenal fistulas, expanding the utility of this technique to address leaks and fistulas of the upper gastrointestinal tract. further study is warranted to clarify the timing and adjuncts to optimize the use of this promising approach. totally laparoscopic alpps combined with the microwave ablation for a patient with a huge hcc hua zhang; department of hepatopancreatobiliary surgery, west china hospital, sichuan university introduction: associating liver partition and portal vein ligation for staged hepatectomy (alpps) is a novel technique for resecting hepatic tumors that were previously considered unresectable due to the insufficient future liver remnant (flr) which may result in postoperative liver failure (plf). the procedure has been accepted and modified in many medical centers worldwide. but reports about the laparoscopic alpps were rare. this study aimed to report a totally alpps combined with microwave ablation for a patient with huge hcc and confirm the feasibility of laparoscopic alpps. methods: a -year-old man had complained of -year history of right upper abdominal pain, and the syndrome was worsened in recent month. abdominal enhanced computed tomography (ct) imaging revealed a cm solid mass in right lobe of liver with non-uniform and unclear boundary, the right posterior branch of the portal vein was invaded. in addition, a small lesion was simultaneous found in left lateral lobe of liver. the tumor was evaluated as unresectable due to the flr was only ml ( %). we decided to perform the laparoscopic alpps procedure. first stage including microwave ablation of the lesion in left lobe, cholecystectomy, ligation of the portal vein and transection of liver parenchyma. the second stage was done days later and consisted of laparoscopic right hemihepatectomy. results: the two stages were underwent by laparoscopy successfully. the operation duration was and minutes, respectively. estimated blood loss was and ml. the hospitalization time in intensive care unit was and days. there was no need for transfusion in both stages. the patient was discharged days after the second stage and the total hospitalization time was days. recovery of the patient was uneventful in addition to the incision infection after the second stage which recovered with conservative management. the patient did not show any signs of liver failure. the ct scan before the second stage showed an enlargement of left lobe, the flr was ml ( . %). there was no signs of residual liver disease in the ct scan days after the operation. the patient showed no signs of recurrence or liver failure in the following up period of six months. conclusion: totally laparoscopic alpps combined with microwave ablation is safe and feasible for the multiple hcc which was not resectable. the hypertrophy of remaining liver was fast and can achieve an adequate volume in a short time. introduction: chronic pancreatitis is a benign, irreversible inflammatory disorder characterized by the conversion of the pancreatic parenchyma into fibrous tissue. initial management should be conservative, surgery is applied in case of failure of medical treatment. the development of minimally invasive techniques has made it possible to perform these highly technical procedures in a laparoscopic manner. materials and method: we have the history of patients with and years with chronic pancreatitis and pancreatic lithiasis of difficult handling but intractable pain to those who decided to surgical management. we performed the procedure under general anesthesia, epidural analgesia catheter was placed. neumoperitoneum technique of cali, at mmhg and approach using a mm umbilical port, working ports of and a of mm port,. the pancreas was exposed by a section of the gastrocolic ligament with a mm ultrasonic scalpel, with cephalic retraction of the stomach, opening of a smaller sac and approaching the transpavity of omentum. the ventral surface of the pancreas was exposed from the neck. an incision was made in a pancreas body with a monopolar hook. primary pancreatic duct lumen was identified and the incision was extended longitudinally from the neck to the tail of the pancreas ( cm). roux's y loop was prepared cm from the treitz ligament, with a jejunum section with a mm stapler, roux's loop was transmecoscopically retrocollic, closing the gap of the mesocolon with monocryl. a -cm jejunum-jejunal anastomosis was performed with endo-gia stapler and closure of enterotomy with - polypropylene intracorporeal suture. jejunal (roux) isoperistaltic loop was placed longitudinally at the opening of the main pancreatic duct, and enterotomy was performed with monopolar in antimesenteric segment. the intracorporeal pancreatico and jejunum anastomosis was performed using a lower and an upper plane, with single points of total thickness with ethnobond - . closed drains were placed towards each anastomosis. this procedure was performed in the patients reported. operative time - min complications none operative time - days minimal bleeding drains no retired in both cases at days year follow-up of patients improved pain\ conclusions: minimally invasive surgery is a fundamental tool for the approach and management of patients with biliopancreatic pathologies. the establishment of multidisciplinary groups, offer an excellent alteranativa in the integral management of the patients. surg endosc ( ) gallbladder anatomy is highly variable, and surgeons must be prepared to identify anomalies of form, number, and position. variants include gallbladder agenesis, diverticulum, duplication, bilobed, multiseptate, phrygian cap, ectopic, and hourglass gallbladder. the hourglass gallbladder has been described from the earliest days of cholecystectomy, as morton described a congenital case in , and else thoroughly described the acquired and congenital strictures leading to the hourglass deformity in . we describe a case of an hourglass gallbladder found during one-step endoscopic retrograde cholangiopancreatography (ercp) and laparoscopic cholecystectomy. this year old male presented to an outside hospital with one day of nausea, and constant, severe, epigastric pain that radiated to his back. he endorsed a history of similar pain several times in the past. his abdomen was soft, nontender, and without murphy sign. laboratory evaluation revealed total bilirubin . mg/dl, alkaline phosphatase u/l, ast u/l, alt u/l, and no leukocytosis. ct abdomen and pelvis revealed cholelithiasis, distal choledocholithiasis, intra-and extra-hepatic ductal dilation, and a . centimeter left liver hemangioma. he was transferred for management of choledocholithiasis, and an abdominal ultrasound revealed cholelithiasis, without gallbladder wall thickening or pericholecystic fluid, and a . millimeter common bile duct without choledocholithiasis. he was taken to the operating room for a one-step ercp and laparoscopic cholecystectomy. upon laparoscopy, dense adhesions to the gallbladder were found. after initially attempting to obtain the critical view of safety, we then embarked on the retrograde "top down" dissection. this isolated a spherical structure measuring . . centimeters. two very thin tubular structures were identified, clipped, and transected after we found they were too small to place a cholangiocatheter. the common bile duct appeared to be pulled anteriorly by surrounding inflammation, though this was later found to be the proximal segment of gallbladder. the intra-operative ercp identified a remnant gallbladder with cholelithiasis and no extravasation of contrast. given the unusual anatomy, we completed the operation, ordered a post-operative ct liver and mrcp, and consulted a hepatopancreatobiliary surgeon. a small remnant gallbladder was identified on ct liver, though not on mrcp. completion laparoscopic cholecystectomy with intraoperative cholangiogram and ultrasound was performed on hospital day . this hourglass gallbladder variant likely occurred secondary to chronic fibrosis from cholecystitis, leading to a proximal and distal gallbladder lumen. in anatomic uncertainty, the "top down" dissection, intraoperative cholangiography, ct liver, and expert consultation are safe methods to avoid iatrogenic injury. introduction: endoscopic entero-enteral bypass could change our approach to small bowel obstruction in patients with prohibitively high operative risk. magnetic compression anastomoses have been well-vetted in animal studies, but remain infrequent in humans. isolated cases of successful use in humans include treatment of biliary strictures and esophageal atresia. while endoscopic gastro-enteric magnetic anastomoses have been described, the associated multicenter cohort study was terminated due to serious adverse events. since then, the technology has evolved and recently our own institution reported results of the first in-human trial of magnetic compression anastomosis (magnamosis), deployed through an open approach. here we present the first case of endoscopic delivery of the magnamosis device and the successful creation of an enteroenteral anastomosis for chronic small bowel obstruction in a patient with prohibitively high operative risk. methods: the magnamosis device has previously been approved by the food and drug administration (fda) for use in clinical trial. our institutional review board approved emergency compassionate endoscopic use of the device in this patient due to a non-resolving small bowel resection and prohibitively high operative risk. case: this is a year old man with advanced liver disease, chronic obstructive pulmonary disease, and history of emergent right colectomy with end ileostomy for cecal perforation. he presented with multiple acute on chronic episodes of small bowel obstruction with a stable transition point in the distal ileum, radiographically estimated at centimeters proximal to the ileostomy. endoscopic evaluation through the ileostomy revealed a traversable obstruction with proximally dilated small bowel. the magnets were delivered via endoscopic snare under fluoroscopic guidance and positioned in adjacent loops of bowel on either side of the obstruction (image ). by days post-procedure, healthy villi were visible through the central portion of the mated magnetic rings (image ). by days the magnetic rings were mobile and the anastomosis was widely patent allowing easy passage of the gastroscope (image ), and the patient's symptoms were completely resolved. the rings passed through the ileostomy days post-procedure. at month follow up, the anastomosis was unchanged (image ). conclusion: this case demonstrates the benefit of an endoscopically created magnetic compression anastomosis in a patient with small bowel obstruction and high operative risk. further studies are indicated to evaluate the use of this technique in similar patients or those with malignant obstruct, ion. desiree raygor, md, ruchir puri, md; university of florida health jacksonville cholecystectomy is one of the commonest operations in general surgery [ ] . occasionally chronic cholecystitis can lead to a small contracted gallbladder. this diagnosis can be misleading as it may represent congenital agenesis of the gallbladder [ ] . a -year-old female with a past history of pancreatitis presented with a three day history of right upper quadrant pain associated with nausea and vomiting. upon exam she exhibited tenderness in the right upper quadrant. her leukocyte count and liver function tests were within normal limits. ultrasound revealed a poorly visualized, contracted gallbladder without stones and a dilated common bile duct (cbd). cholescintigraphy revealed non visualization of the gallbladder after two hours, which was suggestive of acute cholecystitis. decision was made to proceed with a laparoscopic cholecystectomy. the abdomen was entered by an open hasson technique and standard trocar placement for a cholecystectomy was performed. on initial inspection, the gallbladder was not readily visible. a structure appearing to be the cbd was present and was mobilized circumferentially (fig. ) . a gauge butterfly cannula was utilized and multiple cholangiographic images were obtained (fig. ). no cystic duct or gallbladder was identified which was suggestive of congenital agenesis of the gallbladder. the patient did well postoperatively, and was discharged home on postoperative day two. the patient's symptoms resolved and she continues to be pain free one month postoperatively. congenital agenesis of the gall bladder is a rare disorder. a high index of suspicion is required especially in the setting of a small contracted gall bladder. if preoperative imaging is inconclusive then diagnostic laparoscopy should be the next step. cholangiogram should be performed routinely to confirm the diagnosis and to rule out an ectopic gall bladder. conversion to open does not offer any distinct advantage, and laparotomy should be avoided if possible given its associated morbidity. there are many reports upper abdominal major arterial aneurysms. however, an aneurysm of left inferior phrenic artery had never been reported. a -year-old woman with liver cirrhosis associated with hepatitis b viral infection was referred to department of surgery for treatment of aneurysm of left inferior phrenic artery. she underwent trans-arterial chemoembolization (tace) for treatment of hepatocellular carcinoma three times, previously. on months after last tace, mm sized highly enhancing nodular lesion of gastric fundus was found on follow-up abdomenpelvis computed tomography (a-p ct). one year later, the size of this lesion increased to mm, and an aneurysm was diagnosed. she underwent angiography and attempted embolization with an aneurysm of the left inferior phrenic artery, but access failed. we performed a laparoscopic vessel ligation. she recovered with no complication and discharged on the th postoperative day. s surg endosc ( ) :s -s yousef almuhanna, vatsal trivedi, fady balaa; university of ottawa a years old female, g and weeks pregnant, was brought to the hospital by ems, after being found on the floor in her toilette surrounded by vomitus and urine. mother-inlaw, who happens to be at the house that time, have heard severe retching followed by a loud bang sound. firefighters have found no pulse and therefore started cpr. return of spontaneous circulation was achieved, yet unfortunately, she had arrested again minutes prior to arrival to er. pocus assessment showed large rvot, and therefore tpa was started on the assumption of pulmonary embolism. upon arrival of blood work, it was found that her hemoglobin had dropped from to . fast was repeated showing moderate to severe amount of free fluid in the morrison's pouch and pelvis. she was then taken to the operating theatre, had undergone laparotomy showing liver segment ii injury. pringle's maneuver and aortic clamping did not control the bleed, therefore finger fracture and venous clips were used to temporary minimize the bleed, and head to interventional radiology suite. after multiple attempts to control the bleed, and the massive transfusion, she vital signs were not maintained, and had arrested afterwards. sarrath sutthipong, md, chumpunut chuthanan, md, chinnavat sutthivana, md, petch kasetsuwan, md; bhumibol adulyadej hospital, bangkok, thailand background: mesenteric panniculitis (mp) is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small bowel and colon. the specific etiology is unknown and no clear information about the incidence. the diagnosis is suggested by ct and is usually confirmed by surgical biopsy. treatment is based on some selected drugs. surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. we reported a case of the mp diagnosed with ct and surgical biopsy by laparoscopic approach. case report: -year-old woman with months history of chronic abdominal pain, mainly localized in the sub-epigastrium, intermittent and mild. she had anorexia but no weight loss or change in bowel habits. no history of medical illness or surgery. the physical examination was unremarkable, except for palpation of ill-defined mass about cm at mid-abdomen, firm, smooth surface with mild tenderness. the laboratory profile and tumor marker were normal. ct of the abdomen, which showed focal heterogeneous enhancement of the mesenteric fat with stranding ( . . cm) with multiple internal subcentimeter lns in the supraumbilical area, which was probably inflammatory in origin and suggestive of mp. f-fdg pet/ct showed faint fdg uptake in multiple mesenteric lns. the patient was subsequently underwent diagnostic laparoscopy with biopsy. intra-operative finding showed a fat-like surface of yellowish mass at mesentery of jejunal segment, incisional biopsy was performed laparoscopically. the histology showed adipose tissue with areas of fat necrosis, fibrosis, foamy macrophages infiltration and predominant chronic inflammation, no evidence of malignancy. ihc studies (including cd , s- , cd and cd ) were performed and the result was compatible with reactive process. treatment was started with mg prednisone once daily and planned for follow-up with repeated ct scan. discussion: mp involves the small bowel mesentery in over % of cases. the diagnosis is made by pathologic findings: fibrosis, chronic inflammation and fatty infiltration. the differential diagnosis is broad and has been associated with malignancies such as lymphoma, well-differentiated liposarcoma and melanoma. the imaging appearance varies depending on the predominant tissue component. a definitive diagnosis is biopsy but open biopsy is not always necessary. no data of laparoscopic biopsy, which has been reported previously. treatment has been reserved for symptomatic cases with a variety of drugs. our case was started on oral corticosteroid treatment and waited for responsive evaluation. background: laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. stapled closure of the appendiceal stump is often performed and has been shown to have several advantages. few prior cases have been reported demonstrating complications from free staples left within the abdominal cavity after the laparoscopic stapler has been fired. case report: a previously healthy year old female initially underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (gia) staplers. her initial postoperative recovery was uncomplicated and she was discharged home the same day. the patient returned to the emergency department on postoperative day with one day of sharp mid-abdominal pain, obstipation, and emesis. her abdomen was distended and mildly tender but not peritoneal. she was afebrile but was found to have a leukocytosis of . . ct demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction. diagnostic laparoscopy was performed through the three prior appendectomy incisions. an adhesion was noted between the veil of treves and the mesentery of a more proximal loop of ileum caused by a solitary free closed staple, remote from the staple lines, resulting in an internal hernia containing several loops of ileum ( fig. ). the hernia was reduced, and the small bowel was noted to have early ischemic discoloration. the adhesion was lysed by removing the staple from both structures to prevent recurrence. through the remainder of the procedure, the compromised loops of bowel began to peristalse and the color normalized. the procedure was concluded without resection. the patient recovered on a surgical floor and was discharged home on postoperative day one. conclusion: gastrointestinal staplers are commonly used secondary to ease of use and low complication rate. it is not uncommon to leave free staples in the abdomen during laparoscopy as retrieval can often be more difficult and time consuming. our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staple. choosing the most appropriate size staple load, to reduce the number of extra staples after the fire, and removing as many free staples as possible can prevent potentially devastating complications. video-assisted thoracoscopic pulmonary wedge resection in a patient with hemopytsis and intralobar sequestration: a case report mary k lindemuth, md, subrato j deb, md; the university of oklahoma health science center case report: a -year-old male with history of noonan's syndrome, bronchitis, and asthma presented with acute hemoptysis. while chest x-ray was unremarkable, a computed tomography angiogram of his chest was significant for intralobar pulmonary sequestration in the right lower lobe. the aberrant pulmonary artery originated from the abdominal aorta, immediately proximal to the celiac axis, and coursed through the hiatus in the retroperitoneum. flexible, fiberoptic bronchoscopy revealed blood within the right lower lobe bronchus with no appreciable source. a right video-assisted thoracoscopic approach was taken for wedge resection of the sequestration. twoportal technique was utilized with the patient on single lung ventilation. the sequestration was easily identified; the anomalous pulmonary artery coursed directly to a large, focal area of hemorrhage noted within the lower lobe pulmonary parenchyma, as seen in image [rectangle marking the aberrant artery and oval marking the sequestration]. pathologically, the specimen was noted to be benign lung parenchyma with bronchiectasis and abundant, acute hemorrhage. discussion: pulmonary sequestration (ps) is a rare, congenital bronchopulmonary foregut malformation. literature describes the incidence of ps to be only . - . % of all pulmonary malformations. as ps is most frequently diagnosed during childhood, the occurrence of diagnosis during adulthood is estimated to be less than per , adults. two types (intra-and extralobar) are described, with intralobar sequestration most common and contained within the normal visceral pleura. both types have aberrant systemic arterial blood supply, most frequently from the thoracic aorta. likewise, both types are nonfunctioning lung tissue, as there is no direct communication with the bronchopulmonary tree. the most common presentation is pneumonia, and often patients will have had recurrent symptoms before diagnosis. it is rare to present with hemoptysis, which is understood to be secondary to elevated capillary pressure within the sequestration and then communication through the pores of kohn. while endovascular embolization of the aberrant pulmonary artery has been described as a safe alterative for surgical intervention, the subjects of these studies have primarily been children and long-term outcomes are unknown. the definitive treatment of ps continues to be surgical intervention. the surgeon should strive to leave as much normal lung parenchyma as possible. video-assisted thoracoscopic resection is well tolerated by patients when compared to thoracotomy. however, it is vital for the surgeon to be aware of the potential risk of life-threatening hemorrhage secondary to the sequestration having systemic blood supply that must be controlled and ligated. case report: a years-old female patient with history of an increased mass and weight loss of kilograms in months, associated with vomiting and nausea for eight months. abdominal ultrasound showed an irregular cyst, without solid projections and without signs of flow in doppler, measuring cm. investigation continued with ct scan that showed a large homogeneous cystic lesion with no septum in the abdominopelvic region, possibly mesenteric, measuring . . cm. a laparoscopic approach for resection of the cyst was then performed. the surgery was performed with a patient in the dorsal decubitus, using three trocars: one in the umbilical region ( -mm) for the camera, and where the pneumoperitoneum was created by the hasson open technique under direct vision; and another two located in the epigastrium ( -mm) and in the right upper quadrant ( -mm) . in addition to the mesenteric cyst, a simple cyst in the right ovary and a solid nodule with a lipomatous characteristic of approximately cm in the abdominal cavity were visualized. total resection of the mesenteric cyst with periprancreatic fibrous tissue was performed. the cyst was punctured and its contents fully aspirated. resection of the right ovarian cyst was also performed. at the end of the procedure the mesenteric and ovarian cysts, the nodule, part of the omentum, and the peripancreatic tissue were removed through the -mm trocar at the umbilicus. patient had no further complications, being discharged four days after the procedure. histopathologic result showed a serous cyst in the right ovary, serous cyst in peripancreatic mesentery with chronic inflammatory process and signs of calcification; no signs of malignancy were observed in any specimen. we aimed to present the succesul therapeutic approach utilizing laparoscopy for safely removing a gastrointestinal stromal tumor. depicted is a year old jehova's witness female who presented to the emergency department for evaluation of bitemporal headache and dizziness and found with profound anemia with hemoglobin . and hematocrit . upon arrival to ed. the patient refused blood transfusion as her religious beliefs, jehovah's witness, preclude her from taking blood products. as part of her work up, endoscopy was performed and revealed a large, approximatelly cm, prolapsed, ulcerated, nodular lesion with active bleeding in the cardia of the stomach. this was temporized but the friable tissue, with no single identifiable lesion for clip placement, left the patient at high risk for re-bleeding. she was taken to the operating room and laparoscopic partial gastrectomy with intraoperative esophagogastroduodenoscopy were succefully perfomed, with minimall blood loss and no intra operative complications. patient was discharged on post op day . we present the case of a -year-old male with a history of morbid obesity with an initial bmi of . , who underwent an elective laparoscopic single anastomosis duodenal-ileal bypass with sleeve gastrectomy (sadi-s). postoperatively he developed an anastomotic leak at the duodeno-ileal anastomosis that would not resolve despite reoperation. he was then converted to a roux-en-y gastric bypass (rygb). postoperative imaging failed to reveal any signs of anastomotic leak and the patient was discharged tolerating an oral diet. he returned to the emergency department days later with a cm sub-hepatic collection arising from the duodenal stump from the surgical conversion. interventional radiology percutaneously drained the collection and found a connection between the cavity and the duodenum. using this connection, a percutaneous decompressive duodenostomy drain was successfully inserted into the duodenum using a guidewire through the abscess cavity along with an extra-enteric drain placed within this cavity. the collection was obliterated and the duodenal leak was controlled successfully with percutaneous drainage, bowel rest with parenteral nutrition and broad-spectrum intravenous (iv) antibiotics. the patient was reintroduced to a bariatric clear diet after a week of bowel rest and the abscess drain was then discontinued during the same hospital admission. the patient was discharged with the percutaneous duodenostomy tube which was removed in clinic days later, after the patient tolerated capping trials and imaging failed to reveal any further collections, oral contrast extravasation or distal obstruction. in this article we analyze notable imaging from the case and review current literature on the different management options for a duodenal stump blowout. we also discuss the basics of the sadi-s procedure and conversion of a sadi-s procedure to a rygb. keywords: anastomotic leak, duodenal stump blowout, sadi-s, duodenostomy tube. pancreatopic heterotopia is often an incidental finding on autopsy, but in some cases can lead to abdominal pain, obstruction, or intussusception. we present a case of pancreatic herterotopia mimicking an internal hernia on radiologic imaging. a year old female with seven month history of chronic abdominal pain treated for low back pain and recurrent urinary tract infections. she was found to have a computed tomography (ct) scan concerning for internal hernia and labs consistent with acidosis. she was taken for a laparotomy and did not have an internal hernia, but an exophytic mass in the proximal jejunum. the mass was resected and a stapled side to side jejunojejunostomy was created. on pathologic review, the specimen was found to be pancreatic heterotopia. her post operative course was complicated by an ileus, but was discharged post op day three. at her two week follow up she had minimal incisional pain and at one year follow-up she had resolution of her left upper quadrant abdominal pain. prior to this report, pancreatic heterotopia has never been described as presenting on ct scan as an internal hernia. although uncommon it should remain in the differential when evaluating a patient presenting with abdominal pain and radiologic evidence of obstruction or internal hernia. case report: a -year-old male patient who was diagnosed with high blood pressure at years-old and presented tetraparesis and intense asthenia for six months. blood tests showed hypokalemia, hypernatremia, and suppressed renin activity. ultrasound of the urinary tract was normal. ct scan of the abdomen showed a hypodense nodule with regular margins, measuring . . cm with a density of hu in the non-contrast phase and heterogeneous uptake after the injection of the contrast in the left adrenal gland. thus, the diagnosis of hyperaldosteronism secondary to the left adrenal nodule was confirmed, and surgical resection was indicated. the procedure was performed with the patient in the right lateral decubitus. two -mm and one -mm trocars were used on the left flank, as well as the -mm portal for the camera in the lower right quadrant under direct vision. the pneumoperitoneum was created by the hasson open technique in the transumbilical incision. the procedure consisted of the dissection, isolation and electrocautery of the left renal capsule and the left adrenal region with ultrasonic device, as well as the periadrenal vessels, adjacent lymph nodes and periadrenal and adrenal fat tissue. the surgery was uneventful and the patient had no further complications, being discharged the next day. histopathologic result showed a completely excised adrenocortical adenoma. conclusions: the hybrid minimally invasive approach proved to be safe and effective for this procedure, and the known advantages of minilaparoscopy such as less trauma, better visualization, better dexterity, better aesthetics, and reduced hospital stay were observed. s surg endosc ( ) background: coccidioidomycosis is a fungal infection endemic to the southwestern united states, central america and south america. coccidioides is ubiquitous in many of these endemic regions, with near % seroconversion in some communities. two-thirds of these mycotic infections may be asymptomatic. the most common presentation of coccidioidomycosis consists of "flu-like" symptoms or pneumonia. less than five percent of symptomatic cases progress to disseminated coccidioidomycosis which may involve any organ system. very rarely infection may include the peritoneum. we report a case of coccidioidomycosis with peritoneal involvement in an immunocompetent individual. case: a -year-old male presented to the emergency department with progressive abdominal pain. he was seen and treated for pneumonia in the emergency department one week prior. the patient worked outdoors in arizona and was otherwise healthy with a family history of malignancy and blood disorders. fever, leukocytosis and ascites on computed tomography scan prompted a diagnostic laparoscopy which revealed peritoneal granulomas positive for coccidioides. the patient was treated outpatient with fluconazole. discussion: since this is the th reported case of peritoneal coccidioidomycosis to our knowledge. the patient described in this case report was an otherwise healthy -year-old male; this is incongruent with many of the previously recorded cases which involved disseminated disease in immunocompromised patients. the patient's family history of malignancy and blood disorders suggests a potential underlying genetic predisposition that could account for this abdominal presentation. possible mutations include genes coding for the interleukin- β receptor and the signal transducer and activator of transcription which have been implicated in increased coccidioidomycosis susceptibility. peritoneal infection presents a unique challenge in diagnosis. in these cases coccidioidomycosis may not be suspected due to nonspecific symptoms and imaging, the infrequency of this extra-pulmonary manifestation and clinical characteristics that mimic the presentation of tuberculosis and malignancy. abdominal infections have been misdiagnosed as appendicular abscesses, iliopsoas abscesses, adnexal abscesses and pancreatic masses. consequently, the diagnosis of peritoneal coccidioidomycosis is often made after laparoscopic exploration of the abdomen and histopathology, as it was in this case report. conclusions: coccidioidomycosis incidence is on the rise in endemic areas and it often falls on the surgeon to make the diagnosis in extra-pulmonary cases. the peritoneal subset of coccidioidomycosis should be considered in endemic areas when a young, otherwise healthy patient presents with abdominal pain. failure to recognize the possibility of coccidioidomycosis may lead to unnecessary treatments and procedures. indocyanine green cholangiography to detect anomalous biliary anatomy steven d schwaitzberg, md, gabrielle yee, ms; university at buffalo jacobs school of medicine introduction: common bile duct injury is the most feared complication of cholecystectomy. imaging with indocyanine green (icg) is a safe and effective technique to detect biliary anatomy in open, laparoscopic and robotic surgery. several studies report detecting aberrant biliary anatomy with the use of icg in laparoscopic cholecystectomy with high success rates. by identifying the cystic duct-common hepatic duct confluence before dissecting calot's triangle, icg allows surgeons to perform "virtual" cholangiography at the start of procedures to identify either normal anatomy or possible anatomic variants. it is clear that icg use is an effective tool to achieve the critical view of safety. however, no reports have suggested icg cholangiography as the last operative step in cholecystectomy to identify hidden biliary anomalies and avoid postoperative bile leak complications. case report: we report a novel use of icg cholangiography in visualizing anomalous biliary anatomy prior to closing, thus avoiding potential bile duct leakage. in our case, icg cholangiography was used to fluoresce the common hepatic duct, common bile duct and cystic duct. the cystic duct was transected, and the gallbladder was removed using electrosurgery. at the completion of the gallbladder removal, the liver was elevated to inspect the clips on the cystic duct and artery. at this point, near infrared imaging was reinitiated, and a small mm structure was noted to fluoresce next to the cystic artery. this structure was identified using white light and subsequently clipped. discussion: the use of icg in this context after the completion of the cholecystectomy facilitated the identification of a small hepatocystic or aberrant duct, which would have likely leaked bile sometime in the postoperative period. based on our experience, we recommend one additional routine near infrared viewing to identify small structures or potential leaks at the completion of cholecystectomy. improved visualization of the extrahepatic biliary anatomy by icg has the potential to translate into improved clinical outcomes. solitary fibrous tumors (sft) are uncommon fibroblastic mesenchymal neoplasms that display a wide range of histologic behaviors. these tumors, which are estimated to account for % of all soft tissue neoplasms, typically follow a benign clinical course. however, it is estimated that - % of sfts are malignant and demonstrate aggressive behavior with local recurrence and metastasis up to several years after surgical resection. we report a case of sft arising from the stomach, which is an exceptionally rare finding and has been reported only six times in the literature. additionally, this tumor was associated with dedifferentiation into undifferentiated pleomorphic sarcoma. to our knowledge, there are no documented cases of a malignant sft arising from the stomach to demonstrate dedifferentiation into an undifferentiated pleomorphic sarcoma. a -year-old male presented to the emergency department with vague complaints of right-sided flank pain. the patient had a history of nephrolithiasis and underwent a ct abdomen. this scan revealed a large heterogeneous mass in the left upper quadrant. the patient underwent endoscopic ultrasonography with fine needle aspiration of the mass, which stained strongly for cd . gastrointestinal stromal tumor (gist) was the favored diagnosis as it is by far the most common mesenchymal neoplasm of the stomach, especially cd positive spindle cell neoplasm. accordingly, the patient began treatment with imatinib; however, after four weeks of therapy, there was no significant radiologic regression. a second biopsy was performed and the specimen was sent for stat immunohistochemistry, which revealed diffuse strong nuclear positivity. a diagnosis of solitary fibrous tumor was provided. surgical resection of the tumor was performed, which measured . cm. the patient was to undergo surveillance imaging every to months post-operatively. surveillance scan showed solitary metastatic disease in the left lateral segment of the liver. he underwent left lateral segmentectomy with an uneventful recovery. our case was complicated by diagnostic dilemma with gist, highlighting the challenges of diagnosing and characterizing sfts. dedifferentiation, or the abrupt transition from a classic sft into a high-grade sarcoma, is a particularly concerning finding in our case, as it is associated with a worse prognosis than classic malignant sft. the stat marker by immunohistochemistry is very specific for sft and may have aided in the diagnosis earlier. therefore, it is imperative to keep solitary fibrous tumor, albeit exceedingly rare, in the differential diagnosis of mesenchymal neoplasms of the stomach. appendiceal diverticulitits is an uncommon pathology that can clinically mimic acute appendicitis. some radiographic distinctions have been reported, but final pathologic examination of the surgical specimen is required to confirm the diagnosis. symptoms are often more mild, which can lead to a delayed diagnosis, and increases the risk of severe complications such as perforation. a year old female presented with a three day history of right lower quadrant pain. she described the pain as constant and radiating to the left lower quadrant. associated symptoms included nausea and vomiting, and decreased appetite; she denied fevers or diarrhea. the patient had no significant past medical history, and surgical history was significant for a total nephrectomy for living donor kidney transplant to her mother. on physical exam she was tender in the right lower quadrant with rebound and a positive rosving's sign. all laboratory results were unremarkable, and she was hemodynamically stable. ct scan was performed and demonstrated a dilated fluid filled appendix with surrounding inflammatory change without abscess or free intra-peritoneal air. she was subsequently admitted to the hospital, made npo, started on iv antibiotics, and was taken to the operating room where she underwent an uncomplicated laparoscopic appendectomy. post-operatively, her hospital course was unremarkable. pathology revealed acute suppurative appendicitis secondary to an acutely inflamed appendiceal diverticula, consistent with a final diagnosis of acute appendiceal diverticulitis. appendiceal diverticulitis should be considered in patients presenting with acute right lower quadrant abdominal pain. although some consider appendiceal diverticulitis a variant of acute appendicitis, it is important to distinguish between the two diagnoses. appendiceal diverticulitis has a higher rate of complications, including perforation, and is associated with a higher risk of neoplasm, particularly mucinous adenomas and carcinoid tumors. appendectomy should be performed in all cases in order to obtain appropriate pathological examination and rule out coexistent neoplasms. laparoscopic appendectomy is a safe and appropriate approach to treatment of appendiceal diverticulitis. upper gi endoscopy and biopsy showed a gastrointestinal stromal tumor (gist) in the stomach. a videolaparoscopic partial gastrectomy was then proposed. the surgery was performed with the patient in the right lateral decubitus. two -mm minilaparoscopic trocars, a -mm conventional trocar for an ultrasonic instrument and a -mm trocar in the umbilical region for the camera were used. pneumoperitoneum was created using the hasson open technique under direct vision. trans-operatory endoscopy was perfomed to identify the tumor easily. initially, the ultrasonic device released the large omentum, and, then, the tumor was resected in the body of the stomach. the gastric wall was manually sutured with a - vicryl, and the tumor was removed in an endobag through the -mm incision in the umbilicus. the surgery was uneventful, with a total time of minutes. the patient had no further complications, being discharged two days after the procedure with good clinical conditions. histopathological result showed a free margins gist. conclusion: the minimally invasive approach proved to be safe and effective for this procedure. the known advantages of video-surgery such as less trauma, better visualization, increased dexterity, better esthetics, and less postoperative recovery time were confirmed. the upper gi endoscopy contributed to improve the safety and efficacy of the procedure, allowing a more precise resection of the gist, as well as the intragastric review of the suture line at the end of the surgery. background: portal vein thrombosis (pvt) is a rare post-operative complication, which has been associated with a wide range of precipitating factors. most commonly described associated conditions include; cirrhosis, bacteremia, myeloproliferative disorders and hypercoagulable states. pvt most frequently occurs as a complication after hepatobiliary surgery, and although possible, very few cases have been documented occurring after laparoscopic surgery of the gastrointestinal tract. herein, we describe a case of pvt in a patient who underwent elective laparoscopic right hemicolectomy and was treated successfully at our center. case: a year-old female with past medical history of depression, migraines and endometriosis underwent an uncomplicated laparoscopic right hemicolectomy at our facility, for recurrent rightsided diverticulitis. she had suffered previous episodes of diverticulitis and desired definitive surgical treatment. her hospital course was uneventful and she was discharged to home on postoperative day . on post-operative day , she presented to the emergency department complaining of severe abdominal pain, back pain and nausea. computed tomography of abdomen and pelvis revealed pvt. she was initiated on therapeutic anticoagulation with heparin. hematology was consulted for hypercoagulable workup. further investigation revealed that she had a family history of a brother who had had a lower extremity deep venous thrombosis, with negative hypercoagulable workup. she had also previously been taking leuprolide and conjugated estrogen and medroxyprogesterone for her endometriosis. she was ultimately found to have a heterozygous prothrombin g a gene mutation. her anticoagulation was bridged to coumadin and she was discharged home. she has recovered as expected, without any further complications. discussion: although more common in patients with cirrhosis after hepatobiliary surgery, pvt is a rare complication that can occur after virtually all types laparoscopic surgeries, including elective right hemicolectomy. patients may be completely asymptomatic, or present with a broad spectrum of symptoms including; severe abdominal pain, fever, diarrhea, or gastrointestinal bleeding. physicians should be aware of this possible complication, since early diagnosis and treatment is imperative to prevent life-threatening complications, such as intestinal ischemia and perforation. a detailed medical and family history is imperative, and all patients with post-operative pvt should undergo complete hypercoagulability workup. this is a case of a year old male with a previous history of a redo-hiatal hernia years prior who presented with two episodes of upper gastrointestinal bleeding with no identifiable source noted on both endoscopy and angiography. during his second admission, initial hemoglobin was . g/dl and endoscopy performed showed massive amount of blood in the stomach. continuous oozing was seen originating in the fundus area but no clear source could be identified. empiric epinephrine was injected to the area but failed to achieve hemostasis. angiography was also negative. repeat endoscopy performed showed no active bleeding, however, distention of the wrap into the gastric cavity was observed. the patient re-bled and was taken to the operating room emergently after failed attempt at endoscopic control. the patient underwent proximal gastrectomy after intra-operative gastrostomy and exploration was unable to identify a bleeding source. the patient was left with an open abdomen and in discontinuity while resuscitation was performed in the surgical intensive care unit. he subsequently underwent a roux-en-y reconstruction and gastrostomy tube placement via the distal gastric remnant. upper gastrointestinal series performed demonstrated absence of leak, and the patient was started on a liquid diet supplemented with tube feeding. his recovery was uneventful and he was discharged home in stable condition. pathology revealed gastric ischemia at the base of the wrap making it impossible to visualize through endoscopy. on reviewing the literature, gastric ulcers and ischemia have been previously described. incidence was up to % and their onset of presentation ranged from the early post-operative period up to years. most were located in the lesser curvature. the exact pathophysiology for its occurrence is not completely understood. factors hypothesized include technical aspect of the fundoplication causing inappropriate tension, vessel disruption and ischemia, and injury to the vagus nerve affecting gastric emptying which was thought to increase gastrin secretion. treatment includes medical management with proton pump inhibitors; however, few cases describe antrectomy with inclusion of the bleeding ulcer. our case presents failed medical and endoscopic management. we recommend take down of the fundoplication in hemodynamically stable patients to completely evaluate the gastric mucosa, identify, and address the source of bleeding. otherwise emergent cases will require staged gastrectomy including the wrap followed by roux-en-y reconstruction. acalculous cholecystitis associated with a large periampullary duodenal diverticulum: a case report peng yu, md, phd, austin iovoli, aaron hoffman, md; department of surgery, suny buffalo, kaleida health system, buffalo, ny introduction: periampullary diverticulum (pad) could compress common bile duct (cbd), and consequently cause obstructive jaundice and cholangitis as few publications have documented. here we first report an acalculous cholecystitis associated with a pad-related cbd obstruction. case: the patient was a -year-old female with a past surgical history of laparoscopic sleeve gastrectomy who presented at the emergency room with upper abdominal pain and vomiting for one day, associated with leukocytosis and left shift. serum total bilirubin raised up to . mg/dl on hospital day (hd) . ct, ultrasound, and mrcp images confirmed a distended, wall-thickening gallbladder with pericholecystic fluid, and a significantly dilated cbd at . cm of diameter ( fig. ) , without cholelithiasis or choledocholithiasis. ercp was unable to be completed due to the post-gastrectomy anatomy and the failure in cannulation into the ampulla which embedded in a large foodimpacted pad (fig. ). on hd , the patient underwent a diagnostic laparoscopy and an intra-operative cholangiogram which confirmed a mildly inflamed edematous gallbladder, and a . . cm large pad with a narrow neck that was distorting the distal cbd (fig. ). since the patient's bilirubin level had been improving, we decided to only do a laparoscopic cholecystectomy. intraoperatively an anatomic variation of the cystic artery encircling the cystic duct ( fig. ) was also identified. postoperatively the patient recovered well during the thereafter inpatient course and at the postoperative -week outpatient follow-up. the pathology of the excised gallbladder confirmed cholecystitis without cholelithiasis. discussion: lemmel's syndrome is defined, in the absence of cholelithiasis or other detectable obstacle, by obstructive jaundice due to pad. since lemmel described this duodenal-diverticulum-obstructive jaundice in , there still have been very few cases reported or investigated. to date there is no report describing the association of acalculous cholecystitis with lemmel's syndrome. this patient's mild acalculous cholecystitis probably attributed to the biliary obstruction and consequent gallbladder hydrops. her symptoms could be from either acalculous cholecystitis or intermittently worsening biliary obstruction. in this case, the contribution of the anatomic variation of the cystic artery is unclear. in the future, if this patient's symptoms recur, the treatment plans for her will be sphincterotomy, removal of the impacted food in the pad, or diverticulectomy. accidental fish bone ingestion masquerading as acute abdomen aim: to report a case of fish bone ingestion masquerading as acute abdomen. case report: a years old female patient presented with complaints of severe abdominal pain since days. there was no history of associated nausea or vomiting, fever or altered in bowel habits. on examination patient had tenderness and guarding localized to the right iliac fossa. blood investigations revealed raised inflammatory markers. ultrasound whole abdomen and contrast enhanced computed tomography (cect) were normal. patient was managed conservatively but in view of persistence of symptoms a triple puncture diagnostic laparoscopy was performed on day of admission. omental inflammation with soapy appendix was found and appendicectomy was performed. on further assessment a foreign body was also found in the ileum which was removed and identified as a fish bone. patient had a satisfactory post operative recovery and was discharged in stable condition. discussion: acute abdomen due to fish bone ingestion is not a very common occurrence. unfortunately the history is often non-specific and these people can be misdiagnosed with acute appendicitis & other pathologies. ct scans can be useful to aid diagnostics. it is however not fully sensitive in detecting complications arising from fishbone ingestion. conclusion: any patient with acute abdomen, with non-specific history and normal imaging may still benefit from a diagnostic laparoscopy. discussion: this patient presented with a bowel obstruction, partial cecal necrosis and neuroendocrine carcinoma. literature suggests that cecal necrosis in the majority of cases is caused by a vascular event, occlusive or non-occlusive. the patient had atherosclerosis and an underlying malignancy which can be associated with prothrombotic states and contributes to an overall risk of thrombosis. the cecum can sustain ischemic ischemic injury in the presence of severe or prolonged hypotension. most frequent causes being decompensated heart failure, hemorrhage, arrhythmia or severe dehydration, only of which was present in this patient. the midgut neuroendocrine tumor is generally located in the terminal ileum, as a fibrotic submucosal tumor cm or less. mesenteric metastases are often larger than the primary tumor and associated with fibrosis which may entrap loops of the small intestine and cause bowel obstruction. this may eventually encase the mesenteric vessels with resulting venous stasis and ischemia in segments of the intestine as seen in this patient. conclusion: cecal necrosis is a rare entity, but its incidence increases with age. isolated cecal necrosis may manifest as a ct-negative appendicitis or a small bowel obstruction in the absence of past surgical history. s surg endosc ( ) laparoscopic transection of the falciform and triangular ligament successfully released the entrapped loop with successful reperfusion by the end of the surgery. in the absence of any prothrombotic comorbidity, the patients were discharged asymptomatic without further anticoagulation. to date only few similar cases have been reported, and most of them described in neonates and pediatric patients. to our knowledge, this cases reporteds in the elderlys. in this patients laparoscopic approach was both diagnostic and therapeutic with the transection the ligament. roberto javier rueda esteban , andres mauricio garcia sierra , felipe perdomo ; universidad de los andes, fundacion santa fe this is a patient´s rare case of spontaneous splenic rupture associated to chronic myeloid leukemia as an uncommon complication. the case report and review of the relevant literature on symptomatology and clinical management is presented. emphasis is made about the importance of including splenic rupture as differential diagnosis for acute abdominal pain, especially in a patient with neoplastic hematopathology, since early treatment increases patient survival and prognosis. esophagectomy is a complex operation associated with serious immediate complications and long term chronic complications. gastric ulcers are a common chronic complication after esophagectomy with gastric conduit reconstruction. these are rarely complicated by significant bleeding or perforation. we report a case of delayed diagnosis of a fistula forming between a gastric conduit and right bronchial tree years after esophagectomy. this was successfully treated using multiple therapeutic approaches including endoscopic localization and resection through a right thoractomy. to the best of our knowledge, our patient is the only survivor from a chronic gastric conduit bronchial fistula. a year old male with type diabetes mellitus, dyslipidemia, asthma and smoking history presented years after an ivory-lewis esophagectomy for a gastrointestinal stromal tumor (gist) with a chronic cough starting years after his esophagectomy followed by multiple episodes of hematoptysis over the next years. the patient was known to have ulcers in his gastric conduit with a massive bleed year after his esophagectomy. repeat endoscopy revealed two large chronic ulcers that had increased in size based on comparison of pictures from endoscopies to years after his esophagectomy despite maximal medical management. the patient presented to numerous specialists at tertiary care centers in canada and the united states. ultimately, in a clinic the patient was observed to cough immediately after the ingestion of water, but not solids leading to a provisional diagnosis of a gastrobronchial fistula. a barium swallow failed to show a fistula (fig. ). however at endoscopy, instillation of saline directed at an ulcer immediately induced a cough, but this was not reproduced when the saline was directed away from the ulcer. the fistula was ultimately demonstrated by placing a wire through the ulcer and visualizing it bronchoscopically in the right superior segmental bronchus . in an effort to pursue a minimally invasive approach two attempts were made to close the fistula with over-the-scope clips (otsc). unfortunately, the patient's symptoms persisted. a wire was placed through the fistula and delivered through the patient's mouth and endotracheal tube. a right thoracotomy allowed access to the conduit, which was opened and the fistula localized using the wire. the fistula was resected and the bronchus closed. at twelve month follow up the patient did not have a recurrent cough or hemoptysis while tolerating a full diet. introduction: roux en-y gastric bypass (rygb) is one of the initial and most studied weight reduction procedures and remains the gold standard for comparison in bariatric surgery clinical outcomes. although rygb is an effective procedure for weight loss, it has been less popular over last several years because of increased morbidity compared to the more utilized vertical sleeve gastrectomy (vsg). early complications of rygb include bleeding, perforation, or leakage. late complications include internal hernias, small bowel obstruction, anastomotic stenosis, marginal ulcers, and gastrogastric fistulas. case report: a -year old female with a past medical history of morbid obesity, diabetes mellitus type , hypertension, gerd, peptic ulcer disease, cholelithiasis, liver dysfunction with ascites, asthma, and a past surgical history of rygb ( years ago) presented to our institution with acute on chronic abdominal pain associated with nausea, vomiting, dysphagia, inability to eat and maintain hydration, and an additional weight loss of about lbs. over the last year. in addition, the patient was a chronic opioid and nsaid user, had an extensive smoking history, and had not followed with her surgeon for years. at the time of presentation, the patient weighed lbs (bmi: . ), had normal vital signs, and appeared cachectic. an upper gastrointestinal study followed by an upper endoscopic examination demonstrated complete obliteration of the gastrojejunal anastomosis and revealed a -cm long gastrogastric fistula originating from the distal end of the gastric pouch to the lesser curvature of the excluded stomach. after conservative measures were initiated to hydrate and metabolically stabilize the patient, the decision was made to proceed with diagnostic laparoscopy and surgical placement of a gastrostomy tube to the gastric remnant. the patient was discharged after tolerating a full liquid diet and gastrostomy tube feedings, for plan of future revision of gastrojejunostomy when optimal nutritional status is achieved. conclusions: late complications of rygb occur at a rate of - %. major risk factors for anastomotic complications include non-compliance, smoking, and opiate and nsaid abuse. though abdominal pain, anastomotic stenosis, marginal ulcers, and fistulas are relatively common late complications of rygb, complete obliteration of the gastrojejunal anastomosis has not been well described in the literature. this case demonstrates the importance of long term follow up post rygb for early diagnosis of late complications and brings attention to this rare, but possible sequele that can arise in patients after rygb. contrast radiograms and upper endoscopic photographs will be presented. introduction: retroperitoneal sarcoma represents approximately - % of all sarcomas and less than . % of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. in a patient with a large fibrosarcoma and associated hypoglycemia, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. laparoscopic surgery represents an alternative technique for radical resection of such tumors as a minimally invasive rather than traditional surgery. only few cases were reported in the literature. introduction: roux-en-y gastric bypass (rygb) is a frequently performed bariatric procedure, of which internal hernia (ih) is a known complication. we discuss a rare finding of occult gastric remnant perforation as a result of an obstructed ih in a post bypass patient. methods: we present a case report of a single bariatric surgeon's experience at a tertiary care hospital. literature review of pubmed confirms the unique presentation and operative findings in our patient, as few similar cases have been published. a -year-old male s/p rygb years ago presented to the ed with right upper quadrant pain, nausea, vomiting, and a leukocytosis of , . bmi was . ; weight was lbs. workup included an abdominal ultrasound showing gallbladder distention without signs of cholecystitis. liver function tests were normal. further imaging included a ct scan, remarkable for a paraesophageal hernia (peh) containing the gastric pouch, and an elevated left hemidiaphragm. the scan showed no evidence of ih or bowel obstruction. an upper gi series was additionally obtained, which was also negative for small bowel obstruction. due to unclear etiology for this patient's symptoms or source of leukocytosis, diagnostic laparoscopy was planned. results: intraoperative findings were significant for ih containing dilated small bowel with twisted and incarcerated omentum through the jejunojenunostomy site, as well as a distended gallbladder without acute inflammation. ih was reduced and closed without bowel resection. cholecystectomy was completed. subsequent inspection of the diaphragmatic hiatus revealed uncomplicated herniation of the gastric pouch. in attempts to dissect the left diaphragmatic crus, a large pocket of purulent material was encountered below the left diaphragm in the region of the remnant stomach fundus. methylene blue test and intraoperative endoscopy did not demonstrate any connection to gastric pouch. the purulence was attributed to an occult remnant stomach perforation related to distal obstructed ih. a drain was left in the abscess and the peh was not surgically addressed. patient was discharged on postoperative day . he has not suffered any further complications or recurrent complaints. conclusion: gastric perforation following rygb is an uncommon complication resulting from ih. this diagnosis was missed by preoperative imaging and was only found after thorough laparoscopic investigation. surgeons should maintain a high clinical suspicion of ih in post rygb patients with otherwise unexplained abdominal symptoms, fever, and leukocytosis, even in the absence of confirmatory diagnostic testing. threshold for operative exploration in this clinical setting should remain low. alejandro garza, md, robert alleyn, md, jose almeda, md, ricardo martinez, md; utrgv obesity is an epidemic condition worldwide carrying significant morbidity and mortality. surgical therapy is the only proven effective method to sustain weight loss. among the different surgical procedures gastric bypass is the most effective. during this surgery, most of the stomach is excluded from the upper gastrointestinal tract which makes future evaluation of the same very challenging. this could potentially lead to delay in diagnosis of any pathology in the bypass stomach. gastric cancer is the th most common cause of cancer and cause of cancer death in the united states. we present a case report of a patient who underwent a roux-en-y gastric bypass and went on to developed adenocarcinoma in the gastric remnant year after her surgery. she underwent an exploratory laparotomy, extended antrectomy, subtotal gastrectomy including the gastro-colic ligament, and incidental appendectomy. pathology showed grade undifferentiated adenocarcinoma that penetrated the visceral peritoneum with clear margins. there was angiolymphatic invasion and perineural invasion along with metastatic carcinoma in out of lymph nodes. introduction: polyarteritis nodosa (pan) is a systemic transmural inflammatory vasculitis that affects medium-sized arteries. inflammation of the vessel wall and intimal proliferation creates luminal narrowing which can lead to stenosis and insufficiency. the same inflammatory process causes disruption of the elastic lamina leading to aneurysm formation and possible spontaneous rupture with life-threatening bleeding. multifocal segments of stenosis and aneurysm formation are characteristically identified as a "rosary sign" or "beads on a string". unlike other vasculitides, pan does not involve small arteries or veins, and is not associated with anti-neutrophil cytoplasmic antibodies. we present the case of a year old female with a significant intra-abdominal bleed that was explored and repaired primarily. she was subsequently found on angiogram and postmortem pathology to have findings consistent with pan. case presentation: year old female who presented to the emergency department with abdominal pain followed by hemorrhagic shock and found to have a ruptured left hepatic artery aneurysm during exploratory laparotomy. this aneurysm was suture ligated with a successful outcome. a mesenteric arteriogram was performed the following day and demonstrated lesions consistent with pan including aneurysms of the left gastric branches, right and left hepatic arteries, and beaded appearance of the iliac artery. however, days after hospital discharge she developed massive pulmonary embolism from which she did not recover. postmortem examination confirmed rupture of the left hepatic artery aneurysm in addition to gross anatomical and histological findings consistent with pan. discussion: polyarteritis nodosa is a systemic inflammatory vasculitis that causes intimal proliferation and elastic lamina disruption. this multifocal disruption of the vessel results in aneurysm formation alternating with stenosis creating a characteristic "rosary sign" on imaging. spontaneous rupture of these aneurysms is rare and almost always fatal due to life-threatening hemorrhage. with acutely ruptured aneurysms, prompt diagnosis, aggressive resuscitation, and hemostasis through transarterial embolization or surgery is paramount for patient survival. while acute rupture of an aneurysm as the result of pan is exceedingly rare, it must be considered as a differential diagnosis in the setting of acute abdominal pain and hemodynamic instability. in a patient known to have a medical history of pan and aneurysm formation, routine monitoring and disease progression should be followed. introduction: , surgeries are done annually in the us for small bowel obstruction, which is most commonly caused by intraabdominal adhesions, malignancy, and hernias. . to . % of small bowel obstructions are due to paraduodenal hernias. paraduodenal hernias carry a % lifetime risk of incarceration with a mortality of to %. case report: the patient is a year old male who presented with severe upper abdominal pain for one day. he was passing flatus and had had a bowel movement the previous day. on examination, the patient was tender over the upper abdomen. computed tomography (ct) scan with iv contrast showed a mesenteric swirl sign. the decision was made to perform diagnostic laparoscopy with possible small bowel resection. intraoperatively, a mesenteric defect was noted posterior and to the right of the duodenum, through which bowel was herniating. the herniated bowel and its mesentery were edematous. the defect was sutured closed, taking seromuscular and mesenteric bites through the stomach, jejunum, and mesentery. the patient had an uneventful recovery postoperatively and was discharged on postoperative day . he returned on postoperative day with periumbilical pain which resolved with conservative management. he was followed up weeks postoperatively and was doing well. discussion: paraduodenal hernias are the most common internal hernias. they are seen more often in males. they are caused by failure of the counterclockwise rotation of the prearterial segment of the embryonic midgut in weeks to of embryonic development. paraduodenal hernias usually present with chronic intermittent abdominal pain, weight loss, nausea, and vomiting. they may present acutely with symptoms of bowel obstruction. peritoneal signs are often not appreciated due to retroperitoneal position of the hernia. ct scan of the abdomen often shows clustering of bowel loops, which cannot be displaced on repositioning the patient. if imaging is equivocal, diagnostic laparoscopy may be undertaken. surgical correction consists of reducing the bowel, resecting nonviable segments, and either closing the defect or opening the sac laterally into the general peritoneal cavity. in summary, paraduodenal hernias are a rare cause of bowel obstruction and as such present a challenge in diagnosis and early intervention. diverticulosis of the appendix is a rare disease found in . - . % of appendectomies, first described in . the clinical presentation may be acute inflammatory with or without appendicitis or it may be an incidental finding in an uninflamed appendix. the congenital type is rare and it has all the bowel wall layers. it most frequently represents as pseudo diverticulum which lacks the muscularis layer. the pathogenesis of appendiceal diverticula is not completely elucidated. its symptoms are similar to and often misdiagnosed for that early acute or chronic appendicitis. while appendectomy is curative for both entities, it is important to distinguish diverticulum of the appendix from appendicitis as it is four times more likely to perforate and may be a sign of an underlying neoplasm. we reported a very rare giant pseudo diverticulum of the appendix in a -year-old male presenting with chronic abdominal discomfort for months. abdominal x-ray showed abnormal gaseous finding. physical exam was significant for a soft rubbery mass in the periumbilical region. blood work revealed slight elevation of c-reactive protein. preoperative ct and mri showed a -centimeter-large cavity composed of thin wall, located at the tip of the appendix with peri appendicular fat stranding. in the concern of pending obstructive symptom and chronic abdominal pain, we decided to perform the resection laparoscopic. the soft mass arose from the tip of the appendix. there were dense adhesions between the appendix, mesentery, and sigmoid colon. after adhesiohedlysis, laparoscopic appendectomy was performed with endogia. the specimen was extracted through a small incision without spillage. hospital course was uneventful and the patient was discharged on post-operative day . the pathological finding was consistent with a pseudo diverticulum of the appendix which lacked muscularis layer and the inner wall of the cavity was lined with a scattered cubital epithelial layer in the continuity with the appendiceal mucosal membrane. here we report a successful laparoscopic resection of an extremely rare giant chronic pseudo diverticulum of the appendix. yvette farran, ms, jorge a miranda, ms, benjamin clapp, md, elizabeth de la rosa, md; texas tech university health sciences center introduction: sigmoid colon intussusception is rarely encountered and given its vague symptomatology diagnosis and management can be difficult. the treatment of an intussusception in adults is different than in children. lipomas as the causative etiology for intussusception are encountered up to . % of the times and up to %- % of the patients require surgical resection for treatment. methods: this is a case report about a year old male that presented with two weeks of worsening abdominal pain and distention. physical exam was only pertinent for abdominal pain on light palpation, guarding and moderate distress. ct scan of abdomen and pelvis demonstrated a lipomatous mass causing complete obstruction of the sigmoid colon with intussusception. this was managed with laparoscopic sigmoidectomy. the patient had an uncomplicated post-operative period and was discharged on post-operative day . pathology of the lipomatous mass confirmed a benign lipoma. discussion: intussusception is rarely encountered in clinical practice in adults and constitutes % of all cases. lipoma induced sigmoid intussusception with complete obstruction is rare. symptoms can be non-specific as in this case. this case report highlights the importance of timely diagnosis and treatment of an intussusception in adult patients. ct scan is the gold standard for diagnosis and often shows a "target sign". other imaging techniques like ultrasound have shown adequate results but remain less effective than ct scan. the treatment in adults is not a reduction by enema like in pediatrics but rather resection of the lead point. this can be appropriately done with a laparoscopic technique in most cases. conclusion: colonic intussusception is rare. surgery is the only treatment for an intussusception in adults since the lead point needs to be removed, and can be attempted safely with a laparoscopic approach. surg endosc ( ) :s -s joshua smith, md, kern brittany, md, amie hop, md, amy banks-venegoni, md; spectrum health case report: year-old female with no significant past medical history presents with a -year history of nocturnal cough that had worsened over the past months and had associated regurgitation. she underwent esophagogastroduodenoscopy (egd) that showed a tortuous esophagus and tight lower esophageal sphincter that required dilation. she received an upper gastrointestinal (ugi) contrast study that showed a dilated, tortuous esophagus with 'bird's beak' tapering, consistent with achalasia, as well as a large epiphrenic diverticulum measuring cm. esophageal manometry confirmed "pan-esophageal pressurization" consistent with type ii achalasia. given her symptoms in the presence of these findings, she elected to proceed with surgery. she underwent laparoscopic, trans-hiatal epiphrenic diverticulectomy, heller myotomy and dorr fundoplication. extensive dissection allowed for approximately cm of retraction down from the chest and we were able to come across it with a single blue load of a mm linear cutting stapler. post-operatively, she tolerated the procedure well with immediate improvement in her symptoms. her ugi on post-operative day showed no evidence of leak, she tolerated a soft diet and was discharged home. she was seen at -week and -year follow-up appointments with complete resolution of symptoms. discussion: epiphrenic diverticula in the presence of achalasia has an occurrence rate of %. large diverticula ([ cm), are even more rare with only a handful of case reports in the literature. historically, thoracotomy or, more recently, thoracoscopic approaches are required for resection. however, thoracic approaches are associated with a % increase in morbidity, namely due to staple line leak and the resulting pulmonary complications. only a single case report exists on our review of the literature that demonstrates successful trans-hiatal laparoscopic resection without post-operative complications of a diverticulum of this size. the shortest documented length of hospital stay postoperatively for similar cases is days, while the average is - days or longer for those with complications. our patient was able to go home on post-operative day after a normal ugi and was tolerating a soft diet. not only does this case show that a large epiphrenic diverticulm can be successfully resected via the trans-abdominal laparoscopic approach, this case makes the argument that patients undergoing any minimally-invasive epiphrenic diverticulectomy and myotomy, with or without fundoplication, may be successfully managed with early post-operative contrast studies and dietary advancement, thus decreasing their length of hospitalization and overall cost of treatment. kazuma sato, shunji kinuta, koichi takiguchi, naoyuki hanari, naoki koshiishi; takeda general hospital background: situs inversus totalis (sit) is a rare congenital condition in which the abdominal and thoracic organs are located opposite to their normal positions. few cases of laparoscopic surgery for gastric cancer with sit have been reported. we report a case of laparoscopic distal gastrectomy with d lymph node dissection performed for gastric cancer in a patient with sit. case description: an -year-old woman was admitted to our hospital for treatment of gastric cancer that was diagnosed by esophagogastroduodenoscopy (egd) at a local clinic after she experienced anemia and nausea. egd identified an irregularly shaped gastric ulcer located at the anterior side of the lesser curvature of the antrum. a biopsy revealed a moderately differentiated adenocarcinoma. she was then diagnosed with sit by chest radiography and abdominal computed tomography (ct). the abdominal ct showed that all organs were inversely positioned and that the wall of the antrum had thickened; it also showed the lymph nodes in the lesser curvature of the stomach, without distant metastasis or an abnormal course of vascularity. the patient was clinically diagnosed with t n m stage iiia gastric cancer according to the japanese classification of gastric carcinoma. a laparoscopic distal gastrectomy with d lymph node dissection in accordance with the japanese gastric cancer treatment guidelines as well as a roux-en-y anastomosis due to an esophageal hiatal hernia were performed. the surgery was safely and successfully performed, although it required more time than usual because the inverted anatomic structures were repeatedly examined during the surgery. the postoperative course was positive, and the patient was discharged on postoperative day without any complications. the final stage of this case was pt bn m stage ia. currently, the patient is doing well without recurrent gastric cancer. conclusion: gastric cancer with sit is an extremely rare occurrence. we experienced a case of laparoscopic distal gastrectomy with d lymph node dissection performed for gastric cancer in a patient with sit. we simulated the operation for sit by viewing left-right reversed ordinary surgical videos. the abdominal ct angiography with a three-dimensional reconstruction helped reveal any variation and confirmed the structures and locations of vessels before the surgery. the operation could safely be performed following the standardized surgical technique by reversing the surgeon standing position and trocar position. sternum or chest wall resection is performed for a variety of conditions such as primary and secondary tumors of the chest wall or the sternum. sternum reconstruction has been a complex problem in the past due to intraoperative technical difficulties, surgical complications, and respiratory failure caused by the chest wall instability and paradoxical respiratory movements. advances in the fields of surgery and anesthesia result in more aggressive resections. nowadays neither the size nor the position of the chest wall defect limits surgical management, because resection and reconstruction are performed in a single operation that provides immediate chest wall stability. chest wall resection involves resection of the ribs, sternum, costal cartilages and the accompanying soft tissues and the reconstruction strategy depends on the site and extent of the resected chest wall defect. here i'll present, the youngest ever case reported, years old girl with rhabdomyosarcoma involving the sternum. i will present the management challenges and the reconstruction options. introduction: neuroendrocrine malignancies constitute . % of all cancers. the gastrointestinal tract is the commonest site, followed by the lung. the last decade has seen a steady increase in their incidence. this is a case series of twenty five such tumours and their clinicopathological characteristics. materials and methods: twenty five patients with neuroendocrine tumours of the gastrointestinal tract were studied with reference to their demographic and clinicopathological characteristics. apart from routine pathological examination, these tumours were also checked for e cadherin expression as an independent marker of aggressive disease. results: the age of our patients ranged from to years. we had female and male patients, contradicting a female preponderance in literature. the vast majority of the tumours we encountered were from the stomach and duodenum, with and patients, respectively. two tumours were at the gastroduodenal junction, two from the appendix, small intestine and pancreas, each, and one each from the rectum and gall bladder. this is in contrast to literature that shows that neuroendocrine tumours of the git most commonly arise from the appendix and small bowel, followed by the rectum, stomach and duodenum. two of these tumours were functional. the diagnosis was confirmed by immunohistochemistry staining for chromogranin a and synaptophysin. grading was done using who criteria that takes into account the mitotic count, ki index and necrosis. of our cases were grade i. further, immunohistochemistry for e cadherin showed that absence of expression correlated with more aggressive clinical behavior. out of twenty five patients were operable at presentation and standard resections depending on the organ of origin with adjuvant therapies were given as required. could only be given palliative care. the functional tumours were treated with radiolabelled somatostatin analogues following uptake studies. conclusion: as neuroendocrine tumours are relatively rare, information about them is not as abundant as with other malignancies. absence of e cadherin expression is associated with more aggressive disease. more studies are required that document the pathological characteristics and clinical behavior in order to offer well rounded treatment protocols that treat not only the primary, but also the generalized effects of the secretions produced by them. targeted chemotherapy is gaining prominence, but more specific drugs directed at the plethora of receptors these tumours express, could potentially revolutionize treatment. ( ) . unfortunately there are no publications from denmark. we would like to present first to our knowledge reported case of double gallbladder in denmark. double gallbladder is a rare anomaly with a prevalence of : in autopsy studies, described first by boyden in ( ) . there are several classifications of double gallbladder that are based on relation between gallbladder, cystic duct and common bile duct ( , ) . non-specific symptoms and inadequate imaging are possible causes of lack of awareness of the condition. removal of all gallbladders, preferably laparoscopic with special attention to the biliary anatomy, is recommended ( ). method: case report with review of the literature. a -year-old female patient of polish origin was hospitalized due to upper right quadrant pain. on admission clinical manifestations and paraclinical abnormalities of pancreatitis were present. ultrasound scanning of the abdomen showed bile stones, ultrasonic manifestations of acute cholecystitis and normal intra-and extrahepatic bile ducts. because of elevated liver enzymes mrcp was performed and showed double gallbladder, double cystic duct and signs of pancreas anulare. scheduled ercp confirmed bile stones in cbd, double gallbladder with double cystic duct, h-type according to harlaftis classification ( ) . because of minor retroperitoneal perforation second ercp was needed for removal of all stones. the patient was then scheduled to laparoscopic cholecystectomy with perioperativ cholangiography. conclusion: anatomical variations of the gallbladder such as double gallbladder are rare and often remain unnoticed. they are most often identified because of clinical manifestations symptoms, diverse imaging studies, during surgery or autopsy. as most of them are not expected, they can contribute to complications during surgery. careful preoperative imaging is very important to prevent accidental bile duct injury. looking at the number of case reports, double gallbladder seems to be slightly more common than expected. the interesting question is whether a gallbladder discovered during an unrelated radiological investigation in a patient that previously underwent a cholecystectomy can represent undetected case of double gallbladder. we would like to present a review of the literature as well as images from mrcp, ercp and laparoscopy. michael jaroncyzk, md, courtney e collins, md, ms, vladimir p daoud, md, ms, ibrahim daoud, md; st. francis hospital; hartford ct introduction: several decades ago, surgical training was saturated with procedures to treated peptic ulcer disease. since the introduction of histamine- blockers and proton pump inhibitors, these procedures have dwindled significantly. however, there are still instances where patients require surgical intervention for peptic ulcer disease. perforation is one of the indications for surgery. the surgical options to treat a perforated peptic ulcer are numerous. one of the most common options is a graham patch. we are presenting a case of a patient with a perforated ulcer that did not have available omentum for the repair. methods and procedures: recently, a -year-old female with a past history of an open total abdominal hysterectomy and bilateral salpingo-oophorectomy presented as an outpatient with chronic lower abdominal pain. she underwent a work-up and imaging that did not reveal any pathology. at diagnostic laparoscopy, she had diffuse lower abdominal adhesions, which were lysed. she was discharged on the same day, but presented to the emergency department two days later with severe abdominal pain and fevers. the work-up revealed tachycardia, diffuse abdominal tenderness with peritoneal signs, leukocytosis and a large amount of free air on imaging. she was emergently brought to the operating room for a diagnostic laparoscopy. during laparoscopic exploration, the lower abdominal cavity appeared normal for a recent lysis of adhesions. attention was turned to the upper cavity to find the pathology. bile-stained free fluid and peri-gastric exudates were identified, but no perforation was visualized. intra-operative endoscopy revealed the site of perforation in the antrum on the lesser curvature. a biopsy was performed and the decision was made to perform a graham patch. however, the omentum was already densely involved with the lower abdominal cavity from the enterolysis. due to the close proximity of the falciform ligament, it was mobilized laparoscopically and the pedicle was used as a graham patch. the patient recovered without any additional issues. the biopsy was reported as a chronic gastric ulcer. conclusion: surgical history has given us many options to treat peptic ulcer disease that are not nearly as common as they were decades ago. perforated ulcers can be managed laparoscopically and graham patches are a common choice for repair. however, the lack of the omentum for a proper pedicle flap can pose a problem in some patients. we have shown in this patient that a falciform pedicle flap can be successfully used as a substitution. laparoscopic management of boerhaave's syndrome after a late presentation: a case report and literature review tahir yunus, hager aref, obadah alhallaq; imc background: boerhaave's syndrome involves an abrupt elevation in the intraluminal pressure of the oesophagus, causing a transmural perforation. it is associated with high morbidity and mortality. having a nonspecific presentation may contribute to a delay in diagnosis and results in poor outcomes. treatment is challenging, yet early surgical intervention is the most important prognostic factor. case presentation: we present a case of a thirty-two-year-old male with a long medical history of dysphagia due to benign oesophagal stricture. he presented with acute onset of epigastric pain after severe emesis. based on computed tomography scan, he was diagnosed with boerhaave's syndrome. presenting with signs of shock, mandated immediate surgical exploration. for which he was taken for laparoscopic primary repair with uneventful postoperative recovery. the golden period of the first hours of insult still applies for cases of oesophagal perforation. the rarity of these cases makes a comparison between the various treatment methods difficult. our data support that the use of laparoscopic operative intervention with primary repair as the mainstay of treatment for the management of oesophageal perforation. lipomas of the gastrointestinal tract are rare benign soft tissue tumors that are often discovered incidentally. these lesions are often asymptomatic, but have occasionally been reported to have clinical significance as will be described in this case report. a year old male initially presented to his primary care physician's office with a three week history of vague intermittent abdominal pain. his pain was located in the mid epigastrium and was associated with mild nausea. past medical history was significant for hyperlipidemia and a right-sided goiter, and he denied any previous surgeries. outpatient work up revealed a microcytic anemia, intermittent melena and hemoccult positive stools. the patient was referred to hematology and gastroenterology. endoscopies revealed gastritis, and small internal and external hemorrhoids. he underwent an outpatient ct scan which demonstrated a . . cm mass within the lumen of the jejunum causing long segment non-obstucting intussusception. subsequently, the patient was referred to surgery and underwent a diagnostic laparoscopy. at the time of surgery, an approximately twelve centimeter segment of proximal jejunum was identified intussuscepting into a distal limb. this segment was attempted to be reduced laparoscopically, however there was significant mesentery within in the intussusceptum and the segment could not be safely reduced. therefore, the section of bowel was delivered through a small periumbilical incision. the intussusceptum was then able to be manually reduced from the intussusception. at this point a large mass was palpated inside the lumen of the jejunum. a small bowel side to side, functional end to end resection and anastomosis was preformed. the bowel was returned to the abdomen and the abdomen was re-insufflated. the remainder of the small bowel was run and no additional lesions were identified. final pathology revealed a . . . cm submucosal partially obstructing lipoma with ulceration at the tip. the patient recovered uneventfully and was discharged home on the second post operative day. this case report describes a submucosal jejunal lipoma that was acting as a lead point for intermittent non-obstructing small bowel intussusception, while simultaneously causing a microcytic anemia due to ulceration at the tip of the lipoma. laparoscopic assisted reduction and small bowel resection is a safe and effective treatment for gastrointestinal tract lipomas that are unable to removed endoscopically. percutaneous endoscopic gastrostomy (peg) is an alternative to laparotomy for open gastrostomy tube placement to provide enteral nutrition for those who are unable to pass nutrition orally. despite being less invasive, the procedure is not without its complications, one of which includes the formation of a gastrocolocutaneous fistula. the case describes a year old female who presented with a peg placed months prior with reports of leakage of tube feeds from the gastrostomy site. as there was concern for possible ileus or obstruction, an upper gi series was completed which seemed to indicate dislodgement of the g-tube. the g-tube was replaced and a follow-up gastrograffin study was repeated which now indicated that the g-tube was within the lumen of the colon. soon thereafter fecal matter was noted to be draining around the g-tube site; however, patient was without clinical signs of peritonitis. the patient was managed non-surgically as she was a poor surgical candidate with multiple prohibitive co-morbidities. the g-tube was removed bedside by cutting it flush at the skin level with the anticipation that the remainder of the tube would be excreted with bowel movements. the decision was then made to attempt closure of the gastric fistula endoscopically which was accomplished with hemoclips. a follow up upper gi study hours later showed no extravasation of contrast through the gastric fistula. the colocutaneous fistula had self-resolved over the next couple days as well. placement of the peg tube through the transverse colon can present with varying ill effects including diarrhea, pneumoperitoneum, peritonitis, gram negative pulmonary infection or feculent vomiting with the formation of a gastrocutaneous fistula. treatment historically for a gastrocolocutaneous fistula has been exploration and excision of the fistula tract with resection of the involved colonic segment. however, there currently is no gold standard for the management of, and really ranges from conservative management to surgical and is dependent on the presenting symptoms. if the peg becomes dislodged with resultant spillage from the colon with resultant peritonitis, surgical exploration is needed with removal of the g-tube and repair of the stomach and colon. on the other hand, non-surgical management has been suggested in management of a well-established fistula. fistula closure may be spontaneous; however, can be inhibited due to delayed gastric emptying or leakage of gastric secretions through the fistula. endoscopic clipping of the fistula tract employing the hemoclips is a treatment option. median arcuate ligament syndrome (mals) is a rare etiology of abdominal pain caused by narrowing of the celiac artery at its origin by the median arcuate ligament with relative hypoperfusion downstream. patients suffer from post-prandial abdominal pain, abdominal pain associated with exercise, nausea, and unintentional weight loss. diagnosis is historically made by demonstrating elevated celiac artery velocities and respiratory variation on dynamic vascular studies. standard of care for mals patients is laparoscopic celiac artery dissection with release of the median arcuate ligament. at our institution, we have encountered fourteen patients (eleven female, three male) diagnosed by elevated peak velocity in the celiac artery by duplex ultrasound in conjunction with ct angiogram, mr angiogram, arteriogram, or multiple modalities. all but one patient had multiple diagnostic imaging modalities, with the most common being ct angiogram; eight patients had invasive imaging. the mean age at presentation was . years in men and . years in women. on average, male patients presented with a longer duration of symptoms, . years (range - years), as compared to women, . years (range - years). symptoms were fairly consistent between genders and included nausea, emesis, abnormal bowel habits, early satiety, post-prandial pain, and weight loss. all male patients reported at least two symptoms, most commonly nausea and post-prandial pain. in female patients, % reported having three or more symptoms. notably, post-prandial pain was universal among men and women, while weight loss was exclusive to female patients as reported by %. pre-operative peak velocities were recorded in all but one patient, with mean values more elevated in female patients as opposed to male patients, cm/s versus cm/s. post-operative duplexes were obtained in seven patients; pooled data show a mean change of negative cm/s for an average of cm/s after decompression. in all cases, the celiac artery trifurcation was visualized and noted to have a distinct change in artery caliber after division of the ligament. in total, % of patients reported significant improvement with return to normal diet and healthy weight gain post-operatively. of the three without complete resolution, two were diagnosed with motility disorders and one was lost to follow-up. our experience demonstrates that laparoscopic release of the median arcuate ligament in patients with significant flow limitation of the celiac artery on dynamic and anatomic imaging can be a successful treatment option for patients with recalcitrant pain and gastrointestinal dysfunction with no alternative diagnosis. matthew a goldstein, ma, kirill zakharov, do, sharique nazir, md; nyu langone brooklyn adhesions are fibrotic bands that form between and among abdominal organs. the most common cause of abdominal adhesions is previous surgery in the area as well as radiation, infection and frequently occurring with unknown etiology. these bands occur among abdominal organs, commonly the small bowel, and can lead to obstruction or remain asymptomatic, akin to the patient discussed here. congenital abdominal adhesions are rare and have received little attention in research and field of study. the patient described in this case is a -year-old female with a past medical history of morbid obesity, bmi of , hypertension and no past abdominal surgical procedures. the patient presented in august for bariatric surgical consultation and was ultimately taken for an attempted laparoscopic sleeve gastrectomy. upon entering the abdomen, significant adhesions were encountered and an additional attending was called to assist in identifying the stomach. the splenic flexure was found to be plastered to the diaphragm and the descending and transverse colon were adhered to the anterior surface of the stomach. additionally, small bowel adhesions encased the area between the right and left hepatic lobes as well as the caudate lobe. after extensive enterolysis, the pylorus remained the only identifiable portion of the stomach. the patient also demonstrated significant hepatomegaly and a wedge resection was performed. the amount of adhesion and matting of the small and large bowel obscured the view of the stomach and the procedure was deemed too dangerous and terminated. this case represents the uncommon scenario in which an abdomen with no prior surgical history presents with extensive, obscuring adhesions. one such recent study describes the influence of cytokines and proinflammatory states as contributors to obstruction and malrotation in children, but this patient demonstrated no significant history. further investigation is needed to determine potential etiologies of symptomatic and non-symptomatic congenital adhesions among bariatric patients who fail conservative treatment. today the patient is doing well and the surgical team will attempt to complete the procedure in the coming months. laparoscopic spenulectomy: an interesting case report riva das, md , daniel a ringold, md , thai q vu, md ; orlando health, abington jefferson health introduction: spenules, or accessory spleens, are a rare disease entity. most often, they are asymptomatic, and found incidentally during radiographic workup for an unrelated problem. torsion can cause a splenule to not only become symptomatic, but also confound the results of usual diagnostic studies. case description: a -year-old female patient with history of uncomplicated hypertension, hyperlipidemia, hysterectomy, cholecystectomy, spinal surgery, and partial left nephrectomy, presented to the hospital with a two-week history of intermittent left upper quadrant abdominal pain. she denied any similar episodes in the past, or any associated symptoms. further investigation with a ct scan of the abdomen and pelvis showed an acute inflammatory process in the left upper quadrant in same location as some colonic diverticulosis, as well as a . cm soft tissue mass. this indeterminate soft tissue mass was described as having decreased attenuation compared with the spleen. differential diagnosis for this mass included malignancy, an atypical splenule, or an infectious/inflammatory mass. an mri was recommended for further evaluation, but did not reveal any additional significant findings. nuclear medicine liver/spleen scintigraphy was performed, which showed no focal activity associated with the indeterminate left upper quadrant mass, therefore making it unlikely to reflect a splenule, and making malignancy the diagnosis of exclusion. following a period of observation with analgesia, intravenous antibiotics, and bowel rest, her abdominal pain did not resolve, and the decision was made to proceed with operative exploration. diagnostic laparoscopy revealed an approximately cm spherical mass in the left upper quadrant located just below the inferior aspect of the spleen. the superior aspect of the mass gave rise to a vascular pedicle, which upon tracing, seemed to originate from the splenic hilum. this pedicle was easily ligated, and the mass removed. pathology revealed an extensive infarcted hemorrhagic nodule with organizing thrombus and attached thrombosed artery, consistent with an infarcted splenule due to torsion along its own axis. the patient had an uncomplicated postoperative course. discussion: this case report demonstrates the unusual presentation and workup of a patient that was ultimately diagnosed with an infarcted splenule, despite imaging findings that did not correlate, and may even have confused her diagnosis. scintigraphy, which is normally the gold standard for diagnosing and localizing accessory splenic tissue, was in this case unrevealing, due to inability of the tracer to traverse the torsed vascular pedicle. operative exploration was both diagnostic and therapeutic. patients which was treated with antibiotics suggested by culture and sensitivity report and local wound care. one patient died due to sepsis at presentation. conclusion: chikungunya virus was found circulating in rodents in pakistan as early as . duodenal ulcer perforation which is a common surgical emergency in our part of the world usually presents with pinpoint perforation in ant wall of first part of duodenum unlike in already diagnosed cases of chikungunya disease where a slit like duodenal perforation is noted in the anterior wall of first part of duodenum. literature and consensus relate this perforation with the excessive use of nsaids due to usual presentation of arthritis in chikungunya disease but the unusual presentation is still to be answered. introduction: bouveret's syndrome is a rare form of gallstone ileus in which an impaction of a gallstone in the duodenum results in a gastric outlet obstruction. gallstone ileus accounts for approximately - % of all cases of small bowel obstruction. the terminal ileum is the most common location for a calculus to cause obstruction followed by the proximal ileum, jejunum and duodenum/stomach respectively. open and laparoscopic surgery has previously been the mainstay of treatment for bouveret's syndrome, however with the advent of new endoscopic techniques and instruments there has been increasing success in endoscopic management. this case report looks at a patient with a gastric outlet obstruction from a gallstone, and discusses the current literature regarding diagnosis and management. case: year old male presented with several day history of epigastric abdominal pain and multiple episodes of nonbloody, nonbilious emesis. he had previously been diagnosed with cholelithiasis, however had refused surgery at that time. on admission the patient was found to have a leukocytosis of . . an ultrasound was performed in which the images were limited due to pneumobilia. a subsequent ct scan revealed pneumobilia, and a large cm gallstone impacted in the first portion of the duodenum causing a gastric outlet obstruction. the patient underwent failed endoscopic attempts at removal and ultimately required a laparotomy, enerotomy with stone extraction. discussion: bouveret's syndrome is a rare variant of gallstone ileus. with newer endoscopic techniques and electrohydraulic lithotripsy, there has been increasing success with endoscopic retrieval of the impacted gallstones. there is some controversy in regards to the need for definitive operative management. stone extraction, without cholecystectomy and fistula repair, has been shown to have less postoperative complications as well as lower mortality rates compared to when a cholecystectomy and fistula repair has been performed. total mesorectal excision (tme) with neoadjuvant chemoradiotherapy (nacrt) is standard treatment for rectal cancer, which has resulted in a decrease in local recurrence. however, nacrt has shown no significant overall survival and some adverse effects mainly caused by radiation therapy. recently, the usefulness of neoadjuvant chemotherapy (nac) has been reported. we retrospectively assessed the efficacy and safety of the neoadjuvant mfolfoxiri compared with nacrt followed by laparoscopic surgery. a total of patients undergoing laparoscopic surgery for lower rectal cancer (clinical stage: ii or iii) from july to february in our department were retrospectively evaluated. patients underwent nac, and patients underwent nacrt. the following data were collected: pathological complete response (pcr), histological grade, down staging, radial margin (rm) and postoperative complications. histological grade was defined as follows: tumor cell necrosis or degeneration is present in less than one third of the tumor area (grade a), between one and two thirds (grade b), more than two thirds but viable cells remain (grade ), and complete response (grade ). these two groups were demographically comparable. down staging did not differ between the two groups. histological grade (?grade b) and pcr were significantly higher in the nacrt than in the nac group (p. ). rm had no significant difference in both groups, but tended to be able to secure negative rm in the nac group ( % vs. . %, p= . aims: increasing evidence suggest that cme may improve overall and disease free survival in colon cancer. our aims were to investigate the safety and efficacy of single incision laparoscopic cme colectomy (silcc) compared to multiport cme laparoscopic colectomy (mpclc) providing the first meta-analytical evidence. methods: pubmed, scopus and cochrane library were searched. studies comparing the silcc to mpclc in adults with colon adenocarcinoma were included. the studies were critically appraised using the newcastle ottawa scale. statistical heterogeneity was assessed with x and i . the symmetry of funnel plots was examined for publication bias. results: one randomized and four case control trials were included ( silcc vs sl introduction: obesity has been associated with increased morbidity following total proctocolectomies with ilealpouch anal anastomosis (tpc-ipaa). however, the incremental added risk of increasing obesity class is not known. the aim of this study was to evaluate the additional morbidity of increasing obesity class for tpc-ipaa. methods: after ethics board approval, the acs-nsqip database ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was accessed to identify patients who underwent elective tpc-ipaa. body mass index (bmi, kg/m ) was classified as normal ( . - . ) , overweight ( . - . ), obesity class-i ( - . ), obesity class-ii ( - . ) and obesity class-iii (≥ ). primary outcomes were overall surgical site infection (ssi) and organ-space infection (osi). secondary outcomes were -day major morbidity and length of hospital stay (los aim: in curatively intended resection of sigmoid and rectal cancer, many surgeons prefer to perform ligation of the root of the inferior mesenteric artery (ima), high tie, because of oncological reasons. however, ligation of the ima has been known to decrease blood flow to the anastomosis. there are few reports of patients undergoing the reduced port laparoscopic approach (rps) including single-incision laparoscopic approach (sils) even among those undergoing laparoscopic lymph node dissection around the ima with preservation of the left colic artery (lca). our objective was to evaluate the quality of this procedure regarding application of rps for the treatment of sigmoid and rectal cancer. methods: the feasibility of this procedure was evaluated in consecutive cases of rps for sigmoid and rectal cancer. a lap protector (lp) was inserted through a . cm transumbilical incision, and an ez-access was mounted to lp and three -mm ports were placed. almost all procedures were performed with standard laparoscopic instruments using a flexible scope (sils). a mm port was inserted in right lower quadrant mainly in rectal cancer surgery (sils + ). our method involves peeling off the vascular sheath from the ima and dissection of the ln around the ima together with the sheath. results: lymph nodes around the ima were dissected with preservation of the lca in cases (group a). the ima was ligated at its root in cases (high tie, group b). in group a, patients were treated with sils and patients were treated with sils+ . in group b, patients were treated with sils and patients were treated with sils+ . median operative time was . , and . min for group a, and b, respectively. the operative time was significantly longer in group a. estimated blood loss was . and . g, and mean numbers of harvested ln were . , and . . none of the other operative results of groups a and b were different statistically. in this series, there was only one anastomotic leakage in group b. conclusion: our method allows equivalent laparoscopic lymph node dissection to the high tie technique. the operative time tends to be longer, however this procedure has a possibility to reduce an anastomotic leakage. introduction: the routine mobilization of the left colonic flexure in colorectal surgery is still a matter of debate. we present our surgical approach with data. this technique may increases the surgical expertise/confidence when the surgical maneuver is necessary. up to % of all splenectomies are for surgery-related injuries; % of those splenic injuries are treated by splenectomy. the iatrogenic splenic injury rate during colorectal surgery is . %. iatrogenic splenic injuries create: increased risk of mortality/morbidity, extended operative time/patient in-hospital stay and increased healthcare costs. risk factors for iatrogenic splenic injury are: advanced age, adhesions, underlying pathology. obesity is not a risk factor. it is debated if the left colonic flexure mobilization is a risk factor for splenic injury. the ligament over-traction is the most frequent damage mechanism. the most dangerous surgical manuever is the spleno-colic ligament surgical dissection. moreover, laparoscopy descreases by almost , times the splenic injury risk. some surgeons are reluctant to routinely take down the splenic flexure. materials and procedures: robotic left colonic/rectal cases with routine splenic flexure mobilization technique have been performed: left colectomy (n= ), rectal surgery (n= ), transverse-colectomy (n= ) and pancolectomy (n = ). conversion rate , %, ebl\ ml, postop-leak ( . %) and % iatrogenic splenic injuries. results: in our approach, there are pathways that need to be mastered for the splenic flexure mobilization:a) medial to lateral dissection (underneath the inferior mesenteric vein); b) lateral to medial (from the lateral peritoneal reflection); c) access to the lesser sac with omental detachment from the transverse colon; d) access to the lesser sac with the gastrocolic opening, following the inferior border of the pancreas. the dissection should be closer to the colon rather than to the spleen. in our experience the routine mobilization of the splenic flexure may have some advantages: a) better (without tension) distal anastomosis formation; b) better perfusion of the proxiaml stump; c) wider oncological dissection; d) no need of going back to the flexure when the proximal stump is too short; e) mastering a surgical manuver useful in other procedures (e.g. distal pancreasectomy). the theoretical drawbacks of routine splenic flexure mobilization can be:a) longer operative time, which is on average increased by minutes; b) risk of splenic injuries, in our experience, no splenic injuries have been registered. conclusions: technical accuracy with cautious dissection/visualization can reduce iatrogenic splenic damages rate. laparoscopy decreases splenic injury rate. robotic surgery may have the potential to further reduce this complications. our data suggest that the routine mobilization of the splenic flexure, has more advantages than drawbacks and it can reduce the iatrogenic splenic injury rate. more trials are needed in order confirm our findings. introduction: the robotic stapler with the endowrist™ technology (intuitive surgical, inc.) includes a larger range of motion and articulation compared to the laparoscopic device, and may provide some benefits in difficult areas like the pelvis. to date, few studies have been published on the application of robotic endowristed stapling. we present our preliminary experience using the robotic stapler in low anterior rectal resection (larr) with total mesorectal excision (tme) for rectal cancer. methods and procedures: between march and september , patients underwent elective robotic larr with tme and primary colorectal anastomosis within the eras program. patient demographic, intra-operative data and post-operative outcomes were compared between the endowrist™ robotic stapler group (rs group) and the laparoscopic stapler group (ls group). results: the two groups were homogeneous in terms of demographic and clinical characteristics. thirteen ( males) and patients ( males) were included in rs and in ls group, respectively. seven patients received preoperative chemoradiation in rs group, in ls group. there was no difference in intra-operative blood loss and total operative time. the median number of stapler fires for patients in rs group and in ls group was (range, - ) and (range, - ), respectively. loop-ileostomy was fashioned in patients in rs group ( . %) and patients in ls group ( . %). the days mortality was nil. two cases of anastomotic leaks have been detected in rs group ( . %), cases ( . %), occurred in ls group, all treated conservatively. the mean length of postoperative stay was . ± . days in rs group, . ± . days in ls group. conclusions: in our preliminary experience the application of robotic stapler during larr with tme has shown to be safe and feasible with acceptable morbidity. even if our case series is pretty small, fewer stapler fires were required in the rsg compared to lsg. we believe that the robotic stapler might lead to a more precise firing during pelvic surgery: it can explain the trend toward a decreased number of fires, that has been well documented in literature to be related to a lower risk of anastomotic leak. further high quality studies are required to confirm these findings. background and objectives: the present study was aimed at investigating the safety and feasibility of laparoscopic ultra-low anterior resection (l-ular) with total mesorectal excision (tme) and transanal specimen extraction for rectal cancer located at lower one-third rectum, and specifically understanding the oncological outcome of the operation. patients and method: a prospective designed database of a consecutive series of patients undergoing laparoscopic ultra-low anterior resection for rectal malignancy with various tumornode-metastasis (tnm) classifications from to at the texas endosurgery institute was analyzed. in this study ultra-low anterior resection is defined as low anterior resection for the malignant lesion at distal / of rectum. results: ultralow anterior resections were completed laparoscopically with tme and transanal specimen extraction. the operating time for the surgery was . ± . minutes, and estimated blood loss during the procedure was . ± . ml. the length of the lesion from the anal verge measured with intraoperative colonoscopy ranged from . cm to . cm, and shortest distance of colorectal anastomosis from the anal verge is cm. since diverting ileostomy was routinely installed after l-ular, none was found to have anastomotic leakage, however patients developed anal stenosis within -month follow-up. therefore the overall rate of postoperative complication is . %. moreover patients were reported to have local recurrence in -year followup with the rate of . %. conclusions: l-ular is safe and effective procedure for the rectal cancer at distal / rectum with comparable local recurrence and postoperative complication rates, thereby suggesting l-ular can be considered as a procedure of choice for rectal cancer at very low location in the rectum. for rectal cancer, however, local full-thickness excisions are fraught with high local recurrence rates -even if limited to early and best selected lesions. this corroborated observation is likely caused by a combination of missed nodal disease and direct implantation of tumor cells into the mesorectum, which upstages even early t lesions to at least a t lesion. the treatment of choice for invasive adenocarcinoma consists of an oncological total mesorectal resection, possibly with other modalities. rectal tumors of uncertain behavior can present a treatment dilemma between over-treatment vs under-treatment. concept: if the nature of a lesion is not certain or if contradictory results have been obtained, we propose a superficial local excision as a mucosal excisional biopsy to establish the diagnosis while avoiding interference with subsequent definitive treatment modalities by preserving the integrity of the external rectal wall and mesorectum. a benign final pathology concludes the treatment, whereas a detection of invasive cancer will be managed with a subsequent oncological resection. methods: this is a case report of a -year-old woman found to have a . cm villous lesion in the mid to distal rectum without proven or disproven invasive cancer. a tems-guided mucosal resection of the rectal mass at cm above the anal verge was performed whereby the lesion was dissected off the underlying muscularis. results: with preoperative discrepant erus and mri staging ut - vs ct lesion, a technically successful mucosal resection of the large rectal mass was carried out. pathology revealed a tubulovillous adenoma without high grade dysplasia or malignancy and a complete resection. conclusion: tems mucosal excisional biopsy of rectal tumors of uncertain behavior allows for a less invasive diagnostic approach that may (a) be definitive treatment if the lesion is proven benign, or (b) confirm the need for more aggressive treatment without having burned any treatment bridges or upstaged an early tumor by violating the mesorectal plane. an oncologic resection with appropriate (neo-)adjuvant chemotherapy can be carried out while preventing the potential for tumor seeding at initial operation. background: adequate visualization of the entire lumen of the large bowel is essential in detecting pathology and establishing diagnoses during colonoscopies. patients are provided dietary instructions and medications in order to achieve adequate bowel preparation. given the extensive amount of preparation required, some patients may be unable to adhere to the prescribed routine, resulting in rescheduling or repeat procedures and misallocation of limited resources. a number of previous quality-improvement efforts have been implemented to ensure adequate preparation prior to colonoscopy. objective: the objective of this study was to develop and assess the feasibility of a novel smart phone application in the delivery of bowel preparation instructions. methods: a novel smart phone application was developed to deliver bowel preparation instructions to patients undergoing colonoscopy for the first time. patients were included in the pilot phase of this project if they were undergoing a colonoscopy for the first time. we included patients who had access to a smart phone, had not previously had a bowel preparation for any reason. we excluded patients with a previous diagnosis of inflammatory bowel disease or colorectal cancer. patient surveys were administered at the time of colonoscopy. patients were questioned regarding the completeness of bowel preparation and adherence to bowel preparation instructions. patient questionnaires were completed to ascertain the ease of use of the smart phone application and any concerns that arose. quality of bowel preparation was assessed by the colonoscopist using the validated ottawa bowel preparation score. this is the pilot study results for the "coloprep" trial (nct ). results: a total of patients were enrolled in the pilot phase of this study. patient satisfaction, adherence to instructions and ease of use of the smart phone application were ascertained. bowel preparation, as assessed by the colonoscopist, was reported. conclusions: this study assessed the feasibility of using a novel smart phone application for delivery of bowel preparation instruction. this pilot study is the initial phase of a randomized controlled trial to compare smart phone application vs. written instructions in the delivery of bowel preparation instructions. the . median follow-up was months. there were no statistically significant differences found in clinical features and laboratory findings between the two groups. no statistically significant difference was found regarding the overall success rates and the complication rates between the conservative and the surgical arms (success rates: . % and . % (p= . ) and complication rates: . % and . % (p= . ), respectively). however, surgical treatment was better than conservative treatment in preventing recurrent diverticulitis (recurrence rates: % and . % (p= . ), respectively). conclusion: conservative management with bowel rest and antibiotics is a safe and effective treatment for right-sided colonic uncomplicated diverticulitis and may be considered as the initial option. on the other hand, laparoscopic diverticulectomy is also safe, effective and adequate. surgery is advocated to decrease the recurrence rate. introduction: it has been hypothesized that the structural and functional changes that develop in the defunctioned segment of bowel may contribute to the development of postoperative ileus (poi) after loop ileostomy closure (lic). as such, longer intersurgery interval between ileostomy creation and lic may increase poi. methods and procedures: after institutional review board approval, all patients who underwent lic at a single institution between - were identified. the primary endpoint, primary poi, was defined as either a) being kept nil-per-os on or after postoperative day for symptoms of nausea/vomiting, distension, and/or obstipation or b) having a nasogastric tube (ngt) inserted, without postoperative obstruction or sepsis. secondary endpoints included length of hospital stay (los) and non-poi related morbidity. patients who left the operating room with a ngt, had a planned laparotomy with a concomitant procedure at the time of lic, had a total proctocolectomy as their index operation, or had secondary poi, were excluded. patients were then divided into two groups based on timing from the index operation to lic (\ months vs. objective: fecal incontinence can be a debilitating problem significantly diminishing productivity and quality of life. sacral neuromodulation has emerged as a first line surgical option treatment in patients with fecal incontinence. though its efficacy has been rigorously evaluated in adult populations there is scant data available for its use in the pediatric pateints with fecal incontinence. this case study discusses the management of fecal incontinence in a pediatric patient with a history of hirschsprung's disease utilizing sacral nerve stimulation. methods: our patient is a -year-old female with a history of hirshsprung's diagnosed in infancy and treated surgically with coloanal pull through at the age of who presented with complaints of fecal incontinence. the patient was wearing pads daily, noting frequent uncontrolled bowel movements as well as having frequent missed days of school due to these symptoms. despite maximal medical management and pelvic floor physical therapy the patient continued to have - episodes of fecal incontinence daily. a ct scan with rectal contrast was used to establish her postoperative anatomy. anal manometry showed low rest/squeeze pressures, absent resting anal inhibitory reflex, and abnormal sensation. furthermore, during balloon expulsion testing the patient failed to pass device. the patient was deemed a candidate for stage testing with sacral nerve neuromodulation. during follow-up, the patient was noted to have resolution of her episodes of fecal incontinence and the second stage was completed. the patient continues to note % continence and dramatic improvement in her quality of life. conclusion: in this patient with a history of severe fecal incontinence due to hirschsprung's disease, sacral neuromodulation has had a significant impact on her quality of life. post-operatively she continues to have marked improvement in her symptoms with - bowel movements a day with no recurrence of fecal incontinence. the use of sacral neuromodulation is a promising treatment for fecal incontinence in the pediatric population. future research investigating the longterm efficacy of this treatment modality in the pediatric population is needed. cases of bowel obstruction caused by colorectal cancer recurrence and progression were excluded. surgical cases ( . %) were considered to be early bowel obstruction and ( . %) were classified as late bowel obstruction. left hemicolectomy (n= , . %) was a significantly more frequent procedure in early bowel obstruction, and abdominoperineal resection (n= , . %) was significantly more common in late bowel obstruction (p. ). both early and late bowel obstruction included adhesive small bowel obstruction (n= ), internal hernia (n= ), and strangulation obstruction (n= ). internal hernia (n= ) and strangulation obstruction (n= ) occurred after left hemicolectomy and abdominoperineal resection, respectively. there is no apparent relationship between surgical procedures and adhesion regions (abdominal wall, intestinal tract, and pelvic cavity). the incidence rate of postoperative small bowel obstruction remained low, and laparoscopic colectomy had been safely performed. however, countermeasures are needed because of the high frequency of both early and late bowel obstruction which occurred after left hemicolectomy and abdominoperineal resection, respectively. improved utilization of resources as an improvement introduction: nowadays, treatment decisions about patients with rectal cancer are increasingly made within the context of a multi-disciplinary team (mdt) meeting. the outcomes of rectal cancer patients before and after the era of multi-disciplinary team was analyzed and compared in this paper. the purpose of the present study is to evaluate the value of discussing rectal cancer patients in a multi-disciplinary team. methods and procedures: in our health institute, weekly mdt conferences were initiated in january . meetings were attended by surgeons, radiologists, radiation and medical oncologists and key nursing personnel. all rectal cancer patients diagnosed and treated in - in the general surgery division of the "carlo urbani" hospital in jesi (an, italy) were included. then, the data from rectal cancer patients in were evaluated, before the adoption of mdt and in year , after the adoption of meetings. datasets regarding demographics, tumor stage, treatment, and outcomes based on pathology after operation were obtained. during an mdt discussion patient history, clinical and psychological condition, co-morbidity, modes of work-up, clinical staging, and optimal treatment strategies were discussed. a database was created to include each patient's workup, treatments to date and recommendations by each specialty. ''demographic variables'' consisted of age at diagnosis, sex, body mass index, comorbidities, american society of anesthesiologists physical status classification system, clinical stage and pathological stage. other analyzed variables included baseline carcinoembryonic antigen (cea), the type of imaging, use of neoadjuvant chemo-radiation, restaging following neoadjuvant therapy, distance from the anal verge, operation type and use of adjuvant chemo-radiation. ''outcome variables'' consisted in a comparison for each group between clinical and pathological stage. results: sixty-five patients were included in this study: thirty patients in (pre-mdt) and thirty-five patients in . demographic variables did not differ significantly between groups. preoperative clinical stages with baseline preoperative cea and postoperative pathological stage were analysed, too. thanks to the mdt and the increased use of the neoadjuvant therapy, a statistically significant difference in reduction of the stage between the clinical and pathological stage in the patients of the mdt group was verified. conclusions: the vast majority of rectal mdt decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account prior to the adoption of multi-disciplinary team. analysis of the implementation of team decisions is an informative process in order to monitor the quality of mdt decision-making. purpose: in japan, lateral pelvic node dissection (lpnd) is the standard treatment for locally advanced lower rectal cancer. there are few reports of patients undergoing single-incision plus one port laparoscopic (sils+ ) lpnd even among those undergoing laparoscopic lpnd. the aim of this study is to describe our initial experience and assess the feasibility and safety of sils+ lpnd for patients with advanced lower rectal cancer. methods: a lap protector (lp) was inserted through a . cm transumbilical incision, and an ezaccess was mounted to lp and three -mm ports were placed. a mm port was inserted in right lower quadrant. a single institutional experience of sils+ lplnd for rectal cancer are presented. inclusion criteria was indications for lld were lower rectal cancer with t - , or t - rectal cancer with metastasis of lateral lymph node, as described by the japanese society for cancer of the colon and rectum (jsccr) guidelines for the treatment of colorectal cancer. perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively. introduction: endoscopic stenting with a self-expandable metallic stent (sems) is widely accepted procedure for malignant colorectal obstruction. we assessed the safety and efficacy of insertion of a sems followed by elective surgery as 'bridge to surgery (bts)' in our institute. methods: this study was a retrospective study in our institute. the data was collected from medical charts from january to june . results: a total of consecutive patients underwent radical surgery for colorectal malignancy during this period. in this series, patients ( . %) were diagnosed malignant colorectal obstruction and intended to a bts. the stent was successfully placed in patients and all the patients were planned to undergo radical surgery. the failed patients underwent stoma creation ( patients) and hartmann's procedure. the technical success rate was % and the clinical success rate was %. the median time from sems to surgery was days ( - days) . open and laparoscopic surgery was performed in and patients, respectively, except for one patient refused radical surgery because of a great age. the tumor could be resected in patients (bts patients) with primary anastomosis. however, diverting stoma creation was needed in patients and decompression rectal tube was placed in patient. the entire patient laparoscopically was no conversion to open surgery. there was no anastomotic leakage in bts patients. the median duration of postoperative hospital stay was days ( - days). the overall postoperative complication was % ( / ) including bowel obstruction and anastomotic stricture. the median follow-up period was days. during the follow-up period, patients were relapsed peritoneal dissemination, ovarian metastasis, and liver and pulmonary metastases, respectively. former patients were diagnosed stage iva at the time of primary surgery. one patient died from sudden death. conclusions: our data suggested that routine use of sems insertion was safe and effective procedure for malignant colorectal obstruction as a bts. moreover, laparoscopic procedure was useful procedure in bts patient. the short-and long-term surgical outcomes were also acceptable. introduction: serpin e , also known as plasminogen activator inhibitor- (pai- ) is an inhibitor of urokinase type plasminogen activator (upa) and tissue-type plasminogen activators (tpa ). pai- plays a role in the regulation of angiogenesis, wound healing, and tumor cell invasion; over expression has been noted in breast, esophageal, and colorectal cancer (crc). pai- is also a potent regulator of endothelial cell (ec) proliferation and migration in vitro and of angiogenesis and tumor growth in vivo. the plasminogen/plasmin system plays a key role in cancer progression by mediating extracellular matrix degradation and tumor cell migration. surgery's impact on plasma pai- levels is unknown. this study's purpose was to measure plasma pai- levels before and during the first month after minimally invasive colorectal resection (micr) for crc. objectives: retroflexion in the rectum at the end of a colonoscopy is a requirement for a complete endoscopic evaluation. retroflexion helps to visualize and detect polyps which would be missed otherwise. currently new endoscopes are available which can do retroflexion in the caecum. aim: our study aims to compare the rate of polyp detection rate in cecum and ascending colon with and without retroflexion in cecum. methods: this is a single center, single operator, retrospective study. a total of two hundred patients were involved. a single center irb waiver was obtained. patients were divided into two groups based on the presence/absence of retroflexion in caecum during their colonoscopy. the data was obtained from records. group a (n= ) had colonoscopy without retroflexion in caecum group b (n= ) had colonoscopy with retroflexion in caecum inclusion criteria: patients undergoing screening colonoscopy between the age of and . results: group a: total of patients were screened. a total of polyps were detected in group a. number of cecal polyps were ( . % of total polyp count). number of ascending colon polyp were ( % of total polyp). on analyzing the pathology % of the cecal polyps were tubular adenoma, % hyperplastic polyps % and % lymphoid aggregate. number of ascending colon polyps were , of which % were tubular adenoma, % tubular adenoma and % tubulovillous adenoma group b: total of patients were screened. a total of polyps were detected. number of cecal polyps detected were ( . % of total polyp count). number of ascending of ascending colon polyps were ( %). on analyzing pathology, % cecal polyps were tubular adenoma and % were sessile serrated. out of the ascending colon polyps % were tubular adenoma, % sessile serrated, % tubulovillous and % hyperplastic polyp. side events: two mass lesions were noted in both group a and b. there was incomplete colonoscopy in group a and b. conclusion: this retrospective analysis reveals a small increase in polyp detection in the cecum with retroflexion, especially in detecting sessile polyps which have more malignant potential. however, a large multicenter analysis will be required to validate the above observation. background: while uncommon, rectal prolapse is a disabling condition affecting older females. in a small subset of patients, concomitant organ prolapses with or without incarceration can lead to significant morbidity. as the field of laparoscopy has evolved, minimally invasive surgical options for rectal prolapse have led to improved quality and reduced morbidity for patients suffering this debilitating disease. methods: the - acs-nsqip databases was queried for patients undergoing a traditional or minimally invasive rectopexy based on cpt codes ( , , , and ) . emergent cases and patients with preoperative infections or inflammatory states were excluded. the primary outcome of interest was a -day postoperative composite morbidity score. statistical analysis incorporated multivariate analysis and binomial logistic regression with p. holding significance. results: these inclusion and exclusion criteria identified patients undergoing traditional ( ) and minimally invasive ( ) rectopexy for prolapse between and . patients undergoing traditional rectopexy were older (p. ), had a higher body mass index (p= . ), more comorbid conditions (diabetes, copd, hypertension) and less functional independence (p= . ). patients undergoing a traditional rectopexy had a higher composite morbidity incidence of . % vs. % for minimally invasive rectopexy (p. ). specifically, minimally invasive rectopexy patients had a . % reduction in wound complications (p= . ) and a shorter hospital stay ( . days vs. . days, p . ) compared to a traditional rectopexy. readmission rates were also . % lower in the minimally invasive group (p= . ). after controlling for the differences in the cohorts, a minimally invasive approach was a significant protective factor against the incidence of -day postoperative morbidity (or . , p. ). conclusion: a minimally invasive rectopexy has improved -day postoperative morbidity compared to a traditional rectopexy and should be strongly considered for the treatment of rectal prolapse. objectives: the short-term safety and efficacy of a self-expandable metallic stent (sems) placement followed by elective surgery, "bridge to surgery (bts)", for malignant large-bowel obstruction (mlbo) have been well described. the aim of this study was to investigate the risk factors for postoperative complications and optimal interval between sems placement and surgery in patients with mlbo. methods: retrospective examination of patient records revealed that the bts strategy was attempted in patients with mlbo from january to march in our institution. two of these patients were excluded because they had undergone emergency surgery for sems migration; thus, patients with mlbo who had undergone sems placement followed by elective surgery were included. of these patients, eight had developed postoperative complications (clavien-dindo grading≥ii) (postoperative complication: poc group) whereas patients had no such complications (no poc group). results: univariate analyses showed that the factors of asa score, number of lymph nodes resected, interval between sems and surgery, and preoperative albumin concentration were associated with postoperative complications. multivariate analysis identified only the interval between sems and surgery as an independent risk factor. furthermore, a cut-off value of days for interval between sems and surgery was identified by roc curve analysis. conclusions: an interval of ≥ days from sems placement to surgery is an independent predictive factor for postoperative complications in patients undergoing elective surgery in a bts setting. thus, an interval of over days is recommended for minimizing postoperative complications. haseeb kothar, ronan cahill; mater misericordiae university hospital current clinical advances in operative near-infrared visualisation of cells, tissues and structures are predicated on the use of commercial available near-infrared cameras to excite and visualise emission energy from non-selective, approved compounds (predominantly indocyanine green (icg)). it is expected that new generation compounds wholly selective for specific cellular components are now needed for further advance and a variety of molecular targets have been proposed and are being developed primarily for oncological imaging purposes. recent publications have however suggested icg itself is retained within malignant tissue differently to its uptake and clearance from surrounding non-malignant tissue which is important for two reasons. firstly, it exploits and makes visual the increased vascular permeability and disordered clearance associated with carcinogenesis which is a common endpoint of a variety of mediators including but not limited to vegf. this raises the useful option of targeting downstream effects of cancer compounds on a metabolic basis as opposed to tagging individual cell or antigen components. this means that a single agent could be used to target a variety of cancers rather then needing a specific one for each specific sub-type as well as obviating the issue of cancer cells heterogeneity even in a single cancer deposit. second, it is very likely that some or all of the "localisation" effect of proposed selective compounds may well be due to a similar phenomenum rather then cell-specific binding and may make distinction from other areas of similar metabolic behaviour (ie inflammatory regions) difficult. the crucial step-advance for such agent development so may well relate to timing of compound delivery and "visualisation window" at the region of interest rather then highly selective oncocellular-targeting. to illustrate this in more detail, we have been examining the tissue-specific effects and actions of near-infrared excitation in patients (n= ) with localised malignant colorectal primaries receiving an aliquot of icg before such examination at the time of resection. icg can be selectively apparent in the colorectal primary minutes after its systemic administration likely due to altered vascular dynamics. additional dose-related work has shown that early administration ( - minutes before examination) does not give useful information related to tumour fluorescence. interestingly none of these patients had fluorescence seen within their regional lymphatics but none also had malignant lymph nodes associated with their large primaries on pathological examination. however, this procedure is not usually performed in laparoscopic apr for its technique difficulty, which may lead to increased rates of complications ( fig. ) . here, we compared the feasibility and peri-operative outcomes of the laparoscopic apr with and without pelvic peritoneum closure (ppc) for lower rectal cancer. introduction: there are reports of increased operative duration, blood loss and postoperative morbidity, caused by difficulties in obtaining good visualization and in controlling bleeding when laparoscopic resection is performed in obese patients with colon cancer. purpose: the aim of this study was to investigate the impact of obesity on perioperative outcomes after laparoscopic colorectal resection performed by various operative methods in our department. patients and methods: we conducted a retrospective analysis of patients with colorectal cancer who underwent laparoscopic surgery between january to december . right colectomy was performed in patients, sigmoidectomy in patients, and low anterior resection in patients. the surgical outcomes were compared between non-obese (body mass index [bmi]\ kg/m ) and obese (bmi ? kg/m ) patients. results: right colectomy cases: the amount of blood loss was significantly increased in the obese group compared with the non-obese group, but operation time did not differ significantly between the groups. there were no significant differences between the two groups in the rate of postoperative complications and duration of post-operative hospitalization. sigmoidectomy cases: there were no significant differences between the two groups in operation time and amount of blood loss. even though the preoperative asa score and the rate of postoperative complications were higher in the obese group, the mean postoperative hospital stay did not differ significantly between the two groups. low anterior resection cases: there were no significant differences between the obese group and the non-obese groups in operation time, amount of blood loss, rate of postoperative complications, and duration of post-operative hospitalization. discussion: although there are some reports of increased operative times in obese patients, the operative procedure was not extended in any of the present study patients. the amount of blood loss was significantly increased in the obese group compared with the non-obese group when right colectomy was performed. among the patients undergoing sigmoidectomy, the postoperative rate of complications was higher in the obese group; however, the preoperative asa status was also higher in the obese group than non-obese group, indicating that factors other than obesity may be involved. conclusion: we concluded that laparoscopic colorectal resection appeared to be safe and feasible in both obese patients and non-obese patients. however, bmi may not accurately reflect the amount of visceral fat present. background: for the complete rectal prolapse (basically longer than cm), we thought sling rectopexy was most reasonable to hang up and fix the rectum, which drooped down and prolapsed due to the relaxation of supporting tissue. we considered ripstein method had enough fixed power of rectum to sacrum. however, complications of rectal stenosis, constipation, mesh infection and mesh penetration were reported. therefore, we modified ripstein method to conquer such complications. aim: a prospective study beyond the randomized control trial (rct) between our modified ( introduction: the results of the japan clinical oncology group (jcog) study suggested that total mesorectal excision (tme) and lateral lymph node dissection (llnd) could become the standard treatment for lower rectal carcinoma. however, llnd must also be performed laparoscopically if surgery for lower rectal carcinoma is to be carried out as a completely laparoscopic procedure. transanal tme (tatme) is expected to provide better results than the conventional tme, both oncologically and in terms of pelvic function, and its use has recently been spreading in japan. we started performing laparoscopic tatme+llnd in our department in july and here report the short-term outcomes. subjects and methods: we used laparoscopic tatme+llnd to treat men and women with ct or deeper rectal carcinoma in whom the inferior margin of the tumor was on the anal side of the peritoneal reflection. this was a retrospective study of short-term postoperative outcomes. surgical procedure: laparoscopic surgery was started simultaneously by two teams, one working transabdominally and the other working transanally. the transabdominal team performed the standard proximal llnd and mobilization of the splenic flexure via five ports. they then dissected the bilateral lateral lymph nodes, mainly in the obturator (# ) and internal iliac (# ) groups. during this time, the transanal team performed laparoscopic tatme. finally, both dissection layers were connected and the cancer was excised. results: six patients had clinical stage ii and two had clinical stage iii lower rectal carcinoma. all the patients underwent preoperative chemotherapy with s- +l-ohp. five underwent a sphincterpreserving surgery, and three underwent rectal amputation. the mean operating time was minutes (range, - minutes), and the mean amount of hemorrhage was g ( - g). the mean number of lymph nodes dissected was , and r resection was performed in all the cases. the mean length of hospital stay was days, and a postoperative complication of clavien-dindo grade iii or higher occurred in one patient (anastomotic failure). conclusions: laparoscopic tatme+llnd performed by two teams simultaneously is an extremely useful procedure that not only reduces operating time, but also is less invasive than laparoscopic surgery. it may also be effective for improving curative nature, nerve preservation, and anal function. objective: in laparoscopic appendectomy, the base of the appendix is usually secured by applying a roeders knot. the aim of this study was to compare the advantages of using staplers and hem-olocks for securing the base of the appendix. method: the study included patients between age of to years with acute appendicitis randomly divided into two groups. in the first group, the base of the appendix was secured using roeders knot. in the second group, mesoappendix was not dissected and was included in the endostapler jaws. the primary outcome was overall morbidity. secondary outcomes were total duration of surgery, total length of stay and ease in difficult cases. result: no morbidity was recorded in any group. the time of the operative procedure was significantly longer in the cases with roeders knot than in the stapler group (p. ) as mesoappendix was not dissected in the later. cases with unhealthy base were progressed to laparoscopic quadricolectomy. apart from the ease of applying a stapler, cases of second group with gangrenous base were easily tackled using endostapler, avoiding the need of a hemicolectomy. conclusion: all forms of closure of the appendix base are acceptable, but endostapler technique apart from providing a secure base, reduces operative time and is an essential tool in cases of gangrenous base. introduction: accurate staging is essential to estimate the prognosis of patients with colorectal cancer (crc) and lymph node evaluation is key to determine it. in non-metastatic crc, the number of harvested lymph nodes is the strongest prognostic factor for outcome and survival. additionally, it is thought that a higher lymph node yield may be representative of a higher quality of surgical care. due to the importance of the association between lymph node evaluation and outcome in crc, it is necessary to evaluate factors which may affect lymph node harvest. introduction: hatmann's procedure is commonly done in treating complicated diverticulitis, negleccted rectal trauma with sepsis and sometimes malignancy. the traditional techniques to restore the intestinal continuity after hartmann's procedure were for many years the standard of care in these operations, but in fact they carry many morbidity and even mortality and failure. laparoscopic techniques is not only carry the advantage of minimal invasive surgery, but also of better visualizationn and magnification. the aim is evaluating the outcome of using the laparoscope in reversal of hartmann's procedure as regard feasibility and safety. patients and method: forty patients were subjected to laparoscopic reversal of hatmann's procedure in tanta university hospital, there ages ranged between to years, the time elapsed after the original operation ranged from months to years, excluding advanced malignany. conversin occurred in cases due to extensive adhesions and bleeding. results: no mortality, or major morbidity in our study and only single leak treated by covering ilestomy. conclusion; laparoscopic hartmann's procedure is feasible, promising tehnique with minimal morbidity. background: minimal invasive surgery has been well established in the elective colorectal surgery and it has been proven better clinical outcome compared with open surgery. in the emergent setting, laparoscope is used mostly in the colecystectomy, appendectomy but laparoscopic emergent colorectal surgery is limited for it's complexity and difficulity. the aim of this study was to envaluate the feasibility of laparoscopic emergent colorectal surgery. methods: this study is prospective collected, observational single center study of patients undergoing laparoscopic emergent colorectal surgery from to . the patient demographics, surgery indication and detail, complication, clinical outcome and hospital stay were collected and analyzed. results: there are total emergent colorectal operations and patients were managed with minimal invasive method. among these laparoscopic emergent surgery, there are male patients and female patients. mean age of the patients was . years (range - years). the main indication for operation: perforation . % ( / ), leakage after elective colorectal surgery . % ( / ), obstruction . % ( / ), ischemia colitis . % ( / ,), bleeding . % ( / ). there are cases in asa , cases in asa , cases in asa . the qsofa score for sepsis: cases was , cases was , cases was , case was . there are cases undergoing laparoscopic lavage with diverting stomy, cases were hartmann procedure, cases were anterior resection, cases were right hemicolectomy, cases were perforation repair, cases were redo anastomosis. there are cases coversion to open method including cases were due to bowel adhesion, cases were due to bowel distension, case was due to severe shock status. mean operative time is . minutes. the overall mortality rate was . % and major complication rate (clavien-dindo grade above ) was . %. re-operation rate was . %. the mean hospital stay was . days. conclusions: this study presents evidence of an initially clinical outcome in emergent laparoscopic colorectal suregry. in the absence of large case series, the benefits of a laparoscopic approach should befall to at least a minority of these patients. confocal laser endomicroscopy (cle) can provide real-time observation of the cell structure and tissue morphology. in our study, we aim to assess the situation of anastomotic perfusion using cle. method: the experimental rabbits were separated into two groups: group a (good anastomotic perfusion, n= ), group b (poor anastomotic perfusion, n= ). the partial colectomy and anastomosis was performed for group a and b. then detection for anastomotic perfusion using cle was carried out after the surgery. during the continuous scanning, we counted the number of blood cells that cross over the certain point of anastomotic stoma in the same period. results: assistant with fluorescein sodium, the blood vessels are highlighted. we can see significant difference of imaging effect between group a and group b. the average number of blood cells are . /min of group a and . /min of group b (p. ), which has significant difference. conclusion: cle can allow real-time observation of the blood flow of anastomotic stoma in vivo. therefore, it is feasible to assess the anastomotic perfusion using cle in colorectal surgery. cigdem benlice, ahmet rencuzogullari, james church, gokhan ozuner, david liska, scott steele, emre gorgun; cleveland clinic background: intraoperative colonoscopy (ioc) is an adjunct in colorectal surgery (crs) especially in patients with malignancies in order to detect location of the primary or synchronous lesions as well as assessing anastomotic integrity. however, effects of intraoperative colonoscopy on short term outcomes during crs is a concern. this study aims to evaluate safety and feasibility and post-operative outcomes of intraoperative colonoscopy in left-sided colectomy patients for colorectal cancer patients by using the nationwide database. patients and methods: patients undergoing elective left-sided colectomy with low pelvic anastomosis without any proximal diversion for colorectal cancer were reviewed from the american college of surgeons national surgical quality improvement program (acs-nsqip) proceduretargeted database ( ) ( ) ( ) according to their primary procedure current procedural terminology (cpt) code. subsequently, patients who underwent intraoperative colonoscopy were identified from concurrent cpt codes and divided into two groups based on the simultaneous intraoperative colonoscopy. demographics, comorbidities, -day postoperative complications were evaluated and compared between the groups. multivariate logistic regression was conducted adjusting for significant factors between the groups. results: a total of patients were identified and ioc was performed for ( . %) patients. objective: laparoscopic ileostomy commonly performed for the patients with colorectal obstruction due to cancer, peritonitis with perforation of colon or the other reason. reduced port surgery is a novel technique that may be performed when considering minimally invasive surgery and desiring a cosmetic benefit. the aim of this study was to evaluate safety and feasibility of reduced port laparoscopic ileostomy for the patients with advanced colorectal cancer before chemotherapy. methods: between july and august , patients who underwent reduced port laparoscopic ileostomy were included ( male and female, age: years old. the outcomes were evaluated in terms of operation time, intraoperative blood loss and perioperative complications. sugical procedures: the patients were placed in the supine position and the operator stood left side. an access device with the wound-protector (ez access, hakko, nagono, japan) was inserted on the future ileostomy site in the right lower abdomen, inserting two of -mm trocars, maintaining pneumoperitoneum at mmhg with carbon dioxide. a -mm trocar was inserted in the left lower abdomen. a -mm flexible laparoscope was inserted from access device port. after exploring abdominal cavity, ileum end was identified. then the marking using dye was put on the ileum of cm proximal from the ileum end. the ileum marked by dye was grasped, and extracted through the access devise. then a blooke ileostomy was created. results: reduced port laparoscopic ileostomy was performed for patients with colorectal obstruction due to cancer before chemotherapy. the mean operative time was minutes, the mean blood loss was . ml. three patient received one additional port. there were no intraoperative complications. five patients ( . %) experienced postoperative complications (two of deep surgical site infection, one of pneumonia, one of outlet obstruction and one of renal dysfunction). there were no other intraoperative or postoperative complications. conclusion: reduced port laparoscopic ileostomy is a safe and feasible procedure for the patients with advanced colorectal cancer before chemotherapy. methods: we performed elective lcr on patients for primary colorectal cancers between june and june . seventy-two patients were excluded in this study following reasons: patients underwent multiple organ resection, and colorectal cancer was diagnosed with stage iv in patients. accordingly, patients were eligible for comparative analysis, with in group po (post operation) and in group c (control). in group po, past operative procedures were as follows: appendectomy ( %), digestive tract ( %), hepato-billiary-pancreatic ( %), gynecologic ( %), urologic surgery ( %), and others ( %). results: there were no significant differences between two groups in asa (grade≤ : vs. %, p= . ), bmi ( introduction: the treatment of rectal cancer requires highly skilled practice by the entire multidisciplinary team. important aims of treatment are: to reduce the risk of residual disease in the pelvis, with lower morbidity and to preserve good sphincter function. the tata procedure is transanal transabdominal radical proctosigmoidectomy with coloanal anastomosis. this technique was first developed in by dr. gerald marks to avoid a permanent colostomy for low-lying rectal cancer. this study reports the long-term results of tata procedure for low rectal cancer. methods and procedures: a prospective study was on patients with low rectal cancer between april and july in a tertiary referral university-affiliated center specializing in laparoscopic surgery. all resections were carried out by a team of dedicated colorectal surgery and standard protocol was used for all pre-and-post-operative care. all the patients underwent total mesorectal excision. results: consecutive patients ( male, female, mean age ) underwent tata procedure, of them ( , %) after neoadjuvant radiochemotherapy. the mean operation time was min (range - ) and the mean estimated blood loss was ml (range - ). the overall incidence of morbidity was , % ( / ) and the mean hospital stay was , days. the mean follow-up period was , (range, - ) months with a recurrence rate of , % ( / ), overall estimated -year survival , % and the disease-free survival rate , %. conclusion: laparoscopic total mesorectal excision with tata procedure is safe with excellent local recurrence and disease-free survival rate. jacek piatkowski, md, phd, marek jackowski, prof; clinic of general, gastroenterological and oncological surgery introduction: more than years ago, laparoscopic technique was considered to be a fully accepted surgical method for treatment of rectal cancer. the following years are a further search for a new surgical method that reduces invasiveness and improves treatment outcomes. it seems that such a method is transanal total mesorectal excision. the aim of this study was to evaluate the new method of rectal cancer surgery (tatme) after years of its use. methods: radicality of treatment (r resection, local recurrence), outcome of surgical treatment and quality of life of patients after surgery were evaluated. results: in the period from . . . - . . . patients ( men, women) were operated in the clinic. in cases the indication for surgery was lower and middle rectal cancer and in cases high grade dysplasia. all patients underwent laparoscopic rectal proctectomy with transanal access (tatme). in all cases, complete oncological radicalization (resection r ) was obtained. the average operation time was minutes. we had used two teams approach (cecil approach) with laparoscopic sets -abdominal and perineal starting at the same time. in the postoperative course, patients had signs of anastomosis leak ( of them required reoperation). the follow-up period is - months. none of the patients had any recurrence of cancer. conclusions: . transanal tme for rectal cancer surgery is an alternative method to conventional laparoscopic surgery. . in a large proportion of patients with lower and middle tumors, the rectum can avoid abdomino-perineal resection with permanent colostomy. background: the double stapling technique (dst) has widely spread colorectal anastomosis especially for anastomosis after low anterior resection. as for the colorectal cancer treatment, heald reported total mesorectal excision (tme) in , and has been accepted as the standard technique for rectal resection due to the decreased local recurrence rate and improved functional results. with advent of dst, there is a background that it has become possible to preserve anus, even in the case with the lesion at lower rectum. laparoscopic surgery for colon cancer was introduced in the s, and has had promising results including long-term outcomes. according to the spread of laparoscopic surgery, laparoscopic surgery had been applied to the rectal resection, with technical difficulty. one of the reasons for the difficulty is that the high rate of anastomotic leakage, a critical adverse effect of low anterior resection (lar). thus, risk factors for anastomotic leakage were widely discussed, including technical factors such as pre-compression and number or firing. the decisive difference in conventional lar and laparoscopic lar in dst, is the stapler used for transection of the rectum. the laparoscopic staplers which are currently available are thought to be not ideal, and there is little evidence of specific specifications of stapler for laparoscopic surgery. materials and methods: all method described in this study was approved by the institutional ethical review committee. we reviewed the colon and rectal wall thickness according to histological examination using h&e staining of distal margin of resected specimen of the patients who conclusions: rstc for severe acute uc is at least as safe as the laparoscopic approach. although the robotic cohort had more comorbidities, major postoperative complications, readmissions, and reoperation rates were less when compared to lstc. rstc was also associated with an earlier return of bowel function and shorter length of stay. a prospective study with larger numbers is needed to see if the superiority of robotic versus laparoscopic approaches is reproducible. s surg endosc ( ) introduction: complete mesocolic excision (cme) has been advocated based on oncologic superiority, but is not commonly performed in north america. furthermore, many data are limited to case series with few comparative studies. therefore the objective was to systematically review studies comparing the short-and long-term outcomes between cme and non-cme colectomy for colon cancer. methods: a systematic review was performed according to prisma guidelines of medline, embase, healthstar, web of science, and cochrane library. studies were only included if they compared conventional resection (non-cme) to cme for colon cancer. quality was assessed using the methodological index for non-randomized studies (minors). the main outcome measures were short-term morbidity and oncologic outcomes. study eligibility, data extraction and quality assessment was performed by two independent reviewers, and disagreements resolved by consensus. weighted pooled means and proportions with %ci were calculated using a randomeffects model when appropriate. results: out of citations, studies underwent full-text review and met the inclusion criteria, of which were unique series. mean minors score was . (range - ). the mean sample size in the cme group was (range - ) and (range - ) in the non-cme group. in the unique studies, included only right-sided resection, and . % ( % ci . - . ) of the remaining were right-sided colectomies. of the studies that reported surgical approach, . % ( %ci . - . ) of cme were performed laparoscopically. there were papers reporting plane of dissection, with cme plane achieved in . % ( . - . ). mean or time in cme group was minutes (range - ) and in non-cme group minutes (range - ). perioperative morbidity was reported in studies, with pooled overall complications of . % ( %ci . - . ) for cme and . ( %ci . - . ) for non-cme resections. anastomotic leak occurred in . % ( %ci . - . ) of cme versus . % ( %ci . - . ) in non-cme colectomies. cme surgery consistently resulted in more lymph nodes retrieved, longer distance to high tie, and specimen length. there were studies that compared -or -year overall or disease-free survival, or local recurrence. only studies reported statistically significant higher disease-free or overall survival in favour of cme. local recurrence was lower after cme in of reported studies. conclusions: the quality of the current evidence is limited and does not consistently support the superiority of cme. more rigorous data are needed before cme can be recommended as the standard of care for colon cancer resections. gilberto lozano dubernard, md, facs, ramon gil-ortiz, md, gustavo cruz-santiago, md, bernardo rueda-torres, md, javier lopez-gutierrez, md, facs; hospital angeles del pedregal introduction: to assess the feasibility of a single-stage colorectal laparoscopic re intervention without ostomy. colonic laparoscopic interventions on patients that previously underwent a minimally invasive procedure, constitutes the current boundary in the management of the acute colorectal pathology. that includes, patients with fecal peritonitis due to diverting procedures already treated surgically. the outcome of our patients could significantly improve if the surgical procedure is performed in one time, with no stoma. method and procedures: from september to june , one hundred thirty-two patients underwent colorectal laparoscopic surgery. five of these patients developed complications: three perforations due to colonoscopy and two due to dehiscence of the anastomosis. these five patients underwent a second laparoscopic procedure that included resection and anastomosis. no stoma required. results: all five patients underwent a second laparoscopic procedure due to an anastomosis leak. no stoma was required. the procedure consisted on resection of the previous anastomosis, re anastomosis, abdominal lavage, aspiration and drains placement. all of them supported with parenteral nutrition. there were no surgical complications. only one patient developed pneumonic symptoms that were solved. conclusion: the reported results, regarding no conversion rate, nor mortality, on our series of patients, suggest that single stage laparoscopic re intervention is feasible, despite fecal peritonitis. introduction: total mesorectal excision is known to be a gold standard surgical procedure for the rectal cancer. subsequently complete mesocolic excision (cme) is recognized as an essential surgical procedure for the colon cancer. the transverse colon is relatively minor location for colon cancer. variety of vessels and mobilization of splenic flexure and dissection close to pancreas make operations for the transverse colon cancer complicated. laparoscopic transverse mesocolic excision in our hospital is presented. method: laparoscopic surgery is conducted with five trocars under the lithotomy position. inferior mesenteric vein is cut after dissection of the descending colon with medial approach. the lower edge of pancreas is exposed near the inferior mesenteric vein and is dissected along toward the tail of pancreas. the splenic flexure is mobilized with lateral approach and the dissection between transverse mesocolon and the lower edge of pancreas is continued in the direction to the pancreas head. coming to the exposure of superior mesenteric artery and vein, the origin of middle colic artery and vein are cut. the transverse mesocolon is separated from the pancreas head and the duodenum with preserving the gastrocolic trunk of henle and the right gastroepiploic vein. the hepatic flexure is mobilized and cme for the transverse colon is finished. this method, the 'tail to head of pancreas' approach, we called, was performed from september . this method is well performed with one series of surgical view, and seems to be a simple procedure as cme with central vascular ligation for the transverse colonic cancer. there were no intraoperative complications, and one postoperative pancreatitis with grade ? of clavien-dindo classification of surgical complications. conclusion: our method, the 'tail to head of pancreas' approach, with transverse mesocoloc excision is simple, safe and feasible. the introduction: anastomotic complication after stapled anastomosis in colorectal cancer surgery is a considerable problem. there are various types of anastomotic complication and they have different severity. this study was aimed to evaluate the impact of intraoperative colonoscopy on detection of anastomotic complication, and its effectiveness in treatment of anastomotic complications after anterior resection (ar) and low anterior resection (lar) for colorectal cancer intraoperatively. methods: from dec. to jul. , a total of patients who underwent anastomosis between sigmoid colon and rectum after colorectal resection were reviewed retrospectively. intraoperative colonoscopy was performed routinely since december in our hospital after anterior resection and low anterior resection. to identify effectiveness of intraoperative colonoscopy, we compared postoperative complications with non-intraoperative colonoscopy group during previous months. intraoperative colonoscopy was performed after anastomosis to visualize the anastomosis line and to perform an air leakage test. if anastomotic defect and moderate bleeding were found in intraoperative colonoscopy, it was managed by means of reinforcement suture or transanal suture repair. we used logistic regression to analyze anastomotic complication between two groups with or without intraoperative colonoscopy. results: of the patients who were performed intraoperative colonoscopy after ar (n= ) and lar (n= ), abnormal findings including bleeding and air leak were found in patients ( . %). among those, cases were observed without any procedure, additional procedures were performed in patients ( . %, transanal suture ( ), lembert suture ( )). postoperative complication was developed in patients; patients had anastomosis bleeding ( . %), patients had ileus ( . %), patient had pneumonia ( . %), patients had minor complication ( . %, acute urinary retention, chylous drainage, laparoscopic port site bleeding). among patients who had anastomosis bleeding, patients were treated by endoscopic clipping, patients were cured by conservative treatment. there was no postoperative anastomotic leakage. the cases of ar and lar were and in non-intraoperative colonoscopy group, there was no significant difference between two group (p= . ). the proportion of laparoscopic surgery was . % and . % on intraoperative colonoscopy and non-intraoperative colonoscopy group, respectively, there was significant difference statistically (p= . ). however, there was no significant difference in anastomotic complication rate between two groups. (rr= . , % ci, . - . ). conclusions: although there was no significant difference in postoperative anastomotic complication rate between two groups, intraoperative colonoscopy may be valuable method for decreasing postoperative complication by visualizing anastomosis line and performing additional procedure. conclusion: it was suggested that lymph node dissection of both middle and left colic regions is necessary for splenic flexure colon cancer, because lymph node metastasis was recognized in both region. surg endosc ( ) :s -s the aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many centers. most centers use laparoscopic colectomy with extracorporeal resection and anastomosis (lc). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sc) remains controversial. the aim of the present study is to compare these two techniques using propensity score matching analysis. methods: we analysed the data of patients who underwent laparoscopic right hemicolectomy with lc or sc between december and december . the propensity score was calculated from age, gender, body mass index, the american society of anesthesiologists score, previous abdominal surgery and d lymphnode dissection. short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sc group was significantly shorter than in the lc group: median (range) ( . - ) cm verses ( - ) cm (p= . ). the vas score on day and day after surgery was significantly less in the sc group than in the lc group: median (range) ( - ) verses ( - ) on day (p= . ) and median (range) ( - ) verses ( - ) on day (p= . ). significantly fewer the number of requiring analgesia in the sc group on day and day after surgery: median (range) ( - ) times verses ( - ) times on day (p= . ) and ( - ) times verses ( - ) times on day (p= . ). there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. conclusions: sc for right colon cancer is safe and technically feasible. sc reduces the length of skin incision and postoperative pain compared with conventional lc. patients were divided into the following groups: cephalo-medial-to-lateral approach group (cml group, n= ) and medial-to-lateral approach group (ml group, n= introduction: laparoscopic technique has been widely used in the treatment of colorectal cancer, while playing its minimally invasive advantages, but also achieved a good effect of radical oncology. however, t colorectal cancer is not recommended laparoscopic surgery. methods: retrospectively collected pt colorectal cancer data from to in guangdong general hospital, all cases were undergoing radical surgery. results: a total of cases were enrolled in the pt group, including cases of laparoscopic group, cases of open group, conversion rate was . %. there was no difference in baseline data (age, sex, bmi, asa, etc.)(p. ). there was a significant difference between the two groups (p. ) in blood loss, postoperative complications and postoperative recovery index. in the pathologic t a/b, combined-organ resection, postoperative recurrence, the laparotomy group had more cases, and there was a statistically significant difference between the two groups (p\ . ). the -and -year overall survival rates were . % and . % for the lap group and . % and . % for the open group (p= . ). meanwhile, the -and -years disease-(p= . ). iiic stage, lymph node status, ca - and adjuvant chemotherapy were independent prognostic factors affecting overall survival. the age, pt a/b, iiic stage, ca - and adjuvant chemotherapy were independent influencing factors of disease-free survival. conclusions: laparoscopic surgery for pt colorectal cancer surgery, it is not only in the play of its minimally invasive but also obtained with the similar long-term effect. but we need more multicenter, prospective, and large sample clinical studies to validate our findings. introduction: lymph node (ln) retrieval after surgery is important. in the present study we evaluated the efficacy of the fat dissolution technique using fluid containing collagenase and lipase to avoid staging migration after laparoscopic colorectal surgery. methods: seventeen patients who underwent laparoscopic ln dissection for colorectal cancer were evaluated. first, unfixed lns within the resected mesentery were explored by visual inspection and palpation immediately after the operation by the surgeon, which is the most common practice in japan. subsequently, the fat dissolution technique was used on remnant fat tissue, and the lns were evaluated again. the primary endpoint was whether the second assessment increased the number of lns evaluated. results: the median number of lns identified at the first and second assessments was and , respectively, resulting in a significant increase in the total number of lns evaluated ( vs. , p\ . , paired t-test). one positive node was identified among all the additional lns identified ( . %; / ). although staging was not altered in any patient, the second assessment resulted in an increase in the originally insufficient number of lns evaluated (\ for stage ii) in three patients, whose treatment may be altered. tumor cells detected after the fat dissolution technique were stained with carcinoembryonic antigen and cytokeratin- . conclusion: using the fat dissolution liquid on remnant fat tissue of the mesentery of the colon and rectum enabled identification of additional lns. this method should be considered when the number of lns identified is not sufficient after conventional ln retrieval, and may avoid stage migration. aim: the aim of this study is to evaluate the pathological resection margin after laparoscopic intersphincteric resection for low rectal cancer. method: from to , there were eight laparoscopic intersphincteric resection cases for low rectal cancer. we evaluated the clinicopathological findings and the positivity of pathological resection margin. results: the median distance from the anal verge to the tumor was mm (range, - ), and the median diameter of the tumor was mm (range, - ). there was no case with neoadjuvant therapy. the estimated tumor depth were ct in cases ( . %) and ct in cases ( . %), and the actual tumor depth were ptis in cases ( . %) and pt in cases ( . %) and pt in cases ( . %). the median distal resection margin was mm (range, - ). pathological resection margin, such as the proximal, distal and circumferential margin was negative in all cases ( %). there was no mortality, but morbidity occurred in two cases (one case of anastomotic leakage and one case of small bowel obstruction). no recurrence nor distant metastasis was observed in the follow up period. conclusion: there was no positive resection margin case in the series. our patient selection, indication and the technique were considered to be precise and appropriate. introduction: the fistulas of the intestine to the vagina or the bladder include a highly morbid entity, with several functional limitation and loss of the quality of life, its diagnosis is complex and more than its treatment, which include a wide range of possibilities that go from the simple derivative colostomy in search of the spontaneous closure of the fistula, under the complete correction of the pathology with resections, anastomosis and mini-vasive reconstructions. give to know our experience in the minimally invasive treatment of whole vaginal and whole vesicial fistules by laparoscopic via, for the last years. results: a total of patients were operated in this period, women and men, all those by laparoscopic via, with intestinal resection, in thick intestine cases, in one small intestine and in another case with the commitment of the two, everyone restriction and intestinal anastomosis and in no matter were colostomy, primary closures of the fistula in patients were required, conversion to open surgery in a case and there was no recurrence, patients had prolonged hospitalization for localized infections, a requirement reintervencion for revision. a patient suffried a umbilical eventration for the extraction site, which was corrected one year after laparoscopy. conclusion: minimally invasive surgery in patients with this type of pathology becomes an excellent strategy for the integral management of these patients. group work guarantees good results. robbie sparks, dr, ronan cahill; mater misericordiae university hospital background: precise preoperative localisation of colonic cancer is a prerequisite for correct oncological resection. effective endoscopic lesional tattoo is vital for small, radiologically unseen tumors planned for laparoscopic resection but its practice may be imperfect. methods: retrospective review of consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection identified from our prospectively-maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation. results: patients ( males, mean age years, median bmi . kg/m , left sided lesions, screen detected, benign polyps, % conversion rate). in operations ( %) tattoo visibility was documented with tattoo absence noted in ( . %) although tattoo was identifiable in the pathological specimen in four. in those with "missing tattoos", six of the lesions were radiologically occult and in three the tumor was found in a different colonic segment then had been judged at colonoscopy. four patients had on-table colonoscopy and five were converted to laparotomy ( % conversion rate, p. ). mean postoperative length of stay was . (range - ) days. one patient's segmental resection contained only benign pathology requiring a second operation to remove the cancer. on univariate analysis, time between endoscopy and surgery (but not patient age, gender, bmi, endoscopist or surgeon seniority, tumor size or location) was significantly associated with absence of tattoo intraoperatively (p= . ). conclusion: recording related to tattoo is variable but definite lack of gross tattoo visualisation significantly impacts the procedure. the mechanism of tattoo absence is multifactorial needing careful consideration but solvable. the aim of the present study was to perform a systematic review of the literature to determine the role of antibiotics in the management of acute uncomplicated diverticulitis (aud). diverticular disease is the most common disease of the large bowel and poses a significant burden on healthcare resources. in the united states alone, the cost of diverticular disease has been estimated to be over $ billion making it the fifth most important gastrointestinal disease economically. the use of antibiotics in the management of aud, however, is primarily based on expert opinion as current high-quality evidence is lacking. recent studies have not only questioned the optimal type and duration of antibiotic regimens, but whether antibiotics provide any benefit in the treatment of aud. conclusions: antibiotic use in patients with acute uncomplicated diverticulitis is not associated with a reduction in major complications, readmissions, treatment failure, progression to complicated diverticulitis, or need for elective and emergent surgery. however, it increases the length of hospital stay. given the risk of selection bias in included studies, further randomized trials are needed to clarify the need for antibiotics in uncomplicated diverticulitis. laparoscopic para-aortic lymph node resection for colorectal cancer aim: we want to highlight the feasibility of a sigmoidectomy using total laparoscopic with a transanal extraction of the specimen. methods: it is a -year-old female patient, obese (bmi= kg/m ) to the antecedents of laparoscopic cholecystectomy and chronic constipation. she was treated three months ago for a sigmoidal diverticulitis complicated with a pelvic abscess. the evolution has been favorable under antibiotic therapy and percutaneous drainage of the abscess. the colonoscopy showed a multiple diverticula located between and cm from the anal verge. prophylactic sigmoidectomy was performed laparoscopically using trocars ( mm supra ombilical, mm fid and mm right flank). the specimen was extracted transanally, thus avoiding a pubic incision. the steps of the intervention were: -mobilisation of left colon -closing of distal left colon stump -rectal stump lavage -opening on the rectum -transanal introduction of the anvil -specimen transanal extraction -closing og rectal stump -colonic positioning of the anvil -coloractal anastomosis. results: the intervention was minutes. no perioperative incidents. the liquid regime was authorized on the night of the intervention. the operating procedures were favorable with an exit to j post operative. the anapath examination of the surgical specimen confirmed the presence of sigmoidal diverticula. conclusion: laparoscopic sigmoidectomy with transanal extraction of the specimen for benign desease is a seductive technique with satisfactory results. it avoids a pubic incision with its parietal and aesthetic complications. chengzhi huang; guangdong general hospital (guangdong academy of medical science) background: colorectal cancer (crc) is one of the most common malignant diseases over the world. of the causes of the death of crc, metastasis to liver or lung are the major factors. however, there is still lack of precise tumor biomarker that precisely predict the clinical outcome of crc. the salt-inducible kinase (sik ) encodes a serine kinase of amp-activated protein kinase (ampk) family, which may play critical roles in tumorigenesis and tumor progression. this study aimed the study the expression and clinical significance of sik and crc patients. methods: the expression of sik protein was measured by western-blot and analysis of immunohistochemistry. sik mrna expression in cancerous tissue was measured by rt-pcr. results: the expression level of sik was correlated with the following factors: tumor invasion (t stages), lymph node metastasis, clinical stages (tnm) and tumor location. the down-regulated sik implies poor clinical outcome measured by kaplan-meier analysis (p-value. ), and may act as an independent risk factor of crc patients. background: surgical specimens for resected colon cancer vary in quality and there remains no universally accepted technique to guide resection margins. a minimum of lymph nodes provides some quality assurance, however this remains a crude marker of optimal oncological surgery. a tool to precisely identify lymphatic drainage within the mesentery could improve the oncologic quality of resection and better guide adjuvant treatment through more optimal mesenteric lymphadenectomy. while fluorescence imaging (fi) has been described to identify nodal disease in several other cancers, feasibility and best practices have not been established in colon cancer. we describe a novel technique of fi using indocyanine green (icg) to identify lymphatic spread and potentially guide optimal mesenteric lymphadenectomy in colon cancer. methods: three consecutive patients with colon cancer undergoing a laparoscopic resection had peritumoral subserosal injection of icg for fi after extracorporealization of the mobilized specimen. three concentrations of icg were injected − mg/ ml, mg/ ml, and mg/ ml. a total of ml was given for each patient. using a modified laparoscopic camera, the icg was excited by light in the near-infrared (nir) spectrum, for real-time visualization of the lymphatic drainage. the main outcome measure was identification of lymphatic drainage. results: three patients with right-sided primary colon cancer were evaluated. all three patients had successful identification of the lymphatic drainage pattern along the mesentery. the most successful protocol was ml (concentration mg/ ml) subserosal injection at points within close proximity ( cm) of the tumor with a -gauge needle, then waiting minutes for complete mapping. no intraoperative or injection-related adverse effects occurred with -day follow-up. the median lymph node yield was . all specimens had tumor-free margins. conclusion: from this small series, fluorescence imaging with icg is a potentially safe and feasible technique for identifying mesocolic lymphatic drainage patterns. this proof of concept and protocol will lead to future studies to examine the utility of fluoresence imaging to guide more precise surgery in colon cancer. introduction: anastomotic leakage in colon/rectal surgery is a dangerous event with an occurance rate ranging from to %. the associated mortality rate is between - %. the white-light intraoperative subjective surgical assessment (the most frequently used approach) underestimates the actual anastomotic leakage rate. intraoperative tissue perfusion assessment by indocyanine green (icg)-enhanced fluorescence has been reported in multiple clinical scenarios in laparoscopic/ robotic surgery, as well as for for bowel perfusion assessment. this technology can detect microvascular impairment, potentially preventing anastomotic leakage. we reviewed the literature and present our data to evaluate the feasibility and usefulness of icg-enhanced ?uorescence in the intraoperative assessment of vascular peri-anastomotic tissue perfusion in colorectal surgery. methods and procedures: a pubmed literature narrative review has been performed. moreover, out of a total of robotic colorectal cases, we retrospectively analyzed icg-enhanced fluorescence robotic colorectal resections ( left colectomies- rectal resections- right- transverse- pancolectomy). results: after icg-technology use, the biggest (n[ ) case-series showed a rate of . - % of cases in which they changed the level of resection based on icg. icg technology may variably reduce the anastomotic leak rate from to %. however, the threshold values to define the actual sub-optimal perfusion are still under investigation. in our experience, out of icg cases performed: the conversion, intraoperative complication, dye allergic reactionand mortality rates were all %. post-op surgical complications: case of leak ( , %) and sbo for incarcerated hernia ( . %). in cases, with normal white-light assessment, the level of the anastomosis was changed after icg showed ischemic tissues. despite the application of icg, anastomotic leak has been registered. conclusions: icg-enhanced ?uorescence may intraoperatively change the white-light assessed resection/anastomotic level, potentially decreasing the anastomotic leakage rate. our data shows that this technology is safe, feasibile and may prevent anastomotic leakage. however, the decision making is still too subjective and not data driven. at this stage icg, beside being a promising technique, doesn't have high level of evidence (most of the reports are retrospective). some randomized prospective trials with an adequate statistical power are needed. a precise injection dose and timing standardization is required. the main challange is to develop a method to objectively obtain a real-time intensity assessement. this may provide objective metric tresholds for an intraoperative evidence/data-based surgical decision making. introduction: according to the world health organization, colorectal cancer is the rd most commonly diagnosed cancer in the world. one of the main risk factors for the development of colorectal cancer is obesity. obesity is seen to increase the risk of colorectal cancer by % in women per kg/m and % in men per kg/m . bariatric surgery is one of the treatments that is considered to achieve and sustain a significant amount of intentional weight loss in patients. considering that fact that bariatric surgery decreases obesity, this intentional weight loss would seem to provide a favorable outcome in terms of diagnosis and prognosis of colorectal cancer. a systemic review of the literature was conducted via pubmed to identify relevant studies from january through may . the main outcome for this study is to assess whether patients who underwent bariatric surgery (restrictive and malabsorptive procedures) had an increased or decreased risk of colorectal cancer. all studies included in this meta-analysis are retrospective cohort studies. results were expressed as standard difference in means with standard error. statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups between bariatric surgery and non-surgery in patients with colorectal cancer. (comprehensive meta-analysis version . . software; biostat inc., englewood, nj). results: four out of studies were quantitatively assessed and included for meta-analysis. among the four studies, , underwent bariatric surgery and , did not undergo bariatric surgery. there is a significant decrease ( . ± . ; p= . ) in the risk in patients developing colorectal cancer in patients who underwent bariatric surgery compared to those who didn't get surgery. conclusion: bariatric surgery patients appear to have a decreased risk of colorectal cancer compared to patients who did not have bariatric surgery. guh jung seo, hyung-suk cho; department of colorectal surgery, dae han surgical clinic, gwangju, south korea introduction: the incidence of rectal carcinoid tumors is increasing due to the widespread use of screening colonoscopy. endoscopic mucosal resection (emr) is a useful method for small rectal carcinoid tumors (≤ mm) because of its simplicity, quick procedure and low complication rates. we aimed to describe our experience and evaluate the outcomes of emr for rectal carcinoid tumors. the patients enrolled in this study were patients with small rectal carcinoid tumors who underwent emr using a submucosal injection technique of epinephrinesaline mixture between august and october . all medical records, including characteristics of the patients and tumors, complications, were retrospectively reviewed. results: the patients were men and women, with a mean age of . years (range, - years). en block resection was performed by emr in all cases. the endoscopic mean size of tumors was . mm (range, - mm). the pathologically measured mean size of the resected specimens was . mm (range, - mm). the mean size of resected carcinoid tumors was . mm (range, . - mm). the tumor shape was submucosal tumor in and polyp in . histological examination revealed that cases had resection margin positive of tumor and case had undetermined resection margin of tumor. of the patients, patients underwent endoscopic treatment and patients underwent transanal excision. no residual tumor was found in additionally removed tissue. there were cases with emr-related complications: early postprocedural bleeding and postpolypectomy syndrome. there was no significant bleeding requiring blood transfusion or perforations. conclusion: endoscopic mucosal resection is considered to be a relatively safe and useful method for treatment of small rectal carcinoids in selected patients. background: disturbance of sexual function after an operation for rectal cancer has often occurred. the relationship between autonomic nerves and arteries in pelvis was examined. methods: clinical studies of male patients with resected rectal cancer were performed using snap gauge method, penile-brachial index and evoked bulvo-cavernous reflex. in canine experiments, pelvic splanchnic nerve (psn) electric stimulation, arterial flow measurement, corpus cavernosum pressure measurement and muscle strip study using drugs were evaluated. results: in clinical studies of male patients, transection of the hypogastric nerve (hgn) and the sympathetic trunk did not affect the erectile function in the postoperative course. in animal experiments transection of these nerves did not affect the increase in inner pressure of the penis cavernosum. in postoperative cases in which only one side of the lower grade branches of the psn (s ) were preserved, the erectile function was preserved. in animal experiments in which the psn of one side was disturbed, the ipa flow of the same side decreased, while the flow of the other side increased. we have evaluated the role of adrenergic components in the psn on the erectile function in the dog. the effect of norepinephrine hydrochloride on canine vascular smooth muscle was examined in vitro. vascular smooth muscle strips from the ipa relaxed longitudinally. electrical stimulation of the psn increased blood flow in the ipa and also elevated the cavernous pressure. these increases were blocked in part by phentolamine, but not by propranolol or atropine. the effects of cholinergic and adrenergic agonists and antagonists on mechanical responses were also examined in muscle strips obtained from various arteries in the intra-pelvic region including the ipa. norepinephrine induced contraction in the iliac artery and relaxation in the ipa, and both the contraction and relaxation responses were blocked by phentolamine but not by propranolol. these findings suggest that in the dog, α-adrenergic components projected through the psn may contribute to penile erection. conclusion: blood flow in the ipa was controlled significantly by the same side psn, but compensatory by the other side psn. it is also conceivable that the erectile function through the psn is controlled by the sympathetic nerve, not by the parasympathetic nerve. in postoperative cases in which only one side of the lower grade branches of the psn (s ) were preserved, the erectile function was preserved. introduction: currently, neoadjuvant chemo-radiotherapy (ncrt) followed by low anterior resection or abdominoperineal resection are the standard treatments for locally advanced rectal cancer. ncrt can improve resecability, achieve better sphincter preservation and reduce local recurrence. although total mesorectal excision is the standard treatment for advanced rectal cancer, recent trends in minimally invasive treatments led to an increase in local excision or "watch and wait" in patients with an excellent response to ncrt. the purpose of this study, part of an ongoing research, is critically evaluating the feasibility of "non-operative treatment" for rectal cancer in a district hospital. methods and procedures: a total of patients with rectal cancer, who where treated with ncrt from january to august at "carlo urbani" district hospital in jesi (italy), were retrospectively reviewed. all patients had histologically-confirmed primary adenocarcinoma of the rectum located within cm from the anal verge. the involved patients completed ncrt and had no recurrence disease, distant metastasis, synchronous malignancies. they were classified according to the mandard's tumor regression grade (trg) into two clusters: group a (trg - ) and b . results: the average age of people is . and were male. five patients underwent abdominoperineal resection and % fell within group a. six patients had lymph nodes involved. four patients suffered relevant complications, such as wound complication, anastomotic leak, operative reintervention and death. univariate analysis showed that the main predictors of tumor regression were the absence of lymph-nodes involvement from initial imaging (p. ), normal initial carcinoembryonic antigen level (p. ) and tumor downstaging in imaging (p. ). in addition, most relevant complications occurred to elderly patients although they observed a good clinical response. besides, % of patients were found to be complete pathologic responders upon examination of the surgical specimen. conclusions: the oncologic feasibility of non-operative management for the patients with complete clinical response after ncrt has been growing, but some studies have suggested lack of oncologic safety in these patients. the patients with a complete clinical response expect good survival, but they may still harbor residual disease. no consensus on "watch and wait" policy in the field of rectal cancer was obtained, yet. our data did not entirely support this policy although it might be the best strategy, based on the predictors of tumor regression, to avoid the complications associated with surgery in elderly patients with significant medical comorbidities and fear of a permanent stoma. introduction: conventional incision laparoscopic surgery procedure for rectal cancer is widely accepted as a successful alternative to laparotomy now, bestowing specific advantages without causing detriment to oncological outcome. evolving from this, single-incision laparoscopic surgery (sils) has been successfully utilized for the removal of colonic tumors, but the literature lacks sufficient data analyzing the suitability of sils for rectal cancer especially for total resection mesorectal excision (tme), particularlyon oncological outcome. we report the short-term clinical and oncological outcomes from a large cases retrospective analysis of observational study of sils for tme procedure of rectal cancer. methods: rectal cancer patients who underwent transumbilical single incision laparoscopic tme surgery were recruited in the current study. short-term perioperative clinical parameters and oncological outcomes were observed and all patients were followed up after surgery. then summarize the preliminary application results. results: operations were accomplished successfully with single incision laparoscopy, patients were converted to multiport approach, and was converted to laparotomy, no diverting ileostomy was performed. the average operative time was ( . ± . ) min, with an average blood loss of ( . ± . ) ml, the median postoperative hospital stay was ( . ± . ) days. all patients received a r resection and the surgical margin were conformed negative in all cases, the median number of harvested lymph node is ( . ± . ), the specimens met the requirement of tme. there were postoperational complications, no operation-related mortality or postoperative anastomotic leakage was observed. no patient appeared recurrent in a median follow up of months. conclusions: total mesorectal excision surgery for rectal cancer can be safely performed using transumbilical single incision laparoscopic technique, with acceptable short-term clinical and oncological outcome. surg endosc ( ) background: any surgical trauma induces an inflammatory response, which is considered as a negative factor in the general immune response, specially in malignant disease. the c-reactive protein (crp) is an acute phase protein often used as a marker of surgical trauma. stent treatment has been used as a treatment option for colonic obstruction in palliative cases for many years, and also as a bridge to surgery in selected cases. in a pilot study we compared the inflammatory response after acute stent treatment or surgery for malignant colonic obstruction. method: we compared two consecutive series of treatment of acute malignant colonic obstruction, stent treatment or emergency surgery during - . all patients were admitted with acute colonic obstruction due to colorectal cancer. choice of treatment was based on attending senior colorectal surgeons' preference, patient comorbidities and disseminated disease was considered. patient age, crp, time to first defecation and length of stay was recorded. results: a total of patients were identified in a retrospective analysis. patients had acute stent treatment and had acute surgical treatment for colonic obstruction, all due to colorectal cancer. median age was y ( - ) with no difference between the groups. there was no difference in metastatic disease between the groups. median time until first defecation after treatment was significantly shorter for the stented patients ( h ( - )) compared with those operated ( h ( - )) (p, ). median hospital stay was also shorter in the stent group, days ( - ), versus days ( - ) in the surgical group (p= , ). crp did not differ between the groups before treatment. both treatments resulted in increased crp levels at postoperative days and , but the crp levels were significantly higher in the surgical group than in the stent group at both time points (pod p= , , pod p, ) conclusion: acute stent treatment in colonic malignant obstruction seems to induce a less pronounced inflammatory response compared with surgery, as shown by a significantly reduced increase in postoperative crp resulting in shorter time to first defecation and a shorter hospital stay. introduction: meckel's diverticulum is the most common congenital abnormality in newborns, present in about - % of them. diagnostic of meckel's diverticulum requires a high index of suspicion, and even with the use of modern imaging technologies, they are often diagnosed intraoperatively. what to do when an asymptomatic diverticulum is found incidentally during surgery for other causes is a matter of discussion. objective: the aim of this article is to report symptomatic and asymptomatic incidentally found cases seen in a fourth-level hospital in colombia. the reports of the histopathologic examinations carried out in the hospital in the last years were reviewed searching for those containing meckel's diverticulum in their diagnosis. patients were divided in asymptomatic and symptomatic groups. the asymptomatic group was defined as patients who were operated for a different indication and a meckel's diverticulum was found incidentally. morbidity was divided in early and late complications after the initial surgery. results: from january to june , a total of pathology reports included the diagnosis meckel's diverticulum. a total of adult patients were retrieved. all of those patients with meckel's diverticulum a total of patients were symptomatic, being sbo the most common complication and required the surgical remove incidentally. conclusion: the correct approach of the patients with diverticular pathology allows the early identification and the appropriate management of the surgical complications that can be presented. robert j czuprynski, md, grace montenegro, md; saint louis university hospital presacral masses are a rare entity, with an incidence of . % and can be classified in several categories, including inflammatory, neurogenic, congenital, osseous and miscellaneous. in this case, a neuroendocrine tumor was identified with concern for iliac chain lymphatic and gluteal metastasis. the patient underwent abdominoperineal resection, excision of presacral mass, lymph node biopsy and omental flap. final pathology returned as a grade ii neuroendocrine tumor arising from a tailgut cyst. a year old female with a ten year history of recurrent perianal, ischiorectal and deep postanal abscesses presents with a presacral mass biopsy proven well-differentiated neuroendocrine tumor. octreotide scan demonstrated avidity for presacral mas as well as left intergluteal lymph node and two internal iliac lymph nodes. chromogranin a, neuron-specific enolase and serotonin markers were all negative. the patient was taken to the operating room and underwent abdominoperineal resection, resection of presacral mass and internal iliac nodes with an omental flap. neuroendocrine tumors arising from tailgut cysts of the presacral space are rare in nature. in a retrospective study from great britain, four of thirty one tailgut cysts had malignant transformation, so it is generally recommended to resect the cysts. in this case, the patient's tumor was a moderately differentiated, grade ii with extensive lymphovascular and perineural invasion. there are no prospective studies showing neoadjuvant therapies in neuroendocrine tumors of the presacral space. according nccn guidelines, patient is currently asymptomatic with low tumor burden. recommended treatment at this time is observation with surveillance tumor markers every - months or octreotide. anastomotic leakage has been commonly regarded as one of the toughing postoperative complications in laparoscopic mid/low rectal cancer surgery, attenuating the short-term clinical benefits. the left colic artery (lca) has been routinely central-ligated in dissection process to guarantee the oncological effects, which may potentially attribute to the postoperative ischemia-induced anastomotic leakage in the patients with left-colic vessel variation, e.g. bypass or absent of riolan arch. however, no specific study focuses on the surgical benefits of lca preservation compares to conventional ones. herein, we conduct a single center randomized controlled trial, demonstrating that lca-preserving technique shows significant reduction rate of postoperative leakage as well as overall complications comparing to the traditional central-ligation group. no difference in survival rate and recurrence in short term is found between the two groups. the lca-preserving strategy is proven to be repeatedly safe and feasible, potentially reduce the risk of anastomotic leakage with comparable short-term outcomes. further investigation is required for both the oncological safety and long-term prognosis for this innovative technique. background: three-photon imaging (tpi), which was based on the field of nonlinear optics and femtosecond lasers, has been proved to be able to provide the -dimensional ( d) morphological feature of living tissues without the administration of exogenous contrast agents. the purpose of this study is to investigate whether tpi could make a real-time histological d diagnosis for colorectal cancer compared with the gold standard hematoxylin-eosin (h-e). methods: this study was conducted between january and august . a total of patients diagnosed as colon or rectum carcinoma by preoperative colonoscopy were included. all patients received radical surgery. the fresh, unfixed and unstained full-thickness cancerous and the corresponding normal specimens in the same patient, were immediately prepared to receive tpi after surgery. for d visualization, the z-stacks were reconstructed. all tissue went through routine histological procedures. tpi images were compared with h-e by the same attending pathologist. results: the schematic diagram of tpi is shown in fig. a . peak tpi signal intensity excited at nm was detected in living tissues. the field of view (fov) was µm and the imaging deep was µm in each specimen. in normal specimens, glands lined regularly and characterized as a typical foveolar, which was comparable to h-e images ( fig. b and d ). in cancerous specimens, irregular tissue architecture and shape were identified by tpi, which was also validated by corresponding h-e images ( fig. c and e ). tpi images can be acquired with a view of d visualization. based on rates of correlation with pathological diagnosis, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value were %, %, %, %, . %, respectively. conclusions: it is feasible to use tpi to make a real-time d optical diagnosis for colorectal cancer. with the miniaturization and integration of colonoscopy, tpi has the potential to make a real-time histological d diagnosis for colorectal cancer in the future, especially in low rectal cancer. erica pettke , abhinit shah , vesna cekic , daniel feingold , tracey arnell , nipa gandhi , carl winkler, md , richard whelan ; mount sinai west, columbia university introduction: alvimopan (alvim) is a peripherally acting µ-opioid receptor antagonist used to accelerate gastrointestinal functional recovery postoperatively (postop) after bowel resection. the purpose of this retrospective study was to compare the time to first flatus and bowel movement (bm) as well as length of stay (los) following elective minimally invasive colorectal resection (crr) in a group of patients (pts) who received alvimopan perioperatively (periop) vs a group that did not get this agent. methods: a data review from to from irb approved databases was carried out. operative, hospital and office charts were reviewed. routine use of alvim for elective crr cases was stared in . besides gi data, preoperative comorbidities and day postop complication rates were assessed. the results with periop alvim were compared to a no-alvim group. the students t and chi-square tests were used. results: a total of pts underwent elective crr. alvim was administered periop to pts ( %). the breakdown of indications between groups were similar. alvim pts were younger ( . vs. . years old, p= . ) and, as regards comorbidities, less likely to have heart disease (cad . % vs . %, other heart disease . % vs . %) but were otherwise similar. the rate of laparoscopic-assisted (alvim, . %; no alvim, %) and hand assisted or hybrid operations (alvim, . %; no alvim, %) were similar. alvim pts had significantly earlier return of flatus ( . vs . days) and first bm ( . vs . , p. for both) than the no alvim group. there was also a trend toward a shorter los ( . vs . days, p= . ) for the alvim group. overall complication rates were similar, however, alvim pts had lower rates of post-operative ileus ( . % vs . %, p. ), sssi's ( . vs %, p= . ), and blood transfusion ( . vs . %, p= . ) than the no alvim group. conclusion: the two groups compared were largely similar (most co-morbidities, indications, crr type) with the differences in age and cardiac issues noted. the impact of the higher rates of sssi's, blood transfusion, and mi in the no alvim group on gi function is unclear. pts who received alvim periop had an accelerated return of bowel function, decreased postoperative ileus and shorter length of stay. these results suggest that alvim is effective in reducing the postoperative ileus but further study is warranted. background: laparoscopic total proctocolectomy (tpc) is selected for minimally invasive surgical treatment of familial adenomatous polyposis (fap) and ulcerative colitis (uc). our policy of tpc is no diverting ileostomy for fap and creating ileostomy for ibd because most of the patients received steroid therapy. objective: we examined the outcome of laparoscopic tpc according to disease of fap and ibd (uc and crohn's disease). methods: twenty-three consecutive patients who underwent laparoscopic tpc between april and march were examined. the patients were divided into fap group and ibd group. results: seven patients of fap and patients of ibd (uc , crohn's disease ) underwent laparoscopic tpc or total colectomy. among them, patients (fap , ibd ) were cancerassociated cases. the procedures of the fap group was tpc with iaca in patients and hals total colectomy with ira in patient. the procedures of ibd group were tpc with iaca in patients, tpc with iaa in patients, total colectomy with ira in patients, of which hals cases. the mean operative time and blood loss were minutes, . g in the fap group and minutes, . g in the ibd group, respectively. diverting ileostomy was constructed in patients of only uc group. early complications of fap group were observed in cases (postoperative ileus , anastomotic leak with conservative treatment ), and those of ibd were observed in cases (ileus , anastomotic leak with conservative treatment , abdominal abscess , wound infection ). the median postoperative hospital stay was days in the fap group and days in the ibd group. complications requiring reoperation were cases (fap : intestinal obstruction, ibd : inflammation of stoma-closure site). no cancer recurrence and mortality were observed. one case of fap underwent additional transanal mucosal resection due to new lesion of adenoma. conclusions: laparoscopic total proctocolectomy for fap and ibd was performed safely, especially less complications occurred in fap patients without diverting ileostomy. in addition, followup of remaining mucosa is important in iaca and ira patients. treatment of complex anal fistula has always been a nightmare for surgeonsby conventional means. even the lowest and simple looking fistula at times comes out to be a complex one with high incidence of recurrence above %. most of the availability diagnostic including mri is nit conclusive and many a times the surgeon remains in a state of confusion as to what is going to come at the operation table. the conventional treatment modalities also usually leave the patient wounded needing almost to weeks to heal with a risk of sphincter damage and a high risk of recurrence. we would be presenting the technical details and results of our series of cases of complex anal fistula treated by video assisted endoscopic therapy. jun higashijima, phd, mitsuo shimada, professor, kozo yoshikawa, phd, takuya tokunaga, phd, masaaki nishi, phd, hideya kashihara, phd, chie takasu, phd, daichi ishikawa, phd; department of surgery, the university of tokushima background: one of the important causes for anastomotic leakage (al) in anterior resection is an insufficient blood flow of the stump. the hems (hyper eye medical system) and spies (laparoscopic icg system) can detect the blood flow of fresh organ intraoperatively by injection of indocyanine green (icg). and thermography also can evaluate the bloodflow less invasively. the aim of this study is to evaluate the usefulness of icg system and thermography in laparoscopic anterior resection. patients and methods: this study retrospectively included patients who underwent laparoscopic anterior resection for colon cancer with double stapling anastomosis procedure. blood flow evaluation of oral stumps was performed with measurement of fluorescence time (ft) using hems and spies. and bloodflow was also evaluated by thermography. result: evaluation by icg system: in all cases, the al rate was . % ( / cases). over ft cases, the al rate was %, higher than that of under s cases and these patinets need additional management, covering stoma or additional resection. and in border cases, ft * sec, al rate is . %, higher than under s cases. in these borderline cases, if covering stoma was performed in patinets with more than three well known risk factors, the al rate reduced to . % and false positive was . %. and under s cases, they need no additional management. evaluation by thermography: in residual intestine, the temperature was siginificantly higher than resected intestine ( . vs . ?, p. ). and the temperature in ft under s cases was significantly higher than over ft over s cases ( . vs . ?). the temperatue and ft was tended to be oppositely correlated (r = . ). conclusion: both icg system and thermography may be useful to avoid anastomotic leakage. introduction: some patients who undergo neoadjuvant chemoradiation therapy (crt) for rectal cancer achieve a pathologic complete response (pcr) in which no tumor cells are discovered during pathologic analysis of the resection specimen. achievement of pcr is correlated to improved prognoses relative to non-pcr counterparts. such correlations are not well established in the context of a community-based hospital. the study sought to examine response rates, recurrences, and survivals in locally advanced rectal cancer patients and compare patient outcomes to those achieved at major academic institutions. methods and procedures: a single-center retrospective chart review was performed at a local, community-based hospital. study population consisted of patients with locally advanced rectal cancer treated with neoadjuvant crt followed by surgical resection. patients with a history of metastasis, inflammatory bowel disease (ibd), hereditary cancer syndromes, concurrent or prior malignancy, and emergent surgery were excluded. results: patients ( . %) achieved pcr in the test population. across both groups, mean age (p =. ), gender (p=. ), and ethnicity (p=. ) were found to be comparable. mean interval between crt and or (p=. ), pre-op stage (p=. ), number of nodes (p=. ), radiation dose (p=. ), tumor location (p=. ), and days of follow-up (p=. ) presented statistically insignificant differences between groups. at years, non-pcr patients ( . %) had a recurrence with zero recurrences in the pcr group. -year mortality presented non-pcr patients ( . %) compared to pcr patient ( . %). conclusion: a multidisciplinary approach to rectal cancer consisting of standardized preoperative treatment and surgical resection can achieve patient outcomes and survival similar to those of larger academic institutions, even in the context of a community-based hospital. objective: the aim of this study was to assess safety and feasibility of total mesorectum excision (tme) within the holy plane based on embryology for rectal cancer. methods: prospectively collected data of consecutive patients with rectal cancer who underwent tatme from november to august were enrolled. surgical outcomes including tme completeness, operative time for tme completion, blood loss, complications, pathological findings and length of hospital stay were assessed. surgical procedure: after performing ractal lavage, self-retaining anal retractor was set, and anal dilators were used for an atraumatic introduction of the transanal access devise (gelpoint path). three of -mm trocars and one of -mm trocar were inserted through the gelpoint path in a quadrant shape. then the gelpoint path was introduced through the anal to rectum. after rectosigmoid colon was temporally clamped using an atraumatic endo bulldog clip, pneumoperitoneum was maintained at mmhg with carbon dioxide via an air seal platform. a purse-string suture using a polypropylen with -mm rounded needle was performed clock-wise to tightly occlude the rectum with a cm margin distal to the tumor. after irrigation with saline and marking dissection line with tattooing the rectal mucosa distal to the mucosal folds, a mucosal transection of rectum was initiated. then a full-thickness rectal transection was performed circumferentially. after dissection of rectococcygeal muscle at o'clock and rectourethral muscle in the anterior wall, circumferential sharp dissection within the holy plane was performed. dissection proceeded between the endopelvic fascia and the prehypogastric nerve fascia in the posterior plane, between the denonvilliers's fascia and the anterior mesorectum in the anterior plane, and between pelvic nerve and the mesorectum with recognition of the neurovascular bandle in the lateral plane. then the dissection connected to the abdominal plane via laparoscopic team with working together until tme completed. results: tme completion performed in ( . %) patients. thirty five ( . %) patients had negative of circumferential resection margin. mean of tme completion time and blood loss were min and g, respectively. one ( . %) patient had an intraoperative complication and ( . %) patients had postoperative complications. no other complications occurred. the length of hospital stay was days. conclusions: tatme within the holy plane on based on embryology is a safe and feasible procedure for rectal cancer. abstract: acromegaly is a debilitating condition marked by excessive production of growth hormone. this leads to disfiguration, cardiopulmonary complications, and increased risk for cancer. with up to a two-fold increased risk of developing colon cancer and worse prognosis for diagnosed patients, earlier and more frequent screening has been recommended. we present a case of a -year-old hispanic male with acromegaly who presented to our hospital with hematochezia and weight loss. a near-obstructing rectal adenocarcinoma with metastasis to the liver was discovered. after completing neoadjuvant chemoradiotherapy, he underwent laparoscopic low-anterior colon resection and simultaneous open hepatic trisegmentectomy. in this case report, we review the literature and current guidelines in screening this high-risk group of patients. introduction: in this study, we discovered that in cme for laparoscopic right hemi-colectomy starting at the ileocolic vessel and proceeds along the superior mesenteric artery (sma) achieved a better oncologic outcome compared with the conventional ones proceeding along the superior mesenteric vein (smv). methods and procedures: patients admitted to a shanghai minimally invasive surgical center were included from september to january and were randomly divided into two groups: study group (n = ) and conventional group (n = ). operation time, blood loss during surgery, liquid intake time, postoperative hospital stay, postoperative complications within days after surgery, specimen length, and number of lymph nodes harvested as well as the positive lymph node rate were observed and studied. results: there was no statistical difference between the two groups with the exception of number of lymph node dissected and the positive lymph node rate for stage iii colon cancer. the study group had more lymph node retrieved and also a higher positive rate compared with the conventional group. the mean number of lymph node retrieved of study group was . ± . , while the conventional group was . ± . (p. ). and the positive lymph node rate for study group was . %, the conventional group was . %. conclusion: when performing the laparoscopic right hemi-colectomy, dissecting the lymph node along with the left side of sma could be achievable and there were no differences of surgical outcomes compared with the conventional ways, while there was a higher number of lymph nodes dissected and positive rate probably leading to a better oncologic outcome. aims: we describe laparoscopic surgery for rectal cancer using needlescopic instruments performed at our department. methods: from to , cases of rectal cancer underwent surgery using needlescopic instruments: cases at rectosigmoid colon, at upper rectum, and at lower rectum. an umbilical camera port ( -mm) and two needlescopic instruments (endorelieftm) were directly punctured into the assistant surgical site. we started with port sites. in low rectum cancer cases, we kept the good pelvic visualization to lifting the peritoneum of the bladder onto the ventral side using the lone star retractor staystm. results: the median age was years ( - years), with males and females, and body mass index was . kg/ m ( - kg/m ). anterior resection was performed in cases, low anterior resection in cases, intersphincteric resection in cases, abdominoperineal resection in cases, hartmann's procedure in cases, and lateral lymph node dissection in case. in addition, one case of t b (bladder) was converted from laparoscopic to open surgery. however, there were no cases in which needlescopic instruments were replaced with conventional forceps. moreover, intraoperative complications related to the forceps were not observed. conclusions: in rectum cancer surgery, needlescopic instruments leave a small postoperative wound; healing is rapid and the cosmetic result is excellent. surgical safety is comparable to that using conventional forceps. there is no problem with the rigidity of needlescopic instruments. however, where the shaft is curved, operative control requires attention to mobility and directionality. in low rectum surgery, use of needlescopic instruments is limited due to the curvature of the shaft during the dissection of the anterior rectum wall, but it is possible to maintain a good field of view by using auxiliary equipment. therefore, more cases could be considered for surgeries using needlescopic instruments with the help of auxiliary equipment. introduction: anastomotic leaks are devastating complications of colorectal operations that lead to significant morbidity and potential mortality. inadequate tissue perfusion is considered a key contributor to anastomotic failure following colorectal operations. currently, clinical judgment is the most commonly used method for evaluating adequate blood supply to an anastomosis. more recently intraoperative laser angiography using indocyanine green (icg) has been utilized to assess tissue viability, particularly in reconstructive plastic surgery. this technology provides a real-time evaluation of tissue perfusion and is a helpful tool for intra-operative decisions, particularly in deciding to revise an intended colorectal anastomosis. our study aimed to determine if there is a statistical significance in colorectal anastomotic leak or abscess rate using icg compared to common clinical practice. methods and procedures: patients undergoing left-sided colorectal operations, between march and february , were retrospectively reviewed. patients' colorectal anastomoses were evaluated using icg angiography (icga) to qualitatively assess tissue perfusion (icg group). peri-operative and post-operative outcomes, including anastomotic leak and abscess rates, were compared to patients who had colorectal operations without icga (control group). the primary outcomes of intra-abdominal leak rate and intra-abdominal abscess rate were compared using exact chi-square tests. the secondary outcomes of -days or return, mortality, and readmission rate were compared using chi-square tests. all statistical analyses were performed using sas software. results: two leading indications for surgery included malignancy (n = ) and diverticulitis (n = ). the majority of patients either had a low anterior resection (n = ) or sigmoidectomy (n = ). all operations were primarily minimally invasive. no statistically significant difference was seen between the two groups in regards to patient demographics, rate of proximal diversion (p = . ), and splenic flexure mobilization (p = . ). patients in the icga group were more likely to have high ima ligation than in the control group ( . % vs. . %, p-value. ). of the icga group, of the patients underwent additional colonic resection while of the did not undergo additional colonic resection. there was no statistically significant difference in primary or secondary outcomes between the two groups. conclusion: icg angiography has become a helpful adjunct in determining adequate perfusion to an intended colorectal anastomosis. this data is unable to support any difference in patient outcome utilizing this technology over surgeons' visual and clinical assessment. our results may contribute to larger studies to determine if there is a true difference in anastomotic leak or abscess rate using this technology. objective: to investigate the feasibility and surgical strategy of complete mesocolic excision (cme) with completely medial access by "page-turning" approach (cmapa) for the laparoscopic right hemi-colectomy. the cmapa is a modified medial approach of cme, which focus on the exploration of surgical plane instead of the recognition of vessels. surgical procedures: ( ) start point: the anatomy projection of ileocolic vessel; ( ) expose the whole trunk of smv to the level of inferior edge of pancreas before ligating any branches, for the purpose of high tie and verifying their location; ( ) enter the intermesenteric space (ims) and right retrocolic space (rrcs) with cranial and right extension through transverse retrocolic space (trcs); ( ) complete mobilize the mesocolon and remove the tumor en-bloc. see figure ? . clinical outcome: from september to march , there were patients underwent cmapa in shanghai ruijin hospital. the average operation time was . ± . minutes, average blood loss was . ± . ml, number of lymph node was . ± . , average specimen length was . ± . cm, flatus time was . ± . days, fluid intake time was . ± . days and average hospital stay was . ± . days. the overall complications rate was . % ( / ). compared to traditional medial approach of cme performed in our center, the blood loss, operation time and hospital stay were significantly reduced by performing cmapa for laparoscopic right hemi-colectomy. conclusion: the advantage of the cmapa ( ) to avoid the laparoscopic "leverage effect" and "tunnel effect". ( ) to make the branches of superior mesenteric vessels more easily recognized. ( ) to offer surgeons an alternative route entering the trcs, ims and rrcs. ( ) to avoid repetitive flipping of the colon complying with the "no touch" principle, and to lower the requirements of assistants. figure : anatomy and surgical planes concerning cmapa. aim: we have reported a possibility of "one-stop shop" simulation for liver surgery by mri using gadoliniumethoxybenzyl-diethylenetriamine pentaacetic acid (eob-mri) (emerging technology, sages )., which is characterized by ( ) one-time examination, ( ) no-radiation exposure, ( ) demonstration of liver vasculatures including biliary tract, ( ) diagnosis of tumors, ( ) volumetry and ( ) estimation of liver functional reserve in each segment. the aim of this study is to investigate usefulness of "one-stop shop" simulation for liver surgery using eob-mri. methods: accuracy of liver vasculatures: d-reconstruction of dynamic eob-mri imaging was done by synapse vincent software (fujifilm medical co., ltd., japan), using a manual tracing method. visualization of hepatic vessels in eob-mri was compared with that in dynamic ct in patients. assessment of liver functional reserve: the standardized signal intensity (si) of each segment was calculated by si of each segment divided by si of the right erector spine muscle. the standardized total liver functional volume (tlfv) was calculated by ∑ [k= to ] (standardized si of segment (k) volume of segment (k)) divided by body surface area. the following formula of resection limit was established using normal liver cases ( % of the liver is resectable) and unresectable cirrhotic patients such as recipients of liver transplantation ( % of the liver is resectable). the estimated resection limit (%)= % (the standardized tlfv of the patient - )/ , . this formula was validated using other patients who underwent hepatectomy. results: accuracy of liver vasculatures: the liver simulation by eob-mri succeeded in demonstrating hepatic vasculatures including biliary tract, diagnosis of hepatic tumors, and volumetry without any radiation exposure. regarding the vessel anatomy at hilar area, biliary tract was more clearly visualized in eob-mri. regarding the hepatic artery, right and left hepatic arteries were well visualized in all cases, however, small-sized middle hepatic artery was visualized in only one out of patients. assessment of liver functional reserve: as a result of validation of the patients, one patient having resection volume with over the resection limit died of liver failure, however, the other cases within their resection limits did not suffer from liver failure. conclusion: "one-stop shop" liver surgery simulation could contribute to safety of liver surgery such as laparoscopic hepatectomy, because of no radiation exposure, accurate assessment of anatomical variations especially biliary tract, and helping decision making of resection volume. showing key steps of the procedure to be viewed. the in-studio program was hosted by an education specialist from the science center and a surgical resident from our institution, with laparoscopic instruments available for manipulation by participants. participants then viewed a video highlighting the roles of all healthcare providers involved in the specialty to be featured, including nurses, physicians, dietitians, psychologists, technologists, etc. live questions and answers were then encouraged between students and surgeons during the surgery broadcast. the program also expanded from high schools to vocational-technical colleges and nursing schools. results: during the - academic year there were sessions presented to schools, with student participants. by the - year this increased to sessions presented to schools, with participants. in sum, throughout the first years of the program, there were schools attending, with a total of , participants. of polled high school participants, % of responders acknowledged considering a career in healthcare after this experience. conclusion: over years, our program has grown steadily in popularity such that schools from several counties attend and regularly return, and we have been asked to expand the program to create a surgical summer camp for students interested in science and technology. live broadcast surgery in an elective, minimally invasive format provides unique visibility and access to surgical procedures for student audiences and promotes future interest in healthcare careers. surg endosc ( ) :s -s p improving trainees' self-assessment through gaze guidance introduction: effective learning to become competent in surgery depends on a trainee's ability to accurately recognize their strengths and weaknesses. however, a surgical trainee's self-assessment is poorly correlated with expert assessment. this study aimed to improve self-assessment by the visual gaze guidance provided through telestration in laparoscopic training. we hypothesized that visual conveyance of where to look or perform actions on the laparoscopic video enhances the trainees' awareness of the gaps in their skills and knowledge. methods and procedures: a lab-developed telestration system that enables the trainer to point or draw a free hand sketch over a laparoscopic video was used in the study (fig. ). seven surgical trainees ( surgical fellow, research fellow, pyg- and pyg- ) participated in a counterbalanced, within subjects controlled experiment, comparing standard guidance with telestration-supplemented guidance. the trainees performed four laparoscopic cholecystectomy tasks -mobilizing cystic duct and artery, clipping the duct, clipping the artery, and cutting the duct and artery, on a laparoscopic simulation. performance assessment, adapted from the global rating scale (grs) instrument, was completed by the trainers and trainees at the end of each task. the mean self-assessment scores were compared with the trainers' scores by the linear mixed model, where the trainees' performance indicated by the trainers' scores was control. the assessment alignment was evaluated by spearman's rho. results: the trainers' scores were significantly lower than the self-assessment scores in the standard guidance, while the scores of the trainers and trainees were much more similar (fig. ) . the correlation between the trainers' and trainees' assessment in telestration guidance was high (r= . , p. ), compared to the standard guidance (r= . , p= . ). the correlation comparison for each grs criterion shows a significant increase (p= . ) in the assessment alignment for depth perception in telestration guidance (r= . , p. ), compared to the standard guidance (r= . , p= . ) (fig. ) . the visual gaze guidance improved the alignment of assessment between the trainer and trainees, especially for the assessment alignment in depth perception. for visual gaze guidance to become an integrated part of the training, further work needs to be conducted to understand how gaze guidance change the nature of the training process. applying to surgical residency: what makes the best candidates? yann beaulieu, beng, louis guertin, md, frcsc, ariane p smith, md, margeret henri, md, frcsc, facs; university of montreal objective: while quotas for canadian surgical residency programs are at their lowest point in ten years, the number of canadian graduating medical students is at an apogee. this year, only spots in surgical residency programs were available for students applying to carms. undergraduate medical students individually collect anecdotal information regarding what influences admission to their surgical subspecialties of interest, as scarce literature covers the topic. we thus surveyed surgeons and residents to analyze the relative importance of modifiable factors and innate attributes in the selection of new surgical residents. methods: an electronic survey was sent to all surgeons and surgical residents affiliated with the university of montreal. participants were asked to specify their surgical subspecialty, their status, their level of experience and whether they were an active member of a residency selection committee. the subjective importance of predefined application elements and candidate qualities was assessed using -point likert-type items. results: of the surgeons and residents to whom the survey was sent, ( . %) and ( . %) completed the survey. evaluations of elective rotations and evaluations of core rotations were considered very important by . % and . % of responders respectively. regarding letters of recommendation, the content was rated very important ( . %) more often than the notoriety of the author ( . %). networking with key surgeons was considered the least important element to prioritize with % of negative assessments. with regards to the fundamental qualities of surgical candidates, the extremes were "clinical judgement" with . % and "innate technical ability" with . % of responders rating them very important. no significant differences in responses were observed between staffs and residents, between members and non-members of selection committees, between different levels of surgical experience and between surgical subspecialties. conclusion: clinical judgement and performance in core and elective rotations along with strong personalized letters of recommendation should be prioritized by medical students aiming for a surgical career. kazuhiko shinohara, phd, md; school of health science, tokyo university of technology background and objective: many types of training devices had been proposed since the early days of endoscopic surgery. however, they are too expensive for daily training of novices. we developed a simple and economical training device made of frozen fruit and agar. material and methods: to make this device, g of agar powder was added to ml of boiling water and boiled for min. the solution was then poured into a stainless steel tray containing frozen blueberries and lychees and refrigerated for h. basic maneuvers required during endoscopic dissection and resection of a tumor with laparoscopic forceps and electrosurgical devices were then performed using this agar model in a conventional laparoscopic training box. results: using this model, endoscopic dissection and enucleation of a tumor with an electrosurgical device could be practiced repeatedly with minimal expense and preparation. background: situs inversus totalis (sit) is a rare congenital anatomy and a challenging condition for laparoscopic surgeries because standardized strategy to overcome such anatomical difficulties. mirror-reversed video images of laparoscopic surgeries for patients with normal anatomy could help to develop surgical strategies for patients with sit. we had a chance to evaluate this idea with a treatment of a patient of early gastric cancer, and describe the surgical results of the case. patient and methods: seventy-two-year-old women with a history of sit was referred to our department for the treatment of early gastric cancer, and laparoscopic distal gastrectomy with d + lymphadenectomy was scheduled. a video record of the same surgery for a patient with similar physical attribute performed before then was retrieved, and was edited with a computer into full length, totally mirror-reversed images of the surgery. designated operator and assistant simulated the operation using the video several times before surgery. results: laparoscopic distal gastrectomy was performed with d + lymphadenectomy while the operator was on the left side of the patient and the assistant on the other side, being opposite positions as usual. laparoscopic b- reconstruction was followed using "delta anastomosis" technique reported by kanaya et al. total laparoscopic procedures were completed with the operation time of minutes and the blood loss below measurable limits. no appreciable complications were observed after surgery and the patient was discharged on postoperative day . no recurrence of the disease was detected until years after surgery, conclusion: although further validation is unlikely because of a rare incidence of this anatomy, the same technique would be recommended for one of the preoperative preparations for similar cases. background: surgical simulation is thought to provide a basis for improvement of resident surgical skill training, in the safety of a simulation setting. it is unclear whether surgical skills learned in a simulation curriculum actually contribute to the improvement of surgical skills when transferred to the or. methods: a ten question online survey was sent to attending surgeons and residents. the questionnaire focused on domains: confidence, independence, transferable skills, improvement of skills/knowledge and time spent on the simulation curriculum. evaluation data was collected and anonymously analyzed. background: minimally invasive surgery poses a unique learning curve due to the requirement for non-intuitive psychomotor skills. programmes such as the fundamentals of laparoscopic surgery (fls) provide mandatory training and certification for many residents. however, predictors of fls performance and retention remain to be described. this single-centre observational study aimed to assess for factors predicting the acquisition and retention of fls performance amongst a surgically naïve cohort. methods: laparoscopically naïve individuals were recruited consecutively from preclinical years of a medical university. participants completed five visuospatial and psychomotor tests followed by a questionnaire surveying demographics, extracurricular experiences and personality traits. individuals completed a baseline assessment of the five fls tasks evaluated by fls standards. subsequently, participants attended a -minute training-course over week one and two on inanimate box trainers. a post-training assessment was performed in week three to evaluate skill acquisition. participants were withdrawn from laparoscopic exposure and retested at four onemonth intervals to assess skill retention. introduction: bipolar energy can cause thermal injury to adjacent organs when used improperly. sages fuse curriculum provides didactic knowledge on principles and best practices for safety, but there is no hands-on component to practice these skills. the objective of this study is to compare the effectiveness of the vest™ bipolar training module in addition to the fuse curriculum. methods and procedures: the study was a mixed design with two groups, control and simulation. after a pre-test that assessed their baseline knowledge, the subjects were randomized to two groups. both groups were given a min presentation, reading materials from the fuse manual and an online didactic module on bipolar energy. the simulation group also practiced on the simulator for one session that consisted of five trials on the effect of activation time on thermal damage and the importance of providing a margin of safety by sealing short gastric vessels. after one week the performance of both groups was assessed using a post-questionnaire. one week after the post-test both groups performed sealing of vessels on an explanted porcine mesentery with vessels perfused. their performance was videotaped and their activation times were recorded. a total safety score was calculated by assessing the proximity of the location of activation to the intestine by two independent raters. wilcoxon -signed rank and mann-whitney u tests were used to assess difference within and between groups. results: a total of residents ( in each group) participated in this irb approved study. median test scores for both groups increased (simulation, p= . and control, p= . ). no difference was found between the two groups in their pre-test (p= . ) and post-test (p= . ) scores indicating learning. the median total activation time for control group was higher ( . s) compared to simulation ( . s) but was not statistically significant (p= . ). there was a moderate agreement between two raters for margin of safety (kappa= . , p. ). total safety scores showed no difference between the two groups (p= . ). conclusions: subjects with simulation training had lower activation time compared to control. training for margin of safety requires more simulation refinement. small sample size and variations in the explanted models contributed to variability in data but even with small sample size, simulation training along with the fuse curriculum trended towards being more beneficial than the fuse curriculum alone. the general, that aims to build educational infrastructure and standardize training and education in laparoscopy throughout mexico. ilap participants engage in didactic and hands-on modules in educational theory, laparoscopic techniques, and simulation based education (sbe), and then develop and implement a -day sbe course for local trainees. the purposes of this study were to understand the existing educational environment at a single institution in mexico and measure the changes in perceptions, attitudes, and engagement in surgical education after an intensive training course. methods and procedures: all faculty and of general surgery resident participants completed a survey that contained items designed to assess the existing educational environment at a large, public hospital in mexico. using a -point likert scale, residents self-rated the quality of faculty feedback and the learning environment within their institution ( =strongly disagree, = neutral, =strongly agree). faculty rated their perceptions of the same educational themes. upon completion of a faculty-lead simulation course, residents rated the educational environment during the course. faculty provided additional qualitative feedback. descriptive analyses were performed. irb-exemption was obtained through lurie children's hospital. results: discordance existed in perceptions of the existing educational environment. the greatest disparity between resident and faculty perceptions included "faculty provide sufficient feedback in the operating room" ( % vs. %), "faculty promote an active learning environment" ( % vs. %), and "residents may ask questions without fear of negative evaluation" ( % vs. %). faculty and residents agreed with "residents are sometimes afraid to speak up in the operating room for fear of retaliation" ( % each). post-course evaluations (n= ) revealed universal improvement in all educational themes during the simulation course. qualitative feedback revealed most faculty plan to incorporate open communication and safe learning into their practice. residents were equally positive, with % optimistic that they will see changes within the educational environment. conclusions: significant discordance exists in resident and faculty perceptions of the educational environment at a large teaching hospital in guadalajara, mexico. after participation in the ilap course, residents noted demonstrable change in the faculty approach to education and feedback, and both faculty and residents expressed optimism for increased engagement in education. the immediate successes of the ilap initiative should be followed over time, as the ultimate measure of success is sustainability and scalability throughout mexico. background: laparoscopic anterior resection is technically challenging and the learning curve is long. well-designed formative assessments can provide trainees effective and constructive feedback, an important element in efficient learning. previously reported assessments for laparoscopic colorectal procedures were developed for summative assessment. we aimed to develop a formative assessment tool to evaluate competence and provide trainees with effective feedback in laparoscopic anterior resection. methods: the assessment tool was developed by an expert panel from mcgill university affiliated hospitals. the procedure was deconstructed into a series of sequential steps including general domains, surgical principles, injury prevention and technical skills specific to laparoscopic anterior resection. the tool contains discrete items with global rating scales for each step of the operation; each domain was scored using a -point likert scale, with anchors for scores of , and . each operation was assessed through direct observation in the operating-room by the attending, a trained observer, and trainees themselves. intraclass correlation coefficients (iccs) were calculated to estimate interrater reliability for ( ) attending surgeon and trained observer, ( ) attending surgeon and self-assessment, and ( ) trained observer and self-assessment. internal consistency was measured using cronbach's alpha. comparison between training levels was done using mann-whitney u-test. the global operative assessment of laparoscopic skills (goals) was also used to assess trainees' general laproscopic skills. spearman's correlation was used to determine association between goals and this procedure-specific tool. overall usefulness of this tool was evaluated using a cm visual analog scale. results: in this pilot study, fourteen operations, performed by experienced surgeons and trainees were assessed. the icc between ( ) attending surgeon and observer was . ( % ci . to . ) ( ) observer and self-assessment was . ( % ci . to . ), and ( ) attending surgeon and self-assessment was . ( % ci - . to . ). the internal consistency of the items was excellent (cronbach's α= . ). there was a significant difference in median total score between experienced surgeons and trainees ( . ± . vs. . ± . ; p= . ). there was strong correlation (r= . ) between goals and this procedure-specific score. overall usefulness of this assessment tool was rated as . ± . . all assessments were completed in about minutes. conclusions: we present a new procedure-specific formative assessment tool for laparoscopic anterior resection and provide preliminary evidence of its reliability and validity. this formative assessment tool could be used for constructive feedback and tracking performance in competencybased surgical training. cullen introduction: one of the key challenges to the proliferation of endoscopic submucosal dissection (esd) in the west has been a lack of training platforms. therefore, the virtual endoluminal surgery simulator (vess) is being developed as a training tool for esd. the aim of our study is to inform the design of vess using cognitive task analysis (cta), which is a human factors engineering framework to describe practitioners' mental models and cognitive processes and incorporate insights into the simulator's design. methods and procedures: cta-based interview questions were developed to probe the cognitive challenges and strategies employed at each stage of the esd procedure. six esd practitioners were interviewed for varying lengths of time. two of these interviews were conducted simultaneously during an observation of a training workshop where the cta participants were instructors (total observation time was five hours, and interview time was * minutes). another interview was conducted during observation of esd procedures (total observation time was hours, and interview time was * minutes). participants had varying levels of experience in esd, with of them being 'super-experts' (exclusively esd exponents), an 'expert' and a fellow. a cta of the data is currently being conducted to systematically inform design of functionalities in the simulator. results: analysis of our data highlights a few prominent themes at each stage of esd: goals, challenges (e.g., avoiding perforation of muscularis); points of decision-making (e.g., partial or full incision for boundary demarcation); skills involved (e.g., dissection); and ambiguity (e.g., unclear lesion boundaries). participants also described risks associated with each stage of esd and strategies to prevent or overcome the same. conclusions: qualitative data for a cta were collected through observations and interviews of esd practitioners. preliminary analysis has indicated prominent themes to consider in the design of the training simulator. the next step in the study is to conduct a full-scale cta of esd based on the current data. the ultimate benefit of the cta would be to incorporate the results into informing the design of vess in a way that is compatible with the mental models of esd trainees, thus enhancing the fidelity and effectiveness of the simulator. background: colonoscopy is an important diagnostic and therapeutic procedure in the management of colonic disease; achieving competence during residency is an integral part of performing high-quality colonoscopy in-practice, regardless of specialty. there is debate and controversy however, regarding what, if any, number of procedures achieves said proficiency. furthermore, there is significant heterogeneity in the current guidelines and studies published to-date on the definition of competence in colonoscopy. objective: to determine individualized learning curves as an alternative to 'number of procedures' for assessing colonoscopy competence. methods and procedures: this is a multi-institutional prospective cohort study involving eleven surgical trainees (novice endoscopists). the main outcome, colonoscopy competence, was assessed by determining the independent colonoscopy completion rate (iccr), the number of procedures required to reach % independent colonoscopy completion and polyp detection rate. individual and overall iccr were calculated using moving average analysis. conclusions: while a benchmark for a minimum number of procedures may be necessary to allow supervisors to adequately assess performance, it is difficult to determine what number is optimal. there appears to be significant heterogeneity in both overall number of colonoscopies completed by each resident, as well as the mean iccr and the number of procedures required to reach the current benchmark for competency. the use of learning curves allows real-time tracking of progress and training tailored to the individual, as we move forward in the era of competency-based medical education. background: with the growing popularity of robotic-assisted surgery, new methods for evaluation of technical skill are necessary to determine when a surgeon is qualified to perform an operation independently. current evaluation methods are limited to point likert scales which require a degree of subjective scoring. surgeons in training need an objective method of evaluation to view progress and target areas for improvement. one method of objectively evaluating surgical performance is a cumulative sum control chart (cusum). by plotting consecutive operative outcomes on a cusum chart, surgeons can view their learning curve for a given task. another method of objective evaluation is the dv logger®, or "black box," which records objective measurements directly from the da vinci® system. methods: we followed two hpb fellows during dry lab simulation of robotic-assisted hepaticojejunostomy reconstructions using biotissues to model a portion of a whipple procedure. we simultaneously recorded objective measurements of dexterity from the da vinci® system and performed cusum analyses for each procedural step. we modeled each variable using machine learning (a self-correcting and autoregressive modeling tool) to reflect the fellows' learning curves for each task. statistically significant objective variables were then combined into a single formula to create an operative robotic index (ori). results: variables that significantly improved over the course of the simulation included completion time (p= . ), economy of motion in arm (p= . ), number of times head was removed from the console (p= . ), total time left master manipulator was active (p= . ), total time right master manipulator was active (p. ), and total time that any arm was active (p\ . ). the inflection points of our cusum charts and plots of objective variables both showed improvement in technical performance beginning between trials and [ fig. and fig. ]. the operative robotic index showed a strong fit to our observed data and improved with additional trials (r = . ). [ figure ]. conclusions: in this study we identified objective variables recorded by the da vinci® system which correlated with the technical dexterity of fellows during a robotics dry lab. we broke a complex procedure down in stepwise fashion with cusum analyses to determine targets for improvement. using variables which correlated with the improved performance of the fellows, we effectively modeled the learning curve with the creation of an operative robotics index (ori). this study successfully models the learning curve of novice robotic surgeons using a novel combination of objective measures. georg wiese, md, paula veldhuis, steve eubanks, md, facs, scott w bloom, md, frcsc, facs; florida hospital institute for surgical advancement introduction: robotic surgery is a specialized skill which requires time and resources to master. in a general surgery residency program that seeks to train competent surgeons in both open, laparoscopic and endoscopic techniques it is difficult to see where adding robotic training will be of benefit and at what cost this will be to the remaining surgical skills. we therefore sought to ascertain robotic surgery's current role in the training of new general surgeons by soliciting the opinions of current general surgery program directors on the role of robotic surgery at their respective institutions. methods: an irb approved survey was created and sent to general surgery program directors across the country to assess how robotic surgery training is being integrated into current surgical training. the survey was sent via email to publicly available email addresses from the acgme website of program directors. it was voluntary in nature and consisted of questions regarding current status of robotic training in residency as well as future goals. results: overall response from our pd survey were at % of the surgical programs with addresses available via acgme, though responses continue to be submitted at the time of this abstract. approximately % of all respondents are from independent, university based programs. % felt that robotics was an emerging skillset important for residents to master versus % feeling that it was more appropriate for fellowship. all respondents noted that robotic surgeons were present at their institution, % within the core faculty, and % indicated that they were actively recruiting robotically trained surgeons. additionally, % of programs indicated that residents were exposed to robotic surgery, % of these on core general surgery rotations. % of respondents indicated that they had a formal robotic training curriculum with % of programs taking measures to integrate robotics into the future curriculum though % lacked specific milestones for such training. finally, opinion was evenly divided among respondents as to whether one could sign off on residents to perform robotic assisted cases upon completion of pgy year with % agreeing with that statement and the remainder indicating some additional training would be necessary. conclusions: our study highlights the emerging field of robotic assisted mis surgery and its increasing role in residency training. it is evident from the data, that robotic surgery is a growing part of residency experience. importantly, however, milestones were significantly lacking for determining resident progress in robotic training. introduction: in chile, medical students have the opportunity to undertake a month-long medicine elective (me) in a community hospital, primary care center or emergency department within the country at the end of their first clinical year. due to the lack of opportunities to practice suturing in the first years, students usually do not have an optimal performance in this type of medical procedure during the me. simulation training programs in suturing improve technical skills, selfconfidence and patient safety in the medical internship. the objective of this study is to evaluate the impact of implementing a simulated suture training program earlier in the medical curriculum, before the me. methods: we conducted a prospective, randomized controlled trial with medical students at the end of their first clinical year. they were randomized into two equal groups. the intervention group received an intensive suture training program consisting in one theory class, four practical sessions and effective feedback from an expert surgeon. the control group did not receive training, remaining with the classic opportunistic learning approach during the me. after the me, all students undertook an electronic survey. statistical analysis was performed on the answers of both groups. per protocol analysis was applied. results: there were no statistical differences between groups in terms of age and sex. four students did not complete the training program. one student in the control group did not reply to the survey. higher self-confidence with regards to suturing was reported in the intervention group in comparison with the control group [ / ( %) vs / ( %), p, ]. also, a greater student desire to carry out suture-related procedures was reported in the intervention group than the control group [ / ( %) vs / ( %), p, ]. in addition, a lower rate of overseeing physician intervention was reported in the intervention group [ / ( %) vs / ( %), p, ] ( table ) . a greater number of patients requiring sutures were treated by the intervention group than the control group, with a median of patients ( - ) against ( ) ( ) ( ) ( ) . the intervention group performed a higher number of sutures with a median of ( - ) vs ( - ), with a statistically significant difference (p, ) in both cases (fig. ) . conclusion: a simulated suture training program prior to the me generates a positive impact on medical students by improving self-confidence and desire to attend patients that require sutures. this leads to a higher rate of both exposure to suture techniques and suture execution. introduction: measuring performance in the operating room (or) is challenging. performance is a multifaceted construct a complex interaction of many behaviors and actions that reflect an individual's knowledge and skill. no assessment tool to date provides an expertise-based, comprehensive evaluation of the various aptitudes necessary to excel in the or, especially with respect to advanced cognitive skills. using qualitative methodologies, we previously defined behavioral themes that guide surgeons' behaviors, decisions, and actions, within a universal framework of domains that reflect intra-operative performance. the purpose of this pilot study was to use this framework to derive a comprehensive assessment tool and to obtain evidence for its validity as a measure of intra-operative performance. methods: an assessment tool was developed by a panel of surgeons and surgical trainees based on the five-domain model of intra-operative performance: ) psychomotor skills; ) declarative knowledge; ) interpersonal skills (two items); ) personal resourcefulness, and ) advanced cognitive skills (ten items). all items were rated on an ordinal scale of (inadequate) to (expert) and equally weighted. surgical residents and surgeons from a single academic center were evaluated on their performance during standard general surgery operations, for example, open inguinal hernia repair and laparoscopic cholecystectomy. for residents, there were evaluators -the attending surgeon and an observing surgeon. attending surgeons evaluated their own performances and were also assessed by observing surgeons. internal consistency, inter-rater reliability, and correlation of total scores with training level (junior residents, senior residents, staff surgeons) were calculated. likert scale questionnaires were administered to evaluate the tool's usability, feasibility, and educational value. results: fifteen subjects ( junior residents, senior residents, surgeons) participated. the total score on the assessment demonstrated significant differences between training levels ( figure) . inter-rater reliability was high (interclass correlation coefficient= . ), as were internal consistency between each domain score (cronbach's alpha= . ), internal consistency amongst items in the advanced cognitive skill domain (cronbach's alpha= . ), and internal consistency amongst items in the interpersonal skills domain (cronbach's alpha= . ). all assessments required less than five minutes to complete. overall, evaluators agreed that the assessment tool was easy to use, was comprehensive, and should be used routinely throughout training to track performance and provide formative feedback. conclusion: in this pilot study, we developed a comprehensive assessment tool for intra-operative performance and provide preliminary validity evidence for the score. surg endosc ( ) introduction: the purpose of this study was to evaluate the validity of our developed system for assessing suturing skills in laparoscopic surgery (fig. ) . we have updated numbers of participants and a comparison method compared with the last year report. methods and procedures: fig. shows our developed computerized system for objective assessment of suturing skills by using a laparoscopic intestinal suturing model, e-lap. the system includes a new artificial intestinal model that mimics living tissue and pressure-measuring and image-processing devices. each examinee performs a specific skill using the artificial model, which is linked to a suture simulator instruction evaluation unit. the model uses internal air pressure measurements and image processing to evaluate suturing skills. five criteria, scored on a five-grade scale, were used to evaluate participants' skills ( fig. ) . the volume of air pressure leak was determined by the volume of air inside the sutured artificial intestine. for example, for the criterion "air pressure leakage", the approximate midpoint of the acceptable range was grade . values lower than the minimum acceptable value received lower grades and those above the midpoint of the acceptable range higher grades. we enrolled surgeons who participated a simulator competition event at the th annual meeting of the japan society for endoscopic surgery (jses houston methodist hosptial, baylor college of medicine introduction: the sages flexible endoscopy course for minimally-invasive surgery (mis) fellows has been shown to improve confidence and skills in performing gi endoscopy. this study evaluated the long-term retention of these confidence levels and investigated how fellows have changed practices within their fellowships as a result of the course. methods: participating mis fellows completed surveys six months after the course. respondents rated their confidence to independently perform sixteen endoscopic procedures ( =not at all; =very). while the pre-and post-course surveys identified anticipated endoscopy uses and barriers to use, the -month follow-up survey evaluated actual usage and barriers to use in each fellow's practice. respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (fes) certification. comparison of responses from the immediate postcourse survey to the -month follow-up survey were examined. mcnemar and paired t-tests were used for analyses. results: twenty-three of ( %) course participants returned the -month survey. % had passed the fes skills examination and % had attended another flexible endoscopy course. no major barriers to endoscopy use were identified. in fact, fellows reported less competition with gi providers as a barrier to practice compared to their original post-course expectations ( % versus %, p. ). in addition, confidence was maintained in performing the majority of the endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (− %; p. ), control of variceal bleeding (− %; p. ), colonic stenting (− %; p. ), barrx (− %; p. ), and tif (− %; p. ). fewer fellows used the gi suite to manage surgical problems than was anticipated post course ( % versus %, p. ). fellows without fes certification reported loss in confidence to independently perform barrx (− %; p. ) and colonic stenting (− %; p. ), and also a % decrease in the use of gi suite to manage surgical problems (p. ) fellows who passed fes noted no significant loss of independence, changes in use, or barriers to use. % of fellows made additional partnerships with industry after the course. % stated flexible endoscopy has influenced their post-fellowship job choice. % would recommend the course to other fellows. the sages flexible endoscopy course for mis fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures six months later, and over % reporting that flexible endoscopy influenced their career choice. additionally, fellows experienced no major barriers to implementing endoscopy into practice. the materials and methods: at our center, we formulated a laparoscopic mentorship program where a senior consultant was paired with a particular trainee resident for a period of weeks. consultants & residents were a part of the study. the or schedules were rearranged to accommodate these pairs. an evaluation of the residents' views was performed prior to the study and once at its completion, using a simple questionnaire with each parameter scored between & . results and discussion: continuous, consistent evaluation by a consultant over an extended period of time allowed them to assess their assigned resident's laparoscopic skill set. all pairs observed an increased frequency of errors being noticed & improved upon. the consultants stressed upon shedding undesirable operative habits. there was a significant improvement in residents' scores at the end of the short study. conclusion: we found that the short-term mentorship program was easy to incorporate within our or schedule and was well received by the participants. continuous short rotations under senior consultants appear to allow residents to not only fully observe and imbibe correct operative techniques, but also helps shed unfavorable habits. we are currently amid the second cycle of our study & looking forward to the results at the end of this academic year. introduction: colorectal cancer is one of the most common cancers in the united states. endoscopic submucosal dissection (esd) is an emerging minimally invasive technique that allows complete en-bloc resection and a much lower recurrence rate at long-term follow-ups. however, performing colorectal esd is technically demanding since the colorectal wall is thin and constantly moving, and potentially higher rates of complications (e.g., bleeding and perforations). hence, an adequate training for colorectal esd is needed to acquire basic proficiency with minimum complications. objectives: a virtual reality (vr)-based simulator with visual and haptic feedback for training in colorectal esd is being developed, which the aim to allow trainees to attain competence in a controlled environment with no risk to patients. in this work, a newly developed application of the virtual simulator that promotes the endoscopists to perform and assess technical skills in esd is developed. training tasks are built based on physics-based computational models of human anatomy with tumors. methods: the main modules of the vr-based simulator for colorectal esd involve: ( ) rendering; ( ) haptic interface; ( ) physics-based simulation; and ( ) performance recording and assessment metrics. the rendering engine allows surgical tasks to be performed in the three-dimensional virtual environment. haptic feedback mechanisms allow users to physically feel the interaction forces. physics-based simulation technologies are employed to enable the complicated simulation for performing virtual surgical tool-tissue interactions. the simulator can also collect learners' performance data to offer feedback based on the built-in metrics. results: four training tasks involving marking, injection solution, circumferential cutting, and submucosal dissection are designed to practice skills with different surgical tools. the marking task aims to identify the lesion. the injection solution task minimizes the risk of bleeding and perforation to protect the muscularis. in the circumferential cutting task, the objective is initial incision of the lesion with the surgical tools. the objective of the dissection task is to remove the tumor from the connective tissue of the submucosa under the lesion. conclusions: the vr-based simulator enables realistic esd tasks to provide a possibility for developing, validating and objectively evaluating the performance metrics in colorectal esd training, and offers an opportunity to rise up the learning curve before application to patients. background: the virtual translumenal endoscopic surgery trainer (vtest) simulator is a virtual reality system that was designed to train the hybrid-notes technique. transfer of skill acquired while training on the vtest was measured in a near-real cholecystectomy procedure staged in the easie-r model. methods: sixteen medical students were divided randomly and evenly into groups: control, training. all subjects performed the cholecystectomy procedure on the vtest simulator to establish a baseline (pre-test). the training group received training sessions, over a period of consecutive weeks, consisting of trials per session or as many trials as can be accomplished in one hour, whichever was achieved first. at the end of the training period, all subjects performed one trial on the vtest simulator (post-test), and again to weeks later (retention test). two months after that, subjects performed the hybrid-notes cholecystectomy procedure on an easie-r model. performance with the easie-r simulator was video-recorded, and three tasks within the cholecystectomy procedure were isolated for evaluation: clipping, cutting, and dissecting the gallbladder. objective performance measures, such as time and error, were extracted from the videos by two independent reviewers, while subjective performance was scored by four expert surgeons who were blinded to the training conditions. expert reviewers used a modified version of the operative performance rating system by the american board of surgery and the objective structured assessment of technical skills (osats) tool. results: there was no difference in task completion time between the control and training groups, (t( )= . , p =. ) in the cutting and clipping tasks. however, there was a significant difference in the number of errors, t( )=- . , p=. . there was no difference in subjective performance between the training groups for the clipping and cutting tasks. in the gallbladder dissection task, however, there was a statistical significance in "instrument handling" based on one of the surgeons' ratings (t( )= . , p=. ), and a statistical significance in "time and motion" based on another surgeon's rating (t( )= . , p=. ). conclusions: results indicate that weeks of training on the vtest simulator did not allow the subjects to transfer their learned skills equally to the near-real environment, even though they retained the skills when tested for retention. this new insight suggests that modification of the training method for different types of surgical skills may be warranted to optimize their transfer to the real environment. examining conclusions: this study provides evidence to suggest that for bariatric surgeons, experience and skills acquired in performing non-bariatric surgery may not translate to improved outcomes in bariatric surgery. as seen in this study, improvement in bariatric surgical outcomes is likely more dependent on experience specifically performing bariatric procedures. as there may be no benefit acquired from performing surrogate procedures, this may have implications in the design of subspecialty training programs and for accreditation purposes. . a universally adjustable cellphone holder was used where smartphones could be placed inside the fls box in order to capture the task from a similar angle as the onboard camera. residents were able to use their own smartphones to record their performance on each of the five fls tasks in high definition (hd) quality. after each practicing session, they would upload their videos to a designated folder on a password-protected computer in the simulation lab. this folder was linked to a cloud-based storage system that fls instructor had exclusive access. the faculty was able to review each video in the next hours and provide immediate feedback to the residents via email, over the phone or in-person. the video library of performance also allowed the instructor to track the progress of the residents and whether they reached proficiency level in all five tasks to take the fls examination. this program was offered to all surgical trainees. results: utilization of simulation lab to practice fls tasks increased significantly across all postgraduate years after implementation of this model. six residents took the fls examination. the passing rate of the residents remained the same ( % before and after) but their scores in fls manual skills improved significantly compared to the group prior to implementation. the residents evaluated this change positively and reported that the use of videos and immediate feedback by faculty was a valuable intervention in their learning experience. conclusions: the smartphone cameras are readily available and can be used for telementoring. incorporation of telementoring in standard proficiency based fls training can promote self-directed learning and improve the access to experts for immediate feedback as a crucial element of effective training in acquisition of laparoscopic skills. background: it is important that making individual procedures a language, and an objective qualitative evaluation for the laproscopic training. recently, task training and the sham operation using the virtual simulator are carried out for medical students as the basic laparoscopic maneuver training, but there are few reports of objective qualitative evaluation for the training. in this study, we investigated rubric evaluation as the qualitative evaluation for laparoscopic training. materials and methods: one hundred and six students in th grade of tokushima univ. were participated. basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator were performed. task execution time and rubric evaluation which includes the evaluation standard that became a language for each maneuver were performed before and after basic task training and sham operation. the group who are bad at laparoscopic maneuver was decided by time exceeded in tasks more than two from before practice. relationship between the group who are bad at laparoscopic maneuver and the group which self-evaluation was higher in a rubric evaluation was investigated. results: in basic task training, average task execution time in all students was shortened after practice compared with before practice, but investigated individual, students exceeded in more than two tasks. rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, all students and tutor showed high score by rubric evaluation after practice compared with before practice. some students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. students who showed high score by self-evaluation in many maneuver of sham laparoscopic cholecystectomy also exceeded in more than two basic tasks. conclusions: as rubric evaluation showed the point of the maneuver is made a language definitely, it was useful for an objective qualitative evaluation for laparoscopic training. pre introduction: bariatric surgery candidates have the opportunity to research bariatric surgeons and hospitals prior to scheduling their elective surgery. pre-operative information sessions are important tools for bariatric surgeons to provide patient education while increasing their patient population. online education is becoming increasingly popular, but its utility over in-person education is uncertain. our objective was to compare patients attending the two most commonly used educational formats: online (webinars) and in-person (seminars) and determine which were more likely to undergo bariatric surgery. methods: we conducted a retrospective cohort study of , patients who attended pre-operative information sessions from january to december by reviewing data maintained by the obesity, prevention, policy and management (oppm) database from our institution. the patients were divided into two groups: those who attended an in-person session (n= ) and those who attended an online session (n= , ). the proportion of patients who went on to have bariatric surgery was compared between the two groups. to categorize the study sample, patient demographics, surgeon providing the information session, and procedure performed were compared between groups. multivariate logistic regression model was applied to compare the effectiveness of in-person session and online session. results: of , patients analyzed, % attended online information sessions ( % female, mean age ). the remaining % attended in-person information sessions ( % female, mean age ). analysis found that . % of patients who attended online information sessions went on to have a bariatric surgical procedure, while . % of patients who attended in-person sessions went on to have a bariatric surgical procedure. after controlling for differences in age and gender, results of multivariate logistic regression analysis indicate that patients who attended inperson sessions were % more likely to have a bariatric surgical procedure than patients who attended an online session ( introduction: knot security is the ability of knots to resist slippage as force is applied, and the optimal number of throws to ensure a secure knot improves efficiency and outcome. the literature on the accepted number of throws per type of suture material has been largely anecdotal, often referring to throws for silk, for polyglactin (vicryl), five for polydioxanone (pds), and six for polyproprolene (prolene). we report a pilot knot-tying study of four suture types to determine optimal numbers of throws. materials and methods: four senior general surgery residents (pgy- and above) and four attending surgeons participated. participants viewed a standardized instructional video and a one-handed knot-tying tutorial. they were instructed to tie one-handed knots, beginning each knot with two throws in the same direction, and square the third and subsequent throws in the opposite direction. each surgeon tied knots, using differenttypes of - suture material: silk, polyglactin, polydioxanone, and polyproprolene. suture types were evaluated using , , , or throws. the participants were randomized to both suture type and order of throw numbers. the knots were then tested on the f.a.s. t knot tester (sawbones, vashon island, wa) for slippage (insecure knot) or breakage (secure knot). generalized estimating equation (gee) analysis was used to determine optimal throw number. results: knots were individually tested on the knot tester for slippage and recorded as % slipped (see table) . the percentage of slipped knots varied by participant and ranged from to %. generalized estimating equation analysis suggested that the only significant variable when determining knot security was number of throws (p= . ), not suture type or participant training level. the optimal number of throws for - silk, polydioxanone, and polypropylene was five, whereas six throws was optimal for polyglactin. conclusion: knot security is dependent on the number of throws placed, and these optimal numbers were higher in our study than the commonly accepted number of throws. evaluation of take introduction: laparoscopic skills can be learned using portable simulators and these skills are transferrable to the operating room. several training regions within the uk have therefore developed and delivered home-based laparoscopic training programmes for junior surgical trainees. although performance improved in some, overall engagement has been poor. similar results have been observed in north america. the aim of our study was to uncover the reasons for poor engagement with home-based simulation with a view to developing a future, more successful, programme. methods: this was a qualitative study utilising focus groups. interviews were undertaken with key stakeholders involved in various laparoscopic home-based simulation programmes through the uk. training equipment comprised the eosim portable simulator paired with online training tasks. the tasks were similar to those used in the fundamentals of laparoscopic surgery programme (fls). basic metric feedback was provided (eg time to complete task). a total of individuals were interviewed, including surgical trainees, consultant trainers, training directors and programme faculty. this generated approximately hours of data which was coded using nvivo software. a basic thematic analysis was performed. results: trainees cited multiple competing professional commitments as a barrier to engaging with home-based simulation. they tended to focus on scoring 'points' which contributed toward career progression rather than tasks which were interesting, or associated with personal development. this approach is perpetuated by the surgical training system, which rewards trainees with points for publications and exams, but not for operative skill. this leads to conflict between trainers and trainees, the former expecting trainees to instead focus upon developing their technical abilities. trainees were unsatisfied with metric feedback and wanted individual feedback from consultant trainers (attending equivalent). trainees generally perceived consultants as lacking interest toward the programmes and training in general. however, some consultants were in fact unaware of the programmes being delivered and others felt lacking in confidence to deliver necessary training to trainees. conclusions: our findings are widely generalizable and have implications for any institution delivering a similar programme. as a means of improving engagement, the the inception of scheduled simulation study days, providing trainees with the opportunity for personalised feedback from consultants, has been suggested. equipping trainers with the necessary competencies to deliver training can be achieved by ensuring attendance at the necessary professional development courses. tackling the 'box ticking' culture is more challenging and may involve a move toward restructuring the current surgical training scheme. introduction: to provide evidence for the face and content validity of a hybrid active-shooter team training simulation and the impact of a hybrid curricular model on learner's engagement and performance. the following study was conducted because hospitals are increasingly threatened by active-shooter incidents, and no active and noticeable training is currently available to train hospital staff members. methods: thirty-five volunteers (medical students, residents and other allied health providers) from the university of minnesota affiliated medical centers were randomly selected and divided into control and experimental groups. the control group (n= ) was given a traditional lecture-style presentation. the experimental group (n= ) participated in the hybrid curriculum which included augmented reality, kinesthetic simulation, and debriefing components. following both curriculum styles, nasa task load index (tlx) surveys were completed by each group member. a final active shooter simulation experience was presented and evaluated by active-shooter trained raters using a checklist of critical actions from the department of defense. a post-simulation nasa tlx survey and post-test were provided. to assess face and content validation of a hybrid team-training simulation exercise to prepare healthcare personnel in the event of a hospital-related active-shooter crisis, a -point likert-scale survey determined the realism, utility, and applicability of this type of training while engagement and performance during the simulation were measured using a nasa-tlx survey and contrasted with the rater's evaluation. our study provided evidence to support the face and content validation of an active-shooter simulation team training curriculum as a useful adjunct to health care institutional safety planning. we demonstrated that this type of training requires an optimal level of cognitive activation to increases learner's engagement and performance. we concluded that the hybrid design of our curriculum was successful in delivering these optimal levels of cognitive stimuli by producing engaging team training simulation experience capable of motivating our learners to acquire the tactical skills and life-preserving behaviors consistent with better survival opportunities during a hospital related active-shooter crisis. the introduction: the virtual electrosurgical skill trainer (vest) provides surgeons and trainees with a hands-on approach to learning the best practices in electrosurgery. it is comprised of five modules covering tissue effects, stray currents, bipolar tools, monopolar tools and or fire safety. the module in this study teaches the origins of stray currents and shows the learner how they can cause damage to non-target tissues via direct and capacitive coupling. the aim of this study was to assess learning using the vest system. methods: the irb approved study followed a single group pretest-posttest design and was conducted at the sages learning center. thirty-eight subjects participated and out of these, % were attending surgeons while the rest were medical students, residents and fellows. % of subjects had prior fuse exposure, while the remaining had none. subjects were asked to complete a five-question multiple choice questionnaire before and after using the simulator. it assessed their knowledge in topics such as direct coupling, capacitive coupling and insulation failure. participants then used the simulator to complete three tasks. first, the subject used direct coupling to seal a vessel and observed the desired effects and potential pitfalls. in the second task the subject was immersed inside the peritoneal cavity and was directed to use the active electrode to observe how the activation of energy can cause capacitive coupling. in the third task the subject practiced evaluating the insulation of electrosurgical tools for defects. wilcoxon's signed rank test was used to differentiate between pre-and post-test scores, and the mann-whitney u test was used to differentiate between the groups of subjects as a function of fuse experience. results: the median score on the pre-simulator assessment was % and the post-simulator median score was % (p = . ). there was no statistically significant difference in pre-assessment scores between attending surgeons and the others (p= . ). subjects with prior fuse exposure scored significantly higher on the pre-module assessment compared to those that had no prior fuse exposure ( % vs %, p= . ). in the post-assessment their median scores were % and %, respectively (p= . ). conclusions: the vest simulator module successfully increased the overall participants' knowledge of coupling in electrosurgery regardless of level of surgical experience. participants with prior exposure to the fuse curriculum had increased knowledge on this topic at baseline as compared to participants without any fuse exposure. introduction: the objective of this study was to assess the reliability of a modified notechs rating scale for the evaluation of medical students' non-technical (nt) skills. the importance of physician nt skills for the safe care of patients is receiving increasing attention in the literature. tools to assess nt skills such as notechs that addresses communication, situation awareness, cooperation, leadership, and decision-making have been shown to be valid and reliable. despite its importance, the assessment of nt skills of medical students, our future physicians, has received little attention. methods and procedures: twenty-seven medical students participated in of acute care simulated scenarios, each approximately minutes long. video recordings of student performance were reviewed and assessed using a modified notechs rating tool adapted for these scenarios with input from a team of clinicians, nurses, and human factors specialists. the rating scale ranged from to , representing very problematic behavior (e.g., not vocalizing concerns or decision process) and representing model behavior (e.g., identifies future problems and remains calm to unexpected events). two reviewers rated all videos independently on the notechs domains and specific subscales. student scores in each nt skill domain and interrater reliability were assessed. results: a summary of the scores of each notechs domain is shown in table . the highest overall average score of a participant was . while the lowest was . . the intra-class correlation (icc; two-way random model) was . , and the cronbach's α coefficient was [ . . the lowest icc agreement was in the situation awareness domain ( . ) while the highest agreement was in leadership ( . ). conclusion: medical student nt skills during acute care simulated scenarios vary significantly using a modified notechs assessment. this newly developed tool provides a framework for educators to evaluate medical students' nt skills during simulation training. it further identified domains where students scored lower, such as situation awareness, and could be targeted for education. the moderate icc, between the . - . range, shows that further refinement of the tool is needed to reliably assess the constructs. future steps to obtain validity evidence include additional raters and applying the tool in non-simulated settings. introduction: a general misperception of the real concept of robotic surgery seems to be revealed in our clinical practice. despite its introduction almost years ago, robotic surgery is still related to many myths and beliefs. before designing a trial to see if these false awareness could impact on outcome, we measured this misperception by a survey. moreover we tested if medical school is able today to give to the future doctors a necessary knowledge about robotic surgery. with the same survey we explore the feelings about the introduction of the artificial intelligence in medicine and the perception of the consequences of a larger use of technology in medicine. methods and procedures: a multiple choice survey was designed and anonymously administered via the platform surveymonkey (http://www.surveymonkey.com). a total of questions were selected from the research team and included in the survey. the questionnaire was divided in three parts: the first was to get information on participants' population; the second asked specific questions about robotic surgery; the third focused on technology use in medical education. results: we received and analyzed questionnaires, of which totally filled. many undergraduates consider robotic surgery as "experimental", will prefer open surgery on themselves and see a risk for robotic surgery in damaging the patient-surgeon relationship. this situation is better for medical students, but still a great diffidence were encountered. % of ug consider robotic surgery as "experimental" vs only . % of ms (q ). most thought robotic surgery had been used for only years or less (q ). . % of ug and . % of ms gave the right answer (p=. ). almost % of ug see robotic surgery as a risk in damaging the patient-surgeon relationship. this is not seen among ms (q ) (p=. ). % of ug are fearful of robots used to operate them. this fear is significantly reduced among medical students (p=. ). ug were less familiar with the indications and uses for robotics. ms gave a correct response more frequently (q , . % vs . %, p= . ). conclusions: our results indicates that nowadays, the robotic surgery is related a lot of misperceptions and a generally low level of information. this general picture is partially mitigated during the medical school, but the level of knowledge is still low. a big effort seems mandatory in clarify every technical aspect and an ethic debate about robotics, technology and ai as part of medical curriculum is advisable. background: learning theory states that a certain level of physiological stress or cognitive activation is required to achieve optimal task engagement and performance by the learners. our study will seek to determine if a hybrid team training curriculum inclusive of a task-oriented interactive virtual environment could help achieve the optimal level of cognitive activation required to result in a higher task engagement and performance. methods: a total of thirty-five medical professionals from the university of minnesota participated in several team training simulations. participants were randomly selected to an experimental and control groups. the experimental group (n= ) was exposed to a hybrid team training module, consisting of a task-oriented augmented reality phase followed by a second and third phase consisting of a kinesthetic simulation scenario and debriefing, respectively. the augmented reality phase presented the trainees to an interactive -degree image of the same clinical room where the simulation would take place allowing for ''situated-learning'' to take place. during the learning phase, trainees were encouraged to interact and communicate with each other while completing the tasks allowing for ''social-learning'' to effect. the control group (n= ), educational component consisted of a traditional audiovisual lecture-style introductory presentation, a simulation, and debriefing. after completing their respective educational components, each group completed a nasa task load index survey to assess the cognitive load experience of the individual educational models. subjects were then exposed to a final simulation (test simulation) similar in content and structure to the initial simulation. this was followed by a second nasa tlx survey. raters evaluated both group level of engagement and performance using a validated checklist of critical actions. results: the experimental groups showed higher weighted overall nasa cognitive load index scores than the control group (p= . ) prior to the test simulation. the weighted nasa score remained elevated in the experimental participant groups following the test simulation, whereas in the control group the post-simulation nasa assessment revealed a decrease in cognitive load (p= . ). expert raters using a validated checklist determined that . ± . % of the experimental (hybrid curriculum) group and . ± . % of the control group appeared to be more engaged and performed better during the simulation. conclusions: pre-simulation task-oriented augmented reality learning environments designed to incorporate situated, and social learning virtual experiences can provide the optimal level of cognitive boost that can result in a higher participant engagement and performance during team training simulation scenarios. introduction: despite the huge importance of laparoscopy, medical students have a brief contact with this surgical specialty during medical school in brazil. usually, they get in touch with this specialty during the surgery clerkship in the last years of medical school. therefore, few students perform clinical research or develop interest for this area during graduation. objective: to awaken the interest in laparoscopy of medical students early in medical school, improving the development of clinical research projects, and to prepare new generations of minimally invasive surgeons. discussion: the academic league of videolaparoscopy was created in under the guidance of dr. gustavo carvalho from the university of pernambuco, brazil. an academic league is a group of medical students who are guided by a tutor to develop three areas: research, teaching, and clinical practice. every year new students join the league after being selected with a multiple question test and an analysis of the curriculum vitae. the students are stimulated to participate in laparoscopic procedures as observers, learning about the techniques and instruments. moreover, there are minimally invasive surgery lectures and courses during the year. general surgery residents can also be part of the program as tutors. they are encouraged to present lectures, and to assist with research projects. medical students participated of this program in years. % pursued a surgical specialty after graduation. % did minimally invasive surgery as a fellowship. conclusions: the students who participate in several activities provided by the league have an increased interest in pursuing the path to become a laparoscopic surgeon. background: surgical education is an active and adaptive process of developing knowledge, technical and non-technical skills. the rise of social media has created a paradigm shift in surgical education, with online learning platforms offering exposure to real-time content, expert instruction, and global collaboration. while these disruptive technologies evolve, their influence on surgical education has not been investigated. our goal was to evaluate the growth and impact of an online surgical education model-the advances in surgery (ais) channel. our hypothesis was that utilization and engagement with the platform continues to grow, providing novel methods of measuring successful education. methods: assessment of the platform's membership demographic, user activity, and engagement was performed from inception in to quarter . the ais channel uniquely provides free, high quality, innovative content from elite surgeons in scheduled and continuously available formats across colorectal, bariatric and endocrine surgery service lines. users login to access content, with demographics, time spent, and content accessed recorded as measures of active account utilization and engagement. the main outcome measures were overall membership trends, utilization patterns by region, content type, and surgical specialty for the platform. results: users were predominately male ( . %), surgeons ( . %), and ranged in age from to years ( . %). the main surgical subspecialty represented was colorectal ( . %). active account usage/weekly recurrence was . % ( % industry benchmark), with users engaged for a mean minutes/session (excluding live events). since inception, steady exponential growth was seen across several dimensions. registered users and unique ip addresses increased from over , and , in to over , and . million in , respectively. the number of countries represented increased to reach across continents. at present, over live surgeries and live congresses have been broadcast from countries, with over , surgical videos available on demand to facilitate surgical education. the greatest engagement is seen with live surgical broadcasts. conclusion: our analysis demonstrated proof of concept for a unique, online surgical education model to provide effective surgical education. success was validated through the increase in overall users, sustained active account usage, and global penetration. user preferences for live surgical broadcasts were seen. knowing the utilization and preference patterns, the platform can continue to evolve and enhance the learners' experience. with this growth and penetrance, there is the potential to globally improve patient outcomes and the quality of care provided. background: a realistic simulator for transabdominal preperitoneal (tapp) inguinal hernia repair would enhance the surgeons' training experience before they enter the operating theater. the purpose of this study was to evaluate the efficacy of d-printed tapp simulator in evaluating preoperative skill before entering operative theater. methods: surgeons in our institution were enrolled in this study. they performed simulation tapp and the performance score was measured using tapp check list. the tapp simulator allows for the performance of all procedures required in tapp. the correlation between post -graduate years (pgys), age, experienced a number of laparoscopic surgery (more than , less than ), experienced number of tapp and the performance score was evaluated. results: strong correlation between experienced member of tapp inguinal hernia repair and the performance score was evaluated in this study (r= . ). however, the correlation between pgy, age and score was weak ( introduction: as the field of laparoscopic surgery grows, the need for standard measures of complex laparoscopic surgical skills is apparent. fundamentals of laparoscopic skills (fls) testing is required to complete general surgery residency, but there is no standard metric to convey expertise in advanced laparoscopic procedures. in an effort to develop a standardized assessment of laparoscopic suturing expertise, a group of experts was surveyed using delphi methodology to reach consensus on observed laparoscopic suturing skills reflective of performing at an expert level. methods: expert laparoscopic surgeons participated in serial surveys via redcap (research electronic data capture). experts included surgeons who perform[ /year laparoscopic procedures that involve intra-corporeal suturing, obtained from the authors' personal and professions networks. using a point likert scale, participants were asked to agree/disagree if different observed laparoscopic suturing skills indicate performing at an expert level. these skills were chosen from prior assessment instruments in the literature and the authors' previously published work. tasks were considered to meet criteria for consensus and eliminated from the next round of the survey after reaching % consensus as "strongly agree." results of the previous round of surveys were shared with participants at the start of the next round. the predefined endpoint for the delphi was set as maximum of rounds, reaching % consensus on each skill, or if[ % of initial respondents fail to return for subsequent surveys. results: after the first round of the delphi survey, respondents met inclusion criteria. preliminary data demonstrated skills that reached consensus ([ % of respondents chose "strongly agree"): forehand suturing, avoiding tissue trauma, having a technically acceptable final product (ie. tight closure), and tying a secure knot at the end of suturing. items did not approach consensus (\ % of respondents chose "strongly agree" or "agree"): alternating hands for each throw while tying, never missing a target when grabbing needle/suture, alternating direction of throws when tying, and backhand suturing. data from all four rounds of surveys as well as the final draft of the assessment instrument will be available at time of presentation. conclusion: preliminary data of this delphi study allowed us to reach consensus amongst a group of expert laparoscopic surgeons on the characteristics of expert laparoscopic suturing, which will allow creation of a comprehensive assessment tool for this domain. validation of such a tool will help advance the surgical field towards true competency-based credentialing and promotion. the study was designed to assess the knowledge of scp among european surgeons (specialists and residents). additionally, surgeons' opinion on usefulness of each of the rules of scp was gathered. the data were analyzed in terms of differences between residents and specialists. this is to set ground for and an educational program and increase the safety of elective laparoscopic cholecystectomy by minimizing the occurrence of cbdi. methods: the data on the knowledge of scp and opinion on usefulness of its rules were gathered in form of an anonymous questionnaire distributed among participants of several surgical conferences in poland. the questionnaire then asked about the surgeon's experience in terms of cholecystectomies performed and the number of complications in form of cbdi. it then listed the scp rules and asked the surgeon about their opinion on usefulness of each of the rules on a -point scale. gathered data were subject to statistical analysis and a comparison between specialists and residents was performed. the study has been registered in the clinicaltrials.gov-nct . , although these numbers are still low. significant differences in the mean usefulness score between residents and specialists were observed in regard to two rules: rule was found more useful by residents (mean score , vs. , , p= . ), whereas rule was found more useful by specialists (mean . vs. . , p= . ). the awareness of the sages safe cholecystectomy program in poland is still low and needs to be promoted. both surgical residents and specialists consider the rules of scp to be useful during surgery, although there are slight differences in the usefulness scores between the groups. an educational program to promote and further implement the scp should be established. introduction: transanal total mesorectal excision (tatme) has attracted substantial interest amongst colorectal surgeons throughout the world. technical challenges of the technique however have been acknowledged by early adopters and this may underpin the early reports of visceral injuries which occurred during the perineal phase. evidence from previous surgical training programs suggest that a structured proctorship programme can shorten the learning curve, operative time and most importantly reduce major complications. the aim of this study was to report on the first national pilot training initiative which was developed in the uk to ensure safe introduction of this technique. methods: a pilot training programme for the uk has been established in partnership with the healthcare industry, and supported by the association of coloproctology of great britain and ireland. the programme consists of three phases: (i) development of a consensus process on the optimum training curriculum of tatme from all relevant stakeholders, including experts, early adopters, and potential learners, to guide the training of this technique (ii) piloting of this training curriculum and (iii) assessment and quality assurance mechanisms to monitor training and measure outcomes. results: a cohesive multi-modal training curriculum has been developed providing clear guidance on case selection, supporting multi-disciplinary and multimodal training including online modules, dry-lab, purse-string simulators, cadaveric training and formal clinical proctoring programme. the uk pilot programme opened for applications in may and, after a rigorous selection process, the initiative was launched in september with trainers mentoring consultant colorectal surgeons from five centres. the selection of learners was based on suitable case volume and prior experience in laparoscopic rectal surgery. objective assessment tools were applied to an unedited video of a laparoscopic rectal surgery case for each applicant. for the selected centres, access to the ilapp tatme app was provided to access educational content including operative video footage, prior to attending a bespoke cadaveric workshop. each learner will then benefit from a structured, centrally organised and funded proctorship programme at their own institutions. a global assessment score form has been specifically designed to monitor training and a formal accreditation process will be used to sign off each learner using competency assessment tool. data on the cadaveric workshop and initial outcomes of the clinical mentorship will be presented at the conference. conclusion: a competency-based pilot training programme for transanal total mesorectal excision has been launched in the uk to support safe introduction of this technique. practicing on a fls trainer box is effective but requires large amount of consumables and is scored subjectively. the purpose of this study is to evaluate the face validity of the intracorporeal suturing task on a virtual fundamentals of laparoscopic surgery simulator (virtual fls). we hypothesize that the virtual fls will demonstrate face validity. methods and procedures: after a video demonstration and a practice period, twenty-three medical students and residents completed an evaluation of the simulator. the participants were asked to perform the standard intracorporeal suturing task on each of the virtual fls and the traditional fls box trainer. the presentation order of the devices was balanced. the performance scores on each device were calculated based on time (seconds), deviations to the black dots (mm), and incision gap (mm). the participants were then asked to finish a -question questionnaire regarding the face validity of the simulator. participants answered questions with ratings from (not realistic/useful) to (very realistic/ useful). a wilcoxon signed ranks test was performed to identify differences in performance on the virtual fls compared to the traditional fls box trainer. results: responses to of the questions ( . %) averaged above a . out of . those questions that rated the highest were the degree of realism of the target objects in the virtual fls compared to the fls ( . ) presently, most training methods for thoracoscopic esophagectomy use live porcines; this presents several problems including cost, long preparation times, and ethical issues. these problems further prevent frequent training. currently, no alternative models for thoracocopic esophagectomy training. we report, for the first time, the development and use of a non-biomaterial training model for thoracoscopic esophagectomy. methods: we collaborated with sunarrow co., ltd. (tokyo, japan) to develop the training model. we created organ models for esophagus, trachea, bronchus, aorta, vagus nerve, recurrent nerve, bronchial artery, lymph node, vertebrae, azygos vein, and thoracic duct, and filled the models with a polyvinyl alcohol hydrogel. the gaps between organs were filled with a filler material mimicking connective tissue. we chose a synthetic resin that closely mimics the characteristics (rigidity or elasticity) of each organ. after each organ was fixed, the model was covered with a filler to create a pleural membrane to allow training in peeling operations. in addition, because a patient plate was attached to the rear of the training model, excision with an energy device was possible and more closely simulated surgical conditions. results: using the training model resulted in a highly satisfactory level of experience in three trainees. the trainees were able to learn anatomical positions and sequence of surgical procedures, including endoscope handling. centre for rural health, aberdeen university introduction: as doctors become expert in a complex procedure, they develop automatic nuances of performance that are difficult to explain to a peer or a trainee (so called 'unconscious competence'). traditional methods which aim to allow sharing of expertise have limitations: concurrent reporting alters the flow of the task at hand while retrospective reporting is subject to bias and often incomplete. iview expert is a technique validated in the aerospace domain which externalises an expert's cognitive processes, without disrupting the task at hand. the aim of this project is to assess the feasibility of adapting the technique to medical training. methods: this was an observational case study in which an expert endoscopist wore a head mounted camera to capture a complex procedure (colonoscopy). captured video was reviewed during a facilitated debrief which externalised the expert's cognitive processes. the debrief was recorded and formed an audio commentary. the video and accompanying audio commentary formed a learning package which was watched by a specialty trainee. the technique differs from standard procedural videos in that it provides a more detailed insight into cognitive processes of the expert. this is achieved through the debrief, which encourages reflection upon kinaesthetic (head movement) as well as auditory and visual cues, resulting in a higher level of experiential immersion. questionnaires examined acceptability and educational value of the technique using likert scales and free text answers. quantitative data were presented using basic descriptions in terms of agreement with statements. qualitative data from free text responses were coded in order to identify key themes. results: the expert agreed that wearing the camera was acceptable and did not interfere with the procedure, nor usual decision making processes. qualitative analysis revealed the debrief process to be associated with a high level of experiential immersion: "as if they were there". both the expert and the trainee strongly agreed that the process was educationally valuable and that they learned something new. qualitative analysis demonstrated that the technique revealed useful and unique nuances of the procedure. the intervention could represent a powerful adjunct to existing training methods, especially amongst more experienced practitioners. we are currently undertaking a larger study involving a greater range of procedures with more learners. introduction: endoscopy is an important skill for general surgeons to possess. however, there is lack of training within surgery residency programs. we implemented a one-day endoscopic surgery course with the aim of improving the confidence of surgical residents in performing endoscopic procedures. we also aimed to examine the effect of the exposure to this course on self-reported confidence in performing endoscopic procedures. methods and procedures: the fundamental of endoscopic surgery course at texas tech university health science center is a one-day course consisting of both didactic training and lab training. the didactic part of the course is taught by attending physicians and focuses on the basics of endoscopy, management of upper and lower gastrointestinal (gi) bleed, and techniques to perform a variety of gi endoscopic procedures on swine esophagus and stomach explant. the lab portion of the course allows residents to perform different endoscopic surgical procedures with the attending physicians providing guidance. residents from pgy- to pgy- participated in the course. a -item questionnaire that measured the self-reported confidence in performing several endoscopic procedures on a - likert scale was administered before and after the course. results: twenty-two participants successfully completed the training and the questionnaires. a significant improvement was observed in the overall confidence in performing a variety of endoscopic procedures ( . ± . , p. ). the improvements remained significant even after controlling for the years of postgraduate surgical training (p. ). conclusion: the one-day fundamental of endoscopic surgery course enabled residents to be more confident with endoscopic procedures. overall, the residents felt that the course was helpful and would like to attend more than one session per year. this course should be held, at least, annually to allow the general surgery residents to become even more confident with this important skill. by being more confident in their surgical endoscopy skills, they will ultimately be able to provide better care for patients. introduction: a course evaluation study on the effectiveness of improving laparoscopic skills of surgical residents using swine models was evaluated through a self-report questionnaire administered before and after course completion. the purpose of the training is to provide surgical residents opportunities to practice and advance their laparoscopic proficiencies. methods and procedures: participating residents in all post-graduate year levels (pgy through pgy , n= ) were provided anesthetized pigs with which to perform a variety of simple to complex laparoscopic cases. prior to training, residents were given a questionnaire composed of eleven questions requiring the subjects to rate their confidence in performing various laparoscopic procedures on a - likert scale. after completion of the course, an identical questionnaire was distributed with two additional questions relating to the overall impact of the course. all statistical analyses were conducted using r statistical software (version . conclusion: overall, one-day hands-on training using swine models improved resident's skills, confidence, and understanding of laparoscopic surgery. the information acquired through the questionnaire emphasized the importance of providing a laparoscopic training course as a standard requirement at all medical institutions. allowing opportunities for surgical residents to practice their laparoscopic skillset will not only help in their individual academic advancements, it will allow them to provide optimum care for their patients. background: learning laparoscopy is difficult and many educational tools including simulation training are required. feedback plays a crucial role for motor skill training but require expert tutors and its time consuming. e-learning increases knowledge acquisition through a more interacting multimedia experience and reduces de costs of learning. in the last decade multiple applications (apps) have been developed for mobile medical training. a new ios app was developed using specially designed educational videos that explain the main technical aspects in advanced laparoscopy through simulation training. the aim of this study is to present the first results of its incorporation in a surgical simulation lab as a complement of effective feedback. methods: twenty-five consecutive residents were trained in our simulation lab through a session validated training program for the acquisition of advanced laparoscopic skills needed for the performance of a laparoscopic hand-sewn jejuno-jejunostomy. every session had written instructions and a basic tutorial video. the app consist two main sections, the first one explains the essential techniques needed for intracorporeal suturing and the second is a complete walkthrough of the validated training program. the trainees were divided in two groups, the first was trained without using the app (napp) and the second group was trained using the app (yapp). both groups of trainees could ask for feedback anytime they needed. trainees were assessed before and after the training program using validated rating scales and the number of necessary tutor-feedback sessions were registered. finally the yapp group answered a survey about the strengths and weaknesses of the app for learning advanced laparoscopic skills. results: twenty-five residents completed the training program; yapp and napp. both groups finalized their training with no statistical significant differences in their scores (p: . ). the number of tutor-feedback needed to complete the training in the yapp vs napp was of [ ( - ) vs ( - ) (p. )] respectively. in the questionnaire all participants considered that the app was effective for learning advanced laparoscopy. over downloads have been registered since the app was published in the apple app store in . we present a novel smartphone app that guides laparoscopic training using simulation-based educational videos with very good results. the use of app guided learning reduces de need of expert tutor feedback reducing the costs of simulated training. jemin choi, young-il choi; kosin university gospel hospital purpose: laparoscopic appendectomy (la) has been widely performed for acute appendicitis. in addition, minimally invasive surgery such as la is common surgical technique to the surgical residents. however, single incision laparoscopic surgery (sils) is a challenge to inexperienced surgical residents. we described our initial experience in teaching sils procedure for appendectomy in our medical center. methods: twenty nine cases of single incision laparoscopic appendectomy (sila) were performed by single surgical resident and cases of la were performed by surgical residents and boardcertified surgeons. a study was reviewed retrospectively. ( ) clinical stressors (i.e., vitals of patient coding). we developed a stress simulator testbed by integrating an fls box trainer with a linux computer, running custom c++ code. the code generated various stressor conditions, while recording sensor data from the trainer and human operator. we tested groups of participants in an irb approved trial including: novices (non-medical students), intermediates (medical students), and experts (pgy residents and fellows). the study consisted of subjects performing the peg transfer and the pattern cut six times (baseline, four randomized stressors, posttest). after each task, the nasa-tlx survey was administered to determine the overall workload of that stressor condition. an analysis of variance was conducted to identify significant trends in terms of stressor type. results: when compared to baseline nasa-tlx scores, the intermediate group had the greatest changes in overall workload than novices and experts (p= . ). additionally, the change between baseline and post-test workload was significantly lower than for the environmental, negative evaluative, and clinical stressors (p= . ). for pattern cutting, subjects reported a significantly lower perception of failure (p= . ) in both the positive evaluative (mean= . ) and post-test conditions (mean= . ), yet, though not statistically significant (p= . ), the measured accuracy in the task during the positive evaluative condition was actually worse ( . %), second only to the pre-test accuracy ( . %). the best accuracy for pattern cutting across all expertise levels was % for the post-test followed by . % in the negative evaluative condition. these results are interesting as they show that despite perceived improvements in performance with a positive feedback condition, performance actually degrades and is better in the negative feedback condition, which is perceived to be more difficult. these results were not found in the peg transfer task, which is arguably an easier task. conclusion: from the evidence gathered in the study, it is clear that there is a correlation between distractors and performance. further analysis is needed to identify the relationship between the type of stressor, and inherent difficulty of the tasks, in terms of which type of stressor best improves learning and outcomes. surg endosc ( ) each received credentials to perform diagnostic and therapeutic ercp from their respective hospitals in nevada, minnesota, and idaho. one continues to teach ercp to general surgery residents, and another taught the skill to fellows in an advanced endoscopy fellowship. all three continue to use ercp in their practice ( to times per month), as they each specialized in a field that utilizes ercp routinely. choledocholothiaisis is the most frequent indication, though ercp is also performed for iatrogenic biliary duct leaks, traumatic biliary or pancreatic duct leaks, chronic pancreatitis, and malignancy. conclusions: training in esophagogastroduodenoscopy and colonoscopy is required for general surgery residents, but the addition of ercp to select residents' training enables them to completely manage their patients' surgical disease. the training of select general surgery residents in this skill has been successful, evidenced by the continued use of ercp in the practices of three residents who completed this training program at our institution. the decision to train residents in this skill should be left to individual program directors and department chairs. we recommend that residents selected for this additional training should plan to practice in specialties where ercp can be implemented. conclusion: same-day discharge after nissen fundoplication and hiatal hernia repair is feasible for select patients. one major challenge for same day discharge is the current insurance provisions required for hospital reimbursement. within the parameters of this study, bmi and asa score did not differ between discharged and admitted patients, while older age and increased procedure duration were associated with need for admission. premkumar anandan, ms, facs; bangalore medical college and research institute introduction: minimal access surgery is an imperative element of enhanced recovery program and has significantly improved the outcomes. enhanced recovery program (erp) synonym "fast track" surgery "was first conceived by dr henrich kelhet. largely described for colorectal surgery and reported to be feasible and useful for maintaining physiological function and smooth the progress of recovery. most of the patients who present for surgical emergency are not adequately prepared and many are not in normal physiological state. the feasibility of enhanced recovery programs protocol in such emergency minimal access surgery remains indistinct. this study was designed to validate an enhanced recovery program in patients who undergo emergency minimal access surgery. introduction: pathways for enhanced recovery after surgery (eras) have been shown to improve length of stay and postoperative complication rates across various surgical fields, however there is a relative lack of evidence-based studies in bariatric surgery. the objective of the current study was to determine if starting a bariatric full liquid diet on postoperative day (pod) zero was associated with shorter length of stay (los) for patients who underwent laparoscopic sleeve gastrectomy (lsg) or roux-en-y gastric bypass (rygb). methods: retrospective review of a prospectively collected dataset was conducted at a single institution before and after implementation of a new diet protocol for lsg and rygb. postoperative diet orders were changed from full liquid diet on pod to pod . length of stay and -day readmissions were reviewed from june to august . independent samples t-tests were used to compare continuous variables and chi-squared tests for categorical variables before and after diet change was implemented. patients were excluded if they were undergoing revision surgery, were discharged directly from pacu, or had significant intraoperative complications or required reoperation within the same admission. introduction: data suggests value in using tap (transversus abdominis plane) neural blockade in abdominal surgical procedures. we deploy tap blockade using liposomal bupivacaine via ultrasound (us) as part of a narcotic sparing pain management pathway for patients undergoing abdominal surgery in our rural community setting. our goal was to evaluate adequacy of postoperative discomfort and the success in avoiding narcotic usage. methods and procedures: records of patients undergoing abdominal surgical procedures performed by one surgeon over an month period were reviewed under irb approval. patients taking narcotics prior to the procedure (except for discomfort due to the condition being surgically treated) were excluded from analysis, as were those admitted to the hospital for postoperative treatment. us guided lateral tap blocks were performed by the surgeon using mg of liposomal bupivacaine and mg of bupivacaine in the or prior to the incision. unilateral block was performed for unilateral procedures (e.g. inguinal hernia) and bilateral for laparoscopic or midline procedures. incisional sites were treated with a field block of mg of bupivacaine. prescriptions for medications included , mg of acetaminophen qid and mg of naproxen sodium tid for days. a prescription for tramadol ( to mg prn up to times daily; tablets with no refill) was given. patients were seen in followup two weeks postoperatively. data (following standard scales/metrics) for patient-reported-outcomes e.g. pain, nausea-vomiting, & fatigue will be analyzed with the above data and the analysis with conclusions will be presented & discussed. federico sertic, md, ashwin gojanur, dr, ahmed hammad, md; guy's and st thomas' hospital introduction: the aim of this project is to assess the quality of post-operative pain relief in colorectal surgery and identify patients in whom pain management has not been effective, in order to improve the quality of post-operative care. effective management of post-operative pain has long been recognised as important in improving the post-operative experience, reducing complications and promoting early discharge from hospital. standards: all patients should be pain free at rest, % of elective patients should be told about what analgesia they will have post-operatively, % of patients should be satisfied with their pain management and % of patients should feel staff did everything they could to control their pain. methods and procedures: questionnaires were given to patients on the day prior to discharge. questions about pre-operative and post-operative pain experience were asked. data regarding post-operative analgesia were collected from medication charts and medical notes. data were collected over a period of two months (august/september ). range of procedures: elective laparoscopic abdomino-perineal-excision-of-rectum with igap flaps, elective laparoscopic right hemicholectomy, laparotomy+bowel resection/stoma formation ( elective, emergency), elective repair of parastomal hernia, appendicectomy ( laparoscopic elective, laparoscopic emergency, laparotomy emergency) and elective reversal of ileosomy. pain scores ( - ): immediately post-operative pain, day post-operative pain, post-operative pain after day and pain on moving/coughing/straining. results: mean immediate post-operative pain score was . ( % of patients with score +), mean day post-operative pain score was . , mean post-operative pain score after day was . , mean pain score on moving was . ( % of patients with score +), mean pain score on coughing/ straining was . ( % of patients with score +). % of patients were satisfied with their post-operative pain management and felt that the staff had done everything they could to manage their pain. % of patients were not aware of their post-operative analgesia regimen and % did not know how regularly they could request analgesia. conclusions: effective management of post-operative pain is a key part of post-operative care and an important component of enhanced recovery programmes. patient satisfaction with pain management has been found to correlate with received pre-operative information. increasing ward nurses' and acute pain teams' knowledge is important in improving patients' pain experiences. interestingly, those patients who had a background of long-term opioid requirements reported that they were satisfied with their pain management. methods and procedures: a patient undergoing a standard ultrasound guided ql block by an anesthesiologist established the baseline anticipated response, and procedure time. the procedure, performed under sedation preoperatively, required over minutes. for this study, patients undergoing laparoscopic colorectal surgery were administered a lateral ql block (modified ql ) under ultrasound guidance by the operating surgeon. ml of a mixture ( ml injectable liposomal bupivacaine suspension, ml . % bupivacaine hydrochloride and ml normal saline) was injected bilaterally, after induction, skin preparation, draping, and prior to the operation. postoperative narcotic use and pain vas scores were documented. results: six patients were administered a bi-lateral ql block intraoperatively. procedures were: laparoscopic sigmoid colectomies, one end ileostomy reversal, laparoscopic completion proctectomy with ileal pouch anal anastomosis, and a laparoscopic descending colectomy. of the narcotic naïve patients, mean pain vas on post op days , and were . , . and . respectively within a multimodality pain management/enhanced recovery program, where standing orders prompting narcotic administration by nursing staff is pain vas . all were discharged on pod or without narcotic prescriptions. two of the patients were chronic narcotic users, and they were discharged on their baseline narcotics, i.e. without additional narcotics. all intraoperative blocks were performed in less than minutes. conclusion: a novel, surgeon-administered lateral ql block under ultrasound guidance, is feasible and provides post-operative pain control. patients are discharged home on no/baseline narcotics. a randomized controlled trial is being constructed based on these striking findings. keywords: lc-laparoscopic cholecystectomy, ga-general anaesthesia, sa-spinal anaesthesia. nikhil gupta, rachan kathpal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: cholecystectomy have shown some advantages when done under spinal anaesthesia (sa) and associated with less intra operative and post -operative morbidity and mortality. laparoscopic cholecystectomy (lc) under regional anaesthesia alone included patients with coexisting pulmonary disease, who are deemed high risk for ga. the aim of the present study is to assess the efficacy and safety of laparoscopic cholecystectomy under sa. materials: this prospective, interventional study was conducted on patients with chronic calculous cholecystitis attending general surgery out-patient department of our institution. results: in our study, intraoperative complications recorded were hypotension, bradycardia, intra op shoulder tip pain, bleeding from the liver bed, bile spillage, post-op pain and vomiting. % patients had intraoperative pain, % had shoulder tip pain, . % had bradycardia, . % had hypotension, . % had bile spillage and . % had bleeding. laparoscopic cholecystectomy under spinal anaesthesia should be promoted more even in developing countries but we need to establish well evaluated safety guidelines that could be followed faithfully for minimizing the risk of complication. background: the "opioid crisis" has taken over headlines with increasing public attention brought to the drastically increasing rates of addiction to prescription narcotics. in , the american society of addiction medicine reported million americans with an addiction to prescription pain relievers and a four-fold increase in overdose related deaths. in a medical setting, increased opiate use is associated with increased rates of delirium, ileus, urinary retention, and respiratory depression. these risks are increased in the obese/bariatric population. transversus abdominis plane (tap) block is a safe and effective approach to achieve optimum pain control. it reduces the use of opiates in patients undergoing major abdominal surgery. however, there is currently no data in the literature examining its use in the bariatric population. our study examines the use of liposomal bupivacaine for tap block in patients undergoing laparoscopic sleeve gastrectomy (lsg). methods: sixteen patients undergoing lsg with tap block were compared with historical cohort of sixteen patients undergoing lsg without tap block (standard group). the primary outcome measured was post-operative in-hospital opiate use (morphine equivalents). statistical analysis was performed using student's t test for continuous variables and fisher's exact test for categorical variables. results: both groups were well matched in regards to bmi, age, and asa class. there was a significant decrease in the post-operative use of opiates with the use of the tap block ( . mg in the tap block group vs. mg in the standard group; p . ). there was no difference in the mean length of stay between the two groups. there was an increase in the mean operative time with use of the tap block ( minutes in the tap block group vs. minutes in the standard group; p. ) conclusions: the use liposomal bupivacaine for tap block provides substantial analgesia, allowing for significant reduction in post-operative opiate use in our bariatric patients. this can be an important adjunct in pain control for the bariatric population and aid in post-operative complication risk reduction. introduction: the objective of this study was to identify variation in weight and demographics in the distribution of pre-operative clinical characteristics between super obese females compared with males who were about to undergo bpd/ds surgery. as the american obesity epidemic increases, morbidly obese patients have become integral to every surgical practice; they are no longer limited to bariatric surgeons. every clinical insight helps the surgeon to optimize outcomes when operating on and managing these medically fragile individuals. in this context, however, clinically and statistically significant differences in demographics, body mass, and in the distribution of weight-related medical problems between super-obese women and men are unknown. introduction: a transversus abdominis plane (tap) block is an ultrasound-guided injection of local anesthetic in the plane between the internal oblique and transversus abdominis muscles to interrupt innervation to the abdominal skin, muscles, and parietal peritoneum. currently there are incongruent findings on the benefit of this regional anesthetic to surgical patients, particularly the obese population. we hypothesized the addition of a tap block in an enhanced recovery pathway (eras) for bariatric patients would decrease opioid use and shorten hospital length of stay. methods: a retrospective review of all patients who underwent bariatric surgery at a single institution from january to december was performed. patients were identified as: no tap block (no tap), tap blocks that were performed after induction either pre-surgery (pre-tap) or post-surgery (post-tap). the primary outcome was time to first opioid (min) and total morphine (mg) equivalents in pacu. objective: prolonged postoperative ileus increases hospital length of stay and therefore impacts healthcare costs. although many surgeons recommend ambulation in the postoperative period to hasten return of bowel function, little evidence exists to support this practice. our hypothesis is that early ambulation does reduce the time to return of bowel function after intestinal surgery. methods: a subset of patients undergoing intestinal surgery from an ongoing, prospective trial evaluating perioperative physical activity was analyzed. preoperatively, patients wore an activity tracker for a minimum of three days to establish a baseline activity level, measured by daily steps. postoperatively, steps were recorded for days. patients were included in this study if they underwent an operation on the small bowel, colon, or rectum. resolution of postoperative ileus was defined as the postoperative day when patients were noted to meet all of the following criteria on review of nursing documentation: passing flatus, stooling or having ostomy output, and tolerating a regular diet without intravenous fluids. "early" postoperative activity was defined as the average number of daily steps during the first two postoperative days. discussion: these results suggest the patients who received an intraoperative block laparoscopically were more likely to be able to spend less time in the post anesthesia care unit and be discharged home the same day. based on these results, additional process improvement ideas will be implemented in an attempt to improve outcomes. riley d stewart, md, msc, frcsc, james ellsmere, md, msc, frcsc; dalhousie university division of general surgery introduction: oropharyngeal and gastrointestinal (gi) perforations from bbq brush bristles are being reported in the literature with increasing frequency. media attention to this problem has increased awareness by the public. most commonly, bbq bristles lodged in the gi tract can be removed endoscopically or pass without complication. rarely, surgical intervention is required for removal of the bristle or drainage of an associated abscess. we report a case of gastric perforation by a bbq bristle leading to a pancreatic abscess. case report: a -year-old male presented to a regional center with epigastric pain and malaise. his medical history included: hypertension, dyslipidemia, gerd, and smoking. his surgical history included: a tonsillectomy, excision of bronchial cleft cyst, and an umbilical hernia repair. on presentation, his laboratory investigations where unremarkable aside from an elevated white blood cell count. investigations including an abdominal x-rays and an abdominal ultrasound were unremarkable. he was initially treated with a proton pump inhibitor for presumed peptic ulcer disease. he returned to the local emergency room, no better than before. a ct scan was arranged which demonstrated a foreign body at the pylorus consistent with a bbq bristle and a peripancreatic fluid collection (figs. & ) . a gastroscopy failed to identify the bristle. he was admitted, placed on iv antibiotics and referred to our center. despite several days of antibiotics prior to arrival, the collection size on repeat ct scan had increased and the patient had ongoing pain. we repeated the endoscopy with a side viewing endoscope. the perforation was identified posteriorly at the pylorus. the bristle had migrated into the peripancreatic space. the perforation was cannulated with a jagtome. fluoroscopy was used to confirm the position of a wire in the fluid collection (figs. & ) . pus was drained from the collection into the stomach by placement of a french pigtail catheter (fig. ) . the patient was discharged pain free the following day. the patient was asymptomatic at weeks' follow-up. a repeat ct scan showed resolution of the abscess and safe migration of the bristle and stent out of the gi tract (fig. ) conclusion: to our knowledge, this is the first reported transgastric endoscopic drainage of a peripancreatic abscess caused by a bbq bristle gastric perforation. this case is a demonstration of the ever-expanding role of therapeutic endoscopy in a surgical practice. andrew w white, md, carl westcott, md; wake forest baptist medical center introduction: endoscopic balloon dilation of the gastroesophageal junction (gej) is generally limited to mm in diameter. in many stenotic or spastic disorders of the gej mm is just not big enough. larger balloon sizes are available ( and mm), although these are deployed under fluoroscopy without endoscopy. thus, these larger dilations are often not feasible at the time of the diagnostic endoscopy because different facilities and/or equipment are needed. also, fluoroscopic mm balloon dilations are associated with a percent perforation rate. to address these shortcomings we present an experience with a retroflexed "against the scope" balloon dilation of the gej. in detail, the gej is visualized while retroflexed and a balloon is then placed through the scope. the gej is cannulated next to the scope and deployed. please see the attached image for example. methods and procedures: a retrospective chart review was performed for a single surgeon during the past five years. we identified those who had retrograde dilations and evaluated the indications, repeat dilations, complications and symptomatic response. results: a total of retrograde dilations were performed on patients with gej related dysphagia. the average age was . years. of dilations were with a mm balloon while other dilations used as small as a mm balloon. dilations were performed for persistent dysphagia after cardiomyotomy between and days after surgery. other indications for dilation were dysphagia after fundoplication ( / ), dysphagia after paraesophageal hernia repair ( / ) and achalasia during pregnancy ( / ). patients required a total of repeat retrograde dilations at an average time of days after previous dilation. there were instances reported where the dilation did not improve symptoms. there was mucosal breakdown noted in instances although there were no perforations. bleeding was noted in instances although this was always minimal and selfresolving. conclusions: retrograde endoscopic dilation is safe and effective in this small series. the mm balloon against a mm scope gives a mm diameter, but a different shape and a decreased total circumference. there is a possible added safety advantage given that the balloon is inflated under visualization. it can be inflated in steps or stopped if it appears too aggressive. in addition these larger dilations were provided at the time of the initial diagnostic egd without extra equipment. more studies are needed to compare retrograde endoscopic dilation to other methods of management of gej stenosis. introduction: robot-assisted surgery allows surgeons to perform many types of complex laparoscopic surgical procedures. more and more patients are treated with this sophisticated system. however, all the instruments used in the currently available surgical robot system is rigid. therefore, there exists a limitation in the extent of reach to the deeper surgical fields. in order to overcome this difficulty, we are developing a novel flexible endoscopic surgery system (fess) which has flexible single port platform of cm in diameter, independently controlled endoscope and instruments, open architecture that is compatible with existing flexible devices and a magnified d hd camera that has sensors of both rgb and infrared. furthermore, the system is smaller and would be more cost-effective than existing robotic surgical system. a preliminary experiment was performed in surgical procedures using porcine model to evaluate effectiveness and feasibility of fess. methods and procedures: experimental protocols were approved by the animal research committees of our institution. we used a female swine of kg. an assistant forcep lifted up the fundus of gallbladder to create good visualization of surgical field. the cystic duct was ligated by laparoscopic clip device from assistant port. blunt dissection was performed by pushing the forceps and sharp dissection by monopolar electrocoagulation. results: the fess accomplished the dissection of the gallbladder from the liver bed successfully. two mm forceps had enough grasping and dissecting force and dexterity. the gallbladder was removed from single port site easily. conclusions: this experiment showed that it is feasible to intuitively operate single-site cholecystectomy with fess. in order to realize a pure fess procedure, an additional novel device to create good visualization of the surgical field is necessary for the fess platform. a prototype has already been developed for evaluation in securing the surgical field. the optimal working range, or "sweet spot" of fess is not relatively large. in addressing this issue, the feature of easy setup is being improved to enable more efficient positioning and shifting of the sweet spot for the surgical field. this mechanism could enhance the expansion of procedures suitable for fess. the target procedures of fess are those specifically suitable for single port surgery, such as transanal surgeries and transcervical mediastinoscopic surgeries. intraluminal procedures and natural orifice translumenal surgery (notes), which are not considered suitable for rigid surgical robot, are also good applications of fess. regression of anal and scrotal squamous cell carcinoma (hpv related) with imiquimod index patient is a year old hiv positive homosexual man with anal-scrotal condylomas (ain) initially resected in , then treated with radiation in for recurrence. recurred in with changes severe enough to ''…consider diagnosis of invasive squamous cell carcinoma…''. patient elected trial of imiquimod % cream three times per week to defer recommendation of abdominoperineal resection. imiquimod has no antiviral effect but stimulates interferon and cytokines to suppress hpv subtypes and , among other immune effects. no data exists as to systemic effects of imiquimod. after three months of therapy, lesions had largely regressed with only one specimen showing ''…concern for squamous cell carcinoma in situ…''. patient has elected to continue treatment pending further biopsy. this report is typical of a number of other reports of small numbers of cases of neoplasia regression with imiquimod % cream to include melanoma-in-situ, basal cell cancer of skin and other cutaneous malignancies as well as vin. a second female patient, years old, hiv+ with hpv lesions (ain ) including urethral lesions, is being treated with vulvar application of imiquimod to determine if urethral lesions will regress. there is no fda-approved indication for mucosal application of imiquimod. biopsies are pending at completion of six month trial of imiquiimod. surg endosc ( ) introduction: training in flexible endoscopy remains a critical skill for surgeons, as therapeutic endoscopy procedures continue to evolve and to supplant standard surgical operations. the role of endoscopy across surgical subspecialties is shifting, as endolumenal procedures (like per-oral endoscopic myotomy and endolumenal bariatric interventions) have become commonplace. while surgical residency minimum case volumes are mandated, little is known about the volume of endoscopic procedures surgical fellows participate in. we aimed to characterize the volume of flexible endoscopy cases logged by surgical subspecialty fellows as a measure of endoscopic platform use by surgeons. methods: operative case logs for fellows enrolled in post-graduate training programs participating in the fellowship council were de-identified (no patient or program specific information) and provided for analysis. the case log is an online, mandatory, self-reported collection of all surgeries, procedures and endoscopies performed during fellowship year. all cases listed within the category of "gi endoscopy" in which the fellow designated their role as "primary" surgeon for the procedure were further sorted based on subcategory and linked to the year of fellowship graduation. rigid endoscopy, trans-anal endoscopic procedures, and those in which the fellows roll was "first assistant" were excluded. introduction: complex pancreatic and duodenal injuries due to trauma continue to present a formidable challenge to the trauma surgeon with a described mortality of - % and morbidity of - %. duodenal fistula formation subsequent to failure of attempted primary repair is associated with significant morbidity and mortality. we present the first reported series of four patients with complex trauma-related duodenal injuries who had failure of primary repair which were managed with duodenal stenting. we compared outcomes to a matched case control cohort of patients with trauma related duodenal injuries. the aim of this study is to document our experience with enteral stents in patients with complex duodenopancreatic traumatic injuries. methods: a retrospective review at a level i trauma center identified patients who underwent endoscopically placed indwelling covered metal stents after failure of primary duodenal repair in the form of high output duodenal fistulas. a matched case control cohort was identified including patients with duodenal fistulas who were not treated with stents. drainage volumes were collected and classified according to source and phase of intervention (i.e. admission to fistula diagnosis, to stent insertion, after removal, and until discharge). results: there was a decrease in the mean combined drain output of ml/day (p= . ) after stent placement. when comparing the sum of all output sources, there was a statistically significant difference across phases (p= . ) and "after removal" was significantly less when compared to the reference phase (p= . ). there was also a change in the directionality of the slope for the sum of all drain outputs with an increase of ml/day prior to stent placement compared to a decrease of ml/day (p= . ) after stent placement. the stenting group demonstrated a decrease in mean drain output ( ml/day vs ml/day, p= . ) and increase in distal gastrointestinal output ( ml/day vs ml/day, p= . ). one patient in the stent group required later operative repair. all other patients in the stenting and control group had resolution of their fistulas over time. there were late mortalities in the control group. the stent treated patients demonstrated diversion of approximately ml/day of enteral contents distally. while all patients eventually healed their fistulas, the stent treated patients demonstrated an accelerated abatement of drain outputs when compared to the control cohort, but did not reach statistical significance. indwelling enteral-coated stents appear to be an effective rescue method for an otherwise inaccessible duodenal fistula after failure of primary repair. kevin l chow, md, hassan mashbari, md, mohannad hemdi, md, eduardo smith-singares, md; university of illinois at chicago introduction: esophageal trauma represents an uncommon but potentially catastrophic injury with a reported overall mortality of up to %. the management of iatrogenic and spontaneous perforations have been previously described with well-established guidelines which have been mirrored in the trauma setting. esophageal leaks are the most feared complication after primary surgical management and present a challenge to salvage. there has been increasing reports in the literature supporting the use of removable covered metal stents to treat esophageal perforations and leaks in the non-trauma setting. we present the first reported case series of four patients presenting with external penetrating trauma induced esophageal injuries, complicated by failure of initial primary surgical repair and leak development, successfully managed with the use of esophageal stents. materials and methods: a retrospective review was performed at a level i trauma center identifying four patients who underwent endoscopically placed removable covered metal stents, either by a surgical endoscopist or an interventional gastroenterologist, after failure of primary surgical repair of esophageal traumatic injuries. demographic information, hospital stay, additional interventions, complications, imaging studies, iss scores, and outcomes were collected. results: our cohort consisted of patients with penetrating injuries to the chest and neck with esophageal injuries ( thoracic and cervical esophageal injuries) managed with esophageal stenting after leaks were diagnosed following primary surgical repair. their initial esophageal injuries included grades , and . leaks were diagnosed on average post-operative day . two patients underwent an additional attempted surgical repair and subsequent leak development. esophageal stents were placed under endoscopic and fluoroscopic guidance within days of leak diagnosis. there was resolution of their esophageal fistulas with all patients resuming oral intake (averaging days after stent placement). three patients ( %) required further endoscopic interventions to adjust the stent due to migration or for dilations due to strictures. mortality was %, all patients survived to be discharged from the hospital with average icu length of stay of days. conclusion: the use of esophageal stenting has progressed over the last few years, with successful management of both post-operative upper gastrointestinal leaks as well as benign, spontaneous, or iatrogenic esophageal perforations. while the mainstay of external penetrating traumatic esophageal injuries remains surgical exploration, debridement, and repair with perivisceral drainage; our case series illustrates that the use of esophageal stents is an attractive adjunct that can be effective in the management of post-operative leaks in the trauma patient. results of the ovesco-over-overstitch technique for managing bariatric surgical complications introduction: since , the preferred method of enteral access has been the percutaneous endoscopic gastrostomy tube (peg). accidental removal is a common complication associated with excessive cost and possible significant morbidity. removal prior to days is considered ''early removal.'' early removal has more significant risk associated with it, and can necessitate emergent operation to prevent peritonitis and sepsis. some patients, who do not exhibit signs of peritonitis, may be simply observed. for these patients, peg replacement would typically be delayed - days to ensure closure. this delay results in prolonged npo status and worsened nutritional status. presented below is a case of early accidental removal followed by endoscopic clip closure, and immediate peg replacement. case report: a -year-old male presented after a large left middle cerebral artery infarct. a peg placement was completed without complication. eleven hours after the procedure the patient had pulled the peg tube out of the abdominal wall. at this time the patient appeared to have no abdominal pain and no signs of peritonitis. twelve hours following the accidental removal of his peg tube, the patient was taken back to the endoscopy suite, and an egd was performed. the previous peg site was identified and appeared closed and ulcerated. the mucosal defect was closed with two endoscopic metallic clips. a peg tube was then placed at an adjacent site. the following day, the patient was restarted on trickle feeds and advanced to regular tube feeding over a period of hours. since that time, his peg has been functioning well. discussion: we propose that in the case of early accidental peg removal, the patient should be examined first for evidence of peritonitis. if initial physical exam and radiographic investigation do not reveal peritonitis or significant pneumoperitoneum, the patient should undergo urgent repeat endoscopy. at this time, the gastrotomy can be closed endoscopically via metallic clips and peg can be replaced immediately. tube feeds can be initiated after a - hour period of dependent drainage with serial abdominal exams. introduction: since its inception in , poem has become a viable procedure for the treatment of achalasia and esophageal dysmotility disorders. however many institutions are in the beginning stages of implementing the procedure into their programs. in view of training, we report the successful ability to dissect and identify common landmarks during a poem procedure performed by trainees under supervision in a high volume poem center. methods: posterior poem procedures performed by trainees with experienced proctor guidance during the period between february to july were evaluated for the frequency of identifying the perforating vessels, the presence of sling fibers, and position on the lesser curvature of stomach evaluated by double scoping method during the creation of the tunnel and myotomy for procedure. results: all poem procedures were successfully completed by trainees (gi and surgery fellows). the average length of procedure was minutes. indication for procedure included patients with type achalasia ( %), with type achalasia ( %) and des ( %). average length of myotomy for all procedures was . cm. during these procedures or perforator vessels were identified in ( %) of patients, sling muscle was identified in patients ( %) of patients. myotomy extended to anterior lesser curvature of stomach on double scope exam in % of patients. no patient had a serious complication requiring intervention. conclusion: trainees performing a posterior poem procedure were able to correctly dissect and identify the sling muscle and/or perforating vessels in approximately % and % respectively of procedures. however the myotomy position was correctly placed in all procedures. this indicates that while ideally the sling fibers and perforating vessels should be identified, a correctly positioned myotomy can still be successfully performed by trainees without identification of these landmarks. introduction: gastroparesis is a rapidly increasing problem with sometimes devestating patient consequenses. surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity but require general anesthesia, advanced skills and create risk of leaks. peroral pyloromyotomy (pop) is a less invasive alternative but is technically demanding and not widely available. we propose an hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow a endoluminal stapled pyloroplasty as an alternative treatment option for functional gastric outlet obstruction. methods and procedures: under general anesthesia six female pigs (mean weight kg) had endoscopic placement of or mm intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a mm laparoscope was used for visualization. endoflip (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the pylorus before intervention, immediately after and at week survival. pyloroplasty was performed using a mm articulating laparoscopic stapler (dextera microcutter). after removing the taggs ports, the gastrotomies were closed by either endoscopic clip, endoscopic suture or suture under laparoscopic vision. the animals were survived for week. after - days, a second laparo-endoscopic procedure was performed to verify healing of the pyloroplasty as well as intraluminal dimensions. at the end of the protocol, animals were euthanized. results: six endoluminal linear stapled pyloroplasty were performed. the mean operative time was min. in all cases, this technique was effective in achieving optimal pyloric dilatation. median pyloric diameter (d) and median cross-sectional area (csa) pre-pyloroplasty were mm ( . - . mm) and . mm ( - mm ). after the procedure, these values were increased to . mm ( . - . mm) and . mm ( - mm ) respectively (p= . the quality of endoscopic examination depends on the quality of endoscopic equipment, experience of the endoscopist and preparation of the patient. contemporarily electronic endoscopes make feasible to transfer image directly to external device which is subsequently linked to computer network and can be transferred further. dynamic image viewed in real time is more accurately interpreted by a physician than a static one. the possibility of simultaneous voice contact makes teleconsultation sterling. the aim of this study was to present our own experience regarding endoscopic teleconsultations. materials and methods: analysis enrolled examinations performed in endoscopic centers located in lesser poland district and in denmark. consultations took place in real time, consulting physicians had more than years of experience in endoscopic procedures and over colonoscopies and therapeutic procedures performed. there were teleconsultations via standard internet connection mb/s. endoscopic centers were equipped with olympus and series linked to video card. each card had its own ip address, and the image was accessible through internet login from anywhere. consulting physicians used computers connected to internet for tracing the image synchronously and giving advice. results: teleconsultations were undertaken in . % of all endoscopic procedures. teleconsultations concerned difficulties in endoscopic image interpretation in cases and decisions regarding further treatment in cases. the consulting physician solved all problems concerning proper endoscopic image interpretation. in cases the elective procedure was rejected. the elective treatment was continued in remaining cases. patients had a complication of polypectomy that was endoscopically treated. conclusions: the opinion of independent consulting physician in difficult clinical cases regarding endoscopic procedures helps to understand the endoscopic image in real time and implicates a decrease in complications after endoscopic procedures. michelle ganyo, md, robert lawson, md; naval medical center san diego introduction: a presacral phlegmon is a contained collection of infected fluid and inflammation within the bony pelvis, posterior to the rectum and anterior to the sacrum, that usually arises as a complication of surgery, malignancy, inflammatory bowel disease, ischemic colitis or perforated viscous. symptoms include low-back pain, pelvic pain and fevers. antibiotics and supportive therapy are the mainstay of treatment. however, if abscess develops, drainage is required usually by trans-gluteal percutaneous and/or surgical methods, both of which are associated with significant morbidity and mortality. endoscopic ultrasound (eus) -guided drainage of perirectal and presacral abscesses is a well described minimally-invasive approach that permits clear definition of anatomy, real-time access to the abscess and creation of an internalized fistula through placement of one or more transluminal stents. however, to date there is no published report describing endoscopic treatment of the more complicated, clinically challenging presacral phlegmon. here we present a case of a symptomatic presacral phlegmon recalcitrant to medical management that was successfully treated with an endoscopically placed retrievable, transmural, lumen-apposing metal stent. case report: this is a case-report of a -year-old, post-partum female who presented with fevers and recurrent lower back pain radiating to her rectum and vagina. her spontaneous vaginal delivery was notable for a second-degree laceration that was primarily repaired at the time of delivery months prior to presentation. her past medical history was otherwise unremarkable. radiographic imaging revealed several perirectal and presacral abscesses that were considered too small for percutaneous drainage. iv antibiotics were started and the largest abscess was targeted for eusguided aspiration. unfortunately, her pain became constant and progressed in severity. a follow-up mri a week later revealed a -cm presacral phlegmon. results: colonoscopy revealed a luminal bulge in the rectum but was otherwise normal. to permit drainage and multiple sessions of endoscopic necrosectomy, a mm lumen-apposing metal stent (lams) was placed transrectally under eus-guidance into the presacral phlegmon. endoscopic debridement with forceps and copious irrigation was performed. over the following weeks the patient reported purulent rectal drainage and resolution of her fevers and pain. repeat endoscopy revealed a normal rectum and no sign of the stent. a follow up mri showed a -cm area of heterogenous tissue in the presacral area. conclusions: although not previously described for management of a presacral phlegmon, lams appears to be a safe and effective, minimally-invasive treatment option. introduction: flexible endoscopy has evolved to include multiple endoluminal procedures such as anti-reflux procedures, pyloromyotomy, and mucosal and submucosal tumor resections. however, these remain technically demanding procedures as they are hindered by the state of flexible technology which has difficult imaging, limited energy devices, no staplers, and cumbersome suturing abilities. an alternative approach is transgastric laparoscopy, which for almost decades has been shown to be a good procedure for pancreatic pseudocyst drainage and full-thickness and mucosal resection of various lesions. we propose to expand the indications of transgastric laparoscopy by using novel endoscopically placed transgastric laparoscopy ports (taggs, kansa, usa) to replicate endoscopic procedures such as endoluminal antireflux surgery. methods and procedures: under general anesthesia female pigs (mean weight . kg) had endoscopic placement of mm-intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a mm laparoscope was used for visualization. endoflip, (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the gastroesophageal junction (gej) before and after intervention. laparoendoscopic-assited suture plication of the gej was performed using - sutures (polysorb®). once the taggs ports were removed, the gastrotomies were closed by using endoscopic clip. at the end of the protocol, animals were euthanized. results: five laparoendoscopic-assited sewing plication were performed. the mean operative time was , min (endoscopic evaluation: . min, tagss insertion: min, endoflip evaluation+ gej plication: , min, gastric wall closure: min). in all cases, this technique was effective in achieving adequate gej plication. median gej diameter (d) and median cross-sectional area (csa) pre-plication were . mm ( . - . mm) and . mm ( - mm ). after the procedure, these values were decreased to . mm ( . - . mm) and . mm ( - mm ) respectively (p= , ). median distensibility (d) and median compliance (c) pre-plication were . mm /mmhg ( . - . mm /mmhg) and . mm /mmhg ( , - , mm /mmhg). after the procedure, these values were decreased to , mm /mmhg ( . - . mm /mmhg) and . mm /mmhg ( . - . mm /mmhg) respectively (p= , ). no intraoperative events were observed. conclusion: a hybrid laparoendoscopic approach is a feasible alternative for performing intragastric procedures with the assistance of conventional laparoscopic instruments; especially in cases where the location of the intervention limits the access of standard endoscopy or where endoscopic technology is inadequate. further evaluation is planned in survival models and clinical trials. introduction: due to previous manipulation or submucosal invasion, colonic lesions referred for endoscopic mucosal resection (emr) frequently have flat areas of visible tissue that cannot be snared. current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. our aim is to describe dissection-enabled scaffold assisted resection (descar): a new technique combining circumferential esd with emr for removal of superficial non-lifting or residual "islands" with suspected submucosal involvement/fibrosis. methods: from to , lesions referred for emr were retrospectively reviewed. cases were identified where lifting and/or snaring of the lesion was incomplete and the descar technique was undertaken. cases were reviewed for location, prior manipulation, rates of successful hybrid resection and adverse events. results: lesions underwent descar due to non-lifting or residual "islands" of tissue. patients were % m, % f, and average age (sd ± . yrs). lesions were located in the cecum (n= ), right colon (n= ), left colon (n= ) and rectum (n= ). average size was mm (sd ± . mm). previous manipulation occurred in / cases ( % biopsy, % resection attempt, % tattoo). the technical success rate for resection of non-lifting lesions was %. there was one delayed bleeding episode but no other adverse events. approximately % of patients have been followed up endoscopically to date with no evidence of residual adenoma. conclusions: descar is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual colonic lesions, providing en-bloc resection of tissue for histologic review. further studies are needed to demonstrate long-term eradication and for comparison with other methods. results: patients underwent fully covered stent placement procedures. indications for stent placement were leak in patients ( sleeve; bypass) and stricture in patients ( bypass, sleeve). five patients had stent migration. three required surgical removal, one patient endoscopic repositioning and one passed the stent per rectum. all eight patients with enteric leak successfully underwent stent placement in conjunction with diagnostic laparoscopy and drainage. all but one of these patients developed an enteric leak perioperative to index procedure. the average duration of stent treatment in these patients was days ( - days). of the patients treated for a stricture, patients ( sleeve, bypass) failed treatment and required subsequent definitive operative revision. average length of time of stent treatment in these patients was days (range, - days) and five had severe intolerance. conclusions: endoscopic stent placement of leak may require multiple procedures and carries the risk of migration; however, this therapy seems to be an effective treatment. failure rates are higher with strictures and are not as tolerated by patients. background: colonoscopy is the most commonly performed endoscopic examination worldwide and is considered the gold standard for colorectal cancer screening. the quality of examination and endoscopic treatment is affected by a number of factors that are verified by recognized parameters such as cecal intubation rate and time (cir, cit), withdrawal time, adenoma detection rate (adr) and polyp detection rate (pdr). advanced endoscopic imaging improves accurate recognition of the nature and variety of pathologic lesions, while the endoscope tips, third eye retroscope and wide-angle endoscopy allow detection of lesions located on the proximal side of the intestinal folds. the aim of the study was to assess the suitability of wide-angle colonoscopy for the detection of colorectal lesions and to analyze the functionality of a special endoscope series regarding cir, cit and withdrawal time. introduction: leak is an uncommon but serious complication of gastrointestinal surgery. when identified post-operatively, percutaneous drains are used to manage abscesses and prevent further peritoneal contamination. if drain position is suboptimal, however, the consequences of persistent leak may necessitate a formal surgical intervention in a hostile abdomen. in select situations, we have utilized natural orifice transluminal endoscopic surgery (notes) methods to enter the abdominal cavity and place/reposition drains under direct endoscopic visualization a part of our comprehensive endoscopic management algorithm for leaks. methods and procedures: a prospectively collected database was queried for patients who had undergone transluminal endoscopic drain repositioning (tedr) as part of multimodal endolumenal therapy for leak (including interventions like defect closure, enteral feeding access, or endolumenal stent placement). inadequate drainage was identified pre-procedurally by undrained fluid collections in conjunction with clinical signs of sepsis. translumenal access was obtained via the leak site and carbon dioxide insufflation was used in all cases. the peritoneal cavity was surveilled and cleared of gross debris by irrigation and suction. intraabdominal drains were located endoscopically and fluoroscopically, grasped with an endoscopic snare or grasper and repositioned adjacent to the leak site to ensure better drainage. results: four patients ( female), average age (range - ), average body mass index (range - ) were managed with tedr as a component of endoscopic treatment of full-thickness gastrointestinal leak. two patients developed leak following revisional bariatric surgery. one patient had an acutely dislodged gastrostomy tube with intraperitoneal leak after multiple laparotomies recently closed with a granulating vicryl mesh. one patient developed a leak at an esophagojejunostomy following total gastrectomy. three patients had adequate drainage after the initial tedr, while one patient required tedr on two occasions. all patients had improved drainage demonstrated by resolution of clinical signs of sepsis and resolution of fluid collections. drains were removed as clinically indicated. conclusion: intraabdominal drains are an essential element in the management of full-thickness gastrointestinal leaks, but are not always able to be adequately positioned percutaneously. transluminal endoscopic drain repositioning via a gastrointestinal defect is a viable option to avoid surgical intervention in an otherwise hostile field and is a novel practical notes application. background: epiphrenic diverticula (ed) arise from increased intraluminal pressures, often secondary to achalasia or another underlying esophageal motility disorder which causes "pulsion" physiology. ed are traditionally thought to contribute to patients' symptoms of regurgitation and dysphagia, and are frequently resected at time of heller myotomy and fundoplication done for treatment of the primary motility disorder. ed excision carries significant risks (staple line leak, pulmonary complications, mortality), and little is known regarding patients with ed and esophageal motility disorder who undergo surgical myotomy without ed resection. the goal of this study was to compare outcomes of patients with ed and esophageal motility disorder who did and did not undergo diverticulectomy at time of myotomy and fundoplication. methods: retrospective analysis of prospectively collected database from to was performed. patients with diagnosis of ed undergoing surgical treatment of symptomatic esophageal motility disorder were included. all patients underwent laparoscopic heller myotomy with toupet fundoplication by a single surgeon at a tertiary referral hospital. patients were stratified according to whether ed was excised or not excised at time of primary surgery. patient-reported symptoms were obtained from pre/post-operative clinic evaluations and mailed surveys during the follow-up period. independent samples t-test and fisher's exact test were used to compare continuous and categorical variables respectively. results: ed was identified in patients prior to surgery. primary diagnoses included achalasia (n = ), nutcracker esophagus (n= ), and diffuse esophageal spasm (n= ). ed was excised in five patients ( . %) and not excised in ten patients ( . %), with no significant difference in frequency of preoperative dysphagia ( % vs. %, p= . ) or regurgitation ( % vs. %, p= . ) between groups respectively. reasons for non-resection included ed was too proximal (n= ), patient/surgeon preference (n= ), and small ed size (n= ). the resection group did not experience any leaks and there were no mortalities in either cohort during the follow-up period. at mean clinic follow-up of days, there was no difference in frequency of residual dysphagia in patients who did or did not undergo ed resection ( % vs. %, p= . ) and neither cohort reported residual regurgitation symptoms. conclusions: this study suggests that leaving ed in place during surgical treatment of an esophageal motility disorder may achieve similar rates of postoperative symptom control. while ed excision in this study did not cause significant excess morbidity, ed resection introduces risk of leak and requires more extensive surgery that may not provide significant benefit to patients. introduction: median arcuate ligament syndrome (mals) has been described in the literature as presenting with a constellation of symptoms including nausea, vomiting, weight loss, and post-prandial epigastric pain. while many of these symptoms are consistent with foregut pathology, a cohort of patients with mals presenting with delayed gastric emptying has not been described in the literature. in this study we report on the possible association of mals with delayed gastric emptying. methods: cases of mal release were collected between and . eight patients were identified who presented with mals and underwent subsequent mal release. all patients underwent laparoscopic or robotic surgery. patients were compiled into a retrospective database and their demographic, symptomatic, imaging, and outcomes data were analyzed. background: laparoscopic fundoplication (lf) is often performed to treat paraesophageal hernia and/or gerd. care is taken to select the right patients for the operation. some patients may not improve, and others experience dysphagia or bloating after surgery. factors associated with patient satisfaction after fundoplication would be helpful during the patient selection process. methods: a retrospective review of a prospectively collected database was performed. queried patients underwent lf from to . non-elective operations and fundoplications after heller myotomy were excluded. of this cohort, patients were included only if they responded to a two-year postoperative quality of life survey. surveys were distributed preoperatively, at three weeks, at one year, and at two years. the surveys include the reflux severity index, gerd-hrql, and dysphagia score. the gerd-hrql asks about patient satisfaction with their current state ( = dissatisfied, = somewhat satisfied, = very satisfied). the cohort was divided according to their answer to this question at two years. demographics and preoperative factors were compared between the groups with kruskal-wallis and fisher's exact tests. univariable and multivariable ordinal logistic regression was performed to identify preoperative symptoms associated with satisfaction at two years. scores on the surveys over time were were also analyzed. results: a total of patients were included in the analysis (dissatisfied = , somewhat satisfied = , very satisfied = ). the only significant demographic or preoperative difference was a high number of paraesophageal hernias in the 'very satisfied' cohort (p = . ). on univariable regression, younger age and paraesophageal hernia predicted satisfaction. several variables negatively predicted satisfaction with an or \ . multivariable regression, controlled for age and hernia type, identified throat clearing, post-nasal drip, and globus sensation as preoperative symptoms less likely to result in patient satisfaction (p = . , . , and . , respectively). subgroup analysis of patients with paraesophageal hernias revealed that patients with bloating preoperatively are less likely to be satisfied at two years. survey scores over time showed all groups improving over three weeks, but while satisfied patients continued to improved, dissatisfied patients symptomatically worsened over time. conclusion: this study confirms previous reports stating atypical symptoms of gerd are less likely to improve after lf. it also shows individuals with paraesophageal hernia tend to do quite well, unless they report bloating preoperatively. patient-centered analysis such as this can be useful when discussing postoperative expectations with patients, and may reveal opportunities to individualize operative approach. objective: the study was performed to assess whether sutured crural closure or mesh reinforcement for hiatal closure yields better results with regards to symptom resolution and recurrence post-operatively. material and methods: a prospective randomized controlled trial was carried out at grant medical college and sir j. j. group of hospitals, mumbai, india. patients were randomized to receive either sutured repair or mesh reinforcement of hiatal closure. outcomes of interest were symptom resolution, quality of life scores and recurrence in the postoperative period. results: patients were recruited for the trial ( -sutured repair, -mesh reinforcement). the two groups were comparable in terms of demographic profiles, symptom severity and findings at esophagogastroscopy and manometry in the pre-operative period as well as size of the hiatal defect measured intra-operatively. post-operatively the mesh repair group had significantly better symptom resolution in terms of early satiety, chest pain and regurgitation (p\ . ) while with respect to heartburn, dysphagia and post-prandial pain there was no significant difference between the improvements demonstrated. improvement in quality of life scores after either procedure was not significantly different. recurrence was higher in the suture repair group ( vs , p. ). recurrence lead to poorer symptom severity scores as well as quality of life scores and one patient underwent re-operation. the change in the symptom severity score from baseline after the procedure at months in the subgroup population. conclusion: mesh reinforcement results in a reduced rate of recurrence and offers excellent symptom control in the short-term without a rise in complications when compared to sutured repair for the closure of hiatal defects in laparoscopic hiatal hernia repairs. material and methods: in a period from to , patients underwent laparoscopic resection ( -gastric resection, -duodenal resection), using different techniques. all patients were investigated with upper gi endoscopy, eus and abdominal contrast-ct, which allows us to get the complete evaluation of tumor, including size, location, type of growth and the gi layer. based on the findings the decision on the type of resection was made. the majority of resections were wedge or partial resections, performed using endoscopic steplers or using ultrasound scissors followed by double-suturing of gatro/duodenotomy. in the cases of tumor location on the posterior gastric wall we mobilized the the greater curvature to get a direct approach to the tumor with extraluminal growth. in the cases with intraluminal growth we used transgastric approach with small , cm incision on the anterior gastric wall for endoscopic stepler. technically the most complex procedures were in the cases of tumor location close to anatomically narrow places and muscle sphincters (gastroesophageal junction, pylorus, duodenal bulb, duodenal flexure), with high risk of stenosis and dysfunction of anatomical sphincters. in such cases we used «lifting-technique» in which we dissect serous and muscle layers circumferentially around the tumor making partial enucleation of lesion followed by total resection preserving almost all normal tissue with minimal suturing and deformity at the site of surgery. ( : ), mean age was . years (sd ± . ), patients ( %) had mis. the type of reconstruction was predominantly with a "pull-up" technique (n = , . %) followed by the kirschner-akiyama procedure (n = , . %), stapled gastroplasty was performed in patients. all the anastomosis were performed at the level of the neck and only one of the patients had a stapled anastomosis, mean operative time was min (sd ± min) including resection of the specimen. primary neoplasms were predominantly hypopharynx (n = , . %), distal esophagus (n = , %), cervical esophagus (n = , . %) and thoracic esophagus (n = , . %). histologic types were mainly squamous cell carcinoma (n = , . %) and adenocarcinoma (n = , . %). mean of hospitalization days was . (sd ± . ). no complications were observed in patients and major complications (dindo-clavien ≥iiib) were found in patients. anastomotic leak was present in patients ( . %) and perioperative mortality ( days) was . %. progressive shift to laparoscopic surgery was evidenced through the years ( - : . %, - : . % and - : . %; p = . ) and reduction in major complications (p = , ) was observed. anastomotic leaks (p = , ) and perioperative mortality (p = . ) did not show significant differences in the present study. conclusions: results in our center show that major complications decrease with time after application of minimally-invasive surgery and no differences in anastomotic leaks and mortality were seen. current data has lead us to abandon open total esophagectomy as a first-choice procedure. introduction: minimal invasive three-fields esophagectomy for minimal invasion is the surgical standard for oncological procedures and benign diseases. cervical dissection has a risk of to % in some series, of, lesion or paralysis of the rnl, but the standard in mckeon approach is %. a high level of suspicion is needed because this type of lesion has an impact on postoperative evolution and the hospital stay. main: to describe three cases of rnl post esophagectomy paralysis in three planes by least invasion. methods: in a period of years, january to june , esophagectomies for bening disease were performed. three patients ( males female) with diagnosis of terminal achalasia and stenosis secondary to caustic ingestion consulted at the minimal invasion service fundcacion valle del lili. they were schedualed for minimal invasive three fields esophagectomy, one patient without complications and early discharge ( postoperative day) but occasional dysphagia, the other two required early reintubation after de surgery with ards, patient requiered tracheostomy, the second patient could be extubated after days but with occasional dysphagia. all three had mild hoarseness after surgery. the patient who required tracheostomy was decannulated at days without complication. results: the three patients underwent endoscopy without complication in the cervical anastomosis stenosis or disorder in the emptying of the gastric tube, swallowing study without alteration and laryngoscopy with paralysis of the left vocal cord. these patients went to speech therapy with total paralysis recovery at months corroborated with laryngoscopy, without dysphagia or hoarseness. conclusion: rnl innervates the larynx and upper esophageal sphincter, therefore lesion or paresis causes symptoms such as hoarseness, dysphagia, difficulty swallowing, aspiration, difficulty in coughing, pneumonia and ards. injury has a predecessor factor in pulmonary complications and prolongation of the hospital stay. % of these patients may require some surgical procedure to restore the function of rnl. noninvasive monitoring of the laryngeal nerve decreases the risk of injury. philip case report: multiple esophageal diverticula associated with achalasia introduction: achalasia is well defined disorder of increased lower esophageal sphincter tone ( ). epiphrenic esophageal diverticulum are a rare disorder believed to result from increased intraesophageal pressure often in conjunction with a motility disorder causing functional outflow obstruction. they are a pulsion-type pseudo-diverticulum with mucosal bulging most frequently from the right posterior esophageal wall ( ) . we present a very rare case of achalasia associated with multiple esophageal diverticula successfully treated with laparoscopic heller myotomy with dor fundoplication. case presentation: a year old woman presented with years of dysphagia, chest discomfort, regurgitation, and weight loss. esophagoscopy showed a patulous esophagus with multiple esophageal diverticula (figure ). barium esophogram demonstrated esophageal diverticula in the distal esophagus and delayed clearance of esophageal contrast (figure ). high resolution monometry revealed a hypertensive mean les, an aperistaltic body on of wet swallows, and panesophageal pressurization in of wet swallows -consistent with type ii achalasia by chicago classification ( ). we performed a laparoscopic heller myotomy with dor fundoplication. the myotomy was extended cm above the gasgtroesophageal junction and cm onto the gastric cardia. an anterior diaphragmatic defect with a moderate type hiatal hernia was repaired with two sutures, ensuring to not impinge the esophagus (figure ). at weeks post operatively the patient reports excellent results. her dysphagia and chest discomfort have entirely resolved. her eckhardt score improved from seven preoperatively to one post operatively. discussion: type ii achalasia is successfully treated in the majority of cases with laparoscopic heller myotomy and partial fundoplication ( ). however, esophageal diverticula typically require both myotomy as well as diverticulectomy for successful treatment ( ) . there is little experience with the surgical management of multiple esophageal diverticula. we propose a two stage surgical approach for these patients. we reason that the risk of esophageal leak or stenosis in the case of multiple esophageal diverticulectomies out weighs the proposed benefit. indeed epidemiologic studies indicate that the majority of esophageal diverticula are asymptomatic ( ) . in the event the patient remains symptomatic after myotomy a second stage operation with diverticulectomies would be possible. this single experience suggests that diverticulectomy may not be necessary in the case of multiple diverticula associated with achalasia. instead, treatment may be directed at relieving the functional obstruction responsible for the symptoms by performing laparoscopic heller myotomy with dor fundoplication. takahiro kinoshita, md, facs, masanori tokunaga, md, akio kaito, md, masahiro watanabe, md, shizuki sugita, md; national cancer center hospital east, japan objective: the optimal surgical approach for siwert type ii cancer is still controversial due to the anatomical complexity of the region. potential advantages of laparoscopic transhiatal approach have not been fully investigated. methods and procedures: we retrospectively analyzed consecutive patients with siewert type ii cancer who underwent laparoscopic transhiatal resection. indication of surgery is patients with siewert type ii cancer with less than cm esophageal invasion. regarding the extent of resection, basically proximal gastrectomy with the lower esophageal resection was selected, aiming at preservation of gastric reservoir function. in terms of reconstruction after proximal gastrectomy, double-tract method was performed. intraoperative peroral endoscopy was routinely employed for determination of the appropriate resection level of the stomach. esophagojejunostomy was employed by overlap method using a mm linear stapler. in order to obtain a wider operative field in the lower mediastinum, the diaphragmatic crus was dissected to widen the esophageal hiatus. results: in patients ( males and females), median operation time was minutes, and estimated blood loss was g. the rate of surgical morbidity was %, and that of anastomotic leakage was %. there was no mortality. the mean length of proximal margin was mm, and no positive margin was recorded. the -and -year overall survival rate was . % and %, respectively. conclusions: laparoscopic transhiatal resection for siewert type ii cancer is technically challenging, but appears feasible and safe when performed by an experienced surgical team. a largescale prospective study is necessary for final conclusion. introduction: mesh use for reinforcement of primary crural closure is controversial. synthetic mesh use poses a risk of erosion but there is no evidence that non-synthetic mesh is useful to minimize the risk of hernia recurrence. we evaluated a fully bioresorbable mesh made from poly- -hydroxybutyrate (p hb) for crural reinforcement after para-esophageal hernia (peh) repair. the aim of this study was to evaluate the safety and efficacy of p hb mesh at the hiatus in patients undergoing peh repair. this was a review of prospectively collected data on consecutive patients that had repair of a peh with reinforcement of the crural closure with p hb mesh. to be considered a peh at least % of the stomach was herniated into the chest. a collis gastroplasty or crural relaxing incision was added for short esophagus or crural tension when necessary. routine follow-up consisted of esophagogastroduodenoscopy (egd) at months for patients that had a collis gastroplasty and a barium upper gi study (ugi), high resolution manometry (hrm) and ph test in all patients at months. a hernia of any size identified during objective follow-up testing was considered a recurrence. overall, there was a significant difference in mean measured tension between the three subjective suture ratings by the surgeons. however, there was substantial variability and overlap amongst the surgeon's ratings (figure) . the tension necessary to approximate the crura during peh repair can be objectively measured and as expected increases progressively with anterior movement up the hiatus. while there was some correlation between a surgeon's subjective assessment of the tension necessary to bring the crura together and actual measured tension, there was wide variability and imprecision from one stitch to another. objective tension measurement may provide a more reliable assessment of when excessive force is being used to re-approximate the crura and potentially improve peh recurrence rates. ahmed introduction: paraesophageal hernia repairs are increasing in prevalence, and unfortunately carry a high recurrence rate. consequently, reoperation is expected to increase in frequency. published data on the outcomes of recurrent paraesophageal hernia (rpeh) repair is very limited. because of the technical difficulties of revisional surgery, we hypothesize that laparoscopic revisional paraesophageal hernia repairs are associated with high perioperative morbidity and poor patient outcomes. methods: all rpeh repairs performed by the foregut surgical service at our institution from to were reviewed. patients were included if their index operation was a true pehr (initial type hiatal hernia repairs were excluded, as well as multiply recurrent hernias). demographics, medical and surgical history, and operative notes from the index surgery were reviewed. details from standardized pre-operative symptom assessment, objective testing and operative details for the revisional surgery were collected. patients were routinely offered month post-operative upper gastrointestinal contrast evaluation. postoperative outcomes included a standardized symptom assessment and results of objective testing at any time after surgery. results: twenty six patients were identified who underwent repair of rpeh. demographic, operative and perioperative data was available for all patients (table ) . twenty four patients underwent followup symptom evaluation (two were lost to follow-up after the initial hospitalization). sixteen patients underwent follow-up objective testing by radiographic evaluation with contrast, endoscopy or both. these subgroups were used to calculate symptomatic and objective outcomes (table ) . conclusion: reoperative laparoscopic surgery for recurrent paraesophageal hernias is technically challenging as evidenced by long operative times. despite this, perioperative outcomes at a high volume center are good, with low morbidity and no mortality. importantly, symptomatic outcomes for this difficult problem are excellent. introduction: hypotension of the lower esophageal sphincter (hles) and the presence of hiatal hernia (hh) have both been associated with gastroesophageal reflux disease (gerd). the exact likelihood with which a hles or a hiatal hernia predict gerd continues to be defined. we hypothesize a synergistic interaction in those with hles and hh in predicting gerd as defined by a positive ph study. methods and procedures: between and , consecutive patients presenting to a surgical practice with symptoms most concerning for gerd, without prior antireflux surgery were evaluated by high resolution manometry (hrm), esophagogastroduodenoscopy (egd), videoesophagography (veg) and an ambulatory ph study. hles was defined as residual les pressure of\ mmhg, hh was defined as having been noted and measured by the radiologist, these were further categorized into any hh, - cm, [ - cm background: while clinical outcomes have been reported for antireflux surgery, there is limited data on postoperative outpatient encounters and their associated costs. the aim of this study is to evaluate the utilization of healthcare and its associated costs during the -day postoperative period following antireflux surgery. methods: we analyzed data from the truven health marketscan® research databases. patients ≥ years with an icd- procedure code or cpt code for antireflux surgery and a primary diagnosis of gerd during - were selected. only patients with continuous enrollment six months prior to the date of surgery and -days after surgery were analyzed. patients with a diagnosis of esophageal cancer or achalasia during the six-month period prior to antireflux surgery, a length of stay [ days following index procedure, a capitated plan, or patients who underwent emergency surgery were excluded. outpatient endoscopy was defined using icd- and cpt codes, and related readmission was defined by clinical classification software. introduction: the development of postsurgical gastroparesis following nissen fundoplication is poorly understood. in this study, we analyze the development of gastroparesis requiring intervention and other subsequent procedures following fundoplication and paraesophageal hernia (peh) repair procedures in the state of new york. methods: using a comprehensive state-wide administrative database (sparcs), we examined all in-patient and outpatient records for adult patients who underwent fundoplication or peh repair as a primary procedure for the treatment of gerd between the years of - . patients with an initial gastroparesis diagnosis were excluded from the analysis. through the use of a unique identifier, each patient was followed until for the subsequent diagnosis of gastroparesis or reoperation. surgical procedures for the treatment of gastroparesis included pyloroplasty, pyloromyotomy, or gastroenterostomy procedures. multivariable logistic regression models were used to identify independent predictors for having subsequent reoperation. results: a total of , patients were analyzed. this included , fundoplication patients ( . %) and , ( . %) with peh repair. in the fundoplication group, ( . %) patients had a follow-up diagnosis of gastroparesis or secondary procedure. ( . %) of the patients who underwent a primary peh repair procedure had a follow-up procedure or gastroparesis diagnosis (table ) . mean time to follow-up procedure or diagnosis was . years for the fundoplication group and . years for the peh repair group. the majority of the follow-up procedures in the fundoplication group were revisional procedures (fundoplication or peh repair) (n = , . %), while ( . %) patients were newly diagnosed with gastroparesis and/or underwent a secondary procedure for its treatment. conclusion: fundoplication and peh repair procedures have a relatively low post-operative incidence of gastroparesis following initial procedure for treatment of gerd. secondary fundoplication or peh repair was more commonly performed compared to any of the surgical procedures for gastroparesis for both procedures. further analysis of association with subsequent procedures is needed. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in cases. the mean operation time was min. the outcome was assessed by reflux test performed on - postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was months ( - months). in cases ( . %) ppi was restarted before months after the anti-reflux surgery. in cases ( . %) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed "the esophagitis score". in this scoring method, a number from - was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p. ). discussion: the number of gerd patients who needed anti-reflux surgery seems to be so high. to extract the patients who needed it remarkably is important. the anti-reflux surgery is most effective for the patients who really have the obvious reflux. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good and satisfied by the patients mostly. surg endosc ( ) :s -s introduction: fundoplication at the time of giant paraesophageal hernia repair is controversial. the proposed advantages are better reflux control and lower recurrence. disadvantages include fundoplication specific complications, might be unnecessary and may not decrease recurrence. we retrospectively reviewed giant paraesophageal hernia repairs (peh) with two point gastropexy in the fundus and body, and no antireflux procedure. data collected is postoperative gerd symptoms, postoperative proton pump inhibitors (ppis) therapy and recurrence. methods: a retrospective review of patients who underwent repair of giant peh from to december of . giant was defined as a hernia with % or more of the stomach above the diaphragm. follow up consisted of upper gi (ugi) study one year postoperatively and reflux symptom questionnaire. patients were followed every months in the surgery clinic and a ppi wean was initiated at the second postoperative visit. the primary outcome we evaluated was discontinuation of ppis. in addition, we utilized a standardized reflux scale and recurrence rates collected. chi-squared was used for statistical analysis. background: gastroesophageal reflux disease (gerd) is a highly prevalent disorder with a multitude of treatment options ranging from lifestyle modifications and medical management to surgical options. despite the numerous treatments available, there is still debate over which approach is most appropriate and effective for patients. this study aims to examine the effect of robotic hiatal hernia repair (rhhr) with the novel addition of esophagopexy in patients with gerd. methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rhhr with a partial fundoplication and concomitant esophagopexy for gerd from november to july . patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was resolution of subjective gerd symptoms and discontinuation of proton pump inhibitor (ppi). recurrence of hiatal hernia was a secondary endpoint. results: eleven patients were identified meeting the inclusion criteria (rhhr + esophagopexy) with a mean follow-up of . weeks ± . weeks. in regards to the rhhr, % underwent a partial fundoplication and the additional % underwent a re-do wrap. this patient cohort was . % female with a mean age of . ± . years. preoperative esophagogastroduodenoscopy (egd) was performed in % of patients with the study showing a hiatal hernia in . %, gastritis in . % and esophagitis in . % of patients. manometry was performed in . % of the patients showing % of these patients with esophageal dysmotility. esophagograms and ph studies were performed preoperatively in . % and . % of patients respectively. preoperatively, % of patients had a documented diagnosis of gerd and were taking a ppi and/or h blocker. after rhhr with esophagopexy, . % of patients had resolution of their gerd symptoms while . % (n = ) remained symptomatic. however, one of two patients reported a subjective decrease in symptom severity following the procedure. despite resolution of symptoms, . % remained on ppis. another % switched to h blockers and one patient discontinued all antisecretory therapy. none of the patients experienced recurrence of their hiatal hernia. conclusion: based on our data, rhhr with esophagopexy results in resolution gerd symptoms in over % of symptomatic patient. in patients with hiatal hernias and gerd, rhhr with esophagopexy does lead to resolution of symptoms, however, the majority of patients remained on ppis. long-term follow up is needed to investigate whether these patients are able to discontinue ppis and remain symptom free. chaya shwaartz, nadav zilka, mustapha siddiq, yuri goldes, md; sheba medical center, israel background: d gastrectomy for gastric carcinoma is a well-established procedure in patients undergoing surgery for gastric cancer and is the standard of care in our institution. reduced pain, early ambulation, and better cosmetics are some of the benefits of minimally invasive surgery for early gastric cancer. we aimed to describe our experience in laparoscopic d gastrectomies undertaken by a single surgeon in our institution. methods: this is a single-center retrospective review of prospectively collected d gastrectomies performed by a single surgeon. between november and february , laparoscopic subtotal/total gastrectomies were performed at sheba medical center, a tertiary center for forgut cancer. clinicopathological characteristics of the patients, surgical performance, postoperative outcomes and pathological data were collected. results: forty-five patients underwent laparoscopic gastrectomy. of these, had subtotal gastrectomy and had total gastrectomy. the median age in our series ( - ). most of the patients in our series had early gastric cancer (t - ) ( %). the mean average of dissected lymph nodes was ± . the mean operative time was ± . the postoperative complications, classified using the clavien-dindo classification. severe complications ([ cd iiia) rate was %. conclusions: laparoscopic d gastrectomy for invasive gastric cancer is safe and feasible when carried out in high-volume centers by an experienced surgeon as part of a multidisciplinary team with careful case selection and appropriate high-quality postoperative support. minimally invasive management of diaphragmatic hernias after esophagectomy: a case report introduction: esophagectomy is a common treatment for both benign and malignant pathologies of the foregut. hiatial paraconduit hernias are rare complications following esophagectomy. in this study, we review our experience with these rare diaphragmatic hernias. methods: a retrospective analysis of all patients presenting with hiatial hernia after esophageal resection at the university of oklahoma health science center between and was performed. data was abstracted from the medical record for evaluation and included demographics, symptoms, repair techniques and outcomes. no patients were excluded. results: a total of ten patients were identified to have paraconduit hernias. during this time interval, there were a total of esophageal resections performed. all patients had esophagectomy for malignant disease. seven of the patients have undergone surgery. two patients are asymptomatic and are being followed at their request, and one patient is pending elective correction. of the seven patients who underwent surgery, the median age was , with males and two females. six of the seven patients underwent minimally invasive ivor lewis esophagectomy and one had an open mckeown procedure. the median time from esophagectomy to hernia repair was months, with range from month to months. the most common presenting complaint was abdominal pain and nausea. one patient was noted to have a paraconduit hernia on postoperative day and taken to surgery for repair during the hospitalization. there was one death in a patient who presented with necrosis of the small bowel. the remaining patients all had laparoscopic approach. one patient required a hand port to reduce incarcerated colon and one patient was noted to have a cecal perforation during port closure requiring repair. all patients had herniated colon, with small intestine or pancreas herniation noted in three. repair was performed by reducing the viscera, a left phrenic relaxing incision, closure of the hiatus around the conduit and then closure of the diaphragmatic defect with mesh. at median follow up of months, there are no recurrences. conclusion: hiatal paraconduit hernias are becoming a frequent finding among survivors of esophageal cancer surgery. our study demonstrates that there is a propensity for patients who undergo minimally invasive esophagectomy to develop these hernias. the vast majority of patients can undergo laparoscopic repair. our recommendation is to perform a diaphragmatic relaxing incision and liberal use of mesh. early results appear to be favorable regarding recurrence. aim: there have been several reports illustrating the safety and efficacy of various surgical techniques in performing laparoscopic esophagojejunostomy (ej). this study aims to compare two established methods of ej anastomosis -circular stapling with purse-string suture ("lap-jack") and linear stapling technique -in laparoscopic total gastrectomy. methods: patients diagnosed with gastric cancer underwent intracorporeal ej anastomosis in laparoscopic total gastrectomy from january, to october, . cases used the circular stapler with purse-string "lap-jack" method, and patients used the linear stapling method for ej anastomosis. were matched using propensity scores, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed. the two groups showed no significant difference in age, bmi, or other clinicopathological characteristics, and there was no conversion to an open procedure. after propensity score matching analysis, the linear group had significantly shorter operating time ( . ± . vs . ± . , p≤ . ) and more sufficient proximal margin ( . ± . vs . ± . , p = . ). no significant difference was found in estimated blood loss, retrieved lymph node, hospital stay, and time for first flatus. there was no postoperative mortality. early postoperative complication of the circular and linear group occurred in ( . %) and ( . %, p = . ) patients respectively. ej leakage occurred in ( . %) cases from each groups, with ( %) case from both group needing radiologic or surgical intervention. no other significant difference in early complication was found. late complication was observed in ( . %) cases (circular = linear = , p = . ) with ej anastomosis stricture in the linear group, but there was no statistical significance. conclusion: both circular stapling and linear stapling techniques are feasible and safe in performing intracorporeal ej anastomosis during laparoscopic total gastrectomy. linear-stapling technique had more sufficient proximal margin and shorter operating time. there was no significant difference in anastomosis related complication between the two groups. masahiro watanabe, masanori tokunaga, akio kaito, shizuki sugita, takahiro kinoshita; national cancer center hospital east, gastric surgery division background: although the current standard treatment for advanced gastric cancer (agc) is open gastrectomy, laparoscopic gastrectomy (lg) is increasingly performed, especially in the east. however, it is a technically demanding procedure, and the feasibility remains unclear. the aim of the present study was to clarify the feasibility of lg for agc. patients and methods: the present study included patients who underwent lg for agc between and . the indication of lg has gradually expanded in our institute, and is currently any stage gastric cancer except for gastric cancer obviously invading adjacent organs or gastric stump carcinoma. we retrospectively reviewed short-and long-term surgical outcomes of the patients. results: male/female ratio was : , and median age (range) was ( - ) years. distal gastrectomy was most frequently performed ( %), followed by total gastrectomy ( %). median operation time and intraoperative blood loss was ( - ) minutes and ( - ) g, respectively. clavien-dindo grade iii or more complication rate was . %. with a median followup period of months, the -year recurrence free survival rates of pstage ii and iii patients were % and %, respectively. conclusion: the outcomes of lg for agc are satisfactory, provided that an experienced team performs the surgery. introduction: the present study aims to evaluate the predictive value of indocyanine green (icg) for the detection and prevention of anastomotic leak following esophagectomy. anastomotic leak is a highly morbid and potentially fatal complication of esophagectomy. ensuring adequate perfusion of the gastric conduit can minimize the risk of postoperative leak. intraoperative evaluation with fluorescence angiography using icg offers a dynamic assessment of gastric conduit perfusion, and can guide anastomotic site selection. methods: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using the search terms "indocyanine/fluorescence" and esophagectomy was completed to include all english articles published between and august . articles were selected by two independent reviewers based on the following major inclusion criteria: ( ) esophagectomy with gastric conduit reconstruction; ( ) use of fluorescence angiography with indocyanine green to assess perfusion; ( ) age ≥ years; ( ) sufficient outcome data for the calculation of leak rates and ( ) sample size ≥ . the quality of included studies was assessed using the quality assessment of diagnostic accuracy studies- . results: our literature search yielded potential studies, of which studies were included for meta-analysis after screening and exclusions. there were eleven prospective and three retrospective studies. the pooled anastomotic leak rate when icg was used was found to be %. pooled sensitivity and specificity for leak detection were . ( . - . ) and . ( . - . ), respectively. when studies involving intraoperative modifications were removed, pooled sensitivity and specificity were only marginally changed to . ( . - . ) and . ( . - . ), respectively. the diagnostic odds ratio was found to be . ( . - . ) across all studies and . ( . - . ) when intraoperative interventions were excluded. only three trials included a control group, giving a sample size of . in studies with a comparator group, icg was associated with an % reduction in the risk of anastomotic leak [or: . ( . - . )]. conclusions: in non-randomized trials, the use of icg as an intraoperative tool for visualizing vascular perfusion and conduit site selection, is promising. however, poor data quality and heterogeneity in reported variables limits cross-study comparisons and generalizability of findings. randomized, multi-center trials are needed to account for independent risk factors for leak rates and to better elucidate the impact of icg in predicting and preventing anastomotic leaks. objective: robotic assistance for bariatric surgery represents a novel application of a rapidly emerging technology. its safety and efficacy remains primarily characterized by smaller, singleinstitution studies. in this investigation, the influence of robotic assistance on short-term perioperative outcomes is contrasted with the more established primary multi-port laparoscopic approach for patients undergoing roux-en-y gastric bypass (rygb), using data from a national bariatric database. methods: a retrospective analysis of , robotic-assist and , laparoscopic rygb patients from the metabolic and bariatric surgery accreditation and quality improvement program national database were reviewed for differences in patient characteristics and short-term outcomes. on bivariate analysis, variables associated with primary outcomes of -day reoperation, readmission and reintervention were imputed into multivariate analyses to determine independent significance. results: robotic-assist bypass patients were older (p\. ), had a higher prevalence of comorbidities and had concomitant operations more frequently performed during surgery (p\. ). on bivariate analysis, robotic-assist patients had a higher rate of readmission than laparoscopic patients ( . % vs. . %; p=. ), but no differences in -day reoperation ( conclusion: robotic-assistance does not confer an increased rate of morbidity and mortality after rygb, and represents a feasible surgical modality for the surgeon willing to adopt the technology and accept its limitations. alicia m bonanno, md, brandon tieu, md, farah husain, md; oregon health and science university introduction: marginal ulcer is a common complication following roux-en-y gastric bypass with incidence rates between and %. most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. revision of the gastrojejunal (gj) anastomosis carries significant morbidity and mortality with complication rates ranging from to %. thoracoscopic truncal vagotomy (ttv) may be a safer alternative with decreased operative times. the purpose of this study is to evaluate the safety and effectiveness of ttv in comparison to gj revision for treatment of recalcitrant marginal ulcers. methods and procedures: a retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from st september to st september . all underwent medical therapy along with lifestyle changes prior to intervention and had preoperative egd that demonstrated a recalcitrant marginal ulcer. revision of the gj anastomosis or ttv was performed. data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate. statistical analysis was performed using t-test and fischer's exact test. results: a total of fifteen patients were identified who underwent either gj revision (n= ) or ttv (n= ). there were no -day mortalities in either group. mean operative time was significantly lower in the ttv group in comparison to gj revision ( . ± vs. . ± minutes respectively, p= . ). recurrence of the ulcer was not significant between groups and occurred following gj revisions and ttv. overall complication rate was not significantly different with % in the gj revision group and % in the ttv group. complications included anastomotic leak ( gj), anastomotic stricture ( gj), aspiration ( ttv), dysphagia ( gj and ttv), and dumping syndrome ( gj). conclusions: our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. however, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups. we present a case of a -year-old female with a history of thyroid cancer who initially presented to an outside hospital complaining of reflux, abdominal pain, early satiety, and -pound unintentional weight loss. endoscopy demonstrated a cm pre-pyloric mass; with initial biopsies of the mass demonstrating only gastric mucosa. endoscopic ultrasound and fna of the lesion also failed to elucidate its pathology. due to the pyloric location of the mass and inability to rule out invasive malignancy, we recommended a robotic-assisted transgastric submucosal resection with possible distal gastrectomy. intraoperatively we found a -degree circumferential pre-pyloric exophytic sessile tumor. frozen sections suggested a benign papillary tumor therefore we proceeded with submucosal resection. the resulting mucosal defect and gastrotomy were closed primarily with absorbable suture. final pathology showed the tumor to be a tubulovillous adenoma with high grade dysplasia arising against a background of intestinal metaplasia. the resection margins were negative for dysplasia. the postoperative course was complicated by a minor leak which did not require operative intervention and subsequent gastric outlet narrowing which required endoscopic dilation and feeding tube placement. however, the patient has recovered well and has advanced to diet as tolerated. gastric adenoma has a prevalence of . - . % in the western hemisphere. the risk of carcinomatous transformation in gastric adenomas is related to size, degree of dysplasia, and villosity. gastric adenomas are considered precancerous lesions. pre-operative pathologic diagnosis of dysplasia is often elusive as biopsies will often miss or under-grade the lesion. guidelines advocate for complete resection with either endoscopic submucosal dissection or surgical resection depending on surgeon preference and local expertise. endoscopic resection has been shown to be safe and efficacious in the removal of adenomas with good long-term outcomes. in this case the pathology of the lesion was unclear after multiple unsuccessful biopsies and required a surgical diagnosis to rule out invasive malignancy. management of gastric adenomas, while rare, may require a multidisciplinary approach between surgical endoscopy, minimally invasive surgery, and surgical oncology to achieve local control in an oncologically sound manner. we show that transgastric submucosal resection can be achieved in a minimally invasive fashion using robotic assistance. objective: parahiatal hernia is a rare type of diaphragmatic hernia with incidence of . - . %. para-hiatal hernias arises lateral to the left crural musculature adjacent to but separate from the oesophageal diaphragmatic hiatus. in view of its rare occurance and little clinical suspicion, it is almost never diagnosed clinically. the current case report is intended to depict the clinical profile of an intraoperatively diagnosed para-hiatal hernia and feasibility of laparoscopic repair of parahiatal hernias. method: laparoscopic fundoplication is frequently performed at grant medical college and sir j. j. group of hospitals, india. during one such case intraoperatively para-hiatal hernia was diagnosed. discussion: primary or true parahiatal hernias occur as a result of a congenital weakness and secondary defects follow hiatal surgery. the primary treatment of para-hiatal hernia is mesh-plasty. this is coupled with fundoplication in cases of large hernia and those symptomatic for gastroesophageal reflux disease. laparoscopic repair of these uncommon hernias is safe, effective and provides all of the benefits of minimally invasive surgery. conclusion: due to its rare occurrence, knowledge about this condition among laparoscopic surgeons is important to avoid diagnostic dilemma. knowledge about its management aids intraoperatvely to avoid performing incomplete procedure. introduction: extended indications of endoscopic resection for early gastric cancer (egc) have been widely accepted. according to current japanese guidelines, additional gastrectomy with lymph node dissection (lnd) is recommended for patients proven to have potential risks of lymph node metastasis (lnm) on histopathological findings. on the other hand, the frequency of lnm in these patients is exteremely low. the aim of this study was to elucidate the accurate risk of lnm based on the number of risk factors (rf) for possible lnm, and to compare the stratified risk of lnm with predicted risk from additional radical resection. methods and procedures: we enrolled egc patients who did not meet absolute or extended indications of endoscopic resection, and investigated the risk stratification of lnm according to the total number of lnm rfs described below; ( ) sm , ( ) lymphatic vessels invasion, ( ) undifferentiated adenocarinoma and [ mm in diameter, and ( ) [ mm in diameter and ulcer formation. we compared the stratification risk to the surgical risk that was calculated based on the japanese national clinical database (ncd) risk calculator in patients with additional gastrectomy after esd. results: the total number of lnm rfs and frequency of lnm were significantly correlated ( / rf; . %, rfs; . %, rfs, . %, rfs, . %; p. , fischer exact test). the estimated frequency of lnm was found to be lower than the predicted value of in-hospital mortality rate based on ncd in . % of / rf-patients who underwent additional gastrectomy with lnd after esd. the present study suggested that some patients must be over-indicated for additional gastrectomy with lnd, and no additional surgical treatment or less invasive surgery, such as local lnd (sentinel node navigation surgery or lymphatic basin resection), might be indicated for some patients with low number ( / rf) of lnm risk factors after esd. aims: laparoscopic proximal gastrectomy has been applied for early gastric cancer in upper third. we previously reported outcomes of laparoscopic total gastrectomy in managing this condition. in this study, we applied this modified technique for upper third early gastric cancer with double tract reconstruction. it is expected that our technique could be useful for treating these cases. methods: from april of to june of , consecutive patients with upper third early gastric cancer were assigned to undergo surgical treatment with proximal gastrectory at our hospital. we had cases of total gastrectory for upper third early gastric cancer in the same study period. background: laparoscopic total gastrectomy for remnant gastric cancer is much more difficult than common laparoscopic total gastrectomy due to severe adhesions to adjacent organs, displacement of anatomical structure. purpose: the aim was to analyze cases of laparoscopic total gastrectomy for remnant gastric cancer at the department of surgery of juntendo university urayasu hospital between november and april . method: we analyzed outcome and feasibility of laparoscopic total gastrectomy surgery for remnant gastric cancer. and we compared with laparoscopic total remnant gastrectomy ( cases) versus laparoscopic total gastrectomy ( cases) in our hospital. results: in the previous laparoscopic surgeries. we performed laparoscopic distal gastrectomy in cases, laparoscopic proximal gastrectomy in pcases, and open distal gastrectomy in cases. all cases were performed laparoscopic total gastrectomy with r-y reconstruction. case of them had been converted to open surgery due to severe adhesions. the mean operative time was min and the mean blood loss was ml. there were no intraoperative complications, and there were postoperative complications as a pancreatic fistula and a bowel obstruction. however, there were no intra-operative complications more than grade according to the clavien-dindo classification. the mean postoperative hospital stay was . days. all cases were without recurrence. thus, there were no significant differences in operative time, bleeding volumes, intra and postoperative complications and hospital stay compared with laparoscopic total gastrectomy. conclusions: laparoscopic total remnant gastrectomy can be performed with similar short-term outcomes to laparoscopic total gastrectomy, and may be feasible and safe procedure, and can become an option of therapeutic strategy. although this study was not powered to show lower recurrence rates with synthetic absorbable as compared to biologic, the . % recurrence rate is consistent with other series utilizing this mesh. it is interesting to note the difference in time to recurrence. these results suggest that while synthetic absorbable mesh may result in lower recurrence rates, recurrence seems to occur earlier. the results also suggest that deconditioning (lower bmi), and difficult cases and/or recovery may predispose to recurrence. these findings can help inform lf mesh selection and predict which patients are at higher risk of recurrence. introduction: little discussion of gastroparesis (gp) following laparoscopic paraesophageal hernia repair (lphr) has been reported in the literature. we wished to examine the incidence in our institution, and identify potential risk factors for development of gastroparesis following lphr. methods and procedures: a single institution retrospective chart review was preformed using cpt codes corresponding to paraesophageal hernia repair and fundoplication to identify patients undergoing laparoscopic paraesophageal hernia repair over a five year period ( / / - / / ) by three surgeons. emergency procedures and reoperations were excluded. in total, patients undergoing non-emergent first time lphrs were identified. size of the hiatal defect was identified when able, via either measurement between the diaphragmatic crura on ct or by medical record documentation. data obtained included sex, age, hernia type, mesh usage, and existence of specific comorbidities associated with gastroparesis. presence of gastroparesis was identified either by documentation of diagnosis via clinical judgment, or by results of gastric emptying nuclear medicine studies, with timing being no longer than months from date of surgery. independent students t-test and fisher exact test were used to determine statistical differences between the groups. results: patients undergoing non-emergent first time lphrs were identified. of these, we were able to obtain the size of the hiatal defect in patients. patients overall were diagnosed with gastroparesis, with an overall incidence of . %. when comparing all patients who developed gastroparesis to those who did not, only females comprised the group which did develop gastroparesis ( males/ females with gp, males/ females without gp, p= . ). age was also found to be greater in the group which developed gastroparesis. for patients in which the size of the hernia defect was identified, the average age was years older in the group diagnosed with gastroparesis ( step under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. the right crus of the diaphragma has been dissected free from the soft tissue around the stomach and abdominal esophagus. in this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid bleeding. after cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. then the inside margin of the left crus of the diaphragma was recognized from the right side. in this part of the procedure, laparoscope uses trocar (a), the assistant uses trocar (b) to pull the stomach to left lower side and the operator's right hand uses trocar (c). step the branches of left gastroepiploic vessels and the short gastric vessels were divided with ultrasonic coagulation and dissection device. the left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. in this part of the procedure, laparoscope uses trocar (a) at the beginning of dividing left gastroepiploic vessels, trocar (b) when dividing short gastric vessels. step the right and left crus are sutured with interrupted stitches to reduce the hiatus. from the right side, the fundus of the stomach is grasped through the widely opened window behind the abdominal esophagus. then the fundus of the stomach is pulled to obtain a degree ''stomach-wrap'' around the abdominal esophagus (fundoplication). using - non-absorbable braided suture, stitches are placed between both gastric flaps. purpose: laparoscopic gastrecomy has been widely adopted as the treatment of choice by many countries and institutions. internal hernia is a well-known complication after rouxen-y gastric bypass in the field of bariatric surgery. however, there were only a few reports of internal hernia after gastrectomy in gastric cancer patients. the purpose of this study was to analyze the incidence and clinical features of internal hernia after gastric cancer surgery in a high-volume center. method: , gastric cancer patients who underwent curative gastrectomy at seoul national university bundang hospital between january and december were retrospectively reviewed in this study. internal hernia was classified into two types, mesenteric hernia and petersen's hernia. result: patients who underwent distal gastrectomy (dg) with reconstruction by billroth ii, rouxen-y gastrojejunostomy and uncut rouxen-y gastrojejunostomy, total gastrectomy (tg) with esophagojejunostomy, and proximal gastrectomy with double tract reconstruction (pg dtr) with esophagojejunostomy and gastrojejunostomy had potential space for internal hernia. among these patients, ( . %) were determined as internal hernia by computed tomography and patients ( . %) underwent surgical treatment of internal herniation. two patients were conservatively managed. all patients suffered from abdominal pain and / ( %) patients showed nausea and vomiting. the median interval between the initial gastrectomy and surgery for internal hernia was days. mesenteric hernia was observed in cases and petersen's hernia in cases. since we started closing the mesenteric and petersen's defects from may of , there were only cases ( %) observed afterwards but there were cases ( %) before closure of the defects. conclusion: internal hernia after gastrectomy is likely underreported. although we analyzed patients with internal hernia, there might be more patients with mild symptoms who were managed conservatively by their own. a high degree of suspiciousness for internal hernia should be maintained in patients presenting symptoms like nausea, vomiting and abdominal pain after gastrectomy with potential space for internal hernia. with our experience, closure of the mesenteric and petersen's defect is helpful in reducing internal hernia. however, due to low incidence, a multicenter retrospective study is necessary. introduction: the increased incidence of anemia in patients with a hiatal hernia (hh) has been clearly demonstrated, as has resolution of anemia after hh repair in these patients. despite this, the implications of preoperative anemia on postoperative outcomes have not been well described. in this study, we aimed to identify the incidence of preoperative anemia in patients undergoing hh repair at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing hh repair between january and april at our institution. we identified all patients with anemia, defined as serum hemoglobin levels less than mg/dl in men and mg/dl in women, measured within two weeks prior to surgery, and compared this cohort to those that had normal hemoglobin values preoperatively. specific perioperative outcomes analyzed included: estimated blood loss (ebl), operative time, need for blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and -day readmission. results: we identified patients undergoing hh repair, of which had preoperative bloodwork available for review. the average age was years and the majority of patients were female ( %, n= ). most were treated electively ( %, n= ) and with a minimally invasive approach ( %, n= ). patients ( . %) had preoperative anemia. compared to patients without anemia, patients with anemia had increased rates of failed extubation postoperatively ( . % vs. . %, p= . ), increased icu admissions ( . % vs. . %, p= . ), increased need for perioperative blood transfusions ( . % vs %, p= . ), and increased rates of postoperative complications ( . % vs. . %, p. ). although mean los ( . days vs. . days, p . ), mean operating time ( mins vs. mins, p= . ), and ebl ( ml vs ml, p= . ) were greater in the anemic group, they did not reach statistical significance, and there was no significant difference in -day readmission rate ( . % vs . %, p= . ). conclusions: anemia diagnosed on preoperative bloodwork appears to be associated with increased failure to extubate postoperatively, need for icu admissions, need for perioperative blood transfusion, and increased overall complication rate after hh repair. however, we found no significant difference in los or -day readmissions between anemic and non-anemic patients. since the majority of patients in this analysis underwent elective repairs, these results would support the preoperative treatment of anemia in patients undergoing hh repair. few studies have compared the procedures' long-term effectiveness with none looking beyond years. this study sought to characterize the efficacy of laparoscopic toupet versus nissen fundoplication for types iii and iv hiatal hernia using a telephone survey. methods and procedures: with irb approval, a review of all laparoscopic hiatal hernia repairs with mesh reinforcement performed over seven years at a single center by one surgeon was conducted. patient demographics and perioperative characteristics were recorded. hiatal hernia was classified per published sages guidelines as type iii or iv using operative reports and preoperative imaging. patients with type i or ii or recurrent hiatal hernia and patients receiving concomitant procedures were excluded. the gerd-health related quality of life survey was administered by telephone no earlier than months postoperatively. patients responded to items concerning symptom severity using a -point scale ( =no symptoms to =symptoms are incapacitating to do daily activities). symptoms surveyed included heartburn ( items), difficulty swallowing ( item) and regurgitation ( items introduction: as the thoracic esophageal carcinoma has a high metastatic rate of upper mediastinal lymph nodes, especially along the recurrent laryngeal nerve (rln), it is crucial to perform complete lymph node dissection along the rln without complications. although intraoperative neural monitoring (ionm) during thyroid and parathyroid surgery has gained widespread acceptance as the useful tool of visual nerve identification, the utilization of ionm during esophageal surgery has not become common. here, we describe our procedures focusing on a lymphadenectomy along the rln utilizing the ionm. methods and procedures: we first dissect ventral and dorsal side of the esophagus preserving the membranous structure (meso-esophagus), which contains tracheoesophageal artery, rln and lymph nodes. we next identify the location of the rln which runs in the meso-esophagus using ionm before visual contact. after that, we perform lymphadenectomy around the rln preserving the nerve. this technique was evaluated in consecutive cases (neural monitoring group; nm) of esophagectomy in prone positioning, and compared with our historical cases (conventional method group; cm background: laparoscopic hiatal hernia repair, particularly large type and type hernias, is associated with high recurrence rates. various use of overlay mesh reinforcement have been described in an attempt to improve outcomes. unfortunately, overlay use of biologic mesh continues to result in high recurrence rates, and more effective repairs employing permanent mesh raise serious erosion concerns and are therefore rarely used. we theorize that employing an interlay technique with permanent mesh (positioned between both crura) will help enhance crural closure and improve rates of hiatal hernia recurrences with minimal risk of erosion. methods: we reviewed all patients who underwent a laparoscopic hiatal hernia repair from april to august by a single surgeon from a prospectively maintained database at a tertiary care referral center (n= ). patients who underwent surgery for achalasia with concurrent hiatal repair were excluded. during this time frame, a new interlay technique of polypropylene mesh was employed upon suture closure of the crura. outcomes of repair were retrospectively reviewed. recurrence of hernia was identified by positive work up of patient's symptoms (new onset dysphagia, gerd, pain). results: a total of consecutive laparoscopic hiatal hernia repair were reported in a period of months. interlay polypropylene mesh was utilized in all repairs. patients were majority females ( . %), had a median age of and had a mean bmi of . . eleven ( . %) patients were redo repairs. majority of patients received a nissen fundoplication (n= , . %) followed by a toupet fundoplication (n= , . %). median length of stay after surgery was day. median follow up was days (range: - days). there were zero reported recurrences. conclusion: laparoscopic hiatal hernia repair with interlay polypropylene mesh appears in the short term to be a safe and durable technique to reduce the incidence of hiatal hernia recurrences. further studies are needed to assess more long term outcomes of this novel technique. zia kanani , melissa helm , max schumm , jon c gould, md ; introduction: laparoscopic fundoplication remains the current gold standard surgical intervention for medically refractory gastroesophageal reflux disease. studies suggest that on average - % of patients undergo reoperative surgery due to recurrent, persistent, or new symptoms. the primary objective of this study was to characterize the long-term symptomatic outcomes of primary and reoperative fundoplications in a clinical series of patients who have undergone one or more fundoplications. methods: patients who underwent laparoscopic primary or reoperative fundoplication between and by a single surgeon were retrospectively identified using a prospectively maintained database. patients undergoing takedown of a failed fundoplication and conversion to roux-en y gastric bypass (for morbid obesity, severe gastroparesis, or or more prior failed attempts) were excluded from the current analysis. all procedures were performed laparoscopically. patients were asked to complete the validated gerd-health related quality of life (gerd-hrql) survey prior to surgery and postoperatively at standard intervals to assess long-term symptomatic outcomes and quality of life. gerd-hrql composite scores range from (highest disease-related quality of life) to (lowest diseaserelated quality of life, most severe symptoms conclusions: patients who need to undergo reoperative fundoplication have more severe gerd-related symptoms at years post-op compared to patients undergoing primary fundoplication. however, good outcomes and morbidity rates of laparoscopic reoperation that approximate that of a primary fundoplication are possible in the hands of an experienced surgeon. adenocarcinoma of duodenum: surgical or endoscopic treatment? introduction: it is well known that the adenocarcinoma of the duodenum (adc) is a quite rare lesion infact represents % of cancer of the small bowel and % of these are localized in the periampullary area: % affect the sub-papillary tract and only % the supra-papillary segment of the duodenum. the adc may arise from duodenal polyps (familial polyposis, or gardner's syndrom or be associated with coeliac disease). until now the treatment was the pancreatoduodenectomy (for anatomo-surgical reasons and for the possibility of regional lymphonode resection). infact in my series of of such procedures, where performed for duodenal cancer. in this last years patients with adc of supra-papillary segment of the duodenum underwent endoscopic submucosal dissection (esd). the purpose of this study were to check the feasibility of the esd in treating such cases. in our experience this kind of endoscopic operation was feasible with high complication rate; perforation in cases ( . %); and bleeding occurred in case ( . %). all the complications were successfully treated endoscopically and the long-term outcomes was favorable. consitering the high rate of complications, the difficult and long procedure, the compliance of patients (c ), the general anesthesia, a very very skilled endoscopist is needed. conclusions: the esd represent a new endoscopic approach enstablished in clinical practice: end is performed following the intraluminal path ( rd space) wich, unlike the others, remain virtual and has to be created by dissecting and expanding the tissues layer between the mucosa and the muscolaris propria allowing the endoscope to gain access. the benefit of esd for treating the adc of the supra-papillary segment of the duodenum, according to our experience, must be validate in the future; a pre-operative pet-tac scan examination must be performed in order to demostred the lesion of the duodenum and if there is any limphatic involvement and no infiltration of the head of the pancreas. yoontaek lee, md, sa-hong min, md, young suk park, md, sang-hoon ahn, md, do joong park, md, phd; seoul national university bundang hospital purpose: this study summarizes the single institution experience of laparoscopic gastrectomy in advanced gastric cancer and evaluates the postoperative morbidities and long-term oncologic outcomes. methods: a total of , laparoscopic gastrectomy for advanced gastric cancer were performed at seoul national university bundang hospital between may and may . the characteristics of patients, surgical techniques, postoperative morbidities, and long-term oncologic outcomes were retrospectively reviewed using electronic medical records. results: patients required conversion to open surgery. the reasons of conversion to open surgery were advanced stage (n= ), intraoperative bleeding (n= ), adhesion due to previous abdominal operation (n= ), small abdominal cavity (n= ), associated disease (n= ), and intraoperative pleural injury (n= ). the mean hospital stay was . days for distal gastrectomy, . days for total gastrectomy, . days for proximal gastrectomy, and . days for pylorus preserving gastrectomy. the mean number of collected lymph nodes was . for distal gastrectomy, . for total gastrectomy, . for proximal gastrectomy, and . for pylorus preserving gastrectomy. the rates of postoperative complications of grade ii or more were . %. there was one case of postoperative mortality due to delayed bleeding after discharge. old age was the only independent predictor of surgical morbidities. background: intrathoracic gastric volvulus is a life-threatening condition of paraesophageal hernia. the therapeutic is a challenge because in acute volvulus it may lead to gastric strangulation and necrosis. most patients are elderly and with a significant associated medical illness which has higher morbidity and mortality of major surgery. we present a laparoscopic surgery is safe in paraesophageal hernia with acute intrathoracic gastric volvulus in a high-risk patient. case presentation: an -year-old woman with underlying of diabetes mellitus and hypertension was transferred from an outlying hospital with anemia, dysphagia, urinary tract infection and aspiration pneumonia. she had severe recurrent emesis after admission. ct scan of the chest and abdomen revealed a large esophageal hiatal hernia, and most of the stomach was in the inferior mediastinum with organoaxial gastric volvulus. endoscopy revealed flat pigmented spot gastric ulcer which compatible with cameron lesion and twisting of gastric folds without evidence of ischemia. the endoscopic reduction was unsuccessful. a laparoscopic surgery was performed and the herniated stomach was successfully reduced. the hernial sac was excised. the crura were approximated and reinforced with composite mesh. nissen fundoplication was performed along with gastropexy of the greater curve of the stomach to the abdominal wall. there was no perioperative complication. she tolerated enteral diet on a postoperative day . she had an uneventful recovery and discharged in weeks after treatment of her associated medical illnesses. she had no relapse of previous symptoms at her six-month follow-up assessment. discussion: endoscopic reduction of acute gastric volvulus may be the first option in a patient with severe comorbidities. however, if there is evidence of ischemia or failure of endoscopic reduction, surgical treatment should be considered. laparoscopic reduction and gastropexy may be a lessinvasive and viable alternative to the more aggressive surgical procedure but definitive surgery with repair hiatal hernia can be done in a selected patient. conclusion: minimally invasive treatments of acute gastric volvulus with paraesophageal hernia, either endoscopic or laparoscopic offer the option for reducing morbidity and mortality in elderly with significant comorbidities. the definitive laparoscopic surgery can be accomplished successfully and safely when it is performed with meticulous attention to the surgical technique and perioperative care. reid fletcher, md, mph, emily ramirez, rn, alfonso torquati, md, philip omotosho, md; rush university medical center introduction: the objective of this study was to evaluate the impact of an enhanced recovery after surgery (eras) program on post-operative length of stay following laparoscopic sleeve gastrectomy. eras programs have been demonstrated to improve outcomes and decrease length of stay in multiple surgical disciplines however relatively little has been published regarding the impact of eras programs in bariatric surgery. methods: an eras program for all patients undergoing bariatric surgery was implemented in february at a single institution. we retrospectively reviewed all patients undergoing laparoscopic sleeve gastrectomy between february and august . as a pre-eras historical control, we also reviewed all patients undergoing laparoscopic sleeve gastrectomy between january and december . baseline patient characteristics, additional concomitant operative procedures as well as -day readmission and complication rates were reviewed. logistic regression analysis was used in univariate and multivariate models to identify factors that predicted early post-operative discharge. data analysis was completed using stata se software (statacorp lp; college station, tx). results: eighty-five patients underwent laparoscopic sleeve gastrectomy after implementation of the eras program while patients were included in the pre-eras control group. there were no statistically significant differences in the baseline characteristics between the two groups and there were no differences in the rate of concomitant procedures performed. there was a statistically significant decrease in post-operative length of stay following implementation of the eras program from . it has been reported that laparoscopic redo surgery is effective for recurrent gerd and/or hiatal hernia after surgery. however, there has been very few reports from japan. we report an initial experience of laparoscopic surgery for japanese patients with recurrent gerd and/or hiatal hernia. among patients who had undergone laparoscopic fundoplication in our hospital from to , patients with recurrent gerd/hiatal hernia underwent redo surgery. preoperative work-up included upper gi series, endoscopy, ct, h ph-impedance and manometry. the patients consisted of women and men with a mean age of . years. the interval from the initial surgery was . months ( days- months). the types of initial fundoplication were nissen: , toupet: , anterior: . the types of recurrence were sliding hernia: and paraesophageal hernia: . one patient with recurrent sliding hernia had poor gastric motility. laparoscopic redo surgery was performed on patients. redo surgery included crural repair with mesh reinforcement: , refundoplication: (nissen-nissen: , nissen-toupet: , toupet-toupet: , toupet-lateral: ) and reduction of the incarcerated paraesophageal hernia: . additional procedure included mesh reinforcement: and pyloroplasty: . open partial gastrectomy was performed for one patient with incarcerated and strangulated hernia. operation time was min. patients was converted to open surgery. oral intake was started on the st pod and postoperative stay was . days. two patients recurred after redo surgery, one of whom underwent re-redo surgery. during the surgery, ivc was injured but rescued by open surgery. eleven patients had good outcome and patients required ppi after redo surgery. our morphological fundoplication score significantly improved after redo surgery. symptom score and acid exposure time were also significantly improved after redo surgery. laparoscopic redo surgery for recurrent gerd and/or hiatal hernia after surgery is safe and effective, although attention should be paid during surgery to avoid injury of the adjacent organs. surg endosc ( ) introduction: cameron ulcers (cu) are linear erosions or ulcerations in the gastric mucosa at the level of the diaphragmatic hiatus in patients with a hiatal hernia (hh) and are frequently associated with anemia. perioperative outcomes of patients with cu undergoing hh repair are not well described. we sought to identify the incidence of cu in patients undergoing hh repair at our institution and determine whether the presence of cu impacted postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing repair between january and april . we identified all patients with cu found on preoperative esophagogastroduodenoscopy (egd). we compared patients with and without cu to determine if they differed in terms of preoperative anemia (defined as hemoglobin levels less than mg/dl in men and mg/dl in women). lastly, we compared outcomes between the cu group and the non-cu group, focusing on need for perioperative blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and -day readmission. conclusions: the presence of cu on preoperative egd is associated with increased rate of preoperative anemia, increased los, and increased icu admission after hh repair. although the cause of anemia in patients with hh is commonly attributed to cu, only % of cu patients were anemic, indicating that differences in outcomes may not only be attributed to a higher incidence of anemia in cu patients. the implications of cu in patients undergoing hh repair need to be further elucidated. laparoscopic heller myotomy as treatment for achalasia objective: aim of this stud was to review our experience with laparoscopic heller dor myotomy. disphagia constitutes the main symptom. diagnosis is performed by means of esophageal manometry. materials and method: over a period of years, patients were treated with heller myotomy plus dor fundoplication laparoscopically. all patients had lost weight, and there was a prevalence of females with an average age of . twenty five patients had chagas disease. they were all assessed with serial x-rays, endoscopy, esophageal manometry, and their symptoms were assessed with a - score, being the most severe. results: there was no conversion or mortality. in patients the mucosa was perforated during myotomy. the mucosa was sutured without altering the result of the treatment. average hospital stay was hours. one patient had to be reoperate because of esophageal perforation with peritonitis. sixty patients were followed up with manometric control and ph-probe testing, and only % of those had pathologic reflux. conclusions: laparoscopic treatment of achalasia is possible and reproducible, while reducing the morbility of laparotomy with relieve of patients symptoms. introduction: stent treatment in the gastrointestinal tract is emerging as a standard therapy for overcoming strictures and sealing perforations. we have started to treat patients with perforated duodenal ulcers using a partially covered stent and external drainage achieving good clinical results. stent migration is a serious complication that may require surgery. pyloric physiology during stent-treatment has not been studied and mechanisms for migration are unknown. the aims of this study were to investigate the pyloric response to distention mimicking stent-treatment, using the endoflip, investigating changes in motility patterns due to distention at baseline, after a pro-kinetic drug and after food ingestion. methods: a non-survival study in five pigs was carried out, followed by a pilot study in one human volunteer. a gastroscopy was performed in anaesthetized pigs and the endoflip was placed through the scope straddling the pylorus. baseline distensibility readings were performed at stepwise balloon distention to ml, ml, ml and ml, measuring pyloric cross sectional area and pyloric pressure. measurements were repeated after administration of a pro-kinetic drug (neostigmin) and after instillation of a liquid meal. in the human study readings were performed in conscious sedation at baseline and after stimulation with metoclopramide. results: during baseline readings the pylorus was shown to open more with increasing distention, together with higher amplitude motility waves. reaching maximum distention-volume ( ml), pyloric pressure increased significantly (p= . ) and motility waves disappeared. after prokinetic stimulation pyloric pressure decreased and motility waves increased in frequency and amplitude at , and ml distentions. after food stimulation pyloric pressure stayed low and motility waves showed increase in amplitude at distentions of , and ml. during both tests the pylorus showed higher pressure and lack of motility waves at maximum probe distention of ml. similar results were found in the human study. the pylorus seems to acts as a sphincter at low distention but when further dilated starts acting as a peristaltic pump. when fully distended, pyloric motility waves almost disappeared and the pressure remained high, leaving the pylorus open and inactive. stent placement in the pylorus results in pyloric distention, possibly changing motility. this study indicates that a duodenal stent placed over the pylorus should have a high radial force in the pyloric part in order to dilate the pylorus and diminish the contraction waves, this might reduce stent migration. introduction: cutting-edge technology in the field of minimal invasive surgery allows the application of singleincision laparoscopic surgery on gastric cancer. however, single-incision distal gastrectomy (sidg) is still technically difficult due to limited range of motion and unstable field of view-even in the hands of an experienced scopist. solo surgery using a passive scope holder may be the key in allowing sidg to be safer and efficient. we report our initial experience of consecutive cases of solo sidg. methods: prospectively collected database of patients clinically diagnosed as early gastric cancer who underwent solo sidg from october until july were analyzed. all the operations were held by a single surgeon and a scrub nurse. a passive laparoscopic scope holder was controlled by the surgeon to fix the field of view. results: the mean operation time (sd) was . (± . ) min, and the average estimated blood loss was . ± . ml. average body mass index was . ± . kg/m . the median hospital stay (range) was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days, and the mean number of retrieved lymph nodes was . ± . . there was no conversion to multiport or open surgery. early postoperative complication occurred on % with three delayed gastric emptying, two postoperative pneumonia, one pancreatitis, and one wound complication. conclusion: solo sidg using a passive scope holder allows sidg to become more feasible by providing a stable field of view. there were no peri-operative deaths in either group. in the elective group, age was not an independent risk factor for complications (or . , % ci . - . ). conclusions: the incidence of major complications and mortality in this series were much lower than those previously reported for elective lpehr, while morbidity after emergency repair remains high. the paradigm of watchful waiting for elderly and/or minimally symptomatic patients with giant peh should be revisited. the impact of vagal nerve integrity testing in the surgical kamthorn yolsuriyanwong, md, eric marcotte, md, mukund venu, bipan chand, md; loyola university chicago, stritch school of medicine background: thoracic and gastric operations can cause vagal nerve injury, either accidentally or intended. the most common procedure, which can lead to such an injury, includes fundoplication, lung or heart transplantation and esophageal or gastric surgery. patients may present with minimal symptoms or some degree of gastroparesis. gastroparetic symptoms of include nausea, vomiting, early satiety, bloating and abdominal pain. if these symptoms occur and persist, the clinician should have a high suspicion of a possible vagal injury. investigative studies include endoscopy, esophageal motility, contrast imaging and often nuclear medicine gastric emptying studies (ges). however, ges in the post-surgical patient have limited sensitivity and specificity. if a vagal nerve injury is encountered, subsequent secondary operations must be planned accordingly. methods: from january to august , patients who had a previous surgical history of a foregut operation, with the potential risk of a vagal nerve injury, had vagal nerve integrity (vni) test results reviewed. vni test was measured indirectly by the response of plasma pancreatic polypeptide to sham feeding. the data collected and analyzed included age, gender, previous surgical procedures, clinical presentation, results of vni testing and the secondary procedure planned or performed. vni testing was compared to other testing modalities to determine if outcomes would have changed. results: eight patients ( females) were included. the age ranged from to years. two patients had prior lung transplantation and six patients had prior hiatal hernia repair with fundoplication. seven patients presented with reflux and delayed gastric emptying symptoms. one lung transplantation patient had no symptoms but his lung biopsy pathology showed chronic micro-aspiration with rejection. the vni testing results were compatible with vagal nerve injury in patients. according to these abnormal results, the plans for nissen fundoplication in patients were modified by an additional pyloroplasty and the plans for redo-nissen fundoplication in patients were changed to redo-nissen fundoplication plus pyloroplasty in patient and partial gastrectomy with roux-en-y reconstruction in patients. the operative plans in patients with a normal vni test were not altered. all patients that had secondary surgery had improvement in symptoms and or improvement in objective tests (ie signs of rejection). conclusion: the addition of vni testing in patients with previous potential risks of vagal nerve injury may help the surgeon select the appropriate secondary procedure. . we present a single-center experience with a "myotomy first" approach for all patients, regardless of diverticular size. the hypothesis is that cardiomyotomy alone will provide satisfactory symptom abatement in some patients. and mis cardiomyotomy causes minimal scarring, so a staged mis diverticulectomy is feasible at a later date if diverticular retention/stasis continues. in order to discuss this treatment algorithm we present our experience with cardiomyotomy alone for patients with epiphrenic diverticula. methods: the electronic medical record was queried for patients with esophageal diverticula who were managed with cardiomyotomy and dor fundoplication alone. pre and post-operative reflux/dysphagia questionnaires were gathered; imaging studies, operative data, complications and follow up were reviewed. results: from march of until the present, patients with esophageal diverticula were treated using the "myotomy first" approach. intraoperative esophagoscopy was done to internally visualize the elimination of the inciting spastic esophageal muscle. preoperatively, all patients complained of regurgitation, followed by dysphagia in ( %) and weight loss ( %). postoperatively, dysphagia and weight loss resolved in all subjects. regurgitation symptoms resolved in ( %) patients. the average size of the diverticula was . cm , the range was - cm . post operative esophagream's showed persistent diverticual, however most had decreased in size. there were no perioperative complications, average length of stay was . days and there were no icu admissions or returns to the or. the average length of follow up for these patients was days where all patients reported being satisfied with their results and none of them have yet desired to pursue diverticulectomy. discussion: a "myotomy first" approach resulted in excellent short term symptomatic control. none of the have retained or re-experienced symptoms of diverticular retention worthy of surgical intervention. in the age of laparoscopic surgery, an esophageal epiphrenic diverteculectomy should be staged. this step wise approach seeks to assure surgical necessity for a morbid endeavor. surg endosc ( ) :s -s the background: the two-stage oesophagectomy (ivor-lewis procedure) remains the mainstay of curative surgery for oesophageal cancers in the uk. gastro-oesophageal anastomotic leak is a potentially devastating complication of this procedure affecting perioperative morbidity and mortality. although the leak rates have improved over the years, it still remains widely variable. intraoperative reinforcement of gastro-oesophageal anastomosis with an 'omental wrap' has been proposed as a measure to reduce anastomotic leak rates. there is some data to suggest that this additional technique reduces anastomotic leak. we reviewed our single institution data to assess if the omental wrap indeed had a 'cocoon' effect in maturing the anastomosis and reducing leak rates. methods: data for all cancer oesophagectomies (ilog) performed in our institute since april - was retrospectively analysed from a prospectively maintained database. the patients were categorised into two groups. masafumi ohira; department of gastroenterological surgery, hokkaido university graduate school of medicine background: in laparoscopic surgery, both surgical technique and adequate support and traction by an assistant are highly important. this study assessed the impact of the first assistant on shortterm outcomes of laparoscopic distal gastrectomy (ldg) and laparoscope-assisted distal gastrectomy (ladg). methods: patients who underwent ldg or ladg for gastric cancer at our hospital, between november and august , were included. ldg and ladg cases of billroth i reconstruction, performed by a single surgeon accredited in endoscopic procedures, were analyzed. the cases were categorized into the following groups according to the first assistant's postgraduate years (pgy) of experience: group a, - years; group b, - years; group c, - years; and group d, [ years. short-term outcomes were compared between the groups. results: we examined cases. operative time was significantly longer in group a than in group b (p= . ). no significant differences in operative time were found between groups b, c, and d. the cases were recategorized into groups as follows: group a, the young assistant group (group y, n= ), and groups b, c, and d, the senior assistant group (group s, n= ). significant differences in operative time and method of anastomosis (circular stapler or delta anastomosis) were observed between the groups (p= . and p= . , respectively), but no significant differences in complication rates were found (p= . ). the unadjusted analysis revealed that the group, method of anastomosis, and body mass index (bmi) were significant factors associated with longer operative time. multivariate linear regression analysis with stepwise model selection using akaike's information criterion (aic) revealed that bmi and group were significant factors associated with longer operative time (p= . and p= . , respectively). multivariate analysis using these variables and the method of anastomosis confirmed the significance of bmi and group for longer operative time, but no significance was found in the method of anastomosis (p= . , p= . , and p= . , respectively). conclusions: our study showed that operative time tended to be longer when the first assistant had experience of less than pgy, but the morbidity did not increase. as with the operator, the first assistant needs adequate training to ensure a smooth operation. steven g leeds, md, marc ward, md, brittany buckmaster, pa, estrellita ontiveros, ms; baylor university medical center at dallas background: gastric contents can reach beyond the esophagus into the larynx and pharynx causing an increasingly prevalent disease called laryngopharyngeal reflux (lpr). magnetic sphincter augmentation (msa) has been used as an alternative treatment for gerd with good success, but there is no data to support its use in lpr. methods: forty-five patients with msa implants for symptomatic relief with both gerd and lpr symptoms were examined. all patients experienced at least one typical gerd symptom as well as at least one extra-esophageal symptom. this was assessed using the gerd-hrql which is questions graded - on each question, and reflux symptom index (rsi) which is questions graded - on each question. patients filled out questionnaires preoperatively, one month postoperatively (early follow up), and at months to year postoperatively (late follow up). the responses on the gerd-hrql were clustered into questions inquiring about heartburn ( ), dysphagia ( ), and regurgitation ( ) like all surgical fields there is a push towards standardization of the post operative course while maintaining safe practices. other surgical fields have streamlined recovery processes in an effort to standardize care and minimize costs. laparoscopic hiatal hernia repair is a complex procedure, but with experience and a team approach, this operation can become a streamline process. methods: a retrospective review was done for over laparoscopic hiatal hernia repairs at a single institution. aspects of post operative care such hospital floor, nursing ratio utilized, pain medication, diet advancement, use of foley catheters and length of hospital stay were tracked. statistical analysis was done to compare utilization of resources as years went on along with complications and readmissions. results: a total of hiatal hernias were performed between and . improvements were noted in nearly every field over time, including faster foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (pcas) and faster advancement of diet. furthermore these patients are now treated on a surgical floor rather than the intensive care unit or step down with a higher nurse to patient ratio, decreasing hospital cost. there were no changes in complications, reoperations or readmissions over the course of the study. conclusions: cost, length of stay and so called "advanced recovery pathways" are all the rage in the surgical literature. anytime a procedure and its post operative course can become less of a "major undertaking" and more routine, the more streamline it becomes. this comes from making a standard protocol that deescalates treatment based on what is actually needed. nearly every aspect of post operative care was simplified; length of stay and cost to the hospital was decreased while no additional complications or readmissions were accrued. the foundation of a formalized advanced recovery pathway will be implemented from these factors which were studied. background: the obesity epidemic continues to worsen. bariatric surgery remains the most effective way to achieve weight loss and resolution of comorbidities. laparoscopic sleeve gastrectomy has become the most common bariatric operation due to excellent efficacy and low morbidity and mortality. the most common complication of sleeve gastrectomy is gastroesophageal reflux disease (gerd), which can adversely impact the quality of life and lead to additional esophageal complications. recently, esophageal magnetic sphincter augmentation (linx®) has become an acceptable alternative to fundoplication for certain patients with gerd. the use of linx® in patients who previously underwent laparoscopic sleeve gastrectomy was described in a case series in . the known complications of these devices include dysphagia, need for endoscopic dilation, and device erosion. the complication profile of linx® in the setting of sleeve gastrectomy has not been reported heretofore. methods: we present a case of a patient with prior sleeve gastrectomy who received a linx® device one year after her bariatric operation due to severe gerd refractory to medical management. initial evaluation demonstrated a hypotensive lower esophageal sphincter and hiatal hernia, but no evidence of stricture or twisting. soon after linx® implantation, the patient developed progressive dysphagia and worsened reflux. repeat evaluation showed esophagitis, a moderate stricture with angulation at the incisura, and a large amount of retained food. discussion: the patient was recommended conversion to roux-en-y gastric bypass, but was deemed to be a poor candidate due to heavy smoking. thus, laparoscopic removal of the linx® device was performed with hiatal hernia repair and gastric stricturoplasty. post-operative fluoroscopic evaluation revealed improvement in the stricture, but persistent gastroesophageal reflux. the patient experienced a significant improvement in her symptoms of dysphagia, nausea, and vomiting. however, once smoking cessation is achieved, she may still need a conversion to roux-en-y gastric bypass in order to address persistent gerd. conclusion: conversion to roux-en-y gastric bypass remains the standard approach to treatment of gerd post sleeve gastrectomy. new approaches to this problem, including placement of linx®, are promising but have not been evaluated for long-term safety and efficacy in the setting of prior bariatric surgery. careful diagnostic evaluation prior to placement of magnetic sphincter augmentation device should be routinely undertaken. postoperatively, close long-term follow up is imperative, particularly in patients with prior sleeve gastrectomy. presence of linx® in a patient with prior bariatric surgery may lead to worsening symptoms if complications of initial operation are present. kazuto tsuboi, md , nobuo omura, md , fumiaki yano, md , masato hoshino, md , se-ryung yamamoto , shunsuke akimoto, md , takahiro masuda , hideyuki kashiwagi, md , norio mitsumori, md , katsuhiko yanaga, md ; fuji city general hospital, shizuoka, japan, nishisaitama-chuo national hospital, saitama, japan, the jikei university school of medicine, tokyo, japan background: esophageal achalasia is one of the primary esophageal motility disorders, and the patients suffer from dysphagia, vomiting and chest pain. timed barium esophagogram (tbe) is a convenient method to assess esophageal clearance, which we usually performed before and after surgery. meanwhile, laparoscopic heller-dor operation (lhd) has been considered worldwide as a gold standard for the surgical management of esophageal achalasia. the aim of this study is to examine the effect of preoperative clearance rate at the lower part of the esophagus on surgical outcomes in patients with esophageal achalasia. patients and method: between august and april , patients who underwent lhd at our institution were extracted from the database. out of patients, patients met our inclusion criteria; such as the patients who underwent lhd as an initial operation with complete evaluation with preoperative esophageal clearance by tbe. these patients were divided into three groups by the degree of esophageal clearance (group a: clearance rate \ %, group b: %? clearance rate \ %, and group c: %? clearance rate). patients' background, pre-and post-operative symptom scores, and surgical results were compared. before and after surgery, the standardized questionnaire was used to assess the degree of frequency and severity of symptoms (dysphagia, vomiting, chest pain and heartburn). moreover, satisfaction with operation was evaluated using the standardized questionnaire. statistical analysis was performed by using krasukal-wallis test or chi-square test, and p-value less than . was defined as statistically different. results: their mean age was . years and of them were male ( . %). one hundred and sixty-eight patients ( . %) were in group a, ( . %) in group b, and ( . %) in group c. the maximum width of the esophagus in group c was smaller than that in other groups (p= . ). as to the pre-operative symptom score, the frequency score of dysphagia was significantly lower in group c (p= . ), whereas the severity score of chest pain was significantly higher in group c (p= . ). surgical outcomes including the incidence of mucosal injury were not different among the groups. moreover, the patient satisfaction with lhd was excellent regardless of preoperative esophageal clearance. conclusion: preoperative clearance rate at the lower part of the esophagus in patients with esophageal achalasia did not affect the surgical outcomes of lhd, but the characteristics of preoperative symptoms in patients with poor esophageal clearance was low dysphagia and high chest pain. surg endosc ( ) ( . cm . cm) was made by dissecting between submucosal and muscular layers at the anterior remnant gastric wall. after creation of the double flap, the posterior esophageal wall ( cm from the edge) and the anterior gastric wall (superior edge of the mucosal window) were sutured for fixation, and . cm from the inferior edge of the mucosal window was opened, and the wall of the esophageal edge and the opening of the remnant gastric mucosa were sutured continuously. the anastomosis was fully covered by the seromuscular flaps with suturing. in latg, roux-en-y reconstruction was performed through a small incision using a circular stapler. introduction: the purpose of this study was to clarify the long-term and short-term outcomes of consecutive patients who underwent thoracoscopic esophagectomy in the prone position using a preceding anterior approach for the resection of esophageal cancer at a single institution. this method was established to make an esophagectomy easier to perform and to achieve better outcomes in terms of safety and curativity. methods and procedures: we retrospectively reviewed a database of patients with thoracic esophageal cancer who had undergone a thoracoscopic esophagectomy (te, patients) or an esophagectomy through thoracotomy (oe, patients) between january and august . to compare the long-term outcomes of te and oe, we used a propensity score matching analysis and a kaplan-meier survival analysis. to analyze the short-term outcomes of te, patients were chronologically divided into three groups: a first period group ( patients), a second period group ( patients), and a third period group ( patients). as for thoracoscopic procedure, the esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. the lymph nodes around the esophagus were also dissected anteriorly and posteriorly. the intraoperative factors, the number of dissected lymph nodes, and the incidence of adverse events were compared among the three period groups using a one-way anova or chi-square test. results: one hundred and twenty-three patients from each group, for a total of patients, were completely selected and paired. background: it is also difficult to anastomose using circular stapler in the narrow neck field. to overcome the problem we modified circular stapling for anastomosis. gastric juice reflux is frequently observed at the esophagogastric anastomosis. we develop and report trapezoidal tunnel method to reduce the incidence reflux. ( ) patients one hundred thirteen cases ( in left lateral and in prone position), with esophageal carcinomas underwent vats-e, respectively. esophago-gastric anastomosis is performed for cases by modified circular stapling and cases by trapezoidal tunnel method. ( ) methods at first the patients are fixed at semi-prone position and esophagectomy is performed in prone position that can be set by rotating and ports are used at the intercostal space (ics). esophagectomy and the l.n. dissection are performed with pneumothorax by maintaining co insufflation. esophago-gastric anastomosis is performed as following, i) trapezoidal tunnel method sero-muscular layer of anterior wall in the near top of gastric conduit is peeled from submucosal layer after parallel horizontal incision of sero-muscular layer, and then trapezoidal tunnel of sero-muscular layer is created. the edge of the proximal esophagus is drawn into the tunnel and esophago-gastric submucosa anastomosis is performed. to wrap anastomosis distal side of parallel line is closed. ii) modified circular stapling at first the circular stapler is introduced into the gastric conduit and joined to an anvil, and close a little. and then a joined anvil is placed into the proximal esophagus and secured by means of a pursestring suture. the gastric conduit opening is closed by a linear stapler. purpose: mesh utilization and its impact on postoperative hernia recurrence following paraesophageal hernia repair remains a polarizing topic. this analysis evaluates the recent trends in laparoscopic paraesophageal hernia repairs and analyzes the impact of operative time on postoperative morbidity. methods: the - acs-nsqip database was queried for primary cpt code for laparoscopic paraesophageal hernia repair with and without mesh ( / ). only elective cases performed by a general surgeon were included. operative time was grouped into quartiles ( - , - , - , - min) and statistical analysis was performed using anova univariate with post-hoc testing and multivariate regression modeling controlling for age, diabetes, renal disease and weight loss. this analysis was powered to detect a greater than % difference in outcomes based on mesh utilization. the outcomes of interest were composite morbidity scores and readmission rates within days of surgery. results: the database identified a cohort of , laparoscopic paraesophageal hernia repairs performed between and . average patient age was years and average patient body mass index was . mesh was utilized in % of cases per year and did not change over the study period (p= . ) however mesh utilization was %, %, %, and % within operative time quartiles - respectively (p. ). postoperative morbidity and readmission rates for each operative time quartile were . %, . %, . %, and . % (p. ) and . %, %, . %, and . % (p= . ), respectively. post-hoc testing indicated statistically significant differences in postoperative morbidity and readmission rates between quartiles and / . multivariate regression analysis documented operative time as a risk factor for postoperative morbidities and readmission, even after controlling for covariates. mesh utilization was only significant for a reduction in the rate of venous thromboembolic complications (or . , p= . ) but did not impact other morbidities or readmission rates. conclusion: this analysis suggests that patients with higher operative times have increased postoperative morbidity and readmission while mesh utilization does not impact postoperative outcomes, after accounting for the longer operative time of a paraesophageal hernia repair with mesh. introduction: gastroparesis is a chronic gastric motility disorder defined by delayed gastric emptying and symptoms such as nausea, vomiting, bloating and abdominal pain. surgical options for refractory gastroparesis include pyloroplasty, gastric stimulator insertion, and gastrectomy. the palliation from a pyloroplasty and gastric stimulator may be synergistic, however concerns remain regarding the possibility of stimulator infection when performing both procedures simultaneously. we present our initial experience of combined laparoscopic pyloroplasty and insertion of gastric stimulator. methods: gastroparesis patients diagnosed by solid gastric scintigraphy or endoscopic evidence of retained food after prolonged npo status who underwent combined laparoscopic heineke-mikulicz pyloroplasty and gastric stimulator insertion between july and july were reviewed. patient demographics, pre-and post-operative symptom scores and outcomes were collected. results were analyzed using statistical tests as appropriate. p value . were considered significant. results: seven patients underwent the simultaneous pyloroplasty and gastric stimulator insertion. six patients ( %) were idiopathic and one patient ( %) was diabetic. one patient was male and six patients were female. charleen yeo, enming yong, danson yeo, kaushal sanghvi, aaryan koura, jaideepraj rao, myint oo aung; tan tock seng hospital introduction: gastric cancer is one of the most common cancers in the asian population, with recent literature supporting the laparoscopic approach in early disease. however, the minimally invasive approach in advanced disease is still controversial. the outcomes of laparoscopic gastrectomy in the elderly have also not been extensively studied. we aim to evaluate our institution's short term outcomes of laparoscopic versus open gastrectomy for gastric cancer-with particular focus on advanced disease and elderly patients. methodology: we prospectively collected the data of all patients who underwent gastrectomies for stomach cancer from to . all patients underwent a partial or total gastrectomy with d lymphadenectomy. the decision for open or laparoscopic approach was decided between surgeon and patient. we excluded patients who underwent palliative resection. all patients were followed up for at least one year post-operatively. introduction: it was an eye-opener when the lancet brought the attention about global surgery. it is estimated that the deaths due to lack of access to surgery is far greater than deaths due to malaria, tuberculosis and hiv/aids put together. there is greater need to stress the importance in developing countries. there is a responsibility at the medical schools to enlighten students about this necessity and arouse interest in concept of global surgery. the students or surgical residents in the future are a great resource to solve this major problem. the first step would be to educate surgical residents. we need to assess the existing awareness about global surgery problem among surgical residents. we can plan a program to train the next generation surgeons. methods and procedure: all the surgical residents in our institution (victoria hospital, bangalore, india) were enrolled for this study. a total of residents were enrolled. a multiple-choice questionnaire regarding global surgery was designed. the received questionnaire was analyzed to assess the depth of knowledge about global surgery. there were multiple choice questions (mcq) and an option was provided at the end for feedback and suggestion to improve the global surgery in our country. each question carried one mark. score more than was considered the cutoff for pass and those students were termed 'informed'. results: ( . %) students cleared the cut off score of and were termed 'informed'. among this group ( %) residents scored marks. ( . %) students did not cross the cut off and were termed 'non-informed'. among these ( . %) students scored marks and did not know anything on the topic. students provided relevant suggestions and opinions to improve global surgery issue. conclusion: there is a great lacuna in knowledge about global surgery among surgical residents. we need to plan a program integrating global surgery in the syllabus of surgical training. the awareness among residents would arouse interest and participation in the future. introduction: minimally invasive surgical techniques (mists) could have tremendous applications and benefits in resource poor environment. these include but are not limited to short hospital stay, reduced cost of care, and reduced morbidity, especially related to post operative infections. there is growing interest in mists in most low and middle income countries (lmic) but its adoption has remained limited largely due to high cost of initial set-up, lack of technological backup and limited access to training among others. one of the most limiting factors is the maintenance of the vision system. an affordable laparoscopic set-up as an example will therefore go a long way in improving access to mists. methods and procedures: a common zero-degrees mm scope is attached on the camera of a low price smartphone (samsung galaxy j , samsung®, seoul, south korea). two elastic bands are used to fix the scope right in front of the main camera on the smartphone. the device is covered with sterile transparent drapes (tegaderm®, m corporate, st. paul, mn, usa). a light source is connected with a fiber optic cable for endoscopic use. the image can be seen in real time on a common tv screen through an hdmi connection to the smartphone, with a sterile drape. holding the vision system through the scope would guarantee to keep the camera in place without issues. to operate in full screen the vision was digitally zoomed at . , without losing quality (that is more related to the intensity of the light). as a collateral project we built a low cost simulator training box with the same camera to train the surgeon, obtaining a high fidelity and affordable simulation setting. results: we were able to perform the tasks of the fundamentals of laparoscopic surgery curriculum using our vision system with proficiency. in a pig model, we performed a tubal ligation to simulate an appendectomy and we were able to perform basic laparoscopic suturing. no major issue were encountered and small adjustment only were required to have an acceptable, stable and clear view. conclusion: there is growing interest in minimally invasive surgeries among surgeons in lmic, but its adoption has remained limited due to reasons such as high cost of initial set-up, lack of technological backup and limited access to training among others. an affordable laparoscopic camera system will therefore go a long way in improving access to mis in such settings. open. there were no deaths or bile duct injuries in our series. two patients undergoing laparoscopic approach were converted to open ( . %). complications, los, and gender were similar between the two groups. the laparoscopic group were significantly younger and had a significantly longer operative duration (table) . long term outcomes were not available for analysis. laparoscopic and open cholecystectomy appear safe in the setting of short term surgical missions. neither group suffered major complications. both had similar immediate outcomes. los for both groups was surprisingly similar and shorter than larger series which may possibly due to patient selection. given similar immediate outcomes and large burden of disease, the open approach should be considered. however, this cost may be extracted in terms of greater pain or longer recovery time for patients, which may outweigh the benefits. further data is needed to study pain, long term outcomes, and return to work. introduction: minimally invasive surgery relies on optimal camera control for the successful execution of operations. one disadvantage of laparoscopic surgery is that camera control is dependent on a surgical assistant's interpretation of visual cues and ability to predict the next field of focus in addition to verbal commands from the operating physician to provide the optimal view. robot-assisted minimally invasive surgery provides the operating surgeon the advantage of dictating their field of view. this study aims to utilize a video processing algorithm to determine the incidence of improperly centered field of view in laparoscopic vs. robot-assisted surgery. methods: in this study, recordings of minimally invasive resection of rectal cancer ( laparoscopic and robot-assisted surgery) were evaluated. recordings were input into matlab® video processing to generate single frames at each second interval. a single reviewer would indicate the pixel which best determined where the camera should be centered based on positioning of instruments, current action (dissection/hemostasis/traction) depicted in the frame, and previous review of recordings. pixel locations were recorded for subsequent analysis. centered views were determined as those with the identified centered position pixel lying within the center quadrant when frames were split into a uniform grid. in addition, distance of each point to the absolute center of the frame was calculated based on the pixel's x and y positions. results: individual operation data was analyzed for percent of centered pixel locations and pixel distance from the center pixel of the frame. robot-assisted surgery demonstrated higher percentage of centered views over laparoscopic surgery ( . ± . vs. . ± . ; p. ). robot-assisted surgery also demonstrated shorter distances to frame center than laparoscopic surgery ( . ± . vs. . ± . ; p. ). conclusion: robot-assisted surgery aims to resolve conflicts of cooperation that occur between surgeon and assistant in laparoscopic surgery by enabling manual visual control of the operative field by the operating surgeon. this study demonstrates that by eliminating such conflicts, optimal surgical view is more frequently obtained. surg endosc ( ) background/objective: valveless laparoscopic insufflator systems are marketed for ability to prevent loss of abdominal collapse and desufflation during laparoscopy. however, community surgeons raised concern for possible entrainment of room air, including oxygen ( ), with these systems. this study seeks to quantify o and non-medical air entrainment by a laparoscopic valveless cannula system to understand the risk of intraoperative air embolism. a communityuniversity collaborative was created to design a model and test this hypothesis. methods: an artificial abdomen was developed and calibrated to equivalent compliance and intraoperative volume of an average adult abdomen. it was connected to a flow meter, oxygen concentration sensor, and commercially available laparoscopic valveless cannula system. background: further advance of near-infrared (nir) imaging capability into greater clinical usefulness will be helped by the development of new targetable agents. to avoid issues related to dose timing and contamination, compounds that become fluorescent only at the site being targeted would be a significant advance. here we build on earlier laboratory work to show step-wise advance of the agent towards clinical trialling. methods: a novel agent (nir-aza) was tested in ex vivo colorectal specimens using two commercially available systems to determine characteristics in biological tissue. it was then trialled in a large animal cohort (n= ) to determine its performance for both intestinal perfusion assessment and lymph node mapping (both stomach and colon) using again a commercially available optical imaging system and including a direct comparison with indocyanine green. results: the novel agent was easily detectable in biological tissue in the near infrared wavelength relevant to commercial instrumentation both as a local depot tattoo and as a lymphatic tracing agent. porcine model trialling again showing excellent detection and tracking characteristics both in the circulation and in gastrointestinal tissue with clear tracking to relevant lymph nodes within minutes evident with the latter. while these studies were non-survival, there was no evidence of local tissue or systemic system toxicity in any case. direct qualitative and quantificative comparison between in situ nir-aza and icg at both intestinal and lymph basin regions showed similar levels of fluorescence. conclusion: the trial compound underwent successful testing indicating proof of earlier projected potential. this is encouraging for further work to advance to first in human testing. introduction: enhanced imaging systems have been developed to alter laparoscopic camera output to facilitate visualization during laparoscopic surgery using several novel imaging modes: clara mode reduces overexposure and reflections while brightening darker areas of the image; chroma mode intensifies color contrast to more clearly delineate blood vessels; and a combined chroma-clara mode. the ies also allows the surgeon to change imaging modes throughout the procedure as needed to facilitate different portions of the operation. we hypothesized that this technology would enhance visualization of critical structures during laparoscopic cholecystectomy (lc) compared to standard laparoscopic imaging. methods: videos and still images from an ies (karl storz endoscopy) were assessed in patients undergoing lc using the four imaging modalities. three time points were assessed: ) after adhesions were taken down but before any other dissection; ) after partial dissection of the hepatocystic triangle; and ) after establishment of the critical view of safety (cvs). seven surgeons blinded to the imaging modalities ranked each modality from (best) to (worst) for each of time points ( dissection points for cases). structures identified on achievement of the cvs were also analyzed. all statistics were performed using spss. rank data was analyzed with the friedman and wilcoxon signed rank tests. results: the median ranks of the chroma and chroma-clara imaging modalities (median [iqr] [ ] [ ] [ ] vs ( - ), p= . ) were not significantly different from each other, but both ranked significantly higher than the clara and standard modalities (median rank [iqr] [ ] [ ] and [ ] [ ] , respectively, p. ). individual surgeon preferences varied; four surgeons preferred chroma-clara, two preferred chroma, one preferred clara, and none preferred the standard mode. in addition, the cystic artery and cystic duct were visible in all cases after achieving the cvs, but the common bile duct was visible in only % of cases. conclusion: enhanced imaging system technology provides modalities that were significantly preferred over standard laparoscopic imaging on retrospective review of still and video images during lc. enhanced imaging modalities should be evaluated further to assess their impact on outcomes of lc and other laparoscopic procedures. introduction: cholangiocarcinoma is often diagnosed at an unresectable stage. endoscopic stent placement is generally performed to release the tumor-induced biliary obstruction. however, stents misplacement and migration, tumor tissue ingrowth and cholangitis are relatively frequent complications. energy-based techniques (radiofrequency ablation and photodynamic therapy) have been proposed as alternatives or in addition to the stent placement, showing controversial results. the use of laser sources in the ablation of the biliary wall has not been investigated so far. this study aims at the evaluation of the optimal power and exposure time to achieve a controlled circumferential intraluminal laser ablation of the common bile duct (cbd). methods: through a laparotomy access, the cbd of pigs was exposed and a small choledocotomy was made. a confocal endomicroscopy (ce) scanning (cellvizio) was performed through the choledocotomy, after injection of ml of sodium fluorescein. the . mm diameter circumferentiallyemitting diode laser probe ( nm wavelength) was introduced in the cbd. laser ablation was performed at w during s (n= ) or s (n= ). the power setting was predetermined on preliminary ex-vivo tests on porcine liver specimen. local temperature control was monitored through a fiber bragg grating, embedded in the laser probe. ce scanning was then repeated. the extent of the ablation was measured on hematoxilin-eosin and nadh stained slides. results: the diameter of the probe was too small to enable a single-shot circumferential ablation. there were no full-thickness perforations. after s from turning laser on, the temperature at the application site reached a plateau with minimal oscillations, and remained at mean values of . ± . °c during both and min. histology revealed that the mucosa ablation, at the contact areas, induced a consistent cellular necrosis (nadh-). ce scanning provided real-time images with a specific aspect of the post-ablation mucosa, including an alteration of the normal glandular structure and a general lack of enhanced imaging. the local application of a circumferential laser source induced a precise and safe mucosa ablation with a long-standing increase in temperature in the cbd, in this experimental trial. however, there is a need of an adapted probe, better fitting the diameter of the cbd to enable a single-shot circumferential treatment. goutaro katsuno, md, phd , yasuhiko nakata, md, phd , nobuyuki kubota, md, phd , teruo kaiga, md, phd , takao mamiya, md , masahiro yan, md , naoaki shimamoto, md , shuichi sakamoto, md, phd ; department of gastrointestinal and minimally invasive surgery, mitsuwadai general hospital, introduction: recently major developments in video imaging have been achieved for performing complete mesocolic excisions (cme) or total mesorectum excisions (tme). indocyanine green (icg) fluorescence imaging is already contributing greatly to making intraoperative decisions for keeping an intact visceral fascial layer, making suitable mesentery division lines and identifying anastomotic perfusions. the aim of this study is to present our experience with laparoscopic procedures for colo-rectal cancers using icg fluorescence imaging (lap icg-fi). patients and methods: we usually use the near-infrared (nir) laparoscopy (stryker corporation, michigan, usa) for lap icg-fi. [indocyanine green fluorescent imaging] visualization of lymph flow: icg ( . mg/ . ml) was injected into the submucosal layer around the tumor at points with a -gauge localized injection before the lymph node dissection. visualization of blood flow: after complete colorectal mobilization, the mesocolon was completely divided at the planned proximal or distal transection line. indocyanine green was injected intravenously and the transection location(s) and/or distal rectal stump, if applicable, were re-assessed in fluorescent imaging mode. results: we experienced lap icg-fi cases with colo-rectal cancer patients. tumor was located at the rectum in of them, at the sigmoid colon in , at the transverse colon in , at the descending colon in , at the ascending colon in , and at the cecum in . tnm stage was -i in patients, ii in , iii in , and iv in . the median (range) age of the patients was ( - ) years with a median (range) bmi of . ( - . ) kg/m . the lymph flow was visualized in patients ( %) intraoperatively. however, a high-quality intraoperative icg lymphangiogram was achieved in patients ( %). in high-quality lymphangiogram, the lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in keeping an intact visceral fascial layer as well as in making a suitable mesentery division line even in the bmi[ patients. a high-quality intraoperative icg angiogram was achieved in all patients. anastomotic perfusion was satisfactory in all cases. in patients ( . %), the use of nir+icg resulted in revision of the proximal colonic transection point before formation of the anastomosis. there were no postoperative anastomotic leakages. no injection-related adverse effects were reported. conclusion: lap icg-fi is a simple, safe and useful tool to help us complete lap cme or tme and check real-time anastomotic tissue perfusion. introduction: recently, the spread of laparoscopic surgery as a standard treatment and the development of information & communication technology have yielded abundant video data of laparoscopic procedures. these data have been accumulated and we can access them anytime, anywhere. however, the direction of how to use the abundant video data are still unclear. conventionally, surgical procedures have been performed based on surgeon's subjective decisions and skills, so called "tacit knowledge". for the purpose of objective analysis of laparoscopic procedures in video data, automatic recognition of surgical tools and understanding of surgical workflow must be the first critical step. we used convolutional neural network (cnn) which is the current trend in machine learning and computer vision tasks. methods: using video database of laparoscopic sigmoid colectomy in our institute, we performed annotation of tools and phases in every frame of the operating videos. for the tool detection, we annotated bounding boxes for both left and right tools in the videos. furthermore, phase annotation was performed by watching the videos in consultation with laparoscopic surgeons. the laparoscopic sigmoid colectomy operation passes through phases; -placement of ports and preparation, -dissection of retrorectal space, -medial approach to ima, -isolation and division of ima, -medial-to-lateral retromesenteric dissection, -lateral mobilization of left colon, -rectosigmoid mobilization, -division of mesorectum, -rectosigmoid resection and anastomosis, -finishing. we used cnn architecture to perform surgical tool detection and workflow recognition. results: we totally labeled tools used in the procedures of laparoscopic sigmoid colectomy and successfully developed tool detection system by cnn. as for surgical workflow, average times of phase - were . , . , . , . , . , . , . , . , . , . min, respectively. workflow recognition system using cnn was also successfully developed, while we needed to extract pure operating scenes in advance for efficient recognition outcomes. we've developed tool detection and phase recognition systems using cnn. we need more datasets to improve the detecting ability for future clinical uses. introduction: surgical environments require special aseptic conditions for direct interaction with the preoperative images and surgical equipment, which hampers the use of traditional input devices. we presented the feasibility of using a natural user interface (nui) for gesture control combined with voice control to directly interact in a more intuitive and sterile manner with the preoperative images and the integrated operating room (or) functionalities during laparoscopic surgery. in this study, efficiency and face validity of using this nui for medical image navigation and remote control during the performance of a set of basic tasks in the or will be assessed. methods and procedures: twenty experienced laparoscopic surgeons participated in this study. they performed basic tasks in the or focused on the interaction with a medical image viewer (osirix; pixmeo) and with the functionalities of the integrated or (or ; karl storz). these tasks were carried out by means of traditional manual interaction, using a computer keyboard and mouse and a touching screen, and using a gesture control sensor (myo armband) in combination with voice commands. this nui is controlled by the tedcube system (tedcas medical systems). time required to complete the tasks using each interaction method was recorded. at the end of the tasks, participants completed a questionnaire for face validation and usability assessment. results: the use of the nui required significantly less time than conventional manual control to show preoperative studies and information for surgical support. however, the interaction with the medical image viewer was significantly faster using the traditional input devices. participants evaluated the nui as an intuitive, simple and versatile tool that improves sterility during surgical activity. seventy-five percent of the participants would choose the gesture control system as a method of interaction with the patient's preoperative information during surgery. conclusions: the presented gesture control system allows surgeons to directly interact with preoperative imaging studies and the functionalities of an integrated or during surgery maintaining the aseptic conditions. for the traditional manual interaction, it is necessary to take into account the possible reaction time and displacement time of the technician to execute the surgeon's requests. a more personalized medical image viewer is required and with higher integration with the capabilities of the presented gesture control system. emma k gibson, bs, jacqueline j blank, md, timothy j ridolfi, introduction: following a generous left hemicolectomy an anastomosis between the transverse colon and rectum may be required. extensive mobilization and retroileal routing is sometimes necessary to create a tension-free anastomosis. retroileal routing is a technique in which a window is created in the ilieocolic mesentery. the colon is routed through this window, beneath the ileum, prior to entering the pelvis. retroileal routing is uncommon and there is no data on this technique when performed in using a hand-assisted laparoscopic technique. the aim of this study was to review our experience with hand-assisted laparoscopic left sided colon resections including retroileal routing of the proximal colon to the rectum. methods and procedures: we performed a retrospective review of a single surgeon's experience with hand-assisted laparoscopic left sided resections over a seven-year period from - . indication for operation, basic demographics, bmi, procedure time, short-and long-term morbidity, and mortality were recorded. results: a total of patients underwent a hand-assisted laparoscopic left sided resection with a colorectal or coloanal anastomosis. of these, underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon. in each case, operations included a midline hand port incision and two mm ports in the lower abdomen. the indications for operation were diverticular disease and neoplasm in nine and four patients respectively. procedures took an average of . ( - ) minutes to complete. postoperative morbidity included intubation for co retention in one patient and a rll effusion in another patient. there were no anastomotic leaks and there were no -day or -day mortalities. conclusion: retroileal routing of the colon following left hemicolectomy occurs infrequently. a hand-assisted laparoscopic approach appears to be a safe and efficient in these technically challenging cases. objective: approximation of the diaphragmatic crus pillars is a key step in hiatal hernia repair. the dogma of successful hernia repair requires tension free approximation of tissue. there are no techniques described to measure tension across the crus closure. aim of this study is to describe a novel technique for measuring the tension exerted on crural sutures and report initial findings. methods: data was collected at institutions by the same surgeon. after hiatus dissection was complete the crus defect was measured both anterio-posterior and transverse dimension. the crus closure sutures were placed posterior and then lateral to the esophagus. the initial suture is started posteriorly with a figure of eight fashion (# ). with each subsequent stitch placed anteriorly (# and # ) or laterally (l , l ) till adequate hiatus closure is achieved. we measured tension on each suture placed as follows. conclusions: the autolap system provides improved image stability, staff interactions, and enhanced ergonomic comfort for the surgical team. it also offers cost-savings from decreased staffing requirements for hospitals that routinely use staff camera holders. the system set up of - min was less variable after cases, representing the learning curve. in addition, our approach identified problems with the system that require improvement by the manufacturer. notably, we identified significant ergonomic problems for human camera holders, which has been previously described and can be addressed by this device. background: gastric leaks continue to be a troubling predicament for physicians and patients alike. they are especially concerning after bariatric surgery. electrolyte abnormalities and dehydration continuously pose a life threatening problem in these patients. methods: this is an irb approved retrospective review of our experience with a biologic tissue mesh plug closure of gastric leaks. our interventional radiology colleagues percutaneously accessed the perigastric collection with a wire and a straight catheter was guided through the gastric wall defect and advanced over the wire until it was intraluminal. the surgeon then placed an endoscope down to the level of the gastric defect. the wire was then retrieved by the endoscope achieving percutaneo-oral wire access. the biologic tissue matrix was then measured and cut to a square and inverted into a cone like structure with a flat straight piece on the open end. the cone patch was then secured to the wire with braided polyglactin suture loop. the wire was then withdrawn back through the gastric defect pulling the plug and patch into position and placement was confirmed by endoscopy. results: we attempted closure of a gastric leak arising after bariatric surgery in six patients. five underwent successful deployment while one had premature disconnection of the plug from the wire and could not be deployed. the five who had successful deployment had immediate success and within days resumed enteral intake of liquids and resolution of the leak. two of the six patients additionally underwent covered stent placement to stent a stenotic area at the incisura angularis from the esophagus to the antrum. this stent was typically removed - weeks later. there were no complications related to the procedure or the plug. only one patient has undergone repeat endoscopy to evaluate the status of the plug. in that patient an ulcer at the plug site was visualized one month after the procedure. three months later endoscopy showed the clean ulcer had shrunk to half of the original ulcer size. conclusion: this novel minimally invasive technique utilizing ir and endoscopic placement of a biologic mesh plug into gastric leaks after bariatric surgery has been highly successful in treating chronic and subacute gastric leaks. we recommend that these endoscopic techniques be used to close gastric defects prior to operative intervention. introduction: laparoscopic surgery has spread worldwide and become a standard procedure among many abdominal surgical fields. the incidence of postoperative adhesion, which is a typical postoperative complication, is considered low compared with that after laparotomy, but once complications develop, such as adhesion-induced intestinal obstruction and chronic abdominal pain, the low-invasiveness of laparoscopic surgery may decrease markedly. while we have previously used a sheet-type absorbable barrier to prevent adhesion, it requires a technique in many cases when it is applied in the abdominal cavity. in this study, we used a spray-type absorbable barrier, which is considered simple to apply, as an adhesion-preventing absorbable barrier following laparoscopic surgery. subjects and methods: a spray-type absorbable barrier for prevention of adhesion (ad spray type l®) was applied to the dissected surface, port region, and beneath the small incised wound in patients who underwent laparoscopic surgery of the large intestine after february . the nozzle is long ( mm in length) and the angle of the tip is adjustable to some extent, so that the spray could be applied easily to the target region, even in areas in which it would be difficult to secure a work space, by rotating the shaft and finely adjusting the angle of the tip. in order for the barrier to remain in the target region, this preparation must remain viscous after application. discussion: approaches for the insertion and affixing of a conventional sheet-type absorbable barrier for the prevention of adhesion has been reported previously by various researchers. the adhesion-preventing absorbable barrier used in this study was a spray type with a long nozzle, which may have been useful because it made the laparoscopic application easy. however, its application requires some experience and time for preparation compared with the use of the sheet type, which could be disadvantageous. further accumulation of cases, including evaluation of prevention of adhesion after use of the adhesion-preventing absorbable barrier may be necessary. christopher g yheulon, md, priya rajdev, md, s. scott davis, md; introduction: evidence has demonstrated that biosynthetic glue for laparoscopic inguinal hernia repair results in decreased pain. however, the two glue sub-types (biologic-fibrin based; synthetic -cyanoacrylate based) have never been compared. this study aims to assess the outcomes of those subtypes. method and procedures: a systematic review of the medline database was undertaken. randomized trials assessing the outcomes of laparoscopic inguinal hernia repair with penetrating and glue fixation methods were considered for inclusion and data analysis. thirteen trials involving patients were identified with eight trials utilizing fibrin and five trials utilizing cyanoacrylate. results: there were no differences in recurrence or wound infection between the glue subtypes when compared individually to penetrating fixation alone or indirectly to each other. there was a significant reduction in urinary retention with fibrin glue when compared to penetrating fixation (or . , % c.i. . - . ). no studies utilizing cyanoacrylate analyzed urinary retention as an outcome. there were non-significant trends in reduction of hematoma and seroma for both glue subtypes when compared to penetrating fixation (or . , % confidence interval . - . ). conclusions: glue fixation in laparoscopic inguinal hernia repair reduces the incidence of urinary retention and may reduce the rate of hematoma or seroma formation. as there are no differences in outcomes when comparing fibrin or cyanoacrylate glue, surgeons should choose the glue that is available at the lowest cost at their respective institution. however, improvement of the optical system is necessary to further utilize this advantage. we are developing an optical lens system covering the range from macroscopic to microscopic. methods: we developed a handheld prototype created by combining the objective lens system of an optical microscope and a telescope lens. a feasibility study using a porcine model was conducted. macroscopic observation was done at a distance followed by microscopic observation in contact with tissue. first, we observed the operative field macroscopically. we then observed the serosa of the small intestine microscopically, and effects of blood flow occlusion were studied. results: ( fig. and fig. ) the same visual field as ordinary laparoscopy was achieved during macroscopic observation, while using microscopic observation it was possible to observe the complex peristaltic movements of the intestine. the minute blood vessels of the visceral peritoneum and larger, deeper blood vessels were also observed. when the mesenteric vessels were occluded, changes in peristaltic movement were seen directly. congestion in blood vessels in the deep layers of the serosa was observed. improvement in peristalsis and congestion were confirmed by restoring blood flow. this system enables direct visual observations not possible with conventional optics. this system can be utilized in both laparoscopic and open surgery. the microscopic visual information obtained by this system may help with intra-operative decision making and serve to facilitate safe and precise surgery. introduction: accurate, real-time visualization is critical for efficient, effective and safe surgery. although optical imaging using near-infrared (nir) fluorescence has been used for visualization of anatomic structures and physiologic functions in open and minimally invasive surgeries, its efficacy and adoption remain suboptimal due to the lack of specificity and sensitivity. herein, we report a novel class of compounds, which are exclusively metabolized in liver or kidney, rapidly excreted into to biliary or urinary systems, and emitted two different nir fluorescence spectrums. methods: novel, water-soluble heptamethine cyanines; compound x (biliary) and compound y (urinary), unreactive towards gluthathione and the cellular proteome were synthesized, and visualized using real-time, dual-color nir imaging device. sprague-dawley rats (n= ) and yorkshire pigs (n= ) were used to demonstrate and validate its usefulness, distributed into a control group (icg; rat n= , irdye cw rat n= ), a biliary group (compound x; rat n= , pig n= ), a urinary group (compound y; rat n= , pig n= ), and dual-labeling group (compound x&y; rat n= , pig n= ). each rat and pig received one or two of the compounds at optimized dose of . -mg/kg intravenously, fluorescence signals and bio-distributions were monitored and recorded over time. the target to background ratio (tbr) was calculated in each target systems and compared to assess sensitivity and specificity. results: compound x was rapidly cleared from liver within min after intravenous injection while the fluorescence signals in biliary system lasted up to h both in rats and pigs. compound y showed significant renal excretion up to h and the urinary signals remained up to h. they were both highly specific to target organs with tbr values of . (biliary), . (urinary) and . (cf. icg) at peak signals. these new compounds have approximately - times higher quantum yields than icg and . - . times higher specificity to kidney and liver than irdye cw. one-way anova showed significant differences between control, biliary, and urinary group (p. .) dual-labeling results also showed a complete separation of these two metabolic systems (p= . ) and a real-time display of these two systems were clearly visualized with pseudo-colored labeling inside the animal body. conclusion: we report a new generation of organ-specific, real-time fluorescent markers for intraoperative visualization, navigation and potential geo-fencing. these new compounds have significantly higher quantum yields and higher specificity to visualize kidney and/or liver than any currently available reagents. background: porcine models have been widely accepted for gastrointestinal surgery studies, due to their similarities to human anatomy, histology and physiology. devices such as laparoscopic staplers have been widely used in bariatrics and are currently the cornerstone of bariatric. there are currently few published articles regarding surgical stapler testing in porcine models by means of a survival design. the purpose of this study is to present a new model for stapler testing in porcines. we present the following study in which we asses a novel stapler's feasibility and safety, and its compatibility to currently used stapler reloads. this novel stapler, the aeon™ endoscopic linear stapler (lexington medical inc., billerica, ma. pending fda approval), has been previously tested in-vitro and in-vivo by the lexington medical engineering department in matters of mechanical function, staple line bursting pressure, staple formation and hemostasis. duffy et al. used this instrument for small bowel anastomoses in a two-week survival study in porcine models. methods and procedures: four porcine animal model was used under iacuc protocol for a -day survival study held at the fiu (doral, fl, u.s.a) research facility. all animals underwent sleeve gastrectomy using the novel stapler handle, combined with the endo gia™ (medtronic, mansfield, ma) mm-staple reloads in two of the animals and aeon™ mm-staple reloads in the remaining two. no reinforcements or oversewing of the staple line was done. these procedures were performed by two bariatric surgeons. animals were monitored perioperatively by the facility staff as per protocol. the animals were euthanized at day . post-mortem assessments were done blindly. gross evaluation and comparison of the gastric tube and their staple lines was done, as well as patency, strictures, and staple line integrity. results: stapler function was equivalent with both reload brands, no technical issues were encountered. - firings were used per animal. no intraoperative complications related to stapler function ensued. no postoperative complications were encountered. all animals survived the full length of the study- days. all sleeves were patent, no strictures or bowel obstruction were present. conclusions: in an animal survival study, a follow-up period of weeks appears to be a good benchmark for stapler testing. the use of the novel stapler for gastric resections appears feasible and safe. further studies such as microscopic examination of the staple lines, might help confirm equivalence, safety and feasibility of these products for the sleeve gastrectomy procedure. jason m samuels, md , peter einersen, md , krzysztof j wikiel, md , heather carmichael , douglas m overby , john t moore , carlton c barnett , thomas n robinson, md , teresa s jones , edward l jones, md ; university of colorado denver, denver va medical center introduction: the purpose of our study was to evaluate the impact of smoke evacuation devices on operating room fires caused by surgical skin preps. surgical fires are rare but preventable events that cause devastating injuries. alcohol-based surgical skin prep serves as the fuel for a fire ignited by electrosurgical instruments. we hypothesized that increasing air exchanges near the tip of the active electrode will reduce the concentration of alcohol thus reducing the incidence of surgical fires. methods: a standardized, ex vivo model was created with a cm section of clipped, porcine skin. surgical skin preparations tested: % isopropyl alcohol with % chlorhexidine gluconate (chg-ipa) and % isopropyl alcohol with . % iodine povacrylex (iodine-ipa). based upon previous studies, a high-risk situation was replicated with immediate energy activation in the presence of pooled alcohol-based prep. the site was draped to simulate a small surgical procedure with approximately square cm exposed. (figure ) a standard and smoke evacuating electrosurgical pencil was activated for s on w coagulation mode in the presence of % oxygen. a standard wall suction was also tested with the tip held cm from the tip of the electrosurgical pencil. a chi-square test was used to compare differences between groups. results: surgical fires were created in % ( / ) of the tests with the chg-ipa and % ( / ; p= . ) of the tests with iodine-ipa. continuous wall suction did not change the incidence of fire. the smoke evacuation electrosurgical pencil significantly decreased the incidence of fire when compared to the standard pencil and continuous wall suction for both preparations (table ) . with chg-ipa, the smoke evacuation electrosurgical pencil decreased the frequency of fire by % (figure , p. ). similarly, when using iodine-ipa, the electrosurgical pencil with integrated smoke evacuation demonstrated a % decrease in fires (figure , p. ). conclusion: alcohol-based skin preps fuel surgical fires. the use of a smoke evacuator electrosurgical pencil reduces the occurrence of surgical fires. elimination of alcohol-based preps and the use of smoke evacuation devices decrease the risk of operating room fires. brian bassiri-tehrani, md, netanel alper, md, jeffrey s aronoff, md, yaniv larish, md; lenox hill hospital ureteral stents have historically been used in pelvic surgery when anatomical or clinical considerations warrant urological expertise to aid in identifying the ureters. in the colorectal and gynecologic surgery literature, prophylactic ureteral stents appear to increase the ability to detect ureteral injuries while not being shown to prevent such injuries. with the increasingly widespread use of laparoscopy and the robotic platform in complex colorectal and pelvic surgery, the utility of stents remains unclear. one of the limiting factors regarding the use of ureteral stents in minimally invasive surgery is the lack of tactile feedback; the inability of the surgeon to directly palpate the stents. one proposed method to overcome this deficiency has been the use of lighted ureteral stents. increased operating time, increased cost, and need for specialized equipment are potential drawbacks of lighted stents. an alternative to using lighted stents in minimally-invasive surgery is to directly inject indocyanine green (icg) into the ureters after cystoscopy-guided placement of ureteral stents. intraoperative visualization of the ureters is acheived by using either the pinpoint endoscopic fluorescence imaging system in laparoscopy, or firefly integrated with the robotic platform. it is hoped that the risk of inadvertent ureteral injuries during colorectal and pelvic operations will be minimized using this technique, due to improved visualization of the ureters throughout the procedure. in this case presentation, we describe a novel use of icg in a patient undergoing a laparoscopic surgery for resection of a . . . cm pelvic mass abutting the bladder, sigmoid colon and left ureter. preoperatively, there was concern that the mass would be intimately adherent to, or even invading, the bilateral ureters based on ct scan findings. after ureteral injection of icg, visualization of both ureters was easily achieved at the time of operation, and the procedure proceeded with careful and safe dissection of the mass with visualization of the ureters at all times. though there is a paucity of studies evaluating the use of icg in the laparoscopic modality, this technique was safe, easy to employ, inexpensive and very useful to visualize the ureters intraoperatively. indeed, larger studies with appropriate sample sizes would help to further validate this novel use of icg. university of colorado -denver, va eastern colorado healthcare system introduction: operating room fires are "never events" that expose the patient to the risk of devastating complications. our group has previously demonstrated that alcohol-based surgical skin preparations fuel operating room fires. manufacturer guidelines recommend a three-minute delay after application of alcohol-based preps to decrease the risk of prep pooling and surgical fires. the purpose of this study was to evaluate the efficacy of the three-minute dry time in reducing the incidence of surgical fires. methods and procedures: a standardized, ex vivo model was used with a cm section of clipped, porcine skin. alcohol-based surgical skin preparations tested were % isopropyl alcohol (ipa) with % chlorhexidine gluconate (chg) and % ipa with . % iodine povacrylex (iodine-ipa). nonalcohol-based solutions included % chlorhexidine gluconate and % povidone-iodine "paint." an electrosurgical ''bovie'' pencil was activated for seconds on watts coagulation mode in % oxygen, both immediately and minutes after skin preparation application, with and without solution pooling. results: no fires occurred with immediate testing of nonalcohol-based preparations ( / ). alcohol-based preps created flames on immediate testing in % ( / ) of cases when pooling was present. without pooling, flames occurred in % ( / ) of cases on immediate testing. after a -minute delay, there was no difference in the incidence of fire when pooling was present ( / vs. / , p [ ) . similarly, there was no difference when pooling was not present ( / vs. / , p= ). (table ) conclusions: alcohol-based surgical skin preparations fuel surgical fires. waiting minutes for drying of the surgical skin prep did not change the incidence of surgical fire (regardless of whether there was pooling of the prep solution). the use of nonalcohol-based skin preps eliminated the risk of fire. introduction: laparoscopic port sites are associated with a significant incidence of long-term hernia formation. in addition, closure with closed loop suture may lead to increased post operative pain thereby limiting patient mobility. the development of novel trocar closure systems could offer a pathway towards quality improvement and warrants investigation. we performed a randomized controlled trial comparing a novel anchor based system (neoclose®) versus standard suture closure. methods: a prospective randomized controlled trial of patients undergoing port site closure following robotic assisted laparoscopic sleeve gastrectomy or gastric bypass was completed ( with neoclose® device and with standard laparoscopic suture closure). each patient had both the camera port and stapling port closed ( port sites in each group). primary outcome measures included the incidence of hernia ( week ultrasound), time for port site closure, and depth of needle penetration. secondary outcome measures were analog pain scoring at post op day , week and week . results: physical exam as well as ultrasound evaluation showed no hernias in either group at weeks. when compared to suture closure, the neoclose® device was associated with shorter closure times ( . ± . versus . ± . s, p. ) and needle depth penetration ( . ± . versus . ± . cm, p\ . ). the neoclose® device was associated with decreased pain at week after the operation (analog pain score . ± . versus . ± . , p. ). no difference in pain scoring was observed on post operative day or at week . conclusions: trocar site closure with the neoclose® device is associated with decreased closure times and needle depth penetration. no difference in the incidence of hernias was identified very early after operation. the neoclose® device led to decreased pain week after trocar closure which is potentially secondary to decreased tension when compared to closure with closed loop suture. long term hernia data ( year) is pending with patients scheduled for follow up physical exams and ultrasounds. federico gheza, md, mario a masrur, md, simone crivellaro, md; uic introduction: robotic instruments provides a better ergonomics during suturing compared to standard laparoscopy. minimally invasive procedures with limited need of few suture may benefit from an economically affordable device able to overcome some limitations of laparoscopic suturing. flexdex surgical recently obtained the fda approval for human use of its articulated laparoscopic needle driver. the official training provided by the company (available at https://flexdex.com/register-for-training) is a h basic dry lab. the training curriculum as well as the accreditation process is not well structured. no literature is available today on this matter. our goal was building a dedicated training, to allow a safe and predictable early use in humans. methods and procedures: the training module design and implementation was done in our minimally invasive laboratory. in the preliminary phase we define with a small group of residents and research specialists a short list of mandatory concepts to detail showing the instrument. a simple suturing task was then performed by the same group with the new device, laparoscopically and with the robot, available in our lab for training only. a more complex task, based on a dedicated self-designed high-fidelity model of urethral anastomosis was then proposed, exploring different options (one flexdex only vs two flexdex, surgeon vs assistant holding the camera). lastly, we applied the new device in animals to evaluate the usefulness of including simple tasks or entire procedures in the training curriculum. results: we were able to define a multilevel, adaptable training module including a basic information session, a dry lab with inanimate low-and highfidelity models and a pig lab. subjects with different level of expertise (medical student, resident, fellow, expert and very expert surgeon) were involved to have an extensive feedback. however, our main focus was to design a training module for laparoscopic and robotic surgeons, to safely introduce the flexdex in their practice. the only outcome for this preliminary work was collected through a "post exposure" survey. the expert surgeon that did the entire training was able to give feedback after his first application of the device in humans as well. conclusions: flexdex is a promising device, available in the united states in approved facilities only. a minimally invasive lab with high laparoscopic and robotic training experience is the ideal setting to build a curriculum. a first adaptable, multilevel, original, high-fidelity training is proposed to be validated with further studies and could be implementable for accreditation purposes. surg endosc ( ) :s -s augmenting spatial awareness in laparoscopic surgery by immersive holographic mixed reality navigation using hololens objectives: endoscopic minimally invasive surgery provides a limited field of view, thus requiring a high degree of spatial awareness and orientation. because of a d field of endoscopic view, a surgeon's spatial awareness is diminished. this study aims to evaluate the efficacy of our novel surgical navigation system of immersive holographic mixed reality (mr) using a head-mounted smart glass display hololens to enhance spatial awareness of the operating field in laparoscopic surgery. the authors describe a method of registering and overlaying the preoperative mdct imaging localization of tumors, vessels, and organs onto the real world in the operating theatre through holographic smartglasses in augmented reality (ar). methods: in this study we included laparoscopic gi, hpb, urology, and gynecologic surgeries using this system. we developed a ct-based patient-specific holographic mr surgical navigating application using hololens, that is a pair of see-through monitors built-in head-mounted display. by reconstructing the patient-specific d surface polygons of tumors, vessels, and organs out of the patient's mdct, mr anatomy was displayed on the see-through grasses three-dimensionally during actual surgery. the hololens features an inertial measurement unit which includes an accelerometer, gyroscope, and a magnetometer for environment understanding sensors, an energy-efficient depth camera, a photographic video camera, and an ambient light sensor. results: the accurate surgical anatomy of size, position, and depth of the tumors, surrounding organs, and vessels during surgeries could be measured using build-in dual infrared light sensors. the exact location between surgical devices and patient's anatomy could be traced on the pair of mr smart-glasses by satellite tracking. the gesture controlled manipulation by surgeons' hands with surgical groves was useful for intraoperative anatomical references of tumors and vascular position under sterilized environment. it allowed the user to manipulate the spatial attributes of the virtual and real anatomies. this system reduced the length of the operation and discussion time. this could support complex procedures with the help of pre-and intra-operative imaging with better visualization of the surgical anatomy and spatial awareness with visualization of surgical instruments in relation to anatomical landmarks. conclusions: the immersive holographic mr system provides a real-time d interactive perspective of the inside of the patient, accurately guiding the surgeon. this helps spatial awareness of the surgeons in the operating field and has illustrative benefits in surgical planning, simulation, education, and navigation. enhancing scene visualization is a feasible strategy for augmenting spatial awareness in laparoscopic surgery. francisco miguel sánchez margallo, phd , juan a. sánchez-margallo, phd , andreas skiadopoulos, phd , konstantinos gianikellis, phd ; minimally invasive surgery centre, cáceres, spain, university of nebraska at omaha, university of extremadura, spain introduction: new handheld devices have been developed in order to address the technical limitations and ergonomic issues present in laparoscopic surgery. the aim of this study is to analyze the surgeon's performance and ergonomics using the radius r drive instruments (tubingen scientific medical, germany) during the execution of laparoscopic cutting and suturing tasks. methods and procedures: three experienced laparoscopic surgeons performed both an intracorporeal suturing task and a cutting task on a box trainer. both tasks were repeated three times. a maryland dissector and a pair of scissors were used for the cutting task. for the suturing task, a maryland dissector and needle holder were used. conventional laparoscopic instruments and their equivalent r drive instruments were used. the order in the use of the type of instruments was randomized. execution time and surgeon's ergonomics were assessed. for the latter, surface electromyography (trapezius, deltoid and paravertebral muscles) and the nasa-tlx index were analyzed. for the cutting task, the percentage of the area of deviation from the cutting pattern (% of error) was assessed. the suturing performance was assessed by means of a task-specific validated checklist. results: surgeons required more time to perform both laparoscopic tasks using the r drive instruments. the use of both instruments had a similar percentage of deviation from the exterior part of the cutting pattern. however, the deviation from the inner part was significantly higher using the r drive instruments (conv: . ± . % vs r drive: . ± . %; p\. ). needle driving was scored lower using the r drive instruments, but quality of knot tying was similar to conventional instruments. the use of r drive increased the muscle activity of the trapezius muscles bilaterally for both laparoscopic tasks. this muscle activity also increased for the left deltoid muscle during the cutting task. surgeons stated that the use of r drive instruments leads to a higher mental and physical workload when compared to traditional laparoscopic instruments. conclusions: despite the novel and ergonomic design of the r drive laparoscopic instruments, the results of this study suggest that an improvement in surgical performance and physical workload is required prior their use in an actual surgical setting. further studies should be done to analyze the use of these instruments during other laparoscopic tasks and procedures. we believe that surgeons need a longer and comprehensive training period with these laparoscopic instruments to reach their full potential in laparoscopic practice. background/objectives: d printing has been shown to be a useful tool for preoperative planning in various surgical disciplines. however, there are only several single case reports in the field of liver surgery. this is because of problematic visualization of anatomy, difficulties in methodology and-most importantly-high costs limiting implementation of d printing. the goal of this study is to evaluate the utility of personalized d-printed liver models as routinely used tools in planning and guidance of laparoscopic liver resections. materials and methods: contrast-enhanced computed tomography images of consecutive patients who underwent laparoscopic liver resections in a single centre were acquired and processed. proper segmentation algorithms were used to obtain virtual models of anatomical structures, including vessels, tumor, gallbladder and liver parenchyma in stl (stereolithography) format. after processing files, models in parts were subsequently printed with desktop ultimaker + (ultimaker, netherlands) d printer, using polylactic acid filaments as printing material. all parts were matched together to create a mold, which was later casted with transparent silicone. models were delivered to surgical teams prior to the surgery as well as used in patients' education. results: up to now, six full-sized, transparent, personalized liver models were created before laparoscopic liver resections and used as a tool for preoperative planning and intraoperative guidance. usefulness of these models has been evaluated qualitatively with surgeons. operative data was obtained for each patient and it will be used for quantitative analysis in further study phases. costs of one model varied between $ and $ and whole process of development took approximately days in every case. conclusions: d-printed models allow precise planning in complex cases of minimally invasive liver surgery by providing high-quality visualization of patient-specific anatomy. implementation of this technology might potentially lead to clinical benefits, such as reduction of operative time or improvement of short-term outcomes. having said that, more data is needed to decisively prove these hypotheses. introduction: modern laparoscopic graspers may risk inadvertent injury to tissues, and have been shown to produce crush and puncture injuries. in addition, the force transmitted to the tissues by grasper handles can be highly variable, dependent on the orientation and amount of tissue engaged by the grasper. we have developed a novel vacuum-based laparoscopic grasper designed to reduce tissue injury from grasping. the aim of this study is to compare the incidence and severity of tissue trauma caused by vacuum-based graspers versus standard compressive graspers while manipulating tissue. we performed an in vivo surgical porcine study to assess gross and histologic tissue injury after grasping trials. grasping trials were divided equally between two adult porcine models; samples of small bowel were grasped with a standard atraumatic laparoscopic grasper (aesculap double-action atraumatic wave grasper) and were grasped with our novel vacuum grasper with varying vacuum head designs ( for head a, each for heads b and c). following grasping, the porcine model was allowed to dwell for hours prior to harvest. gross injury was graded as follows: ) no injury, ) ecchymosis only, ) serosal injury, ) seromuscular injury, and ) perforation. histologic injury was graded as follows: ) serositis, ) partial-thickness injury to the muscularis propria (mp), ) full-thickness mp injury, and ) full-thickness mp and mucosal injury. mann-whitney u test was performed to compare both gross and histologic injury scores between the groups. results: on gross assessment, no samples were noted to have injury more severe than ecchymoses following grasping. the vacuum grasper was found to cause more ecchymosis (median= ) than the compressive laparoscopic grasper (med.= , u= , p. ). on histologic assessment, the compressive grasper caused significantly more severe injury (med.= ) compared to the vacuum grasper (med.= , u= , p= . ). subgroup analysis showed that heads a (med.= , u= . , p= . ) and b (med.= , u= , p= . ) caused significantly less injury compared to the compressive grasper. head c (med.= , u= . , p= . ) also showed less injury but did not reach statistical significance. conclusion: this study demonstrates that our novel laparoscopic vacuum grasper produces less tissue trauma than standard compressive graspers. vacuum-based grasping is a viable alterative for reducing inadvertent tissue injury in laparoscopy. minimally invasive surgery centre, cáceres, spain, university of nebraska at omaha, university of extremadura, spain introduction: the aim of this study is to analyze the surgeon's performance, workload and ergonomics using an ergonomically designed handheld robotic needle holder during laparoscopic urethrovesical anastomosis in an animal model, and comparing it with the use of a conventional laparoscopic needle holder. methods and procedures: six experienced surgeons performed an urethrovesical anastomosis in a porcine model using a handheld robotic needle holder and a conventional laparoscopic axialhandled needle holder (karl storz gmbh). the robotic instrument (dex®, dextérité surgical) has an ergonomic handle and a flexible tip with unlimited rotation, providing seven degrees of freedom. the use of the surgical instrument was randomized. for each procedure, an expert surgeon evaluated the surgical performance in a blinded fashion using the global operative assessment of laparoscopic skills rating scale. besides, the quality of the intracorporeal suture was assess by a validated suturing-specific checklist. the surgeon's posture was recorded and analyzed using the xsens mvn biomech system based on inertial measurement units. the surgeon's workload was evaluated by means of the nasa task load index, a subjective, multidimensional assessment tool. the patency of each anastomosis was assessed using methylene blue. results: all urethrovesical anastomoses were completed without complications. only one anastomosis with the robotic device failed the patency test. surgeons showed similar surgical skills with both instruments, although they presented greater autonomy with the conventional instruments (p =. ). for the suturing performance, the use of the robotic device led to an increase in the number of movements during the needle driving and lower tendency to follow its curvature during the withdrawal maneuver (p=. ). the level of workload increased with the robotic device. however, the surgeon's satisfaction with the surgical outcome did not differ using both instruments. the use of the robotic instrument led to similar posture of the shoulder and wrist and better posture of the right elbow (p=. ) when compared to the conventional instrument. conclusions: the use of the robotized needle holder obtained similar results for the surgical performance and surgical outcome of the urethrovesical anastomosis when compared to the conventional instrument. we consider that aspects such as the surgeon's autonomy, dexterity in driving the needle and workload could be improved with a comprehensive training with the new device. inertial sensors can be an alternative for actual and crowded surgical environments. surgeons acquired a better body posture using the novel robotic needle holder. surg endosc ( ) :s -s introduction: temporal and spatial tissue temperature profile in electrosurgical devises, such as ultrasonic scissors and bipolar vessel sealing system, was experimentally measured, and the incidence of postoperative complications after thoracoscopic esophagectomy was assessed according to the electrosurgical devises used. methods and procedures: experiment of thermal spread: sonicision (sonic) was used for ultrasonic scissors and ligasure (ls) was used for bipolar vessel sealing system. each device was activated in order to cut porcine muscle at room temperature. temperatures of both the device blade and porcine tissues beside the device were measured using a temperature probe. each experiment was performed at least three times. room temperature was degrees. clinical analysis: the patients who underwent thoracoscopic esophagectomy with -field lymph node dissection in the prone position were selected in the study. incidence of postoperative complications after thoracoscopic esophagectomy was compared according to electrosurgical devises. bronchoscopy was used for diagnosis of recurrent laryngeal nerve paralysis (rlnp). sonic and ls was employed in and patients, respectively. material: we compared consecutive cases using d laparoscopic surgery versus cases of d conventional laparoscopic surgery from january to june . all surgical procedures were performed by experienced laparoscopic surgeons using d (einsteinvision system) and hd conventional laparoscopic optic. d-laparoscopic surgery offers the depth perception of the surgical field that is lost with the conventional ( d) laparoscopic surgery, and in many series is reported to be better in terms of surgical performance. outcome measures was operation time, surgical performance, blood looses, complications and surgeon satisfaction with the procedure. results: cholecystectomy was the most frequent surgery performed with cases ( %); hernia surgery cases ( %); fundoplication cases ( %), appendectomy cases ( %), left colon excison with colo-rectal anastomosis cases( %), and other cases ( %) wich included ovarian cyst excision, liver biopsy, prostatectomy and pediatric surgery. we compared each d procedure with a standard laparoscopy case performed by the same surgeon during the time of the study. d vs d surgical procedures outcome measures are shown in table . we found better results in operation time, surgical performance and less blood looses in favor of three-dimensional laparoscopy (. ). conclusion: d laparoscopy reduces operation time related to better performance during the procedure. depth perception facilitates dissection, intracorporeal knotting, mesh placement and colo-rectal anastomosis. surgeons reported better surgical performance and comfort during d laparoscopy; there were any reported side effects such as headache or dizziness. background: social media (some) uniquely allows international collaboration, with immediacy and ease of access and communication. in areas where surgical management is contentious, this could be a valuable tool to frame the current state, propose best practices, and possibly guide management in a rapid, cost-effective, global scale. our goal was to determine the ability to use twitter-a some platform-as an alternative surgical research tool. methods: twitter was used to host an online poll on a pre-selected controversial topic with no current consensus guidelines-pathological complete response in rectal cancer. an influential colorectal surgeon published the survey "t n rectal cancer undergoes a complete response" on two separate occasions. both polls were open for duration of three days. two methodologies were tested to increase exposure and direct towards relevant participants: first, tagging several worldwide experts, then using the well-established hashtag #colorectalsurgery and publishing during an international surgical conference. the main outcome measure was the feasibility, validity, reproducibility, and methods to further participation of a twitter survey. results: the tweet polls were posted three weeks apart. there was no cost and the time required for the process was three minutes, demonstrating the feasibility. providing three closed options to select from facilitated validity. the poll's anonymity limited knowledge of the participant's qualifications, but public comments and "retweets" came from surgeons with experience ranging from trainee to department chair. a robust volume of respondents was observed. the st post received votes, "likes", "retweets", and comments from a diverse international group ( countries). all tagged members participated in the forum. the nd received votes, "likes", "retweets", and comments. the results were reproducible, with the majority favoring option on both occasions ( % and %, respectively; p= . ). treatment recommendations, their rationale, and open questions were identified in the thread. conclusions: some can be used as a research tool, with valid, reproducible, and representative survey results. while exposure was comparable across the two methods, tagging specific members guided experts to provide more opinions than using conference and specialty hashtags. this could expand awareness, education, and possibly affect management in a transparent, cost-effective method. the anonymous nature of respondents limited the ability to make conclusions, but interest and opinion leaders for further study can be easily identified. this demonstrates the potential for some to facilitate international collaborative research. background: despite the technological advancement of a minimally invasive approach to pylorus -preserving pancreaticoduodenectomy (pppd), the morbidity is still high. among the many complications, postoperative pancreatic fistula (popf) is reported in high incidence rate, which varies from researcher to researcher, and a fistula risk score (frs) has been developed to predict the popf. the aim of this study is validate the fistula risk score in minimally invasive approach of pppd and find the other meaningful parameter for prediction of popf. method and materials: from january to august , laparoscopy attempted right-sided pancreas resection was performed on patients including robotic reconstruction in the division of hepatobiliary and pancreas at yonsei university health system. among them, patients were excluded due to total pancreatectomy (n= ), open conversion (n= ), pancreaticogastrostomy and hybrid manual anastomosis (n= ), non-measurable drain and missing datas (n= conclusions: fistula risk score is significant prediction factor of popf including biochemical leaks. in addition to the previously known frs variables, our data showed that bmi is an important predictor of popf with clinical relavancy in a minimally invasive approach of pppd. laparoscopic hemi-hepatectomy for liver tumor satoru imura, hiroki teraoku, yuji saito, shuichi iwahashi, tetsuya ikemoto, yuji morine, mitsuo shimada; tokushima university introduction: with progress of surgical technique and devices, laparoscopic liver resection became a realizable option for patients with liver tumor. major liver resection such as anatomical left or right hemi-hepatectomy has also been introduced in many centers. herein, we evaluate surgical results of laparoscopic hemi-hepatectomy for liver tumor. patients and methods: until march , consecutive patients who underwent laparoscopic or laparoscope-assisted hemi-hepatectomy (left: , right: ) were reviewed and the surgical data such as operation time, blood loss, postoperative complications were analyzed retrospectively. results: of the patients underwent left hemi-hepatectomy, cases were primary liver cancer, cases were metastatic tumor, and cases were benign tumor. pure laparoscopic surgery was performed in cases. the mean blood loss was ( - ) ml, mean operating time was ( - ) minutes and mean postoperative hospital stay was ( - ) days. the rate of postoperative complications was . % (wound infection; n= ). all right hemi-hepatectomy was performed by laparoscope-assisted method. of the patients underwent right hemi-hepatectomy, cases were primary liver cancer, cases were metastatic tumor, and cases were benign tumor. the mean blood loss was ( - ) ml, mean operating time was ( - ) minutes and mean postoperative hospital stay was ( - ) days. the rate of postoperative complications was . % (biliary stenosis; n= ). the patients with hepatocellular carcinoma were followed up for a median of ( - ) months. recurrence occurred in cases and none of them had died at the time of follow-up. conclusion: laparoscopic hemi-hepatectomy is a safe and effective procedure for the treatment of benign and malignant liver tumors. ibrahim a salama, professor; department of hepatobiliary surgery, national liver institute, menoufia university abstract background: iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. better outcome of such injuries have been shown in cases managed in a specialized center. objective: evaluatation of biliary injuries management in major referral hepatobiliary center. patients and methods: four hundred seventy two consecutive patients with post-cholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist and radiologist) at major hepatobiliary center in egypt over years period using endoscopy in patients, percutaneous techniques in patients and surgery in patients. results: endoscopy was very successful initial treatment of patients ( %) with mild/moderate biliary leakage ( %) and biliary stricture ( %) with increased success by addition of percutaneous (rendezvous technique) in patients ( . %). however, surgery was needed in ( %) for major duct transection, ligation, major leakage and massive stricture. surgery was urgently in patients and electively in patients. hepaticojejunostomy was done in most of cases with transanastomatic stents. one mortality after surgery due to biliary sepsis and postoperative stricture was in cases ( . %) treated with percutaneous dilation and stenting. conclusion: management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging for early referral to highly specialized hepatobiliary center. introduction: simple liver cyst is the solitary non parasitic cystic lesion of the liver. teatment of symptomatic liver cyst varies from simple aspiration to hepatic resection. each treatment has its own merits and associatied complications. laparoscopic unroofing (fenestration) offers the best balance between efficacy and safety. polycystic liver disese (pcld) treatment by this method are less clear because of high failure rate. liver resection though more effective carries higher risks. treatment of hydatid disease are controversial. materials and method: simple cyst may be asymptomatic and picked up as incidental findings on ultrasound examination for other abdominal complaints. few cyst have symptoms of mass effect or with complication effect due to haemorrage, rupture, infection. on examination liver is palpable. compression over bile duct give rise to jaundice. the commonest symptoms are pain, early satiety, nausea and vomiting. simple cyst are more common in female after years of age. the cyst located antriorly inferiorly and laterally are the ideal case. investigation like ultrasonography is important. it will helps us to detect the cyst nature, will help to differentiate bet ween simple cyst from poly cystic liver disease, from neoplastic liver. in endemic area of hydatid liver disease serological test is mandatory. ct scan is important regarding details information about to localise the cyst, to identify the liver tissue arroud the cyst, relationship of cyst with the nearby vital structures, number of cyst, calcification and carcinomatous changes in its wall. aspiration of cystfluid, biological and cytological examination to rule out the presence of infection, biliary communication and malignancy. recently, ca - estimation is helpful for the differentiating the simple cyst from the cystadenoma or carcinoma. for jaundice patient ercp is impotant to locate the intraductal polyp causing the biliary obstruction or cyst causes the compression of the biliary tree. for bleeding in cyst mri is helpful. carcinoma at epithelial lining may occur. result: laparoscopic de-roofing (fenestration) less radical procedure ensures adequate drainage of cyst content into the peritoneal cavity. the cyst wall can be removed using harmonic scalpel so smoked produced and fogging of lens can be minimized. the interior surface inspected with care to exclude neoplastic growth and biliary communication. whole operative procedure, duration of postoperative recovery, hospital stay is much shorter in this procedure. large cevron incision can be avoided. no recurrence in two years follow up period. liver resection and total cystectomy theoretically minimizes the recurrence risk but invoke the a real risk of postoperative complications and death. conclusion: careful case selection and meticulous surgical skills are the two major determinants of the outcome. in the llr group, the first port was placed with an alexis® wound retractor (applied medical, usa) and free access® (top corporation, japan) at the abdominal defect made by previous sc. an additional or trocars were placed as needed. results: all patients in the llr group were treated using the laparoscopic approach. there were no other significant differences in patient background and characteristics. operative duration was similar for these groups. blood loss, complication rate, and hospital stay in the llr group were significantly decreased compared with the olr group. conclusion: in concurrent liver resection and sc, the open approach may require multiple large incisions, but the laparoscopic approach can complete procedures with a stoma wound and a few port wounds. additionally, use of a platform on the wound for sc enhances safety and efficacy for dissection of intraabdominal adhesions and a clear operative view. primary hepatic lymphoma: the importance of liver biopsy diego t enjuto , carlos ortiz , laura casanova , jose luis castro , pablo sánchez , jaime vázquez , norberto herrera , benjamín tallon , carmen jimenez ; hospital severo ochoa, hospital san rafael, hospital henares primary hepatic lymphoma (phl) is a very uncommon lymphoproliferative malignancy. it accounts for only . % of all extranodal non-hodgkin lymphoma and . % of all cases of non-hodgkin disease. the diagnosis is made when there is only liver involvement or when there is minimal non-liver disease. bone marrow, spleen, or hematologic affection should be excluded to confirm the diagnosis. we present our experience with two phl's that were correctly diagnosed thanks to laparoscopic liver biopsy. -year-old male admitted because of a -month history of right upper quadrant pain and nonmeasured weight loss. liver function tests and cholestasic enzymes showed normal values. serologic tests showed negative results for both hbv (hepatitis b virus) and hcv (hepatitis c virus). ct (computed tomography) scan showed three intrahepatic lesions in segments v, vi, and vii. ct-guided fine needle did not reach the diagnosis so a laparoscopic hepatic biopsy was performed. the final diagnosis was burkitt-like lymphoma. chemotherapy with r-chop (rutiximab, cyclophosphamide, adriamycin, vincristine, and prednisone) modality was started and completed after cycles. it is currently years since the patient was diagnosed and there are no clinical or radiological signs of recurrence. -year-old male who complained of diarrhoea and abdominal pain. chronic hb infection with no viral charge was detected. ultrasound showed heterogeneity of the whole left hepatic lobe and an mri was performed. a ten by segen centimeters lesion occupying the left hepatic lobe enhanced in arterial phase was seen suggesting adenoma. laparoscopic hepatic biopsy was completed to reach a definitive diagnosis. non-hodgkin lymphoma follicular type has just been confirmed with the histology and immuno-histochemistry. chemotherapy with r-chop should be started in the following weeks. phl's diagnosis is hard to achieve. fine needle biopsies are frequently negative because of the large area of necrosis. surgical biopsies are sometimes indispensable to get enough tissue to reach the diagnosis. phls are sometimes misdiagnosed as hepatocellular carcinoma because of its relation to hcv meaning a major hepatic resection. that is the reason why we consider that all diagnostic measures should be undertaken to rule out a different type of tumor. surgical resection is normally not needed in phls; as they are chemosensitive lesions. surgical options usually add unnecessary morbidity and mortality to these patients. chemotherapy standard treatment for phl consists on r-chop combination. pancreatic neoplasm enucleation -when is it safe? case report and review of the literature elaine jayne buckley , k molik , j mellinger ; siu-som, hshs pediatric surgery introduction: solid pseudopapillary tumors are rare neoplasms accounting for - % of pancreatic malignancies with a low risk of recurrence and metastasis. pancreatic malignancies are less common in pediatric populations, though small case series have identified that pseudopapillary tumors comprise between and % of pediatric pancreatic neoplasms. as these tumors have a low risk of metastasis, the mainstay of treatment has remained surgical excision. several surgical approaches have been described from extensive resections such as pancreaticoduodenectomy to local enucleation. we present a case of enucleation of a large pseudopapillary tumor from the pancreatic head complicated by pancreatic fistula. a literature review was performed given the rarity of this tumor to review surgical approaches, to compare complications and long-term outcomes, and to identify specific strategies to decrease the risk of pancreatic fistula. case description: a year-old female presented with months of abdominal pain. computed tomography identified a right upper quadrant mass felt to be consistent with a lipoma. follow up ct at months suggested the mass was more likely a gastrointestinal stromal tumor (gist), and surgical resection was recommended. enucleation of the mass was chosen in view of a wellcircumscribed appearance, clear operative tissue planes, and concern for long-term morbidity of a more extensive resection given the patient's young age. pathology demonstrated an . cm pseudopapillary tumor with negative margins. her post-operative course was complicated by a grade b pancreatic fistula, managed with nutritional support, external drain maintenance, and endoscopic stenting. the patient achieved healing of the pancreatic fistula after four months. results: our literature review demonstrates no difference in recurrence, mortality or morbidity between types of surgery. pancreatic fistula contributed to the majority of postoperative morbidity in all cases. recommendations for enucleation include small ( - cm) tumors with between and mm margin from the main pancreatic duct. techniques identified to minimized post-operative pancreatic fistula include preoperative imaging of the duct anatomy, preoperative pancreatic stent placement, and intraoperative ultrasound to identify the pancreatic duct. some literature supports preservation of pancreatic parenchyma, particularly in younger patients, to reduce endocrine and exocrine dysfunction given the low rates of recurrence and metastasis with this rare neoplasm. conclusion: our case demonstrates complications of enucleation of a large pseudopapillary tumor with successful multidisciplinary post-operative management. with the risk reduction strategies identified, we suggest that enucleation may be considered for pseudopapillary tumors in younger patients to preserve pancreatic parenchyma and long-term pancreatic function. introduction: recent advancements in minimally invasive techniques led to increased effort and interest in laparoscopic pancreatic surgery. laparoscopic distal pancreatectomy is a widely accepted procedure for left-sided pancreatic lesions. in other cases, the adoption of laparoscopic pancreaticoduodenectomy has been hindered by the technical complexity of laparoscopic reconstruction. hybrid laparoscopy-assisted pancreaticoduodenectomy (hlapd) in which pancreaticoduodenal resection is performed laparoscopically, while reconstruction is completed via a small upper midline minilaparotomy, is combines the efficacy of open approach, and the benefits of laparoscopic approach. the purpose of this study is to report our experience of hlapd and to define the learning curves. methods: patients with benign and malignant periampullary lesion underwent hlapd by a single surgeon between july and may were retrospectively reviewed. the clinicopathologic variables were prospectively collected and analyzed. the learning curve for hlapd was assessed using cumulative sum (cusum) and risk-adjusted cusum (ra-cusum) methods. results: the most common histopathology was pancreatic ductal adenocarcinoma (n= , . %), followed by intraductal papillary mucinous neoplasms (n= , . %), ampulla of vater cancer (n= , . %), and common bile duct cancer (n= , . %). the median operation time was min (range, - min) and the median estimated blood loss was ml. based on the cusum and the ra-cusum analyses, the learning curve for hlapd was grouped into four phases: phase i was the initial learning period (cases - ), phase ii was the technical stabilizing period (cases - ), phase iii was the second learning period (cases - ) and phase iv represented the second stabilizing period (cases - ). there was a statistical difference in terms of surgical indication between phase ii and iii (p= . ). conclusions: hlapd is a technically feasible and safe procedure in selected patients. this procedure has benefits of both open and minimally invasive procedure, and could be a stepping-stone for transition from open to purely minimally invasive pancreaticoduodenectomy. in silico investigation of the background: wilson's disease is a rare autosomal recessive genetic disorder of copper metabolism, which is characterized by hepatic and neurological disease. the gene atp b (on chromosome ) leads to wilson's disease is highly expressed in the liver, kidney, and placenta and encodes a transmembrane protein atpase (atp b), which functions as a copper-dependent p-type atpase. methods: here, the rare codons of atp b gene and their location in the structure of atp b protein was studied with rare codon calculator (racc) (http://nihserver.mbi.ucla.edu/racc/), atgme (http://atgme.org/), latcom (http://structure.biol.ucy.ac.cy/latcom.html) and sherlocc program (http://bcb.med.usherbrooke.ca/sherlocc.php). racc server identified arg, leu, ile, and pro codons as rare codons. results: results showed that cyp a gene have single rare codons of arg. additionally, racc detected two rare codons of leu, single rare codons of ile and rare codon of pro. atp b gene analysis in minmax and sliding_window algorithm resulted in identification of and rare codon clusters, which shows the difference features of these algorithms in detection of rcc. analyzing the d model of atp b protein show that arg residue constitute hydrogen bonds with glu and glu that with mutation of this residue to ser this hydrogen bonds were disrupted and may interfere in the proper folding of this protein. moreover, the side chain of arg don't forms any bond with others residues that with mutation to thr form new hydrogen bond with the side chain of arg . these addition and deletion of hydrogen bonds effects on the folding mechanism of atp b protein and interfere with the proper function of the atp b position. his forms the hydrogen bonds with the his and it seems that this hydrogen bond close together two region of this protein and it seems that has a critical role in the final folding of atp b protein. conclusions: computational study of diseases such as wilson's disease and involved genes (atp b) help us in understanding of disease's physiopathology and finding new approaches for detection and treatment. pancreatic stump leak and fistula formation are significant causes of morbidity in patients undergoing distal pancreatectomy (dp), with incidence of % to as high as % in a large systematic review. we present a case of a year old female, four months status post distal pancreatectomy and splenectomy for pseudopapillary neoplasm of pancreatic tail. patient presented to our institution with day history of left upper quadrant pain and general malaise. differential diagnosis on admission was abdominal wall abscess vs incarcerated incisional hernia. physical exam was positive for severe tenderness to palpation over a * cm cm non reducible mass in left upper quadrant with surrounding skin erythema. patient underwent a diagnostic laparoscopy and intraoperative findings revealed extensive adhesions to the anterior abdominal wall and a loop of small bowel was found adhered to the previous incision site in left upper quadrant. upon further dissection we entered a large cm cavity with saponified caseous material. the saponified material and thick tan fluid were evacuated into an endocatch bag and two large bore jackson pratt drains were left within the cavity. further examination showed that the small intestine was normal with no signs of obstruction or ischemia. fluid studies and cultures were sent and showed yeast like organisms and negative for acid fast bacillus. we report an unusual presentation of a distal pancreatectomy stump leak in the formation of an intra-abdominal saponified fluid collection four months after the primary procedure. given the high incidence of pancreatic stump leak and fistula formation after distal pancreatectomy, much effort has been made to identify factors associated with higher incidence of leaks and their usual and unusual presentations, which will be reviewed in this report. initial concerns regarding healthy donor's safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation (ldlt) have delayed the development of laparoscopic donor hepatectomy in adult-to-adult ldlt. however, decreased blood loss, less postoperative pain, shorter length of stay in hospital, and excellent cosmetic outcome have well been validated as the advantage of laparoscopic hepatectomy. hence, the safety and feasibility for laparoscopic donor should be further investigated. we present initial experiences and safety for totally laparoscopic living donor right hepatectomy. in cases who received elective living donor right hepatectomy for adult-to-adult ldlt, totally laparoscopic approach was applied from may up to august . the anatomical variation of portal vein was not considered as an exclusion criteria, but all donors were with type i portal vein variation. the bile duct anomaly was preoperatively evaluated with magnetic resonance cholangiopancreatography (mrcp) and was never excluded for totally laparoscopic approach. d conventional rigid º rigid laparoscopic system was used in cases and the remaining cases used d flexible laparoscopic system. in about %, hepatic duct anomalies (type , a, b) were identified. the operation time was from hours to hours. and the time for the graft removal was within minutes. the hepatic duct transection was performed under operative cholangiography via a cystic duct and the patency of left hepatic duct was also confirmed by operative cholangiography. however, during postoperative period, bile leakage was identified in only case and resolved after the biliary stent insertion by ercp. during operation, there was no transfusion and the inflow control like pringle maneuver was not used at all. v or v were reconstructed in cases and large right inferior hepatic vein was prepared for anastomosis in cases. all grafts were removed through the suprapubic transverse incision. most donors were discharged at days after hepatectomy. during the short-term follow-up period in the donors except this case, complications were not identified. conclusively, totally laparoscopic right donor hepatectomy in elective adult-to-adult ldlt can be initially attempted after enough experiences of laparoscopic hepatectomy and ldlt. however, the true benefits of totally laparoscopic living donor right hepatectomy should be fully assessed through various experiences from multi-institutes. background: the role of neoadjuvent chemotherapy on the treatment of pancreatic cancer remains widely controversial. studies have evaluated its effect on resectability and survival; however, few have studied the consequence of neoadjuvent therapy on surgical outcomes and complications. methods and procedures: a retrospective analysis was performed utilizing the targeted pancreas module of the national surgical quality improvement project (nsqip) for patients undergoing pancreaticoduodenectomy. neoadjuvent therapy was defined by chemotherapy and/or radiation in the -days before surgery. patient demographics, operative characteristics, and -day outcomes were compared amongst patients undergoing neoadjuvent chemotherapy, radiation, chemoradiation, and no neoadjuvent therapy. both univariable and multivariable analysis were completed. results: pancreaticoduodenectomy was completed in , patients. , patients had no neoadjuvent therapy; underwent both chemotherapy and radiation; underwent chemotherapy alone, and underwent radiation alone. there were no differences in demographics or comorbidities. no difference in -day mortality was found; however pancreatic fistula formation was affected by neoadjuvent therapy. neoadjuvant radiation increased fistula formation (or: . , % ci: . - . ) while neoadjuvent chemotherapy (or: . , % ci: . - . ) was protective. conclusion: neoadjuvent therapy significantly impacts surgical outcomes following pancreaticoduodenectomy. given that pancreatic fistula formation can delay post-operative chemotherapy, it may be reasonable to refrain from neoadjuvent radiation therapy for patients with resectable and borderlineresectable disease. the influence of thickest background: the use of stapling devices for distal pancreatectomy remains controversial, due to concerns about the development of postoperative pancreatic ?stula (popf). pancreas thickness might be associated with popf, but suitable thickness of stapler remains also inconclusive in view of reducing popf. methods: we routinely use thickest endo gia™ reloads with tri-staple™ (covidien, north haven, ct) for pancreas closure during laparoscopic left side pancreatectomy (lp) since . we compared short term surgical results of the consecutive ten patients underwent lp using new stapler (ns) and patients with lp using other type of stapler (os) focusing on popf. results: no patients developed clinically relavent (cr)-popf in ns group and two patients ( . %) with os group experienced cr-popf. however, there was no difference of cr-popf between two groups. pancreas thickness on stapling point were not different between two groups ( . mm vs . mm, p= . ). in ns group, patients ( . %) developed a popf, whereas in os group, patients ( . %) developed a popf. there was also no difference of popf between groups. conclusion: the gia™ reloads with the thickest tri-staple™ allows effective prevention of cr-popf after distal pancreatectomy. however, there was no advantage over thinner stapler for lp. introduction: single-incision laparoscopic hepatectomy (silh) has been showed feasible and safe in experienced hands for selected patients with benign or malignant liver diseases. there were only small series reported and most of the procedures were minor liver resections. we herein present our experience of silh during a period of months. methods and procedures: consecutive patients underwent silh which were performed by two experienced laparoscopic surgeons with straight instruments. patient characteristics and surgical outcomes were analyzed by reviewing the medical charts. results: the patient age was . ± . ( - ) years with male predominance ( patients, . %). six patients ( . %) had liver cirrhosis proved by pathologic examinations. nine procedures ( . %) were indicated for malignancy. four major hepatectomies (over two segments) and nine minor ones were performed including seven anatomical resections. the abdominal incisions were para-or trans-umbilical except one which was along the old operative scar at lower midline, while most of them (n= , . %) was within cm in length. inflow control was carried out by either individual hilar dissection or extraglissonian approach instead of pringle maneuver. the operations were all accomplished successfully without additional ports or open conversion. the operative time was . ± . ( - ) min and the estimated blood loss was . ± . ( - ) ml. five ( . %) patients encountered complications and four of them were classified as clavien-dindo grade i. the postoperative length of hospital stay was . ± . ( - ) days. there was no mortality. conclusion: silh can be performed safely and efficaciously for selected patients with benign and malignant liver diseases including cirrhosis. not only minor but also major liver resections are feasible. this innovative procedure provides low postoperative pain and fast recovery. before adopting this demanding technique, surgeons should be familiar with both single-incision laparoscopic surgery and laparoscopic hepatectomy. better outcomes after the learning curve could be anticipated. background: laparoscopic distal panreatectomy (ldp) has been replacing the open procedure for benign or malignant diseases of the pancreas. however, it is often difficult to apply ldp for pancreatic ductal adenocarcinoma (pdac) because its aggressive invasion to adjacent organs or major vessels. objectives: the objective of this study was to report our experiences for laparoscopic extended pancreatectomy with en-bloc resection of adjacent organs or major vessels for left-sided pdac. methods: we reviewed data for all consecutive patients undergoing ldp for left-sided pdac at asan medical center (seoul, south korea) between april and december . the patients who underwent laparoscopic extended panreatectomy with en-bloc resection of adjacent organs or major vessels were included in analyses. results: of total patients, underwent laparoscopic extended pancreatectomy. there were male and female patients with a median age of . years. resected adjacent organs or vessels were as following: stomach in , duodenum in , colon in , kidney in , superior mesenteric vein in , and celiac axis in . median operative duration was minutes, and median length of hospital stay was days. pathological reports revealed the following: a median tumor size of . cm, the tumor differentiation (well differentiated in , moderately differentiated in , and poorly differentiated in ), t stages (t in , t in , and t in ) , and n stages (n in and n in ). r resection was achieved in patients, and most r resection were tangential retroperitoneal margins. postoperatively, clinically relevant postoperative pancreatic fistula was occured in patients, and there was no -day mortality. median overall survival was . months and year survival rate was . %. conclusions: although laparoscopic surgery has limitations in treating extensive diseases, some selected patients can be applicable for laparoscopic extended pancreatectomy with acceptable complication and survival rates. who underwent hepatic resection was included. these patients were divided into llr or olr. demographics, tumor characteristics, recurrence rates and over-all survival were compared between the groups. results: patients were included and grouped into llr (n= ) and olr (n= ). the average tumor number was ± for both groups, while the mean tumor size was . cm and . cm for the llr and olr group, respectively. when compared with olr, llr had lower post-operative complication rates ( . % vs . %, p= . ) and shorter hospital stay ( vs days, p= . ), although the difference was not statistically significant. overall, recurrence-free and disease-free survival was comparable between llr and olr. introduction: single port surgery has been described since with cholecystectomy, colectomy, gastrectomy, and others. nevertheless, few cases are still reported in field of hbp surgery. herein, we report single port pancreatic surgery developed from our previous experience. we had started single port surgery in , since then we have done more than cases of single port surgery using surgical glove port including cholecystectomy, appendectomy, and colectomy. because we consider this experience should develop to pancreatic surgery, cases of single port staging laparoscopy for potentially resectable and borderline resectable pancreatic cancer and cases of single port plus one port distal pancreatectomy (spop-dp) have been done in our institution. single port staging laparoscopy for pancreatic cancer. resectability was proved in ( %) out of patients while patents had unresectale factor such as small liver and peritoneal metastases that was not able to detect pre-operatively. the length of hospital days were . ± . days and the days to chemotherapy were . ± . days. single port plus one port distal pancreatectomy (spop-dp) spop-dp starts with . cm skin incision on umbilicus. subsequently, a wound retractor is installed at umbilical wound. then, a non-powdered surgical glove ( . inches) is put on the wound retractor through which three -mm slim trocars and one -mm trocar are inserted via each finger tips. a semi-flexible laparoscopic camera is inserted via the middle finger port. -mm port is used when laparoscopic us, mechanical stapler, endo intestinal clip or retrieval bag were needed. an additional -mm port is inserted at left subcostal lesion mainly used for surgeon's right hand instrument. gastric posterior wall is fixed to abdominal wall by suture instead of manual retraction. pre-compression before transection of the pancreas was done using endo intestinal clip before firing. discussion: as we have seen in these two decades, surgery has dramatically been changed by laparoscopic surgery or robotic surgery. nevertheless, because of technical difficulty and relatively high post-operative complication rate, introduction of reduced port surgery to hbp surgery has just started. spop-dp using endo intestinal clip, glove port and gastric wall hanging method is feasible. but its advantage is not clear so far, multicenter rct is highly desired to clear the benefit of reduced port surgery for pancreas. introduction: scoring systems (ss) are an essential pillar of care in acute pancreatitis (ap) management. we compared six ss (acute physiology and chronic health examination (apache-ii), bedside index for severity in ap (bisap), glasgow score, harmless ap score (haps), ranson's score and sequential organ failure assessment (sofa) score) for their utility in predicting severity, intensive care unit (icu) admission and mortality. methods: ap patients treated between july and september were studied retrospectively. demographic profile, clinical presentation and discharge outcomes were recorded. predictive accuracy of six ss was assessed using areas under receiver-operative curve (auc) with pairwise comparisons. results: patients were treated for ap. twenty-two ( . %) patients were excluded for insufficient data. / ( . %) were male and mean age was . ( - ) years. most common aetiology was gallstones ( . %). mean length of stay was . ( - ) days. ( . %) patients had severe ap, ( . %) required icu admission and ( . %) died. table below shows positive predictive value (ppv), negative predictive value (npv) and auc of six ss in predicting outcomes. pairwise comparisons revealed ranson's (p. ) and sofa (p. ) scores were superior than other ss in predicting all three outcomes. auc of sofa was greater than ranson's score in predicting severity (p. ), but similar in predicting icu admission (p= . ) and mortality (p = . ). conclusion: sofa score is superior to classical ss in predicting severity, icu admission, and mortality in ap. introduction: necrotizing pancreatitis is often a devastating sequelae of acute pancreatitis. historically several approaches have been described with variable outcome. open necrosectomy is associated with higher morbidity ( %) and mortality ( %). endoscopic necrosectomy often is tolerated well but associated with stent migration and multiple procedures. video-assisted retroperitoneal debridement is tolerated well but associated with severe bleeding if adjacent blood vessels are injured during the procedure leading to severe complications. methods: in our series, we perform a step up approach by involvement of a multidisciplinary group consisting of general surgeons, gastroenterologists, infectious disease physicians, critical care internalist, interventional radiologist and nutritional services to formulate a management plan. the necrotized pancreas is initially drained with an ir guided drain, fluid cultures sent for microbiology and treatment with appropriate antibiotics if deemed necessary. the drain is gradually upsized to a fr sized drain to form a well-defined tract for surgical debridement; a preoperative ct scan of the abdomen with iv contrast to access the location and proximity of the vasculature around the necrotized pancreas. a collaboration with the interventional radiologist to discuss possible ir embolization of splenic artery prior to surgical debridement. the patient would then undergo video assisted retroperitoneal pancreatic necrosectomy and a sump drain left in-situ at the pancreatic fossa. post-operative management in the surgical icu would be lead by the critical care internalist. results: three patients were managed by this multidisciplinary approach with excellent outcomes. one patient underwent preoperative ir embolization followed by surgical debridement; second patient underwent embolization immediately following debridement; one patient did not require any embolization but had ir on standby if needed to intervene. post-operatively all three patients recovered well. they all were tolerating good oral intake and were discharged to rehabilitation facilities. conclusion: our preliminary experience demonstrates that an early multidisciplinary plan by various subspecialties can result in a pragmatic and successful approach to this potentially catastrophic condition. introduction: liver resection with preservation of as much liver parenchyma as possible is called parenchymal sparing hepatectomy (psh). psh has been shown to improve overall survival by increasing the re-resection rate in patients with colorectal liver metastases (crlm) and recurrence. the caudal-cranial perspective in laparoscopy makes the cranial segments ( , a, , and ) more difficult to access. the objective of this systematic review is to analyze feasibility, safety, morbidity, and oncologic outcomes of laparoscopic psh. methods: a systematic review of the literature was performed. medline/pubmed, scopus, and cochrane databases were searched. a search strategy was published with the prospero registry. a systematic review was conducted on all cases reported, they were categorized by area of resection and quantitative meta-analysis of operative time, blood loss, length of hospital stay, complications, and r resection was performed. results: of the studies screened for relevance, studies were selected. because interventions or endpoints were noncontributory or reporting incomplete, were excluded. only publications remained, reporting data from patients who underwent laparoscopic psh. the highest oxford evidence level was b and selective reporting bias was common due to single center and noncontrolled reports. among them, ( . %) resections were in the cranial segments ( . %), a ( . %), ( %), and ( . %), which previously would have required laparoscopic hemi-hepatectomies or sectorectomies. the most common tumor type was crlm ( %) and the second most common tumor type was hepatocellular carcinoma ( %). feasibility of laparoscopic psh was %, conversion rate was %, and complications were seen in % of cases. no perioperative mortality was reported. no standardized reporting format for complications was used across studies. meta-analysis revealed a weighted average operating time of minutes, estimated blood loss of cc, and length of stay of days. r resections were achieved in % of cases. conclusion: laparoscopic psh of difficult to reach liver tumors are feasible with acceptable conversion and complication rate, but relatively long operating times and relatively high blood loss. in future studies, data on long term survival and specific tumor type recurrence should be reported and bias reduced. yangseok koh , eun-kyu park , hee-joon kim , young-hoe hur , chol-kyoon cho ; chonnam national university hwasun hospital, chonnam national university hospital purpose: laparoscopic surgery has become the mainstream surgical operation due to its stability and feasibility. even for liver surgery, the laparoscopic approach has become an integral procedure. according to the recent international consensus meeting on laparoscopic liver surgery, laparoscopic left lateral sectionectomy ( conclusion: this study showed that laparoscopic lls is safe and feasible, because it involves less blood loss and a shorter hospital stay. for left lateral lesions, laparoscopic lls might be the first option to be considered. keywords: laparoscopy, left lateral sectionectomy. outcome analysis of pure laparoscopic hepatectomy for hcc and cirrhosis by icg immunofluorescence in.-a propensity score analysis introduction: in laparoscopic hepatectomy, the surgeon cannot use their hand to palpate the liver lesion and estimate margin of resection. the use of icg immunofluorescence technique can show up the liver tumour and has the potential to facilitate a throughout assessment during the operation. method: between and , there were patients undergone pure laparoscopic liver resection for hcc in our hospital. patients had undergone surgery by the conventional laparoscopic approach. patients had laparoscopic hepatectomy with additional icg immunofluorescence augmented technique. the surgical outcome was compared with propensity score analysis in a ratio of : . result: patients had icg immunofluorescence assisted laparoscopic hepatectomy (group ). patients using conventional laparoscopic liver resection with propensity-matched were selected for comparison (group ). the median operation time was minutes vs minutes p= . , the median blood loss was ml vs ml (p= . ). additional tumours were identified by icg technique. patients had suspicious lesion picked up by icg technique but proven to be benign pathology on frozen section examination. the sensitivity of tumour detection by group was %. % r resection was achieved in group and group respectively. hospital stay was days vs days (p= . ), post-operative complication was ( %) vs ( . %) (p= . ) none of the patient developed icg related complication. conclusion: in the current study, the new technique showed equally good short-term outcome when compared with conventional laparoscopic hepatectomy. icg immunofluorescence augmented reality is a promising technique that might facilitate easier identification tumour during laparoscopic hepatectomy. surg endosc ( ) :s -s taking the training wheels off: transitioning from robotic assisted to total laparoscopic whipple introduction: there is a substantial learning curve to performing minimally invasive pancreatoduodenectomy (mis-pd) for surgeons who are trained in open pd. the learning curve to transition from robotic assisted pd (rapd) to total laparoscopic pd (tlpd) is not well established. methods: mis-pds performed between january and june performed by sc as a surgeon or co-surgeon were included for analysis. mis-pds were performed using a robotic assisted technique prior to august , and tlpds were performed subsequently. rapds performed prior to were excluded to limit the comparison to rapds after the initial learning curve. demographics, clinical and pathologic outcomes, operative and post-operative outcomes were compared. results: a total of rapds and tlpds were scheduled during the study period. there was no statistically significant difference in age, body mass index, or prior abdominal surgery. median time from initial clinic consultation to surgery was days for the rapd group versus days in the tlpd group (p= . ). conversion to laparotomy was required in of patients ( there were no operative complications or mortality. the mean hospital stay was ± . hours. there was no postoperative jaundice, bile leak, intra-abdominal collections or mortality. conclusion: when surgery is indicated for difficult acute calculous cholecystitis, laparoscopic subtotal cholecystectomy with control of the cystic duct is safe with excellent outcomes. however, if the critical view of safety can't be achieved due to obscured anatomy at calot's triangle, conversion to open surgery or cholecystostomy must be performed to prevent bile duct injury. scott revell, md , joshua parreco , rishi rattan, md , alvaro castillo, md ; u. miami -jfk gme consortium, university of miami, miller school of medicine introduction: over the last two decades the increasing incidence of benign liver tumors has led to the expanded need for clinicians to make therapeutic decisions regarding the utilization of open, minimally invasive and ablative techniques. the purpose of this study was to compare outcomes of the management of benign liver disease based on operative approach and pathology. methods: patients aged years or older who underwent liver surgery for benign liver tumors from to were identified in the nationwide readmissions database. patients were compared based on liver pathology, resection versus ablation, and an open versus laparoscopic/robotic approach. the outcomes of interest were in-hospital mortality, prolonged length of stay (los) [ days, and readmission within -days. univariable analysis was performed for these outcomes and multivariable logistic regression was performed using the variables with a p-value . on univariable analysis. results were weighted for national estimates. results: there were , patients undergoing surgery for benign hepatic tumors in the us during the study period. the most common pathology was benign neoplasm ( . %) followed by hemangioma ( . %), and congenital cystic disease ( . %). resection alone was performed in . %, ablation alone in . %, and resection with ablation in . %. a laparoscopic/robotic approach was used in . % of cases. the overall mortality rate was . %, a prolonged los was found in . %, and readmission within days occurred in . %. an increased risk for mortality was found with hemangioma (or . , p= . ) and congenital cystic disease (or . , p= . ). resection with ablation was associated with an increased risk of prolonged los (or . , p. ), while a laparoscopic/robotic approach was a protective factor for prolonged los (or . , p. ). patients treated with ablation alone were at decreased risk for readmission (or . , p. ). omar m ghanem, md , desmond huynh, md , tomasz rogula, md ; mosaic life care, cedars sinai, introduction: laparoscopic sleeve gastrectomy is the most commonly weight loss procedures performed worldwide. as such, there is great diversity in the techniques utilized. this study aims to identify and categorize the differences in techniques and assess the need for guidelines in this field. case description: surgeons were surveyed on the techniques they employ on biweekly basis using the international bariatric club facebook group. the survey included sleeve staple line reinforcement, preoperative work up, intraoperative hiatal dissection, bougie size, distance from pylorus to distal staple line, and intraoperative leak testing. surveys were conducted between may and july . each survey was active for weeks after which data was collected. participants were required to select a single answer per question. discussion: when surveyed on staple line reinforcement (n= ), surgeons used no reinforcement, over-sewed, buttressed, clipped as necessary, over-sewed as necessary. for preoperative work up (n= ), utilized routine endoscopy, routinely obtained upper gi series, routinely obtained both endoscopy and upper gi, and employed endoscopy or upper gi series only in patients who were symptomatic. for hiatal dissection (n= ), surgeons dissected the hiatus routinely, dissected only when obvious hernias intraoperatively, dissected only if the hernia was detected on preoperative work up, and dissected in the setting of gerd symptoms. for sleeve caliber sizing (n= ), bougie \ f was used by surgeon, bougie size f, f, f were utilized by , bougie size f and f were utilized by , bougie[ f were used by , and gastroscopes ( f) were used by . with regards to distance from pylorus to where the sleeve staple line was initiated (n= ), participants started \ cm away from pylorus, between and cm, and started [ cm from pylorus. finally, for preferred intraoperative leak test during sleeve (n= ), methylene blue was used by surgeons, air leak test by , used both, and opted for none. conclusion: this study characterizes the wide varieties in the techniques used during sleeve gastrectomy. a great number of variations exist in every parameter surveyed; however, there is little evidence comparing the effectiveness and safety of these variations. in this setting, further randomized controlled trials are necessary and should be used to construct guidelines to best optimize outcomes in this extremely common and necessary operation. yen-yi juo, md, mph, yas sanaiha, md, yijun chen, md, erik dutson, md; ucla introduction: bariatric surgeries are commonly performed in accredited centers of excellence, but no consensus exists regarding the optimal readmission destination when complications occurred. our study aims to examine the impact of care fragmentation on post-operative outcome and evaluate its causes and consequences among patients undergoing -day readmission after bariatric surgery. methods: the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) database was used to identify patients who experienced -day unplanned readmission following bariatric surgery. non-index readmission was defined as any readmission occurring at a hospital other than the one where initial surgery was performed. primary outcome was -day mortality after surgery. logistic regressions were used to identify risk factors for nonindex readmission and to adjust for confounders in the association between non-index readmission and -day mortality. results: a total of , patients were identified as experiencing -day unplanned readmission following bariatric surgery, among whom ( . %) were non-index readmissions. occurrence of postoperative complication during initial hospitalization was the most significant risk factor for non-index readmission (or . , % ci . - . , p= . ) in our multivariate logistic regression. the three most common reasons for readmission were similar within the two comparison groups, including nausea/vomit, abdominal pain and anastomotic leakage. similar proportion of patients underwent reoperation among the two comparison groups ( . vs . %, p= . ). even after adjusting for occurrence of complications, being readmitted to a non-index facility was still associated with a . -fold odds of -day mortality ( % ci . - . , p\. ). conclusion: non-index readmission significantly increases the risk of -day mortality following bariatric surgery. patients were more likely to visit a non-index facility if complications occurred during their initial hospitalization. further patient education is required to re-inforce the importance of continuity-of-care during management of bariatric complications and guide patient's decision making in choosing readmission destinations. introduction: sleeve gastrectomy has become the most performed bariatric surgery. removing part of the stomach causes weight loss by restricting food intake and regulating the production of incretins, particularly ghrelin. however, prognostic factors to weight loss after sleeve gastrectomy have been difficult to find. the goal of this research was to study the correlation between the volume of resected stomach and weight loss. methods and procedures: volume of resected stomach of patients undergoing sleeve gastrectomy was measured. a standard laparoscopic technique was used. calibration was performed tightly around a fr bougie, and stapling started - cm from the pylorus. the standardized technique for measurement involved insufflation with a g catheter with saline solution to a pressure of cm h o immediately after removal of the specimen. resected stomach's volume, gender, age, bmi, height and % of total weight loss (%twl) at months and year were prospectively recorded. correlation between variables was analyzed with pearson's test and linear regression models. conclusion: removed stomach was larger on men than women and its size slightly correlated to height. however, volume of resected stomach did not seem to have an incidence on short termweight loss. gastric size should not be considered as a prognostic factor for weight loss in patients undergoing sleeve gastrectomy. revisional bariatric surgery after initial laparoscopic sleeve gastrectomy: what to choose salman alsabah, eliana al haddad, ahmad almulla, khaled alenezi, shehab akrouf, waleed buhamid, mohannad alhaddad, saud al-subaie; amiri hospital introduction: bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (lsg) being the most performed procedure as of . however, inadequate weight-loss may present the need for a revisional procedure. the aim of this study is to compare the efficacy of laparoscopic re-sleeve gastrectomy (lrsg), laparoscopic roux-en-y gastric bypass (lrygb) and gastric mini-bypass surgery (mgbp) in attaining successful weight loss following initial lsg. methods: a retrospective analysis was performed on all patients who underwent lsg at amiri and royale hayat hospital, kuwait from to . a list was obtained of those who underwent revisional bariatric surgery after initial lsg, and their demographics were analyzed. introduction: the aim of this study is to identify potential risk factors or early indicators, specifically related to perioperative blood pressure, and its association with perioperative hemorrhage in the bariatric population. laparoscopic bariatric surgery in the united states has been steadily increasing over the past several years. between and , the annual number of cases has increased by %. although rare, hemorrhagic complications (hc) occur at a rate of - % and can lead to significant morbidity and mortality. by identifying factors which may place a patient at higher chance of hc, surgeons can potentially mitigate those risks. these modifications could reduce morbidity and limit the requirement of transfusions or reoperations. methods and procedures: a retrospective case-control series was performed to include all patients who underwent either laparoscopic sleeve gastrectomy (sg) or laparoscopic roux-en-y gastric bypass (gb) in at a single bariatric center of excellence. a total of patients were identified with perioperative hc. each patient was matched : for procedure, body mass index, and medical comorbidities. peak systolic, diastolic, and mean arterial pressures were compared between groups at time of admission, intraoperative, and during remainder of initial hospital stay. welch's t-tests were used for comparison between groups. results: a total of procedures were performed with de novo sg, and de novo gb. revisional bariatric cases were excluded from the study. hc occurred in ( . %) total patients, gs and gb. four patients required operative treatment for hc, were treated laparoscopically and required laparotomy. the mean diastolic pressures at time of arrival on day of surgery was higher in patients who develop hc (p= . ) and mean peak diastolic pressure intraoperatively was lower in patients who develop hc (p= . ). there was no statistical difference in peak systolic or mean arterial pressures throughout the hospital stay. conclusions: bariatric surgical patients with elevated preoperative diastolic blood pressures are at an increased risk of postoperative hc. additionally, decreased peak diastolic blood pressures may be an early indication of an hc in bariatric patients. introduction: bariatric surgery in the adult population is recognized as one of the most effective treatments for obesity and its comorbidities. nonetheless, the safety, efficacy, and substantial outcomes of bariatric surgery in young adults are still not well documented. the aim of our study is to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (lsg) in young adults (\ years old) versus older adults (≥ years old). methods: we retrospectively reviewed all patients who underwent bariatric surgery at our institution from to. propensity score matching was used in order to balance covariates, matching for common demographics and comorbidities between the younger patient population (\ years old) and the control group ([ years old). all tests were two-tailed and performed at a significant level of . . statistical software r, version . . ( - - ) was used for all analyses. results: of patients, . % (n= ) met our inclusion criteria after matching. we found . % (n= ) patients under years old and . % (n= ) patients greater or equal to years old (control group). we observed that our younger population distribution was predominantly caucasian and female, . % (n= ) and . % (n= ) respectively. the mean age was . ± . years with a preoperative body mass index (bmi) of . ± . kg/m in the younger group compared to . ± . years and a bmi of . ± . kg/m in the control group. diagnosis of diabetes and hypertension were present in . % (n= ) and . % (n= ) of our younger group, respectively. no statistical significance was found when assessing the percentage of bmi loss (% ebmil) at and months follow-up as shown in table . when comparing the % ebmil at months follow-up, the younger group had . % more ebmil than the control group (p= . ). when assessing post-operative complications we observed no statistical significance. conclusions: bariatric surgery is equally effective and safe in young adult population demonstrating a significant better %ebmil at months following bariatric surgery. following prospective studies are needed to elucidate the resolution and behavior of comorbidities in a younger bariatric population. minimally invasive conversion of sleeve gastrectomy to rouxen-y gastric bypass for intractable gastroesophageal reflux disease: short term outcome background: surgical management recommendations for intractable gastroesophageal reflux disease (gerd) after sleeve gastrectomy (sg) remain controversial. this case series demonstrates our experience with treatment of post-operative intractable gerd using minimally invasive conversion of sg to roux-en-y gastric bypass (rygb). patients and methods: this is a retrospective review of a prospective data registry (mbsaqip) from jan through sept . eleven patients, female and male, were evaluated. of the surgeries, were laparoscopic, assisted with xi da vinci robot, and assisted with si da vinci robot. all patients presented with intractable reflux on high dose ppi. three had a history of aspiration pneumonia. ± . %, respectively. one was omitted due to pending results. conclusion: several solutions exist for operative management of intractable gerd after sg including redo-sleeve gastrectomy, combined gastrectomy with fundoplication, conversion to gastric bypass or anti-reflux procedures such as linx. reports remain small in series and require further study to evaluate the consistency of results. we found minimally invasive conversion of sg to rygb is a highly effective and safe option for treatment of intractable gerd. setthasiri pantanakul, chotirot angkurawaranon, ratchamon pinyoteppratarn, poochong timrattana; rajavithi hospital background: obesity is an important health problem affecting more than million people worldwide. esophageal dysmotility is a gastrointestinal pathology associated with obesity; however, its prevalence and characteristics remain unclear. esophageal dysmotilities have a high prevalence among obese patients regardless of gastrointestinal symptoms. objective: to identify the prevalence of esophageal motility disorder in asymptomatic obese patient. materials and methods: prospective study was performed between june and march . a total of of morbid obese patients who visited the bariatric and metabolic clinic at rajavithi hospital (bangkok, thailand) underwent preoperative evaluation with high resolution esophageal manometric test with manoscantm eso (smith medical). tracings were retrospective analysis and reviewed according to chicago classification criteria for esophageal motility disorders. results: among asymptomatic obese participants, twenty five of them were female. the mean age was . ( - ) years old. most of the participants were classified as class three obesity or over. the mean bmi was . kg/m . no hiatal hernia was found and the anatomy of esophagus was normal in all patients. the mean irp was . mmhg. twenty-one patients ( . %) demonstrated high irp over normal limit ([ mmhg) . four patients demonstrated premature contraction (dl\ . second). hypercontractile esophagus was identified in patients and ineffective motility disorder was found in patients. two patients were diagnosed as distal esophageal spasm (des). two patients were compatible with type achalasia and patients ( . %) have esophageal outflow obstruction. none of the patient demonstrate incomplete bolus clearance even high irp or abnormal motility. conclusion: this study reveals a high prevalence of esophageal dysmotility in asymptomatic thai obese patients. the most common abnormality were esophageal outflow obstruction and ineffective motility. the chicago classification of esophageal motility disorder may not suitable among obese population. sitembile lee, ms , chike okolocha , aliu sanni, mdfacs ; philadelphia college of osteopathic medicine ga campus, eastside bariatric and general surgery introduction: roux-en-y gastric bypass (rygb) is the most popular bariatric procedure performed worldwide, accounting for % of all bariatric procedures. however, in patients with a body mass index (bmi) ≥ kg/m (super-super obese) the rygb procedure can be technically challenging. this has led to the adoption of a single-stage treatment such as one anastomosis (mini) gastric bypass (oagb/mgb) in the super-super obese patients. proponents of the oagb/mgb claim the clinical outcomes are comparable to the rygb. the aim of this study is to compare the outcomes of the two procedures by examining the literature. methods: a systematic review was conducted through pubmed to identify relevant studies from to with comparative data on rygb versus oagb/mgb on super-super obese populations. the primary outcome was the percentage excess weight loss (%ewl). other outcomes include operative times, complication rates and length of hospital stay. results were expressed as standard difference in means with standard error. statistical analysis was done using randomeffects meta-analysis to compare the mean value of the two groups (comprehensive meta analysis version . . software; biostat inc., englewood, nj introduction: obesity is becoming more prevalent in patients with inflammatory bowel disease (ibd). the obese body habitus increases the complexity of surgeries that are often needed to treat ibd. some surgeons may delay definitive surgical treatment because of obesity. little data exists on bariatric surgery in the obese patient with ibd. methods: we retrospectively identified patients who had known diagnosis of ibd who underwent bariatric surgery from to . demographics and post-operative outcomes were assessed. results: patients were identified: with ulcerative colitis (uc) and with crohn's disease (cd). of the uc patients, none of the patients had surgery for uc and only one was on a biologic. of the uc patients, had adjustable gastric band (agb), had gastric bypass and had sleeve gastrectomy. one patient with agb had it replaced for slip and subsequently removed for dysphagia. uc preoperative bmi average was . . postoperative bmi was . with excess weight loss (ewl) of %. average follow up was months. of the cd patients, patients had ileocolic resections and one had total proctocolectomy with end ileostomy. one was on remicade and one on mp. of the cd patients, had agb, had gastric bypass and had sleeve gastrectomy. one agb patient had conversion to gastric bypass because of dysphagia and poor weight loss. a second abg patient had band removal because of dysphagia. cd patients' preoperative bmi average was . . postoperative bmi was . with average ewl of %. average follow up was months. overall, agb patients had % ewl, sleeves % and gastric bypass %. two uc patients had post-operative flares, one immediately post op and one month post-operative. four of the band patients had dysphagia, with one replacement, two removals and one conversion to bypass. there were no leaks, intraabdominal infections, fistulas or wound infections. conclusions: uc patients appear to have higher excess weight loss compared to crohn's patients; ewl % compared to % but was not statistically significant. agb had poor results in both uc and cd patients. sleeve gastrectomy and gastric bypass results in effective weight loss for obese patients with ibd. gastric bypass in ibd patient is controversial, but may be appropriate in the right clinical setting. introduction: previous studies suggest that modest preoperative weight loss is associated with improved weight loss following bariatric surgery. however, there remains a need to investigate factors which may successfully predict preoperative weight loss among bariatric patients. methods and procedures: this analysis included patients who underwent laparoscopic roux-en-y gastric bypass (rygb), sleeve gastrectomy, or gastric banding at an academic medical center in california. data were measured at patients' consult and preoperative clinical visits. preoperative weight loss outcomes were categorized as follows: no weight loss, lost weight, or gained weight. associations between categorical sociodemographic and surgical characteristics and preoperative weight loss outcomes were assessed using the chi-square test of association. associations between continuous measures and preoperative weight loss outcomes were assessed using anova. a sub-group analysis was completed among participants who lost weight prior to bariatric surgery. wilcoxon-rank-sum and kruskal-wallis tests were used to evaluate associations between patient characteristics and the number of pounds lost. results: patients (n= , ) were predominately ages - ( %), female ( %), white ( %), and privately insured ( %). patient race was significantly associated with weight loss outcomes (p = . ): whereas % of white patients lost weight prior to surgery, only % of black patients lost preoperative weight. among privately insured patients, % lost weight. in contrast, % of patients insured by medi-cal/medicaid lost weight (p= . ). on average, lower baseline excess body weight was associated with no weight loss. patients who lost preoperative weight (n= , ) were included in the sub-group analysis. male sex (p\. ), black race (p. ), undergoing laparoscopic rygb (p= . ), no previous abdominal surgeries (p= . ), upper tertile baseline weight (p. ), waist circumference (p\. ), percent body fat (p\. ), bmi (p. ), excess body weight (p. ), and systolic blood pressure (p= . ) were associated with more pounds lost. conclusions: this study demonstrates various associations between sociodemographic and clinical patient characteristics and preoperative weight loss. given previous literature indicating the positive relationship between preoperative and postoperative weight loss following bariatric surgery, the results of this study suggest an opportunity to improve preoperative weight loss among specific groups. yen-yi juo, md, mph , usah khrucharoen, md , yijun chen, md , yas sanaiha, md , peyman benharash, md , erik dutson, md ; background: besides rate and extent of weight loss, little is known regarding factors predicting interval cholecystectomy following bariatric surgery, which are important factors in a surgeon's consideration during decision-making regarding whether to perform prophylactic cholecystectomy. in addition, no previous studies have quantified the incremental costs associated with ic. we aim to identify risk factors predicting interval cholecystectomy (ic) following bariatric surgery and quantify its costs. methods: a retrospective cohort study was performed using the national readmission database - . cox proportional hazard analyses were used to identify risk factors for ic. linear regression models were constructed to examine associations between cholecystectomy timing and cumulative hospitalization costs. background: patient-reported outcomes after bariatric surgery are important in understanding the longitudinal effects of surgery. the impact of hospital practices and surgical outcomes on followup rates remains unexplored. objective: to assess the effect of hospital-level practices and -day complication rates on -year follow-up rates of a standardized patient-reported outcomes survey. methods: bariatric surgery program coordinators in a statewide quality improvement collaborative were surveyed in june about their practices for obtaining patient-reported outcomes data one year after surgery. hospitals were ranked based on their follow-up rates between and (accounting for overall performance and improvement). univariate analysis was used to identify hospital practices associated with higher follow-up rates. multivariable regression was used to identify independent associations between -day outcomes and follow-up rates after adjusting for patient factors. results: overall, follow-up rates improved from ( . %± . ) to ( . %± . ) though there was wide variability between hospitals ( . % vs . % in ) . coordinator survey response rate was %. sixty-one percent of all surveyed coordinators perceived that surgeons prioritize high follow-up rates. when asked how long were their patients followed for, % of coordinators noted their programs provided lifelong follow-up. patient reminders about the -year survey were used by % of programs, mostly during clinic visits ( %). most programs ( %) had implemented strategies to improve follow-up rates, such as handing out the survey ( %) during clinic visits. follow-up providers included surgeons ( %), nurse practitioners ( %), and/or registered dietitians ( %). patient disinterest ( %), loss to follow-up ( %), survey length ( %), and lack of staff/ resources ( %) were the factors most commonly perceived as barriers to high follow-up rates. when compared to programs in the bottom quartile of follow-up rates, those in the top quartile were more likely to hand out the survey to patients during clinic visits ( % vs . %; p= . ) and had lower rates of risk-adjusted severe complications ( . % vs . %; p= . ), readmissions ( . % vs . %; p= . ), and reoperations ( . % vs . %; p= . ). conclusions: hospitals vary considerably in their -year follow-up rates when seeking patientreported outcomes data after bariatric surgery. there were also significant differences in programspecific practices for obtaining these data. hospitals with higher -year follow-up rates were more likely to physically hand surveys to patients during a clinic visit and had lower -day severe complication, readmission, and reoperation rates. improved -year patient-reported outcomes follow-up after bariatric surgery may be a proxy for higher quality perioperative care. david merkle , kazim mohommed , danielle r rioux , dilendra weerasinghe, md, facs ; nova southeastern university, herbert wertheim college of medicine, bariatric surgery is gaining popularity not only for its weight loss benefits, but also for its metabolic effects. we present a -year-old female patient with symptoms of neuroglycopenia, occurring -years post roux-en-y gastric bypass surgery. during one of her syncopal episodes, her blood sugar was noted to be mg/dl. continuous glucose monitoring demonstrated post prandial hypoglycemia, averaging episodes per day, with a maximum of episodes in one day. upon further evaluation, the lab results of the hba c, chromogranin a, somatostatin, and urinary sulfonylurea levels were all normal, with the c-peptide level within the upper limit of normal. ct scan of the abdomen and pelvis did not show any obvious masses in the pancreas, and since the chromogranin a level was normal, it lead to the empiric diagnosis of nesidioblastosis by exclusion. we placed the patient initially on medical management which included a carbohydrate restricted diet of g per meal, eating - small meals per day, and taking mg of acarbose three times per day. overall, symptoms have improved, and she has - episodes per month, compared with about episodes per day. we will also present the data with regards to other invasive treatment options, which are available when medical treatment options have failed, such as gastric bypass reversal versus distal gastrectomy. vertical banded gastroplasties (vbgs) were a common bariatric procedure in the s but have largely fallen out of favor due to unsatisfactory weight loss and a relatively high incidence of longterm complications such as dysphagia and severe gastroesophageal reflux disease (gerd). one of the ways to address these undesirable effects is to convert to a roux-en-y gastric bypass (rygb). the aim of this study was to assess the safety and efficacy of vbg-to-rygb conversion. outcomes of vbg revisions performed at an academic center between and were reviewed. of the vbg revisions, gastrogastrostomies were created in two patients, two underwent a planned -stage conversion, and vbgs were converted to rygbs. patients were operated on an average of years after their initial vbg. presenting symptoms were weight regain (n= , . %), dysphagia (n= , . %), or severe gerd (n= , . %). fourteen patients ( %) had a gastric staple line dehiscence. of the vbg to rygb conversions, were laparoscopic, were converted to open, were open, and were robotic-assisted. average operative time and length of hospital stay were . minutes and . days, respectively. within the first months post-operatively, twelve ( %) patients required readmission directly related to surgery, while eight ( %) visited the emergency department. eight patients ( %) required at least one unplanned operation due to complication(s) during the entire follow-up: small bowel obstruction (n= , at -week, -months, and -months), necrosis/leak of remnant stomach requiring remnant gastrectomy (n= ), tracheostomy for prolonged respiratory failure (n= ), bleeding (n= ), anastomotic leak (n= ), and hemothorax requiring vats (n= ). four patients ( %) had a contained perforation that was medically managed and five ( %) developed a gastrojejunal anastomosis stricture requiring endoscopic intervention. one patient ( . %) developed pulmonary embolism. there was no mortality directly related to surgery. complete resolution or improvement of gerd/dysphagia was appreciated in all patients in the short term follow-up. patients who presented with weight regain had a mean bmi loss of . ± . points in the median follow-up time of . months up to a year after conversion to rygb. in summary, reoperative bariatric surgeries after vbgs are complex, requiring longer operative times and length of stay. our study found % risk of severe complications requiring reoperations, compared to the previously cited % in short and long-term complications. conversion of vbg to rygb provides excellent relief of severe gerd and dysphagia and is a viable option for significant weight reduction. introduction: bariatric surgery is a safe and effective treatment for severe obesity and its comorbidities. however, concomitant splenectomy is sometimes required due to uncontrolled bleeding during the surgery. limited literature exists regarding the effects of concurrent splenectomy on outcomes of bariatric surgery. this study aimed to determine these outcomes. methods: adult patients with obesity who underwent primary, elective laparoscopic roux-en-y gastric bypass (lrygb) or laparoscopic sleeve gastrectomy (lsg) with concomitant splenectomy were identified from the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip, ) and national surgical quality improvement program (nsqip, (nsqip, - datasets. using propensity scores (based on baseline variables), patients who underwent primary bariatric surgery were matched : to a control group (primary lrygb/lsg without concomitant splenectomy) and thirty-day postoperative outcomes were compared. continuous variables and categorical variables were categorized as medians with interquartile range (iqr) and counts with percentages, respectively. background: several previous studies have suggested a correlation between weight loss and age after bariatric surgery. objective: the aim of our study is to further address age as a preoperative factor to determine the amount of weight loss after bariatric surgery. materials and methods: we performed a retrospective analysis of outcomes of a prospectively maintained database of , obese patients who underwent either sleeve gastrectomy (sg) or roux-en-y gastric bypass surgery (rygb) at our hospital between and . we analyzed the -month, -month, and -year postoperative percent total body weight loss (%tbwl) of obese patients who underwent bariatric surgery based on their preoperative age. results: the average age of patients included in the study was years old with a range of - years. an inverse relationship between preoperative age and postoperative weight loss was observed. younger patients achieved a higher % tbwl than older patients at the -month, -month, and -year postoperative follow-up. the average %tbwl for all patients at the -month, -month, and -year postoperative follow-up periods were . %, . %, and . %, respectively. at the -year follow-up, for every decade increase in age (above the average age of ), patients lost % less tbwl. conclusion: in our study, younger patients tend to lose a greater amount of %tbwl than older patients after bariatric surgery. results: patients participated in the survey. the median age was yo (iqr: - ) and . % were females. the following responses were encountered when asked about the importance of surgery-related factors: the study population indicated the following responses regarding expectations from magnetic surgery compared to conventional laparoscopy: there was no significant evidence of different responses by demographic groups. additionally, . % of the population indicated that a surgeon performing magnetic surgery should be more skillful than a surgeon performing conventional laparoscopy. conclusion: this study represents the first report of bariatric patient's perception regarding surgery-related factors. notably, nearly % of the cohort indicated that cosmesis after surgery is an important factor, whereas the responses regarding the rest of the factors were indicated as expected. the bariatric population included in this study had a positive perception of magnetic surgery. furthermore, the population perceived that this technique is associated with better outcomes, better cosmetic results, and higher surgeon dexterity. introduction: although much is known regarding medical outcomes of metabolic surgery, less is known regarding quality of life outcomes. we hypothesized that the collection of patient-reported outcomes (pros) could help us understand quality of life in this patient population. we chose to primarily use patient reported outcomes measurement information system (promis) instruments because of their broad applicability, low cost, and ability to use computer-adapted technology to survey. methods: we implemented the routine collection of pros as part of clinical care in december, . patients were offered tablets in clinic, and were asked to complete the surveys at most of their visits. we used computer-adapted technology to decrease the length of time needed to survey. we collected the following promis instruments: depression, pain interference, physical function, and satisfaction with social roles. we also collected the gerd-hrql, a general health question, and a current health visual analog scale (vas). we retrospectively reviewed our results from december through september . results: our response rate was % over the last year of collection. in total, assessments were completed by patients. the mean scores in our total patient population were as follows: vas , gerd-hrql , general health , depression , pain , physical function , and social roles . for promis instruments, the mean for the national population is , with as the standard deviation. for the depression and pain scores a higher score is worse, while a higher score indicates better quality of life for social roles and physical function. conclusions: routine collection of patient reported outcomes can be implemented in a metabolic surgery clinic. health-related quality of life appears to be decreased in this patient population compared to the general public. further work is ongoing to learn about postoperative trends, as well as differential effects of metabolic procedures. the effect of peri-operative antibiotic drug class on the resolution rate of hypertension after roux-en-y gastric bypass and sleeve gastrectomy. results: in total, rygb and sg were included in our analysis. no significant differences were found between cefazolin and clindamycin regarding hypertension resolution rates after sg. there was a significant difference in the resolution of hypertension after rygb with the use of prophylactic clindamycin or cefazolin. as shown in figure , patients who underwent rygb and received clindamycin had a significantly higher rate of hypertension resolution compared to cefazolin. this effect started at weeks post-operatively ( . % vs . % respectively, p= . ) and persisted up to the -year ( . % vs . % respectively, p= . ). we found no significant differences in patient age, sex, number of pre-operative hypertensive medications, pre-operative bmi, or %bmi change after year to account for the significant effect of antibiotic choice on hypertension resolution. conclusion: this study represents the first clinical report to suggest an impact of the type of antibiotic administered at the time of rygb on co-morbidity resolution, specifically hypertension. future studies will be needed to confirm that the mechanism of action for this novel finding is due to the differing modifications of the gastrointestinal microflora population based on the specific peri-operative antibiotic administered. introduction: laparoscopic adjustable gastric band with plication (lagbp) is a novel bariatric procedure which combines the adjustability of the laparoscopic adjustable gastric band (lagb) with the restrictive nature of the vertical sleeve gastrectomy (vsg). the addition of plication of the stomach to lagb should provide better appetite control, more effective weight loss, and greater weight loss potential. objective: the purpose of the study was to analyze the outcomes of lagbp at months. setting: this is a retrospective analysis from one surgeon at a single private institution. methods: data from all patients who underwent a primary laparoscopic lagbp procedure from december to june were retrospectively analyzed. data collected from each patient included age, gender, weight, body mass index (bmi), and excess weight loss (ewl). results: sixty-six patients underwent lagbp. the mean age and bmi was . ± . years and . ± . kg/m, respectively. all patients were beyond the -month postoperative mark. no patient was lost to follow-up. the patients lost an average of % and . % excess weight loss (ewl) at months ( . % follow-up) and months ( . % follow-up), respectively. also, the patients lost a mean bmi of . kg/m and . kg/m at months and months, respectively. the total number of fills during the study period was , and the mean fill volume was . ± cc. dysphagia was the most common long-term complication. the mortality rate was %. conclusions: lagbp is a relatively safe and effective bariatric procedure. in light of recent studies demonstrating poor outcomes following lagb, lagbp may prove to be the future for patients desiring a bariatric procedure without resection of the stomach. the median interval between (lrygb) and reoperation is months in group a and months in group b. the median percentage of excess weight loss (%ewl) is % vs %, respectively (p= . ). patients % ( in group a) were admitted in an emergency with an acute abdomen pain. ct scan was performed in patients % and has shown signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed by laparoscopy in patients % and by laparotomy or conversion in patients %. in all cases internal hernia was reduced and closed all defects. in only one patient in (group a) small bowel at jja was resected. there was no mortality and one patient had pneumonia with acute respiratory distress which was treated medically. conclusions: the closure of mesenteric defects at (lrygb) by tight non-absorbable continued sutures is recommended because it is associated with a significant reduction in the incidence of internal hernia. introduction: laparoscopic roux-en-y gastric bypass (rygb) is a common and effective form of bariatric weight loss surgery. however, a subset of patients will fail to achieve the expected total body weight loss (tbwl) greater than % after months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. although alternative procedural interventions exist for operative revision after suboptimal rygb weight loss, laparoscopic adjustable gastric banding (lagb) provides an option with short operative time, low morbidity, and effective results. we have previously demonstrated that short-term ( -month), and mid-term ( -month) weight loss is achievable with lagb for failed rygb. the objective of this study is to report the long term year outcomes of lagb after rygb failure. methods and procedures: a retrospective review of prospectively collected data before and after rygb when available, and before and after revision with lagb was performed. background: saline filled intragastic balloons have become a common outpatient procedure for the treatment of obesity. acute dilation, ischemia and necrosis of the stomach has been described in the medical literature. gastric necrosis from acute gastric dilation is a rare but life-threatening condition, which requires timely diagnosis and management. we present a case of partial gastric ischemia with necrosis hours following placement of a saline filled intragastric balloon. postoperative complaints of bloating, nausea and vomiting are common complaints following placement of saline filled intragastric balloons and can lead to a delay in diagnosis. early diagnosis and management is essential in avoiding this life threatening complication. case report: a year old woman, bmi , comorbid conditions of diabetes mellitus underwent uncomplicated placement of a saline filled intragastric balloon for treatment of obesity. hours after placement the patient complained of cramping and bloating. hours following placement the patient developed vomiting and presented to an emergency room for evaluation. she was found to have blood glucose exceeding and a severely dilated stomach with pneumotosis on ct evaluation. ng tube decompression and icu management of the severe hyperglycemia was initiated. removal of the intragastric balloon was delayed - hours until an appropriate endoscopic retrieval kit could be obtained. endoscopic retrieval was performed without incident and near complete necrosis of the gastric mucosa was noted. the antrum was the only area spared. hours after retrieval a laparoscopic evaluation of the stomach revealed full thickness necross of the entire fundus and greater curve. indocyanine green (icg) fluorescent dye was used to assess vascular integrity of the remaining stomach and to define lines of resection. resection of the greater curvature was performed using icg florescent dye to ensure that the angle of hiss was viable and well perfused. the patient had a full recovery and subtotal gastrectomy was avoided. conclusions: spontaneous gastric distension exacerbated by gastric outlet obstruction following placement of a saline filled intragastric balloon can occur. unrecognized this condition can lead to ischemia, necrosis and perforation of the stomach. appropriate evaluation of patients following placement of intragastric balloons is essential. recognition of this condition can be delayed due to the complaints of cramping, bloating and vomiting which are typical following placement of saline filled intragastric balloons. untreated, gastric ischemia and necrosis can lead to early perforation which is associated with a high mortality rate. introduction: morbid obesity has become a growing health risk in the united states with up to % of americans suffering with obesity. bariatric surgery remains the best treatment for morbid obesity. the recent use of laparoscopic sleeve gastrectomy (lsg) as a single stage procedure has met with great success because of its quick learning curve and minimal postoperative complication rates. however, there are concerns if the lsg is an effective procedure for long-term weight loss. although criticized at first, the mini-gastric bypass (mgb) surgery has become a great option for morbidly obese patients because of the ability to lose weight with minimal post-op complications. the aim of this review is to assess the outcomes of lsg as it compares to mgb for the management of morbid obesity. introduction: we hypothesize that a jejunoileal anastomosis and partial diversion using magnamosis, a novel magnetic compression device, is technically feasible and will improve insulin resistance and metabolic syndrome similarly to patients who underwent bariatric surgery. metabolic surgery has demonstrated improvements in various parameters including insulin resistance, triglyceride levels, and cholesterol. it may be technically feasible to perform a less-invasive operation through partial diversion, and thereby stimulate an increase in incretins from the l-cells of the ileum to glean these benefits. methods and procedures: we performed a laparotomy and jejunoileal partial diversion using magnamosis in five rhesus macaques with induced insulin resistance through dietary modifications. after surgery, weight was monitored and a metabolic laboratory evaluation was performed weekly. timed tests were performed at baseline and again at and weeks postoperatively for triglyceride levels, glp- , insulin, glucose, and bile acids. the primates were followed for weeks prior to euthanasia. results are represented as mean±sem and all p-values were calculated using a two-sample students' t-test. introduction: many studies concerning individuals seeking bariatric surgery indicate a higher prevalence of psychiatric disorder in this population, both before and after surgery, however results are not conclusive. the aim of this study was to investigate changes in psychiatric health after gastric bypass surgery. methods: patients within the catchment area of the department of psychiatry of the south alvsborg hospital, operated with gastric bypass surgery during - were identified through the scandinavian quality registry (soreg). patients files were examined and psychiatric diagnoses and alcohol/drug abuse were recorded preoperatively and with a follow up time of years. results: a total of operated patients were identified. of these patients had been in contact with the psychiatric department before or after surgery. patients had attempted suicide preoperatively, but no attempts were made postoperatively, all women. patients attempted suicide postoperatively without a previous history of suicidal attempts, men woman. four patients with a preoperative history of alcohol abuse were identified, all women. these individuals did not seem to abuse alcohol/drugs postoperatively. postoperatively patients with an alcohol/drug abuse were identified, men, women. none of them had a former history of abuse. of the patient performing suicidal attempts postoperatively, men woman, had a postoperatively emerging alcohol/drug abuse. conclusion: preoperatively known alcohol/drug abuse or suicidal attempts do not seem to predispose for postoperative abusive problems or suicidal behavior. preoperative identification of individuals prone to alcohol/drug abuse or suicidal attempts seems difficult. introduction: in the past, our group has popularized models for gastric bypass, sleeve and gastric imbrication. there are currently no models to predict weight loss following single anastomosis duodenal switch. surgeons who offer this procedure are left to guess based on their limited experience how their patients will do following surgery we have developed a simple office based algorithm to predict weight loss following this procedure. method: patients met the criteria for this study. these patients underwent surgery at a single institution from june to december . non-linear regression analysis was performed to interpolate weight loss at one year. a multilinear regression was run to determine the significant variables. a model was then constructed to predict weight loss after single anastomosis duodenal switch. results: bmi, htn, gender, and the interaction between htn and dm were found to affect weight loss. the model achieved a r value of . and the average error of prediction in the model was . %ewl. conclusion: today too many surgical practices offer procedures tailored to surgeon instead of the needs of the patient. using our models predicting postoperative weight loss can be a straightforward process using easily gathered data. all surgeons should be doing this currently in their own practice to allow patient to choose targeted healthcare interventions based on patient's personal goals. surg endosc ( ) introduction: there is a long-standing practice of testing anastamosis both in upper and lower gi surgery. post-operative leaks in bariatric surgery are an uncommon but serious compilation increasing morbidity and risk of mortality. the present study looks at the practice of performing an intra-operative leak test during roux-en-y gastric bypass (rygb) and sleeve gastrectomy (sg). methods and procedures: the study was divided in two independent phases of six months and months. data was collected from all patients undergoing sg, rygb or revision rygb within those two periods. to confirm the integrity of the staple line all patients underwent a methylene blue and air test intra-operatively. this was followed by a gastrograffin swallow the morning post procedure. results: total number of patients in the study was . there were four positive intraoperative tests. one patient was a primary rygb and three patients were undergoing revision rygb. all were reinforced and subsequent recovery and gastrograffin swallow showed no leak. one revision rygb had an undetected small bowel injury distal to jejuno-jejunostomy that was not identified on intraoperative or next day imaging. we used multivariate statistical analysis to study our population sample and classified the impact of each factor or their combination with the use of principal component analysis. we used systematic clustering to identify subpopulations that have significant differences in statistical distribution. result: the main determinant of total operative time was the surgeon and the level of his assistant. prior surgeries, bmi and smoking history had a statistically significant impact on the laparoscopic time (p value. ). removing the impact of various surgeons, we detected four clusters of patients based on more than patient characteristics. we noticed total or time had two different clusters: one with a standard-deviation of - min while the other had over min. conclusion: this study may have practical implications on improving scheduling. the different comorbidities of these bariatric patients helped to stratify patients into these main cluster groups. better predictability on length of operative procedure can lead to more efficient use of or time and staff, thus ultimately leading to savings for the hospital. in addition, we used automated noninvasive tracking methods to identify phases of bariatric procedures that will allow more accurate estimated or time to efficiently schedule cases. the smart or, which is equipped with multiple noninvasive sensors, allows for error free tracking and monitoring without human interference. objectives: successful outcomes after bariatric surgery (bs) require a comprehensive educational program (cep) focused on post-surgical dietary and lifestyle changes. at our institution, patients must comply with a -week life-after-surgery program prior to surgery. since many patients are not able to participate in-person, an online cep was created to improve accessibility. to evaluate comprehension, a -question test is administered at the last preoperative visit to participants of both classes. the primary objective of this study is to evaluate the effectiveness of online versus inperson cep in terms of comprehension and post-operative weight loss. methods: patients who underwent bs from august -may were retrospectively reviewed at a single institution. all patients who underwent the in-person or online cep, completed the -question test, and had post-operative follow-up for at least months were included. baseline demographic, operative, and weight data were obtained using the electronic medical record. background: body weight loss after bariatric surgery is affected by several factors. diabetes status or preoperative body mass index (bmi) would affect the body weight loss after surgery. age and sexuality may also be the predictor. furthermore, the malabsorptive procedure is considered more effective for body weight loss than the restrictive procedure alone. we investigated the contribution of preoperative background data and procedures to the body weight loss after surgery. methods: this was a multicenter, retrospective study to validate the efficacy of bariatric surgery for morbidly obese patients in japan. patients underwent sleeve gastrectomy (lsg) or lsg with duodenal-jejunal bypass (lsg/djb) in each institution from january to december , and whose bmi was kg/m or more at the first visit were included in this study. we investigated the percent excess body weight loss (%ewl) at months after surgery. univariate and multivariate analyses were done to evaluate the predictive factors of body weight loss. we defined that %ewl more than % as well response (wr background: despite its known safety and efficacy, bariatric surgery is an underutilized treatment for morbid obesity in the united states. objective: our goal was to identify factors associated with failing to proceed with surgery despite being considered an eligible candidate by a bariatric surgery program. methods: this is a retrospective study that includes all patients (n= ) who attended a bariatric surgery informational session (bis) at a single center academic institution in . eligible candidates were identified after clinical evaluation and multidisciplinary candidacy review (mcr). we compared patients who underwent surgery to those who did not (i.e. dropped out) by evaluating patient-specific, insurance-specific, and bariatric surgery program-specific variables. univariate analysis and multivariable regression were performed to identify risk factors associated with failing to undergo surgery among eligible candidates. introduction: the elderly are a special subset of the population due to their limited physiological reserve with aging. revisional bariatric surgery is becoming more common with increase in primary bariatric procedures. data on safety, weight loss, and metabolic effects of revisional bariatric surgery in elderly is limited. the aim of this study was to assess the safety and efficacy of revisional bariatric surgery in the elderly. methods: clinical data of all elderly patients ( years and above) who underwent elective revisional bariatric surgery at an academic institute between and were reviewed. demographic data, perioperative variables, and postoperative outcomes were studied. results: a total of patients were identified with a female predominance ( : ). mean age was ± . years. mean bmi at the time of revisional surgery was . ± . kg/m . the primary indication for revisional surgery included management of postoperative adverse events (n= , . %) and weight recidivism (n= , . %). in patients with postoperative complications, the most common indications for revisional surgery were dysphagia (n= , . %), marginal ulcer (n= , . %), gastric outlet obstruction (n= , . %), and fistula formation (n= , . %). the most common type of revisions included conversion of vertical banded gastroplasty to roux-en-y gastric bypass (rygb, n= ), revision of rygb (n= ), conversion of adjustable gastric banding to sleeve gastrectomy (sg, n= ), and sg to rygb (n= ). two out of seven ( . %) patients with -day postoperative readmissions had serious complications that required reoperation. one of them underwent small bowel resection for ischemia and the other had thoracotomy for hemothorax evacuation developing secondary to a gastropleural fistula. while there was no mortality over the first days postoperatively, two patients died months after surgery due to infectious complications. in the median follow-up time of (interquartile range, - ) months, mean weight and bmi changes of − . kg and − . kg/m were observed. twenty-three ( . %) patients had diabetes at time of revisional surgery. a mean reduction of . mg/dl in fasting blood glucose and . % in glycated hemoglobin were noted between baseline and last follow-up. conclusion: revisional bariatric surgery in elderly is associated with high complication rates. our data indicate that revisional bariatric surgery can potentially alleviate symptoms and resolve complications of primary bariatric surgery. elderly patients should have their risk stratified and weighed against the benefits of surgery. anne-marie carpenter, bs, alexander l ayzengart, md, mph; university of florida introduction: bariatric surgery is the most effective treatment for morbid obesity. of all available procedures, laparoscopic sleeve gastrectomy (lsg) is now the most popular worldwide. common complications of lsg include gastroesophageal reflux, stricture, and staple-line leak. although rare, portomesenteric venous thrombosis (pmvt) and liver retractor-induced injuries are increasingly reported. we present a case of isolated left portal vein thrombus after routine lsg that was likely caused by prolonged compression of left liver lobe by the nathanson retractor. case presentation: a -year-old female with a bmi of and biliary colic due to cholelithiasis underwent lsg with hiatal hernia repair and cholecystectomy. she tolerated the procedure without complication and was discharged home on the following day. on postoperative day , she presented to the emergency department with fever and epigastric pain. contrast ct revealed an isolated filling defect within the proximal left portal vein; abdominal doppler demonstrated an acute thrombus occluding the left portal vein with normal flow in the main and right portal veins. the patient was treated with a -month course of therapeutic anticoagulation with lovenox. a complete hematologic workup did not uncover any hypercoagulable conditions. the patient recovered well and remained asymptomatic at her follow-up visit weeks after operation. discussion: pmvt is a rare surgical complication with multifactorial etiology. in bariatric surgery, evidence suggests lsg elicits more frequent pmvt compared with roux-en-y gastric bypass. a systematic review cited the incidence rate of pmvt as . - % after lsg. the mechanisms are thought to be due to pneumoperitoneum, procoagulant obese state, manipulation of portomesenteric venous system during division of the gastrocolic ligament, and postoperative dehydration. liver retraction is paramount during laparoscopic bariatric surgery to provide adequate visualization of the upper stomach and diaphragmatic hiatus. most methods of liver retraction produce significant pressure on the liver parenchyma by compressing it against the diaphragm. three types of liver injury have been documented in literature: minor congestion, traumatic parenchymal rupture, and delayed liver necrosis. uniquely, we propose an additional type of injury-left portal vein thrombosis due to compression of left liver lobe with the nathanson retractor. conclusion: the case described herein represents the first documented report of isolated left portal vein thrombosis after lsg. this is a unique presentation of retraction-related liver injury causing pmvt by mechanical compression of liver parenchyma. as surgical procedures increase in duration, intermittent release of liver retraction should be performed at regular intervals. introduction: up to % of patients experience internal hernia (ih) after laparoscopic roux-en-y gastric bypass (rygb). studies have shown that antecolic roux limb orientation, and closure of the mesenteric defect reduce, but do not eliminate, the incidence of ih. we hypothesize that despite operative differences, ih occur more frequently in patients who experience significant weight loss. this study aims to determine whether those patients who present with ih following rygb experience greater than % excess body weight loss (ebwl). methods: a retrospective chart of all patients who underwent ih repair following rygb at our institution between sept and sept was performed. all applicable cpt codes to encompass ih repair were reviewed (n= ). patients with ih repair after rygb were identified. results: of the patients, were female. the mean pre-rygb weight was lbs (sd± . ), bmi . kg/m (sd± . ). all procedures but one were performed in an antecolic configuration; the other retrocolic-antegastric. fifteen cases were laparoscopic and two were open; nine had the jejunal mesenteric defect closed, eight did not. the average weight loss from the time of rygbp to ih presentation was . lbs (sd± . ) and %ebwl from rygb to the nadir weight was % (sd± ). when evaluated by t-test, there was no statistical difference in bmi at the time of program initiation, rygb, or ih presentation, as well as number of pounds lost, %ebwl, or time to ih presentation, when comparing patients for whom the mesenteric defect was closed or not. average time from rygb to ih presentation was . years (range - days) . conclusion: in our limited cohort of patients who have presented with internal hernia after rygb, there was an average of % ebwl. this is greater than the average expected %ebwl at our institution and others, suggesting that ih may occur in patients with greater weight loss at a higher frequency. mesenteric defect closure did not appear to have any influence in this limited cohort, suggesting that weight loss is a stronger factor in ih development. we plan a more extensive evaluation in a larger cohort of patients to determine if greater %ebwl is a predictor of ih formation in patients undergoing rygb. introduction: introduction of enhanced recovery after surgery (eras) pathways has led to early recovery and shorter hospital stay after laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg). this study aims to assess feasibility and outcomes of postoperative day (pod) discharge after lrygb and lsg from a national database. methods: patients who underwent elective primary lrygb and lsg and were discharged on pod and were extracted from metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) dataset. a : propensity score matching was performed between cases with pod vs pod discharge, and the -day outcomes of the propensity-matched cohorts were compared. high risk patients were excluded from the analysis. purpose: the aim of this study was to evaluate a large volume, multi surgeon bariatric surgery center producing the largest sample size to date proving efficacy (% weight loss) and safety of sleeve gastrectomy following band removal in one or two step procedures. methods: all patients undergoing conversion of lagb to lrygb ( ) and lsg ( ) regardless of one step vs two step conversion from january to january were included. a retrospective analysis of our prospectively maintained database was performed to compare outcomes in patients undergoing conversion to lrybg vs lsg after lagb to identify the outcomes. introduction: the purpose of the study was to describe the use of intraoperative indocyanine green (icg) fluorescence angiography to identify the blood supply patterns of the stomach and gastroesophageal junction (gej). we hypothesized that identifying these vascular patterns may help modifying the surgical technique to prevent ischemia-related postoperative leaks. methods: patients underwent laparoscopic sg and were examined intraoperatively with icg fluorescence angiography at an academic center from january to september . prior to the construction of the sg, ml of icg was injected intravenously and pinpoint® technology was used to identify the blood supply of the stomach. afterwards, the sg was created with attention to preserving the identified blood supply to the gej and gastric tube. finally, ml of icg were injected and pinpoint® technology was used again to ensure that all the pertinent blood vessels were preserved. results: patients successfully underwent the procedure with no complications. the following blood supply patterns to the gej were found: the incidence of overall accessory blood supply to the right-side dominant pattern was more common than expected. in about half of the cases where an accessory vessel was found in the gastrohepatic ligament, the blood flow was toward the stomach (and not the liver). furthermore, the incidence of accessory blood supply from the left side was found in % of the cases. % of patients had both the left side accessory and accessory gastric artery pattern. in these particular patients, if a concurrent hiatal hernia repair is performed, these accessory blood supplies are at risk of being injured if care is not taken to preserve them, rendering the gej relatively ischemic. conclusion: icg fluorescence angiography allows determining the major blood supply to the proximal stomach prior to any dissection during sleeve gastrectomy so that an effort can be made to avoid unnecessary injury to these vessels. background: morbid obesity, a common medical concern with significant health risks, has a prevalence of . % among u.s. adults. bariatric surgery provides effective weight loss for morbidly obese patients with improvement in their comorbid conditions. traditionally, routine intraoperative drain placement (idp) and postoperative esophagram (ugis) were thought to identify early postoperative complications. recently, these interventions have been scrutinized for their effectiveness. we hypothesized that idp and postoperative ugis do not alter outcomes in bariatric surgery and only increase hospital length of stay (los). methods: two cohorts, each consisting of patients from either or were analyzed from our institution. in the cohort, all patients had idp and an ugis on postoperative day , prior to starting a clear liquid diet. in the cohort, no patients had idp or ugis, but instead were started on a clear liquid diet on postoperative day , in the absence of vomiting. all patients in each cohort underwent either a laparoscopic sleeve gastrectomy or a roux-en-y gastric bypass. a retrospective study was performed to analyze whether there was a significant difference in postoperative complications, length of stay, and operating room time between these two cohorts. those who underwent t dm remission were less likely to be vdd at all time points. the rates of vdd appear to be slightly higher in rygb at each time points. the rates of macrocytic anemia, microcytic anemia and hypoalbuminemia were low and varied depending on surgical procedure, with no relevant increase following surgery (see figure ). conclusions: vitamin d deficiency is prevalent among diabetic patients with obesity presenting for bariatric surgery. the postoperative management was successful in addressing vdd following surgery; those who experienced t dm remission after surgery were less likely to be vdd. further prospective studies are needed to explore this relationship. surg endosc ( ) :s -s introduction: it is well known that morbid obesity is strongly associated with high blood pressure. cardiovascular risk reduction is a well studied and described result of bariatric surgery. the objective of this study is to quantify hypertension resolution in patients who underwent bariatric surgery at our institution. methods: we retrospectively reviewed all the patients who underwent either laparoscopic sleeve gastrectomy (lsg) or laparoscopic roux en y gastric bypass (lrygb) at our institution between and . we selected those patients who were on antihypertensive medical treatment and had a -month follow-up. hypertension resolution was defined as the interruption of any blood pressure medications within the follow-up period. we compared the patients who had resolution of hypertension (group ) with patients who did not (group ), based on demographics, comorbidities, and outcomes. chi-square and student t-test were used for categorical and continuous variables respectively. results: out of patients, ( . %) patients met the inclusion criteria, out of which, ( . %) had a complete resolution of hypertension within months. the patient population included in group was predominantly female n= patients ( . %), diabetic (n= , %), with a mean bmi of . ± . kg/m , a mean age of . ± . years, and a preoperative systolic blood pressure mean of ± . mmhg. the most common procedure performed was lsg with n= ( %). comparison between group and group based on age, gender, bmi, and diabetes showed no statistically significant difference. estimated bmi loss % at months, type of procedure and % ebmil showed no statistically significant difference between the groups. conclusions: rapid weight loss is associated with a drastic reduction of blood pressure. besides weight loss, we did not identify a clear correlation between risk factors when we compared patients who had resolution of hypertension with patients without resolution. further prospective studies should be done for better understand these findings. the mount sinai hospital, university of chicago introduction: for many patients, hiv has transformed from a life-threatening illness into a manageable chronic disease. reflecting trends in the general population, obesity is increasingly prevalent among hiv-positive patients. surgical intervention has shown the greatest effectiveness in treating obesity. it is unknown, however, whether physician attitudes reflect the changing trends in obesity care for hiv-positive patients. methods and procedures: medical students from the first, second, and fourth years of training were invited to participate in an irb-approved survey, handed out during didactic sessions, which was designed to assess their knowledge and attitudes regarding bariatric surgery in hiv-positive patients. self-reported demographic information of respondents was also collected. the outcome of interest was the proportion of correct responses. univariate and multivariate regression analyses were performed. results: surveys were completed by medical students. demographic covariates included the following: age, sex, race, bmi, and year of training. age, sex, race, and bmi were not statistically significant in the multivariate model. however, in both univariate and multivariate models, each additional year of training was associated with a significant increase in the proportion of correct responses (multivariate model beta coefficient= . , p. ). conclusions: obese and hiv-positive patients suffer from well-documented stigma in health care. these findings suggest that medical training corrects common misperceptions of obese and hivpositive patients, and may lead to a better understanding of the appropriateness of bariatric surgery for hiv patients. whether these attitudes are predictive of referral practices remains to be seen. introduction: obesity is a common problem worldwide with numerous associated comorbidities and is associated with an increased risk of developing some cancers. despite bariatric surgery being associated with a risk reduction for cancer development, some will develop cancer after surgery and little is known about complications which might arise during multimodality cancer treatment. here we report the case of a year-old female who developed an unusual giant marginal ulcer (mu) post laparoscopic roux-en-y-gastric bypass (lrygb) while receiving systemic chemotherapy for an early stage breast cancer. case report: in summary, a year-old female with a preoperative bmi of kg/m had an uncomplicated lrygb one year prior to her presentation. she was a non-smoker, was abstinent of alcohol and did not use nsaids, steroids or other ulcerogenic medications. eight months post procedure with a bmi of . kg/m she was diagnosed and treated with bcs plus slnb for a pt n m er/pr +ve her −ve breast cancer. one week following her third cycle of docetaxel and cyclophosphamide, she presented with two days of melena, small volume hematemesis and abdominal discomfort. the patient was resuscitated with prbc, started on a ppi infusion and had free air ruled out on a cxr. upper endoscopy was complete showing a giant mu at the gastrojejunal anastomosis, biopsies ruled out malignancy and h. pylori. subsequent ct abdomen/pelvis identified contrast extravasation from the anastomosis confirming a free perforation. broad spectrum antibiotics were started and a diagnostic laparoscopy complete. a graham patch repair utilizing omentum and abdominal washout were complete with placement of surgical drains. the patient was supported with parenteral nutrition while npo. diet was advanced after an upper gi series on post operative day showed no ongoing leak. the patient was discharged on post operative day , recovered and although further chemotherapy was discontinued she completed whole breast radiotherapy. conclusion: leaks and hemorrhage are early postoperative complications that are not seen intraoperatively in our experience. furthermore, endoscopy significantly increases mean operative time. routine use should be left to the discretion of the surgeon but should not be considered an essential step of the sleeve gastrectomy. the objective of the study: surgical site infection (ssi) following bariatric surgery contributes to patient morbidity and additional use of health care resources. we investigated whether a ssi quality control initiative in the form of a refined preoperativeantimicrobial protocol affected the rate of ssi following laparoscopic roux-en-y gastric bypass (lrygb). we reviewed all lrygb procedures performed between june and december at a single bariatric surgery centre of excellence. two preoperative antimicrobial protocols were compared. patients undergoing surgery prior to february received g of cefazolin whereas patients undergoing surgery after february , received a new antimicrobial protocol consisting of g cefazolin, mg metronidazole and ml oralchlorhexidine rinse. the primary outcome was day ssi including superficial ssi, deep incisional ssi and organ/space infection as defined by the centre for disease control. clinic charts and provincial electronic medical records were reviewed for emergency department visits, microbiology investigations and physician dictations diagnosing ssi. outcomes were assessed using a students t-test. results: two hundred seventy six patients underwent lrygb of which received the refined antimicrobial protocol and received cefazolin. the refined antimicrobial protocol significantly decreased the rate of deep incisional ssi compared to cefazolin (n= , . % vs n= , . %; p\ . ). the refined antimicrobial protocol resulted in an insignificant overall reduction in the rate of superficial ssi (n= , . % vs n= , . %; p[ . ) and organ/space infection (n= , . % vs n= , . %; p[ . ) respectively. conclusions: a preoperative antimicrobial protocol using cefazolin, metronidazole and chlorhexidine oral rinse appears to reduce the rate of ssi following lrygb. this protocol may be most effective to prevent deep incisional ssi. additional patient cases or alternative study design including a randomized control trial is required to better understand the efficacy of this protocol. background: for many years, the roux-en-y gastric bypass (rygb) was considered a good balance of complications and weight loss. according to a several short-term studies single anastomosis duodenal switch or stomach intestinal pylorus sparing surgery (sips) offers similar to weight loss to rygb with fewer complications and better diabetes resolution. however, no one has substantiated complication and nutritional differences between these two procedures over the midterm. this paper seeks to substantiate previous studies and compare complication and nutritional outcomes between rygb and sips. methods: a retrospective analysis of patients who either had sips or rygb from to . complications were gathered for each patient. nutritional outcomes were measured for each group at , , and years. regression analysis was applied to interpolate each patient's weight at , , , , , , and months. these were then compared with t tests, fisher exact tests, and chi squared tests. results: rygb and sips have statistically similar weight loss at , , , , and months. they statistically differ at and months. at months, there is a trend for weight loss difference. there were only statistical differences in nutritional outcomes between the two procedures with calcium at and years and vitamin d at year. there were statistically significantly more long term major complications, minor complications, reoperations, ulcers, small bowel obstructions, nausea, and vomiting with the rygb than sips. conclusion: with comparable weight loss and nutritional outcomes, sips has fewer short and long-term complications than rygb and better type diabetes resolution rates. introduction: the purpose of this study is to determine the risk factors that contributed to increased postoperative complications, as noted in prior studies within the publicly funded insurance population undergoing bariatric surgery. methods and procedures: data was collected via a retrospective review of the medical records of patients who underwent laparoscopic roux en y gastric bypass or laparoscopic sleeve gastrectomy from to at a single institution. for each patient, data was collected in the following categories: baseline demographics, insurance status, medical comorbidities, immediate complications, re-admissions and associated complications, and follow up out to years. results: a total of patient charts were reviewed, patients were categorized as private insurance and patients were categorized as public insurance. there was no statistically significant difference in mean patient age (private . years vs public years), sex (male:female %: % for both groups), or bmi ( vs ). there was a statistical significance in relationship status in the categories of single ( % vs %), married ( % vs %) or living with a partner ( % vs %), as well as employment status ( % vs %). when comparing comorbid conditions preoperatively there was no difference except for diabetes which was less common in the private insurance group % vs %. readmission rates for complications were significantly different as well at % vs % with public insurance patients having increased complication rates and readmissions. there was no difference in follow up percentages at each time point for the two groups. interestingly postoperative bmi was significantly different in the two groups until year out ( vs ) when the difference disappears. conclusions: our current data set confirms prior research that documented higher complication rates in public insurance patient populations without differences in long term results in regards to weight loss. it also shows that the public insurance group is possibly at higher risk for complications and readmissions postoperatively due to the lack of social support at home given that a much higher percentage of them are single or divorced, and lack employment. it is likely that this lack of support at home prompts more frequent readmissions and associated complications. introduction: gastric bypass has been an acceptable treatment for the morbidly obese patient, with proven efficacy on weight loss and remission of co morbidities, especially diabetes (t dm). laparoscopic sleeve gastrectomy (lsg) is gaining momentum as an alternative procedure for the morbidly obese patient. the aim of this study is to assess the resolution of t dm by examining hba c, bmi, fat %, and % excess weight loss in t dm patients in our lsg patients. methods: we performed a retrospective chart review of t dm patients before and after lsg, analyzing hga c, bmi, % weight loss, fat %, and diabetic medications. data was analyzed by using spss version . paired t-test was applied to see the significance of bmi, weight, fat % and hba c before and after the procedure. introduction: gastroesophageal reflux disease (gerd) is a known risk following laparoscopic sleeve gastrectomy (lsg), with up to % of patients affected by the disease postoperatively. of these patients, an unknown number progress to medically refractory gerd. due to their postsurgical anatomy, these patients have limited options for intervention. while endoluminal therapies are available, surgical revision to roux-en-y gastric bypass (lrygb) has become an accepted revisional treatment. despite this therapeutic option, many payors deny coverage for this treatment. in this study, we report outcomes of revision of lsg to lrygb and difficulties in obtaining insurance approval for the operation. methods: we conducted a retrospective review of all patients who underwent a revisional bariatric operation at a single institution between january and august . we analyzed all patients who underwent conversion of lsg to lrygb. we collected data on -day mortality and morbidities, pre-and postoperative antacid use, and the insurance approval process. results: within the study period, we identified patients undergoing revisional bariatric surgery. seventeen patients had undergone conversion of lsg to lrygb. all of these patients underwent revision due gerd refractory to maximal medical therapy. the average body mass index was kg/m , and our average operative time was minutes. one patient required laparoscopic cholecystectomy within days due to acute cholecystitis, and another patient required reoperation for control of staple line bleeding. there were otherwise no -day morbidities or readmissions. fifty nine percent stopped all antacid medication by six months, and % stopped by months. of the % percent of patient still on proton pump inhibitor therapy, none of those patients complained of reflux symptoms. of non-medicare patients, % were initially denied insurance coverage for revision. only one plan accounted for all initial approvals. twenty five percent of denied patients eventually paid out of pocket, and the remaining % ultimately secured coverage after an appeal process. with no significant differences in mortality or hospital stay. significantly shorter operative times were observed in the adolescent group ( . ± vs . ± , p. ). in univariate analysis blood transfusions and vte rates were significantly lower in the adolescent group but there was no difference after risk-adjusted logistic regression analysis. analysis of readmission data showed lower rates in adolescents compared to young adults ( . % vs . % p= . ). however, adolescents are more frequently readmitted secondary to gallstone disease ( . % vs . %, p. ). the most common reason for readmissions in both groups was nausea and vomiting with fluid/electrolyte depletion, followed by abdominal pain. conclusion: adolescent bariatric surgery is feasible and safe, with outcomes similar to that of young adults. lsg is currently the most common bariatric procedure performed in adolescents which is reasonable given the relative lack of co-morbid conditions within this group. nausea and vomiting are the most common reason of readmission in both groups, but gallstone disease is significantly higher in adolescents, suggesting that this population should be carefully screened for gallbladder disease preoperatively. further studies regarding long-term results are needed to elucidate long-term outcomes, such as the durability of comorbidity resolutions in adolescent patients. introduction: revision bariatric surgery is always considered to be associated with higher complication rates. there is currently controversy in the literature regarding one stage and two stage revisions. methods: the present study is ongoing longitudinal prospective analysis of data of revision surgery in a single unit. the revision surgery was offered after initial failed or complicated gastric band, sleeve gastrectomy and roux-en-y gastric bypass (rygb). results: there were forty-two individuals who had revision bariatric surgery. the age of the cohort of patients ranged from twenty-six to seventy-five years. thirty-three were females and nine males. all patients who were hypertensive or diabetic at the time of their initial bariatric operation had a relapse of their co-morbidity prior to their revision surgery. the two stage revisions patients had their band removed at another facility, had a compilation from the band itself or did not wish for revision surgery initially. of the two failed bypasses one had a large pouch and very short limbs. the other had a gastro-gastric fistula and ultra short limbs. there were no deaths in this study. one patient who underwent one stage revision of a gastric band to bypass had an iatrogenic small bowel injury that required a second operation. amelioration of diabetes and hypertension was seen in all who had relapsed. weight loss was good in all patients except for the those undergoing revision from short limbed to long limbed bypass. conclusion: there is enough evidence that revision surgery is feasible, and can ameliorate metabolic co-morbidities after failed band and sleeve. two staged surgery is not necessarily safer compared to one stage revision. in the present study an inadvertent iatrogenic injury occurred in one stage revision group but is not true reflection of increased complications. the association between preoperative endoscopic esophagitis and post operative gerd in sleeve gastrectomy patients samer elkassem, md; medicine hat regional hospital introduction: gerd is a common complication after sleeve gastrectomy (sg). the purpose of this study is assess the relationship between pre-operative findings of endoscopic esophagitis and postoperative gerd in sg patients. the hypothesis of this study is that patients with pre-op esophagitis are more likely to have gerd post-op than patients with no esophagitis pre-op. methods: a retrospective review of sg patients who had pre-operative endoscopy and followed prospectively for at least one year was preformed. patients were divided into two groups based on pre-op endoscopic findings: those with no findings of esophagitis (ne), and those with endoscopic esophagitis, including barretts (ee). patients were followed for at least one year, and assessed for usage of a proton pump inhibitor (ppi) usage. the two groups were compared using both student t-test and chi square test. results: a total of patients did not have any findings of esophagitis on pre-op endoscopy (ne group), and patients had findings of endoscopic esophigitis (ee). there was no difference in preoperative demographics and post-op weight loss at one year (table i) . follow-up ranged from one to years post-op. the dependency on ppi usage and de novo reflux are shown in table ii . introduction: patients with "super-super obesity", defined as a bmi≥ , are at higher risk of weight-related health problems and might benefit more than others from metabolic and bariatric surgery. however, these benefits need to be weighed against the potential for increased operative and perioperative risks. accurate data regarding these patients is critical to guide procedure choice and informed, shared decision-making. the metabolic and bariatric surgery accreditation and quality improvement program (mbsa-qip) is a national accreditation and quality improvement program, which captures clinically-rich specialty-specific data for the majority of all bariatric operations in the united states. this is the first analysis of the mbsaqip participant use file (puf) focusing on this at-risk subpopulation. introduction: sleeve gastrectomy represents one of the most common surgical procedure used in bariatric surgery. the most feared complication following laparoscopic sleeve gastrectomy is the leak that occurs at the staple line. one method to reduce the risk of leak is the use of reinforcement material at the suture line. in this study, the efficacy of sutures and fibrin glue in the prevention of staple leak has been compared retrospectively. materials and methods: a total of patients undergoing lsg between october and august at the medical faculty of firat university were retrospectively assessed using the hospital database system records. results: there were males ( %) and ( %) females, with a mean age of years (range: - y), and body mass index of kg/m . while no reinforcement material was used in patients ( %) at the suture line, reinforcement sutures or fibrin glue were used in ( %) and ( %) patients, respectively. postoperative leak occurred in patients ( . %), and ( . %) of these had no use of reinforcment material for leak prevention, while additional sutures or fibrin glue had been used in patients, one in each group ( . %). one patient died due to leak and the consequent development of sepsis ( . %). discussion: lsg is increasingly more frequently used in bariatric surgery practice. however, an increase also occurs in the rate of complications. a discrepancy exists in the published literature regarding the benefit of reinforcment the suture line on the risk of leak risk. in our patient series, patients without the use of additional material in the staple line had a significantly increased risk of leak. conclusion: despite some controversy, strong evidence exists on the effectiveness of fibrin glue in the prevention of leaks in patients undergoing laparoscopic sleeve gastrectomy. background: laparoscopic bariatric surgery has been performed safely since . in a persistent search for fewer and smaller scars, single port and acuscopic surgery or even notes have been implemented. the goal of this study is to analyze the safety and feasibility of using a low cost incisionless liver retraction compared to a standard laparoscopic retractor for sleeve gastrectomy. methods and procedures: candidates for sleeve gastrectomy that fulfilled nih criteria for bariatric surgery were selected. those younger than and/or with prior upper-left quadrant surgery were excluded. all patients signed written consent. patients were randomized : to either a standard port technique with a fan-type liver retractor through a mm port (group a); or a port technique with the liver retracted by a polypropylene suture passed through the right crura and retrieved at the epigastrium with the use of a fascia closure needle (group b). all surgeries were performed by the same surgeon. surgery length from insertion of first port to withdrawal of the last was the primary endpoint. anthropometric data, % of pre-surgical total weight loss (%ptwl), visualization of the surgical field, complications inherent to liver retraction and postoperative morbidity were recorded. background: comprehensive web and hospital based preparative patient education allow the morbidly obese patients to understand weight loss surgery, its benefits, the necessity of follow up and the risk of weight regain. while the inhouse seminars provide a face-to-face interaction with the bariatric program staff, the online seminars are easily accessible and more cost effective. the primary objective of this study is to compare demographics and weight loss surgery outcomes between patients who participated in the online vs in-house preparative seminars. methods: after obtaining institutional review board approval, a retrospective chart review was performed involving patients who underwent bariatric surgery between january and december at a tertiary care center. the patients were divided into two groups based on their choice of educational seminar, online or in-house, prior to their initial consult with a surgeon. data was collected on age, type of insurance, length of stay (los), longest follow up and change in bmi to assess weight loss. results: one hundred and eighteen patients were included in this study. eighty patients attended in-house seminar while completed online seminar. the various types of surgery (laparoscopic gastric bypass, sleeve gastrectomy, and band) were similarly represented between the two groups. there was no difference in the type of insurance policy between the groups. patients who elected to take the in-house seminar were on average years older than those who chose the online course, which was statistically significant (p. ). there were no differences in los, longest follow up after surgery, and weight loss at months between the groups. conclusions: based on mbsaqip registry data, patients age or over did not have higher odds of a -day readmission compared to younger patients after lsg or lrygb. rates of -day readmission, reoperation, and death were similar, but rates of complications (e.g. pneumonias, unplanned intubations) were higher in the older group. bariatric surgery in the elderly should therefore be performed only after careful and patient-centered selection processes. introduction: revisional bariatric surgery has become more common in recent years. it is to address short and long-term complications of primary bariatric surgery as well as the issue of weight regain. the aim of this study was to retrospectively analyze the indications for reoperation and short-term outcomes in our institution. methods and procedures: between and , patients who underwent bariatric surgery in our center were included in a prospectively collected database. demographic data, primary and revisional bariatric procedures, reasons for revisions and outcomes were recorded and reviewed retrospectively. results: a total of patients underwent bariatric surgery at our institution and % of these (n= ) were revisional bariatric surgery. we identified groups of patients according to their primary procedures: adjustable gastric band (agb), roux-en-y gastric bypass (rygbp), vertical band gastroplasty (vbg), and sleeve gastrectomy (sg). of the patients, ( %) had abg as primary procedure. of those, % had their band removed due to food intolerance and severe dysphagia and % had a conversion to either rygbp or sleeve gastrectomy (sg) due to weight recidivism. in the rygpbp group (n= ), % of the patients presented with late complications. of these, % had an acute presentation (small bowel obstruction, internal hernia, or perforated marginal ulcer) requiring emergency surgery. only % patients needed gastric bypass takedown due to severe hypoglycemia. weight recidivism was noted in % of the patients that necessitated either revising the anastomosis, trimming of the gastric pouch or gastrogastric fistula takedown. in the vbg group (n= ), % of the patients experienced weight recidivism that required conversion to rygb and % of the patients required the vbg to be taken down due to obstructive symptoms. in the sg group (n= ), % of the patients experienced early complications needing a second procedure. weight recidivism was found as the most common reason for conversion ( %) to rygbp. twenty nine percent of the patients in this group underwent conversion to a rygbp due to severe de novo gerd. introduction: our aim was to systematically review the literature to compare weight loss outcomes and safety of secondary surgery after sleeve gastrectomy (sg), particularly between roux-en-y gastric bypass (rygb) and biliopancreatic diversion with duodenal switch (bpd-ds). sg was originally developed as the first part of a two-stage procedure for bpd-ds. however, it is now the most common standalone bariatric surgery performed in the united states. the majority of sg are done as the sole bariatric operation but in %, a second operation is necessary, due to insufficient weight loss, weight regain or reflux. the most common second-stage operations are rygb at % and bpd-ds at %. there are a few small case series comparing rygb to bpd-ds as a secondary surgery after sg. these studies suggest that after failed sg, bpd-ds results in greater weight loss but higher early complication rates than rygb. we had one mortality, related in part to supra-therapeutic anticoagulation perioperatively. one patient underwent successful heart transplantation and additional patients were reactivated on the transplant list. conclusion: laparoscopic sleeve gastrectomy is effective in advanced heart failure patients for meaningful weight loss, reactivation to the transplant wait list, and ultimately cardiac transplantation. however, this complex population carries a high perioperative risk and close multidisciplinary collaboration is required. more data is needed to best optimize perioperative management of these patients. the introduction: bariatric surgery is a highly effective treatment for severe obesity. while its effect on improvement of the metabolic syndrome is well described, its effect on intrinsic bone fragility and fracture propagation is unclear. therefore, the aims of this systematic review of the literature were to examine ( ) the incidence of fracture following bariatric surgery, ( ) the association of fracture with the specific bariatric surgical procedure ( ) conclusion: it appears that the overall risk of sustaining a fracture of any type after undergoing bariatric surgery is approximately percent after an average follow up of . years. the greatest risk of fractures is associated with the bpd, with the rygb being the most favorable. fractures following bariatric surgeries tend to follow osteoporotic and fragility patterns. post-operative supplementation of vitamin d, calcium and weight bearing exercises need to be optimized, and long term follow-up studies will be needed to confirm that these interventions will indeed reduce fracture risk following bariatric surgery. background: the effect of sleeve gastrectomy on gastroesophageal reflux (gerd) remains controversial. it is currently common practice to perform a hiatal hernia repair (hhr) at the time of the sleeve gastrectomy, however, there are few data on the outcomes of gerd symptoms in these patients. the aim of this study was to evaluate the effect of performing an esophagopexy hiatal hernia repair on gerd symptoms in morbidly obese patients undergoing robotic sleeve gastrectomy (rsg). methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rsg and concomitant esophagopexy for hiatal hernia repair from november to july . patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was subjective gerd symptoms and recurrence of hiatal hernia. results: thirty-seven patients were identified meeting the inclusion criteria (rsg+hhr+esophagopexy) with a mean follow-up of . over the past years there have been several bariatric surgeries cancelled secondarily to abnormal pre-operative test results within eastern health. these surgeries are often cancelled the day before their scheduled surgery, which does not provide sufficient time to book other patients. the end result is that the or gets underutilized and the bariatric surgery waitlist grows. prior to any major surgery patients are often subjected to a routine screening process, which includes a history and physical along with diagnostic screening tests and screening blood work. a preliminary analysis was done of the first patients through the bariatric surgery program at eastern health assessing the coagulation study results and outcomes. analysis showed that out of the first patients % were found to have a history of bleeding, % were using anticoagulants preoperatively, another % were noted to have a family history of bleeding. in the preoperative blood work that was done, % were found to have an elevated ptt/ inr for which hematology ended up being consulted in % of the patients. overall this did not change the preoperative management of these patients and they went on to have their surgery. intraoperatively patient was noted to have excessive bleeding and this was found not be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. post operatively there was bleeding in patient which required transfusion, however this too was found not to be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. overall this initial analysis showed no difference in operative management or delay in surgery secondarily to abnormal preoperative assessment findings. further analysis of a larger population of the bariatric surgery program patients is needed in order to determine whether any changes should be made to the preoperative assessment protocol. introduction: patients undergoing bariatric surgery frequently present with various obesity-related psychiatric comorbidities, including depression. furthermore, previous literature has demonstrated a positive association between depression and cardiovascular disease, and obesity serves as an independent risk factor for cardiovascular disease. however, the relationship between preoperative depression and cardio-metabolic risk factors following bariatric surgery remains unknown. methods and procedures: this retrospective analysis utilized data obtained from patients (n= , ) who underwent bariatric surgery at a single academic medical center in california. patients underwent either laparoscopic roux-en-y gastric bypass or sleeve gastrectomy. using medical record data, patients were preoperatively categorized as follows: not depressed, history of depression but not currently on anti-depressive medication, and history of depression and presently taking anti-depressive medication. patient demographic characteristics were obtained preoperatively. clinical and biochemical risk factors for cardiovascular disease were evaluated preoperatively and and months following bariatric surgery. anova, kruskal-wallis, and chisquare tests were applied where appropriate. results: in this sample, % of patients were not depressed, % had a history of depression but were not taking anti-depressive medication preoperatively, and % had a history of depression and were taking anti-depressive medication preoperatively. at baseline, depressive history was positively associated with female sex (p\. ), older age (p\. ), white race (p\. ), medicare insurance (p\. ), previous abdominal surgery (p\. ), length of stay (p\. ), requiring an inferior vena cava filter (p=. ), total cholesterol (p\. ), and triglycerides (p =. ). on average, patients with a history of depression taking anti-depressive medication weighed less than patients with a history of depression not on medication and patients without depression preoperatively (p=. ) and (p=. ) and (p=. ) months after surgery. after six months of follow-up, preoperative depressive history was positively associated with total cholesterol (p=. ), triglycerides (p\. ), hba c (p=. ), and fasting serum concentrations of insulin (p=. ). after months of follow-up, preoperative depressive history was positively associated with higher levels of total cholesterol (p=. ), ldl cholesterol (p=. ), and triglycerides (p= . ). conclusion: a history of depression prior to surgery was associated with higher levels of total cholesterol and triglycerides at baseline and and months postoperatively. after months, preoperative depressive history was also associated with higher levels of ldl cholesterol. this study suggests that, on average, bariatric patients with comorbid depression have worse lipid profiles prior to-and up to one year after-bariatric surgery relative to counterparts without depression. yen-yi juo, md, mph, yas sanaiha, md, erik dutson, md, yijun chen, md; ucla introduction: anastomotic leak is one of the most morbid complications of roux-en-y gastric bypass (rygb), yet its risk factors are ill-defined due to the rarity of the complication. we aim to identify both patient-and operative-level risk factors for anastomotic leak after rygb using a national clinical database. methods: a retrospective cohort study was performed using the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) database. all adult patients who underwent laparoscopic or open rygb were included. multivariate logistic regression models were used to identify patient-and operative-level variables associated with development of anastomotic leakage. clinically relevant anastomotic leakage is defined as those that required readmission, intervention, or reoperation. introduction: hyperammonemia secondary to ornithine transcarbamylase (otc) deficiency is a rare and potentially lethal disorder. the prevalence of otc deficiency is reported to be : , to : , in the general population. otc deficiency has been reported in patients presenting with neurological symptoms after roux-en-y gastric bypass (rygb), and less than cases have been reported in the literature. the aims of this study are to examine the apparent incidence of this uncommon disorder in patients after bariatric surgery and to examine potential predictors of mortality. methods and procedures: this is a single center, retrospective study in a large, urban teaching hospital of postbariatric surgery patients who developed hyperammonemia from january to august . elevated plasma ammonia with an elevated urinary orotic acid level is accepted as consistent with a diagnosis of otc deficiency. all patients in our program are instructed on a post-operative diet containing grams/day of protein. descriptive and correlative statistics are calculated for all variables. results: between january and august , bariatric surgical procedures were performed at this single medical center. seven women with neurological symptoms had plasma ammonia levels above the upper limit of normal range. their average bmi is kg/m . two patients underwent vertical sleeve gastrectomy (vsg), underwent vsg with duodenal switch, and underwent rygb. all patients were hospitalized. the mean peak plasma ammonia level is umol/l (range: - ). the mean urinary orotic acid level is . mmol/mol creatinine (range: . - . ). there were patients with no orotic acid level checked, secondary to demise. no patient had clinical features or findings of progressive hepatic failure. there are four mortalities ( . %). serum folate and peak lactic acid levels are predictors of mortality with p-values of . and . respectively. the apparent incidence of otc deficiency is : in post-operative patients. conclusions: in our post-operative population, hyperammonemia results in a high mortality. its apparent incidence, secondary to otc deficiency, amongst bariatric surgery patients is higher than that reported in the general population. since otc deficiency is identified after multiple bariatric surgical procedures, further investigation will be important to examine potential mechanisms for its development which may include a genetic predisposition (possibly triggered by nutritional deficiencies), upper gut bacterial overgrowth (supported by elevated serum folate levels), or preexisting, subclinical hepatic dysfunction. introduction: the use of closed suction drains is associated with poor outcomes in many anastomotic operations and routine use is not recommended. in this context, intraoperative drain placement for primary bariatric surgery remains controversial. recent studies demonstrate that drains confer no benefit to patients; however, data are limited to descriptive single center experiences with low sample size. in order to characterize this practice gap, and implement evidence based recommendations, we sought to evaluate the use of closed suction drain and outcomes following primary bariatric cases using the mbsaqip registry. methods: we used data from the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) public use file for patients who underwent a non-revisional laparoscopic roux-en-y gastric bypass (rygb), laparoscopic sleeve gastrectomy (lsg), or laparoscopic adjustable gastric banding (lagb). we excluded patients with asa status greater than or conversion to an open procedure. we analyzed demographics, preoperative comorbidities, procedure type for patients who did and did not undergo drain placement. adjusted rates of postoperative complications and mortality were then compared based on receipt of postoperative drain placement. results: of the , included patients who underwent laparoscopic bariatric surgery, , ( . %) underwent intraoperative drain placement. drains were more often placed in patients who underwent lrygb, were older, had higher preoperative bmi, had higher preoperative asa status, and had more comorbid conditions. after patient level risk adjustment, there was no difference in rates of leaks requiring intervention ( . % versus . %, p= . ) or mortality ( . % versus . %, p= . ) for patients with and without drains. in patients who underwent drain placement, there were higher rates of transfusion ( . % versus . %, p. ), reoperations for bleeding ( . % versus . %, p= . ), all reoperations ( . % versus . %, p. ), and surgical site infections (ssi) ( . % versus . %, p. ). conclusion: our analysis demonstrates that nearly one quarter of all laparoscopic bariatric surgery patients undergo drain placement. we found that drain placement is more common in preoperatively higher risk patients and following higher complexity procedures as suggested by associated increased rates of transfusion and reoperations for bleeding. we found no benefit to drain placement in terms of interventions for clinically significant leaks or mortality. finally, patients who underwent drain placement were more likely to develop ssi suggesting routine placement is not without risk. although further prospective studies are warranted, our analysis demonstrates that drains have the potential for harm with minimal protective benefit for patients after primary bariatric surgery. sleeve gastrectomy ( % n= ) and laparoscopic roux-en-y gastric bypass ( % n= ) were the two types of surgeries done in our population. the risk of developing atrial fibrillation was calculated preoperatively and found a -fold higher risk in females and -fold greater risk in males when compared with the ideal risk for each category. at months follow-up the preoperative risk was . ± . % with an absolute risk reduction of . % corresponding to a relative risk reduction of . % with males having a more significant change at months follow-up. these findings and the electrocardiographic changes at months follow-up are better described in background: the sleeve gastrectomy (lsg) is the most popular procedure worldwide to treat obesity. among those that are obese, gerd has a prevalence of . percent. many surgeons do not perform lsg in these patients because only . percent of symptomatic patients showed resolution of gerd-like symptoms after concomitant sleeve gastrectomy with hiatal hernia repair. many surgeons perform the gastric bypass on gerd patients with hiatal hernias because they believe its superior for the resolution of gerd. when they do this they overlook the many long term complication associated with gastric bypass. also, many patients do not want the gastric bypass under any circumstances. surgeons need to be open to finding better way to reduce the high recurrent rates of gerd after lsg. materials and methods: this is a single institution, multi-surgeon, retrospective study involving morbidly obese patients in a prospectively kept data base from january of through july of . these patients all had gerd with preoperatively identified hiatal hernias on egd. all patients were dependent on anti-reflux medications. there were ( . %) males and ( . %) females. bmi ranged from to . hiatal hernias measured from cm to cm. all lsg patients received a primary crural closure, with or without gore bio a mesh placement, at least weeks prior to the sleeve gastrectomy. post-operatively, patients were interviewed for gerd symptomatology and anti-reflux medication dependency. results: of the patients, ( . %) patients had resolution of gerd-like symptoms and off all anti-reflux medications after the staged hiatal hernia repair and sleeve gastrectomy. patients ( . %) had improvement of gerd but still dependent on anti-reflux medication. patients ( . %) had no resolution or improvement of gerd. there was one post-operative complication of laryngospasm with pulmonary edema status post extubation. there were no mortalities in the series. conclusions: in this study, staged hiatal hernia repair, at least weeks prior to sleeve gastrectomy, doubled the published rate of gerd resolution from % to %. % showed improvement in symptoms at one year. this rate is comparable to gerd resolution after gastric bypass. this may be an alternative approach to hiatal hernias in the morbidly obese patient with gastroesophageal reflux disease who do not want a gastric bypass. background: bariatric surgery is a common procedure in general surgery. gastric bypass has been performed laparoscopically for over two decades and multiple techniques are described. the circular stapled anastomosis, one of the earliest methods for gastrojejunostomy, is performed in two ways: a transoral method to introduce the anvil and a transabdominal approach developed later. the former technique requires passing the anvil of the circular stapler through the mouth, down the esophagus, and into the gastric pouch. in the latter method, a gastrotomy is made, the anvil is introduced, and the gastrotomy is stapled off, creating the gastric pouch. this study aims to objectively compare the two methods of circular stapled gastrojejunostomy in terms of surgical site infection (ssi) rate. methods: a retrospective chart review of patients undergoing laparoscopic roux-en-y gastric bypass with one of two surgeons at a bariatric center of excellence in an academic hospital from january introduction: laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed procedure in the treatment of morbid obesity, but there is significant variability in its performance. from national database analysis, more restrictive sleeve construction, based on smaller bougie size, has not correlated with greater weight loss. we hypothesize that bougie size is not reflective of actual restriction, or that sleeve restriction does not correlate with weight loss. we performed qualitative and volumetric analysis of immediate post-sleeve contrast studies to determine the association of sleeve restriction with post-operative weight loss and complications. methods: between and , patients underwent immediate post-sleeve contrast studies. based on standardized vertebral body height assessment by preoperative chest radiograph, sleeve diameter at intervals (including the narrowest point) was measured in mm, and the volume above the narrowest point of the sleeve was calculated. sleeve shape was assumed as dual-tiered or simple truncated cone based on morphology. sleeve restriction, morphology and volumetric analysis were associated with clinical outcomes including complications, post-op symptoms, and weight loss at months. background: variability in surgical technique resulting in narrowing at the incisura angularis, twisting along the staple line, and retention of the gastric fundus has been implicated in increased gastroesophageal reflux disease (gerd) following laparoscopic sleeve gastrectomy (lsg). standardizing creation of the sleeve based on anatomic landmarks may help produce more consistent sleeve anatomy and improve outcomes. methods: a retrospective review of all patients undergoing lsg from january to november at a single institution specializing in bariatric surgery was performed (n= ). patients underwent either traditional lsg with use of a f suction bougie to guide creation of the sleeve (n = ) or anatomy-based sleeve gastrectomy (abs, n= ). abs was performed using a gastric clamp to maintain predetermined distances from key landmarks ( cm from gastroesophageal junction, cm from incisura angularis, cm from pylorus) during stapling. patient demographics, perioperative characteristics, and post-operative outcomes were compared using chi-square and student's t-tests as required. helicobacter pylori (hp) is prevalent in up to % of the population worldwide with increased rates observed in the bariatric population. bariatric surgery has seen a rapid expansion over the last years with the growing rates of severe obesity. higher hp rates are thought to be associated with increased rates of postoperative complications including increased marginal ulceration and leak rates. accordingly, some bariatric centers have adopted routine pre-operative screening and hp eradication programs. yet, while hp correlation with gastritis and malignancy has now been well defined, its impact on patients undergoing bariatric surgery remains unclear. background: the risk of developing a hiatal hernia in the obese population is . fold compared to patients with a bmi \ . most hiatal hernias after bariatric surgery are asymptomatic and when symptoms are present they may be difficult to differentiate from overeating or maladaptive eating habits. the aim of this study was to define the risk and symptoms associated with a hiatal hernia in the post-bariatric surgery cohort. methods: a retrospective review of prospectively collected data for patients who underwent laparoscopic hiatal hernia repair who previously had primary roux-en-y gastric bypass (rygb) or sleeve gastrectomy (sg). data collection spanned a five-year interval ( / - / ). preoperative and follow up data were collected from medical records and questionnaires in the clinic or by telephone. variables obtained include age, gender, psychiatric history, pre-index procedure bmi, pre-hiatal hernia repair bmi, post-hernia repair bmi, pre and post operative symptoms, and associated morbidity. all hiatal hernia repairs were done laparoscopically, with posterior cruroplasty after circumferential hiatal dissection. results: we identified patients with a symptomatic hiatal hernia who had previously (range: - years) underwent bariatric surgery. fourteen rygb patients presented at a mean of . years compared to sg patients who presented at a mean of . years after index procedure. diagnosis was by a combination of ugi ( %), ct scan ( %) and egd ( %). mean follow up was . months (range: - months). laparoscopic hiatal hernia repair was successfully performed in all patients with % mortality. dysphagia and regurgitative symptoms markedly improved in [ % of patients however, nausea, vomiting and abdominal pain were not changed in - % of patients ( figure) . conclusion: hiatal hernia following bariatric surgery is a rare but important cause of bloating manifested as nausea and vomiting, abdominal pain, regurgitation or reflux, and food intolerance or dysphagia (barf)-and should be further evaluated with imaging or endoscopy when present. laparoscopic repair of hiatal hernia is warranted and results in resolution of symptoms in the majority of symptomatic patients. mid-term outcomes of sleeve introduction: obese patients suffer from multiple organ comorbidities which contribute to a shortened lifespan. one of the effects of obesity is thought to be pseudotumor cerebri, which is secondary to increase in intracranial pressure (icp) in the absence of an obstruction. over the past two years, we have measured icp after insufflating with a laparoscopy device. we found that icp increases dramatically and it correlates with the amount of insufflation in the abdomen. over the years, there have been studies in obese patients and intra-abdominal pressure. these studies have shown that some obese patients have an intra-abdominal pressure of - mmhg. increasing intraabdominal pressure is thought to escalate intracranial pressure (icp). the objective of this pilot study was to observed change in icp after the raising intra-abdominal pressure. method: in this retrospective chart review preliminary study, pressure in each of the patients either normal pressure hydrocephalous or high pressure hydrocephalous receiving a ventricle shunt were measured by manometer. once the shunt was placed into the ventricle, we attached a manometer to measure the opening pressure. after we accessed the abdominal cavity using the standardoptiview technique, we created a pneumoperitoneum. after achieving an intraabominal pressure of mmhg, were measured the icp using the manometer. spss software version was used for data analysis. paired t-test was applied on icp before and after the procedure. introduction: postoperative bleeding represents an infrequent, yet serious complication after bariatric surgery. differences in the rate of postoperative bleeding reported for the two most common weight loss procedures-laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg)-are ostensibly confounded by patient and surgeon specific preoperative, intraoperative and postoperative factors, in particular, by the utilization of staple line reinforcement or oversewing. with this understanding, we aim to use a large national database to definitively characterize differences in bleeding rates between lsg and lrygb. conclusions: after appropriate risk-matching, lsg patients have a reduced likelihood of a postoperative bleeding event compared to those undergoing lrygb. this difference is likely more pronounced with intraoperative securing of the staple line via oversew, buttress or an alternative method. these findings from a large national database represent an important consideration for surgeons and patients alike when evaluating the appropriate bariatric operation. background: bariatric surgery has shown to be the most effective treatment, with documented improvement in obesity-related comorbidities. the type of health insurance coverage plays an important role in the access to bariatric surgery, but might also affect postoperative outcomes. the objective of this study is to determine whether there is a difference in outcomes based on the type of insurance months after bariatric surgery. methods: we retrospectively reviewed all the patients that underwent bariatric surgery at our institution from to . we divided the patients into two groups, based on the type of insurance, private (group one), and public (group two). we compared demographics and months outcomes between the groups, using t-test for continuous variables and chi-square for categorical variables. we also compared months estimated bmi loss between different private insurances using anova. introduction: bariatric surgeons are now performing primary and revisional procedures on the extremes of age. there is controversy surrounding the safety and effectiveness of bariatric surgery among older age groups compared to younger age groups. to address this knowledge gap, we designed a study assessing short-term bariatric surgery outcomes among various age groupings across a large national database. methods and procedures: de-identified patient data across from the mbsaqip registry was used. age groupings were organized into young, middle-aged, and older adults (in years) as follows: \ , - , and [ , respectively. the following -day outcomes were evaluated between all possible pairwise age groupings: mortality, surgical site infection (ssi), and readmission; logistic regression was used to compare outcomes between age groupings controlling for primary vs. revisional index operation, patient factors, and procedure factors. a p value of . was deemed statistically significant. results: a total of , patients were identified (age range: to [ ); % (n= , ) underwent primary bariatric operations while % (n= , ) underwent revisional cases. older adults had significantly worse outcomes than middle-aged and younger adults, respectively, for over comparisons across all outcomes; in contrast, younger adults had significantly worse outcomes than middle-aged adults for only comparisons across ssi and readmission. for primary bariatric cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the following categories: asa , laparoscopic sleeve gastrectomy (lsg), or laparoscopic roux-en-y gastric bypass (lrygb). for revisional cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the setting of female gender, caucasian race, or asa . regarding ssi, older adults undergoing primary lrygb had significantly higher organ space infections compared to younger adults. in addition, older adults who had revisional lrygb had significantly higher deep surgical site infections compared to middle-aged adults. following primary bariatric cases, older adults had significantly higher readmission rates compared to younger adults in the presence of male gender, caucasian race, asa , copd, or after lsg. following revisional cases, older adults had significantly higher readmission rates than middle-aged and younger adults, respectively, in the setting of pre-operative chronic steroid use. conclusions: overall, older adults had worse short-term outcomes compared to their younger counterparts following primary and revisional cases. further research is required to investigate these findings with the goal of targeting interventions to improve outcomes among bariatric surgical patients. background: the obesity epidemic in the united states has been accompanied by surge in bariatric surgery. nearly , bariatric procedures were performed in the us in , % of which involved roux-en-y gastric bypass (rnygb). while rnygb has proven an effective tool in combating obesity, it also alters a patient's anatomy in a way that makes traditional ercp a difficult, if not impossible option for interrogating the common bile duct. one way to approach the post-rnygb patient with obstructive jaundice is to access the peritoneal cavity via a laparoscopic/ robotic approach followed by direct cannulation of the gastric remnant with a laparoscopic port, allowing passage of an endoscope. the aim of this study was to evaluate our single center experience with minimally-invasive transgastric ercp (tg-ercp) from to . methods: we compiled a list of all patients who underwent laparoscopically or robotically assisted tg-ercp at our institution from - . we then examined patient demographics, procedural details, postoperative outcomes, and success rate, with success defined as cannulation of the ampulla, clearance of obstruction if present (stones/sludge/stenotic ampulla), and completion imaging of the biliary and pancreatic ducts. results: patients were included in the study. cases were performed robotically ( %), and laparoscopically ( %). ercp was successful in cases ( %). all unsuccessful attempts were aborted when the endoscopist was unable to pass the scope through a tight pylorus. median time of operation was minutes ( minutes if concomitant cholecystectomy was performed, minutes if not). median length of stay after operation was days (range - days). median estimated blood loss (ebl) was ml. post ercp pancreatitis occurred in patients ( . %), and was mild and self limited in all cases. patients had postoperative bleeding requiring transfusion. both of these had concomitant cholecystectomy. discussion: in patients with biliary obstruction and anatomy not suitable for traditional ercp, tg-ercp is a viable option. it can be performed with in a minimally invasive fashion (either laparoscopically or robotically) with a high success rate and low morbidity. as the population of patients who have undergone rnygb continues to grow, so does the likelihood of encountering one with obstructive jaundice. tg-ercp, therefore, should be thought of as an essential tool in the armamentarium of the general surgeon. introduction: primary palmar hyperhidrosis (ph) is a pathological condition of over perspiration caused by body produces an excessive amount of sweat. this disorder affects to decrease quality of life of patients. thoracoscopic sympathectomy is minimally invasive and an effective procedure to treat hyperhidrosis. different of level of sympathectomy has been debate for the best outcomes. many researchers studied about short term outcomes but no empirical research evidences long term outcomes of thoracoscopic sympathectomy in thailand. this study purposed to evaluate and compare the long term clinical outcomes between patients who underwent t and t thoracoscopic sympathectomy for ph with particular attention to patient satisfaction and quality of life. methods and procedures: sixty patients with ph underwent thoracoscopic sympathectomy. patients were divided into two groups by the level of thoracoscopic sympathectomy as t group and t group. they were investigated the improvement of sweating, compensatory sweating, satisfaction and quality of life. the long-term investigation was designed to examine clinical outcomes at before surgery, six months after surgery, year after surgery, years after surgery, and last follow up days were compared within group and between of t and t group. they were subjected to telephone interview using multiple questionnaires to investigate surgery outcomes, degree of satisfaction, and quality of life improvement. results: sixty patients responded to the telephone interview. patients demographic data and also recurrence rate of ph between t and t group was not significant different (p= . ). both groups improved severity of sweating without any statistical significant. but the t thoracoscopic sympathectomy led to significantly lower incidence of compensatory hyperhidrosis when compared with t group at back and trunk sites. the t group had higher overall satisfaction than t group with was not significantly different. long term result are followed after years. conclusions: there was no difference in decreasing severity of sweating between t and t level of thoracoscopic sympathectomy. both group equally archived patient satisfaction. but the t level of thoracoscopic significantly had lower severity of ch and better quality of life in long term period. introduction: acute pancreatitis due trauma is commonest cause of pseudocyst in pediatric age. due to limited literature available and under diagnosis by pediatricians, the true incidence of pseudocyst in - age group is not known. material and methods: retrospective analysis of pediatric age ( - years) patients who underwent laparoscopic cystogastrostomy at distric teaching hospital was done. patients data, presentation, investigations, opetation done and post operative course was studied. result: total of patients ( males & females) had mean age of . years, mean weight of kg. etiollogies included blunt abdominal trauma ( ), idiopathic ( ), gallstones ( ) . average cyst diameter was . cm. laparoscopic cystogastrostomy by transgastric approach was successfully possible in cases with no conversion. cystogastrostomy was performed using sutures in patients and ultrasonic energy device in patients. gastrotomy was closed with sutures in all cases. mean operative time was minutes. post operative imaging at months revealed no persistence or recurrence of cyst. conclusion: minimally invasive laparoscopic approach for chronic pancreatic pseudocyst in pediatric age group is safe and effective strategy and should be adopted as primary modality of treatment. introduction: videoscopic neck surgery is developing despite the fact that only potential spaces exist in the neck. gagner first described the endoscopic subtotal parathyroidectomy with constant co gas insufflations for hyperparathyroidism in . the cervical approach utilizes small incisions in the neck thus making it cosmetically unacceptable and cannot be used for lesions greater than cm. the axillary approach makes it difficult to visualize the opposite lobe. the anterior chest wall approach utilizes port access at various positions on the anterior chest wall depending on the surgeon. this technique also allows bilateral neck exploration. hence we have been able to perform total thyroidectomies with central compartment clearance for papillary carcinoma and near-total thyroidectomies for large multinodular goiters, materials and methods: three incisions subplatysmal plane pneumoinsufflation with carbon dioxide (co ) ports creating a subplatysmal palne dissection begins at the inferior pole posterior dissection clipping superior thyroid vessels specimen freed up thyroid lobectomy was performed in the twenty cases. the average blood loss was ml mean operative time was min there were no complications and no cases were converted to open. there were no cases of recurrent laryngeal nerve injury or postoperative tetany. no subcutaneous emphysema, ecchymosis or hypercarbia was observed in any patient. all patients were discharged on the second postoperative day except the first on the fifth day. in conclusion this approach seems to be safe in case of unilateral lobectomy but early to say it is superior to conventional thyroidectomy especially in total thyroidectomy. introduction: laparoscopic sleeve gastrectomy (lsg) is one of the most commonly performed weight loss surgeries. prolonged hospital admissions are associated with both increased morbidity and mortality and increased strain on the health care system; studies are now investigating the safety and feasibility of outpatient lsg. this study examined a single surgeon's postoperative admission trends for patients who underwent lsg. the patients were divided into two cohorts based on the date of surgery, and we hypothesize institutional experience has a significant impact on postoperative stay and hospital readmission rate. methods: this is a retrospective study on lsgs performed by a single surgeon in a tertiary center from - . inclusion criteria: patients [ years old, bmi [ with comorbidities or bmi [ , and patient approval by the bariatric surgical program in victoria, british columbia. patients with prior weight-loss surgery were excluded. patients were discharged home on a care plan involving: nurse and surgeon telephone follow-ups within one week post-surgery. patients were divided into two cohorts: cohort a (procedures between - inclusive) and cohort b (procedures between - inclusive). results: patients were included in this study: females ( . %) and males ( . %). the mean preoperative age was . ± . years, and the mean preoperative bmi was . ± . kg/m . the average postoperative discharge day for the population was day . ± . and the average or time was . ± . minutes. one patient in cohort b was re-admitted pod with a diagnosis of postoperative edema managed conservatively and is included in the analysis as pod . a second patient in cohort b returned to hospital (pod ) for abdominal pain and was managed conservatively as outpatient. conclusion: there was a significant difference in the average postoperative discharge day between patients in cohort a and cohort b who underwent lsg with patients in cohort b requiring a shorter average admission time. this study suggests that with increasing institutional experience and a postoperative discharge plan, patients undergoing lsg may be discharged on postoperative day one safely. surg endosc ( ) introduction: minimally invasive techniques have revolutionized the art of the surgical practice. the laparoscopic approach to cholecystectomy has become the gold standard and is the most common laparoscopic general surgery procedure worldwide. in an effort to further enhance the advantages of laparoscopic surgery, even less invasive methods have been attempted, including smaller and fewer incisions. the objective of this study was describing our results of years of needlescopic cholecystectomy. methods: since march all patients that underwent to needlescopic cholecystectomy micro-laparoscopic procedure with instruments of mm were included in this study in a prospective database and the information was analyzed. results: between march and september , needlescopic cholecystectomies have been done at texas endosurgery institute in san antonio, texas by a single surgeon. % of the patients were female. the average age was . (range of - years old). average operating time was . minutes (range of - minutes). the minute operation required laparoscopic cbd exploration, accounting for the extended time. average estimated blood loss (ebl) was cc (range of - cc). % of cases required conversion to standard mm cholecystectomy and was completed without incidents. all patients were followed up at weeks, weeks, and months after the procedure. only patient presented with a hernia at the umbilical site. otherwise no wound, bile duct, bile leak, bleeding or thermal injury complications were identified. conclusions: micro-laparoscopic procedures with mm instruments in this specific procedure of needlescopic cholecystectomy is safe and feasible, and is a cosmetic alternative to the standard laparoscopic cholecystectomy. there's still less report about thyroid cancer cases in toetva. this study reviews all cases of thyroid cancer which surgery were performed. there were cases of toetva in thyroid cancer and cases of opened thyroidectomy. objective: to review and report in terms of surgical outcome, complication, post-surgical treatment and recurrence in all cases of thyroid cancer surgery, especially in toetva technique. material and methods: from march -july in police general hospital, a total of patients underwent toetva with cases of toetva in thyroid cancer and cases of opened thyroid surgery in thyroid cancer. all patients were recorded in multiple parameters. results: this study have total of thyroid cancer cases which cases ( %) were male and cases ( %) were female, with an average age of . most clinical presentation was thyroid mass or nodule which was at cases ( . %), case ( . %) was non-toxic goiter and case ( . %) was grave disease. the clinical presentation mean time was . years ( weeks- years). there were cases ( . %) with a mass at right lobe, cases ( . %) with a mass at left lobe, and cases ( . %) with mass at both lobes. the size of thyroid mass was . ± . centimeters ( - centimeters). there were cases ( . %) had euthyroid, case ( . %) had subclinical hyperthyroid, cases ( . %) had subclinical hypothyroid, and cases ( . %) had hyperthyroid. for type of surgery, there were cases ( . %) of toetva surgery and cases ( . %) of opened total thyroidectomy. most patients at cases ( . %) didn't have any post-operative complication. and there were hypothyroid cases ( . %), transient hypocalcemia with no symptom cases ( . %), and transient hoarseness cases ( . %). after toetva surgery performed, cases ( . %) were redo completion thyroidectomy, cases ( . %) were transaxillary completion thyroidectomy, cases ( . %) were redo toetva, and case ( . %) deny for reoperation. and cases ( %) didn't have any complication after redo surgery, cases ( . %) were hypothyroid, cases ( . %) were hypocalcemia and hypoparathyroid, and case ( . %) was transient hoarseness. after did thyroidectomy, ultrasound neck shown that cases had no residual or recurrence thyroid mass, cases had residual thyroid tissue. all cases received radioactive iodine ablation. radionuclide total body scan showed no evidence of distant functioning metastasis. conclusion: three-year short-term followed up toetva in thyroid cancer has shown less complication and no recurrence cancer. objective of the study: sentinel node navigation surgery (snns) in gastric cancer has been investigated for almost two decades in an effort to reduce operative morbidity. indocyanine green (icg) with enhanced infrared visualization is one technique with increasing evidence for clinical use. we are the first to systematically review and perform metaanalysis to assess the diagnostic utility of icg and infrared electronic endoscopy (iree) or near infrared fluorescent imaging (nifi) for snns exclusively in gastric cancer. methods and procedures: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using search terms "gastric/stomach" and "tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy" and "indocyanine green" was completed in may . all human, english language randomized control trials, non-randomized studies, and case series were evaluated. articles were selected by two independent reviewers based on the following major inclusion criteria: ( ) diagnostic accuracy study design; ( ) indocyanine green was injected at tumor site; ( ) iree or nifi was used for intraoperative visualization. the primary outcomes of interest were identification rate, sensitivity and specificity. titles or abstracts were screened after removing duplicates. the quality of all included studies was assessed using the quality assessment of diagnostic accuracy studies- . results: ten full text studies were selected for meta-analysis. a total of patients were identified with the majority of patients possessing t tumors ( . %). pooled identification rate, diagnostic odds ratio, sensitivity and specificity was . ( . - . ), . ( . - ), . ( . - . ) and . ( . - . ) respectively. the summary receiver operator characteristic for icg+iree/nifi demonstrated a test accuracy of . %. subgroup analysis found improved test performance for studies with low risk quadas- scores, studies published after and submucosal icg injection. iree had improved diagnostic odds ratio, sensitivity and identification rate compared to nifi. heterogeneity among studies ranged from low (i \ %) to high (i [ %). conclusions: the idea of snns in gastric cancer is intriguing because of the potential to limit operative morbidity. we found encouraging results regarding the accuracy, diagnostic odds ratio and specificity of the test. the sensitivity was not optimal but may be improved by a carefully planned and strict protocol to augment the technique. given the limited number and heterogeneity of studies, our results must be viewed with caution. objective: to evaluate the feasibility, cost effectiveness and safety of single incision laparoscopic surgery using routine laparoscopy instruments. method: cases of acute appendicitis and cases of symptomatic gallstone disease were included in study. cases were enrolled in study and prospective observational study was performed. ruptured appendicitis/abscess formation were excluded from study. similarly empyema gallbladder/gallbladder perforation were also excluded. results: total cases included; cases of appendicitis and cases of symptomatic cholelithiasis. mean age of appendectomy group was . ± . years and mean age of cholecystectomy group was . ± . years. in our study, mean operative time for sil appendectomy was . ± . min. post-operative fever was noted in cases ( . %). mean post-operative pain as per vas score taken after hours, on pod was . . average post op stay in hospital was . days, port site infection occurred in one case ( . %). patient satisfaction score obtained on the scale of - on one month follow up was . , while scar cosmesis score was . . in our study, cases underwent sil cholecystectomy, of which were male ( . %) and were females ( . %), and mean age of patients was . yrs. mean operative time in our study was . min, mean post-operative pain taken on pod as per vas score was . , mean post-operative hospital stay was . days, port site infections occurred in cases. post-op fever was noted in cases, post-operative patient satisfaction score obtained at month follow up was . and scar score of . on the scale of - . no case required drain placement and conversion. conclusion: sils can be performed using conventional laparoscopic instruments especially in a government setup where per capita economic burden to patient will be less. though it has more operative time, it has comparably less post-operative hospital stay, causes less pain, and has significantly more patient satisfaction regarding post-operative scar and cosmesis. since sils has more patient acceptance and satisfaction, it can be offered to all patients undergoing laparoscopic surgery. it is very useful in government setup where lower economic class of patients will also benefit, irrespective of unavailability of special instruments and financial constraints, as it can be performed using routine laparoscopic instruments. in the year we started to practice the pericardic window by laparoscopy to diagnostic of head injury hidden in precausal trauma, although lucketally for our society, this type of injury has decreased considerably, we have achieved an important number of patients and in the last year we have performed the procedure for another type of pathologies and also diversified the approach route according to the case. objective: sharing accumulated experience in years in the pericardic window practice by laparoscopy or thoracoscopy. material and methods description of cases results: during this period, we have accomplished cases of laparoscopic pericardal window with two unique ports for the diagnosis of head injury in trauma precordial, additionally there were practiced windows through traumatic trauma of which have been derived in treatment of cardiac injury on this way, without performing open approach. in another scenario, we have performed pericardial spill treatments for different causes by minimally invasive via. no complication or mortality associated with the procedure has been presented. conclusions: the pericardic window performed by a minimally invasive surgery is an effective, replicable strategy for the management of diagnosis and the medical and traumatic treatment of this pathology. patient selection is key and work in multidisciplinary groups guarantees good results. introduction: for the transabdominal preperitoneal repair (tapp) for groin hernia, single port surgery (sps) has been reported to reduce the abdominal wall damages. to reduce the length of the umbilical scar and to keep the view of triangulation, we use one needle forceps plus sps. patients and methods: from may to july , consecutive tapp patients were retrospectively investigated. there were male and female. we use two mm ports ( for the scope and for the operator's right hand forceps) through an umbilical multi-channel port and additional mm needle instrument is pierced above the pubic bone. a mm flexible scope allowed us to keep the triangular formation easily. we studied the safety and usefulness of this method from the viewpoints of operation time and the complications. results: median operation time of single side hernia ( cases) was min ( - ) and the bilateral case ( cases) was min ( - ). five cases needed one or two additional mm ports, and one case with severe preperitoneal adhesion due to the previous prostate cancer surgery was converted to open method because of the venous bleeding. other complications were spermatic cord injury and postoperative seroma that required the percutaneous puncture. umbilical scars and the pierced needle instrument scars became gradually invisible within or months. there were no incisional hernia nor wound infections in our series. these data was comparable to the conventional laparoscopic hernia repairs. conclusions: operation scars of this method had better cosmesis than the conventional tapp or sps tapp, and there were no differences between our sps-tapp with one needle foerceps and conventional method in operation time and the complication rate. our method was demonstrated as a less invasive approach for laparoscopic groin hernia repair. clinical application: fj clip is a stainless steel that can be used to hold organs in the abdominal cavity. it is available in two sizes: mm and mm. the device is short, it has a strong grasp, and it causes no or only negligible organ damage. we have used fj clip in the performance of local gastric excision (n= ), colectomy (n= ), and cholecystectomy (n= ) with no resulting difficulty. f loop plus is a g stainless steel loop-like device into which we can insert φ . mm nt alloy thread, which we draw out extracorporeally via simple puncture. laparoscopic total and proximal gastrectomy. we made a small incision at the umbilicus and inserted a -mm camera port and -mm metal cannula. we placed two (left and right) epigastric ports. retraction of the left hepatic lobe was easy with use of the -mm fj clip and a -mm penrose drain. for # lymph node dissection, we used the fj clip to grasp the upper part of the stomach, inserted the f loop plus from the upper right abdomen. for # dissection, we grasped the pyloric vestibule and pulled it leftward. for dissection of the upper edge of the pancreas, we grasped the left gastric arteriovenous pedicle and pulled it toward the abdomen. the fj clip's grasp and traction exerted on the stomach wall were strong and effective, and there was little organ damage. reconstruction (roux-y) or double tract were performed within the abdominal cavity by hand-sewn purse string suture of the esophageal stump, insertion of an anvil, and use of an automated anastomosis device. we have experienced total and proximally cases to date, but there have been no complications, and both intraoperative bleeding and operation time were within normal limits. conclusion: we believe the fj clip and f loop plus will replace conventional forceps for various tasks in reduced port gastrectomy. introduction: pulmonary anatomical resection is considered as standard treatment for early staged lung cancer. uniportal video-assisted thoracoscopic surgery (uvats) has recently showed favorable surgical outcomes, but remains technically demanding, especially in a complex procedure such as anatomic segmentectomy. needlescopic instruments facilitates complex laparoscopic surgeries with nearly painless and scarless postoperative outcomes, however, its utilization of thoracoscopic surgery were mostly for minor procedures such as bullectomy and sympathectomy. we presented our initial experience of lung cancer surgery performed by uniportal vats and additional needlescopic instruments, and we also compare the operative results with conventional uniportal vats. methods: from december to august , consecutive patients with lung cancer undergoing anatomical lung resections including lobectomies and segmentectomies were reviewed retrospectively. of these patients, patients received conventional uniportal vats (uvats), and patients received needlescopic-assisted uniportal vats (na-uvats). we compared the peri-and post-operative outcomes in these groups. results: there was no significant difference in demographic, anesthetic, or operative characteristics in two groups except for age. the mean operation time was statistically less in the na-uvats group ( . ± . min vs . ± . min, p= . ). the intraoperative blood loss was significantly less in the na-uvats group ( . ± . ml vs . ± . ml, p= . ). there were two major pulmonary arterial bleeding events and one conversion to thoracotomy in the uvats group. the hospital stay, duration of chest tube drainage and post-operative pain scale were comparative in the two groups. conclusion: under the assistance of additional needlescopic instruments, uniportal vats can be performed more efficiently and safely without compromising its benefit in less postoperative pain and early recovery. purpose: we applicated the v-loc into abdominal wall closure in single incision laparoscopic appendectomy (sila) from . the aim of our study is to present our experience of abdominal wall wound closure technique using barbed suture in sila and comparision of perioperative outcomes with conventional method of layer by layer abdominal wall closure after sila. methods: from august to june , sila was performed on patients with acute appendicitis at the department of surgery, hallym sacred heart hospital. under approval of institutional review board, data concerning demographic characteristics, operative outcomes, postoperative complications were compared between both v-loc closure group and conventional layer by layer closure procedures. in v-loc closure group, after removing the appendix, divided linear alba was closed using unidirectional absorbable barbed suture v-loc - with continous running fashon. begins at the end of incision, and coming back with reinforced running. subcutaneous closure was also done using same thread, and the subcuticular suture along incision line was performed with remaning portion of v-loc. results: the demographic data of patients's characteristics were similar between the two groups. the use of barbed suture significantly reduced the suturing time for abdominal wall closure (p= . ) compared with conventional suture. the postoperative incision length was significantly shorter in v-loc group than conventional group (p= . ). the rate of surgical site infection were similar in both group. no incisional hernia were noted in both group with median follow up periods of . months. the total costs of the procedure were comparable in both group under korean drg system. the use of barbed suture in abdominal wall closure in single port laparoscopic appendectomy is safe, and feasible method, reduces the suturing time, thereby decreasing the total operation time, and incision length with cosmetic effect. angela m kao, md, michael r arnold, md, julia e marx, paul d colavita, md, b todd heniford; carolinas medical center introduction: morgagni hernia is an anteromedial congenital diaphragmatic hernia seen in approximately in live births and rarely identified in adulthood. patients may be asymptomatic, have intermittent symptoms, or present acutely with incarceration/obstruction. given this, surgical repair is recommended, but a standardized technique has not yet been described. methods: a prospectively collected hernia-specific database was queried for all adult morgagni hernias performed at a tertiary hernia center. demographics and peri-operative data were compared. ( ) repair. the most common ( . %) method of repair included suturing mesh to the diaphragmatic portion of the defect and securing the anterior-inferior edge to anterior abdominal wall with transfascial sutures and/or tacks. four patients ( . %) underwent primary repair. average defect and mesh size was . cm and . cm , respectively. three patients ( %) underwent a concomitant paraesophageal hernia repair. mean ebl and length of stay was ml (range - ml) and . days (range - days). postoperative morbidity included transient postoperative hypoxemia ( patients) and pleural effusion ( ) . there was no mortality, mesh complications or recurrences with a mean follow-up of months. conclusions: morgagni hernias patients were more often older, obese, and women. these hernias remained unrepaired in % of patients despite their having had previous abdominal surgery. a laparoscopic or robotic approach offers an effective hernia repair with minimal complications, short hospital stay, and excellent long-term results for both elective and acute operations. mesh repair, sutured to the diaphragm and sutured/tacked to the abdominal wall, appears to be a very successful means to repair larger defects. introduction: hydatidosis is a zoonotic disease caused by echinococcus granulosus. it is endemic in the mediterranean, south america and middle east. it is a systemic disease wherein lungs are the second most common organ involved, after liver. radio-imaging plays an important role in diagnosing and determining the extent of the disease. surgical enucleation of cyst has been the classical treatment for this disease. bilateral lung involvement has been traditionally treated by median sternotomy or a bilateral thoracotomy. video assisted thoracoscopic surgery (vats) is an effective surgical approach in such settings. materials and methods: at our center, we have operated cases of pulmonary hydatidosis thoracoscopically over the past years. in all cases, area around the cyst was cordoned off with . % cetrimide soaked gauze pieces. a pericystotomy is performed with ultrasonic shears & the germinal membrane is delivered en masse into an endo-bag. an air leak test after saline instillation into the cavity, is a standard part of the procedure. for those cases with cysto-bronchiolar communications, the defect was sealed by either suturing or glue application. traditionally, bilateral cases & cysts larger than cm in size were tackled by an open approach. but, in our experience, cyst size, bilaterality & presence of complications are not contraindications for vats. all cases are administered perioperative albendazole ( mg twice a day, administered for three cycles of days each, with a gap of days in between) which helps in preventing recurrence and also takes care of any inadvertent intra-operative spillage. introduction: minimally invasive surgery (mis) is the standard approach for most of the surgical procedures performed by general surgeons. traditionally the majority of operations for trauma are performed open due to the complexity of the cases, however, trauma surgeons are expanding their armamentarium to include mis in a variety of acute procedures. we report our experience with the application of laparoscopy in a variety of trauma cases. methods: a retrospective review of trauma cases performed between / - / . during that time laparoscopic cases were performed after traumatic injury. patient demographics, injury severity (iss), injury mechanisms, the types of procedures and outcomes will be described. means and standard deviations were calculated and t test were performed. a p value of . was statistically significant. results: demographics-a total of trauma cases were performed laparoscopically during the study period. the majority were male, n= and the age was sd . obesity was documented in %, hypertension or cad was in %, and substance abuse was in %. blunt trauma was in % and penetrating %. the iss was sd . surgical procedures-the majority, %, of the procedures were completed laparoscopically. non-therapeutic laparoscopy was performed in %. repair of diaphragmatic or traumatic abdominal wall hernias were %. hematoma evacuation and control of bleeding was %. control of solid organ bleeding and repair was performed in %. intestinal repair occurred in %. for the cases that required open conversion iss was sd vs. laparoscopic cases iss was sd , p= . . outcomes: the overall length of stay was days sd . there was n= late death in a poly-trauma patient that required open conversion for complex solid organ and intestinal injuries. there was n= case of a community acquired pneumonia, and n= case of a recurrent pneumothorax. conclusions: a descriptive series of trauma operations approached with mis techniques is described. this cohort had high injury severity and a predominance of comorbid conditions. laparoscopy was successfully applied in the majority of cases for a variety of therapeutic procedures and mortality and morbidity was low. mis is safe and is gaining momentum for application in traumatic injury. objectives: laparoscopic distal gastrectomy for early gastric cancer is a standard treatment in japan described in guidelines. the surgical procedure has been shifting from laparoscopic assisted to complete laparoscopic surgery. in this study, we evaluated the outcomes and safety of the laparoscopic assisted distal gastrectomy. methods: for the marking of the oral side transecting line, the clipping at oral side of cancer lesion was performed by gastro-endoscopy before surgery. the lymph node dissection (d +/d ) is performed laparoscopically. as the dissection of the pancreatic superior region, the assistant hold the left gastric artery and keep the good view by retracting the pancreas. the common hepatic artery and proximal side of splenic artery are exposed. both sides of the left gastric artery and vein are exposed. left gastric vein and left gastric artery are cut after clipping and sealing. lymph node dissention of hepato-duodenal ligament is done and right gastric artery is cut after clipping and sealing. minor curvature of upper gastric wall is exposed (no , dissection). billroth i reconstruction by the circular stapler (cdh) is performed. through the upper median incision with cm, operator pulls out the stomach and transects the oral side of stomach with linear stapler after palpating the clips. duodenum is transected after purse string suture. gastroduodenal anastomosis is performed by cdh. results: two hundred cases were analyzed. the operation time, blood loss and the conversion to open surgery rate were minutes, ml, and . %, respectively. as postoperative complications, anastomotic failure, pancreatic fistula and postoperative bleeding were %, . % and %, respectively. the reoperation rate was %. one surgical death due to cerebral infarction was experienced. there were no patients with ppm (pathological proximal margin) positive and too much pm distance. frequency of abdominal wall incisional hernia and ileus were % and %, respectively. conclusion: although there is the disadvantage that small laparotomy can be made in the upper abdomen, laparoscopic assisted distal gastrectomy with billroth i reconstruction in our procedure is enough good from the viewpoint of the precision of proximal margin, and the incidence of serious complications. introduction: minilaparoscopy (mini) is a modality of minimally invasive surgery that attempts to produce less surgical trauma to the abdominal wall by reducing the diameter of surgical instruments to mm. searching for better outcomes in inguinal hernia repair, surgeons have looked for new and less invasive alternatives such as single-incision surgery, single-port surgery and mini. minilaparoscopic transabdominal preperitoneal hernia repair (mini-tapp) demonstrates some of the known advantages of mini general surgery procedures such as enhanced visualization, improved dexterity and great cosmetic outcome. it is safe and reproducible since it does not differ from standard laparoscopy. introduction: the celiac plexus is a structure located in the retroperitoneum, at the level of the lumbar vertebra, which is located in the prevertebral region and has sympathetic fibers. patients with advanced gastrointestinal cancer and associated pain, one of the management strategies is pain control. neurolysis of the celiac pleural by laparoscopy was first reported in humans in in patients with advanced pancreatic adenocarcinoma with excellent results. experience will be shown in the simplification of the technique for the procedure. method: neurolysis of the celiac pleura was performed in patients with advanced gastrointestinal cancer, stomach %, pancreas % liver % other %, no complications associated with the procedure, pain improvement was achieved in % of patients after process. the standardization of the technique by laparoscopy and its simplification, has made this procedure that is replicable and safe. description of the technique: patient in french position, technique of trocars, umbilical trocar mm and trocars of mm paraumbilical, staging laparoscopy is performed and sampling if necessary, is identified in the region of the lowercurvature of the stomach, the celiac trunk and the emergence of the left gastric artery are identified and cc of % alcohol diluted to the medium in the lateral fatty bearing are instilled through a pericranial under direct vision, verifying the non-arterial instillation of the alcohol. there were no complications related to the procedure. results: we report the experience of one group who underwent celiac pleura neurolysis in patients with advanced gastrointestinal cancer, gastric cancer %, pancreatic cancer %, liver cancer % and another %. the most frequent pathology report was adenocarcinoma, % of the patients were managed at hours with sustained effects, up to months of follow-up. with a significant decrease in pain medication. only patient required new laparoscopic neurolysis because of difficult-to-manage pain. the operative time of this procedure was minutes. the standardization of the technique, the use of low cost inputs, makes this type of procedure easily replicable with goodresults in pain management in cancerpatients. conclusions: mis is offered as one of the fundamental tools for the management of palliative procedures in gastrointestinal cancer. neurolysis of the celiac pleura with standardization of the technique, use of low cost elements, and the surgeon's skills make this procedure an option of management and control of pain in patients with advanced gastrointestinal cancer, is easily replicable, economical and insurance. background: the non-absorbable polymer clip offers a solution to the disadvantage of traditional metallic clip. due to its metallic property, it is not only expensive but also causes artifacts on imaging studies and often migrates into cbd. this study compares the traditional standard metallic clip with hem-o-lock used in laparoscopic cholecystectomy (lc) in regard of the safety and efficacy?. material and methods: this study includes patients who underwent lc implementing metallic clip (mc) and patients implementing hem-o-lock clips (h )?. both clips were applied to cystic duct and artery, then the gallbladder was dissected from the liver bed by diathermy. the intraoperative and postoperative parameters were collected including duration of the operation and complications?. results: the median operative time was not statistically different between the mc and the hc group ( . vs . minutes, respectively; p= . ) with no significantly less incidence of bile spillage ( vs. , p= . ) . no statistically significant difference was found in the incidence of postoperative complications between both groups ( vs. , p= . ). no postoperative bile leakage was encountered in both groups. conclusion: hem-o-lock clip provides a complete hemobiliary stasis and a secure cystic duct and artery control. its cost effectiveness is also attractive while provides efficacy equivalent to that of the standard metallic clip. introduction: most of the blunt thoracoabdominal injury patients always have multiple organ injuries. plan of definite treatment depends on the preoperative diagnosis. in isolating diaphragmatic traumatic injury without others organ injury laparoscopic approach is helpful, decrease a length of hospital stay as well as decrease a wound complication. authors describe the laparoscopic treatment of the patient who had rupture of a diaphragm from blunt trauma in an emergency setting. methods and procedures: a years old man presented with motor vehicle accident and mechanism of injury was blunt thoracoabdominal injury. he complains about chest tightness and tachycardia. complete evaluation and ct scan ware performed. stomach was herniated to the left chest and diaphragmatic ruptured was found neither others great vessels nor solid organs injury. the laparoscopic approach was desired and left diaphragm was repair by non-absorbable sutured without intraoperative complication. results: the patient has been discharged days post-operative with full recovery. chest x-ray was taken before discharge, in out-patient department weeks as well as months after discharge which shown no diaphragmatic herniation. conclusion(s): laparoscopic approach in isolated traumatic ruptured diaphragm patients is safe and should be considered. short-term outcome of laparoscopy-assisted distal gastrectomy with roux-en-y reconstruction through mini-laparotomy for gastric cancer since , we have introduced laparoscopy-assisted distal gastrectomy (ladg) with b-i reconstruction through mini-laparotomy. regarding to reconstruction, roux-en y reconstruction are also one of the choice in ladg, however, the technical feasibility has not been well documented so far. the purpose of this study was to compare the short-term outcome of ladg with roux-en-y reconstruction through mini-laparotomy compared to that of ladg with b-i anastomosis. between and , patients who underwent ladg for gastric cancer in oita university were enrolled in this retrospective study. since , the roux-en-y reconstruction has been performed as a standard method in our department. these patients were divided two groups based on anatstomosis; roux-en-y (r-y) group (n= ) and billroth i (b-i) group (n= ). baseline characteristics, operative results (including complications) and pathological results were evaluated. there were a considerably greater number of patients with advanced clinical stage and having ≥t invasion in the r-y group. estimated blood loss was lower in r-y than in b-i (p. ) and operative time was longer in r-y than in b-i (p. ). there were no significant differences in all grade intra-operative complications (p= . ). in addition, there were no significant differences in all grade post-operative complications between the two groups except internal hernia. hospital mortality was % in each group. ladg with r-y reconstruction through mini-laparotomy was technically feasible as well as ladg with b-i anastomosis. utilization of laparoscopy associated with blunt abdominal trauma: the nationwide inpatient sample - kenneth w bueltmann , marek rudnicki ; advocate illinois masonic medical center, chicago, il, university of illinois introduction: the incidence of trauma and its heavy burden upon the healthcare system remain strong. paradigm shifts in the management of these cases has, however, improved the mortality in such cases. it can be expected that improvements in management, when combined with the benefits of laparoscopy, will demonstrate positive impacts upon treatment outcomes. methods: the nationwide inpatient sample was referenced for inpatient stays for the years to . abdominal trauma cases were selected and identified as hollow (ho) or solid organ (so) type, and as blunt or penetrating. the trauma subset was then scanned for the presence of discrete laparoscopic procedures, laparotomy, and converted cases, and flagged accordingly. conclusion: utilization of laparoscopy in treatment of intraabdominal solid and hollow organs injury increases over time. although current analysis based on available hcup nis data include any procedures done during post-traumatic hospitalization, its results can lead to conclusion that minimally invasive technique is being utilized in increased fashion. introduction: single incision laparoscopic (sil) surgery is a laparoscopic procedure which leaves a single small incision in navel, and has been reported to be less invasive than and as safe and efficient as the conventional multiport laparoscopic (mpl) surgery. the long-term rate of incisional hernia after sils colectomy is unknown, and the risk factors of incisional hernia formation is not fully elucidated. methods and procedures: this is a retrospective from a prospectively collected database. the investigation took place in a high-volume multidisciplinary tertiary private hospital in japan. introduction: laparoscopic approach in the acute surgical care setting continues to be underutilized. we aim to report the successful diagnostic and therapeutic use of laparoscopy in the management of a nontoxic patient presenting with acute abdomen and to highlight the benefits of a minimally invasive approach without added morbidity. case report: presented is a -year-old male with history of cad s/p cabgx two years prior and no abdominal surgical history who presented to the ed with sudden onset severe, diffuse, abdominal pain of six-hour duration with n/v. there was no trauma to the abdomen. he had mildmoderate hypertension, but was otherwise hemodynamically stable. on examination, the patient was in severe distress and writhing in pain. fast exam was unable to be performed secondary to pain. cta of the abdomen revealed mesenteric abnormalities with associated small bowel edema in the rlq suspicious for small bowel ischemia. he was taken to the or for diagnostic laparoscopy. he was found to have an omental adhesive band to the abdominal wall with herniation of the small bowel through the small opening. approximately cm of ischemic, nonviable small bowel was resected and anastomosed intracorporeally. he tolerated the procedure well and was discharged home on post-operative day . discussion: primary omental related internal herniation of small bowel is exceedingly rare. there have been only few cases reported in the literature ( , , , ) . two were diagnosed on exploratory laparotomy, one on diagnostic laparoscopy and one at autopsy. the one who underwent diagnostic laparoscopy did not require bowel resection. in presenting this case, we hope to illustrate the role of laparoscopy in the management of acute abdominal pain due to bowel compromise. introduction: morgagni hernias are a rare finding in the adult population, and represent - % of all congenital diaphragmatic hernias. multiple approaches to these rare hernias have been described in the literature. here we present a novel technique of laparoscopic trans-abdominal repair using a combination of the endo-close device (medtronic, minneapolis, mn) and the ti-knot (lsi solutions, victor, ny.) methods: in a patient with a large left anterior diaphragmatic defect we performed trans-abdominal suturing utilizing the endo-close to perform primary closure of the defect, using the ti-knot to secure the pledged sutures along the anterior fascia. due to the size of the defect ( cm) this primary repair was buttressed with polyester mesh. in a second patient with a smaller ( cm) classic right-sided anterior diaphragmatic defect we similarly performed laparoscopic trans-abdominal suturing using the endo-close to traverse both the anterior and posterior fascia and the ti-knot to secure the sutures in order to perform a primary repair of the hernia. both patients presented had an uneventful postoperative course and no indication of recurrence at months. conclusions: morgagni hernias present unique technical challenges. in our experience the combined use of trans-abdominal suture with laparoscopic knot replacement device allowed for completion of both cases laparoscopically with minimal tension on the repairs. feasibility of concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis: first case report worldwide ibrahim a salama, md, phd; department of hepatobiliary surgery, national liver institute, menoufia university introduction: situs inversus totalis is a rare anomaly characterized by transposition of organs to the opposite site of the body. combined laparoscopic splenectomy and cholecystectomy in those patients is technically more demanding and needs reorientation of visual-motor skills. presentation of case: herein, we report a year old girl presented with yellowish discoloration and left hypochondrium and epigastric pain diagnosed as hereditary spherocytosis (hs). the patient had not been diagnosed as situs inversus totalis before. the patient exhibit a left sided "murphy's sign" and spleen palpable in right hypochondruim. diagnosis of situs inversus totalis was confirmed with ultrasound, computerized tomography (ct) and magnetic resonant image (mri) with enlarged right sided spleen and presence of multiplegall bladder stones with no intra or extrabiliary duct dilatation. the patient underwent combined laparoscopic splenectomy and cholecystectomy as treatment of hereditary spherocytosis (hs). discussion: feasibility and technical difficulty in diagnosis and treatment of such case pose challenge problem due to the contra lateral disposition of the viscera. difficulty is the laparoscopic technique encountered in skelatonizing the structures in calot's triangle, which consume extra time than normally located gall bladder with right sided standing surgeon and the position changed to left sided standing surgeon during splenectomy. in review up to date medical literature this is the first case reported worldwide. conclusion: provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder disease as in hereditary spherocytosis (hs) as changes in anatomical disposition of organ not only influence the localization of symptoms and signs arising from a diseased organ but also imposes special demands on the diagnosis and surgical skills of the surgeon. objective: to identify the preference among medical students of the following surgical approaches: open surgery, conventional laparoscopy, minilaparoscopy (mini), single incision laparoscopic surgery (sils), natural orifice transluminal endoscopic surgery (notes), and robotic surgery. methods: an online google questionnaire was filled by medical students of different years in medical school. before answering the questionnaire, they watched an online video showing the different techniques, its advantages and disadvantages. the questionnaire consisted of questions about the hypothetical situation where the participants were going to be submitted to an elective cholecystectomy and they could decide which technique they would prefer. all statistical analysis was performed using the r software program, version . . . the chi-squared test was performed for categorical variables where appropriate. a p value . was statistically significant. results: one hundred and eleven medical students answered the survey. ( . %) were female and men. most of the students were between to years old ( . %). they were in the first four years of medical school. when asked if they would consider notes or single incision even if they know that they are new procedures and with not completely established security standards, . % ( ) answered that they wouldn´t consider with no difference between gender (p= . ). when asked if only conventional laparoscopy, robotics or mini were offered, which one they would choose: % of women and . % men chose mini first (p= . ). about the factors that they would consider the most important when choosing the surgical technique, they answered safety first ( . %), followed by the surgeon´s experience with the procedure ( . %), with no statistically significant result between genders (p= . ). when asked if they would consider an open technique even with the other techniques available and compared according to their year in medical school, students closer to finishing medical school would not consider it, with a statistically significant result (p= . ). regarding the most important factors they would consider and compared by year in medical school, safety and experience of the surgeon performed best, with a statistically significant result (p. ). conclusion: among the available surgical approaches, minilaparoscopy tends to be the preference among women medical students who considered safety the most important aspect. the closer they get to the end to medical school, the less they consider the open technique. background: extension of the single incision for the purpose of specimen removal in singleincision plus one additional port laparoscopic surgery (sils+ ) can undermine the merits of sils + , either by increasing wound-related morbidity or by destroying cosmesis. methods: we retrospectively analyzed the clinical outcomes of patients underwent elective sils + anterior resection, either with transanal specimen extraction (tase, n= ) or transumbilical specimen extraction (tuse, n= ), for colorectal cancer from january to june . this study included patients with a tumor diameter less than cm, measured by preoperative computer tomography. results: both groups were similar in patient's basic information and oncologic condition. most surgical data and postoperative clinical variables were comparable between tase and tuse group, except for increasing operative time in tase ( . + . vs. ± . min, p= . ) and reducing wound complications in tase ( % vs . %, p= . ). dosage requirement of narcotic analgesics was not inferior in tase group compare to tuse group. no significant differences were observed in conversion rate, perioperative and overall morbidity between the two groups. conclusion: although sils+ with tase prolonged operative time compare to with tuse, implement of tase is expected to provide benefit of reduced wound-related morbidity in patients with a tumor diameter less than cm. medhat ibrahim, md; al-azhar university, naser city, cairo, egypt purpose: morgagni hernia (mh) is a rare condition. mh is less than % of surgically treated diaphragmatic hernias in infants. there is no specific symptom for the maorgagni hernia. open surgical repair was the golden stander before the introduction of the laparoscopic surgery in the children and infant. there are many different laparoscopic techniques for mh repair have been reported. i report laparoscopic repair of mh in five infants using primary sutures closure with inrta-corporeal knot tying and ethicon secure strap device. this study is an evaluation of the safety and efficacy of this new laparoscopic technique of mh repair in infants with it is short-term outcomes follow up. patients and methods: five infants with mhs underwent laparoscopic repair by hernia sac excision then two primary sutures, non-absorbable proline through the full thickness of the anterior abdominal wall and the posterior rim of the defect, intra corporeal sutures knot tying, ethicon secure strap device which was used to complete the colures of the defect. there was no insertion of chest tube or drain. results: five infants with mh were operated upon. there were males and female. all cases were left side mh, male-female ratio was : . intraoperative and postoperative analgesia requirement was minimal (paracetamole mg/kg/rectal suppository/ hours for the first hours). ceftriaxone mg/kg single dose at the anesthesia induction. all operations were completed laparoscopic. all infants started and tolerated oral regular feeding with in hours from surgery. none of the patients developed intraoperative or postoperative complications. the maximum follow-up was months (mean, months). all patients are in good health without recurrence or port site compilation. conclusion: this easy save technique of mh repair is reducing the operative time and postoperative hospital stay. it is minims the need of postoperative analgesia, anti biotic. the early oral feeding is also a good benefit. the introduction: transumbilical single port laparoscopic appendectomy (tspla) is the most popularized single port surgery in the world. it provides more cosmetic benefits than conventional laparoscopic surgery. however, single port appendectomy requires longer operation time and advanced surgical skills. we aimed to investigate the learning curve for tspla. material and methods: data were collected from patients who underwent tspla by single surgeon between march and february . the learning curve were analyzed using a cumulative sum control chart (cusum) for operation time and complication. results: a total of patients were included in this study. mean operation time is . ± . minutes. there was no open or multi-port conversion. based on cusum for operation time, learning curve were cases. conclusions: tspla is a safe and effective alternative procedure. the learning curve could be overcome safely without major complications. our results suggest that the cases are sufficient to achieve surgical skills for tspla. introduction: anastomotic leakage (al) is a life threatening complication after minimally invasive ivor lewis esophagectomy (tmie ile) and has diverse treatment strategies such as conservative treatment, endoscopic treatment and surgery. however, there is no consensus on which treatment strategy is best. the aim of this study was to analyse various therapeutic strategies for al and their outcomes. methods and procedures: this retrospective multicentre study was performed in three highvolume hospitals. all patients that developed al after tmie ile in the period of january -july were included. the different endoscopic (stenting, clipping and suction-drainage) and surgical treatments and their success-rate were described; success was defined as clinical improvement after primary treatment. primary endpoint was the time until oral feeding was resumed. secondary endpoints were hospital stay and the total amount of surgical, endoscopic and radiologic interventions. results: in total patients that developed al were identified; four patients received antibiotics only. in the remaining patient, endoscopic treatment was performed as primary treatment in %; % received primary surgical treatment. basic variables were similar in these groups. median postoperative day of diagnosis of al was day in the endoscopic-group and day in the surgical-group (p= . ). admission to the icu as a result of the leakage was necessary in % in the endoscopic-group versus % in the surgical-group (p. ). however, median icu-stay was significantly shorter in the endoscopic-group ( days versus days, p= . ). success-rate of the primary treatment was similar; % and % respectively (p= . ). primary and secondary endpoints were comparable for both the endoscopic-and surgical-group; median time until oral feeding was resumed was days and days respectively (p= . ), median total hospital stay days and days respectively (p= . ) and the median number of interventions was in both groups (p= . ). conclusion: endoscopic treatment appears to be a safe and efficient therapy for al after tmie ile. a patient-tailored approach based on the condition of the patient and the morphology of the leak can be adapted to avoid surgery in a selection of patients. this may prevent surgical reoperations and reduce icu admissions. background: lymph node (ln) dissection around recurrent laryngeal nerve (rln) is one of the most important and difficult procedure in esophageal cancer surgery because of high rate of ln metastasis and risk of rln palsy. especially around left rln, the surgical area is far and narrow by thoracic approach which tends to results in insufficient ln dissection. therefore, we tried to remove this ln by imaging lymphatic chain to dissect sufficient ln. surgical procedure: we perform thoracoscopic esophagectomy by semi-prone position using - mmhg thoracic air pressure. after dissection of right rln ln, middle and lower esophagus, encircle the esophagus at the level of bifurcation of bronchus and pull toward right side by tape to dissect the dorsal and left side of upper esophagus. dissect the tissue including left rln ln from trachea by pulling esophagus up to dorsal side and try to move this tissue toward dorsal side of left rln so that this rln ln tissue can recognize as the "lymphatic chain". to increase the mobility of esophagus, cut the esophagus at the level of aortic arch and pull further up this upper esophagus to dorsal side. cut the esophageal branch of rln and separate this lymphatic chain from rln. at the end of thoracic procedure, this lymphatic chain is attached to upper esophagus. after the upper esophagus has pulled out from cervical site, lymphatic chain can easily recognize at the esophageal wall. result: we performed this lymphatic chain procedure in cases. to evaluate this procedure, cases of conventional method by same prone positioned esophagectomy was used for control. there was no statistical difference between these two groups in amount of blood loss (lymphatic chain: conventional= ml: ml, p= . ), rate of rln palsy ( . %: . %, p= . ). although the thoracic operation time was extended in some degree ( min: min, p= . ), number of dissected ln was increased ( . : . , p= . ) and recurrence along left rln has been relatively fewer by this method ( . %: . % p= . ). conclusion: ln dissection around left rln would be easy and sufficient by imaging lymphatic chain. further improvement is needed to secure this procedure and further evaluation should be done to support this data. introduction: to evaluate the role of robotic assisted surgery as part of an appropriate patient work-up and treatment of ipmn and its consistency in terms of perioperative and long term results. few reports described singular minimally invasive procedures for ipmn. this study aims to describe a comprehensive, oncologically adequate treatment of ipmn in a minimally invasive unit with an extremely high robotic penetrance. methods and procedures: we retrospectively analyze our database of resected ipmn between and . this case series includes consecutive, unselected patients: all candidates with a preoperative diagnosis of ipmn were approached robotically. results: among robot assisted pancreatic resections, we identified patients with ipmn. one was excluded for having less than months follow-up, so patients were included and analyzed. they underwent duodenopancreatectomy in cases, distal pancreatectomy in cases and central pancratectomy in . all but one indications followed the most updated available guidelines (sendai from to and fukoka from to ; american gastroenterology association guidelines were used for comparison only). one patient was operated even if the guidelines were suggesting to follow up, because of a strong familiar cancer history. the final pathology for this patient was high grade dysplasia. in another patient we were inside fukoka's recommendations, but outside aga guidelines and the final pathology was adenoma in chronic pancreatitis. postoperative morbidity was . ( low grade complications, one grade a pancreatic fistula, now considered a biochemical leakage only) and mortality was zero. one conversions to open surgery occurred only: a dp in jehowah's witness with a bulky mass behind the portal vein. the mean follow up was months (range: - ), with only one loss to follow up after months for a high grade dysplasia. conclusion: in hepatobiliary pancreatic minimally invasive centers the treatment of ipmn can be grant following the same principles of major cancer centers, with comparable results. large unbiased studies are needed to evaluate if a minimally invasive approach could modify the ratio between operated and surveilled patients. reducing the use of catheters, tubes and imaging after hiatal hernia surgery significantly reduces length of hospital stay sophia s oswald, candice l wilshire, md, brian e louie, md, ralph w aye, md, alexander s farivar, md; swedish medical center introduction: historically, standard post-operative management of patients undergoing laparoscopic hiatal hernia surgery has been placement of a foley catheter and nasogastric tube (ngt) at the time of surgery with removal early on postoperative day (pod) one, at which time an upper-gastrointestinal series study (ugi) would be performed. we initiated a quality improvement project, seeking to assess if we could safely forego placement of foley and ngt along with the ugi, unless clinically indicated. our aim was to determine if this decreased overall length of stay (los), and how often and which demographic of patients needed placement of foley or ngt postoperatively. methods and procedures: we reviewed patients who had undergone laparoscopic hiatal hernia surgery between and under a single thoracic surgeon. patients were excluded for poor esophageal motility (peristalsis \ %), previous esophageal surgery, and presence of a paraesophageal hernia (peh) with over % of the stomach contained in the chest. eligible patients were further stratified into two groups: fast track and non-fast track. fast track was defined as patients who left the operating room (or) with no foley or ngt, and did not receive a routine ugi on pod one. non-fast track was defined as patients who left the or with a foley and ngt and received a routine ugi on pod one. los was measured in hours from the start of surgery to the time of discharge. results: of the patients included, were categorized as fast track and as non-fast track. the two groups were similar in terms of age, gender, bmi and asa; however, the fast track group had fewer paraesophageal hernias and shorter surgery times [table] . the hospital los, however, was significantly shorter in the fast track group, even though there were more postoperative urinary catheters utilized. no patients in fast track group needed an ngt placed or ugi ordered during initial stay. conclusion: in more straightforward laparoscopic hiatal hernia surgery, surgeons can safely forego ngt and foley placement, as well as ugi evaluation the following morning. these initiatives may translate to a quicker discharge from the ward, and may allow safe transition to performing these cases in hour ambulatory outpatient setting. further evaluation of additional interventions and patient education to decrease los are underway. the conclusion: laparoscopic surgery seems to be a safe and feasible option, with long-term benefit for primary tumor resection with metastatic colorectal cancer, but optimal treatment has yet to be defined. the canadian association of gastroenterology (cag) has implemented the colonoscopy skills improvement (csi) program across canada with a goal of improving colonoscopy quality. the programs' efficacy has not yet been formally assessed. this retrospective cohort study was performed on fourteen endoscopists practicing in a tertiary referral center who have undergone csi training between october and december . procedural data were collected before and after csi training. data were extracted from the electronic medical record (emr) and entered into spss version . for analysis. student's t-test was used to compare groups for continuous data; chi-squared tests were used for categorical data. data were collected for a total of procedures; were done before csi training and procedures since csi training. our sample size provided % power to detect a mean difference in adr improvement of %. the most common indication for colonoscopy was family history of colorectal cancer in ( . %) patients. while age ( . yrs v. . yrs, p. ) and gender ( . % male v. . % male, p= . ) were similar, they were statistically different between groups. groups were comparable in terms of indication, and completion rate ( . % v. . %). adr improved significantly after completing the course ( . % v. %, p. ). an improvement was also noted in both polyp detection ( . % v. . %, p. ) and polyp removal ( . % v. . %, p\ . ). we have seen a significant increase in adr at out institution since implementing the csi program. gastric stomach cancer is a rapid major cause of cancer-related death globally, have higher incidence in men and it is noticeable by its heterogeneity. a lot of studies have expressed out the molecular basis of this cancer, include pathogenesis, invasion and metastasis. the invention of new technologies has help to bring out several novel biomarkers that have diagnostic and prognostic value. therefore, this review centers on biomarkers for the early diagnosis, treatment and prognosis of gastric cancer, elaborate the clinical important of serum tumor markers in a patient with this cancer as well as checking the growths, prognosis together with epigenetic changes and genetic polymorphisms. a deep and rigorous search was carried out in pub med/medline using specific words; "gastric cancer", with "tumor marker". our search yielded important reports about related topic from books and articles that were published before the end of september . conclusively, scientists are utilizing time and resource to salvage this nemesis which is of global burden. classical and novel biomarkers are important for treatment as well as pre-post diagnosis of gc. major causes for this disease are cigarette smoking, infection by helicobacter pylori, atrophic gastritis, male sex, and high salt intake. the treatment of which early diagnoses is of important to the management, after pathological diagnoses by stage prognosis and metastatic setting, although the outcome proved not so good includes chemotherapy, and oral medication are oxaliplatin, capecitabine, cisplatin and -fluorouracil ( -fu). introduction: emergent appendectomy is the standard of care in usa based on tradition rooted in theory that delaying surgery allows for progression of disease and poorer outcomes. antibiotic treatment alone has been shown feasible in the treatment of uncomplicated appendicitis. in clinical practice surgical treatment can be delayed due to a multitude of medical and logistical reasons. this study evaluates the relation between timing of surgery to outcomes. methods and procedures: consecutive adult patients undergoing appendectomy in a teaching community hospital were risk stratified using the acs risk calculator. time from imaging to incision defined early and delayed groups. statistical analysis was used to determine association between risk level, timing of surgery and outcomes. results: % of patients in this study were considered high risk. average time to incision was . hours. shorter time to incision was associated with a statistically significant lower length of stay (p. ). for every hours in surgery delay, one day was added to the length of stay. no statistical difference was found between time to incision and other outcome variables of clinical complications, conversion to open appendectomy or frequency of complicated appendicitis. length of stay was longer than predicted by acs risk calculator in both high and low risk groups. a multidisciplinary, obesity-focused approach improves diagnosis of obesity-related illnesses: a new paradigm for the care of patients with obesity roderick olivas, aaron brown, md, racquel s bueno, md, cedric s lorenzo, md; university of hawaii -department of surgery introduction: patients suffering from the burden of obesity are at significant risk for medical problems that lead to premature death and disability. we hypothesize that a multidisciplinary bariatric team will be better equipped to recognize and diagnose these conditions. this study hopes to quantify that a patient focused approach leads to increased recognition of obesity-associated comorbidities, thus improving quality of care and surgical outcomes. methods and procedure: a retrospective medical chart review of patients who underwent bariatric surgery from / / to / / was performed comparing patient problem lists obtained from their primary care providers upon entry into the bariatric program, and the final problem list generated after evaluation by the program's multidisciplinary team. the total number and specific comorbidities identified before and after multidisciplinary team evaluation was analyzed with a paired t-test and manova, respectively. comparison of the number of comorbidities identified against specific patient demographics was conducted using paired t-test. results: a total of patient charts were selected and met inclusion criteria. the sample consisted of % women and % men; the mean age was . ; the mean bmi was . ; % were morbidly obese (bmi ) and % were obese . the total number of comorbidities identified after evaluation by a multidisciplinary team was significantly greater (p=. ), with the average number of comorbidities diagnosed before and after being . and . , respectively. a significant increase (p. ) in the identification of comorbidities before and after evaluation were noted for all demographics, and no disparities regarding gender, age, marital status, employment status, bmi, or ethnicity where identified. conclusion: patients with obesity unknowingly suffer from many obesity-associated comorbidities simply because their health care providers have failed to recognize the existence of these conditions. surprisingly, this include diseases that are highly associated with obesity, such as osa and t dm, for which obese patients should be screened. although the root of this dereliction is yet to be determined, insufficient obesity-focused education and inherent weight bias among providers must be considered. assessment by a multidisciplinary bariatric team resulted in the identification and treatment of an increased number of comorbidities in this patient population. increased recognition of obesity-related comorbidities improves quality of care, which can translate into improved surgical outcomes. introduction: it is known that surgical residents suffer from sleep deprivation. no recent study evaluated the type and number of calls received at night. lately, burn out, depression and suicide have been the subject of interest in studies and media because of the higher rate among the residents compared to general population. the objective of our study is to evaluate junior resident's level of fatigue and the quantity and quality of calls received during on-call nights in general surgery at chus. methods and procedure: transversal study conducted on junior residents that were on-call in general surgery at the chus between april and august , . the participants detailed all the calls received between pm and am on an database created on the application handbase and completed a daily calendar of their on-call night noting all the tasks they did every half hour (surgery/consultation/sleep). the level of fatigue was evaluated at the end of the night at am with a visual analog of sleep scale on a score over points. results: the level of fatigue / (tired) or / (exhausted) was reached in closed to % of the oncall nights. the median number of calls by night was and the median duration of sleep was only . hours. the median lenght of uninterrupted sleep was . hours by night. among the total nights and calls analyzed, % were ''not pertinent'' and % were ''reportable in the morning''. more than % of the nights had at least one call ''not pertinent'' or ''reportable in the morning'' that have interrupted the junior resident's sleep. the level of fatigue was significantly correlated to the number of calls received during the night (spearman's rho=+ . , p. ) and to the number of uninterrupted hours of sleep (spearman's rho=− . , p. ). conclusion: the level of fatigue is very high among the junior residents in general surgery. many of the calls received during the night are not pertinent or could have been delayed to the morning. our results lead us to the conclusion that interventions and recommendations should be made to raise nurses and resident's awareness about the situation to reduce the unnecessary calls and the level of fatigue of the residents. we hope that on-call resident sleep will be better preserved and that will result in fewer health issues for them (burn out, depression, suicide). without interruptions: does twitter level the playing field? heather j logghe, md , laurel milam, ma , natalie tully, bs , arghavan salles, md, phd ; thomas jefferson university, washington university, introduction: frequent interruption of women in conversation has long been noted anecdotally, and studies confirm that women are interrupted more often than men. such interruptions can diminish perceptions of authority and compromise women's self-confidence. on twitter, users cannot be interrupted in the same way they can be in live conversation. thus the platform may provide a means for women to overcome this obstacle. to determine the degree to which women surgeon leaders utilize twitter compared to their male colleagues, we examined the twitter accounts and activity of the leaders of three national surgical societies. methods and procedures: lists of surgeons holding leadership positions in three surgical societies; the american college of surgeons, the academic association of surgery, and the society of american gastrointestinal and endoscopic surgeons, were obtained and duplicate names were deleted. table details the organizations and leadership positions included. the twitter accounts of these leaders were then identified and confirmed by reviewing the accounts for surgical content. account duration was calculated from the join date. the number of tweets, accounts following, followers, and likes were recorded for each account. outliers were defined as two standard deviations from the mean. results: one hundred sixty-eight men and women surgeon leaders were identified. forty-nine percent of the men and % of the women were found to have twitter accounts. mean account durations for men and women were similar, . years and . years, respectively. outliers for total tweets ( men, women), accounts following ( men), followers ( men), and likes ( men) were excluded from analyses. almost all positive outliers were men. there were no negative outliers. overall, excluding the outliers, there were no significant differences between men and women in any metric. conclusion: among leaders in the surgical organizations analyzed, a higher percentage of women than men have twitter accounts. those with the greatest number of tweets, accounts following, followers, and likes, however, are overwhelmingly male. thus, although women in this sample were more likely than the men to have twitter accounts, men were more likely to gain influence through their accounts. increasing women's influence in this public forum may position them as much-needed role models for the current and next generations. surgical societies may help reduce the disparity in women's representation in surgical fields through education of their members on how to use social media. introduction: the aim of this study was to report the perioperative morbidity and short-term outcomes of a case series of robotic-assisted laparoscopic transabdominal preperitoneal (tapp) inguinal hernia repairs. methods and procedures: a retrospective review (january through december ) of patients who underwent either unilateral or bilateral robotic-assisted laparoscopic tapp inguinal herniorrhaphy by two attending surgeons was performed. patient demographics, perioperative morbidity, operative time, and follow-up data were analyzed. results: patient demographics are summarized in table . mean operative times for unilateral and bilateral inguinal herniorrhaphy were . ± . and . ± . minutes, respectively. mean robot console times for unilateral and bilateral inguinal herniorrhaphy were . ± . and . ± . minutes, respectively. postoperative complications included urinary retention ( . %), conversion to open repair ( %), and delayed reoperation ( . %). no major bleeding, surgical site infection (ssi), or mortality was observed. at first follow-up visit ( ± days), symptoms/signs included groin/scrotal swelling ( %), seroma ( %), groin pain ( %), burning ( %), numbness ( %), and persistent urinary retention ( %). % of patients required a second follow-up visit. two patients underwent reoperation for suspected recurrence but instead a cord lipoma was found without a hernia defect. conclusions: robotic-assisted tapp inguinal herniorrhaphy can be performed with operative times and short-term outcomes similar to those published for open technique. the robotic-assisted tapp inguinal herniorrhaphy is a safe and an efficient minimally invasive surgical option with lower ssi risk and better cosmetic results. gunnar nelson, nathan lau, phd; virginia polytechnic institute & state university introduction: the fundamentals of robotic surgery (frs) and fundamentals skills of robotic surgery (fsrs) are universal curriculums covering a range of topics to assure a high level of surgical skills for optimal patient outcomes. this assurance of skills should include management and response to adverse events. thus, we reviewed frs and fsrs to identify any gaps in educational contents pertaining to how surgical teams are trained to handle adverse events in robotic surgery. methods and procedures: we conducted a literature search through google scholar, journal of robotic surgery, and plos one on frs and fsrs from to . we reviewed articles on preparing medical professionals in handling adverse events during robotic surgeries. besides the two curriculums, we also surveyed the literature on the characteristics of the adverse events and responses of the medical team. this literature survey provided a basis for recommending additional education contents to frs and fsrs. results: in our review, the frs contains modules consisting of an introduction to robotic surgery, with cognitive, psychomotor, and team training/communication skills. meanwhile, the fsrs contains different tasks, half of which on human-machine interaction and another half on operative interaction. both curriculums appear to lack contents on managing adverse events in robotic surgery. according to fda data, , adverse events were reported per , surgeries, of which (i) % relates to broken pieces of surgical instruments falling into patients, (ii) . % pertains to burning holes in tissue from electric arching, and (iii) . % relates to unexpected operations of the instrument such as power outage and issues with electrosurgical units. thus, medical professionals should be trained to manage common adverse events in robotic surgery. for frs, augmenting the five current scenarios in the communication section with common adverse events (i.e., broken pieces falling into patients) would minimize complications under abnormal circumstances. for fsrs, the most logical method would be augmenting the operative interaction tasks with adverse events to train medical professionals. conclusion: we discovered universal curriculums on robotic surgery lack education contents for training medical professionals to manage adverse events and out of the , procedures, ( . %) pertained to device malfunction. to protect the patient's health, universal curriculums must incorporate contents preparing medical professionals in responding to adverse events, particularly device malfunctions, during robotic surgeries. introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for laparoscopic cholecystectomies. we report the first single-institutional experience utilizing this new robotic platform. methods: approximately robotic cholecystectomies were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node ( figure ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between and years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than month and a bmi\ . a retrospective review of a variety of prospectively collected pre-, peri-and postoperative data including but not limited to patient demographics, intraoperative as well as postoperative complications was performed. cholecystectomies were performed by expert level laparoscopic surgeons. results: the standard laparoscopic technique and setup was easily applicable to the senhance robotic system for this particular surgery. operative time and perioperative complications were comparable to reports of standard laparoscopic cholecystectomies. there was no significant learning curve detected in our case series. conclusion: we report the first experience with laparoscopic cholecystectomies using the new senhance robotic system. there were no major perioperative complications and operative time was comparable to standard laparoscopic cholecystectomies well reported in the literature. this case series suggests that the senhance robotic system can be safely and easily used for laparoscopic cholecystectomies by experienced laparoscopic surgeons. background: the ergonomic benefits or robotic surgery for the health of the surgeon are widely touted as benefits of this technique, though concern remains over a perception of increased risk of injury to patients, particularly in the novice robotic surgeon. injury to the bedside surgeon and assistants due to robotic movement can also occur, though not previously reported. we describe a finger fracture to the bedside surgeon due to entrapment between robotic arms and discuss potential risks to the surgeon in robotic procedures. procedure: a distal pancreatectomy and splenectomy was performed utilizing the davinci si system (intuitive surgical, inc., sunnyvale, ca). during the operation, hemorrhage was encountered which required an instrument exchange that was delayed by self-testing failures. after the instrument was validated and advanced into the field by the bedside surgeon, the operator abruptly took control of the device to reposition. the external portion of the active arm was then rapidly and forcefully propelled laterally toward a stationary retracting arm. the bedside surgeon's hand was still engaged on the instrument being inserted and became trapped between the two arms, leading to a right middle finger crush injury. results: the bedside surgeon sustained a fracture to the distal phalanx at the insertion of the flexor tendon with significant hyperextension of the joint. there was temporary paresthesia of the fingertip. while flexor tendon function was preserved and surgery was not required, the surgeon was required to maintain continuous splinting and was unable to return to full duty for a total of weeks. the surgeon has mild residual hyperextension. conclusions: while complications to the patient have previously been attributed to the robotic platform, this case demonstrates that there are other inherent hazards to members of the operative team. as is natural with all indirect visual surgical techniques, the operator becomes intensely focused on the internal view and instruments in the field. this spatial separation is accentuated on the robotic platform as the isolated console provides a complete visual field immersion, no tactile feedback, and a disconnect between the rapid, sizeable outward arm motions need to produce small internal movements. given the need for maximum dexterity internally, the device doesn't have external proximity sensors to prevent arm-arm or arm-operator collisions. while many bedside operators report anecdotes of collisions with the device, this case reveals the forces involved at the human-machine interface can lead to more significant injuries. robtic approach to non-midline abdominal wall hernias: a single institution experience from a high volume center emily benzer, do, j. stephen scott, md, facs; university of missouri introduction: the objective of our study was to evaluate our experience with robotically repaired non-midline abdominal wall hernias at a high-volume robotic surgery program. we also will discuss the technical advantages of the use of robotic technology in repair of these unusual hernias which have typically had higher recurrence rates then midline hernias. laparoscopic approach for lateral ventral abdominal wall hernia (spigelian) and lumbar hernia has been described, however the success of robotic assisted repair for these hernias has yet to be determined. methods: a retrospective case analysis of all robotic abdominal hernia cases between june and june at an academic institution with a single high volume robotic surgeon was performed. the operative details of robotic repair of non-midline abdominal hernias, patient demographics, length of stay and smoking status were recorded and analyzed. the technical advantages of the use of robotic technology for example circumferential fixation of the mesh, ease of intracorporeal suturing, and the use of wristed instruments to gain better angles for posterior fascial release were evaluated. results: a total of cases were identified. the average age of the patients was . years (range - years) and patients were predominantly female ( %). spigelian hernias represented % (n = ) and lumbar hernias % (n= ). all patients had primary closure of their defect and patients ( %) had a posterior myofascial release performed. mesh types placed included polypropylene uncoated (n= ), polypropylene coated (n= ), and biologic (n= ). with uncoated polypropylene mesh placed had peritoneum closed over the mesh. the average length of stat was . days (range - days). there were no recurrences identified over a mean follow up period of . months (range . - . months). conclusion: robotic assisted repair of non-midline abdominal wall hernias is a viable option in the elective setting with no recurrences noted in this case series. the technical advantages of using robotic technology were identified and discussed in detail. these advantages theoretically improve outcomes in these patients however further analysis on long-term outcome and costs will have to be determined in future studies. the inguinal hernia repair has seen several critical improvements in recent times due to the implementation of new techniques, including laparoscopic repair, as well as robotic repair. with over , inguinal hernia repairs performed annually, it is important to identify the safest and most patient-friendly method. for surgeons, robotic assisted laparoscopic surgery is gaining in popularity for its dexterity and d visualization. but despite the growing interest in robotic hernia repairs, there is a scarcity of literature to support its superiority over open inguinal hernia repair. this study hypothesizes that patients who undergo robot assisted laparoscopic inguinal hernia repair will have decreased immediate post-operative pain, shorter recovery room stays, decreased narcotic requirement, and overall decreased pain at follow up compared to open inguinal hernia repair. in this study, we performed a retrospective analysis of patients who underwent either an open or robotic assisted laparoscopic inguinal hernia repair at stamford hospital, from july -july . the following characteristics were analyzed for both subsets of patients: gender, bmi, type of repair, operative time, recovery room time, immediate post-operative pain, and post-operative pain at follow up. our study demonstrated longer average operative time for patients undergoing robotic hernia repair compared to open repair, which was statistically significant (p value=. ). patients who underwent robotic inguinal hernia repair spent less time in the recovery room compared to patient who underwent open repair. in addition, patients in the robotic hernia group required less narcotics in the recovery room compared to patients who underwent open repair (p value = . ). there was no statistically significant difference between lengths of hospital stay between the two groups. this study highlights several possible advantages of robotic inguinal hernia repair, including lower post-operative pain scores, less narcotic usage required in the post-operative period, as well as shorter recovery room time. the results from this study should increase interest in investigating the superiority of robotic inguinal hernia repair. future plans for study involve comparing robotic to laparoscopic repair. in addition, we plan to continue to follow the study patients to look at additional qualitative metrics, including time to return to work and time to return to daily activities. introduction: buccal mucosal grafts (bmg) are traditionally used in urethral reconstruction. there may be insufficient bmg for applications requiring large amounts of graft, such as urethral stricture after gender affirming phalloplasty. rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger graft dimension. laparoscopic transanal minimally invasive surgery (tamis) has been described by our group. due to the technical challenges of harvesting a sizable graft within a confined space, we adopted a new approach using the intuitive da vinci xi® system. we demonstrate the feasibility and safety of a novel technique of robotic tamis (r-tamis) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. methods and procedures: irb approval was obtained. three female-to-male transgender adults (age range: - years) presenting with post-phalloplasty urethral strictures underwent robotic rectal mucosal harvest. the procedure was first rehearsed on an inanimate model using bovine colon. the surgery was performed under general anesthesia with the patient in lithotomy position. the gelpoint path transanal access platform was used. the rectal mucosa was harvested by the robotic instruments after submucosal hydrodissection. specimen size harvested correlated with clinical surface area needed for urethral reconstruction. following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. the rectal mucosa graft was placed as an onlay for urethroplasty. results: there were no intraoperative or postoperative complications. average graft size was cm (range: - cm). every case had excellent graft take for reconstruction. all patients recovered without morbidity or mortality. they reported minimal postoperative pain and all regained bowel function on the first postoperative day. all reported significantly less postoperative pain and greater quality of life in comparison to prior bmg harvests. the procedure has been refined to increase efficiency and decrease operative time by maintaining adequate insufflation, retraction of the mucosal graft, and maintaining graft integrity. conclusions: to our knowledge, this is the first use of r-tamis for harvest of rectal mucosal graft. our preliminary series indicates the robotic approach is feasible and safe. it constitutes a promising minimally-invasive technique to employ in urethral reconstruction. demonstrated feasibility and avoidance of the challenging recovery associated with bmg harvest warrants further application and long-term evaluation of this procedure. prospective studies evaluating graft success, donor site morbidity and long-term outcomes are needed. introduction: the proportion of robotic minimally invasive procedures that are being performed annually is growing rapidly, specifically in the field of general surgery. a robotic approach to minimally invasive procedures potentially confers a number of benefits ranging from a magnified viewing field to greater attenuation and translation of hand movements leading to improved stability and maneuverability. it is paramount that a robust curriculum is designed for training surgical residents in robotic techniques. the aim of this project is to assess the current state of robotic surgery training at the ohio state university, with specific regard to whether it is currently temporally effective in addition to establishing a baseline against which the robotic surgery curriculum can be compared. methods and procedures: data were obtained for cases performed at the ohio state university hospital east, between january and september of . case time, date, type, and attending surgeon were recorded and tracked for review. of the cases, were cholecystectomies, were unilateral inguinal hernia repairs, and were bilateral inguinal hernia repairs-for a total of procedures included in the analysis. chief residents were trained in two-month blocks, beginning in january of . mean console operative times for the first and second months were compared for cholecystectomies as well as unilateral and bilateral inguinal hernia repairs. results: mean console time decreased for cholecystectomies (− . %; n= ), bilateral (− . %; n= ) and unilateral (− . %; n= ) inguinal hernia repairs from month one to month two. there was a large amount of variance across training blocks, but there was a systematic improvement in operative time across the training period. average operation length was shortest for cholecystectomies (m= . min), followed by unilateral inguinal hernia repairs (m= . min), and finally bilateral inguinal hernia repairs (m= . min). discussion: this preliminary data suggests that residents are able to decrease their robotic operation time over the course of the two-month rotation. although sample sizes were relatively small for each block, the consistency of the trend supports this conclusion. further data collection will allow for more precise estimates in the future, and stronger conclusions to be drawn. these results show that rapid improvement is possible and provide motivation to establish robotic surgery curricula for general surgery residents nationally. robotic pancreas-sparing treatment of pancreatic neuroendocrine tumors: three case reports and review of the literature alessandra marano, giorgio giraudo, stefano giaccardi, desiree cianflocca, diego sasia, felice borghi; santa croce e carle hospital introduction: pancreas-sparing resections would be the ideal procedure in case of small pancreatic neuroendocrine tumors (p-nets) reducing the risk of exocrine and endocrine insufficiency. compared to standard resection, this type of surgery is safe and feasible without increasing the risk of postoperative complications except the overall rate of clinical pancreatic fistula (pf), which did not result in higher mortality or overall morbidity. robotic surgery for pnets enucleation has been rarely described but initials experiences have shown that this approach is associated with favorable outcomes. the aim of this study is to describe three cases of dv®si™ pancreatic enucleation for p-nets located in the uncinate process, in the body and in the posterior aspect of the tail of the pancreas, respectively. a brief review of the literature regarding the application of robotics for pnets enucleation is also included. methods and procedures: this study includes patients undergoing dv®si™ enucleation for pnets with a maximum diameter no more than cm and a distance between tumour and main pancreatic duct (mpd) greater than mm. at surgery, exposure of the pancreas was achieved by separation and traction of the gastrocolic and gastropancreatic ligaments. the pancreas was explored: an intraoperative ultrasound was used ensuring negative margins and leaving the mpd intact. thus, a cross-stitch through the tumour was made routinely in order to pull the tumour. enucleoresection was carried out with monopolar scissors and bipolar forceps. the tumour was placed into a specimen bag and removed from the trocar port. a drain was always left. results: median total operative time was min. no conversion neither intraoperative complications occurred. median length of stay was . days. two patients presented a pf grade a (classification isgpf) while a pf grade b occurred in case of pancreatic tail net enucleation. final pathology revealed two insulinomas and one non-functioning net of the pancreatic body. at a median follow-up of months no pancreatic insufficiency, reoperation or tumour reoccurrence was observed in all cases. the robotic approach for the treatment of p-nets is safe and feasible and, in selected cases, it may extend the indications of minimally invasive pancreatic-sparing surgery. in particular, the robotic approach provides a more precise dissection and may ensure negative margins and the mpd intact. these preliminary results are consistent with literature data about over robotic pancreatic enucleations for p-nets that shows favourable surgical outcomes, especially if compared with those of open surgery. introduction: rectal cancer continues to be a surgical challenge. new technologies must be incorporated into practice and, at the same time, oncologic surgery and overall outcomes must be improved. the use of da vinci robotic surgery systems has spread rapidly in the field of rectal cancer treatment showing several technical advantages and favorable outcome compared to laparoscopy. since the introduction of the robotic platform in our institution in , we have adopted a single-docking robotic technique for rectal resection. the aim of this study is to present our standardized technique and to analyse the clinical outcomes of the first robotic rectal procedures. methods and procedures: prospectively collected data reviewed from consecutive patients who underwent single docking totally robotic (da vinci® si™) dissection for rectal cancer resection between june and august under eras program. robotic rectal surgery was performed without changing the position of the robotic cart but only the robotic arms are repositioned between two phases: ) vascular ligation, and sigmoid colon to splenic flexure mobilization; and ) pelvic tme. results: there were men ( %) and the median age was years (range- - ). thirty-five patients had neo-adjuvant chemoradiotherapy whilst patients had bmi [ . procedures performed included anterior resection (n= ) and abdominoperineal resection (n= ). protective ileostomy was performed in patients. the median operating time was min (range- - ). there was one conversion and two intra-operative complications (one bladder lesion and one ureteral lesion, respectively). median length of stay was . days (range, , and readmission rate was %. thirty-day mortality was zero. anastomotic leak rate was %, and all patients except by one were managed conservatively. the mean lymph node harvested was (sd± . ). radial margin was negative in all patients. at median follow-up of months, there were no local recurrences. the single docking robotic technique is a safe and feasible approach for rectal surgery: in our study it has demonstrated favourable clinical outcomes and the adoption of a standardized stepwise approach was useful especially during the initial learning phase. to the best of our knowledge, this is the largest series from italy to report this standardized approach and the short-term clinical and oncological outcomes. in the complex laparoscopic surgical procedure, there is a problem such as that the laparoscope and the surgical instruments interfere with each other because multiple instruments is concentrated in one place. this problem is significantly appear in the laparoendoscopic single site surgery. therefore we suggested multi degrees of freedom (dof) manipulator with mantle tube for assisting laparoendoscopic surgery, which manipulator has two flexion and one telescopic mechanisms actuated by wire. it is possible to insert any thin surgical instruments such an endoscope the mantle tube of the multi dof manipulator, which the manipulator can let those surgical instruments access the operative field from different axis with other instruments. the use of this manipulator has two advantages, one of which is avoidance of fighting between instruments and laparoscope. the other is that become possible to ensure a satisfactory field of vision in the operative field. in this report, we assumed that this multi-dof manipulator is used as laparoendscope. in order to evaluate the performance of this manipulator, the operation time of the test in the abdominal cavity simulator (fasotec inc.) was measured. the test is a contact test to multiple-targets, which is a test that bring a forceps contact multiple-targets in the abdominal cavity simulator according to the defined pattern. as a general comparison and evaluation target for this measurement result, it is compared with the case using the same access method as the conventional rigid endoscope. in this test, the number of contacts between forceps and laparoendoscope were recorded by using electrical device. subjects (n= ) are adult men who trained the peg transfer in the above simulator. it was compared of total operating times of the test and the field of vision obtaining each device. from these results, using the suggested manipulator device rather than using rigid laparoscope a satisfactory field of vision is obtained, and it is possible to short the operating time approximately seconds, and to small the number of contacts significantly. therefore it was shown that the effectiveness using the suggested manipulator device. for this reason, use of this device is expected to facilitate the complex surgical operation. additionally, it is performed para ablative operation of swine liver tissue in the abdominal cavity simulator, as previous step of clinical test. the operative field in this test was surveyed, the refinements of this manipulator for improvement performance were described in this report. yoshiyuki usui, md, phd, ichiro akiyama, md, phd, hironori kunisue, md, phd, hideaki mori, md, phd, tetsuya ota, md, phd; okayama medical center background and methods: we have performed approximately cases of gasless endoscopic thyroid surgery since for years. this surgery was performed through a small subclavian incision and using a wire traction and inserting an endoscope. we have modified and improved our surgical techniques by inventing various surgical instruments. here we introduce four newly invented surgical instruments, chronologically. results: we made u-retractor ( ), u-trocar ( ), u-kelly forceps ( ), and u-suction tube retractor ( ). all surgical instruments were modified from conventional surgical instruments. the u-retractor was a piercing retractor, each end of which had a sharp tip and a retractor. this retractor was inserted from the -cm working port outside the body and retracted the muscles effectively. the u-trocar was reversely set from inside to outside to make the working space wider. the u-kelly forceps which had a special ratchet were made to dissect loose connective tissue around the thyroid gland avoiding injury of the recurrent laryngeal nerve. the u-suction tube retractor facilitated a wider working port and eliminated the mist created by the ultrasonically activated scalpel effectively. recent data showed no difference of operative time, hoarseness, blood loss and hospital stay between conventional thyroid lobectomy and gasless endoscopic lobectomy. conclusion: gasless endoscopic thyroid surgery has been improved in the last years. this procedure made the excision of not only benign thyroid tumors but also small thyroid carcinomas. this operation is still cost effective, because almost all surgical instruments are reusable and is a satisfactory experience to both the patients and surgeons. objective: to put forward the importance of complete (r ) resection for the treatment of retroperitoneal tumors increasing overall survey. methods: in this study; patients having the diagnosis of retroperitoneal tumors with different histopathological subtypes whom were hospitalized in emergency surgery department of istanbul medical faculty between the years of and were evaluated retrospectively. the database of the department was analyzed. operational backgrounds, histopathological results, radiological evaluations, and assesments about relapses, and overall survey were obtained from the medical archieve. results: the average follow-up time was , years. all of the patients included into the study were undergone operations. the average time of hospital stay was calculated as days. of the patients were found to have positive surgical margins in their histopathological evaluations. overall mortality rate of the study was % ( / ). we have observed a direct correlation between complete (r ) resection and disease-free survival. patients having relapses had worse prognosis in terms of overall survey ( % mortality rate). after having done the statistical evaluation, surgery was found to be the main determining factor for the assesment of overall survey. conclusion: reference to an experienced and multidisciplinary surgical center after an early diagnosis has upmost importance for the treatment of retroperitoneal tumors. surgical approach constitutes the main element in the management. overall survey is directly correlated with complete (r ) resection. novel fluorescent dyes for real-time, intraoperative, organ-specific visualization of biliary and urinary systems using dual-color near-infrared imaging ; children's national health system, nih/nci p multidisciplinary approach for management of necrotizing pancreatitis: a case series prabhu senthil-kumar university of alberta, centre for the advancement of minimally invasive surgery introduction: the objective of this study was to systematically review the bariatric surgery literature to understand how weight loss is reported. the incidence of obesity has increased globally. according to the world health organization more than million were obese in . in the last decade, bariatric surgery has been increasingly utilized as an effective treatment option for severely obese patients. currently, bariatric surgeries are among the most commonly performed operations. the primary outcome of such procedures is weight loss which has been shown to vary according to the type of surgery. however, there are different methods used to report weight loss which makes it difficult to directly compare outcomes between studies. a previous review by dixon et al. in revealed a wide heterogeneity in weight loss reporting. however, there have been no recent reviews on the reporting of weight loss in bariatric surgery. methods: a search of the medline electronic database was performed for studies published in using search terms gastric bypass/sleeve gastrectomy, weight, human, and english. articles were selected by two independent reviewers based on the following inclusion criteria: ( ) adult participant ≥ years predictive factors for excess body weight loss after bariatric surgery in japanese obese patients takeshi naitoh hypertension resolution after rapid weight loss: a single institution experience cristian milla matute reoperative bariatric surgery: analysis of indications and outcomes: a single center experience iman ghaderi objective: to observe the effects of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass rat model. method: in order to verify the effect of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass, twenty-two type- diabetes sprague-dawley rat model established through high fat diet and low dose streptozotocin (stz) administered intraperitoneally were assigned to one of three groups: gastric bypass with duodenal-jejunal transit (gb-djt n= ), gastric bypass without duodenal-jejunal transit (rygb n= ) and sham (n= ). body weight, food intake, blood glucose, as well as meal-stimulated insulin, and incretin hormones responses were assess to ascertain the effect of surgery in all groups. oral glucose tolerance test (ogtt) and insulin tolerance test (itt) were conducted three and seven weeks after surgery. results: comparing our gb-djt to the rygb group, we saw no differences in the mean decline in bodyweight, food intake, and blood glucose -weeks after surgery. gb-djt group exhibited immediate and sustained glucose control throughout the study outcomes with sham operation did not differ from preoperative level. conclusion: preserving duodenal-jejunal transit does not impede glucose tolerance and diabetes remission after gastric bypass in type- diabetes sprague-dawley rat model is bariatric surgery effective for comorbidity resolution in super obese patients? methods: a retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of at least one or more of the following comorbidities-t dm, htn, osa, or hld-at the time of initial visit who had undergone either a sleeve gastrectomy (sg) or a roux-en-y gastric bypass (rygb) at our hospital between and . the patients were stratified based on their preoperative body mass index (bmi) class: bmi methods: we retrospectively reviewed all patients that underwent laparoscopic sleeve gastrectomy (lsg) at our institution from - . common demographics and comorbidities were collected as well as creatinine, preoperatively and up to hours after surgery. the renal function was calculated using the ckd-epi formula, derived and validated by levey et al. acute kidney injury was defined as an increase in serum creatinine by ≥ . mg/dl within hours after surgery. all tests were two-tailed and performed at a significant level of . . statistical software r, version . . ( - - ) was used for all analyses. results: of the patients reviewed conclusion: the impact of laparoscopic sleeve gastrectomy in renal function is evident within the first hours after surgery. patients undergoing lsg, especially patients with baseline chronic kidney disease stage ≥ are at increased risk of developing acute kidney injury in the perioperative setting the body mass index (bmi), fasting plasma glucose (fpg), glycosylated hemoglobin (hba c), serum triglyceride, serum cholesterol and blood pressure of all patients were measured before and at months after surgery. the results were collected and analyzed. results: patients suffered from metabolic disease undertook lsg surgery successfully (a mean age of years), were male and were female. all of patients suffered from obesity and the mean bmi of them was . ± . kg/m before surgery. among them, patients had type diabetes mellitus (t dm), patients had hypertriglyceridemia (htg), patients had hypercholesterolemia (hc) and patients had hypertension. the mean bmi of patients at months after surgery was . ± . kg/m and decreased significantly (p. ). the mean excess weight loss (ewl%) of patients was . %± . %( %* %) at months after surgery. the average levels fpg, hba c of t dm patients at months after surgery were . ± . mmol/l, . %± . % methods: we retrospectively reviewed all patients who underwent bariatric surgery from to . we assessed kidney function using the chronic kidney disease epidemiology collaboration (ckd-epi) and cardiovascular risk using framingham risk score (frs) equation pre-operatively and at and months of follow-up. our population was divided into two groups: patients with ckd stage ≥ (gfr\ ml/min) and patients with normal gfr. significance. results: of the , patients reviewed, . % (n= ) met the criteria for ckd-epi glomerular filtration rate (gfr) and framingham risk score (frs) calculations. after matching, patients ( . %) were left to analyze, % (n= ) of which had a laparoscopic sleeve gastrectomy. eighty-six patients ( %) had an impaired kidney function (ckd≥ ) (group ) and patients ( %) had a normal gfr (group ). common demographics and comorbidities after matching are described in table . the mean creatinine in group was . ± . mg/dl versus . ± . mg/ dl in group (p
). glomerular filtration rate was . ± . ml/min in group and ± . ml/min in group . furthermore, when the frs was calculated at months follow-up, patients with impaired kidney function had an absolute risk reduction of . % corresponding to a relative risk reduction (rrr) of group . the percentage of estimated bmi loss was found to be similar in both groups ( . ± . and . ± . respectively p= . ). conclusions: bariatric surgery, especially lsg, has a positive impact on kidney function particularly in patients with chronic kidney disease stage or greater. despite these patients having a higher preoperative cardiovascular risk, they showed similar risk reduction when compared to patients with normal kidney function at months of follow-up the impact of socioeconomic factors and indigenous status jerry t dang only ( . %) patients underwent urgent conversion for management of complications after sg. three patients had intraoperative complications necessitating blood transfusion. fourteen ( . %) patients required readmission within days postoperatively. six patients ( . %) required surgical interventions including for gastrointestinal leak, for hemodynamic instability, for a cecal perforation, and for a small bowel obstruction. there were no mortalities within the first year of revisional surgery. in patients with bmi[ kg/m at the time of revisional surgery, at the median postoperative follow-up of (interquartile range, - ) months, a median (interquartile range, - ) kg/m reduction in bmi was observed. overall, ( . %) patients had persistent type diabetes at time of revisional surgery. improvement of diabetes was observed in patients ( . %) after conversion of sg to rygb. among patients with gerd symptoms, subjective symptomatic relief was reported at the last follow-up. conclusion: weight recidivism is the most common indication for revision of sg objective: to evaluate laparoscopic mini-gastric bypass in the treatment of morbid obesity. method: three hundred patients with a mean bmi of . . kg/m underwent a laparoscopic mini-gastric bypass between to . a laparoscopic approach with five trocar incisions was used to create a long narrow gastric tube; this was then anastomosed ante-colically to a loop of jejunum cm. distal to the ligament of treitz peri-operative and short-term follow-up results up to does age or preoperative bmi influence weight loss after bariatric surgery? one-way anova or the kruskal-wallis test was used to compare continuous data across all groups. subsequent analysis of categorical data was achieved by chi-square or fisher's exact test. statistical significance was accepted as p. . results: a total of patients ( % male) were analyzed. average age and preoperative bmi were . ( . ) years and . ( . ) kg/m , respectively. preoperative comorbidities included: diabetes ( . %), hypertension ( . %), hyperlipidemia ( . %), previous myocardial infarction ( . %), obstructive sleep apnea ( . %), chronic obstructive pulmonary disease ( . %), gastroesophageal reflux ( . %), tobacco use ( . %). the asa classes of patients undergoing sg were ii ( . %), iii ( . %), and iv ( . %). the follow up rate at , and months was . %, . %, and . %, respectively. the -day mortality and readmission rate were % and . %, respectively. the %ewl was not different among age groups at , or months for the total, male, or female cohorts. among preoperative bmi groups, %ewl was not different in any cohort at or months, but was different at months for the total cohort (p. ) and female cohort (p\ . ), and trended toward significance in the male cohort (p= . ). the highest %ewl was found to be in patients with preoperative bmi of - . there was no difference in -day mortality or readmissions among groups a crp≥ mg/dl had a sensitivity for a complication of % and a specificity of %. primary bariatric surgery patients with a post-operative complication had higher crp levels compared to those who did not ( . ± . mg/dl vs . ± . mg/dl; p= . ). there was no difference in crp levels for patients with a -day reoperation or readmission. there were no mortalities. conclusions: bariatric surgery patients with elevated post-operative crp levels are at increased risk for -day complications. the low sensitivity of a crp≥ mg/dl suggests that a normal crp methods and procedures: the patients, who formed the previously published cohort, were contacted and their charts were reviewed. follow-up visits, symptom severity scores, and any subsequent medical or surgical interventions were collected. symptoms were assessed using the symptom severity score (sss) and the gastroparesis cardinal symptom index (gcsi) questionnaires. success was defined as a sss of or less. results: out of original patients, patients ( males, females) were available for follow-up ( patients declined participation, were lost to follow-up, patient was deceased, and was excluded after undergoing esophagectomy for unrelated indication) mbbs ; grant government medical college and sir jj government hospitals methods and procedures: twenty-six nh patients with dm were prospectively randomized to undergo either lrygb or lsg. patients were followed for -years with primary end points consisting of total weight loss (twl), percent excess body weight loss (%ebw) and impact on dm as measured by fasting blood glucose (fbs) and hba c. in addition, baseline, week, and , , , , and months post-operative levels of glucagon-like peptide (glp- ), peptide yy (pyy), leptin, and ghrelin were collected. results: a total of / patients completed follow-up. the %ebw at year for lrygb and lsg were % and %, respectively. resolution of dm occurred in / patients, the remaining three subjects were in the lgs arm. pre-operative fbs in lrgyb and lsg groups, were and , respectively. pre-operative hba c in the lrygb and lsg groups, were . and . , respectively. fbs at year for lrygb and lsg were and , while hba c for lrygb and lsg were . and . , respectively. a consistent post-operative decrease in fbs was only seen in lrygb. lrygb ghrelin percentages increased at , , and months, while levels decreased in lsg. leptin percentages decreased in both groups. the ppy levels remained relatively unchanged in both groups. lrygb glp- levels increased at week, , , and months. lsg glp- trends were similar except at months where glp- levels decreased. conclusion: lrygb and lsg resulted in equivalent post-surgical weight loss and resolution of dm in the nh population video assisted thoracoscopic thymectomy (vats) has emerged as a minimally invasive alternative to the standard transsternal approach. we present herewith the surgical and neurological outcomes after vats their operative time, blood loss, conversion rate and post operative parameters like intensive care unit (icu) stay, inter-costal drainage (icd) indwelling time, hospital stay were recorded. neurological outcomes were assessed based on myasthenia gravis foundation of america (mgfa) post intervention status classification. statistical analysis was done using stata software. results: ninety patients underwent thoracoscopic thymectomy during the study period. vats was done through right approach in ( . %), left approach in ( %) bilateral approach in patients ( %) and subxiphoid approach in ( . %). there was conversion to open approach in ( . %) patients due to dense adhesions at westchina hospital of sichuan university were included. all of the operations were performed by a single skilled surgeon. we divided our patients into two groups based on whether isao was used. of them, patients received isao for lps and patients received lps without isao. surgical skills and safety were evaluated. results: there were no significant differences in preoperative patients characteristics of the two groups. significantly less intraoperative blood loss( . ± . ml vs . ± . ml; t=− . , p= . ) were observed in group of isao conclusions: isao is technically feasible, safe surgical skills for patients reveived lps, and its represents an effective method to decreased intraoperative blood loss. p modular laser-based endoluminal ablation of early cancers: in-vivo dose-effect evaluation and predictive numerical modelling giuseppe endoscopic submucosal dissection enables en-bloc removal of early gastrointestinal neoplasms. however, it is technically demanding and time-consuming. laser-based ablation (la) techniques, are limited by the lack of depth penetration control and thermal damage (td) prediction. our aim was to evaluate a predictive numerical modelling (pnm) of the td to preoperatively select the optimal power and exposure time enabling a controlled ablation down to the submucosa (sm). additionally, the ability of confocal endomicroscopy (ce) to provide information on the td was assessed at the histology, there was an increased damage depth per higher j applications. the r value at . j was . ± . , and was significantly lower when compared to energies from j (r= . ± . ; p. ) up to j ( . ± . ; p\ . ). safe m and sm ablations were achieved applying lower p settings ( . and w), at different t values, leading to an mp impairment only in and % of the cases, respectively. ce provided relevant images of the td, consisting in architecture's distortion and disappearance of the gland's contours. the predicted damage depth we also analyzed early gastric cancer patients who received lpg-ip with cm jejunal interposition. anastomosis procedure was overlap method for eshophagojejunostomy and gastrojejunostomy, feea for jejuno-jejunostomy. results: the comparison between otg/opg-ip shows no significant difference in perioperative complications and qol scores, significant smaller body weight loss in opg-ip group. lpg-ip group also shows good result in short term outcomes. consideration: as comparison in open surgery implies superiority in jejunal interposition, we have introduced lpg-ip. esophagogastrostomy after proximal gastrectomy is simple but has a risk for sever gerd symptoms, no optimal procedure for reconstruction after proximal gastrectomy has yet been established. although laparoscopic jejunal interposition is relatively complicated in procedure, we can safely perform in combination with common anastomosis techniques. conclusion: body weight loss in otg-ip group is smaller compared to otg group consecutive patients with early gastric cancer underwent solo spdg (n= ) and mldg (n= ) performed by same surgical team. solo spdg can be defined as practice in which a surgeon operates alone using camera holder. mldg usually requires two or three surgical assistants. the inclusion criteria in this study were (i) pathologic proven stage i-ii gastric cancer (ii) no other malignancy (iii) more than d lymph node dissection (iv) r surgery. one-to-two propensity score matching was performed to compensate for the differences between two groups. results: after the propensity score matching, solo spdg (n= ) and mldg (n= ) patients were selected. mean operation time ( ± . vs ± . mins, p= . ) and estimated blood loss (ebl) ( . ± . vs . ± . ml, p= . ) were significantly lower in the solo spdg group than in the mldg group. the hospital stay and the use of pain control were similar between the two groups. although the initiation of semi fluid diet was similar, the time to first flatus was earlier in the solo spdg adhesional omental hernia: a case report an unexpected cause of small intestinal obstruction in crohn's disease strangulation inguinal hernia due to an omental band adhesion within the hernia sac: a case report omental adhesion, intestinal herniation, and unexpected death in the elderly small bowel obstruction secondary to greater omental encircling band-unusual case report the median operative time was min. the median postoperative hospital stay was . d. histological examination of the tumors revealed carcinomas, adenomas, and carcinoid. complications occurred in ( %) patients, viz., ssi (two patients), pancreatic fistula (two patients), bleeding (two patients), passing failure (one patient), and cholangitis (one patient). however, no severe postoperative complications (clavien-dindo classification grade or higher) were reported in these cases. conclusion: our cases showed that duodenal tumor resection using lecs enables curability through a minimally this study aimed to compare the outcomes of tltg with those of latg by using a meta-analysis. methods: we searched pubmed, embase, and cochrane library in may, to locate prospective or retrospective studies on surgical outcomes of tltg versus latg. the outcome measures were postoperative complications such as anastomosis leakage and anastomosis stenosis, operation time, blood loss, time to flatus, time to first oral intake, and postoperative hospital stay endoscopic thyroid lobectomy: our early experience at tertiary care hospitals of lahore univariate analysis was performed followed by logistic regression to identify independent predictors for the primary outcome. results: forty-six out of ( %) patients referred for gp required jt insertion to treat malnutrition. etiology of gp included: % idiopathic, % diabetic, % post-surgical. thirty-six patients ( %) reported severe daily symptoms. twenty-five patients ( %) had successful return to oral intake while ( %) required prolonged feeding access, reinsertion of a jt or tpn initiation. on multivariate analysis patients who had a pyloroplasty (p= . , or . ) and those who were married (p= . , or . ) were found to be independent predictors of successful discontinuation of tube feedings. on subgroup analysis -hour gastric emptying time normalized after pyloroplasty (p= . ) in patients which had a successful re-initiation of oral intake while persistent gastric emptying refractory to pyloroplasty was associated with failure. the group of patients who underwent pyloroplasty did not differ in terms of demographics, marital status (p= . ) and preoperative gastric emptying (p= . ) from those who did not. gp etiology (p= . ) psychiatric conditions (p= . ) and substance abuse laparoscopic transabdominal repair of morgagni hernia rebekah macfie average procedure length was . minutes. average hospital length of stay was . days, with all patients tolerating a regular diet prior to discharge. our -day readmission rate was / ( . %). / ( . %) patients required repeat egd evaluation for either recurrence of symptoms or impacted food bolus. at week follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppi from their daily medication regimen. at month follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppis. at year follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppis. conclusion: as a recently introduced surgical option, no long-term data exists detailing the linx procedures ultimate success rates and complication profile mini-laparoscopic vs traditional laparoscopic cholecystectomy: preliminary report deniz atasoy since the introduction of minilaparoscopic cholecystectomy (mlc) in , it gained little interest that could be attributed to decreased durability of the reduced size instruments, poorer optical resolution and smaller jaws of the instrument tips. our aim was to compare the outcomes of mlc with traditional laparoscopic cholecystectomy (tlc) one developed choledocholithiasis on postoperative day one and after ercp the course was uneventful. the other patient developed choledocholithiasis and acute pancreatitis on the sixth postoperative day and was treated conservatively. the stone in the ampulla had fallen by itself without a need for ercp single-incision plus one additional port laparoscopic surgery for colorectal cancer with transanal specimen extraction: a comparative study two patients had a previous attempt of hernia repair, one with mesh. one patient did not have any immunosuppression due to hiv infection, whereas the other were on cyclosporine, tacrolimus and/or mycophenolate mofetil. there were two laparoscopic and two open cases, mean operative time was . minutes ( - ), mean blood loss was ml ( - ). mesh used were biological porcine dermis in one case, polypropylene with absorbable hydrogel barrier in three cases. mean mesh length and width were cm ( - ) and . cm ( - ) respectively. one patient underwent a component separation, though none of the patients had the fascial defect closed. there were no intra-operative complications. three patients were readmitted for hyperkalemia, abdominal pain, and seroma respectively. neither recurrences nor reoperations were reported. mean follow-up was . days ( - ) conclusion: post liver transplant incisional hernia repair is feasible either laparoscopic or in an open fashion. because of the size and location of the defect, fascial closure is unlikely achievable. the use of standard techniques and materials give a similar result of the non-transplant population. p technique of esophagojejunostomy using orvil after laparoscopy assisted total gastrectomy for gastric cancer shinichi sakuramoto there was a significant difference in mortality between the two time-periods, / patients died during - and / died during - (p= . ). those who died were significantly older ( years ( - )) than the survivors ( y ( - )) (p= . ). five of the patients who died in the previous group died without any intervention. / of those who had an acute open necrosectomy died. surgical necrosectomy correlated significantly with mortality (p= . ). the only patient who died in the recent group died without any intervention. none of the patients receiving minimal invasive drainage in this group died until now only cases in adults and fewer than cases in children have been reported in world literature, with surgical management being the only option. an innovative, minimally invasive laparoscopic excision of the abdominal sac was performed and the scrotal component was managed by jaboulay's procedure. this is probably the first case report in world literature describing laparoscopic management of hydrocele-en-bissac. case report: a year old male presented with complaints of bilateral hydrocele and swelling in right lower abdomen since one year. computed tomography of the abdomen revealed an encysted hypodense lesion with enhancing walls along the right side of pelvis, anterior to the psoas muscle and extending through the internal ring into the right inguinal region upto the scrotal sac; measuring . cm . cm suggestive of an encysted hydrocele of cord associated with hydrocele of both scrotal sacs excessive gastric resection may result in postoperative deformity of the stomach, with consequent gastric stasis in food uptake. to minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we have developed laparoscopic wedge resection (lwr) with the serosal and muscular layers incision technique (samit) for gastric gastrointestinal stromal tumors. this samit is simple and does not require special devices. purpose: the purpose of this study was to clarify whether lwr with samit for gastric gists is technically feasible in term of short-term outcome methods: all patients who went through lsg in our department between / to / have been evaluated for bleeding complications, after implementation of anti-bleeding policy: blood pressure was controlled to mmhg during stomach resection and staple line was reinforced throughout it's length with a running - absorbable v-lock suture. drains were used selectively. results: out of patients who went through the procedure ( . %) suffered hemorrhagic complications: patients had? hb[ gr%. patients received - red blood pc's. no patients were re-operated for bleeding. patients were readmitted for infected hematoma and had ct guided drainage. one patient ( . %) suffered from leak. conclusion: implementation of anti-bleeding policy in lsg is very effective. there is no need to use expensive buttress material to achieve these results. drains can be used selectively. the impact of this policy on leak rate needs to be fifty procedures immediately prior to, immediately after, and eight months after completion of training were included for each endoscopist. data were extracted from the electronic medical record and entered into spss for analysis. student's t-test was used to compare groups for continuous data, and chi-squared tests were used for categorical data. data were collected for procedures. patient groups pre, post, and eight months after csi training were comparable in terms of age ( . yrs, . yrs, and . yrs), sex ( it's in the bag; can stoma output predict acute kidney injury in new ostomates? robert fearn colostomy output stabilised rapidly, whilst ileostomy output increased progressively throughout the first postoperative days as can be seen in chart . twelve patients ( %) developed aki during index admission. length of stay was significantly greater in the aki group at ( % ci - ) days vs ( - ) days. highest daily stoma output was non significantly higher in the aki group ml ( % ci - , ml) vs , ( - , ml) as was mean daily stoma output at ml ( - , ml) vs ml ( - ml) (chart ). seventeen patients ( %) were readmitted for any reason, ( %) specifically for aki. in total patients ( %) developed aki within three months of their stoma surgery only of whom had developed aki during their index admission. all patients who developed aki following their index admission were ileostomy patients. conclusion: acute kidney injury in new stoma patients is associated with prolonged hospital stay and readmissions with associated morbidity and healthcare costs consecutive laparoscopic bariatric operations were performed, including primary roux-en-y gastric bypasses (lrygb), primary adjustable gastric bands (lagb), primary sleeve gastrectomies (lsg) and secondary bariatric surgeries and revisions. all bariatric procedures were approached laparoscopically ( procedures were stapled and were nonstapled). the mean patient age was years ( - ), females represented % and mean bmi was . kg/m ( - ). there were no perioperative mortalities, no conversions to open surgery and no intraoperative blood transfusions. there we two major intraoperative complications (hypopharyngeal perforation- , malignant hyperthermia- ). mean hospital stay was . days ( - days). eleven patients ( . %, in gastric bypass group and one in lsg group) required -day reoperations for postoperative complications (staple line gastrointestinal bleeding- , anastomotic leak- , strangulated port site hernia- , unexplained severe abdominal pain- , intestinal obstruction- , and intraabdominal abscess- ). there were no long term ( -year) mortalities in patients that required reoperation. there was one transfer to another institution. the dynamics of further improving safety was such that there was no complication on the recent consecutive stapled procedures and the mean hospital stay was . days ( - days). detailed subgroup analyses will be provided. conclusions: with well-controlled and structured pre-, intra-, and post-operative care, laparoscopic bariatric surgery can be performed with minimal reoperations and zero mortality in a teaching institution does concomitant placement of a feeding jejunostomy tube during esophagectomy affect quality outcomes? md, facs; icahn school of medicine at mount sinai background: placement of a feeding jejunostomy tube (fj) is often performed during esophagectomy. few studies, however, have sought to determine whether concomitant placement affects postoperative outcomes of esophagectomy of these, ldg was performed patients and odg was performed . we compared elderly patients (aged years or more) with younger patients in each operative procedure. (ldg: elderly , younger ; odg: elderly , younger ) preoperative comorbidity and surgical results were analyzed. multivariate analysis was performed to detect predictive factors for postoperative complications. results: in both ldg and odg groups, the operative time and amount of blood loss did not differ, while comorbidity was more common in elderly patients than in the nonelderly, and there were fewer retrieved lymph nodes in elderly patients. the incidence of all postoperative complications did not differ between both groups in each procedure, and there were no significant differences in the time to first flatus or postoperative hospital stay. however, in terms of specific postoperative complications, respiratory complications were more frequently observed in eldery group with odg significantly (p= . ), while not with ldg group. in multivariable analysis, age was not independent predictor of postoperative complications. conclusion: odg for eldery patients requires attention particularly in postoperative respiratory complications. ldg is a safe and less invasive treatment for gastric cancer in elderly patients who have greater comorbidity. p examining the role of preoperative ineffective esophageal motility in laparoscopic fundoplication outcomes tyler hall there were no significant differences in complications or recurrence rates. preoperative quality of life measures did not vary between the cohorts nor did postoperative scores at three weeks or six months. patients with % ineffective clearance exhibited worse gerd-hrql scores one and two years postoperatively conclusion: preoperative ineffective esophageal motility was shown to result in comparable short-term quality of life following ars. however, gerd-hrql scores at one and two yearsshowed worse outcomes in patients with preoperative iem robotic surgery as part of oncologically adequate ipmn treatment: indications, short and long term results federico gheza eligible patients who had minimally invasive surgery were stratified in multiport laparoscopic and robotic cohorts, and included if they had poi/sbo after surgery. comparative analysis assessed the demographic, perioperative, and postoperative outcomes. the main outcome measures were the incidence rate, associated variables, and time to ileus/ sbo across the mis platforms. results: during the study period total patients were reviewed- laparoscopic and robotic. postoperatively, ( . %) laparoscopic and ( . %) robotic patients suffered from poi/sbo laparoscopic sbo occur significantly later after the index procedure than robotic sbo ( conclusions: the rate of poi/ sbo is considerable and comparable across laparoscopic and robotic approaches. however, there are distinct differences in the severity, time to occurrence, and impact on quality measures, such as los and readmissions between laparoscopic and robotics. this information could be an important factor in which approach the surgeon choses laparoscopic surgical procedure was standard with using laparoscopic linear stapler. responses to surgery were evaluated a month after the operation based upon the american society of hematology evidence-based practice guidelines for itp. results: there was no open conversion in this study. the mean operation time and blood loss were min and g, respectively. there was no case using blood transfusion during and after operation. with regard to complications, one patient ( %) had a postoperative pancreatic fistula that did not require percutaneous drainage. positive responses, including the complete and partial remissions, were achieved in % ( / ). the mean follow-up duration was months, and the -, -, and -year relapse-free survival rates were % for all three time points. conclusions: the present study demonstrated that ls for itp can provide good long-term outcomes two cases of conversion from sp-c to open surgery were excluded. all procedures were followed postoperatively for a minimum of months, and wound complications such as bleeding, fat lysis, infection, or hernia were recorded. patients were classified as having a wound complication or not. results: pure transumbilical sp-c was completed . %, additional trocars were used in . %, and the rate of conversion to open surgery was . %. after a median follow-up of . (range, - ) months few cases performed with hand assist, notes, or single-incision. utilization of robotics was highest for bpd/ds ( of , cases, . %). the greatest number of robotic-assisted cases were sleeve gastrectomy ( , of , , . %) and gastric bypass ( , of , cases, . %). relatively few operations were converted to a different approach (see table). operative time was longer when using robotic approaches for both sleeve ( . vs . minutes, p. ) and bypass ( . vs . , p\ . ). postoperative los was no shorter when using robotic-assistance (see table). unadjusted -day outcomes revealed slightly higher rates of readmission for both operations when using robotic-assistance (see table), and slightly higher rates of complications after robotic sleeve gastrectomy p comparision of perioperative and survival outcomes of laparoscopic versus open gastrectomy after preoperative chemotherapy: a propensity score-matched analysis adjustment for potential selection bias in the surgical approach was made with propensity score-matched (psm) analysis. perioperative and survival outcomes were compared between the lag and og groups. results: in total, patients were identified from the database. after psm analysis, patients who underwent og were one-to-one matched to patients who underwent lag in the setting of nact. these two groups had similar outcomes in terms of intra-and postoperative complications and -year overall survival. however, the lag group had a longer operation time (p= . ) and lower estimated blood loss (p= . ). moreover, compared with patients in the og group, those in the lag group had fewer days until first ambulation conclusion: the present study indicates that lag performed by well-qualified surgeons for treatment of locally advanced gastric cancer after preoperative chemotherapy is as acceptable as og in terms of oncological outcomes. p outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease: effectiveness and economic benefits kyung won seo, phd; kosin university college of medicine purpose: laparoscopic antireflux surgery (ars) is an alternative treatment option for gastroesophageal reflux disease (gerd) in the world. however, the effectiveness and economic feasibility of ars versus medical treatment is unknown. this study was performed to evaluate the effectiveness and economic benefits of ars. methods: nine patients with gerd were treated using laparoscopic ars between and . surgical results and total cost for surgery were reviewed. results: seven men and women were enrolled. preoperatively, typical symptoms were present in patients, while atypical symptoms were present in patients. one patient underwent partial fundoplication due to absent peristalsis and the other underwent nissen fundoplication. postoperatively, typical symptoms were controlled in of patients, while atypical symptoms were controlled in of patients. overall, at months after surgery, reported partial resolution of gerd symptoms, with achieving complete control. the average cost of ars for nine patients was usd. conclusion: laparoscopic ars is effective for controlling typical and atypical gerd symptoms. the cost of ars may be more economical over the long term compared to medical treatment since laparoscopic surgery is reported to affect respiration and circulation, we should take indication of lag for elderly patients into consideration carefully. indication of lag for elderly patients, however, is still controversial. the aim of this study is to assess the safety and validity of lag for elderly patients. method: medical records were retrospectively reviewed for patients who underwent lag for gastric cancer between and . in this study, patients over years of age were defined as elderly patients. patients were divided into two groups according to age; group a (age ≥ , n= ), group b (age \ , n= ). preoperative characteristics and postoperative outcomes were analyzed. two-tailed student's test and/or pearson's chi-square test were used for statistical analysis. results: there were no significant differences in male/female ratio and body mass index between two groups. number of patients whose asa physical status was ≥ , and/or performance status was ≥ did not differ total gastrectomy ( . vs . %, p= . ), proximal gastrectomy ( vs . %, p= . ). intra-operative blood loss, operating time, and number of harvested lymph nodes did not differ between the two groups. as for postoperative complications such as intra-abdominal abscess ( . vs . %, p= . ), anastomotic leakage ( vs . %, p= . ), significant difference was not observed between the two groups. in addition, respiratory and cardiovascular complication was not observed in elderly patients. incidence of clavien-dindo classification ≥grade ( . vs . %, p= . ), and postoperative hospital stay ( . vs . days, p= . ) did not differ. conclusion: short-term outcomes of lag in elderly patients were not different from those in young patients the essential role of the transcystic duct tube (c-tube) during laparoscopic common bile duct exploration (lcbde) towakai hospital introduction: laparoscopic common bile duct exploration (lcbde) is a standard surgical procedure for the treatment of common bile duct stones (cbds). however, there are some problems associated with cbd drainage after operations even if performing with the primary closure. therefore, we developed a new drainage tube, c-tube, which contributes to shorter drainage periods and reduces perioperative complications. method: c-tube is a type of bile drainage tube which is fixed to the cystic duct with an elastic band. closing the duct with an elastic band as soon as c-tube is removed prevents bile leakage from the stump of the cystic duct. the essential roles of this tube include: . assisting suturing during operations, . use during intra-and post-operative cholangiograpy, . assisting post-operative endoscopic sphincterotomy when necessary we included patients from -years prior to our intervention and compared this with patients who had follow-up after implementation. we excluded patients having revisions, gastric banding, and patients whose primary surgeon had left during the data collection period. we analyzed demographics and follow-up rates at , , , , and months. chi-square test was used to evaluate for significance, and results were corrected for multiple comparison. results: patients met inclusion criteria in the pre-intervention group, and in the postintervention group. of those, were analyzed for the year follow-up visit. the pre-intervention group had males, females, and an average age of . approximately / of the surgeries performed were sg, / were rygb. the post-intervention group had males, females, average age of . approximately half of the post-intervention cases were sg while the rest were rygb. conclusion: bariatric surgery is a useful tool in aiding weight loss and improving comorbidities. it is essential that patients receive long-term follow-up and monitoring to achieve these goals. our program now uses a system of phone call reminders for scheduled visits, as well as calls and letters for annual visits surgeon's evaluation of an intraoperative microbreaks web-app workload questions were modified nasa task load index (physical demand, mental demand, and complexity) and procedural difficulty on - ( =maximum impact) scales. primary outcomes were the impact of microbreaks on surgeons' physical performance, mental focus, pain/discomfort and fatigue with checkboxes for improved, no change and diminished. secondary outcomes were microbreaks impact on distraction level and workflow disruption using a - ( =maximum impact) scale. descriptive statistics were calculated for median and interquartile ranges (iqr) of these responses. results: seven surgeons ( male, female), with a median (iqr) surgical experience of ( . , ) years, completed ten surgical days with a median (iqr) operative duration of ( , ) minutes/surgical day. the median number of microbreaks/surgical day was . the median (iqr) for mental demand, physical demand, surgical complexity and difficulty are shown in table . following each surgical day, surgeons reported / improved physical performance situs inversus totalis (sit) is inherited in an autosomalrecessive fashion with complete abnormal transposition of thoracic & abdominal viscera. its incidence varies from in to live births. for those undergoing surgery, laparoscopic approach is preferred as it avoids inappropriate incisions. however, due to mirroring of the viscera, the surgeon faces constant visio-spatial disorientation during laparoscopy. p ''how to be a surgeon and not dying trying'' control of basic physiological parameters in perioperative phase second main variable: blood pressure (bp) with manual measurement sleeve. preoperative bp and immediate postoperative bp were measured, we were not able to measure intraoperative bp due to the lack of consent of the surgeons involved for the use of other devices different from the heart rate band. secondary variables: years from graduation, years of practice, age, body mass index (bmi), number of medical co-morbidities, number of jobs, sleeping hours the night before. we took measurements to surgeons during a laparoscopic cholecystectomy. results: the mean preoperative heart rate was . bpm. the mean minimum intraoperative heart rate was bpm. the mean maximum intraoperative heart rate was . bpm ( % with tachycardia at the surgery). the mean immediate postoperative heart rate was . cpm. the mean heart rate minutes after the postoperative phase was . cpm. at the immediate preoperative phase % of surgeons had elevated bp level (usual normotensives) articles were randomly selected and the gender of the first and last authors determined. results: of the bariatric surgery publications reviewed, only % of first authors and . % of last authors were female surgeons. even though the proportion of female authors has increased over time, this is not proportional to the increase in the number of female surgeons or surgery residents (figure ). discussion: female surgeons are under-represented in bariatric surgery research. the number of female surgeons and residents has a continuous up trend over the last few decades our survey also included the validated quick-dash (disabilities of the arm, shoulder, and hand) questionnaire for upper-limb symptoms and the ability to perform certain physical activities. the quickdash is scored into two components: disability/symptom score, and the optional work module, which represent the impact of disability on daily activities and work responsibilities, respectively. both scores range from - , with a higher score indicating greater disability. surgeons were grouped according surgical focus (open, lap, or ra), and comparisons were made between groups. surveys with more than % of responses missing were excluded. statistical analysis were done using spss . , with α= . . results: completed surveys were evaluated (open: n= , lap: n= , ra: n= ). the survey response rate was %. . % of respondents were general surgeons, and mean age was ± . years. surgeons reported an average of ± . cases performed per month ra: . %, p= . ). likewise, there were no differences in the mean disability similarly, there was a positive correlation between mean work scores and reported pain in the upper-limb for lap and ra, both p. . conclusions: this nationwide survey revealed a similar prevalence of pain in the upper-limb among surgeons performing open, laparoscopic and robotic-assisted procedures. likewise, similar disability scores were reported between the three surgical groups. older surgeons performing laparoscopic and robotic-assisted approaches reported a higher impact of upper-limb problems interfering with their daily activities, unlike open surgeons. among all surgeons who reported pain in the upper-limb, laparoscopic and robotic surgeons were more likely to report that this pain interferes with their work activities an analysis of subjective and objective fatigue between laparoscopic and robotic surgical skills practice p d laparoscopic versus robotic gastrectomy for gastric cancer: comparisons of short-term surgical outcomes lin chen, xin guo patients who underwent d-lag (n= ) or rag (n= ) for gastric cancer were enrolled. the clinicopathological factors and short-term surgical outcomes were compared with retrospectively analysis. results: the clinicopathological factors between the two groups were well matched. postoperative recovery factors including the days of first flatus, days of eating liquid diet and hospital stay were similar. the rate of postoperative complications between the two groups were with no statistical differences in the subgroups of patients with total gastrectomy, d-lag had less blood loss and shorter operative time than rag (p= . and p. ), while for distal gastrectomy, blood loss and operative time showed no statistical differences. conclusions: this study suggests that d-lag is a novel and acceptable surgical technology in terms of surgical and oncological outcomes. d-lag is a promising approach for gastric cancer therapy methods: patients underwent robotic surgery between the beginning of to first half of in turkey were included. data were obtained from a prospectively maintained database. patient, surgeon and hospital identifiers were encrypted. parameters were operation type, operation year, robotic system used (s, si, xi), hospital volume and surgeon volume. high volume robotic colorectal hospital and surgeon was defined as the caseload within the forth interquartile ( th- th) based on the median value. results: there were colorectal procedures. surgeons performed robotic colorectal surgery at hospitals. ( . %) and ( . %) procedures were performed with the s-si and xi platforms respectively. hospitals have both of the si and xi platforms. hospitals are the si, hospitals are the xi hospital currently. the number of robotic colorectal operations increased gradually by years (figure ). the median numbers of colorectal procedures were (range - ) and (range - ) per hospital and per surgeon respectively among those hvrcs, the numbers of si and xi users were and respectively. the surgeons who performed more than procedures continued to use robot in their practice except one surgeon who stopped at . only left colectomies and no right colonic resection were performed before introduction of the xi platform first robotic cases and implementation of a robotics curriculum in a general surgery residency domenech asbun armonk ny) and utilized student's t test and chi-square. we also performed a linear regression analysis to determine the effect of or time, robotic surgery, and diagnosis on operating room costs and postoperative length of stay. results: laparoscopic and robotic cholecystectomies were performed. demographic parameters (age, gender, medical comorbidities, preoperative albumin and bmi, surgical history and smoking) were comparable. primary diagnosis was significantly different (chi-square . ), driven by more acute cholecystitis in the laparoscopic group. / robotic cases and / ( . %, p = . ) laparoscopic cases were converted to open ( for adhesions, for failure to progress, and for visualization of anatomy after adjusting for or time and diagnosis, robotic surgery was associated with a $ increase in costs robotic surgery is independently associated with increased or cost, but individual hospital systems must decide if this additional cost outweighs increased robot utilization and training benefits for physicians and staff robotic abdominal wall hernia repairs: technical considerations and lessons learned inguinal hernia repairs (ihrs) comprised the majority ( . %) of cases ( . % male, mean age . , mean bmi . ). there were unilateral ihrs with an average operative time of . ± . min and an average ebl of . ml. there were bilateral ihrs with an average operative time of . ± . min and average ebl of . ml. thirteen ihrs were combined with umbilical hernias and two with incisional hernias. average operative time for combined procedures was . min and average ebl was . ml. fifty-five incisional hernias were repaired robotically ( . % male, mean age . , mean bmi . ), four of which were retrorectus and two of those required transversus abdominis release. median hernia size was cm ( - cm). mean operative time was . ± . min and average ebl was . ml. twenty-three ventral/umbilical hernias were repaired robotically ( . % male, mean age . , mean bmi . , median size . cm ( - cm), mean operative time . ± . min, average ebl . ml). one spigelian hernia (operative time min, ebl ml) and one parastomal hernia (operative time min, ebl ml) were repaired robotically. there were no major complications and only groin seroma requiring percutaneous aspiration. nine patients required conclusion: this study demonstrates improved outcomes of robotic inguinal hernia repair compared to an open or laparoscopic approach. robotic hernia repair showed overall lower -day complication and readmission rates, and shortened los. while open approach had the highest rate of opiate use we retrospectively investigated consecutive overweight gc patients (bmi≥ ) underwent distal gastrectomy with d lymphadenectomy ( for rag and for lag) performed by two surgeons. the clinicopathological and surgical features were compared between groups. the cutoff point for initial phase (phase i) and stable phase (phase ii) were determined by cumulative sum (cusum) curve of operation time. results: generally, the surgical outcomes including postoperative complication rate, duration of postoperative hospital stay and lymph nodes harvest in the overweight patients have comparable results between rag and lag groups. the cutoff determining phase i and ii according to the cusum figure for rag group was and cases for surgeon a and b, respectively. and comparison analysis showed that the operation time of phase ii rag was significantly shorter robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy: a single-center experience including perioperative morbidity and short-term outcomes patient factors, treatment factors, and outcome measures were collected in an attempt to gain insight and to generate ideas to potentially improve outcomes. results: there were no operative complications. six patients ( %) had failed gastric pacemaker placement prior to intervention. nine patients ( %) reported improvement in their symptoms and overall quality of life. four patients ( %) reported no improvement in symptoms and required additional intervention for symptom control and supportive care (one underwent roux-en-y gastric bypass, three underwent laparoscopic jejunostomy feeding tube placement to maintain nutrition). conclusion: robotic-assisted pyloroplasty is a safe option that improves symptoms and quality of life in % of our patients patients were matched into cohorts by procedure type. outcomes were analyzed using unpaired t-test and fisher's exact test. results: cost data was available for patients undergoing ras or la procedures. significant increases in equipment, labor, and overhead costs resulted with ras vs. la. variable-labor and variable-overhead costs were significantly higher in la procedures. higher supply costs and longer procedure time was seen with ras in all cohorts however, total -day costs were not significantly different in any group. conclusion: ras led to significant increases in fixed clinical, operative and pathologic factors were reviewed and analyzed. results: seventy patients underwent robotic surgery for rectal cancer during the study period. the locations of tumor were upper rectum, lower rectum. the procedure were as follow, high anterior resection in , low anterior resection in , isr in , apr in patients. eight patients underwent bilateral lymph nodes dissection (llnd). the procedures were performed successfully in all cases. mean age was . years, and % of the patients were men, and the mean body mass index was . (range, . - . ) kg/m . median operative duration was ( - ) minutes. median blood loss was ( - ) ml. median postoperative stay was ( - ) days. mean harvest lymph node number was . ( - ). surgical margins were negative in all cases. there was one conversion due to bleeding during the llnd and anastomotic leakage occurred in two patients. morbidity was %. there was no mortality postoperatively in this series. conclusion: in early series of the selected patients, this technique appears to be fesible and safe when performed by surgeons skilled in laparoscopic colorectal surgery the inactive electrode was placed touching small bowel to simulate accidental thermal injury. the bowel tissue at the site of temperature change was immediately resected and examined histologically for tissue injury. student t-tests were used for all comparisons with a p-value less than . considered statistically significant. results: comparison of the laparoscopic and robotic techniques are displayed in table . energy transfer was quantified using energy leak (per ma), which in these tests averaged . degree celsius change ( % ci . - . ) at the inactive electrode. surface temperature heated to a maximum of . degrees celsius, more in the robotic system than laparoscopy but still clinically negligible. pathology results from in vivo testing showed only thermal injury to the serosa without deeper mural injury. conclusions: stray energy transfer occurs in both laparoscopic and robotic surgery in amounts that are measurable but without clinical relevance. the average change in tissue temperature is less than degrees celsius laparoscopically and less than degrees robotically. while the robotic surgery appears to transfer more stray energy, no significant bowel injuries were caused in either group. p robot assistance can improve the performance of laparoscopic extensive concomitant adhesiolysis: results from a large observational study federico gheza outcomes compared were operative time, conversion rate, overall complications, gastrointestinal (gi) related complications (wound infection, abdominal abscess, anastomotic leak, ileus and small bowel obstruction), hospital length of stay, and -day re-admission rate. two sample t-test was used and p. was considered statistically significant. results: fifty-five robotic colectomies were matched with laparoscopic counterparts based on type of operation: right colectomy (n= ), sigmoidectomy (n= ), low anterior resection (n= ), proctocolectomy (n= ), transverse colectomy (n= ), abdominoperineal resection (n= ), and total abdominal colectomy (n= ) we assessed if technical obstacles of laparoscopic suturing were decreased and if laparoscopic skills overall were improved. surgical outcomes were compared relative to our historic values; we assessed procedure time and operating room efficiency, including set up and turn-over times. results: overall, the d/flexdex system permitted a greater improvement in working speed, superior optical visualization, and better suture handling compared to standard laparoscopy. all surgeries were completed without any complications. historically, we considered laparoscopic suturing to be complicated and inefficient. we relied on tacking devices for mesh fixation, suturing was previously completed with large cumbersome straight laparascopic devices. however, with flexdex and endoeye flex d, tacking devices have been eliminated and suturing technique improved. the mean total procedure times remained comparable for inguinal and hiatal hernia surgeries, and slightly longer for ventral hernias. operating room efficiency, including mean set up and turn-over times also remained unchanged. the acquisition cost for both the olympus endoeye flex d laparoscopic imaging system we performed a cost analysis which showed an average total cost of $ , for laparoscopic sleeve gastrectomy and an average of $ , for robotic assisted. the total reimbursements were $ , for laparoscopic sleeve gastrectomy and $ , for robot assisted. this translated to an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. we analyzed these differences for bypasses as well. laparoscopic bypasses averaged minutes laparoscopically vs robotically. we found an average cost of laparoscopic $ , vs robot assisted $ , , with a contribution margin of $ , laparoscopic vs $ , robot assisted. conclusions: in our study we noted increased operative times with robot assisted operations, especially bypasses which could be explained by increased use of the robotic system for difficult cases such as revisional bypasses. the impact of cost is especially important in this financial climate, and judicious use of resources becomes important when determining surgical approach average or time for rih was minutes compared to lih which was minutes. average intraoperative cost for rih was $ , compared to lih which was $ . of note, one lih was converted to open, whereas none of the rih required conversion. average los was . hours for rih compared to . hours for lih. postoperative pain at one week follow up was the same between both groups. two postoperative surgical site occurrences (sso) occurred in the lih group ( groin seromas), whereas no ssos occurred in the rih group. eleven ventral hernia repairs were examined, were robotic (rvh) and were laparoscopic (lvh). average or time for rvh was minutes compared to minutes for lvh. average intraoperative cost for rvh was $ , compared to lvh which was $ , . no procedure from either group required conversion to open. average los was . hours for rvh, and . hours for lvh. again, postoperative pain was the same at one week follow up for both groups. there were no postoperative complications noted in either cohort. conclusion: operative time and procedural costs for rvh and rih repairs were shown to be longer and more expensive when compared to their laparoscopic counterparts. however, with increased operative experience using the robotic platform, surgical time did show a decreasing trend does robotic system have advantages over laparoscopic system for distal pancreatectomy? results: a total of consecutive patients underwent minimally invasive distal pancreatectomy (ldp n= ; ra-ldp n= ). most common pathologic finding was pancreatic ductal adenocarcinomas ( cases). there was no in-hospital mortality or cases of conversion to open surgery in this study. spleen-preserving approach was performed more often in the ra-ldp ( %) than in the ldp ( . %) groups (p= . ) both groups showed no significant differences in the total number of lymph nodes, number of positive lymph nodes, tumor differentiation, tumor stage, and resection margins. conclusions: ra-ldp is a safe and feasible approach that has an advantage of performing spleenpreserving distal pancreatectomy, with perioperative and short-term oncologic outcomes comparable to those of ldp. p robot-assisted alpps technique mike fruscione right portal vein embolization was not feasible secondary to the proximity and size of the right hemi-liver tumor burden relative to the right portal vein. the pre-operative planned procedure was a right trisectionectomy and microwave ablation of the segment lesion. results: using the da vinci xi surgical system (intuitive surgical, inc.) the right portal vein was dissected, doubly-ligated, and divided. the liver parenchyma was split from the inferior edge to the dome mm medial to the falciform ligament and down to the middle hepatic vein which was preserved to maintain adequate venous outflow. the patient was discharged home on post-operative day two. on post-operative day six, ct volumetrics demonstrated a flr of %. on post-operative day seven, a second stage alpps procedure was performed where the right hepatic artery, middle and right hepatic veins and right hepatic duct were ligated and divided. segments a/b, , , and were removed. the patient was discharged home on post-operative day five they were asked to answer demographic questions and rate their comfort level ( =not comfortable, =very comfortable) with aspects of robotic surgery. paired t-tests and wilcoxon tests were used to assess whether there were changes in comfort level before and after labs, and chi-square goodness of fit tests were used to assess whether dry lab (using inanimate objects), wet lab (using a porcine model), or simulator modules were thought to be most helpful in obtaining specific robotic skills. results: the survey response rate was % (n= ). ninety-one percent of residents felt that robotic surgery is not intuitive. prior to simulation, % of residents felt inadequately prepared to safely operate on the robotic console. following simulation, % felt better prepared and more confident to participate in robotic surgery for the first patients whom we treated (the first-stage group), we invited a visiting expert from a high-volume center to perform the procedure jointly with our hospital's surgeons by using a dual console. for the subsequent patients (the second-stage group), the procedure was performed by our hospital staff alone. in this report, we describe our experience of introduction of robotassisted colectomy and discuss issues for the future. patients and methods: the operative procedure was sigmoid colectomy, low anterior resection, and intersphincteric resection. the median number of lymph nodes dissected was . . the mean operating time was minutes for the first-stage group and minutes for the second-stage group. the median console time was minutes for the first-stage group and minutes for the second-stage group, with no significant differences between the two groups. the mean operating time other than console time was minutes for the first-stage group and minutes for the second-stage group, significantly longer in the latter group. the mean amount of hemorrhage was . g in the first-stage group and g in the second-stage group. no significant differences were found between the two groups in the mean length of postoperative hospital stay. none of the patients in either group developed a complication of clavien-dindo grade iii or higher. conclusions: the use of dual console system was particularly useful for the introduction of robotassisted surgery in our hospital. for the patients whom we treated, we found almost no difference in console time between the first-and second-stage groups. the high-quality instruction received via the dual console was considered to have had a beneficial effect on the operators' learning curve. however, the operations that were set up other than console time, such as roll-in and docking, took significantly longer in the second-stage group when the proctor was not present select specimens from each trial were immediately resected and evaluated for histologic thermal injury. experiments were repeated times based to detect an expected difference of five degrees. student t-tests were used for all comparisons with significance set at . . results: stray energy transfer was higher in the single incision setup compared to the traditional setup (figure ). stray energy in the assistant grasper caused . ± . °c of temperature change in the standard configuration, and . ± . °c in the single incision configuration (p= . ). doubling energy output to w amplified the same finding robotic single-site cholecystectomy of cases: surgical outcomes and comparing with laparoscopic single-site procedure jae hoon lee incisional hernia occurred one case in each group. rssc is safe and feasible procedures. with accumulating of experience, rssc had more short operative time than sslc. comparing to sslc, rssc is relatively suitable to acute gallbladder disease and high bmi and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy. p initial experience using da vinci xi robot in colorectal surgery anna r spivak, do, john marks, md; lankenau medical center introduction: the xi robot has been developed to facilitate multiquadrant abdominal surgery. this report presents initial experience to evaluate feasibility and safety of xi robot in colorectal surgery. methods: all cases performed on xi robot were prospectively entered into a robotic database that was queried for colorectal cases performed from intraoperative complications were encountered in cases ( . %), requiring conversion to laparoscopy. none were converted to open. mean length of largest incision . cm. median ebl ml. there was no mortality. there were ( . %) immediate postoperative morbidities: postoperative abscess, bowel perforation, two postoperative bleeds, two hernias, two hematomas, smv thrombosis, small bowel obstruction. perioperative blood transfusions were required in . % of cases. there was one anastomotic leak. median time from surgery to low residue diet and discharge was days. conclusion: initial experience shows robotic colorectal resection with da vinci xi learning curve for robotic sleeve gastrectomy and roux-en-y gastric bypass: achieving equivalence to laparoscopy residents and fellows participated in an analogous fashion in both arms of the study, and patients undergoing re-operative bariatric surgery were excluded. results: a total of patients undergoing rsg (n= ) or rrygb (n= ) were included. for the overall robotic cohort, median age was (range - ), % were american society of anesthesiologists (asa) score , % were asa score , and mean body mass index (bmi) was ± with no differences between procedures. there were no conversions to open. there was one patient with portal vein thrombosis after rsg which occurred in the th rsg and one patient who underwent re-operation in the immediate post-operative period for hemorrhage at the gastro-jejunal anastomosis in the rrygb group; this occurred in the th rrygb. there were no leaks, strictures, or mortalities in either group. mean length of stay was days± for rsg with no difference based on number of procedures performed. in the rrygb group, los decreased after the first five procedures from days± to days±(p= . ). for both procedures, operative time decreased by number of procedures performed (figure). equivalence to lsg in operative time ( minutes± ) was reached after eight robotic procedures were included. the da-vinci xi® was used for the operations. age, gender, body mass index (bmi), asa score, indication for surgery, urgency of procedure, type of procedure, docking number, operation time, estimated blood loss, complications, short (≤ days) and long term ([ days) complications were evaluated. results: patients ( females) were included. median age was . median bmi was , median asa score was . total and completion rrp-ipaa were performed for and patients respectively. the indications were as follows: medical refractory uc (n= ), cancer/dysplasia (n= ), fulminant colitis (n= ), toxic megacolon (n= ), medical treatment resulting in growth retardation (n= ), medical treatment refractory bleeding (n= ). patient with toxic megacolon had an emergent operation. the median docking number was and for completion and total rrp-ipaa respectively. median operative time was minutes. median blood loss was ml. all patients had a stapled ileal j pouch anal anastomosis. all patients had a diverting loop ileostomy at the time of ipaa creation. no intraoperative complications were observed. no conversion to open surgery was needed. the median time to flatus was day. the median time to oral intake was day. patient had a laparotomy on postoperative day due to intra-abdominal bleeding. patient had a bleeding from ileostomy which was treated endoscopically. superficial surgical site infection was observed in patients. patient had a pouchitis managed with oral antibiotics. patient had an ileus responded to conservative treatment. patient had a per-anal bleeding stopped spontaneously. patient had a urinary tract infection responded to antibiotics. patients had pouchitis, patient had a perianal fistula requiring a loop ileostomy and a parastomal hernia was developed in another patient in long term follow up ) were significantly different between the two groups. , pairs undergoing primary and pairs undergoing revisional procedures were successfully matched. robotic gastric bypass was associated with a significantly longer operation length than laparoscopic gastric bypass for both primary (median difference minutes, p. ) and revisional (median difference minutes, p. ) procedures overall, there were no significant differences in anastomotic/staple line leak, -day readmission, reoperation, re-intervention, total event, and mortality rates between matched cohorts. conclusion: when controlling for patient characteristics, those undergoing primary and revisional lrygb and rrygb had no difference in early morbidity. despite the prolonged operative duration, the robotic approach was not associated with any clinical benefit or increased complications for primary or revisional gastric bypass surgery preoperative risk factors were collected. we focused on perioperative outcomes and in hospital complication rate. results: thirty-three patients underwent robot assisted giant hiatal hernia repair at our institution. patients ( %) were years and older and patients ( %) had a bmi higher then. there were no significant differences in patient characteristics between the groups. no patient underwent conversion to open or standard laparoscopy. no mortality was observed and no transfusions were needed. four patients ( %) had a complication, two of them were older than years old. three of the four patient ( %) that had a complication were obese. there were no statistical differences in mortality % and . % of them were with s-si and xi platforms respectively. the median numbers of procedures were (range - ) and (range - ) cases per hospital and per general surgeon respectively. the high volume surgeons (higher than th percentile) performed ( %) of the cases. the xi platform has been the main tool for colorectal surgery only (figure ). conclusions: while xi platform significantly increased caseload in general surgery by facilitating performance of colorectal surgery, its preference in other general surgical fields is not superior to si laparoscopic inguinal hernia repair (tapp) -first experience with the new senhance robotic system robin schmitz ; intuitive surgical inc, loma linda university medical center introduction: crohn's disease is an incurable inflammatory disorder that can affect the entire gastrointestinal tract. while medical management is considered first-line treatment, approximately % of patients with crohn's disease require surgery within years of their initial diagnosis. traditionally, surgery has been performed via an open approach with poor adoption of minimally invasive technique. the aim of this study is to demonstrate the feasibility of robotic-assisted approach as a minimally invasive option for surgical management of crohn's disease and compare the perioperative outcomes with traditional laparotomy. methods: patients who underwent elective resection of the intestine for crohn's disease by roboticassisted or laparotomy approach from to q were identified using icd- codes from premier healthcare database. all the procedures were performed by either general surgeons or colorectal surgeons. since hospital characteristics were comparable between the two cohorts before propensity-score matching, : matching was performed using patient characteristics such as age, gender, race, charlson index score and year of the surgery to create comparable cohorts. sample selection and creation of analytic variables were performed using instant health data (ihd) platform (bhe methods: we conducted a retrospective analysis of , mis inguinal hernia repairs ( , robotic, , laparoscopic) from through with data collected in the premier hospital database. patient, surgeon, and hospital demographics of robotic and laparoscopic inguinal hernia repairs were compared. the adjusted odds ratio of receiving a robotic procedure was calculated for each of the demographic factors using a multivariable logistic regression model. statistical significance was defined as p. . sas software version . was used for statistical analysis. results: the odds of a procedure being robotic increased from inguinal hernia repair is one of the most common general surgery procedures with over , performed annually in the united states. when compared to traditional open inguinal hernia repair (oihr), laparoscopic inguinal hernia repair (lihr) has been associated with faster postoperative recovery rates and lower postoperative pain. with advances in the robotic platform, robotic inguinal hernia repair (rihr) is an available technique that is currently being explored. this study examines lihr and rihr as described in literature to see if one is superior to the other. study design: search terms: ''inguinal hernia repair surgical complications including hematomas ( . %), seromas ( . %), and trocar site infection ( . %) resolved with antibiotics, with a . % postoperative complication rate. conclusion: rihr repair is a safe alternative to lihr, with fewer postoperative complications and a faster recovery time. however, operative time as well as or room time is significantly longer, which may increase overall cost laparoscopic or robotic approach were chosen on a schedule availability basis. data was collected prospectively and it involved anthropometric data, presence of type diabetes mellitus (t dm), % of preoperative total weight loss (%ptwl), surgical time, postoperative length of stay, -day complications, and need for readmission or reoperation. comparison between groups was carried on with t-test for continuous data and with chi-square test for dichotomous variables. a p lower than . was considered significant. results: overall sagb were performed, laparoscopic and robotic. a long and thin gastric pouch was created calibrated by a fr bougie and a . cm antecolic antegastric gastrojejunal (gj) anastomosis was groups (laparoscopic vs robotic) were comparable regarding age ( vs . years, p= . ), bmi ( . vs kg/m , p= . ), %ptwl ( . vs . %, p= . ) and % with t dm ( vs there were fewer men in the laparoscopic group ( . vs % there were ( . %) major complications in the laparoscopic group: bleedings from the gj anastomosis, one of which required reoperation, severe dumping syndrome, gerd requiring revision and gj stricture that underwent relaparoscopy. the only complication ( %) in the robotic group was an acute pancreatitis. readmission rate was % in both groups and reoperation rate was % for laparoscopic and % for robotic surgeries. conclusions: totally robotic sagb with manual gastro jejunal anastomosis was safe and feasible in this early experience compared to laparoscopic approach multi degrees of freedom manipulator with mantle tube for assisting endoscopic and laparoscopic surgical operations masataka nakabayashi, phd , yuta hoshito, masters student p step by step anatomic mapping during laparoscopic transabdominal adrenalectomy lateral flank approach ranbir singh steps analyzed were: right adrenalectomy: step ) mobilize liver; ) medial dissection; ) adrenal vein isolation; ) inferior dissection; ) adrenal off kidney; ) detachment. left adrenalectomy: step ) division splenorenal ligament; ) develop plane pancreas/kidney; ) mobilization medial/lateral borders adrenal; ) adrenal vein isolatoin; ) dissection adrenal off kidney; ) detachment. structures were identified as yes/no and results expressed as percentage total n of cases seen at each step. results: structures identified at each step are shown (table) incisions were made at the oral vestibule under the inferior lip. a -mm trocar was inserted through the center of the oral vestibule with two -mm trocars above incisors. the subplatysmal space was created down to the sternal notch, and carbon dioxide was insufflated at pressure mmhg to maintain the working space. parathyroidectomy was performed using laparoscopic instruments. intraoperative parathromone levels were measured minutes after excision of gland. primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within postoperative days (sf- ), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. result: one patient experienced a transient recurrent laryngeal nerve palsy which was spontaneously resolved within month. no permanent recurrent laryngeal nerve injury was found no mental nerve injury or infection was found. conclusion: with highly sensitive localising sestamibi and ct scans, focussed exploration is the current standard of treatment. among all minimally invasive surgeries, toepva is a feasible, safe, and almost pain-free surgical option when combined with intraoperative parathormone monitoring for patients with hyperparathyroidism indocyanine green is a water soluble nontoxic compound exhibiting near infrared renal function and long-term survival. indocyanine fluorescence helps in assessing vascular flow, tissue perfusion and aberrant anatomy and thereby leads to lower conversion rates in partial nephrectomy. we aim to present our experience in patients who underwent partial nephrectomy over years. materials and methods: of the partial nephrectomies performed at our institution, were done by laparoscopic approach alone and rest by patients who underwent llr for whole hepatoma in our facility, underwent llr for a solitary hepatoma and were divided into "before standardization" (bs; n= ) and "after standardization" (as) groups (n= ). patient background, characteristics, and perioperative outcomes were compared between these groups. procedure: we chose the devices according to phases of liver transection. a soft-coagulation monopolar device was used for marking surface. an ultrasonically activated device was used for transection of the liver surface within a -cm depth. crash and sealing with biclamp were indicated for deep-phase transection. the cavitron ultrasonic surgical aspirator was used if the lesion was close to the major glisson's sheath or the major hepatic vein. results: no significant differences in the patients' background were found between the two groups. the operative durations were min ( - min) and min ( - min) in the as and bs groups, respectively, with a significant difference (p. ). the blood loss volumes were cc ( - cc) and cc ( - cc), respectively (p= . ). the lengths of hospital stay after llr were days (range, - days) and days ( - days), respectively, with a significant difference iwao kitazono, phd , kentaro gejima , hizuru kumemura , akira hiwatashi , yuichiro nasu , fumisato sasaki , akio ido , yutaka imoto ; cardiovascular and gastroenterological surgery, kagoshima university graduate school of medical and dental science, digestive and lifestyle disease, kagoshima university graduate school of medical and dental science introduction: in locally-treatable gastrointestinal tumors, laparoscopic endoscopic cooperative surgery (lecs) is a minimally-invasive technique that can avoid excessive resection of the gastrointestinal tract. objective: to share our therapeutic guidelines and surgical technique of lecs for gastroduodenal tumors. subjects: nineteen patients who underwent lecs for gastroduodenal tumors ( patients with gastric tumor and patients with duodenal tumor).[results] ) gastric tumors ( gist, glomus): . site of lesion was u ( patients), m ( ), or l ( ), . operative procedure was acquired in a stepwise manner from classical lecs ( patients) to inverted lecs ( ) to non-exposed endoscopic wall-inversion surgery: news ( ). . operative outcome revealed no postoperative complications. ) duodenal tumors ( adenoma, m cancer, ectopic pancreas): . site of lesion was bulbus duodeni ( patient), superior part ( ), or descending part ( ); . operative procedure was esd followed by laparoscopic continuous suture in a single seromuscular layer for patients with preoperatively confirmed or suspected cancer, or full-thickness resection followed by albert-lembert suture along the short axis for patients unable to undergo esd. in all cases, c-tube was placed to prevent bleeding and perforation at the site of resection due to exposure to bile; . operative outcome included successful endoscopic hemostasis upon bleeding from exposed vessel on postoperative day in patient and anastomotic leak in patient. the event of anastomotic leak resolved after days of bile drainage through c-tube and conservative therapy. compared with patients who underwent esd alone, those who underwent lecs had significantly larger diameters of resected specimens and tumors (p. ) but no significant difference in the incidence of postoperative bleeding and delayed perforation. conclusion: for gastroduodenal tumors, lecs is a minimally-invasive and safe therapeutic option as it combines advantages of both laparoscopy and endoscopy. in particular, c-tube placement for bile drainage was effective in reducing exposure of the suture site to bile as well as supporting drainage after anastomotic leak. introduction: in japan, transurethral balloon catheters (tuc) are currently inserted in most surgical patients to maintain a urine outflow route and to measure the urine output both intraoperatively and postoperatively. however, tuc insertion not only causes postoperative pain but can also lead to urinary tract infections. temporary suprapubic catheters (spc) are used in the field of obstetrics and gynecology as a method of postoperative management to avoid performing transurethral procedures. in the field of surgery, especially in laparoscopic surgery, spc also considered how it would be a useful way to reduce patient suffering. here we report our prospective study on whether an spc can be safely inserted as a substitute for tuc during laparoscopic-assisted colectomy. subjects and methods: the subjects in this study were patients who underwent laparoscopic surgery for primary colorectal cancer from to , and who would normally have had their urinary balloon catheter removed early after surgery. during surgery, an angiomed cystostomy set was installed for patients who gave their consent to participate in this study as an alternative to a urinary balloon catheter. we prospectively collected patient information including sex and age, in addition to other perioperative data, such as, time required for cystostomy, complications accompanying cystostomy, sense of discomfort or pain associated with the vesical fistula after surgery, the time of the removal of the vesical fistula, the frequency of releasing the vesical fistula, postoperative complications. results: our subjects included cases who gave their informed consent to have an spc inserted. an spc was inserted into the remaining case. the mean surgical duration was min, and the spc insertion was performed at a mean of min after the start of surgery. insertion required a mean duration of . s. the bladder of one case ( . %) was perforated, and hematuria was observed at the time of insertion in two cases ( . %), but surgery completed without any incident. six out of cases ( . %) demonstrated neither urinary urgency nor independent urination on the day the catheter was clamped. however, the clamp was released two to four times, and draining of an average of ml urine, urinary urgency, and independent urination were confirmed - days later. conclusion: spc is a procedure that avoids crossing the urethra and its associated disadvantages. here we were able to demonstrate that the procedure can be safely used in laparoscopic surgery patients.our objective is to devise methods for proper port placement to overcome the ergonomic challenges. procedure: patients with sit were operated laparoscopically in our hospital in the period of may to november , males suffering from cholelithiasis without cholecystitis and female with acute appendicitis. after thorough review of literature and proper planning, the patients were posted for surgery. for laparoscopic appendectomy, a thorough initial diagnostic survey is performed on introducing a scope through the umbilical port and confirming the exact location of the appendix. the two working ports are introduced accordingly, which is usually a mirror image of the standard port sites. the appendix was visualised in the left iliac fossa and after meticulous dissection, the appendix and mesoappendix were divided using an endostapler. the operative time was minutes and there were no intraoperative or postoperative complications.the port placement for laparoscopic cholecystectomy in such a case is trickier as the anatomical variation and the contralateral disposition of the biliary tree demand an accurate dissection and exposure of the biliary structures to avoid iatrogenic injuries. it is important to conform to the principles of triangulation during port placement. the mirror image of -port placement is convenient for left-handed surgeons. whereas, to make the procedure comfortable for right-handed surgeons, the working ports need to be shifted caudally with the surgeon standing between the patient's legs. the mean operative time was minutes and there were no minor or major intraoperative or postoperative complications.conclusion: ergonomic comfort is vital to a smooth procedure. while mirroring ports suffices for appendectomy, all other procedures require forethought for port placement. it should be noted that ambidexterity is a desirable skill in the operating room for a laparoscopic surgeon.priscila r armijo, md, chun-kai huang, phd, gurteshwar rana, md, dmitry oleynikov, md, ka-chun siu, phd; university of nebraska medical center introduction: the aim of this study was to determine how objectively-measured and self-reported fatigue of the upper-limb differ between laparoscopic and robotic surgical training environments. methods: surgeons at the sages conference learning center, and at our institution were enrolled. two surgical skills practical environments were utilized: ) a laparoscopic training-box environment (fls) and ) the mimic® dv-trainer (mimic). two standardized surgical tasks were chosen for both environments: peg transfer, and needle passing. each task was performed twice. objective fatigue was evaluated by muscle activation and fatigue, and comparisons were made between fls and mimic, for each surgical task. muscle activation of the upper trapezius, anterior deltoid, flexor carpi radialis, and extensor digitorum were recorded during practice using surface electromyography (emg; trignotm, delsys, inc., boston, ma). the maximal voluntary contraction (mvc) was obtained to normalize muscle effort as %mvc. the median frequency (mdf) was calculated to assess muscle fatigue. subjective fatigue was self-reported by completing the validated -scale score piper fatigue scale- (pfh- ) before and after practice. statistical analysis was done using spss v . , with α= . . results: this abstract represented the performance of trainees (fls: n= , mimic: n= ) as part of larger cohort of the study. for peg transfer, emg analysis revealed that mimic had a significant increase in mean muscle activation for the upper trapezius and anterior deltoid, both p\ . . conversely, practice with fls led to significantly more muscle fatigue than mimic for the same muscle groups (upper trapezius: p= . , anterior deltoid: p= . ), represented by a significantly lower mdf. similarly, for needle passing, mimic had a significant increase in mean muscle activation for the upper trapezius (p= . ) and anterior deltoid (p= . ), but practice with fls significantly induced more muscle fatigue effort for anterior deltoid (p= . ). survey analysis revealed a significant decrease in self-reported fatigue after performing fls tasks (before: . ± . , after: . ± . , p= . ), but no difference after mimic tasks (before: . ± . , after: . ± . , p= . ). conclusions: although different muscle groups are preferentially required in the performance of fls and mimic, our analysis for both surgical tasks showed practice with mimic required more activation of shoulder muscles, whereas practice with fls could lead more muscle fatigue for the same muscle groups. interestingly, surgeons reported improved or no change in perceived fatigue after the tasks, despite of having an increase in muscular activation and effort. subjective selfreport fatigue might not truly reflect the level of fatigue when trainees practice surgical tasks using fls or mimic. objective: to investigate the prevalence of musculoskeletal (msk) injuries in bariatric surgeons around the world. background: as the popularity of bariatric surgery increases, efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. however, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with a recent report showing a - % prevalence of physical complaints in surgeons performing laparoscopic surgeries. methods: a web-based survey was designed and sent out to bariatric surgeons around the world. participants were queried about professional background, primary practice setting, and various issues related to bariatric surgeries and msk injuries. results: there were responses returned from surgeons from countries around the world. . % of the surgeons have had more than years of experience in laparoscopic surgery, . % in open and . % in robotic surgery. % of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in . % of the surgeons. it was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic, with . % of the surgeons reporting that this pain has affected their task accuracy/surgical performance. a higher percentage of females than males reported pain in the neck, back and shoulder area when performing laparoscopic procedures. supine positioning of patients evoked more discomfort in the wrists, while the french position caused more discomfort in the back region. only . % sought medical treatment for their msk problem, of which . % had to undergo surgery for their issue, and . % of those felt that the treatment resolved their problem. conclusion: msk injuries and pain are a common occurrence among the population of bariatric surgeons, and has the ability to hinder performance at work. therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life.introduction: the use of robotic technology is rapidly increasing among general surgeons but is not being routinely taught in general surgery residency. we aimed to evaluate our first robotic cases during which time we developed a robotic surgery curriculum incorporating residents. methods: the first robotic cases performed at our institution from - by two surgeons were analyzed. a residency curriculum was developed and instituted after the first months. it consisted of online modules offered by intuitive surgical resulting in certification, simulator training, hands on workshops for cannula placement, docking, instrument exchange, camera clutching and other introductory tasks. patient demographics, type of procedure, resident involvement, total operative and console times, comorbid conditions and complications were evaluated. unpaired t tests were performed for statistical analysis. results: females and males comprised this series with an average age of years ± . the majority of patients, % had comorbidities, with a predominance of hypertension, % and diabetes, %. the bariatric patients had an average bmi of ± . a variety of procedures were performed including hernias, foregut and bariatric. residents participated in % of cases. there were no differences in total operative and console times in cases with residents except bariatric procedures. there were complications in this series; postoperative ileus, gallbladder fossa hematoma and an enterotomy. there was one early conversion to open in a complex foregut case and no deaths in this series.conclusions: we report our initial experience of robotics in a variety of general surgery and complex foregut cases. the implementation of a robotic surgery program and residency curriculum was safe with similar outcomes related to operative times and complications. as mis expands with the application of robotics in general surgery, residency curriculums will need to be revised. further data is needed to determine residency learning curves between robotics and laparoscopy.background: robotic surgery has made a large impact in the fields of urology and gynecology. its use is significantly increasing in the fields of general and bariatric surgery. evidence remains unclear as to the clinical impact on outcomes, and significant questions remain as to the impact of cost. our goal was to evaluate the economic impact of robotic surgeries in general and bariatric surgery at our institution. methods: this study is a retrospective analysis of minimally invasive general and bariatric procedures done at a single institution from january through june . we performed a cost and reimbursement analysis of robotic versus conventional laparoscopic surgery. the cost evaluation included operative time, operating room costs, length of stay and overall hospital expenses. in addition, we looked at reimbursement and the contribution margin per cpt code. results: our study included a total of patients who underwent laparoscopic and robot assisted general and bariatric surgeries. the average time duration for laparoscopic surgeries was minutes vs minutes for robot assisted. we performed a cost analysis which showed an average total cost of $ , for laparoscopic and an average of $ , for robot assisted. the total reimbursements were $ , for laparoscopic and $ , for robot assisted. this translated to an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. for general surgery we found an average cost of laparoscopic $ , vs robot assisted $ , , with a contribution margin of $ , laparoscopic vs $ , robot assisted. for bariatric surgeries we found an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. conclusions: robotic surgery has been associated with higher costs and longer operative times. in this economic climate of increased cost awareness with institutions under increasing financial pressures, judicious use of resources becomes important when determining surgical approach. although cost of robot assisted surgery may decrease with time, other quality factors may be important in patient selection. although there is no clear evidence that institutions lose money with robot assisted surgery, in our experience the contribution margin is lower with robot assisted surgery as compared to conventional laparoscopy.introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for inguinal hernia repairs using the transabdominal preperitoneal approach. our series is the first experience in the field of general surgery utilizing this new robotic platform. methods: from march to september , inguinal hernia repairs in patients were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node (figure ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between and years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than month and a bmi \ . a retrospective chart review was performed for a variety of pre-, peri-and postoperative data including but not limited to patient demographics, hernia characteristics, intraoperative and postoperative complications. results: male and female patients were included in the study. median age was . years (range - years), and median bmi was . (range . - . kg/m ). median docking time was minutes (range - minutes), and median operative time was minutes (range - minutes). two cases were converted to standard laparoscopic surgery due to robot malfunction and intraoperative bleeding respectively. one patient developed a postop seroma that did not require any further intervention. conclusion: we report the first series of laparoscopic inguinal hernia repairs using the new senhance robotic system. compared to previously published conventional laparoscopic or robotic tapp hernia repairs these data suggest similar outcomes in operative time and perioperative complications. additionally there was no significant learning curve detected due to its intuitive applicability. therefor the senhance robotic system can be safely and easily used for tapp hernia repairs by experienced laparoscopic surgeons. this is a video presentation of years old female, who presented with suprapubic pain and mass to gynecology office. she has a history of robotic hysterectomy and sbladder sling operation years ago. this was complicated with peritonitis and long icu stay, due to what she was called ''bowel injury'' but treated only conservatively with antibiotics and subsequent abscess drainages at that time. she has occasional appearing nodule and pain at the left suprapubic region. ct ordered by gynecology read as abdominal wall hernia with long sigmoid diverticuli in hernia. also there was small amount of subcutaneous air at the tip of herniated diverticuli. after antibiotic treatment and improvement, colonoscopy shows, actually the diverticuli is the limb of the sling going through the simoid and anchored in subcutaneous fat on abdominal wall ahich represents clocutaneous fistula as gets infected. clip was placed on sling and repeat imaging comfirmed that the localion of this sling fits to location of so called ''hernia'' the sling limb was resected robotically and colon was repaired with side stapling of clolonic wall. the abdominal wall defect is repaired with long term absorbable suture. as far as we have found, the presentation and treatment of this complication is unique and could not find a similar case to guide us for the plan. background: robot-assisted surgery using da vinci surgical system (dvss) is thought to have many advantages over conventional laparoscopic surgery. it was reported that the use of the surgical robot might reduce surgery-related complications, then a multi-institutional historically controlled prospective cohort study on the feasibility, safety, effectiveness and economical efficiency of robotic gastrectomy (rg) for resectable gastric cancer was conducted in japan. this study evaluated the safety of rg using dvss xi. methods: this single-center, prospective phase ii study included patients with resectable gastric cancer (umin ). the primary endpoint was the incidence of post-operative complications greater than grade iii according to clavien-dindo classification during one month after surgery. the secondary endpoints included all adverse events and completion rate of robotic surgery. results: from oct to jan , patients were enrolled for this study. the incidence of post-operative complication greater than grade iii was %. the overall incidence of adverse events was . % (grade i; . %, grade ii; . %). no patient required conversion to laparoscopic or open surgery; thus, the rg completion rate was %. conclusion: this study suggested the introduction of rg using dvss xi for gastric cancer seems to be safe and feasible. priscila r armijo, md , dmitry oleynikov, md , sages robotic task force* ; university of nebraska medical center, sages robotic task force introduction: while robotic companies continue to aggressively market and promote the use of robots in general surgery, little is known about how this technology is employed by general surgeons, and what is expected of this technology from both novice and experts in the field. the aim of this study is to evaluate the needs of general surgeons who are new to robotic surgery and the needs of established robotic surgeons. methods: the sages robotic task force survey, a one-page survey, was designed and sent electronically to all sages members. questions regarding fellowship training, area of expertise, robotic simulation and in clinical case use, services offered in the current hospital, mentorship, likelihood of switching to a different approach, and expectations for the robot were included in the survey. two groups were created based on previous use of davinci® system in a clinical scenario, or not. statistical analysis was conducted using ibm spss v. . . , using fischer's exact and pearson's chi-squared tests where appropriate. results: sages members answered the survey. surprisingly, respondents ( %) had used the davinci® in a clinical setting. among these, ( %) had additional fellowship training, compared to ( %) in the non-clinical use group, p= . . of all surgeons with additional fellowship training, the great majority ( %) had specialization in advanced gi, mis and bariatric surgery, followed by colorectal ( %). most surgeons are performing less than cases per month using the robotic system, and with the majority of cases performed using the platform being hernia repairs ( %), followed by foregut-related procedures ( %). interestingly, from all the surgeons who replied the survey, only . % are planning to switch from open procedures to its robot counterpart, whereas . % are planning to adopt robotic-assisted procedures rather than laparoscopy. conclusions: the majority of sages members who responded to the survey have used the davinci® in a clinical setting in the past. surgeons who stated they perform mainly laparoscopic procedures were likely to continue to adopt robotic techniques, whereas those who perform open hernia repair for example were not very likely to switch to robotic approach. while the use of the robot may be enabling surgeons who used to perform mostly open procedures in the urology or gynecology fields, laparoscopic skills predict robotic utilization in general surgery. hernia and foregut appear to be the most common procedures that are being utilized.aim: while conventional multiport laparoscopic splenectomy has become gold standard for some hematological or splenic diseases, reduced-port laparoscopic splenectomy (rpls) including singleincision laparoscopic splenectomy (sils) is regarded as highly challenging. herein, we describe the technical refinements for safe rpls especially for patient with splenomegaly. methods: in all cases, access was achieved via a . -cm mini-laparotomy at the umbilicus into which a sils tm port or e-z access ® with three -mm trocars was placed. a -mm flexible scope, an articulating grasper, and straight instruments were used. our rpls is characterized by the followings: a) early ligation of the splenic artery to shrink the spleen, b) application of our original "tug exposure technique," which provides good exposure of the splenic hilum by retracting (tugging) the spleen with a cloth tape, and c) safe introduction of stapler under the guidance with a flat drain into the splenic hilum. results: rpls patients ( men and women, ± years old) comprised hematological disorder (n= ), splenic disease (n= ), and liver cirrhosis (n= ). in patients ( %), rpls was successfully completed: sils in and sils plus one additional port only in patients. conversion to open surgery was necessary in patients including liver cirrhosis with remarkable collateral varicose veins around the spleen. operation time and blood loss were ± min and ± g, respectively. weight of the extracted spleen was heavier than normal and ± g (maximum g). no intra-or postoperative complication occurred. the postoperative scar was nearly invisible. conclusions: rpls might safely be performed even for splenomegaly (up to , g). however, care should be taken for cirrhotic patient with collateral veins. rpls can be the procedure of choice even in the patients with splenomegaly and who are concerned about postoperative cosmesis. the aim of this feasibility study was to evaluate laparoscopic sn biopsy for laparoscopic snns in early gastric cancer patients. subjects and methods: this study includes patients with ct n m (primary tumor \ cm) gastric cancer who underwent laparoscopic sn biopsy in conjunction with radioisotope and dye methods between jan. and jul. . first, we looked for green-dyed sns after injection of indocyanine green (icg) without near-infrared light system, and then tried to detect the radioactivity of sns using a hand-held gamma probe inserted through a small incision at the umbilical port. after the areas where sns were distributed were resected, a gastrectomy with prophylactic lymphadenectomy was performed according to the gastric cancer treatment guidelines of the japanese gastric cancer association. we looked for undetected sns in the resected specimen at the back table. results: among cases, there were ( %) in which sns were not detected in the resected specimen. there were cases in whom sns were detected in the resected specimen. in both cases, the primary tumors were located in the middle and greater curvature of the stomach. in case , laparoscopic sn biopsy identified the left ( sb) and right ( d) greater-curvature lymph node (lns) as sns, however, lesser-curvature ( ) and infrapyloric ( ) lns remained as sns in the resected specimen. in case , the left ( sb) and right ( d) greater-curvature lns were identified as sns intraoperatively, while the lesser-curvature ( ) ln remained as an sn in the resected specimen. the sns overlooked with laparoscopic sn biopsy method were detected by radioisotope only. no cases had ln metastasis, and the -year relapse-free survival rate of these patients was %. conclusions: our feasibility study of laparoscopic sentinel node biopsy for early gastric cancer showed that we should search for sns of the lesser curvature carefully even if the primary lesion is located at the greater curvature. key: cord- -q gb qkq authors: singh, b. p. title: forecasting novel corona positive cases in indiausing truncated information: a mathematical approach date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: q gb qkq novel corona virus is declared as pandemic and india is struggling to control this from a massive attack of death and destruction, similar to the other countries like china, europe, and the united states of america. india reported cases novel corona confirmed cases as of april , and out of which cases were reported recovered and deaths occurred. the first case of novel corona is reported in india on january , . the growth in the initial phase is following exponential. in this study an attempt has been made to model the spread of novel corona infection. for this purpose logistic growth model with minor modification is used and the model is applied on truncated information on novel corona confirmed cases in india. the result is very exiting that till date predicted number of confirmed corona positive cases is very close to observed on. the time of point of inflexion is found in the end of the april, means after that the increasing growth will start decline and there will be no new case in india by the end of july, . a novel corona virus is responsible for epidemic popularly known as covid- is a new strain that has not been identified previously in humans. who declared covid- a pandemic on march , . [ ] the virus that caused the incidence of severe acute respiratory syndrome (sars) in in china, middle east respiratory syndrome (mers) in in saudi arabia and the virus that causes covid- are genetically related to each other, but the diseases they caused are quite different. [ ] these viruses, in general, are a family of viruses that target and affect mammal's respiratory systems. the sars corona virus spread to humans via civet cats, while the mers virus spread via dromedaries. in case of the novel corona virus, typically happens via contact with an infected animal, perhaps the common carriers are bats initial reports from seafood market in central wuhan, china. novel corona virus is spreading throughout the world at alarming speed. worldwide it has exploded to cases and caused deaths by april , . [ ] developed countries like italy, spain, france and united state of america etc. are struggling to overcome from the pressure created by novel corona virus. india with a huge population about . billion, amongst majority of the people are living in poor hygienic condition and the medical facilities like number of doctors and hospitals are less in india as compared to developed countries indicates that the situation of india will become very critical but comparatively better public health system and political control in india than the above developed countries. india reported cases novel corona confirmed cases as of april , and out of which cases were reported recovered and deaths occurred. the first case of novel corona is reported in india on january , when a student returned from wuhan, china. [ ] the government of india was quick to launch various levels of travel advisories beginning from february , , with restrictions on travel to china and nonessential travel restrictions to singapore, south korea, iran and italy. [ ] the efforts to control by the hon'ble prime minister narendra modi ji through janata curfew (public curfew) on march , , can be seen as the beginning of wide-scale public preventive measures. india has launched several social distancing measures and personal hygiene measures during the second week of march. [ ] since huge population of about . billion, thus india has chosen a flexible strategy of largescale quarantine and limited testing because of less number of testing kits and also the cost of testing is too much. the country is relying on the people power; thousands of health-care workers are working out across the country to trace and quarantine people who might have had contact with those with novel corona. people are typically only tested if they develop symptoms. countries such as south korea isolated infected people based on widespread testing, but some scientists say that india's mass surveillance approach could achieve a similar goal, and be relevant for other low and low-middle income countries facing kit shortages. under the lockdown, people are allowed out for essentials, such as food and medical care, but in most states people under quarantine are closely monitored by social workers and cannot leave their homes in some places. if public health workers do not trace all infected individuals during the lockdown, india will need to continue its period of stringent physical distancing. for the spread of novel corona virus, when disease dynamics are still unclear, mathematical modeling helps us to estimate the cumulative number of positive cases in the present scenarios. now india is interring in the mid stages of the epidemic. it is important to predict how the virus is likely to grow amongst the population. a mathematical modeling approach is a suitable tool to understand the dynamics of epidemic. in the study some mathematical approach to understand the dynamics of novel corona virus in india has been discuss. we obtained the truncated information on cumulative number of corona positive confirmed cases in india from march to april , from covid india.org. [ ] all cases are laboratory confirmed following the case definition by the govt. of india. some studies modeled the epidemic curve obeying the exponential growth. [ , ] the nonlinear least square framework is adopted for data fitting and parameter estimation for -ncov at this early stage. in this study first exponential and then logistic growth curve has been used to model the novel corona epidemic, since epidemics grow exponentially not linearly. but it is surprising that exponential growth curve always provide increasing number of daily new cases. there is no saturation point. another deterministic model used for understanding the dynamics of epidemic is the sir model, which has been used to accurately predict incidence like sars. in the sir model, we need to know the input parameters first the stats we feed into the model. [ , , ] the first one is r called the basic reproduction number. it is essentially the number of new cases a single infected person will cause during their infectious period. it is one of the most important parameters for assessing any epidemic. corona virus has an r ~ . . in contrast, the h n virus had an r ~ . in the swine flu epidemic. [ ] the r will inform us about how many people will get infected with one infected person. other one is the case fatality rate (cfr), which is the percentage of infected people that will die due to the infection. the cfr for corona virus has been reported between . - %. the lower values are more appropriate in resource better settings of medical facility. but sir model assumes that every person is moving and has equal chance of contact with each and every other person among the population irrespective of the space or distance between different people. it is assumed that the transmission rate remains constant throughout the period of pandemic. also this model considered to have the same transmission rate for who have been diagnosed and are in quarantine or those who have not been quarantined. the harmonic analysis methods and dynamic model estimates show that the number of covid- infected would be (if there were infected individuals as of march , , who was not taking any precautions to spread), , (if there were ) and , (if there were ). [ ] a growth curve is an empirical model of the evolution of a quantity over time. growth curves are widely used in biology for quantities such as population size in population ecology and demography for population growth analysis, individual body height in physiology for growth analysis of individuals. growth is also a key property of many systems such as an economic expansion, spread of an epidemic, the formation of a crystal, an adolescent's growth and the condensation of a stellar mass. this is the simplest growth model, in which population grows at a constant rate over time. linear growth is described by the equation . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint where t p represents the numbers or size of the system at time t,  t p represents the system's numbers or size of the system one time unit later, and a is the system's (linear) growth rate. many times this model fails to explain natural phenomenon. exponential growth (unlimited population growth) another simple model describes exponential growth, in which population grows at a constant proportional rate over time. the relation may be expressed in either of two forms, depending on whether reproduction is assumed to be continuous or periodic. [ ] exponential growth results in a continuous curve of increase or decrease, whose slope varies in direct relation to the size of the population. with the current incidence of the novel corona virus going on, we hear about exponential growth. in this study, an attempt has been made to understand and analyze the data through exponential growth curve. the reason for using exponential growth curve for studying the pattern of novel corona virus incidence is that epidemiologists have studied these types of happenings and it is well known that the first period of an epidemic follows exponential growth. the exponential growth function is not necessarily the perfect representation of the epidemic. i have tried to fit exponential curve first, and at the next point to study the logistic growth curve because exponential curve is only fit the epidemic at the beginning. at some point, recovered people will not spread the virus anymore and when someone is or has been infected, the growth . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . will stop. logistic growth is characterized by increasing growth in the beginning period, but a decreasing growth after point of inflexion. for example in the corona virus case, the maximum limit would be the total number of exposed people in india because when everybody is infected, the growth will be stopped. after that the increasing rate of curve starts to decline and reach to the minimum. in the figure , predicted values of the cumulative number of novel corona positive cases obtained by method and is drawn along with observed cumulative number of novel corona positive cases. bothe the methods provide moderately good estimates but the tendency of both the curves are unlimited increasing. the rate of growth of method is slightly lesser than the rate of growth of method . the number of total infected cases by april , would be about (method ) and (method ). if we do not adjust the method for tablighi spread then the total infected cases by april , would be about . thus we can obtain the effect of tablighi spread is about percent. the logistic model reveals that the growth rate of the population is determined by its biotic potential and the size of the population as modified by the natural resistance, or, in other words, by all the various effects of inherent characteristics, that are density dependence. [ ] natural resistance increases as population size gets closer to the carrying capacity. logistic growth is similar to exponential growth except that it assumes an essential sustainable maximum point. in exponential growth curve, the rate of growth of y per unit of time is directly proportional to y but in practice the rate of growth cannot be in the same proportion always. the logistic curve will continue up to certain level, called the level of saturation, sometimes called the carrying capacity, after reaching carrying capacity it starts declining. the factor y is called the momentum factor which increases with time t and the factor ) ( y k  is known as the retarding factor which decreases with time. a system far below its carrying capacity will at first grow almost exponentially however, this growth gradually slows as the system expands, finally bringing it to a halt specifically at the carrying capacity. [ , ] the logistic relationship can be expressed as . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . and are the number at given time and respectively provided that y y y t t t t t t t    . you may also estimate the parameter a and b by method of least square after fixing k. to predict confirmed corona cases on different day, logistic growth curve has been also used and found very exciting results. the truncated information on confirmed cases in india has been taken from march to april , . the estimated value of the parameters are as follows k= . , a= . and b=- . , with these estimates predicted values has been obtained and found considerably lower values than what we observed. on april and , the number of confirmed corona cases are drastically increasing in some part of india due to some unavoidable circumstances thus there is an earnest need to increase carrying capacity of the model, thus it is increased and considered as and the other parameters a and b are estimated again which are a= . and b=- . . the predicted cumulative number of cases is very close to the observed cumulative number of cases till date. the time of point of inflexion is obtained as . i.e. days after beginning. we have taken data from march , so that the time of point of inflexion should be april , and by may , there will be no new cases found in the country. the distribution of the new cases is in the red color in the figure , which is quite normal and obvious. as mentioned in the above paragraph method provided natural estimate of the total infected cases by may , is . this estimate is obtained when no preventive measure would be taken by the government of india. the testing rate is lower in india than many western countries, so our absolute numbers is low, when government initiate faster testing process then we have observed more number of cases and fount this logistic model fail to provide cumulative number of corona confirm cases after april , thus there is a need to modify this model. in order to the modification i have taken natural log of cumulative number of corona confirm cases instead of cumulative number of corona confirm cases as taken in the previous model. this model provides the carrying capacity is about cases and time of point of inflexion april , . the present model provides reasonable estimate of the cumulative number of confirmed cases till date (see appendix and figure ) and by the end of july, there will be no new cases found in the country. india is in the comfortable zone with a lower growth rate than other countries studied. our mathematical model shows that, the epidemic is likely to stabilize with cases by the end of july, . a study advocated of days single lockdown i.e. lockdown up to may , reduce infected cases below but our study contradict it. [ ] the government has adopted a strategy of large scale quarantine and limited testing to flatten the epidemic curve and reduce the death rate. the projections produced by the model and after their validation can be used to determine the scope and scale of measures that government need to initiate. in conclusion, if the current mathematical model results can be validated within the range provided here, then the social distancing and other prevention, treatment policies that the central and various state governments and people are currently implementing should continue until new cases are not seen. the spread from urban to rural and rich to poor populations should be monitor and control is an important point of consideration. mathematical models have certain limitations that there are many assumptions about homogeneity of population in terms of urban/rural or rich/poor that does not capture variations in population density. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint covid- ) -events as they happen who statement regarding cluster of pneumonia cases in wuhan, china coronavirus update (live): covid- virus outbreak -worldometer. available at india covid- tracker: a crowdsourced initiative consolidated travel advisory in view of covid- revised strategy of covid testing in india a preliminary analysis of the epidemiology of influenza a (h n ) v virus infection in thailand from early outbreak data simple framework for real-time forecast in a data limited situation: the zika virus (zikv) outbreaks in brazil from to as an example healthcare impact of covid- epidemic in india: a stochastic mathematical model prudent public health intervention strategies to control the corona virus disease transmission in india: a mathematical model-based approach age-structured impact of social distancing on the covid- epidemic in india gupta mohak corona virus in india: make or break modelbased retrospective estimates for covid- or coronavirus in india: continued efforts required to contain the virus spread methods and materials of demography on the rate of growth of the population of the united states since and its mathematical representation date observed predicted % lci % uci new cases residual march - - - - - - - - - - - - - - - - - april - key: cord- - nt op authors: koh, david; lim, meng‐kin; chia, sin‐eng title: sars: health care work can be hazardous to health date: - - journal: occup med (lond) doi: . /occmed/kqg sha: doc_id: cord_uid: nt op nan reported probable sars cases and deaths. the case fatality ratio varies from to %, depending on the age of the patient, with an overall estimate of - % [ ]. these figures will undoubtedly change with time as more cases emerge. the aetiological agent is a novel coronavirus (sars-cov), with patterns of spread suggesting droplet or contact transmission [ , ] . clinical features are those of atypical pneumonia, with the common presenting symptoms being fever and dry cough. sars patients are classified as either 'suspect' or 'probable' cases [ ] . a suspect case is a patient who presents with a history of high fever (> °c) and a cough or breathing difficulty. in addition, there must be one or more of the following exposures within days of the onset of symptoms: either a close contact with a person who is a suspect or probable case of sars, or a history of travel to a sars-affected area. a suspect case is upgraded to 'probable' with the appearance of radiological changes consistent with pneumonia or respiratory distress syndrome (rds), or in the event of death, autopsy findings consistent with the pathology of rds without an identifiable cause. at the time of writing, there is no validated, widely and consistently available laboratory test for infection with the sars-cov. however, from may , the who amended the definition of a probable case to include a suspect case of sars who has positive laboratory tests for sars-cov, under conditions drawn up by the who. empirical therapy for sars has included corticosteroids, a broad spectrum antiviral agent and antibacterial cover [ ] . health care workers (hcws) are a high-risk group for sars-cov infection. according to the who, they constitute the biggest, single group of probable sars patients worldwide. as at may, % of sars patients in singapore and % of cases in hong kong [ ] were hcws. the majority of cases in canada ( . %) have been attributed to exposure in a hospital or health care setting [ ] . as at april , more than hospital workers at three greater toronto area hospitals have become ill with sars [ ] . unfortunately, a number of deaths have occurred among hcws. an early casualty was dr carlo urbani, the who expert working in hanoi who was among the first to identify the clinical disease, and in whose honour it has been proposed that the causative agent bear his name. the index case (and first reported death) of the hong kong outbreak was an elderly chinese physician who had treated sars patients in guangdong. three doctors, two nurses and a health care attendant in singapore have also succumbed to sars. the vulnerability of hcws can be explained by their close contact with patients. the innocuous, 'flu-like' clinical presentation of sars does not help to raise the index of suspicion. in the early stages of the outbreak, there was also not the same degree of vigilance with regards to potentially high exposure situations such as aerosol-generating procedures. these included aerosolized medication treatments (i.e. nebulizers), the use of high-flow venturi masks and non-invasive positive pressure ventilation for sars patients, airway suctioning and endotracheal intubations. as a poignant illustration, in singapore, a cluster of probable and suspected cases was traced to a single sars patient who was initially undiagnosed for days and treated for gastrointestinal bleeding, chronic kidney disease and diabetes [ ]. the cluster included hospital staff working as doctors, nurses, radiographers and housekeepers. an occupational health audit, which included a walk-through of the hospital 'hot spots' carried out by the authors, revealed a small number of deficiencies which could well be weak links in an otherwise strong preventive chain. that the cluster of cases included housekeepers is also significant-preventive measures need to target much broader groups of hcws than just the doctors and nurses in direct contact with patients. frontline hcws like counter clerks, porters and ambulance drivers are also at risk, and must be educated and protected. the encouraging news is that with the institution of stringent infection control measures and personal protection, the situation appears to have improved somewhat. this was the case in a singapore hospital [ ] , where the experience was reported as: 'we did not see any further transmission from this index patient after we implemented strict infection control measures involving use of n masks, gown, gloves, and handwashing before and after patient contact'. doctors in hong kong [ ] are also 'hopeful that further cases among our staff will be prevented' after rigid application of infection control measures. substantial risks remain. until we know more, precautions should include placement of patients in isolation rooms with negative pressure relative to the surrounding area and the use of n respirators for people entering the room. precautions to avoid droplet contact should include the use of gowns, gloves and goggles as a minimum for contact with patients or their environment. higher-risk procedures with the potential for splattering or spraying of sputum or other body fluids require the use of full-face shields, and improved respiratory protection such as the use of powered airpurifying respirators. perhaps the most important personal hygiene measure that all hcws can adopt is regular handwashing. excellent guidelines on infection control and exposure management are available at various websites, such as those of the us centers for disease control and prevention [ ] , health canada on-line [ ] and the who [ ] . the adoption of extra-stringent control measures involving the donning of personal protection equipment is often a new experience for hospitals, clinics and their staff. the adoption of these measures on such a large scale, involving all hcws with contact to patients, is unprecedented in sars-affected countries. an audit of these newly implemented safety measures might reveal lapses. even if adequate measures, including the provision of facemasks, gloves and gowns, and proper waste decontamination procedures are in place, their observance may be lax because of lowered vigilance or simply human error. for example, the tight seal around the wearer's face may be compromised if respirator fit testing is not properly carried out; and improper handling of contaminated biohazardous waste might result in serious consequences. training of staff and close supervision by trained professionals knowledgeable in occupational health and safety methods are therefore vital. the psychological well-being of hcws must also not be overlooked. hospital staff tend to be on physical and emotional overdrive in an already overstretched system. the precautionary need to home-quarantine entire health care teams upon discovery of a new cluster of sars cases further strains resources, and may even result in hospital shut-downs. forcibly quarantining hcws in hospitals, as has happened in some countries, raises further questions concerning the hcws' individual human rights and their societal 'duty to care'. there is bound to be significant disruption in home life as well. staff anxiety under these abnormal conditions naturally runs high, especially when there is fear of contagion, and of infecting family, friends and colleagues [ ] . it is therefore important to implement proactive, remedial actions to avoid burnout among overworked and highly stressed hcws. appropriate psychosocial support and scheduled rest periods should be in place before people run themselves into the ground. sars is a new occupational disease which we are only beginning to come to grips with. it is also a grim reminder that health care work is potentially hazardous. in the battle against sars, the safety and well-being of the 'troops'-hcws all over the world-must be accorded the priority it deserves. department of community, occupational and family medicine, faculty of medicine, national university of singapore, singapore severe acute respiratory syndrome (sars)-multi-country outbreak a novel coronavirus associated with severe acute respiratory syndrome identification of a novel coronavirus in patients with severe acute respiratory syndrome case definitions for surveillance of severe acute respiratory syndrome (sars). revised outbreak of severe acute respiratory syndrome in hong kong special administrative region: case report the war against an unknown pathogen: rising to the sars challenge sars among ontario health care workers severe acute respiratory syndrome (sars) in singapore: clinical features of index patient and initial contacts severe acute respiratory syndrome (sars): infection control infection control guidance for health care workers in occupational medicine health care facilities and other institutional settings. severe acute respiratory syndrome (sars) the immediate psychological and occupational impact of the sars outbreak in a teaching hospital key: cord- -twn poq authors: nikolay, birgit; salje, henrik; sturm-ramirez, katharine; azziz-baumgartner, eduardo; homaira, nusrat; ahmed, makhdum; iuliano, a. danielle; paul, repon c.; rahman, mahmudur; hossain, m. jahangir; luby, stephen p.; cauchemez, simon; gurley, emily s. title: evaluating hospital-based surveillance for outbreak detection in bangladesh: analysis of healthcare utilization data date: - - journal: plos med doi: . /journal.pmed. sha: doc_id: cord_uid: twn poq background: the international health regulations outline core requirements to ensure the detection of public health threats of international concern. assessing the capacity of surveillance systems to detect these threats is crucial for evaluating a country’s ability to meet these requirements. methods and findings: we propose a framework to evaluate the sensitivity and representativeness of hospital-based surveillance and apply it to severe neurological infectious diseases and fatal respiratory infectious diseases in bangladesh. we identified cases in selected communities within surveillance hospital catchment areas using key informant and house-to-house surveys and ascertained where cases had sought care. we estimated the probability of surveillance detecting different sized outbreaks by distance from the surveillance hospital and compared characteristics of cases identified in the community and cases attending surveillance hospitals. we estimated that surveillance detected % ( % ci %– %) of severe neurological disease cases and % ( % ci %– %) of fatal respiratory disease cases residing at km distance from a surveillance hospital. detection probabilities decreased markedly with distance. the probability of detecting small outbreaks (three cases) dropped below % at distances greater than km for severe neurological disease and at distances greater than km for fatal respiratory disease. characteristics of cases attending surveillance hospitals were largely representative of all cases; however, neurological disease cases aged < y or from the lowest socioeconomic group and fatal respiratory disease cases aged ≥ y were underrepresented. our estimates of outbreak detection rely on suspected cases that attend a surveillance hospital receiving laboratory confirmation of disease and being reported to the surveillance system. the extent to which this occurs will depend on disease characteristics (e.g., severity and symptom specificity) and surveillance resources. conclusion: we present a new approach to evaluating the sensitivity and representativeness of hospital-based surveillance, making it possible to predict its ability to detect emerging threats. we propose a framework to evaluate the sensitivity and representativeness of hospital-based surveillance and apply it to severe neurological infectious diseases and fatal respiratory infectious diseases in bangladesh. we identified cases in selected communities within surveillance hospital catchment areas using key informant and house-to-house surveys and ascertained where cases had sought care. we estimated the probability of surveillance detecting different sized outbreaks by distance from the surveillance hospital and compared characteristics of cases identified in the community and cases attending surveillance hospitals. we estimated that surveillance detected % ( % ci %- %) of severe neurological disease cases and % ( % ci %- %) of fatal respiratory disease cases residing at km distance from a surveillance hospital. detection probabilities decreased markedly with a a a a a distance. the probability of detecting small outbreaks (three cases) dropped below % at distances greater than km for severe neurological disease and at distances greater than km for fatal respiratory disease. characteristics of cases attending surveillance hospitals were largely representative of all cases; however, neurological disease cases aged < y or from the lowest socioeconomic group and fatal respiratory disease cases aged ! y were underrepresented. our estimates of outbreak detection rely on suspected cases that attend a surveillance hospital receiving laboratory confirmation of disease and being reported to the surveillance system. the extent to which this occurs will depend on disease characteristics (e.g., severity and symptom specificity) and surveillance resources. we present a new approach to evaluating the sensitivity and representativeness of hospitalbased surveillance, making it possible to predict its ability to detect emerging threats. • many countries rely on hospital-based surveillance for the detection of infectious diseases of national and global public health relevance. • it is often difficult to access suitable external reference data to assess the capacity of a surveillance system to detect cases and outbreaks or to characterize cases. • we demonstrate a novel approach using healthcare utilization data to evaluate the sensitivity and representativeness of severe infectious disease surveillance in bangladesh. • the capacity to detect cases and outbreaks decreased with distance from surveillance hospitals. • cases captured by surveillance differed from cases in communities by age and socioeconomic status. • geographic coverage of surveillance could be improved by including other hospitals in the surveillance system. • the presented approach is applicable for a wide range of infectious diseases in different settings, taking some practical considerations into account. • hospital-based surveillance may have low sensitivity in rural areas at greater distances from surveillance hospitals, suggesting a risk of unrecognized transmission of emerging infectious diseases. a well-functioning disease surveillance system is crucial for the identification and control of outbreaks, and hence the prevention of national and global health emergencies [ ] . the world health organization (who) highlighted the value of national surveillance systems in the international health regulations ( ) , an agreement among all member states to develop and maintain sufficient capacity for the detection, reporting, and control of public health threats of international concern [ ] . infectious disease surveillance should enable (i) the timely detection of outbreaks, (ii) the quantification of health problems, (iii) the identification of subpopulations at risk, and (iv) the assessment of temporal trends including the impact of control strategies [ , ] . national surveillance systems typically collect data from patients seeking care at sentinel hospitals or other healthcare facilities and can provide useful information for public health purposes. however, hospital-based surveillance generally underestimates disease burden since only a proportion of cases visit a hospital for care [ ] . low case detection may also undermine the value of hospital-based surveillance for outbreak detection. moreover, if patients captured by the surveillance system are not representative of all cases in the community, surveillance statistics could lead to erroneous interpretations of disease patterns and misallocation of prevention resources. in particular, sex, socioeconomic status, or distance can affect healthcare seeking at hospitals, especially where access to care is limited [ ] [ ] [ ] [ ] . surveillance evaluation guidelines, such as those established by the us centers of disease control and prevention, list sensitivity and representativeness among the attributes that a public health surveillance system should possess and that require assessment [ , ] . in order to follow these guidelines, we need external reference data that are often unavailable in resource-poor settings [ ] . here, we present a new approach to evaluating the capacity of a surveillance system to detect and characterize disease cases, with emphasis on outbreaks of emerging infections that often occur as small case clusters in remote areas. we apply our methodology to assess hospital-based surveillance of severe neurological infectious disease and fatal respiratory infectious disease in bangladesh. the field teams obtained written informed consent from participants or their guardians (if < y of age) during community surveys. healthcare utilization survey protocols were reviewed and approved by the ethical review committee of the international centre for diarrhoeal disease research, bangladesh. how epidemiological studies can be used to identify cases with severe symptoms in communities and capture their personal and healthcare utilization characteristics (data collection stage) (fig ) . in addition to detailing how we collected the data in this study, we provide information about how the approach could be varied in other settings. we subsequently demonstrate how such data can be used to evaluate the sensitivity and representativeness of surveillance systems (evaluation stage). we then apply our approach to the detection of severe neurological infectious diseases and fatal respiratory infectious diseases in bangladesh as a case study. selecting study locations. the first step was to randomly select communities at differing distances from the surveillance hospitals. we specified catchment areas of selected hospitals based on hospital records and subsequently randomly selected small administrative units from which all communities were surveyed. selection of communities could also be done through census data or using detailed population maps of the area. identifying people with diseases in the selected community. study teams visited the selected communities and identified cases that had had the disease of interest. the retrospective identification of severe disease cases in the community was based on syndromic criteria, used as a proxy for clinical case definitions that would be applied in healthcare facilities. the in the bangladesh example, the catchment areas of surveillance hospitals were first defined based on hospital records (e.g., areas where > % or > % of cases reside) [ , ] . subsequently, small administrative units were chosen at random from within the catchment area, and all communities in the selected areas were surveyed. cases in the community were identified based on lists of deaths in addition to community networking strategies (rural settings) or house-to-house surveys (urban settings). information on symptoms (to establish case definitions), healthcare seeking behavior, and characteristics of cases was collected. in other settings, the exact survey procedures may vary according to the context. identification of such cases in the community is often the most problematic step, and the optimum strategy will depend on the local context, the severity of the disease, and the specificity of disease symptoms. collecting information on healthcare seeking and personal case characteristics. to estimate case detection probabilities, identify biases in case statistics, and characterize the healthcare utilization behavior in the population, we needed information about the healthcare seeking and personal characteristics of cases. in particular, we needed to identify whether the cases attended a surveillance hospital. such information was obtained during household visits of identified cases. to understand the impact of distance from the hospital, we approximated the locations of households by the central positions of the small administrative units. alternatively, household locations could be recorded precisely using gps devices. quantifying the probability of detecting a case. we estimated the case detection probability as the proportion of cases who reportedly attended a surveillance hospital among all cases identified in the community. we further assessed how this probability changed with distance from the surveillance hospital. quantifying the probability of detecting outbreaks. we subsequently used the estimated case detection probabilities to quantify the capacity of the surveillance system to identify disease outbreaks. we estimated outbreak detection probabilities for varying outbreak sizes and for outbreaks occurring at different distances from surveillance hospitals. assessing the representativeness of detected cases. we evaluated the representativeness of detected cases by estimating the difference between case statistics (proportions of specific case characteristics) based on all cases in the community and based on identified cases who attended the surveillance hospital. the investigated characteristics included sex, age, and socioeconomic status. assessing alternative surveillance strategies. to investigate how sensitivity and representativeness of the surveillance system could be improved by integrating other healthcare providers, we applied the evaluation procedures as described above to other healthcare provider types. we demonstrate the application of the proposed evaluation strategy by using it to assess the capacity of hospital-based surveillance for severe infectious diseases in bangladesh, which is based on tertiary care hospitals located throughout the country. we used data from two surveys carried out in catchment areas of some of these hospitals that investigated the healthcare utilization behavior of individuals with severe neurological infectious disease or fatal respiratory infectious disease (fig a) [ , ] . these disease types are of great public health relevance in bangladesh (e.g., japanese encephalitis and influenza) but also represent symptoms typical of other emerging infectious diseases (e.g., nipah and severe acute respiratory syndrome). a first survey collected data between june and march about cases with symptoms of severe neurological infection that occurred within the previous mo in small administrative units (mean population size of , people) in the catchment areas of three surveillance hospitals [ ] . a second survey collected data between april and february about acute respiratory infection (ari)-related deaths that occurred within the previous mo in administrative units in the catchment areas of surveillance hospitals [ ] . we considered ari-related deaths as a proxy for respiratory disease of sufficient severity to require medical attention. the surveillance hospital in dhaka city was excluded from the original studies because of the difficulty of defining the catchment area (a step necessary for the original study purpose), as people nationwide seek medical care in dhaka. the surveys followed procedures as previously described and summarized below [ , ] . characteristics of the study population are described in fig. a in s text. [ ] . sixty-eight percent of the population in bangladesh lives > km from a surveillance hospital (including the dhaka surveillance hospital), a distance at which case and outbreak detection probabilities are low. (c) probability of surveillance case detection by distance. the observed probability was calculated as a moving average over a km distance window. case detection probabilities were estimated using logbinomial regression models including distance as an explanatory variable. evaluating hospital-based surveillance the catchment areas of selected hospitals were first specified based on hospital records (s text). small administrative units (mean population of , people) were subsequently selected randomly within the catchment areas, and all communities in the selected areas surveyed. the identification of cases in selected communities was based on social structures, i.e., cases were identified by visiting public meeting points, such as mosques, markets, or tea-stalls, where health problems in the community are often publicly discussed. cases were subsequently confirmed by household visits. in urban areas, house-to-house surveys were conducted to compensate for less pronounced community structures. additional fatal respiratory infectious disease cases were identified through lists of deaths provided by administrative officers. for both disease types, the identification of cases was based on syndromic criteria. we defined severe neurological infectious disease as fever with altered mental status for > h or with unconsciousness for ! h, or fever with altered mental status, unconsciousness, or a new onset seizure that resulted in death. fatal respiratory infectious disease (ari-related death) was defined as having any two of the following symptoms in the d prior to death: sudden onset of fever, cough, breathing difficulty, feeding difficulty, or runny nose. deaths in children aged < y were also classified as ari-related deaths if there was a sudden onset of breathing difficulty in the d prior to death. during surveys, information was collected on healthcare utilization behavior and personal characteristics of identified severe neurological and fatal respiratory disease cases. cases or their household members were asked whether the case visited the surveillance hospital or any other healthcare provider, including other nonlocal hospitals, during his/her illness. further, information on sex, age, socioeconomic status, and geographic location of households of cases was collected. we defined "community cases" as all severe neurological or fatal respiratory disease cases identified during community surveys (whether they attended a surveillance hospital or not) and "surveillance cases" as the subset of community cases who reportedly attended a surveillance hospital. for each case identified in community surveys, we identified whether they attended their nearest surveillance hospital. we then estimated the distance to that surveillance hospital as the distance between the residence administrative unit centroid and that specific surveillance hospital using qgis [ ] . age was categorized as < , - , - , and ! y. a socioeconomic status index was generated by principal component analysis based on household assets (electricity, working television, bicycle, motorcycle, sewing machine, mobile phone) and categorized into tertiles (lowest, middle, and highest) [ ] . in sensitivity analyses, we explored the use of continuous age and socioeconomic status classified into quintiles (s text). socioeconomic status was missing for of , fatal respiratory disease cases, who were excluded from the analysis where this information was required. three fatal respiratory disease cases were excluded from all analyses due to missing healthcare seeking information. we estimated the disease-specific case detection probability as the proportion of cases who reportedly sought care at a surveillance hospital among all cases identified during community surveys (number of surveillance cases/number of community cases) and computed % confidence intervals ( % cis) based on the clopper-pearson exact method [ ] . we quantified case detection probabilities by distance from a surveillance hospital using log-binomial regression analysis separately for severe neurological and fatal respiratory disease cases. we further investigated more complex functional forms of distance in log-binomial regression models. we fitted models with polynomial terms up to the fifth degree and models with basic splines with knots at various positions (between and km distance). model fit was compared based on the akaike information criterion (aic), and the models with lowest aic were selected. the fit of selected models was compared to the observed proportion of cases who attended surveillance hospitals at different distances (moving average over a distance window of km). we estimated the proportion of the population living > km and > km from a surveillance hospital using gridded population density estimates of × m resolution [ ] . to quantify the capacity of the surveillance system to detect outbreaks of varying sizes, we calculated the probability that at least one case was detected: pr outbreak is the outbreak detection probability based on a one-case threshold, pr is the case detection probability, and s is the outbreak size. this calculation assumes that the probability of detecting a sentinel case is independent of other cases. we used distance-specific case detection probabilities estimated by log-binomial regression and obtained confidence intervals of outbreak detection probabilities based on the % ci limits of case detection probabilities. we further estimated the size of the smallest outbreak that would be detected with ! % probability by distance from the surveillance hospital. for emerging infectious diseases of global health importance, such as nipah, severe acute respiratory syndrome, or avian influenza, a single detected case may be considered an outbreak. for other disease systems (e.g., endemic diseases or diseases for which differential diagnosis is difficult), an outbreak may be declared only after more than a single case is detected over a specified period of time and within specified geographic boundaries [ ] . we can extend the framework to estimate the probability of identifying an outbreak with different outbreak thresholds applied, and we provide examples for outbreaks defined as detection of at least two cases or at least five cases. we calculated the probability of detecting at least two cases (pr outbreak ) as one minus the probability of detecting no cases (pr ) and exactly one case (pr ): likewise, we estimated the probability of detecting at least five cases (pr outbreak ) as one minus the probability of detecting no cases (pr ) and exactly one (pr ), two (pr ), three (pr ), and four cases (pr ): we investigated the representativeness of surveillance cases (sex, age, and socioeconomic group) by comparing the proportion of cases with a specific characteristic (and exact binomial confidence intervals) among community cases to the proportion of cases with that characteristic among surveillance cases. we quantified the absolute difference in proportions (proportion of cases with characteristic among surveillance cases minus proportion among community cases) with % cis and p-values using bootstrapping ( , bootstrap iterations) [ ] . based on the collected healthcare utilization data, we evaluated how the sensitivity and representativeness of a surveillance system may be improved by integrating other healthcare providers. we classified healthcare providers as (i) surveillance hospitals, (ii) other hospitals (government and private clinics), (iii) qualified private practitioners, and (iv) the informal sector (unqualified practitioners such as traditional healers, village doctors, homeopaths, and pharmacies). we estimated the proportion of cases attending each healthcare provider class, with exact binomial confidence intervals, and estimated outbreak detection probabilities based on proportions attending the surveillance hospital plus (i) other hospitals, (ii) qualified private practitioners, or (iii) informal healthcare providers. furthermore, we compared the proportion of cases with each characteristic (sex, age, and socioeconomic group) among community cases to the proportion among those attending each healthcare provider class and quantified absolute differences in proportions with % cis and p-values using bootstrapping ( , bootstrap iterations). all statistical analyses and graphics were implemented in the r computing environment; maps were created using qgis software [ , ] . the studied communities were located within km (severe neurological infectious disease) and km (fatal respiratory infectious disease) of a surveillance hospital. in these communities, of severe neurological disease cases ( %, % ci %- %) and of , fatal respiratory disease cases ( %, % ci %- %) attended a surveillance hospital. adjusting for distance, the case detection probability was nearly twice as high among severe neurological disease cases than among fatal respiratory disease cases (risk ratio . , % ci . - . ; p < . ). at km distance, an estimated % ( % ci %- %) of severe neurological disease cases and % ( % ci %- %) of fatal respiratory disease cases were detected by the hospital-based surveillance. the detection probability decreased with distance from the surveillance hospital, and the decline was faster for fatal respiratory disease than for severe neurological disease. a km distance increase resulted in a % ( % ci %- %; p = . ) relative reduction in case detection probability for severe neurological disease but a % ( % ci %- %; p < . ) relative reduction for fatal respiratory disease (fig c) . including more complex functional forms of distance in the log-binomial regression models did not improve model fit based on aic (table a and figs . b and c in s text). the probability of detecting an outbreak of exactly three cases (if a single detected case was considered an outbreak) dropped below % at distances greater than km for severe neurological disease and at distances greater than km for fatal respiratory disease (fig a) . fig b and c show the minimum number of cases required for surveillance to detect outbreaks with a probability of ! % if different outbreak thresholds are applied. for outbreaks defined as detection of at least one case, we found that an outbreak of fatal respiratory disease required cases ( % ci - ) to be detected with % probability at km from a surveillance hospital, but cases ( % ci - ) to be detected at km. in contrast, the impact of distance on the outbreak size requirement was much more limited for severe neurological disease: eight cases ( % ci - ) at km and cases ( % ci - ) at km. for outbreaks defined as detection of at least two cases, severe neurological disease cases ( % ci - ) and fatal respiratory disease cases ( % ci - ) would be necessary for an outbreak to be detected at km distance, and severe neurological disease cases ( % ci - ) and fatal respiratory disease cases ( % ci - ) at km. the necessary outbreak sizes increased further when a five-case threshold was applied, so that severe neurological disease cases ( % ci [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and fatal respiratory disease cases ( % ci - ) would need to occur for an outbreak to be detected at km distance, and ( % ci - ) and ( % ci - ), respectively, cases at km. surveillance hospital attendance among community cases varied by case characteristics, leading sometimes to biased disease statistics among surveillance cases (table b in s text). for severe neurological disease, individuals aged < y represented % of community cases but only % of surveillance cases (p < . ). additionally, the proportion of cases in the lowest socioeconomic group was lower among surveillance cases than among community cases ( % versus %; p = . ), while the proportion of individuals aged - y was higher ( % versus %; p = . ) (fig a) . for fatal respiratory disease, the proportion of individuals aged ! y ( % versus %; p < . ) was lower among surveillance cases than among community cases, while the proportion of individuals aged < y ( % versus %; p = . ), individuals aged - y ( % versus %; p < . ), and cases in the highest socioeconomic group ( % versus %; p = . ) was higher (fig b) . we observed a slight difference in the proportion of females for fatal respiratory disease ( % among surveillance cases versus % among community cases; p = . ), but not for severe neurological disease ( % versus %; p = . ). results were consistent in sensitivity analyses with age as a continuous variable and socioeconomic status classified into quintiles (figs. d and e in s text). a substantial proportion of cases (severe neurological disease % [ % ci %- %]; fatal respiratory disease % [ % ci %- %]) visited multiple healthcare providers during their illness. forty-eight percent ( % ci %- %) of severe neurological disease cases and % ( % ci %- %) of fatal respiratory disease cases attended any hospital, including surveillance hospitals (fig ) . including other hospitals that were attended by cases in the surveillance system could have increased the overall case detection probability by % (absolute increase) for severe neurological disease cases and % for fatal respiratory disease cases. the capacity to detect outbreaks would have increased, so that outbreaks containing four severe neurological or eight fatal respiratory disease cases would have been detected with ! % probability for any distance in the range - km from the original surveillance hospital, compared to and cases, respectively, with the current system ( fig. f in s text) . however, since individuals who attended any hospital had similar characteristics in terms of sex, age, and socioeconomic status as those attending surveillance hospitals (fig. g in s text), this expansion would not have increased disease detection in key groups such as the lowest socioeconomic group. only with the informal sector incorporated in the surveillance system would cases in such groups be detected. we described an analytic approach for evaluating the sensitivity and representativeness of hospital-based surveillance systems and applied it to surveillance for severe neurological diseases and fatal respiratory infectious diseases in bangladesh. we quantified the proportion of cases detected and the probability that the surveillance system would detect different sized outbreaks by distance from the surveillance hospital. finally, we characterized biases in surveillance statistics and identified potential improvements to the surveillance platform. we estimated that approximately one-quarter of severe neurological disease cases and onefifth of fatal respiratory disease cases occurring km from a surveillance hospital would be detected with current surveillance. the proportion of cases attending a surveillance hospital declined significantly with increasing distance between individuals' residence and the surveillance hospital, substantially faster for fatal respiratory disease than for severe neurological disease. these low detection probabilities mean that hospital-based surveillance in bangladesh (like in most other resource-poor countries presumably) would likely miss a high proportion of single-case public health events. of greater relevance is that surveillance system capacity to detect outbreaks and detection probabilities increased substantially with the number of cases. the required number of cases to detect outbreaks with high probability varied with disease type and distance from the surveillance hospital. it could be as low as about ten cases if the outbreak occurred < km from the surveillance hospital but increased quickly with distance for evaluating hospital-based surveillance fatal respiratory disease. for outbreaks defined as a single detected case, we found that more than half of outbreaks with ten cases of fatal respiratory disease would be missed if the outbreak occurred > km from the hospital. such detailed quantification of outbreak detection probability is essential to ascertain the likelihood that an emerging threat can be detected early enough to be contained [ ] . in some circumstances, authorities may have to wait until more than a single case is detected to recognize that an outbreak is occurring. in particular, difficult differential diagnoses and lack of appropriate diagnostic tests mean that only when a number of cases are detected from the same area and over a short time frame will an outbreak be identified and further investigations conducted. in addition, where a low background level of transmission is expected (such as with endemic diseases), public health authorities may wait until a particular threshold is exceeded before declaring an outbreak. in both of these scenarios, where multiple cases need to be detected by the hospital before an outbreak is recognized, the optimal number of detected cases and their spatial and temporal separation will depend on the disease system. we can incorporate this information into our flexible framework and provide examples where we calculate the size an outbreak needs to be for scenarios where at least two or five cases need to be detected (fig b and c ). in particular, this demonstrates that if an outbreak is identified only once five cases are detected at the surveillance hospital, the size of the outbreak would have to be substantially larger (e.g., nearly total cases of a fatal respiratory disease at km from a surveillance hospital) for there to be a % chance of an outbreak being identified. this highlights the possibility that, by the time an outbreak reaches sufficient size to be detected by the system, outbreak control measures may be much less effective at controlling spread. thresholds for case counts that trigger an outbreak response should be crafted taking this possibility into account. low detection probabilities for outbreaks that occur far from surveillance hospitals are an important concern because pathogens with high case fatality such as japanese encephalitis and nipah virus are nearly exclusively found in rural communities in bangladesh [ , ] , and evaluating hospital-based surveillance these communities are usually located far from surveillance hospitals. rural environments are also considered to be at highest risk for the emergence of novel pathogens [ , ] . population distribution maps suggest that % of the population in bangladesh live in communities > km from a surveillance hospital (representing million individuals) and % live > km from a surveillance hospital (representing million people) (fig b) . strengthening healthcare-based surveillance in these areas should be a priority, and cost-effective approaches to achieving surveillance targets need to be identified. there is increasing recognition of the value of novel data sources to improve the sensitivity of infectious disease surveillance, some of which can provide crucial information in remote areas [ ] . novel approaches include surveillance for media reports of disease clusters, as used for various infectious diseases in bangladesh [ , ] , and training of local drug sellers to recognize and report disease symptoms, as rolled out nationally to enhance tuberculosis surveillance in ghana [ ] . other surveillance data streams, such as monitoring over-the-counter medication sales, telephone triage, and webbased queries, have been successfully integrated in surveillance systems in resource-rich settings [ ] . we found that cases attending surveillance hospitals were not necessarily representative of all cases in the community. in particular, the youngest severe neurological disease cases and the oldest fatal respiratory disease cases were less likely to attend surveillance hospitals, and attendance was also lower among cases in the lowest socioeconomic group. similar variation in hospital attendance has been reported in other resource-poor settings [ , , ] , indicating that hospital-based surveillance in these countries may have comparable limitations. disease statistics obtained through hospital-based surveillance have to be interpreted in the light of detected biases, and correction factors may need to be applied. for example, underestimating severe neurological disease among young children may mislead any future japanese encephalitis vaccination strategy [ , ] . differential surveillance hospital attendance may also influence the capacity to detect emerging infections, such as the avian influenza a (h n ) virus that emerged in in china with observed cases mainly among elderly men [ ] . overall, access to appropriate care was poor-over % of community cases with severe disease or who died in our study never saw a qualified provider. such low access is a common problem in low-income settings and means that a large proportion of the population, and particularly subgroups that are potentially at highest need, do not receive the required medical attention [ ] [ ] [ ] [ ] . for example, difficulties accessing qualified healthcare providers for elderly people, who are often at greatest risk of respiratory disease, can have severe consequences for the outcome of disease. previous studies have demonstrated that accessibility to healthcare is a significant predictor of morbidity and mortality among elderly individuals with respiratory disease [ ] . the study showed that healthcare utilization behavior varied by disease type, which may be due to different characteristics of cases such as their age, socioeconomic status, and geographic location (fig. a in s text) . the majority of fatal respiratory disease cases were ! y old and may have faced limitations in mobility; moreover, rapid progression of disease to death may have prevented cases in this age group from seeking appropriate care. cases and their family members in general may have also perceived neurological symptoms as more severe, resulting in higher motivation to attend a qualified healthcare provider [ ] . we evaluated potential improvements of surveillance by analyzing healthcare seeking behavior among cases identified in communities. while the majority of individuals did seek care, much of this was in the informal sector, which cannot easily be incorporated into surveillance activity. nevertheless, including other hospitals attended by cases in the surveillance system (the exact location and number of these hospitals was unfortunately not identified during surveys) would double case detection probabilities and allow detection of medium-sized outbreaks (< cases) in a wider geographic area. however, in the case of bangladesh, such extension is likely to be prohibitively expensive. mapping other hospitals in bangladesh that may serve as surveillance sites would allow testing of various surveillance scenarios to identify the optimal location of surveillance sites while keeping the same total number or to quantify the number of sites needed to achieve a target surveillance coverage [ ] . many emerging infectious diseases originate as spillover infections of zoonotic diseases into the human population [ ] . therefore, mapping the occurrence of relevant zoonotic diseases (e.g., avian influenza) and combining such maps with the estimated outbreak detection probabilities would allow highlighting of surveillance gaps for particular types of emerging infectious diseases. the capacity of surveillance systems to detect outbreaks will depend not only on the probability that a case attends a surveillance hospital, but also on whether the case undergoes confirmatory laboratory testing and is subsequently reported through the surveillance system by the hospital. here we assumed a "best-case scenario" with a fully functional surveillance system at the hospital level, where each case who attends the surveillance hospital is ultimately recognized and confirmed as a case. case detection at the hospital may however be incomplete, since case definitions at hospitals may differ from syndromic definitions, a surveillance sampling frame may be applied, or resources and trained personnel for the diagnosis and reporting of cases may be limited [ ] . the calculation of case and outbreak detection probabilities may be adjusted for misdiagnosis and underreporting at hospitals if such information is available. we further assumed complete detection of cases in communities during surveys. although a few cases may have been missed, this assumption is justified as we investigated severe disease conditions that are easily remembered by family and community members. moreover, survey procedures combining interviews of key informants and house-to-house visits were specifically designed to capture near-complete case information. further, any missed cases are unlikely to impact our estimates, as such impacts would occur only if there was differential healthcare seeking between those detected and those missed. we investigated spatial differences in hospital attendance based on the straight-line distance of communities from the surveillance hospital. if available, other distance measures such as travel distance or travel time may provide a more accurate indicator of distance from the surveillance hospital. in some cases, these measures may strongly vary with the season, and it would be interesting to explore how that may impact the probability of detecting an outbreak. we assumed that cases did not visit other surveillance hospitals than the catchment hospital. given the poor road infrastructure in the country, it would be very unusual to travel to a tertiary care hospital that was not the closest one. it is possible that some individuals traveled to dhaka; however, these are likely to be wealthier individuals who would visit small private healthcare facilities that are not part of the surveillance network. the surveillance hospital in dhaka was not included in our study. this is unlikely to have biased our assessment of the performance of the surveillance system outside the capital. indeed, this would introduce a bias only under the unlikely scenario that many cases in our study who did not attend the nearest surveillance hospital (and were therefore not captured there) instead attended the surveillance hospital in dhaka (and were captured there). surveillance system performance in the capital city may however differ from elsewhere, and a comprehensive assessment of the national surveillance system would therefore have to include dhaka. moreover, hospital-based surveillance is only one surveillance type in bangladesh, and other data sources need to be considered to assess the country's overall capacity to detect public health events. the described methodology is applicable to assessing surveillance for other severe diseases in resource-poor settings, keeping in mind practical constraints. conducting community surveys may be labor intensive, time consuming, and expensive depending on the setting and may be particularly challenging in densely populated areas such as dhaka. nonetheless, such surveys are valuable tools for obtaining external reference data and simultaneously assess heterogeneities in healthcare access. the effectiveness of community networking may depend on the social structures in the study area; where social links are weaker (e.g., in urban areas), house-to-house surveys, even though more labor intensive, may be more suitable for the identification of cases in the community. the proposed strategy is valid for diseases of sufficient severity to require medical attention and to be remembered by cases and family members. the approach is syndromic (i.e., disease types are classified based on a set of symptoms), and the classification specificity may vary by disease. in conclusion, this study allowed us to quantify the sensitivity and representativeness of hospital-based surveillance and to identify weaknesses, particularly in detecting small-to medium-sized outbreaks in remote areas. these findings highlight difficulties that low-middle-income countries may have in meeting international health regulations requirements, despite considerable investment in hospital-based surveillance platforms. international infectious disease law: revision of the world health organization's international health regulations geneva: world health organization public health surveillance toolkit. a guide for busy task managers. washington (district of columbia): world bank guide to monitoring and evaluating. geneva: world health organization world health organization. who report on global surveillance of epidemic-prone infectious diseases. geneva: world health organization neonatal morbidity and care-seeking behaviour in rural bangladesh health care utilization and symptom severity in ghanaian children-a cross-sectional study inequalities in public health care delivery in zambia inequities among the very poor: health care for children in rural southern tanzania updated guidelines for evaluating public health surveillance systems framework for evaluating public health surveillance systems for early detection of outbreaks low-cost national mediabased surveillance system for public health events influenza-associated mortality in in four sentinel sites in bangladesh a novel low-cost approach to estimate the incidence of japanese encephalitis in the catchment area of three hospitals in bangladesh incidence of influenza-associated mortality in bangladesh disaggregating census data for population mapping using random forests with remotely-sensed and ancillary data qgis development team. qgis geographic information system. version . . open source geospatial foundation project constructing socio-economic status indices: how to use principal components analysis the use of confidence or fiducial limits illustrated in the case of the binomial innovation in observation: a vision for early outbreak detection an introduction to the bootstrap r: a language and environment for statistical computing. vienna: r foundation for statistical computing strategies for containing an emerging influenza pandemic in southeast asia recurrent zoonotic transmission of nipah virus into humans hospital-based surveillance for japanese encephalitis at four sites in bangladesh emerging infectious diseases of wildlife-threats to biodiversity and human health investigating the zoonotic origin of the west african ebola epidemic early detection of pandemic (h n ) intensifying tb case detection: update -ghana. geneva: world health organization syndromic surveillance for local outbreak detection and awareness: evaluating outbreak signals of acute gastroenteritis in telephone triage, web-based queries and over-the-counter pharmacy sales targeting vaccination against novel infections: risk, age and spatial structure for pandemic influenza in great britain optimizing infectious disease interventions during an emerging epidemic an overview of the characteristics of the novel avian influenza a h n virus in humans pneumonia and influenza hospitalizations in elderly people with dementia optimizing provider recruitment for influenza surveillance networks global trends in emerging infectious diseases hospitalization records as a tool for evaluating performance of food-and water-borne disease surveillance systems: a massachusetts case study the international centre for diarrhoeal disease research, bangladesh (icddr,b) acknowledges with gratitude the commitment of the us centers for disease control and prevention to its research efforts. icddr,b is also grateful to the governments of bangladesh, canada, sweden, and the uk for providing core/unrestricted support. conceptualization: bn hs sc esg. key: cord- - c ut authors: nan title: cis annual meeting: immune deficiency & dysregulation north american conference date: - - journal: j clin immunol doi: . /s - - -z sha: doc_id: cord_uid: c ut nan abstract/case report text oral lichen planus (olp) is a t-cell mediated chronic inflammatory tissue reaction in which presentation can range from asymptomatic plaques to painful, erosive, bullous, or ulcerative lesions. here, we present a year-old female with a novel ctla- variant, multiple autoimmune conditions, and unusual tongue lesions. our patient was healthy until years of age when she developed hashimoto's thyroiditis. at , she developed psoriasis. at , she was diagnosed with alopecia totalis and epstein-barr virus (ebv) with resultant and persistent anemia, thrombocytopenia, lymphopenia and neutropenia. she had chronic abdominal pain and diarrhea since age . esophagogastroduodenoscopy revealed lymphocytic esophagitis and active duodenal inflammation with increased intraepithelial lymphocytes. colonoscopy revealed mildly active chronic colitis with eosinophils. whole exome sequencing revealed a heterozygous c. dela (p.q rfs* ) pathogenic mutation in exon of ctla- . family history is remarkable: father (splenomegaly and psoriasis) and brother (autoimmune hemolytic anemia) have ctla haploinsufficiency with the same mutation. abatacept was initiated with re-growth of hair, improvement in cytopenias, improvement in psoriasis, and some reduction of gastrointestinal symptoms. since her abdominal pain persisted repeat endoscopies after six months of abatacept revealed persistent active lymphocytic esophagitis with some improvement in inflammatory injury in her duodenum and colon. physical exam revealed glossitis with a gel-like coating and ulceration on her tongue, xerosis along her face and scalp without other abnormalities ( figure) . she denied recent dental procedures, appliances, or tongue biting. her wbc ranged from - x ^ cells/l and hemoglobin . - . g/dl. absolute lymphocyte count ranged from . - . x ^ cells/l. immunologic evaluation revealed low iga and pan-low lymphocyte subsets (table) . ebv pcr ranged from - , copies/ml. tongue scraping revealed candida dubliniensis and she responded to days of fluconazole. two months later, she developed painful white patches along her tongue and subsequent kilogram weight loss recalcitrant to viscous lidocaine, antacids, and days of fluconazole. incisional tongue biopsy revealed ulceration with underlying granulation tissue with lymphocyte and plasma cell infiltration consistent with olp ( figure) . periodic acid-schiff diastase stain and grocott stain were negative. aerobic culture was normal. no fungus was isolated within days. epstein-barr encoding region in situ hybridization was negative. two weeks of topical dexamethasone lead to temporary improvement. her tongue lesions waxed and waned over the following months. due to persistent psoriasis, methotrexate was initiated without worsening in her tongue lesion. to our knowledge, this is the first case of olp reported in a patient with ctla- haploinsufficiency. ctla- haploinsufficiency may present with variable clinical phenotypes including increased risk of ebv viremia and malignancies. therefore, after ebv and malignancy are ruled out, olp may be a prudent diagnosis to consider in a ctla insufficient patient with unusual oral lesions. mutations of bcl b appear to be associated with lymphoproliferation and autoimmunity as well as susceptibility to herpes virus infections. additional research focusing on characterization of dna binding sites of bcl b as well as the downstream expression of associated target genes is needed. these data combined with longitudinal analysis of additional patients with confirmed bcl b mutations, will help clarify determinants of bcl b pathogenesis and highlight potential therapeutic strategies. consanguineous marriages in tribal cultures, such as that in the united arab emirates significantly increase the prevalence of autosomal recessive disorders. premarital genetic screening and counseling, thus, are expected to reduce the frequency of these diseases. in this pilot study, diagnostic exome sequencing was used in the premarital screening program to identify recessive pathologic variants preventable by premarital counseling. a total of pathologic or likely pathologic variants were identified in studied emiratis ( couples), averaging . variants per person. four percent of the persons had negative diagnostic exome sequencing; the remaining had one to eight variants per person. of the distinct variants, ( %) were novel. twenty ( %) couples had pathologic or likely pathologic variants of inborn errors of immunity (iei). two couples ( %) had iei pathologic or likely pathologic heterozygous variants in both partners imposing risk for autosomal recessive disease in the offspring. other eighteen couples ( %) had pathologic/ likely pathologic heterozygous variants present in only one person of the couple. total of sixteen ( . %) iei variant identified and eight ( %) were novel. fourteen known phenotypic iei diseases were recognized (table. ). these preliminary results support a need for nationwide premarital genetic screening, and primary immunodeficiency registry to identify common and novel pathogenic variants with high heritability rate. these results will aid adopting a preand post-connectional reproductive carrier counseling to reduce autosomal recessive diseases. also, it will assist the diagnosis of these complex diseases in our community. table pathologic or likely pathologic variants of primary immunodeficiency (pid). abstract/case report text background: chronic granulomatous disease (cgd) is a primary immunodeficiency disorder caused by defects in the phagocytic nadph oxidase complex, leading to increased susceptibility to infection and inflammatory or autoimmune disease. up to % of patients have gastrointestinal (gi) involvement and meet diagnostic criteria for inflammatory bowel disease (cgd-ibd). objectives: we analyzed cgd patients from the united states immunodeficiency network (usidnet) registry to determine whether ibd may change the presentation, treatment, and outcomes of cgd patients, as compared to those without ibd. methods: a retrospective evaluation of cgd cases from the usidnet registry was completed. cgd-ibd was defined as the presence of any major physician-reported inflammatory, non-infectious gi tract disease manifestation, including crohn disease, ulcerative colitis, ibd endoscopy findings, gi fistulas, gi strictures, gi obstruction, and proctitis. demographic information, genotypes, symptoms and conditions, infections, antimicrobial therapies, immunomodulator use, and allogeneic hematopoietic stem cell transplantation (hsct) data were analyzed. results: patients with a diagnosis of cgd were identified. met criteria for ibd; were categorized in the non-ibd group. crohn disease and colitis were the most common gi disease manifestations in the cgd-ibd group (n= ), followed by gi fistulas (n= ). cgd-ibd patients had an increased average frequency of infections ( . events/patient) compared to the cgdnon-ibd group ( . events/patient). in both groups, lower respiratory tract infections were the most common infection type and aspergillus was the most common organism. enteric organism infections were more common in ibd patients. temporal data regarding the timing of infections were not available. immunomodulators, including biologics and interferon-gamma, were used at a significantly higher rate in ibd patients compared to non-abstract/case report text down syndrome (ds) is characterized by the occurrence of three copies of human chromosome (hsa ). these patients often develop chronic mucocutaneous candidiasis (cmc) and autoimmune thyroiditis, mimicking patients with heterozygous gain-of-function (gof) stat mutations, which enhance cellular responses to the three types of interferon (ifn). hsa contains a cluster of four interferon receptor (ifn-r) genes: ifnar , ifnar , ifngr and il rb. a gene dosage effect at these four loci may contribute to the infectious and autoimmune manifestations observed in individuals with ds. we report high levels of ifn-αr , ifn-αr and ifn-γr expression on the surface of monocytes and ebv-transformed-b (ebv-b) cells from ds patients. levels of ifn-ɣr , encoded by a gene on chromosome , were similar in the immune cells of ds patients and healthy controls. total and phosphorylated stat (stat and pstat ) levels were constitutively high in unstimulated and ifn-α-and ifn-γ-stimulated monocytes from ds patients, although less so than those in patients with gof stat mutations. following stimulation with ifn-α or -ɣ, but not with il- or il- , pstat and ifn-ɣ activation factor (gaf) dna binding activities were significantly higher in the ebv-b cells of ds patients than in controls, this response resembling the dysregulated responses observed in patients with stat gof mutations. plasma type i ifns concentrations were high in about % of the ds patients tested. a genome-wide transcriptomic analysis involving principle component analysis and a comparison of interferon modules was performed on circulating monocytes. it showed that ifn-stimulated genes (isgs) were expressed more strongly in ds than in controls. ds monocytes have intermediate levels of ifn-α-and ifn-γ-induced isgs relative to monocytes from healthy controls and from patients with gof stat mutations. by contrast to patients with gof stat mutations, circulating th counts were normal and the proportion of terminally differentiated cd + t cells was high in ds patients. the constitutive upregulation of type i and type ii ifn-r, at least in monocytes of ds patients, may therefore contribute to the autoimmune diseases observed in these individuals. scid screens (positive screen defined as trec values less than units/ul per statewide criteria). results forty nine neonates were identified with low trec values. ( %) of these infants had repeat trec screening, ( %) of which were found to have a positive second trec screen. lymphocyte subsets were evaluated in of these infants and of which were noted to have lymphopenia (defined as absolute lymphocyte count less than ). infants were noted to have low cd levels (defined as < cells/ul) and were noted to have low cd levels (defined as less than cells/ul). of note, % of the infants with cd and cd lymphopenia had normal repeat trec levels. of the infants were noted to have low b cell levels (defined as < cells/ul). infants had quantitative immunoglobulin levels and of these two were noted to have igg levels less than . of note one infant was diagnosed with partial digeorge syndrome via microarray. in our study population, no infants were diagnosed with scid. discussion our study shows that testing for trec levels on newborn screen may be beneficial in identifying not only scid, but also other immunologic conditions. infants in our study had evidence for both cell mediated and humoral immunodeficiency which necessitated further workup and follow up from allergy and immunology specialists. it may be beneficial to develop further programs to track infants identified with abnormal trec levels on newborn screens to determine if they develop signs of immunodeficiency syndromes later in life. abstract/case report text the patient was transferred to our adult clinical immunology transition clinic for low igg and iga, elevated igm and b cell lymphopenia, treated with subcutaneous gamma globulin. his medical history was relevant for recurrent respiratory infections since two years-old, failure to thrive and developmental delay. he also developed chronic auto-immune hemolytic anemia (aiha) at ten years old, accompanied by prominent lymphoid hyperplasia. our initial evaluation at the age of twenty years old showed massive polyadenopathy and splenomegaly. work-up confirmed flair-up of aiha. at that point, the diagnosis of apds was raised. he also had mild intellectual impairment and dysmorphic features such as a mild degree of ocular depression, deep-set eyes, vaguely triangular face, small chin, but had normal stature. a customized panel for usual genes involved in classic hyperigm syndromes, apds, noonan and kabuki syndromes came back negative. at years old, an urgent coloscopy was performed because of acute abdominal pain and showed diffuse ileal lymphoid hyperplasia. biopsies confirmed reactional lymphoid hyperplasia without infection nor malignancy. a second genes ngs panel associated with pid identified a heterozygote mutation in tap ; expression of hla class was normal on flow cytometry. the patient was then started on sirolimus for an "apds-like syndrome" despite the lack of genetic confirmation. six months after introduction of mtor inhibitor, his abdominal pain had completely disappeared. tep scan showed complete resolution of axillar, retroperitoneal and inguinal lymph nodes and significant regression of splenomegaly. a third large non-biased + genes ngs panel revealed a pb de novo deletion that included the splice site of pik r exon typically involved in apds : c. _ + del p.(asp glufs* ) , which was missed by the first two panels. indeed, oligonucleotide-selective sequencing technology used for the previous panels was associated to mapping errors of short reads and difficult detection of large deletions. interestingly, the patient also presented some but not all dysmorphic features of short syndrome which is related to pik r haploinsufficiency. in this new era of genetic testing, this case is a reminder that we need to be aware of the pitfalls of genetic tests and that clinical judgment is still our best diagnostic tool. abstract/case report text intro: patients with chronic granulomatous disease (cgd) are theorized to have a lower risk of malignancy related to their lack of free radical formation. there are relatively few reports of malignancy described in patients with cgd. we report three cases of malignancies in the large cohort cgd population at the national institutes of health followed between - to add to the seven cases described in the literature. case : a -year-old man with x-linked chronic granulomatous disease with a history of severe inflammatory bowel disease, who presented with progressive left-sided chest pain in , decreased appetite and weight loss. transthoracic lung biopsy showed atypical cells and a pet/ct showed abnormally dense mesentery and widespread hypermetabolic abnormalities. a mesenteric biopsy showed metastatic pancreatic adenocarcinoma. palliative care was initiated. patient expired four months after diagnosis. case : a -year-old man with x-linked chronic granulomatous disease and severe inflammatory bowel disease requiring total proctocolectomy and who had been remotely treated with infliximab, presented in with right upper quadrant pain. abdominal ultrasound and mri of the liver showed multiple liver lesions. biopsy of these lesions revealed hepatocellular carcinoma. patient underwent two courses of radiolabeled itrium spherules. however, his disease progressed and he expired approximately five months after diagnosis. c a s e : a n -y e a r-o l d m a n w i t h x -l i n k e d c h r o n i c granulomatous disease and inflammatory bowel disease who presented in with fevers, abdominal pain and pancytopenia. during the course of his hospitalization, he developed sepsis which led to his demise. on autopsy, an incidental finding of papillary thyroid carcinoma was made. discussion: these three patients all had poorly controlled inflammatory bowel disease. additionally, patients with cgd are typically exposed to higher doses of radiation, leading one to expect higher rates of radiation induced malignancies. however, there are still relatively few case reports of cancer in the cgd population. tissue biopsy is necessary for diagnosis. due to end organ damage secondary to the underlying disease in the first two cases, treatment options were limited. managing infections during chemotherapy can be complex due to drug interactions with chemotherapeutic agents. abstract/case report text myeloperoxidase (mpo) deficiency is the most common inherited defect of phagocytes that impairs microbial killing since the toxicity of the respiratory burst is dampened without myeloperoxidase release from the azurophilic granules. a significant portion of these patients remain asymptomatic, however there is a clinically variable phenotype that can present if they do become symptomatic. fungal infections with candida strains appear to be the most frequently reported. we present an adulthood case of recurrent invasive candidal disease due autosomal recessive myeloperoxidase deficiency from a pathogenic missense variant in the mpo gene (c. c>t (p.arg trp)). a -year-old caucasian male was in his normal state of health without any major illnesses until years of age when he was diagnosed with candida osteomyelitis of the heel, followed by cryptococcal meningitis the following year which ultimately required a ventriculoperitoneal shunt. in , he had a prolonged hospitalization after presenting with lethargy, headache and vomiting that culminated in seizure activity and prompted an emergency room visit. imaging at the time showed ventriculomegaly, and fluid from the shunt revealed yeast, but no bacteria. he was started on broad spectrum antifungal therapy and admitted for further management. cerebral spinal fluid and blood cultures confirmed invasive candida albicans meningitis. during this hospitalization, he also developed sepsis secondary to serratia marcescens. because of the pathogens that were being isolated, our service was consulted. of note, our patient does not have diabetes mellitus. a neutrophil oxidative burst assay showed an absent respiratory burst compared to control. a primary immunodeficiency panel to identify genetic variants was also sent to invitae. variants in cyba, cybb, ncf , and ncf were not identified, making chronic granulomatous disease less likely. peroxidase staining was negative on neutrophils and normal on eosinophils, suggesting a diagnosis of mpo deficiency. this led to mpo gene sequencing for deletion and duplication analysis. a homozygous pathogenic variant consistent with a molecular diagnosis of a mpo related condition was identified. immunoblotting of patient-derived immune cells demonstrated an absence of mature enzyme. although not typically indicated, given the severity of his presentation, our patient remains on fluconazole for long term prophylaxis. his younger brother also had a history of invasive disease with candidaosteomyelitis and meningitis. a neutrophils oxidative burst assay showed similar results in his brother and similar results with peroxidase staining, also suggesting a diagnosis of mpo deficiency. confirmatory genetic testing has not been performed yet. their father, who reported severe skin infections with candida, had peroxidase stains performed on neutrophils and eosinophils which were both normal. we have presented a patient without a significant history of diabetes mellitus who developed invasive disease from candida and serratia and was ultimately diagnosed with myeloperoxidase deficiency. abstract/case report text introduction: juvenile xanthogranuloma (jxg) is an often benign, histiocytic proliferative disorder of the mononuclear phagocytic system. patients typically present with localized cutaneous lesions. systemic disease, especially central nervous system involvement, rarely occurs but has significant morbidity and mortality risk. no standard evaluation nor therapy regimen exists for systemic jxg and little is known about the genomic alterations underlying its pathology. case report: a full-term male infant presented at months of age with post-prandial abdominal pain, fevers, altered mental status and weight loss. abdominal ultrasound and ct identified renal masses. a chest ct was obtained showing a paraspinal mass with possible neural foramina extension. mri brain and total spine was consistent with diffuse leptomeningeal disease involving the left frontal convexity, brainstem, cerebellum, and multiple cranial nerves. abnormal enhancement was also present along the entire surface of the spinal cord extending into the cauda equina with additional enlargement of the cervical/upper thoracic cord with intramedullary enhancing masses and a right paraspinal mass. renal biopsy yielded a pathologic diagnosis of disseminated jxg. integrative clinical sequencing of the mass identified a somatic driving alk rearrangement (kif b-alk in-frame fusion). tumor and matched germline dna sequencing did not detect any alterations in the ras/mapk pathway. bone marrow biopsy was negative for disease with cerebrospinal fluid analysis showing numerous monocytes and macrophages consistent with jxg. the patient was started on therapy consisting of systemic dexamethasone, intrathecal methotrexate/hydrocortisone and systemic intravenous cytarabine. his first cycle was complicated by pseudomonas aeruginosa bacteremia and gangrenous cellulitis of the perianal region, treated with systemic/topical antibiotics and topical gm-csf. following completion of the initial cycle of therapy, the patient was noted to have declining neurologic status, including seizure-like activity. repeat mr imaging revealed worsening cns disease with new subdural fluid collection and progression of leptomeningeal enhancement and intramedullary cervical lesion. in light of disease progression, the decision was made to continue dexamethasone treatment, but add adjunct intrathecal cytarabine, and transition to targeted alk inhibition via daily oral ceritinib, given its predicted cns penetrance followed by ceritinib in combination with systemic intravenous clofarabine. significant clinical and radiographic improvement was noted with the new targeted treatment regimen. ceritinib therapy was tolerated well overall after a % dosing reduction made for initial grade gastrointestinal toxicity and grade hypertriglyceridemia (non-life threatening but level > mg/dl). following continued treatment with daily ceritinib and completion of cycles of clofarabine therapy, our patient experienced complete disease remission. he continues to do well on daily ceritinib monotherapy with plan to complete an additional year of therapy. conclusion: our report highlights the potential benefit of real-time integrative clinical sequencing in the management of systemic histiocytic lesions, specifically non-langerhans cell conditions. it has the potential to identify novel somatic genetic alterations, other than the typical lchassociated braf mutations of the mapk pathway, that may be therapeutically targetable. treatment with nd generation alk-inhibition in our pediatric disseminated jxg patient was a novel, biologicallyrationale management approach with minimal toxicity and potentially contributed to his complete remission. abstract/case report text background: c glomerulonephropathy (c gn) is a progressive kidney disease with the predominant pathological feature of c deposits around the glomerular capillaries. c gn patients suffer from dysregulated activation of the alternative pathway as the result of autoantibodies or congenital genetic defects that stabilize cleavage of c . despite therapy involving immunosuppression and complement-pathway inhibition, the prognosis for c gn is poor. we report a patient with autoantibody-mediated, refractory c gn who demonstrated no improvement on rituximab but achieved sustained remission on bortezomib. follow up studies after one year demonstrated clearance of the culprit autoantibody, normalization of c levels, and improved pathologic appearance of the kidneys. this case supports the idea that c gn is frequently driven by pathogenic autoantibodies that may not clear with rituximab alone. plasma cell directed therapy has the potential to clear these autoantibodies and halt the progression of disease. case presentation: we report the case of a hispanic male with chronic renal dysfunction initially diagnosed with membranoproliferative glomerulonephritis on renal biopsy at years of age. despite cellcept and prednisone, over the next years, he had worsening proteinuria and an increase in protein-to-creatinine ratio. renal biopsy suggested c gn, and lab studies revealed a factor-h autoantibody and c level below the assay limit of detection. after initiating eculizumab, the proteinuria temporarily improved; however, the proteinuria eventually worsened, and he was referred to immunology. we hypothesized that the factor h-binding autoantibody was the cause of dysregulated c cleavage and disease progression, and blocking the terminal complement pathway with eculizumab would not halt upstream c -mediated kidney injury. at the age of , rituximab and plasmapheresis were administered to clear the factor-h autoantibody. three months after rituximab administration, the factor-h autoantibody level decreased to the normal range, but he continued to have significant proteinuria with low serum albumin and undetectable c level. we concluded that the relevant autoantibody was not solely produced by differentiating memory b cells, so we decided to target the plasma cell compartment. bortezomib was started at the age of , and eculizumab was continued given his initial response to treatment. after adding bortezomib, factor h autoantibody levels dropped below prior levels and serum c level normalized. renal biopsy at the age of showed evidence of imp r o v i n g c d e p o s i t i o n a n d l e s s p r o m i n e n t g l o m e r u l a r hypercellularity, with stable mesangial hypercellularity, interstitial fibrosis, tubular atrophy, and sclerotic glomeruli. although his proteinuria did not worsen, it remained persistent, suggesting that earlier introduction of bortezomib could have prevented disease advancement. there has been no further progression of kidney failure. conclusions: the majority of c gn patients harbor autoantibodies to components of the alternative pathway of complement. this case provides evidence that at least some of these autoantibodies are indeed the cause of complement dysregulation, and thus are prime targets for therapy. b cell targeting therapies may be inadequate to decrease autoantibody levels for some patients. early initiation of bortezomib, or other plasmacell directed therapy, may effectively induce complement normalization and disease remission in these cases. inhaled corticosteroid and a long-acting bronchodilator. he has no family history of immunodeficiencies or congenital disorders. computed tomography(ct) chest showed bronchiectasis. his complement studies and isohemagglutinin titers were also normal. his serum immunoglobulin(ig) and lymphocytes on presentation are shown in table . he had a poor response to polysaccharide pneumococcal vaccination. he was diagnosed with combined igg /igg subclass/iga deficiency and was started on immunoglobulin replacement therapy and prophylactic rotating antibiotic therapy. thereafter, his clinical course markedly improved with a reduction in the frequency of rti's as well as the number of bronchiectasis exacerbations. there was high suspicion for an underlying genetic disorder based on his constellation of neurodevelopment disorders and immunodeficiency. cytogenetic evaluation with array comparative genomic hybridization(cgh) analysis showed duplication of xq and xq consistent with mds. discussion: mds is caused by duplications involving the mecp gene locus of the x chromosome at xq . it has a % penetration rate in males whereas females act as carriers and are usually unaffected. rarely, cases of de novo mutations causing mds have been reported. chromosome microarray analysis is currently the best initial clinical test when mecp duplication syndrome is suspected. management needs a multidisciplinary approach involving geneticists, neurologists, ophthalmologists, physical medicine and rehabilitation specialists, psychologists, gastroenterologists, and allergy and immunology specialists. prophylactic treatment with ivig and antibiotics has been the standard of care for immunodeficiency in these patients. prognosis is guarded and most male patients die in the mid to late 's because of severe rti's secondary to immunodeficiency. conclusions: this case confirms the association of mds with combined iga and igg subclass deficiencies. clinicians should consider pursuing genetic evaluation for mds in patients with neurodevelopmental disorders and immunodeficiency because the diagnosis of the syndrome can change the overall approach to management and expectations in prognosis. abstract/case report text introduction: c nephritic factor is an autoantibody that binds to the alternative pathway c convertase (c bbb). this results in unchecked overactivation of the alternative complement pathway, which can lead to renal disease, partial lipodystrophy, retina disease, and frequent infections. in this case, we present a patient with partial lipodystrophy and low c , subsequently found to have c nephritic factor. case description: a year old female presented with a month history of low c levels. she was diagnosed months ago with poststreptococcal glomerulonephritis (psgn) after presenting with hematuria and elevated aso titers. she had c levels drawn - months after time of diagnosis and c level was low at (normal range - ), which was consistent with psgn. it was rechecked months after time of diagnosis and was still low. she was referred to rheumatology at this time and was found to have a positive ana titer : . tests for lupus and anti-phospholipid syndrome were negative. c normalized to the low-normal range at months after time of diagnosis to . her pediatrician checked to make sure it remained normal around months after initial diagnosis and c was low again at . c was normal at . she was referred to immunology for further evaluation. during this time she was asymptomatic with no fevers, infections, hematuria, rashes, joint pain, or joint swelling. she has no history of hospitalizations other than the first for psgn. mother denied family history of autoimmune disorders. physical exam: physical exam was notable for abnormal subcutaneous facial fat with normal fat distribution in the rest of her body. the rest of the exam was unremarkable with normal cardiac, pulmonary, abdominal, and skin exam. testing: c level was rechecked and low at . c nephritic factor was elevated at . (normal range . - . ). alternate pathway complement (ah ) was confirmed twice and was undetectable, < (normal level greater or equal to ). total hemolytic complement (ch ) was low at (normal level - ). other complement levels were checked and c q, c , c , c , c , c , c , and c complement were within normal range. discussion: the overactivation of the alternative complement pathway by c nephritic factor can result in various clinical manifestations, such as c glomerulopathy and acquired partial lipodystrophy in predominantly the face and the upper torso. the exact mechanism of how c nephritic factor is related to facial and upper body lipodystrophy is not known. one proposed mechanism is that adipocytes in the face and upper body produce more factor d, which is a complement protein utilized by c nephritic factor. overactivation of the alternative complement pathway on the adipocyte then leads to formation of the membrane attack complex, resulting in adipocyte lysis. eye disease, such as retinitis pigmentosa and macular degeneration can develop. c nephritic factor can also lead to more frequent infections and renal disease. patients need to be closely monitored. if patients develop c glomerulopathy, they may need to be considered for immunomodulatory therapy, such as steroids and other immunosuppressants. project manager/ucsf benioff children's hospital senior clinical research associate/ucsf benioff children's hospital associate professor/department of clinical pharmacy, ucsf staff research assistant iv/ucsf benioff children's hospital senior supervisor/ucsf benioff children's hospital laboratory specialist/ucsf benioff children's hospital research specialist/ucsf benioff children's hospital assistant professor/ucsf benioff children's hospital clinical professor/ucsf benioff children's hospital assistant professor/ucsd rady children's hospital staff pediatrician/tuba city indian health service staff pediatrician/phoenix children's hospital associate professor/seattle children's hospital chief, genetic immunotherapy section/niaid, nih professor/university of minnesota professor/ucsf benioff children's hospital abstract/case report text background: artemis-deficient scid (art-scid) represents % of all scid, but occurs in / births in navajo and apache native americans. artemis protein, encoded by dclre c, is essential for repairing dna double-stranded breaks, including those generated during v(d)j recombination of antigen receptor genes as t and b cells develop. artemisdeficiency causes not only t-b-nk+ scid, but also increased sensitivity to alkylating drugs and radiation. art-scid is the most difficult scid to treat with allogeneic hematopoietic cell transplantation (hct) due to high rates of rejection and gvhd, incomplete immune reconstitution, and toxicity following intensive conditioning regimens. as an alternative, we developed a self-inactivating lentiviral vector containing the human artemis promoter and dclre c cdna (aproart). we are evaluating its toxicity and efficacy in a phase i/ii gene transfer trial in art-scid patients. methods: newly diagnosed infants with art-scid and older patients with insufficient immunity despite prior allogeneic hct were eligible if organ function was acceptable. infants needed to have no matched sibling donor and be at least months old at conditioning. cd + cells were isolated from bone marrow or cytokine-mobilized peripheral blood, cultured with cytokines, transduced x with aproart, and cryopreserved. patients received daily doses of busulfan, targeted for a cumulative exposure (cauc) of mg*hr/l, with infusion of thawed cells on the following day. results: we treated newly diagnosed infants (art - & - ) with median age . m (range . - . ) and previously-treated patients (art - ) ( . y, . y and . y), with a median follow-up of . m (range . - . ). the mean (sd) bu cauc was . ± . mg*hr/l. patients received a median of . x aproart-transduced cd + cells/kg (range . - . ). the average vector copy number (vcn) and transduction efficiency in the marrow grafts exceeded those in the pbsc grafts: . ± . copies/cell vs . ± . (p= . ) and ± % vs ± . % (p= . ), respectively. there were no serious busulfan side effects. all patients had transduced peripheral blood leukocytes by w and of developed gene marking in t, b, nk and myeloid cells by w (fig. ) . gene-corrected cd , cd , cd / ra/ccr , cd and cd cells appeared in of patients (fig. ) , with art having t, nk and myeloid marking without b cells at m post infusion. normalization of lymphocyte proliferation to pha occurred in the evaluable (> w) infants (fig. ) , all now outpatients off isolation. two infants and previously treated child developed autoimmune hemolytic anemia (aiha), with requiring immunosuppressive therapy. infections included rhinovirus at presentation in art that resolved with t cell reconstitution. after discharge art acquired and recovered from norovirus and art acquired and recovered from cmv and rotavirus. analyses of insertion sites and t cell receptor diversity are pending. conclusion: infusion of aproart-transduced autologous cd cells into art-scid patients pretreated with very low exposure busulfan resulted in multilineage engraftment of transduced cells with evidence for t and b cell immune development. aiha, the only complication to date, occurred early and appears to resolve following restoration of t cell immunity. these encouraging results suggest potential effectiveness of ex vivo gene therapy for art-scid. ( ) submission id# mailan nguyen, md , susan canny, md, phd , andrea ramirez, md , ivan chinn, md abstract/case report text background: systemic lupus erythematosus is a heterogeneous disorder of the immune system. systematic genetic evaluation of patients with childhood-onset sle (csle) has begun to identify phenotypic clusters of csle patients with classic sle-causing genetic variants, as well as revealed unexpected genetic mimics of lupus. we report patients diagnosed with csle with similar typical and atypical lupus features, who were subsequently found to carry pathogenic nras variants that are the cause of ras-associated autoimmune leukoproliferative disorder (rald). cases: all patients ( females, male) presented at < years of age (average age . months, range - months) with antinuclear antibodies, anti-double-stranded dna antibodies, autoimm u n e h e m o l y t i c a n e m i a , s e v e r e t h r o m b o c y t o p e n i a , antiphospholipid antibodies, hypocomplementemia and nephritis. additionally, the patients all displayed fevers, organomegaly, lymphadenopathy and hypergammaglobulinemia. two out of patients had a malar rash, leukopenia, lymphopenia, anti-smith antibodies, serositis or arthritis. no patient had oral or nasal ulcers or photosensitivity. despite the fevers, lymphoproliferation and systemic autoimmunity, the patients did not display overwhelming immune dysregulation (peak ferritin - ng/ml). interestingly, the patients were found to have monocytosis ( - %), as has previously been reported in rald. double negative t cells were within normal range in the patients in which this was tested. all patients required aggressive immune modulation for control of their disease manifestations. two of the developed severe infections, specifically pneumococcal sepsis, during therapy. current follow-up covers an average of . years (range . to years). the patients responded to corticosteroids and were given sequential trials of various steroid-sparing therapies. in general, they appeared to benefit from both b cell depletion and t cell-directed modalities (cyclosporine, rapamycin), which are not first line therapy in csle. unfortunately, patient developed a fatal pulmonary infection while on treatment; her underlying disease was felt to be quiescent. due to the early-onset of disease, each patient was selected for genetic evaluation ( by exome sequencing, by gene panel). this lead to the discovery of pathogenic nras variants (c. g>a, p.g d) in all patients, assumed to be somatic, although this was confirmed in only case. conclusion: ras-associated autoimmune leukoproliferative disorder can present indistinguishable from csle with positive autoantibodies, immune cytopenias, arthritis, nephritis and hypocomplementemia. clinicians should consider evaluating for rald in csle patients who present at an early age ( < years) with predominant features of lymphoproliferation and hematologic abnormalities, particularly monocytosis. t cell-directed therapy with cyclosporine or rapamycin should be considered for rald. ( ) human ctla loss-offunction causes dysregulation of foxp + regulatory t (treg) cells, hyperactivation of effector t cells, and lymphocytic infiltration of target organs. patients also exhibit progressive loss of circulating b cells, associated with an increase of predominantly autoreactive cd (lo) b cells and accumulation of b cells in non-lymphoid organs. inherited human ctla loss-of-function demonstrates a critical quantitative role for ctla in governing t and b lymphocyte homeostasis. ( ) this case highlights the importance of next generation sequencing (ngs) in diagnosing and managing complex presentations with multi-system involvement. case presentation: patient was diagnosed with diffuse large b cell lymphoma at age and treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (r-chop) in / . he underwent autologous stem cell transplant with preparative carmustine, etoposide, cytarabine, and melphalan (beam) in / . he subsequently developed recurrent giant condyloma acuminata following transplantation requiring surgical resections, refractory immune thrombocytopenic purpura (itp) requiring aggressive systemic steroids and high dose ivig at least yearly, experiencing hypogammaglobulinemia, recurrent sinopulmonary infections, disseminated herpes zoster, and kaposi sarcoma. in / , he underwent ct/pet, revealing extensive hypermetabolic lymphadenopathy and splenomegaly. bone marrow biopsies were negative for lymphoma, although showed a slightly hypocellular marrow ( - % cellularity), % blasts, and eosinophilia without peripheral eosinophilia. repeated evaluations for hiv, syphilis, histoplasma, cmv, hhv , hhv , bartonella, coxciella, brucella, htlv, toxoplasma were negative. htlv and antibodies had been negative prior to transplantation. tonsillectomy / due to progressive enlargement showed reactive follicular hyperplasia with focal acute tonsillitis without granulomas or viral inclusions. repeated lymphocyte enumeration and proliferation studies were normal. a repeat pet scan / revealed persistent diffuse lymphadenopathy involving the neck, chest, abdomen, and pelvis. left lung biopsy revealed non-caseating granulomas without lymphoma. stains for ebv were negative. repeat pet scan / indicated disease progression prompting a left axillary excisional lymph node biopsy, revealing ebv lymphadenitis with large, reactive follicles with interspersed inflammation and loosely formed granulomas and cd positive b cells within the follicles. ebv blood pcr was negative. afb and fungal stains were negative on all biopsies. in / , his igg was ( - ), iga ( - ), and igm ( - ) with only out of protective serotypes to pneumococcus post-vaccination at . or greater. in / , igg was ( - ). custom ngs panel showed a heterozygous missense variant in ctla c. c>g (p.s r) located in the transmembrane domain. this variant of uncertain significance is suspicious and strongly suggests the diagnosis of ctla -related autoimmune lymphoproliferative syndrome . patient was referred to the national institute of health, where he received a bone marrow transplant. conclusion: primary immunodeficiency diseases comprise a group of highly heterogeneous immune system diseases and around forms of pid have been described. ngs has recently become an increasingly used approach for gene identification and molecular diagnosis of human diseases guiding treatment to patients who may otherwise have poor outcomes. ( ) ( ) submission id# erik newman, md , cullen dutmer, md allergy and immunology fellow/university of colorado and children's hospital colorado assistant professor of pediatrics/section of allergy & immunology, children's hospital colorado, university of colorado school of medicine, aurora, co, usa abstract/case report text introduction: inherited defects of the complement system are rare disorders that can result in unique susceptibility to infections with select bacteria. patients with a deficiency of a complement protein early in the complement pathway (affecting c qrs, c , c , factor h, or factor i) have increased susceptibility to infection with encapsulated bacteria, most notably streptococcus pneumoniae and neisseria species. in contrast, patients with a deficiency of a complement protein at the terminal end of the complement pathway (affecting c , c , c , c alpha/beta/gamma, or c ) almost universally present with severe, recurrent, or disseminated neisseria species infections. most genes encoding complement proteins are found on autosomes, in which specific complement deficiencies result from biallelic mutations. although particular complement deficiencies occur at higher frequencies in certain populations, the prevalence of specific complement deficiencies is unknown in many parts of the world, especially in underdeveloped regions, including sub-saharan africa. herein, we describe a young congolese boy with an atypical presentation of c alpha deficiency. case description: a -month-old congolese boy with consanguineous parents (first cousins) presented with recurrent infections. prior to an evaluation of his immune system, he was hospitalized five times. his infections included episodes of acute otitis media, bacterial pneumonia, and viral pneumonitis. a bronchoscopy revealed diffusely edematous airways and growth of candida albicans, moraxella catarrhalis, and streptococcus pneumoniae in bronchoalveolar lavage cultures. concurrently, his respiratory pcr panel was positive for adenovirus. his initial immune evaluation included assessments of his serum immunoglobulin levels, vaccine titers (tetanus, diphtheria, haemophilus influenzae, and streptococcus pneumoniae), neutrophil oxidative burst, lymphocyte subsets, and ch , in which only his ch was abnormal ( u/ml). his ch remained low on repeat assessment ( u/ml), at which time an ah was pursued and also returned with a low result ( % of normal). a complement system genetic panel identified a homozygous intronic variant in c a (c. - g>a). functional confirmation of the variant revealed that the patient had a significantly decreased c level ( mcg/ml) and absent c function. discussion: we present a case of a young congolese boy with c alpha deficiency and a clinical presentation atypical for defects in terminal complement proteins. our patient presented primarily with recurrent respiratory infections, including streptococcus pneumoniae pneumonia, but without a preceding history of meningococcal disease. while it is well established that patients presenting with terminal complement pathway defects have an increased susceptibility to meningococcal disease, it is less clear if they have increased susceptibility to pneumococcal infections. occurring between exons and , the homozygous intronic variant in c a identified in our patient is predicted to result in abnormal splicing. while the allele frequency of this mutation is relatively high in the african population ( . ), functional confirmation of the variant demonstrated a decreased c level and absent c function that support the pathogenesis of the mutation. the discrepancy between the allele frequency and reported disease cases could be explained in part by varying clinical manifestations seen in c deficiency or underrecognized disease in sub-saharan africa. abstract/case report text rationale: scid is a syndrome characterized by profound t, b, and (in some cases) nk cell defects that is universally fatal unless immune reconstitution is achieved. a total of scid infants have been given allogeneic bone marrow transplantation at duke university medical center without pre-transplantation chemotherapy or post-transplantation graft-versus-host disease (gvhd); % received t cell-depleted haploidentical parental marrow and ( %) are known to be deceased. post-transplantation follow-up ranged from months to years. the aim of this cross-sectional study is to characterize the clinical status of a large cohort of survivors treated at a single medical center. methods: clinical status was assessed by detailed questionnaires delivered by mail or electronically. adult (≥ years old) and pediatric questionnaires were based on patients' age. patients were also contacted by telephone and evaluated at clinic visits. molecular type of scid, demographics, type, date and age at transplant were obtained from a clinical database. results: fifty questionnaires were completed to date from survivors ranging in age from to years. twenty-nine/ were adults ≥ years at the time of the questionnaire. genetic defects were known for all patients-xlinked scid was the cause in about half ( figure ). twenty-three of patients were on immunoglobulin replacement. thirty of reported having received immunizations, and about half of those received live vaccines. fifteen of reported they were taking no regular medications; reported taking prophylactic antibiotics. >we found substantial scholastic achievement, with / adult patients reporting college attendance. two had post graduate education including doctorate level degrees. occupations included physician, nurse, factory worker, musician, teacher, and engineer. one patient had children. twenty-seven / adult patients shared their height and weight and % ( / ) had a healthy bmi (bmi . - . ), while % ( / ) were overweight, and % ( / ) were underweight (< . ) . in pediatric patients, the average age and sex-adjusted bmi was at the th percentile and only had a bmi that was < th percentile. thirty-four/ patients reported seeing an immunologist regularly. in the adult group, % reported no longer seeing an immunologist. the health conditions reported were similar to those common in the general population, and included rashes, warts and mouth ulcers. most reported these were transient, self-resolving issues. thirteen of ( %) reported having adhd, higher than nih reported rates which estimate adhd in . % of adults and % of children). ten of ( %) reported having anxiety, similar to the nih reported prevalence of . % in the general population. / (~ %) reported having no active concerns about their health. conclusions: overall, our findings are consistent with those in the last update done by railey et al, j. peds. : [ ] [ ] [ ] [ ] [ ] [ ] [ ] in this population. patients are doing well with most problems similar to those common in the general population. most have a healthy bmi. adhd had a higher prevalence than in the general population. more than / of scid patients are not seeing an immunologist regularly, and a majority do not have any active concerns. . genetic causes of scid in the patients whose questionnaire data are presented. x-linked scid was the most common, followed by ada and il- r deficient scid clinical fellow/national institute of allergy and infectious diseases (niaid/nih) research nurse/nih-nhgri professor of pediatrics and allergy and immunology/ann & robert h. lurie children's hospital of chicago chief, laboratory of clinical immunology and microbiology/national institute of allergy and infectious diseases, niaid/national institutes of health, nih abstract/case report text rationale: myopathy has been occasionally documented in patients with primary immunodeficiency (pid). however, data on frequency and patient characteristics associated with myopathy are lacking. we performed a descriptive analysis of patients with primary immunodeficiency (pid) in the usidnet having myopathy as a feature of their primary disease. methods: the usidnet registry was queried for the spectrum of myopathic disorders in pid patients that had been entered into the registry as of november , . results: a total of pid patients with myopathy were identified, of which ( . %) were female. median age at onset of symptoms related to pid was years (range . - years, iqr . - years). median age of diagnosis of pid was . years (range . - years, iqr - . years). age at onset of myopathic disorders was not known. twenty-eight ( . %) patients had a diagnosis of common variable immunodeficiency (cvid), ( . %) had agammaglobulinemia, patients each ( . %) were diagnosed with severe combined immunodeficiency, hypogammaglobulinemia, or 'hlh and pigmentary disorders', while patients ( . %)were reported in each category of combined immunodeficiency (cid), autoimmune lymphoproliferative syndrome (alps), and autoinflammatory disease. thirty-five patients ( . %) had a causative gene variant identified attributable to pid. the most common variant identified was btk ( patients) followed by aire, lyst, cybb ( patients each) and pi kcd ( patients). eighteen individual patients had other variants identified ( figure ). patients had cellulitis or skin/ subcutaneous tissue infection, patients had a 'skin or subcutaneous tissue abscess', had pyoderma gangrenosum, and patient with eczema herpeticum. within this cohort of patients, the most common myopathy listed was myositis ( ) followed by 'muscle weakness' ( ), dermatomyositis ( ) , myalgia/s ( ) , myalgia/myositis ( ), myopathy ( ), polymyositis ( ) , steroid-induced myopathy ( ) . no patient had an infectious myositis or muscle abscess listed. eighteen patients ( . %) had a myopathic disorder at the time of diagnosis of their pid. thirtyone patients ( . %) received prednisone, ( . %) received hydrocortisone and ( . %) received dexamethasone. two patients had a diagnosis of adrenal insufficiency. nine patients ( . %) underwent hematopoietic stem cell transplantation. nine patients ( . %) died; median age of death years (range . - . years, iqr . - . years). ). one patient with chronic granulomatous disease had myopathy due to duchenne muscular dystrophy, which was listed as a cause of death. no other myopathic disorders were listed as a cause of death for the other patients. conclusion: myopathy and inflammatory myopathic disorders occur at relatively high frequency in pid, and may be present even at the onset of clinical symptoms. the underlying etiology can be speculated to be multifactorial. further subgroup analysis is warranted to elucidate possible variant-specific or treatment-associated characteristics of myopathy in pid. laboratory studies at years revealed normal igg/iga/igm but markedly elevated serum ige ( , ku/l), anemia (hb . g/dl), thrombocytopenia ( x /l) and lymphopenia ( cells/l), with low t and b cell counts, very low proportion of naïve t cells, skewed repertoire of cd + t cells, undetectable trec levels, and impaired t cell proliferation to mitogens and antigens. there was an elevated percentage of circulating plasmablasts ( . %) and of dysreactive cd low cd low b cells ( . %). at the age of , hsct with reduced intensity conditioning was performed from her phenotypically hla-matched father, with improvement of t and b cell count and function. whole exome sequencing (wes) identified a homozygous missense variant in the mannosidase alpha class b member (man b ) gene (p.asp asn), that segregates with disease in the pedigree. the man b asp residue is evolutionary conserved. the p.asp asn allele has a minor allele frequency of . in gnomad, with no homozygotes. the cadd score for this variant is . , significantly higher than the mutation significance cutoff score ( . ). man b is involved in the lysosomal degradation of glycoproteins and demannosylation of free n-glycans. in particular, man b cleaves man glcnac to generate man glcnac . serum n-glycan profiling revealed elevated man /man and man / man in the patient. n-linked and free glycan profiling by mass spectrometry (ms) showed accumulation of man glcnac , man glcnac and man glcnac glycans in patient fibroblasts as compared to control cells, consistent with defective lysosomal glycoprotein degradation. lentiviral transduction of wild-type man b into patient fibroblasts led to normalization of the n-linked glycan profile, with reduction of man glcnac from . to . times control levels, and of man glcnac from . to . control levels, indicating rescue of the impaired deglycosylation ( figure a ). western-blotting demonstrated defective n-glycosylation of lamp and icam proteins in patient fibroblasts ( figure b) , which were corrected upon lentiviral transduction of wild-type man b ( figure c ). overall, our results indicate that loss of man b enzymatic activity leads to dysregulation of deglycosylation and abnormal mannosylation of glycans. in conclusion, we have demonstrated that man b deficiency accounts for a novel autosomal recessive cdg with prominent features of immune deficiency and immune dysregulation. abstract/case report text heme oxygenase- (hmox ) is a rate-limiting enzyme that catalyzes the degradation of heme to carbon monoxide, ferrous iron, and biliverdin, which becomes bilirubin. these byproducts are implicated in inflammation, cell homeostasis, and antioxidant defense( ). hmox -deficiency is an extremely rare autosomal recessive disorder with a complex presentation of a wide spectrum of symptoms, including hemolytic anemia and hyperinflammation, requiring genetic testing for confirmed diagnosis ( ) . we report the fifth known case of hmox -deficiency ( ) ( ) ( ) , a boy who presented at years of age with aspects of the characteristic phenotype, but also had early onset asplenia, interstitial lung disease, and previously undocumented immune deficiency. patient's presentation was notable for hyperinflammatory exacerbations triggered by viral and bacterial infections as well as vaccinations. episodic flares occurred every few months lasting weeks to months with fevers of - f, hypoxia, leukocytosis above , /mm , hemolytic anemia with negative coombs, thrombocytosis exceeding million/ mm , transaminitis, hemoglobinuria, hyperferritinemia to , ng/ml, and elevated ldh to , iu/l. immune evaluation revealed normal immunoglobulin levels and adequate vaccine titers to both protein and carbohydrate antigens. although class switched populations were normal, b-cell phenotyping showed absent immature and transitional b-cells, low mature memory, and reduced cd + memory b-cells at % (normal > %). mitogen stimulation with phytohemagglutinin and anti-cd were decreased ( . % of control and . % of control, respectively). t-cell phenotyping demonstrated cd population heavily skewed to immaturity with % of cells with naïve phenotype cd ra+cd +ccr +. there were few effector-memory t cells and the cd population was skewed towards immaturity with > % of the cells naïve. liver biopsy was performed secondary to hepatomegaly yielding mild to moderate sinusoidal fibrosis. bone marrow biopsy revealed a normocellular marrow with % blasts, increased megakaryocytes, and extensive hemophagocytosis. natural killer cell function was very low, while soluble il- ra level was normal. further workup for hemoglobinopathies, metabolic defects, congenital disorders of glycosylation, lysosomal storage disorders, wilson's disease, autoimmune hepatitis, inherited and autoimmune hypercoagulability disorders, connective tissue disorders, myositis, and myopathies were all unremarkable. imaging demonstrated asplenia and howell-jolly bodies were present. hemophagocytic lymphohistiocytosis (hlh) genetic testing showed no variants. he was suspected to have systemic juvenile idiopathic arthritis (sojia) with episodes of macrophage activation syndrome. the frequency of his autoinflammatory flares increased such that he was corticosteroid dependent by age , having failed methotrexate, azathioprine, and anakinra. he was started on tocilizumab with laboratory improvements, but his lung disease progressed and became oxygen dependent. lung biopsy confirmed nonspecific interstitial pneumonitis (nsip) with cholesterol granulomas also seen in sojia. ultimately, chronic lung disease led to his death at age . whole exome sequencing yielded a paternal frame shift hmox and maternal splice donor hmox resulting in absence of protein. bone marrow transplantation (bmt) in hmox deficient mice have rectified phagocytotic defects and thereby their autoinflammatory phenotype, but no human reports for bmt treatment of hmox -deficiency has been described. here we describe a phenotype expansion for hmox deficiency to include not only asplenia and hepatomegaly, but also interstitial lung disease with cholesterol granulomas and inflammatory flares. abstract/case report text introduction: mutations in the gene encoding signal transducer and activator of transcription (stat ) cause autosomal dominant hyperimmunoglobulin e syndrome (ad-hies) characterized by recurrent skin and sinopulmonary infections, atopic dermatitis, and elevated serum immunoglobulin e (ige) levels. treatment is largely aimed at controlling symptoms and preventing infections with no standard of care. there is a paucity of literature describing the utilization of biologic therapies in the ad-hies patient population. we present patients from one family with ad-hies successfully treated with monoclonal antibody therapies targeted at il- , il- and il- . case descriptions: patient : -year-old female with stat lof c. c>t (p.arg trp) with a history of atopic dermatitis and asthma requiring - steroid courses per year with frequent school absences. she developed a severe pruritic rash covering her upper body months ago that failed to respond to antihistamines and topical antibiotics prescribed by her primary care provider. given her poorly controlled asthma and our concern for a follicular type morphologic variant of atopic dermatitis, dupilumab was initiated. her scoring atopic dermatitis (scorad) prior to initiation of biologic therapy was . and improved to . following doses ( weeks) of dupilumab with clear dramatic improvement in her skin and quality of life ( figure ). she also reports decreased asthma severity with no steroid courses, reduced albuterol usage, and significant decline in school absences since initiation of dupilumab. patient : -year-old female with stat lof c. c>t (p.arg trp) who is the sister of patient . she has a history of severe asthma requiring frequent emergency department visits, hospitalizations, and - steroid courses per year despite therapy with high-dose fluticasone-salmeterol. spirometry prior to april demonstrated an obstructive pattern with an fev ranging from - %. she was initiated on mepolizumab in april . subsequent spirometry demonstrates an fev average of % with a range of - %. she had one hospitalization in early but otherwise no hospitalizations for asthma since initiation of biologic therapy. patient : -year-old female with stat lof c. c>t (p.arg trp) who is the paternal first cousin of patients & . she has a history of severe atopic dermatitis with associated pruritus and picking behaviors, poorly controlled despite daily triamcinolone application. she previously failed ultraviolet therapy and crisaborole. she also has a history of severe asthma requiring - steroid courses per year despite high-dose fluticasone-salmeterol. dupilumab was started in may . scorad prior to initiation monoclonal antibody therapy was . and declined to . following weeks ( doses) of dupilumab therapy with marked improvement in skin appearance and pruritus ( figure ). discussion: we present three cases of ad-hies caused by stat loss-of-function mutations treated successfully with monoclonal antibody therapies targeted at il- or il- and il- . to the best of our knowledge, there is no published data describing the use of these biologic agents in the treatment of ad-hies. future studies are needed to clarify the role of these cytokines in the pathogenesis of ad-hies and to elucidate clinical indications for biologic therapy in this patient population. informed consent was obtained from all individual participants included in the study. abstract/case report text ctla- is a potent inhibitor of t cell proliferation that competes with costimulatory receptor cd for its ligands cd and cd expressed on antigen presenting cells. heterozygous loss-offunction mutations in ctla- have been identified in patients with lymphocytic infiltration of multiple nonlymphoid organs (lo et al). the patient is a -year-old jordanian male born at term to nonconsanguineous parents, hospitalized at mo for lll pneumonia, and at mo and at mo he was evaluated in the ed and diagnosed with non rsv-bronchiolitis with lll infiltrate thought to be secondary to atelectasis. at yo he developed lll pneumonia and respiratory failure requiring picu admission. he was treated with ceftriaxone. after discharge, he had weeks of intermittent fever, progressive fatigue, productive cough, and ftt. he received courses of cefdinir, clindamycin, and tmp-smx without improvement. chest ct revealed left lung consolidation, lll bronchiectasis, lul tree in bud opacities, and hilar lymphadenopathy. bronchoscopy with bal revealed no bacterial growth and no acid-fast bacilli. srrna ngs was positive for h. influenzae. lung biopsy demonstrated acute and chronic bronchiolitis with bronchiolitis obliterans and intraluminal polyps, with lymphocytic infiltration involving the bronchi and bronchioles. the lung parenchyma showed airspace filling with foamy macrophages and chronic interstitial inflammation. acid fast and fungal stains were negative. he was treated with systemic steroids for bronchiolitis obliterans with noted improvement. the severity of lung disease at such an early age prompted an immune evaluation. sweat test, anca, anti-pr and hiv were negative. total immunoglobulins were normal for age, and titers to s. pneumoniae, diphtheria and tetanus were protective. lymphocyte enumeration revealed elevated t and nk cell numbers for age. lymphocyte proliferation to pha, pwm, candida and tetanus were normal. dihydrorhodamine assay was normal. b cell phenotyping was normal. there was normal expression of cd , hla-dr and cd on activated t cells; of note the patient was on systemic steroids when tested. invitae gene pidd panel revealed a variant in ctla : c. g>a (p.gly glu) that has been shown to be pathogenic in one patient (schawb et al). flow cytometry showed normal frequency of t follicular helper cells and t regulatory cells compared with controls, however ctla- expression by t regulatory cells was lower than control. due to the severe and progressive nature of the patient's lung disease, therapy with x weekly azithromycin and abatacept mg sq weekly was initiated. we report a case of ctla- haploinsufficiency presenting with recurrent pneumonia and bronchiolitis obliterans in a -year-old child. based on patient registry data, our patient appears to be the youngest child diagnosed with ctla- haploinsufficiency reported in the literature to date (schawb et al). notably, our patient l a c k s o t h e r f e a t u r e s c o m m o n l y d e s c r i b e d i n c t l a - haploinsufficiency, including autoimmune cytopenias, gastrointestinal disease, lymphoproliferation, and hypogammaglobulinemia. this case illustrates the importance of consideration of this diagnosis in young children with severe lung disease without other evidence of immune dysregulation. our hope is that prompt recognition and early treatment administration will prevent disease progression and further decrease in pulmonary function. splenectomy, he had an episode of pneumococcal meningitis at age , and sepsis of unknown origin at age . over the past several years he has developed chronic tinea corporis, onychomycosis, and otitis externa infections despite numerous antimicrobial regimens. at age , the patient developed urinary retention, walking, and balance difficulties. he was found to have diffuse white matter changes on mri, elevated wbc, and positive oligoclonal bands. initially, he was diagnosed as progressive ms treated with steroids with partial improvement. csf microbiology studies including afb stains, bacterial, fungal, mycobacterial cultures, cryptococcal antigen, vdrl, t. pallidum particle agglutination (tppa), as well as, pcr for cmv, ebv, vzv, enterovirus, hsv - , jc virus and t. pallidum were all negative. peripheral blood studies included mycobacterial blood culture, pcr for cmv, ebv, hhv- , in addition to serology for cryptococcal antigen, and coccidioides species, all of which were negative. additional neurological complications include granulomatous uveitis and oscillopsia, which he developed around age . immune evaluation performed at age revealed low igg and igm, and the patient was started on grams of monthly ivig. cbc with differential was notable for normal monocyte count and thrombocytopenia, mild neutropenia (table ). immunophenotyping revealed absent b cells and nk cells, while the cd t cells were elevated. cd t cells were normal (table ) . at age , whole-exome sequencing identified a heterozygous missense mutation in gata c. c>t, p.(arg trp). after the diagnosis of gata haploinsufficiency, he was found to have myelodysplastic syndrome with multilineage dysplasia (mds-mld) on bone marrow biopsy. he is currently awaiting bone marrow transplant discussion: we present a -year-old male with cytopenias, splenomegaly, leukoencephalomyelopathy, granulomatous uveitis, and recurrent fungal infections found to have a pathogenic heterozygous missense mutation in gata . leukoencephalomyelopathy in gata haploinsufficiency has been associated with jc virus and ebv infection. our patient did not have any evidence of a chronic csf infection. to our knowledge, myelopathies have not been reported with gata c. c>t, p.(arg trp). this case highlights the variable nature of presentation in gata haploinsufficiency, and the need for clinical awareness of this entity in order to facilitate early diagnosis and appropriate therapy. immunoglobulins* white blood cells . x * /l (n: - ) magnetic resonance imaging (mri) of the brain and spine showed numerous enhancing parenchymal nodules (figure one). brain or spinal biopsy was requested, but not recommended by our neurosurgery service. lumbar puncture evaluation was performed. cerebral spinal fluid showed no bacterial or fungal elements. both quantiferon gold for tuberculosis and three consecutive sputum cultures for acid fast bacilli were negative. he continued his sirolimus and the intravenous immunoglobulin replacement was increased to two grams/kg. the patient was cleared from respiratory isolation and discharged after two weeks in our facility with mild improvement in his neurologic status. within five days he was sent to a nationally renowned hospital. at this facility, extensive evaluation for his neurologic deficits were performed including culture and pcr for bacteria, virus, mycobacteria from csf bone marrow, lymph node, blood, and induced sputum. these were noncontributory. he was given high dose corticosteroids for two days. one of our facility's sputum cultures was reported with acid fast bacilli. but sputum mycobacterium tuberculosis pcr was negative. repeat mri scans of the brain and spine showed improvement (figure ), so no brain biopsy was performed. he was sent back to our facility with the recommendation to start a targeted pi kinase inhibitor on compassionate grounds as he was not eligible for the clinical trial because his weight was less than kg. but pretreatment abdominal ct revealed multiple low-density lesions scattered throughout the liver (figure ) not previously seen on prior noncontrast ct four months prior. discussion: although this gain in function mutation of the pi kδ signaling pathway disorder has been well characterized, this is a rare report of a patient with pasli immunodeficiency with central nervous system and later liver lesions pet imaging showed subcarinal, mediastinal, retroperitoneal lymphadenopathy, splenic enlargement to cm and bilateral lung nodules ( figure ). excisional biopsies of left axillary and left lower lobe of lung were performed and showed low-grade b-cell lymphoma (mucosal) and underlying lymphoproliferative disease. invitae alps and cvid panels ( genes) revealed a heterozygous variant of unknown significance in exon of fas (c. a>g(p.asp gly) unlike most fas mutations causing alps, this mutation is in the extracellular region rather than the death domain . the c. a>g variant has been reported in a single patient with alps phenotype, affecting fas protein function by inhibiting binding to fas ligand (fas-l), reducing fas-l induced apoptosis . this fas c. a>g mutation was found in alps affected brother and was absent in the unaffected father. the patient's mother passed away prior to testing. since diagnosis, the patient's malt lymphoma has been treated with rituximab weekly for the first month and then monthly. he continues to receive monthly ivig for hypogammaglobulinemia. after two years, ct demonstrates a significant decrease in pulmonary nodules and splenomegaly ( figure ). the patient's forced vital capacity (fvc) improved from . l ( % predicted) to . l ( % predicted). conclusion: we report the first case of malt lymphoma seen in a patient with alps. it is unknown whether the unique fas c. a>g mutation in the non-death domain contributes to malt lymphoma progression. we propose malt lymphoma is a malignant transformation of chronic inflammation that has the potential to occur in patients with alps. in the future, improved knowledge of mechanistic pathways of inflammation in lymphoma development and progression is important in the optimal management of alps. abstract/case report text background wiskott-aldrich syndrome (was) is a rare x-linked disorder characterized by combined immunodeficiency, eczema, microthrombocytopenia, infections, autoimmunity and increased risk of hematological malignancies. gene therapy (gt) using autologous cd + cells is an emerging alternative treatment with possible advantages over standard allogeneic hematopoietic stem cell transplant. we report the outcomes of a phase i/ii clinical trial in which was patients underwent gt using a self-inactivating lentiviral (sin-lv) vector expressing the human was cdna under the control of a . kb fragment of the human was promoter. subjects and methods: five patients with severe was (clinical score - ) were enrolled (table ) . cd + cells were transduced ex-vivo and reinfused after conditioning with busulfan and fludarabine. two subjects (p , p ) had autoimmunity pre-gt, manifested as skin vasculitis and autoimmune cytopenias. results: all subjects were alive at median follow-up of . (range . - . ) years. multi-lineage vector gene marking was sustained over time. all had clinical improvement of eczema, infections and bleeding diathesis. was protein (wasp) expression was increased over baseline but remained below normal levels. proliferation of t cells in response to anti-cd improved post-gt. humoral immune deficiency improved, with normalization of igm, and independence from ig replacement and vaccine responses in those tested. platelet levels increased to > x cells/ul in only the two subjects with a vcn ≥ in transduced stem cells. podosome formation in monocyte-derived dendritic cells was near absent pre-gt and improved in all subjects post-gt, but only reached healthy control levels in the subjects with highest vcn. in contrast to other trials using this sin-lv, two patients (p and p ) had flares of autoimmunity post-gt, offering the opportunity to study the poorly understood mechanistic features of immune dysregulation in this disease. selfreactive vh - -expressing b cells and cd lo b cells remained elevated in most patients. however, despite wasp expression in foxp + tregs, those with autoimmunity had poor numerical recovery of t cells and tregs at the time of clinical symptoms ( fig a) . in addition, il- producing regulatory b cells (bregs) were highly deficient pre-gt, recovered in subjects who did not experience autoimmunity, but failed to recover in p and p ( fig b) . moreover, transitional b cells, which are enriched in bregs and are potent inducers of treg populations, also recovered poorly in those two subjects ( fig c) . there have been neither severe gt-related adverse events nor abnormal clonal expansion in transgene-marked cells to date. conclusion in summary, our data confirm and extend the safety and efficacy of gt in correcting disease manifestations associated with was, with the longest overall follow-up reported so far in studies using sin-lv. in addition, our findings suggest that higher vcn is needed in order to correct myeloid compartments such as platelets and monocytes. finally, we report the novel finding of the restoration of bregs and suggest that recovery of this compartment, along with tregs, is protective against development of autoimmunity post-gt. overall, these data suggest a mechanism for breakdown of immune tolerance in was with important therapeutic implications and prognostic value. this is an -year-old hispanic female who initially presented with failure to thrive, recurrent fevers and intermittent cough with episodes of perioral cyanosis. symptoms started at age months and were attributed to recurrent viral and bacterial infections. at months old, she was hospitalized with fever and hypoxemia (o saturations %). cxr showed prominent interstitial lung markings and she was diagnosed with pneumonia. ct scan confirmed cxr findings and ruled out anatomical anomaly. she was lost to follow up for years, and re-presented with worsening respiratory status. a repeat ct scan demonstrated worsening interstitial thickening. immune workup, including quantitative immunoglobulins, ch , lymphocyte subsets and vaccine response titers (pneumococcal and tetanus), was unremarkable, except for elevated igg levels. genetic testing for surfactant dysfunction mutations was negative. thoracoscopic lung biopsy revealed interstitial fibrosis, pas-positive granular alveolar proteinosis, type ii cell hyperplasia, and lymphoid follicles. at age , she was admitted for a pericardial effusion. rheumatology was consulted for evaluation frequent fevers and persistently elevated inflammatory markers, with concern that the pericarditis was autoinflammatory. she had an elevated ana (> : homogeneous pattern), il- ( . pg/ml), and igg ( mg/dl) at that time. she had an atypical anca pattern with positive myeloperoxidase antibodies. anti dsdna, smith and scl were negative. she was treated with steroids and hydroxychloroquine with some improvement in her oxygen requirement. one year later she had an additional episode of pericarditis, treated with colchicine. a few months later, she was admitted with newonset gross hematuria and elevated serum creatinine (to mg/ dl). kidney biopsy showed anca vasculitis with glomerulonephritis ( % crescents, no scarring or fibrosis). she provisionally received a diagnosis of microscopic polyangiitis, with lung and kidney involvement. she did not have peripheral vasculopathy. she was started on cyclophosphamide, rituximab, and iv steroid pulses. cyclophosphamide was discontinued due to recurrent episodes of posterior reversible encephalopathy syndrome (pres) after infusion. her igg level decreased as she developed nephrotic range proteinuria. a primary immunodeficiency genetic panel was sent to evaluate for monogenic immune dysregulation syndromes and revealed a tmem gene mutation (c. g>a) which has previously been reported in other subjects with savi (stingassociated vasculopathy of infancy syndrome). sting is a cytosolic dna sensor that leads to type i interferon production upon stimulation. this gain-of-function mutation was confirmed by measuring interferon signature gene expression at the nih (fig ) , and her diagnosis was revised accordingly. the patient was started on a jak-inhibitor (tofacitinib) to block interferon signaling. unfortunately, the patient is now deceased, due to overwhelming infection and multi-organ system failure. conclusion: genetic testing can be crucial in aiding the diagnosis of complex patients with immune dysregulation and can provide an opportunity for targeted therapy, which should be employed as soon as able to stop disease progression. abstract/case report text background: activated phosphoinositide -kinase δ syndrome (apds- ) was first described in as a monogenetic immune dysregulation syndrome with a variable phenotype. increased sinopulmonary and herpesvirus infections are well described, but fungal infections such as candidiasis have been rare. to date, disseminated histoplasmosis has not been described. history: a yo caucasian male who was previously diagnosed with common variable immunodeficiency (cvid) in late childhood due to recurrent sinopulmonary infections presented with recurrent fever, pancytopenia, severe splenomegaly, and lymphadenopathy. urine histoplasmosis antigen and beta-d-glucan were elevated. a bone marrow biopsy demonstrated granulomatous inflammation. transbronchial biopsy of a subcarinal lymph node was consistent with granulomatous disease. this led to a diagnosis of disseminated histoplasmosis. he was treated with amphotericin b and then months of itraconazole, with improvement of his symptoms. he was admitted to the hospital about years later when he presented with fatigue, fever, chills, dark urine, and scleral icterus. he was found to have an acute worsening of chronic anemia with a hemoglobin of . g/dl. due to elevated ldh, presence of schistocytes on peripheral smear, and undetectable haptoglobin, he was diagnosed with autoimmune hemolytic anemia, despite a negative direct coombs. a bone marrow biopsy specimen was hypercellular with marked erythroid predominance, with normal flow cytometry and no blasts identified. infectious workup was negative. ct chest during the workup revealed new right hilar and mediastinal lymphadenopathy, in addition to calcified right hilar and subcarinal lymph nodes, bronchiectasis, and stable hepatosplenomegaly. transbronchial biopsy of lymph nodes showed benign lymph nodes with calcified necrotizing granulomata and presence of non-viable fungal species, presumably "old" histoplasmosis. family history: family history was significant for mom dying at years-old from undefined cns infection. immune labs: · panlymphocytopenia: absolute lymphocyte count of /ul, cd + t cells /ul, cd + /ul, cd + /ul, cd + /ul, cd +cd + /ul. cd +/cd + ratio . · decreased class-switched memory b cells and plasmablasts · elevated t central memory cells and activated (hla-dr+) cd + and cd + t cells · hemoglobin . g/dl, platelets , /ul, anc ranging from /ul to /ul · iga mg/dl, igm mg/dl; reportedly had low igg prior to initiating ivig in childhood · ebv pcr and cmv pcr negative genetics: · pik cd (c. g>a), consistent with diagnosis of autosomal dominant apds- . discussion: gain-of-function variants leading to increased pi kδ activity have been shown to cause both b and t cell dysfunction, leading to impaired immunologic responses to bacterial and viral infections. recurrent sinopulmonary infections and herpesvirus infections are commonly seen and while mucocutaneous candidiasis has been reported in cohorts of patients with pik cd, other fungal infections are not common. severe disseminated histoplasmosis infections have been described in primary immunodeficiencies characterized by signaling defects in the il- /ifn-γ pathway, stat deficiency, cd l deficiency, gata deficiency and in stat gain-of-function mutations. to our knowledge, disseminated histoplasmosis has not been previously reported in patients with pik cd immunodeficiency. abstract/case report text the reported case represents the first case of nbas disease detected by newborn screening program for primary immunodeficiency, based on krec assay. the patient came to our attention due to the complete absence of krecs and normal trecs on dbs (dried blood spot) while hospitalized for low weight at birth ( , g), intolerance for enteral feeding, hepatosplenomegaly, slightly elevated liver transaminase, head and face eczematous dermatitis. during the st month, he also presented klebsiella pneumoniae urinary tract infection and methicillin-resistant staphylococcus aureus sepsis. peculiar phenotypic features including triangular face, proptosis, flat philtrum, mild retrognatia, hirsutism, loose and slightly wrinkled skin, and apparent reduction of subcutaneous fat were noticed at birth. complete blood count showed lymphocytopenia, marked hypereosinophilia. serum immunoglobulin g (igg) were markedly decreased, iga and igm were undetectable. extended immune-phenotyping showed complete absence of cd + cells, low count of cd + lymphocytes, and reduced natural killer (nk) levels. at month of age a colonoscopy was carried out for persistent diarrhea and reduced tolerance to enteral feeding. the histological examination of mucosal intestinal biopsies showed signs compatible with autoimmune enteropathy. for this reason immunosuppressive therapy with rapamycin was started without consistent clinical amelioration. many cvc-sepsis occurred in the last months, associated with persistent gastrointestinal symptoms and severe growth restriction. despite the absence of experience data in literature for nbas syndrome, we retain that hsct represents the only resolutive therapy for him. abstract/case report text case: a -year-old female with asthma and allergies presented to immunology clinic with a history of chronic fatigue and sinusitis. fatigue occurred daily every - weeks and was described as not feeling rested even after hours of sleep. chronic sinusitis required - prolonged antibiotic courses per year. nasal cultures grew methicillin-sensitive and -resistant staphylococcus aureus and haemophilus influenzae type b (hib). three separate sinus surgeries over the prior few years reduced her sinus symptoms. other infectious history was significant for recurrent urinary tract infections with e. coli and klebsiella, recurrent otitis media as a child, and a diagnosis of transient hypogammaglobulinemia of infancy that resolved at years of age. review of systems revealed axillary lymphadenopathy for - days twice per year not related to infection. she had longstanding eczema that responded to topical tacrolimus, multiple environmental allergies, and recently diagnosed asthma that improved with inhaled budesonide/formoterol. as a teenager she received allergy immunotherapy for a few years but stopped due to frequent adverse reactions. family history revealed that father died from cancer. physical exam was unremarkable. laboratory evaluation demonstrated normal igg mg/dl, igm mg/dl, iga mg/dl, elevated ige mg/dl, normal t and nk cell enumeration, mildly low total b cells ( cells/mcl, . %), and normal b cell subsets (cd +igm+cd - %, cd +igm+cd + %, cd +igm-cd + %). tetanus antibody titer was protective, but hib antibody titer was undetectable at < . mcg/ml with marginal response after vaccination ( . mcg/ml). pneumococcal serotype specific igg levels (mayo) were mostly undetectable with of serotypes protective at baseline and only protective post vaccination with pneumovax . cd / cd blastogenesis was poor. due to poor antibody response and continued sinus infections she was started on igg replacement. her fatigue and sinus symptoms improved moderately but she continued to require antibiotics and sinus ct scans continued to demonstrate significant disease. a focused exome sequencing panel was pursued and a novel heterozygous card variant was found (c. g>t, p.r l). discussion: the card /bcl /malt (cbm) complex is a critical signaling adapter that facilitates several downstream immune responses predominately through nf-kb. mutations in several different domains of card result in a clinical entity collectively referred to as card -associated atopy with dominant interference of nf-kb signaling (cadins). cadins is associated with a broad range of clinical manifestations but most have marked atopy with infections, poor t cell proliferation, and varying levels of poor antibody response. both our variant (p.r l) and a previously reported pathogenic variant in the same amino acid (p.r g) involve a change from a charged arginine to a non-polar amino acid in the critical bcl / card binding interface. iκbα degradation was not present in b cells from our patient ( figure ) confirming the functional defect in nf-kb signaling. thus, we present a novel variant that fits cadins both clinically and genetically. clinicians should be aware of cadins when patients present with recurrent infections in the setting of significant allergic disease. i b degradation assay. stimulation: μl of whole blood was stimulated in a ml facs tube with ng/ml phorbol -myristate -acetate (pma; sigma, cat# p ) at °c for , , or min, at which point ml of pre-warmed x lyse/fix buffer (bd, cat# ) was added. cells were fixed for min at °c, centrifuged and washed twice with facs buffer (pbs supplemented with % fbs and mm edta). staining and permeabilization: fc receptors were blocked for min at rt (human trustain fcx; biolegend), followed by a min stain on ice with anti-cd af (clone rpa-t ; biolegend), and anti-cd bv (clone hib ; biolegend). cells were washed with facs buffer and permeabilized for min on ice with ml phosflow perm buffer ii (bd biosciences, cat# ) that had been precooled to - °c. after permeabilization, two ml facs buffer was added and the samples were centrifuged. after three additional washes, the cells were stained with anti-iкbα pe (clone /ikba/mad- ; bd biosciences) for min at rt. samples were washed three times and data were collected on a cytek dxp flow cytometer. data were analyzed with flowjo software. abstract/case report text introduction: wiskott-aldrich syndrome (was) is a rare, but well-defined x-linked disorder. loss-of-function mutations in the was gene result in classic was and x-linked thrombocytopenia (xlt), while gainof-function mutations lead to x-linked neutropenia (xln). classic was phenotypic features include recurrent infections, microthrombocytopenia and eczema along with increased susceptibility to autoimmune disorders and malignancy. most males with classic was are diagnosed in early childhood and early death can result from its various clinical manifestations. case: we present a -year-old male who was referred to immunology for hypogammaglobulinemia. as an infant he had moderate eczema, and at the age of two was diagnosed with immune thrombocytopenia (itp) with baseline platelets of - x ^ /l. infectious history was notable for one episode of pneumosepsis and recurrent otitis media, influenza, and herpes labialis infections. around the age of , he was diagnosed with common variable immunodeficiency (cvid) based on the finding of low immunoglobulins. he developed diffuse large b cell lymphoma at age , and was treated with cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab (chop-r). at age he developed abdominal pain with bloody stools. investigations confirmed an endoscopic and pathologic diagnosis of ulcerative colitis. due to the severity of his disease, he has required maintenance therapy with vedolizumab. he was again noted to have hypogammaglobulinemia at which point he was referred to immunology at our centre. there was no significant family history of immunodeficiency, malignancy or autoimmunity. blood work was notable for normal white blood cell and lymphocyte counts, platelets of x ^ g/l, low igg at . g/l ( . - . g/l) with normal iga, igm and ige. lymphocyte subsets including t, b and nk cells were within the normal range. genetic testing was performed and he was found to have a known pathogenic mutation in the was gene (c. g>a, p.asp asn) which has been previously reported in association with was and xlt. he has since been placed on immunoglobulin replacement and has been referred for consideration of hematopoietic stem cell transplantation. discussion: was is a rare syndrome that can have a similar phenotype to other immunodeficiency disorders including cvid, omenn syndrome and ipex (immune dysregulation, polyendocrinopathy, x-linked). individuals with cvid present with hypogammaglobulinemia and recurrent infections, and these individuals also have an increased susceptibility to autoimmune disorders, gastrointestinal disease and malignancies, especially lymphoma. although eczema is a common disorder, its presence in addition to features of early onset thrombocytopenia, immunodeficiency, autoimmunity and/or malignancy in male patients should heighten the suspicion for was. it is important to make the diagnosis of was as hematopoietic cell transplantation and gene therapy are potentially curative treatment options. abstract/case report text secondary immune deficiencies (sid) are caused by varied mechanisms and are common in patients with hematological malignancies such as chronic lymphocytic leukemia (cll) and multiple myeloma (mm). in this setting, both the disease and its treatment (such as b cell ablation therapy) contribute to the development of secondary antibody deficiency. infections remain a major cause of morbidity and mortality in cll and mm patients. this underscores the need for early recognition and stratification of risks in order to guide appropriate treatment, including immunoglobulin replacement therapy (igrt). new guidelines for the use of human normal immune globulins in sid patients were implemented by the european medicines agency (ema) in . despite these new guidelines, significant variations remain across european countries in the assessment and approaches aiming to achieve reduction in infection burden, including different strategies for initiation, dosing and discontinuation of igrt. the same is true for north america where igrt is widely used off-label to prevent infections in patients with sid due to hematological disease or other reasons. in order to address this variability, a task force comprising both immunologists and hemato-oncologists drafted statements aiming to test for consensus. statements were related to six major areas: definition of infections, measuring igg levels, initiating igrt, igrt dosing, scig usage and discontinuing igrt. this was followed by an international delphi consensus exercise in three rounds which aimed to develop recommendations on how to diagnose, treat and follow-up patients with antibody deficiency associated with hematological malignancies. the first delphi round consisted in testing the statements with a panel of sid specialists and subsequently their comments were used by the task force to refine the statements. in the second delphi round, the refined statements were presented via phone interviews to the same panel to assess their level of agreement with each statement (ranging from "i totally disagree" to "i totally agree"). consensus was considered to be reached per statement if % of the experts agreed with each statement overall. the cut-off for overall agreement was "i somewhat agree". if the expert chose level or less the reasons underpinning his/her choice were discussed. consensus was achieved for all statements on level ("i somewhat agree"). only statements did not achieve consensus on level "i mostly agree". in delphi round , panelists who had not "mostly agreed" with these five statements were given the opportunity to reconsider their assessment based on the feedback from other panelists, which was shared with them. the panelists then chose to maintain or refine their assessment. analysis of the full results on the six key areas identified by the task force will be presented at the conference to offer recommendations and help guide the management of sid in patients with hematological malignancies. abstract/case report text introduction: mast cells (mcs) are hematopoietic-derived immune cells, whose precursors migrate within tissues reaching maturation and differentiation. masitinib, a selective tyrosine kinase inhibitor, is efficient in controlling the survival, differentiation, and degranulation of mcs. aim: to optimize mast cell-differentiation from human bone marrow (bm) hematopoietic stem cells, and to find best cell culture conditions for proliferation, differentiation, and maintenance of mcs, which is important when studying particularly mcs' response to cytotoxic compounds. material-methods: to produce mcs in vitro, the first method (m ) we used was a modified semi-solid culture method ( ). briefly; human bm mononuclear cells (mncs) were obtained with ficoll gradient from bm sample of a patient with idiopathic thrombocytopenic purpura. colonyforming unit (cfu)-mast was developed from mncs in methylcellulose medium supplemented with scf ( ng/ml) + il- ( ng/ml), and il- ( ng/ml; only first week). - weeks later mast cell colonies were transferred into suspension cultures, in which mcs matured and multiplied up to - weeks and were used in experiments till th week of culture. on the other hand, in our second method (m ); mncs were separated by ficoll, seeded in well-plates with imdm containing fbs %, pen/ strep, and a little amount of methylcellulose, and incubated at o c, %co . cultures were then supplemented with imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) on day ; and imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) + il- ( ng/ml) on day . beginning on day till the end, imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) were added to cultures. for both methods, morphological assessment of colonies/cells were evaluated under an inverted microscope (figure and ). verification of mcs was performed by immunoflorescence staining for anti-tryptase andchymase antibodies, and by toluidine blue staining. macrophages were verified by anti-cd- immunoflorescence staining. mcs were exposed to masitinib or dmso for the evaluation of dose-related effects of masitinib, and cytotoxicity was evaluated by mtt assay. results: in m , culture conditions were easier to handle compared to m . in m , high amounts of mcs in immature and pre-mature forms were appeared as early as - days, and peak levels of proliferation rate was around - weeks of culture, which was about weeks earlier than m . culture could be maintained till weeks in both methods. although mcs are non-adherent cells, in liquid method adherent bm cells such as fibroblasts, endothelial cells and mesenchymal stem cells have adhered to the plate and grown up, providing an attachment site for mcs and serving as a natural bm nest, mimicking in-vivo environment, for mcs to grow and proliferate ( figure ). attachment of mcs has provided medium exchange available without changing culture dishes. when mcs were exposed to masitinib ( . , , and μm/μl), approximate survival rates were %, %, %, respectively. discussion: in our liquid medium method, the adherent bm cells not only provided a natural nest supporting mc development and differentiation, they also served as an attachment site for mcs. as the cells slightly adhered, when trypsinized shortly, they easily detached and used for experiments. and we also report for the first time that adding a little amount of methylcellulose to the liquid medium provides ease of aggregation of cfus, and easy development of mcs. we suggest that our liquid culture may be superior to semi-solid method, that it is faster and easier to handle. in studies subjects crossed over to subcutaneous (sc) igiv-c %, and in the third study crossover was to immune globulin sc (human), % caprylate/chromatography purified (igsc %). a total of pi patients from these studies were included in the poppk analysis and serum igg concentrations were included in the final pk analysis. the pk of igg following iv and sc administration was adequately described by a two-compartment model with first-order elimination from the central compartment. administration of igiv was modeled as an infusion directly into the central compartment. absorption of exogenous igg from the depot site of sc infusions into the central compartment was modeled as a first-order process with an absorption rate constant (ka). the full model was constructed by incorporation (forward selection process) of covariates of interest into the model. after completion of the covariate model development, the final model showed that igg pk was not influenced by (a) the igsc formulation used in the different studies ( % vs. %), (b) gender, and (c) age (pediatric vs. adult). body weight was identified as a significant covariate having an effect on clearance and volume of distribution. based on the final pk results, serum clearance of igg for the reference population was estimated to be . l/day. the volume of distribution of the central and peripheral compartments accounted for . l and . l, respectively. the intercompartmental clearance was . l/day, and the absorption constant from the depot (ka) was . day- . the absolute bioavailability of igg after sc administration was calculated as . %. the developed method was used to evaluate alternative dosing intervals following sc administration. the equivalent of a weekly igsc maintenance dose administered , , , , or times per w e e k , o r b i w e e k l y p r o d u c e d o v e r l a p p i n g s t e a d y -s t a t e concentration-time profiles and similar area under the concentration versus time curve (auc), maximum concentration (cmax), and minimum concentration (cmin) values. the results of the evaluation and simulations for igg exposure following a switch from igiv-c % dosing (every -or -weeks) to sc dosing further suggest that a range of dose-adjustment factors (daf), from : to : . would be sufficient to provide clinically effective trough igg concentrations throughout the course of treatment at various treatment frequencies. current us product labeling for igsc % specifies a daf of : . for transitioning immune globulin dosing from iv to sc, and specifies igsc % dosing frequencies of weekly or more frequently ( - times per week). in this poppk analysis all sc dosing regimens evaluated theoretically would provide viable alternative administration options for maintaining adequate immunoprotection in pi patients with dosing flexibility over a range of regimens. however, in % or more, no causative gene can be found going down to undefined inflammatory syndromes (uis). anti-il drugs (ail d) revolutionized some il- mediated diseases, such as traps, caps, hyper-igd/mkd and fmf. nevertheless, treatment response among disorders are not the same as well as no specific study was designed for uis. papa et al, , recently suggested the use of anakinra for the treatment of uis, especially those refractory/intolerant to colchicine with severe or very symptomatic phenotype. this paper aims to retrospectively report for the first time the experience with canakinumab in monogenic and multifactorial disorders in a single, private center in brazil. patient and methods: patients's records that received canakinumab from january to december at clinica croce, ima-brazil, were revised. demographic and clinical data were extracted and descriptively described. all statistical analysis are presented as: average (minimal; maximum; standard deviation). results: a total of patients with autoinflammatory diseases were enrolled and % (n= ) are female. of them, % (n= ) patients had a monogenic disease: % (n= ) caps, % (n= fmf), % (n= ) mkd, % (n= ) homozygous nlcr and % (n= ) pami syndrome. multifactorial disorders were % (n= ) patients : % (n= ) recurrent idiopatic pericarditis, % (n= ) schnitizler syndrome and % (n= ) uis. the average age of the first symptoms was , years ( ; ; , ) and the average age of diagnosis was , years ( ; ; , ) while the aveage of diagnosis delay was , years ( ; ; , ). all patients had used, prior to anti-il , corticosteroids with % prevalence of cushing syndrome and % (n= ) tried at least one steroid sparing agent without clinical success due to: intolerance or non-effective disease control or side effects. in the fmf group (n= ) % tried colchicine prior to canakinumab and this drug was not effective to % because of amyloidosis status and in % colchicine-induced hepatitis was observed. canakinumab was effective for disease control in % (n= ) considering: control of clinical manifestations, amyloidosis reversion and normalization of acute reactants markers. the only side effect observed during the follow up were acute flu-like symptoms and psicomotor agitation ( , % , n = ). the average time of follow up is of , months ( ; ; , ). canakinumab could be discontinued in just one patient with uis. conclusions: this is the first report of canakinumab use for autoinflammatory disorders in brazil. canakinumab is an effective and safe drug for monogenic and multifactorial disorders control. no serious adverse effect could be observed in the years maximum follow up of this drug. neither, no specific infectious disease more prevalent in south america, such as yellow fever, dengue, zika or chikungunya was observed. abstract/case report text a -year-old caucasian male with autosomal recessive hyper igm syndrome type (higm ) due to aicda mutation, diagnosed at age , presented with a newly developed mediastinal mass. he receives routine ivig, pulmonary function tests (pft's) and chest x-rays. at age , patient was noted to have cervical and inguinal lymphadenopathy. ct scan indicated left mediastinal, hilar and pleural lymphadenopathy with soft tissue infiltration around the descending thoracic aorta and esophagus. biopsy indicated no evidence of a lymphoma or infection. years after initial workup, routine pft's showed a declining diffusion capacity by %. patient complained of intermittent chest pain but displayed no clinical symptoms of cough, dyspnea, dysphagia or reflux. ct scan which revealed an extensive illdefined soft tissue mass extending from the thoracic outlet to the level of the esophageal hiatus that encased vascular structures resulting in narrowing and occlusion of left upper lobe pulmonary artery and left lower lobe pulmonary arteries respectively. imaging demonstrated homogenous ventilation to bilateral lungs and decreased perfusion in the left lung compared to the right lung. infectious workup was negative for atypical infections. biopsy revealed miced cellular infiltrate with no predominenant cell type or evidence of malignancy, consistent with previous lymph node biopsy years prior. cd and cd stains revealed aggregates and scattered b-cells and t-cells, respectively. removal of mass was proposed but due to the ambiguous borders and location, surgical excision was not possible. patient was given doses of rituximab ( g), doses mg/kg pulse steroids hours apart, and daily sirolimus (level was adjusted based on sirolimus level). follow-up ct scan indicated significant interval improvement with - % reduction of the soft tissue mass. blood flow in the left lower lobe pulmonary artery has still not returned. this may be due to collaterals and may be a separate problem from compression due to the mass. cytotoxic t-lymphocyte antigen (ctla- ) is an inhibitory immune regulator critical for governing t and b cell homeostasis. heterozygous ctla mutations can cause a syndrome of immune dysregulation with a variable clinical phenotype including hypogammaglobulinemia , autoimmune cytopenia and endocrinopathies, lymphoproliferation, predisposition to malignancy, tissue specific lymphocytic infiltration of brain, lung and gi tract as well as colitis. methods: we retrospectively reviewed medical records of all patients with ctla haploinsufficiency evaluated at the nih between - . a pathologic variant in ctla was confirmed in all patients. we analyzed frequency of campylobacter species detected in the stool samples by pcr based biofilm rapid array as well as reflex bacterial stool and blood cultures when available. results: forty-six patients aged - years were evaluated at the nih between and . six of patients ( %) had at least one episode of campylobacter species associated acute or worsening diarrhea, with one patient also having campylobacter bacteremia. all patients with positive campylobacter species in stool samples had clinical histories and/or endoscopic biopsy findings consistent with enteropathy or colitis predating the incidence of campylobacter infection. two of the six patients ( %) had recurrent or chronic campylobacter infection, while four of the six patients ( %) had multiple gastrointestinal pathogens detected by stool pathogen screening at various times. conclusions: campylobacter species infection of the gastrointestinal tract seem to occur at an increased incidence in our ctla haploinsufficient cohort. to the best of our knowledge, this is the initial report for the association between ctla haploinsufficiency and campylobacter species infection of the gastrointestinal tract. although ctla- is a critical immune checkpoint involved in mucosal immune homeostasis and gut microbiota-immune system cross talk, the underlying mechanism predisposing to campylobacter infection in ctla- deficient patients remains to be explored. our study suggests screening of stool for campylobacter species in patients with ctla haploinsufficiency associated enteropathy. ( ) submission id# abstract/case report text ikaros transcription factor and ikaros family members are critical for development of lymphocytes and other blood cell lineages. full length ikaros (isoform ) contains six c h zinc fingers (zf), four nterminal dna binding zf and two c-terminal dimerization zf. somatic ikaros mutations and deletions have been associated with increased predisposition to b-acute lymphoblastic leukemia (all) as well with poor disease prognosis. recently, germline ikaros mutations affecting the n-terminal dna binding domain and acting in a haploinsufficiency or dominant negative manner were reported to be associated with common variable immunodeficiency (cvid) and combined immunodeficiency (cid), respectively. herein we describe a novel set of germline heterozygous ikaros allelic variants affecting the c-terminal dimerization domains in four unrelated families. clinical manifestations include hematopoietic cytopenias presenting as evans syndrome, and hematologic malignancies including t-cell all and burkitt lymphoma; other manifestations observed were b-cell lymphopenia and hypogammaglobinemia, but recurrent or severe infections were not prevalent or characteristic. we demonstrate that mutants affecting dimerization abolish ikaros homodimerization as well as heterodimerization with ikaros family members aiolos and helios. these variants also affect dna binding at dimerization sites and pericentromeric targeting. opposed to previous allelic variants reported, dimerization changes alter post-translational sumoylation and gene transcription regulation. our data show that mutations affecting ikaros dimerization are mainly associated with cytopenias and/or malignancies, have a different mechanism of action than previously reported variants, present with incomplete clinical penetrance, and contribute to the growing spectrum of genotype-phenotype ikaros associated diseases. introduction: there has been much discussion regarding the return of secondary findings in genetic sequencing research. opinions differ on whether researchers should return secondary findings to participants at all and if so, what the best method is to do so. we have opted to systematically identify and return pertinent secondary findings to participants in our cohort of patients with immune-mediated diseases that undergo exome sequencing. additionally, exome sequencing may determine multiple or other genetic diagnoses in addition to the primary diagnosis, which we call "incidental findings." here, we discuss the secondary and incidental findings discovered in our cohort thus far. methods: individuals in our protocol underwent consent for exome sequencing, including a discussion of the possibility of secondary findings. exome sequencing data was analyzed, and variant pathogenicity was scored using the acmg criteria (richards et al); variants determined to be likely pathogenic, pathogenic, or otherwise clinically important were confirmed via clia-certified sanger sequencing. confirmed variants were returned to participants. we then queried internal databases for cases involving secondary and incidental findings. results: as of november , exome sequencing, interpretation and reporting had been completed for participants. we detected a total of secondary findings in ( . %) participants, including variants in apob, brca ( ), brca ( ), dsp, fbn , kcnh , ldlr, mybpc ( ), ryr , pkp ( ), and vhl. additionally, we detected possible dual/multiple genetic diagnoses in ( . %) participants, some of which explained an unusual clinical presentation or symptom. these included individuals with variants in multiple immune-related genes, including one individual with variants in gata and tnfrsf a, and those with variants in genes related to multiple organ systems, including an individual with variants in ifngr and sco . discussion: exome sequencing in this cohort detects not only important secondary findings, but also discovers a significant portion of individuals with multiple genetic diagnoses. notably, exome sequencing may provide further context or explanation for unusual phenotypic presentation and help determine specific symptom etiology even when a primary genetic etiology is already known. additionally, these secondary and incidental finds may be important to consider when delineating risks and symptoms of novel or recently-discovered conditions. abstract/case report text background: immune dysregulation and lymphoproliferative disorders including alps like disease, hlh ebv driven lymphoproliferative disease leading to rare lymphomas require a multidisciplinary approach utilizing expertise in immunology and hematology/oncology to care for these patients as we learn the molecular etiology of their underlying disorders. at texas children's hospital, the immunology lymphoproliferative evaluation and diagnostic (ilead) clinic was created to provide a comprehensive clinical and research approach to caring for patients with these rare disorders. in an effort to streamline care and access, we recently on-boarded an advanced practice provider (app) . methods: a chart review was conducted months before and after onboarding the app for ilead patient visits. we reviewed the following patient care and access parameters to determine increase in efficient and effective patient care as well as improved access to the clinic. these parameters included: referral process, time of referral placement to appointment, number of patient visits, wait time in clinic, lab interpretation and reporting time for disseminating results to families, and collaboration process with other specialties. results: within months of the app starting our average wait from placing the referral to first appointment fell by an average of %. in addition, we created an algorithm to prioritize patients with immediate need to be seen. by streamlining the referral process and patient priority, we developed a "pre-clinic" conference process by which all patients are reviewed and preliminary plans are made prior to the patient's arrival. this has translated into our ability to increase the number of patients seen in clinic from to and decreased the wait time in clinic by approximately minutes. since the app started, no patient has been in clinic for more than minutes. this has also led to an increase in rvu generation. in terms of efficiency in patient care, all labs are now ordered while in the room with the patient by the app and physician providers. in turn, all labs are resulted directly to the app who reviews labs, collaborates with physicians for care and reports to families in a timely fashion within - weeks of labs being resulted compared to greater than month previously. to improve collaborator communication and post visit plans, a post-visit clinic summary was created. this has been effective in reducing the time to other specialty referrals, follow up visits and effective care for ongoing clinical needs. conclusions: the addition of an app in our ilead multidisciplinary clinic which provides specialized care for patients with immune dysregulation and lymphoproliferative disorders effectively increases work productivity of providers and enhances patient care by increasing access to care, decreasing wait time in clinic and time of reporting of results and future plans. the app with knowledge and expertise in immunology and immune dysregulation is a cost effective way to enhance provider and patient support. with the overwhelmingly positive results, future plans include expanding our multidisciplinary clinic to other services that care for patients with suspected immune deficiency. abstract/case report text introduction: pediatric lymphoproliferative disorders represent a clinically and genetically heterogeneous group of conditions. misdiagnosis and delayed diagnosis can contribute to substantial morbidity and mortality. identification of molecular etiologies and underlying disease mechanisms may facilitate timely interventions and guide targeted or curative therapies. methods: the study was performed through retrospective chart reviews in accordance with all local ethics and irb committees. the study was designed to investigate a cohort of pediatric patients who met criteria for non-malignant lymphoproliferative disorders from texas children's hospital and collaborating centers for underlying genetic etiologies. results: a total of affected individuals from families met criteria. distribution between male and females was nearly equivalent: males (n = ) and females (n = ). approximately half of the cohort was hispanic (n = ). overall kaplan meier survival was % (n = ). whole exome sequencing was performed in all subjects and available family members. likely disease-causing genetic defects were identified in of families ( %). within these families, ( %) carried variants in genes in international union of immunological societies established primary immunodeficiency diseases. potential novel genetic causes of immune deficiency or immune dysregulation were also discovered. mechanistically, all of the implicated genes had roles in modulating lymphocyte activity; initial activation, cytoskeletal organization, or apoptosis of lymphocytes; or regulation of inflammation. all subjects less than one year of age had an identified gene in one of the three mechanistic categories with the dominant mechanistic genetic category being defective control of lymphocyte signaling ( %). in addition, % of patients between and years of age were found to have a potential genetic diagnosis underlying the lpd, with a more equal distribution of mechanistic categories compared to patients greater than years of age where only % have a genetic cause. other important disease manifestations identified were ebv-associated disease in subjects ( %) and subjects ( %) met hlh- criteria. conclusion: primary immunodeficiency diseases and other genetic abnormalities of the immune system underlie a significant percentage of pediatric lymphoproliferative disorder cases. greater than % of patients less than years of age have a genetic etiology underlying the lymphoproliferative disorder. many of these gene defects can be treated with targeted therapies or hematopoietic stem cell transplantation. genetic testing therefore plays an essential role in the diagnosis and management of children with these conditions. abstract/case report text a -year-old gentleman with a history of immune dysregulation polyendocrinopathy enteropathy x-linked (ipex) syndrome with known pathogenic variant in foxp presented to our emergency department with two witnessed episodes of tonic-clonic seizures earlier that day. he has had a longstanding history of recurrent infections and autoimmune conditions since birth, and was being treated with monthly ivig infusions and sirolimus while awaiting bone marrow transplantation. his symptoms on admission included foaming at the mouth, generalized shaking, bladder incontinence, and tongue biting that lasted about five minutes. family reported recent sores inside his mouth and lips, but denied any recent fevers, neck pain, headaches, chest pain, abdominal pain, nausea, vomiting, and sick contacts. he lives on a farm with livestock and reportedly had recent tick exposure. his last ivig infusion was two weeks prior to admission, at which time he also received inactivated flu vaccine. in the ed, a third seizure was witnessed by multiple medical providers. he subsequently received lorazepam and lacosamide with interval improvement. he underwent diagnostic lumbar puncture, as well as extensive evaluation for infections. he was started on empiric antibacterial and antiviral meningitis coverage. analysis of the csf showed a lymphocytic pleocytosis; bacterial cultures and hsv / pcr were negative, as was a -pathogen meningitis/ encephalitis panel performed by pcr. eeg was negative for seizure-like activity, and brain mri showed mild atrophy without sclerosis in the left hippocampus. subsequently, anti-infectious therapy was stopped, and patient was discharged with outpatient followup scheduled for suspected non-infectious aseptic meningitis that was potentially triggered by flu vaccination versus ivig. on day four post-discharge, however, pcr for ehrlichia chaffeensis in the serum returned positive, and he was started on oral doxycycline. ehrlichiosis is a rare tick-borne illness that may cause various nonspecific symptoms including fever, headaches, myalgias, and generalized malaise. most prevalent in the mid-atlantic regions of the united states, tick-borne ehrlichia spreads through the mononuclear phagocytic system and can infiltrate many organs including the kidney, liver, lungs, and heart. csf penetration can cause sometimes fatal meningoencephalitis. aseptic meningitis due to ehrlichiosis has been described in recent literature. cases in hiv patients and transplant patients on chronic immunosuppressive therapy have been severe, resulting in organ dysfunction in many instances and death in a few. however, this case marks the first documented ehrlichia infection in a patient with primary immunodeficiency. this patient's presentation of aseptic meningitis and clear exposure history fits the clinical picture. his relatively benign course could be due to preserved t effector function not seen in persons with hiv or transplant patients with significant immunosuppression. patients with ipex usually present with autoimmunity and allergies, but are also prone to significant infections. it is important to perform a comprehensive workup, including testing for atypical infections, in patients with immune dysregulation syndromes who present with symptoms of unclear etiology. special attention should be paid to patients who live in areas with known endemic exposure risks. empiric antibiotic therapy may need to be considered early to prevent delays in treatment. abstract/case report text introduction autosomal recessive hypomorphic mutations in pgm have been described to result most commonly in either hyper-ige or severe combined immunodeficiency (scid) clinical phenotypes in humans, with one report of an individual with combined immunodeficiency without atopy. herein, we describe a series of individuals newly diagnosed with pgm deficiency functionally confirmed using lectin-based flow cytometric analysis of peripheral blood mononuclear cells, that broadens the associated clinical phenotypes to confirm cid without atopy and childhood evans syndrome. in addition, we present new disease-causing pgm variants, and functionally confirm the pathogenicity of a fourth (p.i t). classical hies phenotype cases . and . identify sisters of spanish descent with a classical hyper-ige phenotype. the younger sibling demonstrated severe atopic dermatitis, mild-moderate asthma, multiple food allergies, one episode of itp, and adhd. the older sibling demonstrated atopic dermatitis, skin infections, and c. albicans otomastoiditis. the siblings were found to have the damaging compound heterozygous variants p.t i and p.q x in pgm . case is a year-old guatemalan boy with prominent atopy including asthma, allergic rhinitis, food allergy, elevated ige, atopic dermatitis, as well as oral hsv who was found to be homozygous for the damaging pgm variant p.i t. cid phenotype with a paucity of atopy case is a -year-old turkish girl who is the daughter of a consanguineous union. she presented with infantile nephrotic syndrome at months of age, and subsequently developed leukopenia, neutropenia, and low igg. complications include bronchiectasis, sinusitis, pseudomonas urinary tract infection, and inflammatory skin lesions without atopy. she was found to be homozygous for the damaging pgm variant p.r h evans syndrome case is a -year-old girl from guatemala. she developed multilineage autoimmune cytopenias including immune thrombocytopenic purpura (itp), autoimmune hemolytic anemia (aiha) and autoimmune neutropenia (ain) at the age of years, refractory to multiple treatments and finally responding to mycophenylate mofetil. she has a history of mild eczema but is without other atopy and suffered from multiple invasive bacterial infections. an additional patient, case , was diagnosed with coombs positive aiha and itp at age years refractory to multiple treatments and finally responsive to cyclosporine. cytopenias recurred year later, resulting in hypoxic brain injury. he died of infectious complications at the age of years. both patients were found to be homozygous for the damaging pgm variant p.i t. discussion this is the first report of pgm deficient individuals presenting with evans syndrome as a primary presentation without additional pathology. while disease-associated mutations appear to cluster around the key conserved domains of the protein, no clear genotype-phenotype correlation is readily observed. in addition to autoimmune cytopenias, pgm deficient individuals have also been reported with splenomegaly, lymphoma, and ebv viremia. thus, in particular for children with lymphoproliferative disease, pgm deficiency should also be considered in the differential diagnosis. abstract/case report text introduction: meningitis is a life-threatening manifestation of cryptococcus neoformans (c. neoformans). it occurs in increased frequency in those with impaired cell-mediated immunity, especially those with hiv/aids. infection with c. neoformans has been seen in previously healthy individuals diagnosed with idiopathic cd lymphopenia (icl). icl is defined by an absolute cd + count of less than cells/m on multiple occasions, usually to months apart, without other apparent cause such as hiv infection, immunodeficiency, or immunosuppressive medications. case description: our patient is a previously healthy -yearold female with cryptococcus meningitis and fungemia. her course was complicated by elevated intracranial pressure requiring extraventricular drain. she was treated with amphotericin and flucytosine for month. notably, the patient was also found to have moraxella catarrhalis (m. catarrhalis) bacteremia without identifiable source. she denied history of environmental risk factors, was not up to date on cancer screening, and recently returned from a trip to italy. initial evaluation revealed lymphopenia ( cells/ul), low cd + ( cells/ul), cd + cells ( cells/ul), and cd / + ( cells/ul), but normal cd + ( cells/ul) and cd + cells ( cells/ul). hiv, ana, leukemia/ lymphoma flow cytometry panel was negative. she also had a normal lymphocyte proliferative responses to pha ( . %), normal cd ra:ro, and protective tetanus titers ( . iu/ml), but only / protective pneumococcal serotypes. initial immunoglobulins demonstrated slightly low igg ( mg/dl). laboratory studies months after presentation demonstrated improved lymphopenia ( cells/ul) continued low cd + cells ( cells/ul), but normalized igg levels ( mg/dl). followup labs also demonstrated decreased cd + b cells ( cells/ ul) and insufficient response to polysaccharide vaccine ( / pneumococcal serotypes). three months after discharge, she is continued on daily fluconazole without recurrence of infections although she still has diplopia and headache. discussion: in a review of cryptococcosis in patients with icl, of them had cryptococcal infection in both the cns and blood. of these patients, was cured, improved, relapsed and then improved, and died. three of these patients were treated with amphotericin and flucytosine. five of these patients had underlying disease and had notable infections with vzv, tb, or hpv, however other infections such as m. catarrhalis were not mentioned. m. catarrhalis bacteremia has been described in children with underlying immune dysfunction and respiratory infection as well as secondary to pneumonia with m. catarrhalis. in cases of m. catarrhalis bacteremia in adults, most had underlying malignancy and/or neutropenia, predisposing respiratory factors, or source for infection. conclusion: this report of c. neoformans meningitis and m. catarrhalis bacteremia in the setting of icl is unusual in that to our knowledge, m. catarrhalis bacteremia has not been reported in icl. cases like this also raise the question as to whether some laboratory abnormalities are secondary to infection, treatment, or underlying disease. it is important to report these cases with icl in order to group disease phenotypes, as continued monitoring and data collection of these cases may lead to discovery of new disease processes. abstract/case report text cytokines play critical roles in regulating the development, survival, differentiation and effector function of immune cells. cytokines exert their function by binding specific receptors on the surface of immune cells and typically activating intracellular jak/stat signaling pathways, resulting in induction of specific transcription factors and regulated expression of target genes. in order to differentiate into an appropriate effector fate, lymphocytes need to integrate multiple signals often provided concomitantly by numerous cytokines that activate shared transcription factors. how these signals are balanced and regulated to yield the optimal class of immune response remains to be completely determined. inborn errors of immunity, or primary immunodeficiencies (pids), result from germline mutations in defined genes, leading to loss-of expression, loss-of function, or gain-of function of the encoded protein. pids are characterised by defects in immune cell development, or their differentiation into effector cells during immune responses, thereby rendering patients not only highly susceptible to infectious diseases, but also autoimmunity, autoinflammation, allergy and cancer. pids are thus an unprecedented model to link defined monogenic defects to immune dysregulation in clinical settings. indeed, pids have unequivocally revealed non-redundant roles of single genes, molecules, signaling pathways and lymphocyte subsets in host defense and immune regulation, and formed the basis of better therapies for immunopathologies. our indepth analysis of inborn errors of immunity of cytokine signalling pathways have identified fundamental requirements for generating long-lived humoral immune responses in humans. here, i will present data relating to our recent studies of how inactivating mutations in il r, il r, znf , stat , stat , and stat , disrupt or dysregulate the generation and function of human memory b cells and tfh cells, thereby precipitating humoral immunity, as well as allergic disease and autoimmunity. abstract/case report text introduction: flow cytometry is a powerful diagnostic tool for detecting hematologic malignancies in a variety of patient specimens including body fluids and lymph node aspirates. cytopathologists are frequently confronted with lymphocyterich effusions, and the definite decision of whether the lymphocytosis is of a purely reactive nature or a presentation of an indolent lymphoma may be an extremely difficult based on microscopy alone. moreover, small proportions of malignant cells that may be missed out by routine morphology can be detected by flow cytometry. objective: the purpose of this study was to evaluate the usefulness of multiparametric flow cytometry immunophenotyping (fci) to confirm the presence of leukemia or lymphoma cells in body fluids and fna specimens. methods: body fluids and fna specimens simultaneously obtained for fci, cytologic analysis and real time pcr from patients were submitted to our flow cytometry laboratory from january to september . the samples studied were body fluids ( pleural fluids and ascitic fluids) and fna samples ( enlarged lymph nodes and lung mass).four color fci method was performed and the following fluorescent monoclonal antibodies were used: cd , cd , cd , cd , cd , cd , cd b, fmc , kappa and lambda light chains, cd , cd , cd , cd c, cd , cd a, cd , cd , cd , cd , cd , tdt, cd , cd , cd , cd , cd , cd , bcl , cd . fci analysis was performed on a beckman coulter cytomics fc flow cytometer using software cxp to analyze data. the cases were diagnosed as leukemia or lymphoma as per tuberculosis ( case). ascitic fluid (n= ) samples showed positivity for angioimmunoblastic t-cell lymphoma ( cases) and dlbcl ( case). fna of lymph nodes (n= ) were positive fort-lymphoblastic lymphoma ( cases), angioimmunoblastic tcell lymphoma ( cases), dlbcl ( cases), hodgkin lymphoma ( case), nodular lymphocyte predominant hodgkin lymphoma ( case), peripheral t-cell lymphoma (nos) ( case), splenic b-cell marginal zone lymphoma( case), tuberculosis ( cases). one fna of lung mass were tumor of neural cell origin. both immunophenotype and cytomorphology positive for malignancy were in / ( . %) cases.cytomorphology was negative/ suspicious in / ( . %) cases, of which both cytomorphology a n d i m m u n o p h e n o t y p e n e g a t i v e w e r e ( % ) a n d cytomorphology negative but immunophenotype positive cases were ( . %). mtb dna was detected in pleural fluid in case and fna sample in cases. conclusion: multiparametric flow cytometry by using comprehensive panel of monoclonal antibodies is a useful diagnostic test to evaluate body fluids or fna as it can demonstrate small malignant populations that may be missed out by routine cytomorphology. clinical laboratory geneticist/department of genetics, university of groningen, groningen, the netherlands abstract/case report text the phenotypes of primary antibody deficient (pad) patients range from milder (e.g. specific antibody deficiency) to severe (e.g. x-linked agammaglobulinemia) deficiency of the immune system. pad patients form a clinically, immunologically as well as genetically heterogeneous group. often, the genetic background has not been elucidated; it probably is not monogenetic in a large subgroup of patients. pad patients suffer most frequently from recurrent bacterial infections of the respiratory or gastrointestinal tract due to immune deficiency, but may also have varying degrees of autoimmune and lymphoproliferative comorbidities due to immune dysregulation. unfortunately, a standardized description of pad phenotypes is lacking rendering robust definitions of pad-subtype diagnoses, including cvid, difficult. this impairs the formation of homogeneous cohorts that can form the starting point for future clinical and genetic research. the pad subgroup of the human phenotype ontology (hpo) immune mediated disorders consortium supported by ern rita and esid is addressing the gaps in standardized phenotypic description of pads. using the hpo dataset, literature mining, and esid, iuis and omim classifications, we aimed to reevaluate and complete the pad-related hpo terms to allow efficient data exchange and matching of phenotypically similar pad patients. as a principle, it was decided to avoid the ongoing variance in pad-subtype definitions and to build the pad-related hpo tree based as much as possible on unambiguously interpretable items. 'hypogammaglobulinemia' was deleted as hpo term, and replaced by separate hpo terms such as 'decreased total igg in blood', subdivided in 'transient' vs. 'chronic', and '(near) absent' vs. 'partially decreased' (the same for igg , igg , igg , igg , iga and igm). 'decreased specific antibody level in blood' was specified further into 'decreased natural antibody level to blood group antigens in blood', subdivided in '(near) complete' vs. 'partial' absence (the same for protein, polysaccharide and protein-conjugated polysaccharide vaccination). relevant hpo terms related to infection and to specific organ manifestations like bronchiectasis, autoimmunity and lymphoproliferation were re-evaluated and completed, and will be linked to pad diseases in the hpo online system by the pad subgroup experts. once finalized, existing pad cohorts will be classified according to the new hpo pad-related terms, and studied by clustering technologies (example of two patients shown in figure ; white = absent, color = present). acceptance and widespread use of this pad-related hpo tree for standardized phenotyping will be essential to empower future multicenter clinical research and related genetic discoveries as well as support clinicians in diagnosing pad through the linkage of hpo terms to pad disease entities. senior investigator oral immunity & infection section/nih/nidcr abstract/case report text leukocyte adhesion deficiency type (lad ) is an autosomal recessive disorder characterized by the inability of granulocytes to emigrate from the bloodstream to sites of inflammation. lad is caused by mutations in the itgb gene ( q . ), encoding the beta- -integrin, cd , which is essential for firm adhesion of leukocytes to the endothelium. in lad survival is compromised, morbidity from inflammatory lesions is high, and treatment is poor. the moderate form of lad is often managed with antibiotics for prophylaxis and during acute infections. after infancy severe gingivitis and chronic periodontitis are universal. periodontal findings affect primary and permanent teeth, causing intense oral mucosal (gingival) inflammation and destruction of tooth supporting bone, which are hallmarks of the disease periodontitis. blocking the il- /il cytokines, which are up regulated in lad gingiva, can reduce bacterial load and resolve inflammatory gingivitis. ustekinumab binds to the shared p subunit of human il- and il- , cytokines that modulate lymphocyte function, including t helper (th) cells and th subsets, thereby blocking them. objective: explore the effect of ustekinumab on lad inflammatory disease. method: prospective study using ustekinumab for oral inflammation. patients receive five doses over year, -or mg depending of weight. results: (two patients have enrolled, p is > year post treatment, p is still on study) patient characteristics · patient : age at diagnosis, yrs.(itgb mutation c. delt (null)); cd (%pmn control): . %; cd a(%pmn); . %. at the initiation of the protocol ( yrs old) wcc: . k/ul; crp: . · patient : age at diagnosis, yrs.(itgb mutation c. a>g,p.g s c. c>t,p.a v) cd (%pmn control): %; cd a(%pmn): . %. at the initiation of the protocol ( yrs old) wcc: . k/ul; crp: . response: patient : oral ulcers before treatment: episodes every two months. during ustekinumab therapy: · oral ulcers: episode in a year · reduction in bleeding on probing: . % · gingival index reduction: % patient : oral ulcers before treatment : monthly. during ustekinumab therapy: · oral ulcers: none in first months · reduction in bleeding on probing : . % · gingival index reduction: . % safety: no significant adverse events were documented during the therapy p had a previous skin lesion that flared leading to iv antibiotics. p had a previous sebaceous cyst drain spontaneously. discussion: two patients showed improvement in chronic periodontitis and a substantial decrease in oral ulcers while on ustekinumab. no clear safety signals were seen. durability of these findings is still unknown. ustekinumab in lad deficiency appears to be safe and potentially effective. post doctoral fellow/servicio de inmunología, inst. multidisciplinario de investigación en patologías pediátricas (imipp), hospital de niños ricardo gutiérrez. chief resident/servicio de inmunología-hospital de niños "dr. r.gutierrez" immunologist/centro de inmunología clínica "dra. liliana bezrodnik y equipo"-servicio de inmunología htal. de niños "dr. r.gutierrez" immunologist/centro de inmunología clínica "dra. liliana bezrodnik y equipo" immunologist/servicio de inmunología-hospital de niños "dr. r.gutierrez" abstract/case report text introduction: primary immunodeficiencies with dysregulation associate defects in the immune homeostasis leading to inappropriate immune response (lack or excess) that causes autoimmunity, allergy and/or inflammation. impairment of different subsets of t and b compartments may be associated with these pids. aim: ) describe t and b memory compartment of pid patients (pts) with dysregulation: cd deficiency, stat gof, stat b deficiency, ctla variant, pi kcd variant and cvid-like (with no molecular defect) and compare them with a group of healthy donors (hd). ) associate ctfh profile with b cell compartment impairment. results: ) pts showed a significant decrease of naïve cd + t cells (cd ra+cd +) ( , % vs , %) (p < . ) with expanded central memory t cells (cd ra-cd +) ( . % vs . %) (p < . ); cd + t cells had higher levels of activation markers (cd +hla-dr+) ( , %vs , %) (p < , ). pts showed a significant increase of circulating follicular t cells (ctfh) (cd ra-cxcr +) compared with hd (mean , % vs , %) (p < , ) with pd- overexpression (p < . ). stat gof, ctla , pi kcd and cvid-like pts showed a skew towards ctfh (cxcr +). regulatory t cells (cd +cd ++ foxp +) were absent in cd and stat b deficiency and decreased in the other pts. within cd + cells, although effector memory (cd ra-cd -) (p < . ), temra (cd ra+ cd -) (p < . ) and hla-dr+ cd + (p < . ) subsets showed a significant increase compared with hd, the behaviour was variable between different mutations. regarding b cell compartment, pts with stat gof, pi kcd and cvid-like showed a severe impairment of switched-memory b cells (sw-mbl) (cd +igd-igm-); the stat b deficient patient had increased frequencies of this subset, while ctla pts had a variable b defect. ) lower sw-mbl values were significantly associated with lower values of ctfh cells (p < . ) (r= . ). cd low b cells were exclusively high in cvid-like pts, and transitional b cells were increase in pi kcd and almost all cvid-like pts. discussion: in summary, patients with dysregulatory syndromes associate a defect of t and b homeostasis (survival, activation and differentiation). specific mutations can differentially affect the quantity and/or the quality of ctfh. there is a strict association between the differentiations of tfh with th profile with the generation of sw-mbl. these alterations may play a role in the pathophysiology of primary immunodeficiencies with b lymphocyte functional impairment. immune monitoring of lymphocyte subsets of patient with dysregulation may approach to the diagnosis of specific monogenic mutations. objective: the purpose of this study is to increase awareness and improve diagnosis of primary immune deficiency (pid) in the heterogenous group of patients with autoimmune cytopenia (aic) by identifying clinical characteristics and laboratory biomarkers that distinguish those with underlying pid, disease activity and guide mechanism-based targeted therapy. methods: patients with aic (autoimmune hemolytic anemia (aiha), immune thrombocytopenia (itp), or autoimmune neutropenia (ain)) were referred to our immune dysregulation team and prospectively enrolled during - . detailed immune phenotyping (igg, iga, igm, lymphocyte subsets, vaccine titers, lymphocyte proliferation to mitogens/ antigens), serum lipopolysaccharide (selps) and autoantibodies were measured and/or collected by chart review and genetic testing for pid was pursued. results: from to , patients were enrolled; two subjects were removed due to parental request or lack of aic diagnosis. of the remaining patients, ( %) were classified as "aic-pid" based on genetic testing and/or immune phenotyping; ( %) were classified as aic-only, and ( %) were asymptomatic family controls. the patients were predominantly children (ages - years, average age . years); % ( / ) were male. among patients who have had genetic testing to date (n= )( %), pathogenic genetic mutations were confirmed in / ( %) of patients. mutations include fas/fasl (n= , including family members without aic), ctla (n= ), q (n= ), and one patient each with nfkb , was, pole- , pi k, casp , card , and cgd; the remainder of aic-pid patients were classified as combined immune deficiency or common variable immune deficiency based on immune phenotyping. lymphocyte subsets (cd +t, cd +t, cd +b, cd + nk) and immune globulins (igg, iga, igm) tended to be lower in aic-pid patients vs aic-only (p < . ). evans syndrome was more common in aic-pid patients ( / , %) compared to aic-only ( / , %). lps was elevated in the serum of aic patients compared to healthy controls (mean vs pg/ml, p < . ). excluding partial digeorge syndrome patients (average lps pg/ml), selps levels were significantly higher in genetically-defined untreated pid patients (average pg/ml) vs. other pid (average pg/ml)(p= . ) or patients with aic alone (average pg/ml)(p= . ). studies are ongoing on specific subsets that are linked to immune dysregulation (switched memory b cells, t-regulatory cells, double negative t cells, t follicular helper cells) and the use of soluble il- as a biomarker of disease activity. conclusions: a high fraction of aic patient were identified with underlying pid in our study. basic immune evaluation with immunoglobulin levels and lymphocyte subsets expedited diagnosis of pid. genetic evaluation distinguished a group of patients with aic-pid and highly elevated lps level, reflecting high bacterial load, which may distinguish them from the rest the aic cohort. the source of bacterial lps can be multifactorial and is yet to be determined. our studies continue focusing on biomarkers that can be applied to the heterogenous group of patients with aic. this will allow early detection and timely initiation of targeted therapies. investigator/dermatology branch, niams, nih head, dermatology consult service/dermatology branch, niams, nih chief, fungal pathogenesis section/laboratory of clinical immunology and microbiology, nih abstract/case report text introduction/background: autoimmune-polyendocrinopathy-candidiasis-ectodermal dystrophy (apeced) is a monogenic autoimmune disease resulting from biallelic mutations in the aire gene. although typically characterized by the classic triad of chronic mucocutaneous candidiasis, hypoparathyroidism and adrenal insufficiency, we recently reported that the clinical spectrum of the syndrome is far broader and that incorporation of an adjunct triad of apeced rash, intestinal dysfunction, and enamel hypoplasia in the classic triad could lead to earlier diagnosis (ferre et al., jci insight, ). among the adjunct triad manifestations, apeced rash occurs in % of american apeced patients by age , most often developing in the first year of life. objectives: to report and describe the clinical features of apeced rash as the first manifestation in a -month old patient with apeced. methods: following enrollment in a niaid irb-approved protocol ( -i- ) the patient was evaluated with history and physical examination, aire sequencing, measurement of interferon-autoantibodies, and skin biopsy with immunohistochemical analyses. results: a -month-old girl with a family history of genetically confirmed apeced in her -year old sister developed discrete circular, maculopapular erythematous lesions on her torso that spread to the face, arms, and legs while sparing the palms and soles. the rash was partially blanching, non-painful and non-pruritic and was preceded by low-grade fever ( □c) without other accompanying symptoms. she had not received medications or vaccinations prior to the rash onset. the lesions increased in size with associated central clearing and resolved . months after onset. the rash recurred with similar appearance times over months with each recurrence lasting between days and . months. as with the first rash episode, recurrences were often preceded by fever ( - □c) without accompanying symptoms or inciting factors. neither topical nor oral antihistamines improved the rash. aire sequencing identified the same compound heterozygous mutations (c. _ del and c. c>t) that the sister has. high titers of interferon-□ autoantibodies were measured in serum. skin biopsy revealed superficial perivascular chronic inflammation and intraepidermal lymphocytes composed predominantly of mixed cd and cd t lymphocytes with few perivascular b lymphocytes. no eosinophils or vasculitis was observed. myeloperoxidase immunostaining revealed extensive karyorrhexis. laboratory studies revealed normal white count and esr, negative anti-ige receptor antibody, and positive anti-ige antibody. at months, she developed oral candidiasis as second manifestation of apeced, thus reaching a diagnostic dyad when applying our proposed expanded diagnostic criteria. she has not developed hypoparathyroidism or adrenal insufficiency; thus, she has not yet reached a classic diagnostic dyad. systematic screening for these endocrinopathies will be needed to avoid lifethreatening complications of acute endocrine failure. conclusions: we report the clinical and histologic features of apeced rash manifesting as the first disease component of apeced in a month old girl. apeced should be considered in the differential diagnosis of recurrent erythematous maculopapular urticaria-like eruptions characterized by mixed lymphocytic and neutrophilic infiltration unresponsive to antihistamines. our case illustrates the clinical utility of incorporating the expanded diagnostic criteria of apeced rash, enamel hypoplasia and intestinal dysfunction into the classic diagnostic triad, which can lead to earlier apeced diagnosis. who presented with prolonged severe neutropenia despite g-csf and seven hospitalizations for febrile neutropenia in the span of ten months. prior to his neutropenia, patient was on monthly ivig, with igg trough - in the past year. he was evaluated for bmt in but declined. patient was first found to be neutropenic in aug when he was admitted with pseudomonas thigh abscess, hsv stomatitis and rhinovirus infection. he was treated with broad-spectrum antibiotics with improvement in neutropenia. the following month, he was hospitalized again with neutropenic fever, left axilla pseudomonas abscess and rhinovirus infection. he underwent bone marrow biopsy revealing left shifted myeloids with decreased maturing forms and t cell predominant lymphoid aggregates, suggestive of autoimmune neutropenia vs. hyper igm syndrome associated with neutropenia. anti-neutrophils antibodies were negative. he was then admitted the following month ( / ) with febrile neutropenia with cxr concerning for viral pneumonitis vs. atypical pneumonia. he was started on g-csf therapy with significant initial response in anc. however, this response was short-lived as he was again admitted in / with febrile neutropenia and upper respiratory rhinovirus infection. he was continued on daily g-csf. due to persistently normal anc for approximately three weeks, he was weaned off g-csf in / . in / and / , he had two more hospitalizations for febrile neutropenia. g-csf was restarted with dose uptitrated to mcg/kg during his hospitalization in april. he was found to be thrombocytopenic with splenomegaly on abdominal ultrasound. anti-platelet antibodies and repeat anti neutrophil antibodies were not detected. he was discharged with close follow up with immunology and hematology. due to his age, he was transitioned to penn allergy/immunology in / . there was close communication between chop allergy/immunology, chop hematology and penn allergy/immunology during this transition period. patient was admitted to hup in / with febrile neutropenia (despite higher dose of g-csf), rhinovirus infection, pseudomonas sinusitis and ct chest findings suggestive of possible fungal pneumonia. due to persistent neutropenia refractory to g-csf treatment, hematology was consulted and repeat bone marrow biopsy showed hypercellular bone marrow with markedly left shifted granulocytic hyperplasia, compatible with g-csf therapy. flow cytometry showed no evidence of plasma cell neoplasm. dose of ivig was adjusted and increased based on his weight. per hematology, he also received an additional high dose ivig g/kg x days for presumed immune mediated neutropenia with immediate increase in anc. despite anc of for days,anadditional g/kgofivigimprovedhisancto> within hours of his first dose. thrombocytopenia also improved to normal range. since then, patient has been on monthly - mg/kg ivig with no recurrence in neutropenia. this patient's prolonged persistent neutropenia with immediate response to high dose ivig is suggestive of autoimmune neutropenia, which should be taken into consideration in hyper igm patients with persistent neutropenia. abstract/case report text background: children with digeorge anomaly (dga) represent a heterogenous group, often classified as either partial dga (pdga) or complete dga (cdga) based upon the degree of thymic hypoplasia. this paucity of t-cell parameters and function has serious implications for infection risk, autoimmunity, and malignancy. however, there are limited studies stratifying children with dga by these subgroups, especially in regard to immune function and subsequent infection risk. study design: single-center, retrospective cohort analysis evaluating the relationship between pdga and cdga to infection risk with particular focus on infection-related hospitalization, pathogenic organism identification, and antimicrobial resistance profiles. the source population includes all pediatric patients < years of age diagnosed with either pdga or cdga while receiving care at duke university from january , to june , . the final analysis sample included patients. methods: to evaluate the differences in immune function between dga subgroups, we will report the proportion of low ( < th percentile for age) t cell immune biomarkers for both subgroups and compare populations using a chi-squared test. to compare per year incidence of infectionrelated hospitalization for dga subgroups, a poisson model with number of hospitalizations per patient as the outcome, an offset equal to the time at risk for hospitalization, and either pdga or cdga diagnosis as the exposure will be used. models will be bivariate. we will report an incidence rate ratio (irr) and % confidence interval ( % ci). to evaluate the impact of cellular and humoral immune function on infection-related hospitalization, we will use poisson models where the outcome is the number of hospitalizations per patient, an offset equal to the time at risk for hospitalization, and low immune biomarker as the exposure. all models will be bivariate. we will report an irr and % ci. infection type and resistance profiles will be completely descriptive. results: as expected, children with cdga had a significantly higher probability of a low ( < th percentile for age) values for total t cells (cd +), helper t cells (cd +cd +), cytotoxic t cells (cd +cd +), and naïve helper t-cells (cd +cd ra+cd l+) as well as a significantly lower probability of low pan memory t-cells (cd +cd ro+) compared to children with pdga. no differences were detected in the percentage of low natural killer (nk) cells (cd +cd +) or b cells (cd +) between subgroups. cdga patients had a significantly higher incidence of hospitalization per year ( . ( . , . )) compared to pdga patients ( . ( . , . )). the irr is . ( . , . ). across both subgroups, the incidence of hospitalization was higher in dga patients who had low helper and naïve t-cells. there is ongoing analysis into hospital-related infection and resistance profiles. notable frequencies include bacteremia ( > %), invasive viral disease ( > %), and opportunistic infections ( > %). conclusions: children who had cdga were % more likely to have an infection requiring hospitalization than children who had pdga, emphasizing the need for thymus transplant for cdga. further analysis of infection type and patient outcomes is critical to enhancing management of this unique patient population. abstract/case report text antibody cross-reactivity among flavivirus has been documented. in recent times zika virus has been emerging in pockets of the mosquito-infested regions, while southwestern saudi arabia is known for arthropod-borne viral diseases and we do not know the incidence or even presence of zika virus in this region. it is restricted to predict the igm and igg antibody detection ranges owing to limited data and colossal cross-reactivity among the zika and other flaviviruses. we tested sera from pregnant women irrespective of their clinical presentation for zika and dengue igm, igg respectively. the zika positive samples were further confirmed by plaque reduction neutralization tests (prnt). from our results, . % ( ) cases were positive for zika igm against . % ( ) positivity to igg. when these samples were assessed for dengue igm and igg, we observed . % ( ) seropositivity for igm and igg respectively. there was no single sample positive for both igm and igg of zika or dengue. however, we observed one sample positive for both zika and dengue igm. upon mapping the overlapping serotiters, there was no significant correlation observed between the dengue igm and igg. whereas zika igg positive sample showed high serotiter for dengue igg indicating the contribution of cross-reactivity for observed zika positivity. screening for the incidence of zika, therefore, becomes particularly hard in a population that has the presence of pre-exposure of dengue and this cross-reactivity makes it hard to determine the zika incubation and antibody prevalence confounded with other flaviviruses. abstract/case report text introduction humoral pid diagnostic protocol includes the analysis of the immune response to different protein and polysaccharide antigens (ags) ( ) . although the analysis of the immune response against the polysaccharides vaccine from pneumococca has been the standard method, the use of s. typhim vi vaccine has appeared as a good alternative ( ) . in this report we show the results obtained with the use of s.typhim vi in adults patients attending the pid outpatient clinic. material and methods patients with humoral-suspected pids were challenged with typhoid polysaccharide vaccine (typhim vi®; sanofi-pasteur). serum was obtained on basal and after weeks of vaccination. specific igg levels against s.typhim were measured using "vacczyme tm human anti-salmonella typhi vi igg enzyme immunoassay kit" (binding-site). results a total of adult patients attended the pid clinics during nov -nov . from those, patients were fully evaluated using a humoral-suspected pid algorithm that includes the s.typhi vaccination. in total male and female patients completed the protocol and were analyzed. twenty patients were considered as responders (ratio pre/ post > x) whereas patients were non-responders. discussion the main advantage of assessing polysaccharide immune response using s.tyhpim is the usual lack of specific igg at the moment of the initial evaluation. in this serie, just one patient has a high basal level (# -vaccinated in the past). thirteen patients had basal levels below the detection limit of the test ( , u/ml) and patients between , and , u/ml, that has been described as a cut otf level for nonimmunised individuals (personal experience, , ). regarding the polysaccharide immune response as a tool to distinguish pid vs non-pid patients, the results showed a good correlation between those non-responders with more clinical relevant pid diagnostics. seven non-responders patients were subsequently diagnosed with a primary (* on table i ) and/or secondary id (** on table i ). despite this, there were patients that we could have classified as strong responders (ratio > x, absolute specific igg postvaccination level > u/ml) and patients considered as weak responders (ratio post/pre > x, absolute specific igg postvaccination level < u/ml). strong responders were considered non-pid after including other clinical investigations and laboratory tests (cell subpopulation study, pcp response) whereas weak responders group consisted in some "minor" forms of pid, like isolated igm or ig subclasses deficits. more patients are needed to confirm this functional classification of pid patients regarding their s.typhi immune response. abstract/case report text activated pi kδ syndrome (apds) is a primary immunodeficiency characterized by recurrent respiratory infections, as well as increased risk of chronic viremia with herpes family viruses, benign lymphadenopathy and b cell lymphoma. it is caused by heterogeneous germline gain-of-function mutations which ultimately lead to the hyperactivation of the phosphoinositide- -kinase δ (pik δ). pik δ exists as a heterodimer composed of a catalytic and a regulatory subunit. it interacts with b cell receptors, t cell receptors, costimulatory and cytokine receptors, and is a key player in a signaling pathway involved in cell growth, proliferation and survival. apds is caused by mutations in the pik cd gene, affecting its protein product p δ (catalytic subunit). apds is caused by mutations in the pik r affecting p a (regulatory subunit). short syndrome is a rare multisystem disorder characterized by short stature, hypertextensible joints, ocular depression, reiger anomaly and tooth eruption delay. the primary causes of short syndrome are heterozygous loss-of-function mutations in the pik r gene. the combination of apds and short syndrome is very rare, with only few cases described in the literature. in this report we present a teenager with a pathogenic variant in the pik r gene, and phenotypic characteristics of both apds and short syndrome. our patient is a -year-old female with a history of growth delay and short stature, delay tooth eruption, recurrent sinopulmonary infections and hypogammaglobulinemia. evaluation performed at a prior institution for recurrent infections revealed low igg levels. she did not initiate therapy at that time and was lost to follow up for several years. at the time of our initial evaluation she reported continued recurrent episodes of upper respiratory infections and sinus infections requiring antibiotic treatment that often did not clear the infections. her physical exam was relevant for short stature ( %ile, z=- . ), low weight for age ( < %ile, z=- . ) and hyperextensibility. her facial features were significant for prominent forehead and triangular face. given concern for immune deficiency, a complete immune evaluation was obtained. her workup revealed low igg levels, with igm and iga within normal limits. she did not have protective titers to s. pneumoniae, h. influenza or diphtheria and tetanus. after administration of vaccine boosters, she was able to generate a response to all vaccines except for tetanus. she had remarkably low absolute b cells ( cells/ul) and percentage ( %), and low cd :cd ratio ( . ). she was started on amoxicillin prophylaxis and monthly ivig replacement therapy. invitae immunodeficiency panel genetic testing was sent and revealed a pathogenic loss of function variant in an intronic splice site in the gene pik r (c. + g>c). after initiating treatment with ivig, her sinus infections significantly improved and she has not had any further episodes. igg levels have remained within normal limits with monthly ivig therapy. this pathogenic variant had been previously associated with apds ; however, it had not been associated with short syndrome. the mechanisms that link both conditions is yet to be identified. this case report emphasizes the importance of screening for comorbidities associated with short syndrome in apds patients, and vice versa. finding the genetic diagnosis for patients with suspicion of primary immunodeficiency (pid) is becoming increasingly important in the management of primary immunodeficiency and estimating the risk for family members. we constantly increase the diagnostic yield for pids by improving the sequencing technology, updating the panels with new genes discovered related to pid, and finding diagnoses from difficult to sequence regions and regions with high homology. here we report our experiences with nearly patients suspected with pid. moreover, we provide a case example, how we increase the diagnostic yield by developing unique techniques for specific genes which cannot be reliably analyzed by ngs alone. diagnostic yield including all immunology related panels was . % ( / ). the majority of the tested individuals were males ( / , . %) and the most common age of testing was between to years ( / , . %). the highest diagnostic yield . % ( / ) is in children from ages to years, whereas in patients over years of age the diagnosis was found for only . % ( / ) of the patients. in two patient cases, our cnv detection algorithm indicated a homozygous deletion in the index patient samples potentially covering the whole ncf gene. additional bioinformatic analysis targeting specifically two coding positions that differ between the ncf gene and the two pseudogenes showed that all reads in those positions originated from the pseudogenes. homozygous deletion in the ncf gene was further confirmed by sanger sequencing two regions in ncf with primers that specifically bind to either ncf or the pseudogenes. while clean ncf sequences from both regions were obtained for a control sample, no ncf -specific amplification product was obtained for the index patient samples. pseudogenes were amplified and sequenced successfully in both index patient samples and positive control samples. loss-of-function of ncf is a well-established mechanism leading to cgd and by overcoming the difficulties regarding ncf deletion detection by ngs, we can improve diagnostic rate in individuals affected with cgd. gata deficiency can lead to a broad spectrum of clinical and hematological phenotypes; in some cases, nk cell deficiency is the primary manifestation, resulting in a greatly increased susceptibility to viral infections and malignancy. gata -deficient patients, particularly those who suffer from severe viral infections, have reduced frequencies of peripheral blood nk cells and loss of function in the existing nk cells. specific loss of the less mature (cd ^bright) nk cell subset is a hallmark of the immune phenotype in gata deficiency, suggesting that generation or survival of nk cell precursors is impaired. given the remarkable spectrum of clinical phenotypes in gata -deficient patients and the poorly understood biology underlying their nk cell defect, we sought to characterize circulating nk cells on a single-cell level. we performed single-cell (sc)rnaseq of lineage-depleted innate lymphocytes from a patient with gata deficiency. as expected from flow cytometric phenotyping of peripheral blood cells from this and other patients, scrnaseq revealed decreased representation of canonical cd ^bright cells. within the cd ^dim population, we identified two nk cell populations that were seemingly unique to the gata deficient patient relative to a healthy donor. pathway analysis defined the first of these populations (population ) by the expression of genes associated with cellular response to stress, extracellular stimulus and inflammation, as well as programmed cell death and regulation of proliferation and apoptosis. the second population (population ) was defined by genes associated with nk cell chemotaxis, cytokine responses and interferon signaling. to extend our findings, we performed scrnaseq of additional healthy donors and analyzed an additional gata -deficient individual who was clinically asymptomatic (yang et al. ). of note, we detected population in seemingly healthy cmvnegative individuals, suggesting it was not uniquely a result of gata deficiency but associated with an inflammatory response and not related to adaptive nk cells generated in response to cmv infection. population , on the other hand, only appeared in our symptomatic gata -deficient patient. we additionally performed bulk gene expression analyses from an unrelated gata -deficient patient that confirmed the altered expression of genes associated with both novel cell populations. current efforts are focused on better defining the functional response of nk cells in these patients and confirming the identification of our novel populations by mass cytometry (cytof). together, our data define the heterogeneity and complexity of nk cells in gata deficient and healthy individuals. perforations have been reported with tocilizumab, a monoclonal antibody of the interleukin (il- ) receptor, suggesting that il- signaling plays a role in intestinal wall integrity. as il- signals through stat , we sought to investigate the potential association between lof stat and intestinal perforations, as well as the incidence and outcome in our patient cohort. methods: we performed a retrospective chart review of patients with lof stat (n= ) followed at our institution, looking for those with non-malignancy associated spontaneous gastrointestinal perforations. the demographic information, stat mutation, comorbidities at the time of perforation, clinical presentation, management, and clinical outcomes were compiled results: ten lof stat patients were identified as having documented intestinal perforations, an approximate rate of %. one perforation was the initial presentation of diffuse large b cell lymphoma (dlbcl) of the duodenum and liver, and was excluded from the rest of the analysis. the other nine perforations occurred between to years old (mean: ), and % were female. stat mutations were localized to the dna binding domain (n= ) and the sh domain (n= ). two of the perforations occurred while inpatient for lung infection. another occurred while recovering from pneumonia at home. two perforations were associated with the initial diagnosis of diverticulitis (at age and ). one perforation occurred in the terminal ileum, one in the cecum, one in the transverse colon, and six in the sigmoid. five patients underwent primary closure of the bowel. four patients required a temporary ostomy, with subsequent successful ostomy reversal. only one patient has since died of pulmonary hemorrhage, the other patients are alive with a mean of years post perforation follow-up, with no recurrence of perforation. one patient with prior sigmoid resection required ileal resection post perforation due to as massive intestinal bleed. conclusion: spontaneous gastrointestinal perforations occurred in our lof stat cohort at a rate of approximately %. one case was associated with malignant infiltration of the gastrointestinal tract and two cases were associated with diverticulitis both known risk factors for perforation. although the pathogenesis of the perforations in lof stat remains unclear, the connective tissue phenotype likely contributes as well as the association with diminished il- signaling, as has been demonstrated with the perforations and tocilizumab. abstract/case report text background granulomatous and lymphocytic interstitial lung disease (glild) is a life-threatening complication that occurs in patients with common variable immunodeficiency (cvid) and monogenic cvid-like disorders, but the optimal treatment is unknown. objective to determine if the use rituximab and azathioprine (rtx-aza) or rituximab and mycophenolate mofetil (rtx-mmf) would improve the radiographic abnormalities as determined by high-resolution computed tomography (hrct) of the chest and/or pulmonary function tests (pfts) in patients with cvid and glild. methods this is a retrospective study of patients seen from july to december with cvid and glild who completed immunosuppressive therapy (rtx ( mg/m ) for weeks, repeated at -month intervals for or total courses, and aza ( . - . mg/kg/day) or mmf ( mg- mg-bid) for months). complete pfts and hrct scans were performed prior to therapy, at the conclusion of therapy, and periodically thereafter. hrct scans were blinded, randomized, and scored independently (in pairs) by two radiologists. all patients underwent whole exome sequencing (wes). number (percentage) and median (interquartile range) were reported for categorical and continuous variables, respectively. differences between pre-and post-treatment and between relapse and post-relapse hrct scores and pft parameters were analyzed with wilcoxon signed ranks test. kaplan-meier survival curves were also done. unadjusted one-sided p-values < . were considered statistically significant. results the glild cohort (n= ) had a : female predominance, and age at glild diagnosis was ( - ) years (table ) . autoimmunity was present in the majority of patients, with thrombocytopenia ( ( %)) the most common manifestation. enteropathy ( ( %)), inflammatory bowel disease ( ( %)), and nodular regenerative hyperplasia of the liver ( ( %)) were also present. splenomegaly ( ( %)) was present in the majority, but polyarthritis ( ( %)) was notably absent. twenty ( %) patients had been previously treated with systemic steroids. hrct scores substantially improved between pre-and posttreatment for rtx-mmf (p= . ) and rtx-aza (p < . , figure ). fev (p= . ), fvc (p= . ), and tlc (p= . ) also improved, but dlco (p= . ) was unchanged (figures and ). excluding two ( %) patients who died . and years after therapy of respiratory failure ( ( %)) and septicemia ( ( %)) respectively, / ( %) patients relapsed . ( . - . ) years following therapy with an estimated % relapse rate after years ( figure ). as of december , of patients that relapsed showed improvement in hrct scores (p= . ), and the remaining patients are still undergoing retreatment ( figure ). four ( %) pneumonias occurred during immunosuppressive therapy, all with severe restrictive lung disease . eight ( %) patients had a damaging mutation in a gene known to predispose (tnfrsf b, n= ( %)) or cause a cvid-like primary immunodeficiency (ctla : ( %); kmtd : ( %); birc : ( %)). immunosuppressive treatment improved the hrct scores regardless of the absence (p < . ) or presence of a damaging mutation (p= . ) ( figure ). conclusion combination chemotherapy appeared to be effective in improving the radiographic abnormalities and pulmonary function of patients with cvid and glild. a majority of patients had sustained remissions, regardless of the presence or absence of a monogenic disorder. iqr=interquartile range, cvid=common variable immunodeficiency, glild=granulomatous and lymphocytic interstitial lung disease, vats=video-assisted thoracoscopic surgery, tbx=transbronchial biopsy, ms=mediastinoscopy excluding b cell malignancy, pft=pulmonary function test, h/o=history of, dz=disease, nrh=nodular regenerative hyperplasia, ibd=inflammatory bowel disease table . baseline patient characteristics since its first description the number of cases has increased progressively [ ] . although described as a predominant antibody deficiency [ ] , various complex phenotypes have been associated with mutations in this gene [ ] . case description. female patient with no remarkable history until years old, when she suffers from a persistent fever associated with purulent abscesses in venipuncture areas and hyperleukocytosis with neutrophilia, so she was treated for about months in hospitals in the city of barranquilla before she was referred to our institution. the patient's clinical picture consisted of persistent fever unresponsive to broad-spectrum antibiotic treatments, skin abscesses, left subphrenic abscess and toes osteomyelitis. the microbiological studies documented a bacteremia by acinetobacter baumannii and isolation in bone marrow of candida parapsilosis. during her care stay in barranquilla, she was approached as a chronic granulomatous disease versus job's syndrome, she received two doses of immunoglobulin with partial control of symptoms. due to the recurrence o f fever, abs ces ses and hyperleukocytosis, they decided to refer to our institution for further studies. upon admission to our institution, the patient presented nutritional compromise, with spontaneous resolution of fever but persistence of high acute phase reactants, with significant improvement of leukocytosis. all the cutaneous lesions she presented were debrided at the site of remission. immunoglobulin levels, lymphocyte populations and dyhidrorhodamine test were normal. she remained with no weight gain, constipation, abdominal distension and hepatic involvement with elevated liver enzymes and prolonged coagulation times. new bone compromise was documented. inflammatory bowel disease, neoplastic or chronic infectious disease involvement was ruled out. during the stay in our institution no microbiological isolation was documented. skin, colon and bone tissue biopsies were performed and extra-institutionally performed liver biopsy were examined, showing as a single common finding leukocytoclastic vasculitis in all tissues. given the heterogeneous nature of the condition, the diagnostic possibility of an immune dysregulation disorder was considered and a therapeutic trial with nsaids and prednisolone at mg/kg/day was started, as well as genetic studies by exome sequencing. the exome results documented a novel mutation in the pik cd gene [c. t> a (p.phe tyr)] as probably pathogenic. the patient has presented a clinical improvement and a significant decrease in inflammation markers. at the moment, we are waiting for the performance of functional tests to define the definitive therapy for this patient. conclusions. this case description highlights the diagnostic difficulties that face in developing countries, where the nonavailability of functional testing has implications on the diagnosis opportunity and establishment of optimal therapeutic for patients with complex diseases such as primary immune regulatory disorders abstract/case report text background: autoinflammatory syndromes, a wide family of diseases, defined as attacks of inflammation that are unprovoked (or triggered by a minor event) and are primarily related to dysregulation of the innate immune system. periodic/recurrent fever syndromes were the former name of these diseases. however, only in two conditions: cyclic neutropenia (cn) and periodic fever, aphthous stomatitis, pharyngitis, and adenitis (pfapa) are febrile episodes truly periodic. for pfapa, although diagnostic criteria differ and there is no consensus research definition, patients are usually not difficult to recognize based on clinical course and presentation . high index of suspicion and understanding the parental experiences and descriptions of febrile episodes is imperative in facilitating early recognition and timely diagnosis. aims: to standardize and summarized the clinical presentation of pfapa, based on parental descriptions and providers observation of febrile episodes. methods: utilizing a query for the icd- diagnosis code m . ( + ) we identified a cohort of children diagnosed and managed for periodic fever, excluding those with monogenetic mutation (e.g. blau, majeed) and those with chronic illness. we reviewed the charts for documented parental report and provider observation of febrile episodes. standardized signs and symptoms were recorded for each patient [ table ]. results: a cohort of children, boys ( %) and girls ( %) with documented, cyclic episodes of fever > , was identified. the average age at diagnosis was . +/- . years. classic symptoms were reported or observed in % of patients ( ). more than half ( %, patients) had documentations of other symptoms, usually reported by parents to occur sporadically during some fever episodes. decreased oral intake and general "ill appearance" was reported by parents in % of patients. when reporting the time intervals, parents usually reported similar length for each episode, typically between - days, and regular interludes, typically between - weeks. the findings are summarized in table . discussion: the findings presented here are in concordance with previously published data describing pfapa as a syndrome affecting young, generally healthy children with identical episodes of fever lasting for a few days, recur with regularity. our data support the approach that parental observation is fundamental in identifying the unique pattern of illnesses. engaging the parents with directed interview is crucial to establish this clinical diagnosis in a timely fashion, prevent misdiagnoses of future febrile episodes as presumptive infections, and avert unnecessary antibiotics courses. this cohort adds the observation that up to % of patients who display this identifiable pattern of illnesses, do not present with aphthous stomatitis, pharyngitis, or adenitis. these classic symptoms although common, are not the rule. the cyclic chronicity of febrile episodes associated with general ill appearance (but not lethargy), and decreased po, in an otherwise healthy child is the clinical gold-standard of this condition. abstract/case report text heterozygous mutations in nfkb are frequently identified among immunodeficient patients with highly variable clinical symptoms. in a world-wide collaborative effort, we characterized the clinical and cellular phenotype and the management of of these patients harboring distinct nfkb variants. nfkb encodes the transcription factor precursor p which is processed to p (canonical pathway). known pathogenic variants cause p haploinsufficiency (due to protein decay) or p -skipping (with expression of p -like forms). most variants however are single amino acid changes with yet unknown effects. all sequence changes were assessed in silico for their probability of pathogenicity including variants which were additionally tested in vitro. these analyses include the sub-cellular protein localization (microscopy), protein expression, stability and processing (western blotting), transcription factor activity (reporter assay) and dna-binding ( figure ); the associated unadjusted odds ratio (or) was not significant, suggesting igrt had restored cases to a similar baseline infection risk as the controls. in a multivariate conditional logistic regression model adjusting for the significantly higher occurrence of risk factors in cases compared with controls in the preindex period, cases were associated with a % lower adjusted odds of major/severe infections in the post-index period versus controls (or= . ; p= . ). conclusions: patients who required treatment with igrt (privigen®/ hizentra®) had previously experienced more major/severe bacterial infections than those not needing treatment with igrt. however, igrt was associated with a reduction in the risk-adjusted odds of major/severe bacterial infections compared with non-igrt treated sid patients with haematological malignancies. abstract/case report text introduction: real-world data are lacking as far as identifying patients with secondary immunodeficiency (sid)/hypogammaglobulinemia who may benefit most from interventions to protect them from potentially fatal infections. this study aimed to identify risk factors for major/severe infections in patients with sid with underlying haematological malignancies. methods: a retrospective database analysis was conducted using the iqvia real-world data adjudicated claims -us database (study period: january -september ). inclusion criteria were adults newly diagnosed with sid (first diagnosis termed the index date), with ≥ months continuous health plan enrolment pre-index (baseline period) and a minimum of months' data post-index (mean: days), with chronic lymphocytic leukaemia, multiple myeloma and/or non-hodgkin's lymphoma and without claims for any ig therapy in the -month baseline period. patient characteristics in the -month baseline period were assessed. over the post-index period, antibiotic/antiviral use and frequency of infections were assessed. the frequency of major/severe infections was determined using diagnosis codes for bacterial, viral, fungal, parasitic, other or unspecified causal pathogen infections. major/severe infections were defined as those requiring inpatient hospitalisation with an infection diagnosis code and/or use of intravenous (iv) antibiotics or iv antivirals in an outpatient setting. a multivariate cox proportional hazards (ph) model evaluated baseline patient characteristics associated with risk of major/severe infections post-index. results: a total of , patients met the inclusion criteria. the mean age of patients was years and . % were male. in the -month baseline period: . % of patients received cancer treatments and . % of patients received antibiotics ( . % iv antibiotics). a total of . % of patients experienced any infection, . % experienced ≥ infections and . % experienced major/ severe infections. the mean number of infections over the baseline months was . for any infection (at the unique diagnosis code level) and . for major/severe infections (unique hospitalisations with any infection diagnosis code and/or unique days with an outpatient iv antibiotic or iv antiviral). in the post-sid diagnosis period, . % of patients had major/severe infections; of the major/ severe infections, . % were identified as bacterial, . % were viral, . % were fungal, while . % did not have a causal pathogen specified. a total of . % of patients experienced one severe/ major infection and . % experienced ≥ severe/major infections ( figure ). the mean annualised number of major/severe infections post-index was . . receiver operating characteristic (roc) curve analysis to optimise sensitivity versus false positives in identifying those at risk of major/severe infections post-index identified a cutoff point of three bacterial infections in the baseline pre-index period as a potential optimal trigger to consider treatment to avoid major/severe infections post-index ( figure ). the multivariate cox ph analysis suggested that hospitalisations, infections (≥ ), or antibiotic use in the -months pre-index (prior to sid diagnosis) were predictive of major/severe infections post-index (post-sid diagnosis) (all p < . ). conclusion: infections are common in patients with haematological malignancies and sid. key baseline predictors for major/severe infections in patients with an sid diagnosis were a history of infections, hospitalisations or antibiotic use. unfortunately, ms/ms detection is limited by the extremely low (e.g., pmol/l) protein concentrations in blood cells. peptide immunoaffinity enrichment coupled to selected reaction monitoring (immuno-srm) is a robust method for quantification of low abundance proteins in complex matrices, including dried blood spots (dbs). in a study of patients, immuno-srm reliably identified wiskott-aldrich syndrome (was) and x-linked agammaglobulinemia (xla) patients using direct quantification of proteins responsible for disease (front. immunol., ). we further expanded our approach for x-linked chronic granulomatous disease (x-cgd), ada and dock deficiency. marker proteins representing platelets, nk cells, and t-cells have also been analyzed to provide additional information about disease processes. these results demonstrate the utilization of immuno-srm as a sensitive platform for multiplexed signature peptide quantification and its potential for pidd newborn screening and clinical diagnosis from dbs. methods: candidate peptides were selected based on ms/ms sensitivity and uniqueness in the proteome. anti-peptide monoclonal antibodies (mabs) were then generated for peptide enrichment from dbs. blood from normal controls, xla, was, xl-cgd, dock and ada deficiency patients was collected after consent on filter paper, dried, and stored at - °c. proteins were extracted from dbs, digested with trypsin, and enriched using mabs bound to magnetic beads. the enriched peptides were then eluted and analyzed with a waters xevo tq-xs. results: a multiplexed immuno-srm panel has been generated for screening eight signature peptides representing five pidd-specific and three cell-type specific proteins from dbs. limits of detection and quantification were femtomoles of peptide, the assay showed a broad linear range, and intra-assay and inter-assay coefficients of variation were < %. in samples from xla, was, xl-cgd, dock and ada deficiency patients, signature peptides are significantly reduced relative to normal controls and patient identification had excellent agreement with clinical and molecular diagnosis. also included in the multiplex panel are cell specific markers for platelets (cd ), t-cells (cd ɛ), and nk cells (cd ). diagnostic cutoffs for each peptide concentration have been established. in was patients, cd levels were significantly reduced consistent with characteristic thrombocytopenia. immuno-srm also has the ability demonstrate the effects of pidd treatment. a was patient analyzed before and after bone marrow transplant showed normalized was protein and cd after treatment. two ada deficiency patients showed normal levels of ada enzyme after rbc transfusion. finally, a high-throughput (ht) immuno-srm method screens pidd-specific peptides in a . -minute runtime meeting high volume nbs workflow requirements. this ht method returned identical results to the standard immuno-srm pidd panel. conclusions: the data herein demonstrate the feasibility of using immuno-srm as a broad clinical diagnostic for identifying and studying pidd patients from easily collected and shipped dbs. significantly, ht immuno-srm workflows represent a promising potential option for nbs of pidds and other congenital disorders. chief, laboratory of clinical immunology and microbiology/national institute of allergy and infectious diseases, niaid/national institutes of health, nih abstract/case report text we have previously used the artificial thymic organoid (ato) system, based on the d aggregation and culture of a delta-like canonical notch ligand -expressing stromal cell line (ms -dll ) with cd + cells, to study t cell differentiation from cd + cells obtained from patients carrying defects that are intrinsic to hematopoietic cells (rag - , ak , il rg) or that affect thymus development (digeorge syndrome). we now report results of in vitro t cell differentiation of cd + cells obtained from patients with either haploinsufficiency or dominant negative (dn) mutations of the ikzf gene. ikzf is an essential transcription factor expressed throughout hematopoiesis and involved in both lymphocyte and myeloid differentiation. heterozygous germline mutations in ikzf give rise to distinct clinical phenotypes, depending on the nature of the mutation. in particular patients with ikzf haploinsufficiency present with common variable immunodeficiency (cvid) associated with b cell immune deficiency, b-all susceptibility, and autoimmune manifestations. no clinical t cell defects are evident among these patients, except for elevated naive and central memory cd +cd + t cells. in contrast, patients carrying dn ikzf mutations present with combined immunodeficiency (cid) characterized by the presence of an increased proportion of naïve t cells, associated with defective generation of memory t cells, impaired t cell activation, signaling and proliferation, reduced t-helper (th) polarization, and susceptibility to pneumocystis pneumonia. different mouse models of ikzf mutations have been developed, however their phenotype does not fully match what reported in patients, and in some models indicates a more severe defect in t cell development. to address these controversies and to gain novel insights into the effects of distinct ikzf mutations on human t cell development, we used the ato system to analyze progression of t cell development from cd + cells obtained from one patient with ikzf haploinsufficiency and one patient with dn ikzf mutation. both patients showed a similar early block in t-cell differentiation a t p re -t c el l s ta g e. ho w ev e r, th e p a ti e nt wi t h i kz f haploinsufficiency showed a more pronounced leakiness, with a residual production of cd +tcrab+ cells, which could account for the milder t-cell phenotype presented in this type of patients. interestingly, the dn patient presented an increased accumulation of cd -cd b-cd aa+ cells. these results show an unexpected role for ikzf in humans in early stages of t-cell differentiation and indicate ikzf as a necessary factor for the induction of cd b expression in t cells. abstract/case report text background: pediatric acute liver failure without an identifiable cause (indeterminate palf/ipalf) is associated with increased rates of liver transplant and mortality. aplastic anemia (aa) may develop weeks after the diagnosis. the immunologic mechanisms that contribute to disease pathogenesis have not been clearly elucidated. we report detailed immunophenotyping of a patient with ipalf/aa. case: a previously-healthy -year-old male was admitted for acute hepatitis presenting with jaundice and hepatosplenomegaly. evaluation for infectious, toxic, metabolic, autoimmune, and rheumatologic disorders was negative. he was pan-lymphopenic (cd +alc cells/μl) with an inverted cd :cd ratio of . on admission. liver biopsy showed severe portal, interface, and lobular inflammation characterized by activated sinusoidal macrophages and perforinexpressing cd +t-cells. compared to a healthy control, the percentage and number of peripheral blood cd +t-cells expressing perforin ( %v. %, v. cells/μl) and granzyme-a/b ( %v. %, v. cells/μl) was also increased, while percentages of perforin+ ( %) and granzyme-a/b+( %) nk cells were normal. bone marrow (bm) showed % cellularity with rare hemophagocytosis. serum cytokine analysis demonstrated il- pg/ml, il- -binding-protein pg/ml, cxcl pg/ml, and sil- rα u/ml, consistent with smoldering hemophagocytic lymphohistiocytosis (hlh), but he did not meet hlh diagnostic criteria. genetic sequencing did not identify pathogenic variants in genes associated with primary immunodeficiencies. he was diagnosed with ipalf and treated with three doses of anakinra and two weeks of ruxolitinib, followed by prednisone - mg/kg/day and intravenous immunoglobulin g/kg/month. immunophenotyping performed after two months of therapy showed persistent inversion of the cd :cd ratio with small expansions of cd +cd -cd -cells and tcr··+t-cells. in the cd +t-cell subset, there was a substantial paucity of naïve cells, with effector memory t cells (tem) being more abundant than central memory t cells (tcm). in the cd +t-cell subset, the majority of cd ro+cells were tem with no detectable tcm, and % of all cd +t-cells were cd +temra. in both cd + and cd +t-cell subsets, activated (hla-dr+) and senescent (cd +) subpopulations were increased, and the majority of cells expressed the exhaustion marker pd- . the hepatic inflammatory infiltrate similarly reflected repetitive antigenic stimulation, with expansion of cd +cd +t-cells. quantitative immunoglobulins and total memory b-cells and plasmablasts (cd +cd +) were normal for age. however, there were no circulating iga-memory b-cells and a reduced number of iggswitched memory b-cells (table ) . given the severity of his phenotype and bm hypocellularity ( %), allogeneic hct was performed using a matched-related-donor ( / ) with conditioning of flu+cy+alemtuzumab. at d+ , he shows improved liver function but persistent pancytopenia, with transfusion-dependence for platelets. discussion: to our knowledge, this is the first description of detailed immunophenotyping in blood from a patient with ipalf/ aa. other studies have identified distinguishing hepatic infiltrates and cytokine/chemokine profiles that suggest excessive activation of cytotoxic t-lymphocytes and macrophages contribute to disease pathogenesis (alonso et al, ). our preliminary data supports this hypothesis and expands the spectrum of immune dysregulation in the t and b cell compartments, proposing a primary immune etiology. immune dysregulation may be concordant with hyperinflammation and cytokine storm, the latter offering potential therapeutic targets. early diagnosis and treatment of immune dysregulation may prevent development of aa. background: x-linked agammaglobulinemia (xla) is one of the first inborn errors of immunity identified, with thousands of patients described to date. infections originally dominated the clinical phenotype, but early diagnosis and immunoglobulin replacement allowed for long term survival as well as recognition of late-onset complications. nodular regenerative hyperplasia (nrh) of the liver is a silent cause of non-cirrhotic portal hypertension. nrh underlying pathophysiology remains blurry and the disease has no specific treatment. nrh has been increasingly reported in primary immunodeficiency but data in xla are very limited. objectives: to assess and characterize nrh in patients with xla. methods: we retrospectively reviewed the medical records of all xla patients referred to the nih between and . hepatology evaluation and liver biopsies were performed when clinically indicated. patients were stratified into nrh+ or nrhgroups, according to their nrh biopsy status (patients with no liver biopsies were classified as unknown). laboratory values are presented as medians. fisher's exact test and mann-whitney test were used to compare categorical and continuous variables, respectively. results: twenty-one xla patient records were reviewed, with a median age at start of follow-up (f/u) of y and a median duration of f/u of years. eight patients underwent at least one liver biopsy of whom ( % of nih xla cohort) were nrh+. the median age at nrh diagnosis was y ( - ). among patients who had liver biopsies, alanine aminotransferase (alt) levels were mildly elevated in all, while alkaline phosphatase (alp) levels were only increased in nrh+ patients (p= . ). both nrh+ and nrhgroups had similar aspartate aminotransferase (ast) levels at baseline but higher values were observed at the end of f/u in the nrh+ group ( vs. u/l, p= . ). persistently low platelet count ( < k/μl for more than months), mildly to highly elevated hepatic venous pressure gradient (hvpg) and either hepatomegaly and/ or splenomegaly were present in all nrh+ patients. in opposition, neither persistently low platelet counts, nor hepato-or splenomegaly were present in the two nrh-patients evaluated. hvpg was normal in the only nrh-patient tested. all-cause mortality was higher among nrh+ patients ( / , %) than in the rest of the cohort ( / , % among nrh-and unknown patients, p= . ). conclusions: based on our retrospective analysis, nrh appears as an underreported, frequent and severe late-onset complication in xla, which is highly associated with increased mortality. persistent thrombocytopenia, elevated alp, elevated hvpg, hepato-and/or splenomegaly were common in liver biopsyproven xla/nrh+ patients and distinguish them from xla/ nrh-patients. based on nrh prevalence, severity, lack of specific treatment and poor outcome in xla, immune-reconstitution (rather than igg replacement and infectious prophylaxis) should be considered early in this population in order to prevent fatal long term complications. abstract/case report text introduction: barth syndrome (bths) is an x-linked recessive disorder caused by a mutation in the tafazzin (taz) gene resulting in an inborn error of cardiolipin phospholipid metabolism (an important mitochondrial inner membrane lipid). it is commonly characterized by intermittent neutropenia and cardiac and skeletal myopathies. we present a case of bths with associated lymphopenia and hypogammaglobulinemia, which has not been previously described in the literature. case report: a two-month old male, born full term with normal newborn screening, was first admitted for rsv bronchiolitis. at this time, patient underwent an echocardiogram given his older brother with hydrops had died hours after birth and on autopsy was found to have dilated cardiomyopathy (dcm). patient was similarly noted to have dcm and thus had whole exome sequencing done that showed a hemizygous mutation in the taz gene (c. g>a). this novel variant resulted in early termination of the protein (p.trp ter) with concern for loss of function. in regard to patient's first year of life, he had frequent uri symptoms, episodes of acute otitis media requiring tympanostomy tubes, but no documented pneumonias or other serious bacterial infections. patient also had gross developmental delay, particularly motor, and feeding difficulties with persistent failure to thrive requiring g tube placement. his absolute neutrophil count ranged from - cells/mm in the first year. at age months, patient was found to be in acute decompensated heart failure with concern for myocarditis (ck , u/l, troponin i . ng/ml) as well as acute hypoxic respiratory failure with respiratory cultures growing pseudomonas. he was incidentally found to have an igg level of mg/dl (normal for age - ) and treated empirically with ivig. when seen by immunology, further workup showed persistent b cell lymphopenia (absolute cd of - /mm ). he also had a low initial nk cell count ( - /mm , later normal) with normal cd and cd t cell counts. tetanus and hib titers could not be assessed as he had recently received ivig. his igg trended up to mg/dl a few days after initial ivig and then subsequently dropped to mg/ dl, with a level of mg/dl two weeks following initial dose. workup for gastrointestinal or renal losses of immunoglobulin were negative. he also shortly after developed enterobacter bacteremia. his igg levels at this time continue to remain around mg/dl. he subsequently required a heart transplant at age months for his dcm. after transplant, he continued to improve from a cardiac standpoint, but his lymphopenia persisted and each time he was weaned off ivig, his hypogammaglobulinemia persisted at - mg/dl thus requiring additional ivig replacement over the course of the next months. the remainder of immunoglobulins were normal initially, but the igm slowly dropped over time to - . mg/dl. patient was started on weekly subcutaneous immunoglobulin replacement at months, doing well clinically at age -month follow up. conclusion: here we present a patient with bths, with a novel variant, who had b-cell lymphopenia as part of his presentation with persistent hypogammaglobulinemia requiring ivig replacement. year fellow/ucla associate professor/division of allergy, immunology, and rheumatology, university of california los angeles chief of pediatric allergy and immunology/harbor-ucla chief, laboratory of clinical immunology and microbiology/national institute of allergy and infectious diseases, niaid/national institutes of health, nih biologist/laboratory of clinical immunology and microbiology, division of intramural research, national institute of allergy and infectious diseases, national institutes of health project scientist/ucla abstract/case report text a -year-old female presented for combined immunodeficiency. at years of age she was diagnosed with rag hypomorphism and started on ivig. as a child, she was hospitalized for pneumonias and cryptococcal meningitis. she suffered sinusitis, hepatitis, tooth abscess, cmv and herpes stomatitis. later, she experienced recurrent cutaneous abscesses, utis, vaginal yeast infections, and hidradenitis. she twice hospitalized recently for pneumonias and diagnosed with mycobacterium abscessus on bronchoscopy. she suffers onychomycosis, osteomyelitis and oral and esophageal candidiasis with odynophagia. on exam, she had white plaques on tongue and buccal mucosa. she had hyperpigmented plaques on forehead and cheeks and thickened nails. immune evaluation was significant for lymphopenia with alc and thrombocytopenia with platelets k. b cells were nearly absent ( absolute count) and nk cells were low at absolute count. ige was absent, igm mg/dl, iga mg/dl and igg mg/dl (on replacement). her total cd + count was , cd + t cells were low at %, but cd + cells normal at %. the cd + t cells were mostly memory phenotype, which probably reflects lymphopenia-induced proliferation of a small number of clones. her cd + t cells also had an elevated amount of memory cells for age, but still had presence of naive cd + t cells. as expected with perpetual lymphopeniainduced proliferation, there was evidence of terminal memory (temra) in the cd + lineage. proliferative responses of t cells were modest. cd + t cells did respond to pokeweed, but less to pha and cona. there were no antigen specific responses. trecs were normal. esr was mildly elevated at . of note, her liver enzymes were elevated with alkaline phosphatase and ast , presumably secondary to prolonged fluconazole use. w es r e v e a l e d a k n o w n p a t h o g e n i c v ar i a n t i n s tat (nm_ . : c. c>g (p.n k)) as well as a heterozygous variant in rag p.m t. the stat mutation is de novo and was previously published as a gain of function mutation. however, when we performed validation studies to evaluate cd + cells with stimulation to ifna, the patient had decreased pstat as compared with control. va . analysis was performed to evaluate rag defect and showed % of t cells with va . expression confirming that the rag defect is not clinically significant. she developed severe thrombocytopenia refractory to platelet transfusions and ivig. she was started on ruxolitinib which improved platelet counts. however, she presented with shortness of breath, persistent tachycardia and was found to have cmv carditis and hepatitis significant for echocardiogram with ef %. cmv pcr is improving with last check iu/ml after month of therapy with ganciclovir. we now are looking for evidence of socs to explain the decreased stat phosphorylation. genetic testing is critical when evaluating a patient with immunodeficiency. our patient demonstrates that genetic mutations cannot be taken at face value and should be evaluated and validated fully to optimize patient care. fellow/university at buffalo / oishei children's hospital abstract/case report text opportunistic infections (oi) are commonly seen in patients undergoing hematopoietic cell transplantation (hct). different strategies for antimicrobial prophylaxis are often employed in the transplant setting to reduce the likelihood of encountering infection. the predisposing risks for infections include the expected neutropenia and lymphopenia following conditioning, prolonged defects in cell-mediated and humoral immunity during the engraftment period, and iatrogenic immunosuppression by medications for graft versus host disease (gvhd). we report the case of a -year-old male with acute lymphoblastic leukemia, which relapsed to chronic myelogenous leukemic blast crisis, and failed a subsequent allogeneic hct with central nervous system relapse. he was subjected to a second allogeneic hct. his immediate post-second transplant course was complicated with skin and gut gvhd, and infection and/or reactivation of coronavirus, respiratory adenovirus, epstein-barr virus, and human herpesvirus . while the herpesviral infections were controlled with antivirals and rituximab, adenovirus c infection proceeded to involve the gastrointestinal tract, and proved persistent over several months despite use of cidofovir. the patient's gvhd and transplant-associated thrombotic microangiopathy necessitated use of further immunosuppressants, including the complement protein c -binding eculizumab (an inhibitor of formation of the terminal c b- complex), ruxolitinib (a janus kinase [jak] / inhibitor) and low-dose interleukin- . h i s c l i n i c a l c o u r s e w a s f u r t h e r c o m p l i c a t e d b y stenotrophomonas maltophilia gut colonization and subsequent bacteremia, as well as multiple gram-positive bacteremia courses. at around day + , there was a life-threatening pericarditis with pericardial effusion and respiratory distress, associated with pneumocystis and stenotrophomonas being isolated from bronchoalveolar lavage. this occurred despite the patient being on pentamidine prophylaxis. the patient eventually recovered on trimethoprim/sulfamethoxazole therapy. we discuss the various risk factors potentially contributing to each oi in this illustrative case. in particular, complement and jak inhibitor therapy are fairly new drugs approved for other indications, whose off-label use in transplant patients is increasing. both have recently been associated with certain oi in the literature, as they are in this patient. abstract/case report text background: autoimmune lymphoproliferative syndrome (alps) is characterized by chronic nonmalignant lymphadenopathy, splenomegaly, hepatomegaly, cytopenias, and other autoimmune manifestations. typically, the biomarker profile of patients with alps includes elevated tcr αβ+ dnt cells, serum igg, serum b , serum il and soluble fas ligand (sfasl). hdl cholesterol can also be significantly low. alps is caused by lymphocyte accumulation due to defects in the fas-mediated apoptosis signaling pathway. these defects cause resistance to physiological apoptosis in lymphocyte populations that results in chronic lymphoproliferation. the molecular defect underlying most alps etiologies is attributed to heterozygous germline or somatic (limited to dnt cell subpopulation) pathogenic single nucleotide variants (snv) in fas. we describe copy number variants (cnvs) at the fas locus underlying alps in unrelated families. methods: through the centralized sequencing initiative at at the national institute of allergy and infectious diseases (niaid), patients undergo genomic workup to identify molecular defects contributing to clinical phenotypes of immune system disorders. all patients receive exome sequencing and a subset of patients also receive array-cgh analysis. patients and results: we performed exome sequencing on patients with a clinical diagnosis of alps. for patients with no molecular defect through exome, we performed cnv analysis. in this cohort, we identified three patients with a copy number variant involving the fas locus. all patients presented with splenomegaly and lymphadenopathy in childhood with ages of onset ranging from months to years old. all patients experienced anemia, autoimmune neutropenia, and thrombocytopenia. they had biomarker evidence showing elevated serum b levels, sfasl levels, and elevated αβ+dnt cell populations. they were found to have very low hdl cholesterol in early childhood ranging from - mg/dl ( - mg/dl). all patients had negative family histories for lymphoproliferative disorders and immunodeficiency. these patients had clinical presentations and biomarker profiles similar to alps patients with germline and somatic fas variants. patient : we detected a~ . mb copy number loss encompassing all of fas. parental studies were not performed. patient : we detected a~ . mb copy number loss encompassing all of fas. parental studies showed this to be maternally inherited. in addition, prior karyotype testing of the bone marrow showed the same deletion. patient : we detected a~ . mb copy number loss encompassing exons - of fas. parental studies were not performed. these results are consistent with the pathogenic nature of copy number variant losses involving fas. the mechanism of disease in these patients is consistent with haploinsufficiency. in family , the mother harboring the fas deletion is unaffected. this is consistent with prior observation of reduced penetrance within a family in alps. conclusion: these three cases harbored causative deletions in fas in the presence of biomarkers indicative of alps and negative results for germline and somatic genetic variant testing. these patients demonstrate that copy number variant analysis should be pursued if there is robust clinical and biomarker evidence of alps as it can lead to a molecular diagnosis and appropriate treatment when exome or next generation panel based fas sequencing is inconclusive. abstract/case report text rationale: the thymus is essential for the development of tcells. patients with thymoma have decreased aire expression and have an abnormal thymic microenvironment where the negative selection of t-cells is compromised, resulting in a broad spectrum of autoimmune-mediated diseases. besides myasthenia gravis, which is found in to % of patients with thymoma, other autoimmune diseases have been reported including erythroblastopenia, systemic lupus erythematosus, inflammatory myopathies, thyroid disorders and good's syndrome. recent studies have described additional autoimmune conditions such as pneumonitis in thymoma patients. we identified a patient who developed chronic cough post-thymectomy and was found to have lymphocytic pneumonitis with associated autoantibodies against lung antigen kcnrg and lung immunopathology consistent with apeced pneumonitis, which implies a common pathogenic mechanism between these conditions. methods: we describe a patient with thymoma who developed autoimmune pneumonitis associated with kcnrg autoantibodies and a characteristic pattern of immunopathology recently described in patients with monogenic disorder caused by primary aire deficiency (apeced) and secondary aire deficiencies (thymoma, rag deficiency). results: patient is a -year-old male with no significant past medical history who was in good state of health until age when he was diagnosed with and received treatment for guttate psoriasis (resolved with uv therapy) and alopecia areata. at age , he developed severe abdominal pain and weight loss. he had an abdominal ct performed that showed chronic pancreatitis and thymoma. one month later, the patient underwent thymectomy and subsequently, underwent ercp and pancreas biopsy, revealing atrophic pancreatitis with negative staining for lgg and lgg . at that time, he was started on pancreatic enzymes with improvement of abdominal symptoms. following thymectomy, he developed persistent dry cough and recurrent symptoms of sinusitis which did not respond to several courses of oral antibiotics to treat his positive culture for pseudomonas. he had a negative work up for vocal cord dysfunction and cystic fibrosis, and negative autoantibodies against ifn-gamma, il- a, and gm-csf. for work up of chronic cough, the patient underwent ct imaging of the chest which revealed diffuse peri-bronchial thickening, mucus plugging, and tree-in-bud nodularity through most of his lungs. he underwent bronchoscopy with bal which revealed n o r m a l b r o n c h i a l m u c o s a a n d a i r w a y n e u t r o p h i l i a . endobronchial biopsies showed basement membrane thickening and dramatic lymphocyte infiltration in intraepithelial and submucosal areas. his bal cultures revealed mycobacterium intracellulare/chimaera. patient was also tested for autoantibodies against lung-specific bactericidal/permeabilityincreasing fold-containing b (bpifb ) and the potassium channel regulator kcnrg that have been associated with the development of pneumonitis in patient with apeced, thymoma and rag deficiency, and was found to have kcnrg-targeted autoantibodies. conclusions: thymoma is a disease associated with secondary aire deficiency. this case illustrates common clinical, radiographic, histological, and autoantibody features in thymomaassociated and apeced-associated pneumonitis, indicating that disorders with primary and secondary aire deficiencies may have common pathogenetic mechanisms. bpifb and kcnrg should be included in the autoantibody profile testing of patients with thymoma and lung disease. immune suppression and antimycobacterial antibiotic treatment are planned. abstract/case report text introduction/background: activated phosphoinositide -kinase δ (pi kδ) syndrome (apds) is a primary immunodeficiency caused by a gain-of-function mutation in the pik cd gene that encodes the p δ catalytic subunit of pi kδ. it is characterized by recurrent respiratory tract infections, lymphoproliferation, nodular mucosal lymphoid hyperplasia, enteropathy, ebv and/or cmv infection, reduced t cell function and high levels of igm. there is not evidence of this disease in peruvian patients. methods: a case series of two pediatric patients with apds. results: the first patient is a girl of non-consanguineous parents. family history shows four maternal uncles died at pediatric ages with unknown diagnosis. at the age of , she presented lymphadenopathy and fever being treated as cat scratch disease without improvement of symptoms. months later, she was hospitalized due to anemia, mild hepatosplenomegaly, ascites and chronic diarrhea and diagnosed with gastrointestinal tuberculosis (tb). a hepatic biopsy only showed reactive hepatitis. however, the patient did not improve her symptoms despite anti tb treatment. years later, she was hospitalized for lymphadenopathy, pancytopenia, chronic diarrhea, ascites and severe hepatosplenomegaly. cmv igg was positive and lymph node biopsy revealed paracortical and follicular lymphoid hyperplasia due to ebv infection without neoplastic proliferation. low cd + t and cd + b cells and high igg levels were found (table ) . at this time, it was suggested the diagnosis of apds which was confirmed by next generation sequencing (ngs) identifying a heterozygous mutation in the pik cd gene (c. g>a, p.glu lys). she was treated with sirolimus and ivig for years. the symptoms persisted despite treatment and died at the age of . the second patient is a -year-old girl also of non-consanguineous parents. family history includes eczema (father) and colorectal cancer (mother). she has had recurrent respiratory infections, chronic diarrhea and poor weight gain since months old receiving symptomatic treatment only. at the age of , she was hospitalized for persistent pneumonia ( p s e u d o m o n a s p o s i t i v e ) , l y m p h a d e n o p a t h y a n d m i l d hepatosplenomegaly. a ct scan showed bilateral bronchiectasis and the sweat chloride test was negative. based on this, a diagnosis of cystic fibrosis was made and treatment was started. however, a genetic study only showed heterozygous mutations in the cftr gene (g d and g x). year later, she presented a neck-located skin abscess. at the age of , she was hospitalized for complicated pneumonia, diarrhea, lymphadenopathy, ascites and severe hepatosplenomegaly. multiple polyps in the duodenum and colon with lymphoid hyperplasia were detected, ebv igm and igg were positive and a lymph node biopsy showed paracortical hyperplasia without neoplastic proliferation. cd + t cells and igm levels were increased (table ) . a diagnosis of apds was suspected and ivig was started. ngs showed the same mutation as the first patient (c. g>a, p.glu lys). conclusion: apds should be considered in patients with recurrent respiratory tract infections, lymphoproliferation, enteropathy and abnormal immunologic function without another explanation. ngs is a useful tool to identify these cases in low-income countries. acknowledgments: we thank drs. raif geha and janet chou, division of immunology, boston children's hospital, harvard medical school for the genetic diagnosis. background: granulomatous-lymphocytic interstitial lung disease (glild) is an increasingly recognized pulmonary complication associated with common variable immunodeficiency (cvid) but the natural history and long term prognosis remains poorly defined. imaging findings with computed tomography (ct) are heterogeneous and visual features do not consistently predict a patient's progression to fibrotic lung disease. computer-aided lung informatics for pathology evaluation and rating (caliper) provides an objective analysis of lung parenchymal texture and quantifies the extent of normal lung, along with abnormal features such as honeycombing, reticular/consolidative and groundglass opacity. this may be useful in cvid patients to monitor changes in character or extent of disease and may facilitate early intervention before the disease becomes more aggressive or advanced. case description: our patient is a -year-old non-smoking female with cvid who has been followed for her cvid and associated interstitial lung disease. for more than twenty years, she has had varying abnormalities found on chest ct and these appear consistent with glild. specifically, she has had variable regions of mixed consolidation, ill-defined nodularity and septal thickening. the changing morphology and distribution made assessment of overall severity and extent of fibrosis versus parenchymal infiltration inconsistent. for clinical decision support we used caliper to analyze the current ct ( ) and compared caliper results for previous ct data. caliper provided a comprehensive analysis of the extent and characteristics of parenchymal features, and objectively determined normal and abnormal regions, some of which were not visually apparent. the caliper color overlay was able to highlight subtle regions of ground-glass opacity in areas that visually were regarded as uninvolved lung and quantify the extent of the reticular densities/ consolidation over time. caliper does not differentiate reticulation from consolidation, does not detect nodularity or septal thickening, and ct imaging cannot distinguish inflammation from fibrosis. however, caliper has the power to quantitatively assess overall disease extent and demonstrate subtle abnormalities that would otherwise have been dismissed as normal, given relative sparing compared to other regions. caliper may also provide evidence for disease progression or therapeutic response that is not otherwise radiographically apparent. conclusion: caliper assessment may be a useful tool as an adjunct for a patient with glild to help quantify the extent and character of lung parenchymal involvement. this information may serve as an important guide for clinicians in the assessment of successful management and early intervention to prevent irreversible fibrosis. patients had a trial of fingolimod without any beneficial changes in immune status. both patients receive pneumocystis jirovecii pneumonia prophylaxis with sulfamethoxazole-trimethoprim. conclusions: these results indicate that s pl deficiency due to sgpl mutations is a syndromic primary immunodeficiency leading to profound lymphopenia and hypogammaglobulinemia. our data emphasize the importance of sphingolipid metabolism for an efficient immune response and the need for more studies to delineate the exact mechanisms on how this happens in humans. after d at °c there was a median - % (range - % to + %; p= . ) change in activity. after d - % (range - % to + ; p= . ), d - % (range - % to + %; p < . ), d - % (- % to + %; p < . ) and after d - % (- % to + % p < . ). a °c stability of d was determined from the median percentage reduction; total allowable error adjusted stability data indicated a °c stability of d. samples stored at - °c following repeat freeze thawing saw a freeze/thaw cycle dependent decrease in ch activity. after freeze/thaw cycle there was a median - % (range - % to + %; p= . ) change, cycles - % (range - % to + %; p= . ), cycles - % (range - % to + %; p < . ), cycles - % (range - % to - %; p < . ) and after cycles - % (range - % to - %; p < . ). allowable error adjusted stability data indicated a maximum of freeze/thaw cycles. conclusion: sample storage and handling can have a significant impact on functional complement assessments. room temperature storage should be avoided unless samples will be analysed on the day of collection, °c storage is tolerable providing that assessment is within d; freezing samples at - °c with limited freeze/thaw analysis would be optimal. however, further investigations into longer-term storage at - °c and - °c would be beneficial. conclusions: gi disease is common in cvid affecting % of patients in our cohort. gi+ cvid patients have a higher frequency of autoimmune manifestations than those without gi complaints. the odds of itp, hypothyroidism, and evans syndrome all showed significantly increased odds in the gi+ group. the results of our study may have implications for both gastroenterologist and immunologist. recurrent infections especially those of the sinopulmonary tract are often the trigger for cvid evaluation. autoimmune and gi symptoms however may be the initial presentations of cvid and overlooked until other more recognizable manifestations evolve. the combination of gi issues and autoimmunity especially thrombocytopenia, evans syndrome, and hypothyroidism should include cvid in the gi differential. for the immunologist, a cbc is standard in the work-up of cvid and may reveal autoimmune cytopenia. evaluation for autoimmune disease and in particular hypothyroidism is not. given our findings an initial immune work up specifically for thyroid disease may be indicated. is the transcriptional factor for many cytokines such as il- , responsible for t cell and neutrophil defense again fungal infection. stat mutation leads to defect of neutrophil proliferation and chemotaxis to inflammatory site as well as production of antimicrobial peptides by respiratory epithelial cells. the poor tissue repair in the cavitary lesions and bacterial superinfection in patient's lung created a culture dish for fungal growth and dissemination. traveling to the endemic area and patient's noncompliance to antifungal prophylactic treatment further increased the risk of histoplasmosis infection. pediatric immunologist/john hunter children's hospital abstract/case report text we present the case of a month old boy, the first child to his nonconsanguineous parents of european descent. he first presented at months of age with a cellulitis of his right fourth finger culture positive for staphylococcus aureus which responded to a prolonged course of flucloxacillin. at months he presented with norovirus positive gastroenteritis leading to a brief admission and slow resolution. the first of two severe episodes of oral stomatitis and respiratory distress occurred at months of age. hsv was isolated from the oral lesions and blood culture during that admission was positive for kingella kingae. no cardiac or bone involvement was identified. a more severe episode of oral stomatitis occurred two months later (age months) swab positive for an enterovirus (not typed). due to airway compromise and rapid deterioration he was admitted to the pediatric intensive care unit. again, kingella kingae was cultured from blood cultures with no obvious focal systemic source. the only notable clinical finding was rapid deterioration and, in retrospect, the absence of any significant recorded fever ( < oc). crp elevation was observed (max. mg/l) and neutropenia was found with each of the more severe infectious presentations but recovered in the interval. baseline immunological investigations were normal (lymphocyte subsets, naïve t cell populations, lymphocyte proliferation, serum immunoglobulins and vaccine responses). serial measurement of circulating neutrophils did not identify a cyclical pattern and they were morphologically normal. a panel of genes relevant to primary immunodeficiency (invitae©) revealed a homozygous mutation in irak ((c. c>t (p.gln *)) which leads to a premature stop codon. this is a known pathogenic mutation leading to disease and is most prevalent in the european population (allele frequency (gnomad) = . ). prophylaxis with sulfamethoxazole / trimethoprim and amoxicillin was commenced along with monthly ivig. he has been well since diagnosis with no further severe infectious presentations. functional testing is underway to assess in vitro host viral defence in our patient and potential novel mechanisms relevant to this rare innate immunodeficiency. case studies will be presented on the five cases of fmp that were diagnosed and treated in . potential exposures were identified in four out of five cases: gardening exposure in one case and vaping exposure in three cases. all five were male, age range - . four were gp deficient, and one was p -phox deficient. historically, the vast majority of cases of fmp could be traced to a significant gardening exposure such as lawn mowing or spreading mulch. this was the first year that we saw patients with no identifiable gardening exposure in the setting of significant vaping exposure. with vaping at epidemic levels, especially among teenagers and young adults, it is important to consider that a vaping history is potentially a risk factor for fmp and counseling regarding the potential risks of vaping should be included in infection risk modification for all patients with cgd. abstract/case report text background: granulocyte-macrophage colony-stimulating factor (gm-csf) plays a critical role in macrophage and dendritic cell maturation and host defense against fungus. autoantibodies to gm-csf are associated with susceptibility to cryptococcus and nocardia infections as well as pulmonary alveolar proteinosis (pap) in otherwise healthy individuals. we report a case of a -year-old previously healthy female who presented with cryptococcal meningitis and was found to have autoantibodies against gm-csf. case presentation: weeks prior to admission, our previously healthy -yearold taiwanese female developed a headache associated with tinnitus and visual changes. the headache worsened over the next few weeks and she developed photophobia, phonophobia, and severe nausea/vomiting. at presentation, her exam was notable for papilledema, bilateral cn vi palsy and right foot & left hand paresthesia. mri brain showed ring-enhancing lesions in the anterior frontal lobe, caudate head, and the inferior globus pallidus. she underwent a diagnostic and therapeutic lp. opening pressure was elevated at and csf studies were notable for low glucose, elevated protein, pleiocytosis ( % lymphocytes) and positive cryptococcal antigen. csf culture grew cryptococcus gattii. ct chest revealed a right upper lobe and a left lower lobe nodule. workup: cbc with diff was unremarkable. hiv was negative. lymphocyte subsets were unremarkable with only mildly decreased nk cells, normal immunoglobulin panel including ige, protective titers to tetanus, diphtheria, and ppsv . targeted genetic sequencing did not identify any known mutations in primary immunodeficiency. notably, anti-gmcsf autoantibodies were detected by elisa and were able to neutralize gm-csf phosphorylation of stat detected by flow cytometry. autoantibodies to ifn-γ were not detected. management: patient was initiated on a -week course of liposomal amphotericin b and flucytosine. her csf cultures were cleared of cryptococcus after days of treatment, but her hospital course was complicated by persistently symptomatic intracranial hypertension, worsening pleiocytosis, and elevated cytokine levels in the csf, all of which were consistent with post-infectious inflammatory syndrome (piirs). she received therapeutic lps - x/week until subsequent ventriculoperitoneal shunt placement. concurrently, methylprednisolone was administered for days with a gradual prednisone taper. these interventions led to improvements in her symptoms, including diplopia, and reduction in opening pressures and inflammatory markers in the csf. lifelong fluconazole prophylaxis was recommended. from a pulmonary standpoint, she remained asymptomatic without signs of pap and has had normal pulmonary function tests (normal dlco) and stable chest imaging. conclusion: in otherwise healthy hiv-negative patients presenting with extrapulmonary cryptococcus or nocardia infections, autoantibodies to gm-csf should be suspected and testing for functional autoantibodies to gm-csf (and ifn-γ) should be sent, as genetic testing will not pick up this disease entity. genetic testing should be considered to rule out gata deficiency and x-linked cd l deficiency. idiopathic cd lymphopenia can be ruled out with lymphocyte enumeration. immediate treatment of cryptococcosis is not necessarily different from patients without gm-csf autoantibodies. long-term prophylaxis (fluconazole if presenting with cryptococcus; trimethoprim-sulfamethoxazole if with nocardia) is likely warranted in addition to monitoring for the development of pap. recognizing piirs in patients with cryptococcal meningitis and management with corticosteroids are critical steps. abstract/case report text background: non-infectious complications cause most morbidity and mortality in common variable immunodeficiency (cvid). cvid with complications (cvidc) is defined by elevated t helper (th ) responses attributed to increased circulating microbial products resulting from mucosal iga deficiency. however, complications do not uniformly occur in those with iga deficiency. objective: we tested whether cvidc occurs preferentially in those with hyper-responsiveness to microbial stimuli, manifested by elevated nf-κb-driven cytokines and resultant th responses in cvid patients with increased circulating microbial products. methods: we applied unbiased high-throughput seromics and mass cytometry, cellular and molecular biology approaches, and clinical record review in a subject cvid cohort. results: cvidc was defined by increased nf-κb-driven cytokines that promote th immunity in blood in association with elevated soluble cd , a marker of circulating microbial products, and elevated tnf production by peripheral blood mononuclear cells stimulated with lipopolysaccharide. this cytokine upsurge was associated with mutation of full-length nfkb p gene product ( delt) but not mutations that also involved the nfkb p product involved in transactivation. cytokine elevation corresponded with increased cd +cd -monocytes expressing higher cd and hla-dr and more central and effector memory cd + t cells, t cell chemoattractants, and t cellpredominant tissue pathology. those with granulomatous or neutrophilpredominant, rather than t cell, pathology had the highest tnf. tnf antagonism improved neutrophilic gastritis in cvid with nfkb delt after t cell targeted therapy failed. conclusion: nf-κb dysfunction underlies th immunopathology and tnf-associated innate inflammation in cvidc. both forms of nf-κb immune dysregulation may divergently shape cvid immunopathology. staff clinician/laboratory of clinical immunology and microbiology, immunopathogenesis section, national institute of allergy and immunology, national institutes of health, abstract/case report text introduction: patients with autoantibodies to ifn-γ develop severe and progressive infections with intracellular pathogens, despite aggressive antimicrobial treatment. we describe the use of daratumumab (anti-cd , targeting plasma cells) in a patient with autoantibodies to ifn-γ and progressive disseminated mycobacterium avium infection. she had progressive disease despite treatment with multi-drug antimycobacterials rituximab, and bortezomib. methods: clinical symptoms, total cd /cd , anti-ifn-γ autoantibody titers, and specific imaging were obtained before and after treatment with daratumumab. anti-ifn-γ autoantibody titers were determined by serial -fold dilutions of plasma and measuring anti-ifn-γ autoantibody levels by a particle-based technique as previously described. results: a -year-old filipino woman had progressive disseminated m. avium with extensive bone and soft tissue involvement (calvarium, ribs, bilateral arm soft tissue, paraspinal muscles, bilateral glutei, left inferior pubic ramus, bilateral iliac bones, sacrum, and bilateral humeri) and a tracheo-esophageal fistula. she received bedaquiline, azithromycin, ethambutol, tedizolid, moxifloxacin, clofazimine and meropenem as well as rituximab g once monthly for months. despite these she had progression of clinical and radiographic disease. bortezomib . mg/m twice weekly for weeks was added, but discontinued for ast and alt elevations. rituximab was continued to maintain cd numbers undetectable but clinical and radiographic disease progressed. while on rituximab, total igg level and anti-ifn-γ autoantibody levels decreased from mg/dl to mg/dl and to , respectively. while on bortezomib, total igg levels remained stable ( mg/dl to mg/dl) and anti-ifn-γ autoantibody levels fell slightly ( to ). after starting daratumumab, there was clinical and radiographic improvement, with reduced pain and disappearance of multiple soft tissue lesions. igg levels decreased from mg/dl to mg/dl and anti-ifn-γ autoantibody levels decreased from to . adverse effects of daratumumab were urticaria, pruritus and shortness of breath after the first infusion and aseptic meningitis after the th infusion. conclusions: daratumumab resulted in clinical and radiographic improvement of disseminated m. avium in a patient with rituximab and bortezimib-refractory autoantibodies to ifn-γ. daratumumab is another potentially effective therapeutic agent for anti-ifn-γ autoantibodies. abstract/case report text next-generation sequencing (ngs) is now routinely used as a clinical diagnostic tool. however, regions of high sequence homology continue to be a major challenge for short-read technologies. regions within ikbkg, ncf , sbds, c a, c b, coro a, fcgr a, fcgr b, pms , slfn , slfn , stat b, unc b , and ups are not available by standard ngs. we discuss strategies for analysis of these special regions. we have developed a strategy for supplementing our disease targeted panels which are performed using capture chemistry and a standard reference file. the supplemental method uses gene specific long range amplicon and a special gene specific reference file for alignment. the genes of interest are separated from their homologous counterparts using specific long range amplification primers. multiple amplicons may be pooled together and prepared for sequencing on an illumina miseq instrument using truseq nano dna library prep. bioinformatic analysis proceeds with a custom reference file in which non-specific regions of homology have been removed. this allows reads to be uniquely mapped despite significant homology; a requirement for variant calling. we prepared specific amplicon for several homologous gene targets including the ikbkg gene and the ikbkg pseudogene (ikbkgp ). both amplicons were sequenced in separate reactions and were compared with the standard capture method. variants which are not called in the standard-capture method due to poor mapping scores (non-uniquely mapped reads) are called in the amplicon method. in the capture method, the variants are visualized in the bam as a mixture of gene and pseudogene, while gene and pseudogene variants are clearly separated and identified in the amplicon method. due to high variability in alignment, many homologous regions do not provide reliable copy number variant (cnv) results and must be removed from cnv analysis. however in some situations, we are able to creatively leverage cnv analysis to identify alleles that mis-align to the pseudogene. the pathogenic ncf gt deletion in exon appears to resemble a copy number deletion event when present as reads from one allele mis-align to the ncf b and ncf c pseudogenes. complement genes, c a and c b, share alignment due to their high homology with each other. cnv analysis in normal samples represents four alleles rather than two alleles. cnv events may have a weak signal with no indication of which gene is affected. variant frequencies from the capture and supplemental pcr analysis can be used in tandem with cnv analysis to detect events and may indicate which gene is affected. we plan to include these strategies in our new inborn errors of immunodeficiency gene panel (ieigp) which will enable us to provide a more comprehensive analysis than is currently available. the im diagnosed were inflammatory bowel disease-like (n = , with perianal fistula in / ), mouth ulcers (n = ), discoid lupus (n = ), autoimmune dermatitis (n = ) and eczema (n = ), chronic lung disease (n = ) and granulomas (pulmonary n = ; ocular n = ; bladder n = ; oropharynx n = ). three patients presented more than one site of inflammatory disease. all patients were treated with systemic or topical immunosuppressive or immunomodulatory therapy, most of them corticosteroids. five patients underwent hematopoietic stem cell transplantation (hsct), median age at hsct was years ( - ), and two died month after hsct. conclusions: although infections are more frequent and have a major impact on patient morbidity and mortality, im are increasingly prevalent in patients with cgd. awareness regarding this possible comorbidity is of major importance, since earlier diagnosis and adequate treatment may be crucial for patients survival and quality of life. there is a gap in clinical knowledge regarding associations between specific pid and different rheumatological diseases. in this study, we are reporting the incidence of various rheumatological conditions reported in a large pid population using the usidnet (united states immunodeficiency network) registry. methods: we used the retrospective usidnet registry to conduct the analysis. we included all primary immunodeficiency patients with physician diagnosed rheumatological diseases. results: the total number of pid patients in our query was . ( . %) patients had a diagnosis of rheumatological disease. this cohort included ( . %) female and ( . %) male patients. rheumatologic complications were highest in the interferonopathies ( . %), complement deficiencies ( . %) and autoimmune lymphoproliferative syndrome (alps) ( . %). additionally, disease patterns were noted to be different in each pid. dermatomyositis was found to be the most common rheumatologic condition in patients with x-linked agammaglobulinemia (xla) with a rate of . %, which was remarkably higher than the reported prevalence in the united states ( . %). alps patients had a higher ( . %) numbers of sjogren syndrome diagnoses as compared to the general population ( . - . %). systemic lupus erythematosus was increased in patients with mucocutaneous candidiasis ( . %) as compared to the general population ( . %) and other pids. rheumatoid arthritis (ra) was reported in patients with specific antibody deficiency ( . %), common variable immunodeficiency (cvid) ( . %) and alps ( . %). wiskott-aldrich syndrome patients had the highest numbers of cases diagnosed with vasculitis ( . %). . % of patients with severe combined immunodeficiency (scid) had reported rheumatologic disease. juvenile rheumatoid arthritis (jia) and systemic sclerosis were reported in . % of patients with digeorge syndrome. conclusions: this study reports that higher numbers of rheumatologic diseases are diagnosed in pids compared to the general population. the incidence of different rheumatological disease was variable based on the pid diagnosis. early diagnosis of these diseases is crucial, given the high risk of irreversible complications. limitations of our study include possible selection bias as majority of cases were enrolled from tertiary care centers. abstract/case report text background disorders of immune dysregulation are associated with autoimmune features. this feature could potentially have an impact on the outcome post hematopoietic stem cell transplantation (hsct). hsct, although curative, can be challenging with the underlying immune dysregulation resulting in significant morbidity and mortality. we present the journey through hsct for these children and the factors affecting the outcome. we analysed the data on children up to the age of years diagnosed to have a disorder of immune dysregulation through gene mutation analysis and who underwent hsct at our centre from to . results . xiap mutation a -year-old boy underwent a haploidentical hsct from his father using fludarabine, treosulfan, and gray radiotherapy with post-transplant cyclophosphamide. after initial complete chimerism and cytomegalovirus reactivation responsive to valganciclovir, he developed progressive diarrhoea almost months post-hsct. a rectal biopsy confirmed cmv reactivation and features of inflammation. he has since been treated for the same and is on follow up for inflammatory bowel disease. his chimerism had dropped to % and has remained stable. the second child is a -year-old girl who underwent tcr alpha/beta depleted haplo sct and is months post-hsct, with no features of gvhd or infections, and is doing well with complete chimerism. . il r deficiency three boys aged eight months, one year, and two years of age, diagnosed to have il r deficiency underwent hsct. all three children needed nasogastric tube feeding, parenteral nutrition, and vigilant monitoring for electrolyte disturbances. in the first two children, we had performed tcr alpha/beta depleted pbsc transplants from their haplo matched fathers. the -year-old engrafted by d+ and is doing well two years post hsct with complete chimerism, no gvhd, and infections. his autoimmunity, including recurrent skin scarring, has resolved entirely. the -month-old, however, had primary graft failure and succumbed to his illness. the -year-old boy underwent matched unrelated donor hsct and engrafted by d+ with completed chimerism documented on three occasions. he, however, had secondary graft failure around d+ , and he succumbed to the illness. . lrba deficiency an -month-old girl with lrba deficiency had presented at four months of age with excessive sweating, hepatosplenomegaly, and recurrent chest infections. she was started on monthly intravenous immunoglobulin replacement and abatacept. she received myeloablative conditioning with thiotepa, treosulfan and fludarabine and underwent a matched sibling donor hsct. she engrafted by d+ and has been well ten months post hsct with complete chimerism, no gvhd, and infections. conclusion disorders of immune dysregulation are a heterogeneous group with a varied spectrum of immune dysfunction. myeloablative conditioning is essential, and there is a high risk of cytokine release syndrome and the need for supportive care. the autoimmune features need to be followed for progression in organs other than the hematopoietic system and may require interventions. as long-term data evolves, more precise definitions for patient and donor selection will enable improving outcomes. we performed a retrospective observational analysis of case records of children up to years of age, diagnosed to have variants of scid, and underwent hsct at our centre from to . results . zap deficiency a -month-old girl presented with oral thrush and submandibular cellulitis from one week of life with failure to thrive. she underwent a tcr alpha/beta depleted haploidentical hsct. conditioning included treosulfan/thiotepa/fludarabine/anti-thymocyte globulin. she engrafted by d+ ; now three years post-hsct with complete donor chimerism without gvhd or infections. . orai- mutation a -month-old girl presented with failure to thrive, generalized hypotonia, oral thrush, and recurrent respiratory infections. she underwent haplo-sct with post-transplant cyclophosphamide with pbsc from her haplo-matched father. conditioning included fludarabine/treosulfan. she had cytokine release syndrome grade , which responded to tocilizumab. she had hypertension throughout the peri-engraftment period and had an episode of pres with seizures. her symptoms abated with neutrophil engraftment by d+ . the post-transplant period was complicated by grade skin gvhd and cytomegalovirus reactivation. she has remained disease-free with complete chimerism three years post-hsct. her hypotonia is steadily improving with physiotherapy. . cernunnos-xlf deficiency a -year-old male presented with recurrent infections from years of age, aplastic anemia diagnosed at years of age, subsequent transformation to acute myeloid leukemia at years of age. he had developed multiple fusarium abscesses during the neutropenic period post-chemotherapy for aml. he was referred for a matched sibling sister hsct when in remission. conditioning included fludarabine/treosulfan. he engrafted by d+ with complete chimerism. he developed progressively worsening skin, gut, and liver toxicity secondary to chemotherapy and succumbed to the illness two months post-hsct. . ikzf mutation an -month-old girl presented with failure to thrive, massive splenomegaly, persistent pneumonia, anemia, and thrombocytopenia. she underwent a matched sibling donor pbsc transplant after myeloablative conditioning with thiotepa/treosulfan/fludarabine. she engrafted by d+ , following which all her symptoms abated. she had secondary graft failure two months post-hsct and succumbed to her illness. . mhc class ii deficiency (bare lymphocyte syndrome) three children, aged months, two years, and four years underwent matched sibling donor hsct. myeloablative conditioning with thiotepa/treosulfan/fludarabine resulted in engraftment. the first child died of invasive intestinal aspergillosis days post-hsct. the other two children are well months post-hsct with complete chimerism without gvhd or infections. the two-year-old girl received one cycle of pre-transplant immunosuppression with fludarabine/dexamethasone to prevent graft rejection pre-hsct as she was referred for a second transplant. conclusion children with scid have traditionally been transplanted using reduced intensity (ric) conditioning with immunomodulation. scid variants require myeloablative conditioning with a vigilant follow up for the detection of graft rejection. radiation sensitive scid associated with dna breakage repair defects require ric and close monitoring for gvhd. advances in hsct, including supportive care and haplo-sct, have provided a ray of hope for these hitherto rare conditions. j clin immunol abstract/case report text immune dysregulation, polyendocrinopathy, enteropathy, x-linked (ipex) (omim # ) is a monogenic autoimmune disorder that occurs due to loss of function variation in foxp causing dysfunctional t regulatory cells. although immunosuppression is a mainstay of treatment for autoimmunity, ipex treatment is frequently limited by insufficient response to therapy or side effects of immune suppression. we present a year old male with ipex whose prior immunosuppressive treatment was complicated by inefficacy and medication side effects, requiring a new approach to treat his colitis and erosive dermatitis. he initially presented with infantile diabetes and subsequently developed dermatitis, squamous cell carcinomas, alopecia totalis, and colitis. his clinical diagnosis of ipex was confirmed by foxp sequencing, demonstrating known pathogenic variant c. g>a (p.ala thr). this variant has been described in ipex affected individuals in multiple publications (ref ). his variant affects at the frkhead domain of foxp and has been associated with others with severe psoriasiform dermatisis and alopecia universalis (ref ). his prior immunosuppressive therapies included at different times combinations of corticosteroids, tacrolimus, sirolimus, azathioprine, infliximab, adalimumab, rituximab, dupilumab, and oral mesalamine. the relative efficacy of these agents based on experiences in a cohort of ipex patients was reviewed in (ref ), with the exception of duplimab, which was not listed in that review. for our patient, management of his widespread autoimmunity has been limited by toxicity or lack of efficacy of medications. notably, his dermatitis had no improvement with duplimab, consistent his low total ige and lack of allergic manifestations. at age , after initiation of treatment with sirolimus, he had spontaneous colonic perforation requiring descending colectomy. after stabilization of his colonic perforation, his multi-disciplinary team of allergy-immunology, gastroenterology, and dermatology initiated tofacitinib. tofacitinib is small molecule inhibitor of janus kinase (jak) signaling pathways that mediate cytokine driven autoimmune activation. it is fda approved to treat rheumatoid arthritis, psoriatic arthritis and ulcerative colitis. the decision to use this jak inhibitor was due to its fda approved use for ulcerative colitis, to target our patient's colitis and his other autoimmune manifestations, specifically his dermatitis. its off label for primary immune dyregulatory disorders including candle, stat -gain of function and stat -gain of function disorders has been published (ref ), but thus far its use to treat autoimmunity due to ipex has not been published. he experienced leukopenia while on mg of tofacitinib, which resolved after lowering his dose. currently, he has had improvement in his colitis and dermatitis, and partial improvement in alopecia. he has been on tofacitinib mg daily for months, with only prednisone mg daily as additional immune suppression. as the number and types of selective immune modulators increases, there is continued need to share the experiences of treating physicians of which therapies have been successfully able to decrease disease manifestations with tolerable side effect profiles. we present a year old male with ipex syndrome with severe dermatitis and colitis complicated by colonic perforation despite standard immunosuppressive therapy, who is safely and effectively being treated with tofacitinib. is not frequently associated with autoimmunity, likely due to impaired il- and il- pathways. however, in our relatively large cohort of lof stat patients, we have noted an increased incidence of systemic lupus erythematosus (sle) diagnoses and sle-like symptoms. herein, we characterized the clinical and laboratory features of the patients in our cohort with sle and sle-like disease, with the aim to better understand the pathogenesis by evaluating ifn stimulated genes and neutrophil net formation. methods a retrospective chart review was performed of patients with lof stat to identify those with sle and sle-like presentations, and included clinical features, laboratories including inflammatory markers, auto-antibodies, and complement levels. rt-pcr was performed for interferon stimulated genes (isgs) from neutrophils and pbmcs of lof stat patients with and without sle, and healthy controls. neutrophil net formation was assessed for lof stat patients with and without sle, and healthy controls. results out of a cohort of patients, five patients (ages - ) were identified who carried the diagnosis of sle, and with slelike disease (ages - ). for those with sle, age of presentation was - years, of were female. clinical features included nephritis ( ), alopecia ( ), autoimmune cytopenias ( ), arthritis ( ), discoid rash ( ), and raynaud ( ). all had positive auto-antibodies, and of had low c and/or c . for those with sle-like disease, age of presentation was - , and of were female. clinical features included alopecia ( ), autoimmune cytopenias ( ), raynaud( ), and nephritis ( ). all had positive autoantibodies, and of had low complements. lof stat patients with and without clinical features of sle had increased expression of isgs from both pbmcs and neutrophils. increased spontaneous net formation was observed for lof stat patients both with and without sle symptoms. discussion although autoimmunity is not a common finding in lof stat , we have identified sle or sle-like disease in about % of our cohort, with a high incidence of kidney disease, including one patient who required kidney transplant. the interferon signature and net formation were unexpectedly high in both the patients with and without the sle features. ongoing studies include whole exome sequencing for possible second mutations or modifiers, the role of ige in the kidney disease, and further autoantibody detection. the increased ifn signature raises the question about jak-stat modulation for therapy. chief, genetic immunotherapy section/niaid, nih abstract/case report text chronic granulomatous disease (cgd), a rare immunodeficiency with decreased reactive oxygen species (ros) production, increased susceptibility to infection, and increased mortality is caused by mutations in any one of distinct phagocyte oxidase (phox) components of the nadph oxidase, nox . in the past, identification of the specific protein defect was primarily determined by immunoblotting using specific antibodies to the phox proteins. recently, however, we have shown using fluorescenceactivated cell sorting (facs) analysis of neutrophils in whole blood permeabilized and stained with specific anti-p phox antibody that p phox protein expression was absent in p phox cgd patients and significantly reduced in p phox cgd carriers [kuhns et al. . blood adv. ( ): - ]. these findings demonstrated that determination of phox protein expression by facs analysis provide an alternative to immunoblotting and can aid in the identification of p phox cgd patients and carriers. we now have extended these studies to patients and carriers with p phox cgd. facs analysis of p phox expression in permeabilized neutrophils demonstrated that p phox expression was absent in four patients with different mutations in ncf [two patients homozygous for c. e (+ ) g>a, one patient homozygous for c. _ del aag, p.glu del; and one patient compound heterozygous for the mutations, e (+ ) g>a and c. _ del aagaaggac]. moreover, the expression of p phox in nine p phox cgd carriers was significantly reduced > % compared to expression in neutrophils from healthy volunteers. another cytosolic phox protein, p phox, has been shown to associate with p phox in a : molar ratio [tsunawaki et al. . biochem biophys res comm. ( ): - ]. the expression of p phox was reduced in both carriers and patients with mutations in ncf . despite reduced expression of p phox and p phox, neutrophils isolated from carriers of p phox cgd exhibited normal dihydrorhodamine (dhr) oxidation after stimulation with phorbol ester and fell within the normal range for ros production (measured by luminol-enhanced chemiluminescence) after stimulation with either fmlf, opsonized zymosan, or phorbol ester with one notable exception. included in this cohort of p phox carriers was a p phox cgd patient (homozygous for a gt deletion at the start of exon in ncf ) who also carried a heterozygous damaging mutation in ncf [c. a>t; p. asn ile]. normal ros production in the presence of reduced p phox and p phox expression suggest that these proteins are not rate-limiting components for maximum nox activity in neutrophils. finally, determination of the expression of specific phox components by facs analysis of permeabilized neutrophils from whole blood provides a rapid and alternative approach to immunoblotting to determine the specific protein defect in cgd, and, importantly, one that could be easily established in most clinical labs. funded by nci contract no. n d . the original clinical observation that defined patients with hyper-ige syndrome (hies) was the presentation of cold abscesses ("job's syndrome"), which indicated a deficient inflammatory response. mutations in the stat gene have now been identified in most classic autosomal dominant hies patients, but we do not fully understand how these mutations cause the clinical presentation. since the discovery of stat mutations, research on hies focused largely on the adaptive arm of the immune system and suggested that the innate immune defects could be secondary. for example, the discovery that there is a th cell and il- cytokine deficiency in hies provided a possible explanation to the neutrophil chemotaxis defects in hies, as il- is one of the chemokines critical for neutrophil recruitment in vivo. the goal of this study was to investigate myeloid cells from hies patients. first we used c a, fmlp, il- , cxcl , and cxcl to study neutrophil chemotaxis in vitro. responses to c a, fmlp, and il- were equally robust in hies compared to healthy controls, demonstrating that neutrophils from patients are capable of efficient directed migration in vitro. neutrophils from all hies patients responded to cxcl and cxcl significantly below that of the healthy controls. cxcl and cxcl are cxcr -specific chemokines. these results indicated a neutrophil intrinsic cxcr -specific defect. we also found that patient-derived cells express comparable levels of cxcr on the cell surface, suggesting a cxcr chemokine receptor signaling defect. after identifying a neutrophil defect in hies, we wanted to get a broader view of myeloid cells in hies in addition to identifying the cxcr specific defect. stat is a transcriptional regulator, therefore we performed transcriptional profiling of hies and healthy control-derived neutrophils and monocytes. as it was shown before, the expression of stat was not different between patients and controls, since hies is usually caused by the decrease in stat activity not by decrease in expression. we found, however, an increase in stat and stat expression as well as significant changes in the expression of genes regulated by interferons. increased expressions of stat / in both neutrophils and monocytes likely provide and explanation for the increase in interferon regulated genes. multiple genes were identified as potential regulators of cxcr signaling. the balance between the stat and stat signaling has long known to be a regulator of immune cell activation, especially in t cells, but less studied in myeloid cells. stat and stat / signaling pathways crossregulate each other in healthy cells. we propose that in hies the decreased stat signaling leads to not only changes in expression of effector (e.g. inflammatory) genes, but also decreases expression of genes in the regulatory (negative) feed-back loop, which are required for decreasing stat / activity. therefore, the immune cell defects caused by decreased stat activity are compounded by the increase in stat / activity. increase in stat / signaling can cause pathologies in the absence of stat defects, as well as further decrease stat signaling, thus contributing to hies. interfering with stat / signaling in hies may represent a therapeutic opportunity. abstract/case report text rationale: t-cell receptor excision circles (trecs) testing on newborn screening (nbs) has been vital for identifying patients with severe combined immunodeficiency (scid). we aimed to determine whether one or more abnormal trecs result on a nbs might predict higher mortality rates despite the absence of an identifiable underlying etiology. methods: newborns with a positive trecs nbs result without the diagnosis of scid or q . deletion syndrome born from october to december were included (n= ). newborns were divided into three groups: group infants had a subsequent normal repeat screen (n= ); group infants did not undergo repeat screening as the majority expired before a repeat screen could be conducted (n= ); group infants had a normal initial screen but subsequent abnormal screen (n= ). cases were matched : to controls on gestational age, birth weight, nicu status, race, birth quarter, and birth year. nbs records were linked to birth and death certificate records. demographic characteristics were compared and mortality rates were calculated between the groups. results: the mortality rate of group was . %, group was . % and group was . %. when compared with matched controls, there was no difference in the mortality rate of group when compared to the control group. there was a significant difference in the mortality rate between cases and controls in both group (p < . , % ci . , . ) and group (p < . , % ci . , . ). the apgar scores in group infants were comparable to their matched controls. infants in group (p = . ) and group (p = . ) had significantly lower apgar scores than the controls. the majority of the infants in all three groups were less than weeks gestation, however, group had a higher percentage of infants born very premature (less than weeks). there was no significant difference in maternal age, maternal education, prenatal care status, cigarette use, or maternal steroid use between the cases and controls in all three groups. conclusions: infants with an initial abnormal screen who had a subsequent normal repeat screen did not have an increased rate of mortality compared to their matched controls (group ). however, group infants (with unresolved repeat screen) and group infants (with a first abnormal value on a repeat screen) did have increased mortality rates when compared to their controls. overall, an abnormal trecs level on nbs without a confirmed negative repeat screen, was associated with higher mortality in our study population. further studies will be needed to determine if the trecs assay can serve as a predictor for mortality in newborns with an abnormal screen. abstract/case report text introduction: primary immunodeficiency refers to a heterogeneous group of diseases characterized by altered function or composition of the immune system, and are grouped into adaptive or innate system defect. immunoglobulin g subclass immunodeficiencies (iggscs) are classified as a b-cell-related adaptive system disorder and are therefore associated with recurrent sinopulmonary infections with encapsulated bacteria, presenting with pneumonia, recurrent bronchitis, rhinosinusitis, and herpes zoster. its primary mechanisms are still unclear, although the cause for this deficiency might be related to gene deletions, transcription errors, or be an effect of allotype. igg immunodeficiency reaffirms its association with the patient's clinical condition and is often associated with igg deficiency. objective: to evaluate the prevalence of igg immunodeficiency in ferraroni's clinic, classify it by gender, age, igg dosage and other subclasses, correlate it with igg immunodeficiency and the clinical presentations presented by the patients under analysis. method records of patients with igg immunodeficiency whose clinical pictures were followed throughout years were evaluated, patients aged from to years. all tests were done at the same laboratory and all patients have consented to be part of this study, which has been approved by the ethics committee. results twenty-four patients with igg deficiency, , % (n= ) were women and , % (n= ) were male, with average of and years, respectively. the average of igg was . mg/dl, and that of igg was mg/dl. of the patients evaluated, . % had upper airway infections (sinusitis, rhinitis, otitis and tonsillitis), % herpes simplex, . % asthma. less prevalent cases were reported as . % of patients had bronchiectasis, . % candidiasis and . % herpes zoster. . % presented the association of igg and igg deficiency. discussion: the role of specific igg deficiency in the infectious setting is still unknown, but it usually occurs in association with other isotypic deficiencies and sinopulmonary infections. furthermore, the igg subclass is relevant on the study of environmental antigens -suggesting its involvement with allergic disordersand has been described in association with other diseases, such as chronic mucocutaneous candidiasis, ataxia-telangiectasia and allergic colitis. igg deficiency is related to increased susceptibility to bacterial infections. studies show a correlation between igg and igg immunodeficiency that generally imply clinical features characterized by recurrent infections by encapsulated bacteria. the data obtained through the analysis of patients' charts corroborated this information, since it was evident that most of the patients had really similar clinical conditions. conclusion: igg deficiency has a direct correlation with higher prevalence of upper airway infections, such as rhinitis, sinusitis and pneumonia, and with an increased incidence of allergic disorders, here presented by our cohort. additionally, research suggests that hies may cause impaired cd + t cell function. we hypothesized that a low percentage of both th and th cells would be predictive of hies and would differentiate hies from atopic disorders. to evaluate this hypothesis, we examined the percentage of th , th , and ifng+cd + t cells, laboratory parameters, and genetic diagnoses from a large cohort of patients to determine which parameters distinguish patients with stat loss-of-function variants. methods: we conducted a retrospective, multi-institutional chart review of over patients who received a th assay at the medical college of wisconsin clinical immunology research laboratory. the th assay is performed by activating pbmcs with pma/ionomycin/brefeldin a and staining for cd , cd , ifng and il- a. the following parameters were included in the chart review: the percentage of th , th , and cd +ifng+ cells, immunoglobulin levels, atopy scores, infectious history, and genetic diagnoses. results: using logistic regression, we demonstrated that the percentage of th , cd +ifng+, and th cells were positively correlated with age, and percentage of cd +ifng+ cells was higher in females than males. we found that the percentage of th and th cells were decreased in both atopic disease and hies, with hies having the lowest values. interestingly, one subject with a stat gain-of-function (gof) variant had an elevated percentage of th and th . in addition, we determined that ige levels were inversely correlated with the percentage of th , cd +ifng+, and th cells, while iga and igm were positively correlated with the percentage of th cells. several different monogenic defects characterized by increased fungal infections exhibited a low percentage of th including tatton-brown-rahman syndrome and cornelia de lang syndrome. conclusions: we confirmed that the percentage of th cells is low in both hies and atopy in a large cohort of subjects, and that the percentage of th cells may be helpful in distinguishing hies from atopic disease. however, since the percentage of th , cd +ifng+, and th cells correlate with age, caution should be used when testing young children. the inverse correlation between ige levels with th and th responses suggests that similar pathway(s) may drive both hies and atopy. additionally, the decreased th responses in stat lof and increased th responses in stat gof hies raise questions about the role of stat in regulating ifng levels. we also identified patients with different genetic disorders with fungal infections in which the th percentages were low, suggesting that the th test may be useful in evaluating individuals with unusual fungal infections. abstract/case report text background:primary and secondary autoimmuune neutropenia (pan/san) are well described entities. several autoimmune neutropenias do not fit the criteria of either pan or san showing peculiar characteristics mainly for older age at onset and/or for duration of the disease; moreover they are not associated , at least at the beginning, with autoimmune markers/diseases aim of the study: to describe a cohort of subjects affected with autoimmune neutropenia, defined as "atypical" (aan), registered in the italian neutropenia registry (inr) and to compare these data with those from subjects diagnosed with pan still in the inr. patient and methods: subjects with neutropenia and positivity of indirect antibodies against neutrophils (registered in the inr from to ) lasting for more than years, or diagnosed after years of age ( up to y), without any associated autoimmune, signs/markers were considered eligible for the present study. results: data from patients were collected: / subjects ( %) were defined as aan and / ( %) as pan. among aan affected patients %, were "long lasting" aan, while % were defined as "late onset" aan .the degree of neutropenia in aan group was mild in %, moderate % and severe in % of the subjects . leukopenia at onset was a common hall mark seen in % of aan patients (median values /mm³ ; range - /mm³ ) especially in the "late onset" aan if compared with pan and " long lasting" one ( p= . ). as for clinical features, almost half of the aan cohort suffered from recurrent or "significative infections", while severe episodes (namely sepsis, meningitis , osteomyelitis , pneumonia, deep abscess or flemmon) were shown in % being more frequent, but non significantly higher than those reported in the pan group ( % )( p=ns) interestingly, recurrent apthae were significantly more seen in the "late onset" aan group if compared with the "long lasting" aan (p= . ). during follow up, markers and/or symptoms of autoimmunity appeared in % of the aan cohort, being another element of peculiarity in respect to pan (p < . ). as for immunological pattern in aan, immunoglobulin values were lower than the references for age in %,while were above them in % of the cohort . lymphocytes subsets evaluation showed decreased value of cd +cd + cells in % of cases, followed by depletion of cd -cd +cd + subtype in %, cd +cd + in % of cases and cd + cd + in % . preliminary study on b memory and t-reg cells values, showed a quantitative deficiency respectively of in % and % of the studied subjects. mutation analysis performed by ngs in % of the subjects identified pathogenic variants of : taci ( ), tinf ( ) and lrba ( ) .comparison between pan and aan is detailed in table . conclusions atypical neutropenia in childhood is a disorder which show many difference with pan; indeed appears an epiphenomenon of a complex immunological disturbances rather than a disease itself. occasionally mutations of genes of immunodeficiency/disimmunity can be demonstrated abstract/case report text background: medications treating ra typically include systemic corticosteroids used to treat inflammation flares, and disease modifying therapies (dmards). traditional dmards include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. recently, biologic/immuneresponse modifiers have come to the forefront for overall therapeutic benefit, however, an unfortunate side-effect may be the risk of increased immunosuppression. this study seeks to determine the occurrence rates of immune deficiencies among patients initiating ra therapies. methods: using the pharmetrics plus commercial claims database from - , ra patients (icd- and - codes: m , m ) over the age of were indexed on their first use of a new biologic therapy. all patients were required to have enrollment six-month pre and one-year post index. cohorts of patients were grouped by medication: methotrexate, adalimumab, etanercept, and rituximab. ra patients receiving adalimumab, etanercept, and rituximab were allowed concomitant use of methotrexate, but could not use any other biologic medications in the post period. a minimal adherence of % was required of all biologic treated ra patients. an additional cohort of ra patients untreated with biologic therapies was indexed on their first ra diagnosis within the time window and used as a control. ra patients with comorbid conditions who would also require biologic treatment were excluded including crohn's disease and ulcerative colitis. between group comparisons were made with the no treatment group as the referent. to account for differences in age, gender, and elixhauser comorbidity conditions patients in each cohort were matched : to the rituximab group. results: , ra patients met inclusion criteria: , in the methotrexate group, , receiving etanercept, , receiving adalimumab, and receiving rituximab. a total of , in the treated groups and , in the no biologic treatment group. demographic information including age and gender were significantly different but numerically similar between the groups, with rituximab group having the highest proportion of female patients but limited dispersion with the lowest proportion being in the etanercept group. healthcare utilization metrics highlighted a significantly higher average number of office visits ( . , sd: . vs no treatment . , sd: . , p < . ) and a higher proportion of rituximab patients being hospitalized ( . % vs no treatment . %, p < . ). the diagnosis of immune deficiency was highest among the rituximab group with . % followed by methotrexate . %, adalimumab . %, etanercept . %, and no treatment . %. after matching, similar rates were seen for healthcare utilization to the pre-match results. the post-match odds of being diagnosed with immune deficiency were significantly greater for the rituximab group (or . , ci: . - . ) than the no treatment group. conclusions: the purpose of dmards is to modulate the immune system and decrease autoimmunity in ra. however, this treatment may lead to significant immunosuppression. this study suggests that treatment with certain biologic/immune-response modifier therapies may be associated with higher rates of healthcare utilization. in particular, the increased post-treatment diagnostic coding of immune deficiency demonstrates the heightened awareness among healthcare providers of the chronic immunosuppressive potential of rituximab. evaluation of potential secondary immunodeficiency pre-and post-dmard use should be incorporated into routine practice. abstract/case report text introduction: autoimmune lymphoproliferative syndrome (alps) is a rare inherited disorder of lymphocyte homeostasis due to a fasmediated apoptosis and characterized by non-infectious and nonmalignant lymphoproliferation, autoimmunity, and secondary malignancies (national institute of health criteria). in spite of recent progress, one third of alps patients still remain gene orphan and they have been previously categorized as alps-u. in some cases, patients fitting alps diagnostic criteria have been shown to carry mutation on genes involved in other immune-dysregulation syndromes. aims: the aim of this study is to compare the clinical and immunological features, and the outcome of a cohort of alps patients with mutations on the typical causing genes (fas, fasl, fadd and casp )-here defined as alps-g -vs the ones without a molecular diagnosis or carrying mutations on other genes (both defined as alps-u). patients and methods the demographic, clinical, biochemical, genetic informations and details about treatment are derived from the alps italian network. search of mutations was performed with sanger pcr and/or next generation sequencing techniques (extended to immunodeficiency genes panel). results: alps patients were registered in our data base; the genetic analysis was performed in subjects ( %): / pts ( %) were alps-g and the remaining ( %) alps-u. six-teen out of ( %) alps-u patients resulted to carry mutations on other genes (lrba, stat +cecr, ctla , baffr, taci, nmlrc , ikbkg, gaucher), and the remaining ( %) were negative. the alps-u subjects showed a more complex phenotype compared to the alps-g group, which was characterized by multi-organ involvement (p= . ) and positivity of autoimmune markers (p= . ). (table ). cytopenia affecting one or more haematopoietic lineages was present in both groups ( % and %) with no significant difference, apart from lymphocytopenia that was more frequent in alps-u group (p= . ) ( table ) . as for lymphocyte subets and immunoglobulin dosage no differences were shown within the two groups. vitamin b and il- were more frequently raised in alps-g group (p= . , p= . ) (table ). four out of ( %) patients did not require any treatment. first-line treatment (steroid or intravenous immunoglobulins) controlled the disease only in / ( %) cases. the response rate to second line therapy -micofenolate mofetile (mmf) or rapamycin-was % and % in alps-g and alsp-u group, respectively. moreover, target therapies or drug combinations were more commonly applied in alps-u subjects (p= . ) ( table ) . conclusions: our study showed that alps-u subjects, despite the alps phenotype, represent distinct clinical entities and that genes associated with other immune-dysregulation syndromes are frequently represented in this group ( / , %). the identification of such disorders is crucial for the management of second-line treatment and/or the administration of target therapies abstract/case report text background: we have shown previously that allergic reactivity to ovalbumin (ova) could be regulated in mice following perturbation of immune networks using combinations of an immune ig along with antiidiotypic ig. we have explored features of this regulation including: its persistence after cessation of administration of combined igs; the ability of heterologous igs to produce immunoregulation; a role for treg induction in regulation; and the ability to attenuate responses in mice presensitized to an allergic stimulus. methods: balb/c mice were sensitized to ova. mice also received weekly injections of immune ig or anti-idiotype ig (at separate sites) from either homologous (mouse) or heterologous (human) sources. in the latter case pooled ivig (given im, hence hereafter imig) was used as a source of anti-idiotype ig, and human anti-tet as immune ig. injections of the ig were given from the time of ova sensitization (to attenuate development of immunity), or after pre-sensitization of mice (to attenuate existing allergic responses). all mice were assayed for development of ova-specific serum ige and igg, as well as the production of ova-induced il- , il- , il- , il- and il- in splenocytes cultured for hrs. in studies examining possible mechanism(s) responsible for inhibition of immunity mice received, in addition to the ig treatments described, infusion of depleting anti-cd , and/or anti-cd antibodies, or a mab to tnfsfr , known to expand tregs implicated in regulation of allo immunity. results: combinations of both heterologous and homologous immune igs and anti-idiotype igs attenuated ova allergic responses in both naïve and pre-sensitized mice. this attenuation persisted in mice greater than weeks after cessation of treatment with the igs used. finally, depletion of either cd or cd cells ameliorated the suppressive effect seen, while the combination of anti-cd and anti-cd essentially abolished suppression. suppression was further enhanced by anti-tnfsfr mab. conclusions: we conclude that the combine ig treatment protocols used produced a long-lasting suppression of allergic immunity, even in pre-sensitized animals. the effects seem to depend upon induction and expansion of tregs and represents a novel approach to treatment of allergic disease in humans and other animals. abstract/case report text background wiskott-aldrich syndrome protein (wasp) is found in the cytoplasm of hematopoietic cells but can transit to t lymphocyte nuclei at distinct developmental timepoints. wasp deficiency is a rare, x-linked combined immunodeficiency disease. affected patients display qualitative but not quantitative t cell defects. we report two immune deficient subjects with nearly identical exon frameshift mutations in was, the gene encoding wasp. one subject lacked circulating t cells, the other possessed several distinct cd t cell populations each expressing quantitatively different amounts of wasp. objective to determine how similar was mutations can cause scid in one person and generate b and t cells with heterogenous wasp expression in another. methods to identify somatic was mutations, we deeply sequenced was exons, introns, promoters and ' untranslated regions at , read depth in genomic dna from various b and t cell populations of each subject and their unaffected relatives. we confirmed genomic variants were transcribed and translated by sequencing was transcripts and analyzing wasp in primary cell lysates, both fractionated and not. to model our subjects' diseases we transfected primary cells and cell lines with mutant was transcripts and then measured viability and nuclear localization via confocal microscopy. results deep sequencing of genomic dna revealed all of subject one's cells carried the same germline exon frameshift was mutation. the mutation was incorporated into subject one's was transcripts and translated into a truncated form of wasp, which was relegated primarily to the cell nucleus. subject two possessed three distinct cd t cell subsets that each carried either the germline exon frameshift was mutation or a variety of somatic mutations that circumvented frameshift wasp expression. evasion strategies included exon skipping, adoption of a cryptic exon splice site and reversion to wild type amino acid sequence. subject two incorporated somatic mutations into was transcripts which encoded either stable near full-length proteins or unstable non full-length ones. subject one's sister and subject two's mother, who both carried the germline exon frameshift mutation, produced only wild type transcripts and proteins. conclusion we report two patients with was mutations encoding truncated wasp. if expressed, truncated wasp localized to the cell nucleus, and this was associated with t cell developmental arrest and severe combined immune deficiency. if, through a variety of epigenetic and somatic strategies, t cells could avoid expression of truncated wasp, they would survive but display phenotypical abnormalities and functional defects. patients with pidds show a higher susceptibility to hematopoietic malignancies, in particular to non-hodgkin lymphomas (nhl) that, generally, account for approximately - % of paediatric cancers and their incidence increases with age. recently new gene defects responsible for pidds with lymphoproliferation as a key clinical sign have been identified. our goal is to investigate possible immune-mediated mechanisms underlying malignant lymphoproliferation in children who did not show other typical symptoms of pidds. we retrospectively selected and reviewed the clinical history of nine patients with nhl ( burkitt lymphoma, large b cell lymphoma and lymphoblastic tcell lymphoma). immunophenotyping and exome analysis of known pidds genes were performed after lymphoma remission. six out of nine patients showed a mild hypogammaglobulinemia at time of presentation, not noticed before. moreover, one patient had history of recurrent respiratory infections, one of hematologic autoimmunity and two of nine were ebv-positive at diagnosis. preliminary results show an aberrant b cell phenotype in four patients; exome analysis reveals a novel heterozygous genetic variation in ikzf gene in one patient with burkitt lymphoma and autoimmune cytopenia was identified. concerning the remaining patients, further studies are ongoing. a detailed review of clinical history of paediatric patients affected from nhl as well as an impaired immunophenotyping can be important indicators of immune-mediated disorder underlying lymphoproliferation and helpful signs of possible pidds that should promptly be investigated by genetic analysis. this will allow an appropriate diagnosis and disease management. abstract/case report text introduction: caspase activation and recruitment domain (card ) encodes a scaffold protein that links antigen receptor activation to intracellular signaling. dominant heterozygous loss of function (lof) mutations in card cause a syndrome of severe atopic dermatitis, elevated ige, and allergic disease. atopic dermatitis can be difficult to control leading to substantial morbidity. dupilumab is a humanized monoclonal antibody that blocks il- and il- signaling approved for treatment of refractory atopic dermatitis. we present a case of a -year-old female with card deficiency successfully treated with dupilumab. case: a -year-old puerto rican female with history of recurrent sinopulmonary infections with episodes of pneumonia, moderate persistent asthma, food allergies, recurrent skin boils, and severe atopic dermatitis was referred for further management and evaluation for autosomal dominant hyper-ige syndrome (ad-hies). her atopic dermatitis was refractory to conventional therapy with topical corticosteroids, twicedaily emollient use, and bleach baths; it was also refractory to immunosuppression with mycophenolate mofetil and cyclosporine. on exam the patient exhibited coarse facial features and a high palate. she had eczematous lesions on the face, trunk, and extremities (scorad ). laboratory evaluation showed: eosinophilia ( cells/ul), elevated ige (> ku/l), low igm ( mg/dl), and elevated iga ( mg/dl). lymphocyte subsets and mitogen response were normal but antigeninduced proliferation was abnormal. autosomal dominant hyper ige score was indicating a high likelihood of ad-hies. no mutations in stat were identified and th cell expression was elevated. dedicator of cytokinesis (dock ) deficiency was also considered but dock protein expression was normal. further genetic testing revealed an base pair deletion in card (c. _ del) predicted to be pathogenic. the combination of the patient's phenotype and large deletion was consistent with card deficiency. despite continued immunosuppression with cyclosporine and aggressive skin care, the patient's atopic dermatitis was still severe and poorly controlled. off label (patient < years) treatment with subcutaneous dupilumab mg every weeks was initiated. at last follow-up, months after dupilumab start, the patient had substantial improvement in dermatitis with clear skin on the face, trunk, and extremities (scorad ). cyclosporine was discontinued and topical medications were applied less frequently. discussion: hypomorphic heterozygous dominant negative loss of function mutations in card have recently been associated with severe atopic dermatitis and allergic disease. treatment of atopic dermatitis in card deficiency remains challenging, but dupilumab appears to be an effective alternative to refractory disease. longer follow-up and a larger cohort of card -lof patients treated with dupilumab are necessary to understand the long-term efficacy and safety for use of dupilumab in these patients. abstract/case report text purpose: the micromilieu within premalignant respiratory papillomas supports persistent hpv / infection and disease recurrence in recurrent respiratory papillomatosis (rrp). these patients show polarized (th -/treg) adaptive immunity in papillomas and blood, enriched immature langerhans cell (ilc) numbers, and overexpressed cox /pge in the upper airway. to better understand the adaptive and innate dysregulation in rrp, we studied blood-derived monocytes, ilcs, and tissue-derived ilcs from rrp patients and controls. experimental design: monocyte subpopulations were isolated, differentiated into ilcs, activated, and then assessed by flow cytometry. monocytes were induced to differentiate into ilcs with/ without added pge , and then activated by il- γ, pge , pge +il γ, or lps. ilc cd expression was identified by flow cytometry. monocyte-derived ilcs, papilloma, foreskin, and abdomen skin ilcs, were also analyzed by qpcr for select chemokine/cytokine mrna expression after isolation, hrs later in culture, and again after poly(i:c) or tnfα stimulation. results: the three monocyte sub-populations differed between patients and controls, and patients' monocytes generated fewer ilcs. classical monocytes generated most, but not all ilcs. pge levels were higher in rrp plasma, and added pge reduced control, but not patients' monocyte-ilc differentiation. pge had no effect on ilc maturation identified by cd expression. papilloma-derived ilcs expressed low ccl- , and high ccl- mrna and were unresponsive to poly(i:c) or tnfα. tissuespecific cytokine/chemokine responses between ilcs from papillomas, foreskin and abdominal skin differed. only papilloma ilcs expressed il- γ after isolation, and they up-regulated ccl mrna hrs later without further stimulation. conclusions: monocyte/ilc innate immunity is impaired in rrp, in part due to increased pge exposure. the immunosuppressive papilloma micromilieu likely alters ilc responses that skew, hpv / -specific th /treg adaptive immunity in rrp. abstract/case report text introduction: familial mediterranean fever is a hereditary auto inflammatory disorder that typically manifests with recurrent fevers, abdominal pain and in some patients there is an associated with amyloidosis leading to eventual renal failure. while there are several common mutations in the mefv gene that when homozygous give these classic symptoms, patients with atypical mutations or heterozygous mutations often have a different clinical course. we present identical twin siblings with compound heterozygous mefv mutations but differing clinical phenotypes. case description: the index patient is a year old girl, conceived via ivf, who began having fevers at age . . her fevers occurred every weeks for months before she was referred to immunology for evaluation. her parents describe her as happy and otherwise not ill appearing during these episodes. genetic testing for familial mediterranean fever revealed compound heterozygous e q and p s mutations in the mefv genes. initiation of colchicine therapy in the affected sibling has resulted in a complete resolution of her symptoms. a trial off colchicine resulted in return of cyclic fevers. her identical twin sister was also tested, and carries the same mutation, but is still asymptomatic. this created great concern amongst their parents who had genetic testing prior to undergoing ivf that revealed no parental mutations in mefv. in consultation with genetics the mother was tested again through the same laboratory that had performed testing on the children. this revealed an identical mutation in mom who is also asymptomatic. conclusions: although classic homozygous mefv mutations have resulted in well described fever syndromes, there is considerably less data on heterozygous and compound heterozygous mefv mutations. in these two identical siblings only one patient has a classic manifestation of familial mediterranean fever. while it is possible that the other twin will develop similar symptoms later on in life, it is also possible that another factor is necessary to trigger symptoms in this unusual genetic presentation of fmf. in addition this case highlights the importance of understanding the testing method used by the laboratory performing the genetic testing. while the mother was initially reported as negative the laboratory that performed her testing only tested for the most common mefv mutations. more complete testing, that included the entire gene sequence, revealed that she did contain an mefv mutation in e q, which although more rare is thought to be pathologic when combined when combined with a second mutation. abstract/case report text there are several lines of evidence that link the pi k/akt/mtor signaling pathway to primary immunodeficiencies. hyperactivation of the pi k/akt/mtor/s k signaling pathway in immune cells can be the consequence of dominant gain-of-function mutations in the genes encoding for pi kδ that cause the activated pi kδ syndrome (apds). patients with these mutations may develop immunodeficiency and immune dysregulation as well as neurodevelopmental delay and growth retardation. in addition, mutations of genes within the pi k-akt-mtor pathway were also known to cause megalencephaly and segmental cortical dysplasia. mutations in akt , a member of the akt family of proteins and a downstream effector of pi k-mediated signaling, was shown to be associated with autosomal dominant megalencephalyassociated syndromes. here we describe a year old girl, born to consanguineous healthy parents, who presented with megalencephaly, developmental delay, hypotonia, cervical lymphadenopathy and hepatosplenomegaly. the patient had recurrent hospital and icu admissions for idiopathic thrombocytopenia (treated with ivig), recurrent laryngitis, recurrent peritonsillar abscess, preorbital cellulitis, conjunctivitis with purulent discharge, otitis media, pneumonia with pleural effusion (required drainage), metapneumovirus pneumonia with respiratory failure, recurrent skin cellulitis, and abscesses that grew mrsa (required drainage). in addition, the patient is known to have asthma and allergic rhinitis. mri of the brain showed megalencephaly, ventriculomegally, thin and dysplastic corpus callosum, a normal cerebellum, and myelination appropriate for age. immunoglobulin levels, lymphocyte subsets and the oxidative burst test were all within normal limits. cmvand ebv were not detected. bacterial cultures grew mrsa (skin), strept. pneumoniae, h. influenzae, and e. coli (urine). extensive metabolic workup was done, which was inconclusive (metabolic/mitochondrial diseases). whole exome sequencing identified an akt variant c. g>a; p.(asp asn) in exon . the variant was identified in the patient but not in the parents and it was confirmed by sanger sequencing. further molecular testing concluded that the variant is caused by a de novo mutation during early development. although pathogenic variants in akt gene were shown to be associated with megaloencephaly-associated syndromes, no associations with immune deficiency have be reported. functional studies will be pursued to confirm the link between the clinical phenotype and the identified variant in the akt gene. complex is a critical signalling adaptor that regulates lymphocyte activation, proliferation, survival, and metabolism. primary immunodeficiencies affecting each component (termed 'cbm-opathies') result in broad clinical manifestations ranging from combined immunodeficiency (cid) to atopic disease or lymphoproliferation. we present the laboratory and clinical findings of two canadian first nations patients found to be homozygous for the same novel card mutation (c. c>t; p.r *) causing complete card deficiency. results: we recently identified an -month-old boy who presented with a severe case of entero/rhinovirus bronchiolitis with interstitial lung disease and a -year-old boy with a history of severe pulmonary infections with bronchiectasis (including pjp), chronic sinusitis, candidiasis, invasive bacteremia, and severe ileo-colitis and oral ulceration requiring total colectomy. testing of both patients demonstrated absent tregs, elevated naïve b cells with absent memory b cells, and panhypogammaglobulinemia. next generation sequencing revealed that both patients were homozygous for the same novel variant of card (c. c>t; p.r *), which rendered card protein undetectable by immunoblot. card deficiency was confirmed by stimulating patient b cells with phorbol -myristate acetate (pma) and ionomycin and immunoblotting for signalling proteins in both the nf-κb (ikkα/β, iκbα, p ) and mapk (mek / , mkk , jnk / , erk / ) pathways as well as cleavage substrates of the malt paracaspase (relb, cyld, bcl , hoil ). nf-κb and jnk activation were completely absent and m a lt p a r a c a p a s e a c t i v i t y w a s l o s t . f u r t h e r m o r e , c oimmunoprecipitation experiments revealed that card was required for optimal malt association with bcl in response to stimulation. to define the impact of card deficiency on the b cell transcriptome, rna-seq experiments were performed. this revealed an inability to upregulate critical genes involved in immunity and tolerance (e.g. cd lg, ctla , il , il ), decreased enrichment in cytokine pathways (e.g. ifn-α, il- , tgf-β), and decreased enrichment in malt -dependent genes. furthermore, rna-seq confirmed the developmental block observed in patient b cells and suggested that b cells were halted at the centroblast to centrocyte transition. both patients ultimately underwent hematopoietic stem cell transplantation (hsct), which restored lymphocyte signalling and activation as measured by nf-κb, jnk, and malt paracaspase substrate cleavage. conclusions: we have presented the most comprehensive clinical and molecular characterization of human card deficiency to date. these two cases highlight the crucial role of card in regulating b cell development, function, and humoral responses, as confirmed by signalling and transcriptomic analyses. furthermore, hsct is potentially helpful for these patients as assays performed on post-transplant cells demonstrated restored signalling and activation. abstract/case report text introduction: primary immune deficiencies (pid) can have a significant impact on the quality of life of patients and their families. as more patients with pid are surviving to adulthood, the need to monitor them closely and ensure they are transitioned appropriately is even more crucial. we compared the perspectives of pediatric and adult immunologists toward the transition of patients with pid at our institution. methods: pediatric allergy/immunology providers at lurie children's hospital and adult allergy/immunology physicians at northwestern university both in chicago, il completed respective surveys anonymously (www.surveymonkey.com). questions were derived from the validated 'attitude' and 'quartt' instruments for transition. respondents were asked to rate their level of agreement on a -point likert scale, ranging from strongly disagree to strongly agree. results: overall, pediatric and adult providers participated (response rate . %). of total respondents, % thought the transition process should be initiated at age - . about % of the adult immunologists selected and older, whereas pediatric providers would begin earlier; . % of pediatric providers note they would initiate transition at age - . both pediatric and adult immunologists agreed that patients should be transferred when the provider felt they were ready ( %) and when they were in stable condition ( %). both adult and pediatric immunologists selected transfer of complete medical file as a preferred communication method for transition. other strategies preferred by adult providers were a referral letter with brief summary of medical history ( . %) and staff meeting with pediatric and adult immunologists ( . %), whereas pediatric providers would prefer a joint outpatient dedicated transition clinic ( . %). pediatric and adult immunologists, patient, parent, and transition liaison were considered the most important active participants in the transition process. the most prominent barriers to a formal transition were unavailability of a transition coordinator or nurse specialists ( %) or of all disciplines of the interdisciplinary team ( %), and limited time ( %). on the other hand, limited demand (too few patients) was strongly rejected as a barrier. all participants agreed during transition patients should be educated about medications and their side effects, their condition and related potential future complications, and symptoms that require seeking health care. over % of participants also agreed that education about how to set up ivig and further insurance needs were important. all participants agreed that the transition process should include assistance on how to promote the patients' independence and self-management skills, medication management/adherence, and understanding of immunoglobulin replacement and side effects. other important transition components included knowing how frequently lab draws are required for monitoring ( %) and having a written individualized transition plan ( %). pediatric providers also thought having an email or telephone help line would be beneficial. conclusion: this study adds to the growing body of literature examining attitudes of immunologists toward transition, and it highlights important transition components and barriers. further work is ongoing to determine the transition needs identified by patients and parents and define markers for successful transfer in order to build a transition policy at our institution specific to immunodeficiency patients. abstract/case report text introduction: bronchiectasis (bq) is an abnormal and irreversible dilatation of bronchi secondary to repeated cycles of airway infection and inflammation. predominantly antibody deficiency is the main group of primary immunodeficiencies (pid) in adults and had been reported up % of subjects with non-cystic fibrosis bronchiectasis (ncfb). hypergammaglobulinemia (igg level higher than , mg/dl) had been observed in . % of ncfb cases (retrospective data). diagnostic delay and inappropriate management of patients with predominantly antibody deficiency can lead to irreversible lung damage or even death from serious infections. the effect of hypergammaglobulinemia on ncfb is unknown. here we present the frequency of immunoglobulin abnormalities (pad and hyperigg) in adults with ncfb in cali, colombia. methods: we present preliminary data of a descriptive prospective study that will include patients with ncfb. women and men > and < years old will be included. all volunteers will be evaluated by a clinical immunologist, complete blood count and serum igg, iga, igm and ige levels will be determined. according with clinical suspicious, igg subclasses, anti-pneumococcal igg response and b cell subpopulations will be performed. the project will be executed in months. written informed consent has been obtained for all subjects included. this project count with irb approvals at universidad del valle and hospital universitario del valle. results: a total of ncfb cases have been included in the study. the mean age was . years ( - years) with a female:male ratio : . moderate-severe dyspnea was observed in / cases (medical research council -mrcdyspnea scale to ). recurrent pneumonia was found in / cases ( %). the main etiologies of bronchiectasis were: post-infection / ( %); idiopathic / ( %); autoimmunity / ( %); primary immunodeficiency / ( %) asthma / ( %); copd / ( . %); primary ciliary diskinesia / ( %); reflux / ( %) and others. primary immunodeficiencies, . % of ncfb cases, were classified as: predominantly antibody deficiency ( cases) including cvid cases, igm deficiency cases, igg subclasses deficiency case, selective iga deficiency case and hypogamaglobulinemia case. combined immunodeficiency (dock deficiency) case. interestingly igg hypergammaglobulinemia was observed in / cases ( . %) suggesting humoral immune response deregulation. conclusion to the best of our knowledge this is the first prospective study evaluating the etiology of non-cystic fibrosis bronchiectasis (ncfb) in colombia. hypergammaglobulinemia and predominantly antibody deficiencies affect % of adults with ncfb in colombia. our study reinforced the necessity to evaluate humoral immune response in patients with bronchiectasis. conflict of interest: authors disclosure any potential financial conflict of interest related to this abstract. acknowledgements: this investigator-initiated research was supported with a grant from baxalta us inc, a member of the takeda group of companies bt - /iir-col-bxlt- . abstract/case report text background: early-onset inflammatory bowel disease (eoibd) is defined as ibd diagnosis in children less than years of age. the occurrence of autoimmune disease in children (where it is relatively rare, compared to adults) may be caused by a highrisk predisposition gene (monogenic disorders). mayo clinic children's center has a unique care model, where a patient who is referred for eoibd meets with a team of physicians, including gastroenterology, immunology, genetics, and nutrition. we describe our experience of our eoibd clinic from an immunologic perspective. methods: we conducted a retrospective cohort study through emr chart review of pediatric patients who were referred to our eoibd program ( - ). first diagnosis of ibd under the age of was the inclusion criteria. we assessed the presentation, clinical correlates, and immunologic evaluation. approval was obtained from mayo's institutional review board. data abstraction and analysis was done using the software jmp. results: pediatric patients met the inclusion criteria, with ( %) males and ( %) females. the median age of ibd diagnosis was years ( - years range). median values and the distribution of variables used in the nutritional and immune evaluation were assessed (fig ) . nutritional assessment was remarkable for low to low normal hemoglobin and ferritin levels. vitamin d and albumin levels were overall within the normal range. growth parameters indicated that the median bmi percentile was ( - ). with immune and genetic screening, one patient was found to have x linked chronic granulomatous disease (cgd). immune evaluation of other patients was overall within normal limits. fecal calprotectin served a reliable non-invasive biomarker for inflammation with the median being . ( . - . ). of these patients underwent gi pathogen panel testing of which ( %) tested negative, four ( %) tested positive for c. diff, and two ( %) others to shiga toxin-producing e. coli. it was also noted during the chart review that most patients had poor disease control despite undergoing treatment with various anti-inflammatory and immunosuppressive drugs. the patient diagnosed with cgd underwent bone marrow transplantation. a higher proportion of patients referred to our program in recent years underwent a more comprehensive multispecialty evaluation. conclusion: awareness of monogenic causes of inflammatory disorders in children has increased in recent years. it is also important to rule out intestinal infections that can act as ibd mimic. identifying monogenic disorders and other ibd mimics helps with targeted therapy and symptom improvement in these patients who have a difficult-to-treat disease. the group of children with eoibd, regardless of whether there is an inborn error of immunity, suffers from very high morbidity and a high burden of disease. comprehensive immune-nutrition assessment of eoibd patients paves way for further in-depth immunogenic assessments and allows for global management. abstract/case report text background: chronic granulomatous disease (cgd) is a primary immunodeficiency (pid) affecting the nadph oxidase system in phagocytes resulting in increased susceptibility to catalase-positive organisms. holland presented the first report of dual impact of cgd and hiv in a patient with disseminated nocardiosis. because their cgd patient admitted to history of iv drug use, he was frequently screened for hiv. case: a -year-old african american male with known cgd tested positive for hiv by western blot in the ed in when he presented with complaints of intermittent fever and cervical lymphadenopathy. his cgd was diagnosed by nbt blood testing at years of age. he had frequent skin infections and fever prior to diagnosis. clinically, he did so well that his cgd diagnosis was questioned by his immunologists. however, cgd was confirmed by additional abnormal nbt tests and, ultimately, dhr flow cytometry testing. during his second infectious disease consultation for hiv, at age , he disclosed that he was bisexual. previously, the patient was screened for hiv and hiv antibodies in due to anal fissure. he was screened again in for marked cervical and supraclavicular lymphadenopathy. his cd + t cell absolute count was noted to be low ( /mm ) in at age . until , his prior hiv screenings were negative. during his cgd treatment course as an adult, he was known to be variably adherent with administration of interferon gamma due to adverse effects, particularly pain at the site of injection and malaise. at the time of his positive hiv western blot in , his cd + t cell count was / mm . after starting hiv antiretroviral treatment, his viral load became undetectable. at age , he had burkholderia cepacia pyelonephritis resulting in left nephrectomy. sepsis from b. cepacia was fatal (positive blood cultures without known primary source) in at age . his recent viral load was still undetectable and cd + count was /mm . summary: our case reveals the complexities of treating a patient with both primary and acquired immune deficiencies. it illustrates the importance of taking a thorough social and sexual history starting in adolescence, including those patients with pid. patients with pid should be followed closely by a primary care physician, in addition to an allergist-immunologist and infectious diseases specialist, to ensure age appropriate medical and developmental screening. the recognition of pids is improving due to better screening, awareness, and treatment. currently, the rate of hiv infection is highest among young homosexual african american males. it remains important to understand the epidemiology of primary and acquired immunodeficiencies to best identify those at highest risk. ( ) submission id# phosphatase and tensin homolog (pten) hamartoma tumor syndrome identified by newborn tcell receptor excision circle screening for severe combined immunodeficiency δ) subunits that are critical for cellular signaling. heterozygous gain-offunction (gof) mutations in pik cd (encoding p δ) result in activated pi k δ syndrome (apds ), while heterozygous loss-of-function (lof) mutations in pik r (encoding p α) result in activated pi k δ syndrome (apds ). given its role as a negative regulator of the pi k signaling pathway, heterozygous lof mutations in pten (encoding phosphatase and tensin homolog, pten) result in a clinical phenotype that approximates that of apds /apds and is therefore referred to as activated pi k δ syndrome-like (apds-l). however, sequelae of heterozygous pten lof mutations extend beyond the immune system and include a group of disorders collectively known as pten hamartoma tumor syndrome (phts). although severe t cell lymphopenia at birth would be unexpected in apds , apds , or apds-l, below normal t cell receptor excision circle (trec) counts have been reported in apds , but only in individuals outside of the neonatal period. herein, we describe an infant girl with a low trec count at birth who was found to have phts. case description: a -day-old girl, born at a gestational age of weeks, was found to have a low trec count of /microliter (normal => ). a second trec count obtained at weeks of age resulted as /microliter. arguing against a diagnosis of severe combined immunodeficiency (scid), flow cytometric analyses performed at weeks of age revealed only a modestly diminished cd + t cell count ( /microliter; cd + and cd +) with a normal percentage of naïve and memory cd + t cells ( % and %, respectively). by months of age, her cd + t cell count dropped to /microliter, which was accompanied by a significantly decreased percentage of naïve cd + t cells ( %). sequencing and deletion/duplication analysis was pursued via a commercially available -gene panel aimed at genetically defined primary immunodeficiency (pid), in which no clearly pathogenic mutations were identified. over the following months, the patient was noted to have macrocephaly, tall stature ( th percentile), axial hypotonia, and gross motor delays. sequencing and deletion/duplication analysis was then pursued via a commercially available -gene panel aimed at genetically defined macrocephaly and overgrowth syndromes, in which a hemizygous pathogenic mutation in pten (c. a>g, p.gln arg) was identified. subsequent flow cytometric analyses demonstrated findings characteristic of apds-l, including expanded transitional and cd lo b cells, decreased isotype switched memory b cells, increased effector memory t cells, a lowered threshold for intracellular calcium mobilization upon b cell receptor engagement, and increased basal akt (protein kinase b) and s (ribosomal protein s ) signaling. discussion: we report the first case of phts identified by newborn trec screening for scid. as pten is not included in most commercially available, scid-or pid-tailored gene panels, phts would be missed by conventional genetic testing. therefore, analysis for variants in pten should be considered in neonates with low trec counts, macrocephaly, developmental delay, and other suggestive sequelae. abstract/case report text primary (or familial) hemophagocytic lymphohistiocytosis (hlh) is a rare, life-threatening hyper-inflammatory syndrome affecting mainly young children. it is caused by mutations in genes involved in the granule-dependent cytotoxic pathway, inducing extreme inflammation and massive tissue infiltration by activated t cells and macrophages. standard chemotherapy-based treatment regimens are toxic and induce remission in only % of patients. to this day, hsct is the only available curative treatment, but the inability to efficiently control the inflammation in many patients prior to transplantation often leads to graft failure, with transplant-related mortality around %. thus, the development of new, more potent and less toxic anti-inflammatory regimens would be a major advancement in the treatment of hlh. here, we hypothesize that combination therapies targeting several jak-dependent cytokines will be more effective than monotherapy to reduce the life-threatening symptoms induced by this pathology. using a perforin-deficient (pko) mouse model, we first tested the effects of blocking antibodies against ifnγ, the dominant cytokine secreted during hlh, in combination with antibodies targeting other highly elevated cytokines, such as il- and il- , on the manifestations of the disease. we found that anti-il- r and anti-il- antibodies, when used in combination with anti-ifnγ antibodies, did not significantly improve the symptoms of hlh compare to anti-ifnγ antibodies alone. further, we found that targeting the jak-stat signaling pathway with ruxolitinib, a specific inhibitor of jak and jak , molecules downstream of ifnγ and il- , but not il- signaling, was as beneficial as anti-ifnγ monotherapy. next, we tested the efficacy of ruxolitinib in combination with anti-il- antibody, as this later cytokine is not jak-dependent and was shown to drive macrophage activation syndrome in other contexts. unfortunately, this combination did not result in better symptom resolution than the use of ruxolitinib only. in contrast, combination therapy using ruxolitinib and anti-ifnγ antibodies showed a striking synergistic effect on the resolution of most disease manifestations, to such an extent that our pko mice presented a clinical phenotype indistinguishable than that of a c bl control mice. our findings demonstrate that jak-dependent cytokines are the main cytokines driving the progression of hlh in pko mice. collectively, our results suggest that anti-ifnγ antibodies and ruxolitinib, although effective independently, should be used in combination to more efficiently suppress hlh progression. these results are particularly relevant since the emapalumab, an anti-ifnγ monoclonal antibody was recently approved by the fda for the treatment of hlh while ruxolitinib will soon be in clinical trials for this indication. this project was supported by funds from the fondation de cancérologie charles bruneau and the canadian institutes of health research (mop- ). abstract/case report text introduction: transcription factor (tcf ), also known as transcription factor e -alpha (e a), is a helix-loop-helix transcription factor which plays a critical role in lymphopoiesis. tcf is required for b and t lymphocyte development. defects in tcf have been associated with agammaglobulinemia , autosomal dominant, characterized by low levels of immunoglobulin and early onset recurrent bacterial infections. deletion or diminished activity of tcf may also play a role in lymphoid malignancies. runs of homozygosity (roh) are contiguous stretches of homozygous genotypes at consecutive polymorphic dna marker positions. roh are important reservoirs of homozygous deleterious variation. the homozygosity heterogeneous hmm (h m ) algorithm was specifically developed for analyzing whole exome sequencing (wes) data. the branch point sequence (bps) is an essential splicing signal located - bases upstream of splice acceptor sites. while bps variants are rare, they may result in aberrant pre-mrna splicing and genetic disorders. these variants may be overlooked by standard wes analysis methods because they are intronic and the mammalian bps is a degenerate motif. objective: describe the method used to identify a bps variant in consanguineous brothers with immunodeficiency, including early onset recurrent infections and b-all, hypogammaglobulinemia, t and nk lymphocytosis, low b cells, and low naïve t cells. methods: wes was performed for all family members. data were analyzed using standard read mapping, variant calling and annotation methods. roh were analyzed using the h m algorithm (magi et al. ). roh from the siblings was intersected (bedtools) and the output was submitted to the genomic oligoarray and snp array evaluation tool (v . ). variants were confirmed by sanger sequencing. results: no candidate disease variants were detected in the coding regions, ' or ' splice sites, or utrs for both brothers; however, analysis of intersected roh revealed a homozygous tcf intronic variant within a putative bps (tcf c. - a>t). sanger sequencing of the mutant cdna revealed activation of a cryptic splice site. heritability for routine childhood vaccines has been shown to range from - %. the genetic component of vaccine response suggests we should be able to predict vaccine response in infants with biomarkers. methods: multi-center study of infants born vaginally at full term and followed through months of life. cord blood was collected at birth & peripheral blood was collected at and months of life. six-month collection was weeks post administration of routine vaccinations, while -month collection was immediately prior to receiving the -month booster vaccines. b cell subsets were analyzed with flow cytometry. vaccine titers and cytokines were measured via multi-plex elisa. study was irb approved. results: our data confirmed the immaturity of the newborn humoral immune system with a lower overall b-cell abundance, a predominance of naïve b cells, an inability to class-switch and produce igg or iga, and a th bias. maturation was observed over the first year with increasing overall b-cell abundance, frequency of memory b-cells producing iga, igg, and igm, and frequency of plasmablasts. scd levels also increased throughout the first year due to microbial translocation reflecting establishment of the microbiome. conversely, cord blood contained high levels of baff, april, scd l, il- , and il- , with levels decreasing thereafter. all infants displayed evidence of humoral immune system activation after getting -month vaccines. total plasmablast levels peaked weeks after receipt of month immunizations. a decrease in total plasmablasts was evident between and months, although levels remained above those at birth, corresponding with the need for -month booster vaccinations to maintain long-lasting immunity. il- and ifn-gamma had a significant positive correlation with memory b cells and plasmablasts at subsequent time points suggesting that these cytokines play a role in b cell differentiation and vaccine response. baff and april cytokines were elevated at birth, consistent with germinal center formation and underwent a compensatory decrease thereafter. april & scd levels in cord blood significantly correlated with higher tetanus titers at months suggesting that vaccine response may be predicted by cytokine biomarkers at birth. response to vaccines was also dynamic with il- levels being significantly correlated with tetanus titers at weeks after receipt of month immunizations. conversely, scd l levels did not correspond to b cell development consistent with a known b cell hyporesponsiveness to cd l in infants. conclusion: humoral immune development is both predictable and dynamic. biomarkers in the cord blood, produced by the infant, are predictors of b cell development and vaccine response in infancy. background: adult-onset immunodeficiency with anti-ifnɣ autoantibodies is a newly described immunodeficiency syndrome characterized by disseminated nontuberculous mycobacterial and other opportunistic infections in previously healthy middle-aged individuals typically from southeast asia. it is caused by the presence of autoantibodies directed against the cytokine ifnɣ, which is required for intracellular pathogen killing by macrophages as well as phosphorylation of the transcription factor stat , which is involved in cell survival gene expression. successful treatment of the immunodeficiency has been described in prior case reports with immunomodulatory therapies, including rituximab. however, there are no standard recommendations for dosing or timing of these agents, or recommendations for longterm monitoring of disease activity. case presentation: a -year-old laotian woman with a history of type diabetes and possible prior hepatitis c infection presented to the immunology clinic for evaluation of immunodeficiency. in the two years prior to presentation, the patient was diagnosed with mycobacterium avium infection involving the parotid gland and lymph nodes of the neck, mycobacterium avium complex bacteremia, histoplasma capsulatum involving the lymph nodes of the neck, and leukocytoclastic vasculitis of the lower extremities. as a child and young adult, she had no severe or recurrent illnesses and did not suffer from any chronic disease. preliminary immunologic testing demonstrated normal t, b, and nk cell subsets, elevated immunoglobulin g, a, and m levels, and protective titers to tetanus, diphtheria, and / pneumococcal serotypes. measurement of anti-ifnɣ autoantibodies was positive, which led to the diagnosis of adult-onset immunodeficiency with anti-ifnɣ autoantibodies. the patient was treated with four doses of monthly rituximab with resolution of the anti-ifnɣ autoantibodies, restoration of normal stat phosphorylation, and depletion of cd -positive b cells. after a -year period of being lost to follow-up, during which she continued to receive rituximab every months at the direction of a local provider, the patient re-presented to the immunology clinic to re-establish care. at that time, the patient had no evidence of anti-ifnɣ autoantibodies based on titers and normal stat phosphorylation. cd -positive b cells remained depleted. the patient also confirmed subjective clinical improvement and denied any interim infectious complications. conclusion: this case provides an example of successful treatment of a patient with adult-onset immunodeficiency with anti-ifnɣ autoantibodies with rituximab. it also highlights the utility of ifnɣ functional testing with stat phosphorylation, which may be used to monitor disease activity and to make decisions about ongoing immunomodulatory treatment. it is necessary to monitor additional immunological markers to refine the diagnosis of a secondary post-lt immunodeficiency to take preventive measures before infections occur. we sequentially measured t lymphocytes and antibodymediated immunity in a -year-old male receiving a lung transplant for idiopathic pulmonary fibrosis to determine which immune indicators could improve the identification of a secondary immunodeficiency. methods: t and b cell numbers, igm, igg, iga, ige and igg subclasses and specific antibodies to s. pneumonia capsular polysaccharides were assessed over a months-long post lt period. the clinical progress, infections and pulmonary function were monitored prior to transplantation and at regular intervals thereafter. results: the patient had progressive idiopathic pulmonary fibrosis starting with an episode of pulmonary hypersensitivity years earlier. he developed increasing respiratory failure progressing to complete dependency requiring a lt in june . he was treated with prednisone, mg/ day continuously for months, then decreased to mg/day. other immunosupressants included mycophenolic acid and tacrolimus and on/ off antibiotics that eventually led to severe tendinitis at - months post lt. at ½-month post lt he developed an early onset bronchiolitis obliterans syndrome (bos) that was controlled by increasing the prednisone dose. sequential immunologic evaluation showed his igg dropping from , mg/dl to after two weeks and then remaining stable at that level for the rest of the observation period. igm and iga had minor variations and ige remained very low. igg fell from - mg/ml pre-lt to - in weeks and remained stable at that level thereafter. antibodies against s. pneumoniae polysaccharides started high, between - ·g/ml for all serotypes and fell rapidly in the first weeks post lt, then continued a steady decline with > % serotypes falling < . ·g/ml at months. twelve of pneumococcal serotype antibodies increased above . ·g/ ml after igg replacement at months. cd t lymphocytes decreased from ± , cells/ul to - at month, remaining at that number after that. cd /th cells increased from - cells/ul to at months when prednisone was tapered down and then decreased to after increasing the prednisone dose again. this decrease coincided with a reduction in bos manifestations. conclusions: immune monitoring revealed an independent decrease of immunoglobulins with a stronger decrease in igg and specific pneumococcal antibodies. the role of th cell increase in developing bos needs further investigation. stat is a frequent target of cancer therapies due to its role in certain malignancies for cell proliferation and metastasis. with lof stat , decreased incidence of some cancers may be expected, however increased rates of lymphoma are described. we sought to describe the incidence and spectrum of malignancy in our relatively large lof stat cohort. methods: we performed a retrospective analysis of lof stat patients evaluated at the nih clinical center to determine the type of malignancies diagnosed, treatments received, and outcomes following therapy. results: a total of patients with malignancies were identified (cancer incidence %). six patients ( %) were diagnosed with non-hodgkin lymphoma (nhl); with diffuse large b-cell lymphoma (dlbcl) and with burkitt lymphoma (bl) with age at diagnosis ranging from years to years with median age of years. pathology staining for ebv was available in four patients; all of whom were negative by eber. all dlbcl patients received da-epoch-r for - cycles, and all achieved complete remission. five of patients with lymphoma are alive and disease-free. one patient died of heart failure years post chemotherapy without disease relapse. two patients were diagnosed with papillary thyroid carcinoma at ages and , one of whom was subsequently diagnosed with nhl. two other patients were diagnosed with basal cell carcinoma of the skin at ages and ; both of whom had prior voriconazole exposure. conclusion: malignancy, most commonly nhl, occurs in patients with lof stat mutations. nhl should be considered in patients with progressive lymphadenopathy, and thyroid carcinoma should be considered in patients with thyroid nodules. patients treated with voriconazole are at an increased risk of skin cancer and require careful skin monitoring. as survival increases, it will be important to monitor the incidence of malignancies diagnosed, as it is possible that decreased stat signaling may prove to be protective of some cancers, such as colon and breast carcinoma, in which increased stat signaling is implicated in pathogenesis. abstract/case report text introduction: recurrent pneumonia is defined as or more episodes of pneumonia in one year or more than pneumonias throughout life (with radiological resolution between episodes). in retrospective studies, up to % of adult subjects with recurrent pneumonia coursed with primary immunodeficiencies (pid). prospective studies evaluating the etiology of recurrent pneumonia are scarce. diagnostic delay and inappropriate management of patients with pid (predominantly antibody deficiency for example) could lead to irreversible lung damage or even death from serious infections. here we present the frequency of primary immunodeficiencies in adults with recurrent pneumonia in cali, colombia. methods: we present preliminary data of a descriptive prospective study that will include patients with recurrent pneumonia. women and men > and < years old will be included. all volunteers will be evaluated by a clinical immunologist, complete blood count and serum igg, iga, igm and ige levels will be determined. according with clinical suspicious, igg subclasses, anti-pneumococcal igg response and b cell subpopulations will be performed. the project will be executed in months. written informed consent has been obtained for all subjects included. this project count with irb approvals at universidad del valle and hospital universitario del valle. results: a total of recurrent pneumonia cases have been included in the study. the mean age was . years ( - years) with a female:male ratio : . moderate-severe dyspnea was observed in / cases (medical research council -mrcdyspnea scale to ). non cystic fibrosis bronchiectasis was found in / cases ( %). the main etiologies of recurrent pneumonia were: primary immunodeficiency / ( %); asthma / ( . %); autoimmunity / ( . %); primary ciliary diskinesia / ( . %) and others. hypergammaglobulinemia represented / ( %) of cases. primary immunodeficiencies, % of recurrent pneumonia cases, were classified as: predominantly antibody deficiency ( cases) including cvid cases, igm deficiency cases, selective iga deficiency cases, igg subclasses deficiency case, hypogamaglobulinemia case and agammaglobulinemia case. combined immunodeficiency: dock deficiency case and ataxia telangiectasia case. conclusion: to the best of our knowledge this is the first prospective study evaluating the etiology of recurrent pneumonia in colombia. predominantly antibody deficiencies and igg hypergammaglobulinemia affect % of adults with recurrent pneumonia in colombia. this study allows us diagnosed more than new cases of adult onset pid. immunological evaluation is critical in the assessment of patients with recurrent pneumonia. conflict of interest: authors disclosure any potential financial conflict of interest related to this abstract. acknowledgements: this investigator-initiated research was supported with a grant from baxalta us inc, a member of the takeda group of companies bt - /iir-col-bxlt- . abstract/case report text introduction: lysinuric protein intolerance (lpi) is an autosomal recessive metabolic disorder due to pathogenic mutations in slc a . it is distinguished by decreased plasma concentrations and increased urinary excretion of lysine, arginine and ornithine and can present with multiorgan involvement and a spectrum of immune deficiency. we present a five-year-old female with lpi, early-onset juvenile systemic lupus erythematous (sle), hemophagocytic lymphohistiocytosis (hlh), and granulomatous skin lesions that were positive for vaccine-strain rubella. methods: retrospective chart review was conducted. laboratory investigations included lymphocyte immunophenotyping by flow cytometry, lymphocyte proliferation to mitogen, quantitative serum immunoglobulins, vaccine titers, autoantibodies, metabolic studies, and genetic evaluation by next generation and whole exome sequencing. results: a five-years-old female of mixed native american and african american race presented at years of age with severe failure to thrive, history of recurrent fevers, joint swelling, recurrent skin lesions, severe anemia and neutropenia, and hypergammaglobulinemia. upon further evaluation, she demonstrated hyperferritinemia and ana, rnp, smith, and ss-a autoantibodies and was diagnosed with early-onset juvenile sle. laboratory immune evaluation revealed age-appropriate lymphocyte subpopulations and lymphocyte proliferative responses to mitogens and antigens, markedly elevated igg, iga, igm with no associated monoclonality, and protective tetanus and pneumococcal titers. given her severe clinical manifestations at an early age, concern for immunodeficiency prompted further genetic evaluation with next generation dclre c sequencing, which was negative, and whole exome sequencing, which revealed two heterozygous mutations in slc a , consistent with lpi. laboratory metabolic evaluation was also consistent with a diagnosis of lpi. she continued to experience recurrent cutaneous lesions on her upper and lower extremities. biopsy findings were consistent with a granulomatous lesion and subsequently identified by the cdc to have vaccine-strain rubella infection. due to recurrent pneumonia and concern for pulmonary alveolar proteinosis (pap), pulmonology was consulted and eventually confirmed pap, and she has required home oxygen supplementation. given her history of recurrent infections and vaccine-strain rubella infection, supplemental ivig was initiated. her sle has been fairly refractory to medical management, including systemic corticosteroids, mycophenolate, rituximab, and cyclosporine. she recently developed hlh at years of age and is currently maintained on canakinumab, mycophenolate, and systemic corticosteroids, yet continues to have sle and pap that has been difficult to control. conclusion: the range of clinical and immunologic findings in lysinuric protein intolerance has varied widely in the literature. our patient presented with early-onset juvenile sle and did not develop hlh and pap until years after initial presentation. despite relatively normal cellular immunity by laboratory evaluation, our patient was identified to have chronic infection with vaccine-strain rubella virus, indicating severe t cell dysfunction, and poses challenges for future immunomodulatory treatment. introduction: x-linked immunodeficiency with magnesium defect, ebv infection, and neoplasia (xmen) disease is caused by lossof-function (lof) mutations in the magnesium transporter (magt ) gene. it is a rare x-linked combined immunodeficiency and selective congenital disorder of glycosylation. clinical manifestations include chronic ebv viremia, recurrent bacterial and viral infections, lymphadenopathy, splenomegaly, autoimmunity, liver and central nervous system (cns) abnormalities. magt deficiency was first noted to result in chronic ebv infection and an increased susceptibility to ebv+ lymphomas. we recently recognized merkel cell carcinoma at a very young age in two xmen patients, leading to our review of the malignancies in this cohort. methods: we reviewed the records of male patients ( seen at the nih) with confirmed hemizygous lof mutations in magt for diagnosis of malignancy, therapy, and outcome. results: we identified malignancy in patients of with magt deficiency ( %). four patients had hodgkin's lymphoma (hl) (ages - years), three had non-hodgkins lymphoma (nhl) (ages - years), one had kaposi sarcoma ( years) , one patient developed eber-negative liposarcoma (age years) after receiving chemo and radiotherapy for severe lymphoproliferative disease (lpd) at age years and two had merkel cell carcinoma at exceedingly young ages ( and years). all patients had chronic ebv viremia. they all received treatment according to established protocols. currently, all except for three patients are alive and in remission, including one post-hsct. overall malignancy survival of %. it is important to note that three patients who did not have malignancy had ebv lpd so severe that it warranted treatment with a malignancy protocol, with one mistaken as having lymphoma. conclusion: xmen immune deficiency, an x-linked glycosylation disorder, is a multisystem disease associated with increased susceptibility to malignancies. initially, ebv driven lymphoproliferation and lymphoma was described with xmen; however, with increasing diagnoses, more malignancies are being recognized. all the recognized malignancies are associated, at least in part, with dnaviruses, including ebv, hhv- , and merkel cell virus. understanding the clinical phenotype and pathogenesis of this disease will improve monitoring and early diagnosis of malignancies for patients with magt deficiency. abstract/case report text background: primary immune deficiencies (pid) constitute a heterogeneous group of over individually rare congenital diseases that involve genes coding for proteins of the immune system, and which result in increased susceptibility to infection, inflammation, autoimmunity, allergy and cancer. the complexity of the diagnostic task, and the intrinsic biases and limitations of the human mind, can be aided by computational tools. among the available machine learning approaches, decision tree algorithms select the best node to split based on entropy and information gain; random forests build dozens or thousands of decision trees randomly to improve accuracy and reduce overfitting. aim: to implement a machine learning-assisted clinical decision support system for the diagnosis of pid. methods: with a local database of patients with suspected iei, we built a decision tree using c . dtc, and a random forest on python . (jupyter notebook, scikit, mathplotlib, pandas, numpy). the database was obtained by conducting an electronic search on medsys of patients with the term "immunodeficiency" in their electronic medical records, and then hand-picking cases in which a pid had been confirmed or ruled out. it consisted of patients, of which had been diagnosed with iei. we first split the dataset randomly into training ( %) and testing ( %) sets. the decision tree was tasked with classifying correctly pid or not. after running the algorithm in the training set, we evaluated in the testing set through cross-validation. results: accuracy was greater than % for the dataset (pid/not). . for the dtc with levels. the attribute with the lowest gini coefficient was low iga ( . ). accuracy for the random forest classifier was . with trees. feature importance was highest for lung infection ( . ), high igg ( . ), low iga ( . ), skin infection ( . ), no isolate ( . ), and allergy ( . ); it was lowest for consanguinity, high igm, central nervous system infection, parasites and no infections. during the random generation of trees, accuracy reached up to %. discussion: we built two classification models. decision trees lend themselves more easily to learning and deriving rules of thumb from their sequences. random forests are more robust and better suited for categoric (as opposed to binary) classification. we next want to develop a chatbot, currently under construction, that will ask relevant questions in optimal sequence, and extract undiagnosed patients with suspected iei, based on statistical "red flags". we also have preliminary results of this process applied to a usidnet database with over , patients, and are also working on multinomial logistic regression and naïve bayesian classifiers for this and other databases. abstract/case report text objectives: acute viral respiratory infections (avri) are associated with significant healthcare resource use and cost. the use of intravenous immunoglobulin (ivig) may be an effective treatment for immunosuppressed patients and reduce overall healthcare resource utilization. the goal of this study was to assess hospital resource utilization associated with ivig use among patients hospitalized for avri. methods: using data from the - premier hospital database, we identified patients hospitalized with a diagnosis of avri [respiratory syncytial virus (rsv), parainfluenza virus, rhinovirus, or metapneumovirus], and who had an immune deficiency (chemotherapy treatment, transplant, primary immunodeficiency disorder (pidd), specific antibody deficiency, other immunodeficiency, or disorders of the immune or lymphatic systems). patients receiving ivig within the first hours were compared to patients who did not receive ivig at all. due to the nature of the need to better understand the treatment effect associated with ivig, we used an inverse probability weight-based regression model. since there were substantially more controls than cases, we randomly drew , controls. a logistic regression model was developed to adjust for factors associated with the probability of ivig use within hours of admission. this propensity score was then used to weigh subsequent models to assess length of stay (total and icu) using negative binomial models and logistic regression for inpatient death. results: a sample of , immunocompromised inpatients were identified, receiving ivig within the first hours of admission and , who did not receive ivig. the ivig group was older (mean age vs , p < . ), had more antiviral use ( % vs %, p < . ), and had less cancer ( % vs %, p < . ). after adjustment for immunity type (transplant, cancer), rsv, pidd, age, prednisone, antiviral use, ribavirin use, urban hospital setting, teaching status, intubation and lung disease, patients with ivig use had . less days of hospitalization (p= . ) and . less days in the icu (p= . ) than non ivig users. conclusions: this data analysis suggests that hospital length of stay and icu length of stay were significantly shorter for immunocompromised patients hospitalized for acute viral respiratory infections who were administered ivig within the first hours of admission, as compared to patients who did not receive ivig. it is possible that ivig use may have an impact on hospital resource utilization and costs. future prospective studies would help further assess the role of ivig in patients hospitalized with acute viral respiratory infections. associate professor/yale university abstract/case report text background: cd ligand deficiency is an x-linked combined immunodeficiency associated with opportunistic infections and increased risk of malignancies. expansion of memory cd + t-cells with senescent features is known to be associated with chronic immune stimulation including aging, chronic infection and malignancy. cd + t-cell characteristics of cd l deficient (cd ld) patients in relation to their clinical history have not been described. objective: we studied correlation between cd + t-cell senescence with clinical histories of cd ld patients. methods: we analyzed the frequency and phenotypic characteristics of peripheral cd + t-cell subsets in four cd ld patients ( , , and years old (yo)) and healthy controls (hcs). t cell excision circle (trec) counts and telomere lengths of the patients and hcs were measured using quantitative pcr. in-depth analysis of cd + t-cells of the yo patient and hcs was done using high-dimensional cytometer time of flight analysis (cytof). results: three patients ( , and yo) with histories of recurrent infections and poor compliance with immunoglobulin therapy (ivig) showed an increased frequency of effector memory cd + t-cells with the senescent phenotype compared to age matched hcs. whereas yo patient with excellent ivig compliance starting at infancy did not show any senescence phenotypes of the cd + t-cells. the telomere length and trec count of each patient correlated with the degree of cd + t-cell senescence and their current ages, respectively. in-depth analysis showed similar expression patterns of molecules related to senescence and cytotoxicity in cd + t-cells including cd , t-bet, eomes, granzyme b and perforin in the yo patient and mid-elderly hcs. conclusion: our findings suggest that prompt diagnosis and compliance with ivig starting at the infancy may prevent early onset cd + t-cell senescence in cd l deficiency. abstract/case report text introduction: immunoglobulin g -related disease (igg -rd) is an immune-mediated fibroinflammatory condition that affects multiple organs. when igg -rd is found in the ocular adnexa, the term "igg related ophthalmic disease (igg -rod)" is used. objective: our case describes a patient with igg -rod without systemic involvement. case: mr. x is a -year-old male with a pmh of cml (on imatinib) and allergic rhinitis who presented to clinic with orbital swelling for twenty years. his swelling had always been responsive to steroids, but would return once steroids were tapered. patient was diagnosed with biopsy proven cml in and is currently taking imatinib. because his peri-orbital edema persisted, a right lacrimal gland biopsy was done which showed "marked lymphocytic infiltrate of soft tissue with lymphoid follicles, many plasma cells, and eosinophils. no atypical histiocytes." flow cytometry was negative for malignancy. results: crp . mg/l. esr mm/hr. igg elevated at mg/dl. ct chest from and ct chest, abdomen, pelvis from were without fibrotic changes. assessment: when diagnosing igg -rd, we categorize diagnosis into three levels (possible, probable, or definite) by three criteria (clinical manifestation, elevated serum igg , and histopathology). this is detailed as follows: clinical exam showing organ specific swelling or masses, elevated serum igg (> mg/dl), and histopathology with either lymphocyte and plasmacyte infiltration and fibrosis or infiltration of igg + plasma cells (ratio of igg +/igg+ cells ≧ % and ≧ igg + plasma cells per high power field). not all these components are required for diagnosis, but meeting histopathologic criteria makes diagnosis more probable. our patient's disease was localized to his eye, and patients with igg -rod have unique diagnostic criteria. these criteria are similar to the criteria for igg -rd, but emphasize enlargement of the ocular adnexa, less frequent fibrosis, and ≧ igg + plasma cells per high power field. our patient's histopathology revealed a lymphoplasmacytic infiltrate, but lacked storiform fibrosis or obliterative phlebitis. his serum igg level was mg/dl, and his biopsy was positive for an igg +/igg+ ratio of % and more than igg + plasma cells per high power field. based on this, he meets criteria for igg -rod. conclusion: igg -rod is a rare condition that is usually associated with systemic organ involvement. our case is unique, as no systemic disease has been detected. we also suspect our patient has been living with igg -rod for several years, as his orbital swelling began in high school. it is important to note that he has been on imatinib, a tyrosine kinase inhibitor, for treatment of his cml. imatinib inhibits c-abl and platelet-derived growth factor receptor, tyrosine kinases involved in profibrotic pathways. patient's lack of fibrosis could also be due to his longstanding use of this drug. it is also possible that he has a rare form of igg -rod without systemic involvement. a limited number of such cases have been reported, but no consensus has been made on why disease course was localized. our patient was started on rituximab, and his serum igg decreased to mg/dl after the first cycle. we hope his disease achieves remission. informed consent: informed consent was obtained from all individual participants included in the study. abstract/case report text platelet abnormalities with eosinophilia and immune-mediated inflammatory disease (plteid) is a recently discovered combined immunodeficiency with inflammatory and allergic manifestations with few cases reported. we describe a female patient with compound heterozygous mutation in arpc b gene with suggestive clinical findings of plteid. a -year-old girl presented with chronic diarrhea since neonatal period, with bloody stools and failure to thrive. she also presented atopic dermatitis, recurrent cutaneous and mucosal ulcers, recurrent respiratory infections ( episodes of otitis media, pneumonias) and many episodes of mucocutaneous candidiasis. family history revealed a sibling deceased in the second month of life, who presented a similar clinical picture and a paternal uncle and second degree cousin that died in the first year of life. there is no history of consanguinity. laboratory evaluation revealed peripheral eosinophilia ( /mm ), normal platelet numbers with low platelet volume ( , fl -reference value , - , fl), normal igm levels with elevated igg ( mg/dl-rv - mg/dl), iga ( mg/dl -rv - mg/dl) and ige ( iu/ml -rv a) associated with plteid. t h e i n f a n t r e c e i v e s a n t i m i c r o b i a l p r o p h y l a x i s w i t h sulfamethoxazole-trimethoprim and fluconazole, intravenous immunoglobulin replacement and was referred to hematopoietic stem cell transplantation (hsct). this case was the first one described in brazil and highlights the importance of seeking for a genetic diagnosis in patients with complex clinical phenotypes. precise diagnosis can impact on treatment approach. live vaccines are generally contraindicated in patients with combined immunodeficiency (cid). however, in less severe cid, such as partial dgs, those vaccines can be considered depending on the immunologic status of the patient. there are recommendations regarding to measles, mumps, rubella (mmr) and varicella vaccines, but yellow fever vaccine (yfv) is generally contraindicated in this population. considering the severity of the yellow fever disease and the absence of specific treatment, the use of this vaccine is an important topic for debate in cases of patients from endemic areas. objective: this study aimed to describe the use of yfv and other live attenuated vaccines in patients with dgs, associating it with their immunological profiles and the presence of adverse effects. methods: retrospective study of medical records of patients with dgs confirmed by mlpa or fish, followed in a pediatric reference center for primary immunodeficiencies between and . collected data included: demographic characteristics, medical history, history of immunization with live vaccines, postvaccination adverse reactions and immunological profile, including immunoglobulins levels, serologic vaccination responses, lymphocyte immunophenotyping, lymphocyte proliferation responses to mitogens and prophylactic treatments (antibiotic or immunoglobulins). results: thirty-five patients with confirmed dgs and median age of years ( - y) were included ( m: f). thirty-three children ( %) received mmr vaccine: nine presented t lymphopenia. two of the patients had cd < , one of them with normal mitogenic proliferation response and the other was not tested. three of the patients had low immunoglobulins levels ( / low igg, / low igm and / low iga), and one of them received intravenous immunoglobulin (ivig). twentynine of had normal serologic vaccination responses. adverse effect was only reported by one patient, who had one episode of fever after the administration of all vaccines. yellow fever vaccine was administrated to children ( %): had t cell l y m p h o p e n i a ( b u t c d > ) , a n d a n o t h e r p a t i e n t h a d hypogammaglobulinemia and received ivig and prophylactic antibiotics. twelve of showed adequate serologic responses to mmr and hepatitis b. only patient reported mild reaction (tremors) two days after the yfv administration. the same patient had normal t cells, immunoglobulins and vaccine responses. twenty patients ( %) received bacillus calmette-guerin vaccine (bcg), ( %) received oral polio, ( %) rotavirus and ( %) received varicella vaccine. no severe adverse events were documented in any patient that received live vaccines, and no patient developed measles, mumps, rubella or yellow fever diseases as a consequence of administration of the vaccine. conclusions: in this cohort of pediatric patients with dgs, yfvand other live vaccines were well tolerated, and no severe adverse events were reported, suggesting that widespread contraindication of yfv may endanger unvaccinated patients with less severe phenotype living in endemic areas. immunological evaluation and individualized decisions are always recommended, and further studies are needed to assess the safety of the yfv in this pediatric population. abstract/case report text introduction: lad-i is a rare inherited disorder of leukocyte (primarily neutrophil) adhesion to endothelial cell surfaces, migration, and chemotaxis resulting from itgb gene mutations encoding for the β -integrin component, cd . severe lad-i (i.e., cd expression on < % of neutrophils) is characterized by recurrent serious infections, impaired wound healing, and childhood mortality. although allogeneic hematopoietic stem cell transplant (allohsct) is potentially curative, its utilization and efficacy are limited by hla-matched donor availability and risk of graftversus-host disease (gvhd). rp-l - (clinical trials.gov # nct ) is a phase / open-label clinical trial evaluating the safety and efficacy of autologous cd + cells transduced with a lentiviral vector (lv) carrying the itgb gene encoding for cd (chim-cd -wpre) in severe lad-i. methods: pediatric patients ≥ months old with severe lad-i (demonstrated by cd expression on < % neutrophils and at least one prior significant bacterial or fungal infection) are eligible. peripheral blood (pb) hematopoietic stem cells are collected via apheresis after mobilization with granulocyte-colony stimulating factor (g-csf) and plerixafor. cd + hspcs are selected, transduced with chim-cd -wpre lv, and cryopreserved. myeloablative conditioning with busulfan (therapeutic drug monitoring (tdm) dosing with adjustments to enable target area under the curve (auc)) is administered over days, followed by infusion of the thawed investigational drug product (rp-l ). patients are followed for safety assessments including replication competent lentivirus (rcl) and insertion site analysis (isa), and for efficacysurvival to age ( months) and at least -year post-infusion without allohsct, increase in neutrophil cd expression, pb vector copy number (vcn), decrease in infections and/or hospitalizations, and resolution of skin or periodontal abnormalities. results: an initial lad-i patient (age years) with recurrent severe infections and documented itgb mutations has been treated as of november . baseline cd , cd a, and cd b expression were < %. mobilization and apheresis procedures were performed successfully and busulfan conditioning was administered at the target auc. investigational product was comprised of . x e cd + cells/kg with vcn of . copies/cell (liquid culture), and was infused without complications. no serious treatment-emergent adverse events were reported. neutrophil engraftment ( consecutive days of anc ≥ ) was observed days post-infusion. pb pmn cd expression months posttreatment was . % with comparable cd a and cd b expression levels; pb cd (myeloid) vcn at . months was . . safety and efficacy data months post-treatment will be available at the time of presentation, in addition to preliminary data regarding a potential additional patient. conclusion: preliminary evidence demonstrates that rp-l enables itgb genetic correction with robust cd /cd neutrophil expression in this frequently fatal primary immunodeficiency. abstract/case report text introduction: the complement system plays an integral role in the innate immune system and links innate and adaptive immunity. complement deficiencies, hereditary or acquired, are rare. acquired deficiencies are more prevalent, occurring in nephrotic syndrome, reduced hepatic synthesis or transiently in sepsis/viremia. they are also seen in the presence of autoantibodies known to cause depletion of complement factors, such as c nephritic factor (c nef). c deficiency is associated with infection susceptibility, particularly to encapsulated bacteria, and immune complex disease. case description: a year old male was evaluated for recurrent infection. in childhood, he had recurrent sinusitis, otitis media requiring tympanostomy tube placement and persistent pharyngitis despite tonsillectomy. as a teenager, he developed glomerulonephritis, progressing to end stage renal disease and requiring transplant at age . the kidney allograft failed years later, with biopsy demonstrating recurrent glomerulonephritis. the patient was transitioned to peritoneal dialysis and later hemodialysis, due to recurrent pd-related infections. his adult course was complicated by recurrent methicillin sensitive staphylococcal aureus (mssa) catheter and soft tissue infections (cellulitis and abscess), sinusitis, sepsis (streptococcal, mssa and tularemia), multifocal pneumonia and a left below knee amputation for osteomyelitis that required revision surgery. patient reported other autoimmune phenomena including a presumptive diagnosis of vasculitis and possible lupus-like syndrome. the constellation of recurrent infections and autoimmune features was most concerning for an early complement deficiency. prior work up was notable for low c , ch and ah with normal c , factor h and factor i. extensive laboratory work up revealed normal c q, c level and function, serum immunoglobulins, vaccine titers, factor b and factor d levels. atypical hus (ahus) panel revealed a heterozygous silent variant in exon of cfh and a heterozygous polymorphism within an intron in mcp/cd , seen with increased prevalence in the patient population with ahus. wes was notable for a variant of uncertain significance in the vcl gene only. c level and function were markedly decreased, alongside low ch and ah . both sc b- level and c nephritic factor were elevated. a diagnosis of acquired c deficiency due to c nef was made and patient was started on bactrim prophylaxis. he has remained free of serious infection since starting antibiotic prophylaxis. discussion: c nef stabilizes the alternative pathway c convertase, c bbb, increasing its half-life and blocking dissociation. this leads to unregulated consumption of c with subsequent deficiency. c nef has been associated with c glomerulopathy, infection and partial lipodystrophy. however, there is marked heterogeneity in clinical phenotypes with reported asymptomatic individuals. our patient's glomerulonephritis likely represents c glomerulopathy. case reports and series of successful treatment of c glomerulopathy with rituximab and eculizumab have not commented on immune outcomes beyond the kidney. other potential therapeutic strategies include plasma cell depletion with either bortezomib or daratumumab. further study is needed to evaluate these therapies influence on both reversal of c depletion and overall impact on immune function in the setting of c nef. abstract/case report text introduction: patients with heterozygous signal transducer and activator of transcription (stat ) gain of function (gof) pathogenic variants exhibit an array of phenotypes including susceptibility to viral, bacterial, fungal and mycobacterial infections, autoimmunity, and cancer predisposition. progressive disseminated histoplasmosis (pdh) is well-described to affect infants. however, no reports have evaluated underlying monogenic immune dysregulation in previously healthy infants presenting with pdh. we report an infant who presented with pdh and associated hemophagocytic lymphohistiocytosis (hlh) leading to the diagnosis of a heterozygous stat gof mutation. case report: a previously healthy -month old male presented with persistent fever, pancytopenia, transaminitis, elevated ferritin, hepatosplenomegaly and coagulopathy. his clinical and laboratory evaluations were concerning for hlh syndrome. he had no prior history of immune hyperactivation or atypical infections. secondary causes of hlh were investigated, and patient was diagnosed with pdh based on marked histoplasma antigenemia. targeted genetic testing did not reveal a genetic etiology of familial hlh. he was successfully treated with a pulse and taper of dexamethasone as well as liposomal amphotericin b with transition to itraconazole. immunologic evaluation at the time of initial presentation demonstrated increased mean channel fluorescence for both perforin and granzyme noted in his nk cells. his nk function was decreased; however, he had a normal cd a degranulation assay. his b-cell panel demonstrated low non-switched memory b-cells, low switched memory b-cells and low total memory b-cells. given his extreme immune activation with histoplasmosis, abnormal immunologic testing, and persistent lymphopenia despite resolution of his infection, a primary immunodeficiency next generation sequencing panel was sent. the results demonstrated a pathogenic variant in stat (c. c>t; p.ala val). this single nucleotide variant has been previously shown to be pathogenic (clinvar). abstract/case report text introduction: cytotoxic t lymphocyte antigen- (ctla- ) is known to have an important role as a negative regulator of immune responses, participating in the control of regulatory t cells and effector t cells. in mice its absence is associated with fatal autoimmunity and several ctla- mutations, leading to low or absent ctla- expression, have been shown in humans to be associated with a phenotype that includes hypogammaglobulinemia (with recurrent respiratory infections) and several manifestations of autoimmunity (enteropathy, granulomatous lymphocytic interstitial lung disease, organ infiltration, splenomegaly, autoimmune cytopenias, lymphadenopathy, amongst others), in an autosomal dominant mode of transmission. one of the published mutations, c.c t, that results in an alanine to valine substitution (p.a v), with a highly conserved alanine at that position, had a cadd score of and was associated with the phenotype above, and was shown to be associated with a low expression of ctla- on regulatory t cells and with low ctla- function (reduction of ctla- -mediated transendocytosis). methods: after irb approval, we searched for ctla- mutations present in the biome biobank· biorepository, containing whole exome sequencing data on patients, with data obtained using illumina· v hiseq sequencing platform. sifting through all the ctla mutations in the data, we identified four patients with the c.c t mutation described above. extensive chart review of the four patients was performed. results: four patients were found with the ctla- c.c t mutation. none of them had any of the described phenotypical characteristics of ctla- deficiency. patient is a -year-old male with history of coronary artery disease, atrial fibrillation, stroke, hypertension, brain aneurysm, chronic kidney disease, gout and depression. patient is a -year-old female with history of morbid obesity. patient is a -year-old female with history of hypertension, obesity, pre-diabetes, dyslipidemia and iron deficiency anemia. patient is a -year-old female with history of peripheral artery disease, hypertension, dyslipidemia, chronic kidney disease and lung cancer. conclusion: prior literature has attempted to characterize the clinical penetrance of ctla- mutations, suggesting it to be around %, with that number applying to different mutations in ctla- mutation carriers. we screened a large biorepository of more than thousand patients for ctla- patients and identified four patients that carry one of the best described ctla- mutations, previously validated from a functional standpoint and associated with a severe phenotype. none of the four patients demonstrated any of the previously described phenotypical characteristics, and all four have ages above the median age of onset of years. with the increasing use and broad population application of genetic studies, it is crucial to define the value of identifying presumed pathogenic variants in the absence of the adequate phenotype, with all the prognostic, therapeutic and ethical considerations it may imply. prior case reports of pil patients with b-cell malignancies have discussed treatment regimens with chemotherapy, radiation, and/or surgery, but neither the use nor the outcomes of allogeneic hematopoietic stem cell transplantation (hsct) in the management of recurring b-cell malignancies have been readily reported. case description: a -year-old man with pil and an accompanying history of lymphopenia, hypoproteinemia, hypoalbuminemia, and hypogammaglobulinemia was diagnosed with diffuse large b-cell lymphoma (dlbcl) of the liver following a preceding history of burkitt lymphoma of the ileum at years of age and dlbcl of the liver at years of age, in which each malignancy was genetically distinct. in addition, the patient had a history of benign nodular adenomatoid hyperplasia of the thyroid at years of age that required a hemi-thyroidectomy. treatment considerations for the patient included chimeric antigen receptor t-cell therapy, autologous hsct, and allogeneic hsct, in which allogeneic hsct was ultimately pursued. prior to hsct, the patient was lymphopenic ( cells/microliter) with significant t-cell lymphopenia ( cells/microliter) and an increased proportion of memory t-cells ( % of his cd + t cells were cd ro+), as well as hypogammaglobulinemic (igg mg/dl; iga mg/dl; igm mg/dl). immediately following treatment of his dlbcl with rituximab, ifosfamide, carboplatin, and etoposide, the patient underwent a matched-related sibling donor hsct with a preparative regimen of busulfan, thiotepa, and fludarabine. now months status-post hsct, the patient has maintained full-donor chimerism and has no evidence of graft-versus-host disease or malignancy. as expected, hsct has not corrected abnormalities in certain parameters associated with his pil, as he continues to display significant hypoproteinemia, hypoalbuminemia, and hypogammaglobulinemia, but he has an improved lymphocyte count ( , cells/microliter). discussion: there is no definitive or curative treatment for pil; furthermore, the genetic etiology of pil remains unknown. supportive regimens to help mitigate or offset manifestations of pil exist, such as adherence to a low-fat diet with medium-chain triglyceride supplementation, but there are no therapies available to prevent or reduce the risk of developing bcell malignancies in this patient population. although previous case reports have detailed successful treatment of b-cell malignancies in pil patients with chemotherapy, radiation, and/or surgery, there are no published consensus guidelines regarding management of b-cell malignancies in the setting of pil, especially if recurrent in nature. for non-pil patients with chemotherapy-refractory disease, or recurrent disease following autologous hsct, allogeneic hsct is a potentially curative option. herein, we describe a pil patient with a history of multiple b-cell malignancies who underwent a successful allogeneic hsct, indicating that allogeneic hsct may be an effective treatment option for similarly affected patients. abstract/case report text introduction diarrhea in young infants is common and generally self-limited. in persistent cases, the differential diagnosis is broad and includes infections, food protein-induced allergic proctocolitis, congenital diarrheas and enteropathies. in addition to monogenic inflammatory bowel diseases, many cellular, humoral, and combined immunodeficiencies should be considered, including but not limited to cvid, ipex and ipex-like phenotypes, lad, dyskeratosis congenita, intestinal lymphangiectasia, omenn syndrome, cartilage hair hypoplasia, cgd, il- axis defects, aid deficiency and wiskott-aldrich syndrome. case presentation a full term infant born after an uncomplicated pregnancy to nonconsanguineous honduran parents presented with non-bloody, non-bilious vomiting and dehydration at days of life. the infant later developed frequent loose stools, some of which were bloody, and failure to thrive. his family and prior medical history, including newborn screen, were normal. an extensive workup was initiated which showed: -persistent and severe anemia with a hemoglobin nadir of . mg/dl -hypoalbuminemia requiring multiple infusions -elevated alpha- -antitrypsin and calprotectin level in stool -profound hypogammaglobulinemia with normal iga, igm and ige for age -normal gross and histologic findings on esophagogastroduodenoscopies and colonoscopies besides a gastric ulcer thought not be the cause of his anemia -normal abdominal imaging including ultrasound, ct angiography and mri -no source of bleeding on meckel scan or exploratory laparotomy -normal dhr assay, g pd level and positive myeloperoxidase stain -immunophenotyping showing t cell lymphocytosis affecting cd + more than cd + compartment, with normal lymphocyte proliferation to mitogens -normal sweat chloride level genetic testing was initiated with a targeted immunodeficiency panel which showed variants of unknown significance in adar, dock , lyst, ptprc and tbx genes, none of which adequately explained his presentation. whole exome sequencing showed that he was a compound heterozygote in the dgat gene. a pathogenic variant c. + t>c (ivs + t>c) was inherited from the father and a likely pathogenic variant c. g>c (p.r p) was inherited from the mother. patient was diagnosed with dgat deficiency, an inborn error of lipid metabolism resulting in protein-losing enteropathy (ple). under gastroenterology's guidance, a low fat diet was initiated, resulting in rapid improvement in stool consistency, weight gain, albumin level and stool alpha- -antitrypsin level. he remains on subcutaneous immunoglobulin replacement therapy for ongoing hypogammaglobulinemia. conclusion: protein-losing enteropathies commonly present with intractable diarrhea and significant laboratory derangements due to malabsorption including hypogammaglobulinemia. as a result of these findings and since many of the etiologies are immunologic in origin, immunologists are an integral part of the evaluation of such cases. in cases where immune system interrogation reveal normal results, genetic testing is crucial in guiding the diagnosis. in our case, whole exome sequencing not only provided the diagnosis but also characterized a variant that was previously of unknown significance as likely pathogenic. dietary management provided rapid improvement in growth and nutritional status. ongoing monitoring will reveal if this management also assists in igg level maintenance and hematologic abnormalities or if even more stringent control of dietary fat will be required abstract/case report text background: foxp gene mutations are associated with immune dysregulation polyendocrinopathy x-linked (ipex) syndrome, a rare xlinked monogenic disease of immune dysregulation and autoimmunity. the classic presentation consists of severe enteropathy, dermatitis, and endocrinopathies (commonly early onset insulin dependent diabetes mellitus). clinical presentation and severity can be variable even in family members with the identical variant. we present a patient with ipex symptomatology and a hemizygous variant in the polyadenylation (polya) signal of foxp that is classified as a variant of uncertain significance (vus). this specific variant was reported in a single case study in which the patient improved after hematopoietic stem cell transplantation (hsct). case presentation: a month-old ex -week gestation boy was admitted with lethargy, hypovolemia, electrolyte disturbances, and acute kidney injury. he developed persistent diarrhea and vomiting after receiving rotavirus vaccine. his family history is significant for early deaths of three maternal unclesone stillborn, one death at months and another at years from unknown gastrointestinal problems. he demonstrated peripheral eosinophilia (to . k/ul), elevated ige, and anemia requiring multiple transfusions. he developed severe enteropathy with hypoproteinemia requiring total parenteral nutrition, continual albumin infusions and maintenance of npo. he had generalized edema, respiratory distress requiring high flow nasal cannula, and repeatedly spiked fevers with negative infectious evaluation. acute kidney injury improved but renal ultrasound showed persistent nephrocalcinosis. endoscopy yielded biopsies demonstrating duodenitis with severe villous atrophy, scanty isolated intraepithelial eosinophils and neutrophils, a few crypts with mucin, reactive epithelial changes and increased lamina propria eosinophils. colon biopsies showed mucosa with focally increased lamina propria eosinophils with scanty neutrophils and surface epithelium without cryptitis. esophagitis with reactive epithelial changes, spongiosis, and many intraepithelial eosinophils was also present. the patient's lymphocytes showed unremarkable proliferation to pha and pwm. cd + cd + t cells demonstrated intracellular foxp expression by flow cytometry. a commercially-available immunodeficiency targeted panel revealed that he was hemizygous for a vus in foxp (exon , c.* a>g non coding). this variant is also referred to as an aauaaa>aauaag or aataaa>aataag change in the polya site. he was also heterozygous for vus at these additional loci: cd a c. c>t abstract/case report text introduction: implantation of allogeneic cultured thymus, partially depleted ex vivo of t cells, can result in naïve t cell development in patients with complete digeorge syndrome (dgs). in a few patients, early and transient skin rash, often characterized as "atypical dgs" or late autoimmune manifestations have been reported following implantation. here we describe a patient with complete dgs who developed immune reconstitution inflammatory syndrome (iris) or atypical dgs following thymus implantation. case description: a female patient was diagnosed at birth with complete dgs due to absent t cell receptor excision circles (trec), hypoplastic thymus, profound hypocalcemia with hypoparathyroidism and cardiac defects. the patient also had microretrognathia, oral motor dysfunction, sialorrhea, recurrent aspirations and reflux requiring a gastro-jejunum feeding tube, low-set ears with right ear microotia, semicircular canals atresia, alopecia and mal-rotated kidneys. prior to thymus implantation, the patient was thriving, had no skin rash, no eosinophilia and no t cells. detailed genetic analyses, did not reveal a cause for her syndrome. at months of age pulmonary aspergillosis was diagnosed presumptively. at months of age the patient received an allogeneic t-cell depleted thymus implant from a male donor, without prior conditioning or post-implantation immune suppressive medications. the procedure was uneventful and the patient returned home after days. results: four months after implantation, a pruritic maculopapular rash appeared on the head and trunk that spread to the extremities including the palms and soles. there was no lymphadenopathy or splenomegaly. an infectious etiology could not be found. eosinophilia and an increase in liver enzymes were noted. there was an increase of cd + and cd + t cells with predominantly memory phenotype, which had been undetectable month earlier. analysis of t cell diversity showed a restricted repertoire with expansion of two v-beta families. there was no evidence of donor cells to suggest graft versus host disease. skin biopsy showed minimal superficial perivascular inflammatory infiltrate composed mainly of cd + histiocytes and rare cd + t cells. the patient was treated with prednisone and cyclosporine. a liver biopsy was performed weeks after initiation of treatment that showed moderate and diffuse peri-portal ductular reaction but no duct associated lymphocytic infiltrate or significant duct epithelial injury or ductopenia. the skin rash rapidly resolved with desquamation, while the liver enzyme abnormalities persisted for two more months. cyclosporine and prednisone were weaned over months. t cell numbers, their response to stimulation and diversity have since normalized, as well as trec and naïve t cell production. the patient is producing appropriate antibodies to protein and polysaccharide vaccines. sixteen months after implantation the patient developed grave's disease with markedly elevated free-t , undetectable tsh and elevated antibodies to the thyroid receptor, which rapidly normalized with ongoing methimazole treatment. the patient is currently months after the implantation and is free of infections, thriving and developing appropriately. conclusions: this patient developed atypical dgs or iris, often associated with autologous and allogeneic hematopoietic stem cell transplants, organ transplants or effective treatment of hiv, after successful thymus implantation for complete dgs. abstract/case report text congenital disorders of glycosylation are a rare group of genetic disorders due to defects in protein glycosylation. phosphoglucomutase (pgm ) is an enzyme necessary for the synthesis of uridine diphosphate n-acetylglucosamine, an important precursor for protein glycosylation. patients with autosomal recessive pgm deficiency have a multisystemic disorder characterized by a neurologic impairment and clinical features classically observed in autosomal dominant hyper-ige syndrome due to stat mutations; including recurrent pneumonias, skin abscesses, elevated levels of ige, and abnormalities in connective tissues and bones. we hypothesized that gp , a highly glycosylated protein and coreceptor of the cytokine il- , would be weakly expressed on pgm deficient cells, due to impaired glycosylation. we studied pgm -deficient patients from kindreds and showed that il- -driven stat phosphorylation was impaired in their pbmcs and ebv-transformed b cells. accordingly, the induction of socs target gene was significantly decreased. in contrast, the patients had normal stat phosphorylation and socs induction downstream of il- , a cytokine whose signaling is independent of gp . flow cytometry and immunoblotting showed significantly lower gp expression in peripheral t-cells and ebv-transformed b cells from pgm -deficient patients compared to healthy donors. we did also show that in vitro inhibition of n-glycosylation, using tunicamycin in ebv-transformed b cell line from healthy donor, alters gp -mediated signaling. collectively, our findings demonstrate that defective glycosylation in pgm -deficient patients results in reduced expression of gp and consequently, impaired gp dependent stat phosphorylation and defective il- signaling. this may account for the overlapping clinical features shared by pgm and stat deficient patients. abstract/case report text introduction: there are no known effective therapeutic modalities for patients hospitalized with moderate to severe acute viral respiratory infections, and treatment is primarily supportive. intravenous immunoglobulin (ivig) has been reported in limited cases to be used in this setting, especially in immunocompromised patients. the primary objective of this retrospective study is to compare clinical and economic outcomes among immunocompromised patients hospitalized with viral respiratory infections who received ivig to those who did not receive ivig at a large academic center hospital. methods: we performed a double-center, retrospective cohort study of all immunocompromised patients who were hospitalized for acute documented respiratory viral infections between and . we divided patients into two groups: those who received ivig therapy for respiratory infections, and those who did not receive ivig therapy. data on age, gender, immune status, viral type, immunosuppression type, respiratory support, microbiological data, length of hospital stay (los), icu los, as well as death and readmission rates were extracted from medical records. in order to adjust for severity bias typically present in observational data such as these, we employed inverse probability weighting (ipw) using all collected baseline covariates. outcomes (death, length of stay in hospital and icu, readmission) were examined using a series of logistic and poisson regression models adjusting for baseline covariates and employing ipw. results: a total of individual hospital admissions were analyzed; patients received ivig and did not receive ivig. there were no significant differences between the two groups in terms of mean age, gender . average age was . , % were female, . % were transplant patients of which . % had lung transplant, . % had liver transplant, . % had bone marrow transplants (bmt), . % had kidney transplant, . % had heart transplant and . % had both solid organ and bmt. . % of patients had a hematologic malignancy, and . % had a primary immunodeficiency. the most common isolated respiratory virus w a s r h i n o v i r u s ( . % ) , f o l l o w e d b y r s v ( . % ) , parainfluenza ( . %) and metapneumovirus ( . %). overall, the use of ivig as associated with a significantly shorter icu length-of-stay, with an (or=- . , p= . ), and a higher hospital readmission rate. in the sub-analysis of patients who received ivig within the first hours of hospitalization (n= ), ivig use was associated with a significantly shorter icu los (or=- . , p= . ), significantly shorter overall hospital los (or=- . , p= . ), and no significant change in readmission rate. conclusions: to our knowledge, this is the first retrospective cohort analysis evaluating the effect of ivig in immunocompromised patients hospitalized with respiratory viral infections. the results suggest that immunocompromised patients receiving ivig may have a shorter hospital and icu los, especially if ivig is provided within the first hours of admission. this may result in reduced healthcare costs. this study is limited by its retrospective nature, and the potential bias that patients treated with ivig are sicker to start with. future prospective studies are suggested to further evaluate these findings. ( , ) . the most common precipitant in children is medication, followed by infection ( , ) . although a clear association between mycoplasma pneumoniae and sjs has been established, there is a scarcity of literature exploring the role of this infection in recurrent sjs in children ( ) ( ) ( ) . case presentation: a -year-old female with prior history of sjs was admitted for mucosal and skin lesions in the setting of community acquired pneumonia. her past medical history included sjs with eye involvement, secondary to mycoplasma pneumoniae (ig m positive), occurring five years prior to this admission. she also had frequent episodes of acute otitis media and sinusitis in early childhood. family history was negative for immunodeficiency. her clinical presentation included respiratory symptoms and fever for days treated with ceftriaxone, followed by cefdinir and levofloxacin. her fever improved the day prior to admission, but she developed conjunctival injection, ocular pain, and ulcerative lesions in her mouth and nares. on physical examination, she had low grade fever with mucosal lesions including conjunctival erythema with serous discharge, painful blisters and denudated skin in lips, perioral area, nares, tongue and oropharynx. initial testing included negative blood hsv pcr, blood culture, rapid antigen testing for group a streptococcus and influenza a/b, and elevated crp in . mg/dl and esr mm/hr. right lower lobe p n e u m o n i a w a s c o n f i r m e d w i t h a c h e s t r a d i o g r a p h . nasopharyngeal pcr and serum igm were positive for mycoplasma pneumoniae. she had a mildly elevated anticardiolipin igm ( mpl), a mildly decreased c ( mg/dl) and a negative ana. she was diagnosed with recurrent sjs secondary to mycoplasma pneumonia infection. she completed treatment with levofloxacin for mycoplasma pneumonia, and received cyclosporine and high-dose methylprednisolone. she had bilateral amniotic membrane transplantation to prevent corneal ulceration . she was discharged after clinical improvement, and recurrent oral lesions were noted at followup. immunological work up as an outpatient revealed normal serum immunoglobulins, normal lymphocyte subsets and low pneumococcal titers with adequate response post-vaccination. sjs secondary to mycoplasma pneumonia infection has predominance of mucosal involvement over rash, which was observed in our patient ( , ) . some case series reported a recurrence of sjs up to % within a -year follow up. almost half of patients with recurrent sjs developed multiple sequelae ( , ) . early diagnosis of sjs, especially in those with prior history of sjs, helps to provide appropriate supportive care, monitoring of complications and treatment of possible superinfections ( , ) . conclusions: there is limited information in the literature regarding the role of mycoplasma pneumoniae associated recurrent sjs in children. it is possible that these episodes are triggered by and/or immune predisposition. there is ongoing discussion regarding whether these clinical presentation should be labeled sjs secondary to mycoplasma pneumonia infection or, depending of the skin involvement, m. pneumonia-associated mucositis (mpam) and m. pneumonia-induced rash and mucositis (mirm) ( , , ). mycoplasma should be treated appropriately in patients with recurrent sjs. abstract/case report text background: growing access to genetic testing has facilitated the genetic evaluation of primary immunodeficiencies but has also greatly increased the number of variants of uncertain significance (vus) encountered in clinical practice. interpreting the significance of vus requires multiple lines of evidence. w e d e s c r i b e a n e u t r o p e n i c i n d e x p a t i e n t w i t h hypogammaglobulinemia, unusual hpv susceptibility, and dual heterozygous pathogenic loss-of-function nfkb and heterozygous missense cxcr vus. family analysis showed the nfkb variant was inherited from his mother, while the novel cxcr variant was present in his father and sister. all four patients presented with recurrent infections, warts, and hypogammaglobulinemia. (figure ) the nf-κb gene encodes p /p transcription factor of the canonical nf-κb pathway, the most common autosomal dominant monogenic cause of common variable immunodeficiency (cvid). cxcr is a g-protein-coupled chemokine receptor with cxcl as cognate ligand. autosomal dominant pathogenic gain-offunction cxcr variants lead to impaired receptor downregulation and retention of neutrophils and other leukocytes in the bone marrow defining whim (warts, hypogammaglobinemia, infections, and myelokathexis) syndrome. all cxcr pathogenic variants truncate the carboxyl-tail of the cxcr receptor, a region responsible for receptor internalization, with the exception of one missense non-truncating variant p.e k. case series: the proband (p ) is a -year-old male with history of recurrent bacterial respiratory tract infections, warts, moderate neutropenia, thrombocytopenia and hypogammaglobulinemia requiring immunoglobulin replacement therapy (igrt). bone marrow biopsy didn't show myelokathexis. next-generation panel sequencing identified a novel heterozygous missense cxcr (c. c>a, p.s y) vus. the serine residue is highly conserved up to zebrafish. this variant was present in heterozygous form in two cases in gnomad database ( , alleles). additional whole-exome sequencing revealed a heterozygous pathogenic nfkb variant (c. dup, pa sfs* ) located in the nterminal rel homology domain, consistent with nfkb loss-offunction. both, the patient's sister (p ) and their father (p ), carry the heterozygous cxcr vus but not the pathogenic nfkb variant, and have history of warts, hypogammaglobinemia, and recurrent infections. the hpv susceptibility is particularly striking in p manifesting by genital warts and hpv-positive oropharyngeal cancer. bone marrow evaluation didn't identify myelokathexis in p (p is pending). the mother of the index case (p ) has cvid requiring igrt and immunomodulation. she shares the nfkb variant with p but is negative for the cxcr vus. extensive t and b cell phenotyping revealed low class-switched memory b cell count ( - counts/ul) in all subjects, and loss of transitional and mature naïve b cells in p and p with nfkb variant. proband b cells showed the highest tendency for apoptosis ( - %) within the family. we describe members of a family with similar presentation (infections, hypogammaglobinemia, warts), however variable combination of nfkb and cxcr variants, where either genetic defect or their combination could explain the clinical phenotype. biochemical consequence of our novel cxcr variant is pending. as the proband showed the most severe immune phenotype and neutropenia, we hypothesize that cxcr has a synergistic effect on nkfb loss-of-function. the contribution of cxcr vus of the clinical phenotype of the two other family members is yet to be determined. background: the yield of diagnosis by exome sequencing for some primary immunodeficiencies (pid) has been less than the typical diagnostic rate for clinical exome analysis (~ - %). the relatively low diagnostic rates for certain subtypes of the pids may be attributed to variable expressivity and/or an incomplete understanding of the genetic basis, among others. additionally the extent of multiple diagnoses and phenotypyic expansion in pid is not well explored. cohorts with highresolution clinical and genetic data are instrumental for exploring these questions. we evaluated the use of human phenotype ontology (hpo)annotated datasets to systematically address the prevalence of these issues using a cohort of individuals with pid who participated in research exome sequencing at the niaid. results: we generated a phenotype dataset of individuals with pids by annotating the clinical features of these subjects obtained from electronic health records (ehr) with hpo terms. exome sequencing of these individuals identified probands with a pathogenic or likely pathogenic (p/lp) variant in a gene associated with the respective clinical presentation. we identified probands where the same gene harbored a p/lp variant in at least three unrelated individuals. we used the clinical and genetic data of individuals in the following areas: ) we identified p/lp variants in aire, pik cd, nlrp , fas, ctla , gata , cybb, stat and tnfrsf b in at least ten patients that explained their clinical presentations. this dataset allowed us to characterize variable expressivity of diseases associated with these genes by capturing the variability in the observed hpo terms among probands with p/lp variants in the same gene. dimensional reduction of clinical features of probands allowed us to cluster patients sharing similar phenotypic profiles. we found clinical presentation of individuals with monoallelic p/ lp variants in aire were relatively less variable and clustered more compactly compared to that of individuals with gata variants. ) the extent of multiple diagnoses in pid is not well explored. the benchmark cohort we developed allowed us to identify candidates for multiple diagnosis or phenotype expansion by comparing the phenotype profile of each patient expressed in hpo terms to the hpo terms typically observed for a given pid. for example, we identified gain-of-function pathogenic variant in pik cd in a patient that explained the clinical features of the pid observed in this patient. however, the patient also displayed developmental delay, congenital hemiplegia, cerebral palsy and absent speech. these features are not known to be associated with pik cd variants, making this individual a candidate for > genetic diagnoses. conclusions: we developed a benchmark dataset where clinical features of patients were described using hpo terms. this dataset allowed us to quantify variable expressivity for certain pid subtypes and to systematically identify potential candidates for multiple diagnosis or phenotypic expansion. abstract/case report text warts, hypogammaglobulinemia, recurrent infections and myelokathexis syndrome is a rare combined immunodeficiency due to autosomal dominant gain-of-function mutations of cxcr chemokine receptor. the late diagnosis of whim syndrome in two ukrainian adolescents highlights the diagnostic challenges in this disease. patient , year-old girl, had recurrent pneumonia since the first year of age; overall she had episodes of pneumonia. she has suffered from chronic bronchitis for last several years. she had recurrent otitis media and chronic pyelonephritis. neutropenia was revealed when she was year old. during episodes of bacterial infections she occasionally had normal value of neutrophils. the girl does not receive any treatment. patient , year-old boy, had three episodes of pneumonia when he was , and year old. others symptoms include recurrent herpetic infection, warts on the hands. since years of age he has haven persistent low neutrophil counts. the child was followed by hematologist and since years of age he has received g-csf ( mg/kg) twice a month. both children have leukopenia - cells/mm , neutropenia - - cells/mm , lymphopenia - cells/mm , low number of bcells - - cells/mm . hypogammaglobulinemia was not prominent in both children, they have slightly decreased level of igg ( , g/l), normal level of igm ( , - , g/l), patient has low level of iga , g/l. patient does not have protective level of antibodies to diphtheria and tetanus anatoxin, and anti-hbs antibodies were absent despite complete immunization. bone marrow aspirate revealed hypercellular marrow with granulocytic hyperplasia which was characterized by hypersegmented nuclei and cytoplasmic vacuolization of neutrophils. on molecular analysis of cxcr , heterozygous mutation c. c>t (p.arg *), known as r x mutation, was detected in both patients, confirming the diagnosis of whim syndrome. replacement therapy with intravenous immunoglobulin was started in both children together with antibacterial prophylaxis and g-scf. vaccination with -valent vaccine against hpv infection was recommended for both patients. whim syndrome is very rare immunodeficiency but may be underdiagnosed. the awareness about rare forms primary immunodeficiency is very important in clinical practice for early diagnosis and treatment. methods: clinical providers recruited from nicer institutions electively completed web-based survey questions related to provider characteristics as well as initial diagnostic evaluation of itp, aiha, ain and es via securequestionpro® software. likert scales ranging from ("rarely" < %), ("sometimes" to %), ("half the time" % to %), ("frequently" to %), and ("almost always" to %) were used to ascertain frequency of evaluation for each diagnostic study. statistical analysis and plotting was done using rv . . . plots were created using packages ggplot , v . . and ggiraphextra v . . . mean likert scale scores were calculated for each study for each suspected disease and plotted on radar charts. results: the survey was completed by providers, including hematology/oncology ( . %), rheumatology ( . %), allergy/ immunology ( . %) and other sub-specialties ( . %). a slight majority of physicians ( %) were fellows or within years of graduation; physician extenders and clinical pharmacists were also respondents. the majority ( . %) of respondents indicated that ≤ new immune-mediated cytopenia patients were seen at their institution annually. the vast majority of respondents ( . %) reported evaluating ≤ new es patients per year at their institution with % evaluating ≤ cases annually. collated data from all respondents showed that in all disease states, the primary evaluation was focused on peripheral destruction mechanisms; the majority of patients are only "sometimes" or "rarely" evaluated for bone marrow failure syndromes, connective tissue disease, immunodeficiency and non-malignant lymphoproliferative disorders, but when done were more likely in es ( figure ). evaluations were biased by sub-specialty with higher degrees of connective tissue focus by rheumatology and immunodeficiencies by allergy/immunology (table ) . genetic sequencing was "frequently" or "almost always" sent in . % of itp, . % of aiha, . % of ain and . % of es p a t i e n t s . p e r s o n a l o r f a m i l y h i s t o r y o f a u t o i m m u n e / hyperinflammatory disease, malignancy or cytopenias most strongly influenced the decision to send genetic testing. lack of insurance coverage/negative financial impact on the patient and concerns about the inability to resolve variants of uncertain significance were the biggest barriers for obtaining genetic testing. conclusions: current practices in the evaluation of immunecytopenias are heterogeneous by sub-specialty and globally limited in scope with few patients being evaluated for underlying etiologies. in particular, despite a known high frequency of pathogenic variants in es, less than a third of patients are undergoing sequencing, highlighting a need to reduce barriers to genetic testing. development of a consensus guideline with multi-disciplinary engagement to harmonize an optimal evaluation for patients with immune-mediated cytopenias is needed. interferon regulatory factor- (irf ) binding protein- (irf bp ) was originally identified as a transcriptional co-repressor of irf ( ). mutated irf bp was identified in a -member family with recurrent sinopulmonary infections, progressive hypogammaglobulinemia, and poor response to protein vaccines ( ) . we have now identified additional families ( subjects) with irf bp mutations. clinical histories show an expanded phenotype with / having chronic gastrointestinal disease; with gastrointestinal manifestations as the initial clinical complaint. five had granulomata in liver(x ), spleen, lung(x ) and gastrointestinal tract. five out of six tested had poor pneumococcal vaccine responses and four patients reported viral infections including varicella zoster(x ), influenza a and sapovirus. irf bp is a amino acid protein containing a highly conserved cterminal protein-protein interaction ring domain (rd). constraint metrics from gnomad indicate mild tolerance to missense changes and intolerance to loss-of-function alleles. we identified categories of mutations: rd mutation or deletion (n= patients), null alleles (n= ) and non-rd missense changes (n= ). functional studies assessing the ability to affect nfatdriven luciferase expression were performed. rd mutations ( / ) had more profound loss-of-repression than wild-type, while missense changes had lesser, but still measurable effects. further, mutation categories and functional studies correlated with clinical phenotypes. of patients with rd mutations, / had infections as presenting symptoms, / tested had hypogammaglobulinemia and / were diagnosed with cvid. one patient with a missense rd mutation had only an infectious phenotype (pulmonary mycobacterium avium) with slight decrease in immunoglobulins; in functional studies this mutation had the least effect of the rd mutations. haploinsufficient patients reported respiratory infections ( / ), recurrent urinary tract infections ( / ), gastrointestinal disease ( / ) and hypogammaglobulinemia ( / ). in contrast, / patients with non-rd missense changes presented with gastrointestinal complaints while only patients had infections (recurrent bronchitis, shingles). gi disease prevalence is consistent with high levels of irf bp expression in the colonic crypt cells (human protein atlas). to confirm this, immunohistochemical staining of colon biopsies from two patients was performed, identifying epithelial and glandular cells of the colon. irf bp is involved in multiple processes, including the negative regulation of nfat signaling( ), tcr signaling( ), inflammatory macrophages ( ) , and pd-l transcription ( ) . interaction with the glucocorticoid receptor affecting anti-inflammatory and metabolic transcription ( ) has also been reported. these observations highlight the irf bp response to type-i interferons (irf ) and tcr stimulation (nfat), regulation of inflammatory macrophages and co-regulation of glucocorticoid receptor mediated signaling. the expanding role of irf bp in multiple biologic systems correlates with the broad clinical presentation we observed in our patients. further studies utilizing irf bp mutation knock-in mice will help characterize the gastrointestinal, lung and immune pathology seen in our cohort. abstract/case report text common variable immunodeficiency (cvid) is a disorder of antibody deficiency arising from over genetic lesions. the clinical presentation of patients with cvid varies from recurrent, severe infections to autoimmunity. the immune dysregulation in cvid is especially difficult to treat and the lifespans of patients suffering from autoimmunity are much shorter than those without such complications. unfortunately, we have no way to identify which patients fall into which categories, or even know how many sub-categories of cvid there are. therefore, the field requires a method to classify patients into categories to precisely recognize and aggressively treat the more severe phenotypes. we address this goal by integrating analyses of patient exomes with analyses of cellular signaling. by analyzing stimulation assays with phospho-protein mass cytometry and high-dimensional data analytics, we aimed to elucidate signaling and phenotyping deficiencies in patients with cvid. importantly, our panel identifies all circulating immune cell subsets in whole blood. in eosinophils, we found amplified responses of pp , pstat , and cleaved caspase- in response to tlr / stimulation. we found additional amplified responses of pstat and pstat in cd lo monocytes. this finding suggests a previously unidentified role for eosinophils and cd lo monocytes to contribute to the pathophysiology of cvid. we found abormal numbers of memory b cell counts, total switched b cell counts, and igm+, cd + b cell (plasmablasts) counts between cvid patients and healthy controls. cd expression on b cells was significantly reduced in cvid patients as well. these b cell results mirror findings from prior, seminal studies on cvid. notably, we have found higher pd- expression in the effector cd t cells of patients. integrating phenotype data, genetic analysis, and mass cytometry data will provide a deeper understanding of each patient's phenotype and how the are clustered. we also expect that a better understanding of alterations in the exomes and functions of the circulating immune cells of cvid patients will lead to new therapeutic approaches. abstract/case report text objectives: primary atopic disorders are monogenic disorders leading to profoundly dysregulated allergic responses. studying patients with these disorders has been instrumental in expanding our understanding of the pathogenesis of allergic inflammation with therapeutic implications for common polygenic versions of allergic disease. clinical findings: we have identified a now -year old boy who presented with severe eczema, extremely high blood eosinophil counts ( . x cells/l, normal range: - . x cells/l) after birth and very high serum ige levels ( υg/l, normal range: - ug/l) since birth. known allergic disorders and parasitic infections are ruled out. given the extreme phenotype, whole exome sequencing was performed on the trio of patient and parents, and the patient was found to have a homozygous mutation in the evolutionarily conserved fibronectin iii domain of the osmr gene (c. t>a, p.v d) (figure ). osmr encodes oncostatin m receptor-beta, a component of both the osm type ii receptor and the il receptor, and is important for keratinocyte cell proliferation, differentiation, apoptosis and inflammation. mutations in osmr have been reported in association with familial primary localized cutaneous amyloidosis, however this condition was ruled out in this patient through skin biopsy which showed no amyloid deposits. methods and results: we modelled the c. t>a osmr mutation in hek cells and observed a loss of expression of the osmr receptor on the cell surface (with normal intracellular protein levels). this observation was mirrored in primary fibroblasts obtained from the patient. signal transduction through phosphorylation of stat and stat and gene expression (il and ccl measured via qpcr) was absent after stimulation with osm in patient fibroblasts. these signaling defects were rescued using a lenti-viral transduction approach to introduce the wild-type (wt) osmr gene. whole transcriptome analysis using rna sequencing confirmed that osm mediated jak-stat signalling pathways were deficient in the patient fibroblasts and were rescued after lenti-viral transduction of wt osmr. rna sequencing analysis also suggested significantly enhanced expression of genes in the nf-κb signalling pathway (e.g.: il and cxcl ) and decreased expression of genes in the tgf-β signalling pathway (e.g.: smad and smad ) in patient fibroblasts at baseline. this was also rescued upon lentiviral transduction. conclusion and future directions: our findings shed light into the disease mechanism of a novel primary atopic disorder, caused by a homozygous missense mutation in osmr. abstract/case report text -year-old caucasian female presented to immunology clinic with hypereosinophilia, eosinophilic esophagitis, peptic ulcer disease, severe gi bleeds, and chronic hepatitis. healthy throughout childhood, with minimal infectious history. in adolescence developed chronic severe myalgias and nsaid overuse, to which the peptic ulcer disease and bleeding were attributed. parents healthy and non-consanguineous. son with severe bleeding episodes and small stature. on exam she weighed lb, bmi . sclerae anicteric. tongue deeply furrowed. cervical nodes palpable. heart and lung exam normal. no hepatosplenomegaly. no clubbing of the digits or edema. skin was clear. wbc , /ul, eosinophils /ul, hemoglobin g/dl, normal platelet count. however, platelet aggregation testing abnormal. bone marrow normocellular, and flow cytometric and molecular analysis did not show hematolymphoid malignancy, primary hypereosinophilic syndrome, or systemic mastocytosis. lymph node biopsies did not show lymphoma or aberrant t cell populations. noted to have chronically elevated creatine phosphokinase, ranging from - u/l over two years at our institution. deltoid muscle biopsy showed non-specific myelopathic changes. an adult dystrophy immunostaining panel was normal. ultrastructure examination showed no abnormal storage material. a genetic panel for metabolic myopathies failed to reveal a cause. total igg, iga and igm normal. ige elevated at ku/l, and igg subclasses showed igg elevated at mg/dl. flow cytometry showed normal t, b and natural killer cell numbers. normal proportions of naïve, mature and activated t cells. vaccine response assessment was normal. evaluation for autoimmune/rheumatologic diseases was negative. liver biopsy demonstrated findings consistent with primary or secondary sclerosing cholangitis (without increased igg staining). given her inflammatory phenotype, additional genetic analysis was sent, assessing for primary immunologic disorders. this identified heterozygous variants of uncertain significance in ctla (c. t>a; ps t), zap (c. c>g; p.d e), and stim (c. t>c; p.l s). analysis of the ctla variant in vitro revealed that it was expressed normally. foxp expressing regulatory t cells were present in normal proportions in vivo and appeared phenotypically normal. this variant was found in her unaffected father. the zap variant is present in population databases (rs , exac . %), and was felt unlikely to be clinically relevant. the stim l s variant, although not shown previously in human patients, has been previously shown in vitro to be a gain of function mutation [ ] [ ] [ ] . furthermore, familial analysis revealed that this was a de novo mutation arising in the patient, and present in her son. humans with other gain of function mutations in stim and the orai channel it activates have overlapping syndromes including storkmorken syndrome, tubular aggregate myopathy and york platelet syndrome, characterized by chronic myopathy and platelet aggregation defects [ ] . the stim l s mutation is predicted to cause constitutive stim activation and calcium influx and likely provides an explanation for the patient's chronic myopathy and abnormal platelet aggregation. neither eosinophilic disease, nor cholangitis, have been described previously in stim gain of function-related diseases. it is unclear whether these issues are related to this novel stim mutation, or to other genetic or environmental influences. treatment of diseases caused by overactive crac channels is challenging as no pharmacologic inhibitors are yet clinically available. nomid/cinca syndrome is one of the periodic syndromes associated with cryopyridines. it is a defect in the innate immune system causing excessive activation of the inflammasome, with consequent il- secretion and neutrophil recruitment. clinically, damage occurs to organs such as the skin (neutrophilic urticaria), central nervous system (meningitis and deafness) and joint (arthritis). levy et al. ( ) evaluated a large series of patients and median onset age was . years, while the median age at diagnosis was years, although the symptoms initiate in the first days of life. treatment includes corticosteroids, which act by nonspecifically blocking all inflammatory cytokines, or by blocking il- specifically. if early diagnosis and treatment of the disease is not made, natural evolution leads to motor and adaptive disability and death in % of cases already in adolescence due to infection, neurological complications or secondary amyloidosis. we report a -month-old male child from nonconsanguineous parents who presented shortly after birth, multiple scaling and erythematous lesions throughout the body, evolving with following symptoms: abdominal abscess, hepatitis, meningitis and pioarthritis. laboratory tests showed elevation of inflammatory tests (esr, crp, amyloid protein a) and leukocytosis. the diagnosis was suspected at the nursery where the patient remained hospitalized for days. a personalized multigene panel was requested. it was identified the variant p.gly val, heterozygous for nlrp gene, not described in the literature, confirming the diagnosis of cinca/nomid syndrome. after discharge, it was introduced prednisolone ( , mg/kg/day) and antiinterleukin- (il- ). after the second dose, skin lesions and joint edema regressed, weight gain, and neuropsychomotor development improved. this case reports a very early diagnosis of nomid/cinca syndrome. it warns neonatologists and pediatricians about the need of precocious recognition of the syndrome, probably improving the prognosis of the patient. professor/university center health abc abstract/case report text background: leprosy affects more than , people worldwide. brazil represents the rd. country in the world in leprosy frequency and maranhão state is an hyperendemic region. the city of imperatriz (ma) stands out as a reference center in the care of these patients. according to few reports, lectin pathway of complement system may play a role in susceptibility to leprosy. mannose binding lectin (mbl) and ficolins (fcns) recognize patterns of sugars and acetylated residues (pamp), respectively, in a wide variety of pathogens, including m. leprae. high levels of ficolins and mbl may act unfavorably promoting the spread of m. leprae. the present study evaluated the role of ficolin and mbl in m.leprae patients and contacts. methods: a cross-sectional case-control analytical study was carried out, evaluating clinical and epidemiological data and serum levels of mbl and fcn (elisa) from july to april . the study was approved by ethics committee and informed consent forms were signed before sample collection. data analysis was performed using the spss . for windows statistics program. results: we evaluated serum samples ( patients and healthy family contacts), . % were female, % under years old, % african-brazilian, % of the families had more than contacts at home. clinical data showed multibacillary forms in . %; dimorphic ( %) and virchowian clinical forms ( . %), up to affected nerves in ( . %) and more than lesions in ( . %). it was observed that ( . %) had a reaction, being type ( %) more predominant. disability grade was found in patients ( . %). in children under years, . % were multibacillary, . % dimorphic and % undetermined; ( . %) also had reactions, % type reaction and degree of disability in . % of children with the disease. the evaluation of serum fcn and mbl levels for the patients (n = ) and contacts (n = ) were . ng/ml and . ng/ml, (p = . ), and . ng/ml (p) and . ng/ml (c) (p = . ), respectively. there were lower values of fcn in patients with type reaction (sudden and intense inflammatory processes) versus no reaction ( . ng/ml vs . ng/ml) (p = . ) and in patients with disability grade (severe sequelae) versus disability grade ( . ng/ml vs . ng/ml) (p = . ). higher fcn values was observed in patients with no disability ( . ng/ml) (p = ). mbl concentrations were higher for patients above years in comparison with patients below that age ( . ng/ml vs . ng/ml)(p = . )) and correlated with the occurrence of a multibacillary clinical form. conclusions: mbl and fcn levels were not different in the patients and contacts of m. leprae, nevertheless the presence of severe forms with sequelae (reaction type and disability grade ) were associated with lower levels of fcn . in addition, it is possible that lower mbl levels could influence the higher frequency of multibacillary disease below years old. abstract/case report text introduction: hyper ige syndrome (hies) is a primary immunodeficiency characterized by elevated ige levels. symptoms can range from severe eczema, recurrent skin infections or pneumonias, and typical dysmorphic facies. there have been wide non-immunologic presentations in patients with hies, including retained primary teeth, scoliosis, craniosynostosis, arterial aneurysms and joint hyperextensibility. an association between hies and autoimmune hemolytic anemia (aiha) has further been described in the literature. however, there have been no reported cases of hies in association with iron deficiency anemia and concurrent pica. we present a unique case of a patient with a history of eczema, recurrent skin infections and pica found to have hies and iron deficiency anemia. case presentation: a -year-old boy with a history of allergic rhinitis presented to the allergy & immunology clinic for evaluation of chronic eczema and recurrent skin infections. the patient had a history of multiple hospitalizations requiring intravenous antibiotics for cellulitis and superinfected eczema since he was an infant. symptoms were refractory to the use of multiple skin barrier ointments and oral antihistamines. his mother further noted that for the past two months prior to initial evaluation, he developed a fixation with eating crayons, baby powder and chewing on drywall. physical exam was notable for a dysmorphic face, broad based nose, pale nasal mucosa with ample clear discharge, high-arched palate and lower incisor supernumerary teeth. his skin was characterized by generalized dryness, lichenification and scaly desquamation with boils on extensor surfaces of knees and elbows. initial screening for hies via t-helper functional assay was consistent with decreased expression of il- . genetic testing revealed stat s g missense pathogenic variant consistent with hies. cbc was also notable for decreased hemoglobin at . g/l and mcv of fl. patient was diagnosed with concurrent hies and pica in the setting of iron deficiency anemia. iron supplementation was started and patient's pica improved. discussion and conclusion: our patient with hies had a peculiar initial presentation with the classic signs and symptoms of hies and pica. the diagnosis of hies can often be delayed due to the wide range of clinical presentations. to our knowledge, the association of hies with iron deficiency anemia and pica has been underreported in literature. screening for anemia should be considered when evaluating patients with hies in order to rule out comorbid iron deficiency anemia which can be easily treated with iron supplementation. abstract/case report text introduction: common variable immunodeficiency is a primary immunodeficiency with variable and diverse phenotypic presentations. the two main phenotypes include a group which primarily exhibits recurrent infections and a group with or without infections and primarily inflammatory and autoimmune complications. the latter, may lead to a delay in diagnosis and is associated with poorer outcomes and higher morbidity and mortality. ( ) another group of patients present with t-cell defects, lung disease, autoimmunity, and infections and may be diagnosed as having cvid but instead can have mutations in lrba or pi kinase. this subset of patients has been referred to as "cvid-like" in the literature. ( ) case presentation: patient is an year old female who initially presented to an outside facility due to days of fatigue, fever, and abdominal pain. upon presentation, she was found to have massive splenomegaly, hepatomegaly, and an abnormal chest x-ray showing mediastinal lymphadenopathy and pleural effusion. laboratory results demonstrated pancytopenia, hypogammaglobulinemia, and low b cells, t cells, and nk cells via flow cytometry. she was transferred to our institution for further work up. she did not have any prior history of recurrent infections, asthma/lung disease, or autoimmune conditions. initial ct of the chest was consistent with granulomatous lymphocytic interstitial lung disease. patient was diagnosed with common variable immunodeficiency with granulomatous lymphocytic interstitial lung disease and was treated initially with high dose ivig, corticosteroid taper, rituximab, and imuran. she had interval worsening of pft and lung disease as shown by ct scan. genetic panel for cvid and related conditions revealed variants of unknown significance. one heterozygous mutation in blnk gene (c. g>a) and one heterozygous mutation in lrba gene (c. g>a). she was started on infliximab with plans to repeat ct scan in months. discussion: mutations in both blnk and lrba have been associated with primary immunodeficiency. mutations in blnk, which is located on chromosome , have been associated with autosomal recessive agammaglobulinemia. homozygous or compound heterozygous mutations in lrba on chromosome , can lead to lrba deficiency which encompasses a wide range of clinical presentations including hypogammaglobulinemia, autoimmune disease, inflammatory bowel disease, antibody deficiency, organomegaly, and recurrent infections. ( ) without genetic testing, the clinical presentation can be difficult to distinguish from common variable immunodeficiency. the patient presented has clinical features that can be seen with mutations in both blnk and lrba, however she is heterozygous for both mutations. further analysis, including measurement of lrba protein expression, is needed to further define her underlying immunodeficiency so appropriate treatment can be administered. abstract/case report text a month-old, previously healthy, unvaccinated male presented with one week of diarrhea and cough and was admitted for dehydration and hypoxemia. his mother and sister both had a history of incontinenti pigmenti (ip). on physical exam, he was alert, afebrile, with tachypnea and subcostal retractions. enterovirus/rhinovirus and parainfluenza were detected, but he became progressively hypoxemic and eventually required intubation and high-frequency oscillatory ventilation. chest x-ray showed multifocal bilateral airspace opacities. empiric treatment for pjp with trimethoprim/ sulfamethoxazole and glucocorticoids was started. tracheal aspirate pcr confirmed p. jiroveci. hiv rna pcr was negative. ivig was started due to suspicion for primary immunodeficiency. although his respiratory status gradually improved, he subsequently developed multiple skin lesions. skin biopsy grew mycobacterium szulgai. m. szulgai osteomyelitis of the right fibula and the left nasal bone was also detected, indicating hematogenous spread of the infection. he was started on four-drug anti-mycobacterial therapy and interferon-gamma (actimmune) at doses ranging from μg/m^ three times weekly to μg/m^ qod. immune work-up revealed t-cell lymphopenia [cd +/cd + /μl ( - , /μl) and cd +/cd + /μl ( - , /μl)] with an abnormally increased proportion of memory cd t-cells compared to naïve cells for age. b-cell numbers were normal, and nk cells were decreased [cd +cd +/cd - /μl ( - /μl)]. nk cell lytic function by k lysis was normal, whereas cd a degranulation was decreased. the serum igm level was normal [ mg/dl ( - mg/dl) whereas iga [ mg/dl ( - mg/dl)] and igg [ mg/dl ( - mg/dl)] were elevated. mononuclear cell cytokine response to ligands for tlr -tlr , tlr -tlr , tlr , tlr , and tlr -tlr was normal. dna sequencing revealed a novel nonsense mutation in exon of the ikbkg (p.gln ter (q x) (cag>tag): c. c>t, confirming the diagnosis of nemo deficiency, which was suspected based on the infectious disease presentation and the maternal history of ip. the diagnosis was further supported by signs of ectodermal dysplasia of teeth that appeared starting at months of age. he underwent hsct using bone marrow from a / matched unrelated donor after conditioning with atg, busulfan, fludarabine and rituximab. actimmune therapy was continued until days prior to transplant. for gvhd prophylaxis, he received tacrolimus and low-dose methotrexate. he achieved full donor chimerism post-transplant and has had no significant gvhd. interesting features of this case include the prominence of ip in mother and sister, which is usually due to female heterozygosity for an ikbkg null allele. such null alleles when inherited by the male fetus are embryonic lethal. our patient's nonsense mutation would be expected to result in severely impaired ikbkg protein expression and function. however, the fact that he had was born at term and initially was healthy coupled with his preservation of normal tlr function suggests that his ikbkg allele is likely to be a hypomorphic mutation. studies are in progress using ebv-transformed b-cell lines from the patient to evaluate ikbkg expression and function. also of interest, our patient was able to tolerate relatively high doses of interferon-gamma therapy without inflammatory side effects or an adverse impact on engraftment or gvhd. abstract/case report text background: primary atopic disorders are caused by genetic mutations that skew the immune system towards severe allergic disease. germline gain-of-function (gof) mutations in jak are a newly described monogenic cause of severe atopy, with affected patients demonstrating profound eosinophilia and allergic inflammation. our initial report of this novel condition identified a dramatic clinical response to the combined jak / inhibitor ruxolitinib. we aimed to determine the long-term clinical response to ruxolitinib in patients carrying a germline jak gof mutation, and to characterize the effect of enhanced jak signaling on t lymphocyte effector functions and hematopoiesis. methods: clinical outcomes were evaluated in two pediatric patients carrying the c. c>a (p.a d) gof mutation in jak after . years of ruxolitinib treatment. t cell phenotyping was performed using extracellular surface marker and intracellular cytokine staining by flow cytometry, and by gene expression signature profiling of rna sequencing data. to evaluate the effect of enhanced jak activity on myelopoeisis, we reprogrammed jak gof patient-derived peripheral blood mononuclear cells into induced pluripotent stem cells (ipsc) and performed directed myeloid differentiation. rna sequencing was performed on rna collected during ipsc myeloid differentiation and from whole blood of affected patients before and after ruxolitinib treatment. results: long-term use of ruxolitinib was associated with improved growth, reduced eosinophilia, and control of allergic inflammation without significant infectious complications, however, anemia represented a dose-limiting adverse effect. t cell immunophenotypic analysis revealed severe t helper (th) cell skewing towards a th phenotype preruxolitinib treatment, in keeping with the allergic clinical manifestations. analysis of myeloid differentiation revealed an increased myeloid to erythroid ratio in colonies derived from jak gof ipscs compared to controls. rna sequencing analysis of jak gof human whole blood and ipscs compared to controls revealed upregulation of cytokine and cytokine receptor genes implicated in allergic inflammation and early eosinophil precursor commitment, including csf- and the interleukin- receptor. reactome pathway analysis of genes upregulated in both jak gof ipsc and whole blood compared to controls showed enrichment of several pathways including interferon alpha/beta, interleukin- /- and interleukin- signaling. conclusions: this work demonstrates a critical role for jak in atopic immune dysregulation, specifically driving a th phenotype and eosinophilia. combined jak / inhibition can reverse much of the allergic inflammation, with dramatic clinical effects. this has important implications for our understanding of the pathogenesis and potential therapeutic targets for early life allergic immune dysregulation. had severe combined immunodeficiency (scid) and/or severe disease in association with their combined immunodeficiency (cid) necessitating haematopoietic stem cell transplantation (hsct). we present clinical and laboratory features of new zealand patients from the same family with a novel heterozygous missense variant in rac [c. t>g, p.ile ser (i s)]. the index patient (p -age y, m) has a history of infectious gastroenteritis, staphylococcal aureus conjunctivitis, recurrent otitis media and recurrent herpes simplex virus (hsv)- cutaneous infections. his siblings (p age y, m; p -age y, f) and his mother (p age y, f) all have a history of recurrent viral (hsv- ) and bacterial (staphylococcal aureus, streptococcal pyogenes) cutaneous infections and/or recurrent sinopulmonary infections that respond to empiric antimicrobial therapy. their neutrophils all had enhanced superoxide production in response to stimulation by fmlp and pma as compared to healthy controls'. these findings suggest that rac i s is an activating mutation causing notable abnormalities in neutrophil morphology and nadph oxidase activation similar to other recently reported mutations. this novel mutation expands the phenotypic spectrum of rac activating mutations. clinical management of affected patients needs to be tailored to their phenotype and disease severity. background and aims: heterozygous mutations in cytotoxic tlymphocyte antigen- (ctla ) are associated with recurrent infections, lymphoproliferation, autoimmunity and lymphocytic infiltration of target organs. disease penetrance can be highly variable even among related family members carrying the same ctla mutation. our evaluation of a subset of the ctla patient cohort followed at the national institutes of health (nih) revealed that % of ctla mutation carriers have gastrointestinal (gi) manifestations which include diarrhea and diffuse lymphocytic enteropathy. our aim was to determine whether the intestinal microbiome, metagenome and metabolome could distinguish patients with ctla haploinsufficiency (ctla -h) based on disease severity, and the presence or absence of gi manifestations. methods: clinical metadata and fecal samples were collected from healthy individuals (n= ) and patients with ctla -h (n= ). patients with ctla -h were classified as having minimal (n= , only endocrine and/or dermatological manifestations) or systemic disease (n= , hematological and multi-organ involvement). they were further classified based on whether they had a history of enteropathy (n= ) or active gi disease ( < bowel movements per day and/or blood or mucus in stool) at time of sampling (n= ). metabolomic profiling (using a panel of metabolites) and s rrna gene sequencing (v region) was performed on fecal samples (total samples: ; number of reads/sample: , to , ; median: , ). a subset of samples were subjected to shotgun metagenomic sequencing based on findings from the s rrna gene sequencing analysis. results: all patients with ctla -h and a history of enteropathy or active gi disease also had systemic disease. fecal samples from patients with a history of enteropathy had a distinct microbial community structure (fig. ) which was significantly less diverse (fig. ) compared to healthy individuals and patients with minimal vs. systemic ctla -h. patients with a history of enteropathy had significantly higher relative abundance of bacterial taxa including shigella-escherichia (fig. ) . shotgun metagenomic sequencing confirmed that samples from patients with a history of enteropathy were dominated by subsets of identified escherichia coli strains, all of which share genes coding for specific types of virulence factors such as curli fibers (facilitate uptake into host cells), flagellar proteins (increase motility) and enterobactins (increase bacterial iron transport). meanwhile, samples from patients without active gi disease at the time of collection were enriched for several taxa including bacteroides nordii and akkermansia muciniphila compared to patients with ctla -h and active gi disease (fig. ) . metabolomic analyses showed that asparagine, -hydroxybutyrate, cytosine and cystine were enriched in samples with abundant e. coli, whereas samples without e. coli were enriched in metabolites involved in pyrimidine (holm p= . ), purine (holm p= . ), and alanine/aspartate/glutamate metabolism (holm p= . ) (fig. ) . conclusions: fecal samples from ctla -h patients with a history of enteropathy were heavily colonized with e. coli strains that are associated with a specific metabolomic profile and that share virulence factor genes that may facilitate host invasion. these data suggest that the microbiome and metabolome can distinguish patients with ctla -h and gi disease, and support the potential use of antibiotics or even antimetabolites to treat ctla -hrelated enteropathy. the dna polymerase delta (pol δ) complex is essential for leading and lagging dna strand synthesis. its catalytic subunit (pold ), carries both polymerase and exonuclease activities and plays a crucial role in dna replication and repair. heterozygous pold mutations have been associated with inherited colorectal cancer and mandibular hypoplasia, deafness, progeroid features and lipodystrophy (mdpl) syndrome. more recently a biallelic loss of function mutation in pold (p.r c) that impairs the stability of the pol δ complex, has been reported in related subjects with recurrent infections, deafness and combined immunodeficiency (cid) with t-cell lymphopenia, cd + t cell oligoclonality but preserved b cell proliferation. we report here a second family in which a novel biallelic missense mutation in pold gene was associated with cid. the proband is a -year-old boy born to consanguineous pakistani parents. since infancy he suffered from failure to thrive and recurrent infections, including episodes of pneumonias, multiple otitis media, sinusitis, recurrent cellulitis at the g tube site, bk viruria and shingles. live and dead vaccines were well tolerated. at years of age sensorineural hearing loss together with profound leukopenia (anc cell/μl, alc cells/μl) and hypogammaglobulinemia ( mg/ dl) were identified. intermittent ivig replacement and antimicrobial prophylaxis were initiated. immunophenotyping at years of age showed severe t cell lymphopenia ( cd + cells/μl, cd + cells/μl, cd + cells/μl, figure . volcano plot of metabolites present in fecal samples enriched with e. coli vs. samples without e. coli. c e l l s / μ l , c d + c d h i f o x p + c e l l s / μ l ) , a n d hypogammaglobulinemia (igm mg/dl, igg mg/dl, iga < ). physical exam was remarkable for multiple acquired nevi in the groin area, teeth abnormalities and global developmental delay. whole exome sequencing analysis revealed a homozygous pold missense variant (nm_ c. c>g, p.q e) absent in public databases (cadd score of ). parents were heterozygous. tcr-vβ family expression was normal in both cd + and cd + t cells, but the proportion of t cells expressing vα . (encoded by the distal trav - gene) was markedly reduced (less than %), consistent with impaired vdj recombination at the tra locus and/or with defective thymocyte survival. constitutive expression of γh ax was observed in t and nk cells after h and h of culture in unirradiated conditions. at h post-irradiation ( gy), reduced levels of p-atm were detected in t and nk cells, and lack of atm, smc and h ax phosphorylation was observed in a subset of b cells, suggesting inability of these cells to mount an effective dna repair response. bone marrow examination showed normal trilineage hematopoiesis but decreased proportion of cd -cd + mature b cells and increased proportion of pre-b cells. conclusion: we report the second mutation associated with autosomal recessive pold deficiency. our findings broaden the understanding of the mechanisms underlying the immune defect in this disease to include b cell maturation arrest in the bone marrow and a dna repair defect that may support the generation of a restricted tcr repertoire in the thymus and increased malignancy risk. abstract/case report text following allogeneic hematopoietic cell transplantation (hct) for scid, the development of a diverse t cell repertoire is essential for optimal immune recovery. high-throughput sequencing (hts) of the trb repertoire is the best tool for the evaluation of clonotype dynamics during immune reconstitution as compared to cdr spectratyping and staining of vβ families. we investigated whether longitudinal hts analysis of trb would accurately assess development of tcr repertoire diversity over time and reflect the quality of t cell reconstitution following hct for scid. we wanted to study the effect of conditioning regimen, scid genotype, donor type on tcr diversity post hct. we hypothesized that repertoire diversity may represent an early biomarker to predict long-term immune reconstitution vs. need for a second intervention. we assessed if the trb repertoire post-hct carried a molecular signature of selfreactivity. methods: the composition and diversity of trb repertoire of scid infants, pre-hct and at d, and mo and yearly posttreatment(s) was studied by hts. median time of follow-up was mo. subjects were part of a prospective study of scid by the primary immunodeficiency treatment consortium. equal amounts of total rna extracted from peripheral blood was used as template to semi-quantitatively amplify trb rearrangements. the vdj statistics file (past program) was used to calculate a shannon entropy (h) index of repertoire diversity and simpson ( -d) index of repertoire clonality. results: trb sequence analysis of scid patients showed poor diversity at baseline, followed by improvement to normal complexity (h index > . ) after hct. similar kinetics of development of trb diversity were seen in patients with il rg, jak , and il r defects (n= ) as in those with rag and artemis defects (n= ). in the latter group, however, hct with no conditioning or immune suppression only was associated with persistently lower diversity than hct with conditioning (p < . ), a difference not found in the il rg/jak /il r group (fig. ) . hct from a matched donor ( / conditioned) correlated with higher diversity than hct from a mismatched donor ( / conditioned) (p= . ). having > cd + t cells/ul at mo post-hct correlated with higher trb diversity at and mo post-hct (p < . ). the trb repertoire d post-hct was enriched for the presence of central cysteines at the apex of the cdr (p < . ), a biomarker of self-reactivity ( fig. ). an h-index of . or lower at d after hct predicted need for second intervention (hct or gt) (fig. ) . conclusions: analysis of trb diversity allows for detailed assessment of development of a diverse t cell repertoire following cellular therapies for scid and confirms the need for patienttailored treatment strategies based on scid genotype. t-cell repertoire d post-hct is characterized by a molecular signature that may contribute to the increased rate of autoimmunity early post-transplant. furthermore analysis of trb diversity at d post-hct may identify patients at risk for failure of sustained immune reconstitution, thus prompting a second intervention without delay. abstract/case report text background atopic dermatitis is a chronic, multifactorial, relapsing inflammatory skin condition which is one of the main known health problem worldwide. atopic dermatitis lesions are frequently colonized by staphylococcus aureus and staphylococcus epidermidis. their susceptibility to form biofilms, ability to form adhesive skin colonies which lead to extremely resistant to antibiotics and immune responses. formation of skin biofilm resulted in complex bacterial communities that have unique effects on human keratinocytes, mouse fibroblasts and host immunity. aims: the aims of this study to confirm the specificity of s. aureus or its secreted factors in induction of pro-inflammatory cytokines il- , tslp and toxicity on human keratinocytes and mouse fibroblast. the second aim to study the inhibitory effect of co-culture of s. epidermidis with s. aureus in term of production of pro-inflammatory cytokines and toxicity. method and materials: human epidermal keratinocytes and mouse embryonic fibroblasts cell lines from t were used as a control strain to examine production of inflammatory response (il- and tslp) and cell death induced by s. aureus in the presence and absence of s. epidermidis. tslp and il- were detected by elisa and the apoptosis of s. aureus and s. epidermidis on these cells was evaluated by flow cytometry. result: recent findings propose the important role of skin biofilms in the pathogenesis of atopic dermatitis. s. aureus have been found to induce secretion of pro-inflammatory cytokines and cause apoptosis of human keratinocytes and mouse fibroblasts. presence of s. epidermidis as skin biofilm found to protects the human keratinocytes and mouse fibroblasts from induction of proinflammatory cytokines and cytotoxicity. conclusions and future work: s. aureus are essential in production of inflammatory response and cell death of mouse fibroblasts and human keratinocytes. future work will be carried out to identify the soluble factors that responsible in induction of pro-inflammatory cytokines. in addition, more studies are needed to be able to understand the mechanism by how s. epidermidis reduce the induction and cytotoxicity caused by s. aureus. j clin immunol in adult patients, in whom arbitrarily defined diagnostic criteria for antibody deficiency syndromes are not fulfilled, is subject to interpretation and decision differences reported by immunologists world-wide. in this study, we explored whether training in one particular program would decrease the variability in diagnostic and treatment approaches seen in the responses to two nationwide questionnaires in the uk and the usa. methods: a -minute online survey originally administered to a cross-sectional sample of us allergists/immunologists (usa/i) in january, , was also answered by a/i subspecialists who had trained in the last years at the louisiana state university health science center allergy immunology training program in new orleans (laa/i). respondents were asked questions on patient assessment, antibiotic use, initial igrt, and immune response assessment in decisionmaking to prescribe igrt. usa/i participants were recruited from the dynata physician professional panel. laa/i participants were recruited by the louisiana primary immunodeficiency network (lapin). results: overall, laa/i had consensus responses to the various practice questions close to % of the time, but outliers were always present, as was also observed in the usa/i. there was a higher frequency in the reported care of patients as described in the questionnaire by laa/i. over % of laa/i assessed vaccine responses prior to commencing igg replacement vs only % of usa/i p < . . all la a/i used the pneumococcal vaccine for assessment purposes while few used tetanus and hemophilus influenza, and none used meningitis or salmonella vaccines. these vaccines were still used by some of usa/i. a high level of concordance was observed among all respondents in that only few regarded pneumococcal antibody testing as the definitive test to commence igrt. high resolution chest ct scan was used more often by laa/i before starting igrt. assessment of effectiveness of igrt was decided after only months by more usa/i, vs laa/i, who tended to wait months to decide to continue or discontinue igrt. conclusions: all a/i responders saw a significant number of patients who do not conform to strict diagnostic criteria for antibody deficiency syndromes. there is diversity in the approach of usa allergists/ immunologists in determining the indication for igrt for non-classical antibody deficient patients. laa/i responses made it obvious that post graduate influences always play a role in shaping the way a/i practice evolves after graduation. drawing on clinician experiences through questionnaires offers a valid contribution to developing consent approaches to improve patients' clinical conditions. diagnostic criteria and treatment guidelines would benefit from practice-based realistic recommendations based on a/i experience. abstract/case report text background: autoimmune lymphoproliferative syndrome (alps) is a rare genetic disorder secondary to a defective fas-mediated apoptotic pathway of mature lymphocytes. it is characterized by chronic nonmalignant lymphoproliferation in the form of lymphadenopathy and/or splenomegaly, autoimmune manifestations such as cytopenias, increased risk of lymphoma, and expansion of tcrαβ+ cd -/cd -(dnt)t-cells. germline or somatic pathogenic variants in fas, fasl, and casp are well described genetic defects associated with alps. the definitive diagnosis for alps, based on the revised nih diagnostic criteria, include both required criteria (chronic non-malignant, non-infectious lymphadenopathy, splenomegaly, or both and elevated tcrαβ+ dnt t-cells) and one of the primary accessory criteria (defective lymphocyte apoptosis or mutation in the genes mentioned above). patients who do not meet the current diagnostic criteria are considered for alps-related disorders. case presentation: we report a -year-old male who presented with recurrent infections, splenomegaly and chronic lymphadenopathy since month of age. due to its chronicity he was evaluated by multiple specialists for malignant and infectious causes. hematological workup including bone marrow biopsy was unremarkable except for an elevated ldh level. infectious workup identified a past cmv infection. clinical course is pertinent for chronic splenomegaly which was identified incidentally at . years of age during an evaluation for intussusception. family history is pertinent for a father with recurrent infections, paternal grandmother with thrombocytopenia of unknown cause requiring platelet transfusions, and paternal cousin with neutropenia. there is no family history of lymphomas. history of chronic lymphoproliferation and recurrent infections prompted an evaluation for lymphoproliferative disorder. full immune workup was notable for elevated plasma il- and il- , normal immunoglobulin levels, lymphocytes subsets, vitamin b level, soluble fasl, and relative frequency (%) but borderline increased absolute count of tcrαβ+ (dn) t-cells. in addition, he was noted to have presence of anti-platelet antibodies, poor lymphocyte proliferation to antigens, and low pneumococcal antibody titers. genetic testing with a pid gene panel identified a likely pathogenic heterozygous variant in prf c. del (p.his thrfs* ), a heterozygous variants of uncertain significance in casp c. c>t (p.pro leu) and stim c. a>g (p.thr ala). the casp variant is present in alleles in gnomad ( k total allele count) and reported deleterious by sift. discussion: unlike the typical alps presentation, characterized by dominantly lymphoproliferation and autoimmunity, our patient's clinical phenotype is striking for recurrent infections, abnormal t-cell function, and poor antibody response. our patient does not the meet diagnostic criteria for alps due to normal relative frequency of dn t-cells. however, presence of elevated of il- , il- , platelet autoantibodies raise concern for alps-related disorder. in addition, family history of recurrent infections and cytopenias raises concern for familial autoimmunity and alpslike phenotype. although casp is associated with autosomal dominant and autosomal recessive alps, the role of this vus is yet to be determined. conclusion: we continue to investigate the pathogenicity of our novel casp vus. further studies include pedigree analysis, fas apoptosis assay and apoptosis pathway testing to assess for the etiology of this alps-related disorder. (word count , max ) abstract/case report text rationale: ocrelizumab is a recombinant anti-cd monoclonal antibody, which binds to a different, but overlapping cd epitope than rituximab. there have been increasing reports evaluating hypogammaglobulinemia and morbidity and mortality in patients receiving rituximab, but there is a paucity of data on hypogammaglobulinemia in patients treated with ocrelizumab. methods: we performed a retrospective review of patients who received ocrelizumab in our healthcare system. we evaluated the demographics, indication for ocrelizumab, frequency of immunologic evaluation, and h y p o g a m m a g l o b u l i n e m i a p r e -a n d p o s t -o c r e l i z u m a b . hypogammaglobulinemia was stratified as mild (igg < mg/ dl or less than lab reference range), moderate (igg < mg/ dl) or severe (igg < mg/dl). results: we identified patients who received ocrelizumab for multiple sclerosis (average number of ocrelizumab cycles = ; range - cycles). there were ( %) female patients, with a mean age of years old (range - ; standard deviation ± t-cells. tnfα, ifnγ, and il- were not statistically different between cgd patients and healthy controls. tnfα, ifny, il- , and il- a expression in patients with cgd who had active colitis or history of colitis were increased as compared to cgd patients without a history of colitis but did not reach statistical significance. in two patients, il- a expression that was elevated pre-hct normalized post-hct. discussion: the mechanism for increased susceptibility to inflammatory disorders in patients with cgd has not been well elucidated. our results agree with previous studies demonstrating increased il- and il- a production from cd + t-cells in patients with cgd indicating a proinflammatory state in these patients at baseline. also, there appears to be an increase in tnfα, ifny, il- , and il- a expression from cd + t-cells that correlates with presence of inflammatory disease vs. those without inflammatory disease indicating that these cytokine perturbations may be able to serve as biomarkers of disease activity. a larger sample size with prospective collection will be analyzed in the future. abstract/case report text background: glucose- -phosphatase catalytic subunit (g pc ) deficiency, is characterized by severe congenital neutropenia, recurrent bacterial infections, mild intermittent thrombocytopenia and a high incidence of congenital cardiac and uro-genital defects. we report the case of a -yo male with chronic neutropenia and thrombocytopenia, who was found to have homozygous pathogenic variants in g pc (c. del, p.phe serfs* ). unique to this case is the patient's long history of misdiagnosis of evans syndrome (chronic autoimmune neutropenia with thrombocytopenia). case presentation: a -yo male with reported diagnosis of chronic autoimmune neutropenia and thrombocytopenia since age was referred to our a b clinic with concern for an underlying immune dysregulation syndrome. he had a history of oral ulcers, gingivitis, recurrent bacterial infections (otitis media, pneumonia, skin abscess) concomitant with severe neutropenia ( < cells/ul), for which he had received treatment with systemic steroids and g-csf since he was years old. he also had history of asthma and short stature, thought to be secondary to his chronic systemic steroid use. we present the first chilean patient with stat gof immunedysregulation . moreover, to our knowledge this is the first stat gof patient presenting with lymphomatoid granulomatosis. this is a severe pulmonary disease in which primary immunodeficiencies including stat gof should be considered in the differential. in this case rituximab successfully resolved pulmonary nodules and respiratory symptoms. there was persistence of mild hepatosplenomegaly but otherwise clinical stability and monitored expectantly until the age of . at that time he presented with fever, left knee and ankle arthritis. he underwent arthrocentesis of the left knee and left ankle, both aspirates were sterile, with notable leukocytosis with heavy neutrophilic predominance. an extensive rheumatologic and infectious workup was non-diagnostic. both sil- r and il- were elevated, , units/ml ( < ) and pg/ml ( < ), respectively. he was treated with systemic corticosteroids, ultimately arthritis resolved after months. at age he presented for the first time with periorbital pain and conjunctival injection of the left eye that persisted after minor trauma. he was found to have nongranulomatous uveitis, which responded ultimately to systemic corticosteroid. he then presented at age with fever and right knee and great toe arthritis. again he underwent arthrocentesis which revealed aseptic arthritis, and at that time was started on anakinra (anti il- β) and prednisone. there was clinical improvement over several weeks followed by return of right knee arthritis, coupled with onset of symptomatic uveitis of the left eye. despite systemic corticosteroids and anakinra and il- blockade, the patient was again admitted shortly thereafter to the hospital with arthritis, fevers, rash and abdominal pain. there was concern for evolving hlh and the patient was ultimately transferred to cincinnati children's for further evaluation and treatment. pertinent inflammatory biomarkers at that time included sil- r of , units/ml and il- level of , pg/ml. in addition to anakinra and systemic corticosteroids, the patient was started on tadekinig alfa (recombinant human il- binding protein) as part of a prospective study. hlh flare ultimately resolved without use of antineoplastic agents, and the patient was discharged home. soluble il- r levels since normalized, and il- levels decreased to less than pg/ml. the patient has been doing well on anakinra and tadekinig alfa, though continues to experience mild to moderate right knee effusion. this case suggests il- inhibition may be an effective therapeutic approach for patients with xiap deficiency. in the absence of neurological involvement and infectious trigger, ruxolitinib was initiated at a dose of mg/m /day, in combination with dexamethasone ( mg/m /day). this treatment led to rapid normalization of the neutropenia ( hours), complete resolution of the splenomegaly ( days) and disappearance of hlh biological markers (triglycerides levels in week, activated hla-dr+ cd t cells in weeks, fibrinogen levels in month), without the need for etoposide or serotherapy. dexamethasone was weaned every two-weeks and stopped after weeks. ruxolitinib was well-tolerated with no side effects. while in complete remission of her hlh, the patient then received alemtuzumab ( . mg/kg total dose) and a fludarabine-based myeloablative conditioning regimen. ruxolitinib was weaned over one week, and a / unrelated transplant was performed with success. the immediate posttransplant period was complicated by a veno-occlusive disease that responded rapidly to defibrotide and a corticosteroidresistant skin and ocular graft-vs-host disease (gvhd) despite a prophylaxis with ciclosporine and mycophenolate mofetil. gvhd was controlled by the reintroduction of ruxolitinib. at months post-hsct, her chimerism is % donor. to our knowledge, this case is the first description of a patient with primary hlh successfully treated in first intent by a combination of dexamethasone and ruxolitinib prior to hsct. our observation suggests that this targeted and less-toxic treatment regimen, that does not include etoposide nor high-dose alemtuzumab, is effective, well-tolerated and could be used in first intent to treat primary hlh. abstract/case report text presentation a -year-old girl, presented in ambulatory consultation, with a -year history of recurrent fever, influenza-like symptoms (sore throat, malaise), associated with self-limited painful genital ulcers (just within the period of fever). the first episode was characterized for an fournier's infection, requiring in-hospital treatment, multiple surgical procedures, antibiotics and hyperbaric oxygen therapy. after that catastrophic debut, she was diagnosed approximately episodes per year pharyngitis (with fever, malaise and sore throat) treated with corticoids, antibiotics and topic medication. the last year, noticed that every episode of fever (total of ) were associated with one or several genital lesions. the patient had no relevant medical history, she didn't receive long-term medication, she received all immunizations, she was sexually inactive, and hadn't apply any topic medication or product on the vulva, there was no trauma history, psychological medical history or sexual abuse. episodic gynecologic examination showed her labia minor several lesions, fibrinous, soft ulcerations on their inner aspect, these lesions had a symmetrical appearance, known as kissing lesions; no vulvar swelling, vaginal discharge or lymphangitis were noticed. there were no other skin or mucous membrane lesions (figure ). investigations viral (hiv, hbv, hcv, ebv, cmv) and treponemal (tpha-vdrl) serologies were negatives. erythrocyte sedimentation rate (esr) and pcr analysis within ulcers episodes were positive. specific antibodies (cardiolipin, anti ro/ss-a, anti la/ss-b, anti ccp, anti ena, anti gliadin, anti tpo anti tpo) serologies were negative. otherwise, important elevation immunoglobulin d was observed ( , mg/dl, twice the normal value): mild elevations of immunoglobulin m and immunoglobulin a were observed. serum subtypes of immunoglobulin g and immunoglobulin e were normal. leukocytosis with monocytes elevation and an increase of lymphocytes b were present. (table ). discussion lipschütz ulcers are uncommon and an often unknown entity for physicians, but it is important to recognize and include it in the differential diagnosis of vulvar ulcerations. this condition is characterised by self-limited painful ulcerations of the vulva or lower vagina in adolescent or young women, non-sexually transmitted, and usually preceded by influenza or mononucleosis-like symptoms. hyperimmunoglobulin d syndrome (hids) is characterized for unremitting fever lasting four to seven days and the presence of palpable tender lymphadenopathy, splenomegaly, arthralgia/arthritis, abdominal pain, and mucocutaneous manifestations. laboratory findings suggestive of hids include elevated age-specific serum immunoglobulin d (igd) and/or immunoglobulin a (iga) levels, elevation of acute phase reactants, and urinary excretion of mevalonic acid during, but not between, attacks. the diagnosis is established if an elevated age-specific level of igd is detected. iga levels are typically measured at the same time but are not required for diagnosis. elevated serum igd is not specific for hids and can occur in patients with certain neoplastic, infectious, heritable, and idiopathic disorders. in the present case report, the patient was treated with colchicine, with favorable evolution and free from new events. levels of ig d, platelets and monocytes remain high. we describe a young female patient presenting recurrent lipschütz ulcers, fever and elevation of serum immunoglobulin d, suggesting that hids could be associated with genitalia ulcers. ( ), and transmission in vivo in extremely low birth weight infants was considered ( ) . based on these considerations, the risk/benefit was considered favorable for restarting pasteurized donor breastmilk feeds. given his small size and young age, we had significant concerns about using ganciclovir prophylaxis and opted to hold this and monitor weekly cmv pcr. the child has been titrated up on these feeds, is gaining weight appropriately, and has had weekly cmv pcrs which are negative x since restarting donor breastmilk. t cells, last checked at weeks of age ( weeks gestational age) remain essentially absent. given the lower risk of nec in premature infants with breastmilk-based enteral feeds, a broader, multi-institutional study is warranted to best examine the safety of pasteurized donor breastmilk in infants with scid and complete digeorge syndrome. transfected with a reporter plasmid (for luciferase), wt or mutant-stat plasmids. nk cell cytotoxicity was measured by cr release assay. we used multiparametric immune profiling to dissect the effect of stat -gof mutations on nk cell developmental phenotype. results: similar to our previous studies, we observed higher levels of stat phosphorylation after two hours of stimulation from the dbd mutation compared to the ccd mutations. the stat activity assay confirmed gain of function observed by flow cytometry, but this activity was higher in k q mutant and d e mutant (ccd-closer to dbd) than v i mutant. all patients demonstrated low nk cell lytic unit compared to healthy donors. interestingly, we observed a correlation between low lytic unit and lower numbers of cd dim perforin + cd + nk cells; much lower in patient with k q mutation. stat -gof patients showed a significant decrease in total nk cell numbers and impaired nk cell maturation was characterized by low expression of cd , and higher levels of immature nk cell markers (cd , nkg a, cd b). conclusions: these data suggest that impairment of nk cell function is affected by the location of the stat mutation and continues to be the case in novel mutations identified. the identification the genotype/ phenotype correlation in the spectrum of the nk cell defect in stat gain-of-function mutants may help to better understand the molecular basis for stat activation and/or function to predict clinical manifestations of disease and ultimately treatment regimens. mutation specific analysis after an amniocentesis showed that one twin was a carrier (l m) and the other was a compound heterozygote (r c and l m). after birth, twin a had a mildly low erythrocyte ada level ( . nmol/h/mg; normal range + ) with normal metabolites and a normal immunophenotype, similar to both parents. twin b showed a normal absolute lymphocyte count and mitogen proliferation, normal t lymphocyte subsets, mildly low b and nk cells with % naïve t cells and a normal trec assay. erythrocyte ada levels were absent in peripheral blood, with mildly elevated metabolites [daxp= . μmol/ml rbc (normal < . ) and %axp= . (normal < . )]. weekly recombinant ada enzyme replacement therapy (ert) was started at week of life with subsequent normalization of the metabolites by week . absolute lymphocyte, t cell subsets were normal at birth but continued to rise slightly above normal range after starting ert. b and nk cell counts were mildly low at birth but normalized by week . genetic testing confirmed the prenatal genotypes in the twin girls. the patient is now months old and doing well with no history of infections. her twin was not an hla match and family is currently awaiting gene therapy approval. discussion: ada deficient patients show substantial clinical and metabolic heterogeneity that tends to correlate with the genotype but phenotypic discordance occurs even within the same genotype. we describe an infant with prenatally diagnosed compound heterozygous mutations in the ada gene (grade-i: r c and grade-ii: l m). ada alleles are graded from -iv with increasing ada expression and decreasing severity respectively. there are reports of children with grade i/iii allele combinations with delayed, late and partial phenotypes. two siblings have been reported with l m allele (grade iii) in combination with a different grade i allele (r q), presenting with combined immunodeficiency at and months. the specific allele combination from our patient has not been previously reported, however, we expected that the grade-i allele likely would be more deleterious than the grade-iii allele. in our case, predicting a future phenotype remains a challenge, creating a dilemma regarding management strategies. however, with only mild metabolite elevations in our patient after birth, we may speculate whether the prenatal diagnosis with early ert precluded the development of a full immunophenotype and it remains to be seen whether nonimmune sequeli may be prevented. conclusion: children with compound heterozygous mutations in the ada gene can pose diagnostic and therapeutic challenges, especially due to the associated metabolic and clinical phenotypic variability. early recognition and treatment may potentially alter long-term morbidity and mortality. (ipex)-like phenotype. immunodeficiency is often combined with impairment of the humoral and cellular compartments. hematopoietic cell transplant (hct) can resolve disease-related manifestations in stat -gof, but overall survival is poor and there is a high rate of secondary graft loss in transplanted patients. jakinibs are a class of medications that block cytokine-induced jak/stat activation. ruxolitinib preferentially inhibits jak and jak and has been used as precision-directed therapy for treatment of stat -gof related manifestations with success in stabilizing and in some cases reversing organ-specific manifestations. the utility and safety of jakinibs for long term treatment of stat -gof and in the prevention of disease-related manifestations is not known. as such, hct is often pursued for patients once disease-related manifestations are controlled with jakinibs. we present a patient with stat -gof mutation with gradual secondary graft loss following hct years ago, that has had continued disease progression despite chronic ruxolitinib treatment. case presentation this is a years-old male diagnosed with a de novo heterozygous stat mutation (c. a>g/a) at age , years following hct for ipex-like disease. he has been treated with ruxolitinib for the last three years. this patient initially presented at months of age with wasting enteropathy, failure to thrive, early-onset type diabetes and hypothyroidism. he had frequent upper respiratory infections during childhood including mycobacterium fortuitum mediastinal lymphadenitis. at years he underwent / matched, unrelated bone marrow transplant following reduced-intensity conditioning. mixed donor chimerism was present in the first days following hct, and he continued to have a slow progressive decline of donor chimerism with full graft loss ( % whole blood donor chimerism) by age . at age , enteropathy returned leading to cachexia and tpn dependence. concurrently, he had recurrent upper respiratory tract infections, lymphopenia, and hypogammaglobulinemia. imaging showed bronchiectasis and lung function was consistent with obstructive lung disease (fev : . l fvc: . l dlco: . ml/min/mmhg). initiation of ruxolitinib at age resolved his enteropathy with discontinuation of tpn and > -pound weight gain. enteropathy has not returned. pulmonary clearance measures have also been employed. dlco initially improved (dlco: . ml/min/mmhg) but obstructive lung pattern continued (fev : . l fvc: . l). after initial improvement, dlco began to decline. over the last years and despite treatment with ruxolitinib, lung function has deteriorated with worsened fev ( . l), fvc ( . l), and dlco ( . ml/min/mmhg). with this progressive decline, the family is now pursuing second hct. discussion jakinibs apply precision-directed therapy for immune dysregulatory features of stat -gof. their use leads to substantial disease control and clinical improvement but does not prevent disease progression. jakinibs should be used as a bridge to definitive therapy with hct in patients with stat -gof mutation. a recent large registry study showed a higher risk of infections (hr . , % c.i . - . ) in children with thymectomy as compared to surgery controls, in addition to demonstrating differences in the risk of cancers, autoimmunity and atopy. limited small studies have described some risk factors for altered immune consequences; however, specific predictors of infections among children with congenital heart disease (chd) undergoing thymectomies have not been systematically assessed. among children with chd and thymectomy, we sought to characterize children with and without reported infections within years postthymectomy and identify predictors of bacterial and viral infections. methods: using a retrospective chart review (institutional irb approved) from / / and / / , we identified children with chd that underwent thymectomy and excluded any known conditions associated with immunodeficiency and those with less than -month follow-up post-thymectomy. first absolute lymphocyte count (alc) after thymectomy was stratified using a cutoff at % of the lower limit of age-adjusted normal values (alc value < % vs alc value > % of the lower limit of age-adjusted normal levels). we sought to assess predictors of reported bacterial (positive blood, cerebrospinal fluid, respiratory cultures and chest-x-ray confirmed pneumonia) and viral infections (positive viral pcr tests) within years postthymectomy. results: we identified children with chd who had thymectomies, of which, % ( / ) were male. the median age at thymectomy was months (interquartile range months- . years); % ( / ) underwent a complete thymectomy; and % ( / ) developed a chylothorax within week post-thymectomy. a substantial proportion of children had an alc below % of the lower limit of age-adjusted normal levels after thymectomy ( % [ / ] pre-thymectomy vs % [ / ] postthymectomy). among children with chd post-thymectomy, % ( / ) and % ( / ) reported bacterial and viral infections within years, respectively. children with post-thymectomy alc values below % of the lower limit of age-adjusted normal levels had higher odds of reported bacterial (or . , % c.i . - . , p= . ) and viral (or . , % c.i . - . , p= . ) infections post-thymectomy as compared to those with an alc greater than % of the lower limit of ageadjusted normal levels (multivariate logistic regression). there was no association with the type of thymectomy (partial vs complete), age at thymectomy, weight at thymectomy, sex or prematurity. conclusions: among children with congenital heart disease with no known immunodeficiency undergoing thymectomy, alc below % of age-adjusted normal levels post-thymectomy may be associated with higher odds of bacterial and viral infections. a retrospective study design with a small sample size poses several limitations; however, this study suggests that post-thymectomy absolute lymphocyte values may be a potentially useful marker to identify higher risk patients in this population. radiological assessments esp. in the ct chest is commonly performed, but has associated radiation exposure and pulmonary function testing, at times, maybe insensitive to small changes in lung pathophysiology. many pids may have overlapping features with short telomere syndromes (sts) a, which are accelerated aging syndromes affecting hematopoietic, pulmonary, hepatobiliary and/or immunological systems, unified by a high cell turnover in these organs. clinical assessment of ageappropriate telomere length (tl) is performed using flow cytometry & fluorescence in-situ hybridization (flowfish). methods: we retrospectively analyzed telomere lengths in lymphocytes and granulocytes using the flow cytometry and fish method .flowfish testing was done at reference laboratories in johns hopkins university (jhu, usa).approval was obtained from mayo's institutional review board. data abstraction and analysis was done using the software jmp. results: patients were included in our analysis with females ( %) and males ( %).the median lymphocyte count of our cohort was . ( . - . ).the telomere length was strongly associated with the presence of lung disease (p= . *) and the presence of interstitial lung disease closely paralleled the changes in telomere length (delta-as compared to age adjusted normal percentiles lengths). shorter lymphocytic telomere length was associated with more severe reduction on total lung capacity (tlc; p= . *). conclusion: shorter lymphocytic telomere length served as a reliable biomarker for interstitial lung disease in pid patients. this may open up newer avenues for assessment of aging pathways in pid and may offer the option of using senolytic therapies in pids. mutations in the il- receptor common gamma chain gene (il rg) result in x-linked severe combined immunodeficiency (scid). the common gamma chain is shared by il- , il- , il- , il- , il- and il- receptors. x-linked scid typically presents with low or absent t and nk cells and normal or elevated numbers of b cells. we report a case of x-linked scid with elevated b and nk cell numbers (t-b+nk+). the male patient had an abnormal newborn screen for scid in north carolina. lymphocyte enumeration performed at days of life showed cd + cells/mm , b cells/mm , and nk cells/mm . he had no naïve t cells. repeat lymphocyte enumeration two weeks later showed that the cd + count had increased to /mm . only . % ( cells/mm ) were cd ra+ naïve t cells. he continued to have elevated b cell and nk cell numbers. chimerism studies revealed the presence of % female cells in mitogen-stimulated pbmc by fluorescence in situ hybridization, indicating the presence of transplacentally transferred maternal cells. lymphocyte proliferation responses to pha and cona mitogen stimulation were very low (less than % of normal). immunoglobulin levels were igg mg/dl, igm mg/dl, and undetectable iga and ige. genetic studies revealed a missense mutation in il rg, c. c>t, resulting in an amino acid substitution (p.ala val) in the extracellular domain. family testing showed that the patient's mother was a carrier for this variant. the father and the two healthy older brothers did not have this variant. of note, the family history was significant for lateral maternal male early deaths. at weeks of age, the patient received an unfractionated bone marrow transplant from his hla-identical brother without conditioning or gvhd prophylaxis. at the time of this report's submission, he is weeks post-transplantation and has had successful engraftment (whole blood-cd + fraction was composed of > % donor cells). he also now has normal t cell proliferation in response to mitogens and normal levels of all immunoglobulins. genetic defects that cause primary immunodeficiency can have variable phenotypic presentations. the patient's phenotype was atypical in that he had elevated nk cell numbers. to further evaluate these cells, we checked for stat phosphorylation following il- stimulation of abstract/case report text background: stat gain-of-function (gof) mutations cause a multisystem disease of early onset autoimmunity and lymphoproliferation, severe post-natal growth restriction, and recurrent and/or invasive infections. treatment of the autoimmune and auto-inflammatory features of stat gof patients relies heavily on immunosuppression and is often challenging. the full scope of phenotypes, treatments and outcomes may be broader when analyzing a substantially larger cohort than those already reported. methods: we gathered and analyzed data on patients from centers world-wide with confirmed gof mutations in stat . retrospective chart reviews were performed in accordance with all local ethics and irb committees to determine clinical manifestations, immunophenotype, treatment regimens, success of treatment methods, and overall survival. funcitonal transcriptional activity was assessed by luciferase reporter assay on each individual mutation. results: fifty-nine individual mutations were identified and all conferred gof by a validated luciferase assay. there were mutations in the nterminal domain, in the coiled-coil domain, in the dna binding domain, in the sh domain, and in the transactivation domain with the overwhelming majority being missense mutations. median age at presentation was approximately years; % of subjects are male and % are female. immunodysregulatory features presented in all patients. autoimmune cytopenias were the most common occurring in % of subjects (n= ), followed by lymphoproliferation in % (n= ) with increased frequencies of double negative (cd -cd -)t cells being found in % of of patients tested, enteropathy in % (n= ), endocrinopathy in % (n= ), interstitial lung disease in % (n= ), dermatitis in % (n= ), and inflammatory brain disease in . % (n= ). growth failure was present in % (n= ) with half of those patients having concurrent enteropathy. infections were reported in % of the cohort to include recurrent and/or invasive viral, bacterial, opportunistic, fungal, and mycobacterial infections. prominent abnormalities of immunophenotyping included t cell ( %) and b cell ( %) lymphopenia with reduced t cell proliferation in response to mitogens or antigens in % of those evaluated patients. fifty-nine percent of the patients hypogammaglobulinemia while % exhibited poor specific antibody responses to recall antigens. overall survival was % at data collection.treatment of stat gof patients often included multiple agents: ivig , chronic and pulse steroids, mtor inhibitors, calcineurin inhibitors, rituximab, mycophenolate mofetil, alemtuzumab, tocilizumab, and jakinibs. those started on jak inhibition showed improvement in clinical symptoms and, to date, there are stat gof patients on targeted jak inhibition. thus far, patients have undergone bone marrow transplant with a % survival rate. discussion: stat gof mutations were first reported in to cause a heterogeneous syndrome of autoimmunity and lymphoproliferation with immunodeficiency and infection susceptibility. earlier treatment with targeted therapy such as jak inhibitors has led to reduced disease morbidity. we report the largest cohort of stat gof patients collected through a multi-national collaboration of the longitudinal data and natural history of stat gof disease. understanding the heterogeneity of presentation and key features that will lead to proper diagnosis and early treatment in an effort to prevent long term disease associated sequelae. we present the case of month old male with a novel heterozygous mutation in tcf and two previously unreported phenotypes: ) absent circulating cd + b cells yet preserved immunoglobulin synthesis and vaccine responses and ) significant thrombocytopenia that improved with immunosuppression. there is also a striking family history of two half-sisters who died during early infancy with similar clinical and lab findings and the same genetic change. the infant boy was born at term with respiratory failure and generalized rash. at birth he had thrombocytopenia ( k/ul) and lymphopenia ( / ul). initial absolute cd + t cell count was low ( /ul), yet he had normal thymic output and proliferative responses to mitogens ruling out scid. cd + b cells were < /ul and bone marrow biopsy revealed decreased hematagones, yet he had a normal igm level ( . mg/dl) elevated iga ( mg/dl), and elevated ige ( iu/ml). igg levels were initially obscured by maternal igg and ivig; in turn he made positive titers to diphtheria and tetanus vaccination. the infant has maintained his own igg production. rapid genome sequencing revealed a heterozygous predicted deleterious vous in tcf , in the second transactivation domain (c. c>t, p.pro ser). the same change in tcf was identified in the deceased half-sisters as well as the father: all infants had different mothers, suggesting autosomal dominant inheritance. the sisters had similarly severe thrombocytopenia and absent circulating b cells; their causes of death were not completely understood. the year-old father has normal platelet levels, very low cd + b cells ( /ul), elevated igg ( , mg/dl) and ige ( , iu/ml), and normal levels of iga and igm. the father also has an elevated number of cd + t cells ( , /ul) with an increased percentage of t cells expressing hla-dr ( %). in the months after birth, the infant boy continued to require frequent platelet transfusions. despite the persistent t lymphopenia, there was evidence of increased t cell activation with elevated levels of soluble il- r ( pg/ml) and increased percentage of cells expressing hla-dr ( %) cd ( %), cd ( %), cd ( %), and cd ( %). a -day trial of prednisone was associated with an increase in his platelet count to > k/ul. he was switched to rapamycin as a steroid-sparing agent, and his platelet count has remained > k/ul for several weeks without transfusions. interestingly, his b cell counts also improved after the steroid trial ( /ul) and his absolute lymphocyte count is normalizing on rapamycin. a potential mechanism could be rapamycin decreasing t cellmediated destruction of platelets or b cells. reassessments of t cell activation markers and b cell phenotyping while on rapamycin will be done in the future. in contrast to multiple published cases of tcf mutations associated with complete agammaglobulinemia and absent b cells, we present a case of an infant with absent b cells yet preserved humoral function as well as severe thrombocytopenia responsive to rapamycin. in collaboration with colleagues at nih, studies are underway to understand whether/how the unique change in tcf is related to either phenotype described above. abstract/case report text background: childhood-onset, chronic, multi-system inflammatory diseases are increasingly being characterized as monogenic inborn errors of immunity. arpc b deficiency is a recently described, rare combined immunodeficiency characterized by recurrent/severe infections, a variety of autoimmune manifestations and platelet defects. we describe a case of arpc b deficiency identified in an adult patient with recurrent ulcers/ bechet-like disease, non-malignant lymphoproliferation and intermittent microthrombocytopenia. patient case: at year of age, our female patient was diagnosed with behcet disease based on a history of bloody stools at months, oral ulcers at months and vulvar lesions at year. she underwent rheumatology evaluations for inflammatory arthritis, episcleritis, eczema, vasculitic ulcerating nodules of the trunk, perineum and extremities, and verrucae forming flat plaques similar to epidermodysplasia verruciformis without a unifying diagnosis. other infections include otitis media, sinusitis, pseudomonas ecthyma gangrenosum, cervical lymphadenitis, and pneumonia. at years old, the patient was referred to our immuno-hematology comprehensive program clinic with a concern for malignancy versus a primary immune regulatory disorder (pird). she had a -month history of drenching night sweats, urticarial plaques, edema in her extremities and diffuse cervical, axillary and inguinal lymphadenopathy. past complete blood counts showed intermittent mild microthrombocytopenia. lymph node biopsies were negative for a neoplastic process but identified plasmacytosis, including focally increased iga-kappa+ plasma cells. expert review of the lymph node biopsy, and further evaluation excluded multicentric castleman disease. consideration was also given to autoimmunune lymphoproliferative syndrome (alps)-like disorders; however, her alps flow cytometry panel was nondiagnostic. her basic immune evaluation showed severe t cell lymphopenia (cd + cells/ cm, cd + cells/cm, cd + cells/cm) with adequate b and nk cells, normal lymphocyte proliferation to pha and pwm, and dysgammaglobulinemia with igg g/dl, iga g/dl, igm g/ dl and ige g/dl. due to concern of an underlying pird, a primary immunodeficiency panel was sent for gene analysis with negative results. however, trio clinical exome sequencing identified biallelic variants in the gene arpc b. one allele has a truncating, nonsense pathogenic variant in exon denoted as c. g>t, p.glu ter. the other allele has a likely pathogenic variant in intron denoted as c. - a>g, resulting in disruption of the canonical splice acceptor for exon . this is predicted to cause exon skipping, with an in-frame deletion of amino acids coded by exon . conclusion: this case highlights the value for evaluation for pirds in patients presenting with behcet-like disease, particularly in the context of other autoimmune manifestations and/or microthrombocytopenia. it also underscores that patients with arpc b deficiency may present with chronic non-malignant lymphoproliferation. moreover, this patient emphasizes the value of exhaustive genetic testing for complex immunologic phenotypes. abstract/case report text lipoyltransferase gene defect is associated with severe mitochondrial dysfunction disrupting lipoic acid biogenesis. clinical manifestations associated with early seizures, hypotonia, cardiomyopathy and pulmonary hypertension and encephalopathy. early neonatal death due to sepsis and cardiovascular collapse is commonly seen. the patient is a week preemie male with congenital heart disease who developed severe intractable lactic acidosis on day of life with increased excretion on organic acids of -methyl- , dihydroxybutyric acid. a mitochondrial disorder , echs or hibch deficiency was suspected. at mo of age the patient was admitted for apneic spells and respiratory compromise. he was found to have elevated crp associated with rhinovirus infection and gram-negative bacteremia. due to the history of failure to thrive and sepsis, immunology was consulted. immunologic work up indicated normal b, t and nk cells with normal dhr, but showed agammaglobulinemia. the patient was started on ivig and whole exome sequencing was done. molecular analysis showed compound heterozygote mutations in the lipt gene: c. g>a (p.arg gln) and c. t>g (pval gly). subsequent biochemical analysis also showed biochemical abnormalities consistent with lipt defect. lipoyltransferase is an enzyme involved in activation of a number of enzymes requiring lipoic acid. it is involved in lipoic acid synthesis. lipoic acid is required for the activity of pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, and branched-chain alpha-ketoacid dehydrogenase. the literature indicates that most patients with lipt defect have a severe, often fatal course. the patient is now almost years old and has stable clinical course without any major infections. he certainly has significant hypotonia and developmental delay. in conclusion, we are presenting the first case of lipt gene mutations associated with agammaglobulinemia who responded well to ig supplementation therapy. our immunologic findings in this case highlights the importance of immunodeficiency work up in challenging cases. as we see more cases lipt gene mutations, we will better understand the clinical spectrum. abstract/case report text a now -year-old male was initially evaluated for concerns regarding food allergy, eczema, food protein-induced enterocolitis syndrome, and failure to thrive. he had reactions of varying severity to multiple foods. these usually involved immediate urticaria or prolonged vomiting, diarrhea, and abdominal pain. ige and skin prick testing was performed to suspected foods and was positive to milk, egg, pork, wheat, peanut, pecan, coconut and corn. these foods had historically caused reproducible immediate symptoms. testing was negative to other suspected foods. he developed an oral aversion and extremely restricted diet. symptoms of abdominal pain, hematochezia, rashes, arthralgias, headaches, fatigue, dyspnea, and palpitations increased. urticaria and severe abdominal pain with vomiting and diarrhea continued intermittently without identifiable triggers on a restricted diet. laboratory markers demonstrated elevated inflammatory markers, anemia, iron deficiency, vitamin b deficiency, and vitamin c deficiency (scurvy). gastroenterology work up did not identify any pathology. gastrointestinal symptoms did not respond to treatment with multiple gerd medications or oral steroids. baseline tryptase was elevated. low histamine diet was initiated and repeat tryptase remained elevated. fractionated tryptase revealed normal mature (beta) tryptase with elevated total tryptase, negative genetics for c-kit mutation, normal urine prostaglandins. family members had tryptase levels drawn. one parent and sibling had elevated tryptase levels, while the other parent's tryptase was normal. hereditary alpha tryptasemia syndrome is defined by elevated blood tryptase levels and symptoms involving multiple organ symptoms. patients with elevated tryptase levels without symptoms are defined as having hereditary alpha tryptase trait. there is significant variability regarding which patients are symptomatic. organ symptoms that may be involved include skin, gastrointestinal, neurologic, connective tissue, cardiac, neuropsychiatric. severe allergic reactions such as anaphylaxis can occur. increased blood levels of the protein tryptase are caused by extra copies of the alpha tryptase gene (tpsab ). treatment is usually directed at specific symptoms, antihistamines, and mast cell stabilizers. research continues into additional treatment options. this patient was started on cromolyn and long-acting antihistamine. his gastrointestinal symptoms and rash/urticaria improved, and he began tolerating a small, but increased, variety of foods. the majority of his constitutional symptoms of fatigue, arthralgias, weakness resolved as he began gaining weight, and hemoglobin, vitamin c and b normalized. his sibling was evaluated and noted to have food allergy, asthma, abdominal pain, gerd, and eczema. she was also started on cromolyn and antihistamines which improved her gastrointestinal symptoms. parent with elevated tryptase was recommended to be evaluated further with allergist. this is an example of a patient with elevated tryptase and multiple organ system involvement. some of his signs and symptoms responded to mast cell stabilizing and antihistamine medications. patients with history of recurrent episodes of allergic reactions to foods and multiple constitutional symptoms would benefit from baseline tryptase levels. family members should also be tested if the patient has elevated tryptase. multiple studies have been published looking at the rates of scid in the united states. the estimated rate of scid prior to screening was per live births. post screening implementation, on average rates of scid were found to be closer to in live births. results : development of a t cell receptor excision circles (trec) scid screen in alberta involved the screening of anonymous term neonates using quantitative pcr for trecs. the cycle threshold for the control gene, rnasep, was set at . as % of our population had a cycle threshold < . ( % ci [ . , . ]). from those bloods spots with adequate dna, a final trec cut off of was chosen, as it would give an accuracy of . %, and fairly low false positive rate of . % ( % ci [ . , . ]). since starting a population based screen for scid in june of , we have identified cases of scid and cases of low trec not caused by scid. to date we have detected one case of reticular dysgenesis, cases of ada scid and one case of x-linked scid. other causes of lymphopenia in the neonatal period detected with abnormal trecs include one syndrome associated with variably affected cellular immunity (charge) and cases of secondary lymphopenia including four cases of prematurity, three cases of diaphragmatic hernia or gastroschisis, four patients with underlying cardiac disease, and one patient with severe hydrops. discussion : canada has multiple unique populations with increased risk of scid. the estimated rate of scid in canada prior to implementation of a population based screen was . per live births. the rate within canada's first nations, métis and inuit populations is . per live births. prior to scid screening, alberta had cases of scid identified between - with an estimated rate of per live births. to date, our screen in alberta has identified cases of scid with a rate of per live births which is significantly higher than previously estimated. given that early diagnosis and definitive management through bone marrow transplant or gene therapy has been shown to reduce mortality this screen will help reduce morbidity and mortality in this vulnerable population. abstract/case report text introduction: human herpesvirus (hhv- ) has the ability to integrate its genome into host telomeres. if this integration occurs in gametes, then the virus can be genetically transmitted and offspring will carry a copy of chromosomally integrated hhv- (cihhv- ) in each somatic cell. this can lead to false attribution of infectious and non-infectious presentations of hhv- , and make the diagnosis of active hhv- infection difficult. we present the case of a patient with meningoencephalitis attributed to hhv- and persistently elevated blood levels of hhv- by pcr concerning for primary immunodeficiency who was discovered to have cihhv- . case description: a -year-old female who carried a past diagnosis of hhv- meningoencephalitis was seen in immunology clinic for follow up of persistently elevated levels of hhv- dna in her blood by pcr. she was born at weeks and as an infant had failure to thrive (ftt), anemia and a varicella like rash after varicella immunization. at the age of , she received flumist vaccine and developed a fever the following day. over the next few days, she developed lethargy, altered mental status, headache, photophobia, seizure, papular rash and oral ulcers. she was admitted to the hospital and csf studies were consistent with viral meningoencephalitis ( wbc, l, m, rbc) although hsv, cmv, ebv and enterovirus were negative. she was treated for presumed hsv encephalitis with days of iv acyclovir and days of high dose steroids. one week after discharge, she again developed papular rash on feet, headache, oral ulcers and lethargy. she was admitted and csf studies this time showed only wbc but positive hhv- . blood and skin swab were also positive for hhv- . immunology was consulted while admitted and work up for primary immunodeficiency was initiated. her work up was normal including responses to vaccine titers, complement studies, moderate in t cells, monocytes, neutrophils, lung and muscle, and low in skin, liver, heart and kidney tissues. analysis of each individual gene expression level by nanostring in comparison with healthy controls demonstrated significantly higher levels of the following irgs: ddx , epsti , gbp , ifi , isg , ly e, oas , oas , oas , rsad , rtp and socs . whole blood rna-seq was performed in patients and pathway analysis with the differentially upregulated genes demonstrated an enrichment of intraluminal vesicle formation and negative regulation of apoptotic signaling pathways. stimulation of pbmcs with the tlr ligands poly i:c, odn, and lps induced a fold increase in ifi and a -fold increase in ifna and ifnb transcription compared to baseline. one patient had constitutive upregulation of stat and stat in monocytes and of stat and stat in t cells. conclusion: we describe a novel immunedysregulatory disease caused by de novo truncating variants in samd l that presents similar to candle with neutrophilic pannicultis and points to an important role of samd l on regulation of adaptive and innate immune responses. acknowledgements: this work was supported by the nih irp of niaid abstract/case report text introduction: ataxia telangiectasia (at) is caused by a defect in the atm gene which is responsible for repair of damaged dna. it is a rare, devastating neurodegenerative disease that results in ataxia and telangiectasias, particularly of the sclera and skin. those with at are at increased risk for immunodeficiency and cancer. the immunodeficiency is variable and may result in deficiency in humoral and cellular immunity in some patients. here we present a patient with ataxia telangiectasia and hypogammaglobulinemia on immunoglobulin therapy who developed recurrent urinary tract infections (uti) and sepsis. case presentation: the patient is a -year-old female with ataxia telangiectasia and hypogammaglobulinemia who presented with three episodes of uti, one of which resulted in prolonged hospitalization due to sepsis and acute kidney injury (aki). she presented with days of flank and back pain and was hospitalized for days for e coli uti. she improved on iv antibiotics and was discharged home to complete treatment with oral ciprofloxacin. due to persistent emesis, she was readmitted weeks later with urosepsis and aki with a creatinine of . mg/dl, over times her baseline creatinine. after additional antibiotics and iv fluids, she improved clinically, renal function normalized and she was discharged home. renal ultrasound was unremarkable with no anatomical abnormalities. she was relatively healthy prior to this with only one episode of bacterial pneumonia in . she receives weekly subcutaneous immunoglobulin therapy dosed at mg/kg with normal igg levels ( , , mg/ dl). at baseline, she had high igm ( mg/dl) and low iga ( < mg/ dl) levels, as well as decreased t cells but normal nk and b cells ( cells/ul cd +, cells/ul cd +, cells/ul cd +, cells/ul cd +cd +, and cells/ul cd +). she has hyperglycemia (on metformin), hypertriglyceridemia (on atorvastatin) and hypertension (on losartan). she is thin and wheelchair bound with bilateral telangiectasias to the sclera, neck, and chest. she has occasional eye bleeding and epistaxis, presumably from her telangiectasias. she has good hygiene and good adherence to medications. she voids voluntarily, has no indwelling urinary catheter and is not sexually active. discussion: patients with ataxia telangiectasia may have frequent viral and bacterial infections, most frequently upper and lower respiratory tract infections, as well as wart and skin infections. based on our review, this is the first reported case of ataxia telangiectasia with hypogammaglobulinemia on immunoglobulin therapy with recurrent utis complicated by urosepsis and aki. despite adequate igg levels on immunoglobulin therapy, our patient continued with recurrent utis. it is uncertain whether her non-ambulatory status, hyperglycemia or related immunodeficiency are the causes for her increased susceptibility to utis. the literature reports patients with at and bladder wall telangiectasias can result in significant hematuria, and perhaps this may be a source of entry for bacteria and consequent development of uti. this suggests that patients with ataxia telangiectasia and recurrent utis may benefit from renal ultrasound and possible cystoscopy to better visualize telangiectasias. we recommend consideration of workup for recurrent utis in patients with ataxia telangiectasia. abstract/case report text objectives: patients with partial rag deficiency frequently present with humoral autoimmunity suggesting breach in tolerance mechanisms and subsequent expansion of autoreactive b cell clones. here we aim to trace polyreactive b cells and their descendants at b cell developmental stages through our in-house bioinformatic pipeline, immchaintracer (ict). methods: the b cell receptor (bcr) was expressed as monoclonal antibodies from single sorted mature naive b cells (n= - per donor) from patients with hypomorphic rag deficiency and healthy donors. xthe recombinant monoclonal antibodies were screened for polyreactivity (dsdna, insulin, lps and ifnα) by elisa. in parallel, igh repertoires were deep sequenced from sorted mature naïve, activated naïve and memory b-cell compartments. our in-house assembled bioinformatic pipeline called immchaintracer (ict) was applied to track down the descendants of cloned autoreactive igh sequences in repertoires of subsets above. results: igh sequences (n= including polyreactive, nonpolyreactive clones) from mature naive b cell from six patients with partial rag deficiency and healthy donors (n= including polyreactive, non-polyreactive) were analyzed with our novel inhouse bioinformatic approach to track lineage fate in repertoire at specific developmental stages. interestingly, . % of the patients' sequences and their descendants were identified in their mature naive, activated naive or memory b cell repertoires, while none of the analyzed healthy donor clones were found at later subsets. furthermore, genealogical analyses of related clones revealed lineage expansion and progressive positive antigen selection of the autoreactive clones in the patients. conclusions our findings demonstrate that peripheral tolerance checkpoint is broken in hypomorphic rag patients. our novel method enables tracing the fate of autoreactive naive b cells in the effector repertoires. we have shown that impaired b cell tolerance allows the expansion and combination of sirolimus and rituximab therapy controlled his autoantibody production which was an important goal for his autoimmune condition. we present a new treatment approach for anti-nmda receptor encephalitis. rituximab was tried on these cases before but the combination of sirolimus and rituximab therapy was never given before. we now recommended that on refractory cases of anti-nmda receptor encephalitis, combination of rituximab and sirolimus therapy can be tried. ( ) submission id# mosaic variants in immune function genes identified through exome sequencing stable with no interim infections and is doing well on thyroid hormone replacement. the current plan is for the patient to undergo a stem cell transplant for the arpc b deficiency as he is at high risk for recurrent infections and severe disease. although this gene mutation is rare, review of the current literature describes patients with this condition that have undergone stem cell transplant and have done well. at this time, this seems to be the best option for management, and it may potentially be curative. abstract/case report text introduction: common variable immunodeficiency (cvid) is a disorder characterized by impaired immunoglobulin production and frequent or recurrent infections, but also associated with an increased risk for developing malignancies such as lymphomas. although intravenous and subcutaneous immunoglobin g replacement has been successful in reducing the number of bacterial infections and prolonging survival, it fails to address other complications that arise from this disorder. we report a case of a patient with cvid who developed mycosis fungoides (mf). mf is a rare form of cutaneous t-cell lymphoma, occurring in about in , to , individuals, lack of treatment could potentially be fatal. case presentation: a -year-old caucasian woman with a history of ulcerative colitis, allergic rhino-conjunctivitis and tonsillectomy was referred to the immunology clinic for evaluation of low serum immunoglobulins. there was no family history of infections or immune deficiencies, but paternal grandfather had colon cancer and maternal grandmother had lung cancer. the patient reported frequent episodes of bronchitis, and sinus infections. immunizations were up to date for her age. medications included azathioprine, cetirizine, fluticasone nasal spray, hyoscyamine, montelukast, lactobacillus, omeprazole, and olopatadine ophthalmic solution. no history of frequent use of systemic steroids. initial serum immunoglobulins revealed normal ige and igm but low iga ( mg/dl, normal range - mg/dl) and low igg ( mg/dl, normal range - mg/dl). cbc with differential, lymphocyte subsets, c and c levels were normal. while she had adequate protective titers against haemophilus influenza type b, diphtheria and tetanus, titers against pneumococcus were < % protective and she failed to mount an adequate response to pneumococcal polysaccharide vaccine. given her diagnosis of cvid, she started scig ( mg/kg every weeks). a year later, she developed a bilateral nonpruritic rash in the abdomen and upper trunk. initial skin biopsy suggested a drug reaction. a subsequent biopsy revealed a superficial perivascular lymphoid infiltrate with focal epidermotropism and positive t cell receptor gamma gene rearrangement, consistent with mf. testing for cell t receptor beta gene rearrangement was negative. while mf treatment consisted of triamcinolone . % ointment, treatment for ulcerative colitis transitioned from azathioprine to vedolizumab. conclusions: cutaneous t cell lymphomas, although uncommon, can be seen in cvid. there are several reasons for the increased risk of lymphoma in cvid. the role of chronic infections and the development of lymphoma as of yet, is not clear. skin reactions to scig products in the areas of infusion are relatively common and resolve promptly. high index of suspicion is crucial in obtaining tissue sample to confirm or rule out malignancy therefore avoiding delaying proper treatment. abstract/case report text patients with lipopolysaccharide responsive beige-like anchor protein (lrba) deficiency present with a plethora of immune related defects including a defective humoral response characterized by low numbers of switched memory b cells and plasma cells, as well as an impaired production of antibodies, leading to recurrent infections. however, the molecular mechanisms behind the defective b cell response remain unknown. to gain better insights into the possible roles of lrba in b cell physiology, we screened for lrba-interacting proteins using computational predictions. twenty-seven proteins involved in vesicle trafficking and autophagy were identified as potential lrba-interacting partners. to validate those potential lrba interactions, we performed coimmunoprecipitations and proximity ligation assays (pla), finding that endogenous lrba interacts with the phosphoinositide kinase regulatory subunit (pik r ) in b cells. pik r (aka vps ) is the regulatory subunit of vps , the catalytic subunit of the pi k-iii complex, which acts as a positive regulator of autophagy by producing phosphatidyl inositol- phosphate (pi( )p). autophagy is a catabolic mechanism essential for cell survival and plasma cell differentiation. in fact, we observed that reduced lrba impaired the production of pi( )p upon autophagy induction. in addition, we observed in both lrba-deficient hela and b cells reduced mobility, abnormal accumulation and increased size of autophaghosomes, accompanied by an atypical lysosomal positioning. these abnormalities are due to a blockade of the autophagosome-lysosome fusion, as detected by reduced lc -ii lipidation upon autophagy induction in the presence of lysosome inhibitors. interestingly, lrba-deficient hela and b cells exhibited enhanced activity of mammalian target of rapamycin complex (mtorc ) signaling, a key suppressor of autophagy whose activation possibly contributes to defective autophagy. taken together, b lymphocytes lacking lrba can form autophagosomes but they fail to fuse with lysosomes. thus, we propose a role of lrba at late stages of autophagy through the binding to pik r . abstract/case report text apds caused by gain-of-function mutations (gof) in the genes (pik cd and pik r ), encoding for the p δ and p subunits of phosphoinositide -kinase δ (pi kδ), results in hyperactivation of the pi k/akt/mtor/s k pathway and lead to immune dysregulation, lymphoproliferation and immunodeficiency. apds manifests with respiratory tract infections, bronchiectasis, susceptibility to herpes group viruses, autoimmunity, cytopenia, lymphoproliferation and lymphoma. gastrointestinal system manifestations include enteropathy, colitis, and liver disease. eosinophilic esophagitis (eoe) or eosinophilic gastrointestinal disease (egd) have been under diagnosed in reported apds cohorts. objectives: to review the incidence, demographics and relevant clinical data for eosinophilic gastrointestinal disease in a single center apds cohort. methods: review of clinical and laboratory findings from apds patients followed at the nih clinical center, from to . results: patients were either historically diagnosed or actively studied at our center for egd. incidence of all egd is % in our cohort and all patients had mutations in pik cd, none in pik r . most patients also had multiple gi manifestations. conclusion: immunopathology and genetic predisposition leading to eoe is complex. eosinophilic gi disease including eoe appears to represent significant gi pathology in apds. this implies that activation of pi k pathway may be directly involved in the etiology of eoe. abstract/case report text introduction: dominant negative mutations in stat (lof stat ; job's syndrome) cause a primary immune deficiency characterized by eczema, recurrent skin and lung infections, and connective tissues and skeletal abnormalities. over the last several years, vascular abnormalities causing tortuous and aneurysmal middle-sized arteries have increasingly been recognized. our institution has been imaging prospectively the coronary and cerebral arteries since - for brain imaging and from - for heart imaging. the purpose of this review is to provide an update on the extent of clinical manifestations noted in hies (continued) pain improved but rapidly worsened with tapering of steroids. the pet/ ct at that time, showed extensive hypermetabolic areas in lymph nodes, femurs, left acetabulum, left pubic ramus, right ischium, sacrum, both iliac bones, eight rib, t and t , both clavicles, both humeral, manubrium, and extension into musculature. initial biopsies were culture negative, s was positive for mac. she was referred to the national institutes of health where she was diagnosed with autoantibodies to interferon-γ . prior to referral, she initially was treated with azithromycin, ethambutol (need to discontinue due adverse effects), amikacin, rifampicin, linezolid, with not no evidence of clinical response. she underwent debridement of epidural anterior abscess to t . surgery involved t - laminectomy, and curettage on several bones. she presented unable to walk secondary to pain and neuropathies. initial laboratory: crp: mg/l; wc . ; hgb: . g/dl; ana : . (strongly positive) cd : ul her first course of rituximab consisted of doses of gm at d , , and monthly thereafter for a total of doses with clinical and radiographic improvement. she was maintained on optimal antibiotics therapymeropenem, rifampin, azithromycin, moxifloxacin, and clofazimine. two years after she completed rituximab, she presented to her home hospital with increased left hip pain and biopsy grew mac. retreatment with rituximab failed to show clinical improvement. her medical regimen was augmented with tedizolid and bedaquiline, however no iv antibiotics were added. rituximab was reinitiated, after the progression of symptoms despite treatment with rituximab; bortezomib, was trialed using the schedule based on the multiple myeloma literature. she completed full cycles (two at the nih, three at home). she subsequently has had clinical improvement and is working again and has not had progressive neurologic decline. the titers of antibodies to interferon-· did not follow the clinical improvement. however, we plan to keep her cd + cells zero and continue the bortezomib given her clinical and radiologic improvement. abstract/case report text for patients with primary immunodeficiencies (pid), finding a genetically defined diagnosis can be critical for prognosis, treatment, and counseling. however, for many patients, determining a genetic etiology remains elusive despite routine gene panel and exome sequencing because of an inability to resolve variants of uncertain significance (vus). crispr-based genome editing could be used to address this need by introducing patient-derived vus into primary human immune cells for further study; however, existing techniques are limited by poor efficiency. we recently developed novel non-viral techniques for large gene editing in primary human t cells and hematopoietic stem cells (hscs). we achieve up to fold greater efficiency than existing tools using crispr cas ribonucleoprotein nanoparticles that are non-covalently linked to homology directed repair (hdr) template dna. whereas mutation analysis has previously been limited to expensive and time-consuming animal models and transformed cell lines, we now have the ability to rapidly recreate any mutation in the native gene locus in otherwise healthy primary human cells. we demonstrate this ability by using our technique to knock-in well characterized loss-of-function mutations in jak and il rg and gain-of-function mutations in jak that are known to cause severe combined immunodeficiency and tumor growth, respectively. we show that these recreated mutations have the expected effects on t cell proliferation and intracellular signal transduction in the setting of il- stimulation. we then use our technique to investigate a prototype case of an adult patient with the unusual combination of common variable immunodeficiency, inflammatory arthritis and uveitis, and neutrophilic urticaria. genetic testing in this patient had previously revealed heterozygous coding vus's in four genes previously associated with a pid disease, including jak , but none of the specific variants have been previously reported. it is thus not clear which mutation (if not more than one) causes this patient's dysregulated cell activation, which limits targeted treatment options with kinase inhibitors or future gene or cell therapy. by knocking our patient's jak variant into primary human t cells and comparing these cells to those carrying wild-type, known loss-of-function, and known gain-of-function mutations, we are able to rapidly characterize the functional impact of our patient's variant and isolate its effect on his complex phenotype. this in vitro genetic engineering approach thus allows patient-specific vus to be modeled directly in primary human immune cells with a rapid turnaround time that is relevant for clinical applications, including molecular diagnosis and screening of pharmacologic or gene therapies. further, similar strategies could be leveraged as a potential basis for future gene correction therapy. abstract/case report text definition : "at variants" comprise a heterogeneous group characterized by the later onset of clinical symptoms, a slower progression, a prolonged lifespan compared to most patients with at and decreased levels of chromosomal instability and cellular radiosensitivity. in these patients, telangiectasia and / or immunodeficiency may be absent, while neurological features are present.( ). material and methods :a years old girl, born out of a non-consanguineous parents with clinical picture consisting in progressive alteration of the march ( months), associated to exotropia, no weight gain or height, alteration of balance while she is sitting, she walks by herself. she has acute bronchiolitis. results and discussion: brain magnetic resonance without alterations. abdominal ultrasonography and cpk normal. ophthalmologist assessment found exotropia, he did not find telangiectasia. motor and sensitive neuro-conduction were reported normal. alpha fetoprotein ng / ml increased. karyotype xx, non-structural alterations. normal auditory-visual evoked potentials. whole exome sequencing (wes): identified the small homozygous pathogenically deletion ¬c. + _ + del taag; p.? have a spelling effect in the splicing. it is not present in the population database or not as a known variant in function mutation of smad has been shown to increase smad phosphorylation in the nucleus in fibroblasts. further research is needed to examine the role of this mutation in t and b lymphocytes, given the interesting immunological phenotype of this patient. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. outbreak of mycoplasma pneumoniae-associated stevens-johnson syndrome characterization of children. with recurrent episodes of stevens johnson syndrome recurrent stevens-johnson syndrome secondary to mycoplasma pneumoniae infection recurrence and outcomes of stevens-johnson syndrome and toxic epidermal necrolysis in children syndrome after mycoplasma pneumoniae infection a review of causes of steven-johnson syndrome and toxic epidermal necrolysis in children submission id# expanded phenotype and genotype-phenotype correlations bsc(hons) msc bmbs mrcp dominant activating rac mutation with lymphopenia, immunodeficiency, and cytoskeletal defects an autosomal dominant scid form due to a gain of function mutation in the rac gene national institute of allergy and infectious diseases (niaid) professor biochemistry/molecular pharmacolog/nyu langone health canada head of the ircm bioinformatics core facility/montreal clinical research institute (ircm) associate investigator/national human genome research institute (nhgri) division of intramural research (dir), national institute of allergy and infectious diseases (niaid) translational and functional genomics branch/chief and senior investigator of the translational and functionanational human genome research institute (nhgri) division of intramural research (dir), national institute of allergy and infectious diseases (niaid) formula versus donor breast milk for feeding preterm or low birth weight infants cytomegalovirus (cmv) inacƟvaƟon in breast milk: reassessment of pasteurizaƟon and freeze-thawing prevenƟon of cytomegalovirus transmission via breast milk in extremely low birth weight infants submission id# the costa rican registry for primary immunodeficiencies department chief/department of pediatric immunology and rheumatology, national children´s hospital "dr. carlos sáenz herrera national children´s hospital "dr. carlos sáenz herrera" cid % (n= ), cid with syndromic features % (n= , at ), antibody deficiencies % (n= , xla ) ada deficiency, cd l-, flh- (syntaxin deficiency), ipex and osteopetrosis. nineteen patients developed malignancies, mainly non-hodgkin lymphomas among at patients conclusions: during the study period, pid were registered, mainly at and osteopetrosis cases. scid represented % and xla % of patients allergy and immunology/ department of pediatric immuunology and texas children's hospital director immunogenetics program/department of immunology, allergy and rheumatology at baylor college of medicine associate professor, director food allergy program/department of pediatric immuunology shearer center for human immunobiology associate professor/department of pediatric immuunology, allergy, and retrovirology granuloma faciale: successful treatment of nine cases with a combination of cryotherapy and intralesional corticosteroid injection intralesional steroid injection: a novel method to treat the symptoms of idiopathic granulomatous mastitis long-term effectiveness of intralesional triamcinolone acetonide therapy in orofacial granulomatosis: an observational cohort study sarcoidosis in the periocular scar as the first finding of systemic sarcoidosis: clinical-radiological characteristics a case of scar sarcoidosis of the eyelid submission id# null mutations: a gene dosage effect shubham goel, phd , hye sun kuehn clinical centre, nih, staff scientist/immunology service certified molecular geneticist/national institute of allergy and infectious diseases, national institutes of health genetic counselor/national institute of allergy and infectious diseases, national institutes of health division of intramural research; chief, immunopathogenesis section/laboratory of consultant/university hospital freiburg center for pediatrics and adolescent medicine cci -center for chronic immunodeficiency medical director professor/division of blood and marrow transplantation and cellular therapies new south wales, australia. professor of medicine and pediatrics/icahn school of medicine at mount sinai senior investigator/laboratory of clinical immunology and microbiology, national institute of allergy and infectious diseases, national institutes of health functional nk assay, t/b/nk panel, tlr assay phd staff scientist/translational autoinflammatory disease section, lcim, niaid, nih, bethesda, md research fellow/translational autoinflammatory disease section post-baccalaureate fellow/translational autoinflammatory disease section pediatric rheumatologist/department of pediatric infectious diseases and immunology shupyk national medical academy for postgraduate education alder hey children's nhs foundation trust hospital, liverpool, uk pediatric rheumatologist/department of pediatrics dra. liliana bezrodnik y equipo dra. liliana bezrodnik y equipo"-servicio de inmunología htal. de niños hospital de niños ricardo gutiérrez pathology department/children's hospital of philadelphia, philadelphia, pa post-doctoral fellow/translational autoinflammatory disease section results: we identified patients with de novo frameshift variants in samd l (c. dela, p.i lfs* reduced toxicity allogeneic hct with a busulfan, fludarabine regimen: a promising approach for non-cgd primary immune deficiencies requiring myeloablation? phd , blachy davila saldana college of medicine assistant professor/division of bone marrow transplant, immunedysregulation and immuno-hematology program, aflac cancer and blood disorders center instructor of pediatrics/division of bone marrow transplantation and immune deficiency, cincinnati children's division of bone marrow transplantation and immune deficiency, cincinnati children's national institutes of health certified molecular geneticist/national institute of allergy and infectious diseases genetic counselor/national institute of allergy and infectious diseases, national institutes of health operations manager and genetic counselor/national institute of allergy and infectious diseases collaborative bioinformatics resource/national institute of allergy and infectious diseases genome in a bottle analysis team/genome in a bottle consortium division of intramural research (dir), national institute of allergy and infectious diseases (niaid) medical genomics and metabolic genetics branch/national human genome research institute, national institutes of health table clinical and demographic characteristics, severity measures, and previous treatments for the pid cohort geographic region, n (%) north central , ( . ) ( . ) , ( . ) northeast , ( . ) ( . ) , ( . ) south ) ( . ) , ( . ) high-potency oral antibiotics , ( . ) ( . ) , ( . ) systemic high-dose corticosteroids copd, chronic obstructive pulmonary disease cd / cd : . , lymphocytes b , natural killer cell/mm . conclusions: although the atm activity corresponding to this new splicing mutation is unknown, it is presumed that it has some residual function, since splicing mutations is associated with better neurological prognosis have been reported (pidd) . at the immunodeficiencies research unit we discuss and pursue the molecular and genetic diagnoses for patients with suspected pid from all around the country. starting this year, we are processing and analyzing our own patients' wes results at the unit. evaluating the diagnostic yield of wes, as a measure of effectiveness or quality control, may result in process optimization and perhaps allow for better patient selection and resource allocation. objective: to describe and characterize our patients with suspected pidd whose dna samples were sent out for whole-exome sequencing; to analyze and compare our wes diagnostic yield after the first batches of patients; to identify patient attributes that may predict a positive diagnostic wes result. methods: genomic dna was obtained from whole-blood samples of patients with suspected pidd from hospitals in mexico city, monterrey and puebla. wes was performed using a ng sequencer (illumina hiseq) in new jersey (admera health, llc), with % coverage and a x depth of the idt xgen library, human genome version (december ). two fastq files for each patient sample were transferred back to our unit, where the bioinformatic workflow was completed. we used galaxy in the cloud for quality control, mapping & alignment, and detection of variants; variant effect predictor to process, map, annotate and filter variants; and igv (broad institute) and genome browser (ucsc) for visualization. we defined diagnostic yield as the proportion of patients with a genetic diagnosis after analysis of their wes results. we performed multivariate logistic regression, tree partitioning algorithm and linear abstract/case report text a -year-old male with x-linked chronic granulomatous disease (cgd) complicated by severe perianal disease and proctocolitis presented with two weeks of open draining lesions on the thighs, bilateral inguinal regions, and gluteal cleft. the wounds became excruciating and prevented normal ambulation. the patient was admitted for iv antimicrobial therapy, local wound care and systemic steroids. wound cultures, throughout his course, yielded growth of klebsiella pneumonia, candida parapsilosis, malassezia globose, escherichia coli, enterococcus faecalis and staphylococcus epidermidis allowing for directed antibiotic and antifungal therapies. despite improvement, the wounds persisted after several weeks of treatment. faced with recalcitrant cutaneous lesions despite aggressive systemic and topical therapies, we looked to alternative options. noting that other granulomatous diseases show response with intralesional corticosteroid therapy, we considered this for our patient ( , ) . for example, patients with idiopathic granulomatous cheilitis had a complete response after three monthly injections of intralesional corticosteroids ( ) . sarcoidosis patients also improve with intra-granuloma corticosteroid injection ( , ) . our patient received mg triamcinolone acetonide injections two separate occasions, administered in multiple open lesions at eight-week intervals. the cutaneous lesion improvement was gradual and complete resolution of the first open wound was noted fifty-two days from initial steroid injection. to our knowledge, intralesional glucocorticoid therapy has not previously been used to treat cutaneous disease in cgd patients. we are reporting the first cgd patient with successful lesion resolution following steroid injection as part of therapy. as such, we believe this case is significant and suggests that direct lesion injection with glucocorticoids can add to treatment options for cgd patients with recalcitrant cutaneous disease. serum igg, alone or in combination with iga and/or igm, were reduced in all patients. t-follicular helper cells were reduced only in patients carrying biallelic mutations (a.ii. , a.ii. and a.ii. ) but not in any patients with monoallelic tcf null mutation. t cell enumeration and function by means of proliferation was normal in all mutation+ individuals. no mutated (truncated) protein expression was detected from patients with either biallelic or monoallelic tcf null mutations. however, wildtype tcf protein was detectable in about half amount in heterozygous patients. cdna data showed either / or / wt/mutated transcripts ratios in homozygous or heterozygous individuals, respectively, suggesting mutated proteins instability; and all together, protein haploinsufficiency for the heterozygous cases. ex-vivo, cd l and il -induced plasmablast differentiation was found to be reduced in / patients tested ( biallelic patient a.ii. and monoallelic patients a.i. , b.i. and c.i. ). moreover, decreased igg, iga and igm production in vitro correlated with reduced plasmablast cell differentiation.in conclusion, all individuals carrying either mono-or biallelic null mutations have immunological penetrance of the b cell defect. however, while clinical penetrance was complete in patients with biallelic mutation, it was partial for those with monoallelic tcf null mutation suggesting a gene dosage effect for clinical penetrance. in addition, our study emphasizes that tcf is relevant to the plasmablast differentiation process as well as for ig production. further studies are being conducted to evaluate the individual roles of e and e on the immune and clinical features. background: heterozygous gain-of-function (gof) mutations in the stat gene result in a hyperphosphorylated state where patients develop recurrent or persistent chronic mucocutaneous candidiasis (cmc), other cutaneous mycosis, bacterial infections, disseminated dimorphic fungal infections and autoimmune disease. furthermore, the nk defect we characterized illustrated an immature cd dim nk cell subset with decreased expression of cd , perforin, cd , and impaired cytotoxic capacity associated with increased susceptibility to viral infections observed in these patients. methods: in this study, we evaluated patients with novel stat mutations (d e mutation, located in coiled-coil domain and k q mutation, located in dna-binding domain). a third patient with the previously reported v i mutation (ccd) was also recruited for this study. in vitro, pbmcs from these patients were stimulated with ifn-α for , , and minutes and levels of phospho-stat on cd dim nk cell subset were measured by flow cytometry. the stat activity (firefly and renilla luciferase activities) was evaluated in u a-stat deficient cells abstract/case report text background: t cell lymphopenia associated with genetic syndromes can be identified with low t cell receptor excision circle (trecs) up on the newborn screen for severe combined immune deficiency (scid). jacobsen syndrome (js), q terminal deletion, is a rare genetic disorder seen in / , births characterized by facial dysmorphisms, platelet abnormalities, neurologic complications, immune system abnormalities including t and b cell defects. we report an infant with js found to have low trecs on nbs and review the immune phenotypes of our cohort of patients with js. methods: a retrospective chart review of all patients with js seen by the allergy immunology service at a large tertiary referral center from / / - / / was performed in accordance with irb standards. result: the index patient had two newborn screens hours after birth and two weeks later in accordance with texas state law. the first nbs resulted normal trecs while the second nbs had low trecs. a third nbs was done per protocol and again showed low trecs. subsequently, lymphocyte subsets at months of age showed severe t-cell lymphopenia: cd cells/ dl ( %), cd cells/dl ( %), cd cells/dl, and low recent thymic emigrants (cd +cd ra+ccr +cd +) cells/dl ( %) with normal lymphocyte mitogen proliferation. a chromosomal microarray (cma) revealed a q deletion known to cause js.over the five year study period we evaluated seven patients with js referred to our center. the majority of patients ( %) presented to clinic with history of recurrent infections including recurrent pneumonia, sinusitis, otitis media, skin abscesses and warts. t-cell lymphopenia was found in of ( %), / ( %) had abnormal lymphocyte proliferation (mitogens and antigens) and met criteria for pjp prophylaxis. in addition, / ( %) had antibody deficiency requiring igg replacement therapy. of the cases reviewed, only patients were born during the period of time that texas was performing the nbs. conclusion: jacobsen syndrome can present with a spectrum of immune defects most notably t cell lymphopenia and antibody deficiency. these patients can present at birth with low trecs. this cohort analysis highlights the importance of considering chromosomal genetic syndromes with features of primary immunodeficiency in evaluating patients with low trecs. further evaluation of larger cohorts gathered from neurology or genetics clinics at multiple centers would be helpful for future study in identifying those who need close immunology care. abstract/case report text introduction: recognized as sentinels of the immune system, mast cells (mcs) and dendritic cells (dcs) are both derived from hematopoietic/ progenitor stem cells in bone marrow (bm). the crosstalk and direct contact between these cells have been well documented and play an important role in modulating immune response. we showed that presence/absence of il- directs cell fate; whether progenitor cells will be differentiated into mcs or dcs. we also report an easy method in which in vitro generation of dcs is possible without external induction of gm-csf or il- . material-methods: to produce mcs and dcs in vitro, briefly bm samples were collected from patients with idiopathic thrombocytopenic purpura., bm mononuclear cells (mncs) were seperated by ficoll gradient, and seeded in plates with imdm medium containing fbs %, pen/ strep, and a little amount of methocult, and incubated in oc, % co (day ). the treatments on the following days were as follows: day , imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml); day , imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) + il- ( ng/ml). on day , groups were formed: group i: imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) + il- ( ng/ml), group ii: imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml), group iii: dmem + fbs %. the cultures were evaluated every days under an inverted microscope. verification of mcs was performed by toluidin blue and tryptaseimmunoflorescence staining. macrophages were verified by cd- immunoflorescence staining. dendritic cells of different stages of abstract/case report text introduction a reduced toxicity busulfan, fludarabine regimen with alemtuzumab or anti-thymocyte globulin (gungor et al.) was efficacious in patients undergoing allogeneic hct for cgd. we report our experience with a similar approach for patients with non-cgd primary immune deficiencies needing a reduced toxicity myeloablative approach. methods we retrospectively reviewed records of consecutive patients who underwent allogeneic hct for primary immune deficiencies with a preparative regimen containing busulfan, fludarabine and alemtuzumab or anti-thymocyte globulin(atg), at three transplant centers between - . busulfan was given either every hours over days with target auc of to μmol/min (based on q hr. dosing) or twice daily over days with target auc of to μmol/min (based on q hr. dosing) or once daily over days with a target auc of - μmol/min (based on q hr. dosing). fludarabine mg/m to mg/ m was given divided over - days. serotherapy included alemtuzumab . - . mg/kg or atg . mg/kg given divided over days. gvhd prophylaxis consisted of cyclosporine and mycophenolate mofetil. results forty patients (was= , hlh= , cd l deficiency= , ipex/veoibd= , scn= , ifngr def./cid/x-scid/msn / lad= ) received busulfan, fludarabine and alemtuzumab or atg for allogeneic hct (first hct in patients and second hct in the patients with hlh). median age was . years (range, . years - . years). patients received a graft from an hla-matched related (n= ), unrelated (n= ), or single allele mismatched related or unrelated donor (n= ). all except one patient engrafted at a median of days (range, - days). one patient developed veno-occlusive disease and two patients developed diffuse alveolar hemorrhage. notably, it was the second transplant for all patients. eight patients ( %) developed grade - acute gvhd and patients ( %) developed chronic gvhd. one patient developed primary graft failure and two patients secondary graft failure. nineteen patients ( %) maintained full donor (> %) chimerism following allogeneic hct. twenty patients ( %) developed mixed chimerism, predominantly in the t-cell lineage, but t-cell donor chimerism progressively increased post-hct. at -year post-transplant, of patients ( %) with mixed chimerism had donor myeloid chimerism > % and t-cell chimerism > %. two patients underwent a second transplant for graft failure. there were deaths in the cohort. overall survival was %( of ) and event free survival was %( of ) at year. conclusion our experience suggests that a reduced toxicity busulfan, fludarabine regimen with alemtuzumab or atg as serotherapy offers a promising approach with low toxicity, durable myeloid engraftment, low incidence of grade - gvhd and excellent survival and can be considered for a variety of primary immune deficiencies where myeloablative hct is desired. abstract/case report text this is an -year-old patient who has the diagnoses of anti-nmda receptor encephalitis with associated catatonia. the patient has history of a pineal gland germinoma diagnosed in august after months of double vision. however, after several months, the patient developed difficulty in sleeping, anxiety and nightmares. the patient presented to emergency department in february with personality changes. he was diagnosed with nmda encephalitis based on the clinical findings as well as presence of elevated serum and csf anti-nmda antibodies. the patient was initially treated with high dose systemic steroids with poor response. due to the worsening of his clinical condition, he was started on plasmapheresis, but had poor response to this therapy as well. these treatments are known standard treatment options for this condition. during his hospital stay, different therapies were discussed. cyclophosphamide was one of the treatment options, but because of the side effect profile and severe toxicity, we recommended different treatment modality. we started the patient on rituximab as well as sirolimus therapy to suppress both t and b-cell responses. after receiving two doses of rituximab in addition to daily sirolimus, the patient showed improvement of his symptoms. and declining nmda receptor antibody titers. this treatment plan was chosen for autoantibody mediated encephalomyelitis due to the fact that rituximab has inhibitory effect on naive b cells, but not on the proliferation of memory b cells and sirolimus has profoundly inhibiting role on memory b cells as well as a t-cell responses. a mosaic gene variant is one which is present in some, but not all, cells within an individual. they are increasingly associated with a number of diseases, including a number of primary immunodeficiency disease (pid). here we systematically analyzed mosaic variants in known or putative immunodeficiency genes from exome sequencing data from individuals. lofreq was used to identify mosaic variants with a variant allele fraction (vaf) of . - . ( . is the vaf for a non-mosaic, heterozygous variant). we removed variants from extreme read-depth (> standard deviations), unmappable, repeat-rich, and duplicated genomic regions. the average number of detected variants per mb was . and the total number of genomic locations with variants was , . mosaic variants were underrepresented in exonic regions, suggesting that coding variants may be deleterious. more mosaic variants were detected in saliva exomes compared to peripheral blood exomes (p-value < x - ), suggesting tissue-specific mosaic variants in buccal epithelial cells and white blood cells of saliva. to understand the clinical relevance of these findings, the variants were further filtered to include only nonsynonymous variants found in fewer than % of samples, leaving a total of , variant locations. of the remaining variant locations, had a pathogenic assertion in the human gene mutation database, and were in international union of immunological societies pid genes. further variant interpretations and clinical correlations are underway. these data suggest that mosaic variants in pid genes are common, vary by location of collection, and may have clinical diagnostic relevance. abstract/case report text introduction/background: the arpc b (actin related protein / complex subunit b) gene is a protein coding gene prominently expressed in blood cells and is necessary for the assembly and maintenance of the human actin-related protein / complex (arp / ). actin polymerization plays a central role in many immune functions including proliferation and differentiation of immune cells, migration, intercellular and intracellular signaling and activation of both innate and adaptive immune responses. defects in the actin cytoskeleton affect hematopoietic cells in the bone marrow and the immune response giving rise to a distinct primary immune deficiency, which is phenotypically similar to wiskott-aldrich syndrome (was). arpc b deficiency clinically presents as a severe multisystem disease which includes platelet abnormalities, recurrent infections, failure to thrive, inflammatory changes in the intestine, eczema, cutaneous vasculitis, eosinophilia, and elevated inflammatory markers. arpc b deficiency is rare and has only recently been described in the literature. here we present a clinical case of a patient found to have a pathogenic arpc b mutation via whole exome sequencing. case report: here we describe a month old somalian boy who presented to the immunology team at months of age with hematemesis, hematochezia, melena, failure to thrive, atopic dermatitis, hypothyroidism, autoimmune thrombocytopenia and recurrent infections concerning for a primary immune deficiency. family history was notable for parental consanguinity and an older sibling with a similar presentation of hemorrhagic gastroenteritis who died in kenya around months of age due to complications of his symptoms. the initial primary immunodeficiency evaluation revealed normal inflammatory makers, normal igg and protective vaccine (prevnar and tetanus) response. iga and ige were elevated at mg/dl and . ku/l respectively. flow cytometry was remarkable for t cell lymphopenia (cd , cd , and cd ) with reduced naïve cd and cd t cells. b and nk cell count were normal. alps panel and was protein expression was unremarkable. whole exome sequencing was performed and revealed homozygotic mutation of arpc b c. t>c, ivs + t>c which was predicted to be a pathological variant. subsequently, dhr flow cytometry with fmlp showed significant increase of dhp fluorescent (mfi . when compared to control mfi . ) consistent with findings from other arpc b deficiency patients. at the time of the most recent clinic visit, the patient has remained abstract/case report text introduction: activation of the nod-like receptor family cardcontaining protein (nlrc ) leads to the formation of an inflammasome. the inflammasome, a large cytosolic multiprotein complex of innate immunity, promotes proteolytic cleavage, maturation, and secretion of pro-inflammatory cytokines, including il- and il- . a gain-of-function mutation (gof) in the gene encoding nlrc or nlrc -inflammasomopathy is characterized by hyperinflammation with persistent elevated il- , infantile enterocolitis, and early-onset macrophage activation syndrome (mas). objectives: to describe phenotypic variation among three siblings with a novel nlrc gof variant and to expand our current understanding of the clinical manifestations of the disease methods: clinical and laboratory features were studied in three siblings of a hispanic family with a novel nlrc gof variant. results: a novel variant, c. g>a (p.arg gln) on the nlrc gene, was identified in a -year-old male with recurrent febrile episodes since one year of age. his laboratory findings showed highly elevated esr, crp, il- , and fecal calprotectin. his endoscopic finding was unremarkable. the recurrent fever partially responded to canakinumab. a -year-old sister with ileocolonic crohn's disease for two years was found with the same nlrc variant and highly elevated il- . crohn's disease was well controlled after adding infliximab infusion to methotrexate therapy. a -year-old sister, who has been asymptomatic and healthy, was tested with the same positive nlrc variant and highly elevated il- . the nlrc variant is inherited from their father, who currently has a diagnosis of psoriasis vulgaris. the il- levels of the three siblings show in the figure patients with flh- develop the classic hlh phenotype early in life, with periods of remission. the pathogenesis is associated with a defect of perforin-dependent cytotoxicity. t-ctl and nk cells fail to remove abnormal cells, consequently, an uncontrolled proliferation and activation of cd + t cells and macrophages develops and generates an inflammatory cytokine storm and a solid organs infiltration. mortality of fhl- is very high without treatment; allogeneic hsct is the only curative therapy. we report the outcome of a child with fhl- , four years after his treatment with an allogeneic hsct using an hla haploidentical donor. case report: a boy born in december , previously healthy, the only child of parents without consanguinity. he has a normal family and perinatal history. when he is years old, he begins suffering from with fever, arthralgia, hepatosplenomegaly and pancytopenia. he meets the diagnostic criteria for hemophagocytic lymphohistiocytosis (hlh) and received treatment with iv methylprednisolone and entered in remission of its hlh. six months later, he restarts his clinical picture of hlh and j clin immunol receives treatment with the hlh- protocol, which leads to remission. ayear later he presents a new episode of hlh that responds to ivig, cyclosporin a and dexamethasone. the possibility of primary hlh is then suggested. when he is years old, the molecular diagnosis is made with the identification of a mutation in the stx gene, the case was classified as fhl- due to syntaxin deficiency. in october , a hsct was performed. at the age of , his clinical status is evaluated and laboratory studies show that his immunodeficiency due to syntaxin deficiency was cured. his -year-old mother, hla haploidentical was used as a donor and a protocol developed for the treatment of osteopetrosis was applied. the hsct protocol did not use a tcell depleted graft. hstc conditioning was done with melphalan days - and - , fludarabine days - to - , anti-thymocyte globulin days - and - , and cyclophosphamide day - . (figure) . clinical and demographic characteristics, including the use of a novel claims-based weighted algorithm (risk vital sign; rvs) and those initiating ivig and scig, were described. stratified analysis based on pid diagnosis codes was performed. probability of receiving available ig treatments based on baseline characteristics was evaluated by logistic regression and propensity score methods. results: selected clinical and demographic characteristics, severity measures, and previous treatments between the overall pid population (n= , ), pid patients initiating scig (n= , ), and pid patients initiating ivig (n= , ) are presented in the table. patient characteristics and previous treatments tended to be stable, although hypertension, obesity, and corticosteroid use increased during the study period. new ig users tended to be older and female, with increased depression, dyslipidemia, and hypertension than all pid patients. new scig users had more diagnoses of respiratory (e.g., asthma, copd) and inflammatory (e.g., arthritis, fibromyalgia, inflammatory bowel disease) comorbidities and less cancer than all pid patients. new scig users compared with new ivig users had increased asthma and copd, fibromyalgia, and inflammatory bowel disease and decreased cancer and peripheral vascular disease. previous corticosteroid use was higher in ig users than all pid patients. among scig users, prior pid treatments of iv antibiotics, and oral high potency antibiotics were similar to all pid patients. ivig users had higher iv antibiotic and antifungal use. rvs was initially developed to identify patients likely to have undiagnosed pid. this analysis applied rvs to patients diagnosed with pid to assess severity. rvs based on -year history in the overall pid cohort was predominantly low, with only . % of patients scoring in the medium and high ranges. rvs was increased in incident ig users, with ( . % medium/high for scig; . % medium/high for ivig). in other markers of severity, scig users had more sinusitis and ivig had more pneumonia than all pid. ig users had fewer abscesses, cellulitis, and otitis media than the full pid cohort. conclusions: this exploratory analysis showed a trend toward increased hypertension, inflammatory and respiratory comorbidity, higher rvs, and previous corticosteroid treatment in patients initiating on ig compared with all pid patients. results could be confounded based on pid diagnosis codes used and warrants further research. author disclosures: mp, cas, and zh are employees and stockholders of the takeda group of companies. jo is a consultant to takeda. jbl is an employee of rti health solutions, an organization funded by takeda to conduct this research. mer was an employee of rti health solutions at the time this research was conducted.presenting author: colin anderson-smits submission topic: immunoglobulin replacement therapy patients in a larger cohort group and to determine if there are patterns of disease not previously reported. methods: we performed a retrospective chart review of patients with lof stat (n= ) followed at the national institutes of health. we specifically looked at tortuosity, aneurysms, and dilation of both coronary and cerebral arteries. epidemiologic information, stat mutation, co-morbidities, and laboratory information were reviewed along with imaging studies, specifically brain mri, brain mra, heart mri, and coronary ct. results: most recently, patients with hies are found to have vascular abnormalities including tortuosity, dilatation, narrowing, and aneurysms of middle sized, cerebral, and coronary arteries. in an effort to determine the extent of vascular involvement in addition to miscellaneous organ involvement, we are reviewing a cohort of patients with hies who were evaluated at the nih. of these patients, are women and are men. of these patients, two have passed away due to vascular events leading to their deaths. there are four patients under the age of , patients between the ages of and , patients between the ages of and , and three patients above the age of (age range - , mean age . ).of the patients, five of these patients were found to have abnormal brain mri/mra at an approximate rate of . %. two of these patients were found to have at least one cranial aneurysm, two of these patients were found to have a level of narrowing or stenosis, and one patient was found to have dilatation.in terms of coronary abnormalities, of the ( . %) patients were noted to have at least one coronary abnormality including dilatation, aneurysm, or tortuosity on heart mri or coronary ct. eight patients ( . %) were found to have dilatation of which four patients were female and patients were male. of the patients, ten patients ( . %) were found to have at least one aneurysm. there were patients ( %) that were found to have at least mild tortuosity. conclusion: vascular abnormalities in our lof stat patients occurred at an exceedingly high rate-cerebral and coronary artery, . % and . % respectively. due to this, patient's with lof stat should be considered for screening with brain and heart imaging. currently, there are no guidelines which outline the appropriate timeline for screening in these patients however following these patients over time will allow us to determine the most appropriate interval for imaging follow up. abstract/case report text year old woman with personal history of severe and recurrent upper and lower respiratory infections, chronic pulmonary disease with bilateral bronchiectasis and several micro nodules, chronic diarrhea without diagnosis (colonoscopy with mild colitis, without cmv. no bacterias no parasits were found in stools), mild osteopenia, focal lesion in right hepatic lobe, atopic dermatitis and anemia. she was followed up in other center and in she was diagnosed with common variable immunodeficiency (cvid) and started treatment with intravenous immunoglobulin (ivig), but with low adherence to it. she did not have referred history of lymphoproliferation nor significant viral infections. she had a daughter with spherocytosis who required esplenectomy and also had bronchiectasis and cvid diagnosis, she deceased at years old due to pulmonary infection. one years old son has anemia. her other daughter and son are healthy. objective: to describe unique management of recurrent viral respiratory infections in a qds patient. case: -year-old male with a history of qds complicated by truncus arteriosus, vsd, hypoparathyroidism, asthma, and autism was followed for a history of "frequent pneumonias." he had daily rhinitis and a history of frequent otitis media which resolved after tympanostomy tube placement at age y. however, over the next two years, he had admissions with various respiratory viral infections resulting in respiratory distress and prolonged oxygen need. viruses detected during these separate admissions varied and included parainfluenza , metapneumovirus, rsv, b and coronavirus nl , coronavirus hku , and rhino/enterovirus ( times total). he was previously on a prophylactic course of antibiotics which made no difference in his symptoms. laboratory evaluation showed protective adaptive immunity with normal immunoglobulin numbers for age (igg mg/dl), along with normal b and t cell numbers. he had protective pneumococcal titers and mounted a normal mitogen response. while his nk cell numbers were normal, his nk t cells were low. his tlr functioning also appeared normal. in order to decrease his overall illness burden and to keep him out of the hospital, ivig infusions (~ mg/kg) were initiated monthly. shortly after initiation of treatment, his nasal purulence and drainage resolved and his family noted that he became more active and playful. treatment was continued for months, during which time he had only one episode of influenza infection needing inpatient management. he has been off of ivig for months without recurrence of his viral infections. conclusion: in this patient, severe recurrent viral respiratory infections despite apparently normal adaptive and cellular immunity presents a unique management dilemma. this was not an issue of recurrent bacterial infections as prophylaxis did not make a difference in the frequency of his infections. his nk t cells were low, which could have contributed to his frequent viral infections as nkt cells are known to play a role in viral immunity. the successful use of ivig treatment in his case points to a different use for ivig, namely for the anti-respiratory virus antibodies which are presumably contained within the formulation.given this finding, it may be prudent to consider ivig in management of qds patients, even with normal immune evaluation, in order to decrease risks of complications associated with severe and recurrent viral respiratory infections. abstract/case report text introduction: smad is a critical downstream signaling molecule for transforming growth factor-β (tgf-β) and bone morphogenic protein (nmp ). initially, smad , also known as dpc deleted in pancreatic cancer locus , was described as a tumor suppressor gene, and somatic deletion of the smad is seen in % of pancreatic carcinomas. subsequently, a germline point mutation in the smad gene (p. i v) was reported to cause myhre syndrome (mim# ). myhre syndrome is an autosomal dominant disease characterized by cognitive impairment, hearing loss, and musculoskeletal anomalies. the immunological phenotype of these patients has not been previously described, despite the critical role of tgf-β in regulating t cell response and the prevention of excessive inflammation. case report: a -year-old boy with myhre syndrome was referred to immunology clinic for evaluation of recurrent ear infections. he developed acute otitis media infections as an infant and had tympanostomy tubes placed at one year of life. he also had a recurrent sinus infections. at two years of age, he was diagnosed with autism and sensory neuronal hearing loss. brain mri showed a mildly hypoplastic pituitary gland, and a thickened corpus callosum with decreased myelination. given these findings, whole-genome sequencing was performed, which revealed a heterozygous de novo mutation in smad (p.i v / c. a>g) consistent with the diagnosis of myhre syndrome. through age , he was in the th percentile for height until he was started on growth hormone, which he responded to robustly. he is now he is in the th percentile for height. he had adenoidectomy due to sleep-disordered breathing at the age of years. he is maintained on montelukast and inhaled corticosteroids for treatment of rhinitis and mild persistent asthma. he is on atenolol for the treatment of primary hypertension. on physical exam, he has facial dysmorphisms, thickened skin, and contraction of the fingers consistent with myhre syndrome. immunologic elevation showed significant hypogammaglobulinemia (igg mg/dl), low iga ( mg/dl) and normal igm mg/dl. igg subclasses showed low igg and igg at mg/dl and mg/dl respectively. although he was fully vaccinated, his tetanus antibody was low at . iu/ml. however, this improved after repeat vaccination to . iu/ml. total t and b lymphocyte counts were normal; however, his memory cd and cd t cells were low for age at . % and . %, respectively. additionally, his switched memory b cell count was low at . %. conclusion: smad gain of function (myhre syndrome) can lead to impaired memory t and b cell formation with significant hypogammaglobulinemia and low iga. although the patient was able to respond to protein vaccination (tetanus), it is not clear if he will be able to maintain a long-term response. in a previous study, a similar gain of key: cord- -jm qmpeg authors: mao, suling; huang, ting; yuan, heng; li, min; huang, xiaomei; yang, changxiao; zhou, xingyu; cheng, xiuwei; su, qian; wu, xianping title: epidemiological analysis of local covid- clusters in sichuan province, china date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: jm qmpeg background: this study was intended to investigate the epidemiological characteristics of covid- clusters and the severity distribution of clinical symptoms of involved cases in sichuan province, so as to provide information support for the development and adjustment of strategies for the prevention and control of local clusters. methods: the epidemiological characteristics of local clusters of covid- cases in sichuan province reported as of march , were described and analyzed. information about all covid- clusters and involved cases was acquired from the china information system for disease control and prevention and analyzed with the epidemiological investigation results taken into account. results: the clusters were temporally and regionally concentrated. clusters caused by imported cases from other provinces accounted for . %; familial clusters accounted for . %; the average attack rate was . %, and the average secondary attack rate was . %; the median incubation period was . d; a total of cases met the criteria for incubation period determination, and in the cases, the incubation period was > d in . % ( / ). a total of confirmed cases were reported in the clusters. ten cases were exposed before the confirmed cases they contacted with developed clinical symptoms, and the possibility of exposure to other infection sources was ruled out; two clusters were caused by asymptomatic carriers; confirmed cases mainly presented with fever, respiratory and systemic symptoms; a gradual decline in the severity of clinical symptoms was noted with the increase of the case generation. conclusions: population movement and gathering restrictions and strict close contact management measures will significantly contribute to the identification and control of cases. transmission during the incubation period and asymptomatic infections have been noted. studies on the pathogenicity and transmissibility in these populations and on covid- antibody levels and protective effects in healthy people and cases are required. so absence of stringent and effective prevention and control could have resulted in serious social consequences. we analyzed the epidemiological characteristics of covid- clusters in sichuan, intended to provide information support for the development and adjustment of local prevention and control strategies. the epidemiological characteristics of local covid- clusters in sichuan reported as of march , and confirmed cases involved in these clusters were described and analyzed using a cross-sectional study design. in accordance with requirements in the guidance for corona virus disease : prevention, control, diagnosis and management [ ] , information about all covid- clusters and cases should be reported to the china information system for disease control and prevention. in this study, information about all local clusters was exported from sub-module "emergency public reporting system" and data about related confirmed cases and asymptomatic carriers from sub-module "infectious disease management information system". based on epidemiological investigation results, transmission chains were constructed and case generations were determined, followed by a comprehensive analysis. this study has covered all local clusters and all confirmed cases and asymptomatic carriers in the clusters, so sampling was not involved. confirmed cases with missing clinical information were not included into the analysis. confirmed cases, asymptomatic carriers and clusters were identified according to the definitions in the guidance for corona virus disease : prevention, control, diagnosis and management [ ] . a cluster outbreak indicated that more than two confirmed cases or asymptomatic carriers were found within days in a small area (such as a family, a building site, a work unit), and there was a possibility of human-to-human transmission caused by close contact or by exposure to infectious source together. all confirmed cases were divided into mild cases (the clinical symptoms are mild and no pneumonia manifestation can be found in imaging); ordinary cases (with symptoms like fever and respiratory tract symptoms, and pneumonia manifestation can be seen in imaging); and severe cases (respiratory distress, rr ≥ breaths/min; pulse oxygen saturation (spo ) ≤ % on room air at rest state; arterial partial pressure of oxygen (pao )/oxygen concentration (fio ) ≤ mmhg. the date of onset for a confirmed case was defined as the date of first appearance of clinical symptoms self-reported in field epidemiological investigation. the date of onset for an asymptomatic carrier was defined as the date on which a positive covid- pathological test was obtained with respiratory tract or other feasible samples. the attack rate was defined as the number of cases divided by the number of exposed persons, where the number of cases was the total number of confirmed cases involved in a transmission chain. as both secondgeneration (g ) and third-generation (g ) cases were identified from close contacts of cases of the previous generations, if any g case developed in a cluster, the number of exposed persons was the number of close contacts of first-generation (g ) cases plus the number of g cases; if any g case developed in a cluster, the number of exposed persons was the number of close contacts of g cases plus the number of close contacts of g cases resulting in the g cases plus the number of g cases; and so forth. the secondary attack rate was defined as the number of second-and later-generation cases divided by the number of exposed persons, where the number of exposed persons was calculated using the aforementioned algorithm except that the number of g cases was not included. the incubation period was determined based on confirmed cases that had been exposed for a single time in transmission chains, whose exposure and onset time were clearly known and in whom other factors potentially responsible for their infection were ruled out. cases for the determination of the attack rate, the secondary attack rate and the incubation period included confirmed cases and asymptomatic carriers. a family dinner was defined as a dinner attended by two or more families. epidemiological characteristics of clusters and demographic and clinical characteristics of confirmed cases were descriptively analyzed. attack rates, secondary attack rates and clinical types of cases and constituent ratios of symptoms were compared using χ test for constituent differences. the regional distribution map in fig. was created by geocoding all covid- clusters and matching them to the city-level layers of polygon and point by administrative codes with the use of arc-gis software. on january , , the first local covid- cluster was reported in sichuan. on january , , a level- public health emergency response was launched, followed by the successive execution of multiple measures with respect to infection sources, routes of transmission and susceptible populations to effectively reduce population movement and gatherings and strengthen the management of close contacts. main measures and the timeline are shown in fig. . on january , , the first local covid- cluster was reported. a total of clusters were reported in january and in february. the daily number of clusters peaked on january , (n = ) and gradually declined after february , . a total of ( . %) clusters were reported as of february , . temporal distribution of cluster reports is shown in fig. . among the clusters, ( . %) were caused by imported cases, and in the infection source of the first case was unknown. the clusters had involved prefectures and districts/counties (fig. ) . chengdu had the largest number of clusters (n = ), followed by dazhou (n = ), nanchong (n = ) and guang'an (n = ). clusters in the four prefectures accounted for . % ( / ) of the total in the province. households were the primary exposure place in the reported clusters, accounting for . % ( / ); living in the same household was the primary form of exposure, accounting for . % ( / ). clusters caused by exposure in multiple places and in multiple forms accounted for . % (fig. ) . significantly more clusters were caused by family gatherings in february than in january (p = . ) ( table ) . in the clusters, a total of confirmed cases were reported, accounting for . % ( / ) of the total in the whole province; among these confirmed cases, were local confirmed cases resulting from clusters, accounting for . % ( / ); the male/female ratio was : , the mean age was . years ( month- years), and patients years of age or above accounted for . % ( / ); involved were ( . %) g cases, ( . %) g cases and ( . %) g cases ( table ); . % ( / ) had a history of travel or residence in wuhan, and . % ( / ) had a history of travel or residence in other provinces except wuhan. the constituent ratios of cases with a history of travel or residence in both wuhan (p < . ) and other provinces except wuhan (p = . ) were higher in g cases were higher in g and g cases, and the differences were statistically significant ( table ) . the confirmed cases were clinically typed as follows: . % ( / ) were ordinary, . % ( / ) were mild, and . % ( / ) were severe; no death occurred. with the increase of the transmission generation, the number of ordinary cases gradually decreased, with a significant difference noted overall (p = . ); a significant difference was found between g and g cases in the constituent ratio of ordinary cases (p = . ). no apparent between-generation difference was found in the constituent ratios of mild or severe cases (fig. ) . among .the number of cases with fever showed a declining trend overall with the increase of transmission generation (p = . ), and significant differences were noted between g and g cases (p = . ) as well as g cases (p = . ) in terms of the constituent ratio of cases with fever. no statistically significant difference was found between generations in other symptoms (fig. ) . among the clusters, g cases were identified in ( . %) and g cases in ( . %); a total of confirmed cases (including asymptomatic carriers) were reported, and on average each cluster resulted in . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) cases; the average attack rate was . % ( . - %), and the average secondary attack rate was . % ( . - . %). starting from february , , we expanded the time window of close contact tracing to cover days prior to the appearance of clinical symptoms in primary confirmed cases or prior to the obtainment of a positive nucleic acid test in primary asymptomatic carriers. attack rates and secondary attack rates before and after this time point were compared, and it was found that, following the expansion of the time window of close contact tracing, both the attack rate and the secondary attack rate increased, with statistical differences identified ( table ) . among the cases, . % ( / ) had been exposed to confirmed cases. in . % ( / ) of such cases, the exposure to the confirmed cases occurred at or after onset of the disease in them. in cases (involved in clusters), the exposure occurred before the confirmed cases they contacted with developed clinical symptoms, and they had been exposed only once while the possibility of exposure to other infection sources could be ruled out. the median time of exposure was d ( - d) prior to disease onset in the confirmed cases they contacted with, and the mean was . d; . % ( / ) of the cases were exposed within d prior to disease onset in the confirmed cases they contacted with. of confirmed cases, the median interval between hospital visit and onset was d ( - d), the median interval between confirmation and onset was d ( - d), and the median interval between isolation and confirmation was − d (− - d). twenty-eight cases met the criteria for incubation period determination (involved in clusters). the average incubation period was . d, the median incubation period was . d ( - d) and the incubation period was > d in . % ( / ). in the clusters, a total of asymptomatic carriers (all were identified during medical observation of close contacts) were reported, including males and females. the mean age was . years ( months- years); and patients years of age or above accounted for . % ( / ). involved were ( . %) g cases, ( . %) g cases and ( . %) g cases. in one cluster, one g case (severe) was found to have spread the disease to one g case (mild) and one g case (asymptomatic). two clusters were caused by asymptomatic carriers and, in both clusters, only g cases developed, including one (asymptomatic) to two (confirmed) transmission in one cluster and one (asymptomatic) to one (confirmed) transmission in another cluster. the possibility of other infections was ruled out in all g cases. by the end of the two clusters, the g asymptomatic carriers had not presented with clinical symptoms or imaging abnormalities. our analysis of covid- clusters in sichuan reveals that the majority of clusters were reported before february and occurred in four regions of sichuan, and three-fourth of the clusters were caused by importations from other provinces including wuhan. the study also found that the proportion of cases with a history of travel or residence in wuhan was significantly higher in g cases than in secondary cases and the clusters mainly occurred in households with a greater proportion in february than in january. these characteristics were similar to clusters in other provinces in china [ ] . the above characteristics of covid- clusters were supposed to be related with several factors. firstly, the epidemic happened during the spring festival in china, when large numbers of people in china returned home for family reunion or visited their friends or relatives, forming a population shift peak, particularly in the midlate january. secondly, chengdu, the capital of sichuan province, as a rapidly growing metropolis in west china, has well-developed transport infrastructure including highways, railways and airlines, which facilitated the spread of the disease [ ] ; big data analysis also showed that chengdu was ranked the top in terms of inflow of people from wuhan [ ] [ ] [ ] ; dazhou and guang'an, located in the northeast of sichuan, are adjacent to chongqing, which was relatively hardly hit by the epidemic among provinces other than hubei in china [ ] . finally, on january , , sichuan launched a level- public health emergency response [ , ], followed by the successive execution of multiple measures with respect to infection sources, routes of transmission and susceptible populations, effectively reducing population movement and gatherings and strengthening the management of close contacts. specifically, on january , , the administration for market regulation, the health commission and the department of commerce of sichuan province jointly issued a document [ ] for strengthening the supervision of dinner gatherings; on january , , the people's government of sichuan province issued an order [ ] requiring suspension of massive gatherings and business of recreational places and banning dinner gatherings. on february , , the provincial headquarters for emergency response issued a notice on strengthening the supervision of dinner gatherings in rural areas [ ] , banning dinner gatherings involving two or more families. the above measures have effectively reduced people's gatherings including festival celebrations and company dinner parties. however, still a minority of people, following traditional customs, organized and participated in family dinners and entertainment activities with inadequate protection during the chinese new year, resulting in the familial clustering characteristic of the epidemic. the attack rate of covid- clusters in our study was slightly lower than . % in a study located in shenzhen [ ] . the interval between hospital visit and onset was shorter than that reported in hunan [ ] ; related data were not available from other provinces. the study also showed that the attack rate and the secondary attack rate were significantly higher after february , than before; cases were mainly confirmed during the isolation period and asymptomatic carriers were identified in the management of close contacts, which suggested that the intensive close contact management measures in sichuan including expansion of the close contact tracing time window to cover d prior to the presence of clinical symptoms (or positive test for asymptomatic carriers) in the confirmed cases they contacted with, implemented from february , , and the conduct of nucleic acid testing at both the start and the end of quarantine of close contacts, implemented from february , , might have contributed to the discovery and control of cases and the reduction of spread. the median incubation period in the limited cases in sichuan was corresponding to the finding in other studies in china that the incubation period in the majority of cases was < d, but being longer than the median incubation period reported in other studies ( - d) [ ] [ ] [ ] [ ] [ ] . it was also found that the proportion of cases with an incubation period > d was higher than that reported in a study in henan ( . %) [ ] . ten cases exposed before the confirmed cases they contacted with presented with clinical symptoms, of which most cases exposed within d prior to disease onset, and these cases had been exposed only once and other potential sources of infection could be ruled out, suggesting covid- is possibly transmittable during the incubation period, similar to a report in zhejiang [ ] . at the same time, the majority of cases involved in the clusters exposed within days prior to onset of the disease in confirmed cases they contacted with, suggesting covid- , like influenza, is possibly contagious at the end of the incubation period or tracing back to d prior to disease onset in seeking close contact could miss earlier infections in the incubation period. what's more, two clusters caused by asymptomatic carriers indicated covid- could be transmitted by asymptomatic infected persons, as is similar to the report in henan [ ] . nevertheless, the asymptomatic carriers had only caused a small number of g cases, indicating the transmissibility in this population may be limited. the above two populations cannot be effectively identified and thus are of special public health significance for sustained transmission of covid- [ ] ; due to limited available data, the transmissibility of the disease cannot be analyzed, and studies on its pathogenicity and transmissibility in these populations are awaited. main presentations of confirmed cases involved in the clusters in sichuan included fever, respiratory and systemic symptoms, basically corresponding to the reported clinical characteristics of covid- cases, and no characteristic clinical symptom was seen [ , [ ] [ ] [ ] [ ] . in clusters, the proportion of ordinary cases and cases with fever decreased with the increase of the case generation, suggesting that the severity of clinical symptoms might gradually lighten with the development of the epidemic. this corresponded to reports that, in the initial period of the epidemic, cases were mainly severe and the case fatality rate was high [ ] and, in the later period of the epidemic, cases were mainly mild [ ] . this is possibly because the virus will maintain moderate virulence during passage and evolution for the purpose of long-time reproduction in human and the infection was limited to the upper respiratory tract [ ] . in addition, it was reported that antibody levels would not last long, and repeated infection was common [ , ] . however, limited data are available and further studies on covid- antibody levels and protective effects are awaited for investigating whether post-infection antibody levels will decline following the mitigation of covid- clinical symptoms or whether repeated infection will occur as a result of the short-term maintenance of antibody levels. the findings in the study are subject to several limitations. on the one hand, as only cases exposed only once were included, the cases calculated for the incubation period was limited. on the other hand, pcr detection of respiratory tract specimens was carried out once each time when close contacts were isolated and released, and the isolation period was days. if an asymptomatic carrier recovered spontaneously during the isolation period, the attack rate might be underrated due to the missing count of cases. in conclusion, our study demonstrated the comprehensive epidemic situation of covid- in sichuan province and confirmed the infectivity during the incubation period and asymptomatic infection, providing a reference for decision makers to formulate and adjust control measures. abbreviations who: world health organization; covid- : coronavirus disease; rr: respiratory rate; spo : pulse oxygen saturation; pao : arterial partial pressure of oxygen; fio : fraction of inspiration o ; g : first generation; g : second generation; g : third generation; pcr: polymerase chain reaction funding this study was supported by the science and technology department of sichuan province (grant no. yfs ). the funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. this study was consulted to the ethics committees of sichuan center for disease control and prevention. ethics approval was not available because all data were collected as part of public health emergency surveillance following the laws of the people's republic of china on the prevention and treatment of infectious diseases. we also did not include any data of patients' personal information and therefore ethical approval was not required and waived off written informed consent. not applicable. director-general's opening remarks at the media briefing on covid- national health commission (nhc) of the prc, national administration of traditional chinese medicine of the prc. guidance for corona virus disease : prevention, control, diagnosis and management people's medical publishing house special expert group for control of the epidemic of novel coronavirus pneumonia of the chinese preventive medicine association. an update on the epidemiological characteristics of novel coronavirus pneumonia (covid- ) analysis on the epidemic factors for the corona virus disease how internet of things big data aid in epidemic surveillance: where did wuhan people go the day before the city "lockdown risk assessment of exported risk of novel coronavirus pneumonia from hubei province chinese center for disease control and prevention. distribution of covid- cases notice of general office of the people's government of sichuan province on issuing level i emergency measures against pneumonia associated with the novel coronavirus emergency notice of departments including administration for market regulation of sichuan province on strengthening the supervision of massive dinner gatherings during the covid- prevention and control period announcement of sichuan headquarters for emergency response to the covid- epidemic sichuan headquarters for emergency response to the covid- epidemic. notice on issuing eight measures for strengthening massive dinner gatherings in rural areas during the covid- prevention and control period epidemiology and transmission of covid- in shenzhen china: analysis of cases and , of their close contacts. medrxiv diagnosis and treatment of confirmed cases of coronavirus disease in hunan province early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china clinical characteristics of coronavirus disease in china epidemiologic and clinical characteristics of hospitalized patients with covid- in zhejiang, china: a retrospective, multi-centre case series epidemiological characteristics of covid- patients in henan, china presumed asymptomatic carrier transmission of covid- potential presymptomatic transmission of sars-cov- advances on presymptomatic asymptomatic carrier transmission of covid- clinical features of patients infected with novel coronavirus in wuhan epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus disease (covid- ) in china offline: -ncov outbreak-early lessons molecular virology. th ed. chaoyang district: people's medical publishing house medical microbiology. th ed. chaoyang district: people's medical publishing house clinical and immunological assessment of asymptomatic sars-cov- infections publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we salute and thank all personnel engaged in the prevention, control, diagnosis and treatment of covid- in sichuan province. the authors declare that they have no competing interests. key: cord- -k h jq authors: abou-al-shaar, hussam; sabbagh, abdulrahman j. title: the undetermined destiny of case reports in the era of sophisticated medicine date: - - journal: world neurosurgery doi: . /j.wneu. . . sha: doc_id: cord_uid: k h jq nan the undetermined destiny of case reports in the era of sophisticated medicine letter: w e read with great interest the editorial by dr. benzel. the importance of case reports is indeed declining in recent years. the continuous development of medicine, the use of sophisticated methodologic tools, the increasing need for cutting-edge evidence-based medicine (which cannot be achieved with case reports), and the continuous restrictions from journals on case reports all have contributed to the "diminishing value" of case reports. however, a few questions remain to be answered here. should authors stop reporting their unique cases? should journals stop accepting such unusual cases? are we in an era where there is no more scientific value in case reports? looking back at history, we find various diseases and discoveries that were described initially as case reports. the perfect example of this is cushing disease. in , dr. harvey cushing first encountered the disease in a -year-old woman, who is historically known as "minnie g." the patient had an unusual and complex clinical presentation in the form of obesity, hypertrichosis, amenorrhea, overdevelopment of secondary sexual characteristics, low-grade hydrocephalus, and increased cerebral tension. , such an unusual clinical combination was not yet described by any medical disorder at the time, which stimulated cushing to begin his lifelong interest and extensive research and investigations. cushing was confident that minnie's unusual presentation was due to a problem of the pituitary gland. because of minnie's case and similar unusual cases reported in the literature, cushing's efforts eventually culminated in in his pivotal work, "the basophil adenomas of the pituitary gland and their clinical manifestations (pituitary basophilism)." in his article, cushing described cases from his own experience (minnie g. was the first case) along with other cases reported in the literature. because of such single case reports, the clinical symptoms of the disease were described and were named after cushing. not only did minnie g. aid in discovering a new syndrome, but her very unusual long-term survival intrigued carney to speculate that she might have had the carney complex of primary pigmented nodular adrenocortical disease. the value of case reports in our opinion goes beyond just mere reporting of unique cases. it expands our understanding of the nature of a disease and helps us, although by a small step, advance our field. this is clearly evident in the case of some recent diseases, such as the middle east respiratory syndrome coronavirus. the disease was initially described as a single case, and extensive reporting of more cases expanded our understanding of the nature of such an infection, its origin, route of transmission, pathophysiologic mechanisms, and clinical implications. the value of case reports is also evident by their role in delineating hidden unusual disease associations, , novel genetic discoveries, new surgical techniques and technical nuances, unique thought-provoking disease pathogenesis, decision-making challenges and conundrums, cutting-edge management innovations, and unusual complications. such unique cases carry new information that can be of huge educational value and are of great interest to the readers. therefore, the answers to the aforementioned questions are not easy. the continuous advancements in the medical field should not diminish the value of case reports. on the contrary, these advancements should aid case reports to be the initial building blocks and cornerstone that employ technical and methodological advances for better understanding of such rare cases and form an infrastructure for future cutting-edge evidence-based medicine. we hope that world neurosurgery continues to provide the platform that can accommodate such rare and innovative case reports and remains the strong infrastructure that authors can rely on to report such cases. the diminishing value of "the case report the pituitary body and its disorders: clinical states produced by disorders of the hypophysis cerebra cushing's case xlv: minnie g the basophil adenomas of the pituitary body and their clinical manifestations (pituitary basophilism) the search for harvey cushing's patient, minnie g., and the cause of her hypercortisolism isolation of a novel coronavirus from a man with pneumonia in saudi arabia evidence for camel-to-human transmission of mers coronavirus frontal dermoid cyst coexisting with suprasellar craniopharyngioma: a spectrum of ectodermally derived epithelial-lined cystic lesions? hypothalamic-optochiasmatic pilocytic astrocytoma associated with occipital and sacral spinal cavernomas: a mere coincidence or a true association a novel missense mutation in the tbx gene in a saudi infant with holt-oram syndrome bolstering the nasoseptal flap using sphenoid sinus fat packing: a technical case report supratentorial neurenteric cysts-a fascinating entity of uncertain embryopathogenesis hemoglobin drop after anesthesia in craniosynstosis: dilemma of operate or not to operate brachytherapy in the treatment of recurrent aggressive falcine meningiomas free esophageal perforation following hybrid visceral debranching and distal endograft extension to repair a ruptured thoracoabdominal aortic aneurysm key: cord- -iw squ n authors: neiva, mariane barros; carvalho, isabelle; costa, etevaldo dos santos; barbosa-junior, francisco; bernardi, filipe andrade; sanches, tiago lara michelin; de oliveira, lariza laura; lima, vinicius costa; miyoshi, newton shydeo brandão; alves, domingos title: brazil: the emerging epicenter of covid- pandemic date: - - journal: revista da sociedade brasileira de medicina tropical doi: . / - - - sha: doc_id: cord_uid: iw squ n introduction: five months after the first confirmed case of covid- in brazil, the country has the second highest number of cases in the world. without any scientifically proven drug or vaccine available combined with covid- ’s high transmissivity, slowing down the spread of the infection is a challenge. in an attempt to save the economy, the brazilian government is slowly beginning to allow non-essential services to reopen for in-person customers. methods: in this study, we analyze, based on data analysis and statistics, how other countries evolve and under which conditions they decided to resume normal activity. in addition, due to the heterogeneity of brazil, we explore brazilian data of covid- from the state health secretaries to evaluate the situation of the pandemic within the states. results: results show that while other countries have flattened their curves and present low numbers of active cases, brazil continues to see an increase in covid- patients. furthermore, a number of important states are easing restrictions despite a high percentage of confirmed cases. conclusions: all analyses show that brazil is not ready for reopening, and the premature easing of restrictions may increase the number of covid- -related deaths and cause the collapse of the public health system. with million cases and , deaths, the largest pandemic since the spanish flu in has now reached over countries in the world. covid- , a disease caused by sars-cov- , started in wuhan but rapidly spread across asia, europe, and america . brazil, which had its first confirmed case on february , , almost two months after the announcement of the outbreak of the disease in china, is now the country with the second highest total number of confirmed cases , . by july , , we accounted for , , cases and , deaths . as a new disease, despite all advances in technology and rapid genome analysis, there are no scientifically proven treatments, such as drugs and vaccines, to protect people or cure infected patients. thus, the main recommendations from the world health organization (who) for the general population are to maintain social distance and hygiene habits such as the use of alcohol-based hand sanitizers and face masks, measures intended to slow the spread of the virus . furthermore, social inequalities in brazil highlight the importance of higher isolation rates since the public health system cannot withstand high pressure. sus, the brazilian public health system, is responsible for the support of % of the population and could collapse if a considerable number of people contract the disease in a short period of time . moreover, people's confidence in the government is referenced as one of the critical points in handling the pandemic successfully. nevertheless, brazil is going through a hard time in the political sphere. as examples that directly impacts the covid- battle, the health minister was replaced twice in two months and the country's president has been frequently seen in groups not complying with the medical community's recommendations, thereby influencing the population , . understanding data is essential for the proper care of the population. therefore, in this study, we analyze the situation of the pandemic in other countries to explore how they dealt with the disease and under which conditions they decided to resume non-essential services . by understanding the evolution of each country and the statistics in brazil, the goal of this study is to evaluate whether the tropical country is gathering knowledge from other regions and easing restrictions according to certain metrics such as the decrease in daily cases and deaths. this article is a descriptive observational study using classical statistical metrics, such as frequency and percentage. the analysis is divided into two parts. first, the aim was to characterize how brazil is evolving in the covid- war. for this, the brazilian data at the federal level were compared with data from other countries regarding three types of information: the number of new cases, the number of new deaths, and active cases. for this analysis, we collected data from john hopkins , which allowed us to obtain the daily and total cases, deaths, and recovered patients, along with the evolution of the pandemic. active cases are not directly obtainable from the hospital database; thus, we computed them using the following equation: active_cases(x) = total_cases(x) -total_deaths(x) -total_recoveries(x), where total_cases(x), total_deaths(x), and total_recoveries(x) are the total number of positive cases, deaths, and recovered patients, respectively, until day x. the measure is a good track to understand how many patients are currently transmitting the viruses or might require hospitalization, which is important for public health policies. furthermore, we also compared the total number of cases in each country according to their size. the relative comparison is essential because countries with different sizes probably have more cases compared to smaller regions. therefore, by dividing the cases by the population size, one can understand the proportion of inhabitants of each country that contracted covid- and the differences and similarities among couples of countries. besides brazil, seven countries are evaluated: south korea, the united states of america, spain, italy, new zealand, germany, and china. along with the comparison of countries, we also compared the first and second positions in the worldwide rank of case numbers provided by . to do this, we used the epidemiological knowledge that virus propagation within the population can fit an exponential model . thus, we used computational simulations in python to fit the total number of cases of brazil and the us as an exponential curve. to perform this analysis, we used the data from the previous two weeks, the approximate period of time sars-cov- remains in an individual organism , to obtain the exponential parameters. then, we projected the data for the next days. another statistic is the testing rate for each confirmed case. testing suspected cases reduces the under-detection probability and enhances the reliability of the data. data were retrieved from our world in data for each country. the results are shown in section . . finally, in section . , we seek to understand how covid- performed within the brazilian territory. disaggregating geographically by state, the analyses aimed to characterize the number of cases, the number of deaths, and their influences on population rates over the time that the virus disseminated throughout the country over months (from february to july). the behavior of dissemination and danger of the virus was characterized by the contamination rate, which describes the speed of spread of the virus through the number of cases normalized by the population of each place per thousand inhabitants, and the lethality rate, which describes the proportion of people who die among all those infected . data were obtained from the state health secretaries' databases and along with information of absolute and relative cases for each of the main states in brazil, we also evaluated the spatial evolution of the pandemic in the state of são paulo, the most populated location in brazil. finally, we discuss the evolution of reopening measures in brazil, showing a map with coping policies for each country. the coping information was retrieved from the news and collected from https://ciis.fmrp.usp.br/covid /. as previously mentioned, it took two months for brazil to have its first confirmed case of covid- , which gave the country a foundation of information and knowledge to better understand the evolution of the disease, as well as the opportunity to see how other countries proceeded with reopening. first, one can start by understanding the situation in wuhan, the breakpoint of the pandemic that previously suffered from sars and the avian flu . despite the recent history of respiratory diseases, covid- is a new challenge that is not yet fully described by science, and the prognosis of patients can be unpredictable. in order to contain the spread of the disease and a high number of deaths, the chinese government ordered a lockdown in hubei, applying severe restrictions regarding social isolation which were widely obeyed . furthermore, the culture of using face masks as a routine probably helped to decrease the rate of transmission . by the beginning of march, china had already less than new cases per day, and, by mid-june, there were under new cases per day . the country was one of the first to reopen and is currently tracking new cases by applying social distancing in workplaces, constant disinfection, and temperature measuring more than once a day , . these actions appear to be effective, considering the number of new cases shown in figure f . new zealand is another country that has succeeded in beating covid- . after days with no detection of covid- , a patient was diagnosed on june , having contracted it in the united kingdom, meaning no local transmission had occurred in three weeks . the reason for such success? travel restrictions and quarantine measures with a low level of confirmed cases . prime minister jacinda ardern has demonstrated strong leadership, convincing almost five million people to respect the stay-at-home guidelines . furthermore, testing and tracking were applied all over the country with the support of mobile applications that use qr codes to scan buildings and alert possible infected people . after one week with zero new cases, new zealand began to ease its restrictions . south korea also used technology, isolation restrictions, and extensive temperature measuring , . in europe, germany also applied consistent rules and strategies to fight the virus, such as intensive care unit (icu) monitoring, testing, and patient tracking , . italy was one of the countries most affected by covid- due to a delay in establishing restrictions in many points of the country. the 'milan does not stop' campaign, for example, ignored the isolation instructions from who in an attempt to prevent the economy from collapsing . after losing control of the disease spread, a lockdown began on march and lasted until may , . although these countries may have established different strategies, most of them relied on who instructions, scientific evidence, and strong leadership. figure shows that almost all countries are on the downside of the curve of new cases. the database of the graphs was retrieved from the john hopkins hospital . the number of active cases in italy, around , , is still high, which requires intense observation of health services capacity since isolation restrictions are being loosened. with no drug or vaccine, all countries must keep monitoring its cases to understand whether it is time to re-apply restrictions or if one proceed to new phases of reopening. however, one can see that brazil and the united states, the second and first countries, respectively, in the number of confirmed cases, do not follow the same patterns in the new cases/deaths and active case graphs, as shown in figures g and h . furthermore, the graph of active cases shows a steep incline, while new cases and deaths are increasing. this is also evident in figure a , where most countries' curves are flattening and brazil and the united states curves continue to increase. as the us and brazil rank as first and second in numbers of active cases , we compared both exponential projections in an attempt to predict the future. in figure b , it appears that brazil will overtake the us in numbers of active cases by the end of august. such analysis considers the relative number of cases in both countries to remove population size influence. this means that besides being the country in south america with the most covid- cases, brazil will also have the highest number of cases worldwide. the situation is even more worrying, as brazil has a low test rate and, consequently, a high likelihood of under detection (figure ) compared with countries that are coming out of lockdown. furthermore, several places in brazil are easing isolation rules and opening non-essential services, such as malls, which are usually environments with low air circulation and, therefore, conducive to the spread of the virus. it should be taken into account that brazil is a very heterogeneous country with high social inequality. the pandemic is affecting the public health system and the population in a non-uniform way, as approximately . million people live in shanty houses. the following section highlights these differences and shows more in-depth features of this enormous country. brazil, with states and one federal district, is the seventh most populated country, and the fifth with the greatest territorial extension worldwide . therefore, the country is inconsistently dealing with the coronavirus epidemic. each brazilian state behaves like a small country, and the segregation of analysis aims to strengthen the action plans. the following analyses considered the five brazilian states with the highest numbers in each indicator. figure a shows the accumulated number of cases over time. in order, the five states with the highest number of cases were são paulo, ceará, rio de janeiro, pará, and bahia. at the end of may, they recorded approximately , cases, % of all brazilian cases. são paulo has been the leader in the number of cases since the beginning, with approximately % more cases than the second ranked state, ceará. this is because são paulo is the industrial center figure : besides the high number of cases in brazil, the country is known for its lower testing rate. this has direct consequences on the under detection covid- , meaning that brazil possibly has more cases than those noted by health care centers. conversely, south korea and new zealand are among the countries with the highest rates of testing and are considered successful cases in the pandemic. and the most populated area of the country, with approximately million people. however, the absolute number of cases alone does not provide a complete picture of the severity and speed of dissemination. thus, figure b shows the contamination rate. the latter four states did not have a large accumulated number of cases, but showed high daily growth in relation to the other brazilian states. a different scenario is observed when analyzing the contamination rate, as shown in figure b . the measure refers to the number of cases normalized by the population of each state per thousand inhabitants. since the end of april, the states of amapá, roraima, amazonas, and acre have presented high community transmission of the coronavirus. this has resulted in a new focus on the north region of brazil. none of these regions were even mentioned in previous analyses. this negative impact of this statistic was clearly seen in mid-april when the state of amazonas became the first brazilian state to be on red alert, asking for international support due to the collapse of the funeral and health system , . with the diversity and immensity of the country, brazil has several areas and different needs that require attention. thus, it is essential to explore different indicators to capture these needs as quickly as possible. figure c presents the death analysis. it is expected that the number of deaths will be proportional to the number of cases. four of the states with the highest absolute number of deaths have already been mentioned as critical in previous analyses; however, the state of pernambuco is unprecedented and had more than , deaths by the end of may. together, the five states with the highest number of cases have reported almost , deaths and represent % of total brazilian deaths. regarding daily case information, the highest number in the country occurred in são paulo on june when deaths due to covid- were recorded in hours. hospital morgues located in rio de janeiro, which also has a high number of daily deaths, are dealing with overcrowding and accumulating bodies day after day . the last indicator explored in this subsection is the lethality rate, as shown in figure d . the lethality rate is the ratio between the number of deaths and the total number of cases of a disease in a given period; it represents the risk that people with the disease have of dying from the disease . brazil has a high rate of covid- transmission. within days, its number of cases had doubled, which translated to , new cases . the heterogeneity and extensiveness show a burdensome scenario within the decision-making process and the need for protective measures. social inequalities enhance the necessity of deep analysis prior to easing restrictions based on intensive care units, infrastructure, and infection rates presented in section . for instance, the north region required significant medical support and structure in order to prevent a worse collapse in the health system. the northeast also showed high lethality and death rates, mainly in ceará and pernambuco. são paulo and rio de janeiro appear in almost all covid- analysis indicator rankings. both states represent the main economic poles in the country, and the high density of people in both areas highlights the importance of continuous tracking and testing. the brazilian government does not seem to be learning lessons from other countries, such as those referenced in section . . as previously mentioned, all of them, except for the united states, only eased restrictions after intensive tracking, testing, and a descending curve in the number of daily cases was shown. são paulo and rio de janeiro, along with other states in brazil, do not follow the same approach (see figure a ). in addition, the number of active cases is still high, along with all other indicator analyses concerning each state. this is an urgent issue and must be addressed in all public spheres so that we can improve our response to the pandemic. in public health, prevention is always the least costly option, especially in this case, where an individual's response to the infection could be death. supported by the quantitative information in figure b demonstrating that brazil is expected to overtake the us in total number of cases (proportionally by population size), the current low isolation rates, low population testing percentage with consequently high under detection, high daily cases, and death rates all suggest that brazil has eased its restrictions prematurely and may face severe consequences in the near future as a result, such as becoming the next global epicenter of the pandemic. coronavirus cases [internet]. worldometers covid- cases in brazil surge to , ranking it as second place to america worldwide coronavírus brasil [internet]. brazilian government covid- lota hospitais e gera colapso funerário em belém demand for hospitalization services for covid- patients in brazil brazil loses second health minister in less than a month as covid- deaths rise [internet]. the guardian sob vaias e frases de apoio, bolsonaro come cachorro-quente em brasília doria anuncia flexibilização gradual da quarentena em são paulo agência brasil an interactive web-based dashboard to track covid- in real time a systematic review of covid- epidemiology based on current evidence science forum: sars-cov- (covid- ) by the numbers coronavirus disease (covid- ) -statistics and research epidemiologia clínica: elementos essenciais, artmed the deadly coronaviruses: the sars pandemic and the novel coronavirus epidemic in china the state council information office -the people's republic of china. full text: fighting covid- : china in action asia may have been right about coronavirus and face masks, and the rest of the world is coming around life after lockdown: how china went back to work zealand's first covid cases in days came from uk how new zealand's 'eliminate' strategy brought new coronavirus cases down to zero new zealand's prime minister may be the most effective leader on the planet coronavirus: aucklanders have to scan qr code to enter council buildings more covid- lockdown restrictions to be eased in new zealand south korea is relying on technology to contain covid- , including measures that would break privacy laws in the us -and so far, it's working south korea's health minister on how his country is beating coronavirus without a lockdown how germany contained the coronavirus oversupply of hospital beds helps germany to fight virus italy's virus shutdown came too late. what happens now? learning from the italian experience in coping with covid- wikipedia contributors. brazil -wikipedia, the free encyclopedia com saúde em colapso, governo do amazonas usará contêineres frigoríficos para mortos do coronavírus governador do am escreve à onu e pede ajuda contra covid- na amazônia [internet]. uol notícias com necrotério lotado, corpos se acumulam em corredor de hospital no rj we thank the university of são paulo for technical support. the study did not require ethical approval since it is a descriptive study and there are no experiments involving humans. the authors declare that there is no conflict of interest. conception and design of the study, performed the computations, performed the analysis, wrote the paper; / ic: conception and design of the study, performed the computations, performed the analysis, wrote the paper; escf: performed the analysis, wrote the paper, reviewed the paper; fbj: interpretation of data, drafted the article, wrote the paper, reviewed the data; fab: model of data server, drafted the article, wrote the paper, reviewed the data; tlms: wrote the paper, reviewed the data; llo: wrote the paper, reviewed the paper; vcl: model of data server, drafted the article, wrote the paper, reviewed the data; nsbm: wrote the paper, reviewed the paper; da: conception and design of the study, final approval of the version to be submitted. key: cord- - chgl authors: bajwa, sukhminder jit singh; sarna, rashi; bawa, chashamjot; mehdiratta, lalit title: peri-operative and critical care concerns in coronavirus pandemic date: - - journal: indian j anaesth doi: . /ija.ija_ _ sha: doc_id: cord_uid: chgl world health organization (who) declared novel coronavirus outbreak a “pandemic” on march (th), . india has already reached stage (local transmission) and the indian government, in collaboration with the indian council of medical research (icmr), is taking all necessary steps to halt the community transmission(stage ). anaesthesiologists and intensivists around the globe are making untiring efforts akin to soldiers at the final frontier during war. all efforts pertaining to adequate staffing, personal protective equipment (ppe) and strict adherence to hand hygiene measures are being stressed upon to prevent in-hospital transmission. in this article, all outbreak response measures including triaging, preparation of isolation rooms, decontamination and disinfection protocols as well as fundamental principles of critical care and anaesthetic management in covid- cases is being discussed. all the recommendations have been derived from the past experiences of sars (severe acute respiratory syndrome) and mers (middle east respiratory syndrome) outbreak as well as upcoming guidelines from the international health fraternity and indian health services. corona virus has created havoc amongst people of all nationalities with disturbingly rising count of affected people worldwide. a large database study of , affected chinese nationals has given a preliminary case-fatality rate of . % with % experiencing mild flu symptoms, while rest of the % having severe symptoms and % being critically ill; death rate increasing exponentially with severity. [ ] although the fatality has till now been reported lower than previous outbreaks of ebola, sarsandmersit is expected to rise if ipc (infection prevention and control) policies are not laid down and followed religiously. an estimated maximum likelihood (ml) of reproductive number of covid- infection was calculated to be . with a serial interval of days which can only be curtailed by strict quarantine measures. [ ] as anaesthesiologists and intensivists, our prime involvement in resuscitation, airway management, peri-surgical as well as critical care of such cases cannot be undermined. the need of the hour therefore is to update ourselves with clinicopathological spectrum of the deadly disease and provide evidence based medical services to all hospitalized cases with suspected covid- infection. all the recommendations below have been influenced by the past experiences of corona virus outbreaks and desire improved measures for personal protection of health care workers and consequent prevention of nosocomial transmission of infection. a systematic literature search was made using search engines including pubmed, google and google scholar with the use of the following single-text words and combinations: anaesthesia, corona virus, covid- , intensivists from the year to . the references of relevant articles were cross-checked and the articles containing all these keywords were thoroughly checked for imbibing the review. the data was also checked with national and international databases from internet and various newspapers. indian health authorities have submitted a total record of lab-confirmed cases- indians, foreign nationalsand cured and discharged post-quarantine till the time of writing this article i.e., th march, . [ ] the first three cases in india were students returning from china. they were successfully isolated in kerala and declared negative.till date, deaths have been reported from our country as a result of this deadly virus with old age (more than years), hypertension and male gender being stated as independent risk factors. [ ] the real number of patients carrying the virus is very difficult to establish as many people are avoiding the tests and many are not disclosing at all. the real danger to us as intensivists and anaesthesiologists is from these patients who have not been tested despite being potentially positive for harboring the virus. in this scenario, it is prudent to follow the national and international guidelines and treat any suspected patient as positive and to take necessary precautions during anaesthesia and critical care of such patients. screeningfor suspect cases n-cov is a positive sense, single-stranded rna corona virus belonging to sub-group sarbecovirus which closely resembles two bat-derived sars-like corona viruses but distant from sars-cov and mers-cov. preliminary phylogenetic analysis suggests bats as the original host of this virus with human to human transmission confirmed via droplet, contact and fomites and average incubation period of - days. [ ] since a vast majority of indian institutions have anaesthesiologists as in charge of the emergency triaging and intensive care units, it becomes essential that our fellow colleagues should be aware of every minute details of this deadly pandemic. the following terminology has been standardized for isolation of a suspect case [ table ]. although wuhan is considered the epicenter of outbreak, the increased number of cases being reported worldwide hasabolished the diagnostic link with ban on all tourist visas to india with effect from th march . for tracing contacts and categorizing risk of procuring infection, refer to table . while the high and medium-risk contacts are advised immediate isolation with controlled local and air travel in medical transport vehicles with laboratory evaluation guided by symptomatology, low risk contacts are advised to avoid prolonged public exposure and if symptomatic get lab tests done when deemed appropriate. however, as anaesthesiologists and intensivists, the biggest challenge we will face in coming times is from the asymptomatic patients oncestage of the disease is crossed. it becomes imperative that during all these times, we should see only emergency and critical patients with an emphasis on personal safety as well as taking all the universal precautions against corona virus. for any emergency surgery in such patients, planning of anaesthesia becomes very crucial while taking all the necessary precautions. planning for anaesthesiaand surgery in covid-suspect cases anaesthesiologists and intensivists are the soldiers at the final frontier of corona disaster as all patients landing up in the hospital with severe respiratory distress will be primarily seen under their domain. while applying all precautionary measures pertaining to health care workers treating covid-infected individuals, necessary critical illness support needs to be provided using the current knowledge about the pathophysiology and management of covid infection. some patients with mild-moderate symptoms can also be encountered by the anaesthesiologists while being posted for surgeries. patients with mild symptoms resembling the symptomatology of other similar flu like illnesses are the real threat as chances of precautionary lapses are high in such cases. further,accidental chances of getting infection becomes highest when the positive patients without any symptomatology are being treated like normal patients. elective surgeries in these patients can be postponed till the resolution of symptoms while an emergency surgery undertaken with due risk consent as this is entirely a new clinical scenario for anaesthesia and surgery. indian journal of anaesthesia | volume | issue | april all suspect patients posted for surgery must be kept in isolation room till their shifting to or (operating room). for the operative procedure, negative pressure isolation rooms with minimum air exchanges per hour. [ ] temporary conversion of otherwise positive pressure ors into negative pressure with independent provision for air conditioning and humidification should be preferred. the negative pressure can be created by reducing the amount of air volume entering the inlet duct, while maintaining the air volume exiting through the other duct. two adjacent ors with one being utilized for the procedure and other as anteroom for the staff and doctors to wear and dispose of all ppes is ideal. the biggest challenge comes from the diversity of operation theater infrastructure set ups in our country which makes it difficultfor the implementation of universal guidelines meant for such outbreaks. therefore, such surgeries should be undertaken only in select centers with all the facilities. the policies for such clinical interventions have to be formulated by the appropriate health authorities at central governmentlevelwhich can be implemented uniformly across the nation. during such emergency surgeries, the following protocols should be followed religiously. this must be done in the isolation itself where the patient is kept. various personal protective equipment have been described for preventing aerosol and droplet transmission from patient to the anaesthesiologist. this includes-gown and shoe cover long length, full sleeved gown and shoe covers which are water resistant provide protection from any spillage of oral, nasal secretions or vomitus. it is essential for all suspect patients to wear surgical masks to prevent any droplet transmission while coughing or yawning. a plastic face shield to cover front as well as side of face, n- masks or pcm or powered air purifying respirators for mouth and nose, eye shields and head caps for peri-orbital mucous membranes and hair respectively must be worn to protect any transfer of virus emitted in patient's secretions to anaesthesiologist's body. all these protective equipment must be checked for proper-fit to prevent any uncovered zone. double-gloving is advised to all health care workers providing care to such patients to prevent any cross-contamination. once any procedure is done, the outer glove should be used to remove gown, shoe cover and face shield while the inner glove removed as soon as possible afterwards and disposed of with all other equipment in double-zip lock plastic container. any evidence of soiling of the glove also reprimands its removal and replacement with fresh pair of gloves. hand washing all the steps of hand-washingwith alcohol based hand rubs must be adhered to strictly before wearing gloves for any procedure, before and after touching any contaminated area, anaesthesia trolley, airway cart or other instruments, and after removing gloves. protocol of keeping alcohol based hand wash at the entrance of every ward and icu helps in better compliance of health care workers.all ppes after exposure should be locked in a double zip lock plastic bag and discarded in a touch-free disposal. [ ] after taking due risk for the procedure, along with nil-per-oral instructions of hours for clear fluids, it is important to counsel the patient's relatives regarding need for strict isolation as well as their own testing. transportation to operation theatre during transportation, covid- infected patients must wear a surgical mask and be transported to the negative pressure or in an evacuated passageway and elevator preferably covered by plastic disposable material to be disposed of thereafter. all the ppes must be worn by the transporting nurse and doctor. these patients are highly anxious especially at seeing the level of protection worn by the team of doctors which gives them an impression of being doomed. adequate premedication in the form of benzodiazepines like midazolam and alprazolam or opioids like fentanylshould be prescribed before shifting to or. all ventilated patients must be intubated and transferred via special bain's circuit connected with the tube via hepa filter. the position of filter must be between the endotracheal tube connector and y-limb to prevent any aerosol transfer from the patient to portable ventilator and vice-versa. [ ] hfnc or bi-pap therapy should be avoided due to increased generation of aerosols. [ ] the patient must be suctioned by closed suction apparatus before transfer and given intravenous sedation and muscle relaxation to prevent any coughing and movement which might lead to disconnection of tube and dispersion of droplets. [ ] adequate training regarding transport of such patients and mock drills should be done for proper implementation. after preparation of all drugs in disposable syringes, arranging for face mask, airway, endotracheal tube, stillete, bougie, laryngoscope blade, circuit, soda lime, etc. all in disposable form, the patient is taken in the or and monitors attached. as all the health care workers have to cover themselves from head to toe, there is decreased heat loss and sweating. this can be mitigated by using a lower temperature setting of - degree celsius in the operating room. [ ] the leads for ecg, nibp, spo and etco should be single use or covered in sterile plastic cover to be discarded after use. in case of predicted difficult intubation, disposable blade and c-mac video laryngoscope should be kept standby while avoiding decision to conduct awakefibreoptic intubation due to potential of coughing during the procedure. [ ] intravenous cannulation must be done with sterile drape and gloves to prevent any spillage. it is recommended to administer anti-emetics or prokinetics in every case as prophylaxis for vomiting. [ ] the patient must be preoxygenated with % o for minutes using the disposable circuit and hepa filter barrier for denitrogenation.it is suggested to use total intravenous anaesthesia in place of inhalational due to lack of isposablevaporizers and cost concern. rsi (rapid sequence induction) is the procedure of choice for intubation to abolish need for mask ventilation and regurgitation. after administering appropriate inductionagent in the form of propofol or thiopentone and muscle relaxant such as succinylcholine or rocuronium in desired doses, intubation is done by the most experienced anaesthesiologist in minimum possible time and confirmed using capnography. in cases of severely decreased po /fio ratio, modified rsi can be done with low pressure ventilation before intubation. [ ] it is important to reemphasize the use of "double-glove" technique during intubation. it is suggested to use total intravenous anaesthesia in place of inhalational for maintenance of anesthesia due to lack of disposable vaporizers and cost concern. the maintenance of anaesthesia can be done using disposable ml syringes and pmo lines. the depth of anaesthesiashould be maintained at all times to prevent any bucking in between the procedure. the setting of ventilatory parameters should be in accordance with the lung protective strategies with optimal peep and pplat< mmhg to achieve an spo > % and admissible hypercapnia. [ ] in case devices like point-of-care ultrasound (usg) have been used during the procedure, the machine and the probe along with the wire must be covered with a plastic sheath which is removed and discarded after use. any invasive procedures like epidurals or putting a central venous line should be done under usg guidance to prevent chances of failure. after the surgery, the decision to extubate should only be taken ideally in asymptomatic patients and threshold for keeping the patient intubated kept low in order to avoid any procedure with assumed dispersion of infective material in the environment. [ ] in case of decision to extubate, the bucking on the tube should be avoided by "deep plane of extubation" along with anti-aspiration prophylaxis. after the patient is transported back to isolation, or should be kept closed with adequate air exchanges before allowing for subsequent patient care. all the ppes and materials used by the operating team and anaesthesiologists must be removed and sent for disposal. the left-over drugs and plastic sheets must be discarded. the pregnant, elderly and patients with co-morbid conditions have been implicated much more than general healthy population in terms of risk of infection and severity. considerations for all these high-risk populations are similar to those advocated during sars and mers outbreak. the individuals must be vaccinated against influenza and pneumonia causing bacteria to prevent secondary lrtis. [ ] the patients with cardiovascular disorders are advised guideline-directed statins and diuretics to prevent potential risk of acute coronary syndrome and heart failure. other co-morbidities must be managed with respective treatment guidelines aggressively to improve outcome. in pregnant females, there is an additional risk of premature rupture of membranes, preterm birth, low birth weight and fetal distress in case of confirmed infection especially in the third trimester. as a precautionary measure, pregnant females should refrain from unnecessary travel and public transport together with practicing good personal hygiene. hence, any confirmed case coming in pregnant state must be screened for fetal well-being and advised betamethasone therapy for fetal lung maturity if anticipating pre-term delivery. the timing of delivery is entirely dependent on the condition of the mother and the fetus, wherein stable cases can be delivered at term vaginally, while critically ill mothers delivered earliest possible. as no shedding of virus has been found in the amniotic fluid, vaginal delivery can be performed but for early cord clamping and maternal separation for weeks postnatally to prevent direct contact transmission. [ ] till date, no guidelines have been issued regarding the anesthetic management of infected pregnant patients for caesarean section. however,spinal anaesthesia have been reported to be safe in one patient undergoing emergency c-section in wuhan. [ ] there is no advisory issued against breastfeeding, but direct suckling from mother's breast is not advocated. rather expression of mother's milk and palade feeding is suitable. after prompt diagnosis based on aforementioned criterion, case must be reported by the provisional public health authorities to the national body within hours in their own jurisdiction and transferred to negative pressure isolation cabin in the icu. as most of the icus are not equipped with negative and positive pressure regulations in india, an alternative approach is using hepa-carbon-photo-catalysis air purification systems as alternate means of source control. [ ] the financial considerations for current icu models running in india to meet international standards in terms of quality assurance and workforce is humongous which can only be met by public-private partnership in health sector and generous gdp devoted to health. the clinical spectrum of covid- suspected patients can range from mild flu like symptoms to those mimicking community acquired pneumonia. in very severe cases, patients can present as ards (acute respiratory distress syndrome) with refractory hypoxemia requiring mechanical ventilation. the history taking, sampling for detection of all viral, bacterial pathogens involved in upper respiratory tract infection in the form of oropharyngeal or nasopharyngeal swabs and lower respiratory tract by sputum, endotracheal aspirate, or broncho-alveolar lavage must be sent for rt-pcr or nucleic acid detection. [ ] throat swab to be collected for all virological examination should be stored in three-shelled receptacle for avoiding any spillage. more than one specimen is found to yield better results. viral rna has also been found in stools, urine and serum of infected individuals, hence can be used as alternate specimens. [ ] the nasopharyngeal specimen and suction tip specimen must be sent for other bacteriological examination to rule out any secondary infection. decreased lymphocyte count, cd and cd cells along with increased crp, esr, il- and normal pct have been most consistent findings with this viral etiology. [ ] abg analysis, liver, cardiac and kidney functions must be monitored for overall assessment of severity of infection. the radiological findings reported in these cases range from diffuse segmental or sub-segmental ground-glass opacities signifying interstitial oedema seemingly like "paving-stone" with extensive exudation into alveolar cavities leading to patchy areas of consolidation. the recent reports confirm more sensitivity of ct-scan than rt-pcr ( % versus %) for diagnosis of covid infection. [ ] supportive therapy in the form of supplemental oxygen and antipyretics should be immediately started in patients with sari. liberal fluid administration should be avoided for risk of worsening oxygenation and periodic hemodynamic assessment used to guide goal-directed therapy.along with it, adequate nutritional support with balanced proportions of proteins, carbohydrates, vitamins and minerals boosts immunity to fight the infection. empirical antimicrobials must be given within one hour based on the clinical diagnosis, local epidemiology and susceptibility data to cover all likely pathogens causing community acquired pneumonia even if suspected to have covid. [ ] a typical coverage would involve injection ceftriaxone gm i/v bd, azithromycin/levofloxacin mg od and doxycycline mg bd.de-escalation must be practiced after microbiological evidence.neuraminidase inhibitor like oseltemavir can be initiated for influenza when there is local circulation or other risk factors. systemic corticosteroids have controversial role in reducing mortality with viral pneumonia or ards. however, in rapidly progressing severe diseases, they provide symptomatic relief and faster resolution of pulmonary lesions, so advocated by many. [ ] [ ] [ ] a landscape of therapeutic agents are being questioned and tested for use against -cov with priority research on remdesivir and lopinavir/ritonavir + interferon beta. dgca body in india has put a nod on "restricted use" of chloroquine phosphate mg bd, lopinavir/ritonavir ( mg/ mg) for treating the virus. [ , ] the samples must be repeated at least every - days for viral clearance until there are two consecutive negative results hours apart in a clinically recovered patient. recognition of patients in respiratory distress not responsive to oxygen therapy must be swift and anaesthesiologiststrained in endotracheal intubation and all necessary equipment must be kept standby if need arises. post intubation by rsi, lung protective strategies involving use of lower tidal volumes ( - ml/kg predicted body weight), high peep and lower inspiratory pressures (plateau pressure < cmh o) for meeting the ph goal of . - . have been postulated to prevent volutrauma, barotraumas, atelectrauma and biotrauma. [ , ] deep sedation in the form of midazolam, propofol or fentanyl infusions are recommended to curb patient's respiratory drive and prevent dyssynchrony. the few indications of continuous neuromuscular blockade in the setting of severe ards has been agreed upon like ventilator dyssynchrony, inability to achieve target tidal volumes or refractory hypoxemia/hypercapnia. [ ] in fulminating cases, prone ventilation for - hours per day and use of ino(inhaled nitric oxide) for bronchodilatation is recommended, failing which ecmo (extra corporeal membrane oxygenation) is the only modality for survival. it should only be offered in expert centres with a sufficient case volume to maintain expertise and that can apply the ipc measures required for covid patients. along with mechanical ventilation, periodic hemodynamic assessment by static procedures like passive leg raising and dynamic procedures like serial stroke volume measurements, variations in pulse pressure, inferior vena cava size, or stroke volume changes with intrathoracic pressure during mechanical ventilation must be done for guiding fluid therapy and achieving optimal response. in resuscitation of adults with septic shock, ml/kg of isotonic crystalloid like ringer lactate must be administered in the first hours for volume repletion. [ ] if map target is not fulfilled on fluid loading and signs of volume overload appear, discontinuation of fluid administration is advised. vasopressors should be then initiated, norepinephrine being the first-line in adult patients. epinephrine or vasopressin can be added if first line drug fails. all these therapies must be instituted timely to prevent multi-organ dysfunction which carries grave prognosis. [ , ] a term called "protected code blue "had come into existence during sars outbreak which emphasize on the use of paprs rather than n- masks and specialized ppes during resuscitation owing to the dynamic nature of the procedure with high risk of airborne transmission. the need for resuscitation should always be anticipated to allow for preparation of isolation room, disposable resuscitation packages instead of trolley and formation of four members team with designated roles. all the team members should wear ppes checked by infection control coach and then enter the isolation bringing the defibrillator and packages along with. [ ] along with standard code blue protocol, each action should be considered in the lines of risk of aerosol transmission versus benefit to the patient. [ ] future research and perspective beyond all these general measures, research is underway in different phases of completion would soon elaborate on candidate vaccines and therapeutic agents like hydroxychloroquine against covid. presently numerous false alarms are being raised from one city to another and from one country to another but nothing concrete or any definite vaccine has been developed till date. the laws of nature will definitely take their own course but till then human beings will be the worst sufferers. this is neither the first challenge nor the final one which humanshave to face when the natural ecological milieu is disturbed. at present best prophylaxis is conveyed by one sentence being used globally "stay home, stay safe" apart from taking other recommended precautions. financial support and sponsorship nil. characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention serial interval of novel coronavirus (covid- ) infections all information related to novel coronavirus host susceptibility to severe covid- and establishment of a host risk score: findings of cases outside wuhan transmission dynamics and evolutionary history of -ncov coronavirus disease (covid- ) situation report - air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus (sars-cov- ) from a symptomatic patient perioperative care provider's considerations in managing patients with the covid- infections cross-contamination via anesthesia equipment? practical recommendations for critical care and anesthesiology teams caring for novel coronavirus ( -ncov) patients outbreak of a new coronavirus: what anaesthetists should know staff safety during emergency airway management for covid- in hong kong features, evaluation and treatment coronavirus (covid- ) for the zhongnan hospital of wuhan university novel coronavirus management and research team, evidence-based medicine chapter of china international exchange and promotive association for medical and health care (cpam). a rapid advice guideline for the diagnosis and treatment of -novel coronavirus ( -ncov) infected pneumonia (standard version) acc clinical bulletin cardiac implications of novel wuhan coronavirus (covid- ) american college of cardiology (acc) novel corona virus disease (covid- ) in pregnancy: what clinical recommendations to follow? emergency caesarean delivery in a patient with confirmed coronavirus disease under spinal anesthesia a family cluster of pneumonia associated with novel coronavirus indicating person to person transmission: a study of a family cluster correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases care for critically ill patients with covid- clinical management of severe acute respiratory infection when novel coronavirus ( -ncov) infection is suspected: interim guidance use of glucocorticoid in the treatment of severe acute respiratory syndrome cases clinical analysis of cases of outbreak of atypical pneumonia in guangzhou in spring the possibility of using lopinave/litonawe(lpv/r) as treatment of novel coronavirus -ncov pneumonia: a quick systemic review based on earlier coronavirus clinical studies ministry of health & family welfare, directorate general of health services(emr division), government of india. guidelines on clinical management of covid- epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: adescriptive study formal guidelines: management of acute respiratory distress syndrome preparing for the most critically ill patients with covid- : the potential role of extracorporeal membrane oxygenation managing sepsis and septic shock. current guidelines and definitions endothelial biomarkers in human sepsis: pathogenesis and prognosis for pathological findings of covid- associated with acute respiratory distress syndrome mount sinai hospital critical care unit. sars resources. protected code blue isa family benevolent fund" • isa encourages members to join family benevolent fund of indian society of anaesthesiologists (isa-fbf) to help our colleagues' and our own families when they face the testing moments of their life. • become an isafbf member, not for you, but to help our colleague's families by donating rs. /-per year /death. • to become an isafbf member kindly visit our website isafbf.com or contact your city branch/state/president/secretary • contact for details & application forms: dr. sugu varghese there are no conflicts of interest. key: cord- - d p woi authors: pinotti, francesco; di domenico, laura; ortega, ernesto; mancastroppa, marco; pullano, giulia; valdano, eugenio; boëlle, pierre-yves; poletto, chiara; colizza, vittoria title: tracing and analysis of early sars-cov- infections outside china: a modeling study date: - - journal: plos med doi: . /journal.pmed. sha: doc_id: cord_uid: d p woi background: in the early months of , a novel coronavirus disease (covid- ) spread rapidly from china across multiple countries worldwide. as of march , , covid- was officially declared a pandemic by the world health organization. we collected data on covid- cases outside china during the early phase of the pandemic and used them to predict trends in importations and quantify the proportion of undetected imported cases. methods and findings: two hundred and eighty-eight cases have been confirmed out of china from january to february , . we collected and synthesized all available information on these cases from official sources and media. we analyzed importations that were successfully isolated and those leading to onward transmission. we modeled their number over time, in relation to the origin of travel (hubei province, other chinese provinces, other countries) and interventions. we characterized the importation timeline to assess the rapidity of isolation and epidemiologically linked clusters to estimate the rate of detection. we found a rapid exponential growth of importations from hubei, corresponding to a doubling time of . days, combined with a slower growth from the other areas. we predicted a rebound of importations from south east asia in the successive weeks. time from travel to detection has considerably decreased since first importation, from . ± . days on january , , to ± . days on february , . however, we estimated % of detection of imported cases. this study is restricted to the early phase of the pandemic, when china was the only large epicenter and foreign countries had not discovered extensive local transmission yet. missing information in case history was accounted for through modeling and imputation. conclusions: our findings indicate that travel bans and containment strategies adopted in china were effective in reducing the exportation growth rate. however, the risk of importation was estimated to increase again from other sources in south east asia. surveillance and management of traveling cases represented a priority in the early phase of the epidemic. with the majority of imported cases going undetected ( out of ), countries experienced several undetected clusters of chains of local transmissions, fueling silent epidemics in the community. these findings become again critical to prevent second waves, now that countries have reduced their epidemic activity and progressively phase out lockdown. two hundred and eighty-eight cases have been confirmed out of china from january to february , . we collected and synthesized all available information on these cases from official sources and media. we analyzed importations that were successfully isolated and those leading to onward transmission. we modeled their number over time, in relation to the origin of travel (hubei province, other chinese provinces, other countries) and interventions. we characterized the importation timeline to assess the rapidity of isolation and epidemiologically linked clusters to estimate the rate of detection. we found a rapid exponential growth of importations from hubei, corresponding to a doubling time of . days, combined with a slower growth from the other areas. we predicted a rebound of importations from south east asia in the successive weeks. time from travel to detection has considerably decreased since first importation, from . ± . days on january , , to ± . days on february , . however, we estimated % of detection of imported cases. this study is restricted to the early phase of the pandemic, when china was the only large epicenter and foreign countries had not discovered extensive local transmission yet. missing information in case history was accounted for through modeling and imputation. a a a a a our findings indicate that travel bans and containment strategies adopted in china were effective in reducing the exportation growth rate. however, the risk of importation was estimated to increase again from other sources in south east asia. surveillance and management of traveling cases represented a priority in the early phase of the epidemic. with the majority of imported cases going undetected ( out of ), countries experienced several undetected clusters of chains of local transmissions, fueling silent epidemics in the community. these findings become again critical to prevent second waves, now that countries have reduced their epidemic activity and progressively phase out lockdown. why was this study done? after being first identified in china in january , severe acute respiratory syndrome coronavirus (sars-cov- ) reached all countries worldwide within a few months [ ] . massive intervention measures [ ] were implemented by chinese authorities in late january to control the epidemic. countries outside china promptly reinforced border controls and intensified active surveillance to rapidly detect and isolate importations, trace contacts, and isolate suspect cases [ , ] . such a massive response did not prevent countries to face importations of cases and experience extended independent chains of local transmission [ ] [ ] [ ] , ultimately resulting in sustained local spread. the effectiveness of measures aiming at preventing importations and local transmissions critically depends on disease epidemiology and natural history of the infection [ , ] , as well as the volume of importations [ ] . for the case of coronavirus disease , the presence of an incubation period, during which infected individuals carry on their usual activities (including travel), was a major challenge for screening controls at airports [ ] . moreover, mild non-specific symptoms and transmission before the onset of clinical symptoms [ ] [ ] [ ] compromised infection control measures for importations and onward transmissions [ ] . imported cases went undetected and contributed to the global spread of the disease [ ] [ ] [ ] [ ] [ ] [ ] . here we systematically collected and analyzed data on the first covid- confirmed cases outside china, to characterize the international spread of covid- pandemic during its early phase. we show that the detailed information carried by case histories provided early evidence of the covid- specific features that enabled the virus to escape containment efforts and reach pandemic proportion. we analyzed importations that were successfully isolated and those leading to onward transmission, characterizing their case timeline. we developed a statistical model to describe trends in importations up to mid-february and quantified the proportion of undetected imported cases. we collected all international cases confirmed by official public health sources in the period from january to february , . case history was reconstructed by searching the scientific literature, official public health sources, and news . case history included dates of travel and symptom onset, date of covid- confirmation, date of hospital admission, date of case isolation, travel history, epidemiological link with other cases, and hospitalization history. international cases included imported cases, secondary cases out of china, and repatriations. cases from cruises were not considered here. information was extracted by ldd and eo and checked by mm. additional cases in the period from february to february were collected and used to validate the results. the full database, along with the database describing clusters, was made publicly available [ ] . this study is reported as per the strengthening the reporting of observational studies in epidemiology (strobe) guideline. strobe checklist can be found in the supporting information (s strobe checklist). the study did not have a protocol. for imported cases with full information on the timeline of events, we computed the average duration from travel to onset, from travel to hospitalization, and from hospitalization to reporting. we used analysis of variance to compare groups of imported cases that generated or did not generate local transmissions. we extended the analysis to all imported cases combining cases with full and partial information on the timeline. we used the analysis of variance and multiple imputation for missing data. results were combined using rubin's approach [ ] . we modeled the total number of imported cases out of china over time accounting for date of travel, delay in reporting, and source areas. we distinguished between different sources: hubei province (h), the rest of china (c), other countries (o). we modeled imported cases over time as a piecewise exponential function depending on the source and on travel restrictions in place. we assumed a different situation in hubei province and the rest of the world because of the level of awareness in the different phases of the outbreak. the exponential functions are defined as follows: where r pre h is the growth rate of cases coming from hubei, and r pre c ; r o , with r pre c ¼ r o , the growth rates of cases coming from the rest of china and other countries, respectively. travel restrictions were modeled by assuming a discontinuity in the growth rate. for hubei, we assumed the growth rate to change from r pre h to r post h after the travel ban of january , (indicated with t h ); for the rest of china, we assumed an analogous change from r pre c to r post c after january , (t c ), date of first flight cancellations [ ] . no change was considered for the other countries (r o constant over time), as no restrictions of travel were established toward these countries. the scale parameters of the exponential functions (i pre h ; i post h ; i pre c ; i post c ; i o ) were assumed to be different among the sources, to account for different traveling volumes and dates of beginning of importations. we modeled the time τ from importation to detection of a case with a gamma distribution, g t (τ), conditioned to the date of case importation, t. the distribution g t (τ) was assumed to have constant coefficient of variation (sd/mean) achieved by a constant shape parameter and a rate parameter varying smoothly in time to capture change in surveillance efficiency. we used a bayesian framework to fit the model to imported cases by origin, travel date, and confirmation date. cases with partial information (e.g., missing date and/or origin of travel) were included by defining latent variables marginalized out during inference. the model was then used to predict imported cases weeks in the future. all details of the analysis are reported in the supporting information (s text). we analyzed clusters of transmission generated by imported cases (index case(s) in each cluster) to estimate undetected importations. a cluster can be seeded by more than index case, e.g., by infected family members who traveled together. the number of clusters of local transmission was modeled with a multinomial distribution according to the number of index cases and whether these were imported cases. as detailed in the supporting information, the likelihood function was a function of observable quantities: the number of observed clusters with imported index case (x ); the number of observed clusters with more than imported index case (x ); the number of known imported cases causing no onward transmission (ỹ); the number of clusters for which an index case was not identified (z); and a fifth and unobserved quantity, the number of undetected imported cases who did not start onward transmission (w). maximization of the likelihood allowed to estimate w from the records of x , x ,ỹ, z and to compute the expected number of unobserved imported cases. additional details are described in the supporting information (s text). we collected cases, including imported cases, cases involved in local transmissions, repatriations, and case of unknown origin. fifteen cases were classified as both imported and local transmissions, since they contracted the infection outside china and traveled to a different country once infected (es , es , gb , gb , gb , gb , gb , gb , kr , kr , kr , kr , my , th , and th in our database [ ] ). fig summarizes the timeline of imported cases. symptom onset occurred after the travel to the destination country for almost all cases for which date of travel and of onset are available ( out of , %). complete information was available for ( %) imported cases, with quality of information decreasing over time (s text, fig a) . among imported cases with full information, the delay from travel to hospitalization was longer in cases that generated secondary transmissions (mean of ± . days compared with . ± . days, p = . ). overall, the duration from travel to first event (whether symptom onset, or hospitalization for asymptomatic) was also longer, although the difference was not statistically significant ( . ± . days versus . ± . days, p = . ). durations of hospitalization were instead comparable among the groups of cases ( . ± . days versus . ± . days for cases that generated or did not generate secondary transmissions, respectively). including imported cases with missing information through imputation, we found the same trend though smaller in magnitude and not statistically significant (delay from travel to hospitalization . ± . versus . ± . days p = . ; delay from travel to onset . ± . versus . ± . p = . , for cases that generated or did not generate secondary transmissions, respectively). this suggests that importations with missing information may be closer in characteristics to index cases leading to onward transmission. the statistical model predicted a decrease in the average time from travel to detection from . ± . days on january , , to ± . days on february , (fig ) . the model predicted a rapid exponential growth of importations from hubei, with a growth rate r pre h ¼ : ( % ci . - . ), corresponding to a doubling time of . days. in comparison, the exponential growth from other territories (rest of china and countries other than china) was slow, r pre c ¼ r o ¼ : ( % ci . - . ). after the implementation of travel restrictions, a negative growth rate was estimated, signaling a decline in imported cases. table b ). the predicted trend of all imported cases over time is shown in fig , compared with the observed data. reported importations were predicted to remain stationary in the second and third week of february and to rise again because of the effect of transmission clusters outside china. imported cases after february , , were in agreement with model predictions (fig ) up to february . data in the successive days diverged from our predictions as they were linked with early detection of multiple imported cases in the middle east and europe from sustained local transmission in iran and italy. forty-two transmission clusters were identified out of china in the timeframe under study. table summarizes the size and country of each cluster. clusters were grouped according to whether the index case ( ) was a traveling case identified prior to cluster detection, ( ) a traveling case not identified or identified retrospectively once the cluster was observed, or ( ) completely unknown. assuming that clusters of unknown origin were linked to one of the already observed imported cases-or, in other words, not linked to an undetected imported case-led to an estimate of ( % ci - ) undetected imported cases. in this scenario, detected cases would amount to % of all imported cases. assuming instead that all clusters of unknown origin were due to undetected imported cases increased the number of undetected cases to ( % ci - ), i.e., detected cases would correspond to only % of the total. we reviewed here all confirmed cases out of china from january to february , , and gathered detailed information on case history and epidemiological links to ( ) identify salient epidemiological features, ( ) assess the impact of travel restrictions in china on the importations of cases worldwide, and ( ) evaluate the effectiveness of control measures against importations. we found a rapid exponential growth of importations from hubei, up to the closure of wuhan airport preventing further travel of cases, combined with a slower growth from other countries in south east asia. the estimated growth of importation before interventions is compatible with a doubling time of . days. time from travel to detection considerably decreased across time, from . ± . days on january , , to ± . days on february , . however, our estimates indicate that only % of imported cases were detected. this study is restricted to the early phase of the pandemic, when china was the only large epicenter and extensive silent transmission in other countries, such as iran and italy, was not discovered yet. the substantially larger growth of importations from china compared with other territories is related to a stronger epidemic activity in the hubei province, origin of the outbreak, with respect to other affected areas [ ] . this difference is likely an outcome of the containment measures in china [ , , ] and of the increased awareness following their implementation [ ] [ ] [ ] [ ] [ ] , leading to more efficient control. identification, rapid management of cases, and contact tracing were indeed proposed by the world health organization as key to contain the epidemic globally. we found that the travel ban in wuhan produced a sharp decline in importations from the region. combined with local containment measures in the rest of china and other countries in southeast asia, this resulted in a substantial overall reduction of exported cases worldwide. indeed, after peaking at the end of january, registered traveling cases declined to plateau at very low levels. on one side, this shows that strict travel bans may be beneficial by reducing importations to manageable levels and by giving countries the time to prepare and strengthen their surveillance systems in the short term, as signaled by a reduction of the interval from travel date to detection over time. on the other hand, however, the decline likely occurred too late when local spreading was already established in many countries outside the epicenter of traveler(s) identified prior to cluster detection a cde ( ), cfr ( ) , cvn ( ), ckr ( ) ( ), cjp ( ), cjp ( ), csg ( ), csg ( ), csg ( ), csg ( ), csg ( ), csg ( ), csg ( ), cth ( ), cth ( ), cth ( ), cae e a the index case was identified independently from secondary transmissions. b cluster associated with traveling cases. c the index case was either identified retrospectively following case investigation prompted by the detection of secondary cases or the identity was not identified; however, the cluster was linked to a specific location/circumstance visited by chinese travelers (shop, conference, bus tour). the epidemic [ , ] . at the end of february, sustained community transmission in iran and italy led to exportations to several other countries in the world in a timeframe of few days [ , ] . this was facilitated by the fact that no local transmission was reported in these countries, preventing the alert to other countries for them to deploy targeted surveillance and control. at that time, indeed, case definition for the importation of a covid- suspect case was based exclusively on china as the origin of exposure or travel [ , ] , with few exceptions including east asian countries [ , ] . monitoring imported cases is critical in territories with sporadic epidemic activity where the attention is concentrated on preventing the introduction of cases. at the time of writing, countries such as china and australia show limited local transmission and are concentrating strong efforts in border controls to avoid a second epidemic wave, that could be fueled by the large proportion of the population still susceptible to sars-cov- . strict measures, such as massive testing and quarantine of incoming travelers, are being implemented to block silent introductions of cases as it occurred at the beginning of the pandemic. we found that during the first half of february, countries outside china witnessed an increasing reporting of clusters with no known epidemiological link [ , ] . our estimates indicate a detection ability of % to ascertain imported cases in countries outside china. this means that approximately imported cases out of have gone undetected. previous detection rates estimates range from % [ ] to % [ , ] , with variations across countries [ , ] . ascertainment was estimated to be even lower (approximately %) when assessed on repatriations [ ] . here, we excluded from this analysis all repatriation events and cruises with outbreaks, as conditions for detection and identification may be different. underdetection may have been due to several different factors including asymptomatic infections, infections with mild clinical symptoms, health-seeking behavior and declaration of travel history, case definition, and underdiagnosis. a relative long prodrome phase preceding symptom onset (approximately days [ ] ) may have limited the tracing and isolation of contacts. we found, indeed, that traveling cases generating transmissions following importation were, in general, spending more time in the community prior to hospitalization-although this result was diluted upon imputation of missing values-signaling that the period of mild or no symptoms during which the individual carries on a normal life is important for the generation of secondary cases. the epidemic emergency starting with one single critical case on february , , in italy and accumulating hundreds of cases in few days [ ] showed that clusters had gone undetected and epidemiological links with the index case were not found. subsequent developments of the pandemic showed that underdetection of importations was a clear pattern in fueling large-scale epidemics that spread unseen in several countries before the first critical cases were finally detected [ , ] . our study is affected by limitations. underdetection of imported cases during the early phase of the pandemic might have been higher than what estimated here, as our analysis is conditional to the identification of clusters of cases. underdetection may also proceed from the imperfect characteristics of rt-pcr (reverse transcription-polymerase chain reaction) tests used to identify infected cases. some cases tested for sars-cov- could have been falsely negative, and this would affect both analyses presented in the manuscript. this is in line with our conclusion that a large part of imported cases may have been undetected. as the number of detected imported cases grew considerably, the quality of the information on case history degraded over time. we used modeling and imputation to account for the missing information regarding the most recent imported cases. extension of this study beyond the early phase of the pandemic is limited by the strong spatiotemporal heterogeneities currently characterizing the pandemic. our assumptions are based on a context of localized epicenter and border controls targeted against importations from china and countries in south east asia who experienced local transmission during the early phase. as the pandemic regime shifted toward a multiple delocalized epicenter in late february, additional travel bans were implemented worldwide to prevent importations from europe and north america. this led to heavy disruptions of the flight network and a change of focus toward within-country transmission. our findings provide critical epidemiological understanding on the rate of importation and detection of cases during the early phase of the pandemic. though effective in reducing international spread, the travel ban in wuhan did not prevent the seeding of the pandemic in other countries, later becoming new epicenters of the pandemic. the epidemiological features of covid- facilitated the silent spread of the epidemic in seeded countries. the lessons learnt during the early phase of the pandemic become critical again to prevent second waves now that countries have reduced their epidemic activity and progressively phase out lockdown. supporting information s text. statistical methods. modeling traveling cases, delay from arrival to detection and index case detection probability. (pdf) s text. additional results. dataset of international cases, results of likelihood estimation, sensitivity analyses, and analysis of imported clusters. (pdf) s european centre for disease prevention and control. covid- situation update worldwide an investigation of transmission control measures during the first days of the covid- epidemic in china world health organisation. coronavirus disease (covid- ) technical guidance covid- : what is next for public health? the lancet coronavirus disease (covid- ) situation report we are calling on all countries to invest urgently in preparedness we are concerned about the number of cases with no clear epidemiological link estimated effectiveness of symptom and risk screening to prevent the spread of covid- . elife factors that make an infectious disease outbreak controllable chinese center for disease control and prevention. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china. zhonghua liu xing bing xue za zhi transmission of -ncov infection from an asymptomatic contact in germany epidemiology and transmission of covid- in cases and of their close contacts in shenzhen, china: a retrospective cohort study estimates of the severity of coronavirus disease : a model-based analysis early dynamics of transmission and control of covid- : a mathematical modelling study report : relative sensitivity of international surveillance. imperial college london covid- response team covid- -situazione nel mondo using observational data to quantify bias of travellerderived covid- prevalence estimates in wuhan, china. lancet infect dis feasibility of controlling covid- outbreaks by isolation of cases and contacts world health organization. coronavirus disease (covid- ) situation reports european centre for disease prevention and control. covid- situation update worldwide queensland covid- statistics covid- current health situation emirates news agency bayerisches staatsministerium fü r gesundheit und pflege ministère des solidaités et de la santé uk government public health. news and communication italian ministry of health covid- india about coronavirus disease (covid- ) malaysia ministry of health. press releases updates on novel coronavirus disease (covd- ) the russian government public health agency of sweden. covid- cdc [internet updates on covid- local situation ministry of health thailand covid- international cases as of multiple imputation for nonresponse in surveys airlines around the world are suspending flights to china as the coronavirus spreads the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak. science assessing spread risk of wuhan novel coronavirus within and beyond china early epidemiological analysis of the coronavirus disease outbreak based on crowdsourced data: a population-level observational study. lancet digit health risk of mers importation and onward transmission: a systematic review and analysis of cases reported to who public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey survey on the likely behavioural changes of the general public in four european countries during the ebola outbreak: media events track changes in observed reproductive number potential short-term outcome of an uncontrolled covid- epidemic in cryptic transmission of sars-cov- in washington state. medrxiv preliminary estimation of the novel coronavirus disease (covid- ) cases in iran: a modelling analysis based on overseas cases and air travel data covid- : italy confirms deaths as cases spread from north european centre for disease prevention and control. case definition and european surveillance for human infection with noel coronavirus (sars-cov- ) global surveillance for human infection with coronavirus disease (covid- ) covid- : guidance for staff in the transport sector israel bans foreigners coming from east asian countries over virus fears the rate of underascertainment of novel coronavirus ( -ncov) infection: estimation using japanese passengers data on evacuation flights temporal dynamics in viral shedding and transmissibility of covid- european centre for disease prevention and control. threat assessment brief: outbreak of novel coronavirus disease (covid- ): situation in italy key: cord- -rgzmpoxv authors: keeling, matt j; hollingsworth, t. deirdre; read, jonathan m title: the efficacy of contact tracing for the containment of the novel coronavirus (covid- ). date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: rgzmpoxv contact tracing is a central public health response to infectious disease outbreaks, especially in the early stages of an outbreak when specific treatments are limited. importation of novel coronavirus (covid- ) from china and elsewhere into the united kingdom highlights the need to understand the impact of contact tracing as a control measure. using detailed survey information on social encounters coupled to predictive models, we investigate the likely efficacy of the current uk definition of a close contact (within meters for minutes or more) and the distribution of secondary cases that may go untraced. taking recent estimates for covid- transmission, we show that less than in cases will generate any subsequent untraced cases, although this comes at a high logistical burden with an average of . individuals ( th percentiles - ) traced per case. changes to the definition of a close contact can reduce this burden, but with increased risk of untraced cases; we estimate that any definition where close contact requires more than hours of contact is likely to lead to uncontrolled spread. kingdom highlights the need to understand the impact of contact tracing as a control measure. using detailed survey information on social encounters coupled to predictive models, we investigate the likely efficacy of the current uk definition of a close contact (within meters for minutes or more) and the distribution of secondary cases that may go untraced. taking recent estimates for covid- transmission, we show that less than in cases will generate any subsequent untraced cases, although this comes at a high logistical burden with an average of . individuals ( th percentiles - ) traced per case. changes to the definition of a close contact can reduce this burden, but with increased risk of untraced cases; we estimate that any definition where close contact requires more than hours of contact is likely to lead to uncontrolled spread. contact tracing is the main public health response to importations of rare or emerging infectious diseases, and was implemented in the uk during the 'containment stage' of the influenza pandemic (mclean et al ) . in more recent years, contact tracing was also a valuable tool following importation of ebola virus disease into the uk in (crook et al ) and the cases of monkeypox in the uk in (vaughan et al ). in general, contact tracing is a highly effective and robust strategy given sufficient resources. the main advantages are that it can identify potentially infected individuals before severe symptoms emerge, and if conducted sufficiently quickly can prevent onward transmission from the secondary cases. contact tracing has proved hugely successful in the treatment of sexually transmitted infections, where the definition of a contact is relatively straightforward, where infection is often asymptomatic and where the time-scales of transmission are slow (hogben et al , rönn et al . in contrast, the use of contact tracing for novel invading pathogens has received less quantitative consideration, in part due to greater uncertainties over social contact structure (although see ahmed et al , hoang et al . modelling studies have often focused on quantifying the importance of pre-symptomatic and pretracing infectiousness, but are usually based on statistical distributions of contact networks (fraser et al , kwok et al . here we leverage detailed social network data from the uk to model both transmission and the act of tracing, and identify the implications of contact tracing for containment of a novel pathogen, using parameters for the novel coronavirus (covid- ) (read et al , li et al . we characterised contact patterns in the uk using a postal and online cross-sectional survey, which asked participants to report the number of social encounters with unique individuals during a given day, as well as the duration and typical frequency of those encounters (danon et al (danon et al , . in total, , respondents reported more than , encounters -one of the biggest studies of its kind to date. the encounter patterns of this study were in good qualitative agreement with other similar studies of social interactions (mossong et al , isella et al . in this study, the daily encounter data was first extrapolated to generate a pattern of contacts over a day period (replicating random encounters and increasing the total duration associated regular contacts), to act as the basis for transmission and contact tracing simulations. using this extrapolated data, we can classify interactions into those which satisfy the definition of a close contact for the purpose of contact tracing. from our social encounter data we can also distinguish interactions with people who could be later identified and traced, from those with unidentifiable strangers (schematic figure ). we assume that all contact of longer than hour or repeated contacts can be identified and traced, whereas shorter meetings with people for the first time are strangers who are unidentifiable. the second element of the simulation is to determine who gets infected from a source case chosen representatively from the survey respondents. this transmission process is stochastic, accounting for both the time spent with each contact and the infectivity on each day (see appendix). taken together these two predictions allow us to bound the efficacy of contact tracing. one of the most notable features of human social contacts is the huge variability in the number and strength of contacts -which is reflected as variation in both the number of secondary cases and the number of individuals that match the contact-tracing definition (figure ). using preliminary estimates of covid- transmission (average latent period days, average effective infectious period . days, r = . and assuming a simple seir formulation (read et al )) we compute the distribution of epidemiological, social and contact tracing characteristics across the population. extrapolating the data from the social contact survey suggests that the average number of contacts over a day period is , although the distribution is significantly over dispersed (with a median of and around % of individuals having > , total contacts). of these total encounters, an average of contacts ( %) meet the definition of a close-contact (in contact for > minutes, phe ) and of these close-contacts we predict an average of ( %) to be individuals known to the infected case that can be traced. therefore, simply considering social contacts, it is clear that there are very many short duration contacts which do not meet the definition of a close contact, and although unlikely to become infected may pose a risk due to their greater abundance. given that the risk of infection increases with duration of contact, the distribution of cases effectively represents a biased sample of all contacts. as expected, given the model assumptions, the expected number of total secondary cases agrees with the assumed r (mean= . , median= , and th percentiles - ). given that these cases are most likely to be those contacts of the longest duration, we predict that % of cases match the definition of a close contact. however, not all of these contacts will be identifiable; assuming that all repeated contacts and contact of longer than hour can be traced, we predict that % of all cases meet the definition and can be identified. however, because of the extreme heterogeneity in contacts between individuals and the stochastic nature of transmission, we would still expect % of all primary cases to generate at least one secondary case that cannot be identified. aggregating across all individuals and under the optimistic assumption that all the contact tracing can be performed rapidly, we expect contact tracing to reduce the basic reproductive ratio from . to . -enabling the outbreak to be contained (figure ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . rapid and effective contact tracing can therefore be highly effective in the early control of covid- , but places substantial demands on the local public-health authorities. each new case requires an average of individuals to be traced, with . % of cases having more than close traceable contacts (figure ). we therefore consider the implications of changing the definition of a close contact. clearly a more strict definition of a close contact (requiring more contact time) reduces the burden on the health services as fewer contacts need to be traced, but also increases the risk of cases being missed. figure provides a quantitative assessment of changes to the close contact definition. definitions requiring more than four hours of contact, are unlikely to control an outbreak as the expected number of untraced secondly cases is greater than one. this therefore places a strict bound on level of contact tracing required. the added benefit from definitions shorter than hour has relatively little impact on the mean number of untraced cases (figure b), but does reduce the probability that some untraced contacts occur. throughout we have used a value of r that represents a population-level average once the local infection has become established. however, the first invasion into any new population or social setting generally has a larger expected number of secondary cases. the first invader enters a completely susceptible population; moreover all their close contacts (eg family members) are susceptible. in contrast, due to clustering of contacts, most secondary cases will be in a landscape with a depleted number of susceptibles -as close contacts such as family members will already have been exposed to the primary case. this susceptible depletion in the local social network may help to explain the change in r t over time reported for covid- (yang et al ). we therefore consider the impact of different values of the initial reproductive ratio (figure ), which could capture this social aspect, or could represent heterogeneity between individuals in the amount of virus shed, or could inform about innate differences in behaviour between china and the uk. given the strong biasing of transmission towards long-duration contacts, the impact of varying initial reproductive ratio is less extreme than might be expected; it is only for the highest values of initial reproductive ratio simulated (> . ) that contact tracing fails to find more than one case such that infection can escape. mathematical models have an important role to play in preparedness for novel infectious diseases, allowing policy makers to plan for potential public health scenarios before they arise. however, in such scenarios reliable data is often limited, so predictions of long term dynamics are generally associated with wide confidence intervals. in contrast, while short term predictions are subject to greater stochasticity, the distribution of possible behaviours can be readily captured. here we have investigated contact tracing of a close-contact pathogen, using novel coronavirus (covid- ) as the example, and considered the efficacy of contact tracing as a control measure. this work brings together a detailed survey of social encounters together with bespoke mathematical modelling of the transmission and tracing processes. given the huge heterogeneties present in social encounters (both in terms of duration and number) mathematical models are vital to interpret the interplay between a low number of high risk encounters (e.g., household members) and the high number of low-risk less-identifiable encounters (e.g., commuters or retail customers). the uk currently defines a close contact as minutes within meters over two weeks before detection (phe ) . under this definition, there are unlikely to be many untraced secondary cases, although the burden of tracing could be large. relaxing the definition of a contact (such that longer contact durations are needed) lessens this burden but at the greater risk of undetected cases ( figure ) . surprisingly, small changes to the reproductive ratio, within the bounds estimated from early data ( figure ) or even changes to the distribution of infectivity, are predicted to have a relatively modest impact of the success of contact tracing illustrating the robustness of this control measure. our model has addressed the simple and optimistic question of whether contact tracing is sufficient to identify secondary infections. the public health implications of this tracing are more complex, and depend on the relative timing of events and the treatment of identified contacts. for contact tracing to be an effective public health measure requires secondary cases to be discovered before they become infectious; hence the time from the primary case becoming infectious to the tracing of their contacts needs to be shorter than the incubation period. longer time scales would allow tertiary cases to be infected and would snowball the tracing process. in addition, those contacts that are traced either need to be effectively screened for infection and quarantined or otherwise isolated so that they do not pose a risk to others. therefore, while contact tracing has the potential to control covid- (and other close-contact pathogens) the ultimate success relies on the speed and efficacy with which suspect contacts can be contained. with contacts positioned by their total contact duration. here, the definition of a contact is someone with whom the index case encountered for minutes or longer. some contacts will be identifiable (green), while others will be unidentifiable (orange). a definition of contact that is too restrictive and inappropriate for the infection means some encounters may fail to meet the definition yet may be at risk of infection; these excluded contacts could be identifiable (light grey) or unidentifiable (orange). (b) examples of ego-centric networks collected by the survey. the participant (ego) is the blue central triangle; circles represent individual contacts, squares represent groups of contacts (size of group indicated). colours represent social settings of encounters (red=home, cyan=work/school, yellow=travel, pink=other) . larger symbol sizes represent longer contact durations, while a closer proximity to the ego indicates the contact is more frequently encountered. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . figure . impact of different assumptions for the definition of a close-contact. (a) the total number of contacts traced (b) the number of secondary contacts that are not traced (c) the probability that at least one secondary case is not traced. for (a) and (b) the crosses mark the mean value, boxes contain the th percentiles while bars contact the th percentiles, colours correspond to those in figure a - prob at least one untraced case . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . figure . impact of different values for the initial reproduction number of the primary case; changing this does not affect the the number of contacts traced (a) the number of secondary contacts that are not traced (b) the probability that at least one secondary case is not traced. for (a) the crosses mark the mean value, boxes contain the th percentiles while bars contact the th percentiles, colours correspond to those in figure a -distributions are across all respondents to the survey and across stochastic realisations. (based on an seir model with latent period , infectious period . , r = . ). prob at least one untraced case . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review lack of secondary transmission of ebola virus from healthcare worker to contacts social encounter networks: collective properties and disease transmission social encounter networks: characterizing great britain factors that make an infectious disease outbreak controllable a systematic review of social contact surveys to inform transmission models of closecontact infections what's in a crowd? analysis of face-to-face behavioral networks epidemic models of contact tracing: systematic review of transmission studies of severe acute respiratory syndrome and middle east respiratory syndrome. computational and structural biotechnology journal early transmission dynamics in wuhan, china, of novel coronaviurs-infected pneumonia pandemic (h n ) influenza in the uk: clinical and epidemiological findings from the first few hundred (ff ) cases. epidemiology & infection social contacts and mixing patterns relevant to the spread of infectious diseases novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions from the contact tracing data, we extrapolate to the estimate the duration of contact ",$ % , between individual i (the respondent) and individual j (the contact) on day d. we then define a close contact of i as all contacts j:where in the uk, we have defined the total contact time t as minutes over a duration d of two weeks before detection and isolation of individual i (phe ).the probability of transmission to individual j from individual i is then calculated as:where $ is an estimate of the transmission rate from individual i on day d. key: cord- -kojb efv authors: elsoukkary, sarah s.; mostyka, maria; dillard, alicia; berman, diana r.; ma, lucy x.; chadburn, amy; yantiss, rhonda k.; jessurun, jose; seshan, surya v.; borczuk, alain c.; salvatore, steven p. title: autopsy findings in patients with covid- : a single-institution experience date: - - journal: pathobiology doi: . / sha: doc_id: cord_uid: kojb efv background: a novel coronavirus, sars-cov- , was identified in wuhan, china in late . this virus rapidly spread around the world causing disease ranging from minimal symptoms to severe pneumonia, which was termed coronavirus disease (i.e., covid). postmortem examination is a valuable tool for studying the pathobiology of this new infection. methods: we report the clinicopathologic findings from autopsy studies conducted on patients who died of covid- including routine gross and microscopic examination with applicable special and immunohistochemical staining techniques. results: sars-cov- infection was confirmed by nasopharyngeal rt-pcr in cases ( %) and by immunohistochemical staining for sars-cov- spike-protein in the lung in the remaining case ( %). the ethnically diverse cohort consisted of males and females with a mean age of years (range: – ). patients most commonly presented with cough ( [ %]), shortness of breath ( [ %]), and a low-grade fever ( [ %]). thirty-one ( %) of the patients had at least comorbidity (mean = ). twenty-eight patients ( %) had widespread thromboembolic disease, as well as diffuse alveolar damage ( [ %]), diabetic nephropathy ( [ %]) and acute tubular injury. patterns of liver injury were heterogeneous, featuring ( %) with frequent large basophilic structures in sinusoidal endothelium, and increased immunoblast-like cells in lymph nodes. conclusion: this series of autopsies from patients with covid- confirms the observation that the majority of severely affected patients have significant pulmonary pathology. however, many patients also have widespread microscopic thromboses, as well as characteristic findings in the liver and lymph nodes. coronaviruses (covs) are single-stranded, enveloped rna viruses that cause respiratory illnesses among humans and animals [ , ] . these ubiquitous viruses cause variably severe diseases that range from the common cold to severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). several cases of elsoukkary et al. pathobiology doi: . / pneumonia reported in wuhan, china in late led to identification of a novel coronavirus, later designated as sars coronavirus- (sars-cov- ), the etiologic agent of covid- [ , ] . since that time, sars-cov- has spread rapidly across the world causing more than ten million infections and more than half a million deaths by early summer [ ] . coronaviruses gain entry into cells via the angiotensin-converting enzyme (ace ), which is expressed in multiple tissue types [ ] . the virus disproportionately affects the respiratory system and, unlike sars and mers, disproportionately affects older patients with comorbidities such as hypertension, diabetes, obesity, and cardiovascular disease [ ] . the reasons for this pattern of morbidity and mortality are yet to be elucidated. extrapulmonary manifestations of the disease have not yet been fully described. postmortem examination is an invaluable tool in understanding the pathobiology of disease. this study contributes to the growing data on this topic [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the purpose of this study is to describe clinical and pathologic findings in major organ systems of patients who died from sars-cov- infection. written or verbal informed consent was obtained for postmortem examination from the next of kin of patients with confirmed or presumed covid- . cases were confirmed by sars-cov- rt-pcr testing in ( %) patients and by tissuebased immunohistochemical staining for sars-cov- spike protein in case ( %) of a patient who died at home and had not been tested previously, but had symptoms and positive family contacts. clinical information and laboratory data were obtained from the patients' electronic medical records. postmortem examination of the brain was not performed due to potential infectious risk related to extraction. two ( %) examinations were limited to the chest, one ( %) was confined to the right lung only, and one ( %) was limited to lung biopsies. the remaining ( %) cases included examination of all thoracic and abdominal organs. the autopsies were performed from to h (median: ) following death. photographs were taken, and representative sections submitted of all the organs and grossly visible lesions. the lungs were insufflated with formalin prior to sectioning. tissue specimens were fixed in % formalin for at least h prior to processing. microscopic examination of all tissue sections was performed on hematoxylin and eosin-stained slides. immunohistochemical stains were performed on select cases and included cd (clone f , leica ncl-cd - ), cd (clone d , leica ncl-cd ), erg (clone epr , ventana ), cd (clone sp , fisher rm- -s), cd (clone l , leica ncl-cd -l ), and c b- (clone ae , quidel a ). special stains performed on various tissue types included pas, pas with diastase, iron, trichrome, reticulin, gms, afb, brown hopps gram (bhg), and warthin-starry. microscopic examination and interpretation of ancillary stains were performed by pathologists (s.p.s., a.c.b., s.v.s., j.j., a.c.). the study was deemed exempt by the institutional review board. data normally distributed were presented as means and ranges. categorical variables were summarized as counts and percentages. statistical analysis was performed with microsoft excel. patient demographics and clinical information are summarized in table and laboratory findings in table . the ratio of males to females was . : , with an average age of years old (range = - years). thirty-seven percent of the patients were white, % were hispanic, % were asian, and % were black. most ( %) were admitted to the hospital from home or died at home. twenty-two percent were from a nursing home, and % were homeless. fifty-three percent of the patients had no history of smoking, % were former smokers (mean pack-year = , range = - ), and for ( %) it was unknown. none of the patients were known to be current smokers. no correlation was seen for patients' blood types. the average oxygen saturation (spo ) upon admission was % (range = - %), with only % of patients having an spo > %. the average temperature (t) of patients upon admission was . ° c (range = - ° c), with % of patients having a t > . ° c. most ( %) patients presented with shortness of breath and/or cough ( %); only had anosmia ( %), and ( %) had diarrhea recorded. a substantial number of patients had multiple comorbidities, particularly diabetes mellitus type ( %), hypertension ( %), obesity ( %), and coronary artery disease ( %). fifty-three percent of admitted patients were transferred to the intensive care unit, and the average length of stay was days (range = - days). fifteen ( %) patients required intubation, which continued for a mean of days, % were maintained with bilevel positive airway pressure (bipap), and % required a non-rebreather mask. treatment included a combination of hydroxychloroquine ( , %), antibiotics ( , %), anticoagu-pathobiology doi: . / lation ( , %) and/or corticosteroids ( , %). the clinical course was complicated by acute kidney injury (aki) in ( %) patients, with ( %) requiring renal replacement therapy. five ( %) patients developed liver failure. the average overall duration of disease until time of death was days (range: - ). twenty-seven ( %) of patients had macroscopic and/ or microscopic thrombi at autopsy (table ) . twenty-two ( %) had elevated d-dimers (range: - , ng/ml). coagulation factors were also prolonged, with a mean prothrombin time of s and a mean activated partial data are presented as n (%) and mean (range) unless otherwise stated. spo , oxygen saturation; na, not available; icu, intensive care unit; nrb, non-rebreather mask; bipap, bilevel positive airway pressure; ace, angiotensin converting enzyme; arb, angiotensin receptor blocker. a intubated on admission or information not available. b comorbidities included: hypertension, hyperlipidemia, diabetes, obesity, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, end stage renal disease, stroke, dementia, and cancer. elsoukkary et al. thromboplastin time of . s. thrombi were most frequently in respiratory (n = , %) and cardiovascular (n = , %) systems ( fig. ). macroscopic pulmonary thrombi were detected in ( %) cases. small intramyocardial vessels contained microthrombi in ( %) and contained fibrin, platelets, or a mixture of both (fig. ). thrombi were also observed in the prostatic venous plexus, trachea, lymph nodes, and kidney. several organs showed concurrent parenchymal infarction, including one case of acute myocardial infarction (mi). the clinicopathologic features of the respiratory system are summarized in table . the average combined lung weight was , g (range = , - g; reference range = - , g). most patients (n = , %) had both exudative and proliferative diffuse alveolar damage (dad). of those patients, ( %) were intubated during their hospital course. three ( %) patients each showed only acute/exudative dad or organizing/proliferative dad. all patients with exudative dad were never intubated and had a mean duration of disease of days (range = - ), while of the patients with proliferative dad were intubated during their admission and had a mean duration of disease of days ( - days). sixteen ( %) showed the presence of alveolar neutrophils and ( %) showed evidence of organizing pneumonia. all cases had some degree of type ii pneumocyte hyperplasia with reactive atypia and bronchial squamous metaplasia. data are presented as n (%) or mean (range). wbc, white blood cells; pt, prothrombin time; ptt, partial thromboplastin time. clinicopathologic findings of cases in which examination of the heart was performed are summarized in table . hypertension was the most common cardiac comorbidity, present in % of cases (n = ). clinically diagnosed coronary artery disease and chronic heart failure were present in % and % of patients, respectively. twelve patients ( %) had two or more concurrent cardiac comorbidities. the majority of patients had elevated troponin (i) (n = , %) which averaged . ng/ml. at autopsy, most patients (n = , %) were found to have mild cardiomegaly, average heart weight (g) among women and (g) among men. histologic examination showed myocyte hypertrophy in cases ( %) and re- mote myocardial injury in patients ( %) as patchy interstitial fibrosis. survey of the coronary tree showed at least moderate atherosclerosis (> %) in patients ( %). acute myocardial ischemia was observed in a minority of patients (n = , %). of these patients, had acute mi due to thrombosis or hemorrhage into an atherosclerotic plaque of a major coronary artery along with concurrent covid- . one patient had persistent lymphocytic myocarditis, diagnosed days prior to the onset of respiratory symptoms and prior to the diagnosis of covid- . no other myocarditis or cardiac amyloid was seen in our cohort. histopathologic abnormalities were observed in the livers of ( %) patients. steatosis was present in ( %) cases and represented the most common finding and could be explained by concomitant obesity, diabetes mellitus, and/or hyperlipidemia. nonspecific portalbased mild lymphocytic inflammation was present in ( %) cases. three cases showed evidence of chronic liver disease with bridging fibrosis and/or cirrhosis of unclear etiology. one patient had a poorly preserved intraductal trematode consistent with fasciola hepatica. large peculiar basophilic structures were found in the sinusoids of ( %) cases (fig. ) . these structures were surrounded by scant or no cytoplasm and were thought to represent nuclear remnants of altered cells. attempts to define their nature by immunohistochemistry using markers for megakaryocytes (cd ), histiocytes (cd ), and endothelial cells (erg) were unsuccessful. sections of the spleen and/or lymph nodes were examined from all cases. due to safety concerns, bone marrow was not obtained except in cases. lymph nodes submitted included hilar, mediastinal, paraesophageal, and paraaortic. microscopic examination showed variable degrees of autolysis in the spleen and lymph node tissues. thus, only a select group of lymph nodes ( patients) and spleens ( patients) from autopsies performed - days after death were reviewed. even with this restriction, the spleens showed significant autolysis, precluding accurate histologic evaluation. the lymph nodes demonstrated relatively preserved architecture, except for one patient with splenic marginal zone lymphoma (smzl), with morphologically intact lymphoid follicles containing centrally located germinal centers ( cases), paracortical areas, and patent sinuses (fig. a) . this was confirmed by immu-nostaining with cd highlighting the intact follicles with central cd -positive germinal center cells outlined by cd -positive t cells (fig. b-d) . the subcapsular and intraparenchymal sinuses were frequently expanded and often contained a variable number of larger transformed cells with prominent nucleoli and amphophilic cytoplasm (fig. e-f ), which were variably cd positive by immunostaining (fig. e inset) . these transformed cells, some of which were immunoblast-like in appearance, were also seen scattered, next to vascular channels or sinuses and in loose groups in the paracortical region. in at least cases, the loose groups of these larger cells were associated with apoptotic debris. these larger cells were present in all cases including the case of smzl. except for the scattered larger transformed cells, the cells in the paracortical areas were largely small lymphocytes or plasma cells. in some cases, the plasma cells were the prominent cell population. while most cases showed predominately cd -positive t cells in the paracortical areas by immunostaining, a few cases had more cd -positive b cells than usual. in addition, many lymph nodes showed prominent vascular congestion. the cases where germinal centers were not identified were from patients who had smzl ( ), were under treatment for acute myeloid leukemia ( ), or had significant fibrosis associated with anthracotic pigment ( ). how- ever, the latter cases showed otherwise normal architectural features including sinuses. clinical parameters for comorbidities and renal function tests on all patients are summarized in table . diabetes and hypertension were frequently present, and patients had subsequent associated chronic kidney disease. two patients had esrd at the time of autopsy, while had aki corresponding to the onset of viral infection. five ( %) required new renal replacement therapy. presenting creatinine ranged from . to . mg/dl (mean . mg/ dl). proteinuria was present in patients with + to + intensity (of with urinalysis performed), but no quantification was undertaken in any patients in this cohort. histologic examination was available for autopsies. the pathology correlated with their underlying comor-bidities, including diabetic nephropathy in patients ( %), extensive tubulointerstitial scarring (> %) in % of cases, with moderate to severe vascular sclerosis in % of cases (fig. ) . tubular autolysis precluded assessment of acute tubular injury in the majority of cases, which was likely the main etiology of aki on chronic kidney disease. the peritubular capillaries were dilated in nearly all cases with inflammatory margination frequently identified. rare other pathologic diagnoses were also seen ( table ; fig. ). two cases showed thrombotic microangiopathy of the glomeruli with acute thrombi focally present within the glomerular hilar vessels and/or peripheral capillary loops leading to endothelial swelling and luminal closure. evidence of complement-mediated endothelial injury was identified by c b- staining in up to % of cases, including the with frank thrombi (table ; fig. e ). in this study, we described the unique and multisystem clinical and pathologic findings in autopsies of patients who died from the novel coronavirus, sars-cov- . clinically, our patient cohort was older with multiple underlying comorbidities, similar to those described in other publications [ , ] . the majority of patients were male, on average in their late s, and had an average of comorbidities, most commonly hypertension, coronary artery disease, obesity, and diabetes. more than half of the patients were caucasian or hispanic, but in distinction to studies from the chinese and european literature, ours was a diverse patient population with deaths seen across the ethnic spectrum [ ] [ ] [ ] . the most common presenting symptoms were shortness of breath, cough, and a low-grade fever. on histologic examination, we observed findings secondary to the patients' preexisting conditions in the heart, lungs, liver, and kidneys, as well as changes secondary to sars-cov- infection such as various stages of dad and multiple thromboemboli in large and small vessels in multiple organs. as previously reported, lung injury was the main cause of death in our patients [ , ] . the virus is believed to infect the epithelial lining cells of the respiratory tract using the ace enzyme as a viral receptor leading to dad, edema, and a marked increase in lung weights at autopsy. notably, the lung pathology was heterogeneous, corresponding to the radiographic findings of patchy ground glass opacifications, and on histology the pulmonary parenchyma demonstrated a range of findings from patchy exudative hyaline membrane disease to organizing pneu- monia, while some areas were histologically normal. these features are most likely indicative of the spread of virus in the lung, but future studies are needed to investigate this in greater detail. multiple authors have reported clinical evidence of cardiac injury seen in the form of elevated troponins, and pathologically concurrent mi and myocarditis [ , , [ ] [ ] [ ] [ ] . similar to other studies, the majority of our patients had elevated troponin (i) [ ] . the most significant histologic finding in our cohort was the presence of intramyocardial thrombi, identified in % of patients. currently, it is known that endothelial injury and thrombosis are seen in patients with sars-cov- infection as a part of microangiopathy [ ] . thrombi are most frequently seen in the lungs [ , ] . however, few reports address microthrombi in the myocardium, which we found in these patients when evaluating random heart sections. we believe that sars-cov- -infected patients have a propensity to develop microthrombi in the myocardial vessels which correspond to microthrombi also seen in other organs. microthrombi are not typically seen in the microcirculation of the heart in conditions other than thrombotic thrombocytopenic purpura and hemolytic uremic syndrome [ , ] . while frank myocardial ischemia was not frequently present, except in case with well-documented mi, the elevated troponins and clinical myocar-dial dysfunction may be due to small-vessel thromboses in addition to general hypoxia. sars-cov- has also been reported to cause myocarditis, mostly reported based on imaging and electrocardiogram changes [ , , ] . as more studies emerge, the link of covid- and viral-associated myocarditis does not appear to have a major role, if any, in the cardiac injury in these patients. in our series, one patient had lymphocytic myocarditis at autopsy. however, the patient had underlying congenital heart disease requiring multiple surgeries, and the myocarditis was temporally distant, arising earlier than viral symptoms. therefore, we believe it was unrelated to the viral infection. no other patient had any inflammatory infiltrates in the heart. no viral inclusion was observed in any cases. liver injury, in the form of moderately elevated aminotransferases, has been reported in up to % of patients [ ] . rare patients have transaminases rise above a thousand [ ] . in contrast to the cardiovascular pathology, few patients had preexisting chronic disease, with the exception of steatosis, similar to other studies [ , [ ] [ ] [ ] . close to a half of our cohort exhibited moderately elevated aspartate and alanine aminotransferase enzymes, and a minority of patients (n = ) developed acute liver failure of unclear etiology. the presence of ace- which is integral for viral entry into the cells is present more on chol- angiocytes compared to hepatocytes; however, no significant elevation in bilirubin or histologic evidence of ductular injury was seen, similar to the study by fan et al. [ ] . nuclear material of sars-cov has been detected in the liver by rt-pcr [ , ] ; however, no specific histologic correlate of direct hepatocyte injury by sars-cov has been reported with the exception of nonspecific findings of acidophil bodies, ballooning hepatocytes, and atypical mitoses. drug-mediated liver damage may confound the interpretation of hepatocyte injury in these patients particularly when treated with lopinovir and ritonavir for covid- [ ] . however, our patients have been treated predominately with hydroxychloroquine which is not known to cause direct liver injury [ ] . a number of mechanisms have been proposed to induce clinically observed liver damage in covid patients such as locoregional viral replication, cytokine storm, hypoxia, hypovolemia, and acute on chronic injury of preexisting conditions [ , ] . we have observed peculiar previously unreported basophilic structures of unknown origin, in % of patients. these structures are singly scattered and located predominately in sinusoids. while immunohistochemical staining failed to prove their identity as macrophage, megakaryocytic, or endothelial derived structures, there is a possibility that ihc staining was compromised on this autolyzed autopsy material. as one of these patients had blue-green crystals in circulating monocytes and neutrophils premortem, which have been ascribed to liver injury in the literature, it is possible that these structures are related [ ] . by further identification and study of these structures, hopefully full characterization will be possible. the renal manifestations of aki in these patients are mostly due to acute tubular injury in addition to chronic diseases from the patients' underlying conditions, particularly diabetes and hypertension, confirming that seen in prior studies [ , ] . acute tubular injury may be related to tubular ischemia alone such as hemodynamic changes or could be further exacerbated by direct viral infection, cytokine mediated injury, or drug-related tubular toxicity. considerable renovascular disease is present with moderate-to-severe sclerosis in % of cases, atheroemboli, papillary necrosis, and cases of glomerular fibrin thrombi also detected. the latter corresponding to patients with more widespread multiorgan thromboses, but overall the majority ( %) had evidence of complement-mediated endothelial injury, by c b- staining, potentially indicating a role of viral-associated endothelial pathology. although the primary target of coronaviruses is the respiratory system, coronaviruses are known to cause dis-seminated infection [ ] . one of unusual sites is the hematopoietic system. clinically patients have lymphopenia and mild thrombocytopenia, as seen in this study. previously reported lymphocyte depletion in the lymph nodes and absent germinal centers have not been observed in this cohort [ ] . we have seen preservation of lymph node architecture with addition of sinus dilatation and congestion, similar to that reported by menter et al. [ ] . it is unclear if viral proteins are present within the lymph nodes and therefore whether morphologic changes in the lymph nodes are a direct consequence of viral replication or a nonspecific change to a viral infection. overall, the autopsies show patterns of injury, chronic and acute. the patients had significant underlying comorbidities, and the more chronic pathologic changes reflect that, including the chronic kidney disease namely diabetic nephropathy and vascular sclerosis, the cardiac hypertrophy, patchy cardiac fibrosis, and coronary artery disease, as well as the hepatic steatosis and nonspecific fibrosing changes. on top of those, there are acute changes either directly due to viral infection or associated with the recent infection which include the pulmonary dad, widespread microscopic thrombi and associated organ infarcts, reactive lymph node changes with immunoblastic-type cells, atypical hepatic sinusoidal concretions/ cells, renal tma, and acute tubular injury in the kidneys. the autopsies all came from a -month period of time when the treatment the patients received was largely antibiotics plus or minus hydroxychloroquine in % of these cases. as the microthrombi became a more regarded complication, anticoagulation was also utilized, also in % (n = ) of the cases. however, of those , still were found to have thrombi in the lungs at autopsy and of the without pulmonary thrombi, had other organ involvement bringing the total to of patients. in comparison, of the patients who were not anti-coagulated also showed thrombi. steroids were not frequently utilized and only given to patients, for days each, and days prior to their death. larger studies are needed to further investigate the impact of anticoagulation and immunosuppression in this disease. in conclusion, this autopsy series of ethnically diverse patients with sars-cov- infection from a single nyc autopsy service shows a multisystemic pathology which leads to death typically in those with comorbidities. while the lung findings are most significant for the majority of those infected, other organ systems are frequently involved including with widespread microscopic thromboses in numerous organs, as well as liver, kidney, and lymph node pathology. autopsy findings in doi: . / these most severely affected patients can serve as a valuable source of information in studying this new disease process. the epidemiology and clinical information about covid- covid- ): a review of clinical features clinical and immunological features of severe and moderate coronavirus disease clinical characteristics of deceased patients with coronavirus disease : retrospective study who. coronavirus disease (covid- ) situation report - tissue distribution of ace protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis covid- autopsies pulmonary arterial thrombosis in covid- with fatal outcome : results from a prospective, single-center pulmonary pathology of early-phase novel coronavirus (covid- ) pneumonia in two patients with lung cancer dying with sars-cov- infection-an autopsy study of the first consecutive postmortem swabs in the sars-cov- pandemic: report on complete clinical autopsy cases ultrastructural evidence for direct renal infection with sars-cov- sars-cov- infection in conjunctival tissue -authors' reply in situ detection of sars-cov- in lungs and airways of patients with covid- postmortem examination of patients with covid- molecular detection of sars-cov- infection in ffpe samples and histopathologic findings in fatal sars-cov- cases sars-cov- -related deaths in routine forensic autopsy practice: histopathological patterns postmortem examination of covid- patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction autopsy findings and venous thromboembolism in patients with covid- : a prospective cohort study endorsed by the isth, natf, esvm, and the iua, supported by the esc working group on pulmonary circulation and right ventricular function. covid- and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: jacc state-of-the-art review fatal eosinophilic myocarditis in a healthy -year-old male with severe acute respiratory syndrome coronavirus (sars-cov- c) myocarditis in a patient with covid- : a cause of raised troponin and ecg changes clinical predictors of mortality due to cov-id- based on an analysis of data of patients from wuhan, china. intensive care med pulmonary vascular endothelialitis, thrombosis, and angiogenesis in covid- thrombotic thrombocytopenic purpura. nat rev dis primers cardiac implications of thrombotic thrombocytopenic purpura coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin liver injury in co-vid- : management and challenges liver injury during highly pathogenic human coronavirus infections coronavirus disease and prevalence of chronic liver disease: a meta-analysis clinical features of covid- -related liver functional abnormality fatal severe acute respiratory syndrome is associated with multiorgan involvement by coronavirus covid- : gastrointestinal manifestations and potential fecal-oral transmission bethesda: national institute of diabetes and digestive and kidney diseases characteristics and mechanism of liver injury in coronavirus disease clinical significance of blue-green neutrophil and monocyte cytoplasmic inclusions in sars-cov- positive critically ill patients the authors wish to acknowledge nector garcia, alisa ramineni, dr. amelia baxter-stoltzfus, dr. mona farahi, dr. william towne, dr. kartik viswanathan, dr. elizabeth crowe, and dr. paul barone for their assistance in performing the autopsies. the study was exempt from institutional review board approval as it did not meet criteria for living human research; however, informed consent was obtained from the next of kin for all patients. the authors have no conflicts of interest to declare. none. key: cord- -k t brjy authors: ren, xiang; li, yu; yang, xiaokun; li, zhili; cui, jinzhao; zhu, aiqin; zhao, hongting; yu, jianxing; nie, taoran; ren, minrui; dong, shuaibing; cheng, ying; chen, qiulan; chang, zhaorui; sun, junling; wang, liping; feng, luzhao; gao, george f.; feng, zijian; li, zhongjie title: evidence for pre‐symptomatic transmission of coronavirus disease (covid‐ ) in china date: - - journal: influenza other respir viruses doi: . /irv. sha: doc_id: cord_uid: k t brjy background: between mid‐january and early february, provinces of mainland china outside the epicentre in hubei province were on high alert for importations and transmission of covid‐ . many properties of covid‐ infection and transmission were still not yet established. methods: we collated and analysed data on of the earliest covid‐ cases detected outside hubei province to make inferences about transmission dynamics and severity of infection. we analysed clusters to make inferences on serial interval and potential role of pre‐symptomatic transmission. results: we estimated an epidemic doubling time of . days ( % confidence interval (ci): . , . ) and a median incubation period of . days ( % ci: . , . ). we estimated a serial interval distribution with mean . days ( % ci: . , . ) and standard deviation . days, and effective reproductive number was . ( % ci: . , . ). we estimated that / ( %) of transmission events were likely to have occurred prior to symptoms onset in primary cases. secondary cases in clusters had less severe illness on average than cluster primary cases. conclusions: the majority of transmissions are occurring around illness onset in an infected person, and pre‐symptomatic transmission does play a role. detection of milder infections among the secondary cases may be more reflective of true disease severity. a novel coronavirus named "severe acute respiratory syndrome coronavirus " (sars-cov- ) was first identified in january as the pathogen responsible for a cluster of cases of atypical pneumonia in wuhan, a large city located in hubei province in central china. , genetic analysis of the virus indicates that it originated from a bat coronavirus. sars-cov- is considered distinct from sars-cov or mers-cov, and coronavirus disease caused by it has rapidly become a global health concern. incidence of infections slowly increased through january with a reproductive number estimated to be in the range . - . . [ ] [ ] [ ] [ ] starting in mid-january , covid- cases began to be identified in other cities in china and also in other countries. , a number of studies suggested the probable phenomenon of covid- transmissions during incubation period, [ ] [ ] [ ] these studies used cluster cases in limited number of families for analysis, and the relative frequency of pre-symptomatic transmission was not quantified. moreover, there was an analysis on publicly available data indicating the existence of negative serial intervals, also implying pre-symptomatic transmission. here, we retrospectively analyse data on cases identified outside of hubei province through the chinese public health event surveillance system at the early stage of transmission in china, in order to provide insights on the transmission dynamics of covid- . data were extracted from the epidemiological reports of the chinese public health event surveillance system, through which the first confirmed case or potential outbreaks leading to clusters of suspected cases for each county were required to be investigated and reported. the extracted variables included demographic data, possible exposure and travel history, and clinical data using a structured form. the events reported by january were included for data extraction. for events by january , which was the date of "locking down" wuhan city, all events ( cases) in the system were extracted, and we used these data to construct an epidemic curve and estimate the incubation period distribution. of the events ( cases) reported between january and january , we focused on those events which included probable human-to-human transmission or epidemiologically linked cases, so that we could capture a larger number of these clusters for analyses of serial intervals, transmission events and comparative severity between primary cases and secondary cases. all cases included in our analyses were laboratory-confirmed cases, and the case definitions followed we drew the epidemic curve by illness onset for cases who reported that they had been in wuhan in the days of preceding onset, and a separate epidemic curve for the other cases. cases with onset dates closed to the end of epidemic curve may not be reported due to delays in seeking medical attention and consequent delays in laboratory testing. to allow for onset-to-reporting delays, we used the nowcasting approach described by van de kassteele et al to jointly estimate the augmented case number on the most recent dates and the onset-to-reporting distribution. based on augmented epidemic curves, then we fitted exponential growth models to obtain estimates of the growth rate and doubling time. we examine the characteristics of confirmed cases and compared the demographics, onset symptoms and results of some clinical tests between confirmed sporadic and cluster primary cases and cluster secondary cases. we also obtained information on secondary cases that had not been to wuhan but had close contact with another case that had been to wuhan and were presumed to be infected by that particular case. in these pairs of primary and secondary cases, we fitted a normal distribution to the serial intervals between illness onset dates, allowing for negative and zero serial intervals, and correcting for growth rates in the early stage of an epidemic. specifically, the parameters of the fitted normal distribution were corrected to normal (µ′,σ) where µ′ = µ + σ ρ for the epidemic growth rate r estimated below (personal communication, neil ferguson). because information was available on the periods during which each secondary case had been exposed to their presumptive infector, we were able to identify cases where exposure is likely to have occurred before or after illness onset in the primary case infector. when the exposure window overlapped the onset date, we used our fitted incubation period distribution to resample infection times at random, excluding any that fell outside the exposure window, and counted the proportion of resampled times that fell before symptom onset in the infector. we collected detailed information on confirmed cases, including and reporting that they had or had not, respectively, been in wuhan in the past days. the demographics of the and cases were very similar (data not shown). the median age was f i g u r e panel a: occurrence by date of illness onset of cases identified outside of hubei province in persons with a history of travel from wuhan in the d prior to onset. panel b: occurrence by date of illness onset of cases identified outside of hubei province in persons without a history of travel from wuhan in the d prior to onset. panel c: augmented occurrence (yellow bars) by date of illness onset of cases identified outside of hubei province in persons with a history of travel from wuhan in the d prior to onset with back filled cases considering delays between illness onset and seeking care and being tested (range - ) and ( %) were male. only three ( %) of the cases who had visited wuhan also reported visiting the huanan seafood wholesale market. figure shows the epidemic curve by illness onset of the cases in persons that had been to wuhan compared to cases in other persons that were presumed to represent onwards transmission. we used data augmentation to correct for reporting delays in cases with recent onset ( figure c ) and estimated that the growth rate was . per day ( % ci: . , . ), and the doubling time was . days ( % ci: . , . ). in this analysis, the mean onset to reporting delay was estimated to be . days ( % ci: . , . ). we obtained data on exposure windows for cases in individuals that had been in wuhan, by assuming that they had been infected while they were in wuhan. we fitted a lognormal distribution to the data on exposure periods and onset dates, correcting for epidemic growth, and estimated that the incubation period had mean . ( %) occurred in those who had a meal together, ( %) were colleagues working together, ( %) were those who took the same vehicle, and ( %) occurred among neighbours. the identified observations of transmission events were used for estimation of the serial interval ( figure b ). we fitted a normal distribution to these data, with allowing negative serial intervals and correcting for epidemic growth, and estimated that the serial interval distribution had mean . days ( % ci: . , . ) and standard deviation . days ( figure b ). in detailed investigations of contact patterns, we obtained information on the period when the secondary infection could have occurred, and related this to the illness onset date of the infector. figure shows that of pairs identified, pre-symptomatic transmission occurred in pairs, post-symptomatic transmission occurred in pairs, and in the remaining pairs, transmission could have occurred either before or after the corresponding infector's illness onset date. in these pairs, we used monte carlo simulations based on the incubation period distribution described above to estimate that / of transmission events had greater than % chance to be pre-symptomatic transmissions. thus, in total we infer that / ( %) of the observed transmission events were likely or very likely to have occurred prior to the onset of symptoms in the infector. we examined demographic and clinical characteristics of all the confirmed sporadic and clusters cases ( table ) . age distributions were similar between the two groups of patients, while less male cases were identified in cluster secondary cases ( % vs %). cluster primary and sporadic cases were generally more severe, with % and % in severe and critical conditions, respectively, compared with % and % in cluster secondary cases. nearly all the primary and sporadic cases ( %) had a radiologic indication of pneumonia, compared with % in the secondary cases. among cluster secondary cases, % had been classified as mild cases, while % ( / ) of the cluster primary and sporadic cases were mild. the primary and sporadic cases showed largely similar onset symptoms as the secondary cases. fever is the most common symptom, followed by headache, fatigue, dry cough and myalgia. generally higher proportions of the cluster primary cases and sporadic cases reported an onset of the symptoms than cluster secondary cases (table ). in addition to systemic and respiratory presentations, a small proportion of the cases also reported gastrointestinal symptoms, including vomiting and diarrhoea. in this study, we report estimates of the transmission dynamics of covid- based on cases identified outside of hubei province. importantly, we examine quantitative evidence for pre-symptomatic infectiousness, a feature which complicates control strategies. we transmission events used to infer the occurrence of pre-symptomatic transmission. dots indicate the dates of onset of primary and secondary cases, and the shaded area in each row indicates the period of exposure of the secondary case to the primary case during which the secondary infection is thought to have occurred. brackets indicate the exposure window when the primary case was thought to have been infected. data were resolved to the nearest day, and so transmission windows are plotted from the start of the first date to the end of the last date, onset dates are plotted in the middle of the corresponding day, and if the secondary onset date is the same as the primary onset date, then the former is offset slightly so that both can be seen note: for patients having clinical test results of both lymphocyte count and proportion, a normal lymphocyte count refers to both the lymphocyte count within the range of - × /l and the lymphocyte proportion to be %- %. patients with either lymphoycyte count or lymphocyte proportion lower or higher than the normal range will be classified as "decreased" or "increased," respectively. a category of lymphocyte count is determined by both the count and proportion of lymphocyte (the proportion is derived as lymphocyte count divided by white blood cell count) in the blood test. demonstrate that the phenomenon of pre-symptomatic transmission is not uncommon, having occurred in a minimum of / transmission events ( figure ). using statistical inference based on our estimated incubation period distribution, we estimated that pre-symptomatic transmission was likely to have occurred in up to % of the transmission events in our data set. this observation should be interpreted in the context of isolation of some cases after illness onset, reducing the amount of post-symptomatic transmission that might otherwise have occurred. this also implies that social distancing measures may be some of the most important strategies to reduce transmissibility, for example closing schools and encouraging, or facilitating working at home, in addition to control of onwards transmission by sequestering symptomatic persons at home or in isolation facilities. our finding was consistent with other reports that the serial interval distribution was similar to, or much lower than the incubation period distribution, , - consistent with the occurrence of pre-symptomatic transmission in case reports. [ ] [ ] [ ] [ ] [ ] pre-symptomatic infectiousness is generally not thought to occur for most respiratory viruses, but measles is a well-known example of a respiratory infection that can be spread before symptom onset, and viral shedding during the incubation period has also been reported for influenza. viral shedding has been reported during the incubation period for covid- , and there were also asymptomatic cases for covid- across all age groups, in varying proportions depending on the intensity of surveillance and testing. , in conducting investigations of clusters of cases, it is often found that secondary cases have on average milder illnesses than primary cases; for example, this was noted for middle east respiratory syndrome coronavirus infections. here, we found that secondary cases were more likely to have milder disease (table ) , which would be consistent with the existence of some milder covid- infections, which were not laboratory confirmed. the cluster investigations that we report here are not likely to represent the full spectrum of mild infections, and better information would be provided by prospective studies of close contacts with repeated collection of respiratory swabs and sera. our estimates of the growth rate of infections in wuhan in early january of around . per day ( % ci: . , . ) are very consistent with previous reports. , our estimate of the effective reproductive number in wuhan is now slightly lower than the previous estimate of r and some other estimates of r - but that is because of the shorter serial interval. we included a limited number of cases in other cities in china that were detected in persons that had not been to wuhan ( figure b ), but the sample size was insufficient at the time of analysis to determine whether there has been sustained transmission in any other cities. the incubation period averaged . days and up to . days in % of infections (figure a) , which is important for specifying quarantine periods and also for understanding transmission dynamics. the city of wuhan was put under lockdown on january , and other nearby cities were also locked down on the following days. this stopped exportation of infections to other chinese cities, and the effect of this intervention has become more apparent in early february, given the delays that occur between infection, illness onset, admission to hospital and then laboratory testing. we restricted the study participants to covid- analysis were also subject to ascertainment of symptom onset date, which was self-reported by the patient and could be less reliable especially at the early stage of symptom presentation. in conclusion, our analysis showed evidence indicative of pre-symptomatic transmission of covid- . quarantine of exposed persons having close contact with infected cases before symptom onset could reduce the risk of further transmission. we gratefully thank benjamin j. cowling, peng wu, jessica y. wong, yiu chung lau, tim k. tsang from school of public health, university of hong kong for their guidance and support on study design, data analysis and interpretation. we appreciate the staff members of the county-, city-and province-level centers for disease control and prevention of china for their fieldwork on case investigation, data collection and validation. clinical features of patients infected with novel coronavirus in wuhan a novel coronavirus from patients with pneumonia in china a novel coronavirus outbreak of global health concern early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia pattern of early human-to-human transmission of wuhan nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov in china, from to : a data-driven analysis in the early phase of the outbreak journey of a thai taxi driver and novel coronavirus first case of novel coronavirus in the united states potential presymptomatic transmission of sars-cov- covid- transmission within a family cluster by presymptomatic carriers in china presumed asymptomatic carrier transmission of covid- serial interval of covid- among publicly reported confirmed cases new coronavirus pneumonia prevention and control program (second edition) . in chinese nowcasting the number of new symptomatic cases during infectious disease outbreaks using constrained p-spline smoothing alternative methods of estimating an incubation distribution: examples from severe acute respiratory syndrome how generation intervals shape the relationship between growth rates and reproductive numbers serial interval of novel coronavirus (covid- ) infections temporal dynamics in viral shedding and transmissibility of covid- estimating the generation interval for coronavirus disease (covid- ) based on symptom onset data quantifying sars-cov- transmission suggests epidemic control with digital contact tracing presymptomatic transmission of sars-cov- -singapore delivery of infection from asymptomatic carriers of covid- in a familial cluster asymptomatic and presymptomatic sars-cov- infections in residents of a long-term care skilled nursing facility a covid- transmission within a family cluster by presymptomatic infectors in china transmission of covid- in the terminal stages of the incubation period: a familial cluster evidence base of incubation periods, periods of infectiousness and exclusion policies for the control of communicable diseases in schools and preschools the dynamic relationship between clinical symptomatology and viral shedding in naturally acquired seasonal and pandemic influenza virus infections viral load of sars-cov- in clinical samples estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship a well infant with coronavirus disease (covid- ) with high viral load middle east respiratory syndrome coronavirus: quantification of the extent of the epidemic, surveillance biases, and transmissibility evidence for pre-symptomatic transmission of coronavirus disease (covid- ) in china key: cord- - b lenw authors: salenger, rawn; etchill, eric w.; ad, niv; matthew, thomas; alejo, diane; whitman, glenn; lawton, jennifer s.; lau, christine l.; gammie, charles f.; gammie, james s. title: the surge after the surge: cardiac surgery post-covid- date: - - journal: ann thorac surg doi: . /j.athoracsur. . . sha: doc_id: cord_uid: b lenw abstract background the covid- pandemic has dramatically reduced adult cardiac surgery case volumes as institutions and surgeons curtail non-urgent operations. there will be a progressive increase in deferred cases during the pandemic that will require completion within a limited time frame once restrictions ease. we investigated the impact of various levels of increased post-pandemic hospital operating capacity on the time to clear the backlog of deferred cases. methods we collected data from four cardiac surgery programs across two health systems. we recorded case rates at baseline and during the covid- pandemic. we created a mathematical model to quantify the cumulative surgical backlog based on the projected pandemic duration. we then used our model to predict the time required to clear the backlog depending on the level of increased operating capacity. results cardiac surgery volumes fell to % of baseline after restrictions were implemented. assuming a service restoration date of either june or july , we calculated the need to perform % or % of monthly baseline volume, respectively, to clear the backlog in one month. the actual duration required to clear the backlog is highly dependent on hospital capacity in the post-covid time period, and ranges from one to eight months depending on when services are restored and degree of increased capacity. conclusions cardiac surgical operating capacity during the covid- recovery period will have a dramatic impact on the time to clear the deferred cases backlog. inadequate operating capacity may cause substantial delays and increase morbidity and mortality. if only pre-pandemic capacity is available, the backlog will never clear. background. the covid- pandemic has dramatically reduced adult cardiac surgery case volumes as institutions and surgeons curtail non-urgent operations. there will be a progressive increase in deferred cases during the pandemic that will require completion within a limited time frame once restrictions ease. we investigated the impact of various levels of increased postpandemic hospital operating capacity on the time to clear the backlog of deferred cases. we collected data from four cardiac surgery programs across two health systems. we recorded case rates at baseline and during the covid- pandemic. we created a mathematical model to quantify the cumulative surgical backlog based on the projected pandemic duration. we then used our model to predict the time required to clear the backlog depending on the level of increased operating capacity. results. cardiac surgery volumes fell to % of baseline after restrictions were implemented. assuming a service restoration date of either june or july , we calculated the need to perform % or % of monthly baseline volume, respectively, to clear the backlog in one month. the actual duration required to clear the backlog is highly dependent on hospital capacity in the post-covid time period, and ranges from one to eight months depending on when services are restored and degree of increased capacity. cardiac surgical operating capacity during the covid- recovery period will have a dramatic impact on the time to clear the deferred cases backlog. inadequate operating capacity may cause substantial delays and increase morbidity and mortality. if only prepandemic capacity is available, the backlog will never clear. key words: cardiac surgery; covid- ; surgical capacity; coronary artery bypass grafting the covid- pandemic has resulted in dramatically lower adult cardiac surgery case volumes, as institutions and surgeons are following state and federal guidelines to curtail non-urgent operations. there will be a progressive increase in deferred cases during the pandemic that will require completion within a limited time frame once pandemic restrictions ease, in order to avoid excess morbidity and mortality [ ] [ ] [ ] . by definition, programs will have to achieve higher daily case rates than prior to the pandemic in order to service the excess demand. the postpandemic surge in adult cardiac surgery could overwhelm current hospital resources without proper planning. data were collected from four institutions across two health systems. each system included two large academic centers and two affiliated community cardiac surgery programs. first, we calculated a combined baseline case rate across centers, pre-pandemic, by quantifying all cases done from january to february , . inclusion criteria included any adult cardiac surgery case being performed in the operating room with a cardiac surgeon as primary or co-surgeon. heart and lung transplant, ventricular assist device, and transcatheter aortic and mitral valve replacements were included. primary extracorporeal membrane oxygenation (ecmo) cases and pediatric cases were excluded. next, we calculated the combined rate of cases during the early part of the pandemic. raw data was collected from march th through april th and this was used to extrapolate a new "pandemic" surgical case rate. march th was the day after the state of emergency was declared in the state of maryland. we calculated the number of patients that would have surgery deferred during the pandemic, and the length of time necessary to service the backlog in a timely fashion once restrictions were lifted. mathematical models were used to investigate the impact of the date that restrictions are lifted, and variable levels of hospital operating capacity on the time that would be required to address the backlog. to calculate the current backlog (b) on any given day (t), we developed the equation b = (r -r p ) (t -t ). this is the difference in the daily case rates multiplied by the number of days that difference had existed. t was then defined as the day that restrictions were eased and full operating capacity regained. next, the number of operating days necessary to perform all the backlogged cases, defined as backlog time (bt), was calculated. the model was designed to predict the length of time required to clear the backlog based on the amount of extra operating capacity a hospital could achieve. our prediction model defined t as the day the pandemic began, and t as the day restrictions were lifted. each hospital's post-pandemic daily case rate would be defined by an acceleration factor (a) multiplied by the original prepandemic case rate, r . the time required to clear the backlog of cases, bt, was then calculated. bt was defined by the equation bt = ( -r p /r ) (t -t ) / (a- ). the acceleration factor (a) represented how much surgical throughput a program could achieve above baseline. this factor would have to be greater than in order to incorporate some amount of deferred cases into the operating schedule in addition to baseline cases. cases were initially curtailed in early to mid-march and then more drastically in april as recommendations to postpone all but emergency operations became stronger. baseline total case rate for the four combined programs was adult cardiac surgery cases per month. during the pandemic that rate initially fell to , then to cases per month once full restrictions were implemented ( % of normal). during this time the number of deferred cases would be estimated to grow to by june and by july . this represents % to % of normal average monthly volume depending on the duration of the pandemic (figure ). the daily case rates were also calculated. we assumed operative weekdays per month. for the combined health systems, the average daily case rate pre-pandemic, defined as r , was . . the daily case rate during the pandemic, defined as r p , was calculated to be . (table ) . we also calculated the baseline and pandemic daily case rates for three broad categories of cases including coronary artery bypass grafting (cabg), open valve surgery, and transcatheter aortic and mitral valve replacements (tavr/tmvr) (figure ). combined cabg/valve cases were counted as cabg because we felt that the patient's coronary disease would often dictate more urgent triage (figure ). isolated valve cases were more likely to be deferred than patients with isolated or concomitant coronary disease. transcatheter cases were treated differently between the health systems. one system's transcatheter case rate fell from per month to cases per month, while the other system increased their transcatheter cases from per month to cases per month. this equated to approximately a % decrease in one system's transcatheter cases and a % increase within the neighboring system. this differential treatment of transcatheter cases partially mitigated the overall backlog accumulation. cabg cases and valves were triaged similarly by the health systems and these case rates fell by % and % respectively. next, we used our mathematical model to predict the number of cardiac surgery cases deferred during the pandemic, and the length of time required to operate on the backlog, dependent on the amount of increased operating capacity institutions could achieve. time to clear the backlog, bt, was calculated using our mathematical model (figure ). this was considered for the possibility of restored services on june or july with varied levels of case capacity (figure ). assuming services were restored june , the backlog could be cleared between - months, depending on degree of increased capacity. if services resumed july , the cardiac surgery backlog would be estimated to take between - months to clear according to the increased capacity achieved. progressively increasing the operating capacity had a dramatic effect on reducing the time to clear the backlog. if capacity is not increased above baseline (acceleration factor = . ), the backlog will never be cleared. in response to the covid- pandemic, adult cardiac surgery programs have dramatically curtailed operating activity, limiting cases to urgent and life-threatening emergencies. this slowdown has resulted in a growing backlog of adult cardiac surgery cases which will require surgical therapy in a finite time frame to improve quality of life and survival. our study analyzed the deliberate deceleration in adult cardiac surgery cases that has occurred at the two busiest cardiac surgical programs in the state of maryland in response to the covid pandemic. we observed a % drop in cardiac surgical volume, and subsequently a backlog that would require a monthly operating volume of % to % of baseline. since this would be challenging to accomplish in one month, we predicted that the amount of time necessary to clear the backlog would range from to months based on varied estimates of post-pandemic increased operational capacity. our data further suggest that deferred cardiac patients were triaged differently during the pandemic and that the composition of the waiting list is directly related to the triaging mechanism. as expected, isolated valve patients were preferentially deferred compared to patients with any coronary artery disease. we were surprised to see the differences in transcatheter case triage between the two systems. one system deferred the majority of transcatheter cases, while the other increased their rate, mainly tavr cases. although our data did not include reasons for triage decisions, this may have been due to differing thresholds for observing patients with severe aortic stenosis and uncertainty regarding best practice when deferring cardiac services. others have attempted to characterize the needs for surgical services after natural disasters by establishing a baseline surgical rate and then examining the incidence of injury during a disaster [ ] . a study of the nepal earthquakes in demonstrated an acute need for surgical therapy that was more than double the annual nepalese operating capacity, highlighting the need to be able to increase surgical capacity at critical times. another study focused on the aftermath of hurricane charley and found a thirty-two percent increase in adverse medical outcomes for patients with chronic medical conditions related to both increased demand and shortfalls in care delivery [ ] . similar to our investigation, these studies focused on increased healthcare demand following unpredictable events. our analysis differed because we analyzed the effect of an unexpected viral pandemic that necessitated a nearly % decline in surgical volume followed by an anticipated surge in surgical demand. our study is novel in that we prospectively attempted to predict system capacity needs in order to service the anticipated surgical surge. this will require local hospitals and health systems to examine capacity, set priorities, and plan for adequate hospital capacity to service the backlog of cardiovascular patients [ , ] . the global cardiac surgery response post-covid will be complicated by prior exhaustion of hospital supplies and human resources from the pandemic, and competition for resources and operating room availability with other surgical and medical subspecialties, which will also have backlogs. the recently published joint statement from the american college of surgeons and others provides guidance on when to safely reopen operating room capacity and includes recommendations for testing, personal protective equipment, and case prioritization [ ] . we believe that it will be important to maintain an incident command approach during the late phases of the covid epidemic as we transition to re-establishing, and increasing, our prepandemic workflow. planning should begin now, and crucially, prioritize patients with significant risks arising from delayed operations. the risks of deferring needed cardiac treatment have been previously demonstrated. reported mortality rate while waiting for surgical or transcatheter aortic valve replacement can be as high as . % at one month and . % at six months [ ] . for patients awaiting coronary surgery, median waiting list mortality rates of . % per month have been reported with mortality risk increasing % per month. additionally, % of patients experienced a myocardial infarction while on the waiting list [ , ] . we have attempted to estimate the resources required in planning for the post-pandemic surge in adult cardiac surgical volume. the capacity estimates for a given health system would depend on the percent increase in productivity targeted post pandemic. by utilizing our mathematical model, a health system could predict the time required for servicing their surgical backlog and adjust operating capacity accordingly. actualizing a plan to increase capacity may occur gradually and this will further increase waiting time for deferred patients. increasing capacity will also require proportional adjustments in resources such as operating rooms, icu and telemetry beds, and provider staff. for the majority of hospitals, or time is the most expensive resource. consequently, increasing icu and telemetry capacity to avoid operating room holds and cancellations is likely the most cost-effective approach to achieving increased throughput. the number of additional beds, nurses, and advanced practice providers needed can be calculated based on baseline resources. maximizing efficiency through early telemetry discharge, decreasing intensive care length of stay, level loading elective cases in the or, temporarily altering staffing models, and staggering cases can help increase throughput capacity [ , ] . another possible solution is to temporarily relocate some non-cardiac surgical cases to other facilities within a health system. in fact, maintaining the incident command center set up by many hospitals and utilizing some of the same workforce and bed solutions employed during the pandemic may be of value in delivering critical cardiac services in a timely fashion. our analysis has several limitations. firstly, we have assumed that historical rates of surgery will accurately predict future rates. this may be incorrect for several reasons. during the pandemic patients may be treated with alternative medical and interventional therapy, obviating the need for surgery. patients treated medically with symptomatic relief may decide not to pursue more aggressive treatment. other patients may be reluctant to incur out of pocket costs during this time of financial difficulty. additionally, there will unfortunately be some degree of attrition of patients from cardiovascular and covid-related mortality. the pent up demand could also accrue more slowly than calculated. cardiac surgeons sit at the bottom of a virtual funnel which begins with patients seeking medical care, referral to a cardiologist, diagnostic testing, and finally evaluation for surgery. each step along this pathway will be delayed during, and likely for some time after, the pandemic. delays would function as a governor on the acceleration of post-pandemic cardiac surgical demand. our study does, however, provide concerning data delineating a large group of patients with surgical level cardiovascular disease whose treatment has been necessarily deferred. our hope is that our modeling can be used to calculate the productivity increase necessary to treat patients in an acceptable time frame. further study could help better define the overall effects of a pandemic on the care of cardiovascular patients. although challenging and costly, early post-pandemic operating capacity will need to be greater than the original daily capacity to satisfy the pent-up surgical demand. not planning for post pandemic volume could result in a second wave of non-covid cardiovascular mortality. mortality on the waiting list for coronary artery bypass grafting: incidence and risk factors mortality while waiting for aortic valve replacement waiting times and prioritisation for coronary artery bypass surgery in new zealand surgical care required for populations affected by climate-related natural disasters: a global estimation medical interventions following natural disasters: missing out on chronic medical needs design of a model to predict surge capacity bottlenecks for burn mass casualties at a large academic medical center surgical subspecialty block utilization and capacity planning: a minimal cost analysis model roadmap for resuming elective surgery after covid- pandemic n.d balancing operating theatre and bed capacity in a cardiothoracic centre development and evaluation of a prospective staffing model to improve retention key: cord- - dwqqgv authors: christian, michael d. title: biowarfare and bioterrorism date: - - journal: crit care clin doi: . /j.ccc. . . sha: doc_id: cord_uid: dwqqgv bioterrorism is not only a reality of the times in which we live but bioweapons have been used for centuries. critical care physicians play a major role in the recognition of and response to a bioterrorism attack. critical care clinicians must be familiar with the diagnosis and management of the most likely bioterrorism agents, and also be adequately prepared to manage a mass casualty situation. this article reviews the epidemiology, diagnosis, and treatment of the most likely agents of biowarfare and bioterrorism. weapons and their potential use by states with the consideration of use by nonstate actors (eg, terrorists). more recent definitions of bioterrorism include both a broader range of potential biological agents as well as considering more diverse groups of potential targets and impacts of biological weapons. spencer defines bioterrorism as "the use of micro-organisms as weapons of catastrophic effect which can be described as: the category or method of use of a weapon system that results in a significant negative impact on a nation's physical, psychological or economic well-being, thereby causing a major modification of routine activity." this definition highlights several key points. first, it highlights that a wide range of microorganisms must be considered and that their impact is not merely physical but may also include psychological and economic factors. spencer further elaborates on his definition of bioterrorism by stating "bioterrorism is best described as the use of micro-organisms (pathogens) or the products of living organisms (toxins) to inflict harm on a wider population, including animals and crops." the elaboration on his original definition highlights that not only are humans directly vulnerable to bioterrorism but we are vulnerable through indirect attacks on our livestock or crops, which has also been termed agroterrorism. , other investigators broaden the definition further to not only include microorganisms and biotoxins but also larger organisms, specifically insects. as with many other medical issues that intensivists face in their busy clinical and academic practices, pressured by ever-increasing time and budgetary restraints, there is a necessity to prioritize efforts and resources toward the most common and higherimpact concerns. it is difficult to provide a clear-cut answer as to where bioterrorism should be prioritized on this list. although some experts state that the risk of a largescale bioterrorist attack is low, in a more recent analysis, us senators graham and talent quote their conclusion form the commission on the prevention of weapons of mass destruction proliferation and terrorism in , which stated "unless the world community acts decisively and with great urgency, it is more likely than not that a [biologic] weapon of mass destruction will be used in a terrorist attack somewhere in the world by the end of ." anthrax in particular remains such a concern, because of both the lethality of the agent and also the potential availability given the number of governments that produced weaponized anthrax in the past. the later issue is of concern because of both the availability of expertise as well as the risk of residual caches of anthrax in failed states that are vulnerable for misappropriation. in addition, it may require less expertise to develop aerosolizable anthrax then previously believed. , box lists the capabilities required of any organization, whether state or nonstate, to conduct and deliver a bioterrorist attack. even a small or moderate bioterrorism event has the potential to overwhelm local medical resources and cause significant civil and economic disruption as a result of the psychological impact of such an attack. given the potential risk for a bioterrorism event and the major impact that could occur, these factors alone provide a strong argument as to why an understanding of bioterrorism is warranted for critical care physicians. however, if these arguments are not persuasive enough, the knowledge that critical care physicians will play a key role in a bioterrorist event, and that their effectiveness in responding to the event is dependent on their medical knowledge regarding bioterrorism agents, should compel one to take the time to read this review. agents used for bioterrorism typically cause critical illness and therefore are of clinical relevance to the intensivist. several of the category a and b organisms (see later discussion) also produce human infections in nature, and therefore, knowledge of their presentation and treatment can also be applied in nonbioterrorism settings. the us centers for disease control and prevention (cdc) has identified and categorized a list of potential bioterrorism agents ( table ). the agents identified by the cdc have been accepted, by most authorities globally, as the highest priority for preparedness and research. those agents from category a form the primary focus of this article. however, relman reminds us that it is important not to solely focus on the agents from the cdc list because they were largely driven by past military programs and do not include agents that were not of particular interest or relevance in the past but may be in the future given technological advances. in addition, military programs focused on weaponizing agents, whereas terrorists could seek to manipulate the natural spread of existing organisms or the development of novel strains. agents this section provides a basic overview and description of the commonly considered bioterrorism threats. specific details about the epidemiology, diagnosis, treatment, and outcomes associated with each of the organisms follow in the subsequent sections. anthrax the bacteria causing anthrax is bacillus anthracis, an encapsulated, grampositive, spore-forming bacilli. , , , when seen on a gram stain, it is often described as box cars given its appearance as a series of railway boxcars in a train viewed from above ( fig. ) . bacillus anthracis is a soil-borne organism and can be found in the environment globally. the organism grows quickly on standard culture media ( - h) and its spores are highly resistant, potentially being viable for decades. in naturally occurring infections, the organism may infect humans by transcutaneous inoculation (cutaneous anthrax), ingestion (gastrointestinal [gi] anthrax, including oropharyngeal), or inhalation (thoracic anthrax). in terms of use as an organism of bioterrorism, it is most likely to be delivered in its spore form as an inhaled agent. once inhaled, bacillus anthracis spores enter alveolar macrophages by phagocytosis and are transported to regional lymph nodes, where they germinate, typically within to days but they may be delayed up to days. , , symptoms start after germination and bacterial replication begins to occur. what causes the variability in incubation period associated with the time from infection with spores to germination to the vegetative bacillus is unknown. bacillus anthracis produces exotoxins: edema and lethal, comprised of components: ( ) edema factor (ef), which impairs neutrophil function and disrupts cell water hemostasis, resulting in massive edema; ( ) lethal factor (lf), which causes release of tumor necrosis factor a and interleukin b, which are believed to mediate the severity of illness produced; and ( ) protective antigen, found in combination with both ef and lf, which allows binding and transportation of the other toxins to and across cell membranes. in addition to the toxins, there are several other virulence factors, including an antiphagocytic capsule. anthrax is not transmitted person to person, but patients should be isolated with droplet precautions as part of standard febrile respiratory infection precautions until the cause of their illness is confirmed. patients with cutaneous anthrax require contact precautions. decontamination should include removing clothing and jewelry and washing skin with soap and water. caution must be exercised not to generate secondary aerosols when handling contaminated clothing items. environmental contamination from patients exposed to an aerosol of bacillus anthracis spore can be performed with a . % hypochlorite bleach solution. this procedure is not sufficient for site decontamination after the release of bacillus anthracis spores, because much more extensive decontamination is required. [ ] [ ] [ ] plague plague is caused by yersinia pestis, a nonmotile, gram-negative, bipolar coccobacillus that can be found worldwide. , , human infections occur in nature regularly, and plague is endemic in regions such as the southwest united states. yersinia pestis virulence factors include: v and w antigens, lipopolysaccharide endotoxin, capsular envelope (antiphagocytic), coagulase, and fibrinolysin. the natural reservoir for yersinia pestis is rodents and the vector to humans is the oriental rat flea (xenopsylla cheopis). plague is highly communicable in the pneumonic form and may present as any of the following clinical syndromes: bubonic plague, primary pneumonic plague, primary septicemic plague, plague meningitis, plague pharyngitis, pestis minor, and subclinical infection. aerosolized yersinia pestis likely produces a clinical presentation identical to pneumonic plague. however, yersinia pestis does not produce spores and is susceptible to destruction by drying, heat, and ultraviolet light, therefore making it significantly more challenging to weaponize it then anthrax. it is more readily transmitted via an infected vector, such as the oriental rat flea, or by person-to-person transmission. the incubation period depends on the clinical presentation; bubonic plague takes to days and pneumonic plague as short as hours to days. isolation for plague requires droplet precautions until hours of effective antibiotic therapy. decontamination is not required specifically for plague. health care institutions should follow their usual procedures for cleaning after patient discharge from a room. tularemia francisella tularensis is the organism responsible for causing tularemia; it has often been associated with rabbits and various rodents and is occasionally referred to as rabbit fever and deer fly fever. , [ ] [ ] [ ] francisella tularensis is a fastidious, small gram-negative, facultative intracellular coccobacillus able to live in soil, water, and decomposing carcasses for long periods. francisella tularensis can be transmitted by direct contact with mucous membranes, cutaneous inoculation through broken skin or bites from infected ticks (or other arthropods), ingestion and inhalation (although human-to-human transmission has not been reported ) . as discussed further in the epidemiology section, tularemia has been previously used as a biological weapon. the mode of deployment as a biological weapon in the past has often been through infected vectors ; however, a modern bioterrorist would most like deploy the agent via aerosolization and it could present as: primary pneumonic tularemia (inhalation), oculoglandular tularemia (eye contact), ulceroglandular (broken skin contact), or oropharyngeal (mucous membrane contact without deep inhalation). tularemia is not communicable between humans, so specific isolation is not required; only standard universal precautions should be used. decontamination for aerosolized exposure should involve remove clothing and jewelry and washing the skin with soap and water. q fever the only category b bacterial organism to receive any extensive discussion in this article is the zoonotic rickettsial organism coxiella burnetii, the causative agent of q fever in humans. [ ] [ ] [ ] coxiella burnetii is a small, obligate intracellular, gramnegative highly pleomorphic coccobacillus. it has a typical gram-negative cell wall structure, but does not stain well with gram stain although it can be seen with a gimenez stain. coxiella burnetii has morphologic forms: large and small cell variants. the small cell form is the extracellular form, which is metabolically inactive and resistant to chemical agents as well as environmental and physical conditions. the large cell variant is the metabolically active and pathogenic intracellular form. the disease is called q fever for query fever, because the causative organism had not been identified at the time of the first documented large outbreaks. q fever occurs worldwide and is associated with contact with sheep, goats, or cattle, particularly during birthing when placental exposure occurs. human infection is through the inhalation of aerosolized organisms from infected animals. coxiella burnetii is highly infectious to humans, and its sporelike small cell variant form makes it a potentially viable biological weapon. most human cases of disease are zoonoses, with human-to-human infection only rarely reported; therefore, only standard infection control precautions are required in the clinical setting. however, coxiella burnetii is highly infectious from culture and therefore should always be handled under biosafety level conditions. environmental decontamination should a culture spill or bioterrorism release occur is difficult given the highly resistant features of the small cell variant. other bacterial agents in addition to the bacterial agents already discussed, there are several other potential organisms that could be used as bioweapons (see table ). [ ] [ ] [ ] rickettsia prowazekii is the causative agent of louse-borne typhus and, similar to q fever, efforts have been made in the past to develop it into a bioweapon. brucella sp are small, aerobic, intracellular gram-negative coccobacilli, which cause primarily zoonotic infections in sheep, cattle, goats, and other animals. brucellosis can manifest as either christian systemic or localized infections and is acquired by contact with or ingestion of fluids from infected animals, particularly by the consumption of unpasteurized milk or cheese. brucella suis was reportedly weaponized by the united states, and possibly other countries, in the past. the organism was to have been aerosolized from a bomb. burkholderia pseudomallei is a gram-negative, facultative anaerobic, motile bacillus that causes melioidosis. there are naturally occurring cases of melioidosis in southeast asia and australia yearly. the disseminated form causes an acute illness, with high mortality. the disease is also known to cause abscesses, which, in some cases, do not present until many years after the initial exposure. burkholderia mallei is a gram-negative, aerobic, nonmotile bacillus that causes glanders. it exists only in living organisms and cannot survive in the external environment. glanders usually presents in humans as a nodular disease with regional lymphangitis; however, systemic dissemination of the organism does occur on occasion, producing septic shock, potentially leading to death. control measures have led to the eradication of glanders from most countries in the world, with the exception of ongoing zoonotic endemics in parts of the middle east, asia, africa, and south america. both burkholderia sp tend to be transmitted to humans through inoculation via a break in the skin, although inhalation is occasionally also a means of human infection. both organisms have been studied, and reportedly developed, as biological weapons in the past by the germans and russians. given the possibility of human-to-human transmission, droplet precautions should at least initially be used for patients with systemic or pulmonary involvement. the more significant transmission risk is from cultured organism, and therefore, any cultures should be managed in a biosafety level laboratory. smallpox once believed to be a disease of the past, smallpox is now one of the most significant bioterrorism threats to the world. , , [ ] [ ] [ ] there are no animal reservoirs for smallpox and the last naturally occurring case was in somalia in . smallpox is caused by the dna variola virus, a member of the genus orthopoxvirus (family poxviridae), which also includes molluscum contagiosum, vaccinia (virus used in the smallpox vaccine), and monkeypox. a large vulnerable population has existed since smallpox vaccination was stopped in the late s and early s. variola is highly communicable, and can be transmitted by airborne, droplet, and fomite (bed linen and clothing) transmission in addition to direct contact. infection starts in mucosa of airway, then the virus replicates in regional lymph nodes before subsequently resulting in an asymptomatic primary viremia to days after infection with spread to the bone marrow, spleen, and lymph nodes. secondary viremia occurs (day [ ] [ ] [ ] [ ] [ ] , in which the virus localizes in the dermis and oropharyngeal mucosa and is marked by the onset of symptoms and infectivity. five clinical syndromes of variola infection are seen: classic (unvaccinated only), modified (vaccinated or unvaccinated), flat (vaccinated or unvaccinated) hemorrhagic, and variola sine eruptione (vaccinated only). variola has several features that make it a potentially good bioweapon, including the ability to be made into a lyophilized form, which can be aerosolized and is heat resistant (box ). however, the virus is easily killed, even in the lyophilized from, by ultraviolet light and disinfectants. the primary concern related to smallpox as a bioterrorism agent is that it was produced in large quantities as a bioweapon by the soviet union and the security of its viral stock remains uncertain after the collapse of the superpower. mathematical models suggest that even a moderate-sized attack infecting to people would lead to a massive global pandemic that would require significant interventions to control, which in turn would carry with them significant economic and civic ramifications. airborne and contract precautions should be used to manage patients with smallpox. clearly, in a large-scale attack or outbreak, isolation of all patients in negative pressure rooms would not be feasible. all fomites (bed linen and patient clothing) should be transported in sealed biohazard bags and autoclaved before washing or incineration. standard hospital procedures for room cleaning can be followed once a patient has been discharged from the room. viral hemorrhagic fevers viral hemorrhagic fevers (vhf) ( table ) are a group of infections caused by families of rna viruses (arenaviridae, bunyaviridae, filoviridae, and flaviviridae), which are believed to primarily exist within animal or arthropod reservoirs, but occasionally infect humans. , , each virus is generally contained to a specific geographic region. all of the viruses have in common that they attack the vascular endothelium, leading to vascular leak and potentially producing shock or coagulopathies. with the exception of hantavirus, natural transmission is primarily by respiratory droplets and body fluids but not by airborne aerosol. aerosol transmission of hantaviruses from the urine of rodents has been well documented. most secondary (humanto-human) transmission of vhf is to family members or health care workers caring for patients with vhf. the primary mode of transmission in these cases is direct contact with infected body fluids and percutaneous exposures. however, questions still remain regarding the possibility of aerosol transmission, particularly for lassa fever or from aerosol-generating procedures. several of the vhf viruses have reportedly been weaponized by the russian and the us militaries. isolation for all vhf is strict droplet and contact precautions. patients who are end stage or have significant pulmonary involvement may warrant airborne isolation in a negative pressure room, if available. for specific details regarding isolation and environmental decontamination procedures for vhf, see the cdc's interim guidance for managing patients with suspected viral hemorrhagic fever in us hospitals, available online at http://www.cdc. gov/hai/pdfs/bbp/vhfinterimguidance _ _ .pdf (accessed january, ). in addition to clinical infection control precautions, it is important to minimize risk to box why smallpox is a good candidate as a bioterrorism agent . it is transmissible by the aerosol route, both in a weaponized from and from infected to susceptible persons. . it is heat stable in a lyophilized form. . the populations of most countries contain a high proportion of susceptible persons. . smallpox is associated with high morbidity and about % mortality. . there is a significant psychological fear of smallpox among both the public and health care workers. . initial diagnosis of cases of the disease may be delayed, given that it has not been seen clinically for more than years. . other than the vaccine, which may be effective only in the first few days after infection, there is no proven drug treatment for clinical smallpox. the laboratory and other health care workers by strictly limiting the number of samples and blood work collected. no fungal organisms are currently on the cdc list of category a or b agents, although it could be argued that some should be considered as potential category c agents. coccidioidomycosis is caused by the soil-borne spore-forming organisms coccidioides immitis and coccidioides posadasii found in the americas. these organisms typically cause a self-limited respiratory illness in immunocompetent individuals. coccidioidomycosis is typically transmitted by inhalation, particularly after events such as earthquakes or dust storms, which generate airborne particulate mater from the soil. human-to-human transmission does not occur. overall, the long incubation period and mild clinical presentations in most individuals make coccidioides an unattractive agent as a bioweapon. however, given the ease of access to the organism and its natural propensity for aerosol transmission, its potential use should not be ignored. keeping an open mind about possible future bioterrorism agents is essential if we are truly going to be prepared. biological toxins technically toxins are chemicals but because of their source (living organisms), biotoxins are typically classified as biological weapons. , , , the cdc list of potential bioterrorism agents (see table ) includes several toxins. in addition, there are several other toxins that also have the potential to be used as agents of bioterrorism (box ). toxins can be deployed via aerosol dispersal devices or by contaminating food sources and have been used as bioweapons in the past ( table ) . to be effectively deployed as an airborne agent, the toxin must be - mm for optimal aerosolization. ricin ricin is a protein toxin obtained from the organism ricinus communis (castor beans). castor beans are available worldwide and ricin is a natural by-product produced in the processing of castor beans to castor oil. the waste products resulting from the processing of castor beans contain approximately % ricin. in its pure form, ricin is a white powder that is soluble in water and stable over a wide range of ph. chemically, ricin is a glycoprotein lectin with a and b chains joined by a disulfide bond. the b chain binds to galactose-containing proteins and lipids on cell surfaces, causing direct membrane damage and release of cytokines, whereas the a chain inhibits eukaryotic ribosomes by removal of adenine from the rrna loop in the subunit, therefore stopping protein synthesis, leading to cell death. ricin is less toxic by weight compared with botulinum toxin or staphylococcal enterotoxin type b (seb), but is more readily available and easy to produce in large quantities than either of these agents. ricin can be deployed as a bioweapon via several routes, including inhalation, ingestion, or injection. clearly, as a bioterrorism agent with the intent to cause mass casualties, inhalation or ingestion is more likely than injection. after exposure, decontamination should include removal of clothing and jewelry, washing with soap and water, followed by rinsing with copious amounts of water. clostridium botulinum toxin (botulism) botulinum toxin is the most poisonous substance known to man with a dose lethal to half those exposed (ld ) of ng/kg. clostridium botulinum is a gram-positive, spore-forming, anaerobic bacillus found in soil and water globally. rarely, the toxin is also produced by clostridium butyricum and clostridium baratii. botulinum toxin is produced in pharmaceutical grade and is commercially available for cosmetic and other medical purposes. seven types of toxins exist and are identified as types a to g, with a, b, and e causing most cases of human disease. the toxin contains chains (heavy, light, nontoxic hemaglutinin). the heavy chain permits the toxin to bind with the cell, and the light chain contains zinc-dependent endopeptidase, which stops calcium release. botulinum toxin binds to peripheral presynaptic cholinergic terminals (including muscarinic and nicotinic) and blocks the calcium-dependent exocytosis process. the central nervous system is not affected by the toxin. botulism is most often considered a food-borne illness, given that most of the naturally occurring cases are the result of ingesting contaminated food products. other naturally occurring forms of toxicity are wound botulism (soil-contaminated wounds) and infantile botulism (ingestion of spores). the spores themselves are heat resistant, tolerating temperatures up to c, but the toxin itself denatures and becomes inactivated with even brief exposures to temperatures higher then c. use as a potential bioweapon includes contaminating food sources or via aerosolization. however, the toxin quickly degrades when exposed to environmental conditions, thus limiting its usefulness as a bioterrorism agent. botulinum toxin cannot cross the skin but can be absorbed by mucous membranes. should exposure to the toxin occur via aerosolization, decontamination should include removing clothing and jewelry, washing with soap and water, and rinsing with copious amounts of water. wash contaminated surfaces with a . % hypochlorite bleach solution to destroy the toxin. micotoxins several hundred varieties of toxins are derived from fungi, with the trichothecenes and aflatoxins being most concerning. aflatoxins are produced by aspergillus flavus or aspergillus parasiticus and are common contaminants in harvested food. aflatoxins bind to and damage dna and cellular proteins. trichothecenes are produced by a large number of fungi including: fusarium, stachybotrys, trichoderma, myrothecium, and cephalosporium. the most likely toxins from the class trichothecenes to be used as bioweapons are: t (trichothecene) and deoxynivalenol (vomitoxin). t causes skin irritation/pain and can be absorbed through the skin or inhaled, and then disseminated systemically, binding to peptidyltransferase inhibiting protein synthesis. it also interferes with dna polymerase and monoamine oxidase. the organs affected first are those are with rapidly reproducing cell lines (gi tract, bone marrow, and skin) as well as impairing proteins involved in coagulation and the krebs cycle. in addition, the breakdown of serotonin, epinephrine, and norepinephrine is impaired. t is a yellow droplet in appearance. should exposure occur, decontamination includes removal of clothing and jewelry, scrubbing the skin with soap and water, and isolating clothing or other contaminated objects. staphylococcal enterotoxins staphylococcal enterotoxins are heat-stable toxins produced by the common staphylococcus aureus bacteria. there are more than types of enterotoxins, with type a commonly known for causing food poisoning and type f causing toxic shock syndrome. the genes for staphylococcal enterotoxins are found on plasmids and bacteriophages, allowing transfer between different strains. seb can be aerosolized and has been studied as a potential incapacitating biological agent. seb is a superantigen, which produces massive stimulation of t cells and cytokine storm, which is rarely fatal but is significantly incapacitating to the victim. if there is exposure, decontamination requires removing clothing and jewelry, followed by washing skin with soap and water. clostridium perfringens epsilon toxin clostridium perfringens is an anaerobic, grampositive, spore-forming bacillus that is found in soil in all parts of the world. clostridium sp produce several toxins, one of which is the epsilon toxin, which commonly causes food poisoning. similar to seb, epsilon toxin could be another potential incapacitating bioweapon. insects were some of the earliest bioweapons ever used against an enemy (see table ). , there are potential ways to use insects in bioterrorism: direct attacks, agents of agroterrorism, or as vectors of disease. direct attacks most often use stinging insects and have been used in the past to defend fortifications and rout enemies from entrenched positions (the bee hive in the log, as seen in cartoons). another insect that has been studied by the indian military as a potential bioweapon is the paederus beetle, found in the middle east, which produces the toxin pederin. pederin is potent, causing intense pain, festering lesions, and blindness if it contacts the eyes. ingestion of the beetle can be lethal, as is injecting pederin into the bloodstream. agroterrorism is "the deliberate introduction of an animal or plant disease as well as damage to crops and livestock with the goal of generating fear, causing economic losses and/or undermining social stability." an example of insects used as an agent of agroterrorism is the medfly (ceratitis capitata), a fruit fly found in parts of the world but not the united states. their larvae eat many plants, causing significant crop destruction. in , a group threatened to release medflies in california if the government did not stop a pesticide-spraying program. if the insects had been released, the estimated damage to the economy would have been $ . billion. insects can be used in bioterrorism as disease vectors. table lists potential vector-borne diseases of concern. epidemiology it is challenging to describe the epidemiology of agents of bioterrorism in the traditional manner for several reasons. first, as discussed in the introduction, theoretic risks are largely being discussed, with many unknown factors involved. further, given that most of the work done in the area of bioweapons has been conducted by military or state organizations, only a small percentage of the overall activities have been publically reported. to provide the best possible overall perspective on the epidemiology of bioterrorism agents, table offers a comprehensive overview of past use of bioweapons as compiled from several sources. , , , , , , , , [ ] [ ] [ ] in addition to the general risks discussed in the introduction, academic health centers potentially play a unique role in the epidemiology of bioterrorism. any public area where mass gatherings occur or any infrastructure critical for the smooth functioning of society are potential targets for bioterrorism attacks. not only do hospitals in general, and academic health centers specifically, fit this profile, but academic health centers may also be at an increased risk because they are also potential sources of agents of opportunity (ao). the term ao is used to connote the use of a routine and unregulated chemical, biological, or radiologic agent by terrorists. table potential bioterrorism vector-borne diseases of concern for humans vector disease two key features of an ao are ( ) its availability, and ( ) a practical means of dissemination. box lists potential biological aos available in many academic health centers. an ao does not have to cause significant morbidity or mortality to be effective; the psychological effects on the public and impact on society/critical infrastructure functioning are sufficient to have a serious effect. aos are of significant concern to law enforcement officials because potential barriers to the development of a highly effective biological weapon are the cost and expertise required to develop them, whereas aos mitigate both of these factors. in the past, the development of bioweapons has required significant funding and labor, which typically only states can mobilize. it has been said that the us military bioweapon program employed more than staff and the ussr bioweapons sections employed more than , staff, both at costs of millions of dollars. although presenting a significant obstacle in bioweapon development, cost does not always prevent nonstate actors from pursuing bioweapons; the aum shunrikyo cult may have spent more than $ million dollars in its failed attempt to develop weapon-grade anthrax. the diagnosis, or identification, of a bioterrorism event is likely the most challenging step in the response. recognition of a bioterrorism event has components: ( ) identifying that an intentional rather then natural phenomenon has produced several cases of illness, and ( ) diagnosing the specific organism or agent causing the illness. they may occur in either order depending on the circumstances. bedside clinicians, specifically critical care physicians, play a crucial role in both aspects of recognizing that a bioterrorism event has occurred. , , recently, a great deal of attention and money has been directed toward bioterrorism detection technologies, such as environment sampling and syndromic surveillance. however, these efforts are highly unlikely to replace the bedside clinician in recognizing the event. , in a simulated anthrax attack designed to test the performance of a syndromic surveillance system currently in use, nordin and colleagues found that performance of syndromic surveillance varies with the infection rate. based on their analysis in a metropolitan area if there was a release of anthrax at a large public venue, a syndromic surveillance system that monitored approximately % of the local population would detect the event most of the time if the infection rate was % and all of the time if the infection rate was more than %, but it would take to days in both situations. therefore, these investigators concluded that "a suspicious clinician may detect the first case of anthrax before a syndromic surveillance system sounds an alarm and public health determines it is an anthrax release." identifying the important role that the beside clinician plays in recognizing a bioterrorism event is not intended to diminish or exclude the role of others in the process, especially not public health. the rapid recognition, and effective response, to a bioterrorism event requires that clinicians and public health officials work together. [ ] [ ] [ ] in some circumstances, such as smallpox, the diagnosis of a single case triggers the alarm that a bioterrorism event has occurred. however, for any of the diseases with a naturally occurring incidence, as well as with a novel organism or illness that has not yet been identified, it is the existence of a cluster of cases in a geographic area that triggers suspicion of a possible bioterrorism attack or emerging epidemic ( table ) . recognition of a cluster of patients typically requires a level of situational awareness that is beyond what an individual clinician can acquire and is usually attainable only by a regional, state, or federal public health agency depending on how widely distributed the cases are. for example, if an anthrax attack took place in a busy international airport, the cases would be widely distributed across a nation or internationally (eg severe acute respiratory syndrome [sars]). in this case, to the individual clinicians receiving the cases of inhalational anthrax, each would be an unusual, but not necessarily alarming, occurrence. however, the reporting of several cases of inhalational anthrax to a federal or international public health agency simultaneously would certainly trigger an alarm. however, we are often left with trying to distinguish between a naturally occurring event (epidemic) and an intentional event (bioterrorism). it can be difficult to distinguish between an artificial incident (terrorism) and a natural occurrence (epidemic). , box lists some of the characteristics that might help christian table case number triggering criteria for considering a potential bioterrorism event disease(s) a a this factor is in part based on the background incidence of disease in a geographic area and therefore varies from location to location as well as based on seasonal variations. for example, a viral encephalitis that is naturally transmitted by an endemic vector occurring in the summer when mosquitoes are prevalent would not necessarily raise concerns; however, a single case occurring in the winter or in a geographic area where that infection is not typically seen may raise concerns immediately. features that suggest a bioterrorism event rather than an epidemic . an epidemic curve that suggests a point source (common source) outbreak or extended source rather then a naturally propagated (transmitted) source (fig. ) . identification of a cluster of cases (large numbers of patients from a similar geographic area with similar symptoms) distinguish between the events based on epidemiologic features. recently, radosavljevic and belojevic have developed a scoring system to help distinguish between a bioterrorism incident and an epidemic ( table ) . these investigators use an interesting approach, which scores several qualitative and quantitative features of the incident categorized under groupings: person (cases), place (spatial distribution), and time. a score of or higher on this system is said to suggest that an artificial (intentional or accidental) event is more likely then a naturally occurring epidemic. the questions considered in this score have to be answered at the public health level, not the individual clinician level, because they require a level of situational awareness not attainable by a clinician in a hospital. the importance of clinicians working effectively with public health agencies is further reinforced by computer modeling work by hupert and colleagues, which suggests that even minor delays in detecting (diagnosing) and initiating the response to a large-scale anthrax attack would make even perfectly executed prophylaxis campaigns ineffective in preventing the health care system from being overwhelmed by cases. as noted in the earlier discussion, identifying the disease or organism involved can be key to identifying the event as a bioterrorism incident. this section provides an overview of the clinical and investigational findings that assist in diagnosing the specific diseases. key to any biological diagnosis are laboratory, particularly microbiological, tests. table summarizes the appropriate specimens and tests for diagnosing potential agents of bioterrorism. however, as with many aspects in critical care, it is important not to be overly reliant on technology. the college of american pathologists regularly tests the ability of laboratories to accurately diagnose, or appropriately refer to a reference laboratory, clinical potential agents of bioterrorism. in their recent testing of laboratories, the college of american pathologists found rates of acceptable identification responses were as follows: bacillus anthracis, % ( ) although the rates of appropriate diagnosis are improving, there still remains a delay in notification of the reference laboratory and a not insignificant failure rate for diagnosing category a organisms other then anthrax. anthrax as discussed earlier, anthrax presents as typically distinct clinical syndrome: cutaneous, gi, and thoracic. , , , diagnosis of anthrax often involves a combination of clinical, radiographic, and microbiological data. the clinical presentation of the anthrax syndromes is outlined in table . cutaneous anthrax most often affects the hands, arms, and face. one of the main differential diagnoses for cutaneous anthrax are spider bites, and table presents clues to help distinguish between the . the diagnosis of cutaneous anthrax can often be made clinically followed by laboratory confirmation. other laboratory and radiologic investigations are of limited use in cutaneous anthrax. conversely, in the cases of gi and thoracic anthrax, the clinical presentation is relatively nonspecific, and radiologic investigations, especially for inhalational anthrax, along with laboratory and microbiological testing are essential for making the diagnosis. with thoracic anthrax, sputum cultures are rarely positive but first blood cultures are almost always positive. with the relatively nonspecific findings associated with thoracic anthrax, it can be challenging for clinicians to differentiate it from the more commonly seen community-acquired pneumonia (cap). kyriacou and colleagues conducted a retrospective review of cases of bioterrorism-acquired thoracic anthrax and compared them with cases of cap or influenza. these investigators found that the most accurate predictor of anthrax was mediastinal widening or pleural effusions on chest radiograph, which were % sensitive, . % specific compared with cap, and . % specific compared with influenza (see fig. ). other features more common in anthrax were: nausea, vomiting, pallor, cyanosis, diaphoresis, altered level of consciousness, and increased hematocrit level. two groups , have developed screening criteria to help diagnose anthrax after a known bioterrorism incident. however, a costeffectiveness analysis showed that although both criteria would have identified cases abbreviations: ct, computed tomography scan; cxr, chest radiograph; mri, magnetic resonance imaging. a for microbiological findings, refer to table . data from refs. , , , , of anthrax, the mayer criteria would have screened only patients (cost $ usd), whereas the hupert criteria would have screened patients ($ , usd). although it is rare with cutaneous anthrax, any case of anthrax has the potential to develop hemorrhagic meningitis. therefore, any evidence to suggest meningitis should prompt appropriate investigations such as neuroimaging and a lumbar puncture. plague as with anthrax, the diagnosis of plague varies significantly based on the clinical syndrome as which it presents. , , plague may present as any of the following clinical syndromes: bubonic plague, primary pneumonic plague, primary septicemic plague, plague meningitis, plague pharyngitis, pestis minor, and subclinical infection. the first syndromes are the most common presentations and their diagnostic features are outlined in table . bubonic plagues is characterized by initial lymphadenitis, most commonly inguinal, followed by the development of a systemic illness, which may include secondary plague pneumonia. primary septicemic plague is similar to bubonic plague, without the initial appearance of buboes. it remains unclear if it is the same entity with subclinical lymphadenitis or a distinct pathophysiologic process. pneumonic plague may be primary, which presents as an acute respiratory infection, or may occur as a result of hematologic spread (secondary) from bubonic or primary septicemic plague. hemoptysis is frequently seen with pneumonic plague and can help differentiate it from anthrax or tularemia. general laboratory and radiologic investigations are nonspecific and the diagnosis is primarily made via microbiology testing (see table ). automated culture detection systems may not detect or can misidentify yersinia pestis, and therefore, if there is a high level of suspicion for plague, the microbiology laboratory should be made aware of this when the cultures are ordered. tularemia tularemia is another disease with several distinct presentations that are variable and dependent on the mode of transmission. , the clinical spectrum of disease includes: typhoidal, ulceroglandular, glandular, oculoglandular, oropharyngeal, and pneumonic tularemia, with the last being the most likely presentation from a bioterrorism incident. the average incubation period is to days, but ranges from to days. the pneumonic form typically presents with: fever, chills, headache, malaise, coryza, cough, chest pain, pharyngitis, abdominal pain, arthralgia, septic shock, respiratory failure, and acute respiratory distress syndrome (ards). the ulceroglandular form presents with cutaneous ulcers . to cm with heaped-up edges and regional lymphadenopathy. ulceroglandular infections may progress to systemic disease similar to the pneumonic form. the typhoidal form does not involve lymphadenopathy. the typhoidal form usually involves the lung primarily, whereas the ulceroglandular form first affects the mediastinal lymph nodes, then progresses to parenchymal involvement. microbiological testing is required to make the diagnosis, although cultures are generally low yield given the difficulty growing the organism. therefore, alternative techniques for identification such as immunofluorescence and polymerase chain reaction (pcr) are preferred. radiologic findings are generally nonspecific, although approximately % of patients with tularemia present with bronchopneumonia, typically bilateral, and may develop cavities. only approximately % have lymphadenopathy and pleural effusions, which is significantly lower than would be expected with thoracic anthrax. q fever q fever, when seen in naturally occurring infections in humans, causes a spectrum of disease from asymptomatic fevers and fevers of unknown origin through to life-threatening infections, typically associated with endocarditis or pneumonia. , the primary concern in a bioterrorism setting is inhaled coxiella burnetii, which presents with fever and cough alone in cases of lower inoculation through to severe pneumonia and respiratory distress with high inoculums. the diagnosis of q fever requires microbiological testing. the chest radiograph and computed tomography (ct) finding are nonspecific and consistent with any other type of pneumonia. there is no significant adenopathy seen on the chest radiograph or ct, which may help to rule out anthrax. other bacteria the other bacterial agents that are discussed are brucella sp and burkholderia sp. brucellosis has multiple clinical presentations and can be difficult to diagnose. typically brucellosis infects organs (lung, liver, spleen), bone marrow, bones, or central nervous system and is an insidious infection, presenting primarily with constitutional symptoms and organomegaly. the incubation period ranges from to weeks. diagnosis of brucellosis is best made by bone marrow cultures or blood cultures, although they are less sensitive. burkholderia mallei causes the clinical disease glanders, which presents as skin nodules and lymphadenopathy after inoculation through the skin, but in a bioterrorism event with inhalation exposure, the most likely presentation would be a nonspecific systemic febrile illness, which may or may not be accompanied by a pustular rash. burkholderia pseudomallei causes the clinical syndrome of melioidosis, a disease with a broad spectrum of presentations, including skin ulcers, pneumonia, acute fulminate sepsis, and chronic abscesses. if used in a bioterrorism setting with inhalational exposure, the acute presentation would most likely be either pneumonia or sepsis. smallpox smallpox can present as of clinical syndromes (table ) : classic, modified, flat, hemorrhagic, and variola sine eruptione. , , the primary challenge in the diagnosis of smallpox is the lack of clinicians who have experience with the disease. the cdc has published a case definition to aid in the diagnosis of cases (box ). classic smallpox begins with a prodrome of fever and constitutional symptoms. after to days, the rash begins to emerge, initially as small red spots in the mouth and throat, which develop into sores that erupt and discharge virus, making the patient highly infectious at this point. at about the same time that the sores in the mouth begin to open, a rash develops on the skin. the rash is said to spread in a centrifugal pattern, starting on the face, then spreading to the extremities. the lesions progress from macules, to papules (day of rash), umbilicated vesicles (day [ ] [ ] , and pustules (day ) before crusting over (fig. ) . in contrast to chickenpox (varicella), in smallpox, all the lesions progress at the same stage and the lesions are more densely concentrated on the face and extremities (figs. and ) . a single suspected case of smallpox is a public health emergency and the local public health agency should be notified immediately if there is a suspected case. imaging does not play a major role, because the respiratory symptoms tend to develop after the skin lesions. a few individuals who care for smallpox victims, or who have been vaccinated, develop a pulmonary form of smallpox without skin lesions. in these cases, chest radiography or ct may be helpful. the chest radiograph shows ill-defined nodular opacities in the upper lung fields, which may persist for months before calcifying. vhf clinical presentation of vhf depends on several factors, including specific virus, virulence of the strain, route of exposure, dose, and host factors (table ) . , the general feature that all vhf have in common is that they cause microvascular damage, leading to symptoms associated with increased vascular permeability, potentially resulting in hypovolemic shock or frank hemorrhage. medical imaging is not helpful in diagnosing these conditions, and the general laboratory findings are nonspecific, but often reveal evidence of hepatitis and hypovolemia. the specific diagnosis depends on microbiological testing (see table ). the diagnosis of a bioterrorism event secondary to the use of biological toxins depends on the presentation of unusual clusters of cases. identifying the specific toxin can be challenging but the clinical presentation of some toxidromes can be useful in suggesting the agent involved. the clinical syndromes associated with ricin poisoning vary based on the mode of entry into the body. inhalation of ricin leads to symptoms within hours, which include dyspnea, fever, cough, pulmonary edema, and chest tightness, whereas ingestion of ricin results in vomiting and diarrhea, leading to dehydration, shock, hallucinations, seizures, and hematuria. the typical onset of symptoms after ricin poisoning averages from to hours up to hours. laboratory findings associated with ricin poisoning are nonspecific but include metabolic acidosis, increased results for liver function tests, anemia, increased creatinine level, leukocytosis, and hematuria. aerosolized botulinum toxin, likely to be experienced in a bioterrorism setting, produces disease that mimics food-borne, infant, and wound botulism clinically. the clinical features that are anticipated with the inhalation of botulinum toxin include descending paralysis starting with diplopia, ptosis, fixed dilated pupils, dysphagia, respiratory failure, urinary retention, and constipation. with the ingestion of botulinum toxin, the clinical features begin with gi symptoms, including nausea, vomiting, diarrhea, bloating, and pain, before the development of the paralysis. onset of symptoms after exposure to botulinum toxin occurs as early as hours after inhalation, but if ingested typically there is a -hour to -hour delay before symptoms begin. however, the onset may be delayed as much as days. the diagnosis of botulinum intoxication is based on laboratory detection of the toxin in blood, food, or stool. the clinical presentations of mycotoxins vary based on the specific toxin. aflatoxin ingestion produces clinical features acutely, including hemorrhagic liver necrosis and pulmonary edema with chronic features, including the development of hepatic cancer. the effects and clinical presentation of inhaled aflatoxin are not known. t can be absorbed through the skin or inhaled. the clinical presentation in the acute phase includes pain on contact with skin or eyes, conjunctivitis, blurred vision, rhinorrhea, epistaxis, dyspnea, wheezing, tachycardia, shock, vomiting, diarrhea, erythema, and blistering. delayed symptoms present approximately week after exposure and include thrombocytopenia, neutropenia, anemia, and coagulopathy. seb is a superantigen, which causes massive stimulation of t cells and cytokine storm, which produces the associated clinical features. ocular exposure results in conjunctivitis and eye swelling, whereas inhalation causes fever, chest pain, gi symptoms, pulmonary edema/ards, and shock. the respiratory effects may not be seen for up to hours after exposure. as with most other infectious diseases, considerations for the management of bioweapons should include consideration of ( ) vaccination to prevent infection/illness, ( ) treatment of infection/illness, and ( ) prophylaxis after exposure to prevent clinical infection/illness. also, as is common with most other infectious diseases, there are often several antimicrobial regimens that can effectively treat a specific bioterrorism agent, and for others there are no effective treatments. table presents the generally accepted international recommendations for vaccination, treatment, and prophylaxis of bioterrorism agents. however, clinicians should always consult the most recent guidelines published by their public health authority when making clinical management decisions regarding bioterrorism agents. in addition to the current therapies, new drugs and vaccines are being developed specifically to address the threat of bioterrorism. with the exception of possibly cutaneous anthrax, there are no specific indications for surgical management of any bioterrorism organisms. even in the case of anthrax, surgical debridement has primarily been used for injection anthrax. , supportive care for victims of a bioterrorism event involves components: the care of the individual patient and the response to a mass casualty event. despite the heightened awareness of the potential for bioterrorist events since , many hospitals remain unprepared for biological threats. a study of uk emergency departments (eds) revealed that % did not have isolation facilities, and only % had departments with independent ventilations systems that would allow for the department to be isolated from the rest of the hospital. in addition, the survey found that isolation procedures in many eds were poor; for example, % would not have isolated a patient with potential sars and % would not isolate a patient with chickenpox. the task force for emergency mass critical care provides guidelines for hospitals to prepare for and manage mass critically ill casualties from events such as a bioterrorism attack. critical care physicians should be familiar with these guidelines and prepared to respond in such circumstances, because if they are not, all of their skills and knowledge for treating individual patients are of little use as the system becomes overwhelmed. supportive care of individual patients can generally be grouped into categories based on the class of agent involved: bacterial, viral, or toxin. bacterial and viral agents typically produce a sepsis syndrome with vascular leak, particularly in the case of vhf, as well as variable degrees of a systemic inflammatory response. supportive management is similar to the standard best practices for managing septic patients (box ). particular attention needs to be directed toward ventilatory support, with lung protective ventilatory strategies to minimize the development or exacerbation of adult respiratory distress syndrome. significant fluid shifts are to be expected given the vascular leak, requiring judicious volume resuscitation and cardiovascular support with vasopressors and inotropes based on goal-directed therapy. supportive therapy for patients involved in bioterrorism attacks with biotoxins varies based on the specific toxin. in the case of exposure to botulinum toxin, the primary support required is mechanical ventilation, hydration, and nutritional support until the paralysis resolves. toxins such as seb produce a response similar to sepsis and are supported by the sepsis protocols described earlier. ricin and mycotoxins both act at the cellular level, and although supportive therapies should be attempted, they may be of little benefit in altering the outcomes for patients. for mycotoxins specifically, there may be a role for the addition of steroids as a component of supportive care. data regarding patient outcomes after exposure to bioweapons or bioterrorism agents are, for the most part, lacking, given the paucity of cases and that most research has been carried out by government or military organizations and the results cannot be shared publically. table summarizes the published outcomes after exposure to bioterrorism agents when data are available. however, the outcomes from previous incidents, and in particular from naturally occurring illness, may not predict future outcomes, because bioterrorism agents may undergo genetic manipulation to increase their virulence or introduce antibiotic resistance, which decreases the efficacy of treatments. although to the average clinician, bioterrorism may seem to be only a remote possibility, it is not only a reality of the times in which we live but also bioweapons have been used for centuries. critical care physicians play a critical role in the response to a bioterrorism attack, and even more importantly, in identifying that an attack has occurred in the first place. an effective response to a bioterrorism incident requires a coordinated effort between clinicians and public health. critical care clinicians must be familiar with the diagnosis and management of the most likely bioterrorism agents, and also be adequately prepared to manage a mass casualty situation. index case of fatal inhalational anthrax due to bioterrorism in the united states the anthrax attacks years later biological weapons control. prospects and implications for the future potential bio-terror agents entomological terrorism: a tactic in asymmetrical warfare bioterrorism: preparing for the impossible or the improbable the threat of bioterrorism anthrax as a biological weapon, : updated recommendations for management bioterrorism-preparing to fight the next war anthrax infection an overview of anthrax infection including the recently identified form of disease in injection drug users the sverdlovsk anthrax outbreak of bioterrorism-related inhalational anthrax: the first cases reported in the united states a biological decontamination process for small, privately owned buildings comparative sporicidal effects of disinfectants after release of a biological agent decontamination after a release of b. anthracis spores threats in bioterrorism. i: cdc category a agents tularemia as a biological weapon: medical and public health management tularemia: the disease and the weapon insects as weapons of war, terror, and torture q fever: the neglected biothreat agent threats in bioterrorism. ii: cdc category b and c agents pathogenic rickettsiae as bioterrorism agents pathogenesis of burkholderia pseudomallei and burkholderia mallei rethinking smallpox an overview on the use of a viral pathogen as a bioterrorism agent: why smallpox? modeling potential responses to smallpox as a bioterrorist weapon the economic impact of a bioterrorist attack: are prevention and postattack intervention programs justifiable? viruses of the bunya-and togaviridae families: potential as bioterrorism agents and means of control interim guidance for managing patients with suspected viral hemorrhagic fever in us hospitals coccidioides species as potential agents of bioterrorism bioterrorism: toxins as weapons developing a consensus framework and risk profile for agents of opportunity in academic medical centers: implications for public health preparedness the history and threat of biological warfare and terrorism unusual epidemic events: a new method of early orientation and differentiation between natural and deliberate epidemics bioterrorism preparedness and response: clinicians and public health agencies as essential partners biologic and chemical weapons of mass destruction simulated anthrax attacks and syndromic surveillance late recognition of sars in nosocomial outbreak critical care and biological disasters: lessons learned from sars and pandemic influenza planning definition and functions of health unified command and emergency operations centers for large-scale bioevent disasters within the existing ics medical management of the suspected victim of bioterrorism: an algorithmic approach to the undifferentiated patient severe acute respiratory syndrome nato handbook on the medical aspects of nbc defensive operations bioterrorism and critical care predicting hospital surge after a largescale anthrax attack: a model-based analysis of cdc's cities readiness initiative prophylaxis recommendations diagnostic analyses of biological agent-caused syndromes: laboratory and technical assistance a review of sentinel laboratory performance: identification and notification of bioterrorism agents radiologic manifestations of potential bioterrorist agents of infection clinical predictors of bioterrorismrelated inhalational anthrax accuracy of screening for inhalational anthrax after a bioterrorist attack inhalational anthrax due to bioterrorism: would current centers for disease control and prevention guidelines have identified the patients with inhalational anthrax from screening for inhalational anthrax due to bioterrorism: evaluating proposed screening protocols the office of the surgeon general at tmm publications state-of-the-art therapeutic medical countermeasures for viral threat agents injection anthrax causing compartment syndrome and necrotising fasciitis the surgical management of injectional anthrax emergency departments (eds) in the united kingdom (uk) are not prepared for emerging biological threats and bioterrorism summary of suggestions from the task force for mass critical care summit prevention of laboratory-acquired brucellosis comparison of efficacy of ciprofloxacin and doxycycline against experimental melioidosis and glanders key: cord- -vgjz ts authors: nan title: th international congress of the european association for endoscopic surgery (eaes) sevilla, spain, – june date: - - journal: surg endosc doi: . /s - - -x sha: doc_id: cord_uid: vgjz ts nan laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. bile duct injury (bdi) is a rare but very serious complication of the procedure, with a significant impact on quality of life and overall survival. the high frequency of bdi with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of bdi is misinterpretation of biliary anatomy. intraoperative cholangiography (ioc) has been advised by many authors as the technique reduces the risk of bdi. however, the procedure has inherent limitations and is therefore reserved for select cases. fluorescent cholangiography using indocyanine green(icg) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. a comparative study was contacted by administering icg intravenously or intrabiliary during the operation. forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups: in group a icg was administered in a dose . mg in ml solution intravenously hour before surgery. in group b icg was injected intrabiliary in a . mg/ml solution mixed with the patient's bile. also, we observed and analysed the following parameters, liver function, b.m.i, asa score and possible complications, before and after operation. results: group a. intravenous icg was administered in patients. there was no any reaction and the extrahepatic biliary anatomy was identified well. there was no bdi or any complication related to the procedure. group b. icg was injected intrabiliary in patients during the laparoscopic procedure. in all but one patient the extrahepatic biliary tree was delineated very well. in one patient part of icg solution was injected into the gallbladder wall and this resulted in a partially confusing image. there was no bdi and no postoperative complication conclusions: fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation orintravenous injection h before the procedure. the later technique is more easy to perform and does not require catheterization of the biliary tree. endoscopia digestiva chirurgica, policlinico universitario ''a. gemelli'', rome, italy; ihu, strasbourg, france; camma group, icube, university of strasbourg, cnrs, ihu strasbourg, strasbourg, france; ircad, strasbourg, france; digestive and endocrine surgery, nouvel hopital civil, university of strasbourg, strasbourg, france; digestive and endocrine surgery, ihu-strasbourg, strasbourg, france aim: surgical societies are united in promoting the critical view of safety(cvs) during laparoscopic cholecystectomy(lc). nonetheless, reports have shown a discrepancy between the operative reports and the correct application of cvs, which may explain the stability of bile duct injury rates. therefore, surgeons and computer scientists at our institution are developing a machine-learning algorithm to automatize cvs assessment. however, the lack of a consistent cvs video assessment framework limits the ability to generate data to train the artificial intelligence. here we describe and test a method for cvs evaluation in videos. method: between march and july , consecutive videos of lc performed at nouvel hospital civil(strasbourg, france) were recorded. two independent reviewers assessed the achievement of cvs in the s video sequences preceding clipping of cystic duct and artery. in addition to the 'doublet view' method, a 'binary' video evaluation method was tested: each of the criteria composing the cvs( structures entering the gallbladder, clearance of the hepatocystic triangle and lower part of the cystic plate) was classified as achieved or not. if the criteria were met, then the cvs was considered achieved. inter-rater agreement for cvs and for each of the criteria was evaluated. results: twenty-two videos( fundus first and partial lc, and broken videos) were excluded from the cvs analysis. cvs elements were assessable in all but one s videos sequences( . %). after mediation, cvs was achieved in / ( . %) of lc. the cystic plate was identified in only . % of videos. inter-rater agreement using the doublet view vs. the binary method was as follows: . %(? = . ) vs. . %(? = . ) for cvs achievement, . %(? = . ) vs. . %(? = . ) for the structures, . %(? = . ) vs. . %(? = . ) for the hepatocystic triangle and . %(? = . ) vs. . %(? = . ) for the cystic plate ( fig. ) . conclusions: reliable cvs assessment is crucial to generate consistent data for machine-learning algorithms aiming at decreasing bile duct injury after cholecystectomy. our binary cvs video assessment method showed higher inter-rater reliability than the doublet view, originally described for assessment of photos. further studies are on going to validate the cvs assessment in videos and support our initial results. surg endosc ( ) the vital role of surgeries in healthcare requires a constant attention for improvement. surgical process modeling is an innovative and rather recently introduced approach for tackling the issues in nowadays complex surgeries, involving complex logistics, much technology, and large teams. surgical process modeling allows for evaluating the introduction of new technologies and tools prior to the actual development and is beneficial in optimization of the treatment planning and treatment performance in operating room. in this study, we first discuss the concepts associated with surgical process modeling, aiming to clarify them and to promote their use in future studies. next, we apply these concepts to analyze the procedure of challenging interventions, minimally invasive liver treatment (milt) methods, with the ultimate goal of improving and optimizing the treatment procedure. the procedure model of current treatment activities and planning of various milt methods and the associated techniques, are analyzed and combined into a generic procedure model of milt, which provides a firm foundation for qualitative and quantitative analysis of different milt procedures. the generic procedure model is validated by data from erasmus medical center (rotterdam, the netherlands) and oslo university hospital (oslo, norway) . the proposed procedure model is designed to be a basis for improvement of the procedure and to determine how and where the new technologies can be best, effectively and efficiently, employed in the clinical practices prior to and/or during actual development of the new technologies for milt. as a conclusion, the current work illuminates the importance of surgical process modeling for improving different aspects of treatment procedures and provides an overview of various modeling strategies that can be used to establish surgical process models. the generic procedure model of various milt methods, including laparoscopic liver resection, laparoscopic liver ablation and percutaneous ablation, is introduced and validated which is a basis for introduction of the optimized procedure model of milt objective: to determine the most appropriate time to start total laparoscopic living donor right hepatectomy (tldrh) based on the experience with laparoscopic liver resection (llr). summary background data accumulation of experience in llr is essential before starting tldrh to ensure donor safety. methods: we retrospectively reviewed data of and consecutive patients who underwent llr and donor hepatectomy, respectively, between and . operative outcomes of laparoscopic major hepatectomy (lmh) were compared between two periods based on tldrh introduction (phase i - vs phase ii . learning curve of llr was evaluated using the cumulative sum (cusum) method to determine the optimal time of tldrh introduction. conclusion: accumulating an experience of at least lmh cases is needed in low-volume lt centers before starting tldrh to ensure donor safety. introduction: the number of surgical adverse events is still too high. an important number of these adverse events occur within the operating room (or) and are in fact preventable. in order to reduce adverse events in the or, we simply need to know what went well and what can be done better. the aim of this study was to analyze and debrief a predefined selection of surgical procedures, with the use of an operating room 'black box', to identify commonly observed safety threats and resilience support events. methods: in the period - , predefined gastro-intestinal laparoscopic cases were recorded by the or black box'. the postoperative surgical team assessment record (star) questionnaire was used. the recordings were analyzed by specifically trained raters, using the systems engineering initiative for patient safety (seips) model of work system and patient safety to identify relevant safety threat and resilience support events. qualitative data analysis was used to identify the most commonly discussed events during the team debriefings. results: in only . % (n = ) of times or team members, when asked direct following surgery, indicated that they had noticed aberrations (n = ) during the case. a mean number of . (sd . ) relevant positive and negative events (e.i. aberrations) per surgical procedure were identified using the black box performance report. on average, . (sd . ) of events identified by the black box were rated as safety threats. most events discussed during the team debriefings were related to communication. conclusion: these results once again highlighting the importance of clear and closed-loop communication in the operating room. theatre staff underestimated the number of aberrations occurring in the or, when asked to retrieve from memory. postoperative structured team debriefing may be important for resolving incorrect assumptions between operating team members to avoid future unnecessary miscommunication. background: the eaes has recently published an intraoperative adverse event classification to assist the direct measurement and routine reporting of minimal access surgery interventions. we aimed to explore the clinically validity and reliability of the classification. methods: a prospective evaluation utilising case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision surgery randomised controlled trial was performed (isrctn ). enacted adverse events identified with the observational clinical human reliability analysis technique were graded with the eaes classification by two blinded, independent assessors. test-retest reliability was explored using grades previously applied during the development of the classification with intraclass correlation co-efficients calculated. clinical validity was assessed using -day morbidity events, the clavien-dindo classification and the highest eaes grade per case. results: laparoscopic cases ( h of surgery) contained error events which were all successfully categorised. excellent inter-rater and test-retest reliability was seen (icc . , % ci . - . , p \ . and icc . , % ci . - . , p \ . respectively. % of patients experienced post-operative morbidity (median event, range [ ] [ ] [ ] [ ] [ ] [ ] . labelling analysed cases by their highest eaes classification grade gave % grade , % grade and % grade procedures. % of grade cases developed a morbidity event, but this significantly increased in grade and operations ( % and %, p = . ). the number of complications and highest recorded clavien-dindo grade increased with each additional grade ( . ± . vs. . ± . vs. . ± . , p = . and median vs. vs. , p = . respectively). anastomotic leak and re-operation were correctly captured by the allocated eaes grade ( . % vs. . % vs. %, p \ . and % vs. % vs. %, p \ . respectively). there was a significant rise in length of stay observed with increasing eaes grade (median vs. vs. days, p \ . ). conclusion: in the context of major laparoscopic surgery, the eaes intraoperative adverse classification is seen to be a clinically valid and reliable assessment method. psychological medicine, nuhs, singapore, singapore aims: neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop is not properly studied before and we planned to do this using functional near infrared spectroscopy (fnirs) which is a non-invasive optical brain imaging tool that measures cortical oxygenation change which is used as a marker of pre-frontal cortex activity (pfca). methods: this randomised controlled trial examined the pfc activity differences in two groups of novice medical students during the acquisition of basic laparoscopic tasks. 'trained-group' had standerdised oneto-one training on the tasks, while the 'untrained-group' had no prior trainining and was just shown a video of the tasks. the pfca was measured pre and post intervention using a portable fnirs device. primary outcome was the difference in the pfca pre and post intervention. secondary outcomes were the differences in pfca between the tasks and between the sexes. results: trained and untrained medical students with an equal sex distribution and a comparable age distribution were invovlved in the study. all students were right handed. trained group had a significantly attenuated pfca in the 'precision-cutting' (p = . ) and 'suture-insertion' (p = . ) tasks compared to the untrained group. subgroup analysis based on sex revealed significant attenuation in pfca in trained females compared to untrained females across of the laparoscopic tasks: 'pegstransfer' (p = . ), 'precision-cutting' (p = . ), 'suture-insertion' (p = . ). no significant pfca attenuation was found in male students who underwent training compared to untrained males. conclusion: a standardised laparoscopic training workshop promoted greater pfca attenuation in female medical students compared to males. this suggests that female and male students respond differently to the same instructional approach. these results may have implications for surgical training and education such as a greater focus on one to one surgical training for female students and use of pfca attenuation as a form of neurobiological feedback as a measure of learning curve in surgical training. robot assisted versus laparoscopic advanced suturing learning curve e. leijte , i. de blaauw , c. rosman , s.m.b.i. botden surgery, radboudumc, nijmegen, the netherlands; pediatric surgery, radboudumc, nijmegen, the netherlands aims: compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills as minimally invasive suturing. this study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted advanced suturing method: novice participants, with the knowledge of basic surgical procedures, were recruited and performed three suturing tasks on the eosim laparoscopic augmented reality simulator or the robotix robot assisted virtual reality simulator. each participant performed an intracorporeal suturing, tilted plane needle transfer and anastomosis needle transfer task. to complete the learning curve, all tasks were repeated for maximal twenty repetitions or until a plateau was reached three consecutive times. clinical relevant and comparable parameters regarding time (seconds), movements and safety were recorded. intracorporeal suturing was used to visualize and compare the learning curves between the groups. results: forty-six participants completed the learning curve, of which laparoscopically and robot assisted. when comparing the suture time, the plateau was reached much faster in the robot assisted group ( - repetitions) than the laparoscopic group ( ) ( ) ( ) repetitions) as shown in figure . there was a significant difference in 'time per suture', during the whole learning curve with median values of versus (first knot), versus (fifth) and and (eighteenth), all with a p \ . . however, the parameter 'adequate surgical knot' was reached earlier in the laparoscopic group than in the robot assisted group. first: % versus %, fifth: % versus %, and eighteenth: % versus %. when assessing the 'needle out of view' parameter, the robot assisted group scored a median of . and . s during the first, respectively eighteenth knot, and the laparoscopic participants had their instruments out of view for and s during the first respectively eighteenth knot. conclusion: the learning curve of minimally invasive suturing can be reduced with the use of robot assisted surgery, with a specific reduction in operation time. the rate of adequate knots seemed to remain lower in robot assisted surgery, although this could be due to the virtual reality aspect of the simulator. introduction: endoscopic sleeve gastroplasty (esg) is a novel promising bariatric endoscopy treatment. gastric volume reduction and delayed gastric emptying are the mechanisms driving weight loss. however, little is known about the factors influencing the effectiveness of weight loss overtime. the present study aims at evaluating the correlation between endoscopic suture appearance and excess weight loss (ewl%) at and months follow up. patients and methods: all patients who underwent follow-up endoscopy at and months after esg were included. esgs were classified in groups according to endoscopic appearance of the gastric sutures: optimal (group ) when all stitches were in place and tights; suboptimal (group ) when one or more stiches were displaced; loose (group ) when all the sutures were completely disrupted. bmi at enrollment and ewl% at and months were recorded and compared to the endoscopic appearance. results: a total of patients were included in the analysis. at months, ( . %) patients had an optimal esg, ( . %) had a suboptimal sleeve and ( . %) had complete sutures failure. bmi at enrollment and ewl% were respectively . ± . and . ± . % for group , . ± . and . ± . % for group and . ± . and . % ± . % for group . twenty five patients had months egds: ( %) presented an intact esg and were classified in group , ( %) in group and ( %) in group . twelve months ewl% was respectively . ± . %, . ± . and ± . %. initial bmi significantly correlated with suture status at both (rho - . ; p \ . ) and months (rho - . ; p = . ) follow-up. furthermore, the sutures' appearance itself correlated with ewl% at both time points (rho ? . ; p = . and rho . ; p = . respectively). conclusion: our preliminary results show that the aspect of the endoscopic suture has a significantly impact on ewl% at and months after esg. furthermore, bmi at enrollment seems to predict endoscopic suture duration overtime. larger studies and longer follow-up are needed to further validate our preliminary findings. background and aim: endoscopic sleeve gastroplasty(esg) is a relatively novel endoscopic procedure that reduces the gastric lumen with proven less complications and less months weight loss compared to laparoscopic sleeve gastroplasty (lsg) . at present there are no studies investigating the role of multidisciplinary approach in esg. the aims of the present study were to evaluate the role of multidisciplinary assessment(ma) prior esg, weight loss outcomes, quality of live improvements and adverse events. material and methods: from may to may all patients that underwent esg were retrospectively evaluated from a prospective database. until september before esg only psychiatric evaluation was requested, while after this date we adopted the guidelines of the italian society for obesity surgery and all patients were evaluated on a multidisciplinary fashion prior esg. the multidisciplinary team was composed by:gastroenterologist, surgeon, psychiatrist, endocrinologist and dietitian. patients were divided in two groups:group were patients with esg before ma and group were patients with esg after ma. we compared this two groups in terms of weight loss outcomes, quality of live improvements and adverse events. quality of live was measured with the bariatric analysis and reporting outcome system(baros).all procedures were done with the apollo overstitch suturing system(apollo endosurgery) and a double channel gastroscope olympus tgif- (olympus japan).all procedures were done in general anesthesia and with insufflation of co . all patients had ambulatory visit t , and months after esg and weight loss outcomes were measured in terms of excess weight loss (%ewl),the total body weight loss (%tbwl) and baros scale were assessed. statistical analysis was done with chi-square test and \ . value was considered significant. results: patients were identified ( female; mean age . , range - ) . mean bmi at inclusion was . (range . - . ). mean %ewl and %tbwl at months was . and . respectively (table ) .non procedure related complications were observed. comparing the two groups there was significant(p \ . ) difference in terms of %ewl and %tbwl (table ) ,with better results in group . there was also a significant improvement in the baros scale in the patients in group . conclusions: ma before esg has a fundamental role in terms of better procedure outcomes for both weight loss and quality of live in obese patients. gastroenterology, hadassah medical center, jerusalem, israel, israel aims: the over-the-scope clip (ovesco) is a novel endoscopic tool that enables non-surgical management of gastrointestinal defects. the aim of this study was to report our experience with ovesco for patients with staple line leaks following laparoscopic sleeve gastrectomy (lsg). methods: a prospectively maintained irb-approved institutional database was queried for all patients treated with ovesco for staple line leaks following lsg from to . primary outcome was complete resolution of leak following ovesco as defined by return to complete oral nutrition and no evidence of leak on imaging. secondary outcome was the number of additional endoscopic or surgical procedures needed following ovesco. results: twenty-five patients ( males, females) were treated with ovesco for staple line leaks following lsg. the median age was years (range - ), and mean body mass index was kg/m . nine patients ( %) were referred from an outside hospital. the median time from index operation to leak diagnosis and from leak diagnosis to ovesco was days (range - ), and days (range - ), respectively. all patients had upper staple-line leaks near the gastroesophageal junction. initial treatment included antibiotics- patients; computed tomography guided drainage and antibiotics- patients; and laparoscopic drainage- patients. ovesco led to final resolution of leak in patients ( %) within days of clip deployment (range - ). leaks which persisted following ovesco were eventually resolved with a combination of ovesco and stent- patients ( %), total gastrectomy and esophago-jejunostomy- patients ( %), and endoscopic suturing- patient ( %). one mortality was noted in a patient who suffered multiorgan failure. the number of additional endoscopic sessions ranged from to (median ). no procedure related complications were noted. all patients were treated with total parenteral nutrition and the total length of stay was days (range - ). conclusions: despite its low success rate, ovesco should be part of the bariatric surgeon's non-surgical armamentarium in treating staple line leaks following lsg. r. bademci , r. vilallonga , p. alberti , r. renato , c. yuhamy , s.s. cordero , l. posadas general surgery, istanbul medipol üniversitesi, istanbul, turkey; bariatric surgery, vall d'hebron, barcelona, spain background: in cases of morbid obesity, treatment is generally applied as either a surgical or endoscopic approach. the number of primary obesity surgery endolumenal (pose) procedures is increasing but the reliability and effectiveness is unclear as yet. the aim of this study was to present a series of cases that required revision surgery due to pose failure and to reveal possible alternative surgeries. materials and methods: a retrospective comparison was made of the data of obese patients with pose failure and conversion to surgical procedures between and in respect of operation, medical illness and bmi results. results: the patients comprised % females, % males with a mean age of . ± . years and mean follow-up period of . ± . months. on average, patients lost . ± . kg, with an average excess weight loss of . %. conclusion: no firm conclusions can be drawn from such a small group. although sg seems to be a safe procedure and should be considered as the first technique to be applied following pose failure, it is possible to perform gastric bypass on patients with this endoscopic precursor. introduction: the population of post bariatric surgery patients is rapidly increasing worldwide. due to the altered anatomy post roux-en-y gastric bypass (rygb), conventional endoscopic management for choledocholithiasis is challenging. these patients are now commonly managed by means of a laparoscopic assisted ercp. although effective, this requires significant resource utilization and potential morbidity related to the need for surgical intervention. we present our preliminary experience with a purely percutaneous management of choledocholithiasis in bariatric patients post-rygb. methods: a retrospective single center review identified five patients with choledocholithiasis after bariatric rygb who underwent percutaneous cbd access and treatment by interventional radiology. four patients underwent percutaneous transhepatic cbd access while one patient underwent percutaneous trans-cholecystic cbd access. in three of the five patients conscious sedation alone was sufficient to perform the procedure. results: all patients had radiologically confirmed choledocholithiasis and were clinically symptomatic prior to intervention. the biliary tree was successfully accessed percutaneously and cleared in all five patients. in the four patients where a percutaneous transhepatic access was utilized, three patients required only fluoroscopic balloon sphincterplasty and sweep of the cbd to clear the ductal stones, while the fourth required percutaneous cholangioscopy assisted lithotripsy for clearance. in the fifth patient with non-dilated intrahepatic bile ducts a trans-cholecystistic approach into the cbd was utilized with percutaneous cholangioscopic assistance to clear the ductal stones. all procedures were completed successfully with no post procedure complications. conclusion: percutaneous clearance of cbd stones in bariatric patients presents a minimally invasive alternative to current surgical practice. the use of conscious sedation and the purely percutaneous approach may potentially reduce morbidity and resource utilization for this increasingly common clinical scenario. laparoscopic narbona-arnau procedure to control the gerd after lsg- years results of a prospective study i.c. hutopila, c. copaescu background: after the laparoscopic sleeve gastrectomy (lsg) alone or associated with calibration of the esophageal hiatus, for some patients the reflux symptoms worsen postoperatively due to development of a hiatal hernia (hh) or due to the recurrence of the hh previously repaired. for these situations, when the conservative treatment fails, are proposed some surgical solutions, one of them cardiopexy with teres ligament-narbona arnau. objective: is to establish a standardized laparoscopic technique for cardiopexy using the teres ligament (narbona arnau technique) and to analyze the procedure's outcomes. methods: the study was performed in a bariatric and metabolic center of excellence-ponderas academic hospital. all the patients undergoing narbona arnau procedure to control gerd after lsg since were included and prospectively analyzed. the selection criteria included lsg patients, presenting hh and symptomatic gerd. preoperative investigations were upper gastrointestinal endoscopy, radiological contrast study, ph-metry, computed tomography with oral contrast. results: patients were included into the study. gerd and hh were preoperatively documented in all the cases. one patient was excluded after years of follow up after being converted to a laparoscopic roux-en-y gastric bypass, for intense relux symptoms. no incidents during surgery. for cases laparoscopic narbona arnau technique was performed concurrent with re-sleeve gastrectomy and gastric curvature plication. without postoperative complications. postoperative follow-up at months, , and years, the percentage of patients without gerd symptoms and free of treatment with ppis was , %, , %, , %, respectively . %. at years postoperatively the upper gi endoscopy showed remission/ improvement of the degree of esophagitis for patients. for the same period of follow-up, the ph-metry highlighted a normal value of demeester score for . % o patients (all the patients had preoperatively high de meester scores). no objective signs of hiatal hernia recurrence at imagistic investigations and upper gastrointestinal endoscopy were encountered. conclusions: complete preoperative evaluation is mandatory for choosing the optimal intervention. laparoscopic narbona arnau technique after lsg is proved to be a good option for the treatment of symptomic gerd, but further studies with high-volume patients are necessary. introduction: the aim of this study was to investigate the influence of baseline glycated hemoglobin level (hba c) level in bariatric patients on postoperative outcomes. we found scarce of clinical data regarding influence of baseline hba c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study. methods and procedures: retrospective cohort study analyzed patients who underwent laparoscopic: sleeve gastrectomy (sg), roux-en-y gastric bypass (rygb) or mini-gastric bypass (mgb) for morbid obesity in seven referral bariatric centers. patients were divided into groups depending on preoperative hba c : hba c \ . %; . - . % and c . %. primary endpoints: influence of hba c level on perioperative ( -days) and postoperative ( -months) morbidity rates, operation time, length of hospital stay (los) and readmission rate. results: study group included , % females and % males. median age was ( - ) years. median hba c was . ( . - . ). hba c \ . % was present in % patients, hba c . - . % in %, and hba c c . % in %. percentage of male patients increased in groups from % in hba c \ . % to % in hba c c . % significantly. same tendency through groups we observed in case of bmi and age. uncontrolled diabetes (hba c c . %) was present in . % patients, while . % patients were not on antidiabetic medications despite having hba c c . %. median operative time in patients was significantly longer than in hba c \ . % and hba c . - . %. -days morbidity rate was . % and did not differ groups significantly, as -months morbidity rate (excl. -days) of . % . los did not differ groups significantly. patients having hba c in range of . - . % and with hba c c . % did not have significantly increased odds for perioperative morbidity, -months postoperative morbidity as compared with those with hba c \ . %. patients with hba c c . % had increased or for prolonged los as compared to those with hba c \ . % (or . ; % ci . - . ). hba c did not influence or for readmissions. patients with baseline hba c c % had significantly increased chances for hospital readmission (or . , % ci . - . ). conclusion: baseline level of hba c did not influence chance for perioperative morbidity, -months postoperative morbidity and prolonged los. patients with hba c c % have increased chance for hospital readmissions. surg endosc ( ) :s -s introduction: surgical resection is crucial for curative treatment of rectal cancer. through improvements in treatment and minimally invasive techniques, -year survival improved to over % of patients. the most recently introduced surgical technique is robotic-assisted surgery (ras). ras and conventional laparoscopy (cl) seem equally effective in terms oncological control. however, ras possibly provides further advantages e.g. d vision or the endowrist function, which have the potential to maximize the precision of surgery and thus has benefits for functional outcomes such as sexual function as well continence. therefore, the aim of this systematic review and meta-analysis was to compare functional outcomes of cl and ras for rectal cancer. materials and methods: this review was done according to the prisma and amstar guidelines andregistered with prosper-o(crd ). the search was planned with the pico criteria and conducted on medline (via pubmed), web of science and central. two independent reviewers first screened titles and abstracts and then eligible full-texts. inclusion criteria were original studies, comparative studies for cl vs. ras for rectal cancer as well as reporting of functional outcomes. quality assessment was done with the newcastle-ottawa-scale for non-randomized studies and the cochrane tool to assess risk of bias for randomized trials. results: the search retrieved hits, of which studies with patients met inclusion criteria. preliminary results yielded a lower rate of urinary retention for ras (odds ratio (or)[ %-confidence interval (ci)] . [ . , . ] ) while there were no differences for ileus (or[ci]: . [ . , . ] ). erectile function (iief) showed no differences after (mean difference (md)[ci] . [- . , . ] , (md[ci] . [- . , . ] ) and months (md[ci] . [- . , . ] ). in terms of urinary problems (ipss) there were no differences postoperative (md[ci] - . [- . , . ]) and month postoperative md[ci] - . [- . , . ] ), but advantages for the cl group after months md[ci] - . [- . , - . ] ). discussion: ras and cl seem to provide similar functional outcomes after rectal cancer surgery. however, the results need to be interpreted carefully as none of the studies had any functional outcome defined as primary endpoint. future studies should evaluate both surgical approaches in terms of functional outcomes and should be appropriately powered. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm .intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ) all patients required a reoperation. intraoperative findings at shows in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to non-infectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. conclusion: our results shows that the use of knotless barbed suture for enterotomy closure after laparoscopic intracorporeal right colectomy is safe, reproducible and associated with shorter operative time. aims: the accurate measurement and staging of rectal cancer, in particular the distal margin of low rectal tumours, is of paramount importance to optimise oncological surgical resection whilst preserving function. it is well recognised that the lower the tumour, the greater the technical challenges, operative time and the possibility of a temporary or permanent stoma. accurate localisation of the tumour is also essential to assist the multi-disciplinary team when considering neo-adjuvant chemoradiotherapy (crtx). the objective was to compare tumour height as reported on magnetic resonance imaging (mri) with endoscopic measurement. methods: a retrospective analysis of rectal tumour heights on pre-operative endoscopy and mri in patients undergoing radical colorectal surgery with curative intent over years from january . rectal tumours were identified as within cm of the anal verge (av). all mri measurements were reported by one of two specialist gastrointestinal radiologists. measurements were taken from the lowermost point of the tumour to the av. endoscopic measurements were as recorded by endoscopists including rectal surgeons, general surgeons, gastroenterologists and a clinical nurse specialist endoscopist. results: records of eighty one patients with histologically confirmed rectal adenocarcinoma were reviewed. median age was years ( to ). twenty three patients had or more endoscopies. on mri the median tumour height from the av was . cm ( . - cm) . on endoscopy the median tumour height was cm ( - cm) . on comparing endoscopy with mri, the median difference was cm ( - cm) . for over a third of patients ( %) tumours were lower on mri than endoscopy, median difference . cm ( . - cm) . only rectal surgeons documented tumour height in relation to the rectal folds. the majority of the repeat endoscopies were performed by surgeons to locate tumours more accurately pre-surgery. on no occasion was it documented whether the tumour had been measured during insertion or withdrawal of the endoscope. conclusions: precise localisation of rectal tumours is imperative to plan complex surgery and give informed counsel to patients. this study demonstrates the urgent need for a standardised protocol for all endoscopists to use while recording the distal extent of rectal tumours. objectives: the aim of the present rct was to compare the incidence of genitourinary (gu) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (lar ? tme) with high or low ligation (ll) of the inferior mesenteric artery (ima). secondary aims included the incidence of anastomotic leakage and oncological outcomes. background: the criterion standard surgical approach for rectal cancer is lar ? tme. the level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on gu function is poorly understood. methods: between june and december , patients who underwent elective laparoscopic lar ? tme in italian nonacademic hospitals were randomized to high ligation (hl) or ll of ima after meeting the inclusion criteria. gu function was evaluated using a standardized survey and uroflowmetric examination. the trial was registered under the clinicaltrials.gov identifier nct . results: a total of patients were randomized to hl (n ) or ll (n ). gu function was impaired in both groups after surgery. ll group reported better continence and less obstructive urinary symptoms and improved quality of life at months postoperative. sexual function was better in the ll group compared to hl group at months. urinated volume, maximum urinary flow, and flow time were significantly (p \ . ) in favour of the ll group at and months from surgery. ultrasound measured post void residual volume and average urinary flow were significantly (p \ . ) better in the ll group at months postoperatively. time of flow worsened in both groups at months compared to baseline. there was no difference in anastomotic leak rate ( . % hl vs . % ll). there were no differences in terms of blood loss, surgica l times, postoperative complications, and initial oncological outcomes between groups. conclusions: ll of the ima in lar ? tme results in better gu function preservation without affecting initial oncological outcomes. hl does not seem to increase the anastomotic leak rate. introduction: robotic single-site cholecystectomy (rssc) has been known to have some advantages such as reducing stress of the surgeon compared to single incision laparoscopic cholecystectomy (silc). however, there are few studies comparing the perioperative outcomes of these two operative methods. patient and methods: between march and february , rssc and silc were performed for benign gallbladder disease in our center. propensity score matching was performed to control variables including sex, age, body mass indes (bmi), diagnosis, american society of anesthesiologist (asa) score and cohorts were selected among the silc group through : matching. the perioperative data of these patients were analyzed retrospectively. the diagnosis was classified into acute cholecystitis, chronic cholecystitis, and gallbladder polyp. results: patient demographics between the two groups were evenly matched. total operation time including docking time was slightly longer in rssc group ( . min vs. . min, p \ . ), but real working time except the docking or set-up was shorter in rssc group ( . min vs. . min, p \ . ). conversion to additional robotic arm or additional port was frequent in silc group ( vs. cases, p = . ). intraoperative bile spillage rate ( . % vs. . %, p = . ) and postoperative hospital stay ( . days vs. . days, p = . ) were comparable in both group. conclusion: both surgical procedures performed safely. but the rssc demonstrated the better performance of the operation with shorter working time and the advantage of overcoming unexpected difficulties during the surgery with low conversion rate compared to silc. even though laparoscopic cholecystectomy(lc) is the gold standard procedure for cholelithiasis, patients are still suffering from various causes of pain. one of main causes is high pressure by pneumoperitoneum which makes peritoneal stretching and diaphragmatic irritation. however, there are few well-designed studies for evaluating pneumoperitoneum. therefore, we conducted a study to compare the postoperative pain after lc at serial different pressure methods. a prospective randomised double blind study was done in patients with benign gallbladder disease. they were divided into groups. each patients underwent lc with different pneumoperitoneum method; group a: far-low ( - mmhg), goup b: low ( - mmhg) and group c: standard pressure ( - mmhg). three groups were compared for pain intensity, duration, analgesic requirement and complications. post-operative pain score was significantly least in far-low pressure group as compared to low or standard pressure group during late periods ( , h). but, there were no pain score difference between far-low and low groups during early period ( , , , h) even though scores of standard group were significant higher than those of low group. number of patients requiring rescue analgesic doses and intraoperative complications were not significantly different among groups. this study demonstrates reducing the pressure of pneumoperitoneum results in reduction in intensity of post-operative pain. this study also shows that low pressure technique is safe with comparable rate of intraoperative complications. however, in immediate postoperative period, there is limitaton of pain relief after low pressure surgery. therefore, there may need new alternatives for pain. background and aim: anatomical hepatectomy with the glissonian approach is widely accepted as an important technique to ensure surgical safety and curability of the carcinoma. however, the histomorphological structure of the hepatic connective tissue is not sufficiently understood by surgeons. this study aimed to clarify the hepatic connective tissue structure using modern tissue imaging and analytical techniques. materials and methods: in total stained thin slices were loaded onto the computer and were reconstructed as dimages and analyzed. results: when the liver capsule enters the liver at the hepatic hilum, it becomes a sheath which envelops the portal pedicle. the hepatocytes in a row that constitute the periportal limiting plate at the edge of the hepatic lobule are firmly supported by the framework of the reticular fiber. the hepatic lobule and the portal area are in contact via the periportal space of mall. the framework of the limiting plate plays a role of a capsule of hepatic lobule (proper hepatic capsule) on the side in contact with the portal area. the binding site between the hepatic capsule and proper hepatic capsule (ppbs) is loose binding and is a layer that is easy to apply to surgical procedures. in order to enter between the liver capsule which became the sheath of the portal pedicle and the proper hepatic capsule at the hepatic hilum, the liver capsule must be dissected to reach the surface of the proper hepatic capsule. then, on the one hand, the portal pedicle is firmly gripped and pulled, on the other hand, the hepatic parenchyma covered by the proper hepatic capsule is pushed to expand between the portal pedicle and the liver parenchyma. at this time, the portal area (glisson's sheath) branched from the sheath of the portal pedicle into the gap of the hepatic lobule breaks like a string. with this dissecting plane, dissecting layer can reach to the next branch of the portal pedicle without entering into the portal pedicle or liver parenchyma. conclusion: understanding the connective tissue constituting the liver and conducting surgery turns the laparoscopic systematic hepatectomy into a standardized procedure. background: postoperative pancreatic fistula (popf) is the primary contributor to morbidity after distal pancreatectomy (dp). to date, no techniques used for the transection and closure of the pancreatic stump showed a clear superiority over the others. this study aimed to compare the rate of popf after pancreatic transection conducted with the reinforced stapler (rs) and ultrasonic dissector (ud) following dp. method: consecutive patients underwent dp from to were retrospectively reviewed. we included dps where pancreatic transection was performed by rs or ud and excluded dps extended to the pancreas head. to overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for popf. results: overall, patients met the inclusion criteria. the rs was employed in patients and ud in cases. after the one-to-one propensity matching, patients were selected from each group. the matched rs and ud cohort have no differences in baselines characteristics except for the mini-invasive approach, that was more common in the ud group ( % vs. %, p = . ). overall, patients ( %) developed a popf, a grade b ( %) and ( %) a grade c. in the rs group the rate of popf was % (n = ) and the ud group % (n = ) with a p \ . . conclusion: the results of this study suggest that the use of rs for pancreatic transection, reduces the risk of postoperative pancreatic fistula. a randomized trial is needed to confirm these preliminary data. aim: this study compares clinical and cost outcomes of robot-assisted single port and open longitudinal pancreaticojejunostomy (rlpj and olpj) for chronic pancreatitis. single incision mis needs more manual skills than conventional multiport operation. the advantage of better operation course is d vision and dedicate instrument. this paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for chronic pancreatitis. materials and methods: clinical and cost data were retrospectively compared between open and ralpj. we collected patients since july, to september, . the patient was supinely placed in reverse trendelenburg position. the assistant surgeon was located between patient's legs. under general anesthesia a trans-umbilical . cm skin incision was made. a single incision advanced access platform with lagis port, glove portÒ (nelis, s. korea) and gelpoint combined with the da vinci si and xi surgical system (intuitive surgical, sunnyvale, ca, usa) pure or plus one was performed. the three arms, no. , no. , and da vinci scope, were in dwelled through the glove portÒ. pneumoperitoneum of mmhg was established through the port. a rigid -degree up scope was used during operation. results: twenty-one patients underwent lpj: open and ralpj. no robot-assisted cases converted to open were noted. patients undergoing ralpj had less intraoperative blood loss, a shorter surgical length of stay, less postoperative pain and lower medication costs. operation supply cost was higher in the ralpj group. no obvious difference in hospitalization cost was found. conclusions: versus the open approach, ralpj performed for chronic pancreatitis shortens hospitalization, less postoperative pain and reduces medication costs; hospitalization costs are equivalent. a higher operative cost for ralpj is mitigated by a shorter hospitalization and less pain control. robotassisted puestow procedure using single port platform is feasible and safe method. the total procedures by da vinci robotic system are safe and easily performed in highly selected patients. general surgery, hospital universitario infanta sofia, madrid, spain; general surgery, hospìtal quirón la luz, madrid, spain aims: the concomitant presence of abdominal wall midline hernias and diastasis recti is frequent. diastasis recti might be a risk factor not only for having but for recurrence of midline hernias. most open surgical procedures not consider the treatment of both pathologies, nor laparoscopic most spread out approaches. the author presents a novel endoscopic, extraperitoneal and retromuscular hernioplasty technique and its preliminary results. methods: a serie of patients is presented. a ct abdominal wall study is performed preoperatively. they all presented abdominal wall midline hernias in presence of a [ . cm concomitant diastasis recti. there were females and males. a totally endoscopic, extraperitoneal and retromuscular repair was performed, that included a midline anatomic restoration, tension-free hernia gap closure, omphaloplasty and skin treatment, if needed in every case. the tension-free massive-meshed hernioplasty included a bilateral totally endoscopic posterior components separation when needed. no drainages were used. all procedures included a bladder catheterization. results: all patient were dispatched within a period under h. no reoperations were needed in postoperative period. postoperative pain was measured by an eva scale. % of the patients have no pain medication after - h dispatching from hospital. % of the patients have a skin suffusion or hematoma. a male patient presented a temporary abdominal asymmetry due to a unilateral posterior component added to his technique. the mean following-up is to months ( - months) . no recurrence was observed. conclusions: preliminary results demonstrate this new approach to be a safe, feasible and a reproductible procedure. the 'terra' novel technique could provide of a new minimally invasive approach to abdominal wall midline hernias repair in the presence of a diastasis recti. only time and new results can predict the spreading out of this 'third way'. results: this study comprised males and females. mean age was years (range - years) and mean body mass index was . gh and mh were found intraoperatively in and cases respectively. mean operative time for all hernias (gh/mh) was min (range - min); min for gh (range - min); and min for mh (range - min). in . % of cases, hernia operative measurement was larger than preoperative size, especially in cases of incisional hernias ( . %). in . % of cases, laparoscopy found additional abdominal wall defects previously undetected by physical examination and by us-and/or ct-scan. a composite mesh and a non-composite mesh (up to cm in size) were used in . % and . % of cases respectively. the ethicon securestrap?? absorbable fixation device straps for sm fixation were employed in . % of cases. mean length of hospital stay was . days. mean follow-up time was months (range - months). in our study, there was one early (\ days) postoperative seroma ( . %), plus one late, small ( cm) symptomless recurrence, but neither needed reoperation. conclusion: the sutureless sm technique facilitates intra-abdominal introduction, as well as the handling and fixation of large/very large meshes. this new approach is safe and fast, even in cases of gh/mh repair. aims: any ventral hernia (vh) combined with rectus muscle separation (rms) must be repaired along with repairing the rms, otherwise there is a high risk for hernia recurrence. open rms repair is vast and traumatic surgery and laparoscopy is not effective. at a new era of repairing abdominal wall hernia by assisted endoscopy started with wolfgang reinhold's milos procedure. these procedures are somewhat complexed and real reconstruction of the linea alba (la) was limited, which done better by ferdinand koeckerling's elar technique. we perfected the elar technique to be fully endoscopic with wide mesh fusing to the muscles immediately by fibrin glue: extended endoscopic hernia & linea alba reconstruction glue (eehlarglue), achieving a low traumatic mis for vh and rms with excellent surgical and cosmetic results. methods: our eehlarglue is a totally endoscopic based technique used since . penetrating with optiview trocar and co pressure to the anterior rectus sheet (ars) level is followed by an extensive endoscopic dissection of the sub-cutaneous fat tissue from the ars. three trocars are inserted at the supra-pubic line enabling the dissection up to the xiphoid and costal margins laterally. any hernia sac is dissected, and the content reduced back to the abdominal cavity. relaxing incisions of the ars are performed longitudinally in the lateral aspect. the la is reconstructed by running two layers of non-absorbable sutures from xiphoid to pubis. a light mesh x cm is applied over the repair and the mesh is fused immediately to the muscles by fibrin glue. results: patients underwent the eehlarglue with follow up of months. all had significant rms of - - cm combined with primary or recurrent vh. recovery was smooth with - days of simple analgesics and return to regular activity within - days. no one had recurrent vh, but two males had limited rms and two early cases seroma formation. conclusions: our eehlarglue enables endoscopic vh repair and la reconstruction with extrastrength received by immediate mesh fusion to muscles with fibrin glue. thus, achieving low traumatic mis, easy recovering and very effective results-a perfect solution for patients with vh combined with rms. results: twelve blinded prospective rcts were used. when compared to tep repair, tapp repair has comparable seroma formation rates (chi = . ; (p = . ); ci - . , . ; i = %) and post-op pain at h (chi = . ; (p = . ); ci - . , . ; i = %). however, tep repair is associated with a significantly shorter operative time (chi = . ; (p = . );ci . , . ; i = %), post-op pain at hour (chi = . ; (p = . ); . , . ; i = %) and shorter hospital stay (chi = . ; (p = . ); ci . , . ; i = %). conclusion: tep is significantly better than tapp repair with regards to operative time, post-op pain at h and hospital stay. there is no significant difference with regards to post-op pain at h and seroma formation. background: primary hyperhidrosis (ph) is a neurological condition characterized by excessive sweating most often of the face, palms or axillae . palmar hyperhidrosis is treated through sympathetic chain clipping or transection .we aiming to compare the efficacy and results obtained with both techniques. patients and methods: sixty four patients underwent of sympathetic procedures from march to february . the patients were categorized into two groups: right sided transection sympathectomy and left sided clipping . patients were evaluated to compare the rates of success, satisfaction, compensatory sweating and recurrence either with transection or clipping of the t andt ganglion .mean follow up was ? _ months. results: sixty four patients males and females undergoing electro-coagulation sympathectomy on the right side and clipping on the left side. with mean age was years (range to years). all patients had balanced demographic data . no statistical difference between the two groups according rate of success. compensatory sweating was observed in patients ( . %) overall with cases of severe unsatisfied compensatory sweating. recurrence was reported in one case with transection and cases in clipping. satisfaction was occurred in cases in transection group and cases in clipping group .pnumothorax was occurred in cases in transection group compared to one case in clipping. no gustatory sweating and over dryness were reported in both groups. conclusion: both thoracoscopic sympathetic transection and clipping of t t ganglion are safe and effective procedure in palmar hyperhidosis treatment. with no differences regarding recurrence rate,satisfaction and incidence compensatory sweating. keywords: thoracoscopic sympathectomy,palmar hyperhidrosis, clipping, compensatory hyperhidrosis. introduction: primary ventral hernias and ventral incisional hernias pose a challenge for surgeons throughout the ages. even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardized method that adequately decreases postoperative complications. hybrid hernia repair is a surgical repair, which has not been adopted widely. it combines both a laparoscopic and open component allowing sac excision, primary defect repair as well as laparoscopic mesh insertion. aims: to evaluate the short-term and long-term outcomes of hernia recurrence for patients undergoing hybrid ventral repair (hvr) for the treatment of primary and incisional ventral hernias. methods: between october- and june- , hybrid vhr was performed in -patients at st mary's hospital, imperial college london. the medical records of these patients were reviewed retrospectively for demographics, comorbidities, prior surgeries, body mass index (bmi), hernial defects, hybrid technique used; mesh selection, operative time, complications and recurrences over a -year follow-up. results: twenty-four patients who underwent hybrid vhr were included with surgery performed by two surgeons. the mean age is -years with a mean bmi of . kg/m . % had incisional hernias and % had primary hernias. the number of hernia defects ranged from to , with the average mesh size used was x cm. extensive adhesionolysis was performed in % of patients. -day postoperative complications; patients developed post-operative seroma, paralytic ileus in , pain control in and urinary retention in patient. there were no conversions to open procedures. the mean length of hospital stay was -days. none of the patients developed chronic pain and only one recurrence over the -year follow-up period. conclusions: the hybrid technique for vhr is safe and feasible, and has important benefits over an open or purely laparoscopic approach, including a low rate of seroma formation, chronic pain and fiveyear hernia recurrence. future investigation may include randomized controlled trials, to fully evaluate the benefits of hybrid vhr, with careful assessment of patient-centred end-points including quality of life and postoperative pain. surgery, medical faculty-university of tetove, tetove, macedonia; general medicine, medical faculty-university of tetove, tetove, macedonia; anestesiology, medical faculty-university of tetove, tetove, macedonia; surgery, clinical hospital-tetove, tetove, macedonia laparoscopic cholecystectomy is widely used operative technique and it's characterized with less postoperative hospitalization and side effects. duration of the hospitalization after laparoscopic surgery depends on several factors of which pain and physical weakness are the most important. dexamethasone is well known; not only for its anti inflammatory effects but at the same time for analgesic and antiemetic effects, although the mechanism of this effects are not clarified yet. objectives: the aim of our study is the evaluation of analgesic effect of dexamethasone on reducing postoperative pain after laparoscopic surgery. patients and methods: in this study, patients aged - years old undergoing laparoscopic surgery, were classified into two groups, patients in each group. the first group were treated with a intravenous injection of mg dexamethasone preoperatively and another dose the next day after operation. the second group received a intravenous injection of normal saline. we evaluated the dose of consumed analgesics and antiemetic's drug during the first h in both groups. results: according to our experience results the total dose of tramadol in a postoperative period in dexamethasone receiving group was smaller than in normal saline group. measure of postoperative pain was assessed using the paper-based vas scale. our result shows that the intensity of post operative pain in a period during first h, after surgery in a group of patients treated with dexamethasone was lower compared with the group of patients treated with normal saline. nausea and vomiting during the first h was significantly lower in the dexamethasone group than in the normal saline group. surgery, hospital quiron sagrado corazon, sevilla, spain; surgery, hospital virgen macarena, sevilla, spain; surgery, hospital virgen del rocio sevilla, sevilla, spain aims: closing the defect (cd) during laparoscopic ventral hernia repair (lvhr) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional lvhr. but tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a component separation (cs) for restoring the midline in medium-large defects.we have developed a new technique for restoring the midline in medium ventral hernias (lira technique) and weanalyzed our results in terms of pain and recurrence compared to our conventional cd series (ccd). methods: we conducted a prospective controlled study of lvhr with ccd from january to december and a prospective controlled study performing lira technique from january to january . we analyzed and compared both techniques in medium size defects ( - cms) in terms of postoperative pain ( , days, , months and year) using a visual analogue scale (vas), bulging (return to prior distance among rectus muscles with the mesh in the sac in ct that didn't need surgical treatment)and recurrence (by physical examination and tomography). results: ccd was performed in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ) and lira technique in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ). the mean average follow-up in both series was year. mean average vas in ccd was . ± . ( day), . ± . ( days) . ± . ( month) . ± . ( months ) and at year. in lira series vas was . ± ( h) . ± . ( days), . ± . ( month), ( months) and ( year) . there are cases of bulging in ccd series and recurrence. bulging and recurrence were absent in lira series. conclusions: lira technique might be a safe procedure in medium size defects for restoring the midline in lvhr, and could be related to a lower pain rate compared to ccd with no recurrence or bulging. surg endosc ( ) :s -s background: the desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endo-surgery [sipes] and needlescopic surgery. intracorporeal suturing and knot tying during sipes remains challenging. the aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. it is an imitation of the principles of sewing machine. methods: the first author discussed the idea of the technique with the co-authors and a demonstration was done on a silicon pad before application of the technique on children with congenital inguinal hernia [cih] for peritoneum closure after needlescopic disconnection of the hernia sac. the main outcome measurements were; feasibility of the technique, knot quality, suture placement accuracy, performance and suturing time and recurrence rate. results: the sutures were snugly applied to the ridges of silicon pad with good approximation and the knot was firmly tightened in all experiments. after applying and mastering the technique on a silicon pad, we shifted to use it on children with hernia defect. all operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. the time required for suturing of the peritoneum around internal inguinal ring [iir] and knot tying, decreased considerably from min s in the first operation to less than min after the fifth operation and stabilized at approximately minute s. no major intraoperative complication and no recurrence. the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of patients were enrolled ( of them underwent tapp and olr). drop out occurred in cases ( of tapp and of olr group). patient characteristics were statistically similar between the groups. tapp procedure had less early post-operative pain (p = . ), a shorter length of stay (p = . ) and less postoperative complications (p = . ) when compared with the olr approach. a slightly higher recurrence rate in the tapp group was found. additionally, there is a trend towards a higher postoperative quality of life and less chronic pain in the tapp group. conclusions: tapp procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications. cannizzaro hospital, catania, italy aim: the purpose of this study was to evaluate the long-term results in terms of safety and efficacy of a new technique to repair incisional ventral hernias with a self-gripping mesh, after a mean follow-up period of months. methods: a retrospective, single-centre study was performed from june to june . all patients undergoing elective incisional ventral hernia repair were included. hernias were diagnosed based on clinical examination at the outpatient clinic. in case of doubtful diagnosis, ct-scan was used to confirm the diagnosis. the component separation technique and, when needed, tar were performed. the self-gripping mesh was placed in sublay position (overlap cm) with the self-gripping surface face down. in all cases drainage tubes were placed in retromuscular and supraaponeurotic position. the following characteristics were collected: age, sex, body mass index (bmi), smoking, comorbidities, number of previous surgical operations, defect size (ehs classification), mesh size, postoperative complications, duration of follow-up. all patients were interviewed by telephone every six months. when patients complained recurrence or other symptoms, visits were organized and when there was the doubt of recurrence a ct-scan was performed. results: a total of patients were included in this study, males, mean age was years. % of patients had bmi [ , smokers and diabetics were respectively % and %. the mean defect size was cm . component separation technique was associated with tar in patients. in cases the size of mesh was cm, while in patients the size of mesh was cm and in cases this was cm. in the other patients the mesh sizes were tailored to defect dimensions. subcutaneous seromas occurred in patients, they were treated conservatively in cases and with percutaneous punction in cases. long-term follow-up demonstrated recurrences in one case, while in another one ct-scan revealed a bulging. no cases of mesh infection, pain or sensation of mesh. conclusions: this study with a mean follow-up period of months demonstrated that the use of self-gripping mesh in sublay position is safe and effective to treat incisional ventral hernias. aim: morgagni hernias present technical challenges. the laparoscopic approach was described at first in , however, as they are uncommon in adult life and, little data exist on the optimal method of surgical management. this study purpose was to analyse a method for laparoscopic repair of morgagni giant hernias using laparoscopic primary closure. methods: this case series describes a method of laparoscopic morgagni hernia repair using primary closure. in all patients a laparoscopic transabdominal approach was used. the content of the hernia was reduced into the abdomen and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. demographic data as age, gender and bmi were collected. operative data (operative time, rate of conversion, blood loss) and post-operative data (short and long term complications, length of hospital stay, need of readmission and reoperation) were recorded. results: retrospectively collected data about patients were analysed. there were ( . %) male and ( . %) females. the median bmi was . ± . kg/m . median operative time was ± min. there were no intraoperative complications nor conversion to open surgery. patients began a fluid diet on the first post-operative day and were discharged after a median hospital stay of ± . days. in a median follow up of months we did not observe any recurrences. conclusions: transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for repair of morgagni hernia. in our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs. can we predict the success of the laparoscopic approach in the adhesive small bowel obstruction? c. tellez marques, e. sebastian valverde, e. membrilla fernandez, l. grande posa, i. poves prim general surgery, parc de salut mar-hospital del mar, barcelona, spain aims: the laparoscopic approach in the acute adhesive small bowel obstruction and internal hernias (asbo) has shown superior to laparotomy in terms of morbidity and hospital stay. especially, in patients who present simple adhesions or internal hernias. according to this, the aim of the study is to determine those preoperative factors associated with simple adhesions and internal hernias, and consequently, improve the success of the laparoscopic approach in asbo methods: a retrospective study of patients who underwent urgent surgery for asbo was conducted from january to may . we compare preoperative variables between single adhesions and internal hernias vs complex adhesions. a p value \ . was considered statistically significant. results: we analysed patients who underwent surgery for asbo, ( %) by laparoscopy and ( %) by laparotomy. conversion rate in laparoscopy was . %. . % of patients presented a single adhesion or internal hernia; and . % were considered complex adhesions. sex and age did not correlate with the type of adhesions. previous surgery (p \ . ), number of previous surgeries (p \ . ), asa (p \ . ) and previous abdominal wall mesh (p = . ) were significantly associated with complex adhesions. laparoscopy as the only surgical history was significantly associated with simple adhesions (p = . ). only appendectomy (p = . ) or supramesocolic (p = . ) previous surgeries tended to present single adhesions but it did not reach statistical significance. the need for intestinal resection was not related to the type of adhesions (p = . ). there was a significant correlation between the findings in the ct (computed tomography) and the type of adhesion found (p = . ). signs of ischaemia on ct were related to the need for intestinal resection (p \ . ). in the multivariate analysis, the number of previous surgeries, asa and ct scan findings were identified as independent factors related to the type of adhesion. conclusions: according to our study, a lower number of previous surgeries, asa i-ii and internal hernia in the ct scan are associated with single adhesions and internal hernias. patient selection is a key factor for the success of laparoscopic approach in asbo. aims: there aims of this study were: (i) to compare england with the united states in the utilisation of minimal access surgery (mas) and in-hospital mortality from four common abdominal surgical emergencies (appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel perforation and peptic ulcer perforation). (ii) within england to evaluate the influence of mas upon in-hospital and long-term mortality. methods: between and , the rate of mas and in-hospital mortality for four abdominal surgical emergencies were compared between the united states and england. univariate and multivariate analyses were performed to adjust for underlying differences in baseline patient demographics. results: , admissions in england for four abdominal surgical emergencies were compared to an estimated , , admissions in the united states. after adjustment for patient demographics, mas was used less commonly england for three conditions; appendicitis (odds ratio (or) . , % ci . - . ), abdominal hernia (or . , ) and small or large bowel perforation (or . , ). in-hospital mortality in multivariate analysis, was increased in england compared to the united states for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , ) and peptic ulcer perforation (or . , % ci . - . ). in england, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , % ci . - . ) and peptic ulcer perforation (or . , . similarly open surgery was associated with increased long-term mortality for three conditions; abdominal hernia (hr . , % ci . - . ) , small or large bowel perforation (hr . , % ci . - . ) and peptic ulcer perforation (hr . , % ci . - . ). conclusions: minimal access surgery was used less commonly and inhospital mortality was increased in england compared to the united states for common abdominal surgical conditions. given the benefits of mas shown in this large study, strategies to enhance adoption of mas in emergency conditions in england need to be optimised and include appropriate patient selection and improved surgeon mas training and experience. surg endosc ( ) :s -s background: in the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related-group (drg) era. factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. the aim of this study is to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. methods: this retrospective study analysed the -year experience in inguinal hernia repair in patients undergoing open lichtenstein (ol), laparoscopic totally extraperitoneal unilateral (utep) or bilateral (btep) hernia repair. demographics, results, costs and drg-based reimbursements were recorded and analysed. results: during the study period, patients underwent ol, patients utep and patients btep. the average total cost amounted to eur in ol, eur in utep and eur in btep groups (p \ . *). the hospital reimbursement amounted to eur, eur and eur in the ol, utep and btep groups respectively (p \ . *). finally, the mean hospital earnings were eur, eur and - eur for each patient in ol, utep and btep respectively (p \ . *). conclusions: in-hospital costs were higher in utep and btep as compared to ol. the drg-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in ol group only, and led an overall financial loss in the btep group. surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view. aims: umbilical hernias are common anatomical defects in swine which become a suitable model for surgical training and research in the field of surgical meshes. the aim of this study was to develop a surgical protocol for a successful laparoscopic implantation of stem cell-coated surgical meshes. methods: large white pigs, weighing - kg and with congenital abdominal hernia were anesthetized for the surgical procedures. non absorbable polypropylene surgical meshes were coated with fibrin glue (fg) (control group) or with fg admixed with porcine bone marrowderived mesenchymal stem cells (fg/bm-mscs). approximation of hernia's borders was performed by intracorporeal suture. the meshes were carefully rolled inside the trocar for laparoscopic implantation. the surgical implantation was performed by laparoscopy using helicoidal staples. laparoscopic inspections and biopsies of the tissue surrounding the mesh were performed at , and days post-implantation. at day , the animals were euthanized and macroscopically evaluated. ultrasonography was used at day , , and to evaluate the size of the hernia. the biopsies were then processed for the histological analysis. results: ultrasonography demonstrated that the mean size of umbilical hernias before mesh implantation was . ± . cm. a decrease in hernia mean size was observed at day and . the laparoscopic procedures allowed a successful mesh implantation in all animals. in most of cases, the implantation site did not show excessive inflammation or tissue adhesions. but one animal showed hernia maintenance. one animal had peritoneal and implant-site infection. foreign body reaction was noted in the histological analysis, although no significant difference was found between the control, and bm-msc group. conclusions: the anatomical similarities between humans and pigs in umbilical hernias make this animal model useful to: i) improve minimally invasive surgical procedures for hernia treatment; ii) evaluate new surgical meshes, and iii) introducing stem cell therapy to hernia surgical repair. the laparoscopic approach is efficient and safe for the implantation of stem cellcoated meshes. gene and protein expression analysis are required to evaluate the molecular changes between the conventional and the stem cell surgical approach. aims: fluorescence angiography with indocyanine green (icg) is used as a marker in the assessment of tissue perfusion, being more frequently used in colorectal procedures. this technology has shown to be a good technique to reduce complications related to vascular supply to the anastomosis. in esophagogastric procedures blood supply to the gastric pouch, jejunum and esophagus could be evaluated by icg fluorescence imaging. it could be also used in bariatric surgery to evaluated the anastomoses, during gastric bypass, and blood supply to the gastroesophageal junction and the angle of his during sleeve gastrectomy. methods: we have collected data during gastric resection due to adenocarcinoma and bariatric procedures that were performed by the same surgeon, using icg fluorescence to evaluate blood supply. the icg was infused before performing the anastomosis in order to evaluate the need to change the transaction line (tl). we analyzed those cases in which the tl was changed and the number of leaks in those cases that we changed this line. results: all the cases were performed by laparoscopic approach: subtotal gastrectomy (sg), total gastrectomy (tg), gastric sleeve (gs) and gastric bypass. there were no changes regarding the tl before performing the anastomosis in any of the four types of procedures (sg, tg, gs, gb). in the analyzed data there is anastomotic leak in one sg procedure ( . %). conclusions: icg fluorescence angiography could be helpful in assessing blood supply during gastrointestinal anastomosis, although we have not find an influence in the results during bariatric and gastric procedures. however, we do not have the sufficient evidence to determine the value of this technology in this entities, being needed more volume and data to improve the significance of the results. aims: hyperspectral imaging (hsi) combines a spectrometer with a camera to analyze the tissues' optical properties in a broad wavelength range, without the need for a contrast agent. it provides extensive real-time information about tissue physiology, including oxygen saturation (sto ). fluorescence-based enhanced reality (fler) is a software solution providing a dynamic, quantitative analysis of the signal evolution of a systemically administered fluorophore, during fluorescence angiography (fa) . the aim of this study was to compare the performance of hsi and fler to assess bowel perfusion, in a porcine, non-survival model of bowel ischemia. methods: in pigs, an ischemic small bowel segment was created and imaged after hour of ischemia. the imaging modalities were applied sequentially to the same area.hsi was performed first, to acquire the sto spectra, by means of the tivita tm system (diaspective vision, pepelow, germany), which provides a spectral range of - nm and a nm resolution. subsequently, fa was performed using a nir-capable laparoscopic camera (d-light p, karl storz, germany), after intravenous injection of . mg/kg of indocyanine green (icg; infracyanine, serb, paris, france). the fluorescence flow was recorded during s, then the slope of the fluorescence flow was analyzed using a proprietary software to obtain a virtual perfusion cartography. the virtual cartography was overlaid onto real-time images to obtain the enhanced reality effect. ten adjacent regions of interest (rois) were selected from hsi datasets and were superimposed to fler-generated cartographies using a custom plug-in software function, allowing for a quantitative comparison of both imaging modalities. hsi was repeated after icg injection. results: the r correlation coefficient between hsi-sto and the fler slope was . . at control hsi after icg injection, the correlation coefficient dropped significantly (r . ). the interference of icg on hsi imaging was clearly identified in the spectral curves. conclusion: sto given by hsi provided results comparable to those obtained with fler in our bowel ischemia model, without the need to inject a contrast agent. icg interferes with hsi datasets, disrupting sto values. surgical treatment is one of the most effective options for treatment of giant hiatal hernia. laparoscopic approach became is a 'gold standard' over the time demonstrating all advantages of minimally invasive techniques over the open procedures. however the utility of robotic operations still remains controversial. aim of the study: evaluate the initial experience of robotic fundoplication in compare to laparoscopic procedures. materials and methods: since the january till the december of thirty operations were operated on. mean age was . ( - ), among them ( %) were female and ( %) were males. mean bmi was . ( . - . ) . laparoscopic procedures were performed in patients ( st group), robotic procedures with davinci system were performed in patients of the second group. nissen fundoplication modified was performed in patients, toupet fundoplication was used for patients. results: the median operative time in laparoscopic group was min, in robotic group- , min. there were no statistical differences between two groups (p = . ). blood loss was minimal in both groups. mean postoperative hospital stay was . days ( - days) in the st group and , days ( - days) in the second. there were no statistical differences between two groups (p = . ). postoperative course was uneventful in all patients of both groups. surgical stress response is associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction syndrome. robotic assisted surgery has been introduced to overcome the limitations of conventional laparoscopy. this technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. these advantages could result in limited intra-abdominal trauma and hence in attenuated surgical stress response over conventional laparoscopy. aims: this study aimed to synthesize data on the effect of robot assisted surgery on surgical stress response. methods: electronic databases were searched with the search terms 'surgical stress', 'stress response', 'oxidative stress', 'robotic assisted surgery', 'c-reactive protein', 'interleukin ', 'interleukin ','cortisol',;'oxidative stress markers', 'antioxidants', 'antioxidant status', 'mda', 'glutathione', 'cortisol', 'acute phase response' up to and including march . results: one hundred forty studies were identified and their title and abstract were reviewed. one randomized controlled trial, six non randomized comparative studies, one experimental study and one case report met inclusion criteria. data were discordant. one prospective trial concluded that cortisol and il- were lower in laparoscopic assisted distal gastrectomy compared with robot assisted distal gastrectomy in another study comparing robotic assisted laparoscopic radical prostatectomy with open radical prostatectomy based on plasma measurements of il- , il- a and c-reactive protein, it was demonstrated that robotic assisted laparoscopic radical prostatectomy induces lower tissue trauma than open radical prostatectomy. in another study, it was reported reduced expression of genes associated with surgical stress response in patients treated with robotically assisted radical prostatectomy compared with patients treated with open prostatectomy. the case report concerned a case of polymyalgia rheumatic after robotic assisted laparoscopic prostatectomy. the experimental trial demonstrated that cortisol and substance p were significantly higher with open thoracic approach versus robot assisted thoracoscopic oesophageal surgery. conclusion: further research is needed to elucidate the effect of robotic surgery on surgical stress, based on a well standardized protocol for the measurement of surgical stress response. purpose: tissue compression is essential to prepare the tissue for proper staple formation. this study evaluates the risk factors of compression injury on the circular stapling line in vitro. methods: to reproduce the artificial bowel wall, a collagen plate was prepared by mixing collagen extracted from porcine with glycerin. artificial collagen plates with mm and mm in the thickness were made for dry and healthy condition and immersed plates in the tap water for min to make wet and edematous condition. circular stapler (cdh a, ethicon, usa) was applied in the collagen plates (dry and wet condition) and optimal compressions. compression line was evaluated for compression injury score. risk factors for excessive compressions and unacceptable injury were analyzed. results: in the dry condition, optimal compression didn't cause unacceptable injury. in the wet condition, excessive compressions were occurred in . % with optimal approximation. unacceptable injury was significantly different in proper and excessive compression cases as . % and . %, respectively. on the univariate analysis, thickness ( mm), wet condition, proximal side, maximal compression, and excessive compression were associated with unacceptable injury. on the multivariate analysis using logistic regression model, excessive compression was significant independent factor to cause tissue injury (p \ . ) and this significance was also proved in the optimal compression group (p = . ). background: minimal invasive appendectomy gained much popularity due to its better cosmoses, early recovery and less wound site infections. single incision laparoscopic appendectomy (sila) has many disadvantages such as, long operative time, bad ergonomics, surgical site infections, high conversion rate and port site hernia. needlescopic appendectomy (na) using mediflexÒ facial closure needle expected to be more superior over sila. here in we compare our results of needlescopic appendectomy with single-incision one. material and methods: one hundred and twenty patients with acute non complicated appendicitis were randomly assigned to na and sila children for each group during the period between january to october . the main outcome measurements included, demographics, operative time, intraoperative complication, conversion rate, post-operative hospital stay, surgical site infection, port site hernia and cosmetic results. results: a total of children underwent appendectomy. there were children who underwent na and children who underwent sila. there were no difference in age ( . vs . years, p = . ), weight ( . vs . kg, p = . ) and hospital stay ( . vs . days, p = . ) between the two groups. there were no intraoperative complication during the two surgical approaches. operative time for na group is significantly shorter than single incision group ( . vs . min, p = . ). no single case of conversion in na group and cases needed conversion in sila group. seven cases of sila showed surgical site infection. cases of sila group presented with port site hernia. the na group was superior as regard ergonomics. the two groups showed equal excellent cosmetic results. conclusion: needles scopic appendectomy and sila are comparable as regard cosmetic results and hospital stay. na proved to be safe, applicable, repetitive and superior over sila as regard better ergonomics, less operative time, absence of surgical site infection and port site hernia. aims: to objectively analyze the surgical performance and surgeon's ergonomics in the use of a novel flexible laparoscopic instrument during intracorporeal suture, and compare it with the use of a conventional laparoscopic needle holder. methods: three experienced laparoscopic surgeons performed five laparoscopic sutures on an organic tissue using the novel flexible instrument (flexdexÒ) and five sutures using a conventional needle holder with axial handle. the new device is based on a mechanical design with no electrical components, which transfers the surgeon's hand, wrist, and arm movements to the instrument tip in an intuitive manner. the use of the instruments was organized in a random fashion. prior to the study, participants conducted a -minute training session with the new flexible instrument. execution time and quality of the suture were assessed for each repetition. besides, flexion and radioulnar deviation of the wrist were recorded using an electrogoniometer (biopac systems, inc.) attached to the surgeon's hand and forearm. the intensity of the forearm's muscle activation was also analyzed by means of a myo armband (thalmic labs). results: surgeons required more time to perform the intracorporeal suture using the novel laparoscopic instrument ( . ± . s vs. . ± . s; p \ . ), but the quality of the suture was similar with both instruments. the wrist flexion ( . ± . °vs . ± . °; p \ . ) and wrist ulnar deviation ( . ± . °vs . ± . °; p \ . ) were significantly lower when using the flexible instrument. during the suturing tasks, the use of flexdexÒ instrument led to a higher muscular activation of the flexor ( . ± . vs . ± . rms; p \ . ) and extensor ( . ± . vs . ± . rms; p \ . ) muscle groups of the forearm. conclusions: the presented novel instrument allows surgeons to perform robotic-like laparoscopic suturing. we believe that with a longer training period surgeons could potentially reduce surgical times with this device. the preliminary results of this study suggest that the use of this new instrument provides a quality of the suture similar to that obtained with a conventional laparoscopic needle holder and an ergonomically more adequate wrist posture. aims: the intraoperative real-time evaluation of tissue perfusion is one key element for successful visceral surgery. traditionally, tissue evaluation is performed visually by surgeons. newer devices for objective quantification have in majority been based on the application of the fluorescent dye indocyanin green (icg). a novel method derived from geographic research is hyperspectral imaging (hsi). the aim of this study was the evaluation of hsi as a promising method for the evaluation of tissue perfusion and its implementation in the evaluation of the gastric conduit during esophagectomy in a porcine model. methods: the hsi camera records a dimensional data cube from a dimensional surgical situs obtaining wavelengths between and nm. the absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. a software calculates different indices in real-time including oxygen saturation. a porcine model (n = ) is used for esophagectomy with gastric conduit formation. ischemia is induced artificially by magnets simulating staplers. different shapes of the gastric conduit and anastomosis formation are evaluated for perfusion metrics in order to obtain recommendations for the optimal formation of esophagogastrostomy. conclusion: hsi is a promising method for intraoperative evaluation of tissue perfusion that does not require application or injection of any agents. the preliminary results in this study showed that the gastric conduit receives its main blood supply from the gastroepiploic arteries and not via the mucosa. further results from the current evaluations enable formation of an optimized gastric tube and esophagogastrostomy in esophagectomy. surg endosc ( ) pediatric surgery, al azhar university, giza, egypt; pediatric surgery, beni suef university, beni suef, egypt background: varicocele is one of the most common causes of infertility. many surgical interventions are used for varicocele ligation including open and conventional laparoscopic multiport or single incision techniques. the aim of the study is to present a new needlescopic lymphatic sparing varicocele ligation using mediflexÒ facial closure needle and gauge vascular access cannula. material and methods: twenty-two male children with bilateral varicocele of grade ii-iii. all children were counseled by clinical examination, doppler ultrasonography, abdominal ultrasonography, and routine laboratory investigations. testicular lymphatics were delineated by subcutaneous injection of / cm methylene blue in anterior wall of the scrotum min prior to surgery. the testicular vessels (both vein and artery) were ligated one cm above the deep inguinal ring using two mediflex needles with preservation of lympatics. the main outcome measurements included; operative time, hospitalization, testicular atrophy, hydrocele formation, recurrence of varicocele and intra or postoperative complication. results: a total of twenty-two male children with grade ii-iii varicocele subjected to needlescopic lymphatic sparing technique. twenty one were bilateral. background and aims: even if the clinical outcomes of robotic rectal resections are under investigation, the related robotic costs have not yet been well addressed, and the differences between the robotic rectal resection costs and the laparoscopic approach are still not well known. we have therefore performed a prospective comparative study of robotic rectal resections (rrr) and laparoscopic rectal resections (lrr) performed at our centre with the aim to evaluate the cost-effective outcomes of robotic versus laparoscopic surgery. study design: this is an observational, comparative prospective non-randomized study which includes patients that underwent laparoscopic and robotic rectal resection reaching a minimum of months of follow up from february to march , at the sanchinarro university hospital, madrid. an independent company performed the financial analysis and fixed costs were excluded. outcome parameters included surgical and post-operative costs, quality adjusted life years (qaly), and incremental cost per qaly gained or the incremental cost effectiveness ratio (icer). the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of rrr and lrr were included. the mean operative time was significantly lower in the lrr approach ( versus min; p = . ). the main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (rrr: . %, lrr: . %;p = . ).the mean operative costs were higher for rrr ( . versus . €; p = . ); however, the mean overall costs were similar ( . € for rrr and . € for the llr; p = . ). mean qalys at year for rrr group ( . ) was higher than that associated with lrr ( . ) (p = . ). at a willingness-to-pay threshold of , € and , €, there was a . % and . % probability that rrr group was cost-effective relative to lrr approach. conclusion: this study provides data of cost-effectiveness differences between rrr and lrr approach showing a benefit for the rrr aim: the efforts were aimed to the introduction of novel surgical technologies to overcome the intrinsic anatomical and technical constraints of rectal surgery. this was the case of the introduction into the clinical practice of laparoscopy and later on of robotic surgery for rectal surgery. however, whether robotic surgery is actually superior to laparoscopy is still debated. the aim of this study was to compare d laparoscopy and robotic surgery for rectal cancer on technical and oncological outcomes. methods: this was a single-center, prospective, randomized controlled trial. all patients more than years of age undergoing elective surgery for rectal cancer situated from to cm from the anal verge were included. patients undergoing abdominal perineal amputation and/or with t and/or m tumours were excluded. patients were randomized before surgery into two arms: arms a ( d laparoscopy) and arm b (robotic), and gave their consensus to the study. demographic data, data regarding the tumour, operative and post-operative data were collected. patients with a follow up shorter than months were excluded as well. results: twenty patients were enrolled in arm a and in arm b in the period time of one year. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. robot-assisted rectal resection results in comparable operative time ( . vs min; p = . ). the conversion rate was significantly lower for arm b ( vs p = . ). postoperative morbidity was comparable between groups. hospital stay was comparable but time required to resolve post-operative ileus was shorter in arm b ( . vs . days, p = . ). overall survival and disease-free survival were comparable between arms ( . % vs . %, p = . , and . % vs . %, p = . , respectively) conclusions: d laparoscopy and robotic surgery are two viable options for rectal surgery. robotic surgery can add some in terms of post-operative outcomes and ergonomics. aim: currently, robotic surgery for rectal cancer is a surgical operation that is being performed worldwide. we also introduced robotic surgery in . however, after robotic surgery, we observed a rise in creatinine kinase (ck), which is unlikely to happen in other surgeries. we studied the postoperative complications of rectal cancer patients who underwent either robotic surgery or laparoscopy during the same period of time. methods: from january to november , patients underwent surgery using robotassisted rectal resection (da vinci si cases and xi cases) and patients underwent laparoscopic rectal resection. in this study, abdominoperineal resection, intersphincteric resection, and lateral lymph node dissection were excluded. result: the operation time for the robotic surgery group was significantly longer than that for the laparoscopic group ( min vs. min; p \ . ). the ck value of the robotic surgery group on pod was significantly higher than that of the laparoscopic group ( iu/l vs. iu/l; p \ . ). in addition, one case of compartment syndrome was observed in the laparoscopic group. there were no significant differences in age, body mass index, intraoperative bleeding, tumor invasion depth, urination disorder, or postoperative hospital stay. in robotic surgery, it is considered that the increase in ck value is caused by the extended operation time, contact of the patient's cart with the left thigh of the patient, and the extra force applied to the abdominal wall caused by the displacement of the remote center. conclusion: in robotic surgery, it is suggested that the measurement of postoperative ck value is important. therefore, an attempt to shorten the operation time and paying attention to the surgical field are necessary to improve the outcomes. aims: anastomotic leak remains as one of the most important and life threatening post-operative complications in colorectal surgery. this complication has important consequences, both acute and long term, longer hospital stay, re-intervention, and increased morbidity and mortality. among all different circumstances that have been related to this entity, blood supply is an important factor that might have influence. fluorescence with indocyanine-green (icg) is used as a marker in the assessment of tissue perfusion in colorectal surgery which might reduce the numbers of leaks. methods: a multicenter analysis of the experience of centers in spain is collected in order to assess the value of icg in colorectal anastomosis. colorectal procedures were performed using icg to evaluate vascular supply in the anastomosis. icg was infused before performing the anastomosis analyzing the number of cases in which the transection line (tl) was changed. we also analyzed the number of leaks in those cases that we changed this line. results: out of the cases performed, cases were performed by open surgery, by laparoscopy, by single-port and with transanal total mesorectal excision(tatme). the following procedures were performed: right colonic resection(rc), splenic flexure partial resection(sf), left colonic resection(lc), subtotal colectomy(sc), total colectomy(tc), hartman reversal surgery(hr), low anterior resection with partial mesorectal-escision(lar) and ultra low anterior resection with total mesorectal-escision(ular). leak rate(lr) was . % ( . %rc, . %lc, . %sc, . %lar, . %ular). overall lr was . % in colonic surgery and . % in rectal surgery. the tl was changed due to icg in . % of the cases ( . %rc, . %sf, . %lc, % tc, . % lar, . % ular), being . % in colonic resection and . % in rectal resection. the relation between leaks and the cases in which the tl was changed, were % ( . %rc, %lc, . %ular). conclusion: icg fluorescence may play a role in anastomotic tissue perfusion assessment. the lr after colorectal surgery might decrease using icg to detect the proper tl before to perform the anastomosis. however, we do not have the sufficient evidence to determine that the changing transaction line can lead to avoid leaks. surg endosc ( ) aims: to analyse the value of postoperative day crp as an early predictor of safe discharge in robotic rectal cancer surgery. methods: a retrospective analysis was performed, including patients who had undergone robotic total mesorectal excision (tme) in a single centre over a -year period (may -september . patients who had a permanent stoma (abdominperineal resections or hartmann's procedure) were exluded from the study, leaving patients for further analysis. as the los is currently used as a performance tool in assessing outcomes in colorectal surgery (with a cut-off established at days), we compared the crp values in these groups. results: fourty one percent of patients were discharged home within days. they had an earlier peak of crp on postoperative day (pod) (median . , ) . the group of patients that were discharge home after days ( %) had a crp peak on pod (median , ). on pod , the group of patients that went home within days had a lower crp ( - -vs. - -) compared to the group of patients that were discharge after days, p = . ). conclusions: a crp peak on pod in robotic tme can predict an early and safe discharge (los within days). background: purposelateral pelvic lymph node dissection (lpnd) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (crt). however, technical difficulties make it possible that lateral pelvic lymph nodes (lpns) are not dissected completely and, thus, remained in the narrow pelvis. near-infrared fluorescence imaging (fi)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. this study aimed to evaluate the efficacy of fi using indocyamine green (icg) to identify lpns during robotic lpnd. methods: rectal cancer patients who were suspected lpn metastasis and had received preoperative crt were prospectively enrolled. icg in a dose of . mg was injected around tumor preoperatively. all procedures were performed with a totally robotic approach. after completing lpnd, fi was checked again for identifying remained lpns and resecting them completely. results: the lpns were successfully detected in ( . %) of the patients. however, after accounting for eight cases, having finished adjusting icg injection, the lpns were successfully detected in ( . %) of patients. the fi-guided lpnd group (n = ) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic lpnd (n = ). however, the mean number of unilateral harvested lpns was . in the fi-guided lpnd group, which was greater than the mean of . in the conventional group. lpn metastasis was identified in % of the fi-guided lpnd group, which was higher than that of the conventional group, . %. conclusion: fi-guided lpnd identifies lymph nodes in pelvic side-wall with great reliability. this contributes to increased number of lpns yield compared to conventional robotic lpnd. this technique should be considered to dissect them completely by preventing subsequent missing of nonvisible lpns. aims: to compare the medium-term oncological outcomes of laparoscopic total mesorectal excision (l-tme) vs. robotic total mesorectal excision (r-tme) for rectal cancer. methods: a retrospective analysis was performed including patients who underwent l-tme or r-tme resection between - . patients with disease stage iv at diagnosis or r resection were excluded. patients were initially included, and cases of r-tme were matched based on age, gender, stage and time of follow-up with an equal number of patientswho underwent l-tme. we compared -year disease free survival (dfs) and overall survival (os). in adittion, a multivariate analysis was performed in order to idenfity independent prognostic factors for -year dfs and os. results: pathological outcomes were similar between groups. however, major complications were lower in the robotic group ( . % vs. . %, p = . ), highlighting the anastomotic leakage rate, which was . % in the r-tme vs. . % in the l-tme group (p = . ). overall, the -year dfs rate was % in the laparoscopic group and % in the robotic group (p = . ). the -year os rate was % in the l-tme groups and % in the r-tme group (p = . ). for disease stage iii, -year dfs was significantly higher in the r-tme group. os was also significantly superior in the robotic group for every stage, reaching % in the stage iii. in the multivariate analysis, r-tme was a significant positive prognostic factor for distant metastasis (or . %ci . , . , p = . ) and os (or . %ci . , . , p = . ). conclusions: r-tme for rectal cancer can achieve better oncological outcomes compared to l-tme, especially in stage iii rectal cancers. the robotic approach has demonstrated to be a significant positive prognostic factor for local recurrence and overall survival, due to the better postoperative outcomes. however, a longer follow-up period is needed to confirm the oncologic findings. university hospital for visceral surgery, university of oldenburg, oldenburg, germany; bremen spatial cognition center, university of bremen, bremen, germany aims: in clinical settings, realistic assessment of one's own abilities can enhance performance and promote patient safety, especially in surgical residents, who inevitably have to acquire skills during real surgery. this study thus implemented the global assessment of laparoscopic skills (goals) questionnaire with the aim to explore divergences between resident self-evaluation and specialist's evaluation on laparoscopic performance, as a first step to implement the goals questionnaire as a tool for constructive and objective feedback. methods: between july and october , seven residents from the university hospital for visceral surgery at the pius-hospital oldenburg participated in this study. at the end of every laparoscopic operation where the resident acted as the primary surgeon, the resident and the supervising surgeon independently evaluated the resident's operative performance using the goals questionnaire. the five dimensions evaluated were depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. a cumulative goals-score (with being the highest possible score) was calculated for n = laparoscopic operations. resident's year of training, the level of case difficulty and the type of laparoscopic procedure performed was also analysed. results: residents overestimated their laparoscopic abilities in . % of the operations (goals-scores: residents: median = , mean = . ; specialists: median = , mean = . ; p \ . ). residents in the first three years of surgical training were more likely to overestimate their performance (residents: median = . , mean = . ; specialists: median = , mean = . ; p \ . ) than those with more than three years of surgical experience (residents: median = , mean = . ; specialists: median = , mean = . ; p = . ). goals score differences did not depend on case difficulty and laparoscopic procedure. conclusions: surgical residents tend to overestimate their intraoperative laparoscopic performance when compared to specialist evaluation. overestimation was found to depend on one's own laparoscopic experience and seem to disappear with gained expertise. these results signify the importance of individually adapted training and the greater need for objective feedback for surgical residents. this approach could in return increase the skill acquisition rate of the resident and in return contribute towards enhancing patient safety. introduction: the delivery of safe surgical care is dependent of various, complex and interrelated factors. substantial data exist regarding the impact of training in human factor skills on surgical outcomes. however, except for the standardized time-out process, the best way to go about improving these skills remains unclear. the aim of this study was to gain more insights in the theatre staff's perception of human factors and their importance on surgical outcome in the operating theatre. methods: the surgical team assessment record (star) questionnaire was used to study the role of human factors, such as communication, situational awareness and organization, contributing to surgical team performance. the self-assessment questionnaire was filled out by the theatre staff, directly after the surgical procedure. conditional logistic regression was used to identify the impact of the role in the operating theatre on the yes versus no answers. results: some questionnaires were completed. the theatre staff rated their team's performance with a median of (iqr . , -point likert scale). the surgical fellows (n = ) rated their personal factors significantly lower compared to the rest of the operating team (median versus , p-value \ . ). the staff surgeon (n = ) indicated significantly more often that there were many distractions ( . %, yes n = ) and noticed aberrations ( . %, yes n = ) during the surgical procedure (pvalue \ . ) when compared to the rest of the operating team. most aberrations reported by the surgeons were related to technical performance. conclusions: human factors play an important role in the surgical environment. situational awareness may be less developed in members of operating teams, compared to the surgeon of that team. further work is needed to elucidate the impact of human factor skills on team performance. a team-based approach to safety interventions is recommended. future studies should determine what type of aberrations and distractions are most relevant and valuable to embark on with team training. dept. of digestive surgery, school of medicine, tokushima university, tokushima, japan; dept. of digestive surgery, tokushima university, tokushima, japan background: the qualitative evaluation for laparoscopic training of medical students was performed using rubric evaluation, and weak points in conjunction with the lack of anatomical knowledge were derived. to conquer these weak points, virtual reality (vr) ? augmented reality (ar) training for understanding of regional anatomy was investigated. materials and methods: one hundred and six students in th grade of tokushima univ. participated basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator. rubric evaluation, as qualitative evaluation, which includes the evaluation standards for each maneuver were performed before and after basic task training and sham operation. the group which self-evaluation was higher in a rubric evaluation was investigated. the d image of vessels and bile duct obtained from mdct of real patient was projected in reality space with microsoft hololens. training of ar image using hololens was performed for understanding of regional anatomy. after training of regional anatomy with hololens, sham laparoscopic cholecystectomy was performed again, and quality of procedure was evaluated by rubric. anatomical questions were. results: rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, several students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. after ar training, all students showed high score in questions related regional anatomy during operation. especially, rubric evaluation of students who showed high self-evaluation in sham operation showed same score with tutor. conclusions: as rubric evaluation showed weak points of detailed parts of maneuver, and vr ? ar was useful for understanding details of regional anatomy for laparoscopic training. background: the eaes has recently published an intraoperative adverse event classification to aid reporting of minimally access surgery events. this includes capture of non-consequential errors. we aimed to investigate the clinical impact of these apparent 'near miss' events. methods: case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision randomised controlled trial was utilised (isrctn ). the eaes classification was applied by two blinded assessors to all enacted adverse events identified on video analysis using the observational clinical human reliability analysis technique. the total number of grade (non-consequential) errors were compared with the number and nature of day morbidity events (graded with the clavien-dindo system) and length of stay. results: cases ( h of surgery) contained error events of which ( . %) were classified as eaes grade (median per case, interquartile range - , range - ). there were significantly more inconsequential errors recorded in patients that developed any early morbidity event than those who had an uneventful post-operative recovery (median . (iqr - ) vs. ( - ), p = . ). a stepwise increase in the sum of eaes grade errors is seen for each additional day morbidity event reported ( . vs. vs. vs. , p = . ) and the highest clavien-dindo grade experienced ( vs. vs. vs. . p = . ). positive correlation is observed between the sum of eaes grade a errors and length of post-operative stay (r s = . , p = . ). conclusion: in the context of major laparoscopic surgery, near misses are commonplace and correlate with surgical outcomes. this may represent a novel surrogate assessment method for intraoperative performance. aims: diagnostic laparoscopy (dl) is an under-utilised procedure that can replace non-therapeutic exploratory laparotomies in many contexts. to date, no validated education programme for dl exists. this study seeks to evaluate the feasibility, acceptability and face, content, construct validity of the laplat curriculum (laparoscopic learning for abdominal trauma; a simulationbased curriculum for trauma dl). this is in addition to the development of a novel d-printed bench-top model for abdominal inspection. methods: this prospective and observational pilot study involved novice medical students and junior doctors. surgeons from the uk and international (n = ) were involved in a two stage delphi-process to determine the components of the training course which were used to formulate a final curriculum. in the absence of an adequate model for abdominal inspection, a novel dprinted abdominal inspection model was designed and produced. after an introductory familiarisation session as well as pre-course cognitive lectures, the novices performed tasks on a virtual reality and bench-top simulator with repetitions of each in a half-day session. outcome measures for construct validity were total time to complete task, accuracy, percentage of horizon maintained and economy of movement. face and content validity as well as acceptability was evaluated by a qualitative and quantitative survey. results: face, content and construct validity as well as acceptability was established. face validity was demonstrated in all components of the course (including pre-course cognitive content and technical tasks) in addition to content validity. all also met an acceptability threshold of / on a -point likert scale. one-way anova tests demonstrated construct validity in all tasks (p \ . ) with learning curves in reducing time observed. using a performance improvement metric, one-way anova tests showed similar rates of improvement per participant between most tasks (p [ . ). the course was rated overall mean . / (± . ). conclusion: this pilot study has demonstrated the feasibility, acceptability and face, content and construct validity of the laplat curriculum as well of the novel d-printed abdominal inspection model. randomised controlled trials are needed to establish higher-quality evidence, as part of a wider curriculum with transfer needed to the clinical environment. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology-surgical propedeutics, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania; urology, training and research center, prof. dr. sergiu duca, cluj-napoca, romania; general surgery, training and research center, prof. dr. sergiu duca, cluj-napoca, romania aims: to evaluate the benefits of systematical use of ex vivoliver model and ct imaging in the planning process for swine laparoscopic liver resections done by residents during training programs. methods: twenty four general surgery residents were equally divided into two groups: first one which performed laparoscopic liver resections without planning stage and the second one which systematically used anatomical data from a swine liver model and interactive ct scans d reconstructions. the planning stage included an interactive tutorial for establishing the strategy for the next resection followed by performing open liver dissection and the same resection on an ex vivoswine model. a total of twelve models were used during this step. afterwards, laparoscopic procedures were performed on sixteen anesthetized domestic pigs, two swine for every team, composed of three residents. both groups were part of a dedicated and continuous training program and used the same 'step by step' protocol for resections. results: the average time for imagistic planning was . min and for open dissection and resection was . min. all teams successfully completed the interventions and followed the standardized protocol without trainers' interventions and with no conversions. the second group obtained better results regarding the time needed for completion and blood loss. also, when the planning stage was applied the resection was more accurate and less functional parenchyma was removed. the 'warming up' by adding the imagistic and anatomical data to the core protocol offer more clarity before laparoscopic liver resections. this also makes an upgrade for our 'step by step' protocol and provides sufficient data to admit this planning stage as mandatory for laparoscopic liver resection on swine during a training program. introduction: submucosal tunnel endoscopic resections (ster) had been increasingly performed for treatment of gastric subepithelial tumors. one of the limitations for ster is the risk of incomplete tumor resection due to close dissection and bridging of tumor capsule. endoscopic full thickness resection (eftr) allowed complete resection of the tumor with margins to prevent recurrence. this study aimed to review the techniques and outcomes of eftr for treatment of gastric subepithelial tumors. method: patients who received endoscopic resection for gastric subepithelial tumors were recruited. the gastric subepithelial tumors were considered eligible for endoscopic resection with size \ mm. all patients received preoperative assessments including eus and ct scan to define the extend of tumors and the proportion of extra and intralumenal components. all the procedures were performed under general anesthesia with co insufflation. eftr started after injection with mucosal incision up to % of tumor circumference, followed by submucosal dissection to identify tumor margin. further dissection was performed using esd devices. after adequate exposure of lateral margins, incision into muscularis propria was performed to achieve full thickness resection. luminal defects were closed by either clips, clip-loop crown method or overstitch suturing. results: from to , patients received eftr for gastric subepithelial tumors. the mean age was . years, and were male. the gist were located at greater curvature ( ), cardia ( ) , lesser curve ( ) and antrum ( ) . the mean size was . mm ( - mm) . most of the eftr were performed in operation theatre while two were done at endoscopy. the mean hospital stay was . days, and mean operative time was min ( - mins). there was no conversion to laparoscopy. closure of luminal defect were performed mostly with clips ( ), followed by overstitch ( ) and clip and loop crown closure ( ) . most patients resumed full diet on day , and all the pathologies confirmed gist tumors with clear resection margins. conclusion: endoscopic full thickness resection is technically feasible and safe procedure for treatment of gastric gist. future research should focus on refining the techniques of eftr and closure of the defect. next generation endoscopic intervention (project engine), osaka university, suita, japan; gastroenterological surgery, osaka university, suita, japan; research & development, -d matrix, ltd., chiyoda-ku, tokyo, japan; research & development, fuso pharmaceutical industries, ltd., cyuou-ku, osaka, japan background: hemostatic peptides have received increased attention. self-assembling peptides (tdms) comprise synthetic amphipathic peptides that immediately react to changes in ph and/or inorganic salts to transform into a gelatinous state. since tdms do not carry a risk of infection, their clinical application as new hemostatic agent is expected to increase. the first generation of these peptides (tdm- ) is currently used as a hemostatic agent in europe. however, tdm- exhibits slow gel-formation and low retention capabilities on tissue surfaces. the second generation (tdm- ) was therefore developed to encourage faster gel-formation and better tissuesealing capabilities, and we subsequently verified its usefulness and increased performance relative to tdm- in preclinical open surgery. aim: the aim of this study was to verify the efficacy of tdm- in terms of its hemostatic effect in endoscopic surgery. materials and methods: evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight female ( kg) pigs in spine position. following systemic heparinization, we established a bleeding model by utilizing flexible endoscopic grasping forceps on the anterior wall of the stomach and duodenum. in the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and ml tdm- was applied to the wound. after tdm- gelation, the endoscope was removed, and the acute hemostatic effect (after min) was confirmed. histologic evaluation was subsequently performed on resected specimens. results: in the endoscopic bleeding model, of the cases ( . %) showed complete hemostatic effects on the anterior wall of the stomach, whereas on the anterior wall of the duodenum, of cases ( %) showed complete hemostatic effects. moreover, none of the gels were displaced from the anterior walls of the stomach and duodenum, and histologic evaluation confirmed no infiltration of inflammatory cells. the new self-assembling peptide (tdm- ) displayed improved hemostatic effects relative to the previous generation (tdm- ) in endoscopic surgery. tdm- had potential usefulness for upper gastrointestinal bleeding. our future work will assess its usefulness for laparoscopic surgery. objective: indocyanine green (icg) is a dye used in medicine since the mid- s for different applications in ophthalmology, cardiology and hepatobiliary surgery; thanks to its selective hepatic uptake and biliary excretion, it can be used to evaluate hepatic function in patients scheduled for hepatic resection surgery. the aim of this study is to evaluate the efficacy and the feasibility of icg guided surgery in the intra-operative localization of liver tumors, comparing the pre-operative radiological aspect, the intra-operative visualization and the post-operative histopathological features of the tumors. materials and methods: icg was intravenously injected for a routine liver function test (limonÒ) in patients who underwent hepatic resection surgery for primitive and secondary liver tumors in the period between november and september . for each patient was performed an intraoperative visualization of the stain both in vivo and ex vivo, using a nearinfrared imaging system. all the images were recorded. results: a correct differentiation between liver parenchyma and tumor area was obtained in . % of cases. five patients were not evaluable due to widespread uptake or complete absence of uptake; it was probably the first cases enrolled in the study for which we were not able to set doses and timing of administration of icg. in patients in which the method had been feasible, we observed a prevalence of nodular pattern in patients with hepatocellular carcinoma ( %) and a predominance of rim pattern in both cholangiocarcinoma ( %) and metastasis ( %). furthermore, in patients with hccs well-intermediate differentiated (g -g ) was found predominantly a nodular pattern ( . %), whereas in poorly differentiated ones was prevalent a rim appearance ( %). regarding radiological correlations, the only one patient who presented an atypical radiological feature in pre-operative evaluation, showed a lesion with no icg captation in intra-operative visualization. conclusions: icg fluorescence imaging is a safe, minimally invasive and quite inexpensive method, that can be easily administered for routine evaluation of pre-operative liver function. it can be a useful support tool in the intra-operative detection of liver tumors, especially in laparoscopic surgery where it is not possible to directly touch the tissue. surgery, bundang cha medical center, seongnam-si, korea; surgery, severance hospital, seoul, korea; surgery, nhimc ilsan hospital, ilsan, korea; surgery, seoul national university bundang hospital, seongnam, korea; surgery, asan medical center, seoul, korea backgrounds & aims: robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. however, robotic liver resection had not generalized, so far. thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by prospective multicenter study. methods: from july to december , five surgeons who were novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed cases of robotic major anatomical liver resection. perioperative patient's clinical data and surgical data were prospectively collected. results: cases of left hemihepatectomy, case of extended left hemihepatectomy, cases of right hemihepatectomy, cases of right anterior sectionectomy, cases of right posterior sectionectomy, and one cases of central bisectionectomy were performed. the most common indications were hepatocellular carcinoma for cases following intrahepatic cholangiocellular carcinomas for cases, liver metastases for cases, sarcoma for case, intraductal papillary neoplasms for cases, mucinous cystic neoplasm for case, hemangioma for case, and intrahepatic duct stones for cases. surgical resection margins for all tumor cases were negative. total average operation time was . ± . min and estimated intraoperative blood loss was . ± . ml (minimal to ml). in terms of severe surgical complication, there were cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous trans-hepatic biliary drainage. only one case out of cases was converted to the conventional open left hemihepatectomy because of bleeding. conclusions: in this study, robotic anatomic major liver resection might be safely performed even by robotic beginners but advanced open and laparoscopic liver surgeons. surgical technique: with the patient at °on right lateral decubitus, access is gained through the path of the percutaneous drainage catheter after opening of the aponeuroses of the oblique and transverse muscles of the abdomen. a mm laparoscopic trocar is inserted and a cavity is created with pneumoretroperitoneum at mmhg. it is accessed with an optic of °and mm, and the work space is extended with aspiration and hydrodissection. with mm grippers, the necrotic material is removed, washed and drained. a two light silicone probe is left, one light for drainage and another one for washing. results: the mean age was . background: minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. in fact, the indication for robotic surgery in pancreatic disease has been controversial. the present study aimed to assess the safety and feasibility of robotic pancreatic resection. methods: we retrospectively reviewed our experience of robotic pancreatic resection done in sanchinarro university hospital. clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. aim: this work aims to study the contact pressure between the moving capsule and a synthetic small intestine in order to provide design guidance for prototyping the self-propelled capsule robot for small-bowel endoscopy. method: since small-bowel peristalsis consists of peristaltic contraction and wave distension, the contacts between the capsule and the small intestine are multimodal. we consider three contact cases for the capsule robot. case : the capsule moves on a flat small intestinal surface; case : the capsule moves in a collapsed intestine with a flat surface support; and case : the capsule moves in a surrounded small intestine. by considering these three contact cases, experimental testing and finite element analysis (fea) were conducted by measuring the contact pressure between the small intestine and the capsule. introduction: traditional laparoscopic instruments have limited degrees of freedom and are not ergonomic. this results in severe limitations in performing complex, and even simple tasks in surgery, limiting many surgeons from performing a variety of minimally invasive procedures. handx tm is a hand-held, electromechanical smart instrument with robot-like features. the instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. the instrument is . mm in diameter, lightweight, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. after the regulatory process was completed we have tested the device clinically through a structured, approved, clinical trial. materials and methods: after irb approval patients were recruited to the trial. we have included a variety of procedures that require suturing and complex tissue manipulation. two experiences surgeons performed all procedures. after completing each procedure the surgeons completed a detailed standard usability (sus) questionnaire. results: procedures were completed successfully without complications or device malfunction. there were female and male patients with an average bmi of . procedures performed were right hemicolectomis with intra-corporeal anastomosis, paraesophageal hernia repairs and fundoplication, diagnostic laparoscopies, tapp procedures, ventral hernias with fascial suturing, and laparoscopic cholecystectomies. the average performance score was . / . the results suggest that the handx device is safe and easy to use and may offer a simple solution for enhancing minimal invasive surgery capabilities and possibly reduce conversion rates while maintaining current standard surgery flow.the handx could potentially extend the surgeon's abilities to access hard to reach anatomy and perform complex maneuvers and present a cost-effective alternative to large console-based robotic systems. objective: endoscopic submucosal dissection (esd) has become widely accepted treatment for rectum neuroendocrine neoplasm. the aim of this study is to evaluate the safety and efficacy of esd with dental floss-assisted suspension traction for rectal neuroendocrine neoplasm. methods: we retrospectively reviewed the medical records of the patients, who underwent esd for rectum neuroendocrine neoplasm at endoscopy center of zhongshan hospital, fudan university. the data of operation time, r resection and adverse events were collected analyzed.in dfs-esd group: after the mucosa was partly incised along the marker dots, the next step was to construct traction device, similar to others in esd, with dental floss and hemoclip. the dental floss was tied to any arm of the metallic clip. the hemoclip was attached onto the incised mucosa, another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. the submucosa was clearly exposed with the traction of dental floss and the resection could proceed. results: patients were enrolled in the study. there were patients treated by esd with dental floss-assisted suspension traction and patients treated by conventional esd. the average tumor size was ( . ± . )cm in both group. the operation time was . ± . min in conventional esd group and ( . ± . ) min in dfs-esd group (t = . , p = . ). according to pathological grading about rectal neuroendocrine neoplasm, there were grade (g ) and grade (g ) in conventional esd group while grade (g ) and grade (g ) in dfs-esd group (? = . , p = . ). among cases in this study, all the basal resection margins were negative, the en blot resection rate was % and the curative resection rate was %. however, pathological results showed tumor tissue close to the burning margin in cases of conventional esd group and in cases of dfs-esd group (? = . , p = . ). conclusions: esd with dental floss-assisted suspension traction for rectum neuroendocrine neoplasm can assist exposing tumor borders, provide good vision during the procedure and offer clearer anatomic structure, so as to simplify operation, reduce operation time and ensure the negative basal margin. it is especially suitable to be promoted in primary hospitals. surg endosc ( ) aims: force feedback and assessment provides detailed insight into tissue manipulation skills. the aim of this study is to evaluate learning curves for basic laparoscopic skills based of force and motion learning curve patterns. morevover, we aimed to detect the favourable time span for this curriculum for each individual trainee. methods: in this prospective cohort study, first year surgical residents participated in a three week at home training course. a mobile box training was equipped with forcesense system for objective force, motion and time based assessment. the system provides seventeen unique metrics. the training goal was set by the mean score of proficient laparoscopic surgeons. each repetition was captured and made available for analyses. continuous force feedback was provided during training. curve fitting was used to estimate the learning curve plateau and the number of repetitions needed to approach the plateau phase and to reach proficiency level. finally, a comparisson between novices and experts was executed. results: a total of attempts, executed by residents were captured and analyzed. significant improvement of motion analysis parameters (e.g. path length and time) was observed for all training tasks, except for the fifth tasks. tissue manipulation skills (i.e. maximum and mean applied force) significantly improved by training tasks , and . learning curve analysis revealed various shapes and lengths of the individual learning curves. a large range in learning curve plateaus was found between trainees and between tasks. each trainee managed to accomplish the preset goals within three weeks. conclusion: force-and motion based assessment provides insight into both tissue manipulation and instrument handling skills. when combined in learning curve analysis, these parameters effectively show progression towards proficiency for each individual trainee over time. we emphasize the variation in learning curves between trainees. therefore, we recommend individually tailored courses provided with objective force-and motion-based learning curve tracking. aims: the posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation.the aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and perfusion assessment in the posterior retroperitoneoscopic approach. methods: six pigs underwent synchronous (n = ) or sequential (n = ) bilateral posterior retroperitoneoscopic adrenalectomy (pra, n = ). fluorescence imaging was obtained via intravenous administration of ml of indocyanine green (icg) using two near-infrared camera systems. fluorescence-based visualization of adrenal glands before vascular division (n = ), after main vascular pedicle ligation (negative control, n = ) or after adrenal division (n = ) was followed by completion adrenalectomy. one of the animals had undergone icg injection h previously, during another study. the dynamic evolution of fluorescence signal intensity over time was recorded and analyzed using a proprietary software. the computed color-coded perfusion cartography was superimposed onto real-time images obtained by corresponding left (l) and right (r) camera systems. the slope of fluorescence signal intensity evolution over time in the regions of interest (roi) served to assess adrenal perfusion by means of quantitative fluorescence signal analysis. results: in the retroperitoneum, the adrenal glands were promptly highlighted after primary intravenous icg administration or showed an increase in fluorescence signal intensity upon reinjection (both glands in a recovery pig and one gland in the sequential approach). after left adrenal main vascular pedicle ligation, the gland displayed low perfusion (blue; rois a -a in figure ), while a weak fluorescence signal after completion adrenalectomy suggests perfusion via collateral vessels. with intact vascular supply, the caudal segment of the right adrenal (a ) gland showed a significantly higher perfusion rate (red) than the ischemic cranial segment (a ). quantitative analysis of logarithmic fluorescence intensity showed a statistically significant difference between perfused and ischemic zones (p = . ) allowing to assess gland vascularity. kidneys (k) and adrenal glands showed distinct perfusion curves ( figure ). conclusions: prior to dissection, fluorescence imaging allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. during adrenal gland surgery, icg injection complemented by a computer-assisted quantitative analysis helps to distinguish between wellperfused and low-perfused segments. giant adrenal tumors:technical considerations and surgical outcome a. giordano, g. alemanno, c. bergamini, p. prosperi, v. iacopini, a. dibella, a. valeri sod chirurgia d'urgenza, aou careggi, firenze, italy objectives: giant adrenal tumors are tumors with size more than cm. these are rare cancer associated with malignancy in % of cases. the size of these tumors is an important topic in literature because of their higher probability of malignancy and possible technical limitations of laparoscopic approach. we report our center's experience on laparoscopic adrenalectomy. materials and methods: in the last ten years we performed about adrenalectomies for benign and malignant adrenal tumors. of these were giant tumors. the medium size was . cm ( - cm). tumors were on the left adrenal gland and on the right. there were women and men, the average age was ( - years). of these cancers were laparoscopically removed and with open approach. cases of open conversion. results: betweenn the tumors laparoscopically removed we recorded cases of carcinoma, endothelial cysts, adenomas ( with aldosterone and with cortisol hypersecretion), myelolipomas, pheochromocytomas and metastases from lung carcinoma. the surgical outcomes in these patients were optimal in terms of good pain control and hospital stay (median days). the average time of the intervention was min with very low blood less ( ml). no postoperative complications were recorded. the removal of the adrenal gland necessitated or trocars. in the dissection and resection phases we always used radiofrequency scalpel. the follow up after and months didn't show local recurrences. conclusions: laparoscopic adrenalectomy offers significant advantages over the open approach. the size of these tumors is still at the center of debate for the choice of the technique. the tumor size is only a predictive parameter of possible malignancy. the laparoscopic approach is a safe and feasible method in terms of surgical and oncological outcomes also for the giant adrenal tumors, only if performed by expert surgeons and in high-volume centers. vascular or adjacent organs infiltration is a contraindication to the laparoscopic approach. aims: adrenal gland size greater than cm is considered a contraindication to laparoscopic adrenalectomy (la). aim of the present case-control study is to compare the surgical outcomes in patients undergoing la for adrenal gland measuring = cm versus = . cm in diameter. methods: from january to august , las were performed in the two authors' centers which follow an identical treatment protocol. eighty-one patients with an adrenal gland size = cm (intervention group) were included in the study. based on body mass index (bmi) class [ kg/m ) , lesion side (right or left), surgical technique (anterior transperitoneal for right and left-sided lesions, anterior transperitoneal submesocolic for left-sided lesions) and lesion type (conn-cushing, pheocromocytoma, primary adrenal cancer or metastases, other type of lesion), patients with an adrenal gland lesion measuring = . cm in diameter were included (control group) and paired to the intervention group. results: comparing the intervention and control groups, statistically significant differences were observed in mean lesion size ( conclusions: the only significant difference between the two groups was the operative time which was longer in the intervention group. conversion and complication rates were also higher in the intervention group but the difference was not statistically significant. based on the present data, adrenal gland size measuring more than cm in diameter is not a contraindication to a laparoscopic approach. ; and orthopaedics and urologists for the remaining . %.the costs from these claims, differed from to % of the total damage burden per year. the review of medical charts of claims related to laparoscopic gynaecologic surgery showed that % of claims were filed for visceral and/or vascular injuries ( % bowel injuries, % ureter). % of the injuries were entry-related. a delay in diagnosing injuries was the primary reason for financial compensation. conclusion: evaluating and learning from complications and claims will improve medical health care. in contrast to overall trends and developments considering medical claims, claims concerning laparoscopic surgery decreased, possible due to a rising learning curve. considering laparoscopic surgery, extra caution is required at moment of entry and the early recognising complications and at pre-operative counselling from patients. the aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations. patients and methods: the study involved patients with spleen injury grade iii who were admitted in our institute in the years of - . the patients were divided on two groups. laparoscopic splenectomy was performed in patients (group i) and 'traditional' splenectomy was carried out in patients (group ii). there was no difference in the demographic data and trauma severity between the two groups.non-invasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations (us), x-ray in multiple views and computed tomography (ct) had been performed before the decision about necessity of an operation was made. results: patients after laparoscopic operations had better recovering conditions compare to patients with the same injury after 'traditional' splenectomy. neither surgery related complications no mortalities were registered in both groups. laparoscopic splenectomy was more timeconsuming operation than 'traditional' splenectomy. we suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced. conclusion: laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. the operation is indicated in patients with spleen laceration more than cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (more than ml/h on serial us examinations). the isolated hydatid disease of the spleen is a quite rare condition, liver and lungs being the most common locations. the treatment requires usually splenectomy, open or laparoscopic. there are few reports in the literature describing a spleen-preserving type of surgery. we present a case of a female patient, y.o., with a large cystic lesion of the spleen, cm in diameter. lab tests and ct scan confirmed that is a hydatid cyst. after albendazole treatment and vaccination the patient was referred to us for surgical treatment. the procedure was performed under general anesthesia and laparoscopic approach was performed with the intention to preserve the spleen. after the cyst was identified and adhesiolysis was done, the area was isolated from the rest of the abdominal cavity with sponges with a betadine solution in order to prevent contamination. a needle aspiration of the cyst allowed the evacuation of ml of purulent content, an indicator of a dead cyst. betadine solution was injected into the lesion. laparoscopic excision of the cyst was performed using advanced electrocoagulation devices and the spleen removal was not deemed necessary. two drainage tubes were placed in the remnant cavity. an abdominal ultrasound was performed in the third postoperative day and no collections were identified. the postoperative outcome was uneventful; the patient was discharged in the th postoperative day. the conclusion is that in selected cases, with the cyst located in the anterior part of the spleen, with proper equipment and experienced laparoscopic teams, the cyst can be successfully treated without splenectomy. deep neuromuscular block was induced with rocuronium . mg/kg. in group , forty patients were enrolled for reversal of profound neuromuscular block during thyroid surgery (sugammadex mg/kg, after identification of vagus nerve). in group , thirty-five patients were enrolled profound neuromuscular block during thyroid surgery(without reversal of nmbd). tof-watch acceleromyograph was recorded in response to adductor pollicis muscle for ulnar nerve stimulation in patients with both groups; recovery was defined as a train-of-four (tof) ratio = . .to prevent laryngeal nerve injury during the surgical procedures, all patients were neurophysiologically detected using ionm. results: the total duration of surgery was higher in group than group ( . ± . , . ± . ;p \ . ). the mean time to recovery of the tof ratio to . was higher in group than group ( . ± . , . ± . ; p \ . ). the mean duration of vagus reverse (v : , milisecond) was higher in group than in group ( . ± . , . ± . ; p \ . ). no significant difference was found between left and right v -v and r -r values in group following nerve monitoring, whereas in group , a significant difference was found between left v -v , left r -r and right v -v values ( introduction: oeosphagogastric oncology trials have often lacked robust methods of monitoring and surgical quality assurance (sqa), leading to difficulty in interpretation of trial results. this study aims to assess expert opinion regarding challenges to sqa in oncology trials and potential mitigating strategies. method: a purposive international cohort of expert stakeholders with experience in oncology trials were recruited including: surgeons; oncologists; trial methodologists, and; trial managers. semi-structured interviews were thematically analysed using grounded theory. spss was utilised to assess differences between trial stakeholders' opinions. results: emergent themes were identified and consensus themes emerged on qualitative analysis of stakeholder responses. key consensus challenges to implementation of sqa in oncology trials included: insufficient resources; limitations of surgical volume in centre selection; differing oncological beliefs and resistance to change adoption; overly prescriptive protocols and standardisation contributing to difficulty in surgeon recruitment; and cultural factors leading to difficulties in providing and receiving feedback. seminal consensus mitigating strategies to overcome challenges to sqa in oncology trials included: trial centre selection according to case volume (n = , %); requirement for specific centre attributes for inclusion in trials including specialist centre designation and participation in national audit (n = , %); consideration for surgeons learning curve in surgeon selection (n = , %); flexible standardisation of trial operating (n = , %); operation manual utilisation to aid standardisation of surgical interventions (n = , %); case monitoring using video (n = , %) or photographs (n = , %); direct intraoperative observation by an expert (n = , %), and; histopathological assessment of resected specimens (n = , %). other methods of monitoring surgical quality advocated included: recording post-operative outcomes; lymph node yield; case report forms; and real time data monitoring (n = , %). oncologists were significantly more likely to state the importance of standardisation of surgery in oncology trials (p \ . ), and trial methodologists significantly more likely to advocate consideration of surgeons' learning curve in surgeon selection (p \ . ). conclusion: surveying international expert stakeholder opinion revealed a wide variety of perceived challenges across all domains of surgical quality assurance. proposed mitigating solutions require consensus opinion to formulate a framework to aid design of sqa measures within future oncology trials. research group did not register a single case of ega leakage while patients in control group (? \ , ). had the leakage which was stopped by means of 'endovac' system. there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to cases in the research group and cases in the control group (? \ , ). there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). neither of the groups had any cases of post-operative mortality. purpose: to investigate the prognostic effects and risk factors of the omission and delay of postoperative chemotherapy of ii/iii gastric cancer (gc), with the goal of providing a reference for interventions of related departments. methods: the clinicopathological data of patients undergoing radical gastrectomy for ii/iii gc were collected and retrospectively analyzed. we defined the chemotherapy delayed until more than days after radical gastrectomy and the complete omission of chemotherapy as unacceptable chemotherapy initiation (uac group), while the chemotherapy conducted within days of radical gastrectomy was defined as acceptable chemotherapy initiation (ac group). the survival between the two groups was compared, and the trends and risk factors of uac were analyzed. results: the total number of patients who underwent totally laparoscopic distal gastrectomy with uncut roux-en-y and delta shaped billroth-i anastomosis was and , respectively. the mean reconstruction time was longer in uncut roux-en-y than in delta shaped billroth-i, ( . ± . vs. . ± . min, p \ . ). the uncut roux-en-y was used more cartridge than delta shaped billroth-i anastomosis ( . ± . vs. . ± . , p \ . ). however there was no significant differences in operation time, estimate blood loss, number of retrieved lymph node and postoperative course between reconstruction methods. postoperative complications more than clavien-dindo grade iiia occurred in cases ( . %) of postoperative early complications and cases ( . %) of late complications. the endoscopic findings showed excellent short and long-term outcomes in terms of very low incidence of bile reflux and reflux-induced remnant gastritis in uncut roux-en-y compared with delta shaped billroth-i anastomosis. conclusions: uncut roux-en-y gastrojejunostomy was a useful reconstruction method with totally laparoscopic distal gastrectomy for cancer, especially for diverting enteral contents from the remnant stomach and preventing remnant gastritis. therefore, it is recommended for young patients with early stage disease who have a long time to live after distal gastrectomy for cancer. operative technique: the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. when seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. the mucosa is then transected with a stapling device to execute fullthickness resection of the specimen. finally, the seromuscular defect is repaired by hand-sewn suture. results: since december , clean-net has been performed in patients with gastric smts. all tumors were resected en-blocwithout rupture. the average operation time ranged from to min with an average of . min. the postoperative course was uneventful. microscopically the surgical margin was tumor-negative (r resection) in all cases. the margin width was small with an average of . mm ± . . conclusions: clean-net is a useful option in the laparoscopic surgical treatment of gastric smt, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided. background: the type of fundoplication-complete or partial is still controversial for the surgical treatment of gerd. laparoscopic toupet ( wrap) fundoplication has less post op dysphagia and gas bloating compared to nissen fundoplication ( wrap) and is advised to be the procedure of choice when esophageal manometry findings are abnormal, however it is considered by some less effective and more difficult to perform. the aim of this research was to determine in the functionality and efficacy of the different types of fundoplication. methods: explanted pigs stomachs weighing - kg were studied. two different studies of the les were performed: distensibility and failure point (occurrence of reflux according to volume added to the stomach). for both studies we first disrupted the lower esophageal sphincter using a rigiflex tm dilating balloon. we then performed three different fundoplications-nissen, toupet, dor and measured the distensibility of the egj after each fundoplication. the failure point was determined following each fundoplication type. results: we used pig stomachs for the distensibility study and pig stomachs for the failure point study. there was no statistically significant difference between the nissen and toupet fundoplications when distensibility was measured, however the egj was more distensible following dor fundoplication (p = . for nissen, . for toupet). when the failure point was measured, nissen fundoplication was significantly more effective than toupet, and toupet was significantly more effective than dor (p = . ,p = . respectively) conclusions: we studied the differences between the mechanical effects on the egj following three different fundoplications, encompassing , , and of the esophagus. we demonstrated that there is a significant difference between dor fundoplication and nissen/toupet when distensibility was measured. there was no difference in the distensibility of the egj following a or wrap. there was, however a significant difference of effectiveness between all three fundoplications. these findings suggest that the and fundoplications have similar functionality while the wrap mechanically prevents possible reflux and support proponents of toupet fundoplication rather than nissen due to the similar functional results while decreasing the post op dysphagia and gas bloating complications. surg endosc ( ) aim: to describe patients undergoing surgical treatment of incident gastro-oesophageal reflux disease and the use of anti-reflux treatment in a danish population-based cohort. methods: all adult danes - undergoing upper endoscopy and receiving a diagnosis of gerd within days were identified. patients with previously diagnosed gerd, peptic ulcer-disease, barrett's oesophagus or cancer of the gastrointestinal tract were excluded. in this study, only patients undergoing anti-reflux surgery within two years of gerd-diagnosis were subsequently included. age, sex, charlson comorbidity index (cci), anti-reflux surgery (primary and re-operative) and endoscopic dilatation were identified using the danish national patient registry. mortality was identified using the national civil registry. pharmacological treatment of gerd (proton pump inhibitors, h \ su \/su-blockers and other prescription anti-reflux drugs) as well as use of nonsteroid anti-inflammatory drugs (nsaid) and anti-thrombotic treatment were identified using thethe danish national prescription registry. all data was linked on an individual level using the unique identification number that all danish citizen are assigned to at birth or first immigration. results: a total of first-time fundoplications were performed, hereof . % performed laparoscopically (n = ) and . % performed using open technique (n = ). at one-year followup, . % (n = ) had undergone endoscopic dilatation and . % (n = ) had undergone reoperation. the -day mortality was \ . %. patients had a median age of years ( - years) and were predominately male ( . %-n = ). a total of . % had cci (n = ). diagnoses were gerd with esophagitis ( . %-n = ), gerd without esophagitis ( . %, n = ) and gerd without specification ( . %, n = ). before initial endoscopy, , % (n = ) used at least one type of anti-reflux drug, dropping to . % (n = ) in the year after anti-reflux surgery. however, even when censoring patients with barrett's esophagus or peptic ulcer disease after initial endoscopy and patients undergoing concomitant treatment with nsaids or antithrombotic drugs, . % still used at least one type of anti-reflux drug after surgery. conclusion: in this population-based study, anti-reflux surgery was safe and lowered the use of pharmacological treatment. however, even when adjusting for competing reasons for use of antireflux drugs, . % used at least one type of anti-reflux drug one year after surgery. the new approach to perform nissen fundiplication m. paranyak, v. grubnyk surgery, odessa national medical university, odessa, ukraine nearly % of patients who undergo laparoscopic anti-reflux surgery at long-term follow-up need for surgical reintervention mostly because of hiatal hernia (hh) recurrence, wrap migration or disruption. purpose: the aim of our prospective study was to evaluate and compare several technics of wrap fixation and determine whether modified nissen fundoplication(mnf) reduce failure rate in the long term follow up. materials and methods: this was a prospective, randomized, controlled trial. from november to october one hundred and thirty-eight gerd patients who underwent anti-reflux surgery were divided into two groups. excluded criteria for our study ware diagnosed hiatal hernia (hh) type iii. in the i group which include patients we performed the following manipulations: nf was supplemented with suturing wrap to the diaphragmatic crura ( patients) on each side using two non-absorbable stitches. such technique permit us to create more symmetrical wrap. in case of weak conditions of crura or short esophagus ( patients) fundoplication wrap was sutured to the body of stomach using two non-absorbable stitches on each side. control group ( patients) underwent classic nissen fundoplication (nf) without wrap fixation. all patients were assessed before and after surgery using validated symptoms and quality of life (gerd-hrql) questionnaires, -h impedance-ph monitoring and barium-swallow. results: baseline characteristics were similar between groups. there were no conversion to open procedure or mortality. mean hospitalization was . days ± . days. at , months (range -- ) of followup, the overall rate of complications after mnf was , % ( hh reccurence) and nf , % ( hh reccurence, slipped wrap). patient in mnf group show significant improvement in gerd-hrql score, from . ± . (preoperatively) to . ± . (postoperatively) (p? \ ? . ). complete ppi independence was achieved in %. in the ii group of patients mean gerd-hrql score decline from . ± . (preoperatively) to . ± . (postoperatively), postoperative ppi treatment was necessary in %. conclusions: according to our study mnf minimized risk of slipped wrap and intrathoracic migration of the wrap and can make positive impact on reducing the failure rate of laparoscopic anti-reflux surgery. aims: comparative evidence across laparoscopic antireflux procedures does not exist. aim of this project was to identify direct comparative evidence between laparoscopic antireflux procedures and synthesize evidence using network meta-analytical methods. methods: the databases of medline, amed, central, opengrey were interrogated. pairwise meta-analyses for each pair of interventions using a random-effects model and network metaanalysis in stata was performed using the mvmetacommand and self-programmed stata routines. differences between direct and indirect evidence were explored by comparing direct and indirect estimates though computing the inconsistency factor within each closed loop of evidence. the ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmetacommand in stata. a hierarchy of the competing interventions was obtained using rankograms. quality of evidence was assessed using grade-nma and the cinema application. results: forty-three publications reporting on randomized trials and some patients were identified. the network of treatments formed a closed loop between °, °and anterior °; and star network between °and other treatments; and between anterior °and other treatments. laparoscopic °, °, anterior °and anterior °were equally effective in the control of heartburn and this was supported by low quality of evidence according to grade-nma. the odds for dysphagia were lower for anterior °(high quality evidence), anterior °( moderate quality evidence), °(moderate quality evidence) and proton-pump inhibitors (moderate quality evidence) compared to °. the odds for gas-bloat were lower for °and anterior °compared to °(low quality evidence). the odds for regurgitation, morbidity and reoperation were similar across treatments, albeit these were associated with very low quality evidence. anterior °had a % probability of being the best treatment in terms of dysphagia. conclusion: under consideration of treatment effect estimates, evidence quality as assessed with grade-nma and other parameters, anterior °, anterior °and °should be preferred over °. further research needs to focus on the comparison between °and °/ °. aims: we have recently demonstrated that the tension of crural closure can be reliably measured intraoperatively (alsgbi conference december ). the aims of this study were to further characterise tension at the diaphragmatic hiatus from our prospective pilot study of patients. methods: a prospective analysis was performed of patients undergoing laparoscopic hiatal hernia repair between april and december . patients underwent crural tension measurement intra-operatively. patients had a pre-operative ct scan of the abdomen within one-year of surgery. hiatal surface area (hsa) was measured intraoperatively and a sauter-fh universal digital force gauge was used to measure the tension of crural closure during cruroplasty. outcome measures included the mean tension of the crural closure and the presence of muscle splitting during the cruroplasty. results: for all patients, the mean crural tension measurement was . n and the mean hsa was mm . pre-operative ct was positively correlated with post-dissection intra-operative hsa (r = . , p = . ), however, strength of association was weak (r = . ) and ct consistently overestimated the size of hiatal defect intra-operatively (mean of differences mm , p = . ). crural tension was positively correlated with age (r = . , p = . ), hiatal height (r = . , p \ . ), hiatal width (r = . , p \ . ) and hsa (r = . , p \ . ). crural tension was correlated to the hiatal width to height ratio to assess the shape of defect and there was positive correlation (r = . , p = . ). tension was calculated for the posterior and anterior halves of the suture cruroplasty. anterior tension was significantly higher when compared to posterior tension ( . n vs . n, p \ . ) . patients had evidence of muscle splitting during the cruroplasty. the group with muscle splitting were significantly older ( vs , p = . ), had larger hsa ( mm vs mm , p \ . ) and higher crural tension ( . n vs . n, p \ . ). the lowest observed mean crural closure tension causing muscle splitting was . n. conclusion: there is now a possibility to optimise this operation with objective measures years after it was first described. initial findings suggest that crural closure up to * n could be the permissible tension threshold for suture cruroplasty and higher tension may benefit from the use of mesh reinforcement. background: endoscopic submucosal dissection (esd) and endoscopic full thickness resection (eftr) are advanced endoscopic techniques which can be time consuming using traditional endoscopic instruments. a new endosurgery platform, designed by fortimedix surgical, was developed featuring flexible articulating instruments to use in combination with a standard flexible endoscope. the platform is intended to perform endoscopic cutting, dissecting, and hemostasis. aim: evaluate feasibility of the platform in the upper gi-tract. project description: the platform was tested in a dry esophageal model as well as a second series with a porcine esophagus and stomach. the system has an external docking station affixed to the operative table to stabilize both flexible instruments for the right and left hand of the surgeon. at the tip of the endoscope, a cap containing instrument lumens is attached to allow advancing and removing the flexible instruments. the endoscope with the cap and instrument lumens attached is advanced via an overtube with outer diameter . mm. in the first series, flexibility and range of motion of the endeffectors was assessed. additionally, the ability to advance the instruments to the intraluminal target area from the docking station and along the scope was evaluated. in the second series, the functional capabilities of the system and instruments were evaluated in a porcine model. preliminary results: : in the dry model, the platform was adequately deployed to the target then range of motion was tested as well as cutting and grasping gastric wall with instrumetn triangulation achieved. the grasping forceps provided enough force to pull the mucosal wall and expose the dissection plane. in the pig model, the distal esophagus and stomach could successfully be accessed and platform deployed. esd was performed using newly designed flexible articulating scissors, dissection-hook, and graspers with good triangulation and sufficient grasping force with traction/counter-traction. the new fortimedix surgical endo-surgery platform applied to a standard flexible endoscope is feasible to perform esd. future studies are planned to determine learning curve and compare it to traditional endoscopic instruments. background: in laparoscopic surgery, we usually observe the organs in the same direction to avoid a mirror-image situation. therefore, we are unable to recognize how far the dissection has proceeded on the other side of the target organs or lesions, especially when the plane of dissection is under the mesentery or organs. this becomes a problem not to understand how far the dissection has progressed and how much more dissection is needed. aim: to solve this problem, we developed a laparoscopic device with tip illumination. project description: the device is configured by the long and narrow part made of polycarbonate resin and a battery-powered light-emitting diode to illuminate the tip by shining light through the polycarbonate resin. during the surgery, the tip of the device is inserted into the deepest part of the dissection area, and the transmitted light indicates how far the dissection has progressed. the tip of the device has a prism structure and light is emitted in a direction perpendicular to its axis. tip position can thus be more clearly identified even with insertion in the same direction as the laparoscopic view. to verify the utility of this instrument, laparoscopic surgeries were performed in a porcine model and cadavers. preliminary results: we performed some laparoscopic surgery such as the medial-to-lateral approach to the white line of the left side of the descending colon for sigmoidectomy, dissection of the posterior surface of the pancreas to the upper edge of the pancreatic body or splenic artery for distal pancreatectomy, and the separation of the anterior surface of the inferior vena cava from the liver to the area between the right and middle hepatic vein for right hepatectomy. we quickly and easily identified the deepest part of the dissection area even if identification had been difficult using other techniques such as placing gauze in the deepest position, inserting forceps into the dissection area or simply depending on the experience of the operator. background: recent advancements within surgery have seen artificial intelligence transform traditional approaches. robotic assistive devices have demonstrated particular success, as safe and cost effective, and are widely supported via industry and local government as a step closer to the future standard of practice. an example of seamless and touchless robotic assistive technology is based on touchless and interactive eye tracker glasses worn by the surgical team thereby enabling the team to perform wider surgical tasks, more efficiently and reduced human error. we introduce a perceptually-enabled, smart operating room (smart-or) based on a novel real-time framework for theatre-wide d gaze localisation in a mobile fashion. this framework enables dynamic gaze based user interaction with a robotic scrub nurse to facilitate meaningful practical integration of human and technology intra-opertively. aims: we tested participant acceptability of a novel robotic scrub nurse during simulated surgery. project description: surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses to select surgical instruments on a screen. the robotic scrub nurse(rn) picked up and transferred the instrument to the surgeon. the study compared human nurse(hn) vs rn. gaze-screen interaction was based on a d gaze framework we developed with synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for real-time d reconstruction of the environment. nasa-tlx and van der laan's technology acceptance questionnaires were collected and analysed using anova. preliminary results: overall, teams of surgeons(st) and scrub nurses(sn) participated. nasa tlx feedback for st and sn revealed no significant difference between in mental, physical or temporal demand. importantly, st and sn reported no significant difference in task overall performance. st reported more significant frustration with rn vs hn. van der laan's scores showed positive usefulness and satisfaction scores in using the rn platform. overall, all outcomes were more positive by sn vs rn. conclusions: this is the first platform of its kind. overall, quantitative and qualitative feedback was positive. the source of frustration has been understood and we believe it can be improved by appropriately modifying robot behaviour. importantly,there was no difference on perception of performance. background: endoscopic tumor resections in the gi tract may be facilitated by more advanced instruments for dissecting and suturing. we have focused on developing an endoscopic suturing technique using a standard flexible pediatric endoscope with new, flexible instruments allowing for complex end-effector movements. aim: perform flexible endoscopic suturing using a standard flexible scope in the gi tract project description: a standard flexible pediatric endoscope and a standard gastroscope were used for testing the new technique. via an overtube, the endoscope and newly designed fortimedix surgical flexible instruments (needle holder; grasper) with a diameter of mm were inserted into the esophagus. suture training was performed in an experimental setting in a box in the dry lab and porcine model . the flexible needle holder was advanced into the esophagus next to the scope, and a suture of the esophageal wall was performed, followed by extracorporeal knot-tying with knots. the test series consisted of training with both resident trainees and surgeons to evaluate the learning curve. each participant performed sutures on the box model and in the pig-esophagus. feasibility, duration of the different steps, and handling problems were documented. preliminary results: test series (box training on esophago-gastric explant) with prototype showed good feasibility. suturing was possible in out of attempts. median duration for single bite: min ( - ); knot-tying: min ( ) ( ) ( ) ( ) ( ) ( ) ( ) . test series (training in pig-model) with prototype showed improved feasibility with better flexibility of instrument shaft: median duration of double bite: min ( - ); knottying: min ( ) ( ) ( ) ( ) ( ) , overall duration intraluminal esophageal double bite suture and closing with knots: median duration: min ( - ). the new flexible endosuture instruments seem feasible to use and perform dependable intraluminal sutures. the training period and learning curve is short and the objective is to apply this system clinically for closure of perforations and fistulas. school of mechanical and aerospace engineering, nanyang technological university, singapore, singapore; general surgery, national university hospital, singapore, singapore; gastroenterology, national university hospital, singapore, singapore; surgery, chinese university of hong kong, hong kong, hong kong background: ideally, endoscopic suturing should mimic surgical closure as the latter is stronger than most endoscopic closure devices. however, endoscopic suturing is challenging due to the confined endoluminal space and lack of dexterity of current endoscopic instruments. we have developed a novel robotic suturing device to overcome these problems. aim: this animal study aims to demonstrate the feasibility of this device in closing perforations. method: the trial was conducted on an anaesthetized live pig. a double-channel colonoscope was first inserted into the rectum. following saline lift, a mm submucosal incision was created in the rectum to simulate a perforation. the robotic suturing device and grasper were inserted into the two colonoscope channels, allowing the endoscope to remain in position for tool exchanges or needle reloading. both the effectors were intuitively tele-operated by the user via a robotic master console. this robotic suturing device manipulated a curved, double-point needle (with a cm - vicryl suture) to penetrate tissues at desired orientations. the needle could be switched between both jaws of the device through a locking mechanism. this facilitated passing the needle through tissues to form stitches or through suture loops to form surgical knots. the articulated joints and five degrees of freedom allowed dexterous steering to reach targets and triangulation with other tools in a confined space. the robotic grasper facilitated handling of tissue and suture. result: a total of four running stitches were performed and secured with a surgical knot by passing the needle through suture loops. the suture was cut and the needle was removed by the robotic grasper through the channel. min and min were required to stitch and tie the knot respectively. there was no complication. conclusion: our novel endoscopic robotic device can suture perforations resulting from complex endoscopic procedures. as our suturing method is similar to laparoscopic and robotic suturing, closure using our device is expected to be as strong as a surgical through-and-through closure. when developed further, this device can be used to close full-thickness resection sites and orifices in transluminal endoscopic surgery. modelling a collaborative robot with the ieee sdc standard for combined focused ultrasound and radiation therapy j. berger, m. unger, l. landgraf, a. melzer medical faculty, university hospital leipzig, innovation center computer assisted surgery, leipzig, germany background: surgical robotics require a smooth integration into the operating room (or) . for this propose the ieee sdc(service-oriented device connectivity) standard has been developed in the or.net project. in preparation for a combined focused ultrasound and radiation therapy (fus-rt) we have shown concepts and evaluations to position ultrasound and interventional devices with collaborative kuka arms. however, the safe and intraoperative cooperation with multiple different or-devices (e.g. an irradiation unit) requires a more sophisticated exchange of the robot's information and functionality. aim: to realize a safe clinical integration, the aim of this work is to implement and evaluate a dynamic connection between the kuka robots and other devices using the vendor-independent sdc communication standard. project description: a kuka lbr iiwa r robot (kuka ag, germany) was modeled inside the sdc standard for medical device communication. the interconnection with other devices was implemented and evaluated on a mobile platform to position a clarius l wireless ultrasound transducer (clarius mobile health corp, canada). all necessary information of the robot was represented in the medical device description of the sdc standard to be shared via network. for each joint of the robot arm the position, torque, stiffness, damping, velocity and functional-states were represented, resulting in a total of parameters. the software was implemented in c ?? on a standard pc accessing the kuka controller cabinet with ros (robot operating system) via ethernet. the accessibility of each parameter, as well as activation commands for planning and movement were tested with an sdc-consumer application. preliminary results: the sdc-provider functionality of the robot was successfully implemented, allowing for dynamic changes of the robot state during interventions. all appliances (sdc standard compatible) in the robots network can react to state changes and send movement and planning commands to the robot via activations. after testing, % of the defined parameters are safely accessible. implementing the medical device communication for the kuka robot enables its integration into any networked operation room that supports the sdc standard. it is, therefore, ready to be set up and evaluated for the application of fus-rt in a clinical environment. background: assessment of perfusion of the left colon with fluorescence during anterior resections for cancer changes surgical decisions in up to % of cases. use of fluorescence has been shown to be associated with lower leak rates, and improved short-and long-term outcomes with reduced costs. given the high incidence of colorectal cancer, fluorescence-guided perfusion assessment could be of great importance in contemporary surgical practice. however, there is currently no standardisation of this technique which represents a significant limitation to widespread adoption. aim: to standardise fluorescence-guided perfusion assessment in rectal anterior resection through a computer vision algorithm. project description: videos were collected by a single surgeon in a referral centre for colorectal cancer treatment. perfusion assessment was used before proximal colon division to identify the best location for transection. a bolus of indocyanine green was injected intravenously and a near-infrared camera used to assess perfusion through fluorescence. photographs of fluorescent imaging of the colon were analysed using a non-supervised learning algorithm called 'k-means clustering'. the first step was to digitally subtract all background pixels, leaving only the area of interest of the colon. this area was then subsegmented into 'clusters' corresponding to perfused and nonperfused areas. a mathematical model was applied based on the sub-clusters centres to select the area for transection with optimal perfusion of the proximal colon. preliminary results: representative images of proximal colon under perfusion assessment were presented to expert surgeons. the optimal point for transection was selected based on their clinical judgement on previously delimited areas indicated by random letters. this was compared with the results from the automated segmentation using the algorithm ( fig. ). the area identified for section by the algorithm included the area selected by the expert surgeons in . - % of test cases. these results need to be further validated due to high risk of overfitting. next steps include the collection of multicentre data with a standardised fluorescence perfusion assessment. after robust training, the algorithm will be validated on real-time clinical data to ensure improved outcomes for patients, which is our ultimate goal. background: endoscopic submucosal dissection (esd) is a flexible endoscopic technique that allows for an en bloc removal of lesions of the gastrointestinal (gi) tract. these procedures are typically time consuming due to the difficult control of the tools, and they often require around min for removing lesions, that can reach - cm in diameter. the probability of intestinal perforation exceeds % and the hemorrhage risk ranges from . % to . %. a flexible robotic endoscope may offer a solution to overcome these limitations, by improving the degrees of freedom (dof) and operational efficiency. aim: within this clinical panorama, the aim of this project is presenting the development of a novel miniaturized robotic device to be coupled to the tip of a traditional endoscope for the surgical dissection of gi neoplasms. project description: the robotic platform consists of the miniaturized robot, the actuator housing (hereafter called external platform), the control unit and the master console (i.e.,two geomagic touch phantom) to allow the user driving and control (figure a ). during the operation, one surgeon stands close to the patient to maneuver the endoscope for exploring the gi tract and reaching the target area. another surgeon operates the miniaturized robot through the master console, carrying out the surgical procedure. the robot has been designed to be coupled to the tip of traditional flexible endoscopes of . mm in diameter. it exploits the flexibility of the endoscope for navigation through the intestine and integrates two-active robotic arms (i.e.,cautery and gripper) extending the dofs, and thus enhancing the efficiency during complex tasks such as manipulation and surgical tissue dissection. furthermore, the endoscope provides the optical system for visual feedback and one working channels for conventional instruments. preliminary results: firstly, a mock-up that faithfully reproduces the miniaturized robot has been realized using a d printer machine (projet mjp , d system, inc.) to verify the feasibility of the design solution. after verifying the potentiality of the d printed prototype, a final device, with the same features (i.e.,dof and geometry) of the d printed prototype, has been designed, fabricated and assembled ( figure b ). background: virtual and augmented reality has been widely used in many fields mainly for entertainment purposes. we think that it could be beneficial to use augmented reality in medical practice. aim: the aim of this study was to evaluate usefulness of d holographic images of patients anatomy displayed using augmented reality goggles during endovascular aortic repair (evar). project description: one of the major challenges during endovascular procedures is working on two dimentional x-ray images of three dimentional vascular anatomy. using d holograms of patients anatomy could be beneficial during the evar procedure and could make the orientation in vascular anatomy easier for surgeon. we performed two endovascular aortic repairs with the assists of microsoft hololens -smart glasses using augmented reality. we used carna life application created by polish company medapp. it was one of the first use of holograms during vascular procedures in the world (second and third stent-graft implantation using holographic imaging in the world). results: two patients with abdominal aortic aneurysms, -years old male and -years old female, were operated on. holograms of patient's anatomy made from preoperative angio ct scans by polish company medapp were displayed during the procedures using microsoft hololens. holograms could be displayed in any place and configuration using augmented reality, which means that the images did not interfere with the surgeon's field of vision. microsoft hololens use voice commends which permits the surgeon staying sterile. stent-graft implantations were successful. both patients were discharged three days after the procedure and the hospitalization was uneventful. seeing precise patient's vascular anatomy reconstructions in three dimention certainly helped us to navigate in a vascular tree. we believe that in the future this technology would enable to reduce the operation time and need for radiation. background: interaction with electronically controlled operating room (or) systems embedded in modern surgical environments is everyday practice for surgeons performing minimally invasive surgery (mis). while there is a non-sterile operating nurse available in the or, capable of interacting with these systems upon request by the surgeon, this indirect control is mostly slow, prone for error and disrupting surgical workflow. facing an unanticipated and unwanted outcome may cause distress emotions. distress emotions are undesirable when performing surgery, since they may impact available cognitive workload. furthermore, they may result in negative communication, hampering or-team empowerment and effective leadership. both factors are known to negatively influence quality and safety in the or. aim: the aim of the tedtrial is to investigate what setup best enables surgeons to interact with the endoscopic operating room setup during surgical procedures. as a result, disruptions of workflow, delays and errors may be reduced. outcome parameters will be objectified using medical data recorder (mdr) derived output and biometric analysis using hexoskinÓ. subjective evaluation of outcome parameters is done using questionnaires. project description: the tedcubeÓ system is a plug-and-play device enabling wearable sensors to act as a wireless alternative for a regular computer mouse, therefore enabling direct hands-free and sterile control of the or. the study is an observational trial with three different arms: intervention group ) direct interaction by surgeon with or environment using tedcubeÓ and myo tm armband, intervention group ) direct interaction of surgeon with or environment using tedcubeÓ and plantronicsÓ wireless microphone headset. the third arm is the control group using indirect interaction of surgeon with or environment using third-person computer interaction. main endpoint of study is the number of workflow disruptions due to the operation of laparoscopic or equipment. secondary endpoints are error rate, delay, team communication, subjectively reported frustration and satisfaction with the system and objectively measured stress as symptom of frustration and anger as distress emotions. preliminary results: primary and secondary endpoints of study are compared among groups. it is anticipated that reduction of miscommunication, error and delay may result in a reduction of distress emotions. trial start is expected q . anticipating the automated intraoperative tissue recognition: intraoperative tissue classification using hyperspectral imaging and machine background: iatrogenic injuries may occur despite a sound expertise in surgical anatomy. hyperspectral imaging (hsi) is an emerging optical method, combining the use of a camera system with a spectrometer. hsi analyzes optical properties of tissues and acquires d data sets with two spatial dimensions (x, y) and one spectral dimension (?). the data sets contain information about tissue physiology, composition, and perfusion. those spectral features coupled with machine learning algorithms might allow for automatic tissue recognition. aim: assessing the ability of an hsi-based machine learning to discriminate the hyperspectral features of different tissues during neck and abdominal surgical procedures. methods and procedures: fourteen pigs underwent laparotomy (n = ) or neck dissection (n = ). twenty data sets were acquired in vivo from abdominal organs and from neck structures by means of a customized hyperspectral camera (diaspective vision, germany). different anatomical structures were manually outlined by a surgeon using an image manipulation software (gimp). each pixel contained a hyperspectral curve and each curve was composed of bands (from to nm with a nm resolution). the curves were normalized using the standard normal variate method. a logistic regression machine learning (ml) algorithm was used to train the model to discriminate tissues, based on the hsi spectral features. the efficacy of the prediction model was tested using the k-fold (k = ) cross-validation. results: a large number of tissue-related hyperspectral curves could be extracted ( thyroid, vagal nerve, fatty tissue, cartilage, carotid artery, muscle, carotid vein, portal vein, biliary tract, gallbladder, hepatic artery, pancreas, duodenum, abdominal adipose tissue). the algorithm used min to 'learn' all data sets, and prediction was provided as an immediate output. overall, prediction accuracy was and % for neck and abdominal structures respectively. in particular, biliary ducts could be identified with a % accuracy and the vagal nerve with an % accuracy (see figure for details). background: a gaze-controlled robotic endoscope is innovative technology with myriad potential applications in the rapidly advancing field of flexible endoscopy. improvements to the current flexible device to allow examination of the gastrointestinal tract whilst minimising procedural discomfort and complications are desirable. aim: to use a gaze contingent framework to manipulate a flexible endoscope through a simulated upper gastrointestinal tract (ugit) model. description: a flexible gastroscope (karl storz pks) was attached to a ur axis robotic arm (universal robots), mounted onto a rail and placed on top of a surgical table. two cogwheel shaped dials were d printed and placed onto the up/down and left/right wheels on the head of the gastroscope ( figure ). robotization of these controls was achieved by using two motors (dynamixel rx- f) to steer the distal tip. this system allows users to operate a robotised flexible endoscope using gaze control. gaze interaction with the screen was based on a d gaze framework we developed with the synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for d reconstruction of the environment. users are able to control endoscope movements without handling the device. the distal tip of the gastroscope was controlled using eye gaze technology. the ur robot was used to enable shaft rotation (initiated by fixed head movements) and linear movements were triggered using a joystick handle (up for forward movement, down for endoscope withdrawal). pause and retroflexion of the endoscope are achieved by moving the joystick left and right respectively. users were asked to navigate an endoscope through an ugit model (chamberlain group) simulating a diagnostic gastroscopy using gaze control and targeting ten points scattered through the stomach. results: four expert endoscopists and one novice used gaze control to successfully navigate a gastroscope through a simulated ugit. all were able to intubate the oesophagus and accurately locate ten targets placed in the fundus, body, antrum and pylorus of the stomach. conclusion: gaze control endoscopy is a feasible concept. it allows ergonomic, user-friendly and intuitive control whilst maintaining the benefits of a flexible endoscope. background: image-guided needle biopsies and histopathological evaluation are the gold standard for the diagnosis of liver neoplasms. most often, however, these are reserved for suspicious, but not diagnostic, situations. radiomic may help to characterize tumor biology by correlating imaging features with relevant tumor-biology information. features derived from radiomic analysis may provide complementary information to support clinical decisions, especially in situations where tissue analysis cannot be performed or is inconclusive. aim: the goal of our technology is to exploit computational capabilities for image analysis in order to identify radiomic features useful for characterizing liver lesions and to identify relevant information related to patient prognosis. project description: patients derived from an internal database and patients randomly extracted from the cancer archive liver dataset were included in this study. lesions were extracted from those volumes using expert annotations ( secondary vs primary; well differentiated vs non-well differentiated). lesions were then split into training and testing sets. first order statistical features were computed and a lasso regression step was performed to reduce the number of features. both logistic regression and random forest models were built using cross-validation to predict the target classes on the test set. preliminary results: only features namely the energy and the volume of the lesion were sufficient, when combined in either model, to predict the differentiation grade on the test set with an f -score of . (± . ). we are currently working on the addition of higher order statistical features to the analysis in order to differentiate primary from metastatic tumors and identify complementary features that may assist clinical decisions in patients with inconclusive hepatic lesions. objective of the technology or deviceideally, the use of medical simulators could provide trainees with initial background information about indications for procedures, endoscopic technique, and early hands-on training experience that could shorten the initial critical learning curve. rationale for using ex vivo models is that in the beginning of the learning curve, the most important issue is having an initial exposure to the basic movements and maneuvers. our objective of is to create a stomach model from renewable polymer, which would closely simulate normal human stomach with gastric pathology for endoscopic diagnostic or interventional skill acquisition/evaluation. description of the technology and method of its use or application stomach model is based in several steps; the first one is in the in-silicodesign of the overall shape, after that we d print the positive two halves of it. the interior detail is obtained shaping the d printer parts with ceramic putty. once concluded, this elaborated part will serve as a template in order to build injection bleeding moulds. in the injection bleeding moulding a mesh is placed between layers in order to provide structural attachment points as stiches or several pathological models that will be incorporated after the casting process. we have developed for these instance polyp moulds, fistulae structures in order to attach endoscopic clamps. the two halves are closed once the pathological models are placed inside via a thermic-fusing and stitching creating a leak proof stomach model. preliminary results if available: our models were evaluated by international experts in ircar/ihu france in interventional endoscopy course and were favorable accepting for next trails in these prestigious institutions. conclusions: future directionsa new endoscopic training model of stomach was made and will be evaluated and validated for feasibility in mastering diagnostic and interventional endoscopic skills. clinical trials will be necessary to compare the ability of the simulator to perform training compared with traditional methods of training in endoscopic procedures. background: endoscopes are the eye of surgeons in minimally invasive surgery (mis). conventional endoscopes are mostly chopstick-like and are steered by the assistant. this limits the field of view and results in issues such as endoscope-instrument fencing, surgeon-assistant coordination. existing robotic endoscope holder enables solo-surgery, however endoscope remains blocking the instrument movement and impairs the operational safety. flexible endoscope such as the endoeye provides angulation at the tip and could enlarge the field of view. however, its steering the view is much more complex compared to the rigid endoscope. aim: to provide an intuitive robotic flexible endoscope with enhanced safety. project description: in this work, we present a robotic flexible endoscope for mis with enhanced safety. in the proof-of-concept system, it contains a flexible endoscope module and a robot manipulator. the endoscope contains a proximal rigid shaft and a distal flexible bending section. it is installed onto the patient side manipulator (psm) of the da vinci research kit (dvrk). visual servoing is adopted to achieve autonomous instruments tracking. during the tracking process, movements of the manipulator as well as the endoscope are minimized to save space for the operation and avoid instrument-endoscope fencing. the endoscope could also be controlled by the surgeon. a foot pedal is used to switch between the tracking-mode and control-mode. preliminary results: a prototype was developed and tested experimentally. in tracking a volume of * * mm , the spaces required by the flexible endoscope are . % (inside the trocar) and . % (outside the trocar) of that occupied by the rigid endoscope. evaluation with the fls tasks involved subjects. all of the participants completed the tasks under the tracking-mode without failure. in the ex-vivo test with porcine stomach, the endoscope successfully guided the detection, dissection and knotting autonomously. background: fluorescence imaging allows to visualize deep-seated anatomical structures, using a deeper tissue penetration of near-infrared (nir) compared to visible light. the most commonly used fluorescent substance, indocyanine green (icg), is not naturally excreted by the urinary system and requires retrograde stent placement and injection. lighted catheters have been proposed to help visualise the ureter. fluorescent dye-coated ureteral catheters could well represent a more effective and less expensive solution. icg is unsuitable for coating materials. aim: to develop a stable fluorescent coating for catheters to be used intraoperatively, working in the same nir window as icg, to facilitate its use with clinically available systems. project description: the coating was developed based on poly(methyl methacrylate) (pmma), a biocompatible polymer, and on specifically designed fluorescent dyes exhibiting icg-like optical properties. three nir dyes (substances a, b, and c) were tested in order to find the optimal one, in terms of fluorescence signal intensity, and were compared to icg in a polymer form and to an icg-based reference card (green balance tm ). the fluorescent coating was applied onto common ureteral stent materials: hydrophilic-coated ultrathaneÒ, silicone-coated latex, and pvc. the coating process involved cycles of immersion into the respective dyes blended in pmma polymer (icg, substances a, b, and c), followed by a drying phase. the various tubes were partly inserted into a porcine ureter, next to the icg-based reference card. images were taken in white light and nir modes using the d-light p camera system (karl storz), at a fixed camera-to-target distance. the fluorescence signal intensity was measured for the different regions of interest (each material/coating combination inside and outside of the ureter, reference card) using proprietary software and normalised against the reference card. preliminary results: the signal intensity was significantly higher for all new substances as compared to icg. substance a showed the strongest fluorescence signal intensity among the tested coatings in all tested conditions and materials and was identified as the ideal candidate to undergo further evaluation and in vivo testing. background: endoscopic resection(er) of early gastric cancers provides tremendous patient advantages. however, post-resection findings of deeper sub-mucosal(sm) and/or lympho-vascular invasion can necessitate a second, surgical intervention. we propose that pre-resection evaluation of the submucosal architecture under the tumour can provide critical information for staging and operative planning. we evaluate three techniques to assess the submucosal architecture underlying the gastric mucosa in a pig model. aim: to evaluate three needle-based methods of evaluating the sm before er. project description: acute pigs were used. a simulation of sub-mucosal tumours (endoscopically and eus visible bleb) by injecting the sm with cc of undyed nac. a linear eus was use for all procedures. the tumours were marked and labelled according to geography. methodology: after creating the tumours, anterior lesions were evaluated using the following g needle-based modalities: confocal microscopy(cm) using the through-the-needle cellvizio (mauna-kea) system; mini-biopsy(mb) using the micro-biopsy forceps moray (us endoscopy) and fine-needle biopsy(fnb). results: cm examinations were video recorded in all a positions. submucosal vascular visualisation was possible in all cases, excellent in / . mb was performed in lesions with a total of biopsies obtained from each lesion (total = ). fnb was performed once in the anterior lesions and twice in the posterior lesions with different needle brands. therefore, there was a total of biopsies collected. passes were performed in each biopsy (total = ). each pass constituted - insertion/withdrawal movements combined with fanning, slow pull technique, no suction and suction ( - cc air negative pressure) to collect the material. all material were sent to an animal anatomo-pathologist blinded to the acquisition method. mean time of confocal examination was min sec ( ' ' '- ' '') . mbtook a mean time of min and fnb was a mean of min for each biopsy. cm identified different patterns of vessels in relation to the probe position (superficial/reticular, middle cross-roads or deep/longitudinal). conclusion: eus-fnb, cm and mb are three potential methods to assess the sub-mucosal space underlying the gastric mucosa. cm offered the most architectural information but required more time to perform. these method's may have a role in better staging patients for appropriate er. background: the overall and disease-free survival of patients with rectal cancer is dependant on its staging, and adequate selection of the treatment strategy. mri has a proven efficacy in rectal cancer local staging and recognition of the adverse prognostic features. however, it can be difficult to utilise it as a navigation tool for surgeons, as it represents a complex three-dimensional pelvic space with a series of individual two-dimensional images. d image reconstruction has been successfully adopted in other surgical fields to overcome these limitations. aim: our primary aim is to develop a bespoke automated generation of patient-specific d pelvic models, which will improve surgical planning and navigation, patient interaction and surgical education. true-size, rotatable d models will offer a more realistic three-dimensional representation of the surgical space and its complex relationships, allowing for a more confident surgical rehearsal and potentially better utilisation of minimally invasive techniques in rectal cancer management. our secondary aim is to develop a large multipurpose database of the d models of male and female pelvis in health and in the disease. project description: our multidisciplinary team consists of colorectal surgeons, radiologists specialising in pelvic mri imaging and computer scientists. virtual d pelvic models are generated based on standard d dicom mri images routinely used for rectal cancer staging, which guarantees the high fidelity of cancer delineation. segmentation of the pelvic anatomy is performed with the use of itk-snap, an open-access, multi-platform software. machine learning technology is then employed to automate the d model generation, making it time-efficient, allowing for its clinical application. preliminary results: in the initial stage, using the manual segmentation, we have created ten models of normal male and female pelvic anatomy. a good inter-rater agreement level was found, which proves reproducibility of the approach applied. various machine learning algorithms are being explored to fully automate the process of d model generation, which will allow for their use in clinical practice and in development of the d colorectal database. the technology will be further implemented in creation of dynamic models of functional pelvic floor disorders. surgery, toho university omori medical center, tokyo, japan; surgery, neuchâtel hospital, neuch tel, switzerland background: laparoscopic gastrojejunostomies are time-consuming and require a specific training. alternatively, sutureless anastomosis can be achieved by means of endoscopically delivered magnetic rings. objective of the study: assessing the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using magnets coated with a fluorescent biocompatible polymer. methods and procedures: four pigs ( acute, survival models) and one cadaver were included in this study. the anastomotic device was composed of two magnetic rings ( x x mm; attraction force newton), each one attached to a cm long thread. the distal ring was inserted endoscopically into the first duodenum, and the extremity of the thread was clipped to the gastric mucosa. twenty-four hours later, a two-port laparoscopy ( mm, mm) was performed, using a near-infrared (nir) laparoscope (d-light-p; karl storz). the magnet's position in the jejunum was detected thanks to the transluminal fluorescence of the dye. magnetic interaction with the metallic tip of the laparoscopic grasper allowed to catch the ring and bring the bowel loop to the future anastomotic site on the gastric wall. simultaneously, the proximal magnet was delivered to the gastroesophageal junction using a flexible endoscope. the magnet was carefully advanced into the stomach allowing precise connection with the distal ring. in one cadaver the procedure was repeated. the sole variation was that, in order to reach the second jejunal loop, the distal magnet was placed using a gastroscope inserted through a transgastric port. in two acute animals, the distal magnetic ring was introduced into the jejunum via an enterotomy. the anastomotic procedure (from the distal magnet detection via fluorescence to the magnetic connection using a hybrid approach) was reiterated times. survival animals were followedup for days and underwent control endoscopies and ct-scans. results: the procedure was easy to standardize and reproducible, with a mean anastomotic procedure time of . ± . min. there were no technical problems and magnetic connection could be precisely directed in all cases, at both the anterior and posterior gastric wall. no complications occurred during the survival period and the anastomoses were patent by day . transluminal fluorescence allowed for a rapid detection of the magnet. colorectal cancer is the fourth most common cancer in high-income countries counting [ . deaths worldwide. survival rate reaches % in case of early diagnosis, falling down to % in case of advanced stage. conventional colonoscopy screening is limited by invasiveness, pain and often need of sedation. wireless capsule endoscopy enables inspection without discomfort, but passive locomotion often leads to incomplete and/or false negative results. the european endoo project (grant agreement ) aims to develop a novel system that overcomes most of the drawbacks of conventional colonoscopy, maintaining accurate and reliable diagnosis and therapy. the system is composed of an active robotic platform that magnetically drives a soft-tethered capsule; magnetic guidance is achieved through the magnetic localization of the capsule in combination with a closed-loop control that maintains an optimal and safe link between the capsule and the magnetic end-effector. a stereoscopic camera is integrated in the capsule for enhanced diagnosis though d reconstruction and automated detection of lesions/pathologies. the different modules of the endoo medical platform are illustrated in the figures. the robotic guidance systemconsists of an anthropomorphic manipulator that controls the capsule through an external permanent magnet. the robot, positioned on a dedicated trolley, is equipped with sensors for performing safe human-robot collaboration. the medical workstationincorporates: screens, buttons and pedals for visualization and command initiation, a joystick for system teleoperation and a back-end for fluidic control and data communication. the soft-tethered capsuleembeds an internal permanent magnet, magnetic sensors, an accelerometer, white and infrared illumination and an hd stereoscopic vision system with two wide-angle customized optics. a controller serves as the main control unitfor performing real-time communication and closed-loop control of the robot, localization system, capsule and physician commands. the synergistic cooperation of academic, industrial and clinical partners within the project allowed to develop and validate the system in in-vitro \/i [ , exvivoand preliminary cadaver sessions, performing comparisons with state-ofthe-art commercial colonoscopes. in conclusion, the endoo medical platform provides: reduced procedural pressures, user-friendly procedures, similar functionalities and performances of commercial devices, comparable procedural times and considerably lower costs with a new painless approach. background: this study is aimed at the comparison of the process of manual and robotic-assisted positioning of the electrode performing radiofrequency ablation with the usage of multifunctional robot-assisted surgical platform. under the control of the surgical navigation system. the main hypothesis of this experiment was that the use of a collaborative manipulator will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. we also check the stability of the electrode's velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. methods: sphere-shaped tumor phantoms measuring mm in diameter were filled with contrast and inserted in cow livers. livers were used for the robotic experiment and an equal quantity for manual. the livers were encased in silicone phantoms. analysis of ct data gave the opportunity to find the entry and the target point for each tumor phantom. this data was loaded into the surgical navigation system that was used to track and record the position of the rf-electrode during the operation for further analysis. results: standard deviation of points from the programmed linear trajectory totaled in the average . mm for the robotic experiment and . mm for the manual operation with a maximum deviation of . mm and . mm respectively. standard deviation from the target point was . mm for the collaborative method and . mm for manual method. the average velocity was . mm/s for the manipulator and . mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was . mm/s and . mm/s respectively.thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. conclusions: this experiment was produced as part of the work on the developing of the robotic multifunctional surgical complex. we can confirm the potential advantages of using robotic manipulators for minimally invasive surgery in case of collaborative practice for cancer treatment. surg endosc ( ) background and aims: laparoscopy has reduced tactile feedback compared to open surgery. in neuropsychological literature there is increasing evidence that visual and haptic information converge to form a mental representation of an object. through the combination of these inputs, this representation is believed to be more refined and robust. we investigated whether tactile exploration of a lifelike anatomical object before executing a laparoscopic action on this object in a laparoscopic box trainer improves performance of this action. description: a randomized prospective cohort study with two groups (a ? b) of ten laparoscopically naïve medical students was conducted. we compared the groups for baseline characteristics and performance, using a basic laparoscopic task (post and sleeve). to investigate the effect of haptic exploration, students performed ten repetitions of a laparoscopic needle action on a lifelike silicone caecum model (applied medical, rancho santa margerita, usa). group a did a pre-test visual exploration of the model. in group b manual exploration of the anatomical model was added to the visual exploration before executing the task. the box trainer was equipped with the forcesense tm (medishield, delft, the netherlands) system for skill assessment using objective force, motion and time parameters. results: baseline characteristics and-laparoscopic performance were comparable (p [ , ) . performances of trials on the anatomical model were captured and parameter outcomes were compared between groups. significantly less force (maximal force, maximal impulse, mean force and force volume) was exerted by the 'touch' group (p \ . ) (fig. ). this group also completed the task with less distance travelled by the instruments (p \ , ). there was no significant difference in time needed to complete the task (p = , ). conclusion: this study showed that, when performing a laparoscopic task on an anatomical model, pre-task haptic exploration of the model results in the use of significantly less force and less movement. adding haptic exploration to a laparoscopic training curriculum could therefore result in more efficient and more refined learning of laparoscopic actions. this, in turn, could lead to better, quicker and safer performance of laparoscopic operations. . esophagogastroscopy was performed before gabe and -week post-procedure assessing gastric abnormalities. weight and fasting plasma ghrelin were obtained at baseline, -, -, -and -months post-index procedure. after months, the sham group was unblinded and received gabe. both gabe and sham crossover to gabe groups were followed for months and received lifestyle therapy (behavioral-diet education). preliminary results: gabe was successful in all patients with no serious complications. significant, progressive weight loss was observed at and maintained at months. ghrelin in gabe group decreased by % ( . pg/ml) compared to baseline and months levels. weight-loss was approximately . % greater in the gabe group versus sham at months ( table ) . itt = intent-to-treat, pp = per-protocol analysis preformed using independent-sample t-test and à paired-sample t-test conclusions: gabe using eles is safe, accompanied by significant and so far maintainable weight loss. gabe using the eles demonstrated a reduction in ghrelin levels. aims: transanal total mesorectal excision (tatme) is the latest colorectal approach that continues to be in the spotlight. this study aims to describe the technique in depth by identifying and understanding technical advantages, errors and adverse events. methods: detailed video analysis using observational clinical human reliability analysis (ochra) was completed on clinical tatme cases performed by international surgeons. error frequency and error pathways leading to adverse events were described. tatme expert surgeons were interviewed and engaged in a workshop to elicit error-reducing mechanisms. results: overall technical errors and adverse events per procedure on average occurred ± . (range -- ) and ± . (range - ) times respectively. inadequate insufflation and poor camera optics were the most frequent set-up problems. instrument handling errors consisted most commonly of excessive grasper movement during the pursestring phase ( times total), inappropriate force applied ( times) with the energy device during the rectotomy, inappropriate force with the grasper ( times) and excessive movement with the energy device ( times) during tme dissection. incorrect dissection planes were created during tme dissection mostly due to insufficient retraction ( times) which didn't allow adequate exposure of the tissue planes. the most frequently occurring consequence was bleeding (mean: times per procedure). rectal perforation ( cases), vaginal wall injury ( cases), and prostatic injury ( cases) were also recorded. adverse events regularly occurred as a result of poor set-up/exposure, inappropriate retraction and/or instrument movement and incorrect plane surgery. error-reducing mechanisms and 'technical tips' describe specific steps and actions, both set-up/equipmentrelated and technique-related, that aim to prevent errors from occurring and avoid adverse consequences. ochra and individual feedback with error-reducing mechanisms developed by this study have been implemented into the national training programme for tatme. conclusion: tatme is an advanced complex procedure during which technical errors and their consequences are not infrequent. tatme requires knowledge of anatomy 'bottom-up', familiarity with its specialised equipment and technical skill working in a narrow space. appropriate structured training and mentorship are therefore recommended. surg endosc ( ) objective: insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. icg has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections and thus possibly reducing the leak rate. objective of this study is to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using intraoperative indocyanine-green dye (icg) angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. methods: this randomized trial involved patients undergoing laparoscopic left-sided colon and rectal resection randomized : to intraoperative icg or to subjective visual evaluation of the bowel perfusion without icg (clinicaltrials.gov nct ). the primary aim was to assess whether icg angiography could lead to a reduction in anastomotic leak rate. secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. results: after randomization, patients were excluded. accordingly, patients were included in the analysis; in the study group, and in the control group. icg angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection, in cases ( %). an anastomotic leak developed in patients ( %) in the control group and in patients ( %) in the study group (p = n.s.). conclusion: intraoperative icg fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. this method led to further proximal bowel resection in cases, however its role in reducing anastomotic leak rate should be studied in further research. endoscopic sleeve gastroplasty (esg) is a promising endoscopic bariatric procedure carried out with the application of transmural sutures resulting in a gastric reduction and gastric shortening. sutures are placed in u shape fashion, from the incisura to the fundus, which is preserved, using an over the endoscope suturing platform (overstitch, apollo endosurgery, austin, texas, usa). the choice of right lankmarks for suturing the gastric wall is extremely important for the efficacy and safety of the procedure. flexible endoscopy suffers from little anatomical reference points. correct spatial relation to precisely target the insertion of the helix device used for retraction and correct orientation of the full thickhness tissue bite require a good undrestanding of the anatomy of the stomach and sourrounding organs including vascular structures that could be inadvertently injured (left lobe of the liver, gallbladder, spleen, short gastric vessels, pancreas, transverse colon). surgeons by training can 'see' the anatomy beyond the gastric wall and undrestand whether they work in a safe layer or whether an underlying structure should be spared. this video illustrates all the potential risks realted with a wrong chioce of endoscopic landmarks when performing esg with respect to gastric and abdominal anatomy. introduction: central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are technically demanding procedures in minimally invasive approach because of difficult expoure and extensive parenchymal transection planes. with limited robotic instruments including absence of cusa, these procedures have been rarely perfomed by robotic approach. method: consecutive robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy were performed. patients were all males and were , , and -years-old, respectively. pathologic diagnoses were all hepatocellular carcinomas of each . , . , and . cm diameter. operative settings were identical for the three kinds of procedure. the patients were placed in supine with a reverse trendelenburg and right side elevation. umbilical -mm camera port, three -mm ports and additional -mm assistant port were used. glissonian approach and icg fluorescence image clearly demarcated the resection planes. parenchymal transection was performed using the maryland bipolar dissector and harmonic scalpel. the rubber band self-retraction method and third arm of robot system helped for stable and excellent exposure of surgical planes result: there were no conversions to laparoscopic or open surgery. the operative time was , , and min and estimated intraoperative blood loss was , , and ml. the pathologic surgical margin was . , . , and . cm. the length of stay after surgery was , , and days and there were no postoperative complications. conclusion: robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are still demanding procedures with long operative time. however, these procedures could be performed safely in regard to short-term perioperative outcomes. robot surgical system provided several benefits for anatomical hepatectomies including a stable and excellent operative field and clear surgical planes. suprapubic hernias (less than cm above the pubic arch in the midline) require important anatomical knowledge because of complexity of their repair and low incidence, by approximately % of all hernias. the problem to repair this type of hernias is that inferior margin of the defect is very close to pubic symphysis, consequently, mesh overlap is often inadequate. treatment of suprapubic hernias is controversial because of limited evidence in the literatura. this video shows the case of a -year-old female patient with suprapubic hernia with a defect of x cm. we performed a laparoscopic repair with a bilateral peritoneal flap of the groin region (as it is perfromed during tapp) for proper view of the pubic symphysis, cooper's ligaments, epigastric and major vessels, nerves and meticulous dissection the space of retzius. the defect was repaired by reconstructing the middle line with a running sutures. subsequently, titanium helical tacks were used to fix the mesh to the pubis and cooper and following the double-crown technique having special attention when fixing the mesh near to inguinal chanal, due to the possibility of causing chronic pain. the peritoneal flap was fixed over the mesh with abdsorbable fixation devices and seal with fibrin glue. laparoscopic repair of suprapubic hernias can be considered as the first option in treatment, because it endeavors to join the advantages of a minimally invasive approach and it is associated to low recurrence. the main advantages are that allows a proper visualization the anatomy and a proper fixation of the mesh. background and aim: thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. we evaluate our cases who undergone the thoracoscopic esophagectomy and consider the future prospective of this operation.transient recurrent laryngeal nerve palsy after lymphadenectomy in this surgery is not rare and induces not only hoarseness but also aspiration or pneumoniae. new method to avoid this complication is desired. patients and methods: patients who received thoracoscopic esophagectomy in our institute from march to october were enrolled and studied retrospectively. operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment or definitive chemoradiotherapy before surgery. overall survival rate of the patients with thoracoscopic approach and with thoracotomy until was analyzed. long term outcome of the patients with thoracoscopic esophagectomy was compared to the result from comprehensive registry of esophageal cancer in japan. short term results of the perioperative parameters were analyzed between left lateral decubitus position and prone position.we had introduced intraoperative nerve monitoring system for prone esophagectomy from . results: there was no significant differences of the survival rate between thoracoscopic group and thoracotomy group based on pathological stage. year survival without neoadjuvant treatment was . % (pstagei), . %(pstageiia), . %(pstageiib), . %(pstageiii), respectively. year survival rate of cstageii and iii with neoadjuvant chemotherapy was . % and year survival rate of the salvage esophagectomy after failure of definitive chemoradiotherapy was . %. every outcomes are as good as any reported results in esophagectomy. in the comparison of the lateral position with the prone position, total blood loss was significantly lower in prone position. inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommended as a minimally invasive procedure for thoracoscopic esophagectomy. transient recurrent laryngeal nerve palsy was observed % of patients. conclusion: thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. nerve monitoring is useful for detecting recurrent nerve and avoiding nerve injury. background: laparoscopic total mesorectal excision (tme), in a wide female pelvis is usually technically easier than in a narrow male pelvis. however, this is not always the case, as the uterus and adnexae may obscure the views and hinder safe dissection, especially in obese patients. techniques such as graspers through additional ports or suspension with sutures through the broad ligament may potentially cause injury or need additional ports/assistants. aim: we present a novel technique using a self-retaining gynaecological uterine manipulator to improve access during deep pelvic laparoscopic surgery in female patients. technical tip: the operation is commenced in the standard manner for a laparoscopic rectal excision. once pelvic dissection is commenced, whenever it is felt that uterine retraction would be advantageous (depending on the level of the rectal tumour, size of the uterus and ovaries, obesity etc.) a self-retaining uterine manipulator (as shown in the video) is used. the tip of this disposable device is introduced into the uterus after dilatation of the uterine cervix. once the balloon at the tip has been inflated, the instrument is secure and hence there is no need for active manipulation by an assistant. the shaft can be rotated to allow anteversion/retroversion of the uterus to varying degrees as required to aid dissection. as the video depicts clearly, it acts as a self-retaining retractor for the uterus and is removed at the end of the operation. though the procedure is being demonstrated by a gynaecologist in the video, the instrument is quite easy to insert and some of our colorectal team have been trained as well. conclusion: the self-retaining uterine manipulator is an efficient tool for uterine retraction in laparoscopic rectal surgery and we have been using it routinely in tme in females for the past years, with no complications. this was previously published as a technical tip in the journal of minimal access surgerybut has never been submitted for peer review as a video. the authors present a video of two clinical cases treated by trans-axillary endoscopic approach. methods: a years-old male and a -year-old male presented with intermittent dysphagia and frequent reflux (class ii of lahey). one had a history of recurrent respiratory infections. the disease was characterized by oesophagogastroscopy (egd) and oesophagogram. trans-axillary approach with areolar port. step-by-step as follows: (i) dissection anteriorly to the pectoralis major muscle (ii) isolation of the anterior border of sternocleidomastoid muscle (iii) omohyoid muscle's isolation (iv) identification of the thyroid's upper pole (v) zd isolation (vi) myotomy of the cricopharyngeal muscle (vii) zd's resection with stapler and its withdrawn with sac. results: both cases progressed without complications. complete local recovery was verified in both cases one month after the procedure. conclusion: this technique seems feasible and reproducible, allowing zd diverticulectomy with a better cosmetic result and perhaps lower surgical site infections (ssi). in the authors' knowledge, this approach to dz has never been published. background: gastric leak occurs in - % of patients who undergo roux-en y gastric bypass (rygb) for morbid obesity. the pathophysiology may be related to gastric ischemia, fistula, or ulcer.gastric leak is a severe complication of gastric bypass (gbp) that is associated with significant morbidity and mortality. fistula may have several clinical impacts, depending on patientrelated factors, fistula characteristics, onset time, and therapy proposal. abdominal drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. methods: we present a video of a clinical case of -year-old lady with body mass index of kg/m who underwent roux-en-y gastric bypass and h later presentedtaquicardia and right cuadrantum pain. the ctscan inform a apical leak at the gastric pouch level. the video shows the relevant aspects of a revisional surgery and the key points to drain the fistula and close de defect laparoscopically. results: after monts, the patient achieved succesful results, defined as a stabel clinical situation with image evidence of gastric fistula remision. conclusions: gastric bypass (gbp) is one of the most efficient bariatric interventions in morbidly obese patients. the most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after gbp. laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed operation worldwide as a primary bariatric/metabolic procedure. however, conversion to other surgical procedures such as roux-en-y gastric bypass (rygb) or one anastomosis gastric bypass (oagb) have been described as treatment options for inadequate weight loss after lsg and unresolved co-morbidities or complications such as leak, stricture, and severe gastroesophageal reflux disease (gerd). we present two clinical cases of weight regain and severe gerd and dysphagia, which account for the main indications to reversal of lsg to either oagb or rygb. aims: we show in the video the surgical technique that we perform by laparoscopic aproach, in order to construct a roux-en-y polipropilene banded gastric bypass lrygb-b. methods: we are performing this procedures within a prospective randomized trial that is design to compare the long term results of lrygb-b versus the standard laparoscopic roux-en-y gastric bypass.the video shows our technique in a case of a years old female with a bmi of kg/m . first we create a vertical gastric pouch of about - ml, and a polypropylene mesh ( x mm) is placed - mm proximal to the anastomosis around the gastric pouch, with the help of a laparoscopic band retractor. after that a cm roux-en-y limb is constructed in an antegastric antecolic fashion, been the lenght of the biliary limb cm. a mm gastroyeyunal anastomosis is performed with a linear stapler, and the enterotomy and gastrostomy are closed with a / barbed running sutures. jejunojejunostomy anastomosis is constructed in similar fashion, but with a lenght of - mm. the petersen space and the mesenteric defect are closed with polipropilene / sutures. results: patients has been operated following this technique, and there has been no complications related to the polipropilene band. (the ramdomized prospective trial is still ongoing). conclusions:the video shows a reproductible easy way to perform a lrygb-b using a polipropilene mesh. introduction: a -year old female patient presented at our clinic two years after initial rouxen-y gastric bypass. she had had a preoperative bmi of , and had a significant weight loss which resulted in a bmi of , at two years postoperatively. she currently suffered from severe dumping with glycaemia levels dropping to mg/dl. pharmacological treatment with metformine, sandostatine and acarbose did not yield any results. on top of these problems she felt less restriction, could eat large portions and had gained kg in the last three months. objective: the usual approach for severe dumping-related hypoglycemia would be to undo the gastric bypass. this patient however was extremely anxious to regain weight, so we sought other options. we assumed that by adding more restriction and slowing down the emptying of the gastric pouch we could alleviate some-if not all-of the dumping related symptoms and prevent further weight regain. methods: in this video we present the banding of a gastric pouch for severe dumping after rouxen-y gastric bypass. results: although unconventional, the banding of the pouch yielded excellent results. the slower pouch emptying and reduced portions resulted in a near complete remission of all symptoms. as an additional benefit we found a slight weight loss of four kilograms six weeks postoperatively. conclusion: the usual treatment of severe dumping-related hypoglycemia would be an undo of the gastric bypass. in this case however the patient was extremely anxious to regain weight, being very pleased with the results her gastric bypass had yielded. in agreement with both the patient and treating endocrinologist we attempted a different approach. the slower pouch emptying and increased restriction offered another way to alleviate the dumping and deep hypoglycemia while concomitantly resulting in weight maintenance. aim: the aim of this video is to present a novel surgical technique to avoid stent migration after endoscopic placement in patients with leakage subsequent to laparoscopic sleeve gastrectomy (lsg) . methods: this video shows the case of a patient (bmi , kg/m ) who developed an upper gastric leakage days after lsg. a ct scan showed a small leakage at the eg junction complicated by intra-abdominal abscess. a ct guided percutaneous drainage of the abscess was performed. a stent placement was attempted endoscopically three times and failed for migration. we decided to place laparoscopically a non adjustable gastric ring (nagr) around the stomach, in order to avoid stent migration.first of all the stent is replaced endoscopically in order to cover the fistula tract. the patient is placed in a half sitting position and the pneumoperitoneum was obtained using a veress needle in left subcostal space. a port technique is used as in standard laparoscopic sleeve gastrectomy.the procedure starts with the mobilization of adhesions, the fistula is identified in the upper part of the tubule.the gastric tubule is isolated and the lesser omentum is opened. the blunt needle at the tip of the ring is passed retrogastrically, a tourniquet can be useful is the positioning turn out to be difficult. the nagr is then closed over the gastric tubule containing the stent. a drain is finally placed. results: the stent was removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of leakage. after months the patient was in a good condition with bmi , kg/m . the stent was endoscopically removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of the leakage. after months the patient was in a good condition with bmi , kg/m . conclusions: this new technique is feasible and effective, as shown in this video; however the nagr can lead to complications, so a strict follow up is needed and if any complication appears, should be considered to remove laparoscopically the ring. introduction: in this case, we will discuss the case of a year old male patient who underwent a laparoscopic cruraplasty and gastric plication resulting in a weight loss of kg. other medical history reported insulin-dependent diabetes, reflux esophagitis and sleeping apnea with cpap. two years after gastric plication the patient presented with passage problems, gastro-esophageal reflux and epigastric pain. to this end a swallow test was performed revealing a large fundus with a restricted passage of contrast. due to the persistent complaints and the abnormal findings on barium swallow a surgical re-intervention was needed. objectives: despite the current bmi of and the age of the patient, conversion from a gastric plication to a roux-en-y gastric bypass was performed. several other surgical options were considered, including an undo of the gastric plication or a dilatation with a resizing of the fundus. methods: in the video we describe the laparoscopic approach for a conversion of a gastric plication to a roux-en-y gastric bypass. results: at months follow-up the patient showed a weight loss of kg and the resolution of his earlier symptoms. the patient had a normal oral intake without any gastro-esophageal reflux or epigastric pain. conclusion: after a gastric plication, partial loosening of the sutures and stenosis are both wellknown complications. as presented in the video, it is apparent that a laparoscopic undoing of gastric plication is not as straightforward as it seems. firm adhesions between folds can compromise the procedure and inhibit a complete separation of the tissues. we believe that in these cases the best surgical approach is to convert to a roux-en-y gastric bypass. laparoscopic sleeve gastrectomy (lsg) is a relatively new surgical approach in the weight loss surgeon's armamentarium. in literature there is a consensus about the importance of mobilizing completely the gastric fundus before transection. the resg (revised sleeve gastrectomyresleeve) may be a valid option for failure of primary lsg. we focused the attention on the consequences that can have an incomplete resection of gastric fundus during an operation of sleeve gastrectomy and how they can be solved by the repetition of this procedure. a sleeve gastrectomy was performed in an obese -year-old woman (bmi = ). three days after the operation, an upper gi x-ray with gastrografin did not show any abnormalities. three months after the surgical procedure, the woman referred frequent episodes of vomiting and a significant weight loss ( kilos). an upper gi x-ray with gastrografin demonstrated the presence of multiple communicating cavities of the gastric fundus. the esophagogastroduodenoscopy (egd) showed that the gastric tube close to the esophagogastric junction was separated from a recess ( - cm in diameter) by an incomplete septum. a severe hypokalemia and consequent ecg abnormalities were treated with intravenous infusion of potassium. then, we performed a laparoscopic operation. the gastric tube was completely released along the suture line of the previous operation and, especially, the posterior surface of the upper part until the left crus of diaphragm became evident. under the guide of the bougie, the recess was removed. results: the clinical course was regular, and the patient was discharged on third post-operative day after an upper gi x-ray with gastrografin which demonstrated the absence of leakage and a normal gastric tube. after year, the patient was very satisfied with the operation. conclusions: the complete mobilization of the gastric fundus allows to see clearly which part should be resected to obtain an adequate gastric tube and facilitate a correct placement of the stapler. in our experience, in patients with a residual fundus, an upper gi x-ray with gastrografin and an egd are needed to exclude the presence of stenosis. then, a resleeve gastrectomy is an efficient and safe procedure to treat this post-lsg complication. weight regain is one of the main problems in bariatric surgery. we have many surgical option but when we evaluate patients with long follow up and bmi of superobese patient before the first surgery, the weight recidivism can arrive up to - % at years.in most cases the first surgery is a restrictive procedure, and in many cases sleeve gastrectomy.here we present a case of weight regain after laparotomic super-magenstrasse (that we consider like a sleeve gastrectomy except for remnant removal) with a big incisional hernia. after a complete multidisciplinary re-evaluation we decided to perform an oagb (one anastomosis gastric bypass) but in this case we decided to create a functional exclusion to the duodenal transit by positioning a minimizer ring. this solution is effective in food diversion and guarantee gastric and duodenal endoscopic exploration in case of need. we think that this technique can represent an option to take in account for selected cases. at the end of bariatric procedure we perform a laparoscopic repair of incisional hernia with mesh in the hope to avoid future surgery and post operative small intestine herniation. patient rejected additional bariatric procedures and in fact she has gained kg two years later (bmi . ). conclusions: lagb gastric erosion is uncommon ( . - %) . intraoperative (such as perigastric approach) and patient related factors (smoking, alcohol…) have been described as risk factors. the most frequent clinical presentation is weight loss failure; band and port issues (such as infection) are also frequent. erosion is infrequent to present as an acute event (\ %: peritonitis, abscess…) or asymptomatically (\ %). diagnosis is mostly performed under upper endoscopy. the most common therapeutic technique is removal of the band (by endoscopy or surgery), repair of the stomach, if needed, and band replacement (at least three months later). some authors have performed immediate replacement but the incidence of recurrent erosion seems to be higher. other options are lagb removal alone or conversion to different bariatric procedure. for endoscopic removal, it has been advised to wait until the band buckle is in the stomach and is sometimes very difficult. replacement of the band is not associated with weight regain. she reports years of evolution presenting moderate intensity heartburn that was exacerbated during the night as well as submit occasional rejurgutation. the intensity of the symptoms is attenuated by maintaining a diet without irritants and improving feeding times. denies hematochezia, unintentional reduction of weight, dysphagia or early satiety. the patient has suffered from obesity since childhood, after pregnancy she had progressive weight gain and difficulty in controlling blood sugar, so she is scheduled a gastric bypass roux-en-y . preoperative endoscopy was performed, evidencing submucosal tumor in the gastroesophageal junction at of the dentary arch, approximately cm in diameter. an endoscopic ultrasound was performed, demonstrating subepithelial lesion of the gastroesophageal junction, hypoechoic, with well-defined borders, pseudobilobulated, . cm x . cm, and dependent on the external muscular layer. a fine needle aspiration is performed in which spindle cells are identified, leiomyoma is likely diagnosed. it is programmed for laparoscopic resection of submucosal gastric tumor, gastric bypass and laparoscopic cholecystectomy. a tumor at the level of the gastro esophageal junction of approximately . cm is identified in the surgery, which can be resected by laparoscopy without complications. the patient is discharged after days of postoperative stay. the final histopathological result: leiomyoma of . cm with free edges. cd (-) gog (-) caldesmon (?)s (?). background: fifty percent of patients who have undergone gastric bypass, posterior reversal and sleeve gastrectomy and finally complete hiatoplasty presents symptomatic gastroesophageal reflux disease. surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous conversion of sleeve gastrectomy to gastric bypass and hiatal hernia repair. methods: we present the surgical techhnique performed to a patient with initial gastric bypass who underwent sleeve gasterctomy for hipoglycemias and hiatoplastia for severe gerd. persistent gerd requested to undergo ligamentum teres cardiopexy. in this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last - cm of esophagus in the abdomen. the distal ligamentum teres is fixed with one stitch to the apex of the angle of his, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. the remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. the procedure concludes with diaphragmatic crus closure. results: after months, the patient achieved successful results, defined as resolution of gerd, no protonpump inhibitor (ppi) use, and manometry measurement over mmhg after surgery. conclusions: ligamentum teres cardiopexy combined with closure of the gastric crus is a late alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia. general surgery, ponderas academic hospital, bucharest, romania introduction: as metabolic surgery techniques evolve during the years, we have to face more and more patients with complications ands uboptimal results after the older/initial procedures. vertical banded gastroplasty(vbg) is one of those procedures that gain momentum during the initial experience in bariatric surgery, but has proven to have dissapointing results and a lot of complications, nowadays surgeons having to deal with difficult revisional operations. aim in this video: we want to present from our experience the difficulties encountered during the revisional surgery, rouxen y gastric bypass (rygbp)aftervbg, and the tips and tricks that will make this a safer and easier procedure. objective: after thorough preoperative assessment and a review of the literature multiple treatment options were considered. the procedure of choice ended up being a laparoscopic adjustable gastric banding, with the objective to achieve optimal weight loss with the lowest risk for complications. methods: in this video we present the placement of an adjustable gastric banding in a patient with a cirrhotic liver and portal hypertension and the possible pitfalls. results: postoperatively there were no complications and patient had a satisfying weight loss both months and year postoperatively. in a short review of the literature we've found that bariatric surgery is feasible in patients with portal hypertension as long as the patient is not decompensated or has bleeding varices. conclusion: cirrhosis and portal hypertension are no absolute contraindication for banding, sleeve or rny gastric bypass as long as the patient is not decompensated or has bleeding varices. the type of surgery is dependent on patient and surgeon-related factors. the aim should be to achieve optimal weight loss with the lowest possible surgical risk in this type of patients. surg endosc ( ) :s -s introduction: in this case, we will discuss on a year old female patient who had undergone a laparoscopic nissen fundoplication years ago due to gerd grade b. because of morbid obesity a n-sleeve gastrectomy was performed year ago resulting in a weight loss of kg. at presentation she had regained all the lost weight, resulting in a bmi of , . the patient history also reported insulin-dependent diabetes and obstructive sleep apnea with cpap. gastroscopy was performed showing a large residual fundus but no esophagitis. on the subsequent upper gi series a relatively wide sleeve with an intact nissen-collar was detected. objectives: a laparoscopic conversion to a roux-en-y gastric bypass was performed. other potential surgical treatment options are a sadi procedure or a sleeve gastrectomy with transit bipartition (santoro procedure). methods: in the video we describe the laparoscopic approach for a conversion of a n-sleeve to a roux-en-y gastric bypass. results: at month follow-up the patient presented with a weight loss of kg. the patient had good restriction on oral intake and did not have any reflux-related symptoms or complaints. conclusion: conversion from a n-sleeve to a roux-en-y gastric bypass is a challenging procedure. the largest pitfall during the creation of the gastric pouch is to staple a double fold of the nissen fundoplication. we believe that in these rare cases of weight regain after n-sleeve, the best surgical approach is to convert to a roux-en-y gastric bypass. four years later, in , a laparoscopic conversion to roux-en-y gastric bypass was performed because of weight regain. she now presents with satisfactory and stable weight loss over the last few years. she was recently diagnosed with a brca- mutation for which she underwent a bilateral ovarectomy and mastectomy. the patient's brother was also diagnosed with this mutation and died of pancreatic cancer at the age of . genetic counseling advised a twoyearly follow-up because of an increased risk up to % of developing pancreatic cancer. control gastroscopy showed a normal esophagus and gastric pouch. control ct scan revealed hypertrophic stomach creases in the excluded stomach. these results prompted a laparoscopy-assisted gastroscopy of the excluded stomach which uncovered hypertrophic stomach glands and intestinal metaplasia on biopsy. methods: in this video we demonstrate the laparoscopic approach for complex revisional bariatric surgery. conversion from rny gastric bypass to a sleeve gastrectomy in a patient who already underwent a vbg. the focus of the video is on a manual gastro-gastrostomy with partial gastrectomy of the fundus and part of the stomach where the old vbg-band was placed. results: after , months follow-up the patient had no complaints and a stable weight. upper gi series shows a normal passage of contrast through the sleeve gastrectomy. conclusion: endoscopic surveillance of the remnant stomach and echo-endoscopy of the pancreas is no longer possible after rny gastric bypass. in cases where the need for such a surveillance arises after a rny bypass a patient-tailored approach is necessary. in our patient a laparoscopic conversion from a rny gastric bypass to a sleeve gastrectomy was performed. this approach keeps the patient's wish for weight loss intact while enabling further surveillance through natural-orifice endoscopy. a -year-old morbidly obese japanese woman with a body mass index of kg/m suddenly complained of swallowing difficulty months after laparoscopic roux en y gastric bypass surgery with retro-colic roux limb route. an internal hernia of the defect of the transverse mesocolon was suspected by computed tomography, and emergency intervention was performed. the surgery revealed no internal hernia. however, strong inflammation and adhesion were observed between the transverse mesocolon and the retrocolicroux limb. in addition, the roux limb on the oral side of the adhesion site was dilated and bent.the adhesion between the transverse mesocolon and the flexed roux limb was dissected, linearized and re-fixedby suturing to the transverse mesocolon. however, since the difficulty of oral intake persisted re-do surgery was performed again. after resecting the roux limb involved in the severe inflammation, a 'new' roux limb was lifted to the cephalad via the ante-colic route. finally, the gastric pouch and roux limb were re-anastomosed with - absorbable sutures in an interrupted full thickness single layer manner. in the present case, we experienced difficulty with both adhesiolysis and determining the accurate target line to resect at the 'old' gastrojejunostomy. however, blocking the blood flow of the 'old' roux limb facilitated the accurate recognition of the target line. esofagogástrica, cirugía general y ap digestivo, hospital regional universitario de málaga, malaga, spain; hepatobiliopancreática, hospital regional universitario de málaga, malaga, spain introduction: marginal ulcer is one a serious complications after a bariatric gastric bypass. tobacco, non-steroidal anti-inflammatory drugs (nsaids) and helicobacter pylori (hp) infection are known risk factors. methods: we present a -year-old women operated years before of bariatric surgery with a gastrojejunal (gy) bypass technique due to intraoperative dehiscence of the staple line after attempting a vertical gastrectomy (sleeve). she has persistent vomiting and epigastralgia from months after the intervention, affecting his quality of life. upper gastrointestinal endoscopy (uge) was performed, describing an ulcer in the gy anastomosis. she started hp eradication treatment, treatment with proton pump inhibitors (ppis), tobacco and nsaids were discontinued, but she had slight improvement. after months the uge was made again, which show peptic esophagitis and marginal ulcers. the plasma gastrin level was normal. due to the persistence of symptoms despite conservative treatment, we decided reoperation by laparoscopy. we found herniated bowel in petersen space, which were reduced and the space was closed. we proceeded to truncal vagotomy. the gy anastomosis was resected ( fig. ) and performed again. finally, we perform antrectomy. the pathological anatomy showed ulceration. she was diacharged home on the th postoperative day without any complications. results: a marginal ulcer after bariatric surgery appears in the jejunal mucosa of the g-y anastomosis. the symptoms are epigastric pain, nausea and vomiting. acid, tobacco, nsaids and hp infection has an important role in their development \ sup [ . \/sup [ the first treatment is medical, discarding out the risk factors, but if it is not effective, it will be surgical, resecting the previous anastomosis. the usefulness of vagotomy is debatable, but the percentage of success increases. in our case, we perform antrectomy to avoid retained antrum syndrome. the hernia through petersen space is a cause of intestinal obstruction and abdominal pain as the case presents. although we believe that the symptoms were mainly caused by the marginal ulcer, the internal hernia was probably a symptomatic cause. conclusion: the treatment of a marginal ulcer is medical, eliminating the risk factors, but if it is not effective, the surgery is indicated. results: bowel's measurements and confection of the gastric pouch are identical in both cases. in the first case, intestinal anastomosis is performed in the inframesocolic compartment once small bowel has been divided. in the second case, such union is made next to the gastrojejunal anastomosis with the bowel uncut, making the section once no leakage has been found conclusions: laparoscopic roux-en-y gastric bypass is currently considered one of the technique of choice in the surgical treatment of morbid obesity. there are variations and alternatives for its realization. to know them can allow to individualize the technique to each type of patient. we present a clinical case of a year old female. she had a vertical banded gastroplasty procedure (in another clinic) years ago with an initial weight loss of kg in a period of months. she was seen at our clinic because she was suffering from dysphagia to solids and general diffuse abdominal pain for the last month. at physical exam we found a bmi of and nothing else called our attention. we did an upper gi endoscopy and egd transit; we concluded that a gastric bypass would offer her the best results. therefore, we converted her vertical banded gastroplasty into a gastric bypass laparoscopically. she had an uneventful postoperative period and was discharged home without complications. aims: sadis emerged as a modification of biliopancreatic diversion with duodeno-ileal switch (bpdds) in which after sleeve gastrectomy (sg), the duodenum is anastomosed to an ileal loop in a billroth-ii fashion. sadis has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients avoiding the high morbidity of biliopancreatic diversion with duodenal switch. clinical case: -year-old patient, subjected to bariatric surgery two years ago, including a sleeve gastrectomy (sg). despite this operation and dietary and hygienic modifications, the patient gained weight in recent months, reaching a bmi of kg/m and an overweight of kg. an endoscopy was carried out on her, which provided evidence of a gastric remnant of moderate size with flexible tissue, normal peristalsis, and fast disposal speed. the case was discussed in a joint session, leading to the decision to apply revision surgery. the decision was taken to apply sadis, a novel technique that had never been used before in andalucia. the rate of weight re-gain after the use of classical techniques such as sleeve gastrectomy (sg) or the roux-en-y gastric bypass (rybg) is considerable high. revision surgery due to weight re-gain is necessary in many of these cases. sadis emerged as a simplified alternative to the use of bpdds as revision surgery following a gv due to weight re-gain with good short-term results, in terms of both weight control and comorbidity control. since only one anastomosis needs to be applied, chirurgical time diminishes, as well as the rate of surgery-related complications. moreover, it could be used, through laparoscopy, for patients who have undergone previous, complex abdominal surgery. conclusion: sadis showed a promising short-term weight loss outcome and comorbidity resolution rate but long-term data are missing and there is currently a high level of technical variability. on the other hand, further studies are required to measure its cost-effectiveness compared to the currently popular bariatric procedures, sg and rygb. aims: the lps sleeve gastrectomy is the most common bariatric surgery technique because it has a low surgical complexity and acceptable weight loss results. however, - % of patients present with an insufficient weight loss, weight regnances, reflux or dysphagia. in these cases, it is recommended to perform a second bariatric surgery to combine a component of malabsorption such as gastric bypass or duodenal switch. the video describes the technique of a laparoscopic biliopancreatic diversion with duodenal switch with a previous laparoscopic sleeve. the objective is to describe the safety of the technique and the subsequent success of it. methods: a -year-old female patient presented morbid obesity with a bmi of after performing a laparoscopic sleeve gastrectomy in . initially, she presented a percentage of excess weight loss of %, reaching a bmi of after two years of follow-up. after this, she suffered a reganancia of all the weight lost despite diet and exercise, presenting a bmi . a study was made with tegd where no complications of the previous surgery or symptoms of gastroesophagical reflux or dysphagia were observed. the lps duodenal switch is proposed in the obesity unit committee in , without immediate postsurgical complications. the patient presented a favorable postoperative period and was discharged three days postoperatively. results: at the present time, the patient has achieved a % excess weight loss and has a bmi of . . presents good oral tolerance with stools a day without urgency. it doesn't present protein deficioncies. vitamin deficiencies are orally supplemented. the lps duodenal switch is a technique that can be performed after a sleeve gastrectomy safely in cases of insufficient weight loss or weight reganancia. the patients presented a greater weight loss after the duodenal switch than after the gastric bypass, observing a lost of excess weight of % compared to %. the differences being statistically significant. weight regain after gastric bypass is a challenging problem. a number of revisional surgical options have been reported. this is a case of a year-old woman years after lrygb. her initial bmi was , lowest after surgery- , at presentation- . the video shows a robotassisted laparoscopic conversion of rygb to loop duodenal switch. the roux limb is transected and dissected to the gastrojejunostomy. the gastrojejunostomy is resected and the gastric pouch is recreated over a bougie. the gastric blood suply is confirmed with icg. a gastro-gastrostomy is created to restore gastric continuity and a sleeve gastrectomy is performed. the duodenum is devided and a duodeno-ileostomy is created cm from the ileocecal valve. the remaining roux limb is resected. the patient recovered uneventfully. conversion of rygb to loop duodenal switch requires creation of as little as two anastomoses, in comparison to standard ds, which requires four. it is a safe option for patients with weight regain after lrygb. methods: irb approval and informed consent have been obtained. a dissection is conducted to separate the descending mesocolon of the gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. the peritoneal layer is incised parallel to the vessel and close to the colonic wall. the dissection is continued anteriorly up to reach the resected parietal gutter. a passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. these maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. a caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. it can be very useful to mobilize the colon in any direction: laterally, medially, or upward. the dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. the specimen is extracted by a pfannenstiel incision. the anastomosis is performed transanally with a circular stapler according to knight-griffin technique. results: we performed a laparoscopic segmental colectomy using this approach for patients with benign sigmoid lesions: diverticulitis, flat polypoid lesions (no lift-up sign), and bowel endometriosis. the mean operative time and blood loss were . ± . min and ± ml, respectively. there were not a single conversion to open surgery and no any leakage or stricture. only cases of intraluminal bleeding and case of wound infection (treated conservatively) were observed. conclusion: we consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall. aims: to show a clinical case with a video of a patient was operated for colon cancer in hepatic angle by a single suprapubic incision (ssilrh). methods: a -year-old male assessed for abdominal pain and weight loss. on physical examination: a painful mass was detected in the upper right quadrant. the colonoscopy revealed an ulcerated lesion in the hepatic angle and the biopsy revealed a moderately differentiated adenocarcinoma. in the abdominal ct a mass of x cm was observed (figure). the patient was operated with ssilrh technique, as shown in the attached video. results: the patient was placed in the supine position and with the legs separated. the surgeon is placed between the patient's legs. a transverse incision of the skin was made in the middle line of . cm to cm above the pubis. the underlying fascia was divided transversely, the rectus abdominal muscle was exposed, a purse-string suture placed in the fascia. an mm reusable trocar was inserted for the chamber, a mm reusable flexible trocar was placed at the o'clock position and another trocar was placed at the o'clock position. the ileocecal valve was released from the peritoneal parietal foil, as well as the mesocolon right by a lateral to medial approach to the second portion of the duodenum. the hepatic angle was also dissected from lateral to medial. for the anastomosis, the mm trocar was replaced with a mm trocar and a stapler was placed. a mm °chamber was inserted through the mm flexible trocar. the small intestine was divided as well as the proximal transverse colon with endogia. an intracorporeal ileocolic anastomosis was performed. the piece was removed through the suprapubic incision. he was discharged after days without complications. the histological studies confirmed a differentiated adenocarcinoma of x x cm. the surgical margins were free, without infiltrated lymph nodes ( / ) with stage pt n . the ssilrh technique allows a complete resection of the mesocolon and complies with the oncological principles. they can present with abdominal pain, nausea, acute abdomen, symptoms of intestinal obstruction or asymptomatic with incidental diagnosis. their diagnosis can be difficult. the objective is to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology. material and methods: we present a video of the surgical intervention of a -year-old patient, with functional dyspepsia, with a casual diagnosis of a pseudocystic mass of the right colon after performing a ct scan: giant diverticulum of the hepatic colon angle with fecaloid content inside it under tension the patient goes to the emergency room for acute abdominal pain, pending colonoscopy, antibiotic treatment is established, and a laparoscopic approach is decided upon after the patient's evolution. results: intervention: complete laparoscopic approach, trocars. large size tumor in the right colon, diverticular in appearance, with stony content inside, with locoregional adenopathies, oncological radical right hemicolectomy, manual intracorporeal anastomosis, correct postoperative, hospital discharge. on the th day. definitive pathological anatomy: giant diverticula on areas of intense mucosal ulceration, free edges. conclusion: the laparoscopic approach of the symptomatic diverticula of the right colon is safe and effective. introduction: minimally invasive transanal surgery (tamis) is a surgical technique whose established indications are the complete exeresis of rectal polyps that are not resectable endoscopically or early rectal neoplasms with good prognosis criteria. transanal devices with gel platform facilitate dissection in this field. however, one of the drawbacks of this approach is the oscillation of the right nerve, which hinders dissection and prolongs the surgical time. material and methods: we present the case of a patient with a central depression neoformation, located cm from the anal margin in the posterior aspect of the rectum in a male patient. the lesion occupies % of the circumference and was considered unresectable endoscopically. the endoscopic biopsies showed a tubulovillous adenoma with moderate dysplasia. results: an exeresis of full thickness of the rectal wall is performed, with subsequent suture of the defect. we show in the video the use of a glove interposed in the pneumoperitoneum gum to maintain the stability of the neumorectum and the technique of dissection and suture, as well as the stability of the neumorectum with this technique throughout the procedure. the use of a glove as a reservoir to stabilize the nemorectum is an economical and easy-to-use method that can safely replace extra devices. aims: endometriosis is a gynecologic disorder defined by the presence of endometrial glands and stroma outside the uterine cavity. deep infiltrating endometriosis (die) invades mm to the retroperitoneum of the pelvic sidewalls, the rectovaginal septum, or the muscularis of the bowel, bladder or ureters. the rectum is being the most common bowel site of involvement. for symptomatic die, medical therapy should always be the first-line treatment. therefore, a minimally invasive approach using laparoscopy is considered the gold standard option and challenging aiming at complete disease excision. also, there are several advantages of natural orifice specimen extraction when compared with abdominal incision that may directly impact the postoperative results of these young patients. methods: we report a case of a -year-old female with a -month history of chronic pelvic pain, dyschezia and rectal bleeding. these symptoms were refractory to hormonal, antispasmodic and opioid therapy. magnetic resonance imaging reported a nodule x cm invading the rectal wall cm to the dentate lane. we performed a laparoscopy and we found the nodule at the uterine posterior wall invading the rectal anterior wall. the nodule was invading into the rectum in a large area so we proceeded with segmental resection and added hysterectomy and salpinguectomy because it was the preference of the patient. the anastomosis was created intracorporeally and the specimen was removed through the vagina performing in this way a totally laparoscopic procedure with natural orifice specimen extraction. results: the total operative time was h, the postoperative stay was uneventful and the patient was discharged on day four. the pathological report showed an endometrioma cm length predominantly involving colonic muscularis propria. conclusion: laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. in addition natural orifice specimen extraction avoids potential complications of abdominal incisions. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy; urology, clinica mater dei, rome, italy aims: we describe a case of a patient affected by a mass in the left kidney and a diverticular stenosis of the sigma. methods: a years old woman complained abdominal pain in the left flank of the abdomen and in the left iliac fossa radiated to the hypogastrium, with fever and no passing flatus. contrast enhanced computer tomography scan (ct-scan) showed a cm mass of the superior pole in the left kidney and a colonic diverticulitis with thickness of the wall and a microperforation of the sigma. she underwent to medical therapy with resolution of the diverticulitis. after weeks a laparoscopic nefrectomy and sigmoidectomy was planned. patient was positioned on the right flank. this position was kept for both the procedures. we performed four trocar accesses along the left subcostal region and a periombelical incision for the specimen extraction. results: post-operative course was uneventful. patient was discharged in post-operative day. istopathological exam showed a renal cell carcinoma confined to kidney with no positive lymph nodes and a diverticular stenosis of the sigma. laparoscopy allowed to perform two fine procedures in a critical situation using few trocar incisions and obtaining good results. background: hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be at least considered in any case. open restoration has been associated with significant morbidity and mortality. many authors have described the advantages of laparoscopic hartmann reversal. we want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique in a patient with previous abdominal surgeries and a rectovaginal fistulae. methods: the transanal and laparoscopic team work simultaneously. by the abdominal approach a pericolostomic incision is made, the distal affected colon is resected and a purse string suture is performed around the anvil of the eea mm single-use stapler with . mm staples (autosuture, covidien). a mm umbilical trocar is located for a °camera and a gelport laparoscopic system (applied medical) with two mm trocars is introduced through the colostomy wound. hard pelvic adhesiolysis was performed and splenic flexure was also mobilized.the gelpoint path transanal access platform (applied medical) is introduced through the anal canal with three trocars in a triangle position. the proximal rectum and mesorectum are dissected until the peritoneal reflexion. the previous stapler line with the resected tissue is then exteriorized throught the anus. the distal rectum is prepared with a circumferential purse string suture. the vaginal defect was sutured transanally. the proximal colon and the anvil are extracted through the rectal stump and connected to the circular stapler, performing an end-to-end anastomosis. results: the total operative time was h. the postoperative stay was uneventful and the patient was discharged on day . conclusions: as in patients with rectal cancer, dissection of the stump in hartmann reversal procedure may be better and associated with shorter operative time. as with any new surgical procedure, it is probably too early to draw conclusions but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a hartmann reversal, especially in challenging cases. intravenous and endoluminal contrast enhanced ct revealed the presence of a large retroperitoneal fluid and gas collection, due to diverticular perforation, extended from pelvis to iliac bifurcation, involving the left urether. no hydrosoluble contrast media leakage or massive pnuemoperitoneum were present. after an initial conservative treatment without significant improvement an emergency laparoscopic left colectomy with primary anastomosis and laparoscopic retroperitoneal collection drainage was performed. the laparoscopic approach was very challenging due to the obesity of the patient and the presence of the abscess. the patient was discharged on pod after requiring re-intervention for dehiscence of the left iliac mini-laparotomy on pod . conclusion: diverticular perforation in obese patients adds a further challenge to its laparoscopic treatment and deserves an aggressive surgical approach since its outbreak. although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. there are few studies comparing patients who underwent laparoscopic left colectomy with intracorporeal anastomosis or with extracorporeal anastomosis. anyway literature shows that there is no significant difference between intracorporeal anastomosis and extracorporeal anastomosis about oncological result. as for right hemicolectomy, intracorporeal anastomosis seems to show a trend towards a faster recovery after surgery due to the shorter time to flatus and lower post-operative pain expressed in the mean vas scale. laparoscopic left colectomy with intracorporeal anastomosis is associated with a lower rate of post-operative complications as for right colectomy. literature results could suggest that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. as usual further randomized clinical trials are needed to obtain a more definitive conclusion. we show a video of a years old patient with a pure splenic flexure colon cancer who underwent to a laparoscopic left hemicolectomy with intracorporeal anastomosis. case presentation: here we describe a case of a year old asthmatic and hypertensive lady with an asa score of iii who presented to emergency after a right knee replacement with a four day history of lower abdominal pain. she was septic upon arrival to the resuscitation roomimmediately prompting the hospital's local septic management protocol. a ct scan of her abdomen showed a rectosigmoid perforation with free intra-abdominal air and fluid. the patient underwent laparoscopic hartmann's procedure within h of admission. after an uneventful postoperative recovery the patient was discharged home after a total of days of hospitalisation. she was followed up at surgical outpatients with no adverse events over the course of the subsequent months. conclusion: this case exhibits the feasibility of laparoscopic hartmann's procedure as a surgical modality for hinchey stage iv diverticulitis. the positive outcome supports the claim that for experienced surgeons laparoscopic hartmann's procedure remains a safe and viable option for elderly comorbid patients in the emergency setting. introduction: mesenteric cysts are a very infrequent pathology, they usually present an anodyne clinic, and their diagnosis is reached casually. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with intra-abdominal cysts of benign etiology, using material with mini-instruments, reducing surgical aggression, maintaining its safety and efficacy.material and method: clinical case: a -year-old man with no personal history of interest. in the last two months he presented episodes of pain in the right hypochondrium, exploration without findings, us-ct scan: a cystic tumor of cm. in hepatic colon angle compatible with uncomplicated benign mesenteric cyst, tumor markers and normal colonoscopy. evidence of interest is exposed. given the evolution it is decided tto. elective surgical. result: intervention: laparoscopic approach, trocars, two of . mm, optics of mm °, benign cystic tumor, with colloid content of more than cm. of diameter in antimesenteric border of colon, which is not possible to separate, mobilization and resection is carried out by endo-gia, including a portion of the colonic wall, appendectomy, extraction in a pocket. good postoperative course, alt to nd day. definitive ap: mesenteric cyst, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of benign intra-abdominal cystic pathology, the use of mini instruments reduces surgical aggression, favoring the recovery of the patient. male, yr, wuth doblue post-operative coloanal stenosi and women, with ultralow rectal neoplatis stenosis ( cm from anla verge). both patients were discharge ater days from prosthesis positionins without pain and complications. the first patient, with protection ileostomy, showed fecal incontinence before the operation and was performed prosthesis positioning because rectal losses of infected material and fever. fecal incontinence was showed also after procedure but he had not fever. second patient, yr, with ultralow rectal tumor, after prosthesis positioning was submitted to radiotherapy and she decided for not to be operated and she survives after months in ful well-being. conclusion: endoscopic prosthesis positioning is a consolidated procedure for treatment of bowel obstruction. this study demonstrated that this procedure is safe and this kind of prosthesis is suitable for correct positioning. results: we present a case of a years old man with faecal occult blood test positivity that was diagnosed by colonoscopy of a villous lesion at cm of anal verge. biopsies were taken showing a tubulovillous adenoma with high grade dysplasia. a rectal mri was done showing the lesion fixed to the postero-lateral left side of the lumen at cm of anal verge. no pathological lymph nodes were reported. extension study was negative. the case was presented in multidisciplinary committee agreeing in local excision. in october the procedure was done without incidents. the patient was placed in lithotomic position finding a lesion occupying of the lumen. resection was done without incidents and posterior suture with continuous barbed sutures. he presented an uneventful recovery being the patient discharged in rd postoperative day. definitive pathological findings showed a ptis with negative margins. after three months of followup the patient remains with good functional results and waiting for the first endoscopic revision. conclusions: tamis is a safe and feasible technique with low morbidity that gives us an alternative for early rectal cancer or big rectal lesions much less invasive than techniques used until now. complete mesocolon excision and d lymphadenectomy are two fundamental points in the oncological surgery of right colon cancer. most of the adenopathic recurrences of colon neoplasia in tumors located in the hepatic angle and the ascending colon are located near the head of the pancreas and the vascular axis of the superior mesenteric vein due to an alleged incomplete dissection. we present a case of right colon neoplasia where we performed a laparoscopic right hemicolectomy associated with a d lymphadenectomy. we use medial to lateral dissection of the mesocolon focused on the dissection of the superior mesenteric vein with the identification of ileocolic vascularization, right colic vessels and henle's trunk. this approach is safe and facilitates a correct resection of the mesocolon, which is approached following the embryological plans and a vascular ligature near the bifurcation. the performance of an extended lymphadenectomy allows a wider resection of the mesocolon and the excision of a greater number of lymph nodes, all of which can contribute to a greater survival. the efficacy of pc treatment is related with a properly preoperative imaging diagnosis of the disease, but the poor sensitivity for identifying small peritoneal metastasis are the major obstacle to achieve a complete resection and that leads to peritoneal recurrence. imageguided surgery using icg, could represent an advance in the detection of small peritoneal nodules. there are only a few clinical studies that have analyzed the role of icg for the staging of pc, specially from ccr, and nearly in all of them the selected approach were exploratory laparotomy. this study presents a laparoscopy case, as a non-invasive way of cs in selected patients with limited pc. a new category, tis, was created for low-grade appendiceal mucinous neoplasms (lamns) that invade or push into the muscularis propia by ajcc cancer staging th ed. management of these tumors depends on stage and histology. traditionally, laparotomy was the most recommended approach, however, if laparoscopy is safe, it could be used. the laparoscopic appendectomy should be done with 'not touch' technique and a radical approach has been recently proposed for its treatment. the laparoscopic radical appendectomy should start by exploring complete abdominal cavity. grasping of appendix should not be done. complete resection of mesoappendix is obligated. cequectomy with stapled endogia is necessary. the specimen must be extracted in an endobag. methods: we report a case of a year-old female patient with a personal history of three caesarean sections. this patient was studied due to chronic abdominal pain. a computerized axial tomography was performed, showing an appendix increased in size and a thick wall. the colonoscopy evidence a lesion that protrudes from appendiceal base which is biopsied. results: a laparoscopic way was used and large and width appendiceal was viewed ( x cm). furthermore, a rounded right anexial tumor was also found. a radical not touch laparoscopic appendectomy with stapled cequectomy was done. the intraoperative study was mucinous appendiceal tumor without serose affection. the final result was ptisnx (lamn) without resection margins affected. after h of admission, the patient is discharged without incidents. conclusion(s): minimally invasive surgery in lamns is possible if it is performed with enough experience, following specific rules and tips to manage this tumors. a correct follow-up should be carried out using tumor markers and computer tomography (ct). introduction: resection of both benign and malignant colovesical fistulae can be particularly challenging and carry with it specific surgical considerations. often there is a large inflammatory mass sat within a narrow pelvis, limiting specimen mobility and consequently access to dissection plains. additionally, with the underlying inflammatory process, the ureters may be displaced anatomically and be at risk of injury. aim: to demonstrate a streamlined and reproducible approach to the laparoscopic management of both benign and malignant colovesical fistula, with specific emphasis on the different modalities for bladder repair. method: the following method portrays an overall technique which is adapted dependant on the clinical scenario and specific intra-operative findings: approach to abdominal cavity in standard fashion.identification of right ureter.poster-medial mobilisation of the mass to facilitate delivery out of the pelvis followed by visualisation of the left ureter on the medial and lateral sides before division of the fistula.division of the fistula in benign disease or resection of the bladder dome in malignant disease.transverse laparoscopically sympathetic suprapubic skin incision.vertical incision through linea alba to deliver bulky specimen.intra/extracorporeal repair of bladder dome. results: all of the considered cases were successfully completed with a laparoscopic approach, irrespective of the malignant status of the disease in question. conclusion: both benign and malignant colovesical fistula disease can make the laparoscopic approach to resection challenging, especially when encountering a bulky mass in a narrow male pelvis. the stepwise and streamlined approach considered here can help facilitate successful and safe laparoscopic completion without the necessity to convert to open. background: primary neoplasms of the retrorectal space are very rare. they are located in anatomically difficult area to be addressed, hence a complete evaluation of the lesion is required to determine the extent of resection and the appropriate surgical approach, which include posterior, abdominal and combined abdominoperineal, depending on the characteristics of the lesion. objective: to show a combined laparoscopic abdominoperineal approach of retrorectal tumor. method: we present a video of a combined laparoscopic abdominoperineal resection of a lowlying retrorectal tumor in a -year-old female without prior abdominal surgery. conclusion: retrorectal tumors are infrequent. their anatomical location can make difficult the surgical approach. preoperative imaging can provide useful information for surgical planning. in the recent years, minimally invasive surgical approach has been proposed. laparoscopic approach is feasible and safe, but it is important to select adequately the patients. background: adult intussusception is a rare clinical event representing only - % of all bowel obstruction cases and % of all intussusceptions and the occurrence of adult intussusception due to colonic cancer is even more rare. aim: we present this case of malignant colo-colic intussusception and literature review to increase the awareness of the incidence of colocolic intussusception due to colonic cancer. case report and literature review: our patient is a years old female was admitted to our hospital due to central abdominal pain, cea level of , she was further investigated with ct scan of the abdomen and pelvis which raised the suspicion of mid transverse colon intussusception due to large polypoid lesion. she was further assessed with urgent colonoscopy which confirmed mid transverse colon tumour with biopsies confirmed adenocarcinoma. laparoscopic extended right hemicolectomy with lymph node dissection was performed. upon laparoscopic exploration it was found that the colocolic intussusception was evident as described on the ct scan and as clearly shown on the video. histologically, the transverse colon carcinoma was a moderately differentiated adenocarcinoma, with no lymph node involvement ' out lymph nodes', tnm staging of pt pn pm and r resection. intussusceptions of the colon in adult are frequently found in the ileocecal portion or sigmoidal colon but rarely in the transverse colon. only two cases of adult intussusception of the transverse colon caused by colonic cancer have been reported. overall cases on literature review reported showing colo-colic intussusception due to colonic malignancy. conclusion: colo-colic intussusception due to colorectal cancer is a rare clinical event, however it should be included in the differential diagnosis of colonic obstruction. laparoscopic surgery is safe in malignant colocolic intussusception. aims: single-incision laparoscopic colectomy (silc) aims to achieve better cosmetic outcomes, less pain, and faster recovery compared to multi-port laparoscopic colectomy, but it also has several limitations, especially the technical difficulties. we report our experience with singleincision robotic right hemicolectomy via video presentation. methods: we arranged robotic-assisted single-incision right hemicolectomy for a -year-old female patient with ascending colon tumor. the operation was performed with gloveport singleport device and a three-arm da vinci robotic surgical system through a small midline umbilical incision. colectomy was proceeded by a medial-to-lateral approach along with one or two accessory instruments for maintaining sufficient bowel traction or surgical field exposure. after vessel ligation, complete colon mobilization and right side omentum division, the robotic arms were undocked to perform anastomosis extracorporeally. results: the operation was performed successfully without drainage tube placement. the total operative time was min. the bowel movement returned on post-operative day ,and the patient tolerated normal soft diet on post-operative day . she was hospitalized for days after operation. the pathology report revealed colon adenocarcinoma (t n m , tumor size . cm), and lymph nodes were harvested. conclusions: single-incision robotic colectomy (sirc) approach seems feasible and safe in treatment of ascending colon cancer. this surgical option provides less pain and wound scar for the patient. moreover, it also achieves further benefits for the surgical procedures compared to silc. reasons being, first, it has better instruments flexibility and precision with endo-wrist, as well as less instruments clashing. second, the improved camera stability achieved through the use of the robotic arm is unattainable through manual hand-controlled methods. third, roboticassisted approach gives us an ergonomic environment, which enables the operator to control the arms while sitting by the console, and also to reassign them whenever they cross each other or block the surgical view. in spite of the advantages above, we still need to sincerely consider each patient's situation for proper management. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify sentinel lymph node, for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.when tumor is in difficult site, as hepatic or splenic flexure, ml of icg solution ( , mg/kg) is intravenous injected. in about - s a real-time angiography of tumor area is obtained; on this guide, vascular dissection and pedicle ligation is performed.after anastomosis, another ml of icg solution is injected to confirm anastomotic perfusion. if there is an ischemic area, a new anastomosis is performed. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and resections of splenic flexure. in ten cases, intraoperative angiography led to the identification of vascular anatomy. in two cases the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to reduce the incidence of anastomotic leak, to facilitate the assessment of vascularization in order to perform oncological resections, and to perform the slnb to study its clinical role on nodal status and for the sln ultrastaging in order to identify the micrometastases. background: surgical emptying of lateral pelvic lymph nodes (llnd) is a strategy used differently when compared the approaches to rectal cancer in the west and eastern countries. there is evidence that = mm lymph nodes in lateral compartment should be removed, even in the setting of neoadjuvant chemoradiation. minimally invasive surgery with nerve-sparing technique and sharp dissection with minimal bleeding may help overcome the significant complexity of the procedure that may have been a technical obstacle to implementation in the past. the standardization of the technique may help implementation with shorter learning curves and excellent surgical outcomes. methods: a -year-old male with distal rectal cancer underwent neoadjuvant crt for a mrt cn m mremvi ? mrcrm ? disease. there was one left obturator node of mm prior to crt. following weeks of crt completion, the patient underwent tatme for the primary disease followed by left lateral node dissection by laparoscopy. results: the present video illustrates the most relevant surgical steps to perform lateral node dissection. the procedure has been didactically divided into steps. the left ureter is identified and retracted using a vessel loop (step ). identification of the common iliac vein and dissection with subsequent identification of psoas and internal obturator muscles (step ). identification and dissection of accessory vessels. ( step ) identification of obturator nerve and obturator vessels (step ). blunt dissection of obturator nerve (step ). identification and ligation of obturatory vessels. (step ) umbilical artery is skeletonized to allow identification and clearance of fatty tissue along superior vesical arteries, internal iiliac artery/vein, inferior vesical artery and internal pudendal artery (step ). postoperative course was uneventful. conclusion: standardization of lateral-node dissection for rectal cancer has paramount importance. laparoscopic lateral-node dissection for rectal cancer provides optimal anatomical view and allows safe dissection of the nodes of interest. aims: the aim of this video is to describe our technique using fluorescence to assess the lymph flow to ensure a complete mesocolic excision and central vascular ligation in order to provide expertise to contribute to the standardization of this new tool. methods: laparoscopic right colectomy with total excision of the mesocolon was proposed in all cases. for the detection of lymph flow, we injected indocyanine green dye ( milliliter of milligrams dye dilution in milliliter of distilled water) into the subserosal to submucosal layer around the tumor at point with a -gauge injection laparoscopically after trocar insertion, and observed the lymph flow using a near-infrared system (visera elite ii, olympus) after injection. we also performed a total mesocolic excision with central vascular ligation in the region where the lymph flow was fluorescently observed. results: ( %) patients were included. no intraoperative or postoperative complications presented. no adverse effects were reported due to the infusion of indocyanine green. the lymph flow was visualized intraoperatively in a satisfactory way helping the surgeon in decision making to determine an appropriate separation line of the mesentery. the section line of the mesocolon was modified in ( %) case based on the findings obtained by fluorescence. the mean operative time was ( ) min. the morphometric laboratory data of the specimens to audit the correct complete mesocolic excision were satisfactory according to the oncological standards. conclusion: fluorescence lymphography during colorectal surgery was feasible and reproducible with a minimum of added complexity. fluorescence-guided surgery may be a helpful technique for determining an appropriate total mesocolic excision in colon neoplasms. aims: this video shows our technique for complete mesocolic excision (cme) during right colectomy for cancer. methods: in this video, a years old patient underwent a laparoscopic right colectomy with cme for a cancer of the ascending colon diagnosed with a colonoscopy performed after positivity to fecal occult blood test (fobt). after ct scan staging we obtained d printed models to clarify patient's vascular anatomy. patient was placed in supine position, trocars were inserted in left quadrants as for standard right colectomy. cme is performed by sharp dissection between the visceral fascia that covers the posterior lay of the mesocolon and the parietal fascia that covers the retroperitoneum (toldt's fascia). the ileo-colic vessels are used as landmark to identify the right anterior surface of the superior mesenteric vessels. with a caudo-cranial approach, the mesocolon is sharply dissected and the root of tributaries venous is ligated, up to the inferior margin of the pancreas. the gastro-colic trunk is dissected out with ligation of the right colic vein, while the gastroepiploic vein is preserved (harvesting the sixth group lymph node). the pancreas-duodenum fascial plane is entered and all the lymphoid tissue around the vessel surface is harvested. procedure is completed with ileo-transverse intracorporeal stapled anastomosis. results: in our experience, between april and december , laparoscopic right hemicolectomies with cme were performed. we had no major intraoperative vascular lesions. no patients needed intraoperative blood transfusion. compared to our series of standard right colectomies we did not notice any significant difference in post-operative complications. the follow-up is too short to demonstrate if the cme approach has a better oncological outcome compared to standard right colectomy. conclusions: laparoscopic cme is feasible, although it requires a higher expertise level of surgical know-how. the quality of evidence is limited and does not consistently support the superiority of cme as compared to standard right colectomy. better data are needed before cme can be recommended as the standard of care for colon cancer resections. h. bando gastroenterological surgery, ishikawa prefectural central hospital, kanazawa, japan aim: in case of right-sided transverse colon cancers, it is necessary to dissect the lymph nodes around the root o f the middle colic vessels. but in this area there are dangerous organs, for example : pancreatic head, duodenum, and gastrocolic trunk. it is the point of our technique that we resect the accessory right colic vein and middle colic vein, and then dissect pancreas head and duodenum at early step of the operation. method: we perform the operation by five trocars. the first step is to transect the great omentum, and confirm the lower edge of pancreas.there are much adhesion between mesocolon of transverse colon and stomach, great omentum. it is very important to dissect the adhesion accurately. secondly, the mesocolon is incised at lower edge of pancreas. it is possible to detect the lower edge of pancreas in obese people. the anterior surface of superior mesenteric vein is exposed. the accessory right colic and middle colic vein are resected. and then front face of surgical trunk, pancreas, and duodenum is dissected caudally as possible. the superior mesentery artery is resected below the mesocolon after flip up of transverse colon. this approach is safe and feasible, because the dangerous organs are handled by direct vision. by that, extraction of intestine is easy from small incision. afer flip up of transverse colon, the mesenteric of ileum is incised. the root of ileocecal vessels is exposed and these are resected. the peritoneum of the front of superior mesenteric artery is incised, and the lymph nodes around the surgical trunk are dissected. this dissected area is easily connected with the one done beforehand. uniquely we resect the mesocolon and major omentum from the root of dissected vessels to resected side of transverse colon. and then right-side colon is dissected medial approach. conclusion: we dissect the dangerous organs in advance. that prevent major injury of them. background: good visualisation of the operative field is a fundamental requirement for safe laparoscopic colorectal surgery. over the past years of the senior author's experience, camera systems have evolved from single to three chip, high definition (hd) and most recently, the k system. in parallel, the rest of the infrastructure such as cables, processors, monitors etc. have also undergone improvements, resulting in improved image quality. aim/methods: we present a video of a case of laparoscopic total mesorectal excision (tme), performed with strict adherence to our previously published 'stepwise approach to laparoscopic colorectal surgery' which places particular emphasis on safety aspects. tme was performed in a year old male patient with history of previous abdominal as well as robotic prostatic surgery. the procedure was filmed with all components including the camera head, cables, processing unit, screens as well as the recording/mixing decks being k. multiple external k cameras were also used. live transmission to a remote audience as part of our masterclass was achieved using appropriate bandwidth and projection on to k screens. results: feedback from the operating team as well as from the live audience was that the image quality was far superior to hd systems. the k system accorded a degree of clarity well beyond usual expectations. the depth of field also appeared to be different initially, but within a few minutes of starting the procedure and acclimatisation, the effects were appreciable. the clarity of the image which showed the fine details of the dissection planes and anatomical landmarks as well as the vibrancy of the vasculature gave a distinct three-dimensional effect to the picture. this excellent visualisation added one more layer of safety and complemented our stepwise approach for a successful procedure. conclusion: the laparoscopic k system, in our practice, proved to bea beneficial visualisation tool to enhance the accuracy of dissection. vital structures appeared to be more vivid and clearer with dissection planes being more easily apparent. in our opinion the laparoscopic k system when combined with a systematic approach enhances safety, especially in complex laparoscopic colorectal surgery. accumulating evidence suggests that laparoscopic surgery for colon cancer has feasibility and efficacy equal to or over conventional laparotomy. for cases with pasthistory of laparotomy, especially history of colon resection, however, there is almost no evidence for laparoscopic recolectomy for metachronous colon cancer. since , we have been used submucosal local injection of indocyanine green (icg) around primary colorectal cancer by using intraoperative endoscopy, and complete mescolic excision (cme) have been convincingly carried out, which was clarified by completely resected icg positive area. although evidence on the oncological efficacy of icg guided surgery has not yet been clarified, since it can be easily judged whether cme is performed clearly, it is considered that icg guided surgery for primary colon cancer is useful for education. recently, we are applying this to ensure convincing cme for patients with colorectal cancer who had a history of colic resection. the representative case is as follows. a -year-old female was diagnosed as advanced sigmoid colon cancer, and laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery was performed years ago. then she was diagnosed as the metachronous descending colon cancer. the feeding artery of the new tumor should be the left colic artery, however, the left colic artery was already resected and genuine feeding artery was not identified by preoperative examination. by injecting icg into submucosa endoscopically during operation, it was clearly observed that the lymphatic flow from the tumor was directed to the inlet portion of the inferior mesenteric vein (imv). re-cme was performed by ligating the inlet of imv. intraoperative icg was also useful for clarifying the borderline for adhesion detachment of pastoperation between the mesentery and retroperitoneum (figure) . interestingly, icg flow in the mesentery direct to of the anus side was disrupted clearly at the past anastomotic site. we believe that laparoscopic surgery under icg guidance is potential useful tool that can confirm evidence to date more intuitively in real time. further studies, ideally randomized controlled trials, are required for define the oncological usefulness of icg guided surgery for re-do colectomy. the operation movie will be presented at the meeting. background: laparoscopic lateral pelvic node dissection (llpnd) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. in this video, we demonstrate the technique of llpnd for rectal cancer patients with suspicion of lln metastases after neoadjuvant chemo-radiation. methods: the principle of this approach is en bloc resection with bilateral peritoneum. the peritoneum is incised lateral to the ureter following the line between external and internal iliac vessels. in the next step, llpnd dissection of the regional lymph node and high ligation of inferior mesenteric vessels were performed. a contralateral llpnd was performed in the same manner as a mirrored technique. after extracting the specimen, an end-to-end double-stapled circular anastomosis was performed. results: the procedure was done safely without any complications.the surgical duration was mins, and the blood loss was ml. the number of harvested lateral pelvic lymph nodes was . the tnm stage was ypt an m . conclusion: this approach enables extended resection during lymph node dissection, allowing autonomic nerve preservation. it is maybe a helpful approach in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis. aims: the aim is to present an inspection method where the anastomosis vascularity is testing simultaneously using the indocyanine green fluorescent angiography intraluminal and intraperitoneal. methods: sixty-five year old female patient underwent standard laparoscopic-assisted low anterior rectal resection for rectal carcinoma. the proximal end of the bowel and the stump of the distal rectum were checked using near-infrared fluorescence imaging with d-light camera. after making sure of adequate perfusion of the bowel, the end-to-end stapled anastomosis was performed under the laparoscopic visualisation. the d-port proctoscope was inserted into the anus. the second icg injection was administered. the perfusion of the anastomosis in transabdominal way and viability of the mucosa in transanal way was evaluated with two d-light cameras simultaneously. the anastomosis was determined cm from the anal verge. an air-water leak and tension of the bowel tests were performed. after evaluation of anastomosis viability with fluorescence imaging, after negative air-water leak and tensions testing, the decision was made by surgeon not to perform preventive ileostomy. results: the patient had no complains for the first three days postoperatively. nevertheless, crp level was growing and was . mg/l on the second postoperative day, and . mg/l on the th postoperative day. the patient complained of the pain in the right iliac area and below symphysis on the th postoperative day. the abdominal and pelvis computed tomography scan with oral contrast was performed which denied our thoughts about the anastomotic leakage. intravenous cefuroxime and metronidazole antibiotics were prescribed. the crp level was . mg/l on the th postoperative day. the patient was discharged on the th postoperative day without preventive ileostomy. conclusion: using the original, standardized colorectal anastomosis inspection method we can determine which patient doesn't need the preventive ileostomy after low colorectal anastomosis. the important causes of anastomotic leak are local ischemia and staple line defect. the purpose of this study was to investigate the combination of methods aimed to reduce the risk of anastomotic leak after anterior resections for rectal cancer. methods: we retrospectively analyzed perioperative outcomes of the first patients, who underwent modified laparoscopic anterior resection with partial mesorectal excision for rectal cancer without preventive stomy. operative technique was modified and included routine preservation of the left colic artery (fig )(aimed to improve anastomotic blood supply), manual suture invagination of the 'dog ears' (fig ) (aimed to reduce the risk of staple line defects), transperineal pelvic drainage and pelvic peritoneum reconstruction (aimed to reduce the risk of reoperation in case of leakage). anastomotic leak rate, reoperation rate, left colic artery preservation rate, additional operative time (time required for left colic artery preservation, 'dog ears' invagination and pelvic peritoneum reconstruction), blood loss, morbidity and mortality were analyzed. results: ( . %) patient developed an asymptomatic leakage, which was managed conservatively. there was no postoperative mortality and no reoperations. median additional operative time was min for the first procedures and min for the last procedures. left colic artery preservation was successful in ( . %) patients. median blood loss was ml. conclusions: additional techniques used in our modification of laparoscopic anterior resection are safe and may lead to improved perioperative outcomes. however, they are associated with increased operative time, which may be reduced with a better learning curve. introduction: parastomal hernias are a significant cause of post abdominal ostomy morbidity with an overall life-time incidence exceeding %. the complications can range from a bulge resulting in stoma bag leakage, to life threatening bowel obstruction. the prevent-trial sought to determine if prophylactic utilisation of polypropylene mesh would decrease the incidence of parastomal hernias, with initial results demonstrating that it was safe to use in permanent end stomas. aim: to demonstrate a reproducible and streamlined technique for laparoscopic parastomal hernia repair with intraperitoneal funnel mesh, and assess the outcomes with the clavien-dindo (cd) classification tool. method: parastomal hernia repairs ( colostomy, ileostomy) were considered, with the following approach adopted for each: swab sutured in stoma orifice to prevent wound contamination.sharp dissection of the stoma using parachute technique.stoma end refreshed followed by change of gloves and instruments.lateral stay sutures placed to tighten sheath later on.pneumoperitoneum temporarily created to assess/divide adhesions.funnel mesh placed in-situ, orientated in the optimal intraabdominal position, and sutured to the peri-colic fat to prevent slip.medial suture placed to narrow the sheath further.pneumoperitoneum re-created and mesh fixed in place with double crown laparoscopic tacks.redundant portion of end stoma excised and stoma formed. results: at median follow up of months: no recurrence.no reported symptoms of pain or decreased stoma functionality.one superficial wound infection treated with drainage at bedside (cd = grade ) conclusion: laparoscopic parastomal hernia repair with intraperitoneal funnel mesh for permanent end stomas yielded good outcomes in our patient cohort. a streamlined and reproducible approach ensures that the technique can be adopted for both prophylactic, primary and recurrent repair. parastomal hernias are common and can be associated with significant morbidity. when taking this into account, in conjunction with the recommendations of the initial results of the prevent-trial, one may consider prophylactic utilisation of a mesh in patients receiving a permanent end stoma. general surgery, rambam medical center, haifa, israel year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy. during last year, patient suffered from recurrent episodes of ascending cholangitis. recently, she underwent ercp and severe stricture of middle cbd was diagnosed. plastic stent was inserted through the cbd. mrcp also showed severe stricture of cbd with dilatation of biliary tree, proximal to the stricture. due to severe and resistant (did not resolved by recurrent dilatation) structure of middle cbd, she was referred to operation. patient underwent da vinci robot-assisted excision of the cbd stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of roux-an-y limb. total operating time was min. day three after operation patient started regular diet and was discharged home on day four. final pathology has shoved part of cbd with severe inflammation. aims: extrahepatic biliary duct resection for the treatment of bismuth i and ii stage klatskin tumor is the standard surgical technique [ ] . methods: a years old patient present at emergency room (er) with right upper abdominal pain with an elevation of the inflammatory markers at the blood exams and fever. the patient was submitted to a computer tomography (ct) that shows a tumor involving the lower tract of the principal bile duct. an endoscopic retrograde cholangio pancreatography (ercp) with biopsy (intraductal papillary neoplasm of the bile duct,ipnb with high-grade dysplasia) and stent placement was performed. considering the good general conditions of the patient and an absence of vascular and nodal invasion at the preoperative imaging, a minimally invasive surgical resection of the biliary tract with cholecystectomy was performed. results: a four port laparoscopic biliary tract resection with cholecystectomy was performed with lymphadenectomy of the hepatic hilum. no vascular or liver infiltration was found. the hepatic hilum was completely skeletonized. the resection of the biliary duct was performed with adequate free margin. a biliary reconstruction with roux-en-y technique was performed and a fully laparoscopic hepatico-jejunal anastomosis was done. and abdominal retro anastomotic drain was placed. the operative time was min. the postoperative course was complicated by a low rate biliary leakage that was treated conservatively. the patient was discharged at post operative day in good general conditions. the histological examination revealed a moderately differentiated in situ cholangiocarcinoma of the principal bile duct with the involving of the cystic duct with free resection margin (pt bn r ). conclusions: laparoscopic resection of the biliary tract is a challenging procedure that allows, in expert hands, to achieve in selected cases negative pathological margin, complete linfonode retrieval and entero-biliary bypass. injury to the extrahepatic bile duct during bile duct or hepatic surgery can be reduced by better real-time visualization. recently, indocyanine green (icg) fluorescence imaging has been used in laparoscopic hepatobiliary surgery. we applied icg fluorescence imaging in patient with huge hepatic cyst which severely deviated extrahepatic bile duct. the patient had received laparoscopic cholecystectomy and huge hepatic cyst stuck firmly with peri-hepatic structures including bile duct. icg fluorescence imaging correctly identified the common hepatic duct and remnant cystic duct and allowed for more meticulous and easier dissection. therefore, icg fluorescence imaging may guide a safe and accurate dissection and excision in hepatobiliary surgery. results: total patients who underwent ercp were , and . percent ( cases) had a first failed ercp and of then were unsuccesfull in the second intent of ercp. intrahospitalary stay was more than days in the percent, in the . percent was to days, with and average of days. conclusions: before, during or after lcbde, ercp remains the gold standard for manegement of choledocolitiasis confirmed by clinics, laboratory and imagenology. lcbde is a very good option that requires experience and specific skills, and especialized equipment. in years the rate of sucess in our hospital was . % and there were no posoperatory complications such as: biliar peritonitis, pancreatitis or liver abscess. aims: easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared (nir) fluorescence imaging after an injection of indocyanine green (icg). neither radiological support nor additional intervention such as opening the cystic or common bile duct is required, making it an easy and real-time technique to use during surgery. the aim of this video is to describe our experience in fluorescence-guided cholangiography in different clinical situations. methods: intravenous injection of icg is used to illuminate extrahepatic biliary anatomy. however, the simultaneous enhacement of liver parenchyma can disturb the visualization of clinical details. the key is in the used dose of icg, the route of administration and the time since its infusion. in the first case, a scheduled cholecystectomy is shown in which a dose ( ml of mg dye dilution in ml of distilled water) administered intravenously h before the intervention was used. the second case shows an urgent cholecystectomy in which the dose ( ml of mg dye dilution in ml of distilled water) was administered intragallbladder during surgery. all patients underwent laparoscopic cholecystectomy with traditional four-port technique. all procedures were performed using a -degree mm laparoscope with nir imaging capability (visera elite ii, olympus). results: there were no intraoperative or postoperative complications. there was no increase in operative time due to the use of icg. in the first case, a clear identification of the cystic duct and the main bile duct was obtained thanks to the biliary excretion of the icg and the intravenous clearance. in the second case, the identification of the cystic duct, the main bile duct and the cystic artery occurred due to the intravesicular absorption of icg. conclusion: fluorescence-guided cholecystectomy clarifies the dissection plane. it can be considered to increase the safety of laparoscopic cholecystectomy. being aware of the doses, times and possible routes of administration is basic to universalize the technique and give it utility in different scenarios. introduction: mirizzi syndrome type is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in hartmann's pouch or the cystic duct with a resultant cholecystocholedochal fistula. the obstructive biochemical changes can be caused by direct extrinsic compression from the impacted gall stone or from the fibrosis caused by advanced chronic cholecystitis, or for the established fistula. objective: we present a case of a mirizzi type syndrome with choledocholithiasis which was solved by laparoscopy approach. material and methods: a -year-old female patient with no past medical history. the history of present illness begans with the presence of icteric dye since the last days; she received symptomatic treatment with poor improvement. a liver and biliary tract ultrasound was performed with report of a mm coledochus, mm wall gallbladder. then an endoscopic retrograde clolangiopancreatography was performed with successful endoscopic sphincterotomy and removal of gallstones. but the patient jaundice persisted after the procedure. the patient underwent cholecystectomy and laparoscopic common bile duct exploration, where the findings were a mirizzi type according to the csendez classification, chronic cholecistitis and choledocholithiasis. results: in this laparoscopic approach we performed a partial cholecystectomy, bile duct exploration with removal of residual gallstones. the closure of the choledocotomy was performed with simple knots using vycril . . a subhepatic drainage was left. the patient showed adequate clinical evolution. after days the patient was discharged. conclusions: it is important to properly identify the anatomy at the time of surgery to avoid injury of the common bile duct. operative treatment of mirizzi syndrome type includes either laparoscopic or open subtotal cholecystectomy or placement of a t-tube or choledocoplasty. near-infrared fluorescent cholangiography (nirf-c) is an innovative intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. thanks to the development of laparoscopes/endoscopes with light sources emitting infrared frequencies, it is possible to visualize anatomical structures (vessels, ureters, bile ducts, etc.) through the luminous intensity of substances (fluorescein, blue of methylene, indocyanine green) which are injected into the patient. this technology may be considered as an important teaching tool for laparoscopic surgery, especially for young surgeons in their surgical learning curve and it could lead to reduce the risk of iatrogenic bile duct injuries during laparoscopic cholecystectomy. the following video is characterized by a series of intra-operative images of biliary anatomy by fluorescence, having an important educational interest, while also detecting anatomical variations of the cystic duct. a. umezawa, minimally invasive surgery center, yotsuya medical cube, tokyo, japan aims: laparoscopic cholecystectomy(lap-c) for cholecystolithiasis has become standard. however, serious bile duct injury has been reported as a complication. repeated colic and chronic inflammation in cholecystolithiasis lead to the so-called difficult gallbladder conditions, such as dense fibrosis and scarring of the tissue. dissection of calot's triangle includes the risk of bile duct injury. critical view of safety (cvs) is the most well-known land mark for safe cholecystectomy. in the revised tokyo guidelines (tg ), important land marks and bailout procedures had been proposed. those are for the difficult gallbladder which are not able to achieve cvs. methods land marks: baseline of segment of the liver and sulcus rouvier should be confirmed. the gallbladder wall itself is also useful landmark. bailout procedure: when the dissection of calot's triangle is considered impossible, bailout procedures should be considered. subtotal cholecystectomy which leave the neck is one of option. the fundus first technique is another approach. however, because fundus first technique has a possibility of leading to serious bile duct injury, it should stop by the neck. in this video, first case shows the importance of landmarks from near miss cases of misidentified injuries. second case shows bailout procedure, subtotal cholecystectomy with fundus first technique. result: in the atrophic gallbladder (case , near miss), it is liable to misidentify the junction of common bile duct as the gallbladder neck. the neck and common hepatic duct were lifted together easily. with confirming the landmark, misidentification was corrected and bile duct injury was avoided.in the case , since the calot's triangle was obscured due to repeated cholecystitis, dissection of gallbladder was performed from the bottom to the neck, and was excised with the cervical portion remained. the remaining neck was reconstituted.in each case, intraoperative cholangiography was performed, and it was confirmed that there was no bile duct injury. without postoperative complications, those patients were discharged pod as usual lap-c. conclusion: during lap-c for difficult gallbladder, the most annoying part is bile duct injury. confirming landmarks and switching bailout procedures can be contributory to avoid bile duct injury and to achieve safe lap-c. aims: choledocholithiasis is an important cause of morbidity and is present in about % of patients submitted a cholecystectomy. his treatment should be done in the same operative time, avoiding the morbidity and hospitalization time and costs of multiple procedures.the transcystic approach is preferable to prevent morbidity associated to choledochotomy.large stones can preclude this procedure. the use of laser lithotripsy to stone fragmentation is an option to provide transcystic extraction. methods: we present a video of laparoscopic transcystic common bile duct (cbd) exploration for choledocholithiasis. results: female patient, years old with a previous hospitalization for acute cholangitis with choledocholitiasis.submitted to laparoscopic cholecystectomy with intraoperative cholangiography that showed the presence of stone in distal cbd with cm size. the use of holmium laser lithotripsy made the stone fragmentation and provided his extraction by transcystic route using a basket.the patient was discharged at th postoperative day, with no complications. conclusion: the use of laser lithotripsy for large cbd stones is safe and effective, making possible the transcystic approach and preventing the choledochotomy morbidity. surg endosc ( ) :s -s gallbladder adenocarcinoma is rare and extremely aggressive. its' incidence is higher in elder females and its progression is rapid and silent with a dismal prognosis if diagnosed at advanced stages. we present the case of a years-old female with dyspeptic complaints. the abdominal ultrasound revealed a cm solid lesion of the gallbladder suspect for malignancy. the ct confirmed the presence of a vegetant mass on the free border of the gallbladder fundus with x mm. we performed a radical cholecystectomy with lymphadenectomy and liver bed excision. the post-operative period was complicated with a urinary tract infection, with full recovery after antimicrobial treatment. the histological sample revealed an adenocarcinoma of the gallbladder (t bn m ) and the patient remains asymptomatic and tumour free months after the surgery. gallbladder cancer treatment depends of the stage and clinical presentation of the disease. complete surgical excision is the only curative treatment and should include a limited hepatectomy and portal pedicle lymphadenectomy. laparoscopic surgery might be an option in early stages, although it is challenging and requires both expertise in hepato-biliary and laparoscopic surgery. seen at the emergency room for a two month history of abdominal pain associated with jaundice. she is evaluated by the surgical team and diagnosed with acute cholecystitis and moderate risk for choledocholithiasis. the initial surgical plan was cholecystectomy with intraoperative cholangiogram. during surgery, firm adhesions are found from the gallbladder to omentum. friable tissue with edema and easy bleeding. difficulty is encountered during the dissection of calots'triangle. an intraoperative cholangiogram is done through hartmans'pouch without identifying correctly the biliary tract. therefore, an endoscopic retrograde cholangiopancreatography (ercp) is done to visualize the correct anatomy. during the ercp, a stenotic common hepatic duct is found and no stones are visualized. a biliary endoprosthesis is placed. she is discharged asymptomatic. a month later, the patient is back in the emergency room with abdominal pain. after an abdominal ct scan, we found that the endoprosthesis had migrated to the th portion of the duodenum. a second ercp is done and this time we found a big stone ( . - cm) aims: when training in the residency you watch your teacher perform laparoscopic cholecystectomy with ease, and even yourself perform several steps. but as a young surgeon, when confronted with a patient with acute cholecystitis, you're filled with emotions, and you do not know where to start the gallbladder dissection. the aim of this presentation is to show to young surgeons that you can, and must achieve, critical view of safety when performing laparoscopic cholecystectomy for acute cholecystitis. methods: we present the case of a years old female patient, bmi of . , who presented with a grade ii (moderate) acute cholecystitis. following tokyo guidelines, we initiated antibiotics and general supportive care, but without clinical improvement. the patient was proposed for laparoscopic cholecystectomy. results: at initial exploration we identified a cm long gallbladder, with a thick wall, difficult to manipulate. we opted for an anterograde cholecystectomy, in our opinion the best option in acute cholecystitis. the dissection was started with hook electrocautery and then continued with a combination of blunt dissection with the aspirator and with the hook. when reaching the pedicle, blunt dissection was used in order to appreciate the anatomy of the cystic duct and cystic artery. after correct identification of these structures they ware clipped and cut. a drainage tub was then placed, and the abdomen deflated. conclusion(s): as a young surgeon, when dealing with acute you must maintain your calm, and try to achieve critical view of safety before transecting the cystic duct and cystic artery. this can be achieved with a combination of blunt and sharp dissection, keeping your camera clean and with a good collaboration with the assisting surgeon. conclusions: here, an easy and reproducible method is described for future macroscopic analysis by the surgeon following a cholecystectomy. in addition, we depict several frequent macroscopic abnormalities in order to provide surgical colleagues with some cases of abnormal macroscopic gallbladders. the left hepatectomy is a demanding and difficult procedure, still limited to reference centers. the caudal approach and exposure of the middle hepatic vein is a reliable way to achieve a safely and reproductible left hepatectomy. with this technique, exposing the middle hepatic vein, we believe that we can perform a safe and feasible laparoscopic left hepatectomy increasing the quality of this hepatectomy. we present a -year-old woman with an intrahepatic and common bile ductlithiasiswhich was previously submitted to an ercp. with an unsolved intrahepatic lithiasis the patient was proposed to alaparoscopic left hepatectomy. the minimally invasive approach for alpps in a patient with a large hepatocellular carcinoma in a liver with severe steatosis is shown. during the first stage a partial alpps is performed. pve is performed in postoperative day one. after days from the first stage both liver volume and function (by hida scan) are re-assessed. right hepatectomy (second stage of alpps) is then conducted by laparoscopic aproach. hepato-bilio-pancreatic, centro hospitalar são joão, porto, portugal a year old woman with a previous history of anxiety and catheter ablation to treat heart arrhythmias, was studied for for multiple pancreatic cysts incidentally discovered on a routine ultrasound. an mri was performed showing multiple cystic tumors throughout the pancreas, the largest of which was mm. this led to a suspicion of multi-focal, side-branch intraductal papillary mucinous neoplasm (ipmn), with minimal dilatation of the main pancreatic duct. an echo endoscopy was subsequently performed indicating probable multifocal ipmn. a fna was carried out during this procedure, with aspiration of cystic content which was sent for cea analysis and cytology. cytology was compatible with mucinous neoplasm with mild atypia and cea u/ml. a splenic preserving total laparoscopic pancreatoduodenectomy was proposed. the procedure was uneventful and the patient was discharged on the th post-operative day. pathology revealeded a mm ipmn, with severe dysplasia and foci of microinvasive ductal adenocarcinoma of mm-pt n r . indocyanine green immunofluorescence guided laparoscopic partial hepatectomy y. tai obtaining negative tumor margin during laparoscopic hepatectomy has always been a very challenging topic for surgeons in that the surgeons are not able to palpate the tumor during laparoscopic surgery. although intraabdominal echo is available, but it demands great experiences and skills. with the guidance of icg immunofluorescence, surgeons can avoid failure of not obtaining enough negative margins nor resect too much healthy liver. icg is often used to estimate the liver function prior to hepatectomy traditionally. it binds to plasma protein and has a peak absorbance at nm and emits fluorescence with a wavelength of approximately nm. icg is preferentially retained in or around biliary malignancies due to impaired biliary excretion of hepatocytes in the affected area. we performed icg immunofluorescence guided laparoscopic partial hepatectomy on a years old male who suffers from hcc located at segment and . icg was injected days prior to the operation day. while evaluation of liver is performed, it also allowed us to use a high-end laparoscopic camera system equipped with integrated filters for detection of near-infrared fluorescence. during the surgery, we were able to clearly locate the borders of malignancies through the use of integrated filters combine with icg injection. the pathology study also confirmed that the adequate tumor free margin ([ . cm) were obtained in both tumors and the patient's condition was stable as well. icg immunofluorescence guidance enables surgeons to obtain optimum result in tumor resection through laparoscopic surgery. it also has the ability to detect bile leakage. with the use of icg immuofluorescence, surgeons will have higher chances to achieve adequate negative margins. background: parenchymal sparing hepatic resection has the advantage of preserving valuable tissue in chemotherapy-treated livers, assuring an adequate future remnant volume without compromising long-term survival. moreover, the laparoscopic approach offers the decreased postoperative morbidity of minimally invasive surgery. whenever technically feasible, this kind of procedure should be considered a suitable alternative to the classic major hepatectomy for the treatment of multiple colorectal liver metastases. methods: -year old male with a previous history of laparoscopic sigmoidectomy in november for a pt n m sigmoid adenocarcinoma. a control scanner three years later showed liver metastases in segments v, viii, ii and caudate lobe. after chemotherapy (xelox), control mri and pet scans showed a good response. he was proposed for a laparoscopic parenchymal-sparing liver resection. results: total operative time was h and min with no intraoperative complications. patient presented a right atelectasis as the only postoperative complication and was resolved with respiratory therapy. he was discharged in days. pathology report showed that lesions on segment v and viii had no viable tumor ( % fibrosis) and lesions on segment ii and caudate lobe had moderately differentiated adenocarcinoma. margins were free in all the lesions. after a month follow up, the patient has no recurrence and normal liver function tests. conclusion: minimally invasive liver resection is possible in patients with multiple bilobar liver metastases and allows to perform parenchymalsparing surgery safely. difficult localization of lesions such as the caudate lobe are not a contraindication for this type of surgery. laparoscopic approach for perihilar cholangiocarcinoma is still poorly reported in the literature due to technical challenges secondary to the combination of major hepatectomy, lymphadenectomy and biliary confluence resection. despite this, in selected cases it can be a good option to provide a short term benefit to patients. the video reports the case of a perihilar cholangiocarcinoma with involvement of left bile duct and therefore requiring left hepatectomy. komagome hospital, bunkyo-ku,tokyo, japan aims: segmentectomy is an anatomic liver resection, in which the tertiary branches of the glissonean pedicles are selectively transected. however, the branching pattern of the tertiary branches varies depending on the case, particularly in segment (s ) and segment (s ). the extrahepatic approach to the glissonean pedicle from the hepatic hilum is very difficult depending on the branching pattern. furthermore, the distance of exposing the secondary branches that are to be preserved becomes longer, and there is an increased risk of biliary leakage and delayed biliary stricture due to excessive traction in laparoscopic surgery. therefore, laparoscopic s and s segmentectomy are considered technically difficult. we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. methods: we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. we identify the targeted glissonean pedicle intrahepatically after the parenchymal transection along the major hepatic vein or its branch running on the intersegmental plane, referring to the preoperative simulation by d imaging. (a)s segmentectomy; after the mobilization of the right lobe, the glissonean pedicles of s (g ) can be approached from the dorsal side by transecting the parenchyma between the ivc and the right hepatic vein. after the division of the g , the parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. (b)s segmentectomy; first, the parenchyma is transected along the middle hepatic vein (mhv) from the root side to the peripheral. g is typically detected on the right dorsal side of the mhv. after the division of the g , the liver parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. results: we have experienced cases of laparoscopic s segmentectomy and cases of laparoscopic s segmentectomy. conclusion: our approach to the g and the g is safe and very useful. laparoscopic anatomical segmentectomy of right anterior section is technically demanding because it is difficult to dissect the deep tertiary branches of right anterior portal pedicle (rapp). we present three cases of laparoscopic anatomical segmentectomy using the extrafascial and transfissural approach: ) anatomical resection of segment , ) anatomical resection of the ventral area ) anatomical resection of segment dorsal area. the extrafascial and transfissural approach means that the liver parenchyma along the fissure lines is opened, then the surgeon can confirm the glissonean pedicles and territory directly. the extrafascial and transfissural approach in laparoscopic anatomical segmentectomy of right anterior section is feasible and effective because this technique can easily be approached to the deep tertiary branches of rapp. repeated liver resection has significant role in patients with recurrent hepatocellular carcinoma (hcc) in several situations. laparoscopic redo surgery is becoming safer along with advance in surgical technique. we have performed laparoscopic re-resection for limited intrahepatic hcc recurrence. the aim of the present study was to investigate its significance comparing with first laparoscopic liver resections. subjects: patients with limited intrahepatic hcc recurrence after open hepatectomy underwent laparoscopic liver re-resection (n = ). methods: adhesion between abdominal wall and visceral organs was carefully divided, after the first laparoscopic port was safely inserted. adhesion between diaphragm and liver surface or between previous liver cut surface and colon or duodenum was also minimally dissected. approach to the glisson's pedicles at the hepatic hilum was often difficult due to previous surgical procedure, thus pringle's maneuver was generally applied. dissection of hepatic parenchyma approaching to the target glisson's branch was often preceded under the ultrasound-guidance. liver resection was performed using lcs, biclamp, and cusa using intermittent block of the hepatic inflow. operation time, intraoperative bleeding, morbidity, mortality, and postoperative hospital stay were compared with those in patients who underwent first laparoscopic liver resection during the same period (n = ). results: operation time was significantly longer in the re-resection group, possibly due to the adhesiolysis. meanwhile, no significant difference was detected in intraoperative bleeding, morbidity, mortality and postoperative hospital stay between the first and the redo surgeries. methods: the donor was a -year-old gentleman who decided to donate part of his liver to his wife suffering from viral liver cirrhosis and hepatocellular carcinoma. his bmi was . kg/m and the preoperatively estimated donor's right liver volume was ml, representing . % of his entire liver. with the recipient's weight of kg, the graft to recipient weight ratio (grwr) was . %. the liver had classic hilar anatomy except that the right posterior intrahepatic duct seperately joined to the left main hepatic duct. after isolation and clamping of right hepatic artery and portal vein, indocyanine green of . mg was injected intravenously. results: the total operation time was min and the estimated blood loss was ml without transfusion. indocyanine green fluorescence image clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. his postoperative course was uneventful and discharged postoperative day . conclusion: real-time indocyanine green fluorescence image may be particularly helpful to delineate anatomical surgical plane and to determine the appropriate division point of hepatic duct during laparoscopic living donor hepatectomy. surg endosc ( ) the correct management of intraoperative volemic status is essential in laparoscopic liver resection in order to control bleeding and to perform even complex procedures with a good profile of safety. central venous pressure is not really reliable in laparoscopy, due to presence of the pneumoperitoneum and patient position. monitoring of haemodynamic parameters via vigileo system is a minimally invasive method to control stroke volume variation, cardiac output, cardiac index and oxygen delivery in order to optimize the anaesthesiological management by controlling venous bleeding and avoiding tissutal ischemia. introduction: non-hydatid liver cysts represent a heterogeneous group of disorders that differ in their etiology, prevalence and clinical manifestations.within them, the simple hepatic cyst is the most frequent.the majority of simple cysts are an incidental finding during the performance of an imaging test for another unrelated cause and few of them are symptomatic or are associated with complications, and surgery is not necessary in most of them. described various therapeutic approaches so far there is no consensus about the optimal treatment of simple symptomatic, complicated or growth-showing liver cysts during its follow-up. currently the laparoscopic approach is widely used for the management of cysts hepatic, with results similar to open surgery but with the advantages of laparoscopy. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the approximation of complicated simple hepatic cysts.material and method: clinical case: a -year-old female patient with a history of: giant hiatus hernia intervention with laparoscopic nissen, fibromyalgia, previous ischemic colitis. hospital admission due to pneumonia and right pleural effusion with us: simple cyst x x mm in segment v hepatic, with dilatation of biliary radicals adjacent to the cyst, distended gallbladder with irregular walls in the hepatic side. ct: cystic lesion in segment iv-v of the liver, which has increased in size, with small microabcesses adjacencies to the lesion, thickening of the gallbladder wall, to assess cholecystitis. antibiotic treatment is established with good evolution, deciding surgery. results: intervention: complete laparoscopic approach, trocars, edematous cholecystitis, large retroyuxta vesicular cyst,with thickened walls with serous content. cholecystectomy maintaining the cyst wall, puncturing and taking samples for cytology and biochemistry of the contents, resection of the cyst wall, partial flare of its internal surface, negative intraoperative biopsy, epipoplasty, with drainage placement.correct postoperative course.pathological anatomy: simple biliary cyst with negative cytology, ck ?, ck -, calretina-. conclusion: the treatment of choice of complicated simple hepatic cysts is laparoscopic.we recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature,we propose cyst enucleation as the best surgical treatment. objective: the objective of the following case is to present a patient with symptomatic polycystic liver disease, which was solved by laparoscopy approach and the management of its complications. material and methods: the case reported is about a years old female patient with abdominal pain in upper right quadrant associated to asthenia, adynamia and hyporexia. ct scan reported heterogeneous liver with multiple ovoid images with regular edges defined which the biggest one measure x x mm with volume of cc on segment and , which comprises stomach, and the other one in segment with a volume of cc and others small sized located in segment , and b. results: in this laparoscopic approach, we performed a cyst unroofing of the two biggest cysts as well as cholecystectomy because of firm and lax adhesions. the patient evolved with fever in the th day postsurgical day and biliary leaking in a volume of cc in hrs. an ercp (endoscopic retrograde cholangiopancreatography) was asked for that was carried out by finding leak at the intrahepatic biliary duct therefore; esphinterotomy with placement of plastic endoprotesis was performed. the patient evolved without complication and was discharged at the th day. conclusions: only symptomatic polycystic liver disease needs to be treated. the choice of treatment is not yet standardized, for voluminous cysts the unroofing ideally by laparoscopy is the gold standard and the ercp is the elected treatment when the biliary leak appears as a complication. introduction: laparoscopic liver resection (llr) for tumors located in the posterosuperior segments of the liver (segments (s) or ) is a challenging procedure. especially, llr for s is difficult because the access of instruments is limited, bleeding control is not feasible, major llr is sometimes required, and obtaining sufficient resection margin is not easy. to overcome this obstacles, we performed llr in s with a lateral approach using intercostal trocars. to obtain competent resection margin, llr through right hepatic vein (rhv) first approach was performed for . cm mass located near the rhv in a year old female. case: after full mobilization of right liver including all short hepatic veins and caudate lobe, rotate the whole liver completely to the left side to approach to the root of rhv. one intercostal trocar was inserted to access the lesion. parenchymal transection started from the confluence of hepatic vein and then, followed along rhv with ligating several small branches from rhv. resection margin was demarcated after localization using laparoscopic ultrasonography. after completion of parenchymal dissection using cusa and ultrasonic shears, hemostatic agents were applied and drain was inserted. operation time and estimated blood loss were mins and ml. the patient was discharged without any complication on postoperative day . final pathological assessment confirmed clear resection margin (safety margin : . cm). conclusion: laparoscopic s segmentectomy with hepatic vein first approach technique is safe and recommended to obtain better resection margin. aims: simple liver cysts are the most common cystic lesions of the liver. most are diagnosed casually in image tests such as ultrasound or computerized tomography, most of which are asymptomatic and do not require treatment. in symptomatic patients (abdominal distension with palpable mass, abdominal pain, dyspnea, jaundice, etc.) the clinical manifestations are usually due to the growth of the cysts or the compression of neighboring structures. liver function tests are usually not altered. intracystic complications occur in less than % of cases and malignancy is exceptional. in this video, we present the case of a symptomatic patient with polycystic liver disease including a large size hepatic cyst. material and methods: -year-old woman with a personal history of arterial hypertension, saos, partial hysterectomy due to endometrial cancer, who was referred to our department complaining of supraumbilical pain and abdominal distension with palpable mases. abdominal ultrasound showed cholelithiasis and multiple simple hepatic cysts. in ct scan, multiple hepatic cysts were found, the largest one of about cm of larger diameter. echinococcus granulosus serology test was negative. there was also no evidence of cancer disease in pet scan. results: a laparoscopic approach was performed with four trocars, three of mm and a hasson trocar inserted thought a umbilical small incisional hernia. aspiration and wide unroofing of the large size cyst and smaller accessible ones was done. the patient also underwent cholecystectomy with intraoperative cholangiography and umbilical eventroplasty. the patient recovered uneventfully and is asymptomatic one year after surgery. conclusion: simple liver cysts rarely require treatment. in some cases, especially in large, complicated and symptomatic simple liver cysts, surgery is indicated. laparoscopic fenestration treatment is the best choice. aims: liver resection is the preferable initial treatment option for solitary or limited multifocal hepatocellular carcinomas. surgical indications for laparoscopic liver resection (llr) are the most important consideration, like liver function, tumor size (diameter less than cm) and location (easy technical access like in the left lateral section or on the surface of the inferior region). partial liver resection or left lateral sectionectomy are the typical procedures for such tumors and are considered the best way to begin llr. with accumulating experience and technical advancement, llr has been performed for tumors larger than cm and for others locations. some requirements to perform llr are to have experience in liver surgery and laparoscopic also, adequate technology and intraoperative ultrasound. methods: a -year-old male smoker, ex-parenteral drug users with chronic hcv liver disease child-a stage. he is diagnosed with a single lesion of cm in segment iii of the liver, biopsied twice without conclusive diagnosis and with a three-phase ct suggestive of hepatocarcinoma li-rads with data of portal hypertension (pht) and mild ascites. after the study is commented on tumor committee deciding surgical intervention. results: a laparoscopic resection of segment iii was performed with trocars. liver is explored by intraoperative laparoscopic ultrasound. vascular control was performed using the pringle technique. liver transection was done with sonostar until identification of intraparenchymal segment iii vascularization, which is sectioned with endogia ( mm) with seamguard. after the resection, we perform hemostasis control with electrocoagulation and hemostatic material. intraoperative bleeding of ml. favorable postoperative evolution, high on the th postoperative day. ap: cm trabecular hepatocarcinoma moderately differentiated pt b, r resection. conclusions: llr allows major liver resections with low morbidity and mortality and the advantages of laparoscopic surgery. an efficient learning curve can be achieved by a parallel evolution of procedures and indications (according to modified bclc staging system and treatment strategy). studies suggest that llr results in less blood loss, shorter postoperative hospital stays, lower abdominal wall trauma and lower incidences of ascites accumulation and postoperative liver failure. with respect to oncological considerations, tumor margins are adequately maintained during llr. v. drakopoulos, s. voulgaris, i. iliadis, k. botsakis, p. trakosari, v. vougas st department of surgery and transplantation unit, district general hospital of athens « evangelismos » , athens, greece introduction: laparoscopic surgery is gaining acceptance in the treatment of liver metastasis. laparoscopic treatment of liver metastasis often presents technical difficulties and requires an extensive learning curve. material-method: we present the case of a year old woman presented with a liver metastasis in section of the liver. the patient had been submitted to a laparoscopic low posterior resection in february . patient underwent laparoscopic left lateral hepatectomy, with the use of three trocars (umbilical mm, and two in the midclavicular line bilaterally.) left lateral hepatectomy was conducted with the use of a linear stapler. the postoperative period was uncomplicated and the patient remains in good condition three months after surgery. conclusion: laparoscopic approach seems to be safe for treatment of liver metastasis, offering better surgical field view and less postoperative complications. year survival rate after laparoscopic hepatectomy is compared to the open approach. general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan purpose: laparoscopic hepatectomy is a quickly growing method for liver tumor because of modern technology. but for the ihd thrombosis, it is still technique dependent. the video was tried to share our experience for special case. material and method: one y/o female patient suffered from fever episode and image show s cm hcc with right anterior ihd obstruction r/o tumor thrombosis, hilum ln enlargement, double right portal vein, hilum adhesion with duodenum, no ascites . lab data : no-b, no-c child a, afp , icg clearance rate . %, plt . heart, lung function exam normal. the laparoscopic right total hepatectomy and hilum ln dissection was conducted. results: laparoscopic approached was performed. the hilum ln dissection was done with vessel and bile duct isolation. hilum ln frozen show negative malignancy. hemi-vessel control was done with resecting the vessel. right hepatectomy was done with preserving middle hepatic vein. the right anterior and posterior ihd was opened and tumor thrombosis was removed from right anterior ihd carefully. the stump of ihd was closed by suture separately. the total op time was min with cc blood loss. post op minimsl bile leakage was found in the drain at day . the patient discharged at day with drain. conclusions: laparoscopic hepatectomy may be a feasible method for hcc even with ihd tumor thrombosis. surg endosc ( ) introduction: the progressive laparoscopic learning in gastric surgery and the great development of instruments and laparoscopic material that facilitates the realization of advanced procedures, has led to an increase in the use of laparoscopy in the treatment of gastric cancer. material and methods: we present the case of a -year-old man without amc with a history of ischemic heart disease who enters our surgery department for cholangitis secondary to choledocholithiasis. ercp is requested during his admission that describes a gastric lesion from which a biopsy is taken, making it impossible to access vater papilla to perform sphincterotomy and lithiasis extraction due to the existence of duodenal diverticula. the result of pathological anatomy of the gastric lesion was compatible with adenocarcinoma. negative extension study. the clinical case is presented in a committee of multidisciplinary tumors and it is decided to perform surgical intervention of both pathologies. a subtotal gastrectomy was performed with a roux-en-y reconstruction. surgical time of min. choledochotomy was performed with lithiasis extraction, as well as intraoperative exploration of the bile duct and main conduits by means of a choledochoscope. results: income of days, with a clavien ii. the definitive pathological anatomy was an ai stage with a total of isolated nodes without evidence of neoplasia in any of them, therefore it does not require adjuvant treatment. the patient is asymptomatic, with nutritional supplementation with follow-up in ccee of surgery. conclusions: in our case, there were no serious postoperative complications when performing gastric resection and bile duct exploration with drainage of the same. from the oncological point of view, the number of lymph nodes extracted and the surgical margins are similar to those obtained in patients in whom we perform open surgery; therefore, although it is a single clinical case, laparoscopy in expert surgeons is a safe and effective technique. the puestow procedure was initially proposed to alleviate the pain in patients with chronic pancreatitis and dilated wirsung duct. its objective is to provide an efficient drainage of the pancreatic fluids and, in the meantime, to preserve the pancreatic tissue and minimize the risk of endocrine and exocrine pancreatic insufficiency. aims: to describe the particular technical aspects and the efficacy of totally laparoscopic puestow procedure in patients with cystic duodenal dystrophy. methods: a years old patient presenting diffuse epigastric pain, vomiting and weight loss was diagnosed at endoscopic ultrasound and biopsy with cystic duodenal dystrophy. a conservative treatment was decided with octreotide and opioids. however, due to the persistence of symptoms surgery was performed. results: due to the association of a dilated wirsung duct, the patient was submitted to a puestow procedure. the surgical procedure was completed in a minimally invasive manner; after dissecting the anterior surface of the pancreas an intraoperative ultrasound was performed in order to identify the wirsung duct. therefore, the pancreatic parenchyma was transected along the wirsung duct, a totally laparoscopic pancreato-jejunostomy on roux en y limb being performed. the early postoperative outcome was uneventful, the patient being discharged in the sixth postoperative day. at one month and six months follow up the need for opioid treatment significantly diminished. a kinking of the enteral anastomosis required a laparoscopic intervention one year after with a very good evolution after. conclusions: totally laparoscopic puestow procedure seems to be a safe and efficient method in order to treat symptomatic patients with cystic duodenal dystrophy in whom a dilated wirsung duct is present. aims: the approach to the intraductal papillary mucinous neoplasm (ipmn) is various, from a radiological follow-up with magnetic resonance (rm) to the surgical treatment with a pancreatic resection [ ] . the surgical approach is various and depends on the localization of the lesion and on the surgical skills [ ] . methods: a years old patient was admitted at the chi possy-saint germain-en-laye with an acute pancreatitis. at the ecoendoscopy was found a pancreatic cystic at the junction of the pancreatic body and tail with a wirusng diameter of mm. a second episode of acute pancreatitis occurred a few months later. after that episode the patient was submitted to a computer tomography (ct) that found a cystic lesion of cm with an increasing dilatation of the wirsung duct. the serum ca - was ui/ml. a laparoscopic sils distal pancreatectomy with spleen conservation was performed. results: a trans-umbilical incision was performed with the positioning of the gelpoint sils platform with the placement of trocars. a distal pancreatectomy with a spleen preservation and without a standard linfadenectomy was performed. the pancreatic stump was closed with an endo-gia mm with seamguard device. any drain was placed. the post-operative course was uneventfull. a ct scan was performed in …. post-operative day which didn't show collections. the patient was discharged in -…… post'operative day. the histological examination shows an ipmn with low grade dysplasia. no invasive carcinomatoses cells were found. the distal pancreatic sils resection with spleen conservation is a feasible and safe technique that combine all the advantages of the minimally invasive laparoscopic approach with the esthetic advantages of the sils approach. pancreato-duodenectomy is a complex surgery, requiring several anastomoses to reconstruct the digestive tract. due to its technical complexity, the laparoscopic approach is not yet the goldstandard and there remains some controversy about its oncological safety. worldwide experience is limited, and its safety and effectiveness are yet under evaluation.we present the clinical case of a years-old woman with a prior history of epilepsy. she was studied due to painless obstructive jaundice and a cm pancreatic head tumour was diagnosed on imaging, causing cbd and wirsung channels' dilatation. the tumour was considered locally resectable and she was proposed for a radical pancreato-duodenectomy.we present the main steps of the surgery including the oncological resection with lymphatic basin clearance and totally laparoscopic reconstruction.the post-operative was uneventful, and the histologic sample revealed a ductal adenocarcinoma (t ) with an r resection and / lymph nodes invaded. although technically demanding, laparoscopic pancreato-duodenectomy is safe and effective requiring teams with experience both in pancreato-biliary and laparoscopic surgery. chronic pancreatitis is characterized by a progressive pancreatic fibrosis with loss of endocrine and exocrine function. one of its main symptoms is debilitating pain. surgical drainage of a dilated pancreatic duct is an option to consider in cases of refractory pain. longitudinal pancreato-jejunostomy allows an effective decompression of the pancreatic channel and a significant improvement in the quality of life. we present the clinical case of a years-old lady with a prior history of gallstones. she was treated for an acute pancreatitis in may , followed by recurrent relapses of pain and enzymatic elevation. she required opioid use for partial pain control and a significant kg decrease on body weight due to 'fear of eating'. the endo-ultrasonography and the mri revealed a chronic pancreatitis with an mm wirsung duct with ductal stones and an atrophic body and tail. we proposed a laparoscopic longitudinal pancreato-jejunostomy. the surgery was performed with trocars, with the surgeon on the right side of the patient. we performed a trans-mesocolic cm pancreato-jejunostomy. the post-operative was uneventful, and the patient was discharged on the th post-operative day, asymptomatic. laparoscopic longitudinal pancreato-jejunostomy, although effective is a technically demanding surgery but brings the benefits of a minimally invasive approach. background: preservation of spleen in distal pancreatectomy is also useful from the maintenance of platelets and the prevention of overwhelming post splenectomy infection. we have performed laparoscopic spleen preservation distal pancreatectomy: lspdp to benign and low-grade tumors of the pancreatic body tail. the aim of this study was to report our surgical experience with the method of svp: splenic vessel preservation and wt: warshaw technique of lspdp, describe our techniques with videos. method: there are three points of our surgical technique. , precede pancreatic dissection, improve the mobility of the pancreas. , confirming the courses of splenic artery and classified them into two major types. , preserving the left gastro-epiploic vessels and short gastric vessels.the postoperative cases of lspdp which performed from april to september was retrospectively studied. result: of consecutive patients were performed lspdp at our institute, were svp and were wt. ages, gender and bmi were similar for two groups. there were no significant differences in operative time, blood loss and length of stay after surgery. comparing pathological finings, wt was associated with a slightly large tumor lesion (median mm vs. . , p = . ). among the median observation period of months, splenic infarction was observed in case in svp and cases in wt. however, they were focal splenic infarctions, they did not need surgery or drainage. there were no cases in which late onset of splenic artery occlusion or esophageal / gastric varices. conculusion: after performing lspd, the function of the spleen was good in all cases. both svp and wt were safe and feasible procedures. this is the case of a -years-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last years. msct revealed pancreatic calcifications from mm to - mm and dilatation of the main pancreatic duct in the body of the pancreas up to mm. the patient underwent laparoscopic local resection of the head of the pancreas combined with longitudinal roux-en-y pancreaticojejunostomy-a technique known as frey's procedure. it is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.after performing the posterior wall of the pancreaticojejunal anastomosis we've faced an intraoperative complication such as volvulus of the roux limb causing serious ischemia of the limb. we were forced to remove all previous sutures in order to untwist the roux limb, thereafter the pancreaticojejunostomy was started anew.the purpose of this video is to demonstrate that frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. we demonstrate that even such serious intraoperative complication as volvulus of the roux limb can be managed without conversion. our center has an experience of over laparoscopic frey's procedures, however this is the first case where we encountered with such complication and we believe this is an experience worth sharing.yet we would like to underline that this approach should be used by highly skilled minimally invasive surgeons experienced in intracorporeal suturing which is the most challenging stage in frey's procedure. v. tomulescu, i. hutopila, c. copaescu spleen preserving distal pancreatectomy (spdp) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. two surgical techniques for spdp have been described. the first technique was described by kimura (spleen preserving distal pancreatectomy with splenic vessel preservation-spdp-svp) and preserves the main splenic artery and vein and excises the tail of the pancreas and those small, short vascular connections to the body;the second technique was described by warshaw and involves resection of the splenic vein and artery before distal pancreatectomy, and conservation of theshort spleno-colic and gastric vessels to keep normal blood flow for the spleen (spleen-preserving distal pancreatectomy with splenic vessel resection-spdp-svr). we present the case of a years old female with / mm tumor of the pancreatic tail on ultrasonography. ct scan confirmed the tumor and endoscopic ultrasonography with fna have shown a solid pseudopapillary tumor. due to the low grade malignancy we have decided to perform a laparoscopic spleen preserving distal pancreatectomy with splenic vessels preservation (lspdp-svp). for lspdp-svp the difficulty is related with the splenic vessels dissection and manipulation. primary dissection and control of main trunk of splenic artery and vein will help to quickly control bleeding during vascular rupture in small vessels dissection. optimal stapling of any tissue requires an adequate tissue compression time to allow elongation of the tissue being compressed, smooth firing of the instrument, consistent staple line formation balanced against the risk of increased tissue tearing and excessive tensile strength. this is why, for pancreatic division, we prefer choosing a cartridge loaded with higher staplers. the pancreatic stump transection line is evaluated for bleeding and when it is needed, hemostatic clips are applied. histology report confirmed a solid pseudopapillary tumor t nomxl v r at this moment with month good follow up. in conclusion lspdp-svp is safe, reproductible and demonstrated very good outcomes when certain indications are respected. surg endosc ( ) aim: advances in minimally invasive surgery has permitted to perform complex techniques by this approach, being the laparoscopic duodenopancreatectomy (lpd) one of these. the aim of this communication is to present a surgical technique video for a complete laparoscopic pd, showing the most important steps of the resective and reconstructive phase, with the anastomosis realized completely by laparoscopy. methods: a surgical technique video is presented showing the main steps for the lpd and a complete laparoscopic reconstruction with an hepaticojejunostomy, duct-to-mucosa pancreatic-jejunostomy and a gastrojejunostomy. results: an years old woman with past medial history of arteria hypertension, dyslipidemia, type ii diabetes mellitus and a breast cancer treated in with lumpectomy and axillary lymphadenectomy plus radiotherapy, recently diagnosed of and adenocarcinoma of the head of the pancreas. the ct scan showed a neoplasia localized in the head of the pancreas without extension to other organs. a laparoscopic pd was indicated after a multidisciplinary committee evaluation. a supraumibical hasson trocar was used for the pneumoperitoneum, three mm trocars and two mm trocars were used. lpd was performed. the resective phase was done following the conventional steps of the open whipple procedure and for the reconstructive phase, a child limb was used for a termino-lateral hepatico-jejunostomy with an absorbable / monofilament; a duct-to-mucosa pancreatic-jejunostomy with an absorbable / monofilament and finally a latero-lateral mechanical gastro-jejunostomy was performed. surgical time was min. postoperative course without complications and the patient was discharged on the th postoperative day. definitive anatomopathological exam: intraductal tubulopapilar neoplasia, x x mm, with wide high grade epithelial dysplasia. free margins. ptisn ( / ). conclusion: laparoscopic pd is a feasible procedure with a high technical requirement which should be performed in specialized centres with high experience in hepatobiliary surgery and in advanced laparoscopic procedures, because of its high morbidity and mortality. conclusions: robotic assistance in whipple may overcome limitations of laparoscopy and offer a minimaly invasive approach to this procedure potentially resulting in lower blood loss and less morbidity. we need further prospective randomized trials in order to determine the exact role of robotics in pancreatic surgery. aims: distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. the most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. spleen-preserving distal pancreatectomy should be attempted in case of benign disease. laparoscopic spleen-preserving distal pancreatectomy (lspdp) is expected to be less invasive than laparoscopic distal pancreatectomy with splenectomy. however, there are few reports regarding the details of the procedure for lspdp, and its safety remains unclear. this study aimed to evaluate the feasibility and safety of lspdp. methods: retrospective analysis of surgery treatment of patients was made. lspdp was conducted in the period from to in the department of laparoscopy surgery of state institution o.shalimov national institute of surgery and transplantology. the average age was : . years, the body mass index (bmi) was . ± . results: laparoscopic distal pancreatectomys was performed in % of cases, were attempted in female and male patients. postoperative pathological examinations revealed cases of serous cystadenoma in the body and tail of the pancreas, case of serous oligocystic adenoma, case of mucinous cystadenoma, case of neuroendocrine tumor (insulinoma), and case of solidpseudopapillary neoplasm. complications related to the surgery were like acute pancreatitis with -fold increase normal plasma amylase confirmed by ct- cases, fluid collection- cases, pancreatic fistula (grade a)- cases. the operation time was . min, (range - min) blood loss of . g (range - g), mean hospital stay was . days (range - days). conversion to laparotomy was in case. mortality was . conclusion: laparoscopic spleen-preserving distal pancreatectomy is minimally invasive, safe, and feasible for the management of benign pancreatic tail tumors, with the advantages of earlier recovery and less morbidity from complications. aims: a pancreatic pseudocyst is an encapsulated, mature fluid collection occurring withing the pancreas that have a well-defined wall minimal or no necrosis secondary to pancreatic injury and mediated by the enzimatic and inflammatory disruption of pancreatic tissue. it is a common complication of acute and chronic pancreatitis. we present the case of a pancreatic pseudocyst located within the body of the pancreas due to recurrent necrotic pancreatitis. the objective of this video is to show the minimally invasive surgical approach of this entity. methods: a -year-old man without medical history was admitted to hospital in the digestive service on times for acute necrotizing pancreatitis. after study in which is evidenced cholelithiasis and pseudocyst in pancreatic body of cm maximum diameter and formation of two peripancreatic collections without signs of superinfection, cholecystectomy is indicated. magnetic control cholangiography was performed after surgery and it showed an increase in the size of the pancreatic pseudocyst, suspecting wirsung's duct disruption. therefore, endoscopic retrograde cholangiopancreatography (ercp) was performed by placing a plastic pancreatic prosthesis and performing a sphincterotomy. after hospital discharge, the patient is re-admitted due to recurrent abdominal pain without analytical alteration. tc abdominal observed an increase in the pseudocyst from to cm. this case was discussed in a multidisciplinary committee and surgical intervention was decided. results: laparoscopic approach is decided and four trocars were placed. initially, a gastrostomy was performed with liquid outlet. an aspiration of the liquid and quistogastrostomy with mm endogia was made. the patient progresses favorably, being high on the tenth postoperative day, without complications. conclusions: almost every pancreatic pseudocyst improves spontaneously and needs no specific treatment. draining is indicated when secondary symptoms to compression, complications or rapidly enlarging are found. depending on the complexity of the pseudocyst, its communication with wirsung's duct and the existence of ductal injury, it may perform a percutaneous, endoscopic or surgical drainage. the goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage. only the surgical procedure is definitive. case: a y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. cardiac investigation was negative and gastroscopy showed a grade b esophagitis. he was treated medically but with only partial response. on a thoraco-abdominal cat-scan the diagnosis of a left sided bochdaleks' hernia was made. the hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed. method: given the clear correlation between the patients' complaints and these anatomical findings, he was referred to our service of abdominal surgery. we performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. the patient was tilted to his right side. mobilization of the spleen was necessary to gain maximal access to the hernia. we were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. the defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers. result: postoperatively the patient recovered well with adequate pain relief and pulmonary support. he could leave the hospital after days. control cat-scan on day postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. on follow-up weeks after surgery the patient had regained normal activities and was symptom free. conclusion: a symptomatic left sided bochdaleks' hernia in adults with an ectopic intrathoracic kidney is extremely rare. we hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate. aims: large incisional hernias repair involves an actual problem for surgeons to face. anterior component separation has been an important method allowing to close the fascia defects without tension while also having underlay mesh reinforcement.therefore, we present a case of incisional hernia reparation performing endoscopic anterior component separation with advantages compared with open approach. method: we present the case of a -year-old woman, bmi kg/m , with previous laparoscopic gastric sleeve and posterior reintervention using open approach. the patient presented a cm size incisional hernia m w . a ct scan was performed, confirming a midline incisional hernia containing colon, with an herniary defect of cm. full minimal invasive abdominal wall repair was proposed. a cm size incision was made in left iliac region to reach the aponeurosis of external oblique muscle. we placed a balloon trocar and subcutaneous pneumo-dissection with mmhg pressure was performed; then, we placed a mm trocar in left lumbar space. the aponeurosis of external oblique muscle was incised and anterior component separation from inguinal to subcostal area was achieved. an extensive intermuscular dissection was performed to achieve complete midline closure. we performed the same procedure on the right side. then, with laparoscopic approach using v-loc n° suture, we completely closed the midline. eventually, we placed a x cm ptfe-c mesh fixed with a double crown of tackers and fibrin glue. results: postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. the patient has been followed up for months without any complication or recurrence in ct scan, confirming the correct minimally invasive reconstruction of the abdominal wall. conclusions: trends in abdominal wall reconstruction and complex-hernia repairs have advanced rapidly in recent years. the goal is to perform a complete abdominal wall repair with no tension in midline incisional hernias. endoscopic anterior component separation and laparoscopic eventroplasty with closure of the defect, leads to a complete wall reconstruction without tension and avoids drawbacks due to primary close defect in those patients with herniary defects wider than cm. aims: endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. to combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose totally endoscopic sublay anterior repair (tesar), a safe and feasible approach for the treatment of ventral and incisional midline hernias. methods: from may to september patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for tesar. exclusion criteria were: complicated ventral or incisional hernia (i.e. incarcerated hernia), maximum defect width [ cm, contraindications to general anesthesia. the procedure consisted of suprapubic access with trocars, complete endoscopic pre-aponeurotic dissection, isolation and reduction of the hernial sac, bilateral incision of the medial rims of recti aponeurosis and dissection of retromuscular plane to create the retromuscular space, sublay non-absorbable mesh positioning and anterior aponeurosis reconstruction. one drain was always placed in the retromuscular space and one drain in the subcutaneous space. results: all procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. no intraoperative complications were registered. total mean operative time was ± . min. no post-operative major complications were registered. only one subcutaneous seroma was registered ( . %), and treated conservatively. the mean postoperative stay was . ± . days. at post-discharge clinical checkups drains were checked and removed when indicated. no wound complications nor recurrence were registered to date. cosmetic and functional results were successful in all patients. conclusions: tesar is a safe and feasible technique for the extra-peritoneal sublay repair of ventral hernias with totally endoscopic approach. it provides accurate hernia repair with good outcomes in terms of resolution of symptoms and post-operative complications. r. mizuno, m. kondo backgrounds: abdominal incisional hernia is found in more than % after abdominal surgery, and risk factors such as wound infection, obesity, elderly, high abdominal pressure are pointed out. laparoscopic hernia repair using intraperitoneal onlay mesh (standard ipom) is becoming widespread in japan since the insurance release in , and our hospital is actively working on it. recently, ipom plus procedure which also carries out fascia suture in addition to laparoscopic mesh placement has been introduced. aims: we report the clinical results of laparoscopic abdominal incisional hernia repair in our hospital. methods: we performed hernia repairs using a mesh for cases from january to september . of these, cases were standard ipom and cases were ipom plus. there was no significant difference in the patient background such as gender, age, bmi, etc, and in the intraoperative findings such as hernia orifice diameters and adhesions. surgical time, postoperative hospital stay, and the rate of complications such as seroma, mesh bulging, postoperative pain, hernia recurrence were compared and examined between the two groups. results: as a result, in ipom plus group, the operation time was longer and the incidence rate of postoperative pain was higher, but the incidence of mesh bulging was significantly lower. also, in some cases since , the ' u reverse stitch method ' is used as an ingenuity of fascia suture in ipom plus. conclusions: laparoscopic abdominal incisional hernia repair has the advantage of being able to reliably confirm the hernia orifice from the intraperitoneal side?it is excellent in the identification of the fragile part of the abdominal wall and in the visibility of the restoration range. with regard to the ipom plus procedure which has been introduced in the last few years, although the operation time is extended, it has usefulness such as reduction of mesh bulging. from the viewpoint of cosmetic surgery, usage of ipom plus will increase in the future. introduction: incisional hernia is one of the most common complications after abdominal surgery. several methods have been introduced, and yet, there is no consensus on the best method of repair. we present a novel method for hernia repair which uses the retromuscular sublay mesh repair through a single incision at the pubic area to improve cosmesis. methods: medical records of patients who underwent single-port retrorectal incisional hernia repair from may to december were reviewed. patients were placed in supine position and a cm incision was made in the pubic area below the panty line. a flap is made upwards until the defect is found and bilateral rectus sheathes are dissected. a mesh is then placed between the posterior rectus sheath and the muscle. results: a total of patients with midline incisional hernia underwent single-port retro-rectal incisional hernia repair. mean age was . ± . years with an average bmi of . ± . . all the patients had midline hernia defect with an average of . ± . cm. mean operation time was . ± . min and estimate blood loss was . ± . ml. there was no postoperative complication, and ( %) patients were discharged on the day of surgery. conclusion: the single-port retrorectal incisional hernia repair is safe and effective while providing good cosmesis to selected patients with incisional hernia. aims: closing hernia defect during laparoscopic hernia repair is a vast extended technique nowadays. however, this technique is associated with mesh placemnt intraabdominally in contact by the abdominal content. nowadays there is a trend to recontruct the midline and to avoid a mesh intraabdominally in those cases suitable for it, as a new step forward of minimally invasive abdominal wall reconstruction. laparoscopic sublay approach with retromuscular placement of a mesh without mechanical fixation after reconstruction the linea alba migth be considered an option in primary hernias of the midline. methods: we present a case of a year old male with an umbilcal hernia of centimeter in diameter associated with rectus diastasis. a laparoscopic approach was performed, using one and two millimeter trocars placed on the left flank. the first step was to open the lateral side of the posterior fascia of the left rectus muscles, dissecting the retromuscular plane until we reach the linea alba getting into the preperitoneal space where the sac was diseected preserving the integrity of the peritoneum. the contralateral posterior fascia was also dissected all the way to the semilunaris line. the midline was closed, including th hernia defect, using a running double loop suture (maxon-loopÒ). a self gripping mesh (progripÒ) is placed in the retromuscular space in a sublay position ( cm long, cm wide). last, we close the fascia of the left rectus muscle using a barbed suture (v-locÒ). results: surgical time was min, being discharged of the hospital on postoperative day . pain was controlled with conventional analgesia and no postoperative complications, nor seroma was detected. conclusions: sublay approach for ventral hernia can provide a midline reconstruction, reestablishing abdominal function and avoiding the use of intraabdominal meshes and traumatic fixation, decreasing postoperative complications and pain. aims: lumbar hernia is one of the rare cases that most surgeons are not exposed to. hence the diagnosis can be easily missed. this is often related to previous surgery as lumbotomies or primary in the superior lumbar triangle. this leads to delay in the treatment causing increased morbidity. we report a case of adquired lumbar hernia in a middle-aged woman repaired by laparoscopic approach. methods: a years old woman with surgical history of a myelomeningocele surgery by posterior approach over years ago, a laparoscopic left nephrectomy years ago with a left colostomy due to a left colon injury during this procedure. a hartmann reversal by laparoscopic approach months later. patient showed a large lumbar mass over cms in the left lumbar region and a large scar near to spinal cord. it was soft in consistency, reducible and expansible on coughing and straining with defined borders. computerized tomography showed a large defect in the superior lumbar fascia over cms in the grynfeltt-lesshaft triangle with the left colon inside. results: patient was placed in a full lateral decubitus position. in order to optimize exposure, a lumbar roll was placed under the lumbar region. a capnoperitoneum ( - mmhg) was built up. one mm and two mm trocars were used and positioned in the left mid axillary line. a optic was used. adhesions were removed and toldt fascia was opened in order to expose the hernia defect bounded by quadrates lumborum, erector spinae muscles, rib and serratus. hernia content was carefully extracted from the sac using a ligasure maryland (covidien medtronic-usa). hernia defect was measured and an intraperitoneal mesh (dinamesh-ipom feg textiltechnik mbh, aachen, germany) was positioned and sutured by tackers to the margins included the bone. patient was discharged in h with a low pain rate and without complications. there is not recurrence in months follow-up. conclusion: laparoscopy might be a safe and feasible approach for repairing lumbar hernias, either primary or adquired, with a low rate of pain and complications s surg endosc ( ) after pneumoperitoneum is done, three mm trocars are placed on the left flank. the defect is delimited by drawing it over the skin of the patient with aid of an intramuscular needle and intraabdominal vision. posterior fascia is opened longitudinally at its medial edge and the retromuscular space is dissected. the arcuate line of douglas and the epigastric vessels are identified. from this point, transversus abdominis fascia is sectioned cranially cm medial to the semilunar line, preserving the neuro-vascular pedicles that reach the rectus abdominis laterally. at supraumbilical level, transversus abdominis fibers advance behind rectus abdominis, so they need to be sectioned to access to the space below the ribs. lateral dissection of this space enables a tensionfree closure at midline. once the procedure is repeated on the contralateral side using two mm and one mm trocars on the right flank, a continuous suture of the posterior fascia is performed with a barbed suture. the anterior fascia is closed with a slowly-absorbable monofilament loop-type suture. finally, a double-layer polypropylene mesh is placed at retromuscular level without any suture and fibrin glue is applied. results: the patient was discharged hous after surgery. no recurrence has been presented to the moment. conclusions: the section of the aponeurotic plane from the arcuate line of douglas enables a more accurate dissection of the retrotransversus plane without sectioning its fibers except for its cranial end, preserving the innervation and vascularization of the abdominal wall. this technical modification aims to simplify a complex laparoscopic procedure allowing its estandarization. aims: the authors present a video with their standardized laparoscopic ventral hernia intraperitoneal mesh (ipom) hernioplasty procedure but introducing a novel laparoscopic technique for tension releasing while hernia gap closure and midline anatomical restoration. methods: a years old male patient with a bmi presents a symptomatic ventral hernia recurrence after a sigma colic cancer open surgery. a ct scan study showed a cm transverse diameter midline ventral hernia. a laparoscopic ipom hernia repair procedure is performed using mm instruments and a mm camera. when checking tension while midline restoration suturing, we decide to add a tension-releasing maneuver: a totally laparoscopic transverse abdomini muscle release (taltar). this maneuver allow right rectus posterior sheath to advance some distance to the midline, in order to provide a tension-free midline closure. a double-faced ready-to visceral contact mesh is now placed and fixed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, lateral asymmetry, umbilical or abdominal wall complications have been reported with this technique. conclusions: depending on the patient characteristics, anatomical hernia factors and surgeon mini invasive experience, a taltar maneuver could be a safe and feasible option for releasing tension when midline anatomical laparoscopic closure. more studies are needed in order to standardized this approach. aims: when primary ventral hernia and simultaneous diastasis recti are diagnosed, there is no consensus among the international surgical community on the surgical treatment regarding indications or surgical technique. however, if diastasis recti is symptomatic of or is associated with midline hernias, the corrective surgery of both pathologies at the same time could be the most recommended option. when we only correct the herniary defect, we risk performing a reparation on an anatomically weak tissue, so the rate of hernia recurrence may increase. we propose a minimally invasive access using totally endoscopic retromuscular hernioplasty. by developing this technique, several advantages are provided, such as no peritoneal opening without intraabdominal access, no mesh fixation needed and simultaneous solving of both pathologies. method: we present the case of a -year-old man, with bmi kg/m and no previous medical history complaining of ventral hernia with associated recti diastasis. a cm size umbilical hernia was diagnosed with a cm size supraumbilical diastasis recti associated. full endoscopy retromuscular hernioplasty was proposed. a cm size incision was made in left hypocondrium, openned the anterior rectus sheath and retracted the rectus muscle. we placed a balloon trocar and open the homolateral retromuscular space after placing two mm trocars in left lumbar space and epigastric position. we crossed-over the linea alba and achieve contralateral retromuscular space. after this step, the hernia sac was reduced and we extended the dissection cm caudal to the hernia ring. both medial posterior rectus sheaths were sutured with running barbed suture n° and a x cm size light-weight, big pore, polipropilene mesh was placed in retromuscular space and unrolled properly with enough overlap. a drain was placed and the anterior rectus sheath incision was closed. results: the patient was discharged h after surgery without remarkable events during his postoperative stay. he has been followed up for months remaining asymptomatic. conclusions: totally endoscopic retromuscular ventral hernia repair in men with umbilical hernia and diastasis recti associated, is feasible and reproducible procedure with several advantages compared to traditional laparoscopic ipom in terms of pain and mesh position. aims: parastomal hernia (ph) is one of the most frequent long-term complications of stoma formation, occurring in %- % of patients. surgical treatment for parastomal hernia is the only cure but a fairly difficult field with a recurrence rate ranging from % to % of cases. due to its advantages, the number of laparoscopic mesh repairs for parastomal hernia has gradually increased over the past decade. according to this common complication, we report a case of laparoscopic reparation of ph using the sugarbaker technique. method: we present the case of a -year-old patient with surgical antecedent of laparoscopic low anterior resection due to rectal cancer, presenting in postoperative period an anastomosis leakage with severe peritonitis was identified and a laparotomy with end colostomy was performed. the postoperative course was uneventful. during the follow-up the patient showed a centimetres size paraestomal hernia, being a m w incisional hernia confirmed with ct scan.the patient underwent full laparoscopic hernia repair, performing a sugarbaker technique, exposing parastomal hernia completely to measure the hernia ring size ( centimetres) and the midline associated defect ( centimetres). a x cm size ptfe-c was selected to allow a -cm overlap over two defects. results: using this approach, the bowel loop was pushed into the abdominal wall and appropriate place between the mesh edge and the abdominal wall is left to allow the bowel loop to pass through. postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. he has been followed up for months without realizing any clinical signs or alterations in ct scan. compared with traditional open surgical repairs, laparoscopic repair has certain advantages including its safe operation, postoperative rapid recovery, fewer complications, and lower recurrence rate. however, it still faces challenges regarding parastomal hernia treatment, and there is a need to improve existing surgical techniques. aims: nowadays, the principal disadvantages of laparoscopic approach in hernia repair are the use of intraabdominal meshes and traumatic fixation. first, intraabdominal meshes involve the contact of the prosthesis with the intestinal loops with the consequent risk of adhesion and fistula. also, using helicoidal sutures in prosthetic fixation produces adhesions to the tackers and a non-negligible incidence of chronic pain. when it comes to lead to better results, placing the mesh in retromuscular space avoids the drawback of contact with the loops, and using self-fixation meshes may decrease the rate of acute and chronic pain. accordind to this facts, we present a case of laparoscopic ventral hernia repair with transabdominal retromuscular mesh placement without traumatic fixation. methods: we present a -year-old patient with a cm diameter hernia showed in preoperative ct scan, m w , with diastasis recti associated. the patient underwent laparoscopic surgery using transabdominal retromuscular route. one mm and two mm trocar were placed in left flank. the posterior rectus sheath on the left side is opened starting cms far from the left egde of the defect. once the retromuscular space is dissected, the hernia ring is dissected and the hernia sac reduced, we continue with the dissection in retromuscular space on the side. craniocaudal dissection is achieved cm distal to the defect margins. the hernia defect with the anterior rectus sheath and the diastasis recti were closed using v-loc running suture. self-adhesive mesh was subsequently placed. the mesh should be overlap cm from the margins of the defect, covering the defect widely, with grips facing upwards. finally, we closed the posterior rectus sheath with peritoneum on the left side with v-loc running suture. results: the postoperative course was uneventful and the patient was discharged h after the surgery. after months of follow-up no clinical or radiological recurrence was showed. conclusions: the combination of laparoscopic approach, retromuscular mesh placement and the use of self-fixation meshes, seems to be an actual useful solution, combining the advantages of each item and avoiding the use of intraabdominal meshes and helicoidal sutures. aims: laparoscopic ventral hernia repair has clear advantages over open repair, including less post-operative pain and earlier return to normal activity. however, a prolonged surgeon learning curve is necessary to perform this technique effectively. robot assistance may improve outcomes of minimally invasive ventral hernia repair with improved three-dimensional visualization and enhanced dexterity with articulating instrumentation. we report a case of robotic rives-stoppa epigastric hernia repair in order to demonstrate the feasibility of the robotic approach. methods & results: a -year-old man came to our attention for the presence of a palpable mass in the epigastric region. the abdominal ct scan showed the presence of an epigastric hernia with herniation of omental content, and the presence of diastasis recti. the patient was then submitted to a rives-stoppa robotic hernia repair under general anesthesia. the da vinci-si surgical system (intuitive surgical inc., sunnyvale, ca, usa) was brought into position over the head of the patient and docked after placement of the ports. three trocars were placed in the hypogastric region along the transtubercular line. a fourth trocar was placed in the left iliac fossa and used by the assistant. the operation started with an extended adhesiolysis and hernia reduction. then, the retromuscolar dissection began by incising the posterior sheath starting from cm above the pubic symphysis. an extended dissection of the rives space was performed to create a correct housing for the mesh. the hernia defect and the diastasis recti were closed using a - absorbable barbed suture. a phasix st tm mesh (bard inc./davol inc., warwick, ri) was positioned in the retromuscular plane, and was anchored with absorbable sutures and glue. the midline incision was closed using a - absorbable barbed suture. the operative time was minute. the postoperative period was uneventful, and the patient was discharged home on the second post-operative day. conclusions: robotic rives-stoppa ventral hernia repair is feasible, safe, and effective when a standardized approach is performed. whether robotics may improve the outcomes of minimally invasive ventral hernia repairs, including lower recurrence rates, decreased post-operative pain, or shorter surgeons' learning curve, will require careful prospective investigation. aims: the authors present a video with a left chronic bochdaleck hernia classical hernioplasty repair but performing a mini invasive thoracoscopic approach and mm instruments. methods: a years old female patient come to hospital due to chronic left dorsolumbar pain. a ct scan study showed a chronic left diaphragmatic bochdaleck hernia. a lateral right decubitus thoracoscopic repair is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with no pain and a clean chest x-ray. in a year time follow-up, not an anatomical or clinical recurrence has been reported. neither chronic pain or respiratory complications happened, with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, left bochdaleck hernia mini invasive thoracoscopic hernioplasty repair using mm instruments could be a safe and feasible option. more studies are needed in order to standardized this approach. surg endosc ( ) abdominal wall surgery has expanded exponentially in the last decade. many techniques have been developed, mainly in minimally invasive surgery. laparoscopic ventral and incisional hernia repair (lvihr) has become a common procedure because of its feasibility and safety but unfortunately, it is not free of complications. chronic postoperative pain and bleeding are frequent complications, prolonging hospital stay and altering quality of life of the patients. absorbable or non-absorbable tacks are the usual method of mesh fixation and sometimes combined with transfascial sutures to secure the mesh. these mechanical fixations pierce the abdominal wall causing nerve or vessel injuries. some studies showed no differences between absorbable tacks, non-absorbable tacks or transfascial sutures concerning postoperative remarkably high pain. some authors consider that a non-penetrating fixation of the mesh getting an effective mesh-abdominal wall interface will reduce significantly the postoperative pain after a laparoscopic ventral hernia repair. tissue glues are used in different medical treatments and also have been used successfully for extra peritoneal mesh fixation in laparoscopic inguinal hernia repair, open ventral hernia repair but not so in laparoscopic ventral hernia repair in spite of good results published in the literature. cyanoacrylate and its derivatives are 'synthetic glues' and classified as medical devices with stronger adherent properties than fibrin glues. experimental studies have reported good results compared with suture fixationand also tissue toxicity doesn't lead to an increased foreign body reaction. some authors have studied the use of cyanoacrylate in laparoscopic inguinal hernia repair but unfortunately, clinical trial reports in ventral and incisional hernia repair were not found in the literature because the lacking of experimental studies that guarantee the safety of intra-abdominal mesh fixation and the interaction of the glue with the intra-abdominal tissue. our group developed an experimental study demonstrating the feasibility, safety and effectiveness of the cyanoacrylate using for intraperitoneal mesh fixation and after this conclusion, started a clinical study. this video shows the methodology for laparoscopic mesh fixation with only glue in our first cases. aims: small epigastric hernias, associated or not with the rectus abdominis diastasis, and small umbilical hernias are common in middle-aged women, particularly with past history of pregnancy. the aim of this video is to illustrate a new extraperitoneal approach to these clinical situations. methods: patients between the ages of and years old, with epigastric hernia orifice up to cm, with or without associated umbilical hernia (up to cm), were chosen for this procedure. the surgery begins with a vertical umbilical incision for the umbilical hernia's correction, and dissection of the pre-aponeurotic plane. two mm trocars (mini-laparoscopy instruments) are introduced at both flanks to enlarge the pre-aponeurotic plane towards the xiphoid appendix. in this way epigastric hernial defects are isolated. the surgery proceeds with defect suturing with braded suture, midline invagination and mesh placement if necessary. results: all patients had an eventful post-operative period and were discharged home at postoperative day . the aesthetic and functional results are optimal conclusion: for selected cases with high aesthetic motivation this technique seems to be feasible and with optimal cosmetic results. this technique allows the mesh placement both in-lay and onlay, protecting it from surgical site infections often present at the classical approac bochdalek hernia is a rare entity in adults. fewer than have been reported in medical literature, the majority of which were incidentally diagnosed. as such, the optimal repair of a symptomatic hernia is unknown. we present a case of adult bochdalek hernia repair. methods: a -year-old obese male patient with a years of chronic dry cough and left lung opacity in chest x-ray. a large posterior and lateral bochdalek hernia with herniation of intestinal loops and fat to the left hemithorax was seen in chest and upper abdominal ct scan. the hernia extended to mid-thorax, caused significant atelectasis of left lung. eighteen months later, due to appearance of chest and abdominal pain following a recent motor vehicle accident, a repeat chest ct was done and a slight enlargement of the hernia was shown. results: the patient was operated laparoscopically, positioned in a semi-right lateral decubitus with double lung intubation. a large left posterior and lateral diaphragmatic hernia which contained transverse and descending colon with omental fat was seen. they were pulled in to the intraperitoneal space carefully. the defect was measured to be * cm. it was reduced to * cm by suturing with a non-absorbable v-loc suture . advancing the camera to the thoracic cavity showed the left lung to be severely atelectatic. after selective recruitment lung was well expanded. a symbotex composite cm mesh was fixed to the defect area by suturs and laparoscopic tacker. the operation and post-operative course were uneventful. chest x-ray demonstrated the bowel below the diaphragm. the patient was discharged on pod . at -month follow-up, chest x-ray was normal. objective: to demonstrate the safety and efficacy of the standardized laparoscopic approach in the treatment of large parastomal hernia. currently, this approach is recognized as the one of choice in parastomal hernia pathology, being controversial which is the best technique of choice: keyhole vs sugarbaker. material and method: clinical case: a -year-old woman with a history of laparoscopic abdominoperineal amputation due to rectal neoplasia (pt n ), a year ago, with symptomatic parastomal hernia with incarceration episodes and inflamation changes in the stomal orifice.tac: large hernia parastomal with intestinal content inside. surgical treatment is decided. result intervention: complete laparoscopic approach, right lateral partial decubitus, trocars, dissection of the hernia defect and reduction of the content, partial mobilization of the pre-stomal colon, with bleeding at the level of the vascular origin, requiring careful hemostasis to avoid ischemia of the colostomy, herniorrhaphy with stitches with extracorporeal knotting, placement of polypropylene/pvdf mesh,fixed with irreabsorbable tackers with administration of biological glue at the edges of the mesh. correct postoperative, discharge at the rd day. asymptomatic and without hernia recurrence at one year of follow-up. conclusions: the technique of sugarbaker using a laparoscopic approach is a safe and effective alternative in the treatment of parstomal hernias. objetives: laparoscopic ventral hernia repair provides advantages in term of low infection rates and postoperatory stay when is compared with open repair. trends in laparoscopic abdominal wall surgery is to complete defect closure without tension in midline. closing the defect in ventral hernias wider than - cms creates high tension in midline and postoperatory pain. it's proposed different techniques to solve this drawback. laparoscopic posterior component separation makes the defects closure easier with no tension and placing the mesh extraperitoneally. methods: years old woman with previous total hysterectomy, a m m w midline incisional hernia was clinically diagnosed and confirmed with ct scan. full laparoscopic abdominal wall repair with defect closure was proposed. trocars in left side were placed and posterior rectus sheath right side in the defect margin is freed. once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. this allows access to the plane between the internal oblique and the transversus abdominis muscles. it's is made the same steps in the left side with trocar on the right flank. the posterior rectus sheath both side is reapproximated in the midline and cms polipropilene mesh is placed and unfolded properly. it's fixed using cyanocrilate glue. one drain is left in retromuscular position and mm trocar wounds are sutured. results: postoperatory course was uneventful. hospital stay h. the drain was removed in day after surgery. after months follow-up no complication or recurrence were identified. methods: this video will show the evidence of gangrenous jejunal segment due to superior mesenteric vein thrombosis in a patient with history of breast ca on hormonal treatment.in this video, the gangrenous segment was resected and primary anastomosis was done using endogia mm. results: a second look after h revealed to be negative for any further ischemic bowel. conclusion: therefore, laparoscopy in acute abdomen is diagnostic and for treatment. introduction: gastric pseudo-volvulation is a rare entity of paraesophageal hernia that is characterized by migration of the stomach into the posterior mediastinum. this clinical-radiological picture has severe complications so in certain cases should be operated urgently. another small group of patients are asymptomatic, although the current literature recommends their regulated surgical intervention. we present a gastric pseudo-volvulation in the mediastinum, with a laparoscopic approach, showing that by systematizing the surgery, it is possible to perform this type of intervention with relative ease and safety material and methods: we present a video of an urgent laparoscopic approach in a female patient of years with a personal history of hypertension, smoking and dyslipidemia. with a hiatus hernia diagnosed more than ten years ago. he went to the emergency department due to significant symptoms of heartburn and reflux, as well as incoerctable vomiting and difficulty feeding one week of evolution. a simple abdomen and postero-anterior chest radiograph was performed, showing a paraesophageal hiatus hernia with almost the entire stomach included in the mediastinum. a thoraco-abdominal axial tomography corroborated giant hiatus hernia with pseudovolvulation and incarceration data. urgent intervention was decided by laparoscopic approach in which hiatus hernia reduction and esophageal abdominalization were performed. closure of pillars and reinforcement with bioabsorbable mesh. gastric and gastropexy toupet of anterior face to anterior peritoneum of abdominal wall. results: the patient had a post-operative h without incident, discharged with a crushed diet. the follow-up and evolution has been acceptable without notable complications. conclusion: the laparoscopic approach, in extreme cases of paraesophageal hiatus hernia with incarceration of the stomach and pseudovolvulation of it, is a correct, safe and effective alternative in experienced groups. surg endosc ( ) case report of incarcerated hiatal hernia. years old female was admited to the hospital due to severe chest pain and vomiting for about six h. physical examination and lab test showed no abberations. chest xray revaled incarcerated stomach above the diaphragm. she was rushed to the or. laporoscopic approach was used, the stomach was removed from the chest and nissen fundoplication was performed. day after surgery patient was asymptomatic, got full oral diet. she was discharged on postoperative day two, without a need of any analgetics. gastroduodenoscopy was performed weeks after surgery and showed proper image of oesophagus, stomach and duodenum, neither signs of hiatal hernia nor inflamation were present. laparoscopic approach is good way to treat incarcerated hiatal hernias and is related with shorter lenght of stay, lesser postoperative pain and better patient comfort. and it should be procedure of choice in this kind of cases. she was operated open technique using a cm long incision in right iliac fossa and the appendix was phlegmonous. the patient began feeling bad from the second day postoperative having temperature over °c, pain and increasing crp. the general condition worsened the next day when the temperature went up till . °c, extreme generalized pain and crp: . the ct abdomen control indicates signs for generalized peritonitis and rises the suspicion for a forgotten large gauze. the patient is operated using laparoscopy technique: identifying and taking out the foreign body, doing adhesiolises, extensive lavage and in the end inserting one drain in douglas. the video is presenting what king of special graspers can be used but also tips and tricks when speaking about identifying the anatomy but also dissection in acute and inflamed environment. postoperatively the patient began to feel better and in the th day was released home. conclusion: this case illustrates that even after open surgery, laparoscopy is a viable solution with the condition that there is available experience in minimally invasive surgery. introduction: foreign bodies can enter inside the human body by different mechanisms such as ingestion, aspiration, trauma or in some cases due to medical procedures. they are potentially life-threatening events, the diagnosis could be challenging and its management depends on their location. case report: a -year-old male was referred to our hospital due to chronic abdominal pain. he had cholelithiasis, medical history of acute pericarditis and past surgical history of left adrenalectomy, left nephrectomy, distal pancreatectomy and colon resection due to an adrenal adenocarcinoma (stage t n m ).abdominal radiograph showed a foreign body in the left lower quadrant of the abdomen, as an incidental finding. this was not detected in ct scans during ten years of oncology follow-up. ct scan revealed an extraintestinal metallic curved object in the right lower quadrant. this finding was not related to any surgical intervention or trauma. diagnostic laparoscopy was performed: the foreign body seemed to be a guidewire, it was included into the omentum and almost stuck to the abdominal wall. the guidewire was reached and carefully extracted through a mm trocar without any evidence of intra-abdominal organ injury. then an elective cholecystectomy was also performed due to his medical history of symptomatic cholelithiasis.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: is extremely rare to discover a guidewire that had migrated into the peritoneal space without abdominal injuries.this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive laparoscopic removal. aims: the authors present a video with their standardized laparoscopic groin hernia transabdominal preperitoneal hernioplasty (tap) procedure but using mm instruments and mm camera approach. methods: a years old male patient with a bmi presents a symptomatic bilateral groin hernia for months. us study showed an indirect bilateral inguinal hernia. a laparoscopic tap hernia repair procedure is performed using mm instruments and a mm camera. a selfgripping mesh preperitoneal hernioplasty and peritoneal flap barbed-sutured hermetic closure was performed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, umbilical or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, a laparoscopic bilateral hernia repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. results: during tapp approach a direct hernia relapse was identified, the previous mesh was included on preperitoneal space and some non-absorbable sutures to inguinal ligament were identified. stitches and nearly total mesh removal (only the part surrounding cord elements was left in place) were performed. x heavyweight polypropylene mesh was employed fixed with gubran Ò and the flap was closed with running sutures. patient was discharged uneventfully the same day. seven months later he did not need analgesics and had no physical impairment. conclusions: post inguinal hernia repair chronic pain can be severe and disabling, and is becoming more prevalent. the origin is complex and meshes and sutures could play a role. the management is multimodal and demanding. for refractory patients, surgery may be an option. laparoscopic, open and mixed approaches have been employed. they usually combine mesh removal and substitution (often in different planes) and groin nerve therapies. nowadays, triple neurectomy seems to be the most effective treatment (more than % pain relief). generally, removal of mesh alone does not lead to lasting pain relief or has worse outcomes compared with associated neurectomy. introduction: mesh repair of inguinal hernia is sometimes followed by adverse effects such as mesh migration, chronic groin pain or recurrence. removal of the mesh is necessary in selected cases. we affront this cases by tapp intervention. methods: we present a video with two intreventions of inguinal recurrent hernia by laparoscopy (tapp). we remar the points to decide explant the mesh or not to explant. the conditions to decide the explant were the proximity to the main vessels in inguinal area (espigastric and femoral vessels) and the plication of the mesh. results: and conclusion as we show in the video, the explant of the mesh is only conditioned by the plicature of the mesh for its migration and recurrence, accompanied usually with pain. we don't remove any time the mesh or the plug if it is in the triangle of doom with firm adhesions to the main vessels. we cover the previous mesh with a new ligthweigth d mesh and closing at the end the preitoneum over the new reparation. introduction: tep technique isn't a controversial area in surgical practice for inguinal hernias anymore, but a fully accepted method. the use of general anesthesia has been the mainstay of laparoscopic hernia repair, but epidural anesthesia is not a contradiction to properly selected patients. material-method: the approach of the extraperitoneal area achieved without use of a dilation balloon, but via the indroduction of the camera and the dissection of the regional structures. trocars ports were used: a mm trocar through the umbilicus for the camera, exactly as in sils (single incision laparoscopic surgery), another one mm is placed in the midline between the umbilicus and pubis, the last mm trocar is placed in the midclavicular line ipsilateral with the hernia. the key for every operation was the tension free technique with placement and fixation of a mesh x cm. in / cases the mesh was placed with tacks on the inside of the inferior epigastric artery-vein complex. all patients were dismissed from the hospital in h, no drain was placed and no major postoperative complications took place. conclusion: tep is a demanding technique with serious learning curve. the use of a dilation balloon for insertion in the extraperitoneal area is not prerequisite. tep is an appropriate method both for first appearing and recurrent inguinal hernias. epiduralanesthesia instead of general anesthesia is no a contradiction for properly selected patients. aims: the aim of this study was to investigate the effects of preperitoneal carbon-dioxide (co ) insufflation during tapp (transabdominal preperitoneal) repair. materials and methods: male patients with inguinal hernia were include in our study. we obtain laparoscopic access at the umbilicus and introduce mm port. two mm working ports are placed lateral. diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. using aspiration needle we insuflate carbon-dioxide ( mmhg) preperitoneal at the level of anterior superior iliac spine while decrease abdominal gas pressure to mmhg. same procedure is made lateral to the umbilical artery. results: we found that preperitoneal carbon-dioxide (co ) insufflation during tapp facilitate the future parietalisation and even can reduce operating time in future improvements of the technique. there were no intraoperative complications related to this procedure. we did not found any potential risk of the technique when is use by trained surgeons. aims: laparoscopic inguinal hernia repairs (lihr) are performed more and more frequently because they offer some advantages; however, we cannot forget their specific complications. lihr are associated sometimes with peritoneal tears that can lead to bowel obstruction. we present two cases of bowel obstruction related to peritoneal defects post tapp procedure and review peritoneal closure, bowel obstruction and options to repair defects. a year-old male was scheduled for tapp due to bilateral relapse. two x tio mesh tm fixed with securestrapÒ, employed also for peritoneal flap closure, were employed. three days later he was readmitted with bowel obstruction with ct suggesting 'adhesions'. a year-old male had bilateral tapp in another centre. seven days later he presented with bowel obstruction. ct showed metallic tackers and suggested 'adhesions' results: first case: after four days of conservative treatment failure, a revisional laparoscopy showed ileum herniation through a peritoneal defect and firm adhesions to the mesh. bowel was labouriously separated and the peritoneal defect closed with two running sutures. he was discharged on the \ sup [ th \/sup [ postoperative day and three years later he is asymptomatic. second: after two days of conservative treatment failure, on laparoscopy, ileum was filmy adhered to polipropilene mesh through a big defect on flap closure. defect was closed with interrupted sutures. as tears persisted, an omental flap was created to cover the area. patient was discharged on the th day and continues asymptomatic three years later. conclusions: lihr bowel obstructions can be divided in adhesive disease and herniation. herniation can be early (through peritoneal defects) or late (trocar site). international guidelines recommends a thorough closure of peritoneal incision or bigger tears (grade b). the closure can be achieved with staples, tacks, running suture, or glue. these last two methods are more time-consuming but less painful. running suture seems to be the best, due to its low costs, tightness and low pain but sometimes can be technically difficult. low intra-abdominal pressures (= mmhg) facilitate suturing. when a herniation appears, careful bowel management is needed and running sutures are recommended. if tears persist, an omental flap can be useful. aims: application of a single port robotic platform to perform an entirely transanal tatme/ tata. methods: the following video demonstrates how a totally transanal proctosigmoidectomy is performed using a novel, single port (sp) robotic platform was used to carry out a totally transanal proctosigmoidectomy, single port robotic tatme/tata. a -year-old female patient with a clinical t n b rectal cancer at the cm level, status post neoadjuvant chemoradiotherapy ( cgy, xeloda) is presented. shown here is the open transanal dissection followed by docking of the sp robot, implementation of the single port instruments (fenestrated bipolar forceps, cadier, scissors, camera, clip applier) through a gelpoint path to complete a totally transanal proctosigmoidectomy including transanal tatme, ima/imv transection, splenic flexure release, and left colonic mobilization, loop ileostomy, and handsewn coloanal anastomosis. results: blood loss was cc. pathology demonstrated a moderately differentiated, rectal adenocarcinoma. the total mesorectal excision was complete (grade ), margins were negative, and all lymph nodes were negative for metastatic carcinoma. the patient was discharged on postoperative day after an uncomplicated hospital course. there was no postoperative morbidity or mortality. conclusions: application of the single port robot to transanal tatme/tata (sprtatme) is presented here. while much work remains to be done to validate the sp robot's safety, this first demonstration of a totally transanal tatme/tata establishes its feasibility and utility. this single port platform stands to greatly expand the application of natural orifice transluminal endoscopic surgery (notes). as shown, the sp robot offers more than sufficient visualization, technical control, and adequate reach to perform such an operation. we present an exciting new avenue by which to complete operations in an entirely transanal fashion, which are classically performed via a combined transanal and transabdominal approach. methods: this video shows the utilization of a new robotic platform to perform transanal endoluminal microsurgery, rtem. presented here is a year old woman with a recurrent rectal adenoma at the cm level, status post a previous tem resection in october . demonstrated is the utilization of the sp robot through a gelpoint path in order to perform a partial fullthickness and full-thickness resection. the robot is introduced through a mm in diameter cannula via a four-channel face-plate. the instruments' two-jointed mobility at the elbows and wrists as well as the novel navigation system are well demonstrated. the docking of the sp robot, utilization of the dissecting devices, and closure of the defect is shown. results: sprtem was performed with a blood loss of cc, and the patient was discharged on postoperative day . there was no postoperative morbidity, mortality, or moderate/severe pain. pathology showed tubular adenoma with low-grade dysplasia in a non-fragmented specimen with negative margins circumferentially. conclusion: initial experience using the sp robot for rtem is demonstrated here. the robot provides wonderful visualization and operative control to the surgeon. articulation of the robot's wrists and arms have the potential to facilitate technical aspects of the procedure. rtem stands as an exciting development in the field of transanal endoluminal surgery. introduction: the application of robotic approach in the esophageal surgical field is in its first phase. the microsuturing and microdissection capabilites of the robotic system can potentially overcome the traditional limitation of the laparoscopic surgery thus enhancing the indications of minimally invasive surgery. methods: we have performed a retrospective analysis of our prospectively maintained database that included patients who underwent robotic-assisted esophagectomy for malignant disease between and . results: ten out of sixteen patients had squamous cell carcinoma meanwhile six had adenocarcinoma. ten mckeown's and six ivor lewis were performed. the mean operative time was min ( - ) and the median blood loss was ml ( - ). no patients required conversion nor intraoperative transfusion. the morbidity rate was / ( . %) : a transitory laryngeal nerve paresis, a pneumotorax and pneumonia. the mean hospital stay was (range - ) days. an r resection rate of . % was achieved with a mean lymph node yield of ( - ). the -year disease free survival was . %, wheres the the -year overall survival was . %. conclusions: robotic assisted minimally invasive esophagectomy (ramie) is safe and feasible, it offers promising results while preserving a good oncology adequacy. this video shows our technique for the treatment of an esophageal diverticolum using a robotic left sided transthoracic approach, followed by a heller myotomy and dor fundoplication using a transabdominal approach. our case is a year old male, who suffered from severe dysphagia, halitosis and gastric reflux who on endoscopic and radiological investigations was found to have low grade and a cm wide esophageal diverticulum, cm from the lower esophageal sphincter. initially conservative management was attempted, however following poor compliance and the persistance of symptoms after year of therapy, surgical intervention was indicated. the operation was performed using the minimally invasive robotic system of the davinci siÒ, starting with the thorax time. the patient is positioned in left side decubitus. the camera-trocar is insert in the thorax via the fifth intercostal space the, two mm and one mm robotic trocars are added. the lung is liberated from pleural adhesions and the esophagus is then prepared exposing the diverticulum which is successfully removed with an endo-giaÒ. the esophageal muscle fibers, near the suture line is reinforced with separated vicryl stitches and the resected piece is extracted via endo-bag. a fr thoracic drainage tube is then placed and the trocar accesses repaired. the patient is the put in supine position with a °anti-trendelemburg angle. three robotic trocars (two mm and one mm) are placed and the robot docking is made from the patient left shoulder. the lesser omentum is divided to visualize and prepare the gastric-esophageal junction (gej) sparing the vagus nerve. the heller myotomy is then performed for cm over the gej and cm under it. the mucosal integrity is assured via laparoscopic and contemporary gastroscopic view. the gastric fundus is attached to the distal esophagus completing the dor fundoplication. post-operative care comprehends the removal of the thoracic drainage during the first post-operative day, the pain management and the progressive realimentation. the hospitalized period lasts day and the patient was dismissed without complications occurred. the uniportal video assisted lung lobectomies gained popularity all over the world during the last years. the technique is safely applied for peripheral pulmonary lesions, under cm, but more and more complex cases are being approached while the indications continue to evolve. our aim is to present the particular aspects of this technique in an -year-old female patient with a giant bullous lesion located in the lower lobe of the right lung. the preoperative work-up for this case is presented and commented. a multidisciplinary surgical team consisting of thoracic and pediatric surgeons was involved. a single . cm length incision in the fourth intercostal space was used for the access. due to the fact that the lesion involved almost the entire lobe and the margins were very close to the hilum, we have decided and performed a right lower lobectomy. dissection and stapling were quite difficult. all the anatomical structures had small dimensions, forcing us to perform an 'artery first approach' in a very narrow space. no complications during or after surgery were encountered. the patient was discharged after four days and she went to school on the sixth day. histopathological examination showed that the lesion was a type ccam (congenital cystic adenomatoid malformation). conclussion: the uniportal video assisted lung lobectomy was safety applied for a giant bullous lesion of the right lung. aim: dunbar syndrome, celiac trunk (ct) compression syndrome, caused by median arcuateligament is a rarely diagnosed disease because of its nonspecific symptoms, which cause adelay in the correct diagnosis. the aim of the study was to demonstrate the usefulness andadvantages of laparoscopic approach in the treatment of dunbar syndrome. methods: we performed laparoscopic release of ct in the department of general, minimallyinvasive and elderly surgery in olsztyn in . all of three patients suffered from severepain of abdominal cavity before the surgery. results: in two cases, there were a complete remission of the symptoms. in one case, there was animprovement. all patients reported relief of symptoms in the first days after the operation.there were no postoperative complications. conclusions: the laparoscopic treatment of dunbar seems to be safe and feasible procedure. thelaparoscopic surgery alone can often eliminate discomfort, while angioplasty and stentimplantation are no longer necessary. introduction: the advances in robotic surgery have permitted the application of such technology to various surgical fields, one of the last of these being hernia surgery. we present a case video of the treatment of a dual-hernia using a robotic retromuscular ventral hernia repair(rrvhr) using the davinci siÒ robotic system. the case report demonstrates the evolution of the trans-abdominal robotic umbilical prosthetic (tarup) in that it utilises a 'double docking' technique to allow the positioning of a large retromuscular mesh. methodology: our patient is a -year-old male who presented with chronic epigastric pain. the abdominal ct confirmed two abdominal wall hernias; an epigastric and supra-umbilical hernia with visceral contents and wall defect diameter of cm and . cm, respectively. using the minimally invasive robotic system of the davinci siÒ we adapted the well known retromuscular mesh technique. the operation was initially intraperitoneal with access to the retromuscular preperitoneale space using a right sided longitudinal incision.(as per standard tarup technique). we proceed with the dissection of the retro-muscular space until the left lateral edges of the rectus sheath, creating a preperitoneal space for the placement of a specifically modified ultrapro polypro-leneÒ x cm mesh. following this we repositioned the davinci siÒ in a symmetrical manner, with ports placed in the retromuscular space. the mesh is positioned and the peritneum subsequently closed with a v-lock sutureÒ. finally we opted for a negative pressure jackson-pratt drain, inserted preperitoneally. results: the patient was discharged on the nd post-operative day without complication follow up continued until months post operatively during which the patient remained asymptomatic, without signs for hernia recurrance . conclusion: the technique highlighted in our video demonstrates the utility of the robotic system in hernia repair. specifically the approach proved a success as it facilites the placement of the mesh totally extra-peritoneally with closure of the posteriore sheath without tension. the added advantages are that the port-sites are distant from the mesh thus reducing infective risk. additionally this technique allows the treatment of large peritoneal defects. surg endosc ( ) aim: to analyse the performance of a robotic fellow during a robotic total mesorectal excision (tme) at the end of the fellowship, and subsequently compare it with their mentor. methods: the fellow is exposed to robotic colorectal lists per week. during the fellowship, assessment of performance is recorded in a structured proforma covering aspects of autonomy, tissue handling and dissection. at the end of the fellowship, areview of cases performed by the fellow and the mentor was carried out in a blindly manner (video footage). results: robotic tme training was divided into modules in order of complexity and the trainee had to achieve sequential proficiency in each module, before progression. docking of davinci robotic system. inferior mesenteric artery exposure and ligation, development of medial to lateral plane and inferior mesenteric vein division. left colonic and splenic flexure mobilization. pancreas identification. rectal dissection (tme). qualitative assessments were recorded by the mentor; the fellow was 'able to perform with verbal help' most of the steps from early on. by the end of the fellowship, all steps were performed in a similar manner in terms of quality and oncological integrity when compared with the mentor. conclusions: at completion ofan advanced robotic colorectal fellowship, high quality trainees can perform every step of the tme dissection in a similar manner with the trainer, when assessed blindly, without compromising oncological integrity. aims: to find safe and simple method in robotic rectal low anterior resection with low tie arterial ligation and lymph node dissection around the root of inferior mesenteric artery. methods: we performed robotic rectal low anterior resection (rlar) by davinci si system in eight patients with rectal cancer. we applied low tie arterial ligation, just caudally to the origin of the left colic artery in all cases. during the procedure, we used tilepro function of davinci si system which enabled to display two other visual informations through external inputs under the normal -dimensional surgeon console view. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were displayed simultaneously under normal operative camera view in the surgeon console. results: left colic artery preservation was completely done in all cases. the mean time to find and expose the left colic artery from the first incision in sigmoid mesentery was min, which was drastically shorter than conventional method. this method needed lesser mobilization of inferior mesenteric artery (ima), and may be less invasive to autonomic nerve around the root of ima which is very important for ejaculation function. conclusion: robotic rectal low anterior resection with low tie arterial ligation was performed safely and in short time, using tilepro intra-operative navigation method. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were very useful in the procedure. we present the method in video. nerve sparing tme and pelvic neuroanatomy for colorectal surgeons p. tejedor, f. sagias, j.s. khan aim: to describe the critical points in which the pelvic nerves can be damaged during a total mesorectal excision (tme) for rectal cancer and the benefits of robotic surgery for identifying these points. methods: there are critical points regarding pelvic neuroanatomy: superior hypogastric plexus (shp): located in front of l -s . the ganglionic sympathetic fibres form the right and left sympathetic trunk, travel along the anterior surface of the aorta and coalesce in the shp at the level of the inferior mesenteric artery (ima). superior hypogastric nerves: they take an anterolateral course into the pelvis. there is an avascular 'holy plane' around the rectum between these two nerves. inferior hypogastric plexus (ihp): lies over the posterolateral pelvis, almost parallel to the internal iliac arteries. this can be identified at the lower end of the rectum. neurovascular bundles(of walsh): in front of the denonvillier's fascia, at and o'clock position. they are responsible for erectile function. results: lack of knowledge or identification of key structures at these points can lead to increased risk of nerve damage and translate into poor functional outcomes. the ima is dissected up to the origin from aorta and here the shp can be seen. care is taken to avoid any damage to these structures. the tme plane is found at the back of ima as the inner most dissectible layer between mesorectum pelvic fascia. right and left superior hypogastric nerves are identified. dissection is carried out posteriorly, laterally and anteriorly. ihp is identified at the lower third of the rectum, when the dissection is about to reach the pelvic floor. care should be taken in not to go too far lateral and damage this plexus. in the anterior dissection, plane is carried in front of the denonvilliers' fascia. the neurovascular bundles can be seen at and o'clock position and the surgeon has to be careful to stay inside that plane in order to avoid damage. conclusions: the precise dissection in robotic surgery results in minimal tissue damage and better visualization and preservation of the pelvic nerves. aims: to describe and evaluate new contributions and eventual advantages of icg fluorescence to perform an icg guided bilateral pelvic lymph node dissection in a patient who underwent low-anterior-resection for rectal carcinoma. we also present the basic steps to avoid ileostomy during rectal surgery in which icg and ghost ileostomy play an important role. methods: a -year-old male patient was referred to our hospital due to abdominal pain and significant changes in usual bowel habits.colonoscopy showed a no obstructing cm middle rectal mass, which was reported as an adenocarcinoma.ct scan and mri revealed a mm polyp in the anterior rectal wall which was located cm from the anal verge. it was involving mucosa and sub-mucosa with muscularis propia invasion. no pathological lymphadenopathies or hepatic metastatic disease were found (stage t n ).a laparoscopic ultra-low-anterior resection plus icg lateral lymphadenectomy with total mesorectal excision was performed. a complete splenic flexure mobilization was performed to achieve a safe tension-free anastomosis. transection line of the proximal rectum was checked after icg intravenous injection. icg was injected around the tumor by inserting an anoscope, just before the surgery. after the dissection of the rectum, lateral lymphadenectomy was performed assisted by icg. an end-to-side anastomosis was made. and a vascular loop was passed around the terminal ileum to create a ghost ileostomy.the procedure lasted min. reactive protein c was monitored to identify an initial leak. the patient was discharge in postoperative day and no complication was detected. results: pathological exam reported a rectal adenocarcinoma. pelvic lymphadenectomy results were: negative nodes, negative nodes and negative nodes from right lymph node dissection, left lymph node dissection and rectosigmoid resection specimen respectively. no metastatic disease was found (stage t n m ). conclusions: in our experience, icg fluorescence imaging system offers important contributions to rectal surgery furthermore than evaluating vascular supply to the anastomosis. lymphatic mapping of the lateral lymph nodes and avoiding ileostomy could be a potential important use in the future. larger studies and more specific evaluations are needed to confirm its role in colorectal surgery and to find its limitations. background: robotic surgery for colorectal cancer is an emerging technique. potential benefits as compared to conventional laparoscopic surgery have been demonstrated. innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery such as hand-eye coordination, a two-dimensional view, and a restricted range of motion. robotic-assisted surgery was established as a new approach to minimally invasive surgery, overcoming these limitations. the following video shows a total robotic sigmoidectomy step by step on the basis of ourexperience. intervention: a -year-old male patient with no previous medical historyand a colon adenocarcinoma, cm from the anal verge, no distant metastases. it was decided to perform a robotic sigmoidectomy. target anatomywas located andwe proceededto the exposure of the mesenteric vessels from medial to lateral. a cautery wasused to open the peritoneum,up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.the vessels weretransected by ligasuretm. we performedthe complete release of the colon taking care to avoid injury to retroperitoneal structures. we usedligasuretm to section the mesocolon in order to prepare the transection of the proximal colon. indocyanine green was used to check the correct vascularization. an endogia tristapletm was used to divide the colon. subsequently, we sectioned the rectumand extracted the specimen through itwith no need to make any auxiliary incisions. we introduced the anvil of the suture device to perform the anastomosis. we sectionedand close the rectum with an endogia tristapletm. finally we opened the proximal colon to introduce the anvil,making a pursestring to fix it and create a side to end anastomosis. outcome: the surgery took min. the patient started oral intake h after surgery and left the hospital on the rd postoperative day. pathological examination ruled out a colon adenocarcinoma pt n . conclusion: total robotic sigmoidectomy is safe and feasible and can be a procedure of choice to achieve a good surgical qualityand avoid assistance incisions in patients with colon cancer. surg endosc ( ) with more and more data now advocating wait and watch policy for these patients which require close radiological and endoscopic follow-up but unfortunately around % of them have regrowth of tumour which will require surgical intervention. the use of robot for cancer resections is becoming more frequent especially in narrow spaces like in an obese male pelvis. the reason being better -dimensional views, more angulation of the instruments and exclusion of tremors, which in turn leads to better dissection and preservation of hypogastric nerves. in this video, we present a robotic low anterior resection for rectal re-growth in an obese -years old male patient. he was offered neoadjuvant chemoradiotherapy after discussion in mdt. he had an complete response with chemoradiotherapy and was decided to offer him watch and wait regime. unfortunately, he developed rectal re-growth in the first year of his follow up. imaging showed t lesion with no distant metastasis and was later confirmed on histology as well. after mdt discussion he was offered robotic low anterior resection. the video starts by showing the clinicopathological features of patient including his radiological and endoscopic images. robotic port sites are shown. the edited video starts with rectal dissection after ligation of inferior mesenteric artery and vein with emphasis on narrow pelvis and preservation of hypogastric nerves, seminal vesicles and intact presacral fascia. postoperative histology was ypt no and patient was discharged home after days with no postoperative complications. background: minimally invasive surgery for colon resection has improved patient outcome, however a minilaparotomy still is necessary to extract the specimen. this report describes a new approach that combine laparoscopic parellel overlap stapling left colectomy with natural orifice specimen extraction surgery, with the aim to minimize abdominal wall trauma. method: laparoscopic left colectomy for malignant diesease was performed using a standard five-port technique. after releasing the left colon via laparoscopy, divide the proximal and distal of specimen with -echelon, and put distal sigmoid colon and proximal transverse colon together. open sigmoid colon cm apart from distal margin, and incise transverse colon at proximal margin. take transverse colon and sigmoid colon side-to-side anastomosis via -echelon. incise posterior vaginal fornix to get into the abdominal cavity and extract specimen through vaginal. outcome parameters such as complications, conversions, operative time, postoperative recovery, and postoperative pain were prospectively recorded in a database. results: surgery was performed for patients with left-colonic carcinoma. no perioperative complications or conversions occurred. the median operating time was min. the median visual analogue scale score of postoperative pain was , and of patients needed analgesia on postoperative day . the median postoperative hospital stay was days. for malignancies, tissue margins were oncologically adequate, the averge number of harvested lymph nodes were . . the -week follow-up period was uneventful. conclusion: the described technique, a combination of laparoscopic parellel overlap stapling and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections. background: open surgical skills training has been well established over centuries, however, there are some significant differences in laparoscopic surgical skills training. it is an obvious advantage that the trainee and the trainer have the same view; however, some of the hurdles include the differences in tactile feedback, hand eye co-ordination, spatial awareness, depth perception and maximizing assistance. aim: we present a video highlighting some of the key challenges faced in laparoscopic colorectal surgical training, show-casing our systematic, structured approach. our approach: we have developed a structured approach starting with junior surgical trainees and progressing through to consultant level as per the levels below: level : attend courses/ workshops level : master camera work level : contra-lateral assisting level : intermediate level trainee-start operating with trainer scrubbed. the trainer is an additional member of the scrub team and stands on the same side as the trainee (does not replace any assistant) level : advanced level trainee-gradual progression from level . trainer un-scrubbed but standing next to the monitor throughout the procedure. level : trainer in theatre but out of sight of the trainee, with little interference level : progression to trainer-once proficiency is achieved at level / , the trainee is trained to become a trainer, for the junior and intermediate level trainees. within each level the complexity of the procedure increases as the trainee progresses through the level. junior trainees (years - of surgical training) are taken through levels - , intermediate (middle years of training) level or and advanced (last - years) up to levels . this way of training allows multiple members of the team to be trained simultaneously in every case. each operating list is preceded by team briefings where the role of every member of the team is clearly identified and followed by individual and collective feedback. conclusion: this training ladder proved very successful through the years. the feedback from trainees at all stages has been consistently positive. several trainees who have progressed to independent consultant practice, in the uk and abroad, are adopting this approach in their practice. introduction: despite the potential microsuturing capabilities of the robotic surgery, most of the esofago-jejunostomy after robotic total gastrectomy are still performed extracorporeal or through mechanical staplers. this can increase the cost of the procedure, the risk related to a improper functioning of the stapler. methods: we reviewed our prospectively maintained database analyzing patients from april to september , who underwent robotic total gastrectomy with hand-sewn esophagojejunostomy for gastric cancer. results: a total of patients were included in the study. the mean estimated blood loss was ml ( - ). the overall operative time was min ( - ). length of hospital stay was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . no conversion was necessary nor anastomotic leakage occurred. the morbidity rate was / ( . %) and included a subhepatic abscess and wound infection trough pfannenstiel incision. a r resection rate was achieved in all cases. the mean of lymph node yield was ( - ). the -year disease free survival was %, the -year overall survival . %. the robotic-assisted hand-sewn esophago-jejunostomy is a safe and no time-consuming technique. it avoids the complication related to the stapler firing and it offers cosmetic benefit to the patient in terms of extraction site. introduction: colorectal endoscopic submucosal dissection (esd) is increasingly practiced for treatment of early colorectal neoplasia. however, colorectal esd is difficult to perform due to lack of retraction as well as instability especially over hepatic flexure. dilumen eip is an external flexible sheath introduced during colonoscopy to stabilize environment for esd. this video demonstrated the use of dilumen eip for performance of colonic esd at the ascending colon method and results: this is a years old lady who received screening colonoscopy and found a mm lateral spreading tumor (lst) type iia lesion at ascending colon distal to ileocecal valve. under general anesthesia, patient received colonic esd using dilumen eip. due to significant looping, the dilumen device was introduced with the techniques of double balloon enteroscopy. after identification of the lst, the balloon in the front would be deployed to the proximal to the lesion while both balloons would be insufflated and created a stable environment. the esd procedure started after submucosal injection with normal saline in mix with indigocarmine, epinephrine and hyaluronate. mucosal incision was performed over the anal side of the lesion, and after adequate submucosal dissection, clips were applied to attach the mucosal flap to the sleeve of proximal balloon and achieved retraction. the submucosa was adequately exposed for dissection using dual knife jet. this enhanced submucosal dissection especially at one area with significant fibrosis. after the procedure, complete closure of the mucosal defect was performed by clips and assisted by the front balloon. the pathology confirmed intramucosal adenocarcinoma with clear resection margins. discussion: the dilumen eip device stabilized the environment within the colon with the double balloon and provide adequate retraction for performance of colorectal esd. surgery, kobe city medical center general hospital, kobe, japan background: robotic surgery has been widely spread all over the world, but robotic gastrectomy is not common and difficult because of complex anatomy and wide-ranging operation fields. in addition, it had been performed only under a few high-volume centers for reasons of the limitation of national health insurance in japan, which means medical expenses not covered by insurance. the situation was changed from this april, so we started robotic gastrectomy to reduce complications more rather than laparoscopic gastrectomy. we report results and aim to present the methods in detail using da vinci si surgical system. methods: we place five trocars, one is umbilical endoscopy port, and other four ports are placed at the reverse trapezoid, almost fan-shaped. using the arm number , the organ can be lifted up so that sharp lymphadenectomy is able to be done by almost a scissor as the arm number while applying the countertraction by the arm number . in order to achieve a clear and bloodless lymphnode dissection while maintaining the oncological safety, we think not only the ultrasonic coagulating scissor but also the electrocautery of the scissor is very essential in robotic surgery. less postoperative complication such as pancreatic fistula or pancreatitis might be derived from robotic surgery because we can avoid pressing the pancreas during the suprapancreatic dissection of lymph nodes. the billroth i reconstruction can be performed using da vinci endowrist stapler under stable and inflexible surgical fields without needing help of surgical assistant. results: from october to december , patients with gastric cancer were operated robotic gastrectomy, included total gastrectomy. there was no conversion to open surgery and no conversion to other procedures derived from intraoperative complications, and the overall operation time is gradually decreasing from the th case. we are now on the way of learning curve shortening operation time, but robotic gastrectomy is no less safer and adequate than laparoscopic surgery. we will show our robotic procedures including lymphadenectomy around subpyloric and suprapancreatic area, and reconstruction with several important points in our video purpose: this report describes the benefits and drawbacks in the use of a novel articulating device (artisential), which has a multi-degree wrist freedom like the davinci endowrist, in performing complete single-port d lymph node dissection (lnd) in single-incision distal gastrectomy (sidg). methods: the artisential was used in performing sidg with d lnd for patients with advanced gastric cancer. all operations were performed by a single surgeon using a threedimensional camera and a passive scope holder in place of a scopist. the artisential was used mainly in the sb and suprapancreatic lnd, an area that is relatively far from the single port. in certain cases when the pancreas needed to be pushed down, such as obese male patients, the intraabdominal organ retractor was used to lift the tissue and the artisential to push the pancreas. operative results and short-term outcome were analyzed. results: twelve patients underwent the procedure without any intraoperative events, conversion to conventional laparoscopy, or surgery-related complications including postoperative pancreatic fistula. all patients underwent single port d lnd by complete exposure of the portal and splenic vein. mean operation time was . ± . mins. and mean number of retrieved lymph nodes was . ± . . the artisential was found to be useful in grasping the tissues behind the pancreas and the major arteries throughout most of the lnd. the articulating motion also allowed the narrow single-port field of view to be clearly seen without the instrument body obstructing the camera. conclusion: the use of artisential in sidg appears feasible and reproducible, and is mandatory in performing a complete d lnd in sidg. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states.the system technology utilizes an articulated multi-linked scope that can be steered along non-linear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation.the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. background: hepatobiliary procedures using a minimally invasive approachare demanding, especially in major hepatectomies. the use of da vinci surgical system allows to overcome some of the kinematics limitations of the direct manual laparoscopy maintaining the potential advantages of a minimally invasive approach . we herein present a case of left hepatectomy and local lymphadenectomy for hepatocellular carcinoma, carried out with the use of the da vinci xi. methodology: a -years old man with a long-lasting hbv chronic infection and ct scan and mri finding of a -cm solid neoplasia of the left hepatic lobe and gallbladder stones, was operated with the da vinci xi platform. the patient was placed in a supine position, with °anti-trendelenburg inclination. the trocars were positioned according with the intuitive indication for the upper quadrants surgery. results: the procedure was successfully completed in min.at first, an intraoperative us scan with the use of tile-pro technology was done to determinate the tumor extension. the hepatic parenchyma transaction and the local lymphadenectomy were performed with monopolar scissors and bipolar grasps. the left hepatic vein section was performed with an endoscopic vascular stapler. there were no surgical complications or need for conversion to laparoscopy or laparotomy. the post-operative course was uneventful and the patient was discharged days after surgery. conclusion: the da vinci xi can facilitate some technically demanding procedures and ultimately widen the range of application of minimally invasive surgery such as hepatic surgery. besides the well-known advantages provided by robotic surgery on d imaging, increased range of motion and augmented surgical dexterity, one of the most interesting and innovative features of robotic technology is the digitalization of the operative view; furthermore the tile-pro multiinput display allows the surgeon a d view of the operative field along with the ultrasound exam for a precise understanding of anatomy and vascularity and of tumor location. during the last few years, robotic surgery as well, as the latest innovation of minimally invasive procedures, takes its position in this particular field with the benefits of overcoming the limitations of conventional laparoscopy. our aim is to demonstrate the advantages of robotic surgery in procedures of hepatectomies, on occasion of a robotic hepatectomy performed by our team. methods: we present video fragments of a robotic left lateral hepatectomy procedure in an elderly female patient with a symptomatic gigantic haemangioma of the left hepatic lobe. we emphasize on the technical aspects and the advantages that the surgeon gains applying the robotic techniques in such procedures. results: the procedure was completed with minimal blood loss and the patient presented an uncomplicated post-operative course, with discharge on the third postoperative day, minimal need of analgesics and full recovery. conclusions: the excellent three-dimensional and high quality visualization that the robotic system offers, combined with the flexibility and the accuracy of the robotic instruments (especially on suturing), provide to the surgeon an important aid, in order to avoid serious complications, such as intraoperative bleeding and post-operative bile leaks. the restriction of the limitations of conventional laparoscopy is far more beneficial and promising for the evolution and the future of minimal invasive liver surgery. aims: the new da vinci xi surgical cart allows multi-quadrant and complex surgical interventions in a minimally invasive fashion. we present a case of robotic appleby left pancreatectomy using this platform and its specific operating bed. methods: a -years old woman with ct scan finding of a -mm hypo-vascular neoplasm of the pancreas body underwent surgery with the use of the new da vinci xi with four arms upper quadrants trocar' disposition. results: the procedure was successfully completed in min. the pancreatic body was mobilized in order to expose the portal-mesenteric axis. the gland was transected using a robotic endo-stapler as well as the splenic vein. after evaluating the patency of collateral circles with intra-operative ultrasound, the common hepatic artery and the celiac artery were transected. then we increased the right tilted position and the neoplasia was detached from the gastric body by a tangential gastric resection using the robotic endo-stapler. finally, the operation was accomplished with the transection of the posterior attachment of the spleen and the pancreatic tail. no conversion or intra-operative complications were recorded. the post-operative course was uneventful and the patient was discharged days after surgery. the da vinci xi with its specific tools helps in performing challenging procedures such as appleby operation for locally advanced pancreatic cancer. in our experience, the robotic endo-stapler permits the operating surgeon to directly control the transaction phase whereas the specific operating bed allows to perform minimally invasive multi-quadrant surgery and to obtain a better exposition of the operating field. results: the whipple procedure was successfully completed in min. thanks to the dvtm the patient's position changed during the intervention to improve the exposure, with the instruments left inside the abdomen and without undocking the robot. the dissection of the pancreatic head from the portal vein and the section of the retroportal lamina were performed with the use of the endowrist vessel sealer device. a personal modified end-to-side pancreatojejunostomy was carried out, with / prolene and gore-tex double layer suture. no intra-operative complications occurred and no conversions to laparoscopy or laparotomy were required. the postoperative course was uneventful. conclusions: the use of the new fully wristed vessel sealer extend makes easier difficult maneuvers such as the fine dissection of the pancreatic head from the portal vein and the section of the retroportal lamina, enabling an optimized approach for vessels sealing and cutting and tissue bundles. moreover, the dvtm allows patient's movements without undocking the system or removing instruments from the abdomen, enhancing the surgical workflow. background: necrotizing pancreatitis is a devastating illness which can develop in up to % of patients who suffer from pancreatitis. it carries great morbidity with an associated mortality rate between to %. many of these patients require drainage of fluid collections to treat sequela related to pain, per-os tolerance, and source control of sepsis if infected. the step-up approach to treatment of this disease has trended towards minimally invasive techniques, considering the morbidity of open debridement. as such, many centers have implemented the use of transgastric debridement via endoscopic cystogastrostomy. this technique, while effective in draining fluid and particulate necrotic tissue, has difficulty in resection of large necrotic tissue, due to instrument and anatomic limitations. current endoscopic accessories designed for polypectomy or foreign body extraction, for example, are not optimal for performing necrosectomy. to overcome this obstacle, additional access sites can be utilized to assist debridement. we describe the first laparoscopic assisted transgastric endoscopic necrosectomy through a percutaneous gastrostomy in a year old male with infected pancreatic necrosis secondary to biliary pancreatitis. aim: to investigate the feasibility of utilizing gastrostomy access to assist in debridement during endoscopic necrosectomy. methods: the patient previously underwent an open necrosectomy and gastrostomy tube placement for acute emphysematous pancreatitis. post-operatively, there was a persistent and enlarging cm infected walled-off necrosis (won). therefore, endoscopic cystogastrostomy was performed using a lumen-apposing metal stent. results: frank pus was evacuated. initial endoscopic necrosectomy was technically challenging due to the large volume of solid necrotic tissue. repeat endoscopic debridement utilized a surgical laparoscopic grasper via the gastrostomy site to aide solid debris extraction (video). this allowed for complete necrosectomy and resolution of the won. the patient did well and was discharged subsequently. conclusion: this is another emerging minimally invasive technique in the step-up approach for debridement and drainage of won. the use of the gastrostomy as a utility port for accessory instruments not only enhanced the technical aspects of the procedure but increased its efficacy as well. further experience is needed to validate the utility and reproducibility of this technique. objective: the presentation of the minimally invasive surgical approach for pancreatic necrosectomy guided by videoretroperitoneoscopy or var (video assisted retroperitoneoscopic), established in our center, as one of the option of the step-up approach treatment for acute necrotizing pancreatitis (anp) methods: the placement of the patient on the operating table should be in decubitus, with right lateral inclination, at - °on the horizontal surface. the pancreatic cell is approached using the drainage catheter previously placed by radiological control (ultrasound or ct) as a guide, which will allow access to the cavity with safety. an incision of - cm is made around the previously placed catheter, crossing the subcutaneous cellular tissue and muscular fascias, dissolving the musculature. it continues in a blunt dissection, until a loss of resistance is appreciated which generally coincides with the outflow of necrotic or purulent material. once the retroperitoneal cell is accessed, a mm trocar is placed and a pneumoretroperitoneum is performed. the -mm trocar allows the joint use of a mm and °optic and the surgical material that allows debridement and cleaning. the aspiration and hydrodissection of the necrotic material, and the extraction of the solid component of the necrosis are proceeded. once the collection is drained and the necrotic material removed, a wash and drain system is placed, like a -way foley type probe. conclusions: in conclusion, the var is an alternative surgical technique, valid and reproducible in the treatment of anp, which offers comparable results and even superior, in some series, to those of open surgery, with satisfactory results in terms of morbidity and postoperative mortality. aim: lung subsegmentectomy is suitable for small and deep, non-palpable lung nodules. since it is difficult to intraoperatively detect the arteries, veins and bronchi of the subsegment, as well as the intersubsegmental borders, complete video-assisted thoracic surgery (vats) for lung subsegmentectomy is challenging. we use preoperative three dimensional ct to detect the arteries, veins and bronchi of the subsegment before conducting complete vats subsegmentectomy, and perform intraoperative bronchoscopy to detect the bronchi and intersubsegmental borders. i would like to describe our experience of complete vats combined subsegmentectomy for a non-palpable lung nodule. methods and results: the patient was a -year-old woman. during health screening, a small groundglass opacity was observed in her right lung on chest ct. the nodule was mm in diameter and was located in s b (horizontal subsegment of the posterior segment) near s (the anterior segment). we preoperatively diagnosed the lesion as well-differentiated adenocarcinoma, and planned combined subsegmentectomy for s b and s a (lateral subsegment of the anterior segment) of the right upper pulmonary lobe. before the operation, the locations of vessels were confirmed by three-dimensional ct angiography. video-assisted thoracoscopic surgery was performed using four ports: two cm ports in the th intercostal space in the post-axillary line and in the angulus inferior scapulae line for the operator, a cm port in the th intercostal space in the mid-axillary line for the assistant, and a cm port for the camera in the th intercostal space in the mid-axillary line. the cm port was also used for removal of the resected specimen. intraoperative bronchoscopy was used for detecting the subsegmental bronchi. she was diagnosed with primary lung cancer (adenocarcinoma in situ, nonmucinous) postoperatively. the tumor was pathologically graded as tisn m . no tumor recurrence has been noted in follow-up of twenty two months. conclusions: the combination of preoperative three-dimensional ct angiography, intraoperative bronchoscopy and complete video-assisted thoracoscopic surgery can be used for performing lung combined subsegmentectomy. aims: minimally invasive surgery is increasingly widespread for the diagnosis and treatment of abdominal pathology. laparoscopy is a diagnostic resource for those cases in which mass biopsy is not approachable through image-guided puncture, and is often therapeutic in the same act. it avoids the morbidity and mortality associated with laparotomy, favoring the early treatment of malignant processes. methods: we present a case of a year old male who was incidentally diagnosed with an oval-shaped pelvic mass in the right lateral wall of the pelvis, adjacent to the vascular bundle of the right external iliac at its origin( centimeter), without sign of infiltration of surrounding structures. no other pathological findings on the abdominal computerized tomography and magnetic resonance imaging were found. due to its localization, it was not accessible to percutaneous biopsy. the first diagnostic impression was a benign tumor of the nerve sheath (schwannoma), without being able to rule out other diagnostic possibilities. to provide a definitive diagnosis the patient was subjected to an elective laparoscopic resection of the tumor. surgical procedure was performed using a millimiter and two millimeter, umbilicus for the optical system and operative on hypogastrium and left iliac fossa respectively. acleavage plan between the tumorand rightiliac vesselswas found. the exeresis of the masswas achieved, and it was extracted using an endo-bagÒ through the umbilical port site. a drain was put in the surgical bed. results: the patient had a short, uneventful post-operative course, being discharged on postoperative day . pathological examination revealed a lymphatic node with metastasis of poorly differentiated carcinoma, with suspected urothelial lineage. cystoscopy was performed with the finding of a centimeter lesion on the right ureteral orifice with calcifications on the surface. biopsies were taken, confirming the bladder origin of the tumor. conclusions: both diagnostic and therapeutic laparoscopy is useful on pelvic masses because of the direct vision into this narrow anatomical space, especially in obese patients, providinga detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor, minimizing the risk of tumor rupture and bleeding. surg endosc ( ) aim: indocyanine green (icg)-enhanced fluorescence has been introduced initially in laparoscopic surgery to provide detailed anatomical information during laparoscopic cholecystectomy and to evaluate vascular supply to garantee correct anastomotic perfussion in order to reduce the risk of anastomotic leak. the uses of icg are increasing, specially in hepatic and oncological surgery in order to identify centinel lymph node and lymphatic mapping.we propose the use of icg imaging during complex laparoscopic colorectal resection in cases presenting ureter obstruction, to prevent iatrogenic ureteral injury. methods: we present a case of a year old female previously diagnosed of pelvic endometriosis with severe pain and symptoms related with episodes of pseudo-occlusion .a colonoscopy was performed finding sigmoid cancer in an area of endometriosis in a narrow colon with difficulties to perform a complete colonoscopy that could be related to the process of pseudo-occlusion. the biopsy was informed as an adenocarcinoma.the ct-scan showed a dilatated left ureter in an area next to the sigmoid colon.we propose a preoperative strategy with a bilateral double j stent insertion, finding a ureter obstruction caused by the endometriosis.icg was injected through the ureteral catheter, guiding us during the surgery to avoid a iatrogenic ureteral injury. results: a laparoscopic left colectomy was performed. the icg allows us to follow the ureter during the surgery, disecting the colon properly from the area attached to the ureter. the prestenotic area of the ureter was marked dilatated up to two centimeters allowing the icg to identify it from the anatomic structures of the areas and guarateeing that there was not spill of icg out of the ureter avoiding a postoperative leak of urine. conclussions: when tumors, or another entities like endometriosis, produce a ureteral occlusion, icg could be injected through a j stent, allowing us to identify and to avoid an injury.icg fluorescence imaging is a safe, cheap, and effective tool to increase visualization during surgery, offering additional information of the anatomy in colorectal surgery. in this video we are going to show three cases of the robotic treatment of splenic artery aneurism and the evolution of the technology that we relied on for the preoperative planning and intraoperative navigation. our preoperative evaluation evolved from a tridimensional virtual reconstruction with augmented reality to patient specific anatomical d printed models, initially made of rigid materials and afterwards made of malleable materials, in order to reproduce hollow anatomical structures such as vessels, feasible to simulate the planned surgical plan. the choice of a robotic approach, in selected cases, allowed to restore the continuity of the splenic artery after the exclusion or excision of the aneurism, in order to preserve the spleen. aims: tumor-induced osteomalacia (tio) is a rare paraneoplastic syndrome in which patients presents bone pain, fractures and muscle weakness caused by the fibroblast growth factor (fgf- ), a phosphate and vitamin d-regulating hormone. in tio, fgf- is secreted by mesenchymal tumors that are usually benign but small and difficult to locate. when medical treatment is unsuccessful, surgical treatment is indicated and conclusive.this video shows our technique for tio surgical treatment guided by indocyanine green (icg) fluorescent angiography. methods: the patient is an -years-old woman with tio confirmed by blood sampling of fgf- , gallium- pet/ct scan and abdominal ct scan which identified a highly vascularized mm nodule in the mesentery along the ileo-colic vascular axis.the patient was scheduled for a diagnostic laparoscopy with tio removal.the patient was placed in supine position. three trocars were introduced in the left quadrants. identified the last ileal loop, following ileo-colic vessels, a small mesenteric bulge was found. the icg fluorescent angiography confirmed the localization of the ipervascularised nodule and helped to define its edges. the nodule was removed through monopolar energy and the hemostasis was optimized through bipolar energy. the specimen was extracted through an endobag using one of the trocar access. results: the postoperative course was uneventful and the patient was discharged on postoperative day . histopathological examination showed an extrasurrenalic paraganglioma. conclusion: tio are often difficult to locate for surgical removal. icg fluorescent angiography allows to facilitate tio localization and removal. the minimally invasive technique decreases perioperative morbidity and mortality. laparoscopic removal guided by icg angiography should be considered when tio needs to be removed and is difficult to locate. aim: this video shows our technique to perform laparoscopic resection of a voluminous left paraaortic paraganglioma. methods: the patient is a -years-old man with a recent medical history offever, lumbar pain and haematuria.abdomen ct scan, performed during admission at emergency department, revealed a x cm left paraaortic retroperitoneal mass with pseudo-aneurysm. after procedure of angiographic embolization (with spermatic artery sparing), the patient was scheduled for a laparoscopic resection of paraaortic tumor. the patient was placed in the right flank position. three trocars ( mm) in the abdominal midline and one trocar in left hypocondrium were placed. at initial examination of the abdominal cavity, voluminous left paraaortic mass arising in the contest of left mesocolon was found, dislocating posteriorly kidney vessels. the parietal peritoneum was divided and the paraaortic lesion was dissected on the aortic plane from medial to lateral and from down to up, preserving the inferior mesenteric vessels; the mobilization was carried on to splenic vein. the vessels, supplying the mass and arising directly from aorta, was isolated and taped with vascular clips. on the inferior margin of the lesion a large vessel, probably connected with previously embolized pseudoaneurysm, was dissected with vascular linear stapler. the mobilization was completed through difficult dissection from aortic plane and mesocolic posterior surface. the colonic perfusion was verified with fluorescence angiography. specimen was extracted through an endobag.a drain was left in pelvis. postoperative day .histopathological examination showed a morphological and immunoistochemical pattern for benign paraganglioma. conclusion: laparoscopic resection of paraaortic paragangliomas is feasible by skilled surgeon. the minimally invasive technique decreases perioperative morbidity and mortality. careful preoperative planning and surgeon's experience with vascular dissection and visceral mobilization are mandatory for a good outcome. aims: posterior retroperitoneal endoscopic approach has been considered for many years as a very complex and unsafe surgical technique. often attributed to a difficult location and visualization of retroperitoneal structures. in addition, surgeons were forced to work in a small and easily altered space due to discontinuous flow with constant changes of the retroperitoneal vision. lately this approach is emerging thanks to technological advances, mainly better visualization laparoscopic cameras and high definition screens, as well as continuous flow insufflators of co , maintaining stable and smoke-free cavity uninterruptedly. methods: it shows a management of a potentially serious complication and the reproducibility of the technique through the retroperitoneal approach. results: to operate with high pressure of neumoretroperitoneum allows to contain the hemorrhage and to value with relative serenity and security, the best surgical option to repair said injury being laborious due to the reduced workspace. conclusions: the posterior or retroperitoneal approach is feasible, safe and fast. although the possibility of injuring the vena cava in right adrenalectomy remains one of the most serious and feared complications. as shown in the video, posterior retroperitoneal endoscopic approach allows repair of vascular injury correctly and safely. methods: four patients undergoing adrenalectomy, two of them with right adrenal pathology and two left. minimally invasive access, endoscopic approach, is exposed in all of them. results: in the first two surgeries, right gland is shown. initially, transabdominal approach, which requires mobilization and separation of the liver to access the retroperitoneal space and subsequent proceed to adrenal extirpation. later, right retroperitoneal approach is observed, with a meticulous sealing of the adrenal vein prior to complete the dissection of the gland, despite the small cavity created by co . in the second part, both left adrenal approaches are exposed. transabdominal pathway is necessary to mobilize left colon and spleen to access a narrow space above the upper edge of the pancreas to locate adrenal gland. this is very different in posterior adrenal approach. conclusions: posterior or retroperitoneal approach is feasible and safe, allowing access to adrenal glands, located in retroperitoneal space, without across peritoneal cavity and its disadvantages. colon and small intestine mobilization is not necessary, with a lower rate of intestinal lesions and postoperative ileus. in the same way, liver or spleen mobilization is avoided. aims: when performing a laparoscopic adrenalectomy, especially in the setting of pheochromocytoma, one of the most important steps is to gain control of the adrenal vein early on in the procedure before great manipulation of the adrenal gland. we present the case of a year old female with episodic headaches and tachycardia and severe uncontrolled hypertension, found to have elevated plasma and urine metanephrines with ct scan localizing a . cm right sided adrenal nodule. the patient was prepared preoperatively with phenoxybenzamine until mildly orthostatic with dry mucous membranes and was taken for laparoscopic right adrenalectomy. methods: after positioning our patient in left lateral decubitus, ports were placed inferior to the costal margin. the right lobe of the liver was mobilized and retracted cephalad and the ivc was exposed. careful and meticulous dissection was carried up the ivc, however no main adrenal vein was encountered. the adrenal gland was then dissected circumferentially and was removed in an endoscopic retrieval bag. there was no difficulty in hemostasis and the patient was deemed to be hemostatic prior to withdrawal of the ports and extubation. results: our patient had no issues with hemodynamic stability and her blood pressure was within normal ranges during and following the case. her hemoglobin was stable postoperatively with . immediately post op and . on discharge. her pre-op hemoglobin was . . conclusions: our video demonstrates a right adrenal gland that was congenitally missing a main adrenal vein. it is very possible that small venous branches were taken with dissection however we believe this report to be important to note in the literature for surgeons performing adrenalectomy. surg endosc ( ) aims: adrenal cysts are the most frequently identified adrenal cysts, although they are a rare entity. typically they are presented by abdominal pain or palpable mass, but nowadays, cystic lesions of the adrenal gland are more often discovered incidentally by radiologic studies. adrenal cysts have an extensive differential diagnoses, which makes a difficult definitive diagnosis and a difficulty in later management. the management of an adrenal cyst can be summarized in three fundamental pillars: discard the functional status of the cyst, evaluation of eventual malignancy by images, and avoid possible complications (hemorrhage, infection), especially in large cysts . methods: clinical case: a -year-old male patient, with no history, studied for nonspecific pain in the right hypochondrium, without other accompanying symptoms. an abdominal ultrasound was performed, a cystic lesion in hcd without being able to identify the origin was seen. complementary explorations of interest are shown (ct), the biochemical study discards functionality of the lesion, negative serology for hydatidosis. the minimally invasive approach is the gold standard in the surgical treatment of adrenal pathology, so a laparoscopic approach is proposed for this patient. aims: endometriosis is a high incidence disease (approximately % of women) with a large impact on women's quality of life and fertility. endometriosis nodules surgical treatment is necessary every time there is evidence of active disease. the aim of this video is to present a minimally invasive technique for the resection of an endometriosis nodule from the abdominal wall. methods: a -years-old woman, with past history of endometriosis and a c-section, presents at the office with a palpable nodule at the rectus abdominis left lateral border, close to the umbilical scar. she had complaints of exuberant catamenial pain and magnetic resonance imaging (mri) showed a mm nodule compatible with endometriosis depot. this technique uses trocars ( ? mm) placed at the pfannenstiel scar. stepby-step as follows: (i) dissection of the pre-aponeurotic plane and isolation of the lesion (ii) lesion excision and its removal with sac (iii) closure of the aponeurotic defect braded suture. results: the post-operative period was uneventful and the patient was discharged home at post-operative day one. the aesthetic result was excellent and the patient was asymptomatic one month after the procedure. conclusion: endometriosis of the abdominal wall is related to previous c-section, is a rare event (incidence . - . %) and usually located in the subcutaneous fat underlying the scar. the presence of nodules in the depth of the muscle is much uncommon and particularly in this clinical case, the nodule was located cm cephalad from the previous pfannenstiel scar. this technique seems easy and reproducible in the authors' opinio. aims: general surgeons often face gynecological pathological findings, either along with other abdominal pathology, or as primitive cases that need laparoscopic expertise. with this particular presentation, our goal is to demonstrate the essential laparoscopic skills and the basic operative strategy that a general surgeon should be familiar with, in order to manage such cases. the presentation is made on occasion of a woman with multiple uterine fibromatosis of the pelvis, who was treated by our team. methods: we present video fragments of the laparoscopic excisional procedure for multiple uterine fibromyomatosis of the pelvis, highlighting the proper strategy in order to conclude the operation effectively and uneventfully, in a minimally invasive fashion. results: patients with multiple, large or other complex forms of uterine or pelvic fibromas can effectively be treated with a minimally invasive approach, with minimal blood loss, very fast recovery and minimal postoperative pain and complications. % of pregnancies require emergency surgery for a non obstetric indication, including acute appendicitis, cholecystitis, adnexal torsion, choledoco-lytiasis, hernias, intestinal obstructions, oncologic pathology or other less frequent indications. laparoscopic approach is the preffered surgical option for the patologies presented above. aims: to present the technical particularities and to analyze the outcomes of the emergency operations in pregnant women operated in hospital. method: a retrospective study including all the pregnant women operated in our hospital between - was performed. the preoperative workup and the surgical indication was discussed by a multidisciplinary medical team. the anesthesic and the obstetrical risk and their management was evaluated and specifically planned for each patient. the intraoperative and post-operative outcomes were recorded. results: patients with gestational age between weeks and weeks who underwent emergency laparoscopic procedures were included in the study. out of the cases we have performed appedectomies, cholecystectomies, adnexal torsions. with a min mean operating time, we had no major intraoperative complications; the technical challenges are presented and discussed. the hospital stay was , days ( - days). no major complications were associated with the laparoscopic approach in these cohort. one pre-term labour in a weeks gestational patient was post-operatively encountered. conclusion: laparoscopic surgery can be the first option for pregnant woman with non obstetrical surgical emergencies; challenges in diagnostic, management and surgical techniques of the multidisciplinary team are expected. the objective of this presentation is to demonstrate step by step the technique to the oncologic surgeon and gynaecologist in training, including some tips and pitfalls. this is a laparoscopic transperitoneal approach in a woman with advanced cervical cancer (figo ib ) that will be treated with exclusive radio-chemotherapy. the purpose of the laparoscopic lumbo-aortic lymph node staging is to define the irradiation field. in this indication false negative in pet ct ranges from to % (depending of the existence of pelvic fixation or not). the limits of this lymphadenectomy are: both ureters as the lateral limit of the dissection, iliac bifurcation as the caudal limit and renal veins as the cranial one. since the tumour is cervical and not ovarian, both ovarian veins are not resected. in the pathologic report, lymph nodes were examined free of cancer spread. the patient have had a radio-chemotherapy with restriction of the irradiation field on the pelvis. lymphocele is a frequent complication that only sometimes needs treatment ranging from dietary changing to percutaneous drainage. if conversion to laparotomy for bleeding this technique loose its benefice but this is a rare complication. this technique is feasible and safe but requires advanced laparoscopic skills. objectives: although extremely rare, isolated splenic metastases are being increasingly diagnosed due to the improvement of imaging, survival times, and surveillance of oncologic patients. this video alerts to the growing diagnostic dilemma with primary lesions of the spleen, particularly in patients with history of cancer, and reviews the laparoscopic splenectomy 'step-by-step'. case-report: -year-old male patient diagnosed with rectal cancer (g adenocarcinoma at cm of the anal verge) after a colonoscopy for rectal bleeding. thoracic and abdominal ctscan and pelvicmri, showed a ct n lesion, without distant metastases, except for a mm suspicious splenic lesion. cea- . ng/ml. after neoadjuvant therapy, a complete response was verified at the th week post-crt with a stable splenic lesion, and a 'watch-and-wait' program was initiated with no evidence of disease at the rd month. pet-ctscan did not show active metabolic features, despite an increase in the splenic lesion. in mdt, elective laparoscopic splenectomy was proposed and afterwards performed uneventfully. with the patient in semi-right lateral tilt, we approached the spleen inferiorly by dividing the splenocolic ligament. then we continued upwards, dividing the gastrosplenic ligament and exposing the splenic hilum, which was then carefully dissected, clipped and divided. finally the splenorenal ligament was divided and the spleen was extracted within an endobag, through a small pfannenstiel incision. pathologic report revealed a splenic lymphangioma. the patient is currently under a 'watch and wait' protocol surveillance with no signs of regrowth or relapse disease after year and months of follow-up. conclusion: one out of five colorectal carcinomas are metastatic at their presentation. isolated metastases to sites other than liver, lung or axial skeleton, are extremely rare, but can be found in the spleen. although the rare splenic secondary involvement is usually associated with breast, lung, melanoma, and gynecologic malignancies, if we consider solitary splenic metastases, colorectal and ovarian carcinomas are important sources. also, imaging including percutaneous biopsy, is frequently insufficient to clarify the nature of splenic lesions. for all these reasons, the decision-making process about this issue can be a true challenge, and will probably end up with laparoscopic splenectomy. therefore, surgeons must be familiarized with a standardized technique. sarcoidosis is a multisystem disease of unknown etiology characterized by the formation of noncaseating granulomas. sarcoidosis should be considered in the differential diagnosis of lymphoid disease. indications for diagnostic splenectomy includes a suspicion of a neoplasic process. the less invasive laparoscopic approach is the gold standard. case report: a -year-old female was referred to a general surgery department to complete a study to rule out lymphoid neoplasia. followed by hematology for cytopenias. biopsy of bone marrow and adenopathies were negative for lymphoid process. patient presented ct with multiple solid ( - mm) lesions in spleen, in thorax showed no pathological changes. laparoscopic splenectomy was performed. access with optical trocar, in mammary line. triangle -mm trocars after pneumo under vision. section with ligasure of gastroesplenic ligament with short vessels and phrenic-splenic ligament. identification and preservation of pancreatic tail. section of splenic vessels at hilar level (branches) with ligasure. lower pole release. release of posterior part with gerota and diaphragm. incision by aid helps in bag without fragmenting. review of hemostasis, extraction of trocars under direct vision. intraoperative findings: spleen with normal external appearance, not megalic. postoperative evolution: satisfactory. first hours without incidents and with analytical control without anemization. tolerance and mobilization starts without incidents. the histopathology report shows granulomas formed by epithelioid histiocytes with the presence of multinucleated giant cells of the foreign body type, in some perisinusoidal granulomas the giant cells with the presence of asteroid bodies in their interior. the material has been revised with the extension of special studies. conclusion epithelioid granulomatosis, non-necrotizing, which suggests sarcoidosis. the procedure lasted min. the hospital discharge was on the next postoperative day and no complication was registered. conclusion: splenectomy can be performed in a classic way, but at present the less invasive laparoscopic approach is the gold standard. indications for splenectomy include splenic tumours of unknown origin, suspicion of a neoplastic process, and splenomegaly. sarcoidosis should be considered in the differential diagnosis for lymphoid disease. postoperative pathological examination confirms the diagnosis. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy aims: we describe an interesting case of a female patient affected by a suspected echinococcus granulosus large cyst of the spleen. methods: a years old woman complained abdominal pain and a sense of gravity in the upper left abdominal quadrant. computed tomography scan(ct-scan) showed a centimetre (cm) cyst of the spleen with thickness of the wall and contrast enhancement uptake referred to an echinococcus granulosus cyst. the sierological blood test assessment, antigens and antybody markes, for echinococcus granulosus infection was negative. a laparoscopic procedure was planned. the patient was positioned on the right flank, four trocars were inserted along the left subcostal region of the abdomen: one millimetre (mm) trocar for camera, one mm for the assistant, and two of mm for instruments. a periombelical minilaparotomy was performed for the specimen extraction. results: post-operative course was uneventful. patient was discharged in third post-operative day. istopathological exam showed a simple epithelial cyst of the spleen. conclusions: laparoscopy is safe and feaseable in case of large cyst of spleen in condition of unclear nature of the cyst. laparoscopy permits to explore the abdominal cavity and to assess the cyst characteristics in a lack overlap between the radiological exam and blood test examination. surg endosc ( ) we describe laparoscopic splenectomy for recurrent splenic cyst after laparoscopic marsupialization and partial resection of splenic cyst. the patient was a -year-old woman with abdominal discomfort and with a -cm palpable mass in the left upper and inferior quadrant. she undergone years ago in another country a laparoscopic operation for splenic cyst. abdominal computer tomography revealed a cystic lesion of the spleen with concomitant huge splenomegaly. serology and oncological marker were negative. we performed laparoscopic splenectomy for the recurrent splenic cyst. the operation took min. histologic examination of the resected spleen revealed a chronic hematoma. the patient had no abdominal symptoms during months of follow-up. postoperative long term follow-up and examination by ultrasound or computed tomography is required after surgical treatment for splenic cyst to exclude the possibility of recurrence after spleen-preserving surgery. hand-assisted surgery is a recognized technique that combines the advantages of laparoscopic approach with the tactile feedback of the laparotomic one. it proved beneficial especially for the treatment of megaspleens due to lymphoma localization, thanks to safer handling of splenic vessels, major bleeding control and more effective detachment of superior splenic pole from the diaphragmatic dome. here we show an hand-assisted splenectomy for megaspleen reaching the omolateral anterosuperior iliac spine due to lymphoproliferative disease, in which the hand, inserted through a right subcostal minilaparotomy, was very useful during the dissecting manoeuvres, the splenic artery recognition and ligation and the isolation of the superior pole of the spleen from the gastric fundus and diaphragm. in any case of huge spleens, the specimen bagging is very difficult to perform in a pure laparoscopic way, not to mention the inexistence of capable endobag; besides, a minilaparotomy would be necessary for the spleen extraction. hand-assisted approach allow to overcome this not underestimable technical difficulty, reducing operative time with similar aesthetic and functional results to that of laparoscopic approach. aim: the evolution of technology and its application to the minimally invasive surgery of the thyroid gland offers new surgical techniques, like the transaxillary approach. this new procedure is still being implemented in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary endoscopic thyroidectomy and emphasize in the most relevant tips to take into account. also, current indications and limitations of this technique will be addressed. methods: a -year-old woman is referred for evaluation of a right thyroid nodule without any associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with well-defined edges and presence of peripheral vascularization. no other nodules are identified. fine needle aspiracion (fna) of the nodule describes a bethesda iii. after evaluation, a right transaxillary endoscopic thyroidectomy was performed. results: dissection begins in the subcutaneous plane above the pectoralis major muscle until identification of the sternocleidomastoid muscle. dissection continues towards the prethyroid muscles in order to perform a lateral approach of the thyroid gland. section of the upper pole allows better exposure of the recurrent laryngeal nerve (rln) which is being monitored intermittenly. identification and preservation of the parathyroid glands is the next step. surgery is completed with the section of the inferior pole of the thyroid along with the istmus. the postoperative period was uneventful and patient was discharged at h after surgery. final pathology revealed a cm nodule without malignancy. conclusion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients with benign pathology, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). further research is required to make a better assessment of the minimally invasive approaches in thyroid surgery. we present the video of a thoracoscopic esophageal leiomyomaenucleation. it has been widely demonstratedthe advantages of theminimally invasive approach in surgery. esophageal thoracoscopic surgery has been suggested as an alternative to open procedures, presenting less surgical trauma, lower risk of bleeding, less postoperative pain, lower wound infection and lower pulmonary morbidity, showing similar oncologic outcomes. although leiomyomas are the most commonof benign tumors of the esophagus, they are relatively rare, presenting an incidence of - per . autopsy series. in our case, the patient was diagnosed of leiomyoma located at the medium third of the esophagus. he referred a history of months of dysphagia for solid and liquids and retrosternal pain. the complementary studies were esophagoscopy, esophagography, ct and endoscopic ultrasonography. the patient was operated by a thoracoscopy approach using ports. it was completed the enucleation of the tumor following the closure of the muscular layer. methylene blue test confirmed no leaks. the patient was discharged on third day postoperative developing no incidences. pathology report: leiomyoma cm size, actin and desmin positive; s- , cd and cd negative. we want to demonstrate the advantages of a minimally invasive approach in this kind of pathology. aims: this video shows our technique to perform thoracoscopic enucleation of large esophageal leiomyoma. methods: the patient is a -years-old woman with a six months history of progressively worsening dysphagia. chest ct scan revealed a cm lesion of middle esophagus with extrinsic compression of mucosa and no increased fdg uptake on fdg-pet scan. barium swallow study showed a lateral deviation of thoracic esophagus due to extrinsic compression. endoscopic ultrasound confirmed the suspicion of esophageal leiomyoma. patient was scheduled for a thoracoscopic enucleation of esophageal tumor. she was placed in prone position and one-lung ventilation was employed. three trocars were placed in intercostals spaces on right hemithorax. azygos vein was identified and transected between vascular clips. esophagus was circumpherentially isolated from mediastinal structures. after myotomy, the lesion was dissected from submucosal-mucosal layer. since air leak test excluded injury of internal layer, muscular layer was closed with a continuous suture. the specimen was extracted through an endobag. a drain was left in place. results: the postoperative course was uneventful and the patient was discharged on postoperative day . final pathological examination confirmed esophageal leiomyoma. conclusion: thoracoscopic surgery in prone position allows removal of large esophageal tumor with several advantages. the minimally invasive technique decreases perioperative morbidity and mortality. introduction: spontaneous esophageal perforation is life threatening disease and requires emergent surgical treatment. recently, the efficacy of minimally-invasive surgery such as laparoscopic and thoracoscopic surgery for esophageal perforation has been reported. we report a novel technique of minimallyinvasive abdominal and left thoracic approach (malta) for spontaneous esophageal perforation. case presentation: -year-old male, who had been under hemodialysis due to iga nephropathy, complained of chest pain after vomiting several times. since the ct scan showed left hydropneumothorax and pneumomediastinum, and the gastrografin study demonstrated extravasation from left side of esophagus, we diagnosed him with the spontaneous esophageal perforation and planed emergent surgery. the patient was placed in the reverse trendelenburg position, and the legs were split, with the left side of the upper body lifted in order to perform thoracoscopy and laparoscopy simultaneously. first, we explored the thoracic cavity through a mm port in the left th intercostal space and added other ports. we identified the rupture site mm in size on the left wall of the lower esophagus and sutured the mucosa and the muscle layer with a running suture respectively. we covered the perforation section with pericardium fat and irrigated the cavity with physiological saline. then transferred to the abdominal cavity, no contamination was found in the abdominal cavity. a feeding tube was inserted into stomach through the round ligament of the liver and the operation was completed. the total operative time was min and the amount of intraoperative bleeding was ml including pleural effusion. postoperatively, the patient experienced left empyema pleurae but no other severe complications and was discharged on postoperative day . conclusion: we experienced a rare case of spontaneous esophageal perforation of a patient under hemodialysis. malta is an effective procedure for emergent esophageal operation because of great visual field of the chest and abdominal cavity without expanding contamination. introduction: digestive caustic injury is associated with high morbidity and mortality with stenosis in the long term. surgical treatment involves resection of the esophagus and reconstruction with the stomach, colon or jejunum. coloplasty provides several advantages but its vascularization is complex and involves anastomosis. classically, vascular assessment was achieved by palpation through laparotomy and color evaluation. indocyanine green (icg) allows a minimally invasive intraoperative angiography in real time. methods: a -year-old female with medical history of caustic ingestion and subsequent esophagogastric stenosis, carrier of feeding jejunostomy. . thoracoscopy (prone position): dissection of the esophagus from the hiatus to the upper thoracic inlet. . laparoscopy: patient in the supine position, placement of five trocars. total non-oncological gastrectomy, post-pyloric section of the duodenum and omentectomy were completed. mobilization of the righ, transverse and descending colon. measurement of the transverse colon with a tape (distance from the neck and the esophageal hiatus). individualization of the righ, middle (with its branches) and left colic arteries and placement of clamps at the right colic, right branch of the middle colic and left colic arteries. cc of icg were injected allowing for an assessment of the colon vascularization. section of the right branch of the middle colic artery. proximal section of the ascending and distal colon near the splenic angle, preserving the marginal arch. silk point to join the staple line of the descending colon and the pylorys. side-to-side mechanical antiperistaltic anastomosis between the distal endo of the coloplasty and the jejunum. finally an anastomosis between the ascending and descending side-to-side mechanical anastomosis using an assistance incision in the left flank was performed. . cervical dissection: extraction of the surgical especimen under laparoscopic control. vascular assessment with icg is performed before and after the side-to-side anastomosis is performed. results: there were no intraoperative complications. the patient was discharged on postoperative day . discussion: we describe the first case of total minimally invasive colonic interposition with icg assessment of the vascularization. this technique, although technically demanding, avoids the drawbacks of the open surgery and allows for a precise assessment of the vascularization of the graft. surg endosc ( ) introduction: large pedunculated fibrovascular polyps are uncommon, mostly benign, intraluminal massess, usually located in the upper esophageal tract. most frequent reported clinical manifestation is dysphagia, followed by regurgitation, chest pain and intestinal bleeding. ct scan, and mri are the key in the diagnostic work-up revealing a sausage-shaped intraluminal mass. endoscopy with ultrasonography and biopsy add important information for the diagnosis and pedicle location. surgical excision is deemed due to potentially life-threating complication related to airway obstruction. the most frequent polyp resection is performed through cervical esophagotomy or by direct esophagectomy. however, this approach is related to a high morbidity and mortality rate. in the last years, few excisions have been reported by a endoscopical approach with a lower post operative complication. material and methods: this video shows the surgical steps of a trans-oral endoscopic surgical resection of a giant ( cm) pedunculated polyp in a year old man. the procedure was performed under general anesthesia. a flexible endoscope probe was used and the distal end of the polyp was extracted through the oral cavity with a loop. the endo-gia stapler was used to cut the base of polyp and finally removed. the anatomo-pathological study confirmed the diagnostic of a fibrovascular polyp with no evidence of malignancy. results and conclusions: the patient had an uneventful recovery with no recurrency at years of follow up. this minimally invasive approach is a safe and feasible procedure to treat large esophageal fibrovascular polyps avoiding the complications related to more aggresive procedure. introduction: leiomyomas are the most common mesenchymal tumors affecting the esophagus and they usually grow in the mid to distal third of it. they tend to be asymptomatic, but sometimes they can grow to enormous size and produce dysphagia. case report: -year-old male asymptomatic patient was referred to our hospital due to an incidental finding. ct scan revealed a x mm rounded submucosal tumor on the dorsal side of the lower third of the esophagus. upper gastrointestinal endoscopy revealed a cystic lesion in the lower esophagus cm from the incisor teeth, with normal overlying mucosa. an endoscopic-ultrasound-guided fine-needle-aspiration of the mass was performed, which was reported as a likely leiomyoma.conservative treatment was performed, no growth was detected during eleven years of follow-up. but it became symptomatic, the patient complained of progressive dysphagia caused by compression so surgical resection was decided.laparoscopic enucleation of esophageal leiomyoma was performed. the tumor was reached by transhiatal dissection. a careful dissection of the mass was performed, preserving the vagal branches. an intraoperative endoscopy was performed to verify the integrity of esophageal mucosa and that the tumor was completely resected. the muscular layer was sutured after enucleation using absorbable suture material and the hiatus was closed with non-absorbable suture material. a dor fundoplication was also performed. a swallow test with a water-soluble contrast was obtained on postoperative day one. no pathological findings were found so the patient was asked to drink.histopathological exam revealed a tumor measuring mm mm mm consistent with leiomyoma.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: surgical excision is the mainstay of treatment and is recommended for symptomatic leiomyomas and those greater than cm. this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive esophageal surgery. introduction: total esophagectomy by means of minimally invasive surgery has proven to be a valid and effective alternative for performing this procedure. however, this procedure is not implemented in most centers. objective: demonstrate the technique of a total esophagectomy by endoscopic surgery for a benign esophageal stenosis. material and methods: clinical case: a -year-old female patient diagnosed with double esophageal peptic stenosis, treated on several occasions with endoscopic dilation by digestive, showing in the last endoscopy: severe esophagitis with stenosis impassable to cms. additional tests of interest are exposed. resolved: intervention: right thoracoscopy in prone position, dissection and complete mobilization of the thoracic esophagus, section of the azygos vein, pleural drainage. laparoscopic time, trocars, gastrolysis respecting the right gastroepiploic vessels, broad kocher until the cava is identified, vascular section of the vessels left gastric, full mobilization of the stomach, subxiphoid minilaparotomy, beginning of the cervical time with dissection of the cervical esophagus, section and fixation of this to a tube, externalization of the piece by abdominal route, creation of the gastric tubular with successive loads of gia, ascending posterior mediastinal plasty with manual esophago-tubular anastomosis, with placement of drainages and feeding jejunostomy. right operative with radiological control with gastrografin on the th day, discharge from hospital on the th day. asymptomatic one year after surgery, with radiological control without alterations. conclusions: the approach of esophageal peptic stenosis with minimally invasive surgery is safe and effective, adding the advantages inherent to this type of technique. (figs. , ) , showing a cystic lesion in the gastric submucosa with a well defined, medial and superior to the lesser curvature of the stomach with exophytic growth. it causes extrinsic compression of the cardia in the gastric body. within the differential diagnosis are gastric duplication cysts or gastrointestinal stromal tumor. a biopsy was taken, discarding the presence of neoplastic cells. finally, a study of digestive transit showed extrinsic compression at the cardial level, which causes difficulty in passing contrast. a laparoscopic approach was performed beginning with the dissection of the abdominal esophagus. the presence of a cystic lesion on the anterior face of the abdominal esophagus was identified (figs. , ) . we proceeded to the complete resection of cyst. the surgery was completed with °f undoplication anterior dor. the patient went home on the rd day without incident. results: duplication cysts are congenital malformations of the gastrointestinal tract contiguous with the esophagus, which can communicate with the esophageal lumen. most are diagnosed in childhood, but when it is diagnosed in adults, they used to be symptomatics. it is more frequent in men. although the pathogenic mechanism is unknown, it is caused by an anomaly during embryonic development. they are located in the thoracic esophagus, at the level of the lower and posterior mediastinum and, less frequently, in the abdominal esophagus, as in our case. they can give digestive symptoms(epigastralgia, vomiting) or respiratory symptoms. the diagnosis is made with eda, ct, and ecoendoscopy of choice, although it may be incidental. the treatment of choice in symptomatic patients is complete resection or cystic enucleation. in asymptomatic surgical is not defined, because it can cause complications, and, malignization due to degeneration is very infrequent. conclusion: the most of duplication cysts are diagnosed in childhood, although it's more frequent in adults to be symptomatic. surgical treatment can cure this disease. however, the choice between these becomes difficult in young patients, where the low incidence does not allow get series of long patients and decisions must be based on results achieved in adults. objetivos: to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology, pointing out the importance of having standardized the procedure to achieve better results. material and methods: case report: a -year-old man with progressive dysphagia until almost complete afagia, with clinical, endoscopic, radiological and manometric diagnosis,compatible with typical primary achalasia. chagas negative serology,we show the complementary studies of interest.dilatation is not performed, preoperative symptomatic treatment with calcium channel inhibitors. intervention: laparoscopic approach, trocars, aberrant left hepatic artery with signs of severe esophagitis,opening of the gastroesplenic-hepatic ligament, no retroesophageal window, dissection of the hiatus and inferior mediastinal, preservation and mobilization of the left hepatic artery and the anterior vagus,meticulous disection of the cardia,standardized myotomy: first proximal cms. with adequate simultaneous traction of both edges of the myotomy, then distal myotomy including - cm, including selectively the distal oblique fibers of les, tutorization with fouché and methylene blue to confirm good step and absence of leakage, dor-type funduplication, pts on each side, fixed to both pillars, hiatalmediastinal drainage. egd on the st day of normal po, dischargeat rd day, asymptomatic and with normal radiological control at year of age. conclusions: laparoscopic mh should be the first therapeutic option, in patients with primary achalasia, even in young patients. the length of myotomy, especially distal to ueg is one of the most important aspects of surgery, most authors (pellegrini) recommend that the myotomy extend - cm in the stomach, even up to cm below the ueg to achieve an effective disruption of the eei.the standardization of the procedure is fundamental to increase safety and effectiveness in these more complex cases. aims: the surgical treatment of giant hiatal hernias is a complex and demanding procedure, not only in terms of performing the operation in a minimally invasive abdominal fashion by avoiding thoracic approaches, but also concerning the management of large hiatal defects which contribute to high recurrence rates. our aim is to present our surgical technique for the reconstruction of such hiatal hernias, exploiting the benefits of the robotic approach and also to highlight the technical aspects of non-absorbable mesh placement in order to bridge effectively the hiatal defects. methods: we present video fragments from a procedures selected from a series of cases of robotic reconstruction of giant hiatal hernias performed by our team, in which a non-absorbable meshes were utilized to restore the hiatal gap. we emphasize on the clear benefits of robotic surgery in these cases and on the strategy of how to avoid high recurrence rates. results: all of our patients, who underwent reconstruction of giant hiatal hernias with this particular technique, experienced very good early post-operative results, very short hospital stay and no recurrence in a -month follow-up. conclusions: the robotic approach for the treatment of large hiatal hernias offers great advantages to both surgeons and patients, by eliminating the restrictions of conventional laparoscopic surgery, minimizing intra-operative incidents and post-operative complications. large hiatal defects are very effectively closed with the use of advanced suturing techniques and non-absorbable meshes in a tension-free bridging fashion. aims: mckeown esophagectomy is commonly used for invasive esophageal carcinoma. as the morbidity and mortality rates for esophagectomy are persistently high, minimally invasive esophagectomy in prone position is expected to reduce respiratory postoperative complications. there is still limited experience for the use of minimally invasive approaches in patients undergoing surgery after neoadjuvant chemoradiation and many concerns about the feasibility, safety, and oncological outcomes of these procedures are still present. methods: we present the case of a -year-old female with a middle third esophageal squamous cell carcinoma, who received neoadjuvant chemoradiation. she underwent laparoscopic and thoracoscopic (prone position) mckeown esophagectomy with hand-sewn esophagogastric anastomosis through a left lateral cervical incision. results: the operation was completed successfully, with no conversion to open surgery. the operative time was h with minimal blood loss and the patient was fed on day and discharged on day post-op. r resection was achieved and the number of total harvested lymph nodes was ( positive nodes, n ). conclusions: minimally invasive mckeown esophagectomy in patients with esophageal cancer and prior chemoradiation is feasible and safe procedure with acceptable oncological outcomes. results: preliminary results demonstrated that minimally invasive ivor-lewis esophagectomy procedure, provided of a better postoperative pain control and less respiratory complications. in order to standarise our procedure, the video shows how three different types of esophagogastric anastomosis are performed, depending on the patient characteristics, anatomical factors and safety and comfort for the surgeon: manual termino-terminal, mechanical termino-terminal and mechanical latero-lateral. conclusions: in our way to standardization, we are still looking for the best type of anastomosis, even though, we find out that, manually performed anastomosis are easier to performed, when the section in esophagus is lower, involving medium and inferior third. in the other hand, mechanical termino-terminal anastomosis seemed to be an ideal option for upper sections. more studies are needed in order to standardized one anastomosis, for all cases. because esophagectomy with radical lymphadenectomy is highly invasive, thoracoscopic esophagectomy (te) is attracting attention as a less invasive procedure. we first performed te with the left decubitus position in . in we developed a hybrid of the prone and left lateral decubitus positions for te, and a total of patients underwent te with a hybrid position . we introduced te with a hybrid position for the following three reasons: ( ) mobilization and lymphadenectomy around the middle and lower esophagus are easier in the prone position. thanks to artificial pneumothorax and the gravity, the middle and lower mediastinum are opened, and which give us good surgical field. ( ) lymphadenectomy along the left recurrent laryngeal nerve (rln) is more reliable and precise when performed in the left lateral decubitus position. we can dissect lymph node around the rln higher position in the upper mediastinum. ( ) unexpected events requiring conversion to thoracotomy (e.g., massive bleeding, injury of other organs, dense intrathoracic adhesion, resection of adjacent organs) are easier to deal with in the left lateral decubitus position. the patient is fixed on the operating table with the semi-prone position and we can easily change patient positions from the left lateral decubitus position to the prone position and vice versa using rotation system of the operation table. the upper mediastinal procedure including lymphadenectomy along the right and left rln is performed with the patient in the left lateral decubitus position, while the middle and lower mediastinal procedures are performed with the patient in the prone position with artificial pneumothorax ( mmhg). theabdominal procedures wereperformed by hand-assisted laparoscopic surgery (hals) and gastric tube reconstruction through aposterior mediastinal route was performed as a standard surgical procedure in our institution. the magnifying effect of thoracoscope enables us to perform more precise surgery and preserve nerve and vessels, and a hybrid position is thought to be feasible and effective methods. ivor lewis esophago-gastrectomy is a standard procedure for the treatment of distal esophageal cancer. among the years, the surgical community standardized the mininvasive abdominal phase. the thoracic phase is much more complex because usually all surgeons get in trouble in the phase of esophago-gastric anastomosis. in fact, is still very difficult and tricky to perform a mechanical circular anastomosis due to problems with the correct handling of the circular stapler through the minitoracotomy and is also difficult to place the anvyl in the proximal esophagus. the linear anastomosis (side-to-side) is a little bit easier but not so effective as the circular anastomosis in terms of leak rate. we think that robotic approach with its endowrist can allow us to overcome these limits and that a tailored double layer hand sewn esophago-gastric anastomosis could be the right choice. we treated patients with this approach and they were all uneventful in the post operative period except for a case of chylothorax we treated successfully with lipiodol injection in inguinal lymphnodes. we need more cases to analyze the technique in terms of leak rate and major complications but we think this is a promising and cost-effective procedure for robotic approach. aim: anastomotic leakage is one of the most dreaded complication after esophagectomy. indocyanine-green near-infrared angiography (nir-icga) intraoperative use has been recently introduced for visceral perfusion evaluation. in this video we present our technique for gastric conduit fashioning according to the nir-icga blood supply evaluation in a total minimallyinvasive ivor-lewis esophagectomy. methods: a years-old man affected by a siewert adenocarcinoma (ct , n , m ) underwent a preoperative neoadjuvant treatment according to cross protocol. at restaging ct-scan no more pathologic nodes were evident (ct , n , m ). the patient was submitted to a total minimally-invasive ivor-lewis esophagectomy. surgical procedure: after pneumoperitoneum induction and trocars insertion, the lesser omentum was opened and a lymphadenectomy at stations a, , , and performed. the esophagus was dissected at diaphragmatic hiatus with lymphadenectomy at station , and . the larger omentum was opened along the right gastroepiploic arcade, that was preserved, the short gastric vessels divided and gastric fundus mobilized. by evaluating the presence of an intense fluorescence at nir-icga, a tailored partial tubulization of the stomach was performed with multiple linear stapler firing. a right thoracoscopy was performed through trocars. the azygos vein ligated and divided. the mediastinal pleura was opened and the esophagus was dissected entirely with an en-bloc excision of nodes at stations , and . nodes at stations , , and were removed separately. the esophagus was sectioned above the azygos vein level and a purse-string fashioned. the cardia and the gastric tube were pulled up and a minithoracotomy performed. a new nir-icga was repeated to verify the good blood supply and tailor the site of anastomosis on a well perfused area. the stomach was opened and a circular stapler inserted. after the end-to-side esophago-gastric anastomosis fashioning, the tubulization was completed by linear stapler firing and the specimen removed. results: the post-operative course was uneventful and the pathologic examination revealed a cardial adenocarcinoma (ypt ,n , r ). conclusions: nir-icga is an interesting and easy-to use tool for surgeons. nevertheless in literature is still not clear which is the best parameter to measure the blood supply. large studied are needed. aim: uses and application of indocyanine green (icg) fluorescence in the field of surgery are growing exponentially. the safety and feasibility of its usage has been proven in several areas and various pathologies of surgery and surgeons are starting to incorporate it into their common practice. however, there are still several aspects to define regarding this technology. we present different uses of icg in the specific area of esophageal cancer. methods: we used icg fluorescence at different moments of a two-field minimally invasive esophagectomy. first of all, peritumoral injection of icg may offer a lymphatic mapping, both in the abdominal phase of the surgery and the thoracic one, improving lymph node dissection by allowing a more targeted and less morbid approach that includes all relevant nodal stations. at the moment of the gastric section, intravenous injection provides assessment of gastric conduit perfusion, therefore optimizing the construction of the graft to avoid the inclusion of poorly perfused areas that may increase the risk of leak of the anastomosis. besides that, the esophagogastric anastomosis can be tested in the thoracic phase of the operation in order to check an adequate perfusion and prevent further complications. results: we consider that icg fluorescence is a promising technology that could be easily introduced in the surgical routine of the esophageal surgeon as an instrument to assess the anastomosis perfusion. icg is also feasible in detecting lymph node drainage from the esophagus, although its technique of application needs to be defined. conclusions: icg fluorescence has opened a new world of possibilities in all the different surgical specialties. its use in the esophagectomy is safe, simple and feasible. in a near future, its application to esophageal cancer surgery could improve survival by predicting and preventing anastomotic leak and guiding in a tailored lymphadenectomy. further research is needed to demonstrate these promising applications. introduction: the oesophagectomy is currently still mandatory in the curative treatment of the malignant oesphagic pathology. this procedure is defined by important morbidity and mortality. the minimally invasive approach aims to reduce the complications without repercussion on the oncological outcomes, however it's not exempt from them being a demanding surgical technique like it is. aim: we present the video of three complications after a three-stage oesophagectomy (mckeown-like) with the thoracic stage via thoracoscopy and the minimally invasive surgical solution for both of them. methods: all three cases represent a three-stage oesophagectomy for malignant esophageal pathology. the first one was a -year-old male who suffered an intraoperative left main bronchus injury. the second case was a -year-old male with no intraoperative complications whatsoever. nonetheless, on the second postoperative day, milky drainage started to appear through the thoracic tube. the third and final case represents an intraoperative hemorrhage, which is the most common complication of this kind of surgery. results: the first case was diagnosed and treated intraoperatively with the use of an adhesive matrix. during the postoperative period the patient showed no further complications. the second case was a chylothorax, diagnosed on the second postoperative day. it was treated initially with conservative measures. due to bad evolution, he underwent surgery on the tenth postoperative day. we can see how we ligated the stump of the thoracic duct in the original surgery and then how we repaired the unexpected leak. after the second surgery, the patient was discharged on the sixth day. the last patient was also diagnosed and treated intraoperatively successfully, with no repercussion whatsoever in the postoperative time. conclusions: the minimally invasive surgery has many advantages in the upper gastrointestinal field. it is a demanding technique, so it is important to be able to treat the complications that may arise with this approach. surg endosc ( ) aims: the use of icg fluorescence is incrising in surgery, mainly as a test of vascular supply in colonic anastomoses. during the last years, other potential uses have been described, such as the identification of the sentinel lymph node and lymphatic mapping in oncological surgery. these advances could allow a better staging in order to decide the most appropriate treatment to each patient. gastric cancer is one of the fields where this could play a key role in the near future. we present a case of a patient who underwent a laparoscopic total gastrectomy with icg-guided d lymphadenectomy, where a personalized lymphatic mapping was performed. methods: a -year-old male patient underwent gastroscopy for gastric discomfort, and a gastric carcinoma was detected at the greater curvature of gastric body. endoscopic biopsy was informed as diffuse type gastric adenocarcinoma. the preoperative staging was completed with echoendoscopy and ct-scan (t bn m ). we decided to perform a laparoscopic total gastrectomy with icg-guided lymphadenectomy. the preoperative day, a gastroscopy was performed to inject . mg of icg in four submucosal areas around the tumor. results: intraoperatively, the lymphatic mapping marked by icg was checked, allowing the identification of the territory of drainage of the tumor to lymph nodes at the lesser curvature, the greater curvature and the splenic artery. a d lymphadenectomy and a total laparoscopic gastrectomy with roux-en-y reconstruction was performed. during the lymphadenectomy, we were able to observe marked lymph nodes in territory , and also observed that the paraaortic lymph node behind the celiac trunk did not become green and the lymphadenectomy at this area was not continued. the patient presented no postoperative complications, and was discharged on the seventh postoperative day. the histological results showed a diffuse type gastric adenocarcinoma pt n and isolated lymph nodes, being one of them possitive (corresponding to the adenopathy marked at the greater curvature). conclusions: lymphatic icg-mapping in gastric cancer is a potential revolutionary advance that could ensure a correct lymphadenectomy, avoiding lymph node understaging. it is necessary to continue carrying out studies that will allow developing protocols to define appropriate lymphadenectomy based on icg-mapping. introduction: petersen's hernia is one of severe postoperative complication after gastrectomy, which may result in massive resection of small intestine. it is considered an essential proscedure to close the petersen's defect for all cases after such reconstruction after gastrectomy as roux-en y method. we report a case of petersen's hernia after radical gastrectomy, which was repaired laparoscopically. patient: the patient was -year-old male, who underwent laparoscopic distal gastrectomy for gastric cancer (d lymph node dissection followed by roux-en-y reconstruction) two years ago. the closure of petersen's defect was not performed in the initial operation. he was aware of abdominal pain and visited emergency unit in our hospital. abdominal ct scan showed internal hernia of petersen's hernia. surgical procedure: in laparoscopic examination, dilation of small intestinal and mastoid ascites was observed. massive small intestine including y-limb entered into petersen's defect from left to right side. we carefully pulled through the small intestine and confirmed absence of ischemic change in the whole small intestine. then the petersen's defect was closed by continuous suturing with - non-absorbable barbed suture. results: the operation time was min and the estimated blood loss was ml. oral intake was started from the next day of the operation. there was no postoperative complication. the patient was discharged on the th postoperative day. conclusion: we could safely perform laparoscopic repair for petersen's hernia. regarding technical points in the procedure, it is important to judge the direction of the small intestine into the petersen's defect, to manage the dilated small intestine gently, and to close the petersen's defect by laparoscopic suturing. introduction: in this case we present a -year old male with a history of morbid obesity, sleep apnea and psychiatric affliction including alcohol and nicotine abuse. in he underwent a laparoscopic roux-en-y gastric bypass. the results were satisfactory, with no complications post-surgery, and a steady weight loss over time (pre: kg, post: kg). in november , he presented with complaints of dysphagia and weight loss ( kg in months). laryngoscopic examination by the otorhinolaryngologist was negative. he was referred to gastro-enterology for gastroscopy. biopsies showed a mildly differentiated adenocarcinoma of the gastro-esophageal junction with submucosal invasion. objective: after negative staging assessment, multiple treatment options were considered. the route of choice ended up being a laparoscopic radical gastrectomy with esophago-jejunostomy, with the objective to achieve optimal oncological results. methods: the procedure is demonstrated in this video. the gastric pouch as well as the remnant stomach, greater and lesser omentum were resected laparoscopically. due to the invasion of the carcinoma into the distal esophagus, a segment of the esophagus was resected as well. following anatomopathological examination on frozen section, the resection margins were reported malignancy free. results: postoperatively, there were no complications. ct scan with contrast showed no signs of leakage. anatomopathological examination confirmed the tumor to be a mildly invasive and poorly differentiated adenocarcinoma with local signet-ring cell differentiation (pt bn ). there was no need for adjuvant therapy. oral intake was sound. conclusion: adenocarcinomas of the gastric pouch are rarely seen following gastric bypass. this patient presented with complaints of dysphagia, and an adenocarcinoma was diagnosed. consequently, the patient had a total gastrectomy at our hospital. the surgery was performed laparoscopically, and was executed with success. to conclude, it is feasible to treat adenocarcinomas after gastric bypass laparoscopically via total gastrectomy and omentectomy. year old, female patient presented with upper abdominal discomfort and microcitic anemia. an ulcerative lesion was found on gastroscopy examination in body of the stomach (near the grate curvature). biopsy was done and pathology result showed poorly differentiated adenocarcinoma. chest computed tomography (ct) was without any significant findings. abdominal ct showed the lesion in stomach without enlargement of regional lymph nodes. her blood laboratory examinations were within normal limits, including serum cea. patient underwent laparoscopic total gastrectomy with modified d lymphadenectomy and roux-en-y esophagojejunostomy. total operating time (ort) was min. three days after operation, patient has developed none st elevated mi and respiratory failure. she was intubated. on day after operation she was extubated, on day patient started regular diet and was discharged home on day . final pathology result confirmed poorly differentiated adenocarcinoma of the stomach. this video shows our favourite technique for laparoscopic d subtotal gastrectomy. we usually perform the procedure with or trocars; after the coloepiploic detachment we perform the gastric transection first! this manoeuvre provides a perfect view for the lymphadenectomy. at the end of our dissection we transect the duodenum with seamguard reinforcement. before going on with the reconstructive phase, we prepare the roux en 'y' with double loop technique, usually without dividing the mesentery. then we remove the specimen through a periumbilical - cm minilaparotomy; we think it's important anyway to check margins and distance from the tumor before going on with the reconstructive phase. from the same minilaparotomy we retrieve the prepared limb for roux en y and we perform a side to side mechanical linear anastomosis outside.then we proceed with performing the anastomosis between the gastric pouch and the alimentary limb by laparoscopy. we like very much this technique for the increased exposition of tissues during lymphadenectomy. laparoscopic roux en 'y' d surg endosc ( ) a body-tc was performed in which axillary, mediastinal adenopathies and images suggestive of hepatic metastases were identified. the biopsy confirms a gastrointestinal stromal tumor. the case discussed in a multidisciplinary committee and the pet-ct study was completed, subcardial gist t n m was diagnosed. neoadyuvance was decided with imatinib for one month and surgery was performed using a laparoscopic approach. the approach was performed with trocars ( mm supraumbilical, two mm subcostal left and right, mm subxifoid and mm left flank). gastrectomy was performed with d lymphadenectomy following the oncological principles of subcardial tumors. the piece was removed in a bag by extending the mm port to mini-laparotomy. esophagogastric anastomosis was performed by hand assisted circular mechanical suture. methylene blue test was carried out. no nasogastric tube left, but drainage tutoring the esophagogastric anastomosis was left. results: the postoperative evolution was favorable. oral tolerance without incidents at fourth postoperative day. the patient was discharged without incidences on the seventh postoperative day. the pathological study of the piece was reported as subcardial gastrointestinal stromal tumor cm with respected surgical margins and lymph nodes free of malignancy, postoperative diagnosis of t n m . one month after surgery, the patient has adequate oral tolerance. she does not report gastroesophageal reflux and at months remains asymptomatic and with good evolution. conclusions: laparoscopic proximal gastrectomy is a technique that is not currently used but can be performed through a laparoscopic approach. it is a safe technique with good clinical and oncological results, especially in the early gastric cancer and gastrointestinal stromal tumors. however, long-term studies are necessary. laparoscopic gastrectomy is a perfectly safe option nowadays for the treatment of gastric cancer. every year the percentage of the laparoscopic approach is rising not only in the east but also in the west. we present a case of a year old female patient with a gastric tumor of the antrum-g adenocarcinoma with a ct n m staging. we perform a subtotal laparoscopic gastrectomy with a d lymphadenectomy and roux-en-y anastomosis. the patient begin clear liquids on the first post operative day and was discharged on the th. the final anatomopathological result of the specimen was a adenocarcinoma (g )-pt n . there were nodes resected all negative. the case was discussed in multidisciplinary team and was decided for clinical follow up with no further treatments. the patient was evaluated one month after surgery with no complaints and will continue the follow up. upper gi surgery, university of verona, verona, italy laparoscopic endoscopic cooperative surgery is an option in medium size submucosal cancers invading the muscular layer, mainly in border area were wedge resections are nor feasible.in this video we report a case of prepiloric gist treated with news technique (nonexposed endoscopic wall-inversion surgery).we think that this technique is feasible and safe and should be considered a valid option with a view to preserving the organ. aim: laparoscopic wedge resection or partial resection is a safe and feasible stomach preserving approach to gastric submucosal tumors (smt) such as gastrointestinal tumors (gist), and it has been widely performed recently. however, it should not be applied to the tumors at cardia in order to avoid stenosis or disruption of anti-reflux mechanism. we have introduced percutaneous endoscopic intragastric surgery (peigs) for smt at cardia since to preserve function of cardia. we will report the tips, techniques, and clinical result of our peigs. methods: from september to august , seven patients with smt at cardia underwent peigs in our hospital. we insert the mm port at umbilicus and investigate the abdominal cavity at first. then the incision is extended to . cm and lap-protector tm is equipped with the site to perform mini-laparotomy. using peroralendoscopy, a stomach was insufflatedand incision is made at an anterior wall of gastric body under direct vision. additional lap-protector tm is placed into the stomach so that the stomach is fixed on the abdominal wall. it enables us to keep direct access to gastric lumen and stable operative field. ez access tm is attatched on lap-protector tm , and intragastric operation is started. subsequently, two trocars are inserted using funada's gastropexy instrument. tumor is dissected by using energy devices, avoiding injury of capsule of the tumor. the defect of the gastric wall is closed by intragastric suturing. we should take particular care not to damage egj during the suturing, inserting peroral endoscopy in and out. results: the mean operation time was ( - ) min and the amount of intraoperative bleeding was . ( . - . ) ml. the maximum diameter of tumors was ( - ) mm. one case was low risk gist and otherwise were leiomyoma. the postoperative course was uneventful in all cases, without leakage or stenosis. total hospital stay was ( . - ) days. no patient had symptoms of esophagitis. conclusions: peigs for smt at gastric cardia is a feasible and safe approach, preserving function of cardia. our procedure achieves great stability and excellent visualization during the operation, which may have led to the fine surgical results. laparoscopic lymphadenectomyin gastric cancer is considered a feasible and safe procedure. data on the compliance of lymphadenectomy in the various lymph node stations is not yet well understood; moreover it is not clear if there are particular conditions relate to the patients impairing the oncological results. this video reports the use of the icg for the lymph node dissection of station number in a case of obese patient and a case of a cirrhotic patient. fist patient, m.a., was a year old man with distal cancer ct n and a bmi. second patient, t.d., was a year old man with distal cancer ct n and a alcoholic cirrhosis child b . in both cases, intraoperative endoscopy was performed to min before the onset of lymph node dissection. . mg of icg was injected into the submucosal layer in quadrants of the primary tumor. a laparoscopic subtotal gastrectomy was conduced with d lymphadenectomy. lymph note navigation were analyzed by novadaqÒ detector. using navigation system we removed the n basin. in both cases dissection were effective and pancreatic surface were easily detectable. number of lymph nodes retrieved was in the case of obese patient and in the case of cirrhotic patient. pathological tnm were pt n ( / n ?) in the first case and pt n ( / n ?) in the second. no n ? metastases were detected in n station for both cases. no pancreatic fistula was recorded. icg lymph node navigation system should be considered a valid support for the surgeon for completion of a correct lymphadenectomy in surgical challenging cases. aims: morgagni hernia is the rarest of congenital diaphragmatic hernias ( - %). its presentation is rare in adults and its finding is usually incidental. it was first described by giovanni b. morgagni in . it is located in the anterior region of the diaphragm. it is caused by a congenital defect in the fusion of the transverse septum of the diaphragm and the costal arches. the need for surgery depends on the presentation, it is recommended early repair before the development of complications. classically, the surgical approach was thoracotomy or laparotomy. currently, the tendency is to use a minimally invasive approach, which has shown good results, lower morbidity and faster recovery. the need to repair the defect with a mesh is controversial, recommended when it is not possible to close the defect without tension. the objective of this video is to demonstrate the safety and efficacy of the laparoscopic approach for the repair of this type of hernia, as well as the different types of mesh that can be used. aims: the treatment of the non-metastatic gastro intestinal stromal tumour (gist) is the surgical resection [ ] . the duodenal gastro-intestinal stromal tumour (gist) is a relatively rare clinical entity. from all the resected gist, only % are duodenal [ ] . the clinical presentation could vary from the most common acute gastro intestinal (gi) bleeding, chronic anaemia, but also acute abdomen caused by tumour rupture and intestinal obstruction. methods: a years old patient present at the emergency department of the chi poissy-st germain-en-laye (paris, france) with acute gastrointestinal bleeding. at the laboratory exams the haemoglobin was . g/ dl. the patient perform a computer tomography (ct) which shows two hyper vascularised lesion at the th duodenum; this lesions has an intra and extraluminare growing. the ct scan didn't show any other abdominal lesions. the patient were submitted to a minimally invasive surgical operation with the multiport laparoscopic technique. results: the resection of the th and th duodenum and of the first centimetre of jejunum was performed with a four trocar laparoscopic technique. a latero-lateral duodeno-jejunal mechanical anastomosis was performed. the operative time was min. the patient start with oral alimentation on the third post-operative day after a ct scan with oral contrast that was negative for anastomotic dehiscence and collections. the post-operative course was globally uneventful and the patient was discharged at fifth post-operative day without complications. the histological examination shows a low risk gist, cd positive and with a ki- inferior of % (classification tnm th edition pt aims: gastric volvulus are a rare condition that sometimes represent a diagnostic challenge for surgeons. here we present the video of a recent case of a gastric volvulus in our area that was treated with a minimal invasive approach. methods: we report the case of a -year-old woman who was admitted in the emergency room (er) with epigastric transfixing pain and impossibility to vomit that had started h prior to the admission. the physical exam showed good vital signs, and her abdomen was soft, with a tendency to tenderness with palpation in the epigastrium without guarding or rigidity. her lab tests were normal and the conventional radiology showed a double gastric bubble. we run an urgent computed tomography scan (ct scan) and a upper gastrointestinal (gi) endoscopy that showed a big type ii hiatal hernia that was complicated with a gastric volvulus. results: first, a nasogastric (ng) tube was placed for decompression of the stomach at the time when the endoscopy was made. the patient experienced a great improvement of the pain with that initial measure and remained stable. after almost a day of appropriate resuscitation, she underwent urgent surgery: we performed a hernia reduction, resection of the hernia sac, hiatal closure and a gastropexy and nissen fundoplication. the patient suffered no complications in the immediate postoperative time and was discharged after six days. conclusion: gastric volvulus are an uncommon emergency that we need to keep in mind. a simple abdomen x-ray can be very helpful, given that the double gastric bubble sign is a typical sign of this condition. it's always mandatory to perform an upper gi endoscopy in order to get to the diagnose and place a ng tube promptly. the surgery can be safely delayed in stable patients with no signs of ischemia, and a laparoscopic approach is associated with a shorter hospital stay and good long-term outcomes in this kind of patients. aims: during laparoscopic treatment of hiatal hernias the dissection can be complicated, but even more so the closure of the pillars, especially in giant hiatus hernias with a large defect. the use of prosthesis is controversial due to the lack of long-term studies and the possibility of secondary complications. the aim of this video is to demonstrate the safety of mesh hiatoplasty in hiatus hernia surgery. methods: we present the case of a -year-old woman with hypertension, hypothyroidism and right hemicolectomy for neoplasia years ago. the patient presented with malnutrition, with a weight loss of kg in the last months. a gastroscopy was performed in which a large hiatus hernia, that caused gastric volvulation, was shown. the upper gastrointestinal oral contrast study revealed esophageal tertiary waves and good passage to the gastric chamber, with an organoaxial volvulation of the stomach that was completely included in the thoracic cavity. results: through a five trocar laparoscopic approach, a large paraesophageal type iv hiatal hernia ( cm hiatal orifice) with complete herniation of the stomach and greater omentum to the mediastinum was observed. after reduction of the hernia content, complete dissection with partial resection of the sac was performed. an extended mediastinal dissection of the esophagus, with descent of the esophagogastric junction until achieving an abdominal esophagus of - cm, was carried out. after posterior and anterior phrenorrhaphy with nonabsorbable sutures, dislacement of the right pillar without diagragmatic opening was evidenced. it was decided to reinforce the hiatorraphy using a c shape composite mesh fixed with nonabsorbable sutures. the procedure was completed with a nissen-type fundoplication. postoperative course was uneventful and the patient remains without hernia recurrence months after the intervention. conclusion: prosthetic reinforcement in hiatal hernia repair can be a very useful resource in large hiatal defects in which a stress-free hiatus closure cannot be achieved. however, its use must be individualized according to the characteristics of the patient, the quality of the tissues involved and the result of simple hiatorraphy. aims: heller myotomy is an advanced laparoscopic surgical technique for the treatment of achalasia, a rare disease in which long time is needed to achieve the learning curve. surgical simulation, using animal models with an anatomy similar to humans, could help improving surgeon performance in a shorter time. the aim of our video is to show an ex-vivo and in-vivo animal model for heller myotomy training. methods: a cadaveric porcine model was developed using a tissue block including the esophagus and the stomach, without the diaphragm, mounted in a physical laparoscopic simulator. training procedures were also performed in an in vivo porcine model. experiments were carried out in the ' jesús usón' minimally invasive surgery centre in cáceres. results: the surgical technique is described step by step, first in the esophagus-stomach ex-vivo model and later in the live animal model. conclusion: surgical simulation using cadaveric an live animals offers a realistic representation, allows training in a safe environment, and can be very useful for advanced laparoscopic training in low incidence pathologies. introduction: esophagic perforation is one of the least frequent complications after laparoscopic nissen fundoplication, but it remains one of the most dreaded because of its morbidity and mortality rates and its technically difficult reparation. aims: to present how the authors dealt with an iatrogenic esophagus perforation post laparoscopic nissen fundoplication. methods: the authors report the clinical case of a -year-old woman who underwent a laparoscopic nissen fundoplication because of a symptomatic large hiatus hernia in a different hospital. the second postoperative day and after resuming oral intake, she presented respiratory and hemodynamic instability. she needed a chest tube that drained purulent content. the patient was referred to our hospital for clinical management. an urgent ct scan with oral contrast was performed without showing any leakage. results: in spite of the results, as the patient was unstable, she underwent an emergent diagnostic laparoscopy. it was found a small anterior esophagus perforation with right mediastinic collection. a running suture of the perforation was carried out and the nissen fundoplication was converted to a dör fundoplication. the operative time was min. she went to the intensive care unit for ten days. five days after the surgery, she was given methylene blue with no exteriorization through the drainages. as postoperative morbidity, she suffered from a right pneumonia and a thoracic collection that was treated by thoracic surgeons. the patient was finally discharged on the th postoperative day. she did well at home. she attended follow-ups without clinical reflux or any other particular condition. conclusions: esophagic perforation is a life-threatening complication that can be managed laparoscopically if it is detected soon after surgery and an expertise is available. surgical treatment of achalasia fails in - % of patients. the most frequent responsible cause is a previous incomplete myotomy, followed by fibrosis and aspects related with antireflux procedure. revisional surgery can represent a greater difficulty and a challenge. in this video we show revisional surgeries after heller's myotomy with dor fundoplication for achalasia. all cases presented a recurrence of the symptomatology and a revisional surgery was proposed. surgeries were characterized by the presence of a herniation of the previous fundoplication, fibrosis around the prior myotomy and/or the formation of a pseudodiverticulum. we show the steps followed and the aspects to consider during the dissection. these cases demonstrate that laparoscopic reoperation for achalasia is feasible, even after open surgery. aims: upside-down stomach (uds) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. uds is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. surgical repair is the only curative treatment option and therefore recommended for these patients. standard procedure includes a hiatoplasty followed by an anti-reflux procedure. in a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences. methods: a -year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. she reported a weight loss of kg in the last months. ct scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately cm, with intrathoracic uds. results: we performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (tutomesh tm ) augmentation. finally, a toupet fundoplication was performed to recreate the antireflux valve. in consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. the esophageal mucosa was unaffected. we treated the lesion laparoscopically with a simple interrupted suture (vicryl tm - ). an intraoperative patent blue v leak test did not identify any leaks. the recovery was uneventful. the patient was discharged on day after surgery and was free of symptoms in her follow-ups. conclusions: patients with large hiatal hernias and uds can be treated successfully and effectively with laparoscopic mesh repair. intraoperative complications can be handled laparoscopically in a safe manner. iatoplasty followed by nissen fundoplication represent the gold standard treatment of hiatal hernia; however it has been reported high hernia recurrence rate, especially in case of giant hiatal defects. in order to reduce recurrence rate, various techniques of hiatoplasty reinforcement have been implemented, such as prosthetic materials apposition. however, in literature have been reported various mesh complications such as esophageal and proximal stomach erosion and late esophageal perforation after ischemia, especially in case of synthetic non absorbable materials.in this video we are going to show the repair of a huge hiatal hernia by hiatoplasty and positioning of an absorbable biosynthetic 'bio a' mesh which is replaced by connective soft tissue over six months, therefore decresing complications and recurrence rate.as usual, we start with the mobilization of gastric fundus and isolation of diaphragmatic pillars by sectioning the aderences between them and herniated viscera. we proceed then with intrabdominal esophagus mobilization and higher mediastinal dissection in order to obtain an adequate esophageal lenght. after the exposition of the hiatus, we approximate the pillars with some non absorbable stitches and we reinforce the hiatus positioning a 'u' shaped bio a mesh over the esophagus, simply fixed to crura with single stitches. then we go on performing nissen fundoplication.the use of this prosthetic material appears to be cost-effective; first series in literature show very low complication rate and less recurrences of hiatal hernia than hiatoplasty without reinforcement. this video demonstrates the technique of laparoscopic identification and complete dissection of the sac of a totally intrathoracic stomach. identification of the sac is performed centrally by scoring the peritoneum overlying the arch of the diaphragmatic hiatus. the inferior edge is retracted and series of blunt dissection is undertaken. once the areolar tissue of the avascular plan is visualized; a raytec sponge is placed and advanced cephalad to expose the extra-saccular space. this raytec is kept in place to allow carbon dioxide to infiltrate and further delineate the anatomy. we then proceed with dissection at the left crus and right crus. complete reduction of the stomach can be achieved without grasping it. this can be performed by applying caudal retraction on the sac. this maneuver exposes the plane outside the sac. this space is divided into two compartments (right and left) separated by a septum which indicates the proximal extent of the sac. this plane is avascular and blunt dissection can easily free the hernia sac from the mediastinal structures and the pleura. this was followed by excision of the sac and hiatal repair which is reinforced with bioabsorbable mesh. the proximal short gastric vessels were then divided and a standard toupet fundoplication was performed. v -upper gi-reflux-achalasia introduction-objectives: the mixed giant hiatus hernias with paraesophageal component are hernias of difficult surgical correction, the laparoscopic approach of these implies a greater experience of the surgical team, given the complexity involved in its management, being the recurrence a complication that neither the use of meshes in this surgery has been able to avoid. in very high-risk patients, the gastric anterior pexy (boerema) may be an alternative to treat or alleviate the symptoms of these large hiatal hernias, although the frequency of recurrence with this technique is very high. material and methods. objective: the objective of the following case is to present a patient with type- hiatal hernia, barrett's esophagus without dysplasia and situs inversus. method: a laparoscopic partial fundoplication was performed on a -year-old male patient with a history of situs inversus totalis, who was seen in our general surgery service presenting a clinical history of retrosternal pain, heartburn and regurgitation. an endoscopy was performed, which reported hiatal hernia type and incompetence of lower esophageal sphincter, with squamocolumnar junction biopsies with report of barrett's esophagus without dysplasia. results: surgical time was programmed, for toupet type fundoplication; there were lax adhesions from omentum to wall, the lax hiatus and already known situs inversus. partial funcuplication was performed, with the usual technique adapted for structural anatomical abnormality, postoperative course without complications, oral initiation at the next day, drainage penrose type was set draining just a little serohematic liquid, diet was progressed and patient was discharged on the third postoperative day without complications. conclusion: situs inversus is the mirror image of situs solitus, which presents subdivision in situs inversus totalis, which is the most usual form, characterized by the mirror location of the intraabdominal and thoracic organs including the heart; in the case presented, the patient was referred with situs inversus and barrett's esophagus, performing laparoscopic fundoplication. the gold standard of surgical management is laparoscopic in benign esophageal pathology. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. in rare instances gerd is associatedwith type iv hiatal hernias in which the part of stomach and other organs migrate into mediastinum.nowadays this condition can cause problems for some surgeons.patient was a -year-old man. he was diagnosed with hiatal hernia in . the condition had beenhaving asymptomatic course until . patient takes omeprazole mg for years. he startedexperiencing chest pains when inhaled and dyspnoea in june . co-morbidities were: arterialhypertension, chronic obstructive pulmonary disease (copd) and obesity (body mass index was . kg/m ). the posterior mediastinum contained the part of stomach, large bowel and small bowelaccording to chest roentgenography. sizes of esophageal hiatus were mm. in our clinical centerwas performed laparoscopic removal of hernia, cruroraphy, mesh repair of the esophageal hiatus andnissen fundoplication in july. during the surgery stomach, the part of small intestine, greatomentum and transverse colon were relocated into abdominal cavity. after cruroraphy, repair of theesophageal hiatus with prolene mesh was performed. the patient was in intensive care during h.total enteral feeding was initiated on second day. patients had been discharged within days aftersurgery. patient was re-examined by a surgeon in september , there were no signs of a reccurence.this case report shows an efficiency and feasibility of the laparoscopic approach to the treatment gerdassotiated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon,great omentum and small intestine to enter the hernia sac. aims: the authors present a video with their standardized laparoscopic hiatal hernia repair and anti-reflux nissen procedure but using mm instruments and mm camera approach. methods: a years old female patient with a bmi presents a symptomatic gastro esophageal reflux disease (gerd) for years. manometry and ph-metry showed a lack of esophageal motor disorders and a severe acid pattern with a . demeester score. panendoscopy study showed a cm hiatal hernia and a los angeles-grade esophagitis. she decided not to go with ppi treatment anymore. a laparoscopic hiatal hernia repair and standardized nissen procedure is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic dysphagia, anatomical recurrence or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, hiatal hernia and anti-reflux mini invasive standardized repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. background and aims: parastomal herniation a very frequent complication in stoma patients. in isolated parastomal hernias (type i or iii)* a laparoscopic sugarbaker repair with intraperitoneal mesh is our preferred technique. if a concomitant incisional hernia is present (type ii or iii)* we currently opt for a retromuscular mesh repair as described by pauli. we adopted a minimal invasive approach using the robotic platform. methods: we performed a robot-assisted laparoscopic pauli repair for a wide incisional henria needing component separation and a small parastomal hernia (type ii)*. a non-slit retromuscular mesh was placed after a bilateral tar (transversus abdominus release) and lateralization of the colon. results: the operation was performed robot-assisted laparoscopically with x trocars without the need to convert to an open procedure. the procedure lasted min. the patient was discharged from the hospital on post-operative day three. one month after the repair our patient presented with a parastomal skin infection for which she received surgical cleaning and wound dressing. ct scan three months postoperative shows good positioning of the mesh with a reinforced abdominal wall. conclusions: the modified sugarbaker repair in parastomal herniation is feasible following a pauli approach (retromuscular mesh positioning) completely laparoscopic, albeit robotically assisted. short-term follow up is promising. long-term postoperative follow-up in these patients is needed. methods: case presentation results: a -year-old caucasian female patient was admitted on emergency due to a progressive alteration of her physical condition and weigh loss, caused by intermitent and intense epigastric pain and vomisments. symptomes occurred several years prior to admittance, but used to be mild and rare. during the last months, the described episodes became more intense, lasted longer and occurred more frequently. percutaneous ultrasound raised the suspicion, while thoraco-abdominal ct revealed an enormous intrathoracic morgagni hernia and gastric volvulus inside the hernial sack. after a careful preoperative preparation (restoring of the nutritional and hydric inballances, amelioration of respiratory parameters), laproscopy confirmed the diagnosis; we gently reintegrated the herniated organs from the thoracic hernia into the abdominal cavity (small bowel, large omentum, transverse-doloco-colon, and thisted stomach); a laparoscopic exploration of the hernial cavity was followed by a thorough hemostasis. do to patient's frailty, we decided to leave the hernial sack in situ. surgical direct repair of the defect technique was done by using extracorporeally tied separate sutures through separate skin incisions. the postoperative outcome was completelly uneventful; patient was discharged on postoperative day . barium contrast at mounths followup showed a slight esophageal diskynesia, but normal gastroduodenal passage; due to aerocolia, the normal position of the transverse colon could be confirmed aswell; no signs of reccurrence where detected. conclusions: although very rare, a morgagni hernia should be suspected and included in the differential diagnosis of patinets with dispeptic syndrome and epigastric/thoracic symptomes. thoraco-abdominal ctscanning is the imagistic technique of choice. laparoscopic approach became the gold standard, being far mora addvantageous as compared to laparotomy or thoracoscopy. direct suture with extracorporeally separate sutures through separate skin incisions was chosen for being less time consuming; for the same resons, the hernial sack was left in situ, with no consequences so far. aims: the giant fibrovascular polyp is one of the rarest benign lesions of the oesophagus. the most common locations of origin are the upper oesophagus or crico-pharyngeal region. the lesion is more common in elderly population, particularly men. symptoms include dysphagia, odynophagia. management options include surgical resection or endoscopic removal with endoloop. we aim to demonstrate the optimal management of these rare lesions using an endoscopic approach. method: we demonstrated the management of -year old patient with a giant oesophageal polyp, excised by minimally invasive endoscopic resection. the patient was placed in supine position and tracheal intubation was performed under general anaesthetic before an endoscopic approach was taken. the oesophago-duodenoscopy visualised a cresenteric shaped lumen due to an intraluminal mass occupying two thirds of the oesophageal diameter. the procedure was a multidisciplinary approach with the upper gi surgical and gastroenterology consultants. the polyp stalk was located in the oesophagus at the level of t and an endoloop was manipulated to surround the polyp. the polyp was then separated from the stalk by cauterisation and resected from the patient. the stalk was then injected with adrenaline to prevent haemorrhage. results: the excised specimen was a cm polyp with stalk originating from the t -t level. histology confirmed diagnostic suspicions of a benign pedunculated fibrovascular polyp. the polyp was covered by non-keratinising squamous epithelium with a discoloured tip demonstrating ulceration. there was no evidence of dysplasia or neoplastic process. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states. the system technology utilizes an articulated multi-linked scope that can be steered along nonlinear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation. the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. surg endosc ( ) the video shows the use of a barbed suture of novel concept. this first prototype thread developed together with assut europe (roma, italy) is characterised by a bidirectional / barbed suture, of cm length overall, with two needles mm in diameter, and circumference. in order to fix the thread to the tissue, on the exact midline of the thread a small ( mm) ball of the same material of the thread is fused with heat. this button as the entire thread is made of polydioxanone, a monofilament material for long-term absorption, self-retaining. this small advancement offera a consistent advancement in endorectal surgery helping in making transverse wound closures as easy as never before. the first stitch is placed on the transverse midline of the rectal wall defect, this way approximating proximal and distal edges. the button keeps the thread under tension allowing the completion of a running suture towards one of the two lateral ends of the would. when the first end is reached the needle is cut and the other needle is grabbed in order to perform the other half of the running suture keeping the right tension on the thread, with no risk of lumen stenosis. the two lateral ends of the suture are self-blocked passing them through the last stitch. no need for clips, knotting or buttonholes to pass through. while illustrating the technique the authors will comment pros and cons of the use of the device. background: the usefulness of robotic surgery has been largely reported; however, there are not enough reports on gist's treatment. the aim of this study is to report a single center experience on gastric gist's robotic resection. gastrointestinal stromal tumor (gists) are the most common mesenchymal tumors (overall incidence - % of all gastrointestinal malignant tumor). they are most frequently located into the stomach. complete surgical resection still remains crucial for patients with gists. in cases of difficult localization of tumor (e.g. posterior wall, his angle) and bigger tumor (more than cm in diameter), there still exist apparent difficulty and limitation to conduct laparoscopic resection. robotic assistance provides wide movements of its arms and was recognized particularly useful in case of difficult tumor localization, especially for those positioned at the posterior side of the stomach wall or around the lesser curvature. methods: six consecutive patients were analyzed focusing on safety (conversion/complications rate; hospital stay), oncological (margin resection, recurrence rate) and feasibility (operative time, technical tip and tricks) profile of robotic approach. results: the mean operative time was ± min, the mean hospital stay ± days. conversion rate was nihil. no intra and post-operative (mean follow-up months) complications were registered. in all cases, the resections were classified as r . conclusions: our experience supports the usefulness of robotic system in case of gist located at anatomically difficult gastric portion, such as lesser curvature or fundus close to gej, confirming the excellent oncological outcomes ( % r ) and the encouraging safety profile ( %). regarding the operative time our data are similar or better as compared to those reported by the previous literatures and didn't differ by the most recent published data for laparoscopic gastric resection. the anatomical hand-sewn reconstruction performed by precise hand-sewn suture instead of the usage of mechanical staplers represents a real great advantages of robotic resection. in our series, no patients suffered from stenosis or leakage after operation. background: we describe the use of a different suture from those historically used in the elaboration of a widely spread surgical technique such as the nissen fundoplication, for the treatment of pathological gastroesophageal reflux or symptomatic hiatal hernias. in our unit we have implemented the use of / irreabsorbable barbed suture to close the diaphragmatic pillars and the °fundoplication with the same continues suture. aim: the objetive of the use of the irreabsorbable barbed suture in the nissen fundoplication is to shorten the surgical times, which would achieve benefits for the patient and the institution, increasing the number of ambulant patients and the number of patients to be operated the same surgical session. objective: the goal of the present study was to demonstrate that intraoperative icg fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. method: fifty milligrams of icg dissolved in ml of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys weeks before a laparoscopic lymphocele marsupialization procedure. results: during the first exploratory laparoscopy, in the flank and right iliac fossa, near the renal grafts, fluorescence was identified in raised areas that were the internal side of the lymphocele lobes. the lymphocele wall was dissected and ml of serous fluid was aspirated after puncturing. a cm breach was then made in the cyst wall using the ultracision harmonic scalpel (ethicon us). afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by stitches. conclusions: laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. intraoperative icg fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery. conclusions: this method proved safe and risk-free, easily reproducible and without the need for a different toolkit than the one of a modern operating theatre. the preliminary analysis shows a strong correlation between the perfusional data so far obtained and the early outcome of the graft. thus opening the way to further analysis aimed to a future better management of post-operative immunosuppressant and support therapy. these results are quite encouraging, even if our study is at an initial stage. conclusions: results show a persistent dread across specialities regarding ai. rather than be seen as threat, ai should be embraced by clinicians as it will ease the ever-increasing daily workload faced. this will enable clinicians to focus their skills on patient centred activities, interventional procedures and development. despite current regulatory hurdles, ai implementation in medicine is unavoidable. this coming revolution presents a unique opportunity for endoscopist and radiologist to refocus their expertise in novel areas. project description: from february to july a three-armed proof of concept study was conducted at three hospitals, in three groups of patients; recurrent ventral hernia, aortic aneurysm, and healthy controls. patients were measured once at the outpatient clinic using an electronic nose based on three metal oxide sensors. measurement data were compressed to low-dimensional vectors using a tucker like algorithm, and used to train an artificial neural network (ann) to provide a classification between patients (? ) and healthy controls (- ). preliminary resultsa total of patients (hernia n = , aneurysm n = ) and controls were included in the study. based on receiver operating curve (roc) analysis, the ann could differentiate between recurrent hernia patients and controls with the following details: area under the curve (auc) . , sensitivity . , specificity . . aortic aneurysm patients and healthy controls could be differentiated with an auc of . , sensitivity of . , and specificity of . . the aeonoseÒ enose can reliably distinguish patients with weak collagen (recurrent hernia and aortic aneurysm patients) from healthy controls. validation of these results in a prospective cohort study is required before clinical application of the device. background: laparoscopic and endoscopic cooperative surgery (lecs) has been performed gastric submucosal tumor (smt) or duodenal tumor. although minimally invasive surgery using thoracoscopy has been the usual approach for esophageal smt, the treatment method combined thoracoscopy and endoscopy has not been established. in addition, submucosal endoscopic tumor resection (set) for esophageal smt was reported using the technique of submucosal tunnel. aim and project description: we planned to resect large esophageal smt located in the upper or middle thoracic esophagus by a combined endoscopic and thoracoscopic approach. because set is only recommended for tumors up to mm in size owing to the limited submucosal space available and the left thoracic approach is restricted by the aortic arch and the trachea. preliminary results (case presentation): a -year-old woman was diagnosed with a benign schwannoma of length mm originated from either the submucosal or the muscular layer of the middle thoracic esophagus by endoscopic ultrasonography, enhanced computed tomography, and ultrasound-guided fine-needle aspiration biopsy. since the tumor had increased in the years and she had a symptom of dysphagia, we planned to resect it by a combined endoscopic and thoracoscopic approach. on endoscopy in the supine position, a submucosal tunnel was created mm proximal to the cranial edge of the tumor, and its only oral end was dissected from the mucosal and muscular layers. this was followed by the resection of the entire tumor by left-sided thoracoscopic procedure in the prone position. endoscopic mucosal closure was achieved by using clips. no postoperative complications were observed. large benign esophageal tumors can be safely excised with minimally invasive surgery by using a combination of endoscopy and thoracoscopy. background: haemorrhage remains a major cause of morbidity and death in all surgical specialties. in laparoscopic surgery. relatively small amounts of blood can obscure the view of the operative field and increase the risk of injury to surrounding structures. excessive bleeding often leads to longer hospital stays, increased healthcare service utilisation, and higher healthcare costs, among other negative consequences. aim: the aim of this study was to analyse the feasibility of purastatÒ, a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery. project description: this was a prospective observational non-randomised study. consecutive patients undergoing laparoscopic colorectal surgery were enrolled. informed consent was obtained from all patients inclusion criteria was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended/ appropriate due to proximity to ureter, pelvic/sacral veins and other important structure. preliminary results: twenty patients were enrolled ( males ( %) and ( %) females). mean age was years (± , years). all patients were undergoing elective laparoscopic colorectal cancer surgery ( right hemicolectomy, sigmoid colectomy, anterior resection). we utilised mls of purastatÒ in all patients. the mean area of application was , cm (± . cm ) with the amount of purastatÒ needed per centimetre being . mls. the mean time to apply the product was secs (± s), whereas the mean time to achieve haemostasis was , secs (± . s). there were no post operative complications in this cohort of patients. mean operative time overall was min (± . min). none of the patients experienced delayed post-operative bleeding and the mean hospital stay was days (± . ). in conclusion, according to the purpose of this preliminary study, we have demonstrated that purastatÒ can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. this is a feasibility study and additional controlled studies would be useful in the future. during last three years the laparoscopic method of surgery in the presence of common bile duct stones was carried out. after performance of intraoperative cholangiography and visualization of stones in the common bile duct laparoscopic, choledochotomy and bile duct stones extraction was undertaken in patients, using flexible choledochoscopy control. in all patients with gallbladder stones was then performed laparoscopic cholecystectomy. results: laparoendoscopic intervention on common bile duct was successfully performed in patients ( . %) and the operation was completed by common bile duct drainage by kehr. in patients due to technical difficulties conversion to open surgery was carried out. postoperative morbidity in the form of bile leakage were diagnosed in patients ( . %). in three cases they stopped spontaneously in - days after the operation. patients were operated on repeatedly and additional suturing on choledocholithiasis was carried out. postoperative mortality was . %. the death of the patient of years was caused by acute cardiovascular failure. institute for image guided surgery, ihu-strasbourg, strasbourg, france; hepato-digestif, nouvel hôpital civil, strasbourg, france; image guided surgery, nouvel hôpital civil, strasbourg, france; gastroenterology, chu-besancon, besancon, france; gastroenterology, chu-lyon, lyon, france; gastroenterology, clinic de trocadero, paris, france background: eus is difficult to learn and has a steep learning curve. therapeutic eus (teus) is even more so. simulators, ex-vivo models and phantoms are the most common current teaching modalities but are felt by many to be unsatisfactory for high-level training. aim: we designed a training curriculum for teus that uses high-fidelity animal models and present a validation study performed by teus experts. project description: different simulated pathologies were created in each of acute pigs. teus experts performed therapeutic procedures in two or more animals over two days. each intervention was evaluated simultaneously using a structured survey by an non-expert observer. data included demographics and procedure details as well as likert-scale evaluation of the quality, realism and education utility of the simulations. global evaluation of the experience was captured from the experts as written comments. all data was consurrently registered and subsequently analysed by two blinded surgical educators. methodology: three types of models were created using surgical access: -tumors (injection of types of hydrogel), -retro-gastric collections ( - cm long intestinal loops filled with oatmeal, oil-water and gel), -obstructions (bile duct and ureteral ligations days prior to experience). gastric, pancreatic and liver tumor models were used for fna and fnb practice. retrogastric fluid collections and choledochal/ureteral obstructions were used for cyst gastrostomy, hepaticogastrostomy, gallbladder drainage and kidney drainage. results: experts age: - , median intervention time min , total of interventions evaluated, overall quality of experience: ( %) ranked - (excellent), ( %) from - (good), ( %) from - (poor), / procedures were successfully completed. models were rated good to excellent quality ( - ) in ( %), poor quality in ( %). for % ( ) of the interventions the model was considered not good enough to be repeated (solid retrogastric tumor and peripheral hepatic lesion). conclusion: high-fidelity live animal models with simulated pathologies are considered to be excellent training tools by experts and may provide a better learning experience for teus. surg endosc ( ) in our short videos, we present scenarios in which this technology helped: to distinguish a significantly dilated cystic duct from the cbd, to identify an anterior cystic artery in the contest of acute inflammation, to identify a luksha duct, to exclude a leak after endoloops positioning on cystic duct. intra-operative augmented visualisation of biliary anatomy with indocyanine green cholangiography is an essential technology tool with the potential to extend the hour window of safety for emergency cholecystectomies, with significant logistics benefits. introduction: endoscopic resection of subcardial polyps has its limitations; especially when it is necessary to dry out the entire gastric wall. uniportal intragastric surgery is a good alternative for the exeresis of subcardial premalignant lesions with gastric preservation. patient and method: we present a video with two cases. technique: we perform a laparoscopy to explore the entire abdominal cavity, then we open a . cm hole in the great curvature; a cm incision is made in left hypochondrium and the uniportal device is placed inside de stomach. we inject serum in the submucosa with a endoscopic needle. when submucosa is completely separated from muscular lay; a submucosal exeresis can be made; but when there is not a complete separation after injection, then we perform a entire wall resection with a cm circular margin. if a complete wall resection is made, then we close the defect with a barbed suture. results: case : years old male with a , cm subcardial polyp, preoperative biopsy was informed as severe dysplasia. in the laparoscopy we saw an unknown lesion in the great curvature that looked like a gist. we placed the uniportal device intragastric and proceed to the submucosal serum injection. as the submucosal lay was completely separated from muscular, then we performed a submucosal exeresis. we close the gastrotomy and made the resection of the great curvature lesion with endostapler. the pathological analysis confirmed the severe dysplasia in subcardial lesion and gist in the great curvature lesion. patient was discharged with no complications after days. case : years old male with a cm subcardial polyp. preoperative ecoendoscopy suggested a muscular layer infiltration but only severe dysplasia was found in the previous biospsy. laparoscopy did not found more lesions, and uniportal intragastric device was placed. a complete wall resection was made, and the defect was closed with manual barbed suture. pathologyst confirmed severe dysplasia and unaffected margin. patient was discharged with no complications after days. conclusion: uniportal intragastric surgery is feasible and safe and may be useful for subcardial premalignant lesions when endoscopic resection is very difficult or not feasible. introduction: the role of icg in bariatric surgery is still unclear. knowing the lack of perfusion in the gastric pouch could be of great interest in revisional surgeries; but the question remains: is the current icg technology reliable enough to make intraoperative decisions in bariatric surgery? methods: we have carried out a check of tissue perfusion with icg fluorescence in several cases of primary and revisional bariatric surgery. a solution of , mg/kg was injected intravenously and icg fluorescence was performed. we looked for the correct staining of the entire gastric pouch and the intestinal loop trying to rule out areas of tissue ischemia. results: the cases in which the test was performed showed a minimal delay of - s between the intestinal loop stain and the pouch. a correct staining was observed in all but one case shown in the video. is the case of a years-old male patient who was operated years earlier in another center; at that time he underwent a sleeve gastrectomy. we evaluated the patient for persistent gastroesofhageal reflux of years of evolution with esophagitis. we offered revisional surgery to perform gastric bypass and hiatal closure. fundus was dilated so a funduplasty was performed instead of using endostappler in the vertical side of the pouch. manual anastomosis gastric bypass was performed. when the icg test was performed, a corner of the pouch does not stain green (an area of , cm) . so the decision was to resect that part and redo the anastomosis or wait and see. it was decided not to resect and the patient was discharged two days later with no complications and good outcome with a months follow up. conclusion: icg fluorescence may be useful in bariatric surgery in the future but more evidence is needed of its usefulness in making intraoperative decisions. background: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging of lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results for detection of aberrant lymphatic drainage outside of the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems in order to identify the lymphatic nodes. aim: the objective of the experimental study is to investigate the possibility to detect the sentinel lymph nodes after the injection of different solutions with indocyanine green in the subserosal colonic layer in the pig. project description: twelve female large white pigs were operated with laparosocpic approach and spies optic filter (karl storz, germany). indocyanine green was injected in the subserosa of the colonic wall ( ml at points). lymphatic flow was observed at - - - - and min, searching for the migration of the icg by the lymphatic channels and its introduction in the sentinel nodes. preliminary results. the identification of the sentinel nodes is very difficult with the solution of icg-sterile water. with this technique we can see the lympjatic channels but not the lymphatic nodes. the adition of % human albumin as a transporter of the icg is very helpful for the correct identifiaction of the lymphatic channels at - - min and the correct visualization of the lymphatic nodes at min after the bowel injection. addition of other transporters like dextran solutions may be helpful too but the time to the correct visualization is longer. there was significant difference among the three groups as regards postoperative les and postoperative ph metery.the incidence of persistent dysphagia was significantly higher in the group i. postoperative gerd symptoms were significantly higher in group iii ( . %. p \ . ). recurrent achalasia was significantly higher in group i ( patients . %, patients in group ii ( . %) and nil in group iii (p \ . ). in conclusion: longer myotomy on the gastric side ([ . cm) ensures complete division of the les with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative gerd. therefore, a myotomy length of . to . cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative gerd. c/t scan of his abdomen revealed a large groin hernia with signs of small bowel obstruction and collapsed distal bowel. emergency theatre was organised for this patient with anaesthetic assessment prior to his surgery. initial plan of local exploration with possibility of small resection was changed once he was under full anaesthetic with muscle relaxation. his abdominal girth provided an opportunity to utilise laparoscopic intervention as an initial approach. laparoscopy with degree lens revealed moderately distended loops of small bowel and a large omental mass along with a loop of small bowel incarcerated in right direct inguinal hernia site. background: robotically assisted surgery is a rapidly developing modality of minimally invasive surgery with proven advantages in the management of cancer. despite its increasing prevalence, there is still an ongoing debate regarding its future role in colorectal surgery. while the prospective randomised multi-centre studies provide research evidence for its potential efficacy, an assessment of its effectiveness and realistic outcomes in everyday clinical practice can add an important perspective to this discussion. the international robotic colorectal registry will allow to compile and pool the international robotic colorectal experience. aims: the aim of the international robotic colorectal registry is to monitor the safety and outcomes, as well as the quality of specimen of robotically assisted colorectal surgery for malignant and benign diseases of the colon and rectum. the primary endpoint is a composite oncological failure. the secondary endpoints include anastomotic leak, resection margin involvement, conversion rate, operative time, post-operative -day morbidity and mortality, long term oncological outcomes, quality of life, functional outcomes and cost-effectiveness. project description: the international robotic colorectal registry is a multicentre web-based, online secure database. the registry has been awarded an ethical approval by a relevant national committee. all surgeons performing robotic or robotically-assisted surgery are invited to participate. the data collected includes patient demographics, cancer characteristics, operative details, histology of the specimen, wound healing, post-operative therapy, readmission, quality of life and functional (bowel, urinary and sexual) outcomes. all the sensitive patient information is encrypted before its introduction into the database. preliminary results: so far, twenty robotic colorectal centres have joined the international robotic colorectal registry. the preliminary results will be published once patients have been enrolled. univariate and multivariate analyses will be performed to identify possible risk factors for poor outcome.the possibility to record open, laparoscopic or other minimally invasive colorectal procedures will facilitate comparison of the outcomes of the robotically assisted surgery and other modalities. the registry will also allow each surgeon enrolled to monitor their skill progression and outcomes over the time. results will be published in surgical literature and presented internationally. background: gastric outlet obstruction (goo) due to benign strictures is an uncommon surgical entity today. this paucity relates to the decrease in its aetiological factors in the modern era as well as to advances in both prevention and medical as well as endoscopic treatments of such condition. the most common of causes relating to peptic ulcer disease, has been subdued for decades with quality acid control medications. on the other hand advances in gastroscopic dilatations skimmed even more the frequency of these cases from arriving to surgical intervention. aim: this presentation gives an update on the standing of this pathology and its surgical management today. it will also shed a light on our early experience in this condition at the royal hospital of muscat in oman. project description: a case series of all patients with goo, who were surgically managed between and results: there were a total of patients, males and females. the cause of obstruction was peptic ulcer disease in , corrosive injury in , iatrogenic perforation in and idiopathic hypertrophic stenosis in . emergency presentation was seen in . management included jaboulay pylorpolasty in , resection in (distal gastrectomy in , total gastrectomy in ) or a bypass (gastrojejunostomy) in . in of the above, the procedure was done by laparoscopy. post operatively, temporary gastric paresis delayed recovery in , however all symptoms resolved in . there were no recurrences at minimum of years of follow up. in spite of advances in medications and gastroscopy interventions, we still seem to identify this condition within our population. although infrequent, they demand awareness from surgeons since they could be managed successfully, especially laparoscopically, with minimal morbidities and early recovery. the introduction of advanced laparoscopy to the unit's setup in recent years, made such option feasible with satisfactory and durable outcomes. background: gists of the upper gi are found mainly in the stomach ( - % of cases) and small intestine ( %). duodenal gists however, comprise a smaller subset with a frequency of to %. the optimal surgical procedure for duodenal gist is still evolving. since wide margins and extensive lymphadenectomy are not required, restrain from more radical resections in this area would be a valid option. aim: this is a video case report of a patient with a gist involving the third part of the duodenum treated by laparoscopic lateral duodenectomy and end-side roux-en-y duodenojejunostomy case report: years lady presented with recurrent mid abdominal postprandial pain with anorexia, nausea and occasional vomiting an ultrasound showed well defined hypoechoic mass of . . cm at the right para-aortic region . ct scan defined the mass as retroperitoneal, intimately related to the pancreas uncinate process and the third part of duodenum with no clear cleavage line between them. an mri endorsed the diagnosis of gist of the duodenum. she was operated upon through a laparoscopic lateral duodenectomy including the gist at the third part of the duodenum. a frozen section confirmed the clear margins . reconstruction was done by a roux-en-y duodenojejunostomy with the alimentary limb taken cm from the dj flexure. she had an uneventful post operative recovery and was discharged well. the histology confirmed a low grade gist tumour hence no further treatment was needed. at follow up six months later, she was doing well and gaining weight. conclusion: complex anatomy of the pancreatico-duodenal area makes conserving the duodenum for tumours rather than a major resection a challenging option. in our case however, with the disease in the third part being of a moderate size, a lateral duodenal wall resection including the mass was possible rather than a segmental resection. this procedure could be an ideal choice for benign, moderate sized tumours in the third and fourth part of the duodenum. background: during laparoscopic colectomy, laparoscopic lymph node dissection and extracorporeal intestinal anastomosis is commonly performed. an umbilical incision of - cm and wide-range mobilization of the intestinal tract is required for extracorporeal anastomosis. previously, we introduced intracorporeal overlap anastomosis in june as a minimally invasive treatment. here, we report its short-term outcomes. aim: we retrospectively compared the surgical outcomes of cases of extracorporeal anastomosis and cases of intracorporeal anastomosis, all of which were performed between june to may . procedures: after lymph node dissection and sufficient mobilization of the intestinal tract, the proximal and distal intestines were resected perpendicularly to the intestinal tract with a -mm linear stapler. the anastomosis was performed after the specimen was extracted from an umbilical incision. the opposite sides of the mesenteric margin cm from the staple line of the one intestinal tract, and cm from the staple line of the other intestinal tract, were marked, and then the respective intestinal tract was positioned to join the opposite mesenteric sides together. an insertion hole was made in the intestinal tract at the marked site. side-to-side anastomosis with a linear stapler was performed, and then the insertion hole was closed with a linear stapler after several temporary sutures. preliminary results: in the extracorporeal anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. furthermore, there were three intraoperative cases of bleeding ( . %), and two postoperative cases of lymphorrhea ( . %) that occurred. however, in the intracorporeal overlap anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. additionally, there were no cases of intraoperative complications, and only one postoperative case of lymphorrhea ( . %). conclusion: intracorporeal overlap anastomosis in laparoscopic colectomy is safe and feasible, and can be used as a minimally invasive treatment. nowadays d-printing it's not a new technology any more but with an exponential developing. there are beliefs that in % of everything that will be produced will be d-printed. in medical field this technology knows the same exponential developing. first used in orthopedics and maxilo-facial surgery now d-printind is used in many other fields for different reasons, like preoperative training models, surgical special instruments, in medical education, etc.. liver surgery is in continuous developing and this is the reason why we need experimental liver model for training and testing. a best liver experimental model should heave liver consistency, to be flexible, to heave the same ultrasound feedback, to be cheap and easy to be reproduced. this is why we developed a liver experimental model made of gelatin by a simple recipe, using a dprinted mold, created after a human liver ct-scan. first was made the segmentation of the liver. after segmentation we create the d virtual liver model and the negative image of the liver, which was used for creation of the pieces of the liver mold, with connections between them and a hole on the top to pour the gelatin solution. ( ) ethical concerns on learning and training with real patients and substitutives such as animals, and ( ) reconciling time devoted to learning with clinical practice, considering the european work time directives. simulation in medical education is and has been the preferred route to address both pedagogical needs. virtual simulation has proven to be a valid tool for training; however, current systems restrict usage to tasks and modules offered, without possibility of personalization. we present the minimally invasive surgery simulator scenario editor (mis-sim) an environment where users can create, edit and run virtual reality tasks designed for medical training. the environment features an editor allowing users to develop learning tasks, defining its learning objectives and task goals in an easy way. a first proof of concept has been implemented for surgical training and training activities (demostrators and short courses) have been carried out in three european sites: spain, the netherlands and hungary. during training activities, different exercises have been created and uploaded to the contents' database. trained technical skills include handeye and bimanual coordination, instrument handling and pulling. preliminary results with users have shown mis-sim training potential, although some functionalities should be made easier. personalization has been highlighted as the key added value of mis-sim with respect to the current competitions in the market: the ability for target users to use virtual reality based learning tools while remaining in complete control of the learning process. mis-sim aspires to break the barrier between vr and medical education by empowering users to create their own tasks. with mis-sim teachers/course creators and learners (healthcare professionals & future healthcare professionals) will benefit from an innovative tool to ( ) create personalised medical learning contents tailored to preferred learning styles, allowing the creation of individualize learning paths; ( ) improve the efficiency of training by focusing on the training needs of the learners and ( ) share and sell vr-based didactic contents. c. tiu , p. sánchez-gonzález , m. chmarra , d. gutiérrez , c. guzmán-garcía , l. sánchez-peralta , g. wéber , f. sánchez-margallo , b. pagador , j. dankelman aims: currently surgical training is largely based on the improvement of technology enhanced learning solutions. the progress of engineering and the diversification of training facilities outside the operating theater results in an even greater contribution of technology in the future. the main reasons to encourage these changes are increased efficiency of simulators and directly increased patient's safety. the goal assumed by the easier project is to develop multi-skill, online platforms for minimally invasive surgical (mis) procedures-based on common pedagogical principles with reference value in a multinational space. the platform will allow the connection of external assets (such as simulators) to centralize all training data from residents. this work presents the milestones of the project during its first year of life. methods: the consortium's activity started with a knowledge elicitation process organizing brainstorms and workshops including experts in mis and interventional techniques, from spain, romania and hungary. this experience led to the formulation of a questionnaire that was implemented online and sent via email to surgeons and residents from the participating countries. results: accumulated experience was used to define the pedagogical needs of the platform. the pedagogical needs form the starting point for defining the technical requirements and specifications. based on them, the design of the platform has been achieved, including its architecture and communication protocol between external assets design, facilitated by the use of state of art educational standards. discussions and conclusions: next steps include the implementation of the easier platform, as well as the definition of cases studies selected by the clinical partners in spain, romania and hungary to solve applications of the platform dedicated to cholecystectomy, lumbar puncture and arthroscopy. a pedagogical model, built by the experience of the consortium, is being used to guide instructional design of the course. finally, results will be validated in a multi-center validation study.the easier project will create a training platform with reference value for european surgery. the structure of the consortium, based on the confluence between collectives with clinical, technological and pedagogical experience, will generate a complex learning tool in surgery embodying technology-based training systems with clinical experience. background: the treatment of groin hernia is an important part of our daily surgical activity. aim: we proposed to evaluate outcomes of the laparoscopic trans abdominal pre peritoneal treatment (tapp) of the groin hernia. project description : one hundred and fifty patients who underwent a tapp for a groin hernia were included in a retrospective study between january and november . results: the gender ratio was . the average age was , years. twenty percent of patients had a history of abdominal surgery. the operative indication was a unilateral hernia in % of cases, associated with an umbilical hernia in % of cases, a recurrent groin hernia in % of cases and a bilateral inguinal hernia in % of cases. the conversion rate was . %. the hernias were classified according to the ehs classification in l type in % of cases, l in % of cases, l in % of cases, m %, l r in % of cases and f r in % of cases. a contralateral inguinal hernia was discovered in % of patients. a polypropylene mesh x cm was fixed by a stapling in % of cases and by a suture in % of the cases. the average operation time was min. the hospital stay average was , day. an antalgic treatment was prescribed in % of patients. the average time to return to normal physical activity was days. a postoperative seroma was noted in % of patients. no cases of mesh suppuration were noted. chronic pain was noted in two patients. no recurrence was noted with an average follow-up of months. conclusion: laparoscopic treatment of the groin hernia by tapp had good results concerning the postoperative pain, early recovery of physical activity and aesthetic damage. a larger setback is needed in our study to evaluate the recidivism rate. background: surgeon's training in ultrasound is viewed and understood differently in different parts of the world. if in united states the need for surgeons' training was accepted and taken over by the american college of surgeons, in europe the practice is completely different from one country to another, from one city to another, from one department to another within the same premises hospital. in some european countries, surgeons currently use ultrasound for diagnosis-especially in urgency, for follow-up, intraoperative, or as guidance for many surgical gestures. during this time, access to ultrasound of other surgical specialties-gynecology, urology, ophthalmology-is considered natural. material and method: once the decision to initiate an ultrasound course for surgeons was taken, a team of experts with technical or clinical expertise in ultrasound was organized. at the initiative of the technology commission, the courses were to be organized at the eaes congresses or others communication events endorsed by eaes. starting from the importance of each ultrasound application in surgery, it was decided to develop different modules to solve different training needs. at this time, the course offered at seville covers the capitols like abdominal ultrasound, guided punctures and trauma. a module dedicated to intraoperative ultrasound is under construction and will be available in november . the course has a skill abilities dominant character, two thirds of it being thought of as a hands-on application on stationary, classical ultrasounds with large screens and also on small size wireless actual devices. results: after his debut in frankfurt in , the course was resumed in london and in bucharest, twice. in this process, new modules and better teamwork skills have been developed. the participants' satisfaction quizzes, coming from all continents, were really encouraging. for the intraoperative ultrasound module the team approach is unique. students will have the opportunity to practice on live animals both laparoscopic and open abdominal procedures conclusions: the ultrasound for surgeons course initiated by eaeas was received with interest. the team will seek to inspect the real needs of training surgeons in this field and will complement and diversify the current platform surg endosc ( ) preliminary results: a total of procedures ( - , ± . ) were carried out in patients. the indications included acute ( leaks following esophageal resection, rupture of the strictured anastomosis following pneumatic dilatation) and chronic conditions (esophagopleurobronchial and gastropleurobronchial fistulas following the resection of esophageal diverticulum and sleeve gastrectomy). the initiation of the therapy was in , and day in case of acute conditions, and after years of the duration of the unsuccessful therapy in chronic cases. the successful closure was observed in patients, patient passed from mods and ards. in case, the initiation of evac was provided as a combined surgical and endoscopic intervention (ct proven distant intraabdominal abscesses). in chronic cases, was discontinued due to the haemophagocytic syndrome of unknown etiology, in the second one, success in reduction of the lesion and symptomatology with long term duration was observed following just applications of evac, despite minimal remanent leakage. the success is to our experience linked to early initiation of the therapy and presumes complex intensive care. the future investigation should specify the timing including preemptive use of evac and the combination of evac with other endoscopic, interventional and surgical therapeutic modalities. the aim of this feasible study is to investigate complete robotic esophagectomy with total mediastinal lymph node dissection (retm) only by the robotic arms. methods: the patient is placed hemi-prone position with one lung ventilation by blocking balloon tube under general anesthesia. the robotic trocar for st arm of da vinci xi surgical system is placed in the th intercostal space (ics) on the scapular line, the trocar of nd arm is placed in the th ics on the posterior axillary line, rd arm trocar is placed in the th ics on the middle axillary line, th robotic arm trocar is placed rd ics on the middle axillary line, and assistant trocar only for taking in and out of gauze is placed in the th ics on the middle axillary line. on the upper mediastinal lymph node dissection, robotic camera exchanges from nd to rd robotic arm to close and identify anatomical structures. esophagectomy with lymph node dissection starts from middle and lower mediastinum to upper mediastinum including along bilateral recurrent laryngeal nerves. all procedure perform under close-up view along the robotic enhanced anatomy to preserve organ functions. background: complete stenosis of the duodenal lumen secondary to a surgical suture in the treatment of a duodenal ulcer is a rare complication. the usual surgical resolution corresponds to a gastrojejunostomy associated or not, to an antrectomy with vagotomy, as a treatment for the peptic disease. the endoscopic resolution of this complication requires the use of complex maneuvers and specific therapeutic instruments. aim: to describe the endoscopic resolution of iatrogenic occlusion after raffia of perforated duodenal ulcer. description: a -year-old man was admitted to the emergency service for four days of pain and abdominal distension associated with abundant retention vomiting. performed ten days ago of a perforated duodenal ulcer, in which manual raffia was performed in two planes and drainage. abdomen and pelvis ct showed great distension and diffuse thickening of the gastric wall. the endoscopy showed abundant gastric retention content, pylorus, and bulb edema, and complete closure of the duodenal lumen, secondary to suture material; it was possible to count three suture threads. with a tipped papillotome and electrocautery, all the suture threads were sectioned, identifying a filiform opening through which a hydrophilic guide is inserted under fluoroscopy until it is sure to overcome the stenosis; we dilated the trajectory with a dilator of mm in diameter and cm in length. with a contrast medium, we observed an adequate trajectory and installed a partially covered duodenal metal stent (hanaro stent) of cm in length by mm in diameter in order to sustain the dilation. he was sent to home with inhibitors of the proton pump. after two weeks, the stent was removed, without complications. he was controlled two weeks after withdrawal, and, with pharmacotherapy, the patient was asymptomatic, making a normal life. conclusion: in this case, the result was positive. satisfactory results can prevent major surgery, which reduces the risk and possible complications. a new range of non-invasive medical tools with a remarkable improvement on the existing market. a manual laparoscopy, with the important novelty of having a bending head with a high degree of movement. this head can get multiple spatial positions to work in surgery and is very easy to use, with the same scissors thimble who controls it, so its performance and learning is very simple and intuitive. the tools can be easily reusable and they can be cleaned and sterilized by ordinary methods, very ergonomic and lightweight . the generic type models we initially have developed are focused in general surgery, but gradually we will develop new applications and different heads for specific medical conditions such as arthroscopy, laryngoscopy, otolaryngology, ophthalmology, orthopedics . its operation is simple and functional, simply moving the scissors thimbles, where they have a dual role, combining the head tilt and the action of opening and closing of this is achieved.the design of this tool allows us to work with some degrees of unparalleled freedom from the existing tools. our instruments replicate the movements of the robot with a simple handheld mechanical instrument, our philosophy is to position our instruments in between a long empty field between the surgeon and the robot. the tip of our instruments are providing the surgeons with angulations impossible to reach with the traditional instruments unless applying huge movements from the hands of the surgeon. we consider that this devices will have a very fast acceptance from the market as this robotic type movements can be managed by the surgeon through the traditional mm trocars, without the need to change to a new surgical technique, just with the traditional method and a very brief training. background: diverticula of the middle thoracic esophagus are infrequent, its etiology may be secondary to traction or pulsion mechanisms. when the etiology is a mechanism of pulsion, they are associated with esophageal motor disorders and its prevalence is estimated between . % and . % of the population . they are rarely symptomatic and the diagnostic is usually incidental. the most common symptoms are episodes of food impaction, chest pain or bronchoaspiration.diverticulectomy and esophageal myomectomy by minimally invasive approach is the treatment of choice in those with large size or associated symptoms. aim: to describe a clinical case of esophageal diverticulum solved by minimally invasive surgery approach. clinical case description: a -year-old patient with a history of epilepsy and hypothyroidism consulted for atypical chest pain and dysphagia to liquids and solids. a study with esophagogastroduodenoscopy was performed: cm from the dental arch, a large wide-mouth diverticulum was identified. we complete the study with an esophagram with barium: voluminous diverticulum in the right lateral face of the middle esophageal and a thoracic ct scan showing esophageal diverticulum located in the carina, from . x . cm to cm from the esophagogastric junction. due to the suspicion of associated motor disorder, high resolution manometry was performed showing a significant motor disorder with alteration of peristalsis and exit obstruction with incomplete relaxation of the inferior sphincter and superior hypertonic sphincter. preliminary results: the patient underwent surgery: diverticulectomy and complete esophageal myotomy by thoracoscopy minimall invasive approach. the patient evolved favorably and was discharged after days with a previus control esophagram without pathological findings. currently, it remains asymptomatic months after surgery. , rectus muscles are re-approximated from xiphoid to pubis using laparoscopic running self-locking, pds sutures to restore anatomy and physiologic function of the abdominal wall. unlike the standard access to the abdominal cavity executed with lateral access, the lap-t technique is performed through sopra-pubic aesthetic approaches, using one mm and one mm bariatric ( cm) instruments laterally, and one mm camera in the middle.the entire procedure is performed in gas-less laparoscopy, with laryngeal mask and intra-peritoneal liquid anesthesia. the repair is consolidated placing an intra-peritoneal semi-absorbable mesh. preliminary results: in all cases abdominal functioning was successfully restored; no higher pain related to the continuous laparoscopic suturing has been reported compared to bridge ipom laparoscopic repair, while allowing for a more physiologic outcome and a stronger repair. the use of miniaturized instruments allowed for minimal tissue trauma and accurate surgical gestures; the tiny trocar sites did not require skin suturing and might reduce the risk of trocar hernias. no intra operative bleeding, no seroma formation, chronic pain, nor mesh infection have been recorded. % follow up at months, % at months with no recurrences observed. the lap-t technique allowed for a sound and anatomic reconstruction, reduced trauma, faster recovery and more satisfactory aesthetic results. surg endosc ( ) background: anastomotic leakage is a serious complication, associated with significant morbidity and mortality. one possible cause of anastomotic leakage is insufficient vascular supply. markers of sufficient perfusion include pink color of the bowel wall, visible peristalsis, palpable pulsations and bleeding from the marginal arteries. these signs are subjective and may be misinterpreted even by experienced surgeons. aim: the assessment of bowel perfusion with the use of indocyanine-green fluorescence angiography might be helpful in decreasing the number of anastomotic leaks. project description: we report a case report of a middle-aged patient without significant medical history who was treated by transanal total mesorectal excision (tatme) for rectal carcinoma. the patient underwent neoadjuvant treatment with radiochemotherapy. during the surgical procedure, indocyanine-green fluorescence angiography showed adequate perfusion of the bowel. the postoperative phase was uneventful and the patient was discharged home on the th postoperative day. preliminary results: indocyanine-green fluorescence angiography is a safe, cost-effective and feasible tool for assessment of tissue perfusion during colorectal resections. background: to properly learn how to perform a laparoscopic suture, along with safe tissue handling, applying an appropriate magnitude of the force on the tissue is essential. for this reason, it is fundamental to investigate and validate if training with real-time visual force feedback improves the suturing performance of laparoscopic novice surgeons. capturing all of the forces applied in laparoscopic in surgery in an unobtrusive way has been difficult in the past. sensor has supplied a novel force-sensing film (forcefilm) that can detect all of the forces applied with laparoscopic instruments without changing the surgical workflow or operation of the instruments. aim: to evaluate the effect of visual force feedback on surgical performance, applied force and surgeon's ergonomics during training of laparoscopic suturing using the sensor technology (sensor medical laboratories ltd.). methods: twenty novice laparoscopic surgeons participate in this study. they perform a laparoscopic suture on an ex vivo stomach tissue from a pig. participants are assigned, in a random fashion, to either group that receives visual force feedback (a) or the control group (b) without visual force feedback. five training trials (t -t ) are carried out in order to assess the learning curve. in addition, an evaluation pretest (t ) and posttest (t ), without visual force feedback but recording the force applied, will be performed after the training trials. the applied force on the tissue and visual force feedback of each instrument are provided by means of the sensor technology. it accurately measures the forces exerted on the tissue from the instrument tip and wirelessly communicates the force information to the surgeon via visual force-feedback. during each trial, several parameters are evaluated such as execution time, applied force, surgical performance, and mental and physical workload. preliminary results: laparoscopic training using visual force feedback leads to an improvement of suturing skills with a reduction of the applied force and therefore providing a potentially positive effect on patient outcomes and surgeon's ergonomics. background: hiatal hernia is a frequent disorder, characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the diaphragmatic hiatus. current anatomic classification is mainly based on the location of the gastroesophageal junction and the presence of a true hernial sac, differentiating sliding from paraesophageal hernias. there is no solid evidence to support an association between gastric carcinogenesis and peh. however, chronic reflux is considered as one of the strongest risk factors of developing adenocarcinoma of the esophagus and proximal stomach. aim: herein, we report a case of an -year-old caucasian female with dysphagia, regurgitation and heartburn accompanied by an iron deficiency anemia, a remarkable total body weight loss and recurrent lower respiratory tract infections due to microaspirations. subsequent work-up with ct, upper endoscopy and barium esophagram confirmed the presence of synchronous distal gastric adenocarcinoma and a giant paraesophageal hernia with complete intrathoracic stomach. after mdt discussion and keeping in mind the patient's age and comorbidity, a d laparoscopic distal gastrectomy with a synchronous hernia reduction with posterior cruropexy was scheduled. project description: the patient was placed in a supine position, five thoracoscopic ports were introduced, and a diagnostic laparoscopy of the abdominal cavity was performed. the stomach was identified through the dilated hiatus into the left thorax. the hernia sac was dissected away from mediastinal structures, then excised to untwist the stomach. after reduction of the stomach to abdominal cavity, a total d ? gastrectomy with a roux-en-y reconstruction was performed. maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency and safety. hampered vision is commonly caused by laparoscopic lens fogging (llf) and lens condensation which has prompted the development of various antifogging fluids and warming devices. numerous tricks have been proposed to overcome this issue, such as heating the scope into a sterile thermos flask filled with hot water, or using one of the commercially available antifogging solutions. however, whether one method is superior to another remains elusive. as most surgeons know, none of these tips are totally efficient, as they don't treat the cause: the temperature difference. taking into account this need, we have developed ehs (endoscopy heater system), a thermoadjustable system by microcontroller, which is implemented in the manufacturing process of the rigid endoscope focused on laparoscopy. the technology enables the self-modulation of the temperature of the endoscope within the different conditions during the surgery, avoiding the % of laparoscopic fogging. with the adoption of ehs surgeons get a clear field of vision avoiding continues repetitions of extraction and insertion of the endoscope in the body during the intervention. in this way the risks of the patients are reduced with a more efficient and shorter duration procedure. ehs also represents an alternative that meets sustainability criteria by reducing energy costs and eliminating much of the waste currently generated by this procedure. therefore, this innovation will disrupt the laparoscopic device market by enhancing safety and effectiveness without introducing new components that could complicate surgical procedures. case report: we presented the case of a year old women with chronic coloenteric fistula. conservative treatment was unsuccessful. the orifice was then closed with two subsequent clips, and the patient recovered well. to our knowledge, this is the first successful case of coloenteric fistula treatment with ovesco discussion: ovesco system is a technique that enables the closure of gastrointestinal defects (perforation sites, leaks, fistulas) . after the system application, the patient can be treated at home as was the case with our patient. a successful closure of the leak or fistula is possible when no extraluminal abscess is present. in our case, we had a cavity (previous sinus or abscess) that drained into the small bowel, thereby forming the coloenteric fistula. this allowed us to succeed with a fistula closure, as the cavity could drain into the small bowel conclusions: looking through the reports, one notes that the success rate of the otsc system procedure for insufficiency of anastomosis or colorectal fistula was - %, but only nine successful reports of chronic colorectal fistula were found). a % success rate is reported if the clip is placed within a week of occurrence of the leak . on considering the financial side, clips could reduce costs and time of hospitalization and avoid patients having to undergo a surgical repair . the major advantage of ovesco clips seems to be their ability to grasp more tissue compared to the standard clips and their strong grip on the wound margins because of their sharpened teeth. the drawback of the clips in fistula sealing is their incomplete grasp when the tissue is fibrotic. most authors agree that ovesco is not very appropriate for fistulas larger than - mm. inguinal hernia repair is one of the most performed interventions in minimally invasive surgery. in this opportunity we report a new technique through the use of innovative devices such as the robotic clamp and magnetic deviceswith this technique and thanks to the magnetized devices and the robotic clamp we have demonstrated to reduce the surgical time between - min as well as to optimize the ergonomics of the surgeon.we explain the technique with a demostrative video and exposition of the devices that are necessary for make it.with this new technique we get a greater capacity of mabiobra for dissection of the peritoneum and later a greater facility for the suture of the same in the repair of the inguinal hernia. a motorized and computerized laparoscopic tool that can be customized to the specific surgeon and procedure a. szold aim: surgeons have different levels of skill and use instruments for different tasks, but laparoscopic instrument are commonly simple mechanical instruments that allow limited degrees of motion, and the same instruments are used regardless of the surgeon or the task. robotized articulating instruments so far have added degrees of freedom, but perform in a standard way for all users and procedures. technology: human xtensions has developed a \ u[hand-held \/u [ motorized smart laparoscopic instrument, that was recently introduced in human procedures. the device has several features that enable to customize it to the user and procedure. the degrees of freedom can be reduced from to , the scale of rotation motion has options that can control both speed and range of rotation, a feature especially useful for the variable types of suturing tasks. results: the variable features were tested in different procedures requiring suturing and grasping. the combination of all optional settings made the instrument customizable to the different skill levels of the surgeons. as such, it enabled to control the complexity of the device and take the surgeon through the learning curve until full control of all features was achieved. in addition, the combination of different controls was used for performing specific tasks requiring different levels of maneuverability. in september , the results of a bomss survey regarding the routine use of pre-operative bariatric surgery were published. they found that % of units surveyed considered routine preoperative ogd completely unnecessary. as part of newly launching bariatric services in a single isolated centre we protocoled that all bariatric patients had to undergo pre-operative ogd, including a clo test, and reviewed if the ogd findings had influenced our surgical choice of operation and any necessary treatment before surgery. all patients embarking on the bariatric programme since its launch in jan to sept were included and had an ogd. the results of these ogds and all the clo tests were reviewed. these ogds were all performed by a single consultant to minimise any potential subjective differences. of the patients, ( %) tested clo positive of which had normal findings on ogd. patients had a hiatus hernia, gastritis, oesophagitis, gastritis and oesophagitis, had other findings e.g. ulcers, polyps' or nodules. the positive clo patients underwent eradication of h pylori. studies have shown that this is a treatable and preventable cause of gastritis/ gastric cancers and potential surgical complications causing prolonged hospital stay in % of patients. knowing about the presence of a hiatus hernia prior to surgery also contributed to the surgical planning, including allowing time for the concurrent correction of the hiatus hernia in the operation. all patients with demonstrable oesophagitis ( %) had their operative choice changed to roux en y gastric bypass thus aiming to prevent post-operative reflux which would have been exacerbated had they undergone a sleeve gastrectomy instead. carrying out a pre-operative ogd had a significant impact in operative choice and additional treatment before surgery and therefore should be advised in all patients. general surgery department, ahievran university, kirsehir, turkey the majority of fatalities worldwide in people under the age of years are caused by trauma . blunt mechanisms account for . to . %of injuries [ ] [ ] [ ] [ ] ,with the abdomen being affected in . to . % of all traumatic injuries. this case contribute to the literature: a patient with sleeve gastrectomy has distorted anatomy at duodenogastric junction, if has bat,her/his small bowel perforation(sbp) will occur on more distal segment. this a unique case before unpublished. years old female who had sleeve gastrectomy years ago presented to emergency department sustained blunt abdominal trauma (bat). when she arrived pyschical exam (pe) revealed an abdominal guarding, tenderness, normal vital signs but those increased h later. wbc values also increased h later. hb was normal.fast showed in cm thickness fluid early in douglas pauch (dp), mm in supravesical, mm diameter in dp h later. abdominal ct: mm diameter fluid in interloop, dp free air at th h from the accident. a diagnostic laparoscopy(dl) was done with diagnossed acute abdomen.there were a sbr-located cm from treitz, intraperioneal fibrin deposits and fluid-repaired with a primary suture.the patient discharged on days without any event. repeat ct scans are recommended for patients with initial suspected bowel injury. we could not do this; cause ct exam could taken in rush hours only but we did repeatly pe that peritoneal iritation signs increased,resulted a dl,surgical therapy. according to the literature; dl may be a good treatment option in these patients, to reduce morbidity or mortality, time to surgery has been emphasized. long interval between presentation and surgery was found to be associated with complications. very few reports of isolated jejunal transection following blunt abdominal trauma have been published in literature. the literature mentioned; the patients with sbp are hemodinamically stable on arrival to the hospital like our case are, a rupture of the jejunum was seen just distal to the duodenal-jejunal flexure but there were a perforation cm below treitz ligament and caused me to think the patient had sleeve gastrectomy and some brid around gastric and duodenal proximal jejunal part of intestines and also caused a new descended treitz ligament. normally external forces across to spine produce a blast effect on small bowel between treitz and ileocolic ligament. introduction: sasi bypass is a novel metabolic/bariatric surgery operation based on minigastric bypass and santoro's operation.it can be offered for patients with weight regain after sleeve gastrectomy. sleeve gastrectomy (sg)is a commonly performed bariatric procedure.weight regain following sg is a significant issue.yet,the understanding of this phenomenon is still unclear.rates of regain ranged from . % at years to . % at years.sasi bypass was an option for some candidates having sg done years back and failed to achieve the required weight loss or having weight regain.in sasi bypass, resleeve gastrectomy of the dilated gastric pouch is done followed by a side to side gastro-ileal anastomosis. the aim of this study is to report the clinical results and the outcomes of sasi bypass as a therapeutic option for patients with weight regain after sg methods: we conducted a retrospective study for morbidly obese patients having history of sg done more than years back and failed to achieve and/or to maintain the required bmi. exclusion criteria:patients with recent history of laparotomy(less than months). procedure was done at sidra hospital in kuwait from november to november . using ports, resleeve gastrectomy was performed over fr bougie tube starting cm above the pylorus then gastro-ileal anastomosis (side to side)was performed cm above the pyloric ring to an ileal loop counted cm from the ileocaecal valve. data was collected from the patients including:weight loss progress,laboratory full results. discussion and results: during the study period: morbidly obese patients with a mean bmi of ± kg/m were evaluated. -%ewl(excess weight loss)reached % at one year. -diabetes was cured in the known diabetic patients (type )within months,and the one known type diabetic patient had better control and less insulin daily doses(results were guided by glycated haemoglobin results every months). follow up laboratory results were normal in % of patients (all were kept on regular vitamins and proteins supplementation)-one patient had postoperative leak(day )from the anastomotic line that was treated conservatively. conclusion: sasi bypass is a promising operation that offers a good weight loss for morbidly obese patients having weight regain after sg conclusions: our study demonstrates a good agreement between the degree of liver steatosis and monocytes fat accumulation as well as between plin levels in liver and circulating monocytes. this suggests that ectopic fat deposition is a generalized feature of insulin resistance in obesity. sg reverses monocyte fat accumulation and restores insulin signalling, which correlates well with insulin sensitivity. moreover, circulating mmp levels significantly dropped after sg suggesting that the state of generalized inflammation characterizing obesity normalizes. her stomach stapled,a foreign tube like body was seen on cut surface of the stomach.the foreign body seen in dissected stomach wall is the tube is in placed a gastric banding insuflation tube.a laparatomy was made and the tube is extracted her stomach sutured primarily,nasogastric decompression,peritoneal drainage was made.her peritoneum was drained.she has a septic condition, leave in icu for a long period.her general status being well and discharged from hospital in days.we learn after the operation not before;she had a gastric adjustable banding and extraction the gastric band, but the tube of gastric band is not removed. alkhaffaf et al present a case of fistulation of the lagb tubing into the jejunum a review of the published data to identify the salient learning points with this and similar rare complications fistulation from lagb tubing is a rare complication that tends to follow removal of an infected port. the clinical presentation is nonspecific, rendering the preoperative diagnosis difficult. the tube and band can be removed laparoscopically, with closure of the small bowel fistula site. securing the tubing to the abdominal wall fascia after intentional detachment from the port might reduce the incidence of this complication.katherine j et al report a late and rare complication of a small bowel obstruction in a -year-old woman from an lagb placed for years. although not a common complication, one that could easily see the safety record of lagb patients tarnished if this small subgroup of patients is not acted upon promptly by emergency departments' unfamiliar lagb surgery. in our case we already made esophagogastroduodenoscopy before operation, ofcourse take past medical history from the patient.the patient hide past operation (gastric banding and removing band and port but leaving insuflation tube). ). there was no difference in the two groups regarding follow-up rate. basic demographics were the same, and other long-term results were similar between the groups. regression models for both post-op complications and failure as defined by baros score did not show that gender is a risk factor. discussion and conclusions: in our study, revisional sleeve surgery were similar. we did not see any significant difference in post-op complications, success of the operation as defined by baros, or subjective feeling of the patients. we do believe that gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling, and that in the case of a sleeve post a band gender is not a risk factor for complication or failure of the procedure. objective: the internal hernia is a rare but a potentially fatal complication of laparoscopic roux-en-y gastric bypass (lrygb). the aims of this study are: ( ) to determine the impact of mesenteric defects closure on the incidence of internal hernia after lrygb; ( ) to determine the symptoms, characteristics and management of internal hernias after lrygb. the median interval between lrygb and reoperation was months in group a and months in group b. the median percentage of excess weight loss (%ewl) was % vs %, respectively (p = . ). the median percentage of total weight loss (%twl) was % vs %, respectively (p = ns). patients, % ( in group a), were admitted to the emergency room with acute abdomen pain. a ct scan was performed in patients, %, and showed signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed using laparoscopy in patients, %, and using laparotomy or conversion in patients, %. conclusions: the closure of mesenteric defects during lrygb is recommended because it is associated with a significant reduction in the incidence of internal hernia. our study intends to analyze the long term results of sleeve gastrectomies performed by d laparoscopic approach. materials and methods: a prospective cohort study was conducted to perform gastric sleeve for morbid abesity. all surgeries were performed by the same surgeon over a period of two years. the operating surgeon is a senior most laparoscopic surgeon with vast experience in laparoscopic surgery. during two years period, cases were operated using d laparoscopy system. scientific calculation was done using spss release . windows software. results: patients, female ( %) and male ( %), with median age of . ± . ( - ) the excess weight lost (ewl) was % in the first year, % in the second, % in the third, % in the fourth, % for the fith year, % for the sixth and % for the seventh. postoperative complications were stenosis of the sleeve always located in the incisura and treated with endoscopic dilatation except one that required conversion to oagb. three leakages, all of them reoperated with drainage and introducing prosthesis by endoscopy in the same act. we have never had a postoperative bleeding of the sleeve. conclusions: d gastric sleeve laparoscopy is a safe and feasible technique for morbid obesity and related pathologies. the ewl is correct in long time. complications are rare but is necessary to have a good level of suspicious in order to a rapid solution. the worst complication is the leak of the sleeve. the oversewn of the gastric section is a good technique to avoid this complication. surg endosc ( ) aims: leak is one of the common complications of laparoscopic sleeve gastrectomy that result prolongation of hospital stay, morbidity and even mortality. methods: i report new approach for the treatment of leaks presented to me post laparoscopic sleeve gastrectomy with laparoscopic roux en y bypass to the leak site at the level of gastroesophageal area. this new approach is possible and feasible, and avoids stenting due to high failure rate, prolonged hospitalization and saves life of patients. results: all leaks healed days from surgery due to well vascularized small intestinal patch, except for leaks that healed after weeks of conservative treatment. aims: analyse the effect of one anastomosis (mini) gastric bypass (mgb/oagb) in the treatment of gastro-esophageal reflux in patients previously submitted to laparoscopic sleeve gastrectomy (sg). methods: a retrospective analysis was performed on the data of patients who underwent mgb/ oagb after a previous sg at policlinico san marco, italy, from january to june . a total of patients, female and males ( % f/ % m) underwent mgb/oagb after sg, due to the development of significant gastro-esophageal reflux disease (gerd), refractory to proton pump inhibitors (ppi), detected with the gerd questionnaire (gerd-q) and esophagogastroduodenoscopy (egds). in three patients ( %) a weight regain was also observed (mean bmi . kg/m , range . kg/m - . kg/m ). mean patients age was . ( - years old). before sg none of the patients had declared symptoms of gerd or was subjected to a therapy with ppi, preoperative egds did not show signs of esophagitis. mean bmi of the patients who developed gerd without weight regain was . kg/m ( kg/m - . kg/m ) at the time of surgery, with a medium ewl% of % ( . - . %). patients were treated unsuccessfully with ppi for at least six months before programming revisional surgery. mean gerd-q score was . results: after mgb/oagb, with a mean follow up of months ( - months), mean bmi was . kg/m and gerd-q score was . however, five patients out of ( %) developed an anastomotic ulcer or a grade c esophagitis. we did not observe any post-operative immediate complication nor any death. conclusion: mgb/oagb is a simple, effective and safe surgical procedure for patients who underwent a previous sg and who developed gerd, with satisfactory results in the short and medium post-operative time, even if there is still concern regarding the complications linked to biliary reflux. v.s. kyosev aims: laparoscopic adjustable gastric band (lagb) was one of the common techniques in bariatric surgery worldwide. the advantages included the possibility of regulation, ease of placement, acceptable weight loss and low rate of perioperative complications. a late complication of lagb is penetration of the gatric band through the gastric wall and migration into the lumen of the stomach. hereby, we present three cases of gastric band migration following lagb. methods: from to we observed cases of gastric band migration in between and years after lagb placement. the patients were hospitalized in surgical department complaining of sudden sharp epigastric pain, nausea and vomiting, with symptoms onset in the last few days. all patients underwent abdominal ultrasound examination, x-ray investigation of the abdomen with oral contrast administration, fibrogastroscopy. in cases the imaging studies revealed gastric band migration into the stomach's lumen and in case-obstruction of the jejunum by the gastric band. all patients underwent laparoscopic surgery. results: two of the patients underwent gastrotomy, extraction of the gastric band and roux-and y-gatric bypass. the patient with jejunal obstruction underwent laparoscopic enterotomy, extraction of the gastric band and cholecystectomy due to concomitant cholecystitis. two of the patients had no additional perioperative complications and were discharged at the th postoperative day. one patient developed fever, left pleural effusion and partial insufficiency of the gastrointestinal anastomosis in the early postoperative period without the need of surgical treatment. the patient was discharged on th postoperative day. all patients were prescribed a diet and monthly blood test of ion balance. conclusions: lagb was one of the most common treatment methods due to the epidemic spread of morbid obesity in western countries. detailed knowledge on possible lagb complications is essential for the treatment of these patients. the diagnosis of lagb complications is often delayed due to its relative rarity and nonspecific clinical manifestations, but in most of the cases it requires emergency surgery for management of life-threatening conditions. results: there was conversion in patients (short mesentery of the small intestine). such postoperative complication like anastomotic leak in patient ( . %) and staple line bleeding in patient ( . %), which was managed laparoscopically. compensation for type diabetes was achieved in ( %) patients, improvement was recorded in ( . %), dyslipidemia in ( . %) and ( . %) patients, arterial hypertension in ( . %) and ( %) patients respectively, what led to metabolic syndrome resolution in ( %) patients. the liquid is allowed to take after day. average postoperative hospitalization- . ± . days. %ewl for months %. conclusions: laparoscopic mini gastric bypass is an effective method of surgical correction of body weight and metabolic disorders in patients with morbid obesity and allows to receive an adequate and stable correction of arterial hypertension, lipid and carbohydrate metabolism, which are components of a metabolic syndrome. introduction: over time laparoscopic sleeve gastrectomy lsg has become the most popular bariatric operation worldwide. a critical step during lsg is ensuring sleeve-size consistency. gastrisail device (gastric positioning system) is a three in one surgical device replacing the standard bougie used in lsg for the application of suction, decompression and to serve as a sizing guide for gastric sleeve creation. the aim of this study is to evaluate the possible merits of gastrisail device in lsg over the standard laparoscopic sleeve gastrectomy. methods: a prospective study of patients randomly divided into two groups: group a composed of twenty patients who undergo lsg with the use of gastrisail and group b composed of twenty patients who undergo lsg with the standard bougie without the use of gastrisail comparing both according to operative time, consistent sleeve formation, delineation and visualization, intraoperative and post-operative complication rates, the lenght of hospital stay,gastric pouch design and percentage of excess weight loss (%ewl). results: regarding intraoperative time, the mean time was . ± . and . ± . for group a and b respectively,while no patients in group b had consistent sleeve formation, patients ( %) had consistent sleeve formation. delineation and visualization were accomplished in % of group a patients, was not accomplished at all in group b patients. the alignment of the stomach was reached in patients in group a but no patients at all in group b, the mean of hospital stay was . ± . and . ± . for group a and b respectively, the smaller tube design illustrated by gastrograffin x-ray at rd post-operative day was accomplished in patients ( %) and patients ( %) in group a and b respectively. there was no significant difference in %ewl in both groups. conclusion: the use of gastrisail device is superior to the standard lsg in consistent sleeve formation, visualization, delineation and good alignment and accomplishment of a small tube design while no significant difference in %ewl. bariatric surgery has spread all over the world. since japan has few patients with morbid obesity compared with western countries, it has been implemented only in limited facilities. however, bariatric surgery in japan is rapidly spreading recently, and many facilities are about to install bariatric surgery. effects of bariatric surgery are known to last for a long time, but some cases require reoperation which is called revision surgery due to late complications or rebound. because of thick subcutaneous and visceral fat, open surgeries are not even always a good solution to make surgery easier in morbid obese patients and all procedures must be completed laparoscopically. therefore, especially in revision surgery, the incidence of complications tends to be increased. as the number of bariatric cases to be increased in japan, cases requiring revision surgery is likely to increase. in revision surgery, it is necessary to select the procedure according to patient condition, and it is necessary to familiar well with those procedures. we will present cases that underwent revision surgery in our department and show the clinical outcome. we have done four revision surgeries after sleeve gastrectomy so far. operative indications are mid-gastric stenosis and rebounding disease. for stenosis cases, we performed roux-en y gastric bypass with distal stomach resection, and for rebounding cases, we performed re-sleeve gastrectomy with duodenal-jejunal bypass. average interval from initial operation to revision surgery is months in rebounding cases, and months in stenosis cases. duration of operation was min in average, and mean estimated blood loss was ml. no postoperative mortality was observed. in rebounding cases, excess bmi loss at year after surgery was . % in average, and both cases achieve diabetes remission at year. one cases of mid-gastric stenosis required a nutritional support with formula diet temporally. in particular after sleeve gastrectomy, revising to roux-en y gastric bypass, re-sleeve gastrectomy, and adding the duodenal-jejunal bypass will be the main techniques. along with an increase of bariatric surgery in japan, it is necessary to acquire sufficient knowledge and skills to carry out revision surgery. methods: we present the case of a year old woman who underwent lsg after lagb removal and lgcp. the patient underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation or erosion. we emphasize that the patient, had undergone three operations of gastric band placement, gastric band removal and gastric plication before sleeve gastrectomy. however, a successful lsg was achieved. results: no severe postoperative complications were mentioned. conclusion: weight loss in the first year was % of the excess weight.sleeve gastrectomy after gastric band removal and gastric plication, for morbid obesity seems to be safe and efficient, especially in casesof absence of gastric erosion. surg endosc ( ) department of surgery, patients were observed with serious septic complications many years after gastric banding operation. we detected a female dominance ( female, male) in patients with a mean age of . years. the leading symptoms were: dysphagia, upper abdominal tenderness and pain, spontaneous fistula formation, fever, masked septic signs, bowel and urinary obstruction. patients underwent video-endoscopy, chest and abdominal ct (computed tomography), fistulography and cystoscopy. results: in still morbid obese patients, laparoscopic procedures were performed with a conversion rate of %: atypic gastric and cardia resection in cases, gastric suture in cases, small bowel resection and suture in - cases. in one case, fistulectomy, abscess evacuation and combined urinary bladder suture and drainage were carried out. the duration of the surgeries were over h with minimal blood loss (\ ml). the foreign bodies were completely removed in every case. intraoperative complication was not occurred. early physiotherapy were promoted, oral feeding were gradually built up from the th postoperativ day depending on the type of the operation. early postoperative complications included recurrent fistula formation (n = ) and wound infection (n = ). all the fistulas were closed after conservative treatment. average hospital stay was days, regular check-ups were held on the rd, th and th months of follow up. conclusion: gastric banding is the most common, routine and safe technique for the treatment of morbid obesity. the development of late, severe septic complications draws attention to the crucial importance of follow up. the surgical management of these patients is recommended in specialized centers in regard to difficult operative conditions and atypic treatment options. aims: single anastomosis duodeno-ileal bypass with sleeve gastrectomy (sadi-s) has been proposed as an alternative to biliopancreatic diversion with duodenal switch (bpd-ds) in order to maintain the outcome of the original procedure simplifying the technical complexity and to avoid potential complications. moreover, it potentially represents the more natural second step bariatric procedure after sleeve gastrectomy (sg). we aimed to report the initial experience with sadi-s of our high volume bariatric center. methods: retrospective analysis of patients who underwent bariatric procedure between july and november was conducted. the primary aim was the evaluation of the safety of sadi-s, defined as the rate of postoperative complications. the secondary endpoint was the bariatric efficacy of the procedure, defined as percentage excess weight loss (%ewl). results: among patients who underwent bariatric procedures at our institution ( . %) patients were scheduled for sadi-s. all patients had multiple comorbidities. initial indication for sadi-s was failed sg in patients (median pre-sg bmi . kg/m \ sup [ \/sup [ ; median months after initial operation respectively) and primary procedure in patients (median pre-operative bmi . kg/m ). the surgical procedure was accomplished with robotic-assisted approach in cases (median operative time min) and with laparoscopic trocars standard approach in the remaining cases (median operative time min). the duodeno-ileal anastomosis was fashioned using a double layer hand-sewn running sutures. no patients showed early post-operative complications, the median postoperative stay was days. at a mean follow up of months the median %ewl was . . to date no patients experienced surgical. one patient develop wernicke encephalopathy months after surgery, but he was non-compliant to multivitamin supplementation. conclusions: at least in a high volume bariatric center sadi-s, both as second step after sg and as primary surgical option, seems to be a safe and effective bariatric metabolic procedure based on solid physiopathologic principles. on the other hand, longer follow-up is necessary to support the use of this procedure as a better alternative to bpd-ds. m.r. elkeleny , a. abo khozima git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery department, faculty of medicine,alexandria university, alexandria, egypt four bariatric cases . female patient with intragastric balloon, minor leak from the balloon leading to ballon migration to the jejunum;hance, small bowel obstruction occured. emergency diagnostic laparoscopy was done, enterotomy and extraction of the balloon, direct repair of enterotomy and balloon extraction through mm port site. . male patient presented after days of lsg with small bowel obstruction due to entrapment of small bowel loop through one of the port sites;therefor, emergency laparoscopy was done with reduction of the herniated segment and closure of the port site. . female patient presented with stricture of the ogj after re-sleeve gastrectomy managed by balloon dilatation which recur after weeks .she was managed by expandable metallic stent for weeks with good response and the stent was removed. . -year-old male patient presented with sever peripheral neuropathy following months after sleeve gastrectomy, and the patient was getting worse; thus, he used wheel chair. he has been making good progress on vitamin b complex injections. the aim of our study was to compare histopathological findings of gastric specimens to preoperative clinical symptoms and to conclude about the need for ugi endoscopy as a routine prior to surgery. methods: the last two years, morbid obese patients were selected to undergo laparoscopic sleeve gastrectomy (lsg) in our institution. for the needs of our study, all of them had ugi endoscopy and were reviewed for upper gi symptoms. histopathological reports obtained according to our protocol, after surgery. results: gastric histology from specimens revealed: no findings in / patients ( . %), gastritis in / patients ( . %) and focuses of incomplete intestinal metaplasia without dysplasia in / patients( . %). finally, two minor leiomyomas with low cellular proliferation rate were fully excised in a patient's specimen. there was no inconsistency between preoperative symptoms and gastric histology, while leiomyomas found were no reported to ugi endoscopy due to size. conclusions: some of the patients with clinical features of food intolerance, gastroesophageal reflux disease, and peptic ulcer disease had finally findings in histopathology of their stomachs. history of helicobacter pylori infection implements a raised incidence of mucosa pathology as well. because only one case revealed carrying significant pathology (leiomyomas), we consider that is safe to proceed with surgery in an otherwise asymptomatic patient based on his previous medical records and blood tests. aims: splenic abscess following laparoscopic sleeve gastrectomy (lsg) is a rarely seen complication. the aim of our study was to present a case of splenic abscess in a morbid obese patient who underwent lsg. as the main concern in these cases is leakage from the staple line, we present our diagnostic and treatment approach. methods: a -year-old, female morbid obese patient (bmi . kg/m ), without any predisposing risk factors, underwent elective lsg in our department. following an uneventful course, she was discharged at the nd postoperative day. however, at the th postoperative day, she readmitted to our unit with high temperature of . o c, left upper quadrant tenderness and leukocytosis. contrast computed tomography (ct) revealed an abscess at the upper pole of the spleen , cm in maximum diameter, without leakage from the staple line. results: the patient was treated with broad-spectrum antibiotics and radiological percutaneous drainage of the abscess. although there was a partial clinical improvement, a week later, a new ct scan revealed the continuous presence of the abscess. despite the stable general condition of the patient a laparoscopic splenectomy was performed and a gradual recovery was followed. the presence of splenic abscess without splenic trauma or leakage from the gastric staple line, is an extremely rare complication and only a few cases have been previously reported. the cause has not yet clarified, but the proposed mechanism involves infarction of the spleen, due to vascular compromise and subsequent infection. most of the reported splenic abscesses were diagnosed during the late postoperative period. in our report we present a case of early onset, hence highlighting the need of clinical awareness for early diagnosis and treatment. introduction: obese surgical patients with obstructive sleep apnea (osa) have a higher risk of peri-and postoperative desaturations and subsequent morbidity and mortality. currently, the best perioperative management of patients without known osa remains unclear. although routine osa screening has been advocated, sleep studies are costly and time consuming. we hypothesized that bariatric patients can be safely monitored on a surgical ward by continuous postoperative pulse oximetry without preoperative screening for osa. objectives: to evaluate outcomes of continuous postoperative pulse oximetry without preoperative osa-screening, and to compare the results to outcomes of patients with osa and continuous positive airway pressure (cpap) treatment. methods: all patients who underwent bariatric surgery between and were included in this single-center retrospective cohort study. all patients were postoperatively monitored with continuous pulse oximetry on the surgical ward. patients with less than two documented saturation measurements were excluded. patient files were reviewed for osa diagnosis, cpap usage and perioperative details. primary outcomes were -day complication rates, intensive care unit admissions due to cardiopulmonary causes and postoperative desaturations of spo \ %. secondary outcomes were icu admissions following all causes, length of stay and rates of reoperation and readmission. results: in total, patients were included. patients ( %) were preoperatively diagnosed with osa, ( . %) were cpap users. complications occurred in . % of patients without osa and in . % with osa(p = . ). desaturations were documented in . % and % (p \ . ), respectively. in both groups, patient was admitted postoperatively to the icu for cardiopulmonary causes that could be related to osa (p = . ). both recovered without further complications. icu admissions, regardless of cause, occurred in . % of patients without osa and in . % with osa(p \ . ). no significant difference between groups was observed in complications based on clavien dindo classification, length of stay, reoperation-and readmissions-rates. conclusions: these findings suggest that continuous postoperative pulse oximetry without preoperative osa-screening is a safe perioperative management strategy for bariatric surgical patients. future studies are needed to assess cost-effectiveness of pulse oximetry vs. routine preoperative osa-screening in a prospective clinical setting. background: the pathology of colon is one of the most pressing and socially significant problems of modern health care, because it leads to reduction of the working population employed in manufacturing, in some cases to disability and reduced quality of life. mini invasive surgery of the colon has a great advantage: speed recovery, shorter hospital stay and better cosmetic results, the quickest return of patients to work. as a result, mini invasive endovideosurgery is firmly established in clinical practice of coloproctology. objective: the choice of optimal surgical method for treatment of colostasis, achievement of favorable outcomes of treatment. introduction: laparoscopic roux-en-y gastric bypass (rygb) is one of the most important bariatric surgical procedures performed worldwide and it can produce an important loss of weight with reversal of metabolic disorders like diabetes and dyslipidemia. even though it has good results, some complications occur after gastric bypass. a rare but serious complication of rygb is the so-called postprandial hyperinsulinemic hypoglycemia. its prevalence has been estimated less than % of cases and its pathophysiology remains unclear. methods: the aim is to present a case series of reversal surgery in patients with severe hiperinsulinemic hypoglycemia after rygbp in the hospital general universitari de la vall d'hebron. unit of endocrine-metabolic and bariatric surgery (eac-bs center of excellence for bariatric and metabolic surgery by ifso). it is a retrospective analysis of a prospective database same surgical team. we present in this study, the main features of those patients. results: between and , patients underwent a laparoscopic reversal procedure to normal anatomy and age mean was year ( years to years). mean preoperative body mass index (bmi) was . kg/m (range - . kg/m ) and were women. all patients presented hypoglycemia symptoms years after and the longest was years after the procedure. the first step of the standard approach was a laparoscopic reversal to normal anatomy with resection of the alimentary rygb limb in cases. a concomitant sleeve-like gastrectomy (sg) was added. four patients presented postoperative complications: gastrogastric anastomosis leak ( ) introduction: laparoscopic sleeve gastrectomy is the most performed bariatric procedure, but complications might interfere with patient's long-term evolution based on its compliance and tolerance, surgical attitude and unpredictable evolution. materials: we present the case of a female obese patient, with type ii diabetes mellitus and blood hypertension, with multiple, sequential bariatric minimally-invasive interventions: sleeve gastrectomy in complicated by postoperative acute gastric dilation and mediogastric stenosis, reoperated for viscerolysis and cholecystectomy, with endoscopic gastric dilations, initially converted to functional one anastomosis gastric bypass ( cm limb), with a non-adjustable gastric ring positioned instead of stapled division. the last operation was complicated months after by persistent biliary gastro-esophageal reflux, chronic abdominal pain, and gas bloat syndrome. in the patient underwent conversion to laparoscopic r-en-y gastric bypass, with gastro-enteral anastomosis resection, band removal and viscerolysis. results: conversion to r-en-y was complicated by biliary leakage post-viscerolysis, treated with laparoscopic approach in the \ sup [ th \/sup [ po day. after multiple surgical and endoscopic interventions, the patient presents short-term favorable outcomes, with no reflux or abdominal pain, with further weight loss and diabetes improvement. conclusion: bariatric surgery has unpredictable evolution in same cases, and conversion to r-en-y seems to be the best solution. lgcp is widely used in developing countries due to its lower cost and good results. material and methods: we performed in our department lgcp for morbid obesity. excess weight loss (%ewl) was % at month after surgery and % at one year. in cases revision surgery was needed for different complications and in cases for inadequate weight loss or weight regain after month follow up. in cases we performed sleeve gastrectomy (in cases after taking down the plication) and in cases we performed a re-plication in one row. results: the rate of revision surgery was % overall and % for inadequate weight loss (excess weight loss \ %) or weight regain. major complications occurred only in one patient (leak with abscess) but it was solved by laparoscopy. minor complications as vomiting and nausea appeared in patients ( %) and were solved with medication. after one year follow up %ewl in these cases was %. conclusions: revision surgery after lgcp is possible. a new plication or sg was the option in our series with good results. further studies are needed to evaluate the use of lgcp in the armamentarium of bariatric surgery. background: roux-en-y gastric bypass (rygb) is one of the most commonly performed bariatric procedures around the world.however, rygb it sometimes carries the risk of rarebut serious long-term complications such as malnutrition and liver failure. we report a case of laparoscopic reversal of rygb. methods: in march , a laparoscopic rygb was performed for a -year-old female without comorbidities and with a bmi of kg/m . all laboratory test results at the preoperative evaluation were within the normal range. abdominal ultrasound revealed moderate hepatic steatosis and oral endoscopy a hiatal hernia with grade b esophagitis. one year later, patient experienced an important weight loss of kg (from to kg) with a bmi of kg/m . however, patient presented general weakness, abdominal pain, ascitis lower extremitiy edema, anemia, progressive caloric and protein malnutrition, vitamin (a, d), mineral (copper) and folic acid deficiencies, nonalcoholic steatohepatitis (nash) and liver function was progressive worsening. results: a laparoscopic reversal of gastric bypass was performed. the operation was successfully performed via laparoscopy. operating time was min. postoperative was uneventful and patient discharge home at day . hepatic biopsy revealed nash with steatohepatitis of % (fibrosis f - / ). eight months after reversal of gastric bypass, patient has improved her clinical situation (no asthenia), maintains of weight ( kg) and has improved her nutritional status and liver function parameters. conclusion: laparoscopic reversal of rygb is technically feasible and might be performed safely after thorough preoperative evaluation in carefully selected patients with malnutrition and liver failure. conclusion: laparoscopic sleeve gastrectomy it's a safety obesity procedure before major abdominal hernia repair. it's a minimally invasively technique with an absence of anastomoses. these factors prevent fewer complications, without using the small bowel, and skin problems and allow resolution of obesity-associated co-morbidities. body weight loss after surgery may be an opportunity to repair the severe loss of domain incisional hernia. bibliography borbély, y., zerkowski, j., altmeier, j., eschenburg, a., kröll, d. and nett, p. general surgery, benhazi medical center, benghazi, libia, general surgery, royal bahrain hospital, manama, bahrain obesity is a worldwide epidemic with an increasing incidence trends and as a consequence obesity related health problems become priority to healthcare authorities in all the countries. laparoscopic gastric plication is an emergent restrictive procedure which claimed to be low cost because they do not need staplers and carries less complications as compared to laparoscopic sleeve gastrectomy. we present here a years female who was operated for morbid obesity four months back where she underwent laparoscopic gastric plication with no immediate post operative complication and her wight loss was adequate. two days before presentation to our emergency department she started to complains of sever attacks or upper abdominal pain and vomiting.clinical examination was unremarkable apart of abdominal tenderness in left upper abdomen. all blood routine were normal and all inflammatory markers were within normal range.ct abdomen showed large cystic lesion around the greater gastric curvature containing fluid and raised possibility of collection. patient was admitted to hospital, in despite of medical treatment her pain persists and necessitate immediate laparoscopic exploration. gastro-gastric hernia at the greater curvature through loosen ethibond suture that was used to plicate the stomach in the previous surgery. we released the suture to liberate the strangulated stomach which is not gangrenous. re-plication was not possible because of the extensive gastric wall edema and as preoperative discussion with the patient she refused conversion to sleeve gastrectomy no intervention was done. post surgery patient was free of symptoms and tolerating oral diet and discharged home on third post operative day with no complications. gastro-gastric herniation could progress to gastric wall gangrene which will result in high morbidity and even mortality. high index of suspicion is required to diagnose the condition . preoperative patient counseling is important to explore the surgical options if deemed necessary to convert to another bariatric procedure. k. chouillard, a. d'alessandro, l. chahine background: bariatric surgery is the best available, long-term treatment for morbid obesity. currently, laparoscopic sleeve gastrectomy (sg) is the most commonly performed bariatric procedure in france. despite its safety and efficacy, long-term complications of sg are not rare including gastro-esophageal reflux disease (gerfd), twisting, stenosis, insufficient weight loss, and weight regain. the goal of this study was to analyze the pattern and short-term results of surgical revision in patients with sg. methods: revisional bariatric surgery, regardless of its motivation, was always a multidisciplinary decision after clinical, biological, endoscopic, and radiological assessment. patients who had revisional surgery after sg were retrospectively identified and subsequently divided in subgroups according to preoperative body mass index ( we aim to present the management and the particular aspects of the surgical technique in a gastrobronchial fistula after gastric sleeve . the mean time between intervention and diagnosis is . - . months. methods: between and , laparoscopic gastric sleeve resections were performed in our bariatric center. we had one case of gastrobronchial fistula associated with an inferior lobe abscess of the left lung, diagnosed months after the gastric sleeve. the patient was subject for medical treatment for h, than a laparoscopic intervention was performed in order to drain the lung abscess and the gastric fistula and to place a feeding jejunostomy. . months after this intervention ( . months after gastric sleeve) a laparoscopic roux-en-y fistulojejunostomy was performed. the evolution was monitorized with blood tests, upper gi contrast series and ct scans. results: the surgical drainage of the lung abscess, along with the antibiotherapy, controlled the infection and allowed the lung cavity to reduce in size, and thus the drainage tubes introduced in the thorax through the diaphragmatic orifice were retracted progressively. also, the feeding jejunostomy allowed a proper nutrition for the patient with a good recovery. however, . months after the drainage intervention, the gastric fistula was not healed, and a decision to interrupt the communication with the lung cavity was made, by creating a laparoscopic fistulojejunostomy. after this, the evolution was favorable, with the healing of the lung cavity, oral feeding was permitted and the jejunostomy was suppressed. conclusions: the treatment of the gastrobronchial fistula is complex (medical, endoscopic or surgical), phased and long lasting until healing. surgery was our initial choice for treatment due to the existence of the lung abscess, which needed to be drained. key words: gastrobronchial fistula, lung abscess, laparoscopy, fistulojejunostomy s.i. filip, i. hutopila, c. copaescu introduction: leakage remains one of the most dreadful complications in metabolic surgery. the main cause of leakage is poor tissue oxygenation due to inadequate vascular perfusion. the study of intraoperative tissue perfusion in real time due to icg enhanced fluorescence could provide valuable information for the surgeon in order to prevent postoperative fistula. aim: to present our experience in using icg enhanced fluorescence in laparoscopic bariatric surgery material and method: in cases of gastric sleeve, cases of gastric bypass and in cases of revisional surgery or redo cases we used intraoperative icg mediated fluorescence to assure the optimal vascularization of the involved tissues. in our video we present intraoperative aspects before and after using icg in different cases. results: in all cases of primary gastric sleeve and gastric bypass with intraoperative use of icg we did not encounter inadequate perfusion. in one case of redo gastric bypass after failed vertical banded gastroplasty for morbid obesity despite intraoperative laparoscopic normal aspect of the gastro-jejunal anastomosis, icg mediated fluorescence allowed to identify an unexpected ischemic anastomosis and we could prevent consecutive postoperative leakage. discussion: presented cases are discussed and result with referral to literature is made. conclusion: intraoperative use of icg is a valuable tool in assessing the perfusion of the tissues and provide essential information for the surgeon in order to avoid postoperative leakage. , including patients, hemostasis with clips has been performed in all cases. however, among these cases nine patients required reoperation for early postoperative bleeding. in five cases a bleeding source from the stapled line was identified while in cases no identifiable source was found. during the second period ( to present) patients were submitted to bariatric surgery and hemostasis was performed by over sewing with a running suture. among these cases reoperation for postoperative bleeding was needed in cases ( . %), but no bleeding from the staple line being encountered ( %). the difference has statistical significance. no significant complications related to the use of this type of reinforcement were encountered. conclusions: over sewing the gastric stapled line in bariatric surgery is superior to hemostatic clip application in preventing the postoperative bleeding from the stapled line postoperative bleeding. a protocol of active search of the bleeders during the bariatric procedure should be implemented and respected in all the cases. gastroenterological surgery, saitama medical university international medical center, hidaka-shi, saitama, japan intestinal endometriosis is a rare disease which is associated with about to % of patients with endometriosis, and it is favorable to the rectum and sigmoid colon. here we report cases (shown in the table) underwent laparoscopic resection for intestinal endometriosis. there were no postoperative complications in all cases, and all patient was discharged on - \ sup [ th \/sup [ postoperative day. before the operation, of patients were diagnosing intestinal endometriosis, and it was difficult to preoperatively diagnose. among them, the symptoms at the time of menstruation were clear was one case. in case of submucosal tumor, preoperative diagnosis seems difficult. additional image examination at menstruation may be useful for diagnosis. d dissection was performed for case , , because malignant disease could not be denied as a preoperative diagnosis. of them were strongly doubted endometriosis in surgical findings. in intestinal endometriosis surgery, pelvic adhesions and fibrosis are often advanced. in the sigmoidectomy, the average operation time was min and the blood loss was ml. in the rectal resection, the average operation time was min and the blood loss was ml. in case and , pelvic adhesion was severe, residual rectum could not be straightened, and side to side anastomosis was performed. in intestinal endometriosis surgery, intestinal anastomosis method should be considered flexibly. conclusion: laparoscopic surgery for intestinal endometriosis was safe, but technically difficult because of fibrosis and adhesion. it is important to accurately diagnose from clinical symptoms and image also intraoperative findings. anastomotic method should be decided according to the case. aim: the aim of the study was to identify and highlight some of the complications one can encounter in bariatric surgery-specific-sleeve gastrectomy and discuss the therapeutic options one has at his disposal. methods: the study was retrospective. we identified a number of patients which had a sleeve gastrectomy done in our clinic for a year period. of these had important surgical complications encountered during the surgery or in postoperative care. results: the group included patients, with an average bmi of [ kg / m . average hospital stay was days, with an average of . days which increased to days when fistulas were encountered. the most frequent surgical complications were bleeding from the gastric suture ( ) and gastric fistula ( cases). other complications encountered were wound hematoma. surgery was required in of the cases of bleeding and of the fistula cases required reintervention. one case was resolved with endoscopic stenting. conclusions: laparoscopic gastrectomy is considered a safe procedure with good results for the patient. although complications are rare they pose a series of technical difficulties for the surgeon due to the weight of the patient and frequent comorbidities which come with obesity. a thorough understanding of the symptoms and good follow-up ensures the best results. aims: to achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (lagb) can be converted to a laparoscopic roux-en-y gastric bypass (rygb). there is limited data on the feasibility and safety of routinely performing a single-step conversion. we assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. to the best of our knowledge this series represents the largest single-center study on conversion from lagb to rygb methods: between october and december , a total of patients who underwent lagb removal with rygb were identified from a prospectively collected database. in all cases, a single-stage conversion procedure was planned. the feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. results: a single-step approach was successfully achieved in ( . %) of the patients. during the study period, there was a significant increase in performing the conversion from lagb to rygb single-staged. no mortality or anastomotic leakage was observed in both groups. only patients ( . %) had a -d complication: most commonly hemorrhage (n? = ? / ), with no significant difference between the groups. conclusion: converting a lagb to rygb can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. with increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. only a migrated band remains a formal contraindication for a one-step approach. surg endosc ( ) . six months after surgery the mean hrql score, was ( - ) in patients underwent to lsg and . ( - ) in patients underwent lgb. twelve months after surgery the mean postoperative questionnaire score was ( - ) in patients who underwent lsg. at ph-manometry the mean percentage time of acid reflux in orthostatism was . (range - . ) and in clinostatism . (range . - . ). the mean demeester score at the distal electrode was . ( . - . ). conclusions: in asymptomatic patients, complete gerd evaluation before bariatric surgery allows better selection of surgical procedure, to reduce the postoperative occurrence of severe or de novo gerd. postoperative gerd evaluation provides useful data regarding the impact of lsg on gastroesophageal reflux. a larger patient sample size is required. aims: vertical calibrated gastrectomy (usually know as gastric sleeve) as unique technique gives better results than the roux y bypass in terms of improvement of anthropometric measures, reduces comorbidities and has a lower rate of postsurgical complications, with an improvement of quality of life. material and methods: an observational, longitudinal, retrospective and comparative study with patients, aged - years,during a period of years. everyone must comply with the protocol of the unit. demographics of the population and the anthropometric data will be measured in the presurgical consultation, the month and the year after the surgery: weight, height, bmi, weight loss percentage,bmi percentage and percentage of excess weight lost. we took data on the cardiovascular risk by the framingham score. the quality of life is measured by baros scale. mayor comorbidities are hypertension, diabetes, dyslipidemia. complications will be measured in absolute frequencies. for de statistical study, we apply type t student or chi square being statistically significant p equal to or less than . . results: there was not statistically significant difference between the techniques of surgery month (p = , ), but they were evident to the year of the same (p . ). not gender or age differences were apparent. mayor complications did not appear in gastrectomy (no leaks), highlighting the number of bleeds with this surgical technique. the bypass there were two leaks. there was no statistically significant difference in cardiovascular risk (p = , ) between the two techniques. there was a more significant decrease in number of comorbidities in gastrectomy against the bypass, with a total disappearance of patients with dyslipidemia. there were no statistically significant differences in baros score, although it was higher in gastrectomy. conclusions:-the vertical gastrectomy as unique technique can be considered superior in the short term, as well as safe, according to the aec quality parameter. we think it will be necessary to continue their studies into the medium-long term. aims: analyze the impact of different bariatric surgeries technics in carbohydrate metabolism and pancreatic beta cell population of none obese adult wistar rats. methods: we used twenty healthy not obese adult wistar rats divided in five groups randomly assigned. each with n = . the control groups were divided into fasting control (f) and sham (surgical control). the surgical groups were separated into vertical gastrectomy (gs), % resection of the middle small bowel (ri ) and gastric bypass (gb). in each group was assessment: beta cell mass modifications, pancreatic islets histomorphometry, proliferation, apoptosis and neogenesis in beta-cell pancreatic population; intraperitoneal glucose test tolerance, body weight and food intake. statistical analysis as evaluated using mann whitney test. results: the malabsorptive and restrictive group have a significantly smaller increase weight than the control groups. the intraperitoneal tolerance glucose test reports incremental glucose area under curve (auc) was significantly higher in the malabsorptive group and lower in the restrictive group compare to the control groups during the second (p \ . ) and third (p \ . ) month of the study. the beta-cell mass was significantly higher in the ri group compared with control groups respectively. there was a significantly increased number of beta-cell per pancreatic insulin positive area in gs and gb. proliferation was significantly increased in ri and gb group, and significantly decreased in sg compared. there was no significantly difference during apoptosis assessment among surgical and control groups. in neogenesis differences between groups were assessed qualitatively by the presence pdx - expression, being higher in rygb. the endocrine pancreas in our model is altered by the anatomical and functional conditions arising from surgical techniques. carbohydrate metabolism conditions are affected by temporary adaptive processes due to surgical alternatives. there is a hyperplasia and hypertrophy of the beta cells in surgeries with a malabsorptive component, as well as greater neogenesis. these results could explain part of the existing relationship between the enteropancreatic axis and the existing incretins. m. buza, c. copaescu introduction: nowadays, we have high volumes of obese patients for whom surgery is the answer, but unfortunately the psychological evaluation has no standard recomandation in preoperative evaluation of bariatric patients. it is argued that surgery success, in addition to the operation itself, relies on behavioral changes and that one of the goals of the preoperative assessment is to prepare the patient for the postoperative period, aiming to optimize surgical results. aim: although no formal standard exists in the literature, there is growing recognition of the important elements to be addressed and the appropriate means for collecting the necessary data to determine psychological readiness for these procedures. methods: information regarding the components of the clinical interview and the specific measures used for psychological testing are discussed. given the limited data on predicting success after surgery, determining psychological contraindications for surgery is addressed. additionally, the multiple functions served by the psychologist during this assessment procedure are highlighted along with the value of this procedure in the patients' preparation for surgery as well as the postoperative follow-up. in our center of excelence for bariatric and metabolic surgery (coe) we introduced since a mandatory pre-and postoperative psychological evaluation for all patients addressing the metabolic program. results: psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also-and more so-to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and the associated lifestyle changes. postoperative follow-up is necessary. the psychological evaluation of the patient undergoing bariatric surgery is an invaluable piece of the larger pre-and post-surgical assessment, aiming better results in the short and long term after bariatric surgery. introduction: a mesenteric cyst is defined as a benign abdominal tumors that is located in the mesentery of the gastrointestinal tract, identified in * of , hospital admissions. mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. the preoperative diagnosis requires all the common abdominal imaging techniques. usually the correct diagnosis may be made only at the operation stage or during the histological examination. all mesenteric cyst should be resected in order to avoid their complications, complete surgical resection is recommended and curative in the majority of cases with a low risk of local recurrence. the laparoscopic approach is the gold standard in the treatment of intraabdominal mesenteric chylous cyst. laparoscopic resection provides less pain, shorter hospital stay, and early recovery for the patient. case report: we report a case of -year-old saudi woman who presented to our clinic complaining of upper abdominal pain and mass in the epigastrium for one week, no history of nausea, vomiting, or recent changes in bowel habits. her medical and family histories were clear and she had never had any abdominal interventions. abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant, ultrasonography and with computed tomography of the abdomen revealed an approximately mm unilocular cyst closely related to the mesentery in the left side of upper abdomen not related to the pancreas .the cyst was excised by laparoscopy complete surgical excision to avoid recurrence within healthy borders, it is contained milky white fluid. the histopathological findings were chronic inflamed mesenteric cyst. a review of the literature considering this rare entity was also performed to evaluate our treatment strategy. conclusion: mesenteric chylous cysts represent a diagnostic challenge and they should be considered when a physician encounters an intraabdominal mass. usually the correct diagnosis may be made only at the operation stage or during the histological examination. the treatment of choice is the complete surgical excision that can be safely performed by laparoscopy. surg endosc ( ) background: diverticulum of appendix is relatively rare, and appendiceal diverticulitis was reported to have a higher risk of perforation than appendicitis. in the us and europe, because of the high risk of perforation, preventive appendectomy is recommended to appendiceal diverticulosis, even if the patient has no abdominal pain. methods: we retrospectively reviewed the records of post-operative patients, who were diagnosed appendicitis or appendiceal diverticulitis on the pathological findings in our institution from january to october . all patients were performed computed tomography (ct) before operation. patients underwent laparoscopic surgery, including appendectomy, cecal resection, ileocecal resection and right hemicolectomy, while patients underwent open surgery. total of cases of appendiceal diverticulitis were analyzed in our study. result: patients had abdominal pain before surgery. patients were diagnosed appendiceal diverticulitis by preoperative ct. all patients underwent laparoscopic surgery ( appendectomy, cecal resection, and ileocecal resection). on the pathological findings, perforation of appendix was found in patients and the pseudo type of diverticula with no muscle layer was found in all patients. patients with appendicitis were treated surgically during the same period. among them, a perforation of appendix was found in cases. the perforation rate was . %. on the other hand, the perforation rate of appendiceal diverticulitis was . % in our study. conclusion: the perforation rate of appendiceal diverticulitis was higher than of appendicitis in our study. for the examination of the treatment strategy, including preventive appendectomy, the accumulation of more cases will be expected. case presentation: a -year-old man was referred to our hospital with right lower quadrant abdominal pain for days. his fever was . °c. his white blood cell count was , / ll, and c-reactive protein level was . mg/dl. ct revealed multiple diverticula of cecum and appendix. micro-abscess and free air were found around appendix. we diagnosed this case as appendiceal diverticulitis and laparoscopic appendectomy was performed. a perforation was found in resected appendix. microscopic study revealed a pseudo-diverticulum. the inflammation of appendix was stronger in serous membrane side than in mucosa side. this finding accorded with appendiceal diverticulitis. introduction: in order to reduce the abdominal trauma and the length of scar incisions (also during laparoscopic surgery) many approaches during the last decade has been proposed, such as single access laparoscopic surgery (sals). the aim of our paper was to update the data of our previous paper with a greater cohort of patients and a longer follow-up, also showing the single access laparoscopic left colectomy (salc) technique in particular with inferior mesenteric artery preservation imap (valdoni's technique). materials and methods: we made a retrospective analysis from october and october of all patients who underwent a sals approach for colorectal disease in the department of general and mininvasive surgery of san camillo hospital of trento. statistical analysis was performed using ibm spss statistics . continuous data were expressed as mean ± standard deviation (sd). categorical data were expressed as absolute number and percentage. the results are presented as -tailed values with statistical significance if p values \ . results: from october until october , salc for colorectal surgery were performed in our unit. of this , were for left colectomy. in cases we performed an imap. the salc with imap were performed only in case of benign disease. the mean operative time was . ± . . only one intraoperative complication were recorded, that was a splenic capsule tear, resolved with apposition of fibrillar haemostats. according to clavien dindo classification there were in particular grade ii complications, a bleeding solved with blood transfusion and one pancreatitis solved with medical therapy; grade iiia complications that was anastomotic bleeding solved endoscopically (the two complications raised in patients with imap) and iiib complications due to anastomotic leakage which needed reoperation. the mean length of incision was . ± . cm. logistic regression did not show any correlation between imap and any complications. conclusion: in conclusion, salc is a safe but very challenging technique which need a longer learning curve than the conventional laparoscopic one. in laparoscopic colectomy, also, imap seems to be safe and effective without correlation with post-operative complications also if performed in single access laparoscopic approach. aims: to describe an infrequent anatomical variation that can give rise to diagnostic and therapeutic difficulties. methods: patient with ivermark syndrome (situs ambiguus and polysplenia) with acute appendicitis and bibliographic review results: a -year-old male who consulted for flank and right hypochondrium pain of h of evolution, associated with nausea without vomiting, no fever noir other symptoms. to the physical examination good general condition. painful to palpation selectively on the flank and right hypochondrium, with involuntary defense and positive decompression at this level. the signs of rovsing and psoas were negatives. in the analytical performed leukocytes of , with neutrophils in % and rpc (reactive protein c) in mg/l. abdominal ct (computed tomograph): cecum and the ilio-cecal valve were visualized at the subhepatic level with tubular structure on the side and seemed to correspond to the cecal appendix which is increased in size ( mm), with findings suggestive of acute appendicitis. sigma and descending colon located in right hemiabdomen. second per duodenal portion located anterior to the superior mesenteric artery. superior mesenteric vein located to the left of the superior mesenteric artery, rotating around it, (radiological signs compatible with intestinal malrotation). no free fluid collections nor pneumoperitoneum. laparoscopic appendectomy on phlegmonous acute appendicitis without incidents. correct post-operative course, being discharged at h; the pathological anatomy was reported as acute appendicitis in phlegmonous. conclusions: ivermark syndrome is a genetic alteration with a multifactorial inheritance pattern, characterized by an alteration in the situation of the mesenteric vessels, which leads to abnormal rotation of the intestine during the embryonic period and alteration of the situation of different intra-abdominal organs, without a specific pattern that is pathognomonic, is associated with congenital heart anomalies between and %. reaching adulthood only between and % of them. a case of acute appendicitis is presented in a patient with this anomaly, which can lead to diagnostic and therapeutic difficulties due to the anatomical variations involved. abdominal tomography is the image method that provides the best performance for the diagnosis of acute pathologies in this type of patients. background: the clinical manifestations which occur in relation to decompression during scuba diving are variable. mild symptoms have often been reported in gastrointestinal tract. this is one of the severe cases with gastrointestinal barotrauma. ischemic colitis caused by air embolism very rare, therefore it is to be reported and discussed. case presentation: a -year-old man visited our emergency room with diffuse abdominal pain and bloody diarrhea days ago. the patient was a skilled diver who took seafood through diving for years. two days before presenting, the patient had severe abdominal pain just after diving for h at a depth of meters. he was immediately transferred to a local hospital for hyperbaric oxygen therapy, but there was no improvement with the symptom. abdomen ct angiography showed terminal ileal, ascending, sigmoid colonic and rectal decreased enhancement with wall thickening. sigmoidoscopy showed diffuse huge ulcerative lesions and ischemic changes on mid rectum and sigmoid colon. emergent subtotal colectomy and temporary loop ileostomy were done, and pathologic findings revealed diffuse mural infarct with serosal abscess formation in whole colon and transmural infarct in terminal ileum. conclusion: surgical approach could be one of the treatment options, though it depends on severity of the symptoms and the patients' conditions. colonic lipomas are extremely uncommon benign tumours, with an incidence ranging between . % and . %. although they are most frequently asymptomatic, when colonic lipomas are [ ?cm, they may present symptoms such as constipation, abdominal pain or rectal bleeding. most colonic lipomas typically occur in middle aged women and are located in the ascending colon and the caecum, while occurrence in other parts of the colon and rectum is rare. in this case report, we describe a lipoma that caused descendent bowel intussusception. a -year-old male presented with longstanding history of constipation. personal history of interest included active smoker, hypertension, hypercholesterolemia, psoriasis with joint affectation and reiter syndrome. he had had no previous surgery. he attended the emergency services on th july with a two-day bowel obstruction, without fever or nausea, being attended by our surgical emergency unit. he had been assessed during the previous months by gastroenterology, with a colonoscopy that showed a cm submucosal lesion that partially occluded descendent bowel, with inconclusive biopsy. an abdominal contrast-enhanced computed tomography (ct) was performed, confirming a welldefined mass located in splenic flexure of descendent bowel, conditioning a large bowel intussusception, nevertheless with no obstructive acute signs. the surgery was scheduled a few weeks later, performing a laparoscopic segmental resection with primary anastomosis including oncologic margins. the patient evolved satisfactorily in the postoperative period and was discharged six days after the surgery without any complications. likewise, he was monitored on a regular basis at our outpatient department and was free of symptoms at the -month follow-up visit. the histological analysis revealed a cm ulcerated lipoma affecting % of bowel circumference. the molecular study, using fluorescent in situ hybridation (fish) showed no mdm gene amplification. laparoscopic segmental resection of the large bowel is a safe and feasible technique for the treatment of large bowel intussusception caused by a colonic lipoma. the complete removal of the lipoma will condition the prognosis. furthermore, in the future, endoscopic surgery using colonoscopy could be employed when having a certain preoperative diagnosis of lipoma. surg endosc ( ) introduction: acute appendicitis is one of the most common abdominal surgical emergency, the diagnosis of which mostly relies on conventional methods such as physical examination and blood tests. the use of ultrasonography and ct abdomen aids in more precise diagnosis especially in patients with atypical presentation or in elderly. aim: this study aims to evaluate the ability of the neutrophil/lymphocyte ratio (nlr), platelet/lymphocyte ratio (plr) and mean platelet volume (mpv) in predicting the diagnosis of acute appendicitis. methods: retrospective analysis of prospectivly maintained data of all patients ( ) admitted with acute appendicitis to the emergency department at a tertiary hospital in the middle east between january till september . medical records and database of patients,who had appendicectomy for clinically and radiologically proven appendicitis, were reviewed. the retrieved data included patient's demographic and laboratory values of white blood cells (wbc), neutrophil (n), lymphocyte (l), and platelet (p) along with their ratios for comparison. results: spss version was used for tabulating the data. the recommended cutoff value of the nlr, plr and mpv in predicting the diagnosis of acute appendicitis was decided by using receiver operating characteristic (roc) curve analyses. at least for nlr, the confidence interval (ci) was . which is percentage of the positive values, since the confidence limit was between to %. our results showed that the laboratory parameters were fairly significant since the confidence interval was . in predicting the diagnosis in our population. conclusion: although appendicitis is a clinical diagnosis but laboratory parameters specially nlr, plr and mpv can be used as an adjunct in the diagnosis of acute appendicitis. literature is scarce concerning the validity of such parameters in our part of the world and prospective randomized controlled trials are needed to prove the efficacy of such rationale. objective: tumors of the cecal appendix represent a subset of colonic neoplasms whose early diagnosis is a real clinical challenge. correspond to . % of all gastrointestinal tumors and their prognosis depends on the type of injury, being the most frequent variety the carcinoid type. appendix involvement in endometriosis is rare, accounting for % of all endometriosis cases, and sometimes mimicking cecal tumors. methods: a -year-old woman with a history of hypothyroidism due to autoimmune thyroiditis and atrophic gastritis with gastric neuroendocrine tumors resected by endoscopy that in the digestive unit reviews, tac with double contrast was requested, showing a lobulated lesion in the cecum adjacent to the ileocecal valve, with contrast enhancement of approximately mm, suggestive of tumor. the colonoscopy evidenced a protruding appendicular osteum with inflammatory aspect that was biopsied. the pathological anatomy of the biopsy reports chronic congestive colitis with edema of the own blade and minimal acute activity, with moderate local eosinophilia.the case was presented in the multidisciplinary oncology committee and it is decided, due to the patient's background, to perform surgery on the lesion. laparoscopic right hemicolectomy was performed, with extracorporeal latero-lateral mechanical anastomosis with endogia signiaÒ mm. results: the patient evolves favorably, with good oral tolerance and depositional habit. she is sent home at the sixth postoperative day. the pathological anatomy reports tumor injury in the appendicular ostium compatible with endometriosis at the base of the cecal appendix implantation, ruling out malignant tumor pathology. conclusions: gastrointestinal tract endometriosis represents - % of cases, being most frequently located in the rectal-sigmoid region. appendix involvement in endometriosis is rare, accounting - % of all endometriosis cases and presents a preoperative diagnostic challenge, because sometimes mimicking a carcinoid cecal tumor. in our case, due to the patient's history, we assumed that the cecal lesion was a carcinoid tumor, so we performed a laparoscopic right colectomy, but if we had known that it was an endometriosis, we could have performed an appendectomy, although in both cases the laparoscopic approach gives us some benefits compared to the open approach aims: the natural history and predictive factors associated with chronic anastomotic complications have not been clearly studied. the aim of this study was to evaluated the predictive factors related to chronic anastomotic complications methods: from january to december , a total of patients who underwent anastomotic leakage were enrolled in this study. all patients underwent anterior resection with or without defunctioning stoma due to colorectal cancer. the patients received follow-up by clinical examination and abdominopelvic computed tomography (ct). they underwent a follow-up ct every months for the first year and then every months for the next years after that. complicated group (cg) underwent chronic anastomotic complications. normal group (ng) didn't underwent chronic anastomotic complications like stricture, fistula, chronic sinus, etc. results: there were no significant differences in gender, age, preoperative chemoradiotherapy and operation type between two groups. low rectum lesion and defunctioning stoma at the time of primary surgery were more frequent in cg (p = . , . ). there were no significant differences in type of anastomotic leakage, international leakage grade and ct findings at the time of diagnosis of anastomotic leakage. however, abnormal ct findings at the time of month were more frequent in cg group (p \ . ). in multivariate analysis, abnormal ct finding at the th months was only significant factor related to chronic anastomotic complications. conclusions: abnormal ct findings at the th month associated with prediction of chronic anastomotic complications. aims: acute appendicitis is the most common cause of acute abdomen requiring surgical intervention in the world. nowadays, standard treatment of acute appendicitis involves a surgical approach, eitherlaparoscopic or open.the purpose of the present study is to evaluate the safety of a discharge within less than h after performing appendectomy as a result of an uncomplicated acute appendicitis. conclusions: patients who undergo appendectomy (open or laparoscopic) for acute uncomplicated appendicitis, without surgical incidents and an adequate social/family network, can be discharged in less than h without a higher risk of post-operative complications or readmissions than patients with longer postoperative stays. it will be necessary to conduct more prospective studies with higher level of evidence that could corroborate our results. aims: median arcuate ligament syndrome (mals), also known as the celiac axis compression syndrome, is a rare condition caused by to the compression of the celiac trunk and the nerves located in this area (celiac plexus) by the median arcuate ligament. it is believed that mals is caused by the median arcuate ligament compression of the celiac plexus nerves over the celiac trunk, but another probably cause may be the lack of blood flow to the organs supplied by the celiac artery, however, this theory is controversial. the first clinical sign of mals is the apparition of postprandial abdominal pain in the upper abdomen. this typical pain forces patients to avoid eating, which can lead to loss weight (often more than pounds). other associated symptoms may include nausea, diarrhea, vomiting and delayed gastric emptying (a delay in food moving from the stomach into the small intestine). in relation to this uncommon condition, we present a clinical case of laparoscopic management of mals. methods: we present a -year-old patient with complaints of recurrent epigastric pain, postprandial vomiting and loss weight. blood tests and gastroscopy were performed to help ruling out more common causes of his symptoms, such as gastroesophageal reflux disease (gerd), gastritis or gastroparesis. as a part of the differential diagnosis, mals was suspected and a mesenteric doppler ultrasound was ordered to check blood flow through the celiac trunk and evaluate a possible compression of the celiac plexus. also, an angio-ct scan was also performed to confirm the diagnosis. once the mals was diagnosed, we decided to perform a laparoscopic approach as definitive surgical procedure. results: the patient was discharged h after surgery with no remarkable events during his postoperative stay. he has been followed up during months, remaining asymptomatic. conclusions: laparoscopic approach in mals offers a superior visualization during the surgery and involves lower morbidity in compare to open approach, which makes it an optimal treatment for this condition. aim: pilonidal sinus is a common disease with annoying and often painful symptoms. traditional surgical techniques for its treatment are characterized by either intense postoperative pain and prolonged wound-healing periods (wide resection, marsupialization) or unsatisfying aesthetic results (advancement or rhomboid flaps). 'endoscopic pilonidal sinus treatment' (epsit) is a new minimally invasive technique which utilises the meinero scope, primarily designed for the endoscopic treatment of complex perianal fistulas in a technique known as vaaft. we present our experience and outcomes in three treatment centers in northern greece. methods: between july and november we treated patients with pilonidal sinus using the epsit technique. the mean age of patients was , and % of them were male. patients were treated in the acute phase with the presence of pilonidal abscess. all operations were performed by two laparoendoscopic surgeons specifically trained in the technique. most patients were treated on a day-case basis. postoperative wound care included daily tract irrigation with ml of saline for a total of days. results: there were no immediate postoperative complications. medium postoperative pain was . on a vas scale. % of patients were discharged on the same day, patients remained in hospital for one day mainly due to social reasons. return to daily activities was immediate. in a maximum follow-up of months we observed recurrences. conclusions: epsit is a promising minimally invasive technique for the treatment of pilonidal sinus. what makes it mostly attractive is the minimal amount of postoperative pain, the excellent cosmetic result and the fast recovery with return to daily activities. introduction: isolated acute chylous peritonitis is a rare event. when presented as an acute abdomen warranting surgical intervention, it is often difficult to determine the cause pre-operatively. here, we report a case of acute chylous peritonitis due to meckel's diverticulitis presented with the clinical features suggestive of acute appendicitis. presentation of the case: a -year-old female presented with abdominal pain and clinical features consistent with acute appendicitis underwent diagnostic laparoscopy. she was found to have four-quadrant chylous peritonitis and ileus caused by an inflamed meckel's diverticulum adhered underneath a loop of small bowel and mesentery leaking chyle. after uneventful postoperative recovery, she was discharged at post-operative day two with oral antibiotics and was advised to take a low-fat diet. aims: perforated diverticulitis with purulent peritonitis (hinchey iii) has traditionally been treated with surgery including colon resection and stoma (hartmann procedure) with considerable postoperative morbidity and mortality. laparoscopic lavage has been suggested as a less invasive surgical treatment. methods: a -year-old woman with a -day history of abdominal discomfort exacerbed during the last h. ct scan showed neumoperitoneum accompanied by free fluid and a cm collection adjacent to descending colon showing diverticula suggestive of covert perforation. after h of non-response to medical treatment, associated with the impossibility of percutaneous drainage through interposition of intestinal loops, colon and lumbar vessels, urgent surgical intervention is decided. results: laparoscopic lavage of all quadrants was performed with saline, l or more, of body temperature, until clear fluid was returned. two non-suction j-pratt drains were placed. intravenous antibiotics were continued for a minimum of h, then oral antibiotics were continued for week. oral fluids were commenced on the first postoperative day and solids were subsequently introduced, depending on clinical progress. conclusion: laparoscopic management is reasonable alternative to the traditional open resection for hinchey grade ii-iii perforated diverticulitis with generalized peritonitis. this approach has a low mortality rate despite patient co-morbidity and disease severity. benefits include stoma avoidance and minimal wound infection. subsequent elective resection is probably unnecessary and readmission in the medium term is uncommon. background: constipation and fecal incontinence are common annoying complications after pull through procedures for hirschsprung disease (hsd). many causes could be the etiology of these problems. perineal descent syndrome could be the major hidden cause of these complications. the aim of this study is to evaluate the role of perineal descent syndrome in the development of post pull through constipation and fecal incontinence in addition to evaluate the role of laparoscopic rectopexy for treatment of these problems. \ b[patient and methods: \/b [ patients treated with pull through for hsd over the period of five years. out of the patients presented with constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. rectal exam, anorectal manomety, defecography, contrast enema, rectal biopsy, emg, proctoscopy and endorectal ultrasound were performed to all patients. patients with stricture, missed aganglionic segment, injured internal anal sphincter, and loss of the sensory mucosa above the dentate line were excluded from the study. anterior wall rectopexy was performed for anterior wall rectocele. posterior wall rectocele was treated by retro rectal mesh rectopexy. emg is repeated weeks and months after surgery. outcome measurements included constipation, fecal incontinence and pudendal nerve latency. results: cases of post pull through constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. patients with stricture, patients with missed aganglionic segment, patients with loss of anal sensory sensation and patients with injured anal sphincter were excluded from the study. defecography showed patients with anterior rectocele ( males and females) and patients with posterior rectocele ( males and females). the patients mean age . ± . years . emg showed prolonged pudendal nerve conduction in all cases. anterior wall and retro rectal rectopexy were performed laparoscopically without complications. constipation was resolved in all patients after surgery. all patients showed fully control in defecation. pudendal nerve latency decreased in all patients. conclusion: perineal descent syndrome proved to be a major hidden cause of post pull-through constipation and fecal incontinence. laparoscopic rectopexy showed a good solution of these complications. cystic lymphangioma is a rare entity. the surgical indication is determined by the size and symptomatology, and consists of the complete exeresis of the tumor. the laparoscopic approach is feasible in these cases, allowing a broad visualization of the anatomy, accessibility to the retroperitoneum in the context of a minimally invasive approach and a better recovery of the patient, without providing an increase in morbidity compared to the conventional. in this way we defend as a technique of choice laparoscopic surgery against these rare tumors for the general surgeon in the abdominal cavity, betting on a minimally invasive surgery. aims: laparoscopicposterior sutured rectopexy is one of the accepted treatment options for fullthickness rectal prolapse. recently, reduced port surgery(rps) has beenan emerging concept that, compared with conventional multiple port surgery (mps), yields reduced postoperative pain and improved cosmesis. the aim of the study is to evaluate the feasibility and safety of rps for fullthickness rectal prolapse. methods: rps was performed by single-incision plus one puncture, using internal organ retractor(ior) to secure operative field. straining one ior by - strings in - directions makes it possible to retract the internal organs three-dimensionally. this multi-directional flexible retraction could secure good operative field. from to , patients (rps: cases, mrs: cases) underwent laparoscopicposterior suture rectopexyfor total rectal prolapse. shortterm outcomes were compared between the two procedures. results: there was no significant difference between rps and mps in median operative time ( vs . min, respectively, p [ . ). the median blood loss volume was not significantly different between rps and mps groups ( . vs . ml, p \ . ). the duration of median hospital stay after surgery was not significantly different between two groups ( . vs days, respectively, p [ . ). the frequency of complications after surgery were not different between them. conclusions: reduced port lap-rectopexy can be a good therapeutic option for total rectal prolapse. a prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over mps. the piccolo project proposes a new compact, hybrid and multimodal photonics endoscope based on optical coherence tomography (oct) and multi-photon tomography (mpt) combined with novel red-flag fluorescence technology for in vivo diagnosis and clinical decision support. for its development it includes different phases of validation. within this framework, the present study has as main objective: to characterize a model of rat colonic hyperplasia, which will be used for the development and validation of the previously mentioned endoscopic technology. secondary objectives: procure the reproducibility of the model chosen and determine the optimal time, after induction of the model. material and methods: animals (rattus norvegicus), wistar, males and females \ -yearold, randomly distributed. group (n = ): by laparotomy, a non-resorbable suture (silk / ), not stenosing, is placed through the wall of the colon. group (n = ): by endoscopy, a . mm long segment of a polymeric catheter is inserted, which is fixed to the wall of the colon by means of a suture. group (n = ): by means of endoscopy, a self-expanding and uncoated metallic stent are placed in the colon. group (n = ): a superficial laser resection of the colonic mucosa is performed by endoscopy. group (n = ): as an extension of the most optimal model. weekly, the animals were anesthetized again to perform a colonoscopy, which determined the degree of mucosal growth in descending colon and colonic biopsies were extracted weekly ( weeks). results: group . growth around the sutures after the second follow-up, diagnosed as hyperplastic polyps after a histopathological analysis. aim: the role of laparoscopy in the management of generalized appendicular peritonitis is controversial. this is due mainly to the lack of scientific data. through this study and a laborious bibliography research, we proposed to report our experience in terms of postoperative results, in the laparoscopic treatment of generalized appendicular peritonitis and to try to identify the risk factors associated with the occurrence of global morbidity and conclude on the feasibility of this technique in its treatment. methods: we conducted a retrospective study including all cases of generalized appendicular peritonitis managed laparoscopically, in the general surgery department of charles nicolle hospital between january and december . results: we identified patients. the mean age was . years. one fifth of the cases required a midline conversion ( . %). the mean operative time was . ± , min. the overall morbidity rate was % including surgical complications. there were no deaths. in uni-variate analysis, comorbidity, crp [ mg /l, operative time exceeding min and midline conversion were significantly associated with postoperative morbidity. co-morbidity, diabetes, asa score [ , delay of consultation [ days, intra-abdominal abscess and operative time exceeding min were significantly associated with medical complications. the univariate analysis also revealed that crp [ mg /l and midline conversion were predictive of surgical complications.the multivariate analysis identified the midline conversion as the only independent factor significantly associated with post operative morbidity (odds ratio = . , % confidence interval [ . - . ] ). conclusion: based on our results, it appears reasonable to continue the laparoscopic management of diffuse appendicular peritonitis. however, enhance this technique is basic in order to reduce midline conversion rate and to shorten operative time, which can lead to post operative complications. aims: currently, acute appendicitis is the most common surgical emergency. laparoscopic appendectomy is the usual procedure to treat acute appendicitis. the aim of this study is to evaluate the safety of electrocoagulation in the treatment of mesoappendix in laparoscopic appendectomy. methods: we have retrospectively studied a prospective database of operated patients of appendecectomy in emergency surgery unit. we have reviewed laparoscopic appendectomies from june st, to december st, . the mesoappendix was electrocoagulated in every laparoscopic appendectomy. the statistical analyses has been done with spss . version. results: our group consists of patients of which . % were male and . % were female. the average age was . years with a standard deviation of . % and p was . years. the most common total stay was day ( patients). the usual post-operative stay was one day ( ). we classified the diagnosis in complicated apendicitis ( patients) and no complicated apendicitis ( patients). the conversion rate was . % ( ). the main surgical complications were: surgical wound infection ( . %); intraabdominal abscess ( . %); and bleeding ( %). only one of the patients that suffered bleeding had complicated appendicitis. the medical complications were catheter sepsis ( . %); respiratory infection ( . %); cardiologicals ( , %); and paralytic ileus ( . %). the treatment of mesoappendix with electrocoagulation is safe and effective since the complications rate is very low. even so, it would be necessary to conduct more prospectives randomized studies in order to get enough evidence about the treatment of mesoappendix with monopolar electrocoagulation. introduction: the difficulty of resection of the rectum is determined by its anatomical relationships, intimately in contact with the bladder, seminal vesicles, prostate and urethra in the case of the male, vagina in the woman and nerve structures that will give defecatory, genital and urinary functionality. this structure creates a big impediment due to problems of visualization and difficult dissection, in such a way that conventional surgical techniques instigates a series of complications derived from this difficulty. we propose a new approach in rectal surgery in patients with inflammatory bowel disease. material and methods: a -year-old man with a history of ulcerative colitis developed a severe acute outbreak refractory to treatment. a total laparoscopic colectomy with a terminal ileostomy was performed in . in he was notified for reconstruction. we evidenced a rectal stump of about cm with signs of inflammatory disease at the mucosal level. a transanal proctectomy was performed with confection of 'j-pouch' and ileoanal anastomosis about cm from the anal margin by laparoscopy. the postoperative courses favorably, being discharged on the sixth day. currently in follow-up in digestive and general surgery, he is asymptomatic and he has an optimum level of quality of life valued by the sf- weeks after the intervention. conclusions: our service introduces the transanal approach to the performance of proctectomy in cases of inflammatory disease, a technique that provides clear advantages by improving visualization and the identification of anatomical structures. in this way, a safe dissection of the pelvis is achieved, adjusted to the serosa of the rectum, with preservation of the mesorectum and the hypogastric plexus, and with the consequent improvement of the genital and urinary function. the result is an equally safe surgery, which implies little increase in operative time and with better and shorter postoperative recovery.the conservation of the pelvic innervation avoids disorders of ejaculation, vaginal lubrication and bladder and rectal motility. the transanal approach for the performance of proctectomy provides benefits in terms of the preservation of the hypogastric plexus, minimizing the anatomical difficulties involved in rectal surgery and maintaining urinary and sexual function. aims: to evaluate the feasibility and outcomes of laparoscopic appendicectomies in both simple and complicated appendicitis, given the increasing trend towards a laparoscopic approach in the last four decades for the treatment of acute appendicitis. we present data from a district general hospital over a -year period. methods: we retrospectively analysed a single consultant's continually updated database of laparoscopic appendicectomies between / / and / / ( months). patient demographics, investigations, intraoperative findings and postoperative outcomes were recorded and analysed. complicated appendicitis was defined as the formation of appendiceal mass or abscess with or without perforation and peritonitis. results: cases of laparoscopic appendicectomies were identified during the specified period. the median patient age was (range - years). true positive rates for uss and ct were % and %, respectively. the rate of negative appendicectomies was %. transanal minimally invasive surgery (tamis) has been used for the treatment of rectal neoplasms such us benign polyps and early rectal cancer. when the tumour is located in the upper rectum or close to the rectosigmoid junction, this approach may be technically dificcult.we present a video of a tamis resection of a large polyp located cm from the anal verge. after properative examination and ct and mri were performed, the patient was prepared for surgery, and a trasnanal minimally invasive surgery was proposed.resection of the polyp was performed with the aim of an endogia and conventional laparoscopic materials. total resection of the polyp with free margin was possible. the postoperative pathology report confirmed a high grade displasia villo-tubular adenoma with a lesion free margin. tamis resection of tumours located above the rectosigmoid junction may be a safe and feasible technique in selected patients. aims: pelvic organ prolapse (pop) is a very relevant problem for women's quality of life and has a prevalence of about % defined by symptoms and up to % when established by physical examination. nowadays, sacrorectopexy for posterior pop and sacrocolpopexy for apical pop are considered the gold standard techniques. recently, we have seen that laparoscopic lateral suspension is a feasible procedure for apical pop, obtaining a success rate higher than % at one year. these results are similar to what we can achieve with sacrocolpopexy. methods: we herein present the case of a -year-old woman with apical and posterior pop, this was provoking an important impact on her quality of life, with obstructive defecation (needing digitations) and urinary incontinence. we proposed sacrorectopexy for her posterior pop and laparoscopic lateral suspension for her apical pop. in the video we can see how we perform a ventral mesh sacrorectopexy, following d'hoore technique; and a laparoscopic lateral suspension with preperitoneal dissection, following the technique described by the team headed by dubuisson and veit-rubin. we used laparoscopic ports ( , , . and . mm). results: patient was discharged home on the second postoperative day and has not had any sign of recurrence or extrusion after more than two years of follow-up. in addition, she has not suffered lower urinary tract symptoms, constipation or pain. conclusions: we present a case in which we have carried out a laparoscopic lateral suspension instead of a sacrocolpopexy for an apical pop, obtaining good short-term and long-term results. we consider it is very soon to assess this technique's efficacy and it has to be validated in studies with larger source of patients. nevertheless, we think this procedure might become an excellent alternative to sacrocolpopexy for apical pop. aims: laparoscopy is a minimally invasive approach with low morbidity. the aim is to show the usefulness of the laparoscopic approach for massive intra-abdominal abscesses, which it is controversial. we report three patients who underwent emergency laparoscopy for peritonitis or massive intra-abdominal abscesses not amenable to percutaneous approach that were suspected to be caused by acute diverticulitis. methods: all patients had diagnosis of acute diverticulitis (hinchey ii-iii grade) with pelvic abscesses situated between sigma and bladder or diffuse peritonitis. the patients with hinchey ii grade had failed conservative management with antibiotics. they underwent emergency laparoscopy under general anaesthesia, with three abdominal ports. intra-abdominal abscess cavities were exposed and the purulent exudate was sampled and aspirated. copious irrigation was performed under direct vision and thorough examination without other findings. the procedure was completed laparoscopically in all cases. results: all patients had favourable evolution. one of them had a properly drained faecal fistula which changed to a purulent fistula on the twentieth postoperative day. this patient underwent laparoscopic left colectomy three months later because he had have a new episode of acute diverticulitis. other two cases showed very good clinical evolution, without evidence of fistula in postoperative period and they were complete asymptomatic one month later. conclusion: in our experience laparoscopic drainage is a feasible, safe, and effective for the treatment of pelvic abscesses and diffuse peritonitis secondary to acute diverticulitis. n. pinheiro, a. ziegler introduction: solitary rectal ulcer syndrome (susr) is characterized as a rare disease whose pathophysiology remains uncertain. it was first described in by cruveilhier and his clinicopathological feature was reported in by mandigan and morson, where he is associated with defective disorders, internal rectal prolapse, and psychological changes. according to works about % of the patients are asymptomatic. when symptomatic the diagnosis can be made through physical examination, clinical history and, often, confirmed by endoscopy with biopsies. treatment depends on the severity of the symptoms and the existence of associated rectal prolapse. according to the literature, conventional surgical options include local excision, rectal mucosectomy, retopexy, and segmental colonic resection. rolato: a -year-old male complaining of anal bleeding at bowel movements years ago. he performed, several times, conservative treatment, but without improvement. he sought proctological care and underwent colonoscopy, in which he showed an ulcerated lesion on the anterior wall of the distal rectum. new investigation with videodefecogram revealed colorectal intussusception with associated mucosal prolapse, being considered the factor causing the ulcer. elected by the sacropromontofixação. evoluiu with improvement of anal bleeding, mucorrhea and anal discomfort. after a proctological examination, which was normal, a control colonoscopy performed after months of surgery revealed rectal mucosa, with residual scarring and disappearance of the submucosal nodule present in the initial examination. reassessed after months, the patient is asymptomatic. conclusion: rectal solitary ulcer whose causal factor was a colorectal prolapse (intussusception) with mucosal exteriorization through the anal canal, which was individually treated with sacropromontofixation. j.p. mali, p.j. mentula, a.k. leppäniemi, v.j. sallinen approximately - % of patients diagnosed with colonic diverticulitis have an intra-abdominal abscess as a complication. abscess diameter of - cm is generally accepted as a cut-off determining the choice of treatment between antibiotics alone and percutaneous drainage. the aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. this was a retrospective cohort study which was conducted in helsinki university hospital, an academic teaching hospital functioning as secondary and tertiary referral center. patients with computer tomography-verified acute left-side colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during - . altogether, suitable patients were included in analyses. those treated primarily with percutaneous drainage or antibiotics alone ( and patients, respectively) were further compared in regards to treatment results. the main measured outcomes were need of emergency surgery and -day mortality. abscesses under mm were mostly treated with antibiotics alone with high success rate ( out of , %). in abscesses over mm, the use of emergency surgery increased and use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at - % regardless of abscess size (figure ). there were no differences in failure rate, -day mortality, need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage versus antibiotics alone, even when groups were adjusted for potential confounders. white blood cell count = . * /l, abscess diameter = mm, and corticosteroid medication were independent risk factors for failure of treatment with antibiotics alone. patients without these risk factor had % and patients with one risk factor had % success with antibiotics alone. percutaneous drainage as treatment for large abscess does not seem to be superior to treatment with only antibiotics. majority of patients with abscesses over mm in diameter undergo surgery as primary intervention. introduction: even today, 'chronic appendicitis' is a clinical term that is not widely accepted nor well documented amongst the medical community. its etiology is the presence of a mass (e.g. fecal mass, hyperplasia of lymphatic tissue, etc.) that continuously and partially obstructs appendix lumen. it is presented as a low intensity, intermittent, with exacerbations and remissions, abdominal pain that is located at the right iliac region. the pain lasts up to several months and it is usually underestimated by the patient. its diagnosis is based on imaging examination. appendectomy is the treatment of choice for chronic appendicitis. the operation is challenging for the surgeon who has to cope with an intensively inflamed area around the appendix without the ease of access to that area. purpose: to present our laparoscopic approach to a chronic appendicitis case and to review the literature. case report: a -year-old woman is hospitalized due to chronic appendicitis. the patient was treated conservatively with the use of intravenous antibiotics in two separate hospital admissions dated and months back respectively. eight weeks after the last exacerbation, she underwent a laparoscopic appendectomy. results: even though the procedure was planned six months after the first episode, the laparoscopy revealed a severe inflammation of the appendix, which was extended to the caecum and the surrounding preperitoneal tissues. although the difficultness of the operation it was completed successfully laparoscopically. the histological examination confirmed without any doubt the existence of 'chronic appendicitis'. the patient was discharged uneventfully the third postoperative day. conclusions: chronic appendicitis is an existing clinical entity that the surgeon may come through during his career. in the hands of experienced laparoscopic surgeon, the laparoscopic approach is feasible and safe. introduction: ventriculo-peritoneal shunting (vps) used in the treatment for hydrocephalus is associated with several complications.the exact cause of such extrusion is not known. visceral perforation is an unusual but serious complication with consequeces such as peritonitis, meningitis or encephalitis. management involves prompt removal of shunt, intravenous antibiotics, an adequate recovery gap so that cerebrospinal fluid culture is sterile and then followed by shunt replacement on opposite side. aim: multidisciplinary approach of extrusion of vps through anus by laparoscopic and external ventricular drainage. case exposure: a -year-old woman had a vps inserted year ago after excision of gangliocytoma due to lhermitte-duclos disease. she was admitted in the emergency department without symptos after trans-anal protrusion of vps catheter. the neurological and abdominal evaluation was normal. laboratory tests did not reveal disorders and abdominal ct-scan suggested perforation, itshowed the insertion of the end of the catheter in sigma, without pneumoperitoneum or intraabdominal free fluid. cranial ct-scan did no describe sings of hydrocephalus. the patient underwent an emergencysurgical intervention. first of all, antibiotic therapy was initiated and neurosurgery's team was performed an external ventricular drain and they disconnected the proximal catheter side. after that, an exploratory laparoscopy was performed. it revealed a microperforation and collection beside to an appendix' base due to the proximity with the catheter. additionally, the catheter was freed from adhesions at the point of entry into the colon and after careful dissectionwe release the vps from colon with a . cm transmural trajectory at the sigmoid level. no free fluid was seen and rest of the bowel appeared normal. the distal end was removed through the anus and the proximal end through a laparoscopic port. we performed a laparoscopic segmental cecum resection and an extracorporeal colo-colonic anastomosis was performed for a mini-pfannestiel laparotomy of assistance. there were no complications in the postoperative period, being discharge on the th day. conclusion: the multidisciplinary approach and the laparoscopic support in the diagnosis and treatment of patients with colon perforation caused bay vps catheter is a feasible and safe option in third level centers. background: acute appendicitis continues to be the most common source of complicated intraabdominal infection worldwide. the high incidence of postoperative complications and dissatisfaction with the results of treatment in cases of complicated appendicitis and peritonitis gave the reason for conducting this study. aim: to evaluate the effect of different laparoscopic trocars position in case of laparoscopic appendectomy for diffuse appendicular peritonitis for the incidence of postoperative complications methods: the results of laparoscopic treatment of patients with acute appendicitis complicated by diffuse peritonitis were analyzed. the first group consisted of ( %) patients operated by triangulation access (type trocar placement according sages guidelines for laparoscopic appendectomy (sages qla). the second group consisted of ( %) patients operated by sectorisation access (type sages qla). postoperative complications were classified by clavien-dindo classification. results: the duration of the operation for the analyzed groups was . ± . vs . ± . min. there were no deaths among this group of patients. the incidence of postoperative complications for both group was . %. postoperative complications in the triangulation and sectorisation group were % and . % respectively (p . ). clavien-dindo iiib complications were noted in . % (n- ) patients and presented with intra-abdominal abscesses (iaa). all patients with iaa were operated in sectorisation group. conclusion: sectorisation trocar placement increases the incidence of intra-abdominal complications for laparoscopic appendectomy for diffuse appendicular peritonitis. introduction: the diverticular disease of the colon is a chronic entity with a variety of abdominal symptoms that can present with recurrent episodes of acute diverticulitis (ad). the prevalence of diverticulosis is not influenced by gender and increases with age, which, according to the increase in life expectancy, explains the accumulation of cases in western countries. the classic diagnostic-therapeutic algorithm of the disease is it has been based on the hinchey classification, the use of antibiotics and the intervention of hartmann (ih) at the acute time and elective colectomy in the multirecurrent cases. the use of laparoscopy with washing and drainage is actualymore extended in cases with peritonitis. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with diverticular disease complicated by severe inflammatory plastron with 'covered' perforation, with several recurrent episodes. material and method: case report: a -year-old man with ap-diverticulitis years ago with complete resolution and normal control colonoscopy. he presents in the last two months three compatible episodes of acute diverticulitis, exploration with plastron-mass in hypogastrium without defense, tac-marked thickening of a segment of cms. of medium sigma, collection not drainable in mesosigma, of cm, which loses the plane of cleavage with loops of thin neighbors with a linear tract that suggests fistulization. evidence of interest is exposed. given the evolution, it is decided surgical elective treatment. result intervention: preoperative ureteral double catheterization, laparoscopic approach, is exposed by video, rectosigmoid resection by diverticular plastron, with negative io biopsy, mechanical colorectal anastomosis. good postoperative course, discaharge at th day. defini-tive ap: perforated diverticulitis, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of complex and severe diverticular disease. aim: tamis resection has been described for the treatment of rectal neoplasms, wether benign or early malignant tumours. since tamis appearance, many different indications have been reported.we aim to show an special indication as seen in this video of a tamis resolution of a rectal stenosis non treatable by endoscopy. method: we present a video of a female patient, previously treated for a large rectal adenoma treated by trasnanal apporach, with a postoperative sepsis which required lateral colostomy and trasanal drainage. after surgery, the patient suffered from a rectal stenosis which couldn' t be solved by endoscopy, so the patient was sent back for a surgical treatment.we decided to performed a trasnanal apporach by tamis and a long and circunferiential stenosis around cm from the anal verge was seen.we performed a rectotomy by electrocautery in the posterior rectal wall until the perirectal fat was seen and the stenosis was passed. a dilatation with a foley catether was also performed. results: postoperative course was uneventful and after months she was prepared for colostomy closure with no complications and remains asymptomatic nowadays. conclusion: tamis approach of rectal stenosis may be a safe and feasible technique in selected cases if conservative treatments fail. iatrogenic endoscopic colon perforation it is a severe, but rare complication of colonoscopy. the incidence of this complication is estimated to be . - . % for diagnostic colonoscopies and . - % for therapeutic colonoscopies. the management of these complications depends on the size of the lesion,the time elapsed between the lesions were produced and diagnostic of the lesions and associated pathology. the treatment can be consevative,endoscopic or surgical(clasic/ laparoscopic) in our sevice in last years we treated cases with iatrogenic colon perforation after diagnostic colonoscopies. all lesions were at sigma level. one case was admission in our service at days after a diagnostic colonoscopy.the pacient was operated clasic,in emergency,we found a fecaloid peritonitis,a perforation at sigma level.we made a colostomy, lavage, drainage but the pacient died after days. in cases we made the operation at maximum h after the lesion was diagnosticated by the endoscopist(directly visualisation).we didn't made radiologic investigation.the pacients were operated laparoscopic,we made suture,lavage,drainage. evolutions of the pacients were good. conclusion: iatrogenic colonic perfortion are rare,but severe complication. laparoscopic surgery can be a choice in treatment of this complication introduction: complicated diverticulitis with fistula is responsible for about % of surgical procedures in diverticular disease and is commonly found in patients with diverticulitis of the sigmoid colon. colovesical fistulas are the most frequent ( %), with highest incidence in males. only a third of these patients have a history of diverticulitis. in most cases, treatment is surgical, and colectomy is performed, whether or not in association with vesical recession. case report: year old male with pneumaturia and fecaluria for the preceding months. the colonoscopy identified a diverticulitis of the sigmoid colon and the subsequent pelvic mri suggested a colovesical fistula. the cystoscopy was not able to identify any fistulous opening, but a double j catheter was placed in the left ureter, as surgical treatment had been proposed. a subsequently abdominal pain motivated a preoperative ctscan which revealed a pneumoretroperitoneum and a fluid collection near the left ureteral tract. the multidisciplinary team on the case decided to perform a percutaneous nephrostomy, followed by an exploratory laparoscopy. the fistula tract was identified and a laparoscopic sigmoidectomy with partial cystectomy was performed, as well as a ureterorenoscopy (with double j replacement). there were no intra or postoperative complications, and the patologic repport had no signs of malignancy. video of the surgical procedure is presented. conclusion: a laparoscopic approach to complicated diverticulitis with colovesical fistula is safe and effective when performed by experienced colorectal surgeons. introduction: diverticular disease is characterized by its high prevalence, being one of the most frequent causes for hospital admission when it comes to gastrointestinal pathology. even though it is more frequent in older patients, there has been an increase in incidence amongst lower age groups. the approach to the disease has also suffered changes in the last few years, showcasing a tendency for less invasive options, deferring elective surgery to later in the course of the disease. this study examines the therapeutic approach to diverticular disease in our hospital. methods: retrospective analysis of demographic data, therapeutic options and surgical outcomes in patients admitted for diverticular disease between january and june . results: patients(n = )were included in the study: ( %)were male and ( %) were female, with an average age of years. patients( %) underwent medical treatment, with surgery reserved for the remaining patients, of which were emergencies, with the other being elective( %).about % of patients were only admitted once, %were admitted twice and % had or more episodes. for the single-admission group, the most common treatment was medical( %of cases), as was the case for the group with or more episodes(in which %of cases were subjected to medical treatment). in the patient group with episodes, %were submitted for surgery, most of which elective.as far as the surgically operated group is concerned, no statistically significant differences were found with regards to patient sex. age, however, was significantly greater for the group that underwent emergency surgery vs that submitted to elective ( . years vs . years,p \ . ).the most common procedure overall was colic recession, with hartmann's operation standing out as the most frequent for the emergency surgery group. length of hospital stay was again higher for the emergency group (vs elective; vs ,p \ . ),as well as the morbidity rate. no statistically significant differences were found with regards to mortality rate. conclusion: knowledge of the natural history of diverticular disease led to changes in the approach to treatment, with a tendency to adopt a less aggressive therapeutic. despite controversy around aspects such as selection of patients for elective surgery, among others, it is key to the approach to diverticular disease that existing recommendations are taken into account, treatment is individualized and outcomes are closely monitored. surg endosc ( ) aims: the objective of this analysis is to establish if there is differences after the procedure of laparoscopy appendicectomy comparing the use of endoloop (el) vs. endostapler (es) in complicated and non-complicated acute appendicitis. methods: we performed a retrospective analysis of a prospective database of patients from february to june . we divided the patients in two groups: depending on that the procedure of the appendicectomy was with endoloop or endostapler. the groups were created selecting patients in order to be homogeneous as to perforation appendix rate, thus a propensity score was performed for sex, age and perforation rate. an univariant analysis was carried out in regard to the differences in the use of el vs es in the apparition of abdominal complication, as well as hemorrhage, ileo, surgical wound infection, collection, reintervention or hospital readmission.qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. introduction: intramural haematomas can develop anywhere within any the gastrointestinal tract . these are most frequently associated with blunt trauma above the level of the sigmoid colon and very rarely occur in the rectum . spontaneous, non-traumatic haematomas are a rare clinical condition usually secondary to haematological blood disorders or anticoagulant therapy . case summary: a -year old gentleman presented to the emergency department with a day history of worsening lower abdominal pain and bloody stool. he presented twice within the previous week with worsening, generalised abdominal pain. the patient had been taking regular aspirin and clopidogrel following insertion of coronary artery stents. on clinical examination, he was guarding with a distended, generally tender lower abdomen but all observations were stable, afebrile. an initial computer tomography of the abdomen reported pneumoperitoneum with haemorrhagic ascites; a differential diagnosis being perforated sigmoid colon with a large localised haematoma. the patient underwent an emergency laparotomy and hartmann's procedure (appendicectomy, sigmoid colostomy and rectal stump). he recovered well with no significant post-operative complications. histology reported the rectal perforation macroscopically associated with an opened haematoma and no evidence of malignancy. the appendix shows reactive appendicitis with serousal inflammation background: ulcerative colitis (uc) is one of the risk factor of developing sporadic colorectal cancer. approximately % of uc patients develop an acute attack of severe colitis, and % of these patients require colectomy. one third of the patients will not respond to steroid therapy. thus, a long-term follow-up has been recommended. case report: we reported a single case of completed years follow of colorectal cancer related ulcerative colitis on years old female patient undergoing emergency operation ( staged total colectomy and j-pouch ileo-rectal anastomosis) after year no responsed of medical treatment before, presenting with bloody diarrhea and anemia. there was no post operative complication reported. pathologic finding was early adeno carcinoma, closed follow up was done each year and for another five years later, no progression of the disease was found in this period and the patients has good quality of life after this procedures. is becoming a standard and feasible surgical method worldwide. % of patients with crohn's disease (cd) and % patients with ulcerative colitis (uc) will require an operation during their life. over the last decade, there have been many studies documenting the safety and feasibility of the laparoscopic approach for ibd in well-selected patients. methods: patients with a cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon and rectum stenosis, patients with uc with ineffective medical therapy, steroid dependence or dysplasia underwent the lcs. from to , ileocolic resections, hemicolectomies, subtotal colectomies and restorative proctocolectomies with ileopouchanal anastomosis were performed either totally laparoscopically or laparoscopically assisted (n = ).the average time of the procedure was min ( - min), average blood loss ml ( - ml) and the conversion to laparotomy was in . %. average return time of the bowel function was . days ( - days) and the average hospital stay was . days ( - days). complications occurred in patients ( . %). cases of the early ileus due to adhesions, cases of the anastomotic bleeding threated conservatively, case of the instrumental perforation of the small bowel, cases of the incisional hernia in minilaparotomy and wound infections occurred. conclusion: in well-selected patients with ibd, thanks to superior short-and long-term outcomes, the laparoscopic approach should be considered a safe and effective method when performed by experienced surgeons. supported by mo . aim: over % of patients with crohn's disease (cd) will require a surgical resection within years of their diagnosis and one quarter will have another resection for disease recurrence. laparoscopy should by preferred approach in surgery in cd due to reduced morbidity, faster recovery time, shorter hospital stay and reduction in adhesions and hernial formation. methods: patients with cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon stenosis were indicated for the laparoscopy. from january to november we performed ileocolic resections, hemicolectomies and subtotal colectomies either totally laparoscopically or laparoscopically assisted. the average time of the procedure was min ( - min). the average return time of the bowel function was . days ( - days) and the hospital stay was from to days. complications occurred in patients ( . %) . in cases early ileus developed due to adhesions, in case was anastomotic bleeding threated conservatively, the incisional hernia in minilaparotomy occurred in cases and wound infections occurred. conclusion: minimally invasive surgery is becoming a gold standard in cd. it is safe and feasible in well-selected patients thanks to short-and long-term outcomes. laparoscopic approach for recurrent disease is still in debate. supported by mo . aim: the aim of the study was to observe when laparoscopy is avoided when treating surgical complications of crohn disease. methods: we did a retrospective study which included all of the patients diagnosed and operated in our clinic for complications of crohn disease during a period of years. results: we identified a number of patients operated for complications of crohn disease. of these were operated by minimally invasive procedures. we observed that laparoscopy was avoided in the case of intestinal fistulas (p = , ). also when sepsis associated the surgical complication-laparoscopy was avoided (p = , ). age under years represented another factor to avoid laparoscopy (p = , ). conclusions: although laparoscopy offers numerous advantages careful selection of the patients is of utmost importance so the safety of the procedure can be ensured. retroperitoneal sarcoma represents approximately - % of all sarcomas and less than . % of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore radical surgery remains the only valid option. complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. hypoglycemia is a rare but potentially lifethreatening presentation of soft tissue tumors the etiology of hypoglycemia may be difficult to diagnose, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. the most likely mechanism of hypoglycemia appears to be production of insulin like substance and increased utilization of glucose by the tumor. laparoscopic surgery represents an alternative technique for radical resection of such tumors rather than traditional surgery. only few cases of retroperitoneal tumors resected laparoscopically were reported in the literature. we report a rare case of years old male presented to ed unconscious due to hypoglycemia.he was resuscitated and admitted for further investigations. hypoglycemic attack recurred again during the same evening of admission. initial investigations were within normal except for serum glucose mg/dl ( . mmol/l). his tsh, glucagon & cortisol levels were within normal, insulin and c-peptide levels were undetectable. only hypokalemia ( . meq/l). he tested negative for the anti-insulin antibodies. his abdominal ultrasound as well as his ct scans showed the presence of a large retroperitoneal tumor ( cm cm cm) with a heterogeneous contrast effect. a glucose supplement was required to maintain the plasma glucose level within normal limits during which complete resection of the tumor which was performed laparoscopically. diagnosis of such hypoglycemia inducing retroperitoneal fibrosarcoma represents great challenge especially when patients presents only with hypoglycemia and no other abdominal symptoms, management using minimal invasive technique to resect and remove such tumors from the retroperitoneal region shows superiority in recovery and limitation of complications when done by experienced surgeons. solitary fibrous tumor (sft) is a rare fibroblastic mesenchymal neoplasm, tipically arising from the pleura, less frequently from other anatomic sites. sft is an indolent neoplasm, but it have been described cases of greater aggressiveness in terms of local recurrences and more rarelly of distant metastases. among the various extrapleural sites, intrabdominal, retroperitoneal localization is the most common site, followed by the pelvis soft tissues and parenchymatous organs. the most common clinical finding of intraabdominal localization is a palpable mass, and the pain is the most frequently associated symptom. the diagnosis is performed by imaging, but the histological as well as immunohistochemistry characterization of the lesion is the latest goal. furthermore, histological features are used to attempt to identify the patient with a hight risk of malignant evolution of the tumor. the gold standard treatment is surgical approach, meanwhile there are no evidences about the efficacy of any adjuvant treatment. we present the case of a -year-old man affected by symptomatic tfs arising from mesosigma treated by surgical radical excision. finally, we propose a review of the literature of last decade. background: laparoscopic right hemicolectomy involves making an additional incision to remove the specimen and perform the anastomosis. recently, natural orifice specimen extraction surgery (noses) has been reported as an alternative approach without any additional incisions or extensions, may lead to better outcomes compared to conventional laparoscopic right hemicolectomy. in this video, we aimed to evaluate the safety and feasibility of noses for laparoscopic right hemicolectomy. methods: we describe the technique with transvaginal specimen extraction and d lymph node dissection in laparoscopic right hemicolectomy by this video. we performed intracorporeal anastomosis combined with a transvaginal route of specimen extraction after medial-to-lateral mobilization. transverse transvaginal posterior colpotomy was performed under aid with visualization. the specimen was pulled into the sterilized plastic bag, passed transvaginally. the vaginal incision was then closed with a running suture. results: the operation time was min and the hospital stay was days. an excellent postoperative recovery was demonstrated and has shown future potential for less incision. the pathologic tnm stage is t n m . conclusions: this video has shown that laparoscopic right hemicolectomy with the noses technique is feasible and safe for selected cases. the long-term benefits of this procedure need to be more evaluated. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify the sentinel lymph node (sln) to search micrometastases that can be missed with the conventional pathological exam, and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.after the transection ml of icg solution is injected to confirm the stumps perfusion. if there is an ischemic area, a new resection is performed.after the anastomosis is performed, another bolus of icg is intravenous injected to confirm the anastomotic perfusion.when the sentinel node is negative for cancer metastases by conventional histological examination, ultrastaging is performed by serial sections. when no micrometastases are identified on these sections, immunohistochemical techniques are applied. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and splenic flexure resections. in two cases, one left colectomy and one right colectomy, the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. the serial sections showed micrometastases in two cases. in the other cases the immunohistochemistry was performed but the exam is still in progress. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to assess the anastomotic perfusion in order to reduce the incidence of anastomotic leak, and to perform the slnb for the sln ultrastaging in order to identify micrometastases. methods: for the last years, tem was performed on patients' with early rectal cancer. there were women and nine men, age to . localization of tumors was - cm from anus. mean size of tumors was . cm. full thickness excision was performed in all patient with suturing of mucosa. during follow-up in three patients' metastasis in lymph nodes of mesorectum were detected. all of these patients were re-operated: laparoscopic colectomy with total mesorectal excision (tme) was done. for the last year in patients with early stage rectal cancer we used indocyanine green (icg) with fluorescent imaging for mapping sentinel lymph node. icg was injected in four quadrants to submucosa around the tumor. during the laparoscopy, sln was detected and removed with morphological examination. results: among nine patients in patients, sln was negative. tem was performed in these patients with good results. after - months no recurrence or metastasis were detected in these patients. in two patients with positive sn laparoscopic tme was performed with low colorectal anastomosis. anastomotic complication was occurred in one patient. conclusion: tem procedure is highly effective in selected group of patients with early rectal cancer. mapping and examination of sln can clarify indication for the tem in the patients with early rectal cancer. purpose: laparoscopic surgery for colorectal cancer provides better short-term benefits and similar long-term outcomes compared with conventional open surgery. unlike minimally invasive surgery, natural orifice specimen extraction (nose) can provide additional advantages by reducing morbidity and postoperative pain related to the surgical extraction site. this study aimed to evaluate the efficacy and safety of a nose procedure using needlescopic instruments for colon cancer surgery. methods: between november and february , patients underwent laparoscopic nose using needlescopic instruments. the first port for the camera was placed at the umbilicus. a -mm or -mm port was inserted in the right lower quadrant. a -mm or -mm port was inserted in the right upper quadrant. individual needlescopic forceps for the assistant were inserted into left upper and lower quadrant ports. thus, a total of ports were placed. the superior rectal artery and inferior mesenteric vein were ligated with clips, and colonic mobilization was performed using a medial to lateral approach. after rectal stump irrigation, the distal rectum was transected using an endoscopic linear stapler. the proximal colon and associated mesentery were transected. after the rectal stump was opened, a wound retractor was pulled through the anus and inserted in the rectal lumen. the resected specimen was transanally extracted through this route. an anvil was intracorporeally attached to the proximal colon, and the open rectal stump was reclosed using an endoscopic linear stapler; colorectal anastomosis was then performed using a double-stapling technique. results: of the patients, were male and were female, with a median age of years ( - years). median body mass index was . . the tumor site was in the sigmoid colon in patients and rectosigmoid colon in patients. median operative time was min and blood loss was ml. there was no conversion to open surgery. no postoperative complication was observed. median postoperative hospital stay was days ( - days). conclusions: nose surgery using needlescopic forceps is an easily performed type of reducedport surgery with a conventional port arrangement. this procedure is feasible for the selected patients. introduction: splenic flexure colon cancer accompanying obstruction is usually managed stent insertion as a bridge to surgery and left hemicolectomy, or subtotal colectomy. however, stent insertion can fail more often than in sigmoid colon because it requires longer colonoscopic approach in the circumstance of impossible bowel preperation. although subtotal colectomy has advantage in the aspect that it is -stage treatment, it needs open surgery in most cases, right colon has to be sacrificed without oncologic neccesity, and preoperative staging and evaluation can be insufficient. despite colostomy is reluctant procedure when considering quality of life, in splenic flexure colon cancer obstruction, we can obtain prompt stabilization of patient state, suffient time to preoperative staging and evaluation, and also we can achieve minimally invasive surgery by using colostomy site as mini-laparotomy and close colostomy before discharge. colostomy site, tumor location, and minilaparotomy site for next radical surgery have to be considered comprehensively before making colostomy incision. colostomy site has to be appropriate as mini-laparitomy site for feasibility of laparoscopic left hemicolectomy and the colostomy has to be included in the specimen with caution to prevent unneccessary lengthening of the specimen. we experienced cases which were treated succefully in this strategy and report them. result: temperary loop transverse colostomy and laparoscopic left hemicolectomy via colostomy site in splenic flexure colon cancer obstruction has advantage of quick stabilization of patient's status, suffient preoperative staging and evaluation, achieving minimally invasive surgery, and also rapid colostomy closure before discharge. our tatme procedure for locally advanced low rectal cancer following chemoradiotherapy y. nakamoto , r. okamoto , f. kimura , h. yanagi , t. nakajima , h. yoshie , n. yamanaka surgery, meiwa hospital, nishinomiya, japan, surgery, yoshie clinic, itami, japan background: short-course chemoradiotherapy using hyper-fractionation method (scrt; gy/ fraction/ days ? s- or xeloda) is performed to secure circumferential resection margin (crm) due to tumor shrinkage, reduction of cancer cells with viability, reduction of radiation hazard for resectable locally advanced lower rectal cancer (more t or n ). the patient underwent radical surgery after one month of scrt. for more locally advanced lower rectal cancer (t or n ), induction chemotherapy is performed before scrt. for patients with poor efficacy of chemotherapy, we also do normal fraction gy radiotherapy. methods: we introduced tatme from last august, and cases were performed so far. in all cases temporary stoma has been constructed, and intersphincter resection (isr) is based on partial isr avoiding total isr considering postoperative anal function. if possible, colonic j-pouch is added, and pelvic floor repair may be added for esr cases and older people. at first one team preceded with the anal operation and shifted to the abdominal procedure, now it is done with two teams with the advantage of getting good visual field from both sides when there is difficulty identifying the right dissecting layer. tatme is very useful in cases such as large tumor, obesity, and narrow pelvis. furthermore, when it is difficult to identify the dissecting layer by scarring after crt, it is more possible to control the crm/drm of cancer. results: cases of isr, case of apr, case of tpe were performed, and in of these cases lateral lymph node dissection was also performed (one side , both sides ). postoperative complications were anastomotic leakage, pelvic floor infection, perineum infection, and bowel obstruction. conclusions: tatme for locally advanced lower rectal cancer is useful even after chemotherapy and scrt. background: although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (sils) and conventional laparoscopic surgery (cls) for colon cancer, few have directly compared the costs of them. we aimed to compare costs between sils and cls for colon cancer. methods: we analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from july to september at severance hospital; were used for analysis after propensity score matching. the total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed. results: the total hospital charges were similar in both groups ($ . vs. $ . , p = . ). however, the patients' total hospital bill was higher in the sils group than in the cls group ($ . vs. $ . , p \ . ) mainly due to the difference of the cost of access devices. there was no difference in the additional costs associated with readmission due to late complications between the two groups ($ . vs. $ . , p = . ). conclusions: sils for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with cls. therefore, sils can be considered a reasonable treatment option for colon cancer for selective patients. aims: technology improvements in medicine allow the development of new minimally invasive approaches. despite every single advantage of these new devices they also can cause technical problems and difficulties for the surgical team. well known from last few years-laparoscopic assisted transanal total mesorectal excision for distal rectal cancer is perfect example for a quite new procedure, based on the combination of forgotten old surgical principles and technology advances. the aim of the study is to analyze the rate of technical problems during the procedure and to measure the impact of them on the operative time. methods: we conducted prospective observational study related to technical problems during the procedure. for the period between september and november in the department of endoscopic endocrine surgery and coloproctolgy at military medical academy-sofia have been performed laparoscopic assisted transanal total mesorectal excisions. we used standard local preoperative work up and postoperative care protocols. we defined technical problem as intraoperative event different from complication leading to delay in operative time. every technical problem during the procedure was recorded and time for resolving the problem was measured in seconds. results: overall technical problems occurred in of the cases. most of them were related to the insufficient smoke evacuation during the cases. the second most common technical problem were the excessive rectal stump spasms during the procedure-this complication occurred in of the patients. mean delay of the procedure related to technical problems is min. in our series we experienced only one intraoperative complication which was specimen perforation during the dissection. three complications occurred in postoperative period-two urinary retentions and one perianastomotic abscess, without need of reoperation. conclusion: technical problems during the procedure can be source of delay in operative time. correct use of devices in operating room is the key to reduce technical issues. technical problems can increase the rate of intraoperative near miss events and complications during the transanal total mesorectal excision. surg endosc ( ) aims: anastomotic leak after rectal cancer surgery constitutes a severe complication associated with poorer oncologic outcome and quality of life. preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity of creating a defunctioning stoma. methods: studies on rectal cancer surgery published between and were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses of individual participant data (prisma-ipd) guidelines. with the aim to generate a score for anastomotic leak, all available per-operative covariates were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. a receiver operating characteristic curve (roc) analysis was generated. we selected as threshold the value that allowed a missing rate of anastomotic leak \ %. the predictive power of the previously selected cut-off was validated in an independent set of patients. results: twenty-six centers provided individual data on patients. with a threshold value of the roc corresponding to . in the training set, the area under the roc curve (auc) was . (p \ . ). sensitivity and specificity of the model's probability [ . to identify anastomotic leak were . % and . %, respectively. accuracy of the threshold value was confirmed in the validation set with . % of sensitivity and . % specificity. conclusions: we trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. the score is now available online (http://www.real-score.org). in ( . %) cases laparoscopic interventions were performed in patients with diverticular colon disease. in the group of patients with colorectal cancer localization of the tumor in the right parts was observed in ( %) patients, in the left-in ( %), in the rectum- ( %). results: in the adenocarcinoma of the sigmoid colon, performed a left laparoscopic hemicolectomy ( cases) and resection of the sigmoid colon ( ). was executed high clipping and intersection of the lower mesenteric vessels, aorto-iliac lymphatic dissection. in the standard scope, lymph node dissection was performed with removal and testing of not less than epi-, para-and mesocolical lymph nodes (max ). the average length of the laparoscopic stage is ± min. laparoscopic right hemicolectomy ( cases) was performed in accordance with the principles of cvl (central vascular ligation) and cme (complete mesocolic excision). intracorporal ileotransversoanastomosis was formed by a semimanual method with endogia universal and v-lock suture material. the average length of the laparoscopic stage was ± min, the open phase was ± . in the tumor of the lower and middle ampullary parts of the rectum ( cases) after neoadjuvant chemoradiotherapy, was executed a laparoscopic total mesorectumectomy. conclusions: the use of minimally invasive technologies in colorectal surgery provides a complete revising of the abdominal organs, adequate scope of resection and lymph nodes dissection in surgical interventions. background: it is thought that complete mesocolic excision (cme) improves the oncologic outcomes for colon cancer. but, precise mesenteric mobilization from retroperitoneum and safe ligations at the origins of central vessels are considered to be technically difficult in single port surgery(sps). to resolve this problem, we utilize retro-mesenteric medial approach for right side colon cancer. herein, we introduce this technique and assess its outcomes. operative procedure: the multi-trocar platform is placed in the umbilical site. d laparosopy is inserted from one of this channels. the surgeon manipulates instruments via the other channels. st step: right colonic mesentery is mobilized medial to lateral from the head of the pancreas and retroperitoneum along the embryonic plane. nd step: the origins of ileocolic and right colic vessels are divided and central lymph node dissection is achieved. rd step: hepatic flexure is taken down from cranial. and right lateral attachment is dissected away and cme is achieved. th step: specimen is extracted and anastomosis is performed using a functional end to end anastomosis extracorporealy. results: from april to december , consecutive patients underwent sps-cme with right side colon cancer. there were in stage i, in stage ii, in stage iii and in stage iv. the mean operative time was min. the mean estimated blood loss was ml. there was no conversion to open surgery. additional port was placed in patients ( . %). intraoperative bleeding was occurred in patient. anastomotic leakage was observed in patient ( . %), intestinal obstruction ( . %) and wound infection in ( . %). conclusion: these results suggest that retro-mesenteric medial approach in single port surgery with right side colon cancer is useful and safe technique. aims: this multicenter, randomized controlled trial (simple trial) aimed to investigate the quality of life (qol) and patient satisfaction of single port laparoscopic surgery (spls) for colon cancer, compared with multiport laparoscopic surgery (mpls). methods: patients with histologically diagnosed adenocarcinoma in cecum, ascending and sigmoid colon were eligible for this trial. eligible patients were randomly assigned to the spls or mpls group at a ratio of : . qol was measured with the eortc qlq-c third edition (korean version) preoperatively and postoperatively at month , , and . in addition, patient satisfaction was surveyed with a five-point questionnaire at postoperative month. to exclude the impact of adjuvant chemotherapy on qol, subgroup analysis for patients with or without adjuvant chemotherapy were carried out. (clincaltrials.gov identifier: nct ) results: total patients were randomly allocated into the spls group (n = ) and mpls group (n = ). in total patients, global health status and five functional scale steadily increased and nine symptom scales also gradually improved over time. but, nausea/ vomiting and appetite loss temporally deteriorated at postoperative month. pain score was significantly worse in the mpls group ( . in the spls group vs. . in the mpls, p = . ) at postoperative month and appetite loss score was significantly worse in the spls group ( . vs . , p = . ) at postoperative month. except for that domains, all the other items of qol between groups were not different until postoperative months. patient satisfaction was significantly higher regarding the operation (p = . ) and the abdominal wound (p = . ) in the spls group. in patients without adjuvant chemotherapy, some items of qol (global health status, physical functioning, role functioning, emotional functioning, fatigue and pain) were significantly better in the spls group at postoperative month. since postoperative month, all of qol domains (except pain score) were similar between groups. conclusion: although postoperative pain was temporarily better in the spls, most of qol domain were similar between the spls and the mpls group until postoperative month. in patients without adjuvant chemotherapy, spls showed better outcomes in some of functional scales and symptom scores at postoperative month. coloproctological surgery, juntendo university, tokyo, japan; gastroenterological surgery, juntendo university, tokyo, japan introduction: laparoscopic surgery causes less postoperative pain compared with pain after laparotomic surgery, and its low invasiveness should be considered for pain control. we have previously controlled postoperative pain by epidural anesthesia. in this study we compared postoperative multimodal analgesia centering on acetaminophen in patients who underwent laparoscopic colorectal cancer surgery with the conventional method. subjects: the subjects were patients who underwent laparoscopic colorectal cancer surgery between january and june . surgery was performed under epidural anesthesia in patients and multimodal analgesia in : periodic acetaminophen administration ? transverse abdominis plane (tap) block in , periodic acetaminophen administration ? local anesthesia of the wound in , and periodic acetaminophen administration ? intravenous patient-controlled analgesia (ivpca) in . the operating roomoccupying time, postoperative pain (nrs), frequency of taking analgesics as needed, and postoperative nausea were investigated for days after surgery and the duration of urethral catheter placement and postoperative intestinal movement were investigated in the epidural anesthesia and multimodal analgesia groups. results: while the time from entering the operating room to initiation of surgery was significantly shorter, the time from completion of surgery to leaving the room was significantly longer in the multimodal analgesia group. there was no difference in the operating room-occupying time. the frequency of postoperative pain was significantly lower in the multimodal analgesia group on postoperative day (pod) . the frequency of taking analgesics as needed was significantly lower in the multimodal analgesia group on pod , , and . no significant difference was noted in the duration (number of days) of urethral catheter placement or postoperative nausea between the groups. regarding postoperative intestinal movement, discharge of gas occurred significantly earlier in the epidural anesthesia group. the total number of incidents of complications in the epidural anesthesia group was . discussion: in laparoscopic colorectal cancer surgery, the effect of multimodal analgesia centering on periodic administration of acetaminophen without epidural anesthesia for postoperative analgesia was sufficient compared with the effectiveness of epidural anesthesia. this approach to analgesia may be useful because none of the potential complications of epidural anesthesia occur. surg endosc ( ) in the last years the application of new technologies like d vision or virtual reality have provided to surgeons the possibility of establish a preoperative surgical plan of each surgery and of each patient. these advances are specially useful in minimally invasive colorectal surgery due to the variability in location, anatomical relationship with other organs and vascular variants of these type of surgeries. the aim of our work is to built a digital -dimensional virtual model of the colorectal ct scan imagen of patients with colorectal cancer. the virtual models are obtained from the preoperative ct scan. the ct scans that we use to this work are general electric healthcare revolution gsiÒ and siemens somatom perspective Ò and the size of each image is mm. a medical software let us build a reconstruction of colorectal digital images where a radiologist has marked the exact image of the tumor so we obtain a d reconstruction which can provide an enhanced understanding of crucial anatomical details like the exact location of the tumor and the relationship with other organs and structures of the patient which can be selectively displayed or hidden. this information has an important applicability into clinical practice since it lets surgeons estimate the colorectal anatomy, tumor size and relationships, providing key landmarks to choose the most appropiate surgery, the best trocar location and a safer dissection specially in some cases whose location can change the kind of surgery radically. we present some cases where virtual models were crucial for the preoperative and intraoperative surgical plan, showing the potential interest of these d reconstructions in colorectal surgery. in conclusion the ct scan colorrectal image reconstruction can provide an enhanced understanding of crucial anatomical details of the colon and tumor location and relations which could contribute to choose the best surgical option and to improve safety in colorectal surgery. background: anastomotic leakage (al) after colorectal procedures are a common surgical experience and represents a significant burden both for patients and surgeons. the incidence of al has been reported to vary between . % to up to %, with rates for the colon and rectum of - % and - %, respectively. they, not only add to potential postoperative patient morbidities and to overall costs of postoperative patient care, but also are considered a quality indicator in colorectal surgery. aim: we aimed to evaluate the clinical burden associated with anastomotic leaks following colorectal surgery. methods: we conducted a retrospective analysis of colorectal patients who underwent conventional or laparoscopic colorectal surgery for colorectal cancer (crc), from january st, to december st, in a single colorectal centre (centro hospitalar de leiria). patient demographics, intraoperative and postoperative aspects were collected and analysed. all statistical analysis will be conducted using stata software (statacorp lp). results: in our cohort of pts, developed a clinical al ( . %), mostly males ( %), with an average age of ± . . male gender and conversion were independent risk factors. the group with al had a higher lohs ( . days vs, . -p \ . ). out of al have been detected after the discharge. the mean diagnostic day was the eighth, and mode estimated at day . when compared with a control group, wcc, eosinophils and crp were statistically significant different in al group, at day and . conclusion: in the present study, no statistically significant risk factors for al in crc surgery were detected, except for male gender and conversion. clinical methods and biomarkers were useful for early diagnosis. technology combined with experience and common sense may be the embodiment of the clinical method. conclusions: our regional screening program has significantly improved early diagnosis and quickened surgical treatment of crc. thanks to this, we obtained an earlier stage at diagnosis, a less invasive surgical approach, and a lower rate of complications and emergency surgery need were obtained also with an improvement in both os and dfs. introduction: surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. we evaluated the outcome of silc in patients of over years with colon cancer with a propensity score matched comparison to assess its perioperative and long-term oncological outcomes. methods: this retrospective cohort study analyzed our experience with silc for colon cancer over years. eighty-seven patients of over years with colon cancer who electively underwent silc were included in this study (elderly group). eighty-seven patients were then chosen out of a collective of patients less than years old in a propensity score matched design (younger group). short-term clinical outcomes in both groups were compared and verified its long-term oncological outcome. results: american society of anesthesiologists score and post-operative complication rate were significantly higher in elderly group. however, the other short-term clinical outcomes including post-operative hospital stay were equivalent in two groups. the rates of -year cancer specific survival were . % in elderly group and . % in younger group, respectively, and the -year overall survival rates were . % and . %, respectively. no significant differences were seen between two groups. conclusions: our initial experiences suggested the oncological and clinical safety of silc in patients of over years with colon cancer. however, further studies are needed to demonstrate the advantages of this procedure compared to conventional laparoscopic colectomy. aim: some clinical trials have reported the safety and efficacy of laparoscopic colectomy for colon cancer. on the other hand, transverse colon cancer was excluded in these trials because of the difficulty of laparoscopic colectomy for transverse colon cancer. in this presentation, we report the tips for laparoscopic colectomy for transverse colon cancer. tips: in our department, transverse colon cancers has been resected by laparoscopically so far. to complete cvl and cme, lymph nodes around middle colic artery should be resected, however many important structure, duodenum, pancreas, superior mesenteric vein (smv) and so on, may be obstacles. this is most difficult point for this surgery. our surgery is as follows. mobilization of ileum and ascending mesocolon from caudal sideconfirm duodenum and pancreasexpose smv and ligation root of ileocecal artery and veindissect lymph nodes around smv and ligation of middle colic artery and accessary right colic veinconfirm pancreas from caudate side of transverse mesocolon and incise the peritoneum along the caudal side of the pancreasdissect lymph nodes sufficiently by dissection from both side of transverse mesocolonmost important point. to dissect lymph nodes safely, confirmation from both side of transverse mesocolon is necessary and dissection should be performed along important structure, smv, pancreas and so on. introduction: we have developed and previously reported single-incision plus one port laparoscopic anterior resection of the rectum (sils ? -ar) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. a consecutive experience from its introduction of sils ? -ar for rectal cancer is reviewed, and its -year oncological outcomes are evaluated retrospectively. methods: one hundred and forty-one patients ( female) with a mean age of . years adopted the sils ? procedure for rectal cancer. a lap protector (lp) was inserted through a . cm transumbilical incision; an ez-access was mounted to the lp and three -mm ports were placed. a -mm port was inserted in the right lower quadrant. results: one hundred and thirty-six patients ( . %) completed with sila ? -ar. the tumor locations in the rectosigmoid, rectum above the peritoneal reflection (ra), and rectum below (rb) were , and , respectively. the median follow-up interval was months. aims: colovesical fistulae came from inflammatory disease or cancer and do have a significant morbidity. the most common location is the sigmoid colon and the most common aetiology is diverticulitis. the treatment of choice is a surgical procedure. the aim was studying compare laparoscopic approach in patients diagnosed by benign (diverticulitis) and malignant (colon adenocarcinoma) colovesical fistulae. methods: from january to march all characteristics of surgical patients with diverticular and colon adenocarcinoma colovesical fistulae were reviewed. patient details (sex, age, symptoms, diagnosis, medical history and anaesthetic risk), surgical approach, hospital stay and complications were recorded. both groups were compared with significance level set at p \ . . results: nine laparoscopic ( %) and open approaches ( %) in diverticular colovesical fistulae were performed, with a conversion rate of %. the procedure done was sigmoidectomy. there were also performed laparoscopic ( %) and open approaches ( %) in colon adenocarcinoma colovesical fistulae. the procedures done were sigmoidectomy, pelvic exenteration, left colectomy, low anterior resection and loop colostomy. comparison between the two groups didn't show significant differences in characteristics but did show significant differences regarding the approach, with more cases performed by open approach in colon adenocarcinoma colovesical fistulae (p = . ). conversion rate didn't show significant differences. patients diagnosed for malignant colovesical fistulae had more complications, cases ( %), ( %) i-ii and ( %) iii-iv-v according to clavien dindo classification, manifesting significant differences (p = . ). laparoscopic approach didn't show significant differences regarding complications. conclusions: generally, surgical approach with colonic resection and partial or total cystectomy is the treatment of choice in colovesical fistulae, although vesical resection can be avoided if it is suspected benign aetiology. whenever laparoscopic approach is performed by experienced surgeons, is feasible in colovesical fistulae and the morbidity and mortality numbers are acceptable. laparoscopic approach allows the advantages of a minimally invasive treatment but implies clinical trials to stablish stronger evidence. aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many center. most centers use multiport laparoscopic colectomy with extracorporeal resection and anastomosis (mce). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sci) remains controversial. the aim of the present study is to compare these two techniques using propensity matching analysis. methods: this study analyzed patients who underwent laparoscopic right hemicolectomy including mce surgeries and sci surgeries from december to december . short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sci group was significantly shorter than in the mce group: median (range) ( - ) cm verses ( - ) cm (p \ . ). the vas score after surgery was significantly less in srhi than in mrhe. significantly fewer patients required analgesia after srhi after surgery. there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. the cost effectiveness was significantly cheaper in srhi than in mrhe. conclusions: sci for right colon cancer is safe and technically feasible. sci reduces the length of skin incision and postoperative pain compared with conventional mce. aim: this study was designed to clarify the utility of laparoscopic surgery for advanced lower rectal cancer after neoadjuvant chemoradiotherapy (ncrt). patients and methods: we investigated -year disease-free survival rate, operative outcomes and recurrence risk factor in patients with lower rectal cancer (ct - , n - ) who underwent laparoscopic surgery after ncrt from to december in kitasato university hospital. results: of patients, patients underwent low anterior resection (lar), patients underwent intersphincteric resection (isr) and abdominoperineal resection (apr). there were anastomotic leakage, and urinary disorder and sexual dysfunction. ypcr rate was . %, but patients ( . %) had recurrence ( liver, lung and lymph node and local recurrence; there is some overlapping). ypt and lymph node metastasis were detected as a recurrent risk factor. the -year relapse-free survival rate (rfs) was . % and the -year overall survival rate (os) was %. conclusion: in this examination, ypt and lymph node metastasis were risk factor for recurrence. the operative outcomes, -year rfs and the -year os are relatively good results. we will conduct further follow-up, and it is necessary to investigate a long term prognosis. laparoscopic surgery is warranted for rectal cancer after ncrt. surg endosc ( ) introduction: synchronous colorectal neoplasia presents an incidence ranges from % and %. classically its surgical treatment consisted in the realisation of a subtotal colectomy (stc), however, several authors have proposed that in certain occasions the realisation of two segmental resections with two anastomoses was not accompanied by an increased risk of anastomotic failure. the objective of this study was to compare the feasibility and safety of the laparoscopic approach of synchronous colorectal neoplasia using two different techniques: stc versus two segmental resections with two anastomoses. methods: we retrospectively reviewed the clinical data of patients over years of age who underwent colorectal surgery between and at a single center. we included patients with a synchronous colorectal neoplasia who underwent laparoscopic surgery, either stc or double resection (dr). results: a total of patients met the inclusion criteria. mainly males ( %) with an average age of years, with a scale of the american association of anesthesiologists superior to ii in % and with an average body mass index of kg / m . the mean operative time was min in the dr and min in the stc, the stc resulted in a higher conversion rate ( % vs %) and intraoperative bleeding ( % vs %), in addition to a postoperative period with more complications, only % of the patients undergoing stc didn't present any complication while % of the patients with a dr didn't present any complication. % of the stc presented anastomotic failure and only % of the dr. the mean hospital stay was days in the dr and . in the stc. in the dr, an average of cm of colon was resected with an average of . lymph nodes, while in the stc, cm of colon was resected with an average of . resected nodes. conclusions: the double resection with two anastomosis is a less aggressive surgery, with fewer complications and a shorter hospital stay, providing similar oncological results. there were no differences in morbidity, re-operations or hospital stay. regarding tumor stage there were no differences between the three groups. as for the resected nodes, we found a mean of in stc, in lc and sr with no statistical difference. there were no differences in the affected nodes among groups. in our patients we didn't find differences in the recurrences rate or in the distant metastases rate.the average follow-up was months (range: - ), with no differences in overall survival. conclusion: segmental resection of splenic flexure neoplasias is safe and feasible, with no differences in morbidity or in the oncological outcomes compared with more aggressive surgeries. introduction: the evaluation of perfusion in colorectal anastomosis is still a field of study and progress for the development of new modalities that allow reducing the ratio of dehiscence or anastomotic leakage (al) in said surgery. our objective with this work is to highlight the utility of indocyanine green (icg) in the said evaluation after colo-rectal surgery. methods: we present a series of cases of colorectal surgery (benign and malignant disease) intervened in the period between and . the population sample has been homogenized according to age criteria, risk factors and comorbidity. a retrospective database has been developed with the spss v. software for the evaluation of the results obtained. the primary outcome measure was al rate with at least month of follow-up. results: a significant reduction in the incidence of al was observed in patients who underwent colo-rectal surgery (p = . ). low al rates were shown in rectal cancer surgery (p = . ). there was no significant decrease in the al rate when colorectal procedures for benign and malignant disease were combined. conclusions: the use of the image by fluorescence with indocyanine green is a safe, reproducible and relatively simple method with which to evaluate the perfusion of the colorectal anastomosis as well as reduce the rate of anastomotic leak in the postoperative period. large well-designed randomized control trials are needed to provide evidence for its routine use in colorectal surgery. introduction: currently colonoscopy is the gold standard investigation for colonic evaluation. although caecal intubation is one of its quality indicators, it is not attained in up to % of cases. this remains a significant concern. limited data are available on the follow-up of patients with incomplete colonoscopy. aims: to assess colonoscopy completion rate, the reasons for incomplete colonoscopy, and the methods used to complete colonic evaluations after incomplete colonoscopy. methods: we performed a retrospective study of incomplete colonoscopies in our unit over a one year period ( ) these results compare favorably with published data. few statistically significant differences between groups suggest varying modalities of treatment broadly result in similar qol. this data highlights a need for well-delivered support programmes for specific issues, for example stoma care and sexual dysfunction. future studies will need to include a baseline questionnaire to truly measure the impact of surgery and measure quality in an increasingly elderly and comorbid population. splenic flexure cancer (sfc), comprising the tumours raised in the distal transverse colon and proximal descendingcolon, accountfor to %of all surgically treated colorectal cancers.in cme forsfc, dissection of both the transverse and descending mesocolon must be considered. however, the use of laparoscopic surgery as a curative treatment for sfc, has never been investigated in adequate controlled trials, because of difficulty in deciding on the appropriate operative procedure, as well as technical difficulties with laparoscopic lymph node dissection. the aim of this multicenter study is to evaluate the oncologic effectiveness of laparoscopic segmental resection with cme with for cancer located at the splenic flexure. we performed a retrospective analysis of all cases of sfc treated with a laparoscopic segmental resection with cme in five different institution. intra and post operative were evaluated. patientes were evaluated, the mean operative time was . ± . min. a total of ( . %) conversions occurred, due to splenic artery lesion, one for difficult adesyolisis and three due to locally advanced tumour. recurrence was observed in ( . %) patients. there was a significant association between disease stage and recurrence (p \ . ) with a higher proportion of stage iv patients in the recurrence group ( . % vs . %). at days follow-up no mortalitywere recorded.during a median follow-up of months (range - ), deaths occurred (all of them for disease progression). keplan mayer curves showed a compareble suvival with other colo-rectal cancer. in conclusion, laparoscopic segmental resection with cme and cvl seems to be an oncologically safe and effective procedure for treatment of sfc. it may be regarded as the standard surgical method for elective management of this disease. in the future, more tailored patient-and tumor-specific segmental resection might be achieved with the use of routine lymph node road mapping. it is very important to establish a minimum number of lymph nodes to analyse for a correct staging. it has been established as . the treatment of colorectal cancer is essentially surgical. the review of the medical literature indicates that laparoscopic colorectal surgery is a safe procedure that has not found significant differences in the survival rate from open surgery. aim: the aim of our study is to compare the outcomes of laparoscopic and open resection for colorectal cancer surgery evaluating lymph node assessment. methods: the patients were collected in our hospital during the period from / / to / / and the number of lymph nodes obtained in lymphadenectomy has been studied comparing the laparoscopic and laparotomy approaches. results: interventions were performed. were laparotomic, were laparoscopic and converted laparoscopic (fig ) . the average number of nodes found in these interventions was , . nowadays, the recommendations to obtain a proper lymphadenectomy is to find more than lymph nodes. analysing our procedures, surgeries had obtained a good lymphadenectomy. according to the approach, , % of the interventions ( ) are laparotomy, , % ( ) are laparoscopic procedures and , % ( ) are by reconverted laparotomy (figure ). the average number of lymph nodes isolated was similar. laparotomy approach found , nodes while , nodes were found in laparoscopy. converted laparoscopy found , ( figure ). conclusion: the treatment of colorectal cancer is essentially surgical. today, there are a lot of studies that support that laparoscopic surgery has a survival rate similar to laparotomy surgery. according to our study, the data collected indicates that the number of isolated lymph nodes in both approaches is very similar. to sump up, laparoscopic colorectal surgery is safe and has demonstrated oncological adequacy comparable to open approach and better short-term outcomes due to a less invasive approach. background: laparoscopic low anterior resection highlights the advantages of laparoscopic surgery (better surgical field, less bloodloss, less postoperativepain, better cosmeticresult). defunctioning ileostomy prevents anastomotic leakage in low rectal cancers, butincreases morbidity, degrades thequality of life and requires a second surgery for its closure. method: in the last months we performed laparoscopic low anterior resections for rectal cancer, whithout performing any protectiveileostomy, afterchecking the anastomosis intraoperatively( men, women. average age: years). the typical placement of trocars included one supraumbilical mm trocar, two right sided mm trocars in the midclavicular line, one mm in the left midclavicular line and one mm trocar in the suprapubic midline which is also used for specimen removal, after a cm transverse extension of the incision. we present themain stages of the procedure (dissection andmesorectal excision, division of the rectum with linear stapler using the 'chinese hat-parnex' technique, creation of an end-to-end intracorporeal anastomosisusing circular stapler under direct laparoscopic vision). results: no major postoperative complication was observed. the mean operative time was min ( - ) and free surgical margins were achieved. in one case a conversion to open surgery occured. the average length of hospital stay was days ( - ). conclusions: the laparoscopic approach facilitates access to the middle and lower rectum, total mesorectal excision and avoidance of ileostomy if possible. it is a demanding operation with extended learning curve, and requires adequate experience in laparoscopic surgery and colorectal surgical oncology. background: in colorectal cancer, local excision is an attractive treatment option, but additional resection is considered when lymph node metastasis(lnm) is expected at high rate. in lower rectal cancer, advanced surgery techniques are required, so it is often difficult to make judgments. the aim of the current study is to assess the reliability of laparoscopic surgery for submucosally invasive rectal adenocarcinoma (pt ) analyzing short-term outcomes and long-term survival. method: this cohort study analyzed patients who underwent laparoscopic rectal resection for submucosally invasive rectal adenocarcinoma (pt ). conversion rate and functional and oncologic outcomes were analyzed. data on long-term results and survival were evaluated. result: surgical procedure was low anterior resection / intersphincteric resection / abdominoperineal resection: / / , and conversion to open surgery was needed for ( . %) patients. sphincter-preserving procedures were performed in ( . %) patients. there were no perioperative mortalities and positive resection margin. the mean length of hospital stay was . days. complications beyond clavien-dindo grade iii occurred in ( . %) patients,the anastomotic leakage rate was . % ( / ). the positive lymph node metastasis rate was . % ( / ). high tumor budding (p = . ), lymphatic invasion (p \ . ), and mucinous /poor histological differentiation (p = . ) were significantly associated with lymph node metastasis on univariate analysis. on multivariate analysis, only lymphatic invasion was associated with lymph node metastasis (p \ . ).the median follow-up time was months (range, - months), recurrence free survival rates was . % ( / ). conculusion: the outcomes of this study suggest that laparoscopic surgery can be used for safe and radical resection of submucosally invasive rectal adenocarcinoma (pt )?and the absence of lymphatic invasion, budding, and mucinous /poor histological differentiation are each associated with low risk of lnm. risk stratification models integrating these factors need to be investigated further. conclusions: this study highlights the complex nature of sarcopenia, as well as its common incidence. minimally invasive surgery had a higher incidence of sarcopenia than that of open surgery when both were performed within an enhanced recovery setting. despite colorectal patients being a typically well-nourished cohort at low risk of complications, there may well be benefit from interventional strategies such as perioperative immunonutrition or pre-habilitation to reduce the incidence of this poor prognostic indicator. backgrounds: urinary dysfunction is frequently observed after rectal resection and justifies urinary drainage. the concept of enhanced recovery after surgery (eras) has been widely spread from the early s. however, the optimal duration of postoperative urinary drainage is unknown. aims: the aim of this study was to comprehend short-term outcome of early removal of urinary catheter after robotic rectal surgery (rrs). patients and methods: (patients) the data of consecutive patients who underwent rrs at two hospitals between april and november were retrospectively reviewed. the main indication of rrs was the patients who need rectal mobilization with autonomic nerve preservation regardless of benign or malignant disease. perioperative management: none of the patients received epidural anesthesia for postoperative analgesia. our basic principle was to remove urinary catheter on postoperative day (pod) . after removal of urinary catheter, trans-urethral catheterization (tuc) was performed in the following situations: ) no autonomous urination over h after removal ) the decrease in urine volume (\ ml/ hr) ) the appearance of subjective symptoms like abdominal distension. when tuc was required even once, residual urine volume was measured with ultrasonic examination device since then. results: twenty seven male and female were included. the median age of patients and bmi were years old and . kg/m , respectively. the surgical procedures included anterior resection (n = ), intersphincteric resection (n = ), abdominoperineal resection (n = ), hartmann's procedure (n = ), and total coloproctectomy (n = ). only one patient received lateral pelvic lymph node dissection. urinary catheter was removed on pod in cases ( . %), on pod in cases ( . %). although tuc was needed in three cases ( . %) immediately after removal, tuc was no longer needed within three days in all three patients. late dysuria was observed in two cases ( . %), and bladder overdistension was suspected in these two cases. conclusions: our study showed that urinary catheter could be safely removed on pod after rrs. however, careful follow-up observation to avoid bladder overdistension is essential after removal. introduction: intersphincterian low rectal resection is a valid alternative to lower rectal cancers located at about - cm from the anus. methods: we present cases from our personal experience for tumors localized - cm from the anus. of them required preoperative radiochemotherapy. in cases, abdominal surgery was performed laparoscopic, having the surgical specimen extracted transanal. lone star device was used for the perineal procedure in all cases. cases required a manually, separate wires anastomosis; the others cases benefited from mechanical anastomosis performed endoanal with - mm circular stapler. we performed complete mesorectum excision in all cases, ligation at the origin of inferior mesenteric artery, complete mobilization of left splenic flexure and lateral protective ileostomy. all pacients underwent inspection rectoscopy before transit reintegration, and cases were reintegrated over a period of - weeks, except for cases which developed a colo-anal fistula, that closed under conservative treatment over a period of - months. results: there were no postoperative anal incontinence. in one case, a relative anal stenosis occured, which required endoscopic dilation. there was case of tumor recurrence and required abdominoperineal resection. conclusion: literature data sustain a - / ratio for very low rectal resection versus rectum amputation. the limit resection under the tumor is accepted as . cm. very good functional results by considering oncological principles, is a sustainable argument for choosing this kind of procedure as an alternative of rectum amputation. in the few studies conducted on crcs, the reported rate of sln micro-metastases is up to - %. the aim of this ongoing prospective study is to assess the predictability of the ex-vivo nirf sln mapping and of the research of micrometastases in nnd crc patients to propose adjuvant chemotherapy. materials and methods: fifty-eight patients undergoing standard oncological crc laparoscopic resection have been prospectively enrolled in two centre. as previously described by the authors, the intact surgical specimen was extracted and opened longitudinally and ml of indocyanine green (icg; mg/ml) was injected submucosally at four corners around the tumor in order to identify the lymphatic pathway and the slns. each sln presenting as negative at conventional histological analysis, was further investigated with ultrastaging techniques including serial sectioning and additional immunohistochemistry, in order to detect the presence of micrometastases. results: thirty patients were n ? , and were nnd. overall, a total of lymph nodes were retrieved. a total of sln were identified (mean . per case) and of those were nnd. after ultrastaging investigations, micrometastatic cases were found in nnd patients. the patients were so upstaged to n . sln located deeper in the mesenteric and mesorectal fat could easily be identified by nirf (even after nchrt). conclusions: in our preliminary series, the ex-vivo nirf sln mapping rightly predicts the status of loco-regional nodes, as confirmed by the histological investigations. the micrometastases' identification let selected patients to undergo the adjuvant treatment with the aim to reduce the risk of recurrence. ( / ) in lateral node positive group and . % ( / ) in lateral node negative group. four of local recurrence were lateral lymph node recurrence. two patients recurred the other lateral side of previous lpl, then they were laparoscopically resected and no recurrence ( , months). two patients recurred the same side after lpl were not curable because of liver metastasis and extensive invasion to the common iliac vessels. conclusion: selective lpl for rectal cancer was safe and good local control for lateral lymph node positive patients. also curable local recurrence resection was possible for non-treated lateral lymph node recurrence. intestinal malrotation is an embriologic anomaly generally discovered in the first months of life due to bowel obstruction. adult presentation is rare and its association with colon cancer is far more rare. we report a case of a years old man affected by asymptomatic intestinal malrotation incidentally found during an abdominal computed tomography (ct) performed for retroperitoneal colonic perforation in a patient with an endoscopically diagnosed aenocarcinoma of the caecum and a large polyp of the descending colon. preoperative vascular anatomic study allowed us to plan a laparoscopic approach safely also with adequate lymphoadenectomy. the abdominal cavity was entered throught a right flank mm optical trocar on the transverse umbilical line. three additional mm trocars were placed in right iliac fossa, right and left hypocondrium respectively. exploratory laparoscopy confirmed midgut malrotation and a fresh flogistic area at the descending colon perforation site. caecum and ascending colon were on midline and attached due to adhesions to sacral promontory. ileocolic artery (ica), middle colic artery (mca) and ima were selectively ligated but not at their origins due to aberrant anatomy. laparoscopic subtotal colectomy with intracorporeal stapled ileosigmoid anastomosis were carried out (endogia mm, double layer / polyglicolic acid suturing of the breech). the anisoperistaltic nature of the anastomosis is due to the disposition of the mesenterium which did not allow an isoperistalting orientation of the two resected stumps. the specimen was extracted throught a pfannestiel incision. the postoperative course was complicated by intestinal obstruction conservatively treated with slow bowel function's restoration. the patient was discharged from the hospital in th postoperative day. unexpectedly specimen histology revealed two villous adenomas with high grade dysplasia. lymphnodes were retrieved from the specimen (ptisn ). to date our case is the only fully laparoscopic colonic resection reported in literature in malrotation as well as the first intracorporeal stapled ileo-sigmoid anastomosis for such disease. the median hospital stay was days. in-hospital mortality was nil. the overall morbidity was %. the median length of follow-up was months. conclusions: our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles. robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). in rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. aims: postoperative inflammation have been reported as one of the independent prognostic factors in several types of malignancies.the aim of this study is to clarify the impact of laparoscopic approach on postoperative inflammatory status after surgery for colorectal cancer, and to analyze the association between postoperative inflammation and prognosis in patients with colorectal cancer. methods: a total of patients with stage l-lll colorectal cancer (crc) who underwent curative surgery were retrospectively analyzed. the maximum crp value measured between the times of surgical resection and discharge was defined as 'max crp'. the optimal cut-off value of max crp that best predicts rfs was determined to be mg/dl by the minimum p-value approach. methods: trainees working in this firm were responsible for data collection. patients who underwent emergency surgery during the calendar year of had the following details collected-the presence or absence of a complication in the -day post-operative period, the type of complication and description of complication along with the grade of the complication (see fig. .) . patients who underwent intermediate to major surgery were followed up at outpatients and were specifically asked for the occurrence of complications from the point of discharge up until the outpatient appointment. with one centralised national hospital-the people who were discharged and subsequently experienced considerable or major complications invariably represented back to hospital via the a&e department. results: a total of emergency surgeries were performed by this surgical firm in , % of these being done laparoscopically. of these cases- patients experienced post-operative complications within the first days after their procedure. this equated to a complication rate of . %. the most common complications were abdominal pain, nausea & vomiting, and wound infection. there were complications for each of these categories. post-operative bleeding occurred in cases with fistulas or leak of an anastomosis occurring in cases. death of a patient occurred in instances once as a result of post-operative bleeding from the site of anastomosis after a whipple's procedure, the nd occurred subsequent to post-operative bleeding from a peptic ulcer and in the rd case occurred in an instance of faecal peritonitis as a result of anastomotic failure after a roux-en-y bypass for a patient with pancreatic malignancy. conclusion: the davien-clindo classification proved to be simple, efficient and useful in analysing post-operative outcomes. the results indicate that despite the emergency setting & elderly cohort of patients-minimally invasive surgery proved to be a safe and viable option. conclusions: in this prospective study, we observed greater rates of detection of adenomas among endoscopists. screening colonoscopy on symptomatic and/or high risk group for crc is valuable in early detection and the prevention of crc. large sample size and long period of screening colonoscopy was needed. limitation of our study was the small sample size and no use of high detention endoscopy. results: the mean intraoperative blood loss volume was significantly less in the lap group than in the open group ( vs. ml, respectively, p \ . ). the mean operative time was not significantly different between the lap group and the open group ( vs min, respectively, p = . ). the incidence of severe postoperative complication (grade or higher in the clavien-dindo classification) was lower in the lap group ( / ( %) vs / ( %), respectively). the mean postoperative hospital stay was significantly shorter in the lap group than that in the open group ( vs. days, respectively, p = . ). conclusions: lap-tpe can be a safe and feasible procedure. background: amyloid light chain (al) amyloidosis is a rare protein deposition disorder with an incidence ranging between - cases per million people. it can present insidiously with localized or multisystem symptoms and usually occurs later in life. prognosis is poor as al typically presents at an advanced stage. intestinal pseudo-obstruction is a rarely reported complication of al amyloidosis. here we report a case of al amyloidosis which was identified during surgery for intestinal pseudo-obstruction. case presentation: a year old male presented to the emergency department with a month history of abdominal pain and distension, as well as marked swelling of his lower limbs. this had worsened in the previous weeks and he had developed intermittent diarrhoea. ct showed ileitis with marked dilation of the proximal small bowel. laparatomy revealed small bowel that was grossly distended that rapidly developed multiple petechiae and subsequent haematomas upon handling. two days later a repeat laparotomy was performed and . m of ishaemic small bowel was resected. histology showed amyloid deposition with positive congo red staining. subsequent cardiac events led to an echo being performed that showed concentric left ventricular hypertrophy attributed to amyloid deposition within the myocardium. free serum light chain ratio was sent and confirmed the diagnosis of al amyloidosis. he has recently been started on a treatment regimen consisting of cyclophosphamide and dexamethasone. discussion: systemic al amyloidosis frequently involves the gastrointestinal tract, typically presenting with chronic diarrhoea and associated malabsorption. only case presenting with pseudo-obstruction has been reported in the literature. al amyloidosis presents insidiously with non-specific symptoms depending on which organs are affected. treatment aims to prevent further deposition of protein within the organs. prognosis is determined by the organs that are affected and the extent of protein deposition within them. cardiac involvement holds the worst prognosis ultimately causing sudden cardiac death. the mainstays of management are early identification and treatment implementation to prevent protein build up and subsequent organ failure. conclusion: a diagnosis of amyloidosis should be considered in patients with intestinal pseudo-obstruction to expedite the diagnosis of al amyloidosis and improve survival. aim: in the management of locally advanced rectal cancer (larc), the achievement of a complete total mesorectal excision (tme) with clear resection margins was demonstrated to be the main predictor of overall and disease-free survival. predicting surgical difficulty in larc patients may be of particular importance to choose the best surgical approach. this study proposes a mri-based score to identify preoperatively larc patients with a high risk of having a difficult surgery. methods: this is a retrospective study based on the european mri and rectal cancer surgery (eumarcs) database, including patients with mid-low larc who were treated with neoadjuvant chemoradiation therapy and laparoscopic tme with primary anastomosis. data on pre-treatment and restaging through magnetic resonance imaging were available for all patients. surgical difficulty was defined as high or low grade taking in to account operative (e.g. duration of surgery), and postoperative factors (e.g. hospital stay). score accuracy was evaluated by estimating sensitivity, specificity and area under the receiver operating characteristics curve (aroc). results: seventeen ( . %) of larc patients were graded as high surgical difficulty. the eumarcs score was developed using the following significant predictors of surgical difficulty: bmi [ , interspinous distance \ . mm, ymrtstage = t b, and male sex. the score ranged from to . the cut-off score to best differentiate patients with a high probability of difficult surgery was = points. this cut-off value showed the best balance in sensitivity and specificity. the eumarcs score demonstrated high accuracy (aroc: . ) conclusions: the eumarcs score was found to be sensitive and specific in predicting surgical difficulty in larc patients who were candidate for laparoscopic tme. the score has the advantage of considering patient and cancer related characteristics that can be all assessed preoperatively and it can be useful in the decision making process. this score has not yet been externally validated. background: recently published two non-inferiority randomised control trials has raised questions on laparoscopic surgery for rectal cancer, showing lower quality pathological specimens to those achieved using an open technique. locally advanced rectal cancers add to the level of difficulty for laparoscopy approach. our study was aimed to assess feasibility of laparoscopic rectal surgery, comparing short term outcomes, quality of surgical specimen, morbidity and mortality, between propensity score match groups of locally advanced and early rectal cancers. methods: prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer at the minimally invasive colorectal unit in united kingdom between and . locally advanced rectal tumours were identified as t b or t with pre-operative mri scans. all the patients were operated by the same team and the procedures were performed laparoscopically. : propensity score matching was performed to create a perfect match in terms of tumour height. results: total of laparoscopic rectal resections were performed during the study period, out of which patients had locally advanced (la) disease and were propensity-score matched for tumour height with non-locally advanced (nla) patients. median operative time was higher for the la surgery group ( min vs min p = . ). however, conversion to open surgery (p = . ), readmission (p = . ), re-operation (p = . ), clinical anastomotic leak (p = . ) and -day mortality rates (p = . ) were all equivalent between the two groups. r resection was achieved in % of la group as compare to % of nla group (p = . ). conclusion: this study demonstrate that standardised approach to laparoscopy is safe and feasible in locally advanced rectal cancers. comparable post-operative short-term clinical and pathological outcomes were seen between la and nla groups. aims: the application of colorectal cancer screening programs, has showed a decrease in recurrence and mortality. for this reason, these programs are being implemented at a national level in the different spanish regions, as has happened in our community.to present the initial short-term results on the morbidity of the immediate postoperative period to days of colon cancer, mortality and hospital stay after the implementation of a screening program in our center. methods: a retrospective study was performed. patients aged between and years were included in the study, diagnosed with colon cancer. they underwent minimally invasive surgery, in most cases, with any type of colonic resection, from january to december . all patients were diagnosed, conventionally or through a screening program, the latter according to the plan implemented in our community. the sample was divided into two groups of patients according to the way of being diagnosed (group si screening = patients, group no screening = patients) and they were compared according different variables: dependent factors of the patient, factor of type colon cancer, factors of colon cancer resection and follow-up. results: both groups were comparable in all study variables. regarding the variables included in the follow-up, no statistically significant differences were found in terms of postoperative mortality-clavien-dindo v. however we found differences statistically significant in postoperative morbidity (p = . ) and in its classification according to clavien dindo i-iv (p = . ). the complications analyzed independently, such as anastomotic dehiscence (p = . ) or postoperative ileus (p = . ), have also presented significant differences, unlike surgical wound infection (p = . ). conclusion: at our center, the application of the screening program has not influenced in the initial stage of colon cancer or its surgical approach. however, we have found a lower overall morbidity rate and minor complications, justified by a lower incidence of anastomotic dehiscence and postoperative ileus. background: colorectal carcinoma is one of the most common malignancies. surgery is the only definitive method to achieve cure for this illness and can be performed via an open or a laparoscopic approach. the pros and cons of each approach have been discussed extensively, with the oncologic efficiency of the laparoscopic approach being one of the leading topics. objective: the aim of this study was to establish oncological non-inferiority of the laparoscopic approach to colorectal cancer. primary outcome measure was defined as number of harvested lymph nodes. secondary outcome measures were medium-term disease free and overall survival as well as length of hospital stay, time to oral feeding and short-and long-term complication rate. methods: this was a single center retrospective chart review. all consecutive patients who underwent colon or rectal resection due to colorectal carcinoma at hadassah medical center between the years - were included. patients who were operated on for recurrent disease or who had metastatic disease at the time of surgery were excluded. patients were divided into three groups according to the surgical approach: laparoscopic, open or converted. medium-term oncological outcomes were the same for all groups. time to oral feeding, length of hospital stay, short-and long-term complication rate were all significantly improved in the laparoscopic group. conclusions: we were unable to prove non-inferiority of the laparoscopic approach regarding the number of harvested lymph nodes. however, all surgical approaches yielded a high number of harvested lymph nodes which is most probably oncologically sufficient, as reflected by the non-existent difference in medium-term oncological follow up. this study supports previous studies showing the superiority of the laparoscopic approach regarding short term recovery and overall complications rates. aims: two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high quality surgery are equivalent to those achieved by open technique. we intend to present short and long-term postoperative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic tme for rectal cancer. we describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. methods: prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon (ap) at the minimally invasive colorectal unit in portsmouth between and were analysed along with data acquired between and from surgeons (tq,nf,ah) at three further international centres. end-points were overall and diseasefree survival at years, and early post-operative clinical and pathological outcomes. results: consecutive patients underwent laparoscopic tme surgery by the principal surgeon (ap). at years overall survival was . % (dukes' a = . %; b = . %; c = . %); disease-free survival was . % (dukes' a = . %; b = . %; c = . %). post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, incomplete resection, major morbidity and day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. conclusion: laparoscopic tme produces excellent long-term survival outcomes for patients with rectal cancer. a standardised approach has the potential to improve outcomes by setting bench-marks for surgical quality, and providing a step-by-step method for surgical training. results: analysis of association of tumor location (sigmoid, right or left colon), operation time, blood loss, extraction site, type of surgical sutures used for wound closure with postoperative complications or specimen quality either did not show significant correlation or could not be conducted due to data nature. unexpectedly, a significant difference was demonstrated between two surgical teams in terms of hernias. majority of cases- ( . %) were performed by surgeon (s ), surgeon (s ) operated on ( . %) patients, nevertheless minilaparotomy closure was usually performed by junior members of the team. conversion rate was . % for s and . % for s (p = . ). operation time and blood loss were smaller in s group compared to s ( . ± . min vs . ± . min, p = . and . ± . ml vs . ± . ml, p = . respectively). specimen quality and early postoperative complications did not differ. postoperative hernia rate was . % for s and . % for s (p = , ). both surgeons used the same specimen extraction sites and materials for wound closure. hernias were more frequent after vertical minilaparotomy- % ( of patients), and in converted patients , % ( of patients), compared to , % ( of ) in transverse minilaparotomy group. there was no association of hernias and wound infections. conclusions: our study demonstrates, that besides consultant dependent surgical surrogates, steps which are often performed by other members of surgical team (such as wound closure) may contribute to complication rate as well. more thorough supervision of wound closure may be needed. aims: laparoscopic complete mesocolic excision (cme) right hemicolectomy is considered a demanding procedure and it is actually adopted in few centers from the west. the aim of the present study is to analyze the safety of laparoscopic cme right hemicolectomy and to compare its short-term results with standard right hemicolectomy in a single western center. methods: prospectively collected data from patients who underwent laparoscopic cme right hemicolectomy between june and november were retrospectively analyzed (cme group) and compared with data from patients submitted to standard laparoscopic right hemicolectomy between april and november (s group). results: no differences were observed between the cme and the standard right hemicolectomy groups in terms of clinical characteristics. in the cme group, . % of patients were = years old, . % of patients were asa class , . % of patients had = comorbidities, . % of patients had bmi [ and . % of patients had = previous abdominal surgeries. no differences were observed in terms of duration of surgery ( ± min vs. ± min; p = . ) and intraoperative complications ( . % vs. . %; p = . ) between cme and s groups; mean blood loss was lower in the cme group ( . ± . ml vs . ± . ml, p = . ). the percentage of overall ( . % vs. . %; p = . ) and severe (clavien-dindo = ) complications ( . % vs. . %; p = . ), redo surgery ( . % vs. . %; p = . ) and readmission ( . % vs. . %; p = . ) was comparable between cme group and s group. a significant difference was observed in the length of specimen ( ± mm vs. ± mm; p \ . ) as well as in the length of proximal ( ± mm vs. ± mm; p = . ) and distal margins ( ± mm vs. ± mm; p = . ) in favor of the cme group. the number of lymph nodes harvested was slightly higher in the cme group ( . ± . vs. . ± . ; p = . ) as it was for the percentage of cases with less than retrieved lymph nodes ( . % vs. . %; p = . ), although these differences did not reach statistical significance. conclusions: this study represents one of the few western experiences demonstrating the safety of laparoscopic cme right hemicolectomy. cme technique showed good short-term results and better quality specimens when compared with the standard procedure. aim and background: peritoneal dissemination of colorectal cancer (pc) makes the complete resection of cancer lesions impossible. in such cases, multidisciplinary therapy is essential with mainly chemotherapy. preoperative diagnosis of pc is usually uncertain by ct or mri image. for diagnosis of pc needs surgical materials with laparotomy. but the laparotomy and resection of pc with general anesthesia tends to make impossible for immediate chemotherapy. less invasive diagnosis of pc is necessary and expected.endocytoscopy (ec) makes the histological diagnosis with precise images gained by high magnification (x ). as a preliminary examination, ec diagnosis for resected specimens of pc were evaluated. methods: two cases of pc diagnosed in operation were evaluated. under general anesthesia, laparotomy was conducted. peritoneal dissemination lesions obviously diagnosed as pc were resected. immediately the lesions were stained by methylene blue solution for to s. ec observation was done according ec classification ) and ecv classification ). results: in two cases, ec observation was successfully done. images of dilated surface microvessels of a nonhomogeneous caliber or arrangement were observed in nbi ec corresponding to ec-v . histopathological diagnosis of resected specimens was metastatic colorectal carcinoma in peritoneum in both cases. conclusions: histological diagnosis for pc is gained by ec with resected specimen. as the result of this investigation, ec examination via camera port in laparoscopic operation might be possible for diagnosis for pc of colorectal cancer in vivo. aims: the aim of this presentation is to demonstrate and analyze surgical complications, arising during laparoscopic colorectal resections for cancer and to analyze the reasons of adverse events. methods: we demonstrate videos from our surgeries, where different types of complications occurred and share our classification of types of mistakes, that may lead to intraoperative complications and ways to prevent them. results: we divide mistakes in laparoscopic colorectal resections into two large groups-'false strategy' and 'dangerous techniques'. the first includes poor diagnosis, too extensive or insufficient extent of surgery and improper enthusiasm in using platforms. prevention of first type mistakes is in thorough training and peer-review of each consultant practice. second type of mistakes includes two subtypes : 'faulty habits'-use of unsafe techniques (blind port insertion, poor vascular exposure prior to clipping, not obtaining 'critical views', unsafe use of energy and stapling devices etc.) and 'failure in a certain case'-when despite correct general approach a complication occurred (misinterpretation of fascial layers or vessels). prevention of 'faulty habits' lies in supervised training in high volume colorectal departments including dedicated surgical devices training. to avoid 'failure in a certain case' standardization of surgical procedure is essential, as the most efficient way to prevent this type of mistake is 'pattern recognition'ability of a surgeon to compare the picture he sees during a procedure with a 'standard' view, he used to have during previously performed standard surgeries-this is apparentely impossible when every procedure is done differently. regular reviews of own surgeries recording and other surgeons' procedures may also fascilitate pattern formation. in case a complication occurres we use the four step course of action: preservation of the view, temporary control, decision on conversion, permanent control. conclusion: as popularity of laparoscopic colorectal resections is growing rapidly the number of intraoperative compliactions is increasing as well. we demonstrate videos of complications and our approach to classification of possible mistakes. systematic aproach to reasons, underlying certain mistakes helps to produce a strategy to reduce intraoperative complication rate. introduction: the drains placement inside the abdominal cavity has traditionally been carried out to evacuate hematic remains or postoperative collections. there is no scientific evidence of the prophylactic use of drainage in elective colorectal cancer (ccr) surgery to avoid anastomotic complications or other complications. however, it is traditionally used. when the anastomotic leak is produced, it is generally agreed that drainage system should be used for therapeutic purposes. aims: the aim of this study is to evaluate the effectiveness of the use of prophylactic drainage in elective surgery of ccr. we would check if they avoided the appearance of complications, and if they are useful when the anastomotic leak appears. methods and results: we analyzed the data collected in our hospital from / / to / / . we studied the number and type of interventions in which prophylactic drainages were placed, the appearance of anastomotic complications and if these drains were effective. interventions were performed during this period of time. % of these procedures had used prophylactic drainage ( interventions). this percentage was up to % in patients who have performed a left colon surgery as a sigmoidectomy or rectal procedure. during this period, there were cases of anastomotic leakage. in all of them had been placed drainage but only of them were effective. conclusions: we have seen that prophylactic drainage is a common practice independently of the location of the anastomosis. the last multimodal rehabilitation guidelines recommended the nonuse of drains systematically above the peritoneal reflection with a high level of scientific evidence. they cause discomfort to the patient and delay early mobilization. however, it may be useful to use drains in the first h of a pelvic floor procedure. there is not enough evidence to show sistematic drainage after colorectal anastomosis prevents complications of the anastomosis or other complications. aims: colonic cancers of the splenic flexure is uncommon and associated with poor prognosis. several studies were published aimed to identify the optimal surgical option for the best oncological outcomes. however, whether an extended colectomy or a segmental resection is required is still controversial. the aim of this study is to analyse the outcome of the two different approaches through the experience of a single centre. materials and methods: retrospective data of consecutive patients with diagnosis of colonic cancer situated at the splenic flexure of our department between and were analysed. based on type of surgical procedure, patients were enrolled in arm a (segmental resection) and arm b (extended resection). arm a patients were treated with segmental resections with a wide mobilisation of the transverse and descending colon and ligation of the left colic artery, sparing the middle colic artery and the inferior mesenteric artery. functional lateral to lateral anastomosis was performed extracorporeally. arm b patients were treated with more extended colectomies, both associated with central vascular ligation. results: out of patients included, were allocated in arm a and in arm b. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. operative time was comparable ( , min vs min, p = , ). the length of the specimen was significantly shorter in arms a ( , vs , , p = , ) . the number of harvested lymphnodes did not differ between the two groups ( , vs p = , )postoperative short term complications was comparable in both arms ( vs , p = , ). no postoperative mortality was observed. overall -year survival and disease free survival rates were similar in arm a and b ( . % vs . %, p = , and , % vs , %, p = , ). hospital stay was similar in the two groups (p = , ). conclusions: despite a shorter length of surgical specimen after limited resections, postoperative complications, lymph node harvest, and survival were comparable in both.in our opinion the extracorporeal anastomosis is functional to both the achievement of a cleaner operative field and a better control of the resection margins. incidence of neuroendocrine tumours in the rectal area has increased in recent years.before the onset of minimally invasive colorectal surgery, these lesion had to be treated by a more radical technique when not suitable for endoscopic resection.selection of the cases is mandatory in order to achieve good results not only surgical, but also oncological. we present our series of neuroendocrine tumoirs treated by tamis approach, including technical aspects, deffect closure techniques and data regarding pathological findings.all cases were low grade carcinoid tumours. resection with free margin was obtained in all cases. defect closure was performed in all cases. the tumours were settled , and cm form the anal verge. postoperative course was uneventful, ann no adyuvant therapy was needed.tamis apporach for rectal neuroendocrine tumours is a safe and feasible technique. proper selection of the cases is mandatory in order to achieve good results. surg endosc ( ) aim: to assess the safety and efficacy of single layer of barbed vs double layer 'hybrid' (interrupted and running) suture for the closure of anastomotic stapler access enterotomy after laparoscopic right colectomy with intracorporeal anastomosis. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm - (ethicon). intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ). all patients required a reoperation. intraoperative findings show in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to noninfectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. aims: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results as it is not influenced by body mass index or lymphatic invasion. intraoperative fluorescence icg navigation also aims for detection of aberrant lymphatic drainage outside the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems to identify the lymphatic nodes. our objective with this study is to rate the use of the intraoperative lymphogram in cases of elective colorectal surgery to evaluate if there were changes in the surgical attitude regarding the performance of lymphadenectomy. methods: indocyanine green was injected into the submucosal layer around the tumor at points with?a -gauge localized injection before lymph node dissection and the lymph flow was observed at , and min after injection, using a near-infrared camera system. in addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was observed to be fluorescent. the following table summarizes the procedures carried out as well as the lymphadenectomy performed before and after the use of icg. in brief, after the application of intraoperative icg it was observed that in % of patients additional lymph nodes were obtained after the expansion of the surgical plan, moreover % affected lymph nodes were spotted after the expansion of the surgical plan. conclusions: intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery is feasible and a helpful technique for lymph node mapping which may lead to intraoperative changes in lymphadenectomy. tamis resection of rectal tumours has proven to be a sefe and feasible technique, specially for lesion located in the mid and low rectum.when the tumour is located in the upper rectum, and specially near the colorectal junction, tamis resection may be more difficult, not only due to technical aspects, but also due to the risk of a free perforation, specially when a full thickness resection is performed.we present our results of tamis resections of lesions located around the colorectal junction. four resections where performed with the aim of an endostpaler in order to achieve full resection without the risk of a free colonic perforation.in cases, an abdominal combined laparoscopic exploration was made, in order to help and assure proper resection of the lesion as well as avoiding intraoperative complications.distance from the anal verge ranged from to cm.postoperative course was uneventful in all cases, and a complete specimen resection was obtained in all cases.tamis resection of tumours located in the rectosigmoid junction may be a safe and feasible technique in selected patients. methods: between january to april , patients with diagnosis of right colon adenocarcinomas underwent right hemicolectomies. the data was analysed for patients demographic, histology, type of surgical approach, intraoperative details (length of surgical procedure, blood loss, blood transfusion, conversion rate) and short-term post-operative outcomes including complications. introduction: postoperative ischemic colitis is a life-threatening vascular gastrointestinal condition, that mainly occurs after cardiovascular surgery. we present a surprising case following a laparoscopic rectum resection. case report: a -year-old diabetic patient with upper rectal adenocarcinoma undergoing laparoscopic anterior rectal resection (partial mesorectum excision) and mechanical anastomosis following chemotherapy / radiotherapy. after h postsurgery he presented abdominal pain, distension and fever. on adominal computed tomography (ct) scan (contrast enema) no anastomotic leakage (al) finfings were revealed. neither digital palpation nor proctosigmoidoscopy ( th day) showed al signs. the patient clinical situation improve with conservative treatment (antibiotics, digestive rest …), c-reactive protein levels decreased and the blood cultures were negative. on the th day he was discharged presenting semiliquid stools. eight days later he needed hospital readmission: air and feculent/purulent discharge from the previos abdominal drainage orifice. ct scan: no evidence of dehiscense found although rectum and sigmoid colon distention and an image of a 'large fecaloma' were observable. on the th day of hospitalization he expulsed a large malodorous segment of tissue with necrotic asppearance (image) through the anus with surprising histologic features: 'complete-thickness necrotic colonic wall'. further rectosigmoidoscopy: complete anastomosis, signs of ischemic colitis proximate to the anastomosis and a fistulous orifice. surprisingly, the patient progressed favorably, being discharged the th day for ambulatory control with a low debit enterocutaneous fistula. histopathological diagnosis: ypt n m . follow up: the fistula discharge quantity increased maintaining diarrheal stools through anus along with persistent anemia and malnutrition. a exploratory laparotomy was schedule. fistulous tract towards a small stenotic segment of colon inmediately proximal to the colorectal anastomosis was identify and resected. finally a terminal colostomy was performed. subsequent postoperative without incidents. currently the patient is asymptomatic. comments: it seems indisputable that a colon segment, proximal to the anastomosis, was necrosed and expelled through a colorectal anastomosis. the mechanism seems inexplicable to us. it is even more disconcerting that there was no disruption of the anastomosis. objectives: fluorescence-guided surgery has emerged as a new imaging modality to improve the detection of liver and lymph node metastasis in colorectal cancer. in right-sided colon cancer, the standard lymphadenectomy should reach the ileocolic vessels and the right branch of the middle colic vessels. the purpose of this study is to perform an objective estimation of lymphatic drainage and metastatic lymphonodes in right-sided colon carcinoma through indocyanine green (icg) lymphography. methods: patients with right-sided colon adenocarcinoma were included, excluding those in stage iv, t and those who underwent urgent surgery. cc of icg peritumoral were injected using a peripheral intravenous catheter at the beginning of the intervention. the lymphatic drainage mapping of the tumor was identified. lymphadenectomy of the ileocolic vessels and right branch of the middle colic vessels was performed extending it to the left branch and origin of middle colic vessels if it was shown in the mapping. results: patients were included. the average age was . in patients the tumor was located in the ascending colon and in patients in the hepatic angle. in patients, the mapping showed lymphatic drainage to ileocolic vessels and right branch of the middle colic vessels. in patients ( %) it showed drainage to the left branch and origin of the middle colic artery, therefore extended lymphadenectomy was performed at that level. in patients, the postoperative period was uneventful. patient presented infection of the surgical wound and another patient developed a cm perianastomotic collection treated with percutaneous drainage. the anatomopathological report showed nodal metastasis in of the patients ( %) in whom lymphatic drainage was observed in the territory of the middle colic vessels with icg. these patients presented the tumor in the hepatic angle. therefore, of the patients with right-sided colon carcinoma ( %) presented nodal metastasis in the territory of the middle colic vessels. conclusions: fluorescent lymphography may improve the results of lymphadenectomy in colon cancer. in patients with tumors of the hepatic angle, lymphadenectomy extended to the left branch and origin of middle colic vessels, could be an adequate alternative. introduction: over the last decade, the common principles of surgical treatment in colon surgery are central vascular ligation (cvl) and complete mesocolic excision (cme). however, the superior mesenteric vessels anatomy, while performing the right colectomy is characterized by wide variability, which can lead to complications, especially during minimally invasive surgical intervention. objective. the purpose of this study is describing vascular variations around the superior mesenteric artery and vein-middle colic, right colic and ileocolic vessels, henle trunk in the laparoscopic right colectomy. materials and methods: the study was held in the 'dobrobut' clinic and o. o. bohomolets national medical university, department of general surgery (kyiv, ukraine) during the - period. patients were included to the study, females ( . %), males ( . %) in the average age of , ± , years. all the patients underwent the laparoscopic right colectomy (cme ? cvl) with d lymph node dissection. recorded video materials from each laparoscopic right colectomy were analyzed during the study. results: ileocolic vessels were the most stable. there were typical anatomical position in all cases. . % of cases, ileocolic vein was identified anteriorly to the ileocolic artery, while . % being posteriorly. right colic vein was absent in . % of cases. right colic vein drainage was to henle trunk and inferior mesenteric vein in . % and . % respectively. the right colic artery was present in % of patients, it's origin was superior mesenteric artery in . % and . % the middle colic artery. the middle colic vein was present and drained to superior mesenteric vein in % of cases. same as the middle colic artery with the superior mesenteric artery origin. henle trunk was present in . %, gastro-pancreato-colic trunk in . % of cases gastro-pancreatic trunk in . %, gastro-colic in . %. conclusions: knowing the options of surgical vessels anatomy, while performing the right colectomy, altogether with surgeons preparation, using the ct-scan data can reduce the risk of iatrogenic damage and complications risks. introduction: the enhanced recovery after surgery (eras) protocol was designed to accelerate convalescence, reduce morbidity and shorten the length of hospital stay (los). one of its major interventions is balanced perioperative fluid therapy. the impact of this single intervention on short-term outcomes is widely discuss. aim: the aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes. material and methods: the analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between november and january . patients were divided into two groups: balanced (= ml) or unbalanced ([ ml) perioperative fluid therapy. all patients were treated according to eras protocol. study outcomes were: recovery parameters, morbidity rate, los, -day readmission rate. results: group consisted of and group of patients. there were no statistically significant differences between the groups in terms of demographic and operative parameters. morbidity was lower in group ( . % vs . %, p = . ). patients in group were discharged home earlier than in group ( vs days, p \ . ). moreover, we observed differences in recovery parameters between the groups: tolerance of an oral diet on the st postoperative day ( % vs. %, p = . ) and patient mobilization on the day of surgery ( % vs. %, p = . ). -day readmission rate was lower in group ( . % vs. %, p = . ). conclusion: a balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter los and lower -day readmission rate. methods: a retrospective analysis was performed including patients who underwent lcs or ocs for cancer treated as emergency in a single centre between and . patients who underwent palliative surgery were excluded. lcs were : propensity score-matched based on pposum and stage of disease with ocs. short-term outcomes included oncological quality, length of hospital stay (los) and postoperative mortality. for long-term outcomes, -year overall and disease free survival (os and dfs) rates were analyzed. results: during the study period, a total of emergency colorectal resections were performed. of them, % (n = ) were coloniccancers. lcs were matched to an equal number of ocs.median age was ( ) years and % were females. median follow-up was ( ) months. the majority of resections were right hemicolectomies ( %), followed by sigmoid resections ( %) and subtotal colectomies ( %). operative time ( ( ) background: total mesorectal excision (tme) offers the best reported rates for local recurrence and survival in patients with rectal cancer. our series from a single high-volume center, assessed the feasibility, safety and long-term oncologic adequacy of laparoscopic total mesorectal excision methods: we reviewed the prospective database of consecutive unselected patients undergoing laparoscopic tme for rectal cancer between and at the department of general surgery, onze-lieve-vrouwziekenhuis hospital (olv), campus aalst, belgium. the objective of the present study was to evaluate the effectiveness of laparoscopic tme, with an emphasis on perioperative variables and long-term oncological outcomes. results: pts with mid and distal rectal cancer up to cm from the anal verge had laparoscopic tme resection. patients ( . %) underwent a sphincter-preserving surgery and the remaining patients ( . %) had an abdominoperineal resection. end-to-end anastomoses: pts ( %), j-colonic pouch: pts ( % introduction: the rica clinical pathway (intensified recovery in abdominal surgery), also called surgical multimodal rehabilitation, is the application of a series of perioperative measures and strategies in those patients who are going to undergo a surgical procedure with the objective of reducing secondary stress to the surgical intervention. in this way, we achieve a better recovery of the patient and significantly reduce complications and morbidity. objective: s to analyze, through our database of patients undergoing crc, the percentage of postoperative ileuses and the following quality indicators: the postsurgical hospital stay, the anastomotic leak, and the infection of the surgical site. to check if the implantation of the rica pathway has meant an improvement in our postoperative hospital stay and with that, a lower sanitary cost. methods and results: we analyzed the data collected from those patients who underwent ccr in our hospital between / / and / / , during which time we implemented the rica clinical pathway. the average hospital stay was days. of the patients, . % presented anastomotic leak, . % infection of the surgical wound and . % paralytic ileus. we have verified how the average hospital stay increases with the appearance of anastomotic leak ( . days), infection of the surgical wound ( . days) and paralytic ileus ( . days). when we divided this -month period into two halves to see the impact of the implantation of the clinical pathway, we obtained the following results: the post-surgical hospital stay in the period from / / to / / was . . the stay from / / to / / was . . the implantation of the rica clinical pathway is providing us with important advantages in our clinical practice, with greater postoperative comfort and an improvement in our quality indicators, such as the decrease in the average hospital stay of our patients. on the other hand, after starting its implementation we have encountered the resistance to change clinical habits and the one that requires a multidisciplinary participation, so adherence to this is being progressive, and requires periodic audits to reinforce and consolidate our achievements, and identify our points of improvement. however, tem has not yet achieved widespread use. recently, transanal minimally invasive surgery (tamis) using single-port surgery devices has been reported. initially facilitated by existing single-port surgery devices, two platforms for transanal access, the gelpoint Ò path (applied medical, rancho santa margarita, ca, usa) and the sils tm port. the gelpoint Ò path is the only platform to be specifically designed for tamis y tatme. objetive: in the present study, usesa gelpoint Ò path was performed in patients with lower rectal neplasms. results: complete full-thickness excision was performed in all cases of tamis and free margins over rectal cancer. on two cases no neoplasm was visualizad. the patient characteristics, operative techniques and operative outcomes were evaluated. the mean age of the patients was . years (range - ). the mean operating time were min (range - ). patients was selsted for tatme, for tamis and two patients for evaluation and biopsy if was necesary. additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. tamis using a gelpoint Ò path was revealed to be easy and safe to perform. although only a small number of cases were treated, and the operation was demonstrated to be sufficiently feasible. conclusion: gelpoint path is a good tool for colorectal surgery in tatme, tamis and evalluation of anastomoses or de novo lesions introduction: several improvements in rectal cancer treatment, in the last decades, resulted in a markedly increased survival. nevertheless, surgery remains the prevalent treatment and to % of operated patients experience some kind of functional abnormalities. as nowadays we acknowledge the importance to focus not only on survival rates but also on quality of life, we craved for a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, we performed a thorough translation with cultural adaptation of the patient reported outcome tool, low anterior resection syndrome (lars) score, to the portuguese language (lars-pt) and population. methods: according to the current international recommendations, we designed this study encompassing three main phases: (i) cultural and linguistic validation to european portuguese; (ii) feasibility and reliability tests of the version obtained in the previous phase; and (iii) validity tests to produce a final version. the questionnaire was completed by patients from six portuguese colorectal cancer units, and completed it twice. results: the portuguese version of lars score showed high construct validity. regarding the test-retest, the global intraclass correlation showed very strong test-retest reliability. looking at all five items, only items and presented a moderate correlation. lars score was able to discriminate symptoms showing worse quality of life in patients submitted to preoperative radio and chemotherapy. conclusion: lars questionnaire has been properly translated into european portuguese, demonstrating high construct validity and reliability. this is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, his sistematic use should be implemented. oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (podh) represents a potentially life-threatening surgical complication characterized by an underestimated occurrence rate and unknown related risk factors. this study analyses the experience of two tertiary designated centers in order to evaluate key elements concerning development and treatment of podh. a cohort of consecutive patients affected by a clinically resectable oesophageal cancer (any t, any n and m ) underwent ivor-lewis oesophagectomy between march and april according to three different approaches: totally open incision procedure (oilo), hybrid (hilo) and totally mininvasive to esophagectomy (milo). all population was retrospectively observed in the context of a postoperative calendarised follow-up in order to record the incidence and postrepair results of podh. patients underwent ivor-lewis oesophagectomy for cancer and ( . %) developed podh within a median follow-up period of months ( - ). surgical repair was generally applied by the mean of laparoscopic cruroplasty ( %) with a conversion rate of %. postoperative morbidity did not include early recurrences but exclusively cardio-pulmonary complications ( patients) with one case of respiratory failure leading to death. the discharge was reached after a median hospital stay of days ( - ) while recurrences ( %) occurred over a median followup period of . months. a wide univariate analysis identified statistically significant associations between podh occurrence and the administration of preoperative chemoradiotherapy, the complete pathological response (cpr) and a lymph node harvest (lnh) larger than stations (p-value of . , . and . respectively). the strong influence of an extended lnh was confirmed by the multivariable analyses ( . ) along with cpr which should however be considered as longer survival-related bias. the minimally invasive surgery and the neoadjuvant chemoradiotherapy represent a considerable part of multimodal treatment for oesophageal cancer presenting a not statistically significant association with podh development while a lnh including more than nodes resulted to be an independent risk factor mirroring the extent of surgical demolition in oesophagectomy. l. barbulescu aim: to asses the safety and effectiveness of robotic total meso-rectal excision vs laparoscopic total meso-rectal excision and to analyse the primary outcomes. methods: the operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of tme. in our center were performed robotic rectal resections and laparoscopic resections from january to present. results: the rtme was associated with longer operation time, early bowel movements, lower risk of conversion and shorter hospitalization. the statistical equivalence was seen between rtme and ltme for non-oncological variables like blood loss, morbidity and reintervention risk. the oncological variables such as number of harvested nodes and positive circumferential resection margin risk were also comparable in both groups. the length of distal resection margins was similar in both groups. conclusion: rtme in patients with rectal cancer was associated with a lower rate of conversion and less incidence of urinary retention. the operative time in rtme was significantly longer than in ltme. the initial oncological and function outcomes of rtme seem to be equivalent with ltme. c. athanasiou aims: two randomized controlled trials failed to show non-inferiority of the laparoscopic total mesorectal excision (ltme) compared to open. ltme becomes particularly challenging in low rectal cancers and in narrow pelves. many surgeons report that robotic tme (rtme) may be beneficial in that setting. our aim was to systematically review the literature and compare the pathologic outcomes of open, laparoscopic and robotic tme for rectal cancer methods: medline, embase, scopus, cochrane library and web of knowledge databases were searched for randomized controlled trials (rct) reporting patholologic outcomes of open, laparoscopic or robotic tme with no language restriction. our primary outcome was quality of tme on macroscopic assessment of the specimen. secondary outcomes included positive circumferential resection margin, distance to radial margin, number of lymph nodes and positive radial margin. the included studies were quality assessed and the jadad score was reported. the grade approach was used to rate the certainty of each network estimate. results: fourteen rcts were included in our study. seven rcts compared the otme to the ltme, six compared the ltme and rtme and one study the otme to the rtme. no statistical significant difference was found in quality of tme when the the ltme was compared to the otme or = . ( . , , ) or the rtme or = . ( . , . ) . no difference was found in pcrm for the laparoscopic or = . ( . , . ) or the robotic approach or = . ( . , . ) when compared to open. distance to radial margin and number or lymph nodes didn't differ between the groups. conclusions: no significant advantage on pathologic specimen quality has been found with the robotic approach. the ltme doesn't seem to compromise the quality of the specimen. h. samura , j. arakaki , k. sugata , y. hori , y. nagamine , f. kohagura , h. motonari , s. kameyama , t. ishimine division of digestive and general surgery, urasoe general hospital, okinawa, japan; department of surgery, urasoe general hospital, okinawa, japan colorectal cancer often invade adjacent organs and it is known that prognosis improves with resection of the involved organ. we report our experience of invaded adjacent organ resection, which include seminal vesicle, uterine and bilateral appendages, posterior wall of the vagina and bladder wall. method: although the range of resection is predicted by image study preoperatively, at the time of operation, it was decided by palpation with a forceps. each operation is evaluated by operation time, blood loss, blood transfusion volume, postoperative complication, postoperative hospital stay, and short term prognosis. result: resection cases of seminal vesicle, posterior vaginal wall, uterine and bilateral appendages and bladder wall were , , and , respectively. the results are shown in the order of seminal vesicle / vaginal posterior wall / uterine / bladder. median age was , , and years old. the median operation time was , , , min, the median blood loss was , , , ml, and only one case of uterine and bilateral appendages resection required the blood transfusion. the average postoperative hospital stay was , , , days. nine cases have postoperative complication, that include delayed wound healing, anastomotic leakage and rectovesical fistula, postoperative ileus, chyle ascites and neurogenic blodder. all of those were improved with conservative treatment. the mean hospital stay in complication cases was days ( - ) and ( - ) days without complications. the median observation period was days ( - ), and there was no local recurrence. all of the case of stage iv were dead. there was no local recurrence and all patient without stage iv are alive, it seems that the resection range was sufficient. conclusion: even with adjacent organ invasion colorectal cancer, it was possible to determine the resection line by palpation with laparoscopic forceps manipulation, and possible to resect margin free of cancer. laparoscopic low rectal resection with/without diverting ileostomy p. ihnát, m. tesar, p. ostruszka, p. gunková, p. vávra background: the construction of diverting ileostomy (di) is recommended to avoid septic complications of anastomotic leakage. the aim of our study was to assess the benefits and risks of di constructed during laparoscopic low anterior resection (lar). methods: retrospective clinical cohort study was conducted in university hospital ostrava, czech republic. all patients undergoing laparoscopic lar with tme because of rectal cancer within a -year study period were assessed for study eligibility. results: a total of patients ( patients without di, patients with di) after laparoscopic lar were enrolled into the study and underwent analysis. both study subgroups were comparable in terms of demographic and clinical features. postoperative -day morbidity was significantly lower in patients without di ( . % vs. . %, p = . ). anastomotic leakage frequency was higher in patients without di ( . % vs. . %, p = . ); surgical intervention was necessary in . % of patients without di. stoma-related complications were noted in . % of patients with di; some patients had more than one complication. surgical intervention because of stoma-related complications was needed in patients ( . %). distinctive complications of di laparoscopic construction (small bowel obstruction due to di semi-rotation around its longitudinal axis) was noted in patients ( . %). mean stoma period (interval between lar and di reversal) was more than months in our study; only . % of patients were reversed without delay (= months). postoperative morbidity after di reversal was . %; re-laparotomy was needed in . % of patients. conclusions: despite benefits of di in protecting low rectal anastomosis, ileostomy construction remains fraught with many stoma-related complications and long stoma periods associated with significantly decreased quality of life. aims: single port laparoscopic is a minimally invasive surgical technique that joint the cosmetic advantages with the well recognized benefits of the standard laparoscopic approach [ ] . we describe a laparoscopic single port hartmann reversal in a patient by the use of the umbilical colostomy site for surgical access [ ] . methods: a years old patient was submitted to a laparoscopic single port hartmann procedure with an trans-umbilical colostomy for a recurrent sigmoid volvulus that was treated at the beginning by endoscopic de-rotation. after three months the patient was reevaluated for a hartmann reversal with a laparoscopic single port technique. after routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. by the use of a gelpoint system with trocars, the intra-abdominal adhesiolisis in performed. the splenic flexure is mobilized to achieve a sufficient mobilization of the left colon that allows the fashion of a tension free anastomosis. the rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. a tension-free colorectal anastomosis is secured with a standard circular mm stapling device inserted transanally. the colostomy wound is closed. the operative time was min. results: the postoperative course was uneventful, the patient was discharged at forth postoperative day, oral intake started on postoperative day three. conclusions: single port laparoscopic hartmann reversal thought the umbilical stoma site is a minimally invasive surgical option that is safe in selected patients and offer the best cosmetic results. [ the progressive evolution of surgical techniques and oncologic protocols on rectal cancer disease facilitates surgeons to challenge the skills for anus preservation in low rectal cancer surgery. the laparoscopic surgery is already one of the best ways to reach the pelvic floor and to try procedures, which were previously difficult to apply through open surgery. the anastomotic leakage has particularly high occurrence if the anastomosis is performed in the anal or distal rectum area. it is evident that although the fecal diversion does not decrease post operatory mortality, it significantly reduce the risk of anastomotic leak and the risk of a second major surgery when the leak occur. diverting stomas are low-risk procedures from a technical point of view, but they potentially expose the patients to postoperative morbidity, impacting the patients' quality of life. it is not easy to decide whether the fecal diversion is needed or not. this decision must be made on a case to case basis, trying to apply the stomas only when they are really needed. we report our initial experience by living a transmesenterial cotton loop around the pre terminal ileum which extremities are turned out usually through the lateral trocar wound in laparoscopy or by applying a dedicated mini incision in open surgery. the purpose is to perform (in case of suspected fistula), a mini invasive diverting procedure, by widening the loop wound and by pulling up the ileum in a lateral loop ileostomy. we applied this procedure to consecutive patients with low colorectal anastomosis and in two of them we performed a lateral loop ileostomy with good results. we believe this can be an alternative that needs to be standardized. purpose: sarcoidosis is a chronic, multisystem inflammatory disorder with unknown aetiology characterised by noncaseating granulomas within involved organs. gallbladder involvement in sarcoidosis is extremely rare and literature review revealed only reported cases to date. in this paper, we present a case of gallbladder associated sarcoidosis. method: a -year-old lady was known to the clinic for regular surveillance of liver steatosis and incidental gallbladder polyps. the largest polyp was mm at presentation in and has grown to mm in . in view of worsening symptoms of biliary colic and growing polyps, a laparoscopic cholecystectomy was performed. results: laparoscopic cholecystectomy was unremarkable and specimens of the gallbladder and lymph nodes were sent for histology. histological examination revealed chronic cholecystitis with polypoid cholesterolosis of the gallbladder and noncaseating granulomata within a lymph node, which strongly suggest sarcoidosis. conclusion: in conclusion, we report a case of incidental finding of gallbladder sarcoidosis over the course of treatment of biliary colic and symptomatic gallbladder polyps. therefore, the definitive treatment for patients with symptomatic gallbladder sarcoidosis is a cholecystectomy. the surgical management of cholelithiasis can be associated with significant morbidities. despite the relatively low incidence of bile duct injuries during laparoscopic cholecystectomy, the total number is large due to the high frequency of the operation. the subtotal cholecystectomy with its variants is a well known bailout strategy to the surgical community. however, there is no agreement on when and how to perform these procedures. indeed, the majority of surgeons will adopt these solutions when there is a struggle to identify the critical view of safety. this struggle results increases the risk of injuries. we hypothesize that a primary intent gall bladder lithotomy and disconnection (glad) when the dissection of the gb pedicle is anticipated difficult dissection is a safe and feasible strategic option. methods: out patients elevtively admitted to aberdeen univesity hospital with gall stone disease between march and november , consecutive patients were operated with glad procedure based on intraoperative criteria. the primary outcome was the operative time. secondary outcomes were length of hospital stay, the criteria to do this procedure will be explained, the outcomes will be listed. indocyanine green is a molecule that becomes fluorescent when excited struck with light of a specific wavelength in the infrared spectrum (nir-infrared), allowing the visualization of anatomical structures in which it has accumulated. the aim of the study is the application of icg enhanced fluorescence in laparoscopic cholecystectomy in order to identify the anatomy of the biliary tract, to reduce the risk of iatrogenic lesions and the conversion rate. the study involves laparoscopic cholecystectomy for cholecystitis and gallstones of main biliary tract. the evening before the surgery, a vial of icg ( mg) diluted in ml of saline solution was intravenous injected. during the procedure, after opening the calot triangle, switching to the nir mode on the camera, the anatomy of the biliary tract and in particular of the main biliary tract is visualized. the cystic duct and cystic artery are isolated, their section between clips is cut and the cholecystectomy is performed. from january patients were enrolled: cases of acute cholecystitis, cases of gallstones of main biliary tract, undergoing preoperative ercp. in cases of cholecystitis, the angiography allowed the visualization of the main biliary tract. in one case, an abnormal course of the cystic duct was identified. in two cases of gallstones of common bile duct, it favoured the visualization of the biliary tract anatomy. all cases were completed with laparoscopic technique. there were no intra-and post-operative complications. icg-enhanced fluorescence is a safe, effective, cheap and rapid tool that can also be applied in small hospitals with no need for training. its use does not extend the time of surgery and allows the visualization of the anatomy of the biliary tract, especially in situations where it can be altered by reducing the conversion rate and potentially the risk of iatrogenic lesions of the main biliary tract. case presentation: patient is a year old female with no significant past medical or surgical history presented to the emergency department with a day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and po intolerance. the pain started a few months prior, however it was self-limited with diet modifications. an ultrasound demonstrated a contracted gallbladder with a mm gallbladder wall. white blood cell count was within normal limits and total bilirubin was slightly elevated to . mg/dl. no palpable mass was noted on physical exam. an mr cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring . x . cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. the patient proceeded with a laparoscopic cholecystectomy. intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. the gallbladder was subsequently removed without any complications. patient's remaining hospital course was uncomplicated. surgical pathology returned demonstrating acute on chronic cholecystitis. discussion: cholecystomegaly or 'giant gallbladder' disease is a rare pathology encountered in the surgical world. there have been few reported cases, most of which occurred in the elderly ([ years). kuznetsov et al. defined an enlarged gallbladder to have a volume of - cc and a giant gallbladder as exceeding cc (the average weight of the liver). the etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. preoperative imaging, such as mr cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. the cause of cholecystomegaly still remains uncertain and warrants further research. the management and treatment remains similar to acute cholecystitis. aims: mini-laparoscopic cholecysectomy (mlc) is considered to be the best variant of minimizing surgical trauma and improving cosmesis in laparoscopic cholecystectomy. the most challenging techniqual step of mlc is clipping the cystic duct. it may be impossible or unsafe when diameter of cystic duct exceeds mm, which is common in severe chronic colecystitis or acure cholecystits. there is very limited data in the literature about the use of mlc in acute cholecystits. the aim of study was to access the first results of new technique of mlc. methods: five women with the mean age of years ( - ) underwent mlc. the st -mm troacar was inserted in the umbilicus and used for the camera and removal of the gallbladder. the nd -mm troacar was inserted in subxyphoidal area and used for the main working instruments, including medium-large polymer clip-applier (hem-o-lok type). the rd and th -mm troacars were placed in right subcostal area and used for mini-graspers (karl storz). in initial procedures we used conventional -mm clip-applier with adopted medium-large titanium clips. to improve safety, we aplied -mm hem-o-lok type clip-applier for the last patient with acute cholecystitis. in this case the diameter of cystic duct was , mm. the clipping was performed successfully. the -mm drain was placed via subcostal troacar incision. also, in this case we applied original technique of removal of the bladder using wound retraction instrument (karl storz). results: in all the cases there were no intra-or postoperative complications. the mean duration of procedures was min ( - min). the postoperative stay was days in every patient. the patients estimated their pain on postop day as 'almost absent' and cosmethic results mo postop as 'exellent'. conclusions: . new technique of mlc alowed to perform the clipping of cystic duct safely, which is essential in acute calculous cholecystitis. was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as cholelithiasis included in the study and were planned either for mini-laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy were explored for outcome while the patients with empyema gallbladder, gangrene, mucocele gallbladder and adhesions were excluded from the study. results: during one year study period, total five hundred patients were diagnosed as cholelithiasis with means age . ± . (sd). of five hundred, ( . %) were underwent for mini-laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), excellent cosmetic results, mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), minor oozing ( . %), port size hernia ( . %). remaining ( . %) were underwent for conventional laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), port size hernia ( . %) along with zero ( %) mortality. conclusion: it has been concluded that mini-laparoscopic cholecystectomy is superior and feasible than conventional laparoscopic cholecystectomy and has decreased early postoperative incisional pain, avoided late incisional discomfort and safe procedure with nearly scarless wounds with superior cosmetic effect especially for young female patients. objective: to determine the outcome of immediate versus late laparoscopic cholecystectomy in acute cholecystitis at tertiary care hospital hyderabad / jamshoro sindh pakistan patients and methods: the descriptive case series study of one year ( - ) was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as acute cholecystitis (cholillthiasis) included in the study and were planned for laparoscopic cholecystectomy and were explored for outcome as immediate (within h) and late components ([ weeks). the frequency and percentage was calculated for categorical variables and mean ± sd was calculated for numerical variables. as this was descriptive case series so there was no any statistical test of significance was applied. results: during one year study period, total one hundred patients were diagnosed as acute cholecystitis with means age . ± . (sd). of one hundred, % were females and % were males. the immediate outcome reported as tissue fragile %, pancreatitis %, slipage of ligature of cystic duct %, empyema gallbladder %, mucocele % and gangrenous gallbladder % while the late outcome reported as adhesions %, cholecystoduodenal fistula and mirizzi syndrome % and %, gallstone ileus %, perforated gallbladder % and cholidochiolithiasis % while the mean ± sd for hospital stay (days) in immediate as . ± . while in late outcome (days) during acute cholecystitis . ± . and after surgery ( weeks later) as . ± . respectively. conclusion: it has been concluded that early lc for acute cholecystitis with cholelithiasis is safe, low cost and feasible intervention and offering the additional benefit of shorter hospital stay and reduce the economical burden. surg endosc ( ) :s -s general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan background: the treatment of common bile duct (cbd) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. a minimally-invasive approach choledocholithotomy is feasible, but can be difficult and converted for the unclear anatomy of the biliary tree. near-infrared (nir) cholangiography by systemic administration of indocyanine green (icg) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. nir fluorescence cholecysto-cholangiography by direct biliary tree administration of the icg can enhance the biliary tree without background noise signal. we created the nir cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application. material and method: ten patients who suffered from obstructive jaundice due to cbd stone and patients received percutaneous biliary tree drainage as first treatment and patients received endoscopic biliary tree drainage. those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. patients received biliary tree icg injection via drain tube and patients by systemic injection. visualization and fluorescence patterns around cbd was recorded. results: in our series, one patient received previous gastrectomy and patients had previous biliary tree surgery. background: laparoscopic cholecystectomy (lc) has become the gold standard for the treatment of gallstone disease. multiple studies have confirmed its safety, lc at index admission is still not widely practiced in ireland. we present our experience in performing index cholecystectomy at cuh after the start of acute care surgery program in may . aim: the aim of this study is to determine the safety of laparoscopic cholecystectomy at index admission, complications,re-admissions, and los. methods: electronic records, theatre records and imaging reports were searched to enroll all patients who underwent lc for gallstone disease at index admission from may to october . patient demographics, indication for surgery, postoperative complications, readmission and conversion rate were recorded.in addition timings of mrcp and ercp, imaging findings, and los were also noted. results: a total of patients underwent lc during the study period. median age was years ( - ). male to female ratio was : . . ( %) patients had acute cholecystitis, ( %)had acute biliary pancreatitis, ( . %)biliary colic and ( . %) had cholecystitis with signs of cbd obstruction. ( . %)patients had obstructive jaundice and one with adenomyomatosis. patients ( %) had preop mrcp while ( %) underwent pre-op ercp. all except patients undergoing ercp had preprocedure mrcp. patients had pre-op cholangiograms. in terms of complications, ( . %) patients had bile leak and one( . %) had re-operation. one patient had the post-op hematoma which was drained percutaneously, one patient had procedure abandoned because of bradycardia upon induction of anesthesia. there was no common bile duct injury, no conversion to open and no days mortality was reported. the average length of hospital stay has been days. ( to days). conclusions: laparoscopic cholecystectomy at index admission for cholecystitis, choledocholithiasis, and biliary pancreatitis, has been a safe and feasible treatment option in our hospital. a safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-led service. index cholecystectomy service can be provided safely across the country to prevent diseaserelated morbidity and multiple re-admissions in patients awaiting interval surgery. when to use the two-stage surgery to treat choledocholithiasis: the size aims: the treatment of choledocholithiasis has been provided by various of studies worldwide. the most common accepted minimal invasive treatment was two-stage treatment using endoscopic retrograde cholangiopancreatography before or after laparoscopic cholecystectomy(ercp ? lc), and one-stage treatment with laparoscopic exploration of the common bile duct(lcbde). in fact, despite several large studies have been published in recent years, the debate for the ideal treatment of choledocholithiasis is way from being concluded. we aim to find the proper treatment option for the patients with variable sizes of choledocholithiasis. methods: we retrospectively analyzed patients who underwent treatments for cholidocholithiasis in our institute between january , and july , . the patients who received either ercp and lc in the same admission, and the patient who received lcbde, irrespective of trans-cystic(ltcbde), or choledochotomy(lcd), were included. the data was analyzed with chi-square test and mann-whitney u test. results: the stone size of the ercp ? lc group is significantly smaller than the lcbde group. we further analyzed the ercp failure case, and the group of stone size [= . mm has a significantly higher rate of procedure failure. the failure rate is increasing with the stone size. conclusions: both the treatment of lcbde and ercp ? lc have similar safety and success rate, and the rate of residual stone was also similar in both group. however, the failure rate for ercp is significantly increased when stone size is larger than . mm in this study. aims: the xanthogranulomatous cholecystitis (xc) is a rare entity that can cause doubt in the choice of surgical treatment, because of differential diagnosis with gallbladder carcinoma (gc). methods: a -year-old patient presented acute abdominal pain in the right upper quadrant, nausea and low-grade fever with signs of peritonitis. he had elevated pcr, leukocytosis with neutrophilia. abdominal ultrasound showed an acute xanthogranulomatous cholecystitis. a laparoscopic cholecystectomy was decided but it was converted to open surgery due to the difficulty in the dissection, with fundus embedded in the hepatic bed and intraoperative finding of hilar adenopathic conglomerate .the postoperative period was torpid, with abdominal pain, jaundice, elevated bilirubin and enzymes of cholestasis. postoperative abdominal tomography showed injury in the iv segment of the liver suggestive of neoplasia. metastatic adenopathic conglomerate at the hepatic hilum caused extrinsic biliary obstruction with hepatic failure later so an internal-external drain was placed in the bile duct. the patient was died a week later. the pathological anatomy reported a stage four of gc. results: xc is a rare, non-neoplastic, inflammatory and destructive entity of the gallbladder wall, considered a variant of chronic lithiasic cholecystitis. it may be due to extravasation of bile or ulceration of the mucosa, causing an inflammatory reaction and fibrosis, with xanthomatous cells. the prevalence is to % in the resected gallbladders. it is more frequent in - years oldfemales. its clinical presentation does not have specific characteristics that differ from cholelithiasis, except for the weight loss. radiologically it is characterized by nodular thickening and increased attenuation of the vesicular wall with signs of cholecystitis, indistinguishable from a vc. the xanthogranulomatous inflammatory foci infiltrate the hepatic parenchyma, having an invasive behavior; hence, it mimics a neoplastic disease. the confusion in diagnostic and the risk of gc (up to %) makes treatment contentious. conclusions: the xc can simulate an advanced gc that sometimes makes us wonder if we should perform a radical surgical treatment; when presented in an emergency situation, our therapeutic decision can focus on solving the acute problem and be conditioned by the patient's general condition. single port transumbilical laparoscopic surgery (sptls) is a techinque that has been around for about years. although the enthusiasm for this type of surgery seems to have diminished in recent years it is expected to rise considering the recent development of sophisticated devices for its execution . we report retrospectively our year experience with procedures performed by sptls technique. in a private practice setting in mexico city. procedures include cholecystectomy ( ), appendectomy ( ), inguinal hernia tapp and tep ( ), hiatus and esophageal ( ) , sleeve gastrectomy ( ), colon ( ), gyn ( ) . different access platforms were employed. we explain our selection criteria for the application of the technique and describe the evolution of the instruments employed during the past years, from laparoscopic conventional to curved and bendable; regular scopes to extra long telescopes with different angles. or time, top bleeding, conversion rate, the need to employ an extra trocar, complications, pathology reports, scheduled or urgent kind of surgery and length of hospital stay were recorded from the beggining; patients variables such as bmi, asa status, tep risk, satisfaction with the procedure and other were recorded . we describe the evolution of our technique, and our learning curve with cholecystectomies. we compare our group of sptls transvaginal assisted laparoscopic hysterectomy (tvalh) patients vs tvalh multiport patients. we explain the feasibilty, and efficiency of the procedure in our hands compared to other series. background: in japan, the severity of acute cholecystitis(ac) is assessed by the severity classification of the tokyo guidelines (tg ). the value of c-reactive protein (crp) is not included in the severity classification criteria. the first line treatment, according to tg , for mild (grade i) to moderate (grade ) ac is laparoscopic cholecystectomy, but laparoscopic surgery may not be feasible in some cases due to adhesion or local inflammation of the gall bladder. aim: the aim of this study is to assess the effect of crp on the open conversion rate in laparoscopic cholecystectomy for acute cholecystitis.method: we conducted a retrospective study. patients who were diagnosed with ac and treated with emergent laparoscopic cholecystectomy between june and may in our institution are included. we set the cutoff value for crp at mg/dl and compared the open conversion rate. secondary endpoints are amount of bleeding, operation time, post-operative course (peak in body temperature and inflammatory markers) and the frequency of complications according to the clavien-dindo classification. results: out of patients had a crp value greater than or equal to mg/dl. the median crp values for the crp \ group and crp = group were . and . , respectively. the open conversion rate of the crp = group was significantly higher than that of the crp \ group ( / , / , p = . ). the most common reason for these conversions was local adhesion ( / ) . there were no differences in the amount of bleeding, operation time, post-operative course, and frequency of complications with clavien-dindo grade ii or higher. background: reports about clinical value of fluorescent cholangiography using indocyanine green (icg) during single-incision laparoscopic cholecystectomy (silc) were increasing. we report clinical value and pitfalls of fluorescent cholangiography during silc for the patients with the infraportal type of the right posterior bile duct. methods: our silc procedure utilized the sils-port with an additional -mm forceps through the umbilical incision. before silc, ml of icg ( . mg) was administrated by intravenous injection. for fluorescent cholangiography, icg fluorescent laparoscope system was used. results: we performed fluorescent cholangiography during silc in patients with the infraportal type of the right posterior bile duct. all procedures were completed successfully. the interval from the injection of icg to the first obtained fluorescent cholangiography before the dissection of calot's triangle ranged from to min. detectability of infraportal type of the right posterior bile duct before dissection in claot's triangle was . % (n = ) and that during dissection in calot's triangle was . % (n = ). the infraportal type of the right posterior bile duct could be identified under fluorescent cholangiography only when it joined into the common hepatic duct. conclusions: utilization of fluorescent cholangiography can lead silc to safe even for the patients with the infraportal type of the right posterior bile duct. its benefit is emphasized when the infraportal type of the right posterior bile duct joins into the common hepatic duct. aims: due to the development of laparoscopic surgery and the progress made in surgical treatment ofhydrocephalus, surgeons may come across patients with ventriculoperitoneal (vp) shunt, as candidates for laparoscopic procedures. according to this fact, we report a case of an unusual complication of laparoscopy surgery that can appear in this kind of patients. methods: we present a case of a -year-old man with medical history of normotensive hydrocephalus with vp shunt, that came to the emergency room complaining of abdominal pain and fever since two days. blood test showed an elevation of infection parameters and inflammatory markers, and the ultrasound study revealed an emphysematous cholecystitis. therefore, we decide to carry out an emergency laparoscopic cholecistectomy. the patient did not present any adverse event during the surgery or the immediate postoperative period, being discharged the third postoperative day and evaluated ambulatory one month after the surgery with no complications. two months after surgery, the patient returned to the emergency room presenting alteration in consciousness and fever. results: during the study of the pacient, an abdominal ct was performed, showing a complete section of the vp shunt in the subcutaneus space of the upper abdominal wall and intraperitoneal migration of the remaining catheter. the patient was transferred to neurosurgery to carry out an emergent replacement of the ventriculoperitoneal shunt. after surgery and intravenous antibiotic treatment, the patient evolved favourably and was discharged a few days later. conclusions: the rate of serious complications associated with a laparoscopic approach is overall low and up to % of them occur during the abdominal access for camera or port placement and may not be recognized until postoperative period. vp shunts should not be a contraindication for laparoscopic surgery. however, laparoscopy approach must be carry out with good anesthetic and monitoring facilities and taking several previous considerations, such as verifying the proper functioning of the vp shunt, identifying the path of the catheter within the abdominal wall to avoid inadvertent damage to the catheter during trocar placement and ensuring that the intraperitoneal portion of the catheter is not twisted or obstructed prior to decompression of the abdomen. surg endosc ( ) introduction: since advantages of robotic surgery is being more emphasized, robotic cholecystectomy (rc) cases are increasing. ajou group had introduced a method called which technique places the trocars transversally on the bikini line and it makes cosmesis and pain beneficial. however, rc with low incision port has several limitations. therefore, we changed port placement which may be a one of safe tehniques for rc. method: this study retrospectively reviewed data for patients who received rc with port changing method (rcpc, n = ) and rc with low incision port (rcli, n = ) from february -february and surgical variables were analyzed. results: patients in both groups had similar demographic features and indications for surgery. the rcpc group required no conversions to conventional robotic surgery and no additional operation, whereas the rcli group had one incisional hernia ( . %) and two bowel perforation ( . %) cases. length of stay ( . ± . vs. . ± . days, respectively; p = . ) did not significantly differ between the rcpc and scli groups. however, the rcpc group had shorter operative time ( . ± . vs. . ± . min; p = . ) than the rcli group, although the parameters mentioned above were not statistically significant. conclusion: robotic cholecystectomy with bikini line incision has some limitations even though it has cosmetic benefits. whereas robotic surgery with changing port method is one of safe and feasible procedures for performing robotic cholecystectomy. also nothing more to say that it gains cosmesis effect and escapes complications. mini surgery, odessa medical university, odessa, ukraine the aim of the study was to optimize the diagnostic and therapeutic tactics for yatrogenic injuries of the extrahepatic bile ducts. methods: patients were examined. typical manifestations were jaundice, cholangitis, biliary peritonitis, external biliary fistula, subhepatic abscess.cholecystectomy main cause of damage.a visual, manual and x-ray examination of the hepato-choledochus and cholangioscopy were performed. ultrasound, endoscopic retrograde cholangiopancreatography, fistuloholangiography or percutaneous transhepatic cholangiography play a leading role in diagnosing. the results: high damage to the bile duct was detected in . % of patients, low-in . %.percutaneous transhepatic drainage under ultrasound control was performed in . % of patients.emergency laparotomy, sanation of the abdominal cavity and external drainage of the bile ducts were performed with bile peritonitis. recovery operations produced . % of patients. reconstructive interventions were performed in . % of patients after - weeks after the first stage. the covery operations were successful in . % of patients. . % of the sick had complications in the form of biloma. a scar stricture formed in . % of patients after - months. patient underwent recanalization of the stricture zone with a dilatation balloon through interchangeable transhepatic drainage. balloon dilatation was performed retrogradely through the large duodenal papilla in patients. deaths in the postoperative period was not observed. conclusions: the surgical team should be strengthened by an experienced surgeon when intraoperative diagnosis of yatrogenic damage to the bile ducts.the operation should be completed by external drainage of the bile duct and the abdominal cavity in the absence of an experienced specialist.recovery operations are shown only with lateral injury of the ducts.the patient must be sent to a specialized institution for radical surgical treatment after stabilization of his general condition. aim of the study sub-hepatic bile collections, biloma and hematoma are rare complications and we present our experience in treatment this complications. material and methods: from laparoscopic cholecystectomy performed in our clinic, three patients (two women and one men) to whom it was performed laparoscopic cholecystectomy, came back two weeks later after they were released from the hospital because of epigastric discomfort, fever and nausea. results: clinical examination after rehospitalization showed tenderness in the epigastrium and right subcostal region. in all patients were measured high levels of leukocytosis and crp . an ultrasound examination of the abdomen revealed a large hypoechoic collection in the sub hepatic space, after the abdominal ct scan was performed, the density of the collection did not indicate the presence of blood in two patients. percutaneous drainage of the collection in both patients was realized under us guidance and - fr catheter was inserted in the sub hepatic region. in the first patient cc of bile-stained liquid, and in the second patient cc of biliary liquid was drained. in a third patient h after surgery signs of significant hypotension and limited tenderness at the right subcostal region occurred. a complete blood count (cbc) showed a decrease in the level of haemoglobin to . g%. ultrasound examination revealed a fluid collection in the sub hepatic space, which is also confirmed by computed tomography. laparotomy was performed and the large sub hepatic hematoma was evacuated. after that the fr abdominal drain was inserted into the sub hepatic space. the postoperative course of all three patients was not complicated. conclusion: sub hepatic biloma and hematoma are rare complications of laparoscopic cholecystectomy, while early diagnosis followed by percutaneous drainage or open laparotomy is the only way to resolve these complications. ( ), hemoperitoneum . % ( ) . the average number of days of hospitalization was . days. there was no mortality at days. conclusion: in the emergency setting the rendezvous technique has an adequate success rate of cannulation and clearence of the bile duct, an acceptable surgical time, few complications, these being more frequent in those patients with inflammation of the gallbladder and without associated mortality at days. there is a need for controlled randomized studies with a greater number of patients recruited and follow-up to determine the usefulness of this technique. intraoperative cholangiography could serve as a fundamental solution to avoid the bile duct injury during laparoscopic cholecystectomy. however, it is difficult to identify the cystic duct to which the contrast catheter should be inserted in cases with high degrees of adhesion around the calot's triangle. in these cases, it is not possible to conduct cholangiography from the cystic duct. for these types of cases, intraoperative cholecystography may serve as an option. however, since the bladder is a bag-like organ that expands when liquids are entered, directly inserting a contrast dye into the bladder would make the bladder itself expand, which makes it impossible for to maintain enough pressure in the contrast dye to flow into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct. also, since it is difficult to control leakage of the contrast dye from the catheter insertion site, it is not possible to obtain enough images to sufficiently understand the anatomical characteristics of the bile duct in many cases. therefore, cholecystography is not generally recognized as a method to be used during surgery. in our facility, we insert the contrast catheter through the bladder after stretching the gallbladder neck as much as possible, hold the gallbladder neck with a removable intestinal clamp, and then apply the contrast dye to the bile duct. through this method, it is possible to insert enough contrast dye into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct to understand the anatomical characteristics of the bile duct, allowing us to obtain appropriate images of the biliary tract. because this method uses equipment that is highly versatile, we believe that it is inexpensive and convenient. during this presentation, we will also conduct a case presentation of the methods of bladder contrasting that we utilize in our facility during laparoscopic cholecystectomy. introduction: retrieval of a thick walled gallbladder during a difficult laparoscopic cholecystectomy (lc) for an acute or chronic calculous cholecystitis can be exasperating. it increases operative time and often necessitates enlargement of mm port to deliver the specimen. the 'in-situ cholecystotomy', which we wish to call the 'delhi maneuver' is very helpful in improving the ergonomics of specimen retrieval, saves time and conserves cosmesis. patients & methods: one hundred and ten patients of acute or chronic calculous cholecystitis were placed randomly in groups. a disposable transparent plastic bag was used in all cases to retrieve the gallbladder specimen through the - mm port using a rampley's sponge holding forceps. retrieval was done using conventional technique in patients (group b). the delhi maneuver was used in the remaining patients (group a). it involved cutting the gall bladder inside the plastic bag in a certain fashion, delivering the gallstones in the bag, and removal of gallbladder preceding the stones. the retrieval time, number of insertions of sponge holder, any rupture of plastic bag as well as the number of cases needing port enlargement were noted. results: the average time taken by delhi maneuver (group a) was min as compared to was min by conventional method (group b). the number of insertions of sponge holder ranged from - in group a (mean ) and - in group b (mean ). four patients needed port enlargement in group a ( %) while patients needed enlargement in group b ( . %). there were incidences of bag rupture in group a ( %) and in group b ( %). the delhi maneuver improved the ease and speed of specimen extraction at laparoscopic cholecystectomy for thick walled gallbladders. it also decreased the need for port enlargement for specimen retrieval. the bile duct injuries are a very complex desease to confront, the inciian managment is to clasificate the injury and to identifie the mechamism of the injury. it's important for the optimal heal of the patient to have a multidisciplinary approach including internal medicine, surgery, endoscopy and interventional radiology specialists. the laparoscopic cholecystectomy responsible for %- % of them.this is a retrospective study on the incidence, classification and management of bile duct injuries in a private sector hospital in monterrey nl. mexico. in this study, bile duct injuries were identified in years of experience in a single center. were categorized using the strasberg classification. variables were evaluated such as type of injury, mechanism of injury, hospital stay, if the surgery was scheduled or of emergency, the moment in which the surgeon evidenced the injury, the way in which the surgeon became aware of the injury performed. the type of management that was given to this lesion was also studied and the days of intrahospital stay and the number of reinterventions or procedures performed were compared.the average age of the patients was years, patients belonged to the female sex, although there were lesions of all kinds in this work, there was a greater incidence in strasberg type a lesions, which represented % of the lesions. the most common diagnosis presented was cholecystolithiasis. in surgeries the evidence and repair of the bile duct was in the same intervention aims: bile leak is a rare but recognised complication after laparoscopic cholecystectomy. this usually occurs after a difficult procedure complicated by adhesions, unusual anatomy or if the surgeon is inexperienced or unfamiliar with the anatomy. this video aims to demonstrate the laparoscopic diagnosis and treatment of this complication particularly for surgical trainees. methods: we report a case of significant bile leak occurring soon after a straightforward laparoscopic cholecystectomy due to very short cystic duct (cd). the procedure was carried out uneventfully but the cd was clipped flush with the bile duct. the patient was discharged on the day of surgery feeling well but readmitted with abdominal pain h later. results: after readmission the patient underwent a ct demonstrating only a small amount of fluid suggestive of a small collection. she was treated conservatively but suddenly deteriorated and a repeat ct confirmed significant intraperitoneal fluid. a diagnostic laparoscopy was carried out urgently confirming a cd stump bile leak where the clips had sloughed off causing the leak. two litres of bile was aspirated with copious irrigation and a latex t-tube inserted into the cbd. patient made a full and rapid recovery. conclusions: this is a rare complication and learning opportunities for trainees are therefore infrequent. this video demonstrates a successful laparoscopic approach to management of postoperative bile leak showing t-tube insertion technique and highlighting the need for careful cd closure techniques during laparoscopic cholecystectomy when the duct is very short. about - % of bile duct stones could not be extracted using conventional endoscopic techniques (baloon, sphincterotomy). there is lower success rate in elderly patients; among the biggest challenges are intrahepatic stones, size of stone is large, etc. aims: to present the case of a recurrent intrahepatic lithiasis and its management using spyglass choledochoscopy.to expose, other cases and the main outcome and complications of other difficult cases of bile duct stones that solvedusing this choledochoscope vs. the traditional one and the beneffits. we present a case of years old male who presented with cholangitis caused by an intrahepatic stone that required multiple sessions of endoscopic retrograde cholangiopancreatography with spyglass for clearance. one year later, he presented again with cholangitis, that required another session of spyglass lithotripsy and cholecistectomy. conclusions: besides ercp, there are different approaches to treat difficult bile duct stones, as transhepatic percutaneous drainage, surgical techniques, or other endoscopic techniques (doubleballoon, enteroscopy). ercp and sphincterotomy are the first step of endoscopic treatment with more than % of success rate, and a low mortality and morbility rate; other steps include some lithotripsy techniques, or the use of biliary stent as a bridge before definite treatment. spyglass is a visualization & intervention system used when common ercp has been unsuccessful, and it is first line for better and direct image of biliary ducts, with °range of motion, with multiple advantages like the concomitant use of lithotripsy devices. aims: the number of elderly people has increased, because of the strong association between age and gallstone disease, both prevalence and incidence of this disease are increasing. this presentation aims to review our current management options of octogenerian patients with acute cholecystitis. methods: we retrospectively analyzed octogenerian patients who were admitted to the our hospital with the diagnosis of acute cholecystitis between january and october . the patients were initially allocated to four different treatment groups as follows: immediate surgery, delayed surgery, medical treatment and cholecystostomy. differences in the outcomes between the treatment groups were evaluated. results: there were males ( . %) and females ( . %) with a mean age of . years (range - years). the patients had different co-morbid diseases, especially hypertension ( , . %) cardiovascular disease ( , . %) and diabetes mellitus ( methods: a retrospective observational study where were analyzed patients older than years who underwent urgent surgery for ac who fulfilled an indication for surgery according to tokyo guidelines . the type of cholecystitis, stay and postoperative complications, the type of intervention, the conversion rate, the need for reoperation and re-admissions in patients older than years were analyzed and compared with those of patients operated on for cholecystitis younger than years. outcomes: a total of patients were registered, older than years ( %) and younger ( %). in cases, cholecystitis were complicated ( . %), cases older than years ( . %) and in cases younger than years ( . %). the approach was laparoscopic in % of the cases older than years, with a conversion rate of . %, not finding statistically significant differences with younger than years ( % laparoscopies with . % of conversions). % of patients older than years had some type of postoperative complication, not finding statistically significant differences in patient younger than years ( %); being the most frequent complication the intrabdomintal abscess ( . % of patients [ years, and . % of those \ years = '' span = '' [ being not statistically significant with % ci. any patient older than years required re-entry after discharge, compared to patients younger than years who were re-entered, not being statistically significant; and any patient older than years required reintervention, while it was necessary to reoperate patients younger than years ( %), being not statistically significant. mortality was very low, finding case in older than years ( . %) and case in younger ( . %), not obtaining statistically significant differences. the postoperative stay in patients younger than years of age has a median of days and in older than years a median of days, not finding statistically significant differences with % ci conclusions: laparoscopic cholecystectomy is safe and effective in the treatment of elderly patients with (ac), there being no differences with younger patients. introduction: significant bile leak is an uncommon but serious complication of laparoscopic cholecystectomy. our study aims to evaluate the efficacy of relaparoscopy in treating symptomatic bile leak and biloma formation. material and methods: patients presenting with postoperative bile leak after different operations on extrahepatic biliary tree from january to december were reviewed retrospectively (in total, , laparoscopic surgical interventions were performed for the period under study). the sites of bile leaks were the cystic duct stump in thirty seven patients, the bile ducts of luschka in fifty two, liver beds in cases after hepatectomy, in had small injury of cbd, and seven patients with tubular stenosis of the common bile duct. results: three main approaches of mini-invasive treatment of bile leakage was used: ( ) percutaneous puncture with or without drain under ct-scan or ultrasound guidance in patients; ( ) endoscopic management in patients (in patients ( . %) were managed with ercp alone and fifteen ( . %) were treated with a percutaneous intervention followed by ercp. endobiliary stent placement was performed after es in patients and without es in twenty seven patients ( ) relaparoscopy has been performed in patients, in cases of biliary peritonitis. conclusions: relaparoscopy was the ultimate method of treating postoperative complications of laparoscopic surgery in . % of patients. in general, this method, as well as laparoscopic intervention, is highly effective in the diagnosis and correction of postoperative complications, with minimal surgical trauma for the patient, with great therapeutic effect and subsequent rapid social rehabilitation of patients. introduction: laparoscopic operations have already become routine, even for pancreatoduodenectomy for periampular cancer. for unresectable cases, endoscopic bibliary stenting or hepaticojejunostomy are usually used. these methods are quite expensive and may be accompanied by complications. materials and methods: laparoscopic cholecystogastroanastomosis was performed in patients with unresectable periampullary cancer. there were females and men and average age was , . the indications for surgery in all patients was unresectable periampullary cancer and biliary hypertension with preserved patency of the cystic duct. the level of bilirubinemia ranged from to lmol/l (the average level was , lmol/l). we used -port technique. optical trocar was placed in the right iliac region, one mm above the navel and one mm in the right hypochondrium after punction gallblaber and aspiration of bile, we cut the apex of the gallbladder and gastric antrum up to . cm and performed cholecystogastroanastomosis with barbed-suture v-loc. results: we had not conversion to open surgery. the average operation time was min. postoperative stay was average days and on median follow-up of month. post-operatively, there were no major morbidity and nil mortality. we had cases of leakage of bile through drainage for up to - days, which spontaneously stopped. all patients showed a decrease in the level of bilirubinemia. patients were later radical operated (pancreatoduodenectomy), while they did not have such phenomena as cholangitis, pancreatitis, inflammation of the hepatoduodenal ligament elements, which we often observe after endoscopic biliary stenting. conclusions: laparoscopic cholecystogastroanastomosis is safe, effective and feasible for patients with periampular cancer and obstructive jaundice. aims: surgeons with the expertise and resources to perform laparoscopic common bile duct exploration often prefer the 'one stage approach' over endoscopic retrograde cholangio-pancreatography (ercp) for the management of common bile duct (cbd) stones. this case series aims to evaluate the effectiveness of lcbde in a single benign upper gastrointestinal (gi) unit. methods: all patients with suspected and confirmed pre-operatively cbd stones who underwent a lcbde between january and october were included. lcbde was performed on the basis of pre-operative suspicion of cbd stone confirmed by intra-operative imaging. results: patients with confirmed choledocolithiasis had lcbde during this time period. the indications for lcbde were deranged liver function tests, dilated cbd or confirmed stones on preoperative imaging. median age was (range - ), % of whom were female. % of patients had confirmed cbd stones pre-op. % of cases were performed as emergencies and conversion rate to open was . %. choledocotomy was performed in % of cases. in % of these t-tube was left in situ. transcystic approach was used in the remaining %. despite positive intraoperative imaging no stones were found on cbd exploration in cases ( %). in patients stones were unable to be cleared with lcbde. the overall morbidity was %. % of patients had gallstone related complications. overall mortality was % (due to bile leak). / patients required re-intervention with re-look laparoscopy (n = ) or ercp (n = ). patients re-presented within months with cbd stones. overall median length of stay was days. conclusions: our case series demonstrates that lcbde is an effective and safe treatment for choledocolithiasis in both the elective and emergency settings. complication rates are comparable with therapeutic ercp ( % specific complications) followed by laparascopic cholecystectomy ( % day morbidity). the variability in anatomic location of subvesical bile ducts puts them in danger during hepato-biliary operations. its prevalence varies between % and %. the origin and drainage of these ducts were limited mainly to the right lobe of the liver, but great variation could be seen. some authors think of them as small bile ducts that drain directly into the body of the gallbladder; others consider them to be networks of miniscule bile ducts between the liver capsule and the gallbladder. recent studies suggest that clinically relevant bile leaks complicate approximately . - . % of cholecystectomies. injury to a subvesical duct is one of the most common causes of cholecystectomy associated bile leak and occurs as often as major bile duct injuries and leaks from the cystic duct stump. indeed, recent studies suggest that about % of clinically relevant bile leaks are caused by inadvertent injury to a subvesical bile duct. there are four types of subvesical bile ducts, including ( ) superficial variations of segmental and sectorial bile ducts, ( ) superficial or intercommunicating accessory bile ducts, ( ) hepaticocholecystic ducts, and ( ) aberrant bile ducts.we present a case of year old patient who developed a coleperitoneum after a routine daycase colecystectomy due to the inadvertent injury of a hepatocholecystic duct. a superior comprehension of ductal anatomy is essential in preventing and managing operative injury to the subvesical ducts, although some times is unavoidable. nowadays, the diagnosis of liver cancer is primarily radiological, as recommended by the principal international societies. in doubtful cases or due to the clinician needs, diagnostic evaluations can eventually be completed with a liver biopsy. the goal is to perform the examination, or the examinations, that guarantee the most elevated sensibility and specificity levels being as little invasive as possible. nevertheless, even using the best radiological tools, the diagnosis is not certain, due both to device limitations and radiology experience. recently, various diagnostic algorithms have been proposed, relating with contrast enhancement characteristics, different radiological techniques, blood examinations and cross evaluations from different radiologists. one of the most recent algorithm purposed is liver imaging reporting and data system (li-rads), that evaluates ct and mri imaging to classify hepatic lesions in different diagnostic categories, in order to perform a better and more precise diagnosis of hcc or other liver benign or malignant lesion. through a retrospective study, we evaluated and compared preoperative imaging and post-operative histological reports. results reveal that li-rads routine use increases hcc diagnosis up to %. background: we previously developed a modified difficulty scoring system (dss-ihd) of laparoscopic liver resection (llr) for patients with intrahepatic duct (ihd) stone. we validated dss-ihd in patients who underwent llr for hepatolithiasis. methods: dss-ihd was based on the extent of liver resection ( to ), stone location ( to ),atrophy of liver parenchyma ( to ), ductal stricture \ cm from the bifurcation ( to ), and combined choledochoscopic examination for remnant ihd ( to ). results: the dss-ihd ranged from to and divided to -level groups of low group (score * ; n = ), intermediate group ( objective: improving the surgical treatment of patients with cholangiogenic abscesses of the liver through the application of minimally invasive technologies. material and method: in the presented study presented results of treatment of patients with biliary liver abscesses. surgical interventions for hepatic abscesses were performed simultaneously with the elimination of the primary pathological process of the biliary system, which caused the occurrence of cholangitis, or in the near future (up to days) after biliary drainage drainage. among patients with biliary liver abscesses, treated with minimally invasive methods, revealed abscesses of the right hepatic lobe, -abscesses of the left hepatic lobe, -abscesses and right and left hepatic lobes. single abscesses were detected in patients, and in -two or more abscesses. in terms of liver abscesses, more than cm were detected in patients, more than cm in patients. drainage of the biliary tract was carried out endoscopically transpapillary and (if the endoscopic approach was unsuccessful) with transcutaneous transhepatic approach. results: drainage under ultrasound guidance was performed on patients with solitary and patients with two or more cholangiogenic abscesses of the liver. laparoscopic interventions were performed on patients. among the patients operated on using minimally invasive technologies, occurred complications ( . %). patient died due to the development of biliary sepsis ( . %). conclusion: percutaneous drainage of liver abscesses under ultrasound control is appropriate not only for single abscesses, but also for their larger number, which has many advantages over other interventions. it was proved possibility of simultaneous drainage of liver abscess and bile duct. percutaneous drainage of the liver abscess, drainage of the biliary tract and laparoscopic surgical intervention are complementary aspects in the treatment of liver abscesses of biliary origin. after laparoscopy residual calculus can be removed endoscopically in more favorable conditions after stabilization of the patient's condition is achieved and the infection-associated disorders are eliminated. in case of localization of abscesses in the marginal segments of the liver, laparoscopic atypical resection of the liver with an abscess is most desirable. general surgery, rambam medical center, haifa, israel background: recently robotic surgery has emerged as one of the most promising surgical advances. despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (hbp) surgery remains relatively unexplored. our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies. methods: a retrospective analysis of a prospectively maintained database on clinical outcomes was performed for consecutive patients that underwent robotic assisted surgery for benign hbp disease at rambam medical center during - . results: there were robotic assisted surgical procedures performed for benign hbp pathologies during the study period. there were anatomical robotic liver resections for symptomatic hemangiomas, cases of giant liver cyst, robotic assisted surgery for type i choledochal cyst, case of benign (iatrogenic) common bile duct (cbd) stricture, cases of robotic (cbd) exploration due to large intra choledochal stones and cases of cholecystectomy for cholelithiasis. the median postoperative hospital stays for all procedures were . days (range - days). general morbidity (minor) was %. there was no mortality in our series. conclusion: robotic surgery is feasible and can be safely performed in patients with different benign hbp pathologies. further evaluation with clinical trials is required to validate it's real benefits. most liver cysts are asymptomatic and tend to have a benign clinical course. however, symptomatic or complicated liver cysts sometimes require surgical intervention. needle aspiration is safe and can be the lease invasive procedure, this procedure is however associated with a high failure rate and rapid recurrence. surgical approach is the crucial and provides definitive treatment for such cysts. thirteen cases were nominated from shonan kamakura general hospital between january and december . mean age and body mass index (bmi) were . and . , respectively. all patients have had any complaint such as upper abdominal pain, dyspnea, and fever. two cases were clinically diagnosed as the infectious cyst and serum crp was elevated before surgery. additional cholecystectomy was planned for one case of chronic cholecystitis with gallbladder stones. all cases were prompted the reduced port surgery (rps) and cases were performed rps with trans-vaginal approach (hybrid notes) and case was chosen in single port surgery. cyst unroofing was performed for all cases. mean operation time and blood loss of all cases were . min. and . ml, respectively. no surgical complication has been occurred in all cases, an infectious cyst case was however required additional drainage for infectious control after surgery. although statistic difference was not shown, fewer blood loss and shorter hospital stay was seen in non-infectious cases, compared to laparotomy cases. mean hospital stay after surgery of whole cases, non-infectious cases, infectious cases was . , . , . days, respectively . no recurrence of any symptom was shown in any cases in observation period ( - days) . laparoscopic unroofing is the definitive treatment for the complicated or symptomatic liver cyst. however, for the infectious cyst, infection control such as intensive drainage and/or administration of antibiotic before surgery may be needed to avoid additional treatment, leading to longer hospital stay. laparoscopic unroofing of liver cyst can be the first choice for symptomatic or complicated liver cyst. also, reduced port surgery can be nominated to achieve less invasiveness. introducction: laparoscopic liver resection (llr) has been increasing since it was first reported in . three international expert consensus conferences on llr surgery were held in louisville, ky, usa, in , morioka, japan in and southampton, uk, in . while most initial minimally invasive liver resections were typically done for benign lesions in anterior o left segments, llr is currently being applied for major anatomic resections, malignancy, cirrhosis and liver donor hepatectomy. clinical case report: this is a -year-old male patient with a history of hta and liver cirrhosis due to hepatitis b virus. hepatocarcinoma is diagnosed in liver segment vi with a size of cm . in the digestive study the patient presents a child a stage, meld \ , without signs of portal hypertension. complete analytical with normal afp and cea . markers. after presentation of the patient in a multidisciplinary committee and being a stadium according to the early bclc classification, laparoscopic surgery with segment vi resection was decided. discussion: laparoscopic liver resection is becoming widely accepted for the treatment of hepatocellular carcinoma. liver resection is a first-line option in very early and early-stage disease. many meta-analysis have shown that llr is better than open liver resection in terms of short-term outcomes for patients with child-pugh a cirrhosis, solitary tumors, and minor resections. in the long-term setting, the results demonstrate that a minimally invasive approach is comparable to an open approach in terms of overall. in conclusion, the current evidence conclude than llrs for hcc are safe and may be considered a standard practice in specific settings. results: there were women ( %) and men ( %). the age of patients ranged from to years. the patients underwent complex examination including abdominal ultrasound, esophagogastroduodenoscopy, and some of them underwent ct (computed tomography). all patients in the first stage were performed antegrade external drainage of biliary tracts with x-rays of the biliary tracts, and specifying the level and extent of the block.total miniinvasive interventions were hold. two patients in connection with the uncoupling of equity ducts were performed antegrade bilobar stenting with preliminary split external bile release.there were complications after carried out interventions in cases, which were associated with dislocation of holangiostomic drainage in patients ( . %); with acute cholecystitis in patient ( . %); with hydrothorax in patients ( . %); perihepatic biloma in case ( . %). patient ( . %) had a recurrence of obstructive jaundice due to germination of endobiliary stent in the late period after stenting. lethal outcome appeared in patient. conclusions: ultrasound examination allows us to determine the level of obstruction of the biliary tract, to substantiate the tactical position in the application of mini-invasive technologies. antegrade miniinvasive technologies in the treatment of tumor lesions of the proximal bile ducts allow timely and effectively stop biliary hypertension and to determine further treatment strategy. acknowledgements this study was supported by the russian science foundation under project ? - - . background: repeat hepatectomy is an effective treatment, with long-term surgical outcomes for recurrent hcc and colorectal liver metastasis(crlm). however, the efficacy of a minimally invasive surgical approach for recurrent liver tumor is not yet confirmed. the purpose of this study is to examine the efficacy of laparoscopic repeat hepatectomy(lrh) compared with open repeat hepatectomy(orh) for recurrent liver tumor. we retrospectively analyzed the clinicopathological features and short-term surgical outcomes between lrh and orh. methods: from to , patients with liver cancer underwent repeat hepatectomy. of those patients, patients underwent partial hepatectomy, patients were undergone laparoscopically, and patients underwent open hepatectomy. we compared the clinicopathological and surgical parameters in the lrh group with those in the orh group. results: there were no significant differences in patients' gender, age, viral infection status, child-pugh classification, tumor size, tumor number, and tumor location in the two groups. the operative times were similar, but blood loss was significantly lower in lrh group ( vs. ml, p \ . ). the postoperative hospital stay was significantly shorter in the lrh group ( . vs. . days, p = . ). postoperative complications(cd = a) were observed only in the orh group, with a complication rate of . %. conclusions: we demonstrate that lrh reduces blood loss and postoperative complications compared with orh. lrh might be a feasible and effective procedure for the selected patients. background: the liver is the most common site of metastatic disease with up - % of all cancers having the potentiality for sending liver metastasis during the disease. consequently, increasing value for surgical resection of hepatic deposits of different types of cancers, the need for accurate evaluation of the extent of hepatic metastasis was established for choosing the most suitable patients for surgery and in planning the extent of hepatic resection. the aim of this work is to evaluate the role of intra-operative ultrasound in the detection of hepatic deposits in intra-abdominal malignancies with special emphasis on its accuracy, sensitivity, specificity. patients and method: this study was carried out on thirty patients who were admitted to the gastrointestinal surgery unit, main alexandria university hospital with intra-abdominal malignancies for whom elective open surgical intervention was recommended in the period from st of september till the th of march . results: in the present study consisted of males ( . %) and females ( . %). their mean age at admission was . ± . years. six of the included patients ( %) were found to have hepatic lesions by using ious including the four cases ( . %) already detected by preoperative imaging. two cases ( . %) were newly discovered in the operative room by using ious. conclusion: the current study has proved that ious demonstrates superior lesion detection over the various non-invasive preoperative imaging modalities causing significant impact on change of the planned surgical strategy laparoscopic approach to the liver has become an integral part of surgery. two consecutive international consensus meeting recommends major hepatectomy has been on the expert hands. tumors located in the right posterior section are considered to be difficult for laparoscopic resection. patients and methods: since , until , cnuhh has been performing laparoscopic hepatectomies including major hepatectomies. among major ones, there are rh, lh, rps, ch, and as. we analyze data on patient demographics, tumor characteristics, operative date, and posterior outcome retrospectively. results: during - , laparoscopic rps were performed. the diagnosis were hcc in and crlm in patients. median operative time was min, and median blood loss was ml. no blood transfusion was occurred. median tumor size was mm, and median resection margin was . mm. six of the patients ( %) were cirrhotic on pathology. there was no conversion and was no postoperative mortality. median hospital stay was . days. conclusion: laparoscopic rps is known challenging procecedure. strict preoperative planning and operative procedure is mandatory. even though it should be performed by the experienced hands both on hepatic surgery and laparoscopic skill, it can be an good option for treatment of the tumor locating over right posterior section. purpose: previously we developed a new sponge (named endoractor) as an organ retraction device in laparoscopic surgery in and have reported that it is useful in various surgical procedures including rectal surgery we confirmed that it is also useful in laparoscopic radiofrequency ablation of the liver in terms of pulling and protecting organ, so we report it materials and methods: a case is an -year-old female with liver cirrhosis. she had primary hepatocellular carcinoma in s lesion with a diameter of . cm very close to the inferior vena cava and middle hepatic vein root and in s lesion with a diameter of . cm we thought she could not put up with hepatic resection because of her poor hepatic reserve capacity. and we could not expect treatment effect by embolization therapy since contrast effect was poor. so we decided to select ablation therapy in the puncture and ablation of the s tumor, since there was concern about the thermal damage of the middle hepatic vein and the cooling effect by the inferior vena cava, we would dissect the right coronary mesentery sufficiently and pull the liver apart from the inferior vena cava and the middle hepatic vein as much as possible using our endoractor also, in the puncture and ablation of the s tumor, it was feared that the stomach would be thermally damaged, so we would place endoclactor between the liver and the stomach to protect the stomach results: when ablating the s tumor, we could pull the liver securely without slipping, so we did not cause thermal damage to the middle hepatic vein. and there was no cooling effect by the inferior vena cava, so we could obtain sufficient cautery margin. in ablation of s tumor, we were able to puncture by stabilizing the lateral segment of the liver on our endoractor, and avoid thermal damage of the stomach conclusion: it seems possible to perform safe and reliable puncture and ablation by using our endoractor as well in laparoscopic radiofrequency ablation surg endosc ( ) surgical reinterventions in patients with complicated hepatic hydatid cysts usually occur as a result of diagnostic or technical failures during the initial procedure. according to recent studies, the most common complication after liver hydatid cyst surgery is local sepsis at the residual cavity and long-term biliary leak. we report the case of a -year-old male with a history of liver hydatid disease four years before the current episode, admitted in our surgical department for intense upper right quadrant pain. abdominal ultrasonography, ct and mri scans revealed three cysts in the gastrosplenic ligament, in liver segments vii-viii, and ii-iii respectively, sized between and cm. the intraoperative aspect during laparoscopy was strongly suggestive for liver hydatid disease. laparoscopic fenestration with tunneling for the hepatic cyst in segment viii, partial cystectomy in the left liver lobe and ideal cystectomy in the gastrosplenic ligament were performed. postoperatively, the patient displayed a constant biliary drainage output of - ml from the cavity remnant in the segment viii. conservative therapy for external biliary fistula and concomitant treatment with albendazole for months were initiated. evolution was slowly favorable with decreased biliary drainage to ml two months after surgery and complete symptom resolution five months after hospital discharge. aims: this study aimed to evaluate the effectiveness of fluorescence imaging with indocyanine green (icg) during laparoscopic deroofing of hepatic cysts. methods: this was a single-center, case-control study. we included patients who underwent laparoscopic deroofing between november and october . imaging with and without icg fluorescence was performed in (icg group) and (non-icg group) patients, respectively. icg was intravenously administered between min and . h before surgery. we performed a standard laparoscopic procedure. we detected a thin bile duct on the hepatic cyst on using intraoperative icg fluorescence imaging. we adjusted the resection line of the cyst wall and ligated the bile duct at the point at which it crossed the resection line. data on age, sex, cyst size, resected cyst size, operative time, estimated blood loss, post-operative hospital stay, complications, and recurrence were compared between the groups. results: the mean cyst size was ± . and ± . mm, the mean resected cyst size was ± . and ± . mm, and the mean operative time was . ± . and ± . min in the icg and non-icg groups, respectively. using icg fluorescence imaging, the bile duct was detected on the cyst wall in patients ( %). all surgeries were completed laparoscopically, and no post-operative complications occurred in either group. recurrence of the hepatic cyst occurred in one patient ( %) of the non-icg group. conclusions: fluorescence imaging with icg is used widely in hepatobiliary surgery for intraoperative identification of biliary and vascular anatomies. this method does not require complicated techniques or instruments. icg fluorescence imaging may facilitate the prevention of intra-or post-operative complications, such as biliary leakage, in laparoscopic surgery. in this study, icg fluorescence imaging was found to be effective in detecting the bile duct on the cyst wall intraoperatively, allowing for wider resection of the cyst and avoiding inadvertent injury. our study suggests that wider resection of the cyst wall might prevent recurrence of hepatic and that icg fluorescence imaging could ensure procedural safety. abdominal ct showed: large hepatic cyst ( x , x cm size), with no malignity signs, that occupies practically the whole right liver, causing subsegmentary atelectasis of the middle lobe, superior and inferior cava vein compression, and displacement of right kidney, pancreas and right atrial. due to breath involvement, a percutaneous drainage is performed achieving clinical improvement and reduction of the size of the injury. the patient was released but a cyst superinfection occurred; once this problem was solved, the drainage was removed. results: in light of the complication, surgical treatment was decided, which confirmed the large cyst located in right posterior hepatic segments with tight diaphragmatic adhesions. we carried out the cyst evacuation and a wide laparoscopic resection of the cyst walls, until the posterior area of the cava vein, combining supra and infrahepatic access. the patient was released on the sixth postoperative day and continues asymptomatic. conclusions: simple cysts can be approached in a no surgical way (punction-aspiration with/ without sclerosing products injections) or in a surgical way (cyst wall fenestrations, cystectomy or liver resections). a conservative treatment will obtain symptomatic relief but with a high risk of recurring. recurrence is the main drawback of unroofing. cystectomy is the better option but may be too complicated depending on the cyst's location. to our patient, we carried out a wide laparoscopic unroofing (even though its posterior localization) to minimize recurrence possibilities. in conclusion, laparoscopic resection of the cyst wall is a simple and effective approach in symptomatic or complicated cases. background: single-incision laparoscopic surgery or laparoendoscopic single-site surgery is emerging as an alternative to conventional multiple-incision laparoscopic surgery. it has a potential benefit of less postoperative pain and faster recovery compared with conventional multiple-incision laparoscopic surgery. single-incision laparoscopic hepatectomy (silh) has been reported in only a few small series and the majority were minor resections. case report: a y/o male patient is a case of chronic viral hepatitis b and early cirrhosis of liver. two atypical hepatocellular carcinomas (up to . cm in diameter) located at the junctions of segments & and segments & were impressed by liver magnetic resonance imaging (mri). we performed single-incision laparoscopic anatomical hepatic resection of the right posterior section via a -cm transverse incision on the right middle abdominal wall. inflow control was carried out with an extra-glissonian approach before parenchymal transection. the glissonean pedicles of segments and were divided by linear staplers respectively as well as a major branch of the right hepatic vein in segment . the operative time was min and the estimated blood loss was ml. the pathologic examination revealed two foci of hepatocyte dysplasia with a safe margin of cm. the patient was discharged eight days after the surgery uneventfully. conclusion: single-incision laparoscopic anatomical right posterior sectionectomy is feasible and safe by experienced laparoscopic surgeons. it provides a fast recovery but needs a long operative time. the mortality in the patient with liver cirrhosis is very high. the aim of this work was to decrease mortality and morbidity by using endoscopic local heamostasis and laparoscopic operations, in the patients with bleeding from cirrhosis by variceal bleeding. methods and material: we observed patients with cirrhosis complicated by variceal bleeding during years. there were patients with child phue a, ones with child phue b, ones with child phue c. all the patients were performed prolonged endoscopic heamostasis with conservative therapy. the main methods that we used were the ligation in cases, sealing in cases, sclerotherapy in cases. in cases we couldn't stop the bleeding with band ligation method and introduce the danis stents into esophagus and stopped the bleeding successfully. to prevent the re-bleeding we performed the laparoscopic dissection the abdominal part of esophagus with suturing the venous vessels, coagulations and dissection of short gastric vessels between stomach and spleen, clipping the left gastric artery and vein in the patients. in patients we performed laparoscopical suturing the variceal veins by introducing the laparoscopic trocars into the stomach. in cases with varices vien of stomach, with non-effective local endoscopic heamostasis we performed laparoscopic resection the fundal part of stomach. results: endoscopic local heamostasis were successful (in %) in cases. the relapse of bleeding were in patients. patients died. there was no mortality after laparoscopic operations. there were cases for trocar wounds infection, cases of subphrenic abscess. goals: the advance of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those affecting the liver and pancreas. there are multiple indications that laparoscopy has in hepatobiliopancreatic surgery, both in benign and malignant pathologies. material and methods: we present the video of a -year-old male patient with a history of right hemicolectomy due to disease-free intestinal lymphoma who, in the control analysis by his attending physician, detects the elevation of tumor markers. an extension study was started showing a hepatic lesion in the caudate lobe with a pathological anatomy suggestive of hepatocarcinoma and an adenopathy suspicious for malignancy adjacent to the right renal vein. the clinical case is presented in a multidisciplinary tumor committee and it is decided to perform surgery. a laparoscopic caudate lobe resection was performed, previously performing intraoperative ultrasound and a lymphadenectomy of the portal territory, vena cava and exeresis of adenopathy of the right renal vein. introduction: major vascular complications during laparoscopic surgery occur approximately in one in cases, but mortality rate can reach - %. most major vascular injuries lead to conversion to laparotomy but successful laparoscopic repair is also possible. simulation training improves laparoscopic performance and possibly reduces surgeons mental strain. materials & methods: during two editions of advanced laparoscopic training course participants had a task to control a major vessel damage (damage). before the task an educational video explaining the methods of obtaining haemostasis was shown. the algorithm of the 'damage' task was as follows: without previous preparation a cm injury of a major vessel was done with l-hook electrocautery. after the injury participants were free to control the damage the way they wanted. heart rate of the participants was measured with an ear electrode. measurements were carried out times-before the injury, immediately after, and afterwards obtaining vessel control. after participants were interviewed for their feelings after the 'damage' task. results: there were vessel injuries in animals. one animal died during the 'damage' task min after desuflation due to relapse of bleeding. there was no conversion to open procedure. temporary vessel control was obtained with different methods. all participants used vicryl . or pds ii . suture for final hemostatic purposes. heart rate of the participants before injury were - ± . bpm, immediately after the injury it rose to - ± . bpm, and after obtaining vessel control were in the range - ± . bpm. a statistically significant difference was found between the ratio of the first and second hr measurement (p = . , t = - . ), and second compared to the third (p = . , t = . ) measurement. participants judged their experience on a -point scale ( - was not helpful at all; -was extremely educative). the educational value of the task received points in cases and points in one case. conclusion: participants feel stress during major vessel bleeding even in animal model, and this stress can result in a serious intraoperative mental strain and significantly increase heart rate. participants found the 'damage' task very useful for their daily practice. the aim of study was to improve the results of treatment of patients with hepatic echinococcal cysts by using of argon plasma coagulation. methods: the analysis of treatment results of patients was put into the basis of this study. it was ( . %) men and ( . %) women in total. an average age of them was . ± . years. the main difference between groups was a way of liver parenchyma coagulation in order to make reliable hemostasis. in main group the final stage of surgical intervention on liver was argon plasma coagulation. it was performed to ( . %) patients. alternatively, monopolar coagulation was performed to ( . %) patients (comparison group). results: in main group in the . % cases pericystectomy was conducted. the resecting surgeries was performed to . % cases. in comparison group was conducted in . % cases. in early postoperative period in main group the complications were observed in . % of cases. the same parameter was . % in comparison group. it led to relaparomies. the forming of external biliary fistulas was observed in ( . %) patients in main group and in ( . %) patients in comparison group. however, all the fistulas have closed spontaneously on th- th day in both groups. hernias of abdominal wall and peritoneal adhesions that manifested by intestinal obstruction of different degree were considered as complications of late postoperative period. these values were % and . % in main group versus % and . % in comparison group, respectively. the resection of hepatic echinococcal cysts with further application of argon plasma coagulation on the cyst bed was accompanied by complications quantity decrease in patients that underwent surgery in early as well as in late postoperative period. in this case more positive dynamics of functional liver values improvements was observed. aims: indocyanine green (icg) fluorescence imaging has been reported as a reliable and safe navigation tool in laparoscopic hepatectomy. however, the factors affecting the sensitivity of tumor detection with icg fluorescence imaging is relatively unclear. the aim of the present study is to analyze the factors of successful icg fluorescence in laparoscopic hepatectomy. methods: this is a retrospective single-center study. this study population consisted of laparoscopic hepatectomies from january to november undertaken at kurashiki central hospital. we excluded patients whose tumors were located more than mm from the liver surface, those who did not receive icg fluorescence imaging, and those who were not injected with icg dye ( . mg/kg) intravenously within days of surgery. the pinpoint endoscopic fluorescence imaging system was used to detect the tumor location. we evaluated the relationship between successful fluorescence and the timing of injecting icg before operation, tumor size, icg r , liver damage and bmi. results: following exclusion, patients were eligible for analysis. among the tumors resected, icg fluorescence imaging detected tumors ( . %), including hepatocellular carcinomas and liver metastases. icg fluorescence imaging detected all tumors in the patients injected with icg to days before hepatectomies . icg fluorescence imaging detected all tumors which were more than mm in diameter. there was no relationship between indocyanine green fluorescence with icg r , liver damage and bmi. conclusions: the injection of icg to days before operation and a tumor size of more than mm can be factors in successful fluorescence in laparoscopic hepatectomy. introduction: cysts in the liver have a wide variety of aetiologies. it is important to characterize the cystic lesion before treating it. the simple cyst has a low prevalence and is more frequent in women. fenestration is a useful option for the treatment of simple cysts in selected patients. case presentation: a -year-old woman was referred to our hospital with a one-year history of intermittent, right upper quadrant pain, with no other associated symptoms. computed tomography and magnetic resonance imaging showed a large cyst ( , x , cm) in the right of the liver. the cyst presented lobulated morphology, smooth edges and well delimited. there were other smaller cysts in the left lobe. hepatic function in blood analysis was normal. biomarkers, tumor markers and hepatitis virus markers were negative. outpatient follow-up and symptomatic treatment of pain was decided. after six months of follow-up, the pain persisted, so surgical treatment was proposed. a laparoscopic fenestration was performed, widely resecting the free wall of the cyst. there was no evidence of a connection to the bile duct. there were no complications. on days she was discharged. discussion: some giant hepatics cysts become symptomatic due to mass effect. persistence of pain is an indication of surgical treatment. laparoscopic fenestration is an alternative for the management of simple hepatic cysts. aim: laparoscopic liver resection for malignant pathology such as colorectal cancer metastases has been a matter of discussion for several groups in the last years. it has been proposed as a safe and feasible treatment but subjects like short and long term outcomes and oncologic results have not been adequately assessed. methods: we performed an observacional retrospective study of patients undergoing laparoscopic liver resection for colorectal metastases in our center. from november to november a total of patients underwent laparoscopic liver resection. data for resection margin, hepatic and extrahepatic recurrence and both disease free survival and overal survival were collected. patients were discussed in a multidisciplinary group with oncologist, radioterapic oncologist and surgeons. the surgical procedures were perfomed by the same team in all the cases to minimize bias. results: a total of patients ( . %) were non resectable at the time of surgery.the mean overall survival was months with a maximum of months. we got a mean of disease free survival in our patients of . months. the hepatic recurrence was %, most of them in high risk patients, and from this group . % underwent a new liver resection. major complications took place in patients ( . %) two biliar leaks, one bowel perforation, two hepatic failure, one evisceration and three respiratory insufficiency needing urgent surgery in three of the cases. mean hospital stay was . days. a mean of days of this stay were in an intensive care unit. conclusions: laparoscopic liver resection for colorectal liver metastases could be a feasible technique when perfomed by trained surgeons. it improves the postoperatory recovery with a reduction of hospital stay and less postoperatory pain without increasing the development of major complications or mortality in the first days after surgery. we got good oncological results that have been improving with the experience acquisition of the surgical team. aged to underwent surgery for cirrhosis with massive refractory ascites child c ( - ), without obvious signs of hepatic encephalopathy. major etiological factors were: viral hepatitis c ( patients ( . %)), b ( patients ( . %)), b ? d ( patients ( . %)), toxicity ( patients ( , %) ). to prevent possible bleeding at the first stage, endoscopic filling of esophageal varices with fibrin glue was performed in patients ( . %). after testing the effectiveness of varices filling, in the following - days decompression surgery of thoracic lymphatic duct was performed under local anesthesia to improve lymphatic drainage from liver and abdominal organs. simultaneously, laparoscopic sanitation of abdominal cavity was performed, with complete evacuation of ascites fluid, rinsing and drainage. fractional post-surgery rinsing was repeated daily for - days towards removing peritoneum edema and improving its absorptive properties. results evaluation was performed , and months after surgery, based on criteria of liver reserves and ascites volume. results: post-surgery mortality from liver failure was . % ( patients) . other patients died of the same cause the following - months. annual survival rate was . %. complete ascites regression over - months after surgery was noted in patients ( . %), significant regression and stabilization in ( . %), moderate regression with need for periodic decompressive laparocentesis in cases. in all patients, functional liver reserves and life quality significantly improved. conclusions: the use of the given technique of refractory ascites correction, in patients with depleted liver cirrhosis, by laparoscopic sanitation with post-surgery fractional rinsing of abdominal cavity, with simultaneous decompression of thoracic lymphatic duct showed very high efficiency and deserves establishment as a clinical practice. t. urade, hepato-biliary-pancreatic surgery, kobe university, kobe, japan aim: anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target territory were established as essential methods for the curative treatment of hepatocellular carcinoma (hcc) and then subsequently applied to other malignancies. however, laparoscopic anatomical liver resection (lalr) is much more difficult to reproduce these procedures and to confirm demarcation of the hepatic segment visually on the monitor. recently, laparoscopic fluorescence imaging system has been used as a tool for real-time intraoperative navigation in llr. the aim of this study is to demonstrate how to perform lalr using indocyanine green (icg) fluorescence imaging. methods: three patients underwent pure lalr using icg fluorescence imaging. the following operative procedures were performed: partial liver resection for hcc, segmentectomy for liver metastasis and right anterior sectionectomy for hcc. in all patients, preoperative d simulation images from dynamic ct were reconstructed using a d workstation to decide on cutting points of the glissonean branches. after mobilization of the liver, intraoperative ultrasonography was performed to identify the location of the tumor and glissonean pedicles corresponding to the tumor-bearing hepatic region. we dissected or transected the hepatic parenchyma to encircle the glissonean pedicles. after clamping or closure of them, . mg of icg was injected intravenously to identify the boundaries of the hepatic segments under near-infrared light. parenchymal transection was started according to the demarcation on the liver surface. the lateral aspect of the parenchymal transection was carried out based on the demarcation between non-fluorescing and fluorescing liver parenchyma as far as possible. results: in all the cases, demarcation lines on the liver surface could be visualized clearly after injection of icg. in addition, boundaries of cone units, segments and sections could be recognized to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. these procedures were completed successfully, and the postoperative courses were almost uneventful. aim: sintrahepatic cholangiocarcinoma is the second most common primary liver cancer after hepatocellular carcinoma (hcc). although the laparoscopic approach of these tumours is not frequent due to its complexity, it is performed increasingly by hepatic surgeons.traditionally, the abdominal surgery in cirrhotic patients has been reserved to selected cases secondary to the high rate of complications. the advance on the treatment of the hcc on liver cirrhosis and the higher safety when performed by laparoscopic approach has encourage some surgeons to extend surgery to child b-c or portal hypertension patients. methods: we present a male of years old, diagnosed in of liver cirrhosis accompanied with portal hypertension. on mri in was found a solid lesion of mm located on segment ii hepatic. biopsy confirmed the diagnostic of intrahepatic cholangiocarcinoma. after a liver function evaluation (child c, meld ), an hepatic chemoembolization was performed. sequentially ct scans indicated a complete radiologic response. after years of follow up, mri showed a recurrence of mm between segment ii and iii of the liver.on multidisciplinary committee liver resection was decided due to suitable liver function and low aggressiveness of the tumour. a laparoscopic left lobe liver resection was performed. sonastarÒ and ligasure tm were used to perform the liver transection and endo gia tm for portal and hepatic veins sections. the surgery develop was complicated due to trend to bleeding that finally was achieve through cauterization. results: early after the surgery, the patient presented a haematic debt through the drain of cc accompanied of hypotension, therefore an emergent surgery was indicated. an exploratory laparoscopy was performed finding hemoperitoneum and diffuse bleeding of the liver surface that was controlled. the patient had a proper recovery and was discharged on the th day post-surgery. the analysis of the specimen showed a . cm cholangiocarcinoma with a . cm margin of resection. conclusion: there is an augmented risk of complications on liver resection of cirrhotic patients with portal hypertension. the laparoscopic approach allows to reduce potential complications, despite bleeding continuous to jeopardize this surgery, this option could be proposed on selected patients. introduction: accessory spleen itself is found in approximately % to % of the population. most ( %) are located near the splenic hilum but intrapancreatic accessory spleens (ipas) are the second most frequent location ( . %) of accessory spleens. in adults, ipas are clinically silent. they may become clinically important because of their radiographic similar appearence of cancer. intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and is located in the pancreatic tail in approximately % to %. ipas can be difficult to differentiate radiologically from hypervascular pancreatic tumors such as pancreatic endocrine neoplasms because theycan share a similar enhancement pattern. as a result, most of the reported cases of ipas have been diagnosedonly after distal pancreatectomy was completed. material and methods: we present the case of a -year-old male patient with a history of large vessel vasculitis followed-up for rheumatology, which showed a pancreatic nodule in a control ct so he was referred to digestive for study. an echoendoscopy was performed. it showed, at the level of the tail, in the third distal, a lesion of x mm, hypoechoic, with rounded morphology and well-defined edges that can not be biopsied given the absence of adequate window for the realization of fine needle aspiration biopsy (fnab). based on these radiographic findings, the differential diagnosis included a pancreatic endocrine tumor. due to the high suspicion of malignancy and the absence of biopsy, he was referred to general surgery for scheduled surgery. a laparoscopic corporocaudal pancreatectomy was performed without incidents and the definitive histology showed an intrapancreatic accessory spleen in the pancreatic tail that excluded the presence of cancer. conclusion: intrapanceratic accesory spleen is a challenging diagnosis to make and it should be included in the differential diagnosis of pancreatic neoplasm. its early identification precludes surgical resection. however, the preoperative diagnosis of ipasmay be difficult, and distal pancreatectomy is a safe and relatively simple operation, most of the reported cases of ipas being diagnosed correctly only after surgery there are various options for treating pps. this paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts based on an anatomical classification. methods: we adopted the laparoscopic approach in patients who had pps requiring surgical drainage. the laparoscopic method had been decided according to preoperative computed tomography (ct) and intraoperative findings. the results shown represent median (range). the aim of this work was to decrease mortality and morbidity in patients with combined trauma. methods and material: for years patients were brought to our clinic with combined trauma. everybody was performed ct and ultrasound examination. patients were performed open laparatomic operation due to massive liver rupture, spleen rupture and massive trauma of bowels, pancreas and kidney with massive bleeding. in circumstances we didn't found the trauma of the abdominal organs and the massive abdominal bleeding after ct observation. those patients were cured conservatively. in circumstances with combined trauma after ct examination we performed laparoscopic operation. in circumstances from the patients, who we started laparoscopic operation in, we conversed to laparotomy, due to massive liver rupture, and trauma spleen and hollow organs. in those circumstances we performed urgent laparotomies with suture ligation of bleeding points, suturing of liver and hollow organs and drainage of abdomen cavity. results: we performed laparoscopic operation in patients. in circumstances with trauma of liver we performed laparoscopic electro coagulation and argon-plasma coagulation. in circumstances with trauma of liver we performed electro coagulation with packing the omenture to its surface. in circumstances with trauma of spleen we performed argon plasma coagulation and used fibrin glue. after laparotomic operations mortality were in circumstances, morbidity were in patients. after laparoscopic operation mortality were in circumstances of severe combined trauma with multiple abdominal trauma and morbidity in patients. conclusion: laparoscopic operations in patients with combined trauma decrease mortality and morbility. aims: in laparoscopic distal pancreatectomy, getting away liver and stomach from the surface of the pancreas is sometimes difficult. when we separate the pancreatic body from the retroperitoneum, we must not injure the pancreas to prevent breaking a tumor. when we cut the dorsal side of the spleen from the retroperitoneum, we rarely cut into the spleen accidentally. based on our experiences, we gradually explored a set of procedural operation steps to resolve these problems. our three-step maneuver simplifies the procedure and improves the efficiency and safety of laparoscopic distal pancreatectomy. methods: as the first step, to get away the liver we sutured the round ligament of liver and crus of the diaphragm using - pds and the both ends were tugged form the outside of the body through both side of the xiphoid process. and the stomach was hung from the outside using two nylon thread like a bridge, so we could see the surface of the pancreas body with a good view. the second step was a rolling up maneuver of the pancreas. when we separate the pancreatic body and tail from the retroperitoneum, we rolled the pancreas with gauze for use in laparoscopic surgery and lifted the gauze up in only one assistant's forceps. then we could find the correct line for dissection clearly. the last step was a hanging maneuver of the spleen. when we cut the dorsal side of the spleen from the retroperitoneum, we hanged the hilum of spleen with cotton tape. with this technique we could find easily the correct line to dissect. results: the operation time was h and min and the estimated blood loss was a little. we did not injure the tumor or spleen in this operation. the patient recovered uneventfully after short hospitalization. conclusion: our three-step maneuver can be effective to perform laparoscopic distal pancreatectomy. about - % of patients with pancreatic collections will develop walled off necrosis, with an associated - % mortality. there are multiple options for intervention and drainage, usually the outcomes after endoscopic drainage are related with the nature of the collections. aims: to evaluate and present the rol of endoscopy in pseudocyst and walled off necrosis treatment, and favorable outcomes. methods and results: we present a case of a years old male, who presented biliary pancreatitis treated with cholecystectomy and transoperative cholangiogram weeks ago. he continued with persistent abdominal pain; his ct scan showed a big walled off necrosis; he was taken to surgery for an endoscopy-assisted laparoscopic cystogastrostomy with necrosectomy, he was discharged days po. conclusions: the step-up management of walled off necrosis has proven to be a better option than conventional surgical or endoscopical techniques alone; by reducing complications and mortality vs conventional necrosectomy. the use of endoscopic treatments reduce the pro-inflamatory response. drainage of walled off necrosis can be done by a transpapilar or transmural endoscopic apporach each one with its own advantages. some authors avoid the use of endoscopy in walled off necrosis because of a higher rate of complications, re-interventions and a greater lenght hospital stay. in our experience, we have achieved excellent results with this combined technique. nearest and long- patients underwent chemotherapy after electroporation procedure. day mortality was . % (n = ) in electroporation group. it was found that erreversible electroporation improved local recurrence-free survival ( and months, respectively, p = . ) and distant recurrence free survival ( and months, respectively, p = . ) . overall survival was and months, respectively (p = . ). conclusion: irreversible electroporation of locally advanced pancreatic cancer is safe. four month chemotherapy followed by surgical procedure is associated with good local response and better overall survival compared with chemotherapy alone. these data will be validated in further multicenter study. introduction: pancreatic pseudocysts are the most frequent complication of acute or chronic pancreatitis. usually asymptomatic, they can be managed conservative or, in case of complications, by several methods, endoscopic, percutaneous or by surgery. material and method: we present the case of a years old patient known with an episode of acute pancreatitis five years ago, who was hospitalised now for an upper gastrointestinal bleeding with hematemesis. the upper endoscopy showed a subcardial bulking with an erosion of the posterior gastric wall, with signs of recent bleeding, managed by clipping. patient work-up showed a cm pancreatic pseudocyst at endoscopic ultrasound. taking into consideration the history of the patient, the size and the complication of the cyst, the patient was proposed for a drainage intervention. results: a minimally invasive approach was decided. using ultrasonography guidance, a posterior gastrotomy was performed with the cystotome, establishing the comunication with the pancreatic pseudocyst. dilatation of the path with mm cre baloon, with partial evacuation of turbid liquid. the drainage consisted in pigtail fr plastic stents. the patient was discharged the following day in a good health condition.the endoscopic ultrasound control at weeks showed complete resolution of the pancreatic cyst and was followed by stent removal. the endoscopic drainage of the pancreatic pseudocyst represents the first treatment option as an alternative to the surgical intervention, being minimally invasive, with low risk and fast recovery. clinical case report: a -year-old man was admitted to the hospital with a diagnosis of severe acute pancreatitis and multi-organ failure. during the first month patient has in uci and non invasive procedures were attempted: enteral feeding by a nasoduodenal tube was started and antibiotics were administered to control sepsis. on day , percutaneous drainage was performed for large retroperitoneal abscess. on days, endoscopic transgastric necrosectomy was performed and the left collection was resolved. due to the multi-organ failure persistence and the evidence of size increase of the right retroperitoneal collection, a vard was decided.the right collection was accessed following the previously pigtail catheter. a mm trocar was placed to create retro-pneumoperitoneum with a pressure between - mmhg. a trocar of mmhg was placed, purulent content was aspirated and a debridement was performed. irrigation and aspirate was performed with normal saline and povidone-iodine solution. drainage was used to perform washes with physiological saline and urokinase.on days, the ct confirmed collection resolution. on days he was discharged. after months, the patient is in good clinical condition. discussion: drainage of the retroperitoneal abscesses via laparotomy is highly invasive and risky. vard enables radical necrosectomy and drainage less invasively. in this patient, the complete resolution of the right collection is obtained with retroperitoneal debridement without complications. we conclude that careful retroperitoneal necrosectomy is a valid alternative for the management of right collections. aims: in this study we analyze laparoscopic approach for hepatocellular carcinoma in order to clarify iwe can take advantage in some outcomes as complications, postoperative recovery or long-term survival outcomes. methods: a retrospective case consecutive study has been taken analyzing: age, sex, body max index, comorbidity, surgical extension and tumor size. the outcomes analyzed were: operation time, intraoperative blood loss, blood transfusion, postoperative morbidity and mortality, intensive care stay, hospital stay, tumor size, r resection, conversion rate, early reintervention, disease-free survival rate, overall survival rate results: in this study patients were analyzed males and females with ages between and years (mean age ) and diverse comorbidities: arterial high pressure ( / ; %), diabetes ( / ; , %) ; dislipemy ( / ; , %) , hepatophaty measured as liver cirrhosis ( / ; , %). all of them underwent laparoscopic liver surgery, in cases non-anatomical resection was performed while in the other a segmentectomy was performed. in cases the laparoscopic was strict, in and assistance incision was needed. operative time was - min (mean: min). blood loss mean was , g/dl and only intraoperative transfusion were needed. massive blood loss was reported in case. postoperative medical complications were observed: hepatic failure and renal insufficiency and in case we observed a postoperative hemorrhage that needed an urgent reintervention. the mean of intensive care stay was day and hospital stay was . days. about oncological outcomes r resection was achieve in / ( %), r in / ( %). at years / cases were free disease, dead by progression of disease and dead by other causes. aim: the purpose of this study is to analyze our initial experience with laparoscopic duodenopancreatic resection. introduction: laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. laparoscopic pancreatoduodenectomy and laparoscopic distal pancreatectomy(ldp) are advocated to improved perioperative outcomes, including decreased blood loss, shorter length of stay, reduced postoperative pain and expedited time to functional recovery. however, the indication to minimally invasive approach for pancreatic surgery is often benign or low grade malignances. material and method. the steps of ldp procedures are similar to the open procedure. we perform destructive part of procedure totally laparoscopically and we prefer to do reconstructive part of procedure using hand-assisted techniques. for the period - , we have been perform pd, ( %) we have done with laparoscopic approach. ( %) of patients were operated totally laparoscopic and ( %) of patients were operated by handassisted techniques. results: a significantly higher conversion rate was encountered when lc was done - weeks after es, as compared to week after ercp. it is estimated that pancreatitis after ercp affects roughly three to percent of patients and many endoscopists quote a post-ercp pancreatitis rate of - %. however, - % is probably a more realistic answer for the majority of ercp endoscopists. wise endoscopists inform their patients that there is a spectrum of post ercp pancreatitis severity, from mild ([ % of cases) to severe ( - % of cases). in mild forms, pancreatitis after ercp may resolve itself. conclusion: endoscopic retrograde cholangiopancreatography is a procedure used to diagnose and treat disorders involving the pancreatic and bile ducts. acute pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography. the assumption is that the duration of the laparoscopic method is longer, but on the other hand the patient have better wound healing and fewer possibility of developing postoperative hernia . the postoperative period is much more simple due to the significantly shorter hospitalization and the faster recovery, and according to patients the level of pain is much smaller as well. however the oncology results are the same. introduction: spiegel hernias are a rare, representing only between . % and % of all abdominal wall hernias. due to its location, below the spiegel line, its diagnosis requires a high index of suspicion. the physical examination only detects % of the spiegel hernias and, in many occasions, imaging tests are necessary for the diagnosis. goals: our objective is to describe the case of an urgent laparoscopic repair of a case of high grade bowel obstruction secondary to a spiegel hernia. material and methods: we present the case of a -year-old male patient with no medical history that comes to the emergency department of our center due to an eight hour evolution of abdominal discomfort associated with nausea without vomiting or other symptoms. the patient was afebrile and hemodynamically stable at all time. on physical examination, the abdomen is soft and depressible, painful on the left flank where a tumor compatible with spiegel's hernia is palpable. in the blood count there is no leukocytosis nor alteration of inflammatory parameters. an abdominal computed tomography (ct) scan was requested from the emergency department which demonstrated a high-grade small bowel obstruction caused by an entrapped loop of distal jejunum conditioned by a left-sided spiegel hernia. given the situation, an informed consent was obtained, and the patient was taken to the operating room for emergency laparoscopic repair. we performed a laparoscopic hernioplasty with ventralpatch mesh between oblique major and transverse and primary closure of defect in continuous suture. after this, the evolution of the patient is favorable, with good oral tolerance and re-establishment of intestinal transit, being able to be discharged h after surgery. the spiegel hernia is a rare entity that requires a high index of suspicion for its diagnosis. despite the limited evidence published in the literature on the laparoscopic repair of incarcerated spiegel hernias, the studies published so far suggest that the laparoscopic repair is a valid alternative to the classic approach when it is performed by a well-trained laparoscopic surgeon. introduction: repair of lateral abdominal wall hernias (both primary and incisional) can be challenging due to the complexity of anatomy, issues with fixation and the low incidence of such cases. a good understanding of abdominal wall and retroperitoneal anatomy, coupled with proficient laparoscopic technique is essential for successful repair via the minimally invasive approach. methods: a retrospective review of a prospectively maintained database was performed to identify patients with lateral abdominal wall hernias who underwent laparoscopic repair from january to july . results: patients with hernias were identified ( primary, incisional). mean patient age was (range - ) and mean bmi was . kg/m (range . - . ). according to ehs classification, the incisional hernia defects were located at subcostal (l , n = ), flank (l , n = ), iliac (l , n = ) and lumbar (l , n = ) regions. background: it is commonly admitted that laparoscopic surgery has the advantage of abdominal wall preservation. however, the increased use of laparoscopy has resulted in certain complications specifically associated with the laparoscopic approach, such as trocar-site incisional hernia. until today, it is not finally clarified 'patient-dependent' factors contributing to the occurrence of postoperative hernia after laparoscopic abdominal surgery. methods: between and , patients were operated due to trocar-site incisional hernia in one surgical centre. 'the patient-depending' factors which caused postoperative trocar site incisional hernia data was collected and retrospectivily analysed. results: port site incisional hernia occurred in % ( patients) after the use of trocars with mm or larger diameter. the presence of metabolic syndrome was the decisive factor in the development of postoperative incisional hernia in % ( patients). in % ( patients) the postoperative hernia occurred on the background of a long cough symptoms caused by chronic obstructive pulmonary diseases. the cause of postoperative hernia in % ( patients) of patients was the condition of lifting a one-time severity or heavy physical work. in % ( patients) of postoperative patients hernia developed due to prolonged constipation of chronic inflammatory colon diseases. conclusions: thus, when the aponeurosis of the trocars is adequately closed, the reason of the occurrence of postoperative hernias was caused by patient-dependent factors which increase intra-abdominal pressure. for this method, small midline incision cm in length - cm away from hernia orifice was carried out initially. dissection of intraperitoneal adhesion was carried out by sils with sils device. subsequently after closure of initial laparotomy unilateral anterior rectus sheath was incised from the same incision and dissection of retro-rectus space up to preperitoneal space was done under laparoscopic vision. dissecting the other side was carried out by same fashion. initial dissection of linea alba could be done by open surgery from initial incision. further dissection of linea alba, retro-rectus space, and hernia orifice was carried out by sils. defect closure of anterior and posterior rectus sheath using barbed suture was also done by sils and self-grip mesh was inserted. additional trocar to assist retro-rectus dissection, defect closure, and decompression of intraperitoneal cavity was inserted as required. aims: the laparo-endocsopic approach of inguinal hernia contiue to bring many clarifications concerning inter-parieto-peritoneal space of this region through in vivo exploration, obtained by magnification by means of specific optic intrumentation. our study aimed to revalue the in vivo fascias, to establish their embryological correspondences and to reunite the variable nomenclature existing in the classical anatomy of this region. these observations find their applicability in tapp and tep hernia procedures, as the old anatomical descriptions are no longer operative. methods: we have tried to identify the structures that delimit the anatomical regions of retzius and bogros in recording of tapp procedures performed on men, on the right side, for small indirect hernias on patintes with clear view of the structures. additional, a review of literature on this subject has been performed through a search in the detabases according to the following keywords: bogros space, retzius space, preperitoneal approach, urogenital fascia. results: retzius and bogros are the medial and lateral compartments of the inter-parietalperitoneal space, located between the transversal fascia and the parietal peritoneum. these narrow, virtual spaces are best highlighted today with the help of insufflation techniques during laparo-endoscopic procedures. a competent and careful dissection confirms a 'deep and superficial' stratification, highlighting embryonic relics derived from the uro-genital fascia: urinaryprevesical fascia and spermatic fascia. in addition, the real retzius space is located previously and the real bogros space is located behind this strcuture. the confluence area of the two spaces is a critical point of laparo-endoscopic dissection, its non-recognition may 'wander' the dissection. conclusions: literature data in this topic reflects a certain terminological confusion using general terms such as 'preperitoneal tissue' or 'arreolar tissue' to denote what we consider to be the urogenital fascia or its prologations. the data obtained were synthesized in several drawings and diagrams very useful in training surgeons to use tapp / tep techniques. aim: spigelian hernia containing epiploic appendage is really rare entity. in this paper, we present a very rare case of spigelian hernia involving epiploic appendage performed laparoscopic hernia repair. case report: a -year-old woman presented to the emergency department with sudden onset abdominal pain in the left lower quadrant. on physical examination, she had a small, palpable tender mass in the left lower abdominal quadrant. temperature and white blood cell count were normal. an inflamed epiploic appendage with an oval shape, a fatty core, and a central thin hyperdense line in the hernia sac was detected on abdominal computed tomography. its intraabdominal relationship with the normal wall of the sigmoid colon was well appreciated (figure a, b) . diagnostic laparoscopy was performed. (figure ) adhesions between the sac and epiploic appendage are released using sharp dissection. a peritoneal flap is then created (figure ). laparoscopic tapp repair was used without closing the defect (figure ) . the patient was discharged on th days uneventfully. aims: morgagni's hernia is an in infrequent, congenital, anterior or retrosternal diaphragmatic defect. the right side is the most frequently affected, up to % of cases. it represents between and % of congenital diaphragmatic hernias. in childhood, they usually attend asymptomatically or with respiratory symptoms. up to % are diagnosed in adulthood, incidentally or after gastrointestinal obstruction debut. the treatment is surgery, which can be by laparoscopic or open approach.we present a case of laparoscopic approach with intra-abdominal mesh placement of giant morgagni's hernia diagnosed in senile age. methods: -year-old woman with a history of advanced alzheimer's dementia, partially dependent in daily life activities and institutionalized who consulted for intermittent episodes of oral diet intolerance associated with vomits of one month of evolution. abdominal examination was anodine. chest radiograph revealed a right lower lung field mass with fluid collected. thoracoabdominal scan showed small bilateral pleural effusion and large, right anterolateral morgagni's hernia, which contains dilated segment of transverse colon and greater omentum . results: laparoscopic approach was performed. hernia was reduced and hernia sac was removed. the defect was repaired with a dual-component (absorbable and non absorbable) mesh anchored with intracorporeal suture. patient recovered and was discharged days after surgery. conclusion: laparoscopic approach for morgagni's hernia reapir is secure and offers the advantages of less post-opertive pain, faster recovery and short postopatory stay. introduction: recently, laparoscopic operations for ileus are increasing. we have undergone laparoscopic operation to adhesive ileus with umbilicar incision at the beginning. the umbilicar incision at the beginning makes it possible to secure the laparoscopic field by peeling the adhesion under direct view, and makes it easy to repair damage to the intestinal tract. surgical procedure: at first, the umbilicus - cm incision was made and peeled the adhesion as much as possible under direct vision. secondly, ez access was set and inserted one mm port, therefore laparoscopic operation was performed with or pieces of mm ports. when the repair or resection of small intestinal due to damage is necessary, it is pulled out through the ez access. objective: to investigate the possibility of problems of laparoscopic ileus operation to adhesion ileus by umbilicar incision at the beginning. introduction: small bowel obstruction (sbo) during pregnancy is a rare condition with an incidence of . - . % and in around % of cases it is most caused by adhesions from previous abdominal surgery. other diagnosis, such as, hernias, malignancy, volvulus or intussusception are extremely rare. when sbo occurs in pregnancy, it carries a significant risk to mother and fetus. its diagnosis of can be difficult to make as symptoms are often attributed mistakenly to the pregnancy. goals: a case report of congenital bowel obstruction during the second trimester of pregnancy handled by laparoscopy. material and methods: we report the case of a year old woman with a history of chronic lung disease, pregnant because in vitro fertilization ( ? weeks) who attended the emergency department with abdominal pain and bloating accompanied by nausea and vomiting for two days. on physical examination she showed a distended, soft, depressible and painful abdomen without peritonism. laboratory tests were normal. a nasogastric tube was placed with generous output fecaloid intestinal contents. abdominal ultrasound by expert radiologists in abdomen showed a moderate amount of free abdominal fluid with normal uterus moderate and sbo to the ileum because of intestinal adhesion. this results were confirmed with an magnetic resonance imaging (mri). results: the patient was operated by laparoscopic approach with three trocars. the main problem was discovered. we founded a congenital adhesion which conditionated the obstructive syndrome. postoperative recovery was uneventful and the patient was discharged h after surgery. conclusion: the non-obstetrical acute abdomen in pregnant patient is a reality that occurs in one of every pregnancies. its diagnosis in more difficult than in nonpregnant patients requiring or high index of suspicion. the laparoscopic approach of acute abdomen during pregnancy is a valid and safe option, even in the early hours after diagnosis of bowel obstruction when it is performed by a well-trained laparoscopic surgeon. aim: intestinal malrotation (im) without midgut volvulus in adults is a rare clinical entity, which is the result of an incomplete rotation of the small bowel during embryogenesis, due to the nonlysis of the ladd bands. these ligaments spread between the duodenum and caecum and do not allow the gastrointestinal tract to take its normal position into the peritoneal cavity. im appears in to - newborns and is usually asymptomatic. diagnosis is usually made in the first month, and presents with findings of an acute abdomen, small bowel ileus and volvulus. im in adults is a rare entity. most of the times it is asymptomatic, but it can cause chronic abdominal discomfort and constipation. we present the laparoscopic management of an adult patient with intestinal malrotation. methods: our patient, a year old female, presented to the emergency room with a -month history of abdominal pain and nausea. all blood tests were normal. an abdominal mri showed intestinal malrotation without volvulus. due to persisting symptoms, she underwent a diagnostic laparoscopy with complete lysis of the ladd bands. the only unusual finding was a slight oedema of the duodenum. results: her symptoms settled postoperatively and she was discharged on the nd postoperative day. since her discharge, she has not developed any similar abdominal pains or complaints. conclusions: symptomatic intestinal malrotation in adults is an unusual clinical entity, but it is definitely one of the differential diagnoses we need to consider in case of chronic abdominal symptoms. the management consists of the division of the ladd bands, and this procedure can be performed safely with laparoscopy. many small intestinal obstructions are due to adhesions after laparotomy, but small bowel obstructions without history of open surgery is relatively few. in diagnostic imaging such as preoperative ct examination, the cause is diagnosed to some extent, but details are sometimes unknown unless operative observation is actually made. in many institutions, laparoscopic surgery is also actively introduced into the operation to relieve bowel obstruction, and its effectiveness is beginning to be recognized. we examined the usefulness of laparoscopic surgery for patients with small bowel obstruction without history of laparotomy from experience in our hospital. aim: from december to october , we searched cases of laparoscopic surgery for a small bowel obstruction without previous laparotomy at our hospital, and clinical findings, surgical results, and postoperative course were examined. results: there were ten cases. eight men and two women. the median age was years ( - yrs.) . reasons for intestinal obstruction were adhesions cases, internal hernia cases, persimmon stones case, small intestine tumor case. four cases of adhesions were emergency surgery. there were cases of emergency surgery and waiting surgery. five laparoscopic operations were completed and five cases during laparotomy transition. the median surgical operation time was min ( - min), and the median bleeding amount was g ( - g). there was no fatal case after operation, only one complications of ileus. the median length of hospital stay was days ( - days) . conclusion: laparoscopic surgery for intestinal obstruction with no history of laparotomy was thought to be a safe and effective procedure. although the transition to laparotomy would be higher in case of emergency, but there was no case of large incisional laparotomy. conclusions: laparoscopic surgery for sbo reduces postoperative complications and contributes to shortening the postoperative hospital stay and to decreasing the rate of recurrences, although it is a retrospective study, which is a safe and a useful approach. furthermore, first episode of sbo without previous operation seems to be an appropriate indication for laparoscopic surgery. background: postoperative adhesion after abdominal surgery may cause intestinal obstruction, chronic pain, or female infertility, which constitutes the major problems after surgery. adhesion formation are reported to be reduced by laparoscopic surgery and the use of anti-adhesion barriers. seprafilm composed of sodium hyaluronate carboxymethylcellulose bioresorbable membrane has been widely used to date, especially in open surgery. the characteristics of seprafilm, which is easily stick when wet, conversely brittle when dry cause it difficult to deliver into the abdominal cavity via the small incision in laparoscopic surgery. therefore, seprafilm is not much used in laparoscopic surgery. although various methods of insertion of seprafilm have been reported, some need special devices, or some acquire skill. methods: we adopted the pre-moistening technique for the replacement of seprafilm in consecutive cases of laparoscopic gastrointestinal surgery. a sheet of seprafilm was cut into equal pieces. to soften the sheets, one of the pieces was placed on a folded wet gauze until it became naturally curled then it was reversed, and the same procedure was repeated. softened sheet is easily to deliver into the abdominal cavity via a small incision by pushing with digital finger. moistened sheet expands naturally in the abdominal cavity. one or two pieces were needed to cover the incision. this process took only a few minutes. results: in all cases, the sheets were successfully introduced into the abdomen and spread widely enough to cover the incision. there have been no adverse effects, no postoperative complications, or gastrointestinal obstruction due to adhesion in the observation period of median two years. conclusions: short term outcomes were good after applying this technique. however, to record the incidents of intestinal obstruction and chronic pain, over years observation is indispensable. long term follow-up studies are required to clarify the usefulness of the anti-adhesive barrier in gastrointestinal surgery. b. east, rd department of surgery, motol faculty hospital, prague, czech republic aim: since when the ipom acronym was used for the first time our views at intraperitoneal mesh positioning has changed several times. despite growing evidence on its possible long term consequences it is still preferred method at some centres for large number of patients. the aim of this study is to point out the pitfalls of this method but also show that ipom is a good technique but only for highly selected cohort of patients. methods: this is a review of the literature focusing on the indications and complications of ipom pointing out controversies among the published articles over last two decades. some mesh material characteristics are being discussed as they are basic for understanding this complex and highly sensitive issue. results: a wide range on indications of ipom from little umbilical to large incisional hernias is advocated by many. however, some opinion leaders promoting this technique as universal and ideal for everyone just few years ago are advising to avoid it if possible lately. a necessary overlap has also been questioned recently. despite improving anti-adhesion barriers and methods of fixation in may a surgical mesh has become classified as risk class iii by the eu parliament and council on medical devices hoping to prevent physiomesh like incidents in the future. the need for post market registries and long term follow up is obvious. conclusion: us as surgeons implant a mesh in our patients and therefore we should be aware of its possible long term effects. no mesh on the market has a long term safety evidence especially in the intraperitoneal space. ipom is a good technique but possess a significant risk of long life complications and therefore should be spared only for those unfit for other methods of repair, patients with too high mesh infection risk, obese or older patients. introduction: acute appendicitis in elderly patients is relatively uncommon and could represent an underlying neoplasm. hence patients over the age of are often referred for a follow-up colonoscopy after management of acute appendicitis. the current routine use of computed tomography (ct) scans in the evaluation of suspected acute appendicitis in elderly patients prior to surgery coupled with intra-operative findings at laparoscopy question the role of follow-up colonoscopy for these patients. aims: to determine the role and optimal timing of colonoscopy in early detection of colorectal neoplasia after treatment of acute appendicitis in elderly patients. methods: all patients aged years and above with confirmed appendicitis admitted to our hospital during the period / / to / / were included. follow-up colonoscopy, diagnosis of colorectal neoplasia and its location in this patient cohort was evaluated. results: number of people aged and above in olol who had appendectomies from the dates / / to / / = . out of them / ( %) had full colonoscopy within years of the appendectomy.of them of the colonoscopies done were maleand were females. / ( %) of these colonoscopies were completely normal. colonoscopy identified colorectal carcinoma in ascending colon ( . %). other pathologies identified included: benign polyp ( %), polyp with low grade dysplasia ( %) and others ( . %) (lymphocytic colitis, ulcerative colitis, medication related ulceration, diverticulosis, melanosis coli, haemorrhoids). conclusions: in elderly patients above years of age: there may be an increased risk of colorectal cancer after acute appendicitis. only % of this patient cohort underwent colonoscopy after appendectomy. the current recommendations suggest the need for follow-up colonoscopy in elderly patients post acute appendicitis. further studies are needed to decide whether routine colonoscopy is indicated after acute appendicitis patients over years. introduction: it is generally accepted that the main aetiology of appendicitis is obstruction due to appendicoliths in adults and lymphoid hyperplasia in children. in contrast, incidental appendicoliths have been reported to occur in up to % of the asymptomatic population. controversy still exists regarding the association of appendicolith and appendicitis. is the appendicolith a causative factor or merely an incidental finding? aims: to determine the association between the presence of appendicolith and acute appendicitis (perforated or non-perforated) vs healthy appendix. methods: we collected the data retrospectively from the electronic records of all appendicectomies performed between january and december in our institution. data collected included: age, sex, appendix histology and the presence of appendicolith. interval or incidental appendicectomies were excluded from this study. we analysed the data using spss software version . results: during the study period appendectomies were performed (males: , females: , age range: - years). cases were histologically confirmed cases of acute appendicitis and of these, were perforated. a normal appendix was identified in cases. the remaining cases were due to chronic appendicitis, sub-acute appendicitis, lymphoid hyperplasia, parasitic infestation, and neoplasm. appendicolith was found in cases, of which were found in a normal appendix and were found in an inflamed appendix. out of the cases of appendicolith with normal appendix: cases were aged between and years old, cases were aged between and years old and case was aged between and years old. out of cases of appendicolith with acute appendicitis, cases were aged between and years old, cases were aged between and years old and case was aged over . conclusions: appendicolith may merely be an incidental finding and is not the primary cause of appendicitis. no significant correlation between gangrenous/perforated appendicitis and the presence of appendicolith. contrary to popular belief appendicoliths are more common in paediatric appendicitis than in adult cases. further research is recommended. over the last years, patient satisfaction surveys have gained increased popularity. nowadays, respect for patients' needs is central to our health care system. hospitals use patient satisfaction surveys to assess quality of care. many hospitals routinely survey patient satisfaction but relatively little data has been published. our acute surgical assessment unit operates from am to pm monday to friday and in its first year saw surgical patients, of whom were discharged and were admitted to the hospital for further management. aims: to assess the levels of satisfaction of patients attending asau at our lady of lourdes hospital. methods: a random sample of patients seen in the asau was surveyed to determine their level of satisfaction and the experience they had whilst attending asau. a novel self-reported patient satisfaction questionnaire was developed and used to assess patients' opinion regarding the treatment they received, the doctor's explanation of their condition, the waiting time and the service in asau. also the questionnaire encouraged patients to suggest improvements to the service. aim: sintestinal obstruction is a very common cause of presentation to an emergency department. the most common cause in patients with prior abdominal surgery are adhesions, but the list of differential diagnosis is large. internal hernia is a very rare cause of obstruction, with a reported incidence of between . and . %. the herniation related with broad ligament defects is even more uncommon. methods: we report the case of a -years-old woman with antecedents of liver transplant, tubal ligation and appendectomy. the patient was admitted refering abdominal pain in the epigastrium of h duration, accompanied by nausea and vomiting. on physical examination, abdomen was depressible, tender in the right low quadrant, without evidence of peritoneal irritation. laboratory studies were normal except for an elevated leukocyte count with a left shift. computed tomography (ct) revealed dilated small bowel loops with a transition point in right lower quadrant. radiological diagnosis was intestinal obstruction, with fibrous adhesion as the most probably aetiology. management was conservative at the beginning, with intravenous hydration, nasogastric tube and administration of gastrografin (diatrizoate) without a good response. results: at h, an exploratory laparoscopy was perform, finding dilatation of small bowel loops and a cm defect in the right broad ligament in which a segment of ileum was herniated. ileal segment was liberated without evidence of ischemia. the hernial defect was closed by laparoscopy with simple silk stitches. the postoperative course was excellent, tolerating oral feeding next morning. the patient was discharged h after surgery. conclusions: internal hernias of the broad ligament are an extremely rare cause of intestinal obstruction, but must be added to the differential diagnosis for female patients due to the risk of intestinal strangulation and perforation. even if clinical and radiological diagnose is difficult, ct is the best tool to delineate the cause and location of the obstruction. laparoscopy allows reduction of the hernia and closure of the defect with minimal invasiveness. because of that, the laparoscopic approach of bowel obstruction should be considered as the first choice if there is the suspicion of an internal hernia, without signs of necrosis or perforation. the laparoscopic approach is a safe and effective tool in the management of postoperative complications. it is well tolerated in critically ill patients and avoids respiratory and wound related morbidity associated with laparotomy. it also reduces diagnostic delay and a considerable number of unnecessary laparotomies, with a high resolution rate and minimal morbidity. it thus represents a valid and necessary alternative in surgeon's armamentarium. in the management algorithm of our institution we always choose the laparoscopic technique as the fisrt tool in case a reoperation is necessary. , small bowel obstruction ( . % vs . %), and colorectal cancer obstruction ( . % vs . %) was found higher for acs unit group, and also progressively higher during the last years. conclusion: according to our study, laparoscopic approach in abdominal emergencies shows an upward trend, and surgeons from acs units seem to have higher rates of laparoscopy than general surgeons in emergency procedures. background: incarcerated and strangulated hernias present a major problem in emergency medicine. there is scarce data about the role of laparoscopy in the management of these patients. laparoscopic repair offers the benefits of the ability to survey the incarcerated organ and to evaluate its viability, apart from the obvious advantages of laparoscopic surgery. the use of mesh repair in these emergent operations is also a major concern, due to the un-sterile conditions in which they are performed. objective: to evaluate the safety and short-term efficacy of laparoscopic emergent repair of incarcerated hernias. methods: retrospective review of prospectively collected data of all the patients who underwent emergent laparoscopy due to an incarcerated hernia between november and october . results: during the study period, patients underwent emergent laparoscopy due to incarcerated hernias ( females, males). had incarcerated inguinal hernias, and had incarcerated umbilical hernias. mean age was . . all inguinal hernias were repaired in the tapp approach, and using an absorbable mesh. all umbilical hernias were repaired using the ipom approach. patients had bowel obstruction, had incarcerated omentum, and one patient had incarcerated urinary bladder. patients underwent resection of an ischemic organ ( bowel, urinary bladder, omentum). mean hospital los was . days. during the follow up period there were no mortalities, and no recurrences. one patient had a wound infection that resolved with antibiotics. conclusion: laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach. further studies with longer follow up time need to be conducted, in order to evaluate the added benefit of the laparoscopic approach. gibraltar is a small overseas british territory with a residential population of approximately , inhabitants, that increases up to , daily due to incoming tourists and cross-frontier workers. as a geographically isolated center we have to provide a varied service including emergency surgery, and elective operating such as colectomies, gastrectomy's etc. one of the challenges faced is the limited stock of red blood cell (rbc) units within gibraltar and reliance on platelets (plt) from across the border from spain. given the immanent brexit we need to prepare for the challenges we will face in these times of political and distribution uncertainty. a prospective audit of all blood use within gibraltar was carried out over months. the number and type of units requested, the number of units given, the speciality, location and indication for requests was recorded. introduction: the use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. the advantages with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer complications. we have collected the cases and indications of laparoscopy in abdominal trauma in the main hospitals in the andalusian capitals and compared with the national registry material and methods: a total of patients who underwent laparoscopic surgery in the main hospitals of seville, cordoba, malaga, cadiz, huelva, jaen, granada and almeria were analyzed. they have been compared with the traumas archived nationally by the spanish association of surgeons taking into account age, sex, score of the american society of anesthesiologists, hemodynamic stability and mechanism of injury. the intra and postoperative variables were compared between groups. results: at the national level, the main cause of abdominal trauma were traffic accidents, therefore, it was the patients who had a greater number of laparoscopies ( . %), followed by stab wounds ( , %) and run over ( . %). in our series, the average age of the patients is years and % are male. only eco-fast was performed in % of the patients, being positive in . % of the cases. as they were stable patients, in % of the cases a tac was possible. in our data, % of the laparoscopies were performed for therapeutic purposes as well as being diagnostic, thus avoiding a posterior laparotomy. conclusion: slaparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. we found that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss and faster return to normal diet. based on our findings we establish the indications of laparoscopy in these patients aims: submucosal aneurysm of small intestine is extremely rare, but its rapture can be lifethreatening. due to the unstable hemodynamics and unknown site of bleeding, emergency laparotomy has been widely performed for the rupture. we will present case reports and show the strategy for minimally invasive treatment for ruptured aneurysm. methods: we experienced two cases of ruptured submucosal aneurysm resected by laparoscopic surgery. case is a -year-old male who was taken to our er with massive hematochezia. ct showed arterial bleeding in the small intestine and angiography revealed bleeding from the ilial artery. selective embolization using gelatin sponge and micro coil was performed and hemostasis was obtained. video capsule endoscopy found the hemispheric elevated lesion with protrusion at the top in the ileum. using balloon assisted enteroscopy, the site of aneurysm was marked with injecting india ink, which allows surgeons to accurately and easily identify the part of small intestine with aneurysm. subsequently, a single incisional laparoscopic assisted partial ileectomy was performed for the purpose of definitive diagnosis and preventing re-bleeding. the ileum with aneurysm was easily identified in laparoscopic exploration owing to the marking, and it was taken out from the incision to perform resection. case is a -year-old female who was transferred to our emergency department with sudden onset of massive melena. ct and angiography were perfomed, and bleeding from the rd jejunal artery were confirmed. subsequently, therapeutic embolization was performed in the same way as case . enteroscopy revealed submucosal elevation similar to case in the jejunum. we carried out endoscopic tattooing, followed by single incisional laparoscopic assisted partial jejunectomy. results: the operative time in case and case were min and min, respectively, and the amount of blood loss was both ml. the postoperative course was uneventful in both cases. case was discharged on the postoperative day , and case was on postoperative day . conclusions: our experience indicates that ruptured submucosal aneurysm of the small intestine can be effectively managed by a laparoscopic surgery with combination of therapeutic embolization and enteroscopic evaluation, which is safe and minimally invasive. background: laparoscopic bilateral inguinal hernia repair may be completed with one large selffixating mesh crossing the midline in front of the bladder. no studies have investigated in detail whether preperitoneal mesh placement induces temporary or more lasting urinary symptoms. methods: urinary and hernia related symptoms were evaluated preoperatively and postoperatively at , and months in patients using the iciq-mluts questionnaire and eurahs-qol score. results: voiding symptoms and bother scores were unchanged at or months, but there was significant improvement at months compared with preoperative findings (symptoms p \ . ; bother score p \ . ). incontinence symptoms improved at month (p \ . ) but not at or months, with a bother score significantly improved at month (p \ . ) and months (p \ . ). diurnal and nocturnal frequency did not change significantly postoperatively, but months nocturnal bother score was decreased (p \ . ). eurahs-qol scores showed significant improvement in all domains for all measurements compared to previous measurements. postoperative symptoms were improved at months, compared with preoperative pain scores (- . ), restriction of activity (- . ) and cosmetic scores (- . ) these findings were statistically significantly (p \ . ). at months, there were no patients with severe discomfort (score = ) for any of domains. no recurrences were diagnosed with % clinical follow-up at months. conclusion: placing a large preperitoneal self-fixating mesh for bilateral groin hernia repair did not cause new urinary symptoms and demonstrated significant improvement in voiding symptoms at months. incontinence and nocturnal bother score were significantly improved. introduction: tep/tapp hernia repair is an increasingly widely used surgical methods for minimally invasive treatment of inguinal hernia. tep advantages to tapp are noincision of the parietal peritoneal sheet, therefore no need for its recovery-sewing or sticking at the end of the procedure, and no need for attachment of the prosthetic mesh to the structures of the anterior abdominal wall, which results in a reduction in the financial cost of operation.various types of meshes with different characteristics are used, depending on the surgeon's preferences.the aim of this study is to highlight mesh-related postoperative complications, which can be serious and life-threatening. material and methods: a retrospective cohort study of cases of unilateral or bilateral tep and tapp hernia repair performed at the university hospital for the period - with a study of early and late postoperative complications potentially causally related to the implanted prosthetic mesh and methods of their treatment. results: for a -year period tapp ( bilateral) and tep ( bilateral) have been performed. three complications (clavien-dindo iva, ivb and v) were found, of which were early postoperative (up to pod)-one in tapp- pod small bowel adhesive ileus due to suture dehyscense of the peritoneal sheet and adhesion of a bowel loop to the surface of polypropylene mesh.one in tep- pod-a large preperitoneal hematoma with haemorrhagic shock at years old female in anticoagulant therapy-an open revision of the preperitoneal space and definitive haemostasis; followed in pod established bladder lesion from erosion from the edge of self-locking polypropylene mesh. suture and drainage performed, but the patient died of decompensation of concomitant diseases. a late complication- months after bilateral tep-erosion of soft polypropylene mesh of sigma (probable undetectable lesion of the peritoneum) with faecal peritonitis-hartmann procedure with laparostoma followed by restitution but persistent chroniosepsis with established abscess in retzii. months after-revision with abscess incision and extraction of infected meshes. discussion: use of biologic meshes is quite expensive, however synthetic non-resorbable meshes implanted in preperitoneal layout is a prerequisite for specific severe postoperative complications. inguinal hernia repair is one of the most performed procedure all over the world, with more than million procedures performed each year, it represents one of the top three most performed procedures. the lichtenstein procedure is one of the first procedures that a young trainee in general surgery learn, not only for its reproducibility and for the great numbers of procedures that could be done in each department, but also because during inguinal hernia repair the trainee learn a lot of skills which are the basis of major surgical interventions. the surgeon's performance for any procedure could be evaluated by way of established learning curves that can predict the minimum number of procedures required to reach the same intra and post-operative outcomes as an experienced surgeon performing the same technique. the aim of our multicentre study was to analyse how many cases are required to stabilize operating time (ot) and intra and post-operative complication rates over the course of the learning curve period for a lichtenstein procedure. from january to december all lichtenstein procedures from four different institutions were recorded in a prospective maintained computer database. the results of the first consecutive procedures performed by three different trainees (group a; group b; group c) were compared with the same numbers of procedures by two senior surgeons of the same institutions (group e, group f). cusum analysis was performed to evaluate the achieving of learning curve. no differences in terms of biometric and hernia type were recorded between the five groups. cusum analysis showed that the trainees achieve the learning curve between the - procedures. no intra or post-opertive complications were recorded during the training period.in conclusion after our analysis we found that at least procedures are needed for the trainees to achieve the learning curve for lichtenstein procedures. background: since its first description in the s, the total extraperitoneal (tep) technique has established itself as a popular endoscopic method for the repair of inguinal hernias. the tep repair is generally viewed as a technically-demanding procedure requiring adequate experience to minimize and handle complications. in this case report, we describe an uncommon complication of urethral injury, which was successfully repaired laparoscopically. case report: mr r is a year old gentleman with no significant past medical history who presents to the department of general surgery, tan tock seng hospital, with a two-month history of a reducible right inguinal hernia, associated with some tenderness. an ultrasonography confirmed the diagnosis of a fat-containing indirect right inguinal hernia. in view of persistent pain, mr r was counseled for a laparoscopic repair of his right inguinal hernia. as mr r was able to empty his bladder just prior to surgery, no urinary indwelling catheter (idc) was inserted. an infra-umbilical incision was made to access the posterior rectus sheath and a balloon was used to bluntly dissect the pre-peritoneal plane. on inspection of the operating field, persistent pooling of blood was noted in the retropubic space. careful inspection revealed a defect in a tubular structure just inferior to the bladder neck. an idc was inserted, which confirmed a . cm defect in the pre-prostatic urethra. decision was made for primary repair using absorbable sutures in two layers. the bladder was subsequently filled via the idc, which did not reveal any leak. we then completed the right inguinal hernia repair using a mesh. mr r made an uneventful recovery and was discharged on post-operative day with instructions to keep the idc in-situ for two weeks. the idc was removed after two weeks and a micturating cystourethrogram was performed, which showed no filling defects along the urethra and no contrast leaks. discussion: though uncommon, urethral injuries can be a complication of laparoscopic tep repair. the key to managing these complications is in the early identification of such injuries intra-operatively. with early recognition and careful assessment, such complications can be managed laparoscopically with minimal post-operative morbidity. aim: the purpose of this study is to report surgical technique and outcome of hybrid tapp procedure (a combination of tapp and ipom) for inguinal hernia patients complicated with preperitoneal space adhesion. methods: hybrid tapp procedure is applied if peritoneal dissection or closure of the peritoneum is difficult due to severe adhesion. the peritoneum should be dissected as much as possible. for the site where adequate dissection was achieved, the collagen mesh is placed outside the peritoneum. in the part where dissection was difficult it is placed inside the peritoneal cavity. in order to prevent mesh migration, the mesh should be directly fixed to the cooper's ligament with a tacker. for this purpose, the peritoneum around the cooper's ligament must be well-dissected, even if it is strongly adhered, so that the ligament can be exposed. the crucial points in the hybrid tapp procedure are fixation of the mesh and prevention of the bowel herniation into the preperitoneal space. at the site where peritoneal dissection is possible, the mesh is directly fixed on the fascia using a tacker. if it is difficult, the mesh is placed in the peritoneal cavity and fixed over the peritoneum. if there is a risk of migration along with peritoneum, transcutaneous full-thickness fixation can be performed using non-absorbable sutures. the preperitoneal space should be closed tightly as soon as possible in order to prevent the bowel herniation into the preperitoneal space. at closure of the preperitoneal space, the peritoneum is fixed on the collagen mesh using non-absorbable sutures. objective: show a tapp approach using a self-fixating mesh( x cm. progrip tm laparoscopic self-fixating mesh, medtronic) with bipolar peritoneal defect sealing, avoiding the use of tackers and performing an easy and sutureless peritoneal closure. material and methods: years old male, asa ii, medical history of beta-latacm allergy, high blood pressure, dyslipidemia and bilateral knee surgery. diagnosed of bilateral inguinal hernia at consultation due to inguinal disconfort. surgical site infection prophylaxis with iv vancomycin. balanced general anesthesia. supine decubitus position with shoulder supporting to allow a forced trendelemburg. degree optical device with trocars disposition: one mm umbilical trocar and mm trocar in both flanks, same distance and height to umbilical trocar. peritoneal opening and flap creation with monopolar energy, blunt maneuvers and pneumoperitoneum dissection. anatomical landmarks identification(cooper's ligament, epigastric and iliac vessels, hernia defect and spermatic cord elements). reduction of hernia sac content(pseudosac in this case, direct hernia) and complete peritoneal dissection to achive a correct mesh placing. mesh is folded in parts(one inferior part, two superior parts) in vertical axis outside the abdomen to facilitate the posterior intraabdominal maneuvers. introduction: into abdominal cavity with grasping forceps and correct unfolding mesh assesment: medially(pubic bone), caudal(cooper's ligament) cranial(more than cm of hernia defect/ deep inguinal ring) and lateral(anterior superior iliac spine). finally, we use a bipolar forceps to close de peritoneal defect. in order to facilitate this step, its necessary to decrease pneumoperitoneum pressure and to use the grasping forceps to bring together both peritoneal flap edges prior to bipolar energy sealing. results: min. surgical procedure. h hospital discharge, no complications. routine outpatient follow up(week, month, months and month later) with an epididymitis episode months after surgery(treated with oral ciprofloxacin). conclusions:-this procedure is an easy implementation technique once the intraabdominal mesh unfolding procedure control is reached.-the use of a self-fixating mesh avoid the use of tackers and its potential disadvantages(e.g. increasing postoperative pain).-bipolar peritoneal sealing offers a quick, easy, cheap and safe peritoneal closure, avoiding the contact of the mesh with the viscera in the same manner. results: we performed procedures within patients. the average age was years. twenty six percent of hernias were bilateral, , % were inguinoscrotal and % in the right side. the median asa score was . the conversion rate was , %. the average duration of the procedure was , min min. overall morbidity was %. there were seromas ( , %) . on -year follow-up, one recurrence ( , %) was found and chronic postoperative pain in one case . we had no mortality. in the univariate analysis, male sex, inguinoscrotal hernias, hernias classified as nyhus a were significantly associated with overall postoperative morbidity. a chronic obstructive pulmonary disease was the only variable significantly associated with the occurrence of medical complications. conclusion: given these results, the tapp technique is a good alternative in the treatment of groin hernias. however, enhancing this approach is essential to reduce the operating time and the postoperative outcomes. introduction: studies have emphasized the impact of a strong safety culture on patient outcomes. consequently, many interventions focus on improving the safety culture, of which teamwork and safety climate are important ingredients. it is known that differences in culture and safety attitudes may also impact teamwork. implementations of safety interventions, such as a ' black box', are dependent upon these differences. the aim of this study was to assess the safety culture at the operating theatre complex, along with the theatre staff's attitude towards a specific quality improvement intervention, a black box in the operating room as a tool for structured team debriefing. methods: the validated dutch version of the hospital survey on patient safety culture was administered to all healthcare professionals working in the operating room complex at one academic medical centre. this survey was supplemented with questions regarding the use of a 'black box', a medical data recorder in the operating room, to measure the staff's attitude towards this quality improvement tool and its potential contribution to patient safety. aims: the aim of the study was to compare two methods of treatment of dunbar syndrome: thelaparoscopic release of median arcuate ligament alone and the hybrid method consisting ofsurgery and percutaneous stent implantation to celiac trunk. methods: we performed laparoscopic release of ct in the department of general, mini-mallyinvasive and elderly surgery in olsztyn in - . all of patients suffered from severepain of abdominal cavity before the surgery. three patients underwent doppler percutaneousangioplasty of the ct with stent implantation one month after the laparoscopy. results: all patients reported relief of symptoms in the first days after the operation. in two cases fromboth groups, there were a complete remission of the symptoms. in one case respectively,there was an improvement. there were no postoperative complications. the results of both methods do not show the differences therefore the surgery alone seems tobe a safe and feasible procedure. it increases the comfort of the patient and brings theopportunity for normal functioning. the method of wedge resection of lungs in patients with limited forms of chemo-resistant pulmonary tuberculosis is developed. in order to evaluate the efficacy, patients underwent surgery (the main group). for comparison, the data on similar operations in patients, made according to the traditional method (with the help of a cardboard weaving machine yo- ) were selected. compared the duration of the stage of resection itself, the frequency of need for additional hemostasis of the parenchyma sutures, the degree of deformation of the pulmonary tissue in the seam area, the frequency of postoperative complications and reoperations, the duration of postoperative inpatient treatment. the developed method, in comparison with the traditional one, has the following advantages: simultaneously leak proofness and hemostasis with minimal electrothermal damage to tissues are provided and there is no need for additional hemostasis, there are no negative effects of manual stitching of parenchyma of lung with abandonment of foreign material, a significant reduction in the duration of wedge resection of the lung from . to . min, a decrease in the number of postoperative pulmonary-pleural complications is achieved by . % and caused by them reoperations-by . %, shortening the duration of postoperative inpatient period of treatment from . to . days. introduction/aims: laparoscopy is a diagnostic and therapeutic resource that is largely used in elective gastrointestinal surgery due to its well-known advantages over the classic open approach. nevertheless, there is still some discussion about its application in emergency surgery. our aim is to analize the use of the laparoscopic approach by the members of the surgical emergency unit from our medical center. methods: a descriptive research based on the data of patients who required emergency surgery, that was performed by the members of the surgical emergency unit of a spanish hospital between november and may , was conducted. these data were analyzed according the pathology that motivated the surgical procedure and the chosen form of surgical approach (open versus laparoscopic). results: out of the patients in whom emergency surgery was performed, suffered from a pathology that actually allowed the laparoscopic treatment. laparoscopy was used in . % of these patients. according to pathology, the most common were acute appendicitis and cholecystitis, in which the laparoscopic approach was used, respectively, in % and % of the cases. regarding other less frequent pathologies, such as gastroduodenal perforation, bowel obstruction, diverticulitis and pancreatitis, laparoscopy had a less significant role. according to the year, a general tendency to increase the use of the laparoscopic approach was found, most notably in the cases of acute appendicitis and cholecystitis (with rates above % in ). conclusions: despite our positive results in the terms of the implementation of the laparoscopic approach in emergency surgery, there is still room for improvement, especially in regards of the less common pathologies. furtheremore, additional studies are needed in order to identify the factors that have had an effect, in favour or detriment, in the development of emergency laparoscopy in our center. aims: laparoscopic surgery, which produces small scars, has become widespread. when performing surgery through small laparoscopic incisions, a surgeon manipulates tools inserted into the abdomen through ports. for minimally invasive accurate procedure, the port as the pivot point should be stabilized on the abdominal wall. however, these laparoscopic incisions are loaded while manipulation because it is difficult for the port to be fixed on. thus, it is necessary for the patient friendly manipulation to be fixed the port mechanically. we developed a new pivot restraint device (prd) attached to a trocar for guiding the tool. the purpose of this study is to evaluate both of reducing the operating time and the load of the port with the prd experimentally. methods: the prd uses gimbal mechanism for two rotating axes and a linear guide mechanism for the insertion axis though into the forceps. in the experiment, the left hand forceps with or without the prd and the right hand forceps without the prd were set on the training box. the box had a measuring system created with a pressure sensitive sensor for the continuous force (resolution . n, fps) applied to abdominal wall fulcrum. the experiment task was performed as following three steps. ( ) the surgeon lifted the g weight for s at the initial position using the right hand forceps. ( ) the weight was transferred from the right hand forceps to the left hand forceps, and held for s. ( ) the weight was moved to the predetermined position, held for s, and returned to the initial position. the surgeons were five endoscopic specialists and five non-specialists. the operating time and the time ratio exceeded n for the left hand forceps were measured. two grouped datasets with or without the prd were compared using two-sided t-test. results: the prd was associated with both of reducing the operating time ( . s vs. . s; p \ . ), and the load of the port ( . % vs. . %; p \ . ) at the statistical analysis. conclusion: the prd could be used for reducing the operating time and the load of the port in minimally invasive accurate procedure. background: pathophysiological changes during laparoscopic surgery and positive pressure pneumoperitoneum (pp) may include (beside cardiovascular changes) elevated intra-thoracic as well as intracranial pressures. however, the possibility of physiological and functional cerebral impairment under pp is still debated. aim: to study the effects of pp on brain activity during different modes of anesthesia and ventilation during laparoscopic cholecystectomy (lc). patients and methods: thirty patients undergoing elective lc were divided to those who were ventilated by intermittent positive pressure ventilation (ippv, pt.) and by high frequency jet ventilation (hfjv, pt.). in those under hfjv we used total intravenous anesthesia (tiva). in those under ippv we either used inhalational anesthesia or tiva. intra-ocular pressures were detected in both eyes, trans-cranial doppler was used to measure the changes in flow of the middle cerebral artery, and cerebral oxygenation (o saturation) was measured too. each parameter was detected during anesthesia before surgery, several times during surgery under pp and after co evacuation. a novel computerized signal analysis by a continuous recording through a single electrode was done to explore cerebral cognitive activity during surgery. results: all surgeries went uneventful and without complications, pp was set to mmhg, and each patient was positioned in a degree anti-trendelenburg posture. cerebral perfusion and oxygenation were not changed significantly during pp. intra-ocular pressures decreased during anesthesia and increased during pp, but to a lesser extent under tiva. however, pressures during pp did not exceed pre-surgical values. we did not observe changes in cognitive brain activity during pp, although enhanced cerebral activity was seen under hfjv. conclusions: increased intra-abdominal pressure during laparoscopic surgery was not accompanied by decreased cerebral functions, maybe due to cerebral circulatory auto-regulation. changes in cerebral cognitive functions under hfjv might be explained either by the different cerebral effects of tiva in comparison to inhalational anesthesia, or due to dissimilar hemodynamic changes during hfjv. aims: gallstone ileus (gi) is a rare complication of cholelithiasis and accounts for . - % of small bowel obstructions. intermittent and non-specific presentation often results in late diagnosis. the triad of rigler is pathognomonic (pneumobilia, small bowel obstruction and ectopic gallstones), so an image test is usually mandatory in order to assure the diagnose. our aim is to expose our experience regarding this topic to show that a minimally invasive approach is feasible in selected cases. methods: since january we treated cases of gi, of whom ( %) underwent laparoscopic surgery. in all cases a ct was made to reach diagnosis. enterolithotomy alone is our preferred procedure for the resolution of this pathology. here we present a descriptive analysis of our data in those cases where a laparoscopic treatment was attempted. epidemiological variables, surgical technique, postoperative complications, days until hospital discharge, recurrence, etc. has been collected. results: % of patients were female( ) and % male ( ). mean age was . size of gallstones varied from to mm and ct located them all in the ileum. two conversions to open surgery were made ( %), in one case because the gallstone could not be found and in the other case due to the need of an intestinal resection. in two cases ( %) la aparoscopic-assisted surgery was performed using a pfannestiel incision for the gallstone extraction and enterorrhaphy. only one case was total laparoscopic approach ( %). two cases needed an intestinal resection and anastomosis, one of them was complicated with a leak that needed reintervention. there were two cases of recurrence during the follow-up time. hospital stay varied from to days, mean of days. conclusion: the widespread use of ct facilitates early diagnosis with high sensitivity detecting rigler's triad. a totally laparoscopic procedure might be ideal for patients specially with solitary stones even though a laparoscopic-assisted approach is an easier technique for surgeons with less experience in laparoscopic surgery. although experience in minimally invasive surgical treatment of gi is still developing, it may be recommended in selected cases and experienced hands. introduction: most of surgical interventions in hospitals in the world, where laparoscope is used, it is common that the vision inside the human body is constantly interrupted by fogging in laparoscope tip. the laparoscope fogging is caused by the difference of temperatures between the optic tip and the abdominal cavity. material and method: we replaces the traditional laparoscope for the ehs (endoscope heater system) with resistance between the internal and external tube that maintains the temperature of laparoscope at ( - °celsius) without modifying the external architecture of traditional laparoscope. results: ehs does not generates any waste like other anti-fog systems, like liquids, plastics covers or electric heater. reduces intervention time, can keep same instruments or accessories for the intervention. all of the above means a saving of resources with have a positive environmental impact. conclusions: the discomfort transmitted by surgeons about the fogging in laparoscopy tip make success of the product and it will replace the current laparoscope which is fogged. aim: synchronous locally-advanced low rectal cancer and prostate adenocarcinoma represent a rare condition and a challenging situation for colorectal surgeons and urologists. the simultaneous resection of both adenocarcinomas after long-course chemoradiation therapy combines two major surgical procedures associated with a potentially increased postoperative morbidity. in the other hand, simultaneous resections minimize the risk of difficult dissections, which are expected if the two procedures are scheduled sequentially. in the past decade, robotic-assisted minimally-invasive surgical techniques have been increasingly used to treat both rectal and prostatic malignancies. especially in case of prostatic malignancy, the robotic approach is considered the treatment of choice because it is associated with significantly lower blood loss and transfusion rate, and much greater functional outcomes compared to laparoscopy. methods: we present the case of a -year-old male patient (bmi: . ) diagnosed with a histologically proven locally-advanced rectal adenocarcinoma (ct an ) located at cm from the anal verge and concurrent histologically proven prostatic adenocarcinoma [gleason score of ( ? )] located in the postero-basal right lobe. the preoperative total-body computed tomography (ct) scan showed no evidence of metastatic disease. after discussion in a multidisciplinary meeting, the patient received a long-course neoadjuvant chemoradiation therapy (ncrt). at the restaging positron emission tomography / magnetic resonance imaging (pet-mri), the rectal lesion was classified as ymrt n . preoperatively, the surgical difficulty was assessed as high, based on the calculation of the eumarcs score (equal to / ). moreover, due to the high-risk status of the prostate cancer (gleason ), it was decided not to preserve the neuro-vescular bundles during the radical prostatectomy. results: the patient was operated on after weeks from completion of ncrt by using the da vinci robot system si with a single docking approach, as previously described, in order to address both cancers. conclusions: this video shows the main surgical steps of the simultaneous robotic resection of the low rectal adenocarcinoma first, of the prostatic carcinoma then, and the mechanical colo-anal anastomosis followed by drain positioning and ileostomy. this video demonstrates the perioperative safety and feasibility of the minimally invasive robotic approach in case of extended and challenging oncologic resections. general surgery, rambam medical center, haifa, israel year old, male patient presented with melena, without abdominal pain, nausea or vomiting. patient underwent colonoscopy and tumor was found in ascending colon (near the hepatic flexure). biopsy from the tumor has showed moderately differentiated adenocarcinoma. his blood laboratory examinations were within normal limits except of hgb level- . . cea and cea - were normal. abdominal computed tomography was normal . patient underwent da vinci robot-assisted right hemicolectomy with extracorporeal anastomosis. total operating time was min. three days after operation patient started regular diet and was discharged home on day four. final pathology result confirmed diagnosis of moderately differentiated adenocarcinoma. introduction: one of the goals of colorectal surgery is to decrease the number of leaks once an anastomosis has been performed. this life-threating entity after elective surgery has been related to the clinical history of the patients, the location of the tumor and to technical reasons, specially due to tension in the anastomosis or to lack of vascularization. tension could be identified during surgery, while vascular supply is evaluated by the surgeons based on a subjective analysis of the color of the colon/ileum. fluorescence tries to make these subjective parameter more objective in order to avoid an anastomosis with lack of vascularization, decreasing the numbers of leaks related to this factor. patients and method: the study presents a quasi-experimental analysis made from january to october in two hundred and eighty-five patients who underwent elective colerectal surgery, performing either a colo-rectal, ileo-rectal or intracorporeal ileo-colic anastomosis. vascular supply was eveluated using indocianyne green (icg) in one hundred and forty-five patients, while one hundred and forty subjects were operated in a previous period without using this technology, being considered the control group. the number of time that the attitude changed and the number of leaks were collected. results: out of the cases performed, were right colectomies (rc), left colectomies (lc) and rectal excision (re). in % the transection line was changed ( , % in rc, , % in lc and , % in rr) . in comparison with the control group, the icg group had a significantly less indicence of anastomotic leak compared to the control group ( , % vs. , %, p = , ), lower rate of terminal stoma after reoperation ( , % vs. , %, p = , ), a shorter length of hospital stay ( days vs. days, p = , respectively), and a low morbidity and mortality. conclusions: the rate of leaks after colorectal surgery decrease using icg to detect the proper transsection line before to perform the anastomosis in comparison with control group. these findings might influence in the final results although it is necessary in the future to find a system that provides greater objectivity by quantifying icg. aims: anastomotic leaks continue being one of the most important complications when a colorectal surgery is performed. this complication is usually related to the level and type of resection, the patient clinical history and surgical technique, where tension and vascular supply are the most important. indocyanine green (icg) fluorescence angiography seems to be helpful in order to evaluate the vascularization at the resection margins. methods: we have collected data on colorectal procedures that were performed by the same surgeon using icg fluorescence angiography to evaluate vascular supply to the anastomosis. in order to asses in which of the different type of colorectal procedure has more value to be used, we analyzed the type of surgical procedure, the percentage change in the resection margin and the number of anastomotic leaks (al). results: all of the cases were performed by laparoscopic approach: left colonic resection (lc), right colonic resection (rc), splenic flexure partial resection (sf), low anterior resection with partial mesorectal escision (lar), ultra low anterior resection with total mesorectal escision (ular) and total colectomy (tc). there was a change of transection line (ctl) in lc ( , %), rc ( %), sf ( , %) and ( , %) in rectal anastomosis (lar, ular and tc). as far as al we found: lc ( , %), rc ( %) and , % in rectal procedures. lc, sf and rectal procedure showed more ctl and less al, while rc showed less ctl and more al. conclusion: icg fluorescence angiography as an additional tool to try to reduce the anastomtic leak rate seems to have more value in the procedures that involve the left colon and the rectum, since that is where we have observed the greatest number of ctl, this could be explained by the riolan's arcade and the variability of the vascular anatomy. however, it seems that this is a line of research should continue developing with longer and larger studies, so in that way we can have more significant results. retrorectal tumors ara rare and often found incidentally. the majority of retrorectal tumours are benign, but they have potential for malignant transformation and therefore should be resected when found. a case of a -year-old female patient with a retrorectal tumor is showed. the tumor was found incidentally on ct scan of the abdomen for evaluation of non specific right side abdominal pain. a mri was also performed and imaging was informed as a probably congenital retrorectal tumor (tailgut cyst) there was no evidence of involvement or invasion of other structures the tumor was palpable at rectal examination. a transanal minimally invasive surgery (tamis) approach was proposed. preoperative preparation was done with a full mechanical and oral antibiotic bowel preparation. preoperative parenteral antibiotics werw administred. under general anesthesia, lithotomy position. the contour of the tumor is not visible due to the small size. palpation of tumor and placement of clips to lolocate was done. placement of gel point path and rectal insufflation. a longitudinal incision was made to the posterior left side of rectal wall. the insufflation of the perirectal extraperitoneal space allowe for excellent exposure of the tumor. the tumor was disected with ligasure. then the tumor was extracted transanally.the proctotomy was closed in a single layer with reabsorbible monofilament continuous suture (pds). no complications after the procedure. the patient was discharged at days. discusion: traditionally, the retrorectal tumors have been resected using a posterior parasacrococcygeal approach, an abdominal approach or a combined abdominal and posterior approach. with the advent of minimally invasive surgery, laparoscopyc approach has been described too. however, tamis approach is feasible, with low pain, morbidity, fester recovery and excellent cosmetic (no scare) results. it can be accomplished using standard laparoscopic equipment, with transanal access. we think that perhaps it could be the gold standar approach for this tumors. aimes: robotic-assisted laparoscopic surgery (rals) is a promising advanced technology that can overcome the inherent limitations of conventional laparoscopic surgery (cls). its advantage includes free-moving multijoint forceps, a motion scaling function, high-quality three-dimensional imaging, and stable camera work by an operator. this study aimed to clarify the short-term outcomes of rals for rectal tumors. methods: this study group comprised patients who underwent rals for rectal tumors (cancer in patients and gastrointestinal stromal tumor in patient), excluding ones with distant metastasis from november through december . the clinicopathological findings and short-term outcomes in rectal tumors were analyzed. results: the median operative time was min ( - ). the median console time was min with a median blood loss was ml ( - ). conversion rate was . % ( / ). the median postoperative hospital stay was days ( - ). patients ( . %) had postoperative complications. patients ( . %) had lymph nodes metastases. the mean harvested lymph node was . . the r resection rate was % ( / ). conclusions: these results suggest that rals for rectal tumors is safe and feasible, and the perioperative outcomes are acceptable. introduction: anastomotic healing defects are a feared complication which might have a fatal impact on the patient. fundamental conditions for proper anastomotic healing include sufficient blood supply. fluorescent angiography using indocyanine green in the spectrum of near infrared light facilitates the monitoring of tissue perfusion during a surgery. aim: a presentation of the results of our non-randomized study in which we assessed prospectively obtained data from a perioperative assessment of anastomosis perfusion by fluorescent angiography using indocyanine green during robotic rectal cancer surgery. method: thirty patients with rectal cancer, who underwent a robotic resection with primary anastomosis, were consecutively included in the study between april , and june , . the study included patients facing a least invasive surgery with a guaranteed payment by a health insurance company. during the surgery, we monitored and assessed the quality of the perfusion of the resection line of the sigmoid colon and subsequent anastomosis by means of fluorescent angiography using indocyanine green in the spectrum of near infrared light. the data were obtained prospectively and subsequently analyzed. results: between april , and june , , we consecutively included rectal cancer patients in the project: men and women. monitoring of the perfusion of the resection line and anastomosis was successful in all cases and perfusion quality was satisfactory across the sample. perfusion insufficiency requiring a change in the resection line level or anastomosis adjustments was not detected with any patient. in two cases ( . %) of tme, we gave up the planned protective ileostomy owing to quality perfusion of the anastomosis. one patient ( . %) suffered from defective anastomosis healing without clinical symptomatology (type a). we found no technical complications related to fluorescent angiography or undesirable effects due to the application of indocyanine green. conclusion: even though we did not register insufficient perfusion in our sample and hence we did not have to change the resection line level or adjust the anastomosis, we may state that fluorescent angiography performed by an experienced colorectal surgeon may potentially reduce the frequency of complications linked to defective anastomosis healing.supported by mo aims: the aim of our study is to demonstrate whether robotic surgery has any influence on the reduction of complications in the aged population undergoing rectal cancer. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer. we divided our population in groups: under year old, between and year old and above year old. we recorded complications in each group intra and post procedure. qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. the analysis of data was applying fisher's exact test or chi-squared test for qualitative variables and variance analysis or student'-t test for quantitative variables. statistically significant values of p \ . underwent multivariate logistic regression analysis. results: the present study included patients ( males).seventy seven patients were under year old, patients were between and year old and patients were above year old. the analysis showed conversion rates of . %, . %, . %, and complication rate of . %, . %, and . % in each group. univariate analysis showed no differences between the three groups. nevertheless, there were statistical differences from bmi, asa and neoadjuvant therapy. in multivariant analysis only neoadjuvant therapy was significant. conclusions: robotic approach do not decrease complications in elderly population. introduction: it has been described the advantages of total transanal mesorectal excision (tatme), with better visualization and access to the lower rectum. we use this access whith the gel point path device, to repair a rectovaginal fistula with stenosis of low rectal anastomosis in two patients, that would be difficult by conventional abdominal approach method: we show our surgical technique for repair a rectovaginal fistula with stenosis of low rectal anastomosis in two female patients operated due to rectal neoplasia. one of the patients underwent prior chemo-radiotheratpy. rectoscopy and image test was performed at the patients prior the intervention. no recurrence signs are recorded at mri.we describe the operation technique: a new anterior rectal resection was performed with a combined transanal (gel point path) and abdominal minimally invasive approach. redo anastomosis whith eea stappler was performed, vaginal repair and epiploplasty. the intervention was especially laborious due to the fibrous tissue. pathology: fistulous path without tumor infiltration in the two patients. at two months, a opaque enema show permeability and absence of leaks in the two patients. the ileostomy was closed at three months. discusion: we believe that transanal access through the gel point path can be a good option for rectovaginal fistula and stenosis of low rectal anastomosis, allowing a better visualization and acces, and making more easy a very difficult intervention. introduction: tamis or transanal minimally invasive surgery for polyp resection has increased fame for several situations in which adenomas with or without dysplasia cannot be removed with conventional colonoscopy. in this video we show the step by step technique performed with the da vinci xi system. material and methods: in this video we show the setting and the location of the patient-side cart and the arms to perform the resection of polyps in different patients and how to develope the procedure. results: after placing the patient-side cart the arms are connected to ports and the camera, double fenestrated grasper and scissors are connected to the arms through a transanal gel-port device. a line is described around the polyp with monopolar energy to determine the place of the dissection. the scissor is exchanged by a robotic harmonic wrist instrument and the complete dissection is performed. the wound is closed using a robotic needle holder and a suture. results: transanal robotic surgery could be safely performed after a standardized technique is stablished. aims: robotic rectal cancer surgery has demonstrated to obtain at least the same results than laparoscopic surgery. however, robotic surgery is associated with high rates of costs, specially when conversion to opened surgery occurs. the goal of this study is to create a predictor nomogram of conversions for robotic rectal cancer surgery. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer from october to november . we performed a bivariant analysis and detected the variables which were related with the conversion: body mass index (bmi) and the t. we divided the patients of the population in two groups depends on obesity (bmi of kg/m ) and on t (t - /t - ). we registered conversions in each group calculating the pretest risk. we performed likelihood index (lr ?/-) for under and above kg/m of bmi, adding in a second step the lr of t; obtaining the prediction index for four groups by using a standardize nomogram. results: the present study included patients ( males). were under bmi of kg/m and above. regarding t, were with a tumor of t - and with t - . the analysis showed a conversion rate of the statistical sample of %. univariant analysis showed significative differences in the bmi (p = . ) and t (p = . ). a nomogram was performed; as regards the bmi, the positive likelihood index in the group of bmi [ a prediction index of conversion of % (lr ? , ) and in bmi \ the prediction index of conversion is % (lr- , ). adding the t group data, for bmi [ and t - the conversion prediction rate is . % (lr- , ); for bmi [ and t - the conversion prediction is % (lr ? , ). bmi \ and t - the conversion prediction is % (lr- , ); imc \ and t - , the conversion prediction is %. conclusion: a standardize nomogram with the variable bmi and t facilitates the selection of patients for robotic surgery in rectal cancer avoiding conversion to open surgery. background: d-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice surgeons due to better depth perception. however, the benefits for experienced laparoscopic surgeons are still discussed. aim: the aim of this study is to compare the results of right hemicolectomy (rc) using a conventional ( d hd) laparoscopic system with rc performed using a d laparoscopic system in terms of duration, complications and results. material and methods: from all laparoscopic right hemicolectomies performed in our clinic we selected all procedures performed by the same team of consultant surgeons using the same technique and divided them in groups. the study group comprised of all patients operated using our d einstein vision . system; all other patients which were operated using our standard wolf hd laparoscopy system comprised the control group. all patients were retrospectively analyzed in terms of patients characteristic, or time, duration of operation, intra-and postoperative complications, length of hospitalization, pain score, necessity of analgesics and number of lymph nodes retrived. risk factors for complications (bmi, smoker, diabetes, copd, bph) were also registered. results: there were patients included in the study group, while the control group comprised of patients. mean operation time in the study group was . min in the study group, while mean or time was . min. mean operation time in the control group was . min, while mean or time . min. one reintervention was noted in the control group and two in the the study group; no conversion to open surgery was noted. there were no significant differences regarding patient characteristics, pain score, wound complications, hernia rate, length of hospitalization or number of lymph nodes removed. conclusions: there were no significant differences regarding the outcome of rc using d laparoscopy; total or time was significantly higher in the study group due to the time needed to set up the d-laparoscopy unit. this is biased by the fact that the d system needs to be set up manually while the conventional hd system is integrated in the or. also, there was no significant difference in complication rate. background/purpose: robotic approach can be a treatment option for patients with pelvic recurrence after primary resection for rectal cancer. however, data regarding patient selection, complication rates, and oncologic outcomes are rarely reported. we aimed to present initial experience and to evaluate feasibility, safety, and oncologic outcomes of robotic salvage surgery for recurrent rectal cancer. methods: ten patients who underwent robotic salvage surgery for local recurrence at the anastomotic site, lateral pelvic side-wall, or lateral pelvic lymph nodes (lpns) were retrospectively evaluated from a prospectively maintained database. results: two patients underwent pelvic mass excision with en bloc resection of anastomosis and redo-anastomosis, and eight patients underwent lateral pelvic lymph node dissection (lpnd) for lpn metastasis; one of these eight patient underwent additional en bloc resection of anastomosis. all patients achieved r resection. the median operation time was min and the median estimated blood loss was ml. there were no conversions. as for intraoperative complications, one patient experienced ureter injury during lpnd because the metastatic lpn was closely abutting to the ureter. the median hospital stay was days. in six patients who underwent lpnd, the median number of harvested lymph nodes was (range - ) and the median number of metastatic lymph nodes was (range - ). with median follow-up months, one patient developed lung and pelvic recurrence at months after salvage operation and seven patients remained in disease-free state at the last follow-up. conclusion: initial experience of robotic salvage surgery for pelvic recurrence in rectal cancer indicated that it is safe and feasible. therefore, the robotic approach can be considered as a treatment option for the treatment of local recurrence in selected patients. introduction: there is uncertainty regarding the effects of simulated patient death. several reports showed increased cognitive load and poorer learning outcomes, and others increased performance without causing stress to learners. we have not found any report studying the impact of animal death in the simulation lab. methods: this was an observational cohort study to assess the emotional and cognitive load of surgeons who experienced animal death in the simulation lab. seventy-four faculty and residents from different surgical specialties training minimally invasive surgery participated in the study. one cohort consisted of surgeons whose animal died during surgery, and the other by those whose animal survived. emotions were assessed using the scale for mood assessment and cognitive load with nasa task load index. results: twenty percent of participants experienced mortality while training anti-reflux surgery ( cases) and other procedures ( cases). causes of death included intraoperative pneumothorax (n = ), hemorrhage (n = ), and cardiac dysrhythmias (n = ). participants exposed to animal death had higher levels of sadness and anxiety, and lower levels of happiness (p [ . ). cognitive load was slightly higher in the exposed cohort (p [ . ). conclusions: these findings suggest that mortality in the animal lab do not have a significant effect on cognitive workload and emotions of surgeons training complex laparoscopic procedures. introduction: the visuospatial profiles of expert laparoscopic surgeons remain unaccounted in the current literature for as the influence of visuospatial ability on laparoscopic learning has mainly been investigated in medical students or novice surgeons and using simulators as means of performance measurement. such knowledge is critical, as without understanding how clinical experience may impact visuospatial processes in surgeons, we hinder our efforts to utilize the available knowledge to support surgical education for the future. this study is aiming to explore the development and influence of visuospatial processes on intraoperative laparoscopic learning. method: the study reports the interim baseline results from the ongoing longitudinal study throughout a -year period of training on laparoscopic surgery. data from surgeons including residents undergoing training were captured and compared to specialists who are working in departments of general and visceral surgery at two large hospitals. the mean experience of the surgical residents was years. the mean laparoscopic experience among the senior surgeons is years, with each surgeon performing an average of laparoscopic procedures per week. visuospatial ability was tested using mental rotation test (mrt), guay visualization of views tests (gvvt), spatial perspective taking and spatial orientation test (ptost) and pictorial surface orientation (picsor). spearman correlation coefficient was used in this study with a p-value of significance at \ . . results: senior surgeons have an overall good visuospatial profile, in the sense that they performed close to optimum on all measurement scales. the spearman rho revealed a significant correlation between scores on gvvt and picsor (r = . , p = . ) and between ptost and picsor (r = -. , p = . ). a significant correlation between years of laparoscopic experience and ptost score was also observed (r = . , p = . ). when comparing residents and senior surgeons, no significant difference on the mrt was observed (m = . , sd = . ), nor between baseline scores of senior surgeons and resident surgeons on all tests. conclusion: the results of this study carry important clinical and theoretical implications, as the results hint towards the idea that intraoperative laparoscopic experience lends little to no influence over the development of visuospatial ability. learning models and laparoscopic technical skills, how to adapt each case to improve objectives: according to da. kolb learning is the result of how people perceive and then process what they have perceived. the aim of this study is to identify the personal characteristics of learning in of the participants in a course of laparoscopic technical skills according to the styles described by kolb. methods: between june and november , participants performed a h course distributed over five consecutive days performing laparoscopic manual intestinal anastomosis in endotrainer. they all filled in kolb's learning style test adapted to spanish. the anastomoses were performed in 'ex-vivo' swine intestines. in each anastomosis we evaluated the quality at the end and execution time. the test and quality variables were analyzed through statistical studies. results: in our study, % of the participants were women and % wew men. %were staff surgeons and % were resident. the median age among residents was years and among the staff years. the most frequent learning model in the sample studied was converging ( %). the predominant model among women was assimilating ( %), which, however, represented only % in men. in men, converging model was predominant ( %). among the staff, the most frequent model was diverging ( %). adaptation style prevailed among residents ( %), being rare among the staff ( %). the mean time of the anastomosis was min for both the adapter model and the assimilator, min, for the convergent and divergent models. the quality of the anastomosis performed by each participant was % for the adapter model, % for the assimilator model, % for the convergent model and % for the divergent model. the predominant style in our study was convergent. among women, the most frequent model was assimilator wheras in men it was the least frequent. in the residents, the most frequent model was adapter however, it was very rare in adjuncts. among residents we do not find divergent styles. the highest quality of the anastomosis was achieved by those who worked with an assimilating style. knowing previously the training style we can individualize the teaching methodology in order to improve competences. aims: assess whether laparoscopic appendicectomies (la) are a superior option to open appendicectomies (oa). specifically, comparing the time taken, complication rates and whether it is more appropriate to perform an la overnight, as opposed to oa. finally, to find out how a range of outcomes differs between different grades of surgeon. methods: an information request was sent to the clinical coding department to derive patient identification numbers for all appendicectomies over a ten-month period ( total surgeries). these numbers were then inputted into the hospital information system where the electronic operation note is present, and specific outcomes were derived and analysed. results: % of operations were oa and % were la. mean la times for consultants, sas and spr were . , and min respectively and oa , and min respectively. their respective conversion rates were %, % and %. oa had a complication rate of . %, la was . %. conclusion: oa are performed more than la. spr doctors had the slowest completion times for la but the lowest conversion rates. sas doctors had the fastest completion times for la and oa but higher conversion. la takes longer than oa but has lower complication rates; key factors when performing at night. key statement: laparoscopic appendicectomies require more surgeon-hours and have the potential to be converted to open, however the rates of complications and serious complications are significantly lower. background: paper based resources have been the standard sources for information for centuries. however, more and more people (patients and staff alike) are looking online for information. while the internet often provides excellent resources, there is often conflicting and confusing material of doubtful veracity. trainee staff and patients/carers should be able to access reliable resources whenever and wherever they are. the aim of this project was to create a high-quality resource fulfilling these needs. aim: we present a video demonstrating our integrated colorectal education website ( http://www.colorectaleducation.com/). our approach: high quality health care provision requires highly trained staff as well as wellinformed patients. information resources for these two groups are usually accessible from different repositories. our integrated website provides a common platform for all those involved in colorectal surgery, to use, learn and reflect on. users are directed to separate sections for patients and colorectal professionals. multiple disclaimers prevent patients accidentally stumbling across clinical/ operative information, whilst providing access to those who wish to do so. trainees struggle with balancing their educational needs with their service commitments. this website gives them the opportunity to view detailed operative training videos on the go. many of videos are chapter based allowing them to stop and re-start with ease. modules are also available for nurses providing them access to relevant educational material. the modular design of the website allows us to build upon it with more topics planned to be added over the next eighteen months. the resource also has detailed chapterised videos for patients due to undergo various colorectal procedures. all have been approved by a multi-professional panel including patients and are designed to provide information, offer support and to allay any anxiety. videos with the care pathway and previous patients' experiences are accessible on demand. conclusion: on demand information has now become the norm with the use of smart phones/ tablets. this website provides patients, surgical trainees and other healthcare professionals access to information and education in a clear and reliable format anywhere in the world. colorectal education, on demand and just a click away! objective: in the last decade the growing interest in robotic surgery is evident as shown by several published articles. the aim of the present study is to evaluate the main outcome of a single center experience and to describe the organizational system we have progressively established in our center in order to improve the development of robotic program in all surgical area. materials and methods: we report a case series of patients who underwent robot-assisted surgery at sanchinarro university hospital since the beginning of the program (october ) until november main patient demographic characteristics, type of surgery, peri and postoperative data and follow-up were evaluated. results: a total of robotic procedures were performed for a total of patients. the prevalence of malignant disease was %. a total of pancreatic surgery were performes; liver resections (mean operating time: min); gastrectomy (mean operating time min); esophagectomy (mean operating time: min); colorectal resections ( rectal resections, sigmoidectomy hemicolectomies right, left colectomy) (mean operating time: min); nissen procedures (mean operating time: min), esofagheous myomectomy for achalasia (operating time: min); adrenalectomy (mean operating time: min); three biliary surgery for benign desease, splenectomy. eight partial resection of the duodenum, one yeyunal resection, one mesenteric cyst resection and retroperitoneal tumor have been performed. conversion rate was %, total morbidity have been %. there has been no peri and postoperative mortality up to days after surgery. the average hospital stay and intensive care were respectively days (range - days) and . days (range - days). conclusions: the organizational model defined in our center is facilitating the constant and progressive development of the robotic program. a broad and flexible availability of the robotic system, a progressive increase of young surgeons joining this technology as well as the institutional and departmental economical effort are the points with which the robotic system may increase its development in a surgical department. aims: endoscopic surgery has been widespread in the field of general surgery. however, in japan, there is no standard program for endoscopic surgery training, and its competency has not been considered for the acquisition of board certified surgeon. the purpose of this survey was to investigate the current situation of endoscopic surgery training and autonomy of young surgeons for endoscopic surgery in japan. methods: the survey was planned to target general surgery members of the japan society for endoscopic surgery (jses) who was post graduate year or less. after approval by the ethics committee of jses, the request for the participating in survey was mailed to object members. questionnaire responses were available in print or online media. the contents of the questionnaire consisted of items, about the conditions of endoscopic surgical training, experienced case number, and the self-assessment of autonomy from to point by zwisch scale in specific procedures of endoscopic surgery. results: the total response rate was . % ( / ). sixty five answers were excluded due to inadequate response and answers were analyzed. of the questionnaire respondents, % were male and % were female. the ratio of board certified surgeon was %. although % of the teaching hospitals had simulators for basic training of endoscopic surgery and % of the respondents practiced basic skill of endoscopic surgery, only % teaching hospitals had specific training programs for endoscopic surgery. the surgeons who operated cases of laparoscopic appendectomy and inguinal hernia repair and cases of laparoscopic cholecystectomy, right hemicolectomy and sigmoidectomy, felt confident to perform each procedure independently. regarding with laparoscopic rectal resection and gastrectomy, even though the surgeons who had cases of experience, they didn't had confidence to perform those procedures independently. conclusions: this study is the first national survey to investigate the status of endoscopic surgery training in japan and the autonomy of young surgeons for endoscopic surgery. in order to develop a training system for not only basic skills but also advanced procedures of endoscopic surgery, cooperation of each teaching hospital, academic surgical society, medical specialty board is necessary. currently there is a debate about what is the most optimal work schedule for residents of general surgery, it is important to respect the free time of residents to avoid burnout, however it is also important have enough exposition to clinical cases that allow a satisfactory development in the clinical practice. this becomes even more important when we talk about the learning of surgical skills. this is where the laparoscopic simulation industry opens a large area of opportunity, for a reasonable price it is possible to practice basic laparoscopic skills without compromising patient safety. this is a pilot study that was carried out during the period from january to june , in a public hospital in monterrey, nl, mexico, the composition between the execution of the standardized exercises of the fls (fundamental laparoscopic surgery) in an endoscopic simulator was performed to residents of general surgery (from first to fifth year) hrs before being on call vs these same residents post call. a series of questions was asked to each resident in each measurement, so in this way they answered the same questions twice, then a comparison of the results of both questionnaires was made. the results of the exercises were assessed and rated by the same person using the criteria established in the fls for the scores of each exercise and for the final grade. an average age of years was obtained, measurements were taken of residents of which are male and female. on average, the residents before be on call performed the exercises with h of having slept while the post call performed the exercises with . h of having slept, the residents before be on call had on average . h without sleep while the post call had h without sleep. the average number of hours worked per week is h, measured by the time in and out of the hospital. in this study, conclusive results were obtained regarding the null relationship of sleep deprivation with the performance of laparoscopic skills in surgical residents. aim: 'precision cutting' is one of skills tasks of the fundamentals of laparoscopic surgery (fls) program, which is cutting a circle on a piece of gauze under laparoscope and assessed by completing time (maximum time limit: s). there is no definition of quality of the final product. the aim of this study is to develop an assessment tool of laparoscopic precision cutting and test its reliability. method: an assessment tool of laparoscopic precision cutting was developed with four items based on completion, degree of deformation, degree of being pulled, and overall appearance of the final product of laparoscopic precision cutting by experts' meetings. the scale of each item was points likert scale. a descriptive sheet with a legend and a text description for each scale (fig) was attached for assessors' reference. for our high school entry medical students, they gained hands-on experiences of laparoscopic skills first time by attending a -hour course at minimally invasive surgery training center, national taiwan university hospital (ntuh). we invited students to participate this study after this training. we collected participants' final products of ' precision cutting' station and assessed them by using this assessment tool. this study was proved by institutional review board, ntuh (irb no: rinb). results: students were enrolled between february to june . two non-medical assessors and a senior surgeon were invited to assess the products. the mean score and cronbach' s alpha value of each item were as followed: completion . ± . , . ; degree of deformation . ± . , . ; degree of being pulled . ± . , . ; and overall appearance . ± . , . . conclusions: in summary, we successfully developed an assessment tool for laparoscopic 'precision cutting' and showed its reliability. the tool could provide qualitative descriptions for objective feedbacks. validating this tool in a large scale is undergoing. purpose: to evaluate whether the participants who experienced this scenario could recall an interventional scenario for testing trainees' situational awareness and intra-operative decision making when they participated this training again. methods: we designed an iodm training course for junior surgical trainees and nurses by using live pigs since sep . in the first simulation, we created an interventional scenario and then provided an educational session. a researcher disconnected the ekg monitor on purpose for creating a scenario that the pig would lose vital signs when the team nearly finished a diagnostic laparoscopy. if the team did not aware the situation after . min, a researcher would remind the team (fig). we used a new developed assessment tool of iodm and an assessment tool for nontechnical skills for surgeons (notss) for self-evaluations and objective assessments. we also discussed with them about their reactions while encountering this interventional scenario. results: between sep to june , teams participated this training and experienced this interventional scenario. fourteen nd year surgical trainees have experienced it before. only one participant ( %) recalled it and made a quick decision while encountering this interventional scenario again. the results of iodm assessment and notss did not show statistical difference comparing their self-assessments in the first and second year. based on the analysis of the discussions, most of them remembered this this interventional scenario and reminded themselves to react it properly before the simulation. however, when they were the primary surgeon of diagnostic laparoscopy, they focused on performing this procedure and tutoring their junior trainee. they had no capacity in their brain to notice the change of vital signs. in addition, although they increased their situation awareness in clinical settings after the st time iodm training, they did not show this ability in the simulation. conclusions: recalling of an interventional scenario for testing situational awareness of surgical trainees was very poor ( / , %) among the nd year surgical trainees. qualitative analysis of discussions showed their brain capacities were occupied by performing new procedures and tutoring others. how to enhance trainees' situational awareness should be addressed. aims: a well-designed learning curve is essential to measure the progress of surgical abilities. learning curves are very important to test the skills of trainees. however, there are still no welldefined criteria for developing good learning curves. as a result, many authors use subjective evaluation criteria. the purpose of this review is to analyse this field of surgical education and to identify the key criteria for good learning curves. methods: learning curves were investigated in the field of laparoscopic and robotic minimally invasive surgery. surgery of appendectomy, cholecystectomy, cholectomy, inguinal hernia repair and gastrectomy were considered. the type of surgery, the year of publication, the design of the study, the surgeon's experience (resident, young or senior), the surgical technique, the number of patients involved in the study and the suggested learning curve by the different studies were taken into account. in the selection of articles, more importance was given to those based on the activity of young surgeons or residents. results: the literature analysis showed conflicting results. the different learning curves for the same surgery may be due to the different evaluation criteria considered. only a few studies investigate the learning curves of young surgeons and residents. conclusions: the data available in the literature on learning curves are contradictory. several factors need to be evaluated in order to create more accurate learning curves. we suggest the introduction of checklists with a score for each parameter to be examined, in order to develop more objective and standardized learning curves. aim: the uk training programme for transanal total mesorectal excision (tatme) has completed its first round of training. the study aim was to design a reporting platform that provided trainees with video-assisted feedback in a clear, concise and useful manner to support their training. methods: an established method of video analysis called observational clinical human reliability analysis (ochra) was used to assess the surgical performance of the trainees during their clinical tatme cases. a reporting form for the ochra results was designed identifying areas of difficulties in each procedure and providing error reduction mechanisms. this was piloted during the national training programme for tatme in the uk. results: the ochra reporting form underwent three modifications before the content and format was agreed upon. the final version is divided into three sections: a. case details, b. ochra findings, and c. suggested error-reducing mechanisms. for part b the tatme procedure was divided into four phases of the operation: . pursestring, . rectotomy, . tme dissection, and . connected phase when the abdominal and transanal teams work together synchronously. for each phase, ochra findings described the most frequently occurring technical inaccuracies/errors, number of consequential errors/adverse events and the most frequent and serious consequences encountered. suggested error-reducing mechanisms in part c were developed and established by an expert workshop and individual interviews with international surgeons experienced in tatme.trainee and mentor feedback stated that the reporting form had a clear format, easy to follow and understand. the error-reducing mechanisms were particularly useful and allowed the trainee to focus on improving specific technical aspects in their subsequent cases. conclusion: video analysis using ochra can provide a wealth of information on surgical performance, especially for trainees at the start of their learning curve. as an exploratory study, validation of the reporting platform is required; however, its potential to offer detailed, individualised feedback to enhance training is promising. laparoscopic pelvic surgery training program-using a new concept d-printed versatile pelvi-trainer r.c. elisei , f. graur , c. popa , e. mois , l. furcea , n. al hajjar general surgery, bistrita emergency county hospital, bistrita, romania; general surgery, regional institute of gastroenterology and hepathology ,,prof. o. fodor,,, cluj-napoca, romania pelvic laparoscopic surgery (rectal, urological, or gynecological laparoscopic surgery) is an advanced surgery which require advanced skills, not easy to acquire. there are a lot of training programs for advanced laparoscopic skills but many of them are not affordable for most of surgery residents in eastern europe, where the training programs are far behind from those in western europe. because of that those training programs need to be improved and optimized. in the european union we want equal and high skilled surgeons. this is why we designed a new concept of pelvi-trainer, a versatile one in order to offer the residents the possibility to achieve advanced laparoscopic skills like perfect coordination, precise movements, ability to cut and suture after a well defined route, all of them in the pelvis tight space. we d-printed this pelvitrainer which has multiple characteristics: cheap and easy to produce, easy to be used, versatile because offer the possibility to achieve the skills named above, and many others, but also to train on real ex vivo animal rectum (suine model). we also believe that with a proper training a medical student and a young surgery resident are able to achieve the same skills like experienced surgery residents or specialists. in order to demonstrate that we need a study to compare the time to perform or more exercises in this new concept pelvi-trainer by the medical students, young and experienced residents and surgery specialists. what we want to achieve with this training program project is to have more and more skilled surgeons in advanced laparoscopy and an equal laparoscopic surgery training all over the country, close to the level of training in the western europe. also we want this training program to make a standardization of the pelvic laparoscopic surgery training first in our country and then in other countries if possible. aims: the objective of this systematic review is to provide an evidence-based overview of the different components of laparoscopic training curricula, emphasizing the value of objective forcebased assessment and how this in implemented in modern laparoscopic training. methods: bibliographic databases of pubmed and embase were searched till april to identify studies reporting on evidence-based laparoscopic skills training. abstracts of retrieved studies were reviewed by two authors independently and those meeting the inclusion criteria were selected for full-text review. results: the search yielded a total of individual records. a total of articles were included. the articles were divided into nine different categories, which include 'metrics', 'benchmark criteria', 'measurement systems', 'timetable', 'training modalities', 'camera settings', 'training tasks', 'serious gaming', and 'competition'. a descriptive analysis of the data is provided. motion analysis parameters, such and path length and time are frequently validated and used for assessment. the results of validation studies on tissue manipulation parameters, such as maximum force and mean force show proved their discriminating power between different levels of proficiency. however, implementation of these metrics remain restrained. conclusions: numerous studies on laparoscopic skills training have been conducted over the years. nevertheless, no consensus is reached towards the use of objective assessment tools. although the value of validated metrics is described well, implementation of objective metrics is limited. we recommend to consider objective force-and motion metrics for feedback and assessment during laparoscopic skills training. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania aims: the aim of the study was to create a new easy learning method of swine liver anatomy for residents in training. based on human liver surgical anatomy we put 'face to face' the similar structures and also the differences using ex vivo porcine models and ct reconstructions from live pigs. methods: having in mind the human liver anatomy, in the first stage we used data obtained from dissection of twelve porcine liver models to create an anatomical pattern, which summarized the most important surgical information. in the second stage, anatomical data obtained from ct scans of twelve living anesthetized pigs were analyzed. the ct reconstructions and volumetry data were added to the gross anatomy pattern to create a more complex learning module. results: the residents established the most frequent description of swine liver anatomy by putting together the information from ex vivo model dissection. the liver parenchyma is divided into four main anatomic lobes: left lateral, left medial, right medial and right lateral. all those lobes are connected only in the posterior part, which allows a very good separation between them by deep fissures. just as in humans, we found eight distinct segments with independent vascularization and biliary drainage. portal vein has a specific 's' shape; in most cases hepatic artery was found like a trifurcation and extrahepatic biliary tree has a very thin wall. in the right hemi-liver, the inferior vena cava passes through the liver parenchyma. most frequent, we found five hepatic veins which are running completely intraparenchymal. the imagistic data offered a very useful d reconstruction with anatomical positions of the vascular-biliary tree and liver segmentation and gave us the possibility to create practical scenarios for resections. perhaps the most important information was to discover and see the section plan and to calculate the volume of the remaining liver after resection. conclusions: the anatomical-imagistic pattern based on \ i[ex vivo \/i [ model disections combined with imagistic data offers a unique mindset before intervention. the concept 'human \ i[vs \/i [ swine' to create an easy method of learning for residents in training can be applied to swine liver anatomy. the learning of surgery is traditionally based on the behaviourist model . goals are set, standards of care fixed, with regular assessments of the level achieved. the teacher exercises control over the student, imposing rules and models, supported by 'reinforcing' actions (reward or punishment). the theory of skinner's program of education, from , is reflected in surgical learning. it foresees a gradual progression by level of difficulty, following a transmission-imitation model . these theories seem currently outdated to face the new challenges of medicine and surgery and to keep up with technological developments. bruner, one of the theorists of the constructivist model, proposed in a method of collaborative learning between those who teach and those who learn. the goal of the method was to improve strategic problem solving. the comparison between various perspectives (between teacher and student), allowed the learner to better absorb knowledge and improve critical thinking. in kapur published on the theory of 'productive failure'. this model makes the error of a single person useful for all his colleagues, privileges the practice of theoretical knowledge, contextualised learning as opposed to abstract learning, and 'guided' practice compared to a 'guided' theory. bruner and kapur's systems favour creativity, critical analysis of a problems origin, and the practical use of knowledge. they represent a hypothesis of learning, based on constructive discussion and a continuos 'give-take' feedback system. in order to put these new models into practice in the clinical context, one may hypothesise and propose the adoption of a formal discussion of clinical cases that are complicated or difficult. thereby making the theoretical lessons more collaborative, intuitive and inclusive. in the surgical field, one could adapt such a concept to surgery simulation, virtual reality and anatomical models. aim: large hiatal hernias have a surgical indication when the patients suffering disabling symptoms such as anaemia, dyspnea, chest pain, gastric reflux. several studies showed that in the case of large hernias the placement of a prosthesis was safe and could protect against recurrence. mini-invasive surgery is the preferred approach for hiatal hernia repair and anti-reflux procedure and the toupet fundoplication has been shown to be the best surgical technique for the hiatal hernias repair.the laparoscopic approach is currently the surgical gold standard but is burdened by technical difficulties especially in the case of large hiatal hernias. the robotic system is designed to overcome some technical difficulties of laparoscopy and the studies available in literature report the safety and effectiveness of the robotic approach in complex hiatal hernias repair. methods: we present the case of a grade iv hiatal hernia treated with a robotic approach in a years old woman (bmi: kg/m ). the medical history consisted of a road accident with a probable mechanism of deceleration, three years before. the patient had been suffering from dyspnea for three years. due to the recent discovery of an anaemia, the patient was subjected to an endoscopic examination with the identification of a voluminous grade iv hiatal hernia. a subsequent computed tomography (ct) scan showed also the partial herniation of the transverse colon. results: the patient underwent to surgery by using the da vinci robot system siÒ (intuitive surgical, sunnyvale, usa) with a single docking approach. the surgery consisted in the liberation of the hernial sac, the placement of a goretex prosthesis and the packaging of a toupet fundoplicatio. the surgery was performed without complication. conclusions: the robotic approach in the hiatal hernia surgery seems to be a valid alternative to laparoscopy, especially in complex cases. the surgical ability in robotic surgery is of paramount importance. general thoracic surgery, kawasaki municipal hospital, tokyo, japan aim: video-assisted thoracoscopic surgery (vats) with carbon dioxide (co ) for mediastinal surgery is known to improve the visualization of medaistinal space. we report our experiences with two cases that underwent vats thymectomy using co insufflation under the one-lung ventilation general anesthesia by double lumen tube. methods: the instruments that were used for vats thymectomy were only the -mm -degree rigid thoracoscope, maryland jaw energy device, cotton made-dissectors, and straight endoscopic grasping forceps. they were used through sealed ports designed for laparoscopic surgery. lowpressure co insufflation set at mmhg were used for compression of surround tissue of mediastinal tumor during the releasing procedure. results: the patients were an -year-old male and a -year-old female. thoracoscope with the mmhg co insufflation provides excellent visualization of the medaistinal space and operation could be done smoothly without any hemodynamic compromise. their pathological diagnoses were thymic cancer and thymoma, type b . the operative times were min and min. the postoperative courses were uneventful and the patients were discharged on day th and rd . conclusion: we have just begun to routinely use co insufflation for mediastinal tomorectomy and present our early experiences of successful vats thymectomy by utilizing co \ su \/su insufflation. aims: this retrospective study aims to evaluate the feasibility of single-incision thoracoscopic surgery (sits) for primary spontaneous pneumothorax (psp), using a novel multichannel port (x gateÒ). methods: between october and november , ten patients who underwent sits using x gateÒ. nine patients were male and was female, with mean age of . ± . years old. a . cm incision is placed in the middle axillary line on the th or th intercostal space, depending on the lesions. postoperative outcomes of these patients were compared with those of patients with psp who underwent conventional three-port video-assisted thoracic surgery (vats). results: there were no conversions from sits to vats. mean operative time of sits group was significantly shorter than that of three-port vats group ( . ± . min vs . ± . min, p = . ). mean number of staplers used in surgery was . ( ) ( ) ( ) ( ) in sits group and ( ) ( ) ( ) ( ) ( ) in vats group (p = . ). mean duration of postoperative drainage was also shorter in sits group ( . ± days vs . ± . days, p = . ). no recurrence and wound infection were observed in sits group. conclusion: sits using x gateÒ is feasible when performed for selected patients with psp. x gateÒ provides good visualization of intrapleural space and esthetic outcomes, as well as a superb maneuverability by decreasing mutual interference of surgical instruments. although conventional three-port vats for psp is well established, sits using x gateÒ can be a permissible alternative. further examinations are required to evaluate efficacy of sits using x gateÒ. aims: haemorrhage remains a leading cause of potentially preventable death in trauma. in particular non-compressible torso haemorrhage is approximated to cause - % of mortality in civilian trauma patients with otherwise survivable injuries and % in war setting. we performed a literature review to assess the potential for using endovascular stenting in traumatic venous injuries and explore the evidence of their efficacy and safety with different venous injury patterns. methods: systematic online search of pubmed performed using key words'endovascular stent', 'venous injury', trauma, penetrating, blunt, abdominal and pelvic. inclusion criteria included all studies that explored the use of endovascular stents following traumatic abdominopelvic venous injuries. english language studies were used. results were presented according to prisma guidelines. results: of the studies generated by the search,there were only four case reports in the literature documenting the use of endovascular stents in traumatic venous injuries dating back to and most recently . the four cases included three retrohepatic ivc injuries, two secondary to blunt trauma and one penetrating; whilst the final case a blunt injury at the ilio-caval bifurcation. all four cases reported successful deployment of stents via the femoral or internal jugular veins, with subsequent resolution of haemorrhage. length of time taken for stent insertion ranged from to min. three of four patients made full recoveries and discharged from hospital, with one patient subsequently dying of a brain injury independent of the successful venous stent insertion. no complications were reported at up to months follow up in remaining cases including stent leak, stenosis or migration. conclusion: endovascular venous stents have been used successfully in managing complex abdominopelvic traumatic venous injuries. in particular retrohepatic venous injuries refractory to hepatic packing and vessel embolization, which are not amenable to direct surgical repair due to anatomical location. however before endovascular stenting can be added to the arsenal of interventional radiologists for abdomino-pelvic trauma, further development of stents custom made for venous injuries as well as prospective studies examining their long term safety and outcomes is needed. tracheal papilloma is a rare neoplasm growing from the tracheal or bronchial epithelium and has no specific clinical presentations. this is a -year-old female who complained of progressive dyspnea for about months. physical examination was unremarkable and the there was no abnormal finding by the chest plain film. chest computed tomography was arranged and revealed a mass lesion located at the tracheal lumen with more than % luminal obstruction. we used fiberoptic bronchoscopy to evaluate the airway and found a mass lesion with pedicle originated from the posterior tracheal wall. cryotherapy was considered for the tumor mass removing to establish a patent airway. the pathologic report revealed tracheal papillomatosis without any malignant component. dyspnea was immediately improved and the patient chose closely observation after the bronchoscopic cryotherapy. aims: recent advances in laparoscopic surgery, both in techniques and instrumentation material, have led to the emergence of innovative technological fields, among which robotic surgery stands out.one of the handicaps of this surgery is its high cost as well as the long learning curve. in this stage a new tool arises, the flexdex semi robotic arm, which combines the precision and the range of movements of robotic surgery with the greater availability, simplicity of use and learning of conventional laparoscopic surgery.the objective of this study is to evaluate the efficacy and safety of the flexdex device in different laparoscopic procedures. methods: flexdex's is a three-axis gimbal technological device integrated in a conventional laparoscopic instrument that translates the surgeon's hand, wrist, and arm movements from outside the patient into corresponding movements of an end-effector inside the patient's body.the greater accessibility provided by the flexdex allows the surgeon to perform sutures in areas of difficult access where mobility with conventional laparoscopic instruments is not optimal. the comfort of the surgeon remains fundamental in any type of surgery, even more when we are in anatomical locations with complex access, especially for the realization of sutures. here is where surgical innovation instruments such as flexdex provides ergonomic comfort for the surgeon and improves the patient's safety, especially in high-risk situations, such as when performing anastomosis. results: we present a prospective series of laparoscopic procedures carried out by the same surgical team being the initial experience in our environment in the use of the flexdex semi robotic arm for the realization of complex anatomical sutures.this is a case series of patients to whom different surgical techniques requiring manual suture have been performed. these being tapp procedures, nissen-type fundoplicature and reinforcements of colorectal anastomosis. it is important to note that in none of the cases complications were recorded conclusions: flexdex can provide an excellent alternative to the robotic systems in complex surgical procedures, offering surgeons the precision and control they desire while maintaining the balance of cost, outcome and patient benefit. background: a new single-port device (fsis-flexible-single-incision-surgery) is presented. this new platform has three working channels, two for rigid instruments and one for the flexible endoscope. the channel for flexible instruments offers a pneumatic sealing to avoid the air's leak of the cavity (abdomen, rectum, vagina) . in this study the preclinical data are shown testing the feasibility and safety for laparo-endoscopic instruments. methods: experimental evaluation of feasibility and safety in two stages. in the first stage a working channel with pneumatic sealing was tested in simulators to use a flexible endoscope. in the second stage (animal model) the single incision device that makes possible to use laparoscopic instruments and flexible endoscopes was tested. the measured variables were: time of the procedure, co employed, adverse intraoperative events, grip's losing, losing of pneumatic sealing, feasibility and safety of the procedure for the surgeon. results: the hysterectomy and double adnexectomy was done with a median time of . min. the median of the co consumption was . litres. only in one case ( . %) the surgeon had problems with the abdominal navigation of the endoscope that was easily solved. the grip's lose wasn't a major problem. the median size of the skin incision was . cm. the median surgeon' score for the feasibility was and for the safety was . . conclusions: the surgeons considered that the use of the device was very feasible and safe. the fsis-device is a universal platform for single-incision-surgery for surgeons and gastroenterologists and for abdominal, rectal and vaginal access. aim: despite the near-infrared fluorescence (nirf) via the intravenous administration of indocyanine green (icg) improves the visualisation of the cystic duct (cd) and the extrahepatic biliary tract (ebt), the back fluorescence of the liver reduces the signal-to-noise ratio.we have modified the technique of nirf cholecystocholangiography with intragallbladder icg injection by using the arrow-karlan tm balloon cholangiography catheter instead of the purse string at the gallbladder's fundus. this procedure allows a high rate of visualisation of the ebt, with few cases of icg leakage.aim: of this study is to confirm the feasibility of this different technique and to analyse the icg spillage from the gallbladder and to identify the ebt. methods: we enrolled nine patients undergoing laparoscopic cholecystectomy for cholelithiasis. the gallbladder was perforated with the cholangiogram catheter, the balloon inflated with . ml of saline and tightened. the bile was drained and the icg bolus injected. a titanium clip was the placed on the catheter strict closely to the gallbladder in order to prevent the catheter dislocation. results: the cd and the ebt were visible before dissection in / and / patients respectively. after dissection the cd was visible in all the patients and the ebt again in / patients. there was only one icg spillage due to a tardive positioning of the clip. in a case of inflamed gallbladder this technique helped in the identification of the dissection plane. conclusions: our preliminary results of this ongoing study confirm the feasibility of this different approach as a possible alternative to the purse string and a good visualisation of ebt. introduction: robotic-assisted surgery is a promising technique for overcoming the limitations of laparoscopic surgery, especially with regards to complex and advanced surgical procedures. here, we describe the establishment and implementation of our robotic upper gastrointestinal (gi) and hepato-pancreato-biliary (hpb) surgery program within our center of excellence for minimally invasive surgery as well as the first-year results. method: robotic-assisted surgery was performed using the davinci xi surgical system tm and performed by two surgeons specialized in minimally invasive surgery (db and tk). our robotic surgery program of upper gi and hpb surgery was established in three steps: ( ) first, surgical procedures with easier degree of difficulty were performed robotically, including cholecystectomy, minor gastric resections and fundoplications. ( ) then, pancreatic distal resections, enucleations, adrenalectomies and atypical liver resections were robotically performed, as procedures with moderate degree of difficulty. ( ) finally, advanced and highly complex procedures were performed, including right hemihepatectomy, complex pancreatic head resections (including portal vein resections), total gastrectomy and esophagectomy. data collected from july till july were retrospectively analyzed with regard to conversion rate, morbidity (clavien dindo grade £ ) and mortality. results: within the first year, a total of robotic assisted upper gi and hpb resections were performed. the first step of establishing our robotic surgical program included eight procedures. here, conversion rate, morbidity and mortality were %. within the second step of establishment procedures were performed. conversion rate, morbidity and mortality were %, % and %. the last step included of advanced and highly complex procedures. these procedures resulted in a conversion rate of %, % morbidity and % mortality. conclusion: our stepwise approach enables a safe implementation of a robotic surgical program for upper gi and hpb surgery with low morbidity and no mortality even for highly complex procedures. however, highly complex procedures required a high conversion rate, which might be caused by the early stage of experience. the standard surgical procedure of choledochal cyst is a complete excision of the cyst with rouxen-y hepaticojejunostomy and laparoscopic surgery had been increasingly used. this is still a challenging way to perform anastomosis due to the small diameter of bile duct and the possibility of bile leak or stricture. robotic system can overcome the shortcomings of laparoscopy with providing three-dimensional view, magnification, and articulated instruments. from jan to dec , patients underwent robotic cyst excision and hepaticojejunostomy by single surgeon. we reviewed the clinical data and compared with laparoscopic outcomes of early (from to ) and late (from to ) group, retrospectively. patients of robotic series were all female with mean age . years and bmi . . the mean size of cyst was . . cm, and todani type ia , ic and iva , respectively. total trocars were used with robotic working arm and assist and camera. the mean operative time . ± . min, and it was similar with late laparoscopic group ( ± . min) and significantly shorter than early group ( ± . min).there were no open conversion in robotic and late laparoscopic group, however, the early laparoscopic group involved % of conversion rates. the hospital length was ± . days in robotic group, and it was similar with late group ( ± . ) and more shorter than early group ( . ± . ). in robotic series, postoperative complications occurred patients. one case included cholangitis which was resolved after conservative treatment. bile leakage was developed in patient, and treated with drain that inserted intraoperatively. last cases showed incisional hernia at postoperative months, and was corrected by laparoscopic herniorrahphy. complications (n = ) in late laparoscopic group included hepaticojejunostomy stricture and stone, bleeding of jejunal branch, portal vein thromobosis, acute pancreatitis, and adhesive ileus. there were no mortaility case in any groups.robotic surgery of choledochal cyst is a safe and feasible option with short-term results that are comparable to laparoscopic approach. general surgery, sanchinarro university hospital, madrid, spain background: the incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. the surgical management of these patients is still under debate. the aim of this paper is to evaluate the safety and feasibility of robotic enucleations. methods: we retrospectively reviewed our prospectively databases from november . demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. results: patients were included. the mean age of the patients was years ( - ). the median body mass index was ( - ). ten lesions were located in the pancreatic head, in the pancreatic body, in the pancreatic tail. operative time was min (range - ), no intraoperative transfusion were needed and in one patient conversion to open approach was needed. in three patients grade b pancreatic fistula occurred. the mean postoperative stay was , days. conclusions: robotic enucleation is a feasible and safe approach, with low incidence of morbidity. the results of surgical treatment of patients with pulmonary tuberculosis were evaluated depending on the prevalence of the tuberculosis process and the type of surgical intervention used. according to the results of the questionnaire, people operated on pulmonary tuberculosis in the period from to years ago, the frequency of cases of tuberculosis reactivation, the complicated course of the remote postoperative period, as well as the mortality and causes of lethal outcomes were assessed. it was found that after sublobular resection and lobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistula- . %, cardiovascular insufficiency-in . % operated. the mortality rate was . % with a total clinical efficacy of . %. after combined resection and bylobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. after pneumonectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. robotic reduced-port splenectomy using single-site platform j.h. lee background: in the era of minimal invasive surgery, single incision laparoscopic splenectomy can offer some advantages compared to conventional laparoscopic splenectomy. but it requires expertise in minimally invasive techniques due to technical difficulties. the da vinci robotic reduced-port splenectomy using single-site platform permits greater freedom of movement and higher levels of accuracy than previous laparoscopic surgery through two small incisions. methods: we performed a retrospective review of all patients who underwent robotic reduced-port splenectomy using single-site platform at our institution between january, and november, . one cm periumbilical incision was made for glove port insertion and the other incision was made at left side of abdomen for additional mm port insertion.the surgical technique is much same as open procedure. short gastric artery was ligated, firstly. splenic artery and vein were ligated individually. during the surgery, any stapling device was not used. vessel sealer was used for hemostasis and mobilization of spleen. a specimen was removed through umbilical port site within lap-bag. result: eight patients ( female and male) with median age of . years underwent robotic reducedport splenectomy using single-site platform (one case with combined robotic cholecystectomy for gall bladder stones without additional trocar). the indications were; hematological disease (n = ), splenic mass (benign n = , malignant n = ). preoperatively measured spleen size was ranged . cm to cm (mean cm). there were no intraoperative complications and open conversion. mean operative time was min. (range - min) including docking (mean min) and console time (mean min) mean blood loss was under ml. mean hospital stay was . days after surgery. one patient underwent oral anticoagulation therapy only for portal vein thromobisis without any symptoms, and thromobisis was resolved at month follow-up ct scan. there were no clavien-dindo class iii or above postoperative complication. conclusions: robotic reduced-port splenectomy using single-site platform seems to be feasible and effective. it seems to overcome certain limits of previous robotic or conventional single-site laparoscopic splenectomy and single-site only robotic splenectomy. we think mm additional port allows to use endo-wrist da vinci instruments such as vessel sealer which enhances dissection efficiency andsafety of procedures. aims: inguinal lymph node dissection carries an important risk of post-operative complications, mainly related with wound complications and long term lymphedema. the minimally invasive approach aims to reduce the morbidity of this procedure, avoiding the traditional groin incision but still allowing a full access to the lymph node basin. the authors aimed to describe their videoassisted inguinal lymph node dissection (vilnd) cases, comparing the surgical outcomes with a sample of open inguinal lymph node dissection (oilnd) cases. methods: we performed a retrospective descriptive study that compared the data from patients submitted to vilnd since (the year in which this technique was first performed in our institution) with the patients submitted to oilnd in and . gynaecologic and urologic malignancies were excluded. the statistical analysis was performed using spssv Ó, with a p value \ . indicating statistical significance. results: a total of cases of inguinal lymph node dissection were analysed, . % of which vilnd (none of them requiring conversion to the open approach). melanoma was the primary tumour in % of patients. the vilnd and oilnd groups had no statistically significant difference between them regarding age, body mass index, smoking status or the reason for lymph node dissection-clinically detected lymph node vs. positive sentinel node biopsy. the mean of isolated lymph nodes in the vilnd ( . ) and oilnd ( . ) groups was also not statistically different (p = . ). there was no difference in the rate of post-operative seroma, wound dehiscence or lymphedema. the rate of surgical site infections was higher in the oilnd group- % vs. . % during post-operative hospital admission (p = . ); . % vs. . % after discharge (p = . ). conclusions: in our population of patients we conclude that the main advantage of the videoassisted approach regarding surgical morbidity lies in the reduction of the infection rate, as the published literature also confirms. the equivalent number of lymph nodes retrieved in both groups points toward the oncological safety of the minimally invasive procedure, that we hope to study further in the future after a longer follow up period. objectives: to evaluate the clinical feasibility of tumor localization technique with radio-frequency identification (rfid) clip marker methods: we developed the proto-type rfid integrated endoscopic clip (rfid-clip) and probe to detect it on serosa surface during the laparoscopic surgery. a pig weighing kg was used as the specimen for the in-vivo test. endoscopist performed the application of the rfid-clip on porcine gastric mucosa. after then, the surgeon tried to find the location of rfid-clip using the detection probe and marked with the electrocautery. after the gastrectomy with cm margin (each to proximal and distal), we confirmed the prediction of rfid-clip location and accuracy of resection. results: rfid-clip location was detected and recorded on the exact site of clip application. detection range was very short and we confirmed there are almost no differences between actual clip location and our prediction. this result might arise from using the low-frequency rfid tag to increase the accuracy through reduction of the range. however, some rfid-clip were not detected because of the issue of clipping trouble, not rfid tag. conclusions: this is a basic study to evaluate the clinical usefulness and feasibility of the new localizing technique. we confirmed the possibilities of this system and it could be the helpful option to provide the information of exact location for the minimally invasive surgery or early gastrointestinal tumors. background: the advantages of laparoscopic posterior retroperitoneal adrenalectomy (lpra) have been described in the literature. the aim of this study was to compare the clinical outcomes of lpra and robotic posterior retroperitoneal adrenalectomy (rpra) and determine the differences that could affect the outcomes. methods: we retrospectively analyzed adrenalectomy cases at asan medical center from to . there were lpra and rpra cases, and their clinicopathological features and surgical outcomes were compared. results: in lpra, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. in rpra, adrenal tumor size and pheochromocytoma were the only factors affecting the operation time. when the adrenal tumor size was = . cm, the operation time of lpra was shorter than that of rpra (p = . ). when the tumor size was [ . cm, there was no significant difference in the operation time of lpra and rpra (p = . ). conclusions: rpra is a feasible and technically safe approach for benign adrenal diseases. the use of rpra could benefit patients with large tumors and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique. methods: twenty years experience at the american university of beirut medical center for laparoscopic adrenalectomy. a total of cases were done laparoscopically with no conversion and minimal complication. the average operative time is mins.the video will show the various steps used for lap redo (lt) adrenalectomy for a cm pheochromocytoma using the lateral position and through trocars. attempt to remove the pheochromocytoma in iraque was complicated by cardiac arrest treated successfully and patient referred to the american university of beirut medical center. results: patient had smooth postoperative course following laparoscopic adrenalectomy and patient discharged days later with no complications. conclusions: even large adrenal masses can be completed laparoscopically in advanced experienced centers in laparoscopy. surg endosc ( ) aims: the adrenocortical of uncertain malignancy neoplasm is a spectrum of classification for adrenal tumors whose histopathological diagnosis is uncertain. clinical case: we present a year old patient with constitutional syndrome and severe hypercortisolism and hypokalemia reason why she was admitted to icu for episodes of ventricular fibrillation. no other medical history of interest except refractory hypertension to treatment. the tc showed a left adrenal mass of . . cm with microcalcifications, areas of necrosis and hemorrhage, no infiltrating, without disease to distance. the surgery was a laparoscopic left adrenalectomy with no evidence of infiltration and no lymph nodes. the histopathology lesion presented a dense proliferation cellular of cortical type, with incomplete fibrous, without vascular or capsular invasion, with a % ki ; positivity vimentin and cd . all epithelial markers, were negative. all this leads to the diagnosis of a neoplasm of uncertain malignancy potential adrenocortical. during the postoperative period, the patient presents a crisis of adrenal insufficiency that was treated with intravenous replenishment corticoidea and later orally with good clinical response. discussion: the adrenal carcinoma has a low incidence ( . %), incidence peak around the years, the most frequent is the mixed secretory. they are - % of the adrenal incidentalomas. it is usually presented to the diagnosis as a locally advanced tumor with metastases (to liver, lung, retroperitoneal ganglia and bone). may present clinically due to hormonal hyperproduction; or be non-functioning tumors. the adrenal carcinoma poses a great difficulty at the time of the diagnosis pathological, and includes as differential diagnosis to other abdominal tumors. the distinction between corticoadrenal adenoma and adrenal carcinoma is sometimes difficult, so it has been defined a spectrum of intermediate category called adrenocortical neoplasm of intermediate or uncertain malignancy. it is obtained with the weiss criteria, being necessary at least of them for confirm the diagnosis of adrenal carcinoma. this category has a low risk of local recurrence or metastasis, but it needs a narrow follow-up. conclusion: adrenal carcinoma of uncertain malignancy implies a new category in those tumors of difficult classification. aims: multiple endocrine neoplasia type (men ) is an autosomal dominant disorder with an estimated prevalence of per , in the general population. among patients suspected to have a pheochromocytoma, the diagnosis is rarely confirmed and only % is presented bilaterally. we present bilateral laparoscopic adrenalectomy in patients with men . method: a -year-old woman with a family history of medullary thyroid cancer and breast cancer. personal history: hypertension, medullary thyroid cancer, breast cancer, laparoscopic cholecystectomy. appendectomy. after a study by endocrinology and suspicion of bilateral pheochromocytoma, discussing the case in a multidisciplinary committee, bilateral adrenalectomy was decided by laparoscopic approach. selective alpha- -adrenergic blocking agent (doxazosin) were utilized before surgery. under general anesthesia left adrenalectomy was performed first in right lateral decubitus position. mmhg pneumoperitoneum was started with the verres needle and trocars ( mm umbilical, mm subxifoid and mm left subcostal).once dissection was completed the gland was placed in a plastic bag and extracted through one of the trocars incisions, then the position of the patient was changed to left lateral decubitus for the right adrenal approach. another right subcostal mm trocar was used. adhesiolysis of previous cholecystectomy was performed to right adrenal approach. adrenal veins were divided between metallic clips.no drainage was employed. results: the procedures were successfully performed without conversion. surgical time was min and hospital stay was days. had a clinical reversion with control of blood pressure monitored by endocrinology conclusions: currently, the laparoscopic approach is the technique of choice for the management of adrenal pathology.lateral decubitus transperitoneal approach is the procedure of choice in most cases. bilateral laparoscopic synchronous adrenalectomy is feasible and safe with good results as in our patient. traditionally the treatment of hyperparathyroidism for patients with familial hyperparathyroidism was subtotal parathyroidectomy or total parathyroidectomy and auto transplantation. in the era of minimally invasive parathyroidectomy, the removal of only abnormal glands guided by preoperative localizing studies has been suggested. aims: this systematic review aimed to investigate the role of focused minimally invasive parathyroidectomy in the treatment of patients with familial hyperparathyroidism. methods: electronic databases were searched with the search terms 'men i', 'familial hyperparathyroidism', 'men a','hyperparathyroidism-jaw tumor syndrome', 'parathyroidectomy', 'minimally invasive ', for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria. results: thirty five possibly relevant studies were identified. abstracts were reviewed and fifteen articles were excluded. twenty studies, that met inclusion criteria were retrieved in full text and included in the systematic review, including three retrospective cohort studies i.e. two presenting data on meni associated hyperparathyroidism and the third study on familial hyperparathyroidism and seventeen small case series or case reports. the two retrospective studies on meni hyperparathyroidism included patients treated either with focused minimally invasive parathyroidectomy or with the conventional approach. these studies presented conflicting data with one supporting and the other negating the focused minimally invasive parathyroidectomy due to the failure of localization studies to identify enlarged parathyroid glands in a great number of patients. conclusion: undoubtedly, the idea of minimally invasive parathyroidectomy in patients with hereditary and familial hyperparathyroidism is interesting. this idea is especially challenging in the case of meni. existing data suggest that focused mimimally invasive parathyroidectomy is feasible under the condition of exact preoperative localization studies. the main advantage of this approach is the minimization of the risk of postoperative hypoparathyroidism. however, data are limited and further research is needed before valid conclusions can be drawn on the suitability of this approach. objective: resection of pheochromocytomas is a challenging procedure due to hemodynamic lability, tumor vascularity and malignant potential.given the technical challenges for resection of large pheochromocytomas, there were hesitations about using the laparoscopic approach for these tumors during the first decade of laparoscopic surgery. however, improvement in imaging modalities,better pharmacological preparation,advances in anaesthesia and laparoscopic surgery rendered laparoscopic surgery for pheochromocytomas safe and efficient. our aim was to evaluate surgical outcomes in patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. design: a total of procedures for pheochromocytoma were performed between january -september . the preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow up were retrieved from the hospital records of patients who underwent adrenalectomies for benign and malignant adrenal tumors in the same period. preoperative localization was established in all patients with computerized tomography (ct) or magnetic resonance imaging (mri), while iodine - -metaiodobenzyguanidine(mibg) scan was reserved for ambiguous cases where paraganglioma or metastatic disease was suspected. endocrinological evaluation and complete adrenal dynamic testing were performed to determine whether the tumor was functional or not. results: eighty-seven tumors were removed from patients. one patient with meniia underwent bilateral resection of pheochromocytomas in two stages. tumor size in laparoscopic procedures ranged from . cm to . cm (mean . cm). forty-three patients had benign disease, potentially malignant (based on pass), malignant with metastasis. eight were in the context of a familial syndrome. sixty -eight patients underwent laparoscopic adrenalectomy, patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, patient had open approach due to inoperable malignant pheochromocytoma and patients had conversions from laparoscopic to open procedure. nine patients received sodium nitroprusside intraoperatively to treat hypertension. one patient developed pulmonary embolism, and succumbed month later. there were no recurrences for the benign tumors during the follow-up period. conclusions: laparoscopic resection of pheochromocytomas despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure. aim: the concept 'large' in transperitoneal lateral laparosopic adrenalectomy (tlla) has been evolving along time, ranging from to - cm depending on different authors. on the other hand, some authors discourage laparoscopic surgery in larger tumors due to the increased risk of malignancy in those larger than - cm, referring to malignancy in out of or cases. paragangliomas are rare tumors originated in extra-adrenal chromaffin cells, with an incidence of - cases per million inhabitants. they can appear in any location between neck and pelvis. sympathetic paragangliomas are usually functional and catecholamines producers. we present a movie of surgical intervention of a -year-old patient who, in study for refractory hypertension, presented paraganglioma producing norepinephrine, whose approach was performed laparoscopically. -year-old woman studied by nephrology for refractory hypertension. on physical examination, only obesity standed out. in blood exams, levels of normetanephrine were observed in plasma of pg/ml and aldosterone pg/ml. abdominal scintigraphy was performed in which there was no evidence of increased activity at adrenal level. abdominal ct shows retroperitoneal extra-adrenal tumor of inter-aortocava location immediately below renal vessels with dimensions of . . cm. after preparation, she was operated. laparoscopic access was performed under exhaustive monitoring. an heterogeneous, polylobulated tumor of cm, located interaortocava, intimately adhered to left renal vascular pedicle, was observed. a cattell-braash and kocher maneuver was performed, with exposure of inferior cava and aorta to iliac bifurcation. complete tumor excision was performed after clipping arterial and venous tributary branches. after the operation, the pacient presented favorable evolution being discharge on the second postoperative day with good control of blood pressure levels. laparoscopic approach of retroperitoneal paragangliomas is a safe technique, which allows minimally invasive access, with consequent improvement in postoperative results. the exact location of lesions and their relationships with surrounding structures, as well as their functional behavior, are very important when considering the best therapeutic strategy for these patients. we present the case of a -year-old obese male patient referred for adrenalectomy after being diagnosed with left adrenal incidentaloma. abdominal mri showed a . / . / . left adrenal mass with normal hormonal levels. after preoperative workup, the patient underwent standard laparoscopic adrenalectomy. the lateral to medial dissection and mobilization of the spleen and pancreatic tail was difficult due to the abundance of peritoneal and pararenal fat. the anatomy was peculiar: the bulky pancreatic tail was located well inferior to the splenic hilum and was visible throughout the intervention and the spleen was quite elongated-long axis = cm. the exposure of the adrenal gland was therefore cumbersome. the operating time was min and blood loss ml. the abdominal drainage was maintained for h. before discharge the patient underwent a control abdominal us examination that only showed a thin line of left pleural fluid. the patient was readmitted days after discharge for chest pain, fever ( . °c) and malaise with no abdominal signs. the emergency ct scan diagnosed left basal pneumonia with minimal pleural effusion and a / cm fluid collection between the spleen and diaphragm while the blood test showed leukocytosis. the patient was treated for pneumonia with an apparent clinical benefit for three days and lowered white cell count but his condition worsened during the forth day. repeat abdominal us demonstrated that the abdominal collection increased in size therefore the patient underwent emergency surgery. during laparoscopic exploration, the collection was unveiled as being pancreatic juice (more than times the normal serum levels of lipase and amylase). after thorough lavage, two drainage tubes were positioned in the left subphrenic space. the postoperative course was uneventful under antibiotic treatment for pneumonia and pancreatic antisecretory medication. the patient was discharged after days with minimal pancreatic drainage and the drainage tube was extracted after more days. the aim of the study was to develop the algorithm and the choice of the method of endoscopic treatment of a combined pathology of uterine leiomyoma and adenomyosis depending on the reproductive plans. methods: the study involved patients with a combined pathology of uterine leiomyoma and adenomyosis. indications for conservative myomectomy were: the size of the uterus is more than weeks. pregnancy; multiple leuomatous nodes and adenomyotic foci up to cm in size; hemorrhagic and pain syndromes, anemia, compression of the adjacent organs; suspected node malfunction; submucous leiomyoma deforming the uterine cavity with foci of adenomyosis; subserous, cervical isthus nodes and foci of adenomyosis; the presence of endometrial hyperplasia, tumors of uterine appendages; growth rate of uterine leiomyoma more than weeks pregnancy for the year; the growth of uterine leiomyoma on the background of drug treatment; infertility associated with leiomyoma and uterine adenomyosis.the laparoscopic myomectomy of the subserous node on the 'leg' with a size of more than cm and nodes of more than cm of intramural location is shown with an interest in preserving the organ.the hysterectomy is indicated for women after years of age who insist on hysterectomy, with a combination of uterine leiomyoma with atypical endometrial hyperplasia. results: the conservative myomectomy and removal of adenomyotic foci were performed in ( . %) patients: from hysteroscopic access- , vaginal access- , laparoscopic access- , abdominal access- in the presence of reproductive plans.the hysteroscopic myomectomy was performed in ( . %) patients, hysterectomy in ( . %) patients: from laparoscopic access- , from vaginal access- , from abdominal access- in the absence of reproductive plans. conclusions: the choice of surgical treatment of uterine leiomyoma and adenomyosis depends on the reproductive plans of the woman and the severity of the lesion.the laparoscopic method of treating a combined pathology of uterine leiomyoma and adenomyosis in the presence and absence of reproductive plans is a priority for women. surgery, policlinico ,,paolo giaccone,,, palermo, italy background: breast cancer in females represents the most frequent neoplasm in all age groups. the risk of getting breast cancer (mc) increases with age. the brca and the brca genes (tumor-suppressor genes, autosomal dominant transmission at high penetrance) alone justify from % to % of cases of hereditary breast cancer. methods: from january to june we have analyzed patients with brca mutation. all patients had in common a genetic mutation of brca or brca tumor suppressor genes. results: the frequency of germline mutation on brca ( patients: %) was identical to brca gene ( patients: %). of the analyzed patients were women ( . % of patients) brca and brca , and men ( . %) all with brca mutation. conclusions: prophylactic surgery must be seen as a way to put the patient in the condition to implement the most appropriate treatment. further studies will be necessary to support the validity of prophylactic surgery in patients with mutations in brca and brca genes. introduction: laparoscopic hysterectomy is a safe surgical technique for removing the uterus with or without including the ovaries and fallopian tubes. laparoscopic surgery of endometrial cancer is a safe method, with the mean time of recovery being two days only. material-method: the case of a yr old woman with metrorrhagia and anaemia (ht , %) due to adenocarcinoma of the endometrius is presented. the patient underwent a laparoscopic hysterectomy and oophorectomy. trocar ports were used during the procedure (a mm transumbilical port, similar to the port used in single incision laparoscopic operations, two mm ports at the level of the anterior superior iliac spines, and a mm port in the middle of the imaginary line between the pubic symphisis and the umbilicus). the uterine vessels and the uterine ligaments were ligated and dissected by using a thermal energy source. the patient's postoperavite course was uneventful. the patient continues to be in good condition, months post-surgery. conclusion: laparoscopic hysterectomy seems to be a safe method for addressing endometrial cancer, as it offers the surgeon a better surgical field, is tissue friendly and causes fewer postoperative complications. it is considered to be a less traumatic operative method, as due to zooming in the picture there is greater accuracy in handling the tissue, and blood loss is minimal. m. shahin background: hysterectomy is one of the most frequently performed surgical procedure. though there are three approaches in hysterectomy (open, vaginal and laparoscopic), still there are controversies regarding the optimal route for performing it. methods: this prospective comparative study included obese patients subjected for panhysterectomy as a treatment. the forty-two patients were allocated into two groups: group (a) subjected to laparoscopic pan-hysterectomy, group (b) subjected to open pan-hysterectomy. results: there was significant difference between the two groups regarding mean operative time, blood loss, analgesic requirements and hospital stay, while no significant difference regarding intra-operative complications. conclusions: laparoscopic hysterectomy in obese patients has emerged as a viable, safe and better alternative to open hysterectomy amongst appropriately trained surgeons. general: endometriosis in the inguinal region is rare. the usual presentation is that of a woman in the reproductive age group. it accounts for . - . % of patients affected by endometriosis. the groin swelling is usually slow growing, painful with exacerbations during menses. the incidence of inguinal endometriosis on the right side is - % as compared to the left. aim: to present our laparoscopic approach for the treatment of the diagnostic dilemma. case presentation: a -year-old woman presented with a palpable mass in the right groin. the swelling was associated with a dull aching pain. the patient was suffering from increasing pain over the swelling during menstruation. she had undergone cesarean section some years ago and the scar had healed by primary intention. mri scan revealed a nodular hypoechoic lesion at the level of the internal inguinal ring with the absence of vascular flow around the lesion. results: since inguinal endometriosis was in the differential diagnosis and it may be associated with pelvic or intraperitoneal endometriosis, a laparoscopic approach was decided. the procedure was successfully completed laparoscopically following the transabdominal preperitoneal approach. the endometriosis was found, after dissecting the internal inguinal ring, firmly adhered to the round ligament. it was excised en bloc with the round ligament. a preperitoneal polypropylene mesh was inserted to protect for future inguinal hernias due to extensive dissection at the level of the internal inguinal ring. no intraperitoneal endometriosis was appreciated. histopathology revealed endometriosis of the round ligament. the patient was uneventfully discharged the next day. on follow up the patient was asymptomatic. conclusions: round ligament endometriosis is a rare entity. it is a disease of specific interest to the physician. it can be confused with an inguinal hernia and thereby pose a diagnostic dilemma. we recommend considering endometriosis in the differential diagnosis of groin swellings in women. the transabdominal preperitoneal approach is feasible and safe in the hands of an advanced laparoscopic surgeon. introduction: sentinel node biopsy is the newest accepted method for surgical staging of early stage endometrial and cervical cancer. aim: to evaluate the role of the technique of indocyanine green (icg) identification of the sentinel lymph nodes in cases of early endometrial cancer. material and method: five patients with early endometrial and cervical cancer were introduced in a prospective study. icg was locally injected during the laparoscopic exploration. novadac pinpoint near to red technology was used. guided biopsies were performed into the marked sentinel nodes and histological results were evaluated. results: sentinel lymph nodes were easily identified by using icg and near-infrared technology. technical details are described. no associated complication was encountered. conclusion: sln mapping using icg in uterine cancers is demonstrated as an effective and safe procedure. laparascopic extraction of an intraperitoneal gossypiboma following c/s and a retroperitoneal gossypiboma following pyeloplasty n. ozlem general surgery department, ahievran university, kirsehir, turkey gossypibomas are forgatten foreign bodies,iatrogenic.their symptoms are different where they are. they extracted with laparotomy in the past but now we can some article mentioned their extraction was made with laparoscopy. case : y o female has abdominal pain after c/s for . years. a gossypiboma was extracted with laparoscopy above umblicus.a superficial surgical site infection existed,drained,subsided. case : yo m had a pyleoplasty operation years ago.a gossypiboma was extracted with retroperitonescopy,no postoperative event. basibuyuk et al reported retroperionescopic extraction of a gossypiboma from single port in first time.althoug every effort taken the incidence of foreign body detected in the body is about . - . %.they are most frequently localized in the intraabdominal cavity followed by tracheobronchial area,pleural cavity,pararenal area,vagina,spinal chord, neck, femur,breast,bladder,pancreas,and they may cause local irritation,and infection.tactile sense is absent in laparoscopy. all radiologic examinations(usg ct pet mri etc) be used to detect.we used usg ct.in the end laparoscopy make the diagnosis and remove gossypibomas in our cases with less postoperative pain and cosmosis. justo et al the computerized tomography (ct) scan is the most useful method for diagnosis; however, sometimes the preoperative diagnosis remains uncertain even after the imaging exam. in that case, laparoscopy arises as a valuable diagnostic tool, as well as a prompt treatment option. concerning gossypiboma, prevention is preferred rather than treatment. notwithstanding, there is no highly reliable prevention system. counting sponges is a method based on staff communication during the surgery with only % sensibility. routine surgical postoperative x-ray (spox) constitutes an early detection system, but the need to incorporate a radiopaque marker and to expose the whole surgical field to maximize its efficacy limits its use. more recently, electronic dispositives based on barcode detection and other technological adjuncts for counting sponges are being developed. none of these prevention systems are reliable when used alone. our education and research clinic was a state hospital before. no surgeon followed above instruction.but now we use all. multiple procedures and surgical teams, long operations and non-elective operations are the evidenced risk factors.c/s operation was learned full opened of ostium of cervix of the patient. urology, japan, nagoya, japan aims: some scoring systems have been suggested to standardize the renal tumor characteristics. among them, renal score is widely used in partial nephrectomy. whereas diameter-axis-polar (dap) score was developed to be more significantly related with postoperative renal function. our study compared dap score with renal score in robotic partial nephrectomy (rpn) outcomes. methods: records of patients who underwent rpn at nagoya daini red cross hospital between april to october were analyzed retrospectively. those include three oncocytomas. accordingly, we calculated the estimated glomerular filtration rate (egfr) just before rpn and month postoperatively in patients. we compared two nephrometry scores with warm ischemic time and change in egfr. results: in our institution, four surgeons performed rpn. according to dap score, patients were high, were middle and were low. according to renal score, were high, were middle and were low. the median warm ischemic time was min ( - ). the median egfr decreased from . ( . - . ) to . ( . - . ) ml/min/ . m . there were no significant differences in warm ischemic time and percentage change in egfr between renal score groups (p = . and . ) but significant differences between dap score groups (p \ . and p \ . ). univariate and multivariate analyses were used to identify factors influencing postoperative renal function. that confirmed that dap score was independent poor predictors of change in egfr after rpn. conclusions: dap score is simpler estimate system than renal score. our study suggested that dap score is a useful scoring system for preoperative evaluation of renal tumor for rpn. further investigation is needed to better understand preoperative dap score. aims: retroperitoneal primary tumors comprise a great variety of neoplasm with different histological typologies, with insidious clinical symptoms and little specificity in most cases. its diagnosis is established through imaging tests and anatomopathological study is needed so complete surgical resection is the treatment of choice. the aim of the video is to demonstrate the safety and efficacy of the minimally invasive approach in patients with retroperitoneal lesions. methods: a -year-old female patient who, in the course of an abdominal pain at the right iliac fossa suspected of possible acute appendicitis, is diagnosed with a right retroperitoneal tumor, compatible with primary neurogenic tumor on a ct. radiographic imaging is a key component of the evaluation of a patient with a retroperitoneal mass, a ct scan is necessary to evaluate the primary site as well as to rule out metastatic disease. after complete biochemical study, nonfunctioning tumor is determined. the study is completed with mri where the lesion is located below the right kidney, in front of the right psoas muscle and lateral to the inferior vena cava, and without contact with these structures. ??it is in intimate contact with the ovarian vein. the complementary tests and iconography of interest of the case are exposed. surgical intervention is proposed with a laparoscopic approach. results: full minimally invasive approach in left lateral decubitus position: trocars-lateral laparoscopic transabdominal approach. laparoscopic liberation of the right colon, kocher maneuver until the inferior vena cava is visualized, identification of a tumor of approximately cm in the right infrarenal region, lateral to the right ureter, which includes the gonadal vessels. resection of the tumor in block with margins previous dissection and clipping of the proximal and distal gonadal vessels with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. definitive result of the specimen: leiomyosarcoma, grade of the fnclcc with negative margin. the laparoscopic approach is a safe and effective technique in the approximation of retroperitoneal tumors, a radical oncological criterion is always needed with correct margins of resection especially in those of uncertain etiology. we started endoscopic thyroidectomy using the lifting method in and have developed single incision endoscopic thyroidectomy (siet) via chest (c-) or axillary incision (a-) by our original retractor since . we created a new approach in . recently, we have applied this method to parathyroid surgery. in this study, we present our method and results in parathyroid surgery with regard to surgical outcome and patients' complaints. method: endoscopic parathyroidectomy of c-siet was performed in patients with hyperparathyroidism (primary , secondary ) in new approach (mean age , male female ). single parathyroid adenoma was diagnosed using ultrasonic device, preoperatively. the patient is placed in a supine position with the neck extended. mm vertical incision is made in anterior chest. flexible endoscope (olympus co. japan) is used through mm trocar detached the retractor. in new approach, the parathyroid and thyroid are exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle. both of the skin and sternal head are lifted up by our original retractor (takasago medical co. japan). parathyroid adenoma behind the thyroid is resected using an ultrasonic scalpel. i would like to present our c-siet procedure. results: no scars in the neck were left in all cases. benign and hemi lateral parathyroid adenoma sized from mm to mm (mean: . mm) were operated. mean operation time is min. in new approach. there was no complication. parathyroid hormone levels decreased in all patients immediately after operation. conclusion: it is a little possible to make recurrent nerve palsy in this approach. new approach is useful to operate and make the working space wider without stress to find out of parathyroid adenoma. our original retractor can be introduced easily in most hospital, because it is not so expensive. most of women satisfied cosmetic results because of hidden scars. objectives: radiofrequency ablation (rfa) is a novel and developing technique for the treatment of parathyroid hyperplasia/adenoma in the context of secondary hyperparathyroidism (hpt) to chronic kidney disease (ckd) and there is little literature on the subject. the purpose of this study is to determine its usefulness by contributing a case carried out in our hospital. methods: we selected a case of secondary htp in a patient of years old with ckd who presented a parathyroid adenoma detected clearly by ultrasound scanning. the patient was dismissed for surgery due to high surgical risk due to his comorbidities. rfa of a right inferior parathiroid adenoma was performed. intact parathyroid hormone (ipth) was measured before arf and min after de procedure, calcium and phosphorus were measured the day after. the treatment was considered effective if ipth levels decreased at least % min after rfa and calcium levels decreased the day after. results: ipth level before rfa was pg/ml. ipth level after min of rfa was pg/ ml, this meant a % reduction (normal values - pg/ml). calcium levels were from . at the baseline to . the day after (normal values . - . mg/dl) and phosphorus from . to . mg/dl (normal values . - . mg/dl). the patient presented dysphonia as a complication that improved with corticosteroid therapy. we are currently waiting for the next analytical controls at , and months after the proceidure. conclusions: rfa of parathiroid adenomas for treating secondary hpt in patients with ckd is feasible in selected patients. this treatment may reduce the morbidity that surgery supposes, it is developed in an outpatient regime avoiding hospital admission and this contributes to a reduction of health costs. however, a longer follow-up is necessary to verify the good results in our case. splenectomy is one of the treatment strategy for advanced portal hypertension due to liver cirrhosis. after splenectomy, thrombocytopenia is dramatically ameliorated, and liver function parameters have also been improved in several clinical settings. however, the mechanism underlying such a phenomenon remains unclear. the aims of the present study was to analyze histological changes of the liver after splenectomy in human, and to speculate the underlying mechanism. subjects and methods: cirrhotic patients with hepatocellular carcinoma (hcc) who had undergone laparoscopic splenectomy prior ( weeks- months) to hepatic resection were analyzed (n = ). non-tumorous liver specimens obtained at hepatectomy were histologically investigated. liver tissues from cirrhotic hcc patients who underwent only hepatectomy were used as controls (n = ). results: after splenectomy, significant leukocytosis, especially increase in monocytes, was observed in addition to thrombocytosis. in the non-cancerous liver tissues, many round-shaped cd -positive macrophages accumulated after splenectomy, while this phenomenon was merely observed in patients without splenectomy. the macrophages were cd ? (m marker) and cd -cd ? , suggesting their anti-fibrotic population. the accumulated macrophages existed around fibrous scar as well as ck ? epcam ? cells spreading out from the ductular reactions (dr). as a result, the number of ki -positive hepatocytes significantly increased after splenectomy. the amount of platelets detected in the liver did not change even after splenectomy. finally, remarked attenuation of the established liver fibrosis was detected after relatively long duration. the accumulated macrophages expressed metalloproteinase (mmp)- and fibroblast growth factor (fgf)- , suggesting these molecules may possibly participate in resolution of established fibrosis and hepatocyte proliferation. conclusion: splenectomy in cirrhotic patients with portal hypertension ameliorate liver fibrosis, and stimulate liver regeneration. the mechanism possibly include hepatic accumulation of anti-fibrotic cd -positive macrophages and stimulation of dr-derived ck ? epcam ? progenitor-like cells. in patients with advanced splenic fibrosis, splenectomy could be a feasible therapeutic modality. the paper tries to establish the role and the opportunity of using laparoscopy in regard with abdominal contusions, as well as its indications or contraindications, combined in a therapeutic algorithm. we analyzed two groups of patients with abdominal contusions divided over two -year periods, - ( patients) and - ( patients) respectively. we have separated the two periods because starting from we have established a strategy for dealing with cases of abdominal contusions where we included diagnostic and / or therapeutic laparoscopy and nonoperative management. the investigation was done by fast echography, ct scan, simple abdominal radiography, peritoneal lavage puncture, and sometimes arteriography. in the second period we determined the diagnostic and therapeutic laparoscopy indications: suspicion of hollow or parenchymal organ injury, or mesentery injury, the presence of hemoperitoneum or fluid in the peritoneal cavity in a stable patient without major hemorrhage, apparent with unique injuries, without immediate vital risk and without other associated severe trauma. we have associated in this last period the nonoperative management for patients with grade and lesions of parenchymal organs that do not have fluid in the peritoneum, or only a very discreet quantity. in the first period, all patients were treated by classic surgery, resulting in unnecessary laparotomies where no visceral lesions were revealed. in the second period, we applied non-operative management to patients out of , patients with grade and splenic injuries, and patients with grade and hepatic lesions. diagnostic laparoscopy was performed in cases, in of them without evidence of lesions, and in other cases of grade lesions no therapeutic action was required. therapeutic laparoscopy was required for one case of splenectomy and one of hepatorrhaphy. diagnostic laparoscopy is useful in abdominal contusions, if certain indications are followed and in selected patients. in our study, with the introduction of modern therapeutic strategies, unnecessary laparotomies were completely avoided, some lesions being even treated by laparoscopy. the new algorithm introduced allowed % of patients to avoid laparotomy. aims: about cases of splenic hamartoma have been described in the literature since it was first described by rokitansky in , it is a rare benign tumor. it is usually a casual finding in laparotomies or autopsies. they are usually asymptomatic, but there are few symptomatic splenic hamartomas and they can be associated with haematological alterations, being in some cases associated with spontaneous splenic rupture and acute abdomen, two thirds of them have multiple tumors. there are no specific data that allow the preoperative diagnosis of this entity, which is performed after the anatomopathological study of the surgical specimen, which must be extracted entirely, this together with the size of the spleen makes the laparoscopic approach difficult. the aim of this video is to demonstrate the surgical technique of a complete laparoscopic approach for this type of lesions, without the need for assistance laparotomies (handport). methods: clinical case: a -year-old man admitted to internal medicine due to fever and left lumbar pain. additional explorations of interest are discussed, including: thrombopenia of probable peripheral origin secondary hypersplenism (fna of bone marrow), ct: splenomegaly with splenic masses, which deform the splenic contour, compatible with atypical hemangiomas, without being able to discard other vascular splenic tumors. results: complete semi-laparoscopic approach, trocars, multilobulated splenomegaly ( x cm.), mechanical vascular section, complete bag extraction after minilaparotomy on the left flank. the patient presented a successful postoperative recovery, being discharged on the th po day. abdominal ultrasound at st week with portal vein thrombosis, which resolves after treatment with heparin. definitive result of the specimen: multiple splenic hamartoma. asymptomatic one year after surgery. the laparoscopic approach is a valid and effective alternative to splenic benign tumor lesions. the size does not contraindicate this type of approach, although the complete extraction of the spleen is recommended for its pathologic study. we recommend eco-doppler control per week, given the risk of portal thrombosis with an existing laparoscopic post-splenectomy. objectives: splenic cysts are a rare entity, currently described between - cases in literature. a female patient's case is hereby presented, giant splenic cyst treated by conservative laparoscopic surgery obtaining good results. method: years old female, without any relevant medical history, examined after abdominal pain on the left hypochondriac region, nausea, postprandial swelling and mass sensation. after exploration the presence of such mass was ratified, the rest of exploration found no relevant findings, no record of previous traumatism nor any other relevant incidence. diagnosis was made through ultrasound and computerized tomography, the existence of a big splenic cyst is confirmed, cm by cm, on the superior section of the spleen, negative results after parasitism test, normal haemogram, coagulation and biochemistry levels. patient was intervened using laparoscopic surgery, performing the deroofing technique on the cyst (two liters of orangey amber serous liquid that was sent for analysis) as well as extirpation of superior wall of the cyst, which was sent to pathological anatomy, a saline solution was used to cleanse the cavity, omentum and drainage were then set in place. results: patient evolved satisfactorily, hospital discharge and drainage withdrawal after h. regular check-ups, after and months, patient presents no symptoms nor recurrence. pathological anatomy confirmed primary splenic cyst and the extracted liquid as cystic. conclusion: splenic cysts are primary ( %) or secondary ( %). diagnosis is performed through imagery tests, cat scan the being standard test used. regarding her treatment there is no clear consensus, due to the fact that up to a few years ago, complete splenectomy was the recommended treatment, techniques with preservation of the spleen are currently being widely recommended through laparoscopy in literature. among the conservative techniques percutaneous aspiration, with or without the injection of a sclerosing agent, partial splenectomy, marsupialisation, cystectomy, decapsulation, unroofing or fenestration can be found. the main issue is recurrence rates. few cases of primary giant splenic cysts treated by laparoscopic decapsulation can be found in literature, this treatment being simple and quick to perform, resenting a recurrence rate lower than other techniques such as aspiration and marsupialization. introduction: technology's progress and its application in the minimally invasive surgery of the thyroid gland offers us new surgical approache's like the transaxillary approach. this new technic still unusual in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary thyroidectomy and emphasize in the most relevant tips to take into account. also we going to review the main limitations we observed so far. statement of the case: we present the case of a -year-old woman referred for evaluation of a left thyroid nodule without associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with welldefined edges and presence of peripheral vascularization . no other nodules are identified. fna of the nodule describes a bethesda iii. after evaluation we decide to perform a left transaxillary thyroidectomy. discussion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). surely, more evidence and experiencie is required to make a better assessment of minimally invasive approaches in thyroid surgery. surgery, taipi city hospital, yan-ming branch., taipei, taiwan; surgery, taipei city hospital, taipei, taiwan the first endoscopic thyroidectomy was performed in using a cervical approach. since then, various remote-access method, have been developed for thyroid surgery to avoid scarring of the neck. trans axillary approach(taa),bilateral axillo-breast approach(baba),and retroauricular approach(raa) are common in use. the main benefit of these procedure is that there are no visible scar that is one of the drawbacks of conventional kocher's incision. however,these methods require more dissection and longer operation time than conventional thyroidectomy transoral thyroidectomy(tovet) is a new approach and has become popular in recent years, however,most surgeons peformed a single procedure because of the limited patients and the learning periods sine ,more than cases were performed,patients received endoscopic thyroidectomy(et) procedure at our hospital. we compare the surgical procedure of bilateral axillo-breast approach(baba) with transoral vestiblar approach(tovet) in our hospital both performed by one single surgeon .the surgen has expended eaqual amounts of time with these two procedures. the patient seletion process,operation time, operation procedure and approach,learnig experience, consmetic effect,onaologic consideration and surgical outcome were discussed yhroughly. presenting a case of a thyroid metastasis from an ovarian carcinoma, we conducted a review of the literature without finding similar reported cases. case: a -year-old woman consults for progressive asthenia, weight loss and ascites. abdominal ct finds a conglomerate in the pelvis involving the ovaries and peritoneal implants, the largest up to cm. an omental epigastric lesion biopsy and paracentesis is performed resulting in adenocarcinoma and omental metastasis from ovarian neoplasm, associated with ca of . patient starts neoadjuvant therapy with carboplatin-paclitaxel. in image controls there is a favorable response. three months later, intervention was carried out; laparotomy hysterectomy ? double anexectomy ? omentectomy ? appendectomy ? pelvic and paraaortic lymphadenectomy.the anatomopathological study shows a low-differentiated endometrioid carcinoma, omentum infiltration and absence of metastatic lymphatic involvement. while getting the maintenance treatment with bevacizumab the patient presented symptoms of arthritis and hypercalcemia was detected ( . ) with pth . a gammagraphy was performed and an increased uptake area was detected in the lower pole of rtl, suggestive of a parathyroid adenoma. we initially proposed the possibility of performing radiofrequency ablation but in a previous thyroid ultrasound we visualize nodular lesions in rtl compatible with adenoma and a mass in the superior mediastinum that seems to correspond the area of greatest uptake in the gammagraphy so finally the procedure is dismissed and surgery is proposed. during the intervention we found a hard consistency nodule in the inferior pole rtl and lymphadenopathies of hard consistency in right vi area that are sent for intraoperative anatomopathological study with the result of adenocarcinoma metastasis without identifying origin. a total thyroidectomy, parathyroidectomy and central ganglion drainage is performed with the result of a parathyroid adenoma, lymphatic invasion of ovarian-grade latent carcinoma and extensive vascular permeation by carcinoma of the thyroid. the patient maintains oncological treatment with carboplatin-caelix. in the last follow-up, the pth and calcemia remains normal. conclussion: although some cases of neoplasic thyroid involvement associated with struma ovarii have been published, no cases similar to the one described are found, neither in our experience, which is why it is an exceptional case. the aim of the study was to evaluate the effectiveness of the use of embolization of the splenic artery in order to prevent portal bleeding. methods: the study included patients, who had esophageal varices bleeding, which developed as a result of decompensated cirrhosis of the liver of various etiologies of classes b and c according to child-pugh. patients were divided into groups. the main group included ( . %) patients who underwent endoscopic ligating of bleeding varix and in order to prevent recurrence of bleedingembolization of the splenic artery with gianturco coils. the comparison group consisted of ( . %) patients who received only drug therapy. to assess the effectiveness of the treatment, the patient's condition was monitored for months. results: the average age of patients in the comparison group was . ± . years. using only drug therapy, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. the average age of patients in main group was . ± . years. performing endoscopic ligation of bleeding varices, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. a statistical analysis of mortality and duration of treatment revealed a significant difference (p \ . ) between the groups in both indicators. after splenic artery embolization in all cases managed to achieve a reduction in blood flow of - %. after months among patients in the comparison group, bleeding relapse occurred in ( . %) cases. in the main group, this indicator was . % ( patients). the indicator in the main group was significantly (p \ . ) different from the same indicator in the comparison group. conclusion: performing embolization of the splenic artery in patients after endoscopic hemostasis of variceal bleeding allows to reduce the pressure in the portal system, which in turn leads to a decrease in the frequency of bleeding recurrences. thoracoscopic esophagectomy for aortoesophageal fistula y. ebihara, t. shichinohe, y. kurashima, s. murakami, surgery ii, hokkaido university, sapporo, japan background: aortoesophageal fistula (aef) is an uncommon but one of highly fatal conditions. there are surgical, endoscopic and interventional radiological treatment options, however, definitive treatment is the surgical intervention. video-assisted thoracoscopic surgery (vats) has been gradually accepted as a substitution for thoracotomy to reduce the invasiveness of the surgery as radical surgery for esophageal cancer. we aimed to evaluate a feasibility of vatsesophagectomy (vats-e) for aef in this study. introduction: achalasia is the most common motility disorder of the esophagus. heller's cardiomyotomy associated with a antireflux technique is the treatment of choice in patients with this disease; however, a small group of patients could present a recurrence of the symptoms being necesary a new surgery, what is an important challenge for most of the surgeons. we report the case of recurrence after a laparoscopic miotomy and dor fundoplication as a paradigm for the appropiate management in this kind of patients. methods: a years old female, who underwent a previous miotomy and a dor fundoplication in due to an achalasia.six years after surgery, the patient showed epigastric pain and dysphagia. the study of the patient was performed with: barium swalow, phmetry, manometry, ct-scan and mri showing a recurrence of her disease.the patient was transfered to our center where she underwent a new surgery.the key points of the new surgery includes the next steps: dissection of the previous adhesions, dissection of the dor's partial fundoplication, avoid dissection of the anterior esophageal wall at the leve lof the hiatus (the area of previous myotomy) in order to avoid perforation of the esophagus, lateral and posterior dissection of the distal esophagus, lateral myotomy at the rigth wall of the esophagus and a toupet's funduplicatury. all of thisis procedures are done under intraoperative endoscopy in order to confirm a good passage to the estmach and to identify a perforationic supervision. results: following theseis steps several patients have been operated in our center with excellent results. in all of these cases, including the patiente presented previously, the symptoms have dissapeared. conclusions: achalasia is a rare motility disorder of the esophagus, being recurrences an important challenge for surgeons. a great proper therapeutic strategy using the different diagnostic exams and the supervison by a group of experts in this kind of entity are the basis in order to obtain good results in these situations. aims: re-do fundoplication is usually performed for recurrent reflux symptoms due to wrap failure or recurrent hiatus hernia. conversely, persistent dysphagia may occur early due to tight wrap/crural repair which should be avoided by good surgical technique. a small group of patients however may suffer progressive dysphagia due to weakening motility (especially in older patients), fibrosis of the wrap or a combination of the two. this video demonstrates the successful treatment of this problem with a laparoscopic conversion from nissen to posterior toupet fundoplication. a year old man underwent an uncomplicated laparoscopic nissen fundoplication in with complete resolution of reflux symptoms. he re-presented years later, still free of reflux but suffering progressive dysphagia and troublesome regurgitation. investigations demonstrated intact wrap and no mechanical obstruction, but confirmed low-amplitude peristalsis. a trial endoscopic dilatation improved symptoms for days before recurrence, suggesting likely wrap fibrosis (which would reduce elasticity and impede passage of food bolus), justifying consideration for a conversion from nissen to toupet. results: this video demonstrates the expected adhesions between fundoplication and inferior surface of left lobe liver, mobilisation and division of the nissen fundoplication, and reconstitution of a posterior toupet fundoplication. the patient made a good recovery and was discharged the following day. three-and six-month follow-up confirmed complete resolution of symptoms with no recurrence of reflux. conclusion: laparoscopic re-do surgery for late-onset progressive dysphagia is a safe and viable option. patients must be thoroughly investigated and carefully selected for an appropriately tailored procedure. they should also be advised of the increased risks associated with re-do surgery. the anatomy can be unpredictably distorted by variable adhesions and this operation should therefore only be performed by laparoscopic surgeons experienced in both primary and re-do fundoplication. methods: i report unusual iatrogenic injury of cervical esophagus that resulted with complete resection post total thyroidectomy for papillary ca of thyroid patient presented days post surgery to our center. the video will show the steps used to treat this unusual complication by neck exploration, laparoscopic trans hiatal esophagectomy with creation of gastric tube with preservation of the right gastroepiploic artery and the neck anastomosis between the cervical esophagus and stomach. were open and minimally invasive esophagectomies. of the patients, were for squamous cell carcinoma, were adenocarcinoma and were of other histological diagnosis such as gastrointestinal stromal tumor and schwannoma. the median length of stay for patients who underwent minimally invasive esophagectomies was days ( to days) while the median length of stay for patients who underwent open esophagectomies was days ( to days). the minimally invasive group had a shorter icu stay of day. for day morbidity, the minimally invasive esophagectomy group had patients who encountered anastomotic leaks, with post operative pneumonia while the open esophagectomy group had patient with anastomotic leak, patient with post operative stricture and patient with delayed gastric emptying. there were mortalities in the minimally invasive group while there were no mortalities in the open group. conclusion: our data show that patients who underwent minimally invasive esophagectomies had a shorter duration of hospitalization with similar perioperative morbidity rates. minimally invasive esophagectomy is a viable surgical option for a select group of patients. aims: there has been an increasing tendency towards minimally invasive surgery for esophageal cancer. our aim was to evaluate the results of the thoracoscopic approach (ta) and compare them with the ones of open approach (oa) at our institution. methods: retrospective review of all patients who underwent esophagectomy due to esophageal cancer (adenocarcinoma or squamous cell) between and were included. patients with siewert iii tumors and those who didn't need a thoracic approach were excluded. results: during the study period were performed esophagectomies, through ta. in . % of these, the abdominal stage was done by laparoscopy. when comparing ta versus oa, there were no statistically significant differences in the baseline characteristics of the two groups (mean age, median body mass index, ecog performance status, asa score, smoking status, diabetes mellitus, pulmonary disease, histologic type, clinical staging and neoadjuvant chemo and radiotherapy). regarding outcomes, there were no significant differences in need of intraoperative transfusion, median intraoperative blood loss, operative time and length of stay. although not significant, in ta group there was a tendency for higher overall morbidity ( . % versus . %, p = . ); major morbidity-ctcae - ( . % versus . %, p = . ); anastomotic leak ( . % versus . %, p = . ) and re-intervention rate ( . % versus %, p = . ). on the other hand, in ta group there was a tendency (although not significant) towards lower rate of respiratory complications ( . % versus . %, p = . ), lower rate of r margins ( . % versus . %, p = . ) and higher median of lymph nodes removed ( versus , p = . ). conclusions: in our series, outcomes of ta were similar to oa, with a tendency towards lower respiratory complications, lower rate of r margins and higher number of lymph nodes removed in ta group. the impact of these findings in survival remains to be seen. the tendency towards higher morbidity may be related to the learning curve, since this were the first cases performed at our center. background: esophagectomy is a surgical procedureburdened by a high morbidity rate. the effect of minimally invasive (mi) approach on elderly patients is still not clear. aim: of this study was to analyze the impact of mi approach on post-operative course according to the patient age. methods: a consecutive series of patients underwent to elective oncological esophagectomy between and . all data were entered into a prospective database. patients submitted to -flield or trans-hiatal esophagectomywere excluded andonly ivor-lewisopen, hybrid or totally minimally invasive esophagectomywere. patients were stratified according to age in groups:group a(= years) patients, group b ([ and \ years) and group c (were = years) .clinical and pathological factors influencing surgical outcome were evaluated. complications were classified according to clavien-dindo (cd). results: as expected outcomes worsened with patients age(cd = b: . % group a, % group b and % group c. p = . ), mortality ( % group a, % group b and . % group c. p = . ) and length of stay ( days group a, days group b and days group c. p = . ).a statistically significant higher incidence of anastomosticleaks was observed among patients submitted to totally mi esophagectomy in group c vs a and b that were respectively , %, % and %. major respiratory complications were not statistically different among these three sub-group. conclusions: old age has a significant impact on outcomes afteresophagectomy. in this subset of patients a mi approachcould also increasepostoperative morbidity. elderly patients should be carefully selected before to be submitted to mi esophagectomy. introduction: esophagectomy is a major surgical procedure with morbidity and mortality related to the patient's condition, stage of the disease, complementary treatments, and surgical experience. minimally invasive esophagectomy (mie) may lead to a reduction in perioperative morbidity and mortality with very good quality of life. material and method: we present the experience of the center of excellence in esophageal surgery regarding totally mie through thoracolaparoscopic modified mckeown three-stage approach followed by esophageal reconstruction by gastric intrathoracic pull-up and cervical esophagogastric anastomosis used for the treatment of thoracic esophageal cancer. results: in the last years, mie was performed initial, in our clinic with extracorporeal preparation of the gastric conduit with reduced lung complications and hospital stay. we introduced the totally minimally invasive esophagectomy with laparoscopic-assisted feeding jejunostomy using a d high definition camera. operative times were: thoracic- min, abdominal- min and cervical- min with a total of min. the augmented d high definition image provided an excellent visual field, that allowed an accurate identification of dissection plans and extensive periesophageal and perigastric lymphadenectomy. the short-term outcomes of the totally minimally invasive esophagectomy procedure were very encouraging with early feeding on jejunostomy and the control of cervical anastomosis was usually performed in the th day postoperative and the patients were discharged in the th day postoperative without any symptomatology. at the first and third-month follow-up was not reported any major complications. the long-term oncological results are being evaluated. conclusions: the totally minimally invasive approach using advanced technology of endoscopic surgery allowed for these patients a simple postoperative evolution, no major complications, and a good recovery after an extensive surgery. the solid experience in open esophageal surgery of the upper gastrointestinal surgeons provides a fast learning curve of complex minimally invasive surgical procedures with reduced perioperative morbidity. long-term follow-up should confirm the results from the literature regarding the survival, which is expected to be for these patients at least equivalent with outcomes after open esophagectomy. introduction: esophageal fistulas, benign or malignant, represent a real challenge for the surgeons and gastroenterologists, regarding the treatment and the outcome. in these cases, endoscopic treatment is the first line approach, being less invasive and sometimes avoiding the need for surgery. this includes clips, stents, glue and even suture. material and method: we have analyzed esophageal fistulas in patients with benign or malignant pathology, diagnosed and treated in the first months of . the management of this complication included a self-expandable esophageal metallic stent. we have evaluated the diagnosis, the surgical intervention, the timing until the development of the leak, the localization and management of the fistula. results: were postoperative leaks and spontaneous esophageal fistulas. the localization was cervical in one case, thoracic in cases and abdominal in cases. for the postoperative fistulas, in patients the treatment included at least one surgical reintervention with lavage and drainage, beside the insertion of an esophageal metallic stent. in the other cases, endoscopic treatment and antibiotic therapy was enough. in cases, the stent migrated needing repositioning. days mortality was %, both patients from postoperative group. conclusions: esophageal fistulas represent a severe complication, usually in patients already immunocompromised. endoscopic management, including self expandable esophageal metallic stent, can be the main approach, by stopping the contamination and by permitting the early per oral feeding. disadvantages include the possibility of migration and the need of removal after - weeks. methods: five hundreds and one patients with esophageal cancer who underwent mie from to at our department were eligible. we considered the risk factors of complications of pneumonia, anastomotic leakage, and hoarseness after surgery, and the risk factors of difficulty of surgery. results: the risk factors of postoperative complications in univariate analysis were more than years old (odds ratio: . , p = . ), more than ii in asa-ps (odds: . , p \ . ), more than g of bleeding (odds: . , p = . ), more than min. of operation time (odds: . , p \ . ), and colon reconstruction (odds: . , p = . ). the one in multivatiate analysis was more than ii in asa-ps (odds: . , p = . ). the risk factors of much bleeding were colon reconstruction (odds: . , p \ . ), and more than of lymph node dissection (odds: . , p = . ). the risk factors of long operation time without cervical lymph node dissection were neo-adjuvant therapy (odds: . , p \ . ), more than of lymph node dissection (odds: . , p = . ), and colon reconstruction (odds: . , p \ . ). the ones with cervical lymph node dissection were more than pstage iii (odds: . , p \ . ) and more than of lymph node dissection (odds: . , p = . ). conclusions: considering those risk factors, we should perform perioperative management more carefully. method: sa -year-old man with a tobacco and alcoholic habit was suspended for years, under treatment for arterial hypertension, who consults for a logical dysphagia of months of evolution. he is diagnosed of stenosing esophageal distal third epidermoid carcinoma txn m . it is decided to place a prosthesis that is effective and subsequent neoadjuvant qt-rt, after weeks of its completion the surgery is performed. results: the surgery is performed in times, initially by laparoscopy. the esophageal hiatus and the greater curvature are dissected preserving the right gastroepiploic, and lymphadenectomy of the celiac trunk with pedicle section of the left gastric. gastric plasty is performed with a section of lesser curvature towards fundus. it is continued by thoracoscopy. a section of the azygos vein is performed, dissection of the esophageal middle and lower third and lymphadenectomy. gastric plasty is promoted, proximal esophagus section and latero-lateral intrathoracic gastro-oesophageal anastomosis. the anatomopathological study reports ypt and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: ivor-lewis endoscopic surgery is safe and meets oncological criteria in selected patients with distal esophageal neoplasia and performed by an experienced esophagogastric unit. background: the rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in japan. we retrospectively reviewed short term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position under artificial pneumothorax by co insufflation in a single institution. this study aimed to evaluate the feasibility of applying this procedure. methods: between july and december , patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation. the thoracic procedure is performed as follows:the lymph nodes around the right recurrent laryngeal nerve are dissected. on the cranial side, the lymph node dissection is advanced to the level of the inferior thyroid artery. then, the assistant rotates the trachea toward the ventral side, and the lymph nodes around the left recurrent laryngeal nerve are dissected. the middle and inferior mediastinal lymph nodes are dissected including supradiaphragmatic lymph nodes and the dorsal lymph nodes around the thoracic descending aorta. then, the esophagus is transected using an automatic suture device. finally, the tracheal bifurcation area lymph nodes are dissected. we retrospectively analyzed these patients. results: the completion rate of thoracoscopic esophagectomy was . %, and the procedure was converted to thoracotomy in five patients, due to hemorrhage,severe adhesion. the mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were . min, . ml, and . , respectively. postoperative complications included pneumonia ( . %), anastomotic leakage ( . %), and recurrent nerve paralysis ( . %). postoperative ( d) mortality was / ( . %) due to ards and nomi, respectively. conclusions: standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation, with a standardized clinical pathway for perioperative care led to favorable surgical outcomes. introduction: recently thoracoscopic surgery has become widespread even in chest procedure in thoracic esophageal cancer surgery. as an advantage of minimally invasive esophagectomy, it is possible to perform sophisticated procedures due to its magnified visual effects. on the other hand, short-term perioperative safety and oncological safety are still unclear. in cases where abnormal anatomy or comorbidity in the thoracic cavity is observed, it is thought that it is necessary to carry out thoracic surgery which ensures safety while keeping in mind the transition to transthoracic surgery. here, we report on esophageal resection of the thoracic esophageal cancer accompanied by a mm saccular aneurysm inside the aortic arch. patient: a -year-old man visited a nearby doctor with a chief complaint of discomfort during swallowing. upper gastrointestinal endoscopy examined middle cervical esophageal cancer and received referral to our hospital. ct revealed a mm saccular aneurysm inside the descending aorta in contact with the thoracic esophagus. preoperative diagnosis was middle thoracic esophageal cancer; -iic ct bn m stageia (uicc th). we performed thoracoscopic esophagectomy and lymph node dissection as curative surgery. the anterior surface of the aorta was exposed from the lower mediastinum and descended ascendingly, reaching the lower end of the saccular anus at the head level of the lower pulmonary vein. peeling off the esophagus dorsal side along the margin of the saccular sac and performing esophageal resection. conclusion: we reported thoracoscopic esophageal resection for thoracic esophageal cancer with chest descending aortic saccular aneurysm. thoracoscopic surgery, which can fully exploit close magnification effect, seemed to be useful for anatomically disqualified cases. introduction: anastomotic leakage from oesophagojejunal (oj) anastomosis after total gastrectomy is associated with a high morbidity and mortality rate. leakage rates reported vary between ?% and ?% but lack of consensus in management. in the past, it often required surgical intervention or radiologically abscess drainage that will keep patients fasted with external drain for a long duration. recently, variable endoscopic options-oesophageal stents, clips, fibrin glue and endoluminal vacuum therapy had been introduced with variable outcomes. here, we presented a case of oj anastomotic leak management with combination innovative endoluminal and radiologically technique to insert double pig-tailed catheter. aim: to introduce the feasibility of double pig-tailed catheter for drainage and management of oj anastomosis leak. a year old man presented with two months history of dysphagia. upper endoscopy (ogd) showed suspicious cardio-oesophageal lesion. histology biopsy confirmed with adenocarcinoma. ct-scan of thorax, abdomen and pelvic showed irregular thickening at cardiooesophageal junction with regional lymphadenopathy. no distant metastases. he underwent uneventful d total gastrectomy. on th post-operative day, patient had spike fever and newly developed atrial fibrillation. urgent ct-thorax, abdomen and pelvis with oral omnipaque. it showed lower mediastinal gas-containing fluid adjacent to oj anastomosis within the left retrocrural space suspicious for leak. ogd evaluation showed pin-hole oj leak. guidewire inserted via endoscopy into left retrocural space under radiologically guidance. double pig-tail fr cm subsequently inserted via seldinger approach over guide wire. the proximal end of pig-tail pushed into left retrocural space and distal end positioned into efferent jejunal limb with crocodile jaw through endoscope. diluted contrast injected and passed down to efferent limb with minimal leak. outcome: after double pig-tail insertion, patient started on clear feed on st day post-insertion. one week later, he was started on full feed. repeat upper endoscopy and stent removal done two weeks later. contrast injection showed small blind ended sinus tract from anastomosis toward left pleural space without obvious leak. conclusion: radio-endoscopic is a novel minimally invasive technique that allows insertion of double pig-tailed internal drainage to control oj anastomosis leak. it allows early enteral nutritional feeding and avoid external drainage. background: the number of gastric cancer (gc) survivors, especially long-term survivors, is increasing. how best to evaluate the diseasespecific survival (dss) of gc survivors over time is unclear. we aimed to assess changes in the conditional survival of patients with gc after curative intend gastrectomy and the evolution of the impact of well-known risk factors. methods: clinicopathological data from , patients who underwent curative intend resection for gc at four specialized centres (three in china and one in italy) and from the surveillance, epidemiology, and end results (seer) database were retrospectively analysed. changes in the patients' -year conditional disease-specific survival (cs ) were analysed. we used time-dependent cox regression to analyse which variables had long-term effects on dss and devised an accurate, dynamic dss predictive model based on the length of survival. results: the median follow-up time was months, and disease-specific death occurred in , cases ( . %). the dss of the patients after surgery was dynamic, and most of the disease-specific deaths occurred within the first years after surgery. based on -, -, -, -and -year survivorships, the cs of the population increased gradually from % to . %, . %, . %, . %, and . %, respectively. subgroup analysis showed that the cs of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (e.g., n b: . %- . %, ? . % vs. n : . %- . %, ? . %). time-dependent cox regression analysis showed the following predictor variables constantly affecting dss: age, the number of examined lymph nodes, t stage, n stage and site (p all \ . , years after gastrectomy). the influence of prognostic factors on dss and cs changed dramatically over time. based on data from several large global centres, we developed an effective model for predicting the dss of gc patients based on the length of survival time. this model can provide personalized long-term follow-up strategies for patients. methods: we retrospectively analyzed clinicopathological data for rgc patients who underwent radical gastrectomy from centers. the prognosis prediction performances of the ajcc th and ajcc th tnm staging systems and the trm staging system for rgc patients were evaluated. web-based prediction models based on independent prognostic factors were developed to predict the survival of the rgc patients. external validation was performed using a cohort of chinese patients. result: the mean number of retrieved lymph nodes was . , and in . % of patients, the number was = . the predictive abilities of the ajcc th and trm staging systems were no better than those of the ajcc th staging system (c-index: ajcc th vs. ajcc th vs. trm, . vs. . vs. . ; p [ . ). within each staging system, the survival of the two adjacent stages was not well discriminated (p [ . ). multivariate analysis showed that age, tumor size, t stage and n stage were independent prognostic factors for overall survival (os), disease-specific survival (dss) and disease-specific survival (dfs). based on the above variables, we developed web-based prediction models, the huang os model, the huang dss model and the huang dfs model, which were superior to the ajcc th staging system in their discriminatory ability (cindex), predictive homogeneity (likelihood ratio chi-square), predictive accuracy (aic, bic), and model stability (time-dependent roc curves). the stratified analysis showed that regardless of whether more or fewer than lymph nodes were retrieved, the predictive performances of the web-based prediction models were still better than those of the other three staging systems. a decision curve analysis showed that the huang model provided better net benefits than the other three staging systems. external validation showed predictable accuracies of . , . and . , respectively, in predicting os, dss and dfs. conclusion: the ajcc tnm staging system and the trm staging system did not enable good distinction among the rgc patients. we have developed and validated visual web-based prediction models that are superior to these staging systems. objective: to perform competing risk analysis and evaluate cancer-and noncancer-specific mortality in patients with gastric cancer after radical surgery. methods: a total of patients from our department (as training set) and a total of patients from the surveillance, epidemiology, and end results (seer) database (as validation set) were enrolled in the study. the cumulative incidence of cancer and noncancer-specific mortality was determined by univariate and multivariate competing risk analysis. results: the five-year cancer-and noncancer-specific cumulative incidence of death (cid) in the training set were . % and . %, respectively, which were significantly lower than that in the validation set ( . % and . %, respectively). multivariable analysis showed that age, tumor site, tumor size and ptnm stage were independent predictors of gastric cancer-specific mortality and overall survival, whereas age was an independent predictor of gastric noncancer-specific mortality. noncancer-specific cid surpassed cancer-specific cid for ptnm stage i patients after approximately years of surgery, but never for stage ii and iii patients. moreover, for stage i patients, the time point when noncancer-specific cid surpassed cancer-specific cid become earlier as age increasing, with only . years after surgery for patients more than years of age. conclusions: age is an independent predictor of gastric cancer-and noncancer specific mortality and overall survival for patients after radical surgery. for patients with stage i gastric cancer, noncancer-specific mortality is a significant competing event, with an increasing impact as age increases. aim: of the study was to analyse the possibility of function preserving gastrectomy based on the sentinel lymph node (sln) concept. methods: during last years in two clinics odessa national medical university we used mapping procedures in the patients with early gastric cancer. there were men and women, age to years, mean age . ± . years. blue dye was injected into quadrants of the submucosal layer surrounding the primary lesion using an endoscopic puncture needle in patients. blue lymphatic vessels and blue-stained lymph nodes can be identified by laparoscopy within min. of the blue dye injection. we used . % indocyanine green in patients, which we injected by intraoperative endoscopy. new technology indocyanine green (icg) fluorescent imaging was used for sln mapping in this patients. results: amany patients, in which we used blue dye for mapping sln, positive sln was in patients, negative-in patients. in all patients distal gastrectomy (dg) was performed with d lymphdissection. from patients with negative sln in patients metastasis in other lymph nodes were detected.among patients in whom we used icg fluorescent mapping positive sln were detected in patients. laparoscopic-assisted distal gastrectomy with d lymph node dissection was performed in these patients. in patients with negative sln partial wedge resection was performed in patients, segmental pylorus preserving gastrectomy was performed in patients. during follow-up period from to months no recurrences or metastasis were detected in these group of patients. qol in this group of patients was much better, than in patients with conventional distal gastrectomy. conclusions: icg fluorescent method is highly effective for detection of sln. in the patients with early gastric cancer function preserving gastrectomy based on sln navigation may be promising strategy to achieve better results. laparoscopic procedure taking advantage of robotic gastrectomy for gastric cancer to prevent pancreatic fistula gastrointestinal surgery and surgical oncology, ehime university, toon-city, japan backgrounds and aims: analysis of japanese national clinical database (ncd) showed that laparoscopic gastrectomy(lg) had rather increased pancreatic fistula (pf) compared with open gastrectomy. on the other hand, last year, multicenter collaborative research result of robotic gastric cancer surgery(rg)was shown that the complications including pf were significantly decreased as compared with lg. in this study, we have employed a new easy to use device in lg to minimize pf during suprapancreatic lymph nodes dissection requiring pancreatic retraction and compared with conventional lg and rg. materials and methods: internal organ retractor (aesculapÒ) to grasp the gastropancreatic fold and the suprapancreatic peritoneum to imitate davinci's forceps was guided with a thread outside the body. patients(jan. * nov. ) were divided into three groups as follows, group lg- (n = ), lg using the standard devices, group lg- (n = ), lg using organ retractor, group rg (n = ). amylase value in drain(d-amylase) and the volume in drainage, intraoperative bleeding, postoperative hospital stay, incidence of cd (] grade iii) were compared among three groups. results: data are indicated as lg- /lg- /rg(mean ± sd), respectively. on the day and third day after surgery, d-amylase were ± / ± / ± and ± / ± , ± (iu/l). d-amylase was significantly lower in lg- and rg group than in lg- the day after surgery. the operation time was significantly longer in rg, ± / ± / ± (min). bleeding volume and hospital stay did not differ among groups. pancreatic fistula (cd ] grade iii)was observed only in lg- group at (%) . discussion: pf(grade]cdiii), which may lead to mortality, occurred in lg- group. a significant elevation of d-amylase on the st postoperative day was prevented in lg- just like rg, which seemed to lead to prevent pf afterwards. the multijoint forceps is known to be an advantage of rg but it cannot be reproduced by lg using a linear forceps. however, another advantage such as vertical grasping and lifting of the gastropancreatic fold at rest could be mimicked by lg using this device, which seemed to enable a safe lymph node dissection and lead to reduce the pancreatic damage. conclusion: this inexpensive and easy to use method taking the advantage of rg seems to reduce surgeon's fatigue and tissue damage(pf). the study presents comparison of perioperative outcome between different surgical approaches for gastric adenocarcinoma (ac). methods: retrospective cohort of patients that underwent gastrectomy for (ac) at rambam hospital during - . patients data was collected based on demographic characteristics, bmi, operating room time (ort), number of lymph nodes (ln), length of hospitalization (loh), and perioperative complications. results: study population included patients after total gastrectomies, of them robotic and partial gastrectomies, of them robotic. age, gender and bmi were similar between patients who underwent any type of procedures. median length of hospitalization (loh) for robotic total gastrectomy was . days and it was significantly shorter than both laparoscopic total gastrectomy (ltg) . days (p = . ) and open total gastrectomy (otg) . days (p \ . ). similar significant differences in (loh) between the groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of (lpg). median(ort) was significantly longer among robotic gastrectomies compared to open, the difference was min in total gastrectomy group and min in partial gastrectomy group (p \ . for both differences), but the difference in(ort) between laparoscopic and robotic procedures were smaller and non-significant. the number of dissected (ln) was similar between the procedures in total gasrectomies. in partial gastrectomies, the number of dissected (ln) was even higher among both laparoscopic and robotic gastrectomies compared to open (p \ . ).) conclusions: robotic total and partial gastrectomies for gastric (ac) are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer ort. objectives: during esophagojejunostomy using a circular stapler after latg, placement of the anvil head via the transabdominal approach proved difficult. the authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head(orvil) via the transoral approach. methods: between january and november , esophagojejunostomy was performed using orvil in patients after latg. the anesthesiologist introduced the anvil while observing its passage through the pharynx. during the anastomosis, we kept the jejunum fixed in position with a silicone band lig-a-loops, thereby preventing the intestine from slipping off the shaft of the stapler. results: esophagojejunostomy using the orvil was achieved successfully in all patients. no other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. the postoperative complications of anastomosis were leakage in two patients and stenosis in patients, in whom mild relief was achieved using a bougie. conclusions: esophagojejunostomy using the orvil is a simple and safe technique. gastrointestinal tract surgery, fukushima medical university, fukushima-shi, japan; surgery, ohara general hospital, fukushima-shi, japan background: juvenile polyposis of the stomach is a very rare disease, and its malignant potential has been reported previously and total gastrectomy has been recommended as a standard treatment. recently, the usefulness of laparoscopic surgery for this case has been reported, however this type of surgery is thought that maintaining the surgical space is difficult because of distended and thickening stomach. case presentation: eight years ago, a -year-old woman who had no family history of gastrointestinal polyposis had been diagnosed with gastric polyposis and polyp-related anemia and received twice endoscopic submucosal dissection to early gastric cancer in another hospital. she had received an annual upper gastrointestinal endoscopy and she had taken iron supplements for anemia caused from the occasional bleeding from the polyps. however, the number of the polyps had increased over time. because she had a loss of appetite, she admitted to our hospital. enhanced computed tomography showed gastric wall thickening and multiple gastric polyps without lymphadenopathy or distant metastasis. colonoscopy showed no specific findings. she was diagnosed as the juvenile polyposis of the stomach, and she received laparoscopic total gastrectomy with roux-en y esophagojejunostomy. in operative findings, although there were the excessive distention and congestion of the stomach, standard laparoscopic surgery could be performed. the resected specimen revealed multiple variously sized polyps throughout the stomach except for lesser curvature and fundus and the histopathological examination revealed that all polyps were hyperplastic polyps without containing cancer. she was discharged on postoperative day . we successfully performed laparoscopic surgery to treat a rare case of juvenile gastric polyposis. introduction: we report a novel technique for combined use of laparo and thoracoscopy for faradvanced adenocarcinoma of esophagogastric junction (aeg). case presentation: a 's years old man presented with far-advanced aeg. an esophagogastroduodenoscopy revealed a type lesion with the entire circumference around esophagogastric junction (egj). contrast radiography revealed a severe stenosis in the egj and wall irregularity from egj to cardia. computed tomography revealed a stenosis of egj, suspected invasion into the left side diaphragm and some lymph nodes metastases at the abdomen. we diagnosed siewert type ii aeg (ct an m , cstage iiia : japanese classification of gastric carcinoma ver. ). surgical technique :the patient was placed in the reverse-trendelenburg position with the left upper body lifted and legs spread, under general anesthesia. the tumor was huge, exposed from the serous membrane and invaded the left crus. first we performed from laparoscopic proximal gastrectomy using five ports. then, three ports were added in the th, th, and th intercostal spaces with the patient in the same body position, and performed thoracoscopic lower esophagectomy under artificial pneumothorax with intrathoracic pressure of - mmhg, which allows the ventilation of both lungs. the lower esophagus was resected under the thoracoscopic view to ensure an adequate margin. following this resection, intrathoracic esophagojejunostomy was performed by using the laparo-and thoracoscopic techniques. the operative time was min, and the blood loss was g. he was discharged on the th day after the operation without any postoperative morbidity. the histopathological diagnosis was pt bn am , p , pstage iv. after adjuvant chemotherapy with capecitabine and oxaliplatin, ramcilumab monotherapy is undertaken now. ct revealed solitary lung metastasis in months after the operation. conclusion: malta for locally advanced aeg invading the surroundings could be performed safely. introduction: despite being the pioneer in laparoscopic surgery, europe did not have similar surgical experience compared to east asia due to decreased exposure to gastric cancer. several studies on minimally invasive gastrectomy for gastric cancer have been conducted in europe. however, some of them did not analyse total gastrectomy as a distinct entity combining both distal and total gastrectomies; moreover, most of them do not provide data on full five-year follow up for each patient. baltic countries stand in between east and west in terms of gastric cancer incidence: incidence rate per , is . in united kingdom, . in lithuania and . in japan. this exposure to gastric cancer provides unique opportunity to investigate the role of laparoscopic gastrectomy. therefore, a case-control study was designed to evaluate laparoscopic (ltg) versus open total gastrectomy (otg), comparing short-term surgical and long-term oncologic outcomes. surgery, jeju national university, school of medicine, jeju, korea; surgery, chosun university, school of medicine, gwangju, korea objective: although mcv (mean corpuscular volume) levels are known to be associated with the prognosis of various diseases, few study investigated mcv as prognostic factor after gastric cancer surgery. the aim of this study is to address the prognostic value of mcv in gastric cancer who underwent curative gastric cancer surgery. methods: patients (june -december ) with stage i, ii, and iii cancer were consecutively included in this study. all patients underwent curative gastric cancer surgery including subtotal gastrectomy or total gastrectomy. overall survival (os), disease-free survival (dfs) and postoperative complications rate were compared between mcv [ group and = group. results: of all patients, the mean mcv was fl (normal range, to fl). the dfs was significantly higher in the high-mcv ([ ) than low-mcv group(= ) (p \ . ) group. there was no significant difference in postoperative complications when compared with clavien-dindo scale. the survival rate of the high mcv group was higher but there was no significant difference. conclusions: mcv may be a predictive factor after gastric cancer surgery. unlike previous studies, patients with low mcv group showed lower dfs. more research is needed on the significance of mcv in variety of disease. methods: and materials. for years we observed cases with gist of stomach and duodenum. seven patients were brought to clinic with the bleeding and two patients were brought to clinic with vomiting and compensate stenosis. in all circumstances we done the ct, mrt and endoscopic examinations of stomach and duodenum with biopsy . in two circumstances we performed endoscopic operation. in one circumstance we successfully take off the gist from the duodenum endoscopically. during the operation we use the endoscopic instruments. in another circumstances,after endoscopic excision the tumor appear the bleeding which was stopped by endoscopic local heamostasis, by putting clipps on the vessels. in circumstances the tumors were in stomach. in circumstances we performed laparoscopic wedge resection the tumors by staplers. in circumstances when the tumor was very big and situated in the fundus of stomach, we performed laparoscopic resection of the fundal part of stomach by using laparoscopic staplers and 'liga sure' sealing. in circumstance we took off the tumor by putting laparoscopic trocars inside the stomach for instruments and for visualization tumor. after excision the tumor and took it of the stomach we sutured the holes in the stomach. we have no mortality after laparoscopic operation. there were no malignisation in all circumstances. we have cases morbidity. in circumstance the bleeding from the stomach that was stopped endoscopically. in circumstance there was wound infection. the aim of the study to decrease the morbidity in the patients with perforated ulcers of the stomach and duodenum. we observed patients with perforated ulcers of stomach and duodenum. women were , men were . average age about years. patients had perforation ulcer of stomach and duodenum. patients had perforations with bleeding. all patients were divided in two groups. the first groups patient operated laporocopically, in the second group patients operated traditionally. results: there were no mortality in the group that operated laparoscopically. in the group that were operated traditionally one patient died after rebleeding. the average stay in hospital in the group that were operated laporoscopically about days. in the groups with traditional operations, were about days. the morbidity in the first group were in cases. pneumonia in cases, suppuration of the troacar points were in cases. in the second group pneumonia were in cases, suppuration of the operation wound were in cases, subdiaphragmatic abscess was in cases. conclusion: laporoscopic operation in during treatment decrease the mortality, morbidity and hospital staying in the patients the perforated ulcer of stomach and duodenum . of the patients of the third group ( . %) were operated about ulcer rebleeding in the hospital, and ( . %)-about the profuse bleeding ulcer. noonr patient had recurrent bleeding. the average treatment time for patients in group was . ± . days. conclusions: the development of hemorrhagic shock in patients with peptic ulcer bleeding significantly increases the risk of rebleeding and mortality. the application of endoscopic hemostasis allows to reduce the risk of rebleeding and mortality compared with conservative antiulcer therapy. surgical treatment can achieve reliable hemostasis, but accompanied by higher mortality and longer duration of hospital treatment. tan tock seng hospital is second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. minimally invasive surgery for both benign and malignant diseases of upper gastrointestinal tract becomes more and more popular nowadays. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them with better understanding of the procedures. the viewing of videos help them with the importance of steps, standardization of steps. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start doing the procedure themselves after the graduation from the residency programme. this is the step by step instructional video of laparoscopic repair of perforated duodena ulcer for surgeons-in-training rotated to our department. in general duplication cysts are rare developmental congenital disorders of the gi tract. three morphological criteria should be met in order to confirm the pathological diagnosis: . they should be attached to the stomach's wall and should be the continuation of it, . at least one of the muscle layers of the stomach's wall should be included and .it should have normal gastric mucosa. the treatment is either enucleation or partial gastrectomy. aim: present our minimally invasive approach to a rare prepyloric submucosal cystic lesion causing gastric outlet obstruction. case report: a -year-old female with vomiting, weight loss and in bad general condition was diagnosed after a full work-up (blood tests, endoscopies, eus, ct and mri) with a submucosal cystic tumor. this cyst first was thought to be a duplication cyst. since the patient was young, our intention was to offer the least invasive surgical technique in order to spare gastrectomy and billroth anastomosis. results: the procedure was completed laparoscopically with enucleation of the cyst through a gastrotomy on the anterior wall of the stomach. after the enucleation of the cyst the gastric mucosa was sutured back and then the gastrotomy was closed with continuous sutures. the result of the pathological report confirmed a rare case of a heterotopic pancreatic cystic lesion. the postoperative course of the patient was uneventful and was discharged with instruction for her diet the th postoperative day. the patient months post-operative has no symptoms. conclusion: in such benign conditions and especially in young patients, gastrectomies could be avoided if possible and give their place to less invasive approaches in order to reduce lifelong risks and morbidity. trangastric enucleation of the cyst although a demanding approach is safe and could be considered as a 'gentler' technique with reduced morbidity. background: pancreatoduodenectomy is considered to be very invasive for early superficial duodenal tumors (sdts), which have a lower risk of lymph node metastasis. partial duodenal resection with endoscopic submucosal dissection for sdts is an attractive technique but it is associated with a high risk of complications. the full-thickness resection of the duodenum wall including laparoscopic and endoscopic cooperative surgery has risk of spreading tumor cells and digestive juices into the abdominal cavity. we have developed novel technique for sdts to decrease the risk of exposure to abdominal cavity of tumor cells and digestive juices, called nonexposed duodenum laparoscopic and endoscopic cooperative surgery (neo-dlecs). aim: the aim of this study is to evaluate the feasibility and safety of neo-dlecs for sdts. surgical procedure: the attachment of the transverse mesocolon was freed from the head of the pancreas and retroperitoneal tissues under laparoscopy. the duodenum and the head of the pancreas were mobilized from the retroperitoneum using the kocher maneuver. a standard esd was performed for the sdt using endoscope. the serosa of the esd ulcer bed was reinforced using the laparoscopic hand-sewn suturing technique in the seromuscular layer around the resected area. after completing the procedure, the endoscope was inserted and passed over the resected area to confirm that there was no stenosis or leakage. methods: ten consecutive patients with sdt underwent neo-dlecs in our institute between march and march . the clinicopathological features of the patients and surgical outcomes were prospectively collected and retrospectively analyzed. results: pathological diagnosis was adenocarcinoma for six patients, adenoma for three patients, and neuroendocrine tumor grade for one patient. the median tumor size was ( - ) mm. the median operative time was . ( - ) min. the median blood loss was ( - ) g. there were no conversions to open surgery in this series. intraoperative perforation was found in two cases during the esd procedure. however, all perforations were closed and reinforced using hand-sewn sutures. no postoperative complications were above grade in the clavien-dindo classification system. conclusions: neo-dlecs is safe and feasible and can be an option for surgical sdt resection. aims: wilkie's syndrome is caused by the entrapment of the rd part of the duodenum between the aorta and the superior mesenteric artery (sma). surgery is indicated for chronic cases and failure of conservative management, being reported a laparoscopic duodenojejunostomy as a minimally invasive option. methods: all cases treated by laparoscopic duodenojejunostomy in our centre because of chronic wilkie's syndrome were recorded. results: females and male underwent a laparoscopic duodenojejunostomy, with a mean age of years (range - ). all patients presented abdominal pain, and weight loss was identified in most of them. a reduced aortomesenteric angle measured by ct scan was the key for the diagnosis (mean angle . degrees, range - ). conventional laparoscopic approach was performed in two patients, the other two patients underwent a sils port approach. mean time of surgery was . min (range - ) and length of stay was days (range - ). after a mean follow-up of . months (range - ), patients improved their symptoms. conclusions: surgery is the mainstay in complicated or refractory cases of sma. laparoscopic duodenojejunostomy has the advantages of the laparoscopic approach (including rapid recovery time, reduced post-operative pain and shorter hospital stay) and it is feasible, safe and effective. in mexico in , gastric cancer represented the rd cause of death; it may manifest in a variety of histologic, anatomic, and genetic patterns, which influences the surgical approach. until now gastrectomy with curative intent is the only treatment that offers potential cure in gastric cancer. in recent years, laparoscopy has emerged as an important modality in the surgical management. in multiple trials no significant difference in recurrence, long-term survival and disease-free survival was observed when compared to the standard open gastrectomy. we present the case of a year old man. with a smoking history of pack years, suspended years earlier. he presented unspecific upper gastrointestinal symptoms; an upper endoscopy was made observing a suspicious depressed lesion of cm located in the greater curvature between the body and the antrum, the biopsy resulted in a poorly diferentiated signet-ring cell carcinoma of the stomach. an endoscopic ultrasound and a thoracoabdominal ct scan showed no evidence of enlarged adenopaties or metastatic disease. initially a diagnostic laparoscopy was made, there was no evidence of carcinomatosis, nor free intraperitoneal fluid; so the greater omentum was dissected towards the splenic and hepatic flexure; a d lymph node dissection was performed, and a subtotal gastrectomy with reconstruction of roux en y was done; intraoperative endoscopy was done to identify the lesion, so adequate margins could be obtained. the patient had a good post operative evolution and was discharged home at th day tolerating oral intake. minimally invasive techniques have proved equivalency of oncologic results when compared to the conventional approach; these techniques are becoming the preferred approach in the treatment of well-selected patients with gastric cancer and have a role in definitive staging, curative resection, and lymphadenectomy. appropriate selection of patients and optimal technical approach are paramount for good outcomes. most data of laparoscopic gastrectomy come from eastern countries, where the prevalence is higher; however western experience is growing along with evolution and development in surgical instruments and new technology. wilkie syndrome is a rare cause of high intestinal obstruction, resulting from the compression of the duodenum between the abdominal aorta and the superior mesenteric artery. the main symptoms are nausea and vomiting, weight loss, early satiety, abdominal distension and epigastric pain. historically, the barium study and arteriography were the diagnostic tests used; more recently the angiotac has shown greater sensitivity. the diagnostic criteria are: dilated duodenum, duodenal compression by the superior mesenteric artery and aortomesenteric angle less than degrees. patients with an acute condition usually respond to conservative treatment (decompression, correction of hydroelectrolyte alterations, nutritional support…). however, those with chronic symptoms usually require surgery preferably with laparoscopic approaches of duodenojejunostomy or the strong's procedure. the strong procedure mobilizes the duodenum by dividing the ligament of treitz. once the duodenal-jejunal junction is mobilized, the duodenum is positioned to the right of the superior mesenteric artery and it is preferred because it provides less morbidity due of the maintaining of the integrity of the gastrointestinal tract, but it has a failure rate of %. gastrojejunostomy allows gastric decompression, but does not relieve duodenal compression, so digestive symptoms may persist, leading to the appearance of a blind loop syndrome or recurrent peptic ulcers. on the other hand, the duodenojejunostomy, which according to some series may be the procedure of choice, may obtain a success rate higher than %. we advocate to initiate the surgical approach with the strong procedure and if it fails to perform to a duodenojejunostomy. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in cases. the outcome was assessed by reflux test performed on - postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was months ( - months) . in cases ( . %) ppi was restarted before months after the anti-reflux surgery. in cases ( . %) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed 'the esophagitis score'. in this scoring method, a number from - was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p \ . ). discussion: to extract the gerd patients who really need anti-reflux surgery is important. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good. background: laparoscopic paraesophageal hernia repair with fundoplication has become more and more popular nowadays due to less morbdity and mortality with shorter length of hospital stay. discussion: tan tock seng hospital is the second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them understand the procedures better. the videos can also help them recognize the important steps and standardized safe approach. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start performing the procedure themselves during their training period. this is the step by step instructional video of laparoscopic paraesophageal hernia repair with fundoplication for surgeons-in-training who are posted to our department. conclusion: the step by step instructional video on laparoscopic paraesophageal hernia repair with fundoplication can help the surgeons in training reduce their learning curve and improve their surgical skills so that they can perform the procedure safely. the human immunodeficiency virus (hiv) is a neurotropic virus. there have been reports of patients with hiv who have esophageal motility problems, sometimes associated with opportunistic infections. the absence of contractility is defined as a major motility disorder according to the chicago v . classification, which is characterized by normal esophagogastric union relaxation and % peristalsis failure. we present the case of a -year-old male patient with a history of acquired immunodeficiency on treatment with efavirenz, emtricitabine and tenofovir. he presented progressive dysphagia, gastroesophageal reflux and pyrosis of months of evolution. physical examination showed no alterations. upper endoscopy is done reporting a normal esophagus and diffuse chronic gastritis. the esophagogram reported inadequate esophageal motility with contrast stasis and a delayed emptying. the esophageal manometry reported an upper esophageal sphincter with high resting pressure. the middle and distal esophagus showed absence of peristalsis with a pan-esophageal pressurization pattern. the lower esophageal sphincter presented normal resting pressure and borderline relaxation ( %). the integrated relaxation pressure was less than mmhg. the diagnostic impression was absence of contractility (chicago classification v . ).medical management was initiated with inhibitors of the proton pump, isosorbide dinitrate and injections of botulinum toxin without success. it was decided to program the patient for a heller myotomy with toupet fundoplication. a trans-surgical endoscopy revealed a complete myotomy with no leakage or obstruction. the patient went home on the second postoperative day tolerating a solid diet.heller myotomy by laparoscopy with partial fundoplication is safe in the treatment of patients with hiv and esophageal motility disorders, reporting a mortality of . %. the effect of endoscopic treatments prior to surgery is controversy aims: epiphrenic diverticulum represents an infrequent entity and it is usually associated with esophageal motility disorders, such as achalasia, distal esophageal spasm, nutcracker esophagus or hypertensive lower esophageal sphincter. nowadays, epiphrenic diverticulectomy, esophageal myotomy and partial fundoplication is the gold standard technique; although it supposes a challenging procedure and it may provoke lots of complications. approach for diverticulectomy usually depends on the distance from the upper border of the diverticulum's neck to gastroesophageal junction, considering that thoracoscopy should be carried out when this distance is more than cm. methods: we presentthecase of a -year-old male patient, with a bodymass index of anda medical history of diabetes, smoking and alcoholism. his symptoms were mainly regurgitation and dysphagia. upper endoscopy showed esophageal dilatation and the presence of a diverticulum with its neck cm over the gastroesophageal junction. ct scan confirmed these findings and manometry showed achalasia. in the video we can see how we perform a laparoscopic diverticulectomy with esophageal myotomy and dor fundoplication. results: patient was discharged home on the second postoperative day with no complication. after more than two years of follow-up, he has not suffered regurgitation, heartburn, dysphagia or chest pain. conclusions: we present a case with an epiphrenic diverticulum secondary to achalasia in which we performed a laparoscopic diverticulectomy, esophageal myotomy and dor fundoplication. some authors suggest that the correction of the underlying motility disorder is the key in the management of these patients and they do not recommend concomitant diverticulectomy for all cases. however, we consider that the complete procedure, adding diverticulectomy, supposes the gold standard and it is feasible to perform for teams which are skilled in esophageal and gastric laparoscopic surgery, despite its high morbidity rates. purpose: a laparoscopic wedge resection for a gastric submucosal tumor closed to gastroesophageal junction or involved to gastroesophageal junction is technically challenging and more aggressive compared with tumors in other sites of the stomach. a gastroesophageal reflux disease would be more prevalent after laparoscopic wedge resection of a gastric submucosal tumor in gastroesophageal junction because of the destruction to low esophageal sphincter. we hypothesized that a prophylactic anti-reflux surgery after this surgery would be less prevalent the gastroesophageal reflux disease (gerd) and more improve the quality of life of the patients. the aim of this study is to analyze our experience with prophylactic anti-reflux surgery after laparoscopic wedge resection for a gastric submucosal tumor of gastroesophageal junction materials and methods: we retrospectively collected data from patients who diagnosed with submucosal tumor of near the gastroesophageal junction underwent laparoscopic wedge resection between january and december . the patients were divided into groups according to operation with prophylactic anti-reflux surgery (group a) and without one (group b). results: there were no difference in the frequency of the preoperative gerd symptoms between the groups, whereas postoperative gerd symptoms and postoperative use of acid suppressive medications were more frequent in the group b (p = . , p = . ). however, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and hill's grade between the groups. in group a, postoperative mean low esophageal sphincter (les) pressure was . ± . . the les pressure was dropped until mmhg in the only one patient. however, there was no reflux symptom in this patient. conclusions: the prophylactic anti-reflux surgery after laparoscopic gastric wedge resection of gastroesophageal junction is an effective method of prevent gastroesophageal reflux symptoms. background: the most critical obstacle is a pancreatic leakage(pl). the most cause of pl might be an activation of pancreatic juice by the mixing of pancreatic juice and intestinal fluid because of the anastomosis technique, the difference of anastomosis between pancreatic duct and caliber of jejunum, and the topple of jejunal mucosa. aim: in this study, we devised the new anastomotic method of pancreato-jejunostomy, so called ' pancreatic stent sliding guide' (pssg) method using a pancreatic duct stent. we would like to demonstrate its method and results. (operative procedure) the cases of hybrid laparoscopic pancreatico-duodenectomies (pd) were done by shuriken-shaped umbilicoplasty with pssg. the pancreatic duct stent, which is fit for a diameter of pancreatic duct, is used for the direct puncture without any incineration. the aims of direct puncture are both the avoidance of the enlargement of anastomotic opening and disturbance of blood flow. the contralateral of anastomotic opening is also punctured and the stent is pulled out of the jejunum. the - pds with the needles at both ends is used for anastomotic thread. firstly, the eversion anastomosis of posterior wall is done by sliding the needle on the stent. and then the anastomosis of anterior wall is done by the same way. the stent of contralateral side is cut and the hole is closed. materials and methods: the cased of pancreato-jejunostomy by pssg method were done by february . the average of patient's age was y.o. the disease of patients were pancreatic cancer (n = ), bile duct cancer (n = ), and papilla vater cancer(n = ). the pancreatic leakage by the isgpf were grade : ,a: ,b: ,c: respectively. in the same periods, we underwent the more ten cases of open pd by pssg method. the pl were only one case of grade a and there were none of clinical pl. conclusion: our new device of pancreato-jejunostomy by pssg might be very effective for the decrease of pl from the view point of machanisms of pl even for laparoscopic pd. year old, male patient presented with upper abdominal discomfort and pain, without nausea, vomiting or weight loss. an sub mucosal lesion was found on endoscopy examination in first part of the duodenum. endoscopic ultrasound has showed . cm sub mucosal lesion in first part of duodenum (anterior wall and close to pylorus). cytology examination from the lesion has showed neuroendocrine tumor. computed tomography of abdomen and chest were normal. his blood laboratory examinations were within normal limits. patient underwent da vinci robotic partial gastrectomy with intra corporeal billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology report confirmed diagnosis of carcinoid tumor with ki less than %. surg endosc ( ) :s -s p -robotics & new techniques-education integrated education for colorectal disease-a digital solution for a digital age united kingdom aims: surgical plume has problem in poor visibility of the operative field, inclusion of harmful chemical substances, and biological risk. it is desirable that plume should be removed appropriately to minimize these risks. we assessed whether these problems can be solved by using commercialized evacuator semi-quantification of residual chemicals in the abdominal cavity: was performed using industrial smoke tester by aspirating the intra-abdominal plume onto filter papers and digitizing the stains. ( ) detection of dna in the exhausted gas from the evacuator: the hepa filter, which was interposed at the inlet or outlet of the evacuator, was analyzed using pcr method to detect any dna derived from porcine tissues. results: ( ) laparoscopic visualization: judgement score were . vs. . for ec and . vs. . for us (evacuator: on vs. off, both p \ . ), indicating the visualization was significantly better in the use of the evacuator on both devices general surgery, royo villanova hospital general surgery minimally invasive surgery centre, jesús usón minimally invasive surgery centre methods: i report my experience at the american university of beirut medical center for laparoscopic adrenalectomy cases, left adrenalectomy and cases for right adrenalectomy. three out of the series are large adrenal of cm, and all of these were completed laparoscopically.the video will show the steps of this procedure.a large rt. adrenal mass measuring cm, wt. gm was removed laparoscopically using trocar techniques. the lateral position facilitated the exposure and ease of dissection. the mass was removed by extending one of the trocar site with muscle splitting using endocatch mm. results: patient was discharged home days after surgery. the operative time was hour. pathology revealed carcinoma with no involvement of the capsule or vascular invasion patients (male: n = ; female: n = ) underwent minimally invasive adrenalectomy (tp: n = ; rp: n = ) at our institute. mean patient age was . years ( - years). besides comparing operative (intraoperative blood loss, previous abdominal surgeries, conversion rate, operative time, tumor size) and perioperative factors (time of hospitalization, time to oral intake, histology, postoperative complications) in each group, perioperative outcomes of a learning curve (lc)-the first procedures in both groups-was also analyzed in terms of tumor size, significantly larger lesions were removed with tp (tp: . ± . mm vs rp: . ± . mm; p = . ). the number of asa (american society of anesthesiologists) ii patients were significantly higher in the tp group while there were significantly more asa iii patients in the rp group conversions ) showed no significant difference. the analysis of lc showed a significant difference in previous abdominal surgeries min vs rp: . ± . min; p = . ] all favoring the tp approach. conclusion: both methods proved to be feasible and safe in terms of minimally invasive adrenalectomy. based on our own experience the tp approach resulted in improved operative time and conversion rates to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the face of a massive splenomegaly or neoplastic pathology. material and method: clinical case: a -year-old man followed in the dept. of internal medicine for a hepatosplenomegaly of probable lymphoproliferative origin. additional explorations of interest are provided. result: intervention: complete laparoscopic approach, right lateral partial decubitus, massive splenomegaly, ? cm, splenuncle of - cm that is resected, section of short vessels, dissection of the splenic hilum, vascular section with endogias, splenectomy with full extraction in a pocket through reduced laparotomy in the left flank for anatomopathological study the aim of this video is to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the case of a massive splenomegaly or neoplastic pathology it can transform into adenocarcinoma. patients and methods: between and we performed laparoscopic nissen fundoplication (lars) in cases of gerd. in cases of gerd patients be was proved by endoscopy and histological examination. the demeester score was higher ( . versus . , p \ . ), and bile re?ux was measured more frequently among the be patients on the other hand during the . years long endoscopic follow up early barrett carcinoma developed in patients, . months after the lars. both patients underwent a limited surgical resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic jejunal segment. there were no complication. histological examination was shown pt n stage disease in both cases. oncological follow up was months long ( . y) and both patients are still disease free. conclusions: although lars can affect regression in a part of be patients, progression to adenenocarcinoma can also occur. endoscopic surveillance is important in the case of be to recognize early cancer, to perform limited surgical resection with low morbidity and long overall-and disease free survival gastric cancer development a nomogram for predicting the conditional probability of survival after d lymphadenectomy for gastric cancer this study aimed to devise a nomogram to predict the conditional probability of cancer-specific survival (cpcs) in gastric cancer (gc) patients after gastrectomy with d lymphadenectomy. methods: clinicopathological data for , gc patients who underwent d lymphadenectomy in a large-volume eastern institution (the training cohort) were analysed. cancer-specific survival (css) was predicted using cox regression models. a conditional survival nomogram was constructed to predict cpcs at and years post-gastrectomy. two external validations were performed using a cohort of , chinese patients and a cohort of italian patients. results: in the training cohort, the -year cpcs was . % immediately post-gastrectomy and increased to . %, . %, . % and . % at , , and years post-gastrectomy, respectively. multivariate cox regression analyses showed that age; tumour site, size and invasion depth; numbers of examined and metastatic lymph nodes; and surgical margins were independent prognostic factors of cancer-specific survival (all p \ . ) and formed the nomogram predictor variables. internal validation showed that the conditional nomogram exhibited good discrimination ability at and years post-gastrectomy (concordance index, . and . , respectively) gastric cancer does non-compliance in lymph node dissection affect oncological efficacy in gastric cancer patients undergoing radical gastrectomy? univariate and multivariate analyses revealed that non-compliance was an independent risk factor for os. logistic regression analysis demonstrated that the extent of gastrectomy, primary tumour site, history of intraperitoneal surgery, bmi and open gastrectomy were independent preoperative predictive factors for non-compliance. cox analysis demonstrated that age, pt, pn, and the extent of gastrectomy independently affected os in patients with noncomplaint lymphadenectomy. however, os was significantly better in the compliant group than in the non-compliant group regardless of the recommendation for chemotherapy. stratified analysis demonstrated that os was significantly better in chemotherapy patients than in patients without chemotherapy and stage ii patients (pt n /n m and pt n m ) in whom chemotherapy was not recommended. conclusion: non-compliance is an independent risk factor after radical gastrectomy for gc we prospectively collected and retrospectively analysed the medical records of patients with proximal gc who underwent lspsd. the data were split / , with one group used for model development and the other for validation testing. results: of the patients enrolled in this study, ( . %) required laparoscopic haemostasis treatment. a multivariate analysis determined the following preoperative adverse risk factors for the model group: gender, preoperative n stage, and terminal branches of the splenic artery (spa), and we developed a scoring system based on these findings. each of these factors contributed point to the risk score. the intraoperative laparoscopy hemostasis rates were . , . , . , and . % for the low-, intermediate-, high-, and extremely high-risk categories, respectively. there were statistically significant differences among groups (p \ . ). with the increase in risk, both blood loss volume (blv) and operative time (min) of lspsd increased significantly (p \ . ).the area under the receiver operating characteristic curve for the score of intraoperative laparoscopic haemostasis was . . the observed and predicted incidence rates for intraoperative laparoscopic haemostasis were parallel in the validation set. conclusions: this simple we compared the survival of src patients with that of tubular adenocarcinoma patients according to bmi. results: the -year survival of src was significantly worse than that of wmd (p \ . ) but superior to that of pd (p \ . ). bmi-stratified analysis showed that in the high-bmi group, the prognosis of src was similar to that of wmd (p [ . ) and better than that of pd (p \ . ). in normal-bmi patients, src had a worse prognosis than wmd (p \ . ) but a more favorable prognosis than pd (p \ . ). src among low-bmi patients displayed much poorer survival than did both wmd (p \ . ) and pd (p = . ). multivariate analysis indicated that the risk of death was lowest for src patients with a high bmi and highest for src patients with a low bmi baseline characteristics were compared in a -patient rspshl cohort and a -patient lspshl cohort. one-to-four propensity score matching was performed to determine between-group differences. result: in total, patients were matched, including patients who underwent rspshl and who underwent lspshl. no significant differences in baseline characteristics were observed between these groups after matching. significant differences in total operative time, estimated blood loss (ebl), splenic hilar blood loss (shbl), splenic hilar dissection time (shdt), and splenic trunk dissection time were detected between these groups (all p \ . ). furthermore, no significant differences were evident between rspshl and lspshl in the overall noncompliance rate of lymph node (ln) dissection ( the highest body temperature within week after operation was used to establish diagnostic thresholds for high body temperature and low body temperature, which was obtained by x-tile software. the study used cox regression to analyze the influence of high body temperature on -year dfs. results: a total of patients were included in the analysis. the diagnostic threshold for high body temperature was defined as °c; patients with a high postoperative body temperature were allocated to the high temperature group (htg), while another patients were allocated to the low temperature group (ltg) cao department of gastric surgery, fujian medical university union hospital, fuzhou, china background: laparoscopic surgery for remnant gastric cancer third step: baring of the right side of the esophagus. fourth step: exposure of left gastroepiploic vessels and lns dissection in the splenic hilar area. fifth step: baring of the left side of the esophagus. the above procedure was performed for rgc patients with stage ct - an /? disease. results: there was no conversion to open surgery. mean operation time was . ± . min, mean blood loss was . ± . ml, and mean times to first flatus p -upper gi-gastric cancer a novel prognosis prediction model after gastrectomy for remnant gastric cancer: development and validation using international multicenter databases fuzhou, china; department of gastrointestinal surgery the model calibration was accurate in predicting -year survival. dca showed that the model has a greater benefit. the results were also confirmed by bootstrap internal validation. in external validation, c-statistics and dca showed good prognostic performance in patient datasets from participating institutions. moreover, we verified reliability of the model in an analysis of patients with different eln counts p -upper gi-gastric cancer a novel abdominal negative pressure lavage-drainage system for anastomotic leakage after r resection for gastric cancer while risk of gastric cancer for ppi users was higher than non-ppi users when duration between - year, = year, = year and = year. the risk of gastric cancer when duration = year(rr = . )and duration = year(rr = . )are higher than risk of gastric cancer when duration between - year (rr = . ). according to location subgroups meta-analysis,risk of non-cardiac gastric cancer for ppi users higher than non-ppi users conclusion: based on a systematic review with meta-analysis, we found the correlation between long-term use of ppi and the risk of gastric cancer and long-term use of ppi may increase the risk of non-cardiac gastric cancer when duration = year p -upper gi-gastric cancer age-adjusted charlson comorbidity index (acci) is a significant factor for predicting survival results: there were patients included in the analysis. the high-acci and low-acci groups had significant differences in preoperative abdominal surgery history, asa grade, tumor size, tumor stage, histologic type, age and comorbidity (all p \ . ). the incidence of postoperative complications was . % in the high-acci group and was significantly higher than that in the low-acci group (p = . ). the overall survival rate (os) and cancer-specific survival (css) rate in the low-acci group were both higher than those in the high-acci group (p \ . ). univariate and multivariate analyses showed that the acci was an independent risk factor for os and css (p \ . ). furthermore, a combination of the tnm staging system and acci showed a trend toward higher prognostic value and higher auc for os and css than the tnm staging system alone (p \ . ). conclusions: the acci was an we aimed to investigate the clinicopathological features and prognosis of patients with mgc and the impact of postoperative adjuvant chemotherapy on long-term survival. methods: the clinical and pathological data of patients diagnosed with gastric adenocarcinoma and undergoing radical gastrectomy from stratified analysis showed that, in advanced gastric cancer (agc), the -year os rates of mgc without adjuvant chemotherapy and sgc without adjuvant chemotherapy were . % and . %, respectively, with a statistically significant difference (p = . ). the -year os rates of advanced mgc after adjuvant chemotherapy and of advanced sgc after adjuvant chemotherapy were . % and . %, respectively, and the difference was not statistically significant (p = . ). the -year os rate of advanced mgc after adjuvant chemotherapy was significantly higher than that of patients without adjuvant chemotherapy ( . % vs. . %, p = . ). conclusions: mgc is a poor prognostic factor after radical gastrectomy for gastric cancer background: whether the tumor-node-metastasis (tnm) staging system is suitable for patients with node-negative gc is still controversial. the modified staging system established by rpa showed good prognostic performance in a variety of cancers. the application of rpa has not been reported in the prognostic prediction of gc. methods: node-negative gc patients who underwent radical resection at fujian medical university union hospital (n = ) and sun yat-sen university cancer center (n = ) with an at least -year follow-up information were selected as the training set. rpa was used to develop a modified staging system. patients from the surveillance, epidemiology, and end results databases (n = ) were selected as the external validation set. results: the -year overall survival (os) rates of patients with th ajcc-tnm stage ia-iiia in the training set were ia %, ib %, iia %, iib % and iiia %. multivariate analysis (mva) showed that larger tumor size, older age, and deeper depth of invasion were independent risk factors for os in patients with node-negative gc (all p \ . ). patients were reclassified into rpa i, rpa ii, rpa iii, and rpa iv stage based on rpa, the -year os rates were %, %, %, and %, respectively, with significantly difference (p \ . ). two-step mva showed that the rpa staging system was an independent predictor for os (p \ . ) were retrospectively collected. patients were classified into two groups according to bmi of \ kg/m ( patients; high bmi group) and = kg/ m ( patients; low bmi group). for these patients, clinicopathological variables were analyzed using propensity score matching to mitigate the selection bias: sex, age, asa physical states, clinical stage, laparoscopy-assisted total gastrectomy (latg) or totally laparoscopic total gastrectomy (tltg), d lymph node dissection, combined resection of other organs, method of anastomosis, jejunal pouch reconstruction. the surgical results and postoperative outcomes were compared and examined between the two groups. results: a total of patients were matched for the analysis. contrary to our expectations, there were no differences in the surgical results about operative time and estimated blood loss (low bmi . ± . min, high bmi . ± . min; p = . , low bmi . ± . g, high bmi . ± . g; p = . , respectively). furthermore, there was no significant difference in postoperative outcome of complication (clavian-dindo [ iiia) and the length of postoperative hospital stays (low bmi cases, high bmi cases baiocchi general surgery, university of brescia-spedali civili, brescia, italy background and aim: recently indocyanine green (icg) was introduced in clinical practice as a fluorescent tracer. the use of icg for sentinel lymph node (ln) mapping was investigated in lots of fields such as breast methods: we conduced a single center prospective trial. we included patients with gastric cancer candidate to surgery. icg was injected intraoperative or the day before surgery, via submucosal or subserosal. total or subtotal gastrectomy was performed open, laparoscopic or video-assisted access. during gastric cancer standard lymphadenectomy we studied lymphatic flow and ln bright in vivo and ex vivo japan introduction: in japan, the number of elderly patients with gastric cancer has been increasing in correlation with the increase in average age of the population. the aim of this study is to assess the safety and efficacy of laparoscopic gastrectomy for cancer in elderly patients compared with the short-term outcome in the nonelderly. method: we reviewed patients who underwent laparoscopic gastrectomy (dital gastrectomy,proximal gastrectomy,total gastrectomy)between ).the incidence of advanced cancer(stageiior more)was higher in elderly patients there were no significant differences in the operating time,blood loss and postoperative hospital stay. there were no significant differences in the incidence of postoperative morbidity. conclusion: in elderly patients, there was a tendency of reduction surgery being selected according to individual condition, but there was no significant difference in the short-term outcome.hence,we conclude that laparoscopic gastrectomy is indicated even in elderly patients. p -upper gi-gastric cancer improved technique of vacuum therapy and carried out ltg . a patient factor (the gender, the age and bmi), an operation factor (operation time, the bleeding amount, lymph node dissection and conjurer), a coincidence related complication (clavien dindo classification, sutural insufficiency of grade more than , anastomotic stricture, anastomotic region bleeding and reflux esophagitis) and the post-operatively length of stay were considered . result: cs crowd met cases ( . %) and ls cluster ( . %) cases. years old of age medians ( - ), men and women were examples ( . %), examples ( . %) and bmi median . ( . - . ) by a patient factor, and a significant difference didn't admit by two groups for days, the post-operatively average length of stay was days by ls group by cs group. conclusion: operation time was short for a coincidence by linear stapler more than a coincidence by circular stapler in comparison of an esophagoenterostomy way in ltg on the day before the operation, we endoscopically clipped several points located cm proximal to the tumor edge to cover about half of the tumor. after lymph node dissection, we incised the stomach with an endoscopic linear stapling device,including the previously placed clips. reconstruction was performed in all patients who underwent billroth i or roux-en-y procedures. result: no complications were observed during pre-operative endoscopic clipping or intraoperatively p -upper gi-gastric cancer small intestinal tumors after laparoscopic surgery in our hospital small intestinal tumors are rarely observed, accounting for about - % (malignant cases: - %) of all gastrointestinal tumors. therefore, occasionally, their diagnoses can be difficult. however, recently, capsule and balloon endoscopes have been widely employed were examined regarding patient backgrounds, diagnostic methods, pathological findings, postoperative courses, and prognoses. results: the subjects consisted of males and females, with a mean age of years. their chief complaints were black stools the median distance from the treitz ligament or bauhin valve was cm ( - ) postoperative complications were abdominal abscess ( cases; . %) and surgical site infection (ssi), hemorrhage, and paralytic ileus ( case each; . %). pathological diagnoses were lymphoma metastatic small intestinal tumor ( cases; . %), and granuloma, lipoma, peutz-jeghers polyp, clear cell sarcoma, malignant mesothelioma, and ectopic pancreas most patients were diagnosed in bleeding, complicated by anemia and black stools. however, as most tumors were relatively close to the treitz ligament and bauhin valve, almost a half could be diagnosed with a small intestine endoscope before surgery patients were classified as popf and no-popf according to their grade b or c popf status. popf was diagnosed according to international study group of pancreatic fistula (isgpf) criteria or clinical findings. patient characteristics, intraoperative parameters, electrosurgical device type, pathological findings, and early postoperative outcomes were compared. electrosurgical devices were classified asthunderbeat (tb) or laparosonic coagulating shears (lcs) based on energy sources. results: eighteen patients developed grade b or c popf. among them, ( . %) and ( . %) were diagnosed with popf according to isgpf criteria and clinical findings ), operation time (p = . ) and electrosurgical device type (p = . ) were significant risk factors for popf following lag ) and tb device (or, . ; % ci ) were independent risk factors for popf following lag. conclusions: operation time and tb use significantly affect the risk of popf and should be considered in future clinical studies. p -upper gi-gastric cancer feasibility and nutritional benefits of double flap with no-knife stapler reconstruction after laparoscopic proximal gastrectomy for gastric cancer were analyzed. receiver operating characteristic curves were generated, and by calculating the areas under the curve(auc) and the c-index, the discriminative ability of crps during different periods were compared, including pre-crp, postoperative days , , and postoperative maximum crp (post-crp max ). a decision curve analysis was performed to evaluate the clinical utility. result: ultimately, patients were included this study and the median follow-up time was ( - ) months. for postoperative recurrence, the auc and c-index of pre-crp were . and . , respectively, significantly higher than the other crps, all p \ . . among = ''''''the = '''' post-crps = '''' post-crp = '''' sub = similar findings were observed for overall survival. conclusion: both pre-crp and post-crp max , cheap and easily obtained, are independent predictors of recurrence for gc. act significantly prolonged the rfs for stage ii/iii gc patients with high-prep p -upper gi-gastric cancer robot-assisted gastroduodenal surgery: a single center experience robot-assisted gastroduodenal surgery (ras) was introduced to overcome the technical limitations of conventional laparoscopy. it provides a d-amplified view to the surgeons and an increased ability to control the operative field by manipulating optics, as well as enhanced mobility and precision of instruments. the aim of the present study is to evaluate the main outcome of a single center experience in gastroduodenal robotic surgery. materials and methods: we report a case series of patients who underwent robot-assisted gastroduodenal surgery at sanchinarro university hospital between conclusions: robot-assisted gastroduodenal surgery is a safe and feasible technique in experienced centers with advanced robotic skills. in the literature, there are only few reports of robotic assisted gastroduodenal resection. further studies are necessary to better confirme our results. p -upper gi-gastric cancer atypical methods: retrospective review of ogd reports before and after the introduction of the new guidelines. inclusion criteria: all elective ogds. exclusion criteria: emergency ogds and elective therapeutic ogds. data recorded: patient demographics, endoscopist, indication, number of photos, anatomical site photographed, pathology identified and whether pathology photographed or not. results: ogds reviewed, before the guidelines (group ) and afterwards (group ). the most common indication was reflux ( %) in group and anaemia ( %) in group clinical utility of systematic pre treatment staging laparoscopic exploration methods: all locally advanced gastric adenocarcinoma managed in surgical oncological unit between st january and th november were prospectively enrolled in the study. in the absence of emergency surgery or preoperative contraindications, all patients with curative intent underwent either preoperative chemotherapy followed by surgical exploration in the intent of curative gastrectomy (g)or systematic pretreatment laparoscopic exploration (l) benkabbou surgical department the patient background (age, gender, bmi) and c-stage of the preoperative factor were matched using propensity score matching method, and the surgical results were compared and examined. results: thirty rg groups matched rag cases. the operation time (rag / lg) was significantly longer in the rag group as . ± . min / . ± . min (p \ . ). amount of blood loss was not significantly different each other; ml / ml (p = . ). pathologically t a case was involved in cases in rag and cases in lg. the extent of lymph node dissection (d ? / d ) was / cases in both groups conclusions: rag in our clinical experiences can be safely introduced and short-term results are comparable to those of lg. verification of superiority of robotic surgery including long-term results seems to influence the future of robotic surgery conclusions: totally laparoscopic gastrectomy is feasible method in terms of surgical outcomes. furthermore, totally laparoscopic total gastrectomy is not technically difficult in advanced gastric cancer such as early gastric cancer and safety method. key words: gastrectomy, reconstruction, laparoscopic surgery, stomach neoplasm aims: meckel's diverticulum (md) is one of the most common congenital anomalies of the small intestine caused by an obliteration defect of omphalomesenteric duct. the objective of this study was to review surgical treatment and clinical outcomes of md, and evaluate the safety and feasibility of minimal invasive surgery (mis) in md. methods: we performed a retrospective analysis of medical record for patients who underwent meckel's diverticulectomy at six hallym-university-affiliated hospitals between d), as well as the average of drainage stay. patients who underwent laparoscopic repair required significantly less parenteral analgesics than the open group.the mean postoperative stay was significantly shorter for laparoscopic group (mean, . d) than the open one.morbidity of medical and surgical complication was higher in open groups ( vs ). the most common complication in both groups was medical complication.more case of pneumonia was occurred in open groups compared to laparoscopic groups methods: a retrospective study using our prospective database was designed to analyse all the resected md in our centre. epidemiological data, clinical setting, diagnostic test and histological results were reported. results: md was resected in patients, males and females, with a mean age of . years ( . - . ). in cases, a laparoscopic approach was chosen. eighty-seven percent of the patients had a presurgical imaging test (ultrasounds, ct-scan or meckel's scan) background: perforated peptic ulcer (ppu) is a substantial health problem with significant postoperative morbidity up to % and mortality up to % worldwide. aims: this study aimed to estimate the sensitivity scoring systems for prognosis morbidity of patients operated for ppu with diffuse peritonitis. methods: a total of patients were underwent emergency repair for ppu with diffuse peritonitis in pirogov russian national research medical university's surgical clinics during - years. different scoring systems used to predict outcome in ppu patients were identified: boey score, peptic ulcer perforation (pulp) score, asa, mannheim peritonitis index (mpi), world society of emergency surgery sepsis severity score (wses score). to quantify the strength of the concatenation of prognostic score and morbidity we use odds ratio (or) with % ci ), respectively. pulp score and asa score have good prognostic value in relation to morbidity, but less than boey, mpi and wses sss. patients with pulp [ had or with % ci of p -upper gi-gastroduodenal diseases gastrostomy tube placed by laparoscopy as a new therapeutic option for continuous intestinal infusion treatment with levodopa/ carbidopa we present year outcomes of our initial consecutive patient cohort. methods: patients were identified in a prospectively maintained irb-approved database ( - ). post-operative eckardt scores and a -point validated system questionnaires were obtained via telephone interviews one patient required reoperation for failed myotomy. the mean eckardt score at years was . (± . ), with all fourteen patients having an eckardt score \ . all patients reported significant improvement in their quality of life. classic gerd symptoms (heartburn and regurgitation) were present in ( . %) patients. proton-pump inhibitors are being used by % of with patients with excellent symptom control. seven patients returned for a repeat egd (median . yrs) with patients having normal anatomy and having la grade a esophagitis ( patient on ppi). barrett's esophagus was not detected. conclusion: long-term results from our early experience with lhm are excellent and durable with only one patient requiring re-intervention in years until recently the esophagectomy was the only choice in treatment of patients with end-stage achalasia. developing of minimally invasive techniques such as a laparoscopic heller miotomy and peroral endoscopic myotomy (poem) allowed to use them as a treatment options. aim: to present an experience of treatment of patents with end-stage cardiac achalasia. materials and methods: since . till the laparoscopic heller myotomy was performed in , and esophagectomies were performed in patients with failed previously myotomy made in other clinics. gastric tube was used to replace the esophagus in patients underwent esophagectomy after skeletization of crura posteriorly to esophagus, two separated rectangular patches of parietene progrip mesh (covidien) measuring x . - cm were attached to the posterior surfaces of the crura. the patches were fixated themselves due to special hooks. than continious twodirections suture was placed through both crura along with the patches using self-gripping v-loc - suture (covidien). the same suture was used for construction of nissen fundoplication wrap . cm long. aditional anchoring stich through the wrap and esophageal wall was placed using ti-cron - suture (covidien). d laparoscopy was used while suturing using richard wolf epic system. results: all the procedures were performed successfully. there were no cases of bleeding from the suturing points either from the crura and the fundus wall. there were no crural dehiscence while suturing, even if the distance between crura was more than cm. the mean duration of suturing facilitated by d laparoscopy was min (range, - min) for crural repair, and min (range, - min) for fundoplication. there were no excessive postoperative pain in all the patients. there were no disphagia month postop in every patient. conclusions: . the new technique of posterior buttress of crural repair using small patches of parietene progrip mesh and v-loc suture showed feasibility and safety. . the use of d in such case most commonly manifested symptoms are cough, sore throat, hoarseness, dysphonia, globus and only % patients with lpr have typical gerd symptoms. also ppi therapy are less effective in patients with lpr in comparison with patients which have typical features of gerd. purpose: to compare the outcomes between surgical treatment and conservative therapy in patients with laryngopharyngeal reflux. materials and methods: for the period chesarev faculty surgery # , federal state autonomous educational institution of higher education i.m. sechen, moscow, russia p -upper gi-reflux-achalasia a case of a primary parahiatal hernia associated with a type i hiatal hernia emergency county hospital parahiatal hernia is a rare disease that occurs when an abdominal organ protrudes through an opening adjacent to an anatomically intact esophageal hiatus. the herniated organ is usually the stomach, although cases of omental and colonic herniation exist we report the case of a -year-old woman which accused epigastric pain, starting years prior, pseudo-angina, heartburn and bloating. based on imagistic findings the patient was diagnosed with a parahiatal hernia and an associated type i hiatal hernia. patient underwent surgery and a cm diameter defect in the diaphragm lateral to the left crus was discovered, through which - % of the stomach had herniated. the hiatal orifice was slightly enlarged but anatomically intact, with an associated small sliding hiatal hernia. we performed closure of the defect, hiatoplasty and a floppy-nissen fundoplication pneumatic dilation with mm balloon was performed under general anesthesia. radiological contrast control and endoscopy reevaluation revealed a perforation just above the squamo-columnar junction. a minimally invasive approach was decided. an fully covered esophageal stent was inserted. radiological control after days reveals left pleurisy and migration of the stent. the same day was performed an endoscopic repositioning of the stent with clip fixation. left pleural puncture was performed and clear fluid was extracted. the condition of the patient got worse and she was transferred on icu ( . ). we performed left pleurostomy and initial exploratory laparoscopy-no intraperitoneal lesions. due to difficult transhiatal access to the inferior mediastinum the surgery was converted to open-perisophageal mediastinal abscess was found, evacuated and drainage and jejunostomy were performed. after a week, the patient presented progressive altered condition, febrile syndrome. thoraco-abdominal ct-scan showed left pleural effusions. left pleurostomy was performed, with extraction of fetid fluid. continuous lavage was instituted. on st of august, the pleurostomy tube drained gastric content, and the clinical examination revealed signs of generalized peritonitis. laparotomy was performed with lavage, drainage and posterior decompression gastrostomy. results: postoperative evolution was favorable, with the suppression of pleural drainage in . and discharge in . with alimentation exclusive on jejunostomy. one month later, she had normal clinical and radiological examination evaluation of efficacy was performed with reflux symptom index (rsi) specific for extraesophageal symptoms, subjective satisfaction and occurrence of dysphagia and gas-bloat syndrome. a rsi score [ was considered as pathological. results: rsi significantly decreased after surgery ( and msa as compared with total fundoplication; , % of patients were satisfied with surgery: a comparison between techniques showed superiority of msa objective: to demonstrate the efficacy of hiatorraphy without the use of meshes in thegiant paraesophageal hiatus hernia, as well as the standardization of our technique, with thetechnical steps that we make successively. material and method: clinical cases: -year-old man,with symptomatic hiatal hernia with progressive intolerance and dysnea. egd: the stomach rotated in a giant hiatal hernia.gastroscopy not completed due to endoscope loop formation within giant hiatal hernia with gastric volvulation. ct: large hiatal hernia,combined volvulation (axial axial mesenteric organ), the stomach in a right subpulmonary situation. results: intervention: laparoscopic approach.hh of large paraesophageal size,double organoaxial-and-mesenteric volvular component,gastric walls very thickened and adhered to the mediastinum.reduction of all content and the sac,is adhered to the pleura, extended med-iastinal esophageal disection, up to vein pulmonary and get enough abdominal esophagus and rule out the presence of an short esophagus,posterior-anterior and left tutorized modified hiatorraphy with stitches in ''u'' with non-absorbable suture on teflon reinforcement patches.nissen fixed to both pillars, intramediastinal drainage.egd at the st day with esophageal stenosis due to inflamation of the nissen, resolved with medical treatment. dischage at th day.asymptomatic and without radiological recurrence after months of follow-up. conclusions: in giant and paraesophageal hiatus hernias, modified primary hiatorraphy together with mediastinal esophageal dissection extended can be an effective and safe alternative, and can be advised as a technical gesture prior to a collis nissen and-or placement of a hiatal-hiatoplasty mesh united states of america aim/background: prescribed opioids for pain control have been implicated as major contributors to addiction through their illicit use. efforts to reduce opioid prescriptions and measure their impact on outcomes are novel. we analyzed how patient outcomes are affected with reduced opioid prescriptions following laparoscopic foregut surgery narcr: %), length of hospital stay (narcs: . days vs. narcr: . days), -day readmission rates (narcs: % vs. narcr: %) and perioperative complication rates. additionally, no significant qol outcome differences between the groups were reported at one month postoperatively. conclusion: our study supports reducing opioid prescriptions as a strategy to counter illicit drug use and addiction patients who underwent paraesophageal hernia repair at a tertiary referral center were analyzed retrospectively. demographic data, asa classification, characteristics of peh, onset of symptom, dysphagia severity score, characteristics of fundoplication (partial vs. total; laparotomy vs. laparoscopy; emergency vs. elective) and surgical outcome (length of stay, complication and -day mortality) were recorded and reviewed. results: patients were included; % were female (mean age of . years old and mean body mass index of . ). mean onset of symptom was . weeks after peh repair, dysphagia severity scores were changed . from . . conclusion: in our series, the dysphagia severity scores reduced after surgery upper gi surgery, the catholic university of korea mary's hospital, incheon city, korea p -upper gi-gastric cancer general surgery biopsy from the mass has showed poorly differentiated signet ring cell adenocarcinoma. chest computed tomography revealed mm thoracic aortic aneurism. abdominal computed tomography showed mm infra renal aortic aneurism and no evidence of metastatic disease general surgery year old, female patient presented with upper abdominal pain, weight loss ( kg during last three month), without nausea or vomiting biopsy was done and pathology result showed intestinal type, her -negative adenocarcinoma of the stomach. chest and abdominal computed tomography (ct) were normal. endoscopic ultrasound (eus) revealed cm lesion with invasion to the muscularis propria (mp) she was treated by neo adjuvant chemotherapy ( cycles carboplatine ? fu). patient underwent laparoscopic partial gastrectomy with modified d lymphadenectomy and billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology result confirmed intestinal type, modified differentiated adenocarcinoma of the stomach economou st surgical department general, visceral and transplant surgery, section minimally invasive surgery, heidelberg university hospital, heidelberg, germany; department of surgery, iuliu hatieganu university, cluj-napoca, romania; general and visceral surgery, klinikum mittelbaden, baden-baden, germany surgery, toyonaka municipal hospital, toyonaka city, osaka, japan; gastroenterological surgery, osaka university, osaka, japan; next generation endoscopic intervention, osaka university, osaka, japan aims: uncomplicated healing of anastomoses in colorectal surgery is the basis for early adjuvant oncology therapy. the basis for proper healing is good blood flow. we use by robotic surgery foor control the firefly by intuitive. since january , icg has used for blood flow in laparoscopic bowel surgery for the d-light system of storz. method: use of icg wants to accurately determine the resection line for free colon operations based on good blood circulation. we use icg pulse in two batches and color detection using d light from storz to verify blood flow. the first dose is given after the skeletalisation of the intestines intraabdominally and the second after the colic anastomosis to verify its vitality. results: in the period under review we performed laparoscopic operations on the free colon, % of the operations were elective. we had . % leakage across the set, however, in the subset of elective operations, we had only a leak of . %. conclusion: in an unselected set of colorectal operations, leakage was . %, but only . for elective operations. in our group there was a clear effect of using icg in elective laparoscopic resections with an intracorporal anastomosis, the effect was not shown in others, probably due to leakage were factors other than blood flow. objective: right hemicoloctomy (rhce) is the first choice in treating the right colon cancer. complete mesocolic excision with extended lymph node dissection at the roots of superior mesenteric artery (sma) branches enables removal of all lymphatic tissue and prevents local recurrence. previously variability of sma branches was demonstrated. the aim of presented study was to compare the distribution of sma branches in two ethnically different cohorts methods: preoperativect scans with vascular d reconstruction were assessed in patients ( - years) from russia and patients ( - years) from turkey with right colon cancer operated in - . the distribution of ileocolic artery (ica), right colic artery (rca) and middle colic artery (mca) was investigated. results: ica and mca could be found on ct scans in all patients, whereas rca had significantly different distribution between patient cohorts: it was visible in ( %) of turkish patients and only in ( %) of russian patients (p = . ). conclusion: these results suggest that there might be ethnical differences in sma branches distribution. in turkish patients all named sma branches ate visible on ct scans in %, whereas in russian patients only in %. the majority of patients from russia don't have rca. ica and mca could be found in all patients regardless ethnicity. knowing the variant of sma branching before the operation can help plan extended lymph node dissection. the national training programme in laparoscopic colorectal surgery (s-micras-lapserb) in serbia was set up to introduce standardized and structured training in laparoscopic colorectal surgery. method: an assessment based structured training programme (lapserb) started in . series of hands on supervised workshops were conducted for four different hospitals using the structured training by single trainer. this study aims at retrospective analysis of prospectively collected data for patients undergoing colorectal resections. we look at short-term clinical and pathological outcome of patients within laparoscopic colorectal resections performed in national training program. results: during the period november until november , laparoscopic colorectal resection was performed in ( male and female) patients. mean age of patients was . ( - ). the most common indication was colorectal cancer ( patients, . %), ( . %) patients were operated due to the colorectal polyps not suitable for endoscopic resection and ( . %) was operated due to ibd. there were ( . %) right colonic, ( . %) left colonic /tme and ( . %) other resections. average number of lymph node harvested in patients with colorectal carcinoma was . . there were / ( . %) r resections mean duration of hospital stay was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . postoperative complications were encountered in / patients ( . %). overall, mortality rate was . % ( / ). conclusions: this study demonstrates successful and safe adoption of laparoscopic technique for colorectal resections. short term clinical and pathological outcomes are compared to published data and shows wider adoption at the national level. standardization of operative technique and structured training remains the key in success. introduction: femal adnexal tumor of probable wolffian origin (fatwo) was first described in . it is a tumor of mesonephiris wolffian duct origin. fatwo is rare tumor which is usualle benign. in the literature has been reported cases and only cases of recurrent disease. next rare tumor in pelvic localisation is sex cord-gonadal stromal tumor of sertoli cells. methods: we present case report of women who presented metastatic fatwo with duplicity of sertoli tumor. results: -year old women underwent years ago exstirpation of tumor in the left broad ligament. histologically there was rare benign fatwo. this year was indicated adnexectomy at gynecology department. during the operation was done bilateral adnexectomy and discovered tumor of anterior wall on upper rectum. microscopic examination showed sertoli tumor on the left ovary. afterward we completed next examinations. colonoscopy without any abnormality. on ct scan was tumor cm without contact to rectum wall, without distant metastasis. the same was described on rectal ultrasonography-normal wall of rectum, tumor probably from uterus. at diagnostic laparoscopy was tumor mass cm, with necrosis arising from anterior wall of the rectum. next small metastasis on pelvic peritoneum. we performed debulking of this big tumor and metastasectomy, there was no infiltration to muscularis propria of the rectum. patient did not have any postoperativ complications. microscopic examination of the rectal tumor and small peritoneal metastasis showed metastatic fatwo. after weeks she underwent laparoscopic second look operation. there were small metastasis on pelvis peritoneum. we removed two biggest metastasis and the rest was destroyed wit j plazma. microscopic examination showed in this metastasis sertoli tumor. conclusion: our patient has metastatic fatwo and sertoli tumor. fatwo is so rare, that in the literaure is not enough information for observation or adjuvant therapy. in one case was described imatinib mesylae (gleevec) therapy with good results. surgeons must be ready to meet new diagnosis. bochdalek hernia is a type of congenital diaphragmatic hernia. in most cases, it is diagnosed during the neonatal period. we present a case of laparoscopically treated congenital bochdalek hernia that led to jejunal strangulation in an adult . case: an fifty eight year old obese(bmi = . ) female admitted for gradually worsening right flank pain, vomiting and respiratory distress for one day. there was no trauma history to chest or abdomen. the past medical history were old cva, well controlled hypertension and dm. she was hemodynamically stable. her right flank was very tender. there was no abdominal distension. initial cbc tests showed leukocytosis ( , /ul) , but electrolytes were normal. chest pa revealed right side diaphragmatic hernia. there was poorly enhanced, herniated small bowel in the right hemithorax on chest ct scan. the patient was taken for emergency operation. on laparoscopy, the normal liver was displaced leftward because of herniated bowel. there was incarcerated jejunum and omentum which could not be reduced. so we widened a cm sized posterolateral diaphragmatic defect first, and then we could reduce the strangulated jejunum( cm in length) and omentum. there was no hernial sac. the defect was closed with -o prolene. finally, the strangulated jejunum was resected and anastomosed extracorporeally. the hospital progress of the patient was not eventful. on post-operative day , the patient was allowed soft diet. the patient was discharged on post-operative day without any complication. conclusion: congenital diaphragmatic hernia is an uncommon condition in adults, but you should keep in mind the diaphragmatic hernia as a cause of intestinal obstruction and respiratory distress in an adult. prompt surgical intervention is required to a favorable outcome. laparoscopic repair of bochdalek hernia is a good management option. aims: intestinal obstruction is one of the most frequent abdominal conditions in the emergency department (ed). up to % of patients having undergone a laparotomy will have an episode throughout their lives, of which % up to % will respond to conservative management. the laparoscopic approach is widely accepted and supported by the studies published up todate. it is recommended in patients with suspected single band, who have less than one previous laparotomy and less than h of clinical evolution. our objective is to validate in our experience that these premises are the appropriate ones in the election of candidates for a minimally invasive approach. methods: we present a series of cases admitted with symptoms compatible with adhesive intestinal obstruction in the ed of a third level hospital during months. all patients underwent abdominal ct to rule out the possible causes of obstruction. emergency surgery was indicated because of failure of a conservative medical treatment or for the findings of the complementary tests. results: a initial laparoscopic approach was performed in the patients, with a conversion rate of % of the cases (resection and anastomosis was required in patients, due to loop suffering or intestinal tumor not seen in the ct). among the patients who required laparotomy, % had more han h of clinical evolution before de surgery and % had free fluid in the tc. as surgical complications: intestinal perforations were produced secondary to the manipulation. there was recurrences of obstruction in the following months. conclusion: the laparoscopic approach is feasible in selected cases and experienced hands. acording to our results it is recommended to perform it in only in patients with less than h evolution and with a single band image in the ct without free fluid. the intestine should be explored avoiding the manipulation of the most extensive loops to prevent complications and keep in mind the possible conversion to laparotomy in case of complications. aim: the aim of the study was to evaluate whether physiologic and operative severity score for the enumeration of mortality and morbidity (possum) is useful to predict the risk of complications in patients older than years. methods: we performed a retrospective study of patients older than years old diagnosed with acute abdomen who were admitted to the department of general, minimally invasive and elderly surgery in olsztyn between may and october . results: the most common disagnosis was ileus. the mortality rate in surgery department was %.after relocation to the intensive care unit, the overall mortality rate was . %. the patients who died a short time after surgery had mortality rates greater than % and morbidity rates greater than % according to possum. conclusions: this study shows that possum seems to be a valuable scale to predict the risk of death after surgery in older patients. patients with higher mortality and morbidity scores should be very carefully selected for surgery. aims: diaphragmatic hernia in adulthood is rare. the most common causes are blunt and penetrating trauma. we present an intraoperative video of the laparoscopic repair of an adult onset, non-traumatic, diaphragmatic hernia in a patient with splenomegaly. method: a year old woman was referred to upper gastrointestinal surgery with epigastric burning and pain in the left side of her chest, radiating to the left shoulder, for one year. there was no recent or distant history of trauma. she has a past medical history of treated hepatitis c, cirrhotic liver disease, splenomegaly, thrombocytopenia and iron deficiency anaemia. gastroscopy was interpreted as a fundal diverticulum. ct abdomen/pelvis with intravenous (iv) contrast showed this to be a left diaphragmatic defect with herniated stomach causing a volvulus, which lay immediately above an enlarged spleen. a ct three years prior to this showed no diaphragmatic hernia. the patient had some symptomatic relief with a proton pump inhibitor and oral antacids, however due to her persistent symptoms surgery was undertaken. the patient had laparoscopic repair of the diaphragmatic hernia. ports were as follows: mm umbilical, mm left upper quadrant, mm right upper quadrant, mm left iliac fossa. a left posterior diaphragmatic defect was found, just above the enlarged spleen, containing the incarcerated fundus of the stomach. the hernia was reduced by gradual dissection of the sac. a cm nonabsorbable polypropylene mesh (proceed) was used to cover the defect a cm margin. this was tacked in place with protack. a single french robinson drain was left in situ. results: the procedure was uncomplicated. oral diet was introduced on post-operative day and the drain was removed and patient discharged on day . there were no post-operative complications. conclusions: the video shows an effective dissection of a left sided diaphragmatic hernia and mesh repair, overcoming multiple technical challenges secondary to splenomegaly and portal hypertension. aims: creating laparoscopic anastomosis is a challenging surgical skill with high clinical relevance. to assure efficient training and enhanced learning curves, constructive and objective feedback is essential. currently there is no appropriate instrument to assess the surgical performance while creating laparoscopic anastomosis. the aim of this study is to develop and validate the anastomosis-objective structured assessment of technical skill (a-osats) score. methods: to obtain an international expert consensus for a procedure specific checklist (psc) for laparoscopic anastomosis, a modified delphi survey with an integrated analytic hierarchy process is currently being performed. each a-osats sub step is assigned a specific weight to determine its importance to the final outcome of the anastomosis. to validate the a-osats score, a laparoscopic side-to-side small bowl anastomosis with a linear stapler and hand-sewn closure of the enterotomy was chosen and is performed by surgeons with varying degrees of laparoscopic experience on a live porcine model. all performances are recorded and rated twice using the a-osats by two blinded experts. results: the final a-osats score includes a weighted psc developed by the modified delphi survey and the already validated global rating scale of previously published osats scores. four key steps (bowel placement, creation of enterotomies, stapling, closure of enterotomy) and sub steps, as well as their definitions, were established during the delphi survey. to validate the a-osats, surgeons ( experts, intermediates, novices) have participated in the study so far. preliminary results showed significant differences between all three levels of laparoscopic experience (novices: . ± . ; intermediates: . ± . , experts: . ± . ; p \ . ) for the overall a-osats score as well as the psc itself (novices: . ± . , intermediates: . ± . , experts: . ± . ; p = . ). conclusions: the a-osats is a weighted score that objectively assesses surgical skill during the creation of laparoscopic anastomosis. preliminary results confirm construct validity of the proposed score. furthermore, by offering the possibility to differentiate single aspects during the procedure, the a-osats allows focused feedback to enhance one's performance. minor changes in weights are expected after the last round of the delphi survey. interand intrarater reliability will be assessed after final inclusion of all participants.aims: to apply augmented reality technology from three-dimensional colon models as preoperative planning method in colorectal surgery. method: from three-dimensional anatomical models of the colon we have developed holograms of augmented reality. the models were obtained from ct images (siemens somatom perspective Ò) with abdominal image cuts with mm thick. the recovery of the images was in dicom format and the processing to achieve the three-dimensional reconstruction was performed with the programs osirixÒ and horosÒ, which made a complete segmentation of the colon surface, and a modification of the image density. in this way models d were obtained of the isolated colon, and in relationship with the bone structure. the application colon d ar was designed (increased hyper experience-visualizer with slam technology) creating a hologram of augmented reality to scale : from each three dimensional model to make a projection of it on the abdomen of the patient by modifying the position in height of the reconstruction, using the bone pelvis as anatomic reference point to calibrate the placement of the hologram. results: in the preliminary phase (from october to december ) holograms of augmented reality were developed in patients with colorectal cancer (right colon, left colon, transverse colon and rectum) to complement the radiological reconstruction with the virtual model. in the application phase (from january ) the holograms developed are going to be applied as a method to improve preoperative study. conclusions: three dimensional reconstruction of the tumor in the preoperative plan of colorrectal surgery combined with hyperreality technology allows to develop models of augmented reality in order to improve colon anatomy knowledge and to plan the surgical technique.aims: laparoscopic adrenalectomy has become the standard of care for most adrenal masses. we report a case of laparoscopic adrenalectomy for left adrenal adenoma. methods: we present the case of a -year-old caucasian female patient with an asymptomatic, left-sided adenoma, that was incidentally detected during abdominal ultrasound. no headaches, palpitations, tachycardia, tremor, dizziness or vomiting were reported. pre-operative blood tests confirmed that the tumor was a non-secreting one and a ct-scan revealed a . . cm left adrenal mass. laparoscopic surgical excision was proposed. the patient was placed in semilateral right-sided decubitus position. four trocars ( epigastric- mm & subcostals- mm & mm) were used, without the use of a liver retractor. the adrenal vessels were clipped not only with the standard laparoscopic clips, but also with the hem-o-lok ligation system. results: the operation lasted for h with minimal blood loss. the patient's post-operative course was uneventful and she was finally discharged four days post-operatively. histology report ensured that it was adenoma of the adrenal cortex. aims: since the first laparoscopic adrenalectomy in (gagner), the laparoscopic lateral transabdominal approach has proved to be the one of choice. it provides an easy anatomical orientation, overall the technique is similar to other traditional laparoscopic procedures. on the other hand, the posterior retroperitoneoscopic adrenalectomy (pra), described in (waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. the advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient. currently there is controversy about which is the approach of choice, having to take into account the learning curve necessary for the retroperitoneal approach and the reduced number of patients with adrenal pathology subsidiary of surgical management. the objetive is to demonstrate the safety and efficacy of the standardized laparoscopic approach of the left adrenal gland with trocars for selected cases. methods: clinical case: -year-old man, resistant hypertension despite concurrent use of three antihypertensive agents, with biochemical and radiological diagnosis of left adrenal adenoma with primary hyperaldosteronism. demonstrative video of the technical steps in a standardized way that we propose for laparoscopic left adrenalectomy only using trocars. results: full laparoscopic surgical approach in right lateral decubitus position: trocars-lateral transabdominal approach. steps: . laparoscopic liberation of the splenic flexure of the colon for the colo-spleen-pancreato-gastric en block mobilization until identification of the left pillar, . dissection of the medial border of the gland, identification of left renal and diaphragmatic vein, as well as the adrenal vein which is dissected and clipped, . dissection of the lateral edge of the adrenal gland, . lower pole dissection of the gland completing the resection with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. asymptomatic, the patient does not need antihypertensive drugs at year follow-up. conclusion(s): the standardization of the procedure allows reducing the number of trocars, maintaining the safety and effectiveness of the minimally invasive approach. aims: cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. the aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in singleadrenal patients or patients requiring bilateral adrenalectomy. methods: prospective study between january and october including pheochromocytoma patients diagnosed with low risk of malignant mutations. all patients agreed to be included in the study. experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. results: a total of eight patients were registered, five associated with men type syndrome and three in the context of vhl syndrome. retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was . days. preservation of the functional cortex without corticosteroids was achieved in ( . %) of out cases with a follow-up of . ± months. today, these seven patients have a preserved adrenal function without hormone replacement. conclusions: cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases. biomedical sciences, university of west attica, athens, greece partial adrenalectomy has been suggested for patients benign adrenal tumors especially in the case of hereditary syndromes, like multiple endocrine neoplasia type , von hippel-lindau disease and neurofibromatosis type i. aims: this systematic review aimed to investigate the role of partial adrenalectomy in the treatment of hereditary pheochromocytoma. methods: electronic databases were searched with the search terms 'men ii', 'von hippel lindau', 'neurofibromatosis', 'laparoscopic partial adrenalectomy', 'robotic assisted partial adrenalectomy' for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria results: thirty five possibly relevant studies were identified. abstracts were reviewed and fourteen articles were excluded as they were review articles or articles presenting data on open partial adrenalectomy. twenty one studies, that met inclusion criteria were retrieved in full text and included in the systematic review. eight studies presented data on partial adrenalectomy in patients with von hippel lindau including two case series with median follow up ranging from to . years and six case reports. thirteen studies presented data on partial adrenalectomy in patients with men ii, including two case series and eleven case reports. recurrence rate was estimated at about % for pheochromocytoma. overall steroid dependence rate was estimated at %. conclusion: minimally invasive partial adrenalectomy is a therapeutic option especially in patients with heritable pheochromocytoma, given that tumors are often bilateral, tumors are commonly benign and severe morbidity and mortality may be associated with life-long steroid replacement therapy such as the possibly lethal addisonian crisis . however, data are limited, follow up is not standardized and not appropriately reported and rcts are difficult to be done due to the rarity of the disease. a multinational registry on the short term and long term outcomes of partial adrenalectomy in hereditary pheochromocytoma would be a significant source of knowledge. results: patients were operated on after an average of months with complaints. in both groups, the leading symptoms were severe dysphagia and severe regurgitation. no intraoperative complication was detected. in the transoral group, one patient had to be reoperated on for bleeding, another patient developed pneumonia in the transcervical group. the average duration of the surgeries ( . vs. min, p \ , ), the time to oral feeding ( . vs. . days, p \ , ) and the mean hospital stay ( . vs. . days, p \ , ) were significantly shorter in the transoral group than the transcervical group. patients were completely symptomless postoperatively. after transcervical treatment, complaints were developed in cases (moderate dysphagia and hoarseness). after transoral surgery, recurrent symptoms were observed in patients, had to be reoperated transcervically due to severe regurgitation. conclusion: transoral stapler diverticulostomy is a fast procedure and offers short hospital stay especially in comorbid, aged patients and intermedium diverticulum size. in the long term, some of the patients may require reintervention due to persistent regurgitation. the transcervical approach has higher perioperative morbidity, which can be performed in patients with less than cm or large diverticulum size. aims: complex hiatal hernias, either implicating large hiatal defects or concerning cases of recurrence, often need apart from the primary closure of the hiatal gap, the re-enforcement of the crura with the use of meshes. our aim is to demonstrate the surgical technique for the on-lay placement of the absorbable mesh (phasix tm st mesh /bard) in challenging cases, presenting both the laparoscopic and the robotic approach. methods: we present video fragments from procedures of laparoscopic and robotic reconstruction of complex hiatal hernias, performed by our team, in which an absorbable mesh was utilized in an on-lay fashion. results: patients having undergone a minimally invasive surgical approach (laparoscopic or robotic) for the treatment of complex hiatal hernias with the use of an absorbable mesh, had an uneventful post-operative course and very short hospital stay and recovery time. the -month follow up revealed no recurrences or late complications. conclusions: treating complex cases of hiatal hernias with a minimally invasive approach can be proven quite challenging, with high recurrences and possible complications rate. a proper surgical technique, either laparoscopic or better (based in our primary experience) robotic, by experienced surgical teams and the use of meshes with the right strategy, minimizes the complications, offers all the benefits of minimally invasive surgery and reduces the recurrence rates. aims: several flexible endoscopic techniques for symptomatic zenker's diverticulum have been developed during the last decade. thulium laser has limited tissue penetration and may decrease the risk of perforation. this study reports the first use of thulium laser through flexible endoscopy for cricopharyngeal (cp) myotomy. aims were safety and efficacy of flexible endoscopic thulium laser myotomy and quality of life (qol) changes after treatment. methods: a retrospective review of a prospectively collected database of patients who underwent thulium laser septum division for symptomatic zenker's diverticulum was done. demographic data, presenting symptoms, diverticulum characteristics, and intraoperative data were analyzed. functional outcome swallowing scale (foss) and m.d. anderson dysphagia inventory (mdadi) questionnaires were administered to determine severity of dysphagia and its effect on qol, both preoperatively and during follow-up visits. all the operations were carried out under general anesthesia. a continuous laser configuration and an emissionpower of w was used in non-contact mode. once the mucosa was opened, the fibers of the cricopharyngeal muscle were divided until the buccopharyngeal fascia was visibile. results: between march and september , patients ( males) underwent flexible endoscopic cp myotomy with thulium laser. mean age was ± . , mostly males ( . %). seven patients ( . %) presented with recurrent diverticulum after previous transoral or open treatment. mean diverticulum size was . ± . cm. preoperative main symptoms were dysphagia ( . %), regurgitation ( . %), and cough ( . %). foss score was = in patients ( . %). mean mdadi global and composite score were . ± . and . ± . . complete division of the septum was achieved in all patients. mean hospital stay was . ± . days. there was only one perforation treated conservatively. no -days mortality was observed. at median follow-up of months, foss was = in ( . %) patient and mdadi global and composite score were . ± . and . ± . . all main symptoms were significantly reduced and qol significantly increased. conclusions: flexible endoscopic approach with thulium laser is a safe and effective treatment option for zenker's diverticulum either as a primary treatment or as a rescue therapy. objective: this study sought to explore prognostic factors for patients with borrmann type iv gastric cancer and to establish a predictive model for survival benefit of postoperative adjuvant chemotherapy in such patients. method: this study reviewed the clinical data of patients who underwent curative surgery at fujian medical university union hospital from to for borrmann type iv gastric cancer using a prospective database. cox regression analyses were performed to identify prognostic factors that formed the basis for a nomogram and risk groups. establishment of risk groups to identify patients with borrmann type iv gastric cancer who would benefit from adjuvant chemotherapy. results: patients who underwent r resection were included in this study.multivariate analysis showed that bmi, tumour differentiation, pt stage, pn stage, and asa score were independent prognostic factors. patients in the act-group had longer os than patients in the sagroup, although the p-value for this difference was marginally above the threshold for statistical significance ( . % vs. . %, p = . ). stratified analysis showed that there was no significant difference in os between the act-group and the sa-group for each ajcc stage (stage ii: . % vs. . %, p = . ; stage iii: . % vs. . %, p = . ).a nomogram was established based on these independent risk factors, and nomogram scores were used to divide all patients into a high-risk group (score [ ), an intermediate-risk group ( \ score = ) and a low-risk group (score = ).further stratified analysis based on ajcc stage showed that the -year survival rate was higher in the adjuvant chemotherapy group than in the surgery alone group for low-and intermediate-risk patients in each ajcc stage, while high-risk patients in stage iii did not significantly differ. objective: this study sought to explore the prognostic factors for smoking patients with gastric cancer and to establish a predictive model for the survival benefit of postoperative adjuvant chemotherapy in such patients. methods: we studied patients who were diagnosed from september to september at union hospital of fujian medical university. cox regression analyses were performed to identify prognostic factors. the kaplan-meier method was used to assess the effect of smoking history on the benefit of adjuvant chemotherapy after gastric cancer surgery. a decision tree algorithm was used to identify smoking patients who benefited from postoperative adjuvant chemotherapy. results: the median follow-up time for the whole group was . months, and the average age of all the included patients was . years.multivariate analysis showed that age (p \ . ), bmi (p \ . ), degree of tumor cell differentiation (p \ . ), and ajcc stage (p \ . ) were independent risk factors for the prognosis of smoking patients. based on these independent risk factors, a decision tree model for the benefit of adjuvant chemotherapy for smokers with gastric cancer was established, and the smoking patients were divided into the low-risk patients . %), medium-risk patients ( - year os, . %) and high-risk patients ( - year os, . %) (p \ . ). conclusion: cigarette smoking may reduce the efficacy of adjuvant chemotherapy after gastric cancer surgery. our decision tree model is simple and effective for identifying smokers who would benefit from adjuvant chemotherapy. objective: our study investigated the effect of lymph node (ln) noncompliance on the longterm prognosis of patients after laparoscopic total gastrectomy (ltg) and explored the risk factors of ln noncompliance. methods: the clinicopathological data of gastric cancer (gc) patients who underwent ltg with d lymphadenectomy from june to december were prospectively collected and retrospectively analyzed. the effects of ln noncompliance on the long-term prognosis of patients with gc after ltg were explored. results: the overall ln noncompliance rate was . %. ln noncompliance was significantly correlated with age, bmi, asa score, tumor size, macroscopic tumor type and tnm staging (p values \ . ). the survival rate of patients after ltg with ln compliance was significantly superior to that of patients with ln noncompliance (p = . ). the stratified analysis of tnm stage indicated that there was no difference between the os of stage i patients with ln compliance and those with ln noncompliance; os of stage ii/iii patients with ln compliance was significantly better than that of those with ln noncompliance. cox regression analyses showed that ln noncompliance was an independent risk factor for os. logistic regression analysis showed that high bmi ([ kg/m ) was an independent risk factor for preoperative prediction of ln noncompliance in cstage ii/iii patients. compared with patients with a low bmi (bmi \ kg/m ), those with a high bmi were more likely to show ln noncompliance during surgery, especially during the dissections of # , # a and # a ln stations. conclusion: ln noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (agc) after ltg. patients with high bmi were more likely to have ln noncompliance, especially during the dissections of # , # a and # a ln stations. ln tracing was recommended for these patients to reduce the rate of ln noncompliance. aim: to study the differences in pathology, survival, and recurrence between special remnant gastric cancer (srgc) and nonspecial rgc (nrgc). method: a total of rgc patients were analyzed in hospitals in china from january to july .we compared the -year overall survival (os) disease-free survival (dfs) rates and used two-step regression explore the influence of the rgc categories on patient outcomes. results: all of the patients divided into srgc group (group s) (n = ) and nrgc group (group n) (n = ). the r resection rate and lymph node (ln) dissection number of group s were significantly higher than group n (p \ . ). the difference in -year os was not significant (p = . ), but the -year dfs of group s was worse than group n (p = . ). twostep multivariate analyses showed nrgc was an independent risk factor for poor dfs. of the patients who had undergone r resection, patients ( . %),suffered recurrence, and the recurrence rate of group s was significantly higher than group n (p = . ), moreover, the ln recurrence rate of group s was significantly higher than group n (p = . ). cox regression analysis showed that age, ca level, n stage and category of rgc were independent risk factors for rgc recurrence. conclusion: srgc has a higher r resection rate and ln dissection number than nrgc, but among patients who had undergone radical gastrectomy, srgc patients had worse dfs and a higher tendency for ln recurrence; thus, they should be treated differently in the clinic. objective: the aim of this study was to report our institution's experience with a novel abdominal negative pressure lavage-drainage system (anplds) for anastomotic leakage (al) after radical gastrectomy (rg) for gastric cancer (gc). background: al is a severe complication associated with high morbidity and mortality after rg for gc. the optimal creation of drainage in al patients after rg remains controversial. methods: the study enrolled patients who underwent r resection for gc at our institution between and . anplds was routinely used for patients with al after january . al rates and postoperative outcome were compared before and after the anplds therapy. we used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with al and failure-to-rescue (ftr) after al. results: al occurred in patients ( / , %), leading to deaths. the al rate was similar before ( - , period ) and after ( - , period ) the implementation of anplds ( . % vs . %, p = . ). age and malnourished were independently associated with al. the ftr rate and abdominal bleeding rate after al occurred were respectively . % and . % for the entire period, but compared with period , it significantly decreased at period ( . % vs . %, p = . ; . % vs . %, p = . , respectively). what's more, only anplds therapy was an independent protective factor for ftr after al. conclusion: our experience demonstrates that anplds is feasible and cost-effective for the management of al after rg for gc. objective: to apply the principles of the 'metro-ticket' paradigm to develop a novel tnm staging system (ntnm) for gastric cancer (gc). background: the 'metro-ticket' prognostic tool for hepatocellular carcinoma has been proven to predict outcome, but a similar concept has not been investigated for gc. methods: the ntnm considered the distance from the origin on a cartesian plane incorporating the pn (x-axis) and pt (y-axis) stages. gc patients undergoing radical resection at fujian medical university union hospital (fmuuh) (n = ) were included. the ntnm was validated using external cohorts from the sun yat-sen university cancer center (sysucc) (n = ) and surveillance, epidemiology, and end results (seer) (n = ) databases. results: ntnm classes with the same distance from the origin have same stage; the stage increases with this distance. among all patients, . % (n = ) were restaged in the ntnm compared with the th edition of the ajcc-tnm classification; . % (n = ) were downstaged in the ntnm compared with the th edition. the ntnm provides significant survival differences between stages (all p \ . ). the survival difference between stages ib and iia was especially large for the ntnm (p \ . ) compared to the th and th editions (p = . ). the concordance index and hazard ratio increased successively with the ntnm stage. similar findings were observed in both external cohorts. conclusion: compared with the ajcc-tnm classification, the 'metro-ticket' ntnm for gc is easier to remember and provides some improvements; therefore, the ntnm may be considered for adoption in future editions of the ajcc-tnm classification. objective: to investigate the prognostic value of complete blood count (cbc)-based biomarkers for patients with resectable gastric cancer (gc). methods: patients with gc who underwent curative resection between december to december were included. estimated area under the curve (auc) and multivariate cox regression models were used to identify the best cbc-based biomarker. time-dependent receiver operating characteristics (t-roc) analysis was used to compare the prognostic impact. results: based on multivariate analysis, the lymphocyte-monocyte ratio (lmr) and hemoglobin (hb) level were the independent prognostic factors (both p \ . ). based on the lmr and hb level, we established the cbc-based inflammatory score (cbcs). higher cbcs was associated with older age, female sex, higher american society of anesthesiologists (asa) score, proximal tumor location, larger tumor size, later stage and vascular involvement (all p \ . ). univariate analyses showed that higher cbcs was also associated with poorer overall survival (os), which was consistent in each stage (all p \ . ). multivariate analysis revealed that the cbcs was a significant independent biomarker (p \ . ). furthermore, t-roc curve of the cbcs was superior to that of the prognostic nutritional index (pni), systemic immune-inflammation index (sii), modified glasgow prognostic score (mgps) and c-reactive protein/albumin ratio (crp/ alb) throughout the observation period. conclusion: preoperative lmr and hb were optimal cbc-based biomarkers for predicting os in gc patients after curative resection. based on the lmr and hb, we developed a novel and easily obtainable prognostic score called the cbcs, which may improve the prediction of clinical outcomes. purpose: the aim of this study was to evaluate the prognostic value of the eighth ajcc tnm staging classification for patients with gastric cancer who had already survived for years. patients and methods: patients who underwent radical gastrectomy at a large eastern center were considered. the prognostic value of staging systems were assessed and compared. additional external validation was performed using a dataset from the surveillance, epidemiology, and end result (seer) database. results: the -year overall survival (os) rate for patients in the training set was . %. with the prolongation of the survival time after surgery, the -year os improved significantly (p \ . ). however, there were no significant differences in survival curves among patients who have survived years after surgery. the auc and c of the eighth ajcc classification for predicting of -year os decreased gradually after surgery and appeared stable after years. for patients who survived years after surgery, we constructed a new tnm staging system (ntnm) according to the survival curves of t stage and n stage. a -step multivariate analysis showed that ntnm, age and sex were independent prognostic factors. the ntnm demonstrated superior prognostic stratification, with higher c-statistic and likelihood ratio chi-square scores and lower aic values than those of the ajcc classification. similar results were observed in the external validation set. conclusion: the ntnm predicted an additional survival more accurately than did the ajcc classification for patients who have survived years after surgery; this may guide decisions regarding surveillance. objective: to investigate the relationship between preoperative sarcopenia and systemic inflammation and evaluate the prognostic impact of these factors on patients with resectable gastric cancer (gc). methods: patients with gc who underwent radical gastrectomy between december and december were included. a multivariate cox regression analysis was performed to identify the prognostic factors. a novel prognostic score (slmr) was developed based on preoperative sarcopenia and the lymphocyte-monocyte ratio (lmr), and its prognostic value was evaluated. results: in total, patients with resectable gc were included in the study. on multivariate analysis, preoperative sarcopenia and the lmr were shown to be independent prognostic factors (both p \ . ). a low lmr was an independent predictor from sarcopenia (p \ . ). based on preoperative sarcopenia and the lmr, we established the slmr. an elevated slmr was associated with older age, higher asa scores, larger tumor size, advanced stages and vascular invasion (all p \ . ). multivariate analysis revealed that the slmr was a significant independent predictor (p \ . ). we incorporated the slmr into a prognostic model that included tumor size and tnm stage and generated a nomogram, which accurately predicted -and -year survival for gc patients. objective: to explore whether adjuvant chemotherapy is still needed in patients aged less than years with pt n - and pt / n gastric cancer. methods: multi-center cohort data of patients with gastric cancer who underwent radical gastrectomy were analyzed. kaplan-meier curves and cox regression were used to analyze the relationships between chemotherapy and prognosis. additionally, nomograms to predict the benefit of chemotherapy were established. results: in total, , patients with pt n - and pt / n gastric cancer were included. patients ( . %) were aged \ years. the -year overall survival (os) was not significantly different between the \ years of age group and = years of age group ( . % vs. . %, respectively; p = . ). lymph node (ln) metastases (hr . ; p = . ) and ln dissection number \ (hr . ; p \ . ) were independent risk factors for the os of patients aged \ years. adjuvant chemotherapy did not improve the -year os for patients aged \ years with pt n - and pt / n gastric cancer (p = . ). however, chemotherapy showed a significant benefit (p = . ) when there were ln metastases and/or ln dissection number was \ . two nomograms were constructed, and the calculated difference was the potential benefit of adjuvant chemotherapy for the patients aged \ years. conclusions: ln metastases and ln dissection number \ were independent prognostic risk factors of patients aged \ years with pt n - and pt / n gastric cancer. patients with these risk factors may benefit from the addition of adjuvant chemotherapy. objective: the choice of reconstruction after distal gastrectomy remains controversial. we have performed roux-en-y (r-y) method after laparoscopic distal gastrectomy(ldg) as a standard since , but we have performed billroth ii (b-ii) method in an increasing number of cases, depending on the patient. we retrospectively investigated the outcomes of patients with b-ii method after laparoscopic distal gastrectomy in our hospital. methods: patients who underwent b-ii and r-y reconstruction after ldg from january to december were included. the patient characteristics, surgical outcomes, and postoperative outcomes between the procedures were retrospectively analyzed. we also compared extend of gastritis on endoscopy and loss of body weight after surgery at year. results: b-ii / r-y : / . b-ii was selected in the elderly patients with poor asa-ps (p \ . ). in surgical outcomes, operative time was shorter for b-ii than r-y (p \ . ), and blood loss was also smaller (p = . ). in postoperative outcomes, there were significant differences in complications (?grade ) (b-ii vs. r-y: . vs. . %, p = . ) and length of stay (b-ii vs. r-y: median . vs. -day, p \ . ). there was significant difference in presence of gastritis between b-ii ( . %) and r-y ( . %) (p \ . ), but no significant difference in loss of body weight (p = . ). conclusion: b-ii reconstruction may be an adequate procedure for high-risk cases because of its shorter operative time and the absence of severe complications. background: numerous studies have shown that the short-term efficacy of three-dimensional ( d) laparoscopic radical gastrectomy (lg) is comparable to that of two-dimensional ( d)-lg. whether d-lg affects the recurrence pattern after surgery has not been investigated. using data from a prospective clinical trial, the present study compares the recurrence patterns between d-lg and d-lg. methods: from january to april , a total of patients were recruited for the clinical trial (nct ). the recurrence types, the first recurrence time and recurrence-free survival (rfs) were compared between the two groups. multivariate analyses of factors associated with rfs were performed to identify whether d-lg affects the recurrence patterns. results: ultimately, patients were analyzed ( in the d-lg group and in the d-lg group), and there were no differences in the clinicopathological data between the two groups. distant metastasis was the most common type of recurrence. there were no significant differences between the two groups in the recurrence types, the first recurrence time or rfs (all p [ . ). according to the th american joint committee on cancer tumor-node-metastasis (tnm) staging system, both groups were stratified into pathological (p) i, ii, and iii stages. the stratified analysis showed that there were no statistically significant differences in rfs between the d group and the d group among patients in each subgroup (all p [ . ). the multivariate analysis of rfs showed that pathological tnm (ptnm) stage and lymphovascular invasion were independent risk factors (all p \ . ). the multivariate analysis of post-recurrence survival (prs) showed that adjuvant chemotherapy was an independent protective factor (p = . ). conclusions: distant metastasis was the most common type of recurrence after lg. the postoperative recurrence patterns, rfs and prs after d-lg were similar to those after d-lg. purpose: the aim of this study is to evaluate the efficacy of delta-shaped anastomosis compared to circular stapler anastomosis in laparoscopic distal gastrectomy with billroth i reconstruction (ladg-bi). method: this is a single-center randomized controlled study. eligibility criteria included histologically proven gastric adenocarcinoma in the lower third of the stomach, clinical stage i tumor. patients were preoperatively randomized to circular stapler anastomosis or delta-shaped anastomosis. the primary endpoint is the number of analgesics use during days after surgery. we compared the surgical outcomes of the two groups. postoperative qol was evaluated using the postgastrectomy syndrome assessment scale- . this trial was registered at the umin clinical trials registry as umin . results: between december and september , patients (delta-shaped anastomosis , circular stapler anastomosis ) were enrolled. there was no difference in the number of analgesics use during day after surgery (median : delta-shaped anastomosis vs. : circular stapler anastomosis, p = . ). there was no difference in the overall proportion with in-hospital grade ii-iiib surgical complications ( %: delta-shaped anastomosis, %: circular stapler anastomosis). there was no operation-related death in either arm. regarding postoperative qol evaluated month after surgery, diarrhea subscale was significantly worse in delta-shaped anastomosis than in circular stapler anastomosis. conclusion: we did not demonstrate the advantage of delta-shaped anastomosis in terms of postoperative pain. since delta-shaped anastomosis tended to cause postoperative abdominal symptoms related to diarrhea, we should carefully apply the delta-shaped anastomosis to ladg. introduction: the use of a three-dimensional( d) camera for laparoscopic surgery has been reported in literature. however, there are only few comparative studies demonstrating its benefits, and no reports on the application of d vision to single-incision laparoscopic surgery. this study aims to compare d vision to the previous two-dimensional( d) system in solo single-incision laparoscopic distal gastrectomy(sidg). methods: medical charts of gastric cancer patients who underwent solo sidg from february to december were retrospectively reviewed. patients were grouped into either d group or d group depending on the type of camera used. all the operations were performed by a single surgeon using a flexible camera(olympus, japan), fixed onto a passive scope holder without the use of a scopist or an assistant. operative data, postoperative outcome, and early complication were analyzed. results: ninety had their operations under d vision and used the d scope. in both groups, there was no difference in age, body mass index, staging, and other demographic or histopathologic criteria. operative time was significantly faster in the d group( . ± . vs. . ± . mins., p = . ) and ebl was also less( . ± . vs. . ± . ml, p = . ). patients in the d group started small fluid diet faster( . ± . vs. . ± . postoperative days, p = . ), and were discharged faster( . ± . vs. . ± . postoperative days, p = . ). early complication was also less in the d group( . % vs. . %) but there was no statistical significance(p = . ). conclusion: the use of the d camera improves operative outcome and hospital stay in patients undergoing solo sidg. the frequency of anastomotic leakage after gastrectomyreaches - %. at the same time, mortality in this group of patients reaches %, and the use of aggressive methods of surgical treatment for the treatment of anastomotic leakage increases the mortality rate from to %. since , vacuum-assisted closure has been used to treat anastomotic leakage of various localizations. the essence of this method is based on the creating a local negative pressure, which is transmitted to the drip cavity through a special porous spongy system. the negative pressure created in the closed cavity, allows you to remove exudate, helps to reduce tissue swelling, improvesmicrocirculation, which in turn contributes to the development of granulations and wound healing with separation of the fistulous course. failures in using the method of vacuum therapy in anastomotic leakage are associated with the great difficulty of delivering a polyurethane sponge with a drainage tube to the leakage zone. in this regard, we have developed an improved method of endoscopic local vacuum therapy, in which the delivery of a polyurethane sponge was carried out with the help of a thread through a pharyngeal ring, a leakage zone and brought out through a drainage tube. this technique has been successfully used in the treatment of four patients with anastomotic leakage after operations on the upper part of the digestive tract. for complete healing of the cavity of the leakage and defect of the organ wall, it took , , and sessions of replacing the vac system, respectively (average . ± . ). there were no complications during the endoscopic local vacuum therapy. when the control endoscopic studies after months after the completion of the treatment at the site of defects of the seams of the anastomoses formed tender scar tissue without signs of narrowing of the organ. aims: enhanced recovery after surgery pathways are safe and effective for patients undergoing gastrectomy. this study aimed to identify perioperative factors influencing the adherence to the protocol, the postoperative course, and the consequent length of stay. methods: between and , patients were referred to our institution for gastric cancer. among these, patients underwent atypical gastric resection and were excluded from this analysis. were assigned to either total or distal gastrectomy and represent the study population. all patients were managed with a standardised perioperative pathway according to eras principles. according to data from the literature and based on our clinical experience, patients with optimal adherence to eras protocol may fit the criteria for discharge within ninth postoperative day, that was considered our ideal threshold for hospital discharge. data were retrospectively collected and analysed from a prospectively maintained database. statistical analyses were performed using spss version for macintosh. the v test, with a significance level of . , was used to investigate the association between the outcome and perioperative categorical variables. when parametric assumptions were met, student's two-tailed t-test was used to compare the means of continuous variables; otherwise, the mann-whitney test was performed. a significance level of . was chosen. logistic binary regression with a backward selection procedure and selection criteria of p-value \ . were exploited to determine significant predictors. results: preoperative, intraoperative and early postoperative variables were considered. among all, multivariate regression analysis revealed that incomplete preoperative immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids infusions [ ml and blood transfusion [ ml, surgery duration [ min, and failure to mobilise patients within h from surgery were associated with delayed discharge. the logistic regression model was statistically significant (p \ . ) and correctly classified . % of cases. sensitivity and specificity were . % and . %, respectively. conclusions: results seem to be clinically rational and focus the attention on the importance of some perioperative clinical issues for the management of postoperative course. these variables could be considered as clinical goals to be reached in order to get an early discharge. objectives: the purpose of this study is to confirm the safety of laparoscopic gastrectomy with intraperitoneal cisplatin administration as a treatment for advanced gastric cancer with potential for peritoneal seeding. methods: from july to august , patients with advanced gastric cancer who underwent ip chemotherapy after diagnostic laparoscopy were retrospectively studied. all patients underwent laparoscopic gastrectomy with ip chemotherapy or ip chemotherapy alone after a diagnostic laparoscopy. gastrectomy was performed for palliative purposes even with seeding. results: the average age of the patients was years. eight patients ( . %) had preop chemotherapy. curative resection (r ) was performed in patients ( . %). in diagnostic laparoscopy, cytology was performed in patients ( . %) and cy was ( . %). peritoneal metastasis was detected in patients ( . %). of the total cohort, the year os rate was . % and the median survival time was months. in the case of stage iiib and below, the -year os rate was %, but it was % in stage iiic-iv group. when the r resection group and the r - resection group were compared, the -year os rates were . % and . %, respectively. hematological toxicity such as neutropenia was not seen in all patients. the mean hospital stay was . days and adjuvant chemotherapy was performed in patients ( . %). background: radical proximal gastrectomy (pg) and lymph nodes dissection are indicated for selected gastric cancers at the upper third of the stomach. with the advent of laparoscopic surgeries, more and more pg were performed by laparoscopic apporaches. in the past years, our team has accomplished and reported the oncological outcome of laparoscopic distal gastrectomies in cases of clinical stage i gastric cancer in taiwan. through the evolution of surgical trechniques and team work, we have cruised the learning curve of laparoscopic gastrectomy and reconstruction. materials and methods: in this report,we would like to present our surgical experience of laparoscopic proximal gastrectomy for gastric cancer patients. from to , pateints with gastric cancer underwent laparoscopic gastrectomies by the same surgical team at the national taiwan university. among them,six consecutive pateints (male:female = : ) with gastric adenocarcinoma of the upper stomach underwent laparoscopic pg in . the demographics, dissection, reconstruction methods and peri-operative outcome are presented. all six patients tolerated the procedure well, onepatient had mild anastomotic stenosis and improved with one session of endoscopic dilatation. one patient needed temporary proton pump inhibitor for controlloing acid reflux. four of the patients were pathological stage i, and the rest two pateint were stage iia and iiia disease. there was no tumor recurrence until now. summary: laparoscopic proximal gastrectomy is technically safe for treating upper third gastric cancers. the long term oncological outcome deserve further observation. introduction: open gastrectomy (og) has long been the preferred surgical approach worldwide for treatment of gastric cancer (gc). nowadays, several randomized, prospective trials have confirmed improvements in postoperative outcomes for laparoscopic gastrectomy (lg) compared to open procedures, with similar oncologic outcomes. however, most part of these studies comes from the eastern countries. material and methods: a prospective non randomized study was conducted with all patients operated of gc at ramón y cajal university hospital from january to december . over patients enrolled, patients underwent lg and og. textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. results: a textbook outcome was achieved in . % of patients operated of gc. the outcome parameter 'no severe postoperative complication' had the greatest negative impact on the textbook outcome. a statistically higher number of patients with early cancer ( % vs. . %) and subtotal gastrectomy ( . % vs. . %) were found in the laparoscopic group. no statistically differences were found between open and laparoscopic approach regarding operating time, rate of microscopic margin positivity, hospital stay, number of retrieved lymph nodes, complications, reinterventions, mortality and readmissions. no statistical differences in textbook outcome were found between both groups ( . % vs. %; p = . ). conclusions: laparoscopic gastrectomy for treatment of gastric cancer seems to be safe and feasible with similar textbook outcomes compared to open gastrectomy. introduction: laparoscopic surgery has been increasing for treatment of gastric cancer. however, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. the aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. material and methods: the first consecutive cases of laparoscopic gastrectomy (lg) performed at our hospital from november to february were enrolled. patients were divided into two groups based on the period they were operated. training phase (tp) was considered between and ( cases) and more-developed phase (mdp) between and ( cases). conversion, lymphadenectomy and retrieved lymph nodes (ln), hospital length of stay, mean operative time, complications, reintervention and mortality rates were compared between the two phases of learning curve. results: the number of retrieved ln was higher in the mdp ( ± , vs. , ± , ; p = , ). furthermore, we have also found less complications ( , % vs. , %; p = , ), a decreased reintervention rate ( , % vs. , %; p = , ) and overall mortality ( , % vs. %; p = , ) in the mdp. there were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. conclusion: although we consider that our learning curve is not completed yet because the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last two years have showed our results are near to the best results published in the literature. aims: lymph node (ln) dissection proves to be essential for oncological gastrectomy, given that the presence of ln metastases is very high, even for early gastric cancer ( . % for t a and . % for t b). this way, d dissection for advanced gastric cancer and d ? for early gastric cancer are the gold standard procedures. some teams are using indocyanine green (icg) lymphography to improve their ln dissections, claiming that this technique facilitates the harvesting of small fluorescent ln that, otherwise, would be difficult to identify by conventional laparoscopic methods. methods: we herein present the case of a -year-old man with a t b distal gastric cancer. endoscopic ultrasound discarded the presence of metastatic ln and ct scan showed no distant metastases. icg was administrated endoscopically the day before the surgery, an amount of mg was injected along the submucosal layer around the tumour. in the video we can see how we perform a laparoscopic distal gastrectomy with d ? ln dissection and roux-en-y reconstruction. icg lymphography helped us to complete our expected ln harvesting, especially for groups (infrapyloric) and (left gastric artery). thanks to this technique, we could resect ln that we might have obviate during a usual laparoscopic procedure. results: patient was discharged home on the sixth postoperative day without complications and with adequate oral tolerance. conclusions: we present a case in which we have performed a laparoscopic distal gastrectomy with d ? dissection and roux-en-y reconstruction. we used icg lymphography to help us to improve our ln harvesting. although it is soon to assess if this technique may increase the number of retrieved ln and in which stations might be more useful, we consider this is a harmless method that may help gastric teams to complete their expected ln dissections. introduction: gastrointestinal stromal tumor (gist) represents around . % to % of gastrointestinal neoplasms, with the mesenchymal tumor being more frequent than the digestive one.the gist can be produced from the esophagus to the anus, at any point, being the stomach of ( to %) and the small intestine ( to %) more frequent sites.it is characterized by the expression of the tyrosine kinase growth factor receptor,cd ,differentiating it from other mesenchymal tumors,which do not express it.it is accepted that its origin corresponds to the interstitial cells of ramón y cajal,which act as a pacemaker for intestinal motility.they are very heterogeneous tumors, which vary in size,morphology and biological behavior,being neoplasms with uncertain malignant potential.the incidence is between the fourth and sixth decades,being the distribution by gender similar. clinical case: female patient of years,who goes to the general surgery service,as interconsultation,after a veda,by dyspepsia.it is reported stomach:ceiling mucosa without alterations,at the level of the greater curvature is seen a tumor of cm,hard to the touch with the biopsy forceps,slightly irregular covered with mucosa of normal appearance. computed tomography: stomach body:rounded image of nodular aspect which does not present heterogeneous enhancement after administration intravenous iodine contrast extending to peritoneal region, measures x x mm liver:hypodense image without heterogeneous enhancement adjacent to this,a mm rounded image that is suggested to be studied with nmr. gadolinium nmr liver hypodense image with well-defined limits without heterogeneous enhancement of cystic aspect. gastric roof,heterogeneous formation,which enhances with gadolinium mmx m-mx mm,having to discard a gist. surgical technique laparoscopic partial gastrectomy. pathological anatomy and immunohistochemistry . cm injury with net edges.uncertain malignant fusocellular nodule, cd ??? actin-dog ??? s -no mitosis or invasion of the mucosa is observed. conclusion: a case of stomach gist is presented,which,the main symptom was dyspepsia,being the clinical presentation very variable,in relation to the place in which it is located. there is fletcher criteria for the risk of malignancy,this being less than . cm,very low risk,less than cm, the patient evolved favorably,without surgical complications.aims: to present the surgical procedure of resection of the lesser gastric curvature and its pedicle with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: an -year-old man with prostate cancer treated with complete hormonal block and epoc, who consults for rectal bleeding of week of evolution. it is diagnosed of gist in gastric lesser curvature, x x cm, very vascularized and infiltrates the wall producing marked imprint on the fundus. it is tributary of left gastric artery. precise blood transfusion and presents hemodynamic stability, is decided surgical resection scheduled. results: the surgery is performed by laparoscopy, with a tumor of approximately cm, which is dependent on the lesser curvature. the esophageal hiatus and the lesser curvature are dissected with section of the left gastric pedicle. atypical gastrectomy of the lesser curvature including gist, making a gastric sleeve dependent on the greater curvature. the anatomopathological study reports pt pn with lymph nodes without adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: the laparoscopy surgery for atypical gastrectomy of lesser curvature is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. aims: to present the surgical procedure of total gastrectomy with d lymphadenectomy with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: a -year-old male with a tobacco habit who consults due to epigastric pain and constitutional syndrome of months of evolution. it is diagnosed of gastric adenocarcinoma t n m . neoadjuvant qt is decided, after weeks of its completion, scheduled surgery is performed. results: the surgery is performed by laparoscopy, showing a stenosing tumor in at gastric antrum of approximately cm. dissection of the greater curvature with section of the right gastroepiploic at its birth and duodenal section is performed. dissection of the lesser curvature with d lymphadenectomy, section of the pedicle of the left gastric and the distal esophagus. the transit is restored with latero-lateral esophageal-jejunal anastomosis and jejunojejunostomy. the anatomopathological study reports ypt a and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require reentry. conclusions: the laparoscopy surgery for total gastrectomy with complete d lymphadenectomy is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. background: in gastric cancer surgery, to secure surgical margin, it is necessary to accurately judge the position of the tumor. however, with conventional marking clips, it is difficult to identify the exact location of the tumor during laparoscopic surgery. purpose: we investigate whether icg (indocyanine green) fluorescence navigation method is effective and safe for determination of cutting line in laparoscopic gastrectomy. patients and methods: subjects underwent laparoscopic gastrectomy (including robot-assisted surgery) based on the icg method for gastric cancer in the period from april to december . the day before surgery, icg diluted times ( . ml of reagent ? . ml of distilled water) was injected at cm from the tumor edge and . ml at the four submucosal layers around. then clip to the same part. gastrectomy based on standard surgery is performed, and the position of the tumor and spread of icg are confirmed by icg fluorescence navigation during operation, and a cutting line is determined. the extent of icg from the tumor is again measured with the excised specimen and compared with the pathological margin. results: among the patients who underwent intraoperative pathological examination, they were negative in all cases except one. the spread of icg was . cm on average, and considering the marking position ( cm) from the tumor edge, securing of . cm or more was possible. the operation time was . ± . min and the estimated bleeding loss was . ± . ml. conclusion: laparoscopic gastrectomy with icg method can evaluate tumor position and spread easily and in real time during operation and it was effective for determining the cutting line in laparoscopic gastrectomy. epstein-barr virus (ebv) has been known as one of causal virus of gastric cancer. ebv-related gastric cancer considered to be about % of the entire gastric cancer, and it is rare that ebvrelated gastric cancer has multiple lesions. the patient was years old female. she was diagnosed with upper gastrointestinal endoscopy with lesion in the lower major stomach body, lower anterior wall of the stomach body, rear wall in the middle part of the stomach, rear wall in the middle part of the stomach, and lesser curvature of the stomach angle, as a result of biopsy, adenocarcinoma was observed from the former four. the patient underwent a robot-assisted total gastrectomy. adding a newly found lesion, the histopathological diagnosis was pt b in the lower major stomach body, pt b in the lower anterior wall of the stomach body, pt b on rear wall in the middle part of the stomach, pt b on rear wall in the middle part of the stomach, and pt a in lesser stomach body, pn , pstageia. pathological examination results showed that the four lesions were positive for tumor cells in eber in situ hybridization and were considered to be ebv-related gastric cancers. she was discharged on the th day after the operation without any postoperative morbidities.there has been no sign of recurrence without postoperative therapy for months. results: a -year-old female with no medical history of interest or allergies to medications, who consulted for palpable mass at mesogastric level to the left of the midline associated with abdominal pain of - months of evolution, without concomitants or relationship with the intake, valsalva or physical efforts, without change in the depositional habit or toxic syndrome. the abdominal ct (computed tomography) revealed a cystic mass in jejunum mesentery, defined edges, about cm in diameter and that does not capture contrast; likewise, there is no ascites, retroperitoneal adenopathies or other intra-abdominal or pelvic masses, radiology recommends completing the study with abdominal mri (magnetic resonance imaging) that informs of possible lymphangioma at the level of the jejune mesentery. surgical exeresis was decided, which was carried out by laparoscopic approach, with emptying of the lesion and enucleation of the lesion without incidents, the postoperative evolution was favorable being discharged at h. the pathological anatomy reported fibro-adipose tissue with presence of lymphatic dilatations associated with a cystic lesion without epithelial lining, with serous fluid and abundant macrophagic reaction compatible with mesenteric lymphangioma. conclusions: the mesenteric cyst is a rare pathology with an incidence ranging from / , to / , , predominating in the fourth decade of life. it is defined as any cystic lesion in the mesentery, and is subdivided according to its origin into lymphatic, mesothelial, urogenital, dermoid, and enteric and pseudocysts. most of the time they are asymptomatic although they can (as in our case) present with abdominal pain and even produce complications such as intestinal obstruction, volvulus, intracystic hemorrhage, infection, rupture, and even malignant transformation. for the diagnosis, the palpation can be of great help, showing mass of well-defined limits and partially mobile. the imaging test of choice is abdominal ultrasound / abdominal ct, supplemented by magnetic resonance imaging. the recommended treatment is surgical exeresis, considering laparoscopy as the first option; if it is complete, it can be considered as a curative treatment. purpose: gastrostomy(og) is an alternative method for nutrition support, especial for the patients with oral-esophagus route obstruction or dysfunction. the most operation were conducted by young surgeon or residents. laparoscopic gastrostomy(lg) was a new coming procedure and the skillful suture techniques were needed. the most the residents can't be qualified for this operation. we designed the method for laparoscopic gastrostomy to provide the traning opportunity of suture skill training and guarantee the patient's safety. material and method: laparoscopic gastrostomy procedure was done with two mm trocar. the lower body of stomach was chose. four point around gastrostomy wound were chose for subcutaneous fixation. the straight needle with - prolene was inserted into peritoneal cavity from upper point, then punctured the sero-muscular layer of stomach. the needle was retrieved out from the same point by guidance of gauge needle. the same way was used for other three points. one purse string around gastrostomy was created by one hand suture method and fastened by köckerling knot tier after insertion of fr foley tube. finally, the peritonization was finished by hand tie externally and knot were keep in subcutaneous layer material-method: we present the case of a year old woman who presented with melena, hematemesis, anemia (ht . %) and being haemodynamically unstable. after the stabilization of the patient, a gastroscopic examination followed, where it revealed a tumor of the fundus (adenocarcinoma). the patient was submitted to laparoscopic total gastrectomy and oesophagojejunal anastomosis, omega type (o), and intestinal anastomosis braun, with the usage of trocars (umbilical mm as inserted in laparoscopic surgery of a single incision, and two mm in the midclavicular line bilaterally). the oesophagojejunal anastomosis was conducted with the use of a linear stapler for the posterior wall and the convergence of the anterior wall with laparoscopic sutures in two layers. patient remains in well condition, months after the operation. conclusion: laparoscopic approach seems to be safe for treatment of gastric cancer of the fundus and of the gastroesophangeal junction, as it offers better surgical field view and less postoperative complications. the restoration of the continuity of the gastrointestinal tube with anastomosis of w type is considered safe alternative to the classic roux-en-y anastomosis. git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery, faculty of medicine, alexandria, egypt background: superior mesenteric artery syndrome is best described as compression of the third part of duodenum by the superior mesenteric artery, resulting in obstruction. the study of this rare medical condition was carried out since decades yet remain obscure. this study aimed to analyze different clinical presentations, diagnostic modalities, treatment approaches and outcomes, as well as to emphasize the importance of long term follow up. methods: thirty-five superior mesenteric artery syndrome cases were collected retrospectively from a facebook group called 'superior mesenteric artery syndrome awareness & support'. a questionnaire was designed using google form to obtain the demographics, presenting symptoms, risk factors and co-morbidities, investigations, means of treatment and the outcomes. data was entered into microsoft office excel for statistical analysis. results: the median age at diagnosis was years. the median body mass index was . kg/ m ;. the median time interval from symptom onset to initial diagnosis was months. the major presenting symptoms were abdominal pain ( . %), nausea ( . %), and vomiting ( . %). abdominal computed tomography scan with contrast ( . %) was commonly used for confirmation of diagnosis. thirteen cases ( . %) were congenital. thirty patients ( . %) had received treatment. the overall management success was only . %. surgical management ( . %) was the most used regimen. conclusion: diagnosis of superior mesenteric artery syndrome is established after a thorough assessment of the clinical presentations and confirmation with suitable imaging modalities. the choice of treatment should be dependent on the causes and severity as different patients respond differently to therapy. recurrence is possible in all patients thus a long-term follow up is required. aims: in the last hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years. treatment for perforated ulcer can be performed laparoscopically in % of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late eventration. methods: a -year-old male presented to emergency room with a three-hour history of progressively worsening epigastric pain and nausea. physical examination revealed rebound tenderness compatible with an acute abdomen. a ct scan showed: important pneumoperitoneum unable to define the drilling point; distended stomach with plenty of fluid inside and dense content fundus / body suggestive of active arterial bleeding . results: the patient was emergently taken to the operating room for diagnostic laparoscopy . perforation shown in greater gastric curvature associated blood remnants. gastrotomy for clot removal is done without observing active bleeding. the gastrotomy was repaired using standard stitches. all exudate was aspirated and the peritoneal cavity was irrigated with warm saline solution the patient had an uncomplicated post-operative course. jp drain was removed and he was discharged one week after surgery. conclusion: the role of laparoscopic surgery in emergencies is well documented. laparoscopic approach is indicated in any case of suspected gastroduodenal perforation and seems to offer the same advantages as for the vast majority of laparoscopic procedures. laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer. the aim: of our study was to evaluate of effectiveness of local injection of platelet-rich plasma for treatment of peptic ulcer bleeding with hemorrhagic shock in experiment. methods: the study was performed on wistar rats according to local and international rules for working with experimental animals. the average weight of animals was ± grams. in all animals our modification of type acetic acid ulcer (susumu okabe, ) was modeled. we randomly divide all animals in groups. rats with only modeled ulcer were included in group . rats with modeled ulcer and hemorrhagic shock after - . ml blood sampling were included in group . in group we included rats with modeled ulcer and hemorrhagic shock and performed local injection of platelet-rich plasma (local periulcelar injection of . ml of autologous platelet-rich plasma). on st, th and th day measurement of the ulcers square and morphological study were performed. results: the data we have received demonstrate a tendency of decrease of ulcers' square in all groups with time flow. we also compared sizes of ulcerative defects in all groups at every point of the study. on the st day of investigation there were no differences (p [ . ) between ulcers' square in all groups. on the th day we found out more rapid decrease of size in group (p [ . ). however, this tendency had no statistical significance. on the th day difference was larger and it was statistically significant this time (p \ . ). also the better ability to stimulate the activity of fibroblasts and revascularization in the young connective tissue with improving oxygenation in the ulcers and enhancing of cell proliferation, differentiation and accelerating of maturation of connective tissue and healing of ulcers was demonstrated in group . conclusion: platelet rich plasma reduces inflammatory response and stimulates proliferation of gastric epithelial cells on th day with the restoration of secretory activity and epithelialization of ulcers in . % of experimental animals on th day, the activation of the fibroblastic reaction during the all experiment and decreasing of ulcers' square. h. fujii, depat. of surgery, japanese red cross fukui hospital, fukui, japan introduction: in conjunction with charmant, a local eyeglass frame manufacturer, we developed novel devices called the fj (free jaw) clip to grasp organs in the abdominal cavity and the f (free) loop plus to pull thread extracorporeally from within the abdominal cavity. product summary: the fj clip is used to grasp organs in the abdominal cavity, a stainless steel, removable forceps for use in laparoscopic surgery. it provides a strong grip but rarely crushes organ tissue. the clip comes in two sizes, one for use in a -mm port and the other for use in a -mm port, and in two lengths, . mm and . mm, respectively. to pull out thread tied to the fj clip, we developed the f loop plus, which is a g by -mm-long special stainless needle with f . -mm niti alloy thread which is used pull suture threads from inside the abdominal cavity to outside the body. case: we performed cases of reduced port laparoscopic and endoscopic cooperative surgery (lecs). we performed reduced port surgery (rps) by making a . -cm incision at the umbilicus, inserting trocars ( mm and mm), and inserting another trocar ( mm) at the left side of the abdomen. we expanded the left hepatic lobe with a -mm fj clip for penrose drain placement, grasped the front wall of the gastric body with a -mm fj clip, applying traction toward the legs to pull up the tissues around the tumor, and resected all layers of the tumor via oral endoscopic submucosal dissection technique. the resected area was closed with a suturing device or interrupted sutures in the abdominal cavity. a year-old female was admitted to the emergency department with complaints of abdominal cramping pain, back pain and diarrhea for one day. she also had fever, ever up to °. in these two weeks, she felt occasionally epigastric pain. her past medical history included hypertension. on physical examination, she was conscious and alert. abdominal examination revealed diffuse tenderness and knocking pain over right flank. laboratory tests indicated an degraded white cell count of /cumm with % band forms, c-reactive protein of mg/dl and abdominal liver function tests (alanine aminotransferase: u/l, alkaline phosphatase: u/l, gammaglutamyl transferase: u/l) without hyperbilirubinemia. abdominal x-ray showed paralytic ileus. our presumptive diagnosis was acute peritonitis, based on the patient's symptoms. empirical antibiotics were administered immediately, and a computed tomography (ct) imaging study was performed. the ct scan showed a stick like foreign body noted between ventral side of pylorus and smv lumen, about . cm in length and associated with perifocal infiltration and segmental smv thrombus formation. (fig. ) however, there is no obvious pneumoperitoneum and no evident ascites is associated. an emergency exploratory laparotomy was performed, revealing stomach perforation at posterior wall with a cm fish bone thourgh pancreas into smv. localized inflammation and fibrosis were identified without obvious fluid accumulation( fig. - ) . removal of fish bone and simple closure of stomach perforation were performed. blood cultures revealed bacteroides thetaiotaomicron. three weeks later, she received a follow-up ct scan which showed smv obliteration with chronic pylephlebitis. aim: here we present a case report about the endoscopic treatment for iatrogenic gastric perforation secondary to a chest tube insertion. methods: a case report of a -year-old male with history of a road traffic accident. described injuries were severe brain injury with gcs \ at pre-hospital care arrival, thoracic injury with several rib fractures on the left hemithorax and hypoventilation on the left side. prior to hospital transfer a chest drain was inserted on the left side, and the patient was intubated. results: at hospital admission, the patient was hemodynamically stable and connected to a mechanical ventilator. thoracic exam showed persistent hypoventilation on the left chest. no other abdominal or pelvic injuries were found in the physical exam. a frontal chest x-ray revealed pneumothorax and the chest tube was not viewable. a further ct scan showed the chest drain placed in the abdominal cavity, into the stomach, besides a subdural hematoma, comminuted pelvic fracture of the pubic rami and a left sacroiliac fracture. during the first h in the icu, neurological worsening was observed, and a new cranial ct revealed enlargement of the subdural hematoma, for what the patient underwent decompressive craniectomy, with improvement thereafter. following a five-day period of stabilization after surgery, the patient was evolving satisfactorily, and the removal of the intragastric chest drain was considered. endoscopy was performed to confirm the placement of the drain, and it was removed under direct vision. approximately twenty five centimeters of the catheter were visualized in the gastric lumen, and then successfully removed. the patient recovered well and was discharged from icu to medical hospital ward after fourteen days, and a week later he was discharged home. conclusion: endoscopic management for gastric perforation after a chest drain insertion may result effective and can prevent open surgery morbidity. aims: intestinal infusion treatment with levodopa/carbidopa (duodopa) is a therapeutic option concerning the advanced parkinson disease cases with no response to the conventional treatment. the drug requires carrying out a gastrostomy either by percutaneous endoscopy way, or by laparoscopy -if the first one is not possible-. later, a duodenum-yeyunum tube is placed in order to infuse the duodopa gel continuously by a portable bomb. in this report, we explain the laparoscopic gastrostomy technique. method: sin this report, we include two patients with advanced parkinson disease: the first one is a year-old female patient suffering from an important gait disorder; and the second one is a year-old male patient with uncontrolled motor fluctuations. in both cases, a percutaneous endoscopic gastrostomy was proposed, but neither was feasible because of the non-traslumination between the gastric and the abdominal wall. under general anesthesia, neumoperitoneum by veress needle was performed. three main trocars and one accessory were placed. at the level of the gastric antrum, a cm incision was conducted to insert a gastrostomy tube, to be the guide for the drug infusion catheter. next, the gastrostomy is fixed to the abdominal wall by the stamm technique, externalizing the catheter through the accessory trocar in the medial line. results: on the first post-operative day, a duodenum-yeyunum tube is placed by endoscopic control through the gastric device. both patients got well satisfactorily, and no complications were described; and they develop a total normal life within the limitations of their underlying disease. conclusions: the duodopa intestinal infusion shows a significative improvement for the advanced parkinson disease symptoms, compared with oral medication; appreciating positive results referring to life quality. when the catheter placement by endoscopy way does not seem posible, gastrostomy by laparoscopy constitutes a valuable surgical option for the treatment of this kind of patients. peptic perforated ulcus (ppu) is a common surgical emergency and laparoscopic repair has been introduced as an alternative to open repair. it has shown good results and allows closure and peritoneal lavage, just like the open repair does but with the advantages of a minimally invasive surgery. the objective is to report the outcome of laparoscopic ppu in our hospital. methods: from january to october , patients with a clinical diagnosis of ppu were assigned to undergo laparoscopic repair. this retrospective study included all husm patients who underwent laparoscopic ppu repair by emergency surgeons. minimum follow-up of months is carried out. results: of the patients in this series, % were men and % were women, between and years of age at the time of surgery, average of years. the time between the manifestation of symptoms and surgery was [ to h in % of patients. in patients there was a history of previous ulcer or non-steroidal anti-inflammatories intake and up to % were smokers. a ct scan was performed in all cases to reach the diagnosis primary closure with simple suture plus omental patch was the elected technic ( %). the approach was performed with trocars in %, trocars in % and in case. cases ( %) were gastric ulcer, duodenal cases ( %) and in one case no perforation was found. the conversion rate was %, in two cases due to technical difficulty and in the other case because the level of the perforation was not found. the median postoperative stay was days although there were cases with intrabdominal complications. there was an exitus due to a metastasic pulmonary neoplasia diagnosed in the immediate postoperative period. there were no cases of recurrence in the follow-up time. conclusion: in most centers, including ours, the rate of laparoscopic management has gradually increased along with the improvement of technical skills. improvements in the outcome of laparoscopic ppu repair are to be expected with more experience surgeon and a good selection of the cases. general surgery, jzu hospital ,,sveti vracevi,, bijeljina, bosnia-herzegovina introduction: diverticulum is an outpouching of a hollow organ. gastric diverticulum is rare form od this disease. incidence of detection varies depending on investigation method. it has been reported in . % cases of autopsies, . % cases of gastroduodenal roentgenographies with contrast, and . - . % cases of upper endoscopies.small diverticula are usually asimptomatic, but bigger diverticula can cause variable symptoms such as abdominal pain, feeling of epigastric fullness right after meal, feeling of discomfort in upper parts of abdomen, and severe 'foetor ex ore' .diagnosis is usually established in procedures such as gastroduodenal roentgenographies with contrast, upper endoscopies and abdominal ct scan. case report: a -year-old woman came to our hospital because of feeling of discomfort and mild pain in upper abdomen that lasted for last year. diagnosis is established after ct scan of abdomen and upper endoscopy procedure. initially she has been prescribed conservative therapy (proton pump inhibitors). since the symptoms persisted, laparoscopic resection of the gastric divertuculum was performed using endogia stapler. considering the feeling of discomfort and abdominal pain dissapeared, the patient was discharged from hospital on the fourth postoperative day. conclusion: asymptomatic gastric diverticula doesn't require treatment. since gastric diverticulum can have complications such as bleeding, perforation and neoplasia, patient without symptoms should be monitored. initial therapy for symptomatic diverticula is conservative therapy (proton pump inhibitors). if conserative therapy doesn't procude expected results, laparoscopic resection of the diverticulum should be considered. introduction: the acute perforation of a gastric ulcer is a serious entity that requires urgent surgical treatment in most of the occasions, it is increasingly accepted that the approach of choice is laparoscopic, depending, above all, on the time of evolution of the process. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the perforation of a pyloric peptic ulcer, even in cases of severe peritonitis, by means of a standardized procedure, insisting on the sequential thorough washing of the cavity.material and methods: we present a video of the surgical intervention of a patient with acute abdomen, with a history of nsaid ingestion, exploration and ct-analysis compatible with perforation of hollow viscus, probably of gastric origin. results: intervention: complete laparoscopic approach, trocars. severe biliopurunitic peritonitis, by pyloric perforation 'acute', liquid culture, suture of the perforation, epipoplasty, sequential thorough washing of the cavity with physiological saline and placement of drainages.correct postoperative period, discharge from the hospital on the th day after completing antibiotic treatment. endoscopy and helycobacter test are performed on an outpatient basis with normal results. conclusion: the laparoscopic approach is safe and effective in acute and complicated gastric ulcer disease, even in cases of severe peritonitis. surgical procedure: the clean-net procedure involves the selective dissection of both the serosa and muscle layer using a laparoscopic monopolar endoscopic scissor. the preserved mucosal layer provides a mechanical barrier between the gastric lumen and peritoneal cavity that aids in the prevention of peritoneal cavity contamination with gastric contents. tumors are observed with an upper gastrointestinal endoscope with the injection of indocyanine green (icg) into peri-tumoral submucosal layers at points. selective seromuscular dissection is performed using a laparoscopic electrocautery monopolar scissor. the mucosa surrounding the gist is then resected using a endoscopic mechanical stapler to prevent exposure of the gastric lumen to the peritoneal cavity and peritoneal tumor cell seeding. results: there were males and female, and the average age was years. the operation time was min, the average bleeding volume was . ml, the postoperative hospital stay was . days. the mean tumor diameter was . mm, the final histopathological diagnosis was gist, schwannoma. there were no postoperative complications of clavien-dindo classification or more. conclusion: clean-net was found to be safe and useful for the treatment of gastric smt with ulceration. year outcomes: laparoscopic heller myotomy stands the test of time aims: laparoscopic cardiomyotomy leads to excellent relief of dysphagia in % of patients and avoids thoracotomy or laparotomy. methods: we present a video illustration of the procedure that was modified at the american university of beirut medical center. so far, patients underwent laparoscopic cardiomyotomy, age range of to years, with males and females. most of them have had previous balloon dilatation. results: all cases were successfully completed laparoscopically without complications. followup of months to years revealed excellent results with complete resolution of symptoms and no need for further medications. this will result in minimal post-operative pain and very short recovery period and is associated with low complication rate. conclusion: cardiomyotomy for achalasia is ideal for laparoscopic approach. magnification allows for precise division of muscle fibers. the new technique of hydro dissection and enseal for division of esophageal muscle allows for completion of the procedure without injury of the mucosa. therefore, adequate release of the obstructing segment followed by anti reflux procedure toupet will lead to excellent results with minimal morbidity and no mortality. aims: laparoscopic repair of huge hiatus hernia methods: twenty two cases of huge hiatus hernia presented to the american university of beirut medical center. patients underwent through trocars in the upper abdomen reduction of the hernial sac from the chest. special care was taken in the dissection of the mediastinum to keep the thoracic fascia and pleura intact. the defect was sutured primarily by -ethibond sutures reinforced by onlay prolene mesh u-shaped was fixed at the rt. and lt. crus and a floppy nissen fundoplication performed . results: the video presentation includes the technical aspects and the method of reducing and repair of huge hiatus hernia.aim: nowadays, there is little experience in the world of applying robotic surgical system (rss) in treatment of patients with hiatal hernia (hh) and reflux-esophagitis (re). the aim of study was to determine the possibility and feasibility of using rss in treatment of patients with hh. materials and methods: a total of patients underwent robot-assisted hh repair without mesh, followed by fundoplication with our original method ( °full symmetric wrap). the clinical and technical analysis did not reveal any advantages over similar laparoscopic procedures, so we abandoned the use of rss for hh type i, and these patients were excluded. there were ( %) patients with hh type iii and ( %) type iv. the surgeries were performed by experienced robotic upper gastrointestinal surgeon and conducted with the davinci si surgical system (intuitive surgical, sunnyvale, ca). results: average operation time was ± ( - ) min. the respondents' mean age was . ± . years (range - ) and bmi was . ± . (range . - . ) cm/kg . average blood loss was ± ( - ) ml. average hospital stay was ± . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days. the average follow-up time was ± . ( - ) months. postoperative x-ray imaging and upper gi endoscopy was conducted in all ( %) patients. there was no hh recurrence diagnosed. we did not observe a relapse of hh or clinical manifestations of re in the early (less than days) and long-term (more than months) postoperative periods. conclusion: we can conclude that robot-assisted surgery is safe, appropriate and justified in patients with hh type iii and iv. all procedures performed to the patients with giant hh revealed clear technical advantages of rss over similar laparoscopic operations: an enlarged d hd image, bendable instruments with endowrist technology allowed for precise dissection of tissues (hernial sac, cicatricial adhesions) in a narrow anatomical space-posterior mediastinum without damage to pleura, pericardium and vagus nerves. we believe that use of rss in treatment of patients with reflux esophagitis and/or hh type i is unjustified, due to the lack of proven advantages over laparoscopy. introduction: the presence of major anatomical obstacles -such as massive caudate lobe-in the confined operative field of laparoscopic hiatal hernia repair (lhhr) poses significant challenge to the foregut surgeon. aim: to provide a safe alternative for lhhr using a laparoendoscopic approach. method: this patient is a year old female, with bmi of . . her past medical history includes diabetes, hypertension and hyperlipidemia. she had gerd for years. her egd showed x cm hiatal hernia and class b esophagitis. manometry showed ineffective esophageal motility. we used the classic five ports approach for lhhr. we found a massive caudate lobe which was comparable to the size of an already enlarged left lobe of the liver. the operative strategies: terminating the procedure proceeding with the standard approach and taking the risk of bleeding from the caudate lobe itself or the inferior vena cava (ivc) with possible catastrophic outcome. using the laparoendoscopic approach. the following three steps facilitated the performance of safe and effective surgery. additional liver retractor this improved exposure and minimized manipulation of the caudate lobe. extracorporeal sliding arthroscopic knots (esak) esak are similar to the knots used in endoloop. they are tied extracorporeally and require a single insertion of the knot pusher as they do not unravel. transoral incisionless fundoplication (tif) we performed tif to avoid a limited operative field and to prevent excessive tissue manipulations associated with laparoscopic fundoplication. tif also preserves the angle of his and produces partial fundoplication which has less side effects of dysphagia and gas bloat syndrome. results: the operative time was min (lhhr min and tif min). there were no complications. patient discontinued omeprazole which she used daily for years. at months follow up, her gerd related quality of life (hrql) and gerd symptom (gerss) scores were ( vs ) and ( vs ). conclusion: the laparoendoscopic repair of hiatal hernia in the presence of anatomical obstacles is safe and effective. longer follow up is needed to assess the durability of this repair. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. nowadays, some surgeons haddifficulties with the laparoscopic approach to treatment of recurrent hiatal hernias.patient was a -year-old man. he requested medical assistance with dysphagia, nausea after eatingand heartburn getting worse in a horizontal position. conservative treatment was not effective.transthoracic nissen fundoplication was performed in . the main complaints of the patientpersisted during the postoperative period. the upper half of stomach and s-like curved esophagus werelocated in the mediastinum according to multislice computed tomography of the thorax in august.in our clinical center was performed laparoscopic cruroraphy, cardiomyotomy and nissen fundoplicationin november. during the surgery the normal anatomical position of stomach has been restored, s-like curve of esophagus has been removed; a gastric cuff (collis-nissen) has been created and anteriorand posterior cruroraphy has been performed. the patient was in intensive care during h. anasogastric tube feeding was continued during the first h. passage of the contrast through theesophagogastric junction was free within h after surgery. patients had been discharged within days after surgery.this case report shows that at the current stage of surgery laparoscopic approach can be useful not onlyfor treatment of primary hiatal hernias-but also for treatment of recurrent ones. aims: laparoscopic heller myotomy procedure, completed with an anti-reflux procedure is technically demanding. we report a case of laparoscopic heller myotomy followed by a dor anterior fundoplication. methods: this is the case of a -year-old caucasian woman with gradual dysphagia for solids and liquids, accompanied by severe regurgitation and chest pain. an initial diagnosis of achalasia was made in , with the use of manometry and barium swallow. endoscopic dilatations were attempted pre-operatively with no clinical improvement. decision was made to perform a laparoscopic heller myotomy, combined with a standard dor anterior fundoplication. a -ports operation took place (one intra-umbilical mm trocar-single incision laparoscopic surgery (sils) technique, two -mm subcostal trocars, and one another mm subcostal trocar for the use of liver retractor). the operation lasted h and min. results: no post-operative complications were noted. the post-operative swallow test showed improvement of the esophageal patency. the patient started a liquid diet three days later and was discharged six days post-operatively. two months later the patient presented no complications. conclusions: heller's myotomy has demonstrated good long-term results in the treatment of esophageal achalasia and the laparoscopic approach has been well established in the last two decades. it is a very demanding operation to perform and the disease is relatively rare, making the learning curve difficult to achieve. aims: achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus. the association of a long-term achalasia and a large size hiatus hernia is an infrequent entity. among the therapeutic options is medical treatment, endoscopic treatment and surgical treatment associated with an antireflux procedure. the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences. the aim of the video is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure. methods: -year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. the complementary explorations and iconography of interest are exposed. results: intervention: complete endoscopic approach, trocars. reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. extended mediastinal esophageal dissection. complete resection of both the sac and lipoma, respecting the posterior vagus. heller's myotomy of cm, including cm distal to the ueg, perforation of mm of the mucosa at the ueg level, suture and blue methylene verification of the sealing. hiatorraphy and dor-type anterior fundoplication as antireflux technique. correct postoperative, with egd control on the rd po day and discharge on the th. asymptomatic at months after surgery. conclusion(s): for achalasia laparoscopic heller myotomy with a partial fundoplication should be the treatment of choice in patients who are at low surgical risk. the length of the myotomy, especially distal to ueg is one of the most important aspects of the surgery, to achieve an effective disruption of the les. the presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, such as perforation. standardization is essential to increase safety and efficacy in these complex cases. purpose: there is evidence that the application of mesh-reinforced hiatal repair has resulted in a significant reduction in recurrence rates in comparison with primary suture repair, at least in short-term follow-up. however, and instead of this, the standard of care for repairing large paraesophageal hiatal hernias (lphh) remains controversial because no clear guidelines are given regarding indications, mesh type, shape and position. the aim of this study is to evaluate our short-term outcomes in management of lphh with a biosynthetic monofilament polypropylene mesh surrounded by a high-purity and adherent titanium dioxide surface coating to enhance the biocompatibility (tio mesh tm ). methods: a retrospective study was conducted on our institution between december and october . data were collected on patients with lphh greater than cm in which a laparoscopic repair was carried on by primary suture and additional reinforcement with a tio mesh tm . clinical and radiological recurrences, dysphagia and mesh-related complications were investigated. results: there were females and males with a mean age of years (range, - years). all operations were completed laparoscopically. median postoperative stay was days. after a mean follow-up of months, patients developed clinical recurrence of reflux symptoms ( . %) and radiological recurrences ( . %). there were no mesh-related complications. conclusions: the use of tio mesh tm for laparoscopic repair of lphh is suited and with a reasonably low recurrence rate in this short-term study. additional long-term studies with enormous numbers carried out for years will be necessary to affirm whether this mesh is convenient in the prevention of recurrences and mesh related complications. background: surgery for refractory gastroesophageal reflux disease (gerd) has a satisfactory outcome, however sometimes fundoplication fails and redo surgery is required. several publications have investigated the feasibility of performing reoperative fundoplications using laparoscopic techniques. the aim of this study was to describe our experience in laparoscopic redo fundoplications in the last years. material and methods: we retrospectively reviewed consecutive patients who required laparoscopic redo fundoplication from january to august .the indications were recurrent symptoms of gastroesophageal reflux disease (gerd) ( . %), recurrent symptomatic paraesophageal hernia ( . %), dysphagia ( . %) and acute volvulus ( . %). results: all redo fundoplications (basically toupet . % and nissen . %) were completed laparoscopically. the mean operative time was min (range, - . min). a mesh was placed in % of cases. intraoperative and postoperative complication rates were . % and . % respectively. the mean hospital stay was days (range, - days). one patient ( . %) from the laparoscopic group required a third operation-one for acute recurrent paraesophageal herniation of the redo wrap one month after surgery, which was repair laparoscopically again. symptomatic outcome was successful in . % without any kind of proton bomb inhibitors therapy. conclusion: laparoscopic redo fundoplication is technically feasible and clinically effective with a reasonable low rate of postoperative complications p -upper gi-reflux-achalasia objectives: in recent years, balloon dilatation (bd) for diseases requiring correction of the impaired patency of the sphincter zones of the esophagogastroduodenal region has become widespread. purpose: to assess the effectiveness of the use of the balloon dilatation in patients with impaired sphincter zones of the esophagogastroduodenal region. materials and methods: in the institute department of surgery for the period from to , bd was performed in patients. of them diagnosed with achalasia of cardia (ac): - stage, - stage, - stage, - stage. patients diagnosed with pylorospasm, patients had compensated stenosis and patients had subcompensated ulcerative pyloroduodenal stenosis. there were males, females, average age ( . ± . ). bd was performed under endoscopic and / or x-ray control by 'boston scientific' balloons with a diameter of - mm, mm and mm, a course of - sessions with an interval of - days and a cylinder exposure of - min. evaluation of bd was performed using esophagogastroscopy, balloon manometry and x-ray passage of barium. results: in the course of the study, the existing indications were refined and new indications were developed for performing an endoscopic bd in pyloroduodenal stenosis and in ac. in patients with stage - ac, a positive result was noted in . % of cases already after the first session of bd. recurrences of ac after bd for up to years were established in ( . %) patients: at stage -in . %, at stage -in . %, at stage -in . % and at stage -in . %. repeated bd courses in case of ac recurrence in ( . %) cases turned out to be ineffective. recurrence of pyloroduodenal subcompensated stenosis was diagnosed in . % of cases in the period of months after performing bd. conclusions: bd is an effective method for correcting the permeability of the sphincter zones caused by the pathology of the esophagogastroduodenal region. keywords: balloon dilatation, achalasia of cardia, pylorospasm, ulcerative pyloroduodenal stenosis, recurrences. introduction: the reoperation in antireflux surgery significantly increases morbidity and mortality up to - %, reaching rates of % in patients undergoing or more surgeries. the advantages of laparoscopic surgery used in this surgical technique have amplified its acceptance and use, resembling its results in terms of feasibility, safety and efficacy of laparoscopic surgery to open surgery.objective: :evaluate the currently literature about antireflux surgery reintervention, focusing on the main indications of re-intervention, type of approach and morbidity and mortality of laparoscopic antireflux surgery. material and methods: a literature search was conducted in two electronic databases, med-line and embase. the search was limited to the period to . terms were used in relation to the procedure or intervention and the underlying disease. we chose observational studies (cohort, cases and controls and series of cases), where the main indication for antireflux surgery would have been gastroesophageal reflux disease. results: a total of studies were selected, most of them were case series ( . %), cohort studies ( %) and case-control studies ( . %). a total of patients. the main indications were anatomical faults, of these failures, recurrent hiatus hernia and sliding occupy the highest percentage, while physiological failures, failure in esophageal and gastric motility occur more frequently. the main type of approach was laparoscopic in %, the conversion rate was . % and the open approach was reserved for complex cases with more than one re-intervention . %, for abdomen . % and chest . %, this last for cases with high esophageal lesions that can not be repaired via trans-abdominal.the main complications were injuries to hollow viscera, such as: esophagus and stomach among others. these complications are related to the complexity of the procedure. mortality has remained low up to . %, however, the cause of death was due to medical complications and not related to the procedure. conclusions: this systematic review on reoperation in reflux surgery has confirmed that morbidity after reoperation surgery is higher than after primary surgery and reoperation indications increase with the use of new technologies (manometry) and the laparoscopic approach continues on the rise, with great adaptation to its use and improvement in results. aims: eras protocol is not commonly used in acute emergency procedures. elective lc is commonly performed as one day surgery, while in an emergency setting of acute cholecystitis, the in hospital stay averages , days. the aim of this trial is the application of eras protocol in patients with acute cholecystitis, undergoing laparoscopic cholecystectomy. methods: a randomized prospective trial was conducted in first surgical department of sismanogleion g.h.a. the study included patients, who were admitted with acute cholecystitis and underwent lc into h from their admission. preoperatively, they all received crystalloid isotonic solutions and antibiotics. . % were submitted to ercp, preoperatively, due to choledocholithiasis. the postoperative care included early mobilization into h after surgery, early fluid intake (into h) and early liquid food intake (into h). they all received systematically antibiotics, analgesics and antiemetic on demand. asa score was not an exclusion criterion. results: conversion to open procedure was necessary in . % of patients, whom were excluded from the study. all the rest were discharged into h from the surgery with the guidance to receive oral antibiotics for more days. readmission was necessary for patients, one week after the operation. the first one presented with bile leak and submitted to ercp with stent placement and percutaneous drainage of the intrabdominal collection. the second one presented with choledocholithiasis and underwent ercp with balloon catheterization. conclusion: it is commonly accepted that eras protocol in elective procedure enhances the postoperative recovery while reduces the in hospital stay and cost. in emergency condition eras cannot be applicated preoperatively. however, a modified post surgery application seems to have advantages equal to those observed in elective procedures. aim: laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic cholelithiasis. administration of one single dose of chemoprophylaxis before an elective laparoscopic cholecystectomy is a broadly accepted practice. however, its value is currently questioned, especially in low risk patients. method: this study was conducted in a high volume surgical department. one hundred and twelve patients submitted to elective laparoscopic cholecystectomy were included in this research. a written consent was acquired after thorough patient briefing. half the patients that underwent surgical operation received one dose of antibiotics min prior to the incision and the other half did not receive any chemoprophylaxis. results: the age ranges from to years old. commonest concomitant diseases were arterial hypertension, type ll diabetes, hypothyroidism and respiratory deficiency. approximately % of patients were smokers and % were obese (bmi [ ). the duration of the operations was between and min. intra-operative gallbladder rupture was observed in patients (rate %). all the patients were discharged the first post-operative day and their monitoring continued for more days. in the chemoprophylaxis group, no surgical site infection or other major complication was observed. from the group that did not receive any antibiotics, one patient developed surgical site infection and specifically infection of the surgical port in the epigastrium, which was treated with drainage of the abscess and oral antibiotics administration. no other complications were recorded. conclusion: our study concluded no statistically significant difference between the two patient groups, which depicts that chemoprophylaxis may not be necessary in elective cholecystectomy operations. on the contrary, antibiotics increase the cost of hospital stay and are often accompanied by multiple mild or severe side effects. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -lmf h oc authors: light, r. bruce title: plagues in the icu: a brief history of community-acquired epidemic and endemic transmissible infections leading to intensive care admission date: - - journal: critical care clinics doi: . /j.ccc. . . sha: doc_id: cord_uid: lmf h oc the ability to diagnose and treat infectious diseases and handle infectious disease outbreaks continues to improve. for the most part, the major plagues of antiquity remain historical footnotes, yet, despite many advances, there is clear evidence that major pandemic illness is always just one outbreak away. in addition to the hiv pandemic, the smaller epidemic outbreaks of legionnaire's disease, hantavirus pulmonary syndrome, and severe acute respiratory syndrome, among many others, points out the potential risk associated with a lack of preplanning and preparedness. although pandemic influenza is at the top of the list when discussing possible future major infectious disease outbreaks, the truth is that the identity of the next major pandemic pathogen cannot be predicted with any accuracy. we can only hope that general preparedness and the lessons learned from previous outbreaks suffice. intensive care, the epitome of the application of modern technology to medicine, arguably began as a response to the increasing numbers of older children and young adults developing paralytic polio during the early s. severe paralytic polio itself turns out to have been among the products of increasing modernity in the western world. clinical recognition of the syndromes associated with the polio virus date back about years. the fact that the disease was caused by a transmissible viral particle was demonstrated by . until early in the twentieth century the virus was readily transmitted throughout the population almost continuously by personal contact and by the fecal-oral route via water. the result was that most people's first exposure to the virus occurred in infancy. at this age most infections resulted in a clinically unapparent infection, in part due to partial protection by maternal antibody, after which lifelong immunity was established. only a few suffered a paralytic episode with the infection, at the time termed ''infantile paralysis.'' as hygienic standards of the advanced economy nations rose throughout the first half of the century, early childhood exposure to the virus declined. an increasing fraction of the population had their first exposure in late childhood or during young adulthood. in these age groups the likelihood that the infection will cause a paralytic syndrome is greatly increased, so both the incidence of clinically recognized infection and that of paralysis rose. by the early s clinically recognized cases had reached - annually for every , people in the united states, making it a major public health concern and a source of a great deal of fear in the general populace. more than % of polio virus infections are asymptomatic. however, at the more severe end of the clinical spectrum are the paralytic syndromes which range from paralysis of one or more limbs (''spinal polio'') to syndromes with respiratory muscle or bulbar paralysis (''respiratory polio'' or ''bulbospinal polio'') with loss of respiratory or upper airway muscle function or both. these more severe outcomes rise in incidence from about . % in infants to more than % in older children and adults. in the early part of the century development of polio with bulbar involvement was associated with a death rate of greater than %, generally from respiratory failure. use of a mechanical respirator to try to avert death was first attempted at the children's hospital in boston in , using an ''iron lung.'' the machine was basically a sealed box with a hole at one end for the patient's head to protrude, attached to two vacuum cleaners. the motors were then cycled to alternately create vacuum inside the box, expanding the patient's chest and causing the patient to inhale through the mouth (outside the box), then allowing air back into the box to permit exhalation. the design was further improved in , and the machines came into increasingly broad use throughout north america and europe during the severe outbreaks of the s. adoption of this therapy resulted in a significant reduction in mortality during these years. iron lungs, however, were cumbersome, difficult to use when trying to provide nursing care, and expensive. a more cost-effective and user-friendly approach to providing respiratory support was clearly needed. this finally came by bringing the positive pressure ventilation (ppv) concept out of the operating room. ppv was first used for respiratory support for polio victims at blegdam hospital in copenhagen, denmark, an innovation attributable to danish anesthetist bjorn ibsen. during this large outbreak in , some medical students were put to work hand-ventilating dozens of patients through tracheostomies until the worst of the paralytic phase of the illness had passed, often several weeks. the concept quickly spread elsewhere and was widely adopted, yielding substantial reductions in mortality. for reasons of efficiency and convenience, patients needing respiratory support were often grouped in a single location where the necessary expertise and equipment were available. the introduction of ppv into a defined area of the hospital used to support respiratory failure was the genesis of the modern icu and represents a signal event in the development of the field of critical care medicine. the introduction of effective vaccines, the salk (inactivated) vaccine in and later the sabin (live attenuated oral) vaccine in , immediately and dramatically reduced the incidence of polio to less than one per , population by the early s and the incidence continued to fall thereafter. the last case of wild strain polio in north america was reported in , and since that time the only cases of paralytic polio have been rare instances of disease due to variants of the live oral vaccine strain. polio does, however, still contribute to illnesses that may require intensive care in the form of the ''post-polio syndrome.'' this occurs in patients who survived paralytic polio decades ago and who, over the years, develop a gradual decline in function in the originally affected nerves and muscles which can years later once again threaten them with disability and, in some cases, respiratory failure requiring intensive care. in july , american legion members attending a convention at a hotel in philadelphia suddenly began falling ill with an acute febrile illness with pneumonia, often associated with extrapulmonary symptoms such as myalgia or diarrhea. many developed acute respiratory failure requiring mechanical ventilatory support in icu. over were affected and died, an alarming mortality rate, especially since physicians caring for the patients had no idea what was causing the illness. conventional microbiologic investigations yielded no convincing pathogens despite intensive investigation for the usual bacteria and viruses and other potential pathogens. epidemiologic and various biologic investigations were quickly implemented by local health authorities and by the centers for disease control and prevention (cdc). these showed that the disease was likely airborne and that it occurred more frequently in older individuals who had underlying lung disease, smoked, or were relatively immunocompromised. analysis of the likelihood of death revealed that those who received tetracyclines or macrolide antibiotics were more likely to survive than those who received only betalactams. however, no causal agent was uncovered, though many potential causes were excluded-most known bacteria and viruses, many biologic toxins and many environmental agents such as toxic chemicals and metals. in , joseph mcdade and charles shepard of the cdc reported the isolation of a novel fastidious gram-negative bacillus from the available clinical specimens. they named it legionella pneumophila. this discovery was quickly followed by an explosion of knowledge about the organism and its ecology, antimicrobial susceptibility, and of other bacteria within the genus. over time, demonstration that it was a widely occurring colonizer of brackish water, particularly in air conditioners, cooling towers, and water heaters and pipes, led to the implication of these reservoirs in several hundred outbreaks of the disease worldwide, especially in hospitals and other public health institutions, and hotels. thus began widespread development of regulations and guidelines for limiting the degree of colonization of these water sources by legionella, resulting in a reduction in the size, number, and scope of subsequent outbreaks. since the initial description of the disease, legionella has, of course, been shown to be one of the major causes of community-acquired pneumonia (cap), particularly in the more severe subset requiring icu care; this fact underlies the major lesson from plagues in the icu the outbreak-the nearly universal recommendation for inclusion of antimicrobial therapy for legionell spp in any treatment regimen for severe cap without another obvious cause. although we now know that no amount of continuing effort can completely eliminate this organism from our environment, and that we will continue to see endemic cases, we also know that clusters of cases should trigger an investigation into finding the point source of the outbreak, a situation that continues to occur several times a year somewhere in the world. in addition, the philadelphia outbreak that defined ''legionnaire's disease'' was the first in the modern icu era to demonstrate that major unknown infectious disease syndromes of severe consequence still exist, presaging the new infectious disease syndromes to be discovered in the years that followed. in the late s, emergency rooms and icus throughout north america began to see an increasing number of young menstruating women presenting with a previously little-known syndrome characterized by sudden onset of a high fever, often associated with vomiting and diarrhea, quickly followed by severe hypotension. early in the course most patients developed a diffuse macular rash, often with mucous membrane inflammation, with subsequent desquamation during convalescence. patients frequently required massive fluid resuscitation because of systemic capillary leak, as well as vasopressor support, mechanical ventilation for adult respiratory distress syndrome, and even renal replacement therapy for acute renal failure, complicating the shock episode. one of the early clusters of observed cases was reported in , and the term ''toxic shock syndrome'' was coined based on the isolation of an exotoxin-producing staphylococcus aureus from mucosal surfaces or the site of a minor infection in the absence of bacteremia. as the case numbers rapidly increased case definitions for the syndrome were formulated and epidemiologic studies mounted. by , over cases had been formally reported to the cdc. the case fatality rate was reported to be as high as % in the more severe cases included in the earliest reports, falling to about %- % as recognition of the syndrome improved. by this time there were clear epidemiologic links between the syndrome and menstrual use of high-absorbency tampons which were often left in place longer than less absorbent products. colonization of the tampon with staphylococcus aureus was also implicated, consistent with the postulated toxin-mediated disease mechanism. within months of these revelations the main manufacturer of the implicated tampons withdrew them from the market and women began changing tampons with greater frequency or stopped using them at the urging of public health authorities. the incidence of the syndrome immediately began to fall and within a few years, with the changing of use patterns of tampons and changes in their manufacture, toxic shock syndrome disappeared, for the most part, but not entirely, from the icu. even at the height of tss incidence in the united states, about % of the cases reported were nonmenstrual and % were in males. subsequent development of the knowledge that the clinical syndrome was due to strains of staphylococcus aureus that secrete a particular toxin (toxic shock syndrome toxin , or tsst- ), which is both absorbable from mucosal surfaces and capable of producing a profound shock syndrome even in the absence of significant invasive infection, soon led to the more widespread recognition of the nonmenstrual toxic shock syndrome. this syndrome, which was almost certainly extant before but little-recognized, was perhaps the main lesson from the outbreak: even trivial staphylococcal skin or wound infections light or mucosal surface colonization in the presence of a foreign body such as a nasal pack for nosebleed can lead to a severe shock syndrome if the organism is present and produces this toxin or one of several related ones. the recognition of the staphylococcal toxic shock syndrome also led to increasing understanding of the role of ''superantigens'' as a mechanism of disease-bacterial toxins capable of activating a large fraction (up to %) of the total t-lymphocyte population. such superantigens have since been implicated in a number of other disease syndromes, among them the streptococcal toxic shock syndrome (see below). over the past two decades, the incidence of menstrual and nonmenstrual staphylococcal tss has been about one per , population in most areas. busy icus will, therefore, continue to see occasional cases. however, there is some recent evidence that case numbers may be on the rise again in at least some areas, possibly because of a resurgence in the prevalence of toxin-producing strains in the community. in , physicians working in infectious diseases and critical care medicine thought they knew all about pneumocystosis. the organism, then thought to be a protozoon, had been first described in by carlos chagas in brazil, and since then had been clearly implicated as a cause of interstitial pneumonia in debilitated and malnourished children (in the aftermath of world war ii) and, later, a cause of severe opportunistic pneumonia in immunocompromised patients, usually those being treated with highdose corticosteroids for connective tissue diseases or lymphoreticular neoplasms. in these patients it caused an impressively aggressive bilateral pneumonia leading to acute respiratory failure. this pneumonia was notoriously difficult to definitively diagnose, requiring bronchoscopy or open lung biopsy to demonstrate the small numbers of characteristic pneumocystis organisms on special silver stains of clinical specimens. the mainstay of treatment at that time was pentamidine, generally given intramuscularly, giving way to trimethoprim/sulfamethoxazole after the publication in of a randomized clinical trial showing that it was at least as effective and generally better tolerated. in the early s, a new form of the infection began to be seen with regularity. young men began to present to hospital with a rather more indolent diffuse bilateral pneumonia that nevertheless went on to cause respiratory failure and which, when investigated, proved to be due to pneumocystis. the course of the disease was quite different from what physicians had been used to up to then. it began more gradually, progressed at a slower pace and was associated with a much lesser systemic inflammatory response. microscopy of respiratory specimens revealed exponentially more organisms than previously seen, such that many patients could be diagnosed from sputum specimens rather than bronchoscopy, and biopsy was virtually never needed. nobody had any idea why this was happening, although it quickly became apparent that the underlying cause of the infection was a new form of severe deficiency of cell-mediated immunity. epidemiologic investigations were soon underway. patterns began to emerge. many of the young men were haitian or had been to haiti. many were homosexual, bisexual, or had worked in the sex trade; others had abused intravenous drugs. the many fewer women with the disease had similar exposures. theories proliferated. was it immunologic exhaustion from exposure to too many microbial stresses? toxins? drugs used in the sex trade? multiple and synergistic viral infections? through the early s, the case load grew. icus throughout north america and, later, in europe and elsewhere, saw increasing numbers of young people, mainly men, plagues in the icu with severe respiratory failure due to pneumocystis pneumonia. by they were being called patients with acquired immunodeficiency syndrome (aids) on the basis of demonstration of low numbers of cd lymphocytes in the blood, but the cause remained unclear. then, in , montagnier and barre-sinoussi at the pasteur institute in france isolated a viral pathogen that they named lymphadenopathy-associated virus (lav). at the national institutes of health in the united states, gallo demonstrated that the virus (which he referred to as human t-cell leukemia virus iii, based on an unproven relationship to other viruses he had previously discovered) definitively caused aids. the virus, now called human immunodeficiency virus (hiv)- was isolated and described and the first diagnostic kits devised, resolving the mystery of causation. montagnier and barre-sinoussi would eventually win the nobel prize in medicine in for their contribution. during the s, patients continued to present with severe pneumonia requiring respiratory support and intensive antimicrobial therapy, often with less than satisfactory results. as knowledge progressed, hiv-associated pneumocystis infection in the icu changed its face several times over the years. at the beginning of the epidemic, most patients presenting for care with hiv/aids and pneumocystosis were severely ill with diffuse pneumonia and hypoxemic respiratory failure and many died, %- % in most centers, prompting widespread debate about whether such patients should even be admitted to icu for mechanical ventilatory support. however, as experience with the disease developed it became clear that an early and aggressive approach could improve prognosis. it was found that in the aids population even minor respiratory symptoms with few or no abnormalities on chest radiograph could be due to pneumocystis infection in the earlier stages, and that even modest degrees of arterial oxygen desaturation signaled impending respiratory failure. earlier bronchoscopy for diagnosis followed by prompt antimicrobial therapy, with pentamidine predominantly in the early s and later primarily with trimethoprim/sulfamethoxazole, led to overall mortality rates falling to the %- % range by the middle of the decade. the advent of systemic corticosteroids therapy for early respiratory failure in aidsassociated pneumocystosis was then shown to further reduce the numbers of patients progressing to advanced respiratory failure, leading to reductions in the numbers of cases needing icu admission and further reducing overall mortality rates to the %- % range. but for patients requiring icu care mortality rates were as high as before the use of steroids and often higher, likely related to the fact that most patients developing respiratory failure had already failed to improve or had progressed despite intensive antimicrobial and corticosteroid therapy. along with these developments in management of the disease, progress was being made on hiv itself. following identification of the virus in , there soon followed increasingly reliable diagnostic tests for the infection, leading to earlier identification of cases and monitoring of cd lymphocyte counts. by the early s, studies supporting widespread use of chemoprophylaxis against pneumocystis in all patients with cd counts < /mm were available and became standard public health agency recommendations. pneumocystosis, which in the s and s was one of the principal causes of hypoxemic respiratory failure in many icus in north america and western europe, began to decline rapidly in incidence, becoming relatively uncommon even before the widespread adoption of highly active antiretroviral therapy, which has, since the mid- s, caused the disease to all but disappear from our icus. although many lessons can be drawn from the battle against aids-related pneumoncystis pneumonia during the s and s, for icu and infectious diseases practitioners one of the main ones comes from the sad fact that once patients had developed full-blown hypoxemic respiratory failure even the best intensive care could only deliver % survival rates. the really large gains in survival came not from better icu technology but from pre-empting the disease on multiple fronts, including earlier diagnosis of hiv infection, early diagnosis and antimicrobial treatment of pneumonia, steroid treatment of early respiratory failure, antimicrobial prophylactic regimens and, later, effective antiretroviral therapy. until , the only members of the bunyaviridae family of viruses known to cause disease in north america were members of the genus bunyavirus, all causing mosquito-borne viral encephalitis, mainly in children (california encephalitis). other members of the family were known to cause serious febrile illnesses, encephalitides and hemorrhagic-fevers in africa and asia (rift valley fever, crimean-congo hemorrhagic fever, hemorrhagic fever with renal syndrome). however, in the spring of wetter-than-usual conditions in the american southwest led to increased availability of food for deer mice, leading to a population explosion and increasing movement of rodents into human-occupied spaces, increasing the chance that humans might be exposed to the rodents and their excreta. in rapid succession, several previously healthy young people, mainly navajos, presented to health care institutions in the four corners area of the southwestern united states, all with fulminant illnesses leading to shock and acute respiratory failure requiring icu care. by early june that year, cases had been identified and had died. in most cases the illness had started with fever and widespread myalgia, soon followed by cough, then by cardiovascular collapse due to a severe systemic capillary leak syndrome and by acute respiratory failure due to low-pressure pulmonary edema. in some cases the time from onset to icu or death was as little as hours, in others a few days. remarkably, although no pathogen was initially identified from blood or tissues, in less than a month after the first report of a possible outbreak, serologic testing had demonstrated antibody cross-reactivity with a range of known pathogens of the hantavirus group, suggesting that the disease was due to a previously unknown member of this group. shortly thereafter exposure to deer mice and their excreta was implicated as the likely source of the infection. the mortality rate for the early cases of hantavirus pulmonary syndrome (hps) was extremely high- % in the initially reported group of patients-mostly due to intractable shock and unsupportable hypoxemic respiratory failure due to acute respiratory distress syndrome (ards). however, this improved with clinical experience as it became evident that administration of large amounts of intravenous fluids in the face of profound capillary leak only resulted in much worse generalized and pulmonary edema, with little improvement in the shock state and only worsening of the respiratory failure. management changed to an approach limiting the amount of fluid administered early in the course together with earlier institution of inotropic support, resulting in a much improved survival rate of about %, generally with minimal or no long-term sequelae in survivors. in subsequent years development of increasingly specific serologic and virologic testing has demonstrated that this disease had been present but unrecognized throughout north and south america long before this outbreak, and that there are several related viruses, each associated with a particular rodent, causing endemic disease and the occasional outbreak. by the mid- s, over cases were reported in states, mainly in the southwest, and cases have since been reported plagues in the icu in small numbers in most other states, canada, mexico, and south america, where several outbreaks have occurred. whereas occasional cases continue to be seen in icus in all these areas, no further major outbreaks have yet occurred in the united states or canada, though clearly remaining a threat under the right conditions; the only currently available preventive measure is avoiding rodent contact. steven simpson, md, one of the intensivists at the health sciences center in albuquerque, new mexico, who was closely involved in the initial four corners outbreak, points out that the event highlights several trends in subsequent disease outbreaks in north america. one is the extreme rapidity with which novel pathogens and potential pharmacotherapeutic agents can now be identified. whereas the pathogen in the legionnaire's outbreak took almost a year to identify, researchers identified the hps pathogen and its source in just months. computerized access to data and data analysis along with virtually instantaneous electronic transmission of information plays a central role in this development. the initial hps outbreak has several icu-related lessons to teach us. while the aforementioned treatment strategies effective in a systemic capillary leak syndrome have been absorbed by the critical care community, it appears that one lesson taken to heart by the local icu teams failed to disseminate to the broader icu community. the initial outbreak was accompanied by a marked element of fear and concern among health care workers, including those in the icu, and a significant level of panic in the local community; a combination of this fear, the requirement for rigorous quarantine precautions, and a marked increase in transfers to the icu of any severely ill patients with symptoms remotely compatible with hps resulted in some compromise of icu operations, due to being completely overwhelmed. this might potentially have been avoided by an awareness that for an effective epidemic response, it is essential to include both hospital and icu operations in each locale. the outbreak also reinforces the principle that nearly all old and most new epidemic infectious diseases have their origin in close contact between humans and other species of animal, both wild and domestic, and new kinds and quantities of such contact are likely to cause new, or newly recognized, disease syndromes. streptococcus pyogenes was one of the first bacteria ever to be conclusively linked to human disease (puerperal infection associated with childbirth). however, over the past years the nature of the diseases stemming from it has changed dramatically on several occasions. at the turn of the last century, it was well known as a cause of streptococcal pharyngitis, erysipelas, and wound infections. it also caused severe septicemic illnesses that frequently led to death. osler knew streptococcus pyogenes as a principal cause of thoracic empyema following pneumonia or severe cases of scarlet fever, and also as a major cause of primary bacteremia with sepsis. these more severe manifestations of streptococcal infection became increasingly uncommon as the twentieth century progressed, particularly after the arrival of antibiotics mid-century. notably, osler did not mention streptococcus as a cause of necrotizing fasciitis or being associated with soft tissue necrosis in wound infections. this syndrome was first described by meleney in ; at that time, it was characteristically a slowly evolving gangrenous infection, usually of surgical wounds, which often responded well to debridement and was associated with a mortality rate of only %. for over a generation after the advent of the modern antibiotic era, streptococcus pyogenes was seldom a problem that led to critical illness-soft tissue infections and light the occasional bacteremia were generally very amenable to treatment; extensive surgery or drainage was seldom required, and cases requiring icu support for shock or respiratory failure were rare. beginning in the mid- s, medical practitioners in centers across north america and europe began seeing previously unknown forms of severe streptococcal disease, soon labeled streptococcal necrotizing fasciitis and streptococcal toxic shock syndrome. streptococcal toxic shock syndrome (strep tss) is any infection with streptococcus pyogenes that is associated with a rapidly progressing systemic toxic response characterized by early onset of high fever and myalgia, often with prominent gastrointestinal symptoms, and by rapid progression to hypotension and multiple organ system failure. the illness usually requires icu support for massive fluid resuscitation, vasopressor and inotropic support and mechanical ventilation. although some cases have primary bacteremia, many others have a localized focus of infection, most often in soft tissues, that only becomes clinically apparent after the onset of shock. streptococcal necrotizing fasciitis is often associated with strep tss and, as mentioned, is often only correctly diagnosed after the onset of shock. the most characteristic story is presentation to a physician or an emergency room with abrupt onset of severe pain, often in an extremity with minimal or no evidence of cutaneous injury. at this stage severe systemic toxicity is usually not present and, since examination of the painful site is also at this stage quite unremarkable, patients are frequently sent home with analgesics and reassurance. over the next - hours pain at the site of infection continues to increase, soft tissue swelling and redness appear above the deeper tissues that are undergoing ongoing necrotizing infection, eventually resulting in full-thickness necrosis evidenced by ecchymosis, cutaneous necrosis, and bullae formation. early or later in this course strep tss frequently occurs. when these cases first began to appear, clinicians' approach to both the sepsis and the tissue necrosis was essentially the same as that used for apparently similar syndromes caused by other bacteria. a broad spectrum antimicrobial was started, fluid resuscitation begun and imaging studies ordered to better define the source of infection causing pain or localized swelling. imaging frequently demonstrated only soft tissue swelling consistent with cellulitis, so surgery was often deferred until superficial signs of tissue necrosis became obvious, and then when surgery was done it was often performed using the conventional approach of trying to conserve as much tissue as possible. the result was that treatment was often too little and too late, with mortality rates exceeding % in many reported series. with the realization that treatment, to be successful, must be swift and aggressive, approaches to therapy changed. emergency physicians were increasingly alerted to the fact that severe pain at any body site, even with relatively minimal localized physical findings and particularly if accompanied by signs of systemic inflammation, could represent necrotizing fasciitis. surgeons began to be consulted much earlier, and any localized pain with swelling more often led to diagnostic surgical exploration rather than imaging and waiting. antimicrobial strategies changed. addition of clindamycin to the usual penicillin or other beta-lactam therapy was advocated and widely adopted, based on results from animal models of the syndrome and on pharmacologic and physiologic considerations, including its ability to inhibit bacterial protein (ie, toxin) synthesis, penetrate necrotic tissues, and inhibit inflammatory cytokine synthesis. toxin neutralization using pooled intravenous gamma globulin was also advocated with the support of primarily historical case-control studies. in most centers, implementation of these approaches has led to dramatic reductions in mortality rates to about %- % although, in the absence of any adequate controlled trials, it remains unclear what the relative contribution of each of these measures has been to the improved outcome. unlike several of the other ''plagues'' discussed above, this is one that is still very much with us. the streptococcus pyogenes strains most strongly associated with severe invasive disease (m-protein types and ) have increasingly been supplanting those associated with less severe disease resulting in an endemic sporadic case-rate for severe disease of one to cases/ , population yearly, with intermittent larger-scale community outbreaks, both of which will continue to require vigilance and an aggressive therapeutic stance from the critical care community. the first case of this apparently novel severe viral respiratory infection occurred in guangdong province in southern china in november . the victim, a farmer, died of an undiagnosed ''atypical pneumonia.'' over the ensuing weeks several more cases of severe respiratory syndromes began to appear in the region, also undiagnosed. by the end of november there had been enough such cases to generate considerable alarm among the medical community in china, generating internet communications between institutions which were picked up by international monitoring agencies. this led to a request from the world health organization (who) for information about the outbreak, but no information was forthcoming from chinese authorities. the first official report about the outbreak was made to public health authorities in guangdong in early january , with a later report to the who in february that, in retrospect, did not fully make clear either the nature or the scale of the problem. transmission of the disease within china continued to occur, leading to rapidly increasing numbers of cases in south china, then throughout the country and to the capitol beijing (where one of the largest outbreaks occurred). exposure of chinese travelers and visitors to the country was inevitable, given the scale of the outbreak. one exposed individual was a physician from mainland china who, incubating the disease during his travel, stayed at the metropole hotel in hong kong in early march. later investigations showed that he transmitted the virus to at least other guests at the hotel, who then carried it by international air travel to taiwan, singapore, vietnam, and canada. one of these contact cases was an american businessman headed for singapore. becoming ill while in transit, he stopped in hanoi where he was admitted to hospital with a severe pneumonia, to which he eventually succumbed. soon after, a number of health care workers who had been in contact with him also became acutely ill. fortunately for the course of the outbreak, one of the consultants on the case was an italian physician working with the who in vietnam, dr. carlo urbani. he immediately recognized that this was a previously unknown severe atypical pneumonia that was relatively easily transmissible and reported it to the who; this led to immediate mobilization of investigative efforts and worldwide alerts about the threat. unfortunately, in the course of caring for the victims of the disease in hanoi, dr. urbani himself contracted the infection and died of it later. as information from china became more available, it became clear that by this time there had already been hundreds of cases and numerous deaths. the majority of the initial wave of cases were noted to have occurred primarily in farmers and food handlers, particularly those working in food markets where live wild animals were kept and sold for food. the second large wave of those affected were health care workers exposed in hospital to patients with the disease. the illness was characterized by fever and myalgia with gastrointestinal symptoms in the initial phase, occurring an average of days after exposure (range - days). many cases got no worse than this, but others went on to develop dyspnea associated with radiographic evidence of a diffuse, patchy pneumonitis which, in some, progressed to ards. an average of light % required mechanical ventilatory support, and when the data were all in from later phases of the outbreak, mortality rates averaged about % overall, worse in the aged and debilitated, lower in the young and healthy. the largest outbreak outside asia occurred in toronto, canada. the index case, a visitor to china, returned to canada and died of pneumonia at home, undiagnosed, in early march . shortly thereafter, one of his sons was admitted to hospital with a severe respiratory illness and died a few days later. by this time, four other family members had become ill and had been admitted to hospital; the first cases of affected health care workers appeared soon after among those who had cared for the dying son of the index case. within days, other instances of transmission from undiagnosed contacts of the initial cases in hospitals, doctors' offices, emergency rooms, and at social events were leading to admission of cases to several hospitals throughout toronto. the response of the public health authorities, beginning soon after the who global alert and coincident with the recognition of the first local cases, was quick and vigorous, including closure of the main affected hospital, intensive follow-up of probable contacts, quarantine of suspected cases based on a fairly inclusive case definition and strict institution of barrier contact protection for health care workers. by mid-april the number of new cases was rapidly declining, although there was one cluster of late cases related to exposure of a large number of health care workers during the resuscitation and difficult intubation of a critically ill patient. a later cluster of cases also occurred in a rehabilitation hospital, where it appeared that unrecognized contacts from the first phase of the outbreak had been transferred and transmitted the disease to other patients and staff. the worldwide outbreak was essentially over by july . there were a total of reported cases from countries, with deaths. intensive epidemiologic and laboratory study of the disease by investigators and laboratories worldwide led to unprecedented rapid growth in knowledge about the causative agent. the virus, more or less simultaneously characterized at a number of laboratories around the world, proved to be a previously unknown coronavirus (severe acute respiratory syndrome [sars]-cov) with capacity to infect and spread from a variety of wild animals to humans. epidemiologic, serologic, and virologic evidence was developed linking human cases to exposure to infected wild animals, including masked palm civets, raccoon dogs, ferrets and ferret badgers, all being sold for human consumption in markets in china. control of their transport and sale and exposures to humans by chinese health authorities was probably one of the major factors in bringing the first outbreak under control, the partial failure of which later led to a second, much smaller outbreak late in . although the initial speculation was that one or more of these wild animals were the reservoir in nature for the infection, it now appears more likely that the viral reservoir is actually bats, with crosstransmission of the virus between bats, food animals, and humans in crowded markets leading to development of strains with the capacity to transmit between humans. public health authorities worldwide learned much from sars about the importance of effective international communication in developing a rapid and effective response to outbreaks of novel viruses, and more about how to go about containing such infections within communities and hospitals. several intensivists involved in the outbreak credit e-mail communications from other international outbreak sites for effective advice on critical elements of disease protection (eg, powered air purifying respirators and full contact rather than droplet precautions) and therapy. for the critical care community, perhaps one main lesson was the importance of ''super-spreading incidents'' in propagating the disease in hospitals. many of these occurred in critically ill patients undergoing resuscitation with difficult or traumatic intubation, generating aerosols in closed spaces which contained many superfluous and inadequately protected health care workers. handling these situations safely depends crucially on identifying the potential risk and undertaking the resuscitation and intubation using the most experienced operators available, adequately protected with basic barrier precautions (eye protection, gloves and surgical face-masks), using sedation or paralysis as necessary to minimize trauma and aerosol generation, and with only essential and adequately protected staff in the room. this likely applies to many other situations with potential for disease transmission to health care workers. unfortunately, this epidemic again points out the primary lesson that was not absorbed from the earlier hps outbreak, namely, the need for detailed preplanning and preparation for a major infectious disease epidemic that is inclusive of hospital and icu operations in each locale. according to participants, the sars outbreak demonstrated many of the same early icu operational problems that plagued the hps outbreak albeit on a larger scale. in the icu era, there has yet to occur a true influenza pandemic with a high attack rate in all age groups and associated high hospitalization and mortality rates, as was seen in the great pandemic. in that worldwide disaster, it is estimated that % of all people became ill with the virus and an estimated - million died. minor recent pandemics in and had less than one twentieth of the impact of the influenza, not greatly different from the yearly interpandemic influenza the world has been experiencing in the years since. interpandemic influenza epidemics since have been caused primarily by h n and h n influenza viruses, to which most of the population has developed some degree of immunity from prior infection or vaccination. the result is what public health authorities have become used to seeing: each year a slightly different influenza a appears in asia with minor antigenic changes in the ha or na surface proteins (termed drift), making it infectious once again for humans whose immune systems have yet to be exposed to the new variant, and a new epidemic is launched. when the ''flu'' arrives in an area, cases begin to appear suddenly and there is rapid spread in the population, usually with %- % becoming infected over a -week period with a peak in case numbers at week two or three. about half of those infected will seek medical attention, many more than once, and one to about per thousand infected will be admitted to hospital with a respiratory syndrome such as pneumonia, chronic obstructive pulmonary disease exacerbation, asthmatic attack, or cardiac failure, the rate depending on age and underlying comorbidities. overall, about . % of those infected die, with mortality rates among those with major comorbidities up to %. these latter cases constitute most of the increase in the icu case load which most units experience every winter. the load is sometimes taxing but usually not overwhelming. a true pandemic is unlikely to play out this way. how different it would be depends on a number of factors: the antigenic difference in the new influenza virus compared with the old (ie, the antigenic ''shift'' to a different one of ha or na protein subtypes due to introduction of a variant from another influenza-susceptible species), how transmissible the new virus is, how virulent it is, how susceptible it is to antiviral drugs, and whether the world is prepared for it with drug availability and vaccines. the prototype severe pandemic was the spanish influenza of , an h n virus. the most recent circulating influenza virus just before that time was an h n that had arrived in . current evidence suggests that an avian influenza virus underwent a period of evolutionary adaptation, possibly in another susceptible species such as swine, fitting it for transmission to humans, which it then did. , this h n virus had not been previously experienced by any segment of the population except the very old, so nearly everyone, particularly non-elderly adults and children, was without immunity and was at risk of severe infection. attack rates, as noted earlier, were extremely high everywhere as were rates of primary influenza pneumonia, complicating bacterial pneumonia, and death. in the united states, death rates were more than -fold higher than in any influenza pandemic since. an outbreak of influenza on this scale, if unchecked by effective antiviral therapy or vaccines, would render icu care such as mechanical ventilatory support for respiratory failure irrelevant. even today, with maximal respiratory support, most patients with diffuse primary viral pneumonia complicated by respiratory failure cannot be saved, and the numbers presenting for such care in a short space of time, if comparable to the pandemic, would overwhelm our current icu capacity within days. currently the main apparent threat of a new pandemic comes in the form of the h n influenza virus. this virus is now present nearly worldwide in migratory and, intermittently, domestic bird populations. from time to time, transmission of the virus from birds to humans occurs, generally from close contact situations. who data indicate that there have been laboratory-confirmed cases of such transmission from to mid- . the mortality rate has exceeded %, although it is likely that many less severe cases do not come to medical attention and are therefore not counted as confirmed case survivors. to date no instances of transmission to humans by humans or other mammals has been documented. however, the threat remains that if this virus were to become capable of human-to-human transmission by adaptation in another susceptible mammalian host such as swine, a pandemic on the order of the event could occur. with no true pandemic for over years, including all of the icu era, health authorities worldwide are deeply engaged in trying to learn the lesson of this new ''plague'' before it actually occurs. it is clear that we will need excellent international communication, rapidly enactable containment and quarantine plans and, if possible, effective antivirals and vaccines to deal with the h n virus. if it evolves as feared and becomes easily transmissible while retaining its current virulence; modern life-sustaining technology alone will be no shield at all. the last years have seen remarkable advances in the ability to diagnose and treat infectious diseases and handle infectious disease outbreaks. for the most part, the major plagues of antiquity remain historical footnotes. however, despite these advances, there is clear evidence that major pandemic illness is always just one outbreak away. in addition to the hiv pandemic, the smaller epidemic outbreaks of legionnaire's disease, hantavirus pulmonary syndrome, and sars, among many others, points out the potential risk associated with a lack of preplanning and preparedness. although pandemic influenza is at the top of the list when discussing possible future major infectious disease outbreaks, the truth is that the identity of the next major pandemic pathogen cannot be predicted with any accuracy. we can only hope that general preparedness and the lessons learned from previous outbreaks suffice. a history of poliomyelitis polio: an american story an apparatus for the prolonged administration of artificial respiration the physiologic challenges of the copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology post-poliomyelitis syndrome legionnaire's disease: description of an epidemic of pneumonia legionnaire's disease: isolation of a bacterium and demonstration of its role in other respiratory diseases toxic-shock syndrome associated with phagegroup- staphylococci toxic-shock syndrome -united states toxic-shock syndrome in menstruating women: association with tampon use and staphylococcus aureus and clinical features in cases epidemiologic notes and reports, toxic-shock syndrome, united states reemergence of staphylococcal toxicshock syndrome in intensity of immunosuppression and the incidence of pneumocystis carinii pneumonia comparison of pentamadine isothionate and trimethoprim/sulfamethoxazole in the treatment of pneumocystis carinii pneumonia pneumocystis pneumonia -los angeles a controlled trial of early adjunctive treatment with corticosteroids for pcp in aids aids-related pneumonia in the era of adjunctive steroids outbreak of acute illness -southwestern united states hantavirus pulmonary syndrome: a clinical description of patients with a newly recognized disease cardiopulmonary manifestations of hantavirus pulmonary syndrome hantavirus pulmonary syndrome -united states: updated recommendations for risk reduction the principles and practice of medicine hemolytic streptococcus gangrene hemolytic streptococcal gangrene: the importance of early diagnosis and operation clinical and bacteriological observations of a toxic-shock-like syndrome due to streptococcus pyogenes streptococcal necrotizing fasciitis: comparison between histological and clinical features antibiotic effects on bacterial viability, toxin production and host response intravenous immunoglobulin therapy for streptococcal toxic-shock syndrome -a comparative observational study. the canadian streptococcal study group epidemiologic analysis of group a streptococcal serotypes associated with severe systemic infections, rheumatic fever, or uncomplicated pharyngitis who -epidemic and pandemic alert and response (epr) acute respiratory syndrome in hong kong special administrative region of china/vietnam public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto isolation and characterization of viruses related to the sars coronavirus from animals in southern china bats are natural reservoirs of sars-like coronaviruses critically ill patients with severe acute respiratory syndrome influenza: the mother of all pandemics molecular basis for the generation in pigs of influenza a viruses with pandemic potential who-epidemic and pandemic alert and response (epr) key: cord- -itiz mqv authors: christoffersen, s. title: the importance of microbiological testing for establishing cause of death in forensic autopsies date: - - journal: forensic science international doi: . /j.forsciint. . . sha: doc_id: cord_uid: itiz mqv abstract microorganisms have always been one of the great challenges of humankind, being responsible for both high morbidity and mortality throughout history. in a forensic setting microbiological information will always be difficult to interpret due to lack of antemortem information and changes in flora postmortem. with this study we aim to review the use of microbiological procedures at our forensic institute. in a retrospective study including autopsies performed at our institute, where microbiological test had been applied, analyses were made with regard to: type of microbiological tests performed, microorganisms found, histological findings, antemortem information, c-reactive protein measurement and cause of death. fiftyone different microorganisms were found distributed among cases, bacteria being the most abundant. nineteen of the cases were classified as having a microbiological related cause of death. c-reactive protein levels were raised in cases of the cases, histological findings either supported or were a decisive factor for the classification of microbiologically related cause of death in cases. as a multitude of abundant microorganisms are able to cause infection under the right circumstances, all findings should be compared to anamnestic antemortem information, before conclusions are drawn. a definite list of true pathogens is nearly impossible to compile. microorganisms have always been one of the great challenges of humankind, being responsible for both high morbidity and mortality throughout history. in a forensic setting microbiological information will always be difficult to interpret due to lack of antemortem information and changes in flora postmortem. with this study we aim to review the use of microbiological procedures at our forensic institute. in a retrospective study including autopsies performed at our institute, where microbiological test had been applied, analyses were made with regard to: type of microbiological tests performed, microorganisms found, histological findings, antemortem information, c-reactive protein measurement and cause of death. fiftyone different microorganisms were found distributed among cases, bacteria being the most abundant. nineteen of the cases were classified as having a microbiological related cause of death. creactive protein levels were raised in cases of the cases, histological findings either supported or were a decisive factor for the classification of microbiologically related cause of death in cases. as a multitude of abundant microorganisms are able to cause infection under the right circumstances, all findings should be compared to anamnestic antemortem information, before conclusions are drawn. a definite list of true pathogens is nearly impossible to compile. ß elsevier ireland ltd. all rights reserved. and/or swaps are collected once suspicion is raised by gross pathology findings during the autopsy. tissue samples were analyzed at the department of clinical microbiology, university hospital of odense. samples are routinely analyzed for bacteria and fungi, using agar culturing. pcr analysis for viruses is performed per request. crp was measured in full blood using ''quickread crp'' produced by orion diagnostica. the ''quickread crp'' supplies results in the range of - mg/l, results below or above this interval will be noted as < and > respectively. though an exact cut off value for crp on postmortem material is not easy established [ ] , values above mg/l are considered raised. the age ranged from ½ months to years, cases were children under the age of , one was between and years old, were between and , and were older than years. twenty-eight were male and were female. in five cases, no microorganisms were found. bacteria were found in ( . %) of the cases, amounting to of ( . %) samples taken. viruses were found in of cases ( . %). fungi were found in eight cases ( . %), amounting to of ( . %) samples taken. no other named fungi than candida albicans was found. in one case c. albicans was the only microbiological finding. bacteria were found in cases where they were not related to cod. virus was only found in one case which was not classified as an infectious cod. in the autopsies cod was classified as infectious in cases ( . %), distributed among: three cases of viral pneumonia ( . %), three cases of bacterial pneumonia ( . %), four cases of sepsis ( . %), two cases of meningitis ( . %), two cases of peritonitis, one due to accidental perforation of the intestine during surgery and one due to perforated appendicitis ( . %), one case of pericarditis ( . %) and three cases of combined opiate poisoning and infection ( . %), table . the cod of the remaining cases, which were not related to microbiological findings, are listed in table . in all, different microorganisms were found including one report of ''normal flora'', table shows the distribution. testing in one case, classified as viral pneumonia cod, did not yield any positive viral findings. however the histological findings were consistent with viral pneumonia (interstitial pneumonitis), and the person had been treated with antiviral antibiotics before death which could cause the negative viral findings [ ] . crp was measured in cases. in nine cases crp was below mg/l. regarding the cases classified as infectious cod, crp values were below mg/l in two cases, cases had elevated crp values (p < . ), and in three cases no measurement was performed. of the cases with an infectious cod, histological examination was of importance in cases ( . %). in two of the cases no microorganisms were found but the histological changes, crp values and other information lead to the conclusion (one case of viral pneumonia and one case of neutrophilic pneumonia in an opiate poisoning case). in four cases, histological findings did not show inflammation to support the microbiological findings, however crp levels above mg/l and the bacteriological results were sufficient to verify the microbiologically related cod. culturing bacteria on agar plates is an old invention whereas polymerase chain reaction (pcr) used for viral detection is a fairly new technique and is still costly compared to agar cultures. hence bacteria and their colonization of the body is the most thoroughly investigated group of pathogens. a single study has used pcr for bacterial detection with excellent results [ ] . though this might be the way to proceed in the future, the skill and equipment required for pcr, compared to using agar plates, could mean that it will not be the investigation of choice in the near future on a worldwide basis. the key point in interpreting postmortem microbiological results is to determine whether detected microorganisms arise from postmortem spread or are the result of true antemortem infection. larsen et al. suggest that to be sure a bacteria was present in the bloodstream before death, it must be cultured from at least two different sites [ ] . however authors do not agree on the most reliable sites for sampling, blood, lung and spleen are generally mentioned, as well as cerebrospinal fluid [ , ] . tuomisto et al. [ ] suggest liver and pericardial sampling as the most reliable within the first five days after death. preferably, cultures should be verified by gross pathologic or histologic findings [ , ] . when bacteria are cultured postmortem, one must consider several mechanisms which could lead to bacteria in the samples. four lines of spread have been suggested [ , ] . a microorganism has genuinely invaded the bloodstream or target organ during life leading to bacteriaemia/ infection/sepsis, the group of cases which could be classified with a microbiological cod. . agonal spread: according to this theory the ischemia in the agonal period or during resuscitation lead to mucosal damage allowing bacteria to invade through the surface in question. . postmortem translocation: the movement of naturally present bacteria across the mucosal barriers, into the surrounding tissue, bloodstream and body. one should expect a mixed growth and not a single isolate bacteria [ ] . . contamination: microorganisms are introduced into the tissue at time of sampling, and were not present in life. the theory of agonal spread is according to a review by morris et al., considered unlikely [ ] . several papers find that elapsed time from death to sampling point does not have a significant influence on false positive bacterial results provided that bodies are kept refrigerated [ , [ ] [ ] [ ] . however animal experiments performed by heimesat et al. [ ] do show a rather large increase in bacteria in extra-intestinal tissue especially up to h after death. perhaps even more interesting, they observe a rise in extraintestinal bacteria already five minutes after death. maujean et al. report an interesting case in which neisseria meningitidis was detected in a putrefied body after days using molecular analyses [ ] . pryce et al. compared antemortem vs. postmortem sampling and concluded that postmortem sampling is as valuable as antemortem, when related to an infectious cod [ ] . the risk of contamination from the autopsy room seems to be small [ ] . table shows the vast diversity of microorganisms found in our cases, and illustrates the large number of possible pathogens. the majority of bacteria could be considered postmortem translocation, however as many of the microorganisms contributing to our normal flora can become pathogens under the right circumstances, all findings must be carefully considered. in our study bacteria were found in cases, of these cases were not classified as having infectious cod, adding to the presumption of a significant postmortem spread. the vast majority of the microorganisms found in these cases are part of our natural flora, and are to be considered opportunistic pathogens, several being able to cause both pneumonia and bacteremia. in six of these cases no clear cod was found, four were sids and two unexplained under the age of two (table ). histology did not show inflammation in any of the samples, and none of the cases had elevated crp values, though in two cases crp measurement was not performed. not surprisingly, these problematic cases are all infants. as several of the bacteria are possible pathogens, infection cannot be completely ruled out due to the fact that a not fully developed immune system could be responsible for the lack of both inflammatory response and rise in crp values. several more or less commonly encountered microorganisms, such as n. meningitidis, neisseria gonorrhoeae, haemophilus influenzae, salmonella species, staphylococcus aureus, streptococcus pneumoniae, b-hemolytic streptococci, klebsiella species, escherichia coli, mycobacterium tuberculosis, members of the enterobacteriaceae and c. albicans should, according to some authors, always be considered pathogens [ , , ] . several of the above are however part of our natural flora, and may be considered opportunistic pathogens [ ] , only causing disease in persons with an underlying illness, immune deficiency, or are perhaps only known to cause disease in children etc. [ ] . generally all cases should be correlated to anamnestic information, if any present, both medical and socio-economic [ ] before a microorganism is classified as a true infection. hence a definite list of true pathogens is impossible to comprise. considering that microbiological testing amounts to only . % of the autopsies in the investigative period versus the yield of cases which were classified as microbiologically related cod ( . %), this inexpensive testing seems to be rather well founded. perhaps microbiological testing should be applied in even more cases. in denmark around % of autopsies do not yield a viable cause of death, and though microbiological testing would be performed on most, the possibility remains that a few of these deaths could be due to infections/sepsis. in this study of cases with a microbiologically related cod had elevated crp values (p < . ). considering that result and the literature on the subject [ , ] , one would suggest that crp measurement is carried out at the beginning of the autopsy. this would give an early indication of a possible infection in cases where antemortem information does not suggest such, allowing for microbiological sampling before significant handling of the body and a hence reduced risk of mechanical contamination, both by direct transfer of bacteria and by displacement of bowel-near blood in arteries and veins. besides the possibility of improved sampling methods we also need to consider other methods to improve the microbiological testing in relation to autopsy. pcr analyses have been proved useful [ ] , and although it seems to be excellent with regards to virus investigations, it does not bypass the biggest pitfall in bacterial analysis, the postmortem spread. since it is even more sensitive than culturing [ ] it might possibly yield an even higher number of positive results. pcr analysis targeting specific bacterial toxins or the toxin-genes might be of some use [ ] , investigations into pm bacterial toxin production could be an interesting area for future work. microbiological sampling remains an important part of the autopsy yielding the cause of death in . % of the cases in which it was performed. optimized storage of the body and precautions to avoid contamination greatly enhance the value of the results. the decision to classify a cod as microbiological rests on a combination of factors, including crp levels, histology and an analysis of the microbiological agents. a raised crp level is correlated with microbiologically related cod and if performed at the beginning of the autopsy could be used as a guideline to initiate a microbiological autopsy, before mechanical manipulation leads to contamination. histology is an important part of the microbiological investigation in almost / of the cases with a microbiologically related cod, verifying inflammation in the cultured material, and in a few cases being the decisive factor, though supported by other information, in the diagnosis where the microbiological results were negative. therefor all sites sampled for microbiological testing should also be histologically examined. in very few of our cases only one single microbiological agent was found or an agent which is without doubt the sole cause of death. several of the microorganisms contributing to our natural flora, colonizing human skin, respiratory tract or other inner surfaces or which are found in abundance in our surroundings can lead to life-threatening infections under the right circumstances, i.e. persons with underlying illness, immune suppression etc. conversely widely found microorganisms known to cause sepsis could be the result of postmortem spread, considering their established virulence, target age group and point of infection. investigators should always take into account all findings and anamnestic information in each case compared to the detected microorganisms before making any conclusions. hence a definite list of ''true pathogens'' is nearly impossible to compile, and we suggest consulting microbiological literature on each microorganism, once it has been deemed of interest due to the above factors. accuracy of cause of death determination without forensic autopsy examination postmortem diagnosis of sepsis the importance of the autopsy in emerging and reemerging infectious diseases determinants for autopsy after unexplained deaths possibly resulting from infectious causes, united states a study of pneumococci and allied organisms in human mouths and lungs after death the routine use of c-reactive protein in forensic investigations particularities regarding the etiology of sepsis in forensic services evaluation of postmortem bacterial migration using culturing and real-time quantitative pcr ii: comparison of a group of cancer patients with a control group procurement, interpretation, and value of postmortem cultures bacteriological investigationsignificance of time lapse after death postmortem bacteriology: a re-evaluation practical and theoretical aspects of postmortem bacteriology sterile site infection at autopsy in sudden unexpected deaths in infancy postmortem interval and bacteriological culture yield in sudden unexpected death in infancy (sudi) comprehensive postmortem analyses of intestinal microbiota changes and bacterial translocation in human flora associated mice the interest of postmortem bacteriology in putrefied bodies microbiological findings in sudden unexpected death in infancy: comparison of immediate postmortem sampling in casualty departments and at autopsy bacteriological sampling of postmortem rooms principles and practice of infectious diseases sudden death caused by fulminant bacterial infection: background and pathogenesis of japanese adult cases postmortem bacteriology in forensic pathology: diagnostic value and interpretation autopsy cases of fulminant bacterial infection in adults: clinical onset depends on the virulence of bacteria and patient immune status cerebrospinal fluid pcr analysis and biochemistry in bodies with severe decomposition staphylococcal toxins in sudden unexpected death in infancy: experience from a single specialist centre key: cord- - a c ee authors: ray, debashree; salvatore, maxwell; bhattacharyya, rupam; wang, lili; mohammed, shariq; purkayastha, soumik; halder, aritra; rix, alexander; barker, daniel; kleinsasser, michael; zhou, yiwang; song, peter; bose, debraj; banerjee, mousumi; baladandayuthapani, veerabhadran; ghosh, parikshit; mukherjee, bhramar title: predictions, role of interventions and effects of a historic national lockdown in india's response to the covid- pandemic: data science call to arms date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: a c ee importance: india has taken strong and early public health measures for arresting the spread of the covid- epidemic. with only covid- cases and fatalities, india - a democracy of . billion people - took the historic decision of a -day national lockdown on march . the lockdown was further extended to may , soon after the analysis of this paper was completed. objective: to study the short- and long-term impact of an initial -day lockdown on the total number of covid- cases in india compared to other less severe non-pharmaceutical interventions using epidemiological forecasting models and bayesian estimation algorithms; to compare effects of hypothetical durations of lockdown from an epidemiological perspective; to study alternative explanations for slower growth rate of the virus outbreak in india, including exploring the association of the number of cases and average monthly temperature; and finally, to outline the pivotal role of reliable and transparent data, reproducible data science methods, tools and products as we reopen the country and prepare for a post lock-down phase of the pandemic. design, setting, and participants: we use the daily data on the number of covid- cases, of recovered and of deaths from march until april , from the novel coronavirus visual dashboard operated by the johns hopkins university center for systems science and engineering (jhu csse). additionally, we use covid- incidence counts data from kaggle and the monthly average temperature of major cities across the world from wikipedia. main outcome and measures: the current time-series data on daily proportions of cases and removed (recovered and death combined) from india are analyzed using an extended version of the standard sir (susceptible, infected, and removed) model. the esir model incorporates time-varying transmission rates that help us predict the effect of lockdown compared to other hypothetical interventions on the number of cases at future time points. a markov chain monte carlo implementation of this model provided predicted proportions of the cases at future time points along with credible intervals (ci). results: our predicted cumulative number of covid- cases in india on april assuming a -week delay in people's adherence to a -day lockdown (march - april ) and a gradual, moderate resumption of daily activities after april is , with upper % ci of , . in comparison, the predicted cumulative number of cases under "no intervention" and "social distancing and travel bans without lockdown" are thousand and thousand (upper % ci of nearly . million and . million) respectively. an effective lockdown can prevent roughly thousand (upper % ci . million) and . million (upper % ci . million) covid- cases nationwide compared to social distancing alone by may and june , respectively. when comparing a -day lockdown with a hypothetical lockdown of longer duration, we find that -, -, and -day lockdowns can approximately prevent thousand (upper % ci . million), thousand (upper % ci . million), thousand (upper % ci . million) cases by june , respectively. we find some suggestive evidence that the covid- incidence rates worldwide are negatively associated with temperature in a crude unadjusted analysis with pearson correlation estimates [ % confidence interval] between average monthly temperature and total monthly incidence around the world being - . [- . , . ] for january, - . [- . , . ] for february, and - . [- . , - . ] for march. conclusions and relevance: the lockdown, if implemented correctly in the end, has a high chance of reducing the total number of covid- cases in the short term, and buy india invaluable time to prepare its healthcare and disease monitoring system. our analysis shows we need to have some measures of suppression in place after the lockdown for the best outcome. we cannot heavily rely on the hypothetical prevention governed by meteorological factors such as temperature based on current evidence. from an epidemiological perspective, a longer lockdown between - days is preferable. however, the lockdown comes at a tremendous price to social and economic health through a contagion process not dissimilar to that of the coronavirus itself. data can play a defining role as we design post-lockdown testing, reopening and resource allocation strategies. software: our contribution to data science includes an interactive and dynamic app (covind .org) with short- and long-term projections updated daily that can help inform policy and practice related to covid- in india. anyone can visualize the observed data for india and create predictions under hypothetical scenarios with quantification of uncertainties. we make our prediction codes freely available (https://github.com/umich-cphds/cov-ind- ) for reproducible science and for other covid- affected countries to use them for their prediction and data visualization work. thousand (upper % ci . million), thousand (upper % ci . million) cases by june , respectively. we find some suggestive evidence that the covid- incidence rates worldwide are negatively associated with temperature in a crude unadjusted analysis with pearson correlation estimates [ % confidence interval] between average monthly temperature and total monthly incidence around the world being - . [- . the lockdown, if implemented correctly in the end, has a high chance of reducing the total number of covid- cases in the short term, and buy india invaluable time to prepare its healthcare and disease monitoring system. our analysis shows we need to have some measures of suppression in place after the lockdown for the best outcome. we cannot heavily rely on the hypothetical prevention governed by meteorological factors such as temperature based on current evidence. from an epidemiological perspective, a longer lockdown between - days is preferable. however, the lockdown comes at a tremendous price to social and economic health through a contagion process not dissimilar to that of the coronavirus itself. data can play a defining role as we design post-lockdown testing, reopening and resource allocation strategies. software: our contribution to data science includes an interactive and dynamic app (covind .org) with short-and long-term projections updated daily that can help inform policy and practice related to covid- in india. anyone can visualize the observed data for india and create predictions under hypothetical scenarios with quantification of uncertainties. we make our prediction codes freely available (https://github.com/umich-cphds/cov-ind- ) for reproducible science and for other covid- affected countries to use them for their prediction and data visualization work. four months since the first case of covid- in wuhan, china, the sars-cov- virus has engulfed the world and has been declared a global pandemic. the number of confirmed cases worldwide stands at a staggering , , (as of : am est april , , microsoft bing coronavirus tracker ). of these, , confirmed cases are from india (figure ) , the world's largest democracy with a population of . billion (compare china at . billion and usa at . million). india has been vigilant and wise in instituting the right public health interventions at the right time including sealing the borders with travel ban/canceling almost all visas, closing schools and colleges in certain states and diligently following up with community inspection of suspected/exposed cases with respect to adherence of quarantine recommendations ( table ) . on march , india took the historic decision of a -day national lockdown starting march , when it had reported only covid- cases and fatalities. in the subsequent days we have seen a steady growth in the number of new cases and fatalities, with growth rates slower than other affected countries but in days, the curve has not yet "turned the corner" or showed a steady decline in the number of newly diagnosed cases (figure ). while india seems to have done relatively well in controlling the number of confirmed cases compared to other countries in the early phase of the pandemic (figure ) , there is a critical missing or unknown component in this assessment: "the number of truly affected cases," which depends on the extent of testing, the accuracy of the test results and, in particular, the frequency and scale of testing of asymptomatic cases who may have been exposed. the frequency of testing has been low in india. according to the indian council of medical research (icmr), only , subjects have been tested as of april . when there is no approved vaccine or drug for treating covid- , entering phase or phase of escalation will have devastating consequences on both the already overstretched healthcare system of india, and india's large at-risk sub-populations (supplementary table ). as seen for other countries like the us or italy, covid- enters gradually and then explodes suddenly. we provide a table listing other highly affected countries along with their first reported case, initial interventions, crude fatality rates, and active case counts in supplementary table for reference. in this article, we take a data-driven approach to explore five extremely time-sensitive and important questions that india faces today in light of the covid- outbreak and the national lockdown: (a) how many cases can india expect at the end of the lockdown period? (b) when will the curve in india reach its apex and will the number of cases go back up after lockdown is lifted? (c) can summer temperatures thwart the outbreak in india? (d) how can the government and the people of india prepare for this crisis during and after the lockdown? (e) how critical is it to have reliable data, data science methods and tools as we envision a long-term strategy during and after the lockdown? this work is the result of the collective public health conscience of a group of interdisciplinary researchers in different parts of the us and in india. we convened virtually after being quarantined in our homes with alternating waves of fear and inspiration surrounding us. we decided to channel our collective energy to study the defining public health and economic crisis of our time and use our data science expertise to search for answers and solutions that can help covid- related policymaking in india. this is our contribution and public service as data scientists. our data science product includes two articles on medium pre and post lockdown announcement, providing critical information for policymakers (reuters, times of india, the guardian, the economic times ) and an interactive app that daily updates forecasts as new case counts are coming in, and publicly available codes for reproducible research. we used the current daily data on number of covid- cases, recoveries and deaths in india to predict the number of cases at any given time. we obtained the data (up to april ) from the novel coronavirus visual dashboard operated by the johns hopkins university center for systems science and engineering (jhu csse). , for our temperature analysis, these counts were aggregated to a month-level for each country, that is, we look at the total number of new cases in the months of january, february and march for each country. we obtained the monthly average temperature for major cities in the countries with covid- outbreak from wikipedia. we analyzed the data from india with standard epidemiologic tools of modeling disease transmission and estimating the theoretical number of cases at any time. one such epidemiologic model is the susceptible-infected-removed (sir) model, which is guided by a set of differential equations relating the number of susceptible people, the number of infected people (cases) and the number of people who have been removed (either recovered or dead) at any given time. recently, this standard sir model was extended to incorporate time-varying transmission rates or timevarying quarantine protocols and is known as the esir model. when using the esir model with time-varying disease transmission rate, it can depict a series of time-varying changes caused by either external variation like government-initiated macro isolation measures, community-level protective measures and environment changes, or internal variations like mutations and evolutions of the pathogen. the r package for implementing this general model for understanding disease dynamics is publicly available at https://github.com/lilywang /esir. to implement the esir model, a bayesian hierarchical framework is assumed where the proportions of infected and the removed people are modeled using a beta-dirichlet state-space model while a latent dirichlet distribution is assumed for the underlying unknown prevalence of the three states. priors for the basic reproductive number r , disease removal rate (consequently, the transmission rate) and the underlying unobserved prevalence of the susceptible, infected and removed states at the starting time are considered. using the current time series data on the proportions of infected and the removed people, a markov chain monte carlo implementation of this bayesian model provides not only posterior estimation on parameters and prevalence of all the three compartments in the sir model, but also predicted proportions of the infected and the removed people at future time point. the posterior mean estimates of the unobserved prevalence at both observed as well as future time points come along with % credible intervals (ci). to get predicted case-counts from the predicted prevalence, we used . billion as the population of india, thus treating the country as a homogeneous system for the outbreak. we made projections of the cumulative number of cases over a time horizon to assess the shortterm impact of lockdown as well as the long-term impact of lockdown and post-lockdown activities. for the short-term forecast on april , we assumed lockdown is implemented until april with either a -or a -week delay in people's adherence/compliance to lockdown restrictions. we compared these projections with two hypothetical scenarios: (a) no nonpharmaceutical intervention (i.e., a constant disease transmission rate over time since the first case was reported in india), (b) a moderate intervention with social distancing and travel bans only (i.e., a decreased transmission rate compared to no intervention). for the no intervention and the moderate intervention scenarios, we chose the transmission rate and the removal rate such that the means for the prior distribution of the basic reproductive number r (the expected number of cases generated by one infected person assuming that the whole population is susceptible) are . and . respectively [the change in r was created based on what we saw in wuhan ]. the value of . was estimated based on the early phase data in india. for the current scenario of lockdown, our chosen mean for r prior starts with . during the period of no intervention, drops to . during the period of moderate intervention, and further drops to . during the -day lockdown period, and moves back up to . after the lockdown ends as described in figure (assuming a gradual, moderate resumption of daily activities). for the longer-term forecast until june , we considered three hypothetical post-lockdown scenarios: (i) people return to normal activities due to the urgent desire for reconnecting after lockdown; (ii) people return to moderate activities as they did during the period with social distancing and travel ban intervention; and (iii) people make a cautious return out of fear for the coronavirus and partake in subdued activities. for these three scenarios, we assume mean for r prior moves back up from . to . , . and . respectively three weeks after lockdown ends on april . we compared these post-lockdown scenarios with another hypothetical scenario involving perpetual social distancing and travel ban only without any lockdown (we fixed the mean for r prior at . over the entire intervention interval). the changes to r values across our simulation scenarios are depicted in figure . to assess the long-term impact of lockdown duration, we considered four scenarios: -, -, -, and -day lockdown periods. in all scenarios, we assume mean for r prior remains at . for the duration of the lockdown and returns to . three weeks after the lockdown period ends (analogous to the "moderate return" scenario). the changes to r values across our simulation scenarios are depicted in supplementary figure . there are many hypotheses regarding the slow growth rate of covid- cases in many countries, particularly low-and middle-income countries (lmics). some of these hypotheses include the use of bacille calmette guerin (bcg) vaccine, younger population, high daily temperature, use of anti-malarials and host genetics. here, we only explore the temperature hypothesis related to covid- incidence. we assessed any correlation between country-wise average monthly temperature and total incidence of covid- . the monthly average temperature for major cities across the world was used to compute the monthly average temperature for each country experiencing covid- outbreak by averaging across the major cities within a country. missing data for average temperature for certain countries was manually appended from www.weatheratlas.com. we computed the pearson correlation coefficient, , between the average monthly temperature and total monthly incidence during each month of january, february and march. we used the fisher's z-transformation to compute z = . log + ,-. ,/. . the standard deviation of , which is known under certain normality assumptions, is used to construct a % confidence interval for . the inverse transform of is then used to obtain the % confidence interval for the correlation . all calculations were carried out in the rstudio platform. under national lockdown (march -april ), our predicted cumulative number of covid- cases in india on april are , and , (upper % ci of , and , ) assuming a -or -week delay (i.e., either a quick or a slow adherence), respectively, in people's adherence to lockdown restrictions and a gradual, moderate resumption of daily activities post-lockdown (figure , supplementary figure ). in comparison, the predicted cumulative number of cases under "no intervention" and the "intervention involving social distancing and travel bans without lockdown" are thousand and thousand (upper % ci of nearly . million and . million) respectively. we are reporting only the upper credible limit here and elsewhere since the lower credible limits are very close to due to the large uncertainty in our predictions arising from many unknowns. we also believe that our point estimates are at best underestimates due to potential under-reporting of case-counts and our model not taking into account the population density, agesex and contact network structure of the whole nation. increase in testing and community transmission may lead to a spike in a single day and that may shift the projection curve significantly upward. regardless of the exact numbers it is clear that, the -day lockdown will likely have a strong effect on reducing the predicted number of cases in the short term. we took a close look at what might be coming in the next few months, based on what we have seen in other countries and an epidemiological model that has been gainfully employed to assess the effect of interventions in hubei province. we estimated that (upper % ci ) and (upper % ci ) cases per , are avoided by may and june , respectively, by instituting a -day lockdown with a -week delay in people's adherence and a cautious release compared to perpetual social distancing and travel ban (without lockdown) ( figure ). this boils down to preventing roughly thousand (upper % ci . million) and . million (upper % ci . million) covid- cases nationwide by may and june , respectively. without some measures of suppression after lockdown is lifted, the impact of lockdown in bringing down the case-counts (the now ubiquitous term, "flattening the curve") can be negated by as early as the first week of june. in fact, in figure a , the pre-intervention ("normal") curve first passes the social distancing and travel ban curve on june . in particular, if people immediately go back to pre-intervention ("normal") activities post-lockdown, a surge in the predicted case-counts is expected in the long-term beyond what we would have seen if there were only social distancing and travel ban measures without lockdown ( . million when post-lockdown activity returns to pre-intervention levels vs. . million under social distancing and travel ban without a lockdown period on july ; figure ). we estimated that (upper % ci ) and (upper % ci ) cases per , are avoided by june and july respectively if people are cautious in their activities post-lockdown compared to the scenario where people return to normal preintervention activities. long-term forecasting under slow adherence ( -week delay) can be seen in supplementary figure . . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint we took the quick adherence epidemiological models and compared the -day lockdown with hypothetical -, -, and -day lockdown scenarios (figure ). when comparing a -day lockdown with a hypothetical lockdown of longer duration, we find that -, -, and -day lockdowns can approximately prevent thousand (upper % ci . million), thousand (upper % ci . million), thousand (upper % ci . million) cases by june , respectively. a -day lockdown does not appear to have a significant impact on cumulative case counts when compared to a -day lockdown. however, purely from an epidemiologic perspective, there appears to be some evidence that suggests a -or -day lockdown would have a more meaningful impact on reducing cumulative covid- case counts in india. we note that longer lockdown periods are accompanied by increasing costs to individuals -notably economicand must be considered. our models suggest that some form of post-lockdown suppression (e.g., extension of social distancing measures, limits of gathering size, etc.) is necessary to observe longterm benefits of the lockdown period. lockdown duration study under the slow adherence ( -week delay) scenario can be found in supplementary figure . we did explore some alternative assumptions and conducted thorough sensitivity analysis before settling on the models presented above. in one example, we assumed that there are actually times the number of reported cases to date to reflect potential underreporting of cases due to lack of testing. in another scenario, we assumed these cases occurred in metropolitan areas to reflect a potential intensification of case clustering. in yet a third scenario, we hypothesized that r prior starts with . instead of . (i.e., a single infected individual would infect . susceptible individuals, on average, instead of ). these scenarios did not appreciably change our conclusions in broad qualitative terms, though the exact quantitative projections are quite sensitive to such choices. across these scenarios, the projected total number of infected cases by the entire first phase of the pandemic varied between - % of the population, again showing the significant variability in these numbers. the estimates we present here may appear conservative and are at best underestimates, and, in all cases, our confidence in these projections decreases markedly the farther into the future we try to forecast. it is extremely important to update these models as new data arise. spatial plots for the average monthly temperatures accompanied by total monthly incidence across all countries from january through march indicate a suggestive pattern of increase in community spread across cities and regions specifically along narrow north east-west directions (figure ). countries in these regions consistently exhibit similar weather patterns. however, in the context of india, a gradual rise in the number of cases is observed starting from january through march. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . the estimates and the % confidence interval for the correlation coefficient for january was - . [- . , . ] with countries having non-zero incidence, for february was - . [- . , . ] with countries having non-zero incidence, and for march was - . [- . , - . ] with countries having non-zero incidence. although the estimates were negative, the % confidence intervals either include zero or the upper limit is close to , indicating weak evidence for any claim of negative association between case counts and daily temperature. any such affirmation will require further data and investigation that accounts for many possible sources of confounding. our projections using current daily data on case counts until april in india show that the lockdown, if implemented correctly in the end, has a high chance of reducing the number of covid- cases in the short term and buy india invaluable time to prepare its healthcare and disease monitoring system. in the long-term, we need to have some measures of suppression in place after the lockdown is lifted to prevent a massive surge in the number of cases that can quickly overwhelm an already over-stretched indian healthcare system resulting in increased fatalities. specific vulnerable populations will be at higher risk of severity and fatality from covid- infection: older persons and persons with pre-existing medical conditions (e.g., high blood pressure, heart disease, lung disease, cancer, diabetes, immunocompromised persons). , supplementary table provides a description of the approximate number of individuals in these high-risk categories in india. beyond the fragile population characterized by health and economic indicators, we have to remember that healthcare workers and first responders at the front line of this pandemic are amongst the most vulnerable. it is important to note that a massive surge in the number of cases can quickly overwhelm an already over-stretched indian healthcare system. the estimated capacity of hospital beds in india is per , , which is an upper bound on treatment capacity. given an average occupancy rate of %, only a quarter of these are available. moreover, critically ill covid- patients (about - % of those infected) will require icu beds and ventilator support. india has only - thousand icu beds with very high occupancy rates and at most ventilator per icu beds. from a purely public health perspective, this analysis shows the impact and necessity of lockdown and subsequent measures of suppression after lockdown is lifted. all the people in india, regardless of their vulnerability to covid- , need to adhere to the public health guidelines issued by the ministry of health and family welfare in india, and continue to be cautious in their post-lockdown activities to guarantee a long-term benefit of the national lockdown. currently, there are many hypotheses regarding differential covid- infection rates and mortality rates across countries. one such hypothesis is that the bcg vaccine -developed a century back for tuberculosis -has a protective effect on the prevalence of covid- and related . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . mortality. a recent pre-print found covid- attributable mortality in countries with bcg policy is times lower than those without a bcg policy in an ecological analysis, after accounting for country-specific confounders like economic status, percentage elderly (those aged ≥ years) in the population, and relative position of each country along the epidemic trajectory. however, the authors caution against over-interpretation of this negative association between bcg use and covid- due to limitations of country-level analysis and many sources of unmeasured confounders. another hypothesis is that much like the flu virus, summer temperatures will thwart the covid- outbreak. our analysis, based on current data, suggests we cannot rely on the hypothetical prevention (with inconclusive evidence) governed by meteorological factors and need public health actions, regardless of the seasonal weather. the management of this covid- crisis requires strong partnership of the government, the scientific community, the health care providers and all citizens of india (and all global citizens). long term surveillance and management of covid- crisis is needed with not just public health in mind but also to take care of the economic, social, and psychological trauma that it will leave on the people. reviving the economy will be critical in the coming months. below we recommend some healthcare, social and economic reforms that can counter the negative impact of severe public health interventions, some of which india has already begun to make progress. (a) aggressively increase the number of tests administered daily as there are often asymptomatic cases who are spreading the infection without knowing. it is of utmost importance that india adopt widespread testing to identify and isolate the infected. rt-pcr diagnostic test can provide reliable and faster diagnosis of the sars-cov- virus. large scale antibody testing should be launched to assess the true scale of this pandemic. the instrument of isolating nearly everyone with a near universal lockdown not only leads to livelihood losses for millions of families but also starvation for others. as we reopen the country, testing high contact, high density areas and setting up a clever surveillance system is critical. immediately prepare to protect the health care workers and first responders who are at the front line of this pandemic. this involves ensuring a steady supply chain of medical resources (masks, gloves, gowns, ventilators), and protecting our healthcare workers physically and psychologically. full gears (protective suit, medical goggle, cap, face shield, mask and gloves) are absolutely essential when seeing suspected cases. these protection strategies worked in china. (c) reduce all non-essential medical care and expand number of hospital beds, icu beds and ventilators. (d) continue to set up covid- testing mobile labs, hospitals and mobile cabins (e.g. by converting stadiums and trains into quarantine and treatment facilities). ensure the healthcare facilities have adequate supply of medications that are currently . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . being recommended. for instance, antiviral drugs "remdesivir and chloroquine are highly effective in the control of -ncov infection in vitro" indicating promise for treating covid- patients. recently though, the study finding hydroxycholoroquine as an effective treatment for covid- has been retracted for bad study design and not meeting expected scientific standards. (f) use pragmatic real-time data for optimally deploying surveillance, community inspection and health care resources. this is key with limited resources. economic recommendations: (j) provide livelihood assistance over the quarantine period to those who test positive. this will incentivize people to get tested and comply with social isolation protocols. for many people in india, loss of several weeks of earnings can be economically devastating and since symptoms are mild for most infected people, it is unreasonable to expect that all people will tightly follow restrictions unless economically protected. to get a ballpark idea of the fiscal burden involved, assume million detected cases, quarantine of weeks per patient, and inr , monthly compensation. this adds up to a bill of inr billion, which is roughly . % of the annual healthcare budget of the central government. (k) during periods of social distancing and lockdowns, there is grave livelihood threat to a lot of poor people even if they are uninfected -street hawkers, auto drivers, barbers and shopkeepers, etc. providing a universal basic income (ubi), or some mildly means tested version of it, over the period of disruption is needed for a successful lockdown. (l) to prevent shutdowns in badly affected sectors, the government may provide goods and services tax (gst) credit to firms based on the difference between past and current sales. once the pandemic is over and normal business resumes, expansionary monetary and fiscal policy will be needed to revive macroeconomic health. there are many epidemiological models to predict the course of an infectious disease and even many that are india-specific. - some use age-structure, contact patterns, spatial information to finesse their prediction. some consider the possibility of a latent number of true cases, only a fraction of which are ascertained and observed. the model we used here is an extension of a . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . standard sir model, called esir model, where we can create hypothetical intervention scenarios in a time dependent manner. the goal of any intervention is to reduce the chance that an infected person meets a susceptible person. we create models for declines/drops in contact probabilities when an intervention is rolled out. thus, there is some intrinsic ad-hocery to our assumptions. any statistical model is wrinkled with such assumptions. similarly, the predictions themselves have large uncertainty (as reflected by the upper credible limits). as we interpret the numbers from any model, let us use caution in not over-interpreting them. a rigorous quantitative treatment often allows us to analyze a problem with clarity and objectivity, but we recommend focusing more on the qualitative takeaway messages from this exercise rather than concentrating on the exact numerical projections or quoting them with certainty. we see tremendous role of data and data science in governing policy as india reopens post lockdown. the release from lockdown will not be in a binary switch on/switch off process but a modulated slow-varying process. we see the following roles and opportunities for pragmatic use of data science in the post-lockdown phase. (a) flexible, athletic, data driven policymaking will need up-to-date numbers and projections at hand, which require granular data, automation and data transparency (b) understand uncertainty in numbers: all models are wrong, some are useful, but note that takeaway messages for intervention forecasting are often the same (c) using technology to create body temperature/expected health status map (e.g., healthweather.us) (d) assess adherence to social distancing using mobile networks, google (e.g., google mobility reports) (e) use survey to identify potential super-spreaders, manage contact network, oversample high risk areas for testing (f) install syndromic surveillance in hospitals, medical claims systems to set up alert; establish expected number of respiratory and flu-like illnesses so departures can set off an alarm. (g) use community health workers in rural areas, community dwellings to identify and isolate cases and conduct cluster testing (h) targeted communication strategies: regarding tests, treatments, contagion level. misinformation and incorrectly analyzed data lead to panic (i) accurate and consistent reporting of case counts and deaths due to covid- are extremely critical our statistical modeling and forecasts are not without limitations. we have very few data points and a long time-window to extrapolate for the long-term forecasts. the uncertainty in our predictions is large due to many unknowns arising from model assumptions, population . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . demographics, the number of covid- diagnostic tests administered per day, testing criteria, accuracy of the test results, and heterogeneity in implementation of different government-initiated interventions and community-level protective measures across the country. we have neither accounted for age-structure, contact patterns or spatial information to finesse our predictions [ ] [ ] [ ] nor considered the possibility of a latent number of true cases, only a fraction of which are ascertained and observed. increase in frequency and scale of testing, and community transmission of the sars-cov- virus may lead to a spike in a single day and that can shift the projection curve significantly upwards. covid- hotspots in india are not uniformly spread across the country, and state-level forecasts may be more meaningful for state-level policymaking. we are assuming that the implementation and effects of public health interventions and policies are the same everywhere in india by treating india as a homogeneous unit. future opportunities for improving our model include incorporating contagion network, age-structure, estimating seir model, incorporating test imperfection, and estimating true fatality/death rates. regardless of the caveats in our study, our analyses show the impact and necessity of lockdown and of suppressed activity post-lockdown in india. rather than over-interpreting exact numerical projections, we recommend focusing more on the qualitative takeaway messages. one ideological limitation of considering only the epidemiological perspective of controlling covid- transmission in our model is the inability to count excess deaths due to other causes during this period, or the flexibility to factor in reduction in mortality/morbidity due to some other infectious or flu-like illnesses, traffic accidents or health benefits of reduced air pollution levels. a more expansive framework of a cost-benefit analysis is needed as we gather more data and build an integrated landscape of population attributable risks. finally, in our strong commitment to reproducibility and dissemination of our research, we have made the code for our predictions available at github (https://github.com/umich-cphds/cov-ind- ) and created an interactive and dynamic r shiny app (covind .org) to visualize the observed data and create predictions under hypothetical scenarios with quantification of uncertainties. these forecasts will get updated daily as new data come in. we hope these products will remain our contribution and service as data scientists during this tragic global catastrophe, and the model and methods will be used to analyze data from other countries. our epidemiologic and mathematical calculations make a convincing case for enforcing the day national lockdown of the largest democracy in the world, acting early, before the growth of covid- infections in india starts to accelerate. we also notice the public health benefit of extending the lockdown by - weeks in our projections. measures of suppression are needed postlockdown to get long-term benefits from the lockdown. however, these draconian public health . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint measures come at a tremendous price to social and economic health that can last months or even years after the restrictions on social mobility are lifted. thus, there is an urgent need for social and economic immunity: not just coverage for testing and treatment for covid- for everyone in india, but subsidies and incentives for the common man to survive the consequences of the severe interventions that are needed to stop the coronavirus from creating a massive catastrophe in india. we also illustrate the critical role of data in aiding policy decisions. finally, our message to the public is to proceed with prudence and caution, and not panic or drown in despair. we should draw hope from the success of south korea and china and the initial promising containment in india. we need to support the community around us and help the government of india to manage the crisis with the best strategies, resources and science. the lockdown has given us time to prepare and act, let us make the best use of it. we are still in a state of national and global emergency and it will take a considerable time for humanity to recover from this global pandemic and return to normalcy. in the meantime, we root for public health, for innovation and science, for home testing kits [there is none yet], for fda approved drugs [solidarity trial], and for a vaccine [ clinical trials ongoing]. in these frightening times, we find inspiration in the power of the common people and the magic of human kindness. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . figure . left: country-wise total monthly incidence of covid- in the months of january, february and march. the horizontal lines approximately indicate the equator, the tropic of cancer and the n latitude. right: average monthly temperature (in c) during the months of january, february and march. these maps were created by smoothing the counts as well as the average monthly temperature across geographical locations by spatial interpolation. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint supplementary figure . short-term daily growth in cumulative case counts in india assuming a -week delay in people's adherence to restrictions. observed data are shown for days up to april . predicted future case counts for april until april are based on observed data until april using the esir model. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . figure . cumulative (a) and incidence (b) graphs for forecasting models assuming a -week delay under -, -, -, and -day lockdown scenarios using observed data through april . . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint who director-general's opening remarks at the media briefing on covid- - microsoft bing covid- tracker. microsoft corporation data for india, united states sars-cov- (covid- ) testing: status update aprilr predictions and role of interventions for covid- outbreak in india historic -day lockdown, predictions for lockdown effects and the role of data in this crisis of virus in india india faces spike in coronavirus cases, says study, in test for health system epidemiologic models show we need aggressive measures in the early phase...lockdown buys us time overcome by anxiety: indians in lockdown many can ill afford. the guardian india could see a reduction in the number of coronavirus cases by next week: study. the economic times an epidemiological forecast model and software assessing interventions on covid- epidemic in china an interactive web-based dashboard to track covid- in real time list of cities by average temperatures evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease differentiall covid- -attributable mortality and bcg vaccine use in countries case-fatality rate and characteristics of patients dying in relation to covid- in italy high temperature and high humidity reduce the transmission of covid- regulators split on antimalarials for covid- covid- ): are you at higher risk for severe illness? the world bank hospital utilizationn statistics: thirty-five year trend analysis, a measure of operational efficiency of a tertiary care teaching institute in south india coronavirus: does india have enough ventilators, hospital beds? the times of india can an old vaccine stop the new coronavirus? the new york times centers for disease control and prevention. cdc -novel coronavirus ( -ncov) real-time rt-pcr diagnostic panel new blood tests for antibodies could show true scale of coronavirus pandemic analysis of , lab-confirmed covid- cases in wuhan: epidemiological characteristics and non-pharmaceutical intervention effects india turns trains into isolation wards as covid- cases rise remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial hydroxychloroquine-covid- study did not meet publishing society's "expected standard prudent public health intervention strategies to control the coronavirus disease transmission in india: a mathematical model-based approach age-structured impact of social distanncing on the covid- epidemic in india covid- for india updates coronavirus statistics: what can we trust and what should we ignore? the guardian covid- community mobility reports food and drug administration. coronavirus (covid- ) update: fda alerts customers about unauthorized fradulent covid- tests world health organization. who director-general's opening remarks at the media briefing on covid- - covid- vaccine tracker. regulatory affairs professionnals society hypertension (women)* † based on est. of . billion from un department of economic and social affairs * age-standardized defined as within -kilometer distance of home or work abbrev.: copd, chronic obstructive pulmonary disease international diabetes federation; nicpr, national institute of cancer prevention and research ¶ date of st case data obtained from jhu csse time series data on covid- † microsoft bing covid- tracker the authors will like to thank the university of michigan advanced research computing services for enabling daily updates to our models and allocating us abundant computational resources. we will also like to thank professor matthew fox from the boston university school of public health for his valuable comments on our rshiny app, key: cord- -iwdusvrw authors: gandolfi, alberto title: planning of school teaching during covid- date: - - journal: physica d doi: . /j.physd. . sha: doc_id: cord_uid: iwdusvrw learning and education are two of the biggest world issues of the current pandemic. unfortunately, it is seen in this work that, due to the length of the incubation period of covid- , full opening of schools in the fall of seems to be impractical unless the spread of the virus is completely under control in the surrounding region (e.g. with fewer than active cases every million people). in order to support the possibility of some in-person learning, we model the diffusion of the epidemic within each single school by a seair model with an external source of infection and a suitable loss function, and then evaluate sustainable opening plans. it turns out that blended models, with almost periodic alternations of in-class and remote teaching days or weeks, are generally (close to) optimal. in a prototypical example, the optimal strategy prescribes a school opening of days out of with the number of covid- cases among the individuals related to the school increasing by about %, instead of the about % increase that would have been a consequence of full opening. as clinical fraction is low in children, these solutions could lead to very few or no symptomatic cases within the school during the whole school year. using the density of active cases as a proxy for the number of pre- and asymptomatic, we get an indication for each country of whether either full opening, or blended opening with frequent testing, or no school opening at all, are advisable. more than one billion students are out of school because of covid- [ ] ; most of them are now using remote learning practices that present several drawbacks [ ] and, in most cases, have been hurriedly arranged. in addition, in most schools, school districts, and countries there is uncertainty on how to plan school activities for the - school year [ ] . as a result, learning and education are two of the biggest world issues of the current pandemic [ , ] . as we see below, the characteristics of covid- , and in particular the length of its incubation period of about days [ , ] , are such that cases within each single school tend to undergo a multifold increase should the school be completely open in the upcoming school year. this makes full opening of schools impractical unless the epidemic in completely under control in a region, or till a vaccine is available: difficulties have been already experienced by the first reopening attempts [ , ] . on the other hand, remote teaching has been put together in an emergency situation, and it appears to have badly affected most students [ ] [ ] [ ] , especially those from less advantaged contexts [ ] . at the same time, it has imposed, and it likely to impose again, an additional burden on many families. therefore, the hypothesis of a fully remote - school year is also impractical for different reasons. to help reconcile such conflicting circumstances, there is thus a need for studies and methods that suggest sustainable opening strategies; they should be aimed at supporting the possibility of some in-person learning while simultaneously containing extra infection transmissions, both at the level of each single school, and in a broader context. in this first work, we focus on a single school. what each school needs is a flexible instrument that incorporates some of the specific details of the school, the students, the personnel, and the surrounding area, and provides indications of the outcome of in-person school activities in terms of the potential spread of covid- within the school. some of the difficulties in this process are that it is hard to estimate the transmission rate within schools; that the individuals involved in the school are subject to potential external infectious transmissions; that asymptomatics are hard to detect; and that policy makers have to establish a relative importance of the two targets (in-person teaching and covid- containment). in this paper, we provide a model whose set-up and parameters incorporate several features of covid- dynamics related to a single school, and then outline the optimization process. we then study optimal solutions for a wide variety of plausible values of the parameters of the model, obtaining both an adaptable procedure that can be conformed to specific situations, and general policy indications. blended solutions appear to be extremely efficient in reducing the potential spread, and together with some detection of asymptomatic cases could offer the possibility of a sustainable planning for the whole year. besides containing the covid- diffusion, these solutions could be pedagogically acceptable, and could also become a driving model for the society at large. in this work we focus on a single school. to model the diffusion of covid- among the personnel and the students of the school, we set-up a suitable system of ordinary differential equations. in particular, we consider seair, a version of the sir model [ ] with an external source of infection [ , ] , and a control. the population is divided into: susceptible (s), pre-symptomatic or, equivalently, exposed (e), asymptomatic (a), infected (i) and recovered (r). variables are normalized so that s + e + a + i + r = . we assume that susceptible individuals might become pre-symptomatic or exposed (e) at transmission, entering a latency period in which they have contracted the virus and are contagious, without showing symptoms. the contagion can be caused by contact with other individuals with viral load, at a rate βc(t) (c(t) is the control, as described below); or, alternatively, it is caused by an infectious contact outside the school taking place at rate α. the asymptomatic members of the school community present a challenge, as they cannot be easily detected while still being infectious for a relatively long time: we assume accessibility to some type of fast screening with sufficient sensitivity [ ] : the contacts with asymptomatics within the school are then reduced by a parameter η, the false negative rate of the screening procedure. exposed individuals either develop symptoms at a constant rate δ, becoming infected, or progress into being asymptomatic with rate γ. the viral load is carried by exposed (e), asymptomatic (a) or infectious (i) individuals; however, infectious individuals are assumed to be isolated, while a large fraction of asymptomatic (a) is supposed to be detected by the screening procedure. both asymptomatic and infected individuals recover at rate ρ. as covid- mortality is particularly low in a mostly young population [ ] , we disregard mortality. the key differences with the usual seir model [ ] are: an external source of infection [ ] , [ ] , the possibility of transmission limited to hours per working day; a control indicating from the start whether, for each day, schools are open or closed; and the presence of asymptomatic individuals. with these assumptions, the system of ode modeling infectious transmissions of concern for the school is: exposed: infected: recovered: j o u r n a l p r e -p r o o f for a certain time interval [ , t ]. we consider weeks, and count time in hours, so that t = . the initial population at the beginning of the school year might be partly immune due to previous infections, but to avoid issues about efficacy and duration of the immunity, we assume that the initial population consists primarily of susceptible, s( ) ≈ , and a small fraction of exposed, so that s( ) + e( ) = . the function c(t) describes the control variable, and c(t) = for all times when the school is closed; these include all hours except from am to pm of those working days in which it has been decided that the classes are in person. for each of the working days, c(t) can be again if remote activities have been decided for that day, or if teaching is in person. formally, with t measured in hours, let m indicate the class of controls c(t) such that for some c i,j ∈ { , }, i = , . . . , , j = , . . . , , and ≤ t ≤ . lemma . . for each solution of ( )-( ), the total population s +e +a+i +r is preserved. in addition, ≤ s, e, a, i, r ≤ proof. let φ(t) = s(t) + e(t) + a(t) + i(t) + r(t); we have that φ( ) = and dφ dt = for all t from ( )-( ); it follows that φ ≡ by uniqueness of solutions of linear differential equations. in addition, r( ) ≥ and r ≥ , so that r(t) ≥ for all t. the other functions have to take the value before becoming negative by continuity. if i(t) = for some t, then i (t) > unless e(t) = , and the same applies to a(t), therefore let's consider the case that e(t) = . but then e (t) > unless s(t) = . in this last case, ( ) implies that all derivatives d n s(t) dt n = , in which case s(t) ≡ ; on the other hand, the system ( )-( ) with s = and nonnegative initial condition has an explicit, unique solution, which is seen to be non negative. proof. let x(t) = (s(t), e(t), a(t), i(t), r(t)) and express ( ) where is the number of hours in a week. take k = . extending c(t) = c for t ≤ , the conditions of peano's theorem are satisfied ( [ ] , ch. , th. ), so that there is a solution to the initial boundary value problem ( )-( ) for some positive t's. by considering r as above, one can see that the solution can be continued to the boundary of r ( [ ] , ch. , th. ), which is t = . in addition, as each component of x(t) satisfies x i ≤ by lemma . , f (c, x) is seen to be lipschitz in [ , ] × { x : x i ≤ for i = , . . . , }. hence, the solution is unique (see [ ] , ch. , th. ). the same reasoning can now be repeated from t = and with initial conditions given by the limit t → of the unique solution determined in the previous time interval. as c(t) has only jump discontinuities, the same procedure can be repeated in each interval, (see [ ] ), to show that there always exists a unique solution for all times t of the system ( )-( ). we are, however, interested in a finite time interval t , and hence in the transient solution up to time t . in the first part of the analysis, we will explore the effect of the opening policies on the number of remote teaching days and infection spreading. for this, we need an appropriate parameter selection. we make a first choice based on current observations, and present results in section , and then evaluate the modifications for a wide range of possible values in the sensitivity analysis section. as time is counted in hours, we need to scale all available parameter estimates, usually expressed for time counted in days, by a factor of . estimates of the infection rate β are typically around . - . [ ] ; however, as the school is likely to elicit more frequent contacts, we adopt the somewhat higher value of β = . / ≈ . × − . the value of β can also be computed from contact matrices and susceptibility. [ ] has contact matrices in school for most countries: averaging the contacts for class ages − with a factor for the number of classes, one gets an average number of daily contacts varying between (germany) and (italy); the contacts need to be revised by the recent containment measures, and related awareness of the population; a reasonable figure would be a factor of / . covid susceptibility (probability of infection upon contact) in school is estimated around . - . , see [ ] figure (b) as our equations are written for the school population only, which is about / of the total population, one needs to use a scale factor ; in addition, one needs to divide by to have the hourly contact number during school hours. in the end, estimates of hourly β range from β m ≈ . × / × × / ≈ . × − to β m ≈ . × / × × / ≈ . × − (this is a range of . - . for the daily β), in line with our choice above. in the stability analysis we consider the other values in this range. the duration of the latency period after infection and before symptoms are developed has been estimated at about days (see for example [ ] and [ ] ), so that γ + δ ≈ / × / = . / ; the clinical fraction, which is the fraction of symptomatic cases, depends on many factors [ ] , and it is substantially lower for younger individuals [ ] . we take a ratio of about , which is γ = . / ≈ . × − , and δ = . / ≈ . × − similarly, the average recovery period is about days, for mild cases [ ] , suggesting ρ = . / ≈ . × − ; more severe cases (i) are excluded from contacts, so their recovery rate is irrelevant: we use the same value of ρ. the parameter η describes how asymptomatic individuals are excluded from contacts with the other individuals; such a separation depends on the availability of detecting tests: we assume that a sufficiently reliable test is available, with a % test sensitivity, so that η = . . this assumption is subject to parameter sensitivity analysis in section below, where we see that a test sensitivity of at least % is needed for our calculations to make sense. we finally consider the external rate of infection. this is due to encounters of infectious individuals from the schools with others outside of the school; it is primarily based on the number of presymptomatic and asymptomatic individuals in the region around the school. this number is clearly unavailable, but an approximation can be obtained from the number of active cases, which is a well established figure [ ] : since about half of the infected shows symptoms, and the symptomatic period lasts longer than (perhaps times as long as) the asymptomatic, which itself lasts as the presymptomatic period of everyone infected, the fraction of presymptomatic and asymptomatic together is about the same as the fraction of active cases; the asymptomatics are not assumed to be detected outside of the school, so we take the density of active cases as a proxy for the density of infectious individuals that can be met outside of the school. a survey of the current situation in about countries shows that the fraction of active cases to the population ranges between . × − and . × − (see [ ] and supplementary material). this number must then be multiplied by the average number of contacts, similar to what done above to estimate β. as external contacts are, for the most part, between students and other individuals outside schools, we use the corresponding matrices in [ ] , with entries averaged over the various age classes: the averages vary between . for germany and . for italy; we then add a factor / for reduced mobility and awareness. susceptibility is taken again at . - . , and the scale factor is . plausible values of α are then in the range from . × . we take an intermediate external infection rate α ≈ . × − . with this value, in the observation period of weeks there is a moderate, but non negligible number of cases even if the school is totally closed; with our selection of parameters the individuals infected outside of the school will be about . % of the total. the parameter α will be carefully monitored in the sensitivity analysis, where it is seen that our optimality results are insensitive to the specific j o u r n a l p r e -p r o o f value of α provided that this lies in a specific range. to aid readability, one can consider an approximate conversion factor of . (to be adapted to local characteristics) between α and the density of active cases: α ≈ . × − corresponds to an overall density of active cases of approximately . × − / . ≈ × − active cases, or active case in inhabitants. this conversion factor and the above range of α will also be used to give a tentative indication of which countries can reopen schools and which cannot. table : recap of the model parameters and their estimated values. as initial condition, we consider two possibilities. in the first one, we assume that there are a few (about %) exposed individuals already present at the start of the school year: we start from e( ) = . . all others are susceptible, so s( ) = . . in the second, we assume that a careful screening is carried out at the beginning of the school, so we take s( ) = . in the second part of the analysis, we introduce a loss function which incorporates the aim of the planner to maximize the number of days with in-class vs. remote teaching, and simultaneously minimize the number of extra infectious transmissions due the opening of the school. for this, it is essential that the planner determines the relative weight τ of these two objectives. once a value of τ is fixed, the aim of the planner becomes that of minimizing a functional that combines these two objectives by the relative weight. to achieve her/his targets, the planner can fix a school calendar, deciding ahead of time which days are in-class and which are restricted to remote teaching; for simplicity, we consider here a plan for the whole year, but monitoring and en route adjustments can also be incorporated. we remain agnostic as to the value of the relative weight τ , and develop tools to analyze all possible scenarios. let s (t) be the fraction of susceptibles at time t in the hypothesis that teaching is completely remote, that is with c ≡ ; s ( )−s (t ) is then the fraction of individuals who receive an infectious transmission even if the school never opens; then, let s(t) = s c (t) be the fraction of susceptibles with opening plan c(t); we is the fraction of extra infectious transmissions due to the opening of the school j o u r n a l p r e -p r o o f journal pre-proof according to plan c(t). in addition, let n (c) = − t c(t)dt/ be the number of remote teaching days (the factor / is due to the number of hours that the school is open in a regular day). the loss function combining the two effects is then where τ is the relative weight of a day of in-class teaching to infectious transmissions: τ / can be interpreted as the number of days of in-class teaching that the planner considers equivalent to a % increase in the infectious transmissions in the school. the planner's objective becomes then with m as in ( ). it is easy to see that using the system ( )-( ) the optimization problem can be cast in a more standard form [ , ] , in which where e (t) is the exposed component of the solution of the system ( )- ( ) for the case c ≡ ; however, as we optimize over the very restricted class of functions ( ) , which are piecewise constant and depend on the finite number of parameters c i,j 's, the general theory of control optimization is not needed here: ( ) becomes a discrete optimization problem. once the parameters have been selected, for instance with the values given in table , we have optimized for each fixed value of τ ∈ [ . , ] by simulated annealing [ ] . for simplicity, we assume here that the decision about remote or in-class teaching is taken for each week, so the control c i = c i,j depends only on i = , . . . , . this still includes possible policies. for a fixed value of τ , we take vanishing "temperatures" k = e −k with ∈ ( , ], and a random initial configuration c ( ) (τ ) = {c , . . . , c } ∈ { , } . at iteration k = , . . . , , a random position m between and is selected and c m is changed intoc m = − c m , whilec m = c m for all other m 's. the system is solved using the opening rulec, and the loss function is computed in the solution. if the loss decreases, then c (k+ ) (τ ) =c; else, we set c (k+ ) (τ ) =c with probability k and c (k+ ) (τ ) = c (k) (τ ) with probability − k . we then repeat by drawing a new random integer m. this is repeated times for each initial configuration. the sequencec (k) (τ ) tends to a (local) minimum of the loss functional; the outputc(τ ) =c ( ) (τ ) of iterations is retained as a candidate (close to) optimal strategies for the given value of τ . in addition to the above, all the configurations c (k) (τ ), k = , . . . , , not only the (close to) optimal ones, are recorded for several values of τ , to get an j o u r n a l p r e -p r o o f idea of the possible scenarios. figure reports remote teaching days vs. fraction of infected in school at the end of the school year for each c (k) (τ ), k = , . . . , and for various values of τ . as benchmark cases we consider the full closure and the complete opening of the school, which is to say, the two most extreme choices of a fully remote teaching or regular hours a day in-class activities for the whole year. as we have assumed that there is a constant source of external infection in the region surrounding the school, even if the school is completely closed, which is c ≡ , the simulations based on ( )-( ) determine a number of cases. we have simulated the fraction of cases at school year end, and the number of cases in a school of individuals in the first two months. the parameters are those selected in the section . , except that we consider a variety of possible rates for the external source of infection. for example, for α = × − , we have that with the school completely closed there would be about . % cases (a+i). in a school with individuals this means that about individuals of the school would be infected (with or without symptoms) in the course of the year from contacts outside of the school. at day the number of infected individuals showing symptoms is about , and we assume that this is in line with the rate of infection in the overall community. if the school is completely open, on the other hand, simulations with c ≡ show a fraction of infected of about . % at the end of the school year, with already % of new cases, infected or asymptomatic, in the first days. in a school of , one would observe about cases, with perhaps a several symptomatic, in the first days, vs. the expected and very likely no symptomatic; a deviation which would not pass unnoticed. table compares the percentage of cases at the end of the school year, and the number of likely cases in the first two months, in the two cases of completely remote and fully in-class teaching. the values of α can be either determined from open cases in the area, contact matrix and susceptibility, as done in section . , or from the fraction of infected (a+i) that it causes at the end of the observation period. this last fraction is called seropositivity, and it is discussed in [ ] and [ ] ). seropositivity at the end of the school year, assuming the school is closed. is in table , column . the range of α covers all cases of interest. in table we assume that there are no active cases in the school at the start of the school year due to a sufficiently accurate initial testing. there is not much difference if we assume a % active cases for the largest values of α, but this last assumption would not be appropriate for small values of α and hide the possibility of opening the schools with almost no restrictions should one can see that complete opening of the school determines about a four fold increase in the number of cases, except for the extreme cases. if the virus is completely under control, which is less than active cases per million, or α < . × × − ≈ − , then the number of cases is so limited that schools can be safely reopen completely (with an initial screening and maintaining the physical distancing measures that are controlling the spread of the virus). if, on the other hand, there are more than about active cases per million in the surrounding region, or α > − then opening the school would not particularly aggravate the situation; but the number of cases is already so high that drastic measures need to be taken, such as keeping all schools closed. the conclusion is that, except in the extreme situations of almost complete elimination of covid- , or uncontrollable outbreak, the number of cases registered in a fully open school is likely to raise concerns from authorities before the end of the second month of school opening in any reasonable scenario; this is very likely to lead to the application of containment measures to the school, such as a forced, unplanned remote teaching. for these reasons, since this situation is likely to occur in most schools and in almost every external evolution of the epidemic, simulations indicate that it is advisable to attempt a sustainable, partial opening. this is the question faced here below. journal pre-proof with the reference parameters identified in section . , we have explored various opening strategies; for each policy c we have recorded the total fraction of infected, measured by the marginal decrease in susceptible s c ( ) − s c (t ), and the total number of remote teaching days n (c). recall that we consider policies with opening or closure applied for entire weeks. one can notice that, due to the form of the loss functional, some policies c are uniformly better than others regardless of the value of τ : define c as strictly preferable to c if s c ( ) − s c (t ) ≤ s c ( ) − s c (t ) and n (c ) ≤ n (c ) with at least one inequality strict; if a policy admits another one which is strictly preferable, the first policy can clearly be disregarded. we say that a policy is perfect with respect to the loss functional if there does not exist a strictly preferable one. on the other hand, once a value of τ is fixed, an optimal policy for τ is a policy minimizing the functional in ( ) . clearly, an optimal policy for some τ is perfect with respect to the loss functional, and, vice versa, a perfect policy with respect to the loss functional can be optimal for an interval of values of τ . in figure we plot remote teaching days vs. fraction of infected in school at the end of the school year for each c (k) (τ ), k = , . . . , and for various values of τ ∈ [ . , ]. such range corresponds to between . and days of in-class teaching rated equivalent to a % increase in the number of infected. notice, though, that figure does not allow one to retrieve the value of τ . one of the (likely) perfect opening strategies is represented by the red dot: it is very likely optimal for τ around . notice, finally, that the figure reports some, but very few of the strategies that are far from perfect or optimal. there are many others that our runs of the simulated annealing algorithm never visited. figure : fraction of extra infected, next to the . %, vs days of remote teaching, for several opening strategies. the potentially perfect, and hence optimal ones for some values of τ , are close to the continuous curve. one special possibly perfect and hence optimal solution corresponds to the red dot before turning to the exploration of specific optimal strategies, let us discuss j o u r n a l p r e -p r o o f the solid line in figure . experimentally, we have noticed that the outcomes of the perfect policies seem to lie close to a specific curve c, which corresponds approximately to where x is the percentage of covid- cases in the school population, and y is the number of remote teaching days. the curve c can be thought of as parametrized by τ , the relative importance of in-class teaching and covid- cases; in an abstract sense, each point on the curve c corresponds to one value of τ , although, as mentioned above, by the discrete nature of the opening strategies, more values of τ give the same perfect strategy. as indicated before, the red dot corresponds to a perfect strategy which is optimal for τ ≈ (see below). this curve c is of both theoretical and practical importance. in fact, . turns out to be a characteristic exponent of the comparison of opening days vs. extra infected; theoretically, it is quite interesting to explore the analytical reasons behind the appearance of such a curve; its role in the analysis of the solutions of the differential system ( )-( ); and the functional dependence of the value of the exponent on the values of the parameters in the system. in practice, if one was able to have some information about the dependency of the exponents from the parameters of the model different from τ , this would give an explicit benchmark for perfect strategies: for instance, if one fixes the number of opening days, then the curve indicates the best result that can be ideally achieved in the containment of the infection, or vice versa, without the need of an explicit numerical minimization. in this section we show one example of (nearly) optimal policy. as mentioned, a choice has been required by the policy maker: such a choice could have consisted of the minimal number of opening weeks, or of the maximal fraction of cases which is allowed by the circumstances. however, we adopted the less intuitive, but more intelligible possibility of using the relative weight of remote teaching vs. percentage of cases, as incorporated by the parameter τ (see section . ). we consider the parameters identified in section . and τ = , which means that days of remote teaching are considered equivalent to a % increase in the number of cases. the aim of the planner becomes then to solve the optimization problem ( ) , with the functional l defined in ( ). this can be achieved by a discrete optimization in { , } . we use here simulated annealing with iterations from a random seed, repeated for random initial conditions. the (possibly) perfect opening strategy indicated by the algorithm is ( , , , , , , , , , , , , , , , , , , , , , , , , , , , , ( ) , , , , , , , , , , , ) where indicates a week of remote, and a week of in-class activities; notice that there is an initial period of closure, before progressing to a regular alternation j o u r n a l p r e -p r o o f journal pre-proof of openings and closures. this is due to the assumed presence of % of cases at the start of the school year, and could be avoided with a very efficient screening before the start of the school year. the solution in ( ) has days of in-class teaching, with the additional infectious transmissions contained to . %, which is an increase of . % of the cases with respect to remote only activity. in a school of individuals this corresponds to creating an extra cases of covid- in the school year, in addition to the who would have been infected in any case. the administrators can decide to realize a stricter or more relaxed containment of the extra cases by assigning more or less weight to infectious transmissions. notice that the solution in ( ) is quite periodic, with alternated weeks of in-class and remote activities; figure shows the evolution of the epidemic functions under the policy in ( ) . table summarizes the change in infectious table : performance of optimal and random solutions with days of in-class teaching. first columns: total number of infectious transmissions; last columns: percentage increase with respect to remote only solution. "optimal" refers to the policy in ( ) identified by simulated annealing. we have also explored the possibility of selecting at random which weeks to open or close, with the constraint of having days of in-class activities, which is to say open out of the weeks. a simulation of the distribution gives that the increment in the number of cases is % on average, with a standard deviation of %, hence the solution in ( ) is more than sd's below what the average random selection would provide; in addition, it is also not subject to possible adverse fluctuations, so it is definitely preferable to a random, unjustified selection. it is, however, the case, that adopting a blended model with alternated open and closed weeks does provide in any case, even without optimization, a sizeable containment of the infection within the school. in section we carry out a sensitivity analysis, which shows that the optimal planning is pretty stable in case of some extra opening or remote days, and is only moderately affected by errors in parameter selection, within certain ranges. the optimal solutions turn out to be blended models, with approximately one week of in person teaching, and one week of remote learning. the pedagogical aspects of such models have been examined in various researches, for instance [ , ] it turns out that there are several advantages in blended learning: • in the current context, it seems to allow a sustainable programming of school operations; • it permits to take advantage of both in person and remote teaching, limiting drawbacks of both; one can, for instance, concentrate in person tests and labs for the in-class weeks, and less participative moments for remote teaching; • in general, it allows the use of a variety of learning modes and methods; • it can provide a pedagogical experience that can be replicated and expanded in the future in order to exploit new technologies while keeping regular personal contacts. of course, there are challenges, in particular concerning the ability of teachers and students to master the needed technologies and the alternating formats [ , ] . in addition, as schools could attempt planning in advance, especially if this is coordinated for most schools in some location, the regular economic and social activities could be somewhat adapted to the school calendar; for instance, more working hours could be planned during the weeks in which schools are open. clearly, there are several difficulties in implementing blended strategies, but the alternative, which is already unfolding in many situations, seems to be chaotic schedules, with schools attempting full openings, and then suddenly going back to closure as the first covid cases surface. we provide a sensitivity analysis in four parts. the first part concerns errors in the determination of the optimal solution. if one of the weeks for which remote teaching is planned by the optimal solution is instead changed to an in-class week, then the increment in the number of cases due to school opening ranges from an extra % to an extra %, compared to the extra % of the optimal solution. if one week is moved remote from inclass, then the increment in the number of cases is reduced to about %. this suggests that altering the number of weeks of opening is not optimal, but does not substantially change the final outcome: therefore, once an optimal policy has been determined, extra openings or closures can be adopted if needed without major changes in the final outcome. in addition, once the flexible blended model has been adopted, one can quickly and easily adapt to major changes in the external conditions, such as a sudden outbreak or a vaccine. the second part of the sensitivity analysis concerns each of the parameters of the model used to determine the optimal solution in ( ). we assume that the optimal policy has been determined, and observe deviations from the expected performance due to possible errors in the parameter determination. for each possible value of the parameters, we compute the fraction of cases in the cases of complete closure f cc , full opening f f o , and optimal solution f opt . then compare the percentage increase of optimal solution with respect to complete closure (f opt − f cc )/f cc with the analogous increment for the full opening (f f o − f cc )/f cc . such comparison is reported in table for the largest and the smallest values of (f opt − f cc )/f cc in the given range of the parameter. in addition, we indicate of each parameter the range of values for which the optimal solution achieves a substantial reduction with respect to complete opening, but limited to determining at most an % increase in the number of cases with respect to school closure. wee see that the most critical parameters are α, β and η. the range of α in which the optimization process has a change of being effective is − - − , which corresponds to about to active cases per million in the area around the school. for the infection rate β, the range in which optimization is effective is . - × − ; this is a very critical parameter, as observations in different countries lead to a range of . × − - × − . so, each region or country should monitor this rate and introduce strict measures to keep β within the above limits. finally, the fraction of undetected asymptomatic η must not exceed %: we assume availability of an easy, rapid and cheap test with a rate of false negative not exceeding %, such as crispr [ ] . the third part is about the selection of τ . in fact, the sensitivity to τ has already been discussed in section . : figure shows that the optimal strategies lie approximately on the curve c with equation ( ); even if the equation is not exact and the dependency on τ is not known analitycally, it nonetheless gives an idea of the variability of the optimal solutions as function of τ . the data plotted in figure has been obtained with τ ranging from to , which corresponds to a range between and days of in-class teaching equivalent to a % of extra cases. there is at most doubling of the cases for τ ≥ , and, correspondingly, for at least of remote teaching. this seems to indicate that next school year will allow no more than days of in-class teaching without pharmaceutical progress; recall that possibly one of two extra weeks can be gained with an efficient initial screening. the last part of the sensitivity analysis is about the weekly schedule. a possible alternative is to schedule opening or closure of the schools for each single day (still with a calendar fixed in advance). the optimization is now over possible policies. optimization by simulated annealing in this case determines a plot similar to that of figure . for instance, the optimal policy for τ = gives an increase of . % in the number of cases, vs. the . % increase of the weekly schedule; the daily schedule consists of of in-class teaching, instead of the which are considered by the weekly schedule. in summary, the daily schedule turns out to offer little advantage with respect to j o u r n a l p r e -p r o o f journal pre-proof the weekly option, but a more complicated implementation process. we have considered the issue of planning in-class activities for the school year ' -' . education is, in fact, one of the areas in which the measures to contain the current covid- pandemic have had a negative impact, with many countries and local authorities struggling to find acceptable plans for the next academic year. in this work we have focused on a single school. to aid the planning of teaching for the school, we have modeled the evolution of the covid- epidemic in the school by an extension of the sir model, with asymptomatic; an external, constant, source of infection; interactions within the school happening only during the hours of opening during week days; a reduced rate of encounter with asymptomatic due to a somewhat efficient screening system applied weekly. we have then determined realistic values for the remaining parameters of the model. next, we have set up an optimization problem, based on a preliminary assessment by the planner of the relative importance of ensuring in-class teaching vs. containing the epidemic spread. for each value of such relative importance and of the other parameters, we have carried out a discrete optimization by simulated annealing to obtain a (close to) optimal strategy within the space of all possible weekly opening policies. modeling of epidemic outbreaks by differential equations dates back to the original paper by kermack and mckendrick [ ] , with an enormous number of recent works on the current covid- outbreak. among these, [ ] discusses the impact of reopening various combinations of schools in england vs. keeping schools closed; results in [ ] are expressed in terms of the reproduction number r , and show that, in many cases, opening of all schools would bring the reproduction number above the critical value of . our model has many fewer categories and variables, and it is focused on one single school. in any case, our results also confirm that opening all schools is not advisable in uk, even with extra testing and blended models (see supplementary material). as far as optimization is concerned, methods similar to those used in this paper have appeared in many other contexts. in particular, several recent studies have considered optimal planning strategies in response to general epidemics [ , ] or, more specifically, to the covid- pandemic [ , ] ; to our knowledge, however, none has considered the current optimization problem for school planning. limitations. there are several limitations to our study. we use a variation of the sir model, in which we have averaged encounter rates and susceptibilities over several age classes and different countries to obtain reasonable parameters. it could be that local deviations from the values we have used might lead to sensibly different outcomes. the model includes no randomness, which, however, is an essential feature of both human interactions and virus spreading; randomness would also allow us to assess the variability of the predictions. as a result, there are no error bars in our predictions, except for the case of a random selection of the weeks of in-person teaching. the external infection rate is taken to be constant, as focusing on a single school does not allow us to model the evolution of the epidemic in the overall area. this rate, however, is not likely to be constant over a long period of time, but is subject to many variations due to expansion or containment of the outbreak. in addition, our results are only a first indication of a modeling methodology for the search of an optimal trade off between in-class teaching and containment of infectious transmissions. even if parameters are carefully and realistically selected, the values are based on information known at the time of this study; when a parameter has a wide range of variability we settle for one representative value; in addition, the worked out examples refer to an ideal school: for each particular concrete situation, one needs to adapt the model to the specific case. we also did not consider other alternatives, such as reducing the number of in-class students for each lesson. many possible alternatives could be conveniently incorporated in a more elaborate model. conclusions. first, we have seen in section . that the regular opening of a typical school would cause a multifold increase in the number of cases among the individuals involved with the school itself, both at days and at school year end. the only exception would be if the virus is under tight control in the region around the school, which is to say with less than active cases per million, in which case one can safely plan a complete reopening. if there are more than about active cases per million in the surrounding region, then the opening of the school would not particularly aggravate the situation; in that case it would, however, not be advisable to carry out any in person activity as the number of cases would be out of control (at least % of the school population in the first days of opening). the second conclusion, discussed in section . , is that careful planning of the opening weeks is capable of making a drastic reduction on the number of extra cases induced by opening the school. optimal or close to optimal solutions consist of blended models, with an alternation of weeks of remote and in-class j o u r n a l p r e -p r o o f activities; with about half of the weeks in class, for instance, one can reduce the number of cases by a factor of ; we have also seen that schedules with a choice between in-class and remote on a daily basis would not improve the reduction much. the likely cause of the need for the weekly alternation is the duration of covid- incubation period. the third result, in section . , is that to identify an optimal opening strategy suitable for a specific situation, planners are first required to explicitly incorporate into their objective the relative value of in-person teaching vs. reduction of covid- spread; once this is done, optimal or close to optimal solutions can be numerically estimated to produce one of the optimal or close to optimal strategies mentioned above. a random choice of the weeks of in-class activities would not reduce the number of new cases as effectively as an optimal choice, but would nonetheless achieve a substantial reduction with respect to full opening. in section we have also seen that the achieved reduction is preserved by small changes in the weeks of in-person activities. as such, one school could identify the number of in-class days or weeks, and slightly adjust the calendar to other needs. finally, in section , we have carried out a sensitivity analysis of the results. these have turned out to be rather stable for small errors in the selection of the model parameters. the more critical parameters are • the contact rate during school opening, a parameter which should be very carefully monitored and controlled via physical distancing and other measures; • the fraction of detected asymptomatic, for which schools should adopt some frequent and possibly not very expensive testing procedure; there is no need to have an exceptionally high reliability of the test itself, and we have shown viable opening policies based on reliability above %; • the external risk rate: as mentioned, one can achieve some control on the spread of the virus in the school only if there are no more than about active cases per million in surrounding area. based on the above broad indications, and pending adaptation to specific situations, we have determined for each country whether full opening is feasible, or whether a blended opening of schools for about half of the weeks, with systematic quick testing of all students and personnel, and physical distancing within the schools, would be sustainable. or whether, finally, school opening is not advisable in the current situation (see supplementary material). covid- educational disruption and response adverse consequences of school closures what will a return to school during the covid- pandemic look like? what parents need to know about school reopening in the age of coronavirus prepping to reopen, california schools desperate for guidance, money. calmatters what is a blended model of learning? by catherine lyst bbc scotland early transmission dynamics in wuhan, china, of novel coronavirus -infected pneumonia the temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov- : an observational cohort study brief: covid- outbreak leads city of gttingen to shut schools through cbsnews: coronavirus flare-ups force france to re-close some schools retrieved the results are in for remote learning: it didn't work research shows students falling months behind during virus disruptions projecting the potential impacts of covid- school closures on academic achievement edworkingpapers jimmy sarakatsannis, and ellen viruleg covid- and student learning in the united states: the hurt could last a lifetime mckinsey and company, working paper mathematical and statistical estimation approaches in epidemiology modeling and analysis of an svirs epidemic model involving external sources of disease childs: an introduction to compartmental modeling for the budding infectious disease modeler saliva is more sensitive for sars-cov- detection in covid- patients than nasopharyngeal swabs. medrxiv age-dependent effects in the transmission and control of covid- epidemics s: epidemic thresholds with external agents gian-carlo rota -ordinary differential equations ordinary differential equations susceptible-infected-recovered (sir) dynamics of covid- and economic impact arxiv preprint projecting social contact matrices in countries using contact surveys and demographic data estimation of the asymptomatic ratio of novel coronavirus infections (covid- ) inferred duration of infectious period of sars-cov- : rapid scoping review and analysis of available evidence for asymptomatic and symptomatic covid- cases optimal quarantine strategies for covid- control models arxiv preprint deterministic and stochastic optimal control optimization by simulated annealing lessons from a rapid systematic review of early sars-cov- serosurveys blended learning guide to blended learning crispr/cas gene editing technology and its application to the coronavirus disease (covid- ), a review a contribution to the mathematical theory of epidemics the impact of school reopening on the spread of covid- in england optimal mitigation policies in a pandemic a simple planning problem for covid- lockdown key: cord- -oig qrr authors: brüssow, harald title: covid‐ : test, trace and isolate‐new epidemiological data date: - - journal: environ microbiol doi: . / - . sha: doc_id: cord_uid: oig qrr in the absence of an efficient drug treatment or a vaccine, the control of the covid‐ pandemic relies on classic infection control measures. since these means are socially disruptive and come with substantial economic loss for societies, a better knowledge of the epidemiology of the new coronavirus epidemic is crucial to achieve control at a sustainable cost, and within tolerable restrictions of civil rights. this article is protected by copyright. all rights reserved. comprising ' participants (gudbjartsson et al., ) . very similar information was reported in data describing household transmission in wuhan, where children showed a % infection rate compared with % in adults. . likewise, in a study from hunan children had a threefold lower infection risk than adults . in contrast, the infection risk in children from shenzhen, china was similar to that in adults (bi et al., ) . however, all studies concur that disease in children is generally mild, if not asymptomatic. asymptomatic cases raise problems for contact tracing and containment, but it is currently not clear to what extent infected children transmit the disease. three asymptomatic sars-cov- -positive adolescents showed transmission to family members (liao et al., ) while data for transmission from children are still absent. one special problem should still be mentioned in this context: in italy, pediatric hospitalization decreased substantially during the covid- epidemic. when the general population avoids hospitals for fear of infection, it can have a negative health impact. an increased number of deaths occurred in italy due to delayed arrival of children in hospitals, while no child died from covid- in italy (lazzerini et al., ) . the fear of hospitals has also been responsible for a deficit in the treatment against stroke in adults in the us (kansagra et al., ) . the statistics for the covid- epidemic have shown that the older population has suffered the greatest loss of life, and that nursing homes have been hotspots for transmission. two detailed studies from the us document these given facts. at the end of february , a cluster of epidemiologically linked covid- cases were reported in several long-term care facilities in washington state. of those, cases were residents (median age y), % of them were hospitalized, and % died. in comparison only cases had been visitors, % of whom were hospitalized, but none died. further cases were among the health care personnel, of whom only % were hospitalized, but again none died. factors favoring the outbreak were: health care personnel who showed up to work with symptoms; some of the personnel worked at more than one facility; and some residents were transferred between facilities. in the early stages of the epidemic, contributing factors to this outbreak were: an unawareness of the risk; a lack of diagnostic tests; and inadequate personal protection equipment (mcmichael et al., ) . currently, . million us americans reside in nursing homes. one in ten of > ' accredited nursing facilities reported covid- cases. an epidemiological survey in such a facility demonstrated the extent of the problem: the first infection in this nursing home was introduced by a symptomatic nurse, and then a week later the first resident tested positive. a further days later, half of the residents from this unit tested positive for viral rna. during the following weeks, to % of the residents in other units of this home became infected, along with % of the staff. notably, more than half of the residents were asymptomatic when they tested positive for viral rna. four days later, % of them had developed symptoms. the rest remained asymptomatic. mortality was high at %. importantly, asymptomatic, pre-symptomatic, and symptomatic residents did not differ with respect to viral load and infectious virus release. all viruses showed identical genome sequences guangdong cases. in guangdong province of china, all return visitors from wuhan/hubei province, their contacts, and all of the local hospitalized patients were tested for viral rna. . million tests were used to identify ' sars-cov- -positive cases; patients had had exposure to infected people from hubei. half of the local transmissions occurred within households. by mid-february, the local spread was controlled, but in march new cases were imported from abroad. sputum samples showed the highest viral titers, followed by oropharynx, stool, and finally nasopharynx samples. critical and severe cases showed higher viral titers than moderate and mild cases, but the differences were small. viruses from patients were sequenced and compared with sars-cov- sequences deposited in the database. single nucleotide polymorphism (snps) were detected at nucleotide positions scattered through the viral genome; variant sites were only seen in a single virus isolate. on a phylogenetic tree, the guangdong sequences were interspersed between the viral sequences from wuhan and those isolated abroad, documenting a recent, single source outbreak of a virus showing a low mutation rate (lu et al., a) . usa west-to-east spread. the first case of covid- in the us was reported on jan at the northwest coast of washington state and was imported from china. from march to the number of cases in the us increased from to ' . epidemiologists investigated the first nine covid- cases on the east coast (connecticut) that were observed in mid-march with genome sequencing. only one sequence exactly matched the viral sequences from china, but the patient had not traveled to china. the viral sequences from seven further patients, clustered with a large us clade known from washington state, documented a rapid west-to-east national spread of the novel coronavirus in the us. international air travel restrictions had no, or low, impact on the epidemic spread in the us. the viral genome was rooted in a single ancestor coronavirus in wuhan by fewer than mutations, and it had accumulated about nucleotide changes per month during its spread across the us, which is a low mutation rate for a ' nucleotide long viral rna genome. with the portable oxford nanopore technologies minion platform, viral genomes were sequenced within hours after having received the sample, theoretically allowing near real-time molecular epidemiology of the epidemic spread (fauver et al., ) . china. in wuhan, index cases of patients suffering from moderate covid- symptoms (fever, cough, fatigue) were investigated for secondary transmission to household contacts. the average household size was persons. the index case persons remained at home for a documented number of days before seeking medical advice. in total, contacts ( %) were infected, without symptoms, and the rest experienced moderate disease. the time lapse between primary and secondary infections was days. the transmission probability was age-dependent: it was % in children and % in adults. the highest transmission rate was seen in to year-olds, but not in > year-old household members. spouses experienced a % infection transmission rate. when the index case was quarantined directly after symptom onset, transmission rate was % . in shenzhen, cases were recorded, % of which were detected through the surveillance of symptoms. most cases were mild ( %) or moderate ( %). only % of infections were associated with severe disease, which correlated with male sex and older age; patients died. the researchers identified ' close contacts for the index cases; % of these had become infected. an increase to % in the rate of infection was seen in those who lived or traveled with index case persons. interestingly, infection risk was comparable for all age groups ranging from to y old. however, half of the children showed no fever, and severe infections were rare in people under the age of . notably, % of secondary infections were traced to only % of the index case persons (bi et al., ) suggesting an important role of "super-spreaders" in infection transmission. it would be helpful for public health if characteristic traits of super-spreaders were known. adding viral-specific igg antibody tests to the toolbox of covid- have allowed the connection between three previously separated infections clusters in singapore. an infected traveler from wuhan attended a church meeting, thereby infecting a secondary person (case x), who transmitted the virus to another subject during a family gathering, who then transmitted the virus to a large number of people in a second church. case x tested negative for viral rna and represented the missing link between the events. case x showed a strong serological response to sars-cov- , then connecting the links in the chain (yong et al., ) . iceland. from among high risk icelanders (persons who were symptomatic, or had contact with infected persons, or who traveled to a high risk country) % tested positive for sars-cov- rna. children under years from that high risk group showed a % rna detection rate compared with % in subjects older than y. before mid-march, travel exposure to austria and italy was a common denominator in the positive subjects. after mid-march, travel to uk was the biggest risk factor. in mid-march, a representative sample of ' subjects from the general population of iceland ( ' inhabitants) was tested, and . % tested positive for sars-cov- rna. in april, another sample of subjects from the general population showed a similar rate of viral excreters. in the general population, males were more frequently virus-positive than females. the highest prevalence was seen in y-old subjects, while no children under y were infected. five hundred viral genomes, isolated from infected icelanders, were sequenced. the genomes were clustered into distinct clades. during the early epidemic phase in iceland, nearly all sars-cov- isolates belonged to the a clade which was also frequently found in central european populations. viral genome sequencing identified networks of up to linked infections. transmission occurred in the early phase via international travel, but later via infection from family members (gudbjartsson et al., ) . airborne: cough, sneeze and speech. australian engineers evaluated the literature about the reach of pathogen transmission by coughing and sneezing. the to meter rule has been set since the s by photography, physical calculations, and through simulations. distinct models (turbulent jets vs. puffs) have been used, but not all used appropriate parameters for humidity and temperature. it remains unclear which conditions apply to the human respiratory excretions when handling infected patients in a clinic (bahl et al., ) . newer high speed pictures of a coughing volunteer show a turbulent jet plume that extends over . meter (tang and settles, ) . high speed pictures of a sneezing volunteer revealed exhaled air, muco-salivary filaments and drops. the turbulent puff cloud disintegrated into droplets that settled within to m distance. some droplets evaporate and become suspended in the puff and travel a room within a few minutes to land to m away from the sneezing person (bourouiba, ) speech generated droplets in front of the mouth increased with the loudness of the voice. holding a cloth in front of the mouth suppressed the droplet detection (anfinrud et al., ) . a who communication led to a controversy saying that there is not enough evidence that sars-cov- transmission is airborne. who defines airborne transmission as being via aerosols as opposed to transmission by droplets. since most covid- transmission seems to occur through close contact, droplets have been considered to be the more likely vehicles. whatever the exact transmission route by air, avoiding crowds, standing next to a person for too long, and increasing the rate of ventilation in closed rooms without air recirculation are reasonable precautions (lewis, ) . physicians recommended face mask use, even when scientific evidence for its effectiveness is lacking, in comments to leading medical journals. recent reviews have concluded that: no randomized trials with masks have been conducted; that the benefit of masks over no masks (but not of respirator masks over paper masks) was shown in an influenza epidemic in australia; that some benefit of masks was seen when worn by symptomatic, but not by asymptomatic cases during an influenza epidemic; that no data exist which directly support the use of mask wearing by the public; that no significant effect was seen for household use of masks against influenza transmission. therefore, who initially recommended masks only for symptomatic cases. cdc first advised against mask use by the public but have now changed their policy by recommending even self-made cloth masks for wide use. harm (e.g. increase of co level under the mask) is low if not used by small children or elderly people with disabilities (cheng et al., greenhalgh et al., ) . as assessed by viral rna detection, air and surfaces in a wuhan hospital were widely contaminated during the height of the epidemic in china. contamination levels were greater on the intensive care unit ward than on the general ward. the transmission of sars-cov- might reach up to meters distance. however, no medical staff in that particular hospital was infected. the authors admit two limitations of the study which prevent firm conclusions from being made. first, viral rna detection does not mean infectious virus detection, and second, the minimum infectious dose of sars-cov- for humans is unknown . when reviewing the official recommendations, the consensus seems to be to use a respirator for high risk interventions which create aerosols in the icu, and to use surgical masks on the general ward with low risk activities (bahl et al., ) . singapore hospital. the environment of three covid- patients from a ventilated hospital infection ward in singapore was tested for viral rna presence by rt-pcr. after routine cleaning of high touch areas and of the floor, no viral rna was found in the air, on hospital room surfaces or on the personal protection equipment of the treating physician. before routine cleaning, however, of room sites (table, chair, floor, window, toilet) and the shoe protection of a physician tested positive. room air samples and hospital corridor floors were, however, negative for viral rna. for infection control, regular room cleaning and handwashing were judged to be essential (ong et al., ) . primit study. it is more problematic to establish a control when a family member with mild infection remains at home. there is only one behavioral intervention study that has proved to reduce respiratory viral transmission within households, the primit germ defense study. the key interventions are web-based instructions about handwashing given to ' intervention subjects in uk, but not to ' controls. infection transmission was reduced by % and infection severity was also reduced, albeit modestly (little et al., ) . the rationale behind the idea was to reduce the viral load by which contacts are particularly exposed, such as through hand-to-eye contact, since the conjunctiva supports sars-cov- replication (hui et al., ; little et al., ) . in italy, the epidemic started in lombardy and veneto. lombardy strengthened their hospital capacity and increased icu beds, while veneto opted for strict containment and mass testing in % of the population. lombardy experienced ' more cases than veneto and also had a much higher crude case fatality rate ( % vs %). the higher death rate is probably explained by the delayed public health response (odone et al., ) as also seen in the us (anonymus, ) . the swedish government had recommended a number of trust based measures (social distancing from old people, handwashing, home office, travel reduction), but refrained from closing borders, schools, restaurants and bars, partly because the swedish law does not allow lockdowns. the case reduction of seasonal influenza and norwalk diarrhea provided documented effectivity of the measures taken (paterlini, ) . however, compared with neighboring finland and norway, sweden experienced a tenfold higher number of deaths for a . fold larger population, but the absolute numbers are still small ( vs. for sweden and finland, respectively, may ). in the us, the individual states and cdc have many legal options for quarantine (for the segregation of exposed people) and isolation (separation of infected people from the general population) in such cases as with sars. the establishment of broad sanitary cordons in which entire geographical areas are quarantined (as has happened in wuhan) will raise constitutional questions in the us. the us recommendations say that patients who show mild symptoms should stay home and notify their employer electronically. low-wage workers cannot afford to stay off work, but the us senate is in the process of establishing bills for paid sick leave and unemployment insurance (parmet and sinha, ) . kong. the control measures that stopped the epidemic locally have included: intense infection surveillance of incoming travelers; isolation of covid- cases in hospitals; contact tracing and quarantine in holiday camps; and school closure but no lock-down, thus preventing the crisis from having a negative economic impact. a total of cases were confirmed, half imported, and the rest locally transmitted with a reproduction number that quickly decreased to values around ; and % of virus-positive subjects were asymptomatic. the control measures also stopped an ongoing seasonal influenza epidemic. surveys showed that the population agreed to participate in the measures. they kept social distancing and made behavioral changes ( % wearing masks outside house, % increased hand hygiene, % staying at home as much as possible). the study could not differentiate the impact of each individual measure. unfortunately the full effect of school closure is still unknown because the susceptibility of children for covid- and their capacity to transmit the infection has not yet been established . china has contained the covid- epidemic through a combination of different measures including drastic ones. an international team of epidemiologists developed a computer model that described the dynamics of the epidemic and tested the impact of the different containment measures by using computer simulations. without any intervention, a -fold higher number of cases would have occurred in china, resulting in over million cases. without travel restrictions, the epidemic would have expanded more widely over the western provinces. early detection and isolation of patients reduced the number of cases by fold, while social distancing and contact reduction led to a . -fold reduction. however, without contact reduction, the epidemic would have, over time, increased exponentially across the regions. initiating the intervention one week earlier would have decreased the number of cases by % or, if done one week later the number of cases might have increased by -fold. a delay of or weeks would have increased cases by -and -fold, respectively. lifting travel restrictions will result in a new rise in case numbers, but even moderate levels of social distancing could keep this increase in check. partial maintenance of npi may prevent, or at least delay, the arrival of second wave infections (lai et al., ) . contact surveys were conducted in wuhan and shanghai during the height of the covid- epidemic in china. before the epidemic, people reported between - contacts (two-way conversations, physical contact) per day. this number was reduced to during the containment period. contact reduction was most significant for school-age children who, before the intervention, reported the greatest numbers of contacts out of all of the age groups, followed by adults at the workplace. during containment, contacts were mainly within families ( - %). the survey was consistent with data from inner city mobility. all contacts of patients in hunan province were placed under medical observation and tested for excretion of viral rna. from these contact data it was deduced that children (< y) had an infection rate that was only a third as high as adults ( - y), while older individuals had a % higher infection rate than young adults. based on these data and on a mathematical infection model, the authors concluded that social distancing alone is sufficient to control covid- spread. proactive school closure alone cannot interrupt transmission but can reduce the peak incidence of the disease by half, and it can delay the epidemic ). these are model simulations based on assumptions on infection transmission by children for which only few data are currently available. the reopening of schools in several countries will hopefully settle some questions with observational data. psychologists argue that contact-seeking is a basic human response to danger. this inclination takes over when an invisible infection threat is perceived. this instinct is only opposed by disgust when infected persons show appalling clinical signs which is not the case for sars-cov- infected subjects in pre-symptomatic or asymptomatic state. it will be increasingly difficult for health authorities to impose social distancing, as proven by the street demonstrations against containment measures in the us and in european countries by differently motivated opposition groups. the authors argue that the increased use of the internet as a substitute for contact can become an important public health tool to achieve physical distancing without social distancing (dezecache et al., ) . by may , the johns hopkins university registered . mio cases worldwide. the lion's share is from the us with . mio cases, compared with ' cases reported by china. one should interpret these data with caution. the definition for a confirmed case of covid- was changed five times in china, which accounts for the increase in knowledge about the epidemic. scientists from the who collaboration center in hong kong calculated that when the fifth version is applied, the total number of cases in china would increase from ' to ' , but the transmission patterns in mainland china would not change . the case number also depends on the intensity of viral testing and the capacity of the public health system to report the number of cases. with nearly ' deaths, the us number greatly surpasses the ' deaths reported in china. it is still difficult to assess the morbidity and mortality impact of the covid- pandemic on the population. even mortality rate is not a clear figure since it is reported differently in different countries. while death is a clear diagnosis, the cause of death isn't. it might not be evident whether somebody died with or from covid- , particularly in nursing homes. some countries attribute death to covid- if the virus was present at death. others attribute each death in nursing homes to covid- during the height of the epidemic -as was done in belgium, which explains its high mortality data. many deaths occurred while people also had underlying health problems (comorbidities), therefore they were already at increased risk of death. an international consortium of demographers called for the publication of excess mortality data. by comparing mortality statistics for a given epidemic period with a corresponding time period during previous years without that epidemic, the absolute impact of an infection can be assessed. such data are still largely lacking in the literature. excess mortality rates should best be calculated for both sexes and for each -y age range separately (leon et al., ) . first data have just now been reported: in march/april the care sector of england and wales alone has seen ' excess deaths over the figures of previous years. covid- deaths at care homes were three times as high as covid- deaths in hospitals (burki, ) . excess mortality calculations have been done globally for seasonal influenza, arriving at ' to ' influenza-associated deaths occurring annually (iuliano et al., ) . while the majority of influenza mortality applies to elderly people, the death rate is also substantial for children at an estimated ' deaths in . in comparison, the global death toll of covid- is now ' (status may ). a direct comparison of these two figures is difficult for two reasons: death levels are affected by vaccination campaigns against seasonal influenza and by strict containment measures for covid- . it seems plausible that without any containment measures covid- mortality would surpass greatly the number of deaths from seasonal influenza. the presumption that the covid- mortality is comparable to that of seasonal influenza deaths is fundamentally flawed because it compares numbers which are obtained by different methods. the death rate for covid- , which has just crossed the ' figure in the us, is an actual count of dead patients. in contrast, the ' to ' annual deaths from seasonal influenza quoted after influenza epidemics in the us are estimates by the cdc of influenza deaths based on calculations from models. the death counts actually reported to us health authorities ranged from ' to ' deaths per year during an influenza epidemic in the us. expressed as deaths per peak week, influenza claimed a maximum ' deaths per week, while covid- took about ' lives per week at its peak in the us (faust and del rio, ) . wuhan. an international consortium of epidemiologists has estimated that ' people were infected in wuhan and that have died; % were infected through household contact, % through public contact, and % in hospitals. from a peak number of new infections, wuhan currently has or fewer new infections per day. safe strategies are now needed for the exit from lockdown measures. when lifting the lockdown to a % pre-quarantine social contact level, a computer model showed that a % face mask wearing would be needed to ensure a complete elimination of infections. in contrast, with only % face mask use and a lifting date of strict measures before april to pre-quarantine level, the conditions in this model would lead to a major second wave of infection. maintaining a contact rate below pre-quarantine level combined with a high percentage of face mask wearing is essential while now the restrictions have been lifted in wuhan-at least until a vaccine becomes available. however, face mask provision for such large populations represents logistical challenges and must not cause a shortage of protective gear for health personnel (zhang et al., a) . in mainland china, ' confirmed cases and deaths were reported by march . in beijing and shenzhen, most cases have been imported from wuhan and the reproduction number r remained below . . in shanghai and wenzhou, local cases dominated but r rose to greater than for only one january week. case fatality was % compared with % in hubei. relaxing the restrictions could lead to a second wave of exponential infection from imported cases in a nonimmune, susceptible population. maximizing economic productivity under the < constraint can, according to this study, only be possible with a real time prevalence determination of new infections through extensive testing . other epidemiologists working on outbreak data from mainland china observed a sub-exponential increase of cases from the beginning, instead of an expected exponential growth for an unconstrained epidemic. model calculations showed that the containment measures (the quarantine of exposed, and the isolation of infected persons) which depleted the number of susceptible individuals for the virus, reproduced the actually observed case development. similar strategies are recommended in the event of a future outbreak (maier and brockmann, ) . harvard model. epidemiologists from harvard university derived projections from model calculations about the future dynamics of the covid- epidemic. when anticipating short term immunity (as observed for seasonal common cold coronaviruses), they predict annual winter epidemics for sars-cov- . with intermediate levels of immunity persistence, epidemics would become biannual. long-term immunity (as in the case of sars-cov) would lead to the extinction of the virus, even in the absence of social distancing. they also calculated that it needed weeks of social distancing to reduce the peak number of infected persons. if the reproduction of the virus is reduced by more than % through lockdowns, the infection peak is predicted to shift to the next winter season with high numbers because no herd immunity has been achieved (kissler et al., ) . a central concept of epidemiology is herd immunity; the percentage of persons with protective immunity needed in a population to stop the propagation of an infectious agent. when this threshold is crossed, the remaining susceptible persons are protected from infection. the threshold level depends on the "force" of the infectious agent which is expressed by the basic reproduction number r ,which is defined as the number of secondary infections caused by an index case. in infection modeling, herd immunity threshold and r are linked by a simple mathematical function. sars-cov- has a higher r "infectious force" than influenza virus, but a much lower one than "flying infections" such as chickenpox or measles. it is anticipated that a population needs a herd immunity of to % protected people to stop the covid- epidemic. the initial strategy of the uk government was to let the epidemic roll over the country to achieve this herd immunity, in contrast to containment policies which prevent exposure, but which also prevent immunity development in the population. this strategy has theoretical advantages (fewer economic losses when a lockdown is avoided, and a protected population in the event that no vaccine becomes available). however, it comes at a cost. if you allow, let's say, % of the population to get infected, you can calculate the cost of this strategy with the help of the infection fatality rate (ifr). in contrast to the case fatality rate (cfr) which expresses the number of deaths per clinically ill patients (which varies from . % to % for covid- ), ifr is the number of deaths per infected individual. the number is, of course, lower than crf. while we know, approximatively, the number of covid- deaths and covid- cases, we do not definitively know the number of infected persons, since this would require large and systematic seroprevalence studies, but which are lacking. current estimates suggest . % as a realistic approximation for ifr. with that figure, one can calculate that achieving herd immunity through natural infection with sars-cov- would cost the lives of ' uk citizen or more than ' ' us citizens. this death toll was considered as too high by the uk government, which then changed strategy by declaring a late containment strategy (randolphe and barreiro, ) . delays in imposing containment measures were predicted to lead to -fold or higher number of cases and fatalities. this prediction might explain why the us and uk have such high case and death statistics in international comparison. mobile phone technology. epidemiologists from the uk and us have developed a real-time datacapture platform applicable for mobile phone use for the self-guided collection of population-level data (cope consortium). the app queries location, age, health risk factors and asks daily for new symptoms and diagnostic test results. a test run with . million users in uk showed that the most common symptoms were fatigue and cough. anosmia (loss of smell) appeared as a strong predictor of covid- , while fever was not a diagnostic criterion unless combined with other symptoms. the reported symptoms predicted that there would be changes in the number of cases as indeed reported from health authorities to days later. the tool will be important for a controlled safe exit from confinement measures. also, long-term effects of the disease, and the impact of the covid- epidemic on social relations, mental health, and financial outcome can be evaluated with this tool. machine learning could also reveal new disease manifestations of the epidemic (drew et al., ) . anosmia is an interesting symptom. a preliminary evaluation of a covid- symptom tracker smartphone app from uk users showed that the loss of smell was reported by % of people with respiratory infection who tested positive for sars-cov- , compared with % of respiratory patients who tested negative. clinical criteria which allow a diagnosis of covid- without a viral rna test would be welcome for mass screening and telemedicine in an epidemic situation. french physicians have also reported that many covid- patients reported loss of smell and loss of taste, without nasal congestion. when these criteria were combined in a retrospective questionnaire this combination of signs had a sensitivity of % and a specificity of % for detecting covid- patients (bénézit et al., ) . these observations are not surprising since the highest expression level of the sars-cov- receptor ace- was shown in the respiratory tract, more specifically in the nasal epithelia. us physicians even suspected that sars-cov- might, in addition to the respiratory and alimentary tract, also infect cranial nerves (i.e. being neurotropic) which potentially explains the observation of neurological signs in % of covid- patients (chu et al., ) . seroprevalence studies. antibody tests are an important tool in a staggered release of population groups out of lockdowns because such tests identify people who have been exposed to the infection and who are potentially immune to infection. so far, only preliminary data became available from ' volunteers from santa barbara county in california. one out of ( . %) showed antibodies to sars-cov- . this number is -fold higher than the number of the official case count was for this area in early april. in a preliminary survey in geneva, less than % of a population sample showed viral-specific antibodies in preliminary surveys. in a town with ' inhabitants in germany, people were antibody tested following carnival parties and an infection rate of % was determined. these datasets cannot be extrapolated to the population at large. in addition, the antibody tests were only validated with a small set of positive and negative test samples, raising concerns about the reliability of the results (mallapaty, ; sood et al., ) . the next challenge will be the acquisition of reliable antibody data for representative samples from entire populations. the covid- epidemic continues to challenge our societies by its toll in deaths, by the disruption of social life; by its disastrous impact on the world economy; by increasing the debt of many nations; by endangering the survival of many industries; and by reversing the worldwide trend for poverty relief. for microbiologists, the covid- crisis has also revealed shortcomings in the public health sector, particularly in that of countries which were exemplary in this field during past decades. in the us, the covid- epidemic has taken more lives in one month than over years during the vietnam war. with more than . million cases, and more than ' deaths, the "america first" slogan has become sadly ironic in the context of covid- . an article in the leading us medical journal, the new england journal of medicine, attributes this calamity to insufficient diagnostic testing caused by the delivery of faulty tests by cdc; non-approval through the fda of working tests by who resulting in a delayed start of viral detection activities; and then followed then by a shortage of test reagents. public health workers were therefore blind to the unfolding of the us epidemic and unable to design efficient containment measures, short of a lockdown. epidemiologists were left without population data for modelling the epidemic in the us at a moment when the country started reopening economic and public activity. in comparison with other countries the us has tragically "failed the test". in the words of this article "the us once a leader, seem oddly lost" (schneider, ) . an editorial in the leading british medical research journal, the lancet, comes to the same conclusion: the cdc, once a pillar and international reference for combating diseases worldwide, instrumental in eradicating smallpox and coping with aids or ebola, has lost its technical competence and public trust due to contradictory scientific messages and the undermining of trust in scientific evidence by the current us administration. according to the lancet editors, the "us administration is obsessed with magic bullets-vaccines, new drugs-while only basic public health principles, like test, trace, and isolate, will see the emergency brought to an end" (the lancet, ). the situation is not better in the uk, once also renowned for its excellent public health research, particularly in the field of respiratory infections (remember the common cold research unit). at the end of may, the uk directly follows the us in the international mortality ranking list with more than ' covid- deaths. the late onset of large scale testing, the lack of personal protective equipment, and a delayed introduction of containment measures have certainly contributed to this high death toll. a correspondent to the lancet deplores that the situation in europe was no better with respect to the lack of a coordinated response to the pandemic. the european center for disease prevention and control (ecdc), which was established in to create a complement to the us cdc, failed to become a hub in europe of knowledge for covid- and a coordination center for europe-wide epidemic counter-strategies. ecdc is underfunded (cdc in : billion $, ecd million $) and understaffed (cdc: ' , ecdc: employees). an emergency structure for a pandemic was not set up, and ecdc played essentially no role in pandemic crisis management, which was done according to eu laws by national organizations without any european coordination (jordana and triviño-salazar, ) . even the city-state of singapore, where the early handling of the covid- was lauded as exemplary public health action, had "blind spots" on their screen in overlooking the miserable living conditions of migrant workers that became hotspots of covid- transmission. of special global health concern are refugee camps from bangladesh to europe. a refugee camp on lesvos/ greece has just one water tap per residents, making efficient handwashing an impossible mission (newland, ) . governments plan to spend billions on rescuing what they consider to be essential national industries. it will be important that they also find the money needed for covid- containment among migrant workers, refugees and populations at risk in developing countries . the beneficial epidemic effect of the lockdowns, obtained at enormous economic costs, would be canceled out if a second wave epidemic should start from these settings with relatively unrestrained viral transmission. at present it is not clear which institution, if not the united nations' suborganizations, will be able to implement such measures. when the leading nation of the western hemisphere leaves now the who, this is a disastrous signal for global public health at this crucial moment of the covid- pandemic. ) visualizing speech-generated oral fluid droplets with laser light scattering ' and counting. the economist presymptomatic sars-cov- infections and transmission in a skilled nursing facility airborne or droplet precautions for health workers treating covid- ? utility of hyposmia and hypogeusia for the diagnosis of covid- epidemiology and transmission of covid- in cases and of their close contacts in shenzhen, china: a retrospective cohort study investigation of a covid- outbreak in germany resulting from a single travel-associated primary case: a case series a sneeze england and wales see excess deaths in care homes wearing face masks in the community during the covid- pandemic: altruism and solidarity comparative tropism, replication kinetics, and cell damage profiling of sars-cov- and sars-cov with implications for clinical manifestations, transmissibility, and laboratory studies of covid- : an observational study impact assessment of non-pharmaceutical interventions against coronavirus disease and influenza in hong kong: an observational study ) pandemics and the great evolutionary mismatch rapid implementation of mobile technology for real-time epidemiology of covid- assessment of deaths from covid- and from seasonal influenza coast-to-coast spread of sars-cov- during the early epidemic in the united states asymptomatic transmission, the achilles' heel of current strategies to control covid- face masks for the public during the covid- crisis spread of sars-cov- in the icelandic population aerosol and surface distribution of severe acute respiratory syndrome coronavirus in hospital wards temporal dynamics in viral shedding and transmissibility of covid- estimates of global seasonal influenza-associated respiratory mortality: a modelling study where are the ecdc and the eu-wide responses in the covid- pandemic? collateral effect of covid- on stroke evaluation in the united states tropism, replication competence, and innate immune responses of the coronavirus sars-cov- in human respiratory tract and conjunctiva: an analysis in ex-vivo and in-vitro cultures projecting the transmission dynamics of sars-cov- through the postpandemic period effect of nonpharmaceutical interventions to contain covid- in china delayed access or provision of care in italy resulting from fear of covid- covid- : a need for real-time monitoring of weekly excess deaths first-wave covid- transmissibility and severity in china outside hubei after control measures, and second-wave scenario planning: a modelling impact assessment is the coronavirus airborne? experts can't agree the characteristics of household transmission of covid- epidemiological and clinical characteristics of covid- in adolescents and young adults an internet-delivered handwashing intervention to modify influenza-like illness and respiratory infection transmission (primit): a primary care randomised trial reducing risks from coronavirus transmission in the home-the role of viral load genomic epidemiology of sars-cov- in guangdong province sars-cov- infection in children effective containment explains subexponential growth in recent confirmed covid- cases in china antibody tests suggest that coronavirus infections vastly exceed official counts epidemiology of covid- in a long-term care facility lost in transition covid- deaths in lombardy, italy: data in context air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus (sars-cov- ) from a symptomatic patient children with covid- in pediatric emergency departments in italy covid- -the law and limits of quarantine closing borders is ridiculous': the epidemiologist behind sweden's controversial coronavirus strategy herd immunity: understanding covid- failing the test -the tragic data gap undermining the u.s. pandemic response seroprevalence of sars-cov- -specific antibodies among adults coughing and aerosols reviving the us cdc covid- : pcr screening of asymptomatic healthcare workers at london hospital effect of changing case definitions for covid- on the epidemic curve and transmission parameters in mainland china: a modelling study global burden of respiratory infections associated with seasonal influenza in children under years in : a systematic review and modelling study virological assessment of hospitalized patients with covid- connecting clusters of covid- : an epidemiological and serological investigation detection of covid- in children in early changes in contact patterns shape the dynamics of the covid- outbreak in china what is required to prevent a second major outbreak of sars-cov- upon lifting the quarantine of wuhan city, china. preprint to the lancet acknowledgements i thank jacqueline steinhauser and sophie zuber for critical reading of the manuscript. the author consults nestlé, his former employer, on the scientific aspects of the covid- epidemic, but he does not consider this as a conflict of interest. key: cord- -csdf a authors: raffiq, azman; seng, liew boon; san, lim swee; zakaria, zaitun; yee, ang song; fitzrol, diana noma; hassan, wan mohd nazaruddin wan; idris, zamzuri; ghani, abdul rahman izaini; rosman, azmin kass; abdullah, jafri malin title: covid- pandemic and its impact on neurosurgery practice in malaysia: academic insights, clinical experience and protocols from march till august date: - - journal: malays j med sci doi: . /mjms . . . sha: doc_id: cord_uid: csdf a the newly discovered coronavirus disease (covid- ) is an infectious disease introduced to humans for the first time. following the pandemic of covid- , there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. with pooling and outsourcing of more health care workers to emergency rooms, public health care services and medical services, further in-hospital resources are prioritised to those in need. it is imperative to balance the requirements of caring for covid- patients with imminent risk of delay to others who need care. as malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in malaysia. the crisis has certainly put a strain on the effective delivery of services and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in malaysia. the following details are various measures put in place as the new operational protocols for neurosurgical services in malaysia. the novel coronavirus, otherwise known as coronavirus disease (covid- ) pandemic in malaysia, is part of the worldwide ongoing pandemic which was first reported in wuhan china in december . malaysia's first case was confirmed on january , detected among travellers from china entering malaysia via singapore. malaysia's response overseen by the national crisis preparedness and response centre (cprc) under the health ministry began as early as january following world health organization (who) initial report of the disease in china. various hospital was designated specifically as covid- pandemic hospitals, gazettement of quarantine centres, reorganisation of health services, formulation of new operational protocols, stockpiling of essential equipment and redeployment of essential medical workforce and manpower to these centres; as well active detection, monitoring and treating covid- patients. these early response measures were escalated to a total lockdown of movement on march , intended to mitigate the spread of covid- , following the declaration of a worldwide covid- pandemic by who on march . the movement control order (mco) in malaysia lasting for a period of months, coupled by the intense proactive measures by the health ministry has successfully kept the number of cases relatively low comparatively, with a total recorded case of , with deaths. malaysia's proactive and stringent measures have and continue to receive international praise and recognition in successfully mitigating the spread and containing covid- transmission. as malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in malaysia. the crisis has certainly put a strain on the effective delivery of services, and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in malaysia. the following details the various measures put in place as the new operational protocols for neurosurgical services in malaysia. role and importance of dedicated operating theatre, instruments and icu care all tertiary hospital should have a dedicated operating theatre (ot) for suspected covid- patients ( ) . the ot requirements should be fully equipped with negative pressure ventilation (recommended). the maximal number of staff is six: i) one specialist; ii) one medical officer; iii) one anaesthetist; iv) one anaesthetist mo; v) one scrub nurse; and vi) one circulating nurse. for elective surgery, kindly refer to its section further below ( ) . limiting ot staff to essential members will help preserve the surgical workforce. the types of neurosurgery cases done are either cranial surgery or spine surgery. endonasal surgery should be avoided during covid- pandemic ( ) . table shows tiers for neurosurgery cases ( ) . a neurosurgical emergency includes cerebral haemorrhages (subarachnoid and intraparenchymal), acute hydrocephalus, tumours at risk of intracranial hypertension, spinal cord compressions with, or at risk of neurological deficit, and traumatic cranial and spinal trauma emergencies ( ) . (table ) ( ) for green level, all elective cases proceed as scheduled. for yellow level, the ot schedule is capped for weeks to % of capacity, yielding a % reduction in all elective and procedural cases. all outpatient procedures black level, significant state or federal resources are needed to fight the outbreak. all urgent scheduled surgical cases will be cancelled. this 'volume limiting approach' encourages maximal adaptability, in which the supply of hospital capability meets the demand for scheduling needs. should be designated to an off-site hospital where covid- patients are not expected to be admitted. there is a hard cap on the number of cases requiring post-operative admission; the -patient limit for all surgical cases (including non-neurosurgical cases). for red level, there is a % reduction in all elective case scheduling. for the team-based paired coverage will go into effect during red levels of covid- . in this model, each hospital (columns) will have three groups of providers. there will be two teams that switch coverage on a -day cycle. each team will cover for days, and then have days off while the second team covers. the transition between teams will occur virtually, avoiding unnecessary team-to-team contact. a backup group substitutes for any team member who shows signs of illness. if a team becomes contaminated, the other team will take over and the alternates will fill the gap. contact between teams and alternate is prohibited. each team will only rotate at one hospital (no cross-covering) and will only have contact with members within their team. teams at the same site will not have any overlapping clinical time with each other. this system ensures adequate coverage, minimises hand-off issues, and, most importantly, minimises transmission risk across teams. due to the likelihood of infection among inpatient providers, there will be a designated 'alternate pool' of providers that will substitute for those who show covid- symptoms. activation of paired coverage system (pcm) ( ) is triggered by a red level of surge. all residents are aware of their role in the pcm ahead of time. site-specific needs are addressed within the team. for example, teams at the main hospital are larger than teams at other satellite hospitals. the pcm is adaptable such that the number of team members can vary, along with the experience level of the team. the core function of the pcm (limiting healthcare worker transmission of the virus) remains. it is also important that neurosurgeons provide their anaesthesia colleagues, nursing staff and the ot with objective data about which cases should be expected to proceed during a covid- outbreak. neurosurgeons need to predict what cases should be classified as an emergency. a checklist that can be applied to neurosurgical cases during the covid- pandemic is as per figure . the checklists help organise surgical staff during times of crisis, such as guiding action during 'red alerts' from neuromonitoring during spinal surgery. the checklist strategy organises surgical staff around the common goal of booking cases during the outbreak. distribution of the checklist to all surgical staff will facilitate effective communication and the ease with which appropriate neurosurgical cases can be scheduled. surgical workforce ( ) the surgical workforce must be able to maintain emergency surgery capabilities including major trauma. it is important to protect and preserve the surgical workforce as well. these will include rotas where some members of the team do not come into work and act as a healthy reserve (refer to a -group setting [surgical team]). when not vital to the effort, keep surgical and anaesthetic staff out of hospital and self-isolating at home to preserve human resources. this will also allow personnel to rest before they return to clinical work. non-surgical solutions to be used to avoid surgery where possible. personal protective equipment (ppe) must be used correctly in line with national guidance. rest, recuperation and psychological support should be factored into all planning. ( , , ) pre-operatively, the patient must be tested for covid- and proceed if negative. full powered air purifying respirators (paprs) for surgeons and all team members in the ot for any of these cases that do actually need to move forward, either for cases in which we cannot wait for test results or for cases that test positive but still need to proceed. for urgent cases (that should be done within week), two covid- tests separated by h with the patient quarantined in the interval between tests before the surgery, with the surgery proceeding only if the results are negative for both tests. if covid positive, papr for all ot staff may be necessary until further data is available. for emergent/unavoidable case for a known or undetermined covid- patient, the surgeon and all ot personnel in the surgical suite should use papr, which filter the air being breathed in addition to face shields and other standard ppe. it is also vital for a cessation of positive pressure ventilation in ot during the procedure until min after the patient leaves ( ). the patient should be isolated and medical personnel should wear full ppe when nursing post-operative patients until covid- status is known. ( , ) regional anaesthesia (ra) is preferred than general anaesthesia (ga) to reduce aerosols. in ga, a negative pressure setting (risk of aerosol transmission) is required. the intubation and extubation are done with full ppe including papr or its equivalent. only essential staff should be present in the ot. postop management is done in the isolation room. thromboprophylaxis should be considered throughout the hospital stay. non-invasive ventilation should not be used. ( ) proper droplet precautions or proper decontamination processes should be followed. there should be an escalation of standard of practice during airway management for all patients to reduce exposure to secretions. hand hygiene should be taken care of with frequent hand washing using alcohol-based hand wash gels, which should be available near every anaesthesia station. the number of staff members present for intubations/ extubations should be limited to reduce the risk of unnecessary exposure. it is also recommended to strongly consider prophylactic antiemetics to reduce the risk of vomiting and possible viral spread. ( , , ) rapid sequence induction (rsi) and use a video laryngoscope (vl) with the goal of a high first pass success rate (fps) is recommended. iv sequence induction without bag mask ventilation is preferred to minimise exposure risks and aerosolisation. preoxygenation for a minimum of min with % oxygen and perform a rsi to avoid manual ventilation of patient's lungs and potential aerosolisation of virus from airways ( ) . rsi (ensure a skilled assistant is available to perform cricoid pressure) or a modified rsi should be performed as clinically indicated. if manual ventilation is required, apply small tidal volumes ( ). placement of a high quality heat and moisture exchanging filter (hmef) rated to remove at least . % of airborne particles . microns or greater in between the facemask and breathing circuit or in between facemask and reservoir bag is required. awake fibreoptic intubations are essentially contraindicated unless specifically indicated. ppe should be provided when performing an aerosol generating procedure. preoxygenation using a bag-valve-mask (bvm) that can be purposely modified for covid- patients with a viral filter, without squeezing the bag. the most experienced anaesthesia professional available should perform intubation if possible. a trainee should avoid intubations of sick patients during this time. the laryngoscope should be resheathed immediately post-intubation (double glove technique). used airway equipment should be sealed in a double zip-locked plastic bag and must then be removed for decontamination and disinfection. there should be no airway carts in the room. thus, appropriately sized equipment should be pre-packed for that patient. the use of deeper sedation extubation to prevent coughing is also preferable as long as the airway is safe. ( , , ) all anaesthesia professionals should utilise ppe appropriate for aerosol-generating procedures for all patients when working near the airway. 'rescue like' crash intubations where ppe cannot be fully adhered to should be avoided. correct donning and doffing of ppe should be adhered to. properly fitted n masks or paprs should be used for all patient. at a minimum, n masks should be used for all patients. for those who are not n fit-tested, have facial hair or fail n fit-testing, paprs should be used if possible. issuance of n masks or availability of paprs for all clinical anaesthesia personnel should be a priority. extended use and/or limited reuse of n masks should follow the centres for disease control and prevention (cdc) and institutional guidelines. a papr provides superior protection and may be warranted for airway procedures in patients with known or suspected covid- . for aerosol-generating procedures, this includes eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown and gloves, in addition to airway protection with n masks or paprs. effective hand hygiene before putting on and after removing ppe must be ensured. procedures for proper donning and doffing, disposal of contaminated ppe, and cleaning of contaminated reusable ppe and anaesthesia equipment should be established following cdc and institutional recommendations. the double gloving technique is used during intubation. the outer gloves are used to sheath the laryngoscope blade and change the inner gloves as soon as possible afterwards. after removing protective equipment, remember to avoid touching your hair or face before washing hands. during extubation, maintain strict hands hygiene, wear a mask with a face shield and carefully dispose of contaminated equipment. the use of two providers for ppe donning and doffing procedures should be encouraged, to allow one person to observe and coach the other through the steps of the routine. appropriate ppe and the procedures for donning and doffing ppe are available at the cdc webpage. approaches to conserve supplies ( , ) the administration should minimise the number of individuals involved. where feasible, use alternatives to n masks (e.g. other classes of filtering facepiece masks, facepiece air purifying respirators and paprs). n masks should be allowed for extended use and/or limited reuse. the use of n masks should be prioritised for that personnel at highest risk of covid- exposure and/or those anaesthesia professionals in high risk categories (e.g. those with prior health conditions, older age). staff should receive training in the appropriate donning and doffing of ppe taught through simulation and videos without using precious resources. in resource-limited situations, extended use of n masks (continuous wearing while seeing multiple patients) is preferred to limit the reuse of n masks (doffing and redonning between patients). n mask life may be lengthened and surface contamination reduced by wearing a plastic face shield or a surgical mask over the n (cdc respirator guidance). use of chlorine or alcohol solution to sanitise n masks is not recommended as it damages mask integrity. heating n masks to °c ( °f) in a dry oven for min seems a promising solution to disrupt viral particles and maintain mask integrity for reuse. further guidance from cdc and partners in health (pih) on reuse of n masks or best practices when no respirators are available (such as wearing two surgical masks) are available. in routine clinical care of covid- suspected or confirmed infections, surgical masks are acceptable ppe, except in the case of aerosol generating procedures (intubation, high flow nasal cannula, non-invasive ventilation, bronchoscopy, administration of nebulised medications, etc). facilities which do not have disposable surgical attire, theatre garb in the form of cloth scrub hats or bonnets should be washed between each use if possible and no less than daily. theatre gowns and drapes should be washed and sterilised between each patient as is currently expected. if theatre gowns are repurposed for isolation units, they should be washed after each prolonged care routine. if surgical ppe is not impermeable, consider wearing rubber aprons under linen gowns and always perform handwashing after doffing surgical ppe and before touching clean items or self. ot management and preparation during covid- ( , ) surveillance on possible further transmission to patients and other personnel should be done. covid- in a patient receiving surgery is sporadically reported with a special focus of management technique. surgical infection usually focuses on patient but it is important to give attention to the practitioner who works in the operation room. an ot with a negative room pressure environment located at a corner of the operating complex, and with separate access, is designated for all confirmed (or suspected) covid- cases. the ot consists of five interconnected rooms, of which only the anteroom and anaesthesia induction rooms have negative atmospheric pressures. the ot proper, preparation and scrub rooms all have positive pressures. understanding the airflow within the ot is crucial to minimising the risk of infection. the same ot and the same anaesthesia machine will only be used for covid- cases for the duration of the epidemic. an additional heat and moisture exchanger (hme) filter are placed on the expiratory limb of the circuit. both hme filters and the soda lime are changed after each case. the anaesthetic drug trolley is kept in the induction room. no unnecessary items should be brought into the ot, including personal items such as mobile phones and pens. before the start of each operation, the anaesthesiologist puts all the drugs and equipment required for the procedure onto a tray to avoid handling of the drug trolley during the case. nevertheless, if there is a need for additional drugs, hand hygiene and glove changing are performed before entering the induction room and handling the drug trolley. a fully stocked airway trolley is also placed in the induction room, as far as possible, disposable airway equipment is used. if single-use plastic anaesthesia or surgical equipment (endotracheal tubes, ventilator circuit tubing, plastic suction tubing, electrocautery handpieces) must be reused, ensure that disinfection aiming for 'high-level disinfection' or 'sterility' is employed. this includes immersion in appropriate concentration glutaraldehyde, phenol, or hydrogen peroxide solution for the recommended duration. the airway should be secured using the method with the highest chance of first-time success to avoid repeated instrumentation of the airway, including using a video-laryngoscope. equipment in limited supply such as bispectral index monitors or infusion pumps may be requested but need to be thoroughly wiped down after use. hospital security is responsible for clearing the route from the ward or intensive care unit (icu) to the ot, including the elevators. traffic should be minimised, especially opening and closing of theatre doors. patients with known or suspected covid- infection should wear surgical masks when being transported through hospital spaces or in rooms without negative pressure isolation. the transfer from the ward to the ot will be done by the ward nurses in full ppe including a well-fitting n mask, goggles or face shield, splash-resistant gown and boot covers. for patients coming from the icu, a dedicated transport ventilator is used to avoid aerosolisation, the gas flow is turned off and the endotracheal tube clamped with forceps during the switching of ventilators. the icu personnel should wear full ppe with a papr for the transfer. in the induction room, a papr is worn during induction and reversal of anaesthesia for all personnel within m of the patient. for operative airway procedures such as tracheostomy, all staff keep their papr on throughout the procedure. during the procedure, a runner is stationed outside the ot if additional drugs or equipment are needed. these are placed onto a trolley that will be left in the anteroom for the ot team to retrieve. this same process in reverse is used to send out specimens such as arterial blood gas samples and frozen section specimens. the runner wears ppe when entering the anteroom. personnel exiting the ot discard their used gowns and gloves in the anteroom and perform hand hygiene before leaving the anteroom. any papr will be removed outside the anteroom. patients who do not require icu care post-operatively are fully recovered in the ot itself. when the patient is ready for discharge, the route to the isolation ward or icu is again cleared by security (using an advance runner to clear the way). a minimum of h is planned between cases to allow ot staff to send the patient back to the ward, conduct thorough decontamination of all surfaces, screens, keyboard, cables, monitors and anaesthesia machine. surfaces in the ot should be thoroughly cleaned between cases including pulse oximeter probes, thermometers, blood pressure cuffs and other reusable materials ( % alcohol solution or . % chlorine solution). as part of minimising contamination in ot, in addition to surface cleaning, using clear plastic sheets (to be changed in between patients) to cover the anaesthesia machine, the monitors as well as the patient's face, especially during aerosol producing airway manoeuvres like intubation and extubation, is recommended. all unused items on the drug tray and airway trolley should be assumed to be contaminated and discarded. all staff must shower before resuming their regular duties. as an added precaution, after confirmed covid- cases, a hydrogen peroxide vaporiser will be used to decontaminate the ot. clear instructional posters for ppe donning/doffing should be prominently displayed. a taped off area just outside of the ot door should be clearly marked for donning and doffing activities. ( ) few steps must be emphasised to reduce the risk of contracting covid- among hcps. some precaution that needs to be taken note are: staff who are more at risks such as older adults (e.g. those over years), those with underlying medical conditions (e.g. heart disease, chronic respiratory diseases, cancer), those at risk due to an immunocompromised from a medical condition or treatment (e.g. chemotherapy) and pregnant staff should take care of the lower risk stream of non-covid- . ( ) ot is potentially a high exposure zones given manipulation of the airway and aerosolisation of respiratory particles, with anaesthesia providers at particularly high risk. it comes with the additional risk inherent in the presence of multiple staff members. the perioperative personnel are at an advantage given their familiarity with maintaining sterility. however, the ancillary staff such as ot cleaners, instrument reprocessing staff and laundry personnel may be at risk. hence, they should take appropriate precautions and wear ppe (goggles or face shield, surgical mask, heavy duty gloves, long sleeved gown, boots) to avoid exposure to contaminated materials. there are no special decontamination methods other than machine laundering with detergent are required for laundering linens; all surface areas should be disinfected with . % chlorine or % alcohol solutions. immediate surgical plan during pandemic ( ) a clear plan should be made to conduct essential operations. elective operations should be indefinitely postponed to preserve vital resources including hospital beds and ppe. exceptions are for cancer or highly symptomatic patients and as such the current guidance is not to postpone (table ) . each hospital must make a plan based on the current availability of resources. to facilitate decision making and avoid conflicts between patients and providers, a triage algorithm for identification of nonemergent conditions can be used. surgical emergencies still require prioritisation. funding must be adequate to support the hospital and staff with critical surgical services that will continue to be required despite the pandemic response. using a checklist to ensure appropriate precautions are taken for operations with suspected or known covid- infection is also important. simulation has been also helpful in establishing new routines in the ot. aerosolgenerating procedures that can be provided using other mechanisms should be avoided if at all possible (e.g. metered-dose inhaler instead of nebuliser treatment). further planning for the repurposing of ots to support critical care whilst not precluding the ability to provide lifesaving operative care is needed. surgical services are already underfunded and poorly prioritised in many health systems, so the commandeering of ots for use as icu, which has been proposed in many high-resource settings, must be done with extreme caution. emergency surgery will still be necessary for obstetrics and to save life (neurotrauma) and limb, and these capacities should not be compromised by taking up all available ot space and ventilators with covid+ patients. as the average reported time spent on mechanical ventilation has been up to days, critical resources and space will be occupied for many weeks and will be difficult to reclaim once repurposed. repurposing of staff for managing covid- cases should be taken into consideration as well. guidance and training should be provided to make the best use of the technical and clinical skills of all perioperative personnel while protecting them from exposure. hospitals, professional societies and ministries of health could also provide physician and nursing staff with basic icu and ventilator management refresher education to improve their capacity to care for covid- patients. up to date guidelines on covid- management should be provided as knowledge and evidence around best management evolves. it is also vital to maintain and support staff wellness. it is important to recognise that doctors, nurses, cleaners and other hospital support staff have significant fears and concerns (the fears of transmitting to family or becoming infected oneself, the increase in work hours and the need for childcare coverage) that must be acknowledged and managed. providers may also be understandably nervous about providing care outside of their normal scope of practice or working beyond their area of competence. leadership can help manage these by providing information in a transparent way, expressing gratitude for the commitment to patients and colleagues, and reassurances that the system will help protect them and support them and their family. national cprc mentioned that severity of the situation and the availability of resources may change on a daily basis. thus, communication is critical, and an effective communication plan both within and between facilities and health system planners, as well as between providers across the health system and even between countries, is essential and should be established immediately. the preparation of healthcare facilities at large for the safe triage, testing and management of patients with confirmed or suspected covid- , and managing surge conditions are needed. ethical considerations in resource management are also very important. in many places, the number of ventilators available for persons requiring ventilatory support will be inadequate. in some settings, it is common to reallocate resources from terminal patients or patients with brain death or very low likelihood of recovery (e.g. severe traumatic brain injury) to those with a higher likelihood of recovery. in settings where resources are severely limited and must be rationed, consider creating a committee or utilising standardised risk assessments to determine allocation decisions in advance. this avoids placing the burden of decision making on the frontline health care workers, as these decisions should be not be made ad hoc by the bedside clinician but through careful deliberations by the institution. cultural and medicolegal context should be taken into account to determine the most appropriate allocation and potential protocols for rationing medical resources and care in advance. critical testing, ppe, icu beds, therapeutics, and vaccines should go first to front line health care workers and others who keep critical infrastructure functioning; these workers should be given priority not because they are more worthy but due to their instrumental value in the pandemic response and difficulty of replacing (instrumental value). should the surgical instrument be reused? ( ). instruments and devices that have been used in procedures for patients with known or suspected covid- should be handled the same as other instruments. reprocessing should follow manufacturer's instructions for use (ifu) and be consistent with recommendations in the local infectious disease unit. covid- is an enveloped virus and is susceptible to the environmental protection agency (epa)registered disinfectants that are used in the health care setting ( ) . there are no additional recommendations by cdc for disinfection and sterilisation of these items used for covid- patients. instruments should be cleaned, decontaminated, dried and stored in a manner that reduces the risk of exposing patients and personnel to potentially pathogenic microorganisms ( ). high-level disinfect or sterilise them according to the manufacturer's written ifu. they should be packed and stored in individual packs that avoid contamination. ( ) patients should perform second pcr + rapid test prior to icu admission. if rapid test positive, then to discuss with covid- hospital. if accepted, then to transfer to covid- hospital. if not accepted, then send to negative pressure isolation room icu using designated walkway (only suspected covid- ) while awaiting second pcr results. if require urgent resuscitation, to transfer to negative pressure isolation room icu using specific walkway (only suspected covid- ). if rapid test is negative, then to send to negative pressure isolation room icu using designated walkway (only suspected covid- ) while awaiting second pcr. if two negative pcr results, then it is considered a non-covid- patient and to be admitted normal icu cubicle. if pcr is not done on admission or only rapid test is done on admission, then a critically ill patient should have pcr done h apart to rule out disease. there is an exception for planned elective admission to icu after elective surgery. for this group of patients, a negative first pcr is adequate, and the patient is to be admitted to a non-isolation cubicle in icu. ( , ) full ppe must be readily available in icu. prepacked full ppe sets including hazmat suit should be put into a bag, to ease donning in the case of emergency. two sets will be readily available in the emergency trolley with additional sets kept at specific storage area in the icu together with papr. two nurses to attend with full ppe first. one person to be exclusively in charge to help donning of ppe of medical staff to ensure that all are properly fitted, with hazmat suit and papr if required. papr and hazmat suit will be needed for procedures like intubation and bronchoscopy. donning and doffing of ppe instructions should be pasted on the wall. nurses and doctors to undergo training on where and how to don and doff in icu isolation room, as well as in other non-isolation cubicles. designated area to doff ppe in non-isolation icu cubicles/wards to be assigned. walkie talkie to be available in isolation room for outside communication (to get medications, additional materials). nurses outside will prepare required materials/medication and put on a trolley, leave it in the airlock to be collected by nurses in the isolation room. ( , , ) glidescope and ultrasound must be fully covered with plastic when in a room. ultrasound transducer to be covered with transducer cover if in use. cleaning should be per biomedic advice. person cleaning equipment should be made aware of the infectious component and be protected with full ppe. outside nurse to be fully protected when removing equipment outside isolation room for cleaning. the same ventilator should be used for negative pressure isolation room icu and should not with ventilator in the other rooms. ( ) the viral filter should be on both inspiratory and expiratory ends. once intubated, to clamp the ett, remove the viral filter for connection with ventilator tubing. etco monitor i.e. capnograph and closed suction catheter to be connected to patient immediately upon intubation. disconnection of ventilator should be reduced. ( ) nurses should be divided into covid- team and non-covid- team. the covid- team to take care of covid- suspect or covid- positive patients. the non-covid- team to take care of the non-covid- patients. the covid- team nurses should not be rotated to non-covid- patients. (e.g. patient a is managed by nurse x, y and z in three shifts. this team should take care of patient a until second pcr results are available) container for contaminated ppe for covid- suspect or positive should be clearly labelled for cleaners to take extra precautions. decontamination of the pathways and negative pressure isolation room icu used by these patients will be per hospital protocol. the whole icu need to be close and decontaminated in the presence of a covid- positive case in nonisolation icu cubicle with no other patients around. for the presence of a covid- positive case in non-isolation icu cubicle with existing non-covid- patients in icu, the whole icu must be closed and decontaminated plus to consider testing these patients (existing non-covid- patients) and transferring to other hospitals. potential covid- case in non-isolation room, to limit one visitor/patient. the covid- positive in non-isolation room, then no visitors allowed in icu. one staff member in front of icu is stationed to monitor visitor flow in and out of icu (get visitor's name and phone number in the case of contact tracing). in the event of a covid- positive case in non-isolation room in icu, contact tracing will include, ( ) existing non-covid- patients in icu during that period, ( ) all visitors who enter icu during that period, ( ) all icu staff entering icu during that period, and ( ) all doctors entering icu during that period. ( ) triage may not be implemented by a facility without clear sanction from appropriate public health authorities. systems for sharing information about the number and severity of cases, equipment availability, and staffing shortages could be activated throughout hospital groups and regional networks. patients are assessed on medical/ clinical factors alone, regardless of their work role. the ontario health plan for an influenza pandemic (ohpip) protocol and the sequential organ failure assessment (sofa) score should be used. candidates for extubation during a pandemic would include patients with the highest probability of mortality. initial assessment using the sofa scoring system (points based on objective measures of function in six domains: lungs, liver, brain, kidneys, blood clotting, and blood pressure) with best score of and worst score of . time trials assessment at intervals of h and h. those showing improvement would continue ventilator use until the next assessment, whereas those who no longer met the criteria would lose access to mechanical ventilation. chronic care facilities will have to provide more intensive care on-site as part of the general process of expanding care beyond standard locations. the proposed justification for such a strategy would be that more patients could ultimately survive if these ventilators were used by the previously healthy victims of a pandemic. setting aside the small number of ventilators in chronic care facilities for use by chronically ill people, who likely will have severely limited access to ventilators in acute care facilities. clinicians providing direct care will relay data to a supervising clinician serving as a triage officer, who will calculate the sofa score and make triage decisions but will not provide direct care. terminal weaning in response to patient preferences can include sedation so that the patient need not experience air hunger. patients who are extubated against their wishes should be offered appropriate palliative care based on their clinical conditions and preferences. because transparency is a crucial element of adherence to ethical standards, clinicians must document decisions regarding sedation with extubation. the guidelines do not support the use of manual ventilation devices for patients who do not meet criteria for ventilator access. daily retrospective review of all triage decisions should be made, to ensure consistency and justice. physicians will need to discuss altered standards of care in a disaster, especially for scarce resources such as ventilators. patients and families must be informed immediately that ventilator support represents a trial of therapy that may not improve the patient's condition sufficiently and that the ventilator will be removed if the patient does not meet specific criteria. elective surgeries and other elective procedures that could result in the use of mechanical ventilators should be cancelled ( ) . ventilators, supplies, and personnel from ambulatory surgery centres and other facilities not being utilised for covid- patients or not experiencing covid- outbreaks should be transferred. anaesthesia ventilation machines capable of providing controlled ventilation or assisted ventilation may be used outside of the traditional use for anaesthetic indication ( , ) . the asa and fda provide specific guidance on how to convert anaesthesia machines for use on covid- patients in respiratory failure ( ) . transport ventilators may be used for prolonged ventilation in certain patients. continuous ventilators labelled for home use may be used in a medical facility setting depending on the features of the ventilator and provided there is appropriate monitoring (as available) of the patient's condition. non-invasive ventilation (niv) patient interfaces capable of prescribed breath may be used for patients requiring such ventilator support, including niv patient interfaces labelled for sleep apnoea. channelling exhalation through a filter is recommended to prevent aerosolisation. continuous positive airway pressure (cpap), auto-cpap and bilevel positive airway pressure (bipap or bpap) machines typically used for treatment of sleep apnoea (either in the home or facility setting) may be used to support patients with respiratory insufficiency. bipap may be used for invasive ventilation. if all other alternatives are exhausted, care providers could consider ventilation of two patients on a single ventilator for short-term use, although there are significant limitations to this strategy. alternatively, manual bag-valve-mask ventilation done by ancillary providers can be considered as a bridging option to mechanical ventilation. the summary of head and neck examination and procedure recommendations can be viewed in table ( ) . ( ) in general, most tracheostomy procedures should be avoided or delayed (even beyond days) because of the high infectious risks of the procedure and subsequent care until such time as the acute phase of infection has passed, when the likelihood of recovery is high, and when ventilator weaning has become the primary goal of care. avoiding early tracheostomy in patients with covid- is suggested because of the higher viral load that may be present at this time. early tracheostomy was not found to be associated with improved mortality or reduced length of intensive care unit stays in a randomised clinical trial of patients on mechanical ventilation. select the patients carefully. if the tracheostomy is assessed as difficult because of anatomy, history, comorbidities or other factors, consider postponing the procedure. considerations may be given to percutaneous dilatational tracheostomy. allow it to be done safely with minimal or no bronchoscopy, endotracheal suctioning and disruption of the ventilator circuit. adequate sedation provided including paralysis to eliminate the risk of coughing during the procedure. ventilation should be paused (apnoea) at end-expiration when the trachea is entered and any time the ventilation circuit is disconnected. choose a non-fenestrated, cuffed, tracheostomy tube on the smaller side to make the tracheostomy hole smaller overall (shiley size for both men and women is adequate). keep the cuff inflated to limit the spread of virus through the upper airway. tracheostomy suctioning is performed using a closed suction system with a viral filter. heat moisture exchanger device is used instead of tracheostomy collar during weaning to prevent virus spread or reinfection of patients. changing the tracheostomy tube should be delayed until the viral load is as low as possible. case series of open tracheostomies performed during the severe acute respiratory syndrome (sars) outbreak can be viewed in table ( ) ( ) ( ) ( ) . making in times of covid- crisis: a proposal to safe and sustainable practice in times of crisis neurotrauma ( ) neurotrauma forms the bulk of emergency neurosurgical cases presenting or referred to neurosurgical centres, varying from cases of concussion to severe head injuries requiring urgent surgical intervention. in the current climate of a pandemic crisis, neurotrauma poses various management and logistics issues to the neurosurgical team in the following aspects as listed. time between injury to intervention determines outcome. urgency of intervention outlines management of patient. ongoing dynamic pathological process in trauma may alter clinical picture between referral to presentation. pre-emptive management plan is essential to ensure optimum outcome from intervention where feasible. pre-operative screening is vital, particularly those requiring surgical management ( ) . all cases undergoing surgery poses high risk to operative team due to potential aerosol generating procedure that may occur from intubation/extubation, positioning of patient to prone/park bench position, tracheostomy procedures and prolonged proximity of surgeon to the head region of patient ( , ) neurotrauma cases should be managed in a neurosurgical centre. most neurosurgical departments in malaysia are situated in major hospitals, often managing high volume of high risk or covid- cases. principle logistic consideration is to whether trauma cases referred from a non-covid- designated hospital should be managed in covid- designated hospital as this may increase risk of exposure to patients. alternative options should be taken into consideration where feasible, such as team deployment to manage patients in referring hospitals, training and privileging general surgeons in management of cases and transfer of patients back to referral hospitals for continuity of intensive care management postoperatively. resource availability ( ) neurotrauma patients require postoperative ventilation with icu care, often for prolonged duration which may limit availability in case of urgent needs. ventilators, ppe and icu are precious commodities in this current pandemic, and fluctuate with time depending on epidemiological dynamics. available resources are commonly and rightly so; prioritised to patients afflicted by the ongoing pandemic, health care workers (hcws) involved in their care. rational balance and anticipation of resource need is essential to optimise usage and sustainable availability in times of crisis. early prognostication ( , ) outcome from neurotrauma depends on various well-defined parameters. brain damage incurred in primary injury remains irreversible in majority of patients; compounded by secondary factors. early prognostication is essential in times of crisis for resource allocation. it is paramount to ensure that optimum patient care and outcome remains priority of intention to treat. determining long term outcome using available prognostic models for decision making in proceeding with active treatment or withdrawing treatment is essential; albeit exceptionally difficult to ensure continuous availability of limited resource. prognostication based decision is best made with team consensus using all available scientific evidence present. ( ) all brain trauma management is in accordance with the brain trauma foundation (btf) guidelines recommendations. all neurosurgical emergencies must be referred to the respective neurosurgical team for consultation and management plans (table ) ( ). brain trauma requiring urgent surgical intervention (decompression) with or without intensive care monitoring is best managed in hospitals with dedicated neurosurgical facilities or available neurosurgical services (level ii). brain trauma not requiring urgent decompressive surgical intervention, but which may require or benefit from intracranial pressure (icp) monitoring and intensive care management (level iib) is best managed in centres with available resources to provide objective assessment and management plan, reduce the duration of icu stay and intensive management and early weaning from intensive therapy. brain trauma not requiring urgent decompressive surgical intervention, but which may benefit from icp monitoring and intensive care management in situations where resource availability is limited may be managed with cerebral perfusion pressure (cpp) based target therapy (level iii) and serial ct scan at h- h intervals in an intensive care setting where feasible. brain trauma requiring surgical intervention but with limited resources available at dedicated neurosurgical facilities; the following may be considered (anecdotal evidence based on local/regional practice): brain trauma not requiring any surgical intervention but requiring close observation is best managed in dedicated neurosurgical centres or available neurosurgical services if the risk of potential deterioration is deemed to be high (e.g. burst temporal/frontal lobes) and duration and distance of transfer may result in a delay of treatment. brain trauma requiring multidisciplinary management is best transferred and managed in dedicated i) deployment of neurosurgical team to primary referral hospital where feasible to facilitate timely intervention ii) surgical intervention in neurosurgical facilities with subsequent transfer back to primary referring hospitals for continuity of intensive care management ( ) screening for traumatic brain injury cases is strongly recommended for safety of hcws. screening recommendations are in accordance with moh guidelines (figure ). risk of covid- /pui/severe acute respiratory infections (sari) should be ruled out as per moh guidelines and hospital protocols prior to transfer of cases for further management (figure ). secondary screening should be done by attending neurosurgical team on arrival. relatives must accompany for confirmation of history of potential exposure as per moh protocol and directives. confounding factors must be taken into consideration during screening, including: i) potential aspiration in patients with low glasgow coma scale (gcs); ii) metabolic response resulting in abnormal white blood cell count (wcc) and elevated temperature; iii) co-existing chest injuries; and iv) post-intubation changes on chest radiograph (cxr) common. note: all ventilated cases pose a high risk of aerosol exposure to hcws. it is vital to be meticulous and vigilant for potential risk: critical resources for optimum neurosurgical services remain limited and may continue to fluctuate in time of crisis. these include ventilators, ppe, icu availability and operative instruments. the rationale for early prognostication is recommended for optimum resource usage and allocation to ensure beneficial outcome and sustainable supply. prognostication is based on available scientific evidence to guide in management options and rationale of resource allocation. early triage is required for timely and appropriate treatment and enables surgeons to prioritise management according to available resources and the potential outcome. this will help in limiting the proportion of patients in a vegetative state and limiting burden to family and available resources at the time of crisis. in the end, it will help to prepare family with a realistic outlook on the potential outcome. prognostic factors include: i) age > ; ii) gcs post-resuscitation: motor score m -poor outcome; iii) pupils-bilateral fixed/ dilated pupils; iv) systolic blood pressure < mmhg -sustainable/multiple episodes; and v) marshall ct grade. age, gcs motor score and pupillary changes are the three main prognostic factors determining the outcome. the caveats to prognosticating outcome include: aneurysmal sah is a devastating clinical entity. the natural history of aneurysmal sah remains unfavourable with a cumulative rerupture rate at % at weeks after initial presentation and overall mortality of %. prognostication of aneurysmal sah is well defined according to the world federation of neurosurgery (wfns) grade system predictive of figure . proposed workflow of patients referred for sah outcome following aneurysmal rupture and hunt & hess grade which predicts mortality rate in patients. management of aneurysmal sah during times of crisis must be guided by expected prognosis as defined using these grading systems. this is essential in times of pandemic crisis as difficult decisions need to be made to preserve life and function in face of limited and precious resources essential to the management of patients ( ). the proposed recommendations can be viewed in figure . aneurysmal sah ( ) adequate resuscitation measures should be instituted on admission where required. these include the airway, breathing and circulation (abc) and mechanical ventilatory support as required with correction of fluid and electrolyte abnormalities if present at primary referral centres. the physician receiving the referral should get an accurate assessment of wfns, and hunt & hess grades on presentation. if hydrocephalus is present on ictus, urgent ventricular drainage should be performed at centres with neurosurgical facilities or trained and privileged surgeons at the designated non neurosurgical centres. a noncontrast ct brain and ct angiogram (cta) are the first line investigative parameter at the admitting hospital before transfer to a centre with neurosurgical facilities or services. when perimesencephalic sah is the likely diagnosis after confirmation by a neuroradiologist, then the patient should be managed expectantly. there will be no further imaging required. however, if aneurysmal rupture cannot be ruled out, then the recommendation is based on the wfns grading. for wfns - , a digital subtraction angiography (dsa) is recommended at the primary centre if available or transfer to centres with available facilities and neurosurgical services. for wfns and , the patient should stay at the primary centre if feasible with a repeat cta in week. a continuous neurological assessment should be documented and if whenever an improvement is noted, then the patient should be considered for transfer. poor grade aneurysm cases may benefit from continued neuroprotection. however, multiple factors should be taken into accounts such as age, comorbidities and available resources to sustain prolonged care in such patients. the decision to consider conservative management if no further improvement in wfns score is the prerogative of attending consultants. the quality of cta is important in determining the next treatment of care. for patients with wfns grade - , if cta deemed adequate by attending consultants for safe and effective definitive management by surgical clipping, then the recommendation is to proceed for surgical treatment as urgently possible at the centre with available neurosurgical services. if cta deemed inadequate for definitive management, then the patient should be transferred for dsa at centres with available radiological and neurosurgical services. the choice of treatment between surgical treatment and endovascular treatments should remain similar to current standards. however, interventional neurovascular services in malaysia are limited to a few major hospitals. transferring patients across states in times of limited resources may result in unnecessary delays and worsening outcomes from potential deterioration during the interim period. thus, various factors should be taken into consideration when deciding the best treatment options in times of crisis. they include: if dsa is required, the option of definitive management of endovascular coiling at the same setting should be considered. there are several reasons which include: i) minimising the risk of aerosol disbursement that is highest during intubation/extubation; ii) early definitive management can be achieved at the same setting with reduced risk of re-rupture; iii) treatment of vasospasm if present for applicable cases done at the same setting; and iv) reducing the risk of exposure to personnel from a second ga procedure. patients with wfns grade may benefit from neuroprotective measures. definitive management should be considered in selected cases such as: i) young age; ii) no morbidities/comorbidities; and iii) choice of treatment depends on available services and following discussion between attending consultant and family. for patients with wfns grade , conservative management should be considered if no further improvement achieved following a period of neuroprotection. the decision is made through a collective discussion between attending physician and family members. a thorough history should be elicited to determine any evidence of sentinel haemorrhage that may appear trivial to patients. an appropriate diagnostic modality is required to look for radiological evidence of recent i.e 'teat sign'. within an applicable timeframe, a lumbar puncture should be considered. an aneurysm with neurological symptoms and signs should be planned and treated in a timely manner as a semi-emergency case; an example is a patient with posterior communicating artery aneurysm presenting with ptosis, rather than a delayed surgery in this current pandemic of uncertain duration to avoid potential irreversible neurological compromise or worsening deterioration. in cases of multiple aneurysms, the treatment should be undertaken for ruptured aneurysm as well as aneurysm with increased risk of rupture, if deemed feasible at the same sitting. arteriovenous malformations (avms) are a heterogeneous group of neurovascular abnormalities with an incidence of . / population. anatomically avms are defined as a complex of abnormal arteries and veins that communicate directly without an intervening capillary bed. avm presents with haemorrhage in as many as % of cases. the natural history of avms is more favourable as compared to aneurysmal sah, with an annual rupture rate of %, and recurrent haemorrhage rate of %- % in the first year following a rupture ( ) . cases of avm presenting with haemorrhage may require urgent surgical management. the proposed recommendations are divided into three categories: i) avm rupture with mass effect; ii) avm rupture without mass effect; and iii) avms not presenting with haemorrhage ( ) ( ) ( ) . any ruptured avm with mass effect should be transferred to a centre with neurosurgical services or facilities. a cta should be performed on admission to confirm the diagnosis of ruptured avm and to determine the location of avm in relation to clot. this will aid a safe surgical access planning. following an urgent surgical evacuation of a clot, the patient should be managed in an intensive care setting for neuroprotection. a post-operative dsa/cta is warranted to look for potential high risk factors for haemorrhage, such as nidal aneurysm/varix and to consider an endovascular treatment if feasible and required. definitive treatment should be deferred safely to a later date if feasible. the patient should be transferred to a centre with neurosurgical facilities, particularly when avm presents with intraventricular haemorrhage (ivh) or cta shows evidence of nidal aneurysm or varix. if no ivh present and cta shows no high risk factors of haemorrhage, the patient may be managed at a non neurosurgical centre with early follow up scheduled in the clinic for review. the management is mainly medical treatment to optimise seizure control or headache. all definitive treatment should be deferred to a later date. ( ) these are rare conditions that comprise of fistulas connecting branches of dural arteries to dural veins or venous sinuses. dural arteriovenous fistulas (davfs) are typically stable lesions with a reported annual haemorrhage risk ranging between %- % ( ), and mortality rate ranges at %- %. endovascular modalities remain the diagnostic and therapeutic modality of choice. the recommendations are proposed for the management of ( ) ruptured cranial davf and ruptured spinal davf. patients who presented with ruptured cranial davf should be transferred to a neurosurgical centre with endovascular facilities for urgent surgical management of clot with mass effect, if present, and definitive endovascular management. patients who presented with ruptured spinal davf requires transfer to a neurosurgical centre with endovascular facilities for urgent treatment, especially when there is rapid neurological deterioration. some patients presented with spontaneous hypertensive haemorrhage that may or may not require surgical intervention. patients that are not a candidate for surgical interventions include: i) small, deep haemorrhage; ii) large haemorrhage without hydrocephalus, ivh or neurological deterioration; and iii) those with supratentorial haemorrhage with a gcs score below unless this is because of hydrocephalus ( ) . a poor prognosis is expected in the following conditions: ii) candidate with gcs score is or less; and ii) the haematoma is very large and death is expected ( ) . in this condition, a careful consideration should be taken and a family meeting should be done sooner. surgical interventions are recommended in the following categories: the diagnosis of middle cerebral artery (mca) infarction depends on the clinical presentation, neurological findings, followed by radiological imaging. patients with suspected transient ischaemic attack (tia) should be assessed by a specialist physician before a decision on brain imaging is made, except when haemorrhage requires exclusion in patients taking an anticoagulant or with a bleeding disorder when noncontrast ct should be performed urgently ( ) . further imaging, such as carotid imaging is essential for any patient presenting with symptoms suggesting of an anterior circulation cerebral ischaemia who might be suitable for intervention for carotid stenosis. patients with tia or acute non-disabling stroke with stable neurological symptoms who have symptomatic severe carotid stenosis of %- % (nascet method) should receive an urgent carotid endarterectomy (within days). the treatment tends to happen in a vascular surgical centre routinely participating in national audit ( ) . the indications for mechanical thrombectomy (mt) ( ) are when there are proximal large artery occlusion as an adjunct to intravenous thrombolysis (ivt), and for those patients with contraindications to ivt but not to mt. another indication is when major vessel occlusion is in the posterior circulation, up to h from known onset. the indications for decompressive hemicraniectomy are as follows ( ) ( ), ventriculostomy is recommended in the treatment of obstructive hydrocephalus. concomitant or subsequent decompressive craniectomy may or may not be necessary on the basis of factors such as: i) the size of the infarction; ii) neurological condition; iii) degree of brainstem compression; and iv) effectiveness of medical management. there are times when an emergency carotid endarterectomy (cea)/ carotid angioplasty and stenting will be useful as clinical indicators or brain imaging suggests ( ) . an example is when a small infarct core with large territory at risk (e.g. penumbra), compromised by inadequate flow from critical carotid stenosis or occlusion. however, in patients with unstable neurological status (e.g. stroke-in-evolution), the efficacy of emergency or urgent cea /carotid angioplasty and stenting is not well established. stroke complicated covid- infection in . % of patients at a median days after symptom onset. stroke mechanisms may vary and could include hypercoagulability from critical illness and cardioembolism from virusrelated cardiac injury. the clinical presentation in stroke patients typically manifested as cns involvements. the most common neurological manifestations in covid- patients were dizziness ( . %), headache ( . %) and encephalopathy ( . %). the most common peripheral signs and symptoms were anosmia ( . %), dysgeusia ( . %) and muscle injury ( . %, detected by elevated creatine kinase). patients with stroke were older, had more cardiovascular comorbidities, and more severe pneumonia. ideally, every stroke patient would be treated as potentially infected, hence the requirement of ppe. many teams have begun using telemedicine both within their own ed and regionally. this solution avoids the use of needed ppe, allows a reasonable stroke evaluation, avoids unnecessary interfacility transfers, and reduces exposure risk for the stroke team. in the setting of the pandemic, full compliance to clinical practice guidelines has become a goal, not an expectation. each team must use their judgement, guided by local realities, and continue to try to treat as many acute stroke patients as possible. patients with large intracerebral haemorrhages, sah or large ischemic strokes at risk for herniation must be monitored in an intensive care setting with appropriately trained personnel, where possible. appropriate resource should be allocated for critically ill stroke patients. appropriate intensive care of these seriously ill patients with haemorrhagic stroke, some of whom are also young and with an excellent long term outcome, should be maintained. however, in each locality, specialists from all intensive care specialities e.g. pulmonary, cardiology, neurology, neurosurgery must discuss the relative merits of prolonged icu care for any particular patient. ( ) the establishment of stroke networks and care systems can deliver a high quality emergency stroke care at all times, particularly at times of crisis. although there is a strong case for such centres to be the system of care, it is particularly important to have services that can continue to function. the hospital should inform the emergency medical system and the public that these centres will be protected and will remain fully operational even during crises. the hospital or stroke team should regularly update and educates the health professionals and the public, especially those who are at high risk of stroke to recognise a stroke and call emergency medical services immediately. those patients should be taken to one of the designated stroke centres to avoid significant delay in transferring patient from one hospital to the other. categorising elective neurosurgical cases at a time of covid- pandemic is adapted and as per guidelines (with minimal modification) -perioperative mortality review (pomr): prioritisation of cases for emergency and elective surgery ( nd revision) ( ) ( table ). the tier status of each case is according to the urgency and the decision will be based on: i) natural history of the disease; ii) patient's neurological status; and iii) availability of manpower and equipment's for surgery ( figure ). to summarised, all elective neurosurgery should be postponed ( , ) . in patients with suspected covid- , the surgery should be deferred for at least days, with an appropriate test taken to confirm the status ( , ) . the elective urgent inpatient diagnostic and surgical procedures should be shifted to outpatient settings, when feasible ( ). dangers during neurosurgical procedure ( , , , , , ) according to limited data from cdc, covid- has been detected in blood specimens and it is unknown whether the virus is viable or infectious in extrapulmonary (outside the lungs) specimens. there have been some reports that covid- is present in stool and maybe transmissible through the faecal-oral route. bronchoscopy, tracheostomy and thoracic cases may have a higher risk for airborne transmission of covid- because the nature of the procedures involves the respiratory tract, which could lead to aerosolisation of the virus. procedures that may aerosolise blood and body fluids during surgery include: i) electrocautery of blood or tissue; ii) laparoscopy; iii) endoscopy; iv) use of intraoperative debridement devices with irrigation (e.g. hydrosurgery, pulse lavage or low frequency ultrasonic debridement); and v) use of high speed powered equipment (e.g. saws and drills). surgical smoke represents another important issue to tackle during surgery. it is recommended for the evacuation of all surgical smoke as it contains hazardous chemicals, ultrafine particles, viruses, bacteria and cancer cells. the earliest detected case of covid- was in china on november . as such, there is currently no research on the transmission of the virus through surgical smoke. however, there is no indication or proof that covid- is not transmissible through surgical smoke. research studies have demonstrated the presence of viruses (e.g. human papillomavirus) in surgical smoke with documented transmission to health care providers. according to limited data from the cdc, sars-cov- rna has been detected in blood specimens and it is unknown whether the virus is viable or infectious in extrapulmonary (outside the lungs) specimens. in similar coronaviruses, viable and infectious sars-cov was isolated from blood specimens, although infectious mers-cov was only isolated from the respiratory tract. of importance to neurosurgeons, the use of high speed drills and also electrocautery during surgery will cause aerosolised blood and body fluid. thus, increasing exposure of neurosurgeons to the virus. however, the risk of transmission of covid- through aerosolised blood and body fluids is unknown. thus, extra precautionary measures must be taken during procedures for protection. proper ppe must be worn during any neurosurgical procedure to prevent transmission. ( , ) covid- was declared a pandemic by who on march because of its rapid worldwide spread. covid- has achieved effective and sustained human-to-human transmission via contact, droplet and likely airborne routes. as with previous outbreaks such as severe acute respiratory syndrome (sars), influenza a (h n ) infection and the middle east respiratory syndrome, this would require heightened precautions and tailoring our anaesthetic practice to reduce exposure to patients' respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. in particular, this should involve minimising the many aerosolgenerating procedures we perform during ga, such as bag mask ventilation, open airway suctioning and endotracheal intubation. during the sars outbreak, intubation was one of the independent risk factors for super-spreading nosocomial outbreaks affecting many healthcare workers in hong kong and guangzhou, china. nevertheless, to avoid any airway manipulation, the use of ra techniques (e.g. peripheral nerve blocks and/or central neuraxial blocks) may be consideration should be given to the available resources, facilities, equipment, consumable and real time logistic capability and feasibility. designated covid- hospitals may not be able to support all elective cases, in particular those that require post-operative intensive care or significant use of blood and blood products surgeons, in consultation with anaesthetist, nursing colleagues as well as patients (or legally accepted next of kin), should weigh the risks of proceeding (exposure, lack of resources) against those of deferment, (progression of disease, worse patients outcomes) including the expectation of delay of - months or more or until the covid- is less prevalent figure . availability of manpower and equipment for surgery preferred. thus, ra manipulation should be considered whenever surgery is planned for a suspected or confirmed covid- patient or any patient who poses an infection risk. ra has benefits of preservation of respiratory function, avoidance of aerosolisation and hence viral transmission. there is no proper guideline and recommendation as of today regarding the use of ra in covid- patients. however, general precautions and ppe should be applied for all the healthcare workers even though the patient is undergoing ra. this is because, in case of failed ra, ga must be used for the surgery. anaesthesia providers for these patients should be well-versed in both ga and ra techniques. for neurosurgery patients, ra such as scalp block must be considered in simple procedures such as borehole. for emergency neurosurgery cases, most of it would be involving patients with poor gcs thus making ra not as feasible as the patient would be already intubated. covid- is an infectious disease introduced to humans for the first time. individuals can be infected by breathing in the virus within metre of a person who has covid- , or by touching a contaminated surface and then touching their own mouth, nose, or possibly their eyes. on january , who declared the outbreak as a public health emergency of international concern (pheic), and by march , the outbreak has rapidly accelerated to become pandemic. until april , there were , confirmed cases, with , deaths, affecting countries, including malaysia ( ). following the pandemic of covid- , there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. with pooling and outsourcing of more hcws to emergency room, public health care services and medical services, further in hospital resources are prioritised to those in need. along with slowing and breaking the transmission of covid- by social distancing, the neurosurgical outpatient clinic, elective and non-emergency surgery are delayed. this will reduce the face-toface contact with potential covid- cases, and shields patients and hcws from the virus. every neurosurgical team has to reevaluate the timing of operation in those patients with neurosurgical disease that are in need of treatment. the real risk of proceeding and the real risk of delay should be carefully assessed. when considering a delay in treatment to a time where covid- is less prevalent, the decision making process must always take into account each patient's courses of disease, social circumstances and needs. it is imperative to balance the requirements of caring for covid- patients with imminent risk of delay to others who need care ( ). currently, patient's screening process is crucial. the moh recommendations of screening involve questionnaires to identify suspected patients ( , ) . patients who meet certain criteria should be evaluated as a patient under investigation (pui). these general questions to all patients include: i) do you have any fever or acute respiratory infection (sudden onset of respiratory infection with at least one of: shortness of breath, cough or sore throat)? ii) do you have any history of travelling to or residing in affected countries in the past days? iii) did you have any contact with a confirmed covid- case within the past days? there are two laboratory tests that can be used to detect covid- ( , ): rt-pcr. the sample commonly taken is upper airway specimens (pharyngeal swabs, nasal swabs, nasopharyngeal secretions). among patients with confirmed positive in respiratory tract, ~ %- % of patients have detected viral load in faeces, ~ %- % in the blood, while the lowest positive rate is in urine samples. ii) rapid test kit (rtk) serology for serum antibody igm and/or igg. this can be used as diagnostic criteria for suspected patients with negative pcr detection. during follow-up monitoring, igm is detectable days after symptom onset and igg is detectable days after symptom onset. the viral load gradually decreases with the increase of serum antibody levels. urgent/emergent cases are previously defined as patients requiring access to surgical treatment within h of the decision to operate ( ) . however, with the current pandemic, access to surgical treatment may be delayed and some patients could face increasing morbidity/ mortality by the time surgery happens. other countries have now come up with guidelines for the triage, or ranking in order of priority, of surgical patients. the american college of surgeons (acs) describes the acuity scales based on tier classification, with most cancers and highly symptomatic patients considered tier a (do not postpone) ( ) . other than trauma and life threatening condition, other treatments are recommended to postpone, if possible. then what will happen to all elective cases that will be pushed back for a further few months? will that add to the mounting burden of long waiting lists that is already stretched? to delineate the current situation, we propose a few steps that will in future, limit and protect both patients and surgeons from the risk of transmission (figure ) . special consideration is given to pre-operative patients needing endoscopic transnasal surgery, even for asymptomatic patients ( , ) . the transmission of covid- is predominantly via respiratory droplets (e.g. coughing and sneezing) and contact with contaminated surfaces ( , , ) . however, earlier studies have shown the presence of the virus in conjunctival secretions and even stool ( ) . hence all body fluids except for sweat should be considered as potentially infectious ( ) . contamination of the surrounding environment may also occur following aerosol-generating procedures (agp) which include the use of high-speed devices or when splashing or spillage of bodily fluid is expected ( ) . appropriate steps especially in these environments need to be taken to disrupt the transmission of covid- and reduce risk of infection. these environments are considered as high-risk environments and include the icu, high-dependency unit (hdu) and ots. the emergency rhesus areas where suspected or confirmed cases of covid- are managed are also considered as high-risk areas ( ) . all highrisk areas require level iii ppe (table ) ( ) . ppe is only a part of the safe system of working ( ) . clinical staff must be trained and competent in the use of ppe in their respective hospitals. table shows the recommended ppe for clinical setting ( , , ) . ppe should be located close to the point of use and should be stored in a clean and dry area to prevent contamination. ideally, ppe is for single use and changed between patients unless in a situation of ppe shortage or when re-usable ppe is used. the used ppe must be disposed of in designated waste streams. the practice of donning (putting on) and doffing (taking off) of ppe must be done in designated areas safe for the respective procedures ( , ) . different hospitals may have different arrangements of clinical areas (ot, wards, clinics, etc.). hence, the physicians must make sure to be aware of the designated areas for donning and doffing prior to putting on ppe. ideally, each clinical staff donning must be supervised by another competent clinical staff especially to assist in donning and to make a final visual inspection of ppe. recommended ppe components: i) protective medical gown should be long in length, long sleeves, rear-fastening and fluid-resistant. also, include protective, fluid-resistant boots with disposable fluid-resistant covers when appropriate (high-risk procedures). for the gloves, the recommendation is to use disposable, non-sterile latex gloves for non-sterile procedures, whereas for sterile procedures is to use disposable sterile latex gloves. double gloving is essential in those procedures. ( ) ii) for the face/eye protector, ideally a disposable visor which covers the whole face including chin will give better protection than glasses and contact lenses. iii) for the respirator/mask, papr is recommended and preferred for high-risk procedures including agp. a minimum of n mask with face protector (i.e. visor) for agp ( , ( ) ( ) ( ) . for sars-cov, there is limited evidence (from observational studies) showing a protective effect of up to % of n masks (equivalent to ffp masks) used by healthcare workers. hence, although the cdc recommends n masks or higher level respirators for agp, n respirators are not recommended for agp in the uk ( , ) . the masks used should be fitted to the face without airleaks. in general clinical setting (other than aerosol-producing procedures), a fluidresistant mask is required. while fabric masks are widely available, this should not be used in any clinical setting. figure shows how to perform a particulate respirator seal check ( ) . i) essential to sanitise hand with alcohol gel before, in between each step and after donning of ppe ii) ppe must be put on in an order that ensures adequate placement of ppe equipment and prevents self-contamination and self-inoculation while using ppe and when taking off ppe ( , ) . figure shows levels of ppe. figure shows the recommended ppe to be used at the primary triage and non-sari area, while figure shows the recommended ppe in the ot, the ideal pressure system is a negative pressure room and if available, the recommended location is at the corner of the operating complex ( , ). the theatre should have a separate entrance. for intubation, the surgeons and personnel that are not involved in intubation should wait outside of the ot until anaesthetic induction and intubation are completed ( , , ) . during surgery (except for endoscopic endonasal procedures), procedures involving high speed devices are considered as aerosol-producing procedures and are high risk. the number of personnel in an ot should be minimised ( ) and full ppe should be applied. a n mask or masks that offer a higher level of protection should be used ( , , ) . endoscopic endonasal procedures are not safe and should be avoided ( , ) . if the surgery cannot be postponed, consider a craniotomy or microscope-based transsphenoidal procedure. during a shortage of ppe, the hospital or physicians are encouraged to minimise the use of ppe ( , ) . there are options available, such as considering telemedicine, where appropriate, to avoid direct contact with patients hence removing the necessity of ppe. the use of sterile gloves should be reserved only for procedures requiring sterility ( , , ) . all elective or non-urgent procedures, which usually require components of ppe should be delayed ( ) . certain areas should be monitored with restricted access, such as areas where suspected or confirmed covid- patients are being treated. some activities that require to be done at proximity to the patient (e.g. at bedside) must be planned early and bundle them together to minimise the number of times entering the room. visitors should not be allowed unless necessary, with restricted numbers and amount of time spent in the area. visitors must have clear instructions and guidance when donning and doffing with strict hand hygiene ( , ) . the use of appropriate ppe should be prioritised ( , ) and rationalised according to the risk of exposure and transmission dynamics of pathogens (air droplets, contact). overuse of ppe will further impact on supply shortages. (table ) the physician usually have to tailor the ppe usage based on the setting and activity being performed. below are some recommendations: extend the use of surgical gowns, masks and face protectors between patients with the same disease, who were confined in the same area without changing in between patients and whilst performing low risk procedures ( , , ) ii) consider re-usable face protectors (i.e. visors or googles) ( the ultraviolet (uv) spectrum is best known for uva, uvb and uvc (germicidal radiation). the spectral ranges for uva, uvb and uvc are nm- nm, nm- nm and nm- nm, respectively. uvc is the one with the strongest antimicrobial/antiviral properties ( , ) . with the rising healthcare awareness, some industry has demonstrated the effectiveness of radiation disinfection, especially uv light disinfection system on surface contamination, such as floors and equipment after the manual chemical disinfection process is completed ( ) . uv light disinfection is an implementation of 'no-touch' technology, is chemical free, does not require changes in the room's ventilation and will not leave a residue after treatment. in healthcare facilities such as icu and ot, this may be an adjunct to disinfection process ( ) . a laboratory study has shown that coronavirus could effectively be inactivated by uvc light ( , , ) . nevertheless, the uv light device is not a substitute for handwashing, mask-wearing and distancing. moreover, the international commission on non-ionizing radiation protection (icnirp) does not recommend the usage of lamps in the home. this is due to lack of adequate instructions of installation, duration of disinfection and increasing cases of skin and eye burns ( ) . who has come out with a fact that uv lamps should not be used to disinfect hands or other skin areas. furthermore, reiteration was made that 'cleaning your hands with alcohol-based hand rub or washing your hands with soap and water are the most effective ways to remove the virus' ( ) . the malaysian medical council has formed an advisory group to define and monitor virtual consultation (during the covid- pandemic). this advisory is guided by the medical act (amended ) which regulates the registration and practice of medicine in malaysia and the malaysian medical council's code of professional conduct. a virtual consultation is a form of telemedicine. telemedicine (teleconsultation, video conferencing, teleworkers, televideo) is a medical service provided remotely via information and communication technology. when the consultation is conducted without physical contact and does not necessarily involve long distances, then it is known as remote consultation. the role of the council is to regulate physicians, not technology. the council reminds physicians that the use of technology does not alter the ethical, professional and legal requirements in the provision of care. the malaysian medical council's jurisdiction is within this country only and physicians must ensure appropriate liability protection is in place to provide indemnity for malpractice. when the health care delivery is affected by any national epidemic or global pandemic, or any other movement restrictions imposed on the public by the government, the use of communication technology can improve the access to care. in this unprecedented time where the situation is seen to be very urgent, rapidly changing and where there is a fine balance between public safety and individual health, it is equally important for medical practitioners to have the virtues of accountability and truth telling. the code of professional conduct clearly says a physical examination is ethically mandatory. a non-physical contact virtual consultation makes a physical examination incomplete other than the visual and auditory observation. however, if a physician under current circumstances conducting such telemedicine virtual consultation feels this is so in good faith, then appropriate treatment can be initiated based on such, without the need for a physical examination in person. in providing medical care using telecommunications technologies, physicians are advised that they must possess adequate training and competency to manage patients through telemedicine. the ethical and legal requirements such obtaining valid informed consent from the patient should be taken, at the same time ensuring that the physician's identity, place of practice and registration status are made known to the patient, and the identity of the patient is confirmed at each consultation. the identities of all other participants involved in the telemedicine are disclosed and approved by the patient, and documented in the patient record. both the physician-site and the patient-site are using appropriate technology that complies with legal requirements regarding privacy and security and accreditation standards where required. considerations must be given to safety and maintaining a high standard of patient care. the physicians must consider whether the telemedicine medium affords adequate assessment of the presenting problem, and if it does not, an arrangement for a timely in-person assessment should be taken. the physician should be prepared to advise remote patients about how and where to arrange for necessary care when follow-up is indicated. with the limitation of telemedicine, the physicians should exercise caution when providing prescriptions or other treatment recommendations to patients whom they have not personally examined. when carrying out a diagnostic evaluation or prescribing medication, a physician conducting a remote interaction should: i) verify the patient's identity; ii) confirm that the remote interaction is appropriate to the patient's situation and medical needs; iii) write any prescriptions in keeping with best practice guidelines and formulary restrictions (and in keeping with ethics guidance on prudent stewardship); and iv) document the clinical evaluation and prescription, as well as any instructions given to the patient. a medical record of the consultation, in accordance with professional and legal requirements, are kept and available to other health care professionals for the provision of ongoing patient care. this is especially important when there is a followup and referral to other specialities. hence, the physician must ensure adherence to the same obligations for patient follow up in telemedicine as is expected with in-person consultation. many centres have implemented the telemedicine in neurosurgical consultation, specifically in patients with confirmed covid- , or recovered patients (pcr negative and beyond days incubation period) that may need comprehensive clinical assessment to be performed. throughout all levels, neurosurgeons are encouraged to convert meetings (with staff, colleagues and patients) to teleconsultation and/or video conferencing ( ) . teleconsultation minimises face-to-face clinic visits for all doctors and patients, including neurosurgeons and their patients ( ). staff and patients over the age of are encouraged to avoid coming to the hospital and clinic. the conversion of many clinic visits as medically appropriate to this new modality allow patients to stay safe at home and allows clinic nurses and staff to help care for covid- patients. another speciality that is using telemedicine is neurology, mainly for the assessment of patients with a suspected stroke. the telemedicine should enable the physician to discuss the case with the assessing clinician, talk to the patient and/or family/carers directly and review radiological investigations ( ) . hence, it is important that a high-quality video link is maintained to enable the remote physician to observe the clinical examination. the physician providing care (at both ends of the system) should be appropriately trained in the hyperacute assessment of people with suspected acute stroke, in the delivery of thrombolysis and the use of this approach and technology. the impact on the quality of care, efficacy of telemedicine and decision-making using telemedicine should be regularly audited ( ) in keeping with physician's fiduciary obligations to patients across that continuum ( ) . timely updates from trusted sources about the relative risk of contracting the novel disease versus a more common one are critical ( , ) . strategic social media use (e.g. hashtags) may be an effective way for agencies to communicate accurate information to the public during times of crisis. residents may be advised to connect with and follow local health agencies and service providers for the most geographically relevant information. researchers may use publicly available 'big data' (e.g. localised tweets) to gauge the risk of communication efforts of local agencies. ( ) ( ) ( ) in the emergency department, there is a surge control for 'forward triage', meaning utilisation of sorting the patients before they arrive in the emergency department. this allows patients to be efficiently screened, is both patient-centred and conducive to self-quarantine, and it protects patients, clinicians and the community from exposure. the physicians and patients are still able to communicate / , either by using smartphones or webcam-enabled computers. the respiratory symptoms (which may be early signs of covid- ) are among the conditions most commonly evaluated with this approach. telemedicine consultations for oncologic patients may not be suitable and individual clinicians must be able to make an appropriate judgment. however, patients will greatly benefit from such virtual clinic consultations over a cancellation. ( , ) the presence of virus within csf fluid and during autopsy can be tested via electron microscopy, immunohistochemistry and realtime reverse transcriptional. there are . % of patients had neurologic manifestations due to neurotropic potential in the covid- virus found in one study. during an early or later phase of the infection, the dissemination of covid- in the systemic circulation or across the cribriform plate of the ethmoid bone takes place. the ability to cross the blood brain barrier into the cerebral circulation is due to the properties of the covid- virus spike protein with angiotensin-converting enzyme (ace ) receptors expressed in the capillary endothelium. the receptor has been detected over glial cells and neurons. covid- virus exploits the ace receptors to gain entry inside the cells ( ) causing neuronal death in mice by invading the brain via the nose close to the olfactory epithelium. in an uncomplicated early stage, findings like an altered sense of smell or hyposmia can be found. once the virus caused respiratory manifestation, there will be neurological involvement with loss of involuntary control over breathing ( ) . tuberculosis ( ) the physician should maintain continuity of essential services for people affected with tuberculosis (tb) during the covid- pandemic. it is anticipated that ill patients with both tb and covid- may have poorer treatment outcomes, especially if tb treatment is interrupted. therefore, accurate diagnostic tests are essential for both tb and covid- . simultaneous testing of the same patient for both tb and covid- would generally be indicated for three main reasons (subject to the specific setting in the country): i) clinical features that are common to both diseases; or ii) simultaneous exposure to both diseases; or iii) presence of a risk factor for poor outcomes to either disease. in tuberculous meningitis with communicating hydrocephalus, the recommendation is to treat with furosemide with or without acetazolamide. some institutions favour daily lumbar punctures with icp monitoring through manometry ( ) . in tuberculous meningitis with noncommunicating hydrocephalus, this will involve invasive neurosurgical procedures such as an external ventricular drain (evd), ventriculoperitoneal shunting or endoscopic third ventriculostomy (etv) ( ) . acute necrotising encephalopathy is a condition that can be triggered by viral infections like influenza and herpes. a case report of a woman who tested positive for covid- developed acute necrotising encephalopathy ( ) . the patient presented altered mental status and a noncontrast head ct images demonstrated symmetric hypoattenuation within the bilateral medial thalami with a normal cta and ct venogram. brain mri demonstrated a haemorrhagic rim enhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions. the patient was started on intravenous immunoglobulin. this is the first reported case of meningitis associated with sars-cov- who presented with convulsion followed by unconsciousness ( ) . the patient had transient generalised seizures that lasted about a minute. the specific sars-cov- rna was not detected in the nasopharyngeal swab but was detected in a csf. brain mri showed hyperintensity along the wall of right lateral ventricle and hyperintense signal changes in the right mesial temporal lobe and hippocampus, suggesting the possibility of sars-cov- meningitis. paediatric neurosurgery accounts for up to % of neurosurgical admissions. in this current crisis, covid- infection among children remains limited in numbers. however, paediatric patients are at risk of exposure from potential family members and caretakers that may harbour the virus and remain asymptomatic. the main consideration is therefore to be vigilant and screen caretakers and family of patients for risk of exposure based on current and updated guidelines provided by the moh ( ). the priority as for all cases in the pandemic crisis remains the protection of healthcare personnel and other non-infected patients as well as the working environment at healthcare facilities. the guidelines provided by moh ( ) applies equally for paediatric neurosurgery cases; principally in deciding for the need of surgical care and intensive management in times of reduced availability of resources. this guiding principle forms the core basis of decision making for paediatric neurosurgery in malaysia as the availability of specialised paediatric intensive care units and specialised instruments are typically present in major hospitals with dedicated neurosurgical units and facilities. with the ongoing pandemic crisis, these subspecialised resources are crucial for the treatment of patients afflicted by covid- . ( ) all non-essential outpatient cases should be postponed. some new cases with symptoms and signs of raised icp or neurological compromise should be reviewed urgently by a neurosurgeon. whereas, new cases with no symptoms or signs of raised icp or neurological compromise should be reviewed via teleconsultation. any pending surgeries should be reviewed with team and mdt to prioritise cases based on the urgency of surgical intervention, taking into account symptoms and signs, radiological evidence of mass effect or vital structure compression, expected radiological progression over time and expected histology along with the availability of vital specialised resources of intensive care, equipment requirements and ot availability. certain logistic factors, such as patient travel and family economic factor that requires one or both parents to be away from work should also be taken into account in the decision making process to ensure compliance of patient and caretakers to the management plan. paediatric neurotrauma ( ) all cases must be screened for risk of covid- as per hospital protocols. the management of paediatric neurotrauma is based on the brain trauma foundation (btf) guidelines. all cases undergoing emergency surgery must be performed under full ppe as per hospital/moh protocols ( , ) . the initial referral should be reviewed by the neurosurgical team or consulted via teleconferencing with the neurosurgical team on admission. the modified paediatric gcs score system (table ) must be applied and made available to referring or primary management team where applicable ( ) . cases of neurotrauma with surgical lesions must be transferred to a hospital with a neurosurgical facility and or services for management. frequent repeats of ct scan should be avoided where feasible and should be factored into the decision making process for applicable cases. there are certain cases of neurotrauma that has positive ct findings but with a nonsurgical lesion ( ) . if the treatment requires an icp monitoring, then the patient should be transferred to a centre with neurosurgical services or facilities. if the treatment does not require an icp monitoring but there is a potential risk of progression and deterioration, then the patient should also be transferred over. however, for patients who do not require intensive care with low risk of deterioration or progression, it is advisable to transfer to centres with available neurosurgical services. if it is not feasible, then the patient should be managed by attending paediatrician/surgeon at primary referral centres with regular consultations to the neurosurgical team. cases with no positive ct brain findings ( ) may be managed at primary referral centres if deemed suitable with a consultation to the neurosurgery team. in a non-traumatic paediatric neurosurgery case, the approach is the same; all cases must be screened for risk of covid- as per hospital protocols. suitable use of ppe must be adhered to for all cases undergoing surgery. the surgeon should: i) consider the option of fastest and simples access route to the lesion; ii) consider biopsy if deemed appropriate over surgical guidelines covid- management in malaysia covid- : recommendations for management of elective surgical procedures american association of neurological surgeons. covid- and neurosurgery cms adult elective surgery and procedures recommendations neurosurgery during the covid- pandemic: update from lombardy, northern italy letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm guidance for surgeons working during the covid- pandemic letter: precautions for endoscopic transnasal skull base surgery during the covid- pandemic just the facts: airway management during the coronavirus disease (covid- ) pandemic adoption of a safe or cautious approach towards surgery covid- preparedness within the surgical, obstetric, and anesthetic ecosystem in sub-saharan africa update: the use of personal protective equipment by anesthesia professionals during the covid- pandemic covid- among medical personnel in the operating room what we do when a covid- patient needs an operation: operating room preparation and guidance just the facts: protecting frontline clinicians during the covid- pandemic strategies for optimizing the supply of isolation gowns personal protective equipment: questions and answers managing icu surge during the covid- crisis: rapid guidelines us department of health and human services. personal protective equipment (ppe) coronavirus disease (covid- ): critical care and airway management issues operational considerations for personal protective equipment in the context of global supply shortages for coronavirus disease (covid- ) pandemic: non-us healthcare settings ministry of health malaysia. intensive care preparedness and management of covid- centers for disease control and prevention. contact tracing for covid- public health service commissed corps. strategies to optimize provision of mechanical ventilation safety recommendations for evaluation and surgery of the head and neck during the covid- pandemic surgical considerations for tracheostomy during the covid- pandemic: lessons learned from the severe acute respiratory syndrome outbreak safe tracheostomy for patients with severe acute respiratory syndrome clinical guide for the management of neuro trauma patients during the coronavirus pandemic preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of coronavirus infection guidelines on management of coronavirus disease (covid- ) in surgery response to covid- in chinese neurosurgery and beyond neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) on pandemics: the impact of covid- on the practice of neurosurgery triage of scarce critical care resources in covid- . an implementation guide for regional allocation: an expert panel report of the task force for mass critical care and the american college of chest physicians society of british neurological surgeons. bnvg/ sbns guide for the neurosurgical management of neurovascular conditions during the covid- pandemic guidelines for the management of aneurysmal sah: a guideline for healthcare professionals from the american heart association/american stroke association arteriovenous malformation (avm) management of incidental cerebral avms in the post-aruba era arteriovenous malformations of the posterior fossa: a systematic review responses to aruba: a systematic review and critical analysis for the design of future arteriovenous malformation trials intracranial dural arteriovenous fistulas: a review the latest national clinical guideline for stroke guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the american heart association/american stroke association using the national institutes of health stroke scale: a cautionary tale guidelines for the early management of patients with acute ischemic stroke: update to the guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the temporary emergency guidance to us stroke centers during the coronavirus disease (covid- ) pandemic: on behalf of the american heart association/american stroke association stroke council leadership challenges and potential solutions of stroke care during the coronavirus disease (covid- ) outbreak ministry of health malaysia. perioperative mortality review (pomr): prioritisation of cases for emergency and elective surgery ( nd revision) [internet]. malaysia: medical development division society of american gastrointestinal and endoscopic surgeons. covid- statement and recommendations from the asociacion espanola de cirujanos practical considerations for performing regional anesthesia: lessons learned from the covid- pandemic preparing for a covid- pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore handbook of covid- prevention and treatment ministry of health malaysia. garis panduan kementerian kesihatan malaysia protocol for urgent and emergent cases at a large academic level trauma center covid- : guidance for triage of non-emergent surgical procedures covid- -infection prevention and control measures covid- : infection prevention and control (ipc) guidelines for management of neurosurgical cases during covid- pandemic effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis infection prevention and control of epidemic and pandemic prone acute respiratory infections in health care letter: considerations for performing emergent neurointerventional procedures in a covid- environment minimizing sars-cov- exposure when performing surgical interventions during the covid- pandemic infectious diseases society of america guidelines on infection prevention in patients with suspected or known covid- ultraviolet irradiation doses for coronavirus inactivation -review and analysis of coronavirus photoinactivation studies far-uvc light ( nm) efficiently and safely inactivates airborne human coronaviruses covid- coronavirus ultraviolet susceptibility evaluation of an ultraviolet c (uvc) light-emitting device for disinfection of high touch surfaces in hospital critical areas susceptibility of sars-cov- to uv irradiation germany international commission on non-ionizing radiation protection. icnirp note on use of uvc lamps to kill/inactivate the coronavirus (sars-cov- ) world health organization. coronavirus disease (covid- ) advice for the public the impact of professional isolation on teleworker job performance and turnover intentions: does time spent teleworking, interacting face-toface, or having access to communicationenhancing technology matter? providing patient care remotely in a pandemic the novel coronavirus (covid- ) outbreak: amplification of public health consequences by media exposure telemedicine in neurosurgery: lessons learned and transformation of care during the covid- pandemic telehealth and telemedicine in the covid- era: a world of opportunities for the neurosurgeons malaysian medical council advisory on virtual consultation (during the covid- pandemic) vascular endothelial growth factor (vegf) as a vital target for brain inflammation during the covid- outbreak evidence of the covid- virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms fluorescence and electron microscopic localization of f-actin in the ependymocytes world health organization (who) information note: tuberculosis and covid- tuberculous meningitis in adults: a review of a decade of developments focusing on prognostic factors for outcome covid- -associated acute hemorrhagic necrotizing encephalopathy: ct and mri features a first case of meningitis/encephalitis associated with sarscoronavirus- impact of the coronavirus (covid- ) pandemic on surgical practice -part (surgical prioritisation) performance of the pediatric glasgow coma scale score in the evaluation of children with blunt head trauma the society of british neurological surgeons. clinical guide for the management of paediatric neurosurgery patients during the coronavirus pandemic early lessons in the management of covid- for the pediatric neurosurgical community from the leadership of the american society of pediatric neurosurgeons anaesthesia and sars infographic for principles of airway management in covid- world federation of societies of anesthesiologists this publication is not a proposed national guideline for the covid- management of covid- neurosurgical patients but a review of management and protocols from local and international peer reviewed and non-peer reviewed publications, web-based information and data until the month of august . we hope that this publication will be used to improve care of neurological or neurosurgical patients and their caregivers/frontlines globally especially in developing countries. none. none. appendix . principles of airway management in coronavirus covid- ( ) www.mjms.usm.my key: cord- - ldtrjf authors: chuang, pei-hung; chuang, jen-hsiang; lin, i-feng title: a dynamic estimation of the daily cumulative cases during infectious disease surveillance: application to dengue fever date: - - journal: bmc infect dis doi: . / - - - sha: doc_id: cord_uid: ldtrjf background: in infectious disease surveillance, when the laboratory confirmation of the cases is time-consuming, there is often a time lag between the number of suspect cases and the number of confirmed cases. this study proposes a dynamic statistical model to estimate the daily number of new cases and the daily cumulative number of infected cases, which was then applied to historic dengue fever data. methods: the duration between the date of disease onset and date of laboratory confirmation was assumed to follow a gamma distribution or a nonparametric distribution. a conditional probability of a case being a real case among the unconfirmed cases on a given date was then calculated. this probability along with the observed confirmed cases was integrated to estimate the daily number of new cases and the cumulative number of infected cases. results: the distribution of the onset-to-confirmation time for the positive cases was different from that of the negative cases. the daily new cases and cumulative epidemic curves estimated by the proposed method have a lower absolute relative bias than the values estimated solely based on the available daily-confirmed cases. conclusion: the proposed method provides a more accurate real-time estimation of the daily new cases and daily cumulative number of infected cases. the model makes use of the most recent "moving window" of information relative to suspect cases and dynamically updates the parameters. the proposed method will be useful for the real-time evaluation of a disease outbreak when case classification requires a time-consuming laboratory process to identify a confirmed case. timeliness and accuracy of case reporting are two of the most important performance measures when evaluating an infectious disease surveillance system [ ] [ ] [ ] [ ] [ ] . laboratory confirmation is usually needed for case diagnosis in many infectious diseases. when laboratory confirmation of the diagnosis is time-consuming, however, there is often a time-lag between the onset date of symptoms and the diagnosis date [ ] . for example, the median time for confirmation of the meningococcal disease is about days based on the national notifiable diseases surveillance system (nndss) dataset for the united states from to [ ] . time from disease onset to diagnosis has been also reported to account for most of the delay in case reporting in korea [ ] . correct estimation of daily cases or daily-cumulative infected cases helps the implement of immediate disease control and allows prevention activities for infectious diseases to be instituted [ ] . using a disease surveillance system, one is able to apply statistical methods, such as cumulative sum (cusum) [ , ] or autoregressive integrated moving average (arima) [ ] [ ] [ ] [ ] [ ] , in order to forecast an epidemic curve or to detect aberrations in disease spread. these estimations are based on having a correct daily number of cases or a daily-cumulative number of cases. an epidemic of dengue fever occurs every year in southern taiwan. in the year in particular, there was a large-scale epidemic with , confirmed cases out of totally , suspect cases [ ] . this epidemic continued until march . surveillance and the control of dengue fever have become one of the most important routine areas of work at the taiwan centers for disease control (taiwan cdc) in recent years. by , taiwan cdc had defined a confirmed case of dengue fever as an acute febrile illness together with one of the following criteria: ( ) isolation of dengue virus; ( ) demonstration of positive results by real-time reverse transcription--polymerase chain reaction (real-time rt-pcr); ( ) demonstration of positive seroconversion or a fourfold increase in dengue-specific igm or igg antibody titers in paired serum samples; or ( ) demonstration of high-titer dengue-specific igm and igg antibodies in a single serum specimen [ ] [ ] [ ] . when the dengue fever case classification only included confirmed cases by this protocol, the time needed for isolating the agent or measuring the titers for the acute-and convalescent-phase serum specimens was significant. the result was that there was a gap between the available daily cases or the daily-cumulative cases for given a day and the actual final confirmed cases for the same day given that all diagnosis had been completed on that given day. assuming that a time cost for laboratory confirmation of diagnosis is sometimes inevitable, daily numbers of infected cases and daily-cumulative number of infected cases may be underestimated during an epidemic. the objective of this study was to develop a new method to estimate the number of daily cumulative cases and that this method will be applied to dengue fever in taiwan, as an example. since there are almost no dengue fever cases occurred during the winter in taiwan, we chose may as the beginning of the dengue epidemic season when estimating the cumulative epidemic curve. the data come from the dengue notification dataset containing suspect cases in taiwan whose date of onset was from may , to april , . all serum samples from suspect cases were sent to the two reference laboratories at the taiwan cdc in order to further identify if they were positive (dengue fever infected) or negative cases. the reason we retrieved data based on the date of onset rather than the report date was to avoid the influence of lag reporting on the course of the disease. all imported cases of the disease were removed. the variables we used were the date of onset, the date of laboratory confirmation (diagnosis date), and the final confirmed status of each suspect case (a binary variable that is either positive or negative). in this article, we use confirmed dengue cases and positive cases interchangeably. no personal identification information was contained in the dataset. our proposed method estimates the real-time daily new number of cases and the daily cumulative number of dengue cases; specifically, these numbers of dengue cases are updated daily. let c be the "current" date when the number of dengue cases is to be estimated. in this study, the date c runs from may , to april , . for the i th reported suspect case counting from the st day of the epidemic season, that is may in this study, we define the suspect case's onset date as o i and the laboratory confirmation date as d i if d i >c on date c, the case i does not have a confirmation result as of date c; on the other hand, if d i ≤ c, this case i is either confirmed to be a positive dengue case or has a negative result as of date c. let the final confirmation status for the i th suspect case be, where as a positive dengue case, and as a negative case. in the situation where there are unconfirmed suspect cases as of date c, we assigned a probability of being a dengue case, p(i), to those unconfirmed cases (d ≤ c). then for each suspect case i, the expected final confirmation status on date c, e i (c), can be written as the values of p i (c), and e i (c)are updated for each case i every day. without applying the proposed method, one would be only able to observe the case status from the upper part of e i (c)in equation ( ) . after e i (c)is calculated for each suspect case, daily new cases are easily estimated by summing the e i (c)over all new suspect cases on date c, and cumulative cases can be obtained by summing e i (c)over all cases from i = to the newest suspect cases on date c. is estimated for unconfirmed cases using information from the confirmed cases before date c within one year. let t i be the onset-to-confirmation time (oc-time), the time interval between the onset date and the lab-confirmation date. the oc-time for the i th suspect case as of date c, t i (c), is calculated as follows, the t i (c) is the oc-time for confirmed cases and the censored oc-time for unconfirmed cases on date c. by applying several steps of bayes' rules, the probability p i (c) is given by: to estimate p i (c) using the information as of date c, we applied the following steps. we first estimated p(y i = ) by calculating the proportion of confirmed positive dengue cases out of the suspect cases using the data with onset date within year before the date c. based on a parametric approach, we assumed the oc-time for a given case status, p(t|y i ), follow a gamma distribution. gamma distributions are frequently used to fit time-delay distributions or time event distributions when carrying out disease surveillance analysis [ , ] . the probability density function of the gamma distribution is , where . the gamma distribution is denoted by with two parameters, the shape parameter α and the scale parameter β, and the mean and variance are αβ and αβ , respectively. the values of α and β were estimated and solved by setting up the sample mean and the sample variance of the oc-time equal to αβ and αβ , respectively. as mentioned in the previous section, the mean and standard deviation of the oc-time were different between positive and negative cases, we estimated different sets of α and β for the positive dengue cases (y = ) and negative cases (y = ) separately. a nonparametric approach was also performed in which the probability p(t >t i (c)|y i ) was simply replaced with the cumulative proportion of confirmed data given their final status. both the parametric and nonparametric models were based on the data within a -year "moving window" before date c. the p i (c) and e i (c) were also updated everyday. to evaluate the performance of the proposed method, we estimated the daily new cases and daily cumulative cases for each calendar date c from may , to april , . four epidemic curves are presented. there are: ( ) the final status curve, which is the number of dengue cases based on their final confirmation status ("real data", "gold standard"). ( ) the daily confirmed curve, which is the number of dengue cases based on the confirmed cases as of date c. ( ) the gamma-model curve, which is the number of dengue cases, estimated using the gamma distribution. ( ) the nonparametric-model curve, which is the number of dengue cases, estimated using the nonparametric distribution. to summarize the magnitude of the bias, we defined the absolute relative bias (arb) at date c as: where are the cumulative cases estimated by the proposed methods or by the confirmed cases observed on date c without using the proposed methods, n c and are the cumulative confirmed cases based on the final status ("real data", "gold standard"). an arb closer to zero is a more accurate estimate. all analyses were performed using sas . . software (sas institute, inc., cary, nc). special sas macros for estimating the cumulative cases and daily new cases, based on our proposed model, were developed. figure compares the daily new cases estimated by the proposed models, the confirmed curve (confirmed new cases observed on date c without using the proposed models), and the final status curve (confirmed new cases based on final status; the "gold standard"). since the daily new cases estimated by the proposed methods or the daily new cases observed on date c were different when viewed on different dates, arbitrary view dates of august , (beginning of the epidemic), september , (rising stage, before the peak), october , (rising stage, before but closer the peak) and november , (around the peak), december , (downward stage, after the peak), and january , (end of the epidemic) were chosen to illustrate the results of the estimated daily new cases. each graph in figure shows the epidemic curves three weeks before the view dates. when viewed on august , most of suspect cases had been lab-confirmed before july thus all four curves were close to each others before that date. from july to august , the estimated curves by the proposed methods (red dashed lines with triangle symbols by gamma distribution and blue dashed lines with cross symbols by the nonparametric method) were much closer to the final status curve (shaded area) than that by simply observing the dailyconfirmed new cases (purple dashed line). similar patterns were observed when the results are viewed on september , october , november , and december . the observed daily-confirmed cases usually underestimated the true daily new cases as would be expected, especially within the two weeks before the view date. the curves estimated by gamma distribution or the nonparametric approach were quite similar. however, the daily new cases, as estimated by the proposed method, did not give an accurate estimate towards the end stage of the epidemic, namely when viewed on january , . the epidemic curves in terms of daily cumulative cases are shown on figure . in this figure, the cumulative number of positive cases was updated every day. the two estimated daily-cumulative curves by the proposed methods are quite similar to the final status curve before january but again the proposed method does not work well during the end stage of the epidemic. table compares the arb of the daily cumulative number of positive cases between the different methods. after the first confirmed positive case appeared on july , , the estimates based on the gamma model results in an estimate closer to the real data than the other methods. for other two curves, the nonparametric method performs worst at the end of the epidemic after january and there was about cases higher than the final status curve. the daily confirmed curve was about cases lower than the final status curve during the peak of epidemic. figure showed the daily parameter estimates, α and β, of the gamma distributions used to dynamically calculate the daily number of positive cases. the parameter estimates varied from day to day and thus the probability of being a positive case changes. for the negative cases, the parameters had a jump during late september. as noted previously, timeliness and accuracy are the two of most important characteristics when we evaluate an infectious disease surveillance system. our results show that when an infectious disease required a time-consuming process for diagnosis, such as the dengue fever using the previously mentioned protocol, the actual daily number of infected cases and cumulative positive cases are potentially underestimated. the proposed method dynamically updates the parameters daily by making use of the most recently available information on suspect cases, and then performed estimates with a lower absolute relative bias than when using observed daily lab-confirmed cases only. as shown in table , the proposed method performed a lower median absolute relative bias (abs range . % ~ . %) than those solely based on daily confirmed cases (abs range . % ~ . %) between july and december . these dates covered the rising stage and around the peak stage which were of public health interest. the proposed method provides a more accurate estimate of the epidemic curves when applied to the dengue fever dataset for taiwan during the - season. based on these results, this approach can be used for the real-time evaluation of the severity of a disease outbreak when case classification requires that a confirmed case involves a time-consuming process. in this study, we first established the different distributions for the onset-to-confirmation time of the positive cases and negative cases. next, either a gamma distribution was assumed in order to estimate the probability of being a confirmed case given cases status in equation ( ), or, alternatively, a nonparametric approach was used. we actually experimented with several types of distribution. the estimates using a log-normal distribution were numerically very similar to the results for the gamma distribution. the estimates using a weibull distribution did not perform as well as the gamma distribution applied in our dengue fever data. from figure , we learn that the shape parameter α changed from . to and therefore an exponential distribution may not be appropriate. for simplification, we have chosen to present only the results from the gamma distribution as one example of a parametric approach and compare this with a nonparametric approach. as shown in figure for daily new cases, the differences in the estimates based on parametric approach with gamma distribution and those with nonparametric approaches were minor. the figure and table for cumulative cases showed that a gamma distribution is a more appropriate assumption for the onset-todiagnosis time when estimating the probability of being a positive case using the dengue fever example; nonetheless, the difference between the gamma and the nonparametric method is again only slight except towards the end stage of the epidemic after january . the reason that the nonparametric method did not work well after january is because p(y i = ), p(y i = ), and p(t|y i ) had not changed substantially, resulting in a near constant estimate of the daily positive cases. in practice, any form of the probability of being a positive case can be assumed. it is also not restricted to certain distributions when the models are adapted to different types of infectious disease. when applying this approach to other diseases, researchers should investigate several distributions according to the shape of their data and choose an appropriate one based on some appropriate measures, for instance, those shown in table . our method estimated the probability of being a positive case based on the data within a -year "moving window" before date c and updated p i (c) and e i (c) everyday. the epidemic profiles of dengue fever are different from one year to another in taiwan. choosing the data from most recent one year was done in order to insure that there was enough information to cover a whole epidemic season. the study shows that before the first positive case appeared on july , the proposed method did not work well and are not that useful (table ). our method worked well after the first positive case appeared during the - season. indeed, it needed only four days to be able to consistently estimate the final status curve. in the - season, taiwan cdc activated a central command center for intensively dengue epidemic control on october . the task of this command center included expanded blood sample collection and it is likely that this resulted in more suspect cases for laboratory confirmation, which might have led to a lower proportion of positive cases. this would influence the estimation of probability of being a positive case over the following few days. as we can see on figure , it also influenced the estimation of the parameters for negative cases. while our manuscript was being prepared, the taiwan cdc changed their laboratory protocol for dengue fever to one that requires only a single laboratory test for dengue surveillance and control. the result is a substantial reduction in the waiting time for laboratory confirmation. however, confirmation time can never be completely avoided with dengue fever. a situation where a large number of serum specimens are sent for diagnosis at the same time will result in overloading at the laboratory, which might increase the confirmation waiting time. as described previously, the estimation used information based on a "moving window" time period before the estimated date and the parameters of the model are updated everyday. since the observed confirmed cases counts on date c are always underestimated as long as there is a time lag, our method potentially can be applied while waiting for further investigation of the status of cases. there are some limitations to our method. firstly, the approach needs sufficient historical data to be available in order estimate the parameters of the model; therefore our model cannot be applied effectively to an emerging disease, such as sars or avian flu. secondly, we used confirmed cases, the dates of onset of which were within year before the date estimated and if a case needs more than -year for diagnosis such a case might never provide any information to the parameter estimation; in such a circumstance a different "moving window" needs to be chosen. thirdly, when missing diagnosis dates exist, the estimated curve using the nonparametric method cannot converge with the final status curve. there were and cases missing confirmation results for the - season and the - season, respectively, at the time that the manuscript was prepared. the nonparametric method estimates by plugging in the cumulative proportion of confirmed data given the final status. as we mention before, at the end stage of epidemic, the probabilities in equation ( ) almost remained unchanged. in this study, we could only assume that the proportion of positive cases out of all suspect cases among the missing observations were similar to those having results, which basically assumes that the missing data were missing at random thus ignorable. when diagnosis of infectious diseases required laboratory confirmation, the time lag between onset and confirmation of a positive cases often exists and case counts are usually underestimated. this study has proposed a statistical method that more accurately estimates the real-time daily new cases and daily cumulative number of infected cases using a dengue fever epidemic as an example. the model makes use of the most recent "moving window" of information on suspect cases and dynamically updated the parameters of the assumed probability distributions. different parametric or nonparametric distributions of the onset-to-confirmation times can be specified for different infectious diseases. the results show that, after the first confirmed case occurred, the estimated daily new cases or the cumulative case count fit the real data well compared to the daily counts based only on the available confirmed cases; this was done by assuming a gamma distribution for the onset to confirmation times and involved the use of a dynamic one-year "moving window" of suspected cases when applied to dengue fever outbreaks in taiwan. this method can be used for the realtime evaluation of a disease outbreak when case diagnosis requires time-consuming laboratory process. how complete and accurate is meningococcal disease notification? public health surveillance of aids and hiv infections updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group cdc's national violent death reporting system: background and methodology an outbreak of leptospirosis, thailand--the importance of the laboratory evaluation of reporting timeliness of public health surveillance systems for infectious diseases syndromic surveillance systems: public health and biodefense timeliness of national notifiable diseases surveillance system in korea: a crosssectional study methods for monitoring influenza surveillance data the relative efficiency of the sets and the cusum techniques in monitoring the occurrence of a rare event time series analysis forecasting and control on the application of integer-valued time series models for the analysis of disease incidence use of time-series analysis in infectious disease surveillance dynamic linear model and sarima: a comparison of their forecasting performance in epidemiology a monitoring system for detecting aberrations in public health surveillance reports number of reported and confirmed cases -by month world health organization: dengue haemorrhagic fever: diagnosis, treatment and control laboratory-based dengue surveillance in taiwan, : a molecular epidemiologic study current status of dengue diagnosis at the center for disease control epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong sars incubation and quarantine times: when is an exposed individual known to be disease free? this study was supported in part by the centers for disease control, department of health, taiwan, republic of china (doh -dc- and doh -dc- ) and was also supported by the aim for the top university plan of national yang-ming university. the authors would like to thank the reviewers' excellent comments for improving this manuscript. the authors declare that they have no competing interests. authors' contributions ifl designed and conducted the study, and finalized the manuscript. phc participated in the design of the study, performed the statistical analyses, and drafted the manuscript. jhc helped conceive the study, participated in the data collection, gave input to the manuscript, and provided medical advice from the public health perspective. all authors have read and approved the final manuscript. key: cord- - yr qon authors: kang, yun-jung title: lessons learned from cases of covid- infection in south korea date: - - journal: disaster medicine and public health preparedness doi: . /dmp. . sha: doc_id: cord_uid: yr qon on december , , the chinese government officially announced that the country had a single pneumonia case with an unknown cause. in the weeks after, south korea had confirmed cases by february , and the number has increased steadily since then. the highly contagious virus known as coronavirus disease (covid- ) infected case no. in daegu; she was the first patient related to sincheonji church. later, the number of cases involved with sincheonji skyrocketed. on march , , the number of confirmed cases was , with dead. this study, through collecting epidemiological data about various covid- infection cases, discovered that getting together in large groups leads to mass infection, and that paying close attention to personal hygiene by means of wearing masks, sanitary gloves, etc., can prevent the spread of covid- . additional epidemiological data and related studies on covid- infections in south korea are likely to support or slightly modify this conclusion. however, this study is significant in that it emphasizes the precautionary principle in preventing and managing infectious diseases, and has a suggestion for public health policies, which are currently in high demand. o n december , , the chinese government announced officially that the country had a pneumonia case with an unknown cause. it is not clear when this case occurred initially. according to reports containing confirmed cases from the medical teams in wuhan, china (december , to january , ), the first patient developed symptoms on december , but had never visited the huanan fish market. later, on january , , the chinese government reported a new kind of coronavirus as the cause of this pneumonia case and provided information on the virus to researchers around the world. the world health organization (who) named the virus coronavirus disease (covid- ) temporarily, but as the english name is rather long in korean, the south korean government decided to call it "corona (corona il-gu)," following the opinion of the korean centers for disease control and prevention. coronavirus (cov) is a virus that can infect humans and various other animals. it is an rna virus with gene sizes from to kb, with four genera (alpha, beta, gamma, and delta). alpha and beta genera can infect humans and animals, while gamma and delta genera infect only animals other than human beings. as implied by its name, the shape of the virus observed through an electron microscope is a crown shape with characteristic protein spikes attached to a ball. the pathogen is covid- , and the source of infection is estimated to be an animal, although the investigation is ongoing. the infection route channel is estimated to be animal → human → human. spread between humans is assumed to be due to droplet infection. secondary infection cases in households and hospitals have been confirmed. clinical manifestations are fever, respiratory symptoms (coughs and dyspnea), and pneumonia. case related to the sincheonji church in daegu (case no. ), the number of covid- cases by sincheonji members in south korea increased sharply. the south korean government, using the church member registry of , members it acquired from sincheonji headquarters, analyzed the connection between church members and covid- cases confirmed until march . according to the analysis, % of the confirmed cases were related to sincheonji. the possibility of mass infection in church services was suggested. as more than covid- cases were confirmed, the cases of infection became more diverse. this study collected and studied various cases of covid- infections to the time of this writing to determine measures of prevention against the spread of the disease, while suggesting a managerial direction for public health, which is in urgent demand now. reports were collected from south korea based on data from the korea centers for disease control and prevention, along with data and presentation examples from the korea centers for disease control and prevention from february to march , . respiratory syndrome caused by severe acute respiratory syndrome coronavirus (sars-cov- ) infection. a person who has been confirmed to be infected with an infectious pathogen according to the examination criteria for diagnosis. test criteria for diagnosis: virus isolation from samples, detection of specific genes in samples. the korea centers for disease control and prevention is an organization belonging to the ministry of health and welfare of korea and is located in cheongju city, north chungcheong province. this institution is responsible for the prevention, investigation, quarantine, testing, research, and long-term transmission management of infectious diseases, chronic diseases, rare intractable diseases, and injured diseases to improve the national health of south korea. the term large-scale group infection refers to a condition in which a large number of people are exposed to each other in a short period of time, because some infectious diseases are clustered among schools, companies, dormitories, factories, or people in a limited physical space at once, and the conditions for causing infectious diseases are established as a group. some disorders occur sporadically in time or place. it is not so important in public sanitation, but it is sometimes necessary to monitor the situation as it happens as an example of group outbreak. nationally, . % of the confirmed covid- cases in korea are verified to be related to mass infections. the other . % cases are due to sporadic infections or the causes are still being investigated. investigating the mass infection cases by regions, confirmed that cases related to sincheonji church in daegu accounted for . % of the overall confirmed cases in the city. more cases were confirmed in public and medical facilities while investigating people who had had contact with the sincheonji followers. in busan and gyeongnam, the number of covid- confirmed cases related to a retreat to oncheon church is . people from busan account for most of the cases, with the number of ; the other two people were from gyeongnam. among the confirmed cases, were geochang church bore the most covid- confirmed cases as a single group in a single region of gyeongnam province. therefore, gyeongnam province government sent an epidemiological investigation team to geochang and started an in-depth investigation in cooperation with the city government of geochang. the number of the members of geochang church congregation is , with people living in geochang and coming from other towns. among the members from geochang, people were confirmed to be infected, while the other were confirmed negative. sixty-two people who had contacted the confirmed cases are all confined in their own homes. among the pilgrims of andong, gyeongbuk parish of the catholic church, who had participated in the pilgrimage to israel, people were confirmed to be infected by covid- . nineteen other people who had contacted with the confirmed cases were also tested to be positive, making the total number of the confirmed cases. as some of the pilgrims are reported to have visited restaurants and eateries after returning to korea, there is a possibility of regional spread. the mass infection among the saengmyeongsam church congregation, which bore confirmed cases of covid- , is reported to have been caused by worshipping and eating together in a small and crowded indoor environment. a sincheonji believer and lecturer from sincheonji church, daegu, who attended the service, is indicated to be the index case. person a, a confirmed case who is currently being treated in a management ward, reported that he was infected after visiting a wedding hall in daegu. he spent only h and min in the wedding hall. on the date of visiting, his wife and son wore masks, unlike himself. elevator person a ( , male), a curate of myeongseong church in gangdong-gu, and person b ( , female), a resident of the same apartment building he lived in, took the same elevator, and both were confirmed positive. person b did not wear a mask in the elevator and became infected with covd- after the short time spent in an elevator. in busan, a middle school student (teenager) was confirmed to be infected with covid- on february , , after visiting the same internet café where a member of the oncheon church had visited. person a, a tour guide, confined himself in his own home when he first developed symptoms (a sore throat) on january , . since then, he recorded his covid- symptoms meticulously in a daily journal. when going to hospitals, he avoided using public transportation and walked, taking only uncrowded routes. he wore masks and gloves even in his home, which led to the negative confirmation of people who had come in contact with him, including his mother living with him under the same roof. patient number from bukgu, busan, who is in his s, confined himself to his home when he heard that he was confirmed positive of covid- and drove by himself even when he visited the selective care center. he always wore masks in his own home and separated his living area, saving his parents; they were both confirmed negative. a covid- confirmed case c ( , male) wore masks and sanitary gloves even in his homes when he developed symptoms of the virus. he sterilized the dishes he used in hot water right after using. even though he was confirmed negative once, he recorded his symptoms and the places he went just in case. after he was confirmed, he provided this information to the prevention authorities and contributed to their quick reaction. pyeongtaek city government in gyeonggi-do announced that all the family members of the second covid- confirmed case were confirmed negative of the virus on february , . cctv footages showed that the patient always wore the mask. cases of covid- figure ). locations of mass infections are churches, hospitals, sanitariums, private educational institutes, and dance studios, where many people gather in a closed and crowded environment and tend to contact each other at a close distance. the chinese national hygiene and health committee admitted the possibility of infection through aerosols in its th edition of covid- treatment guide, providing "long-time exposures to dense aerosol in relatively closed environment." aerosol means solid or liquid small particles floating in the air, ranging from . μm to μm. according to scientific definitions, small particles that can travel far distances for a long time are classified as airborne, while bigger aerosols are classified as droplets. this means that the spread through aerosols can manifest in two types, one being droplet infection by direct contact and one being airborne spread. generally, droplet infection occurs when the infected person sneezes, coughs, talks, or exhales; this is called the first aerosolization. in contrast, airborne spread is due to the spread of droplet nuclei with the size of < μm, left behind when the water in droplets evaporates. as the droplet nuclei are light and can float in the air for a long time, they can be especially dangerous. although religious services conducted in crowded spaces like churches and temples are vulnerable to infections, there are no specific prevention guides from the government. most churches hosted services as usual, despite the possibility of regional infection with more and more cases of covid- cases being confirmed. contact between hundreds and thousands of the members in the same space was inevitable, making people vulnerable to covid- with its strong infectivity. furthermore, the korea centers for disease control and prevention suggests the possibility of limited but constant spread in groups through holiday services and small meetings. private educational institutes and physical training facilities bear similar dangers. even though the government postponed the start of semesters for kindergartens, elementary schools, middle schools, high schools, and universities for fear of mass infections, many private educational institutes and physical training centers are insisting on operation, threatening covid- prevention. according to a report on there are even cases of infection that go against the explanation provided in the chinese national hygiene and health committee's th edition covid- treatment guide, which says that the condition for spread through aerosol is "long-time exposures to dense aerosol in relatively closed environment." the cases of infection in the elevator and the wedding hall, where the patients spent only a short amount of time together, prove this false. the patients of these two cases are similar in that they did not wear masks. from the perspective of prevention and management, blocking the route of airborne infection is critical. there were also many desirable cases where the infection spread was prevented by using masks and sanitary gloves (table ) . [ ] [ ] [ ] patients, after feeling their symptoms or finding out that they had contact with confirmed cases, confined themselves to their homes and shunned crowded places to prevent infecting others. they always wore masks and sanitary gloves, and even though their uninfected family members were under the same roof, these measures allowed them to be confirmed negative. the mask used at this time was a disposable non-woven-material mask. in contrast, when the confirmed cases did not wear masks or confined themselves in distribution of covid- occurrence types. cases of covid- infection in south korea disaster medicine and public health preparedness separate rooms in their homes, all their family members were diagnosed to be positive. these are cases where wearing masks and using proper individual hygiene decided the positive outcome of prevention. the temporary conclusion of this study, based on limited epidemiological data and information on confirmed cases currently available, is that group meetings lead to mass infections of covid- , and that caring for individual hygiene by wearing masks and sanitary gloves can prevent its spread. however, in the current epidemic, the group that needs the most masks are the medical staff working on the front lines. therefore, an individual's wearing of a mask should be limited to patients suspected of having an infection. this conclusion can be supported or modified according to additional epidemiological data and research results on covid- infections in south korea. however, this study is meaningful in that it emphasizes the precautionary principle in preventing and managing infectious diseases, and has a suggestion for public health, which is currently in urgent demand. clinical features of patients infected with novel coronavirus in wuhan china novel wuhan ( -ncov) coronavirus the outbreak cases with the novel coronavirus suggest upgraded quarantine and isolation in korea corona corresponds to korea, being caught by sinchon and conservatives the government " % of confirmed people are infected with sincheonji" president moon "practical actions % of korean corona confirmed 'cold infection'… the largest is shincheon daegu church corona group occurrence related to busan hot spring church… " busan, gyeongnam". newsis epidemiological survey of geochang churches in korea. hankyoreh zumba · pilgrimage · hospital community outbreaks "another primer ?news_id=n &plink. (korean) suwon city, members of life sam church. confirmed. sport news subsequent hospital infections occur… concerns about analysis of local health care system mary's hospital confirmed by … "the biggest seoul outbreak arcid= &code= &cp=nv. (korean) confirmation of medical staffs, days of quarantine medical staff at bundang jesaeng hospital and patients corona 'group infection'. financial news chilgok severe disability facility 'millal house', corona confirmed by gyeongsangbuk-do, more than half of new patients second south hospital situation ona… bonghwa blue sanitarium infections worried that the dance instructor confirmed by corona in cheonan will become a local super evangelist quarantines' confirmed people related to the apartment in seongdong-gu we are frustrated with school infection spread… busan office of education appeals to parents the sixth person who confirmed coin karaoke… small scale infection is a reality. hankyoreh → no. → family' cases of infection in korea ?volumeno= &member no= . (korean) confirmation "don't be attentive in hour of daegu wedding corona ' confirmed. ohmy news where do youth acting school?… 'pc · karaoke' in various places never go to harm"… 'corona journal' with few copper wires and symptoms wearing masks and hygiene gloves at home… carefully record the symptoms and movement pyeongtaek's nd corona confirmed family 'negative'. yunhap news chinese authorities add coronal disturbance path aerosol technology: properties, behavior, and measurement of airborne particles preventing airborne disease transmission: review of methods for ventilation design in health care facilities viral infections acquired indoors through airborne, droplet or contact transmission aerobiology and its role in the transmission of infectious diseases coronavirus infection- domestic outbreaks postponement of school opening, 'combination', and teaching instructors… outbreak 'emergency'. nocut news the authors declare that they have no competing interests. the author (y.j. kang) wrote the entire manuscript and holds final responsibility for the decision to submit the manuscript for publication. the author read and approved the final manuscript. key: cord- -o s upf authors: du, wenjun; yu, jinhong; wang, hui; zhang, xiaoguo; zhang, shouwei; li, qiang; zhang, zhongfa title: clinical characteristics of covid- in children compared with adults in shandong province, china date: - - journal: infection doi: . /s - - - sha: doc_id: cord_uid: o s upf aims and background: the covid- outbreak spread in china and is a threat to the world. we reported on the epidemiological, clinical, laboratory, and radiological characteristics of children cases to help health workers better understand and provide timely diagnosis and treatment. methods: retrospectively, two research centers’ case series of consecutive hospitalized cases including adult and children cases with covid- between jan and feb from jinan and rizhao were enrolled in this study. epidemiological, clinical, laboratory, and radiological characteristics of children and adults were analyzed and compared. results: most cases in children were mild ( . %) and conventional cases ( . %), with mild clinical signs and symptoms, and all cases were of family clusters. fever ( . %) and dry cough ( . %) were described as clinical manifestations in children cases. dry cough and phlegm were not the most common symptoms in children compared with adults (p = . ). in the early stages of the disease, lymphocyte counts did not significantly decline but neutrophils count did in children compared with adults (p = . ). there was a lower level of crp (p = . ) in children compared with adults. there were ( . %) asymptomatic cases and ( . %) symptomatic cases among the children cases. the age of asymptomatic patients was younger than that of symptomatic patients (p = . ). even among asymptomatic patients, ( . %) cases had lung injuries including ( %) cases with bilateral involvement, which was not different compared with that of symptomatic cases (p = . , p = . ). conclusions: the clinical symptoms of children are mild, there is substantial lung injury even among children, but that there is less clinical disease, perhaps because of a less pronounced inflammatory response, and that the occurrence of this pattern appears to inversely correlate with age. since the first atypical pneumonia case was reported in wuhan, china on december , [ ] , the pathogen was soon identified [ ] and tentatively named -ncov by the world health organization (who) [ ] . on feb , the world health organization officially named it sars-cov- (severe acute respiratory syndrome coronavirus- ) and the sars-cov- infection was named as the covid- (coronavirus disease ) [ ] . the infection quickly spread in china, and internationally [ , ] and is still on-going. previous studies reported the main clinical characteristics of covid- . fever, cough, shortness of breath, muscle ache, confusion, and headache were described as clinical manifestations. laboratory tests and chest computed tomographic (ct) scans were also evaluated and the results suggested that decreased lymphocyte counts and bilateral pneumonia were common clinical features, especially in severe cases [ , ] . at present, there is no effective anti-virus drug and vaccine for covid- , so early detection and isolation treatment are important to control the progression and spread of the disease. however, the current data mainly come from hubei province, especially from wuhan city. clinical features, especially in children, have not been reported outside hubei province. in this study, we analyzed and compared the epidemic characteristics and clinical features in children and adults in shandong province, china. the aims were to help health workers better understanding the clinical features of covid- in children and provide timely diagnosis and treatment. the present study is a retrospective descriptive clinical study. a total of cases including adult and children cases of confirmed covid- from the jinan infectious diseases hospital and rizhao people's hospital, which were the designated hospitals in jinan and rizhao city, between jan and feb were enrolled in this study. the project was approved by the ethics board of jinan infectious hospital (no. ). informed consent was obtained from each patient or their guardian. all patients enrolled in this study were diagnosed according to the pneumonia diagnosis and treatment plan for the new coronavirus infection formulated by the national health commission (trial version ) [ ] . diagnostic criteria for asymptomatic cases: individuals infected by sars-cov- who remain asymptomatic throughout the course of the infection with or without abnormal chest ct imaging findings. diagnostic criteria for mild cases: mild clinical symptoms, no radiographic findings of pneumonia. diagnostic criteria for common cases: fever, respiratory symptoms, and radiographic manifestations of pneumonia. diagnostic criteria for severe cases: ( ) respiratory distress, respiratory frequency ≥ times/min; ( ) hypoxemia, with resting oxygen saturation ≦ %; and ( ) arterial partial oxygen pressure (pao )/oxygen absorption concentration (fio ) ≦ mmhg ( mmhg = . kpa). the diagnostic criteria for critical cases: ( ) respiratory failure and mechanical ventilation is required; ( ) shock; and ( ) complicated with other organ failure requiring icu care. there are four types of infection: ( ) imported cases defined as a history of a sojourn in hubei province within days of onset of the illness. ( ) family cluster defined as or more than people with confirmed cases in one family. ( ) close contact defined as close contact with cases from hubei province. ( ) unclear; the method of infection is unknown. a child is defined as less than years of age. the medical records of patients were analyzed. information recorded included demographic data, exposure history, symptoms, signs, laboratory findings and chest computed tomographic (ct) scans. epidemiological, clinical, laboratory, and radiological characteristics data were obtained with data collection forms from electronic medical records. the date of disease onset was defined as the day when the symptom was noticed. throat swab specimens were collected from patients with suspected covid- . covid- was confirmed by rt pcr using the same protocol. the dual-target detection kits were provided by the shanghai jienuo company. results: the cut-off value was , a ct value < was positive, a ct value > was negative, and - was a gray area (the diagnosis needs to be repeated). to characterize the effect of sars-cov- on the biochemical indicators and production of cytokines in the acute phase of the illness, plasma cytokines (pct, crp, and il- ) and biochemical indicators were measured using the human cytokine standard -plex assays panel and the bio-plex system(bio-rad, hercules, ca, usa) for all patients according to the manufacturer's instructions. the normal range for each indicator is shown in table . retrieved data were recorded into microsoft ® excel for mac (version . ) and analyzed. the statistical package for social sciences version . (spss . ;spss inc., chicago, il, usa) and the prism statistical software package (version . ; graphpad software inc. la jolla, ca, usa) were used. measurement data were described as mean ± standard deviation. background factors were compared using student's t-test (numerical data) or the χ test (categorical data). differences were regarded as significant if the p value was less than . on either side. a retrospective analysis was performed on patients in jinan and rizhao, shandong province from jan to feb . there were adult cases among the cases, with a median age of . years (range - years), and cases ( . %) were males. most of cases were mild ( cases, . %) and conventional ( cases, %), with only severe case ( . %). the most common symptoms at onset of the illness were fever ( . %), dry cough ( . %), phlegm ( . %), pharyngalgia ( . %) and fatigue ( . %). less common symptoms were, headache ( . %), anorexia ( . %), myalgia ( . %), chest distress ( . %), nausea ( . %), diarrhea ( . %), dizziness ( . %), and vomiting ( . %) ( table ) . there were children cases among the cases, with a median age of . years (range - years), and cases ( . %) were males. all the cases in children were familial clusters (p = . ), with cases ( . %) of the mild type and cases ( . %) of the conventional type and no severe or critical case. clinical symptoms in children were mild or even absent, only ( . %) cases showed signs of fever, cases ( . %) had dry cough, and case had phlegm, other clinical signs of headache, fatigue, pharyngalgia, and myalgia were rare in children. none of the children developed anorexia, chest distress, dyspnea, nausea, vomiting, diarrhea, dizziness, or abdominal pain. however, dry cough and phlegm were not the most common symptoms in children compared with adults (p = . ) ( table ) . laboratory tests of children and adults were analyzed. the results showed that the white blood cell counts of children were all normal, with decreased neutrophil counts (p = . ) and increased lymphocyte counts (p = . ) compared with adults ( table ) . considering the physical characteristics of the children with lymphocytes making up % of the white blood cells before years and the proportions of lymphocytes and neutrophils in white blood cells being close to that of adults after years, we further analyzed the difference in blood cell counts between children over years and adults. there are cases over years ( . %) among children cases, the neutrophil counts ( . ± . × /l) were more decreased in children over years than in adults (p = . ). however, lymphocyte counts ( . ± . × /l) showed no difference (p = . ) between the two groups. covid- caused liver function damage, cardiac muscle damage, and coagulation function changes. the abnormal rate of alt, ast, ldh, ck, myo, pt, and d-dimer was %, . %, . %, . %, . %, . %, and . % in adults and . %, . %, %, . %, %, . %, and . % in children, respectively ( table ). the value and positive rate of ldh in children were more significantly increased than in adults (p = . ; p = . ) ( table ). according to evaluation of infection indicators, the value of pct showed no difference between children and adults, however, the value and positive rate of crp were more significantly increased in adults than in children (p = . , p = . ) ( table ). of the cases, cases had complications of lung injuries ( . %) including children and adults. a total of children ( . %) and adults ( . %) had lung injuries with bilateral involvement, with no difference between the two groups (p = . ). however, lung injuries in adults were more severe compared with that in children ( table , fig. ). there were ( . %) asymptomatic cases and ( . %) symptomatic cases among the children cases, with a median age of . years, and cases ( . %) were males in the asymptomatic cases and with a median age of . years, and case ( . %) was male in the symptomatic cases. the age of asymptomatic patients was younger than that of symptomatic patients (p = . ) ( table ) . the white blood cell and lymphocyte counts were more decreased in symptomatic children cases than that in asymptomatic children cases (p = . , p = . ). although there were statistically significant differences in levels of cr and ast between asymptomatic and symptomatic children cases, these differences were within the normal range and had no practical clinical significance. even among asymptomatic patients, ( . %) cases had lung injuries including ( %) cases with bilateral involvement, with no difference compared with that of symptomatic cases (p = . , p = . ) ( table ). the severe acute respiratory syndrome corona virus (sars-cov- ) infection outbreak has spread in china and around the world [ , ] . who defined it as a public health emergency of international concern (pheic). coronaviridae (covs) are the largest known single stranded rna viruses [ ] . they have been categorized in three groups, alpha-covs, beta-covs, and gamma-covs according to phylogenetic analyses and antigenic criteria [ ] . the human severe acute respiratory syndrome (sars) virus, the middle eastern respiratory syndrome (mers) virus, and the sars-cov- all belong to beta-covs [ ] . the bat coronavirus (bcov) and the sars-cov- share . % sequence identity. bats were once thought to be the source of sars-cov- . however, sufficient evidence is lacking. a total of cases including adult and children cases, of which only case was the severe type and no one was in critical condition, is far lower than reported in wuhan [ , ] . there were no deaths reported because of few cases of the severe or critical type. the reason for this is considered as follows: ( ) there is no major epidemic in the regions except hubei province for strong prevention and control and ( ) the virulence and pathogenicity of the virus decrease in the nd and rd generation of transmission [ ] . all cases of children belong to the mild or conventional type of covid- , and all children are part of family clusters. previous studies found no cases in children, who were once thought to be less susceptible [ ] . according to the current trend, all people including children are susceptible to sars-cov- , and person-to-person transmission develops familial clusters [ ] . the reason why all children are in family a retrospective analysis on clinical features of children of covid- compared with that of adults from two research centers was made. the findings showed that clinical symptoms were mild in children with fever and dry cough being the most common symptoms, and other symptoms were rare. however, dry cough and phlegm are not the most common symptoms in children compared with adults. this is because a lower inflammatory response to lung injuries causes milder clinical symptoms in children compared with adults. previous reports indicated that decreased lymphocytes counts were common clinical features, especially in severe cases [ , ] . as a result of viral infection, white blood cell and lymphocyte counts can be reduced by consumption. however, similar results did not appear in our study, with only a total of cases including case of a child with decreased lymphocytes counts, and the value of lymphocytes counts showed no significant differences in children over years compared with adults. on the other hand, neutrophil counts decreased in children compared with adults (p = . ). so, lymphocyte decline is not an important indicator for the diagnosis of childhood cases and the neutrophil count decline should be focused on. these may be due to a lower inflammatory response in children. sars-cov- infection may induced lung injuries, liver function damage, cardiac muscle damage, kidney damage, and coagulation function changes [ , ] . among these laboratory tests, elevated ldh is more common in children than in adults (p = . ). an elevated ldh is commonly seen in cardiopulmonary disease and inflammation. the elevated ldh suggests that the sars-cov- infection appears to be more likely to cause cardiopulmonary injury and inflammation in children, although lung inflammation in children is less severe than in adults. of course, since the level of ldh is not high in children, it may not have practical clinical significance. both crp and il- are major indicators of inflammation. an elevated level of crp and il- was shown in adults, but not in children, which suggests that inflammation caused by viral infection, especially in the lungs, is less severe in children than in adults. in addition, lung injuries are not uncommon in children and are characterized by bilateral involvement, which is similar to that of adults. however, lung injuries in adults were more severe compared with children (fig. ) . of the children cases, cases were asymptomatic cases. the age of asymptomatic patients was younger than that of symptomatic patients. the white blood cell and lymphocyte counts were more decreased in symptomatic children cases than that in asymptomatic children cases, which was due to a lower inflammatory response in asymptomatic children cases. even among asymptomatic patients, . % of cases had lung injuries. therefore, lung injuries caused by sars-cov- is still relatively obvious. the ct findings may further provide the reason why elevated levels of crp were shown in adults, but not in children and elevated levels of ldh are common in children. the spike-protein (s) of sars-cov that mediates entrance to human respiratory epithelial cells by interacting with cell surface receptor angiotensin-converting enzyme (ace ) is the most important means of pathogenesis [ , ] . the number of ace receptors are significantly lower in children than in adults and more in the lungs than in other organs [ ] , which may be the primary reason why children have fewer clinical symptoms and organ dysfunction than adults and lung injuries even among asymptomatic children cases. in addition, the weak immune response triggered by viral infection because of children's weakened immune function maybe responsible for this state. in summary, most cases in children were mild and conventional cases, with mild clinical signs and symptoms, our data suggest that there is substantial lung injuries even among children, but that there is less clinical disease, perhaps because of a lower pronounced inflammatory response, and that the occurrence of this pattern appears to inversely correlate with age. acknowledgement thanks to dr. edward c. mignot, shandong university, for linguistic advice. author contributions yjh takes responsibility for the integrity of the data and the accuracy of the data analysis. yjh, wh, zxg, and zsw had full access to all data in the study. dwj had the idea of and designed the study. lq contributed to the review and zzf approved the final version. the authors have no conflicts of interest to disclose. ethical approval the project was approved by the ethics board of jinan infectious hospital (no. ). pneumonia of unknown cause-china, emergencies preparedness, response, disease outbreak news, world health organization (who) early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia chinese center for disease control and prevention. coronavirus disease (covid- ) situation reports chinese center for disease control and prevention. coronavirus disease (covid- ) situation reports epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study clinical features of patients infected with novel coronavirus in wuhan interpretation of "guidelines for the diagnosis and treatment of novel coronavirus ( -ncov) infection by the national health commission (trial version a novel coronavirus from patients with pneumonia in china the continuing -ncov epidemic threat of novel coronaviruses to global health: the latest novel coronavirus outbreak in wuhan, china origin and evolution of pathogenic coronaviruses genomic variance of the -ncov coronavirus who. novel coronavirus ( -ncov) situation reports. situation report- clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china coronaviruses post-sars: update on replication and pathogenesis early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a familial cluster of pneumonia associated with the novel coronavirus indicating personto-person transmission: a study of a family cluster coronavirus spike proteins in viral entry and pathogenesis comparative genetic analysis of the novel coronavirus ( -ncov/sars-cov- ) receptor ace in different populations key: cord- - blol to authors: karadag, engin title: increase in covid‐ cases and case‐fatality and case‐recovery rates in europe: a cross‐temporal meta‐analysis date: - - journal: j med virol doi: . /jmv. sha: doc_id: cord_uid: blol to the new coronavirus (covid‐ ) infection reported in china in december has become a pandemic in a few weeks, affecting the entire world. in this respect, it is crucial to determine the case‐increase, case‐fatality, and case‐recovery rates to control covid‐ . in this study, the case‐increase, case‐fatality, and case‐recovery rates of covid‐ in european countries were analyzed with the meta‐analysis method using data released by the health organizations and who. the data were obtained from the website of health organizations of european countries and the website of who until may . the analyses were carried out on covid‐ ‐diagnosed cases in european countries. the case‐increase, case‐fatality and case‐recovery rates of covid‐ were calculated using % confidence intervals ( % ci), single‐arm meta‐analysis, cross‐temporal meta‐analysis, and meta‐regression random‐effects model. the standardized case‐increase rate of covid‐ is % ( % ci [ . , . ]) and the average case‐increase rate in european countries has started to decline by around % ( % ci [ . , . ]) weekly. the countries with the highest rate of case increase are belgium, sweden, russia, the netherlands and the united kingdom. although the case‐fatality rate of covid‐ patients was . % as of may ( % ci [ . ‐ . ]), this rate is . % ( % ci [ . , . ]) in standardized time ( th week). the case‐recovery rates of patients are % ( % ci [ . ‐ . ]). this study presents important results regarding the covid‐ pandemic in europe. although the rate of increase in new covid‐ cases has dropped, there is not much decline in the case‐fatality rates and no increase in case‐recovery rates. the case‐fatality rate of covid‐ in europe was estimated to be in the range of % to . % and a minimum of weeks (as of may) is expected to have the figure below % in a country with an average case‐increase rate. monitoring case fatalities in belgium, the netherlands and sweden, and treatment successes in germany and austria play a role of utmost importance. italy have taken the second and third places in the world with the most number of covid- cases. these countries have also a very high case-fatality rate. it has been assumed that the virus has been circulating within the european population since january based on the number of cases and the advanced stage of the disease. estimating the rates of case increase, case fatality, and case recovery are key parameters for understanding the basic epidemiological characteristics of the pandemic. although several studies have been conducted to determine the case-increase, case-fatality, and case-recovery rates at various stages of the outbreak, studies involving reliable rates of case increase, case fatality, and case recovery on the basis of metaanalysis in the european specific for covid- are limited. , the available evidence on the contagiousness, case fatality, and case recovery of covid- is focused on china. , in initial studies, the case-fatality rates were reported as %. however, this figure was calculated with a small group of inpatients. afterward, as more data found, the case-fatality rate dropped to . % and to . % and then to . %. serious attention has not been paid to these basic epidemiological characteristics in europe, and considering the rapid increase in covid- in europe, it is of paramount importance to understand the rate of the case increase, case fatality and case recovery in europe to guide the applications of prior prevention and control measures. therefore, the epidemiological characteristics, case-increase, casefatality, and case-recovery rate of covid- in europe using the data of a -month period from january until today were found using the method of meta-analysis. data were analyzed using microsoft excel and comprehensive meta-analysis . ® . the health organizations of european countries and who conducted a comprehensive systematic literature review in their online databases on may to provide the data required for meta-analysis. the search terms are covid- ; -ncov; the number of daily cases, deaths, and discharges. in addition, laboratory-approved covid- cases were included in the analyses to guarantee the comprehensiveness and accuracy of the research. all search results were evaluated ( figure ) according to the preferred reporting items for systematic reviews and meta-analyses (prisma) and the final analysis was conducted on covid- diagnosed cases in countries. to minimize the potential for biases such as sampling or measurement bias in undertaking a meta-analysis study, rigorous methods should be used to locate, select, and aggregate the results of individual studies. incorporating an assessment of the risk of bias of these studies is essential in interpreting their results and may help to avoid underestimating or overestimating the parameter of interest. in this study, ahrq's guidance on constructs to include or exclude from risk-of-bias assessment was taken into account in evaluating the risk of bias. as the country dataset was used instead of research data, the guideline was adapted according to the study. therefore, the risk of bias of each country's data included in this study were evaluated as follows: ▪ in terms of the risk of precision, the laboratory-confirmed covid- cases, deaths, and recovered cases in each country were taken into account. the cases which were not laboratory-confirmed were excluded. ▪ the number of cases, deaths, and recoveries announced by the health organizations of the countries were confirmed by data from who and other health institutions. unconfirmed data were excluded from the analysis because of the risk of biased, bad, or inadequate reporting. ▪ a standard calendar has been created for covid- cases, deaths, and recovered cases in countries for applicability risk (see section . for details). ▪ publication bias was assessed using the funnel chart and the trim and fill test. no evidence of bias was observed in the data included in the meta-analysis according to funnel graphs. in addition, there was no difference between the size of the effects observed in the trim and fill test conducted according to % ci in the random-effects model and the size of the virtual effects generated according to the randomeffects model to correct the effects caused by bias. there are different methods to calculate the case-increase rate. however, as the covid- outbreak only has a -month period, the rate of new cases diagnosed daily in this study was calculated as the ratio ofthe new cases to the total number of cases. the first covid- cases were not detected on the same date in the european countries and the rate of new cases/total cases was very high in the first days of the pandemic, therefore, the analyses were standardized as day on the th day in all countries. in addition, case rate analyses were standardized by population, as the populations of case countries were not similar. the weighted average of the case-increase rate calculated for each day of the week was used for the case-increase rate of each week. the case-fatality rate was determined as the ratio of those who died from covid- disease to the patients with covid- . in calculating weekly case-fatality rates, the average of fatality rates calculated for each day of that week was used for the fatality | karadag rate of each week, starting from the day following the first death. the use of epidemiological velocity terms interchangeably in the literature has become a common nomenclature error. therefore, the fatality rate should not be confused with the mortality rate. a mortality rate-often confused with a case-fatality rate-is a measure of the number of deaths (in general, or due to a specific cause) in a population scaled to the size of that population per unit of time. a case-fatality rate, in contrast, is the number of dead among the number of diagnosed cases. the case-recovery rate was determined as the ratio of the number of patients recovering with the diagnosis of covid- disease. in the calculation of the case-recovery rates, the day of the th incident was accepted as the th day and calculated as the ratio of the total number of case recovery to the relevant day for the case-recovery rate on the st, th, th, nd, th and th days. meta-analyses were carried using microsoft excel and comprehensive meta-analysis . ® software. heterogeneity between the studies was tested using the cochran χ test and i , when i was below %, a stabilization model was used. when i was over %, a random effect model was selected. the combined case-increase rate and % confidence intervals ( % ci) single-arm meta-analysis and the cross-temporal meta-analysis random-effects model (weighting, case sizes of each country were taken into account) weighted effect size were calculated. to investigate the heterogeneity, the percentage of population the over -year-olds, and the population growth rate to the rate of increase in cases, the rate of case fatality and case recovery were tested using the meta-regression random-effects model. p < . was considered statistically significant. the study examined the increase of covid- cases in european countries using cross-temporal meta-analysis. therefore, analyses were standardized to the th day, on which the case was spotted, as the zeroth day. the reason for starting the analyses from the th case is that the increase rate below cases is very high due to the small numbers. in addition, case increase analyses have been standardized by the population due to the fact that the populations of case countries are not similar. in addition, the meta-regression analysis shows no statistically significant effect of the population rate above -year-olds on average case-increase rates (p > . ). considering the day on which the th case was seen as the zeroth day, the weekly case-growth rate, increase difference, standard deviations, and effect size (es) were used to define d and r of the difference. ( ) firstweek secondweek ( ) considering the day, on which the first case-fatality was seen as the zeroth day, the weekly case-fatality rate, case-increase difference, standard deviations, and effect size (es) were used to define d and r of the difference (equations and ) . the case-fatality rate in europe was found to be % higher in the second week (d = . , r = . ) compared to the first week. the case-fatality rate was . % higher in the third week compared to the previous week (d = . , r = . ) and the case-fatality rate was . % higher in the fourth week compared to the previous week (d = −. , r = . ). the daily case-fatality rate was . % higher in the fifth week (d = − . , r = . ) compared to that of the fourth week (table ). in the meta-regression analysis, no statistically significant effect was found in countries with the population rate of the above -year-olds and the population density on the case-recovery rates (p > . ). considering the day, on which the th case was seen as the zeroth day, the weekly case-growth rate increase difference, standard table ). this meta-analysis includes laboratory-approved case data obtained between january and may to analyze the epidemiological characteristics of covid- in europe. this study, covering european countries and cases, reflects the latest data since the emergence of covid- . the results showed relatively low heterogeneity in terms of single-arm meta-analysis. the sensitivity analysis also showed that the results were not affected by countries' data and that there was no bias. furthermore, meta-analyses of randomized controlled data were not found to be superior to nonrandomized data in terms of evidence level. the cases included in the analysis were between january and may. the meta-analysis based on the random effect model showed that covid- had a case-increase rate of %. it was also noted that the discharge rate of patients was %, and the casefatality rate was %. the results of the cross-temporal meta-analysis in europe showed a decline in the case-increase rate of cases. a country with a european average case-increase rate was estimated to have a minimum of weeks (as of may) to experience a decline below %. there is not much variation in weekly case-fatality rates at covid- according to the results of a cross-temporal meta-analysis. the analysis estimated that the case-fatality rate of covid- in europe would range between % and . %. the case-fatality rate of sars-cov, which was a similar outbreak, was %, while the casefatality rate of mers-cov was over %. , in contrast to the two viruses, covid- has a lower case-fatality rate. according to the clinical trials, it has been observed that the elderly (> years) were reported to be in the majority of deceased patients in conclusion, while there is a negative trend in the increased rate of cases in european countries, differences in population characteristics, treatment methods and health infrastructure affect case-fatality and case-recovery rates. even though the first months of the pandemic has ended, the case-recovery rate of patients is relatively low. although the clinical effect of some drugs has been discussed in recent days, it has been reported that plasma therapy had a definite healing effect for survivors, especially in severe, cases. this indicates that countries having a case increase in the number of patients recovering with plasma treatment will recover faster from the pandemic. in addition, while italy, spain, and the united kingdom are more involved in the number of deaths in research, reports and other studies, belgium, the netherlands, and sweden, where case-increase and case-fatality rates are high and the rate of case-recovering patients is relatively low, should be followed carefully. some limitations of the study should be taken into consideration. first of all, our results are limited to the early term of the pandemic on a country basis. in addition, a country is an extremely rough unit of analysis. also, the number of confirmed cases may be biased for various factors, whereas these factors were probably stable in our case over a short period of time when they were analyzed. engin karadag http://orcid.org/ - - - monitoring transmissibility and mortality of covid- in europe clinical features of patients infected with novel coronavirus in wuhan coronavirus disease (covid- ) in italy case-fatality rate and characteristics of patients dying in relation to covid- in italy different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study imperial college london mrc centre for global infectious disease analysis. news/wuhan coronavirus the reproductive number of covid- is higher compared to sars coronavirus covid- patients' clinical characteristics, discharge rate,and fatality rate of meta-analysis assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement assessing the risk of bias of individual studies in systematic reviews of health care interventions. agency for healthcare research and quality methods guide for comparative effectiveness reviews trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis a dictionary of epidemiology epidemiology in medicine meta-analysis of well-designed nonrandomized comparative studies of surgical procedures is as good as randomized controlled trials from sars to mers, thrusting coronaviruses into the spotlight sars and other coronaviruses as causes of pneumonia clinical features of three avian influenza h n virus-infected patients in shanghai clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province covid- in colombia endpoints. are we different, like national health commission of the people's republic of china's main website how to cite this article: karadag e. increase in covid- cases and case-fatality and case-recovery rates in europe: a cross-temporal meta-analysis key: cord- - xvj zey authors: chakrabarti, sankha shubhra; kaur, upinder; banerjee, anindita; ganguly, upasana; banerjee, tuhina; saha, sarama; parashar, gaurav; prasad, suvarna; chakrabarti, suddhachitta; mittal, amit; agrawal, bimal kumar; rawal, ravindra kumar; zhao, robert chunhua; gambhir, indrajeet singh; khanna, rahul; shetty, ashok k; jin, kunlin; chakrabarti, sasanka title: covid- in india: are biological and environmental factors helping to stem the incidence and severity? date: - - journal: aging dis doi: . /ad. . sha: doc_id: cord_uid: xvj zey the ongoing corona virus (covid- ) pandemic has witnessed global political responses of unimaginable proportions. many nations have implemented lockdowns that involve mandating citizens not to leave their residences for non-essential work. the indian government has taken appropriate and commendable steps to curtail the community spread of covid- . while this may be extremely beneficial, this perspective discusses the other reasons why covid- may have a lesser impact on india. we analyze the current pattern of sars-cov- transmission, testing, and mortality in india with an emphasis on the importance of mortality as a marker of the clinical relevance of covid- disease. we also analyze the environmental and biological factors which may lessen the impact of covid- in india. the importance of cross-immunity, innate immune responses, ace polymorphism, and viral genetic mutations are discussed. could also be infected by sars-cov- . older individuals with pre-existing chronic health condition shave a higher risk of developing severe complications after sars-cov- infection. covid- has emerged as a pandemic of respiratory illness ever since the first cases appeared in wuhan, china, in december [ ] . currently, it has spread to countries/territories worldwide, with > , infected cases and > , casualties (www.worldometers.info/coronavirus/). this ongoing pandemic has witnessed global political responses of unimaginable proportions. many nations have implemented lockdowns that involve mandating citizens not to leave their residences for nonessential work. the rules of lockdown vary from country to country. the indian prime minister announced a nation-wide lockdown from the midnight of th march . only essential services would be functioning and government services apart from health, law and order, banking, power and a few others have been suspended altogether. while the response by the indian government both at the central and state levels has been commendable and timely given the global covid- crisis, we deliberate some of the other reasons why the authors believe covid- may have a lesser impact on india. the world's second-most populous country lies around the th rank among nations for the number of diagnosed covid- cases (www.worldometers.info/coronavirus/). the first case of covid- was detected in india in the southern state of kerala on th january and was a medical student who had returned from wuhan. two other cases, also medical students back from wuhan soon surfaced from kerala (https://weather.com/en-in/india/news/news/ - - -kerala-defeats-corona virus-indias-three-covid- -patients-successfully). the indian government implemented thermal screening of inbound international air-travelers. such measures were implemented for china around th january and then, in a stepwise fashion, expanded to include all international passengers (https://pib.gov.in/pressreleaseiframepage. aspx?prid= ). interestingly, thermal screening is far from a fool-proof way to detect sars-cov- carriers, many of whom may be in the middle of the incubation period or mild cases and hence asymptomatic. further, the quarantine of international travelers on arrival was initiated only for those from china and its immediate neighbors at the beginning and then expanded for travelers from other countries, that too in a phased manner, while observing global trends of covid- spread. domestic travel in india continued unabated without incorporating any screening. further, the initial testing criteria with confirmatory qrt-pcr (quantitative reverse transcription polymerase chain reaction)-based tests for suspected patients, released by the indian council of medical research (icmr), emphasized testing only those with laboratory-proven contacts or recent foreign travel (www.icmr.nic.in/content/covid - ) . with such restrictions, the movement of several sars-cov- positive patients, whether asymptomatic or symptomatic, must have occurred all over india. however, weeks after the first case was diagnosed, india has a covid- count of (www.mohfw.gov.in/). in contrast, the first two italian cases were chinese tourists who arrived in milan on rd january, and tested positive on th january, the same time when the first indian case was recorded [ ] . the case positivity in italy exploded after the fourth week since march st when daily more than new cases (more than new cases daily since th march) were diagnosed (https://ourworldindata.org/coronavirus). it is curious that among the two countries which reported their first case at almost the same time, the progression has been so disparate. one may argue that testing in india has been sluggish in contrast to aggressive testing by some developed nations. however, india had tested samples (nasal/throat swabs for qrt-pcr) from patients suspected to have covid- , as of th march which still gave a testing positivity rate of . %, a figure which has not increased significantly over time or with changes in testing criteria (https://icmr.nic.in/sites/default/files/ whats_new/icmr_website_update_ march_ am_ist .pdf). a further update by the icmr pegged the figure at samples by th march ( . % test positivity). in comparison, italy at the top of the spectrum had carried out nearly tests as of th march with positives, which translates into a positivity rate of tested individuals of . %. south korea, on the other hand, adopted a comprehensive strategy of community testing. such an approach translated into positives in tests ( . %) (www.statista.com/statistics/ / covid -tests-select-countries-worldwide/). a few other countries at different ends of the spectrum are represented in the graph in figure . one instantly notices the surprisingly low rates of covid- positivity in india, and the south korean example implies that higher testing may not necessarily alter the incidence rates of covid- . this low rate of covid- positivity remaining constant over a couple of weeks has led most experts to believe that community spread of the disease has not taken place in india as yet. such inference is, however, intriguing and needs careful analysis. the reports of hospitalization of covid- patients appeared in china from mid-december and given the average incubation period of days for the manifestation of the disease, the viral spread likely started in china in early december [ ] . the geographical proximity of india to china and the regular unrestricted movement of people between two countries through multiple daily direct and indirect flights throughout december until mid-january should have made a densely populated nation like india rapidly invaded by covid- . considering these, we propose several possibilities for the low incidence of covid- in india, which include both environmental and biological factors. the population density of india is persons/km , which is higher than the six countries with maximum covid- cases. such a finding is a paradox as countries with higher densities and people staying closer to each other are theoretically at a higher risk of contracting communicable diseases transmitted by fomites or aerosols. similarly, the examples of south korea ( persons/km ) and japan ( persons/km ), which have a relatively lower incidence of covid- and a higher population density, support this curious case. trying to explain this paradox would require further research. in the köppen classification of climatic zones of the world, both wuhan, the apparent epicenter of the pandemic and most of italy are categorized as type c (mild temperate) whereas much of india has either a dry (type b) or tropical climate (type a). however, this again raises queries on why iran having a dry desert climate (type b) bore the brunt of covid- cases [ ] . it has been suggested that high temperatures and high relative humidity levels significantly reduce sars-cov- transmission [ ] . it may be fortuitous for india that as it enters the weeks deemed to mark its entry into phase of the epidemic, the climate over large portions of the country is taking a turn for this same high temperature, high humidity state. like other animal and human corona viruses, sars-cov- is also a positive-strand rna (approximately kilobases) virus which codes for a replicase enzyme associated with other enzymatic activities and several structural proteins of which the spike protein (s) is essential for viral entry into host cells [ ] . sars-cov, hcov-nl and sars-cov- enter the host cells through the protein angiotensin converting enzyme (ace ) on the cell membrane and the viral entry requires the cleavage of s protein by a serine protease (tmprss ) [ , ] . ace protein is expressed in many different types of cells, and the virus can invade multiple organs [ ] . since pulmonary alveolar cells and mucosa of the gastrointestinal tract have high expressions of ace , sars-cov- can easily invade these organs [ , ] . the invasion of lungs leads to the most critical pathology of pneumonia with severe respiratory distress and hypoxemia that accounts for the significant mortality in this disorder. enhanced production of pro-inflammatory cytokines and chemokines by immune effector cells leading to a cytokine storm is thought to be the cause of multiple systemic and respiratory symptoms. the genomic sequences of sars-cov- from multiple isolates show more than % identity which is sufficiently different from other human corona viruses and its origin has been traced to a bat corona virus [ ] . apart from sars-cov and mers-cov which caused severe respiratory diseases following outbreaks in and , there are four endemic human corona viruses, hcov- e, hcov nl- , hcov-oc , hcov-hku in populations that are responsible for various types of respiratory illness which are generally self-limiting in young and immunecompetent persons [ ] . the defense against any viral infection involves both innate immunity and adaptive immunity. while adaptive immunity relies on antibodies and t-cells which can recognize viral antigens with high degrees of specificity, the innate immunity utilizes receptors (pattern recognition receptors of several types) which recognize broad structural motifs present in bacteria or viruses but generally absent in host cells. there are currently no established data on the specific role of either humoral or cellular immunity or innate immunity in patients recovering from covid- , but immune response associated with sars-cov and mers-cov has been studied in some detail [ ] . it can be assumed that some degrees of sequence homology or conformational similarities among the structural proteins, especially the s protein, of sars-cov- and the endemic corona viruses (hcov- e, hcov nl- , hcov-oc , hcov-hku ) may result in cross-reactive immunity (circulating antibodies or primed t-cells) in persons with prior exposure to the latter viruses, and this may modulate the course and outcome of covid- . this kind of crossreactive immunity modulating the host-response to viral infection is well-known and widely studied in infections with flaviviruses (between different subtypes of dengue viruses or between the dengue virus and zika virus) [ , ] . although the cross-reactive immunity may be protective in some cases, it may lead to augmented harmful reactions in other cases which has been termed antibody-dependent enhancement (ade), and these processes have been established from epidemiological studies as well as in animal models [ , ] . thus, the possibility of a protective cross-immunity in the indian population against covid- cannot be ignored in explaining a rather mild effect of the current coronavirus pandemic in india in comparison to that in europe and the usa. it is important to note that the presence of crossreactive antibodies in the sera of patients infected with different types of human corona viruses have not been studied extensively. however, one study reported that sera of subjects who had sars-cov infection developed cross-reactive antibodies to hcov- e and hcov-oc [ ] . similarly, sera of convalescent patients of sars-cov have been shown to contain neutralizing antibodies against mers-cov [ ] . likewise, sera of convalescent patients of sars-cov contain neutralizing antibodies that inhibit the entry of sars-cov- in vero cells [ ] . therefore, cross-reactive antibodies generated as a result of infections from other human corona viruses may have a protective role in a population affected by covid- . of note, antibodies against mers-cov have been detected in a significant fraction of persons exposed to camels and dromedaries without any clinical evidence of prior mers suggesting that mers-cov can infect individuals without any symptoms, and yet induce signs of protective immune response [ ] . it is noteworthy that many corona viruses are widely present in cattle, pigs and chickens producing a variety of diseases affecting the respiratory and gastro-intestinal systems in these species [ ] . the animal corona viruses do not infect human beings unless a mutation breaks the species-barrier. nonetheless, a large number of people working in dairy farms and livestock sectors come in close contact with animals and extensively handle the raw meat of these species in markets and houses with bare hands, which may expose the circulating immune cells to viral proteins through minor injuries in the skin. such exposures may result in the development of crossimmunity because of possible antigenic similarities among human and animal corona viruses. another interesting observation is the apparent exclusion of malaria-endemic zones by the covid- epidemic. india, large parts of africa, and parts of south america that report ongoing malaria transmission have had a low incidence of covid- . the reasons are not known, but an explanation may lie in the ensuing cytokine storm, that may be involved in the severe respiratory manifestations of covid- [ ] . it is now widely accepted that not only malaria but many other acute infective conditions such as sepsis have deleterious effects mediated through the human body's response to the infective agent, in the form of a cytokine storm [ ] . it is plausible that persons in malaria-endemic zones, which may also be endemic for several tropical pathogens including viruses, have recurrent cytokine fluctuations in response to minor and subclinical infections. these recurrent fluctuations may have a de-sensitizing effect on the body's immune system, which prevents an uncontrolled and detrimental immune response and thus severe clinical disease in sars-cov- infection. hence, many infected patients, may not manifest any symptoms and, as a corollary, may not meet testing criteria, resulting in a low positivity rate. it may be mentioned here that a novel therapeutic approach has been tried recently in covid- utilizing the immunomodulatory role of mesenchymal stem cells to attenuate the cytokine storm [ ] . apart from cross-immunity, an essential mechanism of the variable outcome of covid- may lie in the polymorphism of ace protein, which is coded by a gene on the x-chromosome. several single nucleotide polymorphisms of this protein have been described which may have implications in altered expression levels of ace or its interaction with s protein of sars-cov- . however, a detailed analysis of such polymorphisms in different populations vis-à-vis the outcome of covid- will require more time [ ] . further, in viral infections, host antiviral mirnas play a crucial role in the regulation of immune response, depending upon the viral agent. many known human mirnas appear to be able to target viral genes and their functions by interfering with replication, translation, and expression. in this context, an interesting, but yet to be peer-reviewed research article, performing a sequence-based analysis has reported a unique mutation in the indian sars-cov- strain affecting the s protein of the virus that allows it to be a target for a mirna (hsa-mir- b) [ ] . while not directly relevant to issues discussed in this article, a possibility also exists that many cases may be missed due to the sensitivity of the tests being performed. mostly pharyngeal and nasal swabs are used for qrt-pcr based diagnostics. a recent article mentions these samples as having only % and % positivity while testing for covid- [ ] . another vital aspect of covid- is mortality in diagnosed cases. mortality is the statistic that is most relevant for developing nations such as india. acute viral illnesses as well as acute infections due to any pathogenic agent, are prevalent in india, owing to dismal standards of hygiene, especially among a large section of its population which lives below the poverty line. an exact number cannot be ascribed to the incidence of viral infections, because of the sheer diversity of such infections ranging from respiratory viral infections (influenza, rhinovirus, adenovirus, coronavirus, etc.) to several arthropod-borne viral fever syndromes. the diagnostic facilities are nonexistent in the periphery, and the majority of these infections may be subclinical or may present with atypical manifestations [ ] . an idea can be obtained from the data of the integrated disease surveillance programme (idsp) of the ministry of health and family welfare (mohfw) of the government of india. during , the idsp reported disease outbreaks in india, of which % were due to viral pathogens [ ] . the authors, in their clinical practice, also treat patients regularly who present with classic symptoms of viral respiratory disease. sometimes, the same patient with comorbidities such as copd visiting multiple times in a year. whereas such patients in affluent nations would be subjected to additional testing and probably annual influenza vaccination, such measures are mostly non-existent in the indian scenario, apart from a few of the apex centers. the majority of such patients with fever, upper and lower respiratory tract symptoms, bodyache and headache may either not turn up at clinics, dismissing their symptoms as another bout of viral fever and resorting to home remedies, or even in case they present to a trained practitioner, supportive management is at best done. even drugs such as oseltamivir are scarcely used in routine practice. even with community transmission of the virus (phase of the epidemic), most cases may turn out to be subclinical and mild. in the end, mortality and not morbidity is the statistic that matters. such a scenario brings us to the critical question; what is the actual attributable mortality of covid- ? a peek into the italian scenario may be helpful. nearly % of covid- -related deaths in italy have been individuals in the + years age group. among the deceased patients, chart details were available for . out of these only patients did not have any comorbidities. among the patients of age < years who died (m= , f= ), clinical information was available for , and each had pre-existing serious comorbidity(www.epicentro.iss.it/coronavirus/bollettino /report-covid- _ _marzo_eng.pdf). even in india, more than half of the deaths that have ensued have affected patients more than years of age, the accepted geriatric age cutoff in the country. although the chart details of the indian patients are unavailable, the available data collected from reputed news sources is presented in table . most cases with fatality, whether young or old evidently had comorbidities. it is common sense that in a patient with a fatality, in the presence of severe renal or pulmonary or cardiac disease, the mere presence of covid- positivity does not confirm the role of coronavirus in causing death. detailed case histories may be revealed in the coming days, which may further clarify the matters. there may be a faulty statistical angle to covid- mortality in india too. italy ( %) stands second in the world after japan ( %) in having a population of > years age (www.worldatlas.com/articles/countries-withthe-largest-aging-population-in-the-world.html). in lifeexpectancy it also ranks second after japan among all countries with a population more than million. italian healthcare provides for universal coverage and is largely free. what this means is a sizeable section of the population in italy has survived to an age that would be impossible for them to do up to, in other countries. contrast this to the situation in india where healthcare services do not have this much peripheral penetration. further, transport and awareness issues as well as societal preferences for the younger earning population, results in neglect of the elderly and failure of free healthcare to translate into health gains for the older population. india's life expectancy stands at years, interestingly less than the mean age of covid- fatalities in italy. so, india may not have the most vulnerable age group for covid- to exert its effect to the fullest. overall, if one analyzes the mortality statistics of india in comparison to other countries (fig. ) , it is clear that the curve has been flat for quite long. a plot between total confirmed cases and total confirmed deaths clarifies the situation in india further in comparison to other major countries (fig. ). the different restrictive measures adopted by the central and the state governments in india like visa and travel restrictions, home isolation and quarantine, and finally nation-wide lockdown are classical methods of prevention of the community spread of sars-cov- . these methods must have played a role in limiting the effect of this pandemic on the indian population. however, we strongly feel that various biological and environmental factors have also contributed significantly to this process, which may result in covid- in india behaving more mildly in contrast to its global effects. the careful analysis of such biological factors will certainly open new avenues to combat outbreaks of novel viruses, through research on cross-immunity, immuno-modulation and perhaps lifestyle management and dietary manipulations. the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak the first two cases of -ncov in italy: where they come from present and future köppen-geiger climate classification maps at -km resolution high temperature and high humidity reduce the transmission of covid- coronaviruses: an overview of their replication and pathogenesis sars-cov- cell entry depends on ace and tmprss and is blocked by a clinically proven protease inhibitor. cell covid- : faecal-oral transmission? human coronaviruses: what do they cause? coronavirus infections and immune responses cross-reactive immunity among flaviviruses. front immunol cross-reaction, enhancement, and neutralization activity of dengue virus antibodies against zika virus: a study in the mexican population human polyand cross-reactive anti-viral antibodies and their impact on protection and pathology antigenic cross-reactivity between severe acute respiratory syndromeassociated coronavirus and human coronaviruses e and oc cross-reactive antibodies in convalescent sars patients' sera against the emerging novel human coronavirus emc ( ) by both immunofluorescent and neutralizing antibody tests presence of middle east respiratory syndrome coronavirus antibodies in saudi arabia: a nationwide, crosssectional, serological study mesenchymal stem cell infusion shows promise for combating coronavirus (covid- )-induced pneumonia understanding the role of inflammatory cytokines in malaria and related diseases transplantation of ace -mesenchymal stem cells improves the outcome of patients with covid- pneumonia comparative genetic analysis of the novel coronavirus ( -ncov/sars-cov- ) receptor ace in different populations comparative analyses of sar-cov genomes from different geographical locations and other coronavirus family genomes reveals unique features potentially consequential to host-virus interaction and pathogenesis detection of sars-cov- in different types of clinical specimens morvan's syndrome-is a pathogen behind the curtain? emerging/reemerging viral diseases & new viruses on the indian horizon prof chakrabarti thanks the maharishi markandeshwar (deemed to be) university, mullana for research support. key: cord- -i brfzr authors: kabba, mustapha s.; forde, martha y.; beckley, kevin s.; johnny, bernadette; jah-kabba, ann-marie b. m.; seisay, samuel b.; dawoh, alusine m.; ogundiran, temidayo title: gossypiboma with perforation of the umbilicus mimicking a complicated urachal cyst: a case report date: - - journal: bmc surg doi: . /s - - - sha: doc_id: cord_uid: i brfzr background: a retained surgical sponge, also known as a gossypiboma, is a rare cause of serious postoperative complications. diverse retained surgical materials including instruments such as clamps and sutures have been reported, but surgical sponges are the most common material. we report an unusual case of a gossypiboma mimicking a complicated urachal cyst that led to perforation of the umbilicus. case presentation: a -year-old female patient presented in our facility with a palpable periumbilical mass and discharge of pus from the umbilicus for months after an open appendectomy. since the onset of symptoms, the patient had been treated conservatively in a peripheral hospital where she had been operated on. as no improvement was seen, an ultrasound scan was performed that suggested an intraperitoneal abscess adjacent to the umbilicus. consequently, the patient was referred to our specialist outpatient department for surgical intervention. suspecting a complicated urachal cyst, an exploratory laparotomy was performed but revealed a retained surgical sponge as the underlying cause. the gossypiboma was resected, and the postoperative period was unremarkable. conclusion: this case demonstrates that gossypibomas, even though rare, continue to occur. they may clinically and radiologically mimic other pathologies, especially abscesses and tumors. preventive measures as well as the inclusion of gossypibomas in the differential diagnosis of intraabdominal masses or fistulation detected in patients with a history of surgery are of utmost importance to minimize morbidity, mortality, and potential medicolegal implications. a retained surgical sponge, also known as a gossypiboma, is a rare but serious postoperative complication that is a nightmare for every surgeon. a range of retained surgical materials including instruments such as clamps and sutures have been reported, but the surgical sponge, possibly because of its amorphous composition and frequent usage, is the most prevalent material [ , ] . for reasons such as fear of litigation, the exact incidence of gossypiboma is difficult to ascertain [ ] . silva and sousa estimated its incidence to be : - : laparotomies [ ] , whereas bani-hani et al. estimated it to be much lower ( : ) [ ] . gossypiboma may lead to chronic abdominal pain, an abdominal mass, bowel obstruction, occult infections, fistulae and transmural migration of the foreign body into the small and large bowel or stomach [ ] [ ] [ ] . we report a case of a gossypiboma with spontaneous perforation at the umbilicus mimicking a complicated urachal cyst, which, to the best of our knowledge, has not been reported before. a -year-old female patient presented to our facility in october with chronic abdominal pain, swelling in the umbilical region, and pus discharge from the umbilicus for months. the swelling started months after an open appendectomy was performed in a peripheral private hospital using a right paramedian incision. one week after the appearance of swelling, the umbilicus started discharging thick offensive fluid, which was associated with abdominal pain. there was no fever, nausea, or loss of appetite. the patient reported a weight loss of kg in months. conservative treatment yielded no improvement. as a result of an abdominal ultrasound scan, which suggested an intraperitoneal abscess ( fig. ) , the patient was referred to our specialist outpatient department. upon presentation, the patient was depressed, dehydrated, and pale. the abdominal examination revealed an everted umbilicus with pus discharge and granulation tissue. in the umbilical region, there was a palpable intraabdominal mass that measured × cm, was moderately tender, and was fixed to the umbilicus but was otherwise mobile (fig. a ). there were no signs of peritonitis, and the abdomen was soft with moderate periumbilical distension. the right paramedian appendectomy scar had healed completely and was unremarkable. a routine blood examination showed a hemoglobin concentration of . g/dl and a white blood cell count of . × /l. further diagnostic tests and imaging could not be performed due to financial constraints. based on the history and physical findings, a provisional diagnosis of an infected urachal cyst or postoperative intraabdominal abscess was made, and the patient was prepared for an exploratory laparotomy. intraoperatively, the abdominal cavity was clean. a well-circumscribed × cm adhesive mass was seen around the ileocecal junction. it consisted of an encapsulated lesion at its center, and an ileal segment, the transverse colon, and the umbilicus were all adhered to the mass (fig. b ). during adhesiolysis, the wall of the central lesion was accidentally opened, thus surprisingly exposing a surgical sponge and thick offensive pus. the bowel loops were further mobilized, resulting in a large mesenteric defect. impaired blood supply to the dependent bowel loop necessitated the resection of a cm long ileal loop, and an end-to-end ileo-ileal anastomosis was created. adhesiolysis and mobilization of the lesion from the transverse colon led to a cm iatrogenic defect, which was sutured. finally, the encapsulated lesion, including the umbilicus, was (fig. c) . the resectate measured × cm in size and contained a retained surgical sponge (fig. d) within a confined collection of pus. the postoperative period was uneventful. bacteriological examinations were not carried out due to financial constraints. consequently, empiric antibiotic therapy with intravenous ceftriaxone and metronidazole was administered for days and was then switched to oral antibiotics, which were given for an additional days. early postoperative enteral feeding was well tolerated with normal bowel activity on the third postoperative day. the laparotomy wound healed by primary intention, and the patient was discharged on postoperative day . follow-up visits in our sop clinic have also been unremarkable. gossypiboma is described as a retained surgical sponge or towel after a surgical procedure [ , ] . other terminologies, such as textiloma, gauzeoma, cottonoid, muslinoma, and cottonballoma, are used to refer to this condition. the most common site of presentation is the abdominal cavity. however, other locations, including the pleural and pericardial cavities, the extremities, the central nervous system, and the breast, have been documented [ ] . to the best of our knowledge, a gossypiboma with perforation at the umbilicus has not been reported before. a retained surgical sponge is a preventable postoperative complication that usually occurs in emergency surgeries, unexpected surgical procedures, prolonged operations, and surgeries on unstable and obese patients. furthermore, it is associated with inexperienced staff, poor organization in the operating theatre, and rapid or failed sponge counting during an operation [ , ] . the possible predisposition to the occurrence of the retained foreign body in our patient at her initial surgery could have been an emergency procedure in a poor organizational setting with inadequately trained staff. essentially, there are two types of pathological reactions provoked by a retained foreign body: an exudative inflammatory process with the formation of an abscess or an aseptic fibrotic reaction that encapsulates the corpus alienum [ , ] . in our patient, the gossypiboma led to the formation of an abscess and discharge of its liquid content at one of the weakest points of the abdominal wall, which in this case proved to be the closely related umbilicus-a process equivalent to the commonly observed spontaneous drainage of abscesses via fistula formation. intraabdominal gossypibomas are usually reported with signs of an intraabdominal mass, bowel obstruction, intestinal hemorrhage, or fistulation. rarely, the retained surgical sponge undergoes transmural bowel wall migration without leaving a defect [ , , ] . the diagnosis of gossypiboma is often challenging, as there is generally a wide range of nonspecific manifestations, and most times, the actual diagnosis is not even considered. in line with this phenomenon, neither the peripheral hospital nor our facility included gossypiboma in the differential diagnosis. the presentation of our patient with a periumbilical mass and discharge of pus at the umbilicus prompted the potential differential diagnosis of an infected urachal cyst. incomplete urachal obliteration during fetal development gives rise to distinct malformations of the median umbilical ligament, such as a urachal cyst. most anomalies are asymptomatic and resolve during early infancy, but some go unrecognized until adulthood. these rare cases can present with acute abdominal symptomatology secondary to infection of the urachal remnant [ ] . the clinical presentation of urachal cysts is nonspecific. urachal cysts are mostly asymptomatic until infection occurs. however, a triad of symptoms consisting of a tender midline infraumbilical mass, umbilical discharge, and sepsis should arouse suspicion of an infected urachal remnant, such as a urachal cyst. without surgical excision, a urachal cyst may slowly increase in size and drain through the umbilicus into the bladder or both, resulting in an alternating sinus [ ] . in our patient, a high index of suspicion for gossypiboma should have been raised by the history of surgery associated with persistent abdominal pain, signs of infection, and a palpable mass. a preoperative diagnosis of gossypiboma using the clinical manifestation and recommended imaging modalities was observed by rajiv et al. in only % of cases, highlighting the fact that a significant number of gossypibomas are diagnosed only intraoperatively [ , ] . in the case of radiopaque impregnation of a foreign body, diagnosis may be facilitated by radiographic and ct images. the sponge we evacuated showed no discernible impregnation, which may have been due to the primary absence of impregnation, as especially seen in resource-poor settings or disintegration [ , ] of the radiopaque material. in such cases, the foreign object may not be readily identified by imaging. removal of the retained foreign body by either open or laparoscopic surgery is the mainstay of treatment. however, if the retained foreign body migrates into the stomach, it could be endoscopically removed [ ] . prevention of gossypibomas is essential and can be achieved by "simply" ensuring and insisting on a thorough pack count before closure of the operating cavity. a routine brief but careful postoperative wound and cavity exploration prior to wound closure should be performed by every surgeon. the use of sponges with radiopaque markers is now strictly recommended. moreover, newer technologies such as radiofrequency chip identification and barcode scanners are helpful for decreasing the incidence of gossypiboma [ ] . however, radiopaque chip identification and barcode scanners are only available in highly developed centers. theatre staff should be regularly sensitized and trained to avoid this preventable condition. this case shows that the diagnosis of gossypiboma can be complicated by its nonspecific presentation, which clinically and radiologically imitates other common pathologies, such as abscesses and tumors, and rare conditions, such as urachal cysts. moreover, gossypiboma is associated with significant morbidity, mortality, and potential medicolegal implications. consequently, prevention of its occurrence and the inclusion of gossypiboma in the repertoire of actively thought differential diagnoses in patients with intraabdominal masses or fistulation concurrent with a history of surgery are of utmost importance. complete transmural migration of a retained surgical sponge: an atypical case in image mimicking intussusception: a case report gossypiboma: complete transmural migration of retained surgical sponge causing small bowel obstruction gossypiboma after abdominal surgery is a challenging clinical problem and a serious medicolegal issue retained surgical (gossypiboma) gossypibomas, a surgeon's nightmare -patient demographics, risk factors, imaging and how we can prevent it transgastric migration of gossypiboma remedied with endoscopic removal: a case report preventableerrors in the operating room: retained foreign bodies after surgery a transmural migration of a gossypiboma in the right colon responsible for a mass which mimicked an abscessed colonic tumor: a case report surgical management for an infected urachal cyst in an adult: case report and literature review infected urachal cyst in an adult: a case and review of the literature gossypiboma posing as a diagnostic dilemma: a case report and review of the literature a study of abdominal gossypiboma initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology not applicable. none. not applicable. ethical approval was given by the medical ethics committee of connaught hospital, university of sierra leone teaching hospitals complex, freetown, sierra leone. for publication of this case report, including the images contained within, informed written consent was obtained from the patient. a copy of the consent form is available for review by the editor of this journal. the authors declare that they have no competing interests. key: cord- -a inlk authors: jaeger, gry; skogmo, hege kippenes; kolbjørnsen, Øyvor; larsen, hans jørgen søiland; bergsjø, bjarne; sørum, henning title: haemorrhagic pneumonia in sled dogs caused by streptococcus equi subsp. zooepidemicus - one fatality and two full recoveries: a case report date: - - journal: acta vet scand doi: . / - - - sha: doc_id: cord_uid: a inlk in spite of yearly vaccination, outbreaks of canine infectious respiratory disease are periodically seen amongst domestic dogs. these infections compromise host defense mechanisms, and, when combined with other stressful events, allow opportunistic pathogens like streptococcus equi subsp. zooepidemicus to create serious disease. early recognition and treatment are tremendously important for a successful outcome in these cases. a polyvalent vaccine was given to racing dogs three days after a competition, followed by two days of rest, and then the dogs were returned to regular training. coughing was noticed among the dogs four days after immunisation. three days after this outbreak one of the dogs was unusually silent and was found dead the next morning. simultaneously two other dogs developed haemorrhagic expectorate, depression and dyspnea and were brought in to the veterinary hospital. streptococcus equi subsp. zooepidemicus was isolated in pure culture from all three cases. they were treated and rehabilitated successfully, and won a sledge race three months later. this paper discusses the necropsy results, treatment regime, rehabilitation and the chronology of vaccination, stressful events and disease. contagious upper airway infections in dogs occur regularly and are most commonly caused by canine parainfluenza virus (cpiv) or bordetella bronchiseptica, amongst other agents [ ] . this clinical syndrome has also been named infectious tracheobronchitis (itb), canine infectious respiratory disease (cird), "kennel cough" or "kennel croup", so named due to its occurrence in environments where many dogs live or stay close together for shorter periods of time. characteristic clinical signs include a self-limiting paroxysmal cough lasting for up to two weeks, which usually resolves without treatment. in norway, immunisation against cird is performed using live attenuated viruses, annually with cpiv and every third year against canine adenovirus type (cav- ) [ ] . however, in spite of vaccination, outbreaks of cird remain common. some dogs with cird will develop serious pneumonia due to an immature immune system or other causes of immunodeficiency. occasionally, bacteria such as streptococcus equi subsp. zooepidemicus can cause fatal pneumonia [ ] [ ] [ ] [ ] [ ] [ ] [ ] . this case-report describes the first canine outbreak of haemorrhagic pneumonia in the nordic countries caused by s. equi subsp. zooepidemicus. most of the animals in the pack of athletic sled dogs showed symptoms of cird with three dogs demonstrating symptoms of severe peracute infection. one sled dog died while two were successfully treated, rehabilitated and returned to competition. to the author's knowledge, this is the first report documenting the chronology from onset of clinical signs, through convalescence to complete recovery for peracute haemorrhagic pneumonia in dogs. the vaccination regimen related to season and extreme training will also be discussed. the affected animals belonged to a pack of racing sled dogs with one owner. twenty-two dogs where in active competition/training at an international level, competing annually in the norwegian, european and world championships. the dogs were a mix of pure bred german shorthaired pointer (gsp), mixed-bred alaskan husky/gsp or mixed-bred gsp/greyhounds. the dogs were mainly kept as outdoor dogs in standard heated kennels, but at times allowed indoor as family pets. in october they participated in the norwegian national championship in -dogs and -dogs classes. prior to the race all dogs were healthy with no signs of infection or disease. three days after the race the competing dogs were vaccinated with duramune dappi + lc vet. fort dodge containing attenuated distemper virus (cdv), strain onderstepoort, attenuated adenovirus type (cav- ), attenuated parvovirus (cpv), attenuated parainfluenza virus (cpiv), inactivated enteric coronavirus (ccov) as well as inactivated leptospira interrogans serovar canicola and serovar icterohaemorrhagiae. after vaccination the dogs rested for two days with no exercise or training. on the third day the dogs continued regular training. following training on the th day post-vaccine, several dogs in the kennel started to cough, and hours later there were more animals in the pack with an intensive cough. all animals had normal body temperature and showed no other clinical signs. six days after the vaccine two of the dogs became anorectic and depressed. one of these dogs stayed overnight in the shelter and was found dead the next morning (case ). the second dog was taken into the owner's family house for the night due to anorexia, intensive coughing and salivation (case ). according to the owner this dog had been vomiting blood during the night and demonstrated a rectal body temperature of . °c. after a telephone consultation with the local veterinarian the owner administered mg ( mg/kg) of oxytetracycline (oxytetral; alpharma) orally and thereafter brought the dog to the small animal hospital at norwegian school of veterinary science (nsvs) km away, together with case for post-mortem examination. the next day a third dog was found anorectic and depressed (case ) and was brought immediately to the nsvs. the rest of the kennelled dogs continued to cough, though no other animals developed further clinical signs. cases and were more intensively trained than the other dogs on day and postvaccination. post-mortem examination revealed epistaxis and haemorrhagic frothy fluids in the trachea and bronchial airways on cut sections. haemorrhages were present in the thymus, epicardium, intercostally, and in the pleural space ml of uncoagulated blood were present. the lungs were congested, wet, consolidated and diffusely to cavernous haemorrhagic, these changes being more severe in the left lung lobes (figure ) . histopathology of the lungs revealed a subacute necrotising suppurative pneumonia, with haemorrhagic, often cavernous areas in the lungs and intra-lesional gram-positive cocci. a large number of macrophages with phagocytosed erythrocytes were present (figures and ) . a subacute pleuritis was also seen. streptococcus equi subsp. zooepidemicus was isolated in pure culture from the lung tissue with identification based on morphology, microscopy, lancefield grouping (streptococcal grouping kit, oxoid, basingstoke, hampshire, england) and biochemical testing. properties included βhaemolytic colonies on bovine blood agar, gram-positive, katalase negative cocci belonging to lancefield group c. glucose, lactose, and sorbitol were fermented, trehalose was not. the isolate was also tested by using api strep (biomérieux®, lyon, france) with the same conclusion. toxicological diagnostic screening of the liver tissue showed no evidence of anticoagulant poisons. clinical data for cases and are present in table . on presentation, the dog was depressed, dehydrated, shivering, hypersalivating with blood stained saliva, and coughed spontaneously with haemorrhagic expectorate. the neck was slightly stretched and auscultation of thorax revealed increased vesicular sounds. thoracic radiographs showed moderately increased attenuation of the ventral part of the right middle lung lobe, moderately to severely increased attenuation of the ventrocaudal part of the right caudal lung lobe as well as air bronchograms (figures and ). these changes are consistent with acute pneumonia. a faint soft-tissue opacity was seen in the lung fissures, interpreted as a possible low amount of free pleural fluid. the dog was treated with intravenous (iv) ringer acetate ml/kg/hr for eight hours, thereafter ml/kg/hr, enrofloxacin (baytril, vet. bayer; mg/kg bodyweight (bw) iv once daily), ampicillin (pentrexyl, bristol-myers squibb; mg/kg bw iv three times daily) and buprenorfin (temgesic, schering-plough; . mg/kg bw iv three times daily). all medications were given for four days. the dog was hospitalised in an oxygen cage. simultaneously as the treatment was initiated an expectorate sample was sent for routine bacteriological cultivation. s. equi subsp. zooepidemicus was isolated in pure culture and directly demonstrated to belong to the lancefield group c of streptococci. complete blood count with serum biochemistry analysis was normal except for a mild leucopenia ( table ). the coagulation profile was normal. on the second day of hospitalisation the dog showed substantial clinical improvement and was normothermic ( . °c), less dyspneic, less tachypneic (respiration rate (rr) = /min), and had reduced salivation and coughing. there was no longer blood in the saliva nor epistaxis. the result from the bacteriological investigation of the expectorate demonstrated sensitivity against penicillin, tetracyclin, cefalexin, ampicillin, amoxicillin/ clavulanate, enrofloxacin and linkomycin. the antibiotic regimen was switched to phenoxymethylpenicillin (apocillin; actavis) mg per os (po) three times daily for days. no diagnostic tests for respiratory viruses were performed. clinical signs gradually resolved over the next few days and the dog was sent home seven days after hospitalisation. control radiographs before departure from the clinic revealed absence of air bronchograms, though a mild to moderate increased attenuation with an interstitial pattern was still present. this animal was presented to nsvs one day after case . the dog had been coughing for several days and gradually worsened with reduced appetite and depression developing on the day of presentation. on physical exam there was moderate dyspnoea with abdominal respiration and increased vesicular sounds, slight neck extension, blood stained saliva as well as fever (table ) . haematology showed moderate leucocytosis due to neutrophilia and monocytosis ( table ). radiography of the thorax showed the same changes as described for case . the dog was hospitalised and medically treated in the same way as for case . clinical progression was similar to case , with normalisation of temperature ( . °c), respiration rate ( breaths/min), heart rate ( beats/ minute) and appetite on the second day of hospitalisation. no salivation or spontaneous coughing was observed unless whilst excited after visiting the exercise figure left lateral radiograph of the lung of case , first day of admission to hospital. the radiograph reveals marked increased attenuation of the ventral part of the right caudal lung lobe and lobus accessorius, and moderate increased attenuation of the right middle lunglobe, with air bronchograms (white arrows). pen. repeat thoracic radiographs on the seventh day of hospitalisation revealed air bronchograms in the right middle lung lobe, but reduced consolidations. the dog was sent home on phenoxymethylpenicillin (apocillin; actavis) mg po three times daily for another days. follow-up hospital care of both dogs included radiographs of the thorax after one, three, five and eight weeks (figures and ) together with complete blood counts (table ) . after thoroughly scrutinising the last taken radiographs together with assessing their clinical condition they started a step-wise training program. the radiographs taken during recovery revealed a very mild interstitial attenuation of the lung lobes that had been most severely affected and mild to faint visualisation of fissure lines which was interpreted as either mild amount of free fluid or mild fibrosis. these minor findings were gradually reduced, but faint fissure lines could still be seen after five weeks for case and after eight weeks for case (figures and ) . the dogs were kept confined for one week after they were released from the hospital, and did run free on a large ( - acres) fenced yard for two weeks. case was in full training eight weeks post infection and case was slightly behind. early in january the following year both dogs participated in a sled race resulting in a time track record, and medal placements in various championships were achieved the following season. the dogs in this highly trained sled-dog pack competed in a sledge dog race after prolonged transportation and were additionally moderately exercised before the race. three days after the sled race the dogs were given a commercial polyvalent canine vaccine containing cdv, cav- , cpv, cpiv, ccov and leptospira. clinical signs of respiratory disease were observed four days after vaccination. immunosuppression in dogs immunised with a similar polyvalent vaccine was reported by phillips and others [ ] . they demonstrated that the absolute lymphocyte count in blood was suppressed on day five and seven following immunisation and that one group of dogs immunised with cdv and cav- also had decreased lymphocyte count on day three post vaccination. all the dogs produced neutralising antibodies to canine distemper virus and some parts of the natural immunity were not influenced by the vaccination. however, the immunisation with polyvalent vaccines significantly suppressed the lymphocyte response to phytohaemagglutinin, a mitogen that induce proliferation in tlymphocytes in vitro on day , and post inoculation, but returned to normal response level by day following immunisation. the combination of cdv/canine adenovirus type (cav- ) or cdv/cav- was believed to be responsible for the suppression in lymphocyte responsiveness. the duration of the suppressed lymphocyte response was at least seven days and was most pronounced on day post inoculation with up to % suppression of mitogen-induced lymphocyte response compared to control dogs. in the present study, the use of modified live polyvalent canine vaccine combined with stress associated with training, competition and prolonged transportation may have suppressed the innate immune response to s. equi subsp. zooepidemicus, which seldom causes pathology in dogs. the possibility of a co-infection with viral pathogens cannot be excluded and may have contributed to this outbreak. outbreaks of haemorrhagic pneumonia in dogs due to s. equi subsp. zooepidemicus have been described following transportation to a race track associated with sudden change in the weather [ ] , in newly arrived densely housed research dogs [ , , ] and in kennelled dogs [ , [ ] [ ] [ ] . in most of these reports the cause of the outbreak of cird is believed to be primary viral agents alone or in combination with environmental factors that induce secondary peracute pneumonia. some of these papers report the use of cdv/cav- vaccine prior to infection with s. equi subsp. zooepidemicus [ ] or a possible dual infection with cdv [ ] , though do not postulate that immunosuppression due to vaccination with modified live polyvalent canine vaccine is significant in this pathogenesis. in a study of experimental parvovirus infection in dogs, potgieter and others [ ] observed that dogs vaccinated with modified live cdv and cav- five days before figure control radiograph of the lung of case eight weeks after admission to hospital. left lateral radiograph reveals a faint line (white arrow) which is interpreted to represent either mild amount of pleural fluid or mild thickening pleura. challenge with virulent canine parvovirus resulted in disease caused by canine parvovirus whereas unvaccinated dogs remained healthy. this may indicate that these animals had reduced immunity associated with recent vaccination. histopathologically, the pneumonia in case was severe with the presence of inflammatory cells, leakage of blood into the lung tissue, and intralesional gram positive cocci, which were likely to be s. equi subsp. zooepidemicus (figures and ) . similar histopathological findings were also described in the paper of priestnall and others [ ] , who specified that s. equi subsp. zooepidemicus is associated with acute and often fatal clinical disease in dogs. a possible source of s. equi subsp. zooepidemicus in the outbreak described in this paper was neighboring horses. however, there may have been sub-clinical carrier animals within the pack as chalker and others [ ] isolated this pathogen from . % of clinically healthy kennel dogs, but where the kennel had a history of endemic cird. s. equi subsp. zooepidemicus is not normally carried by dogs, but it can probably cause disease in a situation where there is high level exposure from diseased dogs or other sources in the environment, an on-going viral infection, temperature stress, transport stress, intense exercise associated with training and competition and vaccine induced immunosuppression. in a retrospective study of cases of streptococcal infections in dogs, four cases ( %) were found to be caused by s. equi subsp. zooepidemicus [ ] . in humans, s. equi subsp. zooepidemicus represents a potential virulent zoonotic pathogen, with infection inducing a toxic shock syndrome following contact with horses [ ] [ ] [ ] . one report used a study population from a re-homing shelter with an endemic respiratory disease, including dogs positive for s. equi subsp. zooepidemicus culture on post-mortem lung wash and negative control dogs. an objective scoring system based on histopathological lung examination demonstrated that ( %) of dogs with a positive culture had evidence of pneumonia caused by s. equi subsp. zooepidemicus [ ] . the lungs of the dogs affected with severe pneumonia caused by s. equi subsp. zooepidemicus had significantly elevated levels of expression of the genes of pro-inflammatory cytokines indicating a strong innate immune response caused by the invading pathogen. paillot and others [ ] demonstrated that three novel genes (szef, n and p) for production of superantigens in s. equi subsp. zooepidemicus are occurring in half of the isolates from cases of disease. the authors indicate that the introduction of these genes to the population of s. equi subsp. zooepidemicus may be the cause of an emerging trend of severe pneumonia caused by this pathogen. however, in the study of priestnall and others [ ] there was no indication that the carriage of these superantigen encoding genes is related to the severity of the histopathological changes. the authors emphasise that further knowledge and alertness of early clinical signs will contribute to enhance the treatment success and avoid transmission of the causative strain of s. equi subsp. zooepidemicus to other animals and humans. the rate of resolution of pneumonia in humans has been defined as the resolution of radiographic abnormalities associated with the disease [ ] . patients with moderately severe pneumonia have a radiological clearance rate of % after month, and more delayed if the pneumonia is severe [ ] . a multicenter cohort study that included adult patients classified as at low risk of short-term mortality concluded that full resolution of symptoms from community-acquired pneumonia (cap) may take more than days [ ] . this study was not specific to athletes, as they are thought to have a better physical health status compared with the general population. when to recommence training for athletes following pulmonary infection depends upon the underlying microbial aetiology and should be individualised [ ] . there is no reason to believe that dog athletes should be advised differently. the long-term rehabilitation of high performance sled dogs may be complicated because of the dual challenge of strenuous exercise and low temperature. as a general rule, caution should be taken to prevent athletes from returning to competition too fast. in human figure control radiograph of the lung of case eight weeks after admission to hospital. ventrodorsal view reveals a mild, mild increased attenuation in the right caudal lung lobe, which was interpreted as likely mild "scar tissue" from the previous severe pneumonia. athletes, potential complications such as pneumothorax, bronchiectasis and hemoptysis has been recorded, as well as acute respiratory failure. furthermore, intense exercise too early in the rehabilitation process can increase susceptibility to viral illness and weaken the muscle performance [ ] . we may speculate that the environmental stress related to the transportation, high-end competition, time of vaccination and too early exercise all contributed to the immunosuppression and consequently the susceptibility to virus-and/or bacterial infection, and where potentially more aggressive and opportunistic bacteria like s. equi subsp. zooepidemicus can progress quickly. it may also be advisable to choose a later moment for vaccination than close up to a challenging physical competition, and to avoid any strenuous exercise for at least ten to days after immunisation. return to play is a hot issue within the top-level sports, but without any specific guidelines post pneumonia. these dogs were in a very good physical shape at the start of the outbreak of haemorrhagic pneumonia, and the two surviving individuals recovered relatively fast and returned to their previous performance level by setting time track records in their first race after recovery. environmental stress associated with intense exercise, competition and prolonged transportation combined with canine vaccination may suppress the innate immune response to viral infections and subsequent s. equi subsp. zooepidemicus infection that only rarely cause pathology in dogs. knowledge and alertness of early clinical signs of acute haemorrhagic pneumonia will enhance treatment success and shorten the rehabilitation period. however, caution should be taken to prevent athletes from return to the competition arena too fast. these high performance sled dogs recovered relatively fast and could prove their fitness by competing and winning international sled race championships three months later. canine infectious tracheobronchitis. in infectious diseases of the dog and cat an outbreak of fatal hemorrhagic pneumonia caused by streptococcus equi subsp. zooepidemicus in shelter dogs the association of streptococcus equi subsp. zooepidemicus with canine infectious respiratory disease hemorrhagic streptococcal pneumonia in newly procured research dogs sudden deaths in greyhounds due to canine haemorrhagic pneumonia outbreak and control of haemorrhagic pneumonia due to streptococcus equi subspecies zooepidemicus in dogs a clonal outbreak of acute fatal hemorrhagic pneumonia in intensively housed (shelter) dogs caused by streptococcus equi subsp. zooepidemicus streptococcus zooepidemicus as the cause of septicemia in racing greyhounds effects of vaccines on the canine immune system peracute haemorrhagic pneumonia syndrome in dogs deaths in racing greyhounds haemorrhagic streptococcal pneumonia in a dog experimental parvovirus infection in dogs characterization of pneumonia due to streptococcus equi subsp. zooepidemicus in dogs streptococcal infection in dogs: a retrospective study of cases isolation of streptococcus zooepidemicus from three dogs in close contact with horses fatal case of toxic shock-like syndrome due to group c streptococcus associated with superantigen exotoxin streptococcus zooepidemicus (group c) pneumonia in a human identification of three novel superantigen-encoding genes in streptococcus equi subsp. zooepidemicus, szef, szen, and szep the radiographic resolution of streptococcus pneumonia pneumonia recovery: discrepancies in perspectives of the radiologist, physician and patient measuring symptomatic and functional recovery in patients with community-acquired pneumonia pulmonary infections in the athlete lower respiratory infections and potential complications in athletes submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution the authors wish to thank field veterinarian steinar dagestad for supplement information about the kenneled dogs. we would also like to thank the staff from the norwegian school of veterinary science including radiologists bernadette helmer & lena stenhaug and all the animal nurses for their intensive loving care. a warm thank to john debenham for language consulting and valuable comments. the authors declare that they have no competing interests.authors' contributions gj did the clinical examinations, drafting and revising the manuscript. . hks evaluated the radiographs initially and the controls. Øk did the postmortem examination. bb and hs did the microbiology testing. hjsl and hs made substantial contribution to the discussion in the manuscript. all authors read, revised and approved the final version of the manuscript. key: cord- - pelqj authors: agua-agum, junerlyn; ariyarajah, archchun; aylward, bruce; bawo, luke; bilivogui, pepe; blake, isobel m.; brennan, richard j.; cawthorne, amy; cleary, eilish; clement, peter; conteh, roland; cori, anne; dafae, foday; dahl, benjamin; dangou, jean-marie; diallo, boubacar; donnelly, christl a.; dorigatti, ilaria; dye, christopher; eckmanns, tim; fallah, mosoka; ferguson, neil m.; fiebig, lena; fraser, christophe; garske, tini; gonzalez, lice; hamblion, esther; hamid, nuha; hersey, sara; hinsley, wes; jambei, amara; jombart, thibaut; kargbo, david; keita, sakoba; kinzer, michael; george, fred kuti; godefroy, beatrice; gutierrez, giovanna; kannangarage, niluka; mills, harriet l.; moller, thomas; meijers, sascha; mohamed, yasmine; morgan, oliver; nedjati-gilani, gemma; newton, emily; nouvellet, pierre; nyenswah, tolbert; perea, william; perkins, devin; riley, steven; rodier, guenael; rondy, marc; sagrado, maria; savulescu, camelia; schafer, ilana j.; schumacher, dirk; seyler, thomas; shah, anita; van kerkhove, maria d.; wesseh, c. samford; yoti, zabulon title: exposure patterns driving ebola transmission in west africa: a retrospective observational study date: - - journal: plos med doi: . /journal.pmed. sha: doc_id: cord_uid: pelqj background: the ongoing west african ebola epidemic began in december in guinea, probably from a single zoonotic introduction. as a result of ineffective initial control efforts, an ebola outbreak of unprecedented scale emerged. as of may , it had resulted in more than , probable and confirmed ebola cases, mainly in guinea ( , ), liberia ( , ), and sierra leone ( , ). here, we present analyses of data collected during the outbreak identifying drivers of transmission and highlighting areas where control could be improved. methods and findings: over , confirmed and probable ebola cases were reported in west africa by may . individuals with confirmed or probable ebola (“cases”) were asked if they had exposure to other potential ebola cases (“potential source contacts”) in a funeral or non-funeral context prior to becoming ill. we performed retrospective analyses of a case line-list, collated from national databases of case investigation forms that have been reported to who. these analyses were initially performed to assist who’s response during the epidemic, and have been updated for publication. we analysed data from , cases in guinea, , in liberia, and , in sierra leone; exposures were reported by % of cases. the proportion of cases reporting a funeral exposure decreased over time. we found a positive correlation (r = . , p < . ) between this proportion in a given district for a given month and the within-district transmission intensity, quantified by the estimated reproduction number (r). we also found a negative correlation (r = − . , p < . ) between r and the district proportion of hospitalised cases admitted within ≤ days of symptom onset. these two proportions were not correlated, suggesting that reduced funeral attendance and faster hospitalisation independently influenced local transmission intensity. we were able to identify % of potential source contacts as cases in the case line-list. linking cases to the contacts who potentially infected them provided information on the transmission network. this revealed a high degree of heterogeneity in inferred transmissions, with only % of cases accounting for at least % of new infections, a phenomenon often called super-spreading. multivariable regression models allowed us to identify predictors of being named as a potential source contact. these were similar for funeral and non-funeral contacts: severe symptoms, death, non-hospitalisation, older age, and travelling prior to symptom onset. non-funeral exposures were strongly peaked around the death of the contact. there was evidence that hospitalisation reduced but did not eliminate onward exposures. we found that ebola treatment units were better than other health care facilities at preventing exposure from hospitalised and deceased individuals. the principal limitation of our analysis is limited data quality, with cases not being entered into the database, cases not reporting exposures, or data being entered incorrectly (especially dates, and possible misclassifications). conclusions: achieving elimination of ebola is challenging, partly because of super-spreading. safe funeral practices and fast hospitalisation contributed to the containment of this ebola epidemic. continued real-time data capture, reporting, and analysis are vital to track transmission patterns, inform resource deployment, and thus hasten and maintain elimination of the virus from the human population. the ongoing west african ebola epidemic began in december in guinea, probably from a single zoonotic introduction [ , ] . as a result of ineffective initial control efforts, an ebola outbreak of unprecedented scale emerged. as of may , it had resulted in more than , probable and confirmed ebola cases, mainly in guinea ( , ) , liberia ( , ) , and sierra leone ( , ) (see section . in s text for who case definitions). control measures for ebola are well known and based on past experience [ ] [ ] [ ] [ ] . however, the lack of local experience in handling ebola outbreaks coupled with severely limited health care resources and poor coordination in the international response led to an initial failure to prevent exponential spread of the outbreak [ , ] . international partners, including the world health organization (who), emphasised four interventions [ ] : ( ) prompt identification and isolation of cases, ( ) tracing of contacts, ( ) safe and dignified burials, and ( ) community awareness and social mobilisation. following several months of intensive efforts to enhance control measures and local community mobilisation, incidence dramatically fell in all three countries [ ] (fig , top row) . to quantify the risk factors for transmission, we analysed reported exposure data collected during the epidemic in guinea, liberia, and sierra leone. we hypothesized that many reported exposures corresponded to transmission events, and that we could therefore discover correlates of transmission and properties of the transmission network by studying available exposure records. analyses were informed by epidemiological knowledge accrued during previous ebola outbreaks and by previous expertise in outbreak analysis. the descriptive analyses and association studies were not prespecified, but rather analyses were designed in response to preliminary examination of the accruing data, and in discussion amongst partners in the team. we also hypothesized that if the interventions deployed to interrupt transmission were effective in this epidemic, we should observe an association between the rate of epidemic spread at the district level and the proportion of cases reporting funeral attendance and/or slow hospitalisation. this latter analysis was decided upon before statistical implementation, and was thus hypothesis-driven. we did not have data to assess the effect of contact tracing or community mobilisation. data were collated during the outbreak to assist with surveillance and the response. national case databases were shared with who and were merged to form a joint line-list (one line of data for each case). the retrospective analyses presented here use data from the three main affected countries (guinea, liberia, and sierra leone) and were first conducted in real time in september and october as part of the response to the public health emergency. they were shared with who, national authorities, and international agencies working in the three countries and contributed to the planning and monitoring of the control effort. in summary, the objectives of these analyses are to understand the drivers of local transmission, the timing of transmission events relative to clinical timelines, and the characteristics of total number of confirmed and probable cases by week is shown in the top row. percentage of cases who reported a non-funeral exposure (triangles) or a funeral exposure (circles) is shown in the second row. the shaded regions represent the % confidence intervals around the proportions. note that cases can report more than one exposure, and so percentages need not add to %. exp., exposure. the transmission network. these are different from and complement the objectives of our previous papers [ ] [ ] [ ] [ ] . however, aspects of the process are the same as in those previous analyses: data cleaning, time series of incidence, and method of estimation for the reproduction number. the same exposure data were used to estimate the incubation period and serial interval in previous analyses [ , ] . the dataset analysed is the most comprehensive available on the current epidemic, and represents a unique resource with which to increase our understanding of the outbreak and of ebola transmission in general. the analysis and presentation of the characteristics of exposures, transmission network, transmission risks, characteristics of potential transmitters and multiple transmitters, health care worker (hcw) exposures, and correlations between epidemic growth and behaviour are all novel. this paper is based on data collected during surveillance and response activities for ebola in guinea, liberia, and sierra leone. the work is based on routine national surveillance for ebola, for which informed consent is not needed. the surveillance was carried out under who integrated disease surveillance and response guidelines in africa (the recommended disease notification system). data were reported to who under the obligations of the international health regulations. all work was carried out under this legal framework. all information on individual patients has been anonymized for analysis and presentation. information from ebola cases was collected using a standardised case investigation form [ ] and the epi info viral hemorrhagic fever application (https://epiinfovhf.codeplex.com/). the cleaning of the data has been described previously [ , ] . the case investigation form records information on exposures that may have led to the infection of the case. cases were asked if in the month prior to symptom onset they had had contact with a potential ebola case and/or had attended a funeral. cases could report details of up to five exposure events with potential source contacts (up to three exposures with potential source contacts outside of a funeral context, and up to two exposures at funerals of potential source contacts); from autumn , an abbreviated form was introduced with up to two non-funeral and one funeral exposure (see s -s texts). cases reported the name of the person they were exposed to and provided details about their relationship to that person (e.g., family, friend, neighbour) and the nature of the exposure (e.g., touched bodily fluids or shared belongings). all names were anonymized using the sha- hashing algorithm [ ] . here, we use "potential source contact", "source contact", or "contact" to describe the person who was named as a potential ebola source, and "exposure" to describe the potential transmission event that took place between the case and the potential source contact (see box for terminology). the potential source contact may be alive or dead at the time of the exposure. ebola cases are classified as confirmed, probable, or suspected. here we analysed data from all cp cases unless otherwise stated. in practice, different countries implemented slightly different case definitions; hence, we also performed sensitivity analyses considering confirmed, probable, and suspected cases combined (see section in s text). we assessed whether cases who reported at least one non-funeral or funeral exposure were different from cases who did not report that type of exposure. this allowed us to assess whether cases who report exposures are representative of the line-list. multivariable logistic regressions were performed using predictors identified as significant (p < . ) in univariable logistic regressions (see section . in s text for a list of predictors included in univariable analyses). the most parsimonious yet adequate multivariable model was then identified (using the akaike information criterion) through backwards stepwise model selection (see final results in tables b and c in s text). to identify potential transmission pairs and thus elucidate transmission networks, we examined whether named potential source contacts were themselves ebola cases. we searched for all named contacts among the names of cases in the line-list to find possible matches. multiple checks were undertaken to verify the consistency of all matched case-contact pairs according to a set of rules (see section . and figure a in s text), in particular comparing dates of symptom onset and exposure. importantly, the exposure data analysed here are retrospective and are completely distinct from prospective contact tracing data, where cases are asked who they had contact with after they became ill; we do not analyse prospective contact tracing data here, as such data were not available to us, but rather focus on identified potential source contacts. we hypothesized that the observed decrease in the proportion of hcws (the positions reported include medical staff and other health-care-facility-based workers) among cases over time (see figure f in s text) was due to decreased unprotected exposure to patients. to address this issue, we compared the estimated slopes from two linear regression models of ( ) • case: an individual in the line-list with confirmed or probable (cp) ebola virus disease status using who case definitions [ ] (see section . in s text). none of our results changed substantially when analyses were run on confirmed, probable, and suspected cases combined (see section in s text). • exposure: an event reported by a case in which the case came into contact with an ill or dead person or attended their funeral. cases could report more than one exposure. • non-funeral exposure: exposure with an ill person, who may be alive or dead, but not at a funeral. cases could report up to three non-funeral exposures. • funeral exposure: attendance at a funeral, which could involve touching the corpse. cases could report up to two funeral exposures. • potential source contact, source contact, or contact: the person with whom the exposure was made. • matched contact: a potential source contact whom we could identify as a reported case in the line-list. • matched exposure: an exposure between a case and his or her matched potential source contact. the proportion of hcws among cases over time and ( ) the proportion of hospitalised patients over time (see section . in s text). note that we define "hospitalisation" as admission to a number of different health care facilities (see box ) . understanding when onward exposure occurred in the clinical course of infection in a primary case could inform the focus of interventions, for instance for early detection of cases or for improving the safety of funerals. we analysed the timing of non-funeral exposure events relative to the following clinical events of the named contacts: onset of symptoms, hospitalisation, and death. here, we describe the analysis of the time from symptom onset to onward exposure; the analyses for hospitalisation and death were similar. we fitted (by maximum likelihood) a distribution to the observed delays between symptom onset and exposure. in brief (see section . in s text for more detail), this likelihood accounted for ( ) multiple exposures (when multiple exposures were reported, only one was likely to have led to infection, so exposures were weighted accordingly), ( ) inaccurate recall of contacts, ( ) inaccurate recall of dates of exposures, ( ) errors in data entry. in order to address issues to , we fitted a mixture of two offset lognormal distributions: the more peaked we regarded as the signal, and the broader we regarded as the noise (see section . in s text). we then interpreted the signal distribution as our best estimate of actual infection times. missing delays were imputed by random draws from the observed data. the analyses described above showed that the non-funeral exposure events were concentrated shortly after the onset of symptoms and around the day of death (see results). we performed an additional analysis to further explore whether one of these two clinical events was we use "hospitalisation" to mean the admission of any patient to a health care facility, as recorded in the case investigation form. this refers to a variety of events in a range of facilities, including • ebola treatment centres or units • referral centres if a case is hospitalised for ebola, who guidelines recommend that the case be isolated. the list above includes a variety of health care facilities where isolation capacity and quality will vary. it should be noted that the meaning of "date of hospitalisation" may be different among cases, depending on how many and which type of facilities they reported visiting in the course of their disease. however, the data do not allow us to distinguish between different meanings of hospitalisation. it should also be noted that not all transfers of patients between different types of health care units may have been recorded in the case investigation form. data cleaning for hospital type is described in section . in s text. more influential for the timing of onward non-funeral exposure events. we compared the ability to predict ( ) the date of death of the source contact based on date of symptom onset of the source contact and the date of exposure reported by the case and ( ) the date of symptom onset of the source contact based on date of death of the source contact and date of onward exposure (see figure o and section . in s text). these two models assume that the timing of onward exposure is mainly determined by the date of symptom onset (model ) or by the date of death (model ). the transmission network can be described by a network of nodes (cases) linked by directed edges (exposures leading to transmission). in order to characterise the heterogeneities in transmission, we analysed the properties of this network. we looked at separate networks for funeral and non-funeral exposures (see section . in s text). for each, we analysed the outdegree distribution, i.e., the distribution of the number of cases naming the same matched contact, which can be seen as a proxy for the distribution of the number of secondary cases per index case. several parametric distributions were fitted to each of the two observed out-degree distributions using maximum likelihood estimation (see section . in s text for a list of the distributions explored). the akaike information criterion corrected for finite sample sizes (aicc) [ ] was then used to select the best distribution. for the best-fitting distribution, % confidence intervals for the distribution parameters were obtained using the likelihood ratio test, and the confidence interval for the corresponding distribution was obtained by numerical sampling. we derived the variance and the coefficient of variation for the offspring distribution (the distribution of the number of secondary cases infected by each case), based on the assumption that the network of exposures shown in figure p in s text is a sample of the full transmission network (see section . in s text). to obtain further insight into potential drivers of transmission, we analysed the data to see if there were predictors of being a potential source contact. we performed four analyses: ( ) a logistic regression, which identified predictors of being named as a non-funeral contact, one or more times; ( ) a logistic regression restricted to cases who died, which identified predictors of being named as a funeral contact, one or more times; ( ) a negative binomial regression, which identified predictors of being named multiple times as a non-funeral contact, conditional on being named at least once; and ( ) a negative binomial regression restricted to cases who died, which identified predictors of being named multiple times as a funeral contact, conditional on being named at least once. predictors included in the univariable regressions were as defined in section . of s text, and the method for identifying the final parsimonious multivariable model is described above. we performed these analyses on confirmed, probable, and suspected contacts who had been named by cp cases. this allowed us to understand the role of suspected contacts in onward transmission compared to cp contacts. we explored the relationship between district-level (second administrative division) transmission intensity and ( ) the proportion of cases reporting funeral attendance amongst those reporting any exposure and ( ) the proportion of cases ever hospitalised and the proportion of cases hospitalised days ( days was the median delay from symptom onset to hospitalisation; see figure m in s text for sensitivity analysis to that threshold). the transmission intensity was quantified by the reproduction number, r, which estimates the average number of secondary cases per index case [ , ] (see section . in s text). we estimated the reproduction number (r d m ) and the proportion (p d m ), for every district (d) in all three countries over monthly intervals (m). (r d m was estimated with the r package "epiestim" [ ] using districtlevel incidence, presented in fig at the country level; see section . in s text.) the relationship between (r d m ) and the proportions was explored using linear regressions. as these quantities were estimated from a sample of data with a level of uncertainty, we used a custom linear regression method that accounts for measurement error [ , ] . the method to compute the correlation coefficient was also adapted to account for measurement error (see section . in s text). all data cleaning and analyses were performed using r software [ ] . of the , cp ebola cases in the line-list, , ( %) cases reported one or more exposures (table ) , giving a total of , reported exposures. temporal trends in case incidence and reported exposures by country are shown in fig . the proportion of cases reporting exposures varied by country (table ); in general, we found that exposure data were less complete for guinea. cases reporting exposures were broadly representative of all cases in the line-list (see tables b and c and figure c in s text for a comparison of characteristics between cases who reported exposures and those who did not). exposure at funerals is a known risk factor for ebola infection [ ] [ ] [ ] , and % of cases who reported any exposure in the current outbreak reported exposures at funerals. most cases ( %) reporting a funeral exposure also reported one or more non-funeral exposures. cases were asked to provide details on the nature of their exposures and their relationships with the contacts, which are shown in table . overall, % of exposures occurred between family members (of those where the relationship was reported). up until the introduction of the new case investigation form (see s -s texts), non-funeral exposures were recorded as one or more types (e.g., an exposure could simultaneously involve shared belongings and exposure to bodily fluids). of those non-funeral exposures for which the type of exposure was reported, over % were reported to involve contact with bodily fluids and/or direct physical contact, and % were reported as occurring in a household (defined as having slept, eaten, or spent time in the same household or room as the contact). these patterns did not change significantly over time (see figure e in s text). for funeral exposures, cases were asked whether they had touched the corpse. of those giving a response, % reported having touched the corpse, with this proportion being greatest for guinea ( %) and least for liberia ( %). this proportion declined significantly after october (p < . ; see figure h in s text), most notably in sierra leone. we were able to identify % of potential source contacts as cases in the line-list. our ability to match contacts did not vary substantially over time (see figure i in s text) or geographically (see figure c in s text). the analysis of matched exposures provides information on the transmission network underpinning the ebola epidemic (fig ) . there was evidence of modest assortativity in exposure patterns by sex (see table i in s text) and country-specific patterns by age (see table j in s text). the most important statistic characterising the transmission network is the out-degree distribution, the number of times each person was named as a contact by other ebola cases. the observed out-degree distribution was best fitted by a logarithmic probability distribution for both funeral and non-funeral contacts (fig a; see sections . and . in s text). since the network is not known in its entirety, but only through a sample of cases and their matched contacts, additional assumptions were needed to infer the true offspring distribution (the distribution of the number of secondary cases infected by each case) from the observed outdegree distribution. under the assumption that the matched exposures are representative of the underlying transmission network, we find high to extreme variability in the offspring distribution ( fig b; see section . in s text). the estimated coefficient of variation for the offspring distribution ranges from . to . depending on assumptions (see section . in s text). this implies that % of cases accounted for at least % of all new infections and that % of cases accounted for at least % of new infections (fig b; see figure q in s text), a phenomenon termed super-spreading [ ] . super-spreading was found to affect both nonfuneral and funeral transmissions equally (see tables f and g in s text). one key potential determinant of the risk of onward transmission is the stage of progression of clinical illness. the risk of transmission was found to increase over time since symptom onset (fig a) , peaking days after onset, with some exposures estimated to have occurred more than weeks after onset. our model estimates a small probability of transmission before symptom onset; however, we do not regard this as strong evidence for pre-symptomatic transmission: all reported dates are prone to recall bias, but it is likely that the date of symptom onset is more uncertain than dates of hospitalisation and death, as it is subjective, so individuals may interpret symptom onset differently. transmission events from non-funeral exposures were estimated to be strongly peaked on the day of and the day after the death of the contact (fig b) . in all, % of non-funeral not all cases who reported funeral exposure explicitly reported whether they had touched the corpse. cases who reported non-funeral exposure could report multiple types of exposure: belongings-"touched or shared the linens, clothes, or dishes/eating utensils of the case [contact]"; bodily fluids -"touched the body fluids of the case (blood, vomit, saliva, urine, feces)"; in same household-"slept, ate, or spent time in the same household or room as the case"; direct physical-"had direct physical contact with the body of the case". relationship was not reported for every exposure. we grouped reported relationships into classes: "close family" is defined as siblings, marital, and parent-child relationships; other family members are considered "extended family"; "neighbour" is defined as tenants, lodgers, landlords, and neighbours; "health care" is defined as hcw-patient relationships and caregivers, or any reference to a patient; "other" includes traditional healers, contacts through religious practice, and transport contacts. type of exposure and relationship type are illustrated graphically in figure d in s text. we sought to determine whether date of death or date of symptom onset was the stronger predictor of transmission risk. we found that date of death was the stronger predictor, indicating that the timing of death is the strongest determinant of when transmission occurs (see figure o in s text). hospitalisation (see box for definition of hospitalisation, which in this context is isolation from the community by admission to any health care facility) aims to improve the clinical outcomes of patients with ebola virus disease, and also to reduce onward exposures. we found that hospitalised cases (who were hospitalised at any stage of their infection) had a reduced risk of being named as a non-funeral source contact (univariable or = . [ % ci: . , figure p in s text for full network) and the contacts they have named as having been exposed to. individuals (cases and contacts) are shown as nodes, and exposures as directed arrows from contacts to cases. arrows are red for funeral exposures, black for nonfuneral exposures, and blue for multiple exposures involving both non-funeral and funeral exposures. square nodes are males, round nodes females, and triangles unknown. red nodes are cases who have died, blue nodes are cases who have survived, and grey nodes are cases with no recorded outcome. of the contact to time of exposure. the green curves show the overall best fits, and the red curves show the best fits for the "signal" distribution (all obtained by maximum likelihood). the red-shaded areas indicate the % confidence intervals of the fitted "signal" distribution. the histogram shows a random set of exposure midpoints (in some instances, only a start or an end date of exposure is recorded; in those instances, the missing date is numerically imputed). note that the fitting procedure is not performed on the midpoints but fully incorporates the exposure window (see section . in s text). the inset panels are the observed cumulative distribution functions for the midpoint (black line) and start and end (grey lines) of the exposures. . ]) and as a funeral source contact (or = . [ % ci: . , . ]) compared to cases never hospitalised. this indicates that hospitalisation reduced but did not eliminate onward exposures. the impact of hospitalisation on limiting onward exposure was stronger in guinea than in liberia (significantly so for non-funeral exposures, see tables m and n in s text). the protective effect of hospitalisation on exposure in sierra leone was not statistically significant. there was no significant increase in the effect of hospitalisation over time for any of the three countries (see tables m and n in s text). previously, we examined the timing of transmission risk relative to symptom onset and death. using the same method to characterise the timing of exposure events relative to hospitalisation, we found that a substantial proportion ( % [ % ci: %, %]) of non-funeral exposures from hospitalised source contacts occurred after their hospitalisation (fig c) . our definition of hospitalisation covers a broad range of health care facility types (box ), each with varying levels of infection control [ ] . in particular, as part of the international response to the epidemic, an unprecedented number of ebola treatment units (etus) were built to care for patients. the previous analysis considered all types of hospitalisation together. when we disaggregated hospitalisation by etu versus other facilities, we found that etus were better than other health care facilities at preventing exposure from hospitalised cases and at providing safer management of corpses. in etus, the observed proportion of non-funeral exposures from hospitalised cases occurring after hospitalisation was significantly lower than in non-etu facilities (p < . , see figure n in s text). moreover, hospitalisation in an etu reduced the risk of being named as a funeral contact compared with non-hospitalised cases (univariable or = . [ % ci: . , . ]) more than hospitalisation in a non-etu facility did (or = . [ % ci: . , . ]; also see multivariable analyses in table l in s text and the next section). although for non-funeral contacts univariable ors were not significant, a multivariable analysis indicated similar effects (see table k in s text). overall, our analyses demonstrate that hospitalisation reduced infectious exposures to cases, but that the effectiveness of hospital isolation measures varied by country and facility type, with substantial scope for improvements. to further explore the characteristics of individuals who were named as potential source contacts (and therefore potential transmitters), we also performed systematic multivariable logistic regressions on the risk of being named as a potential source contact (see tables k and l in s text). based on the final multivariable model, individuals significantly more likely to be named as a non-funeral contact were those who were more severely affected at presentation ( to determine whether there were any factors associated with being multiply identified as a potential source contact, we conducted a multivariable negative binomial regression to explore predictors of the number of times cases were named as non-funeral and funeral source contacts, conditional on being named at least once (see tables p and q in s text). cases with reported haemorrhagic symptoms were found to be named as non-funeral contacts . times more often than cases not reporting these symptoms ( % ci: . , . ). cases hospitalised in an etu were found to be named as non-funeral contacts . as many times as non-hospitalised cases ( % ci: . , . ). also, hcws were found to be named as non-funeral contacts . as many times as non-hcws ( % ci: . , . ). travel outside one's village of residence prior to becoming ill was the only significant predictor for a case to be named multiple times as a funeral contact (relative number of times being named compared to cases who did not report travelling was on average . [ % ci: . , . ]). sex did not appear as an important predictor of exposure risk in any of the analyses that we performed. hcws have been at particularly high risk of infection, especially during the early part of the epidemic [ ] . hcws reported that % of their non-funeral exposures were with other hcws or patients, versus . % reported by non-hcws. consequently, hcws reported a lower percentage of exposures with family members ( %) compared to non-hcws ( %; see figure f in s text). this demonstrates that hcws were often infected whilst working. consistent with these data, the matched contacts reported by hcws were more likely to have evidence of hospitalisation at some point in their illness than the matched contacts of non-hcws (or = . [ % ci: . , . ]). in the absence of data on the total number of hcws working in each of the three countries over time, we could not estimate the relative risk of infection of hcws compared to non-hcws. however, several indicators point to falling risk through time. since june , the proportion of hcws among all cases has decreased over time (see figure f in s text). the rate of decrease in this proportion (estimated monthly relative decrease since june: % [ % ci: %, %]) was faster than that seen in the incidence of hospitalised cases (estimated monthly relative decrease: % [ % ci: %, %]; see also figures f and g in s text), suggesting an improvement in infection control measures and increased awareness of ebola among hcws over time. the analyses presented so far describe individual risks of infection. we next explored, in a hypothesis-driven manner, whether local epidemic transmission intensity was correlated with local population measures of presumed heightened risk of infection. we first examined whether the proportion of cases reporting funeral exposures in each district by month was correlated with the estimated reproduction number r in that district at that time. having accounted for uncertainty in the estimates of both quantities [ ] (see section . in s text), we found a positive correlation for liberia (r = . , p = . ) and sierra leone (r = . , p < . ) and no significant correlation for guinea (r = . , p = . ) (fig ; see figure j and table d in s text). this analysis suggests that across the three countries an absolute reduction of % in the proportion reporting funeral exposures would lead to an absolute reduction of . in r ( % ci: . , . ; p < . ). in particular, reducing the proportion reporting funeral exposures to less than % ( % ci: %, %) would be sufficient to reduce r below , the threshold value for achieving control of the epidemic. however, this result varies by country, and is an association that does not prove causation, since reductions in funeral exposures could have been accompanied by changes in other control measures and other effects of community mobilisation. in that case, the measure is a surrogate for the total effect of interventions that correlate with reduced funeral exposures. another factor potentially influencing changes in transmission intensity is how promptly cases are hospitalised and isolated. we found no association between the proportion of cases that were hospitalised and the estimated district-level reproduction number r (see figure k in s text), likely because the line-list predominantly includes cases who have been hospitalised. however, we found a negative association between the estimated district-level r and the proportion of hospitalised cases admitted within days after onset of symptoms in liberia (r = . , p = . ) and sierra leone (r = . , p < . ). no significant correlation was found in guinea (r = . , p = . ) (fig ; see figures l and m in s text). this analysis quantifies the impact that earlier hospitalisation has in reducing transmission. across all three countries we estimate that increasing the proportion of cases hospitalised within days of symptom onset by % would reduce r by . ( % ci: . , . ; p < . ). in particular, if % ( % ci: %, %) of hospitalised cases are admitted within days, r is predicted to be < . again, the effect varied by country. we found no correlation between the two predictors we analysed, i.e., the proportion of cases reporting funeral exposure and the proportion of cases hospitalised within d of symptom onset (naïve r = . , p = . ; see section . in s text). this shows that both factors are independently associated with the level of transmission, at least in liberia and sierra leone, and, together, they explain a substantial proportion (approximately %) of the variance in epidemic transmission intensity observed in these two countries. the analyses in this paper draw on , exposures to potential sources of infection, to provide a quantitative basis for understanding ebola epidemiology and to validate the choice of interventions used to combat ebola in the current and future outbreaks. these analyses were initially performed in september/october as part of the who ebola response during the epidemic and have been updated to be shared with the scientific community. the current ebola outbreak has been of unprecedented scale, occurring across three countries of diverse cultures with varying levels of urbanisation. our analysis provides a unique overview of ebola transmission that complements detailed investigations that have been performed in localised settings in this and previous outbreaks [ ] [ ] [ ] [ ] [ ] . small studies may allow more detailed reconstruction of transmission and identification of risk factors for infection by comparing cases and non-cases, which is not feasible at a larger scale. however, analyses such as identifying district-level correlates for transmission intensity and determining when exposures occur with respect to clinical events are only possible with this unique large-scale dataset. our analysis confirms that exposure to ebola cases at funerals is an important amplifier of ebola transmission, in line with a study focused in sierra leone [ ] . the significant correlation we found between the district-level reported frequency of funeral exposures and local transmission intensity provides support for the policy emphasis on safe and dignified burials. . the scatter plots show these monthly proportions against monthly estimated reproduction numbers r (method as previous [ ] ) for the supplemented incidence (i.e., incidence based on two data sources including the line-list, see [ ] ). each point is a district-month. trend lines are shown with % confidence intervals (shaded areas). we use a weighted regression method that takes account of the uncertainties in the data [ ] . the area of each circle is proportional to the weight of that point (see section . in s text). in the bottom row, the black trend line is for the whole dataset. see figures j and l this effect was not replicated in guinea, which suggests we have less understanding of drivers of transmission in that country. our results also highlight the importance of exposure to individuals who are dead or dying from ebola outside the funeral context, as has been observed in past outbreaks [ , [ ] [ ] [ ] , ] . cases who died were more likely to be named as contacts than those who survived, with most transmission occurring within a few days on either side of the reported date of death-coincident with the timing of peak viral load [ , ] . this reinforces existing evidence [ , [ ] [ ] [ ] , ] that exposures to individuals who are dead or dying from ebola contribute to transmission, even where those exposures occur outside the specific context of funerals. as in past outbreaks [ , , , ] , and consistent with other analyses of the current outbreak [ ] , such exposures have most often been between close family members, perhaps explaining why most such contacts have occurred in the household. early hospitalisation in facilities with the ability to isolate patients effectively-a key element of control efforts for ebola-is clearly a priority to reduce community transmission. investigations of the initial phase of this epidemic, as well as previous outbreaks, have highlighted the potential role of within-hospital transmission before or shortly after ebola is identified as the causative agent [ , ] . here we found that hospitalisation, defined broadly as anything from visiting a clinic to admission to an etu, reduced transmission risk, showing that prompt hospitalisation may be an effective intervention as long as appropriate control measures are applied. however, hospitalisation did not eliminate transmission risk, indicating that improvements in infection control are needed in many health care settings. it should be noted that the meaning of date of hospitalisation may be different among cases, depending on how many and which types of facilities they visited in the course of their disease, and furthermore that there is potential for misclassification in the recording or interpretation of information on hospitalisation. in particular, while the health care facility of first admission was commonly reported, patient transfers to other facilities may not have always been recorded. thus, there may be ambiguity about the type of health care facility a case was in at a particular time. such missing information reduces our ability to resolve differences between types of facilities in their effectiveness at implementing case isolation, which could lead to underestimation of differences between facility types in isolation effectiveness. however, our results are broadly consistent with analyses of the outbreak in conakry [ ] . half of reported non-funeral exposures where the matched contact was eventually hospitalised occurred after the reported date of hospitalisation. these results underscore the importance of further improving infection control in all health care facilities, but particularly in non-etus. however, in contexts where hospital bed capacity is insufficient or infection control in health care settings is imperfect, greater consideration might be given to measures to reduce within-family exposure-for example, via education and/or providing a home protection kit with hand disinfectant, protective equipment, and clear guidance for those caring for sick family members. another striking feature of the epidemic revealed by our analysis is the high level of heterogeneity in the number of times a case is named as a potential source contact. such heterogeneity has been observed for some other emerging infectious disease epidemics [ , [ ] [ ] [ ] , in particular the middle east respiratory syndrome coronavirus outbreaks [ ] . in principle, understanding the drivers of this heterogeneity might allow for the design of targeted interventions. however, our analysis found very few epidemiological predictors for being named as a source contact multiple times, suggesting that simple demographic characteristics are unlikely to pinpoint those most at risk of super-spreading. heterogeneity in transmission, particularly when associated with transmission in close communities, implies that epidemic trajectories may be difficult to predict at a local level [ , ] . local flare-ups are possible when case numbers are low and declining. continued vigilance during the ongoing declining phase of the epidemic is essential. the data we have analysed have several limitations. not all ebola cases are recorded in the national databases shared with who. moreover, data on exposures were reported by only approximately one-third of cases. the remainder of cases may not have had the chance to report exposures or may have been unable to recall any. additionally, data collection teams and methods varied by country, district, and hospital facility, meaning observational or collection bias may have affected the data. all data (e.g., symptoms at presentation) were either selfreported or reported by friends/family or inferred by the interviewer and may therefore suffer from subjectivity and recall bias. in particular, there may be biases in the exposures reportedfor example, cases may recall funerals or exposures to family in more detail or have different perceptions of what constitutes exposure. recall and data entry errors (e.g., spelling mistakes, mistyped dates, and misclassification) and missing data may have affected our results, for example, they limited our ability to match the contacts named in the reported exposures. we accounted for this in our analyses as much as possible by discarding inconsistent data, imputing missing data, or explicitly accounting for noise. however, some biases may remain. performing these quantitative analyses on such a large scale was only possible due to the enormous commitment of ebola responders in the region throughout the epidemic, which is particularly remarkable given the very challenging circumstances in the affected countries. in generalising our findings, we need to recognise the relatively unique nature of this crisis. measures that were promoted, including emphasising bed capacity, safe funerals, behaviour change, and community mobilisation, followed the recognition that targeted case finding and contact tracing could not be scaled to meet the exponentially growing burden during the early phase of the epidemic. however, these latter measures, supported by continued community mobilisation, should be prioritised during new ebola outbreaks and during the end phase of the current epidemic, when capacity can meet need. our analyses provide a quantitative basis for prevention measures against the spread of ebola, but also highlight the challenges faced in the field. a compassionate response protocol needs to acknowledge that, as we found, most reported potential transmissions occurred between family members close to the time of death of the case. this provides evidence that ring vaccination methods, such as those trialled in guinea [ ] , may be an effective way of delivering vaccines against ebola in the context of limited supply or in hard-to-reach populations. hospitalisation was found to be protective, but left substantial room for improvement. the association between reported funeral attendance and district-level epidemic trends highlights the continued need for improving access to and acceptability of safe burials of ebola cases. more robust associations could be detected using case-control studies, but these are hard to coordinate during an emergency situation. in their absence, the analyses reported here have already provided key insights into the drivers of the epidemic. heterogeneities in transmission made the road to ebola elimination likely to be marked by episodic flare-ups [ , ] . ebola is controllable using the simple measures that have already been implemented in this outbreak, but complacency as case numbers decline could prolong the epidemic for months. continued real-time data capture, reporting, and analysis are vital to track transmission patterns, inform resource deployment, and thus hasten elimination of the virus from the human population. genomic surveillance elucidates ebola virus origin and transmission during the outbreak emergence of zaire ebola virus disease in guinea ebola haemorrhagic fever outbreak in masindi district, uganda: outbreak description and lessons learned the epidemiology of ebola hemorrhagic fever in zaire ebola haemorrhagic fever in zaire report of a who/international study team what factors might have led to the emergence of ebola in west africa ebola virus disease in west africa-no early end to the outbreak geneva: world health organization geneva: world health organization who ebola response team. ebola virus disease in west africa-the first months of the epidemic and forward projections who ebola response team. west african ebola epidemic after one year-slowing but not yet under control ebola virus disease among children in west africa who ebola response team. ebola virus disease among male and female persons in west africa fips - . gaithersburg (maryland): national institute of standards and technology world health organization. case definition recommendations for ebola or marburg virus diseases. geneva: world health organization model selection and multimodel inference: a practical information-theoretic approach estimating individual and household reproduction numbers in an emerging epidemic a new framework and software to estimate time-varying reproduction numbers during epidemics regression techniques for the detection of analytical bias deming: deming, thiel-sen and passing-bablock regression. version . - . r project for statistical computing vienna: r foundation transmission of ebola hemorrhagic fever: a study of risk factors in family members ebola hemorrhagic fever associated with novel virus strain, uganda ebola hemorrhagic fever transmission and risk factors of contacts superspreading and the effect of individual variation on disease emergence rapid assessment of ebola infection prevention and control needs-six districts geneva: world health organization chains of transmission and control of ebola virus disease in conakry, guinea, in : an observational study cluster of ebola virus disease controlling the last known cluster of ebola virus disease-liberia epidemiology and risk factors for ebola virus infection in sierra leone decreased ebola transmission after rapid response to outbreaks in remote areas containing hemorrhagic fever epidemic, the ebola experience in uganda ebola hemorrhagic fever, kikwit, democratic republic of the congo, : risk factors for patients without a reported exposure the contribution of ebola viral load at admission and other patient characteristics to mortality in a médecins sans frontières (msf) ebola case management centre (cmc) transmission dynamics and control of ebola virus disease outbreak in nigeria the reemergence of ebola hemorrhagic fever, democratic republic of the congo temporal variability and social heterogeneity in disease transmission: the case of sars in hong kong predicting super spreading events during the severe acute respiratory syndrome epidemics in hong kong and singapore super-spreaders in infectious diseases middle east respiratory syndrome: a global health challenge multiscale, resurgent epidemics in a hierarchical metapopulation model dynamics and control of diseases in networks with community structure the ring vaccination trial: a novel cluster randomized controlled trial design to evaluate vaccine efficacy and effectiveness during outbreaks, with special reference to ebola ebola transmission linked to a single traditional funeral ceremony liberia confirms ebola case two months after being declared free of the disease the authors would like to thank the many field staff from guinea, liberia, and sierra leone involved in ebola case finding, detailed data collection, treatment and testing of patients, and data entry. this study was carried out in support of the ebola response in guinea, liberia, and sierra leone, and is based on data routinely collected by national and international staff in collaboration with who.the authors would also like to thank sir david cox for his helpful advice. the conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the u. s. department of health and human services, the public health service, the centers for disease control and prevention, or the authors' affiliated institutions. use of trade names is for identification only and does not imply endorsement by any of the groups named above. conceptualization: imb aco cad nmf cf hlm. key: cord- -l wv authors: shenoy-bhangle, anuradha s; putta, niharika; adondakis, michael; rawson, james; tsai, leo l title: prospective analysis of radiology resource utilization and outcomes for participation in oncology multidisciplinary conferences date: - - journal: acad radiol doi: . /j.acra. . . sha: doc_id: cord_uid: l wv rationale and objectives: radiology participation is necessary in oncology multidisciplinary conferences (mdcs), but the resources required to do so are often unaccounted for. in this prospective study we provide an analysis of resource utilization as a function of outcomes for all mdcs covered by an entire radiology section and provide a time-based cost estimate. materials and methods: following institutional review board approval, prospective data on all mdcs covered by abdominal radiologists at a single tertiary care academic center were obtained over nine weeks. a predefined questionnaire was used by a single observer who attended every imaging review and recorded the total time spent by the radiologists and several outcome measures. the total time recorded was used to provide a time-based cost estimate using a national salary survey. results: six radiologists participated in a total of mdcs, with cases reviewed and discussed. ( %) cases were performed at outside facilities requiring full reinterpretation. clinically significant revisions to original reports were recorded in ( . %) cases. radiologist input directly resulted in alteration of cancer staging in ( %) patients and specific recommendations for follow-up diagnostic workup in ( %) of cases. the mean total time devoted by the staff radiologist per week to mdcs was . hours/week, nearly a half of full-time effort, or % of total effort per radiologist. the total annual projected cost of radiology coverage for each weekly mdc was $ , . conclusion: section-wide radiologist participation in mdcs directly resulted in change in clinical management in nearly half of reviewed cases. this was achieved at a notable time cost, highlighting the need for efficient integration of radiology mdc participation into radiologist workflow and compensation models. m ultidisciplinary conferences (mdcs) are an increasing part of radiologists' workflow not only at major academic and tertiary referral centers but also in the community setting ( ) . the american college of surgeons first established the commission on cancer accreditation program to provide standards for the establishment of mdcs ( ) . now there are over certified medical centers in the us, with each site required to register the composition of their mdcs with minimum attendance rates for participants, including radiologists. the importance of a multidisciplinary approach to management of oncology patients and the importance of a radiologist's presence and contribution to improved clinical decision making has been studied and validated in the context of breast cancer, hepatocellular carcinoma, pancreas cancer, gastrointestinal tumors, and gynecologic cancers ( À ) among others. a majority of these papers focus on a multidisciplinary approach to patient management in an oncology setting or the added value of reinterpretation of imaging studies by specialized radiologists. for example, pawlik et al. reviewed cases in one multidisciplinary pancreas clinic and demonstrated ( %) cases with altered clinical stage and overall ( %) cases with altered management as a result of the discussion at the mdc that also included input from radiologists ( ) . mdc impact on radiology and pathology workflow was previously studied in a single conference setting, highlighting time demands, but without a translation into cost, or reference to outcomes ( ) . since that study, the radiologist's role in mdcs has been shaped by technical improvements such as the introduction of online transfers of outside hospital (osh) studies directly to picture archiving and communication systems (pacs), as well as the overall increasing number of mdcs, necessitating a more current evaluation. furthermore, there has not been a study that has examined the impact of mdc coverage across an entire section. the purpose of this study is to fill these knowledge gaps by collating both resource and basic outcome data from a consecutive set of mdcs currently supported by an entire imaging section, and by calculating the associated cost. this prospective study was approved by our institutional review board and was healthn insurance and n portability accountability act compliant. the study was conducted at our -bed hospital which also serves as a tertiary referral oncology center with specialized oncology care, serving approximately , outpatients a year. our hospital network includes a network of satellite hospitals and partnered health centers that refer oncology patients for specialized care. this study encompasses all (a total of ) weekly mdcs covered by the abdominal section at our tertiary referral center: gastrointestinal oncology; genitourinary oncology; gynecologic oncology; liver tumor board, liver tumor multidisciplinary clinic, pancreaticobiliary tumor board, and pancreaticobiliary multidisciplinary clinic. the description of conference style and participants is provided in table . although all of these conferences are focused on oncology patients, non-oncology cases referred for second opinion to our clinical colleagues from the hepatobiliary or pancreas center are also included. the mdcs are staffed by six fellowship-trained abdominal radiologists (out of a total of members of the section) who subspecialize in the conference focus areas, with one faculty member covering two of the conferences. there are backup radiologists from the same group who attend the mdc if the primary radiologist is unavailable. an abdominal imaging or body mri clinical fellow typically participates in each of the conferences. the radiologists' workflow for mdcs is comprised of two parts: a review of the cases prior to the conference and presentation of cases at the conference. the initial report of these cases is provided either by any of the radiologists from the same group, but not necessarily those reviewing cases for the mdc, or by radiologists at outside institutions. centers outside our institution that are affiliated with our network have separate radiology departments and their studies need to be imported into our pacs, and are thus considered outside studies. reviews are usually performed within hours prior to each conference after a final list of cases is sent by the mdc coordinators to all participants. a clinical fellow usually previews the cases, followed by a review with the staff (attending) radiologist, who makes all final decisions regarding image interpretation and recommendations. the findings are then presented at the mdc; at five of the mdcs, the fellow is the presenter, while the attending presents at the two pancreaticobiliary mdcs. however, the corresponding attending is present at every conference for any additional questions or review of addon cases. data was collected from mdcs conducted consecutively from june , to august , . a single researcher (n.p.) attended all review sessions with the clinical fellow and attending radiologist. the researcher then attended all of the mdcs, with the exception of genitourinary oncology, which overlapped with the liver tumor conference. for the genitourinary oncology conference, the attending radiologist covering the mdc (l.t.) recorded the data from that conference and emailed the results to the researcher at the conclusion of the conference. the attending radiologists were all fellowship-trained in abdominal imaging with to years of faculty experience. all studies were reviewed on a pacs workstation. any studies from an osh were required to be imported into our pacs system before being reviewed for an mdc. the data collected by the observer was obtained using the same standardized questionnaire for every mdc. the data included logistical information, including the time spent by the fellow and the attending previewing and reviewing the cases, respectively, the number of osh versus in-network cases that were reviewed, the time spent reviewing osh studies, and the number of "add-on" cases (less than hours before the mdc or cases added on at the mdc without prior notice) that were requested after the final mdc lists were sent. all radiology findings and recommendations discussed at review and mdc were recorded for each case, along with management decisions reached by the multidisciplinary group. the data from each case was then measured for four basic outcomes that highlighted contributions directly attributable to the radiologist: ) any changes from the original imaging report that the attending radiologist deemed clinically impactful to warrant presentation at mdc, ) changes in cancer staging for oncology cases, and ) instances when the radiologist either recommended a new diagnostic imaging study at the mdc, or ) recommended cancelling a planned follow-up imaging study for lack of added value. examples for each are provided in table . all data were transferred immediately to an anonymized master spreadsheet for tracking and statistical analysis. categorical variables were described by counts and percentages while continuous variables were described by mean and standard deviations. conversion of radiology time to full time equivalents (ftes) was based on a standard -hour work week. a cost conversion was calculated using the us national median salary obtained from medscape's compensation overview ( ) . data were collected over a total of mdcs over nine weeks. means are presented as mean § standard deviation. there was a mean of . § . and median of eight mdcs for each conference type. a total of cases were reviewed, with a mean of . § . and median of nine cases reviewed per conference. key results are presented below, with summary data shown in table . clinical fellows spent a mean of . § . hours and median of . hours per mdc, or . hours/week. attending radiologists spent a mean of . § . hours and median of . hours per mdc, or . hours/week. these times did not include the time spent by the attending radiologist and the fellow presenting at the conferences, which were each an hour long. when taking this into account, clinical fellows and attending radiologists spent a total of . hours/week and . hours/week, respectively, exclusively on mdcs. . cases ( . %) were add-ons. these included cases that were emailed to the radiologist after the official final list was emailed to the mdc group, as well as cases added during the mdc. these cases were typically reviewed during or immediately after the conference directly with the mdc team, and the time spent could not be reliably quantified to include in the total measured review times. revisions to the original radiology report were presented at mdc in a total of ( . %) cases. of these revised reports, more than half ( cases, or . %) involved alterations (both upstaging and downstaging) in cancer staging ( % of total cases). in ( . %) of cases, the radiologist provided direct guidance for diagnostic follow-up at the mdc. the us national median radiology salary in was $ , ( ) . in our study, a total of . hours/week were spent by six staff members, or . hours/week per attending. this corresponds to a yearly cost of $ , per physician or $ , for the section, and an annual cost of $ , for each weekly mdc. mdcs are a critical component of the clinical and educational missions of medical centers. the benefit of radiology input in mdcs is widely accepted, however, the costs associated with this have not been previously studied. our study is the first to provide an estimate of such resources while also sampling across a diverse mixture of mdc types covered by an entire radiology section. we also focused on the time spent by clinical fellows and attending radiologists previewing studies and participating at each mdc and translated it into fte for attending radiologists to assign an estimated cost per physician, per section, and per mdc. these observations have implications on clinical workflow and compensation models as there continues to be an increasing overall demand for radiology support in mdcs as well as emphasis on valuebased healthcare as highlighted by the american college of radiology (acr) imaging . initiative ( ). the time spent by faculty radiologists on mdc conferences averaged . hours/week, or . fte. when divided across the six participating faculty members, this represents . hours/ week/radiologist, or % of total effort per fte. this is slightly increased in comparison to a study a decade ago that calculated hours preparation time per meeting hour spent by the radiologist for one specific mdc involving both imagers and pathologists ( ) . our calculated time of . hours/week/radiologist represents a lower limit and likely an underestimation, as other mdc-related consultations routinely occurring outside of the review period, in particular the time spent on add-on cases ( . % of total cases) could not be accurately recorded. although more add-on cases may have a benefit in that the radiologist takes less time to review such studies, this has been discouraged by our practice as such cases are not reviewed to the same depth as others, nor are they viewed properly on a pacs station, increasing the risk of errors or misses. additionally, our department benefits from having clinical fellows help reduce the faculty preparation time. our abdominal fellows participate in mdcs as part of a dedicated conference rotation, and we consider this activity an essential part of our academic mission ( ) . we calculated a yearly cost of $ , for each radiologist to participate in the mdcs in our study. this translates to $ , per year total for coverage of all mdcs, or an annual cost of $ , for each weekly mdc. if we extrapolated this nationwide using conservative estimate, accounting only for -commission on cancer accredited sites and assuming only a single weekly multidisciplinary conference at each site and a minimum of % participation rate as required by commission on cancer ( ), the cost of radiology effort would be approximately $ . million per year in the us. nearly one-third of reviewed cases ( . %) and the total time spent on review by attendings ( . %) were osh studies, reflecting a large community referral pattern driven mostly by cancer care. while osh cases presented at the two liver mdcs always resulted in an official second opinion report issued by our radiologists, this was not performed for the remaining mdcs, where the findings were instead summarized on an online medical note generated by the conference coordinators. this meant that only out of , or . % of imported osh scans were issued full radiology reports following mdc review. multiple studies have stressed the value of official second opinion reads by subspecialists ( , À ), highlighting a potential area of practice improvement. the increased number of second opinion reports may also generate additional revenue in the form of professional fees, though at our institution a portion of our osh volume comes from our network affiliates which, in our state, precludes additional billing. thus, the move towards requiring an official second opinion read on all osh studies would likely add to total time costs with a partial increase in revenue. in . % of cases the radiologist provided direct recommendations for follow-up or next imaging studies. much of this likely stemmed from additional clinical information discussed live at the mdcs and participation by subspecialized radiologists. these results are concordant with the results from the study by chingkoe et al. ( ) where a change in management was seen in . % of patients following review by the radiologist for a single pancreas mdc. this change in management encompassed changes in diagnosis; in clinical stage; in treatment as well as any additional workup that might be required. changes to the original report were presented by radiologists in about a fifth of all cases. of these, more than half ( % total) were changes to oncologic staging, similar to that observed at a pancreas-specific mdc ( . %) ( ) . this was in part due to subspecialty staff reviewing or reinterpreting inhouse and osh studies, thereby providing second opinion expert reads. we also attribute some of these discrepancies to additional clinical history or supplementary studies obtained during mdc review that lead to new observations or interpretations. discrepancies resulting from interpretive errors or misses are placed in our quality review database for review and education. in many radiology departments there is no time reserved specifically for mdc review. this is currently the case at our institution, where there is no dedicated time allotted to the staff for reviewing cases for mdcs and the effort required is diverted from clinical or personal time. this can present a challenge in sections where the existing clinical workload may be at capacity and mdc participation may not be captured in traditional rvu-based compensation models. given the trend towards increased utilization of subspecialized mdcs for patient management, there may be a need to reconsider workflow designs, particularly at a time when burnout is highly prevalent ( , ) . indeed, since this study, new lymphatic, pelvic floor dysfunction, and prostate mdcs have been added, with coverage provided by the same group of six radiologists. with the incorporation of these new mdcs, we estimate the total effort per covering radiologist to be increased from % to %. there may be several solutions to address the increased radiology demand for mdc participation. the creation of protected time to allow for uninterrupted mdc reviews would provide some separation from concurrent clinical demands and would likely improve the educational component for the fellow. a centralized and streamlined approach to importing osh studies and assigning them earlier to the reviewing radiologist for official second opinion reads would save time and provide more consistent documentation. with the recent rise of telemedicine in response to the covid- pandemic, virtual readouts and conference presentations offer greater convenience as mdcs can be performed remotely, potentially expanding the number of participating radiologists and reducing preparation time related to travel ( ) . regardless of these changes, there will be an associated cost based on radiologist time, as shown in this study, which would need to be taken into account, whether it be borne by the department, the institution, or the radiologists themselves. there are limitations to this study. first, we were limited to observing radiologists during scheduled reviews and at mdcs; additional input or decisions made outside of these times, for example, on follow-up emails or dictation of second opinion reports, were not recorded, resulting in an underestimation of the review/consultation time and some outcome measures. also, not every osh original report was available, leading to an underestimation of discrepancy rates. we did not stratify the severity of discrepancies found in original radiology reports which would have allowed deeper insight into the overall impact of radiology input. however, we did establish a baseline threshold, based on the clinical decisions of the attending radiologists, to only include findings that were significant enough to warrant discussion at the mdc; thus, discrepancies or new findings that were deemed irrelevant to patient care and management were excluded. this study focused on a cost analysis specific to radiology. the outcomes observed in our study, for example the % changes in oncologic staging, suggest a clear benefit from radiologist participation in mdcs, as validated by prior studies. a more comprehensive cost-benefit analysis would be desirable though challenging due to the wide range of different mdc subspecialties, each requiring disease-specific measures. such studies focusing on the general benefit of mdcs, including long-term clinical impact, patient satisfaction, and quality of life, are still needed ( ) . the rise of online medical records and accessibility of records via patient portals also poses unique challenges, for example in cases of discrepancies reported in second opinion reports ( , ) . indeed, the results of this study will form the basis of future investigation focusing on value analysis. take home points . a total of . fte, or % effort per radiologist, was required for mdc participation, corresponding to a yearly total cost of $ , per radiologist. this translates to an annual total radiology cost of $ , for each weekly mdc. . changes to the original reports were made in approximately one-fifth of cases. this highlights the value of radiology participation in mdc and an established peer learning process. . a third of cases and attending review time were dedicated to review of outside studies. professional fees from second opinion reports would help offset these costs. . the trend towards increased radiology participation in mdcs warrants consideration of required time and costs when incorporating this into institutional workflows. implementing a multidisciplinary tumor board in the community practice setting cancer program standards: ensuring patient-centered care edition the effect of a radiology conference consultation on cancer patients management improving patient care by incorporation of multidisciplinary breast radiology-pathology correlation conference the impact of a multidisciplinary breast cancer center on recommendations for patient management: the university of pennsylvania experience the requirements of a specialist breast unit subspecialized radiology review at multidisciplinary pancreas conference: impact on patient management efficacy of the multidisciplinary tumor board conference in gynecologic oncology: a prospective study utility of a multidisciplinary tumor board in the management of pancreatic and upper gastrointestinal diseases: an observational study evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer multidisciplinary team meetings and their impact on workflow in radiology and pathology departments medscape radiologist salary survey supporting the academic mission second-opinion interpretations of gynecologic oncologic mri examinations by sub-specialized radiologists influence patient care breast imaging second opinions impact surgical management hepatopancreaticobiliary imaging second-opinion consultations: is there value in the second reading? clinical impact of second opinion radiology consultation for patients with breast cancer specialized second opinion interpretations of breast imaging: impact on additional workup and management quality and value of subspecialty reinterpretation of thoracic ct scans of patients referred to a tertiary cancer center clinical impact of second-opinion musculoskeletal subspecialty interpretations during a multidisciplinary orthopedic oncology conference burnout in radiology burnout in academic radiologists in the united states virtual read-out: radiology education for the st century during the covid- pandemic the impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: a systematic review of the literature implications of direct patient online access to radiology reports through patient web portals online portals: gateway to patientcentered radiology key: cord- -o aosx q authors: lipsitch, marc; donnelly, christl a.; fraser, christophe; blake, isobel m.; cori, anne; dorigatti, ilaria; ferguson, neil m.; garske, tini; mills, harriet l.; riley, steven; van kerkhove, maria d.; hernán, miguel a. title: potential biases in estimating absolute and relative case-fatality risks during outbreaks date: - - journal: plos negl trop dis doi: . /journal.pntd. sha: doc_id: cord_uid: o aosx q estimating the case-fatality risk (cfr)—the probability that a person dies from an infection given that they are a case—is a high priority in epidemiologic investigation of newly emerging infectious diseases and sometimes in new outbreaks of known infectious diseases. the data available to estimate the overall cfr are often gathered for other purposes (e.g., surveillance) in challenging circumstances. we describe two forms of bias that may affect the estimation of the overall cfr—preferential ascertainment of severe cases and bias from reporting delays—and review solutions that have been proposed and implemented in past epidemics. also of interest is the estimation of the causal impact of specific interventions (e.g., hospitalization, or hospitalization at a particular hospital) on survival, which can be estimated as a relative cfr for two or more groups. when observational data are used for this purpose, three more sources of bias may arise: confounding, survivorship bias, and selection due to preferential inclusion in surveillance datasets of those who are hospitalized and/or die. we illustrate these biases and caution against causal interpretation of differential cfr among those receiving different interventions in observational datasets. again, we discuss ways to reduce these biases, particularly by estimating outcomes in smaller but more systematically defined cohorts ascertained before the onset of symptoms, such as those identified by forward contact tracing. finally, we discuss the circumstances in which these biases may affect non-causal interpretation of risk factors for death among cases. the case-fatality risk (cfr) is a key quantity in characterizing new infectious agents and new outbreaks of known agents. the cfr can be defined as the probability that a case dies from the infection. several variations of the definition of "case" are used for different infections, as discussed in box . under all these definitions, the cfr characterizes the severity of an infection and is useful for planning and determining the intensity of a response to an outbreak [ , ] . moreover, the cfr may be compared between cases who do and do not receive particular treatments as a way of trying to estimate the causal impact of these treatments on survival. such causal inference might ideally be done in a randomized trial in which individuals are randomly assigned to treatments, but this is often not possible during an outbreak for logistical, ethical, and other reasons [ ] . therefore, observational estimates of cfr under different treatment conditions may be the only available means to assess the impact of various treatments. however, observational studies conducted in the early phases of an outbreak, when public health authorities are appropriately concentrating on crisis response and not on rigorous study design, are challenging. a common problem is that disease severity of the cases recorded in a surveillance database will differ, perhaps substantially, from that of all cases in the population. this issue has arisen in the present epidemic of ebola virus disease in west africa and in many previous outbreaks and epidemics [ ] [ ] [ ] [ ] [ ] [ ] and will continue to arise in future ones. here we outline two biases that may occur when estimating the cfr in a population from a surveillance database, and three more biases that may occur when comparing the cfr between subgroups to estimate the causal effect of medical interventions. we also briefly consider the applicability of these biases to a different application: comparing the cfr across different groups of people, for example, by geography, sex, age, comorbidities, and other "unchangeable" risk factors. such factors are "unchangeable" in the sense that they are not candidates for intervention in the setting of the outbreak, though some could, of course, change over longer timescales. the goal of estimating the cfr in groups defined by such unchangeable factors is not to understand the causal role of these factors in mortality, but to develop a predictive model for mortality that might be used to improve prognostic accuracy or identify disparities. such box . definition of the cfr. the cfr itself is an ambiguous term, as its definition and value depend on what qualifies an individual to be a "case." several different precise definitions of cfr have been used in practice, as have several imprecise ones. the infection-fatality risk (sometimes written ifr) defines a case as a person who has shown evidence of infection, either by clinical detection of the pathogen or by seroconversion or other immune response. such individuals may or may not be symptomatic, though asymptomatic ones may go undetected. the symptomatic case-fatality risk (scfr) defines a case as someone who is infected and shows certain symptoms. infection in many outbreaks is given several gradations, including confirmed (definitive laboratory confirmation), probable (high degree of suspicion, by various clinical and epidemiologic criteria, without laboratory confirmation), and possible or suspected (lower degree of suspicion). this paper describes issues in estimating any of these risks or comparing them across groups, but does not go into the details of each possible definition. furthermore, unlike risks commonly used in epidemiologic research (e.g., the -year mortality risk), the length of the period during which deaths are counted for the cfr is rarely explicit, probably because it is considered to be short enough to avoid ambiguity in the definition of cfr. however, a precise definition of the cfr would need to include the risk period, e.g., the -month cfr of ebola. clearly, the definition of cfr for a particular investigation should be specified as precisely as possible. predictions may be affected by survivorship bias and selection bias, but not by confounding, as we discuss. two biases that may affect the estimation of an overall cfr are presented in table : for diseases that have a spectrum of clinical presentation, those cases that come to the attention of public health authorities and are entered into surveillance databases will typically be people with the most severe symptoms, who seek medical care, are admitted to hospital, or die. therefore, the cfr will typically be higher among detected cases than among the entire population of cases, given that the latter may include individuals with mild, subclinical, and (under some definitions of "case") asymptomatic presentations. laboratory confirmation as an inclusion criterion may reduce this bias if it is able to detect a wider spectrum of presentations, or may exacerbate it if the probability of receiving a laboratory test is higher for more severe cases and/or if test sensitivity is higher for more severe cases. the magnitude of this bias may be uncertain for a long period because the spectrum of clinical presentations is itself uncertain at the start of an outbreak of a new disease [ , ] . all proposed approaches to estimate and correct for this bias (table ) require auxiliary data sources to estimate how the reported subset of cases compares with the overall population of cases. the availability of such auxiliary data sources will depend on the context of the outbreak. during an ongoing epidemic, there is a delay between the time someone dies and the time their death is reported. therefore, at any moment in time, the list of cases includes people who will die and whose death has not yet occurred, or has occurred but not yet been reported. thus dividing the cumulative number of reported deaths by the cumulative number of reported cases at any moment will underestimate the true cfr. the key determinants of the magnitude of the bias are the epidemic growth rate and the distribution of delays from case-reporting to death-reporting; the longer the delays and the faster the growth rate, the greater the bias. heuristically, the underestimate will be proportionate to the expansion of the epidemic during the delay between the time a case enters the database to the time the death of that case enters the database (if it occurs). fig illustrates an example where the delay is weeks, the epidemic doubling time is weeks, and the underestimate is by a factor of / . . this bias may be corrected for in various ways, and to varying degrees, using information on the growth rate of the epidemic, the distribution of times from case-report to death-report, and the distribution of times from case-report to recovery-report (i.e., report that the case is no longer at risk of dying of the infection). a simple approach is to limit analysis to those cases with sufficiently long follow-up for a death to have been recorded had a death occurred, but this approach may result in an exceedingly small sample size if applied early in the epidemic. several such strategies are described in table . here, and in table , we discuss the sources of three biases that threaten the validity of a causal interpretation of a difference in cfr between groups who have received different interventions. such a difference might be measured as a risk ratio (rr), the ratio of cfr in group a to that in group b, or as an odds ratio (or), the ratio of the odds of dying in group a and group b, or as table . potential biases that can affect the estimation of cfr (and thereby also the comparison of cfr across groups). direction outbreaks in which analysts have noted this bias may be operating preferential ascertainment of severe cases: in an infection with a range of manifestations from relatively mild to highly severe, milder cases are less likely to appear in surveillance databases than more severe ones; therefore, the cfr among ascertained cases will be higher than that among all cases. spuriously increases estimate of cfr influenza h n pdm [ ] [ ] [ ] , influenza h n [ ] , influenza h n [ ] (though this hypothesis has been refuted [ ] ), middle east respiratory syndrome [ ] , ebola (this article) [ ] note: these solutions are listed in approximately the temporal order in which they may be practical, from early in the outbreak to later on; details will depend on the epidemiology of the outbreak. use sentinel surveillance sites to estimate multipliers between various levels of severity and extrapolate to a larger population [ ] . survey-or health-facility-based surveillance for symptomatic infection [ ] in a defined population, combined with enhanced surveillance for severe outcomes (particularly death) in the same population. use travelers from high-burden areas with low ascertainment to low-burden areas with higher ascertainment to estimate incidence of infection in source population [ , ] , thereby providing a more accurate denominator for comparison to deaths in source population. surveillance pyramid approaches: reconstruct conditional probabilities of appearing at one severity level conditional on reaching a lower severity level; combine data sources that have relatively complete ascertainment of higher severity levels (e.g., hospitalization, icu, death) with those having relatively complete ascertainment of lower levels (e.g., seeking medical attention, hospitalization) [ , ] . cfr can then be estimated as a product of conditional probabilities with associated uncertainties [ ] . serologic ascertainment of infection [ , ] to provide a population denominator for infections regardless of symptoms, combined with active surveillance for more severe outcomes. individuals ascertained by a different mechanism, e.g., named healthy contacts of cases who subsequently test positive, could be a more representative group in whom to assess severity [ ] . bias due to delayed reporting. during an ongoing epidemic, at any week w the persons who have died up to time w will not be the only ones to die of the infection among those who became cases by w. the denominator of the cfr (cases) includes persons who have not yet died of the infection, but will do so in the future. thus the cfr by w will be less than the true cfr. this bias will be particularly severe for infections that are increasing rapidly in incidence and for which the infection-death time interval is long. spuriously decreases estimate of cfr sars [ ] , influenza h n pdm [ ] , ebola [ , ] limit analysis to those cases with sufficiently long follow-up for a death to have been recorded had a death occurred. while this may lead to extremely small sample sizes near the beginning of an epidemic, this strategy is more feasible after a local epidemic wave, including reporting delays, has passed or nearly passed [ , ] . limit analysis to those cases known either to have died or recovered, but exclude those with unknown outcome (biased if severity affects outcome ascertainment) [ ] [ ] [ ] . apply a competing-risk kaplan-meier-like method or a parametric mixture model to the full dataset (biased if the times to death and time to recovery have different distributions) [ , ] . fit the distribution of times to death and to recovery to estimate the true cfr [ , ] , or inverse-probability weight deaths using the conditional probability of having survived by w, given that one dies [ ] (biased if the probability distribution is incorrect). a risk difference (rd), the difference between the cfr in group a and group b. we use the term relative cfr to refer to any of these measures, and call a relative cfr non-null when it differs from (ratio) or (difference). when these biases are present, a relative cfr, different from the null value in group b compared with a does not imply a causal effect of group. for example, if group a is non-hospitalized patients and group b is hospitalized patients, an odds ratio of death less than may not imply a beneficial effect of hospitalization on the odds of death. similarly, a relative cfr greater than may not imply that hospitalization is harmful. we use the estimation of the causal impact of hospitalization on mortality as our example throughout this section. note that exactly the same reasoning applies to assessment of another intervention or to a comparison of two interventions, for example, a comparison of treatment at center a versus treatment at center b. the first bias arises in a naïve comparison of mortality between those who have and those who have not been hospitalized. if some individuals die before they can be admitted to a hospital, they will by definition not become hospitalized. therefore, even in the absence of any effect of hospitalization on the risk of death, there will be fewer deaths among those hospitalized than among those not hospitalized. we will refer to this bias as "survivorship bias." in an ongoing epidemic, there will typically be a delay between the reporting of a case and the reporting of the death of that case, if the infected person dies. thus, at any moment, there will be some cases reported who will die of the infection but who have not yet died, or whose deaths have not yet been reported. simple division of the number of deaths reported by week w (green), by the number of cases reported by week w (blue) will underestimate the cfr because the numerator does not include all those cases in the denominator who will eventually die. with a reporting delay of weeks for deaths compared to cases, the reported deaths curve will be shifted weeks to the right, relative to the curve of the total number of cases reported by week w who will die (red). if the epidemic doubling time is weeks, as shown here, the underestimate of cfr will be by a factor of about / . , with the exponent being the number of epidemic doubling times that pass between case reporting and death reporting. in reality, there will be a distribution of reporting delays rather than a fixed delay, making this a heuristic rather than exact approach. the problem is ameliorated in an epidemic that grows more slowly or less than exponentially. for more details, see references in table . this bias can be eliminated using data on the time d since the person became a case. the analysis would then compare the risk of death between those individuals who became table . potential biases that can affect the comparison of cfr across groups (relative cfr), using the example of comparing the cfr among hospitalized and non-hospitalized persons to assess the relative cfr for hospitalization. direction outbreaks in which analysts have noted this bias may be operating possible solutions/means of detecting the bias survivorship bias: those who die before being hospitalized cannot, by definition, be hospitalized; a crude comparison of deaths among hospitalized and non-hospitalized cases will therefore reflect the "protective" effect of death against hospitalization. this is an example of reverse causality because for these individuals, death prevented hospitalization, rather than hospitalization preventing death. spurious protective effect of hospitalization on risk of death ebola (this article) conditioning analysis on survival up to day d of symptoms, and analyzing hospitalization on day d as the intervention, will avoid this bias, as individuals who die before hospitalization will not be included in the analysis. this analysis can be repeated for different values of d and potentially combined in a parametric model. individuals identified before becoming cases (e.g., as healthy contacts of infected persons) and actively followed regardless of clinical severity could be analyzed separately as a prospective cohort for whom the course of disease could be observed and this restriction readily made. confounding: if individuals are hospitalized in response to predictors of poor prognosis, hospitalization will be noncausally associated with poor outcome. this problem is common in the pharmacoepidemiology literature [ ] . alternatively, in situations of triage, when beds or other resources are limited, individuals with better prognosis may receive hospitalization (or another intervention), creating a spurious beneficial effect of hospitalization. may be in either direction, depending on whether those receiving the intervention have better or worse prognosis. ebola (this article), h n pdm (effect of antiviral treatment on death) [ ] , influenza h n (effect of antiviral treatment on death) [ , , ] in principle, analysis can adjust for prognostic factors that also predict hospitalization via matching, stratification, or multivariable analysis. in practice, such information may be unavailable [ ] . such adjustments will be more readily made if data are obtained prospectively from a cohort of cases identified before becoming cases. selection bias occurring because mortality and hospitalization both affect the probability a case will appear in the database [ ] : when inclusion in a database can occur as a result of either of two (or more) factors, the association between these two factors within the database will be biased relative to that in the source population. for example, if death and hospital admission are both means by which cases are ascertained and enter a database, as may be the case for ebola datasets, hospitalization will be spuriously associated with death in the dataset even if hospitalization has no causal effect in preventing death. direction of bias depends on the probabilities of inclusion in the dataset depending on exposure and outcome. ebola (this article) without knowledge of how cases came to enter a dataset, the magnitude of this bias cannot be evaluated. under assumptions about the proportion of cases entering the dataset for various reasons, a sensitivity analysis could be performed to assess the plausibility of assigning any observed protective effect to this bias [ ] . this bias too may be avoided by prospectively following a cohort of individuals who are identified before becoming cases. the second source of bias is confounding. severity of disease will likely affect the probability of hospitalization and the probability of death. as a common cause of the exposure of interest (hospitalization) and the outcome (death), disease severity is a confounder of the causal effect of hospitalization on death. if hospitalization is offered to especially severe cases or-in the setting of extreme triage-to especially mild cases, then hospitalization would spuriously appear harmful (if hospitalization went to especially severe cases) or beneficial (if it went to especially mild cases). there may be other confounders of this effect besides disease severity. individuals living in rural areas may be at greater risk of mortality (e.g., due to malnutrition) and also less likely to be hospitalized (due to longer travel time to hospital). place of residence (or travel time to hospital) in this setting would be a confounder of the effect of hospitalization on death. the standard approach to reducing confounding is to stratify, restrict, or adjust for prognostic factors that affect the propensity to receive the treatment (in this case to be hospitalized) [ ] . however, such information may frequently be limited or unavailable in databases compiled during outbreaks, especially in resource-limited settings. the third source of bias is selection occurring because mortality and hospitalization both affect the probability a case will appear in the database. during an outbreak, many cases may not appear in the database because they are not ascertained or because information about them is not obtainable. in particular, cases who are not hospitalized, and cases who do not die, may be less likely than other cases to appear in the database because they are less likely to come to medical or public health attention. if appearance in a database is the common effect of hospitalization and death, then the association between hospitalization and death among cases in the database may be non-null even if hospitalization and death were independent in the population of all cases. the direction and magnitude of the association between hospitalization and death among cases in the database will then be the result of combining the association due to this selection bias, the association due to a potential effect of hospitalization on mortality, and the association due to confounding. hypothetical examples are shown in tables - . in these tables, the association in the population between hospitalization on day (an arbitrarily chosen day) and death is negative; individuals hospitalized on day (an arbitrarily chosen day) of symptoms have a lower probability of death than those who are not hospitalized on day of symptoms. if we assume that this analysis has avoided survivorship bias by limiting analysis to cases still alive on day , then the population-level association would reflect a combination of the causal effect of hospitalization on day on risk of death, and confounding by severity or other factors. this population-level association is the same in tables , , and , but different probabilities are assumed for inclusion in the database, depending on whether an individual is hospitalized on day , dies, or both. relative cfrs on the rr, or, and rd scales for hospitalization on day are calculated for each hypothetical example. the hypothetical data in these tables show that selection bias in such a circumstance may be either positive or negative on each of the three scales, depending on the specific probabilities of selection in each of the four states. table shows an example of negative bias on the rr, or, and rd scales (overestimating the protective effect of hospitalization on day expressed as a lower value of each relative risk measure). table shows an example of a positive bias on the rr and rd scales and a negative bias on the or scale. table shows an example of positive bias (underestimating the protective effect of hospitalization on day expressed as a higher value of each measure) on all three scales. from experience, it seems that when databases are assembled in this way, it is rarely possible to tell why an individual case has come into the database. in the absence of such information, it is difficult to imagine how adjustments could be performed. however, sensitivity analyses could be performed to assess how strong such biases are likely to be [ ] . we have stated already that survivorship bias can be avoided by limiting analyses of the intervention to those who remain alive on a certain day after becoming a case. one strategy that would help to resolve the other two sources of bias is to limit analysis to a cohort of cases who were identified before they became cases; for example those who were identified as healthy contacts of known cases, and were followed prospectively. confounding occurs because individual factors like severity of infection or place of residence (which could affect both the probability of exposure-receiving the intervention-and the probability of the outcome-mortality) are not accounted for in the analysis through stratification, restriction, or adjustment. selection bias in this setting occurs because the exposure and the outcome both affect the probability of inclusion in the database. follow-up of a cohort of contacts ascertained before becoming cases could eliminate hospitalization and mortality as predictors of inclusion in the database, thus eliminating the form of selection bias we have discussed. it would provide an opportunity for subscript p represents the population values, while subscript d represents the values measured for those cases included in the data base; selection bias produces the discrepancy. the extent of selection bias may be measured as or s ¼ s s s s , where s ij is the probability a case with exposure (hospitalization at day ) i and outcome (mortality) j appears in the database. in this example, selection bias spuriously enhances the negative association between hospitalization on day and death, on all scales: rr, or, and rd. gathering data on severity and other predictors of exposure and outcome, which would facilitate control of confounding, though not guarantee to eliminate it. such a cohort would also provide a natural setting for analyses that avoid survivorship bias. the cost of such improvements in inference would be the need to ascertain such contacts and maintain surveillance of those individuals, following them to obtain data on relevant covariates. such a strategy-which has been followed in cases of exposed health-care workers in settings with high resources and few cases-would likely have benefits for the individuals followed (e.g., increasing the probability they receive care if infected) and for reducing transmission (if such individuals were promptly isolated upon evidence of infection). however, it has not been possible so far in the large ebola outbreaks in west africa to do this routinely. it is often of interest to predict the probability of mortality for an individual case of an infectious disease based on that individual's demographic and clinical data, without placing any causal interpretation on the factors used to predict outcome. for example, in , there was much interest in whether morbid obesity (or obesity in general) was predictive of worse outcome in infection with the novel pandemic strain of influenza a/h n [ ] .the primary goal was to improve estimates of clinical prognosis, although observations about prognosis could later be used to generate causal hypotheses for further testing. similarly, observations of disparate rates of severe outcomes by geography within new york city did not initially involve causal judgments about why certain areas had worse outcomes, although they could be used to guide enhancement of services in areas with worse outcomes [ ] . even for a well-understood disease like polio, it may be necessary to identify unusual demographic patterns of mortality in order to understand and respond effectively to an outbreak [ ] . prognostic exercises such as these cannot suffer from confounding bias because no causal interpretation is attached to the conclusions. they can, however, suffer from selection bias. returning to the ebola context, one might wish to know whether pregnant women infected with ebola are at greater risk of death from ebola infection than other cases [ ] , for example, in order to give them greater supportive care. if the probability of entering the database depends on whether an ebola patient is pregnant and on whether she ultimately dies of the infection, then the probability of death given pregnancy will likely differ in the database from the value in the population of direct interest for a clinical or public health decision maker. if the goal of analysis is to inform public health decision makers on the value of efforts to prevent infection in pregnant women, then the population-wide cfr among pregnant women is the value of direct interest. if, on the other hand, the goal of analysis is to inform health care providers at a treatment center to make a better clinical decision based on an accurate prognosis of the patient presenting to them, the quantity of direct interest is the probability of death among pregnant women in the population they encounter-those admitted to the treatment center. table . effect of selection bias on estimates of relative cfr on the risk ratio (rr) odds ratio (or) and risk difference (rd) scales. joint frequencies of hospitalization and death in the whole population among those alive at day of symptoms this value, again, will differ from that in the database, which may (in our running example) have been enriched for individuals entered in the database because they died of the infection. it will also differ from that in the overall population. the general point is that selection bias can be operative if the population on which analysis is performed is not a representative sample of the population for which the value of the cfr is sought, and selection bias of this form can lead to spurious conclusions in prognostic estimates as well as in causal ones. as in the case of causal inference, prognostic estimates will avoid selection bias to the extent they can be performed on a randomly chosen cohort of cases, identified via tracing of healthy contacts, for example. to determine the appropriate scope and magnitude of public health response to an infectious disease outbreak, it is important to estimate the cfr and the determinants of its variation [ , ] . for example, in the influenza pandemic, early point estimates of the cfr ranged over orders of magnitude, from a value below that of seasonal influenza, which would have justified a modest response, to values around %, approximately half that of the pandemic, which would have indicated the need for massive interventions to protect public health [ , [ ] [ ] [ ] ] . to a large degree, this variation reflected judgments that one or the other of the biases in table was more important, judgments that were difficult to make accurately and confidently on the rapid timescale required for decision making [ ] . in other situations, accurate assessment of the cfr is not as crucial for decisions about the scale of response required; for example, in the ongoing ebola epidemic in west africa, the uncertainty about the cfr is limited to a range between high values and very high values, and it is not clear that any greater response would be indicated by a % cfr than a % cfr [ ] . either way, a rapid and massive response is warranted. even when the overall cfr is not a key input to decision making, there is obvious value to inferences about which conditions lead to a lower cfr, whether these be specific treatment, particular types of supportive care, or hospitalization in general. moreover, treatment facilities might be evaluated by the proportion of their patients who survive; here the relative cfr calculated would be for treatment in one facility versus treatment in another. there will be a temptation to conclude that treatment facilities with higher cfr are doing a worse job-that is, to apply a causal interpretation to observed differences in the cfr. even in settings with more resources to measure covariates, methods of risk-adjustment of comparative outcomes to account for the mix of patients seen are complex and controversial [ ] . in an emergency setting, with few covariates available to characterize the "case mix" of a health care provider, causal interpretation of differences in cfr would be particularly prone to error, potentially producing conclusions that mislead and thereby damage control efforts. for instance, if through confounding, larger referral treatment centers primarily receive patients who have survived infection for some time and are therefore less likely to die, independently of treatment, this may be erroneously interpreted as more effective treatment in these centers. similarly, if certain treatment centers preferentially admit the most symptomatic patients, they may falsely appear to be less effective or even harmful to patient outcome. with at least five separate sources of bias in cfr or relative cfr estimates, and only imperfect solutions typically available for most due to lack of data, separating causal from non-causal factors in relative cfr estimation seems extremely risky. this is not to deny that data should be gathered or analyzed; on the contrary, the biases here suggest that more thorough data gathering is necessary before analyses of such quantities as relative cfr are relied upon for any decision. there has been much debate, particularly in the area of ebola treatments, about whether randomized studies comparing a treatment to a placebo are ethical [ , ] . whatever one's view on this debate, it seems likely that some observational (non-randomized) studies of the effectiveness of particular therapies, or the comparative effectiveness of two or more therapeutic approaches will occur, whether for ethical reasons, logistical reasons, or both. such studies-in which a key endpoint will be mortality-will be vulnerable to the sorts of biases described in this article, particularly in cases in which the true effect size of the treatment is limited. the biases described here should be kept in mind when evaluating the conclusions of such studies, and wherever possible, studies should be designed to minimize them. small studies conducted using systematic approaches to enrollment and follow-up of patients may be more precise and less biased than studies with larger sample sizes that use databases collected for other reasons. similarly, there may be situations in which efforts are made to administer scarce therapeutic agents to those most likely to benefit from them. such efforts rely on estimates, formal or informal, of the prognosis of patients with and without the treatment, depending on variables such as the time since they became symptomatic. these estimates, too, may be affected by the biases discussed. in the current ebola outbreak in west africa, such data gathering has not routinely occurred, for a number of reasons, including lack of health system infrastructure [ ] and prioritization of crisis response and other directly lifesaving activities. in future outbreaks of other diseases, as in the past with pandemic influenza, setting up systematic approaches to gather data useful for such assessments should be a priority [ , ] . meanwhile, emphasis on recording for each patient in a database the time, place, and circumstances (e.g., hospital, clinic, funeral, contact tracing) under which the information is being gathered can substantially improve our ability to account for biases induced by a database with unplanned entry criteria. to reduce the impact of the biases identified on causal and (where applicable) prognostic inference, it appears desirable when possible to limit analysis to a subset of cases who have been followed prospectively since they became cases. these individuals might most likely be identified by forward contact tracing, in which cases are asked to name healthy individuals with whom they have had contact, and those individuals are followed to identify further infections. it has previously been noted that cases identified by contact tracing are more representative of cases in the general infected population than those identified because of symptoms, medical need, or death [ , ] . use of such a sample does not guarantee to eliminate biases, as there may be residual confounding not adequately controlled in the analysis or subtler forms of selection bias (e.g., differential loss to follow up within the sample) [ ] , but should significantly reduce them. we have emphasized the relevance of several biases to interpretation of datasets gathered in an emergency, such as the early phases of an emerging infection. while the downward bias in estimation of the cfr due to delayed reporting of deaths is most acute in rapidly growing epidemics, the other biases described may apply regardless of the overall trajectory of an epidemic, and thus may apply to endemic diseases as well as emerging ones. nonetheless, due to the sense of urgency to gather data and scale-up a response simultaneously, datasets assembled during infectious disease outbreak or emergency settings are especially prone to include unplanned mixes of cases who enter the dataset for various reasons. biases of the sorts described here should be systematically considered whenever one attempts to extract causal inferences from such observational data, and alternative, more systematic data collection should be considered when possible. • datasets available at the onset of new epidemics of infectious diseases are often collected for reasons other than epidemiologic analysis of absolute and comparative casefatality risks (cfr), and estimates of such quantities based on these data may be subject to biases, the relative magnitudes of which are difficult to ascertain and vary by situation. • major sources of bias affecting the estimation of absolute cfr are differences in severity between all cases and the subset of cases who enter the dataset, typically leading to inflated estimates of cfr, and more rapid reporting (less delay) in reporting cases than in reporting the deaths of those cases, typically leading to underestimates of cfr. • biases affecting the causal interpretation of relative cfr (causal attribution of different cfr in different groups to a particular intervention in one group, e.g., hospitalization) may arise from survivorship bias, in which individuals who survive longer may be more likely to receive the intervention; from confounding, in which a common factor (e.g., disease severity) affects the probability of both the intervention and mortality; and from selection bias, in which individuals are more or less likely to enter the dataset as a function of whether they receive the intervention and whether they have the outcome. • these biases may be severe enough to lead to qualitatively mistaken inferences about the severity of the infection or about the impact of interventions (such as hospitalization) on mortality, and may be particularly misleading when comparing, for example, the effect of hospitalization at different centers, given that cases hospitalized at different centers may enter the dataset for different reasons. • methods exist to identify and reduce these biases. in particular, the use of small but carefully defined cohorts of individuals who are followed from the time of infection or symptom onset (perhaps those identified via contact tracing) may ameliorate many of these biases. epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong basic methods for sensitivity analysis of biases assessing the severity of the novel influenza a/h n pandemic a structural approach to selection bias h n surveillance group. improving the evidence base for decision making during a pandemic: the example of influenza a/h n studies needed to address public health challenges of the h n influenza pandemic: insights from modeling interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the united states-early targeted layered use of nonpharmaceutical interventions. department of health and human services randomised controlled trials for ebola: practical and ethical issues middle east respiratory syndrome coronavirus: quantification of the extent of the epidemic, surveillance biases, and transmissibility improving the evidence base for decision making during a pandemic: the example of influenza a/h n human infection with avian influenza a h n virus: an assessment of clinical severity seroevidence for h n influenza infections in humans: metaanalysis comment on "seroevidence for h n influenza infections in humans: meta-analysis epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong the severity of pandemic h n influenza in the united states changes in severity of pandemic a/h n influenza in england: a bayesian evidence synthesis pandemic influenza a(h n )v in new zealand: the experience from under-reporting and case fatality estimates for emerging epidemics notes from the field: outbreak of pandemic influenza a (h n ) virus at a large public university in delaware pandemic potential of a strain of influenza a (h n ): early findings use of cumulative incidence of novel influenza a/h n in foreign travelers to estimate lower bounds on cumulative incidence in mexico optimizing the precision of case fatality ratio estimates under the surveillance pyramid approach estimating infection attack rates and severity in real time during an influenza pandemic: analysis of serial cross-sectional serologic surveillance data the infection attack rate and severity of pandemic h n influenza in hong kong transmission scenarios for middle east respiratory syndrome coronavirus (mers-cov) and how to tell them apart assessing the severity of the novel influenza a/h n pandemic ebola virus disease in west africa-the first months of the epidemic and forward projections case fatality rate for ebola virus disease in west africa methods for estimating the case fatality ratio for a novel, emerging infectious disease non-parametric estimation of the case fatality ratio with competing risks data: an application to severe acute respiratory syndrome (sars) managing and reducing uncertainty in an emerging influenza pandemic assessment and control for confounding by indication in observational studies effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza a h n pdm virus infection: a meta-analysis of individual participant data effectiveness of antiviral treatment in human influenza a(h n ) infections: analysis of a global patient registry strengthening observational evidence for antiviral effectiveness in influenza a (h n ) determinants of antiviral effectiveness in influenza virus a subtype h n a structural approach to selection bias basic methods for sensitivity analysis of biases risk factors for severe outcomes following influenza a (h n ) infection: a global pooled analysis pandemic (h n ) surveillance for severe illness and response investigation of elevated case-fatality rate in poliomyelitis outbreak in pointe noire ebola hemorrhagic fever and pregnancy use of risk adjustment in setting budgets and measuring performance in primary care ii: advantages, disadvantages, and practicalities evaluating novel therapies during the ebola epidemic ebola: the teaching and learning moment household transmission of pandemic influenza a (h n ) virus in the united states we thank lina nerlander for helpful suggestions on an earlier draft. key: cord- -uwzmvlr authors: tuge deressa, chernet; file duressa, gemechis title: modeling and optimal control analysis of transmission dynamics of covid- : the case of ethiopia date: - - journal: nan doi: . /j.aej. . . sha: doc_id: cord_uid: uwzmvlr a mathematical model to estimate transmission dynamics of covid- is developed. a real data of confirmed cases for ethiopia is used for parameter estimation via model fitting. results showed that, the diseases free and endemic equilibrium points are found to be locally and globally asymptotically stable for ro< and ro> respectively. the basic reproduction number is ro= . . optimal control analysis also showed that, combination of optimal preventive strategies such as public health education, personal protective measures and treatment of hospitalized cases are effective to significantly decrease the number of covid- cases in different compartments of the model. it is reported that [ ] up to the present, the world has witnessed the happening of seven strains of human coronaviruses including sars-cov,mers-cov and the current coronavirus -ncov named covid- . covid- was declared a pandemic by the world health organization(who) on march, [ ] . as of july th , covid- pandemic has claimed several hundreds of deaths globally and become the greatest threat of its kind in our generation [ ] . it also posed a huge risk to public health and economics all over the world [ , ] . the ethiopian federal ministry of health confirmed its first case of covid- on march, , in addis ababa [ ] . despite the fact that the number of confirmed cases and deaths reported varies from time to time, the outbreak has taken the lives of several hundreds and affected different livelihoods in ethiopia. since the first case of covid , various mathematicians around the world develop different mathematical models to understand the transmission dynamics of the virus, estimated the basic reproductive number and investigated effects of different intervention strategies via optimal control analysis. for instance, in [ ] real data of confirmed cases of covid- in wuhan, china from january , to january , is used in a model developed to estimate the basic reproductive number the authors developed a . . r  fractional model and solved it numerically. a mathematical model for predicting transmission dynamics of the pandemic for italy is considered in [ ] .the result indicated that the combination of restrictive social distancing measures with widespread testing and contact tracing can result in ending the covid- transmission in italy. analysis of covid- infection, based on real data is made in [ ] by developing a mathematical model for wuhan, china. in [ ] fractional order covid- sidarthe model is developed to predict the evolution of the pandemic and investigated the impact of different plans to reduce the transmission of the disease with different values of fractional order. there are also many other mathematical models that reported on covid- pandemics, refer [ ] [ ] [ ] [ ] . mathematical models developed were mainly used to investigate the effects of different non-pharmaceutical intervention strategies via simulation using different computing soft-wares [ ] . different scholars used different type of mathematical models in their analysis. for instance, an seir model was introduced by wu et al. [ ] for estimating the spread of the pandemic and obtained the basic reproductive number to . tang et al. [ ] used a deterministic . r  model to estimate the basic reproductive number to be as high as and concluded . r  that, contact tracing followed by quarantining and then isolation can mitigate the spread of the pandemic via reducing the basic reproductive number. kiesha et al. [ ] used seir model to simulate the outbreak of coronavirus in wuhan and indicated that imposing restriction on wuhan people movement could help in delaying the peak time of the pandemic. roda et al. [ ] claimed that sir model performs better than seir model and used it to predict covid- epidemic in wuhan and predicted the potential of a second outbreak after the return-towork in the city. pang et al. used seihr mathematical model to investigate the effectiveness of quarantine measures applied in wuhan city and factors affecting its effectiveness [ ] . it is not only for covid- that models were used to study the dynamics but also for several other infectious diseases. in [ ] a mathematical model for the deadly disease named ebola hemorrhage fever is developed and investigated the detail of endemic equilibrium points. sir model with delay in the context of fractional derivative with mittag-leffler is considered in [ ] . the author established the global and local stability of disease free and endemic equilibrium points using lyapunov direct method. mathematical models that investigated the dynamics of various infectious diseases are numerous in the literature [ , ] and the references there in. most of these studies have either restricted their domain of study to a particular country or they used data from a certain particular region. some of the studies also overlooked the issue of optimal control analysis. moreover, to the best of authors' knowledge, no study has been conducted on transmission dynamics of covid- for the case of ethiopia. to this end, the main objective of this work is to develop a mathematical model for the transmission dynamics of covid- followed by mathematical analysis in order to come up with evidences that may help for designing mitigation strategies relevant to the context of ethiopian. in this paper a mathematical model for covid- relevant to study the transmission dynamics of coronavirus in ethiopia is developed. the existence and uniqueness of solution of the model is proved. local and global stability analysis of the diseases free and endemic equilibrium points are established. parameter estimation based on real data of confirmed cases is made. the basic reproductive number suggested by the model is calculated. the importance of the basic reproductive number in target setting to control the pandemic is discussed by calculating sensitivity indices of the parameters of the basic reproductive number. optimal control analysis of the model with three control strategies namely: public health education, personal protective measures and treatment of hospitalized covid- cases were investigated followed by numerical simulation. discussions, conclusions and limitation of the model are well specified. in this work, a mathematical model for covid- transmission dynamics is developed based on compartmental approach of six groups named, s-susceptible, e-exposed, isymptomatically infected, a-asymptomatically infected, h-hospitalized and r-recovered/ immune compartments. the total population at any time is given by humans are recruited into the compartment  considered in the model. the above mentioned is the scenario that governmet of ethiopia is using in combating the deadly covid- pandemic, in the sense that the data of confirmed cases of covid- in ethiopia is organized incorporating all the compartments we have used in developing the model of this study. it is these data that we translated into a mathematical model. it seems logical to divide infected cases of covid- into symptomatic and asymptomatic cases, in agreement with the observed property of coronavirus infection (majority are asymptomatic and the remaining symptomatic) in ethiopia and elsewhere in the world. moreover, the isolation/hospitalization is considered to be effective in reducing the transmission of covid- [ ] . in addition, it is known that coronavirus infected people don't get infectious immediately after contraction of the virus and this ensures the importance of considering the compartment of exposed cases. as a result, the aforementioned scenario and modification of seir [ , ] model are used to develop the present model. the model developed and the parameters used are indicated in system of differential equation ( ) and table . . the biological validity of the mathematical model depends on the solution of the dynamic system being positive and bounded for all values of time . the boundedness and positivity of the solution is proved in the subsequent lemmas. remain positive in + . proof: it is assumed that all the parameters used in the model are positive and hence we can set a lower bound for each of the equations in ( ) as follows: . solving the above inequalities respectively leads to: . thus, for all and are positive in , of ( ) there applying groonwall's inequality leads to, ( ) and are all bounded since, , thus, the region ( , , , , , ) is positively invariant region for model ( ) . then either the solution of ( ) enters in a finite time or asymptotically. hence the region attracts all solution of ( ) in  since has a continuous first derivative in ,it is then locally lipschitz. as a result, by the f ℝ + well known fundamental existence and uniqueness theorem [ ] and lemma and proved above, there exists a unique, positive and bounded solution for the system of differential equation ( ) in ℝ + . and that satisfies the quadratic equation where, the basic reproductive number, denoted by , is defined as number of secondary infections r appears from one infected individual. it provides a threshold condition for the stability of the system. finding through jacobian approach using linearization of the dynamic system r often doesn't work for complex systems [ ] . thus, we obtained by establishing the next r generation matrix, , and calculating a spectral radius of the matrix at [ ] . the matrices and are obtained by linearizing the mathematical model ( ) about dfe that t v  resulted in the jacobian matrix given as: after constructing a matrix (m) from infectious components of the and partitioning it into dfe j transmission (v) and transition (t) matrices, we have: the spectral radius of the next generation matrix is the basic reproductive number note that, can also be written as where this section deals with the local stability analysis of the diseases free and the endemic equilibrium points. necessary condition: since both and , then from the and are positive r r , for the two negative eigenvalues of the jacobian matrix are . the sign of the real part of the remaining four eigenvalues are determined from a characteristic equation ( ) by routh-hurwitz stability criteria: necessary condition: the coefficient is positive and can be shown to be positive as follows, in this subsection we showed global asymptotical stability of the dfe and eep using lyapunov function method. i. global stability analysis of dfe the locally asymptotically stability of the dfe proved earlier indicates that covid- can be eliminated from ethiopia when if the initial sizes of the cases in each of the r  compartments or in the society is very close to the dfe; initial size is in the basin of attraction of dfe, . in order to show that the stable in the positively invariant region defined in section .  consider a lyapunov function candidate defined by, ( , , , , , ) differentiating with respect to time in the direction of the solution of ( , , , , , , ) ( ), and then substituting the appropriate values from ( ) and leads to, note that, by the inequality of arithmetic and geometric means we have   differentiating in the direction of the solution of ( ) leads to, l replacing by their respective expression from model ( ) we get, , , , , , we can now write since all the parameters used in model ( ) eep is globally asymptotically stable. note the implication of theorem is that, covid- will institute itself in the society whenever regardless of the initial size of infectious individuals in the population. parameter estimation is made based on real data of covid- confirmed cases of ethiopia for the first days from march to july available online at [ ] https://en.wikipedia.org/wiki/covid- _pandemic_in_ethiopia. some of the parameters are calculated from the data as follows: the total population of ethiopia is approximately and the life expectancy of ethiopians [ ] one symptomatic case was confirmed, no individual was confirmed asymptomatic, no hospitalized and no recovery cases. consequently, assuming initial number of exposed cases to be , the initial number of population is assumed where it is also learnt from the data that, in the last days of the pandemic hospitalized or isolated cases were recovered from the diseases. hence, the recovery rate of hospitalized  cases is calculated as, = / = . /day.  some of remaining parameters are estimated from the mathematical model ( ) via model fit using a computing soft-ware matlab a by optimal estimation of parameters; least square curve fit along with trust-region-reflective to find bounded estimated parameters. the result of model fit versus confirmed cases of covid- is portrayed in figure . thus, values of the parameters used in this work are obtained from assumption, calculation, model fitting and from the literature and are indicated in table . all negative and hence the endemic equilibrium point is locally asymptotically stable, and is in agreement with the analytical proof made in subsection . . in order to determine the best control measures using the basic reproductive number, the normalized sensitivity index, which measures the the relative change of with respect to r  denoted by ,and defined as is useful [ , ] . the magnitude of sensitivity analysis of the reproductive number ( ) shows that the most sensitive parameters in descending order are and so on. increasing the , , , , , ,... it then follows that, if the transmission from asymptomatic cases to suspected cases is reduced by a fraction of at least ( i.e. ), then the transmission of covid- . now, the objective is to find an optimal control for the preventive strategies/measures for the relatively reduced coasts of the prevention strategies. the necessary , and u u u and sufficient conditions for the existence of optimal control are established by pontryagin maximum principle [ ] . the function that minimizes the number of exposed cases , number of symptomatically infected cases , number of asymptomatically infected cases and number of hospitalized cases over a time interval of can be defined as, where the control set is given by constraint given by system of differential equation ( ). the necessary conditions that need to be satisfied by optimal control called pontryagin's maximum principle converts equation ( ) and ( ) . differentiating the hamiltonian function with respect to the compartment variables gives the adjoint variables corresponding to the system given as follows: and are the adjoint variables , , , , , ( , , , , , ) , . now, setting the transversality condition: we obtain the optimal controls and the optimality conditions respectively as: note that, state equation ( ), the adjoint equation ( ) together with the characterization of the optimal control ( ) and the transversality condition ( ) are said to be optimality system. the sections and subsection treated above describe analytical behaviors of the optimal control. the corresponding numerical simulation of the optimal control is treated in the next section. in this section numerical solution for the optimality system is presented. the initial conditions used in the simulation are as can be seen from figure above, the peak for the spread of the virus is observed around th day of the pandemic. the result indicated that there are about exposed, asymptotic, symptomatic and hospitalized cases at the peak. case ii: in this case, all the three intervention strategies namely: educating the public , using of personal protective measures , and treating the hospitalized case iii: this case considered the combination of optimal personal protective measure and optimal treatment of hospitalized cases with no any public health education intervention . the simulation result of the effect of these two intervention ( ( ) , ( ) , ( ) ) u t u t u t    strategies is almost identically the same as in figure . in mitigating the transmission of covid- i.e. case ii. but as to case iii, the full intensity of using personal protective measures has to be prolonged to the first days before it slowly gets down to the lower bound at the end of the pandemic. note that, it has been checked that cases where and as can be seen from figure , using the intervention strategy 'treating hospitalized covid- cases' alone with the maximum effort couldn't reduce the number of exposed, symptomatic and asymptomatic cases as the number of cases in figure is the same as number of cases in figure for the compartments . applying this control strategy , and e i a alone reduced the number of hospitalized cases from ( figure ) to ( figure ) at the peak. further, the control profile of this case is the same as case ii for of figure ( ) u t case v: in this case, optimal practice of public health education is considered without the intervention of personal protective measures and treatment of hospitalized cases . the simulation result for the effect of optimally practicing this intervention strategy is presented in figure for the optimal profile of and in ( ) u t as can be seen from figure , the control profile that the optimal time range for public education is ranging from th - th only for days. further, figure reveals that the peak of the pandemic for this case is around th day but it is around th day in figure . one can also anlyze from figures and that using optimal public education alone could have reduced the duration of the pandemic, the peak period and number of cases in each of the compartments. case vi: this case considered the optimal practice of personal protective measure without intervention of the other two control strategies: public health education and treatment of hospitalized cases . the simulation result of the control profile is depicted in figure where as its effect on the number of cases in the compartments identically the same as in case ii. it can be observed from figure above, the usage of personal protective measures is optimal for the first days of the duration of the pandemic. comparing cases ii and vi, one can learn that both cases lead to the required result of mitigating the transmission of the pandemic independently. however, in case vi the practices of personal protective measures need to be applied optimally for the first days as compared to days for case ii. despite the effort made by the gvernment to teach the public and many ethiopians effort to maintain personal protective measures and treatments of hospitalized cases being underway, the transmission of covid- is increasing from time to time (see figure ) . consequently, it seems reasonable to make numerical investigation of nonoptimal intensity of practicing personal protective stratgies to appreciate their effect in decreasing the number of cases in the compartments of model ( ) . accordingly, we assumed and simulted the ( ) ( ) u t u t   model for different percentage values of pesonal protective measure ( ) %, %, % u t  and the result is shown in figure below. figure it can be inferred that, if at least % from each of the symptomatic, asymptomatic and hospitalized cases maintained practicing personal protective measures at an optimal level from the onset of the pandemic, then the number of cases in the compartments would have reduced (black) as compared to the graph with no personal , , and e i a h protective (red) measures . the figure further reveals that a pretty improved result ( ( ) ) u t  would have been obtained for in the different compartments. % and % u  in this study, a mathematical model for transmission dynamics of covid- for the case of ethiopia is developed and its different properties including local stability analysis of the diseases free and endemic equilibrium points have been checked. some of the parameter estimates were taken from spencer et al., [ ] and the remaining parameters were computed via model fitting based on real daily data of covid- confirmed cases of ethiopia from march to july, . it is then calculated that the basic reproductive is . . r  an optimal analysis of the model for the purpose of assessing the effect of public health education, effect of personal protective measures and effect of treating hospitalized or isolated cases in mitigating transmission of covid- was conducted. the result showed that the optimal practice of combination of all the three intervention strategies significantly reduces the number of exposed, symptomatic, asymptomatic and hospitalized cases (see figures and ) . likewise, optimal usage of personal protective measures alone led to the required decreases in the number of cases in the compartments except that the optimal application of the control measure needs to be maintained relatively for a longer period of time (see figure ). it is also found that combining control strategies personal protective measures and treatment of hospitalized cases (case iii) is as good as combining the three strategies (case i) in combating the deadly covid- pandemic in ethiopia. in this work, the parameters that need to be targeted for suppression of covid- pandemic by decreasing the basic reproductive number, are identified. for instance, it is shown that if the target is to decreasing the rate of transmission from asymptotically infected to suspected individuals then reducing this parameter to at least can suppress coronavirus from , ,  .   ethiopia. the same type of work can be conducted in different countries by adapting to their situation. moreover, optimal combination of the three intervention strategies proposed in this work or optimal combination of any two of the strategies or optimal practice of personal protective measures alone reduced the number of covid- cases in the compartments as shown in the simulation results. hence, the result of this study can be used as a policy input for the government of ethiopia and other countries. the government of ethiopia has to take necessary measures to make personal protective measures a mandatory practice throughout the period of the pandemic. personal protective measures such as wearing facemask, regular hand washing and social distancing if practiced with optimum effort, can significantly decrease the disturbing effect of covid- and safeguarded the nation. the government can also target its control strategy on reducing the basic reproductive number, taking into account the sensitivity analysis results of this work while considering the limitations of this work given below. it is ethical to make clear that mathematical models are in general approximations of real phenomena and as such they are naturally inaccurate. moreover, the parameters used in any mathematical models are determined based on observations and experimentations using different numerical methods of computing software and hence are uncertain. therefore, readers should take into account the limitation of the models while interpreting the findings. the dynamics of covid- with quarantined and isolation, advances in difference equations situation report - , data as reported by a mathematical model for simulating the phase-based transmissibility of a novel coronavirus pneumonia of unknown aetiology in wuhan, china: potential for international spread via commercial air travel nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modeling study world health organization, ethiopia, first case of covid- confirmed in ethiopia modeling the dynamics of novel coronavirus ( -ncov) with fractional derivative modelling the covid- epidemic and implementation of population-wide interventions in italy a conceptual model for the coronavirus disease (covid- ) outbreak in wuhan. china with individual reaction and governmental action novel fractional order sidarthe mathematical model of the covid- pandemic impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand estimation of the transmission risk of the -ncov and its implication for public health interventions a mathematical model for the novel coronavirus epidemic in wuhan, china mathematical modeling and epidemic prediction of covid- and its significance to epidemic prevention and control measures the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study. the lancet public health nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study. the lancet estimation of the transmission risk of the -ncov and its implication for public health interventions the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study. the lancet public health why is it difficult to accurately predict the covid- epidemic transmission dynamics and control strategies of covid- in wuhan on the mathematical analysis of ebola hemorrhagic fever: deathly infection disease in west african countries. biomed research international sir epidemic model with mittag-leffler fractional derivative reproduction numbers of infectious disease models. infectious disease modelling modelling the spread of covid- with new fractal-fractional operators: can the lockdown save mankind before vaccination differential equations and dynamical systems a nonlinear epidemiological model considering asymptotic and quarantine classes for sars cov- virus on the definition and the computation of the basic reproduction ratio r in models for infectious diseases in heterogeneous populations wikipedia, the free encyclopedia epidemiological parameter review and comparative dynamics of influenza, respiratory syncytial virus, rhinovirus, human coronavirus, and adenovirus the reproductive number of covid- is higher compared to sars coronavirus high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus extending the type reproduction number to infectious disease control targeting contacts between types uncertainty and sensitivity analysis of the basic reproductive rate: tuberculosis as an example an introduction to mathematical epidemiology we, the authors of the manuscript, thank jimma university college of natural sciences for all the supports. key: cord- - yumc em authors: gnavi, roberto; demaria, moreno; picariello, roberta; dalmasso, marco; ricceri, fulvio; costa, giuseppe title: therapy with agents acting on the renin-angiotensin system and risk of severe acute respiratory syndrome coronavirus infection date: - - journal: clin infect dis doi: . /cid/ciaa sha: doc_id: cord_uid: yumc em exposure to agents acting on the renin-angiotensin system was not associated with a risk increase of covid- infection in italian matched case-control studies, nested in hypertensive patients and the other in patients with cardiovascular diseases or diabetes. angiotensin-converting enzyme (ace ) is a functional receptor for severe acute respiratory syndrome coronavirus (sars-cov- ) that facilitates the entry of the virus into the cells [ ] . as agents inhibiting the renin-angiotensin-aldosterone system (raas) could increase the levels of ace , recent studies have raised concern over the association between these agents and both sars-cov- infection and illness severity [ ] [ ] [ ] [ ] [ ] . consequently, patients treated with ace inhibitors (aceis) or angiotensin ii receptor blockers (arbs), in particular those with diabetes or cardiovascular disease, should be considered at higher risk of developing severe coronavirus disease (covid- ) infection (cvi), and of experiencing unfavorable outcomes [ , ] . therefore, it has been suggested that these patients should be carefully monitored or even have their therapy substituted with calcium channel blockers [ , ] . however, the hypothesis of a link between agents inhibiting the raas and cvi is still under debate [ , ] , and whether patients should switch to other antihypertensive therapies is controversial. research to clarify the role of raas blockade therapies and cvi is highly needed [ , ] . in the first half of february , the first cases of covid- infection were recorded in italy [ ] , that, at present, is one of the leading countries in the world for both the number of diagnosed cases and for case fatality. diabetes, hypertension, and cardiovascular diseases, conditions that are frequently treated with aceis or arbs, are among the most prevalent comorbidities in these patients [ , ] . as, to the best of our knowledge, a relationship between acei or arb treatments and increased risk of cvi has never been demonstrated [ ] , the aim of the present study was to determine whether an association exists between therapies based on agents acting on the raas and cvi in populations at greater risk of being diagnosed with sars-cov- infection: hypertensive patients and patients who were affected by a cardio-cerebrovascular disease. we conducted population-based case-control studies nested in cohorts built using administrative data from the piedmont region ( inhabitants in northwest italy, with a high rate of cvi). the population is covered by an automated system of databases, which record, among others, all drugs dispensed from all regional pharmacies, all hospital discharges, and a regional register of persons with diabetes. from the beginning of the cvi epidemics a surveillance system was implemented to collect all cases identified by reverse-transcription polymerase chain reaction testing for sars-cov- . these archives can be linked together by a unique anonymous identifier that is encrypted to protect the patient's privacy. from the regional surveillance system, we obtained a random sample of confirmed cases of cvi occurring in the first month of the epidemic from february (beginning of the epidemic) to march , who were linked to the populations, to include only cases within cdd or hy. from the same population sources, we randomly selected controls for each case, matched for year of birth and sex. cvi cases were ineligible for resampling as controls. exposure to aceis or arbs the regional drug database was used to identify cases and controls who had been prescribed aceis or arbs at any time from june to october (last available month), considering atc codes c a or c b for aceis, and c c or c d for arbs. the risks of cvi associated with drug dispensation of aceis or arbs, considered both separately and together (to take into account possible switch from one medication to the other), were estimated by fitting conditional logistic regression models, expressed as odds ratios (ors) and corresponding % confidence intervals (cis). to take into account the dose of medication prescribed (ie, to explore for a dose-response relationship), the number of boxes prescribed was grouped into classes ( , - , - , and > ). all calculations were made using sas version . software (sas institute, cary, north carolina). out of hy and cdd subjects, we identified and cases, respectively, of cvi, who were matched with and controls. in the hy population, . % were male and the mean age was . years, whereas the mean age of the cdd population was . years and . % were male. among the hy population, . % of cases and . % of controls had at least prescription of agents acting on the raas, while among the cdd population, . % of cases and . % of controls received at least prescription. in both populations, there were no differences between cases and controls by size of the municipality of residence (supplementary table) . in neither of the populations was the prescription associated with the risk of sars-cov- infection. in the hy population, ors for aceis, arbs, and the combination of the were, respectively, . ( % ci, . - . ), . ( % ci, . - . ), and . ( % ci, . - . ). in the cdd population, ors for aceis, arbs, and the combination of the were, respectively, . ( % ci, . - . ), . ( % ci, . - . ), and . ( % ci, . - . ). there was no association with the level of exposition, thus excluding a dose-response relationship ( table ) . as a sensitivity analysis, we considered that some controls could be unknown cases of cvi and thus a differential misclassification could have occurred. we repeated our analysis for the hy population exposed to aceis or arbs (or, . ) considering both % and % misclassification of controls. ors showed a slight change only, to . and . , respectively. the question whether therapy with agents acting on the raas increases the susceptibility to cvi has raised concern among practitioners and citizens alike [ , ] , with conflicting opinions [ ] but no sound evidence [ ] . the key message of our analysis is that no association, regardless of causality, could be determined. our study has several strengths. we used a nested casecontrol design enrolling both cases and controls within unselected populations of subjects at increased risk of developing cvi. the consistency of ors in these independent populations can be viewed as a confirmation of our results. the study was conducted using data retrieved from the regional surveillance system of confirmed cvi cases. all agents acting on the raas were included, and, as they are dispensed and reimbursed only by prescription, we are confident to have included all dispensations. moreover, the potential confounding due to differences in access to diagnosis is probably low, given no differences in the size of municipality. our study also has potential limitations. given the high prevalence of undiagnosed or unknown cases of cvi in the general population, differential misclassification of controls is likely to have occurred. however, even assuming % of misclassification, the ors changed slightly, confirming the absence of association. second, the use of a database of dispensed drugs rather than usage data might have overestimated the use aceis and arbs; in addition, not considering the last months closer to the onset of the disease could have slightly affected the prevalence of drug users; however, it is unlikely that these would have affected cases and controls differently. finally, given the small sample size, an association between agents acting on the raas and cvi cannot be ruled out. despite the above limitations, at the time of this writing, our study is the first contribution to explore the question whether agents acting on raas increase the risk of being infected by sars-cov- , and the first available evidence of safety of this class of drugs. we are aware that further epidemiological research is desirable, ideally considering larger cohort studies to confirm our first findings. however, as studies gathering a large population of confirmed cases require time and may be demanding, smaller but more timely studies can contribute to give answers to urgent public health questions. furthermore, as our study was limited to explore whether raas therapy increases the risk of sars-cov- infection, the question whether raas therapy worsens the outcomes of cvi patients remains to be clarified. in conclusion, on the basis of our study, as also mentioned by the major cardiology societies [ , ] , there is no reason to modify current antihypertensive therapy. supplementary materials are available at clinical infectious diseases online. consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author. . abbreviations: acei, angiotensin-converting enzyme inhibitor; arb, angiotensin ii receptor blocker; cdd, circulatory disease/diabetes; ci, confidence interval; or, odds ratio. sars-cov- cell entry depends on ace and tmprss and is blocked by a clinically proven protease inhibitor covid- and the cardiovascular system are patients with hypertension and diabetes mellitus at increased risk for covid- infection? can angiotensin receptor-blocking drugs perhaps be harmful in the covid- pandemic? covid- and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. what is the evidence? renin-angiotensin-aldosterone system inhibitors in patients with covid- rapid response: re: preventing a covid- pandemic: ace inhibitors as a potential risk factor for fatal covid- at present there is no evidence to abandon reninangiotensin system blockers is there an association between covid- mortality and the renin-angiotensin-system-a call for epidemiologic investigation case-fatality rate and characteristics of patients dying in relation to covid- in italy prevalence of comorbidities and its effects in patients infected with sars-cov- : a systematic review and meta-analysis baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region position statement of the esc council on hypertension on ace-inhibitors and angiotensin receptor blockers hfsa/acc/aha statement addresses concerns acknowledgments. the authors thank the consorzio per il sistema informativo del piemonte for its essential contribution in prompt data gathering and data management, and dr chiara pasqualini of the regional unit for infective diseases, azienda sanitaria locale alessandria, for her valuable contribution in collecting and accessing data of the regional surveillance system.potential conflicts of interest. key: cord- -n wfe of authors: peng, shu; huang, liu; zhao, bo; zhou, shuchang; braithwaite, irene; zhang, ni; fu, xiangning title: clinical course of coronavirus disease in patients after thoracic surgery and challenges in diagnosis date: - - journal: j thorac cardiovasc surg doi: . /j.jtcvs. . . sha: doc_id: cord_uid: n wfe of objectives: to illustrate the clinical course and difficulties in early diagnosis of coronavirus disease (covid- ) in patients after thoracic surgery. methods: we retrospectively analyzed the clinical course of the first patients diagnosed with covid- after thoracic surgery in early january . postoperative clinical, laboratory, and radiologic records and the time line of clinical course were summarized. potential prognostic factors were evaluated. results: in the confirmed cases ( female, male), median days from symptom onset to case detection was . insidious symptom onset and misinterpreted postoperative changes on chest computed tomography (ct) resulted in delay in diagnosis. there were fatalities due to respiratory failure, whereas severe and mild cases recovered and were discharged. all patients had once experienced leukocytosis and eosinopenia. remittent fever and resected lung segments ≥ were associated with fatality. conclusions: the case fatality rate of postsurgical patients subsequently diagnosed with covid- was . %. insidious symptom onset, postoperative leukocytosis with lymphopenia, and postsurgical ct changes overshadowed the early signs of viral pneumonia. dynamic symptom monitoring, serial chest cts, and tests for viral rna and serum antibody improve the chance for prompt detection of covid- . consideration should be given to preadmission and preoperative screening and strict contact isolation during the postoperative period. the early signs of covid- were disguised in postoperative thoracic patients, resulting in a . % fatality rate. the pandemic of coronavirus disease (covid- ) caused the cancelation of elective surgeries and clinics in many regions in china. however, emergency surgeries continue to be performed, and urgent surgeries in cancer treatment cannot be postponed indefinitely. since severe acute respiratory syndrome coronavirus (sars-cov- ) is infectious in asymptomatic carriers with a variable incubation period ( - days), the recognition of infection in clinics and wards is important for physicians of all specialties. although % of patients present with apparently mild respiratory infection, covid- has a case fatality rate of approximately %. [ ] [ ] [ ] thoracic malignancy may also present with mild respiratory symptoms. in addition, after thoracic surgery patients may also have cough, dyspnea, reactive fever, and postoperative radiologic changes. these postoperative changes may overshadow the symptoms of covid- . without sufficient experience and precaution, prompt diagnosis of covid- may be delayed and nosocomial transmission may occur. this study describes the clinical course of patients who underwent thoracic surgery for malignancy in the early phase of the pandemic before the formal declaration of outbreak and were consequently diagnosed with covid- . we illustrate the risk of thoracic surgery during this pandemic. to be considered as a possible case, a patient needed to have been admitted for and undergone thoracic surgery at the department of thoracic surgery at the central campus of tongji hospital, tongji medical college, huazhong university of science and technology between january and january , . all postsurgical patients who tested positive for covid- by real-time reverse transcriptase-polymerase chain reaction (rt-pcr) were eligible for inclusion in the case series. cases were classified as nonsevere, severe, or critical according to the clinical guideline of the china national health commission. patients were defined as "critical" if they ever met any of the following criteria: respiratory failure requiring mechanical ventilation, septic shock, or multiple organ dysfunction in the intensive care unit. patients were defined as "severe" when suffering from either dyspnea with respiratory rate ! /minute, or partial pressure of arterial oxygen/percentage of inspired oxygen ratio < mm hg or blood oxygen saturation %, or lung infiltrates > % within to hours. the remaining cases were defined as "nonsevere." regardless of consequent recovery, cases were classified by the most severe criteria they ever met during the postsurgical course. positive exposure history was defined as a history of close contact with family members suspicious for covid- infection, or if a patient sharing their ward had confirmed covid- . fever was defined as an axillary temperature more than . c. a putative case was defined as clinical suspicion of covid- resulting isolation of patient before rt-pcr detection of viral rna. delay in diagnosis means covid- was not initially suspected due to insidious onset of symptoms that mimicked the usual postoperative course, or due to the first computed tomography (ct) scan of the chest after surgery being interpreted as postoperative changes rather than as being suspicious for viral pneumonia. the case id number ( - ) represents a specific patient and is used to identify that same patient consistently in all figures, tables, and text. demographics, comorbidities, and clinical documents were collected from the hospital information system. for accuracy, researchers independently recorded data using a standardized data-collection form. first symptom and onset of disease was derived from medical records, temperature charts, patient recall, and recall of their primary care surgeons. possible time of exposure was determined through contact tracing, which included evaluation of patient recall, duration of patient placement within beds and wards, co-location with other patients ultimately diagnosed with covid- , and information about families and visitors during their hospitalization. ct images of the chest were analyzed and recorded by radiologist and thoracic surgeon independently. researchers were not involved in collection of biological samples for rt-pcr, and setting of ct parameters in this retrospective analysis, protocol for rt-pcr and chest ct were same to as that in the reference article from tongji hospital. all patients had perioperative education, including breathing exercises and "intention to cough after operation" once every hours during the day to improve lung expansion. as we experienced rapidly changing patient outcomes in the midst of a pandemic, our treatment modalities also changed rapidly, including an initial period in which patients received prophylactic antibiotic and ambroxol after the case id being diagnosed as covid- , a practice that was later stopped. as our experience with and our understanding of covid- increased, we standardized our approach to initiate oral oseltamivir and moxifloxacin and a ct of the chest immediately after the first onset of fever. rt-pcr tests were requested if a ct of the chest showed characteristics consistent with viral pneumonia. rectal diclofenac ( mg, every hours) was used to control pain and fever. patients were transferred to isolation wards as soon as covid- was suspected. all patients received supportive care with oxygen supplementation regardless of their oxygen saturations. information regarding nonspecific antivirals, corticosteroid and mechanical ventilation are shown in table e . ethical application was made to and approved by the institutional review board of tongji hospital, tongji medical college, huazhong university of science and technology (tj-irb ; date of approval: march , ). consent from the covid- cases analyzed in this report was waived due to its retrospective nature and that data would be deidentified at publication. median and range or mean ae standard deviation was used to describe continuous data. single comparisons were performed by independent samples t test. normality was tested by the shapiro-wilk test. categorical variables were assessed by fisher exact test to evaluate associations between case fatality and surgical, laboratory, and clinical features. all analysis was computed by ibm spss statistics (version ; ibm corp, armonk, ny). in total, patients were admitted to the surgical unit between january and january , . on january , all nonemergent surgeries were cancelled as the pandemic nature of covid- was realized. therefore, patients were consequently discharged home without surgical intervention. of the patients who had already been operated covid- ¼ coronavirus disease ct ¼ computed tomography ggo ¼ ground-glass opacity rt-pcr ¼ real-time reverse transcriptasepolymerase chain reaction sars-cov- ¼ severe acute respiratory syndrome coronavirus on, developed postoperative fever and were considered putative cases of covid- , of whom had covid- confirmed by rt-pcr and were included in this case series. there was patient who developed fever and died at home without autopsy who was not included in this case series due to uncertainty of cause of death. unknown to the admitting staff, and before the pandemic nature of covid- being recognized, patients had postoperative positive exposure history to covid- ( figure ). evidence of nosocomial transmission is apparent in the majority. the date of first exposure in case id is uncertain, since her husband had covid- diagnosed before her onset of symptoms. demographics, comorbidities, and pathology of neoplasm are shown in table . in general, no one had impaired liver and renal function preoperatively, and patients had thoracic malignancies. all had undergone radical tumor resection within month of developing symptoms consistent with covid- infection. duration from possible postoperative exposure to onset of symptom ranges from to days ( figure ). events from surgery to diagnosis of covid- are shown in figure . median days from surgery to putative covid- infection was (range - days), to positive rt-pcr test was (range - days), to death was (range - days, n ¼ ), and to discharge upon recovery was days ( - days, n ¼ ). of the confirmed cases, symptom onset included dry cough ( / ), dyspnea ( / ), and fever ( / ). there were cases in which infection was not detected at their insidious onset of symptoms but only after fever developed and ct of the chest was done. case id had dry chough after resuscitation with tracheal intubation on the day of operation due to hypokalemia with sudden cardiac arrest. she was discharged home days postoperatively, and her infection was detected after another days by chest ct after her husband had confirmed covid- infection. case id had a history of bronchial asthma and became dyspneic days after right upper lobectomy. a ct was taken days later after onset of fever at which time covid- was putative. − all patients had ct of the chest before and after surgery. of the cases, case id and id had preoperative ground-glass opacifications (ggos). case had multiple ggos proven as synchronous multiple primary lung adenocarcinoma on pathology (stage ia and stage ib, tables and e ). case id (figure ) was asymptomatic during the weeks prior to operation with a normal leucocyte and lymphocyte count; he had abrupt fever within hours after operation, followed by rapid deterioration and death within days. on retrospective analyzes of his chest ct days prior to operation, we revealed subpleural illdefined ggo in the right lower lobe with increased extent and intensity day later ( figure ). of the cases deemed to have had postoperative exposure (except for case id ), (case ids , , , , , ) were diagnosed putatively after the first postoperative chest cts in which the following features were noted: peripheral or subpleural distribution, multifocal located ill-defined ggo, sign of "crazy-paving," bronchial wall thickening, and irregular consolidations that were rapidly increasing in extent and intensity ( figure ). the first postoperative cts of the chest of another patients (id , , , ) were initially interpreted as having postoperative changes but were later realized to be indicative of covid- . these ct scans contained the following features: cord-like consolidation or opacity, irregular patchy consolidation, irregular ggo with diameter less than mm, subpleural consolidations, and reticular changes ( figure ) . at the last follow-up on march , critical cases had died (figure , ids , , ) , and severe (ids , , , ) and mild cases (ids , , , ) were discharged upon recovery. clinical and laboratory features are shown in table , and detailed information of each patient is listed in table e . the median of symptom-onset days after operation was (range - days). in general, all patients had fever and dyspnea. the critical cases had remittent fever until death. all patents had normal complete blood count and clinical biochemistry preoperatively, with leukocytosis or lymphopenia at day or day postoperatively followed by eosinopenia. the critical cases had an absolute eosinophil count approximating ( /l) when arterial oxygen saturation dropped below %. in summary, leukopenia occurred in cases ( . %), patients had elevated liver enzymes ( . %), and all patients had hypoproteinemia, hypoalbuminemia, and elevated lactate dehydrogenase. factors potentially associated with fatal cases (n ¼ ) are shown in table . none of the preoperative factors was associated with death. however, resected lung volume (! segments), persistent fever, and postoperative reduction of total protein and albumin were significantly associated with fatality (p < . ). increase in lactate dehydrogenase and liver enzymes also showed marginal association with death (p ¼ . , p ¼ . , respectively). across the covid- cohort in china, the proportion of severe and critical disease was % to . %, and . %, respectively, - and was . % and . %, respectively, after thoracic surgery in this case series. it appears that sars-cov- may significantly increase the risk of death during the thoracic postoperative period. in addition, the virus is contagious during the incubation period, which may lead to nosocomial transmission even within well-organized hospitals with strict infection control procedures. the overlap between symptoms of covid- and the usual thoracic postoperative clinical course may result in delayed diagnosis: fever and cough from reactive pleural effusion and atelectasis are common after thoracic surgery ; dyspnea may be secondary to lung resection and chronic obstructive lung disease; many thoracic postoperative patients suffer chest tightness and fatigue, loss of appetite, and nausea due to postoperative analgesics; and antibiotics are usually self-limiting. therefore, in this pandemic, thoracic surgeons must make their patient rounds with greater caution to distinguish infection from noninfectious symptoms, perhaps to assume infection by default. as a result of our experiences, we have provided hospitalized patients with a daily self-checking form to record possible symptoms with onset, duration, severity, and dynamic changes to help early detection of infection. case fatality in this study was significantly associated with resected lung segments (! ), severity of postoperative hypoproteinemia or hypoalbuminemia, and peak value of lactate dehydrogenase. we cannot determine causality, nor control for other factors, including comorbidities and surgery. case id with a smoking index of had an asymptomatic period for weeks and had onset of fever within hours after operation. whether this was due to a long period of incubation (known to be up to days) or exacerbated by the stress of the surgical procedure cannot be assessed. case id had history of colon cancer, marginal pulmonary function test (forced expiratory volume in second . l/s, forced expiratory volume in second/forced vital capacity . %), and a smoking index of . case id had arterial hypertension (stage i, high risk), left ventricular dilatation (ejection fraction: %), and coronary artery atherosclerosis (coronary artery disease reporting and data system ). of the fatal cases, matched analysis over a much larger sample size is required to answer whether surgery or types of surgery increase morbidity and mortality in patients with covid- . we observed leukocytosis with lymphopenia in cases and leukopenia in cases ( . %), which differs from previously reported covid- cases with an incidence of . %, . %, and %, respectively. leukocytosis after major surgeries is physiological in the early postoperative period, and in other postoperative settings, lymphopenia can occur in % to . % patients within days. , thoracic surgery is also associated with lymphocyte reduction. these nonspecific postoperative laboratory changes make detection of infection on these parameters alone extremely challenging. nonetheless, persisting abnormal white cell counts for more than week is infrequent postoperatively but is common in this case series of covid- . in addition, we observed an impressive reduction of lymphocyte and eosinophil counts in all cases, suggesting their prognostic value should be explored in future studies with larger sample sizes. in this case series, the average time from symptom onset to rt-pcr-confirmed diagnosis was about weeks, a time frame unsuitable for hospital practice, which is highly dependent on rapid diagnosis and isolation of cases in hospitalized patients for infection control. serum antibody detection has better reported sensitivity ( . %) and specificity ( . %) ; however, the time to their detection remains uncertain. we know that immunoglobulin m became detectable to days after severe acute respiratory syndrome infection, and if this is similar in the case of covid- such delays will remain challenging in the hospital setting. ct scan shows small irregular ggo in the right upper lobe and subpleural cord-like consolidation (c), which were not rare as postoperative reactive change. after days, ct shows typical signs of viral pneumonia (g): diffuse ground glass opacifications with "paving stone" signs and, irregular subpleural cord-like consolidation. d, a -year-old male patient (case id ) days after right lower lobectomy. chest ct (d) shows pneumothorax, subcutaneous emphysema, postoperative changes, and inflammation around chest drain. after days, he had sudden onset of fever and ct scan revealed (h) multiple diffuse ggos in the lung peripheries with reticular consolidation. postoperative changes from thoracic surgery may overshadow early ct signs of covid- infection. through retrospective analysis, we found cases of misinterpreted ct of the chest ( preoperatively, and postoperatively), which had rapid progression of ggos on repeated ct scans indicative of active covid- infection. one had ill-defined peripheral ggo with interstitial pneumonia before operation (figure ). the remaining had irregular patchy or cord-like consolidation, small irregular ggo and reticular areas of increased opacity and were misinterpreted as postoperative reactive changes, which later on turned became clearly consistent with active viral pneumonia ( figure ). hence, a ct scan at a single time point cannot exclude suspicious sars-cov- infection; rather, repeated ct scans during the postoperative course can assist in diagnosis. during the outbreak, we had to continue emergent surgeries under the risk of covid- . as a result of our experience we increased our precautions, replacing postoperative chest radiographs with ct scans and ordering covid- rt-pcr and serum antibody tests for patients with fever, cough, dyspnea, lymphopenia, eosinopenia, or atypical signs of inflammation on chest ct. although a limited sample size, our experience suggests that physicians should be aware of a possible greater risk of death in patients with covid- who have ! lung segments resected and persistent severe hypoproteinemia, hypoalbuminemia, and elevated liver enzymes after thoracic surgeries. in general, patients infected with covid- who underwent recent thoracic surgery were found to have greaterthan-anticipated incidence of severe illness ( . %) and fatality rate ( . %). as a result of this, nonemergent surgeries were postponed locally, including stage i thoracic malignancies (except for small cell cancer and low differentiation cancer). case detection in the incubation period remains challenging both pre-and postoperatively. similarities between the usual thoracic postoperative course and symptoms of covid- viral pneumonia may cause delays in diagnosis. in our experience, if operating in this pandemic environment for any cause, all patients should undergo the following management regimen: a preadmission ct of the chest, oropharyngeal swab, and serum antibody test for covid- ; if negative, quarantine in a hospital ward for week should be implemented; a second oropharyngeal swab and serum antibody test for covid- should then be performed; if both tests are negative, the patient can undergo the planned operation. contact restriction is required for hospitalized patients. postoperative patients with symptoms or known history of exposure to covid- should be quarantined and monitored dynamically for symptoms and laboratory abnormalities by repeat cts of the chest postoperatively. there are some methodologic limitations to this case series. due to the retrospective nature of this analysis, the presumed date of exposure and symptom onset from medical records and personal statements may be affected by recall bias. the baseline characteristic of the patient varied with respect to underlying comorbidities and preoperative pulmonary lung function; additionally, the different types of the early signs of covid- were disguised in postoperative thoracic patients, resulting in a . % fatality rate. the journal of thoracic and cardiovascular surgery c volume -, number - presumed asymptomatic carrier transmission of covid- full spectrum of covid- severity still being depicted epidemiologic features and clinical course of patients infected with sars-cov- in singapore characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention chinese clinical guidance for covid- pneumonia diagnosis and treatment clinical characteristics of deceased patients with coronavirus disease : retrospective study correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases does atelectasis cause fever after surgery? putting a damper on dogma clinical features of patients infected with novel coronavirus in wuhan lymphopenia at days postoperatively is the most significant laboratory marker for early detection of surgical site infection following posterior lumbar instrumentation surgery association of preoperative cell counts with outcomes after operation for congenital heart disease the role of lymphopenia in the development and severity of postoperative pulmonary complications after lung surgery development and clinical application of a rapid igm-igg combined antibody test for sars-cov- infection diagnosis production of specific antibodies against sars-coronavirus nucleocapsid protein without cross reactivity with human coronaviruses e and oc key words: covid- , surgery, lung cancer, esophageal cancer, postoperative, sars-cov- authors have nothing to disclose with regard to commercial support. the journal of thoracic and cardiovascular surgery c - key: cord- -jk ej c authors: qian, hua; miao, te; liu, li; zheng, xiaohong; luo, danting; li, yuguo title: indoor transmission of sars-cov- date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: jk ej c background: by early april , the covid- pandemic had infected nearly one million people and had spread to nearly all countries worldwide. it is essential to understand where and how sars-cov- is transmitted. methods: case reports were extracted from the local municipal health commissions of prefectural cities (municipalities) in china, not including hubei province, between january and february . we identified all outbreaks involving three or more cases and reviewed the major characteristics of the enclosed spaces in which the outbreaks were reported and associated indoor environmental issues. results: three hundred and eighteen outbreaks with three or more cases were identified, involving confirmed cases in prefectural cities. we divided the venues in which the outbreaks occurred into six categories: homes, transport, food, entertainment, shopping, and miscellaneous. among the identified outbreaks, . % involved three cases, . % involved four cases, and only . % involved ten or more cases. home outbreaks were the dominant category ( of outbreaks; . %), followed by transport ( ; . %; note that many outbreaks involved more than one venue category). most home outbreaks involved three to five cases. we identified only a single outbreak in an outdoor environment, which involved two cases. conclusions: all identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major sars-cov- infection risk. in less than months, sars-cov- has rapidly spread to nearly all countries worldwide and by april it had infected more than a million people, and killed nearly , people. understanding where and how sars-cov- is transmitted from an infected person to a susceptible person is essential for effective intervention. the once-in-a-century covid- pandemic occurred right in the age of artificial intelligence and big data. many clusters/outbreaks were identified via contact tracing by local health authorities in china and elsewhere using both traditional and new technologies. the identification of these clusters allowed the health authorities to quarantine close contacts for effective intervention and provided an opportunity to study the characteristics of where and how these clusters occurred. the first covid- patient was identified in wuhan in december , and the largest number of confirmed chinese cases occurred in hubei province, of which wuhan is the provincial capital. since january , the local health authorities of cities outside hubei have reported online the details of most identified cases of infections. in this study, we identified the outbreaks from these case reports from the local municipal health commissions of prefectural cities (municipalities) in china, not including hubei province, between january and february and reviewed the major characteristics of the enclosed areas in which these outbreaks were determined to have occurred and associated indoor environment issues. we collected descriptions of each confirmed case from the local municipal health commission website of prefectural cities in mainland china, not including hubei province. each local municipal health commission announced a description of the confirmed cases each day. the case descriptions generally included age, sex, venue of infection, symptoms, date of symptom onset, hospitalisation, and confirmation and history of exposure. many described cases also included the individual trajectory and relationship with other confirmed cases, and quite often clusters had already been identified. we consulted the websites nationwide except for those of cities in hubei province and collected all available data up to february . data from a few major cities -beijing, shanghai, and guangzhouwere not included in our analysis due to insufficient case descriptions. case descriptions from hong kong, macao, and taiwan were collected from their health authorities. we input the data into a database in a unified format and conducted crossvalidation to ensure data reliability. a total of cases with the minimum required descriptions (i.e., the information listed above) were found; these accounted for . % of the , confirmed non-hubei cases in china by february . in this study, we defined a cluster as an aggregation of three or more cases that appears to be linked to the same infection venue (e.g., an apartment, an office, a school or a train) during a sufficiently close period. we defined an outbreak as a cluster in which a common index patient is suspected, and we excluded tertiary and highergeneration infections in counting the number of cases involved. we also excluded outbreaks that involved only two cases to exclude possible spouse-to-spouse transmission and to reduce the workload due to the large number of clusters or outbreaks with two cases. we also identified the index patient(s) of the identified outbreaks and their date of symptom onset. we divided the identified outbreaks into categories for further analysis. first, six categories of infection venues were considered: homes (apartments and villas), transport (train, private car, high-speed rail, bus, passenger plane, taxi, cruise ship, etc.), restaurants and other food venues, entertainment venues (gyms, mahjong, cards, tea houses, and barbershops) and shopping venues (shopping malls and supermarkets), with an additional miscellaneous venue (hospitals, hotel rooms, unspecified community, thermal power plants, etc.) . second, four categories of infected individuals were considered based on their relationship: family members, family relatives, socially connected and socially non-connected. the funding bodies had no such involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. the corresponding authors also confirms that they had full access to all the data in the study and had final responsibility for the decision to submit for publication. we identified outbreaks involving , infected individuals in cities. the top three cities (table s ) were shenzhen, guangdong ( outbreaks, · %; cases, · %), chongqing ( outbreaks, · %; cases, · %) and bozhou, anhui (nine outbreaks, · %; , · %). the average number (sd) of cases per outbreak was ·  · . among the identified outbreaks, more than half ( ; · %) involved three cases, more than a quarter ( ; · %) involved four cases, and only five ( · %) outbreaks involved ten or more cases. table s briefly describes four outbreaks, including the largest outbreak in a shopping mall in tianjin ( cases). among the outbreaks, involved only family members, involved family relatives, involved socially connected individuals, involved socially non-connected, and only three involved multiple relationships. in addition to family members, family relatives and socially connected individuals constituted a large proportion of the infected cases ( figure a ). eighty-three of the identified outbreaks had multiple possible venues, which means either that the exact venue of infection cannot be identified or that more than one venue was involved in the infection. if we double-or triple-count these venues, we have a total of infection venues for outbreaks ( figure b ). among the outbreaks, ( · %) occurred in a home (one in a villa; all others in apartments), ( · %) in transport, at a restaurant or other food venue, seven at an entertainment venue, and seven at a shopping venue (shopping mall and supermarket), with an additional at a miscellaneous venue (e.g., hospital, hotel room, unspecified community, and thermal power plant). most of the home outbreaks included three to five cases ( with three cases, with four cases, and with five cases). the average number of cases was · for the home outbreaks, · for transport, · for food venues, · for entertainment venues, · for shopping venues, and · for miscellaneous venues. the proportion of large outbreaks was high for shops and food venues, possibly because more susceptible individuals were present in these venues than in homes. shopping and entertainment venues were each associated with only seven outbreaks. this seems to suggest the difficulty of implementing preventive measures in places with large numbers of susceptible individuals. between december and january , we also identified outbreaks with known start and end dates of the suspected infectious period (figure a ). the identified outbreaks peaked between and january (figure a ), which coincides with the celebration period of the chinese new year (cny). cny lasted from new year's eve on january to the lantern festival (i.e., the th of lunar january) on february. the official holiday in mainland china was from to january . the peak date for the number of transport outbreaks was to days earlier than that for the home outbreaks as people travelled home for cny. because home outbreaks dominated, the changes in the temporal profile of the number of cases ( figure a ) closely follows that of the home outbreaks ( figure b ). however, for outbreaks with more than six cases, no particular pattern was identified over time, which suggests a sporadic nature. among the outbreaks with a known suspected infectious period, included a known date of symptom onset for the index patient ( figure ). we further divided those outbreaks into two subgroups according to the index patient's symptom-onset date: on or before january ( outbreaks) and after january ( outbreaks). the average time from symptom onset to the ending infectious date was · ± · days for those on and before january and · ± · days for those afterward. the first salient feature of the identified outbreaks that involved three or more cases is that they all occurred in indoor environments. although this finding was expected, its significance has not been well recognised by the community and by policy makers. indoors is where our lives and work are in modern civilisation. the transmission of respiratory infections such as sars-cov- from the infected to the susceptible is an indoor phenomenon. the emergence of homes as the most common covid- outbreak venue in china is not surprising. during the covid- epidemic in mainland china, homes became temporary quarantine places. our estimated home dominance of · % is close to the official estimate of % of the so-called household clusters among the nearly clusters (not outbreaks) defined by the china national health commission. after wuhan announced its city lockdown on january, the warning message spread throughout the country. people in provinces outside hubei also began to stay at home. most chinese families have one child, and some families may also include grandparents. the relatively low number of cases in these home outbreaks might be considered an advantage of compulsory home quarantine because transmission was limited to the small number of family members. similar stay-athome policies have now been implemented elsewhere during the pandemic. the rising trend shown before the peak period in figure was probably due to the introduction of imported cases due to the spring festival travel season (chunyun in chinese), a period around cny during which many people leave cities in which they work to visit their rural families. the chunyun brought people from the epicentre wuhan to their home all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi.org/ . / . . . doi: medrxiv preprint cities before wuhan's lockdown on january. social and family gatherings continued after january in most cities outside hubei. interventions such as contact tracing and confinement of estates, villages, and individual buildings were implemented gradually in most cities outside hubei immediately after cny, which explains the sharp declining curve after january. our study does not rule out outdoor transmission of the virus. however, among our , identified cases in china with sufficient descriptions, only one outdoor outbreak involving two cases occurred in a village in shangqiu, henan. a -year-old man had a conversation outdoors with an individual who had returned from wuhan on january and had the onset of symptoms on february. the second salient feature of the identified outbreaks is the relatively small number of outbreaks that involved or more cases. the largest outbreak occurred in a tianjin shopping mall and involved cases, although wu et al. reported that cases were involved (table ) . this feature contrasts with the sars-cov epidemic, during which major super-spreading events in hong kong and singapore alone were identified to involve as many as cases, and super-spreading events dominated the epidemic. the occurrence of many small outbreaks (in number of cases) in the covid- pandemic suggests a different transmission pattern from that of the sars-cov epidemic. some virus, epidemiological, and environmental factors could have contributed to this observed difference between the sars-cov epidemic and the current covid- pandemic. we cannot pinpoint the exact transmission routes from these identified outbreaks. most health authorities advised that the covid- virus is transmitted mainly by close contact and via the fomite route (e.g., china nhc and cdc ). the china nhc also suggested that longrange aerosol transmission may occur when certain conditions are met, such as in crowded enclosures or spaces with poor ventilation. frequent close contact occurs and high touch surfaces exist in buildings. - we do not have data on the hygiene conditions and human density of the infection venues of the outbreaks studied here. the exact location of the infection venues and the necessary parameters such as the floor area or the number of occupants were not provided in the case reports. instead, we reviewed the current design standards of thermal and ventilation conditions, occupant density and close contact behaviour in the various indoor environments discussed here (table s ). the required ventilation rates vary significantly among homes, offices, trains, and buses. for example, the required ventilation rate is only · l/s per person in shopping malls and · l/s per person in public buses, whereas a ventilation rate of to l/s is required for good indoor air quality. an international systematic review showed that a rate as high as l/s per person may be needed. many existing buildings are crowded, poorly ventilated, and unhygienic. a comprehensive review of ventilation conditions in chinese indoor environments by ye et al. showed that the co concentration can reach , ppm in some buildings. the design and operation of buildings have also been under pressure to reduce energy use and increase human productivity. balancing the need for energy efficiency, indoor environment, and health in both urban planning and building design has not been easy. the quality of indoor environments might be sacrificed by putting a greater focus on cost than on health. this study has limitations. we only studied outbreaks in china, where very strict intervention measures were implemented. we relied fully on the case reports of the local health authorities in each city, and variation exists in the details and the quality of their original epidemiological investigations. we also made no attempt to access any of the infection venues, and the details of each of these indoor spaces remains unknown. this study shows that the individual indoor environments in which we live and work are the most common venues in which the virus of the once-in-a-century-pandemic is transmitted among us. an individual infected in one building may infect others in the building(s) that he or she later visits. people are in constant contact as they move from one indoor space or building to another, which creates an indoor contact network through which a virus can spread. the buildings and transport cabins in various parts of the world are thus connected and facilitated the spread of the covid- pandemic virus. the association between crowding and infection has been known since pringle. the most dramatic example might be in the cruise ship outbreak on the crowded diamond princess, of which the peak basic production number was predicted to be or · before quarantine and much higher elsewhere. the world's first statutory housing policy, the artisans and labourers dwellings act was developed following th century empirical evidence that crowding led to a high incidence of infectious disease. a recent systematic review by the world health organization also found an association between crowding and infection. a lancet editorial in declared '[t]he right to a healthy home'. one who meeting also declared that 'everyone has the right to breathe healthy indoor air' and that 'the provision of healthy indoor air should not compromise global or local ecological integrity, or the rights of future generations'. we hope that in the post-pandemic future, mankind will reflect deeply on the need for a healthy indoor environment. all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi.org/ . / . . . doi: medrxiv preprint the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi.org/ . / . . . doi: medrxiv preprint (a) (b) all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi.org/ . / . . . doi: medrxiv preprint (c) figure s . two hundred and thirty-one outbreaks with known starting and ending dates of suspected infectious period, arranged by (a) starting date of suspected infectious period, (b) ending date, and (c) median date. all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi. org/ . org/ . / all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi. org/ . org/ . / the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi. org/ . org/ . / figure s . provincial distribution of the identified outbreaks and number of cases involved in these outbreaks. table s . brief summary of outbreaks with to cases. shop ( ), liaocheng, shangdong between january and february, workers from the zhenhua supermarket (振华量贩聊城闸口店) were confirmed to be infected. seven of them worked in the f shopping area. six other secondary infections were reported (five family members of the two cases and one close contact of the third case). local health authorities identified close contacts by february, and a free check and test were offered to all customers who visited the shop from to jan. based on our collected data, cases were involved. according to news reports (wenzhou news network, ), a total of cases were involved in this outbreak, including administrators, shopping assistants or cleaners, and customers of wenzhou intime department store (温州银泰百货商场). the patient with the earliest onset of symptoms was a female cleaner ( january) and the last was a female customer ( february). the first case was identified on january. the mall was closed on january. the local health authority traced more than , people who visited the mall or nearby for minutes or more, including , workers in the mall and nearby residents. the mall was opened again on march. ( ), tianjin based on our collected data, cases were involved. according to wu et al. ( ) , cases were involved. six shop workers and nine customers in a shopping centre were infected, with onset dates between january (a shop assistant) and february (a customer). the shopping complex was built in , with a , m shopping area, mainly on the first and second floors. there were workers including shop assistants. people were purchasing clothes and gifts before cny, so the shop was very crowded with at least , visitors to the venue during the possible infectious periods. the outbreak mainly occurred on the first floor, where clothes, shoes, jewellery, and small appliances are sold. the building was closed on january. all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is . https://doi.org/ . / . . . doi: medrxiv preprint 宁夏 ningxia table s . characteristics of indoor environments as required by standards where covid- clusters occurred. all rights reserved. no reuse allowed without permission. the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is in general, we tried to review the chinese standards/studies of chinese buildings and cited international standards or studies elsewhere if needed. who, a. coronavirus disease (covid- ) situation reports. situation report - by air infiltration rates in the bedrooms of residences and estimated parametric infiltration rate distribution in guangzhou air change rates in urban chinese bedrooms patterns of human social contact and contact with animals in shanghai social mixing patterns in rural and urban areas of southern china preferred interpersonal distances: a global comparison hou et al. ( ) stated 'the result is that in approximately % of chinese bedrooms, regardless of climate region or season, the only outdoor air entering bedrooms is by infiltration the authors are grateful to shengqi wang, xiaoxue cheng, luping ma, ya lei, siying mei, ziying zhou, yiran lu, mengjie duan, yifan li, qionglan he and ziang xi, who helped collect the original data. the authors declare no conflict of interest.h. qian, t. miao, and y. li contributed equally. y. li and h. qian contributed to study design, hypothesis formulation, and coordination. l. liu, x. zheng and d. luo contributed to data collection and initial data analyses. h. qian and t miao contributed to major data analyses. y. li wrote the first draft of the paper, and h. qian and t. miao contributed to major revision. all of the other authors contributed to revision.all of the authors approved the submitted version and have agreed to be personally accountable for their own contributions. key: cord- -xem alih authors: marraha, farah; al faker, ibtissam; gallouj, salim title: a review of the dermatological manifestations of coronavirus disease (covid- ) date: - - journal: dermatol res pract doi: . / / sha: doc_id: cord_uid: xem alih coronavirus disease (covid- ) caused by severe acute respiratory syndrome coronavirus- (sars-cov- ) has affected countries and territories around the world. the virus has spread rapidly, and the disease is still extending up to now. the pathophysiology for sars-cov- has not been well elucidated, and diverse hypotheses to date have been proposed. initially, no skin manifestations were observed among patients with covid- , but recently a few cases have been described. in this review, we discuss these various cutaneous manifestations and skin problems related to personal protective equipment, as well as different cutaneous anti-covid- drug-associated reactions. we also focus on the currently proposed managements of these rare manifestations. e first case infected by severe acute respiratory syndrome coronavirus- (sars-cov- ) was reported in wuhan, china, in late november . in december , several patients have been presented to the hospital for acute pneumonia of unknown origin [ ] . later, sars-cov- has been found in the lower respiratory tract of hospitalized patients, and the world health organization (who) recognized the disease as covid- (coronavirus disease ) on january , . e virus has spread rapidly, and the condition is still extending up to now. on march , the who declares the covid- outbreak as pandemic [ ] . we are still counting to this day , , confirmed cases with , deaths worldwide. initially, no skin manifestations were observed among patients with covid- [ , ] . e first case was described in ailand with petechiae rash mimicking a dengue fever [ ] , and then a few other cases followed [ ] [ ] [ ] [ ] . ese skin lesions can guide clinicians for diagnosis if the patients present other covid- symptoms; however, viral infection cannot be the only cause; mediated inflammatory responses and drug reactions can also be suspected. e aim of our literature review is to report the various cutaneous manifestations described to date associated with covid- , the skin problems related to personal protective equipment, and the different cutaneous anti-covid- drug reactions [ , ] . we also discuss the different interventions proposed to manage these patients [ , ] and solutions to protect skin and mucous membrane barriers for healthcare workers [ ] [ ] [ ] . since the epidemic began in europe, some countries have presented virus-spreading indicators higher than others. in italy, the first cases were detected in the last ten days of february. its case fatality rate at present is . %. in france, the mortality rate has continued to increase, reaching . % (july , ). in the united states, the first cases appeared around march . e country represents more than % of the cumulative cases worldwide. as for morocco, the first case emerged on march ; official indicators seem to display volatile trends. it is tough to demonstrate a correlation between them. e growth factor can vary from a value of to a value of . within hours. e contamination rate displayed every day (new cases in hours compared to the number of tests carried out in hours) is also very volatile ranging from % on march to % on april and . % on july . as for the mortality rate, it decreased from . % to . % lately (july , ) [ ] . e pathophysiology of covid- has not been well elucidated, but it seems similar to that of sars-cov [ ] . sars-cov has the appearance of a crown under electron microscope. it is composed of genomic rna and four structural proteins: spike (s), envelope (e), membrane (m), and nucleocapsid (n). it can attach to the host cell by binding its s protein to the receptor protein membrane [ ] [ ] [ ] [ ] . a number of studies showed that angiotensinconverting enzyme (ace ) is a receptor on the host cell membrane, with a high affinity to sars-cov- protein (s) [ , ] . yet, the significance of this binding affinity is still under intensive research study [ ] . ace is shown to be expressed by epithelial cells of the intestine, kidney, blood vessels, and most abundantly in type ii alveolar cells of the lungs [ , ] . importantly, hamming et al. [ ] demonstrated that ace is also present in the basal cell layer of the epidermis extending to the basal cell layer of hair follicles, which might explain the cutaneous manifestation of covid- . decreased ace function can cause dysfunction of the renin-angiotensin system (ras) and intensify inflammation, vascular permeability, and neutrophil accumulation [ , ] . rapid viral replication can also cause cellular apoptosis and triggers a cascade of inflammatory reaction, as well as an increase in cytokine and chemokine blood levels [ ] . erefore, the inflammatory response of the body also plays a crucial role in sars-cov- -induced lung injury cases, since the high production of these cytokines is responsible for the accumulation of cells and fluids (cytokine storm) [ ] . ese cytokines arriving at the skin and reaching the various cells of the cutaneous immune system can cause the dermatological lesions described during covid- infection (urticarial lesion, erythema, and vesicles) [ ] . wenzhong et al.'s latest hypothesis suggests that lung damage and inflammation are secondary to extreme lung cell poisoning [ ] . in fact, orf , a sars-cov-transcribed nonstructural protein, could bind to porphyrin as well as other proteins and can attack the heme on the -beta chain of hemoglobin. consequently, this will decrease hemoglobin and gas exchanges, which eventually results in ground-glasslike lung images. several cases of patients with covid- showed leucopenia, lymphocytopenia, increased d-dimer level, and prolonged prothrombin [ , ] . besides, abnormal findings of different organs function assessment may indicate multiorgan failure [ ] . it has been suggested that covid- is a zoonotic infection as the first infected people were exposed to the wet animal market in wuhan city [ , ] . however, the intermediate host is still unknown. e virus is transmitted by inhalation of aerosol droplets from the infected patients [ , ] . e fecal-oral transmission was also hypothesized [ ] . erefore, it is essential to strictly adhere to environmental and hand hygiene to control the infection [ ] . so far, the golden clinical diagnosis methods to confirm cases of covid- include the detection of nucleic acids in the nasal and throat swab sampling by real-time polymerase chain reaction (pcr) [ ] . e identification of sars-cov- specific igm and igg antibodies can also be useful for diagnosis [ ] . patients e most common symptoms in covid- are fever, fatigue, and dry cough, succeeded by other symptoms, such as headache, nasal congestion, sore throat, myalgia, and arthralgia [ , ] . initially, no skin involvement during covid infection was observed, but more recently, some cases (table ) have been reported [ , , , ] , as well as the skin problems related to personal protective equipment. secondary skin reactions to the different treatments suggested are also possible. e frequency of the skin lesions associated with covid- infection varies according to the series; in a chinese study of positive cases, the incidence was only . %, while in an italian series of patients it was . % [ ] . joob and wiwanitkit described in ailand, where the first case of covid- outside of china was reported, a skin rash with petechiae in a case of covid- [ ] . because of the frequent dengue cases in this country, it was the first diagnosis to be mentioned. after the appearance of other respiratory problems, covid- has been diagnosed by rt-pcr. in italy, in a series of cases, recalcati reported, after the exclusion of patients who have started new drugs in previous days, that . % of the patients developed skin manifestations [ ] . eight of the ( %) had skin eruptions with symptoms in the beginning and the rest after hospitalization. erythematous rashes were the most common sign ( %) and then urticarial ( cases) and chickenpox-like vesicles ( case). however, no documentation has been assembled in these cases (photos or biopsy) to prevent the spread of infection. at the end of march, the french society of dermatology launched a call for a case, after discovering erythematous maculopapular lesions on the faces of three patients with a very probable or confirmed covid- infection [ ] . finally, cases have been reported, of which % of them had frostbite-like lesions. an american team with a series of patients with dermatological lesions tried to study the characteristics of pernio lesion or chilblain lesions in acral skin. despite the absence of a confirmation test of covid- infection in all these patients, the results showed that of them had pernio-like lesions and most of them were young. e localization of these lesions was in the feet in % of the cases, in the hands in . % of the cases, and in both in % of the cases [ ] . in another spanish study [ ] , including children and adolescents with acral lesions, four clinical patterns were described: acral erythema ( %) (figure ), dactylitis ( %), purpuric maculopapules ( %), and mixed pattern ( %). rt-pcr could not confirm the presence of the virus. e authors believe that it is secondary to a realization of a diagnostic test at an early stage of the disease. coagulopathy and thrombocytopenia are also common complications for covid- infection [ , , ] . in wuhan [ ] , patients with covid- might present acroischemic lesions; there were patients, in a critical situation, hospitalized in the intensive care unit with different clinical presentations, including finger/toe cyanosis, skin bulla, and dry gangrene. four patients among them were diagnosed with definite disseminated intravascular coagulation (dic). a team from italy [ ] tried to collect cases from a website, and cases were collected, but only pictures were analyzed: of patients had erythematous-edematous lesions and of had blistering lesions. a report by fernandez-nieto et al. [ ] describing the characterization of acute acro-ischemic lesions in patients showed two different clinical presentations: chilblain- fernandez-nieto et al. [ ] described a patient in madrid with an urticarial rash that appeared six days after the first symptoms. ey also mentioned the presence of other cases with different skin manifestations, and for that, a prospective study is in progress. in france, henry et al. [ ] reported a similar case; however, the urticarial rash in this patient was inaugural. e only associated symptoms were odynophagia and arthralgia. is eruption was in the form of disseminated erythematous plaques with facial and acral localization. estébanez et al. [ ] published another type of cutaneous manifestation: lesions in the form of yellowish erythematous papules located in the heels. a very recent publication in italy [ ] suggested that papulovesicular eruption (varicella-like) was rare but specific to covid- . twenty-two patients have been reported with the same clinical presentation; itching was present in . % of patients. and the eruption was generally localized at the trunk. another article by the same authors [ ] detailed the case of a little girl who has papulovesicular skin eruption on the trunk, face, and genital tract ( figure ); after days, the patient had a moderate fever and was tested positive for sars-cov- . sanchez et al. [ ] described a new clinical presentation of skin lesions associated with covid- . ey reported a skin eruption similar to that of pityriasis rosea: erythematous and squamous plaque, in the trunk, upper arms, and periumbilical. a spanish publication has classified the skin lesions observed during covid- into types: maculopapular eruptions in % of cases, urticarial lesions in % of cases, acral areas of erythema with vesicles or pustules in %, other vesicular eruptions in %, and livedo or necrosis in % [ ] . in the pediatric population, the frequency of coronavirus infection is estimated to be less frequent than adults (< %) [ , ] . a particular presentation has been reported in children in europe and north africa, with a lesion similar to kawasaki syndrome [ , , ] . hence, the who established a preliminary definition and case for multisystem inflammatory disorder in children and adolescents [ ] to help define and recognize these cases for better management and possible surveillance. clinical presentation includes fever, rash, mucosal inflammation associated with gastrointestinal problems, myocardial dysfunction, and sometimes even hypotension or shock [ ] . according to a french series, concerning children with this syndrome, the skin rash was present in % of patients, edema with plantar and palmar redness was present in % of patients, and % of them had dry lips [ ] . as part of this syndrome, the skin eruption can be very varied; for example, an erythema multiforme rash has been described in a -year-old patient [ ] . other lesions have also been reported, such as androgenic alopecia (aag) [ ] , sebopsoriasis, herpes, and exanthem [ ] . also, nonspecific erythematous lesions in the trunk and face have been described [ ] . to control this infection, all personnel must wear personal protective equipment (ppe) for an extended period in addition to other safety and health measures. eczema is the most common problem among healthcare workers [ ] , often secondary to frequent hand hygiene and long-time gloves wearing [ ] . besides, humidity, prolonged contact with masks, and goggles may cause a variety of cutaneous diseases such as contact and pressure urticaria or contact dermatitis and pigmentation of the nasal bridge [ , ] . in a survey study [ ] , lan et al. found that participants among healthcare professionals mentioned that they had damaged skin. e nasal bridge was the most affected area and then hands, cheek, and forehead. dryness and desquamation were the most common symptoms, and these damages depended on the hours of work, especially for gloves wearing. another questionnaire distributed among patients objected that wearing of masks has caused in . % of cases side effects including first, nasal bridge scar. wearing of gloves has caused in . % of cases skin reactions [ ] . we are currently carrying out a study to clarify the consequences of wearing personal protective equipment on the skin. to date, health personnel have completed the questionnaire. because of frequent handwashing to prevent the disease, dry skin was present in . %, with erythema in . % of cases (figure ) . exacerbations of preexisting dermatoses such as acne, rosacea, atopic dermatitis, and neurodermatitis have been observed [ , ] . is can be explained by the prolonged wearing of masks during the epidemic. e occlusion generated by protective hats may provoke pruritus and folliculitis or exacerbate seborrheic dermatitis [ ] , and the frequent use of disinfectant and soap can impair the hydrolipid mantle of the skin and increase the risk of contact dermatitis [ ] . e current stress generated by the global situation and confinement can also exacerbate dermatoses [ ] . treatments. preventive measures are currently the best strategy to fight covid- . while vaccines and monoclonal antibodies against sars-cov- are under development, several other therapies are proposed [ , ] , hence the interest to review the skin side effects of these molecules. chloroquine/hydroxychloroquine (hcq), a widely used antimalarial and autoimmune disease drug, has been demonstrated to inhibit sars-cov- and blocks viral activity by increasing endosomal ph [ ] [ ] [ ] . however, the use of this drug remains controversial; some studies have tried to prove the effectiveness of this treatment [ , [ ] [ ] [ ] . nevertheless, each had methodological deficiencies [ ] . other studies are underway with a large sample. chloroquine is widely used in dermatology disorders and autoimmune disease; its toxicity is infrequent [ ] , and reactions can be mainly gastrointestinal and cutaneous (pruritus or urticaria), usually mild [ , ] . few cases of hcq toxidermia have been reported. acute generalized exanthematous pustulosis (agep) was the most common presentation [ , ] ; it appears like a sterile nonfollicular pustule with an erythematous base [ ] . also, drug reactions with eosinophilia and systemic symptoms (dress) have been described in four reports [ ] . besides, rare cases of hcq and sweet syndrome have also been reported [ , ] . e moroccan health ministry and national technical committee for prevention and control of covid- decided on march , , to adopt the therapeutic protocol based on using hydroxychloroquine under medical supervision, and no problem has been noticed yet. other prescription drugs such as otc, antibiotics, healthcare products, and a variety of plants can also cause a skin reaction. zheng and lai [ ] reported cases of urticaria, urticarial vasculitis, and other pruritus lesions in coronavirus pneumonia patients after accepting anti-covid- medicines. healthcare institutions and policymakers developed various plans to control the pandemic, including preparing hospitals and clinics, developing a strategy for the identification of suspected covid- cases, and implementing a strategy to reduce the spread [ ] . prevention of nosocomial infection should be another priority; this will require specialized protocols and training of the medical staff. in most countries, several dermatological services have been transformed into a structure for the treatment and isolation of patients with covid- infection, and many private dermatology practices have closed doors [ ] . different solutions have been proposed. [ ] revealed that over % of the patients were interested in using telehealthcare (medical consultations and electronically transmitted prescriptions). during a patient visit, the dermatologist and the patient should both wear a surgical mask with hand hygiene. e dermoscopy should be performed with caution and only if necessary to prevent dermatoscope from becoming a possible source of nosocomial spread [ ] . in addition, this exam should be avoided for specific sites such as hands, nails, face, eyes, and mucosa, and for all patients with signs and symptoms suggestive of covid- [ ] . several skin diseases, such as psoriasis, as well as depression and anxiety, can increase the risk of -ncov infection [ , ] . phototherapy and the other hospital treatments are needed to be adjusted to avoid displacement [ ] . up until today, there is not enough evidence or guidelines for managing the patients with severe inflammatory skin disorders treated with immunomodulators during this pandemic, and there is no proof that these persons may have a more increased risk of becoming infected with covid- [ , , ] . e first treatment option in this particular period must be the one who has lower effects on personal immune functions such as il- inhibitor [ ] . other treatment options include decreasing the dosage of traditional immunosuppressants (methotrexate and cyclosporine) [ ] . on the other hand, there has not been any recommendation or indication justified to stop or reduce the systemic corticosteroid dose [ ] . in the case of skin cancer, surgical treatment, if indicated, should not be delayed, especially in critical localization [ ] . e wearing of the ppe for an extended period and the cutaneous complications that generate with stress and anxiety can reduce the efficiency of the health workforce [ ] . as such, it has been recommended to use latex-free gloves or use of cotton gloves inside it to avoid cutaneous hand problems. moreover, the use of cleansing products containing moisturizing ingredients and the application of hand cream frequently are highly recommended [ , , ] . e alcohol hand sanitizers may be used more frequently as they have been shown to be less irritating than washing hands with soap [ ] . to avoid friction and pressure from wearing the mask, it has been suggested to wear a properly fitted mask, in different ways, and apply moisturizers or gel just before [ , ] , or combine a paper towel with facial mask [ ] . e medical training of future doctors and the scientific communication between dermatologists have also been affected. in morocco, the ministry of national education has deployed an online platform for continued remote instruction for students. e department of dermatology and allergology of the ludwig maximilian university hospital [ ] has presented numerous online case studies and offered opportunities for continuous education. other similar projects with different features and focus already exist on the internet [ ] . to date, several skin manifestations related to covid- have been reported, but additional efforts are needed to collect further data. it is essential not to forget the patients who suffer from other skin diseases and to insist on preventive measures for healthcare professionals. no data were used to support this study. e authors declare no conflicts of interest. e epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak cutaneous manifestations in covid- : a first perspective covid- pandemic and the skin: what should dermatologists know? covid- can present with a rash and be mistaken for dengue covid- et lésions cutanées-point d'étape covidskin de la sfd- avril syndrome de sweet médicamenteuxà l'hydroxychloroquine:à propos de cas dermatology staff participate in fight against covid- in china advice regarding covid- and use of immunomodulators, in patients with severe dermatological diseases european task force on atopic dermatitis statement on severe acute respiratory syndrome coronavirus (sars-cov- ) infection and atopic dermatitis occupational skin disease among health care workers during the coronavirus (covid- ) epidemic consensus of chinese experts on protection of skin and mucous membrane barrier for healthcare workers fighting against coronavirus disease skin damage among health care workers managing coronavirus disease- coronavirus disease (covid- ) situation report- understanding sars-cov- -mediated inflammatory responses: from mechanisms to potential therapeutic tools coronavirus humains (hcov) coronavirus spike protein and tropism changes coronavirus disease (covid- ): a clinical update coronavirus infections and immune responses sars-cov- invades host cells via a novel route: cd -spike protein tissue distribution of ace protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis clinical features of patients infected with novel coronavirus in wuhan, china clinical and histopathological features and potential pathological mechanisms of skin lesions in covid- : review of the literature covid- : attacks the -beta chain of hemoglobin and captures the porphyrin to inhibit human heme metabolism priorities for global health community in covid- pandemic e origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak-an update on the status clinical and coagulation characteristics in patients with critical covid- pneumonia and acro-ischemia pernio-like skin lesions associated with covid- : a case series of patients from countries chilblain-like lesions during covid- epidemic: a preliminary study on patients classification of the cutaneous manifestations of covid- : a rapid prospective nationwide consensus study in spain with cases assessment of acute acral lesions in a case series of children and adolescents during the covid- pandemic comment on: cutaneous manifestations in covid- : a first perspective. safety concerns of clinical images and skin biopsies urticarial eruption in covid- infection cutaneous manifestations in covid- : a new contribution varicellalike exanthem as a specific covid- -associated skin manifestation: multicenter case series of patients varicella-like exanthem associated with covid- in an -year-old girl: a diagnostic clue characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of patients during the covid- outbreak digitate papulosquamous eruption associated with severe acute respiratory syndrome coronavirus infection paediatric multisystem inflammatory syndrome temporally associated with sars-cov- mimicking kawasaki disease (kawa-covid- ): a multicentre cohort special dermatological presentation of paediatric multisystem inflammatory syndrome related to covid- : erythema multiforme a preliminary observation: male pattern hair loss among hospitalized covid- patients in spain-a potential clue to the role of androgens in covid- severity covid- : how it can look on the skin. clinical and pathological features in covid- patients cutaneous signs in covid- patients: a review anticoagulant treatment is associated with decreased mortality in severe coronavirus disease patients with coagulopathy multisystem inflammatory syndrome in children and adolescents temporally related to covid- hyperinflammatory shock in children during covid- pandemic selfreported hand eczema in a hospital population e adverse skin reactions of health care workers using personal protective equipment for covid- breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid- associated pneumonia in clinical studies remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial a pilot study of hydroxychloroquine in treatment of patients with moderate covid- efficacy of hydroxychloroquine in patients with covid- : results of a randomized clinical trial should chloroquine and hydroxychloroquine be used to treat covid- ? a rapid review clinical efficacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review hydroxychloroquine in systemic lupus erythematosus: results of a french multicentre controlled trial (plus study) acute generalized exanthematous pustulosis induced by hydroxychloroquine: three cases and a review of the literature generalized pustular figurate erythema: a newly delineated severe cutaneous drug reaction linked with hydroxychloroquine pustular dress syndrome secondary to hydroxychloroquine with ebv reactivation sweet's syndrome following therapy with hydroxychloroquine in a patient affected with elderly-onset primary sjogren's syndrome clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china emergency management for preventing and controlling nosocomial infection of the novel coronavirus: implications for the dermatology department ethical outpatient dermatology care during the coronavirus (covid- ) pandemic e coronavirus (covid- ) epidemic and patient safety unmet digital health service needs in dermatology patients art of performing dermoscopy during the times of coronavirus disease (covid- ): simple change in approach can save the day! dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection challenges of covid- pandemic for dermatology rational hand hygiene during the coronavirus (covid- ) pandemic personal protective equipment recommendations based on covid- route of transmission medical education and care in dermatology during the sars-cov pandemia: challenges and chances . . . dermatology online with interactive technology (doit) key: cord- -q hqra authors: paul, kishor kumar; salje, henrik; rahman, muhammad w.; rahman, mahmudur; gurley, emily s. title: comparing insights from clinic-based versus community-based outbreak investigations: a case study of chikungunya in bangladesh date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: q hqra abstract background outbreak investigations typically focus their efforts on identifying cases that present at healthcare facilities. however, these cases rarely represent all cases in the wider community. in this context, community-based investigations may provide additional insight into key risk factors for infection, however, the benefits of these more laborious data collection strategies remains unclear. methods we used different subsets of the data from a comprehensive outbreak investigation to compare the inferences we make in alternative investigation strategies. results the outbreak investigation team interviewed , individuals from homes. ( %) of individuals had symptoms consistent with chikungunya. a theoretical clinic-based study would have identified % of the cases. adding in community-based cases provided an overall estimate of the attack rate in the community. comparison with controls from the same household revealed that those with at least secondary education had a reduced risk. finally, enrolling residents from households across the community allowed us to characterize spatial heterogeneity of risk and identify the type of clothing usually worn and travel history as risk factors. this also revealed that household-level use of mosquito control was not associated with infection. conclusions these findings highlight that while clinic-based studies may be easier to conduct, they only provide limited insight into the burden and risk factors for disease. enrolling people who escaped from infection, both in the household and in the community allows a step change in our understanding of the spread of a pathogen and maximizes opportunities for control. infectious disease outbreaks have the potential to place a significant burden on public health resources. understanding who is at risk of becoming infected is critical for the focused targeting of interventions. due to relative ease of access and limited cost requirements, outbreak investigations typically focus on cases that present at formal healthcare centers such as hospitals or community clinics. for example, data collection performed as part of epidemiological investigations during the recent epidemics of ebola, zika and mers focused on quantifying the number of cases and their characteristics. (al-abdallat et al., , lu et al., , teixeira et al., these case-counting exercises provided key insights into fundamental epidemiological parameters such as the basic reproductive number and case fatality rates, and allowed the projection of the future course of the epidemic. (aylward et al., , lessler et al., , lewnard et al., , yamin et al., however, without information on the underlying population, and especially characteristics of individuals who avoid infection, these approaches limit our ability to make mechanistic insights, quantify burden of disease, and identify risk factors for infection, hampering efforts to develop targeted control strategies. cases that present at healthcare centers may only represent a small minority of all cases. in addition, some individuals are more likely to visit formal healthcare providers than others, including those with more severe illness, and differences in healthcare seeking can vary by age, gender and socioeconomic status. (chowdhury et al., , nikolay et al., , pandey et al., household-based outbreak investigations, where investigation teams visit affected j o u r n a l p r e -p r o o f communities, permit a more comprehensive understanding of pathogen spread that limits the impact of healthcare seeking patterns. (france et al., ) however, these investigations are usually still focused on identifying individuals that got sick. (boore et al., , france et al., without also understanding who is avoiding infection in a community, it is difficult to identify the key risk factors for infection, limiting potential inferences. the possible insights from alternative investigation strategies have not previously been systematically compared. here, we use the results of a detailed chikungunya outbreak investigation from bangladesh as an example to consider the inferences made under different investigation scenarios. chikungunya virus is a mosquito-borne alphavirus transmitted to humans by aedes mosquitoes causing acute fever, joint pain, and skin rash. (aubry et al., ) chikungunya fever was first recognized in in tanzania. (lumsden, ) since then, outbreaks of chikungunya have been regularly identified across the tropics and sub-tropics. the first chikungunya outbreak in bangladesh was identified in in two northwestern districts bordering india.(icddr) since then regular outbreaks have been detected. (khatun et al., , salje et al., b here we use the results from a detailed investigation of an outbreak of chikungunya virus in a village in tangail, bangladesh where the outbreak team visited every household in the community and interviewed all members in each household. the comprehensive household investigation captured both those who did get infected and those that escaped from infection. the objective of this study was to compare our approach, in terms of the inferences about the outbreak, to more limited investigation strategies. in late november , a local health official of gopalpur sub-district in tangail households in the village consented to being enrolled in the study. questionnaires were administered in all households to identify suspected cases, identify demographic characteristics, and travel histories of individuals within households. suspect cases were defined as residents with acute onset of fever with rash or joint pain within months prior to beginning the investigation. study staff administered questionnaires to household heads about household members' demographic data and history of illness, water source, construction materials, and mosquito control measures in the household. potential mosquito breeding containers in and around the participating households with stored water were inspected for presence of larvae. suspected cases were asked about their symptoms with onset date and specifics about their treatment seeking behavior. the gps location of all homes was also recorded. determining the etiology of the outbreak all household members, irrespective of their suspected case status, were asked to provide a single ml blood specimen for laboratory testing. blood specimens were spun in the field to separate serum, which were then stored on ice and transported to the virology laboratory of iedcr. the serum samples were tested for igm antibodies against chikungunya by enzyme linked immunosorbant assay (elisa) (standard diagnostics, inc., south korea). suspected casepatients who had igm antibodies against chikungunya in their serum were termed laboratory confirmed cases. we created four different datasets that allowed us to consider different outbreak investigation strategies: this dataset consisted of all suspect cases that reported that they visited a formal healthcare setting (defined as government or non-government primary healthcare center/clinic/hospital) following the onset of symptoms. this dataset consisted of all suspect cases, irrespective of their healthcare seeking behaviors. this dataset consisted of all suspect cases plus controls consisting of household members of these cases. this dataset consisted of all members of all households in the community, regardless of symptoms. the epidemic curve was constructed using symptom onset date of chikungunya cases. gps locations of households with and without chikungunya cases were used to prepare spatial distribution maps. for the case-only datasets (datasets a and b), we compared the age and sex distribution of the cases with that for the district from the census (bangladesh bureau of statistics, ) . for the datasets with information on individuals who escaped from infection (datasets c and d), we initially used simple logistic regression to compare the demographics, typical apparel worn, travel history within the last six months, and household characteristics of cases with non-cases. we then built multivariable logistic regression models to identify adjusted risk factors for chikungunya fever. we initially placed all variables with a p-value of < . in the unadjusted analysis into a multivariable model. we then used backward stepwise selection using the akaike information criterion (aic) (sauerbrei et al., ) to identify the best model. not all individuals who get infected will present with symptoms. we attempted to capture these individuals by asking for blood samples from all community members. to assess the impact of j o u r n a l p r e -p r o o f misclassifying asymptomatically infected individuals as controls in datasets c and d, we conducted sensitivity analyses where these individuals were reclassified as cases. all participants provided written informed consent prior to interviews and blood specimen collection and the ministry of health and family welfare, government of bangladesh reviewed and approved the outbreak investigation plan. the ninety-five suspect cases reported visiting a formal healthcare facility for symptoms consistent with chikungunya between july and november, with the peak number of cases occurring in j o u r n a l p r e -p r o o f october (figure : panel a). cases sought care in three different centers: sought care in a government run community clinic, in a government run sub-district health complex and in a private clinic. the median age was years (interquartile range (iqr) = - years) and the majority ( %) were female (table ). if we used the age and sex distribution of the district from the national census, we find that there is an increased risk of disease in those between the ages of - compared to those aged below years (or . , % . - . ) and that females were at increased risk of infection compared to males (or of . , % ci: . - . ) ( table ) . an additional suspect cases were identified in the community who did not seek care in formal healthcare facilities. of these, individuals visited a local pharmacy and individuals visited the informal sector (unlicensed medical practitioner, traditional healer, and homeopath). the distribution of dates of symptom onset for all cases was nearly identical to the distribution for those that visited clinics (spearman correlation of . ) ( figure a ). the proportion of suspect cases visiting a clinic varied between % in - years age group and % in ≤ years age group ( figure b) . the conclusions about age, sex, educational levels, use of mosquito controls and clinical presentation of suspect cases were similar when using datasets of all cases or only those that sought care in clinics (table ) , however, those who presented to clinics were more likely to travel outside the district ( % vs %, p-value . ). cases who attended formal healthcare settings also appeared to come from similar parts of the community as cases who did not (figure a-b) . similar to the analysis using clinical cases only, using data from the national census identified increasing risk among females for being a case (table ) . inference from community cases plus controls from same household j o u r n a l p r e -p r o o f incorporating controls from the households where cases reside allowed us to assess additional potential risk factors for being a case. consistent with inferences using census data, logistic regression models that used household controls also identified increased risk among females (aor . , % ci . - . ) ( table ). in addition, this analysis showed that cases were significantly less likely to have secondary (aor . , % ci . - . ) or more formal (higher secondary) education (aor . , % ci . - . ) compared to the household controls. incorporating data from the entire community showed that the chikungunya outbreak was largely constrained to the center of the village, with few households affected on the east and west borders but virtually all households affected in the center ( figure c ). this is despite the entire community only being a few hundred meters wide. the expanded dataset also allowed us to understand the risk factors for infection in the wider community. as with the previous analyses, females had an increased risk of being a case (or: . , % ci . - . ) ( table ), although the difference by sex was concentrated in adults with no difference among children ( figure c ). further individuals who reported usually wearing clothing that exposed both limbs had . the odds of being a case compared to individuals wearing clothing that exposed upper limbs only ( % ci . - . ). those who had travelled outside tangail district within the last six months also had increased odds of being a case (aor . , % ci . - . ). individuals who had higher secondary or more formal education (aor . , % ci . - . ) were less likely to be a case than individuals without formal education. we did not identify any household characteristics that were associated with being a case, including presence of mosquito larvae (aor . , % ci: . - . ), daily use of anti-mosquito coil (aor . , % ci: . - . ), number of j o u r n a l p r e -p r o o f household members (aor . , % ci: . - . ), and number of rooms in the household (aor . , % ci: . - . ). fifty-two individuals without symptoms tested positive for chikv. we found no significant demographic differences between symptomatic suspected cases and igm-confirmed asymptomatic cases in those who gave blood (table s ). in sensitivity analysis, we removed these individuals from the 'control' population and included them in the 'case' populations. risk factors for being a case identified in the previous analysis remained similar in both scenarios where we considered household contacts as controls and individuals from all community households as controls (supplementary information, table s ). however, we found important differences in the probability of providing blood. those with symptoms were . times more likely to provide blood than those without symptoms. further, among asymptomatic individuals, only % of children - years provided a sample compared to % among those - (table s ). there were also significant differences by sex ( % of asymptomatic males gave blood compared to % of females, p-value < . ) and educational level with more educated people less likely to provide samples (table s ). outbreak investigations are central to informed responses to public health emergencies caused by the emergence of an infectious pathogen. however, outbreak investigations currently largely revolve around case-counting exercises that limit our ability to identify who is at risk for j o u r n a l p r e -p r o o f infection and who is not. here, by using the results of a comprehensive outbreak investigation, we have been able to explicitly explore the impact of different investigation strategies in the same outbreak. we found that a clinic-based study that used data from all the formal healthcare settings would have identified a quarter of all cases and, using census data, have correctly identified female sex as an important risk factor for disease. however, it is only through the recruitment of people who did not get sick that we could identify the importance of travel history, educational level and apparel usage in determining who gets sick. controls from the wider community were also required to demonstrate which household-level characteristics were important for risk, showing that the use of mosquito coils was not protective, and to map spatial heterogeneity in risk, key to intervention development and deployment. this study highlights the significant heterogeneity in healthcare seeking. even in a small community such as this, cases visited nine different sources of healthcare, three of which could be considered formal healthcare settings. infectious disease surveillance activities are unlikely to be able to collate datasets from this diverse range of healthcare sources, even among only those within formal sector, suggesting that outbreak investigations that rely on cases that seek healthcare likely substantially underestimate the magnitude of outbreaks. using the results of our study, we provide our assessment of the ability of different investigation strategies to capture key characteristics of an outbreak (table ). in practice, the decision to expand outbreak investigations beyond information available from healthcare systems will depend on the resources available. where outbreak teams are already performing communitybased case-investigations, the additional time and effort to also collect data on those without symptomsboth from case-households as well as neighboring householdsmay be marginal. this comprehensive outbreak investigation employed ten field-based investigators and took seven days to complete. an investigation strategy only focused on cases in the community would have taken only marginally less person-time as finding cases in the community anyway typically requires comprehensive door-to-door surveys. our findings highlight how this additional data collection effort can help reveal the drivers of transmission, allowing mechanistic insight into pathogen spread and maximizing opportunities to control, many of which would not be possible from case-based investigations (table )..where it is collected, an additional major benefit of the comprehensive dataset is that it can inform mathematical models that reconstruct entire outbreaks, allowing us to estimate the mean transmission distance (previously estimated here at meters) (salje et al., b) . travelling outside tangail district within the six months before the outbreak was associated with increased chikungunya fever risk. human movement can introduce chikv into new areas, causing epidemics (chretien and linthicum, ) . no other areas of bangladesh were reporting outbreaks of chikv at this time, though outbreaks may have been missed due to poor surveillance. although individuals of all ages were affected by chikungunya in this outbreak, incidence increased with age among females, potentially linked to increased time women spend at home compared to males, increasing their risk of being bitten by the largely home-dwelling aedes mosquito (salje et al., b) . in this outbreak, household use of mosquito coils was not protective against chikungunya, which is consistent with the findings from a recent meta-analysis on household level risk factors for dengue, which is also spread through aedes mosquitoes (bowman et al., ) . serum samples have the potential to provide important information about the level of asymptomatic infection during an outbreak, as has previously been shown during previous chikv outbreaks (salje et al., a , sissoko et al., . in addition, this outbreak investigation was carried out six months after the outbreak began and community members may have been unable to reliably recall their symptoms or the date their symptoms started, particularly for milder illnesses, which may have led to an underestimation of suspected cases. serological confirmation could help detect any missing infections. however, our study highlights how some caution needs to be taken when interpreting serological data. firstly, while we sought to obtain blood samples from all participants, only one in five individuals agreed. we found that the probability of agreeing to provide blood depended strongly on having had chikungunya symptoms (individuals who had symptoms were more likely to provide samples). children, women and those with a high educational level were less likely to give blood. secondly, the sensitivity of the commercial assay we used has been estimated to be < % in individuals where igm is still circulating (johnson et al., ) and is likely to be even lower here, as the blood draw occurred after igm antibodies would have waned to undetectable levels for many infected individuals (kam et al., ) . future studies should consider underlying biases in who is providing blood as well as considering the use of complementary igg assays to help improve the interpretability of serological findings. this investigation suggests that chikungunya virus has become an emerging public health problem in bangladesh, and outbreak investigations of emerging infections often have the objective of estimating attack rates of diseases and identifying the risk factors that lead to infection. our analysis suggests that the optimal strategy for attaining these objectives during an outbreak is to conduct case finding, testing, and data collection in communities. many recent j o u r n a l p r e -p r o o f outbreaks of emerging infections have suffered due to a lack of detailed information about attack rates and risk for infection, due to their limited investigation strategies (ahmed et al., , ballera et al., , khatun et al., . future investigations of emerging infection outbreaks should consider using these more intensive strategies, at least in a subset of investigations, to improve our understanding of these infections and our public health response. according to institutional data policy of the international centre for diarrhoeal disease research, bangladesh (icddr,b), summary of data can be publicly displayed or can be made publicly accessible. to protect intellectual property rights of primary data, icddr,b cannot make primary data publicly available. however, upon request, institutional data access committee of icddr,b can provide access to primary data to any individual, upon reviewing the nature and potential use of the data. requests for data can be forwarded to: this work was supported by centers for disease control and prevention (cdc), atlanta, usa [cooperative agreement no: u ci ]. in addition, the government of bangladesh, canada, sweden and the uk provided core/unrestricted funding support for this work. the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. chikungunya virus outbreak hospital-associated outbreak of middle east respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description chikungunya outbreak ebola virus disease in west africa--the first months of the epidemic and forward projections investigation of chikungunya fever outbreak in laguna bangladesh population and housing census added value of a household-level study during an outbreak investigation of salmonella serotype saintpaul infections is dengue vector control deficient in effectiveness or evidence?: systematic review and meta-analysis delivery complications and healthcare-seeking behaviour: the bangladesh demographic health survey chikungunya in europe: what's next? household transmission of influenza a (h n ) virus after a school-based outbreak first identified outbreak of chikungunya in bangladesh laboratory diagnosis of chikungunya virus infections and commercial sources for diagnostic assays early appearance of neutralizing immunoglobulin g antibodies is associated with chikungunya virus clearance and long-term clinical protection an outbreak of chikungunya in rural bangladesh estimating potential incidence of mers-cov associated with hajj pilgrims to saudi arabia dynamics and control of ebola virus transmission in montserrado, liberia: a mathematical modelling analysis ebola virus outbreak investigation an epidemic of virus disease in southern province, tanganyika territory general description and epidemiology evaluating hospital-based surveillance for outbreak detection in bangladesh: analysis of healthcare utilization data gender differences in healthcare-seeking during common illnesses in a rural community of west bengal reconstruction of years of chikungunya epidemiology in the philippines demonstrates episodic and focal transmission how social structures, space, and behaviors shape the spread of infectious diseases using chikungunya as a case study selection of important variables and determination of functional form for continuous predictors in multivariable model building seroprevalence and risk factors of chikungunya virus infection in mayotte the epidemic of zika virus-related microcephaly in brazil: detection, control, etiology, and future scenarios effect of ebola progression on transmission and control in liberia the authors have no competing interests to declare. j o u r n a l p r e -p r o o f key: cord- -row mn authors: chan, jasper fuk-woo; lau, susanna kar-pui; woo, patrick chiu-yat title: the emerging novel middle east respiratory syndrome coronavirus: the “knowns” and “unknowns” date: - - journal: j formos med assoc doi: . /j.jfma. . . sha: doc_id: cord_uid: row mn a novel lineage c betacoronavirus, originally named human coronavirus emc/ (hcov-emc) and recently renamed middle east respiratory syndrome coronavirus (mers-cov), that is phylogenetically closely related to tylonycteris bat coronavirus hku and pipistrellus bat coronavirus hku , which we discovered in from bats in hong kong, has recently emerged in the middle east to cause a severe acute respiratory syndrome (sars)-like infection in humans. the first laboratory-confirmed case, which involved a -year-old man from bisha, the kingdom of saudi arabia (ksa), who died of rapidly progressive community-acquired pneumonia and acute renal failure, was announced by the world health organization (who) on september , . since then, a total of cases, including fatalities, have been reported in the middle east and europe. recent clusters involving epidemiologically-linked household contacts and hospital contacts in the middle east, europe, and africa strongly suggested possible human-to-human transmission. clinical and laboratory research data generated in the past few months have provided new insights into the possible animal reservoirs, transmissibility, and virulence of mers-cov, and the optimal laboratory diagnostic options and potential antiviral targets for mers-cov-associated infection. introduction: the "new sars"? ten years after the devastating epidemic of severe acute respiratory syndrome (sars) caused by sars coronavirus (sars-cov), which resulted in a total of deaths among more than confirmed cases in over countries, the world is facing a new challenge posted by a "sars-like" infection caused by another novel coronavirus emerging from the middle east, which was originally named human coronavirus emc/ (hcov-emc) and recently renamed by the coronavirus study group of the international committee for taxonomy of viruses as middle east respiratory syndrome coronavirus (mers-cov). e the complete genome of the virus was sequenced and released in october after the isolation of the virus from two patients with severe community-acquired pneumonia in bisha, the kingdom of saudi arabia (ksa), and doha, qatar, first announced by the world health organization (who) on september . as of may , , the total number of laboratory-confirmed cases of mers-cov infection has increased to with deaths, including two cases confirmed retrospectively from a jordanian cluster of severe respiratory disease reported by the ministry of health of jordan in april (table ) . , , e although the number of laboratory-confirmed cases remains limited, the severe clinical manifestations with an unusually high mortality rate of over %, the spread of the infection beyond the geographical confinement in the middle east, and the epidemiological evidence of human-to-human transmission arising from the recent clusters of cases in a family in the united kingdom (cases to ), and in hospitals in ksa (cases to , and ) and france (cases and ), have raised significant concerns on the possible emergence of another sars-like epidemic in the near future. in anticipation of the potential spread of this highly pathogenic virus from the middle east and europe to other parts of the world, especially the densely populated southeast asia, an updated review of the latest research findings on mers-cov and their implications on the clinical management of mers-cov infection is essential. viral genomic studies reveal the first lineage c betacoronavirus associated with human infection mers-cov belongs to the genus betacoronavirus in the family coronaviridae under the order nidovirales. coronaviruses are enveloped viruses with positive-sense singlestranded rna genomes. studies in their biodiversity, comparative genomics and phylogeny in the past years have improved our understanding of this family of viruses. e according to the most recent classification by the coronavirus study group of the international committee for taxonomy of viruses, there are four genera in coronaviridae, namely alphacoronavirus, betacoronavirus, gammacoronavirus, and deltacoronavirus. , the genus alphacoronavirus contains two human coronaviruses, hcov- e and hcov-nl , which are associated with the common cold. no human coronavirus has been discovered in gammacoronavirus and deltacoronavirus, which mainly contain avian coronaviruses with just a few mammalian coronaviruses. the genus betacoronavirus is comprised of four lineages (a, b, c and d) which contain four coronaviruses associated with human infections: hcov-oc and hcov-hku (lineage a), sars-cov (lineage b), and mers-cov (lineage c). mers-cov is the first known lineage c betacoronavirus associated with human infection and is phylogenetically closely related to the other lineage c betacoronaviruses including tylonycteris bat cov hku (ty-batcov-hku ) and pipistrellus bat cov hku (pi-batcov-hku ), which were discovered in lesser bamboo bats (tylonycteris pachypus) and japanese pipistrelle bats (pipistrellus abramus), respectively, captured in hong kong, china. , , analysis of the genome of mers-cov revealed that it has a genome size of , bases with the rdrp and s genes having over % and around % amino acid identities with those of ty-batcov-hku and pi-batcov-hku . , molecular clock analysis using the rdrp gene showed that mers-cov might have diverged from the most recent common ancestor of lineage c betacoronaviruses in year w ad ( bc to ad). it is postulated that the emergence of mers-cov represents another series of interspecies transmission events in coronaviruses, from bats to possibly other animals and then to humans, a scenario similar to the sars epidemic. epidemiology reports and cell line susceptibility studies suggest possible animal reservoirs and human-to-human transmissions epidemiological linkage with animals, including camels, goats, sheep, and farm animals or their caretakers before symptom onset in some of the reported cases supported the hypothesis of mers-cov being a zoonotic agent (table ) . furthermore, in vitro data from cell line susceptibility studies showed that the virus had a broad species tropism and was able to replicate in bat, primate, porcine, rabbit, and civet cell lines. , as in the case of sars-cov, which likely emerged from its natural animal reservoir the horseshoe bats (rhinolophus sp.), and jumped to other mammals during their caging in the wild life markets of south china and then to humans, mers-cov might have also originated from bats to these susceptible animal species before adapting to humans. , , in addition to pipistrellus bats, which are the natural hosts of the closely related pi-batcov-hku and are also found in the middle east, rousettus, rhinolophus, myotis, and carollia bat cell lines are also susceptible to mers-cov infection in vitro. active surveillance of different bat and animal species predominantly found in the middle east would help to delineate the natural bat reservoir and the evolutionary pathway of mers-cov among other susceptible animal species. indeed, a recent study showed that a number of different bat species in ghana and europe are infected with coronaviruses, which also share close homologies with mers-cov. determination of the virus' animal hosts might in turn facilitate the control of the outbreak as in sars, where closure of the wet markets likely contributed to the cessation of the epidemic. human-to-human transmission represents a new stage in the evolution of mers-cov infection. there are, so far, six the seroprevalence and transmissibility of mers-cov remain undetermined, although animal-to-human and human-to-human transmissions both appear to be limited at this stage (fig. ) . among persons seeking medical attention in a hospital in jeddah, ksa, none had mers-covspecific igg detectable by indirect immunofluorescence assay, suggesting that the current situation is likely to be different from those of other human coronaviruses which are endemic in humans. , the lack of secondary cases among nearly contacts of cases and who did not practice optimal infection control measures before the diagnosis of mers-cov infection was confirmed, implied that this novel virus might be less efficient than sars-cov in human-tohuman transmission. , , however, the findings of these studies should be interpreted with cautions for two reasons. first, only a relatively small number of subjects ( / in case and / in case ) were tested by reliable laboratory tests. second, the timing of testing was not clearly described and might be suboptimal for the purpose of excluding the diagnosis. it has been proposed that a second test should be performed in symptomatic patients with initially negative results by reverse transcriptionpolymerase chain reaction (rt-pcr), within the first days of symptom onset, based on the observation in sars where viral load peaked at day of symptom onset. , e therefore, the apparently limited spread of mers-cov at present might be an underestimation and ongoing transmission of the virus should be cautiously monitored. unlike its close relatives in bats, mers-cov is highly pathogenic in humans. the most common clinical presentation among the laboratory-confirmed cases of mers-cov infection is acute severe community-acquired pneumonia with acute renal failure following an estimated incubation period of e days (table ) . , this is unusual among human infections caused by coronaviruses, in which severe pneumonia with respiratory failure is seldom seen, except in sars. the other human coronaviruses, namely hcov- e, hcov-nl , hcov-oc , and hcov-hku , predominantly cause acute self-limited upper respiratory tract infections, and only occasionally cause lower respiratory tract infections in the elderly and immunocompromized populations. only two of patients (cases and ) had a self-limiting, mild, influenza-like illness not requiring hospitalization. asymptomatic or mild infections have otherwise not been detected among the other contacts of confirmed cases by rt-pcr of upper respiratory tract specimens and/or serological tests, saudi residents in jeddah by indirect immunofluorescent antibody testing of archived sera, and french hajj pilgrims with upper respiratory symptoms and rt-pcr of prospectively collected nasal swabs. , , , the other ( . %) patients, many of whom had no underlying medical condition, developed rapid clinical deterioration with lower respiratory tract involvement and respiratory failure requiring ventilator support within a few days to week after initial systemic symptoms of fever, myalgia, and malaise, and upper respiratory tract symptoms such as rhinorrhea and sore throat. this correlated with the finding in our recent cell line susceptibility study, which showed that mers-cov replicated much better in the lower respiratory tract cell lines including calu- (polarized airway epithelium), a (lung adenocarcinoma), and hfl (embryonic lung fibroblasts), than the upper respiratory tract cell line hep- (laryngeal epidermoid carcinoma). another in vitro study also showed that pseudostratified human bronchial epithelium cultures are highly permissive to mers-cov infection. in ex vivo organ cultures, mers-cov productively replicated in both human bronchial and lung tissues, whereas sars-cov only productively replicated in lung tissue. recently, a macaque model showed that mers-cov caused acute, localized to widespread pneumonia, resulting in mild to moderate clinical disease resembling the illness observed in humans. radiologically, pneumonia is evident by focal consolidations involving single or multiple lobes, with progressive involvement of bilateral lung fields, especially the lower zones. in case , thoracic computed tomography scans revealed mediastinal hilar lymphadenopathies, airspace opacities with air bronchograms, scattered ground-glass opacities, interstitial septal thickenings, and nodularities in the upper lobes without significant pleural and pericardial effusions. acute renal failure was the other dominant clinical feature in mers-cov infection and is seen in at least six of the reported cases. many of the remaining severe cases probably also developed renal impairment, although their clinical details were not available. this was unusual, even when compared to sars in which . % of the patients had abnormal urinalysis and detectable viral load by quantitative rt-pcr in urine, but only . % developed acute renal failure with histological evidence of acute tubular necrosis and most did not require renal replacement therapy. this clinical presentation correlates with the in vitro finding of efficient replication of mers-cov in kidney cell lines, including hek , vero, llc-mk , and p. , , more importantly, the presence of renal involvement appeared to be a poor prognostic factor, as those with renal failure either died or required renal replacement therapy, while two cases without renal impairment survived ( table ). the lack of extrapulmonary lesions observed in the macaque model of mers-cov infection suggested that acute renal failure was more likely due to hypoxic damage than a direct viral cytopathic effect. other clinical, laboratory and microbiological findings reported in mers-cov infection included pericarditis, disseminated intravascular coagulation, leukocytosis with neutrophilia and lymphopenia, thrombocytopenia, anemia, hyponatremia, hypoalbuminemia, elevated liver enzymes, lactate dehydrogenase, c-reactive protein, and procalcitonin levels, possible secondary bacterial pneumonia caused by klebsiella pneumoniae, staphylococcus aureus, and acinetobacter sp., and coinfection with other respiratory viruses, including influenza a(h n )pdm and type parainfluenza virus. , , e , it is interesting to note the absence of watery diarrhea in the acute phase of mers-cov infection, despite the in vitro finding of viral replication in the colonic cell line caco- (colorectal adenocarcinoma), in contrast to sars in which around % of patients developed enterocolitis. , it remains to be seen in future case cohorts whether this is due to under-reporting, or a genuine difference in clinical presentations between the two diseases. together with severe acute respiratory and renal failure, these clinical features underscore the success of the innate immune evasion mechanisms of mers-cov in humans, leading to overwhelming infection and possible cytokine dysregulation, as reflected by the lack of interferon through inhibition of interferon regulatory factor family (irf- ). , the discovery of dipeptidyl peptidase (dpp ), a multifunctional -amino-acid-long type-ii transmembrane glycoprotein exopeptidase expressed on human non-ciliated bronchial, renal, enteric, hepatic and prostatic epithelial cells, which is important in the regulation of hormone and chemokine bioactivity, glucose metabolism, t-cell activation, chemotaxis modulation, cell adhesion, apoptosis and regulation of tumorigenicity, as a functional receptor for mers-cov, provides further insights into the unique pattern of organ involvement and unusually severe clinical presentation of this emerging infection. clinical utility and practical concerns of published laboratory diagnostic options several laboratory methods are available for establishing a virological diagnosis of mers-cov infection. the most definitive tests are viral culture from respiratory, fecal, urine, or tissue specimens, and/or a fourfold rise in the serum neutralizing antibody titers taken at to days apart. the first clinical isolate of mers-cov was cultured on monkey kidney cells, like vero and llc-mk , which showed cytopathic effects of syncytium formation, rounding and detachment of cells. subsequent studies have identified various human cell types, including bronchial epithelial, colonic, hepatic, renal, and neuronal cells, monocytes and histiocytes that support the replication of mers-cov. however, the use of viral culture is limited by the requirement of a biosafety level three setting, which is not available in most clinical microbiology laboratories. a serum neutralizing antibody test has the disadvantage of requiring convalescent sera and is therefore mainly used for diagnosis in the convalescent instead of acute phase. , furthermore, the sera of sars patients may contain lowtiter cross-reactive neutralizing antibodies against mers-cov, which may lead to the wrong serodiagnosis, especially in countries where the general population had previous exposure. it remains to be seen whether neutralizing antibodies against mers-cov might also crossreact with other closely related lineage c betacoronaviruses, like ty-batcov-hku and pi-batcov-hku . in most of the laboratory-confirmed cases, diagnosis was established by the detection of nucleic acid by rt-pcr of respiratory tract samples, including combined nose and throat swab, sputum, tracheal aspirate, bronchoalveolar lavage, and/or urine taken between day (cases and ) and day (case ). two highly sensitive real-time rt-pcr assays targeting regions upstream of the e gene (upe), with sensitivity of up to . rna copies per reaction and within an open reading frame (orf) b, with sensitivity of up to rna copies per reaction, have been proposed for screening and confirmation of mers-cov infection, respectively, and are available in about half of the countries in the who european region. , additional testing of other gene targets with partial or whole genome sequence analysis may also be used for confirmation. , for example, pan-coronavirus rt-pcr targeting the rdrp gene was used in case and a real-time quantitative rt-pcr assay targeting the n gene has been used in in vitro studies, and may also be useful for clinical diagnosis, although further evaluations are needed. other potential diagnostic options which might be used in areas without rt-pcr are n or s protein-based enzyme-linked immunosorbent assays, which were shown to be highly sensitive and/ or specific for the diagnosis of sars. of note, the detection of other respiratory viruses in the respiratory tract specimen does not preclude the need for specific mers-cov testing in patients with epidemiological risk factors, or unusually severe disease, despite antiviral treatment as exemplified by the presence of coinfections in cases e . the exceptionally high crude mortality rate of % in mers-cov infection is partly due to the lack of specific anticoronavirus treatment and effective vaccine. in most of the cases, intensive supportive treatment with extracorporeal membrane oxygenation, renal replacement therapy, and empirical broad-spectrum antibacterial and antiviral agents were used. case , who is still in a critical condition nearly months after symptom onset, also received a corticosteroid in the initial phase of treatment, but its efficacy is unknown. its use might be limited by serious side effects and the availability of ecmo for organ support during the critical phase. alternatively, type i interferons appear to be promising therapeutic options, as mers-cov has been shown to be much more sensitive than sars-cov to the antiviral action of interferon in vitro. the replication of mers-cov was shown to be reduced in human lung ex vivo organ cultures treated with type i interferons. a recent study showed that while both interferon-a b and ribavirin reduced the replication of mers-cov in vero and llc-mk cells, the combination of the two drugs achieved the same endpoints at a much lower concentration, which might facilitate their clinical applications. other potential specific antiviral targets include type ii transmembrane serine proteases (tmprss ) and endosomal cathepsins, which are responsible for mers-cov s protein activation required for virus-cell fusion and entry of the virus into host cells. the identification of dpp , but not angiotensinconverting enzyme (ace ), aminopeptidase n, and carcinoembryonic antigen-related cell adhesion molecule (ceacam ), as a functional receptor for mers-cov implies that in vivo manipulation of dpp levels and development of inhibitors against the s domain-dpp interface might have potential therapeutic roles in mers-cov infection, as with ace analogues in the case of sars. finally, the recognition of the predicted receptor-binding domain /critical neutralizing domain at residues to in the mers-cov s protein might facilitate vaccine development for this emerging infection. in the past few months, following the who's announcement of the first two cases of mers-cov infection on september , , clinicians and scientists worldwide have collaborated closely in an attempt to prevent a sars-like epidemic from happening again. the discovery of certain important characteristics of mers-cov including its genome arrangement, phylogenetic relatedness with other coronaviruses, in vitro tissue and species tropism, and functional receptor, enhanced our understanding of the clinical presentation, pathogenesis, epidemiology, and design of diagnostic and therapeutic options of this emerging novel human coronavirus. however, key questions concerning the definitive animal reservoirs of the virus, evolutionary process, transmissibility, and the prognostic factors and optimal treatment modalities of the infection, remain elusive. more importantly, the increasing number of laboratory-confirmed cases in the middle east, and the recent evidence of human-tohuman transmission in europe are suggestive of continuing viral adaptations in humans, which might precede a largescale epidemic. indeed, as of june , after the acceptance of the article, the total number of laboratoryconfirmed cases have increased to with fatalities. additional clusters of cases involving household and/or hospital contacts were reported in ksa, italy, and tunisia. collaborations between global and local health authorities and their sustained support for further research on mers-cov are crucial to control this "new sars". severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection coronavirus as a possible cause of severe acute respiratory syndrome the severe acute respiratory syndrome relative rates of non-pneumonic sars coronavirus infection and sars coronavirus pneumonia is the discovery of the novel human betacoronavirus c emc/ (hcov-emc) the beginning of another sars-like pandemic isolation of a novel coronavirus from a man with pneumonia in saudi arabia severe respiratory illness caused by a novel coronavirus middle east respiratory syndrome coronavirus (mers-cov); announcement of the coronavirus study group genomic characterization of a newly discovered coronavirus associated with acute respiratory distress syndrome in humans latest outbreak news from promed-mail: novel coronavirus e middle east recovery from severe novel coronavirus infection evidence of person-to-person transmission within a family cluster of novel coronavirus infections contact investigation of a case of human novel coronavirus infection treated in a german hospital world health organization. global alert and response: novel coronavirus infectioneupdate. geneva: who coronavirus diversity, phylogeny and interspecies jumping severe acute respiratory syndrome coronavirus-like virus in chinese horseshoe bats characterization and complete genome sequence of a novel coronavirus, coronavirus hku , from patients with pneumonia molecular diversity of coronaviruses in bats coronavirus hku and other coronavirus infections in hong kong comparative analysis of coronavirus hku genomes reveals a novel genotype and evidence of natural recombination in coronavirus hku infectious diseases emerging from chinese wet-markets: zoonotic origins of severe respiratory viral infections comparative analysis of twelve genomes of three novel group c and group d coronaviruses reveals unique group and subgroup features complete genome sequence of bat coronavirus hku from chinese horseshoe bats revealed a much smaller spike gene with a different evolutionary lineage from the rest of the genome covdb: a comprehensive database for comparative analysis of coronavirus genes and genomes comparative analysis of complete genome sequences of three avian coronaviruses reveals a novel group c coronavirus ecoepidemiology and complete genome comparison of different strains of severe acute respiratory syndrome-related rhinolophus bat coronavirus in china reveal bats as a reservoir for acute, self-limiting infection that allows recombination events coexistence of different genotypes in the same bat and serological characterization of rousettus bat coronavirus hku belonging to a novel betacoronavirus subgroup discovery of seven novel mammalian and avian coronaviruses in the genus deltacoronavirus supports bat coronaviruses as the gene source of alphacoronavirus and betacoronavirus and avian coronaviruses as the gene source of gammacoronavirus and deltacoronavirus isolation and characterization of a novel betacoronavirus subgroup a coronavirus, rabbit coronavirus hku , from domestic rabbits recent transmission of a novel alphacoronavirus, bat coronavirus hku , from leschenault's rousettes to pomona leafnosed bats: first evidence of interspecies transmission of coronavirus between bats of different suborders taxonomy of viruses. virus taxonomy: release (current genetic relatedness of the novel human lineage c betacoronavirus to tylonycteris bat coronavirus hku and pipistrellus bat coronavirus hku differential cell line susceptibility to the emerging novel human betacoronavirus c emc/ : implications on disease pathogenesis and clinical manifestation human coronavirus emc does not require the sarscoronavirus receptor and maintains broad replicative capability in mammalian cell lines bats are natural reservoirs of sars-like coronaviruses isolation and characterization of viruses related to the sars coronavirus from animals in southern china human betacoronavirus c emc/ -related viruses in bats, ghana and europe clinical and molecular epidemiological features of coronavirus hku -associated community-acquired pneumonia the united kingdom public health response to an imported laboratory confirmed case of a novel corona viral replication in the nasopharynx is associated with diarrhea in patients with severe acute respiratory syndrome viral loads in clinical specimens and sars manifestations clinical progression and viral load in a community outbreak of coronavirus-associated sars pneumonia: a prospective study incubation period as part of the case definition of severe respiratory illness caused by a novel coronavirus lack of nasal carriage of novel corona virus (hcov-emc) in french hajj pilgrims returning from the hajj , despite a high rate of respiratory symptoms efficient replication of the novel human betacoronavirus emc on primary human epithelium highlights its zoonotic potential tropism and innate immune responses of the novel human betacoronavirus lineage c virus in human ex vivo respiratory organ cultures pneumonia from human coronavirus in a macaque model acute renal impairment in coronavirus-associated severe acute respiratory syndrome human cell tropism and innate immune system interactions of human respiratory coronavirus emc compared to those of severe acute respiratory syndrome coronavirus world health organization. global alert and response: novel coronavirus infectione update. geneva: who dipeptidyl peptidase is a functional receptor for the emerging human coronavirus-emc assays for laboratory confirmation of novel human coronavirus (hcov-emc) infections crossreactive antibodies in convalescent sars patients' sera against the emerging novel human coronavirus emc ( ) by both immunofluorescent and neutralizing antibody tests the spike-protein of the emerging betacoronavirus emc uses a novel coronavirus receptor for entry, can be activated by tmprss and is targeted by neutralizing antibodies detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction laboratory capability for molecular detection and confirmation of novel coronavirus in europe inhibition of novel b coronavirus replication by a combination of interferon-a b and ribavirin a predicted receptor-binding and critical neutralizing domain in s protein of the novel human coronavirus hcov-emc global alert and response (gar): middle east respiratory syndrome coronavirus (mers-cov) e update key: cord- -u qv uc authors: cherry, james. d. title: the chronology of the – sars mini pandemic date: - - journal: paediatr respir rev doi: . /j.prrv. . . sha: doc_id: cord_uid: u qv uc severe acute respiratory syndrome (sars) was a new human disease in the autumn of . it first occurred in southern china in november and was transported to hong kong on february , by an infected and ill patient. ten secondary cases spread the infection to two hospitals in hong kong and to singapore, toronto and hanoi. in march a novel coronavirus (sars-cov) was found to be the causative agent. within weeks from the first sars case in hong kong it had spread to an additional countries or special administrative regions. the mini pandemic peaked during the last week of may and the last new probable case was on july , . there were a total of probable cases and deaths. sixty-six per cent of the cases occurred in china, % in hong kong, % in taiwan and % in both singapore and canada. twenty-one per cent of all cases occurred in healthcare workers. it is an honour to have been asked to contribute the lead paper in this symposium on paediatric sars. of all the participants in this symposium i have the distinction of having had no first-hand experience with sars. nevertheless, i do have some credentials. in march of i travelled to and through hong kong, shanghai, taipei, seoul and narita and realised on my trip back to los angeles on march th that i needed a chapter on sars for the th edition of our book 'textbook of pediatric infectious diseases' which was soon to be published. so, with the help of four hong kong colleagues this chapter was written in under weeks and is the most complete reference to date relating to paediatrics. sars was apparently a new human disease which first occurred in southern china in the autumn of and spread to countries or regions with a total of cases and deaths. [ ] [ ] [ ] the aetiologic agent of sars (a previously unrecognised coronavirus; sars-cov) was isolated and its genome sequenced in record time. [ ] [ ] [ ] [ ] [ ] [ ] following an incredible global public health effort, the mini pandemic was brought under control within months of its initial occurrence. the overall effort demonstrated unprecedented international cooperation and this was facilitated by electronic transmission of information. in general, worldwide media coverage was unusually accurate and provided pictures to augment scientific data. as of june st , there were approximately citations related to sars in the medical literature. however, of these publications only about . % are related to children. during the third week of march both the who and the cdc published preliminary case definitions for severe acute respiratory syndrome (sars). table contains the who initial definitions of suspect and probably cases and table the cdc original definition of a suspected case. , following the rapidly expanding knowledge about sars paediatric respiratory reviews ( ) (table ) . the cdc case definition was updated on four occasions throughout the epidemic as understanding of the clinical, laboratory, and transmission characteristics of sars associated coronavirus increased. the most recent version from the cdc, which is exceedingly complex, is presented in table . transmission of sars apparently first occurred in fosham city, guangdong province, china. , the primary case may have been a -year-old man who had a fever for days and respiratory distress. he was hospitalised and treated in an intensive care unit. he recovered but his wife, aunt, and aunt's daughter all became ill. [ ] [ ] [ ] [ ] viral particles were seen on electron microscopic examination of swabs and sputum specimens from sars patients. the sars virus grew in vero cell and fetal rhesus kidney cell tissue cultures. cytopathic effect was noted in the vero cell cultures in to days and in the fetal rhesus kidney cell cultures in to days. , this virus, which was a novel coronavirus (sars-cov), was rapidly identified using both conventional virologic methods and cutting edge molecular biology. the genome was completely and rapidly sequenced in several laboratories. [ ] [ ] [ ] [ ] [ ] this was a significant accomplishment when one realises that coronaviruses have the largest genomes ( bases of positivestrand rna) found in any rna virus. sequence data allowed the rapid development of highly specific diagnostic tests and also helped in the epidemiologic study of the mini pandemic. the genome sequence data from human isolates assisted in the search for the origin of the disease when similar viruses were isolated from himalayan palm civets and raccoon dogs in a live animal market in shenzhen, china. the viral genomes recovered in nasal swabs from the palm civets were . % homologous to the human sars-cov isolates. early in the epidemic orf reading frame sequences from human isolates were identical to those from the palm civets, which suggested animal to human transmission. as noted above, sars originated in southern china in november . presumably the first case or cases were the result of transmission from palm civets to humans. subsequently, human to human transmission occurred. apparently, human to human transmission did not occur outside of china until february , when the adult physician from guangdong province, whose illness commenced on february , stayed at the metropole hotel in hong kong. the chronology of events related to the metropole hotel is presented in fig. . case a (the primary case) stayed on the ninth floor of the hotel on february , and was then admitted to hospital # the following day and died on february , . secondary cases related to case a, in addition to cases b to k, were four healthcare workers at hospital # and two of the patient's family members. and -cough or breathing difficulty and one or more of the following exposures during the days prior to onset of symptoms: -close contact b with a person who is a suspect or probable case of sars -history of travel to an area with recent local transmission of sars -residing in an area with recent local transmission of sars . a person with an unexplained acute respiratory illness resulting in death after november, , a but on whom no autopsy has been performed and one or more of the following exposures during to days prior to onset of symptoms: -close contact, b with a person who is a suspect or probable case of sars -history of travel to an area with recent local transmission of sars -residing in an area with recent local transmission of sars a case should be excluded if an alternative diagnosis can fully explain their illness. as sars is currently a diagnosis of exclusion, the status of a reported case may change over time. a patient should always be managed as clinically appropriate, regardless of their case status -a case initially classified as suspect or probable, for whom an alternative diagnosis can fully explain the illness, should be discarded after carefully considering the possibility of co-infection -a suspect case who, after investigation, fulfils the probable case definition should be reclassified as 'probable' -a suspect case with a normal cxr should be treated as deemed appropriate and monitored for days. those cases in which recovery is inadequate should be re-evaluated by cxr -those suspect cases in whom recovery is adequate but whose illness cannot be fully explained by an alternative diagnosis should remain as 'suspect' -a suspect case who dies, on whom no autopsy is conducted, should remain classified as 'suspect'. however, if this case is identified as being part of a chain transmission of sars, the case should be reclassified as 'probable' -if an autopsy is conducted and no pathological evidence of rds is found, the case should be 'discarded' a the surveillance period begins on november to capture cases of atypical pneumonia in china now recognized as sars. presence of two or more of the following features: fever (might be subjective), chills, rigors, myalgia, headache, diarrhea, sore throat, or rhinorrhea mild-to-moderate respiratory illness temperature of > . f (> c) * and one or more clinical findings of lower respiratory illness (e.g. cough, shortness of breath or difficulty breathing) severe respiratory illness meets clinical criteria of mild-to-moderate respiratory illness and one or more of the following findings: --radiographic evidence of pneumonia or --acute respiratory distress syndrome or --autopsy findings consistent with pneumonia or acute respiratory distress syndrome without an identifiable cause possible exposure to sars-associated coronavirus (sars-cov) one or more of the following exposures in the days before onset of symptoms: travel to a foreign or domestic location with documented or suspected recent transmission of sars-cov a or close contact b with a person with mild-to-moderate or severe respiratory illness and history of travel in the days before onset of symptoms to a foreign or domestic location with documented or suspected recent transmission of sars-cov a likely exposure to sars-cov one or more of the following exposures in the days before onset of symptoms: close contact b with a person with confirmed sars-cov disease or close contact b with a person with mild-to-moderate or severe respiratory illness for whom a chain of transmission can be linked to a confirmed case of sars-cov disease in the days before onset of symptoms tests to detect sars-cov are being refined and their performance characteristics assessed c ; therefore, criteria for laboratory diagnosis of sars-cov are changing. the following are general criteria for laboratory confirmation of sars-cov: detection of serum antibody to sars-cov by a test validated by cdc (e.g. enzyme immunoassay) or isolation in cell culture of sars-cov from a clinical specimen or detection of sars-cov rna by a reverse transcription polymerase chain reaction test validated by cdc and with subsequent confirmation in a reference laboratory (e.g. cdc) information about the current criteria for laboratory diagnosis of sars-cov is available at http://www.cdc.gov/ncidod/sars/labdiagnosis.htm a case may be excluded as a sars report under investigation (sars rui), including as a cdc-defined probable sars-cov case, if any of the following apply: an alternative diagnosis can explain the illness fully d or antibody to sars-cov is undetectable in a serum specimen obtained > days after onset of illness e or the case was reported on the basis of contact with a person who was subsequently excluded as a case of sars-cov disease; then the reported case is also excluded, provided other epidemiologic or laboratory criteria are not present case classification sars rui reports in persons from areas where sars is not known to be active sars rui- : cases compatible with sars in groups likely to be first affected by sars-cov f if sars-cov is introduced from a person without clear epidemiologic links to known cases of sars-cov disease or places with known ongoing transmission of sars-cov c) is expected. however, clinical judgment may allow a small proportion of patients without a documented fever to meet this criterion. factors that might be considered include: patients' self-report of fever; use of antipyretics; presence of immunocompromising conditions or therapies; lack of access to healthcare; or inability to obtain a measured temperature. initial case classification based on reported information might change, and reclassification might be required. a types of locations specified will vary (e.g. country, airport, city, building, or floor of building). the last date a location may be a criterion for exposure is days (one incubation period) after removal of that location from cdc travel alert status. the patient's travel should have occurred on or before the last date the travel alert was in place. transit through a foreign airport meets the epidemiologic criteria for possible exposure in a location for which a cdc travel advisory is in effect. information about cdc travel alerts and advisories and assistance in determining appropriate dates are available at http://www.cdc.gov/ncidod/sars/travel.htm. b close contact is defined as having cared for or lived with a person with sars or having a high likelihood of direct contact with respiratory secretions and/or body fluids of a person with sars (during encounters with the patient or through contact with materials contaminated by the patient) either during the period the person was clinically ill or within days of resolution of symptoms. examples of close contact include kissing or embracing, sharing eating or drinking utensils, close (i.e. < feet) conversation, physical examination, and any other direct physical contact between persons. close contact does not include activities such as walking by a person or sitting across a waiting room or office for a brief time. c the identification of the aetiologic agent of sars (i.e. sars-cov) led to the rapid development of enzyme immunoassays and immunofluorescence assays for serologic diagnosis and reverse transcription polymerase chain reaction assays for detection of sars-cov rna in clinical samples. these assays can be very sensitive and specific for detecting antibody and rna, respectively, in the later stages of sars-cov disease. however, both are less sensitive for detecting infection early in illness. the majority of patients in the early stages of sars-cov disease have a low titre of virus in respiratory and other secretions and require time to mount an antibody response. sars-cov antibody tests might be positive as early as - days after onset of illness and often by days after onset of illness, but sometimes not until days after onset of illness. information about the current criteria for laboratory diagnosis of sars-cov is available at http://www.cdc.gov/ncidod/sars/labdiagnosis.htm. d factors that may be considered in assigning alternate diagnoses include the strength of the epidemiologic exposure criteria for sars-cov disease, the specificity of the alternate diagnostic test, and the compatibility of the clinical presentation and course of illness with the alternative diagnosis. e current data indicate that > % of patients with sars-cov disease mount an antibody response to sars-cov. however, health officials may choose not to exclude a case on the basis of lack of a serologic response if reasonable concern exists that an antibody response could not be mounted. f consensus guidance is in development between cdc and cste on which groups are most likely to be affected first by sars-cov if it re-emerges. sars-cov disease should be considered at a minimum in the differential diagnoses for persons requiring hospitalisation for pneumonia confirmed radiographically or acute respiratory distress syndrome without identifiable aetiology and who have one of the following risk factors in the days before the onset of illness: ( ) travel to mainland china, hong kong, or taiwan, or close contact with an ill person with a history of recent travel to one of these areas, or; ( ) employment in an occupation associated with a risk for sars-cov exposure (e.g. healthcare worker with direct patient contact or worker in a laboratory that contains live sars-cov) or; ( ) part of a cluster of cases of atypical pneumonia without an alternative diagnosis. guidelines for the identification, evaluation, and management of these patients are available at http://www.cdc.gov/ncidod/sars/absenceofsars.htm. g during the sars epidemic, cdc case definitions were the following: suspect case; ( ) meets the clinical criteria for mild-tomoderate respiratory illness and the epidemiologic criteria for possible exposure to sars-cov but does not meet any of the laboratory criteria and exclusion criteria or; ( ) unexplained acute respiratory illness that results in death of a person on whom an autopsy was not performed and that meets the epidemiologic criteria for possible exposure to sars-cov but does not meet any of the laboratory criteria and exclusion criteria; probable case; ( ) meets the clinical criteria for severe respiratory illness and the epidemiologic criteria for possible exposure to sars-cov but does not meet any of the laboratory criteria and exclusion criteria. was investigating the outbreak in hanoi became ill and returned to bangkok. patients c, d, and e were the primary cases in singapore and their illnesses led to cases in singapore and three cases in germany. patients f and g were the initial cases in canada and case f was subsequently linked to a cluster of cases in toronto. patients h and j were linked to outbreaks among healthcare workers in hong kong hospitals # and # . patients i, l, and m were suspect cases in the united states. case k was a potential primary case in ireland. on february , the hanoi office of the world health organization was contacted by officials at the vietnam french hospital. they were concerned about the unusual influenza-like illness that patient b had which they suspected could have been due to an avian influenza virus. dr. carlo urbani from the who office answered the call and rapidly determined that the illness which had spread throughout the hospital was unusual. he carried out an extensive on-site investigation and worked with the hospital staff to set up quarantine procedures. his efforts led to the containment of sars in hanoi. unfortunately, he became ill with sars on march , and died in an isolation room in a bangkok hospital on march , . he did not live to see the worldwide successes of sars control which resulted to a great extent from his early detection of sars. following fig. were india, japan and mongolia. of these countries, no secondary transmission occurred in india, japan was later removed from the list and in mongolia there were nine cases with eight of these being importations. as of may , new countries or administration regions included bulgaria, china, macao sar, columbia, finland, poland and the republic of korea. of these countries or regions only macao sar and the republic of korea had accepted cases and in both regions the cases were imported. in the june nd report one case in the russian federation was noted but this was subsequently removed from the data set. eighty-seven per cent of all probably sars cases occurred in hong kong or china and information relating to these cases in presented elsewhere in this symposium. only five other countries (canada, taiwan, singapore, the united states and vietnam) had more than probable cases. in canada there were cases with the first case occurring on february , and the last case on june , . the vast majority of cases in canada ( %) were secondary to five primary importations and % of the cases occurred in healthcare workers. in taiwan % of the cases were importations and % occurred in healthcare workers. in singapore % of the cases were importations and % of the locally acquired cases were in healthcare workers. in singapore the epidemic was controlled within weeks of the initial importation. all probable cases in the united states were importations. however, only eight of these were laboratory confirmed. in vietnam, of the cases were the result of local transmission. the outbreak was controlled within weeks of the first and only imported case. in summary, the sars mini pandemic of - probably does not deserve to be called a pandemic. however, the death rate in adults was sobering. in reality, significant epidemic disease occurred in only five countries and the special administrative region of hong kong. nevertheless, sars was an eye opener in regard to the number of healthcare workers who became infected. hopefully the clinical lessons relating to isolation practices, personnel protection and the effective use of quarantine will be retained. personally i will be less cavalier in my approach to patients with fever and respiratory illness. severe acute respiratory syndrome (sars) world health organization. summary of probable sars cases with onset of illness from world health organization. consensus document on the epidemiology of severe acute respiratory syndrome (sars) the genome sequence of the sars-associated coronavirus identification of a novel coronavirus in patients with severe acute respiratory syndrome characterization of a novel coronavirus associated with severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome the sars coronavirus: a postgenomic era world health organization. severe acute respiratory syndrome (sars) outbreak news: severe acute respiratory syndrome (sars) trends in tuberculosis morbidity -united states world health organization. case definitions for surveillance of severe acute respiratory syndrome (sars) tracing the path of sars: a tale of deadly infection update outbreak of severe acute respiratory syndrome -worldwide coronavirus as a possible cause of severe acute respiratory syndrome identification of severe acute respiratory syndrome in canada world health organization. summary on major findings in relation to coronavirus by members of the who multi-centre collaborative network on sars aetiology and diagnosis isolation and characterization of viruses related to the sars coronavirus from animals in southern china key: cord- -v pwvst authors: ma, lin-lu; li, bui-hui; jin, ying-hui; deng, tong; ren, xue-qun; zeng, xian-tao title: developments, evolution, and implications of national diagnostic criteria for covid- in china date: - - journal: front med (lausanne) doi: . /fmed. . sha: doc_id: cord_uid: v pwvst recently who has characterized covid- as a pandemic. diagnosing the disease accurately and decreasing misdiagnoses and missed diagnoses is very important for management. therefore, we have analyzed the seven versions of china's national guidelines to examine how the diagnostic criteria roadmap has developed and evolved, in order to share our experience worldwide. in this article, we present the developments from the first to seventh versions, involving changes of case classification, changes to “suspected case,” changes in “confirmed case,” changes in clinical classifications, changes in “severe case,” and unchanged criteria. we have also discussed the reasons and implications for these changes and are looking forward to providing suggestions for worldwide understanding and management of this pandemic. a nucleic acid test is currently accepted as the gold standard method to confirm diagnosis. in addition, imaging examination and epidemiological history should also be considered as auxiliary diagnosis methods. since december , a new disease caused by novel coronavirus ( -ncov) has resulted in a worldwide outbreak ( ) ( ) ( ) . the disease has been named coronavirus disease (covid- ) and the virus has been named severe acute respiratory syndrome coronavirus (sars-cov- ) ( ). it is vital, both for individuals and governments, to have accurate diagnostic methods for this disease and to minimize misdiagnosis and missed diagnoses in order to facilitate prevention and treatment. because covid- is a new disease, our awareness and knowledge are gradually increasing based on ongoing research findings and clinical practice experience; hence, the diagnostic criteria are also evolving. the outbreak has continued to increase worldwide and on march , who characterized covid- as a pandemic ( ) . therefore, we aim to share our experience with the rest of the world based on an analysis of the evolving changes in the diagnostic criteria incorporated in the different versions of china's national guidelines for covid- . we searched for all versions of the diagnosis and treatment guidelines for covid- , which have been issued by the national health committee of the people's republic of china (http://www.nhc. gov.cn/) up to march . the first to seventh versions were included and the data necessary to estimate the changes in diagnosis of covid- were extracted. two authors independently reviewed the full text. discrepancies were resolved by discussion and consensus. besides extracting all the context of diagnostic criteria, the issued data, clinical classification, and definition of severe disease were also collected. all changes have been compared and presented in a separated table for suspected cases, confirmed cases, and severe cases. other changed and unchanged items have also been described. all analyses used microsoft excel and powerpoint . the first version was issued on january , and the seventh version on march . table presents the changes in these seven guidelines. the criteria for case classification developed considerably over time. in the first edition, three types were described: observed case, confirmed case, and critical case; however, from the second edition onwards, the term "observed case" has been changed to "suspected case, " and the criteria for "severe case" has been added. in the third edition, more clinical manifestations were added, and were classified as moderate, severe, and critical according to the severity of clinical symptoms. in the fifth edition, the form "mild" was added. hence, in the seventh edition, the types were suspected case or confirmed case, with four clinical levels of severity: mild, moderate, severe, and critical cases. in the fifth edition, the term "clinically diagnosed cases" was defined for hubei province. in hubei province, the suspected patients who had imaging features of pneumonia were designated as clinically diagnosed cases. however, this type was merged into "suspected case" in the sixth and seventh editions. the term "observed case" used in the first edition was changed to "suspected case" in the second edition. for a patient to be diagnosed as suspected this had to be based on the epidemiological history and clinical manifestations. from the second to fourth editions, it had to include any two epidemiological history features in addition to clinical manifestations. however, from the fifth to seventh editions, a comprehensive analysis was required which included epidemiological history along with clinical manifestations; cases without clear epidemiological histories were added as a criterion judged by the presence of clinical features. epidemiological history initially included direct or indirect contact with related markets in wuhan, which was mentioned in the first edition. however, this item was deleted from the second edition onwards, but "a history of contact with patients with fever or respiratory symptoms from wuhan city within the last days before symptom onset, or with a cluster of confirmed cases" was added. then in the fourth edition, the contact scope was enlarged to include other places where covid- had spread and also included an epidemiological relationship with -ncov infected cases. for clinical manifestation, "symptoms without obvious improvement or with progressive severity after days of standardized antimicrobial therapy" was mentioned in the first edition. however, this was deleted from the second edition onwards, and it only included fever, imaging features of covid- , and total white blood cell counts showing normal, decreased, or reduced lymphocyte count. in the fifth edition, the fever symptom was expanded and respiratory symptoms added; the criterion of "suspected case" was divided into inside hubei province and outside hubei province. the suspected patients having imaging features of pneumonia were designated as clinically diagnosed cases. in the first edition, to define the case as "confirmed, " it was necessary to collect the respiratory tract sample for viral whole genome sequencing, and this needed to show high homogeneity to the known novel coronaviruses. the real-time pcr test for nucleic acid in the respiratory tract or blood samples was added in the second and third editions. the pathogenic detection via blood samples was added in the fourth and fifth editions; the serological evidence was added in the seventh edition. in the seventh edition, if "the specific igm antibody and igg antibody of -ncov are reported in serum as positive, " or "the -ncov specific igg antibody in serum changes from negative to positive, or rises ≥ times in the recovery phase above that in the acute phase, " this is also diagnosed as covid- . there was no clear clinical classification in the first three editions. in the first edition, it specified a clear criterion for "critical case, " and the criterion for "severe case" was added in the second and third editions. the clinical stages were added in the fourth edition, which divided confirmed cases into moderate severe and critical stages; the mild stage was then added in the fifth to seventh editions. the mild stage was defined as persons having slight clinical symptoms without any imaging features of pneumonia. the criterion for severe case has evolved since the second edition. compared with this edition, "oxygen saturation during inhalation ≤ %" was modified to "oxygen saturation during inhalation ≤ %" in the third to seventh editions; additionally, the descriptions of rapid sequential organ failure assessment (qsofa) score, curb- score, and coalescent pneumothorax were also deleted. the "other combined clinical conditions that necessitate hospitalization" in the second and third editions was also deleted in the latter four editions. the description "pulmonary imaging shows leafy lesions or progressive lesions > % in h" was deleted in the fourth and fifth editions but was reincorporated in the sixth and seventh editions. in the sixth edition, "the necessity to adjust the arterial partial pressure of oxygen (pao )/fraction of inspired oxygen (fio ) for patients from high attitude areas" was added. in the seventh edition, "severe cases" were defined and divided into children and adults. the criteria for critical case were almost unchanged in these seven editions, except that in the third to seventh editions, "respiratory failure" was expanded to "respiratory failure occurs and mechanical ventilation is required, " and "septic shock" was revised to "shows symptoms of shock." we believe there are two major reasons for these changes: our increasing knowledge and awareness of covid- and the feedback from clinical practice. because covid- is a new infectious disease, we are still learning its etiology, source of infection, transmission route, capacity for transmission, clinical manifestation, diagnostic criteria, treatment, and other relevant information. in the early stages, the clinical symptoms of covid- are similar to common flu or pneumonia, which only present as fever and/or a cough ( ) . hence, only observation and empirical antimicrobial therapy were given for mild cases. when the -ncov was extracted from patient samples, the antimicrobial therapy was then deleted from the treatment criteria of suspected cases. in response to the rapid increase in the number of cases which were submitted by wuhan city, many government departments reacted rapidly ( ) by establishing a joint prevention and control mechanism, increasing the information about covid- , raising public awareness of the outbreak, revising "observed case" to "suspected case, " and providing centralized isolation for suspected cases. then, with reports of increasing numbers of confirmed and suspected cases in many regions, especially when human-human transmission was confirmed, and many cases were presenting with no history of living in or contact with wuhan ( ), the designation of suspected case was not limited to a person's epidemiological history, and isolated cases whose clinical manifestations met the criteria of suspected case were included. according to the whole genome sequencing result of -ncov and compared with other novel coronavirus ( ), etiological detection become the main piece of evidence and the core criterion for diagnosis of covid- . relevant research also continued to search for an optimal nucleic acid detection kit for rapid diagnosis, and the rapid real-time pcr test was established ( ) . when sampling included blood, as well as samples from the respiratory tract, this increased the availability of different specimens ( ) . then serological evidence was included in the etiological evidence category based on relevant studies, and this supported bringing the specific antibody positive result into the confirmed criteria. the frontline doctors and nurses also accumulated more and more clinical experience of seeing and treating covid- . hence, the clinical severity stages were designated according to patients' symptoms from the third edition of the guideline, to facilitate individualized treatment and surveillance of patients. we found some patients' rt-pcr test became positive again after recovery from covid- ( ) . moreover, due to the nucleic acid testing being too slow to meet clinical requirements, this resulted in many people not being correctly diagnosed. hence, in the fifth edition of the guideline, suspected patients who had imaging features of pneumonia in hubei province were considered as clinically diagnosed cases, and then given standardized treatment. this "clinically diagnosed case" was canceled when the capacity of nucleic acid detection improved. we can see that the diagnostic criteria of "severe case" became more detailed and specific. oxygen saturation during inhalation was reduced from ≤ to ≤ %, and qsofa score, curb- score, and description of coalescent pneumothorax were removed. the qsofa score and curb- score were usually used to assess the severity and prognosis of community-acquired pneumonia ( ) , but many studies believed they do not have an ideal correlation with prognosis of covid- , the reason being covid- is more dangerous ( ) . hence, they were deleted from the diagnostic criteria for severe cases. when confirmed cases came from the high-altitude areas having a low concentration of oxygen, the necessity to adjust pao /fio values for cases from these areas was added in the sixth edition. also, along with defining suspected and confirmed cases and the accumulation of clinical experiences in children, the "severe cases" definition for children was added in the seventh edition. some diagnostic criteria were significantly changed over the seven versions of the guidelines. there were many descriptions added relating to epidemiological histories of suspected cases, this indicates that relevant epidemiological studies should be performed as quickly as possible after an outbreak in order to detect the routes of infection and provide evidence for diagnosis and control. for the diagnostic criteria of covid- , from nucleic acid tests to clinical imaging features, from etiological evidence to serological evidence, diagnostic means and methods continue to increase ( ) . however, we must acknowledge that every diagnostic method has its own strengths and weaknesses. for example, a nucleic acid test may produce false-negative results and has a longer detection time, while imaging tests have a short detection time but accurate results are dependent on the radiologists' skill level. besides, some diagnostic criteria remain little changed, such as the criteria for severe case which is almost unchanged. this is because when covid- patients enter the critical phase it is often accompanied by organ failure and shock; these changes develop rapidly and have a high fatality rate. hence, the standard has been maintained for better clinical monitoring and judgment. when the case definition was gradually broadened as knowledge increased, it had a substantial influence on the proportion of infections being detected as cases. when cases are classified in detail, different types of patients are treated with customized interventions, and medical resources can be properly allocated. a study has found through modeling evaluation that from the first version to the second version, the proportion of infections being detected as cases increased by . times ( % confidence interval [ci], . - . ), from the second version to the fourth version it increased by . times ( % ci, . - . ), and from the fourth version to the fifth version by . times ( % ci, . - . ) ( ) . after adding the category of "clinically diagnosed cases" in the fifth edition, , new clinically diagnosed cases were added ( ) . many highly suspected patients who did not receive virological testing due to insufficient detection capabilities were able to be isolated in designated hospitals in a timely manner, with priority given to virus detection and treatment, so as to reduce the potential infection rate and mortality. after all clinically suspected cases were able to be tested by the laboratory, the "clinically diagnosed cases" were deleted in the sixth version. although the use of radiological evidence to confirm viral pneumonia may be an important alternative to the diagnosis and monitoring of covid- , it also brought some problems. this procedure may include some patients with common pneumonia; hence criteria for clinically diagnosed patients also needs to include the nucleic acid results at a later stage to correct the actual number of cases. in addition, with the surge of patients, it was necessary to have enough hospital beds quickly to ensure the early diagnosis and treatment of patients. this requires more funds, equipment, and medical staff input, which poses a challenge to the country's regulatory and economic capabilities ( ) . the nucleic acid test is currently used as a confirmed diagnosis method. in addition, imaging examination and epidemiological history should also be considered as auxiliary diagnosis methods. we suggest approaching covid- diagnosis with caution, doing as much as we can to reduce misdiagnosis and missed diagnoses, exploring and combining different methods, and actively seeking new methods, especially for screening asymptomatic patients and also identifying people who retest as positive again after recovery. all datasets generated for this study are included in the article/supplementary material. x-tz and x-qr: conceptualization. b-hl, td, and l-lm: writing-original draft preparation. x-tz, y-hj, and x-qr: reviewing and editing. all authors have read and agreed to the published version of the manuscript. this study was supported, in part, by the national key research and development program of china ( yfc ) and the special project for emergency science and technology of hubei province ( fca ). we express our gratitude to jean glover from tianjin golden framework consulting company for english editing. we also express our gratitude to the experts of all versions of the diagnosis and treatment guidelines for covid- by the national health committee of the people's republic of china. a novel coronavirus outbreak of global health concern early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a rapid advice guideline for the diagnosis and treatment of novel coronavirus ( -ncov) infected pneumonia (standard version) genetic diversity and evolution of sars-cov- world health organization. who characterizes covid- as a pandemic - transmission of -ncov infection from an asymptomatic contact in germany a new coronavirus associated with human respiratory disease in china detection of novel coronavirus ( -ncov) by real-time rt-pcr detection of sars-cov- in different types of clinical specimens positive rt-pcr test results in patients recovered from covid- qsofa is a poor predictor of short-term mortality in all patients: a systematic review of , patients improved molecular diagnosis of covid- by the novel, highly sensitive and specific covid- -rdrp/hel real-time reverse transcription-polymerase chain reaction assay validated in vitro and with clinical specimens effect of changing case definitions for covid- on the epidemic curve and transmission parameters in mainland china: a modeling study national health commission of the people's republic of china awareness, attitudes, and actions related to covid- among adults with chronic conditions at the onset of the u.s. outbreak: a crosssectional survey key: cord- -yppi a authors: nan title: th european congress of pathology, ljubljana, slovenia, september - , date: - - journal: virchows arch doi: . /s - - - sha: doc_id: cord_uid: yppi a nan introduction formation of terminal villi with syncytiocapillar membranes is necessary for optimal maternal-foetal exchange and especially for oxygen diffusion. immature placentas with little number of syncytiocapillar membranes may worse foetal nutrition and gas exchange. the aim of this study was to estimate the role of villous tree immaturity in the development of intrauterine hypoxia. materials and methods placentas from singleton pregnancies were investigated. according to ultrasound and doppler velocime-try data, apgar score, placentas were divided into groups with chronic hypoxia ( ), iugr ( ), acute intrauterine hypoxia ( ), from normal pregnancies ( ). estimation of the degree of maturity according to gestational age was made on routine histological slides. vascular endothelial growth factor (vegf) and placental growth factor (plgf) concentration in placental tissue homogenates were investigated by elisa method in placentas. results the frequency of placental immaturity was -fold higher in placentas with hypoxia in compare with control group. preterm maturation of placental tree accompany with severe foetal hypoxia, a very high mortality and morbidity. concentration of vegf in placental tissue was elevated in placentas with terminal villi deficiency, and concentration of plgf was elevated in placentas with synchronous immaturity. conclusion due to importance of the placental maldevelopment it is necessary to devise methods of its early diagnostics and investigate mechanisms of villous tree development. determining of vegf and plgf may be useful for this purpose. molecular analysis of hereditary hemochromatosis g weirich, r langer, h nina, n jörg, h hoefler institute of pathology technische universität münchen, munich, germany hereditary hemochromatosis (hh) is an autosomal recessive disorder, common in individuals of northern european descent (prevalence close to : ) . hh is characterized by increased iron absorption and iron deposits in various organs. hh patients may develop liver and pancreas cirrhosis, primary liver cancer, diabetes mellitus, and cardiomyopathy. in the majority of cases, hh is caused by mutations of the hfe-gene on chromosome p. hfe encodes an mhc class-i gene, a putative negative regulator of iron uptake. three hfe mutation are common, c y, h d and s c. patients with a homozygous c y genotype most often endure a severe clinical course, whereas homozygotes for h d may develop mild forms of the disease. heterozygotes are usually symptom-free, but show elevated serum ferritin levels. it has been speculated that secondary iron overload (heavy alcohol, chronic hepatitis, ?-thalassemia) may be a critical co-factor in those heterozygotes that develop symptoms of hh. hh not associated with hfe mutations is much less common. within this heterogeneous group of non-hfe hh, three subtypes have been attributed to genetic alterations. juvenile hemochromatosis (hfe ) is a rare but severe disorder mapped to chromosome q. hfe has recently been mapped to the transferring receptor gene (tfr ) on chromosome q . hfe follows an autosomal dominant trait and is associated with mutations of the ferroportin gene (slc a ) on chromosome . except for juvenile hemochromatosis, hfe, hfe and hfe are amenable to mutation analysis. the advent of modern high throughput technologies such as denaturing high performance liquid chromatography (dhplc) has sparked clinical mutation screening programs, which also include screening of patients suspected to be affected by hh. in addition, dhplc-based mutation screening can also be performed using archival formalin-fixed, paraffin embedded tissues (ffpe). we present here results from hfe-analyses of ffpe from autopsy cases using dhplc and direct sequencing. introduction diseased tissues contain all the information on the genetic and epigenetic changes that caused the disease and determine its outcome (prognosis). recent developments in genome and proteome research offer the opportunity to unravel this information and provide new insight into the molecular pathogenesis of diseases. aims: we are establishing a unique human tissue resource for genome research based on a collection actually comprising . mio paraffin-embedded and frozen tissue samples stored at the temperature of liquid nitrogen. materials and methods this collection is being expanded by national and international interdisciplinary cooperations. blood samples, patient history, laboratory parameters, treatment and outcome information are included in addition to tissues. special emphasis is placed on quality control and compliance with ethical and legal criteria. all protocols follow established standard operating procedures in accordance with guidelines of the fda and recommendations of european countries. informed consent is obtained from patients and appropriate security measures guarantee patient confidentiality. results to make this resource available to a wider scientific community, we generate disease-specific gene libraries and produce tissue micro arrays. well defined expandable cell lines and nude mice xenografts are established for characterization of gene function. conclusion proper access to collections of diseased human tissues is currently a major limiting factor for genome research in medicine. there is an urgent need of tissue banks that meet highest quality and legal criteria. introduction neural cell adhesion molecule (ncam) is highly expressed on cells of the murine metanephrogenic mesenchyme at early stages of kidney development. during further development, ncam can still be detected on epithelial cells of comma and sshaped bodies as well as on interstitial mesenchymal cells. during maturation of the fetal kidney ncam gradually disappears from all epithelial structures and is confined to small areas of interstitial medullary cells. in the adult murine kidney ncam expression is virtually absent. materials and methods in the present study ncam expression was analyzed by immunohistochemistry and western blots in adult human kidneys, including healthy kidneys and kidneys with different glomerular diseases associated with incipient interstitial fibrosis (if). ncam positive cells were characterized by triple immunofluorescence staining using antibodies against human ncam combined with a panel of antibodies against neurofilaments, a smooth muscle actin (asma), hla class ii, cd and cd , and dapi for nuclei staining. digital pictures from every fluorescence channel were taken and superimposed for the specific staining using the analysis dokutm software from soft imaging systems. results in adult human kidneys, ncam expression was restricted to rare interstitial cells with a dendritic morphology, long cytoplasmatic extensions and elongated nuclei, which were localized predominantly in the outer medulla. in comparison to healthy kidneys, the number of ncam-positive interstitial cells increased in the initial phases of if in different forms of glomerulonephritis. western blot analysis of renal tissues with incipient if showed the exclusive expression of the kda isoform of ncam; other isoforms were not detectable. staining with antibodies against neurofilaments clearly differentiated nerve cells from ncam-positive interstitial cells, which are neurofilament negative. they are also asma negative, though the number of the asma+ cells increased at the early stages of if. however, some of the ncam-positive cells clearly express the stem cell markers cd and cd . conclusion these data indicate that a subpopulation of ncampositive interstitial cells may be renal progenitor cells, which can participate in the initial phases of if. introduction cell migration from the host to the transplanted organ results in chimerism ( ) , and seems to be associated with chronic transplant rejection ( , ). however, early detection of recipient cells might provide an important clue for anti-rejection therapy. materials and methods cases from sex-mismatched renal transplants (male kidney into female receiver) with consecutive biopsies (one, six, and twelve months) were analysed by fish and immunohistology (c-kit and smooth muscle actin). in additional cases of renal transplants each at day and twelve months after transplantation, glomeruli were microdissected and a rt-pcr for c-kit and ß-actin was performed. umbilical vein endothelial cells served as positive control. results glomeruli: transplant glomerulopathy shows increasing numbers of y-positive cells with progression of the sclerosing lesion. by lm -rt-pcr, increased c-kit transcription is observed compared to controls, while immunohistology is negative. arteries: recognition of vascular lesions as chronic transplant vasculopathy was easily possibly by fish, but not by light microscopy. tubuli/ interstitium: infiltrates of acute interstitial rejection change sizes from focal/large to disseminated/small over time. chimeric cells are seen in tubulitis but also in tubular epithelium with ischemic damage. conclusion transplant glomerulopathy is a lesion of chronic rejection associated with the appearance of c-kit positive, recipient cells. chimeric cells can be demonstrated in transplant vasculopathy and in damaged tubular epithelium, possibly homing to ischemic lesions as part of a repair process. . lancet ; : ; . liver transp ; : ; . transfusion ; : introduction the aim of our demonstration is to call attention to a unique pediatric case with as yet unknown ultrastructural changes in the glomerular basement membrane (gbm). case report the full-term female patient - g/ cm -has been developing well with the exception of early (intrauterine?) unilateral intraocular hemorrhage, which necessitated the enucleation of the bulbus at the age of month. nine months later, varicose enlargement of the left saphena vein was observed, and microscopic hematuria was detected. later selective proteinuria and mild hypertension was found. at the age of year an open renal biopsy was performed. light microscopy showed thick-walled and dilated capillaries of glomerular tufts. collagen iv staining demonstrated corrugated positivity in the gbm, also seen in col iv alpha chain. chains alpha and appeared normal. immunofluorescence gave only strong global igm positivity. electron microscopy showed peculiar mostly circular splitting of the gbm lamina densa with inclusions of small amorphous densities as well as of some remnants of cellular organelles. analogous changes were observed in adjacent arterioles. at present, the year-old child with signs of somatic underdevelopment is being treated for mild hyperazotemia, anemia and renal hypertension. her body shows some asymmetry, the skin is thin, pink, but no areas of hyperextensibility are seen as well as any hypermobility of joints. nmr investigation of the brain disclosed a slowly growing mass in the left thalamus. conclusion the classification of the case among connective tissue disorders is difficult, type iv of ehlers-danlos syndrome seems to be the closest. chronic renal thrombotic microangiopathy (tma) following radiation: study of cases introduction there is evidence for roles of the cip/kip family of cdki (p , p ) in mediating growth arrest in glomerular cells. mature podocytes, highly specialized cells with a complex cellular structure (interdigitating foot processes) leave cell cycle and may undergo nuclear division, but not cytokinesis, because this would involve the breakdown of the actin cytoskeleton. it has been recognized that mesangial cells proliferate and accumulate matrix in re-sponse to certain forms of injury. the aim of the current study was to elucidate the role of cdki expression in human glomerular diseases. material and methods the analysis was performed on groups of renal biopsies (every consisting of cases): minimal change disease (mcd), membranous glomerulonephritis (mgn), mesangioproliferative proliferative glomerulonephritis: iga (igan) and igm nephropathy (igmn). we examined the expression of p , p , ki and pcna by immunohistochemistry. adult nephrectomy specimens (n= ) without evidence of glomerular disease served as controls. morphometric analysis was additionally done in mcd, igan and igmn cases. color sampling was performed to extract "brown" nuclei stained for p and all nuclei of glomerular cells. then the number of segmented "brown" nuclei was calculated per area of glomerular profiles and related to the number of all nuclei. results immunostaining for p was abundant in normal podocytes and some mesangial cells. there was no evidence of p and proliferation markers ki and pcna in normal glomeruli. in mcd and mgn expression did not change. in contrast there was a marked decrease in staining intensity for p in mesangial cells in patients with igan and igmn. the ratio of stained for p nuclei was . % and . % for mcd and igan, igmn group, respectively (p= . ). interestingly also podocytes focally -in sclerotic portions of glomeruli -revealed a marked decrease of p . this loss of immunostaining occurred predominantly in mesangial cells and podocytes expressing ki and pcna. this was accompanied by the de novo nuclear immunostaining for p . conclusion the decrease in p level is required to induce podocyte and mesangial cell proliferation. also the increase of p was observed. thus changes in cell cycle regulatory molecules play central role in determining the renal response to injury and may underlie the development of progressive glomerulosclerosis. understanding mechanisms regulating cell proliferation may target future therapies on these molecules. comprised microhaematuric patients. the thinning was global in patients, and segmental in . the third cohort contained nonhaematuric patients who had a globally thinned gbm and focal proliferative lupus gn or minimal change np, respectively. in summary, cases of global tbmnp ( + nm; controls: + nm; p<. ), and cases of segmental tbmnp ( + nm; p= . ) were verified. conclusion tbmnp manifests with either a globally or a segmentally thinned gbm. tbmnp is not infrequently associated with other glomerular diseases. the clinical and morphologic data should be considered simultaneously when the diagnosis of tbmnp is made. supported by otka t- (budapest, hungary) grant to i.b. simultaneous quantitative gene expression analysis in human renal biopsies in patients with lupus nephritis (lgn) introduction inflammatory flares, enhanced proliferation and delayed apoptosis are important pathomechanisms in lgn. these are associated with increased expression of genes previously studied by semi-quantitative immunohistologic detection of an individual gene product. the aim of this study was to perform a simultaneous quantitative comparison of expression of genes tentatively relevant to pathogenesis of lgn. material and methods renal tissue samples, fresh frozen ( ) and formalin-fixed ( ), obtained by percutaneous biopsy of patients with lgn (who class ii, iii and iv) were used. formalinfixed zero transplant biopsies served as controls. from µm thick sections, glomeruli were laser-microdissected, rna was extracted and transcribed. a real-time, quantitative pcr analysis was performed using vcam- , fractalkine as markers of inflammation, il- , pdgf-ßr as markers of proliferation, bax, fas ligand and tnf-r as regulators of apoptosis and ß-actin as housekeeping gene. results frozen biopsies allowed detection of all genes; formalinfixed only of some. there was no correlation between levels of gene expression and age, sex, proteinuria or activity/chronicity indexes. who class ii cases showed increased levels of vcam- , pdgf-ßr and bax but not fractalkine as compared to controls. who class iii and iv cases showed higher expression of fractalkine, il- and pdgf-ßr than who class ii cases. in who class iii cases, il- , and fractalkine levels were clearly, while bax levels were slightly higher than in who class iv cases. conclusions . real-time quantitative pcr is useful for a simultaneous analysis of gene expression in frozen samples of human renal biopsies. . in this limited study, class ii lesions, as expected, showed lower expression of genes in comparison with classes iii and iv. however, class iii lesions seemed to exhibit higher expression levels of genes involved in proliferation, inflammatory cell infiltration and apoptosis regulation compared to class iv, possibly relating to a different pathogenesis of those two classes. haemorrhagic glomerulonephritis (gn) and massive pulmonary haemorrhage in goodpasture syndromeunique case report introduction diagnostic use of ttf- as an organ specific marker for thyroid and lung origin of carcinomas was documented mostly in tissue sections, while the information on ttf- in cytology samples is still insufficient. the aim of the study was to analyze the expression of ttf- by immunocytochemical detection in cytology samples. we obtained material by fine needle aspiration biopsies (fnab) of primary and metastatic neoplasms ( cases). first, methodological approach with ttf- was tested in thyroid tissue ( goiters, adenomas, carcinomas). afterwards, we analyzed primary and metastatic lung adenocarcinomas, primary and metastatic extrapulmonary adenocarcinomas, primary lung tumors and metastatic lung carcinomas of other types and metastatic carcinomas of different types. additionally, metastatic malignant melanomas were also included in the study. finally, we tested metastatic tumors of unknown origin. results all primary and / metastatic lung adenocarcinomas stained positive with ttf- . two of metastatic tumors of unknown origin stained positive, however primary tumor was not found. except for thyroid samples, normal lung, metastatic microcellular and macrocellular carcinoma of lung origin, none of other primary or metastatic tumors stained positive for ttf- . conclusion in fnab specimens, ttf- can confirm thyroid origin of carcinoma and more importantly, determine the lung origin of metastatic or primary adenocarcinoma. therefore, ttf- could be used for early identification of primary site (pulmonary vs. extrapulmonary) in fnab of metastatic adenocarcinomas skipping further expensive investigations. comparable to the digital radiology, recent significant developments in the microscopic slide scanning, data storage technology can contribute to the development of digital histology laboratory techniques. the aim of the study is to evaluate this technology in a routine setting. methods in the daily routine in a university pathology department to slides were prepared from to cases in a day. from the usual paraffin blocks µm sections were prepared and processed. the bar-coded slides were digitized and stored on a digital slide server. commercial short and long term storage may be used. the evaluation of the slides was done in local and remote access. for specific tissue types (colon, gastric) automated tissue component segmentation and analysis modules were developed. for the d reconstruction of serial sections a dedicated program was developed. results the daily prepared slides ( - pcs) could be scanned in the night. the virtual microscopy analysis yielded concordant results with the optical microscopy analysis. teleconsultation based on digital slides and virtual microscopy was applicable in selected cases. the automated algorithms could classify gastric biopsy specimen cases with high accuracy ( %). d reconstruction yielded a more detailed insight and diagnosis. reports including the low resolution digital slide image, high resolution selected field of views, alphabetical report were sent in e-mail to the referring specialists in higher safety and speed as compared to the traditional way. conclusions the digital histology laboratory technology improves the specialisation in pathology allowing remote access to selected tissue types, the reporting process' safety and efficiency. experiences in the production of digital slides by an automated high-resolution scanner system after automated slide preparation introduction this study aims to investigate the expression of ret/ptc and p in the local normal, benign and malignant thyroid lesions in order to shed light on the pathogenesis of papillary carcinoma and explain the high prevalence of this condition among the nodular hyperplasia (multinodular goiter) cases in the local population. archival blocks from follicular adenomas, nodular hyperplasia and papillary carcinoma cases were retrieved from husm pathology department files. they were studied by immunohistochemistry for the presence of ret/ptc and p mutant protein. normal tissues from cases served as controls. results . % normal thyroid tissue, % follicular adenomas, . % nodular hyperplasia cases and . % papillary carcinomas expressed ret/ptc mutation. ret/ptc expression in papillary carcinoma was not associated with coexistence of nodular hyperplasia lesion. p is expressed by % of papillary carcinoma. no association was found between p expression of nodular hyperplasia with or without coexisting papillary carcinoma. p , not ret/ptc was an excellent predictor of tumour lymph node metastasis and capsular invasion. it is also a significant prognosticator of survival outcome. conclusion ret/ptc mutation is highly prevalent in local papillary carcinoma, indicating a significant role in the pathogenesis of this tumour; with no apparent role in tumour behaviour and survival outcome. p on the other hand appear to be a significant factor in the latter events. the two genes appear to act in two different pathways; the former being the initiator, and the later perpetuator of papillary carcinoma. vascular invasion in pleomorphic adenoma of salivary gland: a possible consequence of fna biopsy introduction benign intravascular invasion in association with pleomorphic adenoma (pa) of salivary glands is uncommon. in none of the reported cases has it been associated with subsequent development of metastases. it may cause a diagnostic and therapeutic dilemma in salivary glands, which appears otherwise benign. no explanation of the etiopathogenesis has been offered in previously reported cases. aim: we suggest that pre-operative procedures undertaken such as fine needle aspiration (fna) of the salivary gland may cause iatrogenic seeding of tumour cells. materials and methods two cases of pa of the parotid gland showed vascular invasion. both presented with a palpable nodule in the parotid gland. one patient had two fnas the other one prior to surgery. both underwent superficial parotidectomy. results histologically both tumours were pas positive with little chondromyxoid component but both were rich in myoepithelial cells. clusters of myoepithelial and epithelial cells were seen within muscular and thin walled blood vessels, both outside the capsule and within the tumour. in spite of genuine vascular invasion there was no cytological evidence of atypia or malignancy. our speculation is that the previous fnas may have caused spillage of pa cells within vessels giving an impression of a potentially malignant tumour. conclusion we recorded two cases of pa with associated vascular invasion. we speculate that preceding operative procedures such as fna may be relevant to the pathogenesis. extra-cellular signal-regulated erk- /erk- pathway activation in human salivary gland mucoepidermoid carcinoma: association to aggressive tumor behaviour and tumor cell proliferation a handra-luca, a lesot, jc bertrand, p fouret université paris vi ufr pitié-salpętrire, paris, france information on oncogenetic events in salivary gland mucoepidermoid carcinoma is so far limited. activation of extracellular signalregulated kinases erk- and erk- is strongly correlated to cancer. using an antibody specific for phosphorylated (active) erk- /erk- , we examined human salivary gland mucoepidermoid carcinoma samples by immunohistochemistry. the comparison in paired tumor and normal tissue samples showed that phosphorylated erk- /erk- expression was higher in tumor cells as compared to surrounding normal salivary parenchyma. using a threshold below which > % of normal samples expressed phosphorylated erk- /erk- , we showed that ~ % of mucoepidermoid carcinomas expressed high levels of phosphorylated erk- /erk- . those tumours where erk- /erk- pathway was activated had a more aggressive tumor behaviour as compared to the group where this pathway was inactive. the association of erk- /erk- phosphorylation to a worse prognosis was independent of histological grade. erk- /erk- phosphorylation was associated with an increased tumor cell proliferative index. there was no relationship between erk- /erk- phosphorylation and her- /neu expression. in conclusion, erk- /erk- pathway is active in salivary gland mucoepidermoid carcinoma and this activation is associated to a more aggressive tumor behaviour and a higher proliferative activity. these data suggest that deregulation of erk- /erk- pathway contributes to mucoepidermoid carcinoma phenotype and, possibly, represent a target for new anticancer drugs. introduction adenocarcinoma of the nose and paranasal sinuses is rare but has been shown to occur with increased frequency in workers exposed to wood dust. histologically the tumours resemble adenocarcinoma of the gi tract and show the same spectrum of histological types and differentiation. therefore tumours at this site may present a diagnostic problem in distinguishing between primary and metastatic disease. immunostaining has shown colonic adenocarcinomas to express cytokeratin ck and carcinoembryonic antigen (cea) but not cytokeratin ck . lung and squamous carcinomas of the head and neck are usually ck positive and ck negative. this prompted assessment of the immunohistochemical expression of ck , ck and cea in a retrospective series of primary nasal adenocarcinomas. the aims of the study were to establish the pattern of expression of ck ck and cea in primary sinonasal adenocarcinoma and to compare it with that seen in colonic adenocarcinoma. materials and methods cases of primary sinonasal adenocarcinoma were available from archival files. these were reviewed and classified into histological subtypes including papillary, tubular, mucinous and signet ring. representative paraffin sections were immunostained for ck , ck and cea. results normal respiratory epithelium included in the sections was positive for ck and negative for ck and cea. / ( %)of tumours expressed ck . all of the tumours expressed ck and all but one of the tumours expressed cea, with showing only focal positivity. there were tumours designated mucinous or signet ring type only one of which expressed ck . conclusion primary sinonasal adenocarcinomas express ck and cea. there is variable expression of ck , which may help to distinguish between primary sinonasal adenocarcinoma, which are positive, and metastatic colonic adenocarcinoma of papillary and tubular subtype, which are negative. poorly differentiated mucinous tumours are indistinguishable by immunohistochemistry alone. provisional extracellular matrix -indicator of oral squamous cell carcinoma (oscc) progression and target for therapy introduction pleomorphic adenoma is the most common tumour of the parotid gland. histomorphologic features and peculiarly tumour capsule play a major role in recurrences of parotid pleomorphic adenomas. cytogenetically, pleomorphic adenomas are characterized by recurrent chromosome rearrangements. the aim of this study was to correlate cytogenetics and histopathology features in pleomorphic adenomas in order to define cytogenetical characteristics of tumours with high risk of recurrence. material and methods histological and cytogenetical studies were performed in patients with pleomorphic adenomas of the parotid gland treated in our institution during the period may -november . structural and numerical chromosomal abnormalities were: rearrangement of chromosome (breakpoint at q - ), rearrangement of chromosome (breakpoint at q ), translocation between chromosome and : t( ; )(q ;q ), hyperdiploidy. results the studied population was distributed into histological subtypes according to seifert classification. hypocellular (stroma rich) pleomorphic adenoma was reported in %, hypercellular pleomorphic adenoma was reported in % and "classic" in %. thirty patients ( %) had normal karyotype while ( %) had clonal chromosomal abnormalities. chromosome rearrangement tumours and hyperdiploid ones tend to be hypocellular. tumours showing chromosome abnormality tend to be hypercellular. conclusions as recurrences most likely appear in hypocellular tumours, patients with hyperdiploidy and chromosome abnormalities could have a greater risk of recurrence because of their histomorphological characteristics. because of the lack of patients, not sufficient statistical significance was demonstrated. introduction pleomorphic adenoma is the most common tumour of the parotid gland. the main issue of pleomorphic adenoma surgery is postoperative recurrence. histomorphologic features and peculiarly tumour capsule play a major role in recurrences of parotid pleomorphic adenomas. the aim of this retrospective study was to define histomorphological characteristics of pleomorphic adenoma for better understanding of recurrence processes. this work corresponds to the preliminary prospective study of a long term follow-up for detection of recurrence. material and methods histological study was performed after reviewing of slides originating from patients with pleomorphic adenomas of the parotid gland. these randomly selected patients underwent parotid surgery in our institution during the period may -november . results the studied population was distributed into histological subtypes according to seifert classification for better analysis. hypocellular (stroma rich) pleomorphic adenoma was reported in %, hypercellular pleomorphic adenoma was reported in % and "classic" in %. thinness of capsule was significantly related to hypocellularity. pseudopodias and satellite nodules were reported in % of this series. conclusions due to capsular characteristics, surgical exerecise should avoid dissection in the vicinity of the tumour to minimize the risk of surgical induced recurrence. according to these findings, enucleation surgery on a pleomorphic adenoma should not be performed anymore. these tumours should now be followed up in order to detect and define risk factors of recurrence. trend of nasopharyngeal cancer at the ibadan cancer registry ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) increase in the incidence of npc over the last here decades. overall, the mean age was . years (age range to years). the females had a mean age of . years (age range - years) while the mean age for the males was . years (range - years). the peak age group of incidence for the females was - while in the males it was the - age group with an almost an equal incidence in the preceding three decades. the ratio of regaud to schmincke type cancer reversed with increasing age amongst the females with the schmincke type being more common in the first decade but this was not reproduced in the males. conclusions there is a steady rise in the incidence of nasopharyngeal cancer over the last three decades. the two main histological types showed differential variation between the sexes suggesting a biological effect in manifestation of this disease. there is a need for health education and increased physician awareness at all levels of health care to stem this trend and especially to detect a role of epstein barr virus infection in aetiopathogenesis of the nasopharyngeal cancer. lactate dehydrogenase (ldh) in peripheral blood lymphocytes (pbl) of patients with solid head and neck tumours b jakovljevic lactate dehydrogenase(ldh)is intracellular enzyme, which take part in process of anaerobic glycolyse. it is located in all cells, but in higher amount in the stromal cells. ldh activity increased in the malignant cells, as well as in the peripheral blood lymphocytes (pbl) of patients suffered from head and neck tumours. the authors present results of their investigations in activity of intracellular ldh in pbl, spontaneous ldh releasing from pbl and correlation between spontaneous releasing of ldh and increasing of intracellular level of ldh in patients with solid head and neck tumours. spontaneous releasing of ldh in all the patients with solid head and neck tumours were to times higher then in the health controlling group. there are correlation between clinical stage of the tumours and spontaneous releasing of ldh. the authors concluded that measuring of level of spontaneous released ldh from pbl, can prove the presence of head and neck tumours in the very early stage. introduction squamous cell carcinoma (scc) constitutes more than % of the malignancies from the head and neck. thereafter, the survival of patients in stage iii-iv is between %- % at years. as most stromal types, head and neck squamous cell carcinomas (hnscc) harbour deregulation in the expression levels of many proteins that participate in critical biological pathways leading to cancer development. the aim of the study was to evaluate the correlation between several molecules implicated in cell cycle and apoptosis in an attempt to define their importance as prognostic indicators in hnscc. material and methods hnscc specimens from stage iii-iv patients were collected prior to chemotherapy. we constructed a tissue-microarray with paraffin-embedded tumours to analyse, by inmunohistochemistry, the expression levels of proteins implicated in cell cycle arrest and apoptosis (p , cyclin-d , cyclin-a, rb, hdm , topoisomerase, chk , cdc , survivin, bcl- , cdk- , cdk- , cyclin d , cyclin e, cyclin b , p , p and p ). results alterations in the expression levels of proteins that participate in the g /s checkpoint were frequent. rb and p proteins were absent in % and % of the tumours, respectively, whereas high expression of cyclin d , cdk- and cdk- was observed in %, % and % of the cases, respectively. on the other hand, des-regulation of markers implicated in the apoptosis were also evident as shown by over-expression of bcl- protein in % of the tumours. this last observation seems to be related to bad prognosis. conclusions definitive conclusions from our results concerning expression levels of each marker isolately, according to tumour location and in relation to survival are still being evaluated. p and mib expression in basaloid squamous cell carcinoma of the larynx inversely correlates with p expression patients, two showed an inverse correlation between p and ki- expression and p expression. conclusion an inverse correlation between p and ki- and p and p was demonstrated in cases. image analysis of dnac showed aneuploidy in all cases. the present study shows that overexpression of p , and ki- , together with a down-regulation of p kip correlates with biological aggressiveness and consequent shortened survival in bscc of the larynx. the dna status doesn't correlate with any of the analysed parameters since all tumours in our series displayed an aneuploid pattern. altogether patients were operated on at the department of transplantation and surgery of the semmelweis university in the past four years, because of clinical symptoms of hyperparathyroidism. chronically impaired renal function was found in cases. the removed parathyroid glands showed histologically hyperplasia in , adenoma in and carcinoma in cases. the oxyphil/chief cell ratio and occasional mitotic and apoptotic figures were determined. the oxyphil component predominated both the hyperplastic and tumorous lesions. apoptosis and mitosis were rarely seen in hyperplasias ( - %) more frequently in adenomas ( - %) whereas in carcinomas - % of the tumor cells showed signs of mitosis and - % were apoptotic. immunohistochemical detection of p , bcl and bax revealed diversity between the various lesions. cytoplasmic p positivity could be observed in the majority of adenomas and in some of the oxyphil cells of the hyperplasias. the carcinomas and about one sixth of the adenomas showed nuclear p positivity. bcl was detected in the cytoplasm of the tumor cells of adenomas and in lower extent in the oxyphil cells of hyperplasias. colocalistion of bcl and bax was found randomly in all types of lesions. no significant differences in the p , bcl and bax spectrum were found regarding the primary and secondary (i.e. renal failure) parathyroid alterations. the very low incidence of carcinomas, the low mitotic and apoptotic ratio in adenomas and hyperplasias point to the potent antiproliferative defense mechanism in the parathyroid cell-population. this may be also reflected in the cytoplasmic co-localisation of various gene products which regulate cell death and cell proliferation. introduction at present the significance of occult axillary lymph node metastasis (om) in early breast cancer patients is not known. the aim of the study was to evaluate the prognostic role of om in stage i breast cancer. materials and methods we studied patients with t breast carcinoma who underwent axillary dissection and originally had negative lymph nodes by routine microscopic examination. patients who developed distant metastases within years after surgery (m group) were compared to age-matched patients who were disease free for years (nm group). we examined lymph nodes by three deeper h&e levels and one section stained with immunohistochemistry for keratin. results we detected om in / patients. all had micrometastases (< . mm). om was identified in patients ( %) in the m group and in ( %) in the nm group (p= . ). micrometastases larger than . mm were x more common in the m group ( / vs. / , p= . ) . tumors in the m group were significantly more often of higher grade, had a higher mitotic index (mi) and showed lymphovascular invasion. the two groups did not differ in size, histologic type, estrogen receptor status or type of treatment. in multiple logistic regression, only high mi and presence of micrometastases larger than . mm showed an independent significant correlation with the occurrence of distant metastases. axillary micrometastases are associated with occurrence of distant metastases and are important prognostic factor in t breast cancer patients. this was not significant for om smaller than . mm. the presence or absence of myoepithelial (me) cells has been considered as an important feature in the differential diagnosis of papillary breast lesions. the aim of this study was to evaluate the usefulness of monoclonal antibodies: alpha-actin (smooth muscle actin) and s- protein, which are known as good markers of me cells in breast tissue. material and methods the distribution of me cells in formalinfixed paraffin-embedded tissue sections of intraductal papillomas and papillary carcinomas were immunohistochemicaly stained by abc method. results alpha-actin reacted strongly and consistently with the me cells in all papillomas. in papillary carcinomas there were no alpha-actin reactive me cells. rare isolated me cells were present in two cases, but they were inconspicuous and these reactions were also considered negative. the me cells failed to express s- protein in four papillomas, while majority were weak positive. all the papillary carcinomas were s- protein negative. conclusions consistency and uniformity of me cells reaction is important because benign and malignant papillary lesions often coexist in the same tissue section. although vascular smooth muscle in the papillary fronds and stromal myofibroblasts may mimic me cells, the number of alpha-actin immunoreactive cells is much smaller and their distribution more irregular. s- protein has broad spectrum reactivity and it is of little value in the differential diagnosis of papillary breast lesions. alpha-actin is more specific marker than s- protein for recognition of me cells in breast tissue. introduction the utilization of lymphatic mapping for breast carcinoma has made intraoperative evaluation of sentinel lymph node (sln) attractive, because axillary lymph node dissection can be performed during the initial surgery if sln is positive. the aim of our study was to evaluate the accuracy of intraoperative sln examination by imprint cytology (ic). material and methods slns from women were examined. for intraoperative cytological examination, touch imprints from bisected slns were prepared, air dried and stained with quick staining method (hemacolor-merck). slns were than formalinfixed and embedded in paraffin. histological sections were evaluated with h&e stained levels and cytokeratin immunohistochemistry (ck-ihc). results histological examination of the sln revealed ( , %) cases with metastatic deposits: ( . %) macrometastases, ( . %) micrometastases and ( . %) cases with isolated tumor cells or clusters (itc) detected by immunohistochemistry. sensitivity and specificity of intraoperative ic was % and %, respectively. ic was significantly more sensitive for detection of macrometastasis: they were detected in out of cases ( %). ic generally failed to detect micrometastases or itc: only one case of micrometatasis was cytologically suspicious for malignancy. out of histologically negative slns, one ic diagnosis was false positive. conclusions ic is a simple and quick method of intraoperative screening for the presence of sln macrometastases in patients with breast cancer. if sln micrometastases and itc are used to determine the need for further lymphadenectomy, more sensitive intraoperative methods, such as rapid ck-ihc on touch preparations, will be needed to avoid second operation. introduction fine-needle aspiration cytology (fna) is an established, highly accurate method for diagnosing breast lesions. however, in recent years there has been increased use of core biopsy (cb) as a diagnostic alternative. this study aimed at comparing the value of fna and cb in palpable and non palpable breast lesions. materials and methods the material consisted of fna samples performed in our institution between and . correspoding histology results from lesions including cb were available for comparison. quality assessment parameters were calculated using metodology detailed in the national health service breast screening programme guidelines. results high specificity ( %) and sensitivity ( %) and low inadequacy rates were found for cb. fna showed high sensitivity ( %). low specificity ( %) for fna due to inclusion of many cell-poor lesions was particularly seen in the submitted material sampled by physicians lacking experience with fna procedures. conclusion cb may be an alternative method for preoperative diagnosis when experienced cytopathologists are not available. cb is superior to fna in fibrotic and collagenous lesions such as lobular carcinoma and radial scar. fna is most accurate when immediate assessment by cytopathologist is performed for evaluation of material adequacy so that additional aspirations can be performed if necessary. atypical ductal hyperplasia (adh): practical relevance in diagnostics and therapy introduction in contrast to ductal hyperplasias, adh belongs to intraductal neoplasias. adh can be distinguished from non-high grade dcis (among other criteria) by its size. therefore, a question that is asked quite frequently is whether such small findings can be removed with sufficient security by minimal invasive biopsy (mib). we prospectively investigated: . relative frequency of adh without associated intraductal or invasive carcinoma . relevance of such small findings in mib specimens. materials and methods between between and between , breastlesions could be clarified by means of mib in the interdisciplinary team. excisions were carried out in all invasive carcinomas and all dcis as well as in all cases with minimal parts of intraductal nonhigh grade neoplasias (with the differential diagnosis adh vs. dcis). additional adhs were diagnosed in excision specimens as incidental findings associated with other targets (except for dcis and invasive carcinomas). the mib-and operation specimens have been examined prospectively by two team pathologists according to the criteria of page and tavassoli. results we diagnosed altogether adhs and dcis. the proportion of adh in all operated intraductal neoplasias (adh+dcis) was . % ( / ). findings with the differential diagnosis of adh vs. dcis could be found in cases of mibs ( , %).the following excision specimens showed in of cases ( %) non-high grade dcis and in of cases adh ( %). the other adh were coincidental findings in excision specimen of benign lesions. conclusions adh is a very rare finding. in adh-like findings in mib specimens even specialised breast-pathologists cannot exclude a non-high grade dcis with sufficient security when applying strictly the most common morphological definitions. the high rate of % of dcis in the specimen of the following operation highlights the indication for clarifying by excision (according to the european guidelines for quality assurance in mammography screening). multifocal stromal invasion in microinvasive squamous cell carcinoma of the cervix -how to measure and stage these lesions o reich, h pickel dpt. obstet/gynecol, university of graz, graz, austria objectives about % of microinvasive squamous cell carcinomas of the cervix have more than one invasive focus at time they first break through into the cervical stroma. it is unclear how the lateral extent of lesions with multiple invasive foci should be measured to distinguish figo stage a and a carcinomas from clinically occult stage ib disease. we believe that three presentations of multiple invasive foci should be distinguished. type i shows plump and coherent infiltration of the cervical stroma at different sites in one ore more step-serial sections. they originate from the squamous epithelium outside the transformation zone or from metaplastic cervical gland epithelium. all foci are contiguous with the epithelium. in this case, the largest lateral spread of each individual invasive focus should be measured. these measurements are added up to determine the total of horizontal spread. the normal tissue separating the different early invasive foci is not measured. in type ii the origin of invasion cannot be seen in all early invasive foci but the greatest lateral extension can be seen in one of the step-serial sections. lateral extension is defined as the maximum distance from one most lateral point of the border between the invasion and the adjacent tissue to the other. the lateral extension of type ii includes the normal tissue separating the early invasive foci. type iii shows the same pattern as type ii, but the maximum horizontal spread cannot be measured in a single step-serial section. in such lesions the width needs to be measured across all the step-serial sections involved and the second dimension must be calculated by knowing the distances between the sections. conclusions these growth pattern of stromal invasion should be considered when measuring the width of early invasive squamous cell carcinomas with multiple invasive foci. lesions with multiple invasive foci taken together measuring more than mm in lateral extension should be classified as stage ib. introduction cyclooxygenases regulate the production of prostaglandins and play a role in tumor development and progression. the aim of this study was to investigate the prognostic impact of expression of the cyclooxygenase isoforms, cox- and cox- in primary breast carcinomas as well as in primary ovarian carcinomas. materials and methods cox isoform expression was determined by immunohistochemistry. results expression of cox- was detected in % of ovarian carcinomas and was associated with reduced overall survival in univariate analysis (p= . ) as well as multivariate analysis ( . ). there was no correlation with other tumor parameters such as grade, stage or type. in contrast, cox- was no prognostic parameter in ovarian carcinoma. expression of cox- was detected in % of breast carcinomas and was significantly associated with several clinicopathological parameters, such as positive nodal status (p< . ), larger tumor size (p< . ), poor differentiation (p< . ), vascular invasion (p= . ) and negative estrogen receptor status (p= . ). in univariate survival analysis a significant association between elevated cox- expression and decreased disease-free survival (p= . ) as well as decreased overall survival (p= . ) was observed. in multivariate analysis expression of cox- was of borderline significance for disease-free survival (rr( %ci) . ( . - . ) ). conclusions our data suggest that increased expression of cox- may play a role in progression of primary breast carcinomas as well as ovarian carcinoma. it remains to be investigated if treatment with selective inhibitors of cox- may be an additional therapeutic option for patients with gynecological tumors. simple endometrial hyperplasia: bcl- , hldf expression and clinical behavior ii the endometrial hyperplastic processes is characterized by major variety of clinical outcomes. the main feature of "spontaneous endometrial hyperplasia" is complete normalization after total curettage (lindahl b., willen r. ) ; there is also proof of recurring hyperplasia. the purpose of present research was to carry out clinical and morphological correlations between various types of endometrial hyperplasia and expression of pro-(hldf) and antiapoptotic (bcl- ) proteins. human leukemia cell differentiation factor (hldf) with molecular mass . kd, having dna/rna hydrolyzing activity, was originally allocated from hl- cell line of promyelocyte leukemia medium, processed by retinoid acid or c -ceramid (kostanyan i.a. et al., ) . previously we have shown that hldf is a useful tool for apoptosis visualization in prostate (babichenko i.i. et al., ) . we performed analysis of patients with histologically documented simple endometrial hyperplasia without atypia: women ( %) had spontaneous recovery after total curettage, in ( %) patients endometrium recovered after gestagen treatment and in ( %) cases persistent recurring hyperplasic process was observed during - years. immunohistochemical research showed that in samples of recurring hyperplasia hldf was expressed in cytoplasm of glandular epithelium, while in sections with spontaneous or aftertreatment recovery, hldf was revealed as a thin line on the surface of glandular cells. bcl- protein was found only in the cytoplasm of glandular cells in all investigated groups. thus expression of the hldf factor in cytoplasm of glandular cells in endometrium allows revealing the disturbance of apoptotic processes in cells and predicting the subsequent recurrence of simple hyperplasia. surface epithelial changes in endometrial adenocarcinoma b djordjevic, d mihailovic, d dimov, l velickovic, v zivkovic, z mijovic institute of pathology, university of nis, nis, serbia and montenegro introduction epithelial changes on the surface of endometrial adenocarcinoma (eac) show greater maturation and better differentiation than the underlying adenocarcinoma. these changes are relatively common and can be misdiagnosed as benign surface changes on curettings, including endometrial metaplasias (em), papillary syncytial change (psc), or microglandular hyperplasia (mgh) . the aim of this study was to investigate surface epithelial changes in eac. material and methods cases with eac ( endometrioid, serous, clear cell and mixed types) were studied. results ( %) of the eac showed surface epithelial changes: four with microglandular pattern simulating mgh; with syncytial aggregates of eosinophilic cell, frequently with papillary or squamoid appearance, simulating em or psc; and with mixed patterns. surface epithelial change often demonstrated focal conjunction with a frankly malignant gland or a fibrovascular core and ranged from rare foci to diffuse surface involvement. cytologic atypia was less pronounced than that of the underlying eac and varied from mild to moderate. mitoses were very rare. in some scanty curetting specimens, distinguishing these surface epithelial changes from benign changes was difficult, as was a diagnosis of eac. conclusion in postmenopausal women with curettings showing features of em, mgh, or psc, caution should be exercised in making that diagnosis, particularly psc, in the absence of evidence of benign shedding, and any associated cytologic atypicality should raise the possibility of the underlying eac. prevalence of cervical neoplastic lesions in egypt: a national cervical cancer screening project. final report introduction reducing morbidity and mortality is one of the main objectives of the health and population policies in egypt. however, data from egyptian studies provide widely varying estimates of the prevalence of pre-malignant and malignant cervical lesions. the main goal was ( ) to define the prevalence of pre invasive and invasive cervical cancer among egyptian women, and ( ) to identify risk factors including hpvs and associated co-factors, as bacterial vaginosis, hsv, cmv, chlamydia, schistosomiasis. the study was a community based full-scale cross sectional, household survey that included women aged between and years conducted between and . however, women with complete data were included in the study ( %). the bethesda classification was used for cervical cytology. three percent of cases were unsatisfactory. normal, metaplastic, infectious, and neoplastic lesions represented . %, . %, . % and . %, respectively. the most common type of infection was bacterial ( . %). neoplastic conditions, were categorized into ascus and agcus ( . %), ascus ( . %), agcuc ( . %), lgsl . % ( . %), hsil ( . %) invasive squamous and invasive adenocarcinoma ( . % for each). colposcopic-guided biopsy was performed on cases representing . % of the epithelial abnormalities. for standardization, a score of ten points including koilocytic atypia ( ) , binucleation ( ), papillomatosis, dyskeratosis, acanthosis and basal cell hyperplasia ( point for each), was applied to qualify a lesion as hpv-related ( points out of ten). unsatisfactory biopsies were encountered in . %. normal biopsies including inflammatory and metaplastic changes and atypical metaplasia represented . % and . %repectively. cervical intraepithelial lesions (cin) ( . %), further categorized as cin i ( . %), cin ii ( . %), cin iii/cis ( . %) were identified. endocervical lesions represented . % and were divided into endocervical glandular dysplasia (egd) ( . %) and adenocarcinoma in situ (ais) ( . %). combined dysplasia was found in . %, while invasive squamous cell carcinoma (sqcc) and lymphoma accounted for . %of the biopsies. on histological basis, hpv was found in association with cin i, cin ii, cin iii/cis and sqcc in . %, . %, . % and % respectively. neither egd nor ais showed evidence of hpvs. in situ hybridization (ish) using the broad spectrum hpv probe recognizing hpvs , , , , , , , , and was tested on biopsy specimens starting from the atypical metaplastic changes and was found to be positive among . %, negative in . % and non significant in . %. interestingly, . % of atypical metaplastic changes were positive. further subtyping with probes / , / and / revealed positivity in . %, . %, and . % of cases respectively. noteworthy, multiple infections with hpv / and / ( cases) and hpv / and / ( cases) were identified. to examine the main determinants of cervical cancer, multiple regression analysis was conducted using high-grade lesions as the dependant variable and risk factors as independent variables. this showed that the only determinant was hpv infection. when the regression analysis was conducted without hpv as one of independent vari-ables, history of treatment from schistosomiasis was found to have or of . ( %ci . - . ) but the model was not statistically significant. conclusion in the egyptian population, the prevalence of the precursor lesions of the invasive carcinoma is % while invasive lesions account for . % of the population. the prevalence of hpv histologically is . % and by ish . %. however, detection of hpvs by ish in this study cannot be precise due to technical limitations and limited number of probes used. evaluation of hpvs using pcr technology will be subject to another study. possible role of irf- in the genesis of endometrial adenocarcinoma. a series of such tumours was investigated using immunohistochemical techniques. relatioships were sought with thymidine phosphorylase (tp), conventional histological features and prognosis. malignant endometria were, by and large, deprived of irf- , as of the cases ( . %) were negative for this antigen. only of the cases were expressing irf- in inner tumour areas. at the invading tumor front, however, irf- was depressed in tumour cells in % of cases. this phenomenon was independent of the extent of lymphocytic response, but it was a strongly associated with tp expression. tp up-regulation and host's lymphocytic response in the area were directly associated. irf- derepression by invading tumor cells was associated with poor prognosis. this prognostic parameter was independent of stage. it is concluded that down-regulation of irf- is a constant finding in endometrial tumorigenesis. however, derepression of irf- may occur in a subset of tumours, and this event is associated with tp up-regulation and aggressive tumor behaviour. morphometric study of gnrh analogue/ hmg/hcg effects on ultrastructure of human endometrial epithelium in the early luteal phase introduction there is a little information about the effects of ovulation induction drugs on morphometry of human endometrium especially at electron microscopic level. the aim of the present study was to determine the effects of long protocol (gnrh analogue/hmg/hcg) on the ultrastructure of human endometrial epithelium at lh+ . material and methods endometrial biopsies were obtained from fertile women (n= ) as well as infertile women (n= ) who had undergone this protocol at lh+ . quantitative and qualitative studies on endometrial epithelium were performed by transmission electron microscopy (tem) and morphometry and the results were statistically compared between the two groups. results qualitative results revealed presence of nuclear channel system (ncs), sub vacuole of glycogen and giant mitochondria (gm) in both groups. similarly, in quantitative analyses, the volume fractions (vv) of glycogen, mitochondria and rough endoplasmic reticulum to cell and the also the vv of euchromatin to nucleus were statistically not different between two groups (p> . ). conclusion these results suggest that ovulation induction by long protocol is not associated with retarded or advanced endometrial epithelial development. introduction historically the diagnosis of mitochondrial encephalomyopathies relied, on the presence of ragged red fibres (rrf) as well as finding ultrastructural abnormalities in mitochondria. currently accurate diagnosis requires a multidisciplinary approach but the usefulness of electron microscopy has been questioned. the aim of this study was to define the diagnostic role of electron microscopy in comparison to histology and histochemistry. patients and methods thirty-five patients who fulfilled a clinical phenotype for mitochondrial encephalomyopathies, were separated into two groups. the paediatric group, which included cases, with an age range of days to years old and the adult group which included cases, with an age range of to years old. all patients underwent a muscle biopsy which was examined by histology, histochemistry and electron microscopy. results in the paediatric group, cases exhibited rrfs, cases showed rrfe and cases had cox abnormalities. electron microscopy revealed the presence of mitochondrial abnormalities in cases and mitochondrial aggregates in others. in cases light microscopy was normal, but in of these electron microscopy was abnormal. in the adult group all patients, showed cox abnormalities, cases had rrfe and others had rrfs. electron microscopy revealed the presence of mitochondrial aggregates in cases and structural abnormalities in cases. conclusions electron microscopy examination is a useful independent diagnostic tool in the investigation of mitochondrial encephalomyopathies. it is particularly helpful, in the paediatric cases, where the classic light microscopical findings are often not well developed. introduction tumour-associated tissue eosinophils (tate) have been observed in human tumours and experimental tumour models, but the mechanism by which eosinophils induce tumour cell damage remains poorly understood. aims: electron microscopy is an essential technique in evaluating sublethal and lethal cellular injuries. therefore, gastric carcinomas were studied by light and electron microscopy, focusing on the relationship between eosinophils and tumour cells and on the nature of tumour cell death. material and methods fresh tumour tissue was obtained in the operating room for immediate fixation and processed for both light and electron microscopy examination from until . results a light microscopy review of cases of resected gastric carcinomas identified cases ( of intestinal-type and of diffusetype) with a massive tate. in cases of intestinal-type adenocarcinomas, eosinophils formed varied-sized aggregates in the tumour stroma. some were seen passing through the neoplastic epithelium, and others were found lying within neoplastic tubules. in cases of diffuse-type carcinoma, eosinophil clusters were seen to surround single tumour cells. with electron microscopy, performed in these cases, tumour cells in intimate contact with eosinophils revealed sublethal and lethal cellular injuries. in particular, sublethal injuries, such as cytoplasmic vacuoles and indiscernible cell membrane, occurred at the contact region. eosinophil "satellitosis" was associated with lethal damage of tumour cells including brush border disorganization, dilation of nuclear envelope, rough endoplasmic reticulum and golgi apparatus forming empty spaces or vacuoles, small condensed chromatin particles, irregular distribution of nuclear pores. these lethal injuries were compatible with non-apoptotic (non-lysosomal vesiculate) cell death. the adenocarcinoma cells, not contacted by eosinophils remained morphologically well preserved. conclusions these morphological data suggest the hypothesis of a direct relationship between eosinophil infiltration and induction of non-apoptotic tumour cell death in some cases of gastric adenocarcinoma. a deeper insight into the molecular mechanisms acting as cytokines that stimulate specific eosinophil functions may assist in the development of novel therapies to better treat human malignancies expression of p and c-erbb- oncoproteins in chronic schistosomal urinary bladder lesions o hammam, h el baz, m wishahi theodor bilharz research institute, giza, egypt this study was conducted in a trial to better understand the genetic mechanisms underlying the proliferative, premalignant and malignant changes frequently displayed in chronic schistosomal cystitis (ch.sch.c.) and schistosomal associated transitional cell carcinoma (sch.tcc) of the bladder. tissue exepression of p (tumor suppressor gene) and c-erbb- (oncogene) was assesed immunohistochemically in bladder urothelial specimens of a well characterized cohort of male egyptian patients ( ch.sch.c; sch.tcc and normal urothelial specimens as controls). both p and c-erbb- oncoproteins were not expressed neither in morphologically normal nor in the hyperplastic epithelium. overexpression of nuclear p and membranous c-erbb- was detected in % of ch.sch.c cases in whom premalignant changes (metaplasia and dysplasia) were displayed. while, in the sch.tcc cases they were detected in % and % of cases respectively. on stratifying these patients according to the well recognized prognostic parameters (histopathological grade, stage, tumor size, multifocality and growth pattern) p was positively correlated with all the forementioned parameters. in contrast c-erbb- was only correlated with tumor size and growth pattern. in conclusion, the results of the current study may suggest the early involvement of both p and c-erbb- in the initiation of the premalignant changes occuring with ch.sch.c and the progression of these changes to malignancy. moreover, the high incidence of p and c-erbb- expression among sch.tcc cases with poor prognostic parameters (higher grade, stage; bigger tumor size; tumor multifocality and nonpapillary growth pattern) may point out to the possibility of using these biomarkers as early predictive markers in ch.sch.cyst. cases displaying premalignant lesions and as poor prognostic indicators for sch.tcc. introduction cd is a neutral endopeptidase which participates in the peptide hidrolysis in the renal proximal tubules. its immunohistochemical detection has been considered useful in the differential diagnosis of renal carcinomas because of its expression in - % of clear cell renal and papillary renal cell carcinomas and its absence in chromophobe renal cell carcinoma (chrcc), a histotype positive for parvalbumin, a protein of the distal nephron. material and methods we studied immunohistochemically chrccs including four with aggressive features (two with sarcomatoid transformation, one with renal vein involvement and one with pancreatic metastasis), for cd and parvalbumin developing the reactions with different methods (abc, envision peroxidase detection and labeled polymer-ap dako envision systems) to prevent false-positive staining due to endogeneous biotin. western blotting was done to confirm the results. as control we stained clear renal cell carcinomas with both antibodies. results cd immunoreactivity was observed in ( %) primary chrccs, three with aggressive features, using all the developing systems. all chrccs were positive for parvalbumin, but not the sarcomatoid areas. western blotting confirmed the specificity of the immunoreactivities. conclusions ) about % of chrcc express cd ) cd is not specific for clear cell and papillary carcinomas of the kidney; ) a panel including both cd and parvalbumin is useful in the differential diagnosis between chrcc and clear renal cell carcinoma; ) three out of four tumors with aggressive features stained for cd , but further studies are needed to highligh the prognostic significance of cd in chrcc. introduction tenascin (tn) is an extracellular matrix glycoprotein, which is expressed during embryogenesis at the epithelial-stromal interface. tn is decreased in normal adult tissue but reexpressed in inflammatory, reparative and neoplastic processes. tn seems to be involved in neoangiogenesis, promotion of invasion and metastasis of malignant tumors. the aim of the study was to investigate the expression of tn in carcinoma in situ (cis), invasive and superficial papillary bladder cancer. material and methods cases of bladder cancer were selected ( who grade i, grade ii, grade iii tumors, cis). we investigated the different staining patterns of tn by immunohistochemistry using a monoclonal antibody against tn (t h ). results immunhistochemical evaluation revealed stromal and cytoplasmic staining. stromal staining was found at the borders of invasive tumors and in the lamina propria of most cis. tn staining of blood vessels was located at the tips of the papillae or in invasive tumor. cytoplasmic tn expression was present in all bladder cancer specimens. in cis positive cells were present in all cell layers or distributed in a pagetoid pattern while adjacent normal urothelium showed staining of superficial cells. in who grade i papillary tumors tn staining was located in superficial cells, in grade ii tumors scattered positive intermediate cells were present, while in grade iii tumors tn was expressed focally in all cell layers. most invasive tumor cell nests showed extensive tn staining. conclusion expression of tn in bladder cancer seems to be associated with dedifferentiation and invasive potential. introduction synchronous, antecedent or subsequent appearance of secondary primary malignancy (spm) in patient with primary renal cell carcinoma (prcc) is yet considered to be extremely rare. recent surveys tend to confirm at least their higher if not even significant incidence. this study was performed to determine the incidence of spm in the patients with prcc as well as its localization and time of appearance in relation to prcc. material and methods of patients who underwent surgery for renal malignancies at department of urology, sestre milosrdnice university hospital during the period from to , data of were available in croatian national cancer registry. there were patients with prcc ( males and female patients) ranging in age from - years (median . years). results and conclusion in our series there were ( . %) patients with spm. secondary malignancies in descending order of frequency were cancer of prostate ( . %), colon ( . %), lungs ( . %), bladder ( , %) and skin ( . %). there were . % antecedent, . % synchronous and , % subsequent spm. only one patient had more than one synchronous second malignancy (urinary bladder, prostate and colon). spm in patients with prcc are of great importance for both the clinician and pathologist. therefore, the clinician should maintain lifetime high-technique follow-up of the patients with prcc. the knowledge of such an existence should raise an interest in pathologist for elucidating etiologic factors. namely, it seems that the frequency of spm in patients with prcc is much higher that previously expected. introduction in our recent studies we showed increased oxidative stress with p gene alterations in urinary bladder lesions in people living in radio-contaminated areas of ukraine, after the chernobyl accident. the aim of the study was to examined whether base and nucleotide excision repair is activated in bladder urothelium by chronic low doses of ionizing radiation in male patients with benign prostate hyperplasia and females with chronic cystitis living more than years in cs contaminated areas. materials and methods bladder biopsies from patients were submitted for histological examination and biopsies from patients -for immunohistochemical study of -hydroxy- 'deoxyguanosine ( ohdg), -oxoguanine-dna-glycosylase (ogg - ), apurinicapyrimidinic endonuclease (ape ) and xeroderma pigmentosum a (xpa). results chronic proliferative atypical cystitis with multiple areas of dysplasia and carcinoma in situ was observed in % of patients from radio-contaminated areas with greatly elevated levels of ohdg, ogg - , ape and xpa in bladder urothelium. conclusion these findings support the hypothesis that significant activation of dna damage repair (base and nucleotide excision repair) is induced by long-term low dose of ionizing radiation. the levels of dna oxidative adducts pointing to mutagenic and carcinogenic potential were in line with the histopatologically diagnosed urothelial lesions. introduction urinary cytology (uc) and cystoscopy remain the standard methods for initial diagnosis and monitoring of recurrences in urothelial tumors. low sensivity of uc and invasiveness of cystoscopy led to develop different ancillary methods to improve sensitivity of uc. specific genetic alterations occurr in bladder cancers (bc), represented by aneuploidia of chromosome , , and loss of chromosome . the aim of the study was to evaluate the use of thin layer techniques applied to uc diagnosis associated with multicolour interphase fluorescence in situ hybridization (fish) for early identification of initial bc and recurrences. methods a total of voided urine specimens were collected, before resection of bladder cancer, from patient with previous bc and flogistic control patient. the samples were processed with thin prep (tp) monolayer technique and cytospin preparation (cs) and in cases with morphological alterations, was performed fish urovysion (vysis) assay, consisting of four probes ( , , and p ) . cytomorphology. results in general tp technique was better for cytomorphology, cleaner background little overlapping, with difficulties when only few urotelial cells are present and in cases of contamination with squamous cells. f i sh technique was positive in all carcinomas, with multiple gain of chromosomes , , , while none of negative controls was aneusomic. only five cases in group of patients in follow-up with minimal atipia, showed fish positity, with prevalence of loss of chromosome ( %) compared to gain of chromosomes ( %). conclusions these preliminary findings suggest that the association of tp preparation with fish anlysis can improve the efficience of uc to detect bc and predict its recurrence. chromophobe renal cell carcinoma: the variant with the best outcome? introduction few large series comparing conventional, papillary and chromophobe renal cell carcinomas (rcc) have been published. most have been heterogeneous, including rcc subgroups of different stage and/or grade. the purpose of this study was to examine the clinico-pathologic features of a series of chromophobe rccs comparing their outcome with that of conventional and papillary rccs in a grade and stage matched fashion. materials and methods the clinico-pathologic features of chromophobe rccs, papillary and conventional rccs were examined, focussing on the following parameters: patient age and sex, tumor size, stage ( ptnm), fuhrman grade, and histology. survival was analyzed using the kaplan meier method. the most important prognostic factors were identified using the cox model. results for patients with localized disease at diagnosis; median, -year, and -year disease specific survivals (dss) were similar for chromophobe ( mths, and -yr dss: %) and papillary ( mths, and -yr dss: . %) tumors. conventional rcc patients had a significantly worse outcome ( mths, -yr dss: . %; -yr dss: . %). the best outcome in low grade (g +g ), low stage (pt +pt ) tumors was observed in chromophobe rccs. in multivariate analysis, conventional (nonpapillary) rcc histology was the major independent adverse prognostic factor whether or not stage and grade were included in the cox models. conclusion chromophobe rcc is a rare rcc variant of good prognosis. this favorable prognosis is maintained when low grade (g +g ) / low stage (pt +pt ) tumors are specifically examined. introduction c-kit is a transmembrane tyrosine kinase receptor, expressed at high levels in hematopoetic stem cells, mast cells, melanocytic cells, germ cells and the interstitial cells of cajal. recently, it has been shown that for certain tumors (especially gastrointestinal stromal tumors and mast cell diseases) c-kit mutation or activation is a major pathogenetic event. only one previous study has been published regarding c-kit expression in normal renal tissue, and none regarding renal neoplasms. in this preliminary report of an ongoing study, we investigated the expression of c-kit protein via immunohistochemistry in various normal and neoplastic renal tissues. material and methods our material included eight fetal kidneys ( - weeks of gestation), seven normal adult kidneys, two cases of renal dysplasia, and renal tumors: renal cell carcinomas, two nephroblastomas, three oncocytomas, one mesoblastic nephroma and one angiomyolipoma. staining intensity was recorded in a three-grade scale. results all fetal kidneys showed cytoplasmic staining of proximal tubules (++). henle loops were also positive (++), especially in older embryos. cytoplasmic and membrane staining (++) of renal tubules was also observed in all normal adult kidneys. the two cases of renal dysplasia studied, had c-kit expression in their normal but not in their aberrant tubules. of the renal cell carcinomas, all conventional type cases (n= ), one sarcomatoid and one papillary type case were negative, while one chromophobe and one granular type were positive (++ and + respectively). all oncocytomas were positive (+++ to ++), and quite interestingly the mesoblastic nephroma was also positive. the angiomyolipoma and the two nephroblastomas were negative. conclusion we conclude that c-kit is expressed in normal fetal and adult renal tubules, as well as in a subset of renal tumors. the expression of c-kit in the latter group may prove to have diagnostic significance and therapeutic implications. background relapsed/refractory acute myeloid leukemia (aml) is characterized by a deteriorating clinical course and resistance to therapy. biological mechanisms responsible for resistance remain unclear, since consistent molecular characteristics of aml at relapse and refractory disease have not yet been reported. methods we explored paired bone marrow biopsy specimens of patients (at diagnosis and relapsed/refractory aml after high dose chemotherapy) in an immunohistochemical study using anti human ki- antigen (mib- ) antibody to determine the proliferation fraction of leukemic blasts. gene expression was analyzed in a different sample set ( at diagnosis and relapsed/ refractory aml) using a "relapse specific" cdna microarray covering genes, selected by literature and suppression subtractive hybridization. microarray results were validated using quantitative real time pcr, immunohistochemistry and immunoblotting. results recurrent and refractory aml blasts demonstrate a highly significantly increased (p< . ) proliferation fraction compared to primary diagnosis. mrna levels of proliferation markers cd and pcna were elevated . -fold and . -fold, respectively, in relapsed and refractory aml compared to diagnosis. enhanced activation of the raf/mek/erk mitogen-activated protein kinase cascade was indicated by increased mrnas of b-raf ( . -fold), cyclin d ( . -fold), mkp- ( . -fold), c-fos ( -fold) , and egr- ( . -fold). additional immunohistochemical and immunoblotting analyses demonstrated an elevation of biphosphorylated erk / protein in recurrent aml, confirming enhanced activation of the raf/mek/erk pathway. conclusion our results provide for the first time evidence that high dose chemotherapy selects or induces leukemic blasts with increased proliferative potential via enhanced activation of raf/ mek/erk cascade. introduction diffuse large b-cell lymphoma (dlbcl) is the most common of the non-hodgkin's lymphomas (nhl), comprising approximately % of newly diagnosed cases. in order to define the role of angiogenesis in dlbcl, mrna and protein expression of the two most important angiogenic growth factors, vegf and bfgf, and two vegf receptors, vegfr- /flt- and vegfr- /kdr were evaluated by real time quantitative pcr (rtq-pcr) and immunohistochemistry in dlbcl. methods we analyzed dlbcl cases, low-grade follicle center lymphomas (fls) and cases with chronic lymphocytic leukemia (cll) for expression of vegf-a, bfgf, vegfr- /flt- and vegfr- /kdr. we used a real-time reverse transcriptionpolymerase chain reaction (qrt-pcr) method to quantify mrna levels of these angiogenic markers using an abi qrt-pcr system. protein expression of these angiogenic markers was assessed by immunohistochemical staining. the results of the current study show that both the mrna and protein expression of vegf and bfgf varied considerably among dlbcl patients, which do not correlate to the microvessel density. vegf mrna expression showed significant correlation with bfgf mrna expression. the vegfr- /kdr mrna expression was higher than vegfr- /flt- mrna expression in dlbcl but their expressions were strongly correlated. histological staining of both vegf receptors in dlbcl sections showed strong staining of both receptors on the microvessel endothelial cells but not on the tumor cells. our data suggest that vegf plays a role in the pathophysiology of dlbcl however autocrine/paracrine stimulation by vegf does not seem to be relevant in dlbcl. the expression of vegf and its receptors raises the possibility of using angiogenesis inhibitors as a novel therapeutic strategy. introduction ecm regulates cellular differentiation, life span, migration and contributes to lymph node compartmentalisation. the aim of this study was analysis of occurrence and distribution of embryonal fibronectin (fn), tenascin (tn) isoforms and laminin chains (ln) in reactive lymph nodes (rln) and follicular lymphoma (fl). material and methods shock frozen tissue of rln and routine material of fl and rln. primary antibodies: all fn variants (ist- ), ed-a fn (ist ), (bc- ), all tn-c variants , tn-cl (bc- ), ln-alpha -( h ), ln-alpha -(bm ), ln-alpha -( c ), ln-beta -( e ), ln-beta -(c ), ln-gamma -( e ), ln-gamma -chain (gb and d b ). apaap-technique. results rln: all fn's, ed-a fn and tn-cl were demonstrated in lymphatic / blood vessels and as reticular depositions in the stroma; spot-like depositions in the follicle center and ribbon-like at the border follicle centre / mantle zone. ln-alpha , -alpha , -beta , -beta and -gamma -chains were positive mainly in lymphatic and blood vessels with depositions in the stroma. ln-gamma -chain was restricted to follicular dendritic cells and ribbon-like codeposited with tn-cl at the border follicle centre / mantle zone. fl: in contrast to normal follicles, a total loss of ln-gamma -chain is regular observed in neoplastic follicles. conclusions . a provisional ed-b fn / tn-cl / ln-gamma chain matrix membrane controls the traffic follicle centre/mantle zone. . in analogy to thymic t cell maturation, a role of ln-gamma -chain (ln- ) can be assumed for b cell maturation mediated by ln-gamma -chain (ln- ) positive follicular reticulum cells. . the loss of ln-gamma -chain indicates neoplastic follicular structures in follicular lymphoma. follicular lymphoma grading by mann and berard are predictive of overall survival and time to treatment failure, however, only grade has favorable os and ttf follicular lymphomas (fl) are a heterogeneous group of tumors, varying in clinical features, immunophenotype, and cytogenetics. who recommends grading of fls by using the method of mann and berard, which recognizes three grades. the aim of this study was to examine whether mann and berard's grading has prognostic significance in patients with follicular lymphoma who were not uniformly treated. samples from patients with follicular lymphoma with follow up ranging from - months (median months) were included in the study. forty-three patients ( %) achieved a complete response (cr), ( %) partial response (pr), while ( %) were considered non-responders during the follow up period of months. twenty-seven ( %) patients died, patients ( %) from dissemination, from transformation to other lymphoma type and ( , %) patients died from non-lymphoma related causes. os rate was significantly worse in patients with ann arbor stage iv than patients ann arbor stage i-iii (p= . ). patients with lower ipi score did significantly better than those with a higher ipi score for os (p< . ) and ttf (p< . ). grade fl patients had longer os (p= . ) than grade and patients. a trend for longer ttf was also found (p= . ). cox regression analysis showed that these results were independent of stage, but were not independent of ipi score. higher grade was also associated with the presence of b symptoms (p= . ) and larger size of the primary tumor (p= . ). follicular lymphomas (fl) are a heterogeneous group of tumors, varying in clinical features, immunophenotype, and cytogenetics. the aim of this study was to examine interrelationship and prognostic significance of bcl and cd protein expression for overall survival (os), and time to treatment failure (ttf). samples from patients with follicular lymphoma were evaluated by immunohistochemistry. bcl- and cd expression levels were determined semiquantitatively. since almost all cases expressed bcl- , fls were designated either "low expression level-group" (llg and +, patients) or "high expression level group" (hlg, + and +, patients) . based on cd expression, fls were designated either "negative" ( patients) or "positive" ( patients). patients with high levels of bcl- expression had favorable overall survival (os) (p= . ) and ttf (p= . ) compared to patients with low levels of bcl- expression. cox regression analysis showed that the results for os, but not ttf were independent of ipi score. patients with cd -negative follicular lymphomas also had worse os (p= . ) and ttf ( . ). our results suggest that expression of cd and strong expression of bcl- protein could be indicators of welldifferentiated follicular lymphoma since such cases were associated with lower histological grade and better clinical outcome. "borderline lesions" with clinicopathologic features in between lyp and alcls. lyp nature (neoplastic vs reactive) is matter of debate because of its benign clinical course and variable molecular findings (t-cellular clonality in less than % of cases). borderline lesions have a favourable outcome similar to lyp but, due to their rarity, limited data are available on their biologic features and clonal status. the aim of this study was to compare possible divergences in the search for clonality in the same individual skin lesions using respectively dna extracted from laser microdissected cd + cells and dna from whole paraffin sections. materials and methods lyp and borderline skin lesional biopsies were tested for tcr-gamma rearrangements by means of pcr on dna extracted respectively from whole-tissue and a pool ( - cells) of cd + cells microdissected using the zeiss-palm robot-microbeam system. results and conclusions pcr analysis of whole-tissue dna documented tcr-gamma monoclonal rearrangement in / cases ( / borderline, / lyp); tcr analysis on dna extracted from microdissected cd + cells showed monoclonal rearrangement in / cases ( / borderline, / lyp). we confirm that pcr analyses on dna extracted by microdissected cd + cells enhance the rate of monoclonality detection mainly in lyp lesions, in which the limited number of atypical cd + cells and predominant reactive cellular background may be responsible for negative or ambiguous signalling when dna extracted by the whole lesion is tested. malignant testicular lymphoma accompanied with complete av block -case report m a -year-old male patient was admitted, with the signs of complete av block and bradycardia accompanied by syncopes. a complete lab examination with us, ct and mri was done which all confirmed a massive tumorous infiltration into the root of mesenterium, presence of lymphadenomegaly around it, as well as nonhomogeneous and unclearly demarcated infiltrative lesion of myocardial septum. the patient completed his anamnesis by imparting that his right testicle was slightly enlarged and periodically painful. semicastration was indicated and the removed tissue was prepared for pathohistologic analysis. the testicle had only peripherally preserved normal tissue, whereas the tumor was clearly demarcated, . cm in diameter. five-micrometre-thick tissue sections from the paraffin-embedded tissue were stained with h&e. the cells were quite variable in their morpholoric features and size. the nuclei were generally hypochromatic, with irregular chromatin distribution. the nuclear morphologic properties varied and included pleomorphic mono-and multinucleated giant tumour cells with multiple nuclear lobulations. nucleoli were conspicuous. also, numerous benignappearing lymphocytes and plasmacytoid elements were scattered throughout the background. this histologic picture could correspond either to spermatocytic seminoma or lymphoma. since the patient needed an urgent therapy, histochemically (pas-) and immunohistochemically (lca +, cd +, cd +), the diagnosis of lymphoma was confirmed. the patient received ct (chop protocol), which resulted in a satisfactory clinical response. in this case, it is interesting to point to the most probable infiltration of the myocardium by the diagnosed lymphoma which elicited the cardiologic symptoms and from which the diagnosing of the patient's disease was to start. diffuse large b-cell lymphoma of bone: an analysis of differentiation-associated antigens with clinical correlation l de leval * , k braaten, m ancukiewicz, e kiggundu, t delaney, h mankin, n lee harris * department of pathology, university of liège, belgium, massachusetts general hospital, boston, ma twenty-nine patients with diffuse large b-cell lymphomas (dlbcl) presenting with bone involvement, including localized primary bone lymphomas (group i), multifocal primary bone lymphomas (group ii) and patients with extraskeletal disease at diagnosis (group iii) were studied. the tumors were subclassified according to the criteria of the who classification and evaluated by immunohistochemistry for expression of antigens associated with germinal center (gc) and non-gc stages of b-cell differentiation (bcl- , cd , mum- , vs c, cd , bcl- and cd ). the presence of a bcl- /igh gene rearrangement was investigated by pcr. all cases were characterized by similar clinicopathologic and morphologic features, and had similarly good overall outcome. the patients ( m, f, median y) had tumors in long bones ( ), axial skeleton ( ), and limb girdles ( ) and multiple sites ( ) . most tumors ( ) were centroblastic, with multilobated cells in cases. almost half of the tumors ( / , %) were bcl- +cd + («gclike»), / cases ( %) were bcl- +cd -(«indeterminate» phenotype) and / cases ( %) were cd -bcl- -(«post-gc like»). the «indeterminate» phenotype was seen only in primary bone lymphoma. mum- was frequently expressed in gc-like and non-gc-like categories. we found no evidence of plasmacytic differentiation by cd and vs c immunoreactivity was distinctly rare ( / cases). cd was detected in tumors, all cd -. bcl- was expressed by % of the tumors but only / cases tested had a bcl- /jh rearrangement by pcr. a survival analysis showed that gc-like tumors had a longer overall survival duration compared to non-gc-like tumors (p= . ). in conclusion, a "gc-like" immunophenotype, characterizes roughly half of large b-cell lymphomas of bone and is associated with an improved survival. ultrastructural characteristics of liver-associated lymphocytes in chronic delta hepatitis b aliev, s khodjaev institute of virology, tashkent, uzbekistan liver sinusoids contain a heterogenous population of lymphocytes including 'pit cells' discovered by wisse in . however, ultrastructural patterns of liver-associated lymphocytes (lal) in delta hepatitis are still not well identified. in present work we investigated lal in chronic delta hepatitis (chd) with electron microscopy. liver biopsies from with chd were fixed in , % glutar aldehyde, postfixed with % osmium teroxide and embedded in epon. ultrathin sections were stained with uranyl acetate and lead citrate. ultrastructural study revealed migration of lymphocytes between hepatocytes in chd. they have heterogenous population of lymphocytes varying in morphology. some of them were large granular lymphocytes and could be natural killer cells. some of lal could correspond to a t lymphocyte. in electron microscopic study of lal we also observed presence of plasma cells and the pattern of intracellular membrane systems common to cells that secrete protein: well developed granular endoplasmic reticulum, large juxtanuclear golgi complex. a centriole occupies a position just marginal to the golgi. the chromatin in the nucleus of these cells is characteristically condensed into large masses just within the envelope. our results demonstrate a heterogenity of lal in chronic delta hepatitis including the presence of b cells. hepatic steatosis in relation to serum apolipoprotein level in egyptian patients with hcv and hcv-associated hcc: histopathological, biochemical and clinico-sonographic study t aboushousha chronic hepatitis c is a known risk factor for cirrhosis and hepatocellular carcinoma (hcc). liver steatosis is common in hcv patients suggesting that specific mechanisms might be involved. the aim of our study was to assess variability in serum apolipoproteins in relation to hepatic steatosis in hcv patients of genotype with or without hcc. material included egyptian subjects; (hcv), (hcv-associated hcc), and controls. clinical examination for stigmata of chronic hepatic affection and ultrasonography for assessment of liver size, surface, echogenicity and the presence or absence of a focal lesion were done. histopathological examination of liver biopsies was done for assessment of hepatitis activity index (hai) and stage as well as the grade of hepatocytic steatosis (hs). biochemical study included liver function tests, lipid profile and assessment of apolipoproteins. results showed a significant decline in apo-a, apo-b, apo-cii, apo-ciii and apo-e lipoprotein in hcv and hcv-associated hcc groups compared to the control group. analysis of hai in hcv patients showed significant association of hs with periportal necrosis, but not portal inflammation or lobular degeneration. in patients with hcv associated hcc, hs was significantly associated with portal inflammation and lobular degeneration, suggesting a correlation between virus activity and hepatocytic neoplastic changes. we concluded that steatosis should be searched for in patients with chronic hcv, being an important cofactor in accelerating the development of hepatic fibrosis and in increasing necroinflammatory activity. a correct therapeutic approach to steatosis would slow down the evolution of chronic hepatitis. introduction nonalcoholic fatty liver disease (nafld) is defined as a constellation of clinical conditions characterized by predominantly macro vesicular steatosis. it can be extremely difficult to reach the diagnosis of nash in the absence of correct clinical data. exclusion of excess alcohol intake is notoriously difficult and requires a desialylated transferin (the method rarely present in laboratories). aim: histomorphologic investigation of liver biopsies from patients with mild laboratory test abnormalities and steatosis complicated by necroinflamatory changes. a pilot study of morphometric characteristics of lipid droplets in nash and alcoholic hepatitis were also performed. material and methods forty liver biopsies with steatosis and inflammation were examined using the method of dixon. ten of these biopsies were morphometrically analysed regarding the lipid droplet features. following morphometric parameters were estimated: ) diameter, ) perimeter and ) area. we used olympus micro image-image analysis software v. . . . the presence and distribution of mallory hyaline was the most variable parameter. morphometric analyses confirm a statistically significant differences for all parameters tested in nash and alcoholic hepatitis, and were more pronounced in nash. conclusion in the cases of fatty change with necro-inflammatory changes and pericellular fibrosis in liver biopsy and presence or absence of mallory hyaline, morphometric analysis of lipid droplets can help in reaching the diagnosis of nash, if testing of desialilated transferring is not possible. the raf/mek/erk (mapk) signal transduction cascade is an important mediator of a number of cellular fates including growth, proliferation and survival. the braf gene, one of the human isoforms of raf, is activated by oncogenic ras, leading to cooperative effects in cells responding to growth factor signals. this study was performed to elucidate a possible function of braf in liver tumours. methods mutations of braf and kras were evaluated in hepatocellular carcinomas (hcc) and in cholangiocarcinomas (cc) by direct dna sequencing analyses after microdissection. the presence of active intermediates of the mapk pathway was assessed immunohistochemically. the results obtained were correlated with histopathological variables and patient survival. results activating braf missense mutations were identified in / cc ( %) and in one case of tumour surrounding liver. kras mutations were found in out of ( %) cc examined and in two cases of tumour-surrounding non-neoplastic liver tissue. in hcc, neither braf nor kras mutations were detected. all cc with kras mutations had an intact braf gene. we failed to observe a correlation between braf or kras mutations and histopathological factors or prognosis of the patients. conclusions our data indicate, that braf gene mutations are a relatively common event in cc, but not in hcc. disruption of the raf/mek/erk (mapk) kinase pathway -either by ras or braf mutation -was detected in about % of all cc and is therefore one of the most frequent defects in cholangiocellular carcinogenesis. prognosis and treatment of cholangitis after cholecystectomy n akhtar, ae kuzmenko, vv khatsko, ga grintsov, am dudin, yg kolkin donetsk medical state university, donetsk, ukraine introduction the purpose of our research was to study prognostic tests of cholangitis after cholecystectomy (ce) for prophylaxis and optimal treatment. materials and methods for years patients with so called "postcholecystectomic syndrome" (pces) were treated, ( %) had a clinical picture of acute cholangitis (ac), which was shown by pains in the right hypochondrium, yellowness of skin and scleras, shivering, high hyperthermia and leukocytosis. patients ( women and men) were - years old, of them more than years. initial operation (ce) was made in various hospitals in terms from months to years ago. the diagnosis was verified by: clinical, laboratory and immunological researches, peroxidation of lipids (pol), ultrasonic research, computerized tomography, fibrogastroduodenoscopy, endoscopic retrograde pancreatocholangiography, transdermic and transhepatic cholangiography, fibrocholangiograpgy, bacteriological researches of bile and blood. results according to investigations, in patients the reason of infringement of bile flow was choledocholithiasis (in a combination with stenosis of big duodenal papilla (bdp) or without it, in -stenosis of bdp, in -cicatricial stricture of hepatocholedochus, in extended stenosis of bdp and a terminal part of the common bile duct (cbd). laboratory prognostic tests (risk factor) ac concern: hyperbilirubinemia, increase of activity of alanine transpeptidase, aspartate transpeptidase, hypoproteinemia, dysproteinemia, decrease of a level of protrombin lower than %, leukocytosis, anemia, increase of the contents of urea in blood, bacteriocholia, concentration of molecule of average weight were higher than . unit, decrease of level of vitamin e, high contents of immunoglobulin m on a background of a low parameter immunoglobulin g. conclusions at the presence of risk factors prognosis was frequently in contrary to expectations and mortality reached to - %. all patients with acute cholangitis after cholecystectomy represented a complicated problem and demanded a complex approach. revealed prognostic tests of the development of acute cholangitis are necessary for taking into account for its prophylaxis and optimum treatment. structural alterations in c-myc oncogene, copy number and expression have been implicated in the pathogenesis and progression of several human neoplastic diseases. however, the biologic significance of c-myc gene in human hepatocellular carcinoma (hcc) is unconfirmed. in the present study we correlated c-myc gene amplification and protein expression with the clinicopathologic features. in hcc cases c-myc amplification in tumour tissue was determined using a differential pcr, a procedure for evaluation of gene amplification in comparison with a dopamine d receptor gene. the c-myc gene was amplified in out of tumor specimens ( %). amplification of c-myc was more frequent in younger male patients with hbv infection and in less differentiated tumors. all cases demonstrated positive staining using anti-c-myc monoclonal antibody with increasing percentage of immunoreactive cells in less differentiated tumors. however, the high protein expression was not statistically correlated with c-myc amplification. histological sectioning of brush bristles allows improved diagnosis of biliary tract and bronchial lesions g bussolati, g accinelli, l macri dept. biomedical science and human oncology, turin, italy brushing of thin ducts such as those of the biliary tract, pancreas and bronchial tree is often used by endoscopists in order to obtain diagnostic material proving the nature of related lesion. the material is spread on slides. cytological examination folows. preservation of the material so obtained is often sub-obtimal, partly because of the presence of fluids such as bile affecting cell preservation, partly because spreading of delicate cells may result in crushing artifacts. to circumvent such problems, we devised an original procedure, where brushes were not smeared, but instead immediately embedded in immersed methanol. then the tube with alcool and brush was sent to the laboratory. in order to induce formation of a glue surrounding the brush, this was immersed while wet into egg albumen (a mixture : of egg albumen and glycerol), then returned to methanol. for paraffin embedding, the metal handling was cut away and the brush was introduced as such into a cassette. sections parallel to the long axis were cut until the metal wire was almost reached, then the block was rotated and new section was obtained from the opposite side. sections were stained in haematoxilin-eosin and with the papanicolau procedure. small fragments of the mucosa, of inflammatory cell aggregates or of related carcinomas were observed. these resulted optimally fixed and allowed a definite histological diagnosis which proved mandatory for proper therapy. advantages and prospects of this novel procedure will be illustrated and discussed. is telomerase catalytic subunit gene re-expression an early event in gallbladder carcinogenesis? were to determine whether a.) differences in the levels of htert exist among different grades of gallbladder epithelial abnormalities, and b.) htert gene re-expression has any role in gallbladder carcinogenesis. material and methods the expression of htert was analysed in gallbladder tissue samples: normal epithelia, reactive hyperplasias, low grade dysplasias, high grade dysplasias and in adenocarcinomas by immunohistochemistry. at least nuclei were quantified per slide and the number of positive signals per nucleus was expressed as a htert index. results the mean htert index increased progressively with the degree of gallbladder epithelial abnormalities: from . (standard deviation= . ) in normal epithelia, . (sd= . ) in hyperplastic epithelia, . (sd= . ) in low grade dysplasia, . (sd= . ) in high grade dysplasia to . (sd= . ) in adenocarcinoma. according to the htert expression, three groups of gallbladder epithelial changes were found: .) normal and hyperplastic gallbladder mucosa, . low grade dysplasia, and .) high grade dysplasia and adenocarcinoma of the gallbladder. the differences between the groups were statistically significant (p< . ). conclusions we believe that occasional presence of htert in normal and reactively hyperplastic gallbladder mucosa merely reflects its regenerative capacity. nevertheless, significantly higher htert indices in low grade as well as high grade dysplastic epithelium and gallbladder adenocarcinoma are most probably the consequence of htert re-expression -an early event in the multistep process of gallbladder carcinogenesis. spontaneous intestinal perforation vs. necrotizing enterocolitis: different entities clinically and pathologically g de hertogh, p van eyken, m miserez, h devlieger, k geboes k u leuven, leuven, belgium introduction necrotizing enterocolitis (nec) is the most common neonatal surgical emergency. however, during recent years an increasing number of laparotomies has been performed for spontaneous intestinal perforation (sip) in premature infants. the aims of this study were to compare the clinical and pathological features of sip and nec and to identify parameters useful to make the differential diagnosis. materials and methods we reviewed the clinical files and biopsies from infants indexed as "necrotizing enterocolitis" or "intestinal perforation" between and . results twenty-six patients had sip and had nec. patients with sip had lower gestational age and birth weight. they presented early with abdominal distension. frequent radiological signs were dilatation of bowel loops and pneumoperitoneum. perforation was in the small bowel in all cases. % survived. patients with nec presented later with more systemic symptoms. pneumatosis intestinalis was present in more than half. the colon was involved more frequently than the small bowel. % survived. cases of nec were characterized by necrosis, inflammation and reparative tissue changes with or without pneumatosis intestinalis. in contrast, the bowel in cases of sip was not necrotic and showed little inflammation. its most distinguishing characteristic was the presence of one or more defects in the internal layer of the muscularis propia. the myenteric nerve plexus and interstitial cells of cajal had developed normally. conclusions spontaneous intestinal perforation and necrotizing enterocolitis differ in their clinical and histopathological characteristics. in our cases, sip was always associated with segmental absence of the intestinal musculature. impact of epitope retrieval in detection of cd (c-kit) in gastrointestinal stromal tumors (gists) using manual and automated immunohistochemical (ihc) procedures introduction gastrointestinal stromal tumours are solid tumours associated with c-kit and pdgf-r expressions. the recent introduction of gleevec/glivec, an effective inhibitor of the activated c-kit and pdgf-r has stimulated interest in standardizing the immunohistochemical detection of c-kit in gist-tissues, assuring an appropriate selection of patients for therapy with gleevec. aims: the dakocytomation anti-human c-kit antibody, code a , was investigated in four different set-ups: ) without heat-induced epitope-retrieval (hier), ) with hier, ) preabsorbing the primary antibody with the synthetic peptide used for generation of the primary antibody and ) testing on fresh versus archival tissue sections. materials and methods tissue sections were obtained from different cases of gist, confirmed by morphology and ihccharacterisation (c-kit, cd , s , sma, desmin). the ihc was performed manually as well as on automated platforms including the techmate™ and the autostainer instruments. results the use of hier consistently displayed a stronger and more uniform staining pattern as compared to an ihc protocol without hier. in few cases the expression of cd was found faintly positive in ihc without hier. automated and manual ihc methods displayed similar staining patterns. the specificity of detecting cd in a protocol using hier was confirmed by preabsorption of the primary antibody with immunogen. storing of fresh cut sections for more than months demonstrated a decrease in ihc cd staining intensity. conclusion epitope retrieval enhances the cd staining intensity in gist-tissue. the specificity of the cd detection in gist's can be confirmed by complete blocking of the positive staining in a parallel set-up, using preabsorption of the antibody by a synthetic c-kit peptide. introduction - % of gastric cancer patients worldwide are under and the clinicopathological features are different from the older age group. here we characterise some of the genetic changes in cases of early onset gastric cancer (eogc). methods using dna isolated from microdissected material, a panel of polymorphic microsatellite markers near known or presumed tumour suppresser genes was used to evaluate loss of heterozygosity (loh). microsatellite instability (msi) status was ascertained using polymorphic microsatellite markers in cases of eogc and in an additional biopsy cases. corresponding immunohistochemistry was performed for p , smad , ecadherin, mlh , msh and msh . ebv status of the carcinomas was determined using eber -mrna in-situ hybridisation. results the most common losses were at loci adjacent to cdh ( %), tp ( - %), runx ( - %) and smad / dpc ( - %). less frequently, losses were detected at p , q , and loci adjacent to apc, p ink a, pten, and tff. no msi was detected in the cases examined. immunohistochemistry revealed abnormalities for e-cadherin in % and p in %. all tumours examined were ebv negative. conclusion common events in eocg are genetic alterations in cdh , tp and runx whereas other loh findings were infrequent. protein abnormalities of e-cadherin and p were commoner than losses near the corresponding gene. in contrast to gastric cancer in older patients, msi does not appear to occur in young patients. these findings confirm that unique genetic alterations lead to gastric cancer in the young and highlight the need for further investigation to elucidate the mechanisms by which they occur. introduction a place of foveolar hyperplasia (fh) in benign epithelial gastric polyps (begp) classification, as well as its role in a development of hyperplastic polyps (hp) is still a matter of controversy. aims: two questions are to be studied: . does fh, hp, adenoma (a) and carcinoma (ca) represent a continuum in terms of ki- proliferative activity ? . are there any differences of the means of ki- labelling index (li) in hyperplastic areas of hp when comparison is made between hps without other lesions (hp-nos) and with hps with different focal lesions such as intestinal metaplasia (hp-im), dysplasia (hp-d) and/or carcinoma (hp-ca)? materials and methods begp from patients were selected to perform ki- immunohistochemical analysis. there were fh, hp (including hp-nos and hp-im, hp-d and/or hp-ca) and a. as controls cases of normal mucosa (n), cases of regenerative fh (fh-r) and cases of ca were used. paraffin sections were studied immunohistochemically for ki- li with application of mib- antibody. the data were analysed using one-way anova models. results it has been found that the means of ki- li between all the groups studied differed significantly (p< . ). ki- li for fh was high ( . ) and did not differ significantly from fh-r ( . ), a ( . ), and areas of low grade dysplasia in hp-d ( . ), but was significantly higher from n ( . ) and hp ( . ). conclusions .we hypothesize that fh may probably represent an early event in begp formation. .there were no significant differences of ki- li results for hyperplastic areas in hp ( . ) independently if there were focal im, d and/or ca simultaneously, or not. introduction among the malignant tumors that occur in stomach, carcinoma is overwhelmingly the most important and common ( - %). the aims of this study were to report how we histologically evaluate gastric carcinoma (gc) on endobiopsies, using who and lauren classifications. additionally, we tried to detect the rhabdoid features in specimens with diffuse gc. the study included gastric endobiopsies, gc being diagnosed in cases ( %), mostly in men ( cases - %). endobiopsies, routinely embedded, were stained by hematoxylin-eosin, giemsa, pas and alcian blue (ph . ). immunohistochemical studies were performed using vimentin and cytokeratin antibodies for detection of rhabdoid features. results and conclusions the highest incidence of gc was in - -year-old aged patients ( %). using lauren classification, cases were categorised as diffuse type ( %), intestinal type ( %) and ( %) mixed type gc. each of these three types were also histologically analyzed according to who classification: intestinal type gc (formed by recognizable well/moderately differentiated glands) and diffuse type gc (consisting in poorly cohesive cells diffusely infiltrating the gastric wall with little or no gland formation). in diffuse type gc with rhabdoid features we evidentiated vimentin and cytokeratin in cells with an eccentric nucleus and a paranuclear inclusion. finally, we pointed out that is very easy to diagnose gc by lauren and who classifications, but is difficult to evidence the mixed type gc due to reduced size of endobiopsies. recognition of the rhabdoid phenotype in diffuse type gc is important because this feature is associated with poor prognosis and unresponsiveness to conventional therapy. gastrointestinal tract. the patient had a -year history of dyspepsia, diarrhorea, mild diabetes mellitus and cholelithiasis. one hour after the admission, he died in hypovolemic shock. taken tissues from all organs were fixed in % formaldehyde and embedded in paraffin. laboratory sections were stained with: he, ab-pas, van gieson, grimelius, masson's argentaffine reaction and bsp methods, using antibody to somatostatin. results cafe au lait spots, multiple skin neurofibromas, mental retardation, skeletal deformities and a variety of tumours arising in the brain (craniopharyngioma), follicular thyroid adenoma and duodenal somatostatinoma, were found during autopsy. duodenal bleeding ulcer of gigantic size, was covered with coagula. in the bottom of the duodenal ulcer was discovered duodenal carcinoid of the glandular architecture, intermingled with solid acinar and trabecular growth pattern; its cells contained somatostatin. marked increase in number and thickness of nerve fibres also was seen, leading to disordered motility and to striking hypertrophy of the muscularis propria. conclusion having in mind that the patient has the sister, and that this disease has hereditary character, we will invite the sister as soon as possible and she will be in the future the target of our investigation. increased expression of muc and muc and decreased expression of muc in colorectal adenoma-carcinoma spectrum: a tissue array study introduction mucin-type glycoproteins are widely expressed in the gastrointestinal tract. little is known concerning the relationship of altered mucin antigens in colorectal polyps. the aims of this study were to determine the different patterns of mucin distribution of muc , muc , muc ac and muc and compare their patterns of expression with respect to histopathologic criteria of malignant potential in colorectal carcinogenesis by tissue array using immunohistochemistry. peritoneal dialysis (pd) is an alternative to hemodialysis for the treatment of end-stage renal disease. the long term exposure to dialysis solutions causes progressive peritoneal fibrosis and functional decline of the peritoneum. the pathologic process that leads to fibrosis is not well understood and most studies have focused on mesothelial cells, probably because they are easy to obtain from peritoneal effluents. the aims of this study were to establish diagnostic markers of peritoneal fibrosis and pathogenic clues to explain the fibrogenic process. the study was focused on submesothelial fibroblasts from normal controls and pd patients. materials and methods parietal peritoneal biopsies were collected from three patient groups: normal controls (n= ), non-pd uremic patients (n= ) and uremic patients on pd (n= ). in order to study myofibroblastic differentiation and mesothelial-to-mesenchymal transition, alpha-smooth muscle actin, desmin, cytokeratins, and ecadherin were analyzed. we also evaluated cd expression by submesothelial fibroblasts. results fibroblasts from normal controls and non-pd, uremic patients showed no myofibroblastic nor mesothelial markers, but an intense expression of cd . the opposite immunophenotypic pattern was present during pd-related fibrosis. expression of mesothelial markers (cytokeratins and e-cadherin) by fibroblastlike cells and alpha-smooth muscle actin by mesothelial and modified mesothelial cells are evidence that mesothelial-to-mesenchymal transition occurs during pd. loss of cd expression was another helpful indicator of fibrosis. conclusion the immunophenotype of submesothelial fibroblasts varies depending on the existence of a fibrogenic condition. this information results useful for the differentiation between quiescent and activated fibroblasts. in addition, it shows interesting information regarding the origin of this cell population. immunohistochemical and genetic high-throughput analysis of gastrointestinal stromal tumors tract. they are characterized by diffuse immunohistochemical positivity for c-kit protein (cd ). the aims of this study were to assess the immunohistochemical and genotypic features of a large series of gist using tissue microarray technique. methods gist were retrieved from the files of dpt of pathology of our institutions and a tissue microarray (tma) was built. immunohistochemistry for cd , actin, desmin, s , nse, mib was performed. interfase fish analysis was carried out for the following genes: mdm , egfr, c-myc, ccd and her- . results % of the tumors resulted positive for cd , % for desmin, % for actin, % for s , % for nse, % for mib . a significant difference between gastric and non-gastric gist was observed for cd , desmin and s . age, size, necrosis and nse positivity significantly correlated with aggressive behavior of the tumors. moreover, an amplification of c-myc, mdm , egfr, ccd in tumors was found. the tumors were all but two borderline or high risk tumors. cases of coamplification were also detected in clinically malignant or histologically high risk tumors. conclusion useful parameters for prognostic evaluation of gist are age, size and necrosis. furthermore, the observed amplification of c-myc, mdm , egfr suggests a role of rb-ccd pathway in the acquisition of malignant phenotype in a subset of gist. digital slide and virtual microscopy based routine and telepathology evaluation of routine gastrointestinal biopsy specimen l berczi introduction the aim of the study was the evaluation of a recently developed digital slide and virtual microscope system, its comparison with optical microscopy on routine gastric biopsy specimen in local and remote access mode. materials and methods h/e stained routine gastric, duodenal and colon (altogether ) biopsy specimen were selected, scanned and evaluated by two specialists on an optical (om) and virtual microscope (vm). the overall concordance of vm to a consensus diagnosis (con) was . % and % of the om to con. the clinically important concordance was % and % respectively. the two methods showed concordance in % and clinically important concordance in . %. the reasons of the discordance was image quality (one case), interpretation difference ( cases). the overall hard disc place for a gastric biopsy was between to megabytes. the scanning time was between to minutes on a commercial microscope (axioplan , carl zeiss, germany) and to minutes on an automated slide scanner (hi-scope, dhistech ltd., budapest) conclusions remote evaluation of the digital slides through internet shows the advantages of the previously used static and dinamic telepathology methods. the digital slide and the virtual microscope are real alternative techniques in the computerization of the histology laboratory and in teleconsultation services. the expression pattern of the muc glycoproteins muc , muc and muc ac may be useful in classifying the various types of intraductal pancreatic neoplasms (ipmns). recent studies have revealed that muc is expressed in ductal pancreatic carcinomas (pdac) only. this study investigates whether muc is expressed in ipmns and in particular in those with invasive components. in addition, muc reactivity was studied in panins of both ipmn and pdac. methods paraffin blocks from resection specimens from pdacs and ipmns ( invasive) were investigated immunohistochemically ([ihc] antibody clone ig ) and by in-situ hybridization ([ish] digoxigenin labeled oligomer nucleotide specific for sequences corresponding to repeat domains of muc ). the normal pancreas is muc negative. of pdacs were positive for muc in both ihc and ish. only ipmns were muc positive, and these cases were of the oncocytic type. invasive ipmn components of the dac type ( / ) and one of muconodular type ( / ) showed muc expression at both the protein and the rna level. in ipmns associated panin lesions of all grades were negative, whereas in pdacs a few panin lesions were positive. conclusions muc neoexpression in the pancreas seems to be a feature of invasive ductal neoplasms (ipmn, pdac), with the exception of oncocytic ipmns. the aberrant expression, in particular the shift from the negative intraductal to the positive invasive component in ipmns, is so far unexplained, but it may be related to the genetic alterations known in ipmns and pdacs. introduction hypermethylation of cpg islands represents an important epigenetic mechanism for silencing of tumor suppressor genes during carcinogenesis. in this investigation, the prevalence of hypermethylation of the dna mismatch repair gene hmlh and of the recently identified hpp gene was investigated in adenocarcinomas of the upper gastrointestinal tract. materials and methods using methylation-specific real-time pcr and fluorescence-labeled dna-probes, hypermethylation of hmlh and hpp was investigated in barrett's-esophagusassociated adenocarcinomas, cardiac carcinomas and in gastric carcinomas. additionally, hmlh protein expression was investigated by means of immunohistochemistry. in a subset of cases the presence of dna-microsatellite instability was tested. hypermethylation of hmlh was found in % of barrett's carcinomas, % of cardiac carcinomas and in % of gastric carcinomas, whereas hypermethylation of hpp was found more frequently in all tumor types ( % vs. % vs. %). in gastric cancer, hpp hypermethylation was found more frequently in tumors with concomitant hmlh hypermethylation ( %), than in those without hmlh hypermethylation ( %, p= . ). complete loss of hmlh protein expression which was present in carcinomas ( cardiac and gastric) was invariably correlated with hmlh hypermethylation and with microsatellite instability. conclusion our data indicate that microsatellite instability and loss of the mismatch repair protein hmlh , which is mainly caused by hmlh gene hypermethylation, is more prevalent in the carcinogenesis of the stomach and the cardia than in the esophagus. moreover, in gastric cancer hmlh hypermethylation is correlated with hypermethylation of the hpp gene. antral g-cells in sporadic fundic gland polyps patients: an immunohistochemical study introduction malignant melanoma is an increasing neoplasm in the western world. advanced tumors gain metastatic potential and are responsible for high mortality rates. during tumor progression a downregulation of the transcription factor ap- a and the receptor thyrosine kinase c-kit was observed. however, mechanisms leading to a loss of both proteins are unknown. besides genetic changes post-transcriptional downregulation by caspase- and - is recently discussed. aims were: i) to investigate malignant melanoma for ap- a and c-kit genetically and by protein expression, ii) to study the implication of activated caspases. methods ssms, nms and metastases were analyzed by direct sequencing analysis for all exons of ap- a and c-kit genes and by immunohistochemistry for the respective proteins and cleaved (activated) caspase- and - . results four tumors showed point mutations in the activation motif of ap- a (exon ). no genetic alterations were detected in the c-kit sequence. immunohistochemistry revealed a progressive loss of dermal ap- a and c-kit expression when comparing ssms with nms and ms which was paralleled by a strong expression of caspase- in the primary melanomas and ms, the later were also characterized by caspase- expression. conclusion tumor progression in melanoma is characterized by a loss of ap- a and c-kit. caspase- probably contributes to this down-regulation, as it was recently shown in vitro. the activation of caspases in melanoma might not only induce apoptosis but could be substantial for tumor growth. introduction in cancer patients, tumor-expression of the angiogenic factor vascular endothelial growth factor-a (vegf-a) correlates with high tumor vascularity and increased metastatis, but how these latter two relate is unclear. we investigated the mechanisms of vegf-a -enhanced metastasis of the human melanoma cell line mel . methods stably transfected mel cells, expressing vegf-a or egfp, were injected into the internal carotid artery or tail vein of nude mice to establish brain or lung metastases (colonization models). subcutaneous tumors were grown to examine spontaneous metastasis to lung. tumors and metastases were examined by (immuno)-histochemistry. results in colonization models, vegf-a expression did not give tumor cells a colonization advantage. metastases originated predominantly by clonal expansion of single cells. in contrast, spontaneous metastasis from subcutaneous tumors was enhanced in tumors with vegf-a expression, this enhanced metastatic potential was induced by a distinct architectural transformation of the s.c. tumors: while mel -egfp and parental mel tumors showed extensive necrosis, mel -vegf-a tumors presented a micronodular growth pattern, with nodules protruding into sinusoidal dilated vasculature. these micronodules proved to be polyclonal, had tissue characteristics and caused metastatic embolism in the pulmonary artery with subsequent metastatic outgrowth. conclusion vegf-a may enhance spontaneous metastasis not simply by increased single cell shedding into the circulation by an increased tumor vascularity but by induction of a micronodular transformation of a tumor resulting in enhanced shedding of (polyclonal)tissue fragments into the circulation. this step of tumorintravasation is probably a rate limiting factor in development of metastasis. correction of cytogenetic disturbances in patients with relapsing genital herpes la lebedinskya, op abaza donetsk medical state university, donetsk, ukraine introduction serious forms of relapses of genital herpes (gh) are accompanied by disturbances of chromosomal apparatus of lymphoid cells (l.a. lebedinskya, ) . correction of the given infringements is the important problem of practical public health service. the aim of our research was development of a complex method of correction of cytogenetic infringements in patients with gh. materials and methods we had investigated and treated patients (complex treatment) with gh in the age of - years, with frequency of relapses of one time in . - months. the control group was made by healthy persons, same age group. cytogenetic disturbances in t-lymphocytes of peripheral blood surveyed determined by metaphase method. complex method of treatment of patients with gh included acyclovir mg times per day before clinical recovery and phytopreparation "bacplan", received by an original way from quercus cortex. phytopreparation "bacplan" shows immunomodulation, anti-inflammatory and antimutagen properties. preparation "bacplan" appointed per os . g per day within days. external - % solution of bacplan in the form of lotion on affected body parts time in day. results average frequency of cells with aberrations of chromosomes (ac) in t-lymphocytes of peripheral blood of patients with gh before treatment were much higher in comparison with parameters of control group (accordingly . ± . and . ± . % p< . ). in patients were marked disturbance of chromosomal and chrmotoid types. in . % cases aberration of chromosomes were registered in - chromosome pairs. after complex treatment of average frequency of cells with ac in patients has decreases to days to . ± . % (p< . ) and practically come nearer to control parameter ( . ± . %). conclusions thus, use of viral specific preparation acyclovir in combination with phytopreparation "bacplan" reduces frequency of structural infringements of chromosomes in t-lymphocytes of patients with gh. different expression patterns of s- versus s- b in primary skin melanoma j timar, n udvarhelyi, z orosz national institute of oncology, budapest, hungary differential diagnosis of melanoma involves immunohistochemistry where s- is a traditional marker which is recently completed by gp /hmb , mart- and tyrosinase. the s- family of ca-binding proteins comprises the a ( - ) and b isoforms. recent microarray analysis identified s- b as the melanocyte lineage marker. in this work we have compared the expression patterns of s- proteins using antibody recognizing both isoforms versus that which is specific for s- b in human skin primary melanoma samples. there were expression patterns observed: focal, herogenous and diffuse for both antibodies. the most frequent expression pattern was the diffuse one ( - %) while the least frequent was the focal pattern ( - %) in case of both antibodies. when the individual cases have been analysed for the expression patterns for the two antibody we found % discrepancy. in about half of these cases ( %) the discrepancy was minor (heterogenous versus diffuse staining pattern), but in almost a third of the cases ( %) it was found to be considerable (focal pattern versus heterogenous or diffuse). we have concluded that the expression patterns of s- and s- b proteins in human melanoma are frequently different. since gene expression studies identified s- b as linage marker, it is highly recommended to use monospecific antibody for routine diagnosis. furthermore, s- b is validated as sensitive serum marker for melanoma progression accordingly it is another indication for the use of anti-s- b antibody in the routine diagnosis. introduction primary cutaneous b-cell lymphomas represent subtypes of extranodal b-cell lymphomas with distinct clinicopathologic features. they account for approximately % of primary cutaneous lymphomas. the most common forms include follicle cell lymphoma, marginal zone lymphoma, immunocytoma, and diffuse large b-cell lymphoma. we report cases of primary cutaneous diffuse large b-cell lymphomas, one in the left gluteal region ( / cm in diameter), and the other in the left leg ( / cm in diameter), both appearing clinically ulcerated. materials and methods routine paraffin embedding and usual stainings, followed by immunohistochemistry were used. results microscopy evidentiated in the papillary and reticular dermis a diffuse pattern of growth of cells with a moderate degree of morphologic variation, with moderate, slightly basophilic cytoplasm and round-ovalar nuclei, with vesicular aspect owing to margination of chromatin at the nuclear membrane, - nucleoli, and frequent mitoses. gomory staining revealed a network of reticulin with reduced intervening spaces. immunohistochemistry evidentiated a diffuse positivity of vimentin and cd (l ), s positivity in few cells, desmin negativity, mic negativity, cd (berh /ki- ) negativity, actin negativity in tumor, but positivity in vessels, ema negativity and pcna positivity in almost % of the cells. conclusion final diagnoses of primary cutaneous diffuse large bcell lymphomas were considered correlating the clinical, morphologic, and immunophenotyping features. although prognosis of most primary cutaneous b-cell lymphomas is favorable, with -year survival rates over %, diffuse large b-cell lymphoma is more aggressive. we appreciated an unfavorable prognosis of both cases, but especially in the patient where the lymphoma occurred in the lower leg, as this location is associated with a more aggressive behaviour. in malignant melanoma cd protein expression is associated with metastatic tumors, higher clark levels and tumor thickness according to breslow n department of pathology, the norwegian radium hospital, norway cd antigen is a kd a cell surface zinc metalloendopeptidase and is expressed by a variety of normal and neoplastic lymphoid and non-lymphoid tissue including melanomas. kanitakis et al. (melanoma res ; : - ) have recently demonstrated that cd expression is significantly more common in metastatic than primary melanomas. we have evaluated biopsies from patients with primary and patients with metastatic melanoma. formalinfixed/paraffin-embedded tissues were studied by immunohistochemistry using mab c from novocastra laboratories and envision+® from dakocytomation. overall, cd was expressed in / samples, but the percentage of cd -positive cell was significantly higher in metastatic tumors (p= . ) and also in primary tumors with higher clark level (p= . ) and tumor thickness according to breslow (p= . ). even though the intensity of expression was associated with depth of invasion (clack levels p= . , breslow p= . ), there was no definitive difference between primary and metastatic tumors (p= . ). we conclude that cd expression in malignant melanoma is associated with tumor progression. sclerosing adenosis of the skin g sclerosing adenosis is a lesion that occurs in the breast; rare cases have also been reported in other organs such as prostate and skin. we report a case of sclerosing adenosis of the skin incidentally found at the periphery of a basal cell carcinoma. a -year-old man had a polypoid lesion of the scalp measuring . cm in diameter. the lesion was surgically removed and, at histology, it was composed of a nodular basal cell carcinoma. below the basal cell carcinoma, there was a well circumscribed but not encapsulated lesion constituted by small, packed glands separated by cellular stroma, reminiscent of sclerosing adenosis of the breast. some glands showed open lumina bordered by cells with eosinophilic, granular cytoplasm while other glands were arranged in solid clusters or elongated cords. two distinct layers of cells were seen bordering the glands: a luminal layer of cuboidal cells and an outer layer of basal cells with scanty cytoplasm and spindle nuclei. at immunohistochemistry the outer cell layer was positive for actin, calponin, caldesmon and keratin antibodies showing therefore myoepithelial cell differentiation. the luminal layer was positive with low weight keratin; moreover luminal cells were decorated by gcdfp- antibody, a marker of apocrine differentiation. to the best of our knowledge this is the first case of sclerosing adenosis of the skin showing apocrine metaplasia of luminal cells. the case here reported is an additional example of the existence of occasional similar lesions between skin and mammary gland. immunolocalization of human sperm protein in skin cancer introduction a variety of cancer	estis (c\t) antigens has been found to be expressed in healthy testis and in a wide range of human malignancies, including melanoma. the effectiveness of these antigens as target for active specific immunotherapy has been largely demonstrated. recently a new human c\t, called sperm protein (hsp ) has been investigated in multiple myeloma and ovarian cancer. the aim of this study was to investigate the expression of hsp in healthy skin and melanocytic skin lesions, in order to evaluate the usefulness of this antigen to develop effective specific immunotherapeutic procedures. methods the authors assessed the immunolocalization of hsp in paraffin embedded formalin fixed specimens of healthy skin (n= ) and tissues representing cutaneous melanocytic lesions [common nevi (n= ), spitz nevi (n= ), blue nevi (n= ), atypical nevi (n= ) and melanomas (n= )]. results hsp was not detected in healthy skin. it was recognized with a high frequency in cutaneous melanocytic lesions in some cells of the dermal stroma, often containing melanin, compatible with melanophages. a higher expression of hsp was observed in hyperpigmented nevi. conclusion the emergent complex function of hsp suggests the necessity of further studies to investigate the relation between melanophages and hsp . although hsp was not detected in healthy skin, its limited detection in resident melanophages recognized in cutaneous lesions, and not in tumoral cells precludes its applicability as target in skin cancer immunotherapy. introduction crimean congo haemorrhagic fever (cchf) is endemic in many countries in asia, africa and europe. the virus, which causes cchf, is a nirovirus from the bunyaviridae family. although primarily a zoonosis, sporadic cases and outbraces of cchf affect humans. case report a -year-old female patient was hospitalized due to sudden onset of fever, headache, vomiting and abdominal pain. during the next days, her condition became worse, she was unconscious, anuric, cyanotic with multiple edema on extremities, large vaginal coagulums and with appearance of haemorrhagic secretion in aspired fluid from the respiratory tract. three days after admission, due to sudden onset of cardiac arrest, patient died. pathologic findings: severe bleeding from the mucous membranes and internal organs were found, particularly emphasized in the liver, kidneys, heart, brain and other organs. widespread hepatocellular necrosis with focal microvesicular steatosis and multiple intracytoplasmatic microvesicular inclusions were the most striking morphological findings. diffuse necrosis of renal tissue was also found. recent haemorrhages in lungs, cardiac muscle, suprarenal gland, spleen, and gastric mucosa were found. lymphoid depletion was detected in lymph nodes. the rt-pcr method for detection cchf virus has been applied in analysing serum and tissue samples. serological testing and testing from paraffin embedded tissue were positive. conclusion autopsy pathologic findings of cchf include widespread haemorrhages of the skin, mucous membranes, pleura, peritoneum. necrosis is frequent in all organs and tissues, often of ishaemic nature. autopsy results of our patient showed similar pathologic findings and by pcr method we confirmed etiopathogenesis of this disease. the modern morphological characteristic of placenta in syphilis z parpiev , g reymnazarova , b magrupov dermatology and venerology, tashkent, uzbekistan first tashkent medical institute, tashkent, uzbekistan we investigated the placentas in three cases of intrauterine death caused by inherited syphilis. grossly, they were small and medium lobular, showed a marked sclerosis of large vessels and they looked white-muddy. the umbilical cord was also sclerotic and showed obliteration of vessels. their weight corresponded to term of gestation, whereas their area was smaller and their thickness greater than in normally proceeding pregnancy, but these differences were not significant (p> . ). results light microscopic investigation revealed avascularized stroma and sclerotic villi with vessels showing obliterating angiopathy. these changes were combined with processes of compensatory character, such as sharply extended subsyntitially located capillaries and large number of small vesels. conclusion in the morphological study of placenta, the attributes of damaged placental tissue and development of compensatory reactions directed towards the maintenance of necessary balance in the mother-placenta-fetus system were revealed. in placenta, contrary to the descriptions of the last years, we found no significant increase of its weight and change in this connection fetus-placenta of factor. the basic changes in placenta were characterized by the development of productive vasculitis with obliteration of the vascular lumina and presence of avascularized terminal villi. the thickening of vessel walls of the main villi as a result of proliferative endarteriitis can be considered as a characteristic attribute for syphilitic infection. the latent membrane protein (lmp ) of epstein-barr virus is one of two postulated viral oncogenic proteins. previous reports have suggested that sequence variations, and in particular a base pair deletion variant called cao, may define different disease populations. we developed a cocktail of rat monoclonal antibodies that were specific for the non-wild type lmp and compared the presence of the antibody staining with lmp dna sequence analysis on clinical samples of nasopharyngeal carcinoma, peripheral t-cell lymphoma, hodgkin's disease and lymphoblastoid cell lines from normal volunteers and patients with npc. results and conclusion our results demonstrate specificity of the monoclonal cocktail for detecting the wild-type lmp and the ability to sub-differentiate between the mediterranean type of lmp and the cao-lmp . visceral leishmaniasis primarily diagnosed in duodenal biopsy: report of three cases f pardal, a silva, v velasco, m teixeira serviço de anatomia patológica, braga, portugal introduction visceral leishmaniasis (kala-azar) is a zoonosis caused by a flagellate protozoan, of the genus leishmania, which is transmitted to man from reservoir animals (like a dog), by a vector of the genus phlebotomus. generally it affects the mononuclear phagocytic system of the bone marrow, liver and spleen. the gastrointestinal system is rarely involved. diagnosis of the infection depends on microscopic identification of leishmanias amastigotes in tissues or blood cultures or by serologic means. aims: visceral leishmaniasis is a rare disease in patients without immunodeficiency, the authors report three cases diagnosed primarily in duodenal and gastric biopsy from immunocompetent patients. materials and methods from the files of pathology department of s. marcos hospital five cases of visceral leishmaniasis have been collected in a years period, all from immunocompetent patients, namely without hiv infections. the authors describe three of the five cases, which were primarily diagnosed by gastro-duodenal biopsy. lately, was noted the presence of amastigotes in other tissues. after histologic diagnosis resulted a full clinic diagnosis of systemic leishmaniasis with advanced stage of disease. conclusions pathology department files reveal a significant percentage of visceral leishmaniasis diagnosed by gastroduodenal biopsy, three of five cases. thus, in no endemic countries for this opportunistic infection and in immunocompetent patients, gastrointestinal biopsy can, eventually be a rapid and sensitive method of diagnosis, since most of the patients present at an advanced stage of disease. impact of the sudden acute respiratory syndrome (sars) on the pathology laboratory: a singapore experience ar chang, a wee, sm chong, t ming pathology department, national university hospital, national university of singapore, singapore the sudden acute respiratory syndrome (sars) is a new global health problem that has received unprecedented attention. the predominant route of infection is by droplets and close contact with an infected person poses the highest risk of being infected with the sars virus. the majority of cases among health care workers have occurred in doctors and nurses who have cared for sars patients. pathologists and laboratory personnel are regarded as low risk for infection because they are infrequently in direct contact with patients. however, they receive specimens, including sputa, bronchiolo-alveolar lavage samples, excised tissues, blood and body fluids from infectious cases. two further possible sources of infection are during autopsies and the onsite processing of fine needle aspiration specimens for immediate diagnosis. not uncommonly, few clinical details are attached with a specimen to alert the laboratory so universal precaution must be in place and all specimens regarded as infectious. but with a new infection such as sars where information on its natural history, infectiousness and mode of transmission are still evolving, greater vigilance and a pro-active approach are needed. during the period march -may singapore was faced with a potentially serious sars epidemic and to minimize the chance of personnel in the pathology department, national university hospital being infected and thus compromise the diagnostic service a contingency plan was implemented. this report describes the impact of the plan on the department. sars is a global disease and pathologists in countries who have not encountered it may find the information useful for preparing their laboratory for the eventual arrival of sars. angiotropic large cell lymphoma of the central nervous system -report of four cases introduction angiotropic large cell lymphoma (alcl), or intravascular lymphoma, is a rare form of high grade non-hodgkin's lymphoma, predominantly of b-cell lineage. it is characterized by extensive proliferation of lymphoma cells within the lumina of small blood vessels particularly of the cns and skin with tendency to disseminate into multiple organs. because of nonspecific manifestations the clinical diagnosis of alcl is difficult as well as the morphological diagnosis, which may be problematic and subtile. methods we studied four cases of alcl with dominant neurologic symptoms in the form of vasculitis, dementia and cauda equina syndrome. the diagnosis was made by autopsy in three cases and by brain biopsy in one case. in one autopsy case, the alcl was associated with aids in a -years old hemophilic boy. results microscopically, in all cases, small blood vessels of the cns were distended by collections of large atypical lymphoid cells which obstructed the vascular lumina. tumor cells cytoplasm was amphophilic, the nuclei were large, irregular with prominent nucleoli. mitoses were numerous. in the vicinity, there were small zones of spongy edema, reactive gliosis and foci of total or selective necrosis. in an autopsy case with diagnosis 'vasculitis' (female -years) there was dissemination into multiple organs. immunohistochemistry shows strong positivity for cd and cd , and the negative reaction for cd , cd ro and factor viii-related antigen. based on the above findings the diagnosis of angiotropic large b-cell lymphoma was made. conclusion the antemortem diagnosis of alcl of the cns may be established by brain biopsy with application of immunohistochemistry. evaluation of cell death in animal model of brain contusion treated by hyperbaric oxygen therapy e vlodavsky, j soustiel rambam medical center, haifa, israel cerebral contusion (cc) remains the most important consequence of traumatic brain injury and has unexplained unique evolving clinical course.the aim of this study was to evaluate the extent of apoptosis in perilesional area of cc and to examine the effects of hypoxia and hyperbaric oxygenation therapy (hbot).the model of cc was based on the technique of cortical dynamic deformation (shreiber et al., ) on sprague-dawley rats. one group of animals afterwards was placed in closed chamber and exposed to mild hypoxemia, simulating posttraumatic hypoxemia. both groups of animals (hypoxia-exposed and non-exposed) were treated by hbot. brains were cut through produced lesion and paraffin sections were stained by tunel method and for active caspase- . apoptotic cells (ac) were counted in five successive perilesional layers of . mm each. it was shown that in the group of rats that were exposed to hypoxia, the width of perilesional area and the number of ac were significantly higher than in non-hypoxic animals, raising from . % to . % at . mm (p< . ).one treatment by hbot induced significant decrease both in the radius of perilesional area and the number of ac in both groups of animals (in hypoxia-exposed animals this effect was even more pronounced).the results of our study prove the role of perilesional area in the 'growth' of cc. hypoxemia caused profound increase in cell death extension. hbot shows marked positive effect in both hypoxic and nonhypoxic animals. we used quantative pathologic monitoring of number of ac to develop the optimal regimen of hbot in animal model of cc. introduction surgery for seizures consists of surgical procedures made in the central nervous system to treat drug-resistant epilepsy. different lesions may be the cause. aims: we review the cases diagnosed between the years and in our hospital. materials and methods the surgycal specimens were stained with hematoxilin-eosin and neural or glial immunostains after paraffin embeding. results the most frequent lesion is mesial temporal sclerosis ( - % of the cases). other causes are tumors; dysembrioplastic neuroepithelial tumor (dnt), neuronal tumors and glial tumors. less frequent lesions are phacomatosis, malformative lesions like cortical dysplasias or vascular malformations, vascular or trauma lesions and inflammatory or unspecified lesions. mesial temporal sclerosis consists of neuronal loss and gliosis in sectors ca , ca , ca and dentate gyrus. between and we diagnosed cases; were women and were males. dnt is a very infrequent, intracortical tumor composed of glia and neurons, usually associated with cortical dysplasia. in our experience we diagnosed cases; women and men. we have found other tumors associated with epilepsy; cases of ganglioglioma ( women and men), cases of gangliocytoma ( women and men), and astrocytic tumors ( protoplasmic astrocytomas, mixed astrocytoma and fibrillary astrocytomas). we also diagnosed other processes associated with epilepsy: cases of cortical dysplasia, of glial scar, of gliosis or unspecified changes and cases of vascular malformation. conclusion pathology associated with seizures is very diverse; a multidisciplinary and experienced team is needed. expression of sperm protein , a novel cancer-testis antigen in human nervous system tumours introduction human sperm protein (hsp ) is a highly conserved protein originally isolated from a rabbit epididymal sperm membrane and testis membrane pellet. recently, hsp has been included in the cancer/testis antigens (ct) family and showed to be expressed in multiple myeloma and ovarian cancer. the aim of the study was to investigate the immunolocalization of hsp in specimens of nervous system malignancies, in order to establish the usefulness of this antigen as target for tumour-vaccine strategies for nervous system tumours. methods the authors assessed the expression pattern of hsp in formalin-fixed and paraffin embedded surgical specimens of nervous system malignancies, including neuroectodermal primary tumors ( astrocytomas, glioblastomas multiforme, oligodendrogliomas, and ependymoma); meningeal tumours; and peripheral nerve sheath tumours ( schwannoma, and neurofibroma), using a standardized immunohistochemical procedure. results hsp was found to be expressed in a low number of tumoral cases (nearly %), with a major expression in astrocytomas histological group ( %). no case among peripheral nerve sheath tumours was found to be immunopositive for hsp . the expression pattern was found heterogeneous in all of the positive samples and it does not correlate with the degree of malignancy. conclusions the low frequency and the heterogeneous distribution of hsp suggest the useless of this antigen as unique target for immunotherapeutic strategies. however, the present study shows firstly the immunolocalization of hsp in some cells of nervous system tumors tissues. the emergent complex function of hsp renders necessary further studies to understand the link between positive-cells and this protein. in vitro fddnp labeling of pathological protein aggregates in the cns of selected "conformational" disease cases introduction a molecular imaging probe - ( -{ -[( -fluoroethyl) (methyl)amino]- -naphtyl}ethylidene)malononitrile (fddnp), is a highly hydrophobic, fluorescent substance, known to label senile plaques and neurofibrillary tangles (nft) in the brain of alzheimer disease (ad) patients. the aims of this study were to evaluate in vitro fddnp labeling of protein aggregates in selected "conformational diseases" of the brain and to determine if they fulfill the tinctorial and polarizing optics criteria for amyloid. material and methods brain sections of patients with confirmed ad, variant ad (vad), amyloid angiopathy (aa), sporadic creutzfeldt-jakob disease (cjd), variant cjd (vcjd), gerstmann-sträussler-scheinker syndrome (gss), pick disease (pid) and progressive supranuclear palsy (psp) were labeled with fddnp, congo red (cr) and pas. analysis was performed using fluorescent microscope (fddnp), and light microscope (cr and pas) with polarizing optics (cr). results in addition to senile plaques and nft in ad and vad fddnp reliably labeled: prion plaques in cjd, vcjd and gss, lewy bodies in vad and vascular amyloid in aa. it did not label pick bodies in pid, and globoid nft in psp. with the exception of fddnp positive hirano bodies in ad and lewy bodies in vad, cr and pas stained all the fddnp positive deposits. all cr positive aggregates also showed birefringence. conclusion in our study, fddnp labeled all protein aggregates that were shown to posses tinctorial and birefringent characteristics of amyloid, but also some that cannot be classified as amyloid. aside from its potential for in vivo diagnostics of some neurodegenerative diseases, fddnp may prove useful in labeling certain pathological protein aggregates in vitro. work supported by mŠzŠ grants - and l - . aim to investigate the development and clinical significance of vascularization in adenomatous alveolar hyperplasia (aah) and peripherally located adenocarcinomas of the lung. material and methods histological slides obtained from patients with aah, and from patients with potentially curatively operated lung adenocarcinomas including normal lung parenchyma are immunohistochemically stained with an anti cd antibody, and subject to quantitative image analysis. syntactic structure analysis measures the absolute and relative features of vessels including the vessel-associated cellular densities. these data are compared in between and associated with tumor volume, post surgical tnm stage, and the patients' survival. results aah displays an increased level of vascularization characterized by regular size and increased number of newly formed vessels. spatial agglutination (clusters formation) of vessels is common in aah. the tumor vascularization (volume fraction vv) amounts to % in aah and to % in lung carcinomas, and increases in advanced tumor stages (pt , pn ). aah displays the lowest, advanced tumor stages the highest numerical vascular density. minimum diameter and circumference of vessels maintain. the density of epithelial cells decreases with increasing distance from the vascular surface in both aah and adenocarcinomas. it is the highest in advanced tumor stages. according to multivariate statistical analysis the patients' survival is closely associated with the pn-stage, tumor volume, cell type and the numerical density of tumor cells within a distance < m to the nearest neighboring vessel. conclusion aah is characterized by probably non-reversible changes in vascular density and spatial vessel clustering. vascularization of pulmonary adenocarcinomas becomes altered in advanced tumor stages. of prognostic significance is the distribution of tumor cells in relation to the nearest neighboring vessel only. changes in vascularization probably play an important role in genesis and development of pulmonary adenocarcinomas. cellular and connective elements between bronchial glands in sarcoidosis: a quantitative analysis z kosjerina, v kosjerina ostric institute of lung diseases, sremska kamenica, serbia and montenegro objective objective of the study was to quantify the inflammatory and connective cells, as well as connective fibres between the bronchial glands in pulmonary sarcoidosis (s). material the study included the bronchobiopsy samples obtained from sarcoid patients. the control group (cg) included young healthy subjects who lost their lives in an accident, having the bronchus sampled at autopsy. the quantity of inflammatory and connective cells was measured by the stereometric numerical density method and the quantity of the connective fibres by the volume density method. results in the examined group the total quantity of all cellular elements between the bronchial glands in s was estimated to range from . /mm to . /mm or . /mm on the average. in the cg, the quantity ranged from . /mm to . /mm , or . /mm on the mean. besides cellular elements, connective fibres were also registered between the bronchial glands. in s, the connective fibres made % of the interstitium volume and only % of it in the cg. this difference is statistically significant. conclusion in sarcoidosis, the total quantity of all cellular elements between the bronchial glands exceeds their quantity in the cg for . times. the most numerous are lymphocytes in both groups, but in s their quantity is . times as high as their quantity in the cg. the quantity of the connective fibres is times as high as their quantity in cg. these differences are statistically significant. depending on the lung cancer stage and type vs. - % by conventional cytology) at an acceptably reduced specificity ( % vs. %, for aqc and conventional cytology, respectively). the role of the aqc cytology test in a comprehensive approach to detection of early (non-invasive and minimally invasive) lung cancers will also be discussed. introduction characterization of bronchial preneoplastic lesions is based upon cellular atypia and disturbed tissue architecture. depending on the individual experience, the grading of such lesions varies considerably. we evaluated immunohistochemical staining for p and mib- in regards of their value in routine diagnostics of bronchial biopsies. material and methods bronchial biopsies ranging from normal bronchial epithelium to invasive squamous cell carcinoma have been stained with antibodies against p and mib- . the biopsies have been divided into groups: squamous cell metaplasia with basal cell proliferation to low grade dysplasia, high grade dysplasia, and carcinoma in situ. for comparison, normal bronchial epithelium and invasive carcinoma have been included. in normal epithelium % of the cells showed positivity for p . with increasing degree of atypia, the number of posititive cells per nuclei increased to % in carcinoma in situ. almost linear progression has been found in the proliferation activity assessed by immunohistochemical staining with mib- . in normal epithelium the activity was < . %, and the number of positive cells increased to % in carcinoma in situ. in bronchial preneoplastic lesions an increasing accumulation of p and mib- can be found in accordance to the degree of atypia. this provides additional and valuable information to facilitate differentiation between low grade and high grade lesions. in regards of an increase in less invasive diagnostic and therapeutic methods, immunohistochemical staining with p and mib- adds valuable information for a correct grading of these lesions, and is therefore of considerable clinical importance. pitfalls in diagnosis and assessment of lymph node metastases in lung cancer -a morphometrical analysis of pulmonary and mediastinal lymphnodes t gumprich, k junker, km müller institut für pathologie, bochum, germany introduction besides histological subtype and tumor size, metastatic spread in pulmonary and mediastinal lymphnodes in lung cancer is also an important factor concerning therapeutic strategies. prior to resection of the primary tumor a thorough staging of pulmonary and mediastinal lymphnodes is performed using computer tomography -but lymphnodes will be judged by size only. in an autopsy study of ten cases with advanced lung cancer, lymphnodes have been dissected. lungs have been resected en bloc, and were cut in horizontal sections according to computer tomographic layers. lymphnodes have been measured and histologically examined. lymphnodes were judged as normal with a transversal diameter of not more than mm. in the histological examination metastases were found in % of normal-sized lymphnodes, while % of enlarged lymphnodes presented as negative. using other parameters did not yield better specifity or sensitivity. discussion: there is a wide range of what maybe the normal size of a lymphnode which is influenced especially by the study collective. we found a variety of size-influencing factors (pneumoconioses, silicosis, previous infections). furthermore, there are differences in size of lymphnodes in collectives from rural and industrial populations. the high number of metastases in normalsized lymphnodes is explained by the highly advanced stage of disease in our study collective. conclusions for imaging diagnostics, sufficient size parameters for lymphnodes are not existing. we are convinced that preoperative staging of lymphnode status is important. in many cases the radiological evaluation on the lymphnode stations is not sufficient to differentiate between reactive enlargement and metastatic involvement. mediastinoscopy is still needed in preoperative diagnostics, because it allows taking biopsies with following histological examination. expert system dedicated on diagnosis in thyroid pathology introduction encoutering diagnostically difficult cases, pathologists usually asks consultations from more experienced colleagues or uses materials in form of journal articles, textbooks, atlases etc. these sources can provide the information in a passive way. usage of expert systems (special computer programs) let pathologists obtain the information in an interactive way and have more accuracy in the diagnosis. our purpose was to create an expert system capable to improve histological diagnostics in area of thyroid tumors and tumor-like conditions. materials and methods materials for our work consisted of more than cases of thyroid tumors and tumor-like conditions (near pictures), representing thyroid diseases. every case was described by two experts according to histologic features and then entered in pc data base. results our computer program can act in two principal ways. these are ) diagnostics -expert system propely, ) learningvirtual textbook. ) using the expert system, pathologist enters new data in pc and marks so many features as he can. then he obtains the information about all the possibilities of probable diagnosis and some other results. entering more features can help to narrow the borders of probable diagnosis. ) applying our program as a virtual textbook, it is possible to learn better the known significance of pathological features, to take a look on the descriptions the experts made etc. the program can also function as a virtual trainer and examiner. conclusion our computer program increases the diagnostic quality in the area of thyroid pathology by means of high capability of information integration and improving pathologist's qualification during his learning. introduction xenin is a biologically active -amino-acid peptide extractable from the gastro-entero-pancreatic system. the aim of our study was to identify the unknown cellular source of xenin and to analyze the expression of xenin in neuroendocrine tumors. methods normal tissue of humans, rhesus monkeys and dogs and a large series of neuroendocrine foregut and midgut tumors were investigated by immunohistochemistry, confocal laser scanning microscopy, immuno-electronmicroscopy and high pressure liquid chromatography, assessed by radioimmunoassay. results in all three species, xenin was expressed in a subpopulation of gastric inhibitory (gip)-cells of the upper intestine. immunoelectronmicroscopy demonstrated presence of xenin in secretory granules ( ± nm diameter). xenin immunoreactivity and extractable xenin was found in of duodenal neuroendocrine tumors, including gastrinomas, somatostatinomas, non-functioning and enterochromaffin cell tumors. in contrast, xenin was absent from gastric, pancreatic, ileal and bronchial neuroendocrine tumors. conclusions the localization of xenin in ultrastructurally characterized secretory granules supports the concept that xenin represents a further endocrine regulatory peptide. the finding that xenin expression distinguishes between endocrine tumors arising in the duodenum from those of nonduodenal origin may be useful for topographical tumor classification and the differential diagnosis of neuroendocrine tumors of the upper gut. (supported by dfg) introduction the tall-cell variant (tcv) is known as a rare but aggressive form of papillary thyroid carcinoma (ptc) with increased incidence of local recurrence and mortality. it is defined as papillary thyroid carcinoma with at least % of specific cellular changes within the tumor cells and occurs in - % of all ptcs. materials and methods in our series of paraffin embedded and h&e stained tumor tissues, tall cell morphology was exactly defined for the first time and then cases of ptcs, including all stages and variants, were investigated concerning tall cell morphology and associated changes within the tumors. results in contrast to previous reports, cases ( , %) were classified as tcv in our series. taken together with minor tumor parts, cases ( , %) presented with tc morphology. these parts were in a high percentage associated with fibrosis and lymphocyte rich areas and showed a higher mitotic activity than usual ptcs. discussion the differences in the occurrence of tcv and tcmorphology between the presented series and previously reported cases might result from until now not clearly defined tall cell morphology as well as from similarities to ptcs, such as the oxyphilic variant, which is extremely rare in our series, and maybe also from often described squamous changes within ptcs. due to these data it is not clear which tumor parts have relevance for prognosis and which tumors should be treated more aggressively than others. in accordance with previous reports concerning the prognostical impact of this variant, we think that the occurrence of tc morphology plays a major role in both development of extrathyroidal growth and metastatic disease. myocardial extensions around venae cavae as a potential substrate of atrial fibrillation altered endothelial permeability secondary to ischemiareperfusion e stefanovic, v kanjuh, n tasic dedinje cardiovascular institute, belgrade, serbia and montenegro introduction during open heart surgery some damages to myocardial capillary endothelium occur, with the consequence to the regarding structure and function of cardiomyocytes as well. cardioplegia (cpl), long term hypoxia and reperfusion are strong contributing factors for these lesions. the aim of the study is to assess ultrastructural changes and permeability of endothelium of myocardial capillaries due to hypoxia and reperfusion during open heart surgery. the study included consecutive patients (pts) who underwent open heart surgery. samples were taken from right ventricle anterior wall and apcal region. biopsies were taken at the end of cardioplegic period, during ischemic period and during period of reperfusion. all patients were divided in two groups depending on duration of period of ischemia or cardioplegia-group (clp< min) and group (clp- - min). all samples were analyzed by electron microscope using quantative stereological analysis. volume fraction of the pinocyte vesicles (pv), mitochondria (m) and endoplasmatic reticulum (epr) were calculated. results endothelium ultrastructure analysis showed increase in permeability of the capillary wall. the worse damage was found after min. of cpl usage: edema of the endothelial cells, widening of the cell junction and other degenerative changes of cardiomyocytes. analyses of result confirmed that the more significant damages were found during reperfusion in group . conclusion our study showed significant changes in endothelial permeability and function after ischemia and reperfusion. disturbances of transendothelial transport may play certain role in the development of heart failure after open heart surgery. the authors compared the clinico-pathological and immunohistochemical features of acute postinfarction cardiac rupture and control (with near the same clinical age without rupture) cases. material and methods cryostat sections of both groups from infarction/rupture and controls were stained with oil red o, sudan black b (bdh chemicals) and were reacted to anti-c-reactive protein (crp), to complement c a and c b- (dakopatts). clinico-pathological findings myocardial rupture occured in elder women with relative smaller weight of heart, thrombosis of one main coronary artery, location in the anterior wall at the first infarction within the first week. microscopically the main observation is the large amount of granular lipid deposition in the area of myocardial rupture even in the cytoplasm of the necrotic myocardial fibers using oil red o and sudan black b staining. immunohistochemistry: the anti-crp and c b- antibodies showed intense staining around the area of the rupture. the inflammatory cells were neutrophils in high numbers in both group. eosinophils were represented in low percentage (below %). conclusion the postulation is, that the granular myocardial lipids in the area of infarction/rupture are phospholipids (mainly mitochondrial cardiolipin), which through binding crp induce pathologic complement activation. in experimental heart infarctions complement target (recombinant etc.) molecules could reduce the neutrophil chemotaxis to the area of necrosis and the size of the infarction. nuclear factor-κb regulates apoptosis of intimal smooth muscle cells introduction apoptosis contributes to reduce intimal smooth muscle cell (smc) hyperplasia following angioplasty or during atherogenesis. nuclear factor (nf)-kb is involved in the regulation of many smc functions. aim of the work was to verify the role of nf-kb in bax-dependent smc apoptotic cascade and its possible targeting for novel biologically based therapies of vascular hyperplasia. methods apoptotic proteins were evaluated by immunohistochemistry and western blotting and nf-kb using a anti-p (rela) antibody recognizing its active form. apoptosis was induced in rat aortic neointimal smcs after endothelial injury in vivo and in vitro by propyonil-l-carnitine (plc). in vivo, expression of constitutive nf-kb activity of smcs of neointima was higher compared to underlying and normal media. treatment with plc associated to reduced neointimal relative volume and increased apoptotic rate of intimal smcs compared to controls. increased apoptotic rate associated to bax overexpression and rela reduced immunopositivity. in vitro, plc reduced g to s phase progression of intimal but not of medial smcs. hoechst staining, flow cytometry and ligation-mediated pcr showed increased apoptotic rate of intimal cells treated with plc together with bax overexpression and the release of cytochrome c. sn , an inhibitor of nf-kb nuclear translocation, induced an increase of apoptotic rate in intimal but not in medial smc cultures, prevented the apoptotic effect of plc and upregulated the cytoplasmic bax expression and the release of cytochrome c. conclusions our studies with inhibitors of nf-kb strongly suggest that this nuclear factor plays a crucial role in the control of intimal smc apoptosis. alpha-actin isoform distribution in normal and failing human heart: a morphological, morphometrical and biochemical study introduction two sarcomeric actins, α-cardiac (α-ca) and αskeletal (α-ska), are coexpressed in adult myocardium and represent the preponderant thin filament actin isoforms of cardiomyocyte contractile units. in the human heart, the relative amount of α-ska mrna increases steadily during development and after birth and becomes the predominant isoform in adults but data in the literature concerning hypertrophy and failure are scarce and controversial. aim of the work was to determine how and where α-ska isoform accumulates during heart development, ageing and with disease. methods by using monospecific antibodies, we investigated by immunohistochemistry and western blotting the distribution of α-ska, α-ca and α-smooth muscle actin (α-sma) isoforms. results at weeks of fetal life, α-ska was localized in a small proportion of subendocardial and papillary muscle cardiomyocytes, whereas a diffuse α-ca staining was observed, associated with a focal expression of α-sma. in normal adult subjects, α-ska positive cardiomyocytes were distributed in a transmural gradient with the highest proportion located subendocardially. in myocardial hypertrophy and cardiomyopathies, the amount of α-ska was increased and a diffuse staining was seen in all layers of ventricular myocardium, with the exception of idiopathic dilated cardiomyopathies. cardiomyocytes were always negative for α-sma. as expected, fibroblasts in post-infarct scars expressed α-sma and tgf-β , but were negative for these proteins in interstitial fibrosis. conclusions changes in the distribution of actin isoforms in hypertrophy and failure provide new insight into the mechanisms by which the heart adapts to work overload and help to define their role in these pathological situations. introduction arrhythmogenic right ventricular dysplasia (arvd) has received much interest, since it may cause sudden cardiac death (scd). yet, pathogenesis remains controversial, not at least because adipose and fibroadipose types are considered different entities by some. the present study has looked into the histopathologic features of hearts with arvd with a particular eye for a clue to pathogenesis. clinical history review and heart macroscopic/microscopic examination (with histochemical/immunohistochemical techniques) were performed on patients dying suddenly with arvd. twenty-three, m/ f were young ( - years) and , m/ f adults ( - years). results )one young had family history of scd. )one adult had cardiovascular antecedents. )seven patients had died during exercise. )both young and adults presented adipose (n= vs ) and fibroadipose (n= vs ) types, whilst each variant basically showed similar overall architectural arrangements. ) occasional inflammatory infiltrates were present in fibroadipose, but not in adipose type. ) left ventricular involvement occurred in young and adult heart. ) coexistent left ventricular pathology was occasionally identified. conclusions ) arvd can be manifest in young and older persons, either as adipose or fibroadipose variants. ) both types are morphologically identical, except that some may have additional fibrosis, occasionally accompanied by small inflammatory aggregates. subtle differences hard to interpret as features distinguishing different entities. ) preferential and almost selective involvement of the right ventricular wall suggests a congenital nature of the disease, particularly since recent insights in right ventricular development have showed "regionalization" of genetic expression in the formation of cardiac chambers. fatty/fibrofatty tissues may appear ab initium through an alternative mesenchymal pathway. a new method of quantitative functional morphology for systemic examination of the cardiac muscle t ghevondyan , h guski , g avtandilov national institute of health, yerevan, armenia medical faculty of humboldt university of berlin, berlin, germany introduction determination of the vital capacities of heart muscle has special importance for cardiac surgery. morphological methods could be the most trustworthy in this respect. but it was not possible yet to extract this information from myocardial specimens. the aim of this study was to elaborate a method, which will be able to determine the volume of vital reserve of myocardium taking into account all known morphological changes and alterations. the investigation was carried out on heart muscle tissue of healthy people, who died accidentally and of patients who died from myocardial infarction. the myocardium of white rats (normal, physically trained, during pancreonecrotic shock) was used. methods of histology, electron microscopy, cytoenzymochemistry, morphometry, micromechanography, statistics and mathematical modelling were used. results most informative parameters were chosen for characterisation of the microcirculatory bed and of the paths of ultracirculation. the property of contractility has been taken as a systemforming criterion. a mathematical model was elaborated, which allows to unite the most important structural changes and alterations from tissue, cellular, ultracellular and macromolecular levels of the heart muscle. the role of endomyocardial biopsy in end-stage heart failure introduction endomyocardial biopsy is considered to be an important diagnostic procedure for the evaluation of patients with end-stage heart failure. the aim of this retrospective study was to evaluate the role of apoptosis, proliferation markers, volume density of interstitium, and myofibril volume fraction for the prognosis in patients with end-stage dilated cardiomyopathy (dcm). methods endomyocardial biopsy was performed during openheart surgery in pts with end-stage dcm. patients were divided into groups, one with shorter survival ( ± months, mean ± standard deviation) and another with survival of more than years after operation. the tunel method was used for the detection of apoptosis, and immunohistochemical methods were used for the evaluation of inhibitor of apoptosis (bcl- ), and proliferation markers (pcna, ki- ). results the increased percentage of apoptotic myocytes, decreased expression of bcl- , pcna and ki- antigen, but lower myofibril volume fraction and lower volume density of interstitium was found in the group with early mortality compared to that with longer survival. conclusion morphometrical analysis of the endomyocardial specimens of the patients with terminal heart failure due to dcm may enable us to get access to crucial information about the status of the myocardium, which may help us to predict the prognosis and optimal treatment of patients with end-stage heart failure due to dcm. introduction trafficking studies in bone marrow transplantation (bmt) more often use fluorescent reporter molecules like the green fluorescent protein (gfp). dendritic cells (dc) represent an interesting population for trafficking analysis, because they undergo steps of maturation, which seem to be related to their localization in the tissues. the aim of this study was detection of ex vivo expanded dcs, transduced to express gfp, in tissues of mice that had received an allogeneic bmt. material and methods tissues of recipient mice were pretreated by fixation in % formalin followed by % sucrose, before embedding in oct and freezing on dry ice. in addition tissues were also fresh frozen and exposed to formaldehyde vapor as cryostate sections. the gfp signals were validated using an anti gfp antibody. additional markers investigated were cd c, cd , cd , h- kb and h- kd. results vapor fixation of slides showed equal properties in containing gfp in comparison with the immersion method. gfp+ dcs were detected in small bowel, lymph nodes, thymus and spleen for up to days after i.v. injection. many of these gfp+ cells were positive for cd c. the gfp signals could be validated on fluorescence and light microscopic level using anti gfp antibodies. conclusions allogeneic dcs survive in bmt recipients for up to days. they migrate into small bowel, mesenterial lymph nodes, thymus and spleen without causing gvhd. the visualization of survival and migration in bmt settings will provide new insights into the immunological role of dcs in vivo and might contribute to the optimization of dc based treatment strategies. breast hamartoma: cytologic, pathologic and immunohistochemistry study of cases introduction breast hamartomas enter the differential diagnosis of breast masses, necessitating an accurate diagnosis. it is still not quite clear into which group of lesions these masses should be categorized. the aim of our study was to investigate the cytologic, histologic and immunohistochemical profile of breast hamartoma in order to obtain a detailed picture of this somewhat unusual lesion. materials and methods this study presents cytological, pathological and immunohistochemical analysis of patients with breast hamartoma. the immunohistochemical panel included: estrogen and progesterone receptors, her -neu protein, p- , ki- , ckmnf , vimentin, alpha-sma. results the patients ranged in age between and years. all patients presented with a palpable unilateral mass. the aspirates contained sheets of both bland ductal cells and lobular units. adipose tissue was present in varying amounts. typical macroscopical and microscopical features were noted. immunohistochemical studies showed estrogen and progesterone receptor positivity in epithelial cells as well as in the stromal cells, in all hamartomas. her -neu protein over expression was noted, p- expression was not observed. ki- showed a - % positivity in epithelial cells in most cases. conclusions the finding of intact lobular units and a relative paucity of stroma in an aspirate from a well-circumscribed breast lesion, may suggest the diagnosis of hamartoma. typical macroscopical and histological features of breast hamartoma were noted. the immunohistochemical profile appears to be similar to that of normal and fibrocystic breast tissue, raising the possibility of a spectrum of lesions. introduction ck-pattern in nos breast carcinoma has been studied extensively, including high molecular weight types, such as ck- , present in rare cases. published data on ck- -expression in less common subtypes of breast carcinoma are limited the aim of this study was to learn more about the immunohistochemical profile of ck- in cmf, a systematic analysis on ck- -reaction in a consecutive series of this variant of breast carcinoma was undertaken, including correlation with some traditionally recorded tumor characteristics. forty-three consecutive cases of cmf were examined for ck- . extent of staining was assessed semiquantitatively and reported as a percentage; its correlation to tumor size and receptor status was calculated. results sixteen ( , %) of the cases comprised ck- labelled tumor cells. though ck- + tumors were less commonly receptor+ and tended to be larger than ck- -cases, statistically significant differences were not obtained (p= . and p= . , respectively). conclusion no specific immunohistochemical profile typifying cmf has been identified. nevertheless, most cmf seem prone to exhibit immunophenotypic aberrations with higher incidence of vimentin+, c-erb-b +, and p- +, lower incidence of her + and er/pgr+. we here demonstrate that ck- -expression can be added to this list. though not statistically significant, a trend towards an inverse relation between basal cell characteristics and receptor expression and a positive correlation between ck- + and tumor size was demonstrated. introduction residual disease leads to most local recurrences, especially in patients treated with breast conserving therapy. this study was undertaken to identify whether assessment of excisional biopsy margins accurately predicts the presence or absence of residual tumor in the lumpectomy bed. material and method the margin status of consecutive lumpectomy specimens followed by re-excision, taken from an equal number of patients with primary breast carcinomas ( infiltrating, in situ), were evaluated microscopically and classified as 'positive' if the tumor was found at the inked margin, 'negative' if the entire tumor was found in > . cm from the inked margins, 'close' if it was within . cm of the inked margins, but did not transected them and 'indeterminate' if biopsy specimen was not inked or the tissue was fragmented. the tumor size and grade of the initial biopsy were also analyzed, as potential predictors for residual disease. results residual tumor was found in % of the patients ( / ): in %( / ) of the cases with negative, in %( / ) with positive, in % ( / ) with close and in . %( / ) with indeterminate margin status. in %( / ) of the 'positive margins' and in %( / ) of the 'close margins' cases no tumor was found in re-excised specimens. in %( / ) of the cases the residual disease was composed entirely of an in situ component of the same histologic type as the initial biopsy. no relationship was found between tumor size or grade and residual disease. conclusions for breast tumors histologically negative margins in biopsy specimens do not guarantee complete excision. 'close' margins may be considered almost equal to 'positive' ones. residual in situ carcinoma in the immediate vicinity of the previous biopsy site seems to represent the advanced edges of the tumor, apparently difficult to be excised completely and most likely responsible for the locally recurrent disease. introduction syringomatous adenoma of the breast is a benign lesion of the nipple, which may be confused with an infiltrating carcinoma. the presence of the myopithelial cells and the immunohistochemical profile is still controversy in the literature. we present the case of an years old patient, with an left nipple mass. materials and methods after excision, the excised tissue was fixed and paraffin embedded and h-e stained. we performed also immunohistochemical staining: with cytokeratin, actin, er, pr, p . the excised tumor measured cm, had ill-defined margins and yellow color.microscopically, the lesion consisted of tubules and strands, composed of small and uniform basophilic cells, diffusely infiltrating the stroma of the nipple. the tubules were lined by two layers of cells, had a comma-like appearance and their lumen was usually open and round. the tumor cells lack pleomorphism. squamous differentiation resulted in keratotic cysts. immunohistochemically, the luminal layer of epithelial tumor cells was cytokeratin-positive and the peripheral myoepithelial cells were actin-positive. the tumor cells were negative for er, pr, p . conclusion syringomatous adenoma of the breast is a benign rare lesion. the pathologist must not confuse it with an tubular carcinoma or with an adenosquamous carcinoma. we demonstrated in this case the presence of the myoepithelial cells. the role of smooth muscle myosin heavy chain in diagnosing sclerosing adenosis of the breast with an infiltrative pattern introduction sclerosing adenosis (sa) of the breast can produce an infiltrative pattern mimicking invasive carcinoma. immunohistochemical markers for myoepithelial cells, such as smooth muscle myosin heavy chain (smmhc), have been shown to stain basal myoepithelial cells in normal mammary glands and fibrocystic changes. absence of myoepithelial cells is associated with invasive carcinoma; however, we have observed occasional attenuation of smmhc staining in sa. studies evaluating the role of smmhc in sclerosing adenosis have not been performed. the intent of this study is to further evaluate the staining pattern of smmhc in sa with an infiltrative pattern. materials and methods twenty cases of sa with an infiltrative pattern were identified, h&e stained, and immunohistochemistry performed for smmhc (m , dako corp), µg/ml, as primary antibody, using a polymer based envision+ detection system (dako corp). normal-breast tissue positive controls and negative isotype matched igg controls were used. cases were then classified into one of three categories: positive (staining > % of myoepithelial cells), intermediate ( % - %), or attenuated (< %). results three of the first ten cases ( %) showed attenuated staining with smmhc. the remaining seven cases demonstrated positive staining of myoepithelial cells. all cases exhibited positive staining within normal lobules, serving as an internal control for each case. ten additional cases of sa have been identified and are being stained with smmhc for evaluation. conclusions preliminary findings show that smmhc yields inconsistent results when applied to sa with an infiltrative pattern. such lesions can have features similar to invasive carcinoma on h&e, and application of smmhc could produce misleading results. co-expression of erbb family members in human breast cancer: her- /neu is the preferred dimerization candidate in nodal-positive tumors introduction overexpression of members of the erbb receptor family has been asssociated with malignant transformation and the amplification of her- /neu in tumor tissue is now an established prognostic factor in breast cancer. in order to initiate signal transduction, erbb receptor monomers need to form homo-or hetero-dimers. the composition of these dimers is thought to greatly influence both quality and quantity of downstream signalling pathways, and to ultimately determine the elicited biological response. material and methods the protein expression pattern of all four erbb receptors egf-r, her- /neu, her- and her- , and expression of their putative ligands egf, tgf-a and hrg was investigated in women with invasive breast cancer by membrane isolation and western blot analysis. results the co-expression of all four erbb family members was detected in , % of cases, and of all of the three investigated ligands in , %. while we did not observe a correlation between egfr and her- /neu or her- protein expression, egfr and her- (p= . ), and her- and her- (p= . ) were clearly coexpressed. the strongest overall correlation, however, was found between her- /neu and her- (p= . ) and between her- /neu and her- (p= . ). this was particularly true in nodal-positive tumors (p< . and p= . , respectively) whereas in nodalnegative tumors the co-expression was either less significant (her- /neu and her- : p= . ) or not significant at all (her- /neu and her- ). the co-expression of egfr/her- was associated with the expression of all three ligands, whereas the her- /neu/her- was correlated with hrg (p= . ), thereby indicating a functional relation between specific receptor-dimer combinations and putative ligands. conclusion taken together, we have performed a comprehensive survey of erbb system expression in breast cancer, and have demonstrated the presence of a co-regulated receptor/ligand system in vivo. her- /neu appears to function as the preferred coexpression partner in nodal-positive tumors, thus rendering him the most likely dimerization candidate in malignant breast tumors. introduction members of the ap- family of transcription factors (c-jun, junb, jund, c-fos, fosb, fra- and fra- ) are able to form jun-jun or jun-fos dimers which bind to the regulatory sequences of target genes. in a prior study on mammary carcinomas, we found that high fra- and reduced fosb expression are associated with indicators of poor prognosis. as most of the proteases involved in degradation of the extracellular matrix and basal membrane (matrix-metalloproteinases, members of the upa/paisystem) are regulated by ap- complexes, we assumed that the expression of single ap- proteins might also be important for the process of invasion of breast cancer cells. method in order to analyze the influence of the single fos family members (c-fos, fosb, fra- and fra- ) on the invasive behavior of mammary cancer, we performed western blot analysis of mmp and mmp and of the members of the plasminogen activator system pai- , upar, and pai- -upa-complexes in breast cancer samples, and correlated the expression of these proteins with that of the ap- proteins. results interestingly, c-fos, fra- (phosphorylated form), and fra- correlated with mmp expression levels. high expression of fra- was also significantly associated with that of pai- and the sds-insoluble upa/pai- complex. on the other hand, the expression of fosb was significantly associated with high levels of mmp . conclusion our results indicate that a shift in ap- protein expression, especially high expression of fra- and fra- , might be involved in invasion of breast cancer cells. (supported by deutsche krebshilfe, no. - -ba ) immunohistochemical study of estrogen receptors and progesteron receptors in primary breast carcinomas and their axillary lymph node metastases nh aksoy, he pestereli, s karaveli akdeniz university school of medicine, department of pathology, antalya, turkey estrogen receptors (er) and progesteron receptors (pr) was investigated in primary breast carcinomas and their axillary lymph node metastases to determine if the malignant cells retained or changed this phenotypic feature during the metastatic process. the data were also compared with the tumour size, histologic type, grade and age. immunohistochemistry with the er (dako- d -n ) and pr (dako-pgr -n ) on formalin-fixed paraffin embedded tissue was used. the er status in primary tumours and lymph node metastases was concordant in patients ( , %) and discordant in ( , %). six of these eleven patients had er-positive primary tumours and er-negative lymph node metastases. the pr status in primary and lymph node metastases was concordant in patients ( , %) and discordant in patients ( , %). ten of these twenty-four patients had prnegative primary tumours and pr-positive lymph node metastases. we observed higher pr positivity in axillary lymph node metastases. the parameters, tumour histology, grade and age showed no statistically significant relation with receptor status. there was a significant correlation between the tumour size and the number of axillary lymh node metastases. the discordance of hormone receptors status between the primary tumour and lymph node metastases might be due to the heterogenity of tumour cells or loss of the phenotypic features of metastatic cells. breast carcinoma in a cancer hospital p arapantoni -dadioti , o tzaida , v leodara , g sotiropoulou , e trichia , pk sotirakoglou pathology department metaxas cancer hospital of piraeus, piraeus, greece department of mathematics and statitics agriculture university of athens, athens, greece a total of cases of infiltrating breast ca, diagnosed in our hospital during the last decade, was studied. the material concerned mastectomies with ispilateral lymph nodes dissection specimens. the patients were classified according the tnm staging system, based upon the primary tumor size (t), the presence of regional axillary nodal involvement (n) and distant metastases (m). this categorization revealed a preponderance of patients with t tumors. the overall decade rate for t , t and t tumors was , , %± , %, , %± , % and , %± , %, respectively. there was a statistically significant difference between the three groups (p< , ). the annual distribution of these groups revealed that since the mean group rate had a tendency to approach the corresponding decade rate, a finding suggesting some degree of stabilization of these proportions. on the other hand, the lymph node metastases were more common in the t tumors. the mean rate for t n+, t n+ and t n+ was , %± , %, , %± , % and , %±- , %, respectively; the difference is statistically significant for the t n+ and t n+ (p< , ) as well as for t n+ and t n+ (p< , ). the annual overall rate of patients with lymph nodes metastases, independently of t (tn+) was , %± , %. in conclusion, there is no tendency of early patient presentation and a more careful intimate medical care. the infiltrating breast cancer in our material, is represented mainly by thet tumors and the great majority of patients come to the hospital in an advanced stage regarding the t and n. introduction breast cancer is a genetically complex disease, which involves the accumulation of various structural and numerical aberrations. in the present study, we assessed the numerical status of chromosomes and x in primary invasive breast carcinomas in relation to clinicopathological parameters, patients' overall survival, and indices of cell growth (c-erbb- , topoisomerase iia) and survival (caspase- , bcl- ). material and methods the number of copies of both chromosomes was detected by interphase chromogenic in situ hybridization with pericentromeric probes on paraffin embedded sections. er, pr, cerbb- , topoiia, caspase- and bcl- expression was immunohistochemically detected (abc/hrp). the results were statistically assessed by univariate and multivariate analysis. results polysomy of chromosomes and x was detected as the predominant aberration ( . % and . % respectively). gain of chromosome copies was associated with high nuclear grade (p= . ), increased tumor size (p= . ), advanced stage (p= . ), the expression of topoiia proliferation index (p= . ), and worse overall survival by multivariate analysis (p= . ). the levels of chromosome x polysomy were elevated in ductal carcinomas of high histological grade (p= . ), in high nuclear grade tumors (p= . ), and were associated with the expression of topoiia (p= . ) and loss of caspase- protein (p= . ). in addition, gain of chromosome x copies was an independent predictor of impaired prognosis of ductal carcinomas (p= . ). conclusion polysomy of chromosomes and x was observed as the predominant alteration in phenotypically aggressive breast tumors, characterized by poor differentiation, increased growth potential and impaired prognosis, whereas gain of chromosome x in particular, is probably implicated in cell survival. expression of survivin, bcl- , p and bax in breast carcinoma and ductal intraepithelial neoplasia (din a) f kayaselcuk , tz nursal , a polat , t noyan , s yildirim , a tarim , g saydaoglu introduction survivin is a recently discovered member of the family of proteins that inhibits apoptosis. this anti-apoptotic compound can be detected in most types of cancer and expression is associated with a poor prognosis. we immunohistochemically investigated the expression of survivin in breast carcinomas and intraductal epithelial neoplasia of breast to determine whether expression of this protein is associated with clinicopathological parameters such as grade, stage, mitotic rate. the study involved patients with invasive ductal carcinoma (idc) and patients with intraductal epithelial neoplasia with mild, moderate and severe, florid ductal epithelial cell hyperplasia. survivin, bax, bcl- , and p monoclonal antibodies were administered by immunohistochemical method. findings were analyzed with statistical methods. results in of cases ( . %) of breast carcinomas and of cases ( . %) of intraductal epithelial neoplasia with mild, moderate and severe ductal epithelial cell hyperplasia stained positively for survivin. none of the histological parameters analyzed were significantly correlated with survivin expression in breast carcinomas. in the carcinoma cases, survivin expression was positively correlated expression of bcl- , but was not correlated with expression of p , bax, c-erbb- and estrogen, or progesterone receptors. some of the intraductal epithelial neoplasia cases with moderate or severe ductal epithelial hyperplasia stained positively for both survivin and p . the breast carcinomas exhibited significantly increased expression of survivin, p , and bcl- than the breast with intraductal epithelial neoplasia. survivin was not correlated with any of the clinicopathological parameters studied, however, it could be a useful tool in early carcinomas and florid, severe ductal epithelial hyperplasia. introduction certain non-malignant and pre-malignant lesions cause dilemmas for the most appropriate management following lncb. the aim of this study was to determine the accuracy of lncb in diagnosising the most frequent non-conclusive findings: benign papillary lesions (bpl), radial scars (rs), fibroepithelial lesions with stromal hypercellularity (flsh), atypical ductal hyperplasia (adh) and intraductal carcinoma (dcis). material and methods in a retrospective review of , imaging guided lncbs ( - ), we found: ( . %) bpl - with surgical correlation (sc) and with mammographic follow-up (mf); rs ( %) with sc in and mf in ; ( . %) flsh all with sc; ( . %) adh -with sc in , and ( . %) dciswith sc in . results ) bpl: patients without changes in mf. at surgery: bpl - with adh and invasive carcinomas ( with mammographic histologic discordance and diagnosed years post lncb). ) rs: without mammographical changes and rs ( with adh). ) flsh: at surgery, fibroadenomas, benign and malignant phyllodes tumours. ) adh: at surgery, ( . %) adh, ( %) dcis, ( . %) invasive carcinomas - of which microinvasive. ) dcis: at surgery, ( . %) dcis; ( . %) microinvasive, and ( . %) invasive carcinomas. conclusions ) diagnosis of bpl at lncb seems accurate when correlating with image findings. ) rs at lncb can be followed mammographically. ) flsh at lncb always requires surgical excision. ) adh and dcis diagnosed at lncb need complete removal of lesion, due to frequent underdiagnosis. introduction estrogen receptor beta (erb) is known to be present in breast tumors; its prognostic and pathophysiological roles, however, remain to be established. the aim of this study was to investigate erb protein expression in a well documented series of invasive breast carcinomas. materials and methods standard immunohistochemistry with a specific monoclonal antibody (clone ppg / , serotec) was performed on paraffin sections; % of strongly immunostained carcinoma cells was used as a cutoff point to classify tumors as erb-positive. statistical correlations were sought with clinicopathological variables (including hormone receptor status) and patients' disease-free and overall survival. cell proliferation was immunohistochemically assessed by topoisomerase iia (topoiia) index. statistical analysis was univariate and multivariate. results erb immunoreactivity was detected in the majority of specimens ( . %)and was positively linked with era immunoreactivity (p< . ) and increased topoiia index (p= . ). a significant favorable impact of erb immunopositivity emerged with regard to disease-free and overall survival in both univariate (p= . , p= . , respectively) and multivariate (p= . and p= . respectively) statistical analysis; progesterone receptor expression was also found to exert an independent favorable influence on patient's survival with less statistical significance though (p= . and p= . ). on the contrary, patients' survival was not significantly impacted by era status. conclusions because of the positive association between erb immunoreactivity and topoiia expression, the presence of erb in breast cancer cells may be considered an indication of increased proliferation. nevertheless, erb immunoreactivity emerges as a valuable, independent indicator of favorable prognosis. aims to determine diagnostic value of lncb in patients with ilc using ec and ck sse . retrospective review of cases diagnosed as ilc either at lncb or at surgical biopsy (sb), between and . immunohistochemical (ihq) study with ec and ck sse was performed at both lncb and sb. three immunoprofiles were established: ec-ck sse + (ihq of ilc); ec + ck sse -(ihq of ductal carcinoma -idc) and ec + ck sse + (ihq of mixed ilc-idc). initial diagnosis at lncb was correlated with final diagnosis (morphologically and immunoprofile). discordant cases were analysed in order to determine usefulness of ihq at lncb. results in lncbs initially diagnosed as: ) ilc ( patients), final diagnosis was ilc in cases (ec-ck sse +) and idc in case (ec+ ck sse -); ) invasive carcinoma probably lobular type (ilcp) ( patients), final diagnosis was ilc in cases (ec-ck sse +), idc in (ec+ ck sse -) and mixed ilc-idc in (ec+ ck sse +); ) idc ( patients), final diagnosis was ilc in all cases (ec-ck sse +), of them ilc pleomorphic-type. in all discordant cases, immunoprofile at lncb was concordant with final diagnosis conclusion % of patients diagnosed as ilcp at lncb corresponded finally to idc or mixed idc-ilc. . % of patients finally diagnosed as ilc were initially interpreted as idc at lncb. our findings suggest that ec and ck sse are of great value to help characterise breast carcinomas at lncb, and improve management of patients. background her- status became an important prognostic and predictive factor in breast carcinoma. there are two main techniques of evaluation her status: immunohistochemistry (ihc) for the protein expression and fluorescence in situ hybridisation (fish) for amplification of her gene. the aim of the study was to compare the results obtained by ihc and fish methods in determination of her status in breast cancer. materials and methods two hundred breast cancer specimens were examined. ihc and fish were performed in every case. ihc was performed with dako herceptest, fish with oncor-qbiogene reagents. ihc results were classed into groups, accordingly to the intensity of membrane staining ( , +, +, +). fish results were divided into three main categories: na -no amplification, la -low amplification and ha -high amplification. the number of copies of chromosome was also assessed. results over % of cases described by ihc as + exhibited also amplification of her /neu gene. remaining cases were positive with ihc, but presented no gene amplification. this might be due to the subjective assessment of the membrane staining or to the procedure of material fixation. another possibility is that overexpression of the protein was caused by mrna stability or disorders in receptor circulation. the majority of cases classed by ihc as + were also negative by fish (over %). nearly one fifth of ihc + were found to exhibit gene amplification. remaining cases showed no amplification of her /neu gene, combined with aneuploidy of chromosome . all cases described by ihc as / + showed no amplification. conclusions ihc is well-established method of assessing her status in breast cancer. nonetheless, group of cases described as + should be additionally examined using fish method because the results are more reliable. in order to improve accuracy and gain the highest quality of her status evaluation, in those cases both methods should be applied. dcis of the breast with excessive cancerization of the lobules simulating invasive carcinoma b nielsen institute of pathology, randers, denmark a -years old woman had a right sided mastectomy with axillary dissection performed, because of suspicious mammografic microcalcifications and finding of malignant cells by fine needle aspiration. grossly, an cm large suspicious area with accentuaded consistency and multiple pale-yellow flecks, representing comedonecrosis, were found. multiple sections representing the suspicious area showed dcis. the ducts were dilated and contained malignant cells and central necrosis. in areas classical cancerization of the lobules were present. furthermore, in multiple microscopic areas the stroma of the lobules were oedematous and infiltrated by lymphocytes. the acini were slightly dilated and covered by one or two layers of malignant epithelial cells, but the central lumen was preserved. the morphology greatly simulated invasive ductal carcinoma. however, by immunohistochemistry the myoepithelial cells were showed to be preserved and the lobular unit were well demarcated with preserved circumscription. the axillary fat contained lymph nodes all without metastasis. it was concluded that the alterations represented a variant of lobular cancerization, earlier described by tavassoli ( ) . spindle cell tumors of the breast are rare entities with difficult differential diagnosis. we report four spindle cell tumors: a metaplastic carcinoma, a fibromatosis, a malignant spindle cell myoepithelioma and an inflammatory pseudotumor. the metaplastic carcinoma occurred in a -year-old woman as a . x . x cm nodule with scarce bland clear cells proliferation and very important desmoplastic reaction; immunohistochemical stains revealed positivity for cytokeratins (mnf ) and vimentin and negativity for actin and desmin. the fibromatosis occurred in a year-old man as an x x cm tumor with bland spindle cell morphology; very little atypia and rare mitoses were identified and immunohistochemical positivity for vimentin was demonstrated. the malignant spindle cell myoepithelioma occurred in a -yearold woman as x x cm nodule with central necrosis; histopathologic examination revealed a malignant spindle cell proliferation with many mitoses and atypical cells; focal positivity for mnf , vimentin, actin and s was identified. the inflammatory pseudotumor occurred in a -year-old woman as a highly cellular spindle cell proliferation with fascicular pattern admixed with myxoid areas and inflammatory cells -type i-ii mammary inflammatory pseudotumor. one important criterion which should be kept in mind in the process of evaluation of a spindle cell tumor of the breast is that these tumors may have deceptive histopathologic appearance -some of them have bland looking morphology despite of their biological behavior (our example of metaplastic carcinoma) and others with worrisome morphology were diagnosed as benign or intermediate malignancy entities (inflammatory pseudotumor). introduction calcitonin receptor (ctr) belongs to the g proteincoupled receptors and it binds calcitonin (ct), which acts on bone and kidneys to maintain calcium homeostasis. however, both of ct and ctr have also been identified in a large number of tissue and cell, suggesting it might has any unrecognized roles. although ctr expression has been found in several breast cancer cell lines and in primary breast cancer, quantitative analysis of ctr expression in matched normal breast tissue and primary breast cancer has not been explored up to date. here we present the detection and quantitation of ctr gene expression in matched normal breast tissue and breast cancers, by using laser capture microdissection. materials and methods fourteen breast cancers and matched normal epithelium from the same patient were laser capture microdissected to obtain pure cell groups and to submit to quantitative analysis by using one step real time rt-pcr. results both normal breast epithelium and cancer cells expressed ctr. as compared with paired normal epithelium, decreased ctr expression was found in of cases breast cancer ( . %) while increased ctr expression in cases ( . %) and no change in cases ( . %). conclusion our investigation revealed that ctr expression was constantly expressed in normal breast tissue and breast cancers. to the best of our knowledge, this is the first report, which revealed that ctr rna expressed in normal breast epithelium. downregulation of ctr is a common phenomenon in the breast cancer, suggesting that it may have important roles on the development of breast cancer. effect of neoadjuvant chemotherapy on her status in patients with breast carcinoma s popovska, t betova medical university-pleven, pleven, bulgaria introduction neoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. the effects of chemotherapy on biological markers such as an oncoprotein expression are not well known. the aim of the study was to determine whether her expression was modified by neoadjuvant chemotherapy. methods forty-nine patients with t - n - m breast cancer were treated in a prospective trial utilizing fec regimen. matched pairs of pre and post-chemo therapy breast tissue were evaluated immunohistochemically for her status using herceptest kit (dako). results her overexpression was observed in / patients ( %). the her status of ( . %) patients was unchanged after chemotherapy. modification was found in cases-decreasing in , increasing in and loss of expression in patient. her status was not changed significantly following primary chemotherapy. conclusions our results showed that, in most patients her status is stable parameter in patients with breast carcinoma after primary treatment with neoadjuvant chemotherapy. the microvessel density in female breast cancer among younger and older age groups introduction breast cancer remains one of the most important oncologic problems worldwide. it seems that breast cancer first detected by the age of - years follows more aggressive clinical course than tumors developing later. young females with breast cancer more frequently present with axillary lymph nodes metastases. expression of the estrogene receptors is less frequent, and the histological grade is usually higher among this group. the main purpose of our study was the evaluation, quantification, and comparison of the angiogenesis in breast cancer among young women, below the age of years and older patients, above years. material and methods tissue samples of breast cancer from patients aged years and less ( cases), and from patients older than ( cases) were studied. ten specimens of non-neoplastic breast tissue from the normal breast in the tumor vicinity (younger patients) served as a control. microvessels were visualized immunohistochemically with use of cd- antibody and counted within the areas of the highest density ("hot spots"). six separate high power fields (hpf), . mm each, were studied in each case. results and conclusion the average microvessels count per hpf in the breast cancer tissue in younger group was higher than in the older age group and non-neoplastic tissue. the differences were statistically significant. the increased density of proliferating microvessels seems to play a role in the aggressive clinical behavior. total frozen section diagnoses have been performed mainly on sentinel lymph node of the mammary gland.the aim of the study was to analyze our result, and estimate whether the telepathology is of practical use or not. material total cases including lymph nodes diagnosed using telepathology. results and conclusion we failed to find carcinoma metastasis in out of sentinel lymph nodes of breast. it was very minute metastasis, and was not contained in the transmitted pictures. our transmission speed is kb that takes about seconds for each picture. there exists a limitation about the transmittable pictures within a restricted time. improvement of transmission speed may solve this problem. in two cases, while telepathologically negative of sentinel node, we found metastasis in the other dissected nodes by permanent section examination. the method of sentinel node identification should be improved. there was a confounding of the specimens that occurred between two patients on the same day. it was a case that happened at the beginning of telepathology. since the surgeon and the technicians are far away from the pathologist, and communication is done by the telephone, it is important for each party to keep in close contact with each other. our result is fairly good considering the limitation of the telepathology. although some issues are still remaining, we conclude that telepathology is now of practical use. pigmented mammary paget disease in a year old man-a case report ar monsef esfahani hamedan university of medical sciences, hamedan, islamic republic of iran mammary paget disease results from intraductal mammary paget carcinoma that extends to the epidermis of the nipple and areola through a lactiferous duct or from invasive breast carcinoma that reaches the epidermis via direct extension from the dermis. pigmented mammary paget disease is a rare clinicopathologic variant of mammary paget disease. it may mimic malignant melanoma clinically and histophatologically. it seems that involvement of the dermo-epidermal junction by neoplastic cells of the mammary paget carcinoma seems to be a prerequisite for the development of the clinical pigmentation. we report a case of pigmented mammary paget disease. the patient was a -year-old male who complained of an erythematous, pigmented scaly plaque around his right nipple measuring x cm with mild fissuring of two year duration. the histopathology revealed pagetoid spread of large cells in the epidermis with pigmentation of basal cells and melanocytes. the ihc confirmed the mammary paget disease and excluded malignant melanoma and squamous cell carcinoma. frozen section evaluation of sentinel lymph nodes in breast cancer introduction the use of sentinel concept as the newest approach in surgical treatment of breast cancer, apart from tumorectomy, means the extirpation and analysis of one or more regional lymph nodes which receives lymph drainage from primary tumor (guardian lymph nodes -sentinel nodes). the presence or the absence of secondary deposit in them is considered the most important predictor of the positive secondary deposit status of the other axillary lymph nodes. depending on histological analysis of sentinel node, the operation is finished with or without the axillary lymph node dissection. materials and methods sentinel concept in surgical treatment of the breast cancer is applied only in the cases where the largest dimension of the tumor is not more than cm (pt ). marking of the sentinel node is conducted before the operation by a combined method, the usage of patent blau color and technetium m as a radio marker. sentinel lymph nodes identity, before sending to a pathohistological analysis, is checked by gamma detection probe. two groups of prospective tests (a and b) were formed with cases each. sentinel lymph nodes from group a in the first stage of the testing were treated by pathohistological method (one hematoxylin and eosin preparation) and then microscoped. the cases in which secondary deposit was not noted, were subjected to a serial cutting and immunohistochemical staining by the ema markers, specific for intraductal epithelium of a breast. sentinel nodes from group b were submitted fresh for frozen section investigation, where they were approached with a series of cuttings and immunohistochemical analysis by the ema markers. the nodes without secondary deposits were fixed in formalin, paraffin embedded and, with the application immunohistochemistry (ema), submitted to serial cutting (similar to the second phase in group a) as a precaution. results in the first stage paraffin samples (group a) were first examined by h&e method, and additionally with immunohistochemistry (using ema). with this additional examination secondary deposits were found in cases ( %). this can only prove already known fact about statistically significant higher sensitivity and specifity of immunohistochemistry compared to h&e. in the second stage (group b) new samples of sn, first investigated by frozen section investigation, were examined by immunohistochemichal method (using ema). in addition, these samples were serially cut and treated like paraffin samples by immunohistochemistry method. the results of these two analysis were identical. facts mentioned above show that sensitivity and specifity of the frozen section analysis using immunohistochemical method (ema) is % (high percentage is probably the consequence of a relatively small number of samples). discussion acquired data suggested that implementation of one of the used methods (serial frozen section analysis with immunohistochemistry) from the sentinel concept is an efficient histo-morphological method in the evaluation of sentinel lymph nodes that make valid intraoperative staging of breast carcinoma possible. the authors came to significant data in both groups of tests and determined sensitivity, particularity and the efficiency of the applied methods. conclusion application of the suggested method would spare a considerable number of patients with pt breast cancer of subsequent axillary lymph node dissection and thus reduce the number of postoperative complications and long term morbidity. introduction needle core biopsy (ncb) of palpable lesion and stereotactic biopsy (smb) of non-palpable mass are the major preoperative methods of breast tumor diagnosis. the aim of this study was to evaluate methods accuracy and to emphasize the main detectable prognostic factors. materials and methods core biopsies ( ncbs and smbs) were performed between january and december . in / cases, the correlation between biopsy results and subsequent surgical excision was available. results the lesion diameter was < cm (in % of the ncbs and % of the smbs). with smb, the average number of tissue core obtained per lesion was . at histology, in % of ncb and in % of smb diagnosis of malignancy was given. the dcis/idc ratio was / for ncb and / for smb, respectively. grade and type of the invasive and in situ carcinoma were determined in both biopsy and definitive excision, and the results compared. the agreement for overall grade was in % with smb and in % with ncb. at surgical excision, / dcis showed foci of idc. in % of smb cases no residual neoplastic tissue was found. conclusions the accuracy of both methods is very high. smb shows highest reliability and accuracy, because of the increased quantity of tissue obtained. the possibility to assess tumour size is limited. the preoperative assessment of the other prognostic factors (type and grade, tumour markers) are key determinants in planning the optimal breast lesions management. expression of mcp- mrna and macrophage infiltrates in invasive breast carcinoma introduction monocyte chemotactic protein- (mcp- ) has been detected in many human tumors; however, its chemoattractant role for macrophages in breast carcinomas is still questionable. the aim of this study was to determine the possible correlation between tumor-associated macrophages (tam) and the number of mcp- mrna in the invasive breast carcinoma. material and methods tissues obtained from surgical specimens of invasive breast carcinomas and cases of normal breast tissues were frozen in liquid nitrogen and kept at - o c until they were used for quantification of mcp- mrna by rt-pcr. the expression was calculated as a number of mcp- cdna copies per copies of g- -phd mrna. paraffin embedded sections from breast carcinomas were immunohistochemically processed for cd staining. positively stained tumor associated macrophages (tam) were counted on three "hot spots" (x ) and mean value was calculated. results the result of rt-pcr showed that in all cases of breast carcinomas ( / ) and the majority of normal breast tissues ( / ) the number of detected mcp- cdna copies was above the detection limit. furthermore, carcinomas showed higher levels of mcp- mrna ( . ± . ) then normal breast tissue ( . ± . ). the value of tam within a single carcinoma was very inconsistent ( . ± . ). statistical analysis did not find a significant correlation between mcp- expression and macrophage infiltrations (r= - , ) . conclusion mcp- is an important factor in the recruitment of macrophages. however, the results indicate that mcp- is probably not the only and/or crucial factor involved in macrophage attraction to tumor locus in breast carcinomas. comparison of mitotic index, growth fraction (evaluated by ki- ), er, pr, cathepsin d, p , and bcl- status between primary breast cancer and corresponding axillary metastatic sites introduction it has been postulated that the equilibrium of different clones within a tumor is eventually overcome by a biologically dominant one with enhanced metastatic potential. therefore, the metastatic tumor should be composed of more aggressive tumor cell clones than the primary one. we analyzed mitotic index, proliferation antigen ki- , estrogen receptors (er), progesterone receptors (pr), cathepsin d activity, protein p , and bcl- oncoprotein status in order to explore the assumed differences in the clonal composition between the primary breast cancer and axillary metastasis. materials and methods er, pr, p , bcl- , ki- , and cathepsin d statuses in patients with the primary ductal invasive carcinoma of the breast and at least one axillary metastatic lesion were analyzed by immunohistochemistry (ihc -dako lsab system). mitotic index was assessed by counting the number of mitoses in primary and metastatic lesions. statistical analysis included t-test for dependent samples, linear correlation analysis, and roc-curve based contingency table analysis. results we found higher mitotic index (p= . , r= . ), higher growth fraction (ki- , p= . , r= . ), and higher level of overexpression of bcl- (p= . , r= . ) in axillary metastatic lesion than in primary breast tumor. there were no significant differences in er (p= . , r= . ), pr (p= . , r= . ), cathepsin d (p= . , r=- . ), and p (p= . , r= . ) status. higher mitotic and ki- rates were associated with lower er and pr expression, whereas higher cathepsin d level was associated with lower bcl- expression, both in primary tumor and metastasis. between the paired primary tumor and axillary metastatic lesions, samples had concordant er, pr, p , and cathepsin d status when analyzed by ihc. tumor clone with enhanced metastatic potential might be characterized with higher mitotic index and overexpression of both ki- antigen and bcl- oncoprotein. basaloid breast carcinoma with pleomorphic lipoblastlike giant cells and neuroendocrine differentiation js reis- filho , liposarcomatous differentiation in breast neoplasms is a rather infrequent phenomenon and so far restricted to rare cases of malignant phyllodes tumour and true liposarcomas of the breast. the terms lipid-rich and lipid-secreting breast carcinomas encompass breast tumours in which neoplastic cells accumulate or secret lipid; however, lipoblasts are not usually seen. recently, we have observed a distinctive type of breast carcinoma in which pleomorphic lipoblast-like cells were seen admixed with the carcinomatous component. an -year-old female presented with a cm hard lump in the right breast with palpable nodes in the right axilla. mammography and ultrasound disclosed two irregular dense central masses in the right breast, measuring cm in aggregate, and an enlarged axillary node measuring approximately cm. a diagnosis of breast carcinoma was made and the patient received neoadjuvant tamoxifen despite the lack of estrogen receptor (er) in the primary tumour. four months later, her disease had progressed and she underwent right mastectomy with axillary dissection.. histologically, both the primary tumour and the / lymph node metastases were characterised by a high-grade carcinomatous component which imperceptibly merged with pleomorphic lipoblast-like cells. immunohistochemistry demonstrated epithelial differentiation in the carcinomatous and liposarcomatouslike components (epithelial membrane antigen, cytokeratins / , / , , and mnf ) . both components were also positive for vimentin, s- protein, and focally for chromogranin, gcdfp- , and e-cadherin. hormone receptors (estrogen, progesterone and androgen receptors), her /neu, p , smooth muscle actin, desmin, synaptophysin were negative. based on the histological and immunohistochemical profile, we believe that this case represents a breast carcinoma with basaloid phenotype and showing divergent differentiation (liposarcomatous and neuroendocrine), features that have to our knowledge not been documented to date. collagenous spherulosis arising in an adenomyoepithelioma of the breast: a hitherto unrecognised association js reis-filho , , lg fulforf , b crebassa , s charpentier , sr lakhani collagenous spherulosis (cs) is a benign epithelial and myoepithelial breast lesion characterised by the accumulation of basement membrane material in the form of eosinophilic or rarely basophilic spherules that exhibit concentric and radiating fibrillar patterns. cs is an incidental finding that usually occurs in association with benign proliferative and pre-invasive lesions. adenomyoepithelioma is a biphasic neoplasm of the breast, composed of both luminal epithelial and myoepithelial cells. despite the shared histogenesis, cs has never been described in association with adenomyoepithelioma. we report a case of a year-old female who presented with cs of the breast arising in an adenomyoepithelioma. the differential diagnosis included adenoid cystic carcinoma. immunohistochemistry with antibodies for cytokeratins (cks) , and / , smooth muscle actin (sma), calponin, smooth muscle myosin heavy chain (smmhc), p , collagen iv, oestrogen receptor (er), progesterone receptor (pgr), ki , and c-kit was performed. myoepithelial cells of the adenomyoepithelioma and the cells surrounding the collagen spherules of cs showed a similar profile (cks and / , sma, calponin, smmhc, p , and s reactivity), luminal cells of both lesions also showed overlapping immunophenotypes (ck , er and pgr positivity). collagen iv highlighted the spherules in cs. ki labelling indices were similar in both lesions. c-kit expression was restricted to the adenomyoepithelioma and no expression was observed in the cs. the association is important to recognise as it could potentially lead the unwary to a misdiagnosis of adenoid cystic carcinoma, cribriform carcinoma or cylindroma of the breast. introduction lymphoepithelioma of the nasopharynx is an undifferentiated carcinoma with a prominent lymphoid infiltrate. tumors, with histologic features similar to nasopharyngeal lymphoepithelioma in other locations are referred as lymphoepithelioma-like carcinoma.(lec). in differential diagnosis of this lesions, medullary carcinoma and lymphoma must be considered. in this study, we report a case of lec of the breast which is very rare tumor.. material and method a -year-old female was noted to have a lesion of the right breast on mammography. an excisional biopsy was performed and sections revealed a well-demarcated elastic mass of cm in diameter. routine histologic examinations and immunohistochemical analysis were performed and compared with reported cases in literature. results clinical features, macroscopic and microscopic findings, immunohistochemical analysis were consistent with lec of the breast. on immunostaining, the tumor cells showed strong staining for epithelial membrane antigen (ema) and low weight cytokeratin (lcw).lymphoid cells stained positively for leucocyte common antigen (lca).the tumor cells showed no staining for cd . staining for uchl - and l demonstrated that there were more t cells than b cells. the tumor cells were immunohistochemically negative for epstein-barr virus (ebv). introduction this retrospective study was performed to investigate the role of dna-ploidy and s-phase fraction in determining prognosis in advanced breast cancer. methods the study included female patients with breast cancer, investigated for the period - . the nuclear dna-content has been measured by cas- (beckton dickinson, image analysis) on intraoperative cytologic samples of the tumour (imprints). the tumours have been divided into diploid, tetraploid, aneuploid and hyperdiploid. results of all patients had aneuploid and multiploid histogram, whereas % of them had developed distant metastases. lymph metastases have been registered in % of the cases with diploid histogram. s-phase has been considerably higher in patients with aneuploid than those with diploid histogram. the survival of of all patients has been analyzed as to the type of their histogram and as to the presence of metastases in lymph nodes and distant organs. the results showed that breast cancer patients ( . %) with aneuploid histogram and metastases in lymph nodes had a survival of less than years, compared to the better survival rate of those patients with diploid histogram and no metastases in lymph nodes. the higher s-stage has correlated to the metastases in lymph nodes and distant locations. conclusion the analysis of all results proved that the dna-morphometry could successfully be used as an independent criterion for evaluation of the biologic behaviour of breast cancer tumours and their prognosis. hypercholesterolemia impairs angiogenesis in patients with breast carcinoma and therefore lowers the risk of metastasis bh introduction angiogenesis plays a key role in tumor progression and it is also necessary for the development of distant metastasis. previous experimental studies indicate that both diet-induced and genetic hypercholesterolemia (hch) impairs angiogenesis. our aim was to investigate the effect of hch on angiogenesis induced by breast carcinoma and to elucidate the possible mechanisms by which it inhibits the progression of the cancer. material and method fifty-one patients with invasive ductal carcinoma were included in the study. of cases had hch and had no hch. all patients were followed for a mean of months after radical mastectomy. the intratumoral microvessel density (mvd) was evaluated immunohistochemically using anti-cd antibody and correlated with clinicopathologic parameters. also the expression of bfgf and vegf were examined immunohistochemically and graded semiquantitatively. results mvd was significantly correlated with tumor grade, vegf and bfgf expression, recurrence, lymph node metastases (lnm), distant metastases (dm) and survival (p< . ). patients without hch had significantly higher mvd ( . . ) than those with hch ( ) (p< . ). in addition the risk of lnm and dm were found higher in cases without hch when compared to cases with hch (p< . ). both bfgf and vegf expression showed significant negative correlation with hch (p< . ). conclusion we suggest that, hch impairs angiogenesis by suppressing bfgf and vegf expression and therefore lowers the risk of metastases in cases with invasive breast carcinoma. the cd antibody (calla) is usually expressed in lymphoblastic acute leukemia and in follicular center cells of lymph nodes. it is also used in breast cancer cell culture to differentiate epithelial cells from myoepithelial cells. usually the smooth muscle actin (sma) is used to identify myoepithelial cells in breast lesions, but this antibody is also positive in blood vessels. this study compares the expression of cd and sma as a marker of myopepithelial cells in breast lesions. we have compared breast lesions, both benign and malignant ( adenosis, fibroadenomas, intracystic papillomas, hamartoma, gynecomastia, intraductal carcinomas, invasive ductal carcinomas, tubular carcinomas, mucinous carcinomas, invasive lobular carcinomas, medullary carcinomas, phyllodes tumors). the antibodies used have been cd ( c, : , dako) and sma ( a , : , biogenex) . results we observed cd expression in the cell membrane of myoepithelial cells and also in some stromal myofibroblastic cells. sma expression was observed in the cytoplasm of myoepithelial cells, in some stromal myofibroblastic cells and also in smooth muscle cells. proliferative breast lesions and benign tumors contain myoepithelial cells expressing cd and sma. in malignant lesions the myoepithelial cell component is lost. conclusions the cd is a myoepithelial cell marker and yields a good, reproducible staining in the studied cases. we think that the use of cd combined with sma is helpful in the differential diagnosis between benign and malignant lesions (epitheliosis vs intraductal carcinoma, tubular carcinoma vs atrophy, adenosis vs invasive ductal carcinoma, papilloma vs intracystic papillary carcinoma). introduction the identification of myoepithelial cells in breast lesions remains of diagnostic value for the discrimination between benign and malignant lesions. p is a p homologue, which is expressed in epithelial basal cells of different organs. the aim of the present study has been to investigate the immunohistochemical expression of p in breast lesions. materials and methods we examined immunohistochemically formalin-fixed, paraffin-embedded, archival breast samples, which consisted of benign lesions and malignancies ( in situ carcinomas, invasive ductal carcinomas, nst and invasive carcinomas special type). the monoclonal antibodies anti-p (biocare medical/menarini), anti-a-smooth muscle actin (biogenex) and anti-s- protein (biogenex) were used. results in all cases, p expression was nuclear. in all benign lesions, there was an almost continuous basal rim surrounding the epithelial structures, whereas it was present but discontinuous in the in situ carcinomas. all invasive ductal carcinomas, nst, were devoided of p staining. p immunoreactivity was noted in a minor fraction of neoplastic cells in / ( . %) in situ papillary carcinomas and in / ( . %) invasive papillary carcinomas. the stromal cells were negative to p . there were s- positive luminal epithelial cells in almost all cases, whereas many fibroblasts of the stroma were positive to smooth muscle actin. conclusion it appears that p is a more sensitive and specific myoepithelial marker than those currently used, with no staining of stromal myofibroblasts. the observed staining in scattered cells, only in papillary neoplasms, might be a clue to the speculated different histogenesis of this specific type of breast tumors. prediction of aggressive outcome in t n m breast cancer introduction small tumour size at the time of diagnosis is one of the most significant prognostic factor of favourable outcome in invasive breast cancer. however, unpredictable breast cancer recurrences and deaths also occur among the group of patients with t n m breast cancers. aims: we set out to identify the clinically useful prognostic features predicting unfavourable outcome in patients with t n m invasive breast cancer. the study comprises cases of invasive ductal or lobular carcinomas diagnosed and treated in turku university hospital and jyväskylä central hospital during the years - . twenty-seven patients had an aggressive disease with a recurrence or death of breast cancer. the prognostic factors of each of the patients with aggressive disease were compared with control patients matched by tumour size, age at diagnosis and histological type of tumour. the follow up time was - years. the clinicopathological prognostic factors of the patients were surveyed. results the prognostic features indicating unfavourable outcome were immunohistochemically detected high ki- expression, high p expression, low estrogen receptor expression and positive her /neu chromogen in-situ hybridization. the number of mitotic figures (mitotic activity index, mai), histological type of the tumour or number of studied axillary lymph nodes did not provide prognostic information. conclusion our study summarizes the immunohistochemical features and criteria predicting unfavourable outcome in t n m invasive breast cancer. detection of overexpression of c-erbb through immunohistochemical and amplification of her /neu established by fish in breast cancer. a comparative study introduction the prognostic and predictive implications of oncogene her /neu activation are very controversial, due to the extensive variation of results, mainly due to the different methods applied. activation of her in node positive patients as an independent prognostic factor has been established and correlated with tumour sensitivity to different therapeutic agents. the overexpression of this membrane receptor has converted it into a new therapeutic aim, requiring the application of a more suitable methodology for each case. objectives to evaluate the most suitable method (immunohistochemical vs. fish) to determine her activation and its correlation with other prognostic factors. material and methods a study of cases of invasive breast carcinoma. histological type: % infiltrating ductal carcinoma; age: - , hormonal receptors: . % (rh+), . % (rh-); histological grade (bloom-richardson mod): . % (g ), . % (g ), and . % (g ). immunohistochemistry was performed in patients with (herceptest dako), and with anti c-erbb (dako : ). scores were used for evaluation: absence of membrane staining ( ), faint and incomplete in > % of tumour cells ( +), weak to moderate in > % ( +), strong complete in > % ( +). fish study was performed on paraffin sections through path vision system with evaluation of nuclei. a good correlation between immunohistochemical overexpression and amplification by fish was observed, especially in cases evaluated as ( +) / ( %), and as ( ) / ( %). no amplification by fish occurred in . % of ( +) / and in . % of ( +) / . % of negative hormonal receptor tumours showed amplification, while only . % of positive receptor tumours amplified. none of the tumours classified as (g ) showed amplification. conclusions we emphasise the necessity to study gene amplification through fish in cases with weak immunohistochemical overexpression ( +). introduction cell cycle progression is governed by cell cycle regulators and inhibitors such as cyclin dependent kinases (cdks), p , p /waf and p /kip . the purpose of this study was to correlate the immunohistochemical expressions of p , p /waf , p /cip and p cdc , with its clinicopathologic prognostic parameters in human breast cancers. materials and methods paraffin-embedded tissue sections from patients with human breast carcinomas were examined for immunohistochemical staining. primary antibodies used in immunohistochemical staining were mouse monoclonal antibody to human p , p /waf , p /cip and p cdc . results the expression rates of p , p /waf and p cdc were . %, . % and . % in breast carcinomas, respectively. in normal breast tissues, p , p /waf and p cdc were not expressed. the expression rate of p /cip was . % in breast carcinomas and % in normal breast tissues. the correlation between the expression of p and p /waf was noted(p= . ). the expression of p /cip was correlated with that of progesteron receptor(pr) (p= . ). the expression of p /waf was correlated with that of estrogen receptor (er) (p= . ) and pr (p= . ). no correlation was demonstrated between survival in patients and expression of p , p /waf , p cdc and p /cip . conclusion the loss of normal cell growth cycle by abnormal cyclin dependent kinases, inhibitors and steroid hormones may play an important role in human breast carcinogenesis. the p dependent p pathway, p gene loss and cdc overexpression were important in development and progression of human breast cancer. withdrawn p- interobserver variability in determination of her protein overexpression by immunohistochemistry using herceptest assay - cases study material and method among cases evaluated in population screening project total cases from all centers were selected and presented to representatives of those centers. the immunohistochemically stained slides came from all laboratories. all ihcs were done using fda-approved dako herceptest. evaluation was performed without knowledge of the original results the results from each researcher were coded. the study lasted hours. the average concordance was nearly %, while the lowest concordance was and the highest - %. this wide range of the results might be due to several things. firstly, the experience in ihc evaluation varied among the participant of the study. secondly, the quality of the stains differed significantly. thirdly, the researchers worked under time pressure and the material was selected to include more cases considered 'difficult' ( + according to dako herceptest or technically inadequate). conclusions to achieve higher concordance among the obtained results, evaluation should be performed by the experienced pathologists. * -participants from: bialystok, bydgoszcz, gdansk, gliwice, kielce, krakow, lublin, lodz, olsztyn, poznan, szczecin, warsaw and wroclaw. the population screening project study was supported by roche-polska. a morphometric analysis of early invasive breast carcinoma using serial sectioning and d reconstruction technique introduction mechanism of early invasion of breast ductal carcinoma has not been completely investigated not only from the genetic point of view but also morphologically. one of the reason is that starting sites of invasion from ductal carcinoma in situ (dcis) might be extremely diminutive that routine histopathological examination should hardly reveal them usually. thus, we examined a large number of complete serial sections from breast carcinomas so as to find out destroyed sites of duct wall from which carcinoma cells have started on invasion. also we reconstructed d images from the sections so as to visualize the sites and to measure the size of those. materials and methods used were three surgical specimens of breast cancer having extensive intraductal components with multiple invasive foci. after formalin fixed and paraffin embedded, six blocks from three cases were selected and sectioned serially in µm thickness. total amount of the serial sections reached sheets (mean / block) indicating . µm in actual thickness. after he stained, invasive lesions connected with dcis were searched and the lesions were reconstructed as d images with a computer-assisted- d-reconstruction system. results although numerous sections containing multiple invasive foci were examined, areas which connected with dcis to invasive lesion through the destroyed site of duct wall were only three. the site were approximately µm, um and µm in diameter respectively, should be called as 'hole' of the duct wall. invasive lesions were extended along the ducts with the holes. conclusion the holes, starting sites of invasion, were apparently smaller than surrounded invasive lesion. histological and immunohistochemical profile of invasive pleomorphic lobular carcinoma y erhan introduction invasive pleomorphic lobular carcinoma (iplc), a distinct subtype of invasive lobular carcinoma (ilc), shares the typical histologic patterns of classical ilc, but the nuclei are more pleomorphic and increased mitotic activity is a prominent feature. we reviewed cases of iplc and compared them with cases of clssical ilc. immunohistochemical analysis was performed in all cases for estrogen (er) and progesterone receptors (pgr), p , c-erbb- , and ki . in this series, the average patient age was . years (age range, - years) for iplc and . years (age range - years) for ilc. tumor size ranged from to . cm (mean size . cm) for iplc and . to cm (mean size . cm) for ilc. axillary lymph node metastasis was detected in % of iplc, and % of ilc. fifty percent of iplc and % of ilc cases had extranodal extensions (p< . ). tumor cells were large with eccentric pleomorphic nuclei and eosinophilic granular cytoplasms. high mitotic activity was observed. immunohistochemically er and pgr positivity in iplc was % and %, and in ilc % and %, respectively. iplc cases showed %, and ilc cases % p positivity (p< . ). c-erbb- was detected in % of iplc, and % of ilc. ki mean rates were % and % for iplc and ilc. conclusion iplc exhibits distinct histologic fetures, higher expression of p protein and ki rate in comparison with classical ilc. the aggressive clinical course of patients with iplc is supported by higher rates of axillary lymph node metastasis and extranodal extensions. introduction c-kit is a proto-oncogene that codes for a transmembrane tyrosine kinase receptor: cd . once activated, c-kit propagates signalling events throughout the cell via multiple signal transduction pathways. it was described an activating mutation in exon of c-kit gene in gastrointestinal stromal tumours (gist), which can be blocked by using a tyrosine kinase inhibitor (sti ). phyllodes tumours (pt) are rare biphasic breast tumours that similarly to gists show a monoclonal stromal proliferation and high recurrence rates. aims: to study the immunohistochemistry expression and prevalence of activating ckit mutations in pt in order to explore whether this disease could be a potential target for treatment with sti . we analysed pt ( benign and malignant) by immunohistochemistry for c-kit expression and direct sequencing of exons , , and of c-kit gene for evaluate the mutational status. c-kit expression was detected in out cases ( / benign and / malignant). no mutations were found for exons , and . in exon we found the same silent alteration in out of cases. conclusions although c-kit expression is a frequent finding in pt of the breast, we did not find activate mutations similar to those described in gists. recently, the role of cyclin d expression in breast cancer had received attention. it causes the activation of cyclindependent kinases in g phase and phosphorilation of the retinoblastoma gene, required for entry of cell into s phase of the cell cycle. recent investigations confer the role of cyclin d once again in g phase. the aim of this study was to analyse the expression of cyclin d in human breast cancer cells and to compare its value with the estrogen receptors and histological parameters. material and methods immunohistochemical analysis for cyclin d and estrogen/progesteron receptors (er/pr) was performed on formalin-fixed infiltrating ductal breast carcinomas. scoring was done using semiquantitative system. the stainining score was ranged from - (called cyclin d -negative) and score larger or equal to (called cyclin d -positive). results according to the staining score % of the breast carcinomas were cyclin d positive, and those carcinomas were associated with higher nuclear and histological grade, while only % were er-positive. conclusion these reslults suggest that higher expression of the cyclin d is related with poor prognostic parameters. c-erb b overexpression in breast cancer with negative lymph nodes background it is known that c-erb b overexpression in advanced breast cancer represents a predictive factor of tumoral agressivity. the aim of this study was to assess the involvement of c-erb b and other prognostic factors expression (hormonal receptors, egfr, pcna) in breast cancer with negative lymph nodes. methods we investigated histopathologically and immunohistochemically selected cases with g ductal invasive carcinoma and no lymph nodes involvement, from breast cancers. we used a monoclonal antibody panel (estrogen and progesteron receptors, egfr, c-erb b , pcna) in formalin fixed paraffin embedded tissues. results we found a significant increased c-erbb overexpression associated with a low er and pgr expression and minimal microangiogenesis as expressed by egfr. the average of proliferative rate assessed by pcna was . %. conclusion immunohistochemical c-erbb overexpression in negative lymph nodes breast cancer, may suggest an early amplification of its encoding gene, which can predict an aggressive biological behaviour (invasion and metastasis), so that this type of patients would benefit of humanized anti-her /neu monoclonal antibody treatment. introduction aspiration cytology of the breast is one of the three components of the triple test for breast cancer diagnosis. ultrasound (us) guidance increases the complete sensitivity of this technique. the aim of this study was to compare the results between a group of mammary lesions aspirated with or without us using the european quality assurance guidance. material and method we analyzed mammary lesions by aspiration cytology with or without us guidance. one group was formed by breast aspirates from women older than fifty years old, included in an screening programme, with palpable and non palpable lesions, using us guidance. another group was formed by breast aspirates from outpatients origin of all ages only with palpable lesions using no us guidance. we analysed and compare the results between both groups using using the european quality assurance guidance for breast screening pathology. results in both groups the positive predictive value of the c results were % (false positive rate= %). the complete sensitivity of us guided aspirates were . % and for the non guided aspirates were %. we compare the rest of values and analyze our deviations from the standards. conclusion the quality of our breast aspiration practice is between the margins of the standards in both techniques, with an increment in the sensitivity with us guidance and a light loose of specificity in the screening group (probably because of patients age characteristics). ultrastructural study of intercellular junctions in metastatic and non-metastatic breast cancer introduction functional and morphologic characteristics of inter-cellular junctions are involved in tumor dissemination. the purpose of this study was to investigate whether the number of intercellular junctions in breast cancer is predictive for the presence of lymph node metastases. materials and methods infiltrating duct carcinomas were the subject of this study, of them without (g ) and with metastatic disease (g ) in axillary lymph nodes. the number of intercellular junctions was counted, and the length of the cell-to-cell contact surfaces was measured in randomly taken electron micrographs. the number of desmosomes/ µm of cell membrane apposition has been statistically compared between both groups. results cell junctions in tumors with lymph node metastases were usually smaller and poorly developed. there were no statistically significant differences in the number of intercellular junctions between both groups [g = %, ( , %; %). g = , % ( , %; %). p= , ]. conclusions although intercellular junctions are more rudimentary in tumors that metastasize, their number is not significantly reduced. therefore, it will be necessary to combine number, size and development of cell junctions in a single parameter to attempt prediction of tumor dissemination. supported in part by grant fis / . introduction numerous publications have been devoted to effects of myoepithelial cells on biology of breast cancer. the cells are thought to be able to inhibit invasion of neoplastic cells by production of inhibitors for serine proteases. some authors suggest that, acting in a paracrine way, myoepithelium can affect breast cancer cells. present study aimed at analysis of the relation between presence of myoepithelial cells (smooth muscle actin, sma) in the structure of a ductal breast cancer and expression of the recognized prognostic factors (er, pr, her- , tgf alpha, ki and p ) in the cancer cells. the studies were performed on samples of primary ductal breast cancers originating from females, including cases at g , cases at g and cases at g grade. immunocytochemical reactions were performed using antibodies directed to sma, er, pr, her- , tgf alpha, ki and p . the study showed that the highest content of myoepithelial cells was noted in tumours of g grade while the lowest content of the cells was observed in tumours of g grade (kruskal-wallis anova rank test, p= . ). in the entire group (g -g ) a positive correlation was detected between the presence of myoepithelial cells and intensity of her- expression (gamma correlation, p= . ) and a negative correlation with proliferation intensity measured by expression of ki antigen (gamma correlation, p= . ). no relation was observed between manifestation of myoepithelium and expression of the other studied variables. our studies confirmed the potential for paracrine communication between myoepithelial cells and cells of ductal breast cancer. immunohistochemical vegf expression in breast carcinomas. correlation with prognostic factors a matilla, l vicioso, l pérez, m Álvarez, i ramírez dpto. anat. patológica. universidad de málaga, malaga, spain introduction vegf (vascular endothelial growth factor) is considered as one of the most important angiogenic factors in breast cancer and its expression in tumor cells correlate with microvessel density. several studies have proposed that vegf may be a relevant prognostic factor. aim: to study the immunohistochemical expression of vegf in different histological types of breast cancer and its relation to established prognostic and predictive factors. we have analyzed carcinomas ( of invasive ductal type, lobular, mucinous, papillary and ductal in situ). immunohistochemical staining was performed on formalin fixed, paraffin sections, using an avidin-biotin immunoperoxidase technique. a rabbit polyclonal antibody for human vegf was used at a : dilution. immunoreactivity was scored from to +. results ( , %) of all invasive carcinomas showed vegf expression (ductal: %, mucinous: %). all but lobular carcinomas were negative or weakly positive. both papillary carcinomas showed strong positivity. staining in dcis was generally absent or weak. vegf positivity correlated inversely with nodal involvement (p= . ) and re status (p= . ). there were no correlation of vegf staining with tumor size, histological grade, p and c-erbb- . conclusion expression of vegf is characteristically weak or absent in lobular carcinomas and them no relevant as a prognostic factor in this type of carcinomas. as vegf staining correlate with absence of nodal involvement, its prognostic value may be mainly due to facilitate invasion of blood vessels, more than to lymphatic spread. introduction squamous carcinoma accounts for approximately % of all primary vulvar carcinomas. although the anatomic localization of this tumor allows early diagnosis and considerably easy surgical accessibility, the prognosis for these patients remains relatively grim. the explanation for this finding should be sought in the fact that most of the patients are diagnosed in the advanced clinical stage of the disease. since radical vulvectomy (a complex and debilitating procedure) is often a therapy of choice, the recent studies have been focused on determining reliable prognostic parameters that would allow individualized, and hopefully simpler therapeutic modalities to be applied in a certain group of patients with the same effectiveness. the aim of this study was to determine the most important clinical and histopathological parameters that influence the prognosis and outcome of patients with invasive squamous carcinoma of the vulva in order to offer them the most suitable form of therapy. moreover, it was designed to assess the clinical significance of dna content analysis by flow cytometry. patients and methods cases of squamous cell carcinoma of the vulva, diagnosed between . and . were selected. in order to assess the influence of the various prognostic factors on survival, the study included clinical and pathohistological parameters as well as the results of flow cytometric dna analysis of paraffinembedded tumor samples from all cases. clinicopathological parameters focused on the age of patients, clinical stage of the disease, menstrual status, diameter and localization of the tumor, histological grade, nuclear grade, combined histological and nuclear grade, depth of tumor invasion, tumor growth pattern, presence of giant cells in the tumor and the form of therapy, while the flow cytometric dna analysis comprised dna ploidy, proliferative activity and dna index. five-year survival of our selected population of patients was , +/- , %. the results of univariate statistical analysis confirmed that statistically significant prognostic parameters included the age of patients (p= , ), clinical stage of the disease (p= , ), histological grade (p= , ), nuclear grade (p< , ) and the depth of invasion (p< , ). on the other hand, the results of multivariate statistical analysis showed that only combined histological and nuclear grade (p= , ) and the depth of tumor invasion (p< , ) can be considered independent, statistically significant prognostic parameters. conclusion the age of patients at the time of diagnosis, clinical stage of the disease, histological grade and nuclear grade are considered to be the parameters of crucial relevance for the prognosis of patients with squamous cell carcinoma of the vulva. however, only combined histological and nuclear grade, as well as the depth of tumor invasion were proven to be independent statistically significant parameters relevant for the outcome of patients with this disease. can a pleomorphic vulvar leiomyoma be a tumor with local aggressive behavior? a case report vulvar leiomyoma is uncommon and its pleomorphic or bizarre form is especially rare. bizarre vaginal and vulvar (bartholin's gland area) leiomyomas were reported in only few cases. this tumor is hard to differentiate from leiomyosarcoma. the main criterion to make a distinction between them is the mitotic activity, which is less than per hpf in the former. case report a -year-old female was referred to the clinic for the evaluation of paravaginal tumor in distal vaginal third and right vulvar area with a history of month duration. she had no history of any earlier disease, and other examinations revealed normal findings. macropathology: the tumor was a large solid mass measuring x . cm in diameter. the tissue was yellow and seemed partly necrotic. micropathology tumor consisted mostly of spindle cells arranged in bundles with round or oval nuclei and large prominent nucleoli or showed hyperchromatism in places where there were cells with giant nuclei. cytoplasm was eosinophilic, elongated with small vacuole. there were areas where cells had two or more nuclei with the earlier mentioned polymorphism. areas of hyaline or myxoid degeneration of the stroma were found. mitoses were not found although the tumor was examined by three independent pathologists from different countries. the tumor margin looked infiltrative. the tumor was immunohistochemically positive for vimentin, smooth actin and desmin. cytokeratin mnf , ema, s- , cd- , and cd- were negative. conclusion we describe a vulvar smooth muscle tumor with marked polymorphism, without mitoses, with myxoid changes in the stroma and with infiltrative margins. because of all these characteristics the tumor was considered biologically aggressive and additional surgery with resection of the tumor site and regional lymphadenectomy was performed. three years after the last surgery the patient is alive and well. trophoblast apoptosis and proliferation in preeclamptic placentas d staribratova , z zaprianov , d dikov , v sarafian plovdiv medical university, plovdiv, bulgaria hospital center lagny introduction preeclampsia is a specific disorder of pregnancy with an increased risk for both neonatal and maternal mortality rates. it is associated with shallow invasion of the placental cytotrophoblast within uterus developing decidual vasculopathy and results in dereased blood flow. the aim of the present report is to determine whether hypoxia influences the rates of apoptosis and proliferation and to compare them with those of normal controls. materials and methods samples were taken from liveborn, singleton preeclamptic pregnancies and normal controls. we used routine light microscopy, immunohistochemical and quantitative studies for bcl- , and bax (to assess apoptosis) and pcna (to assess cellular proliferation). bcl- -and pcna-positive trophoblast cells were counted in a minimum of high-powered fields, of consecutive sections free from any infarction of at least paraffin blocks. results while increased apoptosis has been estimated in study groups, the rates of proliferation seems to be unaffected. placental pathologic features of preeclampsia d staribratova , z zaprianov plovdiv medical university, plovdiv, bulgaria introduction the clinical and placental features of preeclampsia are subject of an extensive study. clinical evidence suggests that this pregnancy specific disorder may be demographically heterogenous. our purpose is to record the range of the most common pathologic features in placental specimens from a gypsy cohort and to compare them with those in nonethnic bulgarian population. review of preeclamptic placentas from liveborn singleton deliveries of gypsy mothers and matching controls from bulgarian population revealed histologic lesions that were considered as belonging to one of the following groups: ( ) vascular lesions; ( ) acute or chronic inflammation and ( ) coagulation-related lesions. for each separate case, additional demographic and reproductive history was collected from the patients' charts. all placentas were studied by previously published standard protocols. nonparametric statistical analysis was applied. results in gypsy preeclamptic group, lesions related to coagulation ( % vs %) and vascular lesions ( % vs %) were more frequent. inflammatory features were equally distributed among the two groups ( %). introduction versican is a chondroitin sulfate proteoglycan, which belongs to the aggrecan gene family. it has not been studied in epithelial ovarian cancer before. the aim of this study was to clarify the relation between versican and hyaluronan in epithelial ovarian cancer and to find out if versican expression affects prognosis in these patients. materials and methods localization of versican was studied immunohistochemically in primary epithelial ovarian cancers and their metastases, as well as in normal ovary specimens. the staining was scored according to the percentage area of strong versican signal of total peri-and intratumoural stroma as low or high. epithelial staining of the tumours was scored as positive or negative. results low and high levels of strong stromal versican staining were observed in and carcinomas, respectively. a low level of strong stromal versican was found to be a significant marker for early figo stage and mucinous histology. stromal versican staining correlated significantly with stromal hyaluronan staining. cancer cell-associated versican positivity was seen in tumours and correlated with clear cell histology and early figo stage. the -year prognosis of patients decreased with increasing stromal versican levels for overall survival. the -year prognosis for recurrence-free survival was slightly better when cancer cells were positive for versican. in cox's multivariate analysis neither stromal nor cancer cell-associated versican had any prognostic value. conclusion enhanced stromal versican expression correlates with hyaluronan accumulation and is associated with unfavourable disease outcome, but it is not an independent prognostic marker in epithelial ovarian cancer. cytobrush-collected malignant cervical epithelial cells display a cancer-specific gene expression pattern in cdna array analysis g hudelist , introduction although it is well known that persistent high-risk hpv infections are the principal causative agents of cervical cancer, the discrepancy between high infection rates and the relatively low rates of high-risk hpv positive women who actually develop carcinoma of the cervix suggest that development of cervical cancer is a multistep process involving additional factors and mutational events. therefore, differentially expressed genes in normal and malignant cervical epithelial cells and the feasibility of gene expression profiling on cervical cells obtained by regular cervical swabs were investigated. material and methods cervical epithelial cells obtained by regular cytobrushes from women with high-risk hpv positive invasive cervical cancer and from hpv negative women without suspicious pap smears were pooled and subjected to cdna array analysis. dot blotting was then performed to detect the proteins which corresponded to the most highly up-regulated genes in the cdna array analysis. results mrna expression of c-erbb- , c-kit, vegfr- , n-myc, k-ras, cyclin-dependent kinase inhibitor (p ink a), cyclin d , nm -h , nm -h , c-met, kgf, kgfr, and stat was increased in malignant samples. several genes associated with antiapoptosis, such as bcl- like protein, cell structuring and/or cell attachment were also upregulated in tumoral cells. conversely, decreased gene expression was observed for members of the transforming growth factor receptor superfamily (tgf-beta), interleukin (il- ), insulin-like growth factor binding proteins (igfbps) and for members of the integrin family. conclusions we identified a mrna and protein expression pattern that might have an important role in the pathogenesis of invasive cervical carcinoma and appears to be specific for malignant cervical epithelium. we hypothesize that the presence of a cancer-specific gene-expression signature assessed by cdna array analysis or immunohistochemical techniques could eventually turn out to become an additional tool to evaluate the dignity of routinely obtained cervical swabs. prognostic features and molecular markers in ovarian borderline tumors e nistor , ad stanescu , cd vrabie , e ionica bucur hospital, bucharest, romania v. babes institute, bucharest, romania university of bucharest, bucharest, romania introduction ovarian cancer represent the fourth most common cancer in women. borderline ovarian serous tumors (bsot) affect women of childbearig age and their prognosis is outstanding. the aims of this study were to characterize the group of patients with bsot and evaluate the significance of various molecular markers expression versus serous papillary ovarian carcinomas (spoc) material and methods we analyzed a total of cases including: cystadenoma, borderline and cystadenocarcinoma. for the bsot the median age was years. eight women with bsot underwent radical surgery and two fertility sparing surgery. the recurrence of disease appeared in one case with fertility sparing surgery. all the cases were analyzed on haematoxilin-eosin stained and immunohistochemistry (the indirect tristadial streptavidin-biotin method) for estrogen receptor (er), progesteron receptor (pr), p protein (p ), proliferative activity (ki ) and carcinoembrionic antigen (cea). results the immunostaining demonstrated a significant increase in the expression of er ( %) and a decrease for p ( %) and ki ( %) in bsot vs spoc (er- %, p - % and ki - %). conclusions the main differences between bsot and spoc was regarding the expression of p and ki . there was no significant correlation between ki and the known histologic parameters of prognostic significance. transvaginal ultrasound and ca serum levels are the most effective diagnostic techniques for the follow up of patients treated conservatively for bsot. introduction gonadoblastoma with dysgerminoma or other germ cell tumor occurs almost exclusively in girls and young women with underlying gonadal disorder. the aim of this study was to review biopsy examinations of the tumours, stage, treatment strategy, follow up and outcome of five girls with gonadoblastoma and germ cell tumours. material and methods retrospective review of patients with gonadoblastoma and germ cell tumours was performed. the patients were , , , and years old. the first -year-old girl (karyotype, xx, normal ovary bilateral) with gonadoblastoma, dysgerminoma and choriocarcinoma had iiic stage disease. she was treated by chemotherapy with cisplatinum and radiotherapy. four patients had gonadoblastoma and dysgerminoma. the second -year-old girl (mixed gonadal dysgenesis, karyotype, , xy) had stage ib and was treated by chemotherapy with cisplatinum. two patients were treated with surgery only: year-old girl (streak gonads, karyotype, , xy) -stage ib and year-old girl (karyotype , xx, der / , xx, - ) -stage ia. the -year-old patient (karyotype, , xx, normal ovary bilateral) -stage ia disease, had adnexotomy only, but because of recurrence (stage iiic) months after the original diagnosis, she was treated by chemotherapy. results our review confirmed the original diagnosis of gonadoblastoma and dysgerminoma and in one case gonadoblastoma, dysgerminoma and choriocarcinoma. all patients were followed up for to months. only one patient, who was initially treated with surgery only (stage ia), had disease recurrence, but achieved durable remission with chemotherapy and further surgery. the latest examinations revealed that all patients were in good health. conclusions because the gonads are often replaced by a tumour, a diagnosis of the underlying abnormality may be impossible. gonadoblastoma is regarded as in situ malignancy, and there is a high possibility for development of invasive germ cell tumour such as dysgerminoma. young girls with unilateral encapsulated gonadoblastoma and dysgerminoma can be treated only by unilateral oophorectomy or salpingo-oophorectomy and subsequent careful follow up to prevent damage of contralateral ovary and preserve the fertility. the patients with gonadoblastoma and mixed germ cell tumor are treated in accordance with other tumour structures. the paper is sponsored by ministry of health of the czech republic (international grant agency) no - , cz introduction cadherins and their associated cytoplasmic protein catenins are cell adhesion glycoproteins that are altered in tumor progression the aim of this study is to reveal the altered expression of e-cadherin, p-cadherin, α-catenin and β-catenin in cervical squamous cell carcinoma progression from dysplastic lesions (low grade squamous intraepithelial lesion-l-sil, high grade squamous intraepithelial lesion-h-sil) to invasive squamous cell carcinoma. material and method immunohistochemical method was used in formalin-fixed, paraffin embedded representative tissue sections of l-sil (cin i), h-sil (cin ii-iii) and invasive squamous cell carcinomas. the presence of immunostaining and the pattern of distribution of e-cadherin, p-cadherin, α-catenin and β-catenin were analyzed. results e-cadherin was detected in . %, . %, . % of l-sil, h-sil and invasive squamous cell carcinomas respectively. the difference was statistically significant (p= . ). the expression of p-cadherin and α-catenin was reduced significantly from l-sil through invasive carcinoma (p= . for p-cadherin, p= . for α-catenin). β-catenin expression was revealed in all lesions with nearly the same frequency, . % l-sil, . % h-sil and . % invasive carcinomas. conclusion loss of adhesion proteins, e-cadherin, p-cadherin and α-catenin is observed in cervical squamous cell carcinoma progression. the presence of β-catenin in h-sil and invasive carcinomas might suggest its role in tumor progression by its effect in wnt signaling pathway in cervical carcinomas. introduction p, e-cadherin and their cytoplasmic domains alpha and beta-catenins are epithelial cell adhesion complexes. their alteration is important in tumor progression. beta catenin is also involved in wnt signaling cascade which regulates cell proliferation. we investigated the altered pattern of cadherin/catenin complex in cervical squamous cell carcinomas. we also tried to find out if there was a correlation between adhesion proteins and clinicopathologic variables (stage, depth of invasion, lymph node metastases) and hpv status. material and methods e-cadherin, p-cadherin, alpha catenin and beta catenin expression in squamous cell carcinomas were investigated by immunohistochemical method. the presence of hpv / infection was detected by in situ hybridization. results there were large cell keratinizing, nonkeratinizing and small cell subtypes of squamous cell carcinoma. lymph node metastases were found in carcinomas. hpv / infection was detected in of carcinomas, all were large cell keratinizing except one. no correlation was found between the hpv status and cadherin and catenin expression of the tumors. e-cadherin was negative in carcinomas, p-cadherin was positive in only carcinomas. strong cytoplasmic beta catenin positivity was revealed in carcinomas. alpha catenin reactivity was seen in of carcinomas. neither cadherins nor catenins expressions were correlated with other clinicopathologic variables. conclusion our results reveal that e-cadherin and p-cadherin expressions are lost in squamous cell carcinomas. however alpha and beta catenin immunopositivity in cervical squamous cell carcinomas might suggest catenins' role in tumor progression in a different way other than their activity in cell adhesion. prognostic significance of karyotype analysis in ovarian carcinomas e introduction traditional prognostic factors of ovarian carcinoma (oc) include disease stage, age, histologic grade and residual disease after surgery. at present it is quite difficult to predict the survival benefit of platinum analogues based chemotherapy. the aim of this study was to evaluate the clinicopathological / cytogenetic profile in a series of ocs and the reliability of karyotype in predicting benefit of chemotherapy and prognosis. materials and methods a series of ocs ( serous, undifferentiated, endometrioid, mucinous and one mixed carcinomas) was investigated for grade ( / : % vs / : %), stage (i/ii: % vs iii/iv: %), residual disease after surgery ( %), chemotherapy ( %), remission ( %) vs progression ( %) after chemotherapy and follow-up (mean: , range: - months). cytogenetics were performed on direct preparations using the qfq banding technique and describing abnormalities according to iscn. karyotypes were classified as diploid/near-diploid ( %) and complex (hyperdiploid, multiple cell lines, fragmented chromosomes) ( %). statistical analysis using chi-square and fisher test was done. statistical analysis demonstrated that low stage (p= . ) and low grade (p= . ) were predictors of good prognosis, while residual disease correlated with a poor outcome (p= . ). diploid/near-diploid karyotype correlated with a favourable prognosis (chi-square: . ). complex karyotypes appeared much more frequently associated with chemoresistance ( % vs %). conclusion our results confirm the correlation between grade, stage, residual disease and prognosis of ocs. in addition, these data suggest that a diploid/near-diploid karyotype might predict benefit of chemotherapy and favourable prognosis. introduction the aim of this study was to critically assess the progression-and recurrence rates of microinvasive (mic) stage ia cervical carcinoma, based on medline search, and to compare these data with our own experience on these tumours in ljubljana medical centre. in the published studies covering the years - , a total of . squamous cell mics were reported, including . stage ia lesions, . in stage ia , and cases of occult stage ib, classified according to figo or sgo classifications. our experience in ljubljana is based on the management of stage ia squamous cell carcinomas (scc), accumulated in the past years and early invasive adenocarcinomas (ac) collected in years. results in the reported . scc mic cases, lymphatic space involvement was recorded in ( %) cases, and in of those, the disease recurred, and progressed to death in patients. in series, mics were associated with ( . %) recurrences. in seven series, ( . %) cases of death due to cancer were reported. lymph node metastases were found in ( . %) cases. even when stage ia and ia carcinomas were treated with conservative surgical approach, very low risk of recurrence ( . %), lymph node disease ( . %), or death caused by cancer ( . %) was reported by these studies. most authors conclude that mic with the depth of invasion < mm, without confluent growth or lymphatic invasion can be safely treated with conization. during - lymphadenectomy was included in operations of mic in ljubljana. the pelvic lns were invariably free of cancer. the -year survival was %, while patients were lost to follow-up. in medline search . cases of stage ia acs were analysed in a -year period. lymph node metastasis were found in ( . %) of cases with lymphadenectomy, complicated with recurrent disease in ( . %) cases compared to the scc mic, the risk of recurrence in ac was considerably higher, . % and progression to death . % ( cases analysed by Östör, ). in our ac patients diagnosed in stage ia there was no recurrence or death of disease. conclusions according to the world literature and our own experience, the prognosis of mic of both squamous and glandular type is very favourable. this suggests that conservative management of stage ia cervical cancer is indicated and safe when strict evaluation of tumour extension and surgical margins of the cone are assured. agnor counts, histological and immunohistochemical characteristics of placenta in preterm delivery with live and dead newborns g burkadze, g turashvili, n meckhvarishvili tbilisi state medical university, tbilisi, georgia introduction the pathology of placenta constitutes one of the most poorly understood domains of general pathology. the significance of histological characteristics of preterm delivery is disputable. the aim of this study was to investigate histological and immunohistochemical characteristics and agnor counts of placenta in preterm delivery with alive and dead newborns. we studied placental tissues in preterm deliveries of live (first group) and dead (second group) newborns (n obstetrics clinic of tsmu, tsmu, - . paraffin sections were stained using h&e, agnor (bio-optica) and immunohistochemistry by ki- , cd , cd , bcl- (dako). results in the first group the number and area of chorionic villi was times lower, the number and area of villous vessels . times higher, the number of villous lymphocytes is . times higher, neutrophils . times higher, hofbauer cells . times lower, syncytiotrophoblasts . times lower (their area was the same), syncytial knots times lower (their area is times higher). the width of nitabuch layer was times greater, decidual tissue . times greater, the number of decidual cells was . times higher, decidual lymphocytes . times higher, neutrophils . times higher, macrophages . times lower, agnor(+) syncytiotrophoblastic cells . times lower, agnor granules did not differ, agnor(+) decidual cells times higher, agnor granules . times higher, ki- (+) syncytiotrophoblasts and cytotrophoblasts times higher. conclusion preterm delivery shows incoordination between proliferation and involution of placental tissue. in death of newborns, morphological changes reflect non-efficacy of adaptative-compensative reactions of chorion-decidual system. institute of pathology, charité university hospital, berlin, germany clontech laboratories inc., paolo alto, california, usa introduction the ubiquitously expressed actin-binding protein gelsolin is known to play a role in modulation of the actin network and regulation of cell motility and cell growth. decreased gelsolin expression occurs in transformed cells and in carcinomas of the colon, bladder, breast, lung and prostate. in the present study we analyzed expression of gelsolin in matched human normal and tumor tissues using a cancer profiling array. we found a decreased expression of gelsolin in cancer tissue of female reproductive organs including ovary. further we examined the expression of gelsolin in human benign and malignant ovarian tissues by immunohistochemistry, observing a diminished expression of gelsolin in borderline tumors and ovarian serous carcinomas compared to epithelium of normal ovaries and benign adenomas. in addition, low levels of gelsolin protein were observed in four of six ovarian carcinoma cell lines in contrast to immortalized ovarian surface epithelial cells. re-expression of gelsolin in the ovarian carcinoma cell lines oaw and es- resulted in a suppression of tumor cell survival in vitro. finally, we showed an up-regulation of gelsolin in ovarian cancer cell lines after inhibition of both dna methylation and histone deacetylation using -aza- 'deoxycytidine and trichostatin a, respectively. conclusion our results suggest that the gelsolin gene has a potential function as a class ii tumor suppressor gene in human ovarian epithelium. steroid cell tumor of the ovary: presentation of two cases i lekka, o tzaida, v leodara, a lountou, p arapantoni-dadioti, i iakovidou pathology department, metaxas cancer hospital of pireaus, piraus, greece two cases of steroid tumor of the ovary, diagnosed at our department during the last five years among a total of ovarian tumors, are presented. steroid cell tumors, previously classified as lipid or lipoid cell tumors are rare neoplasms of sex-cord-stromal origin derived in almost all cases from ovarian stromal lutein cells or from leydig cells and rarely from adrenal rest cells. they have been subclassified as steroid cell tumors not otherwise specified (nos), stromal luteomas and leydig cell tumors. in our report we present two cases of the nos subtype: one occurred in a -yearold woman and the other in a -year-old postmenopausal woman. both patients presented with a pelvic mass and signs of virilization (resulting effect of elevated serum testosterone). both tumors were composed of characteristic eosinophilic-granular or vacuolated (lipid rich) neoplastic cells lacking crystals of reinke and expressing the appropriate immunohistochemical phenotype. based on thorough pathological examination and evaluation of several findings such as tumor size, necrosis, haemorrhage, cellular atypia, mitotic activity, we classified the first case as a malignant and the second as a benign one. various aspects of the clinical and pathological presentation, differential diagnosis and treatment of these tumors are discussed. choriocarcinoma following term pregnancy uncommonly choriocarcinoma follows a normal pregnancy. the aim of this study was to stress the importance of a correct and rapid diagnosis which will allow a high rate of success in therapy for this neoplasm. material and methods histopathologic and immunohistochemical studies were performed to an endometrial curettage and a hysterectomy specimen. case report a -year-old female presented with uterine bleeding three months after a normal delivery from a term gestation in which placenta was not submitted for study. endometrial curettage was performed, and it showed a dimorphic population of atypical cytotrophoblast and syncytiotrophoblast cells. cytotrophoblast cells had pale cytoplasm with single nucleus, eosinophilic nucleoli and prominent mitotic figures. syncytiotrophoblast appeared as large multinucleated cells with polygonal basophilic cytoplasm. extensive necrotic and hemorrhagic areas were found. there was no presence of placental villi. neoplastic cells expressed strongly ß-hcg and cytokeratin. with a diagnosis of choriocarcinoma, hysterectomy was performed and showed areas of normal proliferative endometrium, and hemorrhagic areas with nests of trophoblastic neoplastic cells infiltrating among myometrial muscle. there was no involvement of cervix or adnexa. treatment was completed with chemotherapy, and one year after diagnosis the patient has not evidence of disease. conclusions the modern treatment with chemotherapeutic drugs is highly effective in complete cure of choriocarcinoma. therefore a quick histological diagnosis has a very important role to reduce the risk of metastasis disease, even avoiding surgery to preserve reproductive function. the mechanism of action and the histological features of uterine leiomyomas (ul) treated with gnrh are still a matter of debate. recent reports suggest that neovascularization induced by specific angiogenic molecules may play a role in the response to gnrh. also a reduced proliferative activity was observed and postulated as a possible histopathological feature of ul treated with gnrh. the aim of this study was to assess the possible role of angiogenesis and to quantify the percentage of proliferative cells in uterine leiomyomas in response to treatment with gnrh from premenopausic patients. material and methods a total of patients were studied, with two groups comprising samples each, including patients treated with gnrh and age-matched control patients. clinical (age, length of treatment, assessment of response to treatment by ultrasonography) and histopathological dates (microvessel density (vessels/mm ) and cellular proliferation assesed by ki- stain in cells were studied. the study group showed cd = , vessels/mm (mean) and ki- = , (mean). the control group showed cd = , vessels/mm (mean) and ki- = , . conclusion the leiomyomas treated with gnrh showed a) high number of microvessel density, b) low proliferative activity and c) significant reduction in size compared with patients without treatment. introduction evaluations of expression of apoptosis related oncogenes are being increasingly called upon in an attempt to better understand the carcinogenesis of cervical carcinoma and to provide possible prognostic information. the aim of this study was to analyze the expression of bcl- , p and mdm- oncoproteins and cellular proliferative marker ki- in early stage cervical carcinoma, with an emphasis on their association with human papillomavirus (hpv) infection, recurrence rate and lymph node status. material and methods using immunohistochemistry, radical hysterectomy specimens with cervical carcinoma (pt b /pt b ) were studied. evaluation of expression of p , bcl- , mdm- and ki- was performed in surface area, center and invasion front of the neoplasms. the hpv presence was determined by card in situ hybridization. results and conclusion in the invasion front bcl- was expressed in ( %), p in ( %) and mdm- in ( %) cases. hpv infection was detected in ( %) cases. carcinomas with a higher ki- labeling index were more frequently hpv positive than hpv negative ( . % vs . %, p< . ). no association was found between p , mdm- or ki- and either lymph node status or recurrence rate. negative staining for bcl- was associated only with the presence of lymph node metastasis ( % vs %, p= . ), and not with the recurrence rate. significant correlation among expression of bcl- , p , mdm- oncoprotein and ki- values was also observed. these results suggest that further study of a larger series is needed to confirm whether bcl- , either alone or in combined evaluation with other markers, could be a useful marker to identify more aggressive behavior in early stage cervical carcinoma. introduction during the past three decades, the incidence of cervical invasive primary adenocarcinoma (aca) has increased. at the same time, incidence of squamous cell carcinomas of the cervix decreased, due to early detection of their well documented precursors lesions. the aim of this study was to determine if dysplastic endocervical cells (ec) have neoplastic potential as a precursor lesions of adenocarcinoma in situ (ais) of the cervix. the malignant potential was determined by assessing the ploidy status, proliferative activity and c-myc expression in normal, dysplastic and malignant ec separately. patients and methods serial sections from patients with diagnosed ais or primary invasive aca were analyzed. one representative slide of cervix which showed normal, dysplastic and malignant endocervical glands simultaneously was chosen from each patient. determination of ploidy status and s-phase by flow cytometry and expression of c-myc oncoprotein by immunohistochemistry in normal, dysplastic and malignant ec was done. results the morphologicaly normal ec were diploid, with normal proliferative activity and no expression of c-myc oncoprotein. the dysplastic and malignant ec had a significant proportion of cells with aneuploidy, higher proliferative activity and c-myc oncogene overexpression. the χ test showed significant association of malignant ec with aneuploidy (p= . ) and high proliferative activity (p= . ). as one third of dysplastic ec are aneuploid, with high mitotic activity, they probably have malignant potential. dysplastic endocervical cells had statistically significant association with c-myc oncogene expression (p= . ). conclusion our results support the existence of pre-malignant glandular lesions while the immunohistochemical detection of cmyc oncoproteine could be helpful in detection of ec with malignant potential even without dysplastic morphologic changes. introduction the attempts to determine the prognostic significance of c-erbb- oncoprotein expression (ope) and its relation to human papillomavirus (hpv) infection in cervical cancer have yielded controversial. the aim of this study was to evaluate the patterns of c-erbb- ope in early stage cervical carcinoma and to assess its prognostic value by exploring its relationships to various clinicopathological characteristics, hpv status and recurrence rate. materials and methods radical hysterectomy specimens from cervical carcinoma patients (pt b / b ) were investigated immunohistochemically for c-erbb- presence. the c-erbb- score (range: - ) was determined in the surface area, center and invasion front of each carcinoma. card in situ hybridization was used for hpv detection. results and conclusion strong c-erbb- ope was detected in , , and cases in the invasion front, center and surface area of the tumor, respectively. there was a significant difference in positive staining rate of c-erbb- between squamous cell, mixed carcinomas and adenocarcinomas ( %, % vs %, p= . ). c-erbb- ope was significantly higher in carcinomas with abundant than in tumors with less abundant peri-tumoral lymphocytic infiltration ( . % vs . %, p= . ). in hpv positive carcinomas ( ), c-erbb- was detected more frequently in type / versus type / lesions ( % vs . %, p= . ). no association was found between c-erbb- expression and recurrence rate, lymph node metastasis or any other clinicopathological variable investigated (age, tumor diameter, depth of invasion, grade, vascular invasion). therefore, immunostaining for c-erbb- is unlikely to be of use as a prognostic indicator in early stage cervical carcinomas, while further study is warranted to examine relationships between hpv infection and c-erbb- ope. the predictive values of estrogen (er) and progesterone receptor (pgr) status and cell proliferation kinetics in cervical carcinomas are still unsettled. the purpose of this study was to clarify the associations among er/pgr status and ki- expression and to determine their relationship to human papillomavirus (hpv) infection, recurrence rate and other clinicopathologic parameters (age, tumor diameter, depth of invasion, histotype, grade, vascular involvement, inflammatory infiltrate, lymph node status) in early stage cervical carcinomas. materials and methods er, pgr and ki- immunostaining was performed in cervical carcinoma radical hysterectomy specimens (pt b /pt b ). er/pgr staining was scored in a semiquantitative fashion, while to evaluate the cell proliferation, the ki- labelling index (li) was assessed in the surface area, center and invasion front of each tumor. hpv status was determined by card in situ hybridization. results and conclusion er positivity was detected in ( %), while pgr positivity in ( %) carcinomas. er/pgr values were in correlation with ki- li in all three tumors' compartments (p< . ). in contrast to er/pgr status, ki- li was strongly associated with hpv infection (p< . ). no relationship was found between pgr or ki- immunoreactivity and either recurrence rate or any other clinicopathological variable investigated. nevertheless, reduced er expression was significantly associated with larger tumor diameter (p= . ) and poor differentiation (p= . ), as well as lymphovascular involvement (p= . ) and lymph node metastases (p= . ). these results suggest that er, pgr and ki- expression are closely related to neoplastic cell proliferation, probably induced by hpv infection. their determination may provide additional prognostic information in early stage cervical carcinomas. immunohistochemical assessment of heat shock protein expression in epithelial ovarian carcinomas: relationship with apoptotic markers as over-expression of bcl- and p purpose heat shock proteins (hsps) occupy a central role in the regulation of intracellular homeostasis and especially hsp and hsp are potent antiapoptotic proteins. overexpression of hsp protects cells from stress-induced apoptosis. the aim of this study was to determine the distrubition pattern of hsp -expression in ovarian carcinomas by immunohistochemistry and to evaluate its relationship with the prognostic parameters and over-expression of bcl- and p proteins. materials and methods thirty-five patients with ovarian carcinoma were included in the present study. expression of hsp was assessed by immunohistochemistry. the relationship between expression of these proteins and other prognostic markers such as stage was evaluated. results hsp was expressed in all of ovarian cancer cells with different intensity. the staining was localized in the cytoplasm and/or nuclei. there was a negative correlation between stage and both intensity of hsp positivity and bcl- positivity (respectively: r= - , ; p< . ; r= - . , p< . ). intensity of hsp positivity was statistically associated with bcl- positivity (r= . , p< . ). there were no significant associations between p positivity and bcl- positivity, intensity of hsp or stage of ovarian carcinoma. conclusions these data show that the intensity of hsp positivity was significantly stronger in early stage than in advanced stage ovarian carcinomas. hsp expression detected by immunohistochemistry was correlated with bcl- expression but not with p protein expression. background avb integrin and pinopodes have been proposed as new markers of endometrial receptivity. there is also a very limited experience on the responses of these markers to hormonal therapies. the aim of this study is to evaluate the effect different hormone replacement treatment on these markers. design we studied fertile controls and women with ovarian failure receiving hormone replacement therapy (estradiol valerate (ev) and vaginal progesterone (vp), group e+ep). those women were divided randomly into two subgroups of patients. group e+p received ev for days and vp alone for days. group e+p+ep was given e+ep therapy but including episodic vp on days and . all women underwent two endometrial biopsies during a single menstrual cycle (days + to + and four days later). avb integrin was detected in frozen tissue using the envision system. pinopode formation was evaluated in tissue fixed in glutaraldehide using a zeiss dsm a scanning electron microscopy. both avb integrin and pinopode formation were semiquantitatively evaluated. results patients in group e+p+ep showed markedly decidualized endometria in the midluteal biopsy and a significant increase of avb integrin expression (p= . for both parameters). no significant changes in pinopode formation were observed in midluteal biopsies. no differences were observed in late luteal biopsies. conclusions avb integrin expression and pinopode formation are signs of endometrial maturation related to progesterone action but their significance in terms of endometrial receptivity in the clinical setting remains to be shown. supported by grant pi (fondo de investigaciones sanitarias). gestational trophoblastic diseases (gtd) are extremely rare conditions, especially the ones associated with ectopic pregnancies (ep). case reports only three cases ( . %, / ) of gtd associated with ep were diagnosed at the department of histopathology and clinical cytology in the last years. the first patient, age underwent salpingectomy for clinical suspicion of tubal pregnancy, whereas in the second, age hysterectomy with bilateral salpingo-oophprectomy (hsop) was performed for a clinical diagnosis of ovarian endometriosis. the third patient, age underwent hsop for malignant ovarian tumour which metastasised to lungs. pathological findings: chorionic villi were found in the tubal lumen of the first patient, showing marked hydropic degeneration, reduced/absent vascularisation and excessive trophoblastic cell growth. diagnosis of partial hydatiform mole was established, and the patient remained under surveillance for the hcg level. atypical trophoblastic cells, which penetrated the full thickness of the tubal wall and invaded the ovarian blood vessels of the second patient, led to the diagnosis of an invasive mole. the third patient was diagnosed with choriocarcinoma due to the presence of a tumour consisting of malignant trophoblastic cells that infiltrated the right ovary, tube and uterine cornu. the last two patients received chemotherapy and have been well for and months, respectively. conclusion due to extremely low incidence of gtd associated with ep, these entities are rarely clinically recognised. therefore, a careful histopathologic examination of the adnexal masses is essential for the establishment of the correct diagnosis and further treatment of the patients. in an organized screening programme for cervix cancer the diagnosis atypia (ascus) has always been a problem. the subsequent histological examination shows different diagnoses, such as negative, inflammation, cin i-iii (sil) and carcinoma. in the county of funen, a well-organized screening programme has existed since .using the cytological diagnosis of atypia, we distinguish between atypia (asc-us) probably inflammatory and atypia (asc-h) probably dysplasia. in previous studies on papsmears we have shown histological follow-up diagnoses for atypia (asc-us): negative . % and cin i-iii . %, and for atypia (asc-h): negative . %, cin i-iii % and carcinoma , %. since june we have implementated liquid-based cytology (lbc) thinprep, cytyc. the aim of this investigation is to show the histological follow-up diagnoses of cytological atypia when using lbc-technique. the total number of lbc-samples in were examined. the recommandations for atypia are a repeated cervical sample, and for persistent atypia or atypia colposcopy, cervical biopsies and abrasion within months. in a total of , smears, including , lbcsamples, were examined. the diagnoses of the lbc-samples were: negative , %, inadequate , % (a reduction of % compared with pap-smears), atypia , % and cin i %. preliminary histological follow-up diagnoses for atypia and were: negative % and cin i-iii %. conclusion thinprep shows two significant advantages: a markedly reduced number of cytological atypia diagnoses ( %) compared with pap-smears and a higher diagnostic quality with fewer false positive diagnoses. introduction ovarian sertoli-leydig cell tumors (slct) are very rare sex cord-stromal tumors and among them, tumors with heterologous sarcomatous elements are exceptional. aims: a unilateral ovarian stage ic slct with heterologous mesenchymal elements is presented. materials and methods a -year-old woman, para , was admitted to hospital with severe abdominal pain. at laparotomy, resection of a large right ovarian cyst was carried out. histological examination revealed a slct, and subsequently surgical staging was performed. no adjuvant therapy was given. at years followup she was well and without signs of recurrence. routine staining of slides from paraffin blocks and immunohistochemistry (ihc) were available. results gross examination revealed a x x cm large multilocular ovarian cyst with smooth interlocular septa and outer surface. microscopy disclosed a slct of intermediate differentiation with a very few leydig cells. major areas consisted of a hypocellular stroma with edema, hemorrhage and necrosis. in a few sections small foci of cartilage were seen. in a number of sections groups of small cells with indistinct cytoplasm and hyperchromatic nuclei were present. mitotic and apoptotic figures were common. ihc revealed a positive reaction for desmin, myf and myogenin, indicating rhabdomyosarcoma of embryonal type. conclusion the most important prognostic factors of slct are stage and grade of differentiation. variants of slct with immature skeletal muscle are often fatal. ihc with myf or myogenin with a high sensitivity and specificity for rhabdomyosarcoma, combined with inhibin is very important in differing immature sertoli cells from rhabdomyoblasts, in order to diagnose the rhabdomyosarcoma and to grade the slct correctly. expression of the nerve growth factor (ngf) receptors trka and p shows biological diversity in ovarian, breast and mesothelial malignancy b davidson , r reich , p lazarovici , va florenes , m skrede , b risberg , c bedrossian , jm nesland the norwegian radium hospital, oslo, norway department of pharmacology, hebrew university, jerusalem. israel department of pathology, northwestern university, chicago, il, usa neurotrophins and their receptors are known to have a central role in biologic processes in the nervous system. however, recent studies have additionally highlighted the role of ngf and its receptors trka (inducer of proliferation) and p (inducer of apoptosis) in the development and progression of malignant tumors, including those of non-neural origin. we studied protein expression of p and activated phosphorylated trka (p-trka) in serous ovarian carcinomas ( effusions, solid tumors), breast carcinomas ( effusions, solid tumors) and malignant mesotheliomas (mm) ( effusions, biopsies) using immunohistochemistry and immunoblotting. p-trka was expressed in ovarian carcinoma cells in effusions in only / ( %) specimens, compared to / ( %) solid tumors, while the opposite was true for p . in contrast, p-trka membrane expression was higher in effusions (p= . ) of mm patients, while the opposite was true for p (p= . ). in addition, p-trka (but not p ) expression was significantly higher in peritoneal mm compared to their pleural counterparts ( / vs. / positive tumors; p= . ). in breast cancer, p-trka expression in effusions was significantly higher than in primary tumors (p< . ) and lymph node metastases (p= . ), while p expression was lower in both effusions (p= . ) and primary tumors (p= . ) compared to lymph node metastases. our results provide the first evidence regarding the role of nfg receptors in tumor progression through site-specific changes in expression. specifically, they may provide biologic evidence for the uniformly and rapidly fatal outcome of breast cancer patients with effusions and of mm patients. the significance of mast cells in the differential diagnosis of uterine smooth muscle tumors bh ozdemir aim to assess the role of the mean mast cell count in the differential diagnosis of uterine smooth muscle tumors. material and method twenty-cases of ordinary leiomyoma, cases of atypical leiomyoma, cases of leiomyosarcoma, cases of mitotically active leiomyoma and cases of cellular leiomyoma were included in the study. the morphological features and clinical presentation was evaluated retrospectively. toludine blue stain was used to highlight the mast cells in the endometrium, myometrium and smooth muscle tumors. at least high power fields were counted. results considerable variation in mast cell numbers was found among smooth muscle tumors (p< . ). the intratumoral mean mast cell count was found significantly higher in ordinary leiomyomas ( . ), when compared with other tumors, including atypical leiomyoma ( . . ), mitotically active leiomyoma ( . ), cellular leiomyoma ( . . ) and leiomyosarcoma ( . . ) (p< . ). no significant differences were found between these tumor groups in regards of the mean mast cell count of endometrium and myometrium adjacent to the tumor. in the endometrium, a drop in the number of mast cells has been demonstrated with advancing age, particularly after menopause (p< . ). in addition cases showed eosinophilia, cases showed basophilia and cases showed allergic reactions to different causes. a significant positive relationship was found between the intratumoral, myometrial mast cell number and basophilia. conclusion these data suggest that intratumoral mast cell quantitation may allow the differential diagnosis in uterine smooth muscle tumors. ovarian carcinoma is the most frequent cause of death in the world among gynaecologic malignancies. diagnosis is usually late, and the biological behaviour is highly variable, depending on several factors such as the histopathological grading, the local and/or peritoneal spread and the proliferation rate. we choose a list of genes involved in cell growth and proliferation (igf , igfbp , ctnnbeta , cdk- c, fgfr ). among these, so far, we analyzed igfbp gene and studied loss of heterozygosity (loh) in tumour tissue in order to identify potential relevant genes in ovarian cancer homeostasis. twenty cases of formalin fixed, paraffin embedded ovarian carcinomas from the archives of the department of pathology of padova university and five effusions (from peritoneal or pleural recurrences) of ovarian carcinomas, were selected for this study. genomic dna and tumour dna for each case were extracted from blood cell, tumour or not-cancer surgery biopsy. loh was searched using published single nucleotide polymorphism (snps) in igfbp gene. pcr product covering the snps from genomic and tumour dna were dhplc separated. three of the twenty patients whose tumour dna was obtained from paraffin material, were heterozygous at nucleotide c/a (dbsnp ref. n. ) and a/c (dbsnp ref. n. ) of the igfbp gene in genomic dna. analysis of tumour dna failed to reveal loh (preserved heterozygosity). in effusion cases, one of five patients showed heterozygosity at the same nucleotides. in these patients, loh was also not identified. our preliminary results suggest that dhplc analysis for loh is feasible, rapid and maybe of potential interest in the identification of genes involved in ovarian cancerogenesis. the progression of low grade squamous intraepithelial lesion (l-sil) to high grade squamous intraepithelial lesion (h-sil) occurs in around % of cases. there are no morphologic changes to predict this progression. aims: to study whether the ki immunostaining pattern and labeling present upon diagnosis of l-sil is able to predict the regression or persistence/progression of the lesion to h-sil of the cervix over a two year period following diagnosis. materials and methods cervical biopsies from patients diagnosed cytologically as cervical squamous intraepithelial lesion (sil) were used. biopsies were performed immediately after the cytological diagnosis resulting in l-sil and h-sil. ki immunostaining was performed on all cases and was classified as suprabasal immunostaining pattern (sbip) for cases without ki- immunoreactive cells in the upper two thirds of the epithelium thickness, or dispersed immunostaining pattern (dip) for cases with ki- immunoreactive cells in the upper two thirds of the epithelium thickness. nuclei in hpf including the total thickness of the epithelial layer of each sample were counted to determine the mean number of cells which reacted against ki- antibody. in situ hybridization was used to demonstrate the presence of hpv and its typing. chi square test, fisher's exact test and student t test were used for statistical analysis with significance set at p< . . results of the biopsies performed cases resulted in l-sil ( s-bip and dip patterns) and in h-sil. % of the l-sil cases that resulted in a s-bip pattern showed persistence/ progression of the lesions while % of the cases that resulted in a dip pattern showed persistence/progression of the lesions. the difference between these values where statistically significative (p< . ). regarding ki- labeling index (li) in l-sil cases, we found that % of the cases ( out of ) with a ki- li less than % persisted/progressed, while % of cases ( out of ) with ki- li over % persisted/progressed. in this case there was also a statistically significative difference (p= . ). we found no statistical differences (p= . ) regarding hpv "in situ" hybridization. % of the cases ( out of ) where hpv was detected by in situ hybridization persisted/progressed while % of the cases did not show hpv by hybridization. conclusions the l-sil cases which showed dip and high ki- li were significantly related with persistence or progression to h-sil of these lesions, while l-sil cases which showed sbip and low ki- were significantly related to regression of the lesions. therefore, we conclude that ki- immunostaining pattern may be of prognostic value to predict regression or persistence/progression of l-sil. introduction sclerosing stromal tumor (sst) of the ovary is a rare tumor. it was first described by chalvardjan and scully in as a distinct subtype in the thecoma-fibroma group. most ssts occur in young patients below the age of years. the most common clinical symptom in patients is menstrual irregularity. in differential diagnosis, thecoma, fibroma, and hemangiopericytoma must be considered. aim: in this report, cases of sst of the ovary were described and compared with other ovarian tumors. material and methods two cases of ovarian sst were examined. the first case occurred in a -year-old female. at operation, the patient was found to have the ovary replaced by a tumor mass measuring x x cm. the second case occurred in a -year-old woman and the tumor mass measured x x cm. the surgical material was fixed in % formaldehyde solution and prepared for paraffin sections. in addition to h&e staining, immunohistochemical analyses were performed. results the clinical features, gross features, light microscopic findings and immunohistochemical results were described and compared with literature. the findings were consistent with sst, which is a very rare tumor of the ovary. the tumor cells showed positive staining for vimentin and desmin. we discuss the results and differential diagnosis. unususal chorangioma of the placenta -a case report w pokieser , w umek , r jahn , w ulrich institut of pathology, lainz hospital, vienna, austria institut of pathology, department of obstetrics and gynecology, university of vienna, austria chorangiomas (ca) are common lesions, occurring in of placentas. it is not clear whether ca are hyperplasias, hamartomas, or true neoplasms. depending on their size and location, they may be devoid of symptoms or may cause difficulties for the infant and the mother. we describe a case of manual removal of the placenta in association with ca. on gross examination the tumor had a nodule-in-nodule appearance and was histologically composed of two well defined nodules. the larger, outer one had the appearance of an usual chorangioma; the inner nodule showed highly cellular vascular proliferation. this architecture might represent a morphological variant of the same disease. in the present case, the placenta had to be removed manually. it remains unclear if this was due to impaired contractility of the uterine wall or due to a lack of decidualisation, following a worse vascular support in the surrounding area of the ca. it can´t be excluded that placenta accreta was caused by strictures after cesarian section which had been performed at the first delivery two years ago. on the other hand a placenta with a nodule form of ca could be less elastic than a placenta with regular architecture. however manual removal of the placenta may be regarded as a further complication of ca's larger than cm in diameter. are muc and muc ac reliable markers in the differential diagnosis of primary and metastatic ovarian carcinomas? a ensari , d ergun , a yorganci , a sertcelik , f ortac , n kursun ankara university medical school, department of pathology, ankara, turkey ankara university medical school, department of gynaecological oncology, ankara, turkey numune hospital gynaecology department ankara university medical school, department of biostatistic, ankara, turkey introduction aberrant expression of mucin glycoproteins has been observed during malignant transformation of human ovarian epithelium. however, there is limited information regarding the expression of these mucin proteins in primary and metastatic ovarian carcinomas. the aim of this study was to examine immunohistochemical expression of muc and muc ac mucin proteins in primary and metastatic carcinomas of the ovary in order to assess their value in the differential diagnosis. materials and methods forty eight ovarian tumours comprising surface epithelial carcinomas ( endometrioid, clear cell, serous papillary and mucinous type) and metastatic carcinomas of gastrointestinal primaries were included in the study. the age of the patients, the histological type and grade of the tumours were evaluated in relation to the expression (percentage distribution and staining intensity) of muc and muc ac studied immunohistochemically. results muc was expressed in ( . %) primary ovarian tumours while muc ac was expressed in ( %) primary tumours in comparison to % expression of muc and . % expression of muc ac in metastatic ovarian tumours. the differences in muc expression between non-mucinous ( . ± . ) and metastatic tumours ( . ± . ) and metastatic and mucinous tumours ( . ± . ) were statistically significant (p< . ). the difference in muc ac expression was statistically significant (p< . ) between non-mucinous ( . ± . ) and mucinous tumours ( . ± . ). conclusion muc proves to be highly reliable in the differential diagnosis of primary and metastatic mucinous tumours of the ovary. deregulation of sfrp and sfrp rna-expression in endometrial stromal sarcoma introduction endometrial stromal sarcomas (ess) are very rare uterine tumours. whereas histology and immunohistochemistry of this tumour are well documented, little is known about molecular mechanisms involved. to characterize ess-altered genes, we generated a genome-wide library by ssh-hybridisation and used it to produce cdna arrays. particular emphasis was also placed on data obtained from qrt-pcr analyses. materials and methods using ssh-library a gene-bank with app. different clones was established. total rna was extracted from frozen tumour tissue and used for cdna hybridisation. qrt-pcr analyses were performed both on frozen and paraffin-embedded tissue samples. results after cdna-array analysis more than genes were selected, sequenced and rearranged to different functional groups. among the most strongly deregulated genes were secreted frizzledrelated protein- (sfrp ) and sfrp . these are putative genes that regulate wnt-signalling pathway and can influence different cell events including cell proliferation. compared to post-menopausal endometrium the expression of sfrp and sfrp was increased in low-grade ess, but decreased in aggressive ess form. these results were additionally verified on paraffin embedded tissue probes by qrt-pcr analysis. conclusion deregulation of sfrp and sfrp expression appears to be one of the crucial features of ess. whereas in low-grade ess these two genes are up-regulated, their down-regulation could be associated with high-grade form of ess. therefore a sfrp and sfrp may not only represent useful markers for early ess diagnosis but may also have prognostic impact and help to distinguish between low-and high-grade ess. (this work was supported by lore-saldow -research fund) introduction fgt-cs is a highly malignant neoplasm with poor response to current chemotherapy. the proto-oncogen c-kit encodes a transmembrane-tyrosine-kinase (t-k) receptor involved in cell diferentiation, that has been found to be expressed in certain solid tumors and may play a role in their tumorigenesis. a t-k inhibitor specific for c-kit (sti ) has been reported to have therapeutic effects in tumors expressing the aberrant forms or high quantities of target protein. contradictory results are reported in the literature about the expression of c-kit in cs. the aim of this study was to investigate the immunoreactivity for c-kit in cs. immunostaining with anti-c-kit (cd ) polyclonal antibody (dako) was evaluated in cs ( endometrial, ovarian, cervical and tubal). only cases with membrane staining were considered to be positive. results c-kit was expressed in cases: in cases only in the carcinomatous component ( endometrial, tubal), in case only in the sarcomatous component (endometrial) and in case in both components (ovarian). positivity was focal and less than % of cells in all cases. conclusion cs of the female genital tract rarely express c-kit. it is unlikely that patients with these tumors will benefit from treatment with the currently avalaible t-k inhibitors. uterine heterologous sarcoma with the component of osteosarcoma on the base of lipoleiomyoma -a case report uterine homologous and heterologous sarcomas are rare neoplasms that are usually misdiagnosed as a component of malignant mixed mullerian tumor (mmmt). we present a case of a -year-old woman who had a heterologous sarcoma with a component of osteosarcoma on the base of lipoleiomyoma, that can be differentiated from mmmt by the absence of epithelial component. in heterologous sarcomas, the other components of neoplasm are rhabdomyosarcoma, chondrosarcoma, osteosarcoma, liposarcoma and combined forms. these neoplasms are misdiagnosed as endometrial stromal sarcomas or as a component of mmmt. they are more agressive than mmmt. immunohistochemical detection of er-β in ovarian sex cord-stromal tumors introduction since the discovery of a second subtype of estrogen receptor, er-beta (er-β), in , approximately years after the cloning of er-α, several reports have been published regarding the tissue distribution of this receptor. in mammals so far studied er-β predominates in the ovary. high expression of er-β was observed by in situ hybridization or immunohistochemistry in granulosa cells of the ovarian follicles. the aim of the present study was to examine immunohistochemically the expression of er-β in ovarian sex cord-stromal tumors. materials and methods ten cases of ovarian granulosa-stromal cell tumors (five adult granulosa cell tumors, two juvenile granulosa cell tumors, and sclerosing stromal tumors) and two cases of sertoli-leydig cell tumor were immunostained for er-β (polyclonal erb , biogenex). representative sections from ten cases of ovarian carcinomas were immunostained for comparison. results positivity for er-β was observed in % to % of the nuclei in adult granulosa cell tumors and % to % of the nuclei in sclerosing stromal tumors. only - % of the nuclei from juvenile granulosa cell tumors were positive for er-β. in sertoli-leydig cell tumors positivity was more extensive in areas of diffuse growth. four cases of ovarian carcinomas exhibited positivity. conclusion positivity for er-β is a common finding in ovarian sex cord-stromal tumors. these findings might have therapeutic implications. adult fibrosarcoma of the vulva ol mejia mejia instituto nacional de cancerología, bucaramanga, colombia introduction sarcomas are rare and unusual lesions of the vulva. the aim of this study was to present a case with analysis of clinical, morphologic and immunohistochemical findings. materials and methods a -year-old female patient presented a rapidly growing of a mass in the pubis and left labium major of vulva of x x cm associated with a second satellite lesion ( months later) in the right inguinal area of x x cm. results histologic examination of both lesions disclosed a malignant neoplasm composed of uniform and orderly spindle cells with occasional epithelioid cells, oriented in curving or interlacing fascicles, forming a herringbone pattern with mitotic figures ( / hpf) and areas of necrosis and hemorrhage. the immunohistochemical profile showed strong reactivity for cd and vimentin, and focal and weak reactivity for smooth muscle actin. immunoexpression for s , nse, bcl- , hmb- , melana, ae ae and desmin was lacking. discussion and conclusions we present a case of a malignant mesenchymal tumor of vulva. due to histological features and behavior, pathologists must discard others spindle cell tumors, such as malignant melanoma, malignant peripheral nerve sheath tumor, monophasic synovial sarcoma or leiomyosarcoma. fibrosarcoma is a diagnosis of exclusion and a wide immunohistochemical panel is useful to make differential diagnosis. introduction serous tumors of borderline malignancy (stbm) of the fallopian tube are exceedingly rare. we report a case of stbm of fallopian tube in a -year woman. material and methods a -year old woman was found to have right adnexal mass on her routine gynaecologic examination. serum ca- was not elevated. at laparoscopy a swollen fallopian tube was removed. during the operation a fine needle aspiration was performed. the cytological findings of the adequate giemsa-stained smears were recorded. haematoxylin and eosinstained sections from the routinely fixed and paraffin embedded surgical material were histologically analysed. results a papillary tumor, with maximal diameter of cm in the dilated part of the fallopian tube toward the fimbrial end, was found. histologic features of the tumor were similar to the atypical proliferative serous tumor of the ovary. two years after the operation the patient is well, without evidence of the disease. conclusion to the best of our knowledge only four cases of stbm of fallopian tube have been reported. our case is unusual due to lack of any symptoms. recent studies have suggested that in the setting of an unknown primary, cdx- immunostaining may be used in identifying a metastatic carcinoma as colonic in origin. aim: we sought to evaluate the immunoreactivity of cdx in a series of primary and metastatic ovarian mucinous neoplasms. materials and methods cases of mucinous tumour of the ovary, including benign cystadenomas, borderline mucinous tumours and mucinous adenocarcinomas, were tested for cdx immunoreactivity. cases of serous and endometrioid lesions as well as cases of ovarian metastases from colonic adenocarcinoma were also evaluated. results cdx immunoreactivity was detected in / ( %) cases of primary ovarian mucinous tumour. particularly, / ( , %) cases of cystadenomas, / ( , %) cases of borderline tumours and / ( , %) cases of adenocarcinomas were immunostained. immunoreactivity was usually related to an intestinal morphology. no immunoreactivity was observed in serous or endometrioid lesions whereas all five cases of ovarian metastases from colonic adenocarcinoma were immunoreactive for cdx . conclusions cdx immunoreactivity may be detected in the majority of benign, borderline and malignant ovarian mucinous tumour whereas serous and endometrioid lesions are unstained for this marker. cdx immunoreactivity is not useful in distinguishing between primary and metastatic ovarian mucinous carcinomas whereas it may be useful in the distinction between endocervical and intestinal type of mucinous tumour of the ovary, which may have clinical relevance. an ovarian primary should be added to the list of cdx positive metastatic carcinoma in the setting of an unknown primary. expression of p ink a in serous lesions of the female genital tract c heffron introduction a spectrum of serous lesions including benign, borderline and malignant tumours and endosalpingiosis commonly arise in tissues of the female genital tract. p ink a is a tumour suppressor protein which functions as a cyclin dependent kinase inhibitor and plays a vital role in the cell cycle control at the g /s phase transition. although well recognized as a discriminator of benign and potentially malignant squamous and glandular cervical lesions, the expression of p in ovarian lesions and their mimics is less well established. the aim of this study was to evaluate p ink a expression in serous lesions of the female genital tract and to investigate its potential diagnostic utility. methods immunohistochemical analysis of p ink a (mouse monoclonal anti-p antibody) was performed on cases of serous epithelial lesions of the female genital tract (n= ) comprising endosalpingiosis, borderline serous cystadenomas of ovary and peritoneum, benign serous cystadenoma of ovary, serous adenocarcinoma of ovary and peritoneum and normal fallopian tube epithelium. results all cases of endosalpingiosis were positive (definite cytoplasmic staining with occasional nuclear positivity) for p ink a expression, as were all normal fallopian tube epithelium samples. varying degrees of p ink a expression were found in the serous neoplasms examined, with no clear pattern associated with any histological subtype. conclusion diagnostic difficulties may arise in the distinction between benign serous glandular lesions and more sinister potentially malignant serous neoplasms. in this study the pattern and degree of expression of p , although showing some differences, does not allow definitive classification of these lesions. epithelioid trophoblastic tumor [ett] is an unfrequent gestational trophoblastic disease [gtd], whose epithelial-like cells derive from chorionic-type intermediate trophoblast. ett mostly shows a benign behaviour, but metastases have also been reported, and pathologic prognosticators are not as yet recognized. the kinase-inhibitor p kip has been seen to be lacking in malignant gtds, while different growth factors, such as the c-kit receptor, have been related to growing trophoblasts of p -null embryos. since c-kit is said to promote trophoblast growth and invasiveness, this study was aimed at immunolocalizing p and c-kit in ett, as compared to a proliferation antigen. materials and methods -after a preterm birth of a living infant, a -year-old woman underwent hysterectomy for a postpartum metratonia. the patient had an antecedent miscarriage. a cervical ett was found, and immunohistology was performed on paraffin sections, using c-kit, p , and ki antibodies, following a microwave antigen-unmasking. positive reactions were recorded either as a focal or diffuse immunostaining. an escavated, hemorrhagic, endocervical lesion was found, which focally infiltrated the myometrium. light microscopy showed poorly limited nodules of epithelial-like cells, arranged in cords and nests, with interposed hyaline material, extensive hemorrhages, and necrotic areas. atypical mononucleate and syncytiotrophoblastic cells occasionally occurred. immunohistology revealed a diffuse presence of c-kit-expressing tumor cells. the p nuclear staining was focally observed to be negative or weak, and ki was totally unlabeled. in conclusion, this slowly-growing ett is lacking in p , but the c-kit over-expression substantiates trophoblastic survival and invasiveness. carcinosarcomas of the corpus uteri r balan, c amalinei, c cotutiu histology department, university of medicine and pharmacy, iasi, romania the aim of our study was to analyze the clinical and morphological characteristics of carcinosarcomas of the corpus uteri. carcinosarcomas of the corpus uteri were studied in postmenopausal women. paraffin-embedded material was stained with hematoxylin and eosin, trichromic, reticulin and pas staining. antibodies against ema, cytokeratins, vimentin, desmin, and pcna were also used. the size of tumor, depth of myometrial invasion, presence of vascular invasion, necroses, cellular atypia and differentiation, and mitotic activity were analyzed. all tumors were characterized by large size, foci of hemorrhage and necrosis. morphological and immunohistochemical analysis proved biphasic structure of the tumors. epithelial component was represented by adenocarcinomas with high ( cases) and moderate ( case) degree of differentiation. all presented homologous pattern -leiomyosarcomas. no metastasis was encountered at the time of diagnosis. as ema was intensely positive, both in malignant epithelium and in the majority of stromal component, we conclude that carcinosarcomas of the corpus uteri represent combination tumors with both elements originating from a single common stem cell. this conclusion was emphasized by the presence of pas positive residues in both components. knowledge evaluation among albanian women on risk factors of cervix cancer k kule , n filipi institute of public health, unit of cancer, department of epidemiology, tirana, albania university hospital 'mother tereza', tirana, albania aim this study evaluates the rate of awareness of women on risk factors and the preventive ways for the cervix cancer. methods the data were obtained through the questionnaire in a sample of women aged - years randomly selected throughout albania (random cluster sample). the questionnaire included questions on: social-demography, sexual behavior, women health, and sources of the health information. results only % of interviewed women were informed on paptest. in % of cases it was the doctor notified the women of the cluster for this screening as an examination of cervix cancer prevention. the pap-test examination had been performed by only % of the women who had prior knowledge on pap-test. in about % of cases the examination was performed for diagnostic reasons and not for prophylactic control reasons. in proportion to total only . % had performed the test, which presents a very problematic situation. among the women who performed pap-test, % were aware of the need of periodical check-up every - year, but % of them never performed it. the reason for not doing periodical screening seemed to be the daily routine and fear of the unknown events. % of women who performed pap-test were from the cities. only % of women use contraceptive methods of the family planning. about % of women had undergone at least one abortion. conclusions the study supports the concept that information on health services as well as health education of women at risk plays an important role in early detection and prevention of cervix cancer. expression of checkpoint proteins p , hus- and rad- and its relation with apoptosis in ovarian epithelial tumours introduction eukaryotic cells show surveillance mechanisms (checkpoints) of genomic integrity. an impaired checkpoint has been linked to genomic instability, and, in higher eukaryots has been associated to risk of cancer. the genes to be studied are involved in the mitotic checkpoint and dna damage checkpoint (like p , the tumour supressor gene frecuently mutated in human cancers). these proteins are also involved in the checkpoint responding to incomplete dna replication (replication checkpoint) termed the rad/hus group of proteins. failure of this checkpoint progress can result in genomic instability, and, in higher eukaryotes may lead to tumorigenesis or certain degenerative disease states. material and methods we have obtained antisera against recombinant hhus and hrad . for this we will clone and overexpress in bacteria and immunize animals to obtain antisera. we will carry out extensive analysis of the expression levels of several proteins by western blot analysis. we looked for possibles associations among hus- and rad- immunohistochemical expression and prognosis in ovarian carcinomas prior to chemotherapy. we studied, in addition to the levels of expression of the mentioned proteins, the localization and modifications of these proteins in epithelial ovarian tumours (benign, borderline and carcinomas) in order to establish the probable relationship between these proteins and ovarian carcinogenesis. results increased levels of checkpoint hus- protein was related to malignant transformation across all types of ovarian carcinomas (p< , ). similar results were observed with the expression of rad- protein, however was not statistically significant (p> , ). in univariate survival analysis, the expression of hus- and rad- protein were not significantly correlated with shorter survival and shorter free period of illness (p> , ). there were positive correlation between the apoptotic index, p and bax and the expression of checkpoint protein hus- (p< , ), but none relation was detected with rad- expression (p> , ). conclusions -the expression of hus- is higher in ovarian carcinomas and low in benign and borderline tumours. -the expression of hus- shows a positive correlation with the apoptotic index and with the pro-apoptotic factors (p and bax). -there was not statistical significant differences in the expression of hus- and rad- among the different histological types of ovarian tumours. -there was a positive correlation between the expression of hus- protein with other prognostic factors such as the figo stages, and the histological grade. unilateral gonadoblastoma associated with , xy pure gonadal dysgenesis (swyer's syndrome): a case report with numerous microcalcifications. the patient underwent bilateral salpingoophorectomy and total hysterectomy. the authors underline the importance of the correct diagnosis and the need of bilateral salpingoophorectomy for preventing the possible progression of the gonadoblastoma into malignant germinal cell tumor. histological and electron microscopic identification and analysis of uncommon particles in tissue after use of orthopaedic implants introduction deposits of solid products occur widely in tissue either from endogenous sources due to pathological changes, or from exogenous sources. after use of orthopaedic implants, particles produced by wear are commonly recognizable and identifiable in tissue by the surgical pathologist. foreign body related tissue re actions may contribute to aseptic loosening of implants, which is regarded as one of the most significant complications in orthopaedic surgery. in the present study we report on very uncommon particles in periprosthetic tissue after aseptic loosening of metallic implants. our study was performed to identify particles in periprosthetic tissue and to clarify whether they may contribute to the loss of implants. materials and methods periprosthetic tissue including joint capsule, acetabular and femoral interface membranes of cases of aseptic loosened cementless total hip replacements was histologically investigated. four cases with present uncommon particles were selected for electron microscope investigation and dispersive x-ray analysis. results in four cases the histological investigation revealed uncommon green to yellow coloured foreign bodies. by the use of electron scanning microscopy and energy dispersive x-ray analysis, these particles were identified as deposits rich in chromium, phosphorus and oxygen. this detection indicates the presence of solid corrosion products derived from implant surfaces. conclusion particles produced by wear and/or corrosion are associated with an alteration of the environment and the development of periprosthetic osteolysis which may result into the loss of the implant. the surgical pathologist should be aware that corrosion products may occur. their identification is helpful to determine implant failures. paratesticular lipoleiomyosarcoma: a case report l kachko, r shaco-levy, i sinelnikov, j goldstein department of diagnostic pathology, soroka medical center, beer-sheva, israel introduction leiomyomatous differentiation in liposarcoma is a rare phenomenon and may occur as a well differentiated liposar-coma with an intrinsic malignant smooth muscle component, so called " lipoleiomyosarcoma" or in the context of "dedifferentiated" liposarcoma. material and methods we have studied a paratesticular lipoleiomyosarcoma in a man years old. gross examination revealed tumor nodules dispersed between identifiable testis and epididymis, the largest of which measured x x cm. the specimen cut surface revealed smooth yellow tissue with distinct areas of gray myxomatous change. microscopically the specimen consisted of a well differentiated lipoma-like, sclerosing liposarcoma with mature adipocytes and fibrous septa containing spindled and floret-like cells. the smooth muscle accounted for about % of the total tumor mass and consisted of fascicles and bundles of spindle cells with very little atypia or pleomorphism. mitotic activity was moderate at most and focal in distribution. the cells colored well with immunohistochemical stain against sma. results and conclusions an extraordinary rare combination-type tumor is presented. only two previous examples of paratesticular lipoleiomyosarcoma have been published. the nature of combination-type tumors and dedifferentiated liposarcoma is addressed. the existence of two lines of tissue differentiation in the same tumor suggests the possibility of two separate tumors arising together or two lines of differentiation appearing from one pluripotent precursor cell. the differential diagnosis includes angiomyolipoma, which should be hmb positive. expression of estrogen receptor (er) and progesterone receptors (pr) in renal angiomyolipoma n savelov, g chemeris, i sokolova cancer research center, moscow, russian federation introduction angoimyolipomas are the most common mesenchymal tumours of kidney. they are more common in female. possibly estrogen and progesterone influence on tumours growth. we investigated the expression of estrogen receptors (er) and progesterone receptors (pr) in renal angiomyolipomas. materials and methods renal angiomyolipomas from patients were tested. the expression of er and pr was studied immunohistochemically. the expression of hmb- , alpha-smoothmuscle actin and vimentin was also studied in all cases. results most angiomyolipomas were of classic morphology with one exception. in that case, classical angiomyolipoma was combined with cystic hamartomatous lesions and involvement of regional lymph nodes. the vast majority of cells in the cases with typical morphology expressed alpha-smooth-muscle actin. expression of hmb- was diffuse or focal. in the case with cystic hamartomatous lesions, an inverse correlation of expression of hmb- and alpha-smooth-muscle actin was observed in both renal and extrarenal components. of the tumours, two tumours were only er positive and three tumours were er and pr positive. in four cases, focal immunoreactivity for er was mainly observed in the spindle shaped cells. in two cases, the immunoreactivity for pr was diffuse, but less than percent of cells were positive. er and pr positivity was diffuse, strong and widespread only in the case with cystic hamartomatous lesions. conclusion to our knowledge, estrogen and progesterone are not critical players in all angiomyolipoma growth, but only in the specific cases. myofibroblastic tumors are sometimes difficult to be distinguished from smooth muscle tumors. recently, cd , a cell surface metalloprotease, was shown to be present in myofibroblasts within the stroma of infiltrating cancers. to clarify the specificity of cd expression in myofibroblasts, we performed immunohistochemical studies on myofibroblastic and smooth muscle tumors. methods and materials consisted of myofibroblastic and smooth muscle lesions, ranging from reactive to benign and malignant tumors. all myofibroblastic lesions arose in soft tissue and smooth muscle tumors in soft tissue and organs. using paraffin sections, immunohistochemical staining for cd (clone: c , serotec) was carried out by an automated stainer (benchmark, ventana). results significant cd -expression was demonstrated only in malignant or borderline lesions, including malignant fibrous histiocytoma ( of cases), low grade myofibroblastic sarcoma ( of ), inflammatory myofibroblastic tumor ( of ), and leiomyosarcoma ( of ). however, no positive reaction was seen in reactive lesions and benign tumors, such as scar ( case), nodular fasciitis ( ), su-perficial fibromatosis ( ), desmoid ( ), leiomyoma ( ), vascular leiomyoma ( ), angiomyolipoma ( ), and glomus tumor ( ) . furthermore, the intensity of staining was almost parallel to the microscopic anaplasia. conclusion the present study demonstrated that cd expression is not specific to myofibroblasts, but seems to be related to the biologic aggressiveness of myofibroblastic and smooth muscle tumors. therefore, cd expression may be a potential predictor of malignancy in these tumors. correlation of metallothionein (mt) and antigen ki- expressions with grade of malignancy (g) in some soft tissue sarcomas dysplasia may be found in the bones during the childhood and adolescence. they can cause pathologic fractures and deformities of involved bone. rarely, some of them (fibrous dysplasia), undergo malignant transformation. the aim of this study is to analyse all the cases of tumor-like lesions of bones in children and adolescents, during the period time - . the study was performed at the institute for pathologic anatomy, school of medicine belgrade. the data source was the bone and joint tumor registry. the study was a retrospective analysis of patients who had tumor-like lesion before the age of . results solitary bone cyst was the most common lesion ( patients). the median age was years for fibrous dysplasia and solitary bone cyst, years for aneurysmal bone cyst and eosinophilic granuloma, and years for non-ossifying fibroma. male to female ratio was : . for fibrous dysplasia, : . for aneurysmal bone cyst, . : for solitary bone cyst, . : for eosinophilic granuloma and : for non-ossifying fibroma. the most common sites were femur for fibrous dysplasia and aneurysmal bone cyst, humerus for solitary bone cyst, tibia for non-ossifying fibroma and bones of scull and vertebrae for eosinophilic granuloma. the most frequent symptoms and signs were pain, pathologic fractures and swellings. conclusion the results of our study mostly correspond to those of the current literature. extraspinal myxopapillary ependymoma. case report and literature review introduction ependymomas are glial tumors that on rare occasions occur in subcutaneous locations dorsal to the sacrum and coccyx. case report a -year-old woman presented with a soft tissues tumor in the intergluteal region. mri revealed a cm large mass, with solid and cystic areas, located below the coccyx, without bone alteration. surgical excision was performed. pathological features grossly, the tumor was encapsulated and showed solid, spongy and myxoid areas with a peripheral hemorrhagic focus. histologically it consisted of medium-sized cuboidalcolumnar cells, with round-oval nuclei, granular cromatin and eosinophilic cytoplasm. tumor cells showed myxopapillary and cystic-papillary growth pattern or were arranged on fibrovascular stalks, with a central hyalinized wall vessel, surrounded by a single layer of cuboidal cells. tumoral necrosis and hemorrhage were observed. the peritumoral stroma was highly hyalinized. the immunohistochemical stains showed vimentin(+), s- (+), gfap(+) and keratins(-). discussion and conclusion extraspinal ependymoma (ee) is a rare tumor usually localized subcutaneously in sacrococcygeal region of young adults; most are of myxopapillary type. ee may arise from normal remnants of the neural tube or from abnormal remnants resulting from embryologic malformations. ee has a greater propensity to metastasize than its intraspinal counterpart, because of easier accessibility to lymph channels. in a study of cases, elson found a metastases incidence of % and no clinical or histologic data was found to predict the biological behavior of the tumor. the differential diagnosis must be done with choroid plexus papilloma, myxoid chondrosarcoma, chordoma, meningioma, adenoid cystic carcinoma and paraganglioma. introduction fungal infections of bone represent about , - , % of all osteomyelitis cases. the disease most often affecting the feet -mycetoma pedis, is also known as madura foot. in our geographic regions mycetoma is extremely rare. it is endemic in tropical and subtropical countries. case report we present a case of mycetoma pedis -madura foot. the patient was a years old woman. the clinical signs were pain, indurations and local redness with a long history of years. the surgical material was routinely stained with hematoxylin-eosin (he). pathologically, a granulomatous inflammation of the bone was confirmed. all pathological characteristic pointed to fungal infection in the form of mycetona pedis. special stains (pas, grocott's hexamine-silver and giemsa) for fungi were performed: and the diagnosis of a mycetoma was confirmed. for the definitive microbiological analysis tissue inoculation on the sabouraud dextrose agar laboratory media was done. pseudoallesheria boydiia sexual staging of monosporium apiospermum was isolated. after microbiological verification of fungal infection the patient was treated surgically. seven months after first operation the patient developed similar clinical signs again. the diagnostic procedure was repeated and mycetoma was confirmed again. the surgical therapy was performed as a therapy of choice because pseudoallesheria boydii does not react to treatment with antimycotic drugs. spindle cell lipoma is a rare entity with an uncertain histogenesis; although the current classification includes this tumor in the lipomatous neoplasms, the immunohistochemical and electron microscopic data suggest a much closer link to the fibrous solitary tumor. we report the case of a years woman with a / / / cm nodule in the scapular area; the histopathologic examination revealed a tumor proliferation consisting mainly of giant cells, most of them multinucleated with floret-like appearance. the stroma consisted of an abundant collagen deposition with rope-like fascicles and prominent myxoid changes, most striking in the periphery of the tumor. the tumor proliferation was contiguous with nearby adipose tissue with no capsule in-between. immuno-histochemical tests revealed diffuse positivity for cd ; pcna was positive in % of the cells. smooth muscle actin, desmin and s -protein were negative in tumor cells. the patient is well with no recurrence of the tumor one year after the resection. despite the highly pleomorphic histopathologic appearance the tumor is benign with an uneventful clinical behaviuor. expression of p protein in gct of bone with lung metastases introduction the giant cell tumor of bone (gct) is a local osteolytic tumor with variable degrees of aggressiveness. in rare cases pulmonary metastases can be observed. the stromal cells are the neoplastic components of the gct, and are probably responsible for biological behavior of the tumor. in the last years cases of gct with lung metastases were diagnosed at the institute of pathology, school of medicine, belgrade. both tumors displayed characteristic histological appearance of gct: a high number of osteoclast-like multinucleated giant cells and two mononuclear cell types. the first one resembles a monocyte, the second are fibroblast-like stromal cell. mononuclear cells had benign cytological characteristics without polymorphism and mitosis. to elucidate the mechanism of metastasing, we searched for the molecular abnormalities of p . we examined the expression of p in stromal cells immunohistochemically. unexpectedly, both tumors were p negative and we could not show correlation between p expression and metastasing of gct to the lung. conclusion although p positivity in other tumors is closely associated with aggressive biological behavior we could not confirm this association for gct. trichoblastic fibroma or primary soft tissue adamantinoma? introduction benign extragnathic tumors that may mimic the histological features of odontogenic ameloblastoma (and ameloblastic fibroma) include trichoblastic fibroma and primary osseous and soft tissue adamantinoma. trichoblastic fibroma is a rare ectomesenchymal tumor of hair germ involving most often the dermis and subcutis of the head and neck. the mean age at presentation is , years.the youngest case reported was that of a shoulder tumor in a year old female. its occurrence in the soft tissue of the upper arm has not been documented. primary soft tissue adamantinomas are extremely rare with isolated cases reported in the region of the jaw and the leg ie. close to sites where odontogenic and primary osseous adamantinomas occur, respectively. no cases involving the upper arm have been reported. we report a case of a benign appearing adamantinoid tumor involving the deep soft tissue of the upper arm. a year old black male presented with a slow growing mass involving the deep soft tissue of the left upper arm without associated cutaneous or osseous abnormalities. results the adamantinoid features in this benign appearing biphasic tumor included nests and acini of palisading columnar epithelium exhibiting reversed nuclear polarity, areas reminiscent of stellate reticulum and an intimately associated spindle cell proliferation. conclusion our favored diagnosis was a trichoblastic fibroma but we discuss the complete differential diagnosis of all tumors with adamantinoid features with respect to clinical, morphological and immunohistochemical characteristics. intraosseous lipoma -a case report intraosseous lipoma is a rare benign tumor of mature adipocytes arising in the medullary canal, most often diagnosed incidentally. most of these tumors occur in the long bones, with propensity for the proximal femur, fibula, and tibia. ribs, calvarium, sacrum, metatarsus and calcaneus are other frequent sites. we report a case of a -yearold female with a histologically verified solitary intraosseous lipoma involving the distal part of the right fibula. radiographically the tumor was a lytic benign-appearing lesion with sharply demarcated borders surrounded by a zone of sclerosis. computed tomographic scan showed the lesion to have features of adipose tissue. the examination was made on surgically removed distal part of the right fibula. for histological verification of intraosseous lipoma, resected bone was decalcified, embedded in paraffin and stained with standard staining with hematoxilin-eosin. histopathologic examination revealed mature adipose tissue with widely scattered trabeculae of bone and central calcifications. this case emphasizes the characteristics of intraosseous lipoma, and highlights the need for clinicopathologic and roentgenographic correlations. fasl, c-erbb , cyclin d , p and tgfb expression in osteosarcomas: evaluation of relationship with clinicopathologic parameters introduction fasl, c-erbb , cyclin d , p and tgfb are molecules which were shown to be related to prognosis of tumors. in this study expression of these molecules were evaluated in osteosarcoma (os) cases. the correlation between the expressions and age, gender of the patients, location, grade, and histologic subtype of tumors were investigated. material and method fasl, c-erbb , cyclin d , p and tgfb expressions were detected immunohistochemically. results thirty-six os cases ( osteoblastic, fibroblastic, five chondroblastic) were included in the study. twenty-two were males and were females. os were located in the extremities ( ), jaw ( ), pelvis ( ), vertebra ( ). twenty-five of were high grade and were low grade tumors. fasl and p were detected in . % of the cases, tgfb in . %, c-erbb in . %, and cyclin d in . %. there were statistically significant correlations between fasl and tumor grade (p: . ), fasl and tgfb (p= . ), fasl and c-erbb (p= . ), p and tgfb (p= . ). no correlation was found among other parameters. conclusion expression of these molecules and detection of correlation between some molecules show that pathogenesis of os is a complex mechanism regulated by several molecular factors. better insight into tumorigenesis may help to provide new therapeutic approaches and idntification of patients with better prognosis. a rotter , s kovac , v pisot , r trebse institute of pathology, medical faculty, university of ljubljana, ljubljana, slovenia valdoltra orthopedic hospital, ankaran, slovenia introduction granulation tissue with macrophages is usually found around loose total hip prosthesis (thp), usually explained with deposition of wear debris from thp. however, we often found a lot of hemosiderin (an insoluble form of storage iron) in macrophages. the aim of this study was to evaluate the amount of hemosiderin in granulation tissue around thp removed after relatively short period of duration, and compare it with an interface tissue around thp of very long duration. we assessed the interface tissue around the loosened thp of the longest duration described ever (judet's thp was removed after years) and compared it with the granulation tissue around thp of short duration (less than six years). at histology h&e, giemsa, and weigert-van gieson staining were used. for the demonstration of hemosiderin perls' reaction and for macrophages cd were used. we compared the results of histologic evaluations performed according to modified mirra's classification: semi quantitative assessment of neutrophils, mononuclear histiocytes, chronic inflammatory cells, giant-cells, metal particles, polymethacrylate globules, necrobiosis, bone chips, necrosis and necrotic debris. but, we also included the assessment of the intensity of hemosiderin deposition. results comparison of granulation tissues of short duration thp to that of -year duration revealed a surprising difference in the amount of hemosiderin particles with intensive intracellular hemosiderin deposition in mononuclear macrophages and giant cells in the first group. in the -year-old thp there was predominantly hypocellular tissue with very little amount of mononuclear macrophages containing slight amount of intracellular hemosiderin deposition and no multinucleated giant cells at all. conclusions we don't know why hemosiderin deposition is more evident in early loosening of thp. hemosiderin deposition may give rise to accumulation of macrophages, perhaps increasing the process of osteolysis and granulation tissue formation. but more 'aggressive' forms of loosening may also cause recurrent bleeding. whether the higher level of hemosiderin is the cause or the result of the loosening of thp is to be determined. the types of tumor and peritumor stroma and biological behavior of fibrohistiocytic tumors introduction tumor-host interaction induces different types of tumor and peritumor stroma which may reveal some aspects of tumor biology. the aim of this study was to establish a correlation between different types of tumor and peritumor stroma of fibrohistiocytic tumors (fh tumors) and their biological behavior. the presence of colagenous-reticular (cr), myxoid (myx) and mixed (mx) tumor and peritumor stroma was determineted on selected paraffin sections stained by masson-trichrome, silver impregnation, alcian blue with and without hialuronidase pretretment and pas reaction of fh tumors: benign (bfh), dermatofibrosarcoma protuberans (dfsp) and malignant (mfh), all graded in three degrees of malignancy. the collected data were statistically evaluated by means of student t proportion test. results the difference in presence of myx and mx tumor and peritumor stroma in relation to the cr type was statistically significant between mfh and bfh (p< , ) or dfsp (p< , ). with an increasing malignancy grade of mfh percentage of tumors with cr tumor stroma was decreasing and percentage of tumors with myx and mx tumor stroma was increasing. however, mfh of g and g malignancy grade did not differ in distribution of peritumor stroma types, but , % of mfhg had myx and mx peritumor stroma. conclusion while myx and mx types of tumor and peritumor stroma are associated with agressive, cr type of tumor and peritumor stroma is associated with benign and less agressive fh tumors. dynamic angiogenic models of human soft tissue tumors transplanted into immunodeficient nude mice introduction animal models were used to study the vascular neogenesis of tumors. we undertook experiments using human sarcomas transplanted into the subcutaneous pad of immunodeficient nude mice. the aim of this study was analysis of: the microvasculature present within the tumor before the transplant; the early stages of the neovascularization; and the types of vascular connections established between the host and the tumor graft. material and methods implants of . - . cm in size of a ewing's sarcoma (es), an osteosarcoma (os) and a fibrosarcoma (fs) were analyzed. the study was successively followed for , , hours, one, two, three and four weeks. he, pas and immunohistochemistry for angiogenic factors were complemented with electron microscopy. after - hours, the implants over-expressed several angiogenic factors. at this stage, the tumors initiated an active angiogenic remodeling in the surrounding stroma where capillary congestion and microhemorragies occurred. endothelial sprouting of the host capillaries was seen. vascular co-option between the endothelial cells, newly formed endothelial cells and the tumor cells was observed. no clear basal lamina was seen. tumor-endothelial cell mosaics and vascular mimicry were detected only in the es and os. conclusions vascular expression and neogenesis varies considerably from the fast es to the fs while the os reproduces patterns that are common in all three. based upon present experience it seems evident that each tumor shows a different type of neovascularization. these models provide excellent examples of all the systems that are involved in the recapillarization of a sarcoma. this work has been supported by grants fis / and fis / from the ministry of health, madrid, spain. prognostic significance of intratumoral neoangiogenesis in childhood osteosarcoma and ewing sarcoma d mikulic , i ilic , m coric , l batelja , j stepan , s seiwerth institute of pathology medical faculty, zagreb, croatia childrens hospital, zagreb, croatia introduction intratumoral neoangiogenesis quantified by microvessel density (mvd) has been shown to be a strong prognostic indicator in a number of malignant tumors, primarily carcinomas. its association with prognosis in bone sarcomas has been subject to less extensive research. the aim of our study was to investigate clinical significance of neoangiogenesis in osteosarcoma and ewing sarcoma. patients and methods a retrospective immunohistochemical study was performed. patients with osteosarcoma and patients with ewing sarcoma were included. sections from diagnostic biopsies were immunostained using factor viii and cd (dako) antibody and microvessels were counted at x magnification on three microscopic fields showing highest mvd per patient. mvd was correlated with overall and event-free survival by kaplan-meier and log-rank analysis. the difference between the mean microvessel counts in patients with or without metastasis and alive or dead was assessed by mann-whitney test. results in patients with osteosarcoma significant statistical difference was found as regards the death risk and risk of development of metastasis between patients with high (> vessels/field) and low (< vessels/field) microvessel counts (log-rank test p= . and p= . , respectively). in patients with ewing sarcoma a trend was noted for the patients with lower (< . vessels/field) microvessel counts to have better outcomes than patients with higher vessel counts, however, the difference was not statistically significant. conclusion these findings strongly suggest that neoangiogenesis quantified by microvessel density is predictive of metastasis and poor prognosis in osteosarcoma. valorization of its role in patients with ewing sarcoma awaits further studies. epithelioid sarcoma -clinicopathological findings in cases m demiryont epithelioid sarcoma is a soft tissue sarcoma of unknown histogenesis with a predilection of young adults and hand/forearm location.the tumor is often multinodular showing central necrosis. epithelioid sarcoma has a high potential of local recurrence and metastasis. six cases were presented. five patients were male with a mean age of . tumor locations were finger, hand and forearm. cytokeratin and vimentin were positive in all cases. four cases showed positivity for cd . desmin and cd were negative. ki- (mib- )proliferation index was - % in cases. initial surgery performed in all of the patients has been local excision with negative margins.three patients received radiotherapy or chemotherapy after the primary excision.except for one patient who was lost to follow-up, local recurrence was detected in all the patients in a period of months to years.three patients died with distant metastasis. epithelioid sarcoma can be easily identified with its typical features, but it can be confused with non-tumor lesions in patients having a long clinical history and a small tumor. radical surgery and regional lymph node dissection may bring benefit; the incidence of the lymph node metastasis is high. radiotherapy and chemotherapy can be added to therapy in the recurrent or metastatic state of the disease. introduction intramuscular hemangiomas are relatively uncommon but significant lesions, and their unorthodox location and infiltrative pattern often raise the question of malignancy to clinician and pathologist. we present the histomorphological and immunohistochemical data of a hemangioma in a -year-old man who presented with an enlarging painful soft tissue mass of his right upper leg. methods the complete local excision of tumor arising in the quadriceps muscle was done. sections of formalin-fixed, paraffinembedded tissue material were stained with he, van gieson, pas, ptah, gomori's reticulin and trichrome, and immunohistochemically for detection of factor viii-related antigen. results grossly, the lesion ( x , cm) was poorly circumscribed, reddish brown and partially haemorrhagic. microscopically, it was composed both of small, capillary-sized and large, cavernous vessels lined by endothelial cells and surrounded by connective and mature adipose tissue. the adipocytic component wasn't prominent. many cavernous spaces were separated by dense fibrous tissue and some of them were thrombosed. foci of hemosiderin deposits and moderate lymphocytic infiltration were also noted. the small vessels in some areas hadn't discernible lumina so that areas appeared solid. mitotic figures and intraluminal papillary tufting were not seen, but infiltration of skeletal muscle bundles and rarely perineural spaces were present. the muscle fibres showed atrophy, degenerative changes and signs of regeneration. the cells lining both cavernous and capillary-sized vessels showed expression of factor viii-related antigen. conclusions presented case of tumor arising in the quadriceps muscle show histomorphological and immunohistochemical features of mixed type hemangioma with pronounced infiltrative pattern. alveolar soft part sarcoma: a review of cases at national cancer institute from colombia ol mejia mejia instituto nacional de cancerología, colombia, bucaramanga, columbia aims to review the histology and immunohistochemistry of alveolar soft part sarcoma with comparison of clinical features. material and methods histology slides, paraffin blocks and files of patients were reviewed. results and discussion there were patients retrospectively analysed, female and male, between year and years old. the initial symptom was mass. the most frequent location was thigh ( %), followed by the leg, orbit, chest wall, trunk, arm and forearm. six patients had haematogenous metastases at the time of diagnosis (lung , brain , lung and bone ). histologically, all tumours were composed of nests of medium sized cells arranged in pseudo-alveolar or lobular patterns, separated by fibrovascular stroma. pas & pas diastase were positive in all cases, with rhomboid or rod-shaped crystals. immunohistochemical staining for myo d showed cytoplasmic positive in cases ( %), desmin in and smooth muscle actin in cases. conclusion alveolar soft part sarcoma is an uncommon neoplasm. the microscopic picture is a constant and typical feature of the lesion, and immunohistochemistry is a useful complementary method for diagnosis. a jiménez sánchez, em huertas valero, ja ramos Ńíguez, r baeza guixot, p sánchez cańizares hospital francesc de borja de gandia, gandia, spain introduction malignant epithelioid schwannoma is a rare variant of malignant nerve sheath tumor (mpnst) that often causes differential diagnostic problems with other neoplasm. material and methods a -year-old woman presented with a palpable tumor located in the supraclavicular region. the lesion was partially resected. grossly, the tumor was firm, gray to whitish and slighty nodular. standard histological procedure and inmunohistochemical study was performed. results microscopic examination revealed a solid proliferation of moderately large, rounded epithelioid cells, with pleomorphic nuclei, prominent nucleoli and atypical mitoses. in peripheral areas the tumor showed smaller cells with nuclei arranged in palisades and central necrosis. immunohistochemical studies showed vimentine, s- protein, and cytokeratine positivity and hmb- negativity. the histopathology and the immunohistochemical results were consistent with mpnst, but a ssx /syt gene fusion was detected by molecular analysis, a characteristic chromosomal change of synovial sarcoma (ss). conclusions spindle cell tumors with epithelioid areas can be difficult to diferentiate by histologic pattern alone. cytogenetic analysis and molecular studies may reveal the diagnosis by demonstrating a characteristic chromosomal abnormality or molecular rearrangement. ssx/syt gene fusion results from the t(x; )(p . ;q . ). the translocation fuses the syt gene from the chromosome long arm to either of highly homologous genes on the chromosome x short arm, ssx or ssx . the translocation t(x; ) is currently regarded as a specific molecular marker of ss. our case shows, that we might consider that ss may have a larger histologic spectrum than previously thought. a case of idiopathic retroperitoneal fibrosis (ormond's disease) and renal supracapsular liposarcoma t georgiev , e nakov , r gajdarski department of pathology, faculty of medicine, sofia, bulgaria department of pathology, military medical academy, sofia, bulgaria background idiopathic retroperitoneal fibrosis is an uncommon inflammatory disease characterized by proliferation and fibrosis of retroperitoneal tissue complicated by obstruction and encasement of retroperitoneal structures. case report we describe a -year-old female patient who underwent a gynecologic operation for left ovarian cyst in october . a periaortic mass alongside with peritoneal nodules were biopsied which revealed endometriosis, necrotic xantomatous nodules and ormond's disease. the last diagnosis was rejected and tumor misinterpreted as malignant fibrous histiocytoma. the course of the disease progressed and on computed tomography a left renal supracapsular tumor measuring / / cm together with a diffuse retroperitoneal fibrosis was demonstrated. in november , a tumor localized in the adipose capsule of the left kidney was removed together with the kidney weighing , kg. the kidney was markedly atrophic. a parallel excision of ten retroperitoneal tissue masses with a size up to / / cm was performed. our final histological diagnosis was highly differentiated liposarcoma. four months later the abdominal ct and the tumor markers were normal. conclusion the symptoms in our case were not specific for renoureteral obstruction and included abdominal pain and mass, weight loss and ascites during the year prior to second operation and finally urinary symptoms. we interpret our case as a slowly growing perirenal lipomatous tumor gradually compressing the kidney and causing slowly progressing retroperitoneal fibrosis. a rare case of thoracic angiomatosis in an adult and review of the literature n lapidus, d andrejev, a arro north-estonian regional hospital, tallinn, estonia introduction angiomatosis is a rare condition in which large segments of the body are involved by proliferating vessels. the majority of angiomatoses present during childhood or infancy. a diffuse angiomatosis affecting thoracic organs is a rare, frequently fatal disorder. the origin of the lesion is unknown. the lesion consists of thin-walled sometimes bloodless capillary blood vessels. the definite diagnosis is usually made by open lung biopsy or autopsy. in our paper we are presenting the rare case of angiomatosis of pleura and lung in -years old woman and the review of the literature. the patient was presented to the hospital with complaints to the pain in the right chest, dyspnea, weakness. the lesion manifested on chest radiographs and ct scans with unilateral pleural fluid and nodular pleural thickening. thoracocenthesis was performed and light brown fluid was drained. cytologically the effusion contained erythrocytes and lymphocytes. further ml more fluid was obtained. the openlung biopsy revealed the extensive diffuse angiomatosis affecting visceral and parietal pleura and subpleural lung tissue. the lesion consisted of bloodless, thin walled, endothelium channels. factor viii-related antigen and cd were the most reliable immunocytochemical markers in highlighting the endothelia. the palliative methods of treatment were not effective, and the patient was treated by total pleurectomy. conclusion diagnosis is based exclusively on histologic finding as the only possibility of diagnosis. open pleurectomy is the most succesful treatment in preventing reaccumulation of the effusion. background chronic inflammation with remodelling of the airway wall structures is an essential characteristic in asthma patients. lysosomal proteinases are involved in extracellular proteolysis, which leads to matrix changes of subepithelial connective tissue in the airway wall. the aim of the study was to localise the expression of different cysteine proteinases and their endogenous inhibitors in lung tissue of asthma patients. material and methods we included ten specimens of bronchial biopsies of asthma patients and lung tissue specimens of fatal asthma case. tissue specimens were fixed in formalin and embedded in paraffin. h&e slides were used for morphological examination. immunohistochemistry was performed on an automated stainer (benchmark, ventana, tuscon, az, usa). we used monoclonal antibodies to visualize cysteine proteinases (cathepsin b, h, l and s) and their inhibitors (stefin a and b, cystatin c) (krka, ljubljana, slovenia). results cathepsin b showed the most intense and wide distributed positive reaction. it was localized in the respiratory epithelium, macrophages, lymphocytes, mucous glands and smooth muscle cells. cathepsin h showed intense reaction localized in the respiratory epithelium, macrophages, lymphocytes, mucous glands, but not in the smooth muscle cells. cathepsins l and s showed positive reaction only in macrophages. the positive reaction of all three inhibitors was weaker compared to cysteine proteinases; it was observed in the respiratory epithelium, macrophages and mucous glands. conclusion these results suggest involvement of cysteine proteinases and their endogenous inhibitors in asthma, showing distinct immunoreactivity and different distributions in the lung tissue of asthma patients. since the inhibitor expression is less intense we can speculate that remodelling of the extracellular matrix may be also a consequence of imbalance between cysteine proteinases and their inhibitors. the correlation between aberrant connexin mrna expression induced by promoter methylation and nodal micrometastasis in non-small cell lung cancer jt introduction reduced connexin (cx) gene expression has been shown in most of lung tumors and lung cancer cell lines. although aberrant cx gene expression was linked with lung tumorigenesis, our understanding to the mechanism was still limited. we hypothesized that the evidence of aberrant cx gene expression was gradually intensified from adjacent normal lung tissues surrounding tumors towards to tumor tissues. materials and methods in this study, lung tumors and adjacent normal tissues were collected to examine cx mrna expression by reverse transcription-polymerase chain reaction (rt-pcr). results our data showed that cx mrna expression in adjacent normal lung tissue was significantly correlated with nodal involvement (p = . ), but the similar trend was not observed in tumor tissues. to verify whether lack of cx mrna expression was resulted from promoter methylation, pcr-based methylation assay was performed for cx promoter methylation analysis. high frequency of promoter methylation was observed in cx mrna negative patients ( of , . %) compared with cx mrna positive patients ( of , . %, p < . ). to elucidate whether aberrant cx gene expression is originated from adjacent normal lung tissues, lung tumors and each of five adjacent normal tissues with various distances from tumor tissues were collected to examine cx mrna and protein expression by rt-pcr and western blot, respectively. as the results shown, cx mrna and protein expressions were gradually decreased from adjacent normal lung tissues to tumor tissues with a positive correlation to the distance from tumor tissues. gel shift assay data also revealed that shifted band binding with ap was only observed in adjacent normal tissues which were far from the tumor tissues. conclusion these results indicate that promoter methylation may interfere with ap binding to promoter to cause aberrant cx gene expression. thus, cx mrna in adjacent normal tissue surrounding lung tumor simply detected by rt-pcr may be act as a molecular marker of nodal micrometastasis in nsclc. introduction an adenoma-carcinoma sequence is recognised in peripheral lung. atypical adenomatous hyperplasia (aah) and bronchioloalveolar carcinoma (bac) are the pre-invasive precursors of invasive adenocarcinoma, which frequently has a 'residual' peripheral bac component. the biology of this neoplastic progression is poorly understood. the aim of this study was to examine the expression of the tumour suppressor gene fhit, cd v , e-cadherin, beta-catenin, mmp- , timp- , and the cell cycle marker mcm at different stages in the proposed sequence. materials and methods sections from formalin-fixed, waxembedded tissue blocks of aah, bac and invasive adenocarcinomas, stained immunohistochemically for the above molecules, were scored semiquantitatively. in invasive tumours, any bac component was scored separately. for mcm a labelling index was determined as the ratio of immunopositive to total cells counted. results fhit protein is abundant until the disease becomes stromally invasive (p< . ). cd v levels are high in aah and bac, but fall in invasive disease (p= . ). e-cadherin and beta-catenin levels rise between aah and bac (p< . ), and remain well expressed thereafter. mmp- and timp- expression is relatively low in aah, rises in bac but falls when tumour becomes stromally invasive (p < . ). the bac component of invasive tumours expresses some molecules in a manner similar to pure bac but mirrors expression in invasive tumour for others. mcm counts increase from . %(low grade aah) to . % in invasive adenocarcinoma (p= . or less) conclusion in peripheral adenocarcinogenesis, loss of fhit is a relatively late event, while cd v loss occurs earlier. fhit loss has potential as a surrogate marker of invasion. e-cadherin and beta-catenin expression probably reflects changes in lesion architecture. mmp- /timp- may be implicated in bac but down-regulated as stromal invasion develops. increasing cell cycle entry is consistent with neoplastic progression. immunohistochemical study of squamous and adenosquamous cancer of lungs g methods using formalin-fixed and paraffin-embedded tissues, we examined by immunohistochemistry tenascine, collagen iv, cd , mmp , mmp , timp , timp , cd , bcl , p , pcna, ki , cyclin d in cases of lung carcinoma - squamous and adenosquamous with (first group) and without (second group) metastases. results the positive staining with tenascine was observed in all cases of squamous and adenosquamous carcinoma, but the most strong expression was found in extracellular matrix and tumor cells of carcinomas of first group. the overexpression of mmp and mmp was found in cases with metastases in tumor cells and stromal cells. the reaction was localised on periferical zone of tumor complexes. at the same time reaction with timp was low in tumor of second group and very low -in first group, reaction with timp was moderate in metastatic tumor and low -in second group. overexpression pcna and ki changed from % to % in group and from % to % in group. the increase expression of cyclin d was only in adenosquamous lung carcinoma. the overexpression of p was found only in metastatic tumors. conclusion there are some difference between squamous and adenosquamous lung carcinomas in expression of proliferation markers, and cyclin d , but no difference in expression of metalloproteinases and their inhibitors. we found more prominent differences in groups of metastatic and nonmetastatic tumors. lack of her- /neu amplification or overexpression in malignant pleural mesothelioma (mpm) introduction the her- /neu receptor, a member of the epidermal growth factor receptor (egfr) family, represents a novel therapeutic target for the newly marketed recombinant anti-her monoclonal antibody herceptin®. mpm mortality continues to rise steeply ( % to % per year) with no known curative modality. approximately % of mpms have high levels of expression of egfr. two recent studies have reported expression of her- /neu in mpm but there was no analysis of overexpression or amplification. in this study, the amplification/overexpression of her- /neu gene has been evaluated in a series of consecutive mpm biopsy specimens. materials and methods the tumour specimens had been formalin-fixed and paraffin-embedded. immunohistochemistry (ihc) for her- /neu overexpression was performed using the dako herceptest kit. only membrane staining intensity and pattern were evaluated using a to + scale with + being the lower limit for a positive test. amplification of the her- /neu gene was tested with the fluorescent in-situ hybridisation (fish) method (ventana inform her- /neu probe) in out of the cases. cases were considered as amplified by fish when the mean number of fluorescent signals per nucleus was greater than four. results of the mpms evaluated for the overexpression of the her- /neu receptor, all scored on the ihc test and all cases additionally assayed by fish were negative. conclusions although the sample size was limited, these findings suggest that mpm do not overexpress or amplify her- /neu, which therefore should not be considered a prognostic and predictive marker in mpm. (this work was funded by the alessandria branch of the italian league against cancer). morphological changes of bronchial glands at the localisation of preceding biopsy introduction at the location of preceding biopsy, in sero-mucous bronchial glands, there are certain changes of regenerative type. hyper-plastic and meta-plastic squamous epithelia partially or wholly fills the acinus and duct of secretory glands. aims: regenerative atypical characteristics found in repeated materials can be misinterpreted as epidermoid or muco-epidermoid carcinoma. material and methods the research used materials made by re-biopsy of bronchia, with regeneratory changes in bronchial glands. presence of morphological parameters was examined semiquantitatively, and then processed with methods of descriptive statistics. results in . % lobular architectonics of the lesion was preserved; fibrin exudates were present in . % cases; granulocytes in stroma were present in . % cases; granulation tissue in . % cases; planocellular metaplasia of duct and acinus was present in every single case. in . % cases mucin-secreting cells were found in squamous epithelia. the squamous cells were diskeratotic in % cases; with polymorph nuclei in . % cases; hyper-chromatic in %; multi-nuclear in . %; with visible nucleolus in . %, and with mitotic activity in . % cases. in . % cases the squamous cells were located in the fibrous tissue. mucus in interstitium was present in . % cases; cystoid formations were present in . % cases. the changes are built of solid material, undifferentiated and/or squamous cells located in the granular tissue or in the fibrin. infiltrates of granulocytes are found in fibrin, stroma, and squamous epithelia. epithelial cells in regeneration show atypical cell characteristics in small percentage and therefore are hard to differentiate from carcinoma. immunohistochemical expression of her- /neu in patients with lung carcinoma g petrusevska , b ilievska, s banev, s smickova institute of pathology, skopje, republic of macedonia the her- protein or p her is a membrane receptor with tyrosine kinase activity encoded by he /neu gene. overexpression of her- /neu has been observed in many human cancer, including lung cancer. there are different reports about the expression of this protein in different lung cancer. the aim of the study is to determine the expression of her- protein in the spectrum of lung cancer (adenocarcinoma, squamous cell carcinoma and small cell carcinoma). the study population consisted of two groups: patients that have undergone to surgical treatment and patients that have undergone to fiber-optic bronchoscopy and biopsy for primary diagnosis.tissue specimens were neutral formaline fixed and paraffin embedded. standard histochemical and immunohistochemical staining were used for diagnosis. expression of her- /neu protein was determined by immunohistochemical staining with hercep testtm (dako). the results were graded - as negative and - as positive. overall incidence of her- /neu overexpression was , % ( of ). higher incidence was found in patients with adenocarcinoma , % ( of ); squamous cell carcinoma , % ( of ) and small cell carcinoma % ( of ). no statistical significant difference was seen with age and gender. her- /neu overexpression was more relevant for patients with advanced tumor: all patients with squamous cell carcinoma were in stage b and , and % with adenocarcinoma were in stage a and b. these results are satisfactory and encourage us to continue this work in the follow-up study to evaluate her- /neu role as predictive and prognostic factor for patients with lung cancer. we applied immunohistochemistry on six neuroendocrine lung carcinomas using moabs specific for extracellular matrix proteins and integrins; moreover transwell test migration assays evaluated the rate of transendothelial migration of ae- neuroendocrine carcinoma cell line throught a monolayer of eahy endothelial cell line expressing laminin-α -chain to establish wheather this protein may favour in vivo vascular invasion and metastasis. results %, %, %, %, % and % of vessels were respectivelly distributed within the parenchyma of these tumors. studies on contignous sections demonstrated that parenchymal vessels were positive for all ecmps, but laminin-α -chain, which was respectively expressed in %, %, %, %, % and % of parenchymal and in %, %, %, %, % and % of stromal vessels of these tumors. in all cases about % of neoplastic cells were α positive. preliminary results of transwell test migration assay indicate that the pretreatment of the ae- cell suspension with anti laminin-α -chain and anti α -integrin moabs reduced their migration through the eahy monolayer. conclusions as known α -integrin is a receptor of laminin-α chain, therefore the up-regulation of this protein in a large number of vessels during tumor angiogenesis may favour metastasis increasing neoplastic cell adhesiveness to newly formed vessels. brain death as a cause of primary lung graft disfunction in an isolated rabbit lung model ma introduction early lung dysfunction observed after lung transplantation has been attributed to an increase of vascular permability. factors involved in this mechanism are unknown. our hypothesis was that brain death (bd) is a preconditioning factor that induces primary lung graft dysfunction. methods twenty-four rabbits were randomized to control (crl) or induced bd (increasing intracraneal pressure above systolic pressure for minutes) groups and were ventilated in volume controlled mode (tidal volume ml/kg, positive end expiratory pressure (peep) cmh o and respiratory rate (rr) to obtain normocapnia) for minutes. isolated lungs were perfused with ml/min (constant flow) and ventilated in pressure controlled mode (peack pressure cmh o, peep cmh o and rr ) for minutes. pulmonary edema and lung injury were assessed by weight gain, change in ultrafiltration coefficient before and after ventilation; and extent of hemorrhage (scored by histology: intensity of alveolar hemorrhage, percentage of alveoli with hemorrhage and number of vessels with perivascular hemorrhage) mean values ( samples per lung) of the indices of hemorrhage showed above were scored ( to ) and added to obtain a score of overall lung hemorrhage (range to ) for each lunch. data are expressed as mean and % confidence interval and were compared with paired t test. conclusions under these experimental conditions bd contributes to pulmonary edema and lung hemorrhage. expression of cyclooxygenase- in nonsmall cell lung carcinomas n akyürek introduction cyclooxygenase (cox) is an inducible enzyme that catalyses the conversion of arachidonic acid to prostaglandins and thromboxanes. cox- is induced by cytokines and growth factors and has been shown to be important in carcinogenesis. the aim of this study was to investigate the expression of cox- and clinicopathologic factors in nonsmall cell lung carcinomas (nsclc) with regard to survival times. materials and methods seventy-seven nsclc specimens were evaluated for cox- expression by immunohistochemical method. staining patterns were assessed semiquantitatively and correlated with tumor histologic type, tnm stage and prognosis. chi-square and kaplan-meier survival analysis was performed. results cox- was not expressed in the normal bronchial epithelium. cox- expression was detected in ( . %) nsclc. expression of cox- was significantly higher in adenocarcinomas than in other histologic subtypes (p= . ). there was no significant relationship found between cox- expression and age, gender, tnm stage, and prognosis. conclusion this study suggests that an increase in cox- expression may be associated with the development of adenocarcinomas. but, prognostic significance of cox- expression is controversial. prognostic significance of cyclin-dependent kinase inhibitor p and bcl- protein in nonsmall cell lung cancer introduction the expression of p , which is known a cyclindependent kinase inhibitor, has considerable value for the prognosis of cancer patients. bcl- gen product (bcl- protein) is implicated in oncogenesis by its ability to prolong cell death through the inhibition of apoptosis. we studied the expresssion of p and bcl- protein to investigate their association between clinicopathologic factors and prognosis in nonsmall cell lung cancer (nsclc) materials and methods patients with nsclc were included in our study.there were patients( men, women), patients had adenocarcinoma (ac) and had squamous cell carcinoma (scc).tumors were examined immunohistochemically with p and bcl- protein expression, using formalin-fixed, parafinembedded tissue. for the evaluation of p expression, the number of nuclear staining was counted and showed as a percentage.bcl- protein was primarily identified in the cytoplasm of tumor cells. statistically, correlation between immunoreactivity and the clinicopathologic factors were evaluated. results p immunoreactivity was observed in ( %) of cases. there were ( %) scc, ( %) ac. statistically, these findings were found significant (p= , ). percentage of p positive nuclei, the average being %. positive bcl- immunostaining was found in ( , %) of cases. cases ( , %) of scc and ( %) of the ac were positive. these findings were not found significant (p= , ) conclusions there is no correlation between p and bcl- expression and clinical parameters, clinical stage, pathologic grade and prognosis. our study suggest that p immunreactivity in nsclc may provide prognostic information. pulmonary hamartoma -report of four cases introduction neuroblastoma is a malignant tumor of early childhood and is very rare in adults, thus we report this case. case report we describe a case of a -year-old man, never before notably ill. basic laboratory values were not significantly anomalous except of mild anaemia and high erythrocyte sedimentation rate. an x-ray scan showed a spherical opacity cm in diameter in the top right pulmonary field paramediastinally. ct displayed a low-density tumor x , x , cm in the apex of the right hemithorax. the tumor was well circumscribed and seemed to be in a subpleural localisation. it was subsequently punctioned with chiba and core needle under ct control. cytological and histological material did not contain any malignant cells. on mr scan there was a well encapsulated extrapulmonary tumor without destruction of ribs, probably of benign origin. tumor extirpation was indicated. the lesion was growing out of spinal chord. it was completely removed. grossly, the tumor looked like an old hematoma. histologically, it had the typical appearance of neuroblastoma -malignant tumor which is found in more than % of cases in patients under years of age. a scintigrafical examination and trephine biopsy showed massive bone marrow infiltration by neuroblastoma. conclusion a -year-old man was confirmed to have a typical early childhood tumor -neuroblastoma in a subpleural localisation. despite the poor prognosis of this tumor in adults and a wide bone marrow infiltration, the patient is well and without signs of disease after surgical resection and two cycles of chemotherapy over months after the initial diagnosis. measurements of dna amount and nuclear size by image cytometry: are these two features sufficient for diagnosis of early lung cancer? background lung cancer represents % of all cancers, but is responsible for nearly % of cancer related deaths due to the fact that it is most often detected in a very late stage. it has been proposed that selected nuclear features could be used to assist lung cancer detection in an early, operable stage. it was shown that both dna amount (dna ploidy) and nuclear size are key features for positive diagnosis in oral, laryngeal, bronchial, and gastric epithelial tumors. we used image cytometry to assess the potential of this approach using nuclei of epithelial lung cells from sputum samples. experimental design sputum samples were obtained by induction method, using hyperosmolar salinic solution, from lung cancer patients and high risk individuals. the cells were fixed and after breaking mucosa with mechanical and chemical treatment, they were cyto-centrifuged onto the microscopy slides. cell nuclei were stained by a dna specific and stoichiometric (feulgen-thionin) stain and dna amount (ploidy) and nuclear size of (on average) cell nuclei from each sample were measured by a high resolution image cytometer. the results showed that there were no statistical differences between the dna ploidy values between control and cancer cases, as very few cancerous cells were found in the sputa of lung cancer patients. interestingly, there was a measurable increase in the mean nuclear area of diploid cells from cancer patients in comparison to control cases. conclusions despite the slight difference in the size distribution the nuclear size feature alone does not provide effective discrimination between the negative and positive populations. pulmonary blastoma: report of cases d yilmazbayhan, mg gulluoglu istanbul university, istanbul faculty of medicine, department of pathology, istanbul, turkey introduction pulmonary blastomas (pb) are rare lung tumors having unique histomorphological features. although they were once regarded in the same group of lung neoplasms with well differentiated fetal adenocarcinomas, recently the two tumors were seperated from each other. we aim to discuss the morphological features and the changes of morphology on recurrences of pulmonary blastomas. we present ten cases of pb, six of which were biphasic, two were pleuropulmonary, and two were cystic. biphasic pb patients were five males and one female, with an age range of - . two female patients with pleuropulmonary blastoma were and years, and cystic pb patients were and years old female and male children, respectively. results one of our most striking histomorphological findings was that four of the biphasic pbs accommodate mature epithelium, not fetal epithelium. one of the other two cases presented with a fetal adenocarcinoma and the tumor recurred as a biphasic pb. one of the cystic pb, which arised in a background of congenital bullous emphysema, recurred with pleomorphic cells forming solid groups. the other cystic pb was diagnosed as congenital cystic adenomatoid malformation. conclusion because of the changing morphological features and composition of epithelial component, classification of the pulmonary blastomas should be reviewed. (romano et al., faseb j. : , ). aim of our study was to investigate in vivo expression of -lo in human mesothelioma. materials and methods immunohistochemical analyses were conducted in five micron sections from human pleural mesothelioma ( epithelial, biphasic and one fibrous type). -lo expression was evaluated using a -lo polyclonal antibody. results immunohistochemical staining was observed in all cases. the staining pattern was cytoplasmic in cases ( epithelial, biphasic and fibrous type), both nuclear and membranous in one case of the epithelial type, both nuclear and cytoplasmic in cases ( epithelial and biphasic type), nuclear, cytoplasmic and membranous in two cases of the epithelial type. conclusion these results are consistent with our in vitro data showing -lo expression in mm cells and strongly suggest that -lo may play a relevant role in the pathobiology of malignant pleural mesothelioma. the present study is scheduled to analyze the intratumoral expression of vascular endothelial growth factor (vegf) in human lung cancer and to determine the relation with microvessel density (mvd), e-cadherin expression and clinicopathological parameters. a -years old male presented with chest discomfort, dyspnea, weakness. heart function tests were normal. ct examination revealed a well demarcated mass in the anterior-superior mediastinum as well as pleural and pericardial effusions. there was no clinical/radiographic evidence of tumor elsewhere. a surgical excision of the mass was performed. grossly, the mass was round, well demarcated, measured x . x cm. the cut surface showed solid whitish or reddish with yellowish foci areas and cystic areas filled with mucinous fluid. histologically, the tumor consisted of sheets and nests of atypical squamoid cells intermingled with gland-like lumens. areas of clear cells were also present. in the tumor stroma, abundant amounts of mucin, foci of necrosis, lymphatic invasion, intense inflammation and cholesterol granulomas were observed. in some areas, the tumor cells were seen in contact to the lining of the cystic cavities. the latter were lined by a single layer of cuboidal or flattened or stratified epithelium with morphological features of squamous cells. at the periphery of the tumor, rare lymphoid follicles, residual thymic elements or degenerative hassall's corpuscles were seen. these histologic features were more consistent with a mucoepidermoid carcinoma arising in association with a thymic cyst. the patient died two months after chemotherapy administration. mucoepidermoid carcinoma of thymus is a rare entity and, to our knowledge, very few cases have been described in the international literature. however, in case of absence of metastatic disease or other common primary tumors of thymus, the diagnosis of a mucoepidermoid carcinoma should be taken into consideration. tissue array for immunohistochemical profiling of intrathoracic localized fibrous tumors ultrastructure of bronchial mucosa in chronic obstructive bronchitis n zoirova, s ariphkhanova uzbek institute of medical rehabilitation and physical therapy, tashkent, uzbekistan the purpose of this investigation was to determine ultrastructural peculiarity of bronchial mucosa in the patients with chronic obstructive bronchitis (cob). the study was performed in bronchial biopsy samples obtained from patients with cob. material was fixed in , % glutaraldehyde, postfixed with % osmium tetroxide and embedded in epon. ultrathin sections were stained with uranyl acetate and lead citrate. morphological three types of cob have been reported, including chronic catarrhal, catarrhal sclerotic and sclerotic forms. catarrhal cob was characterized with significant increasing of goblet cell count as compared to the bronchial mucosa in controls. hyperplasia of endoplasmic reticulum and golgi complex was observed. in the goblet cells, numerous secretory droplets were crowded together where they have been deposited from the surrounding cytoplasm. in ciliated cells, few cilia were seen in longitudinal section extending from the apical pole of epithelial cells, fragmentation of the endoplasmic reticulum and appearance of autophagosome were detected. in other types of cob, number of cell rows was decreased with different secretory activity of goblet cells. interepithelial migration of lymphocytes with the damage of the basement membrane was described. our findings demonstrated more aggressive changes of bronchial mucosa in sclerotic cob. chest trauma-induced rupture of benign mediastinal teratoma followed by a possible implantation of the tumor into the parietal pleura: a case report introduction mediastinal teratomas rarely rupture. an unusual case of chest trauma-induced rupture of benign mediastinal teratoma followed by a possible implantation of the tumor into the parietal pleura is reported. case presentation in a -year old woman, a pre-employment plain chest radiograph and ct of the chest revealed a large mediastinal tumor. two smaller tumors were located on the left parietal pleura. on operation completely obliterated left pleural space and three well-encapsulated tumors were found. microscope examination revealed three well-differentiated teratomas with no evidence of malignancy. three years before the detection of the tumor the patient had a blunt chest trauma, with a left-sided chest pain and shortness of breath, which gradually disappeared. at the time the plain chest radiograph was analyzed as normal. retrospectively an unusual mediastinal line, adjacent to the aortic arch, was disclosed. this line could be due to a small mass in the mediastinum. the left diaphragm was elevated, and a small leftsided pleural effusion could have been present. we suspect that teratomas located on the parietal pleura were caused by implantation of the tumor cells after the rupture of the mediastinal teratoma into the pleural space during blunt chest trauma. conclusion the chest trauma seen in presented case, could be at least a trigger, if not the only cause of the mediastinal teratoma rupture. the rupture was probably followed by both, obliteration of pleural cavity and possible implantation of benign tumor into the parietal pleura. the introduction malignant mesothelioma is an aggressive tumor with adverse prognosis (median survival - months) both in treated and untreated patients. in fact, only few patients survive more than two years. the identification of prognostic factors is critical to evaluate life-expectancy and crucial to approach novel therapeutical strategies. the study was performed to evaluate the use of mib- and p kip antigens as prognostic indicators of survival in malignant mesotheliomas. materials and methods a series of surgical biopsies of patients with known follow-up were immunohistochemically examined. the results were compared with survival data and correlated with clinical and histological parameters. for immuno-histochemistry, sections were stained for mib- and p kip antigens using abc method. number of positively stained nuclei was evaluated in consecutive high magnification fields ( neoplastic cells were considered the minimum number to include the case in the study). results mib- , which is largely expressed in sarcomatoid mm (p= . ), is more represented in patients with shorter (< months) then in subjects with medium ( <months< , p< . ) and longer (> months, p< . ) survival. on the other hand, p is more expressed ( ± . ) in patients with longer (p< . ) then in subjects with shorter survival. pearson's analysis showed no significant correlation between mib- expression and p , but this was predictive of survival in the entire population (r= . , p< . ). conclusion the findings suggests that p and mib- expression, although reliable attribute of mm, represent independent markers of prognosis in malignant mesothelioma. familial clustering of malignant mesothelioma without direct contact to asbestos. a genetic study introduction very few papers dealt with clustering of familial malignant mesothelioma (mm). most of these, who developed mesotheliomas, presented work or domestic history of exposure to asbestos, but only in very few of them asbestos did not demonstrated any association. the aim of this study was to contribute to the hypothesis of a genetic predisposition in the pathogenesis of the mesothelioma. methods we report two cases of pleural malignant mesothelioma that affected two young sisters as part of a nine-member family with enviromental exposure to asbestos. they were affected by marfan's syndrome and both developed pleural malignant deciduoid mesothelioma with long survival. we have performed comparative genomic hybridization (cgh) analyses of tumor samples to identify critical chromosomal regions involved in the onset of mm. we found similar chromosomal changes in both cases and in particular we found losses at q -q and q . -q chromosome. conclusions early onset s. and same genetic impairments in the two sisters suggest that genetic factors may induce the onset of this cancer in those subjects who are exposed even to small environmental amounts of asbestos. however, the specific chromosomal changes we found might provide evidence for locations of relevant suppressor genes of familial mm. video assisted versus needle biopsy of the pleura in patients with pleural effusion results correlation was found between p- -posivity tracheal mucosa and tnm classification system: p- index: control group= %, group t = %, t = %, t = %. conclusion the opinion that the presence of p- oncoprotein reflects mutation of the p- gene is commonly accepted. other data published evaluating the relationships between p- and tnm-stage, g-stage, tumor size and site, age and sex, did not reveal any dependencies, although some studies have suggested such correlations. our analysis had shown a correlation between tnm stage and p- index of tracheal mucosa, but is significant only between control group and t , and control group and t . authors expect such results that show the correlation between prognostic factors in laryngeal malignant epithelium and tracheal epithelium. undifferentiated nasopharyngeal carcinoma (lymphoepithelioma). report of four cases v blažičević, m mrčela, Ž kotromanović clinical hospital, osijek, croatia background nonglandular nasopharyngeal carcinomas are much more common in some areas of the orient than the other parts of the world. they are subtyped as keratinizing squamous cell carcinoma (type ), nonkeratinizing carcinoma (type ) and undifferentiated carcinoma (lymphoepithelioma). we present on four undifferentiated nasopharyngeal carcinomas and detail clinical and histopathological characterisation of these rare cases. methods all our patients were male, white and - years old. initial complaints were various: hearing loss, epistaxis, headache, and dysphagia. examination of the nasopharynx showed us entirely normal features, or fullness, surface granularity, or obvious carcinoma. but, all our patients had cervical lymph nodes metastases, two of them bilateral. involved lymph nodes were typically posterior of the sternocleidomastoid at the level of the angle of the jaw. results histologically, lesions show cytologically uniform cells with ovoid vesicular nuclei prominent nucleoli and indistinct cell borders resulting in a syncytial pattern. an inflammatory infiltrate rich in lymphocytes and occasionally containing prominent eosinophils is usually a component of lymphoepithelioma, but diagnosis is based solely on the nature of the neoplastic epithelial component. neoplastic cells are negative for lca, but positive for cytokeratin and ema. conclusion undifferentiated nasopharyngeal carcinoma (lymphoepithelioma) is very rare. about % to % of patients are initially seen with cervical lymph node metastases from an occult primary. such lesions may be different or impossible to distinguish from lymphoma on haematoxylin and eosin stained sections, particularly when the lesion appears as a lymph node metastasis from an occult primary. ancillary methods like immunohistochemistry and molecular techniques or detection of serum antibodies against viral proteins may be necessary. "atypical" pleomorphic adenoma of the parotid gland introduction pleomorphic adenoma is a benign, epithelial tumor, composed of cells that demonstrate both epithelial and mesenchymal differentiation, with the absence of abnormal cytomorphologic features. we present the case of -years old white women, with a mass localized in the superficial, lower part of the right parotid gland. on clinical examination, the lesion was nodular, painless swelling, of smooth surface, measuring x mm in diameter. the tumour was excised, fixed in formaline, embedded in paraffin and the sections were stained with he, pas and alcian blue. the tumour was composed of both epithelial and mesenchymal-like tissue, with a complete capsule at the periphery. there was no neoplastic tissue within or extending through the fibrous capsule. on the other hand, the epithelial component expressed mild, limited, abnormal cytomorphologic features, such as enlarged, pleomorphic and hyperchromatic nuclei. conclusions presence of prominent cytomorphologic atypias and capsular involvement in a pleomorphic adenoma causes concern about malignant transformation, but a lesion with mild or focally limited cytological atypias is designated as atypical pleomorphic adenoma and indicates an increase likelihood of malignant transformation if the tumor recurs. gene expression profiles were determined in fresh-frozen samples of mucoepidermoid carcinoma (mec), acinic cell carcinoma (acc), salivary duct carcinoma (sdc), and adenoid cystic carcinoma (adcc), using cdna microarrays containing cdna fragments of cancer-related human genes. the validity of findings was checked by means of real-time reverse-transcript polymerase chain reaction studies. seventy-five genes were found to be more than . times overexpressed and less than . times underexpressed than in samples of normal parotid gland. five genes, namely fibronectin (fn ), tissue metalloproteinase inhibitor (timp ), biglycan (bgn), tenascin-c (hxb), and insulin-like growth-factor-binding protein (igfbp ) were overexpressed in all of the types of carcinoma studied. sixteen genes, including mothers against decapentaplegic homolog (madh /smad ) and prostate-specific membrane antigen (psm/psa) were underexpressed in all types of carcinoma studied. average-linkage hierarchical clustering undertaken in relation to selected genes showed that high-and low-grade mecs formed one group of tumours, acc/sdc another. significance analysis of microarray findings identified genes related to the mec group, associated with the acc/sdc group. our results indicate genes that may be involved in carcinogenesis in the salivary glands. gene expression in normal and malignant salivary tissues was also found to be similar in several respects to gene expression in normal and malignant pancreatic and prostate tissues. rare tumours in the sinonasal tract p nagy, f salamon national medical center, dept. of pathology, budapest, hungary introduction sinonasal neoplasms include numerous groups of different histogenetic types. the epithelial tumours have the highest prevalence among them in the daily routine, but we can encounter such lesions, which may cause diagnostic difficulties. the purpose of this study is to determine the least frequent tumours in our sinonasal biopsy files. we collected those kinds of tumours which occurred only once in our series. we reviewed our archive material of a year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) five cases were selected. the histologic slides were re-examined. he, special stains, immunohistochemistry and electronmicroscopy were applied. the cases in the order of their occurrence: . fibrous solitary tumour, we supported our original opinion by cd immunostaining performed retrospectively. . chordoma, in addition to the morphologic features the s and cytokeratin co expression were pathognomic. . pnet, in this problematic case finally the cd positivity proved to be diagnostic. . intestinal-type adenocarcinoma, the mucocele-like appearance and the highly differentiated colonic type epithelial structures reminiscent of adenoma caused our dilemmas. . meningeoma, the immunohistochemical results were not convincing. we established the diagnosis by means of electronmicroscopy. conclusions the incidence of sinonasal neoplasms is low. the recognition of the unusual lesions in this region is a challenge for the pathologist. ancillary techniques may be necessary in the diagnostic process. squamous cell carcinoma: diagnostically problematic variants f salamon, p nagy national medical center, dept. of pathology, budapest, hungary the diagnosis of squamous cell carcinoma (scc) is seldom problematic. although it may cause difficulties for the pathologist to verify its uncommon varieties. the aim of this study was to distinguish the rare variants of scc from the conventional ones in our laryngeal tumour file and to present the most instructive cases. material and methods we reviewed our archive material of a year period ( ) ( ) ( ) ( ) ( ) . four cases were selected. the histologic slides of the preoperative biopsies and the surgical specimens were re-examined as well. he, special stains, immunohistochemistry and electronmicroscopy were applied. results . " carcinosarcoma" with rhabdomyosarcomatous differentiation. this case represents a unique example of the spindle cell carcinoma category. . verrucous carcinoma with verrucous hyperplasia. the interpretation of the latter term is a complicated issue. by virtue of our patient's follow-up we encountered this dilemma. . papillary squamous cell carcinoma (pscc). this -year long case history is a well-documented instance of a papilloma-papilloma with dysplasia-carcinoma sequence. . adenosquamous carcinoma. it was not easy to justify the clinical suspicion of malignancy preoperatively. furthermore we faced a differential diagnostic problem when we evaluated the removed larynx. conclusions in all the cases we managed to establish the definite diagnosis only by the thorough examination of the surgical specimens. additionally we found special features as far as the morphology and histogenesis are concerned. so we can confirm the subheading of the corresponding afip fascicle for this tumour group: diagnostically problematic variants. intraocular leiomyoma: case report introduction intraocular leiomyomas are rare tumours probably arising from the ciliary body smooth muscle. they represent a diagnostic dilemma and must be differentiated from neural tumours and, more importantly, from amelanotic melanoma. they occur more frequently in women, usually between the third and sixth decades of life. case report we report the case of a year-old woman with gradual loss of vision in her right eye. slit-lamp examination and binocular ophthalmoscopy showed a large and pigmented ciliary body mass located in the inferior quadrants. a and b ultrasound examination revealed a multicavitary tumor with low internal reflectivity measuring x . x . mm. enucleation of the affected eye was decided. histopathological examination showed a solid neoplasm composed of interlacing and tightly packet of spindleshaped cells with little intervening collagen. nuclei were oval with blunted ends with no significant atypia. mitotic activity was negligible. immunohistochemical stains for smooth muscle actin, hhf- , vimentin and desmin were positive. no stain was noted for s- protein, ae -ae cytokeratin, cam . cytokeratin, hmb- , glial fibrillary acid protein, neurofilaments, neuron-specific enolase and synaptophysin. final diagnosis was leiomyoma and the patient is free of disease two years after surgery. conclusions intraocular leiomyomas are of clinical concern since they are difficult to differentiate from more aggressive neoplasms, especially amelanotic melanoma. in this particular case, the situation was even more complicated because the lesion was clinically pigmented. once removed, the diagnosis was not difficult and was based on conventional histopathological examination along with confirmatory immunohistochemistry. results twenty-six of cases were male and were female. follow-up was available for cases and ranged between to months. eight cases died and had recurrences. the recurrent tumour histology changed from type to in cases, remained unchanged in . none of the clinical parameters were correlated with the survival. the type of therapy seemed to have no impact on survival. according to who classification cases were type , were type and were type and it showed correlation with survival (p= . ). lymphocytic infiltration, which, was added to who system, were seen by cologne classification in of tumours, but did not have an impact on survival. cellular morphology and atypia suggested by hsu's classification had no significance as well, although most of the tumours were classified as type a (% , ). ebv infection was found to be present in of cases. however no correlation with other parameters was found. conclusion in accordance to literature we concluded that who classification is the only parameter that has an impact on survival in npc. vascular endothelial growth factor expression and microvessel count in laryngeal squamous cell carcinoma -related antigen. paraffin embedded tumour specimens were stained with vegf and f-viii using immunohistochemical methods. vegf staining was evaluated as negative (<% of tumour cells) or positive (>% of tumour cells). staining intensity was graded mild, moderate and severe. for evaluation of f-viii staining, average counts of the three most vascular areas on an x field were recorded. statistically correlation between immunoreactivity and the clinicopathologic factors of laryngeal carcinomas was evaluated. results vegf expression in the tumour cells was found positive in all cases (% ). staining intensity was detected as severe of cases, moderate of cases, mild of cases. in evaluation of f-viii staining, average mvc of all cases was found , . statistically, no association was observed between the vegf expression, f-viii of carcinoma cells and histologic grade, tnm stage, tumour size and tumour site. association was observed between the vegf expression and mvc (p= , ). in additional, significant correlation was observed between the vegf percentage of positive tumour cells and staining intensity (p= , ). conclusion our data suggest that in laryngeal squamous cell carcinomas, vegf expression and mvc of carcinoma cells are not prognostic markers. acinic five cases of acinic cell adenocarcinoma, diagnosed in our laboratory during a period of years, are presented. four of them concerned salivary gland tumours of the parotid gland, the main site of their development, and the fifth was found as an endobronchial mass. the patients ranged from to years of age and the greatest stromal diameter varied from , to , cm. microscopically all neoplasms had the typical morphological features consistent with acinic cell adenocarcinoma. this neoplasm has distinct clinicopathological features and a rather indolent biological course, in spite of its malignant potential, responsible for the prevalence of the term carcinoma instead of "stromal". a broad histo-and immunohistochemical investigation was performed confirming the diagnosis. a review of the available reference is reported. relationship of p oncoprotein expression with histological grade and outcome of patients with oral squamous cell carcinoma introduction an alteration in the p tumour suppressor gene is the most frequent genetic abnormality in human cancers. overexpression of the p oncoprotein and histological differentiation were investigated in routinely formalin-fixed and paraffin embedded squamous cell carcinomas of the oral cavity. p oncoprotein was detected in all specimens with the monoclonal antibody do- . p oncoprotein expression was scored in the following way: score < %, score - %, score > % positive cells. results and conclusions using histological differentiation, all specimens are divided in three groups: group i -well-differentiated ( cases), group ii -moderately differentiated ( cases) and group iii -poorly differentiated carcinomas ( cases). in the first group % specimens were negative, %highly positive for the p oncoprotein. in the second group, positive detection of the p oncoprotein was observed as low in , % of cases, moderately in % and highly positive in , %. in the third group % expressed low positivity for the p oncoprotein and % of the cases had moderate and high positivity respectively. patients' survival was monitored for a five years. in the group with the highestp oncoprotein expression , % of the patients survived years or longer and , % survived less than years. mutation in the p tumour suppressor gene is highest in the well-differentiated squamous cell carcinomas, and its expression decreases in poorly differentiated carcinomas. immunohistochemical prognostic factors in laryngeal squamous cell carcinoma introduction the molecular mechanisms of growth and progression of laryngeal carcinoma are not studied well. the aim of the present study was to investigate the prognostic significance of over expressions of p protein, cyclin d , c-erbb , and markers of cellular proliferation (ki- and pcna). materials and methods primary tumours were studied on a series of patients. all patients were treated between the years and . the expression of p was analysed with monoclonal do antibody, cyclin d (clone dcs- ), c-erbb (polyclonal antibody hercep test), proliferate activity with ki- (clone mib- ) and pcna (clone pc ) results overexpression of the p protein was found in % of patients, cyclin d in %, and c-erbb -in % of patients with laryngeal squamous cell carcinomas. the reverse relationship of cyclin d with -year survival of patients (p< . ) was revealed. overexpression of the p protein was correlated with lymph node metastasis (p< . ). the value of pcna index in patients with metastasis is significantly higher than those in patients without metastasis (p< . ). the pcna index was correlated with the stages of the tnm. high level of the ki- index and the pcna index really decreases -year survival in patients. no significant correlations were found between positive p , cyclin d , c-erbb , ki- and pcna immunostaining and anatomical localization and histological grade. conclusions immunohistological examination of c-erbb is not a valuable prognostic factor in laryngeal carcinoma. high proliferation index (ki- and pcna) and expression of cyclin d correlate with worse prognosis of the disease. overexpression of the p protein is correlated with progression of laryngeal cancer. introduction warthin's tumor (wt) is a well-recognized benign neoplasm of salivary gland. granulomatous inflammation occurring in wt is a rare phenomenon. it has been suggested that prior fine needle aspiration (fna) biopsy might be the triggering factor. mycobacterial infection has also been reported as a cause of granulomatous change seen in wt. we report six cases of wt with granulomatous inflammation to analyse the possible relationship to prior fna. materials and methods a computerized search of pathology file of chang gung memorial hospital yielded cases of wt from to . granulomatous inflammation was described in six cases ( . %). fna cytology was performed in two cases before surgical excision. clinical history, histology and cytology slides were reviewed. ziel-neelsen stain was performed. results all tumours occurred in parotid gland. there were men and women. their age ranged from to yrs (mean ) and the tumor size ranged from to cm (mean ) in maximal dimen-sion. all six cases showed typical features of wt accompanied by multiple granulomas composed of epitheloid histiocytes and multinucleated langhans giant cells with or without necrosis. no acid-fast bacilli were found in any of these cases. history of prior fna was identified in two cases. both specimens also showed granulomas and features of wt. conclusions the pathogenesis of granulomatous inflammation in wt remains speculative. prior fna has been suggested to be the cause. however, this hypothesis cannot be supported by our observation of granulomas in the cytology specimens of two of our cases. it is most likely an immunologic reaction to the tumor, but a ziehl-neelsen stain should be performed to exclude the possibility of mycobacterial infection. malignant peripheral nerve sheath tumor masquerading as an allergic nasal polyp introduction approximately % of all malignant peripheral nerve sheath tumours (mpnst's) occur in the head and neck. of these, % are sporadic. the mean age at presentation is years. sinonasal tumours are extremely rare and whilst they share the morphology of mpnst's at other locations, they tend to be of low grade at this site. we describe a unique case of a high grade mpnst clinically simulating an allergic nasal polyp in an otherwise healthy child without identifiable risk factors. methods a year old black boy presented with an obstructive nasal mass, which was first felt months earlier. the clinical diagnosis was an "allergic polyp" and the mass was excised without antecedent roentgenographic investigations. results the x x cm tumor was unencapsulated but circumscribed, lobulated and friable. histologically, predominantly highgrade sarcomatoid and epithelioid areas were seen. however, differentiating features of peripheral nerve sheath tumor were also found. these included alternating hypercellular and hypocellular areas, palisading nuclei, perithelial accentuation of cells and serpentine, buckled nuclei. in low-grade areas, axons were demonstrated by silver staining. of the broad panel of immunohistochemical stains done, only s protein positivity was observed. the latter was uncharacteristically prominent. conclusion the young age of the patient, the tumor location and clinical presentation as an allergic polyp, the predominantly high grade microscopic appearance and the strong s protein positivity of this mpnst are unusual and hence worthy of documentation. follicular dendritic sarcoma in a black teenager -report of a south african case and literature review t n c) . histologically, the tumor cells were large with a low nuclear:cytoplasmic ratio, vesicular chromatin, and prominent nucleoli. the cells were arranged in organoid and trabecular patterns in a background of extensive necrosis and mitotic figures. ultrasound biopsy of the liver revealed metastatic disease. the patient died within weeks of surgery. the cause of death was unknown. no post-mortem examination was conducted. immunohistochemical expression of antikeratin ae /ae , chromogranin, and synaptophysin was evaluated. electron microscopy was performed. the tumor cells stained with anti-keratin ae /ae , chromogranin, and synaptophysin. electron microscopy revealed dense core granules. these findings, along with the morphologic criteria, fit with a lcnec. conclusion lcnec is a rare tumor in the larynx. recognition at this site is essential so that proper patient management can be initiated. analysis of blood serum lymphocytic phenotypes in chronic hepatitis c infected patients with advanced fibrosis and periodontium diseases introduction few studies focus on periodontium diseases in the course of chronic viral hepatitis c. the aim of this study was analysis of the relationship between the stage of periodontium disease and a number of lymphocytic phenotypes in blood serum of patients infected with chronic hepatitis c and advanced fibrosis. the study included patients (mean age of , years), whose blood serum revealed the presence of hcv-rna, demonstrated with rt-pcr method, while biopsies helped to reveal chronic hepatitis with septal fibrosis or cirrhosis. periodontium inflammation was assessed according to the following criteria: inflammation limbus, swelling, gingival pocket depth, presence of supragingival and subgingival calculus and gomphiasis. each criterion was assigned or point, cumulatively from to points. flow cytometry analysis included monoclonal antibodies: cd , cd , cd , cd /cd /cd , cd provided by becton-dickinson. analysis of morphological parameters and fluorescence was performed with cellquest computer software. results all patients with advanced liver fibrosis were found to show signs of advanced periodontum diseases (mean cumulative value of , points). the diseases most frequently encountered included: bleeding and calculus (n= ), deep gingival pockets (n= ) and gomphiasis (n= ). the degree of periodontal disease depended on the total number of t lymphocytes (p< , ) and on the number of t helper lymphocytes (p< , ). no significant dependencies were found between the degree of a periodontal disease and nk cells, b-lymphocytes or t suppressor. conclusion degree of periodontum disease in patients infected with hepatitis c is dependent on low values of t and t helper lymphocytes in blood serum. adenomatous ductal proliferative foci accompanied the warthin tumour in parotid gland t ohuchi , adenomatous ductal proliferation (adp) and intercalated duct hyperplasia (idh) which are two new similar disease concepts in the field of salivary gland have been reported recently focusing on the relationship of precursor lesion to some salivary gland tumour, differential diagnosis, and possibility of dedifferentiated lesion. we report here a case of warthin tumour accompanied by the foci of the adenomatous ductal proliferation in the parotid gland and these epithelial foci exhibited the histological and immunohistochemical findings resembling tubular type of basal cell adenoma. a -yearold female received the resection of warthin tumour in the parotid gland, which was diagnosed as a benign parotid gland tumour. macroscopically, this tumour showed two small legions in the parotid area, x mm and x mm in sizes respectively. the bigger legion was a typical warthin tumour consisted of papillary epithelial projections into cystic spaces associated with variable number of lymphocytes. papillary projections were lined by eosinophilic two cell layers having luminal columnar cells and basal polygonal to triangular shaped cells. on the other hand, histologically, the smaller legion resembled tubular type of basal cell adenoma. this lesion showed ductal proliferation with some admixed acinar cell complexes having a fibrous capsule in its half area. ductal proliferation consisted of bilayered structure (inner luminal cells were strongly positive for cytokeratin and weakly positive for s- protein). some stromal areas around the ductal components appeared to be cellular with spindle shaped cells strongly positive for s- protein immunohistochemistry. introduction malignant rhabdoid tumour of the oral cavity is very rare. to our knowledge, there has been one reported case of malignant rhabdoid tumour of the tongue so far. patient and methods a case of an -year-old female with malignant rhabdoid tumour of the tongue is presented. a patient presented with the induration of the anterior third of the tongue of months duration. the surface was bulging, berry-shaped and bleeding, suggestive of an animators lesion. the radial excision of the tongue was performed. results histopathological analysis revealed a solid tumour measuring cm in the largest diameter. the tumour was composed of epithelioid, eosinophilic cells with "rhabdoid" features; some of these cells contained rounded eosinophilic cytoplasmic inclusions that displaced the nuclei to the periphery. most of the cells showed strong diffusely distributed vimentin immunoreactivity and focal epithelial membrane antigen and keratin immunoreactivity. angioinvasion was present at the periphery of the tumour. following pathological report re-excision of the tongue was done and the patient received chemotherapy. seven month after the diagnosis, respectively, the patient showed no signs of tumour recurrence or metastases. conclusion although there has been a contradiction whether malignant rhabdoid tumour represents a distinctive clinicopathological entity or a phenotypic pattern shared by heterogeneous neoplasms, most of the authors support the diagnosis of "rhabdoid tumour" because the morphological pattern is attended by aggressive biological behaviour. a case of sarcomatoid salivary duct carcinoma ex pleomorphic adenoma in buccal mucosal region results and conclusion correlation of the presence of merkel and langerhans cells as well as the extent of mononuclear cellular infiltrate in the perimatrix according to the degree of ossicular defect and the destruction of the bony walls were made. we found that these cells are predominantly seen in the cholesteatoma with aggressive and destructive growth. they were seen in the less degree in the skin. the role of high-resolution flow cytometry in the grading of mucoepidermoid carcinomas malignancy with poor prognosis, but occasionally arises in the various mucosa of general site including nasal or paranasal sinuses and oral cavity. it shows wide variety in cellular morphology and histological architecture and, therefore, can be easily disregarded as other neoplasm in such instance above. we describe herein a series of malignant melanoma arising in the head and neck mucosa, which diagnosis was corrected in our review, and discuss its histological and immunohistochemical characteristic as well as important clues for diagnosis. materials and methods six cases were selected from the pathology files of kurume university hospital. histological sections were routinely processed, stained with h&e, and observed with a light microscope. immunohistochemistry and special stains were done as needed. among these, two arose in ethmoid sinus and the others in nasal cavity, inferior nasal choncha, tongue and palate, respectively. age ranged between and years old (average . ). the tumours showed undifferentiated morphology with anaplastic or sarcomatoid appearance and cellular population included ovoid, polygonal and spindle cells, occasionally intermingled with those with rhabdoid or plasmacytoid features. immunoreactivity for hmb , melan-a and cd , know as melanoma-related markers, considerably varied for each case, while that for s protein was relatively stable and useful for initial screening. melanin deposition was easily passed by, especially if it appeared in the stroma rather than neoplastic cells themselves, but quite important as well as intraepithelial spread of atypical melanocytes. if resected together, also mucosal tissue should be examined carefully. tenascin expression in salivary gland tumors: an immunohistochemical study in cases introduction tenascin is an extracellular matrix glycoprotein, which interacts with other extracellular matrix proteins and cells. it is reported that tenascin expression is detected in different localizations of normal salivary gland tissue and in most of salivary gland tumours. it is accepted as an indicator of invading potential in a report. the aim of this study is to detect whether tenascin expression patterns relate with type and malignancy of salivary gland tumours. material and method cases of salivary gland tumours: warthin's stromal, mixed stromal, myoepithelioma, basal cell adenoma, basal cell adenocarcinoma, acinic cell carcinoma, adenoid cystic carcinoma, malign mixed stromal were included in our study. antibody anti-tenascin was applied to the paraffin sections. results tenascin expression was observed in all tumours. most invasive expression was observed in mixed tumours, generally in extra cellular matrix localization and in the pattern of coarse clusters. warthin's tumours demonstrated dominantly epithelial tenascin expression, sometimes in globular pattern. in malignant salivary gland tumours tenascin expression is relatively rare compared with benign ones. conclusion our findings suggest that tenascin expression may show variations in patterns and localizations in different kind of salivary gland tumours. tenascin expression is not a feature of invasive potential but may be responsible of epithelial mesenchymal interactions, stromal growth, cell differentiation and production of mixoid and chondroid matrix. links between nucleolar and extracellular matrix proteins: tenascin and ki- in vocal cord biopsy m krstulja department of pathology, medical faculty of rijeka, rijeka, croatia introduction it is postulated that cancerogenesis goes through interchange of differentiation and proliferative processes. the aim of this study was to investigate morphogenesis and proliferation in the epithelial compartment of hyperplastic, dysplastic and neoplastic vocal cord mucosa with simultaneous expression of tenascin and ki- . materials and methods vocal cord biopsies were analysed: invasive squamous cell carcinomas, in situ squamous cell carcinomas, hyperkeratoses with low dysplastic change, papillomas and nodules with hyperkeratosis. immunohistochemistry was performed for each marker separately as well as simultaneously for both markers. results tenascin was expressed in differentiated and neoplastic tissues, decorating the membrane/cytoplasm of cells in carcinoma and dysplastic mucosa, but only the intercellular epithelial junctions in papilloma and hyperkeratosis. ki- , a nucleolar protein, decorated nuclei, nucleoli and chromosomes of cells engaged in mitosis in homotypic and heterotypic bioptic tissue. a double staining for tenascin and ki- revealed synchronous decoration of cytoplasms and nuclei in invasive squamous cell carcinoma ( / ), in cells of in situ squamous cell carcinoma ( / ) and occasionally in cells of dysplastic hyperkeratosis ( / ). simultaneous staining was not found in homotypic tissue. neoplastic cells in mitosis had tenascin stained membranes/cytoplasms or were tenascin negative. in dysplastic hyperkeratosis basal cells in mitosis had rarely tenascin positive membranes ( biopsy only). conclusion the observation that tenascin (a marker of morphogenesis) and ki- (a marker of proliferation) express simultaneously in neoplastic epithelial cells makes a difference regarding homotypic proliferation. introduction anaplastic thyroid carcinoma with an osteoclastoma like component is a rare type of thyroid neoplasm. the origin of the osteoclastoma like element has been a source of controversy, with conflicting theories emerging from the literature, some supportive of an epithelial origin with others favouring macrophage/ histiocytic lineage. ret/ptc is a fusion transcript associated with papillary thyroid carcinoma but not previously described in a tumour of this type. our aim was to examine more closely the osteoclastoma like component and assess the histogenesis of this tumour. materials and methods electron microscopy, histochemistry and a broad immunohistochemical panel were performed. in addition pure populations of each constituent cell type comprising the tumour were isolated using laser capture microdissection. after rna extraction, each of these was examined by rtpcr for chimeric transcripts of ret/ptc- and ret/ptc- . at this stage of our study, due to small differences in each epulis type, no far-reaching conclusions can be drawn. further studies of cd and mdm- protein in the same group of patients seem to be justified since in the authors' opinion, they will explain biological behaviour of that type of tumours. conclusions great proliferation activity of the cells in all types of epulides analysed with pcna, with low ki- and lack of p activity, was observed. adenoid cystic carcinoma and polimorphous low grade adenocarcinoma of salivary glands. a morphometric study c giardina results nuclei of plga resulted significantly larger and with a more regular shape than nuclei of acc. multivariate analysis discriminated the % of nuclei by utilizing variables: nuclear area and variables obtained by the nuclear asymmetry evaluation. conclusion morphocytological differences could have a discriminating power between plga and acc, they seem to be more important than architectural differences and could be related to their different biological behaviour. oral synovial sarcoma -a report of two cases and a review of the literature introduction the head and neck region constitutes the second most common site of involvement for synovial sarcomas, accounting for up to % of all cases. intra-oral synovial sarcomas are rare, with only cases having been reported. the aim of this study is to report additional cases of intra-oral synovial sarcoma, which occurred in the floor of the mouth and retromolar areas respectively in middle-aged black males and to review the clinico-pathologic features of all previously reported intra-oral cases. the current cases were immunohistochemically stained with ema, cd , bcl- , vimentin, cam . , mnf , ck , s- protein, hba , cd and calretenin; and subjected to ultrastructural studies. the literature was reviewed over a period of years, examining a total of cases of oral synovial sarcoma. the intra-oral cases differ from lesions occurring in other sites only in respect of a more marked male predilection, and a generally painless presentation. this is the first report demonstrating calretinin immunopositivity in intra-oral synovial sarcomas. even though in the oral cavity possible earlier detection, easy accessibility and small size renders them more amenable to surgical excision, their biological behaviour remains aggressive with a poor long-term prognosis. conclusion this study clearly demonstrates the histomorphologic, immunohistochemical and cytogenetic similarity of intra-oral synovial sarcomas to that of synovial sarcomas in general. the unusual intra-oral location often results in these lesions being misdiagnosed. these tumours should be considered, as both primary and metastatic tumours, in the differential diagnosis of intra-oral spindle cell malignancies. thirty nine years long follow up of the patient with dermatofibrosarcoma protuberans background dermatofibrosarcoma protuberans (dfsp) is an infiltrative, aggressive, nodular stromal with a great potential to relapse, that appears early in the life, in % of cases at the head and neck region. during last ten years there were five patients with the dfsp at the clinic for maxillofacial surgery of the military medical academy that makes . % of all cases with mesenchimal malignancy. here we present the most extreme case of the dfsp. case report s.s. was years old when she injured a small subcutaneous stromal at the right side of her forehead. ten years later it was cm wide and excised for the first time, as well as two years later when the relapse of the same size, this time involving the bone, was removed and the patient went through radiation therapy. after four corrective operations in a meantime, at her age of and the relapse cm wide from the right frontal region was removed. three years later, at her age of , stromal sized cm was excised from her right buccal mucosa. two years later, at her age of , local relapse was widespread into the right parotid gland, superior eyelid and frontotemporoparietal region including dura. two years after extensive ablative surgery and delicate reconstruction with scary compromised local cutaneous flaps, the relapse from the previously hardly mutilated right forehead region together with dura was removed. six years later, at her age of , the right orbit was exenterated together with excision of adjacent temporoparietal tissues. one year later the local relapses from the right infraorbital and buccal region were removed. two years after another stromal cm sized from the periorbital region was removed. after two years, at her age of , the lesion from her cheek was removed. it has been her tenth, but obviously not the last surgery. almost one year later there were no signs of local relapse or regional metastases at her routine postoperative check up. in spite of such a great mutilation of face and psychological disturbances connected with it, this is a case of successful surgical management of the dfsp. few times some differential diagnostic dilemmas appeared, but careful and detailed revision of all specimens definitely confirmed the dfsp. multiple and multifocal malignancy -a case report background it is well known that one either benign or malignant stromal can appear multifocally, as well as the fact that histologically different tumours can exist coincidentally. there is just a few papers concerning on how many different concomitant tumours can appear in the human body. this is a case of years old male with several tumours of different malignancy degree and morphologically benign or semimalignant cutaneous lesions. case report during previous years three times he underwent surgical excision of epitheliomas of the scalp, body and limbs. the third one has been removal of the epithelioma of the right frontoparietal region. at his age of because of the stromal sized cm in the right parotid salivary gland, followed by paralysis of the frontal and paresis of buccal branches, along with laboratory finding of . leukocytes, right-sided radical parotidectomy and suprahyoid dissection of the neck has been performed. pathohistologic analysis confirmed malignant mixed stromal of the parotid salivary gland. postoperative irradiation therapy has been applied in fraction and total dose of gy. nine months later the patient has been operated again because of an exulcerated, cm diameter cutaneous lesion of interscapular region, which has proved to be the infiltrative squamous carcinoma g- grade. at the same time the chronic lymphoproliferative disease in the form of chronic lymphocytic leucosis a grade has been diagnosed (although the reactivity following the neoplastic process could not be excluded), but specific haematological treatment has not been indicated. nine months later nine cutaneous facial lesions have been removed: malignant mixed stromal of the left auricle, senile keratosis from the left temporoparietal region, chronic dermatitis from the forehead, squamous carcinoma g- and seborrhoic keratosis one inch inferiorly, two lesions, sebaceous adenomas from the right zygomatic region, corneal squamous carcinoma g- from the right parietal region, baseocellular carcinoma from the left one and adenoid type of baseocellular carcinoma from the right supraclavicular region. the patient has been operated without complications and came five times for monthly control in a good general condition, without relapse, regional or distant metastases. later on we ascertained that the patient suddenly died during a sleep seven months after surgery. conclusion pathohistologic examination of removed tissues and revision of the former specimens undoubtedly excluded the spreading of the one and same stromal in different regions, but proved multifocal appearance of tumours of the same embryologic -ectodermal origin in very different structures. melanoma of the oral cavity -a case report background melanoma is a capricious malignancy followed by reputation of aggressive growth and dissemination, able to originate from any tissue containing melanin. in less than % it appears at mucous membranes. here we present a case of such localization. case report during last ten years there were patients with primary cutaneous head and neck melanoma who underwent surgery because of secondary deposits at the neck, but only one patient, r.m., years old (pale skin, dark hair and eyes, never working outside), who appeared four years ago with inoperable intraoral melanoma involving tongue, base of mouth, mucosa of the left cheek, retromolar region, tonsillar fossa and soft palate, including a single pendular mass from the left palatoglossal arc that almost completely narrowed his isthmus faucium. the first pigmentation he noticed eight months before his first admittance suffering of disturbed swallowing for few weeks. although there was no sign of regional or distant metastases, only the last-mentioned mass has been removed and pathohistologically verified as melanoma. patient was able to breathe normally, and continuing with his previous way of life. he received dtic during the first four postoperative months. one year later, smaller mass from the same location has been removed again. routine laboratory analyses, radiographic examination of the lungs, ultrasonographic examination of the neck and abdomen never revealed any changes. the third reduction under the same circumstances took place one year later and has been followed with minimal doses of adjuvant immunotherapy. conclusion this is a rare case of such a large, inoperable intraoral melanoma that has been three times reduced at the place of its exophytic growth into throat, otherwise demonstrating no signs of regional or distant spreading, as well as any disturbances in patient's general condition during last four years. introduction recent studies have shown that stromal reaction in cancer has an important diagnostic and prognostic significance. cd -positive stromal cells and myofibroblasts may play an important role in host response to cancer. the aim of this study was to analyse the expression and significance of cd , alfa-smooth muscle actin (sma), and tgfbeta in epithelial hyperplastic lesions (ehl) and squamous carcinoma (sc) of the larynx, and tried to reveal the mechanism of myofibroblast formation in sc. we investigated samples of resected larynxes with sc, laryngeal biopsies of ehl and sc, and samples of normal laryngeal mucosa. immunohistochemistry was performed with antibodies against sma, cd , cd , tgfbeta and tgfbeta receptor. the expression of tgfbeta mrna was detected by rna in situ hybridisation. results stroma of normal mucosa and ehl contained scattered cd -positive cells, but there were no sma-positive myofibroblasts. stroma of sc contained sma-positive myofibroblasts but there were no cd -positive stromal cells. in normal mucosa and ehl, tgfbeta and its receptor were present in epithelial cells and scattered stromal and inflammatory cells. in sc, tgfbeta , its receptor and tgfbeta mrna were found in stromal cells, inflammatory cells and some stromal myofibroblasts. conclusions disappearance of cd -positive cells and appearance of sma-positive myofibroblasts in the stroma is associated with transformation of laryngeal ehl to sc. this pattern of stromal reaction is limited to invasive carcinoma and should be regarded as an additional marker of invasion. our results also support the hypothesis based on experimental studies that tgfbeta may be one of the mechanisms of transformation of stromal cells to myofibroblasts in sc. introduction loss of heterozygosity (loh) on short arm of chromosome p is frequently found in squamous cell carcinoma of larynx and hypopharynx (lhscc). this is a region where potential stromal suppressor gene, frequently changed in pulmonary cancer, the fhit gene, is located. we wanted to determine whether there is presence of molecular and/or immunohistochemical changes in fhit gene in patients with lhscc. materials and methods dna was isolated from stromal and adjacent normal tissue using standard procedure. non-isotopic loh analysis was performed with micro satellite markers d s , d s , d s , d s , d s . formalin fixed tissue samples were stained immunohistochemically with antibody against fhit protein and reactions scored according to % of nuclear positivity in stromal cells. results loh at p was detected in ( . %) and microsatellite instability (msi) in ( . %) tumours, which were mostly moderately differentiated ( . %). introduction permeation of fixatives into tissue for optimal dna preservation for molecular pathology studies is related to tissue type and fixative but also to glycosaminoglycan content of the ground substance. this may alter with age, warranting further study. the aim of this study was to assess nuclear dna preservation related to age and fixation agent. materials and methods fresh standardised testicular tissue samples from dogs - months (i), months - years (ii) and years and over (iii) were used for immediate dna extraction (t ), extraction after hours (t ) and after days (t ) of immersion in formaldehyde-based and formaldehyde-free, commercially available fixatives. dna extraction used standard protocols, commercially available kits (qiaamp minikit, qiagen, the netherlands), standard primers for the betaglobin gene preserved between species (myo /my , digene/abbot, usa) and quantitative pcr (realtime light cycler, roche, amplification cycles). in formaldehyde free fixatives, initial loss of extractable dna in t samples of young (i) animals was % as compared to % in older (ii+iii) animals (p< . , student t-test). the same, with a significantly poorer result (p< . ) was found in formaldehyde based fixation, with loss of % in young (i) as compared to % (p< . ) in older (ii+iii) animals. at days, further loss to % of t values occurred in all age groups (p< . ), with formaldehyde free fixatives retaining the proportional age associated difference. in formaldehyde based fixatives at t , loss to % of t values was found (p< . ), again without statistically significant differences between age groups. the g a polymorphism of ccnd correlates with susceptibility and prognosis of breast cancer in taiwan cp yu a frequent g a polymorphism of ccnd gene located on the splice donor site on exon -intron boundary is implicated in influencing cyclin d mrna splicing and production of two distinct mrna transcripts. although cyclin d is believed to perform an important role in cell cycle progression, this g a single nucleotide polymorphism (snp) seems to be a critical modulator of its functions. it has been reported that the prognostic significance and mrna splicing regulatory effect of g a varies with tumor type and ethnic diversity. to explore the association between the ccnd g a polymorphism and the breast cancer susceptibility as well as other prognostic parameters, we employed infiltrating ductal carcinoma (idc) cases and native controls in this study. there is obviously correlation between the genotype distribution of these two groups (p= . ), and the aa genotype reveals a higher association and risk than the ag+gg genotypes (p= . with c test and or . , % ci . - . , p= . ). moreover, there is no statistical significance found between genotype or allele frequencies and tumor stage, grade, nodal involvement, or patient'¦s age. however, the trend tests of ccnd g a genotype distribution or allele frequencies to the increasing of tumor grade or tumor stage are significantly different when comparing the a vs. g allele (p= . in both tumor grade and stage) or aa vs. ag+gg genotype groups (p= . and . in tumor grade and stage, respectively) but no significance when comparing gg vs. ag+aa or ag vs. aa+gg genotypes. these results suggest that ccnd g a polymorphism correlates with idc susceptibility, and a allele reveals an increased risk in carcinogenesis of idc and worse prognosis. the new hope*-fixative as an enhancement in molecular pathology e during the last years the growing demand for the detection of prognostic and diagnostic biomarkers has been slowed down to a large degree by the use of formalin and its influence onto antigenic structures and nucleic acids, although other reasons also exist. with regard to morphology a limitation in the possibilities, compared to frozen sections, takes place. with the introduction of the hopefixation to date both has become possible; substantially enlarged possibilities concerning the detection of dna, rna and proteins together with a formalin-like morphology. this will be demonstrated by presenting several examples like preservation of nucleic acids (dna, rna), the detection of those by pcr and rt-pcr, in situ hybridization and the preservation and delectability of proteins by immunohistochemistry. we conclude that hope-fixation opens up new possibilities, especially within the growing number of diagnostic and prognostic biomarkers. *hepes-glutamic-acid-buffer-organic-solvent-protection-effect introduction high-risk human papillomaviruses (hpv) represent a major risk factor for the development of cervical cancer. quantitative real-time pcr for viral load determination of hpv in archival cervical cancer specimens could be of clinical and prognostic relevance. the aim: we investigate the prognostic value of hpv status and viral load. furthermore, we compared the applicability and sensitivity of three molecular hpv-detection methods. materials and methods all examinations were carried out from formalin-fixed, paraffin-embedded tissue of cervical carcinomas. hpv status was detected by signal amplified chromogenic in situ hybridization (sa-cish), conventional polymerase chain reaction (pcr), and detection and additional quantitation was performed using real-time pcr. results patients with low viral load of hpv in stage i carcinoma had a significantly better prognosis than hpv -negative patients (p= . ). additionally, high viral load of hpv in patients indicating a higher stage carcinoma strongly tended to benefit prognosis compared to hpv-negative patients. our evaluation of the molecular hpv-detection methods showed a higher sensitivity of real-time pcr and conventional pcr compared to sa-cish. conclusion it appears that cervical cancer patients can be distinguished in a hpv -negative subgroup revealing a worse prognosis, and a lower-stage subgroup with low viral load, respectively a higher-stage subgroup with high viral load, both indicating a better survival, maybe due to an altered immune status caused by hpvinfection. these findings are crucial to accord each patient the individual therapy, and point out the importance of quantifying viral load and the necessity of real time-pcr in hpv-diagnosis. laser capture microdissection in -d coculture models as a novel tool to study tumor-stroma-interactions introduction cellular adhesion, migration and invasion are essential processes in tumor progression and do include actions by malignant cells as well as by the stromal microenvironment. in vitro, these interactions can be studied in coculture models. in conventional coculture systems, the different cell types are grown together in glass-slide based chambers with medium. in situ analysis can be easily performed, however, for mutational or gene expression analyses the cell compartments have to be dissociated and sorted. we present a novel technique for co-culturing fibroblasts and carcinoma cells and separating them without cross-contamination. methods our method is based on cell cocultivation on a . µm thin membrane followed by laser microdissection of tumor and stroma cells. for identifying the tumor cell compartment, immunolabeling for the laminin gamma chain was performed, a marker that is expressed only in epithelial tumor cells. dna and rna was isolated from the microdissected cells. rna quality was tested by rt-pcr for a housekeeping gene transcript and for the laminin gamma chain gene transcript. results co-cultivation on the membrane did not influence growth behaviour and cell morphology. the rna quality from the microdissected co-cultured and immunostained cells could be successfully proved by rt-pcr. laminin cdna was amplificable only in tumor cells and not in the co-cultivated fibroblasts indicating no cell-cross-contamination during microdissection. conclusion our technique provides a suitable tool to study tumor -stroma interactions at the dna or rna level for expression profiling and genetic analyses. p expression in prostate cancer and its correlation with microvessel density i pavlenko, a matsionis rostov regional bureau of pathology, rostov on don, russian federation introduction angiogenesis is important in the development and progression of all cancer types, including prostate adenocarcinoma (pca). increased vascularization may be influenced by p status. the aim of this study was to evaluate mvd in prostate cancer and its relationship with p nuclear accumulation. methods paraffin-embedded tissue from patients with well-, moderately and poorly differentiated prostate carcinoma was examined immunohistochemically using monoclonal antibodies against cd , vegf and p (clone do- ). a modified semiquantitative weidner score and computerized image analysis was used to assess mvd. results expression of immunohistochemically detected p protein was found in of cases ( %). p nuclear accumulation was observed in two different groups of cancers -poorly differentiated pca with high vegf expression and high mvd, with high level of serum psa ( cases) and moderately differentiated pca without significant microvessels with low serum psa ( cases). we suppose p mutation in the first group of patients which leads to increased angiogenesis as the result of loss of wild-type p induced anti-angiogenic control. in our opinion p detection in the second group of p + patients is the result of overexpression due to stabilization but not mutation. conclusion p overexpression is observed due to either mutations or protein stabilization. increased angiogenesis seems to be influenced by p mutations, while low mvd is observed in cancers with non-mutated p . immunohistochemistry alone is not able to detect p mutations, additional techniques are need for this purpose, especially in patients with p nuclear accumulation. malignancy-associated x chromosome loh in foregut endocrine neoplasms: further evidences in lung tumors introduction association of x chromosome allelic losses (loh) with tumor malignancy has been found in foregut-derived gastropancreatic endocrine neoplasms, but not in midgut carcinoids. also lung endocrine tumors originate from the embryological foregut. they are classified into "typical" carcinoids (tc), "atypical" carcinoids (ac), large cell neuroendocrine carcinomas (lcnec) and small cell lung carcinomas (sclc), in order of increasing malignancy the aim of this study was to investigate x chromosome loh and its association with malignancy in a series of endocrine tumors of the lung. materials and methods dna extracted from tcs, acs and lcnecs from female patients was pcr-amplified using fluorescently-labeled primers for microsatellite markers spanning the whole x chromosome. for loh evaluation, amplimers were analysed in an automatic dna sequencer (ceq , beckman coulter). all samples were formalin-fixed, paraffin-embedded and dna from tumoral and non-tumoral adjacent tissue was available results allelic losses were absent in tcs, while loh on x chromosome was found in of acs ( %) and in of lcnecs ( %). allelic losses were generally wide, involving all or most informative markers investigated conclusions allelic losses on x chromosome, absent in benign "typical" carcinoids, progressively increased their frequency from intermediate-grade "atypical" carcinoids to high-grade lcnecs. therefore the observation that x chromosome loh is associated with malignancy, already demonstrated in gastro-pancreatic endocrine tumors, is extended to another group of foregut-derived endocrine neoplasms, the lung endocrine tumors we investigated formalin-fixed, paraffin-embedded tissue samples. from each paraffin-block four times one to two µm sections in three steps and two µm sections were cut and put to . ml reactiontubes. one tube of the thin sections and the thick sections were exposed to heat/cold shocktreatment, one tube had a proteinase-k treatment for only three hours instead of overnight, and the thin cuts in another tube were treated with a riboliser. dna amount and purity measured by spectrophotometry after extraction. pcr was performed with routinely used srdna-primers. results over all we obtained best results with cutting up thin sections and proteinase-k treatment overnight. this tissue yielded the best purification, the highest dna amounts and strongest bands in agarose gelelectrophoresis. second best were thick and thin sections with heat/cold shock-treatment and proteinase-k treatment overnight. conclusion the mechanical opening of the mycobacterial wall using a standard microtome is a feasable way to obtain higher dna-amounts -purity and -complexity resulting in stronger signals following pcr. impact of tumour suppressor gene pten on cell cycle and apoptosis in prostate cancer cell lines introduction the progression of prostate cancer from androgenresponsive to an androgen-unresponsive status remains the greatest problem in the treatment of this disease. aims: to study the relationship between telomerase activity and gene expression after bicalutamide treatment in prostate cancer cells. material and methods androgen-responsive (lncap) and androgen-unresponsive (du- ) prostate cancer cell lines treated with µm bicalutamide for hours were analysed by affymetrix hg-focus array chips and their expression pofile was compared with control. the decrease of telomerase activity which was associated with increase of p waf /cip and decrease of dyskerin and hsp were found in lncap cells only. dna damage-responsive genes were upregulated in both cell lines. in lncap cells, the increase of p waf /cip was associated with induction of p -dependent gene expression (gadd α, bax, mdm- and trail-r ). we have also found induced transcription of pro-apoptotic genes represented by bnip -like, bcl- , cbx and tradd and the decrease of anti-apoptotic protein, survivin. in du- cells, we observed an increase of mt p , trail-r , gadd , gadd α expression together with a decrease in expression of survivin and the pro-apoptotic bnip gene. conclusion the decrease of telomerase acivity in lncap cells after bicalutamide treatment could be explained by changes in expression of p waf /cip , dyskerin and hsp . bicalutamide upregulates dna-damage genes in androgen-responsive as well as androgen-unresponsive prostate cancer cell lines. this work was supported in part by msm and nc/ - . introduction bicalutamide, an androgen antagonist used in the prostate cancer treatment, has a significant cytostatic effect on cancer cells. the aim of this study was to analyse the changes of bcl- family members after bicalutamide treatment in androgen-responsive (lncap) and androgen-unresponsive (du- ) prostate cancer cells. comparing the toxicity and potential carcinogenicity of two antiestrogens. a short-term study with microarray analysis in female rat liver introduction tamoxifen and toremifene are triphynylethyle antiestrogens used in the treatment of breast cancer. tamoxifen is genotoxic hepatocarcinogen in the rat, whereas toremifene is not. in humans, long-term tamoxifen treatment causes an increased risk of endometrial cancer. the major difference between the genotoxicity of the two drugs is the formation of liver dna-adducts in tamoxifen-treated rats. differential gene expression in rat liver after administration of antiestrogens was studied by microarray analysis. materials and methods equimolar doses of antiestrogens were given p.o. to six week old female sprague-dawley rats for days. total rna was isolated using trizol reagent. equal amounts of total rna from four animals in the same group was pooled and then purified from mg total rna using mg oligo(dt)cellulose. our cdna array contained approximately cdna clones selected from the tigr rat gene index. the samples were hybridized to rat cdna array scanned with a gms scanner (afflymetrix). image analysis was performed using the genepix pro software. normalization was performed using lowess normalization. the results from rat cdna array were evaluated according to 'significance analysis of microarrays' (sam). results sam plot for tamoxifen vs. control revealed significant genes from which were positive significant (up-regulated, red) q < %, . particularly the nadph-cytochrome p oxidoreductase and microsomal epoxide hydrolase were upregulated genes which are apparently related to tamoxifen-induced carcinogenesis. sam plot for toremifene vs. control revealed significant genes from which were positive significant q < %, . conclusion microarray technology gives important information of the toxicity as well as carcinogenicity of antiestrogens in experimental conditions. the ret proto-oncogene tyrosine kinase receptor is activated by a ligand complex comprising glial cell line-derived neurotrophic factor (gdnf) and gdnf family receptor alpha- (gdfralpha ). they are expressed in multiple organs during development and also in some types of human tumors in adults. the aim of this study is to investigate ret, gdnf and gdfralpha expression in normal tissue and tumors derived from the gastrointestinal tract, circumstance that we have not found it published in the literature. material and methods ret, gdnf and gfralpha expression was analyzed in samples of fresh frozen and formalin-fixed tissues from tumoral zone, and adjacent non-affected tissue of biopsies from patients with gastrointestinal cancer using rt-pcr and immunohistochemical methods. results presence of ret, gdnf and gfralpha transcripts in most of normal tissues was confirmed by rt-pcr. immunohistochemical study showed positive staining in citoplasms of glandular epithelium of the mucosa, ganglionar cells and muscular fibers (only gdnf) of esophagus, stomach, duodenum, colon and rectum but not in jejunum and ileum. gastric oxyntic cells were negative. sixty four gastrointestinal tumors ( adenocarcinomas and cases of gist) were also studied. by immunohistochemistry, % of cases showed citoplasmic immunoreactivity for gdnf; % for ret and % for gfralpha . these findings were confirmed by rt-pcr. there was not association with microscopic type, size, grade or duke stage. our study shows ret, gdnf and gfralpha positive protein and mrna expression in normal tissues and in the majority of tumors derived from the gastrointestinal tract. there is no association with microscopic type, size, grade or lymph node metastasis. this expression gives no prognostic information in the clinical management after two years follow-up of our patients. expression analysis of ret and its gdnf/ gfralpha ligand complex in breast cancer introduction the ret proto-oncogene tyrosine kinase receptor is activated by a ligand complex comprising glial cell line-derived neurotrophic factor (gdnf) and gdnf family receptor alpha (gfralpha ). they are expressed in multiple organs during development and also in some types of human tumors in adults. in this study we evaluated the expression of ret, gdnf and gfralpha in normal mammary tissue and different types of breast cancer. material and methods ret, gdnf and gfralpha expression was analyzed in samples of fresh frozen and formalin-fixed tissues from tumoral zone, and adjacent non-affected tissue of mastectomies from patients with different types of breast cancer ( dic, lic, medullary carcinoma, mucinous carcimoma, papillary carcinoma and fibrosarcoma) using rt-pcr and immunohistochemical methods. results normal breast ductal epithelium express ret, gdnf, and gfralpha . by immunohistochemistry, , % of breast tumors showed citoplasmic immunoreactivity for ret, , % for gdnf and , % for gfralpha . rt-pcr confirmed mrna expression in , % of cases for gdnf, , % for ret and , % for gfral-pha . by chi-square analysis, ret expression was associated with less tendency to the regional lymph nodes metastases (p< , ) and low grade differentiation (p< , ). there was not association with microscopic type, size or stage. conclusions we found that ret and its gdnf/gfralpha ligand complex are expressed in normal breast tissues and in a high percentage of different types of breast tumors using immunohistochemistry and rt-pcr. univariant analysis also revealed that only ret expression was associated with less tendency to the lymph nodes metastases and low grade dics (highly differentiated tumors). the short time follow-up of our patients (less than two years) gave no information about clinical outcome. telomerase activity in chronic b-lymphocytic leukemia r telomerase, the enzyme that elongates telomeres, contains an rna template complementary to ttaggg repeats that permits de novo synthesis of telomeric dna onto chromosomal telomeric ends. recent findings have suggested that activation of telomerase is one of the most common and fundamental steps in cancer genesis, although reactivation or telomerase up-regulation alone might be insufficient for cells to proliferate indefinitely. telomerase expression seems to be concomitant with the attainment of immortality of cancer cells, but there are contradictory reports about telomerase activity in early and late b-cll stages. in order to investigate the telomerase activity in patients with cll and its correlation with the clinical stage, frozen blood lymphocytes samples from patients with cll ( males, females), and age matched controls ( males, females) were investigated for telomerase activity using the 'telomerase pcr elisa-plus kit' from roche, based on the telomeric repeat amplification protocol. binet and rai stages were evaluated at the time of sample collection, and re-evaluated after - months. results were analyzed with a commercial statistic software package. the study showed that peripheral lymphocytes telomerase activity from b-cll patients is significantly higher ( , times; p< , ) compared to normal lymphocytes. the age and sex of patients does not influence the telomerase activity, while it is age dependent in healthy controls (pearson correlation - , ; p< , ). the study also showed that telomerase activity is increased more significantly in advanced stages of the disease, and correlates with the disease course. introduction deltan-p isoforms may act as oncogenes, owing to their ability to bind to p -reporter genes without inciting their transcription, thus blocking the p -driven cell cycle arrest and apoptosis. a novel mechanism, linking p and wnt pathways has recently been proposed. briefly, in vitro studies have suggested that deltan-p may block the phosphorylation of beta-catenin, leading to its nuclear accumulation and triggering beta-catenin-responsive transcription of genes related with proliferation and oncogenic biological behaviour. to test this new mechanism, the authors evaluated the co-expression of deltan-p and beta-catenin in a large cohort of human neoplasms. methods two sections of tarp- multi-tumour tissue microarray, composed of normal tissue cores and human neoplasms (breast (n= ), colon (n= ), lung (n= ), prostate (n= ) and ovary (n= ) neoplasms, melanoma (n= ), and glioblastoma (n= )) were subjected to immunohistochemistry with deltan-p and beta-catenin monoclonal antibodies. p nuclear expression and b-catenin membranous, cytoplasmic, membranous+ cytoplasmic, and nuclear localisation were independently evaluated by three of the authors. results p expression and beta-catenin nuclear localisation were found in . % and % of squamous cell carcinomas, . % and % of breast carcinomas, . % and % of lung adenocarcinomas, . % and . % colon adenocarcinomas, % and . % of prostate adenocarcinomas, . % and % of ovary carcinomas, . % and . % of malignant melanomas, and . % and . % of glioblastomas, respectively. no statistically significant association between p and nuclear beta-catenin expression was found for all tumours. conclusions at variance with squamous cell carcinoma cell lines, p -driven nuclear accumulation of beta-catenin is an unusual phenomenon in human neoplasms. caution should be exercised when translating the results of studies performed on cell lines to human neoplasms. four gist had no identificable kit sequence alteration in exon . mutations in c-kit seemed to be associated with favorable response to sti- (p= , ). conclusion kit mutations in exon are common in diseminated gastrointestinal stromal tumors and appear to be associated with response to sti- . the use of macro-array to study the effect of intestinal trefoil factor on gene expression in caco- derived enterocytes intestinal trefoil factor (itf) is a member of the trefoil family of peptides. it increases resistance to apoptosis, enhances mucosal healing and restitution in vivo and promotes migration of intestinal epithelial cells in vitro. the aim of this study was to investigate the influence of itf on gene expression in intestinal epithelial cells. the human colon carcinoma cell line caco- develops structural and functional characteristics of normal enterocytes when kept in culture. enterocyte-like caco- cells were treated with recombinant itf during hours. rna was isolated and labelled cdna was synthesised. the cdna probe was hybridised to the human unigene set colony filters (rzpd). after several washing steps, the amount of signal was measured using a phospo-imager. spot intensities were measured and signal quality was evaluated. using a fold increase or decrease as a cut off, comparison of the gene expression between un-stimulated caco- cells and cells stimulated with itf using the macro-array technique revealed a few hundred genes that were potentially differentially expressed. our data show that the macro-array is a powerful technique to screen for differen-tial gene expression as a result of trefoil administration, helping to study signalling cascades. however, it is necessary that the huge amount of data obtained is filtered through repeated hybridisations, only to retain the relevant changes and these data must be confirmed using other methods like quantitative real-time pcr and eventually studies at protein level. introduction melanoma therapy still remains without notable success of any pharmacological agent. gastric pentadecapeptide bpc is a peptide with various pharmacological effects on different organ systems including wound healing and inflammation. its possible effect on cell growth and differentiation was not investigated on human cancer cell lines. human melanoma cells were maintained in rpmi- medium supplemented with % fbs and antibiotics. cells were grown to confluency in humidified incubator ( % air atmosphere, %.co ) at °c. upon reaching confluency, cells were maintained in chemically defined medium (cdm). bpc was added in the culture medium in the various concentrations ( pg. and ng, respectively) for a period of hours. cell morphology was observed daily under light microscope and the photomicrographs were taken. after harvesting cells were prepared in etoh for flow cytometry analysis. results microscopy did not reveal any changes upon treatment with bpc after h comparing to controls. flow cytometry showed % of cells (p> . ) were in g -g phase. control cells had total s-phase fraction of . %. however, upon introduction of bpc , in concentration of pg/ml, the percentage of cells in sphase was decreased by % compared to controls. moreover, the concentration of ng/ml bpc lowered total s-phase fraction by % comparing to controls and by % comparing to bpc in picogram values (p> . ). conclusion we assume that gastric pentadecapeptide bpc could act as a inhibitory agent during g -s transition state of cell cycle thereby preventing dna synthesis and cell growth. introduction histones play an important role in the structural and functional properties of chromatin. their protective role against radiation-induced damage of dna is well established. the aim of this study was to evaluate relation between expression of histones genes and radiosensitivity of brain gliomas in vitro. five human glioma cell lines obtained from dsmz (germany) were irradiated with gy and gy doses (co- ) and further grown for , and hrs. the expression of genes coding for histones h , h a, h b, h , h was measured with real-time quantitative rt-pcr assay (taqman). radiosensitivity of the cell lines was assessed with cytokinesis-block micronucleus assay. cell lines were regarded as radioresistant and radiosensitive at micronuclei per binucleate cell ratio (mn/bnc) < . , and > , respectively, as measured over a dose range of - gy. results the global number of copies of histone mrna did not differ in both groups. in radiosensitive cell lines (gamg, -mg-ba) expression of h b was highest in / cases, while in radioresistant (gos- , -mg-ba, u- -mg) h predominated in / cases. in both groups significant decrease of global histone genes expression after gy dose was found. relative increase of h and h b fractions after irradiation was observed. conclusion overall expression of histone genes does not seem to influence radiosensitivity of glioma cells. probably, more important is the profile of expression, e.g. differences between h and h b genes. this profile may be a useful adjunctive criterion in the choice of treatment protocol for brain glioma. introduction the detection of breast cancer (bc) micrometastasis in effusions is difficult since the malignant cells are rare and spread amongst the normal population. rt-pcr for human mammaglobin (hmam) has been described as a new, sensitive method for use in bc cell research. some authors have proposed using this assay for screening bc effusions for bc micrometastatic disease. the aim of this study was to investigate the possible application of rt-pcr for hmam for assessing bc cells in effusions and compare this methodology with cytological examination. the study was performed on fluid specimens ( bc, other types of cancer and without known carcinoma). the samples were analyzed by staining with ee, papanicolau technique, and by nested rt-pcr for hmam. results / ( %) cases of bc pathology were positive using nested rt-pcr for hmam. all cytology positives were also positive by nested rt-pcr. in contrast, bc cases that were positive in the molecular test were negative according to the staining assay. hmam was also detected in / ( %) specimens of other types of cancer and only / ( . %) samples of non-neoplastic origin. conclusion nested rt-pcr for hmam was more sensitive than cytology in determining bc micrometastasis in effusions. positivity was not restricted to samples from bc patients as specimens from other tumors and only . % of patients without cancer were also positive. this test could be helpful in investigating neoplasticity in effusions. introduction hepatic ischemia-reperfusion injury results from implementation of pringle's manoeuvre to prevent blood losses in patients undergoing liver segment resection. reoxygenation after the ischemic period leads to failure of hepatic microcirculation, leucocyte invasion and kupffer-cell activation. subsequent production of inflammatory cytokines and ros (reactive oxidative species) are triggered, thus causing oxidative stress and damage of liver parenchyma. the goal of our study is to evaluate markers associated with the severity of this particular type of oxidative stress at the gene expression level. we have analyzed liver tissue biopsies at different timepoints obtained from patients undergoing liver segment resection. in each case, the first sample is taken before clamping, the second sample is taken after minutes of ischemia, and the third sample is taken after minutes of ongoing reperfusion. we compared mrna levels of several genes (sqstm , hspa a, gpx , sod , hmox) in every set of samples by quantitative rt-pcr analysis. significant elevation of hspa a at timepoint was detected in of cases. this finding suggests that hspa a may represent a useful marker for oxidative injury of hepatic tissue. at the same time, we show that the detection of changes in gene expression within minutes of reperfusion is possible by quantitative rt-pcr from a single biopsy. we hypothesize that individual differences in gene expression may reflect severity of the inflicted ischemia reperfusion injury as well as patient prognosis. the clinical significance of our preliminary results is currently under investigation. automated tissue microarray evaluation and normalization using a dna scanner oridis-biomed gmbh, graz, austria institute of pathology, graz, austria introduction tissue microarray (tma) immunohistochemistry is gaining importance in drug target validation. hundreds of tissue samples on a single slide enable simultaneous immunohistochemical assessment of protein expression. correlation of expression levels of the target antigen with clinical parameters can facilitate determination of disease relevance and therapeutic potential. the aim of this study was to extend the scope of this technology, we developed a robot for automated tma production. we further assessed the use of a dna microarray two color laser scanner for automated analysis of tma immunohistochemistry and the use of an internal reference antigen for standardization to the tissue content. the tma robot was developed in cooperation with an engineering company. a breast carcinoma tma was stained with an estrogen receptor (er) antibody. lung carci-nomas tmas were double stained with combinations of rabbit and mouse antibodies. immunoreactivity was detected with fluorescently labeled secondary antibodies. the slides were evaluated using a cdna array scanner and software. fluorescence intensity for er ihc on a breast carcinoma tma correlated positively with independent assessment of the diagnostic er immunoreactivity score, suggesting that ihc quantitation can be achieved with the dna array scanner. double ihc on lung tmas demonstrated that one antigen reference can normalize tumor marker ihc signals for the cellular content of tma cores. ihc signal normalized in this fashion correlated with clinical parameters in agreement with published results. manifestation of metallothionein (mt) correlates rather with cell differentiation than with intensity of proliferation. introduction metallothioneins (mt) are proteins which are supposed to play role in the cell cycle. numerous publications describe positive correlation between intensity of mt expression and proliferative potential of cells. our study aimed at examining the relationship between mt expression and intensity of proliferation, measured using ki antigen. the studies were performed on samples of ductal breast carcinomas of g , g or g grade of differentiation as well as on samples of normal epithelium and planoepithelial carcinoma of uterine cervix. paraffin sections of the examined cases served to perform immunocytochemical reactions using mouse monoclonal antibodies to mt and ki . double staining reactions were also performed using the same antibodies. the performed studies showed that mt expression in breast cancers of g grade was significantly lower than in cancers of g or g grades (p= . ). in the case of ki , the least intense expression characterized cancers of g grade and the most intense reaction was noted in cancers of g grade (p= . ). no relation between mt and ki expressions was observed in g and g groups of breast cancers (p> . ) while in the g group as well as in the entire group of breast cancers (g to g ) a positive correlation between the two expressions was noted (p< . ). analysis of reactions in the non-keratinising stratified flat epithelium and in the planoepithelial cancers of uterine cervix showed no correlation between expressions of mt and ki . however, mt expression was detected only in the least differentiated cells of the epithelium. conclusion our showed that mt expression tends to correlate more with cell differentiation extent than with proliferative potential of the cells. is the activation of akt a prognostic parameter in colorectal cancer? akt (protein-kinase b, pkb) is a serine-threonine kinase that is activated mainly by insulin, igf- receptor and erbb family receptor signaling in a pi -kinase dependent manner, and is implicated in tumor proliferation in breast, ovarian, pancreatic and gastrointestinal cancers. the phosphorylation of its substrate proteins result in increased growth and decreased susceptibility to apoptosis. the activation of the pi k-akt pathway is downregulated by pten phosphatase, and mutations or a loss of pten activity results in a high constitutive activation of the kinase. the aim of the present study is to investigate the levels of the activation of the pi k-akt pathway in a series of colorectal carcinomas and to evaluate its role on tumor resistance to chemotherapy. we achieved surgical colorectal carcinoma specimens at pt stage. all patients received at least two chemotherapy lines based on platinum and cpt- after surgery. levels of activation of akt were tested by immunohistochemistry in primary tumors using a polyclonal antibody that recognizes the phosphorylated akt at ser . in the series, ( . %) showed staining for phosphoakt in tumor cells. phos-phoakt was detected in tumor as clusters of cells related to necrotic foci and differentiated areas and correlated with less response to chemotherapy. these results point out that . activated akt is often overexpressed in human colorectal carcinomas and .activated akt can be a parameter of chemotherapy resistance in colorectal cancer. mutational analyses of the ret proto-oncogene in slovenian men families introduction alport syndrome (as) is a progressive inherited nephropathy, characterized by irregular thinning, thickening and splitting of the glomerular basement membrane (gbm), associated with hearing loss and ocular symptoms. as is caused by col a mutations in its x-linked form and by col a and col a mutations in its autosomal recessive form. the mutations in col a and col a have been reported in familial benign hematuria (bfh). aims: we screened col a , col a and col a genes in slovenian families with x-linked as and in slovenian families diagnosed with bfh to determine pathogenic mutations, to correlate them with clinical features and to confirm or provide precise diagnosis. materials and methods genomic dna was isolated from blood. screening for mutation was done by the optimised ssca after pcr amplification of each exon of col a , col a and col a and changed samples were sequenced. we found six different mutations in col a gene in as suspected patients. one of the mutations was present also in three families with bfh. in col a gene three and in col a four mutations, all in heterozygous state, were identified only in patients with bfh. eleven of the mutations are new and private. four rare variants of unknown pathogenesis and many polymorphisms were found in the col a and col a genes. a mutation was detected in % of as patients and in % patients diagnosed with bfh conclusions our study broadened the spectrum of mutations in col a , col a and col a and demonstrated the involvement of the col a and col a genes in the pathogenesis of bfh. introduction prion diseases are a group of fatal neurodegenerative disorders. the commonest human prion disease is creutzfeldt-jakob disease (cjd). sporadic cjd is genetically characterized by a lack of pathogenic mutations in prnp gene but methionine/ valine polymorphism at codon determines the susceptibility to sporadic and other non-genetic forms of cjd. homozygosity for either methionine or valine increases the risk for acquiring cjd. aims: we searched for changes in prnp gene of healthy populations and scjd cases and compared genotypes of codon in order to prove differences among populations and non-familiar origin of scjd cases and also to confirm the influence of codon homozygosity on the disease development. material and methods blood samples from six populations (slovenian, afro-american, pima indian, cheyenne indian, finnish, german) and brain or blood samples from scjd slovenian cases were collected and dna was extracted. pcr-ssca was performed and changed samples were sequenced. introduction tumour suppressor gene rassf encodes different isoforms, derived from alternative splicing and differential promoter usage. the major transcripts a and c are expressed in all normal tissues, but transcript a is missing all cancer tissues. loss of expression is mainly corellated with methylation of the cpg island promoter sequences of rassf a but mutations in exons have also been found. we examined the status of promoter methylation and potential changes in the coding region of the rassf a gene in colon cancer tumours. materials and methods isolated dna from tumours of colon cancer was used for exon amplification of rassf a gene. for identification of mutations and polymorphisms ssca was used. abnormal patterns on ssca plates were sequenced. for determination of methylation status of the cpg islands we used cobra method. results cobra analysis revealed the hypermethylation of cpg islands. sequencing analysis of exons showed different nucleotide changes. we identified c>a mutation (r s), g>c mutation (d h), g>t mutation (a s), g>a mutation (r h), g>a mutation (r q) and c>a mutation (l i). r s, d h, r h and l i mutations have not been published yet. conclusions these results indicate that hypermethylation of the promoter of rassf a gene in colon tumours and missense mutations in protein itself could be involved in tumorigenicity of colon cancer. introduction pineal lesions are rare and comprise , - % of all intracranial tumors. various histological types of tumors arise in the pineal region. the aim of this study was to determinate histological types, immunohistochemical expression, age and sex distribution of lesions in pineal region. twenty-four expansive lesions in the pineal region, obtained between and , were analyzed. formalin-fixed, paraffin embedded surgical specimens were stained routinely and immunohistochemically for panel of antibodies; synaptophysin, neuron specific enolase, neurofilament, chromogranin a, glial fibrillary acid protein, cytokeratin, carcinoembrional antigen, β-hcg, human placental antigen, α-fetoprotein and ki- . results histology revealed six germinomas, seven pineocytomas, three pineoblastomas, five glial cysts and one ganglioglioma, pilocytic astrocytoma and epidermoid cyst. the study group consisted of females ( , %) and males ( , %) ranged from to years of age. all germinomas were in male patient while glial cysts were diagnosed in female patients. slightly female predominance was observed in pineal parenchymal tumors. immunoreactivity for neuron specific enolase, synaptophysin, neurofilament and for chromogranin a was positive in the pineocytomas, and partially expressed in pineoblastomas. the mean ki- index in pineoblastomas and germinomas were significantly higher than in pineocytomas. germinomas showed focal immunoreactivity for β-hcg, human placental antigen, α-fetoprotein and low immunoreactivity for cytokeratin and carcinoembrional antigen. conclusion the most common tumors are pineal parenchymal tumors and germ cell tumors. glial pineal cysts are also common. occasionally other types of tumor are found. immunohistochemistry is an important method in differential diagnosis of pineal tumors. immunohistochemical study of the metastatic brain tumors with accent of the role of thyroid-transcription factor- introduction the exact diagnosis of the metastatic brain tumors /mbt/ is challenge for the surgical pathologist especially in a case of unrecognized primary site. the aim of this study was to determine reliable immunohistochemical panel based on the histological features of the mbt. materials and methods sixty five cases with solitary mbt operated in neurosurgical department of the hospital were examined from the time period - ; thirty nine were of unknown primary origin ( %). immunohistochemical studies were performed using antibodies to ck-s, ema, nse, synaptophysin, psa, vimentin, s- protein, hmb , ttf- and gfap. results diagnosis of the mbt of unknown origin were as follow: squamous cell carcinoma - cases from total , small-cell undifferentiated - from , large cell undifferentiated - from , adenocarcinoma - from , adenosquamous - from , clear cell - from , papillary carcinoma - from , tubular - from , spindle cell - from , unclassified - from . the primary site of adenocarcinoma, undifferentiated small and large cell and clear cell carcinoma was established by using ttf- (positive in from lung cancer, . %), neuroendocrine markers, ck- and psa. after the investigation only three tumors were of unknown origin ( . %). the origin of the rest unknown before studies of mbt, confirmed with radiographic and endoscopic data were: lung - from total, breast - from , kidney - from , skin- from , thyroid gland - from , stomach - from , prostate - from . the colon, testis and ovary, at one case each, were known before operation. conclusions immunohistochemistry remains important and still very helpful method in determining primary origin of the mbt generally in undifferentiated neoplasmes and adenocarcinomas. among the most reliable tumor markers should be included ttf- , for its frequent expression in the lung cancer, predominant among mbt. brain calcification simulating brain tumour. a case report a shmeleva, s romodanov neurosurgery institute, academy of medical science of ukraine, kiev, ukraine objectives the aim of this study was to describe the plural calcifications in the brain. the patient was a -year-old man. he had a severe headache and disorientation, he felt weakness in the left arm. the patient was mentally handicap. st scan showed a tumour located in the deep parts of the right temporal lobe. with a working diagnosis of tumour, the patient underwent the operation. the surgical specimens were prepared by standard histological techiques. results macroscopically, the lesion appeared as a stone. a histological examination demonstrated a massive deposits of calcium in the parenchyma of the brain. calcification developed as small granules in the vessels and calcospherites of various dimensions were formed by confluence. there were zones of haemorrhage, neuronal loss, edema and proliferation of astrocytes. conclusions this patient is an interesting clinical case of dementia characterized pathologically by diffuse calcification. carcinoid tumour metastatic to the orbital muscle. a case report introduction optical contrast is sensitive to monitor dynamic and functional changes, such as blood concentration, tissue oxygenation, and cellular swelling. optical imaging has been widely employed in clinical applications including the investigations of functional neuroanatomy and neuroactivity. due to the overwhelming scatter of light during the propagation inside biological tissues, past attempts to visualize brain architectures non-invasively with the optical contrast have been severely restricted by the unsatisfactory spatial resolution. the aim of this study was to investigate the feasibility of a novel non-invasive transcranial imaging of the structure and function of brain in vivo accomplished with laserinduced photoacoustic tomography (pat). material and methods pat visualized the tissue structures in rat/mouse brain based on the high sensitive intrinsic optical contrast while utilizing the diffraction-limited high spatial resolution of ultrasound. results two-dimensional (or three-dimensional) rat (or mouse) brain structures, with and without lesions, were imaged clearly. in response to whisker stimulation, functional cerebral hemodynamic changes in cortical blood vessels around the whisker-barrel cortex were also mapped successfully. pat imaged hyperoxia-and hypoxia-induced cerebral hemodynamic changes as well. conclusions this study demonstrates that (i) structural pat of soft tissues lesions in the brain presents high intrinsic contrast, (ii) functional pat based on intrinsic optical signals can map the hemodynamic changes in the cerebral cortex and (iii) in contrast to other previously used optical methods, this technique enables completely non-invasive neuroimaging with high spatial resolution transcranially. this novel functional neuroimaging technique, will help to advance the research in neurophysiology, neuropathology, and neurotherapy significantly. microscopic disorders of cortical development of brain and the etiopathogenetic relevance of their detection in patients with temporal lobe epilepsy due to hippocampal sclerosis introduction hippocampal sclerosis (hs) represents a common structural basis of temporal lobe epilepsy (tle). however, the etiological factors and mechanisms leading to its development still remain unexplained. the aim of this study was to identify the disturbed neuronal migration and differentiation (nmd) in the temporal lobe resected for hs and to evaluate its potential role in the individual pathogenesis of hs. we present neuropathological findings in the resected hippocampus and the pole of the temporal lobe in patients with hippocampal sclerosis with an attention paid to the histopathological identification of defects of nmd in the temporal lobe. the morphological findings were correlated with the results of clinical examinations and the patients´ histories. results 'initial precipitating injuries' that are thought to cause the development of hs (febrile seizures in early childhood, head injury or meningoencephalitis) were present in the history of patients. in the remaining cases, no predisposing factors were found. defects of nmd were observed in cases; in three of these, no predisposing factors were identified in the patients´ histories. we suggest that in these cases, hs arises due to previously undetected disorders of cortical development. a latent neocortical malformation may also contribute to the development of hs in patients with an initial precipitating injury in anamnesis. conclusion histopathological examination of resected epileptic brain tissue can provide insights into the individual pathogenesis of epileptic disorders, especially by the detection of microscopic disorders of cortical development. supported by: gacr / /d , vz fnm , vz msmt and introduction cerebellar liponeurocytoma is a newly recognized rare clinicopathological entity of the posterior fossa, with advanced neuronal/neurocytic and lipomatous differentiation. the term 'cerebellar liponeurocytoma' was recently adopted by the who group to replace several other different terms used up to now. this tumour shows many morphological similarities to medulloblastoma and neurocytoma, but according to available literature has more favorable prognosis then typical medulloblastoma. we report a case of cerebellar liponeurocytoma in a -years-old woman who developed typical symptoms of a posterior fossa tumor. computed tomography (ct) scan disclosed a heterogeneous tumor mass in the left cerebellar hemisphere. the lesion was totally resected. methods the surgical specimen was rinsed in saline solution and fixed in % paraformaldehyde in phosphate buffer at ph . for hours, embedded in paraffin and prepared for histological and immunostaining. results microscopically, the tumor was composed of small less differenerentiated, round or oval closely packed medulloblastomalike cells and vacuolated cells with macrovesicular lipid accumulations giving in some large areas an appearance indistinguishable from mature fat cells. glial and neuronal differentiation was histopathologically and immunohistochemically (gfap, nse, nf) noted. these cellular components were intermixed in different proportions without distinct separation. many tumor cells of all types showed single or multiple smaller lipid vacuoles in their cytoplasm. conclusion our case provides evidence that mature adipose-like tissue in these tumors appears as result of progressive lipidization of neuroectodermal tumour cells rather than as result of adipose metaplasia. introduction determination of proteins taking place in the control of proliferation in normal cells helps a better understanding of cellular transformation and proliferation mechanisms. object although they do not arise from a tissue normally thought to be a target tissue for progesterone, meningiomas show a number of epydemiologic and clinical features which suggest that females sex hormones can play a role in their development (higher incidence of meningiomas in woman, rapid progression of symptomas and icreasing in size during the pregnancy and during the luteal phase of the menstrual cycle, as well as significant association of meningiomas with obesity and breast carcinomas). the aim of our study was to investigate the progesterone receptor contents of bening meningiomas (who gr. i), which is completly excised and evaluated possible relationship between receptor content and sex and age of the patients, histological tipe of meningiomas and localisation of tumor. material and methods tissue samples, fixed in formalin, and embedded in paraffin were evaluated immunohistochemically for progesterone receptors using specific monoclinal antibodies. the correlation between number of positively nuclei and progesteron status was determined by the analitic statistical test mann-whitney. % of the meningiomas tested were positive for progesterone receptors. progesterone receptors in the benign meningiomas in the male patients was significantly higher when compared to the female patients (p< , ). neonatal intractable seizures revealing diffuse and bilateral cortical dysplasia. a case report s bellefqih , c rambaud , t lacaze , jj hauw , g lyon , d seilhean groupe hospitalier pitié-salpétrire, paris, france hôpital antoine-béclre, paris, france cerebral cortical dysplasia is generally focal and sometimes related to tuberous sclerosis. it is believed to result from disrupted neuronal migration during cortical development. we report an unusual case of neonatal diffuse and bilateral cortical dysplasia revealed by refractory epilepsy. a male infant, born at weeks' gestational age (ga) without familial history of neurologic disease, presented at birth a convulsive encephalopathy, associated with severe hypoxia with pulmonary hypertension and iterative hypoglycemia. a foetal goitre was attributed to hyperdose therapy for maternal graves' disease between and ga. the patient died at weeks of life from respiratory failure after intensive care. all the iso-and allocortical areas examined were normal at gross examination, but microscopically dysplastic. there was disorganization of the laminar architecture and presence of large multipolar neurones diffusely distributed over the cortex. they showed positive immunoreactivity with neurofilaments and synaptophysin, and were negative with gfap and vimentin. numerous ectopic neurons were found in the white matter. in addition, c shaped thickened inferior olive was noted. the cerebellum, including dentate nuclei, and other brain stem nuclei were normal. focal cortical dysplasia lesions are localized malformation of the isocortex with positive gfap and vimentin in dysplastic neurons. in this case, the dysplastic lesions were diffuse and astrocytes were normal. no genetic investigation was available, but the negative immunostaining of large cells by gfap does not favour the diagnosis of tuberous sclerosis. the pathogenesis of this exceptional disease remains obscure but the responsibility of the foetal thyroid disorder cannot be excluded. structural genomic abnormalities of chromosomes and in myxopapillary ependymomas in an attempt to clarify the chromosomal status of these tumors and identify commonly aberrant regions in the genome we have combined molecular/cyto/genetic methods to study genomic abnormalities in mpe. comparative genomic hybridization analysis of / tumors identified concurrent gain on chromosomes and as the most frequent finding. the majority of the tumors were also studied using microsatellite analysis ( markers for chromosome and markers for chromosomes ) and interphase-fish with centromeric probes for chromosomes and . our combined results were consistent with polysomy and in cases, polysomy either or with partial gain in the other chromosome in cases, tetrasomy or partial gain either or with complex rearrangement in the other chromosome in cases. in the remaining cases allelic imbalance alone of either chromosome or was identified. other numerical abnormalities observed included gain of chromosomes , , , , , , , q, and x and loss of chromosomes and . the combination of gains of genetic material from chromosomes and seems to be common in mpe and may represent genomic events of importance in the development of the tumor. nonsymptomatic nontumor cysts of the pineal gland: frequency and morphological characteristics the effect of bcl- protein and ki- expression on the prognosis of medulloblastomas introduction medulloblastoma is the most common primary central nervous system tumor in childhood and accounts - % of all intracranial neoplasms in children. aim: in this study the correlation between the patients survival and prognostic factors (ki- and bcl- ) and the tumor size in ct scan were evaluated. material and method selected cases were analyzed. immunohistochemical staining was applied as polyclonal antibody for ki- (dako-a- ) and monoclonal antibody for bcl- (bcl- / /d novo castra) on paraffin blocks.fisher's qhisquare, correlation and mann-whitney-u tests were used for the statistical analyses. results the ages of these patients were ranged between - (mean . ).the size of the tumoral mass varied between to centimeter. patients were alive without illness. patients were lost due to tumor. we could not found a statistical revelance between neither immunohistochemical staining (bcl- , ki- ) nor tumor size on survival rates. conclusion due to radiotherapy and chemotherapy following surgery, the survival rates of medulloblastoma has increased despite the agresiveness of the tumor. there are reports showing no correlation between expression of the bcl- with the outcome of patients. further investigation about the correlation of the prognostic factors with the outcome is required. introduction results of glioma treatment are still unsatisfactory. an accurate histopathological study supplemented with examination of tumour parameters, like proliferation potential and apoptosis may be invaluable in designing an individualised therapy. the aim of this study was to analyze clinical data and histo-clinical correlations in recurrent brain tumours of astrocytic origin. one hundred surgically removed supratentorial gliomas were studied (mean age: . yrs). histological grade was determined according to who classification and the daumas-duport scale (st.anne/mayo). proliferation activity was measured using the pcna index and agnor count. the expression of bcl- protein was examined with immunohistochemistry. results and conclusion the initial symptoms of glioma were headaches and vomiting ( %), paresis ( %), epilepsy ( %) and aphasia ( %). the tumour location was predominantly in the left hemisphere, in the temporal ( %), parietal ( %) and frontal ( %) lobes. the pcna index correlated with who grade (giiindex %, giii - - % and giv - %). for grades i, ii, iii and iv progression free survival (pfs) was: . , . , . and . months respectively. the agnor count did not correlate with who grade, daumas-duport grade or pfs. bcl- expression was observed in single cells in gi and gii tumors, in % and % of cells in giii and giv, respectively. the daumas-duport scale is simple and useful in prognosing. bcl- expression does not correlate in a linear manner with tumour grade. as gliomas are extremely heterogeneous, for better characterization of the clinicopathologic correlations new prognostic factors are needed. introduction schilder's type of myelinoclastic sclerosis is rare variant of multiple sclerosis in children and young adults. usually, brain lesions occur in the white matter like solitary, or less often multifocal, acute plaques ranged in diameter more then cm. case report the -year-old female patient was referred to our hospital with progressive right-sided hemiparesis, motor dysphasia and frontal lobe syndrome. symptoms started days earlier with acute headache and no febrile state was reported. mri of the head revealed two oval lesions with hyperintensity in t weighted images of left frontal and parietal lobe. the first diagnostic impression was of glioblastoma multiforme. results from standard blood and urine tests, tumor markers and cytological analysis of bone marrow were normal. analysis of csf and culturing csf and serum for bacterial, viral, protozoan and fungal infections were negative. analysis of csf revealed increased immunoglobulins, ocb and increased intratecal synthesis of igg. a stereotactic biopsy was performed one month after first symptoms. neuropathology findings. the biopsy after neurosurgical treatment yielded five needle cores of grayish cerebral tissue. hematoxylin and eosin-stained sections of paraffin embedded tissue showed demyelinating white cerebral tissue with relatively sharply defined margins. lesion was infiltrated by macrophages (cd immunopositive cells and luxol fast blue negative) and large reactive astrocytes with ki and pcna nuclear positivity. around blood vessels were scattered perivascular cd and cd lymphocyte. silver impregnation and nf immunostaining showed that the axons within the plaque are attenuated but not destroyed. conclusion clinical and pathological findings suggested a demyelinating disease destroyed huge parts of white matter in before health mid-aged women, without previous infection or vaccination. accordingly we diagnosed schilder's type of ms. stereotactically guided brain biopsy: six years' experience of pathologic interpretations from turkey e erden , a okcu heper , a savas ankara university, school of medicine, pathology department, ankara, turkey ankara university, school of medicine, neurosurgery department, ankara, turkey introduction stereotactic biopsy is a widely used procedure in brain lesions. the aim of this study was to analyse the reasons of the discordance between the results of the intraoperative crush preparations (icp) and final permanent paraffine preparations (fppp) of stereotactically guided brain biopsies (sgbb) in our hospital, and find out the clinical benefits of this procedure. total ct and/or mri guided brain biopsies performed between - were analysed retrospectively. icp and fppp preparations were evaluated and discordant cases were detected. then we evaluated the reasons of discrepancies. results the correct diagnosis was achieved by stereotactic biopsy in . % of the patients. of them were diagnosed as neoplasia and were diagnosed as non-neoplastic pathology. there was discordance between icp results and fppp diagnosis in . % of the stereotactically diagnosed patients. the patients diagnosed as neoplasia were treated by rt and/or kt and the non-neoplastic pathologies were taken in suitable treatment and follow-up scheme. conclusion to improve the diagnostic accuracy of the sgbb, the following items should be taken into consideration: the quality of the icp with giemsa staining is very important. in the biopsies from the lesions, which are suspected as neoplasia having, microscopic features such as gliosis, edema, hemorrhage must be interpreted as non-diagnostic. the number of the biopsies must be increased in the presence of necrosis. epitheloid and pleomorphic cellular groups can mimic benign and malignant pathologies. interpretation of the icp and the fppp should be done by the same pathologist. intraneural capillary haemangioma of spinal nerve root. case report p xirou , s barbanis , i efstratiou , p sevastiadou , i tsitouridis papageorgiou general hospital, department of pathology, thessaloniki, greece papageorgiou general hospital, department of radiology, thessaloniki, greece intraneural haemangiomas of the spinal nerve roots are rare. the few cases reported in the literature are usually of the capillary and less often of the cavernous type. these lesions occur in adults, mainly males and the majority of them are located in the cauda equina. a case of intraneural capillary haemangioma involving one lumbar nerve root is reported. the patient, a year old male, presented with a -year history of severe intermittent low back pain. magnetic resonance imaging detected an intradural, extramedullar, space occupying mass at the level of l -l , causing displacement of cauda equina roots. laminectomy and complete removal of the lesion were performed without neurological problems. on gross examination the resected specimen was a redbrown, well demarcated, lobular mass, measuring . cm in greatest diameter. remnants of a nerve root were recognized at the periphery. histological examination showed that the lesion was located within the endoneurium. it consisted of multiple small dilated capillaries, often showing incomplete lobular pattern, dispersed within normal nerve fascicles. the endothelial lining showed neither nuclear atypia nor mitotic activity. in the substrate mild edema and focal inflammatory lympocytic infiltrations were found. haemangiomas of the spinal nerve roots often pose a challenging diagnostic problem, and knowledge of their existence is relevant since they can mimic other more frequent tumors of the region. introduction sensorimotoric polyneuropathy has rarely been reported as a presenting paraneoplastic neurological disorder associated with anti-hu antibodies. electrophysiological studies suggest a dysfunction of axon-schwann cells, but the exact pathological mechanisms remain unclear. case report a -year old woman with short history of weight loss and parastesias in the legs was admitted to the hospital. triparesis and dyspnea were found. mri scan showed leukencephalopathy, eeg revealed diffuse encephalopathy. sensorimotoric axonal polyneuropathy was present in emg, and small lesion in the lung was found on the ct scan. anti-hu antibodies were present in the serum and in the cerebrspinal-fluid. autopsy revealed macrocellular adenocarcinoma of the lung with neuroendocrine differentiation and sensorimotoric neuronopathy/ encephalomyelitis. methods the brain, spinal cord, sensory ganglia and a part of sural nerve were fixed in formalin, paraffin embedded and stained with h&e. other part of sural nerve was prepared for immunofluorescence, semi-thin and ultra-thin sections. results axonal degeneration without any inflammatory reaction and a very few signs of regeneration were found in the sural nerve. the inflammatory destruction of spinal ganglia neurons, axonal degeneration in dorsal columns and motor neurons inflammatory destruction in the spinal cord were found. neuronal degeneration, glial proliferation, perivascular inflammatory infiltrates and some cd + lymphocytes surrounding single neurons were a common finding in the brain. conclusions this study shows that inflammatory destruction of the spinal ganglia neurons and motor neurons in the spinal cord was the main cause of clinically rapidly progressive sensorimotoric polyneuropathy in the anti-hu positive patient with macro cellular lung carcinoma with neurendocrine differentiation. isolated extranodal spinal rosai-dorfman disease. a case report ai freitas rc silva l costa, v velasco, p monteiro, m teixeira, f pardal de oliveira hospital de sao marcos-serviço de anatomia patológica, braga, portugal introduction sinus histiocytosis with massive lymphadenopathy was first described in , by rosai and dorfman, as an idiopathic histiocytic disorder, which typically involves lymph nodes. lately, involvement of many other organ systems has been documented, either alone or in association with nodal manifestations. nowadays, rosai-dorfman disease is a wellrecognised clinico-pathologic entity. extranodal disease has been reported in % of the reported cases, occasionally representing the first and exclusive manifestation of the disease. although central nervous system involvement has been well documented, the spinal canal is affected only exceptionally. we report a case of an isolated extranodal spinal rosai-dorfman disease with review of the literature. the authors describe a old woman with a history of spastic hemiparesis in which radiology disclosed a dural-based intramedullary spinal cord lesion at c level. the authors describe the histologic and immunohistologic features of the lesion and discuss the differential diagnosis. conclusion isolated cns rosai-dorfman disease without contemporary lymph node involvement can be a diagnostic challenge. pathologists must be aware of this disease in order to make a correct diagnosis and avoid diagnosis of malignant histiocytic lesions. ezrin immunoreactivity: is it a usefull marker for the prognosis and grading of astrocytoma? ie gurer , ga gökhan , t uçar akdeniz university scholl of medicine department of pathology, antalya, turkey akdeniz university scholl of medicine department of neurosurgery, antalya, turkey introduction the actin-binding protein ezrin is supposed to increase the invasiveness of the malignant cells. in this study, the value of ezrin immunoreactivity (ir) was invastigated as a grading and prognostic parameter in astrocytomas. material and method ezrin ir was studied in low grade and high grade astrocytomas. the mean age of the patients was . . monoclonal ezrin antibody (ms- -r neomarkers) was applied on the sections of the paraffin-embedded tissues. immunostaining intensity of ezrin was estimated as semiquantitatively. when no staining was visible the score of , mild staining scored as , moderate , and severe staining scored as . also positive stained areas were evaluated as percantage ( %, - %, above % staining areas). statistically man-whitney u, kruskal wallis and spearman tests were used. results there was no correlation between prognosis and neither the grade nor the staining intensity of ezrin ir. conclusion there are controversial reports especially about the prognostic value of ezrin ir in different types of tumors. there is one report about the association of ezrin ir with the increasing malignancy of astrocytic tumors. results of our study revealed no evidence of correlation between prognosis and ezrin ir for grading of astrocytomas. we conclude that ezrin is not a usefull factor for the prognosis and grading in astrocytomas. introduction hereditary cystatin c amyloid angiopathy (hccaa), an autosomal hereditary disease uniquely found in iceland, usually leads to early death of young adults from cns vascular complications following a disease progress of several years. histopathological characteristics are cystatin c amyloid deposits in meningocerebral blood vessels, narrowing, splitting of media, segmental fibrinoid necrosis and microaneurysms of small arteries and arterioles. associated changes: hemorrhages, infarctions and reparative reactions depending on length of the disease course. this study is a part of an investigation mapping the distribution of cystatin c immunopositive deposits outside the cns in hccaa. material and methods formalin fixed, paraffin embedded autopsy material from patients, females and males, was studied by conventional light microscopy (he, congo red; thioflavin s) and immunohistochemistry (avidin-biotin-peroxidase) with cystatin c antibodies (abc-complex kit from vector). for electron microscopy and specific identification of cystatin c deposits specimens were fixed in macdowell's fixative and embedded in l.r. white resin and immunogold labelled (colloidal gold labelled protein a. sigma). results and conclusion cystatin c immunoreactive deposits were found in most organ systems outside cns. the deposits were primarily located in the adventitia and perivascular tissue of small blood and lymphatic vessels and vascular smooth muscle; in subepithelial connective tissue of intestinal surface epithelium and glandular epithelium; in peripheral nerves. cystatin c immunoreactive blood vessels were not obviously damaged as those in the cns possibly reflecting environmental factors different in these two separate locations not yet identified and characterized. details of cystatin c deposition in the vascular walls will be demonstrated. neurological disorders are among the most prominent clinical manifestations of antiphospholipid syndrome (aps). they are predominantly related to thrombo-occlusive vascular events in central nervous system, vasculitis playing little or no role. case report a -year-old female with a history of seven spontaneous abortions presented with sudden onset of pain and numbness in her right and later left foot followed by pruritic rash over her hands and back and livedo reticularis around knees. emg showed signs of axson injury in multiple nerves. laboratory tests showed lymphopenia and antiphospholipid antibodies of igg class in medium titer at the begining and in low titer three months later. anca, ana, ena, anti-dna were negative, platelet count, complement, lupus anticoagulant and tumor markers were normal. sural nerve biopsy revealed active necrotizing arteritis of small epineural arteries. intimal circular fibrinoid necrosis was accompanied by pyknosis, karyorexis and myofibroblast proliferation in media. inflammatory infiltration by lymphocytes, macrophages, plasma cells and segmented leucocytes was present in intima, but was most prominent in adventitia. thrombosis in organization was observed. vasculitis was present also in arterioles and venules. immunofluorescence showed scarce focal granular deposits of igm, iga class, and complement components c and c q in media of small epineural arteries, together with abundant fibrin deposition. it has been suggested that aps can not be the cause of vasculitis and that vasculitis in aps is associated with an independent underlying disease, such as systemic lupus erythematosus. except for suspected aps, our patient did not fulfill the criteria for any systemic autoimmune disease that could present with vasculitis. immunoautoradiographic characterization of serotonin transporter in human pineal gland m the mechanism that regulates human pineal gland melatonin synthesis is not completely clear. in fact, several studies performed on animals demonstrated the possible role of serotonin and the involvement of its receptors -ht( c) and -ht( a) in the modulation of this process even if is not clear how it is realized. the aim of our study is to verify the presence of serotonin transporter (sert) in the pinealocytes, a molecule involved in the reuptake of -ht from synaptic space, and to represent the action site of i.r.s. antidepressant drugs. we tested with immunoautoradiographic method (iarg) frozen slices conserved at - c o , derived from twenty cadaveric epiphysis ( men, women) by utilizing a mouse monoclonal anti-sert antibody followed by a secondary biotinilated anti-mouse igg antibody, consecutively linked with an avidine/[ h]-biotine complex for a precise localization of the researched molecule. the tritium sensitive films were exposited to treated slices in special cassetes. after thirty days of exposure at - c o , the films have been developed and fixed to obtain auto radiographic images in which the radioactivity distribution followed a continuum pattern in sequential slices of each subject. it was the expression of sert presence in epiphysis. this is the first study that demonstrate the presence of sert in human epiphysis. we suppose that serotonin in human is not only a melatonin precursor synthesized in the pinealocytes but it is involved in the neuroendocrine regulatory mechanism of the gland. loss of heterozygosity (loh) studies allow to identify sites harbouring tumor suppressor genes involved in tumor initiation and progression. this study was performed to establish the frequency of loh on chromosome q in glioblastoma. cases of glioblastoma were examined ( women, men; age: - years). two cases were secondary glioblastoma. in all cases the representative neoplastic tissue and normal brain tissue were cut out with lancet from respective paraffin blocks. dna was isolated with proteinase k with phenol/ chloroform extraction and isopropanol precipitation. polymorphic markers were localized close to three supressor genes pten (d s , d s ), lgi (d s ), dmbt (d s ) which are known to be lost or mutated in glioblastoma. the fith marker was d s q . . fragments were pcr-amplified and analysed using automated sequencer abi . signals from neoplastic and normal tissue were calculated. result under , was scored as loh. in cases at least one marker from chromosome q was lost. cases with loh were men, both secondary glioblastomas showed deletion in q. the mean patients' age with and without qloh was similar. cases showed loh only in pten locus. in cases deletions were stated in two or more loci, what might suggest loss of longer part of chromosome . cases with loh in q revealed additional changes in different chromosomes: loh in p ( cases), p ( ), q ( ), p ( ), q ( ), q ( ), q ( ), p ( ). our results are similar to the other studies, showing changes in q in about % of glioblastoma. histopathological changes of the skin in systemic lupus erythematosus ta vervekina, ba magrupov, gsh shamukhitdinova tashkent, uzbekistan introduction morphologic examination of the skin is of great importance for the diagnosis of various nosologic forms of rheumatic diseases. the aim of the present study was to evaluate histopathologic changes in skin biopsies of patients with systemic lupus erythematosus (sle). material and methods skin biopsies of patients ( women and men; age range from to years) with preliminary diagnosis of sle, based on clinical data and laboratory analyses, were studied with the purpose to specify the differential diagnosis. biosy tissue specimens were fixed in % neutral formalin, embedded in paraffin, and serial sections were stained with haematoxilin-eosin, picrofuxin, and the combined rhitter-olesson staining. after treatment of the specimens with . % trypsin, direct immunofluorescence technique was carried out for detection of immunoglobulins g and m at the dermo-epidermal junction (lupus band-test). results our study established the presence of hyperceratosis with formation of keratic clogs, epidermal atrophy with vacuolization of basal cells, vasculitis, eosinophilic degeneration of collagen and an atrophy of appendages. specific immunostaining for immunoglobulins g and m at the dermo-epidermal junction was observed in all except in cases. we did not observe inflammatory cell infiltrates in dermis in any case. conclusion the pathogenesis of skin histologic lesions in sle is most likely associated with immunological reactions and therapy carried out earlier. structural peculiarities of different nevuses and their prognostic value e stupina first tashkent medical institute, tashkent, uzbekistan for the time being the causes of skin melanoma have not been clearly understood. development of skin melanoma was related to preceding pigment formations in % to % of patients. among a variety of investigation methods histologic one is basic to establish the final diagnostic. complex morphologic study was carried out on skin biopsies with different types of pigment nevuses and melanomas. of them biopsies were selected for the thorough pathomorphologic investigation. light microscopy, electron microscopy and morphometric method were used. serial sections for light microscopy were stained with hemotoxylin and eosine, picrofuchsin-fuchselin by van-gizon, combined staining by riter and oleson. the findings have shown that the rate of pigment skin neoplasms of all the biopsy material of a specialized institution came to , % among neoplastic and , % among non-neoplastic skin lesions. pigment nevuses more frequently occurred in females aged to years applied for medical aid, while melanoma in ones above years. intradermal nevus was diagnosed in , % of cases, its proliferative activity was expressed in % of patients. in , % of patients skin melanona was assigned to - th grade of invasion according clark's classification. each form of pigment nevus had morphometric peculiarities, significantly differing in dimensions of the cell, nucleus and their ratio. the most reliable parameter of malignization was the length of the nucleus and cell axial section circle. of frequently occurred nevuses intraepidermal (borderline) one was more predisposed to malignization which was evident from significant increase of all morphometric parameters. introduction cutaneous ciliated cysts are a rare type of skin cyst, usually presenting themselves in women between the nd and th decades of life. their origin is unknown and has been related to müllerian remnants based on similarities of the epithelium to the fallopian tube, but the occurrence of cases in men has given rise to the possibility of a sweat gland origin. case report a year-old woman complained of an asymptomatic, longstanding, lesion located in the skin of the thigh. once removed it was seen to correspond to cyst with clear fluid inside. histopathological examination revealed a dermal cyst with ciliated cuboidal epithelium, usually double layered, but with some pseudostratified areas. occasionally, papillary projections were seen in the lumen. there was no evidence of cellular atypia or mitotic activity. immunohistochemical staining with oestrogen and progesterone receptors was strongly positive throughout the lesion. the clinical and histopathological findings fit in with the diagnosis of a typical cutaneous ciliated cyst of the lower limbs (cutaneous ciliated cyst). this is a rare cyst usually arising in the lower limbs of young women. its origin is unknown and the demostration of sex-hormone receptors has been used to favour the müllerian origin. nevertheless, some cases have been reported in men, which has diverted attention towards sweat glands as a possible origin of the cyst. the real incidence of the sex-hormone receptor if unknown, since it has not been clear in most published cases. introduction p protein is essential for the regulation of cell proliferation and its aberrant accumulation is usually seen in malignant tumors but, also, occurs in squamous epithelium of inflammatory skin diseases characterized by hyperproliferation. the aim of this study is to elucidate the role of the p tumorsuppressor protein in the pathogenesis of different hyperproliferative, non-malignant and malignant skin diseases, and association between p overexpression and cell proliferation. we also investigated the influence of ageing on p and ki- protein expression. material and methods hundred and fifty skin specimens, consisting cases of each, normal skin (ns), psoriatic skin (ps), keratoacanthomas (ka), basal cell carcinomas (bcc), squamous cell carcinomas (scc) were examined immunohistochemicaly to assess p and ki- protein expression. results p immunostaining of ns, ps, ka, bcc and scc was positive in . %, . %, . %, % and . % cases, respectively. p and ki- positive cells were present in basal (ns) and suprabasal layers (ps), and not only in cancer nests of ka, bcc and scc, but also in dysplastic and even morphologically normal epidermis adjoining cancers. the positivity of p and ki- protein differed significantly among the groups, with no differences in p expression between ns and ps, and in ki- expression between ps and ka. within all groups, there was a significant correlation between p and ki- protein expression. localisation and age were significantly related to p and ki- expression in all groups, except for localisation in ps, and age in bcc. conclusions our findings suggest that p overexpression occurs widely in neoplastic and non-neoplastic skin lesions. it is associated with the cell proliferation in normal, as well as, in changed epithelium. p accumulation is an age related process and significantly related to sun exposure, especially in ns and ps, as well as in ka and scc. we also suggest that p overexpression begins in the early stage of carcinogenesis, before the appearance of malignancies in skin, and may be a useful predictor for the detection of nonmelanocytic skin cancer. background maspin, a member of the serine proteinase inhibitor (serpin) family, has been recently pointed to as a tumor suppressor gene and angiogenic inhibitor. objectives of this study were to investigate role of maspin and beta-catenin in basal cell carcinoma (bcc). we studied immunohistochemically their expression in basal cell carcinomas together with trichoepitheliomas (te) and normal skin controls. microvessel count (mvc) was also done using fviii-related antigen. we examined the correlation of nuclear and/or cytoplasmic maspin expression with histological type, age, gender, invasion of safety margin, as well as stromal reaction (lymphocytic or fibroblastic. all primary antibodies (maspin, beta catenin and fviii-related antigen) as well as detection kit (abc peroxidase/dab quick test), were purchased from novocastra labs.uk. maspin expression was strongly cytoplasmic and membranously expressed in te and down-regulated in nodular bcc. nuclear maspin expression was found in . % of our cases. it was statistically positively correlated with invasion of safety margin (p= . ) and with infiltrative type (p= . ) and negatively correlated with a mvc > (p= . ). cytoplasmic maspin was correlated to a strong fibroblastic stroma (p= . ). beta-catenin expression was found in both te and bcc with the same intensity and was only correlated to younger age(p= . ). conclusion cytoplasmic maspin expression could differentiate between te and nodular bcc nuclear maspin expression could be related to aggressive behaviour of bcc and is realted to lower mvc (< ). introduction trichilemmal carcinoma (tc) is rare skin tumour occurring in the sun-exposed areas (largely on the face or ears) of the elderly. clinically, it may be mistaken for a squamous cell carcinoma, basal cell carcinoma, nodular melanoma or keratoacanthoma. although the histological picture suggests a high-grade malignant neoplasm, tc has an indolent course, and conservative surgical excision with clear margins is curative. aim: histological and histochemical examination of rare cases of tc of the skin. materials and methods we report two patients (males) with tc on the ears, presented as slow-growing nodules. tumour biopsy specimens were routinely fixed and processed. deparaffinized sections were stained by he, pas, pas-d. results histologically tumour cells showed a solid and a lobular growth patterns in continuity with the epidermis, with foci of pilartype keratinisation and peripheral palisading. tumour nests were mostly composed of large atypical cells with clear cytoplasm containing pas-positive, and diastase sensitive materials. these cases were treated only with surgical excision, and there has been no evidence since of local recurrence or metastasis. conclusion we believe that careful histopathological examination of pillar appendage tumours will help to classify the wide range of clinically and histologically different tumours and to establish the exact diagnosis. introduction pigmented cutaneous metastases from breast carcinoma are uncommon and may simulate malignant melanoma both clinically and morphologically. we report a case of a -year-old female who developed multiple cutaneous pigmented metastases twelve years after radical mastectomy for left breast carcinoma. materials and methods hematoxylin-eosin and immunohistochemically (streptavidin-biotin method) stained slides from three different regions of the chest skin and from the scalp plaque. results numerous darkly pigmented plaques and nodules have been developed over a -month period on the back of the chest spreading anteriorly to the right subcostal region together with large, focally eroded scalp plaque. histopathological examination revealed full thickness dermal infiltration and superficial subcutaneous fat involvement with cords and nests of neoplastic epithelial cells showing ductal structures and intracytoplasmic lumina in some areas. irregular nests and single tumor cells at epidermodermal junction were accompanied with melanophages in papillary dermis. immunohistochemically all tumor cells were cytokeratin positive and cytokeratin negative while epidermal and most superficial dermal nests showed hmb- and melan-a reactivity as well. scalp metastasis displayed less pronounced epidermotropism and only focal, single cell hmb- and melan-a positivity. conclusion epidermotropic breast carcinoma metastases may mimic malignant melanoma not just clinically and morphologically but also immunohistochemically and that might be related to the location of metastatic lesions. immunolocalization of lactoferrin in pigmented lesions of the skin g barresi, g giuffre, f fedele, m grosso, v barresi, g tuccari department of human pathology, university of messina, messina, italy lactoferrin (lf) expression has been immunohistochemically investigated in formalin-fixed paraffin-embedded bioptic skin samples ( nevi, melanomas, vulgaris or seborrhoic pigmented warts, pigmented basal cell carcinoma; specimens of normal skin were utilized as control. on µm thick sections, depigmentation and antigen retrieval procedures were performed. lf immunoreactivity was revealed by a rabbit anti-human lactoferrin (dako, denmark, : ), incubating all sections at c overnight; successively, bridging antibody and pap complex for min at room temperature (rt) were applied. for the demonstration of peroxidase activity, the sections were incubated with - ' diaminobenzidine tetrahydrochloride-h o substrate solution for min at rt in darkness; slides were then slightly counterstained with mayer's haematoxylin. quantification of lf immunoreactivity was performed using the intensity-distribution (id) score based on both the percentage and the staining intensity of positive neoplastic cells. an evident cytoplasmic immunoreactivity for lf was encountered in melanocytes, either in nevi or in melanomas; no ap-preciable differences were found among junctional, intradermic or compound nevi as well as between spindle or epitheliod cells melanoma. basal cell carcinomas were always unstained, even if some degree of positivity was found in areas which showed squamous differentiation; sheets and whorls of keratin also exhibited a strong immunoreactivity, when encountered in warts. if the lf immunoexpression could represent the result of an endogenous synthesis by cells in order to have greater availability of iron for their metabolism or to modulate an unspecific inflammatory or anti-oxidant response remains to be fully understood. cutaneous melanomas were detected at an increasing rate worldwide. even thought many patients are diagnosed at an early stage, the death rate continues to rise due to the increasing incidence of more advanced lesions. the aim of this study is to detect in cases of malignant melanomas. materials and methods analysis were performed in paraffinembedded cases of cutaneous malignant melanomas ( cases in situ and cases invasive melanomas). apoptotic index (ai) was determined using the in situ end-labeling technique(tunel), who quantify apoptotic cell death at single cell level and tissues. discussion and conclusion ai was high in the cases of in situ melanomas, but in invasive melanomas (nodular melanomas, superficial spreading melanomas with vertical growth phases, acral lentiginous melanomas etc) ai was decreased in tumor cells. we considered that usually apoptotic cells represent ~ % of tumor cells. at cases of cutaneous malignant melanomas in which ai was high ( %), frequently at in situ melanomas, the prognostic is good, when in the others cases in which apoptosis is missing or is very rare in cells ( %), the prognostic is reserved. this nonmorphologic technique to evaluate the prognosis of melanoma must be regarded as investigational and cannot yet be recommended for routine application. all necessary pathologic data, such as tumor location, size, depth, ulceration, mitotic activity and growth phase, can be obtained by examination of standard microscopic preparations of malignant melanoma as stained with hematoxylin and eosin. introduction small vessel vasculitis is a group of disorders of unknown etiology, possibly associated with connective tissue disease (ctd). the aim of this study is to find correlation between clinical, morphological and immunological changes in the skin and muscle biopsies of the patients with ctd, where small vessel vasculitis is the main finding. we analyzed skin and muscle biopsies from patients with ctd: dermatomyositis, systemic sclerosis, syndroma raynaud, vasculitis, sle, polyarteritis nodosa. were females, and males. the age of the patients was between - . standard histological and histochemical stainings (he, pas, van gieson-elastica) were done. small vessel vasculitis was found throughout skin and muscle biopsies, characterized with thickening of the basal lamina, tiny fibrinoid necrosis (if present), swollen endothelial cells and perivascular edema with lymfocytes. the muscles were necrotic with regeneration and fibrosis and reduction in the intramuscular capillaries. the changes were positive on pas and elastic tissue staining. direct immunofluorescence technique was done with antihuman igg, igm and iga antibodies. granular or linear immunofluorescent deposits were found at the dermo-epidermal junction zone and in the vessel walls. antinuclear antibodies were done by indirect immunofluorescence technique using serum from same patients of which % were positive. lymphoid cells around the vessels and in healthy muscle fibers were positive for markers for t cells (cd ro and cd ). conclusion there is correlation between morphological and immunohistochemical changes. the presence of immunologic deposits in the vessels suggests possible autoimmune etiology. cutaneous angiomyolipoma introduction angiomyolipoma is a benign tumor almost exclusively seen in the kidney. cutaneous angiomyolipoma (aml) is a very rare benign vascular tumor that consists of a proliferation of blood vessels, smooth muscle bundles, and mature fat tissue. aml occurs more often in adult male patients and is often seen in acral locations. case report a -year-old man who had a -year history of a painless, solitary, noninvasive nodule on the right auricle lobule. the patient had no signs of tuberous sclerosis. material and methods the lesion was cm in diameter and clinically appeared to be a lipoma. the lesion was excised. skin specimens was fixed in % buffered formalin, routinely processed, and embedded in paraffin. it was examined by routine light microscopy with histochemical and immunohistochemical stains. results on sections, the lesion was a well-circumscribed nodule in the dermis. there was fibrous pseudocapsule around it. the nodule was composed of an intimate mixture of mature adipose tissue, blood vessels, and bundles of smooth muscle cells. combination of different types and sizes of vessels were particularly evident. cellular pleomorphism, mitotic figures, and mucoid degeneration were absent. reactivity for hmb- was negative. the histopathological diagnosis was angiomyolipoma. conclusion amls are very rare at extrarenal locations. in , argenyi presented the first report of cutaneous angiomyolipoma in the upper helix of the ear. the reported lesions were located at acral sites. as most cases of angiomyolipoma were long-standing lesions located at acral sites, and therefore exposed to external forces, some angiomyolipoma could be considered to be a degenerated with replacement by fatty tissues. the primary b-cell cutaneous lymphoma is a low frequent disease in a general hospital. its nodal equivalent has very different behaviour and prognosis. aims: to study the incidence, behaviour and follow up of the b-cell cutaneous lymphomas in our hospital over a period of years. material and methods in a total of cases between and we have cases of b-cell cutaneous lymphoma. the skin biopsies were diagnosed acording eortc classification. we did histological and immunohistochemistry studies. these included cd , cd , cd , cd , cd , bcl- and ki . results eith cases of were salt and cases were folicular lymphomas. the ages are between and and is no sex predominance. salt lymphomas were located two in the face and six in the trunk. all the cases of folicular lymphoma were in the face. the immunohistochemistry study in salt lymphoma showed positivity for cd and cd and negative for cd , cd and cd . the expression of ki was very low. the reactive foliculars centers were demostrated with the negativity of bcl- . the folicular lymphomas showed positivity for cd and cd and the number of positive cells for ki was bigger. conclusions in a general hospital in our country the incidence of b-cell cutaneous lymphoma is very low. the majority of the cases arrive with surgical excision, that is a good therapeutic approach. the general pathologist must be aware with reactive limphoid infiltrates because the majority of the cutaneous lymphomas are low grade neoplasies. background cd expression is a distinct feature of both b and t cell activation. the presence of cd + large atypical lymphoma cells in a cutaneous infiltrate has been considered a characteristic feature of lymphomatoid papulosis/cutaneous cd +. recently, however, cd expression has also been described in some nonneoplastic infiltrates of de skin. design twenty skin biopsy specimens from patients with scabies were evaluated. of these, the lesions had been present for more than months in cases. the diagnosis of scabies was based on the presence of characteristic clinical features and the demostrations of sarcoptes scabiei mite. for each biopsy, a panel of histopathological and inmmunophenotypic features was independently assesed by two pathologists. cd , cd , cd , cd and s- protein expression was evaluated in each case. results cd + cells, either in isolation or in small clusters, were seen in biopsy specimens ( / ; %). cd + cell clusters were located in the papillary and superficial reticular dermis and tended to show a perivascular pattern. all biopsy specimens obtained from long-standing (> months) scabies lesions demonstrated the presence of cd + cells. in contrast, no cd expression was observed in lesions of less than months duration. cd + large cells can be detected in skin inflammatory lymphoid infiltrates associated with scabies, particularly in long-standing (> months) lesions. cutaneous cd expresion, therefore, is not an exclusive feature of neoplastic lymphoid proliferations. probably as the result of persistent antigenic stimulation, cd expression can also be detected in activated lymphoid cells of nonneoplastic infiltrates associated with insect bites, viral and bacterial infections and peculiar drug reactions. introduction malignant transformation of melanocytes is a multistep process characterized by distinct histopathological stages. differentiation between naevi, especially dysplastic naevi and melanoma, can sometimes be difficult to assess by conventional histopathological analysis. the aim of this study was to analyse the differences in proliferative activity and apoptosis between intradermal naevi (in), dysplastic naevi (dn) and cutaneous melanoma (cm). materials and methods fifteen in, dn and cm (thickness less than . mm) were immunohistochemically stained for ki- which was used as a proliferative marker, whereas bcl- and p were used, respectively, as an anti-apoptotic and apoptotic marker. statistical analysis showed a signifficant difference in proliferative activity and the overexpression of p (p < . ), while observed differences in bcl- expression were not statistically significant between these three groups. conclusion proliferative and antiapoptotic activity showed a progressive growth from benign to malignant melanocytic lesions. the strongest expression of p in dn suggests that its overexpression could be the first step in the loss of cell cycle regulation and possible malignant transformation of melanocytes. introduction it is now known that myofibroblastic transdifferentiation in glomerulus takes place during mesangial activation. material and methods we analyzed functional disorders (filtration, concentration insufficiency) and kidney biopsies of patients aged from to years with various forms of glomerulonephritis. we used standard histological, immunohistochemical, immunofluorescence methods as well as electron microscopy in our research. for studying myofibroblastic transdifferentiation we stained tissue immunohistochemically for alpha-smooth muscle actin (alpha-sma) and then carried out a quantitative analysis of the results. results seventy patients had myofibroblasts in kidneys. we found out that level of alpha-sma expression correlates with decrease of glomerular filtration. while disorders of concentration a lot of myofibroblasts appear in kidney interstitium. but we have not found any correlation between clinical forms of glomerulonephritis and those cell growth we had seen. and we should mention that for patients without glomerular or interstitial fibrosis we didn't reveal any changes in cells phenotype. conclusion so we conclude that myofibroblastic transdifferentiation must be considered as an early symptom of kidney sclerosis and can be used as a prognostic criterion. cc tsai , hc hsu dept. of pathology, far eastern memorial hospital, taipei, taiwan, republic of china dept. of pathology, national taiwan university hospital, taipei, taiwan, republic of china introduction to early detect renal and metabolic diseases, a mass urine screen in elementary and high school students was started in in taiwan. we retrospectively reviewed the nephropathologic features to elucidate its value. materials and methods one hundred students, boys and girls, who were found to have hematuria and/or proteinuria by this urine screen program and received renal biopsy, formed the basis of this study. the glomerular pathology was divided according to disease severity into two groups. results group i diseases ( %) showed minor histologic alterations, including minimal glomerular change in cases and mesangial cell proliferation in . among them, children had electron microscopic examination, ( %) had thin glomerular basement membrane (tgbm) disease. group ii diseases ( %) had more severe glomerular changes, including iga nephropathy in cases, membranous nephropathy (mn) in , lupus nephritis in , focal sclerosis in , chronic glomerulonephritis in , and type i and type ii membranoproliferative glomerulonephritis in one case each. these findings confirm that glomerular diseases often progress silently. we found a high frequency ( %) of iga nephropathy and mn in group ii diseases and a close association of mn with hepatitis b virus infection. conclusion we conclude that mass urine screen in school children and renal biopsy are very useful for the early detection of the progressing glomerular diseases and provide great opportunity for early therapeutic intervention and long-term follow-up to better understand the natural courses of glomerular diseases, including tgbm disease. introduction the purpose of the study was to establish a correlation between morphometric kidney biopsy parameters and routine laboratory findings in patients with nephrotic syndrome. material and methods kidney biopsies of patients with nephrotic syndrome were studied using standard techniques of paraffin sections stained with haematoxylin and eosin, picrofuxin van gieson and pas reaction. direct immunofluorescence on snap frozen sections was performed using commercially available antibodies against iga, igm and igg. of the patients, ( . %) were men and ( . %) women, with an average age of . ± . years. biopsy study revealed different types of chronic glomerulonephritis of various incidence: membranous gn ( ), mesangioproliferative gn ( ), mesangiocapillary gn ( ), focal segmental glomerulosclerosis ( ) and terminal sclerosing gn ( ) . morphometric analysis using the semi-automatic image analyser »integral- mt« included cross-section surface areas of the glomeruli and glomerular capillaries, the numerical density of total number of cells per glomerulus, numerical density of mesangial cells, cross-section surface area and numerical cells density of the proximal and distal tubules and cross-section surface area of the peritubular capillaries. routine clinical laboratory analysis included the level of proteinuria, serum creatinine and creatinine clearance, erythrocyturia, leukocyturia and cylinders in urine. a correlation of clinical laboratory parameters with mathematical morphometric models was established for each type of gn associated with nephrotic syndrome. the role of proliferation, growth arrest and apoptosis in the carcinogenesis and prognosis of renal cell carcinoma ga gökhan , g karpuzoglu , t köksal akdeniz university school of medicine department of pathology, antalya, turkey akdeniz university school of medicine department of urology, antalya, turkey introduction nuclear grade and stage are insufficient to predict the clinical behaviour of renal cell carcinoma (rcc). therefore additional prognostic factors are needed. in this study we investigated the role of proliferation, growth arrest and apoptosis in the carcinogenesis and prognosis of rcc using ki , cyclin a, bax, p and bcl- . material and methods formalin-fixed paraffin embedded tissue blocks from patients were studied. cases were divided into low/high grade and low/high stage. apoptotic index (ai) was evaluated as morphologically in h&e stained sections. proliferation index (pi) was detected by using ki and cyclin a immunostaining. ai, pi, p , bcl- and bax expressions in tumor tissue (tt) and in adjacent non-tumoral tissue (ant) and associations with clinical and histopathological parameters were analysed statistically. results the mean indices for apoptosis, ki and cyclin a were: . ± . ( - ), . ± . ( - ) and . ± . ( - ) in tt as well as . ± . ( - ), and . ± . ( - ) in ant, respectively. the number of cases in which the expression of p , bax and bcl- were detected was: ( . %), ( . %), ( , %) in tt, and ( %), ( , %), ( %) in ant, respectively. statistically, there was a significant relationship between the values of tt and ant for ai but not for the pi and the other parameters. only ai and pi significantly correlated with the grade. conclusion in this study the role of pi as a prognostic indicator in rcc was again confirmed. our observations suggest that apoptosis, cyclin a, bcl- and bax may have roles in the carcinogenesis of rcc and that ai may be used as a prognostic indicator. introduction isolated microscopic hematuria (imh) in children always raises the question of the necessity of renal biopsy. many authors consider imh as minor abnormality where glomerular changes are not expected, but general agreement has not yet been achieved. the aim of this study was to evaluate contribution of renal biopsy to diagnosis of glomerular disease in imh. material and methods biopsy was performed in children with imh of proven glomerular origin. mean duration of imh prior to biopsy was . years. biopsy specimens were examined by light (lm), immunofluorescence (if) and electron microscopy (em). results patients ( . %) were found to have glomerular abnormalities. on lm patients had normal glomeruli (ng), mesangial proliferative glomerulonephritis (mepgn), focal segmental glomerulosclerosis (fgs) focal glomerulonephritis (fgn) and membranoproliferative glomerulonephritis (mpgn). if revealed cases as iga nephropathy. em discovered gbm changes consistent with alport syndrome in patients and diffuse thinning of gbm in . in children, subepithelial hump-like deposits were found and considered as the sign of acute postinfectious glomerulonephritis in resolution. one of cases of mpgn showed to be type ii (ddd). on follow-up, of children with alport-like gbm changes developed full clinical picture of the syndrome. further surveillance is needed to confirm the significance of em findings in others. conclusion in children with imh renal biopsy is justified and should always be analyzed by light, immunofluorescence and especially electron microscopy, because em was decisive for final diagnosis in about % of all cases. mesoblastic nephroma of adult. report of a case introduction mesoblastic nephroma is a very uncommon tumor in adults, similar to the congenital mesoblastic nephroma of infancy, first described by bolande et al. microscopically the tumor consist in uniform spindle cells proliferations with numerous vascular spaces, nest of glomeruli, renal tubules that often cystic and dysplastic and lack of nuclear anaplasia or mitotic activity. case report a -year-old woman was admitted to the emergency services for acute abdominal pain in september . she was diagnosed with acute pancreatitis. in cat (without urologic symptoms) a solid mass in the upper pole of the right kidney was founded. with a clinical diagnosis of renal cell carcinoma a radical nefrectomy was performed. follow-up was without event and had no recurrence years afterwards. the right kidney weighed grs. and was unremarkable except for a cms-diameter circumscribed, yellow-tan, solid tumor in the upper pole. microscopic ex-amination revealed a tumor composed of spindle cells, mostly smooth-muscle cells and fibroblast, with numerous vascular structures and some areas of renal tubules with clear cytoplasm. in some places there was atrophic tubules. no mitotic figures were identified. immunohistochemistry findings: the majority of spindle cells were positive for actin, desmin and smooth-muscle actin, and vimentin. and the tubular epithelium stain for ema and keratins. conclusion a combination of histological and immunohistochemical findings is useful to distinguish mesoblastic nephroma from other tumor of the kidney with spindle cells. introduction hyperparathyroidism occurs in patients with chronic renal failure and is usually associated with multiglandular parathyroid hyperplasia. clonal analysis has suggested that in renal hyperparathyroidism glands initially grow diffusely and polyclonally. mechanism of monoclonal proliferation observed with appearance of nodular hyperplasia is not well understood. it might be induced by certain genetic disorders such as overexpression of prad/cyclin d induced by dna rearrangement of the parathyroid hormone gene. the aim of this study was to analyse the expression of cyclin d in normal and hyperplastic, diffuse and nodular parathyroid glands in order to ascertain the possible difference. materials and methods hyperplastic parathyroid glands, from uremic patients who underwent surgery during the period - , were analysed. immunohistochemistry for cyclin d protein was performed on normal parathyroid glands and selected hyperplastic, of diffuse and of nodular type. overexpression of cyclin d was considered to be present if % or more of the sample showed positive nuclear staining. results in normal glands, the mean value of nuclear positivity was . %. overexpression for cyclin d was present in / ( %) diffuse and / ( %) nodular hyperplastic glands. no significant difference was found. conclusion in comparison to normal, hyperplastic glands (nodular as well as diffuse) overexpress cyclin d protein. these results indicate that overexpression of cyclin d is not limited only to neoplastic proliferation, as the most studies showed, respectively this genetic abnormality is not the only responsible mechanism for the monoclonal proliferation. proteins of extracellluar matrix as predictors of glomerulonephritis outcome s Čužić , m Šćukanec-Špoljar , b jelaković , z sonicki , d kuzmanić , m laganović pliva inc., pharmaceutical industry, zagreb, croatia klinički bolnički centar "zagreb", croatia Škola narodnog zdravlja "andrija Štampar", zagreb, croatia introduction chronic renal insufficiency develops only in those cases of glomerulonephritis in which the lumina of postglomerular capillaries in the renal cortex are narrowed due to expansion of the extracellular matrix (ecm). aim of the study was to compare the composition of interstitial ecm proteins with clinical data in various forms of primary glomerulonephritis (gn). material and methods we examined renal biopsies from gn patients, while normal renal tissue was obtained from nephrectomy due to small renal tumour. specimens fixed in b and/or dubosque fixative were analysed by immunohistochemistry (appap-method) using a monoclonal antibodies against tenascin (tn), fibronectin (fn), collagen i, iii and iv (coi, coiii, coiv) (dako). the same fixatives were used for control renal tissue. evaluation of fibrin was performed on frozen sections by immunofluorescence. clinical data were: proteinuria and serum creatinine level, obtained by standard laboratory methods, immunotherapy and ace-genotype. results fifty patients had proteinuria at time of biopsy and of them continued to have it during the follow-up period. patients with persistent proteinuria had more often interstitial fibrosis with elevated content of coi and coiv. only % of patients who responded well to immunotherapy had deposits of fibrin. there were patients with elevated creatinine at biopsy with similar composition of ecm as patients with proteinuria. majority of patients with interstitial fibrosis had ace-genotype ii although this genotype wasn't the most common in the cohort. conclusion our study showed that persistent proteinuria could be linked to interstitial fibrosis and fibrin deposits. patients with ii ace-genotype are more prone to develop interstitial fibrosis. introduction haemorrhagic fever with renal syndrome (hfrs) in slovenia is caused by two hantavirus agents -puumala and dobrava serotypes. there is still a lack of clinical and pathological information, especially about the dobrava virus associated disease. the aim of this study was to analyse and compare the clinical course, outcome and pathological features of hfrs caused by these two virus serotypes. the clinical course of patients ( women) aged ± years (range - ) treated in the nephrological department for serologically confirmed hantavirus associated hfrs was analysed, a serological diagnosis was made using immunofluorescence test and enzyme-linked immunosorbent assay. kidney biopsy specimens of patients were analysed by light microscopy, immunofluorescence and electron microscopic techniques. a semiquantitative scale for gradation of cumulative tubulointerstitial lesions and interstitial haemorrhagic lesions was applied (scores - ). results seventeen patients ( . %) had puumala and ( . %) dobrava virus infection. all patients were febrile and had proteinuria, and other clinical features were: nausea and vomiting ( % of patients), oliguria ( %), abdominal pain ( %), headache ( %), haemorrhages ( %), myalgias ( %), diarrhea ( %), neurological and ophthalmological abnormalities ( %), hypotension ( %). pancreatitis ( %) and elevated transaminases ( %) were observed only in patients with the dobrava serotype. none of the patients in this study died and there was none with permanent haemodialysis dependence. comparison of clinical and pathological features of dobrava and puumala diseases is given in the a need for haemodialysis and the creatinine level at discharge were not associated with the age of patients. those patients who needed haemodialysis, had clinical haemorrhages or had elevated creatinine at discharge, also had higher haemorrhagic and cumulative tubulointerstitial lesion scores, but differences were not significant. elevated serum creatinine above basal levels was present at discharge in patients ( %), range - µmol/l and some patients remained with chronic renal insufficiency. conclusion our results show that dobrava virus infection is associated not only with a significant mortality, comparable to hantaan virus infection, but also with a worse clinical course of renal disease than puumala. the histopathology of the kidney in dobrava and puumala is characterised by haemorrhagic necrotising tubulointerstitial nephritis involving particularly the outer medulla, with quantitative and not qualitative differences between these two infections. renal parenchymal malakoplakia after kidney-pancreas transplantation. case report introduction malakoplakia is an unusual chronic inflammatory disease rarely involving parenchyma of the transplanted kidney. it represents an unusual host response, probably due to leucocyte bactericidal defects to an infecting agent, usually gram-negative organisms, of which escherichia coli is the commonest. malakoplakia in renal transplant is very rare (to date only six cases have been reported) and is associated with a high rate of graft loss and significant mortality. case report we report a -year-old female recipient of kidneypancreas allografts immunosupressed with tacrolimus (prograf, x mg) and mycophenolate mofetil (cellcept, x mg). the patient had suffered from recurrent urinary tract infections. three years after transplantation she was admitted to the hospital with decreased kidney graft function. percutaneous kidney needle biopsy was performed and diagnosis of malakoplakia was established. histologically, on the inflammatory background many mi-chaelis and gutmann bodies were present and confirmed ultrastructurally. the patient was treated with antibiotics and simultaneously immunosuppression (tacrolimus) was reduced. gradually, her renal function improved (with serum creatinine of umol/l). for the entire following year, the patient has been monitored regularly and her renal and pancreas function are stable and both her allografts remain in situ. morphometric study of transbronchial biopsies in pulmonary transplantation e conclusion in our series of tbb for transplant pathology, the aa and nv are the most important morphometric parameters of the biopsy to reach the diagnosis of ar. conversely, the nf does not show significant statistical difference between diagnostic biopsies and nd biopsies. the importance of glomerular deposits of von willebrand factor in human renal allografts bh ozdemir aim to evaluate the role and prognostic importance of glomerular endothelial cell alteration in human renal allografts. material and methods we examined patients with renal transplantation among whom showed acute rejection (ar) and chronic rejection (cr). biopsies were immunostained for von willebrand factor (vwf), fibronectin (fn) and cd . glomerular staining for vwf and fn was graded in a semiquantitative manner using the - + scale. results in the cr group there was markedly increased expression of vwf and fn in the glomeruli, whereas only of ar cases showed intense (grade ) glomerular vwf (gvwf). a significant difference was found between patients with ar and cr with regard to gvwf (p< . ). a positive correlation between the degree of gvwf and early interstitial fibrosis was found in cases with ar in follow-up biopsies (p< . ). the presence of transplant glomerulopathy was found significantly earlier in cases with grade gvwf in ar group (p< . ). we found strong correlation of both intraglomerular fn expression and macrophage infiltration with the degree of gvwf both in ar and cr groups (p< . ). the outcome of grafts that showed intense (grade ) gvwf was significantly worse than the outcome of those grafts with grade and glomerular vwf during the follow-up (p< . ). conclusion increased gvwf deposition in cases with ar is in risk of early transplant glomerulopathy, early interstitial fibrosis and early graft loss. in conclusion, it may be beneficial to use new therapeutic approaches such as anticoagulant medicine for the treatment of ar and cr in future. introduction acute renal allograft rejection is the most important threat to graft survival, and must be diagnosed and treated as early as possible. clinical, radiological and histopathological confirmation of the diagnosis is essential. several factors are being investigated as potential diagnostic markers for acute rejection (ar), and one of these is the hepatocyte growth factor (hgf). the aim of this study was to investigate the presence/density of hgf in core needle biopsies from renal allografts with ar using immunohistochemical staining. the study involved cases of kidney recipients whose allografts were investigated for an initial ar episode without any other pathology. all the patients received cyclosporine-a anti-rejection treatment. each archived slide was reexamined according to the modified banff classification, and patients were categorized as type i ar (group ; n= ), type ii ar (group ; n= ) and type iii ar (group ; n= ). normal histopathological findings in graft biopsies were obtained as controls (group ; n= ). the clinical findings of patients were reviewed from archived records. the sections were stained immunohistochemically with monoclonal anti-hgf antibody. the mesenchymal cells (interstitial macrophages and glomerular endothelium) that showed cytoplasmic positivity were then counted using ocular micrometer. the results were statistically analyzed using mann-whitney u test. results on analysis of the groups' mean cell count, the only significant finding was higher concentration of hgf in the ar patient group than in the control group (p< . ). concerning all other parameters studied, the only significant differences were higher blood urea nitrogen and creatinine levels in group compared to group (p < . ). conclusion our results showed that presence/density of hgf increases in favor of acute rejection and accompanies the histopathological findings. therefore we suggest that density of hgf, excreted in renal allograft tissue, may be a useful marker for supporting ar diagnosis. graft biopsies after renal transplantation in children: differences between fk and cya immunosuppression materials and methods biopsies were examined. besides light microscopy (lm) and electron microscopy (em), igg, iga, igm, fibrinogen, c and c d were detected by immunofluorescence (if). immunohistochemistry (ihc) was performed using cd , cd ro, cd , and cd antibodies to study the presence of different types of cells in acute rejection. banff's classification was used to evaluate the samples. results graft rejection was found in ( . %) biopsies -hyperacute rejection (har) ( . %), borderline changes (bch) ( . %), acute rejection (ar) ( %), and chronic rejection (chr) ( . %). cya and fk nefrotoxicity (tox) was present in ( . %) biopsies. c d ( biopsies from patients) showed linear positivity of peritubular and glomerular capillaries in patients, with har and ar. these three grafts failed and the same pattern was seen in the excised grafts. in all ar cases, ihc proved the prevalence of cd ro+ cells in rejection infiltrates, including tubulitis. the rejection infiltrate contained from % to % of monocytes-macrophages. em showed disjunction and tubular epithelia regression in tubulitis. ar and tox findings in patients receiving immunosuppression with fk were compared with a group given cya. no significant differences in the rate of toxic manifestation were found between the groups of patients on fk and those on cya. more frequent findings of toxicity were noted in fk patientsb iopsies (p= . ). ar was found more frequently both in the patients (p= . ), and in the biopsies (p= . ) of cya-treated subjects. conclusion fk seems to be more potent suppressant than cya in spite of its persistent toxic effect. the paper is sponsored by ministry of health of the czech republic (international grant agency) no: ne/ - . introduction bk polyomavirus causes a variety of infections in the urinary tract, involving transitional and renal tubular epithelium in immune suppressed patients, including transplant recipients. it can cause irreversible loss of graft function. we report a case of polyomavirus infection in a transplant recipient diagnosed by renal biopsy, urinary cytology and electron microscopy of the urine. patient and results a -year-old female patient underwent renal transplantation, and received immunosuppressive treatment with tacrolimus, mmf and prednisolone. serum creatinine level increased and hydronephrosis was observed in ultrasonography in the rd month. a renal biopsy was taken. no glomerular or vascular changes were observed. some tubular epithelial cells displayed pleomorphism, hyperchromatism with chromatin irregularities and clumping, and intranuclear inclusion bodies. no immunostaining was detected with anti-cmv, hsv and ebv antibodies. cytopathic tubular lesions in biopsy, many decoy cells in urinary cytology and intranuclear viral particles in electron microscopy of the urinary sediment proved the bk-polyomavirus infection. as the high serum creatinine levels persisted, despite alternative immunosupressive therapies, two more renal biopsies were taken, and acute rejection banff grade ib and iia was diagnosed respectively. the patient is still under a novel antiviral treatment as the focal tubular cytopathic changes were present in the latter biopsy. serum creatinine levels were still high, even though urinary cytology is normal. conclusion as we have seen in this case, the differential diagnosis between rejection and infection in renal transplant biopsies is critical and complicated for both clinicians and pathologists, as well as patients. introduction the analyses of serums or tissue specimens from the patients with autoimmune diseases are dispersed between microplate reader elisa techniques and immunofluorescence (if) microscopy techniques. the number and the complexity of if morphological parameters are becoming greater, as well as their association with some of the clinical conditions. the quantity of the morphological signs and the notice capability exceed the possibilities of the experts who are not morphologists. the aim of this paper is to present compilation of if morphological slides and their association with the clinical conditions, indicating the real position of this kind of diagnostics. material and methods more than serums and tissue specimens from different locations were used as study material. the methods used were indirect iif microscopy with commercial and own antigens, microplate reader elisa techniques (mpr-elisa) and direct if microscopy. the study showed that the morphology of antinuclear and anticytoplasmic antibodies, using hep- kits was easily examined, wider, and associations with some clinical conditions could be easily done. the antigens for mpr-elisa techniques derived from recombinated genetic technology, unlike those produced from extraction showed better correlation with indirect if microscopy. the own antigens originating from the domestic animals and human cadavers, used for indirect if microscopy in bullous diseases, had the same value as the commercial ones. conclusion in order to emphasize the importance of this paper, we can conclude that, undeservingly, very few papers from this area are being presented in the pathological congresses and are left to other specialities. the gastrointestinal stromal tumors (gist) are rare tumors. there have been few factors identified that predict survival and biological behavior. this study analizes the experience in two university hospitals. forty nine patients with gist were identified from the tumor registry of both institutions. a retrospective review of patient clinic data, tumor and treatment variable was done. expression of p and cellular proliferation antigens (ki /pcna) was also analyzed with overall survival as the main outcome variable. statistical analysis was performed by log rank test and cox regression model. significance was defined: p< . . as results we found that median age was years (range - years). twentyfive patients were women ( %) and were men ( %). hispanics were predominant race with patients ( %) followed by caucasians with patients ( %) and african american patients ( %). the stomach was the most common site of presentation ( %) followed by small bowel ( %). mean tumor size was cm (range - cm). complete resection was performed in patients ( . %). actuarial -year survival was . % with a median follow-up of months . univariable analysis identified overexpresion of p (p= . ), cellular progression antigens (ki /pcna) (p= . ), high grade (p= . ), tumor size bigger than cm (p= . ), and incomplete resection (p= . ), as significant negative factors, hispanic race (p= . ) and good performance status (p= . ) were significantly associated with prolonged survival. on multivariable analysis, overexpression of p was the only independent negative factor. in conclusion, p is the most significant negative prognostic factor for survival in gist. introduction granulomatous gastritis (gg) is a poorly understood entity, reportedly identified in less than % of all gastric biopsies. a precise definition of granulomas has rarely been given, in particular mg, well-described in intestinal disorders, have not been focused on in gastric lesions. aims: we summarize our experience with gg, including mg, and record prevalence as well as associated background morphology. materials and methods among gastric biopsies from . patients ( . gastroscopies), gg was diagnosed in patients. groups of histiocytes producing conspicuous alteration of gastric architecture were classified as well-defined granuloma (wdg); subtle collections of histiocytes failing to distort surrounding glands were labelled mg. the background morphology and presence of microorganisms were recorded. results the distribution of types of granulomas were as follows: mg only patients, mg and wdg patients, wdg only patients. the background morphology of cases with only mg/wdg with/ without mg included chronic gastritis (n= / ); chronic active gastritis (n= / ); ulcus (n= / ); lymphocytic gastritis (n= / ); carcinoma (n= / ); otherwise normal morphology (n= / ); h. pylori (n= / ). conclusion in concert with previous reports, we identified gg in less than % of all gastric biopsies. since the identification of mg requires assiduous histologic examination, such subtle features may be overlooked; hence our calculated prevalence of gg is a minimun value. the functional relation between mg and wdg is uncertain. however, their coexistence in a proportion of gg could support a precursor function of mg in the development of wdg. additionally, the background pathology of biopsies with mg and wdg were comparable. intravascular signet ring-like cells cd /lysozyme positive in gastric ulcer due to chronic use of nsaid, diagnostic implications in endoscopic biopsy and surgical management of an unusual invasive cancer mimicker j nuncio, j arista-nasr, b martinez pathology department, instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico a -year old man treated with naproxen during two years was admitted because of hypovolemia and peritoneal irritation. a panendoscopic study was performed and an ulcer localized at the large curvature of the stomach was disclosed. the microscopic examination of the endoscopic biopsy reveled invasive intravascular and stromal neoplastic signet-ring cells. because of the subsequent poorly differentiated carcinoma diagnosis, a gastrectomy was performed. in the specimen the ulcer showed necrosis, edema, fibrosis, chronic inflammatory infiltrate with lymphocytes and plasma cells. additionally atypical cells with irregular and hyperchromatic nuclei or vacuolated cytoplasm were seen in the lamina propia and infiltrating the muscular layers; isolated signet-ring-like cells were also seen. there was no involvement in regional lymph nodes. histochemical study with periodic acid-schiff, mucicarmin, and colloidal stains revealed mucosubstances in these cells. a poorly differentiated carcinoma was initially diagnosed. however the immunohistochemical studies were positive for histiocytic markers (cd- , s- protein and lysozyme) and negative for epithelial markers (cytokeratin, and ema). the positivity mucus stains in the histiocytes could be explained in this case by phagocytosis of mucous substances released from broken hyperplastic glands in the vicinity of the ulcer. to our knowledge, atypical histiocytic infiltration in gastric ulcers has not been previously described; thus, it should be included in the group of gastric carcinoma mimickers; with this basis, the pathologist must to be careful in the assessment of vascular permeation or stromal infiltration by neoplastic cells overall in endoscopic specimens. ileal mucosa changes after total colectomy in patients with juvenile polyposis and familial adenomatous polyposis a tertytchnyi , a talalaev , d sotnikov , v lukin russian state medical university, moscow, russian federation centre of children's health, russian academy of medical science, moscow, russian federation introduction we studied follow-up ileal mucosa biopsies from patients with juvenile polyposis and patients with familial adenomatous polyposis who had been previously underwent total colectomy with mucosal proctoectomy with the creation of straight ileoanal anastomosis. patients' age ranged from to years (mean . years). the follow-up ranged from months to years (mean . months). aim of this study was to identify the long-term changes in ileal mucosa after total colectomy in patients with polyposis coli syndromes. methods the biopsy specimens have been taken from the posterior wall of terminal ileum. paraffin sections were stained with h&e, van gieson, periodic acid schiff (pas) and gomori's aldehyde fuchsin -alcian-blue (gaf-ab) stains. six biopsies were subjected to electron microscopy analysis. results on histological examination ileal mucosa revealed focal shortening of villi and lengthened crypts. the villi were lined by increased number of goblet cells. mucin histochemical studies demonstrated partial conversion of the epithelium to a colonic sulfomucin mucin profile by positive gaf-ab staining in cytoplasm of goblet cells. only out of patients had increased number of mononuclear cells in lamina propria. the electron microscopy examination revealed shortening and rarification of microvilli of absorptive enterocytes. conclusion follow-up biopsies show incomplete and focal neocolonic transformation of ileal mucosa. nevertheless, in most of the cases ileal mucosa preserved its architectural and histochemical characteristics. we failed to identify evidences of chronic inflammation that made us suggest that chronic terminal ileitis is not a common long-term event in patients with polyposis coli syndromes after total colectomy. eosinophilic gastroenteritis with pleural outflow and ascites. a case report introduction in our region eosinophilic gastroenteritis is a very rare disease. etiology is unknown. case report a -year-old female patient was admitted to the clinic due to slight cough, right side pleural outflow and ascites, without other symptoms. gynaecological ultrasound, ultrasound of the upper abdomen, ct refer to ascites besides normal findings of abdominal and pelvic organs. laboratory examinations were normal except peripheral blood eosinophilia and increased values of ca . cytological findings of pleural outflow and ascites revealed a great number of eosinophilic granulocytes but without malignant cells. patohistological findings during explorative laparotomy resected parts of both ovaries, a lymph node, a hyperplastic part of pylorus, a knot from a small bowel designated as a tumor, and an appendix were taken out for a patohistological examimation. both ovaries reveal normal ovarial parenhima. a regional lymph node showed reactive changes with hyperplastic follicles and prominent germinative centers. the main histological finding reveals pyloric stromal edema and a dense infiltrate of eosinophilic granulocytes throughout the muscle layer as well as eosinophils situated in perivascular spaces which is accompanied with swelling of endothelium of capillary blood vessels. eosinophilic granulocytes were found in the smooth muscle layer of intestine as well as in the subserosal tissue. lumen of the appendix was obliterated and the muscle layer and the subserosal tissue contained eosinophils. conclusion from our review it is visible that eosinophilic gastroenteritis can represent a great diagnostic problem especially when it is accompanied with pleural outflow and ascites and increasing values of tumor markers. that can possibly mislead a diagnostic procedure to the neoplastic rather than the immunological or allergic disease. three years after surgery the patient is well. expression of tnf-alpha and il- in patients with chronic pancreatitis n shirinskaya , v akhmedov emergency hospital, omsk, russian federation omsk medical academy, omsk, russian federation introduction to study the serial levels of tnf-alpha and il- in patients with chronic alcoholic and chronic relapsing pancreatitis. methods consecutive patients with chronic pancreatitis admitted to the emergency hospital ( patients with alcoholic pancreatitis and -with chronic relapsing pancreatitis) were studied. serum levels of tnf-alpha and il- , were determined on and days after admission and in remission by immunoenzyme multiplied. results in group of the patients with chronic alcoholic pancreatitis on day one after admission the high levels of tnf-alpha ( , ± , pg/ml) and il- ( , ± , pg/ml) were marked with the subsequent consecutive decrease of these values for days (tnfalpha- , ± , pg/ml, il- - , ± , pg/ml) and in the period of remission (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml). in patients with chronic relapsing pancreatitis the low levels of cytokines on days one after admission (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml) were marked with the deferred peak of values on day (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml), and decrease in the period of remission ± , pg/ml, pg/ml) . conclusion the deferred peak of cytokines levels (on days) in patients with chronic relapsing pancreatitis can testify indirectly about more expressed cytokines disturbance. the majority of glomus tumors are benign neoplasms that occur in the dermis of extremities. however, rare case have been reported in the visceral locations, most often in the stomach. case report the tumor occurred in a -year-old male who presented ulcer-like pain. ct scan diagnosed a submucosal tumor. there was no endoscopic biopsy specimen. a wedge resection of stomach was performed with a frozen section study that conclude to a carcinoid tumor glomus tumor was confirmed by further study of multiple sections of a surgical specimen and by immunhistochemical study. conclusion correct identification of this essentially benign, very rare gastric tumor can prevent unnecessary radical operative procedures. composite carcinoid-adenocarcinoma of the ileum associated with transitional cell carcinoma of the urinary bladder i venizelos , d sioutopoulou , z tatsiou department of histopathology, athenes, greece it is well known that sometimes carcinoid tumor is associated with other tumors. approximately % of carcinoid tumors in the small intestine are associated with non-carcinoid neoplasms, most frequently adenocarcinomas of the gastrointestinal tract. the concurrent occurrence of carcinoid and other tumors in various organs is extremely rare. here, we present a case of a -year-old male who was admitted to our hospital with a -month history of haematuria. on cystoscopy a large tumor of the urinary bladder has found. a total cystectomy was performed. during the operation, while exploring the abdomen, a tumor with maximum diameter cm was found in the terminal ileum, from which a biopsy was taken. microscopically, the bladder tumor was a papillary transitional cell carcinoma grade ii and the tumor of the ileum fulfilled the criteria for a composite carcinoid adenocarcinoma. the carcinoid component was positive for chromogranin and nse and negative for ema, cea and ca - whereas the adenocarcinoma component was positive for ema, cea and ca - and negative for chromogranine and nse. -months after the operation there is no metastasis radiologically and the patient is in a good condition. due to the small number of tumors reported as composite carcinoid-adenocarcinoma there is need for larger number of similar cases as well as long term follow-up to determine their natural history and prognostic significance. we describe the first reported case of composite carcinoid-adenocarcinoma of the ileum associated with carcinoma of the urinary bladder. mutational analysis and expression of cdx homeobox gene in cases of colorectal carcinomas e pilozzi, m rapazzotti onelli, c fidler, v ziparo, js wainscoat, l ruco istopatologia ospedale sant'andrea facolta, roma, italy introduction cdx is a transcription factor specifically expressed in normal intestinal epithelium. it plays a role in the regulation of cell proliferation and differentiation. experimental evidences suggest that it could have a pro-oncogenic effect since cdx overexpression up-regulates bcl- and reduces p ; it is up-regulated by ras activation and its ectopic expression has been reported in intestinal metaplasia, in carcinomas of the stomach and in barrett's esophagus. despite these observations the role of cdx in colorectal carcinogenesis is not yet fully understood. in fact it has been shown to be down-expressed in colon cancers at mrna and protein level. the aim of the study was to investigate the presence of cdx gene mutations. materials and methods twenty cases of sporadic colon carcinomas were collected. total rna and dna from neoplastic and normal tissues were extracted. cdna was synthesized and used as template in rt-pcr using oligonucleotide for cdx and â-actin. cdx three exons were pcr amplified and directly sequenced. results we found lower expression of cdx in tumour samples in four out of ten cases. sequencing showed a transversion g>c ( / cases) of exon and a t>c transition in exon ( / cases) that, being present in the corresponding normal tissue, were regarded as polymorphisms. no base substitution was observed in exon three. conclusions our results showed that cdx expression is reduced in colon carcinoma. however cdx was not found to be mutated suggesting that alterations, other than base substitution, may affect cdx gene in colon cancer. we are now looking at cpg islands methylation in the same cases since methylation could be a likely explanation of the low expression of cdx . aim this study investigates tgfbeta , tgfbeta and tgfbeta proteins expression in patients with colorectal carcinoma and evaluates their correlation with classic prognostic markers and patients' survival. design the study comprised patients with colorectal carcinoma. according to astler-coller system, tumors were of stage a, -b, -c and -d, whereas tumors were low-grade and high-grade of malignancy. on paraffin sections the streptavidin-biotin technique, using antibodies to tgfbeta , tgfbeta and tgfbeta (santacruz, usa) was employed. staining results followed morphometric analysis and were correlated with clinicopathologic parameters. results tgfbeta protein was expressed in / ( %) carcinomas whereas tgfbeta and tgfbeta proteins were detected in all tumors examined. normal colonic mucosal epithelial cells expressed less tgfbeta (p< . compared to neoplastic cells) and less tgfbeta (p> . compared to neoplastic cells), but not at all tgfbeta . statistical analysis revealed higher expression of tgfbeta in low grade carcinomas (p= . ) and higher tgfbeta presence in advanced stage tumors (p= . ). tgfbeta expression was related with higher disease free survival and higher total survival (p< . respectively). tgfbeta presence was correlated with worse prognosis (p< . ). cox analysis revealed that besides tumor grade and stage, tgfbeta expression constituted independent prognostic factor. conclusions this study shows that in cases of colon adenocarcinoma there is different expression of tgfbeta , tgfbeta and tgfbeta . tgfbeta may be implicated in the pathogenesis of these tumors since it is expressed only within neoplastic and not normal cells. tgfbeta is related with higher disease free survival, higher total survival and constitutes an independent prognostic factor. in the late stages, tgfbeta seems to be involved in tumor progression and it is related with worse prognosis. cdx is useful in distinguishing primary colorectal adenocarcinoma form pulmonary, mammary and pancreatic adenocarcinomas metastatic to the colorectum g groisman, a meir, m amar hillel yaffe medical center, hadera, israel background the large bowel may be the site of metastasis from a number of tumors including pulmonary, mammary and pancreatic adenocarcinomas. the histological distinction of primary colorectal adenocarcinoma from these metastatic lesions may be difficult. the aim of this study was to evaluate the utility of the intestinal marker cdx in distinguishing primary colorectal adenocarcinoma from pulmonary, mammary, and pancreatic adenocarcinomas metastatic to the large bowel. design routinely processed mucosal biopsies of adenocarcinomas involving the colorectum [ primary, metastatic (lung , breast , pancreas )] and control cases of primary lung, breast, and lung adenocarcinomas were immunohistochemically stained for cdx (biogenex, san ramon, ca, usa). the intensity and extent of the staining were recorded semi-quantitatively. results cdx diffussely and strongly stained the normal colorectal epithelium as well as all cases of primary colorectal adenocarcinoma. in contrast, all cases of metastatic lung, breast and pancreas adenocarcinoma as well as all control cases were cdx negative. conclusions cdx immunostaining is useful in discriminating primary colorectal adenocarcinomas from pulmonary, mammary and pancreatic adenocarcinomas metastatic to the large bowel. we recommend its use as a component of any antibody panel put together to discriminate between primary and secondary colorectal tumors. infiltrative and proliferative activity in central versus peripheral parts of colorectal cancer introduction growth of primary and metastatic tumour is accompanied by formation of stroma composed of connective tissue and new blood vessels. colorectal cancer is a malignancy characterised by marked desmoplastic reaction both in primary tumour and in its secondary foci (metastases). presented report was aimed to describe quantitatively microvessel density in primary tumour and lymph node metastases from this neoplasm. materials and methods study material included cases of colorectal cancer with metastases to the regional lymph nodes. investigated group comprised women and men (aged - yrs); tumours were t and four were t according to tnm classification. microvessels were highlighted using monoclonal anti-cd antibodies. vessel counts were performed in five fields of each primary and metastatic focus (x ; . mm ). numbers of blood vessels in colorectal tumour were counted in areas free from prominent necrotic foci and non-specific granulation tissue due to process of reparation. vessel density in nodal metastases was determined in fields occupied by neoplastic cells forming their own connective tissue stroma. results in the primary tumour group mean vessel density was . vessel/mm (median value . ; range - ). in metastatic foci the same parameter was . vessel/mm (median value . ; range - ); no statistically significant difference was detected. only slight correlation was found between the microvessel densities in primary and metastatic tumours (r= . ; p= . ). conclusion presented results seem to prove the similar pattern of neovascularisation in both groups, whereas marked differences in this process can be observed between subsequent analysed cases. early diffuse-type gastric carcinoma, especially signet ring cell carcinoma, often shows the superficially spreading growth pattern, and one of the unsolved questions concerning the histogenesis of this type of carcinoma is whether it is monoclonal or multiclonal in origin. we have performed human androgen receptor gene assay (humara assay) based on the random inactivation phenomenon of x chromosomes in female and reported that most of this type of carcinomas were of monoclonal origin ( / cases). however, this method demonstrated only probability of monoclonality in each lesion. recently, % of diffuse-type gastric carcinomas have revealed mutations of the e-cadherin gene at the early stage of their progression, and in-frame skipping of exon has been seen frequently. thus, we performed an immunohistochemical analysis of early signet ring cell carcinomas using e-cad delta - , which is a specific antibody against a peptide spanning the fusion junction region between exons and of mutant ecadherin. e-cad delta - specifically reacts with tumor cells expressing e-cadherin mrna lacking exon . seven of cases were positive for this antibody. in each positive case, the paraffin blocks of the tissue slices that included the whole tumor were analyzed using e-cad delta - . although some signet ring cells with abundant mucin in the upper and/or lower layers of a layered structure did not react with this antibody, tumor cells were confirmed to express e-cadherin mrna lacking exon- by reverse transcriptase-polymerase chain reaction with paraffin-embedded formalin-fixed tissues. these findings suggest that they are of monoclonal origin ( / cases) and support our previous data using humara assay. e tsikou-papafragou , t papadaki , m tsamouri , e nikolaou , c barbatis korgialenion-benakion hospital, athenes, greece evangelismos hospital, athenes, greece introduction malt lymphoma is the commonest primary gi lymphoid malignancy but for correct diagnosis and classification, immunohistochemical and molecular analysis have been proven necessary. the aim of this study was to demonstrate the value of current methodology for diagnosing gimls by presenting four unusual cases. materials case . a years old male with common variable immunodeficiency. an obstructive ileal tumor cms was resected and multiple biopsies were taken along the gi tract from nodular areas. case . female years old with generalised lymphadenopathy, lung shadows, dyspepsia and duodenal nodularity. case . female age underwent gastrectomy with initial diagnosis of high grade b lymphoma. case . female age , had gastrectomy/ splenectomy for relapsed gastric lymhpoma which had been diagnosed as malt type. methods immunophenotypical analysis for detection of cd , cd a, cd , bcl- pr, bcl- pr, cd , cyclin d , cd , cd , cd ro, cd , ki- and genotypic analysis for the clonal igh, tcva genes (case ) and the igh/bcl- rearrangement (case ). results per case: . atypical burkitt lymphoma with diffuse lymphoid hyperplasia of the gi tract (cd / / a+, bcl- +/ -, ki %). . generalised follicular b lymphoma, grade according to the who classification with involvement of the duodenum. . diffuse large b cell lymphoma with aberrant cd ro expression. rearrangement of the igh genes and not of the tcva gene. . cd -mantle cell lymphoma with anaplastic foci in the spleen. clonal rearrangements of the igh and concomitant igh/bcl- gene rearrangements involving tonsils, stomach, spleen and abdominal lymph nodes. conclusion all cases represent unusual types of gimls easily misclassified or graded without thorough immunophenotypic and molecular analysis. the incidence of gastric cardiac adenocarcinoma has increased in the last decades. gaining insight in the pathogenesis of this lesion is hampered by the limited knowledge of the origin and histology of cardiac mucosa (cm). currently, the location, extent and even the existence of cm are controversial. aims: we studied the development of the gastro-oesophageal junction (goj) in embryos, fetuses and infants to clarify whether cm is a normal structure at birth and where it is located. materials and methods twenty-one autopsy cases were evaluated. age range: weeks gestational age (ga) - months. the distal oesophagus and proximal part of the stomach were embedded entirely. serial sections were stained with haematoxylineosin and alcian blue/periodic acid-schiff. the following parameters were measured: length of abdominal oesophagus; length of columnar-lined oesophagus; length of cm; distance from cm to angle of his. results cm was present in all evaluated sections. its mean length varied throughout gestation. a maximum value was reached at a ga of weeks ( , mm). after term delivery, it was very short ( , - , mm). cm was proximal to, or straddled the angle of his in all cases. during gestation, the mucin staining pattern of the cm was to a high degree similar to that of the developing pyloric mucosa. conclusions cm develops during pregnancy and is present at birth as a normal structure. if the angle of his is taken as a landmark for the goj, cm is located in the distal oesophagus. gastric mucosa-associated lymphoid tissue (malt) and non-malt lymphomas: clinicopathological study of cases s taban, a dema, n tudose university of medicine and pharmacy, timisoara, romania introduction histologic features of low-grade b-cell malt lymphoma of the stomach have been well described in recent years, but its relationship with the more common large b-cell gastric lymphoma has not been clarified. the authors investigate clinicopathological differences among low-grade and high-grade gastric lymphomas. methods clinical and histopathological aspects of consecutive gastric lymphoma cases found in gastrectomy specimens were studied: cases of low-grade malt lymphoma (lg malt lymphoma), cases of high-grade malt lymphoma appearing in low-grade malt lymphoma (hg/lg malt lymphoma), cases of high-grade malt lymphoma (hg malt lymphoma) and cases of diffuse large cell lymphoma (dlcl). results mean age were as follow: lg malt lymphoma- , years; hg/lg malt lymphoma- , years; hg malt lymphoma- , years; dlcl- , years. there was a male predominance of malt lymphoma patients (male to female ratio- / ). macroscopically, the most common pattern of lg malt lymphomas was the superficial spreading type with or without ulceration, whereas hg malt lymphomas and dlcl exhibited a solitary tumor-forming lesion. b-cell immunophenotype was confirmed in cases, only one case of dlcl was a t-cell lymphoma. conclusions in our study, the prevalence of high-grade malt and non-malt lymphomas was , %. our results suggests that some gastric lymphomas with high malignancy can arise through blastic transformation of the lg malt lymphomas, this process(change) seems to take about ten years at least. background the recently described serrated adenocarcinoma accounts at least . % of colorectal malignancy. it develops from serrated polyps. dna microsatellite instability (msi) is more common in serrated adenocarcinomas than in conventional adenocarcinomas, but the frequency of msi-low and msi-high in these tumours is unknown. materials and methods an unselected series of serrated adenocarcinomas were included. msi status was evaluated using panel of five markers d s , d s and d s ) . a tumour was considered to present msi-high if two or more markers showed msi, msi-low with one marker, and mss when none of the markers showed msi. results dna msi was observed in . % ( / ) of serrated adenocarcinomas, . % ( / ) being msi-high and . % ( / ) msi-low. msi status showed no association with gender, age, location, size, dukes stage, grade or mucinocity. msi-positive serrated adenocarcinomas tended to have better prognosis ( -year survival . %) than mss cancers ( -year survival . %), but this was not statistically significant (p= . , log-rank). conclusions serrated adenocarcinomas show prevalence of msilow higher than that reported for colorectal cancers ( to %), supporting idea that serrated carcinomas are formed through a pathway differing from other carcinonomas. absence of any association of msi and clinicopathological features could be due to homogeneity of these neoplasms although a more extensive material is necessary to show more conlusively absence of any association. a trend for better prognosis in msi -positive serrated adenocarcinomas probably reflects the biological behaviour of msi observed earlier in colorectal carcinomas in general. thyroid hormone receptor beta- expression in colorectal cancer is associated with polypoid growth type and k-ras mutations t hörkkö, tj karttunen, p jernvall, mj mäkinen department of pathology, university of oulu, finland background the action of thyroid hormones is mediated via their receptors (tra , tra , trb and trb ). trb expression is abnormal in cancer cells in vitro and in some malignant neoplasms, but the role trb in colorectal carcinogenesis is unknown. materials and methods trb expression pattern was evaluated by immunohistochemistry in operated colorectal cancers and correlated with k-ras mutations and clinicopathological features. results in normal mucosa, cytoplasmic trb immunoreactivity was seen mainly in the superficial parts, while nuclear reactivity was most prominent in the cryptal epithelium. in tumours, nuclear expression was observed in % of cases and cytoplasmic staining in %, both mostly co-existing. cytoplasmic staining for trb was more common in polypoid ( %; / ) than in flat carcinomas ( %; / ; p= . ). k-ras mutations were more common in tumours with cytoplasmic expression of trb ( . %; / ) than in those without ( %; / ). in lymph node metastases, occurrence of nuclear staining of trb was more pronounced than in the primary lesion (p= . , wilcoxon). conclusions expression of trb is present in normal colorectal mucosa and is mostly retained in carcinomas, suggesting that thyroid hormones and their receptors may be involved in the physiological regulation of normal colorectal epithelium and in the pathogenesis of colorectal cancer. association of expression with k-ras mutations indicate occurrence of functional linkage between trb and ras signaling. observations of a high expression in lymph node metastases and in polypoid cancers offer new clues to factors affecting metastatic cascade and growth pattern of colorectal cancer. gastric mucosal calcinosis in chronic renal failure patients materials and methods a review of the records for crf patients who underwent endoscopic biopsy revealed gmc (patient group) and non-gmc (control group) cases. for each subject we recorded the number and sites of biopsies, and reassessed for inflammatory activity, mucosal atrophy, intestinal metaplasia, lymphoid aggregates, helicobacter pylori, amyloid deposition, and gastritis type. age, sex, cause of renal failure, time from renal failure diagnosis to biopsy, type of dialysis, indications for endoscopy, saca use, and serum levels of calcium, phosphorus, calciumxphosphorus product and parathyroid hormone were also recorded. the gmc cases were classified according to pattern of deposition (nodular, granular, mixed) and disease severity (mild, moderate, severe). results the incidence of gmc was . %. in gmc group there was male preponderance ( %). compared to the control group, the gmc group had a significantly higher number of corpus biopsies; a significantly lower number of antral biopsies; a significantly lower frequency of mucosal atrophy; and a significantly lower parathyroid hormone level (p< . for all). none of the gmc patients had used saca. conclusion unlike previous reports, these results show that gmc is not linked with saca use or female gender in crf patients. there was also no correlation with mucosal injury. these findings suggest that gmc is probably a metastatic process, not a dystrophic one. the value of histology in diagnosis of inflammatory bowel disease (ibd) v tzioufa, g karayannopoulou, i venizelos, a asimaki, e vrettou, c kalekou, t kehaya, a kriaka, e nenopoulou, k patsiaoura aristotle university of thessaloniki, greece in patiens with colitis colorectal biopsy is helpful in the differential diagnosis between ibd and other forms of colitis and also between ulcerative colitis (uc) and crohn's disease (cd). however the histological features in biopsy specimens are not always sufficient for a definitive diagnosis and there is need to establish more sensitive and specific criteria for the distinction between uc and cd. a retrospective blind evaluation of biopsy specimens from patients with the endoscopical diagnosis of colitis was undertaken in order to assess the value of histology in the diagnosis of ibd and the degree of inter-observer agreement. twelve experienced pathologists participated in the study. twenty histopathological features according to a modified version of the british society of pathology guidelines for the evaluation of colorectal biopsies in suspected ibd were studied and the results were statistically analysed. the clinical diagnosis after follow up was uc in cases, probably uc in cases, ibd cases, cd cases and nonspecific colitis cases. higher than % agreement (by all or participating pathologists) on the diagnosis of uc based only on histologic parameters was reached in of the cases for which clinical follow up proved the diagnosis of uc. unanimous agreement on the diagnosis of non-specific colitis was reached in of the cases. our results indicate that although detailed assessment of a combination of histopathological features and the experience of histopathologist are important for the diagnosis of ibd, the final diagnosis depends on combination of histopathology with the clinical and endoscopical evaluation. s taban, a dema, n tudose university of medicine and pharmacy, timisoara, romania aim the authors presented two cases of polipoid tumor lesions (gastric and anal) with pseudomalignant changes. multiple sections from the stomach and anal mucosa were analysed by light microscopic and immunohistochemical methods. in the gastric hyperplastic polyp, there was surface ulceration with granulation tissue and acute and chronic inflammation. within the stroma were numerous atypical cells with bizarre cytomorphology and atypical mitoses. the second case was a fibroepithelial polyp of the anus with collagenous stroma covered by squamous epithelium. stromal cells with two or more nuclei were found and showed atypical nuclear features. in both cases, mast cells were frequently observed and sometimes intimately related to the stromal cells. immunohistochemical study revealed that the stromal cells stained positive for vimentine and negative for actine, desmin, cytokeratin, s- protein and leukocyte common antigen, so considered to be fibroblastic cells. clinical follow-up was available. none of the patients followed developed metastases or recurrences. prognostic value of nm and c-erbb- expression in colorectal cancer v delektorskaya, a perevoschikov, ne kushlinsky cancer research centre, moscow, russian federation increased expression of genetic markers is observed in a variety of malignancies, including colorectal cancer (crc). overexpression of these markers in the primary tumor is known to predict outcome after colonic resection. in this study we aimed to evaluate the expression level of the nm and c-erbb- proteins in crc and its correlation to prognosis and liver metastasis. protein expression was examined immunohistochemically in formalin-fixed, paraffinembedded tissue from colorectal patients. crc showed a high level of nm protein expression in % of primary tumors and % of liver metastasis. expression of c-erbb- was observed in % of primary carcinomas and % of distant metastasis. the positive expression of protein markers in primary lesion was significantly higer in the cases with liver metastasis than in those without metastasis. no significant relationship was observed between nm and c-erbb- expression and other clinicopathological parameters. these results suggest that nm and c-erbb- expression play an important role in the progression of crc and could provide additional information for the development of liver secondaries. introduction sporadic gastric carcinomas (gcs) with high level microsatellite instability (msi+) tend to be poorly differentiated adenocarcinomas with abundant lymphocytic infiltration and are associated with a relatively good prognosis. the aim of the study was to define whether the nature and the activation status of lymphocytes infiltrating neoplastic epithelial cells (iels)of msi+ gcs could be involved in an increased apoptosis of tumor cells and could be consistent with a tumor-specific immune response. materials and methods tumor cells apoptosis and immunophenotype of iels were investigated by immunohistochemistry in msi+ gcs. for comparison, a series of msi-gcs with similar histological features was investigated, including cases, which were positive for epstein barr virus infection (ebv+). results msi+ and msi-/ebv+ gcs displayed a significant higher mean number of cytotoxic iels than msi-/ebv-tumors (cd : . and . versus . ; cd : . and . versus . ; tia- : . and . versus . ; p< . ). in addition the activated iels were more frequent in msi+ than in msi-/ebv-gcs (mean granzyme b immunoreactive iels: . versus . ; perforin . versus . ; p< . ). the percentage of apoptotic tumor cells, evaluated with the m cytodeath antibody, was higher in both msi+ and msi-/ebv+ gcs than in msi-/ebv-gcs ( . % and . % versus . %; p< . ). the lymphoid infiltration in msi+ gcs was significantly higher than that of msi-gcs (except for ebv+ gcs) and this might explain the increased apoptotic index and the relatively better prognosis of these tumors. introduction goblet cell carcinoid (gcc), also known as mucinous carcinoid or adenocarcinoid, is a rare tumor of appendix, which exhibits both endocrine and adenocarcinoma differentiation. different mucin phenotypes are associated with neoplastic transformation in epithelial tissue in various organ systems. muc apomucin is a mucin gene product specific to intestinal goblet cells. muc is suggestive to inhibit cell-to cell adhesion. in the present study, we retrospectivelly studied the clinicopathological features and immunohistochemical expression of muc , muc and muc a in gcc. materials and methods three appendiceal gcc were retrieved from our pathology files from to . medical records and histologic slides were reviewed. the expression of muc , muc and muc a was assessed by immunohistochemistry. results all three cases were males and the age ranged from , and yrs. two patients presented with acute appendicitis. the other one had ruptured diverticulitis and renal cell carcinoma. two patients had appendectomy, and one patient had right hemicolectomy and right radical nephrectomy. histologic examination showed infiltrative small nests and glands of tumor cells with goblet cells and mucinous cytoplasm. perineural invasion was noted in one case. the tumors had invaded through the appendiceal wall to subserosa in two cases and to adjacent cecum in one case. the tumor cells are positive staining for synaptophysin. there was strong and diffuse reactivity in the tumor cells with muc , muc and muc a antibodies in all three cases. follow-up ranged from month, months, and months. all were alive and without recurrence. conclusions these observations suggest that there is no differential expression of muc , muc and muc a in gcc and both muc and muc may play a role in cancer cell growth and invasion. gastric parietal cell carcinoma: report of three cases ml gomez-dorronsoro, r beloqui, i amat, p de llano, a cordoba, b larrinaga, e borobio hospital de navarra, pamplona, spain gastric parietal cell carcinoma is an infrequent newly recognised variant of gastric carcinoma with only cases published in the literature. the present study describes the findings in three cases of gastric parietal cell carcinoma consisting of parietal cells. we have used light and electron microscopy, and histochemical stains. we have studied three cases, two men and one woman, aged between and years. the tumour size ranged from , to , cm. the surgical specimens were stained with hematoxylin-eosin, alcian blue and ptah. small pieces of formalin fixed tumor tissue were collected in one case, and fresh tissue fixed in glutaraldehyde in another both for electron microscopy. involvement of the gastric wall was observed in all tumours. the tumour pattern was characterised by an arrangement of tumour cells in sheets, elongated cords or in diffuse poorly cohesive sheets interspersed with a lymphocytic infiltrate. tubular differentiation was only focally present in one of the cases. all the cases were composed by a large number of parietal-like cells with abundant eosinophilic cytoplasm, with a mixture of signet ring cells population in one of the cases. alcian blue stain was negative throughout the tumour, whilst ptah stained many tumour cells. ultrastructurally the tumour cells were characterised by abundant mitochondria, tubulovesicles, intracellular canaliculi and intercellular lumina filled with microvilli. the three tumours presented are primary gastric carcinoma with cytological and ultraestructural patterns of parietal cell differentiation. they represent a morphologically distinct type of carcinoma, which has been said to have a favourable prognosis. aim the aim of study is to investigate do really cd + cells have cytotoxic or suppressor influence upon gastric epithelium. material and methods we have examined biopsies from patients with peptic ulcer and -with gastritis only. samples were formalin fixed, paraffin-embedded, stained with h/e, toluidineblue, gimsa stain, pas reaction. comparative immunohistochemical analysis of cd + lymphocytes, proliferative markers: mib- and pcna were performed. we evaluated the amount of cd + cells in mm and the proliferative activity of epithelium per nuclei. biopsies were examined electronmicroscopically for the detection of cell-to-cell interactions and subcellular alterations of gastric epithelium. results distribution, amount and characteristics of cd + cells are different in mucosa around ulcer and in gastritis (g.) cases without ulcer. in active g. around ulcer cd + cell are , ; without ulcer - , , but in inactive g.- , . in helicobacter pylori-infected subjects cd + are located in addition at the lymphatic follicles. we have not proved any rise of apoptosis, exfoliation or ultrastructural injuries of epithelial cells in the areas of collections of tlymphocytes of this subtype. in sites of increased amount of cd + cells there is high proliferation activity of epithelium ( , - , %) due to the broadening of labeled nuclei zone with mib- antibody. conclusions the amount of cd +cells correlates with activity of gastritis as this kd glycoprotein realize molecular reactions between mediators or against h.pylori, food and other antigens in lamina propria, but it has no external direct domain upon gastric epithelium, capillaries or glandulocytes. the incidence of gastric cancer decreases worldwide. despite declining (due to intestinal type), incidence still remains the second cause of death amongst all malignancies worldwide. diffuse type of gastric cancer shows constant incidence. therapy and prognosis directly correlate with extent of the disease and reliable prognostic factor is still lacking. the aim of the study is to establish a value of two morphometric methods -nuclear area and microvessel density and their influence to the survival of the patients with advanced gastric cancer. patients who had undergone gastric resections for gastric cancer were analysed in this study. we estimate size of the tumor, histologic type (according to lauren's classification), stage, nuclear area (median value of nuclear areas in cancer cells measured with computerised nuclear morphometry) and microvessel density (median value of f viii-positive microvessels in five x power field) for each case. statistical analysis was performed and p-values lower than , were considered significant. nuclear area shows statistical significant correlation with size of the tumor, tumor stage, tnm classification and metastases in regional lymph nodes, microvessel density does not. in univariate analysis to survival, size of the tumor, tumor stage and tnm classification have p< , . nuclear area only in intestinal type of gastric cancer correlates with survival (p< , ). in multivariate analysis, size of the tumor, tumor stage and tnm classification have an influence on survival. reliable prognostic factors in patients with gastric cancer are still stage and size of the tumor. diffuse type of gastric cancer is still an enygma. spreading and metastazing of intestinal type of gastric cancer could be predicted using a nuclear-area method as a support in therapy planning and prognosis. the role of microvessel density in prognosis is unreliable. f iordanidis, e vrettou, e nenopoulou, p hytiroglou, c papadimitriou pathology dept. medical school. aristotle univ., thessaloniki, greece introduction the kit receptor normally becomes dimerized and its tyrosine kinase phosphorylated (activated) upon the ligand binding, then enabling it to phosphorylate other proteins in the signal transduction pathway that ultimately carry the proliferation signal into the nucleus. the aim of this study was the evaluation of ki- (mib- ), proliferative cell index, in correlation to c-kit stain intensity, histological grade and immunophenotype in gists. we studied a series of gists (c-kit positive) in correlation to age, anatomic location, size, morphological features, mitosis and necrosis. also we stained with vimentin, cd- , smooth muscle actin (sma), s- protein and ki- with abc method on paraffin sections. results the average age of the patients was years (ranging from to ), included male and female patients. were located in the stomach, in the small intestine, in the colon and in the esophagus. microscopically the tumors showed a fusiform cytology and of them showed a mixed fusiform-epitheloid cytology. the average tumor size was , ± , cm (range , - cm). we found necrosis in tumor with size> cm. the tumor cells expressed vim %, cd %, sma %, s- % and ki- ranging from - %. the most gists showed c-kit positivity in % of tumor cells with a small minority showed more focal staining in as few as % to % of tumor cells. the stain intenisty was mild to moderate. conclusion in our study, the ki- expression was associated with tumor size and not with c-kit staining profile, other immunophenotypic features or histological parameters. expression of pcna and ki- protein in colorectal carcinomas. correlation with tumor grade v zivkovic, a nagorni, v katic, j gligorijevic, b djordjevic, m milentijevic, z mijovic institute of pathology, medical school, nis, serbia and montenegro introduction the prognostic significance of pcna and ki- proliferation markers in colorectal carcinomas is debatable. therefore, we evaluated immunoreactivity of the tumor for pcna and ki- antigen in colorectal carcinomas with different histological grades. methods the paraffin embedded tissues were immunostained for pcna and ki- antigen by employing streptavidin-biotin(lsab) method. results pcna was positive in % of carcinomas and localized in the nuclei of malignant cells.immnunoreaction for ki- was demonstrated in all carcinomas and mainly and strongly expressed in the nucleoli.positive staining for pcna and ki- correlated positively with increasing grade. the labelling index was significantly higher in the poorly differentiated carcinomas than in the well differentiated tumors. conclusion the expression of pcna and ki- proliferation markers clearly shows differences between colorectal carcinomas of varying differentiation grades and it is useful as a diagnostic and prognostic parametar. introduction collision tumours have been thought to arise from the accidental meeting and interpenetration of two independent tumours. here we present three cases of gastroesophageal junction tumours that could fill these criteria. we employ molecular and genetic techniques to ascertain the clonality of these tumours in order to determine whether they represent true collision tumours. methods p immunohistochemistry was performed, and p sequence analysis was carried out on rt-pcr material derived from fresh frozen tissue. mutations were subsequently confirmed in paraffin embedded material. standard and laser microdissection techniques provided tumour-enriched samples from which dna was isolated. analysis of loss of heterozygosity was performed using the microsatellite markers d s , d s , d s , d s , d s , d d , d s , tp , p alu and bat . results p immunohistochemistry was positive for both tumours in each case. all three tumours possessed a p point mutation that was identical in both components. polymorphic microsatellite analysis confirmed shared losses of heterozygosity with an identical pattern of retention and loss at six loci in each component. genetic differences were also observed between tumour components. conclusion a comparison of immunohistochemistry, p sequence and the pattern of loh for a spectrum of polymorphic microsatellite markers for three possible collision tumours suggests that both components are derived from a single precursor cell that undergoes divergent differentiation in the evolution of the tumour. the evidence presented here refutes the "collision hypothesis" and introduces a new histopathological entity of a cardia tumour with distinct diffuse signet ring cell and squamous components. a nasierowska-guttmejer, w michej department of pathology, cancer centre, warsaw, poland introduction gists are the most common mesenchymal tumors of the gastrointestinal tract. they are histologically heterogenous group and a practical diagnostic criteria for gists is c-kit (cd ) expression by immunohistochemistry. the aim of this study was to present morphological pattern of radically operated and disseminated gists. material and methods material included gists treated between and in cancer center, warsaw. thirty pts. had been radically operated of gastric gists and pts. -intestinal gists. fifty three pts. had peritoneal and liver dissemination. the histopathological diagnosis based on the type of cells, mitotic activity and tumor size. the immunohistochemical expression of cd (dako), cd (dako), sma (dako) and s p (dako) were performed in each of the case. results . microscopic spectrum. majority ( %) of cases had heterogenous pattern-spindle and epithelioid cells with high mitotic activity-more than mitoses per hpf. the intestinal and disseminated tumors had generally spindle cell histology with variable myxoid matrix or extracellular collagen globules reffered to as skeinoid fibers. the majority of gastric gists were composed of epithelioid, polygonal cells with perinuclear vacuolization. .the immunohistochemical analysis revealed strong and diffuse cd expression in of cases, whereas cd was expressed in cases. four cases were negative for cd and positive for cd . a minority of the tumors expressed smooth muscle actin which was focal. conclusions the heterogenous histologic pattern of gists cd (+) correlated with dissemination, diameter over cm and more than mitoses per hpf. carcinosarcoma of the esophagus: two cases of the unusual neoplasm m malinowska, a nasierowska-guttmejer department of pathology, institute of oncology, warsaw, poland introduction esophageal carcinosarcoma comprise approximately - % of all esophageal tumors. this is the first published report in poland of the unusual malignant neoplasm consisted of both carcinomatous and sarcomatous components. materials and methods two patients with esophageal tumors were presented. they were analyzed using endoscopic, histological and immunohistochemical procedures. an endoscopic examination showed polypoid tumors in the lower esophagus. esophagogatrectomy with lymph node dissection was performed. the resected specimens were fixed in % formalin and paraffin embedded tissue sections were stained with routine hematoxylin and eosin. immunohistochemical analysis for vimentin, cytokeratin, p and mib were performed. results histologically, the neoplasms consisted of two components, squamous cell carcinoma and sarcomatous components. in case , the sarcomatous component was with no specific differentiation and in case resembled malignant fibrous histiocytoma. a gradual transition between two components was found. in case regional introduction the cyclin-dependent kinase inhibitor p is a critical downstream effector in the p pathway and this protein acts as tumor suppressor in a negative cell cycle regulation. aims: we investigated the prognostic influence of p waf /cip reactivity in gastric carcinomas in relation to the p expression. materials and methods the expression of p waf /cip and p protein was revealed immunohistochemically in gastric carcinomas. staining patterns were assessed semiquantitatively and correlated with clinicopathologic variables and survival times. median follow-up time was months (range - months). chisquare and kaplan-meier survival analysis were performed as statistical analysis. results the p waf /cip protein was detected in ( %) and p protein in ( %) of cases. p waf /cip expression was significantly higher in stages i and ii carcinomas than in stages iii and iv carcinomas (p= . ). in tumors without lymph node metastasis, p waf /cip expression was significantly more frequent in tumors with lymph node metastasis (p= . ). low p waf /cip expression significantly associated with p protein expression (p= . ). the survival rate of patients with p waf /cip -positive tumors was significantly better than those without p waf /cip expression (p= . ). in patients with p positive tumors showed significantly poorer prognosis than in patients with p negative tumors. conclusion the status of p waf /cip expression may have prognostic value in gastric carcinomas and evaluation of the expression of both p and p waf /cip might provide more prognostic information. introduction the normal motility of the gastrointestinal tract depends on the enteric nervous system, the smooth muscle layers, and the interstitial cells of cajal (iccs). the aim of this study was to investigate both the distribution of interstitial cells of cajal and the pathohistology of the enteric nervous system in colonic inertia. materials and methods large bowels were obtained from patients with colonic inertia. the patients have been treated surgically with total abdominal colectomy and ileorectal anastomosis. control large bowel specimens were collected from patients with non-obstructing neoplasia. colonic specimens were investigated with monoclonal anti-neurofilament antibody and cd antibody and compared with those of control patients. the analysis of iccs included registration of the number and process length of the myenteric and muscular iccs. in the patients with colonic inertia the myenteric plexus showed moderate or severe hypoganglionosis compared with the control group. the apparently normal axon bundles in the myenteric plexus stained markedly less than normal ones with monoclonal antibody. myenteric iccs were evident as single cells or cell clusters closely related to the small myentric ganglia. the iccs did not form the typical networks seen in the normal bowel. muscular iccs were markedly reduced in number compared to the number seen in normal bowels and were mainly expressed at the innermost layer of the circular muscle layer. conclusion the enteric nervous system and iccs are altered in colonic inertia and may play a crucial role in the pathophysiology of colorectal motility disorders. immunohistochemical detection of the hmlh and hmsh proteins in hereditary and sporadic colon cancer tissues germline mutations of hmlh and hmsh mismatch repair genes (mmr) are associated with hereditary nonpolyposis colon cancer (hnpcc). somatic impairment of these genes can be detected in sporadic colon cancers (cc). all these tumours are characterised by microsatellite instability (msi). the aim of this study was to correlate the results of immunohistochemical detection of hmlh and hmsh protein with results of mutational and msi analyses. patients and methods there were included: cc samples from hmlh /hmsh germline mutation carriers, cc samples from non-carriers, and cc samples from patients not subjected to mutational analysis. immunohistochemistry was performed using mouse monoclonal antibodies (anti-hmlh , clone g - ; anti-hmsh , clone g - , pharmingen, usa). msi was analyzed at abi prism genetic analyzer, mutational analysis by dna sequencing. results loss of nuclear protein expression was detected in all tumours from mutation carriers, all of these exhibiting a high grade of msi (msi-h), and in of msi-h tumours from the other patients. none of the tumours with stable microsatellites or a low level of msi exhibited a nuclear protein loss. immunohistochemical analysis was able to detect msi-h tumours with a % specificity and a % sensitivity. conclusion immunohistochemical detection of hmlh and hmsh proteins is a specific method of detection of tumours with mmr gene inactivation and might be used as a screening method of hnpcc. the msi-h cases with retained nuclear protein expression might express non-functional protein or carry another mmr gene defect. suppported by nc - . study of mucin changes in colorectal adenomacarcinoma sequence m danciu , ms mihailovici , m stan , a trifan , c sfarti , s khder , am gruia university of medicine and pharmacy, iasi, romania institute of gastroenterology and hepathology, iasi, romania introduction mucins are known to have a protective role for the colorectal epithelium against extrinsic noxious factors (including carcinogens), changes of its characteristics being an early process in the adenoma-carcinoma sequence. aims: quantitative and qualitative evaluation of mucin changes in hyperplastic polyps (hp), adenomatous polyps (ap) with different degrees of dysplasia and adenocarcinomas (ac) of colon. material and methods we selected colorectal endobiopsies ( hp, ap and ac). thin serial sections were stained with hematoxylin-eozin, van gieson and alcian blue (ab) ph (for strongly sulphured mucins) and ph . (for acid mucins: weakly sulphured mucins, hyaluronic acid and sialomucins). observations were made only on intracellular mucins. intensity of the stain was analyzed and compared with non-tumoral (normal) adjacent mucosa. results and discussions normal mucosa and hp showed a preponderance of sulphomucins (ab ph ) comparing with sialic acid (ab ph . ). in ap (especially in those harboring high-grade dysplasia) we detected sialomucins in . % cases and the depletion of sulphomucins ( . %). in ac sialomucins were identified in . % cases, while sulphomucins only in . % cases. significant depletion of sulphomucins occurs in ap with moderate and severe dysplasia and in ac, but it was also observed in ap with mild dysplasia. this suggests the possibility that without a proper mucin secretion consisting mainly in strongly sulphured mucins, colorectal epithelium is more vulnerable to environmental carcinogens. histological this study is a continuum of the analysis until . we analyzed biopsy and operative materials from the stomach and small bowel. we used the following histochemical stainings: he, van gieson, reticulin, as well as immunohistochemical stainings with the following antibodies: ckws, lca, s , actin, desmin, nse, chromogranin, synaptophysin, vimentin. results and conclusion the analyzed group of cases consists of patients of age between - years with male predominance ( : ). four of the analyzed ten cases were located in the stomach and in the small bowel. cases were benign, histologically composed of bundles of spindle cells with slightly pleomorphic nuclei and eosinophilic granular cytoplasm, with hyalinised collagen between the cells. the mitoses were either rare or absent. immunohistochemical analyses were most frequently positive for s , actin, desmin and synaptophysin. three of the cases were ranked as malignant, using the following diagnostic criteria: size of the neoplasm, existence of metastases and histological appearance with anaplastic spindle cells arranged in bundles and whorls with high mitotic index ( mitoses per hpf) and marked positivity for actin, desmin and vimentin. what is the relation of age, gender and histological types to the subsite location of colon carcinoma? introduction characteristics that determinate the anatomic site within the colon where the carcinoma is most likely to occur would be very useful in choosing optimal factories for screening of colon cancer /cc/. aims: to study any association of gender, age or histological types with cc in the left or in the right colon. materials and methods retrospectivitaly are studied cases of cc in nmtb between and .the age and the gender of patients were determined. localization, histological type and tnm staging of the cancer are identified on the histological slides. results cases of cc at the age between - years old are diagnosed. gender, age and histological type were independently significantly associated with the frequency of the development of right and left colon carcinoma. the gender distribution of cc is in benefit of male independently of sub site location as they are suffered of cc in the younger age in comparison with the female. independently age, gender and localization prevails the histological type adenocarcinoma with different morphological and functional differentiation. one cc in the left colon is developed on the background of fap. solitary are the cases with congenital fap and lynch ii. in the most cases cc was diagnosed in advanced stage. solitary is the cases with tis and t . conclusion we consider: /cc is more frequently in the male colon; /in cc predominate histological type of adenocarcinoma; /cc is developed in the middle and in the age advanced in years; / cases with multicentrical cc with metachronic carcinoma are solitary. introduction cathepsin b (cb) and l (cl) are cysteine peptidases with capacity of degrading extracellular matrix. cb expression in colorectal cancer (crc) has been related with tumor progression. there are no data about the cl immunohistochemical expression. the aim of this study was to analyse the expression of both cb/l in crc and to relate these findings with clinicopathological data. material and methods epithelial and stromal immunohistochemical expression of cb and cl was studied in and samples respectively. cb was analysed in adenomas. global and local infiltrating edge data were recorded. clinico-pathological parameters were correlated with the immunohistochemistry. results cb/l expression in normal epithelium was apical, with scarce macrophages in the lamina propria. an increase of both cb/l was observed in tumoral stroma, with higher cb at the infiltrating edge. the both global and deep stromal cb increased according to the t (p< , ). neoplastic epithelial cb revealed a basal stain whereas cl was occasional. epithelial cb tended to show high expression in t (like high grade dysplasia) and low expression in t that increased progressively in t - (p= , ) . no differences were evidenced either as a function of n state, gender, site, differentiation or histological type. conclusions cb/l immunoexpression in colon have a distinctive pattern which is altered in carcinoma. whereas increased cb stromal expression ise related with local progression, epithelial positivity seems to play an important role in the first steps of carcinoma. high stromal cl isassociated with carcinoma but cl epithelial expression seems not to be contributory. introduction new approach on estrogen and progesteron receptors of the gastric signet ring cell carcinoma explains its histogenesis and poor prognosis. the pointed out facts are the reason for this study. material and methods the material was obtained from surgically resected stomach, together with ovaries. after two months from gastrectomy right mastectomy has been done. the specimens were fixed in % formaldehyde and embedded in paraffin. the sections were stained with he, pas, hid-ab ph= , methods and abc using estrogen and progesteron antibodies (dako). results histologically, mucin-producing signet ring carcinoma that diffusely infiltrates the antral wall and the ovaries known as krukenberg tumor, has been found. histochemically, type b signet ring cell carcinoma was discovered: cells contained blue positive (sialo) mucin. ductal type of breast carcinoma with lymph node metastases also was found. immunocytochemically, estrogen and progesteron positive receptors were discovered in cancer cells of the stomach, breast and ovaries. introduction primary gastric low-grade marginal zone b cell lymphoma of malt type is a distinct disease entity with a characteristic histological presentation and clinical behavior. the development of gastric malt lymphoma is dependent of h.pylori infection. many reports have stated that the cure of h.pylori infection can induce a complete remission of low-grade gastric malt lymphoma. we performed a prospective study to evaluate the outcome of patients with low-grade gastric malt lymphoma and the histological characteristics before and after therapy. we prospectively enrolled patients with h. pylori positive low-grade gastric malt lymphoma (stage i e except one patient in stage ii e). paraffin sections were stained with: he, giemsa, pas and immunohistochemical lab methods. the patients were examined by endoscopic ultrasound before and after eradication therapy. results endoscopically, enlarged gastric folds, erosions or ulcerations, hyperaemia or intragastric nodularity, with preferential localization in the antrum, were described. histologically, the neoplastic cells infiltrated between pre-existing lymphoid follicles, then colonized the lymphoid follicles. the resemblance of these cells to the centrocyte has led to the term "centrocyte-like (ccl)" cell-neoplastic component of malt lymphoma. in some cases the cells had monocytoid appearance, but plasma cell differentiation also was prominent. typical lesion for malt lymphoma -"lymphoepithelial lesion", was frequent, representing infiltration of the glandular epithelium by clusters of neoplastic lymphoid cells with associated destruction of gland architecture and morphological changes within the epithelial cells, including increased eosinophilia. after the eradication of h.pylori, the patients were regularly followed-up with endoscopic and histological assessment. patients achieved complete remission within weeks, one had partial gastrectomy induced by ulcer with severe dysplasia, but with regression of malt lymphoma (within weeks), but the remission of the patient with stage ii e was achieved within months. lamina propria appeared "empty" with gland loss. scattered lymphocytes and plasma cells were seen within the lamina propria and there were nodular collections of small lymphocytes. lymphoepithelial lesions were scanty or absent. conclusions the time taken for achieve remission of gastric malt lymphoma in these patients varied from to months. the only significant prognostic variables were stage and tumorgrade. comparative evaluation of the prognostic value of muc and muc antigens in colorectal adenocarcinoma introduction during the last decade, information accumulated regarding the experssion of human mucins. muc belongs to the group of membrane bound mucins. it is assumed to play various roles in tumor immunology. muc is marker of goblet cell or mucinous differentation of adenocarcinoma. the significance of muc and muc as prognostic markers in colorectal adenocarcinoma with mucinous differentation and mucinous adenocarcinomas was studied because previous investigations revealed inconsistent results. materials and methods tissues from operated patients with mucinous or mucinous differentiation of colorectal adenocarcinomas were investigated. all specimens were classified according to who and tnm classification, including lymph node status and distant metastases at the time of the surgical intervention. formalin-fixed paraffin-embedded colorectal cancer tissues were cut ( µm) and deparaffinized acording to standard histological techniques. classical he, histochemical pas and hid-ab ph= , and immunohistochemical bsp techniques were applied. the obtained results were evaluated by the x test. results the muc immunoreactivity showed a strong correlation with tumours progression (as suggested by advancing tnm stages) and also de-differentiation (as reflected by tumorous grading). localization and histological grading were also statistically signifficant. on the other hand, muc did not show any association with the data concerning prognosis. conclusions according to our data, only muc presents as an independent prognostic factor of colorectal adenocarcinoma. muc should therefore be considered as a potential target of immunotherapeutic strategies. sporadic form of colon cancer of a -year-old boy i stojanovic, v katic, j gligorijevic, k katic, m andjelkovic-matic institute of pathology, medical faculty of nis university, nis, serbia and montenegro introduction sporadic form of colon cancer is one of the most frequent cancers in adults, but very rare in children; thus we report this case. case report we describe the case of a -year-old boy who had the agressive sporadic coecal cancer, surrounded by nodular lymphoid hyperplasia.the boy underwent to partial colectomy cum omentectomy during the night with clinical diagnosis "acute abdomen". the surgical-pathological stage was: stage iii (t nlmo). the patient received postoperative therapy, but he died with liver metastases eight months from surgery. materials and methods formalin-fixed paraffin-embedded coecal cancer and surrounding nodular tissue were cut and deparaffinized according to standard histological techniques. he, pas, hid-ab ph , and immunohistochemical lab techniques were applied. results fungous advanced carcinoma, mm in diameter, induced stenosis and clinical symptoms of occlusion. histologically, it was poorly differentiated adenocarcinoma with high mitotic index(high activity of ki- ) and neuroendocrine differentiation; cancer cells were diffusely positive for p protein. immunological reaction to muc , muc ab and muc , as well as to b lymphocytes, was negative. microscopic examination of surrounding malt showed large, confluent lymphoid follicles without germinal centres within lamina propria, causing nodular appearance of the overlying mucosa. b lymphocytes were markedly depressed in this nonhereditary form of colon cancer. conclusions the authors have suggested that antibody deficiency, environmental, endocrine and genetic factors cooperated in the development of this nonhereditary coecal carcinoma. the histological findings in the gastroesophageal junction of fetuses introduction the histopathological concept of the gastroesophageal junction has been changed by american pathologists providing the evidence that the gastric cardia is not a physiological structure. instead, it develops through glandular metaplasia of the squamous epithelium of the distal esophagus due to gastroesophageal reflux. methods, results and conclusion the development of the esophageal and gastric mucosa in the gastroesophageal junction was studied in fetuses of - weeks of the gestational age. during the th - th week, the esophageal multilayered epithelium was covered by a continuous layer of columnar mucous ciliated cells which were present only focally till the th week and disappeared later. before the th week, the gastric mucosa was formed by pits only. the glands started as proliferating tubules in the basal parts of the pits in the th week. further, they differentiated into oxyntic glands. the mucosa of the corpus was fully developed in the th week. the cardiac mucosa was absent in all the fetuses examined between the th and st week of gestation. this supports the view that the gastric cardiac mucosa is not a physiological structure but that it results from glandular metaplasia of the distal esophageal mucosa due to gastroesophageal reflux. mr jalali nadoushan , a dievan beigi , n fallah , b mofid shahed university, tehran, islamic republic of iran shahid beheshti university of medical sciences, tehran, islamic republic of iran introduction there is not enough studies about relationship between colon cancer and abo and rh blood groups in compare to gastric cancer. therefore in this study we will examine abo and rh blood groups distribution and correlation of them with pathologic stage of colon adenocarcinoma. methods data on age, sex, abo and rh blood types and pathologic stage (wall thickness involvement and involvement of lymph nodes) of the patients with colon adenocarcinoma; were under surgical operation, were collected from three tehran hospitals. and also data on abo and rh blood groups from healthy persons from above hospitals collected by randomized selecting as control group. results the distribution of abo blood groups in patients was different from control group; however, blood group a in patients was . % higher than the corresponding control. there was no significant association between abo blood groups and pathologic stage of colon adenocarcinoma. the distribution of rh in patients was likely equal with control group; although, there was a significant relationship between rh (+) and wall thickness involvement (p< . ) and involvement of lymph nodes (p< . ). conclusion -abo blood group a is more common in patients with colon adenocarcinoma. -rh(+) has correlation with poor prognosis in colon adenocarcinoma. introduction vascular endothelial growth factor (vegf) is a cytokine involved in tumor angiogenesis. compelling data implicate that deregulation of p protein function may be associated with increased neovascularization and aggressive tumor growth. the aim was to investigate the prognostic significance of vegf overexpression and microvessel count (mvc) at the deepest invasive site in colorectal carcinoma tissue as well as their relationship with p protein expression in tumor tissue. material and methods surgical specimens of operated colorectal carcinomas were studied by immunohistochemical methods for detection of vegf and p protein in tumor tissue and cd positive microvessels. median folow up was . month (range, - months). results vegf expression and nuclear p protein overexpression were found in , % and % of colorectal carcinoma. vegf and p protein positive status was identical in . % of tumors. the dukes stage c and high mvc were significantly more frequent in vegf positive tumors ( . % and . % respectively) comparing with vegf negative tumors ( . % for both dukes stage c and high mvc). hypervascularity significantly correlated with advanced dukes stages, but not with the p protein expression. survival analysis showed that vegf and p protein expression as well as hypervascularity of colorectal carcinomas correlated with poor survival (p= . ). conclusion vegf is an important angiogenic factor in colorectal carcinoma, and its expression being dependent on p protein expression. our data suggest that combined analysis of vegf, p protein and mvc may be useful for predicting the more aggressive biological behaviour of colorectal carcinoma. occult involvement of lymph nodes in the splenic hilus and along the splenic artery in patients with proximal gastric carcinoma m bjelovic introduction the aim of this study was to find out the incidence of occult metastatic involvement in lymph nodes in the splenic hilus (lymph node group according to jrsgc) and along the splenic artery (lymph node group according to jrsgc) as well as to identify pathological features that might be prognostic factors associated with involvement of these lymph nodes in the patients with proximal gastric carcinoma. material and methods total of patients with advanced proximal gastric carcinoma and up to positive perigastric lymph nodes (t /t n category) have been studied in the period between and . histopathological features (tumor size, macroscopic and histologic type, grade of differentiation, depth of penetration, invasion of intramural lymphatics and veins) as well as lymph node involvement have been routinely examined according to tnm and jrsgc systems. detection of microcarcinosis (occult lymph node involvement) in lymph nodes groups and has been performed by multiple serial sectioning and using immunohistochemistry (monoclonal antibodies against cytokeratins and , lsab+ technique) and classified according to modified kikuchi criteria. results occult lymph node involvement in lymph node group has been observed in patients ( , %). three of them ( , %) had only single cell micrometastases (g type of microcarcinosis) and patients ( , %) had micrometastatic deposits greater than microns (g type of microcarcinosis). occult lymph node involvement in lymph node group has been observed in patients ( , %) expressing single cell micrometastases in one case and micrometastatic cell clustering (up to microns in diameter) in another case. conclusion occult involvement of lymph node groups and could be expected in lymph node positive patients with more than three positive perigastric lymph nodes. in the patients with advanced proximal gastric carcinoma examined pathological tumor characteristics could not be associated with the involvement of lymph node groups and . lymph node micrometastases in patients with gastric carcinoma: immunohistochemical evaluation introduction for patients who underwent curative resection for gastric carcinoma, lymph node status seems to be a major prognostic factor of disease recurrence. contrary to histologically overt lymph node metastasis, the biological significance and prognostic relevance of micrometastatic lymph node involvement are still controversial. we examined frequency and distribution of micrometastases in lymph nodes obtained from patients with advanced gastric carcinoma ( , lymph nodes per patient) without primarily histologically overt lymph node metastases. identification of lymph node micrometases was performed using multiple serial sectioning and immunohistochemical detection of cytokeratin and positive cells. the results were correlated to tumoral histological type, growth pattern, depth of penetration and vascular invasion. results the overall detection rate of micrometastases showed their occurence in more than half of examined patients ( / or , %) and in , % of examined lymph nodes ( / ). most of them were so-called single cell micrometastases ( , %), followed by cluster-type of micrometastases up to microns ( , %) and few greater than microns ( , %). the incidence of micrometastases was , % ( / ) in lauren`s diffuse type of carcinoma contrary to % ( / ) in lauren`s intestinal type of carcinoma. in addition, there was no significant difference in occurence of micrometastases in cases with and without penetration of muscular layer, contrary to cases with serosal tumoral involvement and obvious vascular invasion. conclusion detection of micrometastases might influence tumour stage migration to tnm stage iii in further % of examined patients with primarily stage ii determined diseases. the frequency of micrometastases seems to be closely correlated to poorly differentiated carcinomas, especially lauren`s diffuse type of carcinoma and higher pt stages, including serosal involvement. however, possible independent prognostic significance is still to be elucidated after survival analysis of larger series of these patientss ubgroups. introduction gastrointestinal stromal tumors (gists) are the most common mesenchymal tumors of the gastrointestinal tract with the stomach as the most common site. the term 'gist' is preferentially used for the tumors that express cd and cd /c-kit and the latter has been suggested as a specific marker for gists. as gists constitute a group of phenotypically heterogenous mesenchymal neoplasms with uncertain biological behaviour, we reevaluated their histogenetic differentiation and proliferative status. material and methods we reexamined clinically, histologically and immunohistochemically cases of paraffin-embedded gists noted in the tumor registry of clinical centre of serbia between and , and especially in regard to their proliferation, measured by mitotic index and immunohistochemically by ki- and pcna expression scores. in addition, evaluation of malignancy of gists was based on mitotic count greater than / hpf and/or tumor size greater than cm and extra-gastrointestinal spread. results most of gastric gists were composed of spindle cells ( %), epithelioid cells ( %) or both cell types ( %), and nearly % showed obvious clinical malignant behavior. immunohistochemical examination showed strong cd expression in %, cd in , % (two of cases exlusively cd positive) in nonmyogenic and non-neurogenic tumors. in addition, in gists with cd expression, focal expression of s- was found in , %, focal sma in % and desmin in , % of cases. ki- and pcna indices were correlated to mitotic index and other criteria of malignancy. conclusion phenotypic differentiation of gists toward smooth muscle were found to be correlated with proliferative indicators of poor prognosis more consistently than those toward partial/focal neurogenic differentitation or uncommited type. deep topographic compartments of colorectal adenocarcinomas: down-regulation of mlh /msh expression results in lack of physiologic cell kinetic balance background topographic tumor cell selection is not well characterized in colo-rectal adenocarcinomas (crc). the contribution of mlh- /msh- expression to cell kinetics by topographic compartments remains unknown in sporadic crc. design we selected ( low-grade, high-grade) consecutive sporadic crc, including stage i, stage ii, and stage iii. mitotic figure counting, ki- index, g +m phase fraction, in situ end labeling (isel) of dna fragments, and mlh- /msh- immunoexpression were scored by topographic tumor compartment (above muscularis propria vs. muscularis propria). statistical correlation between proliferation and apoptosis variables was performed in each topographic compartment. variables were studied by topographic compartments and considered statistically significant if p< . . physiologic correlations were preserved only in the superficial compartment for mitotic figures, ki- expression, isel index, and mlh /msh expression. g +m phase fraction correlated with mlh- expression only in superficial compartments (p= . ) and msh- expression only in deep compartments (p= . ). conclusions superficial compartments of sporadic crc are characterized by high cellular turnover and maintained cell kinetic balance. mlh- and msh- expression in sporadic crc is inefficient (no g +m phase fraction differences by topographic compartments) and is dissociated (only one gene product correlates with g +m), eventually resulting in mutation accumulation and cell progression. gastro the biologic behaviour of gists has been difficult to predict based on the original criteria proposed in the early s. many isolated histological features, such as site, size, extent of bowel-wall involvement, necrosis, cellularity, mitotic counts, atypia, etc., had to be evaluated and integrated into a single and reproducible result that had also to be as accurately predictive as possible. therefore numerous studies have been performed in order to reach the ideal combination of factors that may predict these tumors correctly. gists were diagnosed either originally or retrospectively after reviewing diagnoses of git spindle cell tumors, examined in our pathology department between the years - . all tumors were defined as gists only when displaying c-kit (cd ) immunopositivity. additional immunohistochemistry was performed to corroborate the diagnosis. we reclassified the tumors according to different proposed classifications and correlated the results with the clinical followup available for these patients. the followup periods ranged between - months for gastric gists (mean- . months, median- . months) and - months for patients with small-bowel gists (mean- . months, median- months). while the median disease-free survival was . months for patients with malignant gastric gists, it was only months for patients with small-bowel malignant gists. the results of the study show that all classifications stratified the patients in a very similar manner although some were more accurate than the others and more user-friendly and therefore probably also more reproducible. the relative high rate of deaths occuring in the smallbowel gist group ( %) as compared to the . % death rate in the gastric gist patients, strengthens the supporters of different criteria to be applied to the gists arising in these different sites. another important issue that has imerged in our study was the much higher incidence ( %) of malignant gists developing in the younger age group ( - years), compared to . % malignant gists in the age group of above years, making this feature to be probably of major significance. it should therefore be considered whether age should be a built-in criterion when evaluating the biological potential of a gist. introduction gastric ulcer disease is the most important disease of the digestive tract becouse this illnes have big frequecy and circle gastric ulcus presents many histologic features characteristics which may be precancerous lesions. gastritis is lesion which is always associated with gastric ulcer. epithelial metaplasias are transformation of one kind of epithelium to other type epithelium and circle gastric ulcus it is very frequency changes of epithelium. the aim of this study was to to find frequency of appearance epithelial metaplasias circle gastric ulcus, types of metaplasias and grade of gastritis. also we searched changes of epithelial mucins. we had citochemistry examination endocrine g, ec and d cells and we wanted to describe immunohistochemicaly feature characteristics in different kinds of epithelial metaplasias. material and methods for examination we use biopsy material:surgery and endoscopic of patients with gastric peptic ulcer. we use standard he method for identification micromorpholic changes; ab-pas (ph , ) and hid-ab method for illustration biochemistry alteration about mucins;grimelius ( ) and masson citochemistry methods; immunocytochemistry avidin-biotin peroxidasa (abc) with antiserotonin, antigastrin, antisomatostatin. results we found cases completly mature intestinal metaplasias (im), cases incompletly im; case imature im and case imature im with displasia. also we detected composition completely and incompletly im in cases, composition incompletly and pyloric metaplasia in cases.we find pyloric metaplasias in cases, colons metaplasia in cases. composition colons and incompletly mature im were detected in cases;composition pyloric and incompletly mature im in case.summary the bigest frequency of appearance metaplastic alteration were in older patients.histologicaly claracteristics metaplasias were imitation some segments of digestive tract. metaplasias include many biochemicaly alterations and it can be present with changes in secretion of mucins.gastric metaplasia is dynamic process with changes both in epithelial and endocrine cells. conclusion metaplasias in gastric mucosa circle gastric ulcer is sign very important alteration.standardisation of research this alteration may be very important guider about prognosis for patients with gaster ulcer disease. choice of immunohistochemical method for detection of defect mismatch repair system c fenger, o nielsen, tp hansen department of pathology, odense, denmark colorectal cancer (hnpcc) and in % of sporadic colorectal cancers, and in the latter the defect is associated with a better prognosis but posssibly also a higher risk for metachronous cancer and a different response to adjuvant chemotherapy. screening for such defects can be done by testing for microsatellite instability, but immunohistochemistry gives similar results with less costs. the aim of this study was to select the optimal antibodies and methods for immunhistochemical detection of proteins involved in the mmr system. material and methods twelve antibodies ( against hmlh , against hmsh , against hmsh and against pms ) were tested using different dilutions and hier-techniques on a material consisting of paraffin embedded tumours from patients with well defined mutations and from controls. the results were evaluated semiquantitatively. the following clones, dilutions and pretreatment regimens were selected: introduction colon's metaplasia may be variant of intestinal metaplasia in the gastric mucosa circle gastric ulcer.it is important precancerous stadium because % colon's metaplasias of gastric mucous membrane transverse in gastric carcinoma. aims: we want to find frequency of appearance colon's metaplasia in gaster mucosa with ulcer disease.also we want to describe histologicaly, histochemicaly and immunohistochemicaly feature characteristics colon's metaplasia in gastric mucosa. materials and methods for examination we use biopsy's matherial:surgery's and endoscopic of patients with gastric peptic ulcer. we use standard he method for identification micromorfologic changes; ab-pas (ph , ) for illustration biochemistry alteration about mucins;grimelius citochemistry method;imunocytochemistry avidin-biotin peroxydasa with antiserotonin, antigastrin and antistomatostatin. results we find two cases so-called colon's metaplasia gastric mucous membrane. it was males in vi decade of life.both of them were detected near parts with intestinal metaplasia and atrophic gastritis. histology's design metaplastic epithelium appear big changes than normal gastric mucosa watched on cellular and tissue level;it was alike epithelium of colon. there was winding and arborescent cryptas, and wasn't find villosity. cells in cryptas were voluminous and they group. predominant componentof cells were goblet cells. cylindric cells also was alike goblet cells. we didn't see paneth's cells. histochemycaly we detected sufficiently sulphomucins and less sialomucins. g cells and ecl cells were insufficient; ec cells were less multiplied. conclusions colon's metaplasia is sign of big intracellular alteration and we can detect this with changes in secretion of mucin. colon's metaplasia gastric epithelium is dynamic process with changes both in epithel and endocrine cells. upregulated expression of relp, a reg-like protein, in inflammatory, metaplastic and neoplastic gastrointestinal mucosa lc andersson we screened expressed sequence tag (est) databases to detect genes specifically expressed in the gastrointestinal tract. we identified a gene, called relp (regenerating protein (reg) family-related protein). the relp cdna encodes a amino-acid preprotein with a -amino-acid signal peptide. the amino acid sequence of relp is - % identical and - % similar to the previously characterized members of the reg protein family. the reg proteins, which all belong to the family of c-type lectins, have been implicated in cell proliferation, migration and differentiation in the gastro-intestinal tissues. the relp gene spans . kilobases and maps to chromosome p - . , whereas the genes of the previously known reg proteins cluster on chromosome . dot-blot hybridisation revealed expression of relp mrna mainly in the gastrointestinal tract, but also in prostate, and testes. immunohistochemical staining demonstrated expression of relp in mucosal neuroendocrine cells of in the small intestine and in the parietal cells of normal gastric mucosa. regenerating borders of gastric ulcera, the goblet cells of inflammatory mucosa in ulcerative colitis and crohns disesase, showed a strongly upregulated expression of relp. areas of intestinal metaplasia in the stomach and esophagus also displayed a robust content of relp. more-over, relp was strongly expressed in mucocellular and mucinous tumors of the gastrointestinal tract. the orthologous gene for mouse relp was also cloned. conclusions relp represents a novel marker of inflammatory, metaplastic and neoplastic changes in the gi-tract. current approach to the biopsy diagnosis of gastrointestinal stromal tumors (gists) -is it possible to predict clinical behaviour? introduction gists are the most common gi mesenchymal tumors showing cd positivity. although according to accepted criteria none of them are 'benign', their metastatic risk depends on the tumor size (ts) and mitotic count (mc). aim: reclassification of a series of gists using morphological and immunohistochemical analysis of paraffin-embedded material and evaluation of the relevant clinical data. material and methods patients with gists fulfilled the criteria of fletcher et al. ( ) . in addition to histological stainings, primary antibodies against vimentin, desmin, actins, s- protein and cd (all dakocytomation) and cd (immunotech) were used for the immunoanalysis. results majority of the tumors was localized in the stomach (n= ) and small intestine (n= ), one in the colon and two were extragastrointestinal. in relation to the accepted mc and ts criterias, of cases were of low and one of very low risk category. tumors belonged to intermediate risk category, mostly due to ts in contrast to low mc. the inclusion of cases into high risk category was based predominantly on the mc (> / hpf and ts - cm /n= / and > cm /n= /; in the last one it was > - / hpf in contrast to ts < cm). conclusion a prediction of clinical behaviour of gists requires a correct histopatological analysis related to initial staging data. although the categorisation of the gists into different risk categories uses both criteria of ts and mc, the significance of the mitotic activity evaluation in our set of cases seems to be higher. multiple gastric composite carcinomas (adenocarcinoma and endocrine carcinoma) with adenosquamous differentiation y kapran , n akbas , m aksoy , f dizdaroglu university of istanbul, istanbul medical faculty, pathology department, istanbul, turkey university of istanbul, istanbul medical faculty, general surgery department, istanbul, turkey a case of multiple gastric composite carcinomas composed of endocrine carcinoma and adenocarcinoma with adenosquamous differentiation is presented. tumours showed a composite architecture both within the site of origin and in lymph node metastasis. a year-old woman had a diagnostic upper gastrointestinal system endoscopic evaluation for her long term dyspeptic complaints. after determination of two concurrent tumours in the stomach she underwent total gastrectomy operation. gross examination of the stomach revealed a polypoid lesion in the anterior wall and an ulcerous lesion in the posterior wall of the corpus. also there were multiple minute nodular lesions both in the corpus and fundus. histopathological examination of the polypoid tumour revealed a well-differentiated tubular adenocarcinoma admixed with an endocrine carcinoma proved immunohisto-chemically. ulcerous lesion was composed of a poorly-differentiated adenocarcinoma showing adenosquamous differentiation admixed with an endocrine carcinoma. other nodular lesions were composed of endocrine tumours having different levels of invasion in the wall of stomach. non-tumourous mucosa harboured atrophic gastritis. this is a unique case of multiple composite carcinomas devoloped in the setting of atrophic gastritis worth to discuss. introduction one of the most common malignant soft tissue tumours in adults is malignant fibrous histiocytoma. these tumours are accepted as an aggressive tumour and mainly treated surgically. primary and metastatic malignant fibrous histiocytomas of the gastrointestinal tract are rarily described. our case is a -year-old woman who had a retroperitoneal malignant fibrous histiocytoma that had metastased to the lung after months following an adequate initial treatment. four months later, because of having recurrent attacks of vomiting and nausea, gastroscopic examination was performed. multiple nodular lesions in her stomach were seen and microscopic examination of these lesions revealed spindle-shaped, pleomorphic tumour cells. the positive immunoreactivity for anti-vimentin and anti-cd justified the diagnosis of malignant fibrous histiocytoma's metastases. total gastrectomy was performed following that diagnosis and she died after month due to renal failure. conclusions this case is presented because of the rarity of distant metastases of malignant fibrous histiocytoma to the stomach and to discuss the entities that should be considered in the differential diagnosis of these tumours. role of p ink a in gastrointestinal stromal tumours introduction the classification based on c-kit/cd expression reordered the formerly rather confuse category of gist. p ink a (p ) is a tumour suppressor gene of the cyclin d-cdk , /ink /rb/e f pathway, altered in > % human neoplasms. it is located on chromosome p , a region consistently involved in dna losses found in malignant gists. aims: we studied the role of p in gists. materials and methods cd -immunoreactive mesenchymal tumours with morphological and clinical features consistent with gist were studied, excluding smooth muscle (desmin+, cd -) and schwannian (s- +, cd -) neoplasms. cases ( gastric, small intestinal and colorectal; males, females; age at diagnosis: - years; follow-up: - -mean: . -months) were considered. immunohistochemistry, rna extraction with semiquantitative rt-pcr and methylation specific pcr (msp) were used. kaplan-meier method followed by log-rank test, and univariate and multivariate analyses with a proportional hazards model were performed (malignancy criteria adopted for uncensored events: recurrence, invasion of adjacent organs, peritoneal dissemination, metastases and death of disease). results a tumoral cell fraction with low/absent p immunoreactivity > % was associated with malignancy; semiquantitative rt-pcr confirmed this result. by msp, cases (all underexpressing p , six malignant) showed p promoter methylation. low/absent p immunoreactivity, together with size, cellularity, mitotic count and presence of coagulative necrosis resulted associated with malignancy by univariate analysis, with the former factor being the only prognostic one selected by multivariate analysis. conclusions p downregulation is implied in gist progression; p promoter methylation is one of its causes; p assessment opens possible perspectives in gist prognostication. introduction regenerative abilities of gastric mucosa glandular epithelium cells are the main mechanism which condition its right function both within the range of gastric mucosa integrity and normal activity of its epithelial cellular elements. the aim of the work was to evaluate dependence between proliferative activity of gastric mucosa glandular epithelium and sex, age, chronic inflammation type and helicobacter colonization. the examinations were conducted on paraffin blocks from gastric oligobiopsies taken from women (of average age- ) and men (of average age- ).to the examinations were rated only cases where oligobiopsies were taken from at least two gastric prepyloric parts (antrum) and corpus with recognized unspecific chronic gastric mucosa inflammation. chronic gastritis was graded according to modified whitehead's classification. helicobacter pylori (hp) was evaluated according to the sydney system. examination of the cells with pcna proliferative antigen expression were conducted separately for foveolar area glands and for glands below gastric mucosa foveolar area. all the measurements were performed separately for gastric mucosa prepyloric part and gastric corpus. in tissue sections, in which were carried out proper immunocytochemical reactions, measurements of the pcna positive cells number in circular, oblique short, oblique long and oblong gastric glands sections were conducted five times. the statistic analysis also included age, presence of hp colonization, gastric mucosa inflammation type and the area where an oligobiopsy section was collected. results no significant differences were found in proliferative activity depending on the place of collecting a section, age and hp colonization, while a higher proliferative activity was found in superficial chronic gastritis, particularly in gastric mucosa prepyloric part. conclusions . chronic superficial inflammation coexists with significantly higher proliferative activity of gastric mucosa glandular epithelium, particularly with connection to its prepyloric part. . changes in gastric mucosa glandular epithelium proliferative activity do not depend on its age and histotopography and hp colonization. introduction chromogranin-a-plus (cha) and d cells exist almost in the whole alimentary canal and in pancreas. these cells have an influence on secretory functions and normal gastric mucosa histostructure. up to now investigations confirmed participation of these cells in e.g hcl and gastrin secretion regulation and in some of the proliferative states of gastric mucosa. the aim of the study was to estimate participation of cha and d cells in microscopic superficial (gchs) and deep (gch) gastric mucosa inflammation's indices. material and methods paraffin blocks from gastric oligobiopsies was the material which was collected from women (of average age- ) and men (of average age- ). to the examinations were classified only the cases where oligobiopsies were taken from at least two areas of gastric prepyloric part (antrum) and corpus, with diagnosed unspecific chronic gastric mucosa inflammation. chronic inflammations were graded according to modified whitehead's classification. helicobacter pylori (hp)was evaluated according to the sydney system. neuroendocrine cells of gastric pylori were counted after proper immunohistochemical identification in circular, oblique short, oblique long and oblong gastric glands sections. all measurements were conducted separately for gastric mucosa prepyloric part and gastric corpus. the results of quantitative researches were analysed with the use of statistic methods. in gastric mucosa antrum there were twice more cha and d cells in comparison with corpus. gastric mucosa inflammation type did not have a significant influence on cells localization in gastric mucosa. the number of cha cells diminished in gchs gastric antrum among patients who were over years old, whereas the same number increased in corpus inflammations of this type. the increase of cha cells number was found in gchs gastric antrum with hp colonization. in these cases d cells number diminished. conclusions . in gchs gastric antrum with hp colonization cha cells number significantly increases while d cells number decreases. . quantitative changes of cha and d cells run differently in gchs and gch both in prepyloric part and in gastric corpus. response to preoperative chemoradiation on rectal adenocarcinoma: histopathological effects and relationship with level of p and pcna expression introduction adjuvant chemoradiotherapy delivered before surgery has been used to improve control and to reduce the likelihood of local recurrence in selected patients with rectal cancer. although the status of p gene and the expression of pcna has been widely studied in these tumors, little is known about their value to predict the responsiveness of rectal cancer to chemoradiation. the aim of this study was to to assess effects of preoperative chemoradiation in advanced rectal adenocarcinoma. we examined the histopathologic effects of chemoradiotherapy on rectal tumors and correlated the efficacy of treatment with the level of p and pcna proteins expression in pretreatment biopsies. results three patients showed no primary tumor in the resection specimen. another eight carcinomas showed a good response to chemoradiation with only small nests of viable tumor cells. grouping these two categories, we considered that the tumor response had been total or subtotal in cases ( %). nuclear accumulation of p protein was detected in ( %) specimens. thirty five tumors showed a high pcna index ( %). no obvious relationship seemed to exist between pretreatment, p immunostaining and response to chemoradiotherapy. tumors with high pcna index were more likely to respond to chemoradiation: / ( %) versus / ( %)(p= . ). conclusion knowledge of proliferative activity of rectal cancer, as determined by pcna immunostaining, should be useful in predicting the likelihood of response to preoperative chemoradiation. introduction mitotic count and tumor size are the main predictors of outcome in gastrointestinal stromal tumors (gist). however, they are not always useful in individual cases. the aim of the present study has been to assess whether mitotic counts performed using phosphorylated histone (phh ) antibody, expressed from the early steps of mitosis, could improve the prediction of prognosis in these tumors. materials and methods sections from gist were stained with phh antibody (upstate biotechnology, lake placid, ny; : , dilution). mitoses were counted per high power fields ( x, olympus bx). in addition, the h&e-based mitotic counts and tumor size were obtained from the pathology reports. patient outcome was recorded as the endpoint. conclusion in the present series, phh -based mitotic counts allow a better prediction of prognosis than h&e-based counts or tumor size. thus, phh antibody could be applied in the pathological classification and grading of these tumors, and in the more precise definition of cases with higher risk of progression. immunohistochemical expression of cyclooxygenase- (cox- ) in human colorectal cancer introduction recent studies have implicated metabolites of arachidonic acid, such as prostaglandin e( ) in colorectal carcinogenesis. cox- , a key enzyme in arachidonic acid metabolism, is present in the majority of colorectal cancer (crc). its overexpression seems to be associated with worse prognosis. the aim of this study was to examine the relationship between the expression of cox- in human crc and the clinicopathological characteristics of the tumor. materials and methods paraffin embedded tissue samples from patients (m: , f: , median age: yrs) with crc (tnm staging: i -iv), who underwent radical surgical treatment in thessaloniki cancer hospital "theagenio" from / / until / / , were evaluated. tumor sections were stained for cox- using a rabbit polyclonal antibody against human cox- and the staining was graded on a scale - , using mononuclear cells as reference. results cox- expression was found in tumor epithelial cells in . % of crc ( / cases) with diffuse mainly, cytoplasmic staining and in inflammatory cells, vascular endothelium and fibroblasts. low cox- expression (grade - ) was found in . %, high cox- expression (grade - ) in . % of cases and the remaining were negative. there was no correlation between clinicopathological characteristics of patients and intensity of cox- expression, although there was a slightly better overall survival rate in low expression group of patients (p:ns) . conclusions this small study shows that cox- protein is overexpressed in most cancer cells in colorectal carcinomas and may be related to overall survival. the expression of bcl family proteins in b-chronic lymphocytic leukemia introduction b-chronic lymphocytic leukemia (b-cll) is a neoplastic disease caused primarily by defects in the apoptosis mechanism. apoptosis is the process of programmed cell death or cell suicide. the bcl- proteins are a family of proteins involved in the response to apoptosis. some of these proteins (such as bcl- and bcl-xl) are anti-apoptotic, while others (such as bad or bax) are pro-apoptotic. materials and methods our study includes peripheral blood specimens from patients with b-cll and healthy individuals (as a control group). using western blot analysis, we examined the levels of bcl- , bcl-xl, bax and bad protein expression. the level of bcl (p= , x - ), bax (p= , ) and bad (p= , ) proteins were significantly increased in all analyzed patients while the level of bcl xl protein (p= , ) showed no difference between patients and healthy individuals. differences between the levels of analysed protein expression in group of patients had no statistical significance. conclusion increased level of expression bcl , bax and bad protein represents the most striking feature of b -cll cells. the variations in expression of only one protein of the bcl family can not represent the prognostic factorr in b-cll. introduction kikuchi -fujimoto disease (kfd) is a distinctive type of necrotizing lymphadenitis with unknown cause, has a selflimited clinical course and affects usually the cervical lymph nodes of young women. although kfd occurs most often in young women, only two cases have been reported during pregnancy. in one of these cases kfd developed initially years before. case report we report a case of a -year-old pregnant woman on her th week of gestation who was admitted with a history of swelling in the right side of the neck and fever of days duration. on physical examination a cm cervical lymph node was palpable. microscopically, the excised lymph node showed large areas of necrosis and extensive karyorrhexis. no neutrophils or plasma cells or eosinophils were identified. it was found an admixture of nonphagocytic histiocytes and t-lymphocytes in the necrotizing area. there was a predominance of cd + cells over cd + cells. the patient received no treatment and months later had no symptoms. later she delivered a healthy boy. five years ago the patient presented similar clinical history and histological diagnosis of the excised cervical lymph node. we present the second reported case of recurrent kfd during pregnancy and the third case of kfd developing during pregnancy. conclusion from our case and the other two reported cases it seems that if kfd occurs in a pregnant woman there is no need to terminate the pregnancy as there was no effect on both mother and fetus. monitoring of patients with follicular lymphoma carrying t( ; )(q ;q ) by real time quantitative pcr introduction follicular lymphomas (fl) are characterized by t( ; )(q ;q ) in a majority of patients. the identification of the translocation is utilized to monitor the disease behavior, and, specifically, to detect minimal residual disease (mrd). qualitative pcr is routinely used but without specification of the tumor cell quantity. real time quantitative pcr (rq-pcr) may be employed to address this issue. aims: rq-pcr was introduced to monitor mrd in patients with fl bearing the t( ; )(q ;q ). materials and methods samples of primary tumors, bone marrow and peripheral blood (bm/pb) specimens were taken in the course of the disease and were used for the t( ; )(q ;q ) assessment. for translocation screening, fish on interphasic nuclei was applied. qualitative pcr was used to detect the break in the major breakpoint region (mbr) of the bcl- gene ( q ). relative quantity of cells bearing mbr t( ; )(q ;q ) was performed by the rq-pcr. fifteen samples of primary tumors and bm/pb in duplicates were investigated with appropriate controls. the relative quantity of cells with t( ; )(q ;q ) was significantly higher in the primary tumors than in the bm/pb samples. the changes of the bm/pb infiltration were found during the course of the disease and included shifts toward the tumor progression or disappearance of the tumor cells. rq-pcr is a technique suitable for monitoring the disease response to the therapy or the disease progression and it is superior to morphology and immunohistochemistry. supported by: iga-mzcr-nc/ - , research project fn-motol/ . phosphatase activity dependent apoptotic effect of transforming growth factor beta in ht human lymphoma cells introduction transforming growth factor beta (tgfb ), a multifunctional cytokine, has antiproliferative and/or proapoptotic effect on lymphoid cells. the continuously proliferating lymphoma cells could be resistant to the endogenously produced tgfb . aims: to study the responsiveness of lymphoma cells using exogenously activated tgfb . the apoptotic effect and depolarization of the mitochondria was detected by flow cytometry, the different gene expression was studied by rt-pcr. the amount, the activity (western blot) and the localization (confocal microscopy) of the signal elements (smads, phoshpo-smad , erk / , jnk, p mapk) and other proapoptotic and survival proteins (bcl- , blc-xl, bid, bax, bad, nfkb, phospho-ikb) were also studied. the role of pp a phosphatase, mek kinase and caspase activity was estimated by different inhibitors (endhothal, okadaic acid, pd , z-vad-fmk, z-ietd-fmk, z-lehd-fmk) in vitro. results ht b cell lymphoma cells lost their sensitivity to the antiproliferative action of exogenous tgfb , but the cells were killed by apoptosis. smad phosphorylation, nuclear localization and the increased expression of tgfb induced early gene (tieg) proved the rapid activation of smad signal. the role of pp a phosphatase activation followed by decreased expression of active phospho-jnk and phospho-erk / was supported by the antiapo-ptotic effect of pp a inhibitors and the proapoptotic effect of specific mek inhibitor. the apoptosis was induced primarily through the mitochondrial pathway. it seems that both main iniciator caspases (caspase and ) took part in the apoptotic response. conclusion these data suggest that exogenous tgfb had double but interrelated actions on ht cells: a) suppression the survival signals produced by protein kinases, which b) allowed the smads to induce apoptosis. therefore, it is possible that the lost sensitivity of malignant lymphoid cells to proapoptotic regulators (such as tgfb ) could be reactivated especially by lowering the survival threshold. the work was supported by otka (t ), ett ( / ett ( / , / , fkfp ( / ) and békésy foundation ( / ). clinicopathological study of chromosome abnormality related hematological disorders introduction cytogenetic abnormalities sometimes determine the subtype of hematological disorders and are common in myelodysplastic syndromes (mds). although chromosome abnormality is frequently observed in mds, the specific characters of this type are not determined. in this study, we examined the clinicopathological characters of hematological disorders associated with chromosome abnormality. aim of this study is to assess whether these disorders are classified in special subtype or not. we selected hematological disorder cases with chromosome abnormality from the bone marrow files of the department of pathology, nagoya university hospital. clot sections of aspirated bone marrow were examined histopathologically. immunohistochemical study was performed using paraffin embedded tissues. results patients, males and femals respectively, with monosomy , with der ( ; ) and with other abnormalities were studied.the median age of the patients was . years (range, - years). pancytopenia was observed in , bicytopenia in and monocytopenia in cases. past history of aplastic anemia was in cases. histopathologically, they were cases of mds, of aml, in all and of others. hypoplastic mds (< % cellularity) were found in cases, of ra, of raeb, of raeb-t and case of mds with fibrosis. all cases of acute leukemia had dysplastic multi-lineage features other than blasts. histopathological characteristics were weak erythroid dysplasia, increased micromegakaryocytes and hypocellular tendency. these characteristcs were common in patients with monosomy and other abnormalities. concusion hematological disorders with chromosome abnormalities share similar clinicopathological characteristics. expression of topoisomerase i and topoisomerase ii alpha as an independent prognostic factor and evaluation of the overall survival in nhl e catalano cooper hospital/university medical center, camden, usa introduction topoisomerase ii alpha and topoisomerase i (topo i and ii alpha) are the key targets for some anti-cancerous drugs that inhibit these enzymes. the purpose of this paper is to examine the expression of topo i and topo ii alpha in different types and stages of nhl's the response of treatment with the overall survival. materials and methods immunohistochemistry techniques with anti-topo i and topo ii alpha were used. the results were evaluated with a semi-quantitative method. results and conclusion cases were studied with topo i and topo ii alpha. we include % of follicular lymphomas, % diffuse, % follicular and diffuse and high grade %. the stage of these tumors were stage i, %; stage ii, %; stage iii %; stage iv, %. the results show a higher intensity expression of the topo ii alpha, and topo i indices, in the higher grade nhl. there appears to be a similar expression between the intermedium and indolent nhl. the survival indicates that the large cell nhl's show a higher response rate and better survival than the mixed or small cell type. the expression of these two enzymes may be useful for selecting the appropriate chemotherapy in nhl. our data, although small, suggests an excellent correlation in response to treatment and longer survival in the nhl that have a high expression of topo i and topo ii alpha. mantle cell lymphoma (mcl): ki- antigen and chromosome ploidy in an estimate of the tumor progression introduction mcl belongs to prognostically unfavorable lymphomas. however, the behavior may vary and it is difficult to predict it. a more aggressive course tends to be associated with blastic and anaplastic subtypes. numerical chromosomal changes and proliferative activity may be of importance to improve the prediction. aims: risk of the tumor progression with the assessment of ki- antigen-positive cell count and ploidy status of chromosome . materials and methods patients with mcl characterized by t( ; )(q ;q ) and by overexpression of cyclin d . the proliferative activity was evaluated immunohistochemically (ihc) by double staining for ki- antigen and cd (to rule out counting admixed ki- positive t-lymphocytes). ploidy status of chromosome was evaluated by interphasic fish. results and conclusion trisomy and polysomy of chromosome ( patients) was associated with blastic/anaplastic forms of mcl with the same frequency as with the common variant. a finding of > % ki- and cd positive cells was associated with the blastic variant of the disease - patients. of them died of the disease progression, one of unrelated cause and one is alive with the disease. of the remaining patients in whom the follow up was available, died of the tumor, and the proliferative activity, measured by counting the ki- positive cells was < %. the assessment of proliferative activity with immunohistochemical demonstration of ki- antigen seems to be useful in prediction of clinical behavior of mcl supported by iga-mzcr-nc/ - , research project fn-motol/ . morphological criteria for differentiation of lymphocyte predominance hodgkin's lymphoma from lymphocyterich classical hodgkin's lymphoma aims to reveal morphological features of differential diagnosis between lymphocyte rich classical hodgkin's lymphoma (lrchl) and nodular lymphoid predominance (nlphl). retrospective analysis of lymph node biopsies (age - ) with histological diagnosis of "nodular paragranuloma" or "hodgkin's disease, lymphocytic and histiocytic variant". immunological data were available in all cases. all patients presented with the early stages of disease. we used the following morphological criteria: growth patterns (nodular, nodulardiffuse or diffuse), distribution and cytomorphology of tumor cells ("popcorn", lacunar, classical, mummified cells), cellular composition of reactive background, presence or absence of secondary and atrophic follicles. the results of morphological algorithm were compared with immunology data in every case. results among biopsies, cases ( %) were classified as nlphl. cases were attributed to lrchl, including cases which were characterized by interfollicular sheets of cells resembling lacunar cells ("cellular phase of nodular sclerosis"), cases had rare classical cells within expanded mantle zone ("follicular variant" of hodgkin's disease). all cases lrchl exhibited secondary follicles. there were no cases of lrchl with "pure" diffuse growth type; both nlphl and lrchl had nodular or nodular and diffuse pattern. cases corresponded morphologically to nlphl or lrchl and this division was confirmed with immunological analysis.. conclusion we proposed the algorithm of morphological criteria for differentiation of nlphl from lrchl bone marrow sinusoids in acute lymphoblastic leukemia (all) v rugal russian institute hematology, st.petersburg, russian federation introduction bone marrow sinusoids regulate the development of hemopoietic precursors and migration of stem cells and mature blood cells in blood stream. the purpose of the investigation was to study endothelium of bone marrow sinusoids in disordered hemopoiesis in all. pretreatment bone marrow trephine biopsy sections from patients with all were studied using morphometric and ultrastructural methods. results development of myelosuppression in all was accompanied by considerable changes in the morpho-functional status of sinusoid endothelium. most vessels became thinned, endothelial cells were flattened. in such vessels cells of endothelium came apart with formation of gaps between cells. the basement membrane was interrupted. however, blast migration continued to be transendothelial. there were vessels in which the structure of endothelial cells was identical to that of blast cells. there were no signs of endo-and exocytosis in such cells. intranuclear virus-like inclusions were found in endothelial cells of sinusoids of patients with all. the above data suggest the involvement of endothelial cells in the disordered haemopoiesis in all. defects of the bone marrow sinusoids in leukemia can be the cause of the early release of blasts into circulation. blast transformation of endothelial cells does not contradict the suggestion about existence of a common cell precursors of the endothelial and hemopoietic cells. complex diagnosis of follicular lymphomas e toth, e csernak, z melegh, n udvarhelyi, t schneider, a rosta, z szentirmay national institute of oncology, budapest, hungary introduction the second most common type of non-hodgkin lymphomas is follicular lymphoma (fl). moreover, follicular lymphomas are the most common type of the low grade lymphomas. in hungary they comprise about - % of all the lymphomas but its occurrence shows increasing tendency. our aim was to survey and revise fls diagnosed in the last years in the national institute of oncology. we studied the diagnostic relevance of histology, immunohistochemistry and the detection of immunoglobulin heavy chain (igh) and bcl- gene rearrangements. materials and methods we surveyed cases which were diagnosed as follicular or centrocytic, centroblastic lymphoma before. after the histological re-examination immunohistochemistry (cd , cd , bcl- , cd , bcl- , cd , p , cyclin d and ki- ) was performed on each case. we studied the igh and bcl- (mbr) gene rearrangement both with conventional and real-time pcr methods from the paraffin embedded blocks. the classification was made according to the new who classification. results after the revision of the cases we found follicular, diffuse large b-cell, mantle cell and marginal zone lymphoma, paragranulomas and follicular hyperplasias. the grade of the fls showed relation to the expression of different antigens. cd and bcl- expression decreased with the grade. p expression was very rare and occurred only in grade cases. the proliferation index with ki- showed good correlation with the grade of fls. the igh showed types of pattern: monoclonal, polyclonal and a sharp line in a polyclonal background. grade and grade - fls were monoclonal almost in the same ratio. we could detect bcl- gene rearrangement in % of the fls ( % grade - , % grade ). all the grade cases which showed bcl- gene rearrangement belonged to grade a group while all the grade b cases were negative. conclusion in agreement with others we found that grade , and a fls showed similar morphological, immunohistochemical and genetical features while gr b fls are more similar to diffuse large b-cell lymphomas. considering the diagnostic relevance of the different methods we can conclude that histology alone is not sufficient. % of our cases were solvable with the help of immunohistochemistry and in % of the cases the diagnosis based on the molecular pathological results. in the remaining % even with the help of all diagnostic tools no unambiguous diagnosis could be reached. the bcl- and p oncoproteins play important roles in carcinogenesis. mutation of the p gene is considered the most common genetic aberration in many cancers including hematologic malignancies. ki- , a proliferation antigen, evaluates the proliferative activity of a lesion. angiogenesis is also critical for tumor proliferation and has a prognostic value. the vascular density of tumor directly correlates with poor outcome in many malignancies. the aim of this study was to investigate correlation between ki- , p and bcl- immunostaining in b cell lymphomas and to identify any relation between these markers and microvessel density (mvd) and histopathological parameters including stage and tumor grade. materials and methods low grade and high grade non-hodgkin lymphomas (nhl) were immunohistocemically stained with p , ki- , bcl- and factor viii. the results were analysed statistically. results there was no correlation between stage and ki- li, mvd, p and bcl- expression. the cases which showed immunoreactivity for bcl- had decreased mvd counts compared with the cases negative for bcl- . p immunoreactivity was correlated with mvd. microvessel counts were significantly higher in patients with high grade nhls. statistical analysis showed association between ki- li, p , bcl- expression, mvd and histological grade. conclusions the levels of ki- , bcl- and p expression and microvessel counts were closely related with the grade of nhls. our findings suggest that apoptosis, angiogenesis and proliferative activity can be used as prognostic indicators in nhls. diffuse large b-cell lymphoma of the maxillary sinus complicated with blastomycotic leptomeningitis sinus; however such a lesion is more likely to arise from an infraorbital lymph node, part of the facial lymph node group. case presentation we present a patient with diagnosed diffuse large b cell lymphoma of the maxillary sinus as well as involvement of the infraorbital region, who suffered from infective complications. -years old male was admitted at the clinic of hematology because of tumor mass in nasal cavity. ct-scan showed tumor mass filling right maxillary sinus. surgical biopsy was done. histochemical and immunohisto-chemical findings suggested a diagnosis of diffuse large b cell lymphoma. other clinical investigations showed i-e clinical stage. treatment with four cycles of chop and mab-thera followed. after that adjuvant radiotherapy was delivered. because of increased body temperature and meningeal symptoms, this therapy was interrupted. microbiological investigations showed positive hemoculture for escherichia coli and staphylococcus aureus, and positive finding of blastomyces in cerebrospinal fluid, while serological analyses revealed positivity for cmv and ebv. beside severe antibiotic, antimycotic and antiviral treatment, the patient suffered from sepsis with main features of suppurative leptomeningitis and acute hepatitis. conclusion this case implies the conclusion that the clinicians should have in mind the possible presence of immune disregulation in patients with nhl, that could complicate the administered chemotherapy and radiotherapy. aim the aim of this study is to determine the most frequent pattern of involvement by nhl of head and neck and to correlate it with clinical outcome of the disease. material and methods a retrospective review was performed on patients with nhl during five years period. paraffin sections stained with standard histochemical and immunohistochemical stainings were histologically analyzed for classification of the nhl accordingly to the who classification of lymphoid neoplasms. clinical histories were used for clinical follow-up. results in fifty cases out of patients with nhl the disease was primary localized in the head and neck region. male-female ratio was , . twenty four cases were primarily nodal, primarily extranodal and had extranodal/nodal expression of the disease. diffuse large b cell lymphoma comprised % of the group: nodal, extranodal and extranodal/nodal. three of these cases were cd + and alk- -. six cases ( %) with b-cll nhl had nodal manifestation. malt-zone lymphoma ( %) showed extranodal involvement in cases and extranodal/nodal in cases. b-lymphoblastic lymphoma ( %) showed cases with nodal, one extranodal and one extranodal/nodal involvement. two cases with burkitt's lymphoma ( ) had typical mandibular localization. follicular lymphoma comprised %, with two nodal and two extranodal involvement. t cell nhl-s comprised % of the group with three nodal, one extranodal and one extranodal/nodal involvement. there was no significant predilection for clinical expression of the nhl of head and neck, and no difference between the mean survival of the groups for these parameter. expression of the bcl- family proteins, caspase (cpp ) and poly adp-ribose polymerase (parp- ) in multiple myelomas v zolota , m melachrinou , i xagoraris , a mouzaki , p aroukatos , d koumoundourou , ds bonikos dept. pathology, univ. patras med. school, patras, greece dept. laboratory hematology and transfusion medicine, univ. patras med. school, patras, greece introduction multiple myeloma (mm) is a malignancy of the bone marrow characterized by the clonal expansion of plasma cells with low proliferative activity. aberrant expression of genes regulating apoptosis/survival seems to be essential in the development of multiple myeloma. the aim of this study was to investigate the immunohistochemical expression apoptosisregulating proteins in bone marrow of patients with initially presented multiple myeloma. methods the expression of bcl- , mcl- , bak, bax, cpp and parp was examined on paraffin sections of bone marrow biopsies obtained from equal number of patients with newly diagnosed mm, using commercially available monoclonal and polyclonal antibodies and lsab technique. specimens containing > % immunostained tumor cells were considered positive. results bcl- , bak and bax positive immunostaining was detected in %, % and % of cases respectively. most positive tumors showed high percentage of tumor cells immunoreactive for the above proteins: > % for bcl- , > % for bak and > % for bax. the mean value for bcl- /bax ratio was . , and the mean bcl- /bak ratio was . . mcl- expression was detected in a small percentage of tumors ( %). cytoplasmic expression of cpp was observed in , % of cases and the number of positive cells was low. nuclear expression of parp was seen in , % of cases and no association was found with the other apoptosis-related antigens, bcl- /bax or bcl- /bak ratio. conclusion the above data demonstrate an overexpression of bcl- , bax and bak in myeloma plasma cells and an increased bcl- /bax ratio. cpp does not seem to mediate any apoptotic event in mms. the role of overexpression of parp remains to be elucidated. immunoexpression of bcl- family members, p , caspase (cpp ), and poly adp-ribose polymerase (parp- ) in diffuse large b-cell lymphomas introduction diffuse large b-cell lymphomas (dlbcl) represent a biologically and clinically heterogeneous group. although these tumors are curable with chemotherapy, their response to treatment varies. apoptosis-related proteins may play an important role in the chemosensitivity or chemoresistance of tumors. the aim of this study was to investigate if the expression of apoptosis-regulating proteins in dlbcl could be indicative of tumor chemosensitivity. methods formalin-fixed, paraffin-embedded tissue from cases of dlbcl [ nodal, extranodal, splenic ( centroblastic, immunoblastic, burkitt's-like, anaplastic, tcrbcl, primary mediastinal)] were immunostained with monoclonal [bcl- (dako), mcl- , cpp (neomarkers), p (biogenex)] and polyclonal [bax, bak (dako), parp (neomarkers)] antibodies using lsab method. specimens containing > % immunostained tumor cells were considered positive. clinical data were available for cases ( chemosensitive, chemoresistant). results bcl- , mcl- , bax, bak, p , cpp and parp positive immunostaining was detected in . %, . %, . %, %, . %, . % and . % of cases, respectively. mcl- , bax, bak and parp were overexpressed in > % of tumor cells in most cases. there was a significant association between the expression of bcl- and mcl- (p = . ). a higher immunoexpression of bcl- ( . % vs . %), mcl- ( . % vs %), bax ( . % vs %), p ( . % vs %) and cpp ( . % vs %) was observed in chemoresistant cases. parr expression was higher in chemosensitive cases ( . % vs . %). in the p -negative group of cases ( cases) those with a strong ( +) parp expression showed a significant better response to treatment (p = . ). a significant chemosensitivity was also detected in the group ( cases) with strong ( +) bax and weak (+) or negative (-) p immunostaining (p = . ). conclusion apoptosis-related proteins, though overexpressed in dlbcl, were not associated with response to treatment. a p (-)/parp( +) or p (+ or -)/bax( +) tumor status may reflect sensitivity to chemotherapy. introduction non-hodgkin lymphomas (nhl) are a heterogenous group of lymphoid malignancies classified according to their morphological, immunophenotypical and genotypical characteristics as well as their clinical behaviour. however, the progression of these diseases may be influenced by various others factors such as apoptosis, proliferation and angiogenesis. aim: a possible correlation between bcl- expression, apoptosis, disease outcome and overall survival in patients with nhl was analysed. material and methods nhl devided in low-(n= ) and highgrade (n= ) were immunohistochemicaly analysed for bcl- expression, while low-and high-grade nhl were procesed for terminate tdt mediated dutp nick end labeling (tunel) method in order to determine the apoptotic index of tumor cells. results were obtained by image analyser and statistically processed. results the expression of bcl- protein, as an antiapoptotic marker was significantly higher in low-compared to high-grade nhl, p= . , whereas the apoptotic index obtained with the tunel method demonstrated inverse results, p< . . in highgrade nhl, partial remission was observed in patients whose tumors expressed significantly higher values of bcl- , (p= . ), while complete remission was observed in a group with a lower expression of bcl- . furthermore, patients with lower bcl- expression showed longer overall survival p= . , whereas patients with a higher apoptotic index showed shorter survival, p< . . in both low and high-grade groups of nhl, bcl- has been found as an independent predictor of patients disease relaps, p< . . conclusion the expression of bcl- is a strong independent predictor of disease progression in nhl patients. the heterogeneity of anaplastic large cell lymphomas (alcl) o mederle, m raica dept. of histology and cytology, university of medicine and pharmacy, timisoara, romania introduction the aim of this study was to investigate the expression of cd and the distribution of the reticular network on the alcl. material and methods twelve cases of lymphomas were analyzed using morphologic and immunophenotypic features. the patients ( male and female) were from to years. five patients presented with generalized lymphadenopathy and seven with involvement of extranodal sites. alcl was composed of large cells that grow in a diffuse pattern and involve the lymph node sinuses. the tumor cells have an abundant eosinophilic or pale cytoplasm. the nuclei were irregular with indentation, multilobated, round to oval. multinucleated cells with wreath-like configurated nuclei were commonly seen. alcl cells may closely resemble cells of malignant histiocytosis. additional features include reed-sternberg-like cells, reactive infiltrate, partial lymph node involvement with localization of tumor cells in the paracortical region resembling hodgkin's diseases. tumor cells are cd +. the regular expression of cd antigen in both carcinoma and alcl (both are anaplastic large cell tumors) has important implication for the differential diagnosis of these tumors. leukocyte common antigen (cd ) positivity excludes an embryonal or any other non-hematopoietic tumor, but its absence does not rule out alcl (a significant portion of alcl are cd negative). antibodies to cytokeratin label embryonal carcinoma but not alcl. thus, if cytokeratin is expressed in an anaplastic large cell tumor simultaneously with cd antigen, it is most likely to be an embryonal carcinoma conclusion this study confirms the view that alcl are heterogeneous group of lymphomas and the cd is a useful marker for the diagnosis. leiomyosarcoma of the meckel's diverticulum. we describe a -years-old male developing a well differentiated leiomyosarcoma of the meckel's diverticulum synchronously with b-cll. the patient suffering disuria and malaise was admitted at the clinic for surgery. clinical examinations showed leucocytosis ( . x /l) with lymphocytosis ( %), anemia (hgb = g/l) and thrombocytosis ( x /l). ct-scan found a tumor mass near the urinary bladder and enlarged spleen. the fnab from the tumor mass revealed neoplastic tissue composed of ribbons of spindle-shaped cells with hyperchromic and pleomorphic nuclei and variable amount of cytoplasm, surrounded by a fine reticulin network. mitoses were rare ( - on hpmf). immunohistochemistry showed positivity for sm-actin and desmin. s- , cd and cd were negative. a leiomyosarcoma was diagnosed. three weeks after the biopsy a large tumor mass ( g) from the vicinity of the urinary bladder was extracted, together with incidental meckel's diverticulum. at the same time a splenectomy was performed because of splenomegaly ( g). pathohistologic examination of the tumor mass confirmed the previous diagnosis, and the pcna proliferative index was estimated to - %. the analysis of the meckel's diverticulum revealed a disturbance of the muscular layer structure caused by a tumor proliferation with the same histological features, infiltrating into the serosa. the pathohistologic examination of the extracted spleen showed partially presence of b-cll infiltration (monoclonal positivity for lambda-light chains, cd , cd , cd , cd ). follow-up shows that the patient is in binet a stage, and still in a good shape without any further treatment. it remains unclear which of the neoplasms developed first. introduction synchronous composite low grade b-cell lymphomas involving the same site is rare and few cases have been reported. we describe three cases of composite lymphoma. material and methods histological, immunohistochemical and molecular study. results the three neoplasms showed different morphological and phenotypic areas: case . years-old female with large splenomegaly. the splenectomy showed a blastoid mantle cell lymphoma (mcl) with nodular pattern, positive to cd , cd a, cd , cd and cyclin d , and a splenic marginal zone b-cell lymphoma cd , cd a and igd. the mcl progressed, with liver and bone marrow involvement, treatment failure and death months after diagnosis. case . years-old female with cervical and inguinal lymphadenopathy. a nodular mcl cd , cd and cyclin-d positive, p negative, was observed. the internodular areas demonstrated a small lymphocytic lymphoma (sll) expressing cd , cd a, cd , cd , and p . progression to peripheral blood involvement of sll, and gastric and nodal relapses of mcl two and four years after diagnosis. case . years-old female with nodal follicular lymphoma expressing cd , cd , bcl- , igd-kappa restriction. the internodular areas showed a lymphocytic lymphoma with plasmacelular differentiation, cd , cd a, cd , igd, and bcl- positive. igh showed a biallelic arrangement, and bcl- /jh rearrangement was obtained, suggesting the presence of two different clones. alive with disease after first chemotherapy cycle. conclusion morphology and immunophenotypic profiles may allow the identification of each component in composite lymphoma. molecular studies can recognize different clones originating the neoplastic compartments. introduction aitl accounts for about % of peripheral t-cell lymphomas (ptcl), presents with advanced stages at diagnosis and follows aggressive clinical course. in - % of cases oligoclonal or monoclonal b-cell populations are detected, usually associated with ebv infection. we describe three cases of aitl with clonal b-cell lymphoma non-related to ebv infection. histological, immunophenotypical, including ebv (lmp- , ebers), and molecular study. results three cases of aitl in three female, , and yearold patients were diagnosed. all of them showed atypical lymphocytes with aberrant t-cell phenotype (cd /cd + with loss of cd ), associated with vascular and dendritic proliferation, the latter showing t-cells cd +. in addition, a population of b-cells with plasmacelular differentiation and immunoglobulin light chain restriction ( kappa/ lambda) was identified. ebv was not demonstrated in these populations. tcrgamma and igh clonality was observed in two cases. the first patient presented isolated nodal aitl involvement, and she is in complete remission after chemotherapy six months after diagnosis. the second patient presented nodal aitl and developed skin involvement two months after the diagnosis. the third patient presented with an atypical ganglionar t-cell proliferation, developing cutaneous ptcl with associated clonal b-cell proliferation one year later and ganglionar ptcl with ailt features two years after the first biopsy. the three biopsies showed identical tcrgamma gene rearrangements in this case. conclusion aitl can show different morphological patterns. alternative mechanisms non-related to ebv infection may be involved in the development of b-cell lymphomas in aitl. introduction histopathological confirmation of clinical suspicion of sarcoidosis is based on finding of non-caseating granulomas in biopsy material, usually in prescalene lymph nodes. reactive sinus histiocytosis seen in relation to various inflammatory and noninflammatory diseases can mimic pregranulomatous phase of sarcoidosis. differentiation of sinus histiocytosis based on histopathological features alone can be impossible. aim of this study is immunohistochemical determination of lymph node cellular response in granulomatous sarcoidosis, pregranulomatous phase of sarcoidosis and reactive sinus histiocytosis using panel of antibodies. materials and methods patient groups under study, each contained patients include those with clinical and histopathological picture of sarcoidosis; the group of patients with clinical picture of sarcoidosis and histologically detectable sinus histiocytosis without granuloma formation and finally, the group free of clinical suspicion of sarcoidosis with 'reactive' sinus histiocytois in lymph nodes. lymph node biopsy tissue processed routinely and stained immunohistochemically using triple-layer apaap protocol with purified antibodies sp and sp from mycobacterium tuberculosis and monoclonal antibodies cd , cd , cd , cd , cd . intensity of immunostaining assessed semiquantitatively by two independent observers using the scale from to + results an increased cd :cd ratio, moderate increase of immunopositivity of cd and slight decrease of immunopositivity of cd , cd , and sp noted in psh when compared with rsh. the most notable difference between studied groups is the intensity of immunostaining with sp and cd antibodies. conclusion both immunostainings were more intense in lymph nodes with sarcoid granulomas and pregranulomatous sinus histiocytosis and can be used in differentiation of these lesions. haemophagocytic syndrome followed by a large b-cell lymphoma showing only bone marrow involvement: case report haemophagocytic syndrome (hps) is a rare disease characterized by generalized histiocytic proliferation showing phagocytosis of hematopoietic cells. it occurs mainly in adults associated either with an acute viral infection, or with non-hodgkin's lymphomas. the latter are usually t-or nk-cell lymphomas. the present case concerns a patient with hps followed by a large b-cell lymphoma showing only bone marrow involvement. this constellation is extremely rare in western countries and has been reported mainly in asia. the patient was a year old male admitted for persistent fever. peripheral blood examination showed pancytopenia. bone marrow biopsy showed haemophagocytosis by proliferating macrophages often situated into dilated marrow sinusoids. no viral infection was detected. the patient was treated with haemopoietic growth factors and showed improvement. after months his blood cell count began to fall again and a second bone marrow biopsy showed, apart from haemophagocytosis, a focal, mainly intrasinusoidal, infiltration by large b-cell lymphoma cells immunopositive for cd and cd ra. epstein-barr virus rna was not detected. dissemination of lymphoma to other sites was not apparent. the patient was treated with cycles of chop and mab-thera and showed remission. some authors believe that these rare cases represent a peculiar "asian" variant of intravascular lymphoma characterized by hps and early involvement of bone marrow without dissemination to other organs. this variant has a poor prognosis and might constitute a distinct biological and clinical disease entity which merits separate consideration because of the problems posed in the initial diagnosis and therapeutic approaches. introduction mycosis fungoides is a mature t-cell lymphoma presenting in the skin and characterised by epidermal and dermal infiltration of small to medium size t-cell with cerebriform nuclei. it is a rare disease wich accounts for no more than , % of all non hodgkin lymphomas. case report a year-old man was refered to the clinic of hematology because of the nodular red dermal tumours on the trunk. these lesions persisted for one year. the blood and bone marrow had not been involved. lymph nodes were normal. the patient had the so called d' emblee lesions, presenting with skin tumours to cm of diameter. the initial diagnostic lesions were rare limited patches and plaques. extracutaneous dissemination did not occur. formaldehyde fixed and paraffin embedded histological sections, taken from surgically resected skin tumours, were stained with he, giemsa, trichrome and immunohistochemical stains. morphology: epidermotropic infiltrates consisted of medium size cells with cerebriform nuclei. a minority of larger cells with similar nuceli and with many mitotic figures also were present. so called pautrier microabscesses consisted of aggregates of cerebriform cells in the epidermis (highly caracteristic for mycosis fungoides) were numerous. in the dermis, infiltrates were band like and diffuse, associated with inflammatory infiltrate consisting of small lymphocytes and eosinophils. conclusions in spite of the presence of bad prognostic factors (very old patients, extent of disease and tumorous form) he had a very indolent course of the disease. the role of the observed inflammatory small lymphocytes and eosinophils is probably very important for the excellent prognosis of mycosis fungoides in this patient. low expression of p protein combined with altered p and rb/p expression status is associated with increased expression of cyclin a and cyclin b in diffuse large b-cell lymphomas introduction reduced p expression combined with alterations in rb or p status, may have cooperative effects resulting in uncontrolled tumor cell proliferation and aggressive malignancies in experimental mouse models and in humans. the aim of this study was to investigate p expression in relation to a) the expression status of p , rb, p , and b) proliferation profile (ki , cyclin a, cyclin b ). expression of cell cycle regulating proteins was investigated immunohistichemically, in cases of de novo diffuse large b-cell lymphomas (dlbcl). results p expression was low/null in large tumor cells in / and intermediate/high in / cases. increased expression of p was observed in / cases. decreased expression of rb/p was found in / and / cases, respectively. low/null p expression was correlated to increased p expression (p= . ). there was a correlation between increased p and decreased rb/p expression levels (p= . ). these findings suggest a tendency for concurrent alterations of cell cycle regulators p , p and rb/p in dlbcl, which might result in impaired tumor growth control. indeed, combined p /p /rb/p expression status analysis, with respect to proliferation profile showed that: ) three alterations in the combined p /p /rb/p status were correlated with increased expression of cyclin b (p= . ) and ) two or three alterations were correlated with increased expression of cyclin a (p= . ). conclusions these findings suggest combined impairment of a complex cell-cycle control network involving the cdk inhibitor p , as well as p and rb pathways, which exerts a cooperative effect resulting in enhanced tumor cell proliferation. introduction the aim of this study was to examine a) cyclins d , e and d expression in relation to other proliferative features (ki , cyclin a and cyclin b ), apoptosis status and p , rb, p , p expression and b) whether distinct clusters of proliferation and apoptosis could be identified in dlbcl. materials and method immunohistochemical expression of cell cycle regulating proteins were studed in seventy-nine cases of de novo diffuse large b-cell lymphomas (dlbcl). results overexpression of cyclins d , e was found in / ( %) and / ( %) cases, respectively, whereas cyclin d was not detected. in / cases, overexpression of cyclins d and e was mutually exclusive, proposing different underlying pathways that induce deregulated expression of these cyclins. in / cases, cyclin d overexpression was equally exclusive with rb/p aberrant expression status, supporting an oncogenic role for cyclin d and suggesting that pathogenetic effect of cyclin d overexpression occurs through perturbation of rb pathway. combined alterations of p and rb/p /cyclin d expression profile were significantly correlated to higher mean values of cyclins a (p= . ) and b (p= . ) indicating that concurrent impairment of p and rb pathways induces increased tumor cell proliferation. cluster analysis of apoptosis and proliferation status permitted separation of dlbcl into distinct groups with low and high apoptotic activity, as well as into groups with low, intermediate and high proliferative activity. conclusions in the present study, identification of separate groups with respect to proliferation and apoptosis profile indicates that groups with discrete cellular kinetic properties can be defined in the dlbcl population. immunotopographical distribution of protein networks involved in cell-cycle and/or apoptosis regulation is useful in thymic histophysiology understanding. the aim of this study was to examine a) p and rb growth control pathways, b) proliferation, c) apoptosis in relation with age. materials and methods p , p , rb, p , ki , p , bcl , bax, bak, cyclin d , cyclin a, and cyclin b expression, and apoptotic index (ai) were investigated in adult, adolescent, infant and newborn normal thymuses, with immunohistochemistry. results and conclusions rb, ki , cyclins a and b expression was elevated in cortex with a decreased tendency toward medulla. apoptotic cells were mainly detected in cortex/corticomedullary junction, but rarely in hassall's corpuscles. mean values of ki and cyclins a, b immunoreactivity were . %, . %, . % (newborns), . %, . %, . % (infants), . %, . %, . % (adolescents), . %, . %, . % (adults), respectively. mean values of ai were . %, . %, . %, . %, respectively. most of hassall's corpuscles were p -positive. p expression paralleled aging, suggesting a role of p in cellular senescence. p was detectable within medulla, but not in subcapsular thymocytes expressions of ki , cyclin a and cyclin b were inversely related to p . p and p showed primarily subcapsular cortical epithelial cell localization. our findings suggest: a) thymocyte apoptosis is mainly p -independent, b) p function as negative cell cycle regulator seems redundant to other negative regulators (p / ), and c) p expression is chiefly p -independent. hassall's corpuscles were p -positive. bcl was principally detected in medullary thymocytes. expression of bax/bak was widely distributed, suggesting an advanced role in thymic apoptosis, compared to bcl . paraffin-embedded bone marrow biopsies of patients were examined by a standard panel approach and evaluated semiquantitativelly. the course of the disease was recognized by evaluation of instrumentalized questionnaires. results a/ mds with less than % of blasts (n= ) /either of myelo-(n= ), megaloblastic (n= ) or bilinear profile (n= )/ -aml evolution appeared in % of patients, b/ mds with more than % of myeloblasts (n= ) -aml diagnosis was established in % of cases. conclusion although the therapeutical aml managment requires 'clinical verification', the identification of the mds blastic proliferation higher than % is of a great clinical importance. however, the clinical manifestation of aml may be influenced by a delay of the increase of blasts in the peripheral blood. introduction there is increasing evidence that bcl and cd expression may be related to apoptosis and cell cycle progression. materials and methods to examine immunohistochemically the expression profile of bcl and cd in cases of de novo diffuse large b-cell lymphomas, in relation to a) the apoptotic index (ai) b) the proliferation-associated proteins ki , cyclins a and b c) the expression of bcl , p , rb, p , p . results and conclusions expression of bcl , cd and bcl was detected in / ( %), / ( %) and / ( %) cases, respectively. the bcl /cd patterns were as follows: bcl +/ cd + ( cases, %), bcl +/cd -( cases, %), bcl -/cd -( cases, %) and bcl -/cd + ( cases, %). significantly positive correlations were found between bcl /ki (r= . , p= . ), bcl /cyclin a (r= . , p= . ), bcl /ai (r= . , p= . ), cd /ki (r= . , p= . ) and cd /ai (r= . , p= . ). high expression of bcl was correlated with null/low bcl expression (hi-square-test, p= . ). these findings indicate that increased expression of bcl and cd is associated with increased apoptosis and proliferation in diffuse large b-cell lymphomas. association between increased bcl expression and enhanced apoptosis might be due to null/low bcl immunoreactivity, since previous in vitro data revealed that bcl overexpression induces apoptosis accompanied by bcl and bcl-xl downregulation. significant correlation was found between increased ai and bcl +/cd + pattern (t-test: p= . , mann-whitney test: p= . ). this result combined with positive correlation between ai and bcl and cd immunostaining may be in accordance to previous studies showing that expression of these proteins has favorable effects on the clinical outcome of these neoplasms. primary non-hodgkin lymphomas of bone: morphologycal and immunohistocehmical aspects introduction primary non-hodgkin lymphoma (nhl) of bone (plb) is a rare clinic-pathologic entity that accounts for approximately % of all malignant bone tumors and - % of all extranodal nhl. we analyzed morphological and immunohistocemical aspects of plb presented as solitary localized bone tumor. methods paraffin embedded biopsy specimens of all patients were diagnosed by the histomorphology and by immunohistochemistry using a wide panel of monoclonal antibodies (ema, lca, nse, tdt, cd , hla-dr, cd a, cd , cd , surface and cytoplasmic ig, cd , cd , cd , cd , cd , cd , cd , bcl , bcl and ki- ). the median age of our pts. was (from to ) with slight female predominance. various sites were involved: tumors were in tubular long bones, in pelvic bones and in spine with infiltration of soft tissue and without bone marrow involvement. all cases were classified as diffuse large b-cell lymphoma (dlbcl) according to morphology and immunophenotype. patohistological analyses showed markedly polymorphous cellular infiltrate with large cells with complex nuclear contours and multilobated nuclei, together with centroblasts-like cells and immunoblasts. all tumors were associated with some degree of fibrosis. immunologic studies showed strong expression of pan-b markers and hla-dr, weak expression of cd and cig (mostly igm) in half of tumors. bcl was positive in all cases as well as bcl . the plasmacytic differentiation was observed in / of cases. the proliferative fraction was high, > % cells in all patients. conclusion our analysis revealed that all plb were of dlbcl type with characteristic morphology and immunophenotype. further study will show the outcome of patients with plb, as well as the validity of various prognostic parameters. peripheral t-cell lymphoma with perifollicular growth pattern expressing cd inflammatory cells. ptcls with nodular or perifollicular growth patterns are very rare. only cases have been reported in the literature. we report an unusual case of ptcl showing perifollicular growth pattern with expression of cd and bcl- . the patient was a -year-old male who presented with a generalized lymphadenopathy, fever, and weight loss. hepatosplenomegaly and polyclonal gammopathy were not identified. cervical lymph node biopsy was performed. the histology showed nodular effacement of nodal architecture with proliferation of atypical lymphoid cells which mainly infiltrate perifollicular area. interfollicular area also showed proliferation of atypical lymphoid cells and high endothelial venules with a few immunoblasts and eosinophils. neoplastic cells were medium-sized, with irregular nuclei and clear cytoplasm. immunohistochemically, the neoplastic cells were cd +cd +cd +cd -cd +cd -cd -bcl- +bcl- +, demonstrating helper/inducer t-cell origin. the cd was strongly expressed mainly in the perifollicular tumor cells, whereas the normal germinal center (gc) cells showed down-regulation of cd . the distribution of cd + perifollicular tumor cells was closely related with cd + follicular dentritic cells (fdcs), suggesting cd up-regulation might be induced by the proliferating fdcs. tcr-gamma gene rearrangement using pcr-sscp was monoclonal. this case could be classified as ptcl, unspecified, and should be discriminated from other lymphomas, including marginal zone b-cell lymphoma and follicular lymphoma. further studies are necessary to clarify the distinction of this tumor from angioimmunoblastic t-cell lymphoma. introduction cd + anaplastic large cell lymphomas (alcls) frequently involve extranodal sites, mainly skin and gastrointestinal tract, but primary bone alcls are exceedingly rare. the aim of this study was to detail the morphofunctional features and outcome of cases of primary bone cd + alcls. materials and methods all the patients (m:f : , median age years, range: - ), but (with simultaneous occurring skin lesions) presented with bone confined lymphoma (osteolytic lesions of jaw, rib, sternum, iliac and pelvic bones). biopsies from all cases were analysed. results and conclusion according to the who lymphoma classification, all cases were cd + alcls ( / common type, / small cell predominant variant). lymphoma population showed a t ( / ) or "null" ( / ) phenotype, expressed cytotoxic associated molecules (tia , granzyme b and/or perforin); cd /alk was positive in / cases, whereas / expressed cd . tcr-gamma clonal rearrangement was detected in / cases. all patients received polychemotherapy; at last follow up they all are alive, in complete remission (mean: months, range: - ). in our cases, the morphofunctional features of the lymphoma population were similar to their nodal counterparts, including cd expression in the younger patients. on such bases, the hypothesis must be considered that primary bone cd + alcls represent the first extranodal site of presentation of a systemic disease. in contrast with similar reported series, our patients run a favourable prognosis and in the single positive case, cd expression does not negatively influence outcome. however, larger series of similar cases must be analysed before definitive conclusions can be drawn. introduction follicular dendritic cells (fdc) form a meshwork in the lymphoid follicle and take part in the regulation of the germinal centre reactions. fdc also interact with the neoplastic lymphoid proliferations. in b-cell chronic lymphocytic leukaemia/small lymphocytic lymphoma (b-cll/sll), fdc structures are reduced. the aim of this study was to evaluate the presence and patterns of follicular dendritic cells b-cll/sll using several anti-fdc antibodies. materials and methods formalin-fixed paraffin-embedded lymph nodes diagnosed as b-cll/sll according to the who criteria were studied using cd , cd , and cna. antibodies after microwave oven antigen retrieval results in cases ( %) fdc meshworks were identified in none of the reactions. in specimens ( %), fdc meshworks were exceptionally rare as follicle remnants at the lymph node periphery or as small irregular clusters not reminding of the normal follicle meshwork. in cases ( %) fdc formed either frequent small irregular clusters, or rings at the follicle periphery, or regular follicular meshworks. reticular structures in a given case were most frequent in cna. stain, scarcer in anti-cd , and anti-cd stains. the majority of cases showing fdc was obtained by cna. ( cases), cd ( cases) and cd ( cases). conclusion fdc structures were absent or scarce in up to % of b-cll/sll cases which can be used as an auxilliary diagnostic criterion. the positive cases showed small irregular clusters, rings at the follicle periphery, or normal follicular meshworks. best results were obtained with cna. antibody. this may be due to better antigen preservation or to non-specifity. introduction myelodysplastic syndromes (mds) are clonal haematopoietic stem diseases characterised by dysplasia and ineffective haematopoiesis. the dysplasia may be often associated with an increased number of myeloblasts in peripheral blood and bone marrow, which represents an important prognostic factor. immunohistochemical detection of blast cells in bone marrow histological sections using cd antigen and its correlation with smear blast count and mds classification are not well established. we report a quantitative study of cd blast cells in mds and acute myeloid leukaemia with multilineage dysplasia (amlmd), and analyse the relationship with both cytologic smear and clinical diagnosis. we have studied bone marrow biopsies diagnosed of mds ( with refractory cytopenia with multilineage dysplasia (rcmd), with refractory anemia with excess blast (raeb) type i and with raeb type ii) and with amlmd. we added controls and calculated the cd blast cells mean per high power field (hpf). cytologic smears were reviewed. results the results were: controls showed - blasts/ hpf, rcmd - / hpf, raeb i - / hpf, raeb ii - / hpf and amlmd - / hpf. conclusions -cd + blast cells density is a good parameter in the histological diagnosis of mds and has a close correlation (p< , ) with smear count results -cd does not distinguish between rcmd and raeb i. -more than blast cells/ hpf raise the diagnosis of raeb ii. more than blast cells/ hpf raise the diagnosis of amlmd. the extrapolation of these features to "dry tap" aspiration remains to be established. inroduction bone marrow angiogenesis has been recently implicated in the pathophysiology and course of various haematological malignancies. little is known, however, about the significance of this phenomenon in hairy cell leukaemia (hcl). methods we evaluated various morphometric characteristics of microvessels, highlighted by means of anti-cd immunohistochemistry, in the bone marrow of patients with typical hcl, before and after treatment with interferon-α. overall bone marrows from hcl patients and twenty control bone marrows were examined. microvessel density (mvd) and several size-and shape-related parameters were quantitated in the region of most intense vascularization using image analysis. results mvd, size-related parameters and the percentage of branching microvessels were higher in hcl than in controls and in partial/non-responders in comparison to complete responders. acvievement of complete response was accompanied by smaller calibre microvessels. interferon-α induced a decrease in mvd and branching values in cases with diffuse marrow involvement. in univariate analysis, progression-free survival was adversely affected by mvd and branching. multivariate analysis indicated that factors related to the size of the microvessels and mvd/ branching independently affected progression-free survival. mvd/ branching was also related to the likelihood of complete response. conclusions our data suggest that the generation of bone marrow microvessels connotes an increased risk for progression and interferon-α treatment failure in hcl. furthermore the prognostic significance of angiogenesis requires the concomitant assessment of mvd, the size of microvessels and the complexity of the microvascular network. key words: hairy cell leukaemia, bone marrow, angiogenesis, morphometry introduction inflammatory pseudotumors are uncommon and enigmatic benign lesions which may develop at several anatomical sites and recent studies demonstrated the frequent presence of epstein-barr virus (ebv) in them. the occurence of inflammatory pseudotumor in the spleen is rare. a case of inflammatory pseudotumor of the spleen is presented and its relationship to epstein-barr virus (ebv) is examined. material and method the case was a -year-old woman in whom a solitary splenic mass was discovered as part of the workup of idiopathic thrombocytopenic purpura. splenectomy was performed. results grossly, the removed spleen, weighing g, contained a tan-white, circumscribed mass, measuring . x x cm. microscopically, the mass was composed of a heterogeneous cellular population of acute and chronic inflammatory cells. plasma cells predominated, but lymphocytes, neutrophils, eosinophils, interlacing fibroblast-like spindle cells and rare multinuclear giant cells were found. amorphous, acidophilic material was present focally with the plasma cell proliferation. plasma cells presented light chains polyclonality. lymphoid cells were mature and mainly of t-lineage. spindle cells exhibited histiocyte phenotype (cd +++). immunohistochemical stain for ebv was negative. conclusions inflammatory pseudotumor of the spleen is a benign tumorous lesion that has been described in only a few cases in the world literature (< cases). its etiology and pathogenesis is unknown and association ebv is not always present. recognition of this rare entity is important, as the clinical manifestations and imaging features could be indistinguishable from a lymphoproliferative disorder or another malignancy of the spleen. introduction the diagnosis of nodal non-hodgkin's lymphoma (nhl) in montenegro has been done only in clinical center of montenegro -incidence of diagnosed nhl can be considered as the incidence in epidemiological sense.the use of monoclonal antibodies since , has improved our ability to diagnose and to treat nhl. aims: by revision of immunohistologically diagnosed cases of nhl between - , we wanted to estimate (a) the frequency of particular clinico-pathological types of nhl, (b) hypothesis about geo-socio-economic influences on patterns of nhl, and (c) the influence of immunophenotypisation of nhl on speciffic chemo-and immunotherapy. materials and methods nhls were diagnosed with the use of he, giemsa, mgp, pas, gomori, lca, bcl , tdt, cd , cd , cd , cd a, cd , cd , and ema stained slides and classified according to the working formulation criteria. results between ' and ' we diagnosed nhl. low, intermediate and high grade malignancy comprised , %, , % and , % respectively. the highest incidence was estimated in : , / . the nhls of fcc origin constitute , % of all our nhls. in % of patients ( ) low grade malignant nhls were highly cd +. nine patients recieved mabthera+chop/or +cop therapy during the last three years.all patients have been in remision. conclusion the estimated pattern of nhl -the most frequent nhl derivated from fcc-is comparable with geographic and socio-economic description of montenegro as ''underdeveloped, ecological, farming european country''.the high frequency of cd + and initial therapeutical results indicate future prospective patho-clinical studies of this issue. i oehri, m baumann, g cathomas kantonales institute for pathology, liestal, switzerland background the multicentric castleman's disease (mcd) is a lymphoproliferative disease with increased risk for non-hodgkin lymphoma. in aids patients, mcd is usually associated with human herpesvirus (hhv ), the infectious agent of kaposi's sarcoma but in contrast to kaposi's sarcoma, hhv infected cells in mcd show evidence of lytic viral infection. similar to other immunosuppression-associated lymphoproliferative diseases it has been suggested that anti-cd antibodies may be useful in the therapy of these lesions. aim of the present study was the analysis of cd expression in hhv associated mcd and their association with lytic viral infection. material and methods formalin fixed, paraffin embeded lymph nodes were analyzed by a double immunofluorescence assay using antibodies against viral proteins and cd . hhv proteins which were analyzed include the latent viral protein lana (orf ) and the viral interleukin (vil- ) and the orf , both associated with lytic hhv infection. results eleven lymph nodes of seven hiv-infected patients with mcd were analyzed. in the mantle zone of the lymphoid follicle, , %, , % and % of cells show positivity for lana, vil- and orf , respectively (p < , ). by double immunofluorescence, % of hhv infected cells showed co-expression of lana/vil- and lana/vorf and % showed co-expression of lana/vil- , respectively. in addition, there was statistical significant correlation between vil- and lana as well as vil- and vorf (p < , ). of the hhv infected cells, , % showed cd expression and no difference between the three viral proteins analyzed were observed ( , %, , %, , % of lana, vil- and vorf , respectively). conclusion the present data support the concept that hhv runs, in contrast to kaposi's sarcoma, through a lytic viral infection in lymph nodes of patients with mcd. however, only a small subset of infected cells show co-expression of cd , independent of the state of viral replication. this small number of infected cells expressing cd indicate little effect of anti-cd therapy. based on the evidence of lytic hhv infection, however, anti-viral drugs inhibiting hhv replication may be more efficient. anaplastic large cell lymphoma -pathological and immunohistochemicals aspects the who classification of nonhodgkin lymphoma (nhl) included also the cathegory of t and null anaplastic large-cell lymphoma (alcl). alcl is a very rare nhl (about %), with the systemic-aggressive variant, and the cutaneous variant. the presence of the t( ; ) and the formation of alk protein identified one subgroup of alcl with a good prognosis. the aim of our study is to analyze the histopathological and immunohistochemical characters of the alcl diagnosed in our department in the last years. cases of t and null alcl (m/f= / , more half of them younger of years) were clinical and immunohistochemical analyzed (by abc indirect methods, with a large panel of monoclonal antibodies). the pattern of lymph node infiltration was diffuse ( cases), parafollicular ( cases) and only with sinus infiltration - case. the pathological subtypes were common ( cases), lymphohistiocytic ( cases), small cell variant ( case), sarcomatous ( case), eosinophils-rich ( case) and neutrophil-rich ( case). immunohistochemically, the malignant cells presented with t-fenotype ( cases) and null ( cases); case (m, y) presents histiocyte markers (cd +cd +ema+alk+). all cases of alcl were cd +, but only cases were ema+ ( cases were cd ro+cd +alk-ema-). / of cases were alk+ ( -t and -null), with a nuclear and a membranous pattern. cases were bnh + ( cases alk+). only case presented cd expression(cd +ema+alk+bnh +). of the cases with t fenotype expressed cd markers (both were cd +cd -). the pcna and ki proliferation markers were positive in a very large percent of the malignant cells (between and %). numerous reactive t-lymphocytes presented a helper fenotype (cd >cd ), and leu- + cells were very rare. the null and t-cell alcl pose numerous problems of differential diagnosis and immunohistochemicals methods are very useful for diagnosis and prognosis of these nhl. myeloid sarcoma - cases analysis f vasilescu , c dobrea , , e niculescu-mizil , a colita , l caban , r stoia , d ostroveanu , a iofciulescu , d terzea , c iosif 'v babes' national institute, bucharest, romania dpt of haematology, 'fundeni' clinical institute, bucharest, romania myeloid (granulocytic) sarcoma (ms) -also known as "chloroma", is a localized tumor of primitive myeloid cells, that can present before, simultaneously with, or after the diagnosis of acute myeloid leukaemia (aml). rarely, ms may represent the first sign of blastic transformation of myelodysplastic syndrome (mds) or chronic myeloproliferative disorders (cmpd). the aim of this study is to present our experience in the diagnosis of ms. in the last years, we diagnosed cases of ms (m/f= / , between and year-old, with , years median). a large panel of monoclonal antibodies (lymphoid and myeloid cell markers) was used for the diagnosis of ms and for the differential diagnosis with nonhodgkin lymphomas (nhl). the tumor localizations were: lymph nodes ( cases, including a bulky inguinal tumor), lymph node and skin ( case), paravertebral ( cases), testis ( case). in our cases, patients presented with ms before the aml diagnosis (f, y, paravertebral ms, months before aml-m , and m, y, years after nhl diagnosis, presented with an inguinal lymph node ms, months before aml-m ). in cases, ms was diagnosed simultaneously with aml (aml-m ; aml-m ; aml-m ), and in cases after aml (m, y, ms with testis localization, years after aml-m ; f, y, lymph node and skin ms, years afteraml-m ). in one case (f, y), years after successful treatment of an acute lymphoblastic leukaemia (all), the patient presented with a lymph node ms, considered as a blastic transformation of a chronic myelo-monocytic leukaemia (cmml). the diagnosis of ms may be very difficult if this tumor precedes the myeloid proliferative disorders, and the differential diagnosis with nhl may pose a lot of problems. introduction b-pll is an infrequent disease, considered by the who lymphoma classification as an aggressive condition and characterized by the presence of b symptoms, massive splenomegaly without significant lymphadenopaty and peripheral lymphocytosis with more than % prolymphocytes. herein we report cases of b-pll to show the wide clinical and genotypic spectrum of this disease. case reports patient . a -year old male with a history of petechiae and ecchymoses of year evolution. a cbc showed significant lymphocytosis with > % prolymphocytes. physical examination revealed an enlarged cervical lymph node and splenomegaly. lymph node biopsy was diagnosed as infiltration by b-pll (cd +, cd a+, igm+, cd -, cd -, cd -and cyclin d -). a bone marrow biopsy showed infiltration by b-pll. cytogenetic analysis of the bone marrow showed a burkitt's variant translocation t( ; ) (p ;q ) molecular analysis of the lymph node showed igh rearrangement and germline bcl- and bcl- by pcr. he was treated with four cycles of fludarabine ( mg/m ) and rituximab ( mg/m ) and is in clinical and cytogenetic remission at year of follow-up. patient . a -year old female with a month history of multiple cervical lymph node enlargement and fever. physical examination was normal and she had no lymphocytosis on the cbc. lymph node biopsy showed infiltration by a non-hodgkin's lymphoma with a prolymphocytic morphology (cd +, cd a+, igm+, cd -, cd -, cd -and cyclin d -). bone marrow biopsy showed focal infiltration by b-pll. cytogenetic analysis of the bone marrow revealed a normal female cariotype and normal fish patterns were found for the following probes: chormosome centromere, q (c-myc), chromosome centromere, q (d s ), q . (igh) and p . (p ). she was initially treated with chop and then switched to fludarabine having achieved a good clinical response after one cycle each. discussion. the association between b-pll and translocation t( ; ) (p ;q ) has been reported in very few cases, however direct involvement of c-myc alterations affecting specifically q has been proposed as an important factor in the pathogenesis of b-pll. in patient , the observed genetic alterations could be of significance to define the genetic spectrum of b-pll. case corresponds to a b-cell prolymphocytic lymphoproliferation with isolated lymph node involvement and no leukemic component. to our knowledge this presentation has not been reported previously and it is not considered in who classification. morphological and immunohistochemical characteristics of this case are fully compatible with a b-pll. even though it has been considered that some cases of b-pll could in fact represent a morphological variant of mantle cell lymphoma, in this case the negativity for cd and cyclin d partially rule out this possibility. bcell prolymphocytic lymphoproliferations constitute an heterogeneous group of disorders in which c-myc rearrengement can be present. in this group of neoplasia therefore, the nodal involvement can be either predominant or the only clinical manifestation, thus we propose to consider the term b-cell prolymphocytic lymphoma/ leukemia instead of b-pll to denote these disorders. background alcl is a particular type of t-cell non-hodgkin's lymphoma originally characterized by a peculiar morphology and the consistent expression of cd . this entity is frequently associated with the translocation t( ; ) (p ;q ) or some of its variants resulting in the overexpression of the chimeric protein npm/alk (alk+), even though in the current classification alk-negative cases are also considered within this group. ebv is classically and constantly associated with certain specific types of lymphoma but its association with alcl is not considered a characteristic feature of this disease. the aim of this study was to investigate the frequency of the alcl-ebv association in a population of adult mexican patients. results eighteen patients with a morphological and immunohistochemical diagnosis of alcl with nodal involvement were included. immunohistochemical and ish analysis was performed for cd , cd , cd ro, cd rb, cd , cd , cd , ema, lmp- , alk.and eber . mean age was years and the male-tofemale ratio was . : . immunohistochemistry and in situ hybridization results are summarized in the next table. all the so considered ebv positive cases expressed lmp- and eber . conclusion in contrast to the information available in the literature we found a high incidence of the alcl-ebv association / ( %). the high incidence of alk-/ebv+ cases / ( %), with morphological and immunophenotypical characteristics of alcl gives rise to the possibility that this is a different subset of t-cell lymphomas with anaplastic morphology in which ebv plays a pivotal roll in the oncogenesis and evolution. these disorders have been considered so far to be alcl /alklymphomas. the high incidence of ebv infection in mexico leads to the development of peculiar lymphoid proliferations as well as associations (ebv/alcl) different from those considered to be frequent in world literature. lazzi s , bellan c , de falco g , schuerfeld k , micheli p , bartolommei s , pileri s cdk is a member of the cdc -like family of kinases. its cyclin partners are members of the family of cyclin t (t , t a and t b) and cyclin k. cdk /cyclin t complex is very important in the differentiation program of several cell types, controlling specific differentiative pathways. limited data are available regarding the expression of cdk /cyclin t in haematopoietic and lymphoid tissues. the aim of this paper is to analyze the expression of cdk /cyclin t complex in lymphoid tissue, in order to assess its role in b and t cell differentiation and lymphomagenesis. in reactive lymph nodes cdk /cyclin t expression was found by immunohistochemistry in germinal center and in b and t cell blasts in interfollicular areas, suggesting a role for cdk in the activation and differentiation of b and t cells. the staining of cdk and cy-clint complex in malignant lymphomas seems to reflect their normal counterpart, as it is highly expressed in lymphomas derived from germinal center cells, such as follicular lymphomas and classical hodgkin's lymphomas and from activated t cells, (i.e. anaplastic large cell lymphomas). diffuse large b-cell and burkitt's lymphomas showed a wide range of values. no expression of cdk and cyclin t was detected in marginal zone and mantle cells lymphomas. however, at rna level we found an imbalance in cdk /cyclin t ratio in follicular lymphoma and diffuse large b cell lymphomas with germinal center phenotype, and in the cell lines of classical hodgkin's lymphomas, burkitt's lymphomas and anaplastic large cell lymphoma, in comparison with reactive lymph nodes. here we report cdk /cyclin t complex deregulation in neoplastic conditions for the first time, representing a step towards better understanding of through which molecular mechanism cdk /cyclin t complex acts on the activation and differentiation program of lymphoid cells and the role of its deregulation in malignant transformation. introduction hairy cell leukaemia (hcl) is a chronic lymphoproliferative disease characterized by the presence of neoplastic b cells with hairy cytoplasmic projections in spleen, bone marrow and peripheral blood. complete or near-complete remission can be achieved by recent chemotherapy protocols. these treatment methods are quite different from the chemotherapy protocols used for the treatment of other lymphoproliferative diseases. an absolute and correct diagnosis, i.e. detection of hcl cells by specific methods, is necessary for the achievement of complete or near-complete remission by special chemotherapy programs. detecting intracytoplasmic tartrate resistant acid phosphatase (trap) enzyme activity in the peripheral blood and bone marrow aspirates is a classical, simple, sensitive and quite specific method for the detection of hcl cells and in the diagnosis of hcl. however, this method is insufficient in some cases. for example, the most of the hcl patients are leukopenic and there are a few number of neoplastic cells in their peripheric blood. an adequate number of neoplastic cells cannot be obtained by bone marrow aspiration because of the increase in reticulin fibbers of the bone marrow. in such cases, bone marrow trephine biopsy is almost the only and the most important method in diagnosis and follow-up of this disease. specific detection of trap enzyme activity in bone marrow trephine biopsy materials is not possible because of the effect of tissue fixation and processing on these materials. in conclusion, a new method for detecting trap enzyme activity in bone marrow trephine biopsy materials and for conforming the diagnosis of hcl is needed. a recently developed anti-trap antibody has been started to be used as an immunohistechemical marker in the diagnosis of hcl. the aim of this study was to investigate the specificity and the sensitivity of anti-trap antibody immunoreactivity in bone marrow trephine biopsy materials in the diagnosis of hcl. material and methods we divided the cases into two groups; a study and control group. the study group included the cases diagnosed as hcl by clinical, haematological and histopathological investigations. the cases in the control group were the cases characterised by non-hcl neoplastic or reactive lymphoid infiltrations, which raised the suspicion of hcl in the differentia l diagnosis. immunohistochemical staining techniques were applied to paraffin block sections of biopsy materials with anti-trap antibody. results and conclusion we found that there is a statistically highly significant difference between trap immunoreactivities of the study and the control groups, and hcl can be diagnosed by trap immunoreactivity in the bone marrow trephine biopsy materials with the specificity of , % and with the sensitivity of %. cathepsin l participation in collagen degradation during the recovery from experimental hepatic fibrosis v ryvnyak introduction cathepsin l is one of the most important lysosomale cysteine proteinase, indispensable for proteolitic processes. the enzyme is capable to degrade the main components of the intercellular matrix. aims: . to determine the participation of cathepsin l in collagen degradation in liver and to reveal the intracellular and/or extracellular localization of the enzyme activity. . to determine which cells of fibrotic liver are sources of cathepsin l. methods biochemically cathepsin l activity and hidroxyproline level was determined in normal, ccl -induced fibrotic rat liver and at , , , , days after discontinuation of treatment. the activity of cathepsin l in fibrotic rat liver at the th and st days was investigated electron-histochemically. cbz-phe-arg- mbna (bachem) served as the substratum. results biochemically in fibrotic liver an increase of cathepsin l activity as compared with normal liver was revealed. during fibrosis regression the maximums of enzymatic activity at the th day ( %) and at the st day ( %) after cessation of ccl -treatment were fixed. at the th day of recovery some diminution of cathepsin l activity was noted. at the th day after toxin abolition enzyme activity was close to control. a close correlation between cathepsin l activity and liver hidroxyproline level was found. electron-histochemically reaction product was revealed in the kupffer cells and fibroblast phagolysosomes containing fragments of collagen fibrils. we also found extracellular localization of cathepsin l in both terms of investigation. the reaction product was noted on the hepatocyte, kupffer cell and fibroblast plasmalemma and on adjacent collagen fibrils. conclusions cathepsin l is directly implicated in collagen resorbtion during liver fibrosis regression. detected extracellular activity of cathepsin l suggests that in addition to the intracellular proteolysis, cathepsin l is secreted by hepatocytes, macrophages and fibroblasts in intercellular space and can take part in extracel-lular collagen degradation. ryvnyak victor laboratory of morphology "nicolae testemitanu" state university of medicine and pharmacy bd. stefan cel mare, kishinev, md- moldova victorrivneac@yahoo.com introduction the solitary necrotic nodule (nns) of the liver is an uncommon lesion with a round appearance near the surface of the liver, with a dense collar of hyalinised collagen surrounding a necrotic core. case reports we present three cases of nns. two patients underwent surgery to remove liver metastasis. we suggest a relationship with the previous hepatic surgery and with the microwave tissue coagulator. the other case have an history of abdominal traumatism by a seizure. the radiological image of nns was misinterpreted as a tumor and the diagnosis by fnac or frozen section could not exclude a metastasis. the potential risk of a malignant secondary tumour existed, and that was why limited liver resection was recommended. several pathogenetic mechanisms have been avocated (infection, parasitic, traumatic, ischaemic, post chirurgical, iatrogenic, etc.) , all of them having an identical morfological appearance. conclusion nns is a rare non-tumorous lesion that might be misinterpreted as a tumor. the correct diagnosis can only be histological. it is important to differentiate the nns from metastases due to the great influence on the treatment. the significance of morphometrical analysis in staging of fibrosis in liver biopsies from patients with chronic hepatitis c a matsionis , e romanova , y kirichenko , y ambalov , p povilaitite rostov regional bureau of pathology, rostov on don, russian federation rostov central hospital, rostov on don, russian federation introduction prognosis of the course of chronic hepatitis c (chc) depends on fibrosis stage and its progression temps in the liver. semi quantitative methods are currently regarded as a routine diagnostic procedure. but it is obvious that these methods are subjective. morphometrical analysis with calculation of fibrosis index (fi) is an alternative method of evaluation. the aim of the study was to compare data obtained after morphometrical analysis of collagen formation to semi quantitative methods results and find out accordance with fibrosis stage. materials and methods liver biopsies from chc patients were used. we applied v.j.desmet ( ) semi quantitative method and software sigmascan pro . for morphometrical analysis of sections. all sections were stained by masson trichrome method for the detection of collagen. fibrosis index (fi) was calculated as collagen area divided all section area. results , % of patients had clinically significant level of liver fibrosis (desmet f , f , f ). f desmet stage was corresponding fi , - , , f desmet (moderate fibrosis) -fi , - , and high level of fibrosis (f and f ) -if , - , . / cases ( , %) showed differences between semi quantitative and morphometrical results. four patients ( , %) without fibrosis by semi quantitative methods showed if corresponding moderate fibrosis (f ). conclusion our results suggest that morphometrical analysis is beneficial in the evaluation of fibrosis stage and should be used for prognosis and monitoring the course of chronic viral hepatitis. introduction hepatic mucinous cystadenomas with mesenchymal stroma have been recognized as rare neoplasms that occur only in females and have recently been postulated as being hormonally dependent. because of the similarity of these neoplasms to ovarian mucinous cystadenomas, we compared the immunohistochemical profiles of these neoplasms arising in two different organs. the aim of this study was to establish whether these two tumors were phenotypically similar. materials and methods we employed the following immunohistochemical stains, estrogen receptor, progesterone receptor, inhibin, ck , ck and alcian blue/ periodic acid-schiff, to cases of ovarian mucinous cystadenomas and to cases of hepatic mucinous cystadenomas with mesenchymal stroma. results both the ovarian and hepatic neoplasms showed similar results with all of these stains. conclusions phenotypically, we have been unable to establish any difference between these two neoplasms. there appear to be two possible explanations for the origins of these tumors: one is that of a displaced ovarian anlage in the developing liver and the other would be that some of the primitive hepatic stem cells are capable of acquiring ovarian characteristics assessment of periodontum condition in hepatitis c infected patients with rapid and slow dynamics of advanced fibrosis p radlowski aim analysis of the relationship between the stage of periodontium disease and the extent and dynamics of fibrosis in patients infected with chronic hepatitis c. the study included patients whose blood serum revealed the presence of hcv-rna via rt-pcr, while biopsies showed chronic inflammation and either septal fibrosis, or liver cirrhosis. fibrosis was evaluated according to scheuer's point scale, with azan-staining method and the authors' own modifications. fibrosis dynamics (fu/y) was evaluated as a quotient of the number of points assessing fibrosis and the number of years of the disease. periodontitis was determined by the following criteria: inflammation limbus, gum swelling, gingival pockets depth, presence of supragingival and subgingival calculus and gomphiasis. each criterion was assigned either or point within the cumulative scale of - points. results all patients with advanced liver fibrosis were found to show signs of periodontosis. the patients whose periodontium condition scored points with the mean value of fu/y amounting to , , while those who scored points showed mean values of fyu/y equalling , . the group of patients with high values of periodontium disease showed significantly higher values of periodontum disease stage (most frequently assessed at points) compared with the group of nine patients with low fu/y values (mean value = p < , ). periodontium score of the patients with cirrhosis and bridge fibrosis showed similar values. conclusion the degree of periodontal disease was found to be dependent on the pace of fibrosis dynamics. molecular evidence for a toxic memory effect in chronic liver disease c stumptner, k wagner, h denk, k zatloukal institute of pathology, university of graz, graz, austria introduction alcoholic liver disease shows a toxic memory effect: patients with a history of alcoholic hepatitis show even after prolonged withdrawal from alcohol rapid reappearance of alcoholic hepatitis upon reexposure to alcohol. this type of liver injury can be mimicked in a mouse model by feeding , . after months of ddc intoxication mouse livers revealed ballooned hepatocytes containing numerous mallory bodies. within four weeks of recovery from intoxication most mallory bodies disappear but rapidly reappear within three days of reintoxication indicating the existence of a toxic memory effect. the aim of this study was to investigate the molecular basis of the toxic memory effect. materials and methods cdna-libraries were generated from normal and ddc-intoxicated mouse livers by subtractive suppressive hybridization. these gene libraries were used to produce cdna-arrays for expression profiling. rna was isolated from mouse livers at different stages of intoxication, recovery and reintoxication and hybridized to the cdna-arrays. expression profiles were analysed by genesight-and imagene software. results and conclusion results obtained demonstrated several groups of genes differently expressed in short-term intoxicated naive and reintoxicated mice. these genes comprised cyp a as well as genes involved in the cellular response to oxidative stress and methionine metabolism. the sustained elevated level of cyp a during recovery and the enhanced induction upon reintoxication could explain why certain drugs lead to enhanced liver toxicity upon repeated administration even after long drug-free intervals. introduction tgf-beta, fas, fasl molecules take part in the regulation of apoptosis. fas is a cell surface receptor present in most of the cells. fasl can be secreted from the surface of the cells and when it binds to fas, they activate the caspases to trigger the apoptosis. although the mechanism of tgf-beta is not clear yet, it plays a role in tumorigenesis. tgf-alpha may indicate inhibitory or stimulatory functions in conjunct with the stage of the tumors and cooperation with oncogenes and growth factors. we aimed to evaluate the correlation among the expressions of fas, fasl, tgf-beta molecules in hcc. material and method in this study fifty cases diagnosed as hepatocellular carcinoma (hcc) between the - years were included. tgf-beta , fas, fasl expressions were evaluated immunohistochemically. results fas, fasl expressions were observed together in % of tissue samples with hcc and % of the nontumoral liver tissue samples. it was noticed that fas and fasl staining were more densely in the lymphocytes of the tumorous areas and neighboring normal tissues than the control group. there was no statistically significant correlation between fas, fasl, tgf-b staining except the positive correlation between the tgf-beta and fas. the poor differentiated cases weakly expressed fas, fasl and tgf-beta . where as the majority of the cases stained cytoplasmic positive, some cases stained either cytoplasmic or membraneous positive. conclusion in hcc, tumor cells use variable pathways for apoptosis. the lymphocytes near the tumorous tissue have an important role in this process. dynamics of liver histology in patients with chronic hepatitis c after interferon-alpha and ribavirin therapy introduction interferon-alpha therapy for chronic hepatitis c improves hepatic inflammation and may change the evolution of disease to cirrhosis and hepatocellular carcinoma. accurate assessment of liver fibrosis is necessary for morphologic diagnostics. the aim of this study was to evaluate the effect of interferon-alpha and ribavirin on liver histology; to compare the semi-quantitative (according to ishak) and quantitative methods for evaluation of fibrosis. materials and methods twenty-two patients ( males, females at mean age years) with chronic hepatitis c were studied. within to months from the pre-therapy biopsy and at least months after the end of treatment patients were followed with second liver biopsy. histological activity in paired liver specimens was assessed by knodell modified score. fibrosis was evaluated according to ishak staging system. in addition, fibrosis was quantified in masson trichrome stained sections using morphometric image analysis. interferon-alpha (mean dose me) and ribavirin were administered for to months. patients were classified as complete sustained responders (n= ), relapsed after therapy cessation (n= ) and "non-responders" (n= ). results after treatment reduction of the histological activity score (at least one grade) was observed in patients ( %). lobular and periportal necroinflammatory lesions were decreased in both responders and non-responders (p< . ). after therapy, dynamics the fibrosis degree and calculated fibrosis ratio were not significant. fibrosis stage was improved in only sustained responders ( %); remained unchanged in patients, and progressed in patients ( %). conclusions improvement of liver histology after interferon-alpha and ribavirin treatment was constricted to the patients who achieved hepatitis c virus eradication. morphometry was the informative method for evaluation of fibrosis dynamics in addition to fibrosis assessment with semi-quantitative classification systems. introduction liver biopsy is one of the diagnostic procedures for neonatal hepatitis (nh)and intrahepatic bile duct paucity (ihbp). in this study we aimed to evaluate the prognostic benefits of quantitative analysis of histopathological changes in nh and ihbp. material and methods we studied liver biopsies in which were nh and were ihbp. the relationships between histopathological and prognostic parameters were analyzed. hepatic histopathological changes such as portal and periportal fibrosis, portal and lobular inflammation, bridging necrosis with fibrosis, pericellular fibrosis, giant cell transformation and extramedullary hematopoesis were evaluated and according to their absence ( ) or presence ( ) a histopathological score was assessed. the sum of these data was accepted as total pathological injury score. clinical prognostic parameters consisted of the patients height, presence or absence of hepatosplenomegaly and ascites, serum levels of alt, albumin, bilirubin, and the value of protrombine time. the sum of these data was accepted as the clinical score. the patiens were also divided into two groups whose clinical scores were < as good prognosis and ≥ as bad prognosis. for statistical analysis pearson's chi-square, mann-whitney-u and roc curve tests were used. results we found a statistically significant negative relation between prognosis and total pathological injury score (p= . ), so as pericellular fibrosis (p= . ). conclusion during the interpretation of liver biopsies of nh and ihbp, scoring of histopathological changes should be done in order to assess the clinical prognostic outcome. moreover, the presence of pericellular fibrosis should be evaluated and reported. immunohistochemical analysis of hepatocellular carcinoma and intrahepatic cholangiocellularcarcinoma using markers supposed to indicate respective levels of diffentiation of the hepatic cell lineage k ishida, m endoh, j takeyama, k sakamoto, m watanabe, t moriya, h sasano department of pathology, tohoku university hospital, sendai, japan it is widely recognized that there are diagnostically problematic cases among primary hepatic tumors. they cause difficulties in distinguishing between hepatocellular carcinoma (hcc) and intrahepatic cholangiocellularcarcinoma (cc). meanwhile, recent progression of study on hepatocyte-diffrentiation has revealed that both mature hepatocyte and biliary epithelial cell should originate from the common cell lineage called as hepatic-progenitor-cell (hpc), bipolar-cell (bc) and/or intermediate-hepatocyte-like-cells. thus, we performed immunohistochemical analysis for hcc and cc using markers supposed to indicate respective levels of differentiation of the hepatic cell lineage, in order to identify the origin of the tumors particular in the diagnostically problematic cases. materials and method surgical specimens of cases of hcc and cases of cc were used. ordinary immunohistochemical staining was performed with following antibodies; hepatocyte monoclonal antigen (hep), c-kit, ck , ck and ck . the results were compared from the view of the histopathological findings and immunohistochemical reactions. results rate of positive (> %) and focal positive (> %) were hep; hcc %, cc %, c-kit; hcc %, cc % and ck ; hcc %, cc; %. ck and ck were similar as previously reported. in addition noteworthily, double positive for hep and ckit was observed on two cases of cc having apparent glandular formation. conclusions ) hcc had a lower positive rate for hep compared with previous reports. ) cc with positivity for hep might exist. ) according to the c-kit staining pattern, we considered that there might be a peculiar variant of tumor cells in cc differentiating both hepatocyte and biliary epithelial cell. introduction proteus anguinus, the sole species of the european cave salamander and the remarkable cave dweller of underground waters in the karst of slovenia is well adapted to poor and discontinuous food supplies. remarkable accumulation of lipid droplets and glycogen deposits in the liver beside slow metabolism allow proteus to survive for long periods without food. the aim of this study was to establish morphological changes in the liver during starvation with particular emphasis on mobilization of the liver energy reserves. material and methods the liver was examined after food deprivation periods of one, four and eighteen months, respectively using light and transmission electron microscopy. glycogen and proteins concentrations were determined spectrofotometrically. total fat in the liver was estimated by folch method. results intense depletion of glycogen was present during first month of starvation. the glycogen wasn't formed in clumps typical for normal liver tissue. after eighteen months of fasting glycogen was re-synthesized, dense glycogen deposits appeared. lipid droplets were less condensed. numerous peroxisomes formed clusters with small and round mitochondria. particular mitochondria increased in size and lost cristae. lysosomes and autophagic vacuoles were numerous, too. dilated intercellular space included electron dense granular material. conclusions carbohydrate and lipid reserves in the liver of proteus serve for metabolic needs during food deprivation. while in many other vertebrates fasting causes depletion of liver carbohydrates, these reserves are maintained in large amounts in proteus. results of our study confirm that a detailed morphological analysis of the liver could be a relevant informative method to prove metabolic adaptability of this organ. evaluation of t lymphocyte subpopulations in chronic hepatitis-relationship with histological lesions ci iosif, f vasilescu, g butur, dc terzea, c dobrea, f andrei, c ardeleanu 'victor babes' national institute, bucharest, romania background intrahepatic t lymphocytes are believed to be involved in immunopathogenesis of chronic viral hepatitis. the aim of this study was to assess the correlation between morphological lesions and t lymphocyte subpopulations in liver and peripheral blood (pb) of patients with chronic hepatitis. methods and results liver biopsy specimens from patients serologically confirmed ( hbv and hcv) were studied by histopathological and immunohistochemical methods. t cell subtypes (cd , cd , cd ) were tested by using monoclonal antibodies on tissue samples and by flow cytometry in pb. results in pb, % of patients have t lymphocyte cd + decreased and % of them have augmented values of t lymphocytes cd +. in liver biopsy the prevalent subpopulation were cd + cell, being approximately twice higher than cd + cells. the observed histological lesions were quantified by ishak score as moder-ate\severe chronic hepatitis. conclusions decreased subpopulation of cd + t lymphocyte might contribute to the severity of liver disease. relatively more frequent cell type was cd positive t cell, having a significant association with a higher inflammatory activity in both types, b and c virus hepatitis. the role of survivin in regulation of proliferative and apoptotic activity of hepatocellular carcinoma introduction imbalance between proliferation and apoptosis is an important factor in progression of hepatocellular carcinoma (hcc). aims: the percentage of proliferative (pi) and apoptotic cells (ai) in hcc compared to non-tumor liver was investigated. the role of unprocessed as well as active form of caspase- , which is an important apoptotic protein was of great interest for this study. expression of survivin, an inhibitor of apoptosis was investigated, too. material and methods twenty patients with hcc were included in the study. two samples were obtained from each patient, one of hcc and one of the surrounding non-tumor liver. mib- antibody was used to determine the proliferative activity. immunohistochemical staining for the detection of active form of caspase- was used to determine the percentage of apoptotic cells and for detection of procaspase- and survivin expression, as well. results ai was higher in hcc ( , ± , ) compared to nontumor liver ( , ± , ), but the proliferative activity in hcc was much higher than apoptotic activity. % of hcc showed positive staining for pro-caspase . positive correlation between expression of pro-caspase and active form of caspase proved to be statistically significant. % of hccs were survivin positive. stronger expression of survivin was detected in hcc compared to non-tumor liver. positive correlation between survivin expression and the grade of tumor diferentiatiation as well as a significant association between survivin expression and both ai and pi was also detected. conclusion our results indicate that survivin promoting cell proliferation in hcc has an important role in hcc progression. the histopathological effects of offloading on liver of rat embryo a khaki , aa khaki , j solimany rad faculty of veterinary medicine of tabriz islamic azad university, tabriz, islamic republic of iran faculty of medicine science.tabriz medical science university, tabriz, islamic republic of iran introduction ofloxacin is an antibiotic from fluroqinolne with a wide range and widely used in various infection diseases. since there is little information about ofloxacin side effect on liver of rat embryo. this preliminary study was planed to see what kind of changes occurs in development of liver in rat embryo. the aim of present study was to determine the histopathological effects of offloading on liver of rat embryo. material and methods fourty nine wistar rats were selected and randomly divided into two groups; control (n= ) and test (n= ). the test group has been received mg/kg (po) ofloxacin daily during pregnancy. however, the control group just received plate. after delivery, liver tissue of neonatal in both groups were taken and prepared for light microscopy. staining method was h&e. results microscopic study of liver tissue specimens showed that in the test group hepatocytes were vesiculated. degeneration and vacuolated pycnotic nuclei were seen when compared to control group. weight of neonatal in test group was reduced when it was compared with the control group (p< . ). conclusion since ofloxacin had side effects on liver of rat embryo, it is not suggested to be used during pregnancy in human. introduction while the underlying etiology of hcc has been well characterized the molecular mechanisms of hepatocarcinogenesis are poorly understood. the extremely poor prognosis of hcc and the limited value of the current standard clinical markers underscore the need for improvent of diagnosis and treatment of this deadly disease. aims: we performed gene expression profiling using cdna microarrays in order to identify novel molecular markers and therapeutic targets for the treatment of hcc. material and methods we used the method of subtractive suppressive hybridization (ssh) to generate cdna libraries that are highly enriched with clones representing genes both up-and downregulated in the diseased liver tissue. the expression pattern of clones representing ~ genes was analyzed in surgically resected hepatocellular carcinomas, focal nodular hyperplasias, one adenoma, and cirrhotic livers by competetive hybridization on custom made cdna microarrays using a pool of non-neoplastic human liver as reference. the expression data were verified independently by quantitative rt-pcr (taqman). results we found genes which were consistently deregulated in more than one third of the hccs under investigation. of these, genes had been previously implicated in hcc, whereas known genes as well as novel genes (with unknown function) had not yet been linked with liver cancer. conclusions the present study revealed a number of genes specifically deregulated in hepatocelluar carcinoma. future work will aim to evaluate the medical relevance of the encoded proteins which will ultimately help to identify potential new markers for better diagnosis/ prognosis of hcc and new targets for therapeutic intervention. introduction actinomycosis is a suppurative and granulomatous chronic infectious disease caused by actinomyces sp. and most commonly affecting the cervicofacial area. aim: to study the clinical characteristics of patients with actinomycosis, with regard to clinical history, presentation, method of diagnosis and comparing to the literature. patients and methods from january to july , a retrospective review was performed on all cases of histologically proven actinomycosis. results ten patients were studied, men and women, - years old. two patients had a history of surgical procedures and/or dental manipulations. two patients had a long history of diabetes mellitus. locations were the liver (patient n ), the feet articulation (patient n ), the lung (patient n ), the jugular lymph node (patient n ), the skin (patients n and ), mandibular (patient n ), the psoas muscle (patient n ), the appendix (patient n ) and the large bowel (patient n ). three patients showed a tumoral presentation (patients n , and ) and two patients had a tuberculosis disease presentation (patients n and n ). the patient n had a clinical presentation of an inflammatory large bowel disease. one patient was diagnosed by cultures positive to a. israelii on microbiologic study and the others patients by surgical biopsy and detection of an actinomycosic granuloma. special stains were used in all cases. three patients received the classic initial regimen of iv. conclusion actinomycosis is an uncommon disease in our country. in these cases gastrointestinal locations were predominant. two uncommon locations were present. there was no iud associated infection. tuberculosis endemic in our country can mislead the diagnosis. further autopsy hazards: mycobacterium tuberculosis in the autopsy room r flavin, s o briain st. james hospital/tcd, dublin, ireland introduction tuberculosis has been the major occupationally acquired disease in the autopsy room. the risk of encountering tuber-culosis at autopsy has fallen with the decreased incidence of the disease and greater emphasis has been placed recently on the hazards of viral diseases. however, tuberculosis may still be found at autopsy. the aim of this study was to assess the magnitude of exposure to mycobacterium tuberculosis at autopsy in a large general hospital setting. methods retrospective search of the autopsy records from - . the patient record and histological slides were reviewed. the quantity of mycobacteria was assessed from the ziehl-neelson stains as scanty, moderate or abundant. results cases of active mycobacterium tuberculosis were identified in the -year period in which autopsies were performed ( per autopsies) of which cases were unsuspected ( %). these included cases of miliary tuberculosis and with pulmonary infection. cases contained abundant organisms. patients tended to be middle aged and male with complex clinical histories. patients were dead on arrival at hospital. conclusion the risk of unexpectedly encountering tuberculosis at autopsy continues and has implications for the health of autopsy room staff, autopsy room ventilation and design, protective equipment and for the involvement of the public health service. introduction the course of chronic hepatitis c virus infection is difficult to predict. although the disease is frequently asymptomatic, the development of fibrosis and cirrhosis are the major complications. among patients suffering from chronic hepatitis c (chc), special group are young drug abusers. immunological toxicity of narcotics modulates the total immunologic response to the viral infection with characteristic morphologic expression of this disease. the aim of this study was to asses which pathological features are associated with liver fibrogenesis and are predictive to fibrosis in chc drug abusers. methods eighty liver biopsies with chc from drug abusers ( actively consumers; free from drugs - months before liver biopsy and free for more than one year before performing liver biopsy) stained by he, trichrom masson, perls and reticulin were analyzed semi quantitatively using standard questioner for determination of patohistological features for histological activity index. results of fibrosis were correlated to all of them. results the fibrosis was , and in this group of young patients (mean age , years). there were no correlation between any of the patohistological parameters and fibrosis, even for lobular necrosis. conclusion histomorphological changes and the extent of fibrosis are in correlation to the duration of drug consumption. morphological expression of immune toxicity of narcotic drugs in chc patients make this disease special entity to which it is not possible to apply standard histopatologic parameters, nor the parameters predicting liver fibrosis. introduction epithelial tumors of the conjunctiva are rare diseases in europe. in sub-saharan countries, an increasing incidence was observed in connection with the hiv epidemic. the definite causes of these tumors are not known. aims: based on tumor material from africa, we search for possible cancerogenic agents and its pathogenetical interaction in conjunctival carcinoma. materials and methods conjunctival specimens of patients from three african centers with the following histological lesions were examined: papilloma ( case), pinguecula ( ), conjunctival intraepithelial neoplasia ( cin i, cin ii, cin iii), squamous cell carcinoma (scc, cases). immunohistological reactions for p and p were done. of tested patients were hiv positive. results and conclusion of the benign and precancerous lesions were associated with histological signs of a solar damage. of the cases showed immunohistologically an overexpression of p , among them all scc. this finding might indicate a p mutation as mostly seen in solar induced skin cancer too. % of the cases with cin iii and scc had an overexpression of p . corresponding findings are known from transformed or neoplastic cervical epithelium in strong correlation with an active hpv (type , ) oncogene expression. no significant differences occurred between hiv positive and hiv negative cases in comparison to the frequency of different histological lesions as well as the p and p expression. the average manifestation age for cin iii and scc in hiv positive cases ( resp. years) was years lower than that of hiv negative cases ( resp. years). the results suggest a multifactorial tumorgenesis (uv radiation, oncogenic viruses, hiv infection) for the conjunctival carcinoma in africa. introduction botryomycosis is an enigmatic pyogranulomatous infection, which may be caused by a variety of non-filamentous bacteria including staphylococcus aureus and pseudomonas aeruginosa. while the exact pathogenesis remains elusive, it is acknowledged that the interrelationship of host and agent factors is fundamental. we describe the clinicopathological features of a rare and particularly mutilating case of delayed onset post traumatic craniofacial botryomycosis. methods an immunocompetent -year-old black male presented with multiple sinuses draining granules involving the frontal, parietal, orbital and maxillary areas. nodulo-fibrous thickening was also present. this had evolved over a three-year period. apart from the history of a head injury requiring cranioplasty years earlier, no other predisposing factors were found. results the diagnostic features of clumped bacteria (cloxacillin sensitive staphylococcus aureus), splendore-hoeppli phenomenon, granulomata and intense fibrosis were confirmed histologically. there was no response to intravenous cloxacillin and the patient died before surgical debridement could be done. conclusion this case report serves to highlight several points. firstly, it illustrates that when considering the diagnosis of post traumatic botryomycosis, the time interval between the traumatic event and the onset of clinical features may span decades. we submit that this is due either to the small size of the bacterial load or their low virulence. secondly, it is our contention that the poor response to antibiotics is due to the severe, impenetrable fibrosis. finally, the destructive nature of the disease underscores the urgency in diagnosis and treatment. tuberculous meningitis in adulthood introduction tuberculous meningitis is a very frequent clinical manifestation of postprimary tuberculosis in childhood as the result of hematogenous dissemination of a pulmonary lesion; in adult patients tuberculous meningitis occurs less frequently, mainly associated with extrapulmonary disease, consequent to the rupture of a subependymal tubercle. case reports we report cases of tuberculous meningitis in adulthood diagnosed by autopsy examination -median age , yrs -in an autopsy series of tuberculous patients in years. all but one of the patients had disseminated disease (lung, lymph nodes, liver, spleen and kidneys). none of the patients presented subependymal tubercles. one patient had dual mycobacterial infection -miliary tuberculosis due to mycobacterium tuberculosis in all the extracranial affected organs and tuberculous meningitis with mycobacterium avium-intracellulare (mac). cerebrospinal fluid examination revealed high cellularity and high albumin concentration in all cases; glucose levels were low, except in one case with normal glucose content -the mac infected patient. one patient had associated systemic lupus erythematosus (sle) and low cd + cells count. the histopathologic appearance consisted of a granulomatous meningitis with giant cells and epithelioids in three cases and polymorphous inflammatory infiltrate including numerous positive bacilli in ziehl-neelsen stain in mac infected patient. conclusion the overall appearance suggested a hematogenous spread of the infection, the immune status correlating with the occurrence of the meningeal disease; in our series we had an immunodepressed patient (sle) and another patient with miliary tuberculosis and superimposed mac infection. also, mac meningitis had a different clinical and histopathologic appearance. introduction clinical presentation and lesion morphology are often suggestive, but not conclusive for mycobacterial (mb) infections. rapid and accurate specific diagnosis is mandatory since appropriate therapy can be chosen only on the basis of the precise identification of the causative agent. one of the most promising tools for rapid and sensitive identification of mb species is represented by amplification of specific sequences of the s rrna mb specific gene on the fragmented dna (max bp) obtained from fixed tissues. methods dna was extracted from cases selected from the archives of the department of pathology, university of padova, with histopathologic features of granulomas, caseous necrosis, and langhans-type giant cells. ziehl-neelsen staining for acid-fast bacilli and pcr/direct sequencing of a bp variable region of the mb s rrna gene were performed. h rv genome was employed as positive control. results mb specific sequences have been identified in of samples analyzed ( %). in two dna samples ( %) an inserted dna product was detected and it is currently under sequencing, while in one sample ( %) no evidence of mb infection has been gained. agreement with ziehl-neelsen was present in cases ( %). conclusion our study suggests that pcr is a rapid, sensitive method for the diagnosis of mb in routinely processed formalinfixed, paraffin-embedded histological specimens and is highly recommendable in cases of chronic inflammation without definite evidence of granulomatous inflammation. introduction cladosporium bantianum is a pigmented highly neurotropic fungus which can be identified easily in tissue sections due to their golden brown colour. cerebral lesions caused by this fungus are rare. case reports we present six cases diagnosed at our institute over a period of yrs. . there were males and female. all patients belonged to the second to fourth decade and had presented with symptoms of space occupying lesion. radiological investigations revealed well circumscribed lesions with ring enhancement. the smallest lesion measured . x . cm and largest measured x . x cm. only two of the six cases had detectable predisposing debilitating illness. one yr. old male had past history of liver tuberculosis and had taken anti-tuberculosis treatment and a yr. old female had systemic lupus erythematosus and was on immunosuppressants. we received four surgically excised specimens and two autopsy specimens of the entire brain. histopathology revealed necrotic areas, micro-abscesses and mainly foreign body type of giant cells. lying within the giant cells as well as freely within the tissue were numerous golden brown to deep brown spherical forms of cladosporium bantianum measuring - microns in diameter and their hyphal forms measuring - microns in diameter, - microns in length with septae and occasional branching. these were confirmed by gomori's methenamine silver stain for fungus and species identification was carried out by culture studies. all the four patients with surgical excision showed recurrence within - months. three succumbed to the disease and one is still alive. conclusion cladosporium bantianum can affect both healthy as well as immunocompromised individuals. it has a fatal outcome. cases are being presented because of the relative rarity. necrobiotic changes of skeletal muscle simulating myxoid sarcoma. report of a case with immunohistochemical and electron microscopic studies kw min , is seo deaciness hospital, oklahoma city, usa wishard memorial hospital, oklahoma city, usa background skeletal muscles are known to undergo bizarre reactive changes in response to traumatic injuries and may produce pseudosarcomatous lesions which may give diagnostic challenges to pathologists. such lesions usually produce proliferative myositis in which atypical spindle cells of fibroblastic and myofibroblastic nature predominate and may simulate the appearance of fibrosarcomas and myofibrosarcomas. however with proper setting of previous trauma history, their true nature can be easily appreciated. we are reporting an unusual case of myxoid cellular lesion found in the abdominal rectus muscle involved in a post hysterectomy abdominal hernia which simulated the appearance of an extraskeletal myxoid chondrosarcoma (emc). its true reactive nature was recognized by electron microscopic (em) study. design light brownish gelatinous material aggregating . x . x . cm was found around the sheath of rectus abdominis muscle of a year old female during a repair surgery of posthyterectomy ventral hernia. the tissue was fixed in buffered formalin and a representative portion of the tissue was fixed in phosphate buffered . % glutaraldehyde and post fixed in osmium with en bloc staining with uranyl acetate. epon embedded thin sections were stained with uranyl acetate and lead citrate. for immunochemistry, paraffin sections were stained for s protein, myosin, and actin by routine abc-peroxidase techniques. results on routine examination, the lesion was characterized by loosely arranged spindly to epithelioid cells in bundles with abundant myxoid stroma. the lesional cells varied in size with frequent bizarre hyperchromatic nuclei. mitosis was rare. the cells showed weakly positive diffuse cytoplasmic stain for all of above antibodies. with the initial impression of emc, an expert opinion confirmed the diagnosis of grade ii emc. however, em revealed the lesional cells to be consistent with skeletal muscle cells having of varying stages of degeneration and regeneration. no ultrastructural characteristics seen in the tumor cells in emc were present. the attending physician was advised of careful follow-up and close observation without any additional treatment. the patient remains with no evidence of disease by year follow-up in spite of incomplete excision of the lesion. discussion and conclusion the myxoid gelatinous material found in the abdominal rectus muscle presented herein showed histopathologic characteristics of emc, however, electron microscopic studies revealed the lesion to be necrobiotic process of the rectus muscle. evidence of no disease in years of follow-up with incomplete excision supports the conclusion the lesion was not malignant as em study indicated. this case exemplifies another variety of pseudosarcomatous reaction of skeletal muscles important in the differential diagnosis in the pathologic evaluation of cellular myxoid lesions. peritoneal psammocarcinoma. a case report with ultrastructural study is seo background psammocarcinoma (pc) is a very rare variant of low grade serous tumors that appears to arise from the peritoneum and ovaries. this tumor has been defined as a serous neoplasm displaying ) destructive invasion, ) no more than moderate nuclear atypia, ) no areas of solid epithelial proliferation except for occasional nests no more than cells in diameter, and ) at least % of papillae or nests are associated with or completely obscured by psammoma bodies. pc shares some clinicopathologic features with serous tumor of low grade malignant potential (lmp), but may have been under-recognized at surgery and gross examination. the present case was incidentally found during a routine hysterectomy procedure for leiomyomas. the pc involved the omentum, peritoneum and diaphragm. we report, to our best knowledge, the first electon microscopic (em) findings of pc. design tumor tissue was fixed in buffered formalin for routine examination. in addition, a representative tissue was fixed in phosphate buffered . % glutaraldehyde and post fixed in osmium with en bloc staining with uranyl acetate for em study. results this tumor met the diagnostic criteria of psammocarcinoma. there were numerous psammoma bodies with or without nests of epithelial proliferation with minimal nuclear atypia. more than % of papillae were either associated with or completely replaced by psammoma bodies. multifocal involvement was noted on the surfaces of both ovaries and fallopian tubes. ultrastructurally, the tumor cells showed markedly villous surfaces with abundant long slender villi. their length/diameter ratio (ldr) was with some variation of their diameter. the cytoplasm contained abundant cytoplasmic organelles and intermediate filaments. intracytoplasmic lumens were absent. decalcified psammoma bodies resembled cut surfaces of geode. discussion and conclusion our case met the proposed criteria for this tumor that arose de novo in peritoneum. ultrastructurally, this tumor shared some findings with serous tumors (junctional complexes, irregular microvilli), but differed by the lack of prominent desmosomes and frequent intercellular lumens. pc differed from mesothelioma in that significantly greater microvillus ldr, prominent desmosomes, tomofilaments, intracytoplasmic lumens, external lamina and glycogen were rountine findings in the latter. our findings justify classification of pc in the group of serous epithelial tumors arising from the coelomic mesothelium. application of electron-and immunoelectron microscopy in the differential diagnosis of pituitary adenomas m maksymowicz, w olszewski department of pathology, institute of oncology, warsaw, poland aim evaluation of practical implementation of electron microscopic techniques in diagnosis of pituitary adenomas. material and methods material consists of consecutive cases of surgically resected pituitary tumors. in pituitary adenomas diagnosed clinically, there were patients with symptoms of acromegaly, patients with hyperprolactinemia, cases of cushing's syndrome and case of tsh hypersecretion. there were clinically nonfunctioning tumors. all cases were diagnosed by histological examination and immunohistochemical identification of known pituitary hormones (growth hormone, prolactin, acth, tsh, fsh, lh and alpha-subunit). the cases evaluated at light microscopy level as pituitary adenomas were examined with electron microscopy and immunoelectron microscopy using a postembedding immunogold technique. results immunohistochemical investigation showed that about , % of specimens of pituitary adenomas contained more than one pituitary hormone. additionally, immunopositivity was discovered in % of tumors from patients with clinical and biological signs of silent pituitary adenoma. ultrastructural analysis provided proper diagnosis of selected cases, e.g. silent corticotroph adenoma or distinction between densely-and sparsely granulated growth hormone secreting adenomas. double labeling immunoelectron microscopy using gold particles of two different sizes greatly facilitated the distinction among mixed growth hormone/ prolactin, mammosomatotroph and acidophil stem cell adenomas. conclusions electron microscopy analysis was valuable to provide a useful informations regarding the diagnosis. our results confirmed practical value of who recommendation for five-tier evaluation of pituitary adenomas (clinical, neuroimaging, histological, immunohistochemical and ultrastructural) . on the basis of our results and the published data, diagnostic postoperative algorithm for proper pathologic management has been proposed. apoptosis, sarcomere disruption and myofibrilar degeneration in skeletal muscles of stable copd patients: an ultrastructural study md ferrer introduction in patients with chronic obstructive pulmonary disease (copd), the diaphragm muscle shows signs of injury, even during clinical stability. in addition, these patients have a markedly increased susceptibility to additional diaphragm injury following inspiratory loading. we have hypothesized that, if sytemic factors play a role in diaphragm injury, limb muscles may also be affected. the purpose of this study is to investigate whether apoptosis occurs in the diaphragm and quadriceps of copd patients, and to evaluate fiber injury in non-respiratory muscles. methods samples from both diaphragm and quadriceps muscles were obtained in patients undergoing thoracotomy for a lowstage lung neoplasm (ln) and stratified into two cohorts according to pulmonary function: ln+copd (n= ) and non-copd patients (ln+non-copd, n= ). in addition, samples form quadriceps muscle in healthy age-matched volunteers were also included (control group). all samples were processed for ultrastructural analysis. the proportion (%) of normal nuclei (nn) and those showing early (ean) and advanced (aan) signs of apoptosis were determined in all samples. digital images of longitudinal fiber sections ( x) were used to determine the area fraction (%) of abnormal myofibrilar structures (aab). results the level of apoptotic signs in the diaphragm of both copd and non-copd groups was minimal and very similar to that of control limb muscle. in contrast, quadriceps muscle of both copd and non-copd groups showed a two-and three-fold increase respectively in the apoptotic nuclei when compared to controls, mainly due to ean. apoptotic bodies were not found. in control quadriceps aab was , ± , %, mostly due to sarcomere disruption, while quadriceps in copd patients was associated with an increased aab ( ± %, p< , ) including myofibrilar disorganization and degeneration. conclusions in patients with copd, the diaphragm is not altered by apoptotic phenomena. muscle remodeling through apoptotic mechanisms as well as through structural changes, such as sarcomere disruption and myofibrilar degeneration, seem to be enhanced in the quadriceps muscle of these patients, regardless of the severity of pulmonary function impairment, suggesting that additional factors such as the degree of physical inactivity either related to the disease or to the preoperative status could also be involved. background renal chromophylic (papillary) carcinoma (cprc) has a propensity for storing hemosiderin in tumor cells. by transmission electron microscopy (tem), some tumors show a prominent lysosomal component, while in other cases, cells contain mostly isometric lipid vacuoles. it has been proposed that the latter would merely represent a papillary variety of clear cell renal cell carcinoma (ccrc). the aim of this study has been to analyze the lysosomal content in chromophylic (papillary) renal cell carcinoma by both immunohistochemical study of cd expression and tem, and to compare these results with those of conventional ccrc. design cases of cprc (n= ) and ccrc (n= ) are the subject of the study. the presence and relative amount of lysosomes and isometric fat vacuoles was investigated by tem (n= ). immunostaining with cd antibody (pg-m , dako, denmark) was performed in representative sections. the presence, distribution and percentage of cd staining in tumor cells was compared with tem data. results expression of cd was observed in all cases of cprc. the mean percentage of positive cells was % ( - %). distribution of positive cells was diffuse in % of cases. of the tem cases, contained abundant fat vacuoles, but only had extensive isometric vacuolation by light microscopy. electrondense lysosomes were less abundant than fat in cases, of which had massive cd expression. detailed examination of fat vacuoles in these cases suggested they were membrane-bound and of probable lysosomal origin. cd expression was also observed in cases of ccrc, all of them with focal distribution, involving a mean of % tumor cells ( - %). these differences were statistically significant (p< . ). conclusions diffuse cd expression is typical of cprc and may be a useful auxiliary diagnostic criterion. the isometric fat vacuoles in cprc are often membrane-bound and of probable lysosomal origin. these findings support the notion that the lipidcontaining, vacuolated variety of cprc is different from ccrc. introduction any lesion in prostate is followed by different proliferative activity of cells. one of the markers, which relate to proliferative activity, is ploidy. it can be determined by cytometry, morphometry or by other methods. aims: study of dna ploidy status in different lesions of prostate by morphometry. materials and methods samples from patients with atrophy, benign prostatic hyperplasia (bph), squamous cell metaplasia (scm), atypical adenomatous hyperplasia (aah), basal cell hyperplasia (bch), prostatic intraepithelial neoplasia (pin) and prostatic carcinoma were processed in formalin, dehydratated in graded alcohols, embedded in paraffin, stained by feulgen-stain. integral optical density was assessed by morphometry on image analysis system. integral optical density of lymphocyte was counted as c ploidy. integral optical density at different prostatic lesions was divided on c. results average ploidy at atrophy was . , bph - . , scm - . , bch - . , aah - . , low grade pin was . . average ploidy at high grade pin was . , high grade carcinoma - . , moderate grade carcinoma - . , low grade carcinoma - . . conclusion increase of ploidy status from atrophy to bph, scm, bch, aah, pin and to carcinoma was observed. regarding to ploidy lesions may be divided in benign and neoplastic processes, with cutoff point between them as . . pseudohyperplastic prostatic adenocarcinoma in transurethral resection of the prostate j arista-nasr, b martinez, j nuncio instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico background the pseudohyperplastic prostatic adenocarcinoma (phpa) is a recently described variant of adenocarcinoma, studied in needle biopsies and prostatectomy specimens. phpa is characterized by malignant glands that simulate benign hyperplastic glands of variable size with complex architecture, papillary enfolding, luminal undulations branching or cystic dilations, columnar cells with macronuclei and nucleoli enlargement. the aim of this study was to define the frequency and microscopic aspect of phpa in specimens originated in transuretral prostatectomy (tup). specimens of transurethral prostatectomy were analized from the surgical pathology department at incmynsz. cases were initially diagnosed as benign glandular hyperplasia (bgh) and as conventional adenocarcinoma (cc) results cases ( . %) with phpa were identified in specimens diagnosed as bhg. these specimens demonstrated phpa in two microscopic areas of mm. both patients are well and free of disease and years after diagnosis. the review of cases diagnosed as cc, three specimens had microscopic segments of phpa. in the outcome the patients developed early bone metastasis. the histopathology study revealed papillary projections, nuclear enlargement, crawled glands, macronucleoli ( / ); cystic glandular dilatation, straight luminal borders, pink amorphous secretions ( / ); nuclear hypercromasia and transition to small cell carcinoma ( / ) . other changes observed were corpora amylacea, double nucleoli and mitoses. conclusions the phpa is a rare neoplasm observed in tup specimens and is observed in only few areas. the false negative frequency in bgh is . %, and % in usual adenocarcinoma. the outcome for these cases is related to the main conventional adenocarcinoma component. vascular endothelial growth factor: an important angiogenic mediator in chronic urinary bladder lesions o hammam, h el baz, a el baz theodor bilharz research institute, giza, egypt vascular endothelial growth factor (vegf) is an overriding growth factor mediating tumor anigogenesis. this study was performed to assess vegf levels of expression in both serum and tissue in benign, premalignant and malignant urinary bladder lesions with or without schistosomal infestation in a trail to study the angiogenic phenotype of these lesions and to address any possible role of vegf as a prognostic biologic marker of bladder cancer. also the impact of schistosomal infestation on the vegf level of expression was assessed.the study included patients: chronic cystitis cases ( schistosomal and non-schistosomal), cases with schistosomal premalignant lesions (metaplasia, dysplasia and leukoplakia) and cases with bladder carcinoma ( schistosomal sqcc, schistosomal tcc and non-schistosomal tcc). eight cases with normal urothelium served as controls. vegf serum concentration was measured by the enzyme immunoassay (elisa) while, its tissue expression was detected by immunohistochemical staining.. significantly higher levels of vegf where detected in the premalignant and malignant cases in tissue (p< . & p< . respectively) and in serum (p< . ) compared to controls. also an aberrant increase in vegf serum and tissue levels was recorded in malignant cases compared to those with chronic cystitis (p< . & . respectively). schistosomal infestation was found to have a positive impact on vegf tissue and serum levels. tissue vegf positive rates was % in all the premalignant and malignant schistosomal associated cases. on stratifying malignant cases according to their histopathological grade and stage, an evident stepladder increase in vegf serum and tissue levels was recorded. vegf serum levels were well correlated with their corresponding tissue level which may indicate that vegf serum levels are reflecting intratumoral angiogenic status. although both vegf serum and tissue levels were positively correlated with tumor histopathological grade and stage, yet this correlation was more evident with the tissue expression (r= . , r= . , p< . in tissue, while r= . , r= . , p< . , p= . in serum with grade and stage respectively). in conclusion, our data indicate that vegf expression level in both serum and tissue may be used as a valuable angiogenic marker for prediction of prognosis. this may help in selecting patients for more intensive surgical or chemotherapeutic approaches. serum vegf concentration may be used as a non-invasive prognostic parameter especially in high risk patients who need continuous follow up. microvessel density in urothelial tumors of the upper urinary tract m raica , c suciu , f baderca , r minciu 'victor babes' university of medicine, department of histology&cytology, timsoara, romania 'victor babes' university of medicine, department of urology, timsoara, romania background angiogenesis in tumors of the urinary bladder is relatively well studied, in spite of some conflicting results and usually correlates with bad prognosis. few data are available about microvessel density (mvd) in urothelial tumors of the upper urinary tract (uut). our purpose was to investigate the mvd in patients with urothelial tumors of the uut and to check for its relationships with stage, grade, and survival. patients, material, and methods there were investigated patients with urothelial carcinoma of the uut. routine-stained slides were reviewed by two independent pathologists for the final diagnosis, t stage, and grade. only cases with invasive and mixed papillary-invasive tumors were included. two cases had lymph node metastasis. additional slides were stained for fviii, cd , and cd . mvd was estimated using the hot-spot method and mean value, calculated on consecutive fields from the tumor area and from the deeper connective tissue (x ). all cases had a follow-up of minimum years. results best results were obtained with cd and cd . in the tumor area, mean values of mvd were . for t , . for t , and for t . the hot-spot method consists of choosing the field with maximum density of blood vessels, and results showed for t , . for t , and . for t . the comparison between mvd and g showed a significant increase from g to g in the mean values and maximal density as well: . / for g , . / . for g , and . / . for g . no relationship was found between mvd and n positive cases. nine patients with high mvd died within years. the extra-tumor mvd had no prognostic significance. conclusions our results show a strong correlation between tumor areas mvd, t, g, and survival. mvd had no value as a predictor of lymph node metastasis. is there any prognostic significance for her protein in urothelial tumors of the upper urinary tract? of her protein in urothelial tumours of the upper urinary tract, and its relationships with the stage and grade. the final purpose was to conclude on the prognostic value of her protein in patients with tumours of upper urinary tract. patients, material and methods there were investigated cases with tumours of the upper urinary tract. routine he stained slides were reviewed for the pathologic diagnosis and grade. additional slides were stained with her- /neu (dako herceptest). interpretation of results was based on the score system (from to + ) already used in breast cancer. results obtained with her- /neu were compared with stage and grade. results eight from cases were positive for her protein ( . %). no relationship was found between her overexpression and 'g'. all but one case with g had a + score for herceptest. conclusions the overexpression of her protein does not correlate with tumour stage, and has no predictive value for lymph nodes metastasis. it strongly correlates with 'g'. introduction some authors consider postatrophic hyperplasia (pah), a glandular hyperplasia that mimics some patterns of prostate carcinoma (pca), without any correlation with neoplastic and preneoplastic condition of the prostate. the association of pah with pca recently suggested (mucci et al., ; tsujimoto et al., ) induced us to analyze the role of pah as precursor of pca. material and methods formalin fixed and paraffin embedded archival sections ( selected patients undergoing radical prostatectomy -mean age = . yr) were studied. twenty cases ( with pah and without pah) were selected for each group: a) bph (benign prostatic hyperplasia), b) pca-ghs< (gleason histological score) and c) pca-ghs=> . slides were immunocytochemically treated with psa, ße , cd , vimentin, cd , ar, nse, chromogranin a, pgp . , p , bcl , ki /mib , incubated with streptavidin-biotin complex (sbc) and revealed by diaminobenzidine (dab). immunohistochemical investigations revealed the presence of basal cells ( ße ) only in pah. the nuclear cell cycle proliferation (mib /ki ) and p mutation were quite similar in number of positive nuclei between pah and pca-ghs< . the chromogranin a were positive in pah, randomly in pca-ghs< , and in nests in pca-ghs=> . vimentin stained nests in pah, whereas were negative in pca. the bcl were positive in pah and negative in pca-ghs< . conclusion these findings suggest a strong overlapping of cell cycle nuclear proliferation and mutation markers, supporting a possible role of pah as a precursor of pca. eosinophilic cystitis: clinico-morphologic aspects d staribratova , d staikov , d dikov , v belovejdov , d staikov plovdiv medical university, plovdiv, bulgaria hopsital centre -lagny, paris, france collaborative study called for review of archived urinary bladder biopsy specimens with inflammatory lesions for the period - . features consistent with the diagnosis of eosinophilic cystitis were identified in cases, thus positioning it at th place with an incidence of , % from all inflammatory lesions. the distribution of clinical signs manifested in these patients often deceptive of interstitial cystitis or tumor processes is as follows: polakisuria, hematuria, suprapubical pains are evident in / , %/ patients; / , %/ presented with acute obstructive pyelonephritis as a result of bladder wall remodeling and case / , %/ revealed combined features of gastroeneteritis and cystitis. inflammed bladder wall and reduced bladder volume is estimated in / , %/ cases, ulcerations in / , %/ papillomatous and solid pseudotumoral lesions are / , %/ and / , %/ respectively. as all clinical signs are nonspecific, the only way to set a proper diagnosis is through bladder biopsy. morphologic confirmation is based on the standard protocols. histochemical (positive ziehl-neelsen stain) and ultrastructural identification of charcot-leyden's crystals are evident in some cases. adenocarcinoma of the male urethra in association with nephrogenic metaplasia f hostalet , je hernández , ja ruiz , a romero department of pathology, 'vega baja' hospital, orihuela, spain. department of urology, 'vega baja' hospital, orihuela, spain. we describe a case of adenocarcinoma of the urethra associated with so-called nephrogenic metaplasia in a year-old male patient that showed a polypoid tumor of the proximal penile urethra. histopathology examination of the biopsy specimen revealed two distinct patterns. the first showed a tumor composed of papillary fronds and glands lined by columnar epithelial cells with eosinophilic and clear cytoplasm, and contained atypical nuclei with frequent mitotic figures. this tumor was interpreted as adenocarcinoma. the second pattern was different, it consisted of small tubules some with mild cystic changes lying in an edematous stroma. the tubules were lined by a single layer of flattened cells with faintly eosinophilic cytoplasm and bland nuclei, mitotic figures were not identified. this area was interpreted as nephrogenic metaplasia and showed a direct transition into the adenocarcinoma. the immunohistochemical study revealed the presence of low-molecular-weight and some high-molecularweight keratins in both types of lesions. the adenocarcinoma cells also showed nuclear staining for p , in contrast, the cells of nephrogenic metaplasia were negative. the nephrogenic metaplasia as well as the adenocarcinoma cells were not stained with psa and pap. the histogenesis of adenocarcinoma of the lower urinary tract remains unclear. the association and direct transition of the nephrogenic metaplasia into the adenocarcinoma in this case suggest the proposed histogenetic pathway that the urethral adenocarcinoma may arise by malignant transformation of nephrogenic metaplasia. introduction benign prostatic hyperplasia (bph) is associated with a shift in sex hormone balance towards an increase in the oestrogen:androgen ratio. this is accompanied by elevated levels of oestrogen receptor alpha (er), predominantly in the stroma. recently, we described a simple, in vitro model to create moderate upregulation of er in human, prostatic stromal cells. the aim of this study was to investigate the hypothesis that in bph upregulated er and the action of androgens differentially regulate expression of several stromal growth factors. materials and methods eight human, prostatic stromal cell strains were subjected to a procedure to upregulate er alpha by exposing them to micro mol beta-estradiol for days, followed by passage and growth in the absence of steroids. four cell strains received instead n mol of dihydrotestosterone for hr. immunoexpressions of er alpha, ar, and six growth factors (fgf- , fgf- , igf- , tgf-beta , ngf and enos) were quantified by flow cytometry. results expression of er was significantly increased above control ( out of cell strains). expressions of all six growth factors were elevated but not significantly so. however, there was a significant positive correlation between the change in er (expressed as percentage of control) and the change in fgf- and fgf- . exposure of four cell strains to dihydrotestosterone reduced the expression of er and all six growth factors in comparison with oestrogen-treated cells. this reduction was significant for er and fgf- . conclusion upregulated er in prostatic stroma have a greater modulating effect on synthesis of certain growth factors than the direct action of androgens and hence may play a major role in the development of bph. the diagnosis of prostatic adenocarcinoma in needle core biopsy is based on major and supportive criteria. one of the supportive criteria is the presence of retraction clefting around neoplastic glands. the aim of our study was to analyze needle core prostatic biopsies in order to determine the frequency of periacinar clefting spaces in tumors and non-tumorous prostatic tissue. materials and methods we analyzed a consecutive series of prostatic cancer cases diagnosed by needle core biopsy to determine the frequency and extent of periacinar clefting. all tumors consisted of at least neoplastic glands. specimens were fixed in % buffered formaldehyde, embedded in paraffin, cut at µm thickness and routinely stained with hematoxylin and eosin. clefting was analyzed on neoplastic and normal glands in three different high power fields. results one third or more of analyzed glands with clefts affecting more than % of circumference were significantly more common in tumors ( . %) than in benign glands ( %). more strict criterion that designated as positive cases with at least % of neoplastic glands (fifteen out of thirty) with clefts that affected more than % of circumference revealed clefts in the malignant cases only ( . %) but not in benign cases ( %). fifteen or more glands with clefts regardless of their extension were also more prominent in malignant cases ( . %) than in benign cases ( . %). conclusion we conclude that retraction clefting represents a reliable criterion for diagnosis of prostatic adenocarcinoma. analyze the causes of ureteral obstruction in a series of patients managed at the department of urology, timisoara county hospital between and . there were selected only those particular cases of ureteral obstruction, others than cases with lithiasis, stenosis of the ureteropelvic junction and transitional cell carcinoma. an additional case was send for evaluation from another institution was also included in the study. for three of the selected cases we performed additional histochemical (alcian-blue-pas) and immunohistochemical study (anti-ck, anti-psa, anti-vimentin, anti-smooth muscle actin, abc and lsab system, visualization with dab). results we identified cases of ureteral obstruction due to unusual pathological lesions. they occurred in men and women. the mean age of the study group was years (range and years). there were malignant and benign lesions that produced ureteral obstruction. in cases, the compression was extrinsic and only in cases the obstruction was intrinsec. the site of ureteral obstruction was in the lower ureter in cases, in the lower and the middle ureter in patients and in the upper ureter in cases. the pathological lesions were: ureteritis cystica - cases, nephrogenic adenoma of the ureter - case, retroperitoneal fibrosis - case, reproperitoneal sarcoma - case, pelvic endometriosis - case, prostate cancer metastasis - case, signet ring cell carcinoma of the colon invading the ureter - case. conclusions after discarding the more common causes of extrinsic or intrinsic ureteral obstruction, the proliferativemetaplastic lesions of the urothelium, the retroperitoneal fibrosis and sarcoma, the endometriosis and metastatic/invasive carcinoma should be considered in the diagnosis. immunohistochemical study of androgen receptor and tgf alpha in human benign and malignant prostate a petrescu , g berdan , c ardeleanu , v jinga , s persu prof. dr. th. burghele hospital, bucharest, romania victor babes institute, bucharest, romania aims that androgen receptor(ar)and tgf alpha might be prognostic of hormonal response and biological behaviour in prostate carcinoma. methods ar and tgf alpha were studied in paraffin sections from men ( treated for prostate cancer and for bph by open, transurethral prostatectomy or prostate biopsy) no patient had undergone previous treatment for the prostate disease. the sections were stained with he to establish morphological characteristics (gleason score) and then were studied with indirect immunoperoxidase method applying monoclonal antibodies to ar(f . . biogenex) and antitgf alpha (clone , biogenex). results were semiquantified using histoscore.nuclei were graded for intensity of ar staining ( -absent, -weak, -moderate or strong) and the percentage of these intensity levels and a total intensity score were determined. we compared the ar and tgf alpha characteristics of prostate cancer (pca) with bph. results increasing gleason grade was correlated with decreasing intensity score and greater heterogeneity of ar staining and increased (+++) tgf alpha immunoreactivity. conclusions our data indicate that ar and tgf alpha content could be useful predictors of endocrine response and biologocal behaviour of prostate cancer. and ductus deferens samples), patients in group b were orchiectomised for the diagnosis of prostate cancer, teratocarcinoma of the testis and/or epididymal cyst (normal epididymal and ductus deferens samples) and subjects in group c were treated by radical prostatectomy or cystectomy for prostate or urinary bladder cancer ( samples of seminal vesicles without inflammatory changes). results hpv dna was detected in ( %) of patients in group a (hpv types , , , , , ) , in ( . %) patient in group b(at present unclassified type) and in ( . %) patients in group c(hpv types , and ).neither koilocytes nor dysplastic changes were observed. conclusion our data confirmed the presence of hpv, both lowand high-risk types, in the male genital tract. they support the idea of a male reservoir of hpv infection. spermatogenetic function of the testis in patients of different varicocele grades É magyar , e erdei , i lellei national medical center, pathology, budapest, hungary national medical center, andrology, budapest, hungary introduction varicocele is one of the main reasons of male infertility. surgical repair may improve sperm quality. the aim of this study is to investigate a grading system of varicocele and its correlation with the histological appearance using a multiple biopsy method. materials and methods bilateral double testicular biopsies of young infertile grade - varicocele patients were examined histologically. spermatozoa numbers counted in ten round shaped tubules, severity of atrophy and presence of maturation arrest was recorded. distribution pattern of observed spermatozoa numbers was evaluated. results grade and cases showed normal distribution. in grade cases five peaks were found indicating group inhomogenity. lower grade varicoceles presented with milder histological changes (mild atrophy or normal spermatogenesis) while in higher grade varicoceles more marked alterations (moderate-marked atrophy and/or maturation arrest) were seen. conclusion grade varicocele cases represent an inhomogeneous group, which should be divided into more categories. modification of the grading system is required. spermatogenetic activity of varicocelic patients cannot be predicted from clinico-radiological examinations so before art a diagnostic testicular biopsy is recommended. synchronous double urogenital cancer -a case report s we present a case of synchronous double urogenital cancer, comprised of invasive transitional cell carcinoma of the urinary bladder and adenocarcinoma of the prostate. cystoprostatectomy was performed in a -year-old male patient with previous cytological diagnosis of transitional cell carcinoma of the urinary bladder and no evidence of prostatic malignancy on preoperative clinical investigations. gross analysis of the urinary bladder revealed a cauliflower tumor mass filling the entire lumen and infiltrating the wall of the bladder. the size of the prostate was slightly increased. histological analysis of the urinary bladder specimens showed poorly differentiated transitional cell carcinoma, with only a few foci of preserved papillary architecture, infiltrating deeply into the muscle layer of the bladder wall. the specimens taken from the prostate gland for the purpose of staging of the neoplasm excluded the existence of infiltration of the prostatic urethra with the previously described neoplasm, but foci of moderately differentiated adenocarcinoma (gleason score ) of the prostate were discovered in its vicinity. the subsequent extensive sampling of the prostate showed organ confined adenocarcinoma. the review of the literature showed that the reported prevalence of synchronous existence of double primary malignant neoplasms of the urinary tract (transitional cell carcinoma of the bladder and prostatic adenocarcinoma) varies between % and %. the prevalence is noted to rise with increasing age. this leads to a conclusion that during standard cystoprostatectomy analysis, extensive sampling of the prostate is needed, even in the absence of macroscopic changes and preoperative clinical data suggesting prostatic neoplasm. multiple synchronous renal cell tumors d passetchnik rostov state medical university, rostov on don, russian federation rostov regional hospital , rostov on don, russian federation introduction the use of the nephron-sparing surgery demands detection of multiple renal cell tumors. materials we performed a retrospective analysis of nephrectomies and autopsies performed in our clinic. results of renal cell tumors ( , %) were multifocal. most of the patients were men. twelve cases were present where the histological subtype of the largest tumor was clear cell. satellite tumors were clear cell carcinoma ( ), papillary adenoma ( ), angiomyolipoma ( ), renomedullary fibroma ( ), bellini duct carcinoma ( ) . six multiple renal cell tumors were found in t , two in t , four in t a stage of the primary tumors. four patients had bilateral neoplasms. in thirteen cases only multiple papillary adenomas and carcinomas were found. usually tumors were no more than cm in diameter. in six cases multiple tumors originated on a background of nephrosclerosis of various genesis (chronic pyelonephritis, gouty nephropathy, amyloidosis). conclusion when conservative surgery of kidney cancer is performed, it should be remembered that % of patients with renal cell tumor have multiple neoplasms, which may cause local recurrence. the origin of multiple renal cell tumors may be bound up with hereditary predisposition or nephrosclerosis creating multifocal tumor field. introduction prostate cancer is a leading cause of cancer-related deaths in men and is the most common malignancy in american males. the heterogeneity of prostate cancer defines the current clinical challenges. one challenge is to identify in early, still potentially curable, stages of prostate cancer, molecular markers that predict aggressive or metastatic behavior. prostate cancer is characterized, like many other cancers, by molecular and genetics aberrations involving chromosome . parkin, mapped at the long arm of chromosome , is a amino acid protein with a molecular mass of kda, an ubiquitin-like domain at its amino terminus and two ring finger motifs flanking a cysteine-rich region. our aim was to investigated whether parkin alterations play a role in development and progression of prostate carcinoma materials and methods we examined parkin expression, by western blot analysis in eight prostatic carcinomas derived cell lines as well as in normal prostate, and in three prostatic intraepithelial neoplasias (pin) and in twenty primary prostatic carcinomas by immunohistochemistry. results parkin protein was undetectable in six out of eight prostate cancer cell lines tested and barely detectable in the remaining two whereas normal prostate showed a substantial expression. preliminary results using immunohistochemistry showed that parkin expression was absent in pin lesions, and in the prostatic carcinomas analyzed. conclusion our findings suggest that parkin might be a useful tool to detect early alteration in prostate cancer. the kdr/flk- receptor of vascular endothelial growth factor in urothelial bladder cancer: relation with clinicopathologic parameters and patients' survival introduction the impact of different angiogenic inducers and inhibitors in the switch of angiogenesis in urothelial bladder cancer, is not clarified. kdr/flk- is a receptor-tyrosine kinase that binds specifically vascular endothelial growth factor (vegf) on vascular endothelium, mediating its full biologic spectrum. although kdr/flk- expression was at first reported to be restricted to the classic endothelium there is increasing evidence that kdr/flk- is also expressed by normal and tumor cells other than endothelial. aims: as data about kdr/flk- protein in urothelial bladder cancer is very limited, we investigated its expression in a series of urothelial carcinomas in relation with clinicopathologic parameters and patients' survival. moreover, prompted by studies suggesting that kdr/flk- may have broader functions apart from angiogenesis we evaluated kdr/flk- expression in relation with markers of cellular proliferation and apoptosis (ki- , p , bcl- ). materials and methods immunohistochemistry (abc-hrp) was performed for the detection of kdr/flk- (mouse/a- , sc- , santa cruz), ki- , p and bcl- using monoclonal and polyclonal antibodies. statistical analysis was univariate (pearson's x , mann-whitney test, log-rank test) and multivariate (cox's model). results kdr/flk- expression was observed in the cytoplasm of cancerous cells in / cases. no significant associations were observed between kdr/flk- expression and clinicopathologic parameters, ki- , p and bcl- expressions. on the other hand, widespread kdr/flk- expression in more than % of cancerous cells, was associated with patients' increased survival, in univariate and multivariate analysis (p= . , p= . , respectively). conclusion although non endothelial kdr/flk- expression has not yet been elucidated, its association with better patients' survival may be related with the failure of non-endothelial kdr/flk- to mediate angiogenic and mitogenic effects, that has been reported in some previous in vitro studies. timp- protein expression in relation with cellular proliferation, apoptosis and survival of urothelial bladder cancer patients introduction the role of tissue inhibitors of matrix metalloproteinase (timps) in cancer progression remains a controversial matter since apart from the well established inhibitory action of timps on mmps, several new functions are now attributing to timps such as growth promoting activity, involvement in apoptosis control and in angiogenesis. the aim of this study was to elucidate the role of timp- in urothelial bladder cancer, we investigated its expression in a series of urothelial carcinomas in relation to clinicopathological parameters, patients' survival and the expression of the ki- proliferation index. materials and methods immunohistochemistry (abc-hrp) was performed for the detection of timp- and ki- proteins, using monoclonal and polyclonal antibodies. statistical analysis was univariate and multivariate. results timp- stromal cell expression was observed in / cases and associated significantly with urothelial carcinomas of high histologic grade (p< . ) and advanced stage (p= . ) as well as with poor patients' survival (p= . ). timp- expression in cancerous cells was found in / cases. timp- either stromal or cancerous cell expression correlated significantly with ki- expression (p= . , p= . respectively). conclusion the association of timp- with ki- supports the growth promoting activity of timp- . moreover, timp- expression in stromal cells may be a valuable marker of adverse prognosis in urothelial cancer patients. gleason score is important predictor for differentiation and biological potential of prostate cancer. nodenegative (p n ) prostate cancer is the best result after radical prostatectomy which is indicated in patients with localised prostate cancer. the aim of the study was to analyze gleason score in patients with nodal metastases of prostate cancer (pc). material and methods we analyzed cases of radical prostatectomies due to localised prostate cancer in the period - in clinic of urology in clinical centre of serbia, belgrade. nodal metastases (stage of disease), average age of the patients, grade and gleason score of tumors and premalignant lesions were analysed. immunohistochemical staining was performed and pathological analyzed. we used statistical analysis anova and h test. results the average age of the patients was . years (range - , pick - ). most cases ( %, p< . ) were in pt a n m , in pt b n m ( . %), in pt bn m ( . %), in pt bn m ( . %), in pt an m ( . %). positive nodal status was present in cases: ( %) in pt bn m -iliac (right , left ), obturatory (right l, left ) and cases in pt bn m -iliac left and obturatory ( right and left). we found gleason score in cases ( . %) in pt bn m versus cases ( . %) without nodal metastases. gleason score was found in cases ( . %) in pt bn m versus one case without nodal metastases (p> . ). gleason score was present in . %, in . %, in . %, in . %, in . %. grade tumors were found in cases ( %), grade in ( %), and grade in ( %). hg pin was present in cases ( . %), lg pin in ( . %). conclusion gleason score differ, but not significantly in prostate cancer with nodal metastases. pelvic lymphadenectomy is necessary for staging purposes in prostate cancer. radical prostatectomy is the most adequate method in surgical treatment of localised prostate cancer. immunohistochemical and molecular evaluation of c-erbb gene amplification and c-erbb protein overexpression in prostate cancer the amplification of oncogene c-erbb and overexpression of c-erbb protein found in some human cancers is associated with more aggressive development of tumor. the previous data suggested an independent role of c-erbb protein as a prognostic factor in human breast cancer. however, the role of c-erbb gene and its protein product in prostate cancer cells still remain unclear. the aim of our study is to show what is the role of c-erbb protein in prostate cancer and to examine association between c-erbb gene amplification and its protein product expression in the histologicaly graded prostate tumor. we have analyzed c-erbb gene amplification by rt pcr and c-erbb protein expression by immunohistochemistry in cases of paraffin embedded slides. the tumors were divided according to who by mostofi classification: cases of g -well differentiated cancer; cases of g -moderately differentiated cancer; and cases of g poorly differentiate cancer. these groups are equivalent to - , - and - gleason classification respectively. results the correlation between c-erbb protein expression and well, moderately and poorly differentiated cancer respectively existed (p< . ). there was no significant correlation between c-erbb gene amplification and c-erbb protein expression in all examined groups. our results suggest that the c-erbb protein expression is an independent factor on the c-erbb gene amplification in prostate cancer cells. it is possible that there are other ways, except gene amplification, for overexpression of c-erbb protein in prostate cancer. comparison of needle biopsy and surgical specimen in prostatic carcinoma s nordling, j vasama department of pathology, university of helsinki, helsinki, finland in finland carcinoma of the prostate is the most common form of cancer in men. the number of radical prostatectomies is increasing in most countries. the radical prostatectomy is normally preceeded by a needle biopsy. at the university central hospital of helsinki radical prostatectomies were performed between and . in patients, the preoperative needle biopsy was available. in many cases the preoperative psa value was also available. the mean psa value dropped from to less than ng/ml. the percentage of seminal vesicle invasion dropped from to . except for the earlier years, the men gleason score was about point higher in the radical prostatectomy specimen than in the biopsy. the mean gleason score has increased, while the stage and psa values have decreased indicating that the criteria for the gleason grading has changed ovewr the years. this makes the comparison of treatment results very difficult. introduction distinguishing atypical adenomatous hyperplasia (aah) from small foci of prostatic adenocarcinoma in needle biopsies of the prostate often presents as a challenge for pathologists. the aim of the study was to establish characteristic immunohistochemical patterns in benign and malignant prostatic lesions so they can be used to classify foci of aah as benign or malignant. materials and methods using immunohistochemistry, prostatic needle biopsies from forty-five patients were evaluated for cytokeratin , p and alpha-methylacyl-coa racemase (p s). twenty-five of these biopsies were benign and twenty contained prostatic adenocarcinoma. results % of the benign prostatic biopsies were positive for cytokeratin and p and % were negative for p s. only one case of benign prostatic tissue was focally positive for p s. when evaluating cases with adenocarcinoma % were positive for p s and % were negative for cytokeratin and p . p s immunostain showed consistently positive staining in areas of low and intermediate grade adenocarcinoma and areas with high grade pin. high-grade prostatic adenocarcinoma was frequently negative for p s. sensitivity and specificity for cytokeratin /p were % and % while sensitivity and specificity for p s were % and %. conclusion cytokeratin was as sensitive and as specific as p and can be used interchangeably in cases of aah. the combination of the two antibodies did not improve sensitivity or specificity. a combination of negative cytokeratin or p with positive p s may be helpful in positively identifying prostatic carcinoma in cases of aah. myofibroblastic stromal reaction in prostatic adenocarcinoma introduction reactive stromal changes that occur in different human cancers probably are involved in local tumor spreading and progression. it seems that myofibroblast plays very important role in stromal reaction to certain types of human cancer. we have analyzed prostatic carcinomas in radical prostatectomy specimens to determine the proportion of myofibroblasts around normal and neoplastic acini. myofibroblast showed positive staining for alpha-smooth muscle actin (sma) and vimentin. positive cells were counted in the hot spots areas under high power magnification (hpf). results were expressed as negative (-) for no staining, (+) for positive staining in up to % of stromal cells, (++) in - % of cells and (+++) for more than % of positive cells. stromal blood vessels were counted in ten hpf. the degree of desmoplasia was also analyzed by mallory staining and expressed semiquantitatively as weak, moderate and strong. results and conclusions highly increased number of myofibroblast was observed around neoplastic acini in ( . %) cancer cases, moderate in ( . %) and sparse in ( . %) cases while there were occasional myofibroblastic cells adjacent to normal acini. there was a positive correlation between the degree of stromal desmoplasia and the proportion of sma and vimentin positive cells in adjacent stroma. the number of vessels in the adjacent stroma was also significantly increased in comparison with normal glands (p< . ). it seems that myofibroblasts are present in the stroma and may play a significant role in the desmoplastic stromal reaction in prostatic adenocarcinoma. results among the srcc, ( %) showed no epithelial differentiation, and in the other cases the epithelial component was conventional rcc in cases ( %), papillary ccr in ( %), and chromophobe rcc in ( %). there was no sex predominance and the average patient age at the time of diagnose was years. sixteen cases ( %) presented an advanced stage at the time of diagnose, and ( %) died of disease. the immunohistochemical study showed that cases were positive for c-kit ( . %), diffusely (> % of the sarcomatoid cells positive), moderately ( - % of the cells), and focally (< % of the cells). conclusion the high expression of c-kit in srcc in our series and the existence of target therapy against cells expressing this marker (imatinib (sti- , gleevec, novartis, basel, switzerland) suggests its potential use in the clinical management of these patients in order to improve their prognosis, especially in disseminated cases. does hpv play a role in the development of bladder tcc? a comparison of pcr and immunohistochemical detection methods the role of human papilloma virus (hpv) in the development of bladder carcinomas remains controversial. varying techniques have been used to identify this virus in transitional cell carcinoma (tcc). here we used two different methods to detect the presence of mucosal hpv in tcc samples. the first, immunohistochemistry, involved using a polyclonal antibody that reacts with the l capsid protein of most known papilloma viruses. the second method is used on a general primer-mediated polymerase chain reaction (pcr) assay. this involves using type-specific oligonucleotide probes to identify different mucosal hpv genotypes from a bp pcr product from the l region of the hpv genome. the two methods produced contrasting results, % of the samples were positive for hpv antigen and % were positive for hpv dna. the reason for such conflicting results is that polyclonal antibodies are not specific and are likely to cross react with other antigens. pcr is specific, more sensitive, and it is widely used to detect hpv in a variety of clinical samples. the results obtained in our study implies that hpv does not play a role in the development of bladder carcinoma, and pcr remains to be the best method to detect hpv in tcc. does tgf-α prevent carcinoma spreading? o gladskikh introduction most human carcinomas including prostate cancer are associated with stromal reaction typified by changes in growth factor expression and over-accumulation of extracellular matrix. our study deals with the differential tgf-α production in neoplastic focuses and in adjacent paraneoplastic stroma in prostate. materials and methods tissue samples from radical prostatectomies were examined. to verify malignant material or benign the immunohistochemical staining against high molecular weight cytokeratin was performed on sections and in heterogeneous primary cultures of the same specimens. the immunohistochemical identification of tgf-α was also performed. the elisa technique for quantitative analysis of tgf-α soluble form in culture supernatants was applied. results majority of selected cancer cases were histologically estimated as small-sized glands with large desmoplastic fibromuscular stroma. the immunohistochemical staining for tgf-α in malignant focuses was much more significant than in neighbouring benign areas on sections in contrast to, the cultures obtained from neoplastic or paraneoplastic portions of prostate tissue which stained positively for tgf-α without any difference. considering that immunohistochemistry shows only latent tgf-α we evaluated its bioactive form in culture supernatans. we found dramatically high supernatant levels of active tgf-α in benign cultures compared to the cultures from the malignant areas. conclusion our data demonstrate that desmoplastic alterations in benign areas adjacent to malignant glands was associated with elevated expression of tgf-α active form. so significant alteration in factor production and accompanied tissue remodeling can be considered as a protective reaction of surrounding stroma against tumor invasion. introduction primitive neuroectodermal tumors (pnets) represent a family of neoplasms, of presumed neuroectodermal origin, that mostly presenting as bone or soft tissue masses in the trunk or axial skeleton in adolescents and young adults. the aim of this study was to report a case of pnet arising from kidney which is a rare localization. methods a year-old-man presented with abdominal pain and abdominal mass. the imaging methods revealed a mass nearly replacing the right kidney and he underwent a right nephrectomy. on gross examination the tumor measured cmx cm with cystic areas and necrosis. microscopically, it was a highly cellular neoplasm of consisting sheets of small-round-to-oval cells with irregular nuclei. immunohistochemical stains were positive for vimentin and cd . microscopic and immunohistochemical findings were compatible with pnet. conclusion although rare, pnet must be included in the differential diagnosis of renal tumors especially in children and young adults. we present a case of renal pnet as an unusual case and discuss the differential diagnosis pathologic stage of urinary bladder cancer at presentation in a non-selected patient population in a high-incidence region of the united states introduction most studies of pathologic stage in bladder cancer (ca) are retrospective, using selected, usually hospital-based, patient populations. the aim of this study was to determine the pathologic stage of bladder ca at initial presentation in a nonselected patient population in a high-incidence region of the northeastern united states. materials and methods all patients newly presenting with bladder ca in the state of new hampshire (u.s.a.) from july to december were identified through the state tumor registry. slides were classified according to who and isup criteria. results of cases, were diagnosed as non-malignant or technically inevaluable, leaving ca cases. ( . %) were carcinoma-in-situ (stage tis). ( . %) were papillary, of which ( . %) were low-grade and ( . %) high-grade. of the low-grade cases, only ( . %) were invasive, all limited to lamina propria (stage t ). of the high-grade cases, ( . %) were noninvasive (stage ta), ( . %) invaded lamina propria (stage t ), and ( . %) invaded muscle (stage ). cases ( . %) had no papillary component and all were invasive; ( . %) were stage t and ( . %) were stage t . cases ( . %) were nonurothelial, including squamous cell ca, small cell ca, and adenoca; of these presented as stage t and as stage t . overall, cases ( . %) were invasive (at least t ) at the time of presentation. this population-based series establishes the distribution of bladder tumor stage at initial presentation and documents a smaller percentage of invasive cancers than most hospital-based series the relationship between mitotic index and nucleolar organizer region with histologic grade in transitional cell carcinoma of urinary bladder mr jalali nadoushan, t rezaei nour, n fallah, sk foroutan shahed university, tehran islamic republic of iran background and object transitional cell carcinoma (tcc) of urinary bladder is the second most common cancer of the genitourinary tract, that the prognosis and treatment is related to several parameters such as proliferative cell markers. in this study relationship between two proliferative cell markers: -mitotic index(mi)& -agnor and tumor grade were studied. methods and materials in a cross sectional descriptive study paraffin blocks of patients with tcc of the urinary bladder in the period from to from pathology department of shahid mostafa khomeini hospital, were obtained and from each one micron sections were provided. tumor grade on basis of who/isup grading system, was determined and number of mitosis on tumor cells were counted. in the other section, after one-step silver nitrate staining, the number of nor also on tumoral cells were counted and the mean of it in each cell were determined. results the high grade tumors possessed more agnor per nucleus than did the low grade ones. significant relationship between tumor grade and mi (p= . , rs= . ) and agnor (p= . , rs= . ), and also between mi and agnor (p= . , rs= . ) were found. introduction the human epidermal growth factor receptor (her ) is overexpressed not only in breast, but in a range of other tumor types including, ovarian, salivary gland, endometrial, pancreatic, non-small cell lung (nsclc) and bladder cancer. however, non-standardisation in her status evaluation or population selection has generated conflicting results among the incidences of her expression in individual tumor types and bladder cancer. the aim of the present study was to evaluate her overexpression and gene amplification with standardized routinely performed assays (dako herceptest, fish-vysis, cish) on a selected population of poorly differentiated urothelial carcinomas of the bladder. materials and methods we analyzed formalin-fixed, paraffin embedded tissue samples of urothelial carcinomas of the bladder at g /pt - as well as cases at g / ptis ( )and pta- ( ) using herceptest to verify the her -status. staining and scoring was performed according to the manufacturers instructions. according to diagnosis of her , all herceptest positive ( +) tissue samples were used for further evaluation with fluorescence in situ hybridisation (fish; vysis) and chromogenic in situ hybridisation (cish) to approve the expected gene amplification. this procedure is in agreement with the standardized guidelines for breast cancer. results ( %) cases were considered as her positive ( + and +) in the primary tumor and therefrom cases ( %) + positive and cases ( %) + positive. out of the cases with + positivity, only two cases showed a fish/cish positivity. no polysomy for chromosome was detected. our results indicate that her may not only be a useful prognostic parameter in poorly differentiated invasive bladder cancer, but accurate determination of overexpression and verification of gene amplification may also have therapeutic importance. the prognostic importance of tumor volume (tv), nontumor volume (ntv), tv/ntv, fibronectin distribution, β-hcg and psa expression in localized prostatic adenocarcinoma bh ozdemir, an sar, fp uyar, b demirhan, a dirim baskent university, faculty of medicine, departments of pathology and urology, ankara, turkey aim to assess the importance of fibronectin (fn) distribution, β-hcg and psa expression in localized prostatic adenocarcinomas with regard to tumor volume (tv), non-tumoral volume (ntv), tv/ntv and with other clinicopathological prognostic parameters. material and method fifty-one radical prostatectomies were whole mounted, serially sectioned and examined for tv, ntv, tv/ntv, capsular invasion, vascular invasion, seminal vesicle invasion and gleason score. the fn distribution, β-hcg and psa expression were examined immunohistochemically. a fn-positive staining was defined as a constant diffuse, or pericellular demarcation of fn-positive fibers surrounding tumor cells at the invasive border. in lack of such staining pattern, fn-negative staining was recorded. results both tv and tv/ntv showed very strong positive correlation with grade, capsular invasion, vascular invasion, seminal vesicle invasion, β-hcg and psa expression (p< . ). β-hcg was detected only in cases ( . %). a significant relationship was found between β-hcg expression and grade, capsular invasion, vascular invasion, seminal vesicle invasion, psa expression (p< . ). the fn-positive staining reaction was significantly associated with lower incidence of capsular, and seminal vesicle invasion (p< . ). tv and grade was found higher in tumors with negative fn staining (p< . ). psa expression showed significant relationship with grade, vascular and capsular invasion (p< . ). ntv statistically showed no relationship with all parameters. conclusion these data suggest that, tv, tv/ntv, fn distribution, β-hcg and psa expression in prostatic adenocarcinoma have strong prognostic importance irrespective of gleason score. the fn distribution could be important for the invasion of the tumor cells during cancer progression. these may allow stratification of patients to type of treatment and may allow selection of expectant management for men with localized prostatic adenocarcinoma. neuroendocrine differentiation in prostate cancer: correlation with biochemical failure after radical prostatectomy s cerovic introduction focal neuroendocrine differenatiation (ned) is a commom feature of prostate cancer (pc), occuring in %- % tumors studied. published results of the evaluation of ned as a prognostic factor in pc after radical prostatectomy (rp) have been contradictory. the aim of this study was to correlate ned in pc in relation to biochemical failure after rp. materials and methods radical prostatectomy specimens from pc patients without preoperative hormonal or radiation therapy were followed for to months. neuroendocrine (ne) cells were identified using a panel of immunohistochemical ne markers: chromogranin a, serotonin, and neuron-specific enolase. ned was scored as ne-negative ( to +) or ne-positive ( to +) per hpf. biochemical progression (bp) was defined as a prostate-specific antigen (psa) level greater than . ng/ml in two consecutive measurements. kaplan-meier method was used to estimate bp-free survival time for each risk group. the cox proportional hazards regression analysis was the model for bp time using pathological and clinical variables. results the total of ( %) patients developed bp after rp. the average time for bp was months. the preoperative psa serum level range < ng/ml in % of the patients. postoperative staging confirmed that ( %) of patients had pt stage and ( %) of patients had pt stage. ned demonstrated in the ( %) pc patient with bp. the average time for bp was months. tumor volume (p< . ), pathological stage (p < . ), tertiary gleason grade (p= . ) and nedf (p< . ) significantly affect the level of postoperative psa progression. conclusion the expression of ned in pc correlates with tumor volume and tertiary gleason grade and represents an independent prognostic factor of bp after rp. expression of vascular endothelial growth factor (vegf) and correlation with microvessel density in benign hyperplasia and prostate carcinoma nj aim the present study is scheduled to evaluate the levels of vegf expression in benign prostatic hyperplasia (bph) and prostate carcinoma and to correlate them with angiogenesis. material and method formalin-fixed, paraffin-embedded tissue sections from patients who underwent radical prostatectomy or transurethral resection of the prostate were studied. our material consisted of cases of bph and cases of prostate carcinoma. microvessel density (mvd), as determined by cd , and expression of vegf were investigated by immunohistochemistry using the monoclonal antibodies cd (dako) and vegf (neomarkers), respectively. results expression of vegf was detected in / ( , %) cases of bph and in all ( %) invasive prostate carcinomas. cytoplasmic immunoreactivity for vegf was detected in epithelial and stromal cells. vegf expression was stronger in carcinomas, when compared to bph (p< . ), while it was minimal to absent in normal adjacent prostate tissue. a positive correlation between vegf expression and gleason score was found (p< . ). microvessel density (mvd) was higher in bph and prostate carcinomas, when compared to normal adjacent prostate tissue. a statistically significant association was noted between vegf and mvd expression (p< . ). our results indicate that generation of new capillary blood vessels begins in bph and keeps progressing in invasive prostate carcinoma. vegf seems to be a key functional regulator of angiogenesis in the prostate gland. the relationship between histologic grade and abo blood groups in transitional cell carcinoma of the urinary bladder b mofid , mr jalali nadoushan shahid beheshti university of medical sciences, tehran, islamic republic of iran shahed university, tehran, islamic republic of iran introduction according to the statistics of , the urinary bladder cancer is the fifth common cancer in iran. the majority of urinary bladder tumors are transitional cell carcinomas. different factors are effective in the prognosis of these patients. one of these factors is the histologic grade. another factor is to determine the abo blood groups and the relationship of it with the histologic grade. thus, this study is conducted to shed some lights on this issue. materials and methods a cross sectional study was conducted in patients with urinary bladder transitional cell carcinoma during - . results of patients, were female ( . %) and were male( . %). the mean age of patients was . +/- . there was no significant statistical relationship between of histologic grade and abo blood groups. there was no significant differences between the abo blood groups frequency in patients with urinary bladder transitional cell carcinoma and general population. conclusion although the existing differences between asian, european and american studies might be due to racial effects, it is better to carry out more studies in this respect in order to comment in this area with more confidence and certainty. introduction a variable degree of mucin secretion may be present in prostatic carcinoma (pc), but true mucinous tumors are rare. prostatic mucinous carcinoma (pmc) is a variant of high-grade adenocarcinoma, with a . % rate of prostate-specific antigen (psa) elevation and a similar rate of response to endocrine therapy. the aim of this study was to report on a case of pmc with signet ring cells treated with radical prostatectomy (rp). materials and methods a -year-old man presented with acute urinary retention and long history of difficult voiding. the serum psa was . ng/ml. the transperineal biopsy of the prostate gland was done and the histology showed a poorly differentiated pc with large lakes of extracellular mucins. isotope bone scan was normal and a ct-scan did not show evidence of extracapsular spread of the tumour. radical prostatectomy was performed. patient died seven month after rp. results histopathologically, over % of the prostate samples were infiltrated by a poorly differentiated pc with mucinous and signet ring patterns. mucin secretion is evident as large pools of mucin and periodic-acid-schiff-positive diastase-resistant intraluminal and citoplasmic globules. immunohistochemical staining for psa and prostate-specific-acid phosphatase was positive, and negative for carcinoembryonic antigen and cytokeratin . conclusion the diagnosis of pmc with signet ring cells requires exclusion of an extra-prostatic origin, mainly within digestive tract. since only small number of mpc cases treated with rp have been reported, treatment and prognosis of this tumour remain unclear. introduction cd is a well-known marker for hematolymphoid neoplasms and is expressed as well in various nonhematopoietic tissues and solid tumors. a systematic study of cd expression in tgcts, however, is lacking. the aim of this study was to investigate the immunoreactivity for cd in the different patterns of tgcts. material and methods immunostaining with mab against cd (clone c ) in unselected cases of primary ( cases: classical seminoma (cs); pure embryonal carcinoma (ec); mixed-non-seminomas; spermatocytic seminoma (ss) and metastatic ( cases) tgcts. in mixed tumors, the different histological patterns were evaluated separately. results cd was expressed in ( %) out of cases in the cs component, in ( %) of teratomas, in ( %) of endodermal sinus tumors (est), in ( %) of cases of choriocarcinoma (chc) or syncytiotrophoblastic giant cells (stgc) and in ( %) of ec. cd was focally positive in ( %) of cases of intratubular germ cell neoplasia (itgcn) and was negative in one ss. conclusions except for ec and ss, cd is expressed in the majority of histological types of primary and metastatic tgcts. cd is useful to highlight minute foci of est, chc or stgc in ec. a tgct is to be taken into account in the differential diagnosis of a cd positive metastatic tumor of unknown origin. further studies are needed to evaluate the eventual significance of cd as a prognostic factor or as a potential therapeutic target in tgcts. introduction it is generally accepted that the prognosis of renal cell carcinoma (rcc) differs according to the histological type, and, whatever the histological type, the tumor stage and nuclear grade are considered the main prognostic factors. however, in many cases of conventional renal cell carcinomas (crcc), these parameters are insufficient to predict the clinical behaviour of these tumors. therefore, several studies have focused on the evaluation of new markers. the cd proteins form a broadly distributed family of cell surface adhesion molecules involved in cell-cell and cell-matrix interactions. de novo expression of cd s and its variant isoforms has been associated with aggressive behaviour in various tumours. the aim of this study was to analyse the prognostic value of cd s and cd v in renal cell carcinoma. materials and methods the expression of cd s and cd v was immunohistochemically evaluated on rcc: were crcc, papillary, cromophobe and collecting duct carcinoma. the expression was compared to usual clinicopathological parameters. results in normal renal tissue no staining was observed. the cd s molecule was upregulated in crcc ( %), papillary, one cromophobe and collecting duct carcinoma. only tumors were focally cd v positive. the statistical analysis showed the correlation between cd s expression and fuhrman nuclear grade (p< , ) as well as ki proliferative index (p< , ). conclusion the expression of cd s molecule appears to mediate a more agressive phenotype to rcc. amplification of cerbb expression in bone metastasis of prostatic cancer: a pilot immunohistochemical and cytogenetic study introduction her- -neu expression is reported to increase in androgen-independent prostatic cancer. consequently, it has been suggested that trastuzumab, an antibody targeting the extracellular domain of her- , could be used in this setting. the possibility of assessing her- expression by immunohistochemistry could be used as a rationale for the treatment of advanced cases with this drug. the aim of this study was to assess whether her- expression is increased in bone metastases of prostatic cancer compared to the respective primitive tumors, and to determine whether this overexpression could be related to gene amplification. materials and methods in this pilot study, primary tumor needle biopsies and bone metastases from patients diagnosed with prostatic cancer were immunostained wit c-erb-b antibody (dako, glostrup, denmark), and the results scored using a threetiered system. in addition, in a bone marrow sample from one of the cases, her gene amplification was investigated using fish. results there was a significant increase in her- expression in four cases, with the same level of expression in primary and metastatic tumors in the remaining three patients. in addition, fish showed no amplification of her gene. conclusion her- overexpression is not a constant event in prostate cancer metastatic to bone. preliminary evidence suggests that in cases with overexpression, it is not related to gene amplification. a larger study will be required, however, to definitively determine the real therapeutic meaning of these findings. introduction sgs are known to occur in association with a variety of hematologic and solid neoplasms. concerning rcc-associated sgs, only isolated case reports have been published. the aim of this study was to disclose the prevalence and clinical significance of sgs in a series of rccs from a single institution. clinicopathologic review of consecutive cases of rcc surgically treated at the hub between january- and march- . immunohistochemical staining with cd , panb and pant antibodies. results sgs were seen in cases, both within the tumor and/or in the nontumor tissue nearby. patients were females and males aged to (median ) years. tumors were conventional clear cell rccs and chromophobe rccs. there were pt , one pt and one pt b. two tumors were fuhrman grade and were grade . in each case, the lymphocytes in the sgs were predominantly t cells. one patient was already known to have a crest syndrome. in another one sarcoidosis was subsequently diagnosed. in the remaining no systemic disease has been found to date. conclusions sgs are found in about . % of rccs. morphology and immunohistochemistry allow no distinction between local sarcoid-like reactions and sarcoidosis. the clinical profile of the patients and the pathologic features of the tumors are not different from those of rccs unassociated with sgs. the finding of tumorassociated sgs must be reported to the clinicians in order to rule out a systemic granulomatous disease, thus avoiding misinterpretation of clinical symptoms or overstaging of tumors. metanephric adenoma in the kidney coexistent with paraganglioma in the bladder: a case report s seckin, i paker ankara numune teaching and education hospital, department of pathology, ankara, turkey we report a case of metanephric adenoma in the kidney and paraganglioma in the bladder in a year-old woman. the patient presented with hematuria. abdominal usg and bt revealed a mass in the lower pole of the kidney and in the posterior wall of the bladder. left nephrectomy and transurethral resection of the mass in the bladder were performed. the tumor in the kidney which measured x x cm. had a yellow to white cut-surface and welldefined margin. histological examination demonstrated a monomorphous population of small cells with bland cytology arranged generally in tubular and occasionally in papillary structures. no atypia and mitotic activity were present. immunohistochemically tumor was diffusely positive for ema, focally positive for pancytokeratin and negative for vimentin. the tumor in the bladder was characterized by well-defined nests of cuboidal cells with granular cytoplasm which were seperated by highly vascularized fibrous septa. sustentacular cells were demonstrated with anti-s protein immunohistochemically. we didn't encounter the coexistence of these two tumors in the literature. we think that it is a coinsidence. co-occurrence of extra-adrenal myelolipoma, renal cell carcinoma and thymoma -a case report k steplewska, d sabat, w zajecki department of pathomorphology, medical university of silesia, zabrze, poland a case of never reported in literature of co-occurrence of a very rare tumour -extra-adrenal myelolipoma (eaml) with two other neoplasms, was presented in the report. -year man after a short hospital stay due to heart ischaemic disease died with the symptoms of acute circulatory insufficiency. an autopsy, which confirmed clinical diagnosis, was performed. a tumour of the size x x cm, which compressed the heart and aorta, was found during the mediastinum autopsy. the tumour was covered with a sack, lobular, gray and beige at the cross-section with blood extravasation, necrosis foci and calcifications (histopathologic result -medullary thymoma). the compressed heart was moved to the middle, right side of the chest. in the adipose capsule of the left kidney, near the lower pole, an encapsulated solid fatty tumour of the size x x cm was found. the tumour was connected to the kidney. histopathologic result -myelolipoma. the tumour was composed of fat cells with normal marrow hematopoietic elements including megakaryocytes. the third tumour, cm of diameter, was found on the front surface of the right kidney (histopathologic result -multilocular cystic clear cell, renal cell carcinoma). none of the tumours was diagnosed during the patient's life. signet ring cell carcinoma of the prostate: pathologic and immunohistochemical analysis of two cases m kowanski, t zabkowski military medical institiute, warsaw, poland introduction signet ring cell carcinoma of the prostate is extremely rare and was first described by giltman in . to date, there have been cases reported in the literature. we evaluated two cases formaline fixed paraffine embedded tissue by histochemical (mucicarmine, alcian blue) and immunohistochemical methods (psa, psap) to confirm our histological diagnosis. results both our cases were high grade adenocarcinomas gleason score ( + ) and were positive for psa and psap. one case contain a small amount of acid mucin, but both were negative for neutral mucin. the combined results from our and from previously reported cases: psa positive in . % ( / ), mucicarmine stain positive in . % ( / ) and alcian blue stain positive in . % ( / ) of cases. conclusion signet ring cell carcinoma is variant of high grade adenocarcinoma of the prostate but results of histochemical and immunohistochemical staining are variable. the isup classification of urothelial tumors was followed by a modified who classification in . the purpose of this study has been to assess the value of both systems in the prediction of progression, in a large series of cases with detailed follow-up. material and methods "superficial" (pta + pt ) urinary bladder tumors are the subject of this work. all tumors were reassessed strictly adhering to published criteria. progression (increased grade or stage) was used as the end-point. results with a relative risk (rr) of for g , progression rr for g was . ( . - . ) and for g . ( . - . ) (p< . ). with a risk of for pta, rr for pt was . ( . - . ) and for pt . ( . - . ) (p< . ). when combining grade and stage, rr for pta (g + ) was . ( . - . ) and for pt (g + ) was . ( . - . ) (p< . ). conclusions strictly adhering to the who grading and staging criteria, both systems result in a very efficient prediction of progression of urothelial carcinoma. grouping g and g into a single high grade category does not improve these results. "superficial" infiltration (pt ) introduces a relevant risk of progression when restrictively identified, thus suggesting that pt should not be lumped with pta for therapeutic purposes. neuroendocrine expression in prostate cancer l velickovic , v katic , v savic , b djordjevic , s zivkovic institute of pathology, nis, serbia and montenegro military hospital, department of surgery, nis, serbia and montenegro introduction presence of neuroendocrine (ne) cells that are suggested to be important regulators of cell growth and differentiation represents uncommon finding in benign and neoplastic prostate epithelium. in order to correlate cellular expression with histological differentiation in benign epithelium and primary prostate cancer, expression of chromogranin a (cga) had been determined. materials and methods he and immunohistochemical analysis with antibody against cga was performed in order to determine the coexistence of ne differentiation in tissues of twelve patients with prostatic adenocarcinoma (pc). results ne differentiation was found in ( , %) tumors. among them, ( , %) had cga positive cells scattered or focally distributed, ( %) intermediated and intensive. there was a significant correlation between the extent of ne features and gleason score (p< , ). these data support the concept that ne differentiation in human prostate cancer has a positive correlation with histological differentiation, i.e. patients with gleason score > had higher cellular expression of cga. the p retinoblatoma gene protein and p expression in transitional cell tumors s ramón y cajal , c corbacho , v fernández, j guinea, c parada, r sánchez hospital vall d´hebron, madrid, spain clínica puerta de hierro. madrid, spain background the retinoblastoma family of proteins (p , p and p ) are implicated in cell cycle regulation, differentiation and apoptosis. p (retinoblastoma supressor gene) alterations seem to be correlated with worse prognosis in urothelial neoplasms, and the status of the other two proteins has been less studied. p mutations are usually associated with intranuclear accumulation of p protein, and have also been correlated with worse prognosis in urothelial neoplasms. design formalin-fixed, paraffin-embedded archival tissue from low-grade and high-grade transitional tumors was immunostained with polyclonal and monoclonal antibodies against the retinoblastoma family of proteins, and with monoclonal antibody against p protein. the avidin-biotin-peroxidase (abc) method was utilized with every antibody (dako, clone rb for p ; santa cruz, clone sc- for p ; santa cruz, clone sc- for p and dako, clone do- for p ). immunostaining was scored quantitatively by pathologists, following previously described criteria, to study p , p and p . nuclear and/or cytoplasmic location was determined by pathologists to study p . results p expression: among low-grade tumors, ( . %) showed nuclear positivity and ( . %) showed a granular cytoplasmic pattern of staining. among high-grade tumors, ( . %) showed nuclear expression and ( . %) showed a granular pattern of staining. p expression: among low-grade tumors, ( . %) showed positivity and among high-grade tumors, ( . %) stained positively. we found no stadistically significative differences regarding p and p immunohistochemical stainings. conclusion due to granular cytoplasmic pattern of staining for p is more frequent among high-grade transitional neoplasms, we propose that p granular cytoplasmic immunohistochemical pattern of staining may be considered a marker of tumor progression in transitional cell tumors. the prognostic value of p cytoplasmic positivity among low grade cases, as well as the prognosis of tumors with p overexpression and p granular cytoplasmic pattern will be discussed. are there any relationship between bellini duct carcinoma and urothelial cell carcinoma? ( ) aexudative -at , productive -at , and mixed -at ., from them ( ) infiltrative -at and destructive -at patients, aexudative type of inflammation was also diagnosed at patients with nonspecific defeat of prostata. patomorfological data's not always can help in diagnostic of tuberculosis of prostate it ties with patomorfose of tuberculosis under influence of treatment. cancerogenesis in prostate: ploidometric differential diagnostics avtandilov background the problem of unification in diagnostics of various prostate tumours and tumour-like lesions has gained a special significance in the modern oncology. aim: use the ploidometry research for studying the epithelial cell clones in the prostate, forming the different stages of cancerogenesis. methods computer ploidometry test was carried out for nuclei of epithelial cells in biopsy specimen of the prostate, taken from patients in different stages of cancerogenesis. histological preparations of micron thickness, stained by feulgen's technique, were subject of the research. nuclei's ploidy was defined by means of the computer image analyzer "imager-ch" ("avtan-san" software version). the integral brightness of nuclei of small lymphocytes, found in histological sections, was tested to define the "tissue ploidy standard" ( c), which, in its turn, was used for obtaining the data on ploidy of epithelial cell nuclei of the prostate gland. inter-phase cell nuclei of clones with normal and hyperplastic prostate gland, areas of prostate intraepithelial neoplasia (pin-i-low grade -and pin-ii-high grade) and adenocarcinoma in different stages of dedifferentiation (well, moderate, poorly) were the subjects of investigation. the research determined that while the cancerogenesis progressed, the proliferative activity (indirect type information) of prostate gland cells and the ploidy of nuclei naturally increased. introduction calcitriol and its analogues affect function of several normal and neoplastic cells, including cells of medullary thyroid carcinoma originating from parafollicular cells. in the cells expression of calcitonin gene takes place, yielding due to alternative splicing calcitonin (ct) and calcitonin gene related peptide (cgrp). the aim of this study was examination of effects of calcitriol and of its two analogues, pri- and pri- on proliferation of two cell lines in vitro and on expression of calcitonin gene. the studies were performed on mtc - (rat cell line) and tt (human cell line) cells originating from medullary thyroid carcinomas. the cells were cultured with calcitriol or its analogues at (- ) to (- )m for days. the estimated variables included: cell number, proliferation-associated antigens (ki- , pcna), ct and cgrp levels in medium (ria), amounts of the two hormones and of their mrnas in the cells (immunocytochemistry or hydridocytochemistry accompanied by image analysis). results calcitriol and its analogues exerted low antiproliferative effect, more evident in mtc than in tt cells. pri- affected production and secretion of the two hormones. evident correlation was noted in tt cells, positive for ct and negative one for cgrp. in mtc cells, the effect was slightly less intense. pri- exerted a similar effect in the two cell lines but only at higher concentrations of the analogue. on the other hand, calcitriol manifested its activity only in mtc cells. effects of studied substances were also examined on cgrp/ct ratio of secreted hormones, which reflected corresponding ratio of alternative splicing of ct gene transcript. in tt cells the ratio decreased in presence of either analogue and in mtc cells the effect was observed following culture with calcitriol and the two analogues. conclusions calcitriol and its analogues exert a weak antiproliferative effect and an effect on alternative splicing of calcitonin gene. allelotyping analysis of gep endocrine tumors mixed medullary-papillary carcinomas are rare neoplasms and must be distinguished from medullary carcinoma with entrapped follicles, papillary variant of medullary carcinoma and solid growth pattern of sclerosing variant of papillary carcinoma. these mixed tumors could arise from uncommited stem cells; it is also possible that these neoplasms could be collision tumors. the aim of our study was to show that these mixed tumors have some particular features. we studied cases of thyroid carcinoma and for diagnosis we used immunohistochemical analyses for thyroglobulin, calcitonin, cea, chromogranin and cytokeratin . we found cases of mixed medullary-papillary carcinoma. these mixed tumors are not so frequent but the admixture of papillary and medullary components confer a different prognosis and a potential response to radioactive iodine treatment. results only four hereditary ( / ) tumours showed genomic imbalances. mtc appeared as sporadic forms. in of the sporadic tumours we detected dna sequence copy number changes (mean: per tumour, range: - ). the minimal common regions for the most frequent gains were narrowed down to q -q , p , and q ( percent), q -q , p , and q ( percent), p -p , p . -p , and q ( percent), and p pter, q -q , and p . -p ( percent). eight high-level amplifications were observed in four samples. p was affected twice. the minimal common regions for the most frequent losses were observed for p ( percent), and q ( percent). conclusion only limited genomic alterations could be detected by cgh for hereditary mtc, which share a germline mutation of the ret proto-oncogene as initial step of cancerization. additional genetic alterations, which are responsible for the progression of these tumours, are not identified yet. in contrast, sporadic mtc revealed a recurrent pattern of genomic imbalances. our data are in accordance in part with the few cytogenetic data, which are reported in the literature and can help to rule out parts of the genome on which further studies should focus on. immunohistochemical analysis of tumor infiltrating immunocytes in thyroid tumors v zolota, p aroukatos, s sidira, d koumoundourou, d papachristou, cd scopa dept. pathology, univ. patras med. school, patras, greece introduction the presence of host inflammatory cells within or at the periphery of human tumors has long been recognized and is commonly viewed as representing a host tumor immune response. in the thyroid gland, the occurrence of chronic lymphocytic thyroiditis (clt) in thyroid cancers has been reported and considered by some authors as a favorable prognostic sign. the inflammatory cell population in consecutive thyroid tumors ( papillary, occult, follicular, myeloid carcinomas and follicular adenomas), accompanied with chronic non-specific thyroiditis, were characterized imunohistochemically, using a panel of monoclonal antibodies against t-cells (anti-cd , anti-cd , anti-cd ), b-cells (anti-cd ), macrophages (anti-cd ) and dendritic cells (anti-s- ). the extent of lymphocytic infiltration was graded as: +(subtle), ++(moderate) and +++(intense and diffuse lymphoid aggregates). results were similar in cell block, although involucrine was negative in three pc. expression of mib- and p is variably detected in benign and malignant proliferative lesions. interestingly, galectin- , ck- and involucrin are invariably detected in papillary carcinomas, although heterogeneous positive expression was observed into the same lesion. conclusions our findings show that galectin- (p< . ), ck- (p< . ) and involucrin(p< . ) are useful to identify papillary carcinoma from other thyroid lesions; however, heterogeneous positive pattern expression is not useful for preoperative diagnostic of conventional cytology. introduction pheochromocytomas are rare neuroendocrine tumors that are highly vascular. their malignancy is extremely difficult to estimate on the basis of histopathological features. vascular endothelial growth factor receptor (vegfr- ) is a marker for lymphatic endothelium. its ligands vegf-c and vegf-d are expressed in many neuroendocrine tissues. our aim was to investigate the expression and the potential role of vegf-c, vegf-d, and vegfr- in various pheochromocytomas. materials and methods thirty-three pheochromocytomas, six of them metastasized, were studied using immunohistochemistry. thirteen tumors exhibited histologically suspicious features, such as necrosis, mitosis count over / hpf, vascular or capsular invasion, but they not metastasized, and were thus called borderline tumors. results and conclusions vegf-c immunohistochemical positivity was found in most pheochromocytomas. the expression of vegf-c was heterogenous and varied also within different tumor groups (benign, borderline, and malignant tumors). however, it tended to be stronger in extraadrenally located tumors. vegf-d positivity was also found in most tumors studied ( / ). interestingly, all malignant tumors (n = ) were totally negative for vegf-d. vegfr- expression was found in out of tumors, but the staining was mostly weak. the expression of vegfr- did not seem to correlate with the expression of vegf-c or vegf-d. in conclusion, vegf-c, vegf-d, and vegfr- are expressed in various pheochromocytomas, however, the diagnostic value of these markers needs further investigations. mixed corticomedullary tumor of the adrenal gland. a case report corticomedullary mixed tumors of the adrenal gland are quite rare, with only seven well-documented cases reported in the literature. we report the light microscope and immunohistochemical features of one case of this rare tumor. the patient is a -year-old woman who presented with hypertension, hirsutism, gain weight and ammenorhoea of -month duration. the surgically resected specimen consisted of a well-circumscribed, single adrenal mass, weighing , gr, and mm in diameter, surrounded by a rim of uninvolved adrenal cortical tissue. paraffin-embedded cut sections were stained by both hematoxylin-eosin and pas.the expression of inhibin, melan a, chromogranin a, synaptophysin, s- protein and acth was examined using the pap method, with appropriate antibodies being applied. the tumor was composed of cords and nodules of adrenal cortical cells intimately admixed with pheochromocytes. immunohistochemical investigations highlighted these two cellular components. the adrenal cortical cells revealed inhibin and melan a immunopositivity, whereas the pheochromocytes were strongly reactive with chromogranin a, synaptophysin, and acth, and the sustentacular cells with s- protein. thus, we report one additional case of mixed corticomedullary tumor of the adrenal gland. introduction the study of apoptotic markers seems to be important in understanding the pathogenesis of chronic inflammatory processes of the thyroid gland. aim: intensity determinations of bcl- and fas immunohistochemical reactions with the quantitative assessment of bcl- and fas gene expressions in inflammatory affected thyroid glands. the specimens were taken from women aged to . the type of inflammation and the intensity of lymphocytic infiltration were assessed according to the mizukami and the waterhouse and doniach classifications, respectively. the expression of bcl- and fas antigens was determined immunohistochemically. moreover, bcl- and fas genes were quantitatively analysed by rt-pcr assay using taqman technology. results intensity of immunostaining for bcl- antigen in patients with chronic thyroiditis was stronger than in patients without lymphocytic infiltration. an increase in the intensity of lymphocytic infiltration did not affect bcl- mrna levels. fas antigen got stained in subjects with mixed inflammation; a presence of oxyphilic cells enhanced the stain reaction. in the case of oxyphilic thyroiditis, the changes in fas antigen were accompanied by a concomitant increase of fas mrna levels. small differences, between various samples of the same specimen, in bcl- and fas mrna and protein levels were found in patients with focal thyroiditis. these differences were related to the intensity of lymphocytic infiltration. conclusions the thyroid gland is characterised by a high degree of antiapoptotic activity. each type of thyroiditis has its own characteristic pattern of bcl- and fas expressed as mrna and as protein. the use of galectin- and cytokeratin in differential diagnosis of thyroid tumors with follicular growth pattern a ryska aim to study the use of galectin- (gal) and cytokeratin (ck ) in differential diagnostics of thyroid tumors with follicular growth pattern. material and methods a series of thyroid lesions ( follicular adenomas (fa), follicular carcinomas (fc), follicular variants of papillary carcinoma (fvpc)) was studied retrospectively by immunohistochemistry using monoclonal antibodies. results the staining intensity of either antibody was evaluated as positive or negative using different thresholds ( , and % of positive cells). generally, the intensity of staining of gal was much higher than that of ck . using % threshold, / fa showed positivity of gal and none was positive in ck . in fc, / tumors were gal positive, / were also ck positive. among fvpc, all cases were gal positive and / were also ck positive. using % threshold, only / fa was gal positive, none was ck positive. among fc, however, all tumors were both gal and ck negative. on the other hand, / of fvpc were gal positive and / were ck positive. the sensitivity, specificity, negative and positive predictive value of gal were . ; . ; . ; . for % threshold and . ; . ; . ; . for % threshold, respectively. for ck it was . ; . ; . ; . for % threshold and . ; . ; . ; . for % threshold, respectively. conclusions the use of gal and ck may be helpful in differentiating fvpc from benign lesions. however, the use of these markers in differential diagnostics of fc from fa is of little value. moreover, due to low intensity of staining, its use in preoperative diagnostics (e.g. in fnac cytoblock specimens) seems to be questionable. adrenal cortical adenoma in association with cushing's syndrome -case report introduction morphological feature of adrenal cortical adenoma by itself doesn't allow reliable distinction between tumors associated with any particular endocrine syndrome. without being aware of the clinical setting and/or endocrinological data, it may be impossible to distinguish them from an incidental nonhyperfunctional macronodule. the aim of this investigation was to represent the only case of adrenal cortical adenoma in association with cushing's syndrome in our material. we have analyzed the only case of adrenal cortical adenoma with cushing's syndrome according to its morphological changes, laboratory data, ct-scan as well as mri of adrenal gland. results gross examination showed a small ovoid adenoma. on section, it appeared yellow to golden yellow with dark brown foci, blood and degenerative changes. microscopically, tumor contained cells with pale, lipid-rich cytoplasm, compact eosinophilic cytoplasm, arranged in trabeculae, short blunt cords, as well as in rounded nests. nuclei were somewhat vesicular with a single small dot-like darkly stained nucleolus. discussion and conclusion our data indicate that being aware of characteristic histologic feature in terms of architectural pattern and cell type for cortical adenoma associated with cushing's syndrome, this could be the purpose of more comprehensive discussion. correlation of histopathology and sequential analysis of gene expression in follicular thyroid neoplasms sj diaz-cano , , s arif , a blanes barts and the london school of medicine, university of london, uk university of malaga school of medicine, malaga, spain background the expression profile and diagnostic relevance of nuclear features, inflammation, and stromal changes have not been systematically evaluated in follicular thyroid carcinomas (ftc). design we selected ft neoplasms ( adenomas, minimally invasive carcinomas, widely invasive carcinomas, and anaplastic carcinomas), classified using standard criteria. histological variables including anisokaryosis, chromatin pattern, nucleolus, nuclear pleomorphism, nuclear/cytoplasmic ratio, necrosis, stromal changes, and tumor interstitial lymphocytes (til) were studied by histological diagnosis (significant if p< . ). oligo(dt)-primed double strand cdna was produced from total rna, and libraries were produced from normal thyroids and ftc. sequential analysis of gene expression (sage) was performed (ftc/control expression factor≥ , significance≤ . ). results til were absent in / neoplasms. minimally invasive carcinomas were distinguished from adenomas by conspicuous nucleolus, increased nuclear/cytoplasmic ratio, and coexistence of apoptosis and myxoid changes in adenomas. the most specific variables of high-grade carcinoma were coagulative necrosis, and nuclear hyperchromatism and pleomorphism. ftc sage showed ubiquitin c and sequestosome down-regulation, and tumor protein translationally controlled and malate dehydrogenase up-regulation. this sage profile correlated negatively with proinflammatory molecules expression (interleukin- beta, chemokine xc-receptor , interferon-induced transmembrane protein , protein tyrosine phosphatase c), brca , and protein phosphatase . the correlation was positive with proliferation markers (myb, mitogenactivated protein kinase , cyclin-dependent kinase , brca /cdkn a interacting protein, and ras oncogene family). conclusions proliferation up-regulation and apoptosis downregulation results in prominent nucleolus and high nuclear/ cytoplasmic ratio for low-grade carcinomas and hyperchromatism and nuclear pleomorphism for high-grade carcinomas. tumor down-regulation of proinflammatory molecules explains til absence. papillary carcinoma of the thyroid with bone formation. a case report introduction papillary carcinoma is by far the most common type of thyroid malignancy. however, ossification in papillary carcinoma is very rare. a case of papillary carcinoma of the thyroid metastatic to cervical and supraclavicular lymph nodes with associated bone formation and extensive calcification is presented. case report a year-old male with a history of gastric carcinoma was admitted to hospital presenting with lumbal pain. a computed tomography scan revealed a calcified nodule, measuring in mm diameter in the thyroid. total thyroidectomy and modified neck dissection were performed. the thyroidectomy specimen showed a well circumscribed, calcified, rock-hard nodule measuring x x cm. histologic examination of the hard nodule after decalcification showed spicules of bone formation and papillary carcinoma. foci of metastatic papillary carcinoma with bone formation were also seen in the cervical and supraclavicular lymph nodes. there was also bone marrow formation both in the thyroid nodule and in the metastatic lymph nodes. immunohistochemically, the tumour cells were positive for thyroglobulin. conclusion ossification in papillary carcinoma of the thyroid is an unusual finding. the mechanism of bone formation is not clear. the presence of ossification both in primary and metastatic tumoral masses suggests that ossification is not a dystrophic process in the preexisting benign thyroid tissue but somehow related to the papillary carcinoma in the present case. introduction c-kit gene encodes for a transmembrane tyrosine kinase receptor which is expressed in a variety of human normal tissues and malignancies, being small cell lung carcinoma one of the most frequent among the latter group. the search for c-kit expression in human tumors bears clinical implications since several tyrosine kinase inhibitors have been proposed in the treatment of c-kit positive tumors. the aim of our study was to investigate c-kit protein expression in a series of merkel cell carcinomas (mcc) and of other extrapulmonary poorly differentiated neuroendocrine carcinomas (pdnecs). merkel cell carcinomas (mcc) of the skin (from patients, of them with follow up information available), and cases of extrapulmonary pdnecs from different sites (bladder - cases, colon - cases, gallbladder and pancreas - cases, parotid - case) were analyzed by means of immunohistochemistry for c-kit protein expression. only a membranous staining was considered specific, and scored according to the percentage of positive cells. results c-kit protein was demonstrated in / ( %) mcc, and in / ( %) of other pdnecs. in mcc, a correlation, slightly below statistical significance (p= . ), was observed between the presence of c-kit expression and clinically aggressive behaviour. conclusion our data indicate that c-kit expression may play a role in the growth regulation of extrapulmonary pdnecs. therefore this group of tumors may be considered as a possible target for tyrosine kinase inhibitors therapy. carcinoid tumors in the thyroid gland. primary or metastatic? report of two cases m volante , m bongiovanni , p filosso , g bussolati , m papotti dept. biomedical science and human oncology university of turin, turin, italy dept. thoracic surgery university of turin, turin, italy introduction the occurrence of well differentiated endocrine tumors (carcinoid) in the thyroid gland is unfrequent and may represent both a differential diagnostic problem with medullary carcinoma, and a potential pitfall in the searching for its primary or metastatic origin. our aim was to determine the differential morphological and immunohistochemical profile of two cases of carcinoid tumors localized in the thyroid -one metastatic from the lung, and the other of unknown origin. materials and methods the first collected case had a clinical history of an atypical lung carcinoid diagnosed two years before, while the other lacked a clinical, instrumental and laboratory history suggestive of a possible primary carcinoid elsewhere. paraffin embedded material was histologically reviewed and analyzed by immunohistochemistry for thyroglobulin, calcitonin, cea, chromogranin a, s- , ttf , and ki- . results the first case (f/ ) presented as multiple nodules in both lobes, composed of poligonal eosinophilic cells arranged in the typical organoid pattern. foci of necrosis were present. the morphological features overlapped with those of the primary lung tumor. the second case (m/ ) presented as a single nodule in the left lobe, morphologically resembling typical carcinoid without necrosis. both cases were negative for thyroglobulin, calcitonin, s- and cea, positive for chromogranin a and ttf , and low proliferating (ki- < % in both). conclusion our data suggest that, even in the absence of a clinically detected primary tumor, the occurrence of a carcinoid tumor in the thyroid gland should be firstly considered metastatic in origin, the lung being the major candidate for the primary localization (as determined by ttf immunostaining). telomerase expression and proliferation activity in gastroenteropancreatic tumours s vural, y kapran, m gulluoglu, u cevikbas, f dizdaroglu university of istanbul, istanbul medical faculty, department of pathology, istanbul, turkey intruduction gastroenteropancreatic endocrine tumours have a variable prognosis and the prediction of biological behavior based on histopathology is not always possible. telomerase is a reverse transcriptase that synthesis telomere dna to stabilize telomere length.telomerase activity is increased in different human cancers. the aim of this study was to determine whether the expression of telomerase (htert) correlates with the histological typing of endocrine tumours and ki- proliferation index. material and methods formalin-fixed, paraffin-embedded tissue sections from gastroenteropancreatic endocrine tumours and normal pancreas were stained immunohistochemically for human telomerase reverse transcriptase (htert) and ki- antigen. results cases were diagnosed as well-differentiated endocrine tumour, were well-differentiated endocrine carcinoma and were poorly-differentiated endocrine carcinoma according to who classification of endocrine tumours. the percentage and intensity of positive neoplastic cells were assessed for each case. expression of htert was observed in one well-differentiated endocrine tumour ( %), in well-differentiated endocrine carcinomas ( . %) and in poorly-differentiated endocrine carcinomas ( %). there was a significant correlation between the expression of htert and histopathological diagnosis (p< . ). also the correlation of htert expression and ki- index was statistically significant (p< . ). conclusion immunohistochemical detection of htert expression in gastroenteropancreatic endocrine tumours may be a helpful tool in addition to morphological findings and ki- index in predicting the malignant potential of these tumours. proliferation, p expression and apoptosis in pituitary adenomas: relationship to tumor behaviour introduction pituitary adenomas are known to vary considerably from the stand point of their intrinsic aggresiveness that might imply a different therapeutical approach. the aim of this study was to estimate the relationship between proliferative activity (ki ), p expression, apoptosis and pituitary tumor behaviour. materials and methods immunohistochemical analysis of ki and p expression were performed in paraffin-embeded pituitary adenomas: functioning; non-functioning; invasive adenomas. apoptotic index (ai) was determined in adenomas by the in situ end-labeling technique (tunel). results ki expression in all adenomas was . % (significantly higher in functioning comparatively with non-functioning pituitary adenomas - . ± . % versus . ± . %). we noticed a positive correlation between the proliferative activity and the tumoral invasiveness (ki labeling index . ± . % in invasive and . ± . % in non-invasive adenoma). p nuclear positivity was identified in % of the invasive adenomas and only in % noninvasive adenomas, with a positive correlation between p and proliferative activity (ki : . ± . in p positive versus . ± . % in p negative tumors). apoptosis was found in % of tumors, higher in some of the invasive ones, with a positive correlation between the proliferation rates and apoptotic indices (ai: . ± . in total versus . ± . in invasive pituitary adenomas). also, some differences were recorded in functioning and non-functioning adenomas (ai: . ± . versus . ± . ). conclusions the data suggest that the assessment of proliferation, p expression and apoptosis might be used to evaluate tumor behaviour and susceptibility of adenomas to therapy. differentially expression of nesp in langerhans islets of the human pancreas and overexpression in endocrine pancreatic tumors nodules, while others recommend to do it only if clinical changes are present. this study was done to determinate the usefulness of systematic repetition of fna in patients with benign cytology result in the initial fna. materials and methods data were collected from patients referred to endocrinology service for evaluation of thyroid nodular disease between and . all patients underwent repeated fna of thyroid nodule. age of patients was . + . years, . % were females, % had uninodular goiters, nodule size was . + . cm. time elapsed between both fna was . + . months. results at second fna, aspirations had benign cytology, were non diagnostic, suggestive of follicular neoplasm and had malignant cytology results. excluding non-diagnostic aspirations, we get % of discordant results. uninodular goiters as compared to multinodular have a higher rate of discordant results. we did not find other variables between groups of concordant and discordant results. twenty-two patients with benign cytology underwent thyroid surgery, without any histological malignant result. conclusion -uninodular goiters with an initial benign cytology have a significant rate of discordant results after repetition of fna. however, in % of these cases the first diagnosis was based on limited material. -our results show that cases of thyroid carcinoma out of patients with nodular goiter were misdiagnosed by initial fna cytology. therefore we recommend systematic repetition of fna cytology in all patients with uninodular goiter. immunocytochemistry in fna biopsy material objective assessing diagnostic value of immunocytochemical methods in destained cytology smear specimens prepared from fine needle aspiration (fna) biopsy material. material and methods investigated material comprised samples from fna biopsies that were diagnosed in - . alcohol-fixed cytology smears were typically stained with hematoxylin-eosin. for immunocytochemical studies, preparations were first destained using alcohol series. following this, chosen antibodies were used either separately, or as a panel ckmnf, ema, lca, tg, ct, hmb- , s- , chr, nse, er, pr, cd (dako lsab system, peroxidase). results immunocytochemical staining was helpful in % of cases. initial diagnosis was confirmed in cases. immunocytochemical staining was important particularly in confirming diagnosis of poorly differentiated neoplasms. it was also helpful in identifying the primary site of metastatic carcinoma in fna cases. in ( %) cases diagnosis based on the investigated method failed. precise diagnosis was not possible either due to negative staining with single marker/panel or when only single cells were stained positive. conclusion immunocytochemical methods in destained smears allow basic as well as discriminating diagnosis even in cases of poor availability of cytologic material. fine needle aspiration of lesions in the thyroid bed. e chmielik, b szczesniak-klusek, d ponikiewska, e stobiecka, d lange oncology center, department of pathology, gliwice, poland introduction clinical suspition of recurrent thyroid carcinoma based on ultrasound examination of thyroid bed with correlation to increased thyreoglobulin level or calcitonin level and/or radiomarker uptake on scintigraphy can be supported or dismissed by fine needle aspiration biopsy (fnab). the aim of this study was assesment of specificity and possitive predictive value of ultrasound-guided fnab of the lesions in the thyroid bed after total thyroidectomy for diagnosis of recurrent thyroid carcinoma. material and methods ultrasound guided fnab of thyroid bed lesions of diameter . - . cm performed by pathologist in patiens after thyroidectomy. immunohistochemistry stain for calcitonin was performed using dako antibody in cases. the recurrent papillary carcinoma was diagnosed in ( . %) patients, the recurrent follicular carcinoma in ( . %) patients, hürtle cell carcinoma in ( . %) patients and medullary carcinoma in ( . %) patients (immunocytochemistry stain for calcitonin confirmed diagnosis in patients). pathologic correlation was able in cases: postoperative examinations confirmed recurrent carcinoma, and cytologic diagnoses were falsenegative. in the remaining patients granulation, purulent inflammation and benign lesions were diagnosed. in ( . %) cases material was nondiagnostic. specifity of the method was . %, possitive predictive value . %. conclusions ultrasound-guided fine needle aspiration biopsy performed by pathologist is valuable and specific method in the diagnosis of recurrent thyroid carcinoma in thyroid bed. introduction fine-needle aspiration (fna) is one of the most useful methods in the diagnosis of benign goiter. in consideration of the goiter; it is the most frequent lesion in the thyroid tissue, significance of fna as a diagnostic method become greater. material and methods in cases diagnosed as goiter we analyzed: ) sex distribution, ) age distribution, ) correlation between clinical and cytological diagnoses and ) goiter classification in accordance with cytological characteristics. results goiter was five times more frequent in females than males ( women, men). the majority of the patients were between and . the youngest was , and the oldest years old. almost % of cytologically diagnosed goiters had the same clinical diagnosis, in only . % of all patients tumor was suspected clinically. we confirmed high correlation between clinical and cytological diagnosis. according to the cytological characteristics all goiters were classified in categories: goiters with and without degenerative changes. hi-square test confirmed statistically significant difference in the presentation of such goiters (hi-square test= . ; p< . ). fna permits a substantial reduction or even elimination of other diagnostic procedures, such as imaging, with consequent saving in time and money. furthermore, benign cystic lesion may be cured by fna (a diagnostic and unexpected therapeutic value). samples, furthermore it is difficult to predict at patient's bedside which ancillary methods, if any, will be necessary. the aim of this study was to demonstrate the value of a universal short-term storage cell medium in processing fnab samples for different ancillary methods. materials and methods after diagnostic smear preparation, the needle and syringe were washed out with the short-term storage cell medium in fnab samples, obtained from to . microscopic smear analysis determined the choice of ancillary method used. cell suspensions were then processed as required for each individual ancillary method. results we used ( %) fnab samples stored in the medium for ancillary methods, while samples ( %) were discarded due to the clear morphology-based diagnosis or sample inadequacy. immunocytochemistry was performed on samples. for various membrane, cytoplasmic and nuclear antigens, adequate immunoreaction without background was obtained in samples stored in the medium overnight ( ) or over the weekend ( ). immunophenotyping by flow cytometry was performed in fnab samples where up to lymphoma antigens per sample were successfully determined when the samples were stored in the medium overnight. high quality flow cytometric dna histograms were obtained from all fnab samples suspended in the short-term storage cell medium. conclusion the short-term storage cell medium that we have been using, allows effective and easy processing of fnab samples for several ancillary diagnostic methods. it preserves cell morphology, various membrane, cytoplasmic and nuclear antigens as well as dna content. fine needle aspiration cytology of ovarian lesions introduction an improved understanding of the pathogenesis of cervical hpv-induced lesions has significantly changed the approach to diagnosis and treatment. the pap smear is still the most effective cervical cancer screening test. however, molecular testing for the presence of high risk hpv-dna increases the ability to identify women with an increased risk for cancer and true cancer precursors. the aim of the present study was to evaluate high risk hpv-dna test systems in cervical cytological material and the correlation with pap smear cytology. materials and methods we analysed routinely processed cytological cervical specimen. material was taken consecutively for pap smear cytology and for hybrid capture (hc) hybridisation assay (digene). the cytological report showed mild to severe dysplasia ( cases were scored as pap i/ii). after performing the hc-assay, dna was extracted from the same sample. hpv-dna detection with conventional pcr using consensus primer (my /my ), followed by subtyping of hpv and was carried out. from the specimens showing dysplasia ( . %), koilocytosis has been observed in % of pap smear cytology. hpv-high risk positivity with the hc hybridisation assay was detected in % and % showed positivity for hpv-dna content with conventional pcr. subtyping of hpv-positive cases resulted in hpv- positivity in %, . were positive for hpv and . % showed a coexistence of hpv and . conclusion our results indicate that hpv-detection with highly sensitive and widely used molecular methods show a good concordance with cytological findings. fine needle aspiration findings of two different types of gastrointestinal stromal tumor mg gulluoglu , d yilmazbayhan , y kapran , k acarli , f dizdaroglu istanbul university, faculty of medicine, department of pathology, istanbul, turkey istanbul university, faculty of medicine, department of general surgery, istanbul, turkey introduction gastrointestinal stromal tumors (gist) are the most common mesenchymal tumors of the gastrointestinal tract, derived from interstitial cells of cajal. the cytologic features of these neoplasms in fine needle aspiration (fna) have been described in several articles. aims: cytologic and histologic features of two gist cases one of which presented with liver metastasis and other with an intrathoracic mass mimicking lung carcinoma radiologically are presented comparatively. sixty year-old male patient with a previous history of gastric gist has had an fna from a liver mass. in the cytologic examination, epithelioid cells with round-oval nuclei, large cytoplasms and indistint cytoplasmic borders, forming three dimentional groups with thin fibrovascular stroma were observed. the other patient was a seventy two year-old female who had an fna from an intrathoracic mass. branching fascicles of spindle cells with indistinct cytoplasmic borders in a necrotic background were observed in the cytologic examination. mesenchymal origin was verified by vimentin immunopositivity. by detailed computerized tomographic evaluation, it was revealed that the mass originated from the gastroesophageal junction. both tumors were resected and histologically examined. cytologic and histologic findings correlated including immunocytochemical and immunohistochemical results which were positive cd and cd , and negative s and smooth muscle aktin immunoreactions. conclusion as they share common histomorphological features with other types of mesenchymal tumors of the gastrointestinal tract, cd immunopositivity is the only diagnostic marker to differentiate these tumors from other tumors of mesenchymal origin. cytologic diagnosis also requires detection of this marker in the neoplastic cells. peritoneal fluid cytology of sarcomas k zachou , e tzartza , a orologa , a skenderi , k patsiaoura , e kostopoulou , k boni hippokratio hospital of thessaloniki dept. cytopathology, thessaloniki, greece hippokratio hospital of thessaloniki dept. pathology, thessaloniki, greece material and methods peritoneal fluid smears of female patients of all ages, were studied. results cases were cytologically diagnosed as malignant ( , %), the majority of which was characterized as adenocarcinomas. histological diagnosis was available for cases. sarcomatous component was reported in only cases, cases were malignant mixed müllerian tumors (mmmt), one was leiomyosarcoma, one rhabdomyosarcoma and one liposarcoma. the cytological findings in the equivalent cases were « abnormal» neoplastic cells in isolation, with enlarged and hyperchromatic nuclei. adenocarcinoma cells were identified in peritoneal fluid smears of patients with mmmt. conclusion cytological diagnosis of sarcoma is rare. even when these «abnormal» cells are found, it is very difficult to give a definite diagnosis of sarcoma, based directly on the cytomorphological characteristics of peritoneal smears. however, such a possibility should be kept in mind by the cytopathologist to avoid missing the diagnosis. r bokun, z tatomirovic, v skuletic institute of pathology, military medical academy, belgrade, serbia and montenegro purpose the aim of this study was to show that imprint cytology is a valuable method in the evaluation of bone tumors as well as to determine its diagnostic accuracy in primary and secondary bone tumors. materials and methods from thirthy three surgical specimens of bone tumor imprints were made, air-dried and stained by may-grunwald-giemsa method. the cytologist gave detailed description of the smears, concluded whether the lesion was malignant and suggested a final diagnosis if it was possible. results were compared with the corresponding histopathologic diagnoses. results out of cases with primary malignant bone tumors (chondrosarcoma , ewing sarcoma , ameloblastoma , synoviosarcoma , malignant osteoclastoma , malignant fibrous histiocytoma , malignant schwannoma , leiomyosarcoma ) the cytologist recognized malignancy in of them and in suggested the final diagnosis. in patients with metastases (squamous cell carcinoma , anaplastic carcinoma , malignant melanoma ), the cytologic and histopathologic diagnoses correlated in all cases. conclusion cytologic analysis of the imprints of bone tumors is valuable as early orientation for the clinicians since the final histopathologic diagnosis needs time because of the decalcination procedure. the correlation of cytologic and histopathologic diagnoses was better for the secondary bone tumors because cytologist was more familiar with their morphology. the value of combined fine needle aspiration and needle core biopsy in diagnostic assessment of pancreatic tumors p sevastiadou , p xirou , s barbanis , i efstratiou , e athanasiou , i tsitouridis papageorgiou general hospital, department of cytology, thessaloniki, greece- papageorgiou general hospitaldepartment of cytology, thessaloniki, greece papageorgiou general hospital, department of radiology, thessaloniki, greece introduction due to the anatomical location of the pancreas, it is often difficult to obtain sufficient diagnostic material from pancreatic lesions. the aim of this study is to present the results and our experience from ct guided fine needle aspiration (fna) and needle core biopsy (ncb) from pancreatic tumors. materials and methods fna using gauge needles and ncb using and gauge needles were performed in patients with pancreatic tumors. both procedures were done under computerized tomography guidance, without complications. twenty one tumors involved the body and the tail of the pancreas results the diagnosed cases were adenocarcinomas, neuroendocrine tumors, lymphoma and pseudocysts. diagnosis was reached in cases by both fna and ncb and in cases by ncb only. other cases were "diagnosed" as suspicious for malignancy by fna only. finally in cases no diagnosis was reached by both methods, due to insufficient material. conclusion according to our experience, we believe that the combination of fine needle aspiration with needle core biopsy of pancreatic tumors under ct guidance improves the diagnostic accuracy. value of fine needle aspiration cytology in subtyping mucinous breast carcinoma background subtyping of mucinous breast carcinoma into pure and mixed type has prognostic implications. aims of the study were to evaluate a) the usefulness of fine needle aspiration biopsy (fnab) in differentiation between pure and mixed mucinous carcinomas, and b) to correlate key cytological features with survival. material and methods we reviewed fnab of women with mucinous breast carcinoma treated at the institute of oncology from to . key cytological features analysed were cellularity, amount of mucin, presence of capillaries, cell pattern, cytoplasmic characteristics and nuclear pleomorphism. type of mucinous carcinoma was determined histologically after resection of the tumour. association of cytological features with cancer specific survival was evaluated by univariate and multivariate analysis. results histological analysis revealed cases ( %) of pure and cases of mixed mucinous carcinoma. nuclear pleomorphism and amount of mucin in fnab differed significantly between the two subtypes of mucinous carcinoma. whereas cellularity of cytological samples, presence of capillaries, cell pattern and cytoplasmic characteristics were not related to prognosis, nuclear pleomorphism and absence of mucin in cytological samples were associated with poorer cancer specific survival. furthermore, the absence of mucin in fnab samples retained independent prognostic significance also in multivariate analysis. conclusions higher grade of nuclear pleomorphism and small amount or even absence of mucin in fnab favor the diagnosis of mixed mucinous cell carcinoma and are features associated with poorer prognosis. cardiac lipoma in a mexican patient -multidisciplinary approach in a right atrium tumor j nuncio , g najera-hernandez , g garcia-ramos pathology department, instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico internal medicine and neurology departments, fundacion medica sur, mexico city mexico primary tumors of the heart are rare. lipomas account for approximately % of all neoplasms of the heart and represent % of benign cardiac tumors. symptoms may be produced by large lipomas, but more often the patients are asymptomatic and the diagnosis is made by chance. recently, the ready availability of high-definition noninvasive imaging, such as echocardiography, computed tomography, and magnetic resonance image, has allowed easier diagnosis. therefore, more cases have been reported. to date up to cases of lipoma have been described. this case describes the multidisciplinary approach to the diagnosis of this rare entity with the use of open heart biopsy from right atrium, to sustain the correct diagnosis. after exhaustive internet-based search, this is the first case reported in latin-american literature, a condition not previously informed from in vivo patient in mexico. the cardiac hydatid cysts are rare cases, representing , - % from all human hydatid cysts. they are commonly located in the left or right ventricle and exceptionally in the interventricular septum. because the symptoms and clinical signs of the cardiac hydatid cysts are non-specific, the diagnosis may be difficult. material and methods we report an intramyocardial hydatid cyst, diagnosed at cardiology center iasi, with an early history of atypical chest pain, the death occuring through anaphylactic shock, secondary to the hydatid cyst endocavitary rupture. the study was made on necropsiy specimens, and the diagnosis was established by using routine morphological techniques. results the gross examination evidentiated an hydatid cyst of about cm in diameter, communicating through a small orifice with the left ventricular cavity and through a slit-like fissure with the right ventricular chamber. the systemic embolism was revealed, only grossly, by the presence of small "hydatid daughters" at the level of the ascending aorta and the pulmonary embolism was confirmed only histologically, by the presence of anhiste membrane emboli in the peripheral pulmonary vessels. the study revealed the morphological aspect defining hydatid cyst, emphasising the necessity of an early diagnosis due to a high risk of death through complications. a case report of arrhytmogenic right ventricular dysplasia -cause of sudden death c borza, d butcovan, c grigoriu, v astarastoaie university of medicine and pharmacy iasi, romania arrhytmogenic right ventricular dysplasia (arvd) is a new form of cardiomyopathy probable more frequent than commonly reported. arvd is a heart muscle disorder of unknown cause that is characterized clinically by an electrical instability associated with secondary ventricular arrhythmia and pathologically by fibrofatty replacement of the right ventricular myocardium. it is a rare but important cause of sudden unexpected cardiac death in young, otherwise healthy persons, especially those that are exercise related. we report a case of cardiac sudden death in a years old man without personal and familial cardiac history. the study was made on a necropsic biopsy specimens from the medico-legal laboratory. the diagnosis was made using routine histological techniques. grossly, we revealed a fibro-fatty right and left ventricular wall myocardial replacement and a focal white thickening of the left ventricular endocardium. histologically, we evidentiated a fibro-fatty myocardial replacement of the right and left ventricle suggesting an arrhythmogenic ventricular dysplasia of cardiomyopathic type and an endomyocardial fibrosis supported by the presence of a subendocardial fibrosis, affecting internal one third of the myocardium. there were no evidence of coronarian and valvular lesions and hypertensive cardiac changes, as well. the study revealed the morphological features defining a fibro-fatty myocardial replacement and an endomyocardial fibrosis evidentiating the case particular features, as well. registered. repeated biopsy revealed ongoing mc in / pts, latehealing mc in / pts, focal-healing mc in / pts, healed mc in / pts, and dilated cardiomyopathy in / pts. amount of cellular infiltrate, degenerative and/or necrotic changes, and fibrosis was reduced in , , and pts, respectively, remained the same in , , and pts, respectively, and increased in , , and pts, respectively (p< . , between groups). the significant reduction was achived in the amount of cellular infiltrate and degenerative and/or necrotic changes, contrary to the amount of fibrosis. applied immunomodulatory therapy made substancial reduction of inflammation with "relative" increase of fibrosis. conclusion interferon-α, as main immunomodulatory agent, has favourable effects on myocardial histology and contractility in patients with biopsy-proven myocarditis. morphological changes in heart died of a heart attack of a myocardium v ubaydullaeva the centre of emergency medical aid, tashkent, uzbekistan diseases cvs take conducting place among the most actual problems of modern medicine. from them it is possible to count the main thing ihd. ihd -the special form of pathology cvs including group of diseases which, according to definition the cart, are treated as follows: «dysfunction sharp or chronic, arising owing to relative or absolute reduction of supply of a myocardium by arterial blood». despite of significant number of the morphological researches devoted ihd, morphogenesis separate displays of it, in particular, ami, and also mechanisms of indemnification and decompensation of hearts are investigated insufficiently. in connection with, the purpose of the present research definition morphofunctional conditions of various departments of heart was above-stated at diagnostics of an intimate ischemia. material and methods for achievement of an object in view researches of hearts died of a heart attack of a myocardium have been lead (have been carried out), and also have been investigated morphometric parameters, such as: weight of a cardiac muscle, pure weight of heart, weight right and left ventricles, an index right and left ventricles, an index of blood supply of a myocardium. all received data have been processed statistically on personal computer with use of standard software package windows excel. results summarizing macro-and the microscopic changes which have been found out by us in a cardiac muscle, it is possible to make the conclusion that the long reorganization occuring in a cardiac muscle in conditions increasing hypoxy, results in an exhaustion processes, to use of all possible resources cardiomyocytes and causes development decompensation. introduction cardiac myxoma, the most common primary tumor of the heart, has a varying clinical presentation and immunohistochemical profile. an abundant mucopolysaccharidic matrix exists, including mucin, within the cardiac myxoma. this study elucidates the clinical presentation and expression of mucin genes in cardiac myxoma. materials and methods from december to february, , the retrospective study included consecutive patients with cardiac myxoma underwent surgical excision. detailed clinical parameters were reviewed as well. mucin genes, additionally, muc , muc and muc ac, have been studied by immunohistochemical method. the expression was scored from to . results ( %) women and ( %) men with a mean age of +/- years comprised the control group. the presentation included asymptomatic ( %), dyspnea ( %), stroke ( %), chest pain ( %), fever ( %), syncope ( %) and tricuspid regurgitation ( %). we divided these patients into two groups; group a contained the myxoma located in the left atrium, group b included three ( %) recurrent myxomas and ( %) myxomas other than in left atrium. they did not differ with respect to many pathological scores, such as vascular proliferation, inflammation, cellularity, and hyaline. however, although less calcification and thrombosis occurred, more congestion was found in group b (p < . ). moreover, muc / ac had a higher expression than muc (p < . ). interestingly, the group a displayed a stronger mucin expression than group b did. conclusion preliminary results demonstrate invaluable and different pathological patterns, including mucin genes, between the myxoma coming from the left atrium and the other sites. introduction nowadays understanding of atherogenesis, russell ross' response-to-injury paradigm, considers atherosclerotic lesions as "a protective, inflammatory-fibroproliferative response" to harmful stimuli. among these stimuli are the major risk factors, which contribute for atherosclerotic cardiovascular complications. arterial blood flow impairment is associated with the progression of intimal atherosclerotic lesions. that is why most of the research work is concentrated upon intima, while adventitia is neglected. several lines of evidence clearly show that adventitia is not an innocent bystander in atherogenesis. the aim of the present study is to evaluate morphologically adventitial changes in atherosclerotic arteries. the cellular components and adventitial thickness are followed in postmortem human coronary arteries. results mononuclear cellular infiltration (lymphocytes, mast cells), neoangiogenesis and collagen overproduction are established in this part of adventitia, that corresponds to atherosclerotic lesion. morphometric analysis reveals increased adventitia/media thickness ratio. the adventitial thickening represents an example of negative vascular remodeling, because of hampering the compensatory enlargement of the affected artery. on the other hand the cellular processes involved in adventitial thickening could be responsible for atherosclerotic lesion initiation. we need further arguments into the cell biology of atherosclerosis, viewed as a vascular healing process, involving also the adventitia, to provide new insights into atherogenesis and alternative therapeutical strategies respectively. study on postmortal autolytic changes of the myocardial blood vessels. experimental study l kostic-banovic , v katic , r karadzic , j stojanovic , g ilic , m zdravkovic , a antovic department of forensic medicine nis, nis, serbia and montenegro department of pathology nis, nis, serbia and montenegro introduction modern forensic medicine practice has not yet been given the methods of investigation that would enable answering with sufficient accuracy to the question of death occurrence time. present work is an attempt to make contribution to that very complex and significant problem in forensic medicine. the investigation has been done on wister rats. the sacrifice was exerted by strangling. to respond on questions how both temperature of microenvironment and passed time influence on coronary arteries, the experimental animals were divided into groups: i ( c), ii ( c) and iii ( c). every group had subgroups, depending of passed time from the sacrifice, beginning of hour, through , , , , , and up to hours. control animals were autopsied and myocardial sections were taken immediately after sacrificed animals. formaldehyde fixed and paraffin embedded blocks were cut and stained by he, van gieson and gomori methods. results in groups ii and iii almost all blood vessels of heart muscle had fragmented walls in the animals examined upon hours after sacrifice. the vessels were almost normal in the group i also up to hours after sacrifice. basal membranes of blood vessels were observed upon hours after sacrifice at the temperature of c. fragmented basal membranes in ii and iii group were found, in the form of spider's web residues. total hemolysis of erythrocytes was upon hour after sacrifice in iii temperature group. however, contours of erythrocytes could be recognized upon hours after sacrifice in i experimental group. conclusion autolysis of myocardial vessels is influenced by two factors: time interval from the death and micro environmental temperature. the temperature exerted more profound influence on autolysis than time interval. the observed autolytic changes could be used in the expertise of the time of death occurrence. introduction heart transplantation remains the only therapeutic option for pediatric patients (pts) with severe, end stage myocarditis. the aim of this study was to determine the presence of viral genome in native heart and the frequency of viral recurrence after heart transplant in pts with myocarditis. material and methods from march to november , heart transplants were performed in children ( month to years m/ f) at our institution. histology/immunohistochemistry was carried out in all native hearts; among inflammatory cardiomyopathy, cases were active myocarditis and dilated cardiomyopathy/ chronic myocarditis. foci of active myocarditis were also found in one case of hypertrophic/restrictive cardiomyopathy and one case of congenital heart disease respectively. retrospective pcr (polymerase chain reaction) and sequencing analysis for detection of cardiotropic viral genomes was performed in native hearts ( %) and in all serial post-transplant biopsies from viral pcr positive cases. results pcr amplified a viral product in native hearts ( %). pcr analysis on postransplant serial biopsies disclosed the same viral infection in of ( %). early enteroviral recurrent myocarditis with identical genotype was demonstrated in cases at month after transplant. fatal outcome occurred in / pts with viral recurrent myocarditis when prompt molecular diagnosis was not available; misdiagnosis of acute rejection in histological monitoring may have concurred in the fatal outcome. conclusion viral myocarditis frequently relapses after heart transplantation in children and is a risk of fatal outcome. molecular study in native hearts is mandatory to improve diagnostic accuracy allowing to a more strict surveillance after transplantation. sudden cardiac death induced by acute viral myocarditis introduction most commonly the sudden cardiac death (scd) is defined as unexpected death from cardiac causes early after of without the onset of symptoms. data suggested that scd is a multifactorial catastrophe involving in most instances myocardial lesions that we confirm by this report. materials and methods five cases were autopsied in institute for forensic medicine because they have died from scd. the mean age was , years, including one boy ( years) and one girl ( years). all specimens were fixed in % formalin. paraffin sections were cut and stained by: he, van gieson and ab-pas, ph= , . results clinical symptoms lasted short time: fatigue, dyspnea, palpitations and precordial discomfort, accompanied by fever. macroscopically, the hearts were normal or enlarged, with dilatation of chambers. the ventricular myocardium was typically flabby and mottled by either pale foci or minute hemorrhagic lesions. histological finding: myocarditis was characterized by an interstitial mononuclear predominantly lymphocytic inflammatory infiltrate and by injury of focal necrosis to myocytes adjacent to the inflammatory cells; focal aggregates of macrophages and microhaemorrhages, often surrounding the conduction system, were also observed. scattered incipient fibrosis inside the areas with disappeared myocytes was one of the features of myocarditis. conclusions the ultimate mechanism of death in viral myocarditis was fatal arrhythmia induced by inflammatory mononuclear infiltrates of the conduction system. surgical pathology of primary cardiac and pericardial tumors in the paediatric age background primary cardiac and pericardial tumors (cpt) are rare at all ages and even less common in infancy and adolescence. aim of this study is to assess the prevalence and pathologic features of paediatric cpt consecutively examined in a single institution. among surgically removed cpt collected at our cardiovascular pathology unit in the time interval - , ( %) occurred in the paediatric age (< yrs). we retrospectively analysed them by histotype, age and clinical presentation, location, type of surgery and outcome. they were male and female pts, age ranging from days to years (median months). the majority of cpt were diagnosed before the age of year ( %), including prenatal diagnosis by foetal echocardiography. in the remaining pts, clinical presentation of cpt was congestive heart failure in , cardiac murmur in , systemic embolism in , and constitutional symptoms in , whereas four were completely asymptomatic and the mass was an incidental finding at echocardiography ( ) or during cardiac surgery for congenital heart disease ( ). pct were located most frequently in the right ventricle ( ), followed by right atrium ( ), left atrium ( ), left ventricle ( ), tricuspid valve ( ), pericardium ( ) and ventricular septum ( ) . all had surgical resection except one who underwent cardiac transplantation. as far as histotype, myxoma was the most frequent ( ), followed by rhabdomyoma ( ), fibroma ( ), angioma ( ), pericardial teratoma ( ) and hematic cyst ( ). no recurrence was found at echo during follow-up and only one pt died three years after cardiac transplantation due to cerebral malignancy. with the improvement of cardiac imaging techniques, cpt have increasingly been detected even early during life. despite the benign histotype, cpt carry the risk of heamodinamic, embolic and arrhythmic complications. prompt surgical resection is indicated in all symptomatic pts and in those with tumour related obstruction. among surgically resected primary cpt in the paediatric age rhabdomyoma is less frequent than expected since it often does not require surgical resection due to its potential spontaneous regression. in vivo histologic diagnosis of primary malignant cardiac and pericardial tumors c basso, m valente, g thiene institute of pathology, padua, italy background primary cardiac and pericardial tumors (cpt) are rare and even less common are malignant ones. aim of our study was to assess the prevalence and histotype of malignant forms among a consecutive series of primary cpt examined in a single institution. in the time interval - among consecutive pts who had an in vivo diagnosis of primary cpt, either by surgical pathology and/or endomyocardial biopsy investigation, ( . %) had a malignant form. they were female and male pts, age ranging from to yrs (mean ± ). besides gross and histologic examination, tumour histotype was defined by immunohistochemistry using a large panel of antibodies and by transmission electron microscopy. primary malignant cpt comprised extracardiac ( pericardial mesothelioma and pulmonary artery sarcoma) and intracardiac masses. the latter group consisted of angiosarcoma of the right atrium +/-right ventricle ( ), undifferentiated sarcoma of the left atrium ( ), fibrosarcoma of the right atrium ( ), malignant fibrous histiocytoma of the left atrium ( ), b cell lymphoma of the right atrium ( ) and leiomyosarcoma of the right ventricle ( ) . in four ( %) a preoperative histologic diagnosis was achieved by transvenous endomyocardial biopsy (all right-sided). four malignant primary cpt, all located in the left atrium, had a preoperative misdiagnosis of myxoma. surgical resection was performed in all but two pts. all pts died with a maximum survival time of months. conclusions primary malignant cpt are rare and represent . % of all primary cpt in our series. the prognosis is poor and generally measured in months independently from the tumour histotype and from surgical resection and chemotherapy. endomyocardial biopsy is a safe procedure to achieve an in vivo diagnosis in the setting of right intracavitary masses. introduction primary sarcomas of the aorta are extremely rare neoplasms, described in occasional single case reports and antemortem diagnosis is difficult because of their polymorphous presentation. the tumours are classified into intimal and mural types according to their location and clinical behaviour. we describe a case of intimal sarcoma arisen in the thoracic aorta of a -years-old woman with multiple embolic abdominal metastases (spleen, kidney, adrenal). case report in november the patient was hospitalized for the embolic occlusion of the left popliteal artery. the recent clinical history revealed irritative cough, dispnea and fever. the laboratory tests reported anemia (hemoglobin: . mg/dl) and the ves was . electrolities, liver function tests and fibrinogen were within normal limits. the antiphospholipid antibody and lupus anticoagulant were negative. a ct-scan showed an intraluminal thrombus-like mass in the thoracic aorta and multiple geographic infarctions of the spleen suggestive for a primary aortic tumor. she died before undergoing to surgery, for left ventricular failure. results post-mortem examination showed mild atherosclerosis and a mass with grayish-yellow, solid, rubbery and mixoid aspects, attached to the wall of the aorta, just after the origin of the left subclavian artery. histologic sections disclosed a spindle-shaped sarcoma cells with pleomorphic nuclei in a myxoid stroma; necrosis was abundant. at immunohistochemistry tumor cells resulted positive for vimentin, actin and cytokeratins. conclusion the preoperative diagnosis of sarcoma of the aorta is possible but it should be supported with imaging techniques; the definitive diagnosis need to be confirmed histologically and immunohistochemically. arterial allografts cryopreservation antigenicity in pigs m santos background coronary surgery requires vascular grafts. donor fresh arterial grafts are useless because of rejection vasculopathy. cryopreservation can be a good way for banking purposes and may limit rejection. the aim of this study was to assess the utility of arterial cryopreservation in increasing the quality of grafts, in an animal model in pigs. material and methods small arteries, less than mm in diameters were implanted in pigs. three groups were done: group (n= ): fresh autograft (au) and fresh allograft (al) one in each side; group (n= ): cryopreservated au and cryopreservated al; group (n= ): fresh al and cryopreservated al. all animals got aspirin for three months and group also cyclosporine a. the implanted grafts were embedded in paraffin and microscopically studied with hematoxilin/eosin and elastic stains for morphology and morphometrics. a basic immunohistochemical study with cd and mac was also performed. results the patency rate of cryopreservated al and au was %, as it was in the fresh au. the inflammatory reaction, evaluated by cd and mac was present in all al arteries, and absent in au cases. in group , the infiltration was lower in cryopreservated, than in the fresh ones. conclusions in our series of pig's arteries, cryopreservation increases vascular patency and the inflammatory response is lower than in fresh arteries. this fact is independent of the immunosupressive therapy. introduction glandular cardiac myxomas are very rare tumors of uncertain histogenesis, displaying glandular structures within otherwise typical myxomas. origin of glands has been attributed to epithelial differentiation of a cardiomyogenic precursor cell or to entrapped embryonal rests. we studied four cases of glandular myxomas ( sporadic and one familial) to define the immunophenotypic profile of the glandular elements. materials and methods histology and immunohistochemistry were performed on serial sections. broad spectrum cytokeratin, cytokeratin (ck ), cytokeratin (ck ), cea, ema, chromogranin a, calretinin, thyroid transcription factor- (ttf- ), ki- and p were investigated. results three patients were males, aged , , , respectively and the fourth a y.o. woman. the glands were either scattered within myxomatous stroma ( cases) or in groups. in the latter case the glands featured villous projections, irregular profile, active inflammation or focal low grade dysplasia, and showed expression of acidic and neutral mucins (mostly sialomucins). cytokeratin and co-expression was found, similarly to foregut derivatives. there were scattered chromogranin-positive neuroendocrine cells in one case and ki- immunostaining showed a very low proliferative activity. there was no reactivity for ttf- , calretinin or p . none of the patients had adenocarcinoma or other neoplasm, either at diagnosis or at - years follow-up. conclusions our findings indicate that glandular component of cardiac myxoma is morphologically heterogenous. the isolated glands suggest a possible divergent (epithelial) differentiation of myxoma cells, but other findings point to the possibility of entrapped foregut rests with mature neuroendocrine and mucous cell populations. work partially supported by grants from the italian ministry of education (rome, to mp) and the associazione italiana per la ricerca sul cancro (milan). infection and immune inflammation peculiarities in atherosclerosis i zota, e foca, e melnic pathology department, the state university of medicine and pharmacy n.testemitanu, chisinau, republic of moldova introduction during the last decade the basic postulate of atherosclerosis etiology and pathogenesis has changed. this review presents a spectrum of data regarding the link between infection and immune inflammation development in atherosclerosis. material and methods this study has been carried out on the human aorta, coronary heart vessels collected from early performed autopsies and on the carotid arteries gathered during surgical vessels remodeling of persons. the patients with cardiovascular insufficiency on atherosclerosis background from to years were taken into study group. chlamydia pneumoniae was detected by routine microscopy on shtive fixed material, and by immunohistochemical reaction performed on cryophilic specimens marked with fits antibodies. hsp- and tnf-α implication have been studied trough immunohistochemical reaction using monoclonal antibodies. this material was fixed in % formaldechyde solution. results chlamydia pneumoniae has been detected in endothelial cells, macrophages, smooth muscle cells of fatty streaks and fibrous plaques. its detection incidence decreases in advanced arterial lesions. we also determined that chlamydia pneumoniae infection is capable to induce immune reaction against hsp- which can be considered like a target in autoimmune reaction. they produce an cytotoxic effect on the endothelial cells followed by permeability disturbances, faciliting the atherosclerotic lesions progress. among the inflammation mediators in increased quantity tnf-α have been detected being localized on the surface and in depth of atherosclerotic plaque around the foam cells. conclusions our outcomes demonstrate the toxic and infectious factors existence which can be considerated decisive in atherosclerosis pathogenesis. this data give us the reason to elaborate other diagnosis and treatment strategy. introduction primary tumours of the heart are rare, the majority are benign, myxomas representing - %. hemangiomas are extremely rare, with an incidence of . %- . %. they usually occur in adults, mostly are an incidental finding. we present a man with asymptomatic cavernous hemangioma of the left atrium. case report transthoracic echocardiogram of a -year-old man with arterial hypertension, otherwise healthy, with normal ecg and chest x-ray, revealed a wide based isoechogenic tumour, measuring . x . cm, located in the moderately enlarged left atrium, attached to interatrial septum and anterior wall, adjacent to mitral valve annulus, sparing oval fossa. it showed minimal mobility but did not cause any obstruction of the blood flow or mitral regurgitation. macroscopically, surgically removed tissue was spongy, partly haemorrhagic. microscopically, there were cavernous venous structures, filled with blood and focally thrombosed. focally, a few smaller capillary channels were found. there was no endothelial atypia and no papillary hyperplasia. discussion and conclusion histologically, hemangioma of the heart has two major differential diagnostic possibilities. in case of a myxoid background, it is possible to be misdiagnosed as myxoma, but in hemangioma there are no myxoma cells and no ring structures. grossly, opposite to myxomas, hemangiomas are rarely attached to the oval fossa. papillary hyperplasia, which is reactive endothelial proliferation in hemangioma, may lead to misdiagnosis of angiosarcoma. angiosarcoma can be excluded only when the whole tumour is examined and no marked endothelial atypia, cellular areas of spindle cells with poorly formed vascular channels, and necrosis are found. compression, obstruction, effusion and bleeding are responsible for clinical picture. symptoms depend also on the location, size and invasiveness. the natural history is unpredictable, for this reason surgical intervention is mandatory. introduction the limb-body wall complex is a congenital syndrome, which includes limb defects, abdominoschisis associated with facial and neural tube malformations. some authors believe that the limb-body wall disruption is separate from amniotic band syndrome. others suggest that both belong to a wider spectrum, with a possible overlap between these two categories. in the present study, we describe a case of lbwc and based on our findings we suggest a new pathogenic mechanism. case report a years-old cap-verdean female gave birth at weeks to a pair of twins. one foetus showed multiple malformations incompatible with life. physical examination showed partial lower extremity amputations. a large omphalocele was also noted. there was a large lumbosacral meningocele and the head showed micrognathia and high-arched palate. there was right hydronephrosis secondary to right ureteral obstruction and cloacal anomaly. the lungs were hypoplastic. the histology of the internal organs was characteristic for the developmental stage and cytogenetic testing revealed a normal male karyotype. discussion and conclusion we believe, that early amniotic bands may lead to vascular insults, proximally and distally by altered haemodynamics. the lower limbs were partly amputated as a result of the continued growth associated with altered vascular supply. the same mechanism may explain the other findings as well. vascular disruption by virtue of altered haemodynamic state may give rise to thromboemboli, which may affect the growth of external/internal structures, distant from the site of disruption. however, this vascular lesion was masked by continued growth of the foetus. therefore, the abs may precede and may cause the lbwc. two cases of pleuropulmonary blastoma k vuopala , h tuominen , r jauhola , p valmari , r herva lapland central hospital, rovaniemi, finland oulu university hospital, oulu, finland pleuro-pulmonary blastoma (ppb) is a malignant tumour of childhood. the most common clinical sign is respiratory difficulty. ppb appears as a pulmonary and/or pleural-based mass and is characterized histologically by a primitive, variably mixed, blastematous and sarcomatous appearance. no metastases have been reported in neonatal cases. we describe two cases that presented ppb. the first was a term male infant of a g p mother. the pregnancy was uneventful. after normal delivery, a male infant with severe respiratory distress was born. by ultrasound examination, a thoracic mass were identified. there was no response to the intensive care. the infant died at the age of . hours. at autopsy, a tumour of g, measuring x cm was found in the left lung. in addition, there was a smaller mass, of cm diameter in the mediastinum. micro-scopically, the tumour masses consisted of ppb. the second case was a -year-old female with persistent fever and respiratory difficulties. in ct scan, the lower lobe of the left lung was replaced with a tumour mass. during operation, the tumour was seen to be infiltrating to the mediastinum and was partially resected, followed by intense chemotherapy. histologically, the diagnosis of ppb was given. the child has shown no sign of the disease during follow-up of six months. the ppb is regarded as the pulmonary dysontogenetic analogue of wilms' tumour, neuroblastoma, and hepatoblastoma. the first case showed its highly aggressive nature, with mediastinal metastases found at birth. causes of intrauterine foetal death associated with placental pathologic features v blažičević , v Štitić , m mrčela clinical hospital osijek, croatia general hospital karlovac, croatia introduction improvements in antenatal and intrapartum care have reduced perinatal mortality, but the rapid advances in intensive neonatal care have had a dramatic effect in reducing neonatal deaths so that stillbirths have become relatively more important. the aim of this study was to identify the relationship between placental lesions and stillbirth. materials and methods we analysed the causes of intrauterine foetal death after the th week of pregnancy during the years - at the departments of obstetrics and gynaecology of the clinical hospital osijek and general hospital karlovac. a complete autopsy was made on each stillborn, including investigation of the placenta, cord and foetal membranes. histological specimens were studied from all internal organs of the foetus and from the placenta, cord and membranes. haematoxylin and eosin stain is used in routine causes, pas staining to assess thickening of the basement membrane and trichrome staining to assess stromal fibrosis of the villi when it was necessary. results there were stillbirths who died before labour - placentas of them were examined and weren't. abnormalities were found in ( . %) placentas and 'normal' placentas were ( . %). autopsy findings in stillborn foetuses: asphixia ( . %), maceration only ( . %), major malformations ( . %), vitium cordis ( . %), anencephalia ( . %), others ( . %). placental pathologic findings: infections ( . %), single chronic and acute infarction ( . %), multiple chronic and acute infarctions ( . %), placental failure for other reasons ( . %), chronic ischemic change ( . %), infections associated with circulatory disturbances ( . %), retroplacental haematoma ( . %), massive subchorial thrombosis ( . %), chorangiosis ( . %), umbilical cord tumour ( . %), intervillous thrombus ( . %), chorionic cysts ( . %). conclusion the most of women with a stillborn infant were quite healthy and did not reveal any risk factors when assessed on clinical grounds. there were patients in whom evident foetal growth retardation had been overlooked at the maternal health centre before the death of the foetus. the importance of routine ultrasound screening for detection of unrecognised risk patients and placentas is emphasized. introduction microscopic diagnosis of oligobiopsy material taken during endoscopic examination plays an important role in diagnosing syndromes of absorption disorders, especially in case of celiac disease. the aim of the study was a morphologic evaluation of the small intestine mucosa and comparison of the used from many years shiner/shmerling classification with a new modified marsh classification. materials and methods during the study, bioptates if small intestine evaluated in the chair and department of pathomorphology in zabrze in the years - were analysed again. out of the bioptates were with i of villous atrophy, with ii, with iii and with iv. study material was from the paediatric hospitals in zabrze and bytom. during routine histopathologic diagnosing, villus atrophy was evaluated in the shiner/ shmerling scale. presently, the marsh scale is being introduced into histopathologic diagnosing. it takes into consideration not only features of villus atrophy and glandular crypts proliferation but also intraepithelial lymphocyte infiltrations. another evaluation of villus atrophy was performed according to the modified marsh classification. the received results are presented in the modified marsh classification: type - ( . %), type - ( . %), type - ( . %), type a - ( . %), type b - ( . %) and type c - ( . %). our study allowed to compare two classifications used in the evaluation of the atrophic and proliferous processes and to select from the shiner/shmerling degree i a group of cases (type and according to marsh), which had no equivalents in the so far used scale. moreover, it was shown that the sub-groups of the type of destructive changes did not correspond fully with the so far used shiner's degrees ii-iv. it enables fast comparison of the atrophy degree with the results received before the introduction of the new modified classification. moreover, a routine application of precise descriptions of histopathologic results of small intestine mucosa in syndromes of absorption disorders facilitates retrospective selection, from the so far used shiner's degree i, of the cases corresponding with marshal types and . conclusions application of the modified marshal classification for an evaluation of the small intestine mucosa in celiac disease enables accurate presentation of atrophic and proliferous changes including selection of type and , which have no equivalents in the so far used shiner/shmerling classification. embryonal rhabdomyosarcoma: a case report s kocmanovska -petreska, b ilievski, p cvetkovski, l spasevska, s kostadinova -kunovska, s duganovska institute of pathology, faculty of medicine, skopje rhabdomyosarcoma is an aggressive malignant skeletal muscle neoplasm arising from embryonal mesenchyme. the head and neck region is the most common site for this tumour in children. neonatal presentation of this tumour is rare. we present an autopsy case of a female newborn having a large tumour mass ( x x cm) in the frontal region, covering the entire upper half of the face. similar subcutaneous noduli with diameter , cm, cm and cm were found on the left cheek, and another with diameter , cm, , cm, cm and cm on the right cheek. the histological examination showed a tumour composed of large spindle cells with myoblastic features and small round to elongated undifferentiated cells. associated with the spindle cells is various numbers of large round or globular cells with hyperchromatic nuclei surrounded by acidophilic granular or homogeneous cytoplasm. cross-striations were found in the spindle cells. imunohistochemically tumour cells were positive for desmin and vimentin. the final diagnosis was embryonal rhabdomyosarcoma. immunohistochemical staining helped to make a proper diagnosis. introduction apoptotic cell death represents an important mechanism for the precise regulation of cell numbers in normal tissues. various apoptosis-associated regulatory proteins may contribute to the rate of apoptosis in neoplasia. the present study analyses the inter-relationship between the expression of the pro-apoptotic bclx (s/l) protein and histological type and stage of wilms tumour. materials and methods bcl-x (s/l) expression was investigated using an indirect immunoperoxidase technique, applying antibodies to bcl-x (s/l) protein. correlation of semi quantitatively scored bcl-x (s/l) levels with histological type and tumour stage was performed for cases of wilms tumours ( classical and anaplastic). results the expression of bcl-x (s/l) protein was present in most cases of wilms tumour ( %). generally, bcl-x (s/l) was expressed in the blastemal and epithelial components of wilms tumour. in most cases, the expression of bcl-x (s/l) was moderate. blastemal bcl-x (s/l) expression decreased with tumour stage. there was no correlation between histological type and expression of bcl-x (s/l) protein. diffuse expression of bcl-x (s/l) protein was observed in cases of anaplastic wilms tumour. these two cases were stage i and of unfavourable histology. in cases of wilms tumour, no immunohistochemical staining was observed. so, these results cannot indicate whether absence of bcl-x (s/l) could play a role in the development of anaplasia. conclusion according to clinical follow-up, the results of our morphologic and immunohistochemical analysis suggest that decrease of the blastemal bcl-x (s/l) protein could be associated with the capacity of wilms tumour for local and distant spread. expression of alpha, beta and gama catenins in wilms tumour s radojevic background loss of catenins is suggested to promote tumour invasion and distant metastasis in tumour development. the aim of this study was to determine the expression of catenins in wilms tumour and their relationship with histological type and stage of wilms tumour. materials and methods catenins expression was investigated using an indirect immunoperoxidase technique, applying antibodies to alpha, beta and gama catenins. correlation of semiquantitatively scored adhesion molecule levels with histological type and tumour stage was performed on cases of wilms tumours ( classical and anaplastic). results beta and gama catenins were present in most cases ( % and % respectively) and were usually coexpressed. anaplastic type of wilms tumour displayed higher beta catenin and lower gama catenin level in comparison with other types. nuclear positivity, in each case, was found to be very strong, but was usually present only in % of tumour cells. beta and gama catenin expression was not correlated with stage of wilms tumour. alpha catenin was present in % cases of wilms tumour. stage iii displayed higher alpha-catenin levels than stage i/ii, suggesting that impairment of their function might exist without actual loss from tumour cells. conclusion our results suggest that the level of catenin expression is associated with histological type of wilms tumour, regardless of tumour stage. observed nuclear expression of beta catenin indicates that the activation of wnt-signaling pathway is crucial step in wilms tumour genesis. comparison of apoptosis and fas, fas-l and bcl- expression in wilms' tumor m ergin, a uguz, s erdogan, g gonlusen, n tunali cukurova university school of medicine dept. of pathology, adana, turkey background apoptosis is a complex process involving many genes that play role as antiapoptotic or apoptotic factors. it controls normal homeostasis of tissues. expression of these genes vary from one type of tumour to another type. the aim of this study is to evaluate the expression of bcl- , fas and fas-l and apoptosis in wilms' tumour (wt). method thirty paraffin embedded tissue specimens were included. immunohistochemical study was performed for bcl- , fas and fas-l and in-situ end-labelling technique (isel) for apoptosis. results the expression of these proteins varied among the tumours. there was no statistically significant correlation between the expressions of bcl- , fas, fas-l and. apoptotic index. conclusion apoptosis is an important mechanism in the growth of the tumours. we suggest that not only bcl- , fas and fas-l play role as regulators of apoptosis in wt but also other apoptotic and antiapoptotic genes involve this process. further investigations are necessary to understand the molecular mechanism of the progression of wt. uncommon tumours of the neuraxis in childhood j vila-torres hospital universitari sant joan de déu. department of pathology, barcelona, spain case a year-old girl presented with seizures and weakness in the left part of de body of -year duration. ct scan showed a mass that filled the right ventricle, with a strong mass effect, peritumoural oedema, midline shifting and slight ventricular enlargement. a partial excision was carried out and the pathological diagnosis was that of choroid plexus carcinoma. the patient died six months later due to adjuvant therapy side effects. in the last who classififcation of brain tumours, grade iii choroid plexus carcinoma is defined as a choroid plexus tumour showing features of malignancy: nuclear pleomorphism, frequent mitosis, high nuclear/cytoplasmic ratio, increased cellular, density, blurring of the papillary pattern, poorly structured sheets of tumour cells, necrotic areas, and often diffuse brain invasion. all those tumours classically displaying a papillary pattern must be considered in the differential diagnosis. case a month-old child presented with respiratory distress since months old. on rx and ct scan, a tumour in the left hemithorax was seen, with right shifting of the mediastinum. the tumour was partially removed. pathological diagnosis was that of spinal canal invasion by a soft tissue lipoblastoma. eight months after surgery the tumour relapsed, infiltrating the epidural spinal canal from c to d . the tumour was fully excised by means of microsurgery techniques, without neurological deficits. this case is an example of invasion of the vertebral canal by a soft tissue tumour previously removed. lipoblastoma is a rare fatty tumour occurring in children in the extremities or less commonly in the trunk or retroperitoneum. the tumour is benign but may recur. grossly, lipoblastoma showed a distinct lobulated pattern of yellow-grey myxoid tissue, histologically composed of highly vascular fat in a myxoid stroma resembling embryonic white fat. differential diagnosis, based on clinical-pathological grounds, include fibrolipoma and myxoid liposarcoma. case a year-old boy presented with partial complex seizures for year duration. nmr showed a discrete hypodense corticalsubcortical lesion in the left frontal lobe. neither oedema nor mass affect was detected on ct scan. the tumour was completely removed by surgery and the pathological diagnosis was that of dysembryoplastic neuroepithelial tumor. this is an intracortical grade i tumour composed of oligodendrocyte-like cells. macroscopically, is a nodular outward expansion of the superficial cortex. histologically, a low-power view of a perpendicular section of the cortical surface shows the characteristic pattern of multiple intracortical nodules and internodular tissue, both containing mucin. also seen, is a specific glioneuronal component of vertical columns of neu-rites transversing the cortex, sheathed by oligodendrocyte-like cells accompanied by mucin and with 'floating neurons' (cortical ganglion cells seen in individual small pools of mucin). case a year-old boy presented with diplopia and proptosis. the nmr showed a hypodense, diffuse lesion in the left temporal and parietal lobes that produced a slight collapse of the left lateral ventricle. two weeks later the patient developed symptoms of time and space cognitive disturbances, language difficulty and seizures. a biopsy was done and the pathological diagnosis was that of gliomatosis cerebri. this is a rare primary brain tumour characterized by a diffuse proliferation of neoplastic glial cells that typically involve multiple brain areas with preservation of brain structures. the diagnosis depends on both histologic and radiologic features. on nmr there is a uni or bilateral diffuse involvement of the white matter extending to the cortex with poor mass effect. microscopically, there is a proliferation of monomorphous astrocytes, grade ii or iii, infiltrating the brain parenchyma freely. some undifferentiated cells show 'naked' nuclei while others look like 'rod' structures. in cases of low cellularity and cytologically bland astrocytes, it may be extremely difficult to make the differential diagnosis with reactive gliosis. gc is associated with a poor prognosis. introduction production of materials for dental implants is of great social importance and is related to the progress in material technology. main directions of development in this discipline concern an accurate choice of implant material in order to fix an implant in a bone tissue firmly and to decrease tissue reactions. new direction of research on implant materials is powder metallurgy. in comparison with the so far used technologies, it has many advantages, such as homogenous fine grained material structure, possibility to make composites including biologically active implants, and also ability to overgrow the implant with bone tissue. aim of the study was morphological analysis of healing of dental alveolus canals filled with metal implants. evaluation of tissue reactions in bones and surrounding soft tissue from several types of metal implants. material and method the experimental study was performed on mixed breed rabbits of - g weight. after premedication with atropine with relanium, surgical procedure was performed in each animal. one of the incisors was extracted and after the canal was formed, metal implant was inserted. the first group (d ) consisted of animals whose dental alveolus canals were filled with cylinder of x mm made of pressed co-cr-mo alloy covered with calcium triphosphate. the second group (d ) consisted of animals whose dental alveolus was filled with implants of cylindrical shape of a size x mm made of pressed co-cr-mo alloy. the third group (d ) consisted of animals whose dental alveolus canal were filled with a titanium screw of a size x mm. the control group (k) consisted of animals whose dental alveolus canal was left only with blood clot. the postoperative wounds were sutured with dexon thread. the clinical and observations and histopathological introduction correct reconstruction of bone defects is a serious problem in orthopedics and in maxillo-facial surgery. hence, numerous experiments and clinical studies on a usage of natural and artificial materials being a scaffold enhancing a reconstruction of bone tissue (i.e. carbon fibre, hydroxyapatyte granulate). deproteinized bovine bone is a new material. it was elaborated in at the mineralogy faculty, mining and steel academy in kraków. the technology of natural animal bone tissue enables its use in filling bone defects, accelerates reconstruction of bone tissue and minimizes unfavorable tissue reactions through total immersion into the reconstructed bone. it gives no incorrect immunological response of the body to the implanted xenogenic tissue. the aim of the study is to evaluate healing processes of the defects made in rat femoral bones and filled with deproteinized bovine bone and to compared it with spontaneous healing. material and method the experiment was conducted on wistar rats divided into groups ( rats per group). the surgically made bone defects were filled with the study material. the animals, whose defects filled with blood clots spontaneously, made up a control group. the healing process in bone tissue was examined clinically and morphologically after , , , , and days after the experiment. results in histopathological estimation, the healing speed of the defect in femoral bone filled with blood clot (control group) was compared to the healing of the defect filled with deproteinized bovine bone (study group). no inflammatory reaction to the implant was observed. moreover, acceleration of the healing of the defect filled with deproteinized bovine tissue was observed. bovine bone was, in the study group, totally immersed in the body's bone tissue, i.e. was surrounded by the arisen on its surface sponge bone. in the last periods of the observation, on the borders of the observed synostoses no osteoblast cell activity was observed and normal bone marrow was found between osseous trabeculae. conclusions osseous wounds filled with deproteinized bovine bone heal without any inflammatory complications. no negative systemic reactions proves that the applied material was properly prepared for implantation. histopathologic studies showed that deproteinized bovine bone accelerates regeneration process of a damaged bone tissue. withdrawn p- the effect of specific inhibitors of caspases on apoptosis of thymocytes induced with paclitaxel although caspases are involved in molecular mechanisms of the execution phase of apoptosis, the precise mechanisms of their involvement in paclitaxel induced apoptosis are still not identified. the aim of this study was to investigate and compare the effects of inhibitors of caspases ( mmol/l) on apoptosis of rat thymocytes induced by paclitaxel ( mmol/l) and colchicine ( mmol/l). the effect of z vad and specific inhibitors of caspases (caspase , and ) after , and hours of incubation of thymocytes with paclitaxel and colchicine were analyzed. after incubation cells were fixed, processed for lm and em, and the percentage of apoptotic cells (apoptotic index) was determined. general inhibitor of caspases zvad and inhibitor of caspase led to a significant decrease of apoptotic index after hours of incubation with paclitaxel (from . % to . % and . %). inhibitor of caspase and caspase lowered the apoptotic index after hours incubation with paclitaxel from . % to . % and . % respectively. inhibitor of caspase did not affect the apoptotic index in controls, while the other used inhibitors reduced it. inhibitors of caspase , and and zvad had similar effects on apoptosis of thymocytes induced by colchicine. these results show that apoptosis induced by paclitaxel is caspase dependent, and that it, due to the effect of inhibitor of caspase , probably involves mitochondria. caspase activity might also be involved in mechanisms of induction of apoptosis of thymocytes by paclitaxel. effects of concurrent administration of lithium and gentamicin on the histoembryogenesis of rat fetus during the developing periods this study was planned to investigate the effects of gentamicin and littium on rat histoembryogenesis and to determine the effects, if any, of lithium as a potent gentamicin inhibitor. the rats were exposed subcutaneously to -mg/kg gentamicin on days - of gestation. lithium administered orally at doses mg/l on days - of gestation. fetuses were collected on day and compared with those of the untreated, and saline treated control as well as with those of the gentamicin and lithium treated groups. all control and cases embryos groups were killed and their tissues were obtained. then prepared for paraffin block, sectioning, h-e staining and light microscopic studies. we fond that gentamicin caused growth retardation versus lithium which dosn't did so. lithium has a state like control but no wary exactly. furthermore, concurrent administration of gentamicin and lithium caused regularity in histoembryogenesis cycle and the normal growth beside the lithium or gentamicin. of course the recent result is not exactly comparable to those of controls. t- toxin, a solitary hypergranular mcs were situated on the external wall of blood vessels. however, on days , and the number of perivascular mcs was increased. more than percent of these mcs showed degranulation. conclusion our results suggest that perivascular localisation and later degranulation of mcs may play an importantant role during the acute reaction in the heart of rats poisoned by t- toxin. effects of bromadiolone on rodent liver: pathohistological findings o- , o- takeda k, p- takeyama j, p- talalaev a, p- talan-hranilovic j, p- tammi m, p- tammi r, p- tanase c, p- tanaskovic italy author index the numbers are the abstract numbers p- o- gruia am o- , p- o- , p- sever m, p- sever-prebilic m skender gazibara m, o- , o- , m, p- p- , p- , p- , p- , p- , p- , p- srebotnik kirbis i, o- arrhythmogenic right ventricle dysplasia and sudden cardiac death. controversial aspects p- basal cell characteristics in breast carcinoma with medullary features (cmf) acknowledgement: dr chu is supported by nhri-ex - sc, nhri-ex - sc and bmrp . all chosen antibodies gave a specific and reproducible staining. there were no false positive or negative results. the panel can be recommended for screening for defects in the mmr-system. immunoexpression introduction several cytological features are taken into account in infiltrating duct carcinoma of the breast. the aim of this study has been to assess the prognostic value of the nucleolar area by means of ultrastructural morphometry. materials and methods forty-six cases of ductal carcinoma of the breast were included in the current study. all biopsies were processed for electron microscopy and electron micrographs were taken at x , magnification. nucleolar area measurements were done using sigmascanpro software and statistical analyses were performed. nucleolar area measures were categorized in terciles. a kaplan-meier estimation was performed to assess those measures related with disease-free interval. measures that reached statistical significance were dichotomized at the cut point with maximum likehood in a cox regression model and then were included in a multivariate analysis. results statistically significant differences were found in terciles per area (p= . ) and per variation coefficient (p= . ). in terms of nucleolar area measurements, any given nucleolar area with a standard deviation . , showed a relative risk for recurrence of . ( . - . ) (p= . ).conclusions ultrastructural morphometry shows that nucleolar features, particularly those related to size heterogeneity, have a significant impact on prognosis. determination of ploidy in different lesions of prostate a ibraeva , m alchinbaev , a seitaliyeva scientific center of urology, department of pathology, almaty, kazahstan scientific center of urology, almaty, kazahstan immunohistochemical correlation between pattern of postatrophic hyperplasia and carcinoma of the prostate ar botticelli penile leiomyosarcoma-morphological and immunohistochemical study g berdan, a petrescu, c ardeleanu prof. dr. th.burghele hospital, bucharest, romania introduction our case is about a years old male patient who was admitted with the diagnosis of a penile tumor, reason why a total penectomy was performed. material and methods fragments of the tumor and penile tissue were fixed in formalin %, embedded in paraffin and sections were stained with he and vg. immunohistochemical tests have been done: actin, vimentin, s , ae -ae , hmb , pcna. results on macroscopic examination, the tumor was bulky, ulcerative nodular, occupying the glans and the distal part of the shaft; it was gray white coloured, with hemoragic areas. microscopic examination revealed a tumorous proliferation of elongated cells with moderate nuclear pleomorphism and mitosis (typical and atypical), organised in a fascicular pattern, well vascularised; the tumor was superficially ulcerated and invaded the corpora cavernosa. the tumor was diffusely positive for actin and vimentin, focally positive for s , negative for ae -ae and hmb , and pcna was %. conclusions the morphological appearance and immunhistochemical results led us to the diagnosis of penile leiomyosarcoma, moderately differentiated. do human papillomaviruses infect proximal parts of the male genital tract? introduction human papillomaviruses (hpv) play an essential role in the pathogenesis of squamous cell carcinoma of the uterine cervix. the male urogenital tract is considered to be a reservoir of hpv infection. our previous finding of hpv in the squamous metaplastic epithelium with dysplasia in the epididymis prompted us to start a study focused on the presence of hpv in the male genital tract. aims: verifying the presence of hpv in the epididymis, ductus deferens and seminal vesicles. materials and methods samples from three groups (a, b, c) of patients were analysed by means of nested pcr for the presence of hpv dna extracted from a paraffin-embedded tissue sections. types of hpv were determined by dna nucleotide sequencing of the pcr products. group a consisted of patients (mean age , age range - , except for one patients years old), group b consisted of patients (mean age , age range - , except for two patients and years old) and group c consisted of patients (mean age , age range - ). patients in group a were surgically treated for non-tuberculous epididymitis ( epididymal introduction glucagonoma is an alpha-cell pancreatic neoplasm with incidence of one in million; the malignancy rate is unknown. the clinical, pathologic, immunohistochemistry and electron microscopy characteristics are described in a mexican cohort of patients. material and methods we reviewed the pathology archives of incmynsz and hocmnsxxi for pancreatic tumors with neuroendrocrine morphology and expression of immunohistochemistry markers for neuroendocrine and glucagon-related peptides. complete clinical history and follow-up were achieved. results six cases of glucagonoma were obtained. electron microscopy was available in two cases. three man and three women with median age of . years, were admitted with glucagonoma syndrome complaints. the tumor localization was: head of pancreas ( / ) and tail ( / ), with average size of . cm. two cases showed hepatic metastasis. the histopathologic study was constant with contrasting architectural, cytologic and mitotic count in all the cases. expression of neuroendocrine markers was observed in all cases, with positive glucagon stain, and negative for secretion markers (insulin, pp, serotonin, calcitonin). in electron microscopy, dense core granules were identified in two cases. discussion there are cases of glucagonoma described in english literature; no one is originated from latin american population. in this series, the neoplasms have equal prevalence for female and male patients, all from elderly group. the morphologic feature extremely varies in each tumor, the malignancy criteria were correlated in two cases with vascular invasion and this coincides with metastasis. a peculiar finding are the only expression of glucagon in tumoral cells, and two malignant cases with liver metastasis. estrogens regulate the development, maturation, and function of various organs, including the thymus. therefore it is suggested that estrogens play important roles in the development of human thymoma. however there is no study about influences of sex steroids to human thymoma. in this study, we examined the immunohistochemical localization of sex steroid receptors for estrogen (er)α and erβ, progesterone (pr)-a and pr-b, and androgen (ar) in human thymoma (n= ), and correlated these findings with various clinicopathological parameters. we used reverse transcription polymerase chain reaction (rt-pcr) and realtime pcr to further study the expression of these receptors in thymoma cases. results immunoreactivity for all sex steroid receptors was detected in the nuclei of thymoma epithelial cells. the percentage of immuno-positive cases and h-score values for each receptor (mean±sd) were: erα, . % and . ± . ; erβ, . % and . ± . ; pr-a, . % and . ± . ; pr-b, . % and . ± . , and ar, . % and . ± . , respectively. results of real-time pcr were consistent with those of immunohistochemistry especially results for erα, pr-b, and ar. a significant positive correlation was detected between immunoreactivity for erα and pr-b. erα immunoreactivity was inversely correlated with tumor size, clinical stage, who classification and ki- labeling index. in addition, the status of erα immunoreactivity was significantly associated with a better clinical outcome in thymoma patients. conclusions sex hormones receptors express in human thymoma, and especially erα may be related to sex, clinical stage and pathological cell type. galectin- immunodetection using a biotin-free system in a series of oxyphilic (hurthle) cell tumors of the thyroid m volante , f bozzalla , r depompa , c pecchioni , a bartolazzi , m papotti dept. biomedical science and human oncology university of turin, turin, italy s. andrea hospital, university of rome, rome, italy introduction galectin- was reported to distinguish follicular and papillary carcinomas of the thyroid from adenomas, but controversial results were obtained in oxyphilic cell tumors, possibly related to endogenous biotin reactivity. the aim of this study was to assess the role of galectin- immunodetection in a large series of benign and malignant oxyphilic tumors. materials and methods galectin- expression was retrospectively analysed in thyroid oxyphilic (hurthle) cell tumors, including adenomas [oa], carcinomas [oc], oxyphilic variant of papillary carcinoma [optc] and in control cases of goiter with oxyphilic changes and hashimoto's thyroiditis. a purified galectin- monoclonal antibody and a biotin-free immunoperoxidase procedure were used in paraffin embedded specimens. results of ocs were focally ( cases) or diffusely ( cases) positive. / optc were focally ( cases) or diffusely ( cases) reactive. overall, malignant oxyphilic tumors were positive in % ( / ). oa had a focal reactivity in % ( / ) of cases, with a preferential subcapsular immunostaining. sensitivity and specificity were % and %, respectively. control oxyphilic goiters were negative ( / ), as opposed to hashimoto's thyroiditis (oxyphilic cells positive in / cases). conclusion the role of galectin- immunoreactivity in the differential diagnosis of benign and malignant follicular lesions is confirmed also in oxyphilic cell tumors. the focal immunoreactivity observed in adenomas may be probably related to a true expression of galectin- , as confirmed by mrna expression by means of in situ hybridisation, and could be related to early malignant changes in tumors still lacking the currently accepted morphological signs of malignancy. introduction fine-needle aspiration (fna) is a very useful method for diagnosing various lesion in the thyroid gland, among them hashimoto's thyroiditis (ht). although many methods may be used, fna is a necessary diagnostic procedure nowadays in order to confirm the diagnoisis of ht. material and methods durind a period of years citologically aspirates were citologically analyzed, stained with he and mgg. the main cytological guidelines in the diagnostic procedure were: . lymphocytic cellularity of smears, . oncocytic follicular cells, . a lot of cellular debris. results from aspirates analyzed ( , %) were diagnosed as ht. there was a high statistical significance in sex and ages for the genesis of ht (χ = , ; p= , ). we analyzed correlation between clinical and cytological diagnosis: in cases initial clinical diagnosis was "thyroiditis", and among them ( %) were cytologically confirmed. from patients with an fna diagnosis of ht the same diagnosis was susspected clinically in cases ( %). several authors noted a high incidence of thyroid carcinoma in patients with ht. we researched association of ht and thyroid tumors, and we did not confirm that ht is a premalignant lesion (χ = , , p< , ). conclusion ht and its association with other lesions could be clearly diagnosed with fna, and we recommend fna as a first line investigation in ht. colposcopic and cytologic findings in hpv infection of the uterine cervix r zivadinovic, v lilic, b djordjevic, s petric gak nis, university clinical center, nis, serbia and montenegro introduction uterine cervical carcinoma is a sexually transmitted disease. hpv infection, especialy types , and oncogene is directly associated with occurrence of preinvasive and invasive changes in the uterine cervix ranging from - %. cyto-pathologic effect of this virus presence in a cell is called koilocytosis and occurs by the effect of fragment e on cytokeratin building protein.koss observed these changes back in , describing them as irregular cavities in cell protoplasm, but only later these cytologic findings were related to hpv infection. in our retrospective study we analyzed colposcopic and cytologic findings of examinees in which the diagnose of hpv infection was established by biopsy. material and methods the mean age of examinees was , , and in regards to parity and menarche there was no statistically significant difference between experimental and control group, since coefficient t was lower than , p< , . therefore we concluded that the sample was representative. results sensitivity of cytology in detection of hpv infection of the uterine cervix was , % and the specificity was %. positive predictive value was % and negative %. the most frequent colposcopic findings in the uterine cervix in case of hpv infection were aceto-white epithel in % and mosaic in %. other colposcopic findings were significantly lower (punctate %, leucoplakia , %). in examinees with colposcopically diagnosed hpv infection in external genitalia, the infection was also present in the uterine cervix in , % which was statistically significant for x = , >(x ( ; , )= , ). conclusion based on the results presented above, we concluded that sensitivity of cytology in the detection of hpv infection of the uterine cervix was low and that it was necessary to combine that method with colposcopy and directed biopsy. in case of colposcopically diagnosed condylomas of the external genitalia and presence of pathologic colposcopic findings of the uterine cervix (aceto-white epithel, mosaic), the presence of hpv infection in the uterine cervix can be expected with high probability. fine needle aspirate of papillary thyroid carcinomas in correlation with histological diagnosis material and methods cases of thyroid aspirates were studied in correlation with histological findings. the patients were - years old (mean age , ). cytological diagnosis was made according to morphological criteria such as arrangement of cells, nuclear atypia and special features (colloid, giant cells, psammoma bodies). cytological diagnosis was in agreement with the histological diagnosis in cases ( , %). cases were follicular adenomas and one hürthle cell tumor. in cases of disagreement between cytological and histological diagnosis the cytomorphological findings were analysed. conclusion cytological evaluation of papillary thyroid carcinomas is of high diagnostic accuracy, although overlapping of cytological criteria between the various pathological entities may lead to false evaluation. the value of universal short-term storage cell medium in processing fnab samples for ancillary diagnostic methods introduction the application of ancillary methods to fnab samples is mainly impaired by a limited quantity of cells in the introduction changes in the collagenous matrix may participate in the pathogenesis and progression of human aortic valve stenosis (as). we investigated the expression, localization, rate of synthesis and composition of type i and iii collagens in as. methods type i and iii collagen mrna expression and the immunohistochemical localization of the collagen antigens were studied from as and normal aortic valves. the concentrations of various type i (pinp, picp, ictp and synthetic peptide sp ) and iii (piiinp and iiintp) collagen antigens were measured by radioimmnoassays in soluble tissue extracts and trypsin solubilized calcified and noncalcified matrices of as samples, and healthy aortic valves of different ages. results the synthesis of type i collagen, localized in the myofibro-blasts adjacent to calcified nodules, was - -fold higher in as compared to controls. the proportion of collagen in total protein fraction was % in the healthy valves, % in the noncalcified matrix and % in the calcified matrix of as valves. in calcified valves the ictp content was -fold higher than in the age matched controls and -fold higher than the young control group. in the controls, ictp (r=- . , p< . ) and iiintp (r=- . , p< . ) decreased with age, whereas sp /ictp ratio increased (r= . , p< . ). conclusions type i collagen synthesis was increased in as. localization of this collagen adjacent to calcified nodules and the profile of the c-telopeptide cross-linking indicate that the ectopic aortic valve calcification may have similarities to bone matrix mineralization.introduction the objective of this study was to determine the potential value of digital thermography (dt) for the assessment of micro-and macroangiopathies of lower limbs in diabetes mellitus (dm). we have studied patients (pts) with dm ( male). pts had dm type i, pts had dm type ii, with age varying from to years. thermograms were acquired using an original pc-interfaced thermograph, averaged and reformatted to x -bit images. analysis included filtering, background cutoff, obtaining x-and y-axis profiles and averaged temperature curves (atc), determination of local maximums and minimums of the atcs, definition of anatomic regions, building regions of interest (roi). results following thermogram patterns were found: . asymmetric unilateral hypothermia of st toe (in % of dm i cases; probably indicating microangiopathy); . bilateral symmetrical hypothermia of both feet at the level of distal phalanges (in % of dm i cases); . unilateral hypothermia of foot ('thermo-amputation'); . unilateral hyperthermia of foot and tibial region; . focal hyperthermic regions (diameter = .. cm; indicating potential subsequent ulceration). atcs and symmetric left-right roi comparisons helped distinguishing between macro-and microvascular disease, between neuro-and angiopathy in dm, evaluating therapy effectiveness. dt was most valuable in surgical cases, permitting ( ) to locate the optimum level of amputation and ( ) to detect early the inflammation. conclusion dt results correlate well with pathomorphology, and depend upon dm type, dm duration, and presence of local inflammation. immunomodulatory treatment improves myocardial histopathology and function in patients with biopsyproven myocarditis aim the aim of this study was to determine the impact of immunomodulatory treatment (interferon-α) on myocardial histopathology and contractility in patients with biopsy-proven myocarditis (mc). methods a total of consecutive pts ( / male, mean age + years, baseline ef= . + . %) underwent endomyocardial biopsy which established diagnosis (using modified dallas classification) of mc (active mc in / pts, focal-active mc in / pts, borderline mc in / pts, and healing mc in / pts). all patients received interferon-α (sc application, miu, time pw, for months) on top of conventional triple therapy for heart failure. rebiopsy was performed in all patients after the termination of interferon-α treatment, and both baseline ef and repeated biopsies were analyzed. semiquantitatively we comapred the amount of cellular infiltrate, degenerative and/or necrotic changes, and interstitial fibrosis. repeated biopsies were than classified as improved, no change and/or deteriorated, for each histopathological variable (by pathologists, in a blinded manner). results by the end of interferon-α treatment ef improved significantly ( + . % vs. . + . %), and no deaths were introduction tumor necrosis factor (tnf)-alpha has been recognized as important physio-pathogenic factor in the initiation and continuation of inflammatory cardiomyopathies. experimental and preliminary human studies have demonstrated that tnf-alpha plays a crucial role in enteroviral-induced myocarditis. the aim of this study was to investigate the expression of tnf-alpha and both its receptors (tnfri and tnfrii) in the endomyocardial biopsies of patients (pts) with viral and non-viral myocarditis. myocardial expression of tnf-alpha was then correlated with different clinical and pathologic findings. material and methods tnf-alpha expression was investigated in endomyocardial biopsies obtained from pts with myocarditis and from control subjects by using reverse transcriptase (rt)polymerase chain reaction (pcr) and immunohistochemistry. viral etiology was diagnosed by pcr in cases. immunohistochemistry was also used to analyse both tnf-alpha receptors (ri and ii). score - was used to grade morphological findings. tnf-alpha mrna and tnf-alpha protein was significantly more present in viral myocarditis than in non-viral myocarditis ( / vs / , p= . ). remarkable immunostaining was observed for both receptors, particularly for tnfri. histological analysis revealed that myocardial necrosis (score . vs . p= . ) and cellular infiltration (score . vs . p= . ) were more prominent in tnf-alpha positive cases. among tnfalpha positive cases, tnf-alpha mrnas were greater in pts with more impaired cardiac function. conclusion our findings indicate that the expression of tnfalpha plays an important role in the pathogenesis of viral myocarditis of any etiology and may influence severity of cardiac dysfunction. cytokine effects are more strictly linked to overexpression of tnfri. recurrence of viral myocarditis after cardiac transplantation: a retrospective study in a pediatric population introduction the objectives of this study was tot verify comparatively clinical age reported antecedents and the morphological aspect of the intestinal mucosa in patients sensitive to gluten, hospitalised at iomc (alfred russescu hospital) in the last years. celiac disease is an inflammation most frequently affecting the proximal small intestine, depending on the presence of gluten in the diet, whose pathogenesis seems to be immunological in nature. methods cases were divided in three groups following clinical manifestations types at hospitalisation time: typical digestive, untypical digestive and extra digestive manifestations. intestinal biopsies, made with crosby probe, in children aged between . and years (one single case was diagnosed as late as at the age of ), regardless of gender. then we analysed morphologically (he usual and pas histochemical staining) and immunohistochemically (lymphocytes b, t with possible subtypes). the lesions counted according to the marsh score were at the first biopsy: - marsh i infiltrating lesions (normal mucosa architecture, villi epithelium infiltrated with lymphocytes; lymphocytosis score: lymphocytes / enterocytes); - marsh ii infiltrating lesions (almost normal villi, enlarged crypts with immature epithelium and infiltrated with lymphocytes); - marsh iiia destructive lesions (partial villi atrophy (va) shortened, flattened villi, slight infiltration with intraepithelial lymphocytes and hyperplasic crypts); - marsh iiib destructive lesions (subtotal va clearly atrophied villi, still recognizable, widened hyperplasic crypts containing immature epithelial cells with a higher growth rate and influx of inflammatory cells); - marsh ilic hyperplasic lesions (total va completely absent villi, with severe atrophy, atrophied, hyperplastic glands and infiltrating lesions). the immunohistochemical tests have indicated the prevalence of t lymphocytes (uchl , cd , cd , cd , gama-delta) both in the luminal epithelium with various degrees of aggression in lamina propria and also spread in stroma. b lymphocytes (l ) are distributed prevalently nodular in stroma. conclusion in conclusion, it is cd t cells that are present in particular in the control of the gluten immune response in patients with marsh i and marsh iii lesions. clinical morphological analysis of early forms of polyarteritis nodosa h mazur- introduction polyarteritis nodosa is a necrotic vasculitis of small and medium size arteries of not fully recognized aetiology. however, it occurs mostly in adults, it can also occur in children. the cutaneous form is one of the types of polyarteritis nodosa. it occurs in children very rarely. polyarteritis nodosa is diagnosed on the basis of histopathologic results and clinical criteria established by the america college of rheumatology. the aim of the study was to present cases of polyarteritis nodosa in children. case reports three cases of cutaneous polyarteritis nodosa in year old girls and case of general form of p.n. in a -year old boy at the beginning a tumour of pancreas head was suggested in the latter case. the final diagnoses in all cases were defined on the basis of histopathologic results the morphologic studies showed: skin and subcutaneous tissue specimens of mm diameter and mm thick were evaluated. epidermis and corium were of normal structure. abundant inflammatory infiltration consisting of neutral and acidophilic granulocytes, lymphocytes and plasmatic cells were observed on the boarder of corium and subcutaneous tissue. the infiltration was situated mainly in arterial walls and surrounding fibrous and fatty connective tissue. different degrees of change advancement were observed in the walls of the vessels. some changes were characteristic for an early stage of a disease and were demonstrated as swelling of the vessel wall and surrounding tissues (degeneration stage). in the oedematous wall fibrin concrement and only a few inflammatory cells were present. other cells included abundant transmural inflammatory infiltrations (inflammatory stage). vessel endothelium underwent desquamation and thrombi begun to appear in the arterial lumen. only in few vessels, the process of considerable advancement of changes was observed -a repair process with consecutive fibrosis and thickening of arterial wall with considerable narrowing of its lumen. the described children were treated successfully with corticosteroid therapy and antistreptococcal prophylaxis with long-term remission. comparative morphologic analysis of the small intestine mucosa in a course of coeliac disease p- effects of sildenafile on ipsilateral testis damage following testicular torsion in rats g kale , ih gol , d orhan , n kale hacettepe university, medical school, ankara, turkey gazi university, medical school, ankara, turkey introduction testicular torsion results in damage of the gonad and it is a surgical emergency. testicular torsion evokes infertility as a result of ischemia. the aims of this study were to determine the effects of a vasodilatator agent sildenafile on the testicular damage following testicular torsion. materials and methods forty-two rats included to the study were divided into groups: group ; control, group ; sham, group : torsion (detorsion is performed hours after torsion and orchiectomy is done at the th hour), group ; torsion, detorsion and sildenafile ( mg/kg), group ; torsion and sildenafile ( mg/kg), group ; sildenafile ( mg/kg) without torsion, group ; sildenafile ( mg/kg) without torsion. testicular specimens were examined histopathologically for johnsen tubular score and tubular diameter. the differences of these parameters between groups were evaluated statistically. results johnsen tubular score and tubular diameters were fond to be significantly different in control and torsion groups (p< . ). johnsen tubular score and tubular diameter were significantly higher in the torsion groups which were given sildenafile, and these parameters were again higher in the group which have taken sildenafile at a higher dose (p< . ). conclusion it is concluded that, by inhibiting cyclic guanosin monophosphate specific phosphodiesterase and resulting in vasodialatation, sildenafile reduces the testicular damage caused by torsion (ischemia). introduction autopsy studies in adult patients who had died of sepsis revealed a profound, progressive, apoptosis-induced loss of cells of the adaptive immune system (hotchkiss et al, new engl j med, ; : - ) . in neonatal sepsis and chorioamnionitis, thymus modifications and shrinkage have been exhaustively described (toti et al, hum pathology ; : - ), while morphology of the spleen has not. the aim of this study was to describe the morphology of the spleen in neonates with early onset sepsis and with chorioamnionitis. material and methods the study population has been described previously (toti et al, hum pathology ; : - . ten preterm or full-term neonates who died because of proven sepsis within hours after birth (mean gestational age±sd, . ± . weeks); foetuses spontaneously aborted ( ± . weeks) because of extensive ascending chorioamnionitis. controls included foetuses with induced termination of pregnancy ( ± . weeks) and babies who died suddenly in the perinatal period, without evidence of chorioamnionitis. spleen cell populations were studied by means of immunohistochemistry. results early onset sepsis in the neonates occurred with severe spleen depletion, involving both b and t lymphocytes. in particular, cd +, cd r + and cd + cells were dramatically diminished in the spleen of neonates with sepsis, in comparison to controls. foetuses with chorioamnionitis also showed spleen cell depletion. conclusion these results indicate that preterm and term neonates show an inflammatory reaction similar to that of adult patients, and that chorioamnionitis is associated with an unspecific inflammatory response comparable to that of sepsis. introduction hemophagocytic lymphohistiocytosis (hlh) is a disorder of an immunological disturbance with proliferation of cells of the mononuclear phagocyte system, with the histiocyte as a central cell. it includes two different conditions: primary or familial hlh, an autosomal recessive disorder in which most patients develop the disease very early in life, and secondary hlh associated with neoplastic, autoimmune and a variety of infectious diseases, occurring as sporadic cases throughout life period. clinically the disease is characterised by the occurrence of a hemophagocytic syndrome of prolonged fever and splenomegaly with laboratory signs of cytopenias, lipid, coagulation and liver abnormalities. hemophagocytosis is readily identified in bone marrow, spleen or involved lymph nodes. central nervous system spread of the disease may be present early, but is frequently seen later during the course of the disease. the aim of this study was to presentat an autopsy case of a months old boy. case report signs of hlh were present right after birth. he was treated by the treatment protocol hlh- . the disease later progressed with cns involvement. a complementary bone marrow donor was not found in time. tissue samples collected at the autopsy were proceeded with standard histological and immunohistochemical methods. results severe bleeding in the right lung with other signs of coagulopathy were found as the main cause of death. hepatosplenomegaly was a prominent feature. we detected hemophagocytosis in the bone marrow, liver and central nervous system. conclusions the diagnosis of hlh must be based on clinical, laboratory and cyto/histological findings. the pathogenesis of familial hlh is still not completely understood. introduction a changeable number of goblet cells in intestine epithelium is rarely a matter of consideration among other morphological factors of small intestine mucous membrane atrophy in celiac disease. it is also not evaluated in the current classifications of goblet cell condition in celiac disease. the aim of the study was to evaluate a number of goblet cells in small intestine epithelium with reference to the degree of atrophy in celiac disease. morphological analysis of bioptates of small intestine mucous membrane, taken for a routine histopathologic diagnosis from patients aged from to years, was performed. the patients were diagnosed and treated in paediatric university hospitals in zabrze and bytom in the years - . specimens were stained with haematoxylin and eosin (h.e.) and alcian blue-pas (ab-pas). villous atrophy was evaluated according to the modified marshal scale. results the following types were defined: type - cases, type - cases, type - cases, type a - cases, type b - cases, type c - cases. then, a number of goblet cells per enterocytes of small intestine epithelium of each oligobioptate were calculated. the received results were evaluated statistically with u mann-whitney test. the average number of goblet cells in small intestine epithelium was calculated in relation to the degree of atrophy with the modified marsh scale: type - . (+/- . ), type - . (+/- . ), type - . +/- . ), type a - . (+/- . ), type b - . (+/- . ), type c - . (+/- , ). the analysis used significant relations between an average number of goblet cells in small intestine epithelium and a degree of mucous membrane atrophy in celiac disease. moreover, a correlation according to rang spearmann test showed a coefficient r= . for p< . . conclusions significant relation between a number of goblet cells in epithelium and a degree of small intestine mucous atrophy in celiac disease. it allows an introduction of a new objective quantitive parameter in the evaluation of atrophic lesions. introduction microscopic evaluation plays an important role in diagnosing small intestine inflammatory diseases. defining a degree of villous and brush border atrophy, enterocytes changes, elongation of glandular crypts allows a correct evaluation of treatment clinical effects and child's body response to the applied selective diet. development of immunomorphological studies contributed to confirmation of the autoimmunological basis of several diseases and of the influence of exogenous factors on their development. due to the new approach, evaluation of the changeable character of inflammatory infiltrations including mast cells and marking activity of enteroendocrinal cells have become very important diagnostic elements. the aim of the study is to examine a changeable intensity of infiltrations from mast cells of small intestine mucosa in children in the course of celiac disease. material and method oligobioptates of small intestine mucosa taken in endoscopy from patients (age - years) at the department of pathomorphology in zabrze in the years - . the patients were diagnosed and/or hospitalised in paediatric university hospitals in zabrze and bytom. a degree of villus atrophy was evaluated according to the modified marsh classification. tissue material in paraffin cubes from the routine oligobiopsy of the patients with celiac disease was qualified for immunohistochemical study. immunohistochemical reactions revealed a presence of brown dyed mass cells in intestine mucosa. the cells were evaluated by counting their number in high power fields (magnification x) in each oligobioptate. the received results were calculated statistically with mann-whitney u test. results mean number of mass cells in intestine mucosa was calculated in relation to the degree of villus atrophy according to the modified marsh classification: type (status normalis) - . (+/- . ), type - . (+/- . ), type - . (+/- . ), type a - . (+/- . ), type b - . (+/- . ), type c - . (+/- . ). the analysis showed significant relation between a number of mass cells and a degree of mucosa atrophy in a course of celiac disease. moreover, a correlation after the rang spearman test showed a coefficient r= . for p< . . conclusions significant relation between a number of mass cells and a degree of small intestine mucosa atrophy in a course of celiac disease was shown. defining (marking) a number of mass cells in small intestine mucosa in a course of celiac disease allows an introduction of quantitive method of atrophic changes evaluation as a new objective parameter, especially in cases difficult to diagnose. morphological analysis of tissue reactions in mandible after dental implants of the pressed cocrmo alloy introduction schistosomiasis mansoni infection increases the level of prostaglandins and leukotrienes that are secreted mainly by macrophages within the granulomas. these mediators have a pronounced role in mediation and modulation of inflammation. most non steroidal anti-inflammatory drugs (nsaids) act mainly by inhibiting the cyclooxygenase pathway of arachidonic acid metabolism, thereby diverting it towards the lipoxygenase pathway. these leukotrienes are important in maintenance of acute and chronic inflammatory condition. methods in present study, we used mofebutazone (cylcooxygenase and lipoxygenase inhibitor) and tenoxicam (cylcooxygenase inhibitor) either alone or in combination with praziquantel (antibilharzial drug) in mice infected with schistosomiasis mansoni. we study their effects on liver pathology as pcna (proliferating cell nuclear antigen), granuloma diameters, percent of degenerated ova and type of granuloma after & weeks after infection. results shown that infection increased the percent of positive nuclei in granuloma and in hepatocytes to be about % & % at weeks and these percentages were reduced to be about % & % at weeks after infection respectively. treatment with mofebutazone and tenoxicam produced a reduction in pcna to be about % & % in granuloma and % & % in hepatocytes at weeks and more reduction occurred after weeks after infection. also, mofebutazone tended to produce more protection to isolated hepatocytes (% viability of hepatocyte) than tenoxicam in schistosomiasis mansoni infected mice. combined therapy with praziquantel produced more reduction in pcna and more protection to hepatocytes. it is evident from the present study that, mofebutazone when combined with praziquantel has shown good tolerability more than tenoxicam which was associated with an improvement in pcna, granuloma diameter, % viability of isolated hepatocytes, liver function tests, a fact that would seen to advocate the use of mofebutazone in bilharzial patient. patterns of injury in car and motorcycle accidents jm suárez peńaranda, c bellido, r rico, mt alvarez iglesias, m rodríguez calvo, i muńoz, l concheiro institute of legal medicine, santiago de compostela, spain introduction the role of the forensic pathologist in road-traffic accidents is to detect atypical injuries that could suggest an alternative cause of death, demonstrate natural diseases capable of creating sudden incapacity, and to collect samples for toxicological examinations. the main objective of this work is to study the different patterns of injuries in car and motorcycle fatalities. material and methods we have studied the autopsy reports of deaths related to road traffic accidents ( involving cars and motorcycles). a complete autopsy was performed in every case including toxicological investigation. results the most common cause of death was head injury, responsible for % and . % of deaths in car and motorcycle accidents, respectively. cranial base fractures were more commonly found in passengers rather than in drivers, both for cars and motorcycles ( % vs. % and . % vs. %, respectively). the distribution of cranial vault fractures was similar with percentages of and . for car and motorcycle drivers, versus and per cent for the respective passengers. nevertheless, brain injury was even more frequent in car accidents, accounting for % of the cases, and in motorcycle fatalities, where every single case showed some degree of brain injury. conclusion our results confirm the importance of head injury in road-traffic accidents, especially when motorcycles are involved, being the most common cause of death. although all motorcycle victims wore a helmet at the time of the accident, it did not seem to provide an effective protection, probably because of the high speeds involved. the incidence of cranial fractures and brain injury is higher for passengers than for drivers, probably due to the lack of attention to the traffic of these latter, and the fact that drivers are usually holding the handlebar or wheel at the moment of the accident. heat-induced epitope retrieval in immunohistochemistry c espersen, b crillesen, b jepsen, jw hansen, th veie, h winther, j askaa department of immunohistochemistry, dakocytomation a/s, glostrup, denmark introduction heat-induced epitope retrieval (hier) has dramatically changed the applicability of immunohistochemistry in routine pathology. hier has increased the number of primary antibodies useful on formalin-fixed paraffin-embedded material and in general improved the histochemical staining. the aim of this study was to compare various buffers for hier on a broad range of primary antibodies. materials and methods hier using four different buffers (citrate ph ; tris/edta ph ; dakocytomation target retrieval solution, high ph, code no. s and dakocytomation target retrieval solution ph , code no s ) for pre-treatment of formalin-fixed paraffin-embedded material has been compared using more than different primary antibodies and the envision+tm visualisation system.results hier with citrate buffer retrieve epitopes recognised by the majority of the tested antibodies. however, in several cases the epitopes could not be detected using this method but were retrieved using tris/edta and/or target retrieval solution, code no. s . also retrieval by means of the target retrieval solution, high ph can be used however, the morphology quite often was partly destroyed. furthermore, some antibodies could only be used after enzymatic pre-treatment whereas hier abolished the histochemical staining. conclusion although hier using citrate ph buffer is a standardised and widely used technique, it is in numerous cases sub-optimal or even obliterate the immunohistochemical staining. in general more epitopes can be retrieved using tris/edta ph or dakocytomation target retrieval solution. bone morphology and calcemia in ovariectomised (ovx) wistar rats l markovic postmenopausal oestrogen deficiency results in bone loss (osteoporosis) in humans and experimental animals. wistar rats provide a useful experimental model of post-menopausal osteoporosis. to demonstrate the histomorphometric and histological changes of bone weeks after bilateral ovariectomy in rats and to investigate the impacts of different hormone replacement therapies on the bone. specimens of proximal femur were embedded undecacified for histomorphometric analysis and of distal femoral metaphysis were procured for pathologic examinations. three weeks after ovx the femoral bmd, mean cortical thickness decreased significantly while the number of osteoclasts increased significantly as compared with sham group. the trabeculae became thinner and irregular which changed the bone microstructure in three dimensions. after treatment with different preparations, the above parameters restored to various extents to the sham operation levels. bilateral ovariectomy induced increased osteoclast activity and bone turnover, therefore caused accelerated bone loss. treatment with combined sex hormones preparation could inhibit bone absorption and stimulate bone formation. this investigation was supported by mstd of srbia. vilnius pathological anatomy in the first half of the th century d sabat department of pathomorphology, medical university of silesia, zabrze, polandthe beginnings of pathological anatomy as a separate medical subject were connected in the area of the republic of poland and lithuania with the vilnius university. the first post mortem was done in vilnius by a priest, stefan bisio only in year. at the end of the th century, jakub briotet, a surgeon and anatomist, created a modest anatomical surgery (study). in , jan piotr frank and his son józef arrived to vilnius and became professors of the university. jan piotr frank became the head of the teaching hospital and józef frank the head of the chair of pathology. in november , he started lecturing for students, which he recalled in his "memoirs": several days after my father, i also started a course with a dissertation "de meliori pathologiam tradendi modo" in this speech i put the main stress on a significance of the explanations at the patient's bed-side and of a good knowledge of pathological anatomy… when in , józef frank became the head of the teaching hospital, he founded the first anatomo-pathological study (surgery). most of the samples kept in spirit in the frank's study were eaten by the starving french soldiers during the retreat of napoleon's army. besides frank's study at the vilnius university at the chair of anatomy, there still existed the study founded by briotet. in , the emperor alexander i destined the ruins of the spaska's orthodox church for an anatomical theater. after seven-year redecorations, the building was opened in . besides the theatre itself, dissection room and veterinary institute, it also included a zoological, veterinary and anatomical museum. the growing anatomical museum had, in , preparations including anatomopathological preparations. after closing down the vilnius university and foundation of the academy of medicine and surgery, pathological anatomy was made an individual subject of study. the first lecturer of pathological anatomy in vilnius was ludwik siewruk. he held the classes till and then he took charge of the chair of anatomy at the moscow university. his successor was jan leonow who continued his work until the tsar's authorities closed down the academy of medicine and surgery in . after the academy had been closed down, all the exhibits of the vilnius anatomical museum, including anatomopathological preparations were moved to the anatomical museum of kiev university. few of them remained in the vilnius medical society. introduction t- toxin, a mycotoxin produced by fusarium fungi, is a well-known cardiotoxin that cause myocardial injury, capillary damage, haemorrhage and focal polymorphonuclear cell infiltration. mast cell (mc) is one of the the earliest multifunctional effector cells of the immune system and important constituent of microvasulature in the heart. aim: we wanted to investigate appearance and localisation of mast cells in the heart of t- toxin-poisoned rats. materials and methods adult female wistar rats were poisoned with a single injection of ld- of t- toxin ( . mg/kg sc). rats were divided into two groups: ( ) control group and ( ) t- toxin group. t- toxin was produced in laboratory conditions from fusarium sporotrichoides fungi. animals were sacrificed after the end of the day , , and of the study. cardiac mcs were counted in whole visual fields, magnified by -fold on paraffin section stained with haematoxylin and eosin (he) and giemsa methods. results in the heart of rats treated with t- toxin, blood vessels were congested with thickned walls, and a large number of mononuclear cells was present nearby. hours after administration of introduction bromadiolone is one of the most commonly used rodenticides. this coumarin anticoagulant blocks multiple steps in the coagulation cascade. it is absorbed through the gastrointestinal tract and accumulated in the liver, mainly. the aim of this study was to investigate pathohistological alterations in the liver after oral application of bromadiolone in rodents. materials and methods adult wistar rats and swiss mice, of both sexes, were fed with a ready-to-use baits of low bromadiolone concentration ( . %), for first three consecutive days. animals were sacrificed every day during the one week period, starting with h after the beginning of the experiment. liver paraffin sections were stained by haematoxillin and eosin (he) method. results the pathological alterations detected in all animals ranged from diffuse degeneration to a focal necrosis of hepatocytes and massive circulatory changes. parenchymal degeneration, diffuse oedema and hyperemia were predominant in the liver of animals sacrificed on the first three days of experiment. dissolution of cytoplasm with nuclear pleomorphism in round or ovoid hepatocytes were seen. thickening of the blood vessels with necrosis of endothelial cells were particularly prominent from the fourth to seventh day of experiment. the most interesting finding is the presence of massive hemorrhages with a focal mononuclear cell infiltrations. the majority of hepatocytes were irregular, with macronodular fat transformation of cytoplasm. these changes were the most intensive in male mice on the day of the study. conclusion multiple oral ingestion of bromadiolone induced prominent pathohistological alterations in rodent liver, especially mice. mobile telepathology -a new intringuing tool s seiwerth, l batelja institute of pathology medical faculty, zagreb, croatiathe mobility of information, patient data and images introduced by telemedicine/ telepathology systems designated a completely new viewpoint in pathology. mostly two areas of diagnostic work are so far covered by telepathology service -second opinion/expert consultation and frozen section diagnosis. frozen section diagnosis, is still a very important issue. smaller hospitals, with no sufficient material for a resident pathologist often could benefit by introduction of telepathology. as in many of these hospitals surgery requiring frozen section diagnosis is not performed on a daily basis the telepathology system is not in full use, producing an unfavorable cost-benefit ratio. also establishing a fully equipped frozen-sections lab yields additional costs and personnel cutting frozen sections only occasionally often produce suboptimal. in this the introduction of a mobile telepathology unit could solve some very important problems. the unit should include a fully equipped mobile frozen sections lab including a macro stand and a microscope with ccd tv color camera and a notebook (laptop) computer. the telepathology software used must be stabile and versatile like the pharos/issa system (vamstech, croatia) used by us. by such a system and synchronization of operation schedules hospitals in a radius of up to km around the referral center could be covered without exceeding standard working hours. the issa-server based system option alerting the consultant and referring pathologist by sms that a consultation case is in his mailbox at the server ads additional time effectiveness. a novel high throughput marker validation tool j korbelik, j matisic, c macaulay b.c. cancer agency, vancouver, canada high throughput genetic and expression screening is generating many possible diagnostic markers and therapeutic targets for wide variety of clinical conditions. the rapid validation of these markers is a challenging process. tissue microarrays can be used for the evaluation of many of these markers. however, they have drawbacks and unresolved issues, which are result of the sampling and sectioning problems. we introduce a novel microarray technique based on cell suspensions. multiple slides can be made, all of which are equally representative of the initial samples. a manually operated mechanical device was designed that can deposit distinct spots on the glass slide. each spot of cells deposited in this manner may correspond to unique source. controlling the number of cells per spot their uniformity and size can be achieved by modifying the viscosity of the cell solution or precisely regulating amount of fluid deposited. a fully automated analysis of quantitatively stained microarray samples has been performed to quantify the number of cells per spot, the size of spots, and how reproducible these parameters are. cellular material used in the experimental arrays constructed to date has been acquired from cell lines and liquid prepared lung and cervical specimens. a variety of molecular markers can be evaluated, with minimal cost. fish probes have been tested on cytology microarrays constructed from different lung cell lines. using cell suspensions generated by the dissociation of tissue would enable the creation of more representative samples for clinical marker/target validation or evaluation. key: cord- -buq d k authors: jannes, g.; barreal, j. title: beta regression with spatio-temporal effects as a tool for hospital impact analysis of initial phase epidemics: the case of covid- in spain date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: buq d k covid- has put an extraordinary strain on medical staff around the world, but also on hospital facilities and the global capacity of national healthcare systems. in this paper, beta regression is introduced as a tool to analyze the rate of hospitalization and the proportion of intensive care unit admissions over both hospitalized and diagnosed patients, with the aim of explaining as well as predicting, and thus allowing to better anticipate, the impact on hospital resources during an early-phase epidemic. this is applied to the initial phase covid- pandemic in spain and its different regions from -feb to -apr of . spatial and temporal factors are included in the beta distribution through a precision factor. the model reveals the importance of the lagged data of hospital occupation, as well as the rate of recovered patients. excellent agreement is found for next-day predictions, while even for multiple-day predictions (up to days), robust results are obtained in most cases in spite of the limited reliability and consistency of the data covid- , the disease caused by the sars-cov- virus, has led to one of the largest pandemics known in recent times. it has caused an effective breakdown of many sectors of the economy and of most social activities, as well as an evidently tremendous concern for the health sector, from hospitals over pharmaceutical companies to scientific institutions. from a hospitalary point of view, three types of cases can be distinguished: asymptomatic and mild cases which do not require hospital treatment, hospitalized patients or inpatients, and patients that require admission to an intensive care unit (icu). the large number of patients in the third group is especially problematic for hospitals, because they lead to a sharp peak in the demand for hospital beds, equipment and medical attention, and thus to a saturation of the icus' available space and resources, both material and human. the current crisis has shown that the national and global healthcare and economic systems were insufficiently prepared to supply the demand for medical equipment and staff required to cope with this situation. these issues are ultimately related to the number of infected, and in particular those that will require hospitalization (regular or icu). many studies therefore focus on analysing absolute numbers and patterns of spread, see e.g. dong et al. ( ) , liu et al. ( ) , bi et al. ( ) ; while health management studies in the context of covid- focus mainly on qualitative aspects, such as the design of an emergency plan [cao et al. ( ) ], adaptation of hospital facilities and the importance of communication with staff [grange et al. ( ) ], or on analysing the risk for hospital personnel [cheung ( ) and yu et al. ( ) ] or for other hospital visitors, such as pregnant women ]. here, a complementary point of view is presented, allowing for a quantitative analysis and prediction of the ratio or proportion of patients that require hospital and/or icu admission. the main advantage of these ratios as compared to absolute numbers is that they are scaleindependent indicators of the strain put on the installations, amount of beds and other resources of hospitals of any size in regions with any amount of population. we mention two key applications here. first, this method allows to forecast which proportion of hospital resources and capacity should be reserved for icu purposes during such crises across all hospitals of a particular region. the scale-independence of the ratios means that it can be applied equally to hospitals of all sizes. second, several countries have made use of temporary hospitals created exclusively for covid- patients. the ratios that we will study, and in particular the uci/hosp ratio, provide a very simple and powerful way of planning the distribution of such temporary facilities. the purpose of this paper is thus to provide policymakers in the health sector with statistical and econometric tools to predict hospital occupation rates, both general and at the icu level, during the first phase of future pandemics with features similar to the current covid- pandemic. these predictions will relie on the identification of temporal patterns and spatial effects in the ratios of hospitalized patients over total cases, icu over hospitalized, and icu over total cases. at the heart of the methodology lies the well-known beta regression, which is ideally suited for modeling rates and proportions, and adds several elements of information to the more common predictions based on logistic distributions, such as villalobos-arias ( ), buizza ( ) , bliznashki ( ) , wu et al. ( ) and huang et al. ( ) , or the weibull distribution, as in zhang ( ) . beta distributions have been applied before to the health sector, in gange et al. ( ) , hunger et al. ( ) and moraes et al. ( ) , but for quite different purposes. a three-step methodology will be developed. first, a beta distribution will describe the probability function for all possible values of the ratios of interest; second, a logistic distribution will be used to estimate the time evolution of raw data of diagnosed, hospitalized, icu patients, and recovered patients; third and foremost, a beta regression will be used to develop a prediction method for the ratios described earlier based on their lagged values and on the proportion of recovered patients. to illustrate this methodology, it will be applied to spain during the early-phase covid- epidemic. there are several reasons why spain is an interesting example. first, spain has been one of the hardest hit countries so far, and thus provides a sample of a statistically interesting size. second, parts of the spanish hospital system have indeed been overwhelmed, which is precisely the focus of this research. third, spain's regional division in autonomous communities, each responsible for the collection and communication of the covid- data, means that spain naturally provides a relatively wide and diverse geographical sample. in this sense, spatial patterns will be essential to describe the evolution of the hospital ratios in the spanish health system. the paper therefore develops distribution models for both spain globally (in the main text) and for its regions separately (in the appendices). the methodology is robust and could be applied to other geographical areas. the paper is structured as follows. in the next section, a data description is given to visualize the early-phase spanish pandemic evolution, both temporal and spatial. the following section describes the statistical methods and the econometric models, with an emphasis on the beta regression with spatial and temporal components. some key results with regard to the current covid- data for spain are discussed next. additional information about the methods and the data, as well as detailed results for the spanish regions separately, are given in a series of appendices. the spanish ministry of health records and provides daily data about the pandemic evolution in each of the spanish regions [ministerio de sanidad ( ) ]. figure shows the mean number of newly recorded cases, hospitalized patients and fatalities per inhabitants per day in each of the spanish regions from -feb- to -apr- , counted from the first non-zero day. the plots clearly show the inhomogeneous character of the spatial distribution for all three variables. madrid (md), catalonia (ct), the basque country (bc) and la rioja (ri) are the areas with the highest impact in proportion to their number of inhabitants, while the south, the north-west and the spanish islands present lower values. note that for the first group ("cases") we take the data initially provided by the spanish ministry of health at face value, regardless of whether these cases have been effectively clinically diagnosed through a medical test, or are just based on a symptomatic analysis. this remark is important because the first category (positive medical test) could include asymptomatic patients, whereas the second category (symptomatic analysis) could include false negatives, for example due to influenza or other diseases. in fact, the uncertainty about the true number of people affected by covid- is one of the major current incognita. coma et al. ( ) suggest that several thousand covid- cases in catalonia alone may have been misdiagnosed as influenza. for italy, modi et al. ( ) estimate that the true number of covid- might be at least twice the official number, while vollmer & bommer ( ) estimate a factor of possibly to worldwide. an advanced mathematical model for undetected infections and their influence on the spread of the covid- virus has been developed in ivorra ( ) . figure shows the temporal evolution of cases, inpatients, icu patients, deaths, and recovered patients in absolute numbers for each spanish region, plotted from the day of the first official case recorded (which can differ by various days from region to region). while the number of cases follows a qualitatively similar evolution in all regions, there are some interesting differences in the evolution of the number of hospitalized patients. in particular, in cm (castilla-la-mancha) and madrid (md) these had already started to go down by april th, while the other regions were still in an increasing phase. as stated in the introduction, this paper aims to provide policymakers and hospital managers with some statistical methods to manage future similar situations, depending on the strain put on icus. we will from now on focus on the proportion of hospitalized patients to total cases ( a), the proportion of icu over total hospitalized patients ( b), and finally the proportion of icu patients over total cases ( c), since these are the variables crucial for the research goal. at the global (spanish) level, these variables are defined as where the summation is over the regions, and the index t indicates that these are calculated day by day. note that the third variable can in principle be obtained as the product of the previous two. as mentioned before, there is a large uncertainty about the real number of infected, so the description "cases" should be taken with caution, since this number can fluctuate a lot depending on whether one refers to "infected" (but not necessarily ill), "symptomatically diagnosed" or "clinically tested", and in the latter case: through pcr or antibody testing. current data on the number of cases is therefore rather unreliable and inconsistent, since different countries or regions use different methodologies. in any case, the methodology that we will present is independent of how the cases are counted. as we will show, it allows an accurate prediction of the three proportion variables just defined. figure shows the geographical distribution of the mean of these three variables over the period considered (starting from the first case recorded until april th). the first map shows . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . the ratio of hospitalized over total cases, and shows that regions such as madrid (md), castilla-león (cl), catalonia (ct) and the basque country (pv) present a higher rate of hospitalization than extremadura (ex), galicia (ga) or la rioja (ri). the second map shows the severity of the hospitalized cases, i.e. the ratio of icu patients over total hospitalized patients, with high recordings in murcia (mc) and the canary (cn) and balearic (bi) islands, and low values in center-north: castilla-león (cl), la rioja (ri) and the basque country (pv). the last plot involves icu cases over total cases, which is crucial to estimate hospital strains. catalonia (ct), aragon (ar) and the canary (cn) and balearic (bi) islands record the highest values; galicia (ga), extremadura (ex) and la rioja (ri) the lowest. the diversity in the recorded patterns is striking. with regard to the ratio of hospitalized over cases (red line), some regions present a relatively constant ratio, such as andalusia (an), aragon (ar) or navarra (nc). others show an increasing pattern, with saturation already achieved by -apr, as is the case in castilla-león (cl), catalonia (ct), or galicia (ga); or not yet, such as in asturias (as). madrid (md) and castilla-la-mancha (cm) had a strongly increasing initial phase, which transformed quite suddenly into a steadily decreasing phase. the ratio of icu over hospitalized (blue) and icu over cases (green) show less obviously striking variety, but can also be divided into roughly constant, increasing and (already) declining. we insist that these are ratios, and therefore do not directly reflect whether the absolute numbers are increasing more or less rapidly. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . in the remainder of this paper, we will use the data up to -apr to construct a model and make predictions, and verify this with the data from -apr to -apr, which is also provided by the ministerio de sanidad ( ). it should be noted that around -apr the criteria for a patient to be counted as a "case" has changed in several regions, which started including asymptomatic patients from this date on. as stated before, the accuracy of the predictions could be further improved by introducing more reliable data. but it is worth stressing that the model itself does not depend on this, and the predictions are reliable and accurate within the assumptions and limitations of each counting method. this paper uses a combination of statistical and econometric analysis in different steps. first, a beta distribution is used to estimate the density and distribution function of the study variables (the ratios defined in eqs. ) for both spain as a whole and the spanish regions separately. note that this distribution does not involve any time parameter. second, a logistic distribution is used to describe the time evolution of the cumulative raw data; in other words, the absolute number of diagnosed, hospitalized, and icu patients, as well as recoveries, is estimated through the use of a logistic functional form. these auxiliary results are used as input for the third and main step, namely the beta regression in which the ratios and their evolution is predicted, and which also includes an analysis of the temporal patterns and spatial effects in the variance of the modelization. we begin by briefly summarizing these different elements. the beta distribution b(α, β) is a family of two-parametric probability distributions limited to the interval y ∈ [ , ]. it therefore naturally applies to probabilities and proportions, such as the ratio of hospitalized over total cases, or of icu over hospitalized cases, that we are interested here. it is historically accredited to karl pearson, based on the beta integral studied by euler and legendre in the th century. the beta distribution is characterized by a probability density function where the parameters α, β > , and the normalization constant is precisely the beta integral mentioned above, with Γ(·) the gamma function. it can be shown that the beta distribution's expected value or mean µ and variance σ are respectively. these parameters allow an alternative definition of the beta distribution [ferrari & cribari-neto ( ) ] in terms of µ and a new parameter φ = α + β, such that b(µ, φ) is described by the equivalent probability density function note that . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . and therefore, for given mean µ, larger φ implies smaller variance. the parameter φ is therefore usually referred to as a precision parameter. this alternative parametrization forms the basis for the beta regression model discussed below. we insist that this distribution describes the probability distribution of all data points, but does not contain an explicit time variable. logistic distributions form the basis for many population models in general [richards ( ] , including epidemic outbreak models [chowell ( ) ], and have been applied to the covid- pandemic for example in wu et al. ( ) . one possible way of writing a logistic population model is where n t represents the population at time t, k * = log(k − n )/n , with n the initial population, r the growth rate, and k the carrying capacity (or asymptote). this is implemented in r through the parametrization asym = k, scal = /r and xmid = k * /r, see the table in fig. a below. note that eq. ( ) is obtained as a solution of the logistic or verhulst equation, which is a first-order differential equation of the form which describes a population (e.g., number of infected) whose size n grows in time proportionally with the existing population size, and with a quadratic saturation effect. this saturation can be due to competition for resources (food, space etc.) for a general population model, or to growing immunity, decrease of the non-infected population, or sanitary counter-measures in the case of an epidemic. we describe this in more detail in appendix a. since the dependent variables represent ratios or proportions, the final step consists of a beta regression [cribari-neto & zeileis ( )]. thus, for a random sample y = (y , , .., y n ) of proportions, where it is assumed that each y i ∼ b(µ i , φ i ), the beta regression model consists of two predictor functions. first, for the means µ i : where θ = (θ , ..., θ k ) τ and x i = (x i , ..., x ik ) τ are k × vectors representing the regression parameters θ j and the independent variables (or covariates) x ij , respectively, and g(.) is a so-called link function. the independent variables x ij could include pandemic features such as the lagged values of the same variables, as well as exogenous factors such as the proportion of recovered patients. to avoid problems of multicollinearity between variables, the correlation matrix and variance inflation factors (vifs) are calculated, see section . . the vector of regression parameters θ (as well as γ, see below) is determined through a numerical maximum likelihood procedure based on the sample y . the scalar product thus gives a linear prediction for the values of g(µ i ). in models with a non-zero intercept (such as we will encounter here), the x i can be taken x i = (∀i). the link function g(·) maps the restricted domain of the beta distribution (y ∈ [ , ]) to the range of the independent variables (in the most general case, r), and can in principle be chosen freely in order to provide an optimal fit. a usual choice, which is known to provide good results in a wide range of applications and moreover is conceptually indicated for the current model because of its relation to the logistic function, is the logit function. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . a second predictor function is developed for the precision parameters φ i : where γ = (γ , ..., γ p ) τ is the vector of regression coefficients and z i = (z i , ..., z p ) τ the set of independent variables. note that basic beta regression models use a constant parameter φ. however, we are interested in analysing the influence of temporal and spatial patterns, as well as cross effects, on the variance of the model, and these can ideally be studied by allowing for space and time-dependent precision parameters φ i , see eq. ( ). in order to select which effects should be included in determining the φ i , an akaike (aic) and bayesian information criteria (bic) are applied [akaike ( ) and schwarz ( ) ]. in these criteria, the following quantities are minimized, respectively, where Λ represents the maximum log-likelihood, n the sample size and k the number of parameters (spatial, temporal or mixed precision coefficients) to be estimated by the model. these criteria thus incorporate a penalty for overfitting, ensuring that only a limited number of relevant parameters are selected. to illustrate the previously developed methodology, it will now be applied to the early phase of the covid- epidemic in spain. we start by modelling the distribution of the dependent study variables defined in eqs. ( ) in spain according to a beta distribution. table shows the beta distribution coefficients (α; β) from eqs. ( ) and ( ) figure represents the density and cumulative distribution functions obtained from the parameters shown in table for the three ratios. the large difference between them is obvious from this figure. in particular, icu/hosp has a strong slope and faster cumulative progress in its probability distribution in comparison with the other two variables. this means that, according to the beta distribution model, all the values for this ratio icu/hosp lie in the narrow range ( − . ), whereas the other two ratios have a wider range. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . table . the graphical results of a statistical analysis showing that this beta distribution model fits the empirical data to excellent degree is given in appendix b. the density and distribution function of the study variables for each spanish region separately are shown in appendix c the table in fig. a records the estimated parameters of the logistic coefficients for the (absolute) cumulative number of covid- cases, hospitalized patients, icu patients, and recovered patients. all coefficients are highly significant, and a functional form is thus obtained to develop an estimation. figure b plots these functional forms, as well as the real data and a forecast for the next two weeks. since the fit between the functional forms and the real data is excellent, the forecast can be expected to be quite reliable, and this will be used to propagate the beta regression and make forecasts for the ratio variables defined in eq. ( ). nevertheless, it should be stressed that the logistic prediction is based on the simple logistic model that we have described in section . and calculated for each variable separately. this gives a rather smooth prediction, with the drawback that any sudden variation in, for example, the number of hospitalized patients will not be accomodated by the next-day forecast for the number of icu patients. in that sense, the beta regression that we will describe next is more powerful, since it incorporates cross effects between the variables. logistic descriptions and predictions can also be made for each spanish region separately. these are developed in appendix d. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . in this section, a beta regression model is developed for the ratios hosp/cases, icu/hosp and icu/cases defined in eqs. ( a), ( b) and ( c). as independent variables, we consider the lags of the two first variables (i.e., their values one day before) as well as the recovery ratio (recovered patients over number of infections). the modelization also includes spatial patterns, temporal trends, and their cross effect through the precision coefficients. to confirm that a meaningful regression model can be built with the independent variables just described, a twofold consistency analysis is performed previously. first, it is verified that the correlations between the independent variables are weak or at most moderate (|r| < . ). second, a multicollinearity analysis shows that the vifs or variance inflation factors are low (vif < ) in all models, so there is no risk of meaningless overfitting [fox & monette ( ) ]. for this reason, the model does not include the lag of the third ratio, icu/cases, since-as mentioned above-this can be obtained as the product between hosp/cases and icu/hosp, and it is thus easy to understand that it is strongly correlated with both, and thus leads to multicollinearity and high vif problems. further details are given in appendix e. a crucial element of the model is the precision parameter φ, defined in eq. ( ) and discussed in section . . this precision parameter determines the variance of the beta distribution, and thus the reliability of the forecast. it can be taken either as a global parameter (a single φ for the whole distribution), as dependent on temporal effects only (φ evolves with time from the onset of the epidemics), as dependent on spatial effects only (a separate φ i for each region i), or a mixed model which includes both temporal and spatial effects. both the aic and the bic criterion indicate that in two of the three cases the mixed model is by far the best, in spite of the fact that it has the highest number of parameters (and thus is the most penalized), i.e.: both spatial and temporal effects are sufficiently relevant and should be taken into account. in the third case (icu/hosp), the mixed-effect model is slightly outperformed by the spatial-effects-only model, but since the difference is tiny we also apply a mixed-effect model here. details of the aic and bic are given in appendix f. table shows the coefficients obtained for the beta regression model of the study variables. the precision coefficients are given in appendix c. the very high significance levels and pseudo-r values indicate that the obtained beta regressions provide excellent models for the empirical data. this is confirmed by the application of the model to the data for spain as a whole, as shown in fig. , as well as for the regions separately, see appendix g. the incidence of the factors considered is quite different. for the hosp/cases ratio, the lagged value of hosp/cases itself is much more important than the lagged value of icu/hosp, and vice versa, which seems reasonable. for the third ratio, icu/cases, the contribution of both lagged values is of the same order of magnitude. the recovery rate, finally, has a small but statistically significant influence on the various ratios. curiously, this influence is in fact positive on the icu/hosp ratio: an increment in the recovery rate leads to a (small) increase in the icu/hosp ratio. this can probably be understood as follows: patients who are considered "recovered" in the early phase of the epidemic are likely to come from the "light" (non-icu) category of patients. removing them from the pool of hospital patients therefore automatically increases the relative share of severe (icu) cases. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . the complete list of the precision coefficients φ i is given in appendix h. here, we limit ourselves to some general observations. the spatial patterns are highly significant for a majority of the spanish regions, for all three ratios. the temporal trends are highly significant for hosp/cases and icu/hosp, but not for icu/cases. the cross effects (spatial and time) are, again for all three ratios, highly significant for a majority of the spanish regions. with respect to their concrete incidence, it is striking that the cross effects for each single region are negative with respect to hosp/cases and positive (with one single exception) with respect to icu/cases. we don't have a straightforward interpretation for this phenomenon, but the main conclusion is that space-time cross effects are relevant for the determination of the precision parameter, and hence for the beta regression model in general and its dispersion in particular. figure plots the mixed beta regression models for the three ratios for the period until -apr. this mixed model (with space-time cross effects) is seen to adjust very closely to the real data, and so will be used next to make forecasts. figure represents the next-day prediction for the three ratios according to the beta regression results. the horizontal plane of this d plot represents all possible lagged values of the hosp/cases and icu/hosp ratios (on a scale from to ), i.e.: the previous values of . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint these variables (at a lag of day). the vertical axis then shows the beta regression prediction for the dependent variable day later, from left to right: hosp/cases, icu/hosp and icu/cases. in this prediction, for graphical convenience, a single constant recovery rate is assumed, namely %, which is the mean recorded by the study database. obviously, this prediction can be further improved numerically by adjusting this recovery rate. once this has been established, the main point of interest is to make predictions for the real data for each ratio. this is represented in fig. . two predictions are plotted here for the period -apr to -apr: the next-day predictions based on the real data, and a prediction based on the logistic forecast of the number of diagnosed, hospitalized, icu patients and recovered cases. in other words, to calculate the prediction for, for instance, -apr, the real-data next-day prediction is based on the beta regression prediction obtained from the recorded ratios -apr, whereas the logistic forecast uses the recorded data only up to -apr, propagates this into a logistic forecast up to -apr, which is then fed into the beta regression to obtain a prediction for the ratios on -apr. as can be seen, the next-day predictions are extremely close to the real data. the multipleday prediction obtained through the fitted values from the logistic expression of table a shows a stronger difference with respect to the real values. however, both in relative and in absolute terms this difference is still very reasonable (or said in other words, the scale of the graphs is strongly adjusted to the range of values, which might lead one to visually overestimate the error). figure : prediction of the three ratios hosp/cases, icu/hosp and icu/cases for spain as a whole based on the beta regression and comparison with real data for the period -apr to -apr. in all three figures, the y-axis range is strongly adjusted to the range of values. nevertheless, it is worth analysing the origin of these differences between the logistic-based beta regression and the real data. first, there is the intrinsic fact that this forecast is used for a prediction several days ahead, whereas the real-data prediction uses the empirical data . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . from the day before and so is much more cautious. however, the main reason for the differences lies in the poor quality of the data. two issues stand out here. first, the different regions have used different criteria and methods to count the number of cases. second, these criteria have even been changed precisely in the period that we use to make our prediction, which is particularly obvious from the jump in fig in the first few days of the prediction. obviously, this makes it highly complicated to make any accurate predictions, and makes it very difficult for hospital managers to make any reasonable planning. the simple logistic model that we have used (see also appendix a) is particularly vulnerable to this, since it does not adapt from one day to the next, which also contributes to the relatively large errors shown in fig . more advanced logistic models, see e.g. [wu et al. ( ) ] could be used to predict the absolute numbers of cases, and derive from it a beta prediction for the ratios that we have studied. finally, it should be stressed that the logistic-based forecast gets the slope essentially correct, and in fact even ascertains the correct value within an error margin of roughly % over the complete time range of prediction performed here (i.e., days). this illustrates the robustness and usefulness of the methodology. the predictions are further specified by region in appendix i. logistic models are the most commonly used statistical models for the study of epidemic evolution. in this article, we have discussed how these can be complemented through the use of beta distribution and regression models. beta models are useful for variables whose values are limited to the range [ , ] and are thus naturally suited to describe proportions. in particular, we have described how they can be used to describe the ratio between hospitalized patients and diagnosed cases (hosp/cases), between icu patients and hospitalized cases (icu/hosp), and between icu patients and diagnosed cases (icu/cases). these variables are particularly relevant for hospital management in the early phase of an epidemic crisis such as the one that we are currently experiencing due to the covid- virus. indeed, these ratios are indicators of the strain put on hospital resources in general, and of icu units in particular. moreover, they have the advantage of being scale-independent, and therefore adaptable to any hospital or region of any population size. they can thus help in planning contingency measures, making resource estimates, and reserving hospital capacity across all hospitals in a given region or country, independently of size. they also provide a robust way of planning the distribution of temporary facilities dedicated exclusively to the epidemic. the beta regression model developed here depends on the -day lagged value of the hosp/cases and icu/hosp ratios, as well as the patient recovery rate. the lagged value of the third ratio, icu/cases, was not used in the model as it would lead to dependency and multicollinearity issues. it was also shown that the most performant model includes mixed space-time effects in the precision coefficient of the beta distribution. these precision coefficients are indicators of (inverse) variance, and allowing them to vary across regions and along time thus allows to minimize the resulting variance. this model has been applied to the early-phase covid- epidemic in spain. it has been shown that next-day predictions for these ratios based on a beta regression model are extremely reliable. for longer-term predictions, the error was obviously larger. the main cause of this error was pinpointed to lie in the lack of consistency and reliability of data in this early phase of the epidemic. this became obvious even at the spanish level: different regions have used different criteria to count covid- cases, possibly also of counting covid-related hospitalized and icu patients, and have even changed their criteria during the crisis. this renders highly difficult a serious statistical analysis of the situation, and more importantly: makes it highly difficult to make serious hospital management predictions and provisions. in this sense, universal guidelines on how to collect, classify and publish data for such pandemics, for example issued by the who, might be useful. nevertheless, the methodology has been shown to be rather robust against these difficulties and to provide relatively reliable forecasts. in particular, for a -day prediction from -apr to -apr, . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . the logistic-based beta regression still gets the slope essentially correct, and the concrete values obtained for the three ratios that were analysed remain within an error margin of % compared to the real data. finally, it should be pointed out that the spanish ministry of health has in the meantime issued updated data. we plan to apply the method developed here on these updated data sets. in particular it would be interesting to see whether propagating the beta regression without the auxiliary logistic step leads to reliable and robust predictions of the ratios when applied to such updated and more realistic data. in this appendix, we briefly review basic mathematical population growth models and how these can be solved with differential equations, see e.g. [boyce & diprima ( ) ]. imagine a population n (e.g., number of infected) which increases with time t at a rate r proportional to the existing population (existing number of infected): the solution is n (t) = n e rt where n = n (t ) represents the initial population. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . taking the (natural) logarithm on both sizes, this can also be written as ln n n = rt or, for any time difference: the main drawback of this model is that it does not include saturation effects. as a population grows larger, competition for resources (such as food) come into play. if the considered model regards a subpopulation (e.g., number of infected), the growth rate could also decline because of the corresponding decrease in the pool of non-infected population members, or because of sanitary counter-measures and forced social distancing. such saturation effects can most simply be modelled as a negative quadratic influence, i.e.: this is structurally identical to the well-known logistic equation, whose solution is therefore the logistic or verhulst function, which in this case can be written as where c = n r−n b . in the long term the population tends to the (stable) value regardless of the initial population n . by defining k = r/b, the expression given in eq. ( ) is found. the function ( ) has the typical sigmoid (s-shaped) form seen in fig. b . finally, let us briefly look at the case in which one is interested in a proportion between two populations. assume that both are described by a simple exponential evolution as described above the ratio z ≡ n m then follows z(t) = z e (r −r )t where z = n /m . only if both populations grow at exactly the same rate (r = r ), a non-exponential result is found, namely the constant ratio likewise, it can be shown that the inclusion of saturation effects will still lead to a logistic function for the ratio of populations. b beta distribution for spain: comparison of model with data figure compares the beta distribution obtained as a fit for the three ratios, hosp/cases, icu/hosp and icu/cases. in each case, the top-left plot provides a comparison between the functional form of the proposed models and the empirical cumulative distribution. the top-right graphs show the corresponding histograms. the two bottom figures represent the q-q and p-p plot, i.e. a comparison between theoretical and empirical values in terms of . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . quantiles (left) and of probabilities (right). the agreement in all cases is excellent, with the exception of t the apparent discrepance in the q-q plots at high ranges is an artifact of this quantile representation, as can be seen from the other graphs. all in all, the agreement between the models and the empirical data is excellent. in each case, the solid line represents the theoretical beta distribution model, the dots (or bars, in the case of the histogram) the empirical data. section . contained the beta distribution analysis for spain as a whole. fig. similarly shows the beta distribution and cumulative density function for each region separately. there is a relatively large variety of slopes and patterns. this can be seen for the ratio hosp/cases, which is more extended in madrid, catalonia, or castilla-león than in other regions, and especially than in aragon (ar), murcia (mc) or navarra (nc). it is also true for the ratio icu/hosp, which has a rather large spread in extremadura (ex), canary islands (cn) or castilla-león (cl), and is much more peaked in madrid (ma), andalusia (an) or aragon (ar). the ratio icu/cases, finally, looks more homogeneous across the regions, with a sharp peak at low values. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , june , . . https://doi.org/ . june , / doi: medrxiv preprint figure a , of hospitalized patients in figure b , icu patients in figure c and recovered patients in figure d . in each figure, the red line represents the real data (as previously, obtained from [ministerio de salud ( )] up to -apr, and the blue line describes the values according obtained from the logistic functional form, region per region, which are extended to a prediction up to -apr. in most cases, the fit between the model and the real data is excellent, especially in the early period studied. in some regions, such as extremadura (ex), castilla-la mancha (cm) or valencia (vc), the empirical pattern changes rather abruptly towards the end of the recorded data, and this leads to larger differences between the model and the data. as mentioned in the main text, this is most likely due to a change in the counting methodology or classification criteria adopted by the regions during this period, which becomes particularly clear in the (temporary) decline in the empirical data in some of the regions, even though these represent cumulative numbers. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , june , . . https://doi.org/ . june , / doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . when constructing a regression model, it is important to verify that the correlation between all possible pairs of variables are low, and that there are no multicollinearity problems. otherwise, this could lead to meaningless overfitting and spurious results. the correlation matrix in fig. a shows that all pairs of variables show adequate correlation values (r < . ) and can therefore be used in the regression model. the vif (variance inflation factor) for each model (no effects, temporal effects only, spatial effects only, mixed space-time effects) are shown in the table of fig. b . low values are obtained in every model (vif < ), so the models avoid the multicollinearity problem. note that the inclusion of the lagged value of icu/cases has also been considered, but since this presented high vif values as well as strong correlation with the other variables, it has not been withheld as an independent variable. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint g beta regression model per spanish region fig. g shows the beta regression model using mixed space-time effects and a comparison with the empirical data for each ratio and for each spanish region separately. it can be seen that there is a wide diversity of patterns across the regions. however, the beta model adjusts to all of them, in most cases to an excellent degree. because of the results of the aic and bic analysis, see appendix f, the beta regression model assumes that the precision parameter is not constant, but depends both on the evolution of time and on the concrete spanish region, as well as on space-time cross effects. these precision coefficients by time and region, as well as their cross effects, are listed in table . note that most coefficients are significant only for two (or exceptionally even only one) of the ratios. however, overall, each block is highly significant, at least for a majority of the regions. this is in agreement with the result of the aic and bic analysis just mentioned. to illustrate this, when looking at the temporal patterns, these are not significant for icu/cases, but they are highly significant for both hosp/cases and icu/hosp. an analogous observation applies to the spatial coefficients: for most regions, the spatial coefficient . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . is not significant for one of the ratios -for aragon (ar), cantabria (cb) and navarra (nc) even for two of the ratios. however, they are highly significant for the two other ratios -or the single remaining ratio for the three regions just mentioned. the significance of the cross effects could be detailed in a similar way. fig. shows forecasts per spanish region for the three ratios hosp/cases, icu/hosp and icu/cases. it shows similar strengths and weaknesses as fig. for spain as a whole. the next-day prediction based purely on the beta regression using the -day lagged ratios is excellent in almost all cases. the multiple-day prediction based on the logistic forecast is quite good for most variables in most regions, although there are some cases with a relatively wide difference. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . information theory and an extension of the maximum likelihood principle epidemiology and transmission of covid- in cases and of their close contacts in shenzhen, china: a retrospective cohort study a bayesian logistic growth model for the spread of covid- in new york elementary differential equations probabilistic prediction of covid- infections for china and italy, using an ensemble of stochastically-perturbed logistic curves maternal health care management during the outbreak of coronavirus disease (covid- ) staff safety during emergency airway management for covid- in hong kong fitting dynamic models to epidemic outbreaks with quantified uncertainty: a primer for parameter uncertainty, identifiability, and forecasts excess cases of influenza suggest an earlier start to the coronavirus epidemic in spain than official figures tell us: an analysis of primary care electronic medical records from over million people from catalonia beta regression in r an interactive web-based dashboard to track covid- in real time beta regression for modelling rates and proportions generalized collinearity diagnostics use of the beta-binomial distribution to model the effect of policy changes on appropriateness of hospital stays responding to covid- : the uw medicine information technology services experience spatial-temporal distribution of covid- in china and its prediction: a data-driven modeling analysis longitudinal beta regression models for analyzing health-related quality of life scores over time mathematical modeling of the spread of the coronavirus disease (covid- ) taking into account the undetected infections. the case of china. communications in nonlinear science & numerical simulation the reproductive number of covid- is higher compared to sars coronavirus evolución diaria de la pandemia de covid- en españa. spanish ministry of health, consumer affairs and social welfare total covid- mortality in italy: excess mortality and age dependence through time-series analysis. preprint from medrxiv intelligent assessment based on beta regression for realistic training on medical simulators. knowledge-based systems a flexible growth function for empirical use estimating the dimension of a model estimation of population infected by covid- using regression generalized logistics and optimization heuristics generalized logistic growth modeling of the covid- outbreak in provinces in china and in the rest of the world infection control against covid- in departments of radiology parametric regression model for survival data: weibull regression model as an example acknowledgments g.j. acknowledges project fis - -c - -p of the spanish micinn. key: cord- -qwk jkqm authors: delmage, d. a.; kelly, d. f. title: auricular chondritis in a cat date: - - journal: j small anim pract doi: . /j. - . .tb .x sha: doc_id: cord_uid: qwk jkqm a four‐year‐old male neutered domestic shorthaired cat developed bilateral thickening of the pinnae, with slight curling, intense erythema and pain. no ear canal disease was present. the cat was negative for feline immunodeficiency virus, feline leukaemia virus and feline coronavirus. biopsy of the ear lesion revealed auricular chondritis. in humans, histologically similar lesions may involve the pinnae, nose, trachea, joints, eyes and heart, and the disease is termed relapsing polychondritis. the cat reported had a history of corneal damage, resulting in corneal vascularisation and opacity, eyelid distortion, necessitating an entropion operation, and radiological evidence of mild cardiac enlargement. the ear disease responded rapidly to treatment with prednisolone and, apart from slight thickening and curling of the pinnae, the cat remained normal and pain‐free. after two years, the prednisolone was withdrawn, and there was no recurrence of the condition in a follow‐up period of months. relapsing polychondritis is very rare in the cat, and is diagnosed by characteristic pinna! lesions (scott , bunge and others , gauguere and others , involving thickening, distortion, pain and intense erythema. to the authors' knowledge, only three cases have been reported in the literature. the present report describes a cat with a lesion histologically similar to the previously reported cases. ocular disease was also present, and mild cardiomegaly was found on routine radiography. the latter signs were also described in the case by bunge and others ( ) , but not in the other two cases. a four-year-old male neutered domestic shorthaired cat was presented with thickening and intense erythema of the inner surfaces of both pinnae; the ear flap edges were thickened, slightly curled, distorted and painful (fig ) . the condition had developed on both pinnae simultaneously, and the cat twitched and flicked the ear flaps frequently. the outer (haired) surfaces were unaffected, and no external ear canal disease was evident. the cat had exhibited an altered demeanour for about three months before presentation, manifested as hiding away, cowering, resentment of handling by the owner, and aggression towards the other cat in the household. increased skin scaling was evident on the lumbodorsal area, and was non-pruritic, with no parasites found on coat brushings and scrapings. this was presumed to be due to reduced self-groo ming. no other skin disease was found, and there was no previous history of skin or ear disease. n ine months previo~s l y, the cat had been seen by another veterinary surgeo n for corneal vascularisation of the right eye. the condition was fluorescein-negative, and was diag nosed as an o ld wound; probably a resolvi ng corneal ulcer. one month late r, the cat had conjunctivitis in both eyes, in addition to blepharos pasm and slight entropion of the lower lid of the right eye. steroid/antibiotic drops we re administered for these conditions. two months later, the entropion had worsened, and a surgical correction was performed. both eyes continued to show intermittent conjunctivitis, at times fairly severe, for several months. corneal opacity, extensive vascularisation and a weakly positive uptake of fluorescein stain were noted during this time, but no further inves tigations we re performed. at the time of prese ntation for rhe ear problem, rh e ocular lesions had largel y resolved, leaving a slight corneal opacity in the right eye. both eyes were now fluorescein-negative, and a schirmer tear rest showed a slight reduction in tear producti o n in rhe ri ght eye ( mm; normal range to mm), wirh normal rear production in the left eye ( mm). the cat was anaes rherised ro obtain biopsy sam ples; rh e left pinna was biopsied, wirh a v-sec ri on taken from the edge, and a circular punch biopsy from the centre (including ca rtilage). blood samples were taken for hae matological and serum biochemical analyses. res ults we re unremarkable, except for hypoalbuminaemia ( g/lirre; normal range to g!l itre) of undetermin ed cause. the blood sa mple was negati ve for feline leukaemia virus (felv) (elisa), feline immunodeficiency virus (f iv) (elisa) and felin e coronav irus (immunofluorescence test). an antinuclear antibody tesr was also negative. a direct coombs' res r was negative at °c, but positive at a dilution of : at °c. t horacic radiograp hs showed mild to moderate globular cardiomegaly on borh lateral and dorsoventral views. the ve rtebral heart score was approximately - (no rmal ran ge - to - ). t he hea rt rate was beats/m inute and there was no radi ological or clinical evidence of co ngestive heart failure. it was fel t that the heart changes were sugges ti ve o f ca rdi o myopat hy, either dilared , hypertro phic o r intermediate. h owever, since no echocardiography o r ecg was performed, a diagnosis of ca rdi omyo pathy co uld no r be confirmed. the cat was euthyroi d ar this time (rota! thyroxine nmolllitre; normal range ro nmol/litre). biopsy of the pinn a showed a curling distortion of the rip of the auricular ca rtilage, with ex tensive intense fibropl as ia , ca pillary proliferati o n and infiltration by neutrophilic leucocytes (fig ) . inflam matory cells exte nded into eroded superfi cial ca rtil age, where there was extensive linea r loss of matrix metac hrom as ia (fig ) . t here was intense mastocytosis o f auri cular dermis, but no histo logical evidence of its cause. focal areas of dermal mi xed lymphocyte, plas ma cell and mast cell acc umulati on were noted . t he ca t was give n i mg of o ral predniso lo ne daily ( mg/ kg bodywe ight dail y; prednicare; animalcare) and within i days showed a marked improve ment. t he ea r fl aps were much less painful and eryt hemarous, and the ca t was playi ng with rh e o ther ca t in the ho use ho ld and showed improved demeanour. the dorsal sca ling had reso lved . there was no alrerari o n ro the righr co rn ea l opac ity, and no pulmo nary or ca rdi ac abn o rm alities were detected o n ausc ultati on. after rhree weeks, th e predniso lone was reduced ro mg daily ( i · mg/kg/day), and afte r six mo nths co - mg o n alternate days. eighteen months later, the prednisolone was withdrawn completely. there was no subsequent recurrence in the ear condition during the months follow-up period. relapsing polychondritis in humans is a rare condition in which auricular distortion and discomfort are major signs. cartilage in other sites may also be affected, and in a proportion of cases this results in saddle nose deformity (collapse of the nasal septa! cartilage), joint disease, laryngeal/tracheal disease (leading to collapse of the tracheal rings), ocular disease, cardiovascular disease and skin disease. fever, hearing loss, vertigo and anaemia may also occur. associated ocular diseases can include conjunctivitis, scleritis, keratitis and keratoconjunctivitis sicca. cardiovascular changes include aortic insufficiency, pericarditis, arterial aneurysms and arteritis (white , michet and others ) . the disease in humans is believed to be a true autoimmune disorder in which autoantibodies (predominantly immunoglobulin [ig]g) to native type ii collagen are found in titres of up to : (mckee ) . this contrasts with the situation in rheumatoid arthritis, in which autoantibodies to unfurled rype i, ii and iii collagen are found, suggesting that antibody production in this condition is an epiphenomenon rather than the cause of disease (foidart and others , ebringer and others , meyer and others . in some strains of rats, idiopathic auricular chondritis is common, and is characterised by histological changes similar to those described in the present case (that is, auricular inflammation, invasion of conchal cartilage by inflammatory cells and chondrolysis) (mcewen and barsoum ) . in the cat, relapsing polychondritis is very rare. to the authors' knowledge, only three confirmed cases have been reported in the literature. the case described here is interesting because it is similar to that described by bunge and others ( ) ; both cats had evidence of ocular and cardiac changes in addition to the pinna! disease, as can occur in human cases. the other changes seen in humans have not yet been reported in cats. gauguere and declercq ( ) , calling the condition plasma cell chondritis, suggested a possible viral aetiology, since one reported case was fiv positive (gauguere and others ) and one felv positive (bunge and others ) ; the present case was negative for fiv, felv and feline coronavirus. the significance of the positive cold coombs' test result in the present case is uncertain. a titre of : is a low positive result; the cat was not anaemic, and did not have signs of cold agglutinin disease, such as punched-out necrosis of the earflap edges, or a vascular pattern of ulceration and necrosis. also, the histopathological findings were not compatible with cold agglutinin disease. it is of interest that a weak positive coombs' test result of : was found in the case reported by bunge and others ( ) . although the disease in cats has been designated relapsing polychondritis, the authors prefer the description of auricular chondritis in their patient, since they have no evidence of involvement of other cartilaginous tissues, nor does the benign clinical course in this case warrant the use of the qualifier 'relapsing'. clinical differentiation of auricular chondritis from aural haematoma and aural trauma is straightforward; haematoma and trauma are unlikely to be bilateral, nor to be as painful or intensely erythematous. aural haematomas may exhibit cartilage degeneration and irregular erosion adjacent to the haematoma (joyce and day ) but do not show the severe, aggressive and extensive changes seen in the present case. other differential diagnoses include scarring from irritation associated with ear mite infestation, actinic scarring and distortion in cats with unpigmented eartips, discoid and systemic lupus erythe-journal of small animal practice• vol •october matosus, and vascular diseases, such as frost-bite damage, and immune-mediated vasculitis. cases of floppy pinnae in cats (pearson , rest ) may have the same aetiology as reported here. it is clear that such cases justify as full an investigation as possible, including cardiac and ocular assessment, and detailed histopathological examination, in order to assist with diagnosis and understanding of this condition. relapsing polychondritis in a cat autoantibodies to cartilage and type ii collagen in relapsing polychondritis and other rheumatic diseases antibodies to type ii collagen in relapsing polychondritis guaguere and p. prelaud. veterinary times/ veterinary business development polychondrite auriculaire atrophiante: a propos d'un cas chez un chat lmmunopathogenesis of canine aural haematoma relapsing polychondritis auricular chondritis in wistar rats relapsing polychondritis -pathogenic role of anti-native collagen type ii antibodies: a case report relapsing polychondritis: survival and predictive role of early disease manifestations floppy pinnae in siamese cats floppy pinnae in siamese cats feline dermatology - -'the secret sits' relapsing polychondritis the authors are very grateful to dr s. p. dunham for examining and commenting on the radiographs. key: cord- -o rbfmie authors: hussein, osama title: second wave of of covid- is determined by immune mechanism date: - - journal: med hypotheses doi: . /j.mehy. . sha: doc_id: cord_uid: o rbfmie a second wave of new severe acute respiratory syndrome coronavirus (covid- ) cases is widely feared. in fact resurgence of cases has been clearly observed in several countries that had seen flattening of the epidemic curve. in general, relaxation of community control measures is almost always blamed for the resurgence of cases. in this letter, the author describes an immunological explanation for the double-peaked epidemic curve of new viral diseases including covid- . according to this hypothesis, a second wave of cases is due to the effective innate immunity in some of the population. these individuals may later develop clinical disease upon repeated exposure. this theory claims that a double-peaked pattern of new cases in a new viral epidemic is intrinsically determined by the pattern of pathogen interaction with the host. according to this hypothesis, relaxation of the community control measures is not responsible; at least in part, for resurgence of cases. countries. in japan, a crisp two-peak incidence curve is clear( ). similar trends are reported from other countries. the notion of epidemics that normally have two peaks of new cases over time is widely accepted( ); although epidemiologists have not characterized this pattern as an established model. in general, the resumption of international travel or the relaxation of the community control measures are are almost always blamed for the resurgence of the disease incidence. in this letter, this author suggests that a double-peaked epidemic curve is an intrinsic feature of viral outbreaks. according to this hypothesis, immune response to virus exposure in different individuals determines the spread pattern in the community. the two principal divisions of the immune response to pathogens are the innate and the adaptive immunity. both divisions play a major role in the body response to viral exposure. together with the development of clonal virus-specific cd + t lymphocytes, these individuals will experience subclinical or clinical viral illness and are responsible for the early rise in the epidemic curve. assuming the above hypothesis is true; a viral epidemic curve will show an early upstroke corresponding to persons who pass into viremia upon initial exposure to the virus followed by a second slower rise due to cases who develop the disease after repeated process of inoculation and clearance at the point of entry. it is fairly reasonable to assume that the latter group of patients may be the healthier individuals who will have lower case-fatality rate. together with the notion of the covid- cases getting milder with time, objective evidence from japan indicates that the second peak in incidence is not accompanied with a corresponding peak in fatality. the implications of this hypothesis are medically and socially relevant. according to this theory, resurgence of a viral outbreak is intrinsically determined by the nature of the virus interaction with the host. relaxation of the community measures or "reopening" of the economy may not be blamed for a second rise in incidence rates. the theory also provides one explanation for the possible observation of decreased case-fatality over time. in conclusion, the author describes an immunological explanation for a double-peaked epidemic curve of covid- and other new viral diseases. e -e . . who coronavirus disease (covid- ) dashboard. geneva: world health organization beware of the second wave of covid- pathogen recognition and innate immunity activation and evasion of type i interferon responses by sars-cov- human cell tropism and innate immune system interactions of human respiratory coronavirus emc compared to those of severe acute respiratory syndrome coronavirus the author has no potential conflict of interest to declare. key: cord- -tj ye mx authors: nan title: abstract book date: - - journal: ann allergy asthma immunol doi: . /s - ( ) -x sha: doc_id: cord_uid: tj ye mx nan introduction: the effect of anti ige has been described as a function of complexing free ige to reduce mast cell implantation and consequent reduction of mast cell degranulation upon exposure to antigen. theoretically, as total free ige drops below ng/ml, improvement occurs as free and cell bound ige equilibrate and allergic reactions subside. initial observations ( togias a et al. j allergy clin immunol. ; :s )suggested that prick skin tests consistently reached their low point at days with significant reduction in size. laynadier (leynadier f, doudou o, gaouar h, le gros v, bourdeix i, guyomarch-cocco l, trunet p : effect of omalizumab in health care workers with occupational latex allergy.j allergy clin immunol ; : - ) noted some reduction in skin testing in sixty percent of patients treated over a six month period with monoclonal antiige. but clinicians since approval of the drug in have noted that even in the presence of good clinical response to asthma, skin test reactivity is still obvious, and in many cases unchanged. methods: following the suggestions for standard clinical follow up by lanier and marshall ( annals may ) , routine skin prick skin testing was completed after informed consent on patients at onset of anti-ige therapy, and repeated at - months. in all instances were skin tests done and photographed in a standard manner. in a few cases, skin tests were repeated on patients receiving anti ige for as long as five years. results: photographic evidence will be presented. in of patients on current therapy, prick skin testing remained at an almost identical photographic level to the baseline analysis, but there was a correlation between the patients with the lowest serum ige and the likelihood of apparent reduction. there was no correlation to reduction of skin testing and clinical response to anti ige since all patients had experience significant quality of life improvements. conclusion: anti ige has variable effects on reducing prick skin testing, with a greater likely hood associated with low or extremely low initial total ige levels. skin testing is more sensitive for detection of allergen-specific ige than is immunoassay for allergen-specific ige. for some assay methods, the qualitative cutoff of . ku/l is inappropriately high. this study was conducted in order to determine whether a particular assay system can be used to measure lower levels of allergen-specific ige. the pharmacia unicap system was studied. all reagents were purchased from the manufacturer, and the study was approved by a local human assurance committee. to determine background of the calibration curve, the fluorescent unit (fu) response of replicates of assay diluent measured with an anti-ige solid phase was determined. the background responses of arbitrarily selected allergen solid phases (oak, timothy and short ragweed pollen; cat; peanut; yellow jacket venom; penicillin g) were also measured. lower detection limits (lld) were calculated using the mean background measurement + standard deviations (sd). to examine linearity of a low-range calibration curve, : dilutions to extinction were made, starting with the . ku/l calibrator. the mean background of the anti-ige solid phase was . fu, sd . and coefficient of variation (cv) of %; the lld was . this lld corresponded to a level of approximately . ku/l of ige. the lld of the allergen solid phases ranged from . fu (yellow jacket venom) to . fu (short ragweed); this corresponded to about . ku/l ige. the low level dilution curve exhibited parallelism with a curve constructed using a zero (diluent) calibrator as a th point in the assay's reference curve. a low level method is capable of measuring specific ige levels lower than the manufacturer's . ku/l cutoff. this would seem to be particularly important in research applications, and in the analysis of certain highrisk allergens. the clinical significance of very low levels of specific ige in the serum warrants study. allergists/immunologists are often consulted on patients with rashes or recurrent infections. the differential diagnosis can comprise a variety of disorders, some of which are rare syndromes that require early diagnosis and specific management. a mo old wm developed persistent rash and worsening eczema. later, he had recurrent severe skin infections, skin abscesses, recurrent sinusitis, and chronic otitis media that required multiple placement of tympanostomy tubes, yet had a persistent tympanic membrane perforation. recurrent wheezing was noted from - yr of age. he had several episodes of pneumonia since yr of age affecting different lobes. he failed to shed the primary teeth and had history of periodontitis and oral thrush. he developed scoliosis and multiple fractures of the upper extremities and ribs. at yr he had staphylococcal bacteremia and osteomyelitis of the acetabulum. in spite of antibiotics prophylaxis, he continued to have recurrent skin infections and lymphadenitis. laboratory evaluation revealed eosinophilia (up to /mm ), normal levels of igg, iga, igm & igg subclasses, except for decreased igg ( mg/dl). he had protective levels of anti s. pneumoniae and h. influenzae, but low anti-tetanus and anti-diphtheria titers. at yr, total ige level was , iu/ml which supported the diagnosis of hyper ige (hie) syndrome; it decreased to iu/ml by yr. rast was positive to hd mite, cat, dog, egg, milk, and pollens. flow cytomerty, nbt and phagocytic index were normal; ch was low ( mg/dl). dexa scan showed osteopenia. chest x-ray showed bilateral infiltrate, atelectasis and scoliosis of the thoracic spine. during his hospitalization at yr, his skin was fair, lichenified with widespread maculopapular erythematous rash. the palms and fingers showed open cracks and pustules, but no weeping lesions. in addition to coarse facial features, his face was eczematous. conclusion: hie syndrome is an autosomal dominant disorder that mimics atopic dermatitis but has severe course, multiple infections, and several complications. although a markedly elevated total ige level introduction: mannose-binding lectin (mbl) is a serum protein in the lectin complement pathway. it is important in innate immunity, and is thought to be particularly relevant in young children during the development of adaptive immunity. deficiency in mbl has been reported in population-based studies as a risk factor in children for infection and hospitalization. additionally, age-dependent variability of mbl has been previously noted. this study evaluates the prevalence of mbl deficiency in children with established recurrent infection who were referred for evaluation of immunodeficiency. method: we prospectively evaluated mbl status of children referred for recurrent infection. serum was collected from october to september . children with known primary or secondary immunodeficiencies were excluded. mbl analysis was performed by standardized elisa using mbl oligomer assays. we performed chart and laboratory review for comorbid diagnoses, quantitative immunoglobulin levels and subclasses, and complement function with ch and ah . results: two-hundred thirty five children were evaluated. mean age was . years (range . - years). mean mbl was ng/ml (range - ng/ml). thirty-one of children ( . %) were mbl deficient, levels < , and among this group the mean mbl level was . ng/ml (range - ng/ml). mean age in this group was . years (range . - years). of the children with mbl deficiency, ( . %) children had levels < . the m:f ratio of children with abnormal mbl levels was . . linear regression analysis showed no correlation of mbl level with age. comorbid diagnoses were variable, including asthma, allergy, and atopic dermatitis. none of the children had symptoms compatible with connective tissue disease. no child with an abnormal mbl level was found to have significant deficiency of igg, iga, or igm. several children had low igg , which were within normal physiologic range. no other concomitant complement pathway disorders were detected. conclusions: our study did not reveal any correlation between mbl level and age. in children with recurrent infections, mbl deficiency was approximately twice the estimated rate of the general population. contrary to previous studies, no other significant immunologic disorders were identified. therefore, mbl deficiency alone is a risk factor for infection in children. t.b. fausnight * , hershey, pa. introduction: the incidence of perioperative anaphylaxis is estimated to be between in , and in , procedures. approximately % of cases of perioperative anaphylaxis are attributed to neuromuscular agents. very little information is reported in the literature regarding pediatric perioperative anaphylaxis. i describe a pediatric patient with suspected perioperative anaphylaxis to rocuronium. methods: a year-old girl with a history of sacral agenesis and neurogenic bladder was scheduled to have bladder augmentation surgery. the patient was taken to a latex-free operating room. during induction of general anesthesia, she was found to be difficult to ventilate. she also became hypotensive. examination of the patient revealed urticaria on her right arm. she was given epinephrine, diphenhydramine, and dexamethasone. the procedure was aborted. the reaction was believed to be from either rocuronium or propofol. results: because of the high incidence of anaphylaxis to neuromuscular agents, allergy skin testing was performed for rocuronium, vecuronium, and succinylcholine. the patient had negative percutaneous skin tests ( : ) for rocuronium, vecuronium, and succinylcholine. she had a negative intradermal skin test to rocuronium at the : dilution. she had a positive intradermal skin test to rocuronium at the : dilution. she had negative intradermal skin tests to both vecuronium and succinylcholine at the : , : , and : dilutions. she underwent surgery weeks after skin testing. she received a test dose of vecuronium and had no reaction. she received doses of vecuronium and multiple doses of morphine without any adverse reactions. propofol was avoided. the surgery was completed without difficulty conclusions: this case illustrates the usefulness of skin testing for neuromuscular agents in a pediatric patient. introduction: extrapulmonary pneumocystis jiroveci infection is rare in non-hiv infected individuals and, to our knowledge, it has not been reported before in a patient with good's syndrome. we report a case of extrapulmonary pneumocystis in a patient with good's syndrome. case report: a -year-old african american male patient with a history of good's syndrome presented with left flank pain of months duration. the pain was constant and associated with night sweats, fever, and chills. furthermore, the patient also reported a -pound weight loss. on exam, patient was found to have multiple hypopigmented areas over his abdomen and left lower extremity, bitemporal wasting, sunken eyeballs, and oral thrush. the patient was also found to have left costovertebral angle tenderness with a palpable solid fixed mass along the left mid axillary line overlying the splenic area. computedtomography (ct) scan of the chest and abdomen showed a . x . cm soft tissue mass at the left lateral aspect of the t vertebral body and . x . cm soft tissue parasplenic mass. the parasplenic mass involved the inferior anterior aspect of the left th and th ribs (see figure) . the giemsastained biopsy of the parasplenic mass revealed pneumocystis jiroveci and was confirmed using immunohistochemical stain with monoclonal antipnumocystis antibodies. the patient's symptoms of night sweats and loss of appetite improved within hours following initiation of trimethoprim-sulfamethoxazole therapy. a ct of the chest and abdomen, repeated six months post treatment, confirmed the resolution of both the paravertebral and the parasplenic masses. conclusion: to our knowledge, this is the first case of extrapulmonary pneumocystis presenting in a patient with good's syndrome. although it is rare, extrapulmonary pneumocystis should be considered in the differential diagnosis of patients with good's syndrome and chest or abdominal mass. introduction: t cells are regulated by cellular interactions with the environment during development. they play a critical role in the regulation and development of autoimmune diseases. we report inflammatory myositis in a -year-old caucasian female with primary t cell-deficiency since infancy. methods: at nine months of age, our patient developed lymphoid interstitial pneumonitis. immunologic evaluation revealed isolated t-cell deficiency. during the first years of life, she had failure to thrive, recurrent sinusitis, oral candidiasis, fungal skin infections, and pseudomonas pneumonia. at years, autoimmune conditions, characterized by a purpuric rash over the nose; face and exposure area of elbows; knees and fingers; raynaud's phenomenon; and nasal septum perforation, developed. inflammatory markers were persistently elevated and autoantibodies detected. by age , she developed proximal muscle weakness with distal joint contractures. dry gangrene of the fingers from a thrombotic incident occurred. results: serial immunologic evaluation revealed low cd - %, # - (normal - %, # - cell/mm ), low cd - %, # - (normal - %, # - cell/mm ) , decreased lymphocyte transformation to antigens but appropriate to mitogens. igg - (normal - mg/dl); iga - (normal - mg/dl), and igm - , (normal - mg/dl) with appropriate antibody responses to vaccine antigens. bone marrow and thymus biopsies were normal. further evaluation was not consistent with known primary or secondary immunodeficiencies. several skin biopsies revealed nonspecific dermatitis without vasculitis. mri of lower extremities showed abnormal signals involving bilateral muscles of thighs and calves. muscle biopsy revealed inflammatory myositis with plasma cell predominance, inconsistent with dermatomyositis or polymyositis. aldolase - iu/l (< ), crp - mg/dl (< . ), esr - (< ), rf : (< : ) and type ii collagen ab - ei/ml (< ) . ana, anca and ace were within normal range. antibodies for myositis and myositis related-antibodies were negative. diagnosis of nonspecific plasma-cell inflammatory myositis was made. a trial of monthly ivig gm/kg resulted in clinical improvement. conclusion: this novel plasma cell myositis occurring in a child with primary t cell deficiency underscores the role t cells play in the development of autoimmune diseases. introduction the incidence of hypersensitivity reactions (hr) is increased in patients treated with multiple courses of carboplatin. the purposes of this investigation were to evaluate the effectiveness of a -hour, -step desensitization protocol and to characterize the immune mechanism of carboplatin hr. methods we analyzed ten consecutive patients over a two year period with documented hr to carboplatin who required continued treatment with a platinum agent. the patients were treated with carboplatin using a -hour, -step desensitization protocol. skin tests were performed on five patients. results ten patients successfully completed planned courses of desensitizations to carboplatin, of which were without reactions. four patients had symptoms during their first (n= ) and third (n= ) desensitizations but tolerated the re-administration of infusions without further reactions. for subsequent courses, the protocol was modified for two patients who had extracutaneous symptoms during desensitization and was unchanged for the patient who had mild urticaria. these three patients tolerated subsequent courses of desensitizations without reactions. the fourth patient with symptoms during desensitization no longer required carboplatin. of the five patients who were skin tested to carboplatin, four had positive wheal and flare reactions. in one patient, the skin test response to carboplatin became negative after desensitization. conclusions the -hour, -step desensitization protocol is safe and effective for treating patients with carboplatin hr. positive skin tests to carboplatin suggest a mast cell/ige-mediated mechanism. conversion of the positive skin test to a negative response after desensitization supports antigen-specific mast cell desensitization. hypothesis: there is an association between food allergies and acid reflux in atopic adults study design: a retrospective chart review of patients was conducted. people who tested positive and people who tested negative for food allergy were included. the prevalence of gastroesophageal reflux disease (gerd) in the total group and each of the study arms was compared to population prevalence. methods: results of allergen specific ige tests (pharmacia immunocap, nj) run for food allergies were reviewed to help locate charts of atopic subjects, with positive, and with negative food allergy results. we reviewed charts for history of heartburn and acid regurgitation or the diagnosis of gerd, laryngopharyngeal reflux (lpr) or peptic ulcer disease (pud). population prevalence ( . %; ci . - . ) of acid reflux was estimated from a historical comparison that studied adults in a similar geographical location. results: in the food allergy positive group, . % of the subjects ( % ci . - . ) had either a history of heartburn and/or a diagnosis of gerd, lpr or pud. in the food allergy negative group, % ( % ci . - ) had acid related disorders. in the total study group of atopic subjects, the prevalence of heartburn, gerd, lpr or pud was . % ). on chi square analysis, the prevalence of acid reflux disorders was significantly higher in the total study group when compared with population prevalence (p= . ). the prevalence of acid reflux disorders between the food allergy study group and in the population shows no significant difference (p= . ). the prevalence of acid reflux disorders was significantly higher in the food allergy negative group when compared with the prevalence in the population (p= . ). there was no significant difference in the prevalence of acid reflux disorders between the two study groups with and without food allergy (p = . ). conclusions: the prevalence of acid reflux disorders was higher in people with food allergy when compared to the population, but missed statistical significance. patients without food allergy had a significantly higher prevalence of acid reflux disorders compared to the population. atopic individuals have a statistically significant higher prevalence of acid reflux disorders, but there is no statistically significant difference between atopics with and without food allergy. abstract background: analysis of dispensing patterns of injectable epinephrine offers a method to study the characteristics of school children with allergic or anaphylactic reactions. objective: to analyze the demographics of children prescribed injectable epinephrine in massachusetts school districts with diverse racial and ethnic enrollment patterns. methods: school nurses in schools (grades pk- ) enrolling , students recorded the characteristics of students prescribed injectable epinephrine including the number and racial mix of students in each school, student age, grade level, race, sex, and allergic disorder requiring epinephrine. surveyed school districts were two predominately white ( %) suburban districts enrolling students and one urban area with a minority population of % enrolling , students. the use of epinephrine for peanut allergy was analyzed in detail. results: a total of of , ( . %) students in three school systems were dispensed injectable epinephrine. males outnumbered females ( to ). whites outnumbered non-whites to . two thirds (n= ) of children dispensed epinephrine had peanut allergy. the second most common allergy was stinging insect allergy (n= ). the rate of dispensed epinephrine for peanut allergy was lowest in the urban school district ( . %) versus the two suburban districts, . % and . % respectively. whites with peanut allergy outnumbered nonwhites to . males outnumbered females to . the lowest rate of prescribed injectable epinephrine for peanut allergy in all three school districts was found in non-white school children- . %. eighty-nine of ( %) school children with peanut allergy were enrolled in grades pk through . there were twice as many white versus non-white ( to ) school children in the urban system with prescribed injectable epinephrine for peanut allergy. only eight (. %) of hispanic and asian students in the were dispensed injectable epinephrine for peanut allergy. conclusions: this is the first study to suggest that there may be a racial disparity in the prevalence of childhood peanut allergy. one possible explanation for this disparity is that varied feeding practices in minority infants and children may induce a state of tolerance and lead to a lower incidence of peanut allergy. f.i. hsu * , h.j. burstein, m.c. castells, boston, ma. introduction: trastuzumab is a humanized igg kappa monoclonal antibody specific for human epidermal growth factor receptor protein, her , used in the treatment of her /neu positive breast cancer. we present the first report of desensitization to trastuzumab in a patient with an ige-mediated reaction to trastuzumab and documented igg-anti-igg human antibodies. meth-ods: a year old woman with metastatic invasive ductal breast cancer (er/pr positive, her- strongly positive), unresponsive to conventional therapy, presented with an anaphylactic reaction to trastuzumab and was evaluated for rapid desensitization by skin testing and serum specific igg antibodies. the patient had previously received trastuzumab. results: the anaphylactic reaction to trastuzumab consisted of diffuse erythema, urticaria, respiratory distress and laryngeal edema. premedication with steroids, h and h blockade, and slow infusion did not prevent a subsequent reaction. skin prick testing with trastuzumab ( mg/ml) was positive with negative controls, confirming an ige-mediated mechanism. igg anti-human igg antibodies (haha) to trastuzumab were confirmed by elisa. the patient was desensitized to trastuzumab mg/kg with an intravenous protocol that started at . mcg/h, and increased in rate every minutes until a final rate of mg/h, for a total infusion time of to hours. premedication included diphenhydramine, prednisone, famotidine, and montelukast. desensitization was confirmed by negative skin prick and intradermal tests ( mg/ml and mg/ml), with positive histamine control. the patient tolerated a total of weekly doses of trastuzumab mg/kg. intradermal skin testing prior to her th and th courses showed reactivity, indicating resensitization. serum levels of tratuzumab were undetectable at week after desensitization. conclusion: allergic reactions to trastuzumab are rare but can include anaphylaxis. in patients with documented haha and/or ige-mediated reactions to trastuzumab and clinical symptoms of type i/mast cell mediator-related symptoms, desensitization can allow continued administration of this treatment by providing tolerance. the clinical effectiveness of desensitizations in patients with ige and haha antibodies remains to be defined. in contrast to reports in the medical literature, details of the medical aspects were limited. there were attacks on infants bringing the total to reported infant attacks to date. two of the infants suffered long term morbidity and died. like those reported in the medical literature, the majority of adults were in long term care facilities, although were in hospitals. overall, of the individuals stung died within one week of stings. no significant medical consequences of stings were reported in of of the newspaper reports as opposed to of reports in the medical literature. conclusion: our data suggest that increasing numbers of fire ant attacks are occurring in medical facilities, where chronically ill, frequently immobile patients come in contact with foraging ants. unattended infants in private homes in fire ant endemic areas also appear at risk. the factors that determine why individuals are stung and the severity of injury after attacks remain uncertain. the presence of fire ants inside health care facilities and homes is a harbinger for fire ant attacks of disabled or infant occupants. we hypothesize that morbidity is determined by the number of stings, the condition of the patient and the type of treatment administered. purpose: to determine if gender confers a risk for positive penicillin (pcn) skin test. method: rates of positive pcn skin tests, according to gender, were determined in patients with a history of pcn allergy undergoing an allergy pre-operative evaluation from june to june . during this period, , patients were seen in the pre-operative evaluation clinic in which had a history of pcn allergy and comprise our study population. a univariate logistic regression analysis was employed to calculate the odds ratio (or) and the % confidence interval (ci) for gender differences in the rates of positive pcn skin test and a multivariate logistic regression analysis was used to adjust for age and history of multiple drug allergies. p-value of . or less was considered statistically significant. results: of the patients, underwent skin testing for pcn, patients did not, and charts were not available for review. the mean age of the study group was years. sixtyfour ( . %) patients had a positive skin test to pcn. of these, ( %) were females and ( %) were males (or . , % ci . - . , p = . ). of those with a negative/equivocal pcn skin test, ( %) were females versus ( %) males. in a multivariate logistic regression analysis adjusted for age and history of multiple drug allergies, female gender again was more likely to have a positive pcn skin test (or . , % ci . - . p < . ). patients did not undergo pcn skin testing, ( %) were male and ( %) were female. conclusion: this is the first report showing that a greater risk for a positive skin test to pcn exists in association with female gender. age and a history of multiple drug allergies are unlikely to be confounding factors to the observed gender risk. further studies are needed to identify other possible confounding factors and/or mechanisms that can explain this risk. a. fiocchi * , p.a. restani , s. cucchiara , g. lombardi , g. magazzu' , g.l. marseglia , k. pittschieler , s. tripodi , r. troncone , a. vierucci , . milan, italy; . roma, italy; . pescara, italy; . messina, italy; . pavia, italy; . bolzano, italy; . napoli, italy; . firenze, italy. background: cow milk substitutes for children allergic to cow milk proteins (cmp) include soy-based formula and cow s milk hydrolysates. neither can rule out a sensitisation risk. objective: prospective assessment of clinical tolerance to a rice-based hydrolysate formula by children allergic to cow milk proteins (cmp) who consume rice openly. patients and methods: ninety-seven children aged to months with immediate reactions to cow milk confirmed during dbpcfc were assessed for clinical tolerance to cow milk by spt with whole milk, -lactalbumin (ala), -lactoglobulin (blg), -and -casein ( -cas, -cas) (sigma chemical, st. louis, mo). whole milk, ala, blg and cas specific ige determinations were performed using cap test (pharmacia, uppsala, sweden) . similarly, sensitisation to rice and hrf were investigated by spt and cap test. patients sera were investigated by immunoblotting for cmp, rice and hrf (heinz-plada, milan, italy). dbpcfc was carried our with g rhf powder masked in neocate tm (equivalent to ml reconstituted formula). results: spt: all patients were positive to cow s milk and/or cmp fractions (> mm wheal diameter). ige determinations gave positive results with cow milk and/or cmp fractions ( / patients tested), rice ( / ) and with hrf ( / ). immunoblots (n= ) were positive for -cas (n= ), -cas (n= ), ala (n= ), blg (n= ) and bovine serum albumin (n= ). similarly, although patients sera largely recognized rice ( / ), only one weakly reacted with rhf. challenge with rhf was negative in all cases. conclusions: we conclude that, despite their frequent sensitisation to rice, children with cma tolerate both rice and rhf clinically. hydrolyzed rice formulas may thus represent an alternative protein source for children with cma. r.c. cartwright * , w.k. dolen, augusta, ga. introduction: conventional treatment of human seminal fluid allergy includes abstinence, barrier protection, or subcutaneous immunotherapy with fractionated seminal fluid. treatment using local intravaginal desensitization with unfractionated seminal fluid has recently been described, but experience with this desensitization method is still limited and little has been reported as to its long-term results. methods: a -year-old woman with a history of allergic rhinitis and asthma experienced anaphylaxis following her first unprotected intercourse since the birth of her first child. ige-mediated sensitization was demonstrated through the use of specific ige testing (pharmacia cap system) and skin prick testing using undiluted seminal fluid obtained from the patient's husband. after approval from the human assurance committee, the patient underwent rush intravaginal desensitization with steadily increasing concentrations of seminal fluid, beginning with a : , v/v concen-tration. results: her specific ige level to human seminal fluid was . ku/l. skin prick testing was positive with a wheal of mm diameter with pseudopods and a flare of mm diameter. desensitization was successful and the patient tolerated local application of whole semen without significant reaction. following desensitization, the patient reported that she and her husband engaged in unprotected intercourse without local or systemic symptoms. over the last year since the desensitization, she has not experienced further anaphylaxis, but she has developed local symptoms if her exposure to seminal fluid was delayed past days. the longest time period between exposures has been weeks. she became pregnant months ago and has not had any pregnancy complications. conclusions: local intravaginal desensitization was a safe and effective treatment for human seminal fluid allergy in this patient. a delay in seminal fluid exposure greater than days was associated with the return of symptoms emphasizing the need for frequent seminal fluid exposure to maintain desensitization. l. terracciano, t. sarratud, a. fiocchi * , p. restani, s. guerci, milan, italy. background kiwifruit allergy in children has been seldom reported and the reactions observed are usually mild. anaphylaxis has not been described. we document the case of an infant who developed anaphylacic symptoms within minutes of his mother eating two kiwifruits and initiating breastfeeding. case history in his fourth month, the boy was admitted into an emergency department with dysphonia, breathing difficulties, generalised urticaria and angioedema of the lips and face. this episode was treated as an anaphylactic reaction with epinephrine, chlorpheniramine and hydrocortisone sodium succinate administered via a percutaneous catheter and symptomatic control was achieved within minutes. after days a second anaphylactic episode of similar severity occurred under the same circumstances. neither episode required critical care. the boy presented two months later for clinical evaluation in our paediatric allergy unit. skin prick tests (spt) were positive only with egg white and yolk while negative to cow s milk (and protein fractions), beef, chicken, pork, codfish, rice, wheat, soybean, maize, potato, carrot, tomato, bean, pea, celery, peanut, dermatophagoides pteronyssinus and d. farinae, grass and banana. spt with kiwifruit was specifically ordered because exquisite contact was suspected, and induced a positive wheal (> mm diameter). positive specific ige determinations (cap-feia from pharmacia, sweden) with kiwifruit ( . ku/l), cat dander ( . ku/l) and egg white ( . ku/l) were returned but determinations with other inhalant and food allergens were all below the cut-off point of . ku/l and total ige levels were ku/l. strict avoidance of kiwifruit by the breastfeeding mother proved effective and nothing untoward happened in the intervening year. currently aged . years, the boy is free from food-related symptoms. prick-byprick tests with native allergens and spt carried out with commercial extracts of allergens associated in the literature with kiwifruit allergy were all negative. comment there are no reports of immediate reactions to kiwifruit under two years. in this case, severe reactions via breastmilk in an infant monosensitised to kiwifruit indicate that nursing may represent a hidden source of exposure. in older children monosensitisation without prior sensitisation to pollen has been described as the major risk associated with severity of symptoms. m. sikora * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: treacher-collins syndrome (tcs) is an autosomal dominant disorder with an abnormality of craniofacial development during early embryogenesis. there is a known relationship between new bone formation and development of lymphocytes and cytokines. the association of tcs and humoral immunodeficiency has not yet been reported. we present a novel case of a year-old caucasian female patient with tcs and common variable immunodeficiency. methods: our patient presented with midface hypoplasia, micrognathia, microtia, conductive hearing loss and cleft palate with a history of recurrent upper and lower respiratory infections. patient had a -year history of chronic sinusitis, recurrent otitis media and pneumoniae which resulted in bronchiectasis. haemophilus influenza and staphylococcus aureus were persistently isolated from bronchial fluids. laboratory work-up for immunodeficiency was initiated. results: immunoglobulin analysis revealed low igg ( - mg/dl); low iga ( - mg/dl); igm ( - mg/dl); igg ( - mg/dl); low igg ( - mg/dl); igg ( - mg/dl); and low igg < . ( - mg/dl). patient had no detectable response to protein-derived vaccines (diphtheria and tetanus) and to polysaccharide-derived vaccines (pneumococcal) at baseline and at - weeks after immunization. t and b lymphocyte enumeration, ch , ah , and mannose-binding lectin were all within normal limits. laboratory findings were consistent with the diagnosis of common variable immunodeficiency. patient began receiving monthly doses of mg/kg/dose of intravenous immunoglobulin resulting in clinical improvement. our patient no longer requires antibiotic therapy for her respiratory infections; pulmonary function has improved and bronchiectasis resolved months after initiation of ivig. conclusion: our finding shows that tcs can be associated with common variable immunodeficiency which suggests a link between skeletal dysplasia and immunodeficiency. a.s. hartel * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: streptococcus pneumoniae is the most common cause of invasive bacterial infection in humans. however, incidence of s. pneumoniae infections in healthy adolescents is low ( / , per year). mannose-binding lectin (mbl) is a c-type lectin which plays a central role in the innate immune response by activating the classical complement pathway and acting as an opsonin by binding c q receptors. several studies have demonstrated an association between invasive bacterial infections, including s. pneumoniae and a homozygous mutation of the mbl gene. however, this association has not previously been described in patients with the heterozygous mutation. methods: a -year-old caucasian female presented with a second episode of meningitis over a -year span. streptococcus pneumoniae was isolated from peripheral blood cultures on both occasions. lumbar puncture revealed wbc , ; % bands; % pmns; glucose mg/dl, protein mg/dl; these results consistent with bacterial meningitis. extensive evaluation for predisposing causes revealed benign arnold-chiari type malformation. further immunological evaluation was initiated. results: evaluation revealed igg mg/dl (normal - ); iga ( - ); igm ( - ), and normal igg subclasses. antibody responses to diphtheria and tetanus vaccines were adequate. antibodies response to pneumococcal vaccine given years prior were protective to all common serotype tests (> . mcg/ml). lymphocyte subset analysis was within normal range. howell-jolly bodies were not detected from peripheral blood smear. evaluation for secondary immunodeficiency was negative, including hiv antibody by elisa. complement analysis showed ch u/ml ( - ); ah % ( - %), and markedly low mbl of ng/ml (> ). genetic analysis of her mbl revealed heterozygous mutation in codon and mutations in two promoter regions (homozygous mutation on h/l variants and heterozygous mutation on p/q variants). conclusion: heterozygous mutation of mbl codon when associated with mutation of promoter regions can result in severe impairment of mbl protein production, and may lead to increased susceptibility to invasive bacterial infections and meningitis. rationale: patients with similar symptoms may have allergic, non-allergic, or mixed rhinitis triggers and can differentially respond to distinct medications. we assessed st in our clinic patient population to characterize factors that influence appropriate diagnosis and treatment of rhinitis type. methods: we used a validated commercial questionnaire and chart review of patients seen in an academic allergy clinic, to assess the number of allergic vs. irritant st and demographic and historical factors (including pharmacotherapy) associated with differences in symptoms. results: the population (n= : female, male) consisted of individuals with a mixed rhinitis history. women had higher st scores than men, including: total scores [ . +/- . vs. . +/- . , p= . (unpaired t-test)]: allergen scores ( . +/- . vs. . +/- . , p= . ); and irritant scores ( . +/- . vs. . +/- . , p= . ). further, patients treated with both azelastine (az) and intranasal steroids (ins) had lower st scores than patients treated with either alone (total st: az . +/- . , ins . +/- . , both . +/- . , p= . ; allergen st: az . +/- . , ins . +/- . , both . +/- . , p= . ; irritant st: no significant difference). conclusions: female patients have significantly higher symptom scores; total, allergic and irritant. rhinitis monotherapy (ins or az) is minimally effective in reducing st but is more effective when used in combination. these data demonstrate rhinitis population heterogeneity and address differential responsiveness to similar medications. increased response to combined drug therapy support the heterogeneous pathophysiology of mixed rhinitis features and may relate to a combination of multiple aeroallergen and air pollution exposure in the houston area. introduction: interaction between eye & nose warrants attention with regard to the propagation and treatment of allergic reactions. the role of topical therapy for rhinitis and conjunctivitis is becoming more widely considered and questions of therapeutic route have been raised. purpose: to elucidate the anatomic and pharmacokinetic interactions of conjunctival & nasal mucosa leading to more rational selection of routes of medication administration. methods:our studies have investigated the effect of ocularly instilled allergen inducing signs and symptoms of rhinoconjunctivitis. study compared effects of allergen administered via conjunctival allergen challenge (cac) or nasal allergen challenge (nac) and analyzed tear & nasal secretions for ecp & tryptase. studies have also used the ability of the cac model to induce rhinitis signs & symptoms to evaluate the relative effects of medication routes: ) ocular v. nasal spray v. systemic; ) ocular + nasal spray v. systemic + nasal spray; ) ocular v. placebo. results: the nac/cac study revealed that, following cac (n= ), significant ocular and nasal signs & symptoms were noted; following nac (n= ), only nasal symptoms were clinically significant. nasal symptom scores between cac & nac differed significantly at timepoint, representing lag in allergen & mediator movement from eye to nose. measurable levels of ecp & tryptase were found in tears and nasal secretions for cac, but only in nasal secretions (with exception of subject) for nac. in cac studies: ) ocular therapy exhibited greater efficacy in ocular itching relief (n= ;p< . ) and was not significantly different from nasal or systemic therapy in nasal symptom relief. ) eyedrop+nasal spray combination exhibited significantly greater prevention of overall rhinoconjunctivitis signs and symptoms than nasal+systemic therapy (n= ). ) ocular therapy offered greater protection from nasal signs & symptoms compared to placebo (n= ;p< . ). conclusion: nac and cac results support the unidirectional flow from eye to nose, the ability of cac to yield nasal symptoms, and the efficacy of topical therapy. tearing, due to inflammation of the inferior turbinate would be the only ocular symptom resulting from nasal challenge. these results offer insight to the nature of the connection between ocular and nasal mucosa and the efficacy of varied medication administration routes for management of rhinoconjunctivitis symptoms. introduction: asthma disease management programs frequently target high utilizers because they are responsible for a large amount of asthma costs. once identified, such "frequent fliers" usually are offered interventions including case management. programs using this approach usually demonstrate reductions in utilization. though the interventions may cause this decline, it could also be due to regression to the mean (rtm) which is a tendency for outliers to become more like the mean over time. in this study we measured rtm in a medicaid hmo asthma population to determine whether targeted case management is effective independent of this phenomenon. we hypothesized that directed case management provides additional utilization reduction beyond rtm. methods: a weighted asthma utilization score was determined quarterly for members of an hmo with asthma from to . rtm was measured by determining how many patients were persistent high utilizers quarterly for year after baseline. to determine the effect of utilization-directed case management, the number of frequent fliers at baseline for each quarter also was determined. results: a total of asthma frequent fliers were identified on january , . by september , only of these individuals continued to be frequent fliers. similar decreases in utilization were seen for frequent fliers identified at the beginning of each quarter of . the mean decrease in the number of frequent fliers is shown in the table. this represents a substantial regression to the mean. the total number of high utilizers at baseline decreased by % after implementation of utilization-directed case management in independent of regression to the mean. this also represented a decrease from . % of health plan members with asthma to . % by the start of suggesting that the decline is not a result of diminishing health plan membership. the benefit appears to be the result of early intervention with members before they become frequent fliers. conclusions: utilization-directed case management can reduce overall asthma utilization by preventing members from becoming high utilizers at an early stage. programs that claim to intervene with plan members who already are high utilizers are likely to be taking advantage of regression to the mean. studies indicate a high incidence of asthma(as) among school-aged children. with the prevalence increasing, significant numbers remain unidentified. they experience morbidity, including school absenteeism, which may be preventable, in part, by adherence to national asthma guidelines. we implemented a pilot study to detect as, as control and initiation of appropriate health care among th grade students in a suburban population. the study was coordinated with the middle school staff and the local county health department. the screen parameters included: student questionnaires, peak flows, exercise with peak flow assessment (frast) , and spirometry as indicated. environmental tobacco smoke (ets) was recorded. results: students screened. no as history and negative screen (d). as history and negative screen (e). as history and positive screen (a). no as history with suggestive written screen and negative screen on exercise (b). no as history and positive screen (c). ets in groups a, b, c: %, %, %. ets in groups d, e: %, %. individual student results were mailed home with medical follow-up recommended for a positive screen. parents of the children who failed the questionnaire or exercise screen (groups a, b, c) were phoned at a - wk interval. no student in-group a or b had medical follow-up. ( %) students in group c had medical follow-up. conclusion: this as screen of th grade students identified ( %) as having significant, undetected as. ( %) with known as had uncontrolled as at the time of screen. ( . %) students with strong suspicion of as based on questionnaire had an acceptable exercise screen. only of the children with a screen suggestive of as or uncontrolled as had medical follow-up. ets was increased in the homes of students with a positive screen and remains a serious health issue. school screening for as has merit, but mail and phone follow-up was insufficient to intervene or initiate acceptable as treatment. references . redline s. et. al. development and validation of school-based asthma and allergy screening instruments for parents and students. ann allergy asthma immunol. ; : - . tsanakas.j.n., et al. free running asthma screening test. arch diseases in childhood. ; : - . american college of allergy, asthma, and clinical immunology screening test ages ( - ) acaai.org. introduction. some laboratory evidence suggests that desloratadine is effective in inhibiting of inflammatory mediators, which play an important role not only in allergic but also in virally induced inflammation. the purpose of this study was to assess its efficacy in acute bronchiolitis developed in young children suffering from concomitant atopic dermatitis (ad). meth-ods. participants were young boys and gilrs aged - who suffered from acute bronchiolitis as established by wheezing, rhinitis and fever. all patients also had concomitant ad as established by hanifin and rafka criteria. patients were allocated to receive syrup formulation of desloratadine (erius, schering plough) , mg/day for days (active group n= ) or no desloratadine treatment (control group n= ) using quota allocation system. we calculated physical global symptom score (combination of cough, wheezing, chest retractions, nasal flaring, blocked nose, runny nose, sore throat - - scale) and respiratory distress assessment instrument (rdai) to examine the patient at baseline and on day th after therapy was initiated, day of normalization of body temperature, respiratory rate, heart beat rate, and use of albuterol. results. both group of patients were comparable on age, gender, family history of asthma, time of onset of the acute respiratory illness, extent of medication taken prior to entering the study, global symptom score and rdai index. all children were evenly treated with oxygen, oral theophylline ( mg/kg/day) and adequately rehydrated. on day th global symptom score of patients receiving desloratadine was , ± , vs , ± , in control group (p= . ). on day th it was also significant difference between active and control groups on rdai index ( , ± , vs , ± , ; p= . ) especially for significant drop in wheezing score in active group. day when respiratory/heart rate normalized, temperature returned to normal, use of albuterol did not differ significantly in these groups. conclusions. our preliminary study is the first to show that desloratadine is an effective agent in viral lower respiratory tract infections of young children suffering from ad. it encourages further gcp trials to explore action of desloratadine in infantile bronchiolitis and concomitant ad. h.j. su * , w.t. lin, p.j. tsai, c.y. huang, p.c. wu, tainan, taiwan. increasing prevalence of childhood asthma has been observed across the world, and found to be associated with, partly, indoor pollution, including bioaerosol exposure. meanwhile, adequate ventilation is shown to be effective in diluting most indoor air pollutants, while only limited data are available addressing directly how the ventilation rate is implicated with childhood respiratory symptoms. this study aimed to examine the concentration distribution of selected indoor air pollutants, including bioaerosols, in domestic environment, and further to assess the effects of ventilation rate, characterized by a co trace gas concentration decay method, on concentration variations of the above-mentioned air pollutants. study subjects were chosen from a prior city-wide questionnaire survey based on positive response to inquiry for physician-diagnosed asthmatic status and wheezing symptoms in the past months. environmental assessments, including ventilation and air quality measurements, were conducted twice, in early winter and the other on early summer. respiratory health diary and pefr (peak expiratory flow rate) were recorded for week concurrent with the sampling activity. increasing ventilation rate is statistically associated with decreasing indoor concentrations of co and tvocs. after adjustment for sex, age, and selected housing characteristics, the or between tvocs concentrations and reporting cough of study children is . , and . between co and nasal congestion. the or between indoor bacterial concentration and the morning pefr less % is . in the similar multivariate logistic regression for data collected from winter study. in summer, the only significant relationship is between ventilation rate and the morning pefr less % of study children, or= . , in a multivariate logistic regression. this study has identified less reporting of childhood respiratory symptoms, especially for coughing and the morning pefr less % are associated with increasing ventilation rate, and higher levels of indoor air pollution appear to be present with greater frequency of the above symptoms. this study suggest quantitatively that proper management of ventilation efficiency may be beneficial for the control of childhood respiratory illnesses. *adjusted for: sex, age, environmental tobacco exposure, use of incense and air conditioner **:p< . ns:no statistical significance with whole model test background: moderate-to-severe allergic asthma can have a substantial impact on a patient's asthma-related quality of life (arql). in addition to asthma symptoms, allergic rhinitis, rhinosinusitis and other related comorbidities are often apparent in patients with more severe disease making it difficult to treat. despite guideline-consistent care, many patients still experience variability in asthma control signaling an unmet need within this population. omalizumab (xolair®) has recently demonstrated clinical efficacy and safety in treating asthma. objective: the aim of this paper is to summarize the arql outcomes associated with omalizumab therapy in moderate-to-severe allergic asthma. methods: we performed a systematic review of arql data from the clinical study reports and published clinical trials on omalizumab. arql was measured by the juniper-asthma quality of life questionnaire (aqlq). results: statistically significant results for arql endpoints consistently favored omalizumab over placebo. the magnitude of the changes in arql were consistently aligned with clinical endpoints. moderate to large effect sizes in the omalizumab groups were maintained throughout the -week clinical trial program and during the -week double-blind extension phase. however, the placebo groups also experienced within-group improvements and moderate effect sizes. a meta-analysis indicated a . to . fold increase in large (> . point) improvements in overall aqlq scores in the omalizumab-treated group compared with placebo during the stabilization and steroid-reduction phases of the clinical trials. conclusions: the consistently positive impact of omalizumab on arql outcomes during the clinical trial program provides evidence of its value as an adjunct therapy in patients with moderate-to-severe allergic asthma. significant differences and large effect sizes were observed despite the fact that the control group received active, guideline-consistent treatment producing a substantial placebo effect. improvements were observed in overall, symptom, activity, emotional and environmental dimensions of the aqlq indicating that omalizumab produced benefits in arql in patients with moderate-to-severe allergic asthma. background: omalizumab, a monoclonal anti-ige antibody, significantly improves asthma-related quality of life (arql) for patients with moderatesevere allergic asthma who express symptoms despite moderate-high inhaled corticosteroids (ics) doses. mean scores can mask underlying variability in arql outcomes. this investigation examined variability in outcomes to elucidate the specific impact of omalizumab treatment. methods: aqlq data (n= ) from two randomized, double-blind, placebo-controlled clinical trials were pooled to assess underlying variability in the mean scores and to identify key drivers of arql treatment-effect differences (juniper-asthma quality of life questionnaire (aqlq)) between omalizumab and placebo (active control) patients. results: correlations between aqlq and other clinical outcomes were low to moderate at best (r= . to r= . ). aqlq assessment captures patient benefit that supplements clinical outcome measures. across all component items of the aqlq patients receiving omalizumab improved more than patients receiving placebo (active control) (p< . ). omalizumab patients reported the greatest improvement for reducing waking with symptoms in the morning (symptoms domain: . vs. . ; p< . ), limitations in all activities done (activities domain: . vs. . ; p< . ), the fear of not having medication available (emotions domain: . vs. . ; p< . ), and symptoms from being exposed to dust (environment domain: . vs. . ; p< . ), compared to placebo (active control) patients. conclusion: arql assessment provides complementary and non-overlapping information on clinical benefit that is distinct from other clinical outcome measures. examination of underlying variability in aqlq mean scores and item-level response extend previously published results on omalizumab treatment effect by showing that aggregate arql improvements for omalizumab patients are strongly influenced by symptom and activity improvement. a. brimer , k. malhi, c. adams, c. dinakar, kansas city, mo. introduction: the desire to belong to a group is a very powerful motivator and is exceptionally strong in the adolescent population. asthma is a disease that makes people feel different. this perception may impinge on patient adherence with medication regimens. we hypothesize that belonging to a club where every member has asthma may encourage identification of the adolescent asthmatic with their peers, and mitigate the perception of being different. objectives: ( ) to investigate the factors that make the asthmatic adolescent feel different ( ) to explore the hypothesis that group activities, such as an asthma club, would help adolescent asthmatics feel less different. methods: as part of an ongoing survey, children with asthma between the ages of - years were offered an anonymous questionnaire in the primary care and adolescent clinics at our hospital. the questionnaire included both multiple-choice and open-ended questions designed to explore the feelings of the respondents. the responses were numerically tallied and reported as percentages. results: at the present time, surveys out of a proposed have been completed. one third of the youth with asthma answering the survey had negative feelings regarding their asthma. nearly forty percent of the respondents reported that their diagnosis made them feel different from their healthy peers. forty-five percent responded that they have felt restricted or excluded from school activities, athletics, and clubs due to their asthma. over one-third of them feel uncomfortable taking their inhaler in front of their friends. most respondents ( . %) indicated that they enjoy group activities. the majority of respondents ( . %) rated playing sports as their favorite group activity. conclusion: almost forty percent of asthmatic youth surveyed indicated that having asthma made them feel different and resulted in restriction/exclusion from school activities, athletics, and clubs. an overwhelming majority expressed a preference for participation in group activities, particularly recreational sports. this social preference towards group activities may be incorporated into an intervention, such as an asthma club, to help asthmatic youth adjust to the disease and its treatment regimen. introduction: airway hyperresponsiveness (ahr) is an exaggerated narrowing of the airways in response to stimuli, such as allergens, histamine, and cold air. ahr is a characteristic feature of asthma linked to chronic airway inflammation. phosphodiesterase (pde ) is an enzyme found in key inflammatory cells involved in the pathophysiology of asthma. inhibitors of pde prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor, which has shown anti-inflammatory activity in vitro and in vivo. this study examined the effect of a single dose of roflumilast on changes in ahr following allergen-induced asthmatic reactions in patients with mild asthma. methods: this double-blind, randomized, crossover study consisted of treatment periods separated by a -to -week washout period. a total of patients (forced expiratory volume in one second [fev ] % predicted) who were hyperresponsive to histamine (provocative concentration causing a % drop in fev [pc fev ] mg/ml) were randomized to receive a single dose of oral roflumilast μg or placebo on day of each treatment period followed by an allergen challenge min after medication. histamine provocation was performed before and h after intake of study drug. results: there was no change in fev min after roflumilast administration, suggesting the absence of direct or acute bronchodilation. allergen challenge elicited early and late asthmatic reactions that were attenuated by a single dose of roflumilast μg. the histamine pc fev in patients treated with roflumilast decreased to a lesser extent than in those patients treated with placebo. the change in pc fev from baseline after challenge was . ± . mg/ml (mean ± sd) with placebo and . ± . mg/ml with roflumilast. the magnitude of the change in pc fev was statistically significantly different between the placebo and roflumilast treatment groups (p= . ). thus, roflumilast decreased the development of ahr by approximately . doubling-dilutions. conclusions: a single dose of oral roflumilast μg attenuated allergen-induced ahr. these data provide further evidence that roflumilast may provide anti-inflammatory activity in vivo and may be an effective treatment for patients with asthma. introduction for the past years we have been tracking pediatric asthma admissions and evaluations at the huntington memorial hospital. during the fall and winter months (oct-march) from to , we noted a . x increase in the number of asthma admissions and evaluations compared with the spring and summer (april -september; , patient encoun-annals of allergy, asthma & immunology ters in years). we have analyzed potential causes for this increase. diesel particulate was estimated in - , and a . -fold increase in the fall versus spring was found in burbank, a city adjacent to pasadena. pollutant particles from the combustion of fossil fuels may act as immuno-adjuvants to allergen exposure as has been demonstrated experimentally in mice and in human nasal exposure studies. methods computerized analysis of asthma admissions and evaluations were calculated according to established codes for acute and chronic reactive airways disease. infectious diseases in patients were analyzed by standard asthma questionnaire. also, pollen and mold counts, as well as diesel particulates and meteorological conditions were studied. results similar numbers of viral infections occurred in the fall of and spring of . among the most prevalent pollens and molds are chinese elm pollen (sept -oct) weed pollens (july -dec), and a newly recognized aureobasidium mold (nov -march). pollen grains can fragment and release respirablesized debris that are loaded with allergens (taylor et al (taylor et al , . the conidia of aureobasidium are also of respirable size and were identified by sequence analysis. fine particulate air pollution (pm . ), containing diesel particles, is increased in the fall and winter in southern california. con-clusions the incidence of asthma outbreaks may vary with air pollution levels in the immediate environment. pollen fragments and particles from fossil fuel combustion can deposit in similar regions of the lower airways. rainfall increases in the fall and winter and this coincides with increased molds and aureobasidium. aureobasidium was recently discovered in high concentrations in pasadena, is known to be allergenic and could be a factor in increased asthma. a mixture of pollens and molds and fine combustion particles may be relevant to this increased incidence of asthma in the fall and winter months in pasadena. background we have previously noted that tree and ragweed pollen grains can be airborne for most if not all daily periods during their respective seasons (aaaai, ) , (acaai, ) . because grass levels are lower than those of trees & weeds (aaaai / nab), we chose a longer daily interval to examine (six hours) that we had for trees (one hour) and ragweed (three hours). methods twenty-four hour microscope slide samples were collected using a burkard day air sampler from / / to / / . the slides were examined @ x along a single longitudinal traverse. the presence or absence of grass pollen was noted per six-hour segment (six successive fields). results the presence of airborne grass pollen during the daily segments was sparse the first two weeks of may. it gradually increased during the next days, and then was detected during most of the daily segments through to the end of june. # ammophila arenaria (aa) is a highly resilient grass with habitat in europe, north america, australia, new zealand, south africa and the mediterranean, used predominantly for dune stabilization. patients with atopic diseases including allergic reactions to pollen are transferred to coastal regions in order to minimize pollen exposure. in spite of the presence of aa pollens, patients experience allergy relief at the coast. our study examines the contradiction between the presence of strong grass allergens and the absence of allergic symptoms in atopic patients, and whether allergic cross-reactions among different types of grass pollen include aa pollen. adult patients presenting symptoms of grass pollen allergy underwent prick testing and rast testing to grass pollen mix and extracted aa pollen. subjects showed positive results in prick and rast testing to aa extracts and were subsequently tested via rhinomanometry for reactions to aa using prick test solutions. subjects showed positive reactions to prick tests for aa extract and grass pollen mix, but did not show specific antibodies. all other sera showed elevated specific ige levels, with specific reactions on protein bands of aa. in sera incubated with grass pollen extract, almost all specific bands previously detected with aa were now inhibited. patients with high levels of total and specific ige to aa showed weak bands after inhibition, demonstrating the allergenicity of aa. comparing data from coastal and mainland weather stations in june and july from to , coastal wind speeds average . to . m/s while inland wind speeds average only . to . m/s. high wind speeds likely dilute pollen concentrations. based on findings of an inverse relationship between wind speed and pollen concentration in the dispersion of ragweed pollen, we hypothesize that concentrations of aa pollens may be similarly influenced. no sensitized patient reported allergic symptoms in coastal areas inhabited by aa plants, indicating that under natural conditions, either the plant modifies its pollen allergenicity or that environmental conditions including salt aerosols, wind patterns, topography or light exposure cause the modification. as such patterns are likely to become more dramatic as the effects of global climate change transform the natural environment, these findings may also become relevant for other grass allergy types. asthma is the most common chronic inflammatory disorders of the airways with increased prevalence in the past decade. it is characterized by airway obstruction, airway inflammation and airway hyperresponsiveness (ahr) to non-specific stimuli. in this study, we examined the effect of a novel class of molecule, ocid , in inhibiting antigen-induced early and late allergic response (ear and lar), ahr, and airway eosinophilia in mouse and guinea pig models of asthma. pulmonary functions were measured in conscious unrestrained animals by whole-body plethysmography. animals were sensitized with ovalbumin (ova; mg, intraperitoneally) with mg alum followed by treatment with ocid ( mg/kg, i.p. twice daily for days). after the last dose, animals were challenged with ovalbumin. pulmonary functions were recorded for ear and lar and hrs later for ahr. this was followed by bronchoalveolar lavage, blood and lung tissue collection. treatment with ocid ( mg/kg) significantly attenuated lar in ova-sensitized and challenged mice or guinea pigs with no effect on ear. ahr to methacholine in mice and to histamine in guinea pigs were prevented by treatment with ocid . ocid attenuated the rise in total number of inflammatory cells in the lung and almost ablated the rise in bal eosinophilia in the lung due to antigen sensitization and challenge. effect of ocid on pulmonary functions and airway inflammation in ova-sensitized and challenged mice were comparable to that of dexamethasone in both models of asthma. these data suggest that ocid prevents the underlying pathophysiological changes in allergic airway inflammation and therefore could prove beneficial in the treatment of bronchial asthma. ma; . madison, wi; . portland, or; . milwaukee, wi; . normal, il; . denver, co; . los angeles, ca; . fremont, ca. introduction. daclizumab (zenapax®), a humanized monoclonal antibody directed against the il- receptor chain (cd ), is approved for prevention of renal allograft rejection and is under evaluation for treatment of asthma. daclizumab inhibits activation of human t lymphocytes by blocking il induced proliferation, and by reducing production of th -and th -associated cytokines. we recently reported that daclizumab improved pulmonary function in a phase ii trial of patients with moderate to severe chronic persistent asthma (jaci, , ( ):s ). we now report additional data from this trial on the possible role of daclizumab as an anti-inflammatory agent that affects asthma outcomes. methods. non-smoking asthmatics age - with baseline fev - % predicted despite use of mcg daily inhaled triamcinolone (taa) or equivalent were enrolled in a randomized, multi-center, double-blind, placebo-controlled trial. patients were randomized ( : ) to i.v. daclizumab ( mg/kg followed by mg/kg every weeks) or placebo added to stable dose taa. starting at week , patients underwent % reduction of taa every weeks while continuing study drug to week . results. patients on daclizumab demonstrated a prolonged time to exacerbation requiring systemic steroid rescue compared to placebo patients (p= . ). exacerbation rates were reduced in the daclizumab group compared to the placebo group for the -week steroid-stable and steroid-taper phases ( . % vs. . %, p= . ). patients on daclizumab demonstrated decreased peripheral eosinophil counts from baseline to week (- ± /mm vs. placebo + ± /mm , p= . ). daclizumab-treated patients with elevated baseline serum eosinophil cationic protein (secp) had a significant reduction in secp from baseline to day compared to placebo patients (p< . ). peripheral eosinophils decreased significantly in daclizumab patients who had no asthma exacerbations compared to an increase in daclizumab-treated patients with at least one exacerbation (p= . ). conclusions. daclizumab reduces time to and frequency of exacerbation in treated asthmatics. the mechanisms of this effect remain to be fully elucidated, but initial findings suggest that associated reductions in circulating eosinophil and eosinophil products may play a role in these therapeutic effects. hae is a genetic deficiency causing a decrease in c esterase inhibitor levels. it is a rare condition (approximate prevalence : to : individuals). it is manifest by acute attacks of swelling which can involve the larynx (a potentially life threatening condition), the gi tract (causing a syndrome similar to an acute abdominal catastrophe) or the skin and soft tissue of the patient including the limbs, face and external genitalia. there is no approved therapy for acute attacks in the usa. pathogenesis of this potentially fatal condition is thought due to excessive activity of plasma kallikrein. dx- is a specific and highly active (ki pm) recombinant inhibitor of human plasma kallikrein undergoing evaluation in hae and cardiopulmonary bypass. it is an animal free product. a double blind, randomised ( : drug to placebo) placebo controlled dose ascending study of dx- in acute attacks of hae was run in the usa and the european union. four dose groups of patients were to be included in the study. the doses were , , and mg/m . the primary outcome variables were proportion of patients achieving a significant clinical response within hours of administration of therapy, and safety. secondary endpoints included site response, dose response, and median time to significant response by site and dose group. dx- met its primary endpoint; % of dx- patients had a significant improvement within hours, (placebo response rate %, difference % p= . ). patients receiving dx- responded in a median time of minutes. there was no difference in proportions of cases that responded within hours between the three anatomical sites. time to significant response did not significantly differ between dose groups and anatomical sites. the safety profile was comparable for patients treated with dx- and placebo, in terms of saes and aes. in conclusion, dx- in this double blind study was shown to be statistically superior by % to placebo and to be at least as safe as placebo. the drug is effective at treating any hae site, including the larynx. dx- represents an important advance in the management of hae. ar is among the most common chronic childhood disorders, and is most effectively treated with intranasally inhaled glucocorticosteroids (ics). recent evidence suggests that intranasal ics therapy may suppress hpa axis function and decrease growth velocity. this study reports -year follow-up data on children ( female, african american), aged to years (mean . years) at entry, enrolled in a long-term growth trial of intranasal taa for treatment of ar. primary measures included height velocity, bone mineral density (bmd), serum osteocalcin and salivary cortisol levels. all subjects followed their expected age-appropriate growth velocities. average growth velocities were . and . cm/year for girls and boys aged < years, respectively, and . and . cm/year for girls and boys aged > years, respectively. mean (+ std) bmd was . + . and . + . gm/cm , mean serum osteocalcin levels were . + . and . + . ng/ml, and mean salivary cortisol levels were . + . and . + . nm/l at entry and -year follow-up, respectively. these results demonstrate no significant effect of one year of intranasal treatment with taa on growth velocity or hpa function in children with ar. patients males, females ranging in age from years to years, received (o) in doses ranging from to injections over to weeks. patients were evaluated with symptoms scores, pulmonary function (pft), blood eosinophil count (bec), medication use, and allergy skin test. st were initially performed by prick and if negative, by intradermal (id) ( / w/v) and if further negative by id ( / w/v). skin tests were performed immediately before and minutes after the administration of o. there was no change in pft or bec. however there were significant reductions in symptom scores, including nocturnal asthma (<. ), exercise tolerance (<. ), sense of well being(<. ). in addition, parenthetically there was a reduction in nasal symptoms (<. ). there were also significant declines in medication use especially for albuterol (<. ). st declined in all patients evaluated and dramatically in many. for several individual allergens st went from prick positive to id ( / w/v) negative. moreover st declined in all instances further, minutes after the administration of o except for patients. in addition to asthma one of the patients had allergic bronchopulmonary aspergillosis and another had allergic fungal sinusitis. three of the patients tested positive on prick test to mouse antigen and in each instance this became negative after administration of o with all patients tolerating o without problem. we conclude: ( .) administration of o is associated with an improvement in symptoms and decreased use of medications ( .) in addition there is a prominent decline in st which is more marked minutes after administration of o compared to immediately prior to administration the explanation of this finding is not apparent. ( .) o appears to be safe to administer to patients even if they demonstrate specific ige to mouse antigen by st a.p. baptist * , t.s. tang, j.l. baldwin, ann arbor, mi. introduction: academic medical institutions are under pressure to shorten or eliminate resident elective rotations due to federal work-hour restrictions. it is unknown if this will affect knowledge and referral patterns for resident and faculty physicians. the objective of this study was to examine the factors associated with resident and faculty perceived knowledge and referral patterns towards allergy/immunology (a/i). methods: a questionnaire was sent to primary care physicians at one academic center. it addressed past history of a/i referrals, referral intentions for conditions that may be seen by allergists, and perceived a/i knowledge. independent variables included history of an a/i rotation, gender, department, years in training/practice, and history of referral to an allergist. results: ( %) completed surveys were returned. using logistic regression with forward selection, we found in the resident physician cohort those with advanced years in training or history of an a/i rotation were more likely to have increased past history of referral to an allergist (or = . , or = . ), increased referral intention for chronic sinusitis to an allergist (or = . , or = . ), and increased perceived a/i knowledge (or = . . for the faculty physician cohort, those with a history of an a/i rotation were more likely to have an increased perceived knowledge about a/i (or = . - . ). in addition, pediatric faculty physicians were more likely to refer asthma (or = . ) and chronic eczema (or = . ) to an allergist than faculty from other departments. finally, faculty physicians with a past history of referral to an allergist were more likely to have refer asthma (or = . ) and allergic rhinitis (or = . ) to an allergist. conclusion: the factors associated with resident and faculty physician perceived knowledge, referral history, and referral intentions towards a/i differ. for residents, senior training level and a history of an a/i rotation appear most important. for faculty, history of an a/i rotation, pediatric department, and past history of referral to an allergist appear most important. given that a history of an a/i rotation may increase perceived knowledge and referral patterns towards a/i, eliminating a/i rotations in medical institutions may have important consequences for patients and the field of a/i. because recent anecdotal reports suggest that hbv may be an effective treatment for patients with multiple sclerosis (ms), there has been a movement of patients to zealous lay practitioners to receive multiple and repeated bee stings. since this practice has real risk of possible fatal allergic reactions as well as emotional and economic costs, properly conducted studies of safety and efficacy are needed. the purpose of the present phase i pilot study was to evaluate the safety of hbv extract in patients with pfms. a total of evaluable bee venom non-allergic patients with pfms ( - years) were enrolled and were randomly divided into groups, each receiving an increasing allergen dose immunization schedule for one year. hyperreactivity to hbv was evaluated by questionnaire, px and hematologic, metabolic and immunologic tests including skin tests. any possible beneficial responses to therapy were evaluated by questionnaire, functional neurologic tests (fnt) and changes in measurement of somatosensory-evoked potentials (seps) prior to and at the completion of the study. no serious adverse allergic reactions were observed in any of the subjects even at the highest doses of bee venom therapy. although of subjects had worsening of neurologic symptoms during the course of bee venom therapy, requiring termination, this response could not be ascribed to side effects of the hbv or to a spontaneous worsening of the neurologic disease independent of treatment since there was no correlation of these events with the bee venom injections. of the remaining , felt that the therapy was beneficial.there were no changes either in fnt or seps measured during the study. the present report represents the first controlled study evaluating the safety of hbv as a possible adjunctive treatment for multiple sclerosis. while this preliminary safety study suggests that administration of repeated injections of hbv in a step-up dosage regimen in appropriately selected non-hbv allergic patients with ms had no serious adverse allergic reactions, because of the small number of subjects studied, it does not permit conclusions regarding efficacy and therefore provides little evidence to support the use of hbv in the treatment of ms. much larger carefully conducted multi-center studies would be required to establish efficacy. i. finegold * , new york, ny. rush immunotherapy (rit) has benefits for inducing immunologic desensitization in shorter periods of time than conventional immunotherapy. however, there is an increased risk of systemic reactions utilizing accelerated schedules. in the past radiocontrast media reactions have been significantly reduced using a standardized protocol. a modification of this protocol was used prior to rit. the oral premedication consisted of mgm prednisone hours, hours and hour prior to rit, fexofenadine mgm at hours and again hour prior to the procedure, and ranitidine mgm, hours prior to rit. patients tolerated the premedications well. a signed consent was obtained prior to rit. patients were desensitized in an office setting with appropriate therapy for anaphylaxis available without an indwelling intravenous line. injections generally began with / dilution of the anticipated maintenance solu-tions and were doubled every - minutes for about - hours and then the patients were observed for hour or more prior to discharge. in this manner patients were desensitized in - half day sessions. the patient was injected again in week, weeks and then weeks. doses were increased if they were not at a full maintenance dose. if reactions occurred this process was appropriately decreased. utilizing this technique patients were treated. the average age was . years old ( - years of age) % were males. % of patients had allergic rhinitis, % asthma, % insect allergy. patients with complicated medical illnesses were excluded. nine patients had systemic reactions requiring an injection of epinephrine. among the symptoms experienced were wheezing, nasal congestion and flushing. no patient required a second injection of epinephrine, intravenous fluids, or hospitalization. the patient reaction rate was % of patients treated or in injections or % of all injections given during the rush protocol. these results are typical of the increased rate of reactions to rit. however, these systemics were mostly very mild and responded to therapy and in only one case was there a delayed hour reaction. thus premedication while not preventing systemic reactions seemed to modify them to make rit in an office setting a practical and effective therapy. we have previously shown that oligonucleotides consisting a novel '- 'linked structure and synthetic immunostimulatory motif cpr (r is a synthetic purine moiety), referred to as second-generation immunomodulatory oligonucleotides (imos), induce potent th immune responses and prevent ovainduced allergic asthma in mouse models. in the present study, we examined local and systemic immune responses of imos following intranasal (i.n.) administration to naive mice. these studies showed that imos produce higher levels of serum and local il- compared with il- . we next examined the ability of s.c. and i.n. administrated imos to reverse ova-induced th immune responses in a murine model of asthma. treatment of ova-sensitized and challenged mice with imos by either route of administration suppressed il- and il- levels with an increase in ifn-gamma secretion in spleen cell cultures and lung homogenates. imos decreased levels of serum ige and igg and induced higher levels of total and ova-specific igg a titers in serum and balf. while both routes of imo delivery showed similar efficacy on serum and balf immunoglobulin levels, s.c. delivery resulted in stronger systemic effects on the spleen cell cytokine production and the i.n. route of administration produced stronger local effects on the lung cytokines. imos also decreased eosinophils in balf and suppressed inflammatory cell infiltration and goblet cell hyperplasia in lungs. these effects in lung were superior with i.n. administration of imo than did with s.c. administration. further studies to understand the effect of low multiple doses against a single higher dose of i.n. administered imos in naive mice suggest that low multiple doses induce strong th responses locally while the single higher dose produces higher systemic responses. these findings suggest that second-generation imos containing cpr dinucleotides potently reverse ova-induced th immune responses with strong th type cytokine induction in ova-sensitized and challenged mice and i.n. delivery is superior to s.c. delivery in reversing ovainduced airway inflammation and mucosal secretion. showed ait was medically inappropriate, lacked documentation of necessity for initiation or continuation and/or had strong contraindications in / ( %) of the reviewed records. method: we audited a convenience sample of our own records for documentation of necessity for (continuing) ait, using a checklist based on the oig report which included the following criteria: an appropriate diagnosis; specific justification; exclusion of strong contraindications; signed, informed consent; a written physician order, and at least annual re-evaluation for continuing ait. results: the first charts in our alphabetized file of total ait charts were reviewed. the patients ( m, f) ranged in age from - yr (mean, yr). the mean duration of ait was . yr (range, . - yr). indications for ait included allergic rhinitis alone ( %) or with asthma ( %) or chronic sinusitis ( %), asthma alone ( %) and venom anaphylaxis ( %). all had initial documentation of necessity. seven charts ( %) had no written order to initiate ait. nine ( %) lacked a signed consent form. no strong contraindication was found. (peak flow documentation showed the asthma cases were well-controlled. three episodes of ait-induced anaphylaxis requiring epinephrine had occurred, but ait was subsequently resumed and well-tolerated.) seventeen ( %) charts had no documentation of re-evaluation during the preceding - months, including with no documented re-evaluation during the previous months or more, of ait. discontinuation of ait was "considered" for patients after . , , and yr of ait, respectively, but all were still receiving maintenance doses. the estimated time for completing this review was - min per chart. inter-pretation: an internal chart review for adherence to ait practice parameters using a checklist such as ours can quickly and easily assess documentation for medicare reimbursement and patient safety. objective(s): immunotherapy is an accepted mode of treatment for children suffering from allergic rhinitis and allergic asthma. this study demonstrates that rapid allergen vaccination (rav) can be as safe as conventional allergen vaccination (cav) in children. rav may also improve patient adherence. study design: pediatric patients, - years of age, diagnosed with allergic rhinitis and/or mild to severe asthma underwent rav over a / hour period in an office-based setting. all patients were premedicated with prednisone and h antagonists for days prior to the procedure. patients were monitored for reactions during the procedure and continued on a cav schedule. adherence was reviewed subsequently. results: a total of pediatric patients underwent rav utilizing a / hour protocol. of the patients, of them were male ( . %) and of them were female ( . %). ( . %) of the patients had allergic rhinitis, ( . %) had asthma, and ( . %) had chronic sinusitis. during the procedure, patients ( . %) experienced systemic reaction, and none experienced true anaphylaxis. seven of the eight patients who suffered a systemic reaction were patients with asthma on inhaled corticosteroids, three of the eight patients were male ( . %) and five of the eight were female ( . %). every systemic reaction occurred within minutes of the injection. treatment usually included one or a combination of the following: nebulized breathing treatment with albuterol, two sprays in each nostril of azelastine, and diphenydramine taken orally or intramuscularly. every patient that was treated was discharged within two hours, and no one required treatment with subcutaneous epinephrine, treatment for recurrent symptoms or hospitalization. all of the patients continued with a conventional allergen immunotherapy regimen following the rapid protocol to reach their maintenance dose. typically, months of build-up period was saved. patients reached efficacious dosages almost immediately. adherence rates were . %, . %, and . % at , , and months respectively. conclusions: effective doses of allergen vaccine can be safely reached using a / hour protocol annals of allergy, asthma & immunology for children. advantages of rav over cav include improved adherence with almost immediate clinical efficacy, and decreased costs. introduction: studies involving allergen immunotherapy (ait) have furthered our understanding of cat allergen, proteases, and dust mite allergen. the impact of these data has not been assessed. objective: to evaluate ait prescribing trends over years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) focusing on new prescriptions before and after published data regarding specific prescribing recommendations. methods: a retrospective review of , ait prescriptions from a centralized allergy and extract laboratory database was performed with respect to published literature on findings and recommendations regarding the ubiquitous nature of cat allergen, effective dosing of cat antigen, combining protease containing extracts with those susceptible to degradation, dust mite antigen dosing, and the use of house dust versus dust mite antigen. results: ) in , cat allergen was included in % of new allergy immunotherapy prescriptions reviewed; in , it was included in % of new prescriptions, a statistically significant increase (p< . ). ) over the past years, the mean quantity of cat antigen included in new prescriptions has been unchanged at ml/prescription. only % of new prescriptions were written at the manufacturer recommended maintenance dose of ml, significantly less than those written below this level (p < . ). ) there was no significant change in the percentage of extracts combining antigens with proteases with antigens susceptible to degradation. in , % of prescriptions containing alternaria and/or cockroach antigen were mixed with one or more antigens susceptible to degradation; in , % of these extracts were still being combined. ) the mean volume of dust mite mix contained in these prescriptions was between - . ml/ ml. ) prescriptions containing dust mite rose from % in to % in . the use of house dust was unchanged over the same period at . % of prescriptions. conclusions: although the percentage of cat containing extracts has increased significantly, dosing of cat allergen has remained unchanged despite published literature recommending higher volumes. protease-containing allergen prescribing patterns have not significantly changed from [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] young stage of life is a crucial period for aeroallergen sensitization, considering the immaturity of the neonatal immune system which may lead to t-cell anergy or a deviation towards th -type response in mice. the aim of this work was to evaluate the influence of oligodeoxynucleotides containing cpg motif (cpg-odn) on ovalbumin (ova) and blomia tropicalis (bt) immunization in early life compared to adult stage. three days old a/sn mice were immunized with ova in al(oh) and boosted on th and th day after immunization (dai) and bled on th dai. groups of mice received mg of cpg-odn or control-odn associated with ova on immunization and boost. some animals from the three groups (ova, ova+cpg, ova+co) were killed at days old and the spleen was collected and prepared to culture. eight to weeks old female a/sn mice were immunized with ova in al(oh) , boosted on th dai and bled on th dai. groups of mice received mg of cpg-odn or control-odn associated with ova on immunization. animals from the three groups were challenged months after immunization and bled days later. similar protocols were performed using blomia tropicalis (bt) extract in the place of ova. neonate and adult co-administration of cpg-odn with ova or bt were able to significantly decrease specific ige antibody levels and increase igg a production. moreover, cpg-odn decreased specific igg levels in the bt immunization. the co-administration of control-odn in neonates decreased anti-ova igg production. after ova-challenge months later of adult immunization, a similar response was detected in the group that received cpg-odn associated with ova, which showed a decreased anti-ova ige and igg and enhanced igg a levels. analysis of cell division of neonate lymphocytes by flow cytometry showed a decreased proliferation in ova+cpg mice group under ova stimulation. this effect was seen either in b cells and t cells. the results showed that immunization with both allergens, ova and bt, associated with cpg-odn decreased the type i hypersensitivity response. the pattern of antibody production suggests th -type response induced by cpg-odn, and the establishment of memory th response. this findings may imply that the use of cpg-odn in early life seems to be beneficial as an strategy to modulate or to prevent the development of allergic diseases. n. horne * , a. capetandes, m. frieri, east meadow, ny. introduction: it has been shown that dust mite allergens can affect the functioning of airway epithelial cells (winton et. al. br j pharm : , . previous experiments showed ca aggregate in the presence of dermatophagoides pteronyssinus (dp) (capetandes et. al. am j clin path, : , ) . it is hypothesized that epithelial damage is associated with airway remodeling characterized by fibroblast dysregulation. to evaluate the response of fibroblasts to damaged airway epithelial cells, the bioactivity of serum-free conditioned media from dp-treated ca cells (dpcm) was assayed with nhlf. methods: all experiments used insulin-transferrin-selenium supplemented dmem (its). dpcm (generated with ca treated with au/ml dp; alk-abello) was added to % confluent nhlf for hours at oc and % co . its from cultured ca without dp (its cm) was added to % confluent nhlf (control). cell morphology and density were evaluated by microscopy and mtt assay, respectively. data were analyzed by anova followed by student-neuman-keuls (snk) at p< . with power analysis. results: % confluent nhlf treated with dpcm showed decreased cell density (figure ) , and increased aggregation relative to its cm or its alone. nhlf in its alone or with direct addition of au/ml dp to its (dp its) showed no or weak aggregation. aggregated nhlf showed % viability and grew to confluence when subcultured to serum-supplemented media. conclusion: nhlf aggregation was greater, and cell density was lower with dpcm than with its, its cm, and dp its. this suggests that dp-treated ca cells release an unidentified factor or factors that contribute to nhlf aggregation and possible apoptosis. identification of these factors would increase the understanding of the fibroblast response to epithelial cell exposure to dp which may be involved in airway remodeling, a feature of chronic severe asthma. j.t. zimmermann * , y.c. huang, m. frieri, east meadow, ny. introduction: budesonide has been demonstrated to inhibit il- , tgf and gm-csf in ragweed and dust-mite (dm) stimulated human alveolar epithelial cells (j allergy clin immunol : a, ; ann allergy asthma immunology : p , ) . rantes production and expression in dm and il- -stimulated a cells has recently been shown to be inhibited by budesonide (allergy asthma proc, in press ). histamine is known to influence immune response by regulating cytokine synthesis (allergy : - ) . in this study we examined the effect of budesonide in the presence of histamine on il- production and expression by a cells. methods: a pulmonary epithelial cells were cultured in dmem for hours in % co in the presence of : of , au/ml dm, - m histamine and - m budesonide. il- production was measured by a sensitive elisa and il- mrna was measured by qualitative rt-pcr using standardized primers for il- with a gapdh control. results: a cells were stimulated by dm ( - pg/ml) (p< . ). budesonide alone decreased il- levels to pg/ml (p< . ), and in combination with histamine further decreased il- levels to pg/ml (p< . ). relative intensity of il- mrna expression was reduced -fold in dm-stimulated cells and -fold in control cells by budesonide. conclusion: budesonide in combination with histamine showed greater inhibition of il- production by a cells than budesonide alone possibly by increasing cell membrane permeability. c.r. oliveira * , a.e. fusaro, j.r. victor, e.a. futata, c.a. brito, a.j. duarte, m.n. sato, são paulo, brazil. antigen-driven bystander suppression induced by oral tolerance could be an interesting approach in the allergy field, considering the high incidence of new allergens sensitization in atopic individuals. to address the influence of non-related allergen exposure on the type i hypersensitivity response to the mite blomia tropicalis (bt) or ovalbumin (ova) in mice and to verify oral tolerance effect in the bt/ova co-immunization model. groups of mice were immunized with bt extract and two weeks later submitted to ova-immunization, or first immunized with ova or co-injected with bt and ova. ova feeding was performed five days prior co-immunization. ige abs were estimated by means of passive cutaneous anaphylaxis reaction and specific ab and cytokines secretion by elisa. mice sensitized with bt and then exposed to ova developed an enhanced ige response to itself and to ova, but such response has not been observed when ova-immunization was prior to btimmunization. co-injection of bt and ova led to a dominant ige response toward ova over bt and vice-versa for the igg response. ova feeding prior co-immunization decreased ige, igg and igg a ab levels against ova in parallel to a bystander suppression, which avoided the outcome of bt-sensitization. these mice showed increased ifn-?secretion levels induced by antigen-specific stimulus. furthermore, effectiveness of oral tolerance was also related with ova amounts employed in the co-immunization since ova feeding prior co-immunization with low amounts of ova led to inhibition of ige ab response to both allergens, whereas inhibition of specific and non-related antigen igg ab response was broken. the results evidenced that, depending on allergenic potential, new allergen exposure may exert an adjuvant effect on the primary sensitized allergen. the bystander effect to non-related allergen by oral tolerance should be an interesting mechanism to control new aller- rationale. cd + cd + regulatory t cells from patients with atopic asthma undergo apoptosis when stimulated by specific allergen. antihistamines are used to control allergic inflammatory diseases, but their influence on treg cells is currently unknown. the present study investigates the influence of desloratadine (d) on apoptosis of cd + cd + regulatory t cells in atopic patients having dust mite induced allergic disease, including allergic asthma. methods. patients (n= ) with positive skin prick tests to house dust mite allergens and a clinical history of allergic upper and/or lower respiratory symptoms were treated with d mg (schering-plough, usa) once daily for days. no patients used systemic corticosteroids, while theophylline and other medications were stopped at least hours before blood collection. blood was sampled before and after treatment with d. the control group was comprised of individuals without allergic respiratory symptoms and with negative skin prick-tests. peripheral blood mononuclear cells (pbmc) were isolated over a ficoll density gradient and stimulated by specific allergen (dermatophagoides farinae) and in a control series by phorbol myristate acetate (pma). pbmc were labeled with anti-cd , cd , cd , and bcl- monoclonal antibodies. the annex-inv-propidium iodide (anv-pi) test was done. lymphocyte subpopulations and apoptosis were analyzed by flow cytometry. results. after treatment with d, atopic patients had no significant differences in the number of cd + cd + cells. during co-culturing of pbmc from patients treated with d with specific allergen a significant increase in cd + cd + cells was observed. simultaneously, treatment with d led to a significant increase in expression of the antiapoptotic protein bcl- in cd + cells. this data paralleled the decrease of cd expression on cd + cells. there was also a decrease in treg cells in the late stages of apoptosis (anv + pi + cells) in d treated patients. conclusions. the antihistamine preparation desloratadine prevented allergen-specific apoptosis of cd + cd + t regulatory cells in patients with atopic asthma. the type histamine receptor may be involved in the regulation of apoptosis and/or survival of cd + cd + t cells. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: solar urticaria porphyrin corresponds to sun sensitivity to a a wavelengths and is due to disturbances of posphorin metabolism. photosensitivity can cause urticaria, erythema, polymorphic solar eruption and in more severe cases vesicles and bullae. photosensitivity was confirmed by light test. methods: protoporhyrin in rbc, uro and coproporphyrins in urines, copro and protoporhyrins in faeces and porphyrin precursors have been studied un all the cases of solar urticaria seen in the last few years. results: in patients, female, males, a diagnosis of porphyria has been confirmed by laboratory methods. clinically patients presented solar urticaria and solar erythema or polymorphic solar eruption. patients, female, males ( - ) presented also neuro visceral symptoms: abdominal pains ( ) vomiting ( ) asthenia ( ) constipation ( ) muscle pains and paresia ( ) depression ( ) anesthesic reactions ( ). in cases the symptoms were associated with anticonceptional drugs. the conjunction of clinical history with laboratory data has allowed to confirm the diagnosis of cases of protoporphyria erytheropoietica, one triggered by anticonceptionals, cases of coporporhyria hereditaria and cases of porphyria variegata. this group comprises one case of erythropoietic protoporphyria induced by estrogens not previously reported. conclusions: research of porphyrins must be done in all the patients with solar urticaria and erythema. the incidence of sun sensitivity in mixed hepatic porphyriaalso presenting neuro-visceral symptoms which can be drug dependent suggests that porphyria study must be mandatory in suspected cases. a.r. narayan * , j. kaplan , v. sirvan , a. chandrasekaran , c. goodwin , l. goodwin , l. guida , m. frieri , . east meadow, ny; . manhasset, ny; . bayshore, ny. rationale: our division has reported that nitric oxide (no) from tracheal epithelium can mediate induction of il- (american journal of respiratory critical care medicine : a, ) . increased levels of il- , ltb- , and no in mononuclear cells (mnc) from cystic fibrosis (cf) patients were noted.(pediatric asthma allergy immunology : - ) . no in mnc from cf was increased by stimulation with aspergillus fumigatus (asp) and rhdnase (j. clin allergy immunol : p ). tnf-is produced from bronchial epithelial cells (bec) in the presence of mnc of normal controls (nc). rantes, a chemokine that facilitates leukocyte migration, is associated with airway inflammation in cf, and asp sensitization in cf patients could amplify pro-inflammatory cytokines such as il- , tnf-, and rantes. methods: we studied the mrna and protein expression of tnf-, il- and rantes in a year-old cf patient and a nc. x mncs from the patient and nc were stimulated with μg/ml of asp with bec at x and μg/ml rhdnase. mrna expression was studied by real time pcr (taqman chemistry abi prism ) and protein levels by elisa. results: tnf-production in supernatants of mnc with bec from nc increased from pg/ml to pg/ml with rhdnase. whereas in cf patients the tnf-mrna expression was greatly enhanced over nc but declined in the presence of rhdnase (fold difference: . - . ). there was no difference in expression levels of nc (fold difference: . - . ) with rhdnase treatment. il- expression in mnc with bec of patients increased . fold compared to nc ( . fold). rhd-nase decreased asp stimulated levels to . fold in patients compared to nc ( . fold). mnc and bec rantes production in patients increased from to pg/ml and decreased to pg/ml with rhdnase, but increased from pg/ml to pg/ml in nc. in contrast, rantes mrna expression in all groups was higher in nc but decreased with rhdnase in both cf and nc ( - fold vs. - fold). conclusion: rhdnase can increase no and decrease pro-inflammatory tnf-and rantes in cf patients stimulated with asp. rhdnase could lead to augmented bactericidal activity and epithelial defense by enhancing no production and decreasing the expression and production of tnf-, il- and rantes. this is a case report of two steroid dependent atopic dermatitis patients who both responded to treatment with omalizumab. patient a is a year-old white male who presented with a history of severe atopic dermatitis for years along with concomitant mild persistent asthma and allergic rhinitis. he had previously received monthly triamcinolone injections, methotrexate and doxycycline with limited response. on presentation he had mild improvement on a regimen of alternate day prednisone mg, fexofenadine mg bid, and zafirlukast mg bid. however, attempts at weaning prednisone were unsuccessful. omalizumab was initiated at a dosage of mg every four weeks. the patient remains prednisone dependent yet free from atopic dermatitis. patient a's diagnostic work up determined a total ige of . ku/l. the patient's specific ige tests were positive for grass mix, weed mix, maple, white pine, peanut, strawberry, gluten, soybean, wheat, oat, and dog dander. specific ige tests were negative for cat dander, egg white, milk, goose feathers, chicken feathers, mold mix, dust mix, and fish mix. patient b is a year-old white male who presented with a history of severe full body atopic dermatitis along with mild persistent asthma and allergic rhinitis. he also was receiving triamcinolone injections with limited success. he responded to alternate day prednisone mg, desloratidine mg bid, and zileuton mg bid. attempts at weaning prednisone failed until initiation of omalizumab mg every two weeks. his atopic dermatitis is now under control with once daily desloratidine and omalizumab every two weeks. he was successfully weaned off of corticosteroid medication and has begun an immunotherapy regimen. patient b's diagnostic work up determined a total ige level of ku/l. patient b's specific ige tests were positive for weed mix, tree mix, maple, peanut, strawberry, dust mix, cat dander, dog dander, egg white, milk, oat, wheat, goose feathers, and chicken feathers. specific ige tests were negative for grass mix, white pine, mold mix, gluten, soybean, and fish mix. these two case reports reveal significant response to omalizumab in severe steroid dependent atopic dermatitis. further research is strongly indicated considering the quality of life issues with severe atopic dermatitis and potential side effects to long-term corticosteroid treatment. eosinophilic esophagitis (ee) has been described in children and is characterized by high levels of eosinophils (> - eosinophils/high powered field [hpf]) in the esophageal mucosa. a recent report indicates that the combined prevalence of the eosinophilic gastrointestinal disorders may be higher than that of inflammatory bowel diseases (ibd). the presenting symptoms of ee mimick those of gastroesophageal reflux disease (gerd), and patients of all ages may experience a delay in time from onset of symptoms to diagnosis of ee. there is a paucity of data in the literature regarding the delay in time from symptom onset to diagnosis of ee. we report the data on four children three years of age and under with ee who experienced a significant diagnostic delay. four young children were referred to the pediatric allergy clinic with a diagnosis of ee (table) . three of the patients were male and one was female. the patients were - months of age at the time of diagnosis, and the diagnostic delay was . - months (average delay . months). the most common presenting symptom was vomiting, and three of the four patients had a history of respiratory obstructive symptoms. all of the patients had received conventional treatment for reflux disease, and one had undergone a nissen fundoplication prior to diagnosis. in all four patients the esophageal biopsy revealed > eosinophils/hpf. three out of four patients had a family history of atopy, and two patients had a known history of a food allergy. skin tests to foods were positive in two patients and rast (radioallergoabsorbent) testing to foods was positive in one patient. recent data suggests that the diagnostic delay in ibd is decreasing as much as %. it is hypothesized that this may be due in part to an increased index of suspicion by health care providers. there is little data available regarding the diagnostic lag in children with ee. it is currently believed that chronic ee can lead to progressive esophageal scarring and dysfunction. stricture formation has also been described in children less than two years of age. given the reported increased incidence of this allergic gastrointestinal disease over the past decade, more data regarding the diagnostic delay of these conditions may be instrumental improving health care providers' awareness of this disorder. a. kohli-pamnani * , e. cooney, p. huynh, f. lobo, new haven, ct. introduction: cutaneous hypersensitivity reactions to amprenavir, an hiv- protease inhibitor, are reported in up to % of treated patients, of whom % have severe or life-threatening rashes, with treatment discontinuation required in % of cases. we report a case of successful desensitization to amprenavir, for recurrent maculopapular exanthem, in an hiv-infected patient with late stage disease and limited antiretroviral (arv) agent options. methods: the patient is a year-old caucasian female with late stage hiv disease (absolute cd count cells/mm , hiv rna , copies/ml) and multiple arv intolerances, who developed a severe generalized maculopapular eruption sparing mucous membranes six days following initiation of a regimen comprised of amprenavir, lopinavir/ritonavir, zidovudine, and lamivudine. a similar reaction occurred following re-challenge with amprenavir alone ( mg oral formulation bid via percutaneous endoscopic gastrostomy (peg) tube), despite concurrent administration of oral prednisone mg/day and loratidine mg/day. results: skin prick testing with amprenavir . mcg/ml was negative, whereas intradermal testing with . mcg/ml was positive with a mm wheal and mm flare. percutaneous and intradermal testing with normal saline was nonreactive. the positive histamine control (skin prick only) yielded a mm wheal and mm flare. subsequently, incremental doses of . mg, . mg, . mg, mg, . mg, . mg, mg, mg, mg, mg, mg, and mg of amprenavir oral solution were administered via peg tube at to minute intervals (table) . the patient successfully tol-erated amprenavir desensitization and has remained on therapy without recurrence of rash out to months of follow-up. conclusions: desensitization may permit continued use of amprenavir in patients with a history of amprenavirinduced maculopapular eruptions who have limited alternate treatment options. efforts aimed at characterizing the mechanism of amprenavir cutaneous hypersensitivity reactions seem warranted, given the frequency of reactions and the limited number of arv agents available for patients with late stage hiv disease. doses of oral solution were administered by peg tube at twenty to thirty minute intervals. introduction: beta-lactam (bl) allergy is the most common drug allergy. in most cases, ige antibodies are specific to the bl nucleus. however, sidechain-specific ige (scsige) to bl has been described. despite this, skin testing (st) to bl other than penicillin (pcn) is not commonly performed. we report a case of a year-old female with a selective allergy to pip, and describe the utility of st to this agent to confirm scsige. methods: st to prepen (pp) and pcn g was carried out with percutaneous (pc) testing followed by intradermal (id) testing. st was also carried out with ampicillin (amp; mg/ml), pip ( mg/ml at pc level; mg/ml at id level-a non-irritating concentration), and pip/tazobactam (tbm; mg/ml at pc level; mg/ml at id level) to exclude the possibility of selective allergy to tbm. case report: a year-old white female with crohn's disease was hospitalized for treatment of intra-abdominal abscesses. she had immediate flushing and urticaria during an infusion of pip/tbm approximately years prior. the allergy/immunology service was consulted for pcn st because her primary service preferred to empirically treat with pip/tbm. she had received imipenem approximately months prior without untoward reaction. st to pp and pcn g was performed with negative responses and adequate controls. she subsequently received pip/tbm, but developed flushing and urticaria during her initial infusion, consistent with an ige-mediated reaction. two months later, st to pp and pcn g was repeated. in addition, st to amp, pip, and pip/tbm was performed. she had positive responses to pip and pip/tbm with negative responses to pp, pcn g, and amp, implying selective ige-mediated potential to pip. she tolerated an oral challenge with pcn vk mg immediately following st without untoward reaction. conclusion: we have described a case in which st to pip was useful for diagnosing scsige in our patient, who had prior reactions consistent with ige-mediated pathogenesis. this information will be helpful in identifying antibiotics she can safely receive in the future. this case supports the utility of st to bl in addition to pcn, in evaluation and management of patients with a history of adverse reaction to bl that may reflect presence of scsige. a.r. vaishnav * , b.s. bochner, baltimore, md. we report the case of a -year-old caucasian male with a -year history of asthma, two episodes of eosinophilic pneumonia and chronic peripheral eosinophilia with baseline eosinophil counts around /μl who developed amnesia and elevated cardiac enzymes in february . another physician had added montelukast in january and because of a good response advair was decreased from / to / bid. in february his eosinophil count increased to /μl and soon he developed left arm numbness, diplopia as well as left arm and leg weakness. at his local hospital, he was found to have elevated troponins and cpks. cardiac catheterization showed normal coronary arteries and good left ventricular function. soon after discharge, he developed confusion and global amnesia. brain mri showed diffuse uptake consistent with global inflammation and/or vasculitis. upon hearing this story, we told him to take mg of prednisone and urgently come to our hospital for admission. within hours, his mental status and visual symptoms improved. physical examination was unremarkable except for subungual splinter hemorrhages. montelukast was stopped and gm/day solu-medrol iv was started. endomyocardial biopsy days later showed mild hypertrophy and fibrosis without eosinophils. repeat brain mri and mra were normal. chest ct showed multiple patchy infiltrates with a new central cavitary lesion in the right lobe. other labs included a negative anca, ana of : , normal complements and csf. our differential diagnosis included churg-strauss syndrome (css) versus hypereosinophilic syndrome (ihes) with myocardial, neurological and pulmonary involvement. serum tryptase was normal as was fluorescent in situ hybridization for the fip l -pdgfr fusion gene. based on this, along with the new pulmonary cavitary lesion on chest ct, the diagnosis of css was made. after days of iv steroids, he was switched to mg/day of prednisone. upon discharge his eosinophil count was /μl on mg of prednisone. after all procedures were completed, he was also started on aspirin mg daily to prevent thrombotic and thromboembolic complications. he was seen in follow-up in clinic and cytoxan mg daily was started. his prednisone is being tapered. he is tolerating the treatment well and so far has had an excellent clinical and laboratory response. introduction-c -esterase inhibitor (c -inh) deficiency is a rare disorder classified into acquired and hereditary forms. both entities are distinguished by recurrent angioedema without pruritus or urticaria. the upper airway, head, neck, extremities and gi tract are typically involved. the inherited form usually presents in the first or second decade accompanied by a family history. the acquired form more commonly presents after the fifth decade. in acquired c -inh deficiency, serological evaluation reveals low levels of c , c -inh, and c q and a normal c level. levels of c q are normal in the hereditary form. the acquired form may be associated with lymphoproliferative disorders and autoimmune disease. acquired c -inh deficiency is typically recognized before the underlying malignant condition is diagnosed. clinical regression has been reported in patients whose underlying disorder responds to treatment. methods-a case report of a -year old female who developed repeated episodes of facial angioedema requiring hospitalization preceded by one year of vague abdominal pain and cramping. data-laboratory investigation of this patient revealed c < mg/dl ( - mg/dl), c q< . mg/dl( . - . mg/dl), ch < u/ml( - u/ml), and c -inh at mg/dl( - mg/dl) with a % activity (> % normal). c was mg/dl( - mg/dl). other laboratory evaluation was notable for a normal cbc with diff, comprehensive metabolic panel, amylase, lipase and spep pattern. ige was elevated at ku/l. hematology was consulted. ct of chest, abdomen, and pelvis were nondiagnostic. peripheral blood flow cytometry revealed a small distinct pop-ulation consistent with a clonal b-cell lymphoproliferative disorder. a repeat test showed skewing towards lamba light chain expression. bone marrow biopsy and aspirate were essentially normal except for erythroid hyperplasia on danazol treatment. the physical examination was without any masses or lymphadenopathy. the patient remained asymptomatic after beginning danazol although elevations in rbc, hgb, hct and absolute lymphocyte count have developed. conclusion-acquired c -inh deficiency is rare cause of recurrent angioedema that has been reported in small cohorts and case presentations. we report another case report that reinforces the need for physicians to evaluate for concomitant lymphoproliferative disorders. chronic urticaria is a distressing condition usually associated with poor quality of life and poor response to symptomatic therapy. a wide variety of causes and mechanisms have been described and in some patients the cause remains unknown. rare cases have been associated with thyroid antibodies and some responded to thyroxin, even in the absence of overt thyroid disease. case report: a -yr-old obese white female presented with a history of persistent urticaria/angioedema for mo. urticaria involved various parts of the body and individual lesions usually lasted < hr. it was often accompanied by facial edema. oral diphenhydramine mg qid caused only little improvement. the patient could not suspect any offending factors. review of systems and past medical history were unremarkable, except for hyperthyroidism at age yr that was treated with "medication" for yr. on physical examination there were several urticarial lesions though she has been taking diphenhydramine. the thyroid appeared normal regarding size, shape and texture. various second generation antihistamines and doxepin were of little help. laboratory evaluation revealed total serum ige of iu/ml (normal < iu/ml) and ch of u/ml (normal - u/ml), but high tsh of . iu/ml (normal . - . iu/ml) and low free t of . ng/dl (normal . - . ng/dl). her antithyroglobulin titer was iu/ml (normal < iu/ml) but the antimicrosomal titer was highly elevated at iu/ml(normal < iu/ml) consistent with hashimoto's thyroiditis. thyroxin therapy was initiated at a dose of mcg/d which resulted in marked improvement within one week and the patient was able to discontinue doxepin and other antihistamines. because of marked drop in tsh to . iu/ml, the thyroxin dose was reduced to mcg/d. her thyroid function tests became normal within two months. she did not experience any recurrence of urticaria or angioedema during over mo of follow-up so far. conclusion: patients with chronic urticaria/angioedema, especially women, should be screened for thyroid autoantibodies and if positive, thyroxin therapy might bring impressive remission in urticaria. hypersensitivity pneumonitis (hp) results from an abnormal immunologically mediated response to an environmental antigenic trigger. typically patients with hp experience transient fever, hypoxemia, muscle and joint pain, difficulty breathing, fatigue, weight loss, and cough. there are two clinical presentations of hp differentiated by onset and resolution of symptoms. patients experiencing acute hp experience the onset of symptoms to hours following exposure to a particular antigen and resolve in to days without specific treatment. however, patients with chronic hp experience symptoms that persist for months to years when exposed to a recognized cause of hp. a year-old caucasian male was referred to our practice with acute bronchitis. his referral was secondary to a history of allergic rhinitis, chronic asthma, gastro-esophageal reflux disorder, and sinus surgery. this non-smoking male was a machine operator at a local factory. he was doing well until he began working in the presence of a heat induction machine and metal lubricating spray called multan ea (hinkle surface technologies), i.d. no.: . multan ea is a product containing naphthenic petroleum distillates, amine salts, amine soap, triethanolamine hexyl, hexylene glycol, ethanol, sodium petroleum sulfonate, and triazine. this lubricant is known to irritate the eyes, skin, and respiratory tract. recent studies indicate that thermal decomposition of triazine, which readily occurs during metalworking, results in the production of formaldehyde. formaldehyde is a known carcinogen, as well as respiratory, skin, eye and digestive tract irritant. the patient developed serious respiratory health problems resulting in work absence and eventually hospitalization. while hospitalized he received a high resolution ct scan which showed diffuse ground glass appearance, and multiple attenuation areas of the lung which are consistent with hypersensitivity pneumonitis. the patient was treated with corticosteroids, and antibiotics with eventual normalization of lung parenchyma by chest ct. this represents the first reported case of hypersensitivity pneumonitis resulting from exposure to the metalworking fluid and respiratory irritant multan ea . a.j. ham pong * , f. chan , s.l. bahna , . ottawa, canada; . shreveport, la. sexual intercourse has been known as the route for semen hypersensitivity reactions to the seminal fluid protein or to a contaminating drug or food. we report a case of anaphylaxis to cephalexin-containing semen by ingestion. history of present illness: a -year-old woman developed a systemic reaction after swallowing semen. since the couple frequently practiced fellatio without any reactions, her husband suspected cephalexin that he was taking over days ( mg qid). her reaction began in less than min and peaked over min; first as itchy oral mucosa followed by wheezing, flushing of the face and upper chest, and nausea. diphenhydramine mg was administered po at min and the reaction subsided over hr. past medical history: she had generalized urticaria to oral penicillin more than yr earlier and had positive penicillin skin test. she also had allergic rhinoconjunctivitis, mild intermittent asthma, and positive skin test to house dust mite, cat and dog epidermals, and pollens of grasses, trees, and ragweed. she also had oral allergy syndrome to certain fresh fruits and tree nuts; hazelnuts caused also diarrhea and colic. neither the patient nor her husband ate any nut-containing food on the days preceding the reaction. family his-tory: allergic rhinoconjunctivitis in the mother, sister and brother. eval-uation: the patient sought allergy evaluation about yr after the reaction. she and her husband gave a consent. her serum ige was iu/ml and skin test positive to penicilloyl polylysine x - mol id, but negative to cefazoline mg/ml for prick and mg/ml for id. she had negative prick test to her husband's seminal plasma both before and after his intake of cephalexin mg qid for days. using a cephalexin bioassay sensitive down to . mcg/ml, the medication level in the husband's urine at min post last dose was mcg/ml and in his serum at min was mcg/ml, but was undetectable in the semen collected at min. conclusion: this is probably the first case report of systemic reaction to ingested semen. the reaction occurred in an atopic, penicillin-sensitive woman and seems to be caused by cephalexin excreted in the semen or through urine contamination ( drop = mcg). in addition to her avoiding penicillin and cephalosporins, she was advised to avoid her husband's semen while him taking such drugs and for at least days afterwards. background:asthma causes serious morbidity & mortality all over yet most asthma educational evaluations and programs have an urban rather than rural focus.there is lack of data on rural north dakota(nd). this nd survey aimed to study knowledge & awareness of management strategies for asthma like use of metered dose inhalers, spacer devices and peak flow meters. methods:the qualitative survey addressed attitudes and beliefs on asthma & its triggers;knowledge of medication delivery routes & use of hospitals and provider visits.a simple questionnaire was self-administered at rural clinics in small towns in southeastern north dakota. questions explored asthma knowledge, extent of family history of asthma & factors aggravating asthma.it was voluntary & the population surveyed included patients, family, teachers, employees at nursing homes, the local hospital & clinics. results:of surveys completed % had no asthma in the family.of those with a family history( %), % had person with asthma, . % had & . % had or more.respondents were aged - years & . % were female.see table. discussion:our survey was rural & comparison with urban areas may help in planning for asthma education & resource allocation. % denied asthma in their family. similarly, nonurban alaskan natives have a lower incidence of asthma compared to nonnatives.our results show a lack of awareness in our area.grain dust exposure was perceived as an asthma trigger but without evidence, local research is needed.in our study smoking was considered a trigger by . % & this may be real.there was lack of awareness of peak flow meters & their role in asthma care.a study showed that compared to other areas even rural nurses used peak flow meters less often to assess and monitor asthma.this suggests a need for comprehensive asthma educational programs in rural areas that are based on national guidelines.we had only a moderate followup rate at %.in comparison, one study had % missed scheduled follow-ups. exercise induced asthma was known to only % of our group. conclusion:the need for better patient-provider communication has been highlighted by the lack of awareness of proven strategies to combat asthma.the use of a simple survey has revealed many unknown facts about asthma awareness in rural nd.further study to determine cost effective solutions to achieve national targets for asthma management are essential. aim: in most studies of asthma, the emphasis was on changes in large and middle airways. the aims of this study:( )to observe the morphologic changes in small airways and lung tissue(salt) in guinea pig asthma models(gpam); ( )investigate the role of vcam- , eotaxin, nf-b and ap- in the inflammation of asthma; ( )explore the functional variation of alveolar type cells in asthma; ( )evaluate the effects of inhaled glucocorticoids on the above annals of allergy, asthma & immunology parameters in salt of asthma models. methods: ( )the gpam were established by ovalbumin challenge. five groups were divided: control, asthma day and day , intraperitoneal dexamethasone, and budesonide inhalation group. ( )the expression of vcam- , eotaxin, nf-b and ap- was determined by immunohistochemical technology and rt-pcr; the dna binding activity of nf-b and ap- by electropharetic mobility shift assay. ( )the balf phospholipide concentration was measured by phosphorus detection. results: ( )significant inflammatiom with infiltration of eosinophils and lymphocytes in salt was observed in asthma groups. ( )the protein levels of vcam- , eotaxin, nf-b and ap- expressed in the salt were significantly elevated in asthma groups than those in control. ( )the mrna expression of vcam- and eotaxin of lung tissue homogenate was significantly increased in asthma group. ( )the dna binding activity of nf-b and ap- of lung homogenate was significantly increased in asthma group. ( )the balf surfactant represented by phospholipides was significantly decreased in asthma groups. ( )glucocorticoids in different ways of intake provided significant effects on the inflammatiom of salt. conclusion: ( )widespread and significant inflammation with eosinophilic infiltration existed in the salt in gpam, indicating asthma is a disease involving the whole airway and lung system. not only there were structural changes, but also impaired function of alveolar cells. the role of small airway inflammatiom may be of great importance. ( )eotaxin and vcam- actively mediated the process of inflammatiom, nf-b and ap- played important roles in the regulation of vcam- and eotaxin. the up-regulation of the above mediators in gpam was expressed in salt similar to that in central airways. we have recently reported that immunomodulatory oligonucleotides (imos) consisting of a novel structure and synthetic cpr or r'pg (r and r' are synthetic purine moieties) stimulatory motif effectively prevent ovainduced asthma in mouse models. in the present study we examined whether these novel imos (hyb and hyb ) can reverse established allergic airway inflammation in mice. balb/c mice sensitized and challenged with ovalbumin (ova) were evaluated for airway hyperresponsiveness (ahr) to methacholine. following ova-sensitization, mice were randomized and treated with placebo or mg or mg/dose of hyb or s.c. during the following days. two days after the final treatment, mice were rechallenged with ova and pulmonary functions were recorded. mice treated with either imo were significantly protected from both early (ear) and late (lar) allergic response, airway hypersensitivity and hyperreactivity to methacholine, bal and peribronchial eosinophilia, bal and serum il- , and total serum ige as compared to vehicle-treated ova-sensitized and challenged animals. there was a significant increase in immature lung dendritic cells (cd c+cd r+) together with increase in serum il- levels and significant decrease in lung dc type cells (cd c+ cd b+cd a-) as compared to vehicle-treated ovalbumin-sensitized animals in the lungs following treatment with either imo. these data suggest that both imos are effective and potent in attenuating key features of established allergic airway inflammation in bronchial asthma, and this effect could be mediated via decreasing lung dc cells and increasing immature dendritic cells. additionally, imos contain a novel '- '-attached structure that provides higher metabolic stability and may permit lower and/or less frequent dosing. hyb was evaluated for its safety and immunopharmacology in a phase clinical trial in healthy human volunteers. introduction -hemoglobinopathies are common in southern europe and mediterranean area the more frequent being thalassemia and sickle cell disease. aside of the major hematological diseases of homozygotic patients minor forms are frequent, thalassemia minor and sickle cell trait. in these cases mycrocytosis with decrease of red cell volume and mean corpuscular volume or abnormal erythrocytes are found and can lead to hemorheologic disturbances in bronchial circulation and bronchial hypereactivity. the rationale of this study is to evaluate the incidence of asthma in hemoglobinopatic patients allergic to house dust mites.methods-from patients seen in the last years in an out-patient allergy clinic cases of hemoglobinopathies have been confirmed by red cell count, hemoglobin electrophoresis, assays of hemoglobin a , f, and s, and sickle cell test.all these patients had allergic disease characterized by clinical history, skin prick test to aeroallergens total and specific ige (rast-cap-feia) and respiratory function evaluation. results -hemoglobinopathies: betathalassemia cases, betadelta thalassemia , sickle cell trait , hemoglobin c. . aside of cases of urticaria, all the patients presented respiratory allergy, rhinitis in cases of thalassemia and hemoglobin c, asthma with or without rhinitis in cases of thalassemia and cases of sickle cell trait. therefore asthma was present in , %. in a group of respiratory allergic patients without hemoglobinopathies, % had asthma and % only rhinitis. conclusions -the prevalence of asthma is higher in hemoglobinopathies.(p< square chi test). hemorheological changes probably greater rigidity of red blood cells and capillary bed can contribute to bronchial hypereactivity. detection of hemoglobinopathies must be done in asthmatic patients with slight anemia or mycrocytosis. we investigated the role of aspirin-exacerbated respiratory disease (aerd) as a risk factor for the development of airway remodeling. patients with aspirin intolerance develop hyperplastic sinusitis with fibrosis and nasal polyposis. we speculated that similar mechanisms could be acting in the lower airway and that these individuals would demonstrate more severe asthma and evidence for airway remodeling. the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) study is a multicenter observational study of subjects with severe or difficult-to-treat asthma. baseline data were compared between subjects years who reported asthma exacerbation following aspirin ingestion and those who did not. the primary measure of asthma remodeling was the maximally achieved post-bronchodilator spirometry. adult subjects with aerd (n= ) were compared with aspirin tolerant subjects (n= ). subjects with aspirin intolerance demonstrated evidence for airway remodeling as shown by lower post-bronchodilator predicted fev . in addition, they were more likely to have physician-assessed severe asthma, to have been intubated, and to have required high-dose inhaled corticosteroids or oral corticosteroids in the previous months. we conclude that aspirin intolerance is associated with remodeling of both the upper and lower airways. asthma is a complex and variable disease with two main components, airway inflammation and smooth muscle dysfunction. according to national and international asthma guidelines, subjects with persistent asthma can be classif ied into one of three categories (mild, moderate, or severe) based upon lung function, symptoms, nighttime awakenings, medications and exacerbations. though it is widely believed that there is a high degree of variability in both pediatric and adult subjects with asthma, few studies have compared variability between them. therefore, an analysis of previously conducted asthma studies was undertaken to evaluate pediatric subjects aged - years (n= ) and adult subjects (n= ) previously receiving short-acting beta -agoinsts alone in seven double-blind, randomized, -week trials. the analysis is limited to subjects who were randomized to placebo in these trials. during the study, subjects exhibited marked fluctuations in asthma severity. despite the fact that all subjects met criteria for moderate or severe asthma at baseline, %, %, % and % of weeks for pediatric subjects and %, %, %, and % of weeks for adults were spent in the intermittent, mild, moderate and severe categories, respectively. a summary of severity classification based upon symptoms and albuterol use is presented below. in addition, based upon pef % predicted, % and % of weeks were spent in the intermittent/mild category for pediatric and adult subjects, respectively. however, fluctuations in pef occurred frequently, with % of pediatric subjects and % of adult subjects experiencing changes in severity based on pef over weeks, indicating more variability in pediatric subjects. this analysis clearly demonstrates that asthma is a variable condition and that both pediatric and adult subjects frequently move between severity categories. furthermore, there are marked differences in severity classifications between pediatric and adult subjects. asthma severity, and consequent optimal therapy, cannot adequately be assessed by discrete, point-intime assessments of lung function, frequency of albuterol use, or asthma symptoms, especially in the pediatric age group. studies suggest that there may be an association between single nucleotide polymorphisms (snps) in the beta -adrenergic receptor gene (adrb ) and the response to beta -adrenergic bronchodilators. polymorphisms at codon have been at the center of this debate. therefore, a retrospective analysis of six large, randomized trials was conducted to evaluate clinical responses to salmeterol administered with fluticasone propionate (fsc) / mcg bid for weeks in patients ( yrs) with moderate or severe asthma and differing adrb polymorphisms at codon . baseline demographics were similar for all genotype subgroups. all measures of asthma improved over baseline and were similar across arg /gly subgroups at weeks. pairwise comparisons were conducted between genotypes and there were no differences other than fev as noted in the table. findings from this retrospective analysis show that regardless of arg /gly genotype, clinical response to salmeterol with an ics was similar during chronic dosing. although prospective studies are needed to fully understand the effect of adrb polymorphisms on response to therapy with a long-acting beta -agonist, this analysis suggests that therapy with salmeterol and an ics together is appropriate for caucasian patients with differing arg /gly genotypes. coronary artery disease(cad) and asthma commonly coexist in adults. iv dipyridamole thallium scintigraphy is considered a safe non-invasive technique in the evaluation of cad when patients can't exercise. dipyrdamole is a purine that blocks reuptake of extracellular adenosine increasing serum adenosine levels after iv administration.this results in a transient coronary vasodilation increasing the sensitivity of the thallium study. methylxanthines reverse the effects of endogenous adenosine by competitively antagonizing adenosine at local purinoreceptors. we report a case of a yr.old female with a year history of stable mild persistant asthma treated with daily salmeterol and low-dose fluticasone. she was referred to cardiology for atypical chest pain. within minutes of a standard iv dose of dipyridamole the patient reported chest tightness, cough, and wheezing. all these symptoms, typical of her past asthma flares, were abolished within minutes of an aminophylline infusion and before albuterol was administered.the stress test was completed and was normal. inhaled adenosine induces bronchconstriction and is used as a probe for bronchial hyper-responsiveness. commercial iv adenosine preparations used in treating supraventricular tachycardia are reported to induce bronchospasm in known asthmatics. since serum levels of adenosine are transiently increased following iv dipyridamole, bronchospastic symptoms during dipyridamole stress tests should not be unexpected. an earlier study found an increased incidence of wheezing in % of patients with known copd/asthma undergoing dipyridamole stress tests despite pretreatment with beta agonists. the marked decline of theophylline use for chronic asthma in recent years may actually be increasing the incidence of this risk. cardiologists performing thallium stress tests are familiar with the risk of asthma flares after dipyridamole. they use iv aminophylline frequently to reverse several types of clinical dipyridamole reactions, including bronchospasm. on the other hand, we are impressed that allergists are relatively unfamiliar with this association. allergists and asthma specialists as well as asthmatic patients should be aware of risk of acute dipyridamole induced bronchospasm during elective cardiac stress testing. it has been shown that adhesive molecules are involved in inflammatory diseases of the lungs such as bronchial asthma. the purpose of the study was to measure and establish possible difference in serum levels of soluble icam- in atopic patients (patients with allergic rhinitis and patients with bronchial asthma) in comparison with patients without atopy (patients with asthma without rhinitis); whether there is a difference in sicam- levels between groups of patients with allergic rhinitis and asthma in comparison with group of patients with allergic rhinitis only and also in comparison with healthy controls. results of the study have substantiated statistically significant difference in sicam- levels between all groups of patients in comparison to healthy control, but no statistically significant difference in sicam- levels between patients with and without atopy (z=- . ) or between patients with allergic rhinitis and bronchial asthma in comparison with group of patients with allergic rhinitis only (z= . ). conclusion: icam- is an important marker of inflammation in patients with allergic rhinitis as well as in those with bronchial asthma. atopic status does not influence differences in sicam- levels. although mean sicam- levels were higher in patients with allergic rhinitis and bronchial asthma ( . ng/ml) in comparison with mean sicam- levels in patients with allergic rhinitis only ( . ng/ml), no statistically significant difference was noted in sicam- levels between these groups of subjects, i.e. asthma itself did not contribute to statistically significant increase of sicam- levels. k. nadarajah * , g.r. green, m. naglak, abington, pa. objective: to study the various clinical outcomes of penicillin skin testing (pst) in a community-based hospital and to determine the percentage of patients who have an antibiotic modification and the choice of antibiotic used following the result of pst. method: this study is a retrospective chart review of all in-patients who were penicillin skin tested during a period of . years(jan to july ). information was collected on patients using a detailed data collection form. data was summarized using descriptive statistics including frequencies and percentages. results: of the patients penicillin skin tested, had a negative test, five had a positive test and in four patients the test was indeterminate(histamine controls were negative). eighty six percent of the patients had a history of penicillin allergy, . % had a history of cephalosporin allergy and . % had a history of both penicillin and cephalosporin allergies. the duration of antibiotic prior to pst ranged from zero to days. there was a . % ( / ) reduction in the use of vancomycin, a . % ( / ) reduction in the use of floroquinolones and a . % ( / ) reduction in the use of aminoglycosides following pst. aztreonam was used in . % ( / ) of patients before pst and in zero patients after pst. use of penicillin-based drugs was % ( / ) after pst and cephalosporin use increased from . % ( / (all third generation cephalosporins)) to . % ( / ( second and third generation cephalosporins)). i.e., % of patients with a negative pst received a penicillin or a cephalosporin. vancomycin usage was higher among pst positive patients. endocarditis was the diagnosis in % of all patients skin tested and staphylococcus aureus ( . %) and enterococcus ( %) were the most common organisms on culture. there were no serious adverse reactions to the use of penicillins or cephalosporins when used following a negative pst, and there were no adverse reactions to penicillin skin testing. conclusion: in the population studied, pst lowers the usage of vancomycin, floroquinolones and aminoglycosides and increases the use of penicillins. third generation cephalosporin usage was increased by pst in our study. overall, pst results in antibiotic modification that could lower the emergence of multi-drug resistant organisms and vancomycin resistant enterococcus. the aim of the study was to find a new marker which could be easily done to predict about possible allergy development in infants. preventive procedure is always economically better than treatment itself.food allergens are able to stimulate lymphocytes even in prenatal period. immunological maturity of newborns is still in the center of our interest because its dependence on many different factors. the question was if cd activity in cord blood and in -year-old children correlates with development or not of allergy? the examined group consists of newborns( , % of boys). breastfed were only children until -months-old and until they were -monthsold. total ige from cord blood and mothers' blood taken at delivery were measured using unicap. immunological detection was done using fluorocytometry(becton nad dako). additionally parents were questionaired( family atopy). our reaults show that positive family atopy history(group a) or elevated level of ige( group b) or symptoms of allergy in first months of life(group c) does not correlate with cd antigenicity. in all subgroups cd frequency was %. our findings show unfortunately that cd cannot be a predictive marker for allergy development. rationale: the etiology of eosinophilic esophagitis (ee) is unknown and the relationship to a type i allergic response is unclear. comparison of patients with positive and negative type i allergy testing may further clarify ee and determine what are the most common food allergens. methods: this is a retrospective chart review of medical records from january to january of children year of age with biopsy confirmed ee (n = ). ee was defined as having eosinophils per high power field on esophageal mucosal biopsy. patients were grouped according to positive (n = ) and negative (n = ) allergic responses on skin or radioallergosorbent testing (cap rast, pharmacia). skin testing with commercial extracts (hollister-stier laboratories and greer laboratories) was performed in an allergist's office. a wheal of mm greater than the negative control on skin testing or ige > . ku/l on rast was considered positive. we performed fisher exact analysis to determine if associations existed between a type i allergic response and factors such as age, symptoms, peripheral eosinophilia, and personal and family history of atopy (asthma, allergic rhinits, and atopic dermatitis). results: ee patients with a positive type i allergic response were significantly younger than those with a negative response (mean . yo, median . yo, range to . yo versus mean . yo, median . yo, range to yo; p = . ). vomiting as a presenting symptom was significantly increased in the allergic population ( %, %; p = . ) and abdominal pain as a chief complaint was significantly increased in the non-allergic population ( %, %; p = . ). personal and family history of atopy and peripheral eosinophilia were similar between groups. the most common allergens were cow s milk ( %), peanut ( %), egg ( %), soybean ( %), and wheat ( %). conclusion: patients diagnosed with ee who present at a young age or who present with symptoms of vomiting may have a type i allergic response contributing to the esophageal eosinophilic inflammation. consistent with food allergies in children, milk, peanut, egg, soybean, and wheat were the most common foods found with allergy testing. because the positive predictive accuracy of food annals of allergy, asthma & immunology testing is only about %, the challenge remains to develop a specific plan to confirm causative foods such as through oral challenges or elimination trials. rationale: the relationship between specific ige and igg levels in atopic individuals is unknown. increasing antigen exposure is expected to increase igg production, however, the influence on ige levels is unclear. to further clarify this relationship the following studies were conducted. methods: three hundred and sixty tandem determinations of specific ige and igg levels in individuals were collected using the immunocap instrument (pharmacia diagnostics) and commercially available reagents. only subjects who had ige levels > . ku/l and igg determinations > mg/l to the same specific allergenic species were included in the study. specific ige and igg determinations were to alternaria alternata, aspergillus fumigatus, penicillium notatum, cladosporium herbarium, felis domesticus, canis familaris, dermatophagoides farina, and periplaneta americana. correlation coefficients were calculated using excel (microsoft). results: the review of this data set yielded tandem determinations of specific ige and igg levels in atopic individuals. the most common ige sensitization was to alternaria. sixtyfour percent of individuals had specific ige directed against alternaria. the lowest ige response rate was for cat and roach. only % of individuals had an ige response to those specific species. correlation coefficients (cc) were calculated between specific ige and igg levels and were positive for all eight species tested. the highest cc was for dog (n = , cc = . ) followed by aspergillus (n = , cc = . ), penicillium (n = , cc = . ), alternaria (n = , cc = . ), cladosporium (n = , cc = . ), cat (n = , cc = . ), and roach (n = , cc = . ). the lowest correlation was for dermatophagoides farina (n = , cc = . ). conclusion: when individuals with measurable specific ige and igg levels are considered, there appears to be a positive correlation between specific ige and igg levels for many allergenic species. factors that influence the correlation are likely to be both genetic and environmental. identifying this link and a clinical application are our next challenge. recently, protein microarray tests are competing with traditional allergenspecific in vitro assays. while the advantages of microarrays in allergy testing are attractive, microarray analysis alone has not been very effective in reducing analysis time and automated microarray equipment typically is much larger than its benchtop counterparts. we have incorporated microarray technology into an automated microfluidic cartridge that provides rapid allergen testing using a compact, low-cost, desktop instrument. the injection molded microfluidic cartridge (fig. a) contains arrays of miniature pumps and valves that direct reagents independently to a solid phase reaction area. standard ige (nibsc) as well as allergens were immobilized within the cartridge to form a protein microarray. a small desktop analyzer actuated the pumps in the cartridge to automatically carry out a chemiluminescence-based elisa reaction. total ige quantitation was performed in a minute reaction. fig.b shows the resultant image of a dilution series of immobilized ige. concentrations ranged from . to iu/ml corresponding to . fg to ng ige per spot. the average cv value for ige quantitation was % showing good linearity (r = . ) and fg sensitivity. this quantitative ige curve is used to eliminate the effects of cartridge variability. specific ige detection was demonstrated using extracts, d. pteronyssinu(dp), a.fumigatus and b. verrucosa(bv). a -step, minute reaction elisa technique was employed. fig. c and d show the resultant images for bv and dp positive serum, respectively. the sensitivity of the dp specific ige test was further investigated using a positive class serum sample confirmed by mast. dilution of the class serum with negative control serum could then be detected on the cartridge down to an fold dilution, resulting in a limit of detection in the range of . - . iu/ml for dp specific ige. we have demonstrated total ige and allergen-specific ige detection with total analysis times less than minutes in a convenient, low cost system using a microfluidic-based microarray cartridge. such rapid diagnosis allows physicians to provide treatment while the patient is still in the office. background: accurate allergen skin tests (ast) are the basis of optimal care of the allergic patient. completing these tests on the first visit can expedite the diagnosis and treatment and offer patients(pts.) efficient use of their time and increase satisfaction. appropriate pre-visit preparation is necessary to reduce the variables that affect ast outcomes. both positive and negative skin test controls are necessary to assure the ast are reliable. methods: we conducted a retrospective chart review of , sequential pts. skin tested at an allergy practice, in order to examine the success of our pre-visit instructions and to identify other medications that may affect ast. pts. were given verbal and written instructions to discontinue antihistamines and other histamine- receptor antagonist medications (h- a) days before their visit. they then underwent ast only if adequate positive (histamine) and negative (saline/vehicle) controls were obtained. results: only ( . %) of the , pts. had inadequate histamine response (ihr). of these pts., ( . %) had used h- a within the prior days. ( . %) pts. had taken h- a in the recent past, but stopped them at least days prior to testing. ( . %) pts. had no exposure to h- a. the use of psychiatric medications in the pts. with an ihr was also examined. of the pts. who discontinued h- a for more than days, ( %) were also taking various medications drugs used in the treatment of psychiatric disorders (ssris, benzodiazepines, atypical antidepressants & antipsychotics) which are not usually associated with h- a. the group of of the pts. with no prior use of h- a included ( %) who were also on various psychiatric medications. the high prevalence of psychiatric medication use in these two groups is in contrast to the to pts. with recent use of h- a in whom % were on psychiatric medications. conclusion: pre-visit patient education about discontinuation of h- a can lead to successful first visit ast in the overwhelming majority of patients ( . %).failure to stop h- a at the appropriate time occurred in only . % of the pts. . % of pts. discontinued h- a for the recommended day interval, but still had ihr. another % of pts. had an ihr yet no obvious use of h- a. a few pts. taking psychiatric medications not normally associated with h- a had ihr. further investigation into this issue is warranted. a. blaziene * , a. chomiciene, l. jurgauskiene, n. ciaponiene, vilnius, lithuania. background: sublingual specific immunotherapy (sit) is accepted as an alternative treatment to subcutaneous sit of seasonal allergic rhinitis. the aim of this study was to evaluate changes in allergen-specific ige and basophil degranulation test (bdt) before and after year of sit with a grass pollen mix. methods: patients ( male and female, aged - years) having sensitization to grass pollen with seasonal allergic rhinitis were treated with standardized grass pollen extracts. the blood samples were collected before and after year of sit assessing allergen-specific ige using an elisa method and bdt using a direct immunofluorescent method employing monoclonal antibodies. results: the sit was well tolerated by all patients. an increase in total ige after sit was observed in all patients. specific ige concentration was increased in ( . %) patients, while the bdt result was greater in ( %) patients after year of sit. conclusions: allergen-specific ige and bdt may serve as markers to indicate the clinical efficacy of sit for seasonal allergic rhinitis patients. a.g. palma-carlos * , s.l. silva, m.l. palma-carlos, lisboa, portugal. introduction -the incidence of primary immunodeficiencies in patients attending an out-patient center for clinical allergy and immunology depends on the recruitment and on patients refered. methods -in the last years patients have been observed in lisbon clinical allergy center reporting allergic diseases or repeated infections or refered by specialists (ent, gynaecology, internal medicine, pediatrics, or gp.). screening for primary immunodeficiencies has been done by electrophoresis, assay of immunoglobulins and complement, igg subclasses and flux-cytometry for t, b and nk cells. results - cases ( , %) of primary immunodeficiencies have been diagnosed. humoral: deficits of iga ( , % of immunodeficiencies), of igg ( , %) of igg subclasses ( , %) of common variable immunodeficiency cvi-( , %), of igm ( , %). complement: cases of c esterase inhibitor deficiency ( , %) cellular: cases of mucocutaneous candidiasis ( , %) in fertile females, cases of cd deficiency ( , %). combined: cases of deficiency of the couple cd /c ligand with igg deficiency ( , %).conclusions -in the present series chronic mucocutaneous candidiasis is the prevalent primary immunodeficiency, due to the number of patients refered by gynaecologists. aside of this group where a decrease of nk cells was the more common immunologic pattern, humoral immunodeficiencies are frequent, mainly cvi, iga, igg and igg subclasses deficiencies. the search for immunodeficiencies must be done in all patients with repeated infections attending immuno-allergology departments. a case of atypical c complement deficiency. c.c. randolph * , waterbury, ct. introduction:c complemennt deficiency occurs in in , individuals .it results in decreased opsonization and chemotaxis with increased prevalence ofsle and other rheumatic disordersas well as enhanced vulnerability to pyogenic infection.there are two types of c complement deficiency :type ( %associated with sle)with no protein translation and type ii with absence of protein secretion.we present a year old white female otherwise healthy with recurrent urticaria and angioedema with c complement deficiency. method:case report:a y/o w/f athlete presented with a two month history of recurrent hives and angioedema which she associated with ingestion of halloween candy .one week before evaluation she had hives with coconut as well.her history was othewise unremarkable except for recurrent uti's, annual sinusitis, pneumonia in as well as migraines.she denied sexual activity.her physical exam was normal.results:an evaluation for autoimmune disease revealed normal esr, ana, dsdna, mono and hepatitis serology as well as lyme titers however her ch was low u/ml(normal - u/ml)and evaluation of complement revealed c mg/dl(normal - mg//dl)and c < . mg/dl(normal . - . mg/dl)with normal c , c -c .her father had nor-malc but c was . mg/dl (normal . - . mg/dl)her sister had c of . mg/dl and normal c and her mother had normal c and c .her workup included positive prick skin test to ragweed, ash and grass and she was started on rhinocort and clarinex seasonally.she has been followed for one year with resolution of hives and is asymptomatic.her diagnosis had been confirmed by a pediatric rheumatologist.conclusion;we present an atypical case of c complement deficiency in an currently asymptomatic individual. background: we diagnosed a month old male with cgd and aspergillus brain abscesses and pulmonary infiltrates. review of the literature suggests he is one of the youngest cases of cgd complicated by cerebral aspergillosis. case report: a ten month old male previously seen for unexplained persistent pulmonary infiltrates since month of age presented to our hospital with lethargy, fevers, and increased irritability. ct scan of the head revealed severe hydrocephalus. multiple brain abscesses were found on surgical exam and cultured for aspergillus fumigatus. he had a history of failure to thrive and hypotonia since birth. family history was significant for parents that were second cousins. there was no family history of recurrent infections or childhood deaths. physical examination was significant for a child with weight and height in the % and %, respectively with persistent fevers > . c, hypotonia, hepatosplenomegaly, and left lower lung field rales. initial immune workup was normal except for elevated total ige of ku/l. cd + ( /m ) and cd + ( /m ) t cells were initially low, but later increased to normal levels without intervention. neutrophil oxidase activity assessed by dihydrorotamine (dhr) oxidation was % of control. superoxide production assessed by cytochrome c reduction was zero. the patient was treated with interferon ? for presumed cgd. his aspergillus brain abscesses improved with intravenous voriconazole and caspofungun. the responsible organism for his recurrent pulmonary infections was not identified, but improved with antifungal therapy and broad spectrum antibiotics. the dhr test of both parents and siblings were normal. antibody testing showed a complete deficiency of the p protein with normal levels of gp , p , and p proteins. evaluation of the exons of the ncf- gene that encodes the p protein were normal. conclusion: mutations due to p protein deficiency are responsible for % of cases of cgd. there has been only one previously reported case of p deficiency without ncf- exon mutations in which a single point mutation in an intron of the ncf-ii gene was identified. fungal infections may complicate cgd, however cerebral aspergillosis is seldom encountered. this case annals of allergy, asthma & immunology reports a month old with cgd due to a p deficiency without exon mutations complicated by cerebral aspergillosis. introduction: lymphoid interstitial pneumonia is an uncommon condition which is considered both as a disease per se or as an inflammatory pulmonary reaction to various external stimuli or systemic diseases; however, at the present time most of the cases remain idiopathic. we present a case of an infant who developed a lymphoid interstitial pneumonia associated to a deficit of interferon-production. methods: we describe a clinical case and review the medical literature. results: we present the case of a five months old male with a history of cough, respiratory distress and four previous hospital admissions regarded as a 'pneumonic' events from two months of age and four siblings dead (two of them with 'abdominal disease' and one of them with candidiasis) during their first year of life. the parents referred no consanguinity. the physical examination showed a malnourished child with signs of bilateral lung consolidation. oxygen supplementation and intravenous antibiotics were started. our patient didn't have neonatal history related to the present compliant. the chest film revealed a diffuse bilateral interstitial pattern which was confirmed by pulmonary ct scan. sweat chloride test, hiv and epstein barr virus serology test were all negative. an initial immunologic evaluation reported slightly increased leukocytic count, hypergammaglobulinemia, lymphocityc flow citometry and nitro blue tetrazolium reduction test in normal parameters. the open lung biopsy showed a thicked pulmonar interstitium with moderate number of lymphocytes with not atypical pattern. our patient was discharged with clinical improvement, ambulatory oxygen supplementation and inhaled fluticasone-salmeterol. in an ambulatory follow-up we evaluated lymphocytic production of cytokines and we found no levels of interferon-. we started weekly administration of oral transfer factor. the patient showed an excellent clinical improvement evidenced by no more oxygen dependence, weight gaining and absence of further hospital admissions. con-clusions: our patient represent a new linkage between lymphoid interstitial pneumonia and primary immunodeficiency characterized by interferonproduction deficit, maybe with a non previously described molecular defect and a probably autosomic recessive inheritance pattern; also we confirmed the transfer factor usefulness to induce gamma interferon endogeous production. objective: marijuana is a schedule class psychoactive control substance more frequently used by the oriental societies( in the event of jubilation) causing altered state of conscience, euphoria, its prolonged use is followed by addiction and dependence.it contains more than chemical entities with over are of the cannabinoid i.e, cannabidiol (cbd), cannabinol (cbn), and delta- , tetrahydrocannabinol (thc) the later on use has been associated with craving for further use of narcotics just to enhance the euphorient effects .the active ingredients i.e, delta- -tetrahydrocannabinolthc) and other cannabinoids(thc) are liquid soluble at high concentrations which alters membrane function, resulting in alterations in immune cell response. cannabinoid has immunosuppressant properties causing impaired cell-mediated and humoral immune system activities, cytokine production, leukocyte migration and natural killer-cell(nk) activity resulting in reduction in the host resistance to bacterial and viral infection, (pms)with hiv infection are at higher risk of developing aids, infection by opportunistic bacteria, fungi, or viruses (pms), when compared to non marijuana smokers, have more respiratory ill-ness.cannabinoids also characteristically as being immunomodulators i.e, generally suppressing but occasionally enhance some immunological responses, some have suggested that the immunosuppressive effects of cannabinoids might be useful clinically; for example, in treating multiple sclerosis.as per clinical response cannabinoids had been found exacerbating existing allergies from antigenic complex (eliciting formation of specific antibodies/metabolites as a hapten, combining with a body proteins). methods .in the follow up studies including individuals(all males age - years) with(pms).of more than months having serum level of tch > um, there have been times reduction in the proliferation of t lymphocytes with a proportionate increase in the proliferation of b lymphocytes, reduction in the cytotoxic activity of t lymphocytes, reduction in macrophage activities i.e, phygocytosis rationale: patients with xla are subject to arthritis and cellulitis. these three relatives have had similar courses, suggesting infectious etiology. methods: two brothers and a cousin, from an african-american family known to carry xla, have been diagnosed with xla and chronically treated with ivig. all three have developed arthritis and cellulitis of a lower extremity. the eldest, now years old, had a -month waxing and waning arthritis and cellulitis that was refractory to the oral antibiotics attempted. his younger brother had not yet accomplished pubertal changes at the age of , and was below rd percentiles for weight and height. he also had several months waxing and waning arthritis and cellulitis refractory to oral antibiotics. he and his cousin have had esophogastroduodenoscopies that show gastritis and duodenitis with heavy growth of an organism visualized by specific staining for h. pylori. the cousin has also experienced more recent weight loss and arthritis/cellulitis. results: the younger brother had a blood culture that grew a curved gram-negative rod. a subsequent culture at the state lab grew a similar organism that was urease-negative. the two brothers are at or near completion of a six-month course of ertapenem and gentamicin; they have had resolution of their arthritis and cellulitis. the younger has gained . kg and experienced his pubertal changes at the age of years. con-clusions: there are prior reports of several different related organisms that can cause arthritis and cellulitis in patients with xla. these include helicobacter, campylobacter, and flexispira species. the urease-negative organism would not be flexispira, but may be a campylobactor species or helicobacter canis. the results from this family suggest that long-term combination iv antibiotics may be indicated for patients with this syndrome. slow virus infections have been reported to affect the central nervous system. parvovirus b , herpes and cmv are usually not included in the diagnosis of cns diseases nor has been associated with cns manifestation in an immuno-compromised patient. in this abstract, we report on a neurological manifestation that can be linked to ebstein-barr/herpes virus and parvovirus-b in an immune deficient patient. a year old female presented to our clinic with a history of chronic fatigue symptoms, daily arthralgias, frequent sinus infections and idiopathic tremors for the past years. the patients neurological evaluation, including mris was found to be within normal limit, despite worsening tremors of her head and arms. a full clinical and labora-tory evaluation was performed which revealed igg subclass, low t-cell numbers and functioning, low response to specific antibodies and positive igm for ebv, parvo and cmv. the patients common immune deficiency coupled with chronic viral infection and worsening tremors led us to try high dose ivig ( g/kg divided over days on cycles of every weeks). within three months of starting ivig, the patient had a large reduction in her tremors and negative igms for parvovirus, herpes and cmv. given our findings, we suggest that ivig may play a role as a neuro-immune modulator, as has been shown in other neuro-immune diseases. we further suggest that the interaction between parvovirus b- , herpes and cmv as part of the slow viruses, combined with underlying immune disorder may lead to neurological presentation and high dose of ivig can reverse the syndrome. purpose: to date, only two patients older than fifty years of age have been diagnosed with velocardiofacial syndrome (vcfs); this case represents the third such patient. methods: physical and laboratory findings of the patient are presented as a case report. results: we describe a sixty-six-year-old male, recently diagnosed with vcfs, confirmed by fluorescent in-situ hybridization (fish), was referred by his psychiatrist for comprehensive care. he had a history of cleft palate and learning disabilities as a child, with the onset of psychiatric illness in his late teens. although there was no history of cardiac disease, the patient had agenesis of the left renal artery as well as other vascular anomalies, including hypoplasia of the left a segement of the anterior cerebral artery. other findings included hypothyroidism, hypoparathyroidism, sensorineural hearing loss, and typical facies. he also suffered from chronic candidiasis. immunologic laboratory studies revealed over a : ratio of cd :cd t cells with a decreased cd percentage, markedly diminished b cell percentage, decreased t cell mitogen responses, and markedly decreased b cell mitogen responses. nevertheless, total serum igg and specific antibody responses remained normal, with a low serum igm. conclusions: this patient meets the criteria for the diagnosis of vcfs; only the third reported case diagnosed over the age of fifty. though his immunologic findings may be consistent with his diagnosis, they may be due in some part to immunologic senescence given his age. background: the classic presentation for patients with xla and mutations in the btk gene includes marked hypogammaglobulinemia, absent b cells, and significant sinopulmonary infections beginning at - months of age. typically, mds presents with anemia, leukopenia, monocytosis, and thrombocytopenia with recurrent infections, skin rash, and hepatosplenomegaly. many of these subjects demonstrate chromosomal abnormalities including monosomy . we describe a case of mds presenting with some features of both conditions. clinical history: we present a year old male with a suspected diagnosis of xla, chronic sinopulmonary disease beginning at mo, diffuse bronchiectasis, and agammaglobulinemia with absent b cells. he had wbc = cells/ul, with % monocytes and platelet count of , /ul. he had no anemia, hepatosplenomegaly, or skin rash. bone marrow biopsy showed mds with absent plasma cells and monosomy in % of his cells. btk expression and sequence analysis were normal. conclusion: while xla is the most likely primary immune deficiency that would present in a male with the clinical picture described above, this case illustrates the importance of maintaining an expanded differential diagnosis in patients with presumed primary immunodeficiency. j. wang * , l. mayer, c. cunningham-rundles, new york, ny. background: chronic granulomatous disease (cgd) usually results in acute or chronic infections with a defined spectrum of bacteria or fungi. other characteristics include inflammatory disorders, including genitourinary or mucosal inflammation resembling inflammatory bowel disease. gm-csf has been used in the treatment of mucosal inflammation in glycogen storage disease ib and crohn's disease with some success. objective: to explore the use of a novel therapy in the treatment of mucosal inflammation associated with cgd. methods: the patient was treated with daily gm-csf ( . mcg/kg/dose subcutaneous injection) along with parenteral antibiotics and total parenteral nutrition. after days on gm-csf, hydrocortisone enemas were added due to continued pain and swelling. results: rectal and abdominal pain significantly improved, blood streaked stools decreased; he tolerated a regular diet and was discharged home days after starting gm-csf. he now has no rectal or abdominal pain and no blood in the stool. conclusions: gm-csf may be a useful therapy for the management of mucosal inflammation in cgd patients. it appears safe and well tolerated and permits avoidance of immune suppressive alternatives. introduction: management of autoimmune cytopenias in patients with cellular immunodeficiency may be very challenging. treatment of these cytopenias with corticosteroids may potentiate the immune dysfunction leading to further infections. methods: we describe a month-old female with a cellular immunodeficiency and autoimmune thrombocytopenia / hemolytic anemia being treated with steroids and ivig without improvement. rituximab, a monoclonal antibody that binds to b-lymphocyte cd surface antigens, was initiated. results: this patient presented at months of age with failure to thrive, eczema and recurrent bacterial pneumonias. she was diagnosed with a t lymphocyte immunodeficiency with decreased absolute numbers of cd ( ), cd ( ), and cd ( ) lymphocytes. t cell function was markedly decreased as measured by pha, cona, and pwm. she developed chronic thrombocytopenia with platelets of less than , and coombs positive anemia with hemoglobin of g/dl. she was placed on mg/kg/day of prednisone with minimal improvement and continued to develop severe pneumonias. rituximab mg/m /week was initiated for doses. her cytopenias improved with an increase in both platelet count ( , ) and hemoglobin ( . g/dl). her absolute cd count fell from to . she was weaned off steroids permanently. she has also continued on ivig, prophylactic antibiotics, and as needed rituximab pending bone marrow transplant. conclusions: rituximab, a monoclonal anti-cd antibody, may be helpful in treating autoimmune cytopenias in patients with cellular immunodeficiency in which steroids need to be avoided. ivig antibody replacement substitutes for the subsequent humoral antibody depletion due to induced secondary b cell lymphopenia. introduction: the patient is a month old male born at full term. during his prenatal course he was noted to have a pulmonary abnormality in his left lower lobe at approximately weeks of age. serial ultrasounds and fetal mri were consistent with the diagnosis of congenital cystic adenomatoid malformation (ccam). histology from elective resection of the lesion performed at months of age revealed no evidence of ccam. silver stain revealed florid pneumocystis jiroveci (carinii) infection. the patient was completely asymptomatic. the differential diagnosis for this infection in the newborn period includes hiv infection, severe combined immunodeficiency, and x-linked hyper-igm syndrome. the infection has also occurred in newborns with apparently normal immune systems. methods: immunology evaluation was performed to evaluate the patient for the listed diagnoses. a complete blood count was performed. lymphocyte subsets were performed by flow cytometry. quantitative immunoglobulins g,a, m and e were measured by nephelometry. specific antibodies to tetanus and diptheria were determined by elisa. hiv status was ascertained by western blot and dna pcr. dichlorofluorescein assay was performed. fluorescenceactivated cell sorter technique was used to evaluate cd ligand. lymphocyte stimulation to mitogens and tetanus were performed. results: the patient had negative hiv / antibodies and a negative hiv dna pcr. the result of the complete blood count was normal with an absolute lymphocyte count of , . the patient had normal percentages and numbers of cd , cd , cd , cd , and natural killer cells. lymphocyte stimulation to mitogens and tetanus was normal. dcf assay was normal. facs revealed normal levels of cd ligand. at months of age he had protective titers to diptheria and tetanus titers of . iu/ml (protective > . iu/ml). at months igg, a, m and e were (normal - ), < , , and < respectively. conclusion: immunologic testing revealed no evidence of severe combined immunodeficiency, hiv infection or x-linked hyper-igm syndrome. the patient remains well clinically with normal growth and development with no subsequent infections. pneumocystis jiroveci pneumonia can be seen in infants with apparently normal immune systems. commercial preparations of igg produced for iv use (ivig), must fulfill regulatory requirements. the method of preparation, however, may produce alterations in the content or function of igg subclasses such as disturbed composition which can be reflected as a lowered clinical effectiveness of the product. we report patients with specific igg immunodeficiency, that, when changed to a new ivig preparation, had lessening of clinical effectiveness of the new product but who also experienced recovery after they were changed to a different ivig product. case . a y/o male with hx of cervical lymphadenopathy associated with recurrent uri, fatigue, cognitive alterations and hypercholesterolemia. he was dx in with a specific igg immunodeficiency for which he was started on ivig infusions mgxkg q/ w which brought his igg levels to normal values mg/dl, ( - mg/dl) with good clinical improvement. when he was changed to a different ivig product with lower iga content his initial symptoms returned with decrease of his igg to mg/dl ( - mg/dl) he was changed to a different ivig product with higher iga content with disappearance of all his previous symptoms. case . a y/o female with history of chronic yeast infection, fatigue, joint pain, asthma, ge reflux, depression, hypothyroidism and shunt for hydrocephaly. she was diagnosed with igg and igg immunodeficiency and started on ivig mg x kg x q/ w. when changed to another ivig with lower iga content she experienced worsening of her symptoms during the months that she was receiving it. she was changed to a different ivig product with a higher iga content with complete improvement of her symptoms. although the content of iga in product ( - ug/ml) was significantly lower than in prod-uct ( ug/ml), the total igg and igg subclass distribution (including igg ) were comparable therefore, the lack of clinical effectiveness of product would appear to be related to qualitative alterations in the product related to methodological preparation possibly in removal of the iga or other physicochemical alterations affecting biologic activity which contributed to a lessened clinical efficacy of the product. we present these cases to alert the allergist-immunologist to these observations when treating patients with igg or igg subclass deficiencies. background: development of atopy has been known to occur in nonatopic recipients of bone marrow transplants ( bmt) from atopic donors. the reverse condition, with atopic recipients losing evidence of specific ige after bmt from non-atopic donors is quite unique. case report: ph is a year old male referred for recurrent nasal congestion. as a teenager, the patient was treated for chronic allergic rhinitis and asthma, atopic dermatitis diagnosed as severe, and multiple food allergy. skin testing done as a teenager showed + reactions to multiple pollen, dog, cat, most seafood, cashew, walnut and pecan. at years of age, he underwent an allogeneic bmt from his non-atopic brother for acute myelogenous leukemia. asthma and atopic dermatitis were observed to clear almost completely and allergic rhinitis improve after the bmt. his blood type changed from + to -. skin testing done on his current visit showed unremarkable responses to all pollen, cat, dog, dust mites and foods with good histamine control. discussion: the negative skin test results suggests that his current nasal symptoms are vasomotor in nature. considering the past severity of his symptoms, it appears unlikely that he lost his specific-ige sensitivity spontaneously. transfer of atopy is known to occur in non-atopic recipients of bmt from atopic donors. in a study of patients undergoing allogeneic bmt for hematologic malignancies, nonatopic recipients developed positive skin tests with profiles similar to atopic donors. a possible mechanism is passive transfer of memory b-cells which initiate specific-ige production with a donor pattern. a reverse of this mechanism could occur with the recipient gaining lymphoid precursors with no atopic tendency leading to clearing of atopy. the literature yielded one report of asthma resolving after high-dose chemotherapy and autologous stem cell transplantation the authors suggested that chemotherapy could have resulted in immune system reconstitution, normalization of the t-cell repertoire and resolution of asthma. introduction: primary central nervous system (cns) lymphomas constitute only a small percentage of central nervous system tumors in adults and are seen more frequently in aids patients and immunodeficiency states. they are extremely rare in children, even those with primary immunodeficiency. we present a -year-old female with combined immunodeficiency who developed an eber+ (ebv-associated) large b-cell lymphoma that was confined to the cns. methods: the patient is a -year-old female that was being evaluated for combined immunodeficiency who presented to our institution with acute fever and seizure activity. results: the patient had a history of recurrent pneumonia, otitis media, sinusitis, and upper respiratory infections. she also exhibited failure to thrive, chronic diarrhea, and sen-sorineural deafness. she was found to have a combined immunodeficiency with severe neutropenia and lymphopenia, low iga, low igm, and poor specific antibody response to protein and polysaccharide antigens. she had no response to a candida delayed hypersensitivity skin test. hiv tests were negative. she was thought to have acute meningoencephalitis causing the fever and seizure activity, however bacterial, viral, and fungal studies were negative. she received multiple anitbacterial, antifungal, and antiviral agents. she died secondary to brainstem compression due to severe cerebral edema. autopsy revealed an eber+ large b-cell lymphoma that involved about % of her brain and spinal cord. no tumor cells were found elsewhere. con-clusions: this case represents a rare manifestation of combined immunodeficiency: the development of a primary cns lymphoma. the tumor cells were found to be eber+ (ebv-associated). ebv is known to be associated with lymphoma, especially in aids and immunocompromised patients. only . % of primary tumor sites in severe combined immune deficiency patients involved the cns in the immunodeficiency cancer registry that was instituted in the s. v. litvinova * , g. muzlaev, krasnodar, russian federation. introduction: glyoma is one of the most prevalent diseases among all brain tumors and more than % of them are malignant. in the previous investigations it has been shown the immune disorders in patients with glyoma tumor. at the same time it was suggested the possible anti-tumor activity of some proinflammatory cytokines (tnf, il , il ), which can penetrate via haematoencephalic barrier and induce the lysis of tumor cells. the aim of this investigation was to study the serum and spinal fluid concentrations of one of the key immunoregulatory cytokines -gamma ifn and il in patients with glyoma tumor. methods: the concentrations of the gamma ifn and il have been studied in serum and spinal fluid of patients with glyoma by eliza method. in control, the same parameters have been studied in patients with brain trauma. results: it has been shown that concentrations of gamma ifn and il in serum and spinal fluid was . - times higher than in trauma patients (p< . ). the serum levels of gamma ifn and il in glyoma patients were . and . pg/ml, accordingly. in trauma patients- . and . pg/ml. the concentration in spinal fluid of the studied cytokines was . time higher than in control patients. conclusion: proinflammatory cytokines gamma ifn and il may be involved in pathogenesis of glyoma and can participate as possible anti-tumor factors of immunity in glyoma patients. a. arrey-mensah * , r.u. sorensen, new orleans, la. rationale: immunodeficiencies need to be ruled out in infants that present with failure to thrive. patients with t-cell lymphopenia, hypogammaglobulinemia and pancytopenia may have a primary immunodeficiency such as scid, or a secondary immunodeficiency that may need to be managed differently. methods: evaluation of cellular and antibody-mediated immunity of a month old aaf admitted with failure to thrive and chronic diarrhea. ohistory of duodenal atresia corrected by creating a blind duodenal loop and anastomosis of the stomach to the jejunum at birth. o mass in hypogastrium. results: immunologic evaluation revealed: " lymphopenia ranging to cells/ul " anemia: hemoglobin . g/dl, retic . " ancs ranging to " thrombocytopenia l to l " cd +: " cd +: " cd /cd r: . " cd : " cd : " mitogen responses were normal: " pha , cpm " con-a, , cpm " pwm, , cpm immunoglobulins: igg mg/dl iga mg/dl igm mg/dl ige iu/ml total protein was . g/dl, albumin was . g/dl the immunoglobulin-g half-life study was days in our patient: metabolic imbalance: hypokalemia ( . mmol/l) hyponatremia ( mmol/l) hypocalcemia ( . mg/dl) blood, stool, urine cultures normal. stool ova, parasite, virus were negative. hiv-pcr (-) radiological evaluation: superior mesenteric vein thrombosis, chronic malrotation and volvulus, dilated duodenal blind loop with possible lymphatic obstruction. the patient improved clinically and all immunological markers normalized after surgical removal of adhesions and obstruction. conclusion: the patient had a secondary immunodeficiency due to lymphangiectasia. lymphangiectasia should be considered in the presence of a lymphopenia with normal lymphocyte function and hypogammaglobulinemia accompanied by hypoproteinemia and hypoalbuminemia. hypogammaglobulinemia and hypoproteinemia were secondary to gastrointestinal losses. the immunological component of q . deletion syndrome (also known as digeorge syndrome;dgs), hypoplasia of the thymus, is quite variable among patients and provides the opportunity to determine the relationship between thymic function and t cell receptor (tcr) repertoire diversity. using a novel measure of repertoire diversity based on cdr length polymorphism called hamming distance, tcrbv repertoire diversity in dgs was found to differ from control subjects by having an overall skewing of receptor expression. as expected from clinical outcomes, there was also great intra-individual variability in dgs tcr repertoires. the degree of repertoire diversity was directly correlated with thymic output as measured by t cell receptor excision circles (trecs), i.e. greater thymic output resulted in more diverse repertoires (see figure below). this result demonstrates a quantitative relationship between thymic function and repertoire diversity in humans and may reflect the balance between thymic output and peripheral expansion to maintain an adequate tcr repertoire. in addition, it may suggest a basis wherein limited repertoire diversity mediates both immune deficiency and autoimmunity. tcr repertoire diversity in dgs, as measured by hamming distance, correlates with thymic output, as measured by trecs (plotted on a logarithmic scale) a. sabra * , s. sabra , h.j. castro , j. malka-rais , j.i. mendez-inocencio , g. santos , j.a. bellanti , . rio de janeiro, brazil; . washington, dc. a major investigative effort of our laboratory has been directed to the study of non-ige mechanisms and their role in the immunopathogenesis of food allergy (fa). we have previously reported th and th cytokine alterations associated with several clinical entities that had overlapping disease manifestations affecting the mucosal-associated lymphoid tissues (malt), of the gi tract (galt), skin (salt), nasal (nalt) and bronchial tissues (balt). the objective of the present study was to evaluate specific immunologic alterations in a group of patients with non-ige fa. peripheral blood cd and cd lymphocyte subset analyses were performed in patients with fa documented by double-blind placebo-control food-challenge (dbpcfc). all patients were treated with an amino-acid based formula (aabf) and then received an open challenge using a panel of commonly offending allergenic food allergens in a normal diet.the clinical picture of all patients with fa were linked to malt-related manifestations; with galt symptoms of diarrhea, vomiting, abdominal pain and ftt, with balt symptoms of asthma, with salt symptoms of eczema, with nalt symptoms of rhinitis and with edema, ascites and anaphylaxis. all subjects had normal serum ige and eosinophil levels, negative ige food rast tests, normal cd (mean + ) and very low cd ( + ) levels in peripheral blood. abnormal cd /cd ratios > . were observed in all patients. age-and gender-matched controls revealed cd /cd ratios ranging from . to . . both patients with anaphylaxis had cd /cd ratios > . all patients responded well to aabf. open challenge to common offending foods from a regular diet (milk, soy, wheat, egg, nuts, beef and chicken), revealed multiple food allergies. after two years of follow-up on an aabf regimen, the patients remain well but allergic to multiple foods. very low cd levels remain as the unique immunological alteration in all patients.these studies suggest that abnormalities of very low cd distribution may play a pathogenetic role in non-ige mediated fa. since cd lymphocytes play a role in immunologic tolerance (it), it is tempting to speculate that the very low cd levels may signal the failure of development of it in our patients predisposing them to the development of allergies to multiple food components. background: mixed connective tissue disease (mctd) is a disease taht have caused controversy, while some authorities consider it a distinct rheumatic disease, others believe that it's an early stage of a fully defined autoimmune disease. the distinctive feature is the presence of the u small nuclear rnp autoantibodies. clinical features involve raynaud's is phenomenon, swollen hands, sclerodactyly, esophageal hypomotility, polyarthritis, and myositis, allof them can be present in others well deined rheumatic diseases. only aew cases have been described in the pediatric population. objetive: to determine the frecuency of mixed connective tissue disease in mexican.children in a tertiary level institution according to kasakawa's criteria, alarcon-segovia's criteria and sharp's criteria and establish if a diagnosis of a well defined autoimmune entity was made during the follow up. methods:medical charts were assessed with the diagnosis of mctd between and in our hospital. results: between and , , cases of autoinmune diseases were treated; with systemic lupus erythematosus(sle), with rheumatoid arthritis(ra), , with scleroderma and , with dermatomyositis. we found only four cases, of them did not complete the kasakawa's criteria but the diagnosis was probable according to alarcon-segovia and sharp's criteria. one of them developed sle after one year of follow up. the case that fulfilled the diagnosis criteria of mctd; raynaud's phenomenon, rnp antibody positive, arthritis, lymphadenopathy, restrictive pulmonary disease, sclerodactily and muscle weakness developed a full blown sle at years follow up. discussion: the disease is extremely rare in children. we conclude that at least in pediatric age the disease may not exist by it's own, but it's an early stage of a defined autoimmune disease, and the terminology "un differentiated connective tissue disease" is more appropriate to define this cases. a. baysan * , h.y. song, s. gupta, l. yel, irvine, ca. hereditary angioedema (hae) is an autosomal dominant disease characterized by episodic angioedema of the skin or mucosa of the respiratory and the gastrointestinal systems. hae is caused by a quantitative (type i) and/or functional (type ii) deficiency of plasma protein c inhibitor, an early component of the classical complement pathway. attacks of hae may be lifethreatening and even cause death when the airway is involved. here, we report a year-old female patient with hae type ii, who has seven affected family members, two of whom died of laryngeal angioedema. the patient had a history of recurrent swelling of the eyelids, lips, tongue and extremities, and respiratory distress since five years of age. she was hospitalized on several occasions one of which required intubation and assisted ventilation. laboratory studies, between the attacks, revealed normal serum ch and complement c levels. complement c level was decreased to mg/dl (n: - mg/dl). c esterase function was impaired, % (n: greater than %) in contrast to normal quantitative c esterase. the patient was on long-term danazol treatment for ten years and experienced side effects, most notably hirsutism. currently, there are limited efficacious and safe treatment options for hae. the treatment of choice for acute attacks and prophylaxis appears to be the c inhibitor concentrate, which is not yet licensed in the us. the present patient emphasizes the need to establish the correct diagnosis and an appropriate management plan in recurrent angioedema. j. hajsam * , l. ponomarjev, krasnodar, russian federation. background: the previous investigations indicate on the positive effects of ncir in different chronic inflammatory and infectious diseases. nevertheless, the mechanisms of the clinical efficacy of ncir remain still unknown. the aim of this investigation is the study of the immune disorders in patients with chronic tonsillitis and the immunomodulatory effects of the complex treatment in combination with ncir. methods: children with chronic tonsillitis in the age from to years old were under the observation. the t cell receptors (cd +, cd +, cd +, cd +, cd +, hla-dr+) have been studied using flow cytometry method. the cytokines (il , gamma ifn and il ) have been investigated by eliza method. the treatment include traditional methods in combination with ncir. control group (without tonsillitis) consists of children of the same age. results: it has been shown that in chronic tonsillitis was dcrease of the number of cd +, cd + and hla-dr+ cells. the decrease of cd + cells was mainly due to decrease of cd + cells. at the same time it has been shown the increase in number of cd + cells. in chronic tonsillitis have been determined the increase in serum proinflammatory cytokine il level in . times (p< . ). at the same time the levels of gamma ifn and il were lower than in control up to - times. the studied treatment method including ncir resulted in increase in the number of cd + and cd + cells. the level of il decreased from pg/ml to . pg/ml. at the same time the serum concentration of gamma ifn and il increased up to . and . times, accordingly. conclusion: in chronic tonsillitis it has been shown the immune disorders in t cell's subpopulations and cytokine production. the efficacy of ncir mainly depends on the normalisation in t cellular subpopulations and increase in the concentration of gamma ifn and il . introduction: viral hepatitis is characterized by suppression of cd +th cell function related to disease severity. the aim of our research was the determination of total ige concentration and anti-c q-autoantibodies levels in patients with viral hepatitis c (vhc) and mixed viral hepatitis (vhb+c) and the investigation of their correlation with t cell parameters. methods: patients with vhc and patients with vhb+c confirmed by pcr were examined. evaluation of serum total ige level was performed by elisa kits produced by "vector-best", russia. immunophenotyping of peripheral blood mononuclear cells (pbmc) was done by cytometry with monoclonal antibodies to cd , cd , cd , cd b, cd , cd , cd , cd and hla-dr-antigens. results: the level of serum total ige in patients with vhc and vhb+c was significantly increased in all groups studied, especially in acute hepatitis c ( . ± . mu/ml, p< . ) compared with the control group. analysis of pbmc subpopulations in patients with vhc and vhb+c was done related to the total ige level: group i - - mu/ml; and group ii -> mu/ml. in patients with viral hepatitis and high total ige level, the content of cd +t-lymphocytes, cd +t-cells and cd /cd ratio were significantly decreased compared with the control group (p< . ). more notable changes were found in patients with acute vhc and vhb+c. the increase in cd +-cell content was seen in groups with both low and high levels of total ige. the content of cd +-cells in patients with high levels of total ige was also increased (p< . ). conclusion: patients with vhc and vhb+c had significantly greater levels of total ige compared with the control group (p< . ). the increase in total ige levels in patients with viral hepatitis is associated with imbalances of t-lymphocyte subpopulations, including a decrease in cd +t-cells, and an increase in b-and nk-cells. title: occupational airway allergy among health care workers (hcw) with latex allergy. introduction: for the last years the frequency of latex allergy has increased. health care workers (hcw) is the risk group of this diseases. latex allergy symptoms occure in different organs -including skin, conjunctive, nose and bronchi. study aim:the aim of this study was to estimate the incidence of airway allergy in group of hcw with latex allergy. materials and methods: the investigations were carried out in a group of hcw, aged - (average age , ). there were two hundred and eight women and forty four men in the group. investigation consisted of questionaire examinations, skin prick tests (latex), patch tests (rubber additives), sige (latex) and spirometry. results: seventy eight ( %) hcw reported undesirable effects after the contact with latex products. fourty ( , %) hcw reported symptoms of airway (nose and bronchi). latex allergy (spt and/or sige and anamnesis positive) was diagnosed in ( , %) cases. the symptoms concerned with: skin, nose and conjunctive ( cases, %); skin and conjunctive ( cases, %); nose and conjunctive ( cases, %); nose and skin ( cases, %); bronchi, skin, nose, and conjunctive ( cases, %) and only skin in cases ( %). conclusions: the incidence of occupational airway allergy in group of health care workers with latex allergy is high ( % of all cases). latex allergy symptoms usually affect skin, but sometimes it includes also other organs -conjunctive, nose and seldom with bronchi. the incidence of anaphylaxis is increasing. the food allergy and anaphylaxis network wishes to expand the use of injected epinephrine by first responders to allergic emergencies. in indiana, there are , first responders, , basic emts, , advanced emts, and , paramedics. the use of injected epinephrine was only permitted by paramedics and advanced emts ( % of all responders). in a bill was introduced to expand the use of injected epinephrine by ems personnel in the event of an allergic emergency. it was sponsored by the indiana allergy asthma and immunology society and the emergency medical services commission of indiana. on july st senate bill no. took effect permitting all first responders to administer, without restrictions, injected epinephrine. once the legislation passed it became the responsibility of the medical director (md) of each ambulance service in the state to implement the change. in an attempt to assess the impact of this legislation we surveyed each of the mds in the state - months after the passage of the bill. mds were notified of the legislation by memo and public meetings. in addition each md received a copy of the legislation. of the mds, ( %) responded to the survey. results: . unaware of the legislation: ( %) . aware of legislation but no implementation: ( %) . aware of legislation with implementation restricted to basic emts: ( %) . aware of legislation and implementation at all levels: ( %) conclusions: twenty-five percent of mds were unaware of legislation. among those that implemented changes the majority ( %) permitted use by basic emts only. allergists, lay organizations, and ems commissioners need to assure implementation of legislation with all mds within the state. a. khadavi * , b. silverman , a. schneider , . great neck, ny; . brooklyn, ny. rabbit anaphylaxis is extremely rare, with one documented case upon inhalation only. we describe a patient with severe anaphylaxis upon consumption of a rabbit. a -year-old female with a -year history of asthma and allergic rhinitis was presented for evaluation. the patient complained of worsening asthma and rhinitis symptoms in the home and upon exposure to outdoor pollen. further history revealed the family had a rabbit as a pet. laboratory testing showed her total ige was ku/l, rast results were normal for tree, ragweed and molds (< . kiu/l). positive results were found for ragweed, dust, cockroach, cat, dog, mouse, peanut and rabbit epithelium ( . kiu/l, class iv). among other environmental control measures, the family was advised to eliminate the rabbit from the home environment, as it could be a potential trigger for their daughters allergy symptoms. two days later, the patient presented to the emergency room with wheezing, coughing and angioedema of the hands and face. she was treated with albuterol, diphenhydramine and oral steroids. the parents said they followed all of our instructions and did not know why anaphylaxis occurred. further questioning revealed that the family consumed the pet rabbit on the same night preceding the anaphylactic reaction. this was the first time the daughter ate rabbit. the parents assumed that only exposure to the live rabbit would worsen her allergy and asthma symptoms, never expecting an allergic reaction via ingestion. they were advised not to feed their daughter rabbit again and were given a prescription for self-injectable epinephrine. this demonstrates either complete identity, partial similarity or cross reactivity between inhaled and food allergens, as has been noted previously with certain other foods such as garlic and crustacean proteins. physicians need to advise food allergic patients that an allergic reaction can develop upon inhalation of the food, as seen with peanuts. but also respiratory sensitization to an allergen can lead to allergic symptoms upon its ingestion. t. nsouli * , j. scheiner , j. malka-rais , j.a. bellanti , . burke, va; . washington, dc. the safety of selective cyclooxygenase- (cox-ii) inhibitors in patients with known nsaid-induced allergic reactions has not been definitely established and is still open to debate. in the present report, we describe two patients with hypersensitivity reactions to naproxen, the first characterized by a systemic anaphylactic reaction and the second by localized urticaria following ingestion of the drug. the first case was a y/o wf with a history of osteoarthritis who, minutes after the ingestion of mg of naproxen, developed generalized pruritus, urticaria, laryngeal edema and hypotension. she was treated in the er with epinephrine, diphenhydramine and iv corticosteroids. epicutaneous and intradermal skin testing to celecoxib revealed negative results similar to a control. an oral challenge with celecoxib was well tolerated by the patient without any adverse responses. the second case was a y/o wf with a known history of chronic urticaria and osteoarthritis requiring regular use of naproxen. a complete allergic and immunologic workup was negative. upon discontinuation of the drug there was resolution of the urticaria. an oral challenge with celecoxib was well tolerated by the patient without adverse sequelae. these two case reports exemplify two extremes in the spectrum of adverse allergic reactions to naproxen, a non-selective cox-i and cox-ii inhibitor, one systemic, the second localized and suggest that the pathogenesis of these symptoms was most likely pseudo-allergic in nature and not immunologically-mediated. the dissimilar chemical structures of naproxen and celecoxib together with their differing mechanisms of action suggest that the absence of allergic reactions to challenge with celecoxib, a cox-ii inhibitor, may be related to a lack of cross-reactivity between the two drugs. although these findings suggest that oral celecoxib could be a possible safe alternative in patients with naproxen-induced drug reactions, it would be prudent to first conduct careful challenges with the drug in a well-equipped medical setting where clinical acceptability and tolerability could be safely assessed. introduction: most fixed and removable dentures are made from casting alloys. many orthodontic appliances are also fabricated from metallic biomaterials. it has been documented in vitro and in vivo, that metallic restorations release metal ions mainly due to corrosion. those metallic ions may be distributed systemically and locally and could pay a significant role in the induction of oral or/and systemic immunoinflammatory conditions. this study determines the frequency of sensitization to metal salts and clinical characteristics in the group of patients with complaints related to adverse effects of dental alloys. methods: patients ( women and men) aged - years with symptoms assumed to adverse effects of dental alloys were studied. all patients were studied with base metal salts, including cu + , co + , cr + , mg + , mn + , ni + , ti + , zn + using patch tests. all patch tests substances were % salts in petrolatum. the patch tests were conducted in accordance with recommendations of the icdrg. occlusion time was days, and patch tests were read when removing the patches (finn chambers on scanpor, epitest ltd oy, tulusa, finland) and to days later. the total number, percentage of irritant and allergic patch test reactions were calculated. results: in of patients ( %) sensitivity to base metals used in dental restorations was noted. symptoms included burning mouth ( %), metal taste ( %), electrical sensations ( %), dry mouth ( %), and taste irritation ( %), but / patients ( %) had no symptoms. local gingivitis ( . %), anomalies of the tongue ( %), stomatitis ( %) and lichenoid reactions ( %) were often seen. the most frequent patch test reactions were caused by ni ( %), cr ( %) and co ( %) . conclusion: this study demonstrated higher frequency of hypersensitivity reactions to ni, cr and co in this group of patients often having symptoms such as burning mouth, metallic taste, electrical sensation, local gingivitis, and anomalies of the tongue. w.y. mak * , s. kearney, b. silverman, a. schneider, brooklyn, ny. the process of intravenous drug desensitization often involves simple but tedious calculations. miscalculations may arise due to human error. for patients who are truly allergic to the drug in question, such errors can be life threatening, if not fatal. we propose the use of a spreadsheet to minimize such calculation errors. spreadsheets, such as microsoft excel, ibm lotus - - , and corel quattro pro, are used extensively in finance for tedious and repetitive calculations. this property of a spreadsheet makes it an ideal tool to assist with any drug desensitization protocol. we chose microsoft excel for its availability at our institution. a general template was initially created with equations in specific cells which were based on the protocols listed in patterson's allergic diseases, th edition and middleton's allergy: principles and practice, th edition. by inputting specific numbers, such as the amount of drug and volume of diluent into key cells of the spreadsheet, the program will automatically calculate the protocol for the given intravenous drug. an example of our pipericillin protocol is listed below. we find that the use of a spreadsheet not only minimizes calculation errors and hence reduces the likelihood of avoidable reactions; but also decreases our preparation time for the desen-sitization protocol. we recommend its use for all allergists performing drug desensitizations. states years ago, the infestation of homes across the northeast, southeast and midwestern states with these insects during the fall and winter months has become increasingly common. in the last years, several investigators have published case reports of patients with allergic rhinitis, conjunctivitis and asthma symptoms associated with suspected inhalational exposure to high levels of proteins from these beetles. we report a series of patients who presented with a spectrum of various allergy complaints ranging from symptoms of allergic rhinitis, asthma, urticaria, angioedema and acute anaphylaxis (with documented elevated serum tryptase) on exposure to high numbers of multi-colored asian ladybeetles(malb.) methods: we performed western blotting with the patients' serum and a whole-body ladybeetle extract made from confirmed h. axyridis obtained from one of the infested homes in that region. results: blots with the patients' serum revealed ige binding to different proteins with molecular weights approximately , and kd. the serum from two patients bound a kd protein possibly similar to the kd protein previously identified by yarbrough et al. jaci ; ; - . ige from four patients bound to an kd protein not previously reported. lastly, serum from two patients revealed ige binding to a kd protein possibly similar to the heavier proteins mentioned in an abstract by magnan et al. jaci ; ; . conclusion: we present five patients with specific ige to malb and allergic symptoms on exposure to high levels of malb. we conclude that malb are likely a significant source of several different allergenic proteins and that malb are increasingly becoming a significant cause of a wide variety of hypersensitivity reactions across the united states. as multiple exposed subjects and several entomologists report that these beetles bite humans, we speculate that a wide range of ige-mediated symptoms including urticaria, angioedema and anaphylaxis can occur by exposure to proteins by inhalation, direct contact and possibly by inoculation of these proteins into the skin by the bite or scratch of this beetle. a case report and literature review. c.s. taylor * , s. ramesh , . getzville, ny; . buffalo, ny. introduction: lentils belong to the legume family and are the staple ingredient of the ethnic indian diet. lentils have been shown to cause allergic reactions and even anaphylaxis. however, little research has been done to distinguish the types of lentils used commonly in the indian diet and their various hypersensitivities. some of these lentils include the black gram (phaseolus mungo), mung bean and split chick peas (bengal gram). case report: we report a -month-old indian boy who presented with severe atopic dermatitis since the age of four months. his dermatitis was exacerbated by the ingestion of peas and beans and resolved with the avoidance of such. at nine months of age, the child was introduced to boiled mung beans and subsequently developed lip swelling within a few minutes. a similar reaction occured with split chick peas. physical exam at consultation revealed severe eczema. skin tests using commercial extract revealed + response to peanut (he had never eaten peanuts), soybean, pea and egg. subsequent skin tests at the follow up visit to prepared reagents revealed much greater than + response to mung bean, chick pea, split chick peas, and black gram. the patient developed a systemic response during testing which required epinephrine. discussion: legume allergy (other than peanut, soy and peas) is rare in the unites states but has been reported in asia and the mediterranean area. it has been reported in one case series that patients with lentil allergy react to more than one lentil. there is a five percent cross reactivity between peanut and other legumes such as soy and peas. however, the extent of cross reactivity between peanut and the other legume sub-groups (ie. lentils) is not well documented. there also appears to confusion in the labeling of the various lentils used in ethnic diets. conclusion: this case has been presented to make allergists aware that there are many differnt types of lentils that can cause hypersenstivity reactions and the importance of considering ethnicity and dietary habits in evaulating for food allergy. background: epinephrine is the drug of choice for the treatment of anaphylaxis however it is frequently underutilized. one possible reason is the fear of adverse cardiac effects. the most common side effects of epinephrine are palpitations, tachycardia, sweating, nausea, vomiting, respiratory difficulty, pallor, dizziness, weakness, tremor, headache, nervousness, anxiety and arrhythmias. a previous study showed that administration of epinephrine, in a small number of healthy adults did not cause any significant cardiac adverse events and vitals sign changes were not clinically significant. the purpose of this retrospective analysis is to determine the safety profile of epinephrine in a large number of patients that were administered epinephrine for treatment of anaphylaxis that occurred in a physician's office. methods: all patients in an allergy office, that were administered epinephrine for acute anaphylaxis between - were selected for this retrospective analysis. a chart review for adverse events and vital was conducted. vital signs and side effects had been monitored every to minutes for minimum of to minutes after the administration of epinephrine. results: patients between the ages of yrs to yrs received injections of epinephrine. after an injections of epinephrine % of the patients had a pulse between - , % between - , and % between - . systolic blood pressure determined % of patients to be between - , with %, between - , and % between - , and % between - . concurrently, diastolic blood pressure was found to have % between - , % between - and % betweem - . the most common reported side effects were tremor, headache and pallor. any rise in blood pressure and heart rate after epinephrine was transient and returned to normal within minutes of observation. there were no serious side effects. all patients responded to the epinephrine and were able to go home. conclusions: this retrospective analysis revealed that the administra-tion of epinephrine is safe and effective for the treatment of acute anaphylaxis in an outpatient setting. the use of epinephrine for treatment of anaphylaxis is life-saving and its use to treat non-cardiac or elderly patients who have anaphylactic reactions should be encouraged. purpose: a clinical pathway was established to decrease the use of vancomycin in surgical patients with self-reported penicillin (pcn) allergy. methods: in , our institution developed a preoperative evaluation (poe) clinic for elective surgical patients. in june , on-site, same-day allergy consultation and penicillin skin testing was made available for preoperative patients with self-reported pcn allergy. we reviewed the antibiotic recommendations, the actual administration of vancomycin, and compliance by the surgeons with our recommendations from july , -september , . results: during this time, , patients were seen for their preoperative medical exam at the poe clinic, and were evaluated for pcn allergy. of these, patients met irb standards to participate in the study. the mean age of the patients was years. the top three surgical specialties represented in the poe clinic were orthopedic ( . %), urology ( %), and neurosurgery ( %). of the patients, underwent skin testing for pcn allergy. eighty-five percent ( %) or of these patients with a history of pcn allergy were recommended to use -lactams such as cefazolin, and ( %) were recommended to avoid -lactams. forty-three ( ) or % had one or more positive skin tests to pcn. of the patients, patients actually received pre-operative antibiotics. of these patients, ( %) of those received cefazolin, ( %) received clindamycin, ( %) received ciprofloxacin, ( %) received levofloxacin. some patients received more than one antibiotic for prophylaxis. only ( %) patients received vancomycin. conclusions: establishment of a clinical pathway in a preoperative clinic that includes allergy testing and consultation reduced vancomycin use to only % in surgical patients with a history of penicillin allergy. h. yarmohammadi * , a. nowak-wegrzyn, new york, ny. introduction: anticonvulsant hypersensitivity syndrome is a potentially fatal drug reaction with cutaneous and systemic reactions to the arene oxideproducing anticonvulsants. in most cases, the hallmark features of fever, rash, and lymphadenopathy are accompanied by multi organ-system abnormalities. fatal outcomes are most often associated with liver failure. recognition of the syndrome, which may have variable presentations, is the key to prompt discontinuation of the drug, close monitoring, and management. case : a y/o male received dilantin for seizure prophylaxis following craniopharyngioma resection. fourteen days later he was readmitted for fever and csf leak from surgical site. he was started on ceftriaxone and vancomycin empirically; an lp and pan culture was done. he continued to have low grade fever and, on the th day of admission, developed a maculopapular rash on trunk. on day th lfts increased and cbc showed eosinophilia. antibiotics were stopped but lfts continued to rise. on day , dilantin was stopped and lfts normalized in days, fever stopped and rash disappeared. case : a y/o girl was admitted to the hospital with generalized rash, facial edema and fever ( degrees c). she developed a pruritic maculopapular erythematous rash over her trunk and face weeks prior to admission. she then developed high fever. three months prior to this visit she had been started on phenytoin ( mg/kg) for control of grand mal seizure. physical exam revealed cervical and axillary lymphadenopathy. she had elevated wbc ( , ), eosinophilia ( %), and elevated lfts. phenytoin was stopped upon admission but hours later she continued to have fever, elevated lfts and devel-oped erythema in her mouth. treatment with ivig and prednisone was initiated and resolution of symptoms was seen within - days after therapy. conclusions: the timely recognition of anticonvulsant hypersensitivity syndrome is important, because accurate diagnosis prevents potentially fatal re-exposure and influences subsequent anticonvulsant treatment options. ivig and prednisone should be considered in situations where prompt improvement of the lfts or clinical symptoms is not observed. the recently published results of a telephone survey about the prevalence of seafood allergy in the us indicate that seafood allergy is a significant health concern. aim of the present study was to retrospectively review our data on the topic. we have interviewed subiects attending our allergy outpatients about any suspected food allergy. over % were years or older. any reaction to food was reported by % of the patients, more frequently by women. of these patients, reported reactions to seafood ( %) with an overall prevalence of seafood reactions of . %: to fish ( . %), to shellfish (including mollusks) ( . %) and to both ( . %). in the case of the reactions to fish it is quite possible that shellfish is also included, as the patients were often unable to tell the role of finfish from shellfish apart. this is most probably due to the fact that seafood dishes or a complete seafood meal in italy generally include both shell and finfish. in only less than half cases there was a convincing relationship between the ingestion of seafood and the reaction. the reactions reported were: gastrointestinal ( ), non life-threatening angioedema ( ), mild oral allergy syndrome ( ), acute urticaria ( ), asthma ( ), rhinoconjunctivitis ( ). the gastrointestinal reactions might not all be true (ige-mediated) allergic reactions, but also toxic. in conclusion, even in a selected population like that attending an allergy clinic and using a broad definition of adverse reaction, seafood allergy appears to be a rare phenomenon and of limited clinical impact, the prevalence of moderate to severe reactions (angioedema and asthma) in the whole selected population being . %. clopidogrel (plavix) is an antithrombotic agent currently used to prevent thrombotic cardiovascular events by inhibiting adenosine diphosphate (adp)dependent platelet activation. clinically, it has been used in patients with aspirin intolerance or who developed neutropenia from ticlopidine. there have been reported cases of clopidogrel causing rash and urticaria. often these patients are told they are allergic to clopidogrel and should not take it again, despite the fact that no workup was ever performed to elucidate whether the reaction was indeed immunologic in nature. a review of the literature revealed no reported attempts at desensitizing a patient to clopidogrel after a presumed immunologic drug reaction. we present the case of a year-old female who initially took clopidogrel ( mg. p.o. daily) for transient ischemic attacks. after tolerating the medicine for five days, it was replaced with an aspirin/warfarin combination, which she took for the next five days. reintroduction of clopidogrel a week later was uneventful, until she developed a pruritic, maculopapular rash on the th, through th days of restarting therapy. at that time, she was not taking any other medications, and had no cardiopulmonary or gastrointestinal complaints. she had discontinued the clopidogrel and was asymptomatic during our consultation. skin testing was done using clopidogrel prepared at concentrations of mg/ml and / mg/ml. at the same time, control skin testing on three non-atopic subjects was performed and produced no reaction to either epicutaneous or intradermal testing. by contrast, the patient had a positive skin reaction at both concentrations on intradermal testing. the patient was hospitalized for an oral desensitization where clopidogrel dilutions were prepared by the hospital pharmacy. the patient tolerated an initial dose of . mg. serial three-fold increases in concentration were given every minutes, until a total cumulative dose of mg. was reached. the patient tolerated the entire procedure and suffered no adverse reactions upon continuation of the treatment. this demonstrates the utility of oral desensitization to clopidogrel in patients with a positive skin test who require this medication. lamotrigine is a non-aromatic anticonvulsant with desirable pharmacological profile. the most common idiosyncratic reaction in children is rash ( - %). severe cutaneous adverse reactions and systemic hypersensitivity reactions are uncommonly reported. method: case presentation an -yearold caucasian female was prescribed lamotrigine in escalating dose for her first generalized seizure. a week later she developed a pink rash on her cheeks gradually progressing to her trunk, hands and feet. three days later she was seen in the er and treated for possible streptococcal-pharyngitis with fever and rash. oral penicillin-v treatment was initiated. the rash continued to spread all over her body with mild pruritis and sores on lips and mouth. few blisters were noted in left ear, hands and feet. later lamotrigine was discontinued. oral steroids were prescribed. she continued to develope new blisters, rash and hemorrhagic plaques and dysuria. she was later transferred to our institute. the physical examination was significant for afebrile girl without pallor and icterus. bilateral conjunctivitis without keratitis evident. tender cervical lymphadenopathy was palpable. multiple ulcers on lips and gingiva were seen. several targetoid lesions on trunk and extremity were noted along with few hemorrhagic plaques on extremities. superficial sloughing of distal fingers and toes was noted. nikolskys sign was not demonstrable. the systemic examination was unremarkable. laboratory tests: hemoglobin . g/dl, wbc-normal range without eosinophilia. normal pt/aptt and inr. liver function tests showed elevated sgpt- iu/ml and sgot- iu/ml with normal bilirubin. urine analysis was normal. serology for cmv, ebv, hsv and hepatitis a and b was negative. skin biopsy showed full thickness epidermal necrosis and sub epidermal clefts. aggressive supportive therapy was initiated. corticosteroids were continued for five more days. prior to being discharged from hospital the rash had dried and most lesions faded. the blisters and oral ulcers had healed. the liver enzymes had decreased. conclusions: we report an occurrence of stevens-johnson syndrome with lamotrigine in a young child. in the literature severe reactions are associated with higher doses or rapid escalation of the dose, and concomitant use of valproate. early recognition and withdrawal of medication is necessary to improve the outcome. introduction: in patients with a history of penicillin (pcn) allergy and negative pcn skin tests to major and minor determinants, - % of patients will tolerate pcn administration without risk of an immediate reaction. in fact, middletons allergy principle & practice reported that no life-threatening false-negative reactions have been reported when pcn was administered after a negative pcn skin test. we describe a case in which a patient with a history of pcn allergy and negative pcn skin tests to the major and minor determinants experienced life-threatening anaphylactic shock when administered piperacillin/tazobactam. case history: a -year-old woman with crohns disease was admitted for treatment of an enterocutaneous fistula. three months before admission, the patient reported a severe reaction to either piperacillin/tazobactam or intravenous (iv) lorazepam needing respiratory support in the intensive care unit. in order to delineate this problem, an allergy consultation was obtained. serum ige antibodies to pcn, measured by a commercial cap system radioallergosorbent test (rast) fluoroenzymeimmunoassay (feia; pharmacia and upjohn, uppsala, sweden), and pcn skin tests to major and minor determinants were negative. a skin test (prick and intradermal) to piperacillin/tazobactam at . mg/ml was also negative. five minutes into receiving . grams of piperacillin/tazobactam iv, the patient reported feeling lightheaded, flushed, nauseated, and diaphoretic. the blood pressure decreased to / from a baseline of / , heart rate /minute and appeared toxic. no wheezing or rash was noted on physical examination. patient was treated with iv epinephrine, diphenhydramine, and dexamethasone and recovered without sequela. serum tryptase, drawn hour after the beginning of the reaction, was elevated at . ng/ml but decreased to . ng/ml hours later. complement levels were normal. conclusion: despite a very high negative predictive value of a negative pcn skin test to the major and minor determinants and reports that no life-threatening false-negative reactions have been reported when pcn is administered after a negative pcn skin test, physicians need to be very cautious in administering piperacillin/tazobactam and other b-lactams in patients with a history of severe reactions such as anaphylaxis to past pcn administrations. a. majmundar * , d.a. khan, dallas, tx. introduction: a variety of adverse drug reactions have been reported after therapy with allopurinol. successful protocols for desensitization to allopurinol have been developed. we report a case of a patient who was successfully desensitized to allopurinol only to develop dress after four months of allopurinol therapy. methods: a year old man was referred to our department with a remote history of rash and fever resulting in hospitalization after initiation of allopurinol. due to severe gouty arthritis unresponsive to colchicine and requirement of chronic steroids, it was recommended to attempt allopurinol desensitization. based on the history of his prior reaction, a slow desensitization protocol was performed beginning with allopurinol μg and increasing the dose weekly to μg, μg, μg, μg, μg, mg, mg, mg, mg, mg, and mg. the patient tolerated the entire desensitization protocol without adverse reaction and was initiated on daily allopurinol at mg per day. results: four months after desensitization and daily allopurinol use, the patient developed fevers and an acute maculopapular eruption on his back and abdomen without mucosal involvement. laboratories demonstrated eosinophilia of cells/mm , elevated ast of , alt of , and ggt of u/l. he was treated with prednisone mg a day which was tapered weekly over weeks with successful resolution of his symptoms, eosinophilia and transaminitis. conclusion: while desensitization to allopurinol can be safely accomplished, allergists need to be cognizant of the potential for delayed serious drug reactions such as dress. wiskott aldrich syndrome is an immunodeficiency characterized by eczema, pyogen infections, and mixed immunodeficiency.we describe a male seven-month old, perinatals antecedents without importance who had an ulcer in site of application of bcg. non-blood relatives, healthy parents. at twomonths-old, he initiated with continuous fever, not quantified, treated with multiples antibiotics without resolution, he was hospitalized, plaquetopenia and anemia were diagnosed, he received a red globules and plateles transfusion, one week after he presented a disseminated dermatosis characterized by erythema and desquamation, at four-month-age presented right axillary adenomegaly, hepatoesplenomegaly and recurrent bilateral media otitis for what was hospitalized in our institute. he was malnutrition, bad general condition, febrile, with disseminated dermatosis affecting the head, trunk and extremities characterized by erythema and desquamation, in addition he had left ankle cellulitis, right axillary adenomegaly, hepatoespenomegaly. during his hospitalization he presented left hand cellulitis, hairy skin abscess, oral candidiasis, required surgical treatment by econdary compartimental syndrome because cellulitis of left ankle. persistent hemogram reported thrombocytopenia with normal platelet volume, blood cultives were positive for grampositive bacterias, isoaglutinines, were normal. immunoglobulines were elevated for the age range, he received antimicrobial and antifungic treatment. but he died. in the autopsy timic alymphoplasia was reported, cortical lymphoid depopulation in lymphatic ganglia and spleen, disease by disseminated cytomegalic inclusion, multifocal pulmonary pneumocystosis, bcgitis, disease graft versus guest. . with the previous features we concluded in a compatible mixed immunodeficiency with wiskott-aldrich syndrome with particular characteristics that make this case interesting. the patient course with cellular immune deficiencie with thrombocytopenia and eczema, even when he didn't have platelet sizing diminished, we consider that the patient had a severe of wiskott s aldrich syndrome and at the moment we are awaiting result of genetic study uasp gene. background : hypersensitivity to mosquito bites (hmb) is a disorder characterized by necrotic skin reaction and systemic generalized symptoms subsequent to mosquito bites. it has been suggested that hmb is associated with chronic epstein-barr virus (ebv) infection and natural killer cell leukemia/lymphoma. we describe here a korean child who had hmb associated with chronic ebv infection and natural killer cell lymphocytosis. case : a -year-old male was admitted with well-demarcated necrotic skin lesions and severe swelling on right ear lobe developed after mosquito bites. he had suffered several similar symptoms since last summer, which complicated as deep scars on skin. hepatosplenomegaly or peripheral lymphadenopathy was not detected. laboratory tests showed wbc , /mm (neutrophil %, lymphocyte %), total eosinophil count /mm , ige by prist above , iu/m. immunoglobulin levels were normal. specific ige for aedes communis by cap was negative. lymphocyte subset analysis demonstrated increased nk cells (cd +cd , %) and decreased cd and cd cells. igm for anti-nuclear antigen (ebna), igm for viral capsid antigen (vca) and igm for anti-early antigen (ea) dr to ebv were negative. but the levels of anti-vca igg (> u/ml), anti-ea dr igg (> u/ml) and anti-ebna igg ( u/ml) were increased. type a eb virus was demonstrated in blood mononuclear cells by dna pcr method, and eber in situ hybridization was negative in necrotic tissues. immunostaining with nk-cell marker (cd ) revealed many immunoreactive cells with the perivascular inflammatory infiltrates in tissue. skin patch tests for mosquito allergen (aedes togoi and culex pipiens) showed positive response to c. pipiens. introduction: scimitar syndrome is a congenital anomaly resulting in anomalous pulmonary venous return from the right lung to the inferior vena cava. recurrent respiratory infections have been associated with scimitar syndrome. methods: we report on a year-old adolescent female who presented to immunology clinic with recurrent pneumonias. results: the patient presented with numerous recurrent pneumonias, multiple er visits, and hospitalizations. she complained of intermittent chest pain, cough, fatigue and exercise intolerance. the patient had a large secundum atrial septal defect surgically corrected at years of age. a cardiac echo obtained at years of age revealed rvh, but was normal at years of age. she was a known atopic asthmatic. previous immunologic workup was normal with iga ( - ), igg ( - ) and igm . at presentation to our clinic pulmonary functions were fvc of % and fev of %. review of previous chest radiographs showed chronic changes with an opacity partially obscuring the right hemidiaphragm. a high resolution chest ct-scan showed a large irregular venous structure extending through the right chest joining the inferior vena cava above the liver consistent with scimitar syndrome. the patient was referred to pediatric cardiology who recommended surgical correction. conclusion: scimitar syndrome may present as recurrent pneumonias and chronic lung disease. a high resolution chest ct scan may be useful in delineating this disorder. background: laryngomalacia is the most common cause of stridor in infants but only rare reports exist of clinically relevant laryngomalacia in adults. objective: to present a case of laryngomalacia in an adult with significant respiratory symptoms initially attributed to asthma. methods: an year-old female with a history of allergic rhinitis and gastroesophageal reflux disease presented to the allergy clinic for further recommendations regarding a prior diagnosis of asthma poorly controlled on inhaled fluticasone, montelukast and albuterol. the patient was clinically diagnosed with asthma at age due exercise related symptoms. the symptoms progressed and intermittent trials of various inhaled steroids provided minimal relief. on evaluation, the patient described constant wheezing which occurred only on inhalation and originated from the throat. symptoms did not respond to albuterol use three to four times a day, rhinitis control and long-term, high-dose, antireflux therapy. baseline spirometry was normal. histamine bronchoprovacation and fiberoptic laryngoscopy were performed for further evaluation. results: histamine challenge was positive with a % decrease in fev with mg/ml histamine. however, laryngoscopy revealed redundant airway tissue most notable over the right arytenoid cartilage, consistent with laryngomalacia, which prolapsed into the laryngeal vestibule significantly obstructing the airway on inspiration only. the patient was referred to otolaryngology and surgical excision using a carbon dioxide laser was performed with subsequent improvement in symptoms and decreased asthma medication use. conclusions: we report an unusual case of laryngomalacia in an adult presenting as asthma, which was successfully treated with laser surgical excision. laryngoscopy of the patient revealing redundant airway tissue most notable over the right arytenoid. c. so * , s. kuhl , . davis, ca; . mather, ca. c. so, s. kuhl u.c. davis medical center, sacramento, ca & sacramento va hospital, mather, ca background: wheezing is an uncommon manifestation of phrenic nerve dysfunction. objective: we offer a description of wheezing attributable to phrenic nerve dysfunction to remind clinicians that dyspnea and wheezing can be caused by cor pulmonale which can be caused by phrenic nerve dysfunction. methods: a -year old male non-smoker presented with chronic dyspnea and occasional wheezing for the last decade. the patient had a remote history of pericardial stripping for presumed tuberculous pericarditis. he also had a non-productive cough and orthopnea. dyspnea was exacerbated by putting his hands over his head and bending over. he had been treated with inhaled corticosteroids and bronchodilators without relief. results: repeated chest x-rays showed a chronically elevated right hemidiaphragm. pulmonary function tests showed a restrictive pattern with: fev . ( %), fvc . ( %), tlc . ( %), dlco/va . ( %) and no bronchodilator response. left heart catheterization was normal while right heart catheterization showed elevated pulmonary artery pressures ( / ) and he was subsequently diagnosed with cor pulmonale. cardiopulmonary exercise testing showed an increase in minute ventilation which was achieved predominantly by an increase in respiratory rate rather than to an increase in tidal volume suggesting restrictive or interstitial lung disease. chest ct showed left ventricular enlargement and no evidence of interstitial lung disease. a fluoroscopic sniff test was performed and showed paradoxical movement of both diaphragms. he was diagnosed as having diaphragmatic dysfunction as a result of phrenic nerve injury from prior pericardial stripping. conclusions: wheezing and chronic dyspnea can be related to phrenic nerve dysfunction. a review and discussion of various causes of phrenic nerve dysfunction, including autoimmune causes, is offered. patients with a history of prior cardiothoracic surgery who present with recalcitrant dyspnea and wheezing may benefit from evaluation for phrenic nerve dysfunction. background: sudden sensorineural hearing loss (ssnhl) is defined by a loss of at least db in contiguous frequencies over a time course of hours or fewer. etiologies of ssnhl include viral infections, ototoxic drugs, autoimmune diseases, trauma, neoplasms, and vascular occlusion, but viral labyrinthitis is the most common cause. in cases of sudden hearing loss, herpes infections can be reported in approximately % of cases caused by viral infections. typically, sensorineural hearing loss is not recurrent. we report a case of recurrent ssnhl is which oral herpes lesion preceded the onset of symptoms on three consecutive episodes. case report: a -year-old male with a history of hypertension, hypothyroidism and chronic tinnitus of the left ear (since a gunshot wound years prior) presented to clinic with a complaint of recurrent episodes of sensorineural hearing loss. the first episode of bilateral hearing loss occurred months prior. an otolarnolgologist treated with a steroid taper and valacyclovir and the hearing loss resolved after one day of therapy. since the initial presentation, the patient reports three subsequent episodes of ssnhl, with two of the episodes responding to prednisone and valacyclovir and one episode responding to steroids alone. oral herpetic lesions preceded at least three of the episodes one day prior to the hearing loss. laboratory data was significant for an elevation of varicella-zoster igg, and of hsv igg. hsv igm was not performed. rpr was non-reactive and ana was negative. a mri of the head was normal. audiogram demonstrated db increase and speech discrimination improved from % to %. the rest of the laboratory data was unremarkable. the patient has been maintained on daily valacyclovir therapy and has had no further episodes of hearing loss. conclusion: our patient experienced hearing loss with concomitant evidence of hsv- stomatitis. this suggests a cause and effect relationship. we found that the antiviral therapy was effective for treatment of the ssnhl in this patient as demonstrated by the absence of further symptoms while on antiviral prophylaxis and conclude the most likely etiology of the recurrent hearing loss was secondary to the recurrent herpes simplex infections. abstract the illness was described for the first time in in the chinese literature by kimm, and szeto, the definitive histological description was published by kimura in , this illness is endemic in asia, but rare, about cases had been reported. kimura disease is extremely sporadic in the rest of the world. the etiology of this disease is ignored but it is believed that there is an aberrant immune reaction to an unknown antigenic stimulus, however epstein barr's virus, human herpes virus and candida albicans had been involved in certain cases. the mast cells had been implicated in its pathogenesis and a th cytokine pattern with the production of interleukin , and rantes which regulate the synthesis of ige and orchestrate the eosinophilic infiltration. on the other hand it is suggested that the eosinophils had undergone an accelerated apoptosis in this illness. case report. it is a year-old boy with a months evolution with the presence of bilateral subcutaneous nodules of x cm in parotid and submaxillary glands, presenting hypereosinophilia ( total eosinophils ) and high ige ( total ige), with normal renal function and negative mycotic and parasitic tests.the histopathologic findings revealed the presence of eosinophilic infiltrates with capillary proliferation and fibrosis. discussion. for the clinical characteristics of the nodules together with the hypereosinophilia, extremely high ige and the characteristic histological lesions the diagnosis is kimura disease. the usual clinical presentation consists on several indolent subcutaneous nodules that grow very slowly in volume, located in the neck and head, accompanied by satel-annals of allergy, asthma & immunology lites adenophaties, and with increment in the salivary glands, there is renal affectation in half of the patients, and the laboratory detects hypereosinophilia and elevation of the total ige. the histological lesions, shows hyperplastic lymphoid tissue with proliferative germinal centers, with infiltration of eosinophils in their interfollicular and perivascular zones sometimes forming an eosinophil abscess and proliferation of poscapillary venules. at the moment he have been treated with prednisone ( mgkdia), with great improvement in the clinical evolution. this is the first case reported in the literature in mexico. introduction: the incidence of cow's milk protein allergy (cmpa) is approximately - % and presents primarily during the first year of life. manifestations of cmpa in the neonatal period include gastroenteritis, colic, lethargy, metabolic acidosis, and hematochezia or melena and appear to be non-ige mediated. ige mediated reactions in the neonatal period, such as urticaria or angioedema, are unusual. case: a -day-old african-american male presented with a day history of rash, swelling, and erythema overlying multiple joints. there was no history of fever, diarrhea, or eczema. he had been on no medications prior to admission. besides mother with a history of childhood asthma, there was no family history of atopy or food allergy. he had been fed cow's milk-base formula (similac ® ) since birth exclusively. physical examination revealed a diffuse erythematous, raised, macular-papular rash, with areas of duskiness and exfoliation. there was angioedema overlying the joints and periorbital areas (figure ). laboratory evaluation included cbc with diff, hgb electrophoresis, lumbar puncture, urinalysis, c q (qualitative and quantitative), c , c , c , and cultures of the blood, csf, and urine which were within normal. percutaneous allergy skin testing for cow's milk allergy was performed revealing a + reaction to cow's milk extract (greer, lenoir, nc) with positive histamine and negative saline controls. rast testing showed . ku/l for -lactoglobulin and . ku/l for cow's milk. he was placed on an elemental formula. skin lesions and swelling resolved completely within hours. at week follow-up the patient was thriving without complaint. conclusion: early sensitization to cow's milk protein in the neonatal period may occur, resulting in ige mediated urticaria and angioedema. the rashes may be misdiagnosed as erythema multiforme or anaphylactoid purpura, since hemorrhagic lesions and cockade pattern are common. physicians should be aware that these reactions may occur so that early recognition and management may be initiated. neonate with periorbital angioedema and exfoliating, urticarial rash. rationale: two patients, presenting with invasive fungal cns infections, were found to have nk cell dysfunction and hypogammaglobulinemia. methods: case reports results: patient # : a year old caucasian male presented with headache, double vision, periorbital swelling, and bilateral sinus disease on ct scan. biopsies showed invasive rhinocerebral mucormycosis. he continued to deteriorate in spite of iv and intrathecal amphotericin b, hyperbaric oxygen, many debridement procedures, and a left orbital exenteration. immune evaluation revealed low igg, low igm and a barely detectable nk cell killing activity. neutrophil respiratory burst was normal. he continued to worsen despite ivig replacement. he had intolerable side effects to ifn-a. gm-csf ( mcg qod) was initiated, in order to boost nk cell activity. this resulted in stabilization of his infection. he was discharged on oral anti-fungal therapy (posaconazole), ivig, and gm-csf. sixteen months later, he continues to remain stable clinically and radiographically on ivig and gm-csf. patient # : a -year-old caucasian male presented with headache, mental status changes, and ataxia. a head ct scan showed a left mass effect and edema. he underwent surgical debridement for ventriculitis and zygomycetes (the same family as mucormycosis) was found. he was started on iv amphotericin b and oral posaconazole. his immune evaluation revealed low igg and igm and low nk cell activity. neutrophil respiratory burst was normal. he was started on ivig and gm-csf after which his nk cell function improved significantly. he remains clinically stable on ivig and gm-csf with persistent radiographic evidence of enlarged ventricles. conclusion: hypogammaglobulinemia is usually not associated with invasive cns fungal infections, suggesting that nk cell dysfunction was likely responsible for the clinical courses of these patients. nk cell deficiency has been reported to be associated with recurrent mucosal candidiasis, suggesting an important role for these cells in the control of some fungi. the spectrum of the clinical presentations of nk cell deficiency is not known since it is not normally included in immune system evaluations. these patients illustrate the importance of including functional nk cell assessment in any evaluation of immune function. introduction: to report a case of successful systemic hydrocortisone desensitization, since allergic reactions and systemic desensitization to corticosteroids have rarely been documented. method: we present a patient with multiple medical problems who has a history of both radiocontrast induced anaphylactoid reaction and corticosteroid allergy. this patient had to undergo cardiac catheterization and corticosteroid desensitization was performed prior to the procedure. results: skin testing to radiocontrast is not considered helpful, therefore patients with suspected reactions to radiocontrast are generally premedicated with corticosteroids and antihistamines to decrease the risk and severity of a reaction. , since this patient experienced an allergic reaction to a corticosteroid previously, she was skin tested to two different corticosteroids. the least reactive skin test revealed a + positive immediate reaction to hydrocortisone. cardiac catheterization with contrast was considered absolutely necessary in this case and corticosteroid desensitization was performed. the half-life of hydrocortisone is the shortest among the tested corticosteroids ( - minutes), so a protocol was developed with short intervals of escalating doses. each dose was diluted yielding a total volume of ml to avoid fluid overload because patient has renal failure. during desensitization, patient developed pruritus and erythema between the rd and th dose that resolved immediately with mg diphenhydramine. after desensitization, the patient continued to be on hydrocortisone mg intravenously every four hours. one hour prior to the procedure, the patient was premedicated with hydrocortisone and diphenhydramine and was administered radiocontrast without any adverse reactions. conclusion: we successfully desensitized our patient to a corticosteroid and premedicated her with hydrocortisone and diphenhydramine before administering radiocontrast. this case illustrates that intravenous desensitization may be a suitable approach to therapy in corticosteroid allergic patients who require systemic corticosteroids administration. autoimmune neutropenia is defined as a decrease in the absolute number of peripheral neutrophils caused by an immunologically-mediated mechanism. autoantibodies directed to neutrophils can lead to the peripheral destruction of neutrophils and/or inhibit myelopoesis in the bone marrow. although recurrent aphthous stomatitis is often the heralding sign of neutropenia, the diagnosis of ain requires the demonstration of specific antineutrophil antibody which acts by promoting the immune destruction and clearance of neutrophils by mononuclear phagocytes. the present case report describes the rare clinical association of ras in an adult. a yr-old black male presented with a year history of recurrent and repeated painful multiple oral ulcers. initially the oral ulcers occurred on a monthly basis then over time the ulcerations on the oral mucosa and tongue began to appear weekly and later continuously. past medical history revealed no drug allergies but a positive history of hypertension. physical exam revealed an otherwise healthy male with no lymphoadenopathy or splenomegaly. laboratory workup revealed : hiv negative, viral culture for h. simplex negative, mild increase in cd , cyroglobulins negative, anti dsdna negative anti-smith and rnp negative, wbc count /ml, neutrophils % (anc ), lymphocytes %, monocytes %, and platelets: , . bone marrow biopsy revealed a normal production of neutrophils. a direct neutrophil antibody assay: revealed an elevated value of , (n= < , ). although following initiation of prednisone ( mg) an immediate increase in anc was seen, the levels fell as the dosage was tapered. the figure below shows the time course and dose-response relationship of anc and prednisone dosage. this case report illustrates the importance of recognition of the relationship of ras and neutropenia, an association that can masquerade as other clinical entities. background: dyspnea, wheezing, and decreased fev are suggestive of asthma. it is essential for the clinician to consider a broad differential diag-nosis as the outcome could be catastrophic if the correct diagnosis is missed. case presentation: we present a case of a y.o. filipino female who was referred to our clinic for the evaluation of cough, shortness of breath, and wheezy respiration associated with changes in voice quality, nasal and palatal pruritus, and postnasal drainage. her initial evaluation revealed mold spore hypersensitivity by prick puncture testing and spirometry with an obstructive pattern with fvc- . l ( %) and fev - . l ( %) predicted and a % reversibility post nebulized albuterol. an initial diagnosis of allergic rhinitis with adult onset asthma was made and she was started on salmeterol, budesonide, montelukast, and pirbuterol. her symptoms persisted and rabeprazole was added to treat possible laryngopharyngeal reflux. repeat spirometry revealed fev - . l prompting treatment with systemic corticosteroids again with no improvement. fiberoptic laryngoscopy was within normal limits. a high resolution computed tomography was obtained and showed a mass in the left side of the trachea which was obstructing % of the airway. bronchoscopy revealed a tumor - cm below the vocal cords with the appearance of adenoid cystic carcinoma which was confirmed by pathology. the tumor was resected by removal of cm trachea with re-anastomosis, followed by a week course of radiation therapy. all medications were discontinued. her symptoms of wheezing, dyspnea, and cough completely resolved. repeat spirometry was within normal limits and she remained asymptomatic. surveillance bronchoscopies have been negative for any recurrence. discussion: adenoid cystic carcinoma (acc) is an uncommon form of malignant neoplasm that occurs within the salivary glands. tracheobronchial acc typically presents with symptoms of cough, dyspnea, and hoarseness. due to its slow growth, acc has a relatively indolent course. in a recent study of a cohort of acc patients, survival was % at years but only % at years. standard therapy is surgical resection often followed by radiotherapy. conclusion: in patients who fail conventional therapies for asthma it is important to entertain other diagnosis and have a systematic approach to establish the correct diagnosis. ipex is an extremely rare, hereditary condition characterized by immune dysfunction, polyendocrinopathy, enteropathy and x-linked recessive inheritance that leads to death without prompt diagnosis. patients usually present by months with severe diarrhea, failure to thrive, and early onset iddm. most children die by one year without a bone marrow transplant. immunologic evaluation is typically normal except for elevated ige, eosinophilia, and autoantibodies. we report a case of ipex in an infant who presented at birth and died at days of multi-organ system failure. this male infant was born at weeks due to chorioamnionitis and prom. at birth, copious green fluid appeared from his rectum and ng tube which evolved into a secretory diarrhea. workup for fistula was negative. at weeks, the patient developed ascites and explorative laparotomy revealed an inflamed appendix. after the laparotomy, the patient had no further stool output and never tolerated enteric feeds. he remained intubated and had problems with apnea and coagulapathy. pathology of the appendix showed an excess of lymphocytes. immune system investigation showed elevated ige ( ) and igg ( ). serum anti-enterocyte igg antibody was positive in the patient and negative in his mother. based on this data, ipex was suspected which autopsy seemed to confirm. autopsies are scarce in patients with ipex. the findings revealed many organs affected by fibrosis but lymphocyte infiltration of only the pancreas and gi tract. the pancreas revealed almost complete loss of the exocrine structure, with invasion of fibrosis and chronic inflammatory cells. the mucosa of the gi tract from the stomach to rectum showed columnar epithelium taken over by fibrosis, capillaries and chronic inflammation. these inflammatory cells were cd + lymphocytes and plasma cells on immunochemistry. the lymphoreticular system was consistent with lymphoid paucity in the thymus, lymph nodes and spleen. preliminary data suggests this patient has a splice mutation of the foxp gene. ipex is an extremely rare disease, often difficult to diagnose while a patient is alive. infants will present in early infancy with diarrhea and endocrinopathies. without prompt diagnosis, death is inevitable. as a result, one must be aware of atypical presentations and considered in patients with total villous atrophy and one other clinical feature such as iddm or autoimmunity. introduction: digeorge syndrome (dgs) is characterized by thymic hypoplasia, parathyroid hypoplasia, and conotruncal cardiac defects, but has a wide variety of clinical manifestations. there is also an increased risk for autoimmune phenomena in later life due to thymic hypoplasia. case report: a year-old aa girl with tetralogy of fallot (repair at age ), developmental delay, asthma, recurrent sinopulmonary infections/skin abscesses, gerd, arthralgias and seizure disorder (due to hypoxic encephalopathy during cardiac surgery) presented to allergy/immunology clinic for immune workup. there was no history of documented hypocalcemia. at age , she developed persistent annular patches on her left leg. a skin biopsy appeared consistent with sarcoid dermatitis. there was no other evidence of sarcoidosis except for slightly elevated ace level. given lack of systemic involvement, the skin lesions were not treated, but resolved spontaneously. at age , she developed swelling of the right mandible, and a bone biopsy revealed garre's osteomyelitis (sterile hyperproliferative osteomyelitis), likely triggered by dental caries, with elevated esr ( ) and polyclonal hypergammaglobulinemia (igg ), but normal crp. immune workup revealed a decrease in cd and cd cells (cd /cd ratio . ), slightly elevated b cells, high-normal range nk cells, normal range t cell cytokine production in response to mitogens and il- , but excessive production of proinflammatory cytokines in responses to lps. in conjunction with facial dysmorphism, dgs was suspected, and fish analysis revealed q . microdeletion. a repeat workup did not reveal evidence of systemic sarcoidosis, and autoantibody screening was negative including lupus anticoagulant. she was treated with a cox- inhibitor, secondary to gerd and mild thrombocytopenia, and her joint symptoms resolved with a concurrent decline in esr (to ) and igg level (to ) after months. conclusion: recurrent infections with fragmented care and resultant chronic inflammation (hence overstimulation of the immune system) may have led this dgs patient to develop atypical autoimmune phenomena and other unusual clinical manifestations. this case illustrates the importance of recognizing the phenotypic features of dgs early in life, and of providing close monitoring and coordinated care. rationale: we report a case of a patient with celiac disease who continues to have symptoms of fevers, nausea, vomiting, night sweats and fatigue despite being on a gluten free diet whose symptoms have been responsive to antihistamines. methods: case report. results: in , this year-old white male suffered from mononucleosis and episodes of prostatitis. he began suffering from fatigue and fevers and was followed at a chronic fatigue syndrome center in . in november , patient was placed on famvir alleviating his sore throat. he was later placed on interferon gamma which was discontinued due to increased fevers, nausea and vomiting. after stopping medication, symptoms abated for sometime. in , patient's father was diagnosed with celiac sprue. in april of , the patient developed a pruritic rash on his right arm. biopsy revealed subepidermal vesicles with pmn's at the tips of dermal papillae. in may of , he developed oral ulcers as well as joint pains. patient underwent endoscopy with biopsies revealing intraepithelial lymphocytosis in the duodenum. patient has been on a strict gluten free diet since october . he reports that some symptoms have improved: skin lesions, itchy eyes, and oral ulcers. however, he has begun to suffer from constipation and continues to intermittently have night sweats, fevers, nausea and vomiting. in february of , he had pruritus that was not alleviated by hydroxyzine. a regimen of benadryl and pepcid was started to aid with the pruritus. the patient reported in the improvement of his symptoms of pruritis, sweats, and emesis. conclusions: diagnosis: celiac disease(cd) patient with persistent nausea, vomiting, sporadic fevers, and fatigue despite maintaining a strict gluten free diet has shown improvement of symptoms with antihistamines. patient has history of chronic infections: prostatitis and chronic ebv. patient also reported alleviation of symptoms after interferon therapy suggesting some autoimmune component to his current illness. cd prevalence in the united states is much higher than once thought . - % of the u.s. celiac disease has been associated with increased risk of lymphoma and malabsorption leading to neurological diseases. this is a rare case of cd associated pruritus responding to antihistamines. rationale: eosinophilic cystitis is a relatively rare condition in children and adults with a varied course. it usually responds to short-term nsaid and steroid therapy. we report a man with a severe case who responded to prolonged oral steroids. case report: a year old caucasian man with a prior esophageal cancer s/p esophagectomy, diabetes, hypertension, allergic rhinitis and chronic obstructive pulmonary disease presented with suprapubic pain, urinary frequency, dysuria, and hematuria. urinalysis showed numerous red blood cells and bacteria but no malignant cells or eosinophils. he was treated with antibiotics with resolution of symptoms. several weeks later he experienced severe suprapubic pain and hematuria resulting in a symptomatic drop in his hemoglobin. he underwent a cystoscopy and biopsy that revealed a chronic cystitis with an inflammatory infiltrate containing numerous eosinophils. he was unresponsive to treatment with nsaid and intravesicular dmso and was then referred to our service. we started prednisone mg/day but the dysuria and hematuria persisted. prednisone was doubled plus a third generation quinolone was added. three weeks later the hematuria and dysuria resolved and he was asymptomatic. the antibiotic was stopped and prednisone was gradually tapered over several weeks. whenever his steroid dose dropped below mg/day he experienced an exacerbation of his symptoms. over the last three years this dose of prednisone has kept his symptoms abated and his renal function stable. conclusion: eosinophilic cystitis is an uncommon diagnosis of unknown etiology. we describe a patient with debilitating suprapubic pain and symptomatic anemia from the hematuria associated with eosinophilic cystitis. for over three years since we first saw him, continued therapy with mg of prednisone/day has prevented exacerbations. this case is unique in the severity of the hematuria experienced and the prolonged relatively low steroid dose needed to suppress exacerbations. we propose that in eosinophilic cystitis patients with severe hematuria who may otherwise be candidates for a cystectomy, a trial of prolonged oral prednisone may be beneficial. rationale: allergic reactions to insulin occurred more frequently in the past, with porcine and bovine preparations. in contrast, allergic reactions to human insulin preparations are now reported in < % of patients treated with insulin. insulin allergy may be manifested as an immediate-type ige-mediated reaction, delayed type hypersensitivity or as serum sickness, varying in severity from mild discomfort to life-threatening events. we present a case to illustrate that an insulin allergy may complicate hospitalization and often be misdiagnosed. methods: a y.o. diabetic female with a history of "insulin allergy" was evaluated. the patient is a long standing diabetic controlled on oral hypoglycemics but required insulin during acute illnesses and hospitalizations. the patient was unable to recall previous types of insulin she had received. during previous hospitalizations, the patient complained of vague symptoms of fatigue, parasthesia, sweating, anxiety, and palpitations. on one occasion the patient had a syncopal episode with hypotension and on another occasion the patient developed a rash and dyspnea after receiving sq insulin. the physcian intrepreted the findings may be due to hypoglycemic. an allergic reaction was not suspected and the patient never underwent any testing. during a recent hospitalization, the patient's history was reviewed and a formal allergy consult was obtained. she underwent epicutaneous and intradermal testing to human insulin preparations. insulin antibody levels were also obtained. results: the patient had negative epicutaneous testing to all human insulin preparations. however, on intradermal testing, the patient had positive reactions to lispro, nph, and lente and negative intradermal tests to insulin glargine and regular insulin. igg and ige insulin antibody test results were < . conclusion: hospitalized patients receiving multiple medications commonly experience pharmacologic, adverse and/or allergic reactions. it is necessary to obtain a thorough history and document all reactions that patients experience to determine what type of event occurred. with a suspicion of drug allergy, skin testing and/or rast assay may provide insight into possible ige mediated reactions. in this case we advised the patient that she may use regular insulin during hospitalizations and that insulin glargine can be used to help achieve optimal glycemic long term control. background: hereditary angioedema type iii (hae iii) is a recently described form of angioedema occurring exclusively in females and characterized by normal c , c inhibitor (c inh) protein and function. hae iii is thought to have an x-linked or autosomal dominant mode of inheritance. we evaluated a year old female with recurrent facial swelling, abdominal pain and laryngeal edema with a family history of similar symptoms in several female relatives. case report: a year old african american female presented with a two year history of recurrent lip, tongue and facial swelling. she also had abdominal pain, diarrhea and shortness of breath. episodes were not associated with hives. her symptoms predated menarche and did not correlate with her menstrual cycle. at the time of presentation she described an increase in frequency of her symptoms that did not respond to antihistamines (diphenhydramine, cetirizine) or prednisone. the patient had no other medical problems. family history was significant for recurrent episodes of facial, lip and tongue swelling in a maternal aunt, grandmother and great grandmother. the patient's great grandmother required tracheal intubation with ventilator support for upper airway compromise. the patient's physical exam was unremarkable. laboratory values drawn during an acute episode of swelling revealed: c inh function = > % (normal > %), c inh protein = mg/ml (normal - mg/ml), c = . mg/dl (normal - mg/dl). dna sequencing at exon to investigate the possibility of an unusual c inh mutation with normal c s binding but abnormal kallikrein inhibition was negative. other lab tests included a normal mast cell tryptase of . mcg/l, a negative rf and ana, a normal angiotensin converting enzyme of u/l (normal - u/l) and positive skin prick tests to a variety of foods which the patient tolerates. based on two case reports of treatment of hae iii with androgens, the patient was started on danazol mg daily with symptomatic improvement. conclusion: hae iii is a rare disease that affects females exclusively. clinically it is indistinguishable from c inh deficiency. the mechanism of inheritance remains to be elucidated. it is unclear why danazol appears to ameliorate symptoms even though there is no evidence for c annals of allergy, asthma & immunology inhibitor dysfunction in this disorder. we believe this to be the first kindred of hae iii reported in the united states. r. dworski * , m. peters, nashville, tn. a four-month-old female identical twin was evaluated for noisy breathing and recurrent cyanosis. she was delivered at weeks of an estimated gestational age after an uncomplicated pregnancy. at birth she was intubated for hours for respiratory distress but the remainder of her neonatal period was uneventful. at age weeks she developed a noisy breathing often associated with cyanosis, particularly in a supine position or while crying. treatments with inhaled albuterol and prednisolone were ineffective. she had no respiratory infections or symptoms of gastroesophageal reflux disease. her growth was normal. her twin sibling was well. the family history was negative for allergies or respiratory conditions. initially she was diagnosed with tracheomalacia. however, the history of cyanotic episodes prompted a search for a definitive diagnosis. she underwent bronchoscopy which showed tracheomalacia when breathing spontaneously and circumferential narrowing of lower trachea likely due to compression. echocardiogram revealed a double aortic arch. the finding was confirmed by computed tomography angiography which demonstrated the presence of a vascular ring composed of double patent aortic arches, each giving rise to the ipsilateral carotid and subclavian arteries. the airway was normal at the aortic inlet, but narrowed markedly at the level of the two arches. a surgical division of the ductus ligamentous and distal anterior vascular arch was performed. aortic arch abnormalities should be suspected in all infants with hoarse coughing or noisy breathing, especially during inspiration but sometimes also during expiration. the diagnosis should also be considered in older children with recurrent bronchitis or pneumonia. respiratory symptoms are more frequent than gastrointestinal manifestations. diagnosis usually occurs in the first year of life. a surgery is often the treatment of choice. postoperative complications are relatively rare. outcome of surgery should be judged after months, including at least one winter season. malacia can delay extubation and recovery following surgery. surgical cure occurs in approximately % of patients. surgery is probably less successful in children with double arches and malacia. a. thatayatikom * , a.j. white, st. louis, mo. background: common variable immunodeficiency (cvid) is the commonest symptomatic primary antibody deficiency syndrome in which b lymphocytes produce low levels of immunoglobulin, leading to recurrent bacterial infection. although hypogammaglobulinemia and susceptibility to the recurrent infection are seen in all patients, other associated conditions such as a non-infectious granulomatous disease have been well described in cvid. corticosteroid therapy has been used with improvement in a subset of cvid with granulomatous disease; however, its treatment remains problematic and a new therapeutic agent is needed. tumor necrosis factor (tnf ) has been demonstrated as a primary mediator in granuloma formation and maintenance. therefore, anti-tnf medications are potentially therapeutic agents of the granulomatous disease. case report: a -year-old caucasian male with cvid and severe granulomatous disease was treated successfully with infliximab, a chimeric anti-tnf monoclonal antibody. the patient initially presented with high fever, chills and abdominal pain; subsequently, he developed acute respiratory failure and adult respiratory distress syndrome. the patient was hospitalized and he required intensive care with ventilatory support. his diagnostic tests revealed elevated sedimentation rate and positive epstein-barr virus (ebv) capsid igm antibody. imaging studies demonstrated bilateral diffuse pulmonary infiltrates and hepatosplenomegaly. open lung and liver biop-sies revealed non-caseating granulomatous lesions without evidence of ebv or other infections. high dose corticosteroid therapy was given with partial improvement, then high dose infliximab ( mg/kg) was given weekly with remarkable improvement. the patient was able to wean off ventilator successfully within weeks and his prednisone dose was dramatically decreased. infliximab infusion ( mg/kg) every weeks and low dose prednisone were continued. a follow-up liver biopsy after months of the infliximab showed no granulomatous lesions. infliximab was discontinued after months of the treatment. there was no serious infection or complication during the period of treatment. conclusion: anti-tnf therapy may be a safe and effective treatment and may allow corticosteroid dose reduction. future clinical studies of anti-tnf therapy in cvid with granulomatous disease are warranted. background: chrug-strauss syndrome is a disorder characterized by hypereosinophilia and systemic vasculitis occurring in individuals with asthma. objetive: to present a pediatric case suffering from a systemic vasculitis. this case fulfilled the churg-strauss syndrome clinical criteria and the histophatology findings were compatible with the diagnosis. case: a year female came to our institution with the diagnosis of severe asthma, chronic sinusisits and polyps requiring high doses of steroids. there was no history of administration of antileukotriene receptor antagonists. months before her admission she presented weight loss, fatigue, cephalea and cough. on physical examination, pallor, respiratory difficulty and signs of bronchospasm were evident. tachycardia and hepatomegaly were also documented. the laboratory test showed anemia, eosinophilia /dl, anca+, sgot , stgop , ige elevated ui/ml. the chest-x ray showed patchy opacities in both lungs and cardiomegaly. pulmonary scintigraphy reported low perfusion in both lungs, predominantly in the left lung.echocardiography demonstrated signs of myocarditis and eyection fraction of %. an open lung biopsy was executed and vasculitis with fibrinoid changes affecting small and medium vessels was reported. treatment was started with oral prednisone mg/kg/d and cyclophosphamide pulses with a satisfactory evolution. discussion: to our knowledge this is the first pediatric case of css reported in mexico. she fulilled the following criteria. asthma, eosinophilia and systemic vasculitis involving the heart, liver and lungs. the disease is extremely rare, specially in mexico. aggressive treatment is necessary as in this case, with a favorable outcome. introduction "all that wheezes is not asthma" is a well-known aphorism among physicians. this same principle exists for patients that present with lip swelling in the allergist's office. we describe a patient who presented with fluctuating lip swelling who was ultimately found to have cheilitis granulomatosa. case history a -year-old male with a history of allergic rhinitis and asthma presented to the allergy clinic with lower lip swelling and occasional upper lip swelling. he was receiving allergen immunotherapy for dust mites and trees. the swelling had been waxing and waning for years, but became more persistent for the previous six months. he denied tongue/throat swelling, dysphagia, respiratory distress, or any triggers for the swelling. chapstick® and vaseline® were used topically on his lips. failed treatments included loratadine, ranitidine, cetirizine, fexofenadine, and montelukast. he was placed on a one-week course of prednisone, which decreased his lip swelling, but it recurred after completion of the treatment. physical exam was significant for diffuse, firm lower lip edema to - times the normal size. there were no oral lesions or tongue swelling. patch testing to a standard panel, preservatives, oral flavors, and dental acrylate was negative. punch biopsy revealed a noncaseating epithelioid granulomatous inflammation consistent with granulomatous cheilitis. he was placed on minocycline mg by mouth twice daily with little benefit. an -week course of oral prednisone resulted in improvement of the lip swelling. conclusion melkersson-rosenthal syndrome (mrs) is a rare syndrome that is characterized by a triad of recurrent facial paralysis, chronic edema of the face and lips, and hypertrophy and fissuring of the tongue. cheilitis granulomatosa is considered a monosymptomatic form of mrs and manifests as a chronic swelling of the lips caused by granulomatous inflammation. the swelling is typically not tender and may be either soft or firm. allergists are often consulted for lip swelling thought due to angioedema. however, as this case illustrates, not all lip swelling is angioedema and one must consider other diagnoses such as melkersson-rosenthal syndrome and cheilitis granulomatosa. progressive multifocal leukoencephalopathy (pml) is a disorder of the nervous system that affects individuals with immune suppression. it has been associated with hiv infection and is present in nearly % of patients with acquired immune deficiency syndrome. the jc virus, a common human polyomavirus, causes this demyelinating disorder. progressive symptoms reflect the multifocal distribution of brain lesions, and include mental deterioration, vision loss, speech disturbances, ataxia, paralysis, and, ultimately, coma. in rare cases, seizures may occur. there is no known treatment for pml. we report a year-old (y/o) male with months weight loss and a sudden onset of confusion, lethargy, and progressive loss of cognition requiring hospitalization. upon questioning he was found to have had recurrent upper respiratory tract infections since infancy successfully treated with antibiotics. as a child he had atopic dermatitis, exercise induced asthma, and myringotomy tubes placed twice. at y/o, he underwent a nasal polypectomy. in , at y/o, a squamous cell carcinoma was removed, and he developed benign cervical lymphadenopathy and common warts. a year later he developed hsv esophagitis. the remainder of his history was unremarkable with normal development and growth and no history of drug abuse, multiple sexual partners, or homosexual contacts. on physical examination, he was thin, ill appearing, with oral ulcers, generalized scanty lymphoadenopathy, multiple common warts on both feet, and occasional ronchi. a brain mri showed a demyelinating process consistent with pml. pcr for jc virus was positive, while hiv pcr was negative; total immunoglobulins and cd counts were low ( we are reporting a year old female with a year history of moderate persistent asthma, who was started on xolair mg sq q wks., and who then presented with a presumed allergic reaction. three hours after her second xolair injection, patient reported developing dizziness, shortness of breath, and felt like she was having an allergic reaction. she was evaluated and observed for two hours in an emergency department. the treating physician reported no wheezing and felt there was no need for treatment. to rule out psychogenic factors, she was given a placebo injection at the next scheduled visit. ten minutes later she reported developing throat tightness and shortness of breath. she had no changes in her peak flows and her lungs were clear. her "symptoms" resolved completely within minutes of receiving placebo epinephrine and nebulized normal saline. patient was informed she had reacted to a placebo injection, as well as placebo epinephrine and albuterol, and counseled. the patient returned to the office every week for the next three weeks to receive blinded injections. she subsequently did not react to either doses of placebo or xolair. she has since tolerated her monthly xolair injections without incident. this case illustrates the importance of ruling out psychologic causes of presumed allergic reactions. introduction :latex allergy, type i ige mediated hipersensitivity, occurs specially in high risk populations, like in patients that have undergone various surgeries. case: a year old boy with asthma and allergic rhinitis since , penicillin allergy and retrospectively, his mother refers lip edema with balloon inflating.at years of age ( ): left orchiorrhaphy because of cryptorchis. between - : surgeries because of sacral giant melanocitic naevus.during the fourth surgical intervention ( ct - ) to collocate a tissue expander, the patient presents perioral and fingertip cyanosis, generalized cutaneous rash and severe bronchospasm.ap: / mmhg, hr x/min. he was treated with iv fluids, steroids, antihistamines and inhaled racemic epinephrine.at the icu his final outcome is satisfactory. laboratory: total ige : . iu/l, skin prick test with glove extract, raw and natural latex extract and purified latex proteins(pseudoeveine, molecular hevein, hev b . and modified hevein)all positive +++. western blot with protein extract of latex positive and elisa with purified latex proteins ( same as above) positive. the last surgery to withdraw the tissue expander was performed with latex free surgical equipment without any problems. discussion: the patient's risk factors for latex allergy are atopy and repetitive exposure to latex articles because of surgery. he presents mild manifestations of latex allergy, till he finally develops full-blown anaphylaxis. diagnosis was made based on clinical history, skin prick test, western blot with protein extract and elisa with purified latex protein. he had a favorable outcome withdrawing latex during the last surgery. introduction: churg-strauss syndrome (css) is a form of primary vasculitis that is a rare diagnosis in an elderly patient. case report: a year old woman presented with a week history of fatigue, vomiting, diarrhea, abdom-inal pain, and right lower leg paresthesia. prior to admission she was being treated for left neck erythema and adenopathy presumed to be cellulitis. she was in good health with no history of atopy until the age of , when she developed both chronic sinusitis, requiring bilateral sinus surgery and polypectomy, * and new onset asthma, * that required systemic steroid control. prednisone was tapered month prior to admission. objective findings included coalescent non-blanching petechiae on her abdomen, peripheral eosinophilia of ( %), * normochromic normocytic anemia, rf= , esr= , ige= , igg= . ana, p and c-anca were negative. ct showed ascites and pleural effusions. egd revealed duodenitis with ulceration and eosinophilic infiltration on biopsy. echo showed pericardial effusion and septal motion abnormality. troponin of without cad was consistent with subepicardial myocarditis. emg confirmed right peroneal neuropathy.* skin biopsy revealed a dense superficial and mid-dermal perivascular and interstitial eosinophilic infiltrate. additional evaluation excluded malignancy, infection, and abpa. treatment with prednisone, mg/kg/day was initiated. a rapid clinical improvement ensued and has persisted. {*acr criteria for css}. discussion: churg-strauss syndrome is a rare form of vasculitis with mean age of onset within the third and fifth decades. it is an uncommon cause (< %) of systemic vasculitis in patients older than . the formes frustes of css is a variant in which early manifestations of the syndrome are hidden by oral and systemic steroids employed in the treatment of worsening asthma often associated with css. this variant makes expedient identification of css more challenging. delayed recognition contributes to a relentless progression of this entity resulting in a systemic vasculitis with multi-organ involvement. early diagnosis, especially in the prodromal and eosinophilic phases, is essential. untreated, css has a high rate of morbidity and mortality. therefore, css and the formes frustes variant must be an integral component in the differential diagnosis of patients presenting with adult onset asthma and/or recurrent sinusitis. common variable immunodeficiency (cvid) is the most prevalent of the primary immunodeficiency diseases. cvid is a heterogeneous group of immunologic disorders of unknown etiology, characterized by impaired antibody responses, hypogammaglobulinemia with normal b cells. the common immunologic defect in patients with cvid is defective antibody formation, and many different immune system defects have been reported in this group of patients. most patients, really, have no identified molecular diagnosis. cvid consists of several different genetics defect. the immunologic defect in cvid is a failure of b-lymphocyte differentiation into plasmacells. b lymphocytes from these patients failed to differentiate into ig-producing cells when stimulated with pokeweed mitogen in vitro, even when cocultured with normal t cells. an overwhelming body of literature suggests that most patients with cvid have intact b lymphocytes of immature phenotype. however the functional classification of cvid patients on the basis of in vitro ig production is time consuming. recently has been proposed a new classification based on the quantitative repartition of memory b cell according to the dual expression of igd and cd . we present a case of a yr old boy. he presented soon in his life frequent infections, of particular severity: pneumonia, meningoencefalitis, sepsis, bronchitis, otitis, linfoadenitis. he also had a -thalassemia intermedia. this clinical manifestations suggested an immunodeficiency. for this reason at years of age serum immunoglobulin and antibody detection showed a reduction in igg subclass and in cd + cells, with normal total igg, iga, igm, normal cd /cd ratio, normal cd , isohemagglutinins and in vitro t cell function. there was also a defective antibody production after tetanus, diphtheria, pertussis immunization. these laboratory findings did not allow, however, a sure diagnosis for cvid. a new immunological evaluation at the age of years old, after the onset of splenomegaly, and enlarged lymph nodes, demonstrated a b memory defect, with a severe deficit of t lymphocytes function in vitro. it was also possible to find a severe deficiency of cd + cells, meaning a defect in memory b cells: we can therfore label this condition as a cvid. in the past two decades there have been conflicting views regarding the clinical importance of igg subclass deficiencies in children. igg subclass plays a vital role in the immune response to polysaccharide antigen. isolated igg subclass deficiency may be widespread and often asymptomatic in children. however, in association with other subclasses and/or other immunoglobulin classes, there may be a significant, symptomatic outcome. the reported patient was diagnosed with familial dysautonomia (fd) at the age of five weeks, presenting with severe hypotonia and tachypnea. hindered by poor pulmonary function, he was hospitalized over fifteen times for recurrent pneumonias, including four lengthy intensive care admissions. daily inhaled-corticosteroids and brochodilator therapies were initiated, along with chest therapy via a high frequency chest wall oscillator. immunoglobulin levels were measured recently and point to low levels of igg , igg and total iga antibodies: igg mg/dl (n - ), igg mg/dl (n - ), igg . mg/dl (n . - . ), igg < . mg/dl (n . - . ), and total iga mg/dl (n - ). since receiving monthly ivig therapy he had no further recurrence of pulmonary infections and was slowly weaned off daily brochodilator therapy. the currently accepted theory is that low igg subclass levels may be associated with increased risk of bacterial infections only in selective groups. fd patients may be in a distinctively susceptible population in which igg levels are critical. the older brother, who was also diagnosed with fd, demonstrated igg , igg and iga levels that were slightly higher but nevertheless on the lower end of the normal range. he suffers from less invasive and less frequent bacterial infections. this may support a genetic association between the fd and hypogammaglobulinemia. alternatively, it may signal that fd patients may have a prolonged variant of transient hypogammaglobulinemia of infancy. follow-up immune profile studies, post-ivig trough levels and broader investigations of the fd population are necessary to determine the severity and prevalence of these findings. pulmonary failure is the dominant cause of death in patients with fd. prompt diagnosis and effective treatment of the associated immune deficiency may be proven essential in the effort to enhance and prolong their lives. s. hassan * , j.a. grant, galveston, tx. rationale: common variable immunodeficiency (cvid), a rare primary immunodeficiency presenting in young adults with repeated sinopulmonary infections as a result of profound hypogammaglobulinemia, was first described by suri et al. (ann acad. med. singapore, ) . we describe a young man with diagnosed but untreated cvid and its eventual course. case description: a -yr-old caucasian male hospitalized secondary to chronic pneumonia and respiratory failure was noted to have non-existent levels of immunoglobulins. history revealed ivig treatment at age , stopped after a year due to non-compliance. although untreated, he denied recurrent sinusitis, otitis media, or bronchitis for almost years but notes a recent inability in keeping up with baseball practice. he is the last of ten healthy siblings. patient started monthly ivig infusions but was noted to have hypertension ( / ), tachycardia ( - ), tachypnea ( - ) on the th month with o saturation of - % and po of % on room air. with a -day history of acute dyspnea, calf muscle and right abdominal pain, he was admitted to the hospital and pulmonary thromboembolism was ruled out. laboratory data: humoral functions (pneumococcal, tetanus toxoid, and hepvac) -undetectable t cell function (mumps, candida, ppd) -normal immunoglobulin (igg, iga, igm) -undetectable flow cytometry -b and nk cell markers normal, mild decrease in the cd /cd ratio high resolution ct thorax -bronchiectasis, bronchial wall thickening, and obstructive changes with airtrapping. minute walk -desaturation to % on l o by nc bnp - echocardiogramestimated ef - %; severe pulmonary hypertension. cardiac catheterization -normal coronary arteries, severe pulmonary hypertension (pa pressure / ). conclusion: cvid patients have a reasonably good prognosis on treatment. untreated cvid is associated with chronic lung infections, bronchiectasis, pulmonary hypertension and right heart failure. although, lung transplant became available during the early eighties (nejm ), this extremely invasive but life saving procedure was undertaken in a patient with cvid and end-stage pulmonary hypertension in (thorax ). lung transplant may be the only way of ensuring survival for this patient. introduction chronic eosinophilic pneumonia (cep) is a rare disorder of unknown etiology characterized as a chronic and relapsing interstitial lung disease with blood or tissue eosinophilia. cep occurs more often in women with preexisting atopic disease. patients with cep respond rapidly to systemic corticosteroids, but often relapse with short, low-dose courses of therapy. while uncommon, extrapulmonary involvement, such as arthralgia, cutaneous purpura, pericarditis, and hepatitis, have been reported. we present a case of a patient who has cep with pericardial effusion. case report the patient is a non-smoking -year-old woman with a past medical history significant for allergic rhinitis and asthma who initially presented with a four-month history of worsening shortness of breath, dyspnea on exertion, dry, non-productive cough, and weight loss (approximately five pounds). her symptoms were refractory to increased dosages of inhaled fluticasone. she then developed intermittent fever up to °c. chest x-ray revealed bilateral apical infiltrates. treatment with levofloxacin for seven days resulted in no improvement of symptoms or roentographic findings. thereafter, she presented with chest and abdominal pain, hypotension, and hypoxia. blood work revealed a white cell count of c/mm with a differential significant for % eosinophilia (absolute eosinophil count of c/mm ). chest ct showed dense consolidation predominantly along the peripheral aspect of the upper and superior segment of the lower lobes, and pericardial effusion. moderate pericardial effusion without evidence of tamponade was confirmed on echocardiogram. left upper lobe wedge biopsy findings included significant tissue eosinophilia, scattered foci of active organizing exudates, and no evidence of granulomatous or necrotizing vasculitis. the patient was treated for cep with a six-month course of prednisone, starting at mg daily, resulting in rapid improvement of her pulmonary and systemic symptoms. background: immunologists are consulted for evaluation of immunodeficiency in patients with recurrent skin infections. disorders of the phagocyte system may be associated with cutaneous infections. methods: case report case: a -month-old african american girl (twin a) presents with recurrent skin abscesses. at months of age, she had her first buttocks abscess, which required incision and drainage with oral antibiotics. a month later, she developed another abscess and was found to be neutropenic, with an absolute neutrophil count (anc) of /μl. cyclic neutropenia was considered and her pediatrician monitored cbcs, which all showed persistent neutropenia (ancs between and ). at months of age, she was hospitalized for fever with neutropenia. immunology was consulted for evaluation of neutropenia. the rest of the past medical history was unremarkable. she was healthy appearing and growth parameters were appropriate for age. her physical examination was unremarkable. immunoglobulins, b-and t-cell markers, nitroblue tetrazolium, complement assay, hemoglobin, platelets and the peripheral smear were normal. antibodies for hiv, cmv, ebv and parvovirus were undetectable. anti-neutrophil antibodies were positive, establishing the diagnosis of primary autoimmune neutropenia (ain). the abscess healed with oral antibiotics. severe neutropenia (anc - ) persisted for three subsequent months without further infections. twin (b) was also found to have persistent severe neutropenia without morbidities, suggestive of primary ain. primary ain is less known among physicians and is typically diagnosed after extensive investigations that exclude other causes of neutropenia. the exact incidence of ain is unknown. it is usually seen in children between and months of age, often with severe neutropenia and self-limiting bacterial infections. the clinical course and presence of antibodies to neutrophil antigens (na , na or cd b/ ) is diagnostic. familial occurrence of primary ain is not reported in the literature. conclusion: primary ain may remain under diagnosed due to lack of characteristic clinical features. although a benign clinical course is likely, severe infections, including pneumonia, sepsis and meningitis, have been reported. genetics may play a role in this disease, as we present primary ain in twins. background: atopic dermatitis (ad) is a chronic inflamatory disease of skin that affects % of the wordl population.the natural history of ad in some patients, evolve to the coexistence with other allergic diseases: allergic rhinitis, allergic conjunctivitis and asthma. the sublingual immunotherapy has demonstrated utility in some patients; however, semi-rush immunotherapy to pollens has only showed utility in one animal case published few years ago. case report: a -year-old infant was referred to us. he began one year before with skin lesions compatible with ad, six months later began perennial rinhorrea and nasal itching. multiple treatments with topic corticosteroids, moisturizing, antihistamines and topic/systemic antibiotics did not demonstrate utility. our evaluation revealed ad lessions that affected % of the total body surface and clinical features of allergic rhinitis (ar).the lab tests revealed eosinophylia ( cell/mm ) in blood cell count, normal levels of total ige but specific ige to dermatophagoides pteronissinus (dpt) was high. the skin prick test reveales the same results. we added environmental control, oral costicosteroids and transfer factor. despite our treatment no improvement was observed. we considered dpt as the principal factor in the maintenance of ad lessions and ar episodes. in the absence of sublingual immunotherapy in our hospital, we decided for semi-rush immunotherapy schedule. we began from . ml of : , w/v concentrations of dpt until , ml of : w/v concentrations in two months receiving three doses per week. no local or systemic adverse events was reported and the ad lesions and ar symptomatology disappeared in the first month of treatment. at this time, no exacerbations have been documented. conclusion: the semi-rush immunotherapy can be useful and safe for treatmente of ad in some patients in whom specific ige to aeroallergens has been demonstrated. introduction: eosinophilic gastrointestinal disorders are a rare group of disorders that can involve the entire gastrointestinal tract. presentations are varied but may include vomiting, dysphagia, abdominal pain, diarrhea and failure to thrive. the diagnosis is made by endoscopic biopsies which reveals eosinophil rich inflammation in the absence of known causes for eosinophilia. peripheral eosinophils and ige may be elevated but can be normal. we report a patient with eosinophilic gastroenteritis associated with an ampullary tubulovillous adnenoma. methods:a -year-old white male with allergic rhinitis and a family history of atopy was admitted for profuse watery diarrhea. he denied any new medications, eating raw foods or recent travels. eosinophils were elevated to . ( % of wbc) and ige was elevated to . multiple stool specimens were negative for ova & parasites and enteric pathogens. serology was negative for strongyloides, trichinella, e. histolytica and toxocara. ast, alt & bilirubin were elevated and a ct scan showed dilated billiary ducts with a possible ampullary mass. biopsy of the ampullary mass revealed a tubulovillous adenoma. biopsies of the duodenum, terminal ileum, colon and rectum were remarkable for focal eosinophilic cryptitis & chronic inflammation in the lamina propria consisting of eosinophils, scattered lymphocytes and histiocytes. all specimens were negative for parasitic infections including duodenal aspirates. he was empirically started on metronidazole and singulair with gradual improvement of symptoms, eosinophils and liver tests. two months after discharge, the patient remained diarrhea free with a normal eosinophil count. conclusion: we report a patient with eosinophilic gastroenteritis and an ampullary tubulovillous adenoma with obstruction of the biliary system. this unique presentation illustrates the diverse nature of gastrointestinal manifestations seen in eosinophilic gastroenteritis. background: zonisamide is an anti-seizure medication chemically classified as a sulfonamide and unrelated to other ant seizure agents. we report a case of hypersensitivity to this agent in a child. method: case report results: this patient is a -month-old girl who developed "peeling of her lips" three weeks after starting zonisamide. one week later she developed a rash that began on her face and generalized over several days to her neck, trunk and extremities. there was no respiratory distress, joint complaints and no angioedema associated with the episode, but fever to prompted referral to our hospital on day of the rash. the rash was macular-papular without discrete urticarial lesions. the rash coalesced with underlying erythema on face, chest and neck. the patient has a known history of seizure disorder, asthma, mild eczema, gastro esophageal reflux, development delay, lactose intolerance and failure to thrive. her other medications were, lansoprazole, topiramate, and albuterol. labs revealed a normal white cell count, an elevated sed rate ( ) and elevated lft's, i.e. sgot and sgpt . the only new medication was zonisamide that was discontinued. she was treated with iv steroids and hydroxyzine. the rash started fading by day and the patient's fever resolved by the third hospital day. liver enzymes returned to normal by day . conclusion: this relatively new anti-seizure agent can be associated with hypersensitivity reactions in children. introduction: kawasaki disease (kd) is an acute chilhood vasculitis. in addition to the diagnostic criteria a broad range of nonspecific clinical features may be observed including aseptic meningitis, vomiting, diarrhea, abdominal pain, sterile pyuria, arthralgia and arthrtis, pulmonary infiltration, pleural effusion and nonspecific paralytic ileum as manifestation of gastrointestinal vasculitis. we describe a child who developed all features of kawasaki disease included the most rarely reported. patient report: a year-old female presented days of high fever, nonsuppurative cervical lymphadenopathy, petequial rash in legs, swelling of feet, distended abdomen, vomiting, obnubilated and hypoactive, incongruent speech, fisured lips and distended abdomen. lab tests showed: anemia ( . g/dl), high wbc count ( , cells/mm ), thrombocytopenia ( , /mm ), hypoalbuminemia ( . g/dl), lactate dehydrogenase (ldh) mcg/l, glutamin transferase (ggt) . csf total proteins , glucose , cells , pm %, mn %, seric complement , cultures were negatives. she developed myocarditis, aneurysms in the right and left coronary arteries. on the th day presented cardiac failure, pleural effusion, paralytic ileum, hydrops vesicular, mechanic ventilatory assistance was required. the first dose of intravenous immunoglobulin (ivig) ( g/k) was infused, heparin and hydrocortisone. on day a second doses of ivig was infused, because of fever, and abdominal vasculitis. steroids ware discontinued, heparin was suspended and aspirin was added as antiaggregant. discussion: our patient presented an unusual and severe presentation of kd with pleural effusion, nonspecific ileum, cardiac failure secondary to myocarditis, aseptic meningitis and thrombocytopenia; all those manifestations had rarely been reported at the same time. she presented with a devastating evolution. complications were resolved. the lastest studies have shown that treatment with ivig plus corticosteroids significantly reduce serum concentrations of proinflamatory cytokines. in this case antiinflamatory doses of aspirin were contraindicated and steroids were used with satisfactory outcome. limited data is available for nonresponding patients to guide therapy. although multiple doses of ivig are sufficient in some patients, some of them remain refractory to therapy and they need corticosteroids to control the vasculitis process eosinophilia is defined by an absolute eosinophil count above . x and can be seen in association with a broad spectrum of disorders ranging from allergic to malignant. idiopathic hypereosinophilic syndrome (hes) should be considered in any patient with an eosinophil count above . x for more than months without commonly recognized causes of eosinophilia and with evidence for organ damage not otherwise explained in the clinical setting. it is potentially an aggressive disease with mean survival of less than a year without treatment. we present a year old male horse breeder, with eosinophilia lasting more than years. prior to coming to our institution, he underwent extensive medical evaluation including bone marrow and gi biopsies, multiple imaging studies with mri and ct scans of the chest and the head as well as detailed evaluation of his cardiac status. all these tests were normal and the patient was empirically started on treatment for possible hes including trials of prednisone, hydroxyurea, interferon alfa, and imatinib, all without lasting resolution of his eosinophilia and causing significant side effects with profound depression of his immune status. finally, in light of the patient's profession, a strongyloides enzyme immunoassay was done and found to be remarkably positive. duodenal drainage confirmed the infestation with this nematode. within a week of starting treatment with ivermectin, his eosinophil count came down by % and eventually normalized. we learn that one should be persistent in excluding all common causes of eosinophilia before considering hes. in case of parasite infestation, premature treatment with immunosuppressors can result in worsening of the infection with potential for poor and even fatal outcome. stool evaluation might not be sensitive enough for detection of parasites and it is therefore necessary to complete a diagnostic work up with appropriate serology. doxil is the pegylated liposomal form of doxorubicin and has been used successfully as a cancer chemotherapy agent in many types of tumors. a hypersensitivity reaction can occur, usually during the first infusion, and appears to be rate related. the symptoms include dyspnea, tachypnea, facial swelling, chills, hives, chest pain, and back pain. we report a case of a hypersensitivity reaction to doxil in a year-old woman with hodgkin's lymphoma. during her first outpatient doxil infusion at mg/min, she developed urticaria, chest tightness, dyspnea, and back pain. these reactions persisted despite being medicated with antihistamines and steroids and immediately resolved during pauses in the infusion. after mg of doxil, the infusion was discontinued. six days later, she was admitted to complete the other half of the dose. she had a negative intradermal skin test to a : dilution of doxil. she was then premedicated with diphenydramine, dexamethasone, acetaminophen, and famotidine. the doxil infusion was started at . mg/min and was soon stopped due to flushing of the hands and face. the infusion was decreased to . mg/min. she was able to tolerate this slow infusion with only mild and tolerable symptoms. when her symptoms worsened, the infusion was stopped for to minutes. she completed the mg infusion of doxil after hours. pre-infusion and post-infusion complement levels were drawn during this second administration of doxil. her pre-infusion c , c , c a, c , c , c a, and bb levels were all normal. her pre-infusion c a and sc b- levels were high, indicating that she might have had some residual or persistent complement activation caused by her first doxil infusion. her post-infusion c , c , c a, c , c , c a, and bb levels were all normal. however, her post-infusion sc b- levels significantly increased, suggesting complement was activated during the second doxil infusion. given her reaction during her first doxil infusion and a negative skin test to doxil, it is highly unlikely that her doxil hypersensitivity was an ige-mediated process. therefore, in patients with a similar doxil hypersensitivity, we suggest a slow rate of infusion of . - . mg/min, toleration of mild symptoms, to minute pauses during more severe symptoms, and continuation of premedication during the entire lengthy infusion. introduction eosiniphilic esophagitis (ee) is an isolated, severe esophageal eosinophilia. patients are usually young males presenting with vomiting, epigastric or chest pain, dysphagia and obstructive respiratory problems. they are often initially misdiagnosed with and treated for gastroesophageal reflux disease (gerd). distinction between the two diseases can be made with biopsies of the esophageal mucosa. while any eosinophils in the esophageal mucosa indicate pathology, gerd typically presents with up to eosinophils per high powered field (hpf, x) while ee most often presents with greater than - eosinophils per hpf. case report the patient is a and one half year old boy who has experienced severe symptoms of gerd from the age of months. he vomits after meals at least - times per day. he coughs when he lies down at night and regurgitates phlegm in the early morning. he has complained of discomfort in his lower chest after eating. his weight has remained at pounds for the last six months. the patient was diagnosed with asthma at age and a half; however, there is no family history of asthma or allergies. the patient initially experienced improvement on lansoprazole, but his symptoms recurred when the medication was discontinued and subsequent courses were ineffective. his physical exam was normal barring slightly edematous nasal turbinates. an endoscopic biopsy showed "numerous eosinphils" (later clarified to eosinophils per hpf) in his distal esophagus. the patient showed allergy to milk and wheat on radioallergosorbent (rast) testing. the patient was started on swallowed fluticasone puffs twice daily and advised to see a nutritionist regarding a wheat and milk elimination diet. conclusion ee is an important differential of gerd-like symptoms in childhood. to avoid misdiagnosis it is critical to evaluate the number of eosinophils present in a biopsy specimen to help differentiate between gerd and ee. children with ee are at increased risk of developing esophageal dysmotility and esophageal strictures. patients often have positive skin prick or rast tests to foods and aeroallergens. alternative treatments such as food elimination diets and glucocorticoids (systemic or topical) are effective in treating symptoms which may not respond to reflux medications. introduction in asherton introduced the term catastrophic antiphospholipid syndrome (caps) to describe patients sharing clinical evidence of multiple (three or more) organ involvement and/or histopathological evidence of multiple vessel occlusions. case report we present a year old female, with lumbar pain, arthralgias, weight loss, fever, malaise, raynaud phenomenom, alopecia, oral ulcers and hepatomegaly. on arrival, she was polypneic with tachycardia, basal hypoventilation, and hepatomegaly was evident. hb: . , leucocytes: . , total lymphocyctes: , , total neutrophyles: , , platelets , . coombs positive. urin exam: proteinuria, leucocyturia and erythrocyturia. creatinine . . diagnosed as sle with pericarditis, cardiac failure and acute pulmonary edema, urinary tract infection and pneumonia, requiring mechanical ventilation and inotropic support, intravenous gammaglobulin and hydrocortisone. acute renal failure and hemodialysis was begun with improvement. suddenly she presented seizures crisis, stuporous, livido reticularis skin and acrocyanosis, external opthamalplexia, bilateral facial diplexia, ocular fundus with arteriolar vasospasm. right facio-corporal hemiparesia, cortical and progressive medular annals of allergy, asthma & immunology segment changes. ct showed multiple left fronto-occipital parietal hypodensities suggestive of lacunar infarcts. diagnosed as neurolupus and caps. initially anti b glp and anti clp were negative with later positivization. urinary tract infection contraindicated high doses of steroids and, intravenous gamaglobulin and anticoagulation were started. with significant improvement. currently the patient is evolving in a satisfactory way. discussion the literature establishes that catastrophic aps is characterized by elevated mortality. in this patient damage was evident to the cns, pns, kidneys and the skin. with the presence of positive antiphospholipid antibodies with an energic antiinflamatory, immunoregulatory and immunosupressive therapy, the function of each affected organ completely recovered. this case exemplifies that the therapy of caps should be undertaken in a sufficient and early manner given the elevated mortality of this syndrome. patient, a -year-old white, male non-smoker physician on high-dose regimen of advair and singulair presents with an -day history of progressive chest tightness. pulmonary function tests showed normal (fev of %) lung function. in the past, whenever inhaled steroid dosages were lowered, patient experienced a reoccurrence of asthma symptoms, despite consistently normal lung function results. to rule out the possibility of a psychologically induced asthma exacerbation, the patient's fractional concentration of exhaled nitric oxide (feno) levels were measured. the patient's feno level was elevated at . ppb. values greater than ppb have been described as consistent with airway inflammation. with an increase in the patient's inhaled steroids, the patient had a remission of symptoms within a week. this case is illustrative of an increasingly common clinical picture where a symptomatic asthmatic may have normal spirometry but elevated feno. as devices for measuring feno become more available in the outpatient clinic setting, elevated feno may be an excellent diagnostic marker in assessing whether airway inflammation is being adequately treated in situations where spirometry values are within normal ranges. introduction the autoimmune thrombocytopenic purpura (atp) is characterized by thrombocytopenia and megakaryocytic hyperplasia. the first choice of treatment consists of intravenous gamma globulin (ivig), corticosteroids and anti-d antibodies and the second line measures are immunosuppressant drugs, splenectomy and danazol. case report a years old male presented in the first year of life ecchymosis in several parts of the body intermittently. in april he presented ephistaxis and lower gastrointestinal bleeding. complete blood count showed platelet count of , /ul. prednisone was started ( mg/kg) with no improvement. at that time, danazol, anti-d antibodies, and ivig ( g/kg) were added. subsequently, the platelet average count diminished to , . the patient was transferred to our hospital. at his admission he presented cushingoid habitus (figure ) and acanthosis nigricans. the immunological tests (aan, ch , c , c , immunoglobulins, anticardiolipins and b glycoprotein) showed no alterations. bone marrow aspirate demonstrated megakaryocytic hypercellurarity. prednisone dose was tampered when the patient presented secondary glaucoma. patient continued his treatment with danazol and ivig ( dosages of g/kg each), hydroxychloroquine and cyclophosphamide with no improvement. thus, months after the immunosuppressant treatment, splenectomy was performed, obtaining partial improvement. at that time ranitidine and hydroxychloroquine were suspended and cyclophosphamide was changed to azathioprine. last platelet count was , /ul. conclusion chronic atp in childhood as the present case account for approximately - % of the total atp patients. chronic atp that does not respond to conventional treatment is a therapeutic challenge. in this patient we used first choice and second choice drugs with no improvement, consequently a splenectomy was indicated, not obtaining the desired response at first. the use of immunosuppressant drugs is not common for this disease, but it could be a good alternative for atp resistant to conventional treatment. this are the most important laboratory test of our patient. background: budesonide is the only corticosteroid available for inhalation by jet nebulizer and is indicated for the treatment of asthma in children. objective: to evaluate the distribution and clinical efficacy of inhaled budesonide administered by nebulization with a modified commercial device. methods: a year old male with severe persistent asthma underwent a lefort procedure for multiple craniofacial abnormalities. the external device maintained his mouth open impeding the proper use of controller medications. as a result he developed an increase in his asthma symptoms. he was subsequently treated with nebulized budesonide delivered with a modified jet nebulizer through the end of a plastic tube in a flow-by manner. we then performed dynamic ventilation imaging after administering . mci of nebulized technetium m-dtpa diluted in two ml of normal saline. images were obtained for five minutes at three seconds per frame. spirometry monitoring was not possible given the obstructive nature of the facial device. results: the patient demonstrated improvement of his asthma symptoms. the ventilation scan showed that the patient breathed the technetium dtpa through the specialized device with delivery to his full lung volumes within seconds. conclusions: we report the successful treatment of a patient unable to use the commercially available methods for administration of inhaled steroids. rationale: hp is a non-ige mediated inflammatory response in the lungs due to a variety of organic antigens, including metal working fluids. the wideranging clinical features include acute, subacute, and chronic forms. elevated antineutrophilic cytoplasmic antibodies and platypnea, defined as dypsnea induced by the upright position and relieved with recumbency, have not been previously reported in patients with hp. case: -year-old white male tool and dye machinist presented with progressive cough, weakness, dyspnea on exertion, and platypnea. symptoms began weeks earlier with coryza and diffuse myalgias. he had lost % of his body weight since symptom onset. examination revealed a pulse of , respiratory rate , and right basilar crackles. resting pulse ox on room air was %, but dropped to % upon ambulation. pft's revealed severe obstruction (fev % predicted) with significant reversibility (fev + %), and a dlco of % (adjusted for va and hemoglobin). hemoglobin was . with a normal leukocyte count and differential. c-anca (anti-pr ) was . (< ), and p-anca (anti-mpo) was . (< ), both performed by elisa. echocardiogram showed an ef of - % with mild pulmonary hypertension; no shunt was present. chest roentogram was normal, but a chest ct revealed a diffuse ground-glass pattern with scattered centrilobular opacities. biopsy was consistent with hp. he was removed from his work exposure to metal working fluids with full recovery of lung function and resoulution of symptoms. conclusions: hp presents as a constellation of symptoms without a single, unique identifying pattern. platypnea and elevated anca's have been observed in a wide range of disorders, all of which were excluded in this patient. platypnea has been associated with hereditary hemorrhagic telangiectasia, pulmonary avm, hepatopulmonary syndrome, recurrent pulmonary emboli, and patent foramen ovale. elevated anca's has been associated with wegener's granulomatosis, goodpasture's syndrome, churg-strauss vasculitis, drug-induced vasculitis, inflammatory bowel disease, and others. elisa is a more specific modality for anca's than indirect immunofluorescence, but it is less sensitive. the possibility of hp should be considered in patients with either of these two abnormalities. rationale: heart disease is the leading cause of death in america and % of persons between and years of age have coronary athersclerosis at autopsy. the presentation in the elderly is commonly atypical. % of myocardial infarctions were silent or unrecognized in the framingham cohort. in patients and older, it is estimated that - % will present with dyspnea without any associated chest pain. we present a case of unstable angina presenting as exercise-induced asthma. case: an year-old white male with moderate persistent asthma, hypertension, dyslipidemia, and a long history of allergic rhinitis presented having had an abrupt increase in his usual exercise-induced asthma symptoms four weeks prior. asthma had been diagnosed at age with spiromety showing moderate obstruction and significant but incomplete reversibility. he had a remote history of pipe and cigar smoking, but had quit at age . he had been well-controlled since that time with his most recent regimen consisting of fluticasone mcg/salmeterol mcg diskus, one inhalation twice daily. his typical exercise-induced asthma symptoms included dyspnea on exertion and chest tightness without radiation, and were relieved with rest and albuterol. the amount of exertion needed to trigger his symptoms, however, was much less than he had previously experienced, and this remained constant during the four weeks prior to his presentation. one week prior he had a normal ecg evaluation by his primary care provider. six months prior he had a normal nuclear cardiac stress test. physical examination was unremarkale except for moderately decreased aeration and + pitting edema of his lower extremities. cardiology performed a nuclear stress test the next day which was abnormal. catheterization revealed % steonsis of his proximal lad. he succefully underwent cabg and is doing well on follow-up. conclusion: the elderly present many challenges to the diagnostician; these include multiple co-morbidities as well as atypical and often late disease presentations. the key to raising suspicion for cardiac involvement in this case was the recognition of the patient's cardiac risk factors in the setting of an abrupt onset of exercise symptoms while lacking other asthma symptoms such as nocturnal cough. cold urticaria is an uncommon form of physical urticaria. this case of a -year-old with cold urticaria and angioedema provides additional information regarding an unusual disorder in the pediatric population. an otherwise healthy -year-old female presented with a complaint of urticaria precipitated by cold exposure over the preceding weeks. she had no recent illnesses and a past medical history significant only for cat allergy. on multiple occasions the patient noted erythema and pruritus of her arms and face after walking through the freezer aisle of a grocery store. urticaria would then develop on regions where she scratched, spontaneously resolving in - hours. on one occasion, urticaria appeared diffusely while taking a shower after the patient had been swimming. the urticaria resolved within a few hours after the patient was given diphenhydramine by her mother. three days prior to presentation the patient experienced upper lip angioedema with erythema, globus sensation and difficulty swallowing after drinking a strawberry slushy. the patient denied any respiratory complaints at that time and her symptoms again annals of allergy, asthma & immunology resolved spontaneously. family history was significant for a maternal history of seasonal allergies. upon physical exam the patient was well appearing. she had - discrete urticaria on each calf. the patient's mother noted that recently these would appear on "cold and rainy" days, attributing them to the fact that the patient's pants left her lower legs exposed. the remainder of her exam was normal and dermatographism was absent. laboratory evaluation consisted of cryoglobulins and strawberry rast, both of which were negative. application of an ice cube to the patient's forearm for minutes resulted in a x centimeter wheal noted minutes after ice removal. a diagnosis of cold urticaria with associated angioedema was made. the patient's mother opted to use diphenhydramine as needed and an epinephrine autoinjector was dispensed. by months after symptom onset, the patient's only complaint was pruritus of her hands if they became too cold. no urticaria were noted. at month follow-up the patient denied any symptoms for the preceding months and had a negative ice cube test. cold urticaria in the pediatric population is a rare entity and not well understood. this case of a -year-old with cold urticaria and angioedema offers additional insight into this unusual disorder. a. khuntia * , m. mcmorris, ann arbor, mi. introduction: chronic granulomatous disease(cgd) is a heterogeneous group of disorders characterized by genetic defects in the ability of phagocytes to generate microbicidal reactive superoxide anions and its metabolites. it manifests early in life, primarily as recurrent infections, caused by catalase-producing bacteria such as staphylococcus aureus, burkholderia cepacia, and serratia marcescens and fungus such as aspergillus fumigatus. the disease may be inherited in an x-linked or autosomal recessive manner, with x-linked disease accounting for - % of cases. the us incidence of cgd is / , live births with an average age at presentation of years for xlinked and . years for autosomal recessive disease. case report: year old male with history of three separate episodes of pneumonia beginning at age . each episode resulted in a hospital admission and intravenous antibiotic therapy after failed oral antibiotic therapy. an extensive pulmonary evaluation was initiated after the third episode of pneumonia, including a chest ct, viral, bacterial and immunodeficiency studies. cbc, complement, immunoglobulins, flow cytometry, viral and bacterial studies were all normal. the ct scan revealed dense nodular opacities in the right upper lobe with surrounding ground-glass opacification and mild bronchiectasis. a subsequent bronchoscopy demonstrated necrotizing granulomatous inflammation. open lung biopsy grew burkholderia cepacia on tissue culture. the clinical history, tissue histopathology and atypical organism found on culture were all suggestive of an underlying immunodeficiency. a neutrophil oxidative burst assay was performed which demonstrated minimal neutrophil activity upon stimulation, suggestive of the diagnosis of cgd. a chemilluscence assay verified the diagnosis of cgd, with minimal fluorescence noted on flow cytometry after neutrophil stimulation. dna analysis demonstrated a p -phox deficiency, resulting in one of the autosomal recessive and less clinically severe forms of the disease. conclusions: this case of cgd is unusual because of the delayed presentation. it demonstrates the importance of a complete immunological evaluation including an evaluation for neutrophil disorders such as cgd in patients of all ages who present with recurrent and recalcitrant episodes of pneumonia, especially when atypical organisms such as burkholderia cepacia are found on culture. autoimmunity may play a role in the development of premature ovarian failure (pof), but the exact mechanism is not well understood. pof is mainly diagnosed after years of age and most women complain of secondary amenorrhea. pof has been reported in combination with presence of ana and autoimmune diseases, but rarely with jra. here we report two cases of pof and positive ana in pediatric patients, one with clinical features of jra. the first patient, an african american -year-old girl, height in th percentile, weight in th percentile, with tenosynovitis of wrists and arthritis of knees and elbows for the past two years, was referred for further evaluation and management. she did not have her menarche yet and laboratory investigation revealed positive ana. the second patient, an african american -year-old girl, th percentile for height and weight, was referred to the immunology clinic with chief complaint of primary amenorrhea and delayed development of secondary sexual characteristics and was found to have positive ana without clinical findings of jra. both patients were tanner stage for breasts and tanner stage - for pubic and axillary hair. both had elevated fsh and lh, karyotype xx and small uterus and small ovaries on pelvic ultrasound. antiovarian antibody was not detected in any of the two patients. the bone age was significantly delayed. pof in karyotypically normal women is frequently seen in combination with elevated serum ana. the clinical spectrum of rheumatoid disease associated with pof ranges from asymptomatic ana positivity to typical presentation of jra. women with pof should be monitored for the emergence of autoimmune disorders including jra, and women with jra should be followed for menstrual irregularities and signs of pof. introduction: many u. s. military personnel deployed to the middle east continue to develop infection with leishmaniasis, a parasite transmitted by the sand fly. pentavalent antimonials have been used as an effective treatment for leishmaniasis for many years. in the united states, sodium stibogluconate (pentostam) is the pentavalent antimonial of choice, and is currently being administered under an ind protocol. side effects of therapy include myalgias, arthralgias, rash, malaise, abdominal pain, pancreatitis, and hypersensitivity reactions. the true incidence of hypersensitivity reactions is not currently known. case reports: two u. s. soldiers receiving pentostam for the treatment of cutaneous leishmaniasis were evaluated in our clinic at walter reed army medical center after experiencing urticaria, angioedema, wheezing and dyspnea after medication infusion during the -day course of daily therapy. due to the concern of a potential ige-mediated reaction, skin testing was performed. after informed consent, skin testing included a prick test at full strength, followed by intradermal (id)testing. soldier # was a -year old male reporting lip swelling, throat tingling, dyspnea and chest pain - hours after treatment # / . skin testing to both lots used during the treatment course showed positive values of x mm and x mm respectively at id : . soldier # was a -year old male reporting diffuse pruritus, hives, dyspnea, and chest pain minutes after infusion # / . skin testing showed positive values of x mm and x mm respectively at id : . due to clinical symptoms and positive skin testing, therapy was discontinued in each case. one control individual showed negative testing to prick at full strength, id : , and id : . conclusion: skin testing with pentostam may provide an objective tool for accurate classification of adverse reactions as igemediated. reliance on skin prick testing alone may not be sufficient to detect pentostam skin test reactivity, as both of these patients reacted to id testing only. a prospective study including pre-and post-treatment skin testing should provide more information on the value of skin testing in providing objective evidence for an ige-mediated process and determining the incidence of hypersensitivity to pentostam. introduction: a -year-old girl with a history of multiple infections was hospitalized with respiratory distress and hypoxia. her past medical history was significant for hypothyroidism, psoriasis, asthma and multiple pneumonias. a cbc revealed an absence of lymphocytes. laboratory: t and b cell subsets showed no b-cells and very low t cells (< cells). inadequate lymphocytes were present for mitogen and antigen studies. serum immunoglobulins were normal and she had antibodies to streptococcus pneumoniae and tetanus. antibodies to rsv, influenza and mycoplasma were absent. chest x-ray revealed interstitial infiltrates bilaterally. a high resolution ct scan revealed septal thickening and confirmed interstitial infiltration. open lung biopsy was consistent with non-specific inflammation with extensive lymphocytic infiltration. bal fluids and biopsy were negative for bacteria, fungi and opportunistic pathogens. clinical course: the patient did not improve with antibiotics and steroids were started. the patient improved rapidly and was discharged to home. biochemical analysis demonstrated a deficiency of adenosine deaminase (ada), a form of severe combined immune deficiency (scid). the patient was started on replacement ada, adagen. a repeat high resolution ct scan showed some improvement. however, the patient continues to be steroid dependant to control her pulmonary symptoms. lymphocyte numbers remain low despite effective ada replacement and the absence of serum datp. she remains clinically stable and receives adagen injection twice weekly. discussion: ada deficiency is a condition, which leads to accumulation of the metabolite datp, which is toxic to lymphocytes. this disease most commonly presents in the first year of life as scid and is fatal unless treated. our case is unusual due to the late onset of severe disease, normal serum immunoglobulin and the presence of some protective antibodies. despite adequate replacement of ada the patient continues to be profoundly lymphopenic, most likely due to steroids. although we do not yet completely understand the underlying lung disease we suspect that the patient has an autoimmune process causing interstitial inflammation. background: atopic dermatitis has a broad range of differential diagnoses. human sarcoptic infestation is characterized by severely pruritic lesions of variable appearance and distribution and may masquerade as eczema. infestation may be difficult to confirm and eradicate. animal transmission has been reported as a source of human infection. objective: to report a case of persistent sarcoptic infestation masquerading as eczema and associated with delusional parasitosis. methods: a -year-old female was referred to allergy clinic for evaluation with a two year history of recurrent, pruritic rash thought to be refractory atopic dermatitis. previous ineffective treatments included topical steroid creams, lindane, topical anti-fungals and multiple otc antiitch preparations. at initial evaluation, she had widespread excoriated papules in various stages of healing over % of her body. she reputed her dog was diagnosed with recalcitrant mange, which necessitated giving him medicated baths twice daily. results: a clinical diagnosis of subacute sarcoptic infection was made and the patient was prescribed two courses of elimite followed by oral ivermectin. her rash quickly resolved except for post-inflammatory hyperpigmentation. three weeks after resolution of primary lesions, she again complained of pruritic eruptions occurring on easily accessible areas and began bringing in medicine bottles of skin debris and scabs for examination. scrapings, koh preparation and skin biopsy examined microscopically showed no evidence of sarcoptic re-infestation. a diagnosis of delusional parasitosis was made. conclusions: the animal to human transmission of sarcoptic infection seen in this patient is rare and responded quickly to appropriate treatment. despite eradication of the infection, she developed delusional parasitosis, a rare psychiatric disorder characterized by fixed, false belief of an infestation by insects or other creatures. she displayed the classic matchbox sign in which samples of skin, scabs and other detritus are brought in for examination. she is currently receiving psychiatric care. background: thimerosal is a mercury derivative that has been used since the s. it is a commonly used preservative in ophthalmic solutions, otic drops, and vaccines due to its bactericidal property. objective: to report the first case of a generalized reaction to thimerosal found in an influenza vaccine. methods: we present a patient who developed a generalized maculopapular eruption after receiving a thimerosal containing influenza vaccine. patch testing was performed to determine if there was an allergy to thimerosal. results: patch testing confirmed a type iv (t cell mediated) sensitivity to thimerosal, further supported by the prior history of a reaction to a thimerosal containing contact lens solution. the patient was asked to avoid thimerosalcontaining products, including vaccinations, unless the benefit clearly outweighed the potential risk of a reaction. conclusion: physicians need to be aware that thimerosal is found in many products including vaccinations. clinicians should also be aware that allergic reactions do occur with exposure to thimerosal even in vaccines. this is the first case report in the literature of a generalized reactions to thimerosal from an influenza vaccine angioedema is a rare condition that has been described in the literature and exists in both inherited and acquired forms. a defect of the innate immune system, more particularly the complement system, is the inciting culprit. the acquired form of c esterase inhibitor deficiency has been divided into two classes and is generally not commonly seen until after the forth decade of life. type acquired angioedema has been described in association with lymphoproliferative disorders, while type is related to excessive complement activation and consumption due to autoantibodies. our case is a -year old man referred from an outside physician for further management of idiopathic edema. he first experienced facial edema in april attributed to sweet myrrh root ingestion. subsequently, in november he developed diffuse swelling of his upper extremities and tongue without airway compromise. a minimal work-up at that time was inconclusive. he fortunately remained asymptomatic until january at which time he experienced two episodes of tongue swelling without etiology. he was seen in his local emergency department and treated with diphenhydramine, corticosteroids, and epinephrine on both occasions with gradual improvement of his symptoms. the patient was not on medications commonly associated with angioedema and did not report insect envenomation. subsequently, he was seen by his primary care physician who ordered a number of laboratory tests including a ch , which was significantly suppressed. in light of this finding, he was referred to our clinic for further evaluation. at the time of presentation to our office, the patient was symptom free. his physical exam was within normal limits. further laboratory evaluation was essentially unremarkable with the exception of comple-ment studies, which are listed in the table. our case demonstrates an elderly patient with evidence of idiopathic swelling. we arrived at our diagnosis of acquired angioedema based on clinical presentation and confirmatory serum complement levels. a low ch at time of presentation allowed us to further delineate the etiology of complement deficiency. the fact that our patient did not present with swelling until after age and the paucity of a family history of idiopathic angioedema makes the diagnosis of acquired angioedema probable. measure of serum c q level confirmed the diagnosis. introduction: certain diseases, widely believed to be of allergic etiology, including atopic dermatitis and episodes of wheezing might be the result of interplay of genetic and environmental factors, at least partially. we describe a child with a rare chromosomal disorder presenting with typical features of atopic dermatitis and recurrent mild wheeze. materials and methods: a new born african-american male was noted to have unusual facial features immediately after birth. the baby was born naturally, without antenatal and neonatal problems. on physical examination, the infant had unusual facial characteristics with tight and taut facial skin, relatively diminished facial pad of fat, pointed chin, and markedly hypertonic extremities. additionally, cardiac exam revealed mumur consistent with uncomplicated asd. frequent reassessments of the infant in the outpatient clinic were done. the child had repeated bouts of wheezing attacks, and facial rashes compatible with the diagnosis of atopic dermatitis. the wheezes were treated in the clinic with nebulaized bronchodilators, and the atopic dermatitis responded reasonably to topical steroid applications and moisturizers as needed. chromosomal analysis of the peripheral blood of the chid confirmed the diagnosis of deletion of long arm (q) of chromosome [ , xy, del ( )(q q )]. karyotypic analyses of the mother and father were normal. the child exhibited features of developmental delay, and seizure activities. anti-epileptic drugs (aed) were instituted. initial eeg was normal and the subsequent eeg showed findings of static encephalopathy. ct scan of the brain revealed absent corpus callosum. neurologic evaluations and physiotherapies were requested for improvement of fine motor skills. he did not seem to suffer from any serious infectious or immunodeficient illnesses. his cbc was normal. he continued to have fair gains in his weight, height, and head circumference. his atopic dermatitis and wheezing episodes remained under control. there were a few hospitalizations for break-through seizures and dehydration from gastroenteritis. a subsequent echocardiography confirmed closure of asd. con-clusion: a child with chromosomal anamoly, atopic dermatitis, and mild intermittent wheeze is reported. despite multiple congenital problems, the child continued to have a stable clinical course. etoposide is a chemotherapeutic agent used to treat many solid tumor malignancies. hypersensitivity reactions have been well described and there are a few reported deaths from anaphylaxis. some suggest that the hypersensitivity is an anaphylactoid type reaction as it may occur during the first dose. case reports of cutaneous complications include stevens-johnson syndrome, radiation recall and diffuse erythema. there are four cases in which diffuse erythematous papules developed after etoposide therapy. all rashes spontaneously resolved within three weeks and biopsies demonstrated keratinocytes in a starburst pattern. we report the first case of an immediate etoposide induced skin reaction that evolved into long lasting hyperpigmented plaques. pretreatement was able to prevent this immediate and late reaction on subsequent exposure to etoposide. a year old female with ovarian cancer was treated with bleomycin, etoposide and vinblastine. three hours after initiation of the third dose of etoposide, patient developed pruritic, erythematous macules on her chest, abdomen, face and extremities. the infusion was stopped and decadron administered. over forty-eight hours, the pruritic macules became hyperpigmented plaques on her chest, abdomen, extremities and face. pruritus resolved after a slow taper of prednisone. the darken plaques were treated with multiple topical preparations but persisted for about three months. biopsies demonstrated superficial perivascular infiltration of lymphocytes and a few eosinophils suggestive of a drug eruption. etoposide was considered essential for this patient so allergy was consulted. the literature supports cautious readministration of etoposide with pretreatment and slower infusion rate to prevent immediate hypersensitivity. we could not guarantee prevention of the late hyperpigmented reaction. the patient was pretreated with prednisone and cetirizine. etoposide was administered in an icu with a slower rate of infusion. etoposide was tolerated without immediate pruritus or erythematous reaction. the patient did not develop the delayed darkened plaques. cautious administration of etoposide after premedication and a slow rate of infusion prevented both the immediate and late reaction previously experienced by this patient. eosinophils normally comprise - % of peripheral white blood lymphocytes. peripheral blood eosinophilia is defined as an absolute eosinophil count > cells/mm and is most often caused by atopy, helminth infections, or collagen vascular diseases. less common causes include adrenal insufficiency and neoplastic processes. eosinophilia can be characterized as mild (< cells/mm ), moderate ( - cells/mm ) or severe (> cells/mm ). although severe eosinophilia has been reported in association with adult hiv infection, studies of hiv-infected children have not shown peripheral blood eosinophilia to be a feature of pediatric hiv infection. we report an unusual case of severe peripheral blood eosinophilia in an adolescent male who was subsequently found to be hiv-infected. a previously healthy -year-old male presented with week history of fever, diarrhea, cough, vomiting, abdominal pain, anorexia and a lb weight loss over the previous months. the patient had recently emigrated from guyana and denied sexual activity, intravenous drug abuse, or other hiv risk factors. there was no known maternal hiv infection. repeated stool specimens were negative for ova and parasites. serologies for e. histolytica, t. canis, and s. stercoralis were negative. an abdominal ultrasound, chest x-ray, serum electrolytes, and liver function tests were all within normal limits. total white blood cell was , with % eosinophils (absolute eosinophil count of , cells/mm ). elisa and western blot were positive for human immunodeficiency virus (hiv- ). cd + tlymphocyte count was cells/mm with an hiv- rna level of , copies/ml. the patients symptoms resolved over the next days without treatment. he was started on combination antiretroviral therapy (zidovudine, lamivudine, abacavir, and efavirenz). absolute eosinophil count continues to slowly decrease with the last count of , cells/mm three months following the introduction of antiretroviral therapy. severe peripheral blood eosinophilia may be a presenting feature of hiv infection in adolescents. hiv testing should be considered in cases where more common causes of eosinophilia such as atopy and parasitic infections are excluded. triad asthma is well described in adults but not in the pediatric literature. this case highlights the successful treatment of a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. a year-old female presented with severe persistent asthma, eib, allergic rhinitis, chronic sinusitis, nasal polyps, and a history of pneumonia. her asthma symptoms were minimal from age until age . she then started flovent and required increasing amounts of inhaled and oral steroids. she required courses of oral steroids per year by age . in addition, she had snoring, fatigue, chronic nasal congestion, rhinorhea, and sneezing despite treatment withallegra and rhinocort. she had received immunotherapy from age to with no clinical improvement. since age she had recurrent sinusitis and had required polypectomies. she noted aspirin caused nasal stuffiness and mild wheezing and therefore avoided it. on exam she had allergic shiners, dennie lines, boggy turbinates, nasal polyps, and diffuse wheezing. on evaluation she had severe airway obstruction. her fev increased from % to % with albuterol. her chest ct had a mosaic pattern due to severe air trapping, and her no level was . a sleep study showed severe hypopneas, and she had pan-sinusitis on ct. she had multiple positive spts, an eosinophil count of and an ige of . she had a normal sweat chloride and ph probe.the differential diagnosis included churg-strauss, abpa, cystic fibrosis, bronchiolitis obliterans, and triad asthma. after a thorough evaluation, she was diagnosed with triad asthma. with weeks of treatment with oral prednisone, her fev improved from % to %. her inhaled controller therapy was increased and she was placed on xolair. she had a polypectomy and then underwent aspirin desensitization. one year after starting treatment her fev remains %. she requires albuterol x/month and has not required prednisone. her eib, allergic rhinitis and congestion are markedly improved. she has had no further episodes of sinusitis, and a repeat sleep study was normal. in conclusion, we treated a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. this is not frequently reported in the pediatric population, and raises questions about the incidence, optimal long term treatment of triad asthma, and the differences from the adult onset of this disease. a.a. white * , r.a. simon, la jolla, ca. background: human disease from mold has traditionally been isolated to infection, allergic disease, or hypersensitivity pneumonitis. specific diseases or pathologic findings other than those listed above have not been well described. we report a case of acute eosinophilic pneumonia related to mold exposure. case presentation: a year old woman developed dry cough and shortness of breath after stachybotrys mold was discovered in her home. a chest radiograph showed bilateral upper lobe infiltrates which worsened two weeks later. treatment with macrolide and flouroquinolone antibiotics was ineffective. a white blood cell count was , /cumm with % eosinophils. an erythrocyte sedimentation rate was mm/hr. aspergillus ige was negative. treatment with prednisone led to complete resolution of the chest radiographic abnormalities and improvement in pulmonary function testing. this patient was given a diagnosis of acute eosinophilic pneumonia with mold as a likely causal factor. discussion: there is dispute amongst health care professionals regarding the significance of environmental mold contamination in the etiology of human disease. this case represents well characterized disease occurring in the setting of mold exposure. while a causal relationship cannot be established, the temporal relationship of mold contamination, symptom onset, and disease progression is compelling. interestingly, a recent report of mold contamination leading to nonspecific interstitial pneumonia/fibrosis has been described. we have observed a patient in our clinic with similar pathology on biopsy and temporal relationship to mold exposure. to our knowledge, acute eosinophilic pneumonia has not been reported in conjunction with mold exposure. conclusion: this case highlights a new condition in which mold may have a causal role. the mechanism is unknown, but likely is through a non-ige mediated immunologic pathway. public awareness of mold as a health concern is increasing. perhaps similar cases will emerge as a history of mold exposure is offered by patients at the time they are evaluated for lung disease. a stronger correlation may then emerge. scuba diving is a commonly practiced activity which normally carries only minimal risks. any severe allergic reaction such as anaphylaxis, however, occurring during this activity could be a particularly dangerous not only because the swimmer is submerged but also because of the lack of proximity to medical care. we report a case of anaphylaxis occurring during scuba diving resulting from an unsuspected hypersensitivity to a latex component of the scuba diving suit. a yr-old white male developed a severe generalized urticarial rash with angioedema of his lips and eyelids, and difficulty breathing within minutes of his applying the suit and entering the water. after being rescued, he was transported to a nearby emergency department where he received epinephrine, antihistamines, corticosteroids and iv fluids with gradual improvement over a hour period. the patient denied being stung by a marine aquatic organism and there was no prior history of allergy or medications usage prior to his reaction. since subsequent investigation revealed that the scuba diving suit contained latex (brazilian rubber), a specific ige rast was found to be strongly positive (class v) to latex. therefore, the patient was advised to use a suit made of neoprene synthetic rubber (polychloroprene) which is a nonlatex containing product. this case report illustrates the importance of a diligent search for hidden sources of latex products which can produce life-threatening allergic reactions in sensitized patients. there has been considerable debate concerning the safety of immunizing egg-allergic children with the combined mmr vaccine. this concern derives from the possibility of an anaphylactic reaction since the mmr vaccine is prepared from attenuated viruses grown on chick embryo fibroblast cell cultures. we have previously reported the safe administration of the mmr vaccine to severe egg-allergic children without development of an adverse reaction (nsouli, tm, et al. ann allergy asthma immunol. ; : ) , a finding consistent with the current report of the committee on infectious diseases, american academy of pediatrics, . the present case report describes an anaphylactic reaction in an egg allergic yr-old-white male consisting of generalized urticaria, angioedema, wheezing immediately following the administration of a second mmr vaccine. the history of hives following ingestion of eggs was confirmed by positive specific ige rast testing. the patient's anaphylactic reaction necessitated emergency treatment including epinephrine, diphenhydramine, and corticosteroids in addition to iv fluids. although the administration of mmr vaccine in egg-allergic children is not considered as an absolute contraindication, the present case report suggests that caution should be observed when administering the mmr vaccine in such patients and that careful medical observation be included together with the ready availability of emergency medical equipment. p. buddiga * , r. turbin, a. baisre, l. bielory, newark, nj. introduction: sarcoidosis is a chronic granulomatous disease of unknown etiology that may have a multi-organ system manifestation and is characterized by the histopathological evidence of nonnecrotizing granulomas. case report: a year old african american woman with a year history of type ii diabetes mellitus, hypertension and sinusitis recalcitrant to multiple courses of antibiotics over months was admitted to the hospital with complaints of right eye proptosis, diplopia, headache and right facial numbness.her exam was consistent with an ipsilateral mild optic neuropathy, complete sixth (vi)nerve palsy, trigeminal, ophthalmic and maxillary division numbness.ct and mri of the face, orbit and brain revealed an extensive process infiltrating ethmoid, maxillary and frontal sinuses;orbits and deep facial structures.chest ct revealed bilateral interstitial nodules and symmetric hilar adenopathy. differential diagnoses included sarcoidosis, lymphoma/tumor, wegener's granulomatosis or fungal infection.labs-purified protein derivative test=negative(neg), antineutrophil cytoplasmic autoantibodies=neg. angiotensin converting enzyme= [ - u/l], fungal & anaerobic and acidfast bacilli culture of sinus secretions=neg.ethmoid, adenoid and maxillary sinus biopsies=multiple nonnecrotizing granulomas. on the basis of compatible clinical and radiographic findings, histopathological evidence and exclusion of other diseases with similar findings, the diagnosis of sarcoidosis was established. she was started on parenteral methylprednisolone and subsequently tapered to oral prednisone after days.concomitantly she was started on methotrexate as a steroid sparing agent.most recent chest x-ray after months of treatment reveals near complete resolution of the hilar lymphadenopathy.at months her optic neuropathy and facial dysesthesia had resolved, and she was left with mild persistent vi nerve dysfunction. conclusion:sarcoidosis that manifests itself as sinusitis is an uncommon presentation and the mechanism involved is thought to be a consequence of the destruction of cilia and mucus producing glands by the granulomatous process.review of the literature indicates that this is the eighth case reported and illustrates that a high index of suspicion of other etiologies must be maintained when there is a refractory response to multiple courses of antibiotics in the treatment of sinusitis. j.b. hein * , p. patel, l. bielory, newark, nj. introduction: cid may result in opportunistic infections such as cryptococcal meningitis. we present an unusual case of cryptococcal meningitis in an hiv-negative patient with severe cd lymphocytopenia. case: a yearold male with a three year history of sarcoidosis presented with acute onset of right-sided body numbness. the patient had been on prednisone mg/day for months prior to presentation. ct and mri scanning showed no vascular defects, meningeal enhancement, hydrocephalus or mass lesions. gallium scanning revealed normal uptake in the liver and spleen, mild uptake in the lungs and nasopharyngeal region, and asymmetric uptake in bilateral kidneys. the patient's initial wbc was , cells/mm , composed of neutrophils/mm , eosinophils/mm , basophils/mm , lymphocytes/mm , and basophils/mm . repeat studies revealed the total lymphocyte count decreased at cells/mm with cd (pan b) cells decreased at cells/mm and cd (pan t) cells decreased at cells/mm . cd count was cells/mm and cd count cells/mm with a cd /cd ratio of . . igg levels were normal at mg/dl. elisa was negative for hiv, and hiv- rna by pcr was not detected. serum ace level was u/l and csf ace level was u/l. csf obtained by lumbar puncture stained positive with india ink and culture revealed cryptococcus neoformans. the patient responded to amphotericin b lipid complex mg/kg/day, and his neurological status eventually returned to baseline. conclusions: the severe lymphopenia in this patient caused predisposition to infection with cryptococcus neoformans. the etiology of the profound lymphopenia likely was multifactorial, including mild sarcoidosis activity (lung uptake on gallium scan) and chronic corticosteroid therapy. however, once cryptococcus became entrenched in the patient's csf, the infection itself likely depressed peripheral lymphocyte numbers even further. this case demonstrates the importance of exploring a broad differential diagnosis when faced with lymphocytopenia. background: isosulfan blue % is a common dye used in sentinel lymph node dissection. the usage of the procedure and dye has increased in numbers, and although rare, several cases of anaphylactic reaction have been reported. objective: we are reporting a patient who had an anaphylactic reaction to isosulfan blue while undergoing breast cancer excision with sentinel lymph node biopsy. methods: the patient is a year-old woman with breast cancer. she underwent breast mass excision with sentinel lymph node biopsy using the lymphazurin % blue dye (isosulfan blue). she has a history of penicillin induced hives but has no other drug allergy. as soon as the dye was injected, she became flushed, hypotensive, and tachycardic. hypotension was refractive to fluid challenge. she was then treated with epinephrine as well as intravenous steroids and cimetidine with relief of symptoms. subsequently, she was evaluated in allergy and skin tests with isosulfan blue % at : , : dilution, and undiluted were performed using histamine as positive control and saline as negative control. this procedure was also performed on two control subjects. results: the patient had a positive skin test (wheal and flare) to isosulfan blue % (undiluted) with the control being appropriately positive for histamine and negative for saline. control subjects had negative response to dye and saline and positive response to histamine. conclusions: isosulfan blue -% dye may cause anaphylactic reactions in patients undergoing sentinel lymph node dissection. . the positive skin test result to the dye plus the negative skin test responses in the controls suggests that the reaction may be immunoglobulin e (ig e) mediated. eosinophilic duodenitis (ed) and gluten-sensitive enteropathy (gse) or celiac disease (cd) are distinct clinical entities with well-defined clinical and laboratory parameters. ed is a rare condition of unknown etiology, which is manifest by eosinophilic infiltration of the gastrointestinal tract and peripheral eosinophilia. gse or cd is a form of non-ige food allergy caused by immune hypersensitivity to ingested gluten. the simultaneous occurrence of the two entities, however, is a rare event. the following presentation is a case report in which both entities were found in the same patient. an y/o white hispanic male presented with severe, chronic, colicky abdominal pain and headache of months duration. hematologic and immunologic studies were within normal limits. serum ige levels were iu/ml (n= < iu/ml), anti-endosomial ab (+), igg antigliadin: u/ml (n=: - u/ml), skin tests for food and inhalant allergens were weakly positive ( +). biopsy of the inferior third of esophagus revealed chronic moderate esophagitis; biopsy of gastric antrum revealed lymphatic hyperplasia; duodenal biopsy showed shortening of the villi with the presence of eosinophils. following treatment with esomeprazole mg bid, famotidine mg qd, montelukast md qd, lactobacillus, a diet free of gluten, rofecoxib mg qd and betamethasone for days, betamethasone the patient improved with partial resolution of symptoms. the presence of duodenal eosinophils persisted despite a gluten free diet, and continued to require repeated bursts of prednisone. since to our knowledge this is rare finding in which ed occurred in association with gse, a high index of suspicion for simultaneous occurrence of ed should be raised in any case of gse that fails to respond to a conventional gluten free regimen. we report the evaluation of a month old male presenting with a pustular rash and choking episodes from birth. by age weeks, he had experienced two pneumonias, one with fleeting infiltrates requiring intubation. persistent eosinophilia ( - /ml) and eosinophils on pustule biopsy were noted. persistence of these and subsequent rsv pneumonia and recurrent draining otitis media led to referral. physical examination showed a thriving male infant with multiple erythematous papules and pustules along the scalp, face, axilla, and trunk. eosinophilia was confirmed. quantitative immunoglobulins were abnormal for igg and ige iu/ml. peanut cap rast was kua/l. hib post-vaccination titer, t cell enumeration/stimulation, and nbt were normal. hiv testing, stool eosinophils, o&p, and hemoccult were negative. cxr, hrct, ekg, and echocardiogram were normal. pustule cultures for bacteria, virus, and fungus were negative. skin biopsy revealed numerous eosinophils in the pustule, dermis, epidermis, and perifollicular region. cd a+ and s- staining were negative for histiocytic infiltration. nemo defect/incontinentia pigmenti were considered but testing was negative and karyotype , xy. bone marrow biopsy revealed numerous eosinophils at different stages of maturation, and no myeloproliferative or neoplastic changes. bronchoscopy was remarkable for % eosinophils on balf. -hour ph probe and impedence evaluation was negative. egd with biopsy was normal except for mild eosinophilic infiltration of the proximal and distal esophagus. with the clinical picture of recurrent pruritic crops of sterile pustules and characteristic skin biopsy demonstrating eosinophil infiltration, the diagnosis of eosinophilic pustulosis (ep) of childhood was made. despite no longterm sequelae or other end-organ involvement in ep, the degree and duration of eosinophilia, and presence of eosinophils in the airways and esophagus, raises the concern for other eosinophilic syndromes. following cardiac, cns, pulmonary, and gi systems is warranted. the infants pneumonias were felt to be due to aspiration, and ear infections the result of humoral immunity nadir or draining pustules in the external auditory canals. immunoglobulin levels will be monitored. this case illustrates the heterogeneity of eosinophilic diseases and raises the question of what drives the mechanisms behind malignant and benign disease. introduction: behcet's disease is a chronic, relapsing vasculitic disease characterized by recurrent oral, genital, and gastrointestinal ulcerations, a wide variety of skin lesions, uveitis, and arthritis. pediatric cases of behcet's disease are uncommon with an estimated prevalence of in , children under the age of . although the disease in children shows similar characteristics as adults, the diagnosis of behcet's disease in the pediatric population remains a challenge. this report describes an year old girl referred to our pediatric immunology clinic for evaluation of recurrent painful oral ulcerations since the age of with no genital ulcerations. the oral ulcers would last for two weeks and heal spontaneously but would reappear to weeks later. the patient had a history of raynaud's phenomenon for the last to years and the recent onset of joint pain. physical examination revealed - white elliptoid lesions - mm in diameter on an erythematous base on the tongue and soft palate. skin examination was significant for hyperpigmented patches over the neck, abdomen, and back. there were erythematous, serpigenous lesions on the palms and punctuated necrotic lesions on the finger-tips. pathergy test was positive. laboratory investigation was unremarkable and cultures from the oral ulcers remained negative. the patient was diagnosed with juvenile behcet's disease. she was started on immunosuppressive therapy with low dose prednisone and responded. conclusion: behcet's disease is a difficult diagnosis to make in the pediatric population. this case demonstrates that in children, recurrent oral ulcerations may be the only initial manifestation of behcet, and an important clinical marker for the disease. rationale: relapsing polychondritis is an uncommon severe inflammatory condition with unknown etiology that can present in a variety of manners. we report a year old patient who initially presented with signs and symptoms of anaphylaxis to shellfish and was later diagnosed with relapsing polychondritis. case report: a year old african-american boy with a year history of asthma and fish and shrimp allergy presented to the pediatric intensive care unit on / / after an episode of severe shortness of breath. his symptoms started shortly after accidental exposure to shrimp. in the intensive care unit, he was noted to be wheezing and stridorous. an initial chest xray as well as subsequent fiber optic laryngoscopy showed sub-glottic stenosis. he was intubated and received mechanical ventilation for greater than a week. after extubation, he stated that he felt fine, but continued to demonstrate audible stridor. pulmonary function tests demonstrated extra-thoracic obstruction, laryngoscopy continued to show sub-glottic stenosis, and esophagogastroduodenoscopy showed erosive esophagitis consistent with reflux. initial lab tests demonstrated a normal eosinophil count, elevated ige ( iu/ml), and positive immunocaps testing to multiple foods. the patient was discharged home with minimal stridor and no wheezing. over the next nine months, the severity of his stridor waxed and waned, but in general it worsened in spite of a strict elimination diet and anti-reflux therapy. on / / he received an emergency tracheostomy. on / / , the patient was again admitted to the hospital. at this time he complained of bilateral knee pain as well as significant weight loss. physical exam demonstrated arthritis with effusions of both knees as well as unilateral auricular chondritis and bilateral episcleritis. antibodies against type ii collagen were positive ( . eu/ml). the diagnosis of relapsing polychondritis was suggested. conclusion: relapsing polychondritis is a rare inflammatory disorder of the cartilage and connective tissue with an unknown etiology. the wide array of presenting complaints as well as the relapsing nature of this disorder often causes significant delay in diagnosis and treatment. in our case there was a period of nine months between the initial presentation and the time when the diagnosis of polychondritis could be made. d.k. geller * , m. ballow, buffalo, ny. introduction: an yo male previously diagnosed with pandas presented to our immunology clinic for ivig. the patient was healthy until age when he developed facial motor tics associated with group a beta hemolytic strep pharyngitis. he was treated with antibiotics and the tics resolved completely. he has had multiple recurrences associated with strep and other viral infections. the tics improve or resolve completely when he is infection free. he has no history of vocal tics, attention deficit/hyperactivity disorder, or obsessional thinking or compulsive behaviors. laboratory: multiple throat cultures positive for group a beta hemolytic strep, positive antistreptolysin and antideoxyribonuclease b titers. discussion: pandas identifies a subgroup of children with an obsessive compulsive disorder and/or tic disorder whose symptoms seem to be triggered by streptococcal infections. the proposed pathophysiology is an immune-mediated mechanism in which antistreptococcal antibodies, antistreptolysin and antideoxyribonuclease b, cross react with the basal ganglia of genetically susceptible hosts. a few studies have looked at immunomodulatory therapies including ivig for neuropsychiatric symptoms including tic disorders secondary to post-streptococcal autoimmunity. we plan a trial of ivig for this patient given the recurrent nature of his tics and the relation to streptococcal and other viral infections. introduction: the chronic granulomatous disease (cgd) is an inheritable disorder of phagocyte cell respiratory burst that result in life-threatening infections. the pulmonary infection is the primary cause of death in greater that % of the cases and the role of surgery in management of this entity remains undefined. case report: a lobectomy was performed in a year-old male who presented a persistent opacity of the medial right lobe with fever, cough, malaise an rapid onset of respiratory failure; skin abcesses were concomitant. his familiar history was unremarkable. a chest tube was placed in a first instance in order to drain empyema, but no progress was observed. a ct scan showed necrotizing pneumonia of the right lung, mediastinal and retroperitoneal limphadenopathy and bronchopleural fistula. a second surgical intervention was undertaken to correct the fistula and pleural debridement was done. at this time, serratia marcenses was isolated from blood culture and lung; a primary immunodefiency was suspected. our evaluation showed nbt reduction on % and dyhidrorhodamine assay (dhra) didn't demonstrate and effective oxidative burst. the subsecuent management was based on specific antibiotic to serratia and prophylaxis with tmp-smz and itraconazole. transfer factor to improve the ifn levels was initiated. the patient's mother showed on dhra two granulocyte populations, with and without oxidative burst. a x linked cgd was consistent. medical progress was observed in the next days. conclusion: despite the poor utility showed by the surgical procedures in the complicated pneumonia in cgd patients in many series, attending to the unusual nature of the pulmonary infections and the high mortality and morbidity associated with thoracic surgery; the management of this case showed that an aggressive approach in the diagnosis combined with some procedures used in immunocompetent patients pneumonia may improve the clinical condition in cgd patients. background: takayasu arteritis is a large vessel vasculitis primarily affecting the aorta and its branches. it is most prevalent in women in the second and third decades of life. initial symptoms are systemic and often self-limited, but the disease may progress undetected over years until signs of vascular insufficiency develop. arteritis is commonly seen in the aortic arch and its branches, although the disease is a panarteritis and vascular compromise can occur in many organs. pathologically, involved vessels show intimal proliferation and fibrosis, and scarring of the elastic lamina. case report: we report the case of a year old southeast asian woman who presented with diplopia, ptosis, dizziness, and progressive dyspnea. past medical history was significant for rheumatic fever complicated by aortic valve insufficiency and hypertension. physical findings on admission included hypertension, asymmetric upper extremity blood pressure (left arm / mm hg, right arm / mm annals of allergy, asthma & immunology hg), wide pulse pressure and a harsh diastolic murmur. admission labs showed anemia (hemoglobin: g/dl, hematocrit %) and an elevated erythrocyte sedimentation rate of mm/hr. transesophageal echocardiography revealed severely dilated aortic root aneurysm with secondary severe chronic aortic valve insufficiency and calcified aortic leaflets not typical of rheumatic heart disease. resection of the aortic valve and aneurysm was performed. pathologic examination of the aortic aneurysm revealed intimal and adventitial fibrosis with focal chronic inflammation and partial loss and fibrosis of media, findings compatible with healed takayasu arteritis. the patient was started on prednisone mg by mouth daily for takayasu arteritis and discharged in stable condition. discussion: this is a case of takayasu arteritis masquerading as rheumatic heart disease. the episode of rheumatic fever was likely the initial presentation of takayasu arteritis, as the systemic symptoms of these diseases can overlap. takayasu arteritis is an insidious disease that often leads to a delayed diagnosis with considerable morbidity for the patient. since takayasu arteritis may go undiagnosed until ischemic symptoms develop, physicians should be alert to the possibility of this disease in young women to avert end organ damage and achieve early remission with drug therapy. we present a fifteen year old boy with disseminated papillomatosis and idiopathic cd + lymphocytopenia (icl). the warts have been present since he was one year old and have progressively worsened. there are more than fifty warts on each of his hands. his legs have multiple warts and about ten warts recently appeared on his lips and around his mouth. his past medical history is significant for no hospitalizations and no blood transfusions. he has never had problems with other infections, and he had a benign course of chicken pox that spontaneously resolved. he has been on cimetidine for six months without improvement. several topical therapies, including imiquimod, have failed. he has a total lymphocyte count of /ul (normal range, - /ul) and a cd + count of /ul (normal range, - /ul). the cd +, natural killer cells, and cd + cells were normal. his hiv test is negative. the serum immunoglobulins were normal as well. lymphoctye proliferation studies reveal an absent response to antigens (candida and tetanus) with a normal response to mitogens. further studies showed no other cause of cd + lymphocytopenia. this case shows that the diagnosis of idiopathic cd + lymphocytopenia should be considered in any patient with widespread viral infection whose hiv test is negative. appropriate evaluation of the cd + count should be pursued. j. ko * , a. nowak-wegrzyn, new york, ny. introduction: approximately % of children with moderate to severe atopic dermatitis (ad) have food allergies. complementary and alternative medicine (cam) is utilized by an estimated - % of patients with allergies. we present a case of a year-old boy with ad referred after receiving a diagnosis of food allergy by a cam practitioner. methods/case: a year-old boy was referred for evaluation of mild ad and possible food hypersensitivity. his ad started at year of age and was limited to the face. he was initially breast-fed and was switched to milk-based formula at months of age. solids were introduced at months of age without difficulty. he had no immediate reactions or noted worsening of ad due to foods. the patient presented to a naturopath for allergy evaluation. based on electrodermal skin testing results, he was reported to be allergic to milk, egg, peanut, rice, and beef (all of which he had tolerated previously). he was restricted from milk and egg for weeks without noticeable change in his ad, which was limited to the cheeks and controlled on topical pimecrolimus. results: his weight and height were both th percentile. physical exam was normal except for - cm dry, erythematous patches on both cheeks and mildly dry skin on flexor/extensor surfaces of both arms. skin prick testing revealed negative tests to milk, egg, peanut, and dust mite. serum ige testing was also negative. since he had no evidence of ige sensitization to commonly allergenic foods, he was recommended to continue an unrestricted diet and discontinue use of a "sippy" cup. his ad subsequently improved on a skin care regimen of postbathing moisturization and topical pimecrolimus prn. asthma and allergies are the # reason for cam use in the us. electrodermal skin testing is a method utilized by naturopathic doctors to detect allergen "sensitivity". however, in two double-blinded trials examining atopic and non-atopic patients, electrodermal testing did not correlate with skin prick testing results, regardless of inter-operator variability. conclusions: allergy patients are seeking cam treatment, and it is important for physicians to be aware of the safety and efficacy of alternative medical practices. the use of electrodermal skin testing has not been proven to detect allergen sensitivity and use of this modality should be discouraged. e.e. mcgintee * , k.e. sullivan, philadelphia, pa. introduction: hematopoietic stem-cell transplantation causes profound tcell immunodeficiency due to the rigorous conditioning involved. following transplant, the t-cell compartment is initially reconstituted through expansion of mature donor-derived t-cells. however, thymopoiesis is necessary to generate naive t-cells with a diverse repertoire. factors affecting thymic function impact the ability of the body to reconstitute the immune system. we report a case of severe t-cell immunodeficiency after two stem-cell transplants for neuroblastoma in a patient with a history of thymic hemorrhage secondary to mediastinal surgery. case: a -year-old female with a history of high-risk neuroblastoma was referred for immunologic evaluation due to a significant infectious history since completing her neuroblastoma therapy. she initially presented at months of age with a right atrial mass that was presumed to be an atrial myxoma. she underwent mediastinal surgery to resect the tumor, which was found to be neuroblastoma extending from her right adrenal gland along the vena cava. a ct scan following her surgery revealed an area of hemorrhage in her right thymus. she subsequently received high-dose chemotherapy and two autologous stem-cell transplants. her infection history was significant for multiple episodes of upper respiratory illnesses, sinusitis, and otitis media requiring myringotomy tube placement on two occasions. immunologic evaluation revealed a dramatically low absolute lymphocyte count with deficits primarily in the t-cell compartment, and reduced proliferation in response to mitogens. immunoglobulin levels were normal; she formed protective titers to diphtheria and tetanus but not to any of pneumococcal serotypes. conclusion: stem-cell transplantation often results in severe t-cell immunodeficiency. the thymus plays an important role in reconstituting the t-cell compartment with naive t-cells generated from hematopoietic stem-cells, which restores tcr diversity. as this case illustrates, damage to the thymus can significantly impair the ability to reconstitute the t-cell compartment. a.k. knight * , c. cunningham-rundles, new york, ny. rationale: this is the first case report of oxcarbazepine induced immunoglobulin deficiency. methods: a y/o white female was referred for further investigation of low serum immunoglobulin found as part of an evaluation for chronic bacterial vaginitis. she was taking oxcarbazepine for chronic pain. this was discontinued and immunoglobulin levels and b cell numbers were tested at intervals. specific antibody responses to pneumococcal vaccine were tested. results: at presentation, on oxcarbazepine, immunoglobulin levels were low [igg , iga < , and igm < mg/dl] and she had a b cell deficiency [ %, b cells (normal - %, - cells/cu mm)]. antibody response one month after pneumococcal vaccine was poor (protective antibody to / serotypes). ( %)] with protective antibody responses to / pneumococcal serotypes. she continued to have iga deficiency. conclusions: the patient's initial evaluation suggested the diagnosis of common variable immune deficiency with hypogammaglobulinemia and specific antibody deficiency. however, these defects reversed when oxcarbazepine was discontinued. it is unclear if persistent iga deficiency was a pre-existing condition, possibly predisposing her to this adverse reaction to oxacarbazepine, or induced by the oxacarbazepine. immunoglobulin deficiency is a known, though rare, reaction to carbazepine, the parent drug of oxacarbazepine; this adverse reaction can occur with its derivative oxcarbazepine as well. secondary hypogammaglobulinemia should be considered before diagnosing primary immunodefiencies such as cvid and committing the patients to lifelong immunoglobulin therapy. introduction: interferon and glatiramer acetate (copaxone) are indicated for the treatment of relapsing-remitting multiple sclerosis (ms). anaphylactic reaction has been reported as a rare complication of interferon and copaxone use. we report a case of interferon - a (rebif) and copaxone hypersensitivity associated with positive skin tests and desensitization to interferon - b (betaseron). case report: the patient is a year-old woman with asthma and allergic rhinitis who was diagnosed with ms in oct ' after an uncomplicated pregnancy and was subsequently placed on rebif. one month after starting therapy, patient developed wheezing and generalized urticaria after receiving a dose of rebif. the symptoms recurred the next day. her neurologist stopped the rebif and started her on copaxone. two months later she developed episodes of generalized urticaria. the patient was then evaluated in our center and underwent skin testing with interferon - a intramuscular (avonex), interferon - a subcutaneous (rebif), betaseron, and copaxone. she had a positive skin prick reaction to copaxone and positive intradermal skin tests to avonex ( : strength), rebif ( : ), and betaseron ( : ) after hrs. the intradermal reactions to all interferon formulations continued to progress upto hrs. her neurologist felt that she would benefit from betaseron therapy. the positive intradermal skin test to betaseron was sufficient to warrant desensitization to prevent immediate hypersensitivity reactions. she underwent subcutaneous desensitization as shown in the table. the desensitization was halted at minutes after the patient developed itching of the hands.* she returned in hrs and we restarted by administering . ml of : strength betaseron. increasing doses were given until the patient received a full therapeutic dose ( . mg in ml). she has since done well with daily doses of betaseron ( . mil units). conclusion: we report a ms patient who developed urticaria and asthma exacerbation in response to rebif and urticaria to copaxone. skin tests confirmed an ige-mediated allergic reaction. she underwent successful desensitization to betaseron. to our knowledge, this is the st report of desensitization to betaseron as well as extension to previous reported cases of systemic reaction to interferon and copaxone. pentoxifylline (ptx) is a phosphodiesterase inhibitor that has been used for ischemic vascular disease because of its effects on red blood cells and platelets. it has been used for systemic inflammatory diseases such as sarcoidosis because of its ability to inhibit production of cytokines such as tumor necrosis factor (tnf-a). we decided to offer a trial to a patient with chronic urticaria since agents that increase intracellular camp have been shown to inhibit mast cell degranulation. we report a case of a year-old female with a history of allergic rhinitis, hypothyroidism, and diabetes mellitus with recurrent episodes of chronic urticaria since adolescence. she had known allergies to various antibiotics but otherwise had an unremarkable history, family history and social history. she was being treated with fexofenadine mg qd, azelastine nasal spray, zafirlukast mg bid, hydroxychloroquine mg bid, levothyroxine mcg qd, doxepin mg qhs, metformin mg bid, and spironolactone mg qd at the time of her initial evaluation. her physical exam was notable only for scattered - cm urticarial skin lesions as well as areas of hypo and hyperpigmentation from previous excoriations. her nasal turbinates were mildly congested with dull membranes. a previous skin biopsy showed only urticaria with increased numbers of mast cells. her workup included normal cbc, urinalysis, spep and complete chemistry profile, as well as negative ana and anti-thyroid antibodies. pentoxifylline mg tid was added to the patient`s regimen. her urticaria resolved within - weeks and was no longer visible at months follow-up. pentoxifylline is a safe medication with few side effects that may benefit patients with chronic urticaria via several mechanisms, including the inhibition of mast cell degranulation and secretion of various cytokines and chemokines. the beneficial effects of pentoxifylline in the treatment of this patient`s urticaria have been seen in other patients. further study is indicated to determine which patients with urticaria are most likely to benefit from pentoxifylline, as well as elucidate the mechanisms of action by which pentoxifylline ameliorates symptoms of chronic urticaria. c.m. mjaanes * , m. boguniewicz, denver, co. we report the case of an -year-old male who since the age of years has suffered from recurrent episodes of left tongue swelling. onset of the swelling is usually abrupt, and generally occurs during the night, awakening him from sleep. he describes a sensation of pain in his tongue but denies any pruritus, throat, lip or eyelid swelling. he has no cough, dyspnea, wheezing, rash, or itchy/watery eyes. the episodes occur infrequently, approximately once every spring . they tend to resolve spontaneously within to hours, however, on occasions, the swelling has lasted for - days. the patient's current episode has been present for weeks and is progressing. today he reports more pain and increased swelling. the child reports no benefit from oral antihistamines. he was treated with dexamethasone during his initial episode and experienced gradual resolution of the swelling. he has never been treated with topical or systemic epinephrine, or additional courses of systemic steroids. there is no family history of angioedema. the child was referred for evaluation of an immunologic/allergic etiology of his unilateral tongue swelling. laboratory studies obtained early in the course of his current episode revealed the following: c level mg/dl; c level . mg/dl; c level . mug/ml; c d level . mug/ml; c esterase inhibitor function % of normal. c esterase inhibitor level . mg/dl; ch units/ml; ana : , negative; beta-tryptase < . ng/ml; total tryptase . ng/ml (all normal). initial evaluation revealed marked swelling along with erythematous and violaceous discoloration of the left lateral and anterior portions of the child's tongue. the remainder of his examination was normal. the patient was referred to the pediatric otolaryngology clinic with a presumptive diagnosis of a glossal hemangioma versus lymphangioma. he underwent a magnetic resonance imaging study which revealed a poorly defined, mass-like enlargement of the anterior and left aspect of the tongue. he was treated with a five day course of prednisolone. after initial regression of the lesion a planned surgical excision was carried out without any complications. in conclusion, this rare case illustrates the unique presentation of glossal hemangioma presenting as recurrent angioedema. highlighted are the differential diagnoses, laboratory studies and clinical features of oropharyngeal swelling. severe tongue swelling. rare skin conditions such as leprosy need to be considered in the differential diagnosis of apparent urticaria and angioedema that is atypical in appearance or response to therapy. a year old male originally from laos presented with chronic recurrent nonpruritic indurated plaques on his face and trunk, and was referred to allergy by his primary physician with a diagnosis of urticaria and angioedema to rule out an allergic reaction to foods. he was otherwise healthy and on no medication, and had a negative personal and family history of atopy. he had moved to the united states from southeast asia in , and visited for several weeks again in . he was treated with prednisone and hydroxyzine without benefit; skin testing to foods was negative, and cbc, differential, sedimentation rate, antinuclear antibody, and liver function testing was normal or negative. a skin punch biopsy from an indurated area on the back showed granulomas with clusters of acid-fast organisms on afb stain consistent with tuberculoid leprosy. as the patient was g pd deficient, he could not be treated with dapsone and was treated alternatively with minocycline mg, rifampin mg, and clofazimine mg daily. he was subsequently started on prednisone as he was determined to be having a reversal reaction; his lesions continue to improve. this patient had a rare condition, leprosy, which was confused with urticaria and angioedema. in patients presenting with atypical apparent urticaria or angioedema, especially if response to standard pharmacologic treatment is poor, a skin biopsy is indicated, and may be diagnostic as in this case. introduction: cutaneous flushing about the face of a toddler within minutes of eating specific foods prompts parents and clinicians alike to pursue food allergy testing. auriculotemporal syndrome, also known as frey syndrome, is an isolated and transient facial erythema about the distribution of the auriculotemporal nerve following mastication. we report a child who was referred for food allergy testing and was diagnosed with auriculotemporal syndrome. case history: a yo wf, prior full-term forceps-assisted delivery, has a history of facial flushing within minutes following ingestion of specific foods. the flushing can be induced by a variety of foods, specifically spaghetti, crackers, potato chips and hard candies, and typically resolves within minutes after eating. the child has no respiratory or gastrointestinal distress during the flushing episode. there is no angioedema, urticaria, or other rash elsewhere on her body. within ten minutes of eating a lollipop in clinic, an erythematous, warm macular eruption appeared in a band-like region anterior to her ear extending from her temporal bone to her mandible. this response occurred bilaterally, with a mildly greater intensity on the right side of her face. no sweating or other symptoms developed, and the flushing began to diminish after thirty minutes of observation. discussion: auriculotemporal syndrome is commonly seen in patients who have undergone facial surgery, specifically about the parotid gland. it is believed to be secondary to a disruption in the fibers of the auriculotemporal nerve. it is theorized that the nerve regeneration following an injury may join the parasympathetic fibers of the salivary gland with sympathetic fibers of eccrine sweat glands. mastication then could result in flushing and sweating over the cutaneous distribution of the auriculotemporal nerve that extends from the temporal region to the mandible, anterior to the ear. although rare in children, auriculotemporal syndrome has been associated with forceps delivery. therapy is seldom of benefit or needed, and the syndrome often resolves spontaneously over many years. conclusion: auriculotemporal syndrome leads to a cutaneous eruption temporally related to the ingestion of foods. allergists should maintain an awareness of this rare syndrome to minimize food allergy testing or eliminate unnecessary food provocation challenges or restrictive diets. m. al-ahmad * , s.s. mace, toronto, canada. introduction: ranitidine is a well-known h -receptor antagonist. anaphylactic reactions are seldom reported despite widespread use of the drug. we report a patient with anaphylactic reaction to ranitidine methods: we report a case of anaphylactic reaction with ranitidine. results: a -year-old female with a history of urticaria over one year period, presented with episodes of anaphylactic reactions of increasing severity over year, after ranitidine ingestion. the first two episodes, occurred one hour after ranitidine ingestion, began with a sensation of burning, and itching in the head followed by dizziness, hypotension and near loss of consciousness. the patient had no significant pulmonary or laryngeal symptoms. the fourth episode, occurred minutes after taking ranitidine tablet, was characterized by severe hypotension. two episodes were managed at the emergency department. a skin prick test with a crushed ranitidine tablet demonstrated a positive mm wheal response, which was negative in a control. investigations for carcinoid syndrome and systemic mastocytosis were negative. conclusion: an ige mediated allergy to ranitidine is possible. anaphylactoid reaction to ranitidine is a well recognized entity. however, to our knowledge, few cases of anaphylactic reaction to ranitidine have been described. hypersensitivity reaction to ranitidine should be considered in patients suspected of having drug-related allergy. introduction: severe combined immune deficiency(scid) and cystic fibrosis(cf) may both present in infancy with a history of failure to thrive, diarrhea, and recurrent respiratory infections. although cf is the most common genetic disease occurring in caucasians with an incidence of in births, scid is a rare condition estimated to occur between in , to in , births. we report a case of x-linked scid where the diagnosis of cf was originally entertained due to similar presentation and misleading laboratory results. case: -month-old caucasian male with month history of recurrent respiratory illnesses, fever, loose stools, thick nasal discharge and failure to thrive. this was his second admission for a respiratory infection. relevant lab results consisted of cultures which grew parainfluenza a virus on np wash and pseudomonas aeruginosa on deep throat culture, chest xray showed patchy infiltrates and a borderline sweat test of mmol/l. despite being treated with broad spectrum antibiotic coverage, albuterol and pulmozyme, his respiratory symptoms were not improving. physical exam revealed a thin infant with palpable though small lymph nodes cervical and groin, diffuse scattered rhonchi and liver edge palpable cm below the costal margin. quantative immunoglobulins were obtained and resulted as an igg of , iga of < , and igm of . review of his chest x-ray was significant for absent thymic shadow. lymphocyte count since admission ranged from - . flow cytometry revealed a cd /cd count of %, cd /cd count of %, cd of % and cd of % of all lymphocytes. t-cell stimulation tests were markedly diminished to both antigen and mitogen. a presumed diagnosis of x-linked scid was made and patient undrewent haploidentical bone marrow transplantation. subsequently, cf gene analysis resulted as negative. discussion: as outlined in the case it is essential to recognize the similarities between the presenting symptoms of cf, a relatively common genetic disease and scid, an uncommon one. although pseudomonas is seen in increased frequency in patients with cf, it is essential to recognize that it is also a leading pathogen affecting patients with antibody deficiency. review of the literature did not reveal any previous cases of individuals with scid reported as having an increased sweat chloride, nor any explanations of why this would occur. while immunodeficiency has previously been associated with some forms of dwarfism, we report the first described case of common variable immune deficiency in a patient with seckel syndrome (bird headed dwarfism). the diagnosis of seckel dwarfism, an autosomal recessive disorder, was made at months of age in this boy based on intrauterine growth retardation, proportional dwarfism, microcephaly, micrognathia, and narrow face with "bird-like" large eyes and beaking of the nose. hematologic abnormalities are reported in an estimated % of such patients, and this child developed thrombocytopenia at the age of years. by age , he had pancytopenia with hypocellular bone marrow. a low cd count ( /ul) was noted and both bactrim and neupogen were begun. his only significant infections, rotavirus and salmonella gastroenteritis, occurred at that time along with frequent otitis leading to pe tube placement at ages and but which subsequently resolved. he has never had opportunistic infections or thrush. by the age of years, he required monthly red cell transfusions for severe anemia. after several months of transfusions, the blood bank reported that he no longer had detectable blood group antibodies during crossmatch; this led to measurement of immunoglobulins. igm was undetectable with low iga ( mg/dl) and low igg ( mg/dl). he demonstrated no protective titers to any pneumococcal serotypes after either conjugated or unconjugated pneumococcal vaccines. response to diphtheria, tetanus, rubeola, and influenza vaccines was adequate. total hemolytic complement was normal. he remains lymphocytopenic (alc = /ul) with low cd ( /ul). after five doses of ivig at mg/kg monthly, platelets have remained between - k/ul and there has not been any improvement in the anemia. although the mechanism for the bone marrow failure in these patients is presumed to be chromosomal breakage, this has not been demonstrated in this child. his karyotype is xy with no chromosomal fragility or deletions detected to date. hypogammaglobulinemia should be investigated in any patient undergoing frequent transfusions who loses blood group antibodies, and suspicion of immune deficiency should remain particularly high in patients with severe growth retardation or dwarfism. n.l. rider * , t. craig, hershey, pa. the objective of this study was to assess the effectiveness of physicians at a university primary care clinic in diagnosing and managing adult patients with asthma. a retrospective chart review of adult patients from this clinic was performed. each chart was evaluated using a survey instrument developed from the national asthma education and prevention program (naepp), which consisted of queries. of the charts evaluated met our entry criteria. overall compliance with the naepp recommendations was %. adherences to the asthma guidelines in the following areas were: diagnosis ( %), treatment/disease control ( %), monitoring ( %), and education ( %). these data suggest that there is an opportunity to improve the care provided to patients with asthma, especially in the areas of asthma education and monitoring, even in a university outpatient facility. these data also suggest that naepp guidelines have not been effectively incorporated into primary care practices. b.m. wahlers * , l. sherwood, t. craig, hershey, pa. objective: our aim was to evaluate adherence to the national heart lung and blood institute (nhlbi), national asthma education and prevention program (naepp) diagnosis and management guidelines, regarding asthma admissions at a teaching hospital. methods: a retrospective chart review of patients over the age of years admitted to the hershey medical center between and with a primary diagnosis of asthma or asthma exacerbation was conducted using a -item questionnaire focused on key aspects of asthma care as outlined in the naepp guidelines. results: overall compliance to the guidelines was . %. maximal areas of compliance were noted in regards to pharmacologic treatments utilized ( %, %). much lower levels of compliance were noted in areas of patient education ( %), instruction in written action plan prior to discharge ( %), provision of peak flow meter for home use ( %), assessment of asthma symptoms and severity ( %), and inhaled steroid prescription on discharge ( %). conclusion: adequate care in terms of pharmacologic treatments is being given but sub-optimal cares in other areas of the guidelines exist. there continues to be room for improvement in regards to asthma management, most notably in the area of education, documentation of triggers, and preparation for discharge with adequate tools to monitor and control symptoms. background: asthma is one of the most common problems of childhood, responsible for a significant proportion of absence from school because of chronic illness. objective: this study was carried out among the school-aged children ( - years) in tehran schools during - , in order to determine the frequency of asthma. methods: according to the recommendation of who, a questionnaire was designed, containing standard questions, and the students were given necessary information to complete the questionnaires. the guidance and high school students completed the questionnaires but the parents of primary school students completed them by themselves. results: seven hundred and eight children out of children had asthma ( . %); this prevalence was higher in the boys ( . %), when compared to the girls ( . %). the prevalence of this disease has been estimated about . % in guidance schools, . % in high schools and . % in primary students. based on this survey, the most common clinical manifestations in asthma were included: prolonged cough lasting more than days ( . %), and exerciseinduced wheezing or dyspnea ( . %), followed by repeated dyspnea or wheezing ( . %). based on the drug responses after receiving solbutamol, the prevalence of asthma was evaluated in the range of . % in primary schools, . % in guidance schools and . % in high schools. conclusions: the prevalence of asthma is high among the students of tehran schools and it needs more careful screening programmes and either more information given to the patients and parents about the disease. in the us, asthma is the most common chronic disease of childhood and affects approximately million children. reasons for inadequate asthma control include: inappropriate therapy, incorrect inhaler technique, poor compliance with treatment, and exposure to environmental triggers. rates for asthma prevalence, hospitalization, and death are highest among children residing in inner cities, and important risk factors for asthma-related mortality include being poor and black. the communities of braddock, north braddock and rankin are among the poorest in allegheny county and are designated areas of greatest health risk. recent statistics have demonstrated an increase in the number of asthma hospitalizations in these communities: . children per , which is double the average for allegheny county and greater than seven-times the overall us rate of asthma hospitalizations. our goals were to assess asthmatic severity and appropriateness of treatment, provide asthma education, and to ensure access to healthcare for asthmatic children living in these medically underserved and predominantly african-american communities. twenty-seven asthmatic children were identified. of the children assessed % were under the age of years, % were aged - years, and % were - years of age. based on nhlbi guidelines the severity of each child's asthma was determined: % had mild-intermittent asthma, % had mildpersistent asthma, % had moderate-persistent asthma, and % had severepersistent asthma. the appropriateness of treatment based on severity was also determined. we found that % of the children with mild-intermittent asthma, % of children with mild-persistent asthma, % of children with moderate-persistent asthma and % of children with severe-persistent asthma were receiving inappropriate treatment. furthermore, of the inappropriately treated children % were undertreated. following the assessment, patients and parents were educated with regard to asthma triggers, pathophysiology, use of peak flow meters, inhaler technique and pharmacologic treatment. patients were also scheduled for outpatient follow-up care. these results demonstrate that inappropriate treatment, especially undertreatment, may be a significant cause of the increased asthma morbidity in this population and underscore the need for aggressive education and innovative methods of ensuring health care. w. li-ling * , t. keng-leong, f.c. stephanie, e. philip, singapore. background: asthma admission is an important indicator of asthma morbidity. little is known about the risk factors associated with asthma admission among high-risk asthmatics. purpose: ) to characterise the profile of high-risk asthmatics who had previous asthma hospitalization. ) to identify predictors and risk factors that are associated with asthma hospitalization. methods: data for consecutive high-risk asthmatics who were enrolled into our asthma program from october to may were retrieved from our prospective database. high-risk asthmatics were defined as patients who had a clinical diagnosis of asthma and who had at least one hospital admission for exacerbation of asthma in the preceding months or at least one severe exacerbation of asthma in the preceding months requiring unscheduled visit for beta -agonist nebulisation. a comparison was made among high-risk asthmatics who had at least one or more hospitalization for asthma in the past months prior to the asthma program enrolment with those who were not hospitalized. statistical analyses were performed using spss version . for windows. results: among high-risk asthmatics, ( . %) had at least one or more asthma hospitalization in the past months prior to the enrolment into the asthma program. hospitalization was significantly associated with female gender ( . % with asthma admission v . % without asthma admnission). a significantly higher proportion of asthmatics with no formal education ( . % v . %), primary education ( . % v . %) and secondary education ( . % v . %) were hospitalized for asthma as compared to the those who had tertiary education ( . % v . %). those admitted were predominantly in lower income group, had poor inhaler technique and have no ownership of an asthma action plan ( . % v . %). those hospitalized were also younger, median age years ( , ) v years ( , ) and had a lower first peak flow reading, l/min ( , ) v l/min ( , ) . conclusion: among high-risk asthmatics, certain population subgroups are at greater risk for hospitalization for asthma. intervention aimed to reduce asthma morbidity should take the above findings into consideration. introduction an association between asthma symptoms and air quality is well established, but controversy exists concerning the role of various air quality indicators. the association of san antonio air quality with emergency department (ed) visits for asthma at our military medical center has not been defined. the objective of this study is to determine the correlation of selected air quality indicators in san antonio with ed visits for asthma for both the general population and for the pediatric population. methods selected air quality indicators were the -hr air quality index (aqi) for ozone, -hr aqi for particulate matter < . μm, pollen counts, mold spore counts, and daily high temperature. the number of daily ed visits coded for asthma was obtained retrospectively. pediatric visits (patients < years-old) were evaluated as a subgroup. pearson correlation coefficients (r) were calculated for all data pairs. results during the days of the study period, there were visits for asthma. of these visits, were pediatric. the number of daily visits ranged from to for all visits and from to for the pediatric visits. r values for all visits were - . , - . , . , - . , and - . ; for pediatric visits, - . , - . , . , - . , and - . for the -hr aqi for ozone, -hr aqi for particulate matter < . μm, total pollen grains/m , mold spores/m , and daily high temperature, respectively. in addition to calculating r values for same-day air quality indicators and ed visits, r values were also calculated for a -day average of air quality indicators with the ed visits. for the -day averages, r values for all visits were - . , - . , . , - . , and - . ; for pediatric visits, - . , - . , . , . , and - . for the -day averages of the -hr aqi for ozone, -hr aqi for particulate matter < . μm, total pollen grains/m , mold spores/m , and daily high temperature, respectively. conclusion there was no significant correlation between the selected air quality indicators and ed visits for asthma, either for the general population or for pediatric visits. this study provides no evidence that air quality is linked to ed visits for asthma in san antonio but the degree to which air quality in san antonio affects asthma symptoms remains unclear. introduction: the aim of this study was to evaluate the level of no in the exhaled air of patients suffering from chronic cough. methods: the study was performed on young (mean age . +/- . years), nonsmoking patients with chronic cough referred to the allergy clinic for evaluation. bronchial provocation challenge with histamine was performed according to the method of ryan. exhaled no was measured on-line using a chemiluminescence analyzer (sievers, usa). all patients had resting spirometry within normal values. results: significant bronchoconstrictive response to histamine at a concentration equal to or lower than mg/ml (pc mg/ml) was found in patients ( . %). these patients had a significantly greater mean concentration of no in the exhaled air ( . +/- . ppb) than those with a pc > mg/ml ( . +/- . ppb; p< . ). receiver operating characteristic (roc) curve analysis revealed that it is possible to identify from among patients suffering chronic cough those who have significant bronchial hyperreactivity (pc mg/ml). using ppb as a cut-off value for the exhaled no concentration, the specificity for bronchial hyperreactivity was . % and sensitivity . %. conclusion: assessment of no concentration is helpful in the assessment of bronchial hyperreactivity in patients having chronic cough. l. abetz * , j. bousquet , e. juniper , e. bateman , h. boushey , w. busse , t. clark , r. pauwels , s. pedersen , . manchester, united kingdom; . montpelier, france; . ancaster, canada; . cape town, south africa; . san francisco, ca; . madison, wi; . london, united kingdom; . ghent, belgium; . kolding, denmark. introduction: the acq has been developed as a measure of asthma control for use in clinical practice or in clinical trials. the reliability, validity and responsiveness have previously been demonstrated for the original item acq, the item (minus fev question) and item (minus fev and short acting bronchodilator use questions) versions. data from the -year gaining optimal asthma control (goal) study was used to assess the predictive value of the acq s , , and item versions in determining asthma control status. method: receiver operating characteristic curves (roc curves), plotting true positive rates versus false positive rates for different acq cut-points, were used to determine optimum cut points for totally controlled and well-controlled asthma. scores for the , , and item versions of the acq were examined at . intervals. results: when predicting totally controlled asthma, the areas under the roc curves (arocc) were . / . / . for the , and item versions, respectively; and when predicting well-controlled asthma the arocc were . / . / . for the , and item versions. in both predictive models, the and item versions provided the best arocc. for the and item versions, the best cut-off point to predict totally controlled asthma was <= . , with arocc of . / . , and corresponding sensitivity of . / . and specificity of . / . , respectively. for the item version the best cut-off point was <= . , with arocc of . , sensitivity of . and specificity of . . the best cut-off points for predicting well-controlled asthma were <= . for the item version (arocc= . ; sensitivity= . ; specificity= . ), and <= point for the and item versions (arocc= . / . ; sensitivity= . / . ; specificity= . / . , respectively). conclusion: results indicate the sensitivity and specificity of the acq in predicting asthma control status. a yo black male with asthma and allergic rhinitis developed gradually worsening cough productive of clear to yellow sputum despite treatment with high dose fluticasone, salmeterol, monteleukast, and prn albuterol. asthma history was significant for an intubation at age and pneumonia at age . physical exam revealed pale turbinates and expiratory wheezes. pulmonary function test showed a severe obstructive lung defect with fev . ( %), improving by % after bronchodilator and fev /fvc ratio %. a chest ct revealed significant bronchiectasis in the right middle lobe, lingula and both lower lobes. evaluation for bronchiectasis showed normal quantitative immunoglobulins, subclasses, and humoral responses, rendering innate immunodeficiency less likely. the diagnosis of allergic bronchopulmonary aspergillosis was entertained, but ige was ku/l and aspergillus titers were negative. a sinus ct failed to show active disease, yet the patient reported chronic yellow nasal discharge despite courses of antibiotics. although he was sexu-ally active with several male partners, hiv testing was negative times, months apart. evaluation for cystic fibrosis (cf) showed no symptoms of malabsorption and a negative sweat test. other tests revealed normal - antitrypsin level, p-anca, esr, ace level, and negative sputum for afb and mycobacteria, helping to exclude other conditions such as -antitrypsin deficiency, vasculitis, sarcoidosis, and chronic infection. with no definitive answer, the diagnosis of cf was pursued, but genetic screening as well as mapping were negative. the diagnosis of primary ciliary dyskinesia was then entertained; however, a mucosal biopsy of the nose did not reveal any structural abnormalities. finally, a sperm analysis revealing azoospermia confirmed the diagnosis of young's syndrome, a rare disease with features similar to cf including bronchiectasis, chronic sinusitis and azoospermia. in young's syndrome however, there is an obstructive process rather than a lack of vas deferens resulting in azoospermia and normal sweat chloride, genetic, and pancreatic testing. this case demonstrates the importance of investigating a persistently productive cough in an asthmatic patient and the differential diagnosis as well as the appropriate work up for bronchiectasis. a final diagnosis is important since appropriate management in each situation may affect long term outcome. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: bronchial challenges are currently done in allergic asthma with allergen, histamine or metacholine.bronchial reactivity to allergens and histamine can probably be variable. purpose to evaluate if the dose of allergen and histamine triggering a significant bronchial obstruction are always correlated in asthmatic patients. methods: a vitalograph model compact has been used throughout the study. allergen challenge has been done with an acqueous solution of house dust mite. bronchial challenges with placebo (sodium chloride) histamine or allergens have been done in all patients. for the provocations with histamine or allergens the threshold dose, inducing a decrease in fev greater than % has been determined in all the cases, as well for histamine as for allergens. a second challenge has been done in all patients with a supra-threshold dose of histamine or allergen corresponding to the double of the threshold. results: provocations have been done in patients either with histamine or allergen. were allergic and non allergic. the threshold dose for histamine were between and ug. in allergic patients and and ug. in non allergic patients.in allergic patients after histamine threshold challenge mean decrease was for fev , % and for fev /vc , %. for supra-threshold dose fev decreases , % and fev /vc , %. after allergen challenge fev decreases , % and fev /vc , %. with supra threshold doses fev decreases , % and fev /vc , %. in non allergic patients there was no changes after allergen challenge. a good correlation in constriction induced by histamine or allergen either for threshold or supra threshold doses (p< . ) was observed but not between the threshold doses of histamine and allergen. conclusions: these results confirm that bronchial obstruction can be triggered by allergens and mediators that the sensitivity of fev and fev /vc for evaluation are roughly comparable after challenge and points to a better sensitivity of a supra threshold dose of allergen or mediators. allergen and histamine challenges don't give the same information. introduction: peak expiratory flow rate (pfr) and forced expiratory volume in the first second (fev ) are currently used in functional evaluation of asthmatic patients but his degree of correlation in obstructive, restrictive and mixed spirometric ventilatory patterns are not well known. the purpose of this study was to evaluate if the correlation between pfr and fev markers of global airways obstruction is comparable in asthmatic patients with obstruction restriction or both. methods: asthmatic patients, males, females have been studied by spirometry with a vitalograph compact in absence of bronchodilatory or anti-inflammatory therapy. patients have been classified in functional patterns according to vc, and fev /cv: normal : vc greater than % of expected value and fev /vc greater than %, obstructive:vc greater than % and fev /vc greater than % restrictive vc, less than % and fev /vc greater than % and mixed vc less than % and fev /vc less than % presenting a so called functional emphysema. results: according to these criteria patients were normal, restrictive, obstructive and mixed. in all the group the correlation between pfr and fev was statiscally significant (p< ) but the correlation coefficient variable. in functionally normal patients r =+ , in restrictive patients + , in obstructive + , in mixed + , and in the sub-group with functional emphysema + , . for this sub-group the correlation coefficient r allows to define fev = + , pfr. conclusions: the report between the two most usual assays of global bronchial obstruction depends on the balance between restriction, (either by interstial fibrosis or hyperinflation) and obstruction and is more close when a more marked obstruction coexist with a restrictive pattern (functional emphysema). in practice pfr has the same value that fev only in more severe cases of ventilatory failure. the dispersion of values and the standard error or regression do not allow to correlate both data in most patients. introduction: the tenor study longitudinally observes the natural history of subjects with severe or difficult-to-treat asthma. this analysis assessed the association between previous and future asthma exacerbations in tenor. methods: subjects eligible for this analysis were years of age at baseline and had at least one follow-up assessment in year and year . recent asthma exacerbations in the past months were defined as: asthma-related emergency room (er) visits, nights of hospitalization, unscheduled physician office contacts; or as a composite measure of at least one of the previous exacerbation events. relative risks (rrs) and % confidence limits ( %ci) were generated comparing exacerbations in year relative to year . exacerbation rates were defined as the number of events divided by total patient follow-up time. no adjustment was performed for baseline characteristics. results: subjects were eligible for this analysis. rrs in year vs. year were: . ( %ci: . - . ) for unscheduled office contacts, . ( %ci: . - . ) for the composite exacerbation measure, . ( %ci: . - . ) for er visits and . ( %ci: . - . ) for nights of hospitalization. over % of subjects with or more exacerbations (composite measure) in year had a similarly high rate in year compared to % of patients without an event in year who went on to have or more exacerbations in year (see table) . conclusion: tenor subjects who experienced an asthma exacerbation in year were at statistically significantly increased risk of subsequent exacerbations the following year compared to subjects not experiencing an exacerbation in year . this increased risk was consistent for all asthma exacerbation outcomes and most elevated for hospitalizations due to asthma. assessment of recent asthmarelated healthcare use is a critical component of the clinical evaluation of subjects with severe or difficult-to-treat asthma. funded by genentech inc. and novartis pharmaceuticals corp. background: preliminary studies investigating yoga and breathwork for asthma have been promising. several randomized controlled trials have shown a benefit from yoga postures and/or breathing versus control, but the control in these cases involved no intervention other than usual care. this study advances the field by providing an active control. methods: a randomized, controlled, double-blind clinical trial was conducted from october to march to determine the effectiveness and feasibility of a yoga and breathwork intervention for improving clinical indices and quality of life for adult patients with mild to moderate asthma. random assignment was made to either a -week yoga intervention that included both postures and breathwork, or a stretching control condition. outcome measures were assessed at , , and -weeks and included the mini asthma quality of life questionnaire (mini-aqlq), rescue inhaler use, spirometry, symptom diaries, and health care utilization. results: sixty-two participants were randomized into the intervention and control groups, and completed the final follow-up measures. intention-to-treat analysis was performed. significant within-group differences in post-bronchodilator fev and morning symptom score were apparent in both intervention and control groups at and weeks; however, no significant differences between groups were observed on any outcome measures.conclusions: iyengar yoga conferred no appreciable benefit in mild to moderate asthma. circumstances under which yoga is of benefit in asthma management, if any, remain to be determined. in order to investigate asthma mortality trends for the u. s. hispanic population, i have collected and graphed data from the national center for health statistics. mortality data for the hispanic population have been available for the entire united states only since and readily available for asthma only since . these data indicate decreases in deaths from asthma (j -j ) from in to in with decreases in the non-hispanic population from in to in . rates of death from asthma decreased for the hispanic population from . per , in to . in , while that for the non-hispanic population decreased from . to . . rates for non-hispanic whites decreased from . to . in . rates of death from asthma have been twice as high among hispanic women as men. rates of death from asthma for non-hispanic blacks have been more than twice as high as those for non-hispanic whites. (national center for health statistics data dictate racial terminology). data for people of hispanic origin include people of any race. these data are affected by both underreporting of hispanic origin on death certificates and undercoverage in the census and resultant population estimates for a net correction of . %. thus, rates of death from asthma have been lower and have been decreasing faster among hispanics than the rest of the population in the united states. allergic rhinitis and asthma are both highly prevalent diseases and often coexist in patients. rhinitis symptoms have been shown to impact the lower airway. as such, the impact of rhinitis on asthma control may be the greatest in patients with the most severe rhinitis symptoms. therefore, this analysis was performed to determine the impact of baseline rhinitis severity on asthma control in patients with both asthma and allergic rhinitis who received either fluticasone propionate aqueous nasal spray (fpans) or montelukast (mon) added to fluticasone propionate/salmeterol / mcg (fsc). a total of patients (> years) with persistent asthma and seasonal allergic rhinitis received fpans mcg qd, mon mg qd or placebo (pbo) in addition to fsc / mcg bid for weeks. at baseline, total nasal symptom scores (tnss) ranged from to . the analysis was restricted to patients whose pre-enrollment asthma therapy did not include fsc. regardless of baseline rhinitis severity, in patients with both asthma and allergic rhinitis, mon added to fsc resulted in no additional improvements in overall asthma control compared with fsc alone. these data suggest that optimal treatment of the individual conditions should be the goal of treatment for patients with coexistent allergic rhinitis and asthma. (sam ) introduction recent studies have demonstrated that parainfluenza and coronaviruses are as important triggers of asthma. parainfluenza viruses are one of the main triggers of virus-induced asthma at summer. parainfluenza viruses often cause severe low respiratory tract infections in immuncompromised patients and in patients with bone marrow transplantation. a retrospective study found that % of pediatric bmt patients with hpiv infection ( % of viral respiratory infections) developed pneumonia and % died. both viruses contributed to fatal asthma. materials and methods for amplification of these viruses, primers which anneal to specific regions of viral genomes: hn-gene for piv , piv and piv and spike glycoprotein gene for coronavirus oc and nucleocapsid glycoprotein gene for coronavirus e were used. pcrdiagnostics was performed on nasal and throat swabs taken from children with atopic asthma exacerbation. results from / to / a total of samples (including negative controls) were tested by pcr. positive for respiratory viruses samples noted in children having asthma exacerbations including . % of all tested samples. piv was detected in . % of all positive samples, piv in . %, and coronavirus oc in . %. piv and coronavirus e were not detected during this study. for negative controls samples were taken from children with atopic asthma in remission. all controls were found to be negative by viral pcr. conclusions respiratory viruses are an important factor in asthma exacerbations in children. piv was the most frequently detected among the positive samples. although hpiv- was less often positive than hpiv- and hpiv- infections in this study, the frequency of the detected coronaviruses may have been influenced by the seasonal activity of these viruses. introduction. in budapest all children come under the regular supervision of a specially trained paediatrician. each paediatrician is responsible for an average of children, often seen up to the age of years. methods. a questionnaire was sent to the district paediatricians of budapest in budapest in , budapest in and . the total number of children in their practice and the number of the asthmatics was assessed. the diagnosis of asthma in every case was established in a paediatric hospital, or a special allergy or pulmonology outpatient clinic. results. in , replies were received from paeditricians, who were responsible for the supervision of , children, of which . ± . % had been diagnosed as having asthma. in replies were sent by physicians, who had a total of , children under their care, including , asthmatics, a prevalence of . ± . %. at the end of , paediatricians having , children answered, noting , asthmatics, a . ± . % prevalence of asthma. conclusion. the current survey of prevalence of asthma in childhood is by far the largest that has been made. an increasing prevalence of the diagnosis of asthma based on clinical investigations was noted, the differences between the investigated years being highly significant. panel report guidelines for the diagnosis and management of asthma have been available since , to standardize and improve the quality of asthma care. however, asthma remains the leading cause of hospitalization for new york city children. implementation of the guidelines has not been fully embraced in the primary care setting. we attempted to increase primary care practitioners' compliance with the guidelines through extensive training. a hospital based pediatric clinic and school based health clinics in the brooklyn inner city, participated from april to march in the program as part of new york city's education and quality improvement project (equip). initially an asthma physician specialist and asthma educator trained the primary care physicians and nurse practitioners in the guidelines. the training was reinforced during monthly luncheon sessions. clinical exam rooms were also supplied with asthma education materials, peak flow meters, and asthma action plans. goals were to identify asthmatics, document asthma severity, give persistent asthmatics written management plans, and utilize appropriate controller medications. compliance was measured by tracking asthma visits with an asthma intake form. prior to this project no consistent attempt had been made in the clinics to regularly classify asthmatic severity, provide written asthma action plans or to place patients on controller medications. after onset of the project a total of asthma visits were evaluated; were from school based health centers and from hospital based pediatric clinic. severity was classified in %( / ) of asthma visits. patients classified as persistent received updated written management plan during %( / ) of asthma visits and %( / ) were placed on controller medications. this asthma management program demonstrated success in improving primary care practitioners' compliance with the naepp asthma guidelines. further studies are needed to determine if compliance with the guidelines persisted after cessation of the extensive training and if such compliance improves asthma outcomes. numerous studies have associated asthma and obesity. although obesity has been identified as a risk factor for asthma, there is limited information on the impact of obesity on childhood asthma. this study examines the effect of body composition on asthma severity and pulmonary function in children. we retrospectively reviewed charts from asthmatic children ages to years, referred to a community-based pediatric pulmonology practice between and . data were included if asthma was the the primary diagnosis and a baseline spirometry was available. asthma severity was classified and body mass index(bmi) was classified as normal, overweight and obese. spirometry results were reviewed. eighty-five patients were reviewed. thirtyone( . %) patients were normal weight; ( . %) were overweight and ( . %) were obese. baseline characteristics such as age, gender and race/ethnicity were similar. asthma severity classification did not differ between normal, overweight and obese children. overall, % were classified as intermittent, % as persistent mild asthma and % as persistent moderate-severe asthma. % of children with intermittent asthma were receiving controller therapy compared to . % with persistent mild and . % with moderate-severe asthma(p= . ). although healthcare utilization for asthma(emergency room visits/admissions) were significantly different between children with intermittent, persistent mild and moderate-severe asthma(p= . ), there was no difference when normal, overweight and obese children were compared. spirometry results showed comparable peak expiratory flow rates(pfr) in all groups; % of predicted in normal weight and % of predicted in both overweight and obese. mean forced vital capacity(fvc) was . %, . % and % and the mean forced expiratory volume in second(fev ) was . %, . % and . % respectively. there was no difference in fev /fvc; . %, . % and . % and forced expiratory flow in mid-lung volumes (fef - ); . %, % and . % of predicted. in this study we retrospectively reviewed asthmatic children and compared bmi, asthma severity and spirometry. we found no difference in asthma severity classification between normal and overweight/obese patients. regardless of the bmi, all indices of spirometry were similar. further studies are needed to examine the impact of obesity on different asthma related disease outcomes. our objective is to further investigate the effect of budesonide, formoterol, and levalbuterol, alone, and in combination, on tgf- production and expression in ragweed (ra) stimulated a cells. meth-ods: a cells were cultured in duplicate for hours at degrees celcius with % co in serum free dmem with or without the following: μg/ml of ra, . x - m of budesonide, . x - m formoterol, and . x - m levalbuterol. tgf- production and expression was measured by a sensitive elisa and mrna assay in cell supernatants and pellets. results: tgf- production and expression from a cells rose markedly in the presence of ra ( . - pg/ml) ( - amol/ml) with significant inhibition following the addition of budesonide, and the combinations of budesonide and formoterol, budesonide and levalbuterol, and budesonide, formoterol, and levalbuterol (p< . ). combined treatment with budesonide and levalbuterol versus budesonide alone reached significance for production and expression (p< . ). budesonide and formoterol compared with budesonide alone reached significance for tgf- production (p< . ). conclusion: combination therapy with budesonide and a long or short acting beta-agonist showed greater effect of tgf- inhibition compared with budesonide alone. this synergistic effect on the distal airways may prevent a subset of asthmatics from developing airway remodeling. g. tamura * , y. sano , k. hirata , s. ishioka , m. nakashima , t. miyamoto , . sendai, japan; . tokyo, japan; . osaka, japan; . hiroshima, japan; . hamamatsu, japan. tulobuterol tape is the world's first long-acting transdermal preparation of a beta -agonist designed to release tulobuterol in an optimal fashion. when it is applied once daily at bedtime, the blood concentration of tulobuterol peaks early in the morning and is kept at effective levels for hours. tulobuterol tape has milder and less frequent adverse events than conventional oral tulobuterol preparations, and when used at bedtime can prevent marked drop in peak expiratory flow (pef) early in the morning. consequently, tulobuterol tape has been commonly used in japan as a long-acting beta -agonist. in the present study, to evaluate its efficacy as a long-acting beta -agonist and to compare its effects at two different doses, we administered tulobuterol tape at doses of or mg/day to patients with persistent asthma already using inhaled corticosteroids. this study was a randomized, double-blind, double-dummy, parallel-group, multicenter trial of -week duration. mean pef in the and mg/day groups were significantly increased from the baseline value by . and . at week , . and . at week , . and . at week and . and . l/min at week , respectively. the increase in mean morning pef in the mg/day group was significantly higher than that in the mg/day group at every point of determination. the mean evening pef was significantly increased in both treatments groups compared with baseline values at every point of determination. although the increase in the mg/day group was greater than that in the mg/day group at each point of determination, the difference between groups was statistically significant only at week . the safety profiles of the two treatments were similar. in patients with persistent asthma who require inhaled short-acting beta -agonists while receiving inhaled corticosteroids, tulobuterol tape mg/day significantly improved pef compared with tulobuterol tape mg/day. introduction: on an average, % of the children admitted annually for asthma to children s hospital require admission to the pediatric intensive care unit (picu). these admissions are highest in the months of august, september and october. aeroallergens such as alternaria and ragweed predominate during this season, and allergies to these allergens may account for the increased number of picu admissions for asthma. objective: we hypothesized that the seasonal increase in the admission rate could be related to allergen sensitivity, particularly to alternaria and/or to ragweed that predominate during late summer and fall. method: data was collected from a retrospective chart review of all patients admitted to the picu for asthma exacerbation between and . skin prick testing (spt) within one year of picu admission was the criteria for inclusion in this study. results: there was a higher prevalence of admissions to the picu for asthma exacerbation during august, september and october ( out of admissions = % of all admissions, p< . ). sixty-one subjects met the one-year spt criteria for analysis. subjects admitted during august, september and october were categorized as group a, and all others were categorized as group b. sensitivity to a total of aeroallergens (tress, grasses, weeds, ragweed, outdoor molds, indoor molds, alternaria, cat, dog, roach and dust mites) was compared between the two groups. there was no statistical significance in aeroallergen sensitivity to alternaria or ragweed between subjects admitted to the picu in august, september and october (group a) and subjects admitted during the other months of the year (group b). conclusion: asthma exacerbation requiring picu admissions is more prevalent during the months of august, september and october. the increased rated of picu admissions did not correlate with the aeroallergen sensitivity to the prevalent allergens during august, september and october. therefore we suspect other factors such as, viral upper respiratory infections, in addition to aeroallergen sensitivity, which may contribute to severe asthma exacerbation during the late summer and fall months. k. kuzume * , shigenobu, ehime, japan. infantile wheezing may be the result of different phenotypes. the aim of this study was to evaluate the risk factors for allergies and the results of allergyrelated blood tests among infants with different types of allergy symptoms. infants were examined physically at birth and at , , , , and months of age, and questionnaires about number of siblings, the family history of allergy, and feeding methods were given. allergic diseases were diagnosed at months of age, and the subjects were divided into groups: infants with atopic dermatitis (ad) only (a group, n= ), infants with both ad and wheezing (a/w group, n= ), infants with wheezing only (w group, n= ), and infants without allergic symptoms (c group, n= ). risk factors were then evaluated. patients ( from the a group, from the a/w group, and from the w group) were given allergy-related blood tests, total serum ige levels, and rast with egg white, milk, and house dust mites at and months of age. the results of the blood tests in control subjects at months of age were compared to the other groups. as shown in table , there were more male infants in the a/w and a groups than in the c group (p< . , a/w vs. c; p< . , a vs. c). numbers of siblings were greater in the w and a/w group than in the a or c group (p< . , w vs. a and w vs. c; p< . , a/w vs. a; p< . , a/w vs. c). the rate of positive family history of allergic diseases was high in the a and a/w groups, compared to the w or c group (p< . , a vs. c and a/w vs. c; p< . , a/w vs. w). the rate of breastfeeding at months of age was high in the a group compared to the others (p< . , a vs. c). patients in the w group had lower levels of total serum ige at months of age, compared to patients in a or a/w (p< . , w vs. a/w and w vs. a). also patients in the w group had lower levels of rast with egg white at months of age, compared to patients a or a/w (p< . , w vs. a/w and w vs. a). the median of total serum ige levels at months of age was higher in a and a/w but not in w, compared to c (p< . , a/w vs. c and a vs. c). in conclusion, there were two different phenotypes of wheezing in infants before months of age. wheezing with ad might be "allergy-related", while wheezing without ad may be related to other factors. as compared to c group: a), p< . ; b), p< . ; c), p< . ; d), p< . as compared to a group: ), p< . ; ), p< . ; ), p< . ; ), p< . as compared to a/w group: f), p< . ; g), p< . ; h), p< . a group, infants with atopic dermatitis only; a/w group, infants with atopic dermatitis and wheezing; w group, infants with wheezing only; c group, infants without allergic symptoms. rast, radioallergosorbent test, n/a, data not available r. amelio * , c. capristo , a. capasso , m. miraglia del giudice , n. maiello , f. decimo , . naples, italy; . napoli, italy. forced oscillation technique (fot) is considered a sensible and specific method to estimate breathing functionality in asthmatic children aged to years, because it doesn't need special collaboration. the aim of our study was to value baseline respiratory resistances with the fot in preschool-aged children with asthma under high dose of budesonide and flunisolide treatment. at this purpose, asthmatic children aged to years were selected: at a first examination (t ) all the patients showed basal value fot at hz frequency (rr ) changes major or equal than % under mcg of salbutamol treatment. days before the study, children selected didn't take systemic and inhaled steroids, cromons, leukotrienes antagonists, teophylline or anti-histamines and they didn't present upper and lower airways infections; then, two weeks before run-in, all selected patients took beta- -agonists at least times per week. all the patients were divided in two groups: group i ( children) under inhalation of flunisolide mcg/kg/dose + salbutamol mcg b.i.d. for days and, for the following two weeks, under inhalation of flunisolide mcg/kg/dose + salbutamol mcg by pmdi+spacer prn.; group ii ( children) under inhalation of budesonide , mg b.i.d. + salbutamol mcg b.i.d. for days, and for the following two weeks, under inhalation of budesonide , mg b.i.d. + salbutamol mcg by pmdi+spacer prn. moreover, we gave diary-card with a simple symptoms score (at t and t ), to get the real perception of the symptoms in the course of study. however, during the treatment, children have ritired from the study. the results obtained were statistically analysed (t student's test). significant rr pre beta- -agonists and ? value reduction was obtained at t and t vs. t . group i had (at t ) such a quick action than group ii reducing airways resistances (p< , ). children treated with flunisolide had lower frequency of breathless and nocturnal cough at t and lower salbutamol use from t to t than budesonide group (p=n.s.). in conclusion, fot is actually a safety method to value efficacy of inhaled steroids in preschool-aged children with asthma. introduction: approximately . % of u.s. adults and . % of louisiana (la) adults have current asthma, and over % currently smoke cigarettes, according to the behavioral risk factor surveillance system (brfss). the purpose of this study is to compare asthmatic smokers vs. nonsmokers in la and the u.s. here we address whether asthmatic smokers utilize more medical care services in the er and outpatient clinics, and whether they were able to fully participate in activities of daily living compared to nonsmoker asthmatics. methods: brfss is a state-based, telephone survey of u.s. adults. the survey collects self-reported information about modifiable risk factors for chronic diseases. this study analyzed data from the brfss survey using sas software. data: out of the current asthmatics, % are cigarette smokers in the u.s. in louisiana, % of asthmatics are currently smoking, which is significantly higher than the national average (p< . ). within the past year, the average number of emergency room visits due to asthma was similar for both locations (la . , us . , p= . ) . nationally, smokers visited the er significantly more frequently than nonsmokers (s . , ns . , p< . ). in la, smokers visited the er twice as often as nonsmokers (s . , ns . , p< . ) the number of annual routine outpatient checkups for asthma was similar based on location (la . , us . , p= . ). smokers and nonsmokers had a similar number of checkups nationally (s . , ns . , p= . ) and in louisiana (s . , ns . , p= . ). the number of days where asthmatics were unable to perform their usual activities was significantly fewer in la than nationally (la . , us . , p< . ). smokers had a significantly higher number of missed days nationally (s . , ns . , p< . ). in la, there was not a significant difference in the number of missed days based on smoking status (s . , ns . , p= . ). conclusion: even though louisiana has a lower prevalence of asthmatics compared to the national average, significantly more of our asthmatics are smokers. asthmatic smokers in la and the u.s. utilized the er more than their nonsmoking counterparts. smokers and nonsmokers had similar numbers of routine outpatient visits. asthmatic smokers missed more days, but this was only significantly different at the national level. other research has shown that young age is highly associated with improper use in children using a mdi and holding chamber (arch pediatr adolesc med ; : ) . the objective of this study was to compare health outcomes achieved by children with asthma using inhaled corticosteroids (icss) delivered by a nebulizer compared with outcomes of children using icss delivered by non-nebulized device. methods: using a managed care organization database (pharmetrics integrated outcomes database), we identified children aged years with an asthma diagnosis and asthmarelated hospitalization/emergency department (ed) visit (july -june and with a prescription claim for an ics within days of discharge. we compared relative risk of hospitalization/ed recurrence from day - (cox proportional hazards regression, covariates=sex, age, current and prior asthma medications, prior oral corticosteroid and short-acting -adrenergic agonist use, initial type of index event) for patients receiving nebulized ics vs other ics by age groups ( - years and - years). results: of patients with claims for ics, received nebulized ics, of which were aged years; received non-nebulized ics, of which were aged years. postindex hospitalization/ed rates were . %. refill rate was higher for patients using nebulized ics. after model risk adjustment, patients using nebulized ics had a % risk reduction for hospitalization/ed recurrence vs those not using nebulized ics (hr: . , % ci: . , . ). in the -to -year age group, patients on nebulized ics had a % risk reduction compared with patients not using nebulized ics (hr: . , % ci: . , . ). in the -to -year age group, patients on nebulized ics had a % risk reduction (hr: . , % ci: . , . ). conclusion: in actual practice, treatment with nebulized ics after an asthma exacerbation is associated with a significant reduction of recurrent hospitalization/ed visits in young children, possibly due to improved technique and compliance. introduction: tenor is a -year, multi-center, cohort study of patients with severe or difficult-to-treat asthma. the objective of the tenor study is to better understand the natural history of patients with severe or difficult-totreat asthma. this analysis assessed the frequency of skin testing in this population and characterized the differences between the positive (st+) and negative (st ) subjects. methods: subjects were asked whether they had ever been skin tested and, if so, the test results. those who were st+ were compared to both st and those never tested (stnd) using clinical and other asthma-related characteristics. subjects years of age were included in this analysis. results: subjects were eligible for this analysis. . % were skin tested in the past, with stnd frequency of . % from allergist sites and % from pulmonologist/other sites. of those tested, . % were positive (allergist . %, pulmonologist/other . %). baseline ige for st+ subjects was . iu/ml vs. . iu/ml for st ; p< . (table) . as shown, the age at asthma onset, duration of asthma, rate of atopic disorders, and the rate at which asthma was triggered by aeroallergens differentiated the st+ from the st group. disease severity as evaluated by fev , healthcare utilization, and medication use, however, was similar between the two groups. in general, stnd were more likely to have values closer to the st+ group, suggesting that the majority of those not tested would have been st+, if administered a test. conclusions: the prevalence of st+ subjects from both allergy and pulmonary practices was high, demonstrating that the majority of these severe or difficult-to-treat patients have allergic asthma. st+ patients showed differences in clinical characteristics compared to st , including a greater likelihood of their asthma symptoms being triggered by aeroallergens. these data also show that the clinical profile of stnd patients may be similar to that of st+ patients, suggesting the utility of a more universal allergic evaluation in severe asthmatics. funded by genentech and novartis pharmaceuticals corp. background current national guidelines for the diagnosis and management of asthma such as the naepp epr , classify asthma severity based on frequency of asthma symptoms, medication use, and measurements of lung function by spirometry or peak expiratory flow variability. recently, the utility of spirometry measurements for assigning asthma severity has come into question. here we evaluate the correlation of spirometry measurements with asthma severity in school-aged children who are mostly naive to anti-inflammatory therapy. methods children were participants in a school-based lowincome asthma mobile van program, the breathmobile. recruitment was through referrals by school nurses and community public health clinics, parental response to flyers, and asthma screening questionnaires. spirometry was performed on all children greater than years of age as part of a comprehensive asthma evaluation. asthma severity was assigned based on symptoms only, according to the naepp epr . results from april to april of the children evaluated on the breathmobile, patients were diagnosed with asthma. classification of severity by symptom frequency according to naepp epr guidelines resulted in % as mild intermittent (mi), % as mild persistent (mip), % as moderate persistent (mop), and % as severe persistent (sp). the percentage of patients and their mean lung functions at baseline evaluation without bronchodilator challenge are shown in the table. there were statistically significant differences (p<. ) between severity groups which was most pronounced for the fef - % when comparing the severe persistent group and the intermittent group. however, mean values appear to be "normal" for all degrees of asthma given current accepted cut-off values, fvc %, fev %, fev /fvc %, and fef - %. conclusion in our study, airflow impairment did correlate with asthma severity, although it was "normal" (fev %) even in children with severe persistent asthma. therefore, a "normal" lung function measurement may be misleading as sole criteria for asthma severity classification. perhaps a higher cutoff point (fev < %) might be a better indicator of asthma severity in children. asthma is the most frequently chronic disease in childhood.our main was to know the prevalence of bronchial asthma in children ( - and - years) in the north zone of mexico city and to compare the prevalence obtained by the written questionnaire versus the video questionnaire in the group of to years, according to methodology proposed by isaac. material and methods: by means of a validated and standardized questionnaire (isaac) that was applied to children from to years and from to . the questionnaires of and years were filled out by their parents. the group from to years answered a questionnaire and a video questionnaire. according to isaac specification and based on a studied population, it was calculated by statcal program the size of the sample. it was choose a haz-ardous sample of children between - years and of the - group years, both sexes in elementary and high school. measures of central tendency and chi were used. results: the final sample size for both groups was children ( of - and adolescents), . % men and . % women. the prevalence of the asthma diagnosis for teenagers was of % (p< . ic . - . ) and it was . % in children (p< . ic . - . ), wheezing in the last months was . % (p< . ic . - . ) in children and of . % (p< . ic - . ) for - years. wheezing induced exercise appeared in . % (p< . ic - . ) in teenager and . % (p< . ic . - ) in the other group. the severity of asthma showed by nocturnal awakness was . % and . % (p< . ), number of crisis in the last year . % and . % for children and teenagers respectively (p< . ). in the video questionnaire of teenagers . % (ic . - . ) answered affirmative on have displayed a shaken breathing on the last year resting and only . % (ic - . ) in the last month. about exercise question . % confirmed have displayed symptoms, . %(ic - . ) in the last year and . % (ic . - . ) in the last month. wide-awake at night . % (ic . - . ) in the last year and . % ) in the last month. conclusions: the prevalence of asthma by diagnosis was higher in teenagers group than in children group. the prevalence of asthma was higher also in this group. rationale: we investigated the relationship of pet exposure and healthcare utilization (hcu) in a cohort of pediatric patients with severe or difficult-totreat asthma in the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) observational study. we hypothesized that pet exposure would increase hcu due to increased airway inflammation. methods: tenor is a -year multicenter cohort study of patients with severe or difficult-to-treat asthma. children ages - were interviewed at baseline regarding asthma-related hcu in the previous months. patients with pet exposure (ppe, n= ) were compared with patients with no pet exposure (pnpe, n= ). responses were analyzed using fisher's exact test. results: ppe were less likely to have severe asthma by physician assessment ( % vs. %; p= . ). in addition, ppe were less likely to have an emergency room (er) visit ( % vs. %; p= . ) or to have been hospitalized ( % vs. %; p= . ) in the previous months. more pnpe had an ige level > iu/ml ( % vs. %; p= . ). ppe and pnpe were similar with regard to presence of allergic rhinitis and skin test positivity. compared with pnpe, fewer ppe with two or more pets had er visits and hospitalizations (table) . among ppe, there were no differences in ige levels or in asthma severity related to the number of pets. conclusions: pet exposure was associated with reduced hcu in the tenor pediatric cohort, with the most pronounced effect seen in reduced er visits and hospitalizations needed by those with multiple pets. ppe had significantly lower ige levels compared to pnpe, regardless of the number of pets. these data support the hypothesis that exposure to pets may paradoxically protect individuals from the development of severe asthma. alternatively, these data may reflect a self-selection in patients with severe or allergic asthma who are likely to avoid having a pet. however, there may be other confounding factors in families with pets that confer a protective effect on asthma severity. introduction: in asthma and other chronic obstructive airway diseases, phosphodiesterase (pde ) is involved in the pathophysiology of the disease and is expressed abundantly in key inflammatory cells. inhibitors of pde are investigational, anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity, which may translate into clinical efficacy in asthma therapy. this study examined the ability of roflumilast to exert direct or acute bronchodilatory activity in patients with mild to moderate asthma. methods: this was a double-blind, randomized, placebo-controlled, crossover study consisting of three treatment periods of one day each, separated by a -to -day washout period. during each treatment period, patients with a forced expiratory volume in one second (fev ) of % to % of predicted received either oral roflumilast μg, roflumilast μg, or placebo. the fev was measured twice prior to administration and periodically up to h following treatment. after h, patients inhaled μg salbutamol from a metered-dose inhaler; fev was measured min later. adverse events, vital signs, and electrocardiogram results were monitored throughout the study. results: median baseline fev was similar for the three treatment periods. both doses of roflumilast did not lead to statistically significant differences versus placebo in the time-averaged fev over the first or up to h after drug intake (p > . ). thus, there was no evidence of a direct or acute bronchodilatory effect with either single doses of roflumilast μg or μg. in contrast, inhalation of the short-acting bronchodilator salbutamol led to a distinct improvement in fev versus baseline in all treatments groups with median fev increases of %, %, and % in the roflumilast μg, roflumilast μg, and placebo groups, respectively. roflumilast was well tolerated. conclusions: oral, once-daily roflumilast exhibits no direct or acute bronchodilatory activity in patients with mild to moderate asthma as could be achieved with short-acting -agonists. these data support the proposed mechanism of action of roflumilast as an antiinflammatory agent. south africa; . guadalajara, spain; . munich, germany; . weinheim, germany; . budapest, hungary; . konstanz, germany. introduction: phosphodiesterase (pde ) is found in key inflammatory cells involved in the pathophysiology of chronic obstructive pulmonary disease and asthma. inhibitors of the pde enzyme are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, oncedaily pde inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity. this study examined the dose-related efficacy of roflumilast in patients with asthma. methods: patients with stable asthma (forced expiratory volume in second [fev ] % to % of predicted) were enrolled in this randomized, double-blind, dose-range finding study. after a single-blind placebo run-in period of up to three weeks, patients received oral roflumilast μg, μg, or μg once daily (n = , , and , respectively) for weeks. efficacy was assessed by change from baseline in spirometric lung function fev and forced vital capacity (fvc), as well as morning and evening peak expiratory flow (pef) recorded in patient diaries. safety and tolerability parameters were monitored throughout the study. results: treatment with roflumilast led to dose-dependent and statistically significant increases in fev , fvc (both p < . ), and in morning pef (p < . ). at last visit, fev improved from baseline by ml ( %), ml ( %), and ml ( %) in patients treated with roflumilast μg, μg, and μg once daily, respectively. similarly, dose-dependent improvements of l/min, l/min, and l/min in morning pef from baseline were reached. roflumilast was well tolerated at all dose levels tested. the most frequent drug-related adverse events were headache followed by gastrointestinal disorders such as diarrhea and nausea. there were no clinically relevant changes in vital signs, electrocardiogram, or laboratory parameters. conclusions: oral, once-daily roflumilast was associated with dose-dependent, clinically relevant improvements of lung function in patients with stable asthma. roflumilast was well tolerated. j.l. izquierdo * , e.d. bateman , p. magyar , u. harnest , p. hofbauer , a. varga , c. schmid-wirlitsch , d. bredenbroeker , t.d. bethke , . guadalajara, spain; . cape town, south africa; . budapest, hungary; . munich, germany; . weinheim, germany; . tatabanya, hungary; . konstanz, germany. introduction: phosphodiesterase (pde ) inhibitors are a new class of anti-inflammatory agents for therapeutic use in inflammatory airway diseases. in several studies, the investigational, oral, once-daily pde inhibitor roflumilast has provided clinically meaningful improvements in patients with chronic obstructive pulmonary disease and asthma. this study examined the long-term safety and tolerability of roflumilast over weeks in patients with asthma. methods: patients with persistent, stable asthma (fev % to % of predicted at randomization) participated in a double-blind, randomized dose-range finding study and were treated with oral roflumilast μg, μg, or μg once daily for weeks. patients completing the -week study per-protocol, then continued treatment in this open-label -week extension study. all patients received oral roflumilast μg once daily during the extension period. adverse events (aes), clinical laboratory parameters, vital annals of allergy, asthma & immunology signs, and ecg were assessed throughout the extension period. results: a total of patients were enrolled in the -week extension study. overall, the most common aes were related to the respiratory system. only a small number of patients ( %) experienced aes that were assessed as at least likely related to study medication. the most frequent drug-related adverse events were headache, diarrhea, and nausea as reported by %, %, and % of patients, respectively. most aes were mild to moderate in intensity and transient in duration; % of patients discontinued the study due to aes. most ( %) of these aes leading to discontinuation were assessed as not related or unlikely related to study drug. out of patients, reported serious aes, which were all assessed as not related or unlikely related to roflumilast. no clinically relevant changes in clinical laboratory parameters, vital signs, ecg, or physical examination occurred. conclusions: oral, once-daily roflumilast μg administered for weeks was well tolerated in patients with persistent, stable asthma. this study provides evidence that roflumilast is associated with a low incidence of aes, which are mostly mild to moderate in intensity and transient in nature, thus, supporting the potential therapeutic use of roflumilast in asthma. paris, france; . madrid, spain; . guadalajara, spain; . harrow, united kingdom; . weinheim, germany; . augsburg, germany; . munich, germany; . kaufbeuren, germany; . konstanz, germany. introduction: in asthma, inhaled corticosteroids (ics) have been the mainstay of maintenance treatment. new therapeutic agents are needed that target key inflammatory processes in asthma as effectively as ics but overcome known limitations of ics. phosphodiesterase (pde ) inhibitors are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor for potential use in anti-inflammatory asthma therapy. this study compared the standard corticosteroid treatment of twice-daily, inhaled beclomethasone dipropionate (bdp) with oral, once-daily roflumilast in patients with asthma. methods: in a randomized, double-blind, double-dummy study, patients (forced expiratory volume in one second [fev ], % to % of predicted) received either oral roflumilast μg once daily (n= ) or inhaled bdp μg twice daily ( μg/day; n= ) for weeks. mean change (lsmean and sem) in lung function parameters fev , forced vital capacity (fvc), and morning and evening peak expiratory flow (pef) from baseline was determined after weeks of treatment. further, symptom score and rescue medication use were assessed. results: both roflumilast μg and bdp μg improved fev from baseline to clinically meaningful levels ( ± ml and ± ml, respectively; both p< . ). similarly, roflumilast and bdp improved fvc ( ± ml and ± ml, respectively; both p< . ) as well as morning and evening pef (p . ). roflumilast μg was statistically non-inferior to bdp μg. roflumilast and bdp led to statistically significant and comparable improvements in asthma symptoms and use of rescue medication. adverse events were generally mild to moderate; the most common drugrelated adverse events reported in the roflumilast group were nausea, headache, and diarrhea. there were no clinically relevant changes in vital signs, ecg, or laboratory parameters. conclusions: roflumilast μg provided clinically meaningful improvement of lung function parameters, reduced asthma symptoms, and decreased the need for rescue medication. oral, once-daily roflumilast was as effective as inhaled, twice-daily bdp in the treatment of asthma. oral roflumilast μg was well tolerated. rationale: evaluation of medical claims from commercial health plans permits assessment of therapeutic interventions on resource utilization. this study investigated the impact of controller therapy in children starting asthma maintenance medications. the risk of obtaining prescriptions for oral corticosteroids (ocs), short-acting beta-agonists (saba) or adding another asthma therapy was evaluated. methods: this was a retrospective observational study utilizing medical and pharmacy claims from a large representative managed care plan from / / - / / . children aged - years old with an asthma diagnosis (icd- , .xx) and an initial pharmacy claim for one of the following regimens: fluticasone/salmeterol in a single inhaler, n= , (fsc), fluticasone propionate alone, n= , (fp), montelukast, n= , (mon), any inhaled corticosteroid plus montelukast, n= , (ics+mon), and an ics plus salmeterol from separate inhalers, n= (ics+sal) were included in the analysis. subjects were excluded if they had received any asthma controller medication in the months prior to the initiation of therapy. regression was used to estimate the incidence rate ratio (irr) for ocs and saba use (negative binomial) and the odds ratio (or) of adding a controller (add) and an ed or hospitalization (ip) event (logistic). all models controlled for demographics, pre-controller asthma-related medications and events, and baseline total health care costs. results: the ratios in the table with a confidence interval excluding unity indicate significantly increased use or likelihood of an event compared to the fsc cohort. controller naïve children started on fsc were less likely to add another controller than mon, fp or ics+sal, and had less use of ocs or saba than the cohorts when studied for months after the initiation of controller therapy. in addition, children treated with ics + mon had a significantly greater or of an ed/ip visit compared to fsc. conclusion: use of fp + sal (fsc) in a single inhaler assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding the potential for selective discontinuation of ics in the multiple controller cohorts. a.s. nayak * , r. nathan , j. williams , s. kundu , m. lloyd , d. banerji , . normal, il; . colorado springs, co; . bridgewater, nj. introduction: inhaled corticosteroids (ics) are recommended firstline therapy for severe, persistent asthma. systemic exposure to ics may suppress hypothalamic-pituitary-adrenal (hpa)-axis function, particularly at doses required to control severe asthma. ciclesonide (cic) hydrofluoroalkane (hfa) metered dose inhaler (mdi) is a novel and effective ics that is converted in the lungs to its active metabolite, desisobutyryl ciclesonide (des-cic). previously, in short-term studies, cic has been shown to have no effect on serum or urinary cortisol levels, which may be attributed to the low oral bioavailability, high serum protein binding and high clearance rate of cic and its active metabolite. this hpa axis analysis was part of a long-term study evaluating the safety of cic and beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallel-group, -month extension of a -week double-blind trial of patients years with severe persistent asthma. patients were randomized in a : ratio (cic:bdp) to receive cic ( g bid) exactuator or bdp ( g bid) ex-actuator. after weeks, the doses of both medications could be titrated to g bid as needed for asthma control. hpa-axis function was assessed at selected centers in a subset of patients at baseline and end of study (at month or early termination) by measuring both peak serum cortisol induced by low dose ( -μg) cosyntropin and -hr urinary free cortisol corrected for creatinine. results: data were available for a small number of patients at centers evaluating hpa-axis (table) . mean baseline levels and change from baseline to end of study values in low-dose cosyntropin peak serum cortisol levels for cic and bdp were comparable. likewise, baseline levels and mean change from baseline to end of study values in -hr urinary free cortisol corrected for creatinine were comparable among the two treatment groups. conclusion: these findings demonstrate that cic to μg daily for months is safe and has no significant effect on hpa-axis function. a. long * , a. rahman , . boston, ma; . wilmington, de. introduction: little information is available regarding the relationships between asthma severity, disease control, and compliance with medications. methods: physicians' perceptions regarding these variables were determined by internet-based general asthma medication usage survey and patient-specific asthma medication usage surveys between december and , , for physicians ( pcps, pediatricians, allergists and immunologists, and pulmonologists). the patient-specific surveys were based on chart information of randomly chosen patients per physician on controller medication. results: of patients, %, %, %, and % were categorized by their physicians as having mild intermittent or mild, moderate, or severe persistent asthma, respectively. overall, % of patients were categorized as having "very controlled" asthma and % as being "very compliant" with their current regimen. worse asthma control, decreased compliance, and increased physician visits were all associated with increased asthma severity classification. physicians reported that only % of patients with severe persistent disease (n= ) had "very controlled" asthma in contrast to % of patients with mild intermittent asthma (n= ). patients with mild intermittent asthma, and mild, moderate, and severe persistent asthma, had a mean of . , . , . , and . physician visits for asthma, respectively, within the past year. physician perception of patient compliance varied less across the groups, with % of patients with severe persistent asthma and % of patients with mild intermittent asthma being rated as "very compliant." the incidence of allergic rhinitis was similar among all severity levels (range: %- %), but patients with severe persistent asthma were more likely to have comorbid conditions, including hypertension, chronic obstructive pulmonary disorder, chronic bronchitis, and osteoporosis, compared with patients in other asthma severity levels. conclusions: decreased asthma control and rates of com-pliance, as well as increased physician visits and comorbid medical conditions, may be associated with increased asthma severity classification. rationale: children with asthma frequently have co-morbid allergic conditions requiring medications. the purpose of this study was to assess whether the controller asthma medication selected would reduce the utilization of intranasal steroids (ins) and prescription nonsedating antihistamines (nsa) for children treated for co-morbid allergy. methods: this was an observational retrospective study that utilized the pharmetrics integrated outcomes database that contains administrative medical and pharmacy claims data from over managed care plans across the united states. children age - years old with a new diagnosis of asthma (icd- , .xx) were identified and observed for months after their initial diagnosis and treatment of asthma (post-index). four cohorts were established based on their controller medication dispensed: montelukast, n= (mon), fluticasone propionate, n= (fp), fp+mon n= , fp/salmeterol in a single inhaler, n= (fsc). results: baseline comorbid diagnosis of allergic rhinitis was observed in - % of the children. the patterns of use of ins and nsa were similar in the months before and the months after the initial asthma diagnosis and treatment. children with a diagnosis of allergic rhinitis were nearly twice as likely to receive a nsa or ins. all treatment cohorts used a similar amount of each allergy medication. the presence or absence of a diagnosis of allergic rhinitis did not alter the findings. the adjusted odds ratio ( %ci) of using a nsa or ins relative to the use of fsc in the post-index period was mon: . ( . , . ); fp: . ( . , . ); fp+mon: . ( . , , ). the table below shows the percent of children dispensed a nsa and/or an ins. the number of units of each allergy medication was also similar across all cohorts. conclusion: the use of mon, fp, fp+mon or fsc for asthma did not alter the rate or quantity of either intranasal corticosteroid or nonsedating antihistamines dispensed to children over the -month period. although allergic rhinitis is a common comorbidity of pediatric asthma, the selection of a regimen containing montelukast did not reduce the use of either nsa or ins compared to asthma treatments with fp or fsc. rationale: medication compliance is recognized as a significant challenge in pediatrics.the purpose of this study was to compare inhaled corticosteroid (ics) persistence in pediatric patients using a single inhaler, containing both an inhaled corticosteroid (fluticasone propionate, fp) and an inhaled long-acting beta-agonist (salmeterol, sal) (fsc), to patients receiving fp alone, fp + sal from separate inhalers, or ics + montelukast (mon). methods: retrospective -month pre-post database study utilizing medical and pharmacy claims. a total of subjects - years of age with a diagnosis of asthma (icd ) were grouped into cohorts: fsc [n= ]; fp only [n= ] ics+sal [n= ]; and ics+mon [n= ]. patients were controller naïve for months prior to the index event (the first prescription of the medication of interest). subjects were required to have continuous enrollment of months pre-and months postindex. subjects with cystic fibrosis, copd, bronchopulmonary dysplasia or respiratory distress syndrome were excluded. ics refill rates, as a measure of persistence, were compared between fsc and the ics components of the other cohorts over a -month follow-up period. results: mean refill rates over the -month follow-up period was significantly greater (p=< . ) for fsc ( . ) compared with the mean ics refill rate in the fp alone ( . ) cohort, the ics + sal ( . ) and the ics + mon ( . ) cohort. patients on fsc filled % more ics prescriptions than patients on fp alone, % more than ics+sal and % more than ics + mon. mean refills were generally higher than the median fills as a considerable number of children had only one fill: fsc ( . %), fp ( . %), ics ( . %) + sal ( . %), ics ( . %) + mon ( . %). conclusion: patients using fsc, are likely to fill their inhaled corticosteroids more often over -months compared with patients using ics + sal in separate inhalers, ics+mon, and fp as monotherapy. improved persistence with ics has been shown in other studies to decrease morbidity and mortality of asthma. use of fsc, a single inhaler, assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding selective discontinuation of ics that may occur when two medications are dispensed. the national health interview survey (nhis) estimates . million united states residents with asthma. noncompliance with treatment has been estimated as between and %. the consequences of noncompliance include absences from work or school, increased emergency room visits, more severe attacks, increased drug side effects, greater cost of care, and death. we questioned compliance in a yo man with severe, prednisone dependent eosinophilic asthma because he had persistent symptoms despite treatment with fluticasone propionate/salmeterol xinafoate / bid, prednisone mg to mg qd, and budesonide ( mcg/puff) puffs bid. after discontinuation of budesonide and prednisone and initiation of methylprednisolone mg bid for hours and then mg qd and beclomethasone dipropionate puffs ( mcg) hfa bid with a spacer, clinical improvement was unexpectedly abrupt. fev increased from % to % of predicted. sputum eosinophil counts decreased from % to %. because of the sudden improvement with the change to methylprednisolone, compliance to prednisone and fluticasone was questioned. to evaluate compliance, the patient's blood, urine, and sputum were tested for synthetic corticosteroids, without his knowledge, using mass spectrometry. the blood level of methylprednisolone was . mcg/dl and prednisolone was . mcg/dl, documenting use of methylprednisolone and the recently discontinued prednisone. the urine levels were mcg/dl of methylprednisolone, . mcg/dl of prednisolone and . mcg/dl of prednisone that further confirmed recent use of prednisone. the sputum testing revealed . mcg/dl beclomethasone, mcg/dl fluticasone and . mcg/dl methylprednisolone confirming compliance to inhaled fluticasone and beclomethasone at the time of the test. thus, contrary to our clinical suspicion, the patient was indeed compliant with his inhaled glucocorticoids and prednisone and subsequently with the methylprednisolone. to our knowledge, this is the first case report to document compliance to inhaled and oral corticosteroids by analysis of synthetic corticosteroid concentrations in blood, urine, as well as sputum. if compliance could be documented with certainty, it could potentially minimize the adverse effects of needless escalating steroid doses, reduce the cost of treatment, and minimize morbidity and mortality as well. rationale:the burden of pediatric asthma extends beyond those children with an asthma diagnosis. children with wheezing frequently have a delay in the diagnosis of asthma that may impede instituting appropriate therapy and reducing disease morbidity. this observational study was designed to assess the treatment patterns of children - years old receiving asthma medication(s) without a diagnosis of asthma compared with children diagnosed with asthma and children without claims for asthma. methods:this was a retrospective cross-sectional study that utilized the pharmetrics integrated outcomes database containing administrative medical and pharmacy claims data from over managed care plans across the united states. three cohorts were selected: children with an asthma diagnosis (icd- , .xx) (dx cohort), children with prescription claims for asthma controllers or rescue medications without an asthma diagnosis (rx cohort) and children with neither an asthma diagnosis nor prescription claims for asthma medications (control cohort). utilization of asthma medications, asthma specific costs and total costs of care were assessed. results: a total of , children were identified: . % in the dx cohort, . % in the rx cohort and . % in the control cohort. the potential asthma cohort was . %. total annual non-asthma related costs for the dx cohort was $ , for the rx cohort was $ , and for the control was $ . only % and % of the total healthcare charges in the dx and rx cohorts retrospectively were asthma related. non-asthma charges were significantly higher in both the dx and rx cohorts compared with the control cohort. in the rx cohort, the ratio of saba prescription claims to asthma controller claims were . -fold higher than in the dx cohort. conclusion: children treated with asthma medications without an asthma diagnosis consume greater health care resources resembling the pattern of health care utilization of children with an asthma diagnosis more closely than controls. further, children with treatment in the absence of an asthma diagnosis appear to be under-treated with controller therapy as recommended by national and international guidelines. background: a recent retrospective study assessed asthma variability in inner-city patients months before and months after enrollment into an naepp guidelines-directed clinical management and educational program. while guidelines-directed care improved asthma symptoms and outcomes, significant variability in disease indices were observed over the -month period. the present analysis evaluates resource utilization associated with this variability. method: economic end points, including hospital/emergency department (ed) visits, total unscheduled office visits, sick visits, and days lost from work or school, were collected from inner-city patients aged years ( % female, % minority, % treated by primary care physicians) enrolled in a guidelines-directed asthma clinical management and education program aimed at minimizing barriers to adherence. patients were stratified into groups: those with high variability in asthma (n= ) and those with low variability in asthma (n= ), with variability defined as number of fluctuations in naepp symptom class in the -month postintervention period (high variability = patients with fluctuations higher than the mean; low variability = patients with fluctuations lower than the mean). results: guidelines-directed therapy was associated with improvements in asthma during the -month treatment period for both groups. patients in the high-variability group had more ed visits, sick visits, total unscheduled visits, and office visits compared with patients in the low-variability group (see table) . conclusions: despite guidelines-directed therapy and overall improvement in asthma control, patients experienced variability in asthma, indicating that even when their disease is stable, their symptoms continue to fluctuate. as a result, asthma variability may contribute to increased resource utilization. introduction: inhaled corticosteroids (ics) are considered first-line therapy for patients with persistent asthma. ics can lead to oropharyngeal adverse events, which may affect treatment outcomes and adherence. the occurrence of these local adverse events is dependent upon several factors, including dosage and duration of ics treatment. ciclesonide (cic) hydrofluoroalkane (hfa)-metered dose inhaler (mdi) is a novel and effective ics, with relatively low oropharyngeal deposition. cic is converted in the lungs to its active metabolite, desisobutyryl-ciclesonide (des-cic). furthermore, cic undergoes limited conversion in the oropharynx, which may account for its improved safety profile. this oropharyngeal safety profile analysis was part of a long-term study evaluating the safety of cic hfa-mdi vs beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallelgroup, -month extension of a -week double-blind study of patients years with severe persistent asthma. patients were randomized in a : ratio (cic:bdp) to receive cic ( g bid) or bdp ( g bid) (both ex-actuator). after weeks, the doses of both medications could be titrated to g bid as needed for asthma control.) oropharyngeal adverse events were monitored, and suspected oral fungal infections were verified by positive culture. results: the incidence of oral candidiasis was lower in subjects receiving cic ( . %), compared with those receiving bdp ( . %) ( table) . the incidence of pharyngitis and hoarseness was . % and . %, respectively, for the cic group, and . % and . %, respectively, for the bdp group. all local adverse events resolved without sequelae, and there were no withdrawals due to oropharyngeal treatment-emergent adverse events. conclusion: after -months of treatment with cic μg or μg twice-daily, the incidence of oropharyngeal adverse events was low. cic treatment resulted in a much lower incidence of oral candidiasis, compared with similar doses of bdp, reflecting a better local tolerance. objective: to determine the prevalence of asthma and asthma-related morbidity, treatment and asthma-risk factors in a selected population. method: a routine health screening, including tests for asthma, was conducted at the new orleans center for creative arts high school. participants ( ) identified their medications and asthma tools in addition to completing the isaac questionnaire. prevalence data included lifetime wheezing, month wheezing, and previous asthma diagnosis. asthma-related morbidity included sleep disturbance, wheezing with exercise, asthma attack rate and night awakening. results: " participants were aged - years ( . % african american, . % white) with . % male, . % female. " cumulative asthma prevalence was . %, lifetime wheezing ( %), -month wheezing . % with girls reporting . times more often ( % ci: . , . ), and wheezing more than times in months . %. " there was a significant association between race and wheezing in the last months (p < . ) with whites reporting . times more often ( % ci: . , . ). asthma morbidity was reported as follows: a. night cough - . % b. wheezing with exercise - . % " parents with a less education (high school or less) were . times more likely ( % ci: . , . ) to have children who developed wheezing in the past months. " higher body mass index (bmi = ) was associated with wheezing after exercise (p < . ) with a . -fold increase ( % ci: . , . ). " among those with current asthma ( / ), were not on any medication, were using bronchodilators, and were on anti-inflammatory medications. three reported using a spacer and reported using a peak flow meter. conclusion: asthma prevalence is higher in this school population than the national average. less parental education, female gender, and bmi = were associated with greater asthma morbidity. the majority of the participants with current asthma reported receiving episodic and inadequate treatment with inhaled corticosteroids. objectives: to determine the prevalence of asthma and asthma related symptoms; to assess its severity among new orleans school children. methods: seven elementary, middle, and high schools in new orleans participated in the screening of students, % female, % male, ages - in the fall, . the -item questionnaire was designed by the international study of asthma and allergies in childhood (isaac) to determine asthma prevalence and severity in children. the isaac questionnaire is a validated protocol used on over , children in countries. asthma is defined as cur-rent wheezing for the purposes of this study. data was entered using spss and sas software for analysis. results: table: presence of asthma symptoms by ethnicity conclusion: asthma prevalence is significantly higher in inner-city school children in new orleans when compared to the national prevalence ( . % to . % vs. . %). asthma prevalence and severity do not differ significantly between african-american and caucasian children in new orleans even after removing the effect of gender and age. video is an effective method of teaching pollen identification. projected digital images offer three-dimensional views of unique pollen detail similar to focusing a microscope. the national allergy bureau™(nab) currently provides pollen counts to the media. these reported levels are obtained by standardized counting methods rather than forecasts based on historical pollination predictions and weather patterns. the american college of allergy, asthma and immunology and the american academy of allergy, asthma and immunology have an interest in ensuring consistent counting and accurate reporting practices. both organizations offer pollen identification training in conjunction with their annual meetings and have used the video for initial training sessions and for experienced counters in advanced courses. there are certified pollen counting stations in the united states and canada with approximately currently active locations. the nab requires the demonstration of ability to count and accurately identify pollen on test slides. an updated recertification process using an interactive web site is currently being developed. ongoing pollen identification training is essential for the continued success of this aeroallergen network. most observers found that the video provided a quality emulation of microscopic viewing and enhanced the depth and detail of individual pollen characteristics. the video received the highest possible ratings by course attendees. in conclusion the video plays a positive role in pollen identification training and the continuing education of experienced counters. the diagnosis and treatment of mold allergies are complicated by the genetic diversity of individual fungal species and the influence of endogenous fungal proteases on extract compositions and potencies. studies examining the biochemical comparability of mold extracts from different sources and their compatibility with other allergens in immunotherapy mixtures are essential to the clinical effectiveness of these products. compositional comparisons of extracts prepared from alternaria, aspergillus and penicillium source materials by u.s. allergen manufacturers revealed variable sds-page protein banding patterns and noticeable differences in total protein and carbohydrate concentrations. alt a levels in alternaria extracts did not correlate closely with total protein levels or with ige-binding potencies measured by elisa inhibition. immunoblot profiles of fungal extracts were more closely related to one another compared to sds-page patterns, suggesting that similar allergenic or antigenic epitopes may be retained in molecules of varying size. parallel elisa inhibition dose-response curves provided statistical evidence that a repertoire of ige epitopes is conserved in many of these products. variations in the potencies of fungal extracts from different manufacturers may result from differences in source materials and/or conditions of extraction and storage. the stability and compatibility of allergen mixtures containing mold extracts were assessed after storage for up to months at - °c using specific immunoblot and elisa procedures. grass and mite allergens compromised by mixing with mold extracts were stabilized by glycerin. alternaria extracts from different sources produced similar effects on grass allergens when added at comparable strengths. degradative effects caused by aspergillus or penicillium products were more closely related to total fungal protein concentrations than to extraction ratios. structural epitopes on cat, ragweed and fungal allergens were stable after mixing with protease-containing mold extracts, indicating the presence of natural protease inhibitors or allergenic protein sequences distinct from those recognized by these enzymes. allergenic extracts labeled as weight/volume or by pnu have no regulatory requirement for determination of activity. alum-adsorbed allergenic extracts are labeled in pnu and are felt to be depot formulations. the purpose of this study was to develop methods to measure important allergen proteins and specific ige binding capability of these alum-adsorbed allergenic extracts and to begin to assess the potency of these non-standardized extracts. allergen proteins are adsorbed to alum particles making their measurement difficult. in this study allergens were released from center-al ® alum precipitated allergenic extracts using . m citrate buffer, ph . the major allergen contents of several lots of each product were measured using monoclonal antibody elisas for group grasses, cyn d bermuda, bet v birch, ole e olive, and pla l english plantain. these assays were developed and validated by alk-abello and optimized for the citrate releasing buffer. direct binding ige was performed by immobilizing serial dilutions of extract to microtiter plates and then adding specific atopic sera and enzyme labeled anti-ige. the methods used were able to measure in vitro allergen activity in the alum-adsorbed extracts. major allergen content was successfully measured in the extracts and the amount was related to the pnu content. as expected, the variability of the major allergens within a particular extract species was higher than in standardized extracts that are adjusted for potency. the extracts demonstrated specific ige binding ability in the binding assay. the ige binding capability at various dilutions was related to the major allergen content. in conclusion, methods were developed to release adsorbed allergen proteins from alum extracts. the extracts were then analyzed for major allergen pro-teins and the ability to bind ige. major allergen content is currently used to monitor the activity of aqueous and glycerinated extracts and this study demonstrates that implementing these testing procedures will improve the consistency and quality of alum-adsorbed extracts. introduction there are over species of smut and rust fungi. ustilago maydis, or corn smut, is a basidiomycete fungus that infects ears of corn. it is responsible for a percentage of grain loss in the united states but eaten as a delicacy in mexico. it grows into large tumor-like structures, called galls, dispersing soot-like spores responsible for the common name, "smut." it is readily airborne and believed to be a causal agent for allergic rhinoconjunctivitis. "corn smuts" was added to the standard screening panel for patients presenting for evaluation of rhinitis in the region of middle tennessee. methods using greer laboratories™ corn smut extract : w/v, patients were tested by prick/puncture method with the hollister-stier quintip™ device. if negative, intradermal testing was performed. positive and negative controls were assessed. based on current national recommendations, wheals mm greater than negative control were considered positive for prick/puncture testing and wheals mm greater than negative control were considered positive for intradermal testing. results patients were tested between november, and march, . / ( . %) met criteria for prick/puncture positivity. / ( . %) met criteria for intradermal positivity. patients prick positive to corn smut had the following prick positive tests: dust mites / ( . %); cat / ( . %); local grass mix / ( . %); local tree mix / ( . %); local weed mix / ( . %), mold mix / ( . %); cockroach / ( %); and dog / ( . %). discussion allergy testing for aeroallergens is available to a limited number of antigens, of which, only a few are standardized. as time passes, relevant antigens are discovered and their importance further elucidated. this assessment reveals a significant presence of corn smut ige largely accounted for by intradermal positivity which may or may not reflect clinical sensitivity. these numbers are provided so that other clinicians may compare to prevalence in their geographical area. further studies are needed to determine the association of corn smut ige with clinical symptoms. h antihistamines are the mainstay of therapy for allergic disorders, including skin diseases. the most common side-effect of marketed antihistamines is sedation, especially when the clinical symptoms require a higher dose than recommended, a condition commonly encountered in dermatological disorders. the present study describes the pharmacology of a new non-sedating h antihistamine, r (hivenyl™). r binds to the cloned human h receptor with a similar affinity (ki: nm) as the reference antihistamines cetirizine (ki: nm) and loratadine (ki: nm). in vivo, r protects rats and guinea pigs from lethal shock, induced by compound / and histamine, respectively (ed : . and . mg/kg respectively). the compound is at least as effective as cetirizine and loratadine. in rats, r inhibits the histamine-and allergen-induced cutaneous reactions (ed : . and . mg/kg) with a similar potency as cetirizine (ed : . and . mg/kg) and loratadine (ed : . and . mg/kg). even so, in guinea pigs the compound inhibits the histamine-and allergen-induced skin reactions (ed : . and . mg/kg) to a similar extent as loratadine and cetirizine. however, in dogs r is more potent in inhibiting the ascaris allergen-induced wheal reaction (ed : . mg/kg) than cetirizine (ed : . mg/kg) or loratadine (ed : . mg/kg). r fails to occupy central h receptors in the guinea pig cerebellum up to mg/kg, in contrast to loratadine (ed : . mg/kg). in vitro and in vivo cardiovascular safety experiments indicate that r lacks the intrinsic capacity to prolong the qt-interval, even at high doses. as such, r (hivenyl™) is characterized as a potent, non-sedating and cardiosafe h antihistamine. it has been selected for further clinical development, mainly in the field of dermatology. the compound will be a suitable tool to explore the activity of a selective h antihistamine in various indications, without the contamination of the sedative activity often observed with other marketed antihistamines when increasing the dose. ciu represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. we have previously reported the clinical efficacy of fxt (prozac), an ssri widely used for the treatment of depression, in the management of ciu (nsouli tm, et al. ann allergy asthma immunol ; : ) . in this presentation we report additional cases of ciu which responded dramatically following the use of fxt. a yr-old female and a yr-old male presented with ciu of and months duration, respectively, requiring oral corticosteroid (cs) therapy for control of their ciu after failure of high dose anti-h (hydroxyzine) and anti-h (ranitidine) agents (table) . testing for food and latex allergy, viral hepatitis, autoimmune thyroid disease and parasitic infection were all negative. a skin biopsy performed in subject # was consistent with an urticarial vasculitis. following one week of oral fxt ( mg qd [subject # ] mg qd [subject # ]) a striking and complete resolution of urticaria in each patient was observed within to days during which time it was possible to successfully taper the cs. both patients have been maintained on fxt therapy with complete control of their ciu. the very favorable response to fxt therapy in these patients in addition to our first case report suggests that this drug may have a new therapeutic application in the management of recalcitrant ciu. background: ipratropium bromide nasal spray (ib) is indicated for treatment of rhinorrhea caused by common cold (cc), seasonal and perennial allergic rhinitis (ar) in adults and children age and up. symptoms of rhinorrhea from cc or ar in children are similar to those in adults, yet there is little data on the use of ib in children under years of age. objective: evaluate the safety and efficacy of ib nasal spray . % in - year-old children with symptoms of rhinorrhea from cc or ar. methods: a total of children ( cc and ar) were treated in an open-label, multi-center study. the cc patients received ib nasal spray ( mcg per nostril) tid for days, the ar patients received ib nasal spray ( mcg per nostril) tid for days. effectiveness was measured using a global assessment questionnaire and daily symptom scores reported by the parent. results: from the global assessment questionnaire, % and % of the parents found ib either "very useful" or "somewhat useful" in the cc and ar groups respectively. regarding effectiveness, % (cc) and % (ar) of the parents reported that ib had either a "good effect" or "excellent effect" in treating rhinorrhea. moreover, % (cc) and % (ar) of parents found administration of a nasal spray either "extremely easy" or "very easy." eighty-one percent (cc) and % (ar) of the parents reported they would use ib again for their child's allergy symptoms. the daily symptom score ( = none to = unbearable) for rhinorrhea decreased from . to . (- %, p< . ) for cc and from . to . (- %, p< . ) from baseline compared to the average on-treatment score, with decreases also seen for stuffy nose and sneezing. the nasal spray was well tolerated with adverse events (ae) reported in % of cc and % of ar patients. the aes were mostly mild to moderate and no potentially systemic anticholinergic or serious aes were reported. conclusions: ib nasal spray . % administered at a dose of either or mcg per nostril tid is an easy to use, safe, and effective therapy for control of rhinorrhea in children to years of age with common cold or allergic rhinitis. chronic idiopathic urticaria (ciu) represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. the pathogenesis of the condition derives from the release of potent vasoactive substances including histamine, and products of arachidonic acid metabolism, e.g., prostaglandins and thromboxanes formed by the action of the enzymes cyclooxygenase (cox) of which cox- is responsible for pseudoallergic and other inflammatory responses. although a number of therapeutic options exist owing to the plethora of mediators produced, treatment has focused largely on the use of h antihistamines and, unsurprisingly, at times without complete resolution of symptoms. in this presentation we report the successful use of a cox- inhibitor for the treatment of chronic urticaria. a y/o white hispanic female presented with a month history of chronic urticaria predominantly on the soles of the feet, with unknown precipitating factors, and fail-ure to respond to prior treatment with: cetirizine, steroids, benadryl, ebastine and epinastine. the patient received a blood transfusion years ago and there was no prior history of allergies. skin testing revealed + reactions to dust mite, pollen, cockroach, shellfish, + reactions to corn, milk and ige = iu (nv < iu), aso = ui (nv < ui). after weeks of treatment with rofecoxib (vioxx) mg, and benadryl, the rash resolved. vioxx was continued for more weeks until complete resolution of symptomatology. this case illustrates that the addition of a selective cox- inhibitor (i.e., rofecoxib) with an h antihistamine may be a more effective regimen for patients with ciu who fail to respond adequately to conventional therapy. introduction: elderly asthmatic patients whose symptoms are controlled by inhaled corticosteroid (ics) therapy may still have breathlessness on exertion. we randomized elderly asthmatic patients stabilized by medium-dose ics therapy into two groups, treated one group with medium-dose ics therapy plus montelukast, a leukotriene receptor antagonist, and the other with increased-dose ics therapy, and compared the effects of the treatment regimens on exercise tolerance. methods:the subjects were patients with bronchial asthma ( males and females, . ± . years) stabilized by ics therapy (with fluticasone proprionate, fp; mg/day) for three months or more with low peak expiratory flow (pef) rates (< %predicted, variability< %). they were randomly divided into two groups ( patients each) to be treated with ics therapy plus montelukast ( mg/day fp + mg/day montelukast; m group) or with increased-dose ics therapy ( mg/day fp; f group). pulmonary function tests, a six-minute walking test, respiratory gas analysis during incremental ( w/min) cycle ergometer exercise were conducted, and exhaled nitric oxide (no) levels were measured before and after two weeks of the study treatment. results: pulmonary function tests showed significant increases in maximal mid-expiratory flow (mmf) and forced expiratory flow at % vital capacity (v ) in the m group (p< . ) but no significant changes in the f group. exhaled no levels decreased significantly in both groups ( . ± . to . ± . ppb in the m group and . ± . to . ± . ppb in the f group; p< . ). the six-minute walking distance extended from ± to ± m in the m group and from ± to ± m in the f group.the peak oxygen uptake (peakvo ) increased significantly in the m group (%peakvo /w from . ± . to . ± . %; p< . ) but not in the f group (%peak vo /w from . ± . to . ± . %). the peak exercise load also increased significantly in the m group ( . ± . to . ± . w; p< . ) but not in the f group ( . ± . to . ± . w). conclusions: the results indicate that concomitant administration of montelukast is more effective than dose escalation of ics on exercise tolerance in elderly asthmatic patients under medium-dose ics therapy. e. meltzer * , y. luo , l. shen , z. guo , c. schemm , y. huang , k. chen , p. king , r. nave , d. banerji , s. rohatagi , . san diego, ca; . bridgewater, nj; . konstanz, germany. introduction: inhaled corticosteroids (ics) are first-line treatment for persistent asthma. ciclesonide (cic) is a novel and effective ics under development. freely circulating, unbound ics is available to cause systemic adverse effects, such as hypothalamic-pituitary-adrenal (hpa) axis suppression. hence, it is important to determine the free fraction of ics in plasma. in separate studies, the protein binding of the active metabolite of cic, desisobutyryl-ciclesonide (des-cic), was evaluated, and the effects of inhaled cic on hpa axis function were determined. methods: human plasma protein bind-ing of des-cic ( . - ng/ml) was determined using equilibrium dialysis. dialyzed samples were analyzed by liquid chromatography with tandem mass spectroscopy to determine free and bound des-cic. in separate clinical studies, the effects of cic (hfa; - μg daily) and placebo (pbo), via metered-dose inhaler (ex-actuator doses), over days, or weeks, on basal hpa axis function ( -hour area-under-the-curve [auc - h] serum or urinary cortisol corrected for creatinine) or stimulated (low-dose [ μg] cosyntropin) serum cortisol were investigated in patients ( years) with persistent asthma. results: the mean % of human plasma protein binding for des-cic was %. in studies measuring serum cortisol auc - h, there was no difference between pbo and cic ( - μg). similar results were observed for -hr urinary cortisol corrected for creatinine. in the rd study measuring low-dose ( μg) cosyntropin-stimulated peak serum cortisol, after weeks of treatment, there was no significant difference in the mean change from baseline versus placebo for either cic (p= . ) or cic (p= . ). conclusions: the favorable pharmacokinetic profile of cic, in particular the high protein binding of des-cic, may explain the lack of hpa-axis suppression. this appears to result in greater systemic safety. purpose: unscheduled office and ed visits for urgent asthma care are an ongoing point of concern. determining preventive variables regarding these unscheduled visits could have a significant impact on asthma costs and quality of life. objective(s): this research addresses the following question: when stratifying by race, gender, age, metropolitan/rural place of residence and comorbidity, do adults with asthma have fewer ed or unscheduled office visits for urgent asthma care if they: a) have an identified primary care provider, or b) have health insurance? method(s): univariate and stratified bivariate contingency table analyses were performed on weighted behavioral risk factor surveillance survey (brfss) data. result(s): adults with asthma who had an identified primary care provider were more likely to have no unscheduled office visits (or= . ) or ed visits (or= . ) for urgent asthma care. this was also true for adults with asthma who had health insurance (or= . for no unscheduled office visits and or= . for no ed visits). these relationships held when stratifying by race, gender and age. the relationships also held for metropolitan residents. the analysis was inconclusive for rural residency and the existence of co-morbidities. conclusion(s): despite race, gender, age and metropolitan residency, having a primary care provider or having health insurance impact whether or not adults with asthma are more likely to have unscheduled office or ed visits for urgent asthma care. further investigations are needed to examine how these factors impact adults with asthma who are rural residents or who have co-morbidities. d. bukstein * , g.a. cherayil , . madison, wi; . brookfield, wi. introduction: costs for plans to process prior authorizations for non-formulary medications, has been estimated to be $ to $ per request. costs for physicians to process these requests has not been extensively studied. methods: dr.bukstein, board certified allergist, developed a data collection tool. the form was utilized by physicians and nurses to document time spent on processing prior authorizations. data collected included, class of medicines requiring the pa, nursing time spent on calling the patient, pharmacist, health plan, nursing time spent completing forms, nursing time clarifying the information for the pa, as well as physician time spent completing pa activities. results: data was collected over weeks in and requests were processed.the class of medicines most often processed was antihistamines, comprising % of requests. nursing calls were tracked and calls to and from patients were the most common call documented. they averaged . +/- . calls per day per nurse. the nurses spent an average of minutes per patient call. calls to health plans averaged . +/- . calls per nurse per day and time spent on these call was . +/- . minutes per call. physician calls documented included calls averaging . +/- . calls per physician per day. these calls averaged . +/- . minutes per call.often the results of the prior authorizations were not known on the day of the request. originally . % of requests were granted the same day. retrospective review revealed . % were approved the first time they were processed. salary and benefits were calculated for nurses and physicians. the hourly rate was defined as $ . per hour for nurses and $ per hour for physicians. the costs for the time spent on the prior authorizations were calculated. during the week study period, over hours was spent by nurses on calls and over hours was spent by physicians on calls during the same time period. the total nursing and physician cost in this specialty practice was $ . per prior authorization. conclusion: there are substantial costs with processing of prior authorization requests for non-formulary drugs on the physician office side of managed care as well as on the insurance side of the process. specialty physicians should have a different process for obtaining non-formulary medications since almost % of their requests are granted. introduction: diabetes mellitus can adversely impact the course and outcome of myocardial infarction (mi). one of the mechanisms underlying this phenomenon is alteration of the course of inflammation and the reparative process following myocardial necrosis. abnormal wound healing, tissue reparation and immune responses in diabetic patients have been intensively studied, but the cellular and the molecular mechanisms are still unclear. transforming growth factor-beta (tgf-beta) is a multifunctional cytokine which plays a critical role in coordination of the course of inflammation and reparation, acting as a potent depressor of inflammation and a stimulator of regeneration. this study investigates the dynamics of serum concentrations of the active form of tgf-beta during the period up to the th day after the onset of a mi in diabetic and non-diabetic patients. results: in non-diabetics a significant increase was observed in tgf-beta on day ( -fold greater than in controls; . ± . and . ± . pg/ml respectively) with further increases reaching a peak on day ( . ± . pg/ml). on day tgf-beta decreased to levels less than on day , but was still greater than in healthy controls ( . ± . pg/ml). in diabetics, concentrations of tgf-beta on days ( . ± . pg/ml) and ( . ± . pg/ml) after mi were similar to diabetics without mi ( . ± . pg/ml). only on day was tgf-beta increased to levels ( . ± . pg/ml) which were fold greater than in diabetics without an mi. thus, in diabetic patients serum concentrations of the active form of tgf-beta are much greater than in non-diabetics. mi in patients with diabetes mellitus is associated with a reduced and significantly delayed increase in tgf-beta . conclusion: tgf-beta deficiency may be a factor associated with low activity of tissue reparation after mi in diabetic patients. introduction helicobacter pylori (hp) is the most common gastrointestinal infection worldwide, but only - % of those infected develop chronic gastritis or peptic ulcer disease. the pathogenesis of ulceration, mechanisms of hp lifelong persistence in gastric mucosa and local immune disturbances induced by this infection are well known, but the mechanisms of resistance and elimination of this infection have not been extensively studied. most study is based only on phenomenological findings, such as absence or low hp colonization in subjects spontaneously producing high levels of il- . the aim of this investigation was the analysis of the efficacy of the recombinant interleukin (ril- ) roncoleukin (biotech, russia) in treatment of hp-associated gastric ulcer disease. methods patients were randomly divided into two groups. the first group of patients was treated with standard therapy including of two antibiotics (claritromycin and amoxicillin), proton pomp inhibitors and h receptor antagonists. patients of the second group were treated with the same therapy, but instead of antibiotics they received . mg roncoleukin into four to six areas submucously using a gastroscopic method and . mg roncoleukin dissolved in ml of . % nacl with ml % human albumin infused intravenously. this procedure was performed three times at an interval of hours. results immunological findings demonstrated that roncoleukin results in an increase of cd +, hla-dr+ and cd +cd + cell levels. there was an increase in the serum concentrations of il ( fold), il ( fold) and ifn (more than fold) while the level of tnf and il profoundly decreased. one month after the end of treatment, the group treated with ril- had hp eradication achieved in . % in comparison to . % of the control patients. in the ril- treated group, the ulcer epithelization period was . ± . days while in the normal treatment control group it was . ± . days (p< . ). conclusion immunotherapy with ril- is a more effective method of treatment of helicobacter pylori-associated gastric ulcer disease when compared with traditional methods of treatment employing only antibiotics. introduction the role of different cytokines and the growth factors is now appreciated in progression of essential hypertension. the participation of et- and tgf in pathogenesis of essential hypertension especially in the process of fibrosis, hypertrophia of vascular smooth muscular fibers, and cardiomyocytes, and the activation of renin-angiotensin system is now recognized, in addition to effects on myocyte cultures. the aim of the investigation was the study of serum et- and tgf levels in patients with essential hypertension. materials and methods patients with essential hypertension ( males and females) with average age . ± . years were studied. all patients suffered from left ventricle hypertrophy documented by echocardiography. the control group consisted of healthy volunteers similar to the investigated patients in sex and age. in all patients the serum concentrations of et- and tgf were determined using elisa (biomedica, biosource). results an increase in the serum concentrations both growth factors were noted in the studied group when compared with the control group. the average concentration of et- in patients with essential hypertension was . ( . - . ) pmol/l. the level of et- in the control group was . ( . - . ) pmol/l (p= . ). the concentration tgf in essential hypertension patients was . ( . - . ) pg/ml and in control group was . ( . - . ) pg/ml (p= . ). there was a positive correlation between the concentrations (spearmen's rank coefficient of correlation was . ; p= . ). con-clusion the increase of the serum concentration of growth factors et- and tgf and their co-influence in patients with essential hypertension, suggests a role of these growth factors in the pathogenesis of arterial hypertension. u. kaza * , c. lauter , . bloomfield hills, mi; . royal oak, mi. introduction: few studies have examined the referral patterns for allergy and immunology inpatient consultations in a community hospital. consequently, an invaluable part of physician and housestaff education is missing. our objective was to examine the number of inpatient allergy and immunology consultations, the reasons for consultations and the outcome of the patients in order to improve physician education. methods:we performed a retrospective chart review of all inpatient allergy and immunology consultations in the years - and in - to determine the reasons for consultation, the recommendations made and if they were followed and the outcomes of the patient. results:we reviewed a total of inpatient allergy and immunology consultations. in the - time period % of inpatient consults were for asthma, % for drug allergy, % for rash. in the - time period % of inpatient consults were for rash, % for drug allergy, % for asthma. the top three reasons for consultations remained the same although the order changed. consultations for immune deficiency, angioedema and rashes increased, whereas consultations for asthma and allergies decreased. there were a total of consultations in - and in - . the number of consultations remained the same despite an increase in overall number of hospital admissions from , in to , in . in greater than % of consultations, allergists' recommendations were followed. in both of the time periods studied, greater than % of patients improved, with less than % having no improvement, in the remainder of cases improvement was not applicable. conclusion:in conclusion, we believe that identifying the reasons for inpatient allergy and immunology consultations and examining the most common recommendations, as well as the outcomes of patients will be a valuable guide in the education of our physicians. by incorporating this information into grand rounds and resident conferences, physicians will benefit from learning about when an allergist can be helpful and how to manage some of the more common allergic and immunologic problems in patients that are hospitalized. the high percentage of providers who follow the advice of allergists indicate that allergists have a great deal of educational value to offer other physicians. while complementary and alternative medicine (cam) has generally experienced increased popularity, its utilization by allergy/asthma patients remains uncertain. our private allergy practice surveyed the use of cam in allergy/asthma patients in ( ). using a similar questionnaire, we assessed the current interest in cam with our allergy/asthma patients and compared the data to our survey. we analyzed completed questionnaires from sequential surveys administered. the results were compared to questionnaires reported in . they indicated that in both study periods ( & ) , the majority of patients wanted to discuss cam ( and % respectively). an equal number ( %) in each study period discussed cam with their primary care provider. sixteen percent ( %) of our respondents sought a cam practitioner for general medical needs in vs. % in . however, there was an increase from % to % of our patients seeing a cam practitioner for their allergies and/or asthma from to . sixty-two percent ( %) would like to consider pursuing cam through our allergy spe-cialty practice or other provider. when asked regarding preferred treatment, % stated combination traditional with cam, % preferred traditional only, % cam only, and % did not know/doctor s choice. more patients are now seeking chiropractic care ( % to %) compared to our results. acupuncture was the first choice cam modality at % in surpassing vitamin/mineral therapy in . currently, the second and third choices were vitamin/mineral therapy and deep tissue massage. while these numbers were small, we were impressed that currently % (two and a half times more since ) of patients in our practice were seeking cam allergy/asthma care from outside of our practice. these results demonstrated that more than half of our patients were interested in pursuing traditional with cam options within our office. given this trend, we have begun discussing the concept of integrative allergy, which to us means integrating evidenced-based cam modalities within our traditional allergy/asthma practice. ( ) introduction: clinical immunization knowledge is complex and demands ongoing training. nationally, basic immunization and vaccine safety education is limited within traditional medical, nursing, and provider education. project immune readiness (pir), a peer-reviewed, web-based, interactive course, was developed in response to this deficit and the need for standardized resources to provide initial and sustainment training for safe and effective immunization services. it is designed for medical personnel with diverse educational preparation. currently, pir offers course modules addressing hours of instruction on specific vaccines, their respective diseases, and general information on immunization healthcare and vaccination procedures. methods: users completed a pre-test (establishes baseline knowledge), an interactive module, followed by a post-test (to observe change from baseline) for each course in sequence. anonymous user and score data were collected as part of a quality assurance and course validation process. learning gain indices (lgi) were calculated based on average mean pre-test and post-test scores for each module lgi of all modules demonstrated substantial increases in user vaccination knowledge. comparing pre and post-testing is an effective method to assess learning gains. the findings support pir as a successful and valid distance-learning tool that establishes and documents core knowledge of medical personnel administering vaccinations. further research is needed to assess the effectiveness of knowledge acquisition and retention, in addition to variance in vaccine delivery after training. this approach to learning may have value as a resource that supports smallpox and influenza pandemic emergency preparedness plans for just in time training. introduction: variances from practice guidelines for the prescription of auto-injectable epinephrine are well documented among practicing physicians, families, and patients. effective patient education requires provider competency. the current study was designed to survey resident physician perceptions regarding auto-injectable epinephrine education, use, and patient education requirements. methods: residents from primary care disciplines at a tertiary care medical center were invited to complete a voluntary, anonymous questionnaire. a total of surveys were distributed and returned: emergency medicine, family practice, internal medicine, and pediatric residents completed the questionnaire. due to the small sample size, responses from physicians in various disciplines were reviewed as a whole. results: respondents ( %) reported that they had previously prescribed auto-injectable epinephrine for allergic emergencies. the majority ( %) of these prescribers reported that their training was inadequate. respondents ( %) reported no training, while respondents ( %) reported that their training was less than that needed to ensure proficiency. respondents ( %) reported that their training was adequate to ensure proficiency. none reported expertise. only of prescribers ( . %) reported that either they or their staff always demonstrated proper medication use to the patient. interestingly, of these providers reported they had not been trained on proper use. the table below summarizes resident training and patient education practices. additional physician knowledge deficits included the proper site of medication administration, the proper interval for replacing medication, and the proper place for medication storage. conclusions: of the residents surveyed, who have previously prescribed auto-injectable epinephrine, % identified training deficiencies. only . % of prescribers reported that the standard of care requirement to demonstrate proper medication use was always met. there is a clear need to improve auto-injectable epinephrine education in all residency training programs. r. bloebaum * , r.k. calabrese , m. . houston, tx; . new york, ny. introduction: pneumocystis carinii pneumonia (pcp) is a major cause of morbidity and mortality in patients with aids. adverse reactions occur frequently to the most effective medication for both the prevention and treatment of pcp, trimethoprim-sulfamethoxazole (tmp-smx). we looked at the immediate safety and efficacy of three protocols for desensitization in aids patients. methods: by retrospective chart review, we identified patients with aids who had experienced previous mild to moderate hypersensitivity reactions to tmp-smx and required desensitization. patients received one of three desensitization protocols based on illness severity or ward attending preference: a -hour intravenous (iv) desensitization, an -day oral desensitization, or a -day oral desensitization. results: of the patients that received desensitization, ( . %) completed successfully. of these, subjects had no reaction during the desensitization process; however, seven of these subjects were on steroids for treatment of other diseases. the remaining five successful patients had mild reactions which were treated symptomatically with acetaminophen, antihistamines or both. eleven patients failed to complete the desensitization: six stopped by the attending physician and four dropped out voluntarily. one patient expired during desensitization from extensive disease complications related to the admitting diagnosis. all protocols were equally successful when comparing the immediate success rates, / ( %) of the hour protocol, / ( %) of the -day protocol and / ( . %) of the day protocol. the -hour iv desensitization protocol was most frequently used in the intensive care unit on critically ill patients. two of these patients, counted as successfully desensitized, died and days post protocol completion secondary to extensive comorbid conditions unrelated to the desensitization. conclusion: given the insignificant differences between the success of the hour iv desensitization and the oral desensitization protocols, we believe that either may be used effectively. further, in patients with mild to moderate hypersensitivity reactions to tmp-smx, an oral desensitization protocol may be used safely in the outpatient setting if given appropriate lab follow up. a. morales * , e. gonzalez, a. contreras, d. lopez, g. lopez, mexico city, mexico. introduction in davis describes job syndrome in two women, in dr buckley reports two children, being known as hyper-ige syndrome (job's syndrome or buckley's syndrome). defined as a primary immunodeficiency, dominant autosomic, characterized by multi-systematic alterations (immunological, skeletal, dermal and dental). it's diagnostic criteria are levels of ige ui/ml, chronic dermatitis, recurring respiratory infections, cold abscesses, pneumatoceles, infections caused by candida, and finally craniofacial alterations. on another front, extraordinary high levels of ige have been reported in patients with allergic illnesses that increase the risk of anaphylaxis, but do not have the job's syndrome criteria. objetive to determine if allergic patients with ige levels higher than ui/ml have diagnostic of job's syndrome. material and methods a retrospective revision was realized from may to april in files of patients treated in allergy services at the instituto nacional de pediatria with a total ige greater than ui/ml, by means of a page with recollected dates. results nine women and men were included with an age range of to years, and an average age to years; ( . %) were diagnosed with allergies; of which . % rhinitis allergy, . % asthma, and . % topical dermatitis of which co-existed in patients. . % presented hereditary antecedents of atopic. the cutaneous tests were positive in ( . %) with a greater reactivity of dermatophagoids. one syndrome of hyper ige was detected. others diagnosed were found as not allergic were hunter's syndrome and toxocariasis. conclusion there are patients with allergies that have total levels of ige as elevated as , ui/ml without correspond to job's syndrome. by which a multi-allergic clinical entity is proposed with levels greater than ui/ml. introduction home monitoring of lung function in asthmatic patients is used extensively in both clinical and research settings, however, little attention is given to device quality control. objective the purpose of this study was to determine the accuracy, precision and usefulness of the airwatch system (enact health management systems, palo alto, ca, usa). methods the subjects included in this study were submitted to spirometry following american thoracic society guidelines (ats ), using collins gs g pft system. afterwards, peak expiratory flow rate (pef) and forced expiratory volume in one second (fev ) were determined using airwatch. fev and pef measures from both devices were compared, by using two sample t-test and pearson correlation coefficient. results a total of patients ( females) were enrolled, and their mean age was . years ( to years). fev measures ranged from . to . l (mean . l), and from . to . l (mean . l), in collins and airwatch, respectively. pef ranged from to l/min (mean l/min) in collins and from to l/min in airwatch (mean l/min). significant difference was noted for pef measures (p< . and pearson correlation r= . ) between the two devices; however, we did not observe this difference when fev measures were concerned. regarless the degree of obstruction (high or low flow rates), these results did not change. conclusion airwatch showed great utility for fev measures when compared to collins spirometer. although airwatch is able to assess lung function at home, on a daily basis, it is not reliable for pef measures. introduction: epidemiologic data show that poorly controlled asthma is a serious public health problem. the degree of implementation of the naepp guidelines in primary care practice remains to be defined. the objective of this survey was to determine if introduction of an assessment tool into primary care practices along with a specially designed program to implement the guidelines would improve diagnosis and therapy. methods: the asthma care network (acn), a program designed to assist healthcare providers in the assessment and management of their patients with asthma, employs a team of specially trained respiratory care associates (rcas), rns and rts, who visit primary care offices to inform staff about various components of the naepp guidelines and assist in their implementation. .a total of primary care providers in sites were recruited as part of the acn program. data from more than , patient visits were collected and analyzed between march and january . the program assessment tool surveyed asthma control and medication prescribing patterns. outcome measures included degree of symptom control, limitation of activity, sleep disruption, use of rescue medication and utilization of urgent care services. these data were collected on an office visit assessment form (ova) completed by both patient and physician. the rcas provided information, education, device training in the use of inhalers and spacers, and a ce course for the staff discussing pathophysiology, assessment and management of asthma. results: a total of , ova forms were completed. among all patient including adults (older than years of age) and children (< - years of age), % (range % to %) reported symptoms consistent with lack of asthma control. approximately % of the survey group had more than markers of uncontrolled asthma. as a result of this assessment, controller medication use increased by over %, % of which was an ics-containing medication. conclusion: the information provided to the primary care health care providers resulted in a considerable increase in prescription of controller therapy, and in particular, increased use of ics controller medication consistent with naepp guidelines. background: patients with allergic rhinitis (ar) demonstrate symptoms of allergy to fruits, vegetables and nuts in - % of cases. oral allergy syn-drome (oas), typical for hypersensitivity to plant food, is based on cross-reaction of pollen-allergen specific immunoglobulin e (ige) antibodies with homologous food proteins. the production of th and th cytokines in allergic rhinitis patients with or without sensitization to food (fruits and vegetables) allergens was assessed. methods: fifty five patients aged - years with allergic rhinitis were observed. group i - patients with ar; group ii - patients with ar and oas. sensitivity to pollen allergens was tested by skin prick tests. the allergic reaction to food in patients with oas was proved by a positive history of oral symptoms caused by eating fruits and vegetables and a positive skin prick test with respective food allergens. blood eosinophil counts and total ige levels were determined during the peak of allergic rhinitis symptoms. il- , il- and -interferon levels were measured by elisa. results: . % of patients were sensitized only to grass pollen, . % only to tree pollen and . % reacted to pollens of grasses, trees and weeds. in patients with oas, skin tests were more often positive to birch ( . %), alder ( . %), and mugwort ( . %). the most common food products implicated in oas were hazelnut ( . %), apple ( . %), carrot ( . %), and peanut ( . %). the allergy to fruits and vegetables was confirmed by positive prick test in . %. during the season blood eosinophil count and total ige levels were elevated in all patients. there was an increase in the production of il- to . ± . pcg/ml in group i and to . ± . pcg/ml in group ii (nor-mal= . ± . pcg/ml). the levels of il- increased to ± pcg/ml in group i and to ± pcg/ml in group ii (normal= . ± . pcg/ml); the level of -ifn decreased to . ± . pcg/ml in group i and to . ± . in group ii (normal= ± pcg/ml). after sit with pollen allergens the clinical manifestations of allergic rhinitis and oas decreased in . % of patients. conclusion: allergic rhinitis patients' sensitivity to food allergens may cause oas in these patients associated with increased functional activity of th responses. patient knowledge and improvement with aller-gen immunotherapy. c.c. randolph * , waterbury, ct. introduction: there is no consensus on objective parameters for improvement in immunotherapy. similarly little is known regarding patient knowledge of immunotherapy. utilizing two published questionnaires ( - ), we assessed clinical improvement based on symptom and medication scoring and knowledge of immunotherapy. methods: the charts of patients of an estimated ( %), ( %) with allergic rhinitis only and ( %) with concomitant asthma, were retrospectively or prospectively reviewed who had been on immunotherapy to inhalants for months to years, mean . years, age range y- y, mean y, male( %), female( %) with caucasian ( %), oriental ( %) and ( %) afroamericans .they completed symptom and medication survey ( ) every months with range of improvement using a decline in likert scale (+) to (-) , mean . ( %) indicated improvement in their symptoms and/or medication . ( %) completed ( ) a question survey of knowledge of immunotherapy. there were questions regarding the outcome of immunotherapy, the years to onset of immunity, the duration until onset of immunity, the danger of immunotherapy and the extract in the vial. the correct responses were recorded to / ( / = . %), ( . %) / , ( %) / , ( %) / , ( %) / . ( %) had a perfect response to all questions. ( %) had no correct responses. conclusion: the majority of immunotherapy patients improved ( %) by symptom and medication scoring over the mean of . years but only % had complete knowledge of the rationale for immunotherapy. further education and repeated surveying of patients on immunotherapy to assure comprehensive knowledge of immunotherapy and achieve better outcomes is recommended by this investigation. as is unique in this study symptom and medication scoring using the rhinitis /sinusitis questionnaire approved by the acaai and a comprehensive questionnaire assessing knowledge should be conducted periodically ie every months to provide objective parameters for improvement. references: .santilli j, nathan r, glassheim j .patient receiving immunotherapy report it is effective as assesses by rhinitis outcomes questionnaire(raq) in private ( )) is a protein involved in the parasite invasion of host erythrocytes and is a leading vaccine candidate for the erythrocyte stage of malaria infection. an increasing number of vaccine clinical trials are being undertaken using various formulations of msp- ( ). comparison of humoral responses among these trials has been limited by the lack of a universal reference standard for specific antibody. the purpose of this study was to develop a human reference standard for msp- ( ) antibody measured in absolute quantity units that could facilitate comparison of interstudy vaccine response. method: we formulated the reference standard by pooling human plasma samples known to contain high titers of msp- ( ) antibody. the specific antibody within the pooled plasma was captured by msp- ( ) adsorbed to nickel resin in a process of immobilized metal affinity chromatography (imac). the intact msp- ( ) antibody-antigen complexes were separated from the nickel resin and total igg in the complexes measured by enzyme-linked immunosorbent assay (elisa). results: our antibody quantitation method yielded a concentration of . mcg/ml of msp- ( ) antibody in the reference standard. conclusion: the reference standard characterized in this study may be useful as a quantitative working standard for msp- ( ) antibody response in future vaccine clinical trials involving msp- ( ). this standardization may facilitate the clinical development of msp- ( ) as a candidate vaccine for malaria infection. background. specific immunotherapy (sit) is currently one of the most effective and widely used treatment methods of allergic diseases including asthma. efficacy of sit depends on the correct choice of patients, severity of asthma and patient's condition when the sit is begun. according to who recommendations, sit is approved for use in patients with mild to moderate asthma. methods. sit with a saline extract of house dust allergen was administered to patients with mild persistent allergic asthma. injections were performed subcutaneously - per day. the course consisted of pnu of allergen and lasted - days. patients were repeatedly surveyed at , and months after sit was completed. dyspnea attacks occurring during daytime and at night were assessed, as was the influence of physical exertion on dyspnea and lung function, and also the number of utilizations of short-acting beta-agonists per day. pulmonary function measurements were performed as was assessment of concomitant allergic rhinitis. % of patients received treatment including cromones, and % utilized inhaled corticosteroids among whom . % had a dose of mcg per day and . % mcg per day. sit efficacy was assessed by clinical symptoms, pulmonary function measurements and amount of concomitant therapy received. results. the number of daytime dyspnea attacks reduced from . ± . per month to . ± . during the months following sit, and . % of patients reduced concomitant asthma therapy. at months, dyspnea attacks increased to . ± . per month, still significantly less then prior to sit. nocturnal symptoms followed the same pattern, occurring . ± . per month prior to sit, . ± . per month months after sit and . ± . per month at the end of the sixth month after sit. . % of patients had no symptoms of bronchial obstruction during the months after sit and their pulmonary function approached normal values, although . % of patients returned to asthma therapy. nasal congestion decreased from . ± . points to . ± . (p< . ), clinical improvement still present for months after sit, but recurring at months after sit. conclusion. sit may be an effective treatment method that improves both asthma and allergic rhinitis for more than months following a brief course, allowing a decrease in the amount of symptomatic treatment. a safe therapeutic vaccine that can alter the allergic response to peanuts would serve a serious unmet medical need. peanut allergy responses are largely associated with downstream events related to antigen specific ige crosslinking of ige receptors and subsequent degranulation of mast cells and basophils. our clinical studies with ragweed have shown that linking immunostimulatory dna (iss) to allergens can decrease ige recognition of the allergen and generate an immunogen that generates protective th responses and reduces harmful th responses. to test this approach to peanut immunotherapy, we focused on the clinically relevant allergen, ara h , as a proof of concept. iss oligonucleotides were linked to ara h at two different ratios: pic ( iss per protein) and hpic ( iss per protein). immunogenicity of pic and hpic was evaluated in c h/hej female mice immunized twice with ug of pic, hpic, or ara h . sera were analyzed for anti-ara h igg and igg a responses. spleens were harvested and ara h -specific ifng and il- responses were measured in vitro. mice were immunized with ara h elicited predominantly igg and il- responses, indicative of a th -type response. animals immunized with pic showed significantly enhanced igg a responses and strong ifng responses, indicative of th -type responses. hpic immunized mice elicited little antibody response, presumably due to iss blocking b cell epitopes, but did induce ifng responses. to assess allergenicity of pic and hpic, histamine release was measured in blood from peanut allergic donors treated in vitro with pic, hpic, and ara h . histamine release was detected at very low concentrations of ara h ( . ng/ml), -fold higher concentrations for pic ( . ng/ml) and was undetectable at concentrations up to fold higher for hpic ( ng/ml). an ige binding competition assay also confirmed reduction in allergenicity following the same trend for the iss-linked allergens. linking iss to ara h increases th responses to the allergen, blocking ige recognition of epitopes on ara h . thus, iss-linked ara h appears to be a promising candidate for a safe immunotherapy product for treating peanut allergic subjects. introduction: immunotherapy has been studied for its adverse effects in some sensitive patients as with worsening of therapeutic response in some amounting to withdrawal of the later. methods: in the allergy center therapeutic trials of immunotherapy(house dust, mixmite) had been undertaken since , in therapeutic dose of . pnu/ml, . pnu/ml, pnu/ml, pnu/ml, pnu/ml pnu/ml, pnu/ml(housedust), . au/ml, . au/ml, au/ml au/ml au/ml au/ml au/ml(mixmite).patients age - years, both sex after diagnostic scratch/prick tests with appropriate antigenic preparations reported for local/systemic adverse effects the details of which were as under, results: please see the attached table for details, in some cases worsening of the existing allergic status was noted, which on analysis revealed initially a slow rise in the allergen -specific ige to be later on fol-lowed by rise of igg & igg & gradual fall of ige.only / patient could not complete immunotherapy for fear of adverse effects. conclusions: with utmost care/follow-up, no incidence of mortality outcome was reported from to late the incidence of adverse effects were significantly lowered on pre-medication with anti-histamines significantly more with elderly than younger age. even with all these documented hazards the beneficial effects far exceeded the harmful effects. background: the prevalence of allergic disease in most human population is steadily increasing. seafood allergy is a serious food allergy, although hypersensitive reactions caused by seafood has long been know, biochemical and immunological studies on seafood allergies had only begun lately. shrimp and abalone are the most frequently reported causes early asthmatic response. objective: to investigate cross-reactivity of shrimp, abalone and derp . methods: shrimp and abalone extracts were prepare from raw seafood. sera from patients from hongkong were studied who had asthma after consumption of seafood. ige elisa analyses comfirmed the combined sensitization to shrimp, abalone and derp . specific-ige elisa assays were accomplished for shrimp and abalone extracts inhibited by derp and derp elisa and immunoblot assays inhibited by shrimp and abalone extracts. results: elisa inhibition showed that most ige antibodies against shrimp and abalone were cross-reactive with derp and the same time, derp elisa was inhibition by shrimp and abalone extract. the elisa inhibition percent (%)of shrimp extract (gm: . %) and abalone extract(gm: . %) by derp were significantly higher than derp by shrimp extract(gm: . %) and abalone extract (gm: . %). (p< . ). furthermore, and there was a significant correlation of elisa inhibition percent between shrimp extract, abalone extract and derp inhibited by each other; sds-page and immunoblot of shrimp and abalone is the and kd allergen respectively. conclusion: this indicates that derp was the sensitive agent. shrimp, abalone and derp demonstrate significant cross-reactivity. these findings confirm that the primary crossreactive allergen of shrimp and abalone is the and kd allergen respectively. b. sun * , a. wu , n. zhong , . guangzhou, china; . hong kong. background: the house dust mites (dermatophagoides farinae (derf) are a major source of aeroallergens implicated in the expression of atopic disorders, including asthma, allergic rhinitis, and atopic dermatitis . in particular, strong circumstantial evidence suggests that house dust mites antigens are important precipitating factors of asthma. many house duse mite allergens are proteases that can elicit airway inflammation by stimulating the release of cytokines in bronchial epithelial cells. objectives: we have investigated whether der f allergen proteases induced cytokine production from the epithelial cell line beas- b. methods: cells were exposed to four different concentrations with serial additions of der f ( . , . , , ug/ml) were incubated for h to h. and compare with those without incubation of allergen. cytokine in the supernatants were assayed by elisa, reverse transcription?pcr was also performed. results: cells treated with der f allergen showed serial changes in the cohesiveness of the monolayer. there was a significant increase in the level of cytokine production compared with the untreaed sample. statistically significantly increased with addition of der f caused the release of il- and il- in time and concentration-dependent manner (p< . , respectively). levels of il- and il- were elevated h and h after allergen exposure, increasing with time, continued increased levels to be present of il- and il- in the supernatants at h and h. at the same time show the concentration dependence of induction of il- and il- expression as well as an increase in the expression of il- and il- mrna. conclusion: hdm-induced airway inflammation may include der f-mediated release of inflammatory mediators, and the proteolytic activity of an allergen may stimulate the release of proinflammatory cytokines from human bronchial epithelium. suggesting that il- and il- production by bronchial epithelial cells may play a role in the pathogenesis of allergic asthma. the purpose of this study is to delineate the immune injury mechanisms that involved in the autoimmune inner ear disease by introducing plasmid dna encoding of th cytokines (inf-g) into the inner ear. b-tubulin is a microtubular protein which we found as an important autoantigenic in meniere's disease as well as other autoimmune hearing loss. hearing loss was induced in mice and guinea pigs when they are immunized with the tubulin molecules. autoimmune hearing loss could be the results of th cytokine responses from autoimmune injury. to test the hypothesis, guinea pigs were immunized with mg of tubulin in cfa and boosted once more. two weeks later, we introduced ug ( ul) of naked dna encoding inf-g was injected into the left side inner ear through round window. same volume of . m pbs was injected into right side as control. abr was recorded before and after the injection. weeks after the injection, the animals were sacrificed and temporal bones were examined with h-e and inf-g immunocytochemical staining. the ears injected with the plasmid dna-inf-g had an enhanced hearing loss ( db), and degeneration of the spiral ganglion was found in these ears. however, the injection of the naked dna encoding inf-g did not change the expression of the inf-g in the inner ears. these results suggest that autoimmune hearing loss could be the result of th responses to inner ear autoantigens. -tubulin is an important molecule in the hair cells supporting cells within the sensory epithelium of organ of corti and found to be an auto autoantigen in autoimmune hearing loss including mèniére's disease. the object of the study is to induce hearing loss in mice with varying doses of antigen and evaluate the pathogenesis of autoimmune hearing loss induced by -tubulin in mice. mice were immunized with , or μg of -tubulin and hearing was evaluated by auditory brainstem responses (abr) and distortion product of otoaccoustic emission (dpoae). all mice had hearing loss by abr and dpoae tests and morphological study of temporal bone showed spiral ganglion degeneration and tunel staining positive cells were noted in these immunized mice. thus this study showed that -tubulin is an autoantigen for hearing loss in animal model as in human autoimmune hearing loss patients including mèniére's disease. supported by nih r dc - introduction: oral polio vaccination (opv) in the united states is currently being replaced with inactivated polio vaccination (ipv) given parentrally. while past studies have looked into the relationship of vaccination and asthma prevalence, none have investigated this relationship with regards to vaccination route namely orally versus parentrally. this study investigates the relationship between vaccination rates for the live attenuated orally administered polio vaccine and parentrally administered vaccines(dtp, mmr)and two potentially dependent factors; asthma prevalence rate and asthma-caused death rate. methods: we looked at data from the national center for health statistics yearly publications of health, united states ( - and the morbidity and mortality weekly report surveillance summaries . two databases were compiled to cover the - age population in the united states since this is the primary period of childhood vaccination. one database contained information for asthma related deaths and vaccination rate (dtp, mmr, opv) covering the years - and the other database compiled information for self reported asthma prevalence and vaccination rates(dtp, measles, rubella, opv) covering the period - . a t-test was used for statistical analysis. results: statistically significant correlation was found between vaccination rates and asthma prevalence rates. data for dtp (p = . ), measles (p = . ), and rubella (p = . ) indicated a statistically significant positive correlation with asthma prevalence. the oral polio vaccine was the only one of the vaccines that failed to display a significant relationship with asthma prevalence rates (p = . ). statistical analysis proved that a correlation between vaccination rates of united states children ages - and asthma-caused deaths was insignificant (p > . ). conclusions: the opv, which is administered orally rather than parentrally, displayed no relationship with asthma prevalence. this could be due to the fact that live attenuated orally administrated polio vaccine may induce mucosal immunity, simulating a normal pathogen route of entry into the body. childhood vaccination had no relationship with asthma-caused death rates. a.s. alfrayh * , riyadh, saudi arabia. introduction: heredity plays a major role in asthma and other allergic diseases, mechanisms underlying the inheritance of these disorders are poorly understood. this study therefore analyzed the risk conferred by family history of asthma and atopy for having childhood asthma. methods : a total of children between - yrs selected randomly in three cities in saudi arabia ( hail, taif and gizan )in - . the questionnaire which is similar to the one used in the international study of allergy and asthma in childhood isaac. were self administerd under medical supervision.apart from the demogrphic details, the questionnaire included questions on symptoms and physician diagnosis of asthma, rhinitis, eczema and family history of these conditions. the family members were grouped as immediate family and relatives. asthma and atopy were defined as ever having had physician diagnosis of such conditions information was also available about exposure to cigarette somke at least one member was a smoker in the household and having pets. relative risk for developing asthma was estimated in terms of odds ratio by bivariate analyses using chi square test and p value was considered significant when less than . . results : history of asthma in the immediate family and relatives conferred a fold and fold risk for development of childhood asthma odd ratio ( or )= . , % confidence interval(ci)= . to . , p= . and or= . , %ci= . to . , p= . respectively. rhinitis in immediate family and the relatives was associated with folds increased risk for childhood asthma or = . , % ci = . to . , p= . respectively whereas history of eczema conferred over folds risk or= . , % ci = . to . , p= . for childhood asthma when present only in the immediate family. history of eczema in relatives was not associated with any risk. of the environmental factors, exposure to cigarette smoke conferred folds risk of developing childhood asthma or = . , % ci = . to . , p= . , whereas exposure to pets was not a significant risk foctor. conclusion : presence of asthma and atopy either in the biological parents or relatives constitute a significant risk for childhood asthma.paricularly in the presence of evironmental risk factors. the murine local lymph node assay (llna) has been developed as an alternative to guinea pig models for the assessment of the contact sensitization potential. however, there is a need to develop a non-radioisotopic endpoint for the llna, because of the radioisotopic method's requiring the use of special facilities. in this study, we investigated to evaluate the lymphocyte subpopulations in the lymph node cells following allergen and irritant treatment. female balb/c mice were treated by the topical application on the dorsum of both ears with sensitizers, , -dinitrochlorobenzene (dncb), toluene diisocyanate (tdi), and a-hexylcinnamaldehyde (hca), and an irritant, sodium lauryl sulfate (sls), once daily for three consecutive days. the lymph node (ln) cells were harvested h after the final treatment. phenotypic analysis of lymphocytes subsets was performed with a flow cytometry. the allergens dncb, tdi, and hca and an irritant, sls increased cell number compared to the vehicle. there was an increase in the percentage of b + cells in mice treated with dncb and tdi compared to the vehicle control, but not in those treated with sls. mice were treated with dncb, hca and tdi showed a preferential increase in the percentage of b +cd + cells compared with vehicle and irritant-treated mice. there was an increase in b +cd + cells of mice treated with dncb, tdi and hca, but no significant increases were observed in mice treated with sls. mice were treated with dncb, and tdi showed an increase in the percentage of b +cd + cells compared with vehicle and irritant-treated mice. these results suggest that analysis of b cell activation marker, cd on b cells may be useful in differentiating allergen and irritant responses in the draining lymph nodes of chemically treated mice. m. frieri * , y.c. huang, east meadow, ny. introduction: nitric oxide (no) is an important biomarker for inflammation in airway epithelial cells and in exhaled breath of asthmatic subjects. we have previously demonstrated no production in antigen-stimulated human bronchial epithelial cells and an effect of omalizumab (monoclonal anti-ige antibody) on no production in those cells [leyko bt et al. j allergy clin immunol ; (suppl ) :a ]. in this study, we investigated the potential role of ige and its receptors on a cells by characterizing the effect of omalizumab on antigen, egf, and il- stimulation of a cells in a medium containing atopic serum. methods: a human alveolar epithelial cells were stimulated with iu/ml of il- , μg/ml of ragweed (ra), au of dust mite (dm), and ng/ml of egf, and exposed to either - m budesonide or . μg/ml omalizumab for or hours. no production was measured in duplicate by a highly sensitive elisa. results: omalizumab but not budesonide inhibited no production at hours in a cells stimulated with il- ( - μm, p<. )and il- +dm ( - μm, p=. ), but not with ra alone. however, at hours omalizumab and budesonide each significantly inhibited no production stimulated by il- ( - μm; - μm), il- +dm ( - μm; - μm), and egf ( - μm; - μm) (p<. ). conclusion: no production is a marker for inflammation. omalizumab demonstrated a significant anti-inflammatory effect in distal alveolar cells by inhibiting no production stimulated by antigen, il- , and egf in a medium containing atopic serum. as persistent inflammation in asthma may play a role in airway remodeling, treatment with omalizumab may have a beneficial effect on chronic airway inflammation in patients with asthma. oral tolerance trigger regulatory mechanisms able to down-modulate antigen-specific t and b cell response. to address the lasting effect of several regimens of oral tolerance to ovalbumin, in naive or antigen primed mice, b-cell function has been focused. furthermore, we analyze specific antibody response up to eight months of post-immunization, proliferative response, b (cd /cd ) expression on b cells and t cell ctla- involvement in oral tolerance. a/sn mice were immunized by intraperitoneal route with μg of ova/ , mg-alum and boost days after priming (dap). ova feeding was done with mg at different days before or after antigen priming. in others protocols, mice were fed twice, before and after priming with a total of mg of ova. all groups were boosted at or or or dap. the results showed that only mice fed at naive status and those fed twice before and after immunization demonstrated a long lasting of ige ab response inhibition up to months of immunization. these mice showed a marked inhibition of antigen-specific proliferative response that was restored with anti-cd mab in vitro stimulation. evaluation by flow cytometry of spleen cells cultured for hours upon ova stimulation, showed an important decrease of b . expres-sion on b cells of naive fed mice, which remained inhibited until months of immunization. after addition of anti-ctla- mab an enhancement of b . expression was detected on b cells of naive fed mice. ctla- molecules expression on cd + t cells of naive fed mice remained unchanged following ova stimulation while a peak of expression was detected at h of ova stimulation in control group. this finding reinforce the t cell anergic status of naive fed mice, due to the less cell division and consequently a low rate of cd +/cd high activated cells. the results showed that antigen feeding before immunization induce a long lasting anergy mediated by an impaired t-b cell cooperation and ab production due to the decrease of costimulatory molecules expression on b cells and negative signaling effects by ctla- expression. introduction: vascular endothelial growth factor (vegf), basic fibroblast growth factor (bfgf) and fibronectin (fn) can promote angiogenesis, a putative component of airway remodeling. (s)-albuterol can exacerbate airway hyperresponsiveness, bronchospasm and release pro-inflammatory cytokines from small airway and smooth muscle cells. our study evaluated the effects of (s)-albuterol ((s))-and (r)-albuterol ((r)) on secretion of these factors on normal human lung fibroblasts (nhlf) and myofibroblasts (myonhlf) in the presence or absence of tgf , il- , or allergens. methods: nhlf were stimulated to differentiate to myonhlf with pg/ml tgf . dose-dependent effects of (s) and (r) [ - to - m] were evaluated for secretion of vegf, bfgf and fn by nhlf and myonhlf with and without au/ml d. pteronyssinus (dp), pnu/ml ragweed (ra), u/ml il- , or pg/ml tgf into serum-free media (its) at o c with % co collected at hr and assayed by elisa. results: in nhlf the following was observed: vegf secretion was -fold higher with - m (r) relative to (s), p< . ; bfgf secretion was increased %- % by - m (s) relative to (r), p< . . a lower concentration of (s) ( - m) in the presence of either dp or il- caused a -fold increase in secretion of bfgf relative to (r), p= . . in the presence of myonhlf the following was observed: - and - m (s) caused a %- % increase in secretion of fn relative to (r). at - m (s), this effect was further increased with the addition of il- , p= . ). conclusion: in a dose-dependent manner, (s)-albuterol stimulated the release of bfgf and fn by nhlf and myonhlf, respectively. this was enhanced by dust mite and/or il- , potentially contributing to the matrix remodeling observed in chronic asthma. vegf over-expression can have a protective effect against chronic hypoxia and can recruit immune cells to the alveoli. increased vegf by (r)-albuterol could contribute to such an effect in vivo in asthmatics. bfgf, in bal and sputum of asthmatics, and fn which contributes to subepithelial fibrosis, can promote angiogenesis. increased bfgf and fn by (s)-albuterol could be detrimental over time by enhancing matrix deposition and remodeling in a subset of asthmatics. o. ozdemir * , c. moore , y. ravindranath , s. savasan , . detroit, mi; . new orleans, la. background: mast cells (mc) have been shown to demonstrate natural cytotoxicity against mouse fibrosarcoma cell line in culture when incubated for - h. this effect has been postulated to be mediated through soluble and/or membranous tnf-. more recently; fasl, mc chymase and serine protease granzyme h with its chymase activity were proposed as mediators of mast cell-mediated cytotoxicity. thus, both 'granule-exocytosis' through chymase, granzyme h and soluble tnf-and 'death receptors' through membrane-bound tnf-and fasl pathways appear to be operative in this process. aims: following our earlier observations on long-term liquid culture-grown human bone marrow mast cell cytotoxicity against human leukemia cells in - h co-incubation experiments, we investigated mast cell-mediated cytotoxicity against natural killer/lymphokine-activated killer cell-sensitive cells in short term ( h) cultures without any stimulation for the first time. methods: human bone marrow mononuclear cells were cultured in methyl cellulose supported with il- , il- and scf. mast cell colonies that developed in six weeks were transferred to liquid medium and maintained for weeks before experiments. cytotoxicity was investigated against k , raji and daudi cells at , and hours of co-incubation by our established flow cytometric cell-mediated cytotoxicity assay. results: after h co-incubation, % ( % early apoptotic and % late apoptotic or necrotic death) and % ( % early apoptotic and % late apoptotic or necrotic death) target cell kill was demonstrated in daudi and raji cells, respectively. daudi cell killing has stayed stable at h ( %; % early apoptotic and % late apoptotic). despite a small numbers of experiments, daudi cell kill was statistically significant at h (p: . ) and h (p: . ) compared to control. however, k cell elimination ( %) has not occurred until h. mast cell-daudi cell conjugates were seen on the wright/giemsa slides (figure) . conclusion: our results demonstrate that human mc can cause cell-mediated cytotoxicity against certain cells in relatively short-term. this further suggests possible contribution of 'granule-exocytosis' pathway to mc natural cytotoxicity, indicating a faster mc response in immune surveillance. o. ozdemir * , m. buyukavci , y. ravindranath , s. savasan , . detroit, mi; . erzurum, turkey. background: the effect of melatonin (mlt) on cellular immunity has been controversial. recently, mlt has been demonstrated to activate t and nk cells through its membrane or nuclear high affinity receptors. it was also shown that pharmacological concentrations of mlt (>nm) could be cytotoxic against different human cancers. aims: our aim was to investigate the effect of mlt alone or in combination with il- on peripheral blood lymphocytes (pbl), lymphokine activated killer (lak) cell generation and its cytotoxicity. methods: pbl were cultured for days in the presence of mlt at different concentrations ( - , - , - m) with or without il- ( u/ml). cell viability was determined by trypan blue exclusion test. cell-mediated cytotoxicity of lymphocytes/lak cells against k- and daudi cells was studied using our established flow cytometric cell-mediated cytotoxicity assay. results: although - m concentration of mlt did not affect cell proliferation much on day , it significantly inhibited proliferation by day (p< . ) consistent with known anti-proliferative effect of mlt. - and - m concentration of mlt also mildly inhibited proliferation on day ; however there was a minimal rebound with - m concentration by day . consistent with the reported mlt-treated pbl's reduced response to mitogens, il- and mlt ( - m) combination suppressed proliferation on days and ; however, with - m mlt concentration pbl counts increased gradually from day to . although mlt treatment alone did not enhance cell-mediated cytotoxicity, il- and mlt combinational treatment at both concentrations ( - and - m) increased it significantly compared to baseline activity (figure) . conclusion: il- and mlt combination at - m concentration resulted in superior lymphocyte proliferation and lak cell-mediated leukemia cell kill. mlt-induced increase in il- r-expression of pbl shown earlier might be the mechanism for our observations. mlt can be considered in immunotherapy as an adjunct to il- treatment. a.e. fusaro * , j.r. victor, c.r. oliveira, c.a. brito, e.a. futata, m. maciel, a.j. duarte, m.n. sato, são paulo, brazil. the maternal exposure to allergens during pregnancy or even in postnatal period may influence the allergy onset to newborns, through antigen or antibody transmission. we sought to verify the effect of maternal antigen exposure before conception, during gestation or in the breastfeeding period on the offspring type i hypersensitivity response. female balb/c mice were immunized or not with ova extract/alum, boosted twice at th and th and mated with normal balb/c male on the th day after sensitization (das). others groups of immunized mothers also received oral administration with ova along pregnancy, or non-immunized mothers received ova only during breastfeeding. offspring from immunized or normal mice were immunized intraperitoneally with ova at do and boosted on the th das. the results showed a important decreased of tgf-levels in the amniotic fluid and milk from immunized mothers before mating in comparison to obtained from normal mothers. ova exposure during pregnancy of immunized mothers decrease significantly the transference of tgf-by breastfeeding, while both tgf-isoforms were founded at high levels in the amniotic fluid. similar levels of tgf-transference by placenta to the newborn was detected in both immunized mother groups. pups from mothers exposed with ag during pregnancy showed an increased spleen cell number, whereas did not produced il- , il- , il- e ifn-secretion induced by antigen neither altered responsiveness to anti-cd or mitogen. maternal ova-immunization induced a marked inhibition of spe-cific ige antibody response in the immunized pups, contrasting to the enhancement of ige responsiveness detected in the immunized pups from mothers which were exposed to ova only at postnatal period. these results showed that preconceptional immunization exert a protective effect on the offspring ige development and an exacerbation of ige responsiveness due to mother antigen exposure during breastfeeding. the findings suggest that rather than in utero antigen priming occurrence, postnatal period may contribute to offspring early life sensitization. financial support: fapesp and lim -fmusp introduction: the reasons for the increased incidence of allergic diseases in westernized countries are still unknown. mercury is an important pollution factor to which humans are increasingly exposed. prior studies on the effect of mercury on mitogen stimulated human lymphocytes indicated a th weighted immune response, but the results were inconsistent and difficult to reproduce. phorbol myristate acetate (pma) is a direct activator of protein kinase c, which has been shown to play a role in mercury induced il- production in animals. therefore we investigated the effect of mercury on pmaactivated human peripheral blood mononuclear cells (pbmc). methods: pbmc from individuals were cultured for days in culture medium containing pma and ionomycin in the presence or absence of mercuric chloride (hgcl ). il- and gamma-ifn concentrations were measured by elisa of culture supernatants. cell death and apoptosis were determined by -aad and annexin staining and fluorescence activated cell sorting (facs). cell-proliferation was assessed by h-thymidin-incorporation. results: after days of culture, pma/ionomycin-stimulated a small amount of il- compared to untreated pbmc ( . +/- . pg/ml versus . +/- . pg/ml). however, mercury induced a more than fold increase in il- production when added to pma-activated cells ( . +/- . pg/ml, p< . ). gamma ifn production was strongly increased in pbmc that were treated with pma/ionomycin (> pg/ml versus +/- pg/ml in unstimulated cells) but dropped markedly in cells treated with mercury plus pma/ionomycin. in addition, mercury induced increased cell death, apoptosis and reduced cell proliferation. conclusions: hgcl strongly stimulates il- production in pma/ionomycin treated pbmc while cell viability and gamma-ifn production drop significantly. these preliminary results suggest that human exposure to mercury may be playing a role in the observed increased incidence of allergic disease in the industrialized world background: mast cells (mc) have been shown to induce natural cellmediated cytotoxicity in long-term ( - hrs.) in vitro assay systems. the cytotoxicity is mediated by at least two pathways: secretory via exocytosis of mc granules containing serine proteases such as granzymes, chymase and soluble tnf-and nonsecretory (cell-to-cell contact) via membranous tnfand fasl. chymase induces apoptosis in neonatal rat cardiomyocytes and human vascular smooth muscle cells. the objective of this study was to investigate mc mediated cytotoxicity against nk/lak-sensitive cells in short term ( hrs.) unstimulated cultures. methods: human bone marrow mononuclear cells were cultured in methylcellulose supported with il- , il- , and stem cell factor. mast cell colonies developed at weeks and were transferred to liquid imdm and maintained for weeks. a flow cytometric cytotoxicity assay was used to determine cytotoxicity against daudi, raji, and k cell lines at hrs., hrs., and hours. the controls consisted of cell lines without mast cells at hrs., hrs., and hours. results: rationale: to establish the antibody response rate in children with recurrent infections and fully immunized with the pneumococcal -valent conjugate vaccine. methods: we have analyzed patients referred to our clinic with recurrent infections despite complete immunization with the pneumococcal -valent conjugate vaccine for age, according to acip guidelines. we assessed the patients by checking their immunization status and the antibody titers to all streptococcus pneumoniae serotypes included in the vaccine ( , b, v, , c, f, f) assessed by standardized elisa. the patients were assembled into groups, a non-immunized group with laboratory data prior to the vaccine, and an immunized group consisting of responders and nonresponders according to their antibody titer (< . or > . iu/ml respectively). the data were analyzed using epi info and spss. results: the mean age was . years for non-responders and . years for responders. there was no significant statistical difference between the groups regarding age, race and sex. ten patients were identified who failed to respond to all serotypes included in the pneumococcal -valent conjugate vaccine. there was no significant statistical difference between the non-immunized and the immunized nonresponders to all serotypes. conclusions: we have identified a special immunological phenotype of specific antibody deficiency (sad) patients with normal total immunoglobulins and normal responses to protein antigens, but who failed to respond to conjugate pneumococcal polysaccharides. a. yates * , r. deshazo , j. butler , g. howell , j. farley , h. liu , n. nanayakkura , g.b.yi , r. rockhold , . jackson, ms; . oxford, ms. introduction: venom from s. invicta consists of % disubstituted piperidine alkaloids and is toxic to insects, birds and farm animals. recent reports of morbidity and mortality in elderly patients after massive fire ant stings suggest the potential for systemic mammalian toxicity. we evaluated the toxic responses to systemic administration of two structurally verified, synthetic s. invicta venom alkaloids, solenopsin a (trans- -methyl- -n-undecylpiperidine) and its cis-isomer, isosolenopsin a, in rats. methods: sprague dawley rats were anesthetized with isoflurane, paralyzed with gallamine, artificially ventilated and instrumented to record arterial blood pressure (bp; mm hg), heart rate (hr; bpm) and % change in left ventricular contractility (lvc; p/ t). in addition, a group of rats was chronically instrumented to record bp and hr while the animals were conscious and freely-moving. results: solenopsin a at to mg/kg iv dose-dependently lowered bp, hr and lvc. at mg/kg iv, hypotension (- ± mmhg), bradycardia (- ± bpm) and decreased lvc (- ± p/ t) were marked. isosolenopsin a, mg/kg iv, produced responses similar to solenopsin a mg/kg iv. solenopsin a mg/kg iv elicited tonic-clonic convulsions and respiratory arrest in conscious, freely-moving rats. hematuria was seen with solenopsin a, but not isosolenopsin a. superfusion of a working, isolated, perfused rat heart with um of solenopsin a elicited a marked, reversible decrease in lvc, and cardiac arrest occurred with um of solenopsin a. conclusion: the results demonstrate that these alkaloids possess significant depressant activity on the cardiac and respiratory systems of rats. the neurologic and cardiorespiratory effects can account for lethality to small mammals in the wild, and may contribute to adverse cardiovascular effects noted in humans after massive fire ant stings. introduction: during asthma attacks, the ph of exhaled breath condensate (ebc) decreases two log orders (ph= . ), returning to normal levels after corticosteroid therapy (ph= . ). ion channels, once thought to participate only in the transport of ions, are now suspected of mediating airway inflammation in asthma as well. to determine whether allergen directly alters airway mucosal ph and ion function, we measured nasal ph and nasal potential difference (pd) before and after nasal allergen challenge (nac). methods: ten allergic rhinitic subjects (mean±sem age . years± . , females) underwent a crossover, single-blinded, placebo-controlled study, where they were challenged with allergen (dust mite, grass, cat) and control diluent in two different occasions in random order via nasal spray. nasal ph was measured on the surface of nasal mucosa with a ph probe. nasal mucosa pd was measured between nasal mucosa and forearm skin. subjects also filled out a nasal symptom scale. measurements were taken at baseline, hour, hours, and hours after nac. results: the nasal symptom score increased significantly immediately after allergen compared to control challenge ( . ± . vs. . ± . respectively, p= . ). there were no statistically significant differences in the nasal ph at h and h, but a significant decrease at h compared with baseline (- . ± . vs. + . ± . , p= . ). the change in ph from h to h correlated significantly and inversely with change in symptoms (r=- . , p= . ) and number of sneezes (r=- . , p= . ) after challenges. nasal pd did not change significantly after challenges. conclusion: allergen decreases nasal mucosal ph in the very late phase after challenge in allergic rhinitic subjects. decrease in airway mucosal ph during asthma exacerbations may be caused by aggravation of allergic inflammation. nasal potential difference does not change after allergen challenge. funding: niaid, acaai foundation introduction: uv induces differentiation of t-and b-lymphocytes, suppresses natural killer cells, renders a tolerogenic effect and induces apoptosis resulting in local and system immunosuppression. methods: lymphocytes were studied using indirect immunofluorescence methods employing monoclonal antibodies to cd-markers cd , cd , cd , cd , cd , hla-i, and hla-ii, from the blood of volunteers (aged - years) before uv exposure (control), after an exposure of blood in vitro to a dose . kj, and after hours of exposure of the medial surface of the elbow joint in vivo (s= cm ), to a dose of . kj. results: the direct exposure of blood results in a significant reduction in the number of lymphocytes, probably due to direct phototoxic effects. significant modifications both of the aggregate number of lymphocytes and amount of t-helpers after uv exposure of the skin were not seen. after uv the number of cells which express the marker cd is sig-nificantly increased. exposure to uv in vitro induces reduced number of cells bearing cd . however on in vivo exposure, a significant increase in number of cells which express cd was observed. uv exposure of blood reduced significantly the hla-i ( . ± . reduced to . ± . ) and hla-ii (dr) ( . ± . reduced to . ± . ) expression. uv exposure of skin increased significantly hla-i to . ± . , while hla-ii (dr) was insignificantly decreased to . ± . . cd expression increased from . ± . to . ± . due to blood uv exposure, while there were insignificant reductions in cd ( . ± . reduced to . ± . ) and cd ( . ± . reduced to . ± . ) expression. conclusion: uv starts a cascade-like response, including apoptosis, leading to changes in nk cell, helper and suppression lymphocyte numbers consistent with an immunomodulating effect of uv radiation. background: previous investigations have shown the involvement of histamine and histamine receptors (h , h , h , h ) in ige synthesis in atopic and lymphoproliferative diseases. ige responses may depend on the concentrations of histamine and histamine receptor antagonists and agonists. the goal of this investigation was to evaluate the role of the concentration of histamine and h /h antagonists along with the importance of pre-existing levels of ige in determining ige responses. methods: ige synthesis was studied in mnc cultures of patients ( - years old) having mild atopic asthma and rhinitis. all patients had high levels of total ige and specific ige to ragweed pollen, house dust mite, epidermal or mold allergens. patients were divided into two groups according to the serum ige and levels of spontaneous ige synthesis: group a -with low levels ( . ± . iu/ml) and group b -with high levels ( . ± . iu/ml). the serum level of total ige in group a was . ± . iu/ml and in group b was . ± . iu/ml. fub hydrogenmaleate was used as an h /h specific antagonist. results: histamine in high concentrations ( - m) suppressed and in low concentrations ( - m) stimulated spontaneous ige synthesis. the h /h antagonist fub activity depends on the pre-existing levels of ige. in high concentrations ( - m), the antagonist increased ige synthesis only in group a, but not in group b having high spontaneous levels of ige synthesis. the synthesis in group a increased . fold (p< . ), but h /h blockade cancelled the ige suppressive effect of high concentrations of histamine ( - m). the addition of histamine into the mnc culture stimulated ige synthesis . fold. fub had no effect on ige-stimulatory effects of low concentrations of histamine ( - m). in allergen (ragweed)-stimulated mnc culture, fub had a co-stimulatory effect on ige synthesis induced by histamine. conclusions: the ige stimulating response depends on the concentrations of histamine and the h /h antagonist as well as pre-existing levels of serum ige and ige spontaneous synthesis. introduction: preliminary data has shown that oral contraceptives can precipitate or worsen attacks of hereditary angioedema (hae). it is thought that estrogens affect the synthesis and degradation of bradykinin with resulting edema. objective: our objective is to determine if there is a difference among the various oral hormonal preparations, namely, combined monophasic, combined multiphasic, progesterone only, and hormone replacement therapy, in regards to their effect on frequency of hae exacerbations. methods: patients in this study consisted of women over the age of diagnosed with hae who receive their care at our institution and women meeting the same criteria who are active in the hae foundation and have access to this association's web page. all patients answered a sixteen item questionnaire about past or present birth control pill or hormone replacement therapy usage and its impact on the frequency of exacerbations. results: of the patients who completed the questionnaire, % had taken or were currently taking oral contraceptive pills or hormone replacement therapy. of the women whom had taken monophasic birth control pills, % worsened with increased number and severity of exacerbations. however, only % of the women that had used combined multiphasic birth control pills worsened. all of the women who had tried progesterone only birth control pills worsened. of those on isolated estrogen for hormone replacement, % had an increased number of exacerbations. when androgens were used concurrently with oral contraceptive pills or hormone replacement therapy, exacerbations decreased to %. conclusion: we are not able to demonstrate a statistical benefit of one oral contraceptive pill preparation over another because of our sample size. however, our preliminary data supports that the oral contraceptive pill which produces less exacerbations and less symptoms is a combined multiphasic pill with concurrent androgen treatment. introduction atopic dermatitis (ad) is associated with multiple immunological abnormalities including imbalances in the subsets of blood circulating lymphocytes forming cellular infiltrates in inflamed skin. many studies of the functional and phenotypic properties of lymphocytes in ad have been limited to either peripheral blood or skin-infiltrating lymphocytes. the purpose of our study was to evaluate and compare the content and phenotypic properties of cd + lymphocytes from blood and inflamed skin of ad patients. materials and methods adult (age - years) patients with chronic ad were selected by the criteria of hanifin. all patients gave written informed consent. the cd + lymphocytes of peripheral blood were phenotyped by flow cytometry. skin biopsies were obtained from eczematous areas, then cryosected and double immuno-histochemistry was performed. for phenotyping of lymphocytes in blood and skin a panel of monoclonal antibodies was used including cd , cd , cd , cd , hla-dr and cla. results immunophenotype analyses of the peripheral blood lymphocytes showed a predominance of cd +cd + cells ( %± . ). most cells were cd +hla-dr+ ( %± . ) and cd +cd + phenotype ( %± . ). double immunohistochemistry of the skin biopsies revealed in the epidermis rare but constant presence of cd +cd +cells ( . ± . cells/mm ) and cd +hla-dr+ cells ( . ± . cells/mm ). in the dermal inflammatory infiltrates the predominant cells were cd +cd + ( . ± . cells/mm ) and cd +hla-dr+ ( . ± . cells/mm ). the dominant inflammatory infiltrate consisted of cd +cla+ phenotype ( . ± . cells/mm ) cells. conclusion in ad skin inflammation is associated with the appearance in the circulation of cd + lymphocytes in activated form (cd +hla-dr+) and lymphocytes with regulatory properties (cd +cd +). these lymphocytes are recruited from the circulation, having the skin homing properties (cd +cla+), and form the main constituent of the dermal inflammatory infiltrate. contact dermatitis (cd) comprises a spectrum of inflammatory skin reactions usually caused by exposure to non-immunogenic low molecular weight substances (haptens). failure to diagnose the condition may result in a chronic and disabling condition with impaired quality of life. a yr-old white male presented with a severe, symmetrically distributed facial maculopapular rash with secondary excoriated lesions. prior to the appearance of the rash, the patient had been applying lubriderm as a skin moisturizer for dry skin. a standardized thin layer rapid use epicutaneous (true) test containing chemical agents suspended in a vehicle and attached to an adhesive backing was applied to the patient's back. at hrs, a positive reaction was observed at the skin site of the paraben mix application. the lubriderm preparation used by the patient contained paraben, in contrast to a newer preparation, advanced therapy lubriderm, which is paraben-free. complete resolution of the facial lesions occurred following discontinuation of the lubriderm and the use of oral and topical corticosteroid therapy. this case report illustrates how a commonly used moisturizer can contain a sensitizing agent that could be detected by standardized patch testing which should be a part of the diagnostic armamentarium of every allergist-immunologist. we report how a commonly used and effective moisturizer (lubriderm) can cause severe allergic cd and that the use of a standardized thin layer rapid use epicutaneous (true) patch test panel can be an effective diagnostic tool for the detection of the offending agent. rationale: this study aimed to establish the possible differences of cutaneous sensitization to common aeroallergens in children under years old. methods:the study was conducted between - and included infants from silesia/southern part of poland/.these infants were refered to our allergy unit due to respiratory symptoms like rhinitis, otitis, pharyngitis, cough, bronchitis recurring;eye's symptoms/ conjunctivitis/ and oral symptoms. the skin prick test/ spt/ to major aerollergens in our environment(hdii, birch, alternaria, cladosporium and trees)were done to -months-old and -yearold children. a spt of mm or larger was considered as positive. patients were classified into three groups: i:positive family atopy ii:smoking ciggarettemother/ or father iii:cat or dog at home iv: coexisting food allergy results: , % of examined children were boys. the prevalence of sensitisation found were as follows:latex , %, birch , %, dpii- , %, grass pollen , %, alternaria- , %. positive spts to latex were first seen in the -months-old group and this prevelance doubled until they finished year. conclusion: in our study, cutaneuos sensitisation start to appear in -months-old chlidren. background: propylene glycol (pg) may induce allergic contact dermatitis (acd) and skin irritant reactions. topical formulations frequently contain pg. it is present in low concentration ( %) in pimecrolimus cream %, a non-steroid inflammatory cytokine inhibitor. objectives: this study was designed to assess the incidence of cutaneous responses to pimecrolimus cream in patients allergic to pg and to determine their nature (acd or irritation) and severity. methods: in this double-blind, randomized, vehicle-controlled, withinpatient study, subjects allergic to pg underwent -hour patch-testing (pg and %, pimecrolimus cream and vehicle) followed by a -day repeated open application test (roat). application sites were assessed by the investigator using a scale ranging from (no reaction) to (spreading bullous reaction) at , , and hours after patch removal and at the completion of the roat. results: pg allergy was confirmed by patch-testing in patients. two patients showed a positive patch-test reaction with pimecrolimus cream and vehicle, indicating an acd. in contrast, no patient demonstrated signs of acd when pimecrolimus cream was applied under normal conditions, i.e. without occlusion (roat). the statistical analysis showed that there were significantly less reactions at pimecrolimus patch-test sites than at the pg patch-test sites (p< . for both pg concentrations, one-sided exact binomial test) and that the median severity was lower with pimecrolimus cream vs. pg (p= . and p< . for pg % and % respectively, wilcoxon signed-rank test). conclusions: this pilot study suggests that pimecrolimus cream %, when applied under normal conditions, can be used safely in patients with pg allergy. introduction: chronic idiopathic urticaria is not always responsive to antihistamine therapy. multiple alternative agents have been tried. we report two cases where tacrolimus has been successful in treating this condition. methods: this is a case report of two patients who have chronic idiopathic urticaria and have been treated with tacrolimus. patient # is a y/o wm who pre-sented with urticaria that had been going on several months. the duration of his urticarial lesions was < hours his urticaria was treated with several medications including: hydroxyzine, cyproheptadine, ceterizine, montelukast, colchicine, and dapsone. he was intolerant to hydroxychloroquine. montelukast seemed to provide some modest benefit but he continued to have daily urticaria with > lesions/day after two months of therapy. tacrolimus was added to montelukast at mg bid. patient # is a y/o wf with a history of biopsyproven urticaria. she had suffered from episodic urticaria since the age of six that was responsive to systemic steroids. after thirty years of having no urticaria, she developed recurrent urticaria at age . at this time, she was treated with hydroxyzine, doxepin, montelukast, loratadine, ceterizine, fexofenadine, colchicine, dapsone, and even prednisone with very little improvement in symptoms. she was then started on tacrolimus mg bid as monotherapy while she was having daily urticaria. results: after one month of treatment with tacrolimus mg bid, patient # had a decrease in the number of urticaria. his dose of tacrolimus was increased to mg/day, and after four weeks, his urticaria resolved. he remained on tacrolimus for a total of six months which was tapered and discontinued. he continues to be in remission from urticaria. patient # had complete resolution of her hives after just two doses of tacrolimus. after two months, she remains free of urticaria on tacrolimus mg bid. conclusion: for patients with severe chronic urticaria unresponsive to multiple therapies, tacrolimus, like cyclosporine, may be efficacious. tacrolimus may also be truly immunomodulatory and capable of inducing remission of urticaria. s.v. gerasimov * , lviv, ukraine. introduction. recent studies suggest that probiotics can be useful in prevention and treatment of atopic dermatitis (ad) in children. as clinical effect of probiotics varies greatly depending on the specific strain, we are currently conduct a search for the most promising probiotic to be used as complementary therapy in infants and young children with ad. methods. we studied infants aged - weeks ( ± ) with ad established using hanifin and rafka criteria. patients were evenly allocated among probiotic (n= ) and nonprobiotic (n= ) treatment groups using quota allocation system. severity of ad was defined using scorad index and infant`s quality of life was assessed using idqol index. patients were examined before and weeks after the treatment with/without probiotic powder formulation (b. infantis, l. acidophilus dds- , billion cfu/day, dds-junior, uas laboratories). we compared pre/posttreatment values of indices above and amount of mometasone furoate ( , %) used employing a paired or unpaired t-test. results. at baseline, infants in either groups were comparable on age, gender, duration of the disease, scorad and idqol indices, and medication taken for the previous weeks. before entering the study all patients were maintained on allergen elimination diet due to milk and egg white allergy. after the treatment with/without probiotics the mean scorad index decreased from , to , (p= , ) and from , to , (p= , ), respectively. however, the mean amount of mometasone furoate used in non-probiotic treatment group was significantly greater ( , g vs , g, p= , ), despite the same recommendation on the use of the drug was given. additionally, parents of children taking probiotics reported an improvement in infant`s quality of life as seen on the decrease of idqol index from , to , (p= , ). in non-probiotic group decrease in idqol was not significant ( , to , ; p= , ) . there were no adverse events in any of the treatment groups. conclusions. our preliminary results suggest that some probiotics may have a corticosteroid-sparing effect and improve quality of life of infants with ad. there is a clear trend towards reduction of scorad index, which did not change significantly, probably due to a limited number of patients involved. introduction : the aim of this study was to analyze the risk factors of severe atopic dermatitis(ad) in the first months of life. methods : the children aged less than months with ad were divided into two groups according to six area six sign in atopic dermatitis(sassad) score. children with score less than was classified as mild ad(n= ) and those with score above as severe ad(n= ). these patients were fed with breast milk or cow's milk formula, and no allergenic food was given except rice and some vegetables. we analyzed the gender, feeding patterns, family history of allergy, number of siblings, total ige and specific ige to common food allergens (egg white, cow's milk, wheat, soy) by cap-feia assay. total eosinophil count was ± /ul in severe ad and ± /ul in mild ad(p< . ). results : ) total ige was . ± . u/ml in severe ad and . ± . u/ml in mild ad(p= . ). specific ige to egg white, wheat and soy ( . ± . u/ml, . ± . u/ml, . ± . u/ml in severe ad; . ± . u/ml, . ± . u/ml, . ± . u/ml in mild ad; p< . ) were associated with severe ad, but cow milk( . ± . u/ml in severe ad, . ± . u/ml in mild ad) showed no difference. ) gender, feeding patterns, family history of allergy and the number of siblings were not significantly associated with severe ad. conclusion : severe ad is associated with sensitization to food allergens in the first months of life, although they are not fed with those foods. background: atopic dermatitis (ad), an inflammatory skin disease diagnosed primarily in children, has been shown to have a negative impact on quality of life (qol). pimecrolimus cream % is a non-steroid, topical calcineurin inhibitor with demonstrated efficacy in the acute treatment and longterm management of pediatric and adult ad. in a -week, double-blind, vehicle-controlled study, a secondary aim was to evaluate the impact on parent's quality of life of a pimecrolimus-based or corticosteroid (cs)-based treatment regimen of children with ad. methods: children aged months to years (mean years) with mild to severe ad were randomized : to receive treatment with pimecrolimus or vehicle cream. emollients for dry skin and pimecrolimus or vehicle bid were applied at the first signs of ad. for severe flares, a mid-potency topical cs (fluticasone or mometasone) indicated for once-daily use in ad replaced the evening study drug application for a maximum of weeks or until all ad resolved. parents completed the parent's index of quality of life-atopic dermatitis (piqol-ad), a -item validated questionnaire, which measures parent's needs-based qol, at baseline, week , and study completion. change in piqol-ad scores at baseline and week were compared between treatments. a negative change indicated improvement. results: parents of patients in both groups reported improvement in piqol-ad scores at week , with greater improvement for the pimecrolimus group. the mean change in piqol-ad score from baseline to week was - . in the pimecrolimus group vs. - . in the cs-based treatment group ( . % vs. . % improvement, respectively). ancova analysis, using treatment and center as main effects and baseline score as a covariate, compared the change in piqol-ad score in two treatment groups. pimecrolimus treatment demonstrated a more favorable change (- . ) which approached statistical significance [p= . ; %ci= (- . , . )]. conclusion: a treatment regimen utilizing pimecrolimus cream % had a beneficial effect on parent's quality of life compared to a corticosteroid-based regimen. this benefit was consistent with other measures of efficacy studied. introduction: atopic dermatitis is a chronic, inflammatory and recurrent skin disorder . its prevalence has increased in recent decades but little is known about it in mexico city. the aim of this study was to evaluate the prevalence and severity of atopic eczema in a pediatric population. methods: a cross-sectional questionnaire survey (isaac phase i questionnaire) was conducted on random samples of schoolchildren aged to years and to years from educational centers of four northern counties from mexico city. those children with a positive response to being questioned about the presence of an itchy relapsing skin rash in the last months were considered to have atopic dermatitis. children whose symptoms resulted in sleep disturbance for or more nights per week were considered to have severe atopic eczema. statistical analyses were done with spss . for windows, chi square . the size of the sample was determined folowing the isaac specifications and calculated with the statcal program. results: complete data was available for children aged to years in schools and children aged to years in high schools. . % males and . % females. response rates were high ( . % for those aged to years and % for those aged to years). the prevalence of symptoms of atopic dermatitis in the last months was . % at age to and % at age to years. medical diagnose of atopic eczema was % and . % for children aged to years and to years, respectively. reported eczema accounted for . % and . % at age to and to years, respectively. children with symptoms of severe atopic dermatitis accounted for % of all those with symptoms of atopic dermatitis. we also found that the majority of the children begun with skin manifestations of atopic dermatitis before the age of years old. conclusions: the prevalence of atopic eczema was very similar for both groups of ages. our results agree with those found in other two studies acomplished in other mexican cities (cuernavaca and chihuahua) and with those from other countries of latin america like brazil, chile and costa rica. although, we found lowest values than those from sweden, japan and australia. studies that include objective skin examination are required to confirm these findings. a. kaplan * , s. meeves , y. liao , s.t. varghese , g. georges , . charleston, sc; . bridgewater, nj. introduction: the symptoms of chronic idiopathic urticaria (ciu) can have a profound impact on patient health and quality of life. the safety and efficacy of fexofenadine (fex) bid for the treatment of ciu has been previously established in two multicenter, double-blind, randomized, placebo-controlled trials. this study evaluated the efficacy and safety of a qd dose of fex hcl mg, as this dosing schedule could offer advantages in terms of patient compliance and convenience. methods: this multicenter, randomized, double-blind, parallel-group, placebo-controlled study consisted of a single-blind placebo run-in period of - days, followed by a (± )-day treatment period. males and females aged years with a diagnosis of ciu and with active disease were enrolled. patients were randomized : to receive either fex hcl mg qd or placebo qd. the primary endpoints were change from baseline in mean daily number of wheals (mnw score) and mean daily severity of pruritus (measured on a -point scale) over the -day treatment period, as assessed reflectively by the patient. secondary efficacy measures included a modified total symptom score (motss), comprising sum of number, frequency, size and duration of lesions, and severity of pruritus. mnw and pruritus severity were also assessed instantaneously at trough drug levels (immediately prior to dosing). results: over the -day treatment period, patients treated with fex (n= ) experienced significantly greater improvements in mnw and pruritus scores compared with the placebo group (n= ) (p< . for both). similarly, over the treatment period, and at individual weekly timepoints, the mean reductions in am reflective, pm reflective and mean daily motss were significantly greater for patients in the fex group compared with those in the placebo group (p . for all comparisons). the mean reductions in instantaneous mnw and pruritus scores were greater with those who received fex than those who received placebo (mnw: p= . ; pruritus score: p= . ). there were no significant differences in the frequency of treatment emergent adverse events between the two treatment groups, and no clinically relevant changes were observed with respect to clinical laboratory data, vital signs or ecgs. conclusion: this study demonstrated that a qd dose of fex hcl mg offers effective and well-tolerated relief from the symptoms of ciu. introduction: the wheals and pruritus associated with chronic idiopathic urticaria (ciu) are often so debilitating that they have a profound impact on patient quality of life. specifically, ciu has been shown to negatively affect patient mobility, sleep, energy levels, social interaction and emotional wellbeing. the purpose of this study was to examine the impact of treatment with fexofenadine hcl (fex) mg on health-related quality of life (hrql) among patients with ciu. methods: as part of a multicenter, randomized, double-blind, parallel-group, placebo-controlled study, designed to evaluate the efficacy and safety of a once-daily dose of fex mg in ciu, the impact of treatment on hrql was also examined. patients were asked to complete the dermatology life quality index (dlqi) and the work productivity and activity impairment questionnaire (wpai) at baseline and at weeks and (final visit or early termination). the primary endpoint was mean change from baseline in dlqi total score, using the mean data of evaluations performed at weeks and as the post-baseline measure. secondary endpoints included change from baseline in individual dlqi domains and wpai scores. additional analyses were conducted to examine the reliability, validity and responsiveness of the hrql measures. results: a total of patients were included in the hrql population: n= fex, n= placebo. patients in the fex group experienced significantly greater improvements in the mean dlqi total score than those in the placebo group (p= . ). this pattern was repeated with respect to the individual domains of symptoms and feelings (p= . ), daily activities (p= . ), leisure (p= . ) and personal relationships (p= . ). both treatment groups reported improvements in productivity, as measured by change from baseline using the wpai. patients randomized to fex experienced significantly less impairment while working (p= . ) and performing activities (p= . ) than those who received placebo. the dlqi was demonstrated to be reliable (cronbach's alpha= . ); both the dlqi and wpai were found to be valid and responsive instruments in this ciu population. conclusion: this study demonstrated that a once-daily dose of fex mg improves the hrql of patients with ciu, as assessed by change in dlqi total score. t. algozzine * , a. lee , s. wong , l. anzisi , . manchester, nh; . centerport, ny; . syosset, ny; . mamaroneck, ny. symptoms of allergic and non-allergic rhinitis may significantly impact a patient's quality of life, by causing fatigue, headache, cognitive impairment and other systemic symptoms. appropriate management of allergic rhinitis is important in the effective management of coexisting or complicating respira-tory conditions (e.g. asthma, sinusitis, or otitis media). in addition, many commonly used over-the-counter (otc) antihistamines can cause performance impairment that may impact daily activities. we designed a brief ten-question allergy survey in an attempt to determine how patients were being treated for their allergies, evaluate a patient's self-assessed impact of their allergies on their daily activities, and identify any difference in treatment outcomes between primary care and allergist practices. patients were invited to complete the surveys anonymously. completed surveys were collected and entered into a microsoft access database for evaluation. minitab was utilized for statistical calculations. four hundred and thirty seven patients completed the survey. fifty-eight percent of survey respondents were women and % were adults (age > ). of those patients surveyed, % (n= ) were under the care of an allergist. compared to primary care, patients treated by allergists reported more allergies ( . vs. . , p < . ) and received more medications on average ( . vs. . , p< . ). pollen was the most common allergy type reported among all patients. while the majority of all patients ( %) received prescription medications, more primary care patients received no therapy or only otc treatment when compared to allergist patients ( % vs. %, p< . ). seventy-four percent of primary care patients reported their allergy symptoms were controlled compared to % of allergist patients (p< . ). patients receiving treatment from an allergist reported less impact of their allergies on daily activities (a lower score signified less impact) compared to patients seen in primary care ( . vs. . , p< . ). the results of our survey suggest that allergists treat more complex patients. these patients had multiple allergies, more uncontrolled symptoms, and utilized more prescription medications. despite these findings, patients treated by allergists reported less impact of allergies on their daily activities. introduction the patogenic mechanism of nasal polyps are unknow.they frecuently are associated with aspirin intolerance, intrinsic asthma, chronic sinusitis, young sindrome, cystic fibrosis, kartagener syndrome and churg-strauss syndrome.chemical mediators found in nasal polyps are as follows: histamine, serotonin, leukotrienes, norepinefrine and possibly pgd .recently, leukotrienes have been implicated in mediation of bronchoconstriction and inflammatory leukotriene levels have also been shown to be elevated in some patients with sinonasal polyposis (figure ) hypothesis antileukotrienes might play a significant role in controlling polyposis and symptoms secundary to sinonasal disease, and they might viable alternative to longterm, oral steroid therapy and repeat surgical debridement purpose this study was undertaken to evaluate the potential role of leukotriene receptor antagonist on recurrent polyposis associated with asthma and improvement of some factor implicated with them design of study:clinical assay, prospective, triple blind. materialsand methods:the study involved patients ( %) males and ( %) women, mean age . years, with a range - years selection criteria:inclusion criteria: nasal polyps associated with astha, allergic or non allergic.exclusion criteria: patients with any concurrent illness, use of sistemic or local corticosteroidsor any kind of antileukotriene within month prior to the beggining of the study.we made an alleatory selection patients recived montelukast ( mgs/day), and nasal steroids, beclometasone ( mgs/day) for months. patients recived loratadine plus pseu-doefedrin mgs/ mgs/day and nasal steroids, beclometasone, patints were operated of fees and transnasal endoscipic polypectomy plus montelukast and nasal steroids, beclometasone ige serum levels .skin prick test .sensitivity in vitro .ct scan . celullarity on nasal lavage (eosinophils and neutrophils) .proinflamatory cytokines (il -il -il ) on nasal lavege by elisa test. results ther was a tendency for more improvement of the group ( surgery-montelukast-local steroid) of symptoms and objective measurments, in second place of improvement the group montelukast-local steroid) and the worse on improvement subjective and objetive was group local steroid and loratadine-pseudoefedrine use as placebo introduction: sensory perceptions of intranasal corticosteroids (ins) vary among products and can be unpleasant and affect adherence to therapy. methods: we conducted a cross-sectional study of patients across allergy and immunology clinics in the united states. respondents were asked to choose between pairs of hypothetical ins that differed by sensory attribute composition. based on prior research, we measured salient sensory attributes: smell, taste, aftertaste, throat rundown, nose runout, and feel of spray in nose/throat. each attribute was described in intensity levels, such as "no taste" (low), "weak taste" (moderate), and "strong taste" (high) ( table) . other outcomes included an importance score for each sensory attribute and patients' willingness to adhere to an ins having the lowest levels of each sensory attribute compared to one with moderate levels. results: preferences decreased with increasing intensity level of each sensory attribute. the most important attribute was aftertaste in % of patients, taste in %, throat rundown in %, nose runout in %, smell in %, and feel of spray in %. only % had more than one attribute tied for most important. if instructed to take ins daily for months, % of patients stated that they would definitely be able to follow their doctor's advice (willing to adhere) if given an ins containing the lowest level of each sensory attribute compared with % for one having moderate levels (p< . ). conclusions: patients' preferences decrease with increasing intensity levels of each sensory attribute and affect patients' willingness to adhere. tailoring ins to patient preferences may lead to improved treatment satisfaction and adherence. introduction:a high prevalence of rhinitis and asthma comorbidity has been persistently noticed in epidemiological studies in last years. our objective was to evaluate the prevalence of rhinitis and asthma comorbidity in a portuguese population including both atopic and non-atopic patients. methods: a retrospective study was performed. clinical records from patients attending an immunoallergology outpatients'clinic during months (from january until june ) were reviewed. data were collected concerning clinical history of rhinitis and/or asthma, aeroallergens'skin prick tests and respiratory function evaluation. results: among the patients attending an appointment during the study period, ( . %) had rhinitis and/or asthma ( . % f; . % m;mean age +/- years). patients with respiratory disease included atopic ( . %) and non-atopic %). diagnosis of asthma, rhinitis or of both diseases was made in ( . %), ( . %) and ( . %), respectively, in atopic patients and in ( . %, ( . %) and ( . %), respectively, in non-atopic patients. rhinitis was diagnosed in . % of atopic asthmatic and in - % of non-atopic patients with asthma. in patients with rhinitis, asthma was also diagnosed in . % of atopic patients and . % on non-atopic patients. conclusions: in this study population rhinitis was frequently diagnosed in patients with asthma and vice-versa, thereby leading to a high prevalence of this comorbodity. this association was more frequent in atopic patients. our data are comparable to those we found in recent literature. these results suggest that clinical investigation of asthma should be mandatory in management of patients with rhinitis as well as asthmatic patients should be routinely submitted to clinical evaluation of rhinitis. introduction: cetirizine hcl (c) has been shown to be more effective than fexofenadine hcl (f) in controlling seasonal allergic rhinitis (sar) symptoms at - hr post-dose, however, the efficacy of c and f was comparable between - hr post-dose. response to treatment in the middle of the dosing interval needed to be addressed. methods: this randomized, double blind, placebo (p)-controlled study was designed to compare the efficacy and tolerability of a single dose of c mg, f mg, and p between - hr postdose in ragweed-sensitive sar subjects. subjects meeting entry criteria were exposed to pre-determined controlled levels of ragweed pollen in the eeu during priming and double blind treatment. subjects assessed rhinitis symptoms at half hr intervals during pollen exposure; at priming, at the qualifying period, at baseline, and from - hr post-dose. the primary efficacy endpoint was the change from baseline in total symptom severity complex (tssc) score at hr post-dose. tssc score was the sum of severity ratings ( =absent to =severe) for symptoms: runny nose, sneezing, itchy nose/palate/throat and itchy/watery eyes. results: a total of subjects (mean age . y; . % females) were randomized: c, ; f, ; p, . baseline characteristics were comparable among groups; tssc: c= . , f= . , p= . . c produced a % greater reduction in tssc score at hr (- . , p= . ) and a % greater reduction overall (i.e., average over the - hr post-dose period) (- . , p= . ) compared with f (- . , - . , respectively). both c and f reduced tssc score more than p ( hr, - . ; overall, - . , p< . ) including all individual symptoms (p< . ). c however, was more effective than f for runny nose and sneezing at hr and overall, itchy/watery eyes at hr, and itchy nose/throat/palate overall (p< . ). rates of discontinuation due to adverse events (aes) were low: c, . %; f, %; p, . %. the incidence of treatmentemergent aes was similar: c, . %; f, . %; p, . %. somnolence occurred in . % of subjects on c, and % on f or p. conclusion: c produced a greater improvement in rhinitis symptoms compared with f and p, at hr post dose and over the - hr post-dose period. all treatments were safe and well tolerated. background: medication utilization patterns of patients suffering from seasonal allergic rhinitis (sar) are not well documented, and although many anti-allergic medications are prescribed for daily use, actual usage is unknown, but recognized to be quite variable. methods: subjects with positive ragweed skin tests were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms, usage patterns and reasons for choice of anti-allergic medication. results: subjects completed the survey ( . %). the prevalence of symptoms were, in decreasing order: sneezing ( . %), runny nose ( . %), itchy/gritty eyes ( . %), stuffiness ( . %), itchy nose ( . %), watery eyes ( . %), itchy palate/throat ( . %), post-nasal drip ( . %), red/burning eyes ( . %), headache ( . %), itchy ears ( . %), cough ( . %), shortness of breath ( . %), and wheeze ( . %). sar patients used antihistamines most frequently ( . %), followed by decongestants ( . %), combination (antihistamine/decongestant) products ( . %), and intranasal corticosteroids ( . %). medications were mostly taken intermittently rather than daily (antihistamines . %; nasal corticosteroids . %), conclusion: a constellation of nasal symptoms were the most common seasonal allergic manifestations, followed by ocular, palatal and ear irritation. antihistamines were the most frequently used medication to treat symptoms, succeeded by decongestants (alone or in combination). a significant proportion of subjects took their allergy medication, including nasal corticosteroids, intermittently rather than regularly, underscoring the relevance of single-dose evaluations of drug efficacy. a.k. ellis * , e. rafeiro, j.d. ratz, j.h. day, kingston, canada. background: traditional assessment of seasonal allergic rhinitis (sar) medication efficacy utilizes randomized controlled trials over - weeks in season. an additional study method employs single-dose responses using controlled allergen challenge such as the environmental exposure unit (eeu). a comparison of allergic symptoms generated by controlled allergen challenge to those occurring in ragweed season symptoms has not been done. methods: subjects with known sar to ragweed were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms. subjects participating in a subsequent controlled allergen challenge study using the eeu, were again asked to complete a similar survey that documented symptoms generated in this model. those who completed both surveys comprised the primary analysis group. results: subjects completed the ragweed season survey, subjects completed the eeu survey, and completed both. symptoms generated by eeu exposure were similar to those elicited during ragweed season, with the exception of cough ( % vs. %, respectively, p < . ). subjects reported that symptoms were more severe in the eeu than those experienced on a typical ragweed season day, but less severe than those during peak ragweed season days. conclusion: allergic upper respiratory tract symptoms produced during controlled ragweed pollen exposure in the eeu were similar in nature and degree to those expe-rienced during ragweed season, supporting evidence that the eeu is a valid model for studying sar. r. nave , m.a. wingertzahn * , s. brookman , s. kaida , t. shah , . konstanz, germany; . florham park, nj; . princeton, nj; . tokyo, japan. rationale: ciclesonide (cic) is a new corticosteroid under development for treatment of allergic rhinitis (ar). cic is a pro-drug that is hydrolyzed to the active metabolite desisobutyryl-ciclesonide (des-cic) in the target tissue. cic has low oral bioavailability and is highly bound to plasma proteins; therefore cic administered as a nasal spray is expected to have minimal local and systemic effects. objective: the primary objective was to evaluate the safety and tolerability of repeated escalating doses of cic ( - mcg/day) given as a nasal spray for days to healthy and asymptomatic subjects with sar. secondary objectives were to determine pk of cic and des-cic and to evaluate the effect of cic on endogenous cortisol. methods: this was a single-center, randomized, placebo-controlled, double blind, modified sequential dose study. six cohorts were randomized. cohorts i-v consisted of healthy subjects given doses of cic up to mcg bid. cohort vi (asymptomatic sar subjects) received mcg bid. each cohort was comprised of subjects who received cic and subjects who received placebo. safety assessments were conducted by recording adverse events (aes), clinical laboratory, eye, and nasal examination findings. serum and urine samples were taken for evaluation of cortisol levels. cic and des-cic serum concentrations were determined by lc-ms/ms. results: no trend was observed for aes when comparing cic and placebo treatment. additionally, no subject experienced a serious ae or withdrew from the study due to an ae during the trial. cortisol levels showed no differences between the dose groups or between activetreated subjects and placebo-treated subjects. additionally, serum concentrations of cic and des-cic in the majority of serum samples were shown to be below the lower limit of quantification (lloq; pg/ml for cic and pg/ml for des-cic), therefore no descriptive statistics could be calculated. con-clusions: ciclesonide nasal spray, at the doses evaluated, was safe and well tolerated in healthy and asymptomatic sar subjects with no detectable effects of cic on serum or urinary free cortisol concentrations. additionally, no pk parameters could be calculated for cic nasal spray, as it was virtually undetectable in serum despite the use of a sensitive assay. the preferred treatment for allergies is avoidance. air filtration is logical but room air purifiers have been of limited efficacy. zephyr™ is a new device which creates an envelope of air % free of allergenic particles around the head of the sleeping person. allergic rhinitis frequently causes daytime somnolence. this is a pilot study of the effectiveness of zephyr on symptoms of seasonal allergic rhinitis (ragweed hay fever) and on daytime sleepiness. methods: subjects age to with ragweed hay fever were studied in the ragweed season using each subject as his/her own control. usual allergy medicines were not allowed, except loratadine for rescue. outcome measures were a symptom score, juniper rhinitis quality of life questionnaire, a tolerability rating, and epworth sleepiness scale. during the first week subjects qualified by symptom scores, then entered the one-week treatment period with zephyr. the third week was a post-treatment observation period. results: of participants, ( %) showed symptom improvement. the whole group averaged % reduction in morning symptoms and % reduction in evening symptoms. sleepiness scores improved %. rhinitis qol improved %. the zephyr system was well tolerated as evidenced by the response to several statements regarding zephyr use and tolerability: (scoring: = strongly disagree, = strongly agree) "the system did not bother me while i was sleeping." (mean score . ) "the noise level did not affect my ability to sleep." (mean score . ) "the temperature was just fine for me." (mean score . ) "the system did not get in my way during sleep." (mean score . ) conclusions: zephyr significantly reduced seasonal hay fever symptoms and daytime sleepiness, improved quality of life, and was well-tolerated by subjects. zephyr may provide maximal environmental control of bedroom allergen exposure irrespective of ambient airborne allergen levels in the room. nasal congestion is an important symptom that is associated with significant morbidity in the rhinitis sufferer. disrupted sleep leading to daytime fatigue, loss of concentration, and decreased productivity are potential results of this symptom. a study employing online interviews with rhinitis sufferers from harris interactive's online database was conducted in order to understand the symptoms they identify with most and to determine the impact nasal congestion had on their daily activities. respondents were at least years of age and experienced nasal congestion from seasonal allergic, perennial allergic, and/or perennial non-allergic rhinitis. the results showed that % of the respondents agreed nasal congestion is the most bothersome symptom of rhinitis; % experienced nasal congestion daily, while % experienced it several times per week. not surprisingly, sleep was the most important factor affected by nasal congestion. two-thirds ( %) of the respondents felt their sleep had been moderately or significantly impacted by nasal congestion, and more than half ( %) felt it was difficult to get a good night's rest because of congestion. sleep was interrupted or disturbed by nasal congestion approximately nights per week, on average. furthermore, sleep disruption from nasal congestion contributed to daytime fatigue; % of the respondents indicated that they were typically tired or fatigued during the day when they experience nasal congestion. in addition, % felt that activities requiring concentration, such as reading, were moderately or significantly impacted by nasal congestion. this study confirms that nasal congestion causes the rhinitis sufferer significant problems beyond that of just a stuffy nose. consequently, healthcare providers need to ensure that their rhinitis patients who have nasal congestion as their primary complaint are managed effectively. desloratadine (dl, clarinex ® ) is a non-sedating oral antihistamine that is metabolized to -oh dl. however, a phenotypic polymorphism has been observed in some patients that results in reduced formation of -oh dl. the prevalence and safety profiles of such poor metabolizers of dl were examined in pharmacokinetic and clinical trials. a poor metabolizer was defined as a subject having a -oh dl to dl auc ratio of < . , or a dl half-life of hours. in pediatric studies, where a sparse sampling approach was uti-lized to screen for poor metabolizers, a plasma concentration ratio of -oh dl to dl of < . at hours classified a subject as a poor metabolizer. a total of , adult and pediatric subjects ( - years old) were phenotyped with a single dose of dl or loratadine. the overall prevalence of the poor metabolizer phenotype was % ( / ). this prevalence was comparable for adult ( / , %) and pediatric subjects ( / , %), and greater in both populations among blacks ( % pediatric, % adult) than caucasians ( % pediatric, % adult). pharmacokinetic analysis found that exposure to dl was approximately -times higher in poor metabolizers than in normal metabolizers. there was no apparent difference in dl exposure among poor metabolizers in different age groups ( -months to < -years, -to < -years, -to < -years, and -years) when treated with age-appropriate doses. the multiple-dose ( - days) safety profile of dl was examined in pediatric poor metabolizers ( - years) in placebo-controlled trials, and in adult poor metabolizers ( - years) in pharmacokinetic trials. pooled ae rates were low and comparable between the poor metabolizer and placebo subjects, as shown in the table below with all aes that appeared in > % of subjects in any treatment group (or > % in adult poor metabolizers). there was no difference in cardiovascular safety profile or ecg results (including qtc interval) among these groups. in conclusion, ( ) expression of the dl poor metabolizer phenotype is independent of age, but higher in blacks than in caucasians, ( ) exposure to dl in poor metabolizers is independent of age when administered at age-appropriate doses, ( ) the safety profile of dl poor metabolizers is not different from that of placebo at all ages down to at least -years old. these results are consistent with the high therapeutic index of dl. desloratadine (dl, clarinex®) is extensively metabolized to -oh dl and subsequently glucuronidated. the enzyme responsible for the formation of this active metabolite is unknown. poor metabolizers of dl represent a subset of the population that has a reduced ability to form -oh dl. a poor metabolizer was defined as a subject having a -oh dl to dl exposure ratio of < %, or dl half-life of hr. pk parameters from adult and pediatric poor metabolizers following repetitive administration of dl were characterized in clinical pharmacology trials and are summarized in the table below. exposure to dl [auc( - hr)] in poor metabolizers was approximately -fold greater than the corresponding values in normal metabolizers; cmax was to -fold greater. the magnitude of the reduction in the formation of -oh dl and the concurrent increase in exposure to dl associated with the poor metabolizer phenotype was similar in pediatric and adult subjects at age-appropriate doses. despite the increased exposure to dl in poor metabolizers, there was no increase in adverse event frequency or changes in electrocardiographic parameters. a: dose normalized to mg. b: least squares mean ratio: anova of log-transformed data extracting sources of variation due to age group and metabolizer status. the ratio is a contrast of metabolizer status. c: lower and upper % confidence interval based on log-transformed data. introduction: many patients with seasonal allergic conjunctivitis (sac) complain of symptoms of dry eyes. we have previously reported that patients with sac experience discomfort from dry eyes anywhere between to days per week and that the overall severity of the dry eye symptoms tend to range from mild to severe. this preliminary cross over study evaluated the benefits of nedocromil sodium % ophthalmic solution used twice daily, compared with nedocromil sodium % ophthalmic solution used with refresh (ocular lubricant), for the treatment of dry eye symptoms in association with sac during weeks. methods: patients who had a minimum of two-year history of sac and dry eyes, a positive skin prick test towards grass pollen and between the ages of to were enrolled. patients were evaluated on four visits and completed a daily diary, which included scales for grading allergic conjunctivitis and dry eye symptoms. at each clinic visit they completed the osdi and the rqlq (rhinitis quality of life questionnaire). the osdi (ocular surface disease index) was developed to assess dry eye symptoms and the impact on vision related functioning. the rqlq evaluates quality of life in patients with allergic conjunctivitis. at the last visit, both the patient and the physician assessed the treatment and the effectiveness, if any, of the addition of refresh to nedocromil sodium % ophthalmic solution. daily grass pollen counts were preformed using a burkhard sampler. results: patients ( male and female) were enrolled and dropped out. patients experienced minimal symptoms at the start of the season due to low concentration of grass pollen. preliminary analysis carried out using a paired t-test was preformed on the ocular average scores for the two treatment periods. there was no significant difference between the treatment groups for redness, light sensitivity and tearing of the eyes. a reduction in dry eye symptoms was reported in all patients using refresh eye drops and the number of drops required varied between patients. during the treatment periods there was improvement in patients rqlq. conclusion: patients preferred the addition of refresh eyedrops in alleviating sac and dry eye symptoms. further studies need to be carried using refresh eye drops in larger number of patients with sac and dry eye symptoms. c. laforce * , raleigh, nc. introduction: the objective of this study was to determine the ability of azelastine nasal spray to improve rhinitis symptoms and quality of life parameters in seasonal allergic rhinitis patients remaining symptomatic after treatment with fexofenadine. methods: this placebo-controlled, double-blind study began with a -week, open-label lead-in period, during which patients received fexofenadine mg bid. after days, patients who improved less than % to % on fexofenadine were randomized to treatment for weeks with: ( ) azelastine nasal spray, ( ) azelastine nasal spray plus fexofenadine, or ( ) placebo. the primary efficacy variable was the change from baseline to day in thetotal nasal symptom score (tnss), which consisted of runny nose, sneezing, itchy nose, and nasal congestion scores recorded twice daily in patient diary cards. in addition, quality of life was assessed using the rhinitis quality of life questionnaire (rqlq). results: after weeks of treatment, azelastine nasal spray (p<. ) and azelastine nasal spray plus fexofenadine (p<. ) significantly improved thetnss compared to placebo. based on patients with complete tnss and rqlq data, the overall rqlq score also was significantly (p<. ) improved compared to placebo. conclusions: azelastine nasal spray was an effective treatment for patients with seasonal allergic rhinitis who did not respond well to fexofenadine and significantly improved quality of life parameters compared to placebo. the results of this study indicate that azelastine nasal spray is an important alternative to oral antihistamines and should be considered in the initial management of seasonal allergic rhinitis. w. berger * , mission viejo, ca. objective: to evaluate improvement over time with azelastine nasal spray in the treatment of patients with moderate-to-severe seasonal allergic rhinitis (sar) who remained symptomatic after treatment with loratadine or fexofenadine. methods: the studies were -week, multicenter, double-blind, placebo-controlled trials that began with a -week, open-label lead-in period in which patients received either loratadine mg qd (study no. ) or fexofenadine mg bid (study no. ). patients who improved < %- % with loratadine were randomized to treatment with: ( ) azelastine nasal spray sprays/nostril bid, ( ) azelastine nasal spray sprays/nostril bid plus loratadine mg qd, ( ) desloratadine mg qd, or ( ) placebo. patients who improved < %- % with fexofenadine were randomized to treatment with: ( ) azelastine nasal spray sprays/nostril bid, ( ) azelastine nasal spray sprays/nostril bid plus fexofenadine mg bid, or ( ) placebo. the primary efficacy variable was the change from baseline to day in the total nasal symptom score (tnss), consisting of runny nose, sneezing, itchy nose, and nasal congestion. symptom severity was recordedam and pm in diary cards on a -point scale ( =none; =mild; =moderate; =severe). results: in both studies, patients treated with azelastine nasal spray experienced increasing improvement intnss over days of treatment.the improvements were approximately -fold greater than placebo at each day of the study, and the differences from placebo were statistically significant (p<. ) at days , , , and overall. in study no. , % of patients treated with azelastine had > % improvement in tnss compared to % in the placebo group. in study no. , % of patients treated with azelastine had > % improvement in tnss compared to % in the placebo group. conclusions: azelastine nasal spray was effective in treating patients with moderate-to-severe sar who remained symptomatic after treatment with either loratadine or fexofenadine. azelastine demonstrated first-day effectiveness, and patients treated with azelastine experienced increasing improvements in rhinitis symptoms over the -day study periods.azelastine nasal spray is an effective treatment alternative to oral loratadine or fexofenadine and an appropriate first-line therapy in the management of sar. introduction: a large, open-label, azelastine (astelin) nasal spray patient experience trial was conducted in patients with sar, vmr, or mixed rhinitis (allergic rhinitis with nonallergic triggers). this analysis evaluated the effect of azelastine nasal spray in treating rhinitis symptoms in a subset of patients with a history of asthma or sinusitis. methods: patients were entered into an open-label protocol and treated for weeks with azelastine nasal spray at a dosage of sprays per nostril bid. after weeks, the patients completed a questionnaire that assessed onset of action, symptom improvement, satisfaction with therapy, and quality of life. results: from a total of rhinitis patients who received azelastine monotherapy during the -week study period, data were analyzed for patients with asthma (n= ) or sinusitis (n= ). a greater percentage of these patients had severe rhinitis compared to the overall population. nasal congestion and postnasal drip were reported as the most bothersome rhinitis symptoms. after weeks of treatment with azelastine nasal spray, > % of patients with asthma and > % of patients with sinusitis reported some or complete control of congestion and postnasal drip. in addition, > % of patients with asthma reported chest tightness, shortness of breath, and wheezing were somewhat or completely controlled, and > % of patients with sinusitis reported that headache and facial pain were somewhat or completely controlled during treatment with azelastine nasal spray. conclusion: azelastine nasal spray provided effective control of rhinitis symptoms, including nasal congestion and postnasal drip, in patients with a history of asthma or sinusitis. introduction: epinastine is an antihistamine with mast cell stabilization and anti-inflammatory properties. epinastine . % ophthalmic solution was evaluated for treatment of allergic signs and symptoms elicited by feline dander in a cat exposure room. methods: participants (n= ) were aged years, with a history of ocular allergy to cats, a positive skin prick reaction to cat dander, and an ocular itching score of (on a - scale) within minutes of entering the cat room. subjects wore a tb mask while in the cat room to reduce the effects of inhaled allergen. after minutes of exposure, drop of epinastine hcl . % was instilled in one eye, and olopatadine . % was instilled in the fellow eye. environmental exposure to cat dander continued for another minutes. prior to instillation, and at , , , and minutes after instillation, conjunctival hyperemia and chemosis (scales of - ), and ocular itching, tearing, ocular burning, nasal itching and rhinorrhea (scales - ) were assessed. results: instillation of a single drop of ophthalmic epinastine significantly reduced ocular itching from a mean pre-instillation score of . to a mean score of . at minutes after instillation (p<. ), despite continuous exposure to cat dander during the entire period. similarly, ocular burning, tearing, and hyperemia were significantly reduced by epinastine treatment (p<. ). chemosis was only weakly induced by cat room exposure, with a mean pre-instillation score of . ; however, epinastine treat-ment decreased that to (p=. ). instillation of epinastine also significantly reduced nasal itching and rhinorrhea scores (p<. ). results for olopatadine were not statistically different; however, the change from baseline in itching scores in the epinastine-treated eyes was greater than that seen in the olopatadine-treated eyes at the majority of timepoints. conclusion: ophthalmic epinastine is indicated for the prevention of itch associated with allergic conjunctivitis.this study shows that treatment of cat-sensitive subjects with ophthalmic epinastine following environmental exposure to cat dander significantly reduced ocular itching and other signs and symptoms of allergic conjunctivitis. objective: the objective of this study was to evaluate azelastine (astelin®) nasal spray, cetirizine (zyrtec®), fluticasone (flonase®), and placebo in the treatment of patients with symptomatic seasonal allergic rhinitis. methods: this was a double-blind placebo-controlled pilot trial in patients with seasonal allergic rhinitis. the study began with a -week, placebo lead-in period, followed by a -week blinded treatment period (day to day ). efficacy variables were: ( ) change from baseline to day in the total nasal symptom score (tnss; consisting of rhinorrhea, sneezing, itchy nose, and nasal congestion); ( ) onset of action based on tnss over the hours following initial administration of study drugs; and ( ) change from baseline to day ( -hour change) in tnss. tnss was scored twice daily (am and pm) on a -point rating scale ( =none, =mild, =moderate, =severe). patients recorded a minimum -hour tnss of on at least days during the lead-in period, and a congestion score of on at least days to qualify for entry. qualified patients were randomized to treatment with: ( ) azelastine nasal spray sprays per nostril bid plus placebo capsules qd; ( ) cetirizine -mg tablets qd plus placebo nasal spray; ( ) fluticasone sprays per nostril qd plus placebo capsules qd; or ( ) placebo nasal spray plus placebo capsules. results: azelastine significantly (p<. ) improved the tnss compared to cetirizine, fluticasone, and placebo beginning minutes after initial administration; cetirizine significantly improved tnss versus placebo at minutes; fluticasone showed no significant differences from placebo over the -hour evaluation period. azelastine significantly (p<. ) improved the tnss at day ( -hour change from baseline) compared to cetirizine, fluticasone, and placebo. conclusions: azelastine nasal spray improved the tnss in patients with moderate-to-severe seasonal allergic rhinitis. in addition, azelastine nasal spray demonstrated a -minute onset of action and significantly improved tnss versus cetirizine, fluticasone, and placebo hours after initial administration. introduction: epinastine, an antihistamine with mast cell stabilization and anti-inflammatory properties, has been developed for the treatment of allergic conjunctivitis. the efficacy and tolerability of epinastine was assessed and compared with levocabastine. methods: eligible patients for this randomized, double-masked, parallel-group, active-controlled environmental clinical trial were - years old with a recent diagnosis of seasonal allergic conjunctivitis. patients instilled drop epinastine hcl . % or levocabastine . % ophthalmic solution in each eye bid for weeks. patients and investigators assessed efficacy and tolerability at study visits on days (baseline), , , , and , and assessed overall efficacy and tolerability at study exit. adverse events were monitored. results: epinastine provided superior itch relief compared with levocabastine (p=. ; see figure) ; mean ocular itch scores over treatment visits were . for epinastine and . for levocabastine ( - scale; =worst; baseline scores were . for epinastine and . for levocabastine). the mean summed score (ocular itching, tearing, and foreign body sensation) over treatment visits was significantly better for epinastine than levocabastine (p=. ).at study exit, % of epinastine-treated patients rated overall efficacy "very good" (the highest possible rating), versus % of levocabastine-treated patients. at minutes postinstillation, % of epinastine-treated and % of levocabastine-treated patients rated tolerability "very good". at study exit, % of epinastine-treated and % of levocabastine-treated patients rated overall tolerability "very good", with investigator ratings being similar. treatment-related adverse events occurred in . % of epinastine-treated patients (most frequent: eye pain and skin itching, . % each) and . % of levocabastine-treated patients (most frequent: double vision, . %; influenza-like symptoms, . %); most aes were mild or moderate. conclusion: our results confirm the therapeutic potential for epinastine as an efficacious treatment suitable for long-term use throughout the allergy season. ophthalmic epinastine was superior to levocabastine for relief of ocular symptoms in patients with allergic conjunctivitis and was well-tolerated. since chronic inflammation is the histopathologic landmark of otitis media with effusion, clinical observations have led us to believe that the combination of a cysteinyl leukotriene receptor antagonist montelukast with an oral antibiotic may be more efficacious than monotherapy with an oral antibiotic in the treatment of serous otitis media. we studied twenty pediatric patients (age years to years) in a randomized open labeled -week trial to compare the efficacy of the combination montelukast ( mg or mg chewables tablets qd dosed according to patient's age) with an oral antibiotic amoxicillin/clavulanate potassium ( mg/kg/day in divided doses every hours) to a monotherapy with an oral antibiotic amoxicillin/clavulanate potassium for the treatment of otitis media with effusion. the efficacy of treatment options was assessed using pneumatic otoscopy, impedance tympanometry, and audiometry to monitor the clinical course of the middle ear effusion in both treatment groups. in the combination group montelukast and antibiotic a resolution of otitis media with effusion occured at the th day. in contrast in the group treated with monotherapy with the oral antibiotic the resolution of otitis media with effusion occured on the th day. in conclusion, the combination of montelukast plus an oral antibiotic is more effective than monotherapy with an oral antibiotic.the combination of montelukast plus an antibiotic may be a safer and shorter therapy given the safety issues with long term use of systemic antibiotics. introduction: a randomized, double-blind, placebo-controlled study was conducted in an environmental exposure chamber (eec) to compare the efficacy of three doses of olopatadine nasal spray, a topical anti-allergy treatment for seasonal allergic rhinitis (sar), versus placebo spray. methods: patients aged - years old with a history of sar were screened, consented, evaluated for a positive skin test to ragweed allergen, and enrolled in this irbapproved study. a total of "primed" patients were exposed to ragweed allergen in the eec and randomized to olopatadine . % (n= ), olopatadine . % (n= ), olopatadine . % (n= ), or placebo (vehicle) (n= ) spray, sprays/nostril once in the morning. symptoms were self-assessed using a point scale (total nasal symptom score, tnss, comprised of sneezing, runny, itchy and stuffy nose) via diaries at periodic intervals during the -hour study period. safety was also assessed. results: obvious trends indicated a dosedependent response to olopatadine . %, . % and . %, though concentrations were not statistically different from each other. all three concentrations of olopatadine were clearly more efficacious than placebo spray at the first time point, minutes, continuing to the end of the -hour session. olopatadine exhibited a safety profile comparable to placebo. conclusions: olopatadine nasal spray . %, . % and . % exhibited dose-dependent responses. onset of action for all three concentrations of olopatadine was apparent at the first post-dose timepoint, minutes, and efficacy was maintained throughout the next hours. olopatadine nasal spray was safe, well-tolerated, and effective for the treatment of sar in the eec chamber. c. slonim * , tampa, fl. objective: to assess patient subjective responses to the treatment of allergic conjunctivitis using azelastine hydrochloride ophthalmic solution. methods: participating physicians selected patients from their practice to receive azelastine hydrochloride . % ophthalmic solution drop per affected eye twice daily for days. patients on prior ocular allergy medications were allowed to participate. after days of treatment with azelastine hydrochloride, patients (n= , ) rated their experiences with azelastine hydrochloride via a self-administered survey. not all questions were answered by each patient. results: at baseline, % of patients reported that their ocular itching affected their work, school, and/or leisure activities at least "somewhat". after using azelastine hydrochloride, % of patients achieved either "moderate" or "complete" relief from ocular itching, including % who reported "complete" relief from itching. seventy-one percent ( %) of patients had been treated previously with a topical prescription anti-allergy medication for their ocular itching. seventy percent ( %) of patients (n= ) who had not been previously treated with a topical prescription anti-allergy medication treatment and % of previous medication users (n= , ) experienced at least "moderate" relief of itching when treated with azelastine hydrochloride. sixty-five percent ( %) of the previously-treated patients rated azelastine hydrochloride as "somewhat better" or "much better" than their previous medication. conclusions: results suggest that azelastine hydrochloride ophthalmic solution is an effective treatment for the ocular itching associated with allergic conjunctivitis as rated by the patient, regardless of whether they had been treated previously with a topical prescription anti-allergy medication. objective: to determine an association between food allergy and acid reflux in adults. method: we conducted a retrospective chart review of atopic adult patients in an academic otolaryngic allergy practice. adults who tested positive and adults who tested negative for food allergy were included in the study. charts were reviewed for a diagnosis of gastroesophageal reflux disorders (gerd). this included a history of laryngopharyngeal reflux (lpr) and peptic ulcer disease (pud). population prevalence ( . %; ci . - . ) of acid reflux was estimated from a historical study (locke gr et al. prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in olmstead county, minnesota. gastroenterology ; : - ) that had a similar subject population. the prevalence of gerd in each study arm, as well as in the total study group of atopic adults, was compared to the historical control. results: subjects testing positive for food allergy had a diagnosis of gerd in . % ( % ci . - . ) of cases. those subjects who did not demonstrate a food allergy were positive for gerd in % ( % ci . - ) of cases. in the total study group, the prevalence of gerd was . % ( % ci . - . ). on chi square analysis, the prevalence of gerd was significantly higher in the total study group when compared with the historical control (p= . ). those subjects who tested negative for food allergy had a statistically significant higher prevalence of gerd than the control population (p= . ). the prevalence of gerd between the group testing positive and the historical control did not show a significant difference (p= . ). when comparing the study arms to each other, there was no significant difference in the prevalence of gerd (p= . ). conclusions: the prevalence of acid reflux disorders was not higher in subjects with food allergy when compared to a historical control. although a statistical significance was noted between adults who tested negative for food allergy and the control population with regards to the prevalence of gerd, this may reflect the fact that individuals examined in an otolaryngologist's office are more likely to have acid reflux disorders than the general population. overall, the atopic subjects did have a higher incidence of acid reflux disorders, but there was no statistical significance between subjects with and without food allergy. a. suryadevara * , d.l. hamilos, boston, ma. introduction: recent studies suggest that crs without nasal polyposis (crssnp) and crs with nasal polyposis (crscnp) represent distinct pathologic entities. we wished to determine whether these conditions differed in their clinical presentation. methods: over a two-year period, new patients coming to a university based specialty clinic meeting criteria for crs were enrolled in an outcomes study. patients indicated which of four major (facial pain/pressure/headache, nasal obstruction, nasal purulence/discharge, and hyposmia/anosmia) and four minor (fever, halitosis, dental pain, cough) criteria for crs they were experiencing. rhinoscopy was performed to look for nasal polyps or polypoid tissue in any sinus area. the prevalence of each symptom was compared in the groups by chi square analysis. results: the population (n= ) had a mean age of +/- . and was % female, % caucasian, . % african-american, . % asian and . % hispanic. most patients ( %) were non-smokers. all had at least major criteria or major + minor criteria for crs at enrollment. forty-one patients ( . %) had crscnp. the mean number of major criteria was greater in the crscnp than crssnp ( . vs . , p= . ). nasal obstruction and hyposmia/anosmia were more prevalent in crscnp (p= . , . respectively). facial pain/pressure/headache was more prevalent in crssnp (p=). ). the most prevalent symptoms in crscnp were: nasal purulence/discharge ( . %)>hyposmia/anosmia ( . %)>facial pain/pressure/headache ( . %)>nasal obstruction ( %). in contrast, the most prevalent symptoms in crssnp were: facial pain/pressure/headache ( . %)>nasal purulence/discharge ( . %)>hyposmia/anosmia ( . %)>nasal obstruction ( . %). none of the symptoms were absolutely distinguishing of these conditions. no differences were found between the two groups for fever, halitosis, dental pain or cough. conclusion: we conclude that patients with crscnp have a greater burden of symptoms of crs and a much higher prevalence of hyposmia/anomsia. these findings are consistent with other studies showing that, in comparison to crssnp, crscnp tends to be more difficult to treat and have a higher rate of relapse after intensive medical therapy (subramanian et al, am j rhinology ; : ). l.e. mansfield * , e.e. philpot , c. posey , . el paso, tx; . research triangle park, nc. daytime sleepiness is a common complaint in sar. patients often complain of mental slowness, difficulty in concentrating, and thinking. the present study evaluated whether effective therapy of sar would decrease dss and improve an objective measure of cp. dss was measured using the epworth sleep scale (ess). objective cp was measured using the test of variables of attention (tova), a validated test. thirty two adults ( males, females with a year history of sar, a compatible physical exam, and corresponding positive allergy testing) volunteered for this week randomized double blind placebo controlled study. after a one week inf placebo (pl) baseline, the subjects received either active inf or continued pl. they maintained daily nasal symptom dairies and ess. the subjects took the tova test at the end of week and week . weekly nasal symptom scores significantly improved with the inf, but not the pl. w vs. w nasal congestion inf , p=. , pl , p=ns; runny nose inf . , . p=ns; pl . , . p=ns; sneezing inf . , p=. ; pl . , . p=ns. total weekly ess was abnormal and decreased significantly in the inf group, but not in pl group. w vs. w inf . , . p=. , pl . , . p=ns. response time of the tova testing, initially somewhat slow, significantly decreased in inf but not pl treatment. w vs. w inf msec, msec p=. ; pl msec, msec p=ns. these results demonstrate that sar is associated with dss and cp problems. the mechanism is likely to be sleeping disordered breathing associated with nasal congestion and obstruction. effective treatment of nasal congestion with inf led to decreased dss and improved cognitive performance. l.e. mansfield * , c. graham , . el paso, tx; . new york, ny. there is increasing recognition that sleep disturbance and daytime tiredness occur during active ar. the mechanism appears to be nasal congestion and obstruction leading to sleep disordered breathing and resultant poor quality of sleep. in our practice, as part of the initial history, questions regarding fatigue, snoring, sleep problems, and tiredness are addressed. sleep problems and tiredness are graded according to the following scale: effect on daily activity ; =not troubled; = a little trouble; =somewhat troubled ; = trou-bled a lot ; = total disruption. we reviewed consecutive charts of patients with allergic rhinitis documented by history, physical examination and allergy testing. there were females and males; age range y to y. ( %) of patients or parents recognized they commonly snored. ( %) stated they were chronically fatigued. the graded answers concerning sleep problems and tiredness were even more revealing of ar patient's perception of their problems see table in general, the higher sleep problem responses were associated with higher tiredness scores. national surveys of unselected populations suggest that about percent of adults consider themselves to have sleep problems. the high frequency of sleep related problems and tiredness in our sample has prompted us to add more detailed questions regarding sleep related events to our intake history. it is our opinion that questions specifically related to sleep and daytime tiredness should be included in all evaluations for allergic rhinitis. we conclude that sleep related problems and tiredness may be more common in patients with allergic rhinitis than previous reported. r.w. weber * , j. garcia , r. faruqi , d. banerji , g. georges , the study investigator group , . denver, co; . bridgewater, nj; nj. introduction: the intranasal glucocorticosteroid triamcinolone acetonide (taa) is a safe and effective treatment for persistent allergic rhinitis (par). a new hydrofluroalkane- a (hfa) propellant delivery system (taa-hfa) has recently been developed. this study primarily assessed the long-term safety of taa delivered via this new device, as well as its long-term efficacy. methods: patients aged - yrs (mean= ) with par enrolled in this -yr, open-label study at centers in the us. patients received taa-hfa μg once daily for a -week run-in period before adjusting the dose to μg or μg once daily based on symptom severity. doses were standardized to μg once daily across all patients at ~ months to ensure sufficient long-term safety data at the maximum dose. physical exams, including measurement of vital signs and laboratory measurements were taken at baseline, months and study end. independent patient and physician global symptom evaluations were performed at baseline, week and months - thereafter. patients recorded any adverse events (aes) on daily diary cards. results: of the patients included in the study, ( . %) reported aes. the incidence of aes was similar to that of other comparable allergic rhinitis long-term studies. the most frequently reported aes were pharyngitis, rhinitis, local reactions, headache, epistaxis and sinusitis (table ) . most aes were mild-to-moderate in intensity; patients withdrew from the study due to aes. there were no clinically relevant changes in physical exams, vital signs or laboratory measurements. a total of serious aes (saes) were reported; breast carcinoma (n= ), depression (n= ), post-operative spinal fluid leak (n= ) and staphylococcal infection (n= ). saes were thought to be not related to the study drug. at final visit, % of patients had either moderate or marked/complete relief of symptoms using global symptom scores. similarly, % of physicians rated their patients as having either moderate or marked/complete relief. conclusions: long-term administration of taa-hfa μg exhibited a good safety and tolerability profile, while providing moderate-to-complete symptom relief in more than % of patients treated for par. introduction: second-generation, 'non-sedating' antihistamines (ahs) have lower tendency to cross the blood-brain barrier and cause central nervous system side effects than first-generation agents. however, studies have suggested differences between second-generation ahs regarding cognitive function impairment. methods: a medline literature search was performed using the search terms 'antihistamine and impairment', 'antihistamine and psychomotor' and 'antihistamine and central effects', as well as with individual ah names (acrivastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, loratadine, mequitazine and mizolastine). the findings for second-generation ahs were reviewed and well-designed, placebo-and positive-controlled studies in humans using objective measures of cognitive impairment were included. results: publications were identified as the inclusion criteria. all included objective assessments such as driving performance, critical flicker fusion and divided attention tasks. there was a large variation in the numbers of available well-designed studies; the most rigorously assessed agents were fexofenadine and cetirizine. a number of the ahs (ebastine, acrivastine, loratadine, mequitazine and mizolastine) were not impairing at recommended doses, but were at higher doses. in a small number of available studies, the newer ahs desloratadine and levocetirizine produced no impairment at recommended doses ( mg); however, higher doses were not investigated. cetirizine studies were variable; impairment at the recommended mg dose or higher was seen in a number of studies. in contrast, fexofenadine hcl, up to a dose of mg, was non-impairing in a large number of studies. only one study indicated impairment in one task (critical tracking) and this was only observed with the first doses of fexofenadine hcl ( and mg) and not subsequent doses; however, the authors concluded that doses up to mg/day should be safe for patients who drive. conclusion: while second-generation ahs are less impairing than the first-generation, some newer ahs produce impairment at or above the recommended dose. these differences become important to the patient when agents cause sedation or if patients over use beyond the recommended dose. in conclusion, fexofenadine was the only ah found to be non-impairing in all studies, even at double the recommended us dose. s. shaver , r.b. berkowitz * , c. lutz , p. jones , c. qiu , s. meeves , s.t. varghese , g. georges , . woodstock, ga; . bridgewater, nj. introduction: fexofenadine (fex) is a h -receptor antagonist, with proven efficacy in the treatment of allergic rhinitis (ar). to date, no live cat-room challenge studies have assessed the efficacy of fex in cat-allergen induced ar. this study assessed the efficacy of a single dose of fex hci mg in preventing and controlling cat-allergen induced ar using the cat-room challenge model. methods: this single-center, prospective, randomized, doubleblind, placebo-controlled, two-way crossover study consisted of a screening visit, one or two priming visits and two treatment periods, separated by a (± )-day wash-out. qualifying subjects were randomized to treatment sequence (placebo followed by fex) or (fex followed by placebo). baseline endpoints were obtained prior to study drug administration, and minutes before entering the cat challenge room for allergen challenge. allergen challenges were initiated . hours post-dose, for both treatment periods. the primary endpoint was the change from baseline in total symptom score (tss; sum of rhinorrhea, itchy nose/palate/throat, sneezing and itchy/watery/red eyes) after minutes of allergen exposure at hours post-dose, compared with placebo. other endpoints included changes in individual symptom scores, including nasal congestion. levels of airborne felis domesticus allergen (fel d ) were determined. results: of subjects screened, were randomized and completed the study; and in sequence and , respectively. mean change in tss from baseline was significantly less with fex compared with placebo at minutes after initiation of the cat allergen challenge (p= . ). significantly greater percentage reductions in the individual symptom scores for sneezing (p= . ) and nasal congestion (p= . ) were observed with fex compared with placebo, minutes after challenge. although levels of fel d varied widely, they were balanced between treatment groups. the overall incidence of treatment-emergent adverse events (aes) was low and comparable between groups; no serious aes occurred. conclusion: this study demonstrated that a single dose of fex hci mg is effective and well tolerated as a prophylactic agent for alleviating the ar symptoms induced by exposure to cat allergen. further large-scale clinical trials are warranted to confirm these findings. rationale: allergic rhinitis in children is thought to be associated with several co-morbid disorders. we conducted the following study to assess whether children with diagnosed hypertrophy of tonsils and/or adenoids evaluated by an allergist were more likely to demonstrate objective evidence of allergen sensitization than children similarly evaluated without evidence of these upper airway obstructions. methods: records from the past ten years were identified in the hospital database by presence of an allergy clinic visit and an icd- code for hypertrophy of adenoids and/or tonsils. we reviewed these records to confirm that the diagnosis was accurate. we included subjects if reliable skin prick or in vitro testing for specific ige to aeroallergens was performed. for comparison, we randomly obtained an age and testing-type similar sample. first group subjects were excluded from the second group. skin testing was performed with commercial allergen extracts applied with a dermapik©. in vitro testing was by unicap© feia. positive skin testing had at least a wheal mm or flare mm greater than the negative control. positive in vitro values were . ku/l or greater or a positive pollen mix. additionally, we performed a search in an insurance database to determine how many local children had a code for allergic rhinitis. results: of pediatric allergy patients with adenoid/tonsillar hypertrophy tested, . % ( % ci +/- . %) had at least one positive test. in without adenoid/tonsillar hypertrophy, . % ( % ci +/- . %) had at least one positive test. the observed difference was . % ( % ci +/- . %). the standard error of the difference in percentage was . ; the z score was . . the corresponding p value is . . the percentage of , children with an allergic rhinitis icd- was . % ( % ci +/- . %). conclusion: the number of allergist-referred children with adenoid and/or tonsillar hypertrophy testing positive for an aeroallergen is slightly less than the number of similar children without these diagnoses testing positive. it is not clear that adenoid/tonsillar hypertrophy is associated with a higher risk of allergic rhinitis. a prospective study with allergy testing of all children with adenoid and/or tonsillar hypertrophy might provide information that could alter referral patterns. w.e. berger * , w. storms , s. kimura , m. beck , s. galant , t. westbrook , . mission viejo, ca; . colorado springs, co; . pensacola, fl; . miami, fl; . orange, ca. background: patients having allergic rhinoconjunctivitis are often treated with nasal spray or systemic allergy therapy, forgoing therapy specifically targeting ocular symptoms. the rhinitis quality of life questionnaire (rqlq) and allergic conjunctivitis quality of life questionnaire (acqlq) instruments can be used to quantify the relative benefit of varying medication regimens. objective: to determine the extent of benefit gained in quality of life when an eye drop treatment for ocular allergy (olopatadine) was added to rhinitis patients' preexisting regimen of nasal or systemic allergic treatment. methods: this was a four week prospective, multi-center, open-label crossover, quality of life study occurring during allergy season. at visit , patients completed the rqlq and acqlq questionnaires to assess baseline quality of life. patients were randomized to receive ocular allergy therapy (olopatadine, patanol bid) concomitant with their systemic or nasal rhinitis treatment(s) for weeks between either visit and visit (group a) or between visit and visit (group b). at visit and visit , patients completed the rqlq and acqlq. results: a total of patients completed this study: in group a, in group b. of these, ( . %) experienced eye allergy symptoms at least day during the previous week as reported in the baseline acqlq. baseline scores of the rqlq and acqlq for both groups were comparable. clinically significant improvement from baseline in global rqlq and acqlq was seen following addition of ocular therapy for both groups (rqlq: - . , - . ; acqlq: - . , - . ). similar improvement was seen across all domains of both questionnaires. the acqlq correlated with the rqlq in the applicable domains. conclusion: many allergic rhinitis patients using nasal or systemic medication also suffer from ocular allergic symptoms. for these patients, quality of life improvement is not maximized; the addition of a topical antiallergy eye drop can result in beneficial effects on quality of life. in this study, the addition of olopatadine eye drops to these patients' medication regimens resulted in significant improvement in not only eye symptom related quality of life domains but in overall quality of life. h. milgrom * , r. lanier , f.c. hampel , b. kittner , . denver, co; . fort worth, tx; . new braunfels, tx; . bridgewater, nj. introduction: fexofenadine, a non-sedating, selective h -receptor antagonist, is currently indicated for use in children aged - years with seasonal allergic rhinitis in a number of countries, including the us, and has an excellent safety profile in this age group. this study was designed to assess the safety and tolerability of fexofenadine in children aged - years with allergic rhinitis (ar). methods: the study had a multicenter, double-blind, randomized, placebo-controlled, parallel-group design. children aged - years (n= ) with ar were randomized : to either placebo twice daily (bid; n= ) or fexofenadine hcl mg bid (n= ), for weeks. both treatments were given orally as granulated powders (capsule content) mixed with two teaspoons of apple sauce. treatment-emergent adverse events (teaes) were recorded for all subjects by parents/caregivers and assessed by investigators. clinical laboratory variables, physical examinations, vital signs and ecg evaluations were also assessed in a subgroup of children (placebo, n= ; fexofenadine, n= ). results: baseline demographics were similar in both treatment groups. while approximately % of children in both groups experienced at least one teae, no unusual or unexpected teaes were observed in the fexofenadine group. when the total group was analyzed for teaes by body system, or assessed separately by age groups of -, -, -and -year-olds, no clinically meaningful differences were observed between the two treatment groups. in both treatment groups, the majority of subjects overall and in each age group experienced teaes rated as mild or moderate in intensity. few subjects experienced teaes considered possibly related to study medication (placebo: . % [ / ]; fexofenadine: . % [ / ]). the percentage of discontinuations due to teaes was also comparable between treatment groups (placebo: . % [ / ]; fexofenadine: . % [ / ] ). in the subgroup assessment, no clinically relevant changes were seen from baseline for laboratory variables, vital signs, ecgs or physical examinations in either treatment group. introduction: the efficacy and safety of fexofenadine hcl mg bid has been proven in two large phase iii studies in pediatric subjects aged to years with seasonal allergic rhinitis. in addition, the safety of fexofenadine has been demonstrated in pediatric subjects to years of age with allergic rhinitis (ar). subsequently, two studies (t/ ; t/ ) have assessed the pharmacokinetics, safety and tolerability of fexofenadine and mg bid in pediatric subjects months to years of age. methods: both studies were of multicenter, randomized, double-blind, placebo-controlled, parallelgroup design and enrolled pediatric subjects aged months to < year weighing . kg and aged ± year to < years weighing > . kg. all subjects had a diagnosis of ar as assessed by previous medical history, pattern, or suggestive physical findings. subjects were randomized to receive fexofenadine hcl mg (t/ ), or mg (t/ ) granulation powder twice-daily, or placebo for a minimum of days. safety was evaluated based on adverse events (aes), vital signs, -lead electrocardiograms (ecgs), and physical examinations. results: a total of and subjects were randomized in studies t/ (fexofenadine hcl mg bid: n= , placebo: n= ) and t/ (fexofenadine hcl mg bid: n= , placebo: n= ), respectively. in t/ , . % ( / ) of children receiving fexofenadine and . % ( / ) receiving placebo experienced at least one treatment-emergent ae (teae). in t/ , the incidences of teaes were . % ( / ) and . % ( / ), respectively. in both studies, most of the teaes experienced were mild or moderate in intensity. the incidence of possibly-related teaes was also similar for both treatments in each study. no clinically relevant changes from baseline to study end were observed for vital signs, ecgs and physical examinations. conclusions: the findings of this study show that fexofenadine mg and mg bid are well tolerated and have a safety profile comparable to placebo in pediatric subjects aged months to years. for seasonal allergic rhinitis (sar) patients that remain symptomatic on an h -receptor antagonist, cetirizine, and a nasal glucocorticosteroid, mometasone furoate, the addition of omalizumab, a recombinant, humanized, chimeric, anti-ige monoclonal antibody, may provide additional efficacy in sub-optimally controlled seasonal allergic rhinitis patients. in this open labeled week trial, patients with symptomatic sar currently using cetirizine, mg qd, + mometasone furoate, mcg/nostril qd, were randomized to continue the existing therapy cetirizine + mometasone or to add-on omalizumab subcutaneously (every weeks to weeks) dosed according to patient's weight, and baseline ige levels to the existing therapy cetirizine + mometasone furoate. the endpoints of the trial include: rhinomanometry, nasal symptom score (composite score of nasal congestion, rhinorrhea, sneezing, post nasal drip and itching) and flexible rhinopharyngolaryngoscopy examination. mean efficacy measurements at the end of the -week trial revealed a significant improvements in all parameters examined in the treatment group receiving omalizumab (as add-on to the existing therapy), compared to the other group. in conclusion, the addition of omalizumab to the combination of cetirizine plus mometasone furoate, is more effective than the combination of cetirizine plus mometasone furoate, for the treament of seasonal allergic rhinitis patients. it appears that when omalizumab is added to the combination h receptor antagonist, cetirizine, and nasal corticosteroid, mometasone furoate, the primary end points (rhinomanometry and symptom scores) are significantly improved. background: based on the official statistic data, the prevalence of allergic diseases in russia has increased more than times during the past - years, but still the lowest of all european countries. in some studies done in some regions of russia based on isaac program, it has been shown that the prevalence allergies is significantly higher than indicated in official statistics of health departments. the goal of this investigation was to study the prevalence of allergic diseases, in children of south russian region. meth-ods: this study was done in two steps according to isaac program guidelines. in the first step a questionnaire was given to a total of school children, ages to (group a) and to years old (group b), from the two cities of krasnodar and novorossiysk in southern russia. in the second step a physical exam, skin prick tests with different allergens (pollens, molds, cat, dust mites, foods etc.), and pulmonary function tests were performed. results: wheezing was reported in . % of group a and . % of group b children within the past months. the severity of asthma reported was mild in % (group a)- % (group b); moderate in . % (group a)- . % (group b) and severe in . % (group a)- . % (group b) in studied children). majority of the cases of asthma was noted to be allergic asthma. in both groups of children there was a high incidence of allergies to perennial allergens such as dust mites, cats, molds and other indoor allergens, . % (group a) and . % (group b). the percentage of allergies to pollens was . % and . %, accordingly. allergic rhinitis symptoms were noted in . % (group a) and in , % (group b). atopic dermatitis symptoms with skin itching observed in . % ( - years old)and . % ( - years old). family history of atopy was noticed in . % of group a and . % of group b children. conclusions: the prevalence of allergic diseases in south russia is similar to the ones in most of the european countries. the prevalence of asthma has been associated with increased incidence of allergies, due to indoor and pollen allergens. the prevalence in rhinitis and atopic dermatitis in south russia is parallel to asthma. acknowledgement: we would like to thank hollister-stier lab., greer and antigen lab. for allergen samples. objective: to examine the cost and effectiveness of telithromcyin vs. azithromycin for treatment of mild acute sinusitis under current levels of antimicrobial resistance. methods: we considered an adult with mild acute sinusitis, and symptom duration of days. a decision analytic model was created to compare strategies of st-, nd-and rd-line therapies: azithromycin/amoxicillin-clavulanate/levofloxacin (azi/amc/lev), and telithromycin/amoxicillin-clavulanate/levofloxacin (tel/amc/lev). we considered outcomes: response to initial therapy, cost, and time to completion of all antibiotic therapy. clinical resolution was due to response to antibiotic, or to spontaneous resolution. we assumed bacteria that were resistant in vitro would only be resistant in vivo % of the time. resistance levels were based on the - us protekt surveillance study. model parameters, such as prevalence of bacterial infection, frequency of causative pathogens, and rates of spontaneous resolution, were based on the published literature. those failing to improve after days were switched to next line therapy. we analyzed claims data from managed care organizations to estimate non-drug charges for initial and follow-up care, and applied a % cost-to-charge ratio. drug costs were estimated using the wholesale acquisition cost plus $ for overhead and dispensing. all costs were adjusted to year $us. results: the model predicted the tel/amc/lev strategy would result in . % improving by days compared to . % for azi/amc/lev. the telithromycin strategy had lower mean cost, $ vs. $ . although telithromycin cost more than azithromycin, the tel/amc/lev strategy had slightly lower total drug costs ($ vs $ ) due to less need for additional antibiotic courses. mean time to completion of therapy was . days for tel/amc/lev and . days for azi/amc/lev. sensitivity analyses showed that tel/amc/lev had superior health outcomes even when only % of in vitro resistant organisms were also resistant in vivo. tel/amc/lev also had lower cost if at least % of cases were bacterial, or if in vitro resistant organisms were at least % resistant in vivo. conclusion: based on results obtained using this decision analytic model, initial treatment of mild acute rhinosinusitis with telithromycin may result in improved outcomes and lower cost than initial treatment with azithromycin. rationale: "delta crud" is the term used to describe rhinosinusitis syndromes in the mississippi delta region. local perception is that it is associated with chemical crop dusting, regional produce, especially cotton, or high rates of mold allergy. the climate is extreme with mild winters, hot humid summers, and large volume rain. thirty-five percent of inhabitants live below the poverty level, % are african american. patients from the agriculturally intensive delta suffer from asthma at almost twice the rate of those in the neighboring hills. rates of pesticide use are among the highest in the nation. there are no prevalence estimates for rhinosinusitis in this region. "delta crud" is chronic in many patients with exacerbations occurring in the summer and fall, especially during chemical spraying and defoliation. we conducted this cross-sectional questionnaire based pilot study to begin characterization of rhinosinusitis in this population. method: the sinusitis treatment outcome questionnaire, with two modifications, was given to consecutive patients presenting to the north sunflower regional hospital er and the sunflower outpatient clinic one month prior to the beginning of summer crop dusting. the question, "do you have delta crud?" was added. the survey was anonymous, allowing irb exemption. results: consecutive patients returned completed questionnaires. ( %) admitted to having "delta crud". patients who claimed to have delta crud had significantly more sinus headache, nasal pruritus, conjunctivitis, and chest symptoms (see table) . there was no significant difference in antibiotic prescriptions, er visits, and missed work. six patients with delta crud had been hospitalized for "allergy reasons" compared with three patients without delta crud. despite severe symptoms just patients received sinus ct scans. only / patients were prescribed intranasal corticosteroids. conclusion: in our pilot study, the prevalence of chronic rhinosinusitis symptoms (delta crud) is %, with severe sinus, pulmonary and ocular symptoms. evaluation and treatment may be suboptimal in this economically disadvantaged rural region. further characterization of "delta crud", pollen counts, ige mediated disease, environmental contributions and comparative studies of related regions are needed. introduction: patients with rhinitis commonly experience sinus pain and pressure (sp+p). many patients with recurrent acute bacterial sinusitis (rabs) base the presence of a recurrence on the severity of sp+p and other nasal symptoms. the ability of patients to differentiate between rhinitis and rabs was evaluated by reviewing the subject screening logs of previously reported clinical trials of flonase (fluticasone propionate) nasal spray, mcg (fp). methods: the efficacy of fp was studied in two trials in subjects with sp+p due to allergic rhinitis and in two trials of subjects receiving cefuroxime axetil to treat an acute episode of rabs. sp+p screening logs were examined to determine how many subjects who thought they had sp+p were excluded from the study for an upper respiratory or sinus infection. rabs screening logs were examined to determine how many subjects with symptoms of an acute episode of rabs were excluded from the study for a negative sinus x-ray or ct scan. rabs symptoms experienced at the screening visit by subjects who qualified for the study were also evaluated. results: of subjects screened in the sp+p studies, only ( . %) were excluded for evidence of sinus or upper respiratory tract infections, as clinically diagnosed by the investigator. out of subjects with screening log data in the rabs studies, ( . %) were excluded for a negative sinus x-ray or ct scan. of the subjects who qualified for the rabs study, the most prevalent symptoms included nasal congestion ( %), mucopurulent discharge ( %), facial pain or tenderness in the sinus area ( %), sinus headache ( %) and malaise ( %). only % of subjects had a fever. only one symptom, nasal congestion, was rated by clinicians as severe for greater than % of subjects in either study ( % and %). conclusions: while most subjects can determine when sp+p is due to allergic rhinitis, many cannot determine when symptoms progress to a sinus infection. symptoms experienced by subjects with rabs were consistent with inflammation, but did not include fever as may be expected with an untreated bacterial sinus infection. under appreciation by patients for the role of inflammation in sinus disease may result in over self-diagnosis of sinus infection and the demand for antibiotics. liposomes are small particles consisting of lipid bilayer membranes, which are used to deliver drugs including amphotericin b, more efficiently and with less toxicity. very few cases of allergy to liposomal amphotericin b (lab) have been reported to date. although there is a report on conventional amphotericin b (cab) desensitization, to our knowledge no case of lab desensitization has been described yet. a y/o patient with lymphoma was treated with lab for pulmonary aspergillosis. within minutes of infusion he developed urticaria, hypotension and tachycardia for which he was treated with the appropriate drugs for anaphylaxis. a second attempt to re administer lab resulted in a similar anaphylactic reaction. desensitization to lab was then successfully completed using a modified protocol based on desensitization to cab (jaci ; : - ) : . mg infusion over minutes . mg infusion over minutes . mg infusion over minutes . mg infusion over minutes mg infusion over minutes mg infusion over minutes mg infusion over minutes mg infusion over minutes conclusion: desensitization to lab, a lifesaving drug for invasive fungal diseases, can be performed successfully. adverse events (aes) were recorded throughout the study. therapeutic comparability was defined a priori as a clinical response within % for hfa vs cfc for the primary efficacy measures. results: baseline demographics were similar between treatments for the intent-to-treat population. mean -h baseline symptom scores for nasal stuffiness, nasal discharge and sneezing were . , . and . , respectively, out of a possible score of . all taa-cfc and taa-hfa doses significantly (p< . ) reduced -h, and am and pm -h reflective scores for nasal stuffiness, nasal discharge, sneezing and ni vs placebo (except cfc μg for sneezing). taa-hfa and taa-cfc were statistically comparable (within . and . for the one-sided % confidence interval) at doses of μg and μg for the primary variables of nasal discharge, sneezing and ni for the -h, as well as the am and pm -h reflective assessment, over the -wk period * , * agrawal p , p , , p , p , p , p , p * , p , p , p * p , p , p , p p * finegold, i. * fink p * * sienra monge * , , * so, c. p * soane * , p * staveren, a.m rates of cardiovascular mortality are higher during peak pollen times. (brunkreef, lancet ) . for this reason, mast cell stabilizing agents and leukotriene antagonists are under development for the treatment of myocardial infarction. conversely, ige mediated disease may be protective against sudden cardiac death.(szczeklik, coron art dis ) ar has not been studied in this context. we conducted a retrospective case control pilot study of va patients who were diagnosed with allergic rhinitis and had an acute myocardial infarction. methods:the electronic medical record of a large va hospital was queried for patients diagnosed with an acute myocardial infarction (ami) in the past six years. patients were divided into groups with and without ar. patients with chronic urticaria, asthma, and eczema were excluded from this study. primary outcome was all-cause mortality. secondary outcomes included lv systolic function and peak troponin levels. results: patients were diagnosed with ami, ( %) of which were also diagnosed with ar. patients with and without ar did not differ in terms of age, ethnicity, tobacco status, hypertension, diabetes, or lipid levels. / ( %) patients with ar died, compared to / ( %) control patients, (p-value: . ). ar patients had lower mean peak troponin values ( . vs. . ), but these were not significant. both groups had similar lv function. conclusion: this pilot study suggests an association between allergic rhinitis and a decrease in ami allcause mortality independent of other factors. atopic patients have been shown to have prolonged bleeding times, reduced platelet aggregation, and delayed thrombin generation which can result in delayed clot production. (szczeklik, thromb haem ) possibly, patients in our study diagnosed with allergic rhinitis were more likely to monitor their health symptoms or had physicians who carefully addressed multiple issues. rigorous prospective studies are needed to determine the role of ar in myocardial infarction. purpose and methods. a formulation of olopatadine hydrochloride ophthalmic solution (olopatadine . %) was evaluated in a randomized, placebocontrolled, double-masked, hybrid environmental study intended to determine efficacy and safety in subjects with histories of seasonal allergic conjunctivitis or rhinoconjunctivitis. in this -week trial, subjects regularly assessed their ocular signs and symptoms. additionally, subjects evaluated both the frequency and severity of their nasal symptoms. daily throughout the study, ragweed pollen counts were obtained from each investigative center. repeated measures analysis of variance was used to compare treatment differences in the slopes for nasal symptoms as a function of pollen counts. results. the nasal results are presented herein. specifically, relative to placebo, olopatadine . % significantly reduced the frequency of pollen effects on sneezing (p= . ) and itchy nose (p= . ), and reduced the severity of pollen effects on sneezing (p= . ), itchy nose (p= . ), and runny nose (p= . ). in this study, the most frequent ocular adverse event that was related to therapy with olopatadine . % was ocular dryness, occurring at an incidence of . %. no treatment-related, clinically relevant changes were observed for visual acuity, intraocular pressure, ocular signs, or fundus parameters. conclusion. olopatadine ophthalmic solution, . % is safe, well-tolerated, and effective in reducing some effects of pollen on the nasal symptoms associated with allergic rhinoconjunctivitis. author index key: cord- -sg esn p authors: yi, lina; zou, lirong; lu, jing; kang, min; song, yingchao; su, juan; zhang, xin; liang, lijun; ni, hanzhong; ke, changwen; wu, jie title: a cluster of adenovirus type b infection in a neurosurgical inpatient department of a general hospital in guangdong, china date: - - journal: influenza other respir viruses doi: . /irv. sha: doc_id: cord_uid: sg esn p background: human adenovirus type is a re‐emerging human respiratory pathogen that is associated with several respiratory infections outbreaks in military and school populations. in this study, we describe the first hadv ‐associated hospital outbreak documented in guangdong, china. methods: active surveillance was conducted in the involved neurosurgical inpatient department. all staff and patients in the involved neurosurgical department were surveyed for any symptoms of fever (≥ °c) and enlarged tonsils during the outbreak period. throat swabs and demographic information were collected for all cases. for each specimen, assays for common respiratory viruses were performed using one‐step reverse transcription‐polymerase chain reaction. hadv‐positive samples were inoculated onto hep‐ cells for isolation. hexon genes, fiber genes, penton genes, and whole genomes were sequenced. a phylogenetic tree was constructed. results and conclusions: forty‐three cases, including laboratory‐confirmed cases and possible cases, were identified. nurses had the highest attack rate of infection, with a rate of . %. the attack rate for doctors and inpatients was . % and . %, respectively. hadv was the sole pathogen identified during this outbreak. the hexon, fiber, and penton genes from seven isolated hadv stains were sequenced. all these genes showed % homology and fell into the hadv [p h f ] cluster, indicating that hadv was the single viral strain for the outbreak. while not conclusive, the epidemic investigation revealed that the outbreak was introduced by nurses from sources outside the hospital. it was likely that a transmission from staff to inpatients had occurred. human adenovirus (hadv) is a common pathogen among children and adults. infections of hadv can cause a variety of clinical diseases, ranging from asymptomatic and self-limited conditions to pneumonia and even death. as of now, at least hadv genotypes have been identified and are classified into seven species (a-g). furthermore, viruses in species b, c, and e are more commonly associated with symptomatic respiratory infections. , [ ] [ ] [ ] [ ] [ ] human adenovirus type (hadv ), a member of hadv-b family, was first identified from a military outbreak in spain in . this virus used to be recognized as hadv-b a by partial characterization of its hexon and fiber epitopes. [ ] [ ] [ ] in , michael et al. revealed that hadv was an emergent respiratory pathogen. it had evolved from a homologous recombination between hadv-b and hadv-b in its hexon gene, which conferred changes in viral serotype and immune activity. in recent decades, hadv has been associated with several respiratory infections outbreaks. , , , crowed communities, military training camps, and schools are common settings for hadv infections. here, we describe a hadv outbreak occurred in a neurosurgical inpatient department of a jiangmen hospital in guangdong province, china. on june , , one local center for disease control and prevention of guangdong was informed that several staff members, including nurses and doctors working in a general hospital, fell ill with symptoms of a fever and sore throat. the hospital is a district general hospital. the by reviewing patients' medical records, we identified the first case and determined the investigation period began on june , days before the onset of the first case. all staff and patients in this neurosurgical department were surveyed for any symptoms of fever (≥ °c) and enlarged tonsils during the outbreak period. laboratory-confirmed cases were defined as persons with positive hadv pcr assays. those not confirmed by the laboratory, but with symptoms and signs (fever (≥ °c) and enlarged tonsils), were defined as clinical-confirmed cases (possible cases). throat swabs from all cases were collected and tested. information on demographic characteristics, onset of illness, and clinical symptoms were collected. for the use of all above-mentioned specimens, written informed consent from all participants involved in the research was obtained (or from their parents or legal guardians in the case of a minor). this study was approved by the ethics committee of the guangdong provincial center for disease control and prevention, and was in compliance with the helsinki declaration. the hexon, fiber, and penton genes of hadv were amplified. the primers we used are listed as follows: hexon-f multiple sequence alignments were performed with clustalw, and alignments were manually edited with aliview. for whole genome sequences, mafft software was used for alignment with default parameters (http://mafft.cbrc.jp/alignment/server/). maximum likelihood (ml) trees were estimated in raxml using the generalized time-reversible (gtr) nucleotide substitution model with gamma distribution among site rate heterogeneity. data analysis was performed with spss . (spss inc., chicago, il, usa). differences with an error probability of p<. were regarded as significant. for categorical data, we used chi-square testing and fisher exact testing as appropriate. the outbreak ranged from june to july , . the first cases were two nurses working at neurosurgical unit a. our investigation identified cases, including laboratory-confirmed cases and possible cases. the onset of illness in all cases is shown in figure . two peaks were observed. the first one was from june - . it included cases, among which were nurses. the second was from june to july . during this period, of infected inpatients were identified. it was observed that, within each unit, the first cases were all nurses. (table ). most cases ( cases) reported upper respiratory symptoms. fever was the most common symptom, followed by sore throat, cough, expectoration, headache, and runny nose. twelve of these cases developed pneumonia. no mechanical ventilation was needed. two cases developed conjunctivitis. most clinical symptoms and signs between infected inpatients and infected medical workers did not differ (table ) . however, there were significantly more inpatients who developed pneumonia (p<. ). we reviewed all inpatients' medical records and surveyed their visitors. neither the inpatients nor their visitors had respiratory symptoms before the outbreak. we also interviewed all the chief doctors and nurses working in these three units and enquired about the staff's routine practice in the involved neurosurgical department. there are separated doctor offices, nurse stations, and nurse resting rooms within each unit. the staff had basically followed the standard infection control procedures when they cared for the patients. in the nurse stations and the resting rooms, the nurses preferred not to wear any protective equipment. they shared most office supplies, such as computers, medical records, and examination records. more often, it was the nurses who visited the doctors' offices for daily work communication, while the doctors rarely visited the nurse stations and their resting rooms, except for the acupuncturist, who was responsible for the entire department and was used to drinking water in nurse station a. there was a dispensing counter in nurse station a from which nurses from unit b and the nsicu sometimes pick up medicines. other interactions between units were fewer. one day before the outbreak, nurses from unit a had a party in a karaoke bar. control measures were implemented from june , when the hospital infection control committee was informed of this possible nosocomial infection. environmental cleaning was enhanced. self-protections, including hand hygiene and surgical mask wearing, were re-enforced. all cases and their close contacts were followed up. on june , due to the increasing number of cases, further control measures were implemented. staff with symptoms were either given medical leave or treated in isolation, as what had been implemented for the infected inpatients. the personnel entering and leaving the involved neurosurgical department were restricted. visitors to the department were required to wear surgical masks. in addition, screenings for similar symptoms were performed in the entire hospital. specimens from cases and the environment were collected and sent to the local cdc for pathogen detection. the fiber gene ( nucleotides (nt)), hexon gene ( nt), and penton gene ( nt) were obtained from eight hadv strains isolated in the outbreak. sequences of each gene were completely identical, suggesting the outbreak was caused by the single viral introduction. phylogenetic trees of fiber, hexon, and penton genes were constructed by integrating all closely related adenovirus sequences from this study identified a cluster of adenovirus type b infection in the neurosurgical inpatient department of a general hospital. through targeted surveys, the possibility of inpatients as the source of this outbreak was excluded. we suggested that the pathogen of this outbreak may have been introduced into the hospital by nurses in unit a. they had a party in a karaoke bar day before the outbreak. one or some our study has limitations. first, several respiratory viruses could cause respiratory infections. previously published data show that it is difficult to make a reliable distinction among these pathogens based on clinical signs and symptoms. to ensure case findings, we used a sensitive definition of possible cases in this outbreak, which may include both adenovirus and non-adenovirus infections, as well as infected patients who may not have been involved in this infection cycle. our investigation found throat swab specimens with a hadvpositive status, while pathogens for the remaining cases were not fully clarified. therefore, the attack rate may have been overestimated. more laboratory tests should be carried out to understand pathogenic characteristics. second, based on our investigation, we implicated that the virus could be intruded from outside of the hospital by the nurse or clinical features and treatment of adenovirus infections molecular identification and epidemiological features of human adenoviruses associated with acute respiratory infections in hospitalized children in southern china emergent severe acute respiratory distress syndrome caused by adenovirus type in immunocompetent adults in : a prospective observational study severe community-acquired pneumonia caused by human adenovirus in immunocompetent adults: a multicenter case series severe pneumonia due to adenovirus serotype : a new respiratory threat? adenovirus infection as possible cause of acute liver failure in a healthy child: a case report adenovirus pneumonia in an immunocompetent adult occurrence of respiratory illness due to an atypical strain of adenovirus type during a large outbreak in spanish military recruits outbreak of acute respiratory disease in china caused by b species of adenovirus type respiratory disease caused by a species b adenovirus in a military camp in turkey outbreak of febrile respiratory illness associated with adenovirus a infection in a singapore military training camp computational analysis identifies human adenovirus type as a re-emergent acute respiratory disease pathogen an outbreak of acute respiratory disease in china caused by human adenovirus type b in a physical training facility epidemiology of human adenovirus and molecular characterization of human adenovirus in china clustal w and clustal x version . aliview: a fast and lightweight alignment viewer and editor for large datasets raxml-vi-hpc: maximum likelihood-based phylogenetic analyses with thousands of taxa and mixed models the general stochastic model of nucleotide substitution incubation periods of acute respiratory viral infections: a systematic review emergence of community-acquired adenovirus type as a cause of community-onset pneumonia cross-sectional study of the relationship of peripheral blood cell profiles with severity of infection by adenovirus type outbreak of adenovirus type infection in israel disseminated adenovirus disease in immunocompromised and immunocompetent children intravenous ribavirin treatment for severe adenovirus disease in immunocompromised children a -year prospective study of the epidemiology of acute respiratory viral infections in hospitalized children in shenzhen, china. influenza other respir viruses molecular monitoring of causative viruses in child acute respiratory infection in endemo-epidemic situations in shanghai a cluster of adenovirus type b infection in a neurosurgical inpatient department of a general hospital in guangdong, china. influenza other respi viruses [a ]. the authors declare no conflict of interest. clinical data and patient samples were provided by jw, ck, and mk. all authors read and approved the final manuscript. key: cord- -rc vn e authors: merrin, jack title: differences in power-law growth over time and indicators of covid- pandemic progression worldwide date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: rc vn e an automated statistical and error analysis of countries or regions with more than cases of covid- as of march , , has been performed. this study reveals differences in the rate of disease spreading rate over time in different countries. this survey observes that most countries undergo a beginning exponential growth phase, which transitions into a power-law phase, as recently suggested by ziff and ziff. tracking indicators of growth, such as the power-law exponent, are a good indication of the relative danger different countries are in and show when social measures are effective towards slowing the spread. the data compiled here are usefully synthesizing a global picture, identifying country to country variation in spreading, and identifying countries most at risk. this analysis may factor into how best to track the effectiveness of social distancing policies and quarantines in real-time as data is updated each day. mathematics is essential to predict and control the course of a pandemic. one approach is mathematical modeling [ ] . many epidemiological models derive from the sir (susceptible, infected, recovered) model [ ] or some more sophisticated versions of it. if there are susceptible, infected, and recovered (or removed individuals), then there are standard shaped curves and predictions you can make based on differential equations, provided you exactly know the transmission rate and recovery rate. these parameters may only be possible to determine from a retrospective analysis. one parameter is r , the basic reproduction number, which represents the number of people an infected person typically can infect over their progression. clearly, if r is much larger than , then there is a significant initial exponential growth of cases that sweep through most of the population. china and south korea have mostly blocked the spread of covid- by enacting social policies and testing so r can definitely be reduced or modulated. the sir equations are also entirely deterministic, while in real systems, there is some stochastic element of variation. sir equations do not have an analytical solution so they are more difficult to solve, and determining the fitting parameters requires sophisticated statistics. usually for an epidemic like the flu everything stays open so the parameters are more or less the same over the entire trajectory of the analysis. things start to become very complicated if different countries enact different social policies over time with different degrees of strengths. sir model parameter themselves would then become functions of time complicating the analysis. spreading the virus may also depend on differences in geography, social networks, social dynamics, or individual behaviors. another approach is not to have any mechanistic mathematical model at all, but to use methods of error analysis [ , , , ] . one can fit the data to different phenomenological functions observed in the past, such as what happened in china over the last several months to make comparisons. in this study, we attempt to analyze differences in the spread of covid- in many countries where growth is rapid to cases or more as of march , . we use the least-squares curve fitting of power-laws and introduce the danger indicator to compare the rate of spread in various countries. both indicators reveal similar information in the current stage of the pandemic. the data analysis follows the proposal of ziff and ziff [ ] , where an early stage involves exponential growth, and a middle stage exists where there is power-law growth. the power-law exponents allow us to make reliable short term predictions of a few days of the worst-case scenarios in hot spot countries compared to that of the usual assumption of exponential growth. timescales for mitigation may be three weeks or more and can be tracked by this analysis. these predictions and indicators may be relevant for estimating the burden on medical infrastructure or influence policy decision making before countries enter mitigation or rather the virus completely sweeps through. of all countries so far, only china and south korea have achieved mitigation compared to other countries where there is still significant power-law growth. this analysis identifies some countries which are in a highly critical situation with expectations of more positive cases and deaths than occurred in china, while others have quite some time to achieve a resolution. in this paper, we display the number of measured positive cases (data set who [ ]) as a function of time on plots where the x and y variables are both logarithmically scaled. this is referred to as a log-log plot. we will try to distinguish between exponential growth and power law growth. here we show exponential growth on a log-log plot appears like an exponential curve on a linear plot. here we show power law growth on a log-log plot appears linear. increasing power law functions on a log-log plot have positive slope. there can be a high degree of overlap with the power law growth and exponential growth in the middle region, but the long term behaviours are different as shown in figure . in this paper, we use error analysis [ , , , ] and curve fitting to analyse the progression of positive cases. in weighted least squares curve fitting, one finds the parameters which minimise the chi squared function. as we saw before, a power-law function can be transformed into a linear function on a log-log graph. there is always an analytical solution to the curve fit of a straight line and thus we can determine α, β, and their uncertainties quite objectively in a standard and simple way. the transformation is with a = ln α and b = β. then, all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. if we want to fit data to a straight line, then we need the coordinates of the statistics x i , the measured values y i , and the uncertainties in the values σ i . then we have for chi-squared. in our cases, x i is the number of days of the progression of the disease since cases. y i is the reported positive tested cases at x i . you cannot repeat the measurement, so we have to estimate the typical uncertainty. we have to use the square root n rule. for example, if there are cases, then the uncertainty would be expected to be about cases with a relative uncertainty of percent. if there are , cases, then the uncertainty would be expected to be about cases with a relative uncertainty of percent. the relative uncertainty is given by more recent points should be weighted more strongly because their relative error is less. a more exact curve fit incorporates the use of error bars. to solve for a and b you calculate ∂χ ∂a = and ∂χ ∂b = and solve the resulting system of linear equations. we use the notation, the uncertainties in the parameters can also be directly computed using propagation of error. all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint if a statistic and its uncertainty are known as x ± σ x then we can transform x into f (x) and the new uncertainty is given by propagation of error. of course, β = b and the uncertainty is obtained directly from the linear curve fit. we also used the fact that y = ln y i so it was also attempted to do an unweighted fit with the following formulas [ ], but there is not much difference in beta for the two methods. see the table at the end of the results. the weighted fit is preferable to compute the error bar in beta. in the future, it may also be attempted to perform a maximum likelihood estimation of the power law exponent since there are some caveats to the weighted method presented here, such as assuming no uncertainty in the x coordinate [ ] . another alternative is to use a software like kaleidagraph, which does a nonlinear least squares analysis based on the levenberg-marquardt method. using a software package like that is cumbersome to deal with all the datasets for each time window as described in the next subsection. also since you didn't write the program, it is not clear that you understand what was computed is right. the weighted linear least squares method is considered sufficient for the time being and works very well automatically in matlab scripts and produces the uncertainty in beta. one last detail is that the data must be linear on a log-log plot, or the points that don't match are outlying. outliers skew the values of α and β and hinder any attempts to make accurate predictions. the initial phase of the data is not power-law, so we restrict ourselves to measuring the last days as a measure of progress in a country. a moving window has the added benefit that you can have a moving window of seven days to see the progress over time as we move the windows backward from now. if the curve stays in a power-law regime, the plot of the exponent is flat versus time. that would be the latest overall exponent. it will also reduce in magnitude as the rate of infections decreases. the data from china and south korea follow this pattern and do not fit a power law for all times because an end-stage of no new infections occurred. basically, a moving window is similar to quantifying the magnitude of slope on a log-log curve over time as an indicator of disease progression. only countries that had reached cases or more were considered as hot spots for analysis. there was a lower cutoff of cases where the data is often irregular. times before cases are less relevant, and you can't even plot time zero on a log-log plot because log is undefined. more cases bring more predictability. the moving window procedure also has the benefit that you don't have to manually and arbitrarily pick when the power law regime starts in the analysis. you can just track it and see if it locks in for the most recent data. some countries go power law after cases or more but the plots presented in the results start at cases to get a better picture. in principle, if you limit the spread of the virus as in south korea and china, then the power-law growth is reduced to a zero exponent. a measure of danger is the time it would take to infect the remaining population of a country versus the time required for a useful quarantine to limit growth. the indicator d we introduce here does just that. the d indicator depends on several variables. • p is the population of the country. • n c is ideally the current total number of infections, but we only have measured positive cases. • α, β are the fit parameters to the number of positive cases at the current time, n c = αt β c . • τ q = days is the quarantine time. • δt is defined as the time it takes for the power-law to extrapolate to the total population of that particular country. the d indicator is a positive function with the following properties. when δt >> τ q then d → . the country would have much time to implement a social distancing strategy. when δt << τ q then d >> . if d is large, and more rapid social distancing is more crucial to reduce future infections. since most countries will not exhaust their populations for some time from march , , then d as a function of time looks very similar to just β as a function of time, so i choose not to plot it or report the values. if significant infection occurs relative to population size, we should probably use measures of spread more in lines with d. people are interested to know when the number of new cases saturates. and if they do saturate, is this substantially lower than the total population, or does it sweep through. south korea and china datasets are most interesting because they show it can stop before sweeping through everyone ( cases hubei china). the hubei province data is the most interesting because it shows an entire trajectory of the infection. there is one problem with china hubei province data. the criteria for a positive test was extended to include lung imaging on february . discontinuities from differences in testing recording are bad for a moving window analysis that we use. instead, as an example, we make an interpolating function, which is a logistic curve. we can see what the moving window method predicts as a basic model on ideal data where testing would have been perfect. for all other analysis in this paper, we assume no interpolating function. also the other china datasets with better measurements for different provinces look like the same progression of beta as we show in figure for this toy model. in summary, we should keep in mind the dropping of beta to zero is what we want to happen as the outbreak comes under control in different countries. if beta is increasing that indicates things are getting worse. all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint figure : hubei china data [ ] as a basic model fit to logistic curve with kaleiagraph. using the logistic curve fit we can get some idea of how beta progresses over the course of the entire model sequence of events using the analysis in this paper. this is done because the actual data is slightly corrupted. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint results the black dots represent the actual data. the curve fit for the last seven days is extrapolated as the black line. the top edge of the graphs is set to the population of the various countries. the x-axis spans days. one indication of the severity of the spread is the relative slope of the power-law on the log-log plot. a higher slope means things are increasing faster soon. notice for the case of the us that the projected time scale is less than days if the curve does not flatten out. the extrapolation has relevance for setting social policy as a worst case scenario. [ht] all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint figure : beta correlates with how drastic the situation is with different countries currently. beta less than . can be considered as under control, beta greater than indicates a potentially dangerous situation. all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint the countries with beta in the - range with one star, - ranges with two stars, - range with three stars, and - range with four stars. beta picks out the most hard-hit countries such as the us, uk, france, belgium, germany, spain, and israel. surprisingly italy is only stars now. the reason why italy is doing so all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint bad could be that they spent many more days at a middle range beta than some of the other countries who started later above cases. the us is the only country with four stars. it even crossed at one point which is definitely significant. many look closely to follow what happens in the us as this is the epicenter with the largest population. different software and algorithms would computer beta differently. there is not much difference if you try to find beta from a weighted curve fitting scheme where uncertainties are estimated from the square root of the the number of positive tested cases versus an unweighted curve fitting scheme. doing an unweighted fit does not provide a direct way to find the measured error bar in beta versus the weighted method derived in the methods. the difference between the two methods is consistent with the actual computed error bars from the weighted analysis. the weighted curve fitting method from the methods is preferable. a plot of the -day window of power-law growth β or d is a good measure of the spread of infections in different populations. the dependence of α does not appear to indicate anything useful for the time being. the powers seem to vary between zero and just over five for the us, which is currently the epicenter. perhaps this has to do with general behavior and connectedness of society rather when the disease first hit the country. the extrapolation of the power-law should enable us to make short term predictions of the number of cases in the future; however, social distancing measures can drop the power as indicated by measurements in south korea and china. in those situations, the crossover occurs when β starts around and takes three weeks or more from the point it starts to reduce. for the case of the us, this might take longer since the exponent is now near . log-log plots with the top scaled to the population of the country give some indication of how long a worst-case scenario could last before more or less everyone is infected. in the case, of the us this could be days or less without mitigation. as we know however a power-law does not continue forever. this time scale should be compared to those for finding vaccines, supplying equipment, or finding medicine to treat covid- . there are several factors to consider in disease progression according to the number of positive cases and if this type of analysis relevant. only people who are sick receive a test. some people who are sick stay at home, and the disease resolves itself. some people are positive but exhibit mild or no symptoms, so never receive a test. the data is only as reliable as countries continue to use the same set of testing standards throughout the pandemic. at some point, there could be so many cases that testing cannot keep up daily with the number of reagents required or available kits. after some point, it would be wise to implement serological testing or random testing of the general population to see a more accurate estimation of the total positive cases. there are several factors to consider in disease progression according to the number of deaths. the numbers of deaths are time delayed from the date of the first infection. the time scale for death is longer than to become symptomatic. the number of deaths may increase in the coming days as hospitals become more overburdened, as is currently seen in spain and italy. there are fewer deaths than positive cases, so the sample sizes are smaller to determine the statistics. whether by using positive cases or death rates, scientists should keep all their options open in tracking the course of covid- . many countries are mobilizing their manufacturing infrastructure to make additional personal protective equipment (ppe), respirators, and ventilators. one technique is to split the tubing of a ventilator to multiple patients. the timescale to produce this equipment should clearly be tens of days and not a hundred. the diy community is also mobilizing to make d printed medical equipment rapidly. companies like dyson have created a ventilator in less than days and plan to deliver , units. it is not clear if these types of numbers are enough to meet the actual future demand or if hundreds of thousands of ventilators or more are necessary. presumably any person who died could have needed a ventilator. spreading out the disease over time would allow more access to successful treatment. initiating social policy decisions in the initial stages of a pandemic is difficult, but we already saw how things unfolded in china with time to prepare. unfortunately, most countries did little and now suffer the consequences. if the question is when is the best time to enact social distancing policies, the answer is now. the best time to plant a tree to get some shade is now if you did not do it twenty years ago. it is too soon to predict the final outcome in terms of infections and deaths by this method. tracking a decrease in a beta down to - . allows one to see the spread being mitigated. it is prudent to follow the examples of south korea and making optimistic predictions depends on what we do now. countries besides south korea and china are all in the middle phase. let's hope we can look towards lowering the beta in the affected area. this study is a step towards trying to visualize the progression of the disease over time to see if social policies are working or not jack merrin would especially like to thank michael sixt for encouraging me to think about these problems while working at home due to restrictions in place. i would like to thank nick barton, simon rella maybe it is time to stop shaking hands. elbow bumps are not good either. perhaps, we should just mathematical epidemiology: past, present, and future the coronavirus curve fractal kinetics of covid- pandemic trajectory of covid- confirmed cases introduction to error analysis. the science of measurements, uncertaintites, and data analysis introduction to error analysis, the study of uncertainties in physical measurements data reduction and error analysis for the physical sciences measurements and their uncertainties: a practical guide to modern error analysis parameter estimation for power-law distributions by maximum likelihood methods key: cord- -icituitn authors: liu, m.; thomadsen, r.; yao, s. title: forecasting the spread of covid- under different reopening strategies date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: icituitn we combine covid- case data with demographic and mobility data to estimate a modified susceptible-infected-recovered (sir) model for the spread of this disease in the united states. we find that the incidence of infectious covid- individuals has a concave effect on contagion, as would be expected if people have inter-related social networks. we also demonstrate that social distancing and population density have large effects on the rate of contagion. the social distancing in late march and april substantially reduced the number of covid- cases. however, the concave contagion pattern means that when social distancing measures are lifted, the growth rate is considerable but will not be exponential as predicted by standard sir models. furthermore, counties with the lowest population density could likely avoid high levels of contagion even with no social distancing. we forecast rates of new cases for covid- under different social distancing norms and find that if social distancing is eliminated there will be a massive increase in the cases of covid- , about double what would occur if the us only restored to % of the way to normalcy. as covid- spreads across the world and the united states, governments and individuals have worked to slow the growth of the disease by reducing the extent to which people leave their homes. in the united states, these actions have largely been acted on by households who have voluntarily stayed home unless they needed to travel, but they have also been bolstered by orders of local and state governments. these orders have occurred over different time periods, and have taken many different forms, but they have had a similar flavor of limiting gathering sizes, closing schools, and shutting down non-essential businesses or shifting their operations to a contact-free experience. that said, many areas of the country never had any form of stay-at-home orders. ultimately, the purpose of the stay-at-home orders is to reduce the amount of contact between people in order to slow the growth of covid- , which is thought to be spread primarily through droplets that require being within a relatively small distance of an infected person. in this paper, we first measure the extent to which social distancing reduces the speed at which covid- spreads. we then run simulations of how covid- will spread over time under different policy regimes. we find that covid- spreads less than proportionately with the number of contagious individuals. we also observe that social distancing during late march and april significantly reduced the spread of the disease. higher population density also leads to an increased spread of covid- . our model gives good out-of-sample forecasts of the disease for the two and half weeks after the end of our mobility data, assuming that the country continues the nearly % return to normalcy observed at the end of april (as compared to the observed peak social distancing levels). we forecast that completely opening up the country to % of the pre-shutdown levels of social interaction will lead to million additional covid- cases (officially diagnosed) by the end of september , corresponding to a doubling of the cases than we would expect if the country continued with the path of % return to normalcy we observe at the end of april. however, there is a great heterogeneity among counties, and according to our simulations % of the counties could open up while still experiencing a low infection rate of less than . % over a -month period. these counties all have low population densities. the model we estimate is a simplified version of a susceptible-infected-recovered (sir) model. we assume that where y i,t is the number of individuals who are infected in county i on day t, r i,t is the rate at which infectious individuals in the county transmit the disease, s i,t is the percentage of the county population that is susceptible to covid- (i.e., the share of people who have not yet had , and y i,t is the number of cumulative individuals who have been infected by day t. the y i,t− −y i,t− term reflects our assumption that infected individuals are contagious from the second day after they catch the virus through the seventh day, leading to a serial interval of . days . this treatment of the infectious population is an approximation to the standard sir models, where the infectious population is typically modeled as a stock that has an outflow at a constant rate. this assumption makes the estimation much easier with the large number of fixed effects we include in our model, and as a practical matter this assumption only has a minimal impact on our estimates of the contagion of covid- . in the supplemental appendix we show that we get extremely similar results if we take the time of contagiousness to be days the main difference between this model and a standard sir model is that a standard sir model constrains ω = . we show in the supplemental appendix that the estimated model with this constraint does not perform well out of sample. we instead find that ω < . this shows that the marginal impact of one more sick person diminishes as more and more people are sick. there are several reasons why this may be expected, with the greatest reason being that contagious individuals may end up endangering many of the same group of unexposed individuals. one might expect this to be the case if people often have the same or overlapping groups of friends or acquaintances. we see some of this directly when, for example, cases are clustered within households, nursing homes, or places of work. in the accompanying supplemental appendix we present a networking model and show that we would get ω < if people have interconnected networks of contact. in order to better understand the variation of the rate of contagion, we allow r i,t to vary according to a number of factors instead of treating it as a constant parameter. thus, we model this specification implies that transmission rates can differ across counties (the county fixed effects α i reflect different population densities and also different demographic compositions), time periods (date fixed effects β t are included mostly to accommodate different rates of testing and also the different rates of reporting that happen on weekdays vs weekends), levels of social distancing d i,t , and different temperatures, h i,t , the impact of which has been debated , , . the social distancing measure, d i,t , is based on cellphone gps location data that are provided by safegraph, and are available for free to researchers studying covid- . we measure social distancing as the fraction of phones that stay exclusively at home during a given day. the ε i,t term is our statistical error term. equation ( ) is estimated by taking the logarithm of both sides, with the details in the appendix. note that the social distancing level by individuals, as well as social distancing regulations, are not determined in a vacuum. rather, we observe that people social distance more in areas that are harder hit by covid- . thus, the ε i,t term may be correlated with the social distancing measures, causing a biased, underestimated impact of social distancing on slowing the spread of the disease. we control for this endogeneity bias by estimating the model using an instrumental variables (iv) technique, where we use the amount of rain as an instrument for social distancing. specifically, we assume that rain directly shifts the level of social distancing, but is not correlated with ε i,t . to estimate the model parameters, we use county-level officially confirmed covid- daily case data of , us counties or county-equivalents from february to april . we omit the data from new york, new jersey and connecticut, as explained in the technical appendix. we append the data with daily county-level weather data as well as cellphone mobility data provided by safegraph. the results are presented in table . we find that social distancing indeed decreases the growth rate of covid- : moving from the observed mean pre-covid level of social distancing ( . ) to the post-covid peak level ( . ), the magnitude of r is reduced by %. we also find that the exponent on the number of contagious people, ω, is . . it is significantly lower than , the exponent assumed in a standard sir model. this shows that there is a strongly concave relationship between the number of infected people and the rate at which the disease spreads. this level of concavity also implies that while initial outbreaks of covid- will expand exponentially, they will quickly turn to a slower rate of growth. the growth looks linear or even plateauing when plotted cumulatively, although the disease will persist for a long period of time and continue building a substantial number of cases. this may explain why the recent growth rate of covid- cases has slowed considerably after a quick take-off, and yet this growth has persisted. we also find that higher temperatures may slow the spread of the virus, but with a much smaller impact. most of the variation of the contagion rates r i,t is captured by our county-level fixed effects, α i , in equation ( ) . in order to understand the drivers of the contagion rates, we run a regression of the county fixed effects α i against county-level demographics. it has been shown in that when the number of fixed effects is large, these coefficients can be treated as data for the purpose of statistical inference. the results are reported in table . we find that population density is a crucial factor influencing the spread of the disease. in fact, covid- would be expected to never flare up beyond a very small base level in / . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . some areas with sufficiently low population densities, as we discuss below. we also observe that greater concentrations of black and hispanic residents and public transit commuters are associated with higher contagion rates. interestingly, higher median incomes are related to greater contagion. we are uncertain what drives this result: one possibility is that people with higher incomes may interact more with nearby cities that have more outbreaks. we also include the share of seniors (age +) and children (below age ) in the population. seniors are marginally more likely to spread the disease, but children show no sign of having a lower rate of infecting people, confirming the finding in . using our model, we simulate future cases beyond our sample period. first, to examine how our model performs, we predict the out-of-sample case numbers from the end of our data period up to may , , under different social distancing assumptions. we start by forecasting the cumulative covid- cases if each county continued the social distancing at the levels observed at the end of april. assuming the observed february level as normalcy, the end-of-april level is at the % between the peak lock-down level and normalcy (so we say that such a level is at % of normalcy). we also implement the same exercise under / . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . several other social distancing benchmarks. these benchmarks are defined specifically in the supplemental appendix. the results appear in figure . we observe that our model forecasts the pattern of disease contagion well if the level of social distancing in early may remained at the level seen at the end of april ( % return to normalcy). finally, we forecast how the disease will evolve up to september , under different reopening strategies. the cumulative and daily cases appear in figures and , respectively. the cyclicality observed in figure reflects the variation we observe in the weekly data, which may reflect different reporting delays or different social-distancing behavior due to the day-of-the-week effect. the forecast shows that social distancing matters, but that the impact of increased mobility becomes higher as we move closer to normalcy. if social distancing is eliminated, we observe that the largest effects will be felt in the first two months. this occurs because of the shrinkage of the uninfected population in each county. note that cases will be elevated to almost double the daily rate that we would observe under a %-return-to-normalcy even into the september of , when cases are likely to reach an almost steady weekly level. our estimates suggest that it will be difficult to return to school and normalcy in the fall of without sparking a large outburst of covid- . ultimately, moving from the %-return-to-normalcy to a full return to normalcy will lead to million additional confirmed cases. if we assume that confirmed cases are only % of actual cases, and that covid- has an . % infection-fatality rate (ifr), as we justify in the supplemental appendix, we would expect , to , deaths by the end of september if the social distancing occurs at % to % levels of normalcy, respectively. we note, however, based on our forecast that % of the counties in the sample ( , ) could completely reopen and still experience a confirmed case rate lower than . % from june to august, . these counties are less populated and account for less than % of the population in our sample. we also note that our analyses do not consider the positive effects of alternative preventive protocols such as wearing facial masks and better hand washing. such protocols may help slow the contagion process. taken together, we demonstrate that the rate of spread of covid- in the united states is concave in the number of contagious individuals. this explains why the growth rate of covid- cases has been slower than expected given the initial exponential growth, above and beyond the effect from social distancing. we empirically identify the substantial impact of social-distancing on combating the pandemic. we also forecast how covid- will evolve in the future, and the timing over which different parts of the country will reach their peaks and how the patterns may affect our reopening strategies. may jun jul aug sep sep date may jun jul aug sep sep . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint in this online appendix, we first present our data. we then discuss our model and assumptions. finally, we present our assumptions for the simulations. our data come from a multitude of sources. we lay out the sources for each of these in turn. data of positive cases are based on the covid- data published by the new york times (https://github.c om/nytimes/covid- -data, accessed on may , ). the data contain the daily confirmed case counts in the u.s. at the county or county-equivalents level. we exclude cases in the states of new york, new jersey, and connecticut due to the large outbreak there and the complicated relationship between new york city (which is the seat of counties) and the surrounding counties. we drop of the remaining counties because we do not have social distancing data for of them, and we cannot match the demographic data for a third (oglala lakota county, sd). this reduces the number of counties to , . in addition, we remove counties that had no confirmed cases in the entire sample period. the remaining , counties and county-equivalents constitute our main sample. these counties account for . % of the total u.s. population and . % of the total u.s. confirmed cases as of april , . there are a few days where there are negative cases that are reported. these are generally corrections to previous over-reporting. thus, we clean the negative numbers of cases by subtracting the absolute value of the negative cases from the proceeding day. in the event that that leads to a negative number of the proceeding day, we iterate again. covid- also has an incubation period of approximately days , . because of this lag between when a person gets sick and when they are diagnosed with covid- , we assume that the cases reported on a particular date actually measure the covid- infections from days earlier. we also assume that the true number of cases is approximately times the number of diagnosed cases. we get this number by assuming that the infection fatality rate (ifr) is . % . we also assume that any deaths that occur happen days after the confirmed test result. on may , , the last day of our confirmed case data, there were , deaths in the us. on may , , there were , , officially diagnosed cases. we hence obtain the factor as ( , / . )/ , , = . . we round this number to . our estimates are not sensitive to the specific factor we use. we use social distancing data from the company safegraph, which collects cellphone gps data from u.s. residents, and has made them available for free to academics studying covid- . these data are collected through a series of pings that the company receives for all users who have installed a number of smartphone apps. the list of apps that collect this information is kept as a trade secret. for each county, we use the fraction of cellphones that stayed near home for the whole day as our measure of social distancing. the safegraph data are published at the census block group level. to accommodate other data sources which are available at a less granular level, we aggregate the this . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . variable to the county level by taking the weighted median, using the number of cellphones in each census block group as the weight. we obtain the demographic data from the census bureau's - american community survey (acs), which contains information of each county's profile of population, ethnicity, age, median income, and commuting pattern. the acs, however, does not report population densities. safegraph, the company who provides us with the social distancing data, also maintains a dataset of the land area of each census block group in the us. we aggregate the land areas to the county level. together with the county population information from the census bureau, we are able to construct the population density data of each county. we gathered historical daily rain and temperature data from national oceanic and atmospheric administration (noaa) (source: https://www.ncei.noaa.gov/metadata/geoportal/rest/metadata/item/ gov.noaa.ncdc:c /html, accessed on may , ). the raw weather data is at the weather station level and we match weather stations to the counties they are in. we use the average values across weather stations within the same county to construct the weather variables for that county. for a small number of counties where there are no associated weather stations, we use the daily state averages as proxies. we obtained county-level voting data from https://public.opendatasoft.com/explore/dataset/ usa- -presidential-election-by-county/table/?disjunctive.state (accessed may , ). this data is explained at https://github.com/deleetdk/usa.county.data (accessed may , ), and the election vote totals originally came from the new york times. shelter-in-place orders (sip) data are compiled by keystone, a strategy and economics consulting firm. the company collects and distributes the sip data (https://www.keystonestrategy.com/coronavirus-covid -intervention-dataset-model/, accessed on may , .) for free to researchers studying covid- . our sample is an unbalanced panel because counties start to have positive number of confirmed cases on different dates. the earliest date we observe in the sample is jan , , and the last day is april , . note that we construct actual cases using reported cases days later, and thus the corresponding sample period based on reported cases is feb , to april , . summary statistics of all of the variables we use in the estimation are presented in table a . note that our case data proceed past the dates used for estimating the model and are up to may , . we use those data for validating the model. those data are publicly available, but we are happy to supply summary statistics for this hold-out sample upon request. in this subsection, we detail the assumptions we make and the estimation procedure. as noted in the main paper, the model we estimate is a modified version of the standard susceptible-infected-recovered (sir) model: where y i,t is the number of individuals who are infected in county i on day t, r i,t is the rate at which infectious individuals in the county transmit the disease, s i,t is the percentage of the population that has not yet had covid- . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . and is thus susceptible to it, and y i,t is the number of cumulative individuals who have been infected up until day t. this model differs from the standard sir in two key ways. first, the standard sir model constrains ω = . we discuss in the paper that there are theoretical reasons to believe that the correct model of transmission involves ω < . as an example, we present a network model below that demonstrates that ω < is possible even using the conventional transmission mechanism. second, the standard sir model does not specify a discrete time frame over which the infected individuals are contagious, but rather builds a stock of infected individuals and assumes that these individuals exit their infected period at a fixed rate. we view our model as an approximation of this process, which greatly eases our estimation and allows us to easily add important variables to explain the contagion process in our analysis. we use a -day infectious window and an assumed latent period of days (y i,t− −y i,t− ). this gives a mean serial interval of . days, which is close to several estimates . in this appendix, we also present the results where we use a -day window (y i,t− −y i,t− ), and show that results are similar. we assume that the rate of transmission, r i,t varies by a set of factors, which we model as r i,t = exp x i,t β + ε i,t . x i,t includes county-level fixed effects, date fixed effects, the measure of social distancing, and daily average temperature. the county fixed effects account for differences in demographics across counties, such as the demographics shown in table of the main paper as well as other unobservable county-specific factors. the date fixed effects account for both day-of-the-week differences in the patterns of travel for people (e.g., the time away from the house to go to work or to go to the park, which may lead to different exposures to the disease) as well as differences in the rate of testing and reporting that occur across time. we assume that the errors ε i,t are uncorrelated across counties. we further assume that ε i,t is uncorrelated across time, although we cluster the standard errors by county. we estimate the model by taking logarithm of both sides. after rearranging we get: note that sometimes y i.t , the diagnosed case number, is for some counties on some dates. therefore, we adjust this formula slightly by adding to y i,t so the logarithmic values are always well-defined: in some counties, y i,t− −y i,t− is for some periods. we do not use those observations for estimation. note that because this is a lagged variable, this is a selection based on independent variables and not based on dependent variables, and hence it does not bias our estimation. one concern that can arise in estimating this model is that the amount of social distancing is likely to be correlated with the error terms, ε i,t in the regression. we address this concern using an instrumental variable (iv) approach, which requires that we find a variable that affects social distancing but is not correlated with ε i,t . we use the amount of rain (measured in mm) as a shifter of social distancing that does not directly cause covid- to spread. we run a first stage regression of social distancing to test whether this instrument has much power. the f-statistic for this test is . , indicating that this is a strong instrument. the main estimation results are presented in table of the paper and replicated in column of table a in this appendix. research on covid- is nascent, and there are different views of how long infected individuals stay contagious. suppose that such individuals are contagious for days instead of days. then the model becomes: we present the estimation results of this model in column of table a . note that this regression has more observations because there are fewer instances where we observe no cases in a county for a -day window than for a -day window. the results are largely unchanged. the coefficient on social distancing levels are slightly lower, but well within one standard error of the corresponding coefficient in column . the exponent on the infectious individuals is . . that is somewhat smaller (but statistically different) than the . we observe with the shorter -day window, but overall the curvature shape is similar to what we have observed with the -day window. the effect . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . of temperature is slightly smaller but similar. as we will discussion below in section simulation, both specifications give similar long-run forecasting results. all county-level demographic factors remain constant over time in our analysis. while our main regression gives many insights, impacts of these demographic factors on the spread of the virus are captured by the county fixed effects. in order to better understand how these factors affect the contagion rate, we next regress the county fixed effects on several demographic variables. the coefficients from this regression should be thought of as the impact of these demographics on the rate of contagion. the results from the model are reported in column of table a (replication of table in the paper). in column we present the results we would obtain if we instead modeled the contagious period to be days. similar to table a , the results are again very similar under this alternative specification. the only statistically significant difference is that the coefficient on log(population density) is slightly smaller, although the effect is of a very similar magnitude. we also observe that the r of the -day contagious period model is slightly lower than the r of the -day contagious period model. while the focus of this paper is on measuring the contagion effect, we consider an exploratory regression to see what is correlated with the rate at which individuals choose to social distance. the results are shown in table a . the results indicate that the levels of social distancing are driven much more by the number of national cases than the number of local cases. the results also indicate that the fraction of voters who voted for trump in the presidential election explains much of the observed levels of social distancing. going from a solidly clinton-voting to a solidly trump-voting county (i.e., going from the minimum to the maximum of trump vote shares) represents a swing of almost percentage-points of social distancing. to put the change into prospective, the social distance measures range from % to %, a percentage-point variation. demographically, higher population densities lead to lower social distancing, but increased compliance with sheltering-in-place orders. more affluent counties have less social distancing. counties with a higher fraction of black population are less likely to social distance, perhaps due to work demands. a greater hispanic population and a greater public transportation population are both associated with more social distancing. supporting the idea that much of the traveling is for work, we see that people are less likely to practice social distancing on weekdays than on weekends. in terms of policy, the closing of schools is the policy that is most-indicative of how much social distancing will occur. we observe that closing public venues is correlated with reduced social distancing, and that limiting gatherings (we treat all gathering size limits of -people or less the same, but most of these limits are for far smaller groups than people) has a statistically significant effect on the amount of social distancing. after estimating our model, we forecast the number of cases that would emerge under different social distancing regimes. for this exercise, we first divide our model's predicted numbers of "true" cases by , which gives us the prediction of diagnosed cases (as described in section positive cases). next, because the , counties in our sample are a subset of the whole nation, on a given date the predicted diagnosed case number is a fraction of the total cases in the us. while this fraction changes on a daily basis, we use an approximation by taking the median of the daily ratios between diagnosed cases observed in our sample and in the whole nation during our sample period. the median of the daily ratios is . . accordingly, we divide our predicted diagnosed cases by . to obtain the national number of diagnosed cases. the first step of our simulation involves validating the model: we predict how many cases would emerge in the weeks after our data (dates: april to may , ) in order to validate our model. the results are shown in figure in the original paper. we observe that we are well able to predict the number of observed cases if the social distancing in early may represented a % return to normalcy, which is defined as stayed home in county i in february, and fractionstayathome i,t represents the fraction of devices staying home in county i on date t. we compute the different levels of social distancing accordingly: for example, a % towards normalcy represents social distancing at the level of . ×(minimum social distancing) + . ×(maximum social distancing). we find that the levels of social distancing at the end of april were approximately at the % return to normalcy levels. overall, our model predicts the national cases well. we next forecast the cumulative and daily cases of covid- through the end of september at different levels of social distancing. those forecasts appear in figures and in the original paper. in figure a below, we replicate figure in the paper but further add the confidence intervals. to avoid cluttering, we only depict % and % return-to-normalcy levels in a . as a robustness check regarding the -day contagion window specification, we also consider forecasting us daily cases under the specification where the contagion window is days. figure a shows the evolutions of daily cases till september , under % and % return-to-normalcy regimes. we overlay the forecasts of both -day and -day specifications for easy comparison. from the figure, we may see the forecasts of -day and -day contagion window specifications are fairly close under the % return-to-normalcy level. for the % normalcy level, the two specifications differ at the beginning but converge quickly. in the long run, the two specifications give similar forecasts for daily cases. one unique feature of our model is that we estimate an exponent on the number of contagious cases. we include this flexibility because such a model fits the data much better, and also leads to forecasts that have more limited growth after an initial take-off of covid- cases, as is commonly observed. to demonstrate our model's better fit, we compare the prediction of our model against an alternative model with the exponent fixed at as the standard sir model in figure a . at the %-return-to-normalcy level that is observed at the end of april, the standard sir model would predict much higher cumulative case numbers than the actual numbers. in contrast, our model's prediction fits much better. we next illustrate that the concave relationship we estimate for the number of contagious individuals on the number of new cases can come from social networks between people. we seek to demonstrate the theoretical feasibility of our results rather than the necessary or sufficient conditions under which the nonlinearity will arise. thus, we simulate a very simplified model of networks and disease process. to do this, we simulate a network with the following process: we take , individuals. we create a network by first randomly assigning that any two individuals will be joined with a common node with probability . (corresponding to each person getting almost friends on average). call these connection "round- friends." we then expand this network by assigning each node to have an edge with each of the round- friends of their friends with a probability of . . we assume that the disease spreads with the following process. we seed individuals to have the disease in period . then in each period we assume that any connected individual will get sick with probability /(number of connections), where the number of connections is specific to the individual, and varies due to the random assignment of the people who are connected (this probability is capped at in case someone is randomly assigned fewer than connections, which is very unlikely). after simulating this process, we then regress (ln (y t ) − ln (s t )) = c + ω ln (y t− ) + ε t . we run this simulation times. the mean value forω = . , with a range of ( . , . ). this shows the plausibility of network effects leading to an estimate in the range that we have estimated in our main model. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint may jun jul aug sep sep date actual cum. cases % return-to-norm. % return-to-norm. cis % return-to-norm. may jun jul aug sep sep date . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint serial interval of novel coronavirus (covid- ) infections high temperature and high humidity reduce the transmission of covid- role of temperature and humidity in the modulation of the doubling time of covid- cases temperature significant change covid- transmission in cities generalized least squares inference in panel and multilevel models with serial correlation and fixed effects cluster of coronavirus disease (covid- ) in the french alps the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. the new engl a systematic review and meta-analysis of published research data on covid- infection-fatality rates serial interval of novel coronavirus (covid- ) infections key: cord- - f hm authors: souza, william marciel de; buss, lewis fletcher; da silva candido, darlan; carrera, jean paul; li, sabrina; zarebski, alexander; vincenti-gonzalez, maria; messina, janey; sales, flavia cristina da silva; andrade, pamela dos santos; prete, carlos a; nascimento, vitor heloiz; ghilardi, fabio; pereira, rafael henrique moraes; santos, andreza aruska de souza; abade, leandro; gutierrez, bernardo; kraemer, moritz u. g.; aguiar, renato santana; alexander, neal; mayaud, philippe; brady, oliver j; souza, izabel oliva marcilio de; gouveia, nelson; li, guangdi; tami, adriana; oliveira, silvano barbosa; porto, victor bertollo gomes; ganem, fabiana; almeida, walquiria ferreira; fantinato, francieli fontana sutile tardetti; macario, eduardo marques; oliveira, wanderson kleber; pybus, oliver; wu, chieh-hsi; croda, julio; sabino, ester cerdeira; faria, nuno r. title: epidemiological and clinical characteristics of the early phase of the covid- epidemic in brazil date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: f hm background: the first case of covid- was detected in brazil on february , . we report the epidemiological, demographic, and clinical findings for confirmed covid- cases during the first month of the epidemic in brazil. methods: individual-level and aggregated covid- data were analysed to investigate demographic profiles, socioeconomic drivers and age-sex structure of covid- tested cases. basic reproduction numbers (r ) were investigated for sao paulo and rio de janeiro. multivariate logistic regression analyses were used to identify symptoms associated with confirmed cases and risk factors associated with hospitalization. laboratory diagnosis for eight respiratory viruses were obtained for , cases. findings: by march , , confirmed cases were notified in brazil, of whom % ( of , ) were hospitalised. of the cases acquired locally ( . %), two thirds ( . % of , ) were confirmed in private laboratories. overall, positive association between higher per capita income and covid- diagnosis was identified. the median age of detected cases was years (iqr - ). the median r was . for sao paulo and rio de janeiro. cardiovascular disease/hypertension were associated with hospitalization. co-circulation of six respiratory viruses, including influenza a and b and human rhinovirus was detected in low levels. interpretation: socioeconomic disparity determines access to sars-cov- testing in brazil. the lower median age of infection and hospitalization compared to other countries is expected due to a younger population structure. enhanced surveillance of respiratory pathogens across socioeconomic statuses is essential to better understand and halt sars-cov- transmission. the first case of covid- was detected in brazil on february , . we report the epidemiological, demographic, and clinical findings for confirmed covid- cases during the first month of the epidemic in brazil. individual-level and aggregated covid- data were analysed to investigate demographic profiles, socioeconomic drivers and age-sex structure of covid- tested cases. basic reproduction numbers (r ) were investigated for são paulo and rio de janeiro. multivariate logistic regression analyses were used to identify symptoms associated with confirmed cases and risk factors associated with hospitalization. laboratory diagnosis for eight respiratory viruses were obtained for , cases. by march , , confirmed cases were notified in brazil, of whom % ( of , ) were hospitalised. of the cases acquired locally ( · %), two thirds ( · % of , ) were confirmed in private laboratories. overall, positive association between higher per capita income and covid- diagnosis was identified. the median age of detected cases was years (iqr - ). the median r was · for são paulo and rio de janeiro. cardiovascular disease/hypertension were associated with hospitalization. co-circulation of six respiratory viruses, including influenza a and b and human rhinovirus was detected in low levels. socioeconomic disparity determines access to sars-cov- testing in brazil. the lower median age of infection and hospitalization compared to other countries is expected due to a younger population structure. enhanced surveillance of respiratory pathogens across socioeconomic statuses is essential to better understand and halt sars-cov- transmission. to investigate individual-level diagnostic, demographic, self-reported travel history, place of residence and likely place of infection, differential diagnosis for other respiratory pathogens, as well as clinical details, including comorbidities, we collected case data notified to the redcap database from february to march , . data was contributed by public health and private laboratories. diagnosis and case definitions (see appendix, pp. ) were based on world health organization (who) interim guidance. to explore the time-lag between the number of imported cases and of local cases we used the granger causality test . geospatial analysis of covid- cases, demographic and socio-economic data based on data from the first covid- reports in brazil , we hypothesized that rates of incidence and testing for covid- are higher in areas of higher per capita income. for the greater metropolitan region of são paulo (gmrsp), per capita income at the gmrsp neighbourhood level ( zones) were retrieved from the pesquisa origem e destino survey (www.metro.sp.gov.br/pesquisa-od/). , notified cases (covid- confirmed, ruled out, and without final diagnosis) resident in the gmrsp were geocoded based on self-reported address using the galileo algorithm and verified using google api. per capita income for each zone was linked to each notified case based on residential address. we compare per capita income for all notified cases between those tested (positive and negative) and untested, and for confirmed cases by rt-pcr. full details on the statistical analysis can be found in the appendix, pp. . to quantify transmission potential of covid- in brazil, an exponential model was used to represent the incidence of covid- at the national level and in são paulo and rio de janeiro states. time series of confirmed cases were modelled as samples from a negative binomial distribution with a mean equal to a fixed portion of the incidence. the analysis was carried out in a bayesian framework with uninformative priors on all parameters apart from the removal rate, which was given an informative prior. the informative prior ensured that the average duration for which an . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . to investigate which factors are associated with a confirmed covid- result and with hospitalization summary statistics were calculated for continuous variables and for categorical variables and summarized as medians (range and interquartile range, iqr), as appropriate. missing data were removed (assumed missing at random) (see appendix table s and fig. s ). uni-and multivariate analysis included only cases with complete information for the relevant variables. these analyses compared demographics, symptoms, clinical signs and comorbidities between confirmed covid- cases (rt-pcr positive) and ruled-out covid- cases (rt-pcr negative). additionally, separate multivariate logistic regression models were built to predict hospitalisation (binary variable: hospitalised vs. not hospitalised) based on symptoms, clinical signals and comorbidities, and to predict testing status (positive or negative for rt-pcr sars-cov- ). the associations between the outcome and independent variables were reported as adjusted odds ratios (aor) with % confidence intervals and likelihood ratio test (lrt) using the univariate and multivariate logistic regression models. model diagnostics were performed to check for model specification errors, multicollinearity and influential observations. a · significance level was applied. the funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report. the corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication. . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint by march , , four weeks after the first report of covid- in brazil, , covid- cases had been notified as covid- suspected infections from cities across all five administrative regions of brazil. of these, , cases were confirmed ( · % of all notified cases) and notified through the redcap system (fig. a) (fig. b) . the epidemic curves of locally-acquired cases followed the curves from imported cases with a lag of two days (granger causality test) (fig. a) . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint these locations used a bayesian approach to fit an exponential growth model to covid- aggregated incidence data. consistent with previous studies in china and overseas , we find that epidemic spread in são paulo and rio de janeiro states is characterized by similar r values of · ( % ci · - · ) and · ( % ci · - · ). the r for brazil was slightly higher with median of · ( % ci · - · ) (fig. ) . analysis of the age-sex structure of confirmed and notified cases compared to the brazilian demographic structure revealed a disproportionately lower proportion of confirmed covid- infections reported in younger categories ( - , - years of age) and a slightly higher proportion in middle-age categories ( - and - years of age) (fig. ) . specifically, compared to the proportion of the total brazilian population per age category, the proportion of confirmed covid- . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint infections in the - and - years of age categories are · -and · -fold lower compared to brazilian demographic structure (fig. a) . we found that most confirmed cases were in males ( [ · %] of , - confirmed cases had missing information for sex and/or age) (fig. a) . the median age of cases was years (iqr, - , range: newborn- years). nearly half ( [ · %] of , ) of the confirmed cases were in the age range of to years of age (fig. a) . similarly, · % ( , of , ) of cases tested for sars-cov- belonged to this age-group (fig. b) , which is substantially higher than the corresponding fraction of the brazilian population ( , , [ %] of , , ). · % ( ) of cases were health care workers. overall, only four newborns, three infants ( to month-old), ten children ( to years old), and twelve adolescents ( to years old) were diagnosed with covid- . in addition, nine patients were pregnant, one in the first trimester, one in the second trimester, four in the third trimester and had missing information). six cases were hiv-positive. proportion (%) of the country's population in each age-sex class is shown as faded bars. . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . (fig. a) . to test whether notified tested cases were associated with socioeconomic status, we evaluated the association between covid- diagnosis and socioeconomic status in the subset of cases in the greater metropolitan region of são paulo (gmrsp) region with geocoded residential information using an ordinal probit model. we found that the proportion of tested cases in gmrsp increased as income per capita increases (z-score = . , likelihood ratio test p-value < . ) (fig. c, table s ). moreover, the increase in the proportion of tested cases for a unit-increase in income is higher in weeks , and compared to week . for the range of income per capita observed, given the same amount of income per capita, the proportions of tested cases were lower in weeks , and than week . overall, there was a noticeable upwards trend in the association between testing rate and per capita income uncovering a widening socioeconomic disparity in testing practice as the number of cases expands. the income distribution of the untested fraction increasingly approximates the average for gmsp, whereas the tested and confirmed cases (both laboratory and clinical epidemiological) are consistently higher over the study period. we also analysed the results for other respiratory pathogens tested in brazil as part of the differential diagnosis by central public health laboratories and national influenza centres (brazilian , fig. s ). . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . in a univariate analysis of , cases with a final classification as confirmed (n= , ) or discarded (covid- ruled out) (n= , ), we found that increasing age, symptoms (cough, difficulty breathing, dyspnoea/tachypnea, sputum production, nasal congestion, nasal flaring, nausea/vomiting, headache, irritability/confusion, difficulty swallowing, intercostal retraction and alteration on chest auscultation) and clinical signs (fever and conjunctival congestion) were higher associated with a negative sars-cov- results (see appendix table s ). overall, a total of · % ( / , ) of confirmed covid- cases had at least one comorbidity. most common comorbidities were heart disease, hypertension, diabetes, and chronic respiratory disease. (figure b) . interestingly, age was not significantly associated with hospitalization after accounting for co-morbidities. . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . of the four fatal cases, one had cardiovascular disease/hypertension, one had both cardiovascular disease/hypertension and renal disease, and two fatal cases had no reported comorbidities. only one case had reported close contact with a confirmed covid- case reinforcing that local transmission was already well established in brazil by march , . . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint these findings provide evidence that sars-cov- transmission in brazil shifted rapidly from a scenario of imported to local transmission. we found that the proportion of tested cases is higher in zones with higher per capita income. we showed that during the first month of covid- in brazil, only · % of the reported confirmed cases were conducted in public health laboratories. our results support similar transmission potential (r ) of sars-cov- in brazil to other geographic regions. overall, our clinical findings demonstrate that chest x-ray abnormalities and o saturation < % are strongly associated with hospitalization. the combination of universal access to diagnostic and the success of interventions will dictate the fate of covid- in brazil. overall, these findings . secondly, our retrospective study has focused predominantly on symptomatic patients ( %) that presented themselves to health services for testing. therefore, we cannot describe the full spectrum of disease. population-based serologic surveys are urgently needed to properly determine the asymptomatic and oligosymptomatic fraction. finally, many patients remained hospitalized when the dataset was extracted, and, we were unable to estimate clinical outcomes given the long duration of infection. together with changes in surveillance guidelines, socioeconomic bias in testing suggests that the number of confirmed case counts may substantially underestimate the true number of cases in the population. additional reasons for underreporting include (i) a significant proportion of asymptomatic infections , (ii) people with mild and even moderate disease are unlikely to present to health services for testing, (iii) limited testing capacity in public health service in brazil in face of the large number of cases due to delays in importing reagents and kits used in molecular testing. close monitoring of state-and municipality-level data will further help to inform mitigation strategies. our results suggest that approximately % of the covid- cases in brazil were skewed towards age groups between to years with substantially fewer cases in younger age groups. this pattern could be explained by (i) a higher risk of exposure of this group due to more frequent international travel (travel bans were only implemented on march , ), and (ii) younger age . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint groups being less likely to acquire an infection and/or less likely to acquire significant symptoms upon being infected . covid- infections were reported in paediatric and pregnant patients [ ] [ ] [ ] . paediatric infection appears to typically be of mild or moderate severity; we observed a similar proportion of asymptomatic infections compared to reports in children in china ( % vs. %) . also, the onset symptoms of pregnant women were similar to those reported in non-pregnant adults with covid- infection. on the other hand, proportion of hospitalisation of paediatric patients in brazil was lower than those observed for children in china ( . % vs. . %) . also, in contrast to china, none of the pregnant women that tested positive for covid- in brazil had pneumonia or were hospitalized , . however, the absence/lower number of hospitalisations could be explained by resource availability and local clinical practice guidelines. despite the small sample size, our findings in pregnant and paediatric patients in the early-phase covid- pandemic in brazil require further understanding of sars-cov- infection in these groups. although clinical features in brazil are similar to those recently reported in other countries , , , we observed that % of confirmed cases reported no symptoms. this should not be considered as an estimate of the asymptomatic fraction. firstly, it is not possible to distinguish true asymptomatic infections from cases in the pre-symptomatic phase. secondly, routinely collected data tends to be incomplete. thirdly, these cases were tested because they were in contact with a known confirmed case. lastly, there is an ascertainment bias towards symptomatic infections due to the case definition used for notification (appendix). other estimates of the asymptomatic fraction have varied widely, including % on the diamond princess ship , - % in the italian village of vo'euganeo and % based on repatriation flight screening . overall, % of covid- cases in brazil were hospitalized compared to % in the usa . as mentioned above, these differences may reflect factors other than disease severity, for example, resource availability, local clinical practice guidelines and testing availability. on the other hand, they may also reflect right censoring, whereby cases that were notified towards the end of the period studied had not yet been hospitalized. this would be expected given the median lag of four days between symptom onset and hospitalization observed in brazil. although age was not a risk factor for hospitalization after controlling for comorbidities, is should be noted that the age distribution among patients who were hospitalized differed from that reported in china, with a higher proportion of younger (< years: brazil, . % vs. china, %) and older patients (> years: brazil, . % vs. china, %) . however, such comparisons need to be taken cautiously due to different testing and notification practises in the two countries. . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . we showed that patients with pre-existing cardiovascular diseases/hypertension were at increased risk of hospitalization. the prevalence of at least one comorbid condition among infected individuals in brazil was similar to that reported in china ( . % vs. . %) . previous studies suggest that persons with underlying health conditions, such as cardiovascular, diabetes and chronic lung diseases, appear to be at higher risk for severe covid- infection than persons without these conditions , . pre-existing cardiovascular disease appears to be particularly important, potentially due to the involvement of the renin angiotensin system signalling pathway . this study provides new information on co-circulation and co-detection of other respiratory pathogens in the early phase of the covid- epidemic in brazil. particularly, we found cocirculation of eight other respiratory viruses, the most common respiratory infections were influenza a and b, and human rhinovirus (hrv). co-detection of sars-cov- with influenza a and human metapneumovirus (hmpv) have also been reported in china , . here we found co-detection of sars-cov- with influenza a and hmpv, and we expanded the description of the other multiple codetection scenarios of sars-cov- with other respiratory viruses, including hrv, influenza b, human respiratory syncytial virus, and other coronaviruses (i.e. coronavirus e/nl , hcov oc /hku ). although, viral co-infection has been reported with many other respiratory viruses, no difference in clinical disease severity between viral co-infection and single infection has been reported . in conclusion, we provide the first description of covid- in brazil. our study provides crucial information for diagnostic screening and health-care planning, and for future studies investigating . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint clinical features of patients infected with novel coronavirus in wuhan, china coronaviridae study group of the international committee on taxonomy of v. the species severe acute respiratory syndrome-related coronavirus: classifying -ncov and naming it sars-cov- genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding clinical characteristics of coronavirus disease in china first case of novel coronavirus in the united states coronavirus disease (covid- ) in italy world-health-organization. coronavirus disease (covid- ) situation reports research electronic data capture (redcap)--a metadata-driven methodology and workflow process for providing translational research informatics support investigating causal relations by econometric models and cross-spectral virological assessment of hospitalized patients with covid- the reproductive number of covid- is higher compared to sars coronavirus percepção do estado de saúde, estilos de vida e doenças crônicas the lancet infectious estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia clinical features and obstetric and neonatal outcomes of pregnant patients with covid- in wuhan, china: a retrospective, single-centre, descriptive study. the lancet infectious clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records children with coronavirus disease (covid- ) in zhejiang, china: an observational cohort study. the lancet infectious covid- : identifying and isolating asymptomatic people helped eliminate virus in italian village international journal of infectious diseases : ijid : official publication of the international society for infectious diseases united states characteristics of and important lessons from the coronavirus the authors thank the clinicians and epidemiologist for technical support. this work was supported key: cord- -phsr jp authors: nan title: abstracts tps date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: phsr jp nan (either in men or women) between metabolic syndrome and incident asthma. conclusion: this study confirmed the significance of obesity as a risk factor for incident asthma. moreover, obesity appeared to be a stronger risk factor than metabolic syndrome. | relationship between helminth infection, blood eosinophils and asthma symptoms in a rural community from the tropics peñaranda d; alvarez l; sierra n; lopez j; zakzuk j; caraballo l institute for immunological research. university of cartagena, cartagena, colombia background: immune response to helminths shares many features with the allergic response. in tropical regions where helminths are highly prevalent, asthma is still a major public health burden. large clinical cohorts suggest that high blood eosinophils (hbe=> cells/ mm ) are associated with asthma exacerbations. however, the association between hbe and asthma severity in rural communities with prevalent helminthic infections is unclear. method: patients with wheezing symptoms in the last year living in a rural tropical community (santa catalina, colombia) where helminths are highly prevalent, were recruited for this study. blood eosinophils were assessed by complete blood count. parasitic infection was evaluated with two serial coprological exams (kato-katz method) and skin prick tests were conducted to determine reactivity to ascaris. results: seventy-three patients (mean age: ; range: - years old) were recruited in this study. a. lumbricoides and t. trichuria active infection ( . % and . %, respectively) were not related to age or gender. a positive spt to ascaris extract, aba- and d. pteronyssinus was observed in %, . % and . %, respectively. mean eosinophil count was cells/mm ; . % had hbe. rate of patients with at least one emergency department visit was . % and hospitalization, . %. blood eosinophil counts (as a continuous variable) were inversely associated with age (p = . ) and higher in helminth infection (p = . ). in crude univariate analysis, exacerbations (er and/or hospitalization) were associated with age (or: . ; % ci: . - . , p < . ) and hbe (or: . ; %ci: . - . , p = . ), but not with helminth infection. for a better definition of asthma, multivariate analysis done in those > years old indicated that hbe, helminth infection and positive ascaris spt were not associated with asthma exacerbations. conclusion: uncontrolled asthma is common in rural places of the tropics. since helminth infection influences eosinophilia, the clinical value of hbe to predict exacerbations is limited in helminth-endemic populations. castro mc ; ferreira j ; sarmento d ; carvalho c ; matos a ; bicho m chln-immunoallergy; lisbon medical school-genetic department, lisboa, portugal; lisbon medical school-genetic department, lisboa, portugal background: the bioavailability of no and endothelial homeostasis depends on the functional polymorphism of -bp del/ins within intron- of dhfr (dihydrofolate reductase enzyme) (rs ) that could interfere in the regeneration of bh (tetrahydrobiopterin) from bh ( , -dihydrobiopterin) and contributes to endothelial dysfunction in asthma. method: asthmatics (n = ) compared with control group (n = ).the polymorphism was analyzed by pcr. control of asthma assessed by (acq and paqlq). statistical analysis with spss . establishing a significance level of p < . . results: there are women and males in asthmatics and women and males in controls (p = . ). in asthmatics: age ( x ± sd): . ± . ; and in control group: age ( x ± sd): . ± . . the genotype frequencies in asthmatics are: dd ( . %); id ( . %); ii ( . %); in control group: dd ( . %); id ( . %); ii ( . %); there is no statistical difference between groups (p = . ). the allelic frequencies in asthmatics are: allele d ( . %); allele i ( . %); in control group: allele d ( %); allele i ( %); there is no statistical difference between groups (p = . ). the genotype frequencies in the uncontrolled asthmatics are: dd ( . %); id ( . %); ii ( . %) ; in the controlled asthmatics are: dd ( . %); id ( . %); ii ( . %); there is statistical difference between groups (p = . ). genotypes id and ii are more frequent in the uncontrolled asthmatics. the allelic frequencies in the uncontrolled asthmatics are: allele d ( . %); allele i ( . %); in the controlled asthmatics are: allele d ( . %); allele i ( . %); there is a trend to have differences between groups (p = . ). allele i is more frequent among uncontrolled asthmatics. the uncontrolled asthmatics are older than the controlled asthmatics (p < . ). there is no differences in gender distribution (p = . ). the genotype ii confers a risk of being uncontrolled asthmatic of . times when compared with controlled asthmatics and adjusted for age: or b : . [ . - . ]; p = . . physiopathology and the emergence of evidence-based clinical guidelines. however, variation still exists among some diagnostic aspects of asthma in real life. it is unknown to what degree diagnosis is affected by the treating physician's medical specialty. results: a total of gps, pediatricians, allergists, pulmonologists and otolaryngologists (orls) replied. although for general application of diagnostic clinical criteria all physicians rated similarly, in general accordance with the mag suggestions, a third of non-pulmonologist practitioners don't recognize chest discomfort as one of the clue symptoms of asthma, but they erroneously believe crackles are (p = . ). we found agreement in almost half of all physicians to erroneously believe that viral illness' induced wheezing in non atopic children predisposes asthma. conversely, - % are aware that allergic sensitization predisposes to asthma. most specialists -except pulmonologists (p = . )-incorrectly listed fev as the best parameter to identify airflow obstruction (ao) and fev /fvc to assess ao severity. % of gps do not know peak expiratory flow (pef) measurements could be valuable, and % of all specialists are not aware that changes in pef can also be used to confirm ao reversibility. to classify asthma, only pulmonologists adequately considered the level of control in similar proportion than severity ( % and %, respectively), which is uniformly the preferred method by most other specialists. conclusion: although in general many clinical aspects of asthma diagnosis seem to be accurately assessed, there is a wide specialityspecific variation regarding some aspects of phenotyping and classification, diverging from mag's recommendations. as such, our results can help to detect knowledge-gaps and to guide the development of more focused specialty-specific learning tools to improve clinical impressions, process medical evidence, and apply it to patient care. | issues, continuous medical education on treatment of acute asthma, exercise induced asthma and asthma in pregnancy should include, per medical specialty background: to unify and improve the management of asthma, including asthma exacerbations, the mexican guideline on asthma ( . %) of employees who stated increased symptoms with flour exposure. among all workers ( . %) employees were diagnosed as asthma and ( . %) workers were diagnosed as ba. conclusion: wheat flour sensitivity is high among workers who are exposed to wheat flour, however the prevalence of ba is similar to the previous data in the literature. johnsen cr ; callesen kt ; jensen bm ; poulsen lk clinic of allergy, dept. of dermato-allergology, gentofte hospital, copenhagen, denmark; laboratory of allergy, gentofte hospital, copenhagen, denmark background: enzymes are well known as sensitizers and causes of occupational allergy primarily in the industries producing and using the products. we present a case of occupational contact urticaria, rhino-conjunctivitis and asthma in a year male chef who was using a transglutaminase enzyme powder obtained from fermentation of streptomyces mobaraense as meat glue in processing of fine culinary dishes. this transglutaminase has been used for protein food preparation in industrial settings since to improve the texture of protein rich foods such as surimi or ham. in this case it was used in small scale in a gastronomy restaurant kitchen spraying enzyme powder with a sieve over raw meat without any protective equipment in contrast to the producer's recommendation. the chef was also found allergic to dried, edible mushrooms also forming part of the meat dish prepared with the transglutaminase enzyme powder. in one occasion he experienced an oral reaction with itching and swelling of the mucosa in the mouth, stridor, angioedema of the face, and urticaria after ingestion of beef meat treated with transglutaminase and rolled in horn of plenty dried mushroom powder. no other symptoms of food allergy were reported but a known cat allergy was. background: formaldehyde and xylene are occupational skin and respiratory irritant and/or sensitizer, exposure to those may be associated with dermatitis, rhinitis and asthma. health care workers, as nurses, laboratory technicians, doctors could be exposed in different tasks in operating rooms, endoscopy and in pathology laboratory. we describe three cases of work-related rhinitis in technicians employed in the same unit of hospital pathology . first case: a woman of years old underwent medical examination in our occupational allergy unit because allergy respiratory symptoms. she has been working for years in pathology laboratory and was exposed to xylene and formaldehyde. she developed rhinitis, rhinosinusitis, hyposmia and cough with sputum after years started work. she had negative skin prick test for common aeroallergens. lung function was normal with a fev /fvc ratio of % of predict. blood cells count reveled % of eosinophils ( /mmc) with total leucocytes. second case: a woman of years old was affected by moderate persistent allergic rhinitis with positive skin prick tests to house dust mite, dog and cat. in the last year rhinitis symptoms worsened in relation to work and improved during vacation. when she was exposed mostly to formaldehyde during shift at the end of it she usually experienced face skin and conjunctival erythema. she developed work-related symptoms after years of exposure in the pathology unit. third case: a woman of years old, who has been working for years in the pathology unit and was exposed to formaldehyde and xylene, in the last year developed moderate-severe persistent rhinitis with hyposmia and chronic cough. she referred to otorhinolaryngologist and an irritant induced rhinitis was diagnosed. she had negative skin prick test for common allergens and normal lung function. results and conclusion: the workers experienced respiratory symptoms in relation to work exposure to formaldehyde and xylene. the suspected causal agents were monitored in the work environment and an exceeding of the recommended limit values was found. preventive measure were adopted with a reduction of exposure and symptoms improve only in the second and third case. challenge test with mannitol is considered to be more specific than test with methacholine. also, duration of procedure is shorter and safer. therefore the study aim was to compare the usefulness of these two tests in monitoring of sict. method: four bakery workers with suspicion of oa underwent single-blind, placebo-controlled sict with workplace allergens accompanied by evaluation of nsbhr with mannitol and methacholine before and after sict. clinical examination, spirometry, skin prick tests (spts) to common aeroallergens and occupational allergens, serum specific ige antibodies to occupational aeroallergens were also performed. results: positive spts results to occupational aeroallergens were found in all bakery workers, specific ige to flours were detected only in two subjects. three out of the four patients displayed positive sict reaction (in two cases early spirometric response). in all of these patients, airway response to methacholine increased significantly. in the first two patients also airway reaction to mannitol was significant, whereas in one subject with early reaction there was no increase in nsbr after mannitol inhalation. the patient with negative sict results did not reveal any changes in nsbr before and after the test, neither to methacholine nor mannitol. | rice-induced occupational anaphylaxis and socio-economic impact-case report method: in this prospective study, a total of students completed a self-administrated questionnaire that comprised different questions and gave information about the participants and their glove use, working habits, signs and symptoms related to these gloves, precautions taken to minimize it, etc. skin prick test is performed through commercial extract latex gloves (stallergenes), while patch test is prepared through latex gloves and adhesives. two types of gloves are used: gloves that contain latex and gloves without latex (vinyl gloves), which are used also as e negative control. results: questionnaire items and diagnostic tests revealed that one-fourth of subjects were suspicious for latex gloves hypersensitivity. their mean value for skin reactions like irritant or allergic dermatitis or contact urticaria was between % and %, while for other symptoms the mean value was under %. logistic regression analysis revealed an association between different questionnaire items and positive allergy tests among suspected cases and diagnosed cases of latex allergy. approximately % of people who work with laboratory animals experience some allergic symptoms and about % of animal technicians go on to develop serious symptoms of asthma. uk government guidelines state that employers must prevent or adequately control exposure of employees to animal allergens and should undertake monitoring to ensure that suitable controls remain effective. the most widely used monitoring method is personal iom filters. however, these need to be attached to a pump and carried by the technician which can be cumbersome and awkward. previous data has demonstrated that allergens from dust mite, cat, dog and pollen could be captured and quantified by a novel type of nasal filter. in this current study, we sought to assess the feasibility of using the nasal filters for the assessment of exposure to mouse allergen in a laboratory facility. method: technicians working in a laboratory animal facility were asked to wear the filters during normal routine work. for comparison, they were also asked to wear an iom filter for the same duration. allergen was extracted from nasal and iom filters by gentle rocking in pbs-tween for two hours. levels of the major mouse urinary protein (mus m ) were quantified using our multiplex array technology, which is highly sensitive and allows for quantification of mus m down to . ng/ml. results: significant levels of mus m were detected in the nasal filter extracts and these levels correlated with the type of activity that was being performed by the technician, as well as the housing environment of the mice. levels were compared to the suggested 'safe' limit of allergen exposure of ng/m . we also found that the technicians grew accustomed to the nasal filters quickly and found them far more practical for every day monitoring that wearing the iom filter and pump. conclusion: these data indicate that nasal filters may be considered a simple and easily wearable method for monitoring laboratory animal allergen exposure. future studies are planned to assess the feasibility of wearing the filters for analysing exposure to other laboratory animal allergens from rat and guinea pig. havana university lower co emission, water and feed consumption and limited waste production. insects are currently allowed both for human and animal feeding in some eu countries, including italy and the risk profile related to production and consumption of insects as food and feed, including risk of allergenicity, is currently under evaluation by efsa. both food and feed products derived from insects require multiple manipulations by the breeder and/or by the workers who transform the insect into the commercial products, thus the occupational exposure have to be considered too. the aim of this work is to evaluate the allergenicity of tenebrio molitor, one most used species for animal feeding. method: t. molitor proteins were extracted from intact dried larvae and from flour of dried larvae. the protein extracts were separated in one-dimensional electrophoresis conclusion: according to these results, the larva flour seems to be less immunoreactive than the intact counterpart, probably due to the processing that causes the degradation of protein bands over kda. working in gastronomy is associated with exposure to many factors with an irritating and allergic potential influencing respiratory system. food products and organic dust are the source of inhaled allergens which may cause sensitization during apprenticeship. the study aim is a prospective observation of incidence of sensitization to selected environmental and occupational allergens among culinary school apprentices and identification of work-related allergic diseases in this group. method: the cohort comprised apprentices. they were examined in the first and the second year of education. questionnaire and allergological tests [(skin prick test) spt to common and occupational allergens, ige level evaluation (total and specific for occupational allergens) and pulmonary tests] were performed]. results: the most frequent symptoms reported by examined apprentices were rhinitis ( . %), conjunctivitis ( %), skin symptoms ( . %), dyspnea ( . %) and cough ( . %). subjects developed nasal symptoms during the second year of education, while in cases the skin symptoms and in subjects conjunctivitis appeared. in cases the work-related symptoms were reported. the most frequent positive results of spts were obtained with dermatophagoides pteronyssinus . %, dermatophagoides farinae . %, grass pollens . %. positive spt to rye and barley flour were found in respectively . % and . % apprentices. . % of apprentices had specific ige to flours. the preliminary results indicate that work-related allergy symptoms and hypersensitivity to occupational allergens are rarely found among culinary school apprentices in the first years of education. the further observation will allow to evaluate the trends in incidence of allergy to occupational allergens, as well as the clinical presentation of allergy in that group. | how multifaceted the clinical presentation and etiology of allergic diseases could be? method: the study was done in children from west georgia randomly and on based of questionnaire of representative cohort. ( ) ( ) ( ) . the cohort was children, - years old, risk factors were studied by way of interviewing, clinical-laboratory dates. for assessing the risk factors, was used 'case control' method. the statistical processing of material was done with computer program sps/sv . inclusion criteria for enrolment were: collectors of dust, gender, existence of moisture and mold consuming of tabasco, atopic dermatitis and seasonality. results: the groups, which we have studied, prevalence of acute respiratory viral infection was %, bronchitis − . %, allergic rhinitis . %, atopic dermatitis . %, food allergy . %. the reliability was high (p < . ) in families with bronchial asthma compared with healthy population. bronchial asthma was detected in . % of population. the hereditary load of allergic diseases in patients with bronchial asthma was . % and in healthy cohort it was . % (p < . ). conclusion: based on the results, we can conclude that, ecological factors and genetic predisposition significantly influences on prevalence of sensibilisation of house dust mite, molds and formation of bronchial asthma. as the genetic and environmental factors that act on an immune system are better elucidated and their roles established, the implementation of more enduring preventive efforts will be developed. however, at present, the best approach to the child at high risk for the development of allergies is to institute dietary and environmental control measures early to decrease sensitization, and to recognize and appropriately treat the evolving signs and symptoms of allergic disease. background: plantation of road-side avenue trees has become a major part of the urbanization programme in kolkata metropolis of india for megacity beautification and environmental management. due to evergreen habits, gulmohor (delonix regia) and chhatim (alstonia scholaris) are frequently selected for plantation programme to generate green belts. however, an increasing incidence of seasonal pollinosis was observed among the inhabitants living in close vicinity to these trees suggesting a possible link between the airborne pollen load and the concomitant respiratory hazards. this prompted us to investigate the allergens in the pollen of these two dominant avenue trees. method: aerobiological surveys were conducted at multiple sites of kolkata for a period of two years using seven-day volumetric burkard sampler to record the pollen concentration in the outdoor ambient air. clinical data and residual blood of pollinosis patients were collected from a public hospital. allergens were detected in the pollen proteome fractionated in d gel by ige-serology. the major igereactive proteins were partially purified by ammonium sulphate fractionation followed by ion-exchange chromatography. the allergenic activity of the fractions was tested by histamine release assay. results: a clear correlation was observed between the pollinosis related morbidity and the aeropollen load especially during the peak flowering period of these two trees. about % and % of the patients displayed positive spt response and ige-reactivity using pollen extracts of gulmohor and chhatim respectively. immunoproteomic analyses revealed the presence of - ige-reactive components in the d pollen proteome of these species. hierarchical cluster analysis with patient immunoblot data identified a kda and a kda protein as major allergens of gulmohor and chhatim respectively. the purified fractions containing each of these two major allergens induced histamine release from granulocytes within a range between and %. method: immortalized human keratinocyte cell line (hacat) and primary normal human epidermal keratinocytes (nheks) were differentiated with calcium chloride for and days, respectively. following the differentiation, the cells were treated with il- ( ng/ml), il- ( ng/ml), and/or hcho ( × ^- %) for hours. the mrna expression of flg, ivl, lor, dsg , dsg , dsc , dsc , as well as tslp was analyzed using quantitative real-time pcr. results: hcho exposure decreased the mrna expressions of structural components (flg, ivl, and lor) and cell adhesion molecules (dsg , dsg , dsc , and dsc ) in a short-period time of exposure ( hours). we also found that hcho exposure significantly enhanced il- -and/or il- -induced tslp production in nheks as well as hacat. interestingly, exposure to hcho alone is enough to increase the tslp mrna expression in both cells. conclusion: our results suggest that hcho exposure might synergistically damage the skin barrier function with il- and il- by increasing tslp expression and decreasing structural components as well as cell adhesion molecules. | skin prick test reactivity to aeroallergens in adult allergy clinic in a tertiary hospital: a -year retrospective study results: five different human sera were screened for specific ige level against different allergen sources using test methods of three different suppliers. the sensitivity of the three different methods can be arranged in the ascending order manufacturer a < manufacturer c < manufacturer b. with the test of manufacturer a, % of the measurements were below the detection limit ( . ku/l), with the test of manufacturer c, % of the measurements were below the detection limit, whereas the test of manufacturer b leads to values below the detection limit in % of the cases. in terms of variation coefficient, the test system of manufacturer c had the best performance. test systems of manufacturers a and b exhibited comparable variation coefficients, which were considerably higher than that of manufacturer c. conclusion: based on these test results, only the test of supplier c is recommendable for determination of levels of specific ige for diagnostics of allergic patients. with the test of manufacturer a, elevated levels of specific ige antibodies for many allergens cannot be detected due to the poor sensitivity of the test system. the test system of supplier b exhibits a good sensitivity but the coefficient of variation is rather high for a diagnostic test. this drawback could be circumvented by multiple determination of one test parameter. although this is an advisable strategy in general, the routine in diagnostic laboratories is incompatible with this approach, since throughput would decrease while costs would increase. this study is another good example for the need of the implementation of a characterized standard material with known values of sige, as demanded by wojtalewicz et al. method: cd c and cd expression on basophils were monitored upon exposure of whole blood samples (< hours) to anti-ige and/or allergenic extracts. staining was conducted on exposed samples using dry room temperature stable antibody panels (dura innovations format) coated in well plates, eliminating all antibody pipetting steps from the workflow. red blood cells were lysed and data was acquired (without further wash steps) on a cytoflex flow cytometer (beckman coulter). staining and lysing were automated using a biomek (beckman coulter). results: the described no-wash preparation protocol, already established for manual preparation mode in tubes, could be trans- conclusion: the hr-test was significantly less likely to be positive, if a patient suffered from monosymptomatic ae than in ae patients with concomitant urticaria. this could signify a higher likelihood of treatment response to antihistamine and other anti-allergic medication in the latter group. background: pathogenetic mechanisms of allergy are polymorphic. they include ige-dependent and ige-independent, allergen-specific granulocyte-mediated and lymphocytic reactions, as well as nonspecific hypersensitivity, which are realized through a variety of mediators: histamine, tryptase, etc. allergen bucal challenge mimics the natural situation and is useful for understanding the mechanisms of allergic airway inflammation and airway hyperresponsiveness (ahr).saliva used as a non-invasive readily available bio-sample for diagnosis instead of blood. biomarkers in saliva are associated with the pathogenesis and clinical outcome of allergic diseases method: aim: to examine mediators for ahr with buccal(mucosal) challenge tests. we examined patients with allergic asthma(the history, positive skin prick test, serum specific ige) and healthy volunteers. saliva were collected. then, both groups were subjected to buccal(mucosal) allergen challenge by a water-salt solution of the mite allergen dermatophagoides pteronyssinus. saliva was recollected in minutes and hours after the provocation. the level of myeloperoxidase, elastase, tryptase in saliva were determined by the elisa. that provocative test did not cause clinical symptoms development or reduction in nasal bronchial patency in any patient. results: in patients with allergopathology, an initially increased level of myeloperoxidase and tryptase in minutes after the provocation, elastase increased in hours (table ) . tryptase in saliva after minutes increased till . ( . ; . ) (me, pg/ml (lq;uq)), p = . . increased tryptase is presence of increased cellular inflammation, e.g. mast cells. its ige-dependent hypersensitivity, because there was the correlation between the elevated level of tryptase and positive prick tests. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity and ige-independent reactions. in healthy volunteers this increase was not observed. the identification of tryptase, myeloperoxidase, elastase can be used for diagnosis of types of ahr. tryptase is a mediator of early (immediate) response to allergen. increased myeloperoxidase and elastase indicates the involvement of the eosinophils and neutrophils in the oral mucous membrane in the allergic process. these mediators have additional roles in the late phase response. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity. conclusion: safe and acute in vitro methods allow to conduct early etiological diagnosis of allergy, which contributes to the effectiveness of therapy; the detection of polyvalent sensitization dictates the need for molecular diagnostics to single allergens, which has a higher prognostic level and the clinical significance of predicting the appropriateness and effectiveness of allergen-specific therapy; laboratory diagnostics of the allergy allows to reveal sensitization at the ( , ) ( , ) ( , . ) *p = . ; **p = . ; ***p = . . subclinical level, which increases early diagnosis and identify persons with a predisposition to allergy; the establishment of causal aller- background: antibacterial chemicals like parabens and triclosan have been associated with allergic disease in children. parabens are also suspected to affect metabolic functions, possibly due to their weak endocrine disrupting properties. furthermore, a possible link has been suggested for eczema and adiposity, and thus, how body burden of chemical exposures affect both of these outcomes are of interest. we aimed to describe the association between exposure to parabens and eczema and body mass index (bmi) in an adult population in norway. method: urine biomarkers of butyl-, ethyl-, methyl-and propylparabens were quantified by mass-spectrometry in adult participants (median age= years) from the rhinessa study in bergen, norway. linear regression models adjusted for gender, age and bmi (for eczema outcomes) and with clustering for siblings, were applied to model possible association between specific gravity standardized urine biomarker concentrations of parabens with bmi and eczema. results: propyl-(ppb) and methyl-parabens (mpb) were detected in % of the urine samples; ethyl (epb) in % and butyl (bpb) in % of the samples. in women, epb and bpb were detectable in % and %, respectively. participants with current eczema ( %) had lower level of several parabens compared to those without eczema (bpb for both genders; epb in women only and sum of all parabens in men only). body burden of epb (geometric mean (gm)) was . μg/l in women with current eczema compared to . μg/l in women without eczema (p = . ). body burden of parabens (mpb and epb) were inversely associated with obesity (bmi> , ( . %) ), as compared to normal range bmi (bmi= . - ( . %)) in both men and women. the concentration of mpb for obese women was gm= μg/l compared to μg/l in women with normal range bmi. for men, the gm for mpb was . μg/l in obese compared to . μg/l in normal weight men (p = . ). conclusion: person with eczema or obesity had lower paraben levels in urine. we speculate that these chemicals might be stored in adipose tissue, and therefore excreted in urine in lower levels among the obese. eczema and obesity was not strongly associated in the current study. method: we retrospectively analysed medical records of patients who were patch-tested with our dental screening series of substances. adverse reactions to dental materials were suspected based on subjective complaints in the oral cavity and/or objective conditions of the oral mucosa. square plastic chambers on hypoallergenic tape were used. patch tests were applied to the upper back and removed by the patient after hours. readings were performed and days after application (d and d ). results were evaluated according to the international contact dermatitis research group guidelines. positive patch test reactions fulfilled the criteria of at least a one plus (+) reaction on d and/or d . the term »contact allergy« is usually used for such reactions. we prefer the term »contact sensitization«. clinical relevance of positive reactions to dental materials was not systematically assessed in this analysis. conclusion: we report a high frequency of positive reactions on d that were not seen on d . this finding demonstrates the importance of an additional late patch test reading in patients with suspected contact allergy to dental materials. background: psoriasis is a chronic inflammatory skin disease. its etiopathogenesis is not exactly known. it is believed that the disease occurs in people with genetic tendency with the effect of a triggering factor. in some studies it is observed that contact dermatitis in psoriasis is increased with respect to normal population. for this reason it is proposed that allergen materials could trigger psoriasis. in this study it is aimed to determine contact allergy frequency in psoriasis cases using patch test. results: of the cases were plaque, of them were guttate, of them were palmoplantar and of them were inverse type. more positivity rate is observed in psoriasis cases ( . %) than control ( %). the positively responsed materials with respect to decreasing number of patients are found as follows: nickel sulphate ( . %), thimerosal ( . %), peru balsam( %), p-phenylenediamine( . %), colophony( . %), n-isopropyl-n-fenil- -fenilendiamin( . %), mercaptobenzothiazole( . %), benzocaine( . %), most frequently plaque type and following guttate type positive responses are observed in evaluations with respect to clinical types. no statistical significance is found between patch test results and pasi values in psoriasis cases. conclusion: patients with psoriasis should be carefully evaluated. sometimes some materials may trigger psoriasis. the composition of the pigments that professional tattooists use are varied inorganic salts of metals or organic vegetable pigments. red tattoos, especially those that contain mercury, are the most common cause of late reactions. method: year-old male patient with no previous allergy history known, who gets a tattoo on his right leg and develops within months, cutaneous erythema and pruritus on the same location as the tattoo. true test ® for skin allergy patch epicutaneous testing is performed. results: and hours reading: showed positiveness for mercury ++, with no late positive reactions after that. conclusion: as allergists we should be familiar with the different types of tattoos available, and know the possible cutaneous complications that each of these decorative techniques can present. it is our responsibility to be able to diagnose any complications at an early stage, establish the most appropriate treatment and, if possible, prevent them by informing the possible users. background: within otorhinolaryngological pathology chronic eczematous otitis externa is one of the most common, usually treated with topical medication successfully; however, there are cases in which the poor response to treatment, or the recurrence thereof, may be due to causes secondary to the medication itself, as observed in cases of allergic contact dermatitis caused by these drugs. case report: we present a -year-old male patient without relevant pathological antecedents or known allergies, who consulted the otorhinolaryngology service of our center for otorrhea of days of evolution, bilateral external otitis is diagnosed and a topical otological combination is recommended (beclomethasone dipropionate . % and clioquinol %, excipient: macrogol) with improvement. however, during the following years the patient presents exacerbations and remissions of the condition, with negative or inconclusive microbiological studies. during all that time he was using the prior topical treatment and other combination treatments of topical antibiotics, corticosteroids and local antiseptics. more aggressive causes of external otitis such as malignant external otitis were ruled out. during the third year of follow-up, a clear relationship of exacerbations was observed with the use of the first combination of topical drugs, so it was decided to investigate allergic sensitization. material and methods: we perform patch tests using true test ® , standard spanish series (geidac -spanish group for investigation of contact allergy dermatitis), topical corticosteroid battery, antiseptic, as well as topical medications used by the patient. results: from the first reading on day two, positivity was observed for: mixture of quinolines ++ patient's otological combination ++ and chlorquinaldol ++; being confirmed in the reading at day four. eczematous external chronic otitis is diagnosed with allergic sensitization to quinolines (clioquinol, chlorquinaldol). we conclude that in the case of chronic external otitis, allergic contact dermatitis should also be investigated as a possible cause, and it is important to perform epicutaneous tests with the patient's own products to evaluate non-common or hidden allergens that may be relevant to their current pathology. most common causes of acd. it is important to distinguish local findings of infection from acd caused by topical antibiotic treatments. here we present a patient with acd with topical use of bacitracin and neomycin combination therapy due to recurrent blepharitis. an -year-old male patient presented with the complaints of itching, redness, swelling of the eyelids and facial edema. he had used various topical ophthalmic antibiotherapy and eye shampoo for years due to recurrent blepharitis. five days ago, due to the redness of the eyelids, burning sensation in the eye, itching of the eyes; he was examined by an ophthalmologist. the eyelids and eyelashes were scaly and dry. the patient was treated with warm water soaked cloth dressing, mechanical eyelash cleaning and topical antibiotherapy (neomycin-simple combination therapy). after the second day of treatment, the patient's topical ophthalmic antibiotherapy was discontinued due to an augmentation of the redness in the eye- | contact allergy after exposure to ivy (hedera helix l) potent steroid treatment associated with systemic antihistamines, but with no improvement. on dermatological examination a small, well delineated, eczema-like plaque was noticed on a digital finger, as a new finding striking with her old burn scars. she denied any symptoms and was in good health condition. a mm punch biopsy was performed and histological report established the diagnosis of squamous cell carcinoma. the patient was transferred to oncology department for further investigation and treatment. conclusion: early diagnosis and prompt surgical therapy are recommended to all patients with chronic wounds and scars who develop malignant transformation. *written informed consent for the publication of potentially identifiable personal details of patient (gender, age, illness, location) was obtained. **in relation to this presentation, i declare that there are no conflicts of interest. ertugrul a; hizli demirkale z; bostanci i dr sami ulus maternity and children training and research hospital, ankara, turkey introduction: the incidence of contact sensitization among adolescent has been increasing. nickel is one of the important causes of allergic contact dermatitis (acd) in this age group. increased exposure to nickel and deterioration of the skin barrier are among the important risk factors in children. the gold standard for diagnosis is skin patch test. we report here an adolescent patient who has allergic sensitization to nickel and cobalt. case: a -year-old female patient admitted in our clinic with a complaint of edema on her face. the patient had applied chickpea water to her face at least once a day for one week because of her acnes. her medical history revealed that she had experienced similar edema on her face after applications of clay mask one year ago. she was diagnosed with cellulitis and she had been treated with antibiotics for five days. on her physical examination, angioedema was observed on her face, especially on the glabellar region. eosinophilia was not found on her laboratory data. c-reactive protein (crp), c and c esterase inhibitor protein levels were also normal. the skin prick test was performed with aeroallergens, chickpea, lentil, bean and nuts, and no reaction had been observed. the patch test was performed with 'thin-layer-rapid-use-epicutaneous' (t.r.u.e) test and chickpea. the patient had positive reactions to nickel and cobalt. detailed questioning disclosed that the patient was preparing the chickpea water in a metal pot. result: chickpea water and clay mask contain varying amounts of nickel. it was thought that the edema of the patient is due to nickel allergic contact sensitization. an increased exposure to nickel and cobalt raises the frequency of sensitization. nickel allergy can cause different clinics ranging from localized lesions to systemic reactions. we want to emphasize that a detailed medical history and the patch test would enable clinicians to demonstrate hidden allergens and then make a correct diagnosis. case report: autoimmune progesterone dermatitis is a condition of hypersensitivity to progestogens. it is not an easy diagnosis given the variety of clinical presentations it may have, ranging from eczema, urticaria, erythema multiforme, folliculitis, to angioedema or even anaphylaxis. manifestations are cyclical, occurring when the levels of progesterone are higher, this is, at the luteal phase of the menstrual cycle, and disappear during menses, with the physiological decrease of the hormone. it can also be triggered by exposure to exogenous progestins. we report the case of a -year-old woman with a cyclical erythematous and violaceous rash related to the menstrual period. the symptoms typically began - days before the onset of menses and ended - days before. the diagnosis was based in the clinical history and intradermal skin tests: skin prick testing with levonorgestrel and medroxyprogesterone were negative, but the intradermal skin test with medroxyprogesterone was positive at a concentration of mg/ml. we performed intradermal testing with the same concentration in three other women with no symptoms to exclude an irritative reaction, which were negative. autoimmune progesterone dermatitis is, perhaps, not so rare, but rather poorly recognized and reported, and thus, underdiagnosed. clinicians should be aware and include always this condition in the differential diagnosis, especially in cases of atypical or intractable skin eruptions. case report: a year old male was referred to a community allergy clinic for assessment of chronic urticaria (cu). allergy assessments for foods, inhalant and inducible physical triggers revealed no association. an autoimmune workup followed, with treatment consisting of standard dose antihistamines (h and h ). blood work revealed a persistently low hemoglobin with low-normal ferritin. hematology consulted and followed attempted iron replacement to no avail. skin biopsy revealed neutrophilic rich urticaria with the presence of eosinophils. serum protein electrophoresis (spep) revealed a monoclonal gammopathy with elevated igm, felt to be of undetermined significance (mgus). c-reactive protein (crp) was consistently elevated ( , ) in conjunction with anemia. rheumatology consulted and cleared of any evidence of vasculitis. hematology considered the anemia to be of chronic disease linked to cu. the cu was resistant to treatment including high dose antihistami- background: isolated head and neck angioedema (ae) can be mediated by bradykinin (bk) or histamin (hi) . the objective of our study was to determine which etiology was most frequent in cases of death by asphyxiating ae in france. we sought all cases of death by isolated asphyxiating ae reported in france between and via death certificates and/or the national pharmacovigilance database. results: the overall mortality by asphyxiating ae for all causes was . / million inhabitants. the death rate of bkae per million inhabitants was . and lethality of . per thousand patients per year. the death rate of hiae per million inhabitants was . and lethality of . per thousand patients per year. we found a times higher risk of death in case of bkae than hiae. conclusion: consequently, particularly severe episodes must be initially considered as bradykinin mediated and quickly reassess any first-line treatment that is inappropriate. case report: we present the case of a -year-old man who suffered recurrent abdominal pain since age of eight, leading to unnecessary emergency surgical interventions and endoscopies before hereditary angioedema due to c inhibitor deficiency (c -inh-hae) was diagnosed at the age of . rare subcutaneous swellings were considered allergic reactions preventing proper diagnosis. family history, positive for recurrent abdominal pain and swellings was totally neglected until diagnosis of c -inh-hae type i was established through appearance of severe oro-facial symptoms in the propositus' grandson. the diagnosis was suggested by the boy's mother, directed by educational materials available in the international hae patients' association website (www.haei.org). this report highlights and emphasizes the importance of accurately evaluated personal and family history to suspect condition that are scarcely known to the majority of physicians. highlights: diagnostic delay in hae and iatrogenic procedures are an underestimated problem, hiding undefined consequences, possibly destructing an entire lifetime. correct, publically available information provided by patients' associations raise awareness about the disease and could put the milestone of establishing correct diagnosis. de luque v ; lara p ; guardia p ; jimenez ar virgen macarena hospital, seville, spain; hospital virgen macarena sevilla, seville, spain background: in the protocol for the study of patients who consult for recurrent acute angioedema with facial involvement, the contactant battery is included (epicutaneous test). we review the results in our patients with facial angioedema to evaluate the contactants to which these patients present sensitization, some of them coexisting with contact dermatitis clinic. we reviewed the patients referred to the clinic for recurrent acute angioedema with facial involvement and to whom a standard battery epicutaneous test was requested. in all these patients, other habitual triggers included in the diagnostic protocol (food, medications, autoimmune diseases, bradyinergic aea/complement deficit …) were ruled out. conclusion: it seems to be profitable to continue including in the diagnostic battery of patients who consult for aea with facial affectation, study of epicutaneous with standard battery. it is a small sample, but the data correlate with what has been published, being more frequent the sensitization to contactants in women and the contactant more frequently involved nickel sulphate. | ace inhibitor-related angioedema-the value of history taking background: angioedema is a well-recognized side effect of angiotensin-converting enzyme (ace) inhibitor therapy. although it occurs in < % of the patients who take these drugs, it seems to be responsible for % of the episodes of angioedema. this entity is underdiagnosed and failure to recognize it leads to recurrence of episodes, with an impact on morbidity and increased risk of serious reactions. our objective is to analyze the clinical, therapeutic and orientation approach of patients diagnosed with ace inhibitor-related angioedema, evaluated at the outpatient consultation (oa) of immunoallergology (ia). a -year retrospective study was performed by analyzing the clinical files of all patients diagnosed with angioedema observed in oa of ia. the following variables were analyzed: gender; age; clinical data; evaluation in emergency department (ed); therapy in the episode; evolution and orientation. the chi-square test was used to study the association between categorical variables: "established therapy"/"disease evolution" and "place of reference"/"withdrawal of ace inhibitor". results: review of cases of patients referred for angioedema. only in % the final diagnosis was "ace inhibitor-related angioedema". the mean age of the patients was . years and % were male. the location of angioedema occurred in the tongue in % and in the remaining sites (lip, hemiface, tongue and hemiface, tongue and lip) appeared in the same frequency, %. none of the patients had airway obstruction. during the episode of angioedema, % of patients were not referred to ed and the therapeutic approach was done with antihistamines in %. in patients who were referred to ed ( %), antihistamines and corticosteroids medications were administered in %. regarding the evolution, it was verified that the duration of the episode was independent of the established therapy (p > . ). regarding the place of reference, % of the patients were referred form hospital (ec or ed) and, in these, the ace inhibitor was suspended in %. in patients referred from general practitioners ( %), in none of them the ace inhibitor had been withdrawal. a causal association between the use of ace inhibitors and the episode of angioedema becomes crucial, since drug withdrawal is indicated. a reference for ai oa should be weighed. therapy with antihistamines and corticosteroids has no proven efficacy. hereditary angioedema (hae) seen by physicians belonging to the hae scientific committee of the aaaeic background: patients with c -inh-hae frequently suffer from anxiety and stress. the impact of prophylactic treatment on anxiety and stress in c -inh-hae patients is largely unknown. here, we analyzed data from the apex- study, a phase ii study that investigated the effects of the oral kallikrein inhibitor bcx . method: c -inh-hae patients with a history of at least hae attacks per month were randomized to receive four different doses ( , , , . mg) of bcx or placebo for days. the depression anxiety stress scale (dass) was administered at baseline and at day . the dass consists of three self-reported scales designed to measure the negative emotional states of anxiety and stress. subjects used a -point severity/frequency scale to rate the extent to which they have experienced each state. results: baseline dass total scores as well as anxiety and stress domain mean (sd) scores for the mg treatment arm (n = ) were . ( . ), . ( . ), and . ( . ) points respectively. placebo scores were generally similar or slightly lower at baseline than for the mg treatment arm. the dass questionnaire data showed statistically significant improvements in total score vs. placebo at day (− . method: a two-phase mixed methods approach was used to develop the hae-rt tool including: phase : delphi study [hae specialists (n = ) and national patient advocacy group members (n = )] was conducted to reach consensus ( % agreement) on predictor variables to include in the tool. phase : retrospective chart review was conducted to assess the predictive findings of the decided variables. a convenient patient sample presenting with angioedema (with and without hae) between january -january were included in the study. results: nine of invited experts ( %) participated in the delphi study. of hae-specific predictive variables, reached consensuses including: (i) recurrent angioedema; (ii) absence of urticaria; (iii) recurrent abdominal pain/swelling; (iv) lack of response to allergic therapy. the retrospective study included patients (n = with hae; n = non-hae; overall % female). hae patients were significantly more likely to have a family history of hae ( % vs %; p < . ); previous recurrent angioedema ( %; p < . ); present with no hives ( %; p < . ); previous recurrent abdominal pain ( %; p < . ); and % responded to allergy treatments (p < . ). a regression analysis categorized observed frequencies (actual patient outcomes from chart review) versus predicted (by model); plotted on a by table and calculated the sensitivity and specificity of the hae-rt which resulted in one hundred percent for both. conclusion: our study demonstrated that expert involvement led to the identification and prioritization of variables that when included an hae-rt tool, were associated with a high level of sensitivity and specificity when applied to known patients. the next step is to observe the effect of the hae-rt tool on patient care in the ed. method: evaluation of cardiovascular manifestation included morphology, serum level of troponin t, electrocardiography (ecg) and echocardiography. evaluation of pulmonary manifestation included spirometry, diffusing capacity of the lung for carbon monoxide (dlco) and evaluation for mastocytosis included bone marrow biopsy and serum total tryptase measurements. results: in the study there were patients - women and men between and years old (the average age was ). there were ( . %) patients with mpcm, ( . %) with bmm, ( . %) with ism and ( . %) with ssm. the average level of serum tryptase was . μg/l ( . - ) . troponin levels was within the normal range in all patients. one patient had lowered the ejection fraction (eflv= %). no one patient had restriction. the average value of a forced lung capacity was . l ( %) and a total here, we describe a case series of twelve mis patients seen at our department over a -year period and report how many of these patients have sm. common phenotypical manifestations of acute hae episodes in this region, to review therapeutic challenges in a rural setting in comparison with world standards, and lastly to evaluate the socio-economic burden inflicted by the disease. method: a sample of individuals from a total of . the exclusion criteria was the inability to attend booked appointments more than times in year ( ). the following methods were used: an interview to formulate a family tree identifying affected individuals in contiguous generations, and review of the acute presentations in the past year ( ) . a questionnaire to obtain the relevant hae associated socio-economic burdens. a chart review to identify the therapeutic strategies in this region. c inh levels, and complement c to confirm the diagnosis. results: polygamy as a local culture was found to be an important factor that perpetuated the genetic burden of the disease. c inh and c levels confirmed hae in all participants individually. clinical features during acute attacks included swelling of extremities ( %), facial swelling ( %), neck swelling ( %), and laryngeal swelling ( %). therapeutic strategies for acute attacks included fresh frozen plasma or fresh dried plasma. danazol was used for prophylaxis. hae has had a significant negative impact upon the socioeconomic status of the affected individuals. conclusion: hae is a newly identified disorder in the broad spectrum of allergy medicine in kwazulu-natal. the diagnosis is simple to confirm but requires an initial high index of suspicion, and therapeutic management still poses a challenge in this region due to lack of resources. genetic counselling is of paramount importance during intervention since polygamy forms part of most cultures in this region. a support strategy is highly recommended in order to help alleviate the socio-economic burden posed by the disease in this region. the socio-economic burden secondary to hae ( participants/ identical questions each) question ( - points) question ( - points) question ( - points) question ( - points) question ( - point) method: a total of medical faculty senior year students were included to study on a voluntary basis. students are divided into two groups. one group was given visual user guide that has not been modified, and a visual user guide on which we have modified to the other group ( figure ). then they were asked to show how to use the inhaler spacer. results: the mean age of the volunteers was . ± years and ( . %) were male. there were students in the group without modification of the visual user guide and students in the other group with modified the visual user guide. sixty-four per cent of the modified user guide group showed correct use of the inhaler spacer, while % of the unmodified group showed correct use (p = . ). the group that given modified visual user guide was more successful in all of the display steps of the inhaler spacer. conclusion: modification of the currently available visual user guide of inhaler spacer in our country will increase the correct usage rate. results: mean fev , fvc, fev /fvc z-score were . ( . - . ), . ( . - . ), . ( . - . ), respectively. restriction had ( . %) and obturation ( . %) patients. fev (p < . , r = . ) and fvc (p = . , r = . ) decreased with age (%pv and z-score). background: children who were treated for leukemia are known to have developed long term impairment of lung function. the reasons that complication are only partially known. the aim of this study was to asses pulmonary function in children treated the lower dlco is the most frequent abnormality in childhood leukemic survivors. hsct and pulmonary infection (in particular cmv pneumonia) is a strong risk factor for impairment of dlco in children. clinical manifestation of dlco impairment is poor exercise tolerance. a screening for respiratory abnormalities in survivors following treatment for childhood haematologic malignancies, seems to be of significant importance. | phenotyping allergic respiratory diseases: an unsupervised classification using latent class analysis allergen groups was significantly associated to uawi (aor[ % ci]: . [ . - . ] ), compared to uasi. results: . % of br and % of py were women, median age was years, % br and % py reported having more than four years of training. although they recognized the main symptoms of ar, % br and % py never asked whether the patient had a medical diagnosis of ar; . % br and . % py did not ask whether the symptoms occurred when close to animals or allergens; % br and % of py did not ask if the patient had a medical diagnosis of asthma; % br and % py did not ask if rhinitis worsens asthma symptoms and . % br and . % py did not ask whether symptoms of rhinitis interfere with their daily activities. results: there was a predominance of female (br: %, py . %, uy: %) median age years old, / worked in the community and / in the emergency departments, % of the br had more than years of education, % from py had between and years, and % from uy had been graduated for less than year. br/uy recognize the main symptoms of ar, however % of those from uy do not ask: if the patient has physician diagnosis of ar, % present shortness of breath, and % a medical diagnosis of asthma, % if rhinitis worsens asthma symptoms and % if symptoms of rhinitis interfere with the patient's daily activities. the prescribed treatment varied a lot, the intranasal corticosteroid use rate was: bd: %, pd: % and ud: %. % of doctors in py, . % in br and % of uy never refer the patient to the specialist. . % of pcd of br, % of py and . % of uy are aware of aria guideline. conclusion: although ar is largely attended by pcp, recognition of symptoms and their impact on asthma, as well as the knowledge about aria guide is low and treatment is not always prescribed according to best practice. allergy education programs, with an emphasis on ar and aria guide, need to be directed to pcp in la for the better assistance of ar patients. | assessing knowledge of allergic rhinitis among final year medical and pharmacy students in croatia-curriculum change necessity? the two factor structured questionnaire was formed by the authors regarding the topics mentioned. t-test was used for statistical analysis. the global results were formed as composites of ( ) ar general characteristics, ( ) ar treatment approach, and ( ) the participants' overall knowledge. of the respondents, ( . %) were female and ( . %) were male (p < . ). medical students had a median score of of correct answers on ( ), of on ( ), and of on ( ), whereas pharmacy students had median score of of correct answers on ( ), of on ( ), and of on ( ). there were no significant differences in knowledge between two student groups. the results indicate an inadequate level of knowledge of ar in both groups, especially regarding the therapy approach. since general practitioners and community pharmacists have a major role in providing treatment to patients suffering from ar, it is important to develop advanced knowledge on this topic during medical and pharmacy degree courses. despite a relatively small study population, it would be advisable to introduce change by improving the core curriculum regarding ar with more emphasis on treatment, but additional research on this topic is necessary. tan r ; cvetkovski b ; kritikos v ; price d ; yan k ; smith p ; bosnic-anticevich s woolcock institute of medical research; university of sydney, sydney, australia; observational pragmatic research institute pte ltd, singapore, singapore; royal prince alfred hospital, sydney, australia; clinical medicine, southport, australia; griffith university, sydney, australia background: people with allergic rhinitis symptoms frequently selfselect over-the-counter medications from community pharmacies without seeking advice from a health care professional. this increases the incidence of complications due to delayed diagnosis and suboptimal treatment. this study aims to (i) compare the demographics, clinical characteristics and medication selected, between pharmacy customers who choose to self-select and those who interacted with a pharmacist when purchasing medication for allergic rhinitis symptoms, and (ii) identify the key factors associated with allergic rhinitis patients' medication self-selection behaviour. a cross-sectional observational study was conducted in a convenience sample of community pharmacies from the sydney metropolitan area. data were collected using a researcher administered questionnaire that included: demographics, pattern of allergic rhinitis symptoms, their impact on quality of life, factors triggering allergic rhinitis symptoms and medication(s) selected. logistic regression was used to identify key factors associated with participants' medication self-selection behaviour. results: of the recruited participants, were identified with allergic rhinitis, of which . % were female, . % were aged more than years old, . % had a diagnosis of allergic rhinitis, and . % self-selected medication(s). significant differences were noted in allergic rhinitis symptoms, impact of allergic rhinitis on quality of life and medication(s) selected between participants who chose to self-select and those who interacted with a pharmacist. participants who experienced moderate-severe wheeze were times more likely to self-select allergic rhinitis medication(s), and those who had allergic rhinitis symptoms impacting on their quality of life were . times less likely to self-select allergic rhinitis medication(s). conclusion: there is a high incidence of self-selection of over-thecounter treatments for allergic rhinitis symptoms in community pharmacy, with the majority of allergic rhinitis sufferers failing to seek pharmacist advice. this research identified predictors of medication self-selection behaviour in community pharmacy among people with allergic rhinitis, which can inform the design of tools/strategies and targeted interventions, aimed at improving pharmacist engagement and future practice in optimising allergic rhinitis management. the weir family health clinic, cork, ireland; university college, cork, ireland background: allergic rhinitis is a common condition that is predominantly managed in primary care. the incidence of allergic rhinitis is increasing. it is frequently under diagnosed, misdiagnosed and mistreated. it has a significant impact on patients' health related quality of life and represents a huge cost both to healthcare systems and society. the aim of this study was to implement appropriate guidelines regarding the management of allergic rhinitis in primary care and evaluate the effect on patients' health related quality of life. method: patients with a history of allergic rhinitis were selected from three general practice bases in west cork, ireland and quality of life of patients was assessed initially in year one and followed up one year later in a general practice setting using the standardised rhinoconjunctivitis quality of life questionnaire (rqlq). allergic rhinitis and its impact on asthma (aria) guidelines and appropriate prescribing were implemented during this year and patient education and structured follow up was arranged in the intervention group. this was compared with the control group who received usual care. results: valid responses were received, from the control group and from the intervention group. the study demonstrated a statistically significant difference in quality of life in the intervention group. in the adult intervention group the quality of life score decreased between and representing an improvement in their quality of life, (t = . ; df= ; p < . ). the difference in the score between the control and intervention groups in was also statistically significant.(t = . ; df= ; p < . ). the numbers in the adolescent groups and paediatric group also demonstrated an improvement in quality of life but the sample size was too small to demonstrate a statistically significant difference. conclusion: as the majority of patients rely on their general practitioners for treatment and diagnosis of allergic rhinitis, primary care represents an important area to target in the management of allergic rhinitis to improve patients' quality of life. the implementation of guidelines has been shown to improve patients' quality of life. this study demonstrates this care can be delivered in a primary care setting with an improvement in patients quality of life but substantial investment in education and resources available to primary care physicians is needed. | the predictive value of allergy tests in the diagnosis of peanut allergy in adults rey-garcia h; gunawardana n; wheeler k; scadding g; durham s; skypala i royal brompton hospital, london, united kingdom background: adults presenting with either new-onset symptoms attributed to peanuts or with early-onset peanut allergy, often wish to know whether they should continue to avoid peanuts. clinical history and standard tests may be sufficient to provide an answer, but for many the tests are inconclusive and an oral food challenge is required. this review was undertaken to determine the most accurate tests. conclusion: these data suggests that peanut spt and ara h provide the most accurate prediction of the outcome of oral food challenge in adults. should components not be available, then spt would be the test of choice being more accurate in all aspects than sige. combining spt and sige improves the sensitivity and negative predictive value of spt alone. however, the best combination is spt and ara h , which increases the overall accuracy to %. further studies are needed before it can be determined whether peanut diagnostic tests can replace the oral food challenge in adult patients. method: retrospective chart review was carried out in a community allergy clinic. patients with rap, bloating and altered stools who underwent bt were characterized by age, gender and atopic status. a separate study to assess patients' outcome post-dietary counselling was carried out to determine impact on symptom management. results: thirty-four patients were assessed for fi from january to december . female gender predominated ( / , %) with an average age of years at presentation. results of fi were positive in / ( %), borderline in / ( %) and negative in / ( %). the average age of patients with a positive, borderline and negative tests were , and , respectively. of the patients who tested positive for fi, ( . %) had comorbid inhalant allergies alone, ( . %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. of the patients who tested negative for fi, ( . %) had comorbid inhalant allergies alone, ( %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. conclusion: patients investigated for carbohydrate intolerance with rap, bloating and altered stools were predominantly female ( %). fi was confirmed in half. atopic status did not help differentiate between the fi positive or negative groups. results of a fod-map elimination diet are separately reported. conclusion: post-bt, % of patients reported symptom improvement. patients who implemented fructose or fodmap avoidance reported symptom improvement. one patient who tested negative for fi reported symptom improvement with a low fodmap diet. patients suspected as being fructose intolerant may benefit from a fructose restriction or fodmap diet, while awaiting bt confirmation. this form of dietary intervention may assist and shorten the natural history of non-specific chronic gi symptoms. inappropriate referrals to a uk paediatric tertiary allergy clinic demonstrate lack of allergy education and knowledge in primary care marriage de bristol royal hospital for children, bristol, united kingdom background: up to % of children have a food allergy. allergy has become an explanation for all manner of nebulous symptoms and self-diagnosis is common. sham allergy tests are easily available giving incorrect results and resulting in unnecessary, potentially harmful abstracts | parentally-imposed dietary exclusions. there are million allergyrelated google searches per year. the rising prevalence of perceived allergic disease has led to an increase in health service utilisation, including increased referrals to secondary care. clinic waiting lists are long and children with severe food allergies have to wait longer than necessary to be seen method: uk paediatric tertiary allergy clinic referrals were prospectively reviewed over three months. five inappropriate referrals deemed most reflective of poor knowledge in primary care were selected as case summaries to highlight this gap in knowledge. results: : schoolchild referred for investigation of allergic cause for a red, watery eye after splashing juice in her eye whilst cutting a kiwi, despite having a co-existent dendritic ulcer. : schoolchild referred for peanut allergy testing after inhaling a peanut and developing wheeze, with all respiratory symptoms resolving following peanut removal. : young child referred for peanut allergy testing after developing a rash on leg following skin contact with faeces hours after ingestion of peanut butter. : teenage boy referred for investigation of likely peanut allergy despite eating peanut butter and tree nuts almost every day. the family were concerned he was allergic to peanut butter. : toddler referred for milk allergy investigation after developing urticaria lasting hours minutes after drinking a bottle of milk. the child had consumed cow's milk formula since birth, and continued to consume milk daily for a further five months following the episode of urticaria. conclusion: provision of allergy services in the uk is poor and lack of investment in allergy services has led to suboptimal recognition and management of food allergy in primary care. allergy education provision for primary care practitioners is inadequate and fails to empower healthcare professionals to discern between allergy requiring full investigation and management, parentally-diagnosed allergy or symptoms which clearly have no association with allergy. progress to improve primary care training for allergy needs to be optimised to prevent further unnecessary referrals and lengthening clinic waiting lists. background: in case of allergic reactions to food or insect venom, quick and adequate treatment, based on clear instruction for use of emergency medication and calling for help, is necessary. however, daily practice shows that patients do not use the prescribed emergency medication because they are afraid to use the epinephrine auto-injector or they do not know how to use it. information and instruction offered by a reliable app could be a useful aid. we aim to develop an app for adult patients and children older than years with allergy to food or insect venom, which offers a step-wise approach to support patients, their relatives or acquaintances in case of an allergic reaction. method: first, the content of the app, including a step-wise approach to treat the allergic reaction has been determined, based on literature, a survey about needs of patients and on consultations of healthcare professionals. subsequently, a web-based prototype has been developed with an adult profile and children profile. the content and flow of this prototype was tested by the project group, as well as by selected healthcare professionals and patients and improved according to the test results. next, the revised prototype was submitted to representatives of patient and professional organizations for final approval. currently the procedure for ce approval is ongoing. finally, the app will be built and offered to the market for ios and android. results: a web-based prototype of the allergy app is available with two profiles: adult and older children. the app is useful for patients with a doctor's diagnosed allergy to food or insect venom, who received emergency medication and instructions to use prescribed medication in case of an allergic reaction. based on severity of complaints, the user is informed about the steps to treat the allergic reaction. in case of a moderate to severe reaction, the patient is advised to use an epinephrine auto-injector, to call the emergency number and, if prescribed, to use medication such as antihistamines, prednisone or inhaler. besides that, the app provides links to websites of expertise centres and patient organisations and includes instructions how to use the epinephrine auto-injector. conclusion: the allergy app will help patients, their relatives or acquaintances to adequately treat an allergic reaction to food or insect venom. involving patients and professionals in the development of the app will contribute to its acceptability and usability. | electronic documentation of drug allergies in a tertiary hospital in singapore: are we relying too much on it? choo kjl; garuna murthee k; naing cs singapore general hospital, singapore, singapore background: singapore has hospitals shared between public and private healthcare system. its healthcare system, ranked # in the world by who in serves a multi-racial population of . million of which % are above years old. drug allergy alert cards (medik awas) were started in s by singapore medical association to improve patient safety. work on computerisation of drug allergy and medical alerts started in the s, a precursor to today's critical medical information system (cmis). cmis serves as a platform across all public hospitals in singapore. it promotes uniform reporting of drug allergy and notification of adverse drug events to the health science authority. yet, we found that there is a lack of awareness of one's own drug allergies. method: all patients admitted to ward (general medicine ward) at singapore general hospital from july to oct were screen for any previously documented drug allergies. consenting patients who had previously documented drug allergies on cmis were interviewed to document their demographics, education level, current medications, knowledge of their own drug allergies and possession of a drug medication alert card. the answers were then compared with their electronic documentation of drug allergies for accuracy. we interviewed patients aged - with documented drug allergies during the recruitment period. % had secondary school education or higher. the majority ( %) spoke english and ( . %) mandarin. almost half had medical problems and are on long term medications (mean . medications); hypertension and diabetes being the top two common diseases. % of the patients could accurately relay their drug allergies; antibiotics and analgesia being the most labelled. only % had a drug allergy alert card while the rest both rely on the hospital's electronic documentation and/or their caregivers to record and relay their allergies to future prescribers. about % received prescription from multiple healthcare sites in both the public and private healthcare system. we found patients' knowledge of their own drug allergies dismal. the cmis electronic documentation provided a false sense of security. unfortunately, the cmis platform is not available to all private hospitals, increasing the risk of mis-prescription due to the lack of information. unless this is made available nationally, patients with drug allergies should be given some written documentation, either a letter or medik awas. how frequent are they and how are they treated? method: for this cross-sectional study, participants were recruited in the waiting rooms of local doctors in the rural bavarian forest region of southern germany (q / ). a paper questionnaire was handed out to the participants, asking for allergies (pollen, animal hair, bee and wasp venom, drugs, food, house dust mites, contact allergies and other allergies) and how or rather by whom (e.g. general practitioner, specialist, self-treatment) these allergies are treated. results: participants with a mean age of . years (sd= . ) and % women were included in this study. . % indicated to have at least one allergy, including pollen allergy most frequently ( . %). women had significantly more often at least one allergy than men (rr= . ; ci [ . ; . ] ) and for almost all examined allergies a significant higher risk of disease. younger age groups indicated more often to have at least one allergy ( - [. ; . ]) seemed to be affected less. participants indicated most frequently that their allergy was treated by a general practitioner ( . %), except of the - -yearold young adults who indicated "no treatment" most frequently ( . %). conclusion: there is a high self-reported prevalence of allergies in the examined rural bavarian region, that increases with decreasing age and is significantly higher among women. moreover, the data on the absence of an appropriated treatment for allergies is alarming. therefore, medical care needs to be improved in rural regions to lower the burden of allergies. | the prevalence of the burnout syndrome among medical professionals involved in allergology education programmes astafieva n ; kobzev d ; gamova i ; perfilova i ; udovichenko e ; skuchaeva l ; michailova i ≥ ) and rpa (low ≥ - , subscales were calculated and analyzed. results: on average students demonstrated: moderate/high ee scores ( - ); moderate/high dp scores ( - ) and moderate rpa scores ( ); higher rpa scores were common ( . %) among junior students, which is also linked with their levels of engagement, and lower ( %) among senior students. junior specialist (starting specialization) had very low scores in all subscales and expressed a very high motivation in their course and new profession. clinical allergologists with significant experience demonstrated moderate / high ee scores ( - ); low dp ( ) ( ) ( ) ( ) ( ) and rpa (below ) scores. high ee scores associated with pressures of service were compensated by a substantial loyalty to their profession and positive assessment of the outcomes of their work. clinical academics demonstrated the highest level of ee scores ( + among + % of the group) with low to moderate dp and rpa scores, the latter being associated with a loyalty to their profession. it was also possible to identify a correlation between engagement in research activities and lower rpa scores. conclusion: burnout is a complex and multifaceted phenomena, which requires further investigation. however, this research identified that students and junior specialists involved in allergology and clinical immunology programmes with higher levels of engagement and motivation to acquire new specialist knowledge had lower levels of ee, while loyalty to the profession and positive assessment of the outcomes of clinical and research work allows to compensate high levels of ee among experienced practitioners and clinical academics and to reduce burnout effects overall. | appeal (allergy to peanuts impacting emotions and life): the first pan-european study to evaluate the psychosocial burden of living with peanut allergy deutscher allergie-und asthmabund (daab)/german allergy and asthma association, mönchengladbach, germany; food allergy italia, padua, italy; aepnaa asociación española de personas con alergia a alimentos y látex, madrid, spain; afpral association pour la prevention des allergies, paris, france; asthma-allergy denmark, roskilde, denmark; anaphylaxis campaign ireland, cork, ireland; brainsell ltd, london, united kingdom; aimmune therapeutics, london, united kingdom background: peanut allergy, one of the most common and rapidly growing food allergies, is most frequently a lifelong condition. current management is limited to avoidance and symptomatic treatment of allergic reactions when accidental exposures occur. peanut allergy can affect the quality of life (qol) of individuals and also that of parents/caregivers and family members. appeal was designed to assess the impact of peanut allergy on qol in peanut-allergic individuals and their parents/caregivers and families. method: the first, quantitative part of appeal is described here and consisted of a pan-european, cross-sectional online survey of approximately minutes in length. the study was conducted in the uk, republic of ireland, france, spain, germany, italy, the netherlands and denmark. over participants were recruited via patient advocacy groups or directly through a specialist survey recruitment panel. ethics committee approval was obtained and all participants provided their informed consent. eligible participants were: ( ) parents or caregivers of a child/adult with peanut allergy; ( ) parents or caregivers responding as a proxy for a child aged under ; ( ) adults. all allergic subjects had self-reported diagnosed peanut allergy. after several screening questions, eligible participants answered a set of clinical questions about their (or their child's) allergies and other conditions, details on the peanut allergy diagnosis, contact with healthcare professionals, worst allergic reaction to date and use of emergency medicine. depending on whether they were an allergic adult, a parent responding on behalf of the child, or a parent/caregiver recounting their own experience, they then answered specific questions on restrictions on life choices, coping strategies and the impact of peanut allergy on feelings and emotions of families, friends and other people. sociodemographic questions completed the questionnaire. the results of the survey are being summarized using descriptive statistics and the data are being analysed on a pan-european level, by country, and according to the participant's perspective (parent, caregiver or individual). conclusion: this comprehensive, pan-european online survey has been specifically designed to uncover the psychosocial burden and effect on qol of peanut allergy in terms of individuals' lives and those of their families. results: pediatric patients were included in the study. . % (n = ) were male. the median age of onset of symptoms (interquartile range) was months ( - ).the median age (interquartile range) of diagnosis was months ( - ). initial reactions associated with cmpa were observed in . % of patients before months old. patients' diagnoses were atopic dermatitis ( %), urticariaangioedema ( %), anaphylaxis ( . %), proctocolitis ( . %), atopic dermatitis and urticaria ( . %), food protein induced enterocolitis ( . %) and eosinophilic esophagitis ( . % method: the study involved patients, who are two years old (and above), diagnosed with cow milk allergy and are observed for at least six months in our hospital. socio-demographic features of the patients, their symptoms, symptom-start ages, age of diagnosis, clinical findings at diagnosis and during observation were recorded in data collection questionnaires. results: the samples were ( . %) boys. the average symptomstart age was observed to be months , average diagnosis age months ( - ) and average age of final check months . when symptoms at entry were observed, . % of the patients had dermal system, . % gastrointestinal system, respiratory system disorders, and % were detected to have developed anaphylaxis. among the patients diagnosed with cow milk allergy, . % showed food reaction to nutrients with lge agents, . % to mixed types, and % to nutrients with non-lge agents. it was also observed that, in the end of . ± . -month observations, sensitivity to cow milk was observed to continue in ( . %) of our patients. when tolerance improvement rates among the patients were compared, anaphylaxis (p < . ) during entry were observed to be influential in continued allergic state. ( . %) patients were able to consume yoghurt, ( . %) patients could consume dairy products and ( . %) patients could not consume dairy products. conclusion: in the end of our investigation, it was observed that ( . %) of the patients developed cow milk tolerance before the age of . when the factors enabling the continuation of sensitivity in cow milk allergy were investigated, anaphylaxis during entry, entry specific lge and pasteurized milk antigen as well as high skinprick test results were detected to be significant. | initial lower threshold was a risk factor of severe adverse reaction during oral immunotherapy for cow's milk anaphylaxis results: before oit, median age was . years old, median threshold to induce initial reaction was . ml, to induce anaphylaxis was . ml of cm and median milk specific ige was . ku/l. twentyseven subjects ( %) dropped out from the protocol, subjects | investigation of heat and matrix effect on milk proteins' allergenicity and the development of hypoallergenic food products reduce some milk proteins' allergenicity (ß-lactoglobulin) . in this project we aimed to investigate the effect of heat and matrix on different milk protein fractions through maillard reaction and eventually develop hypoallergenic food products that have milk protein with low reaction risk. method: milk cake matrix is prepared in different flour/sugar (f/s) ratio ( f/ s, f/ s, . f/ s) and baked minutes at °c. proteins that cake contains are separated using sds page and stained with coomassie blue to check total protein. in parallel specific proteins are detected by western blotting using pooled sera from patients with milk specific ige> ku/l for incubation results: in normal milk cake recipe ( f/ s) ß-lactoglobulin bands are disappeared but casein bands did not differ in size. in order to investigate the matrix effect f/s ratio is changed and it is found that when this ratio decreases, with the affect of heat and maillard reaction, milk casein bands' intensities also decrease in sds gel coomassie staining. in western blot experiments it is also shown that milk specific ige bound weakly to casein bands in low f/s ratio cake ( . f/ s) whereas in cakes that have high f/s ( f/ s) ratio it bound significantly higher. and ß-lactoglobulin proteins' structure and lower the milk specific ige bindings to milk proteins in low f/s ratio cake through maillard reaction. | extensively hydrolyzed formulas for the management of cow's milk protein allergy in infants: is extensive hydrolysis sufficient to guarantee success? method: to better understand the range of ehfs, we aimed to analyse samples of commercially available ehfs from countries and various manufacturers, with a focus on suitability for cmpa management. samples were de-identified and coded for the analyses. molecular weight (mw) distribution of hydrolysates and residual proteins and peptide profiling were assessed with sds-page gel and size exclusion-high-performance liquid chromatography (se-hplc), as they reflect both the design of the formula and the quality management applied during production. osmolarity, nitrogen fractions, lactose content, total and free amino acids, β-lactoglobulin, and casein content were quantified and β-lactoglobulin residual allergenicity was assessed. results: peptide mw distribution displayed significant variation, with the percentage of peptides with mw > . kda varying from % to %. mw distribution was shown to be positively correlated with β-lactoglobulin specific in vitro degranulation. twenty % of samples had non-measurable β-lactoglobulin content (smaller than or at the limit of quantification (loq): . mg/kg); however, % of samples had β-lactoglobulin content greater than the loq, with high variability from . to mg/kg. surprisingly, even in samples featuring a high degree of hydrolysis, significant levels of residual β-lactoglobulin were quantified. conclusion: lack of consensus over the definition of 'extensively hydrolysed' is reflected in the wide range of degree of hydrolysis in commercially available ehfs, and can result in products that are mislabelled as 'extensively hydrolysed' and may be high-risk or even unsuitable for the management of cmpa. results of these analyses also highlight that degree of hydrolysis alone is not sensitive enough to characterise ehfs, and that whilst a high degree of hydrolysis is desirable, further quality control measures are essential to ensure clinically safe and suitable products. actionable guidelines to better define hypoallergenic formulas based on extensively hydrolysed milk proteins are warranted. background: assessing the effect of baked milk products on accelerating unheated milk tolerance in patients with cow's milk allergy. method: a randomized clinical trial was done on patients ( months- years old) divided randomly to case and control groups matched for age and sex. baked milk in form of muffin for months followed by baked cheese in form of pizza for next months was given to the patients in case group. skin prick test and serum ige (sige) levels (immunocap) of milk, casein and betalactoglobulin were measured before and after the study. the ones having milk sige less than ku/l and being asymptomatic during the study underwent oral food challenge test for evaluating unheated milk tolerance. chualalongkorn university, bangkok, thailand; kk women's and children's hospital, singapore, singapore; university of the philippines, philippine general hospital, manila, philippines background: problems in recognising cow's milk allergy (cma) and lactose intolerance (li) in infancy may lead to a delayed or incorrect diagnosis, as well as inappropriate dietary interventions. method: between january and november , a survey was conducted online in china, india, singapore, thailand, mexico, kuwait, united kingdom, australia, and paper-based in the philippines. the survey consisted of multiple-choice questions on cma and li in infants aged under months, two case scenarios (non-ige cma and anaphylaxis) and questions on educational needs (likert scale [ ] [ ] [ ] [ ] [ ] . data on the type of medical practitioner and clinical setting were collected. responses were summarised as percentages and categorised by country. results: responses were received from general practitioners ( . %), paediatricians ( . %), paediatric allergists ( . %), paediatric gastroenterologists ( . %) and other specialities ( . %). there were significant misconceptions about the clinical importance of primary li in infancy. while primary li rarely manifests before years of age, . % of participants felt it was a significant clinical problem in the first year of life. regarding secondary li, % of respondents recommended lactose restriction for viral gastroenteritis, and % for cow's milk protein-induced enteropathy. while the management of ige cma was relatively well understood, there were greater knowledge gaps for non-ige cma. % of practitioners appropriately identified extensively hydrolysed formula (ehf) as first-line treatment of cma in formula-fed infants. however, the distinction between lactose-free and lactose-containing ehf appeared to be an area of uncertainty. in india, . % used soy-based formulas as first- results: patch tests were positive in ( . %) and negative in others. positivity to milk was seen in patients ( . %), to soy in ( . %), to egg white in / ( . %), to wheat in / ( %), to potatoes / ( . %), to corn (maize) in / ( . %), to rice in / , and to peanut in / ( . %). patients were requested to withdraw the suspected food(s) from their diets during a months period. preliminary follow-up data show the improvement of one or more symptom in / patients (gastroesophageal reflux in , appetite in , stool consistency in , respiratory symptoms in , pain in , eczema in ). conclusion: patch tests are informative, easy to use tools in order to identify potential causes of common lasting symptoms in children with negative or weak rast results and introduce beneficial changes in the daily diet. longer follow-up is necessary in order to refine and assess the benefit of such strategy. background: currently in the us, in children suffer from food allergies. at present, there is no cure and strict avoidance of the relevant foods is the only way to prevent allergic reactions. elimination diets put infants and children at risk for nutritional deficiencies and impaired growth. we examined the role of the registered dietitian (rd) in advising patients and families of food allergic children. method: a retrospective review of clinical notes was performed for the first consecutive children who required a dietetic consultation in a dedicated food allergy clinic. we examined common questions from parents that were addressed by the dietician during the consultation. results: patients were aged months - years (median: months) and were diagnosed with the following food allergies: cow's milk: . %, egg: %, tree nut: %, peanut: %, wheat: %, soy: %, fruit/vegetable: %, legume: %, fish: %, sesame: %. the most common questions for the dietitian included: ways to meet nutritional needs following a prescribed allergen-restricted diet ( %), meeting vitamin d and calcium requirements on a milk protein-free diet ( %), suitable oral supplements and recommended serving sizes ( %), appropriate order of solid foods introduction in food protein-induced enterocolitis syndrome (fpies) ( %), cautionary food ingredient statements ( %), baked milk protein introduction ( %), cross-reactivity risk of milk protein with soy ( %) and crossreactivity of nuts in retail bakeries ( %). conclusion: parents of children with food allergies have multiple questions with regards to nutrition. dietetic input in the food allergy clinic addresses important issues for children and families including successful avoidance of allergen-containing foods while ensuring optimal nutrition, decreased exposure to high-risk situations and avoidance of allergen cross-contamination. | multicenter prospective study of a stepwise single dose oral food challenge of egg background: oral food challenges (ofcs) are necessary for allergy management. we previously reported that a low-dose ofc can avoid complete elimination, even if patients react to higher doses of causative foods. nevertheless, this approach has only been validated in a retrospective single-center trial. we have previously reported that the median time for initial symptom onset is minutes for egg ofc using a single exposure. therefore, this study aimed to confirm the safety and effectiveness of a stepwise single-dose ofc in a multicenter, prospective study. who showed a positive reaction to low-dose ofc, only patient ( %) showed a severe reaction: barking cough immediately improved with adrenaline inhalation. among patients with a positive reaction to medium-dose ofc, none had a severe reaction. the median times to symptom onset were and minutes following low-dose and medium-dose ofc, respectively. patients in the three groups, divided according to threshold doses, differed significantly in sige levels against egg white and ovomucoid. conclusion: this multicenter prospective study confirmed that stepwise single-dose ofc to egg will help to clarify the severity of egg allergy, and will contribute to improved food allergy manage- method: the study design was a retrospective cohort study extracting data from the electronic chart of children older than years who visited our out-patient clinic for egg or milk allergy and who underwent an oral food challenge test (ofc) twice within months between november and december . the patients were divided into five groups according to their treatment schedule, which consisted of those who: a) started from / of the first ofc reaction threshold and maintained / till the end of oit; b) started from / of the threshold and maintained / ; c) started from / of the threshold and maintained / , d); conventional slow oit (started from just below the first ofc reaction and increased . - . times every few weeks); or e) continued elimination. we determined the presence or absence of an increase in threshold reacted to the allergen, any adverse events during oit, and food-specific ige reduction. results: the number of participants was and their median age was years. the number of patients in groups a, b, c, d, and e was , , , , and , respectively. the percentage of patients in groups a, b and c showing an increase in reaction threshold to the allergen was higher than that in group e (p < . ), and that in group b was higher than that in group d (p < . ). the number (percentage) for group a, b, c, d, and e was ( . %), ( . %), ( . %), ( . %), and ( . %), respectively. there was a significant difference in the frequency of adverse events during oit between group a-c and d, which was as follows: ( . %), ( . %), ( . %), and ( . %), for the respective groups (p < . ). there was no significant difference in the percentage of patients showing a decrease in food-specific ige in each group. conclusion: the regimen starting from / of the ofc reaction threshold and maintaining the dose at / was safer and more effective for increasing the threshold reacted to the allergen than the 'conventional slow oit' regimen. elimination continuation was not effective for increasing the threshold reacted to the allergen. legumes allergy was presented in different clinical features; urticaria and angioedema in ( %) patients, anaphylaxis in ( . %) patients, atopic dermatitis in ( . %) patients, eosinophilic esophagitis in ( . %) patients and as food-related enterocolitis in ( . %) patient. thirteen ( . %) of the patients had asthma, ( . %) had allergic rhinitis. fourteen ( . %) of the patients with single legume allergy showed improvement. the patients who developed tolerance, of these ( . %) had peanut allergy, ( . %) had lentil allergy and ( . %) had chickpea allergy. two of patients with multiple legumes allergies, it developed tolerance to all the legumes they are allergic. conclusion: peanut and lentils were the most frequent legumes that displayed allergic reactions in our study. in these patients the rate of allergy to non-legumes food is high. in patients who were allergic to single legumes, the symptoms were ameliorated in . %. conclusion: cashew nut is a potent allergen and can cause quite severe reactions. avoidance of pistachio nut and other related allergens should be advised to patients after allergologic investigation. in the majority of the patients, presence of atopic dermatitis with food allergy is noteworthy. therefore, it would be useful to investigate these patients for cashew and other tree nut allergy before they present with a serious clinical reaction. and jellyfish sting. serum allergen-specific ige test was negative; skin prick test was positive for natto and pork. we performed an oral food challenge with natto, pork, crustaceans, and wheat, and she developed a general itchy rash after hours of eating natto. h blocker was administered and she recovered soon. however, the general itchy rash relapsed after hours. hence, we intramuscularly injected epinephrine, h -blocker, and steroids; then, her symptoms did not relapse. based on these findings, we inferred that anaphylaxis caused by natto could be associated with a jellyfish sting. discussion: although association between japanese fermented soybeans (natto) allergy and jellyfish sting has been previously reported, its anaphylaxis is a rare event. in this case, we suggest that anaphylaxis was caused by natto allergy, which was perhaps related to jellyfish sting. hence, further investigation is essential to elucidate the association between fermented soybeans allergy and jellyfish sting. introduction: non-celiac gluten sensitivity (ncgs) is a syndrome characterized by intestinal and extra intestinal symptoms related to the ingestion of gluten-containing food, in subjects that are not affected by either celiac disease (cd) or wheat allergy (wa).once the gluten-containing foodstuff is removed from the diet, the patients will have relief of their symptoms. case: a -year-old girl was referred by his general practitioner with history of occasional constipation and abdominal pain (especially after main meals and defecation), short stature and low weight. the growth indices were proper for her age till she was . then after there was a stunting. she had short stature and low weight. despite different types of supplementation, there was no improvement in growth indices, so she was referred to a pediatric endocrinologist for gh therapy. primary investigations and anti-ttg, iga, anti-ema all were normal. after a consultation with a pediatric gastroenterologist, a genetic study of hladq and were done because of the highly suspicion of celiac disease. the results were also negative. at last she was referred to immunology-allergy clinic for evaluation of probable food allergy. ige level was checked and a prick test was performed which they were not indicative of any suggestive food allergy. because of the history of the abdominal pain and constipation which was more prominent after meals, negative results of genetic study, spt to wheat, and serologic markers, a gluten free diet was suggested for her with the suspicious of non celiac gluten sensitivity. a significant improvement in her symptoms was noticed within weeks of starting gluten free diet. she has kg of weight gain and height improved from cm to cm in months. she continued to improve on a gfd and when seen in the follow-up clinic months later reported complete resolution of symptoms and another cm and kg gain in her height and weight. conclusion: non-celiac gluten sensitivity syndrome is a diagnosis made by excluding celiac disease and wheat allergy. it should be taken into consideration especially in patients who have the suspicious symptoms of celiac without supporting lab data, and also negative spt to wheat. the young man in question along with his parents were keen to proceed, so with some hesitation we proceeded to a hazelnut oral provocation challenge, having very carefully explained the risks of undertaking such a challenge. he successfully completed the challenge and experienced no allergic symptoms and is now able to have hazelnuts in his everyday diet. discussion: this young man wanted to confirm if indeed he was allergic to hazelnuts. not being hazelnut allergic would mean that he would be no longer allergic to any nut and would not have to take precautions prior eating products. positive results to both cor a and cor a , hazelnut storage proteins are associated with the patient possibly experiencing systemic reactions, at a higher risk of experiencing anaphylaxis it they were to ingest hazelnut. these facts in conjunction with his specific ige to hazelnut would have prevented us from proceeding to challenge was it not for this young man's persistence that he wanted to proceed to challenge despite the risks. conclusion: appearances are deceptive, as this case demonstrates; allergen-specific ige and component testing can only predict the probability of an allergic reaction, the final test in the diagnostic process is the oral provocation challenge. the patient and his family were happy for me to share the above with other health care professionals. method: we present the case of a female of years old diagnosed of acu with poor control of the symptoms at maximum doses of antihistamines. we decided to associate omalizumab treatment. the patient had a good control of the symptoms with omalizumab at dose of mg/ weeks, but in the th month she presented an erythematous, raised and pruritic lesion in the area of injection together with localized abdominal edema at hours of the administration, with two weeks of evolution without symptomatic treatment. we decided to discontinue omalizumab alter a second episode with half doses. results: we performed a skin biopsy of the lesion and epicutaneous tests with the drug. immediate hypersensitivity tests were not taking due to the impossibility of stopping antihistamines. skin biopsy showed a perivascular lymphocytic inflammation of the superficial and deep dermis with frequent presence of perivascular and interstitial eosinophils, suggestive of a hypersensitivity reaction. results: nine months before presentation at our clinic, the patient had been hospitalized and treated with imipenem and tmp/smx for pulmonary nocardiosis. once discharged, she had been prescribed oral tmp/smx alone, according to antimicrobial susceptibility. at our first evaluation, the patient presented with fever, macular erythematous non-pruritic (vasculitic-like) skin lesions on the upper limbs, polyarthralgia and bilateral ankle arthritis. tmp/smx was transiently stopped. after four days, there was a dramatic improvement, with resolution of all signs and symptoms. she was tentatively diagnosed with a viral infection and thus tmp/smx was started again. however, after three days, the symptoms (fever, arthritis and skin lesions) recurred. laboratory investigations showed increased levels of inflammatory markers. complete blood count with differential, serum creatinine, urinary sediment, liver enzymes, rheumatoid factor, antinuclear antibody, c , c , immune complexes, serology for rickettsia, borrelia and coxiella were all negative. hence, tmp/smx was stopped again and cutaneous lesions, fever and arthritis resolved spontaneously in five days. conclusion: given the clinical course and the resolution after the withdrawal of tmp/smx, we diagnosed a sslr due to sulfonamides. to the best of our knowledge, this is the first case of sslr occurring after a nine-month therapy with tmp/smx and allergists/immunologists should be aware of the possibility of such a reaction even after months. case report: * we received written informed consent for publication of these clinical details and/or clinical images included in my abstract was obtained from the patient. drug rash with eosinophilia and systemic symptoms (dress) syndrome is a severe adverse cutaneous reaction that usually appears - weeks after treatment with the causative drug. this syndrome is characterized by severe dermal rash, fever, eosinophilia, and internal organ involvement, and clinically, diffuse maculopapular eruption, exfoliative dermatitis, and facial edema are often observed. we performed blood tests and laryngeal fiberscopy for the diagnosis of the patient. intradermal test with delayed reading and patch test were performed months after the end of treatment. a -year-old man had begun treatment with carbamazepine for epilepsy. after weeks of treatment, he observed skin rash with pruritus on both lower extremities, and after weeks, his skin lesions had begun to spread over his whole body, and he complained of several new symptoms, including hoarseness, dyspnea at rest, and dysphagia. an examination revealed maculopapular rash, facial edema, and bilateral cervical lymphadenopathy. laryngeal fiberscopy revealed both arytenoid and epiglottic swelling. laboratory studies revealed eosinophil counts of /μl and increase in alanine aminotransferase level to u/l. a diagnosis of dress syndrome was definite according to the regiscar group criteria. carbamazepine, the suspected culprit drug, was withdrawn, and systemic corticosteroid was initiated. the patient experienced rapid improvements in hoarseness, dyspnea, and dysphagia. after days of treatment, laryngeal fiberscopy revealed complete resolution of both arytenoid and epiglottic swelling. to the best of our knowledge, our case is the first reported case of dress syndrome to manifest with laryngeal edema. case report: bortezomib (velcade Ⓡ ), a targeted therapy works by blocking the action of proteasomes in side cells, is commonly used to treat newly diagnosed as well as relapsed/refractory myeloma. bortezomib has been reported to have gastrointestinal symptoms, peripheral neuropathy, neuropathic pain and thrombocytopenia as its most common side-effects. although several cases of skin lesion caused by bortezomib have been reported, severe cutaneous adverse reaction (scar) such as stevens-johnson syndrome (sjs) is very rare. we here report a case of bortezomib induced sjs. a -year-old female patient, who was diagnosed with multiple myeloma, received bortezomib and melphalan /dexamethasone therapy. after the th dose of bortezomib, she presented with fever and maculopapular skin rashes spreading from face to the trunk. erosive lesions in the oral mucosa and corneal ulceration with conjuntival injection were observed. she was diagnosed as sjs. the symptoms of sjs improved after bortezomib was discontinued and systemic steroids and intravenous immunoglobulin were administered. drug patch test was performed, the result was positive in bortezomib. this is the first case report of bortezomib induced sjs in this country, which was diagnosed by a patch test. although the scar by bortezomib is generally considered very rare, we suggest that clinicians be aware of potential adverse reactions, including sjs. case report: we report the case of a healthy -year-old woman with history of red erythematous macules in both hands, one hour after taking a fluconazole ( mg) tab for a vaginal candidiasis. it faded spontaneously. she didn't recall if she had ever taken that medicine, but denied known drug allergies. although fde is primarily a clinical diagnosis, we conducted an oral challenge test with fluconazole ( mg). two hours after intake of the drug the patient started complaints of pain and erythema in both hands and the challenge was stopped. two days after the challenge, she developed red painful erythematous macules on the same sites of the first episode. due to the specificity of the challenge, local patch testing was not performed. introduction: the classic form of a fixed drug eruption is one or more anular or oval erythematous patches as a result of systemic exposure to a drug. these skin lesions normally resolve with hyperpigmentation and may recur in the same location with re-exposure to the drug. other types of fixed drug eruptions have been described, being fixed drug urticaria a rare form of presentation. ( , ) case report: in the last years, a year old woman has developed more than episodes of a wheal in the right supraciliary region minutes after taking mg of oral ibuprofen. the symptoms resolved in less than hours without treatment and without leaving residual lesion. after the last episode, she refers good tolerance to g of oral paracetamol. she denies local traumas. she also refers mild spring rhinoconjunctivitis well controlled with antihistamine, and sneezing with house dust. a -year-old-m patient had psoriasis vulgaris for years, and had been using methotrexate at intervals of years. despite the addition of phototherapy, he underwent a new treatment with biological agent (antitumor-necrosis-factor; anti-tnf), since the disease control was insufficient. before anti-tnf, preventive treatment against latent tuberculosis (tb) activation was indicated with positivity in tuberculin skin test ( mm). he was given inh mg/day, and at the th day of treatment, desquamation, erythema, and subsequent exfoliation developed in his hands and foots dorsum. inh was withdrawn. in order to distinguish the lesions from psoriasis attack, skin biopsy was performed and reported as erythema multiforme-like dermatitis with no relation to psoriasis. the lesions were completely improved at weeks of topical steroids, and inh was re-initiated at the same dose. a week after the initiation of the drug, skin lesions similar to previous reoccurred with more severity and progression from distal to proximal extremities. cell counts, renal and hepatic function tests, and hepatitis markers in blood were in normal limits. skin lesions were retracted after weeks of topical steroids, and withdrawal of inh. there was positivity in skin patch test with inh at hours. finally, for tb prevention an alternative drug rifampicin ( mg/kg/day) was given, and the patient successfully completed with no adverse event. his psoriasis lesions were improved with anti-tnf which was started after month of tb prevention with rifampicin. in these days which the use of biologic agents is increasingly widespread, inh use will be more prevalent than the past. even tough, it is effective and safe in most of the patients, its adverse event dermatitis may be a reason to withdraw in patients with dermatological diseases. in this case, diagnostic drug allergy evaluation should be performed to optimize the second-line treatment of tb infection, in addition to early withdrawal of the culprit drugs. background: around % of cancer patients will receive radiotherapy (ionizing radiations) as a treatment, either as a single therapy or as an adjuvant to chemotherapy and surgery. several side effects have been described due to radiotherapy, of which we can mention erythema multiforme and stevens johnson syndrome, but in lower prevalence. erythema multiforme can be described as an acute skin condition and may be present within a wide spectrum of severity. erythema multiforme minor represents a localized eruption of the skin with minimal or no mucosal involvement. the papules evolve into pathognomonic target or iris lesions that appear within a -hour period and begin on the extremities (see the following image). lesions remain in a fixed location for at least days and then begin to heal. it is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers precipitating factors and complex interactions may trigger the appearance of signs and symptoms. these include especially recurrent herpes simplex virus (hsv), epstein-barr virus (ebv), histoplasmosis, alcohol, systemic diseases and immunological factors. method: -year-old male diagnosed with prostate adenocarcinoma who underwent transurethral resection and was taking trinomia (ramipril, atorvastatin, acetyl-salicylic acid) after his th rte external radiotherapy session, he presented erythematous maculo-papular lesions in the suprapubic area with some vesicles. therefore, withdrawal of treatment was decided and the performance of a skin biopsy. days later, regarding the improvement of the lesions, rte was continued, presenting incipient exacerbations of the lesions but it allowed us to end the cycle of treatment. results: skin biopsy results (anatomical pathology): basal keratinocytes, which blur the dermoepidermal interface, with lymphocyte exocytosis at this level, associated with isolated images of spongiosis. the dermis shows a superficial perivascular lymphocytic inflammatory infiltrate of moderate intensity. compatible with erythema multiforme. conclusion: radiotherapy is a technique of increasing use, so it is important to recognize the associated cutaneous lesions that appear less frequently and are sometimes underdiagnosed. diagnosis is both clinic and pathological and is usually late in most cases so it is vital to take into account this skin disease complication in order to be properly managed. including chinese herbal medicine is usually considered to be without any allergic and adverse reaction. method: visits were made to pharmacies in hong kong and luoyang, china and a martial art monastery/temple in dengfeng, china. some cam were found to have ingredients with potential allergic and adverse reaction. results: three cam, one from hong kong ( ), one from shaolin martial art monastery/temple in dengfeng ( ) and one from luoyang ( ), china were found to contain chinese herbal medicine with potential allergic and adverse reaction. ( ) cordyceps ling-zhi complex ingredients: cordyceps sinensis "caterpillar fungus", tremella fuciformis "snow fungus", ganoderma lucidum (ling-zhi) "reishi mushroom" and others years old female patient who has ulcers in oral mucosa and purple, itchy lesions on her right hand palmar area, little finger, index finger, on her left hand palmar area, pollex finger. in her history, she has relapsing vaginal yeast and she hasn't any hypersensitivity reaction with fluconazole before month ago she started to take fluconazole because of vaginal candidiasis. after using fluconazole she started to itch from described areas and dark redpurple eruptions appeared. she was prescribed oral methylprednisolone and topical pomade which included corticosteroid for four days but she didn't aware of fluconazole related drug reaction. lastly four days ago she took fluconazole and metronidazole for severe vaginal yeast. hours later pruritus, same eruption appear on the same area, lip and tongue angioedema than she had dyspnea, dizziness, hypotension, arrhythmia and consciousness. she had admitted to the emergency department and performed adrenalin. after a day bullae and ulcers came into existence in her oral mucosa. in her blood analysis there was mild increase in white blood cell count ( . /mm ), eosinophil count was normal ( /mm ), biochemistry parameters were in normal limits, crp and sedimentation rate were in normal limits, total ige was iu/l. introduction: tuberculosis is a disease that most commonly affects the lungs, which is transmitted by the respiratory tract and drugs are the most important factor in the treatment. non-resistant tuberculosis infection is usually treated with hrze. in rare cases, a hypersensitivity reaction may develop against one or more of the drugs during treatment. case: a -year-old female patient was diagnosed with culturepositive pulmonary tuberculosis and hrez treatment was started by the related department. seven days later she referred to the policlinic with edema and itchy erythematous lesions which are common in her extremities, which developed after hours of taking her medication. liver and kidney function tests and eosinophil count were normal. drug eruption was considered with current physical examination findings. the treatment was interrupted, short time systemic corticosteroids and antihistamine treatment started. desensitization planned. there was no feature in the prick and patch tests with drugs. desensitization was performed with isoniazid, no reaction was observed during the procedure. six hours after the procedure, the patient applied to the emergency department with painful edema and pruritic erythematous lesions in the extremities. desensitization procedures with rifampicin, ethambutol, pyrazinamide were performed without any problems after the lesions were regressed. isoniazid was withdrawn from the treatment protocol. outcome: we would like to present on this case that drug eruption may develop in the form of maculopapular rash after desensitization. this study aims to compare ethmoid mucosa and nasal polyp regarding density of tissue eosinophil and its sensitivity, specificity, and correlation with clinical characteristics for diagnosing ecrs. method: patients with crs with polyps scheduled for endoscopic sinus surgery were enrolled. specimens were collected from polyp apex, polyp pedicle and ethmoid mucosa. tissue eosinophil from these three sites in the same patient were compared. using eosinophilic mucin as a reference, sensitivity, and specificity of each site for diagnosing ecrs was assessed. correlations between tissue eosinophilia (defined as greater than / hpf) and clinical characteristics of ecrs including asthma, serum eosinophilia, and eosinophilic mucin were analyzed using each site of specimens. results: thirty patients with crs with polyps were enrolled. polyp apex, polyp pedicle and ethmoid mucosa gave similar results regarding tissue eosinophilia in patients ( . %). eleven ( . %) patients were ecrs (having tissue eosinophilia at all sites) and five ( . %) were non ecrs (no tissue eosinophilia at any sites). median tissue eosinophil was significantly greater in polyp apex ( , and polyp pedicle ( , iqr: - ) than ethmoid mucosa ( , iqr: - ), p = . . sensitivity of polyp apex, polyp pedicle and ethmoid mucosa for diagnosing ecrs were %, % and % respectively. specificity were %, % and % respectively. correlations between tissue eosinophilia and asthma were significant when assessing ethmoid mucosa (p = . ), and polyp pedicle (p = . ) but not polyp apex (p = . ). correlations with serum eosinophilia, and eosinophilic mucin were not significant (p > . ) when assessing any specimens. gov/pubmed/) was performed using the following key words: "obstructive sleep apnea syndrome"; "allergy rhinitis"; "hypoxia"; "intermittent hypoxia"; "fluctuating hypoxia"; "cyclic hypoxia"; and "hif- α" results: osas may affect the prognosis of ar patients based on the following evidence: ) ar is thought to be a cause of osas. ) exposure to hypoxia could mediate immune activation in ar and affect the response to treatment. ) hif- α expression may be a risk factor for ar. ) intermittent hypoxia can induce robust expression of hif- α. conclusion: first, improvement of ventilation during sleep represents an efficient strategy for treating ar. therefore, continuous positive airway pressure or nasal surgery to resolve a nasal obstruction could be added to ar treatment. finally, medications that target hif- α, such as digoxin, can be tested as adjuvant therapy. method: forty patients diagnosed with allergic rhinitis and olfactory dysfunction were recruited in current study in the group and . patients of group were administered with no treatment and patients administered with the traditional chinese acupuncture therapy were incorporated into the group . before the treatment, all of them underwent t&t olfactory testing, nasal sinus computer tomography scanning and visual analog scale (vas; - ), and repeated the assessment after four-week treatment. results: improved total t&t olfactory testing scoring averages and vas scoring averages was observed in eleven patients treated with traditional chinese acupuncture compared with four patients in the observation group. no side effect was found. no significant differences in olfaction recovery were found according to age, gender, or duration of disease between the two groups. the observation group underwent nasal endoscopic sinus surgery and the control group underwent external approach surgery, and the therapeutic effect of the two groups were investigated. results: the total effective rate was % in observation group and % in control group, the total effective rate of observation group is significantly higher than control group (p < . ). the recurrence rate was % in observation group and % in control group, the recurrence rate of observation group is significantly lower than control group (p < . ). complication occurrence rate of observation group was % which is significantly lower than control group % (p < . ). the therapeutic effects of endoscopic sinus surgery on chronic sinusitis in geriatric patients are better than conventional external approach surgery which is worth clinical application. results: (descriptive). the equick app is user-friendly even for vkc patients with sub-optimal reading ability. home use between clinic appointments allows responsive temporal data gathering of qol, symptoms, medication scores and impact of medical interventions. equick may be used in future as a research tool in gathering outcome data following interventions for vkc. ectoine, a substance deriving from halophilic micro-organisms, is a strong water structure forming solute exerting cell protective antiinflammatory and antiallergic properties. method: purpose of our study was to assess the efficacy of the preventive administration of % ectoine eye-drops ( times a day for months) to shorten the duration of vkc relapses (which begin, in our country, very early in spring and usually end in october), or to mitigate the attacks, which are only controlled by topical corticosteroids or cyclosporine resulting in an important burden of side-effects. in this retrospective study, we included children of both sexes ( males and females), under the age of years (mean age . years), affected by vkc from more than years/seasons and treated for more than months during a year, with cyclosporine eye-drops. these patients underwent, from february to september , the additional-to-the-usual protocol treatment with % ectoine eyedrops. results: % of the included subjects astonishingly had no relapse of vkc, % needed topical cs or cyc treatment but it was started months later compared to previous years, % needed the topical drugs months later and % had a similar to previous years course (no ectoine efficacy). the treatment was well tolerated and only child had to stop it because of local allergy to the eye-drops. the preventive administration of % ectoine eyedrops was able to stabilize and to delay vkc attacks in more than % of the selected patients showing the importance of anti-inflammatory and anti-allergic properties of this product. following international criteria we considered normal levels of vitamin d the levels between nmol/l ( ng/ml) and nmol/l ( ng/ml), a potential deficiency between nmol/l and nmol/l and a severe deficiency less than nmol/l. results: . % ( children) of akc group patients presented vitamin d low levels, among them children showed a potential deficiency and a severe deficiency. . % ( subjects) of vkc patients suffered a deficiency in vitamin d which was mild in and severe in patients. . % ( children) of sac group showed a deficiency in vitamin d which was potential in and severe in subjects. conclusion: our study shows that in different forms of allergic conjunctivitis many children are suffering a vit. d deficiency and it can be supposed that a correlation between the severity of the allergic form and the level of vit. d deficiency exists. we recommend allergists and ophthalmologists to check vit. d levels in children suffering from allergic conjunctivitis because its deficiency is very common and many are unaware of it; in case of a vit. d insufficiency it is fundamental to give a vit. d suitable-to-the-case supplementation. method: children ( males and females, mean age . ± months) affected by vkc and allergic rhinitis from more than years were treated with mometasone furoate nasal spray spray bid × weeks in a month, for consecutive months as a co-seasonal treatment at the beginning of eye allergic symptoms. other systemic or topical treatments did not vary compared to the previous years. results: a quick questionnaire administered to children and their care-givers showed that nasal symptoms regressed after a mean period of . days from their beginning but, impressively, in more than % of them, these patients did not show a vkc typical relapse along the months of mometasone treatment, moreover the following summer period was milder in subjective ocular symptoms in more than % of the patients. our experience pointed out that incs adjunctive treatment was positively associated with a regression of eye and nose symptoms in children suffering from vkc, confirming previous literature data which concern milder forms (seasonal allergic conjunctivitis or allergic rhino-conjunctivitis) compared to the severe forms (like vkc) we analyzed in our work. one of the involved mechanisms of action can be the alleged effect on the reduction of substance p in tears; it is supposed to reflect the neuropeptides levels in ocular tissues. | patient response to mp-azeflu in an allergen exposure chamber onset of action (ooa) timing may impact treatment adherence. mp-azeflu, intranasal azelastine hydrochloride (aze) and fluticasone propionate (fp) in a single device, has proven to have greater efficacy and faster ooa than a combination of oral loratadine and intranasal fp (lora/infp), but the clinical relevance for patients is unclear. this single-center (ontario, canada), randomized, double-blind, double-dummy, three-period crossover trial examined by which extent mp-azeflu provides clinically relevant symptom improvements according to different efficacy parameters. method: ar symptoms were induced in asymptomatic, ragweedsensitive patients via ragweed pollen challenge in an environmental exposure chamber. patients received a single dose of mp-azeflu, lora/infp, or placebo and were monitored for hours. symptoms were assessed using total nasal symptom score (tnss) and total ocular symptom score. responder analyses included the number of patients to achieve relevant response (rr) to therapy ( % or % reduction in tnss), time to rr (ie, first time point at which rr was reached), and minimal clinically important difference (mcid) in ooa. background: nasal allergen provocation test (napt) is a standardized diagnostic tool indicated in the diagnosis of allergic rhinitis, to design and monitoring allergen immunotherapy, and to study the pathophysiology of airway allergy. unfortunately, until now very few studies have evaluated its reproducibility and safety. in this study we wanted to analyse the safety and reproducibility of napt in a large group of rhinitis patients and healthy controls. unit until december . a bilateral saline challenge followed by a bilateral napt were performed in symptoms-free individuals. the response was assessed by nasal-ocular symptoms and acoustic rhinometry. all subjects signed a written informed consent. the safety of napt was checked by the occurrence of extra-nasal/ ocular reactions (enor), severe adverse events (sae), and use of rescue medication (rm). enor was assessed by clinical symptoms, physical examination, cardiopulmonary auscultation, spirometry, and oxygen saturation. the reproducibility of napt was tested by comparison of the results in or more sessions with≥ -month interval. background: nasal hyperreactivity (nhr) is self-reported by a majority of patients with allergic rhinitis (ar) and is likely mediated by neural-immune interactions. the combination of fluticasone propionate (fp) and azelastine (aze) hydrochloride administered in a single spray (mp-azeflu) has been shown to be superior to fp or aze alone in patients with seasonal ar (sar). we hypothesize mp-aze-flu may reduce neuro-immune mediators in ar with nhr. in a post hoc analysis of three pivotal studies of mp-azeflu, we analyzed the efficacy of mp-azeflu, fp, and aze in patients with ar with and without nonallergic triggers. method: in three randomized, double-blind, controlled trials, patients with sar were randomized : : : to mp-azeflu, fp, aze, or placebo (pbo). patients self-reported sensitivity to nonallergic triggers. change from baseline in total nasal symptom score (tnss) and treatment differences between active agents and pbo were calculated. results: across patients in three studies, mean age was . years and mean age at ar symptom onset was . years. overall, % reported ≥ nonallergic trigger, which included sudden temperature/humidity change ( %), tobacco smoke ( %), perfumes/fragrances ( %), incense/candles ( %), and cleaning products ( %). change from baseline in tnss for patients with ar and nonallergic triggers was greater with mp-azeflu than with fp or aze (table) , and patients with nonallergic triggers improved slightly less than patients without nonallergic triggers in both the mp-azeflu and fp groups. background: in low-income countries (lics), assessment of phenotypes, prevalence and risk factors for allergy-related diseases (ards) using allergen-specific ige may be complicated by environmental exposures such as helminths. these exposures may also induce cross-reactive carbohydrate-specific ige profiles that could inhibit allergic effector responses. we sought to elucidate the molecular basis of ige sensitisation among individuals in uganda, using a component-resolved approach to ige measurement. we employed the isac ® allergen microarray to assess plasma ige reactivity to purified natural and recombinant allergen components in participants of three studies: a trial of intensive versus standard anthelminthic treatment in the rural helminth-endemic lake victoria islands (n = ), a parallel urban survey of allergy outcomes in a lower helminth exposure community (n = ) and a study on asthma risk factors in children from the urban setting and from nearby rural schools (n = ). data on sensitisation to crude allergen extracts were obtained by skin prick testing (spt) with cockroach and house dust mites (hdm), and by immunocap ige testing (cockroach, hdm, and peanut). results: the rural setting was characterised by high prevalence (≥ %) of sensitisation to crude extracts (immunocap ige> . ku/ l) but low sensitisation to the major, established, allergenic components on the microarray (≤ %, ige> . isu). however, sensitisation to cross-reactive carbohydrate determinant (ccd)-bearing components and venoms was more common in rural (up to %) versus urban (up to %) individuals, and was associated with helminth infection. urban individuals mounted higher responses to allergenic components of dust mites but responses to other components were similar between the two settings. sensitisation to allergenic components was higher among asthmatics and spt+ children but ccd sensitisation profiles were similar between asthmatics and nonasthmatics, and between spt+ and spt-school children. conclusion: we show that, in lics, ige to crude allergen extracts (detected in standard immunocap assays) reflects sensitisation to a myriad of environmental exposures (absent in more developed countries), such as ccds expressed by helminths, and may not accurately define ard phenotypes in this setting. however, our data does not seem to indicate that ccd-specific ige detected by isac ® microarray protects against ards. considered minor allergens. due to their sequence homology and conserved structure, they show a high cross-reactivity. the objectives were to study the ige/igg binding properties of polcalcin in relation to the calcium ions, and the ige cross-reactivity between purified polcalcin from olea europea (ole e ) and two recombinant polcalcins (rphl p and rbet v ). method: ole e was purified by immune-affinity chromatography using polyclonal antibodies anti-rche a . serum samples were obtained from patients allergic to grasses recruited at hospital de guadalajara (spain), all of them positive to phl p with sige values ranging from . to . ku/l. equal volumes of all sera were used to prepare a pool. calcium binding assay was performed either by addition or not, or depletion of ca + . ole e was incubated with . mm cacl or with mm egta ph . (ca + chelator agent) at the same time as the antibody in immunoblot or elisa assays with the pool of sera or with anti-che a polyclonal antibody. crossreactivity assay was performed by immunocap inhibition. aliquots of the pool of sera were previously incubated with amounts of ole e ranging from . to . ng. the same dilution of the pool of sera without ole e was used as a control. after hours of incubation, sige (ku/l) binding to rbet v or rphl p was determined. results: a kda protein was purified from the o. europea extract and identified by lc/ms-ms as ole e . in the calcium binding assay there were no differences between the samples with or without ca + . however, the addition of egta to the reaction completely inhibited the binding of the polyclonal antibody by immunoblot and also produced a . % reduction of ige binding by elisa. in the cross-reactivity assay, a % inhibition of ige binding was obtained with . ng of ole e for rbet v and . ng for rphl p . the maximum rate of achieved inhibition was . % for rbet v and . % for rphl p . conclusion: native purified ole e contains the ca + necessary to bind to the specific antibodies and the depletion of ca + inhibited this binding. high cross-reactivity of ole e with rphl p and rbet v was demonstrated. | effect of glutathione-s-transferase pi on the cysteine protease activity of the house dust mite allergen der p background: environmental proteases have been proposed to be involved in the pathogenesis of allergic disorders via different mechanisms, such as the disruption of epithelial tight junctions, the cleavage of surface proteins, the activation of damage and pathogen-associated molecular patterns receptors, and the alteration of redox status. der p from house dust mite is one of the most clinically relevant indoor allergens worldwide, which exhibits cysteine protease activity and has been linked to allergenic rhinitis and asthma. however, it is unknown whether the host microenvironment could regulate der p activity once it reaches the mucosal surface. glutathione-s-transferase pi (gstpi) is an anti-oxidant and detoxification enzyme. gstpi is the predominant gst in human lung epithelial cells, where it is expressed in high levels. polymorphic variants of gstpi have been associated to various inflammatory lung disorders such as allergic asthma. more recently, gstpi has been identified as a redox regulator through protein s-glutathionylation, a post-translational modification where glutathione (gsh) is conjugated to cysteine residues. method: this work aimed at determining if gstpi affects the cysteine-protease activity of der p , compared to gstmu -a different gst isoform-by using different in vitro approaches. results: we found that gstpi increased der p -activity, but not gstmu. our results suggested a potential role of gstpi in upregulating the protease activity of der p allergen. however, the clinical implications of these findings in allergic airway diseases needs for further investigations. | cari p , a novel polygalacturonase allergen from papaya acting as respiratory and food sensitizer biswas sarkar m; sircar g; ghosh n; das ak; jana k; dasgupta a; gupta bhattacharya s bose institute, kolkata, india background: papaya was globally reported to elicit ige-mediated hypersensitivity. certain papaya sensitive patients with food allergic symptoms were found to experience recurrent respiratory distresses at peak flowering period of papaya even after quitting the consumption of papaya fruits. the immunoreactive protein present both in pollen and fruit proteome was detected by ige-serology and identified by mass spectrometry. one such allergen, designated as cari p was cloned, and purified as recombinant protein. the ige-reactivity of rcari p was examined by immunoblot using patient sera. the allergenic activity of rcari p was evaluated by histamine release assay from ige-sensitized granulocytes. the aggregation and folding pattern of rcari p was assessed by size exclusion chromatography and circular dichroism spectroscopy respectively. the presence of cari p in papaya fruit was searched by igg-immunoblot using allergen-specific rabbit antisera. a mouse model of papaya allergy was established to study the role of rcari p in eliciting respiratory and food hypersensitivity. results: a kda ige reactive protein commonly present in pollen and fruit proteome of papaya was identified as endopolygalacturonase. recombinant cari p remained monomer and the cd-spectra revealed predominantly β-sheet characters. the melting curve of the allergen showed partial refolding from a fully denatured state indicating the possible presence of conformational ige-epitopes in addition to the linear ige-epitopes of food allergens. out of papaya allergic patients displayed ige reactivity to rcari p . rcari p at μg/ml, induced histamine release from challenged granulocytes within a range of % to % (i.e. ± . %; n = patients). expression of cari p was detected in the peel and pulp tissues of papaya fruits at two edible stages of fruit maturation. in mouse model, rcari p exhibited a comparable level of eosinophil infiltration and goblet cell hyperplasia in lung and duodenum histology. conclusion: cari p the first major allergen reported from papaya with a dual role in respiratory sensitization via pollen inhalation and sensitization of gut mucosa via fruit consumption. the recombinant allergen can be used as marker allergen for molecular diagnosis and immunotherapeutic management of papaya allergy. background: lipids can be potent stimulators of the immune system, and their role in allergy is highly investigated and debated. since many allergens bind lipids, one question that arises is the relative importance of the lipids versus the lipid-allergen complex in eliciting the immune response. also of interest is an evaluation of the importance of the allergen-lipid complex. in our characterization of the structure of the cockroach allergen bla g , we discovered that it could promiscuously bind a variety of lipids in a large central cavity. this suggested that bla g could be used as a prototypical allergen and lipid delivery vehicle to test in various models of sensitization. method: cd spectroscopy. nmr spectroscopy. molecular modeling. we have developed an hplc procedure to strip the phospholipids derived from the e. coli-based expression system, and reconstitute the allergen with a variety of lipids. using cd spectroscopy and nmr, we have verified that the protein conformation is highly similar in the presence and absence of lipids. temperature dependent cd spectroscopy revealed that unloaded bla g is the least stable, and the melting temperature increased with increasing fatty acid chain length up to c . similar cd melting experiments revealed that bla g could bind lipoteichoic acid (lta) from gram positive bacteria, but did not interact with lipopolysaccharide (lps) from gram negative bacteria. molecular modeling studies have suggested that the stoichiometry of phospholipid binding is likely phospholipids per bla g and give insight as to the different binding characteristics that would allow bla g to bind lta but exclude conclusion: these biophysical studies will allow the design of bla g -lipid systems to test a variety of sensitization models. | sal k , a new allergen from salsola kali sola jp; pedreño y; fernández j; cerezo a; peñalver m probelte pharma, murcia, spain background: the polcalcin from salsola kali was identified and sequenced (genbank kt ) and the recombinant protein was characterized as a minor allergen with a prevalence of % of patients with a spt positive to s. kali. the objective of this study was to purify the polcalcin from s. kali pollen and to include the allergen in the website for the systematic allergen nomenclature (www.allergen.org). method: the native polcalcin from s. kali (npsk) has been purified from pollen after a first step of protein extraction and then diverse chromatographic steps: a size exclusion chromatography to remove particles minor than kda, an ionic exchange chromatography, a hydrophobic interaction chromatography and a final step of size exclusion chromatography to obtain the purified sample of polcalcin. the purity of the npsk has been determined by sds-page and the binding capacity to a specific polcalcin antibody from rabbit serum was tested by immunoblot. the specific antibody had previously been obtained by immunization with the recombinant polcalcin from s. kali. the allergenicity of the npsk has been assayed by immunoblot with a pool of sera of patients sensitized to s. kali. the identity of the purified npsk has been analyzed by peptide footprint in hplc-ms/ms after digestion with trypsin. all the information about the polcalcin from s. kali was sent to who/iuis allergen nomenclature sub-committee. the npsk showed a high purity in sds-page with a molecular weight of approximately kda and this purified protein reacted with the specific polcalcin antibody from rabbit serum. the ige binding capacity of the npsk was confirmed by immunoblot using a pool of sera from patients sensitized to s. kali. the analysis of peptide footprint confirmed that the purified protein is a polcalcin. the who/iuis allergen nomenclature sub-committee included the polcalcin from s. kali in the website for the systematic allergen nomenclature as a new minor allergen named sal k . conclusion: the polcalcin from s. kali has been purified from pollen and tested for its ige binding. it is included in the website for the systematic allergen nomenclature as the new allergen sal k . background: alt a protein is the major allergen from the fungus alternaria alternata and responsible for chronic asthma, yet little is known about its physiological role and immunological activity. our main purpose was to investigate the mechanism through which alt a induces an allergic response in bronchial epithelium. method: although alt a has a unique topology, we studied the structural relationship by in silico procedures consisting of three distinct structural alignment methods in order to understand its nature. the immunological properties of the allergen were investigated by using monocyte cell line thp and human peripheral blood mononuclear cells. results: its crystal structure has been recently reported and claimed to be exclusively in fungi without equivalent in the protein data bank. data obtained in silico show that this allergen shows some structural relationships with a number of other β-barrel proteins such as human lipocalin (lcn ). besides, our experimental data demonstrate that alt a is also able to interact with lcn , human lipocalin. in this way, the results obtained from several immunological assays showed that alt a is able to produce a response of the immune system through different immune innate receptor pathway inducing the th cytokines. background: increasing evidence of cross reactivity syndromes between pollen grains and fruits, with immediate or delayed reactions, has been reported. while some syndromes such as the birch pollen/apple syndrome are well documented, some other such as the cypress pollen/peach syndrome remain to be understood. for the latter, significant progress has recently been made with the discovery of a new allergen family, the gibberellin regulated proteins (grps), which has been shown to be responsible for the observed cross reactivity i.e. pru p and bp ( , ) for the peach and the cypress pollen respectively. grps are small cationic proteins with anti-microbial properties and have been shown to be over produced in response to a stress. herein, the case of a patient, born and raised in the south of france but currently living in paris, has been studied. this patient has been suffering since childhood from allergic rhinoconjunctivitis to cypress pollen and from some oral symptoms to peach and other fruits (including pomegranate). method: in addition to the clinical exploration and cutaneous tests, a very thorough biological characterization of the patient samples has been performed through various specific ige quantitation techniques, western blotting after one and two-dimensional gel electrophoresis and flow cytometry based basophil activation testing (bat). results: specific iges to cypress pollen, birch pollen, peach, orange and apple have been found. pr allergenic proteins are recognized by iges but no ltps. the presence of specific iges to cypress pollen bp , peach peamaclein (pru p ) and a cationic kda protein from pomegranate has been shown through western blotting after gel electrophoresis separation of the protein extracts. the use of bat finally enabled to demonstrate that the basophils of this patient were, ex vivo, strongly activated with protein extracted from orange and cypress pollen and also with purified proteins such as bp and pru p . conclusion: these results unambiguously show that the cypress pollen grp, bp , is clinically relevant, similarly to its homologous protein in peach, pru p . it can be proposed that these two allergens are at the basis of the observed cross-reactivity syndrome. the search for new cross-reactive allergenic grps in pollen, fruits or vegetables may enable to better understand other pollen/food associated syndromes that still remain unexplained. background: nine allergens of phleum pratense have been described until now (iuis database) and classified into groups based on their function and cross-reactivity. group and allergens are considered the most immunodominant, due both to their greater ige-binding capacity and the number of patients ige-reactive to them. previously published studies have estimated that group is recognized by almost % of grass pollen-allergic patients, and group by %. however, until now a comparative of the ability of these allergens to provoke an immune response has not been performed. the objective was to study the immunogenicity of the major allergens phl p and phl p , by analyzing the ability of the recombinant forms (rphl p and rphl p a) to induce a humoral immune response. method: five mice were immunized with the same amount of each recombinant protein: rphl p and rphl p a (indoor biotechnologies) ( μg plus two boosters of μg). the specific igg antibodies produced by each mouse were tested against the recombinant proteins by direct elisa and the title of each of them was determined by optical density (o.d.). additionally, the recognition of both allergens in native and depigmented-polymerized (dpg-pol) extracts of p. pratense was studied by direct elisa using these generated antibodies. results: preimmune sera were negative. all mice produced antibodies against the corresponding recombinant protein. the immune response (sigg) was statistically significant higher in mice immunized with rphl p than in those immunized with rphl p ; it was needed times more rphl p serum than rphl p a serum to obtain the same o.d. values. the difference in responses was higher in the group of mice immunized with rphl p than with rphl p a. differences in the recognition of phl p and phl p in native and depigmented-polymerized extracts of phleum pratense was also observed. it was necessary times more rphl p serum to produce the same signal than rphl p a serum in native extract and it was necessary times more rphl p serum to produce the same signal than rphl p a serum in dpg-pol extract. conclusion: rphl p a is more immunogenic than rphl p , which was also probed with native and dpg-pol extracts. background: glioblastoma (gbm) is an incurable primary malignant brain tumour with a median life span of less than months despite multimodal treatments. therefore, there is a serious need for the development of innovative medications. several epidemiological studies underlined an inverse correlation between pre-existing igemediated allergy and gbm risk, where having such an allergy decreased the odds of developing gbm by to %. we aim to delineate the intrinsic immuno-biological and molecular mechanisms that can be responsible for these correlations, based on the hypothesis that allergies may promote a state of increased immuno-surveillance in the brain through the presence of immunological factors such as immunoglobulins, cytokines and cells involved in th -driven allergic reactions. we consider that as the major immune cell type of the brain, microglia should be implicated in this beneficial association and may favour the elimination of the nascent tumour in brain parenchyma in an allergic context. we implemented a long term allergic airway inflammation by repeated nasal instillation of house dust mite (hdm) extract in a syngeneic orthotropic mouse model of gbm. we followed animal survival and the tumour growth by mri. in addition, we purified microglia from allergic vs non-allergic mice in order to assess their cytotoxic function against the gbm cell line ex vivo and their secretory capacities. finally, we investigated immunoglobulin reactivity against gbm antigens in the context of allergic reactions by reverse phase protein array (rppa). we demonstrated an increase of the animal survival that was correlated with a delayed tumour engraftment and a reduced tumour growth. these phenotypes were associated with functional modification of microglia from sensitized mice. indeed, these microglia showed a rise in the production of il- and tnf-a as well as an increase in cytotoxic functions against a gbm cell line ex vivo. in parallel, we observed an increase in serum igg reactivity against gbm antigens in mice sensitized with hdm compared to control mice. results: in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l compared to only patient ( %) with xla (p = . ). more importantly in patients ( %) with cvid this decrease was observed in a period longer than months compared to patient ( %) with xla (p = . ). in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l and only in patients ( . %) with cvid this decrease was observed in a period longer than months. we did not record any platelet count decrease bellow × /l in patients with xla however the difference with cvid did not reach statistical significance. no thrombocyte count decrease bellow × /l was observed in either group. none of patients required immunosuppressive treatment for immune thrombocytopenia (itp). conclusion: although the statistical significance was documented only in temporary platelet count decrease below × /l it is obvious that numbers of thrombocytes commonly fluctuate in some patients with cvid. the mechanism leading to these temporary decreases is unclear. monitoring of complete blood count is a basic follow-up investigation in patients with cvid. introduction: wegener's granulomatosis (wg) is a systemic disease that may affect all organs, most frequently the ears, noses, throats, sinuses, lungs and kidneys. it is a rare autoimmune disease, also called granulomatosis with polyangiitis, and characterized by necrotizing granulomatous inflammation in small and medium sized blood vessels. anti-neutrophil cytoplasmic antibody against to proteinase (c-anca) is thought to be responsible for autoimmune inflammation. the coexistence of wg and common variable immunodeficiency (cvid) is extremely rare. in this report, we describe a patient with wg and cvid who was treated with immunosuppressive drugs and intravenous immunoglobin concomitantly. case report: a twenty-four-year-old male patient was referred to our clinic for immunological evaluation due to recurrent infections, fever of unknown origin and neutropenia. the patient had been diagnosed with wg and taking immunosuppressive therapy for three years. he had chronic renal failure due to wg and had also been on peritoneal dialysis for three years. serum igg, iga levels, peripheral blood cd + b cell percentage and absolute count of the patients were found to be low according to reference limits. he was diagnosed with cvid after excluding secondary reasons for hypogammaglobulinemia and he started to receive mg/kg intravenous immunoglobulin (ivig) therapy once in a month. also, the treatment that consists of mycophenolate mofetil (mmf) and glucocorticoids was continued to decrease c-anca levels in serum. he has been accepted as a candidate for kidney transplantation, and prepare for this purpose. discussion: the management of the patient with cvid and wg may be complicated. it is considerably difficult and needs competency and courage. moreover, the cases similar to ours, are extremely rare. therefore, the authors should share their own experiences on cvid and discuss them by comparing the data obtained from other cases. background: leukocyte adhesion deficiencies (lads) are a group of three genetic disorders leading to defective leukocyte adhesion to the endothelium and as a consequence decreased leukocyte recruitment and immune defense. lad-i is caused by mutations in the gene encoding the ß -integrin cd on chromosome .lad-iii is a rare primary immunodeficiency syndrome, characterized by homozygous mutations in the kindlin- gene (official symbol fermt ). we have aimed to evaluate our patients who were followed up with lad for the last years, retrospectively. method: all data of the cases were obtained from the file records of age at diagnosis. results: seven patients from separate families were included in the study. four patients were lad-iii and patients were lad-i. the female to male rate was / . the age of diagnosis is ranged from days to years. the median umbilical cord detachment was days ( - days groups: up to times ( people) and from to times ( people). healthy donors were examined as a control. flow cytofluorometry method was used to study peripheral blood and assess the parameters of innate and adaptive immunity results: it was found that at a frequency of edema up to times a year there are changes in the t-system of adaptive immunity, which are shown by a decrease in the expression of late activation markers (cd + hladr+ . ± . %, in control . ± . %), an increase in the number of cd + cd + cytotoxic lymphocytes ( . ± . x /l, in control . ± . x /l) and as an increase in their functional activity (cd + gr+ . ± . x /l, in control . ± . x /l). the nature of disorders of cellular factors of the innate immunity is manifested by decrease in the adaptive resources of neutrophils (kstnbt . ± . u.e., in control . ± . u.e.). patients with hae with a frequency of edema up to times a year, we observed the disorders of the humoral link of adaptive immunity, which consist in an increase in the number of circulating b lymphocytes ( . ± . x /l, in control . ± . x /l). in addition, with the strengthening of the hae clinic, changes in the system of innate immunity progressed very fast and consisted in increasing the amount (cd + . ± . x /l, in control . ± . x /l), and functional activity (cd + gr+ . ± . x /l, in control . ± . /l) of natural killer cells results: we included children, mostly males ( %), aged between month and years. . % of patients (n = / ) showed abnormal absolute results of lymphocyte count for age. we found more patients evaluated in the age group of to years ( . %), followed by - years ( . %), lymphopenia was found in . % of patients. b lymphocyte deficiency was the most common pattern ( %) followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population ( . %) . some patients were affected in all three series ( . %). the cd / cd ratio decreased in . % of the patients. the majority of the children were males between the ages of month and years. . % of patients showed abnormal absolute lymphocyte count for age. b-cell deficiency was the most common pattern followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population. | indicators of the humoral immunity in the mechanical jaundice of benign genesis the aim of the investigation was to study the indices of humoral immunity in patients with benign mj, depending on the level of bilirubin. method: patients with mj and practically healthy volunteers were examined. patients with a level of bilirubin less than μmol / l - , with a bilirubin level of - μmol / l - and with a bilirubin level of more than μmol / l - patients. the concentration of immunoglobulin classes a, m, e and g in serum was determined by enzyme immunoassay. the statistical significance of the differences was determined using the ranked mann-whitney test. the critical level of significance in checking statistical hypotheses was assumed to be p < . . results: of the contacted dermatologists, participated ( women, men; mean age . ± . ) which results in a response rate of . %. the guideline compliant prescription rate of biologicals in patients with csu was . %. the most prevalent barriers in the prescription were the high cost of the treatment ( . %), low reimbursement for doctors ( . %) and the fear of a recourse claim ( . %). however, a lack of evidence or an insufficient efficiency were not con- case report: eosinophil associated gastrointestinal disorders (egids) including eosinophilic colitis are commonly associated with atopy. aeroallergen sensitization may accompany food allergy in these patients. a case with eosinophilic colitis responsive to anti-ige monoclonal antibody (omalizumab) treatment is presented. an eleven-year-old boy had bloody diarrhea lasting nearly one month in autumn for last years. this year diarrhea lasted more than months. colonoscopic biopsy revealed lymphoplasmacytic inflammatory cells including eosinophils leading to a diagnosis of ulcerative colitis. corticosteroid and mesalazine treatment was started with a good clinical response. recurrence of diarrhea during corticosteroid dose reduction suggested corticosteroid dependent ulcerative colitis. eosinophilic/allergic colitis was an alternative diagnosis when seasonal recurrence, lack of weight loss, eosinophils in biopsy and high serum ige level were considered. colonoscopy done after cessation of therapy for one month, revealed exudative ulcerous lesions, lacerations, loss of haustration compatible with colitis (inflammatory/allergic?). presence of significant mucosa associated lymphoid tissue in biopsy supported any inflammatory, reactive process. he had recurrent bronchiolitis until age six and allergic rhinitis in spring for three years. total ige and mix aeroallergen specific ige were high ( iu/ml, . kua/l), absolute eosinophil count was normal ( /mm ). food skin prick and patch tests were negative. he had positive skin reactions with dermatophagoides, grass and olea pollens (induration diameter: , , mm, respectively). pulmonary function test was normal. he was considered as eosinophilic/allergic colitis and omalizumab was started according to manufacturer's dosing table ( mg/ weeks). rectal bleeding decreased after first dose and ceased after the second dose. early colonoscopy examination after rd month of therapy showed that exudations disappeared and haustrations became evident. microscopy revealed mild nonspecific colitis. few patients with eosinophilic colitis improved with omalizumab were reported before. ige-mediated processes are responsible from eosinophilic inflammation in egids, making anti-ige therapy as a promising treatment option. | design of liposomal carriers modified by glycoconjugates for liver cell delivery of nucleic acids used. the surface of liposomal nanoparticles can be modified to increase the selectivity of intracellular delivery. it is well known that asialoglycoprotein receptors of hepatocytes have a strong affinity to galactose carbohydrate. therefore, the aim of this study was to assess the effect of the modification of the liposome surface by glycoconjugates on the selectivity of intracellular transport of nucleic acids into the liver cells. method: liposomes based on ornornglu(c ) were chosen previously as the effective nucleic acid delivery system. we modified liposomes with novel lactose-based derivatives. every of four glycoconjugates was added to ornornglu(c ) in an amount of , and %. as a result, variants of modified liposomes were obtained. to determine the cytotoxicity, an mtt test was used. using luciferase test, the selectivity of penetration was evaluated on nonspecific t (human embryonic kidney) and specific hepg (human liver cells) cell lines. results: modified liposomal compositions ornornglu(c ) - + lacc ( %) and ornornglu(c ) - + lacggg ( %) had the lowest cytotoxicity similar to that for unmodified ornornglu(c ) . the ic , calculated based on the data of mtt test, was . and . , vs. . mg/ml, respectively. ornornglu(c ) - + lacggg ( %) showed a . -fold increase in transfection activity on the nonspecific t cells, compared to unmodified ornornglu(c ) , whereas the modification of ornornglu(c ) - + lacc ( %) resulted in a -fold decrease in transfection activity. however, the ability of these variants to penetrate the specific liver hepg cell was significantly higher by and times, respectively, than for unmodified ornornglu(c ) . results: the greatest inhibitory effect of sbfhd was observed in mdm infected with hiv- bal: % and % suppression of hiv replication was achieved at concentrations of . μg/ml and . μg/ ml, respectively. the activity in pbmc and dc was less pronounced (the respective ic values were . μg/ml and . μg/ml). studies in endometrial hec- a cells demonstrated that sbfhd suppressed cd -independent entry of hiv- ( tcid /ml) by %, %, and %, respectively, at , , and μg/ml. the effect was also observed after increasing the dose of the virus. at tcid /ml, sbfhd suppressed hiv infection by % ( μg/ml) and % ( μg/ml). the cytotoxicity of sbfhd in this system was low. similar results were obtained with colorectal caco- cells. sbfhd exhibited no spermicidal activity at concentrations of up to mg/ml. combining within a single microbicide two agents that target distinct steps of hiv life cycle will maximize its efficacy (via synergistic effects and/or interference with multiple stages of the transmission). we therefore explored the synergistic potential of combinations of sbfhd and azt, the classical nucleoside rt inhibitor. in these experiments, % suppression of hiv infection was reached at concentrations of sbfhd and azt, which were significantly lower than the respective ic values of each component (determined in parallel experiments). the synergistic effect was most pronounced for the combination of . μg/ml sbfhd (which is times less than the ic ) and . nm azt (which is times less than its ic ). cd expression was increased after the co-culture with reishi, shiitake and boletus mushrooms (c - . ( . - . )%; pma - . ( . - . )%; )%; shiitake - . ( . - . )%; boletus - . ( . - . )%). method: the study included men (mean age ± . years) before and immediately after staying in countries with a hot climate. results: the development of lymphopenia observed in the first week of observation. this was accompanied by a decrease in the number cd + lymphocytes expressing the markers of late activation (cd + hladr+ . ± . x /л и . ± . x /л). revealed significant decrease of cd + cd + foxp + regulatory cells in the first week after returning from the area of adverse climatic conditions, as well as a significant sustained decrease in the number cd + cd + hladr+(p < . ). change of the effector link of innate immunity was determined in significant reliable decrease in relative (cd + . ± % and . ± . %, respectively, p < . ) and absolute (cd + . ± . x /l and . ± . %, respectively, p < . ) in the number of a population of natural killer cells in the first week of observation. in the context of acute stress marked a significant increase in relative and absolute numbers of b lymphocytes ( ± . % ( . ± . × /l) before a trip to countries with a hot climate and ± . % ( . ± . × /l) in the first week after returning, p < . ). the activity is the production of antibodies was not changed. (ast) which is the intramuscular injection of patients own serum, is a promising therapy with a substantial efficiency on ciu patients. in this study we aim to assess the efficacy of ast on chronic urticaria patients by dlqi questionnaire. method: this was a single-blind randomized clinical trial which evaluated the efficacy of autologous serum therapy compared to oral antihistamines in patients with ciu. ciu patients received the ast. every session cc of each patient's blood was centrifuged at the speed of rpm for minutes and . cc of the serum was injected intramuscular into the patient's deltoid muscle weekly for weeks. the control group consisted of ciu patients took mg of cetirizine daily for weeks. patients answered the dlqi questionnaire at the first session of treatment as baseline and weeks after the last session(week ) as response to treatment. the mean baseline score of dlqi for ast group was conclusion: pharmacotherapeutic and inpatient costs for patients with prevalent ar and asthma were lower in those prescribed ait than in those not prescribed ait in all years, both with and without including the cost of ait itself. this indicates that treatment with ait is associated with lower cost burden for health services. background: immunotherapy with peptides rather than conventional whole allergens is being developed to improve the benefit/risk balance of subcutaneous immunotherapy (scit). lolium perenne peptides (lpp) demonstrated reduced allergenicity following ex-vivo analyses, allowing higher doses to be given over a shorter period to improve treatment adherence and compliance. such treatment resulted in significant reduction in symptoms and rescue medication intake during the grass pollen season. here we report the safety of lpp immunotherapy in adults. background: a new allergoid from alternaria alternata was characterized to determine its reduced allergenicity in vitro. the objective of this study was to determine the skin response to the allergoid and to evaluate the clinical tolerance of the immunotherapy with the allergoid product using a rush schedule. method: to assess the skin response (sr) two groups of patients were included: group with patients sensitized to a. alternata and with respiratory disease caused by this mold; group (control) with patients sensitized to others allergens and non-atopic patients. the sr was determined by spt using three concentrations of the allergoid: p (lowest concentration), p (four times higher than p ) and p (estimated to obtain a wheal area similar to histamine mg/ml). in spt was also used a native extract of a. alternata (n) and histamine mg/ml (h). all products were tested in duplicate in all patients and the sr was evaluated by comparing the median of the wheal area produced by different products. to evaluate the clinical tolerance to immunotherapy the patients of group were treated with the allergoid product using a rush schedule consisting in a dose of . + . ml the first day and . ml after one month (maintenance dose). the clinical tolerance was determined as the percentage of adverse reactions (ar) to the treatment and the classification of ar was established according to eaaci. the number of patients included to evaluate the sr was (group : ; group : , atopic and non-atopic) with an average age of . (range . the spt data from group were expressed as median and interquartile range of wheal area (mm ): h: . ( . - . ); n: . ( . - . ); p : . ( - . ); p : . ( - . ); p : . ( . - . ). it was determined that sr of allergoid was reduced in % respect to the native. the products n, p , p and p did not produce any response in patients of group . to evaluate clinical tolerance, patients of group were treated with the allergoid product with a rush schedule and only two ar were registered ( . % of doses). these were retarded local reactions with a wheal diameter higher than cm. no systemic reactions were registered and all patients continued the treatment. the allergoid from a. alternata produces a significant reduced response to spt due to its reduced allergenicity. the treatment with an allergoid product in a rush schedule is safety and clinically well tolerated. background: in our study we aim to determine the more effective, the total cost of years of patients using scit was tl per person whereas the total cost of years of patients using slit was tl per person. when we compare the total cost data of both groups, we found that they are close to each other. while the greatest portion of the cost data of patients with scit treatment was direct costs associated with the treatment itself ( %); the remaining part of the total cost was indirect ( %) with non-medical expenses such as transportation ( %). in the slit group, direct costs including drug expenditures have a larger percentage ( %) and it was significantly more costly compared to the direct costs of the scit group ( %). transportation costs were found to be more costly in the scit group ( %) when compared to the slit group ( %). similarly loss of parent work days in the scit group(% ) was found to be significantly more expensive compared with slit group ( %). our study results show that slit is a similar treatment for clinically and laboratorially and has a similar efficacy to scit to reduce the patients' complaints and to the need for medication. for cost-effectiveness however medicines for treatment of scit are less costly; when long term total treatment costs are calculated slit and scit treatment are economically close treatments. the protein content of the new acd was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in acd, involved in glutaraldehyde modification, was reduced in . % respect to ncd and it can be considered as the polymerization degree. regarding to the allergenic profile, through elisa inhibition was determined a reduction of times in the capacity to bind ige of the proteins in acd respect to ncd, whilst the igg binding capacity was maintained. in immunoblot there was no reaction of acd proteins to specific ige from sera. the analysis by peptide footprint determined the presence of fel d and others allergens in acd. the content of major allergen fel d in acd was determined as . μg/mg. the new developed and characterized allergoid from cat dander has an excellent safety profile and will allow a safer immunotherapy to treat the allergy to felis domesticus. results: the protein content of the new aaa was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in aaa, involved in glutaraldehyde modification, was reduced more than % respect to naa and it can be considered as the polymerization degree. regarding to the allergenic profile, in immunoblot there was no reaction of aaa proteins to specific ige from sera and by elisa inhibition was determined a reduction of % in the capacity to bind ige of the proteins in aaa respect to naa. the igg binding capacity in aaa was maintained. the analysis by peptide footprint determined the presence of alt a and others allergens in aaa. the content of major allergen alt a in aaa was determined as . μg/mg. a. alternata shows an excellent safety profile and allows a safer immunotherapy to treat the allergy to this mold. she was an otherwise healthy woman: she took no drugs and she did not have any remarkable concomitant diseases. the distribution and appearance of the remaining body hair was normal and the hormonal level profiles (lh, fsh, estrogens, progesterone and testosterone) did not show any significant alteration according to her age. a year old woman with allergic rhinitis underwent sq glutaraldehyde-modified ait to house dust mites (d pteronyssinus and g domesticus) without any incidences and complete tolerance to maintenance dose without local reactions during a year period. two years after ait discontinuation, patient first experienced a local urticarial reaction with multiple hives at previous sq ait injection sites minutes after mg of ibuprofen intake. these symptoms recurred at least in seven occasions when patient was exposed to ibuprofen (in five) and metamizol (in two). results: case : dermatologist diagnoses localized hypertrichosis. case : a single blind, placebo controlled oral challenge (sbpcoc) with ibuprofen mg was performed and elicited multiples hives in the circumscribed area in the arm where ait was conducted. subsequently, sbpcoc with aspirin was carried out showing the same reaction although a controlled challenge with celecoxib was negative. conclusion: local hypertrichosis is a very rare injection-disease associated with injected allergen vaccine treatment. we also firstly described a recall urticaria phenomenon after allergen immunotherapy which has been only elicited after different nsaids intake. results: there were included patients, in five spanish hospitals. following aria guidelines, . % of patients were diagnosed of persistent moderate/severe rhinitis. the mean age was . ± . years, being . % female. moreover, . % of the patients had concomitant mild/moderated asthma. the period between the diagnosis of rhino-conjunctivitis and the informed consent signing was . ± . years. according to international guidelines, eight systemic reactions were registered, representing . % of the administered doses: five reactions grade , (described as nonspecific ocular pruritus, nasal herpes, general discomfort, localized non-specific pruritus plus nausea and non-specific pruritus in throat), a grade i reaction described as rhinoconjunctivitis and two reactions grade ii, registered as generalized urticaria and asthma. all reactions were classified of mild or moderate intensity and only two required symptomatic treatment. there were five clinically significant delayed local reactions, which were higher than cm or involved modifications in next dose. regarding efficacy parameters, immunoglobulin titers between baseline and final visit according to specific igg and igg significantly increased. cutaneous reactivity also decreased significantly in the dose response skin prick test. results: patients were included, to accelerated and to polymerized cluster group schedules. according to aria criteria, . % of patients presented persistent moderate/severe rhinitis. the mean age was . ± . years, being . % male. moreover, . % had concomitant mild/moderated asthma. immunoglobulin titers method: the quantification of total proteins in the products was carried out by means of a colorimetric technique using the bradford reagent (sigma-aldrich™, us) in accordance with the manufacturer's instructions. the absorbances of each standard and samples were obtained in a scinco™ s- spectrophotometer (seoul, korea) at nm. all samples were analyzed in duplicate. the electrophoretic profile of the proteins in the tested allergens was obtained according to the procedure described by laemmli, under denaturing conditions in a polyacrylamide gel at . % concentration and stained in silver. in each lane approximately μg of total proteins were applied. commercial extracts of the main allergens marketed in mexico were obtained, rossel ® , alk ® , alerquin ® , alergomex ® , allerstan ® , ipi asac ® ; and they were assigned randomly with the numbers , , , , and . results: the following protein concentrations were found in the various extracts analyzed: see table conclusion: differences were found in the protein profiles ana- background: a new allergoid from cat dander was developed and characterized to determine its reduced allergenicity in a % and the maintenance of igg binding capacity. the objective of this study was to develop an immunogenicity assay in mice with the new allergoid and a native extract from cat dander. the study included female balb/c mice separated in three groups of mice each: group , immunized with a mold allergen extract (control); group , immunized with a native extract from cat dander with a fel d content of . μg per dose; group , immunized with the new allergoid from cat dander with a fel d content of . μg per dose. all mice were immunized four times by subcutaneous injections with a volume corresponding to / of the recommended human maintenance dose with an interval between injections of weeks. one week after the last injection the mice were sacrificed and the serum was obtained. to determine the specific antibody title indirect elisa were performed using a cat dander extract as antigen, sera from mice as primary antibody and antimouse igg or igg as secondary antibody. elisa assays were performed using serial dilutions of sera or a simple dilution by duplicate to determine the specific antibody title as arbitrary units/ml (au/ml). the data were analyzed by one-way anova and tukey hsd test to compare the averages of specific antibodies in each group. results: the immunization with both the native extract and the allergoid from cat dander produces specific igg and igg . regarding to igg, a higher title was observed in group respect to group in a curve obtained after elisa with serial dilutions of sera. the specific igg title obtained in terms of au/ml was . ± . in group , . ± . in group and . ± . in group . concerning to igg the au/ml obtained was . ± . in group , . ± . in group and . ± . in group . the increase of specific igg or igg in mice from group respect to mice from group and control group was statistically significant (p ˂ . ). the safety profile of the allergoid from cat dander allows a treatment with higher dose of allergens to produce a greater response to immunotherapy to induce formation of specific this was an open, multicenter clinical trial, in patients aged between to years with rhinoconjunctivitis with or without concomitant mild asthma sensitized to house dust mites (hdm). the aim was to evaluate the safety and tolerability of the vaccine. secondary endpoints included were: changes in immunoglobulin levels (specific ige, igg and igg ) versus d. pteronyssinus and d. farinae and changes in cutaneous reactivity. patients were under study treatment for weeks: five for the induction phase (weekly injections) and for the maintenance phase (monthly injections). results: patients were included. there were withdrawals from the trial; no one was related to treatment. the patients mean age was . years, being % female. . % were diagnosed of persistent moderate/severe rhinitis according to aria guidelines and . % presented concomitant mild asthma. regarding to safety results, systemic adverse reactions were registered which corresponded to . % from a total of administered doses. the most of systemic reactions were grade i, ( . %) described as rhinitis or urticaria, grade or nonspecific ( . %) and reaction ( . %), was grade ii. all of them were mild or moderate and only needed treatment. among local reactions, ( . %) were clinically relevant late local reactions, meaning a wheal at injection site > cm and /or requiring a dose readjustment in the next administration; ( . %) were clinically relevant immediate local reactions meaning a wheal > cm. concerning the efficacy parameters, cutaneous reactivity at the final visit versus baseline was, in average, significantly decreased, and specific titers of igg and igg against tested hdm increased significantly at final visit. patients completed the study. mean values in rqlq questionnaire (total score) decreased from . to . points ( . % score reduction) in final visit, reflecting a statistically significant improvement (p < . ). annual episodes of rhinoconjunctivitis decreased from . to . (p < . ). . % of patients improved from persistent to intermittent rhinoconjunctivitis (p < . ) and . % from moderate/severe to mild intensity (aria) (p < . ). moreover, . % of asthmatic patients at baseline, did not have any bronchial symptoms after -year treatment (p < . ). mean value of treatment satisfaction was . (sd= . ) and . (sd= . ) for patients and physicians respectively. | evaluation of safety and tolerability of "allergovac poliplus" in polysensitized patients with allergic rhinitis-rhinoconjunctivitis with or without asthma: an observational prospective study (apolo) background: the objetive of this study was the safety and tolerance assessment of "allergovac poliplus" scit treatment, with allergen combination-mixtures in polysensitized patients, as well as the evaluation of the clinical improvement and patients' satisfaction after treatment. method: this is a prospective observational clinical study. allergovac poliplus treatment is being administered in a " -day" or in an abbreviated schedule. polysensitized patients (to pollens or mites), with rhinitis or rhinoconjunctivitis, with or without asthma, and between - years have been included. all adverse events are being recorded. visual analog scales (vass) are being used to evaluate clinical improvement, tolerance and satisfaction after treatment ( months). results: a total of patients have been included, with an aver- results: in all groups prevailed severe forms of the disease and the phenotype of frequent exacerbations. groups were comparable in age composition and structure of severity. observations in the group of vaccinated pcv continue the dynamics of decreased dyspnea up to . ( . ; . ) results: of a total of pts under scait, were excluded due to data unavailability, and included (♀ ( %), mean age ± years (minutes: max md ), age range [ - ] being most prevalent ( %). the most frequent diagnosis was rhinitis/rhinosinusitis ( %), followed by asthma ( %), diagnosis coexisting in abstracts | pts ( %). other diagnosis such as conjunctivitis ( %), atopic eczema ( %) and food allergy ( %) were also found. mite sensitization occurred in patients ( %) of which ( %) were monosensitized. the pollen sensitization was verified in ( %) with monosensitized pts ( %). the double sensitization mitespollens was displayed in ( %). sensitization to epithelia and fungi occurred respectively in ( %) and pts ( %). it was found that pts ( %) presented sensitization to the groups of allergens (mites, pollens, fungi, dander). an average of ± pts started this treatment per year. prescription included laboratories with the following %: a- . ; b- . ; c- . ; d- . ; e- . ; f- . ; g- . ; h- . ; i- . ; j- . . option for extract of physical modification ( %), physical-chemical ( %) and chemical ( %). table shows the frequency of distribution of scait composition. conclusion: in this population sensitization to mites was predominant being the most prescribed scait followed thru sensitization to grasses with the respective scait. the majority of the population was polysensitized. however, in composition preference the choice of group of allergens prevailed and only % had more than one sort of pollen and % pollen+mites. polysensitization is a reality, nonetheless the choice of ait composition should be guided thru scientific criteria and not through the availability of mixtures encouraged by laboratories. background: allergen immunotherapy (ait) has been proven to be an effective treatment of allergic diseases in numerous studies. however, its use in seniors remains limited and questionable, due to common comorbidities and limited evidence of efficacy and safety of ait in aging population. the aim of presented study was to assess the safety of ait in patients over years of age undergoing subcutaneous immunotherapy (scit) and analyze the potential risk factors of adverse reactions in this population, compared to younger adults. we followed subcutaneous immunotherapy in a group of patients treated in the outpatient clinic of medical university of lodz, of whom were aged and older ( between the age of - , aged - and patients above the age of ). we recorded detailed information of each administration and corresponding adverse reactions over the period of years. we compiled results of our observations with patients' medical records to compile a database, which we then analyzed using statistical software. method: a total of cases with seasonal allergic rhinitis undergoing pre-seasonal immunotherapy and cases followed with conventional drug treatment were included in the study. immunotherapy and control groups were divided into monosensitized (only pollen) and polysensitized (at least additional allergen except pollens) patient groups according to skin prick test reactivity. all patients were followed between march-september with symptom and medication scores, and visual analogue scale (vas). the quality of life was assessed using the mini-rqlq questionnaire. phleum pratense (phl p) specific ige and specific igg (uni-cap , phadia) measurements were performed before and after weeks of immunotherapy in all patients. gramineae pollens were counted during the grass pollen seasons. results: mean age was . ± . and . ± years, female/ male ratio was / and / , the number of monosensitized/polysensitized patients were / and / in immunotherapy and control groups, respectively. in the immunotherapy group, june-july symptom scores, may-june-july-august vas scores and june combined symptom-medication scores were lower than the control group (p = . ). furthermore, improvements in activities-practical problems and other quality of life scores were significantly different between two groups (p < . ). in immunotherapy group, phl p specific ige and phl p specific igg levels measured after immunotherapy were significantly higher compared to those before immunotherapy (p < . , p < . , respectively). phl p specific igg levels measured after immunotherapy were also significantly higher in the immunotherapy group than in the control group (p < . ). there was no difference in terms of clinical and immunologic parameters in monosensitized and polysensitized patients (p > . ). conclusion: clinical improvement with pre-seasonal allergoid immunotherapy is accompanied by an important increase in specific igg blocking antibodies despite short-term injections. our findings show that pre-seasonal allergoid immunotherapy has similar clinical efficacy and b cell response in polysensitized subjects compared to monosensitized patients. | the safety trial of sequential sublingual immunotherapy with japanese cedar droplet and house dust mite tablet matsuoka t ; kuroda y ; igarashi s ; fukano c ; natsui k ; ohashi-doi k ; masuyama k university of yamanashi, yamanashi, yamanashi, japan; torii pharmaceutical co. ltd., tokyo, japan background: sublingual immunotherapy (slit) is recognized as the only treatment option with the potential to provide long-term posttreatment benefits. in japan, the prevalence of japanese cedar (jc) pollinosis is very high, about % of the population, of which the majority are co-sensitized to hdm. slit is now well established, safe and convenient treatment form for allergic disease, and recently, jc slit-droplet and hdm slit-tablet products were approved in japan for treatment of jc and hdm induced allergic rhinitis, respectively. however, the safety of sequential jc slit-droplet and hdm slittablet has not yet been investigated. therefore, we investigated the safety trial on slit combined with jc droplet and hdm tablet in allergic patients. method: eleven subjects with jc pollinosis and hdm rhinitis were enrolled. patients were treated once-daily with jc slit-drops for weeks, followed by weeks of sequential slit treatment where the jc slit-drops and the hdm slit-tablets were administered daily with a minute interval ( st: jc-slit drops, nd: hdm slit-tablet). the primary endpoint was the frequency and severity of adverse events (aes) during sequential slit by common terminology criteria for adverse events (ctcae) v . and slit grading system. serum antibodies were measured as the secondary endpoint. results: eleven patients were recruited. aes after jc slit-drops administration were found in patients out of cases ( %). aes after sequential slit were found in patients out of cases ( %). all aes were graded or . no severe aes were observed during the study period. the levels of jc-and hdm-specific ige and igg in serum were increased during treatment. conclusion: sequential-administration of jc slit-drops and hdm slit-tablets was well tolerated by patients suffering from both jc pollinosis and hdm rhinitis. background: according to the ema guideline on the clinical development of products for specific immunotherapy products should be tested in phase ii at different doses in several study-arms to establish a dose-response relationship for clinical efficacy before confirmatory trials can be initiated. allergen exposure in an aec may be used as primary endpoint. the study was a single-center, randomized, double blind, placebo-controlled, phase ii trial, treatment duration months. grass pollen allergic patients ( - years of age) with seasonal rhinitis/rhinoconjunctivitis (arc) with (mild, gina i) or without concomitant asthma were randomized to three different dosages of a liquid phase iii study is in preparation. as part of an effort to prepare the analysis plan using the csms as primary endpoint, the grass pollen data of the european aeroallergen network (ean) was used to identify the window within the grass pollen season (gps) with optimal correlation between the grass pollen counts and the csms. method: ean currently includes information from more than active and historical pollen-monitoring stations in europe including countries. the ean database used for analysis included grass pollen data collected during - . the daily allergy symptoms and medication were recorded spontaneously using an app questionnaire on the subject's smart phone. the csms was re-calculated using the ean database, using the recorded symptom scores with estimation of the medication score using similar methods as recently published. the correlation between the daily grass pollen count and the daily csms was analyzed with a mixed effects model accounting for patient-specific correlations and symptom levels. conclusion: these results confirm a statistically significant correlation between grass pollen counts and the csms. importantly, these findings suggest that the optimal window to observe treatment effects after immunotherapy may be a short interval after start of the gps and during the peak gps, due to generally higher csms values. this provides sufficient basis to consider additional sensitivity analyses to evaluate the treatment effect of grass mata mpl scit on the primary csms endpoint during a shortened window after the start of the gps and to consider excluding the overlapping period between the bps and gps from the primary analysis. | combo-vas as a tool to assess efficacy of allergen immunotherapy ciprandi g ; silvestri m ; olcese r ; tosca ma ospedale policlinico san martino, genoa, italy; istituto g. gaslini, genoa, italy background: allergen immunotherapy (ait) is at present the unique cure for respiratory and venom allergy. usually, ait lasts for some years, but its efficacy is longstanding. criteria for assessing ait efficacy are mainly based on symptom severity improvement and saving of symptomatic medications. in this regard, there are different score grading for both measuring symptom severity and drug use. visual analogue scale (vas) is a well-defined and validated method widely used in many diseases, including allergic disorders. vas is a psychometric tool measuring the patient's perception of symptoms, emotions, pain, drug use, etc. recently, it has been published an eaaci position paper concerning the recommendations for the standardization of clinical outcomes used in ait trials for allergic rhinoconjunctivitis, but it is complex. so we would propose a simpler way to measure ait efficacy by vas, in particular a combo-vas based on one vas for symptom and one for medications. results: globally patients were retrospectively evaluated. all of them were treated with a -year ait course: were defined as responders and as non-responders. in responders group the combo-vas mean value was (iqr - ) at baseline and (iqr - ) after ait treatment. in non-responders group combo-vas mean value was at baseline and (iqr - . ) at the end of ait. the difference was significant (p = . ). the d combo-vas was − . % in responder group and − % in non-responders group (p < . ). conclusion: combo-vas, i.e. the sum of vas for symptoms and medications, could be an easy and quick tool for assessing ait efficacy and reflects the patient's perception. therefore, it could be very fruitful in clinical practice. | rapid up-dosing in sublingual specific immunotherapy is safe, well-tolerated and effective in patients suffering from tree pollen allergic rhinitis background: an optimised up-dosing period of specific immunotherapy (sit) is desirable for better patient compliance because a long or complicated up-dosing scheme is sensitive to disruption. the aim of this study was to compare the safety, tolerability and effectiveness of an optimised up-dosing scheme with two preexisting schemes of sublingual sit (slit) in patients under standard medical care. method: this was a prospective, open, active controlled, multi-center non-interventional study in germany and austria to document the treatment of children and adults with allergic rhinoconjunctivitis and/or allergic asthma treated with a slit containing purified, aqueous extracts of birch, alder and hazel pollen. the investigators were free to select an up-dosing scheme for included patients: scheme a consisted of an up-dosing period of up to days at the patient's home using three different solution strengths to reach the maximum dose; ultra-rush scheme b performed only with the highest solution strength at the physician's office within hours, and the optimised scheme c which was initiated at the physician′s office and continued at home using exclusively the highest solution strength within (long-term) or (pre-seasonal) days. data on up-dosing and maintenance treatments were documented by physicians during patient visits and by patient diaries. the study was approved by ethic committees, and all patients or parents gave their informed consent. results: in total, patients aged - years were included into this study. scheme a was applied by patients, patients decided on regimen b, and patients on the optimised scheme c. conclusion: one-day ur-scit conducted in an outpatient clinic was safe and well-tolerated in patients with ad sensitized to hdm. ur-scit can be a safe and useful option to start a subcutaneous allergen immunotherapy for ad. | factors affecting on adherence to allergen specific immunotherapy results: among enrolled patients, ( . %) patients failed to complete at least years of ait, which were regarded to be nonadherent in this study. univariate analysis revealed that male, younger age group less than years, cluster and ultra-rush schedules, atopic dermatitis, the absence of associated diseases, and follow up of other department were found to be associated with nonadherence to ait. in multivariate analysis, younger age group less than years (or . , % ci . - . ), cluster ( . , . - . ) and ultra-rush schedules ( . , . - . ) , and absence of follow up of other department ( . , . - . ) were independently associated with non-adherence to ait. no association was found in gender, diagnosis of allergic diseases, kind of allergen extracts, and patients' distance from hospital. conclusion: various factors are related with ait non-adherence to interfere the effectiveness of immunotherapy. clinicians need to be aware of the factors associated with non-adherence to ait and consider them when choose to maximize ait adherence. | cost-effectiveness of allergen immunotherapy to grass in patients with allergic rhino-conjunctivitis and asthma background: allergen immunotherapy (ait) has been shown to reduce symptoms and medication use in subjects with rhino-conjunctivitis and asthma. however, long-term cost effectiveness of this therapy needs to be evaluated. our aim was to assess cost effective of ait, both subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit), vs. pharmacotherapy alone in subjects with rhino-conjunctivitis, with or without allergic asthma, to grass pollens. method: a markov cohort state-transition model with a time horizon of years was used to assess the costs and effects of -year ait in adults. relative efficacy of the treatments expressed as standardized mean difference was estimated using an indirect comparison on symptom and medication score extracted from available meta-analyses. the rhinitis symptom utility index was used as a proxy to estimate utility values for symptom score. the societal perspective, through the human capital technique, was used to estimate indirect costs, to represent the scenario of a country with nationalized medicine. data on drug and other medical costs were derived from published sources as well as ait duration and asthma occurrence. additional sensitivity analyses were performed to test the robustness of our results. results: in the base case analysis, using italy clinical practice patients with moderate-to severe allergic rhino-conjunctivitis (ss ranging from to points) and a mean age at entry of years, both scit and slit were associated with increased cost but superior efficacy compared to pharmacotherapy alone. the results were most sensitive to variation in efficacy estimates and ait persistence rates. conclusion: this analysis suggests that ait is cost effective relative to pharmacotherapy alone. scit, despite significantly higher indirect cost burden, seems to be the most cost effective option. the results should be interpreted in the context of the data input and modelling assumption used. | ielisa as a tool to measure ige binding towards single modified peanut allergens background: immunotherapy has shown to be a potential treatment for food allergies but needs further research to improve safety. modification of peanut allergens to reduce their allergenicity is a promising approach to develop a safe and effective immunotherapy as shown by the successful completion of a first-in-human safety and tolerability study using hal-mpe in adult patients with peanut allergy (eudract - - ) . in order to assess the impact of modification on individual peanut allergens and to assess its impact on ige binding by individual patient sera, we have developed peanut allergen-specific inhibition elisas. with this methodology we are able to identify patients with residual ige binding to modified peanut allergens. method: ige inhibition elisas (ielisas) were developed and performed to test ige binding towards purified ara h and ara h and their reduced and alkylated (modified) versions, using the individual responses of single patient sera. results: ara h -specific ielisas showed that modification of ara h results in > % reduction in ige-binding for all individual sera tested. ara h -specific ielisas showed that modification of ara h also results in > % reduced ige-binding for most of the sera, but some sera were identified which showed residual, %- % ige binding to mara h . in some of the latter sera, the presence of ige binding to a linear hydroxyproline-containing peptide could be confirmed as a possible source for the residual ige binding to mara h . we have developed a methodology to assess residual ige binding to modified peanut allergens. the sensitivity of the allergen-specific ielisas allowed us to discriminate between patient sera in which ige binding to mara h and to mara h was virtually completely absent and sera in which - % residual ige binding to ara h was observed. the clinical importance of these observations is yet unknown. future clinical studies will need to reveal whether the patient-specific ige binding profiles to individual modified peanut allergens do correlate with the adverse events profile of immunotherapy with modified peanut extract. | design of a phase ii allergen immunotherapy study to determine the optimally effective and safe dose of subcutaneously administered tyrosine adsorbed modified grass allergen+mpl (mpl) adjuvants for the treatment of allergic rhinoconjunctivitis (arc) due to grass pollen. there is increasing evidence that the effectiveness of allergy immunotherapy to control arc symptoms is related to the cumulative allergen (or allergoid) dose administered. previously, two clinical studies have been conducted using a conjunctival provocation test (cpt) as primary efficacy measure for a similar scit mata mpl product for birch allergy [eudract - - and - - ] . these studies showed a . fold increase in cumulative dose to achieve~ % increase in efficacy, with a relative reduction in total symptom score (tss) of . % compared to placebo and no safety signals of concern. the shape of the dose response curve was curvilinear, where this high dose almost reached plateau. method: this is a multi-center (~ clinical study centers across europe), randomized, double-blind, placebo-controlled, parallel-group study in~ adult patients with moderate to severe seasonal arc with or without mild asthma. a positive cpt is to be achieved at screening and verified prior to randomization. the primary outcome is the post-treatment tss following cpt. a wide range of cumulative dose regimens is used ( , , and su) applied over weekly injections to establish the shape of the dose response to support dose selection for phase iii. the design of the current phase ii grass allergoid scit study will be discussed, including the rational of using cumulative dose regimens and placebo and the pre-selected shapes of the dose response curves. in addition, the number of patients screened and randomized will be presented by country, gender and/or age category and screen failures will be categorized. conclusion: this phase ii study was initiated to establish the dose response of a grass mata mpl scit product, using cpt to measure the effect of a wide range of cumulative dose regimens. the achievement of its aim will be an important milestone in the development of an efficacious and safe state-of-the-art grass scit. conclusion: we observed that the specific nasal challenge with house dust mite generates an inflammatory response within the first hours, but we did not demonstrate any correlation with the response to immunotherapy after six months. | tolerability of a two week rush updosing with modified allergens in pollen allergic subjects in the day-to-day practice background: in two phase iv studies the tolerability of a subcutaneous rush up-dosing, using three injections in two weeks, has been tested and proven to be save in adults. in the course of a non-interventional study (nis) now the tolerability of this treatment scheme was tested in the day-to-day practice. conclusion: over % of the patients could reach the highest dose of . ml. the overall tolerability is very good. the data from daily practice confirm the data that were previously obtained in two phase iv studies. siges from patients, evaluated during the st semester of at an outpatient clinic. all patients presented persistent moderatesevere allergic rhinitis, in pollen season and had not been submitted to it. all patients had positive spt for grasses (grass) and olive (olea). sige-tot for phleum pratense and olea europaea and some sige-crd (rphl p , rphl p , rphl p , rphl p , role and nole ) were determined. physicians were divided into groups (group if < years of practice and group if≥ years of practice) and were asked to choose which it to prescribe for each patient (none, only grass, only olive or both grass and olive), according to spt and sige results. results: fifteen physicians ( % with ≥ years of practice) participated in the survey. considering only the sige-tot results, the it choice (group / ) was: no vaccine in %/ %; grass vaccine %/ %; olive vaccine %/ % and both grass and olive vaccines in %/ % of the patients (p = . ), the intergroup agreement was % (kappa . ). according to the sige-crd results the physicians chose (group / ): no vaccine at %/ %; grass vaccine in %/ %; olive vaccine in %/ % and both vaccines in %/ % of patients however, data on control of allergic rhinitis (ar) after discontinuation of therapy are insufficient. the aim of our study was to assess sustained control of ar in three consecutive years after grass-pollen slit discontinuation. method: a total number of patients [ ( . %) males; mean age years, age range - ] well-controlled after a three-year course of slit with grass pollen extract were prospectively evaluated in three consecutive years after discontinuation of therapy. conclusion: a three-year course of grass-pollen slit seemed to have a long-term effect on control of symptoms in patients with ar. the authors declare no conflict of interest. results: all patients showed a positive sensitization profile by skin prick test to either betula and/or alnus. in % of patients this profile was furtherly confirmed with serum specific ige levels to betv , (mean . ku/l). allergic symptoms in patients with birch/alnus pollen allergy after ingestion of certain food can result from crossreactivity of bet-v -specific ige to homologous pathogenesis-related proteins, particularly the pr- protein. conclusion: within the allergy history we emphasize on focusing on sao symptoms as many patients under-recognize them. among the sensitization profile of these patients it is quite important to highlight cross reactivity between bet v and alnus. the other patient suffered from anaphylaxis(grade ii) induced by minimum amount of lettuce consumption without co-factors. both patients suffered from oral allergy syndrome to peach and allergic rhinitis. spts to foods and pollens were performed with commercial extracts, prick-through-prick with fresh plant foods, while specific ige was determined accordingly. ltp syndrome was defined as a sensitization to pru p and symptoms elicited by at least unrelated plant foods. co-factors were also investigated. results: the first patient was sensitized to lettuce, peanut, hazelnut, sunflower's seed, peach and banana, and plane tree, olive tree, grasses, parietaria and mugwort. sige to lettuce was . kua/l, to pru p was . kua/l and total ige was . u/ml. co-factors, such as exercise, were involved. the second patient was sensitized to peanut, walnut, hazelnut, almond, sunflower's seed, cashew, lettuce and peach, and, plane tree, olive tree, grasses, parietaria, mugwort and willow. sige to lettuce was . kua/l, to pru p was and total ige was . ku/l. no co-factors were identified. background: garlic (allium sativum) is a vegetable that belongs to amaryllidaceae's family. hypersensitivity to garlic is not very common. it has been mainly reported in occupational allergy but it also may cause contact dermatitis, rhinoconjunctivitis, asthma, urticaria, gastrointestinal symptoms and anaphylaxis after its ingestion. some studies have identified alliin lyase, a kda protein, as a major garlic allergen and it seems to be a heat-sensitive allergen. we report on a -month-old infant who presented, minutes after an accidental ingestion of garlic sauce, generalized erythema and cough. she was still breastfeeding and she had never abstracts | eaten garlic before (although the mother usually consumed garlic). the patient had never tasted other vegetables belonging to amarylidaceae's family either but zucchini, with good tolerance. we performed skin tests and specific ige (sige) to different vegetables. a raw garlic extract was also carried out and analysed in the patient by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: prick by prick with garlic was positive ( mm) and negative to onion, leek, asparagus, zucchini and saffron. skin prick tests to commercial extracts of mugwort, grass pollen, peach ltp and profilin were negative as well. specific ige to garlic was . ku/l (out from a total ige ku/l) and ku/l to onion and asparagus. sds-page immunoblotting assay with patient′s serum revealed ige reactivity with proteins of kda and kda. conclusion: we report a garlic ige-mediated anaphylaxis case in an infant with proteins of and kda as the relevant allergens. the mechanism of sensitization in the present case remains unclear. the authors hypothesized that breastfeeding, cutaneous contact or inhalation might be possible mechanisms involved. chong kw ; saffari se ; chan n ; seah r ; tan ch ; goh sh ; goh a ; loh w allergy service, department of paediatric medicine, kk women's and children's hospital, singapore, singapore; centre for quantitative medicine, office of clinical sciences, duke-nus medical school, singapore, singapore; yong loo lin school of medicine, national university of singapore, singapore, singapore background: the predictive decision points for both peanut skin prick test (spt) wheal size and serum ige concentrations, in peanutsensitized children, have not been evaluated in singapore. we aim to assess these for purposes of risk stratification and prediction of oral food challenge (ofc)s' outcomes by means of a retrospective chart review. results: the number of patients evaluated was , of which had clinical diagnosis of peanut allergy based on recent immediate reaction to peanut (pa group) and were tolerating peanuts regularly (pt group). the mean age of both groups were similar, . ± . and . ± . years in pa and pt groups respectively. there was a high prevalence of atopic diseases in both groups, with atopic dermatitis ( . % in pa, . % in pt), and other food allergies ( . % in pa, . % in pt). presence of rhinitis was statistically higher in the pa group compared to the pt group, with odds ratio of . ( % ci: . - . ) . a wheal size of ≥ mm and a peanutspecific ige of ≥ ku/l provided for a % positive predictive value. the larger the wheal size on spt, the higher the probability of a clinical reaction to peanuts. the results will help us in deriving preliminary cut-off values when conducting future prospective studies with ofcs in our peanut-sensitized cohort (whom had no prior peanut exposure), and to eventually reduce the need for expensive and potentially risky food challenges. | ginger: flavory, spicy …allergenic? a report of four patients with allergy to ginger background: ginger (zingiber officinale) belongs to the family zingiberoidae, along with cardamom and turmeric. the edible portion is the horizontal rhizome, and it is very appreciated for its aroma and spicy flavor. it also presents great interest for its therapeutic and culinary use. hypersensitivity to ginger is rare and has been scarcely reported. we report cases (p , p , p , p ) of adverse reactions to ginger after its ingestion and with good tolerance to cardamom and turmeric. method: skin prick tests (spt) to environmental allergens and prick-by-prick with ginger were carried out. total ige, and specific ige to ginger were also determined. a raw ginger extract was prepared. this extract was analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). background: food allergy is divided into groups according to pathophysiology: ige-mediated, ige-and non-ige (mixed type), and non-ige (cellular type). however, in clinical practice, patients who fall under more than one group may be observed. method: patients who were diagnosed with food allergy at our clinic from january to december were included in the study. the medical files of patients were retrospectively evaluated, their symptoms and findings after consumption of foods were recorded, and they were categorized into groups (ige-mediated type, non-ige type, and mixed type) according to their symptoms and findings. results: a total of patients ( . % male) with food allergies were included in the study. according to categorization via symptoms and findings, the distribution of patients was as follows: ( . %) ige-mediated type, ( . %) non-ige type, ( . %) mixed type. the remaining ( %) patients were found to show various combinations of symptoms and findings that fit more than one group. in this study, we observed that food allergy symptoms and findings were distributed in a broad range which caused difficulties in the categorization of more than one-third of our patients. background: fish allergic patients suffer a lifetime of strict dietary restrictions. crocodile meat is a nutritious alternative choice in many countries around the world; however, it has recently been reported to also trigger severe allergic reactions. in these two case reports from pediatric patients were sensitised to the major fish allergen parvalbumin (pv), a potential cross-allergen. bony fish contain predominantly pvs of the β-lineage, which are the most common trigger of allergic reactions in fish allergic patients. in most other vertebrates, pvs of the α-lineage are most abundant, which have been reported as a causal allergen in frog, cartilaginous fish, and chicken allergies. we aimed to evaluate the allergenicity of crocodile meat in fish allergic children, with focus on pv. method: over children with clinical history of ige-mediated fish allergy were identified, skin tested to commonly consumed fish species using commercial and in-house preparations, and serum samples were collected. a sub-cohort was skin tested to crocodile using heat-treated tail muscle tissue from saltwater crocodile (crocodylus porosus). extracted proteins and purified pvs were analysed by sds-page, immunoblotting, and mass spectrometry. serum from all fish allergic children was analysed for ige reactivity to the crocodile pv. this reactivity was compared to those of raw and heated crocodile protein extracts as well as protein extracts and purified pvs from frequently consumed fish species. results: more than fish allergic children were positive on skin testing to crocodile (wheal size> mm), demonstrating its clinical reactivity. in vitro analyses revealed ige reactivity to crocodile pv in serum from more than half of all patients. two βand one α-crocodile-pv isoforms were identified. pvs constituted approximately % of total proteins in heated crocodile extracts, with β-pv ( kda) being times less abundant, but up to times more ige-reactive than α-pv ( kda). αand β-pvs from crocodilians, including alligators and crocodiles, share more than % and % of their amino acid sequence, respectively. conclusion: crocodile pv is a new allergen as per the iuis guidelines. fish allergic patients may be at risk of severe allergic reactions upon ingestion of crocodile meat due to strong ige cross-reactivity of β-pvs. this study suggests that fish allergic individuals and health professionals need to be aware of potential allergic reactions to meat from crocodilians, termed 'fish-crocodile syndrome'. background: we present a -year-old nonatopic woman that in december after eating a seafood paella with green pepper presented asthenia, nasal obstruction, incoercible vomiting and diarrhea. later she ate a grilled loin sandwich in a bar and she had the same symptoms (she asked the waiter at the bar and the chef had cooked her sandwich in the same pan where he had cooked green pepper just before). after that, she suffered from abdominal pain, nausea, abdominal distension without diarrhea two hours after she ate an omelet sandwich with certain flavor of green pepper. at present even the casual smell of pepper causes her nausea. the woman eats everything including spices and just avoids pepper. method: skin prick tests were performed using extracts from food (nuts, fish, mollusk, fruits, vegetables, legumes), aeroallergens (mites, abstracts | pollens and epithelia) and purified proteins (pru p , profilin, polcalcin, alfalactoalbumin, betalactoglobuline, casein). we also performed prick by prick to raw and cooked green pepper. sds-page immunoblotting according to laemli under reducing conditions (with -mercaptoethanol) was performed to study the molecular mass of the ige-reactive proteins. extracts from green pepper and green pepper seed were used. the prick tests were all negative and the prick by prick test to raw and cooked green pepper was positive in both cases. blond was taken from all patients to specify the levels of allergenspecific ige against allergen components of immunocap isac test, the result≥ . isu-e was assumed as positive. results: in the study group, in patients ( %) specific antibodies against ltp were detected, the isu-e level range . - average . isu-e on average, in patients with detected ltp ige was detected for . components belonging to the ltp, however the highest number % patients were detected ige only for ltp. in subjects ( % of respondents with detected ltp), ige was detected against art v and this is the only ltp component whose occurrence was statistically significant (p = . ). in patients ige was detected against pru p , jug r , pla a ,; patients ige to ara h ; patients cor a ; patients ole e , patients tri a , and in person para j . background: the birch pollen-associated oral allergy syndrome (oas), an ige-mediated local allergic reaction, is the most common manifestation of pollen-associated food allergies. its origin is explained by cross-reactions between birch pollen-and food-allergens belonging to the pathogenesis-related protein subfamily (pr- ). [ ] so far, there is no marker available for its detection and no standardized test established to evaluate objectively the subjective feelings experienced by oas. the diagnosis is based on a characteristic history and on detecting the sensitization to triggering allergens in skin prick test (spt) and laboratory examination. method: the aim of this study was to evaluate whether the food skin prick test could be a helpful marker in the diagnosis of a birch pollen-associated oas. for this exploratory study, data from - was collected retrospectively at the dermatological outpatient department of the ordensklinikum linz elisabethinen. patients with positive spt results for birch pollen were included. the variables age, gender, tree pollen-(birch, alder, hazel) and food-spt, laboratory tests (ige, bet v , bet v , gly m ) and symptoms (oas, rhinoconjunctivitis allergica, atopic dermatitis, anaphylaxis) for statistical analysis. results: there was an association between food-spt and oas but also between the negative oas patients and food-spt (p = . - . ). all of the bet v sensitized patients with positive gly m results had also a positive food-spt result. conclusion: there was no evidence for a possible role of food-spt as helpful markers in the diagnosis of birch pollen associated oas. maybe gly m could be a helpful marker, but more data are needed. bet v seems to be the cause of birch-pollen associated oas, due to the dominant sensitization pattern to major allergens in austria. background: eggs are among the foods most frequently causing allergy. the most common one is hen egg, although we may consume other bird's eggs such as duck's, those of goose, quails and seagulls. clinical and serological crossreactivity between hen egg proteins and those of other birds eggs have been described. allergy to other species eggs are less frequent and are usually described in patients allergic to hen eggs. we report a case of food allergy after ingestion of duck egg in an adult patient without hen egg allergy. the patient was a year-old man who had symptoms of generalized itching, swelling uvula, erythema neck and deglutition difficulty immediately after he ate eggs from duck and hen. he claimed to have eaten hen eggs almost daily without clinical symptoms and he had not previously ingested duck egg. he denied allergic reactions to any other food but did complain of seasonal allergic rhinoconjunctivitis in the spring. we performed skin prick test with extracts of egg and feathers, prick by prick test with cooked and fresh yolk and white from duck and hen egg and oral challenge with hen eggs. specific serum ige was measured to hen proteins and we carried out a western blot with the proteins of allergenic extracts from different eggs (white and yolk of quail, chicken, goose and duck) and an inhibition of western blot with ovalbumin as inhibitor allergen. results: skin test with extracts of eggs and feathers, cooked and fresh hen and duck eggs were positive. total serum ige was . ku/l. specific ige to hen's egg was class two for hen egg white, ovoalbumin and class one for yolk and ovomucoid. oral challenge with heated egg yolk negative and with egg white was positive. the patient's serum recognized mainly and intensely several proteins of white and egg yolk of quail and duck with a molecular mass around to kda respectively. on the other hand a protein around and - kda was unique recognized in white eggs of hen and goose. the western blot inhibition revealed ovalbumin inhibited the protein recognized in the egg white but not egg yolk involved in. background: management of tree nut allergy is usually based on the avoidance of the suspected tree nut (tn), as well as peanuts and seeds, either because of the risk of cross-reactivity and/or contamination, or due to the clinical severity. objective: to assess the sensitization pattern and clinical reactivity patterns to different tn, peanut and sesame seeds (ss) in patients with a history of reaction to at least one of these foods. results: a total of patients with confirmed nut allergy were included; % female, median age [interquartile range] of years; % were atopic. the most frequently involved foods were walnuts ( %), hazelnuts ( %), almonds ( %) and peanuts ( %). anaphylaxis was the clinical presentation in % of the patients. in those with a history of reaction to only one nut ( ), the most prevalent was peanut ( %). in the patients that reacted to more than one nut, the most frequent combinations were walnut/hazelnut ( ), walnut/almond ( ) and almond/ hazelnut ( ). of these patients, tolerated other nuts. two had sesame seed allergy, one reacted only to ss. nine patients ( %) were sensitized to foods that they tolerated. fourteen ( %) patients were sensitized to ltp and of them reacted to more than one nut. conclusion: these data concur with the existence of different sensitization profiles (primary, concomitant or cross-reactive), which may predict different clinical reactivity patterns and therefore, influence dietary recommendations. background: buckwheat (fagopyrum esculentum) is a polygonaceae weed, not a cereal, which is increasingly been consumed and used as an alternative food in the diet of celiac patients. despite its wide use, allergy to buckwheat has unfrequently been reported in our setting. method: two female patients, aged and , suffered an immediate severe allergic reaction after eating a bread and a pancake containing buckwheat among its ingredients. the first patient presented generalized urticaria, palpebral angioedema and pharyngeal occupation. the second one showed those same symptoms, as well as abdominal pain, nausea, dyspnea, dizziness, hypotension and loss of consciousness. skin tests and specific ige determination to aeroallergens and food allergens were carried out, including prick-prick test with buckwheat and all other components contained in the food involved. buckwheat allergens were studied by sds-page and ige-immunoblotting of one of the patients. results: prick-prick tests yielded strongly positive results to the food itself and buckwheat, and negative to the remaining food components in both cases. cap was positive to buckwheat ( . ku/l and > ku/l, respectively). basal serum tryptase levels were normal. both patients were not sensitized to cereals, ltps, profilins or pr- proteins. for the first patient, the skin tests were negative for other foods, seeds and nuts. the cap was negative for ltps, profilins and storage proteins of peanut and other nuts. the second patient who had the most severe reaction, was also sensitized to hazelnut(cap . ku/l), pistachio ( . ku/l), almond( . ku/l), walnut( . ku/l) and sesame( . ku/l), which were not included in the pancake. the buckwheat immunoblot of the first case, under non-denaturing conditions, revealed a ige-binding protein of -kda. ige-immunoblotting under reducing condition showed protein bands of , , and kda in the buckwheat extract. conclusion: two cases of anaphylaxis by buckwheat flour contained in two frequently consumed foods are presented. the absence of sensitization to ltps, together with the pattern of specific ige binding in the immunoblot in one of the cases suggests that the responsible allergen could correspond to a storage protein of buckwheat, without cross-reactivity with other seed and nut allergens. buckwheat must be taken into account as an unsuspected food allergen capable of causing severe allergic reactions. background: allergy to linseed (linum usitatissimum) has infrequently been reported despite of its wide use in bread and in a range of "health food" products. linseed contains potent allergens which have not yet been characterized. we studied three patients who presented allergic reaction after eating different foods which contain linseed. two of them (patient p and patient p ) had anaphylaxis and the third one (patient p ) had oral syndrome, abdominal pain and diarrhoea. p was also allergic to mustard and p to sesame seed. all of them tolerated the remaining seeds, nuts and food. baseline tryptase levels were in normal range in all patients. skin tests and specific ige determination to inhalants and food allergens were carried out. linseed allergens were studied by sds-page and ige-immunoblotting. skin tests: patient : prick tests were positive to pollens and linseed, and negative to ltp, profilin, nuts, seed and the remaining food; patient : prick tests were positive to linseed and mustard and negative to other food and inhalants; patient : prick tests were positive to linseed, pollens, sesame and nuts (peanut, hazelnut, almond, pistachio). we present three cases of severe allergic reactions to linseed. the pattern of specific ige binding in the immunoblot seems to lead to storage proteins as the responsible allergens. | pr- sensitization-looking it up in food allergy background: pr- protein group sensitization is found in patients with respiratory allergy, mainly in areas inhabited by trees of the betulacea or fagacea families. its role in food allergy is, however, more frequently described in the context of cross reactivity. our aim was to characterize the pattern of molecular sensitization of food allergic patients sensitized to pr- protein group with immu-nocap isac ® (isac). the remaining patients, with more severe reactions, were all co-sensitized to either ltp and/or storage proteins (sp). only of the patients without pfa were co-sensitized to ltp or sp versus of with pfa (p < . ). conclusion: pr- sensitization is rare in our population. approximately half of the patients had allergy to plant foods, but the majority were co-sensitized to ltp and/or sp. the few patients only sensitized to pr- had minor reactions. among the patients without plant food allergy, co-sensitization to ltp and sp was significantly less common. according to these results, in our population, pr- seems to be less relevant to food allergy, when compared to reported results from other european countries. gür Çetinkaya p; uysal soyer Ö; esenboga s; sahiner Üm; sekerel be hacettepe medical school, ankara, turkey background: pistachio is a tree nut belonging to "anacardiacea" family, and constitutes % of tree nut allergies. this nut most often abstracts | cross-reacts up to % with cashew which is located in the same family. pistachio allergy is mostly seen in iran, turkey, the united states, and china where this tree nut is frequently consumed. in this study, we analyzed age and cut-off values for development of tolerance to pistachio. method: children who had reported allergic reactions with pistachio, and who have not consumed pistachio, but had positive spt and/or specific ige levels were enrolled into the study. spt and specific ige levels were measured in all patients. oral provocation(op) tests with pistachio were performed by patients, and of them had positive test result. the median age of tolerance development was months (iqr: . - . months). the most commonly involved systems during op tests were skin ( %, n = ), gastrointestinal system ( %, n = ), and lower respiratory tract ( %, n = ). concomitant allergic diseases were atopic dermatitis ( %), asthma ( %) and allergic rhinitis ( %). there was a positive correlation between skin prick test diameter (spt) and specific ige levels (spige) (r = . , p = . ). spt of≥ . mm to pistachio nut was found as highly predictive of clinical allergy (auc: . , %ci: . - . , p < . ). any relation was not determined between eosinophil, basophil counts, triptase levels, and op test positivity. conclusion: pistachio allergy is one of the frequently seen nut allergies in turkey which may cause serious allergic reactions including anaphylaxis. op test showed that tolerance was achieved by the median age of months, and a cut-off level of . mm was best predictor for positive reaction. in an oral challenge test, the patient responded with generalized urticaria, swelling of the lips and difficulty breathing at a cumulative dose of . g peanut protein, however, without blood pressure drop. (grade , moderate symptoms). the patient was treated with anti-ige for months (with mg every weeks sc). oral desensitization began with ingestion of μg peanut, escalating to mg, on the first day and escalating weekly doses of peanut from mg to mg ( peanuts). then anti-ige was discontinued while the patient ingested peanuts every day. we have followed the patient's sensitivity to peanuts from before anti-ige treatment to after anti-ige washout with basophil testing. results: the patient completed desensitization without side effects, and continues to ingest peanuts a day. basophil sensitivity was reduced -fold by anti-ige treatment, but returned to baseline levels after anti-ige washout. conclusion: anti-ige allows rapid desensitisation of peanut allergic subjects with peanut oral immunotherapy. in the majority of subjects, this desensitization is sustained after anti-ige is discontinued. additional studies will help clarify which patients would benefit most from this approach. the return of basophil response to pre-treatment levels suggests that the patient is desensitised, and depends on the daily ingestion of allergen. what do we (not) know? background: the use of biologic prosthesis is a well-established surgical procedure. acute and delayed complications may occur, but accurate epidemiologic data about allergic reaction to graft tissue is lacking. methods: a years old boy referred to our unit for urticaria and gastrointestinal symptoms which developed a few years before. he received a biologic porcine vascular duct during a cardiovascular surgery at days of life. at the age of urticarial episodes occurred, and a diagnosis of beef allergy was made. after the exclusion of beef meat from the diet, most symptoms resolved, but the child began to complain about occasional episodes of vomit and diarrhoea. results: skin prick tests confirmed the beef meat sensitization and prick-prick test resulted positive against raw pork meat but not against cooked pork meat. in vitro tests demonstrated the presence of pork meat specific iges ( . kua/l). component-resolved diagnostic tests revealed allergy sensitization toward bos d (bovine serum albumin, bsa; porcine serum albumin was not tested due to lack of a specific test). after accurate exclusion of pork meat from diet, a complete remission was achieved, and the diagnosis of pork meat allergy was confirmed. conclusion: bsa is a major beef allergen, responsible for the raw beef-cow milk cross-reactivity but with a scarce importance in milk allergy. it is highly homologous with human serum albumin and other mammalian serum albumins, including porcine albumin. porcine albumin is also highly homologous with cat serum albumin and therefore responsible for cross-reactivity in patients affected by cat-pork syndrome. we hypothesize that the implanted porcine tissue was the trigger for pork meat allergy in our patient, as this condition is exceptional in childhood and that our patient never owned a cat. few cases of pork allergy due to porcine tissue implantation have been reported so far. of interest, pig sensitization was recognized as a rare but possible cause of blood-culture negative endocarditis in patients with porcine bioprosthesis according with anamnesis, increased ige level against pork, tissue eosinophilia during autopsy. background: desensitization to foods is assuming a new paradigm in food allergy. this technique is becoming widespread especially for patients with egg and milk allergy, but the effect of desensitization on the consumption of similar but not identical foods is still uncertain. material and methods: we describe the case of a -year-old patient, with a history of chicken egg allergy, who had been successfully desensitized tolerating cooked and raw chicken eggs for a year. the patient came to the office after presenting an episode of anaphylaxis immediately after eating fried quail eggs. an immunological study was carried out. we performed skin prick test with chicken egg′s proteins (white, yolk, ovoalbumin and ovomucoid). an immunoblotting to detect specific ige to egg proteins was also performed. for this purpose, the following extracts were used: chicken egg white and yolk (commercial extract form alk) and quail egg white and yolk prepared following a similar procedure (extracted in % phosphate buffer (w/v)). conclusion: we present the case of a patient with specific allergy to quail egg white and yolk, probably through ovotransferin, but not to chicken egg. the desensitization against chicken eggs does not allow the consumption of eggs of other species of birds, such as quail eggs, and this indication must be made specifically to patients after a protocol of desensitization against chicken′s eggs. case report: seven years ago we presented the case of a year-old male, who suffered two acute episodes of oral pruritus, lip angioedema, epigastric pain, generalized urticaria and dizziness after ingesting lettuce. he previously tolerated salads (including lettuce). he was later diagnosed with non-ltp-dependent lettuce anaphylaxis and an aspartyl protease was identified as a new lettuce allergen with cross-reactivity with other members of the compositae family. since the diagnosis he has avoided lettuce and all the other compositae. we present the patient's curious outcome after years of follow up. methods: total ige, basal tryptase, specific ige to lettuce by immu-nocap, prick-prick and oral challenge tests with lettuce and other compositae. sds-page, immunoblotting and molecular characterization of ige binding bands by mass spectrometry. skin prick tests and specific ige to lettuce were repeated on several occasions in the following years. after years an oral challenge test with lettuce was carried out. results: prick-prick test was positive to fresh lettuce ( × mm) and to other compositae (raw endive, chicory, thistle, artichoke and chamomile). prick-prick test was negative with these boiled compositae. basal tryptase was . μg/l. total ige in serum was ul/ml. specific ige by immunocap was positive to lettuce ( . ku/l) and negative to profilin, ltps and thaumatin. oral challenge test with endive was positive and negative with cooked compositae (artichokes and thistle). sds-page and immunoblotting detected an intensely binding ige band about kda, common for endive and chicory, which was identified by mass spectrometry as an aspartyl protease. no bands were detected at ltp ( kda) and profilin ( kda) . in the first two years after the diagnosis, prick-prick test and specific ige to lettuce remained positive (cap . ku/l and . ku/l, respectively). after years, prick-prick test and specific ige to lettuce became negative (cap . ku/l). with this findings a new oral challenge test with lettuce was carried out which result turned out negative. we report the first case of spontaneous tolerance to lettuce in a patient who previously presented lettuce anaphylaxis and identify an aspartyl protease as the causative allergen. introduction: eosinophilic esophagitis (eoe) is an emergent allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. recently, it has been seen that eoe develops in up to . % of patients with ige-mediated food allergy undergoing oral immunotherapy (oit). ingestion of baked milk and egg was associated with increased development of tolerance to regular milk and immunologic changes have been reported in subjects ingesting baked milk and egg, similar to those seen in food oral immunotherapy studies. case description: we present the case of a -year-old girl, with history of ige mediated cow′s milk allergy and rhino conjunctival and bronchial asthma symptoms. prick test against milk proteins showed: milk mm, alpha-lactalbumin mm, casein mm and to beta-lactoglobulin: negative. total ige: ku/l. specific ige to milk: , alpha-lactalbumin: , ku/l; casein: ku/l and beta-lactoglobulin: . ku/l. we performed an oral food challenge with baked milk which was well tolerated. then, we performed an oral food challenge with fresh milk and she presented facial urticaria and pharyngeal pruritus. after months eating baked milk every day, she had symptoms of dysphagia and esophageal food impaction. for this reason, we performed an esophagogastroduodenoscopy (egd) and biopsies which showed white exudates and vertical furrows. the histological study showed eosinophil count> per high-power field. eosinophilic esophagitis was diagnosed and she started treatment with esomeprazole mg. the egd was repeated weeks later with similar results in the biopsy. she was treated with a comprehensive diet free of cow′s milk proteins. after weeks she was asymptomatic and endoscopy and biopsy findings were normal. we report the case of a cow′s milk allergic patient who developed eoe after introduction baked cow′s milk which apparently was tolerated in her diet. the avoidance proved efficacy in inducing the remission of eoe. method: we examined bottle-feeding infants with food allergy aged from to months. serum vitamin levels were measured by immunoassay methods (retinol binding protein (rbp), vitamin b , hydroxy vitamin d), biochemistry methods (vitamin c, vitamin e) and microbiology methods (vitamin b , vitamin b ). as criteria for complete sufficiency standards adopted in the russian federation were used (the lower limit of normal levels: rbp - . μmol/l; b - ng/ml; -hydroxy vitamin d- ng/ml; vitamin c - . mg/dl, vitamin e - . mg/dl; vitamin b - μg/ml; vitamin b - ng/ ml). results: complete sufficiency were observed in infants ( . % cases), one vitamin deficiency in infants ( . %), two vitamins deficiency in infants ( . %), three and more vitamins deficiency in infants ( . %). should be used after vitamin status asses, mainly using monovitamin medication. results: patients were followed with the diagnoses of cma and asthma. age at the beginning of symptoms and start of oit were in the range of - months and - years, respectively. they had high total ige ( - iu/ml), milk spige ( . - kua/l), casein spige background: food allergies may affect up to % of school-aged children. it has been shown that approximately % of all anaphylactic reactions caused by food allergy are firstly presented at (pre) school. therefore, it is of high importance that (pre)schools have a policy on food allergy management and the use of an epinephrine auto-injector (eai). to our knowledge, limited is known on the policies of food allergy management at (pre)schools. the aim of this study was to investigate the policy on food allergy management in preschools and primary schools in the northern part of the netherlands. results: we included preschools and primary schools in this study. we showed that . % of the preschools and . % of the primary schools had a child(ren) with food allergy. only . % of the participating preschools and . % of the primary schools had a policy on allergen avoidance and only . % of the preschools and . % of the primary schools had a policy for the use of an eai. the majority of the pre-and primary schools in the northern part of the netherlands have children with food allergy. however, only a limited number of (pre)schools do have written guidelines for food allergy management in (pre)schools. additionally, there is limited experience how to use an eai at (pre)schools. therefore, an evidence-based policy on food allergy management in (pre) schools is needed. background: food allergies are the most common cause of anaphylaxis in childhood. here we present cases had anaphylaxis due to cow 's milk allergy, and treated with specific oral tolerance induction (sotİ) to cow' s milk. method: soti protocol was administered according to previously published by longo et al. skin prick test were performed according to standard methods with allergens. cow's milk specific ige was investigated with immunocap system. in all cases, the wheal size of the cow's milk in skin prick tests or the specific ige levels was higher than level of positive predictive value of %. results: case : a years old male patient who had anaphylaxis after milk consumption. soti treatment was started one year ago. there was no complications during the dose increasing phase. however, he had two episodes of anaphylaxis during the maintenance phase. in the final visit, we observed that he could drink ml milk and could consume dairy products. case : eight-year-old male patient has an intensive care-of-hospitalization story due to anaphylaxis three times after milk consumption. his accordance to strict diet was bad, and had frequent asthma attack. anaphylaxis developed times during the dose increasing phase in soti protocol. after soti treatment, he could consume ml cow's milk and dairy products without problems. case : a -year-old male patient followed-up for asthma and cow's milk allergy. it was learned that anaphylaxis developed times after milk consumption. he was fed in accordance with the milk-free diet. he has used fluticasone nebules, montelukast, mometasone nasal spray, and cetirizine. anaphylaxis developed times during the dose increase phase of soti administration. there were many mild to moderate anaphylactic episodes during the maintaining phase. after the soti treatment, he could consume ml milk and dairy products. background: cow's milk protein allergy (cmpa) is one of the most common food allergies in early childhood. small dietetic group sessions for parents of infant with non-ige mediated cmpa were held to meet increasing demands and reduce waiting times. parents were given information on cmpa, advice on weaning and milk reintroduction using a locally designed milk ladder. parents were also advised to contact the dietitians via telephone if they had further questions. we aim to evaluate the sustained effectiveness and patient satisfaction of the group sessions. method: parents and carers who attended the group dietetic sessions held between november and july were included in the survey. feedback were obtained via a self-designed questionnaire using a likert-type scale, rating several questions from (least satisfied) to (most satisfied). initial feedback was obtained directly after the session. we followed these patients up a year after the initial session via telephone and postal questionnaire. results: overall attendance rate of the group sessions held was % (n = ). during the initial survey, participants found the group session useful (mean score . out of ) and felt more confident in managing cmpa (mean score . ). we successfully obtained follow up feedback from participants. majority agreed that the group sessions have been informative (mean score . ). they also said they felt confident weaning their child on milk-free diet (mean score . ), and in reintroduction of cow's milk in diet (mean score . ). % (n = ) said that they would have preferred an individual session. % (n = ) have contacted the dieticians via telephone after the initial session, and % (n = ) had requested individual consultations. % (n = ) have attempted reintroduction of cow's milk in their child's diet using our local milk reintroduction guide. the mean age at first challenge was months (age range to months), with average of two attempts. % (n = ) have been successfully challenged and are managing well on a normal diet. we recognised the limitation in obtaining feedback via telephone and postal questionnaire, which resulted in the poor follow-up response rate. overall, parents felt more confident in managing cmpa and the positive responses were sustained a year on, highlighting the success of these group sessions. follow up opt-in sessions could be offered to provide additional support and allay parental anxiety in challenging their child with cow's milk at an appropriate age. results: goats and rabbits were immunized with specific allergoids, the allergoid-specific igg titer determined and sera pools produced. the allergoid reference material was comprehensively characterized. while ige reactivity of the allergoids was not detectable anymore, igg reactivity was maintained. allergoid-specific assay parameters as serum dilution, reference dilution and sample dilution factor to obtain at least six data points within the pseudo-linear range of the inhibition curve were determined. with these set parameters the evaluation of the analytical method was performed. the assay showed very good results in terms of linearity, accuracy, precision, reproducibility and robustness for all investigated allergoids as well as aluminum-adsorbed allergoid-preparations. conclusion: with the developed immunological inhibition assay, it is possible to determine the specific igg reactivity of allergoids in different preparations. the performance of the analytical method met all pre-defined acceptance criteria, which will be confirmed in the next step by a validation procedure according to ich-guidelines. case report: we present the case of a -year-old patient, diagnosed with rhinitis and asthma due to sensitization to pollens, as well as dyshidrosis and allergic contact dermatitis to cobalt. the patient presented a cutaneous pattern consisting of erythematous papules, some scaly, very pruritic, of initial appearance in the upper limbs - days after initiation of administration of specific immunotherapy extract (depigoid forte grasses, leti ® ). subsequently generalize lower limbs and neck. she presented them repeatedly and late after - days of the first doses administered. she referred partial control of pruritus with oral antihistamines, without total resolution of lesions for weeks. immunotherapy was suspended persisting the skin lesions for more weeks. according to the personal history of sensitization to metals, and the clinic presented in a temporal relationship with the use of an extract of immunotherapy with aluminum hydroxide, a study was requested with epicutaneous tests with aluminum hydroxide as well as with epicutaneous tests with immunotherapy extract. aluminium hydroxide and depìgoid forte grasses extract epicutaneous test were negative. in subsequent visits the patient reported that coinciding with the start of immunotherapy, presented at home and mainly in her bedroom a plague of cimex lectularius, popularly known as bedbugs, proving that they had been the cause of bites on their skin, and later skin reaction. patient reported that with the elimination of said pest the skin lesions disappeared. the administration of its immunotherapy extract was tolerated. cimex lectularius, commonly known as bed bugs, is a hemiptera insect of the family cimicidae. the clinical picture usually corresponds to multiple pruriginous lesions from the prurigo type, to multiple erythematous plaques, some infiltrated and others with a urticarial appearance, or even bullous. the lesions last for to weeks without treatment, and while the older ones heal, new ones may appear. in our patient it was not considered as an initial diagnosis, having considered immunotherapy as an etiological factor, but we must not forget that although in our country it is not a reason for frequent consultation, either due to underdiagnosis, because of the transitory nature of the pathology or because of scarce number of causative agents, it is important to consider insect bites in the differential diagnosis of dermatosis. di cara g; salvatori c; testa i; pacitto a; bizzarri i; isidori c; tarsia m; esposito s università degli studi di perugia-dipartimento di scienze chirurgiche e biomediche, perugia, italy background: house dust mites (hdm) are one of the most important allergens involved in childhood respiratory diseases, and the most frequently prescribed extract for sublingual immunotherapy in children (slit). despite the improvement of standardization methods for the production of slit, the differences in cultivation and purification processes used to produce raw materials for specific immunotherapy extracts may still impact on the final composition of mite allergen extracts. our study investigated the total protein and main allergen content of five commercial hdm sublingual immunotherapy extracts using sds-page and immunoblotting. recombinant allergens of group and group major allergens were used to test the immunogenicity of such extracts. method: hdm slit extracts were purchased from five italian suppliers (alk-abellò, allergy therapeutics, anallergo, lofarma, stallergenes). the protein composition of extracts was evaluated analysing equal volumes ( ml/lane) by sds-page ( % separating gel) and subsequent immunoblotting. for identification of allergens in the extracts, western blot analyses were performed with rabbit monoclonal antibodies (raybiotech) against der p and der p . the total protein content in the five tested commercial extracts showed a relevant variability. the protein contents ranged from . to . μg/mg for what concerns der p , while der p showed a greater variability, ranging from . to . μg/mg. sds-page showed a similar pattern of distribution in of the tested extracts, which showed protein bands of comparable intensity, while extracts showed a lower total protein count. extract showed a higher intensity band corresponding to the molecular weight of tropomyosin. western-blotting showed a similar concentration of der p in most extracts, while der p was more variable. conclusion: our analysis of five commercial extracts commonly used for sublingual specific immunotherapy against hdm showed important variations in term of total protein content. a less evident but still relevant difference was also evidenced when testing the major allergen content, with up to % variation in der p and up to a -fold variation in der p concentration. this differences, likely related to the different production and extraction methods, could still be responsible of a different immunological response in children who underwent slit. method: we evaluated children who had completed their immunotherapy treatment. along with demographic data we were able to record skin prick test (spt) results and mrqlq at start and end of treatment. we only included patients who had completed pre and post treatment questionnaires in the study to allow a comparison. the scores were evaluated using a student t test. results: patients' starting age ranged from to years (mean years). of the children had completed pre and post treatment questionnaires. all had grass pollen allergy confirmed on spt at the start of treatment. patients ( %) had isolated grass pollen allergy on spt and ( %) had multiple allergies. mean start treatment score for all patients was on mrqlq. mean score at end of treatment was , indicating a % reduction in total mrqlq score (p value < . ). for those with multiple allergies the mean total mrqlq scores were at start of treatment and at end of treatment, indicating a % reduction (p value . ). for those with isolated grass pollen allergy scores were at start of treatment and at end of treatment indicating a % reduction (p value < . ). conclusion: for children with uncontrolled symptoms of allergic rhinoconjunctivitis, grass pollen immunotherapy is associated with statistically significant improvement in quality of life. this improvement is most beneficial for patients with isolated grass-pollen sensitivity on spt. those with multiple aeroallergen sensitivities on spt did show an improvement (not statistically significant) post-treatment. grass-pollen immunotherapy is an effective treatment for rhinoconjunctivitis to offer patients in a rural dgh setting. background: allergic asthma is a common clinical refractory disease, most patients with asthma are accompanied by varying degrees of allergy. in clinical practice, treatment of this disease using specific immunotherapy has proven effective. in the current study, we examined the effectiveness of specific immunotherapy in a total of patients admitted to our hospital from to . method: to investigate the clinical efficacy of allergic asthma-specific immunotherapy. patients were selected, of which were males, aged to years, females, aged between to years old, all patients were clinically diagnosed only as allergic asthma. the patients were randomly divided into two groups, including the observation group containing cases, the control group of cases. all patients were first treated with conventional basic treatment. the observation group was subsequently treated with specific immunotherapy. both groups were followed-up and the treatment efficiency were analyzed. results: after treatment, both two groups of patients showed improvement, in the observation group, the effective rate was %, while for the control group, the effective rate was %. observation group showed significantly better outcomes than the control group. conclusion: in allergic asthma treatment, adding specific immunotherapy on the basis of routine treatment is beneficial and could be widely used in clinic. case report: atopic dermatitis(ad)is the most common itchy dermatosis that affects millions of children and adults. during recent years, diagnosis and treatment based on component resolved diagnostics (crd)is recommended. we report a -year-old boy with severe atopic dermatitis. he had positive family history of atopy. the atopic dermatitis was developed since infancy. he was referred to our clinic when he was years old. he had generalized xerosis with ulcerative eczematous lesions on his neck, popliteal and antecubital areas. he had mild eosinophilia and his serum total ige level was iu/ml. daily bleach bath, moisturizing agents, topical steroids and systemic antibiotics in addition to antihistamine were prescribed. he had multiple food and aeroallergen sensitization in skin prick test (spt). he started to eliminate some foods according to the spt results. he was suffering from recurrent relapse even after strict food avoidance; so treatment with cyclosporine was initiated for him, with partial response. crd showed sensitization to alternaria alternata (alt a specific ige: . ku/l). allergen immunotherapy by alternaria alternata was started. after accomplishment of buildup phase, he had significant improvement and we were successful to taper and finally discontinue cyclosporine. now he is on maintenance phase of immunotherapy, his skin is in optimal condition only by hydration and moisturization. result: a -year-old thai girl is a known case of severe asthma since one year old. her asthma was uncontrolled asthma even treatment with high dose combination of inhaled corticosteroid and long acting beta agonist (ics/laba), montelukast and omalizumab. spirometry revealed the force expiratory volume in one second (fev ): % predicted, fev /forced vital capacity (fvc): % predicted and % improvement of fev after salbutamol ug inhalation. allergic sensitization showed specific ige to cat: . kua/l. slit with cat allergen started at the dose of au per month and increased to au per month (scit dose is au per month) for three-year-and-six-month course. after slit, her asthma symptom improved significantly. she can exercise without exacerbation and plays sport at school. her last episode of asthma exacerbation was . year ago. her fev (% predicted) was improved from % predicted to % and the fev bronchodilator response decreased from % to %. conclusion: an improvement of pulmonary function and asthmatic symptoms of the presenting case would support the efficacy of slit of cat allergen in a patient with severe asthma. ra developed during pollen scit in this case might be related with immunomodulation effect of immunotherapy. background: we report a case of -year-old woman with allergic rhinoconjunctivitis and mild persistent asthma due to sensitisation to seasonal pollens and molds with bad clinical evolution and not response to conventional drug therapy. we decided to start subcutaneous allergen specific immunotherapy with alternaria extract in our immunotherapy unit in accordance with the guidelines of the european academy of allergology and clinical immunology (eaaci) and we used a cluster regimen. the immunotherapy was not well tolerated: the patient had two grade systemic reactions with the first dose in two attempts. method: sensitisation was diagnosed through skin prick test with aeroallergens standard panel and serum specific ige by elisa. due to the bad tolerance to immunotherapy, molds molecular diagnosis by immunocap, study of the molecular weight to specific ige binding proteins by sds-page ige immunoblotting, and cross-reactivity study by means of immunoblotting-inhibition assay were performed. a. fumigatus extract was able to produce a total ige binding inhibition on the kda band of a. alternata extract when ige immunoblotting assay was performed. conclusion: respiratory allergic disease due to alternaria is difficult to control, the use of subcutaneous specific immunotherapy could be of significant benefit. most of the allergic patients to a. alternata are sensitized to alt a , major allergen from a. alternata. however, our patient is sensitized to a kda alternaria protein due to cross-reactivity with a. fumigatus allergens, this sensitization could explain the bad tolerance to the alternaria immunotherapy. background: the association between natural pollen exposure, clinical symptoms as well as allergen-specific immune responses has not been investigated at a molecular level. our aim was to monitor the effect of seasonal birch and grass pollen exposure on clinical symptoms as well as specific b cell and t cell responses to defined allergen molecules in sensitized subjects during two consecutive years. method: grass pollen sensitized (n = ) and birch pollen sensitized (n = ) subjects were included in this study and were followed for two consecutive years ( ) ( ) . subjects were taking part in a clinical trial for the recombinant grass pollen vaccine (bm ) but did not receive immunotherapy for the allergen they were sensitized to. before, during and after the respective seasons ige and igg levels as well as t cell responses to the major birch pollen allergen bet v and the major grass pollen allergens phl p , , and were measured. pollen counts were recorded throughout the year and patients kept a daily diary including symptom medication score (sms) and visual analogue scale (vas). results: we noted that ige levels specific for bet v and the grass pollen allergens increased most in the seasons in which patients experienced the highest peak symptoms according to vas and sms but not depending on cumulative pollen counts. increases in allergen-specific t cell responses were observed in the pollen seasons as compared to shortly before the pollen seasons in the grass pollenallergic patients also in association with vas and sms but not in the birch pollen allergic subjects. no relevant changes of allergen-specific igg levels were observed during the two years observation in grass and birch pollen allergic patients. we found an association of increases of allergen-specific ige increases shortly after the pollen season with clinical symptoms in the pollen season as reflected by vas and sms which was not necessarily reflected by cumulative pollen counts in the season. these results may be important for the analysis of allergen-specific immunotherapy trials. background: the morbidity and mortality of severe asthma is much higher than that of mild to moderate asthma. this study was performed to understand the clinical characteristics of severe asthma in korea. results: data from the questionnaire showed that bronchial asthma was diagnosed before pregnancy only in women ( . %). patients ( . %) were diagnosed with chronic bronchitis at the pregestation stage. asthma attacks were experienced repeatedly during a lifetime in . % of patients, . % of patients noted long periods of dry cough at night, among them . % had wheezing. the cold did not precede the wheezing breathing in . % of patients. difficulty in breathing on waking was noted in . % of patients, at night- . %. after examination, the diagnosis of asthma was confirmed in . % of the respondents ( people). symptoms of rhinitis are noted in % of women surveyed, % of rhinitis was allergic. before examination, the diagnosis of ar was only in . % of patients. the incidence of symptoms of asthma and ar in pregnant women is significantly higher than the reported cases of these diseases, which leads to untimely initiation of treatment. method: a total of nonsmoker asthmatic patients without concomitant pulmonary pathology are recruited to our study. all patients underwent spirometry tests, measurement of fraction of exhaled nitric oxide and sputum induction to asses sputum cell counts, demographic features and current medications were recorded. using the variables of age at onset, bmi, allergy status, fev %, fev /fvc, asthma severity and induced sputum cytology cluster analysis is performed. results: clusters are identified. cluster : (n = ) early onset atopic asthma, consists of mild asthmatics with a good asthma control and lower bmi. cluster : (n = ) severe atopic asthma, consists of lowest spirometry measurements with a least act scores. induced sputum cytology shows a neutrophilic character, while having also the highest percentage of eosinophils. cluster (n = ) late onset obese asthma, nonatopic asthmatics having high spirometry measurements, with a lower act scores. cluster (n = ) nonatopic mild asthma, consists of patients with the best respiratory functions and least inflammation in means of lowest total ige, feno, sputum cell counts. conclusion: identification of asthma phenotypes in different countries will improve our understanding on the heterogeneity of the disease among the different geographies. results: results and discussion. in the course of analysis, obesity was more common in children with bronchial asthma − % than in the comparison group-in . %. obesity of the st degree was diagnosed in patients of the main group, ii degree-in , and iii degree- and iv degree-in patients e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesitymore than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: sds bmi ≥ . ). conclusion: thus, the results obtained indicate a high prevalence of constitutional-exogenous obesity in children with bronchial asthma and precedes the formation of the underlying disease e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesity-more than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: method: postal questionnaires were distributed to an unselected group of asthma patients (n = ). healthy non-asthmatic volunteers were recruited amongst university and hospital co-workers (n = ). the presence of self-reported nhr, the type of triggers evoking nasal symptoms, asthma phenotype, medication use and environmental factors were evaluated. results: patients and controls completed the questionnaire (responder rate of % and % respectively). nhr was reported in % of asthma patients and % in non-asthmatic controls (p < . ), with changes in temperature being the most important inducer of nasal symptoms ( % of asthmatics), followed by strong odours ( %) and cigarette smoke ( %). interestingly, nhr was more prevalent in patients with severe ( %) compared to mild ( %) asthma symptoms (p = . ), and more prevalent in atopic ( %) compared to non-atopic ( %) asthmatics (p = . ). most asthma patients reported more than one trigger evoking nasal symptoms, with % of patients reporting or more triggers evoking nasal symptoms. results: the mean score of cbcl questionnaire in case group with . ± . was significantly higher than in comparison with a control group with . ± . (p = . ). the mean scores of the subscales of social isolation (the case group: . vs control: . , p = . ), anxiety-depression ( . vs , p = . ), intellectual problems ( . vs . , p = . ), and aggressive behaviors ( . vs . , p = . ) were significantly higher in children with asthma than in healthy children. the study showed a significant correlation between the mean duration of asthma and a general score of cbcl (p = . , cc= . ). moreover, there was also a significant correlation between asthma severity and cbcl scoring (p = / , cc= . ). conclusion: behavioral disorders in children with asthma are significantly more than healthy children. the duration of asthma and the severity of asthma, are related to and can predict behavioral disorders in children with asthma. background: assessment of asthma control is an integral part of the management of asthma. whilst asthma control test (act) is a commonly used questionnaire to assess symptom control, its utility in predicting long term risk of exacerbation has not been well studied. aim: to analyze the factors associated with uncontrolled asthma symptoms using act and its impact on predicting future exacerbation. method: severe asthma patients on at least step background: most of the asthma-scoring tools detect the asthma severity from patients' symptoms but there is no scoring tool using parameters to define risk of asthma exacerbation. thus, this study use factor analysis to evaluate the relationship of parameters in childhood asthma. method: the descriptive study using factor analysis in asthmatic children aged less than years old, who attended thammasat university, the center of excellence for allergy, asthma and pulmonary diseases, thailand. the participants or caregivers were inter- the factors which have the major impact on asthma control are changing bed sheets less than once per month and using dust mite-proof bed sheets. this study is supporting non-pharmacological strategies but further studies are needed to create a more efficient asthmatic symptom checker. were not different between the controlled and uncontrolled group. the act score in the controlled group was significantly higher than the uncontrolled group (p < . ). the study showed that cigarette smoke is one of the significant factors that can trigger asthma exacerbation (p < . ) and mosquito repellent coil smoke is also significantly associated with asthma exacerbation (p < . background: experimental studies have demonstrated that tumor necrosis factor family member (tnfsf /light) plays an important role in airway remodeling. there is little data available concerning in vivo regulation of tnfsf /light expression in humans. the aim of this study was to evaluate serum concentration of tnfsf / light in different subsets of asthmatic patients. the study was performed on nonsmoking asthmatic patients (a), including mild-moderate-severe asthmatics controlled on inhaled corticosteroids (aics) and asthmatics evaluated twice during asthma exacerbation (aex) and during subsequent remission (arem). in addition age and sex matched nonsmoking healthy controls were included (hc). serum tnfsf /light concentration was evaluated using elisa method. in asthmatic patients lung function tests, exhaled nitric oxide concentration (feno), serum total ige concentration (t-ige), allergen-specific ige concentration (s-ige) and peripheral blood eosinophilia were evaluated. ( + /- pg/ml) was significantly greater than that in hc ( + / - pg/ml; p < . ). among all asthmatic patients studied the greatest tnfsf /light serum concentration was demonstrated in aex ( + /- pg/ml), which was significantly greater than that in aics ( + /- pg/ml p < . ). during resolution of asthma exacerbation a significant decrease in serum tnfsf /light concentration ( + /- pg/ml; p < . ) was demonstrated. in arem the mean serum tnfsf /light concentration was comparable to that seen in aics (p = . ) but was still significantly greater than in hc (p < . ). no significant correlation could be demonstrated between serum tnfsf /light concentration and baseline lung function parameters, exhaled nitric oxide concentration, serum t-ige or s-ige concentration or peripheral blood eosinophilia. conclusion: enhanced production of tnfsf /light seen in asthmatic patients, which is further upregulated during asthma exacerbations may play an important role in asthma pathogenesis. method: two models of aspergillus fumigatus-induced allergic airway inflammation were used in the study: long terms ( weeks) and short terms ( weeks background: chalcone is identified as an inhibitor of the interaction between cxcr or cxcr and their ligand cxcl . therefore it is called a neutraligand. the chemokine cxcl , interacting with the cxc-receptor (cxcr ) can play a role in the progression and development of bronchial asthma. asthma is defined as a chronic disease characterized by episodes of obstructive events which affects about million people over the world. the aim of this study is to approach the mechanism of the anti-inflammatory effect of the cxcl neutraligand chalcone and also to assess its impact on the migration of dendritic cells in a murine model of allergic airway inflammation. method: chalcone is administered intranasally to balb/c ovalbumin (ova) asthma mice and control groups as well. our results indicate that the cxcl neutraligand chalcone can modify the inflammatory reaction in an airway allergic hypereosinophilia model. furthermore, found out that cxcl neutraligand chalcone prevents dc migration to the airways and airway jnc ganglia during allergic airway inflammation. the detection of the cxcr -cxcl pathway and its role in the pathophysiological actions of asthma offers a promising target for allergic diseases treatments. method: four groups of balb/c mice were defined: control and asthmatic, with and without treatment. asthmatic groups were sensi- overexpression of ptgdr in pulmonary cells associated to a generalized increase of cytokine expression. conclusion: in a mouse model we confirmed the involvement of ptgdr in allergic asthma by the increase of its expression levels after ovalbumin sensitization. we also identified a reduction of ptgdr levels in response to dexamethasone treatment. the in vitro model suggests that ptgdr induces an inflammatory response, increasing the cytokines levels. | immune imbalance between transcription factor t-bet/gata and allergic asthma results: t-bet mrna expression of peripheral blood lymphocytes in patients with allergic asthma was lower than that of the normal control group, and the expression level of gata- mrna was higher than that of the normal control group (p < . ). the th percentage of peripheral blood lymphocyte subsets was lower than that of the normal control group (p < . ), the percentage of th cells was significantly higher than that of the normal control group (p < . ), and the changes in t-bet/gata expression and th /th ratio was highly correlated. our objectives were to assess the changes of bmp and bmp serum levels in the response to allergen and methacholine challenge tests and the correlation between bmp and bmp serum levels and fev before and after allergen and methacholine challenge tests. method: study group consisted of patients with asthma and healthy volunteers. spirometry, skin prick tests, allergen and methacholine challenge tests were performed in compliance with eaaci, ers and ats guidelines. personalized clinic surveys including act ™ were performed. venous blood was collected before and after hour, and hours afterwards the provocation to edta-ke-filled test tubes. evaluation of bmp and bmp serum protein levels was performed using specific elisa immunoassay kits according to the manufacturer's protocol. results: the increase in bmp and bmp serum level hours after provocation test correlates significantly with the concentration methacholine during provocation time (p < . ). bmp serum level before the provocation, hour and hours after provocation, correlates negatively with fev change (p < . ). the median bmp level hours after provocation was significantly lower in patients with negative methacholine challenge test compared to the control group (p = . ). the median bmp level hours after provocation was higher in patients with positive allergen provocation test than in patients with negative test results (p = . ). the bmp serum level hours after positive methacholine test is lower and correlates inversely with fev change in every time point, which could indicate that serum level of bmp is a predictive factor of fev change. the higher bmp serum level, the lower fev change was observed. this could suggest the protective influence of bmp in patients with obstructive pulmonary disease, i.e. asthma. the higher bmp serum level hours after positive allergen provocation test result shows that the bmp could be an indicator of the response to a specific trigger. background: inflammation and coagulation are closely linked events. thrombin is the key enzyme in coagulation system. besides its well-known functions in hemostasis, thrombin plays a role in inflammation. the aim of our study was to evaluate thrombin generation in children with mild asthma and demonstrate associations between thrombin levels and control of asthma. method: forty-two children with mild asthma and forty-nine healthy children included in the study. asthmatic children had no asthma exacerbation during the last months. patients (n = ) who had mild persistent asthma, were using either inhaled steroid or montelukast. all patients performed spirometry. thrombin levels were measured by thrombin generation test. thrombin peak levels, endogenous thrombin potential, thrombin lag time, time to thrombin peak and thrombin tail time were recorded. results: thrombin lag time was significantly longer in children with asthma ( . ± . ) compared to those in control group ( . ± . ) (p < . ). children with asthma also had longer thrombin tail time compared to control group ( . ± . vs . ± . , p = . ). thrombin peak was inversely correlated with fef - (- . , p < . ). thrombin lag time was inversely correlated with fef - (- . , p < . ). thrombin generation parameters did not show difference according to asthma control treatment, asthma control scores and having atopy. conclusion: coagulation/anticoagulation balance is disturbed in mild asthma but this disturbance may not be as strong as to increase thrombin levels. factors increasing inflammation may cause an increase in lag time, and increase in inflammation and excessive fibrin deposition may contribute to airway narrowing. background: cytokines represent key mediators in the onset and persistence of inflammatory process, in both asthma and copd. il- , which belongs to il- family, it might act in a similar way with il- at the beginning of the inflammatory process. its role in atopic skin diseases has already been demonstrated, but there are conflicting results related to its role in respiratory allergic diseases. the aim of the study was the evaluation of il- plasmatic level in patients with asthma and copd and the its correlation with clinical and lung function parameters. method: fifty consecutive patients with bronchoobstructive diseases were included in the study. thirty-two patients presented asthma and patients had copd. the evaluation included: number of exacerbation in the last year, disease's severity, spirometry. plasmatic levels of il- and il- were determined in all patients. results: the mean age was higher in patients with copd dermatophagoides pteronyssinus [house duste mite (hdm), ug/ mouse] were administered oro-tracheally on days , , , , , , and . at was performed in a treadmill during weeks in moderate intensity, from day until day . results: at inhibited hdm-induced total cells (p < . ), eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in bronchoalveolar lavage (bal), and eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in peribronchial space. at also reduced bal levels of il- (p < . ), il- (p < . ), il- (p < . ), cxcl (p < . ), il- (p < . ), il- (p < . ), il- (p < . ), while increased il- (p < . ). airway collagen fibers (p < . ), elastic fibers p < . ) and mucin (p < . ) were also reduced by at. at also inhibited hdm-induced airway hyperresponsiveness (ahr) to methacholine . mg/ml (p < . ), . mg/ml (p < . ), mg/ml (p < . ) and mg/ml (p < . ). mechanistically, at reduced the expression of stat (p < . ), stat (p < . ), stat (p < . ) and jak (p < . ), similarly by peribronchial leukocytes and by airway epithelial cells. socs expression (p < . ) was upregulated in leukocytes and in airway epithelial cells, socs (p < . ) was upregulated in leukocytes and socs down-regulated in leukocytes (p < . ) and in airway epithelial cells (p < . ). conclusion: at reduces asthma phenotype which is followed by positive modulation of socs-jak-stat signaling in peribronchial leukocytes and in airway epithelial cells. rodolfo a ; paciência i ; rama t ; leão l ; silva d ; rufo j ; mendes f ; padrão p ; oliveira fernandes e ; moreira p ; delgado l ; moreira a porto, portugal; potentially irritating chemicals that may have a cutaneous drying side effect. this study aimed to evaluate if skin barrier function, as measured by transepidermal water loss (tewl), is affected by a training session in swimmers compared with football players. environment impact on the human respiratory health (clinicaltrials.gov identifier: nct ) and football players were invited to participate. due to the lack of prior information no sample size calculation was possible and all athletes that provided informed consent were included in the analysis (n = , females, aged to years). tewl was measured using the tewameter ® tm before, immediately after, and minutes after a hours training session. the probe was held on the dorsum of hand, the volar forearm and the antecubital flexure for s. the average of two consecutive measurements was recorded. non-parametric statistic was used were appropriate. ethical approval was obtained from the university clinical research ethics committee and informed consent provided. results: mann-whitney u test showed significantly higher baseline median tewl level on football players hand's dorsum compared with swimmers, median (p -p ) respectively . ( . to . ) and . ( . to . ); p = . . friedman test revealed a significant effect of swimming on tewl on the hand's dorsum, volar forearm and antecubital flexure (p < . ) while football training affected only the hand's dorsum (p = . ). differences in changes after swimming and football training were significant only for tewl in volar forearm (p = . ). in conclusion, our exploratory findings do not provide support for a specific deleterious effect of swimming, compared with football training, on the training induced changes in tewl. background: exercise-induced bronchoconstriction (eib) is defined as transient, reversible airway narrowing occurring during or after exercise, is common among elite athletes and associated with epithelial damage. however, little is known about the existence of eib in young athletes. the goal of this study is to investigate the presence and to evaluate potential (bio)markers of eib in young high-school elite athletes in different sport disciplines versus age-matched control subjects. method: high-school selected elite athletes ( - years) from different sport disciplines: basketball (n = ), football (n = ) and swimming (n = ) performing at least hours of sport per week (median= h) and control subjects (performing less than hours of sport per week) were recruited. the eucapnic voluntary hyperventilation (evh) test was performed according to ats guidelines and adapted for this age group. lung function was measured before, immediately after and , , minutes after the evh test. the test was considered positive if a maximal fall in fev of % was measured on at least one time point and exhaustion was excluded. a blood sample was obtained at baseline. sputum induction and skin prick test for the most common allergens were performed after the evh test. results: fifteen swimmers had a positive evh test ( . %), which is higher than in basketball players ( . %), football players ( . %) and controls ( . %). . % of the swimmers were atopic which is also higher than in basketball players ( . %), football players ( . %) and controls ( . %). serum clara cell secretory protein (cc ) levels are significantly higher in swimmers ( . ± . ng/ml) compared to indoor athletes ( . ± . ng/ml) and controls ( . ± . ng/ml). a significant positive correlation was found between the magnitude of maximal fall in conclusion: young elite swimmers have a higher prevalence of eib compared to basketball and football players. atopy and/or chlorine is a risk factor for the development of eib in young elite athletes. cc levels and sputum uric acid levels are increased in athletes compared to control subjects suggesting the presence of epithelial damage already at young age. this is especially observed in young elite swimmers, pointing to a probable role of exposure to chlorineby-products in combination with intensive exercise. results: data from subjects ( females, . %) were analyzed. frast was positive in ( . %) patients ( females, median age of years (iqr - )). in this group, ( . %) had a previous diagnosis of asthma, ( . %) practiced federated sports, ( . %) had smoke cigarette exposition and ( . %) had a bmi > kg/m . . % of patients showed a Δfev % > % in the first minutes after finishing the challenge. median fev reduction was . % ) and ml . frast was more frequently positive in patients with previous diagnosis of asthma (p < . ). there were no differences related to conclusion: frast is an important tool to diagnose exerciseinduced bronchospasm without asthma (eib wa ), as well as to diagnose asthma. in our study, frast was fundamental to access eib wa in % of patients with rsee, and confirmed asthma diagnosis in % of cases with previous asthma diagnosis and negative sbt. there was no difference in the prevalence of atopy between patients with positive and negative frast. patients older than years-old presented higher Δfev % compared to younger patients (p = . ). higher levels of feno were observed in patients with positive frast (p = . , p = . ), both in patients with and without previous diagnosis of asthma. a positive correlation was observed between feno levels and Δfev % in the whole sample (r = , p = . ); when these data were analyzed considering a previous diagnosis of asthma, only patients with this condition showed a positive correlation of feno and Δfev % (r = . , p = . ). conclusion: our results evidenced that higher feno was associated with atopy and a positive frast, both in patients with and without previous diagnosis of asthma. higher feno seems to correlate with Δfev % in patients with previous diagnosis of asthma. background: specific immunotherapy is the casual treatment for allergic rhinitis. a year old professional footballer suffer from severe allergic rhinitis since two years. during may, june and july his level of playing, concentration and durability decreased about %. patient was complaining of runny nose, nasal blockage, each eyes, sneezing, tearing. method: we did skin prick tests -which showed greatest allergy to grass pollen. we confirmed the allergy by specific ige and nasal provocation tests. spirometry was done-fev %. the patient was qualified to undergo specific immunotherapy. however, because of his profession, it was hard to find a day without trainings to get the vaccine. after long discussion, patient decided to start specific immunotherapy-scit. results: the patient start the immunotherapy. he was attuning very irregularly, because of matches, injuries, trips, trainings, and lack of time. several times we had to call the patient to remind him about the immunotherapy. after one year of scit the patient felt big improvement. during grass pollen season he suffered from mild allergic symptoms, and just for few days. after next year of immunotherapy, the patient had no symptoms of allergic rhinitis during the grass pollen season. however, it was the reason for him, to stop sit, before rd year of immunotherapy. conclusion: such a treatment-specific immunotherapy-is a burdensome method for both, for professional athletes and doctors. such a patients need to be on special observation, and cooperation with trainers must be obtained, if we want to see results. to improve compliance we have to keep in touch with patients, to remind them about next visit. gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: late allergic response (lar) is a good asthma model. it has been shown, in individual challenge tests that mite allergen induces more frequently late allergic responses (lar) than cat allergen. the aim of this study is to compare the frequency of lar in asthmatic subjects allergic to mite with asthmatic subjects allergic to cat. method: asthmatic subjects allergic to mite were compared to subjects allergic to cat (gina or ). the subjects had prick tests≥ mm compared to the negative controls and specific ige ≥ . ku/l. the dose selected for the mite and cat allergen was the airborne allergen concentration inducing the most frequently early asthmatic response (ear) (a % drop in fev ) and lar (a % drop in fev ). results: the frequency of lar with mite allergens was . % and % with cat allergens (p = . ). the frequency of ear for mites was . %; of . % for ear or lar, and % for ear and lar. in contrast, with cat allergens, % of patients had an ear, % had ear or lar and % had an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. the frequency of lar in asthmatic subjects allergic to dust mite exposed in alyatec ® eec was higher than in asthmatics sensitized to cats. our results confirmed previous results with individual bronchial challenge. therefore, it appears that the mite model is more interesting in the study of asthma. exposure chamber in strasbourg (alyatec ® ) in asthmatic patients allergic to cat allergens gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: as recommended by the task force on environmental exposure chamber (eec), allergenic and non-allergenic exposure must be better controlled in eec. it is the aim of alyatec's eec. the aim of the study is to validate alyatec's eec by determining the concentration of fel d inducing % of early asthmatic response (ear) and/or late phase asthmatic response (lar) in subjects sensitized to cat. method: it was a randomized, double blind, cross-over study including group a: asthmatic subjects allergic to cat and group b: asthmatic subjects allergic to another allergen. all subjects were first exposed to placebo. group a was exposed to fel d concentrations. the number and size of particles were recorded online during the exposure. group b was exposed to the concentration of fel d which fulfills the objective of the study. the mean age of subjects was years (± ). for the concentrations of fel d , we obtained more than % ear and/or lar. the mean time necessary to obtain an ear was: . ± minutes and . ± minutes for the lar. the mean fall in fev during ear and lar was − . % and − . % respectively. we didn't observe any severe reaction. no subjects in group b experienced any symptoms during exposure. we have validated alyatec's eec in asthmatic subjects allergic to cat allergens. we also demonstrated its specificity. background: the best test and strategy for diagnosing asthma especially in those patients with negative bronchodilator reversibility tests still remains unclear. in this study we aimed to investigate the diagnostic yield of peak expiratory flow (pef) variability for the patients with symptoms suggesting asthma but negative bronchodilator reversibility tests. method: subjects referred to our outpatient clinic with suspicion of asthma were enrolled in this study. demographics and referral symptoms were recorded, asthma control test (act) scores and health related quality-of-life scores (aqlq, sf ) were calculated. monitoring of pef variability during -weeks and bronchial challenge test with methacholine (bpt) were analyzed. asthma was diagnosed by having pef variability ≥ % and/or positive bpt. results: thirty out of enrolled patients were diagnosed as having asthma. when we compare asthmatic patients with nonspecific respiratory symptomatic subjects there were statistically-significant differences regarding to wheezing (p = . ), activity limitation (p = . ), total symptom score (p = . ) and basal fef (p = . ) in the favor of asthma cases. multiple logistic regression analysis revealed that lower basal fef - was an independent predictive factor of asthma diagnosis (p = . ). when the bpt positivity was assessed as gold standard for the diagnosis of asthma, the sensitivity and specificity of pef variability for different cut-offvalues (≥ %, > % and >% ) were . - . %, . - . % ve - . %, respectively. conclusion: fef - is an important diagnostic parameter for asthma. although current guidelines recommend pef variability of % for the diagnosis of asthma in general, this cut off level may not be appropriate for this defined group of subjects. our results suggest to use a cutoff level of > % while excluding asthma and ≥ % while confirming the diagnosis of asthma for patients with asthma suspicion but without shown reversibility. de barayazarra s background: in recent years obesity has been considered as a factor that contributes to the development of asthma, increases exacerbations and leads to poor control of it due to resistance to drugs to control this pathology. it is known that obesity produces chronic systemic inflammation; one of the markers that are affected is the levels of c-reactive protein (crp), which are increased. objective: evaluate, lung function, the use of medications to control asthma and systemic inflammation, after bariatric surgery. results: obese asthmatic patients with surgery, non-asthmatic obese patients with surgery, obese asthmatic patients without surgery. a significant difference was found between the severity of obesity and forced expiratory volume in patients with asthma and without asthma of second (fev ) before surgery with an average of . % at the beginning of the study and . % at months (p: . ). in the non-operated group, fev at the beginning was % and . % at months (p: . ). the crp, before surgery in all operated patients had crp: , at months after surgery they became negative, crp: (p: . ). in obese asthmatics with surgery at the beginning, % used medication, and at months only % in obese asthmatic patients without surgery, . % used the medication at the beginning, at months . % (p: . ). method: patients with asthma aged to and a predetermined positive methacholine pc were recruited and underwent a single challenge to cause bronchoconstriction of~ % comparing the outcome of the device with spirometry. the subjects were monitored at baseline, after a~ % fall in fev and after bronchodilation back to baseline. the study protocol allowed for an interim analysis of the initial subjects at which point the sensor was calibrated to optimise sensitivity. a further subjects were studied using the optimised sensor. results: all subjects successfully completed the study. the device was found to be straightforward to use by both operator and subject with no concerns regarding safety. the initial sensitivity of the device was found to be suboptimal in the first eight patients to reliably detect changes in lung function. after adjustment to the device the tests results of the remaining subjects were analysed. . % of subjects were female. the mean age of all subjects was . years. an average baseline fev value of . (s.d. . ) was observed. changes in lung function were detected in % of subjects. a baseline value, drop in lung function and reversal were measured in % of subjects. the mean percentage drop observed in % of subjects using the investigational device was . %. the mean percentage increase observed using the investigational from drop to reversal was . %. the device (using ebc ) was able to detect changes in lung function tracked using fev . this provided proof of concept that the device could potentially be used to monitor lung function more effectively in the home than peak flow and supports further development to optimise the device and demonstrate functionality in clinical asthma. method: ninety four patients under years of age seen in the allergy department due to common asthma symptoms (wheezing, dyspnea, cough, chest tightness) with normal spirometry and negative bronchodilator response, underwent mct during and . the variables studied were: sex, age, body mass index (bmi), asthma symptoms, exercise symptoms, rhinoconjunctivitis, family history of atopy, sensitization to respiratory allergens, spirometric data and fractional exhaled nitric oxide (feno). results: of the total sample, half were women ( . %) and the other half were males ( . %). mean age was . years. bmi was normal in most of them (with an average of . kg/m ). the most common symptom among the patients with positive mct was cough ( . %), followed by dyspnea ( . %), wheezing ( %) and chest tightness ( . %). . % had symptoms of asthma with exercise and . % had rhinoconjunctivitis. . % had a family history of atopy. . % were sensitized to aeroallergens, mainly to pollens (grass and olive tree). . % of the mct′s were positives, with a mean pc of . mg/ml. . % had a moderate-severe result (pc ≤ mg/ml), . % mild (pc - mg/ml) and . % bordering (pc - mg/ml). the mean feno was . ppb. conclusion: in our series, the completion of a test of hrb was decisive to confirm the diagnosis of asthma in most patients of a pediatric population with symptoms of suspicion (cough, mainly), normal spirometry and negative bronchodilator response (with normal feno in most of them). therefore, we consider it important to include in the routine clinical practice hrb tests in the pediatric population with suggestive symptoms of asthma, despite normal functional and/or inflammation tests. | cut-points of the ′control of allergic rhinitis and asthma test′ (carat) asthma subscale based on an international survey patients with asthma) in kashan, iran. the data collection tool was a questionnaire with questions, designed to gather information on demographic asthma patients, the current use of mobile functionalities, and the willingness to use these functionalities to receive selfmanagement services, which was distributed among patients with informed consent. the collected data were analyzed by descriptive statistics method using spss software. results: the most use of patients from mobile phone functionalities was to receive information about asthma symptoms and allergens and irritants via mobile internet ( . %). patients were most likely to use social networking ( . %) in comparison with other mobile phone functionalities, to receive reminders about appointments and medication. the respondents were most likely to use social networks through mobile phone functionalities, to receive asthma self-management information ( . %), to communicate with other patients ( . %), to receive reminders about medication use, and to perform a peak flow meter test ( . %) and to get an alert when the asthma is not controlled ( . %). the findings show that asthma patients are currently using the internet search for educational information and they have a tendency to use social networks to receive asthma-related services. patients believe that mobile health is an appropriate intervention for providing educational information, reminders, and alerts and communication with other patients. | concordance between the determination of asthma control through the gina guidelines and the act questionnaire-results of the efimera study background: the exacerbation of asthma, progressive worsening of acute episodes, is one of the most frequent attending reasons at hospital emergency unit . several factors causing poor control of asthma, such as inadequate therapy, have been described. in the present study, estimations of asthma severity by researchers were assessed by comparing the concordance between the assessment of asthma control through the gina guidelines and the act questionnaire method: cross-sectional observational study on the evaluation of factors related to treatment that influence the poor control of asthma was assessed through the gina guidelines and the act questionnaire. patients referred to a pneumologist or allergist by a primary care for the first time were evaluated. two variables were collected for the assessment of asthma control: one derived from the gina guidelines and another derived from the act questionnaire. regarding the gina assessment, researchers' evaluations guidelines were compared with the scoring calculated from the variables registered in the crd. both measures were compared in terms of sensitivity-specificity to determine their ability to classify patients. the patients included in this study (n = ) had a mean age of ± years, with a % of women and an average disease evolution of . ± . . the control of asthma according to "gina results: pts were reasonably representative of those in sls asthma (at sls baseline: . % male; mean age . yrs; mean asthma control test [act] score . ) . the most frequently reported symptoms during sls asthma for these pts were cough/ breathlessness, followed by wheeze, phlegm and chest tightness; breathlessness and wheeze were perceived as the biggest impactors on pts' lives. the aspects of daily life most impacted by asthma were reported as walking at a hurried pace, strenuous physical activity, and asthma-related frustration. since sls began, % of pts in this subset reported improvements in overall asthma ( % no change; % worsening). perceived changes in symptoms are shown (table) . most pts ( . %) reported avoiding places with dust, smoke or fumes. most pts ( . %) perceived no change in overall qol; . % reported improvement. being an act responder during sls (total act score ≥ or ≥ change at end of sls) was associated with reported improvements in overall asthma symptoms, lower impact of asthma on qol, and higher perceived confidence/control in managing asthma. more pts ( . %) in the ff/vi arm reported an overall improvement in asthma vs uc ( . %); the most evident differences between treatment groups were for breathlessness, wheezing and chest tightness. improvements in confidence/control in managing asthma were reported by . %/ . % of pts (ff/vi) vs . %/ . % (uc). conclusion: breathlessness and wheezing were key symptoms in sls asthma and had the biggest impact on pts' daily lives. this patient-centred study enriches the findings of sls asthma. funding: gsk (study ) | asthma and copd treatment adherence and breach using tai questionnaire suarez-vergara m; fuentes-soltero f; garcia-nunez i; ignacio-garcia j background: adherence is defined as medication (inhalator) intake following the dosage and schedule prescribed. adherence mistakes are a public healthy problem according to the big morbi-mortality presented in patients with an incorrect intake. our aim is to evaluate the adherence level and fulfillment in patients with asthma or copd using tai (inhalators adherence test) questionnaire. method: patients with a diagnosis of persistent asthma or copd were selected. we used to size adherence and breach type the tai questionnaire. adherence is defined as good when patient′s test reaches points, medium ( - points) and bad (less than points). breach type is defined as erratic when points between questions to are less than , deliberate when questions to are less than , and unconscious when questions and are less than points. a correct fulfillment is defined when questionnaire reaches points plus points of conscious fulfillment. results: fifty-five patients more than years old (mean age . years and . % males) were selected. a . % of them were asthmatics, . % copd and . % a mix phenotype. a . % presented a correct fulfillment with conscious fulfillment, and the other . % presented good, medium or bad adherence with a breach type. according to adherence level, a medium adherence was defined in patients ( . %), with an erratic mistake in patients ( %). bad adherence was seen in patients ( . %) , with the three breach types in patients ( %). good adherence with unconscious breach type was defined in patients ( . %). conclusion: tai questionnaire confirms a good adherence and fulfillment in less than % patients. an erratic mistake is the most frequent breach type defined in our patients. educational protocols should be applied to improve adherence and fulfillment. | what is adhesion to treatment of asthmatic patients like in argentina according to the tai questionnaire? background: asthma is a chronic inflammatory disease of the airways, which requires an adequate treatment and control. the adhesion of a patient to an asthma treatment is a critical factor in order to achieve and maintain control. this adherence arises from a consensual agreement of the doctor-patient relationship; it is a complex multifactorial variable in which the variability in human behaviour in relation to its environment influences. background: the association between ambient pollen and asthma has been studied intensively with inconsistent results, attributed to differences in study population, geographic factors (geoclimatic features), data sources, measurement of pollen (different types of traps), and different outcome occurrence (hospitalizations or emergency department visits). we investigated the associations between daily sales of short-acting β -agonists (saba) and outdoor pollen concentrations in the central france area. the relationship between daily changes in pollen concentrations and daily saba sales obtained from the social security database was analysed with generalized additive models, taking into account confounding factors such as air pollution, weather conditions, and day of the week. results: the daily saba sales (mean, sd) rose from . ( . ) conclusion: this study indicates that outdoor pollens contribute to asthma morbidity in the general population. it confirms the highly allergenic role of fraxinus, betula and quercus pollens, but also shows a relatively unknown association between treated asthma and carpinus and platanus pollens, despite their counts being less than % of overall pollen concentration. results: of asthma patients (mean age . years, female . %), regular ocs use was identified for patients ( . %), periodic ocs use for patients ( . %), and no ocs use for patients ( . %) -year post-index. regular ocs users had a greater mean age, were more often male, and had greater eosinophil counts, lower lung function, and greater prevalence of comorbidities than did the periodic and no ocs users (p < . ). total yearly cost was greatest for the regular ocs users (€ ), followed by periodic ocs users (€ ) and no ocs users (€ ) (p < . ). among regular ocs users, hospital admissions were the main cost driver ( . % of total cost), while gp consultations were driving the total cost in periodic and no ocs users ( . % and . % of total cost, respectively). conclusion: in this sample of patients with asthma in sweden, the total yearly cost of health care resource utilization for a regular ocs user is twice as high as for a patient with no ocs use, demonstrating substantial economic and clinical burden in asthma patients on regular oral steroid treatment. method: children with physician-diagnosed asthma who attended to an outpatient pediatric allergy and asthma center were enrolled in the study along with control subjects. asthma severity and control status of the patients were evaluated according to recent gina guidelines. laboratory investigations including skin prick tests, complete blood counts with differential, total ige levels, serum periostin levels and pulmonary function tests were performed. results: a total of children ( with asthma and age and sex-matched control subjects) with a median age of . years (range . - . ) were enrolled. asthma severity was mild in ( . %), moderate in ( . %) and severe in ( . %) children. children with asthma had significantly higher periostin levels than controls ( . ± . vs . ± . ng/ml; p < . ). the mean serum periostin levels of children with severe asthma ( . ± . ) were significantly higher than in children with moderate asthma ( . ± . ) and mild asthma ( . ± . ) (p < . ). serum periostin levels were found to be significantly correlated with asthma severity (spearman's rho [r]=. , p < . ). analysis using roc curves identified the role of periostin levels in determining children with severe asthma (auc: . , % ci: . - . , p < . ]. conclusion: serum levels of periostin, a novel asthma biomarker, were higher in asthmatic children, and were associated with asthma severity. adam i ; selevestru r ; rogut v ; sciuca s background: nowadays, data from several epidemiological studies confirm the important role of fungi in respiratory disease in the indoor as well as in the outdoor environment. in general, exposure to fungi occurs via inhalation, skin contact, or ingestion. alternaria alternata is one of the most common fungi associated with presence asthma and persistence and severity of asthma. although exposure to a. alternata is also may represent a risk factor for development of asthma. in ukraine has been an increase in the number of the mold sensitized children for the last few years. at the same time we can see increasing frequency ba at the children of pre-school age. method: thirty five children aged - years with allergic rhinitis and high level of asthma predictive index (api) sensitized to a. alternata were included in a -year cohort study of the efficacy and safety of slit (diater laboratories, spain) using standardized sublingual extracts containing molds (alternaria alternata). treatment efficacy was analyzed using the score of symptoms such as difficulty in nasal breathing, rhinorrhea, sneezing, itching of the nasal mucosa (upper palate) and discharge from the nose and recurring wheezing. we also have analyzed the level api during the period investigation. symptoms were measured before starting treatment, and at , and months after starting immunotherapy. results: slit significantly reduced both symptoms and medication score: nasal symptoms ( % vs. control group) and the use of rescue medications ( % vs. control group), and improved fev (in children aged≥ years). in the slit group, api decreased by % for the first year, by % for the second year. no patient had a systemic reaction during therapy. our results have shown that slit is an effective treatment in pediatric patients suffering from allergic rhinitis and high api with significantly improved clinical outcomes (less symptoms and less medication intake) in comparison with children treated with symptomatic drugs only. in this study, large and statistically significant differences in symptom and medication scores were demonstrated in patients receiving slit compared to control group. sublingual immunotherapy is effective for allergic rhinitis in children especially early age and is generally advantageous because of the convenient administration and safety profile and ensure prevention of developed ba. bednarek a background: the classification of asthma based on the severity of its clinical course has been recommended by gina since . this division is useful for the patient's initial assessment when asthma is being diagnosed and essential decisions concerning an appropriate therapy are made. the objective of the work is to evaluate the influence of a clinical form of asthma on vaccine immunity in preschoolers following three years after the programme of mandatory vaccination has been realised. the study encompassed preschool children (mean age of . ± . years old) with asthma being newly diagnosed, including patients with mild asthma and ones with moderate asthma, whose vaccine immunity (igg specific antibody titer) was assessed after the mandatory early childhood vaccines had been administered. monovalent vaccines (hbv+ipv+hib) along with a three-component combined vaccine (dtwp) were given to children while a six-component vaccine (dtap+ipv+hib+hbv) was given to the remaining children. the vaccine doses were consistent with the polish immunisation programme and manufacturers' recommendations. the elisa immunoenzymatic method was applied to assess titer of specific antibodies to diphtheria, tetanus, pertussis, poliomyelitis and h. influenza type b. the level of hbv antibodies was measured chemiluminescently. the immunity class for particular vaccinations was assessed according to the test manufacturers' instructions. results: children suffering from mild asthma had considerably more frequently vaccinations on time (p < . ) and the type of vaccines (monovalent, highly-combined) administered to them did not have a significant influence on a clinical form of asthma in the children examined (p > . ). apart from the vaccines against hepatitis b and rubella where considerably more frequently a high antibody titer occurred in children with mild asthma, the titers of antibodies to other vaccines, namely diphtheria, tetanus, pertussis, hib and mumps, were not associated with a clinical form of asthma. the protective antibody titers in the children with asthma were found in % after vaccinating them against poliomyelitis (≥ u/ ml) and measles (≥ ml u/ml). significantly higher current weight was solely found in the children with mild asthma (m = . , sd= . ; p < . ). conclusion: there are some clinical and cultural differences among the four southern chinese cities within the canton province. this study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and qol for healthcare interventions. having a smoker in the family is independently associated with poor asthma control and qol. were classified into two groups (levocetirizine group (l) and montelukast group (m)) and we treated each group for another week. to evaluate the therapeutic effectiveness, we used symptom score (ss) and ebc leukotriene e (lte ). ebc samples were collected with rtube. each parameter was checked at , , week therapeutic period. results: most ar patient showed clinically improvement with and week fluticasone therapy ( wk ss= . , wk ss= . , wk ss= . p < . in l group; wk ss= . , wk ss= . , wk ss= . p < . in m group). lte levels of ar were higher than control ( wk vs. pg/ml), and were reduced after week fluti- mic were: md allergic rhinitis, wheezing apart from colds, eosinophilia ≥ %. outcome was defined as md asthma and at least episode of asthma during the previous year or more than episodes of wheezing during the months regardless of asthma diagnosis. results: from a total of of parents approached, ( %) agreed to participate in a phone interview. ( %) children were diagnosed with asthma. the age at the time of admission (mean, abstracts | (sd)) was . ( . ), at the time of phone survey . ( . ) months, respectively. positive loose api at - years of age had sensitivity of . %, specificity %, positive predictive value (ppv) . %, negative predictive value (npv) . %. positive stringent api at - years of age had sensitivity of %, specificity %, ppv . %, npv %. background: asthma is the most common chronic airway disease in childhood, with a high unmet need for new treatments due to insufficient symptom control in a relevant percentage of patients. ethics and resource factors limit the feasibility of large, long pediatric trials required to assess outcomes such as exacerbations and symptoms. for diseases like asthma, where the disease process is largely similar in children and adults, with the same expected therapy outcome, the international council for harmonisation advise extrapolating adult data to those of a younger age, reducing unnecessary pediatric trials. here we assess the partial extrapolation used in the clinical development of tiotropium. phase trials in adults (aged - ), adolescents (aged - ) and children (aged - ) with symptomatic severe (primotina-/pensie-tina-/vivatina-asthma) or moderate asthma (mezzotina-/rubatina-/ canotina-asthma), respectively. trials lasted - weeks, all with tiotropium respimat μg add-on vs placebo as two puffs once daily. results: in adult trials, lung function, symptoms and exacerbation endpoints were evaluated in a confirmatory manner: tiotropium significantly improves lung function and asthma control, and reduces risk of exacerbation, vs placebo ( conclusion: based on similarities in disease profile and magnitude of treatment responses between age groups, it is reasonable to expect tiotropium add-on to produce clinically meaningful improvements in exacerbation and symptom endpoints in children and adolescents, as in adults. the robust tiotropium clinical program supports using a partial extrapolation to avoid overly long and large trials in pediatrics. | clinical state of treatment and examination during last years before remission about asthmatic children in long-term remission cases method: remission cases (no symptom and no therapy) for years of asthmatic children were studied. clinical background and treatment (drugs) was studied during last years before remission annually. acetylcholine inhalation test by standard method was performed, and respiratory threshold of acetylcholine (rt-ach) was obtained. fev %, and serum ige also examined. these data were compared before remission with years after remission. results: mean age of cases at year before remission was . years old. male to female ratio was . . severity of asthma was all mild type, and number of attack was to times in a year. there was no admitted case during this study. the long-term therapeutic drugs were leukotriene receptor antagonist (anti lt) in cases, and/or inhaled corticosteroids (ics) in cases, but cases had no treatment for the control. geometric mean of rt-ach (after then: years before and after remission) was μg/ml and μg/ml. the mean fev % was % and %. geometric mean of serum ige level was iu/l and iu/l. complicated cases of atopic dermatitis decreased after remission, but the incidence of allergic rhinitis increased slightly. conclusion: characteristics of asthmatic children during last years before remission were mild type, had several times of attack in a year, and the treatment was mainly anti lt and/or ics. fev % was within normal range, and serum ige level was not changed after remission. rt-ach had the tendency to improve during years before and after remission. these data is supposed that airway hyperresponsiveness is one of the indicators for quitting treatment. | clinical aspects of polyvalent mechanic bacterial lysate (pmbl) treatment in children with uncontrolled asthma our results indicate that long-term treatment with omalizumab in children can help to achieve better asthma control and reduce the amount doses of basic therapy. method: allergic rhinitis (ar) and allergic rhinoconjunctivitis (arc) diagnosed-patients' demographic information, accompanying-asthma, the allergic history of the family, the onset of symptoms, types of aeroallergens sensitivity were noted from patients' files in our hospital's pediatric allergy clinic. results: in this study, patients were evaluated. the mean age of the patients were . ± . years and % (n = ) were male. ( %) patients had ar and ( %) patients had arc. background: allergic rhinitis (ar) is a disease characterized by symptoms of nasal discharge/congestion, sneezing, and pruritus, and is caused by an ige-mediated immunological response to inhaled allergens. we aimed to evaluate pollen season and out of pollen season pulmonary function tests (sft) of patients with ar in our study. method: in our study, the demographic characteristics and aeroallergens were recorded from patients' files with ar diagnosed. in addition, pollen season and out of pollen season sfts were evaluated and compared. conclusion: in patients with ar, fev and fvc values are seen to be lower during the season even though there is no lower respiratory symptom. therefore, sfts of patients with ar should be evaluated during pollen season. results: among the clinical manifestations, the most common combination of allergic rhinitis (ar) and conjunctivitis (ac) is noted in . % of adults and . % of children, but in children aged - , the combination of ar and ac is observed only in . %, among - years old- . %, while in the remaining age groups it is encountered in more than %. higher percentage of isolated ar is also observed among young children- . %, and those of the results: allergic rhinitis was a main symptom in . % of children with pollen-food sensitization. in all of them concomitant allergic disorders were noticed: bronchial asthma ( . %), atopic dermatitis ( . %). only in . % temporal association between ingestion of pollen-related foods and nasal symptoms was observed (mainly apple and peanuts); occurring also outside the pollen period. the simultaneously sensitization to animal origin food allergens was stated in . % of children with sar, but only in two of them milk and white egg proteins were an additional exacerbation factor of nasal symptoms. in . % anaphylactic reactions to food allergens were registered. . % of children were asymptomatic despite pollen-food sensitization. the statistically significant differences were noticed in comparison to the control group. conclusion: . allergic rhinitis in children, similar to adults, is a common manifestation of pollen-food syndrome and this type of sensitization should be taken into account regardless to age. . children with pollen-related food allergy have the predisposition to multiorgan clinical manifestation. . the lack of association of symptoms with plant-origin foods in the majority of cases and the asymptomatic course of food sensitization in more than one third of patients indicate the need for follow-up. | clinical benefit of the screening of suspected food allergen using multiple allergen simultaneous test in the patient with pollen-food allergy syndrome (pfas) background: the quantitative fluoresce enzyme immunoassay immunocap (ic) system has been widely used for detection of allergen-specific ige for the diagnosis of allergy. however, the system can only detect ige against a single allergen, the multiple antigen simultaneous tests has been developed such as the fluorescence enzyme immunoassay view allergy (va) or chemiluminescent enzyme assay mast iv (ma) and both assay detect more than allergen-specific ige. in this study we examined the diagnostic capability of these two systems for screening test in the patient with pfas. method: total number of participants are (male/female: / ), aged . ± . (range ~ ) years old. all the patients showed oral allergy syndrome (oas) to rosaceae family plants (apple, peach) and/ or kiwi and/or banana, also showed tree pollen allergy. specific ige assay were performed using ic, ma or va. results of greater than class were to be regarded as positive, and the concordance rates between the assays were assessed. results: the correlation of sensitivity between pr- (rbet v , rmal d , rpru p , measured by ic) and specific ige to apple (measured by va), specific ige to peach (measured by ma) in oas patients to rosaceae family plants were assessed. rbet v , rmal d , rpru p were found to be . %, . %, . % positive measured by ic while the specific ige to apple (supposed to be including pr- ) were found to be % positive measured by va. on the other hand, the specific ige to peach (supposed to be including pr- ) were found to be only . % positive measured by ma, this detection rate was lower than that of va (p < . ). also, the correlation of sensitivity between pr- (ract d , measured by ic) and specific ige to kiwi in patients with oas to kiwi were assessed. ract d were found to be . % positive measured by ic while the specific ige to kiwi (supposed to be including pr- ) were found to be . % and . % measured by va and ma, respectively (p < . ). additionally, all the oas patients to banana found to be positive for the specific ige to banana measured by va, but only patient was detected as positive measured by ma. conclusion: in this study, we found that va showed better agreement of sensitivity and specificity with ic compared to ma in the oas patients to rosaceae family plants, kiwi, or banana. therefore, it may be clinically useful for screening of allergen specific background: the hygiene hypothesis for autoimmune and allergic diseases, which exists nowadays, shows that human immune system is dependent on various environment factors. we consider the effects of humic substances (hs) to be important in understanding the hygiene hypothesis. due to urbanization, the amount of human interaction with hs found in soil has significantly dropped. the goal of our work was to study allergenic potential and antimicrobial activ- conclusion: hs appear to be exogenous immunocorrectors, and also to have an ability of suppressing propagation of allergic reactions and sensibilization, which leads to conclusion that they seem to play a major role in hygiene hypothesis. moreover, hs selectively interact with bacterial cell wall, and this effect could be used in order to create antimicrobial drugs based on hs. background: peach tree pollen has been identified as having relevant allergens (the third most prevalent after olive tree and grass pollen) in areas of high cultivars (murcia, east-spain). when analyzing molecular components in sensitized patients, along with pru p , we have identified other relevant inhalant allergens one of which was named pru p x. because pollen of different species share allergens and with plantderived food, we have also studied peach tree pollen sensitization in a non-exposed population (madrid, central-spain). the aim was to study the association between peach tree pollen and several panallergens, as well as the relevance of pru p x in our area (madrid). method: a total of patients who came to our allergy unit in those patients with positive spt to at least one pollen we also performed peach tree pollen spt. if positive, we tested pru p , pho d , pho d and pru p x. to study the clinical relevance of these findings, we also performed nasal provocation test (npt) with peach tree pollen and pru p x. results: a total of patients were sensitized to peach tree pollen. from these, % had also positive spt to pru p and none of them to pru p x. positive spt to polcalcin were found in the % of the cases and to profilin in the %. in patients sensitized to peach tree pollen npt was performed being cases positive to peach tree pollen and none to pru p x. conclusion: peach tree pollen sensitization in non-exposed patients with allergy to other pollens is high although primary sensitization is unlikely. these patients present clinical response when exposed to that pollen that needs further evaluation. in our study, one third of the patients were also sensitized to polcalcin and pru p and none to pru p x. we have not found clinical response to this new inhalant allergen identified in highly exposed peach tree pollen population. results: the bet v elisa . -ep complete kit format (including pre-coated plates and all buffers and reagents) allowed for the consistent measurement of bet v in birch pollen extracts within the same lab (intralab cv= . %) and between different labs (interlab cv= . %). the average recovery from matrix spiked samples (crs in birch pollen extracts) ranged from - %, with an average recovery of % (n = ). assay time was reduced from several days to two hours compared to the original method. the performance of the bet v elisa . -ep kit was comparable to that of the stallergenes greer candidate standard method and has been successfully cross-validated. this will enable allergen manufacturers and regulatory authorities to adopt a standard method for bet v determination, which, ultimately, may be included in the european pharmacopoeia. the development of a certified elisa represents a major step forward in the standardization and quality control of allergen products. | an isoform of the ole e allergen assembled by proteomics could explain the cross-reactivity with pollen and food nsltps results: a total of peptides were obtained by de novo sequencing. ten of them allowed the completion of the full-length amino acid sequence of the allergen. after purification, role e was obtained with a yield of . mg/l of cell culture. immunological assays confirmed that the recombinant isoform of ole e shared most of the allergenic and antigenic properties of the natural allergen. moreover, we observed its implication in cross-reactivity with pollen extracts, and plant-derived food extracts. conclusion: these results suggest that the presence of this isoform in the olive pollen could explain the co-sensitization observed in some allergic patients between ole e and nsltps from foodderived extracts and might be used for a more effective clinical diagnosis of olive pollen sensitized patients. background: penicillium oxalicum, one of the prevalent airborne fungi in india, was selected to detect its spores as potential source of allergens and also to identify and characterise its major ige-reactive component. the airborne spores of penicillium oxalicum was detected by andersen -stage air sampler at different parts of west bengal. the allergenic potency of p.oxalicum was tested by spt, elisa and immunoblotting. total protein was resolved in -d and -d gel electrophoresis and allergens were identified by -d and -d immunoblots. identification of major ige-reactive protein spots was made by mass spectrometry based maldi-tof-tof. major allergen was partially purified by ion exchange chromatography. results: aerobiological investigation clearly indicated the predominance of p. oxalicum spores ( cfu m − ) in the air of west bengal, india. sensitivity of patients to spore antigens was highly correlated with rhinitis. in sds-page, bands were detected with molecular weight range of - kda. the allergenic potency of spores was confirmed by skin-prick test, elisa and dot-blotting. eleven ige-reactive proteins were detected as allergens by -d and -d immunoblots, of which % patients were sensitized to kda allergen. this kda protein was found to be the major allergen which was further characterized by mass spectrometry based maldi-tof-tof. this major allergen (pi . ) was partially purified by ion exchange chromatography. the eleven allergens were identified from spore of penicillium oxalicum fungi for the first time from india. immuno-proteomic identification of major ige-reactive protein ( kda background: airway epithelium (ae) is one of the largest cellular surfaces exposed to the environment. ae constitutes a physical barrier due to the presence of intercellular apical junctional complexes between neighboring cells. in the past years evidence indicates an association between epithelial airway dysfunctionality and allergic asthma. it is still unclear if an impaired epithelial barrier could be the cause of allergy development as opposed to the consequence. one of the most common comorbidities of asthma is house dust mite (hdm) allergy. it has been shown that hdm allergen der p can disrupt the epithelial airway due to its protease action against cellular apical junction complexes damaging the epithelial monolayer. in the last decade, metabolomics has been successfully employed as a new approach to describe metabolic changes in biological systems. metabolomics focuses on describing and identifying small molecules to explain complex biological processes. we theorized that metabolomics could be used as a new tool to detect damage of epithelial barrier in vitro after der p exposure. method: human cell line calu- cultured at air-liquid interphase (ali) was used as an in vitro model of bronchial epithelium. ali culture system allows establishing different compartments, mimicking the conditions found in the human airways: a basolateral compartment in which basolateral surface of the cells is in contact with the culture medium, and an apical compartment where the apical cellsurface is exposed to air. after days in ali, the cells were exposed to either der p or pbs as a control in the apical side for hours. then, apical and basolateral media were collected and processed for metabolomics analyses. results: metabolic profiles from samples were obtained, these were composed by and features for apical and basolateral media, respectively. of these, using mann-whitney unpaired test as statistical analysis, and features were found changed within the apical and basolateral compartments, respectively. specifically, in the apical compartment there were signals significantly increased and decreased after der p exposure; whereas for the basolateral compartment, signals were found to be significantly decreased and increased after exposure. background: mites are one of the major causes of allergies. it is known that allergen concentration varies depending on the species of mites and the degree of allergy induction is different, but the difference in microbiota according to mite species is not known. in addition to allergen, endotoxin or bacterial dna, adjuvants of allergen derived from the microbiota in the mites, are also present in the feces. bacterial endotoxin is found in gram-negative bacteria, acting on tlr and acting as an adjuvant to allergies. method: three species of mites (d. farinae, d. pteronyssinus, and t. putrescentiae), known to cause allergies, are cultured in same condition(autoclaved media, %rh, °c)and analyzed for microbiota of each species. using the next generation sequencing that complements the existing sanger sequencing, we analyze the difference of microbiome according to the dust mite species and measure the level of endotoxin. method: six hundred and thirty five patients ( . % males and . % females, mean age . years old, range to years old) were included. all of them referred respiratory symptoms (rhinitis, conjunctivitis or bronchial asthma) and had skin prick tests positive with any pollen. patients were skin prick tested with a battery of common pollens in our area, including three species of chenopodiaceae: chenopodium album, salsola kali and salsola oppositifolia. results: three hundred and forty tree ( %) patients were sensitised to pollen of any chenopidaceae species: ( . %) to chenopodium album, ( . %) to salsola kali and ( . %) to salsola oppositifolia. the prevalence of skin sensitisation to pollen of salsola oppositifolia was . % in the population studied and . % in patients sensi- results: in patients aged - years of age in . % of the cases ige reactivity was at least to one allergen tested. the majority of patients (more than / ) had a complex sensitization profile and reacted on average to more than allergens. the highest frequency of sensitization in ukraine among patients who turned to the clinic among adults was found phl p ( . %), amb a ( . %), fel d ( . %), bet v ( . %) and children ( . %, . %, . %, . %), respectively. when analyzing the results of tests for the source of the allergen, most often among house dust mites (hdm) allergens in adults and children is sensitization to fel d ( . %), as well as to hdm: in adults (der f - . % der p − . %, der f - . %, der p - . %) and in children ( . %, . %, . %, . %), respectively. among fungal allergens the most common is sensitization to alt a and varies from . % in adults to . % in children. among pollen allergens in adults is sensitization to phl p ( . %), amb a ( . %), bet v ( . %), cynd ( . %), art v ( . %), bet v ( . %) and in children ( . %, . %, . %, . %, . %, . %), respectively. tests for food allergens in adults and children are more common on pr- proteins. in children, sensitization to milk and egg proteins is more common than in adults. conclusion: most patients who came to the clinic have a complex ige reactivity profile in which pollen sensitization predominates. among hdm allergens, more than / of the examined have sensitization to the cat's proteins. sensitization to mold alternaria alternata in children occurs times more often than in adults. results: total children were examined, aged - years (median years). % children were sensible to two and more components . %to and more components. the frequency of sensitization to inhalation components was . %, to food abstracts | components- . %. among the most frequent inhalation components were feld - %, betv - %, amba - %, phlp - %, alta - %, the sensitization to house dust mites (hdm) was most often observed to der p - %. however, the analysis of these protein by the level of isu showed that the highest levels were for der f median (iqr . - . ), whereas for fel d - . (iqr . - . ). among food allergens, sensitization was most commonly observed to pr- proteins - %. children sensitized to pr- proteins were in most cases sensitized to -mal d ( %), cor a . ( %), pru p ( %).this co-sensitization was accompanied by a high correlation of isu levels among these components. sensitization to celery and kiwi was less common, the level of these proteins was also low. the frequency of sensitization to storage proteins was %, among which the highest level of isu was in ara h median . sensitization to ltp proteins was detected in % of children, among which the most commonly detected pru p protein was . %. the sensitization to profilins, which was evaluated at the level of bet v , was found in % of children, but the levels of these proteins were not high. among the food products of animal origin, the most frequent was sensitization to egg component gal d − . %, however, isu levels were the highest to milk component bos d − . (iqr . - . ). the most frequent causative inhalation allergens were epidermal allergens and weed pollen, however, the highest level of isu was to hdm and mould. among food allergens, the most commonly observed sensitization was to pr- proteins. hypereosinophilia of peripheral blood was observed in children under study, which was % ( . %). as a result of testing patients with a wide panel of allergens, % of the patients had diagnostic levels of antibodies to allergens siged , . %to allergens siged . in % of cases, a significant level of antibodies to plantain allergens sige w was detected, . % to dandelion allergens sige w , . % to evergreen trees sige t , to maple sige t to . %, to allergens of olive tree sige t - %, to the banana allergens sige f - . %, to the egg protein sige f in . %, in % to the milk allergens sige f , to the food mixture sige f x - . %, to allergens of mold fungi mx − . %. among the leading household allergens were registered in the st group and in the nd group of the investigated children -d pteronyssinus ( . %, . %), and d. farinae results: the prevalence results are expressed in the table . we have not observed any significant association in allergic rhinitis patients group with any ltp or pr- molecules. for atopic dermatitis only rara h (or with % ci - . ( . - . ) and njug r (or with % ci - . ( . - . )) were associated significantly. for asthma, the most important molecules were rbet v , raln g , rcor a . , rcor a . , rmal d , rpru p and rapi g (p-values for or less than . ). conclusion: future studies focusing on the evaluation the association of cross-reactive molecules with allergy phenotype should be done. background: the fuzzy/green kiwifruit (actinidia deliciosa), widely grown commercially, contains various pulp allergenic molecules, including the major allergen cysteine protease actinidin. methods. this case report is about a -year-old male patient with house dust mite allergic persistent rhinitis and intermittent asthma, presenting a convincing history of anaphylaxis immediately after eating a kiwifruit on empty stomach, followed, a few months later, by a severe oral allergy syndrome after licking a slice of raw kiwi. previously, the patient ate kiwi without any problems and had no manifestations of pollen or latex allergy. skin prick testing was done with commercial allergen extracts, while prick-prick testing was performed with raw kiwifruit, avocado and banana. molecular approach consisted in assessment of serum specific ige to native extracts and molecular allergen components using patient-friendly allergen nanobead array multiplex test and singleplex capsule-enclosed activated cellulose solid phase fluorescence enzyme immunoassay. results. regarding kiwifruit allergy, the patient presented positive prick-prick tests with raw edible kiwifruit components: outer pericarp and inner pericarp (each mm wheal) and columella/core ( mm wheal) and negative with kiwifruit whole seeds, avocado and banana, and pollen extracts. serum specific ige to kiwifruit were detected ( . ku/l), but specific ige values were negative (≤ . fiu/ml) for actinidin act d , thaumatin act d , kiwellin act d , nsltp type act d , bet v -like major latex/ripening-related protein act c , act c chitinase_iv, act d cross-reactive profilins bet v (birch pollen profilin) and hev b (latex profilin), and also negative (< . ku/ l) for pr- ract d . moreover, specific ige to avocado were nor found (≤ , fiu/ml). although ige against seed proteins cupin/ s globulin act d and s albumin act d were not determined, this was not considered of great importance since allergic symptoms were also induced by licking kiwi pulp, in which abundantly expressed actinidin enzymatically degrades seed storage proteins, and prick-prick test was negative to kiwifruit seeds. conclusion: in a patient with anaphylaxis to kiwifruit, positive skin tests to its pulp and detectable serum specific ige to actinidia deliciosa, a detailed molecular allergy diagnosis is necessary, including assessment for act d glycoallergen or other molecules, not performed in this patient. | is pr- sensitization a portuguese phenomenon as well? background: bet v , a major allergen found in birch pollen, belongs to the pr- protein group. in our practice, some bet v sensitized patients have been identified, residing in areas without this tree genus in its flora. our aim was to characterize a portuguese patient population with pr sensitization. method: a group of patients in whom immunocap isac ® (isac) study was performed, between january and june , were analyzed. all subjects with one or more pr- sensitizations were selected, and their clinical records reviewed. a sequential sample of the last subjects (n = ) who underwent isac study, was then used for comparison. results: out of isac studies performed, only were positive for pr- protein group. median age was . years, % (n = ) were male. pr- sensitized individuals were more likely to live in portalegre district compared to the control group ( / vs / ; p < . ). patients were positive for pr- family pollens ( . %), frequently bet v (n = ), followed by aln g (n = ) and cor a (n = ). out of the patients were sensitized to pr- foods, mostly cor a . (n = ) and mal d (n = ). skin prick tests revealed birch as the main sensitizing pollen as well ( / ). moreover, only four patients were skin prick tested for fagaceae trees which were positive for oak ( ), chestnut tree ( ) and cork tree ( ) . all patients were co-sensitized to other pollens, namely grass and all had respiratory allergy. nine patients were food allergic, although seven of them were co-sensitized to other cross reactive (ltp/profilin) or species specific proteins. conclusion: although pr- sensitization is known to be rare in our population, mostly alto alentejo inhabitants showed sensitization to this protein family in our sample, either by in vitro and/or in vivo methods. this phenomenon is consistent with the native plant species of this region, which should be taken into account when studying the allergic profile of these patients. in our sample, all pr- sensitized patients had respiratory allergy while this protein didn't seem to be relevant when it comes to food allergy. further studies are needed to characterize which plant species belonging to this protein family are more significant for our country's aerobiology context and to determine its clinical relevance. included. allergic asthma, rhinitis, conjunctivitis and eczema allergic symptoms were diagnosed. all patients were tested by immunocap with mugwort pollen extract and the natural components nart v , nart ar , nart v , and nart an . results: the positive frequency and sige levels of the four components in the artemisia allergic patients from southwestern china were significantly lower than that from the north. art v and art an were the highest recognized allergens, followed by art v and art ar . patients from northern china were more likely to have abstracts | asthma ( %) than patients from southwestern china ( %), and being sensitized to more than two allergens increased the risk of asthma. sensitization to art v , art v and art an played a significant role in the development of asthma. artemisia pollen allergic patients is helpful to assess the potential risk of asthma. conclusion: a small but significant part of the population react to ragweed pollen extract and are not identified as disease-positive by standard sige tests. there is a need for targeted tests towards a larger spectrum of allergen molecules. in ragweed allergic individuals, this allergy can be the main cause of overall sige levels and also of in vivo reactions (tested by spt). | molecular profile of pollen sensitization of tashkent residents with respiratory allergy background: in paediatric cohorts, a correlation between specific ige (sige) levels to house dust mite extract or allergen components and the occurrence of asthma has been shown. higher levels of sige to mite extract were associated with a higher risk of wheezing. moreover, asthmatic children recognized more allergens and had higher sige levels to nder p as well as rder p , and . we sought to investigate potential differences in sige levels or sensitization patterns between asthmatic and non-asthmatic patients in a mixed paediatric and adult house dust mite allergic cohort. method: total ige and specific ige against house dust mite extracts (dermatophagoides pteronyssinus and farinae) and allergen components (rder p , , , and ) were determined in house dust mite allergic patients. patients had diagnosed asthma ("asthmatic", % females, mean age ± years, % younger than years), whereas had rhinitis (and conjunctivitis) without respiratory symptoms ("non-asthmatic", % females, mean age ± years, % younger than years). results: total ige levels were markedly higher in asthmatic compared to non-asthmatic patients ( vs. ku/l, p = . ). positivity to rder p ( vs. %, p = . ) as well as rder p ( vs. %, p = . ) differed between both groups. specific ige levels to house dust mite extracts and allergen components (rder p , , , and ) and positivity to rder p and did not differ between both groups. conclusion: in contrast to previously published data, sige levels to house dust mite extracts or allergen components were not statistically different between asthmatic and non-asthmatic patients in our mixed paediatric and adult house dust mite allergic cohort. only higher total ige levels and a higher reactivity to rder p and were found in asthmatic patients. however, larger studies are needed to confirm clinical relevance of these findings. results: prior treatments reported at baseline (bsl) included: . % of pts were receiving or more second-generation h -ah at approved dose (recommended first-line), . % were receiving them at increased dose (second-line); . % were receiving omalizumab (third-line); . % had no treatment. the majority of pts ( . %) had uncontrolled csu (uct< ) at bsl (table) . treatment changes were most evident at the bsl visit, with an increase in pts receiving omalizumab ( . %) and a decrease in those receiving no treatment ( . %) vs. prior therapy. these changes were associated with improvements in rates of hives and/or angioedema, uct and qol scores at month , but only modest improvements thereafter (table) . a sub-analysis of pts with uct< and who were receiving the approved ( . %) or increased dose h -ah ( . %), revealed that few pts had recommended escalation from the approved to increased dose h -ah ( . - . %) or from increased dose h -ah to omalizumab ( . - . %) (table) . conclusion: poor physician adherence to guidelines was evident throughout aware. initial improvements in disease activity and qol plateaued after month , possibly owing to fewer changes to recommended therapies. greater physician adherence to guidelines is needed for better symptom control in pts with uncontrolled csu. results: we revealed that in russians urticaria is associated with rs *arg/gln genotype of the il gene (p = . ) and rs *cc genotype of tlr (p = . ) gene polymorphism. in tatars the association with disease development was shown for rs *tt genotype of tlr gene snp (p = . ). the rs *c allele of tlr gene polymorphism is associated with acute and chronic forms of urticaria (p = . and p = . , respectively) and rs *c allele of il gene polymorphismwith acute urticaria (p = . ). method: csu patients from the urtica cohort (clinicalttrials.gov number: nct ) participated in the study. a questionnaire was carried out evaluating the triggers identified by the patients, the comorbidities and the treatments received. patients with a self-report of skin exacerbation by foods, nonsteroidal antiinflammatory drug (nsaid) or physical triggers were subjected to a controlled provocation test with the suspect food, medication or physical stimuli report by the patient. the levels of anti-tpo ige were measured during a period of clinical control and during two exacerbations in all patients. results: % of the patients had at less one inducible urticaria demonstrated by provocation tests ( % dermographism, % cold, % pressure). self-reported exacerbation for a food ( %) or medication ( %) were high, but positive provocation tests were low ( % and % respectively). patients had (+) anti-tpo ige during the baseline period. among them, % presented a significant elevation of anti-tpo ige during at less one of the two exacerbations. . % of patients (n = ) with (−) anti-tpo ige, presented elevation of anti-tpo ige one of the two exacerbations. conclusion: foods, drugs and physical triggers must be verified by challenge tests to avoid unnecessary lifestyle restrictions in patients with csu, nevertheless self-report is usually greater than positive provocation tests. increase concentrations of anti-tpo ige seems to be implicated in urticaria exacerbations in some patients with csu. brzoza z ; adamczyk k ; wcislo-dziadecka d ; zbiciak-nylec m ; brzezinska-wcislo l adipokines. the aim of the study was to evaluate the possible contribution of leptin to chronic spontaneous urticaria pathophysiology. the study included chronic spontaneous urticaria patients and healthy subjects. the leptin level in both examined groups was measured. results: no statistically significant difference in leptin level was determined between the studied subgroups. we are among the first to present the effects of exploration aimed at assessment of the possible role of adipokines in chronic spontaneous urticaria pathogenesis. in this study we did not prove any difference in leptin level. in our opinion it is valuable to perform further studies in this area. the microorganisms were inactivated with phenol, and the concentration was adjusted to microbial cells/ml (labeled as a / ). dilutions / and / were made from the product labeled / . the dot blot technique was used to detect the presence of specific ige to the different microbial antigens and controls (anti ige / and fold dilution ½ and ¼). the dot blot images were processed with a documentation system (gel doc ez, bio-rad), and the different microbial antigens in different dilutions were compared with the positive anti-ige controls. results: all patients have specific anti ige to microbial antigens (see table below). the presence of microorganism-specific ige could explain, the relationship between the infections and / or microorganisms in ciu, as well, the urticaria control by omalizumab, even when it has not been detected ige sensitizations to common allergens. finally, these findings, showed that the bacterial allergy could be one line of research to understand the unresolved etiology of urticaria. background: dermographism is the most common form of inducible urticaria. it shows itself as hives made by scratching or rubbing on the surface where it has been produced and with the same morphology. the pathogenesis has not been clarified nor has it been associated until now with the sensitization to allergens. we have studied the relationship between the presence of dermographism and domestic mites sensitization. we have selected patients older than years old. all of them had symptoms compatible with dermographism at the moment of medical evaluation. at least one third of patients additionally showed rhinitis and/or asthma symptoms. we performed:: -skin prick tests with our basic neumoalergens (mites d. pteronyssinus y lepidoglyphus destructor, pollen, molds, dog, cat and horse dander, latex and anisakis simplex). -determination of specific ige levels for dermatophagoides pteronyssinus, lepidoglyphus destructor, and anisakis were measured in serum by using the immunocap (thermo fisher scientific). -blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram. results: blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram were normal. we divided patient in different groups. background: urticaria results from the appearance of pruritic papules and/or erythematous plaques caused by substances from mastocytes present in the skin, notably histamine. chronic urticaria is defined as flare-ups that occur at least two or three days per week over a six-week period. in addition, affected subjects are often prone to an atopic or auto-immune profile that promotes urticaria [ ] . the association of polyphenols (ambora, green tea) and the soothing active ingredients slow down the itching biological process from the outset by reducing the release of pruritic mediators (e.g. histamine, cytokines, etc.) of immune cells such as mastocytes and lymphocytes, involved in urticaria. in this context, the purpose of the study was to evaluate the efficacy and the tolerance of an anti-pruritic spray containing the polyphenols and the soothing ingredient. the tested product aims to quickly calm the itching in subjects with chronic urticaria. results: on average, the product was applied . times per day with a significant decrease of d-pruritus scale (- %) and sensations of itching (- %) between d and d . in terms of quality of life, a significant decrease of the skindex score was observed (- %). the product soothed the pruritus within seconds for all subjects and the anti-pruritic effect lasts at least hours for % of subjects. the product also showed very good cosmetic properties and was well tolerated; no intolerance case was reported. showed near complete remission. in the week before omalizumab and for a few days after, her urticaria flared but on of weeks she was largely asymptomatic (uas - ). after years of successful treatment she reported an increase in csu activity. no trigger factors could be identified. add-on treatment with cyclosporine was refused, montelukast showed no, and prednisolone only transient benefit. over a period of months wheals occurred almost daily and a maximal score of was achieved on uas . we replaced omalizumab with cyclosporine but this was subsequently discontinued due to side effects. months later the patients' csu remained poorly controlled with up to wheals occurring almost daily despite rupatadine mg/d. due to the good initial response to omalizumab and lack of good treatment alternatives, a trial of re-treatment was considered. results: within week of re-commencing omalizumab she once again achieved near complete remission of csu with uas ≤ on of weeks. the mechanism of action of omalizumab and the development of resistance to it in csu, are incompletely understood. our case shows that some csu patients developing resistance to omalizumab may benefit from a subsequent trial of re-treatment, particularly if treatment alternatives are poorly tolerated. manipulate and store data by electronic means. this includes e-mail, sms text messaging, video chat and online social media as well as all the different computing devices that perform a wide range of communication and information functions. a rapid increase in the use icts in recent decades is an enormous contributing factor in the development of a number of novel clinical and public health intervention strategies. the aim of the present study is to assess the level of ict use and to examine patterns of preferences among patients with chronic urticaria (cu). method: we will conduct an anonymous multicentre cross-sectional study, starting from january , to investigate the use of icts in patients with cu, using a questionnaire as a survey method. this questionnaire will assess the frequency of use of social media and icts in patients, and their preferences for receiving and asking disease-related information. the survey will consist of items, evaluating demographical information, time with disease, medication currently used, and additional aspects of social network use. results: we will use a chi-squared test to assess the association between internet access or owning a cell or smartphone, and age, gender, type of urticaria, educational level and number of years since diagnosis. we will employ the same test to assess the association between the independent variables previously introduced and the frequency of use of each ict type (short messaging service [sms], facebook, twitter, youtube, email, internet, linkedin and skype) as well as agreement in receiving and seeking information (i.e. asking questions to the practitioner) through such icts. we will perform adjusted regression analyses between categories of age, gender, educational level, type of urticaria, years since diagnosis and the use and level of interest shown in communicating through icts. our aim is to report on remarkable findings from a registry of a large sample of patients, potentially providing clues for its approach and results: patients with a median length of months suffering from urticaria were registered, being % women; mean age . years. in % of patients no causal agent was identified. parasites were found in . % and thyroid peroxidase antibodies in . %, while autologous serum skin test was positive in % and igg to mycoplasma in % of evaluations. two thirds of patients reported wheals on uas , with just / having concomitant angioedema. almost / reported significant affection on quality of life because of itch by cu-q ol. just % of patients achieved total control on first anti-histamines provided, and less than half had good control of urticaria. cetirizine was the first choice in %, followed by fexofenadine ( %) and first generation anti-histamines ( %). method: cases at - years of age which were being followedup in our clinic with diagnosis of chronic urticaria and were not receiving any antihistaminic medication for last one month were included in the study. cu-q ol, uas- , psqi and psg results of the patients were evaluated. correlation of data with each other in regard to sleep disturbances was evaluated. results: patients were included in the study. patients' mean total score in cu-q ol was . ± . . patients' mean uas- value was . ± . . mean total psqi was . ± . , the ratio of total scores ≥ and those with poor quality of sleep was . %. mean epworth sleepiness scale (ess) score was . ± . , with total score ≥ in . %. in psg, mean apnea-hypopnea index (ahi) was . ± . , with . % of the patients having ahi ≥ . when patients having ahi< were compared with patients having ahi ≥ , no significant difference was determined in regard to total cu-q ol score, mean score for questions concerning status of sleep, uas- and psqi. when correlation analysis was performed between cu-q ol and total score for questions concerning status of sleep, a positive correlation was determined with psqi (p = . ). conclusion: it was demonstrated in our study that patients with chronic urticaria had poor quality of sleep and this disturbance was independent from ahi. omalizumab was discontinued due to absence of improvement in csu symptoms after three consecutive doses. the plasmapheresis without intravenous immunoglobulin replacement was initiated. results: the symptoms were relieved during the first procedure and the disease improved shortly thereafter. the following weeks the symptoms still occurred but with lower intensity and severity. (angioedema was gone). the second attempt with omalizumab was successful after this course ( procedures of plasmapheresis). case report: rosacea is a chronic skin disorder associated with flushing, erythema, dryness, burning and stinging, and inflammatory papules and pustules. new treatments available or in development target the inflammatory and erythematous components of the disease. these agents include the selective alpha- receptor agonist brimonidine. allergic contact dermatitis to brimonidine is an unusual condition. in addition to this, urticarias due to brimonidine are rarely reported. we report on a -year-old woman who, immediately after apply a thin layer of brimonidine gel as preparation for a rosacea treatment on her face developed facial urticaria, which reverted in approximately four hours with systemic steroids. she had previously tolerated this product without any problems, but has not use it again ever since. skin prick-tests with brimonidine ( . mg/ml) and latex were realized in the patient. skin prick-tests with brimonidine were realized in eleven healthy control subjects. results: skin prick-tests with latex was negative in the patient. skin prick-tests with brimonidine were positive in the patient ( x mm). the prick-test with brimonidine was negative in teen healthy control subjects. we report on a case of immediate urticaria due to brimonidine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. we highlight this case because it is the only case described in the literature with a positive prick-test. method: the study was in accordance with the helsinki declaration and was previously approved by the national comity of ethics. this was a one dose study conducted on fasting young healthy volunteers, of which were females and five males. the mean age was ± years old and the body weight . + . background: cetirizine is a potent h -receptor antagonist indicated in the treatment of allergic rhinitis and urticaria. cetirizine is widely used due to its potent antihistaminic effects in yielding strong and fast relief of itchy sensation, sneezy and rhinorrhea and its unlikely probability to manifest anticholinergic side effects in therapeutic doses. histamine flare and wheal inhibition by anti-h are widely used as a standard to test and compare the effect intensity and duration. our study aimed to test these effects of cetirizine in young healthy adults. method: this was a double-blind, single dose study in healthy young adults, previously approved by the national comity of ethics. eleven females and five males with a mean age ± years participated in this study. histamine skin pricks were tested before and after they received a tablet of mg cetirizine as previously scheduled. twenty minutes after each test flare and wheal were drawn in a transparent paper which was then scanned and measured with a software. wilcoxon signed ranks test two-sided with significance at % level was used to analyze the differences. claims that the preparation relieves itch within seconds of its application. we performed a simple study to verify this claim. we used irp in consecutive subjects, males, median age , range - years, whose workup implied ast. their preliminary diagnoses were "asthma" ( subjects), "allergic rhinitis" ( subjects), "atopic dermatitis" ( subjects) and "food allergy" ( subjects). all of them had refrained from systemic antihistamines for at least one week. standard skin prick tests (spt) were applied as appropriate, including histamine controls to assess the level of their skin sensitivity. subjects were asked to mark their sense of itch in the area of the skin to be tested on mm visual-analogue scales (vas) starting from " "-"no itch" to " "-"unbearable itch". vas assessments were repeated minutes after ast was done; then irp was applied according to the manufacturer's instructions, and the vas assessments were repeated after seconds and minutes. results: there vas assessments are shown in table format: table irp did not affect the wheal and flare of the histamine control, nor did it abolish positive spt. no differences were outlined between subjects with different diagnoses. the commercially available itch relieving preparation not containing defined pharmacological antihistamine is effecting in relieving itch associated with allergen skin testing. before ast ( ) . ± . vs ( ) p < . represent the first-line treatment for osteoporosis-related mastocytosis. we report a case of sm with bone pain and with an area of osteolysis in the femur as first sign and symptom. we had to consider the risk of adverse reaction when we decided to treat the patient with bp, but the patient was under antihistaminic treatment and also we made a premedication to reduce the risk. the pk/pd model available was informed by data from clinical trials. the pd endpoint data was available from two studies and used to characterize the effect of bilastine on wheal and flare. moreover, food effect had been characterized in pk studies and the data was used to model the effect of food in the pk of bilastine. the pk parameters relative to the fed state were then used to simulate the temporal evolution of the wheal effect using the pk/ pd model. all analyses were conducted by nonlinear mixed effect modeling (nonmem v . ). using the pk model developed (food effect model) and the pk/pd model already available, monte-carlo simulations for plasma concentrations and pd over time were performed for both the fed and the fasting states. results: . a reduced bioavailability (f) and a slow absorption constant characterized the pk of bilastine when administered concomitantly with food (f = % relative to the fasting state and ka = . hour − , a -fold reduction compared to fasting conditions). the rest of the pk parameters remained unchanged. onset of action was hour for bilastine both in fed and fasted conditions. maximum wheal inhibition occurred at . hours (fasted % and fed %). from to hours, the percentage reduction with bilastine for both fasted and fed was between % and % after the third day of treatment. a % inhibition in wheal effect was maintained during hours for both conditions after the third day. the results of the simulations show that even if the pk is altered with food, the pd is maintained unchanged. conclusion: even if a significant food effect was described for bilastine at a pk level, the difference is not translated directly into the pd. therefore, the antihistaminic effect of bilastine remains unaffected by the concomitant administration with food. the results of these simulations will be further confirmed in a dedicated clinical trial. results: we also found no correlation between the different tgt parameters and other clinical and analytical parameters associated with uc (table ) results: both cetirizine products have no differences in respect to the pharmacodynamic and pharmacokinetic parameters analyzed. the % confidence interval of the mean ratios of the auc - , auc -inf , cmax, auce - , and e max , between the test and the reference, were within the bioequivalence ranges ( %- %) in both cases. no statistical difference was revealed when comparing the respective t max and te max too. the two cetirizine products tested were bioequivalent. the bioequivalence was evident even when tested with the pharmacodynamic parameters. there is strong evidence that supports the use of histamine skin prick test for the bioequivalence evaluation of different cetirizine products. | bradykinin-mediated angioedema associated with combination of angiotensinconverting enzyme and dipeptidyl peptidase iv inhibitors: a disproportionality analysis from the who database method: we performed a disproportionality analysis using data from the who pharmacovigilance database by a case-noncase study, until the / / . we extracted all individual cases safety reports (icsrs) included in the high level term "angioedemas", according to the medical dictionary for regulatory activities classification. given the absence of term "bma", we selected only the icsrs of angioedema without associated symptoms evoking another underlying mechanism, such as histamine angioedema (e.g. pruritus, urticaria, rash, etc.). drug class exposure was "acei" and "dpp i", considered suspect or concomitant, using the atc classification. we results: there was no correlation between mother's disorders such as periodontitis, rhinitis, diabetes etc. and the onset of ar (p > . ). a multivariate analysis showed, neonatal jaundice (p < . ), respiratory system infection (p < . ), diarrhea (p < . ), eczema (p < . ) in the first months of life and home environmental factors (house decoration (p < . ), mold environment (p < . ), keeping flowers (p < . ), passive smoking (p < . )) increased the risk of ar. besides, there was no significant difference in current height and birth weight of the participants between ar and control group. however, ar group had significantly lower current weight (p = . ) and age (p < . ) compared with the control group. paternal age and maternal age in the ar group were significantly higher than the control group (p < . ). conclusion: diseases in the first months of life and home environmental factors increased the risk of sequential ar. the older parents increased the possibility of ar in the offspring. the data of general characteristics of participants were statistic analysis by z text analysis. *significance at p < . . results: anosmia was more frequent in crs than in rhinitis ( . % vs . %, p < . ) and in crswnp than in crssnp ( . % vs . %, p < . ). lms was higher in crs than in rhinitis ( [ - ] vs [ - ], p < . ) and in crswnp than in crssnp ( [ - ] vs [ ] [ ] [ ] [ ] [ ] [ ] [ ] , p < . ). in addition, lms was associated with loss of smell in patients with hyposmia (or = . [ . , . clinics. patients were submitted to confirmatory exams including oral provocation test with aspirin. nasal polyps were removed by functional endoscopic sinus surgery and eosinophils in this tissue were quantitated. eosinophil counts in peripheral blood was obtained. serum periostin was measured by elisa and total ige was determined using immunocap. as control groups, ( f/ m) patients with par and healthy subjects ( f/ m) were selected. samples of nasal tissue and blood were collected from these subjects during elective surgery for correction of anatomical variations, and compared with the patients with aerd. results: ar symptoms were significantly improved in the treatment group compared with the control group ( . % ( / ) vs . % ( / ); p < . ). furthermore, the mean total vas score for patients in the treatment group was reduced from . ± . before treatment to . ± . after treatment (p < . ). moreover, the reduction in free ige levels was greater in the treatment group than in the control group. the results of this study suggest that the chinese herbal medicine ber may be effective for improving the symptoms of ar. a multicenter clinical trial is needed to confirm this finding. results: in patients with "eosinophilic" polypoid rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . mlg and in patients with "neutrophilic" polypous rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . ml. the study showed that disruption of the transport function, changing the concentration of hydrogen ions method: this prospective controlled study was carried out on crs patients underwent ess. patients participating in the study were divided into two groups-group : partial middle turbinectomy (n = ) and group : partial middle turbinectomy and middle turbinate fenestration (n = ). objective assessment of olfactory function using the university of pennsylvania smell identification test (upsit) and subjective assessment of symptom using visual analogue score (vas) were performed before and months after surgery. results: there were significant improvement comparing postoperative and preoperative upsit in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). the vas were also significantly improved postoperatively compared to preoperatively in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). patients undergoing partial middle turbinectomy and middle turbinate fenestration were more likely to show improvements in upsit ( . ± . vs . ± . , p = . ) and vas ( . ± . vs . ± . , p = . ) compared to those with only partial middle turbinectomy. conclusion: partial middle turbinectomy and middle turbinate fenestration during ess is an effective method for improving postoperative olfactory function. | nasal irrigation for the alleviation of nasal symptoms in pregnant women with allergic rhinitis we sought to determine specific ige responses to bacterial pathogens in sera from cystic fibrosis patients and analyze their kinetic during disease course. genes, respectively. in contrast, most of healthy donors had normal homozygous genotype with tt- . ± . %(n = ) and cc- . ± . %(n = ) with low frequency of mutations; gg- . ± . %(n = ) and tt- . ± . %(n = ) and heterozygous genotype tg- . ± . %(n = ) and ct- . ± . %(n = ) for il- and il- genes, respectively. following a month treatment, there was a significant reduction of cytokine levels in the il - . ± . and increased in the il - . ± . , when compared to the beginning of therapy and after months (p < . ) results: at baseline the st group had serum levels of il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/ l; nd group had il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/l vs il- ( . ± . ) pg/l; il- ( . ± . ) pg/l; ifn-γ ( . ± . ) pg/l in the control group. after months, there was a significant decrease in pro-inflammatory cytokine levels in the st (il- : ± . ; ifn-γ: . ± . ) pg/l and nd group (il- : . ± . ; ifn-γ: . ± ) pg/l, respectively. conversely, il- increased in st and nd groups to . ± . pg/l and . ± . pg/l (p < . ). conclusion: prior to the study initiation patients with tuberculosis had higher il- , ifn-γ and lower il- content than healthy controls. two-month chemotherapy produced significant reduction in proinflammatory cytokines and increase in anti-inflammatory il- , with levels approaching those of healthy controls. thus, tuberculosis drugs appear to have the anti-inflammatory effect in tuberculosis patients, which was predictive of positive clinical outcome. | antibiotic resistance: ligands of innate immunity take the challenge in this work, we aimed to perform an ex vivo hrsv infection in precision-cut lung slices (pcls) from human, rhesus, and cynomolgus macaques, comparing whenever possible the response with the viral surrogate poly i:c. method: pcls containing airways were prepared from lung sections of human, rhesus, and cynomolgus macaques. the slices were inoculated with hrsv-a iu/ml, uv-inactivated hrsv, or vehicle control for hours. macaque slices were also incubated with poly i:c μg/ml with and without the immunosuppressive dexamethasone μg/ml. viral replication, tissue viability, and immune response assays were assessed in supernatants, lysates, or slices. the inoculum infectivity of iu/ml as well the uv-inactivation were confirmed by plaque-assay on hep- cells. immunofluorescence staining using a fitc-labeled anti-rsv showed the presence of infected macrophages in pcls, but not in mock infected samples. hrsv stimulation slightly decreased tissue viability, as seen by live/dead staining and ldh assay. the viral infection increased ip- production in pcls of human, rhesus, and cynomolgus macaques, reaching respectively . , . , and . fold-increase in comparison to the vehicle controls. poly i:c stimulation caused ip- response comparable to hrsv in rhesus and cynomolgus pcls. the ip- production ratio comparing hrsv/poly i:c was . in rhesus and . in cynomolgus pcls. conclusion: hrsv infects ex vivo pcls of human and non-human primates, inducing the release of the pro-inflammatory chemokine ip- . this response is comparable to the viral surrogate poly i:c. in the future, these systems can be used to further investigate host response to hrsv, especially in the context of asthma development. however, a relatively small number of reports are related to the association of ebv with allergic diseases, in particular atopic ones. we found that among patients with activated ebv infection, polysensitization was found to be . times more frequent, chest syndrome was . times more common and hyper-ige syndrome occurred . times more frequently. in most of these patients, atopy was not detected in medical history. method: we evaluated the laboratory test results of five boys ( . %) and six girls ( . %), children ( with hbov and with cov). their average age at the study time was . ± months. nasal swab specimens were taken from these patients who admitted to our hospital with respiratory symptoms between - . patients are recalled after an average of ± . months. isaac questionnaire and skin prick test to common inhalated allergens were performed. results: only one patient had family history of atopy. forty percent of the patients with cov and % of the patients with hbov developed rhinitis. one patient with cov and one patient with hbov developed recurrent wheezing. one patient with cov developed atopic dermatitis. all skin prick tests were negative. it was noteworthy that . % of the patients were passive smokers. conclusion: hbov and cov may be associated with rhinitis but there is a need for more patient groups for a clear result. rna_lig (ccg-agg-aug-cga-ggc-uug-uu) . to study chemotaxis in vitro, a boyden chamber was used -wellfiltrationplatemultiscreentm -mic with a pore size of μm (millipore, usa). chemotaxis was studied in dynamics after , minutes and a day using the above ligands. as control, rpmi- medium without glutamine was used (paneco, russia). the statistical analysis was carried out using the computer statistical program biostat conclusion: with all the data provided, a drug induced hypersensitivity was diagnosed. we present a case of immediate allergic reaction with eosinophilia due to carbapenems, with tolerance to other beta-lactams antibiotics. written informed consent of patient has been obtained in the two cases. discussion: the first case shows cutaneous immediate hypersensitivity response to infbeta a. literature reports a few cases of urticaria and anaphylaxis but this is the first for the pegylated formulation. polyethylene glycol (peg) confers to a drug modified pharmacokinetics, solubility and immunogenicity. immediate reaction to peg (macrogol) have been described when combinated in vaccines or drug pils. dmf is a known cause of contact dermatitis related to footwear, wallets and furniture. flushig is a reported side effect of dms in ms managed with dose reduction. this case shows the possibility to immediate sensitization to dmf. as the armamentarium to treat ms now combines immunomodulatory and biologic drugs, the avaliability of diagnostic and desensitization protocols for hypersensitivity reactions must be keeped in mind. case report: drug rash with eosinophilia and systemic symptoms (dress) syndrome is an uncommon but serious hypersensitivity drug reaction, manifested with rash, fever, lymphadenopathy and visceral organ involvement. table) . drug withdrawal and prednisolone treatment leaded to attenuating of mentioned skin symptoms within days, associated by occurrence of a exfoliative dermatitis. one week after admission, the patient developed fever that lasted for days with enlarged lymph nodes on submandibular, paracervical, axillar and inguinal regions. a preventive antibiotic therapy is started and weeks later, the lymph nodes were not palpable and the skin got the normal appearance. corticoid therapy is reduced gradually according to symptoms resolvement. case : a -year old woman presented to our department with a -day history of pruritic, macular rash, periorbital swelling, cheilitis and fever. she had started some weeks ago the allopurinol for asymptomatic hyperuricemia, had longer history for treatment of arterial hypertension and type- diabetes mellitus (olmersartan, nitrendipine, methyldopa, furosemide, regular and glargine insulin), and experienced nephrectomy and cholecystectomy. the patient was febrile, while blood tests revealed eosinophilia, increased seric creatinine/urea levels (due to nefrectomy), and severely-altered liver parameters (see table) . the allopurinol withdrawal, topical and systemic corticoid therapy, and the liver protectors attenuated serologic transaminases levels and patient's skin lesions within few days, followed by substantial improvement of laboratory findings one week after therapy start. the treatment dosage was gradually tapered and finally stopped within a period of months in accordance with attenuating and complete resolvement of the clinical and laboratory abnormalities. our case demonstrated that dress syndrome is a severe drug reaction, but the immediate introduction of treatment and supportive measures can improve disease's outcome even after a temporary exacerbation or severe affection of internal organs. case report: a -years-old woman, diagnosed of ischemic cardiopathy, developed an anaphylactic shock minutes after the administration of ml sulphur hexafluoride intravenous during an echocardiogram. she was treated in emergency room with a total recovery. months earlier, she had developed an extensive erythematous-maculopapular rash converging in plaques in relation with adhesive dressings which had been placed during a hospitalization due to thoracic pain. an allergic contact dermatitis was suspected and recommendations thereon were given. interestingly, an arteriogram with iodixanol (icm) was carried out one week before skin reaction with good immediate tolerance. methods: blood test: blood count and serum chemistry were done during both reactions to contrast media. serum tryptase level was not measured during the anaphylaxis, but its baseline level was quantified later. conclusions: we present a patient with a double sensitization to parenteral contrast media: an anaphylactic shock due to sulphur hexafluoride and an atypical delayed exanthema related to iodixanol, and diagnose was obtained with st in both cases. this is the first documented case with a positive immediate st to sulphur hexafluoride. with the culprit drugs mixed with % and % petrolatum resulted negative. patient was suspected to have behcet's disease, and consulted to rheumatology department. oral colchicum dispert twice a day was prescribed. afterwards, patient achieved to take oral amoxicillin-clavulanate for a week without any hypersensitivity; and has been following by oral colchicum dispert maintenance therapy since then. the reported patient had one anaphylactic perioperative reaction to morphine and another anaphylactic reaction to tramadol during her diagnostic investigation. remain the question if this patient had two allergic anaphylactic reactions with cross-reaction between morphine and tramadol, or two non-allergic anaphylaxis due to "hypersensitive" mast cells. case presentation: a -year-old female was diagnosed with rectal adenocarcinoma. one year after radical surgery, progression with pulmonary metastasis was shown. in first line of systemic therapy she received premedication with pantoprazole, metoclopramide, clemastine and dexamethasone, followed by cetuximab infusion. during first minutes of infusion, grade anaphylactic reaction occurred. a reaction started with generalized pruritus, urticaria, rhinitis, followed by hypotension, bradycardia and loss of consciousness. she was treated with fluids, clemastine and methylprednisolone. next day she received same premedication followed by panitumumab. during first minutes she had grade reaction with generalized urticaria. the third day she had generalized urticaria minutes after metoclopramide application. skin prick tests with cetuximab ( mg/ml) were negative, but intradermal test were posi- bat response was highly positive for both cetuximab and alpha-gal, with comparable values and dose response curves. thus, we showed %, %, %, % and % of cd positive basophils for stimulation with cetuximab ( - . μg/ml), and %, %, %, and % for stimulation with alpha-gal ( . - . ng/ml). bat response to panitumumab was negative (< %; - . μg/ml). drug provocation with panitumumab was negative and patient received treatment with panitumumab. in the operating theatre, the skin is disinfected using povidoneiodine and pupil dilation is carried out with tropicamide (showing no immediate reaction in the surgery). method: as we are dealing with a late cutaneous reaction, the study of the medicine involved is carried out by means of epicutaneous medicine testing. in order to do the study of aflibercept, we wore gowns, two sets of gloves, a mask, eye protection and in a containment hood in the outpatients hospital. the patient diagnosed himself with dermatitis when in contact with povidone-iodine and despite the fact that the cutaneous provocation was negative, it is known that when there is surgery involved, there needs to be moistness and occlusion for it to show up clinically. the application of this antiseptic seems to lose its irritation and allergic properties when it dries on the skin and therefore tends to give a negative result in these patients, but this does not mean that they are not allergic to this antiseptic. we report the case of a year old man who experienced erythema and pruritus immediately after an intravenous injection of ranitidine and hyoscine butylbromide given for gastric pain treatment. results: spt and idt were performed for ranitidine ( mg/ml and . mg/ml respectively) and hyoscine butylbromide ( . mg/ml and . mg/ml respectively) being exclusively positive for ranitidine at idt dose with a × mm papule (histamine control × mm). oral provocation test for hyoscine butylbromide was negative. bat for ranitidine and famotidine were carried out, being negative for both drugs. conclusion: skin tests for h ra are the best option when studying a suspected reaction to h ra and are also useful for assessing cross-reactivity between other h ra. the sensitivity for bat in diagnosis of drug allergy is about %, and the specificity up to %, although these percentages make reference to the common drugs studied (beta-lactams, quinolones, pyrazolones, etc). specific studies for h ra are still to be done. in our case we had a negative result for the bat test, although we proved ranitidine was responsible for the reaction. conclusion: gentamicin is an aminoglycoside antibiotic used systemically for septicemia and as prophylaxis during surgery. immediate type allergy (type i) to gentamicin is rarely reported. since , approximately only five cases have been reported in literature. in our case, initial theories were pointed towards cefazolin as beta-lactams report a higher rate of allergic reactions. after an exhaustive allergological study, results disproved our initial theory indicating gentamicin as the responsible drug. giangrande n ; bobadilla-gonzález p ; garcía-menaya jm ; cámara-hijón c allergy department, infanta cristina university hospital, badajoz, spain; clinical immunology department, san pedro de alcántara hospital, cáceres, spain background: polyethylene glycol (otherwise known as macrogol or peg) is a polymer with a wide application as an excipient, solvent and dispersing agent in food, cosmetic and pharmaceutical industry. it presents distinct length polymer chains with a molecular weight from to g/mol conferring them specific properties. macroglol with a molecular mass between and g/mol is commonly used as osmotic laxative previously to colon endoscopy and radiologic examinations. after the introduction, anaphylactic reactions to macroglol are rarely reported, considering it safe and well tolerated. we report on a -year-old man who, immediately after of the topical application of benzindamine in left inferior limb developed acute urticaria in this limb, which reverted in approximately hours with systemic steroids. she had previously tolerated this product without any problems. skin prick-tests with benzindamine ( . mg/ml) and latex were realized in the patient. skin prick-tests with benzindamine were realized in eleven healthy control subjects. results: skin prick-test with latex was negative in the patient. skin prick-test with benzindamine was positive in the patient ( × mm). the prick-tests with benzindamine were negative in eleven healthy control subjects. we report on a case of contact urticaria due to benzindamine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. some of the drug used in daily clinical practice can cause allergic contact urticaria and should therefore be borne in mind. background: the use of new oral anticoagulants which act as direct inhibitors of activated factor x is constantly increasing, due to lower rates of serious and fatal bleeding events than warfarin/acenocoumarol. rivaroxaban, the first commercialized drug in this group, is the most used for prevention of thromboembolic events. however, < cases of hypersensitivity reactions have been described so far, most of them delayed and severe. to present a case of delayed hypersensitivity to rivaroxaban, diagnosed by a positive ltt (lymphoblastic transformation test). a year old woman with hypertension and chronic atrial fibrillation (af) was referred to our clinic for suspected drug allergy. she reported that months before, for af she was started on oral amiodarone and rivaroxaban, presenting on the seventh day with both of them generalized erythema, pruritus, micropapular rash and facial angioedema. no oral or other mucosal were observed, neither pustules, vesicles or blisters. blood eosinophilia, enlarged lymph nodes, renal and hepatic injury were discarded in emergency, where the new drugs were discontinued and replaced by acenocoumarol. the rash subsided one week later, with oral antihistamines. before and after the episode the patient also has been taking losartan and hydrosalurethyl, with good tolerance. she denied other adverse reactions. in allergy department we performed skin prick tests and intradermal tests with amiodarone ( . mg/ml and . mg/ml) and rivaroxaban ( . mg/ml and mg/ml), and a ltt with both drugs, months after the reaction. background: patients with history of beta lactam allergy, often self-reported, are commonly encountered in the hospital setting. this frequently leads to increase use of broad spectrum and more expensive antibiotics that may be unnecessary or even less efficacious at times due to fear and concerns about potential disastrous outcomes. nonetheless, with increasing awareness, many patients are now being referred to allergy service for formal evaluation. we aim to look at patients who underwent evaluation for beta-lactam hypersensitivity and determine the number of patients that were successfully de-labelled. method: a retrospective analysis was conducted with patients referred for evaluation of questionable beta-lactam allergy to the allergy service in our institution from the years - . initial evaluation process included a thorough history to determine the type of hypersensitivity reaction and suitability for further testing. patients underwent skin prick test (spt) and intradermal (idt) with either (a) both major and minor determinants of penicillin, benzyl penicillin, amoxicillin and ampicillin, and/or (b) the culprit drug itself. if skin testing was negative, oral or intravenous (iv) drug challenge was then performed after informed consent. clinical details and reactions were documented. patients were also contacted post challenge to ensure no delayed reaction had occurred. results: a total of patients were evaluated for beta-lactam allergy in the year period, of these were females and were males. of the referred patients had presumed penicillin group allergy and had cephalosporin group allergy ( patients had both penicillin group+cephalosporin allergy). cases ( %) were successfully de-labelled. beta-lactam allergy was confirmed in patients ( %); identified by positive spt in two patients, positive idt in six patients and positive drug challenge in patients ( patients developed rash/urticaria, had respiratory symptom and patients developed anaphylaxis). patients were referred before any drug allergy labelling was done, out of which were confirmed not to have beta-lactam allergy. conclusion: in our study, % of patients were confirmed not to have true beta-lactam allergy. we were able to successfully remove beta-lactam allergy label from the electronic record for % of the patients. results: a total of % referred amoxicillin-clavulanic acid (ax-clv) as trigger for the hypersensitivity reactions (hrs), followed by ax ( %), penicillin ( %) and cephalosporins ( %). almost % of hrs were immediate (< minutes). positivity of skin tests was observed in % subjects, of bat in % and of rast in %. in conclusion: the label of penicillin allergy is quite often erroneous. this involves using of more expensive and less effective therapeutic alternatives, which also facilitate the emergence of multi-resistant micro-organisms. hence the importance of confirming the diagnosis of allergy. finally, we did not find differences in the study of penicillin allergy in patients older than years compared with the general population. background: severe cutaneous delayed drug reactions (toxic epidermal necrolysis -ten-, stevens-johnson syndrome -sjs-, acute generalized exanthematous pustulosis -agepand drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome -dress/dihs-) among others, are a rare but potentially fatal complications of drug treatment. although its epidemiology has been described in different latitudes, it is unknown in latin america. our aim was to describe the epidemiological characteristics of severe cutaneous reactions to drugs in countries of latin america. method: an online questionnaire was designed to report new and old cases (since ). it was a modified and adapted version of enda questionnaire for drug allergy interesting group. sociodemographic data, type of reaction (ten, sjs, dress-dihs, agep), culprit drug (s), treatment, complications, mortality and sequelae, were described. three centers from colombia, one from argentina, one from brazil and one from paraguay were included. an excel database was created, in which cases were recorded and analyzed. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. the main culprit drugs were aromatic anticonvulsants in cases ( %), beta lactam antibiotics in ( %), non-beta lactam antibiotics in ( %) and allopurinol in ( . %). in % of the patients the suspect drug was withdrawn. thirty one patients ( . %) received systemic corticosteroids. complications occurred in cases ( %) and death in one patient ( . %). seven patients ( %) had some type of sequelae. countries, dress/dihs was the most frequently reported clinical entity, and the anticonvulsants were the main triggers. complications were frequent, but mortality was low. | drug-induced cough: analysis of nationwide spontaneous reports in korea over ten years using who-adverse reaction terminology (who-art) indicative of cough. results: from cases of spontaneously reported adverse drug event cases, a total of cases ( . %) were identified as drug-induced cough. most cases occurred in adults ( . % of the subjects) and females were more common than males ( . % vs . %). regarding severity, only cases ( . %) were classified as serious based on who criteria. the most common causative drug category was antineoplastic and immunomodulating agents ( . %), followed by cardiovascular drugs ( . %). the most common causative drugs were ace inhibitors including perindopril and ramipril. conclusion: in the nationwide spontaneous reports of adverse drug events, many cases of drug-induced cough have been reported so far. much attention is needed to find new causative drugs of cough in the future. background: allergological assessment to determine the mechanism of the perioperative reaction and to identify the agent responsible and recommendation of a range of drugs or agents likely for future surgery is essential, but it often poses a significant challenge. in this study, we analyze our experience in the investigation of adverse reactions during anesthesia in the last years. method: a total of patients who attended our allergy unit with suspected perioperative reactions between january and december were reviewed retrospectively. the severity of the perioperative allergic reactions was graded according to ring and messmer system. results: grade iii, ii and i reactions were observed in , and patients, respectively. in patient we didn't know the reaction suffered. tryptase measurements were available for patients. of those, and patients had elevated and normal levels respectively and suffered grade reaction. ige mediated reactions was diagnosed in patients ( %): for ßlactam antibiotics ( . %), for patent blue ( . %), for neuromuscular blocking agents-nmbas ( . %), for latex ( . %), for colloids ( . %) and for ranitidine ( . %) . cefazolin was the ß-lactam antibiotics causing the largest number of reactions. non-ige-mediated reactions was diagnosed in patients ( %). the allergy tests were negative and tryptase levels were normal. conclusion: in our series, among the patients who suffered allergy reactions during anaesthesia and the cause was subsequently identified, ß-lactam antibiotics were the most common causative agent ( . %), followed by patent blue ( . %), nmbas, latex, colloids and ranitidine ( . % each agent). in contrast, data from other authors indicated that nmbas were the most common cause of anaphylaxis, followed by latex, hypnotics, antibiotics, plasma substitutes and opioids. these differences might be due to the small size of our study, which was limited to our centre over the last years and thus may not be representative. diagnostic evaluation. all patients signed an informed consent. we made a retrospective analysis of their clinical records and excluded patients whose records were missing or incomplete. it was analyzed each patient's medical history (focusing allergic disease) and clinical reaction to the suspect drugs. signals/symptoms at pcc were characterized. we also studied the variation of the dpt's results when it was performed after a pcc. aim: to define and quantify the ongoing pharmacy needs in sustaining a large drug allergy assessment program. method: a retrospective review of pharmacy files was used to identify and quantify the drugs and dosages most frequently used and to determine prescription trends within the allergy testing program over the last years. results: initially, this reaction was thought to be a result of a drug allergy, but upon further review and the onset of fever, we determined that it met the diagnostic criteria of jhr. his twin brother was diagnosed with penicillin and betalactamic allergy. neutrophilia % was to be underlined in the blood test. after this, drug oral challenge with penicillin was performed, ruling out penicillin allergy. conclusion: it is not uncommon to confuse drug allergy with jhr. jhr should be an anticipated reaction to early doses of antibiotic treatment for treponemal diseases, such as syphilis. antibiotic treatment should be continued; it is not a warrant to stop treatment. clinicians should be aware and anticipate jhr as a potential complication to early doses of antibiotic for spirochetal diseases such as syphilis or lyme, leptospirosis. the patient was unresponsive in oral drug provocation tests with amoxicillin-clavulanic acid, clarithromycin and trimethoprim sulfamethoxazole for months. the patient could use these drugs. results: chronic abacterial inflammation of the prostate gland was accompanied by a significant increase in concentration of slpi, il- , tnf-α, il- in the seminal plasma and serum concentration, and a decrease in the concentration of il- and tgf-β compared to healthy men (p < . ). there was no statistically significant difference between slpi, il- , tnf-α, il- , il- , and tgf-β in the ejaculate of patients with inflammatory and non-inflammatory forms of cap (p < . ). the concentration of il- in ejaculate of patients with inflammatory forms of cap was significantly greater than in patients with non-inflammatory form of cap (p = . ). the inflammatory and non-inflammatory forms of cap are pathologically similar with changes in the concentration of the studied cytokines except for il- in both forms with signs of inflammation. the terms "leukocytic" vs "non-leukocytic" chronic abacterial prostatitis are more correct than "inflammatory" and "non-inflammatory" when describing chronic abacterial prostatitis. results: the status of all patients after dc immunotherapy was evaluated as satisfactory. heart rate, blood pressure in patients remained within the age norm. skin had normal color without rash or peripheral edema. there were no local or systemic allergic reactions. the body temperature after the injection did not exceed °c. conclusion: these results show, for the first time, that among mastocytosis patients, besides the already known periodontal disease risk factors that include diabetes, age, osteoporosis and alcohol consumption, the bone marrow mast cell burden is also associated with increased periodontal disease severity. results: metformin at relatively low doses ( - μm) was shown to mildly suppress ige-mediated responses, including degranulation ( % reduction, p = . ), tnf-α ( % reduction, p = . ) and il- ( % reduction, p = . ) secretions in bmmcs. importantly, metformin at the same doses potently inhibited mast cell responses in all parameters ( % reduction, p < . for degranulation; % reduction, p < . for tnf-α; % reduction, p < . for il- ) in mast cells treated with an ahr ligand, , -dihydroindolo[ , -b]carbazole- -carbaldehyde (ficz). mechanistically, its inhibitory effect was mediated through the suppression of ficz-induced mapk activation, intracellular calcium release and ros generation. metformin also blocked ahr-mediated pca in vivo ( % reduction, p < . ). conclusion: metformin, a common anti-diabetic agent, was shown to exert inhibitory effect on ahr-mediated mast cell activation in vitro and in vivo, suggesting its potential utility as a newer form of therapy for asthma and allergic diseases; this is particularly relevant when considering the adverse effect of the exposure to environmental polycyclic aromatic hydrocarbons. gasser p ; brigger d ; zbären n ; jardetzky t ; pennington l ; eggel a results: in one of affected family members, we were able to identify the c. a>g mutation in the plasminogen (plg) gene that was recently described to be associated with hereditary angioedema. this mutation leads to a missense mutation with an amino acid exchange p.lys glu in the rd kringle domain of plasminogen. there is no direct relationship between the earlier described cases with this mutation and the family we report here. in all affected members of the family, the symptoms manifested in early adulthood, with swelling of the face, the tongue and the larynx. the frequency of attacks was variable, between once in a year to once in a month. in one of the three family members, we found a slightly decreased level of coagulation factor xii and of plasminogen. icatibant proved to be very effective for the treatment of acute attacks in the affected family. the occurrence of the same c. a>g (p.lys glu) mutation in the plg gene in many families with no or only unknown distant relationship suggests that the disease might have been inherited through the generations without being purged from the population. the mutated amino acid exchange appears to be significant for the function of plasmin or plasminogen. we found a decrease in plasma levels of coagulation factor xii and plasminogen, which may be beneficial markers for diagnosis and monitoring of this disease. several biomarkers are useful in the diagnosis (fibrin degradation products (fdps), d dimer (dd), and fragments of prothrombin + ). also, a correlation between the levels of biomarkers and activity phases of the disease has been detected. alterations in coagulation parameters have an etiopathogenic role in the ae attack, but have not been considered as biomarkers of activity phases. tgt is a global coagulation test which quantifies in vitro the ability of plasma to generate thrombin and estimates alterations in coagulation parameters. the objective is to assess the usefulness of the thrombin generation test (tgt) to characterize patients with hereditary angioedema (hae). method: seventeen hae patients from hospital la fe were recruited to obtain blood samples in remission and during ae attacks. none of them experienced thromboembolic events. plasma was collected in citrate tubes to obtain platelet rich plasma. hemostatic parameters were analyzed:. tgt was conducted using a calibrated automated thrombogram (cat) method and a fluoroskan ascent as a reader. results were analyzed via thrombinoscope v . citrated plasma was incubated with calcium, tissue factor, phospholipids and a fluorogenic substrate. a thrombin generation curve is generated, obtaining parameters: latency time (lagtime), thrombin generation maximum speed (vo), maximum peak of thrombin generated (peak), time to generate the maximum peak of thrombin (ttpeak), total quantity of generated thrombin (etp), and the end time of thrombin generation (starttail). tgt parameters from healthy donors were used as controls. results: thirty-eight samples were collected from seventeen hae patients ( . % female). fifteen ( . %) samples were collected during ae attacks. tgt parameters and fdps were significantly higher in hae patients compared with controls (p < . ), although no significant differences were found in tgt between acute attacks and remission. a decrease trend in tgt is observed in ae attacks. fdps were increased during ae attacks, but normalized at remission periods. these results support the involvement of coagulation in the pathophysiology of hae, although no increase in prevalence of thrombosis is observed during acute attacks. method: the repeated measures design study included patients in two groups: the slit group, patients- follow-ups per allergen (p), and the vit group, patients- p. the slit group had patients treated for hdm ( p), and patients on pre-coseasonal pollen ait (grass p, ragweed p, birch p). the vit group had patients on rush protocol ( for bee and for wasp) and patients on conventional protocol ( bee, wasp, and for both). the ige and igg levels were measured by the immunocap method. the friedman test was used to compare data. results: when compared to placebo group, slit+vitamin d group therapy was more effective in the reduction of nasal symptoms (p = . ), asthma symptoms (p = . ) and combined symptommedication score (p = . ); there was no significant difference between groups in medication and ocular scores. we observed a significant improvement of fev (vitamin d group p = . , placebo group p = . ) and fev %vc levels (vitamin d group p = . , placebo group p < . ), within both groups, between visits. feno results did not differentiate statistically significantly the study participants in terms of receiving slit along with vitamin d or placebo. significant increase in the percentage of cd + cd + foxp + and in tlr positive cells in children receiving slit+ vitamin d was observed compared to placebo group. increase in cd + cd + fox-p + induction, and in tlr positive cells recruitment were independently associated with better clinical effect of slit in children. conclusion: overall, ait with a high-polymerized ash pollen extract was well tolerated. as ash pollen are supposed to be an important allergen during spring time, it is recommended to include spt and npt with ash pollen in the test panel for allergological diagnostic. additionally, determination of ash pollen specific ige could be applied. furthermore, appropriate ait should be considered for ash pollen allergic patients. a | impact of sublingual immunotherapy with a five-grass pollen tablet on grass pollen allergic rhinitis and asthma: a real-life, long-term analysis in france background: data on the fulfilment of prescriptions of symptomatic medications in patients with grass pollen allergy were analysed to evaluate the long-term effectiveness of sublingual immunotherapy (slit) on allergic rhinitis (ar) and asthma. method: by using data in the lifelink ™ treatment dynamics database (iqvia, paris, france), we compared two cohorts of patients with ar: a group treated with oralair® (stallergenes greer, antony, france) slit tablets (n = ), and a matched control group having received symptomatic medications only (n = ). oralair®'s effectiveness was assessed as the change in symptomatic medication fulfilments between the pre-index period (before the initiation of slit) and the follow-up period (after slit), and as the onset of asthma or the progression of pre-existing asthma (based on fulfilments of prescriptions for asthma medication). the number of fulfilments per year was calculated for each patient and each period. results: in line with prescribing guidelines, the mean duration of treatment with oralair® was . months per season for either seasons or seasons. the mean number of symptomatic medications for ar fulfilled per patient and per year in the pre-index period was . ± . in the slit tablet group and . ± . in the control group. in the follow-up period, this value fell for the slit tablet group (to . ± . ) but did not change significantly in the control group ( . ± . ). when considering individuals not taking any asthma medications in the pre-index period, asthma onset during the treatment period was observed in . % of those in the slit tablet group and in . % of those in the control group. the corresponding values for the follow-up period were . % in the slit tablet group and . % in the control group. when considering individuals already taking asthma medications in the pre-index period, the mean ± sd number of asthma medication fulfilments in the pre-index period was lower in the slit tablet group ( . ± . ) than in the control group ( . ± . ). the corresponding values for the treatment period were . ± . and . ± . , respectively. in the follow-up period, the number of asthma medication fulfilments fell more in the slit tablet group (to . ± . ) than in the control group ( . ± . ). oralair® tablets have long-term effectiveness by relieving allergic rhinitis and slowing a progression to asthma. b | a real-life, retrospective analysis evidencing slower long-term progression of asthma in grass pollen allergy patients treated with sublingual immunotherapy tablets | an examination of the reasons for treatment discontinuation and non-compliance to allergen immunotherapy background: allergic rhinitis (ar) patients treated with subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) may be non-compliant or discontinue treatment too early, which can negatively impact efficacy. therefore, understanding the reasons for non-compliance and treatment discontinuation is vital to help improve compliance, persistence and thus outcomes. this study reported reasons for treatment discontinuation to scit and slit and non-compliance to slit in patients with ar in published real-world studies. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for allergic rhinitis, scit, slit, non-compliance and non-persistence. across all studies,~ % of patients were non-compliant, and -year drop-out rates ranged from % to %. reasons for noncompliance and treatment discontinuation in this subset of patients were stratified according to the who dimensions for adherence (patient-related, treatment-related, or socio-economic). results: from the publications identified, six studies reported reasons for non-compliance to slit (n = ) or treatment discontinuation (n = ) to scit or slit, and the results were grouped for analysis. the majority of patients cited treatment-related factors as the primary reason for discontinuation ( % for slit, % for scit). common reasons were a length of treatment for slit and frequency of injections for scit. % of patients discontinued scit due to patient-related factors such as travel to doctors and waiting time for administration. only % of slit patients discontinued due to patient-related factors. socio-economic reasons for discontinuation were low for both therapies ( % slit and % scit). conversely, for non-compliance to slit, socio-economic factors were the most frequently cited reasons ( %), and included taking time off work and financial concerns. conclusion: of patients who discontinued therapy, treatmentrelated factors were the most cited reasons for scit and slit, reflecting concerns with administration and treatment length. noncompliant slit patients cited socio-economic factors as common reasons for non-compliance, suggesting financial concerns over a long treatment course. differences in reasons for non-compliance and treatment discontinuation may be due to patients assigning differing importance for compliance (a day-to-day decision) compared to the long-term decision to discontinue treatment. results: % of patients had monosensitization to rbet v component. the rest % had combinations ige to rbet v and ige to one, two or even three minor allergens ( %, %, % accordingly). after courses of slit by standardized pollen extracts symptoms of arc and pfas decreased in % and % patients accordingly. in group patients with monosensitization to rbet v : patients had a reduction of arc ( % had - degree by ado); patients had reduction of pfas. patients hadn't finished treatment due to allergic reactions. among patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patient hadn't finished treatment due to allergic reactions. in patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients with sensitization to rbet v /v /v showed the similar results: patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients had sensitization to all cra, and only patient who also received slit with grass allergens had reduction of arc only ( degree by ado). as the result of the study it was identified that beneficial effect of slit is highest in patients with monosensitization to rbet v . the increase of sige sensitization profiles to minor birch allergens caused less efficacy of slit treatment. dermatophagoides pteronyssinus immunotherapy is independent of sensitization to blomia tropicalis among children with allergic rhinitis and asthma method: children ( - years old) with allergic rhinitis and asthma sensitised to both dp and bt received years dp-scit. clinical symptom and medication scores, serum specific ige and specific igg were evaluated during dp-scit. in order to investigate whether the treatment outcome was dependent on the sensitisation pattern between dp and bt, patients were further grouped into dp and bt co-sensitisation and cross-reaction, according to positive or negative ige against bt major allergen (btma) blo t and blo t . btma+ group, with specific ige to either blo t or blo t , was defined as the co-sensitized group; btma-group, with no detectable ige to both blo t and blo t , was defined as the cross-reactive group in this study. results: all the recruited patients completed year of dp-scit, ( %) patients completed years of treatment. after years of dp-scit, compared to baseline, all patients had significant reduction in symptom and medication scores. lung function (fev ) was significantly improved as well. % of the patients were free of medication use and asthma symptoms, % of them were free of rhinitis symptom, and the fev % in all patients were higher than % of predicted. dp-scit induced significant increases in dp and bt specific igg . in % of patients, dp specific igg increased more than fold and bt specific igg increased more than . fold. further investigation in btma groups showed moderate correlation (spearman r = . , p = . ) between specific ige against dp and bt in the btma-group (n = ), indicating specific ige cross-reactivity. no specific ige correlation (spearman r = . , p = . ) was found in the btma+ group (n = ) indicating co-sensitisation to both dp and bt. the two groups showed almost identical change in clinical responses. dp and bt specific igg significantly increased during dp-scit, no difference was found between the two btma groups. conclusion: dp-scit can induce specific igg cross-reacting with bt allergens. patients with specific ige sensitisations to both dp and bt may have clinical benefit from dp-scit treatment. moreover, the clinical benefit of scit was independent of ige cross-reactivity or co-sensitisation to dp and bt. method: we investigated allergic rhinitis children who were basically sensitized to house dust mite and received house dust mite slit for year and months. among patients, patients were mono-sensitized to house dust mite (group ) and patients were poly-sensitized aside from house dust mite (group ). we also assigned another allergic rhinitis children who were only treated by medication as control group. nasal symptoms (rhinorrhea, sneezing, nasal obstruction, nasal itching, sleep disturbance) and anti-allergic medications use were assessed at every -month visit. results: the symptoms of allergic rhinitis started to improve after months of slit and significantly improved after a year and a half in group and group compared with control group. there was no significant difference between group and group . anti-allergic medication use in group and group significantly decreased after a year and a half compared with control group and there was no significant difference between group and group . conclusion: house dust mite slit was more effective than treatment only by medication. the effect of house dust mite slit was similar between mono-sensitized and poly-sensitized allergic rhinitis children. house dust mite slit could also be recommended to polysensitized allergic rhinitis children. method: a prospective, randomized, double-blind, controlled, multicenter phase ii study was conducted with four different concentrations of cluster allergoid clustoid wiesenlieschgras (group : tu/ml; group : tu/ml; group : tu/ml; group : tu/ml). out of patients screened, grass pollen allergic patients ( - years) were randomized. the cluster build-up phase was followed by four monthly maintenance injections of . ml. the efficacy was evaluated by the change of the threshold concentration step needed to induce a positive reaction in a titrated nasal provocation test (tnpt) before start and after end of the study (pre-post analysis). the safety profile was assessed for each treatment group by analyzing treatment-related adverse events. background: allergen immunotherapy relies on the consistent administration of allergen extract, therefore compliance to these treatments (subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) tablets and drops) is vital for efficacy. as scit is administered as an injection by a healthcare professional, and slit is self-administered, compliance to scit may be perceived as superior. therefore, a review of real-world studies investigating compliance to scit, slit-tablets or slit-drops was conducted. real-world studies, instead of clinical trials, were included in this review as they are more likely to reflect actual clinical practice and patient compliance. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for ar, scit, slit-tablets and slit-drops, and real-world compliance. compliance was reported according to ispor medication compliance and persistence work group definitions. results: from the publications identified, eight studies (seven slit [one slit-tablets, two slit-drops, four unspecified], one both scit+slit-tablets) reported compliance rates and were included in the analysis. real-world compliance rates ranged from % to % for slit administration and % for scit administration. only one study compared compliance of slit to scit, with similar rates reported over three years ( % and % respectively). three studies reported "good" compliance (physician-reported or patients consuming > % of allergen extract) to slit-drops or slit-tablets. the good compliance rates were higher for slit-drops ( %- %) compared to slit-tablets ( %- %). observed compliance to slit-drops or slittablets did not vary by country or geographical region. the percentage of patients defined as having "good" compliance to slit-tablets or slit-drops did not vary by study length or patient population. conclusion: whilst compliance to scit may be perceived as superior to slit-tablets and slit-drops, comparable compliance rates between scit, slit-tables and slit-drops were identified across real-world studies. differences between perception and real-world results may be explained by a lack of direct comparisons between scit and slit administration. limitations included discrepancies in definitions of compliance, as well as methodology between studies. however, these are common to reviews analysing compliance, regardless of therapy area. conclusion: in the allergic rhinitis patients, successful compliance for -year slit compared with control was approximately %. method: igg inhibition elisa: rabbit igg antibodies specific for grass allergen allergoids are pre-incubated with different concentrations of alum-adsorbed grass pollen allergoid. the mix is added to an allergoid coated microtiter plate. unbound igg will bind to the allergoid coat and is subsequently incubated with anti-igg hrp labeled conjugate and stained with tmb. results are expressed as percentage inhibition relative to the uninhibited value. the concentration of alum-adsorbed allergoid that is required to inhibit % igg is used as read-out. circular dichroism: far-uv cd spectra ( - nm) were recorded on a j- spectropolarimeter. a cuvette with a stirring compartment was used to keep the suspension homogeneous during measurement. results: the igg inhibition elisa assay is specific for grass pollen allergoids (not for other allergen allergoids), has a good inter-and intra-assay precision and is robust for assay variation. thermally stressed alum-adsorbed grass pollen allergoids were used to show that the igg inhibition assay can be used as a stability indicating method. severe thermal stressing resulted in a higher % inhibition value, indicating a loss of igg epitopes. furthermore, far-uv cd analyses showed that there is a close relation between the decreasing igg binding capacity ( % inhibition values) and the loss secondary protein structures by unfolding (cd-ratio / nm values). the igg inhibition assay was demonstrated to be a valuable method to determine the stability of alum-adsorbed grass pollen allergoid preparations. in addition, a relation was shown between the igg binding capacity and the change in secondary protein structures. | design of a pivotal phase iii trial of allergen specific immunotherapy (ait) using a high-dose house dust mite (hdm) allergoid in patients with allergic bronchial asthma method: male and female outpatients (age - years) asthmatics allergic to hdm are enrolled. during the baseline phase, the patient's minimal dose of ics required to achieve asthma control will be assessed. after the baseline period, approx. patients will receive double-blind placebo-controlled treatment for approx. months, followed by a nd period of weeks to assess the minimal ics dose and further months of observation for the assessment of asthma exacerbation. based on the results of the dose finding study regarding the efficacy endpoints and the safety profile, the optimal allergoid dose is considered to be pnu. results: competent authorities and ethic committees in all participating eu countries, serbia, russia and ukraine approved the study design. the primary endpoint of the trial is the change in predefined dose steps of the minimal daily ics dose required to achieve asthma control after approximately months of subcutaneous ait. all efficacy data will be determined using daily questionnaires and the acq by e-diary for months from october to january. the aim of this clinical trial is to demonstrate efficacy and to evaluate safety of ait with an allergoid preparation of major allergens of dermatophagoides pteronyssinus in patients suffering from allergic bronchial asthma caused by house dust mites. asthma increases the burden of allergic disease and health care costs, especially when uncontrolled. with the development of a high-dose preparation we intend to treat asthmatic patients highly efficiently. romantowski j; jassem e; lata j; wasilewska e; chelminska m; specjalski k; niedoszytko m background: specific immunotherapy (sit) is the only causal treatment in patients allergic to airborne allergens. it has been proven to be widely effective in allergic populations, but individual patients vary in terms of response to the therapy. the aim of the study was to assess the factors that might affect the efficacy of sit. method: patients treated with sit for grass pollen or house dust mites were included. the efficacy of sit was assessed with the use of allergy control score (acs), performed before and at least after one year of sit. the following variables were assessed as potential risk factors for a poorer response to sit: age, gender, type of allergy, type of allergen, type of vaccine, type of sit and smoking history. background: specific immunotherapy (sit) is a suitable treatment option for asthma and allergic rhinitis (ar), but it is not commonly used in korea. in the achievement of the treatment, it is important that immunotherapy is applied with ideal dose and regular intervals and it is essential for the patient compliance. the aim of this study is to investigate evaluate compliance with immunotherapy protocols of patients who were treated with sit in clinic and their satisfaction of the treatment. we performed a multicenter, cross-sectional survey using a specially designed questionnaire that was given to allergy specialists and patient in korea. a member of the trained research group conducted face-to-face questionnaire interviews with each respondent. conclusion: this study shows that most patients are ar with asthma. in our study sit compliance and satisfy are found to be high in both groups. aim: to identify the frequency of regress claims in a dermatological setting and to assess its impact on general prescription behaviour and immunotherapy. method: all physicians of the psoriasis-praxisnetz süd-west e.v. (n = ) were invited to participate in a web based questionnaire study on the topics of dermatology and medical law. the survey was separated into two sub-polls which were carried out after a first poll deciding whether the topic of medical law is of any interest for the dermatological practice. the topic of interest was located in the second poll. results: overall, dermatologists participated in this study. most participants were form bavaria, baden-wuerttemberg or rhineland-palatinate and had more than years of experience as a dermatologist. out of the participating physicians . % (n = ) already experienced a previous regress claim. of these, . % (n = ) stated, that the experienced regress claim changed their prescription behaviour. half of these participants (n = ) further stated, that the fear of a possible recourse affects their prescription behaviour, whereas only out of the other participants declared a possible influence. missing values excluded, this leads to a substantial hesitation in physicians who experienced a prior recourse ( . % vs . %). nevertheless, this seems not to affect the usage of allergen immunotherapy, as all physicians who already experienced a regress claim, stated to use allergen immunotherapy. the fear of a possible regress can change physicians' prescription behaviour but does not seem to have an effect on the prescription of allergen immunotherapy. therefore, the topic should be addressed from another perspective such as providing trainings on relevant regulations for physicians who experienced a prior recourse claim. this approach could also improve patient centred care related to modern treatments. results: the sds were significantly reduced in patients subjected to slit (p < . ) year after the onset it. vas also was significantly reduced (p < . ) with satisfied control of sar and the same time with translation from moderate-severe to mild-moderate sar, after slit. nbh was also significantly reduced (p < . ) year after the onset slit. in patients receiving pht only, sds, vas and severity of sar did not change and significantly higher (p < . ) from the value obtained in the experimental group. nbh also remained unchanged and significantly higher (p < . ) then in experimental group. precoseasonal slit added to pht shows short-term beneficial clinical effects in polysensitized patients with sar and scuad phenotype. results: ten studies ( children, adults; median sample size, ) met the inclusion criteria. the risk of bias was moderate to high in all but one studies. low strength evidence supports the assumption that ait is effective in reducing symptoms and medication use, with only out of studies reporting higher benefit in the ait group vs comparator group. subgroup analyses of studies sharing similar characteristics did not explain inconsistency. safety does not appear was not major concern for alternaria ait. conclusion: this is not enough strength of evidence to suggest that mold ait is efficacious for the treatment of respiratory allergies. high-quality studies with an adequate sample size are needed. abstracts | | tolerability of a two week rush updosing with modified trees, modified grasses or modified grasses/trees mixture in pollen allergic subjects in the day-to-day practice table) severe systemic reactions (grade iii and iv) did not occur. conclusion: rush immunotherapy is an effective therapeutic method for patients with allergic rhinitis. it seems that in cases requiring faster response to treatment, this immunotherapy can be considered as a substitute for conventional immunotherapy. | design of a pivotal phase iii allergen immunotherapy study to assess the efficacy and safety of subcutaneously administered tyrosine adsorbed modified birch allergen+mpl results: the design of this study, including sample size and primary and secondary endpoints, will be discussed based on prior experience gained in two dose finding studies. in addition, the number of patients screened and randomized will be presented by country, gender and/or age and screen failures will be categorized. results: the primary analysis showed an absolute difference in tcs between placebo and du of . ( %, p < . ). the odds of experiencing a severe day during the bps were approximately doubled in the placebo group compared to the du group (or = . , p < . ) and the odds of experiencing a mild day were halved (or = . , p < . ). similar results were seen for the tree pollen season (tps), covering both alder, hazel and birch pollen seasons. the total rqlq score was improved for du compared to placebo during the bps and tps (p < . , except for the last week of the tps), with the most pronounced effects during week - of the bps (absolute difference: . - . , p < . ). treatment was well tolerated. the most frequent adverse reactions were mild or moderate local reactions related to the sublingual administration. no deaths were reported and no serious adverse events were assessed as related to the sq tree slit-tablet. conclusion: treatment with the sq tree slit-tablet improved arc symptoms and need for symptomatic treatment. the du group had less "severe days" and more "mild days" during the pollen seasons. the quality of life was similarly improved. these findings substantiate the clinical relevance of the sq tree slit-tablet for patients with arc induced by pollen from the birch homologous group. nagaraju k ; nagaraju k ; katare s ; kapatkar v ; shah a ; rathod r results: total n = subjects (mean age . ± . years, . % males) completed entire study. the mean incidence of artis reduced from . ± . episodes at baseline to . ± . (p < . ), with . % subjects not suffering from any episode. the mean duration of episodes reduced from . ± . to . ± . days (p < . ). % of episodes (vs % at baseline, p < . ) required antibiotics for mean duration of . ± . days (vs. . ± . days, p < . ). none of arti episodes in follow-up period required hospitalization as against . % episodes, (mean duration ± . days; p < . ) before pidotimod therapy. the number of school days lost & work days lost showed reduction of . ± . days(p < . ) & . ± . days(p = . ) respectively. the average expenses incurred in treatment of artis shows significant reduction of rs. ± (p < . ). adverse events were reported in ( %) subjects, which were mild in nature. a statistically significant increase in absolute counts of t-& nk cells was seen in explorative assessment of immune markers. the study shows pidotimod to be well-tolerated effective therapy in reducing the incidence and severity of recurrent artis, thereby providing additional benefit of reduction in discomfort & healthcare cost due to recurrent artis. thus, pidotimod can be considered as potential therapeutic option for treatment of recurrent artis in children. martignago i ; ridolo e ; incorvaia c department of medicine and surgery, university of parma, parma, italy; cardiac/pulmonary rehabilitation, asst pini/cto, milan, italy background: two registered sublingual immunotherapy (slit) products are available to treat grass-pollen induced rhinoconjunctivitis, consisting of the -grass (phleum pratense) and the -grass pollen tablets. no study of direct comparison of the efficacy of the two products was performed. we report the case of a patient who was treated in different years with the -grass or the -grass tablets with contrasting efficacy. the patient was a -year old woman suffering from years of grass pollen induced rhinoconjunctivitis. in slit was started with the -grass pollen tablets, but in , due to unavailability of the product, slit was performed by the -grass pollen tablets. in the third year of treatment slit with the -grass pollen tablets was resumed. for the -grass tablets slit was initiated before the pollen season and stopped after months of treatment, while for the -grass tablets the treated was prescribed to be continuous. the efficacy of slit was evaluated by symptom-medication scores as reported in diary cards by the patient during the month of may, when the grass pollen usually reach the higher concentration in the atmosphere in lombardy, where the patient lives. results: the mean symptom-medication score in the first year of treatment ( -grass tablets) was . , compared with a mean score of . in the second year ( -grass tablets). the patient was unsatisfied of the symptoms control and asked to resume for the last year of slit the -grass tablets. the mean symptom-medication score in such year was . . no clinically relevant adverse event was reported with any slit product. conclusion: based on the momentary unavailability of the -grass pollen tablet, it was possible to assess in a same patient the clinical outcome associated to either of the two registered slit products. a significantly different efficacy of slit with the -grass tablets compared with the -grass tablets was observed. | fusion proteins consisting of bet v and phl p form ige-reactive aggregates with reduced allergenic activity najafi n ; hofer g ; gattinger p ; smiljkovic d ; blatt k ; selb r ; stoecklinger a ; keller w ; valent p ; niederberger v ; thalhamer j ; valenta r ; flicker s background: bet v and phl p representing major allergens in birch and grass pollen, occur as monomeric proteins with high allergenic activity as assessed by clinical provocation testing in patients. she did not suffer more hymenoptera stings after the last reaction. one bee sting several years before bst resulted in no reaction. she has no symptoms with honey, vegetable or other food ingestion. methods: total ige and specific ige were determined using inmu-nocap system (thermofisher, scientific inc). apis, vespula and polistes (hørsholm, denmark) were also performed. prick tests showed negative results for all extracts tested. intradermal skin tests were positive for apis at μg/ml, but negative for vespula and polistes. our patient was diagnosed of anaphylaxis due to apis venom, thus bst was contraindicated and an epinephrine autoinjector was prescribed. she rejected hymenoptera venom immunotherapy. conclusion: to our knowledge, this is the first case of anaphylactic reaction after bee sting therapy. bee sting therapy should be considered a risk factor for anaphylaxis. patient reported good control of their disease, improved their quality of life, tolerating contact and exposure to numerous horses as well as contact with clothes of people who had been exposed. although ita is absolute contraindication on uncontrolled asthma with a degree of evidence ia, our case had only "transitory" con- and immunocap among wasp allergen components-i , i , i were %; . , %; . and %; . respectively and honey bee allergen components-i , i , i were %; . , %; . and %; . respectively. agreement between polycheck and immuno-cap i and i allergen components were %; . and %; . respectively. agreement between polycheck and euroline i and i allergen component were %; . and %; . respectively. based on wasp and bee components in all three systems, sensitization pattern was analyzed. similar test results were found between euroline and immunocap systems. the comparative studies carried out showed a markedly higher compliance of results with the euroline tests compared to polycheck with the immunocap system. percent agreement was extremely high and kappa value was substantial or almost perfect in the case of bee venom allergy between euroline results: a total of patients were included; ( %) males, with a mean age of (± ) years; ( %) beekeepers, ( %) were atopic, ( %) had asthma, ( %) rhinitis and ( %) cardiovascular disease, and of these patients were on ace/beta blockers. vit with honeybee was proposed in ( %), wasp ( %) and polistes ( %). the mean duration of vit was (± ) months. however, completed less than months. of the total, patients ( %) were not treated with vit. eighty-eight patients ( %) participated in the telephone interview: completed vit ( %), were still on vit ( %) and did not undergo vit ( %). of those who completed vit, ( %) were restung and went to the emergency department (er). twenty-four patients ( %) were stung while still on vit. of those never on vit, ( %) were re-stung and went to er. the severity of the reactions according to mueller of the patients who completed vit (mean follow-up time was months ( - months)) and were stung again was: local reaction in ( %), grade i in ( %); grade iii in ( %). one had a toxic reaction after multiple stings. in those who were stung during vit, ( %) had local reactions, ( %) grade i and ( %) grade iii. of those who were not treated and were re-stung: ( %) had grade i, ( %) grade iii and ( %) grade iv. in this series, the patients who did not undergo vit presented a greater number of systemic reactions when re-stung as well as more severe reactions (p < . ). conclusion: in this group with indication for vit, the reactions of the re-stings were less severe in the patients who had completed or who were on venom immunotherapy, as expected. three quarters of those who did not undergo treatment had severe anaphylactic reactions when they were stung again. this study reinforces the importance and the efficacy of immunotherapy in the treatment of hymenoptera venom allergy. method: this is a retrospective, descriptive study of cases diag- method: data were issued from the reference centre in mastocytosis of toulouse university hospital. ms diagnosis was determined using world health organization diagnostic criteria. hymenoptera venom immunotherapy was performed with an ultra-rush protocol (table) . results: seven patients were included ( women, men), median age years old. during the anaphylactic reaction, cutaneous signs missed in all cases. the reaction was most often severe: grade (n = ), grade (n = ), grade (n = ). three patients suffered from digestive symptoms and one from respiratory manifestations. basal tryptase in serum reached . - . μg/l. hymenoptera venom specific ige were low ( . - . kui/l) except for one patient ( . kui/l). ait was initiated with vespula venom in patients, polistis in patient, apis mellifera and vespula in patient, vespula and polistis in patients. no reaction was observed during ait. four restringing accidents led to increase the cumulative dose to μg and μg in patients. in these patients, the diagnosis of mastocytosis was made due to the resting. conclusion: hymenoptera venom ait using ultra-rush protocol seems well tolerated in patients with systemic mastocytosis. specific studies are necessary to determine the real tolerance profile of this protocol. collaboration with reference centres for mastocytosis should be considered for all patients with mastocytosis associated to hymenoptera venom allergy. dose (μg/ml) results: see table. conclusion: there is a shift or immunomodulation in terms of sige to vespids. even in patients double sensitised who were receiving venom of only one of the vespids. albanesi m background: slit has been suggested as an alternative route for allergen-specific immunotherapy. aim of this study was to investigate allergen-specific antibody responses in birch pollen allergic children who had received slit for two years using recombinant allergens. method: children (n = ; - y o) with respiratory symptoms of birch pollen and oral allergic syndromes (oas) were studied. ten children received slit with staloral, were treated by slit with microgen, and children received only symptomatic therapy (control group). sige and sigg levels to rbet v , rbet v , rbet v were measured twice (before therapy started and after two years) using quantitative immunocap and a panel of more than microarrayed allergens using immunocap isac technology. clinical efficacy of slit was evaluated by recording symptoms upon allergen contact and need of rescue medication. results: all children were sensitized to the major birch pollen allergen, bet v and one patient from each of the groups showed to bet v , no patient had sige to bet v . after two years of slit clinical improvement was observed in the slit patients. in the staloral group there were no respiratory symptoms in patients and a decrease of symptom severity in the other cases as well as a partial or complete tolerance to pr allergen-containing food in the patients. microgen treatment had no influence on oas symptoms but decreased of pollinosis severity in children. however, there were no statistically significant differences of bet v -specific levels measured before and after treatment in the slit and control groups (mann-whitney, p > . ). in this real-life study we found that birch allergic children who had been treated with slit showed a reduction of clinical symptoms but we did not find a significant induction of allergen-specific igg levels in the slit-treated group when compared with children who had only symptomatic treatment. conclusion: our study confirms the scarcity of food additives allergy. it also suggests that even when the diagnostic of allergy was excluded with a negative oral food challenge, families remain suspicious about industrials feeding products containing food additives. these results should reassure health professionals and parents who incriminate too frequently food dyes and conservators when a manifestation which mimics allergic reactions occurs. background: autumn/winter birth has been reported to be a risk factor of food allergy (fa) development. a putative mechanism is that dry/cold weather causes and exacerbates infant atopic dermatitis (ad), which is a major risk factor for food sensitization through inflamed/damaged skin. we investigated prevalence of fa among infants under well skin care in relation with seasons of birth (sob). we recruited full-term newborn infants without perinatal diseases at an obstetric/pediatric clinic. participants were followed up for skin status and food allergy symptoms until months of age. sob were defined as spring (march-may), summer (june-august), autumn (september-november) and winter (december-february). ad was diagnosed based on the united kingdom working party's criteria. use of moisturizer (mo) and topical corticosteroids (tcs) was recorded. primary outcome was fa based on apparent immediate allergic reaction after ingestion of causative food. we classified infants who avoided any food because of sensitization or mother's anxiety as suspected fa. results: six hundred and thirty-one infants were screened for month-period and infants were enrolled in this study. of them, infants were born in spring-summer (s-born) and infants were born in autumn-winter (w-born). fa developed in ( . %) infants and ( . %) infants had suspected fa. there was no difference (p = . ) in prevalence of fa and suspected fa between s-born and w-born. multivariate analysis revealed ad at and months of age was a significant risk factor for fa with or= . ( %: . - . ) and or= . ( % ci: . - . ), respectively. prevalence of ad at months of age was higher in w-born than s-born but prevalence promptly decreased thereafter and stayed low with early use of mo and tcs. prevalence of ad was rather higher at months in s-born than w-born. results: cases and controls were included. the median age was years, (q -q - ). men and women were almost equally represented ( . % males). alcohol consumption associated with the intake of mammalian meat or innards as the trigger factor. the overall prevalence of a positive result of sige to α-gal was abstracts | . % ic % ( . , . ); cases _ . % ic % ( . , . ) controls _ . % ic % ( . , . )_. among cases sige anti α-gal positivity rate ranged from . % (rural), to . % (half-urban) and . % (urban). the rates of positivity were . %, (northern) . % (center) and % (mediterranean). a positive result of sige to α-gal was more frequently observed among men ( . %) than women ( . %) and associated with history of tick bites, practice of outdoor activities, pet's ownership and the antecedent of having eaten mammalian meats or innards previously to the development of symptoms background: a special challenge in the st century for allergists is allergy to food, which is considered "the second wave" of epidemics of allergic diseases. panallergens occur in unrelated organisms and perform a similar function in them. in their structure, they have highly conserved amino acid sequence regions and a similar three-dimensional structure, and thus meet the requirements for cross-recognition by ige. results: in patients ( %) isac test has been shown to have specific ige for panallergen components. mostly, the presence of ige for pr- proteins has been shown in patients. in patients ige to ltp; patients ige to ccd; patients to profilin; patients to tropomyosin; patients to serum albumin, person to tlp. an important aspect is undoubtedly the occurrence of simultaneous sensitization to several panallergens. analysis of data from the study group showed that isolated sensitization to one panallergen concerned only pr proteins ( patients), tropomyosin ( patients) and profilin ( patient). in the remaining patients, the analysis of the isac test results showed that two or more panallergens were allergic. in the study group, asige for the component responsible for the occurrence of real food allergy was detected in ( %) patients. mostly, the presence of ige for jug r has been shown in patients. in the study group, panallergens were more likely to be responsible for food intolerance than specific food allergens. results: of children, children had peanut allergy only, children had tree nut allergy only, and children had both. the mean age was . ± . years in peanut allergy, . ± . years in tree nut allergy, and . ± . years in both. male to female ratio was significantly higher in tree nut allergy ( . %) than peanut allergy ( . %). among tree nut allergens identified, walnut ( . %) was most frequent, followed by almond ( . %), hazelnut ( . %), pine nut ( . %), chestnut ( . %), cashew ( . %), pistachio ( . %), and macadamia ( . %). mean serum total ige level was kua/l in tree nut allergy and kua/l in peanut allergy. mean serum specific ige level to peanut, walnut, almond, hazelnut, and pine nut was . , . , . , . , . , and . kua/l, respectively. children with peanut allergy had higher rate of co-sensitization with soybean and higher soybean-specific ige levels than children with tree nut allergy. however, there was no difference in co-sensitization rate with tree pollen between peanut and tree nut allergy. children with peanut allergy showed significantly increased co-sensitization rate with egg white and wheat compared to children with tree nut allergy. a . % of the children with peanut allergy and . % of tree nut allergy showed co-sensitization with aeroallergens. a total of % of the children with peanut allergy showed decreased specific ige levels within - years. conclusion: prevalence of peanut and tree nut allergy is similar. tree nut allergy develops later than peanut allergy and more common in male. children with peanut allergy showed higher co-sensitization rate with soybean, egg white and wheat compared to children with tree nut allergy. | natural history of egg allergy in a large cohort of infants with food allergy shows its high prevalence but also its transient nature in a months of follow-up background: the cohort of infants ( boys, girls, - months) with the food allergy has been followed for months. as more than % of infants manifested atopic dermatitis (ad), a condition closely linked to egg sensitisation, we focused our attention on egg allergy, following its natural history as well as a development of atopic march. method: the diagnosis of food allergy was based on a personal history, clinical examination, skin prick tests and/or atopy patch tests with native foods. laboratory tests were performed within year of age the latest. the specific ige levels against food allergens were measured using immunocap or immulite. patients with ad were scored according to scorad system. the oral food challenges (ofcs) with cooked/baked egg were done in children at the age of months except for children at risk of anaphylaxis. results: within the whole cohort the allergy to cow milk proteins was confirmed in pts ( . %), to egg in pts ( . %), to wheat in pts( %), to lentil in pts ( . %) to banana in pts ( . %), to soya in pts ( . %) and to potatoes in pt ( . %). in a cohort of egg allergy patients we found out that: % of pts presented the early onset of allergy-up to months of age, % of pts presented severe ad (scorad > ), % of pts showed cosensitisation to peanuts, % of pts had early sensitisation to inhaled allergens, and majority % of pts presented with early onset allergic rhinitis and/or asthma. we proved that egg allergy is closely linked with the early onset of allergy symptoms, with severe forms of ad, co-sensitization to peanuts, early sensitisation to inhaled allergens and an early onset of allergic rhinitis and/or asthma. we also proved that the egg allergy in infancy is transient. the tolerance to baked/cooked egg was achieved in about % of pts at the age of years, unlike previously published results claiming the reach of tolerance in % of pts at the age of years. in these patients we studied: sex, personal history, type of reaction they presented, time of onset of symptoms and food involved. results: out of a total of patients over years of age (from to years old) who have been attended the consultation for the first time during these period, patients ( . %) ask about possible allergic food allergies. of these patients who came for possible allergic pathology, patients ( %) presented positive results. these are the other item we have studied: . sex of patients: % of the patients are women. these patients because of that, it is important to remember that food allergy can also appear in old people. the food that is mainly involved in our population is fish and seafood. a much higher percentage than in other populations, probably due to the mediterranean diet of spain. the symptoms mainly involved are itching and skin lesion, which is the characteristic symptom of a mild allergic reaction. in our population, there was patients with a anaphylactic shock, a much higher percentage than in other studies. the experience with this group of patients is still limited. more studies are needed to know better this patient profile. background: cow's milk allergy (cma) is the first atopic disease in children. diagnosis suspicion in the emergency room (er) is increasingly frequent, however, further assessment by an allergist is often difficult to schedule. therefore, screening for cma through a blood test (specific ige) while the infant is still in the er has gained momentum in recent years. we set out to analyse (a) symptoms which had led the emergency physician to prescribe specific ige, (b) the prevalence of confirmed cma among infants screened in the er, and (c) the long-term outcome of the screened infants. method: a retrospective study of medical records and laboratory results was performed. patients were infants under months, without a previous diagnosis of cma, attending one of the two pediatric er of the university hospitals of marseille, france. allergy blood tests were specific ige to cow's milk extract (immuno-cap, thermofisher, sweden). in infants with specific ige to cow's milk extract of . kua/l or higher, ige directed to the main three individual proteins (casein, alpha lactalbumin et beta lactoglobulin) were also measured. results: infants were included from december to june . the sex ratio was . . % of infants were atopic et % were currently or had been breastfed. the most prevalent symptoms were vomiting and reflux. one third of infants were hospitalized after the er visit. following the er visit, % of infants attended a specialized consultation with an allergist. % of infants with a follow-up visit were diagnosed with an ige mediated cma. infants with cma developed further food allergies (egg, nuts, cashew…). it is difficult to diagnose it. the emergency pediatrician are increasingly confronted to infant with symptoms evoking cma. thus they prescribe sige and extensively hydrolysed proteins because they know that ige-positive infants can be ige-negative during the interval between the er visit and the follow-up one. after bad results interpretation of blood assay after er visit, cma was probably over diagnosed without prick test for ige positive allergy and no eviction/ reintroduction test for non ige. the lack of allergist is probably leading to over prescription of blood assay in er to diagnose cma and prolonged eviction of milk. results: a total of patients were included ( % female) aged from to yo with an average . ± years. % of patients had history of atopic disease: % rhinitis, % asthma, % prior food allergy, % eczema, % drug allergy, % eosinophilic esophagitis (ee) and % chronic urticaria. mean serum total ige was . ui/ml. sensitization to aeroallergens was present in % of patients, the most common were dust mites ( . %), pollen ( . %) or both ( %). in ( %) patients, first symptoms of fa appeared ≥ yo, with an average age of ± . yo. in this group, were diagnosed with ee, with eosinophilic colitis and with eosinophilic gastritis. from the remaining patients, had history of reaction with more than food group (fg). cutaneous reactions were referred in % of patients followed by anaphylaxis ( %) and gastrointestinal symptoms ( %). the fg most commonly implied were: fresh fruits (n = ), seafood (n = ) and tree nuts (n = ). fa diagnosis was confirmed in % of patients, the remaining had negative ofc. in ( %) patients, their symptoms started under yo, with an average age of . ± yo. from this group, ( %) were diagnosed ee. from the remaining patients, cutaneous complaints were the most frequent ( %) followed by gastrointestinal ( %) and respiratory symptoms ( %). the most common fg implied were: fresh fruits(n = ), seafood(n = ) and tree nuts(n = ). only one anaphylaxis was referred. fa was confirmed in %, the remaining had negative ofc. in patients with history of anaphylaxis of had positive st and/ or sige; one had negative sp and sige, with ofc positive. the blood donors were classified based on their clinical symptoms related to possible as contact via fish intake: allergic to as ( %), chronic urticaria ( . %), unspecific dyspepsia ( . %) and asymptomatic ( . %). the prevalence of sensitization (anti-as ige > . kua/l) were . % (ic: . - . %; mean . kua/l; median . kua/l) with a maximum value of . kua/l. raw fish consumption was the only variable associated with statistical significance (p < . ) to as sensitization ( . % vs . %, respectively). albacore and codfish were the most consumed species associated to seropositive results ( %), followed by hake ( %). coastal population ( . % vs . %), non-previously frozen fish consumption ( . % vs . %) and > times per week fish consumption ( . %) were other seropositive associated factors. background: oral allergy syndrome (oas) is an ige-mediated allergy caused by raw fruits and vegetables in patients with pollen allergy, which is known as the most common food allergy in adults. however, there has been no nation-wide study on oral allergy syndrome in korea. the aim of this study is to investigate the prevalence and clinical manifestations of oas in korea. method: twenty two investigators from hospitals and private clinics participated in this study. the patients with allergic rhinoconjunctivitis and/or bronchial asthma with pollen allergy were enrolled to the survey. the questionnaires include demographics, a list of fruits and vegetables, and clinical manifestations of food allergy. pollen allergies were diagnosed by positive results of one or more pollen allergens including birch, alder, hazel, beech, oak, willow, poplar, bermuda, meadow, orchard, rye, timothy, mugwort, ragweed, hop japanese on allergy skin prick tests (allergen/histamine ratio ≥ +) and/or serum specific ige levels using multiple allergen simultaneous tests (mast ≥ +) or immunocap (≥ . ku/l). conclusion: this is the first nation-wide study for oas in korea. the prevalence of oas in korea was . %, in which substantial proportion had anaphylaxis. these results will provide useful information for clinicians to apply in clinical practice. we conducted a self-administered, questionnaire-based survey in - during the -month checkup. children were considered to have food allergies if they were diagnosed by a physician or if they had been instructed to avoid a causative food after medical examination by interview. we divided the year into three periods. the months of march-june were considered spring, july-october as summer/fall, and november-february as winter. while the season of onset for the boys occurred in . %, . %, and . % in spring, summer/fall, and winter, respectively, it was . %, . %, and . %, respectively, for the girls. thus, the onset rate was the highest in winter for both genders. in boys whose mothers did not consume folic acid (fol − ), the food allergy onset rate was significantly higher for boys whose mothers ate no eggs and for boys whose mothers ate - eggs per week than for those whose mothers ate eggs daily according to the dunnet multiple comparison test. however, no relationship was observed with egg intake if the mother had consumed folic acid (fol + ). on the basis of seasons, fol − and egg intake by mothers affected only children born in winter, with a significant difference in the dunnet multiple comparison. among mothers who did not eat eggs, fol + was . % and fol − was . %; for mothers who ate - eggs per week, fol + was . % and fol − was . %; and for mothers who ate eggs every day, fol + was . % and folwas . %. thus, consumption of folic acid seemingly annulated the effects of eating eggs. however, for girls, neither folic acid nor eating eggs had any effect on the onset rate. conclusion: since this effect varied according to the birth season, consumption of folic acid, a methyl group donor, appeared to affect the allergy onset in children. results: skin prick test with commercial extracts of tuna ( mm), cod ( mm), rooster ( mm), hake ( mm), salmon ( mm), trout ( mm) and anisakis ( mm ige to shrimp, lobster, crab and mixed seafood were all undetectable. dermatophagoides pteronyssinus , to assess for tropomyosins was negative. outcome: the patient continues to react to both hdm and shrimp, despite undetectable ige levels to tropomyosin associated components. this is the only testing available in south africa currently and hence we are unable to look at other proteins. the relationship between tropomyosins in shellfish allergy and mite allergy has been well documented and investigated, but other allergens are now also being implicated in cross-reactions. we also established the level of ige specific to allergen components using the immunocap isac method. allergen-specific ige was not elevated to any shrimp allergens available in immunocap isac: n pen m (tropomyosin), n pen m (arginine kinase) and n pen m (calcium binding sarcoplasmic protein). the patient was diagnosed with a shrimp allergy. the molecular diagnostics used did not explain which allergen component is the patient allergic to. it is possible that the patient is allergic to hemocyanin, which can also cross-react with house dust mite allergens, but confirmation of this diagnosis requires further investi- results: the groups were identical in terms of the age and sex (table ) . ara h ige correlated (spearman test) with the cumulative protein dose (threshold dose) r = − . (p = . ) but not with reaction severity r = . (p = . ), or the use of adrenaline r = . (p = . ). patients with ara h ige < ku/l had higher threshold doses ( vs mg) than children whose ara h ige was ≥ ku/l (p = . ). there were no significant differences in severity of the reaction or in use of adrenaline (table ) . the level of ara h ige is relevant in predicting the threshold dose at peanut exposure. a low reaction threshold dose increases the risk of reaction at an accidental exposure leading potentially to a severe reaction. flaxseed allergy is uncommon and most of the cases reported involved anaphylaxis. cross reactivity has been described with other seeds. case report: a -year-old atopic girl diagnosed with egg allergy and rhinoconjunctivitis and asthma due to pollens. when she was eight, she presented two reactions consisting of conjunctival, periorbicular, malar erythema and abdominal pain after eating egg free french toasts cooked with flaxseed. she was treated with oral antihistamines. the allergic workup included prick-by-prick test with flaxseed which was positive and skin prick tests with mites, molds, cockroach, cat, dog, profilin, ltp and pollens with positive results for olive and grass pollens. the serum total immunoglobulin (ig) e was u/l, and specific ige to flaxseed was . kua/l. the flaxseed extract was resolved with sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) and an ige immunoblotting was performed under nonreducing conditions. the patient's serum showed specific recognition of a -kda band in the immunoblot. proteins were identified using mass spectrometry (maldi-tof) that showed results highly consistent with conlinin, a s storage protein of flaxseed. we described for the first time a patient with allergy to flaxseed due to conlinin, a s storage protein of flaxseed. background: cyperus esculentus is an herbaceous plant that has edible tubers called tiger nuts. in spain, they are used mainly in the elaboration of the well-known "horchata" or tiger nut milk, which is obtained by macerating tiger nuts with water and sugar. tiger nut allergy has rarely been reported, despite of its widespread consumption. case report: we present the case of a -year-old male with a history of oral syndrome allergy with several fruits (peach, melon, banana, kiwi, apple, pear and plum) and seasonal allergic rhinoconjunctivitis due to grass pollen. he reported oral pruritus, vomiting and cutaneous itching in both arms and hands immediately after drinking tiger nut milk. he became asymptomatic without treatment after - hours. the allergic workup included skin prick tests with profilin, ltp, latex and fruits that were positive to melon and watermelon and negative to profilin, ltp, latex and the rest of the fruits. prick-by-prick tests with melon, banana, kiwi, apple, pear, tiger nut and tiger nut milk were positive. the serum total immunoglobulin (ig) e was . μg/l, and specific ige was negative to profilin, ltp, bet v and all the tested fruits. background: specific blood ige tests for food allergens are mainly used to confirm a suspect food allergy than to diagnose such an allergy. this is due to the low positive predictive value and the high negative predictive value they have. nevertheless, they are very helpful when they are interpreted in the context of medical history by an experienced allergist. we analyzed the prevalence of sige in children with suspected food allergies. we retrospectively analyzed the all the consecutive laboratory tests of sige for food allergens during the two-year period ( ) ( ) ( ) . tests were of children diagnosed or suspected to have food allergies. a quantitative immunoblot assay was used to measure the circulated different sige. t-test, wilcoxon signed rank test, and chi-square were used to make comparisons. results: fifty-six ( . %) men and ( . %) females, . + . years old with a maximum of years and a minimum of months old were part of children whose tests were analyzed. one-third of the tests ( . %) reveals more than one sige present and . % of the tests resulted negative for the sige for the allergens tested (table) . only ( . %) children have very high concentrations (> iu/ml) of egg whites sige, and ( . %) have egg yolk sige. concentrations of . % of sige positive cases were . - . iu/ml. in our study more than half of the children suspected of food allergies resulted negative for sige for most common food allergens. seventy-nine percent of the positive cases had relatively low sige. only a few positive cases have higher sige than iu/ml. our data support the recommendation that sige couldn't be decisive in food allergic diagnosis, but they may help if they are interpreted cautiously. method: seven patients with a mean age of . years and female to male ratio of: : , with a background history of hypertension treated with an acei presented with oro-pharyngeal irritation (itch, tingling), face and tongue angioedema and laryngeal constriction, on ingesting fresh fruits (cherries, apples, plums, peaches, apricots, strawberries, grapes), vegetables (parsnips) and/or nuts (peanuts, hazelnuts). two patients required admission to emergency department and three received adrenaline auto-injector. six out of seven patients underwent skin prick testing to common aeroallergens and the index foods. in five cases, immunocap/isac testing was undertaken. in one case the diagnosis was based on the history and in one other case it was based on history and skin prick tests. results: a diagnosis of pfas was confirmed in all patients through the clinical history, spt and/or specific ige serology to the offending food confirming predominant sensitisation pr- allergens. primary food allergy and spontaneous angioedema was excluded in all patients. in the cohort studied, the pfas symptoms were unusually severe. we therefore postulate that this was secondary to concurrent use of acei. the management of these patients to sensitization to a β-casein with high homology between only the first milks. more precisely, the allergen candidate could be γcasein, which is derived from β-casein by proteolysis, whose abundance increases during cheese production from fresh milk, and which is absent in cow's milk. a lactoglobulin specific to buffalo's milk may also be responsible. in case of ewe's and goat's milk allergy without cow's milk allergy, sensitization to buffalo's milk should systemically be seeked out. we recommend inclusion of all mammalian milks in the list of the mandatory allergens for declaration on food products. method: prick tests with fruit battery, ltp and profilin was made. analytical with blood count, immunoglobulins, triptasa, total ige and specific ige to banana, apple and orange. finally, open oral provocation with fruits was performed. the diagnostic key was given by the mother of the patient who attended consultations because the infant had erythema in the temporary zone after drinking sea water on the beach. associated with salivation, the patient presented erythema in the malar area lasting a few seconds many times. the prick tests with fruits, ltp and profilin were negative. hemogram: eosinophils/μl, total ig e: . iu/ml, specific ige to fruits were negative. triptase: . μg/l. method: here we describe a variety of cases of nsltp allergy presenting to a tertiary allergy centre in the north west of england. results: nsltps have been found to be major allergens in various foods and they are likely to produce severe and systemic allergic reactions. this is reflected in the cases we present here. these proteins are highly cross-reactive due to extensive sequence homology and are panallergens. nsltps are remarkably heat stable and retains its allergenicity in processed foods. it is assumed that nsltps may sensitise both by inhalation and ingestion. an intriguing aspect in nsltp hypersensitivity is the extreme variability of its clinical expression. co-factors are often needed for the clinical expression of nsltp hypersensitivity. conclusion: patients regardless of where they are from, presenting with multiple severe/systemic food allergies need to be investigated for nsltp allergy. these patients require specific dietary advice on foods to avoid and a tailored management plan on how to deal with their allergic reactions. cow's milk as well as cow's milk products are tolerated. material and methods: skin prick tests with different sorts of milk, cheese and milk proteins were performed, specific ige antibodies were measured, a basophil activation test with cow's and goat's milk was performed and an oral provocation test (opt) with cow's milk, cow's milk cheese, raw milk and raw milk cheese was conducted. results: skin prick tests were positive for sheep's milk, goat's milk, goat's milk casein, feta, pecorino and parmesan cheese. elevated specific ige against goat's milk ( . ku/l) and sheep's milk ( . ku/ l) were detected. activation of basophil granulocytes after incubation of the patient's blood with cow's milk and goat's milk was measurable but also in the non-incubated control blood. all cow's milk products were tolerated in the opt. conclusion: despite consistent homologies between whey and casein proteins of mammals and high cross-reactivity between cow's, goat's and sheep's milk an isolated goat's and sheep's milk allergy with tolerance of cow's milk is possible. skin testing and specific ige help to distinguish from allergy against cow's milk proteins. diet counseling is possible after opt. introduction: salmon roe's allergy, without concomitant fish allergy, is rarely described in western countries. there are few studies on its allergenicity. objective: to report of a case of salmon roe allergy without concomitant fish allergy in a western country. case report: a -year-old male with house dust mite allergic rhinitis and asthma, describes for the st time, in , an acute episode of dyspnoea, rhinorrhoea, ocular pruritus, epigastric pain and nausea, a few minutes after the ingestion of a sushi meal with rice, salmon, salmon roe, wasabi, soy and ginger. these complaints motivated observation in the emergency room, where it was still documented uvular oedema. he was prescribed intramuscular adrenaline, intravenous steroids and anti-histamines with complete symptoms resolution. the patient declares not had eaten other foods, taken any drugs including nsaid, been infected or practised exercise. skin prick tests with food extracts (salmon and other fish, shellfish, soy, rice, egg total, egg white, egg yolk, ovalbumin and ovomucoid) were negative. skin prick-prick tests were positive for salmon roe ( × mm) and negative for egg (white and yolk), ginger, salmon, flying fish roe (tobiko), sturgeon roe (caviar) and black scabbard fish roe. specific-ige (sige) to salmon roe extract was . kua/l (immu-nocap-phadia) and negative against extracts from salmon fish and other fish (< . kua/l). sds-page immunoblotting with salmon roes extract showed a kda-ige binding band, that may correspond to a lipovitelin. after the allergic reaction the patient have tolerated abstracts | salmon fish and other fish roes (tobiko, caviar and black scabbard fish). no oral provocation test with salmon roes was performed given the severity of the reaction. conclusion: this report is an example of a severe allergic reaction to salmon roe without concomitant fish allergy, where the clinical history and the in vivo and in vitro tests were important to an accurate diagnosis. the authors believe this is the first report of a salmon roe anaphylaxis in our country and highlight the importance of this allergen in the western countries, given the increase of sushi consumption in these countries. case report: the prevalence of food allergy is increasing worldwide and consumer habits are changing. pomegranate (punica granatum) was commonly consumed in the mediterranean area but in the last few years became also popular in the different parts of europe. a -year-old boy was admitted to our emergency department suffering from allergic reaction within minutes after consumption of pomegranate. he presented with skin pruritus, generalized urticaria and eyelid edema. symptoms resolved within an hour after oral intake of cetirizine. prick-to-prick test with pomegranate was positive (wheal diameter × mm). he had a history of anaphylaxis with egg (urticaria and wheezing) at the age of month, meanwhile consumption of egg is well tolerated. an episode of anaphylaxis with unknown origin appeared at the age of years (urticaria, wheezing and abdominal pain). skin prick tests with aeroallergens revealed birch pollen allergy and he was diagnosed with allergic rhinoconjunctivitis. dietary elimination of pomegranate was suggested and adrenaline auto-injector was provided. we have analyzed omalizumab effectiveness and safety in patients with csu from our database. clinical response was categorized as: no response, partial or complete response by using the urticaria activity score (uas ). furthermore, the dosage, administration frequency and any side effects were recorded. results: effectiveness: out of patients ( %) achieved complete response. ( . %) after a single dose of mg ( patients) or mg ( ); patients ( . %) after two doses of mg ( patients) or mg ( ) results: multi-ethnic adolescents accounted for approximately . % of the total sample of adolescents. prevalence of asthma was significantly higher in multi-ethnic group than non multi-ethnic group. we examined if maternal or paternal foreign born status had a differential effect: in multi-ethnic family with foreign-born father, prevalence of asthma was significantly higher. parental region of country at birth had a significant influence on the prevalence of asthma. adjusted logistic regression analysis was used to determine risk factors for occurrence of allergic disease. residential area, perceived household economic status, parental region of country at birth, and body mass index (bmi) had a significant effect on prevalence of asthma. conclusion: population admixing appears to have significant effect on the prevalence of asthma. further study will be needed to clarify the effect of population admixing on prevalence of allergic disease. several studies have aimed to explore the possibility of mirs as biomarkers for various diseases. in our study we examined six different mirs, previously shown to be involved in eosinophil development and other immune responses, in serum from non-allergic and allergic asthmatics and healthy control subjects in order to determine their potential ability to be used as biomarkers for varying forms of asthma. method: serum from healthy individuals as well as age matched non-allergic asthmatics (naa) and allergic asthmatics (aa) were utilized. additionally, the naas and aas subjects had high eosinophila (≥ . × cells/l) compared to healthy controls (≤ . × cells/l) and eosinophil cationic protein (ecp) in serum was measured. asthmatic subjects were included irrespective of inhaled corticosteroid usage. rna was extracted from serum, reverse transcribed and subjected to qpcr analysis. expression changes in six candidate mirs, mir- , - , - a, - , - , and - , were investigated. results: two mirnas, mir- and mir- a, were significantly upregulated in aas as compared to naa or healthy subjects. additionally, mir- was upregulated in naa, but not aa or healthy subjects. furthermore, the expression change observed in the aa mirs appeared to correlate with the use of inhaled corticosteroids, but not in the naa mirs. finally, mir- and mir- expression levels were altered based on the number of eosinophils, which correlated to ecp levels, in naa subjects. conclusion: using six mirs found in the literature to be involved in eosinophila or immune responses, we were able to detect expression changes in the serum of healthy and asthmatic individuals. moreover, were able to distinguish between healthy individuals, aas, and naas on inhaled corticosteroids or with differing eosinophil levels, leading to the possibility that these mirs may be valuable future biomarkers for asthma. background: some studies report that certain sensitization profiles may increase the risk of a more serious allergic respiratory disease. the aim of this study was to describe the sensitization patterns to major allergens of dust mites in our area and investigate the association of these patterns with a specific clinical picture. method: multicenter study performed in hospitals for months. we recruited patients older than years with rhinitis and/or bronchial asthma, with a history of allergy to dust mites and both skin test and specific ige to d. pteronyssinus, d. farinae or l. destructor positive. der p and der p were determined to all of them. we analyzed patients with an average age of . years, . % women, . % smokers, . % rhinitis and asthma, . % only rhinitis and . % only asthma. % of patients presented sensitization to d. pteronyssinus, . % to d. farinae and . % to l. destructor. the detected sensitization patterns were: both der p /der p positive . %; der p positive . %, der p positive . % and both der p /der p negative . %. it was observed that patients with higher specific ige levels had more severe forms of respiratory disease, with isolated asthma or associated with rhinitis. for d. pteronyssinus, d. farinae, der p and der p > ku/l there is a greater number of cases of asthma associated with rhinitis, while for l. destructor > . ku/l greater number of cases of asthma. no relationship was observed between a specific sensitization pattern and an increased risk of asthma. conclusion: . specific ige values greater than ku/l for d. pteronyssinus, d. farinae, der p and der p , were significantly associated with a higher probability of asthma and this association was significant for l. destructor> . ku/l (class ). . there are four well-defined sensitization patterns in our population that are influenced by geographic location, being the double sensitization to der p and der p the most prevalent and allowing the correct characterization of % of the cases. none of them increased the risk of asthma. kobori t ; nagao m ; ekenkrantz t ; borres m ; sjölander a ; fujisawa t national mie hospital, tsu-city, japan; thermo fisher scientific, uppsala, sweden background: reliable biomarkers for diagnosis and management of asthma in young children are needed since pulmonary function test and exhaled no measurement, good biomarkers for asthma in older children and adults, are difficult to perform in young age. we have developed a sensitive and stable assay system to measure eosinophil-derived neurotoxin (edn), an eosinophil granule protein, that is released upon activation, and that may serve as a marker for eosinophilic inflammation also in young children. method: volunteer children from - years old were recruited and an isaac-based questionnaire was filled out by their caregivers. venous blood was obtained to measure serum and plasma edn and eosinophil count. edn was measured with a research assay developed on the immunocap ® platform. conclusion: blood edn may be a reliable biomarker for diagnosis of asthma in preschool children. conclusion: feno measurement as an add-on option in asthma management to identify asthma patients with th driven airway inflammation is less costly than the use of standard diagnostic methods. new biologics may have an additional impact on overall asthma treatment costs. our model demonstrates that incorporating feno measurement may help to optimize asthma medication and reduction in physician visits as well hospitalizations due to severe exacerbations. | peripheral airway inflammation assessed by fractional measurement of the exhaled breath temperature is a leading feature of asthma background: airway inflammation is considered to be a hallmark of asthma. the potential clinical benefits of assessing it non-invasively has led us to develop a method and device for measuring the temperature of the exhaled breath (ebt=exhaled breath temperature) reflecting the thermal state of the airway mucosa. studies have demonstrated that ebt is increased in asthma, proportionately to the level of control of the disease. in an attempt to further increase the usefulness of this approach, we have further developed a device to allow the assessment of the relative contribution of the central and peripheral airways (caw and paw). now we present the frebt data gathered from patients with suboptimal control of their asthma and from healthy subjects. method: in this cross-sectional study we included volunteers: patients with suboptimally controlled asthma of mild to moderate severity (median age , range - years, men) and nonsmoking subjects without respiratory disease (median age , range - years, men). we measured the fractions corresponding to caw and paw sampled with a fast reacting inflatable balloon valve system operated by a computer during a single breathing cycle. it allows steering of the expired airflow through channels with sensitive temperature sensors. during an initial deep inhalation, the inspired volume is measured and the sequence of valve openings is adjusted so as to yield volumes of air characteristic of caw or paw during expiration. the ratios between [pawebt-cawebt] over the total ebt [%] measured during the same manoeuvre (fractional ebt, frebt) were calculated and compared between asthmatics and controls. results: there was high statistically significant difference between the frebt ratios of asthmatics and controls: . ± . (mean ± sem) vs . ± . , p < . . as the magnitude of the ratio depends on the difference between pawebt and cawebt, higher values of the frebt ratio point to bigger contribution of the peripheral lung tissues, presumably indicative of peripheral inflammation. multiple regression analysis with frebt ratio as dependent variable identified only asthma diagnosis as significant predictor (p < . ) and excluded all other anthropometric indices. conclusion: peripheral airway inflammation assessed by frebt measurement appears to be a leading characteristic in asthmatics compared to healthy subjects. method: we examined outpatients ( % male, aged - year, mean age . years) with severe asthma according to ers/ ats ( ) definition treated with high dose of ics/laba± tiotropium, antileukotrienes and omalizumab. some patients (n = ) had orally steroid-dependent asthma. they referred to our secondary care center by gps. pulmonary function tests were measured by dry spirometer ( , vitalograph ltd., uk). skin prick tests or serum specific ige to common inhalant allergens (house dust mite, animal dander, pollen) were used to assess atopic status. results: seventy five percent (n = ) of patients with severe asthma had fao in % of those was diagnosed concomitant copd. duration of asthma was . years in patient with reversible airway obstruction (rao) and . years in those with iao (p > . ). early (before age years) onset of asthma was established in % of patients with rao and in % of patients with fao (p > . ). prevalence of atopy did not differ between both groups ( % vs %, p > . ) but total ige level in serum was higher in severe asthmatics with rao than fao ( me/ml vs me/ml respectively, p < . ). most of atopic patients with severe asthma both with fao ( %) and roa ( %, p > . ) were sensitized to house dust mites (d. pteronyssinus and d. farinae). hypersensitivity to pollen was diagnosed in % patients with foa and in % with rao (p > . ), to cat and dog dander in % and % respectively (p < . ). the majority ( %) of patients with severe asthma had fao. hypersensitivity to house dust mites was most common in severe atopic asthmatics with foa and roa where as sensitization to animal danger was associated with presence of foa. | loss of smell as a clinical marker of severe asthma and its association with upper airway inflammatory diseases background: asthma is frequently associated with rhinitis and chronic rhinosinusitis (crs) while severe asthma is more associated with crs with (crswnp) than without (crssnp) nasal polyps. loss of smell (los) is associated with crs, mainly with crswnp. we aimed to assess loss of smell as a clinical marker to discriminate crs from rhinitis and severe from non-severe asthma. method: in a cross-sectional multicentric study, asthmatic patients (n = ) were evaluated by pulmonologists and ent specialists using gina, aria, and epos definitions. los was evaluated by severity [vas scale, - mm, median (iqr,inter-quartil range)] and by prevalence of anosmia (hyposmia vas > - mm, anosmia vas> mm). results: los was present in . % of asthmatics (hyposmia . %, anosmia . %). los was more severe [ mm ( - ), p < . ] and anosmia more frequent ( . %, p < . ) in severe persistent asthma than in moderate [ mm ( - ); . %] mild [ mm ( - ); . %], or intermittent [ mm ( - ); . %] asthma. in addition, los was more severe [ mm ( - ) vs mm ( - ), p < . ] and anosmia more frequent [ . % vs . %, p < . ] in crs than in rhinitis patients. in those asthmatic patients with crs, los was even more severe [ mm vs mm ( - ) p < . ] and anosmia more frequent ( . % vs . %, p < . ) in crswnp than in crssnp. conclusion: loss of smell and specially anosmia may clearly discriminate severe from non-severe asthma and crs (specially with np) from rhinitis alone in asthma patients. thus, los may be considered a significant clinical marker of severe asthma and its association with upper airway inflammatory diseases. | last station in the eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis march: eosinophilic asthma with radiological findings associated with blood eosinophilia yilmaz i ; nazik bahçecioglu s ; türk m ; tutar n ; oymak fs ; gülmez i erciyes university school of medicine, kayseri, turkey; department of chest diseases, kayseri, turkey; division of immunology and allergy, kayseri, turkey background: eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis (eacrs/np) is a subphenotype of adult-onset eosinophilic asthma. blood eosinophil levels are shown to be highly elevated in patients with ea-crs/np and have potential for tissue infiltration. we aimed to demonstrate the clinical features of the patients who have a blood eosinophil level above % and have thorax computed tomography findings due to blood eosinophilia. results: we identified patients who met the above criteria. we defined this group as "eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis with radiological findings related to blood eosinophilia" (earr). the mean age was . ± years and % was female. nasal polyps, aspirin exacerbated respiratory disease and atopy was present in %, % and % of the patients, abstracts | respectively. the mean blood eosinophil count was . cells/mm ( %). the majority of earr patients had upper lobe dominant ground-glass opacities. the mean follow-up period was . ± . years. earr patients did not evolve into eosinophilic granulomatous polyangiitis in the follow-up. method: we aimed to identify features more probably associated with asthma in a unselected group of patients with diagnostic criteria for aco. we consecutively selected the first consecutive patients with diagnostic criteria for aco. all patients were evaluated by accurate clinical history interview, assessment of asthma control test (act) and copd activity test (cat), lung function and exhaled nitric oxide (fe no ) measurements, sputum cytology, blood eosinophil count, serum total ige and periostin levels, methacholine and adenosine-mono-phosphate (amp) bronchial challenges. all these measures were repeated after an oral corticosteroid (ocs) trial of methylprednisolone mg/day for days. we defined parameters that we expected improved after the ocs trial, and therefore considerable as markers of asthma: fev , fef - , fev /fvc, fe no , act, sputum and blood eosinophilia, methacholine and amp challenges. patients with improvement of at least of these parameters after ocs trials were defined as "responders" to the treatment, and therefore more likely to be asthmatic than copd or aco. results: five ( %) patients were classified as responders and they were characterized by having basal higher fe no values ( . ± . vs . ± . ppb, p = . ), greater bronchial reversibility basal values of serum periostin and total ige, and blood eosinophils were higher in responders but without reaching the statistical significance. conclusion: fe no and the degree of bronchial reversibility (and possibly also the degree of response to an amp challenge) are reliable biomarkers to distinguish asthmatics among those with suspect aco. method: the preliminary case-control study included obese persons with asthma who were matched for age and sex and nonobese asthma subjects. non fasting serum levels of adiponectin, and leptin were measured by commercially available immune assay kits, and routine biochemical parameters were analyzed in both the study groups. the results show statistically significant lower levels of serum adiponectin and higher serum leptin levels in obese asthma subjects with respect to non-obese asthma patients (p < . ). moreover, an inverse correlation was also observed between serum adiponectin and serum leptin in obese asthma subjects (p < . ). our results indicate the association of these hormones might act as a significant predictor in the progression of asthma. moreover, the role of serum adipokines is promising and might potentially act as a meaningful drug target in the pathogenesis of asthma. background: overweight/obesity is known to be a possible factor for poor asthma control. the aim of the study is to determine the serum concentrations of leptin in atopic asthmatic patients and its relationship with body mass index (bmi), asthma severity defined by medical treatment and asthma control defined by the asthma control test (act). method: we randomly selected adult patients previously diagnosed with allergic asthma based on gina (global initiative for asthma) guidelines, returning for follow-up to an outpatient allergy/ immunology clinic during november . following an informed consent, the patients were asked to fill act, their bmi was recorded, and elisa blood assays for leptin were drawn. exploratory data analysis, spearman's correlation ( % ci by bootstrapping), and partial correlations were performed. results: female/male ratio was / , mean bmi was . ± . conclusion: leptin was significantly associated with overweight/ obesity in asthmatic subjects, and showed higher values for women. leptin inverse correlation with act did not reach statistical significance, likely owing to underpowered estimates, in a small sample characterized by an elevated mean bmi and severe allergic asthma. background: immunoglobulin lowering may be associated with recurrent wheezing symptoms and clinic by increasing the tendency to viral respiratory tract infections. in this study, it was aimed to investigate the frequency of immunoglobulinemia in preschoolers with wheezing. the study was conducted between . . and . . between. university of health sciences, ankara child hospital, the children allergy and immunology clinic included patients who had been followed up and treated for at least one year with recurrent wheezing attacks within younger than months. the immunoglobulin (g, a, m) values of the patients were retrospectively analyzed. immunoglobulin levels were determined to be normal and low according to age limits. the study included patients ( . % male, . % female) under the age of years with a mean age of . months. the mean follow-up period of the patients is . years. in . % of these patients, at least one immunoglobulin was found to be low. none of these patients had any signs or symptoms of immunodeficiency. immunoglobulin a was low in % of the patients, immunoglobulin g in %, and immunoglobulin m in . % of all patients. conclusion: immunoglobulin was found to be low in these patients when there was no immunodeficiency and preschool wheeze was diagnosed. this should be etiologically investigated as to whether if this is a special group in preschoolers with recurrent wheezing and hypogammaglobulinemia combination. method: asthma severe unit is formed by allergists, pneumologists, pediatricians and otorhinolaryngologists. hematologists and immunologists make specific collaborations. we present the partial results of our data collection, which include patients with severe asthma according to ers/ats task force, selected by peripheral eosinophils > according to wagener et al. we followed them up to assess control for year. we obtained cellularity in sputum using induced sputum technique. values of il of th , th , th pathway, periostin and ilc were not yet available. results: median age was ± , feno ± , exacerbations previous year . ± . , act . ± , fev % ± and dose of inhaled corticoids (budesonide equivalent) ug ± . most of the patients were sensitized ( %) and . % were polysensitized. the most frequent sensitization was dust mites ( %). % had received immunotherapy of whom . % with lack of response. not sensitized patients were older. sputum cell analysis of patients was performed, % had sputum eosinophils> %, mean sputum eosinophil value was . ± . and peripherally ± . correlation among sputum and peripheral eosinophilia was . (p = . ). the peripherally eosinophil value > had a sensitivity of % and a specificity of % for the detection of sputum eosinophils > %. no differences were observed in sputum cell count depending on allergic sensitization. % had an uncontrolled asthma. presence of polysensitization, rhinitis or polyposis were not statistically related with the control. different patterns were observed in function of cause of poor control: patients with obstructive pattern (fev < %) were older and received more inhaled treatment. patients with high rate of exacerbations had more sputum eosinophilia and neutrophilia. both groups had worse act and received more oral steroids. patients who received oral steroids were more often sensitized to fungi in some follow-up visits. not significant differences were observed in control according to the act. asthma had more sputum neutrophilia, were older, received higher inhaled steroids dose and had adult onset asthma. the only control variable related with sputum eosinophilia was exacerbation. fungi sensitization was more frequent among patients with oral steroids. method: a randomized, double blind, placebo controlled study with patients from the de la salle university medical center with a mean age of with partly or uncontrolled asthma. they were assigned to either cm glucan or placebo group for two months. act score and %fev postbronchodilator were assessed at the st visit, th week follow up, and th week follow up visits. an independent and paired t-test were used to determine mean changes in act scores and %fev between the groups. results: in the two treatment groups, those in the cm glucan group had a greater % fev mean change of − . compared to placebo which had only − . , a mean difference of − . , and a trend toward significance with a t-test p value of . . in terms of changes in act score, those in the cm glucan group had a mean change of . and . for placebo, a mean difference of . and was not significant at t test p value of . . the result of the emanuel trial showed a trend of improvement among patients on both groups in terms of act score and %fev postbronchodilator. however, it was not statistically significant. | lung function improvements with tiotropium in patients across all ages: impact of episodes of asthma worsening during phase trials vogelberg c ; casale tb ; bleecker er ; goldstein s ; szefler s ; engel m ; el azzi g ; dewberry h ; hamelmann e method: post hoc analyses involved phase iii, randomized, double-blind, placebo-controlled trials: in patients aged - years (rubatina-/canotina-/vivatina-/pensietina-asthma) who received tiotropium ( or . μg) or placebo, as two puffs once-daily via the respimat, as add-on to ics ± other controllers; and in adults (pri-motina-asthma replicate trials) who received once-daily tiotropium μg or placebo, as add-on to ics/laba ± other controllers. we analyzed change from baseline for peak fev ( - h) and trough fev at week in vivatina-and pensietina-asthma, and week in pri-motina-/rubatina-/canotina-asthma, comparing patients with and without episodes of asthma worsening during the trials. asthma worsening was defined as an episode of progressive increase in dayto-day asthma symptoms (recorded by patients and confirmed by the investigator) or a decrease of patient's best morning pef ≥ % from mean for ≥ consecutive days. as a post hoc analysis, p values are nominal. results: there were no differences in baseline disease characteristics between those who experienced episodes of asthma worsening and those who did not, within specified age and asthma severity groups. placebo-adjusted lung function improvements were observed with tiotropium μg in patients who experienced episodes of asthma worsening and those who did not during the trials (table ) . there was some variability in subgroups with low numbers of patients. conclusion: once-daily tiotropium add-on had a similar efficacy in adult and pediatric patients with symptomatic asthma, irrespective of whether they experienced episodes of asthma worsening or not during the trials. these data support the broad efficacy of tiotropium and show largely consistent improvements in lung function even in patients who experience episodes of disease worsening. | cochrane review of the use of antibiotics for acute exacerbations of asthma method: we searched the cochrane airways trials register, trial registries and reference lists of primary studies. we extracted outcome data and assessed risk of bias in duplicate and used current cochrane methodology throughout. our primary outcomes were intensive care unit (itu) admission, duration of symptoms/exacerbation and adverse events. we included six studies, including a total of adults and children. trials were of varied methodological quality and we were able to perform only limited meta-analysis. one study reported a single itu admission but no other studies reported admissions to itu. two studies investigating macrolides reported diary card symptom score and showed antibiotics improved symptoms (md − . , % ci − . to − . ). one study including participants reported more symptom-free days in the macrolide group than usual care. one study of a penicillin including participants reported asthma symptoms at hospital discharge; the between group difference was reported as non-significant. serious adverse events were rare; events were reported across the three trials (n = ). the pooled effect estimate for all adverse events from three studies was imprecise (or . , % ci . - . ). no deaths were reported. conclusion: our results confirmed that omalizumab significantly improves disease control and is a safe add-on therapy. also in appropriate patients with controlled disease over time, efforts to stepdown other asthma medications will be appropriate. ( ) aerd: aspirin exacerbated respiratory disease; sd: standard deviation. data are n (%), mean ± sd or n/n (%). c-act: asthma control test for children, fev : forced expiratory volume in one second; fev /fvc: the ratio of forced expiratory volume in one second to forced vital capacity, pef: peak expiratory flow; feno: fractional exhaled nitric oxide, vas: visual analogue scale *these included allergic rhinitis, asthma, eczema, atopic dermatitis, food allergy, etc. **there were , and missing data in treatment a, b, and c, respectively. this study examines the potential treatment effects of sq ® hdm slit-tablet on qol measured by sf- v in people with aa and ar. the analyses are based on data from the mt- trial (eudract no. - - ) and utilize data from the sq-hdm treatment group ( subjects) and the placebo group ( subjects). throughout the trial, qol was measured at each of visit - via sf- v . this yielded psychometrically-based physical and mental health summary measures, as well as a sf- v total score. according to trial design, the use of inhaled corticosteroid (ics) was reduced by % for a three months period (visit and ) and completely withdrawn for the last three months of the trial (visit and ). results: by estimating a simple regression on differences in sf- v total score from baseline measurements (visit ), a positive and statistically significant treatment effect on the overall qol of the sq-hdm treatment compared to the placebo group in visit and was found. further analyses show that the qol improvements are mainly driven by increases in the general mental health score, which are carried through to visit . in particular, the mental health and role emotional domains show statistically significant improvements. the results show that the sq ® hdm slit-tablet improves qol measured by sf- v in patients with hdm induced aa and that this effect is driven by improvements in the mental health domains. | impact of treatment prescription, adherence to treatment and use of inhalers in asthma control-results of the efimera study method: cross-sectional multicenter observational study conducted with patients who use any type of medication with inhaler devices. patients referred from primary care and seen by a pneumologist or allergist for the first time were evaluated. the following data was collected in a single visit: adequate prescription according to gina guidelines (gina); specific and general treatment adherence using morisky-green questionnaire (mg) and inhaler adherence test (tai); disease control with asthma control test (act) and assessment of inhaler use technique were measured with the extended tai. results: patients included in this study (n = ) had a mean age of ± years, an average disease evolution of . ± . years, % of which were women. according to gina recommendations, . % of patients have insufficient or inadequate prescription. when measured by the mg test the . % of patients showed bad adherence, meanwhile measured by the tai test adherence was . % measurements of inhaler use technique resulted in % of patients having one or more mistakes regardless of whether the device was a mdi or dpi. several factors showed to be related with bad asthma control: inadequate prescription (or: . [ . - . background: it is well known that the constant and prolonged tobacco smoking affects the natural history of asthma. vaping is the act of inhaling and exhaling the vapor produced by an electronic device called e-cigarette (e-cig), whose basic structure includes a power source and an atomizer. two types of vaping are the most popular ("mtl" and "cloud chasing"). we have created a web-survey with questions concerning epidemiological data, quality of life and symptoms worsening in asthmatic vapers. the survey has been advertised through various social networks and local press. people responded, including asthmatics ( %). the asthmatics were: males %, under %, - years %, - years %, - years % and over %. % used ecig-only, % smoked and vaped together, %. those who preferred mtl-type of vape were % and "cloud chasing" were %. results: to the question: "has vaping ever worsened asthma symptoms?" % answered no, % yes. to the question: "as asthmatic, would you suggest to an asthmatic smoker to start vaping instead of smoking?" . % answered no, . % yes. to the question: "how much nicotine do your vaping liquids have?" % answered mg/ml, % . mg/ml, % mg/ml, % mg/ ml, % mg/ml, % mg/ml and % mg/ml. to the question: "do you take medications for your asthma?" % declared to use a drug as needed, % used a single drug daily, % used more than one drug daily and % declared "i don't take any asthma medication". we related (χ test) the worsening of asthma symptoms with the nicotine content (p = . ), the type of vaping (p = . ), the current therapy (p = . ) and we did not find a statistically significant correlation. vaping has undoubtedly shown an advantage in terms of improvement of symptoms compared to cigarette smoking (p = . ), in particular . % subjects who smoke and vape did not have a worsening of symptoms, while . % of them had a worsening. the vaper-only users who never worsened were ( . %) and ( . %) had a worsening. conclusion: despite the limits related to the online survey as a data source, e-cigs seem to be a useful tool in the pathway to quit smoking. in fact, % of the asthmatics who smoked traditional cigarettes would recommend switching to e-cig and % did not worse their asthma symptoms. background: despite the success of pharmacotherapy, more than half of patients with persistent bronchial asthma (ba) do not achieve disease control. in recent years, the issue of approaches to treatment based on the identification of phenotypes of the disease has been increasingly discussed. this approach becomes the key to optimizing therapy for asthma, allowing the personification of treatment. anti-ige-therapy using omalizumab is one of the most researched variants of phenotype-specific treatment. method: aim of our study was to investigate of the causes of uncontrolled predominantly atopic asthma, the frequency and effectiveness of the personalized therapy in real clinical practice. patients with uncontrolled severe atopic asthma were examined in outpatient department of the city hospital during . all patients underwent physical examination, pulmonary function testing, and total serum ige evaluation. results: % of patients had uncontrolled asthma due to inadequate basic therapy of the disease. the change in therapy allowed them to achieve control of the disease. obstructive sleep apnea syndrome (osas) was revealed in . % of patients. these patients underwent cpap (continuous positive airway pressure) therapy. % of patients had gastroesophageal reflux disease (gerd). % of patients had an elevated level of serum ige level and needed anti-ige therapy. in . % of cases, the initial serum ige level was more than iu/ml which was a contraindication to therapy of omalizumab. patients received omalizumab therapy. this therapy led to relief of symptoms and decreased frequency of asthma exacerbations. results: it was found that the prevalence of obesity among the patients with asthma and being treated in inpatient conditions in - was . % of patients, which is comparable to the prevalence of obesity among the population in general. the data of the patients suffering from asthma and obesity treated both in inpatient and outpatient conditions, was analyzed and it is set that obesity does not affect the severity of the clinical course of asthma. it is shown that obesity does not affect the control of symptoms of asthma. thus, the control of asthma symptoms depends on timeliness of diagnosis, the adequacy and terms of appointment of basic asthma therapy, the presence, severity and adequate treatment of concomitant diseases, psychoemotional background of patients, their compliance and adherence to therapy. results: the causes of smoking in asthmatics were not significantly different from the control (p > . ). patients most often used smoking as "support for emotional stability". the motivation to smoking cessation was higher in the asthmatics group ( %) than in the control group. the main reason for smoking cessation was a deterioration in health - %. the majority of smokers - %, performed attempts for smoking cessation. low level of br was revealed in % asthmatics ( % non-smoking asthma patients and . % of cases in the control group, p < . ), cf had low values and was lower in asthmatics group in compare to the control group (p < . ). the pac values correlated with the level of br: a low level was determined in % in smoking asthmatics, in % in nonsmokers with asthma and . % in smokers of the control group obstructive sleep apnea (osa). all of the patients were on regular treatment with low dose inhaled corticosteroids for at months and start treatment with continuous positive airway pressure (cpap) .to assess quality of life, we used asthma symptom control tools (asthma control test) .patients performed daily peak flow meter and spirometry (once a week) during period of weeks after start using cpap. results: during the study, of the followed patients had no exacerbation of asthma. four of patients during this period had exacerbation, due to upper airway infection so they were excluded from study. results of following showed that there was improvement in quality of life in all patients included in study but there no statistically significant improvement in pulmonary function tests fpt. huang y ; yao t ; huang y ; chiu c ; tsai z ; kao p ; lu k ; fang h ; lin c ; gau c ; lee w ; tsai h results: the rate of preterm birth among the study subjects was . %. the prevalence of physician-diagnosed rhinitis was . %. there was no significant association between preterm birth and physician-diagnosed rhinitis (p = . ). when stratifying by atopy status, we found that preterm birth was associated with physiciandiagnosed rhinitis among children without atopy (adjusted or [aor] = . , % ci = . - . , p = . ), but not among children with atopy (p = . ). when further classifying by gender, greater protective effect of preterm birth on rhinitis was only found in boys without atopy (aor = . , % ci = . - . , p = . ). the results suggest that preterm birth may have a protective effect against the development of childhood rhinitis in our study population. the protective effect is only observed in boys without atopy. further investigations will be merited to confirm these findings and to investigate underlying mechanisms. background: folic acid supplementation (fas) during pregnancy has been suggested due to its protective effect against neural tube defects. at present the effect of fas during pregnancy on childhood rhinitis has remained unclear. we aimed to investigate the relationship between fas during pregnancy and childhood rhinitis. logistic regression analysis with covariate adjustment was performed. adjusted covariates included sex, age, number of older siblings, breast feeding duration, maternal smoking during pregnancy, maternal allergy, maternal education level, maternal age and socioeconomic status results: the prevalence of physician-diagnosed rhinitis was . %. there is a significant association between fas and physician-diagnosed rhinitis (adjusted odds ratio [aor] = . ; % confidence interval [ci] = . - . for fas ≥ months) compared to the group of never use. in the stratified analysis by atopy status, maternal fas during pregnancy was significantly associated with physician-diagnosed rhinitis in the atopic group (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months), but not in the non-atopic group. when further stratified by gender, significant association between maternal fas during pregnancy and physician-diagnosed rhinitis was only found in boys with atopy (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months). the results demonstrate that maternal folic acid supplementation during pregnancy might increase the risk of childhood rhinitis, especially among boys with atopy. further investigation will be needed to validate our findings and to understand potential underlying mechanisms. according to sequence data from detected adv (in all groups of patients) belongs to species f type and samples to species c type (rei group). bv type was identified in strongly positive (ct ≤ ) swab samples in ari group. conclusion: simultaneous testing of respiratory and stool samples together shown that at least . %/ . % of study subjects had dual/mixed infections, respectively, including %/ . % of respiratory disease patients, . %/ % of gastroenteritis patients and . %/ . % of patients with combined respiratory/enteric infections. we found no virus combination specific for different groups of patients. | neonatal respiratory supports and future asthma-like presentation in prematurity with bronchopulmonary dysplasia results: of all the tests analyzed . % were males and . % females with a mean age . ± . years old. half of the tests ( . %) reveals positive specific-ige to more than one allergen and . % ( ) have no serum specific-ige for the tested allergens (table ) . sixteen patients ( . %) have very high concentrations (> iu/ml) of derm. pteronyssinus specific ige, ( . %) of derm. farina, ( . %) of rey pollen and ( . %) of oak and timothy grass pollen. further studies are needed in order to elucidate the effect of these cytokines on allergy development and protection. shinohara m ; matsumoto k department of pediatrics, ehime university hospital, toon, japan; department of allergy and clinical immunology, national research institute for child health and development, tokyo, japan background: probiotics consumption during perinatal and postnatal periods reportedly reduces the risk of atopic dermatitis in the offspring, whereas such probiotics consumption did not affect ige levels or the risks of other allergic diseases; the precise mechanism how probiotics consumption reduces the risk of atopic dermatitis remains unknown. we hypothesized that probiotics consumption may reduce skin hypersensitivity to histamine. to test this hypothesis, we investigated whether perinatal/postnatal consumption of yogurt associates with skin hypersensitivity to histamine or not. method: this was a cross-sectional study enrolled motherinfant (≥ -months-old) pairs. physician-diagnosed allergic diseases and food consumption, such as milk, fermented drinks, and yogurt, by mothers during the third trimester of pregnancy and by infants during the first months of life were assessed using self-questionnaires. skin prick tests (spts) to saline and mg/ml histamine were performed using bifurcated needles, and wheal sizes were measured minutes after the puncture. the spt wheal sizes in infants with eczema/atopic dermatitis (n = ) were significantly larger than those in infants without eczema/atopic dermatitis (n = ; . ± . mm vs . ± . mm, respectively, p = . ), and thus these infants were excluded from the further analyses. the spt wheal sizes to histamine in infants with daily yogurt consumption during the first the aim of this study was to evaluate the prevalence and clinical relevance of sensitization to profilins in atopic patients with food allergy. the study was performed on a group of children age - years with sensitization to at least one plant-derived food allergen (ige > . ku/l). the included patients had never been treated with allergen immunotherapy before the study. the presence of ige to recombinant (r) rbet v , rart v and ramb a in serum was evaluated using elisa method as previously described (jbc ; : ) . in addition serum level of igg to rbet v , rart v and ramb a was also evaluated. results: sensitization to profilins was found in out of ( . %) patients (p+). sensitization to all studied profilins was demonstrated in each p+ patient. the remaining children, with pollenfood sensitization, were not sensitized to any of the studied profilins and they served as a comparator group (p−). analysis of the clinical status revealed that asymptomatic patients in regard to plant-derived food hypersensitivity were found more frequently among p+ ( %) than p− ( . ; p < . ) patients. sensitization to profilin was associated with positive ige to the same food allergens as in the control group. clinical manifestation of pollen-food sensitization expressed as allergic rhinitis, bronchial asthma and atopic dermatitis was comparable between groups, except of oral allergy syndrome, which was not seen among p+ children. similarly, history of anaphylaxis to plant-derived foods was registered only among p− ( . %) patients. interestingly, all patients with sensitization to profilins had also elevated level of serum igg against rbet v , rart v and ramb a . results: no significant difference of physician-diagnosed eczema (p = . ) or current eczema (p = . ) was observed between children born full-term and preterm. after stratifying by atopy status, we found that children born preterm had a more than three-fold higher risk of having physician-diagnosed eczema (adjusted or (aor) = . ; % ci = . - . ; p = . ) and current eczema (aor = . ; % ci = . - . , p = . ) than their counterpart in the non-atopic group. no statistical significance was observed for the association between preterm birth and eczema in the atopic group. no association between preterm birth and eczema was found when stratifying by gender. our results reveal that non-atopic children born preterm have a higher risk of developing eczema. the results suggest potential modifiable effect of atopy on the association between preterm birth and eczema. further studies with a larger sample size are needed to validate the findings in this study. background: there is a need for more knowledge about factors of importance for a successful transition from childhood to adulthood among adolescents with allergic disease and especially those with severe allergy. therefore the aim of this study was to describe experiences of living with severe allergy from the adolescents and their parent's perspective and thereby identify factors of importance for transition from pediatric to adult care. method: a qualitative study was performed based on six focus groups interviews, two with adolescents and four with their parents. in total adolescents (age - years old) and parents participated. the interview guide contained questions about experiences of living with severe allergy. the transcribed data was analysed using systematic text condensation. results: in total four themes were presented, two themes occurred in both the adolescent and the parent's focus groups, to be special and to be prepared. for two themes there was a difference between the adolescents and their parents. the theme, the importance of the parents, only occurred in data from the adolescents and the theme the meetings with health care only occurred in the parent's data. the adolescents felt that they had low priority in the class and several stated they were teased at school and their parents felt that focus on their child often was in a negative way. the adolescents described that they took responsibility for their diseases while their parents expressed a need to protect. the adolescents stated that one of the parents were always present or had been during the years, the reason being safety and security. only the parents mentioned experiences from healthcare. parents who described that they had continuity in healthcare meetings and where met by high competence and with a professional approach were more satisfied with the support from the health care. one factor that was felt to be important was whether the doctor involved the youth in the conversation or not. the teenagers in this study relied on their parents while also taking responsibility for their illness at the same time. parents, on the other hand, showed a tendency to overprotect their adolescents. for healthcare professionals it is important to involve the adolescents in the care to facilitate the transition. results: . % of the children used antibiotics currently and . % out of them used antibiotics ≥ times yearly. current wheeze (w) was established in . %, sleep-disturbing w in . %, exerciseinduced w in . %, dry night cough apart from a cold in . %, and asthma in . %. current antibiotics use ≥ times yearly was positively associated with current w (aor: . ; . - . ; p < . ), sleep-disturbing w (aor: . ; . - . ; p < . ), exercise-induced w (aor: . ; . - . ; p = . ), dry night cough (aor: . ; . - . ; p < . ), and diagnosed asthma (aor: . ; . - . ; p = . ) while antibiotics use < times yearly was positively associated only with current w (p = . ) and dry night cough (p = . ). the results suggest an aggravating role of antibiotics use on asthma in school age thus further supporting the recommended restriction of antibiotics exposure. results: after questioning . % % ci, . - . were suffering from respiratory diseases, having symptoms of chronic disease: cough- . %, wheezing- . %, tightness in the chest- . %. the risk factors (passive smoking, open fire house warming and no air conditioning) were commonly met in major cases at ill children rather than healthy ones ( . % % ci, . - . ). as a result of studies made of the equal to . ± . , comparative the end of lessons equal . ± . (p ≤ . ); air relative humidity varies during lessons equal with . ± . (norma toilet %- %); co concentration exceeds allowable limits − . ± . (mac − . %). conclusion: respiratory morbidity in high school examined has a tendency to increase. we noticed deviations from the hygienic norms: the indoor temperature and relative humidity was lower and the co level was twice higher than the normal one. the "asthma ever" outcome was reported in cohorts. cohorts defined this as parental reported asthma (with or without specifying that it was doctor-diagnosed), cohorts used gp records as the only source of diagnosis, and used parental report or gp records. the "current asthma" outcome was reported in cohorts. there was little consistency with how current asthma was defined or worded, with different definitions used. the most common definition of current asthma, reported times, was "asthma ever and either asthma symptoms in the last months or asthma medication in the last months". other criteria included in asthma definitions were bronchial hyper-responsiveness, reversible airway obstruction, positive exercise test, and asthma symptoms reported at a previous questionnaire. only one "current asthma" definition was based exclusively on prescription data: "dispensed two asthma medication during the past year". nine cohorts reported asthma outcomes without specifying how it was defined, and were categorized as "asthma unspecified". conclusion: "asthma ever" and "current asthma" are two main asthma outcomes used to define asthma in child cohort studies. definitions of asthma vary substantially across cohorts. case report: thereby we present two case reports of two children with impairment verbal communication as part of asd and allergic diseases. the first patient was a year old boy with sneezing, rhinorrhea night cough and eye redness. he had been suffering for almost years from the above mentioned symptoms. he had family history for atopic diseases and was for month breastfed. specific ige revealed sensitization to birch, alder, hazel, oak, mugwort pollen and dog epithelia and dermatophagoides farinae. specific ige resulted positive for nuts and rye flour. the second patient was almost year of age in the tame that he presented in our hospital. he cried and screamed all the time because of severe atopic dermatitis and typical symptoms such as itching all over the body and his impairment of verbal communication. specific sensitization showed sensibilization to egg white and egg yolk, to nuts, rye and wheat flour. the food specific ige leaded to positive results to alder, birch, hazel and oak pollen, but also to grasses, ragweed and mugwort. prick by prick test showed positivity to egg white and egg yolk. atopy patch test to pollens resulted negative. results: the first patient symptoms were well controlled after treatment with antileukotrienes. his verbal communication was also improved after a year or more. the second three year old patient after required a combination of specific treatment with antihistamines, corticosteroids, immunosuppressive drugs and diet recommendation. afterwards he had a reduced level of itching and anxiety but compared to other children he had a severe eczema. erythema multiforme (em) is an acute, immune-mediated, mucocutaneous condition that is most commonly caused by infection and drugs. it is characterized by targetoid lesions, sometimes accompanied by oral, genital or ocular mucosal erosions. there was no pediatric patient that had previously been reported in the literature with development of type reaction after omalizumab treatment. we presented a case who developed em to omalizumab therapy. an year-old female patient was admitted to pediatric allergy clinic with complaints of fever and rash. she had been diagnosed with chronic spontaneous urticaria (csu) years ago and she was planned to treat with omalizumab ( mg, subcutaneously every week) because of the inadequate response of antihistamines at a medical center. her complete blood counts, liver, renal, thyroid function tests and serum c ,c ,c esterase inhibitor protein levels introduction: celiac disease is an autoimmune disease triggered by exposure to gluten in genetically predisposed individuals and characterized by chronic inflammation of the small intestine. chronic urticaria is a skin disease, characterized by the appearance of pruritic wheals with or without angioedema, whose underlying mechanism cannot be identified. objective: to report a sporadic case of an -year-old boy with chronic urticaria associated with celiac disease. methods: an -year-old boy(weight kg, rd- th percentiles) was admitted to our clinic with a -year history of chronic urticaria. during the first three years, he was under antihistamine treatment(of incremental doses)and occasionally received preparations of cortisone according to the eaaci guidelines. he was asymptomatic for years until treatment was discontinued. eight months earlier, after a viral infection, a recurrence of urticaria, involving the trunk and extremities without angioedema was noted. subsequently, he was under antihistamine treatment with cetirizine but had an uas- score of . total laboratory investigations were performed. results: laboratory control was negative except for positive antibodies to celiac disease(anti-transglutaminase > u/ml, anti-endomysial, gliadin antibodies).further control with colonoscopy and biopsies (from duodenum and stomach) were obtained. the histopathological findings along with the clinical findings indicate celiac disease, type b marsch-oberhuber and grade b corazza-villanacci. in the past, similar cases have been reported. efforts have been made to associate chronic urticaria with celiac disease, although the mechanism remains unclarified. evidence suggests that the duration of gluten exposure, among otherwise asymptomatic patients with celiac disease, is related to the development of other autoimmune mechanisms. this can be explained by resolution of urticaria manifestations after the onset of gluten-free diet. in our case, three months after gluten-free diet, an improvement of urticaria with decreased uas- score of was observed. conclusion: he specific case of subclinical diagnosis of celiac disease in a child with chronic resistant urticaria further reinforces the suggestion that screening for celiac disease should be included in the diagnostic approach of chronic urticaria. | allergy to gingival balm in an infant with cow's milk protein allergy we report a case of an infant with a diagnosis of cmpa with an allergic reaction to a gingival balm caused by the presence of cmp in its constitution. furthermore, it is important to reinforce that milk proteins were labeled in an unusual form which might increase the risk of misunderstanding. these findings illustrate the difficulty in implementing total avoidance of common food allergens as well as the need to improve their labeling, particularly in non-food products. bakiri ah results: after specific treatment with corticosteroids, antihistamines, emollient creams, disinfectants and antileukotriens he was feeling better, he was smiling again and wished to have the chance to play with his classmates again. conclusion: this case report shows an association between level of stress and risk for atopic dermatitis. as previously showed children with low educational level parents and boys with higher stress have increased risk of having severe atopic dermatitis as compared to "no stress" boys. so early treatment and diagnoses are key important factors improving the children`s social life. results: the data cover immigrants (mean age . , range - ) and locals (mean age . , range - ). a slight difference in male prevalence ( . % vs %, p = . ), and pet possession ( . % vs . %, p = . ) were found between immigrants and locals, respectively. no differences were find in term of age and symptoms at presentation. the pattern of sensitization to the different allergens showed no statistically significant differences between migrants and controls. the rate of monosensitization resulted slightly higher in migrants ( . %) than controls ( . %). pollen-only sensitization was statistically higher among migrants than control ( . % vs . %, p < . ). monosensitization was more frequent among patients who have been living in italy for less than years ( . % vs %, p = . ). the opposite phenomena can be seen among polysensitized patients. conclusion: migrants are more frequently monosensitized than locals and tends to cluster towards either a pollen or dust mite sensitization. sensitization to house dust mite tends to appear early (< years of stay). pollen or mixed sensitization is more frequent the longer the residence time. | allergenonline.org: update of comprehensive allergen and celiac protein searchable databases for risk assessment of novel food proteins goodman re ; baumert jl ; taylor sl ; ebisawa m ; ferreira f ; bohle b ; van ree r ; kleine-tebbe j ; abdelmoteleb m ; koning f ; amnuaycheewa p conclusion: allergen and cd databases have been updated following a described review process. they can be used to identify proteins that might represent risks of food allergy or cd for affected consumers. han dh ; lee jw ; yim hj ; ko yk ; kim d ; rhee c seoul national university hospital, seoul, south korea; seoul national university bundang hospital, seoul, south korea background: stress can change the immune response and aggravate various allergic diseases. we already demonstrated in previous allergic rhinitis cohort (arco) kids study that stress might be a risk factor for pediatric allergic rhinitis (ar). the aim of this arco study is to investigate relationship between stress intensity, symptoms severity and quality of life as well as allergic markers in adult ar patients. results: as stress intensity increased, the proportion of moderatesevere ar patients was significantly increased. ar patients in high stress group was likely to belong to moderate-severe group (or, . ; % ci, . - . ). global vas of ar symptom was . ± . in high stress group and . ± . in low stress group, respectively. the each rqlq domain score was significantly higher in high stress group than in low stress group. total rqlq scores were . ± . in high stress group and . ± . in low stress group, respectively. however, as the level of stress increased, there were no significant changes in serum levels of allergic markers. our results suggest that stress may affect ar symptom severity and quality of life in ar patients. | skincare and synbiotics for the prevention of atopic dermatitis or food allergy in newborn infants: a × factorial randomized non-treatment controlled trial dissanayake e ; tani y ; sahara m ; mitsuishi c ; nagai k ; sato y ; suzuki y ; nakano t ; yamaide f ; shimojo n (n = ). the skin care group was advised to apply an emollient - times/day especially on cheeks and peri-oral area. the synbiotics group consumed a mixture of fos ( g) and bifidobacterium bifidu-mol ( × )/day. the last group received both. emollient application was not prohibited in the no-intervention group. interventions were carried out from birth to months of age. the development of ad was assessed at month, months and months by a pediatrician and at year by a questionnaire. ad was diagnosed using guidelines of the japanese society of dermatology. sensitization to food allergens was assessed by allergen-specific ige levels at months of age. results: skin care and synbiotics, alone or in combination, did not prevent the development of ad at year of age or the sensitization to food allergens at months of age. conclusion: our data suggest that skin barrier protection using emollients may be insufficient to prevent the development of ad as other factors affecting skin barrier integrity and trans-epidermal water loss such as the method of skin washing may have an additional effect. the probiotic bacterial species used may also affect the outcome as lactobacilli have been shown to be more beneficial. more studies are required to confirm the effects of skin care and synbiotics on ad. results: in the population number of girls exceeded the one of boys (p < . ), especially within the age group from to years. questioning, for months, symptoms of allergic rhinitis (rhinorrhea, sneezing, nose itch, nasal obstruction and eyes' itch) were identified in . (p < . ); symptoms of bronchial asthma (wheezing ( %), episodes of cough at night ( . %), intolerance to physical load ( . %), indoor and outdoor ( . %), coughing and rales in response to stimulus ( . %)) in . % of the population; atopic dermatitis (dermatitis, itch, revelation in early age, involvement of large areas in early age, damage of extremities bending and stretching surfaces in adults)- . % (p < . ); food allergy- . % (p < . ) etc. at the second stage of clinical studies, on the basis of prick-testing, average ige, in our case, was - times greater than normal level. results of study of allergens showed sensibilization to domestic dust (d.f. and d.p.) ( , %) (p < . ). in . % of cases there was stated sensibilization conditioned by cat and dog epidermal allergens results: among the women with available serum, . % were sensitized of whom . % were monosensitised, and . % polysensitised (to two or more allergens). sensitisation to inhalant allergens dominated ( . %), with grass being most common ( . %). only . % were sensitized to food allergens, most often to peanuts ( . %), while among the . % who reported ddfa, ige reactivity to foods were identified in . %. compared to women with no asthma, women with dda ( . %) were in a significantly higher background: regular exercise has been known as beneficial that it reduces the risk of chronic diseases including allergic diseases. however, little has known regarding the relationship between exercise and allergic diseases in korean adolescents. we analyzed the national data whether exercise is related to the prevalence of allergic diseases in the population of korean adolescents method: data from sixth korean national health and nutrition examination survey ( - ) that included adolescents from to years old was analyzed. we defined regular exercise according to physical activity guidelines for americans. multivariate regression analysis was performed to find whether lack of exercise could be a risk factor for allergic diseases. results: the prevalence of asthma, allergic rhinitis (ar) and atopic dermatitis (ad) were . %, . % and . % in korean adolescents, respectively. after adjusting for factors, lack of exercise was not associated with asthma and ar, but was significantly related to ad in korean adolescents (adjusted odd ratio . , . - . , results: it was found that over % of ch up to y.o. having the ad within allergic disease (ads). the most significant symptom was a long-lasting itchy rash lasting for month in . ± . % of g and . ± . % of g. the first morbidity of ad was noticed at the age of up to y.o. among . ± . %. at the age of ch - y.o. and older than y.o. the skin ads onset was noticed for . ± . % and . ± . % accordingly. the ad sl was determined as follows: %moderate (mo), %severity (s), % were ± kua/l, ± iu/l respectively. skin prick tests were positive in . % of the patients ( . % multiple allergens). grass pollens ( %) and dermatophagoides ( . %) were the most common allergens. average vitamin a and d levels were . ± μg/l ( - ), . ± . ( - ) respectively. thirty percent of the patients vitamin d levels were mildly low, . percent was low. in control group % was mildly low, vitamin a levels was low in . % of the patients. none of the children in control group had low vitamin a levels. we didn't find any statistical significant difference for both vitamin levels between patient and control groups. vitamin a deficiency was mostly found in asthma patients whereas vitamin d deficiency was mostly in allergic rhinitis and asthma groups. passive smoking and vitamin d deficiency was significantly related (p = . ). there wasn't any relation between asthma attacks and vitamin levels. conclusion: in conclusion vitamin a and d levels weren't found significantly related with allergic diseases but was found lower than control group. patients having chronic diseases are one of the population groups that are chronically exposed to drugs. this study aims at evaluate the impact of this factors in developing drug allergies in the medical staff. method: this was a cross-sectional study that included nurses from the uhc "mother theresa" of tirana. they were asked to fill up a questionnaire where questions about chronic diseases and drug allergies were included. . % were females and the mean age was . (+ . ) years old. relative risks with % ci were calculated for different groups. results: . % ( ) nurses reported to have at least a chronic disease. the most common non-atopic disease was hta followed by the groups of autoimmune and thyroid diseases. nurses who had one chronic disease have a rr of . ( % ci = . - . , p < . ) to develop a drug disease higher than those who didn't had any chronic disease, and those who have more than one chronic disease have a rr of , p < . ) to develop a drug disease. the presence of chronic diseases can be a risk factor to develop a drug allergy probably through the increased risk to drug exposure. these patients may be exposed to drugs not only through therapy but also through hospitalizations and other forms of health care. lapeere h ; oosterlinck p ; vermeir p ; vermeire i ; coppens m ; gevaert p ghent university hospital/ghent university, ghent, belgium; ghent university hospital, ghent, belgium; ghent university hospital/ghent university, ghent, belgium background: the key to managing latex allergies in healthcare professionals and patients lies in correct recognition and appropriate action. . million people are employed in the health care sector. while there are no overall statistics on the prevalence of latex allergy in that work force, studies do indicate that %- % of health care workers regularly exposed are sensitized, compared with %- % of the general population. latex allergy is defined as an immune mediated reaction to latex products (e.g. balloons, contact dermatitis for gloves, condoms, surgical catheters); these encompass immediate and delayed hypersensitivity reactions. method: based on the experience of the belgian dutch pathway network, a -phase method to develop, implement, evaluate and continuously follow up a care pathway for latex allergy was designed and implemented. the purpose of the study was to develop and implementation of latex allergy clinical care pathways to provide all staff at ghent university hospital with appropriate knowledge and skills to identify and manage patients who have a known latex allergy or those at risk of developing latex allergy. results: care pathways, also known as clinical pathways, are used all over the world to implement and monitor patient-centered care processes in a transparent way. care pathways are defined as a complex intervention. -phase method consists of: ) screening phase; ) project management phase; ) diagnostic-and objectification phase; ) development phase; ) implementation phase; ) evaluation phase and ) continuous follow-up phase. this phased approach is based on the deming cycle, better known as the "plando-study-act" (pdsa)-cycle. conclusion: this method can offer support to multidisciplinary teams (re)designing and implementing safe, efficient, effective, person-centered, timely, equitable, continuous and integrated care processes. however, the method is no guarantee to success. the key to success is the collaboration and critical attitude of the entire multidisciplinary team when implementing pathways. background: cord blood ige (cb-ige) were considered to be a useful predictive tool for allergic symptoms especially in early childhood. there is only sparse knowledge about their importance for health in later life. the aim of our work was to determine the importance of cb-ige for allergic symptoms in young adults. we also studied the possible modifying factors for cb-ige concentration. results: resutls shown as daily mean, pollen grains/m³: table . the daily means of pollen concentrations of cupressus arizonica, platanus acerifolia and plantago lanceolata in our area differs from other sites in madrid city. although cupressus arizonica and platanus acerifolia counting were lower, plantago lanceolata counts were higher, representing a relevant pollen in our area. the clinical relevance of these findings is under evaluation by our group. method: grass pollen counts were performed since - using a burkard days spore trap located in our allergy center in madrid. the beginning of the algid period of pollination was considered the first of three consecutive days with more than grains/m and the end, the last day of three consecutive days with more than grains/m . madrid, barajas meteorological station data, was used. skin prick tests (pt) to grass pollen was also studied in comparison conclusion: total grass pollen concentration did not suffer any increase or decrease in its counts despite the dramatic increase of the temperature. an advance at the beginning and the end of the season was seen. these changes significantly correlate with the temperature increase during may and july. discrete decrease in the sensitization prevalence. since several years, the reference method to monitor the biological particles concentrations has been the hirst method: a volumetric pollen trap, located on the roof of building for background measurements, sucks continuously l of air per minute, particles depositing by impaction on a coated tape. the tape is then analyzed by optical microscopy. the hirst method produces accurate but past data. nowadays, many researches are focused on the development on new devices to get real time information. method: rapid-e from plair sa is a device using red laser beam to determine the size and the shape of sucked particles and an ultraviolet ray to measure the fluorescence of these particles. the results: the correlation coefficients got between rapid-e and hirst trap are higher than % for most of calibrated pollens, this correlation reaching % for all pollen taxa: • plane % • pine % • birch % • oak % • plantain % • dactylus % • urticaceae % conclusion: new calibrations are planned for and a real time information will be set up. results: the quinquennial media concentrations since - were . ; . ; . ; . ; . ; . ; . and . grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the beginning and the end of the actual season advanced days respectively in regard to the period from to . the annual prevalence of positive pt to platanus in was % an % in . the quinquennial media from to was , , and %. conclusion: platanus pollen counts had a dramatic increase that meaningfully correlates with the dramatic increase of the temperature. a discreet advance at the beginning and the end of the season was seen. these changes did not influence in a longer duration of the season. we observed a significant increase in platanus pollen sensitization prevalence whiting madrid pollinosis patients. results: the quinquennial media concentrations since - were , , , , , , and grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the actual season beginning advanced in days and the end has results: over % of house dust samples collected between april and may from central european countries were found to contain bet v allergen at levels well above the limit of detection of . μg/g for elisa . ep kit and . μg/g on maria. samples were found to have much higher levels of bet v allergen from midto-late april, particularly those that were collected in germany, belgium and hungary. samples taken from outside of the pollination season were tested and found to be negative for bet v . in conclusion, we found that bet v allergen can be detected and quantified in house dust samples. these data suggest that household dust is a source of pollen allergen and could therefore be contributing to asthma and allergic rhinitis symptoms in individuals affected by pollen allergy. household dust may also be considered as a source of bet v allergen which could contribute to allergic sensitization. | cupressaceae pollen in the atmosphere of alentejo: disruption of pollen grain during air transport spring, depending on the temperature. despite being considered moderately allergenic, it might be responsible for winter allergic outbreaks. as ornamental trees, they are found scattered throughout the territory but are more abundant in pockets of wild forest, outside alentejo. despite being more common in mountain, this pollen type is captured in considerable amounts in alentejo, portugal, where its aerobiological features and allergenic impacts are poorly characterized. the aim of this work is to characterize the aerobiology of cupressaceae pollen, to evaluate the effect the meteorological conditions and the source of this allergenic pollen type in the atmosphere of evora, alentejo. method: pollen were collected using a hirst type -day pollen trap and pollen was identified following standard methodology. background: allergic rhinitis caused by pollen is one of the most common allergic diseases. the presence of pollen in the air is currently centrally monitored at roof top levels, and not in the direct living environment of sensitized subjects. in the current project we aimed to develop a handheld pollen sampler, called pollensniffer, that can collect pollen in the living environment of the allergic subjects. as a first step this device was validated against the standard burkard pollen sampler and used to monitor local pollen concentrations at street level in the city of leiden. method: rooftop level pollen were monitored routinely by a hirst type pollen sampler (burkard, uk). the pollensniffer ( | does the allergy risk due to pollen exposure information is useful for the allergy sufferers? sindt c; oliver g; thibaudon m background: in france the information for the allergy sufferers is not made with pollen counts, which have not a real signification, but with the allergy risk due to pollen exposure. method: since more than years, rnsa (réseau national de surveillance aérobiologique), the french aerobiology network, has measured the pollen exposure in the main cities of france, using background: the effect of environmental factors on allergic sensitizations is still unclear. rural areas vs cities have different exposure levels to pollutants and aeroallergens. these differences could give clues on the causes of higher allergic sensitization rates in children exposed to city air. method: two studies with children aged years old were initialized to analyse the airborne drives of allergic sensitization: seal (günzburg, children) and ae r kids (munich, children). capillary blood was collected and the parents filled in a questionary. sensitization rates were quantified using the immunocap ® isac sige array. pollen data were measured at both locations. results: in günzburg more children were sensitized to aeroallergens, however munich children showed significant higher sensitization to phl p (p < . ), despite the lower concentration of pollen. in günzburg % children had no sensitization at all compared to % in munich. % of the children in munich spend at least hour per day outside and % of the total have no animals at home. % felt symptoms of hay fever in the last months, the majority between march and june, which correlated with the pollen flight. results: the total rate of atopy in crd patients was . %, and asthma patients was the highest ( . %). the positive rate of phadiatop in urban asthma patients ( . %) was significantly higher than that in rural areas ( . %, p < . ) and the phadiatop positive rate of office staff ( . %) was significantly higher than that of outdoor workers ( . %, p < . ). the total rate of atopy in copd patients was . %, and in patients with acute exacerbation was . %. beside, atopy is a risk factor for dyspnea (or = . , p < . ), and the fvc levels in copd patients with atopy were significantly lower than those without ( . l vs . l, p < . ). optimal scaling analysis show that, there were a correlation between the tige and smoking coefficient (cronbach's alpha = . %). in addition, the correlation between the level of tige and phadiatop sige was so strong in the patients with mild to moderate asthma (r s = . , p < . ), but it was weak in severe asthma patients (r s = . , p < . ), and up to . % of the gold iii iv patients with low phadiatop level (≤ ku/l) had a high level of tige (≥ ku/l) compared gold i ii ( . %). conclusion: the rate of atopy in patients with crd is high, and atopy is an important factor affecting the process of crd. the patients with severe copd or asthma is likely to has high serum tige level but the level of common allergen sige is low, so the allergy screening strategy should be adjusted and we should pay attention to those patients, therefore, it is necessary to screen the sensitization situation of crd patients at first, and the results can guide the treatment, management and prevention of crd. background: due to a limited amount of epidemiological data [ ] it has been thought that many severe allergic asthmatics in germany remain unidentified and are therefore not adequately treated. a pilot project demonstrated that more than % of patients, having been mean total ige (sd) was . ( . ) ku/l. . % of the patients had no sensitization towards any of the specific iges tested, whereas % were positively tested on - allergens and further . % showed sensitizations towards > allergens. conclusion: approximately % of online recruited (severe) asthmatics had a total ige level of > ku/l and ≥ sensitization (allergen-specific ige) towards atopic allergens. this further supports the high prevalence of atopy in asthma. results: patients (mean age: ± . years, range - years, m/f ratio: . ) who suffered from allergic rhinitis or allergic rhinoconjunctivitis enrolled in this study. highest rate of skin sensitivity was for weeds/grasses pollen including salsola kali, amaranthus retroflexus, chenopodium album and compositae family ( . %, . %, . % and . % respectively). among tree's pollen; ash ( %), walnut ( . %) and mesquite ( . %) were the most common. less than % of patients showed skin reactivity to indoor allergens and storage mites, mix of cockroaches and house dust were the most common ( . %, . % and . % respectively). the results of current study confirmed the importance of weed/grass and trees pollen as the major source of allergic sensitization in our area. interestingly the rate of sensitization to indoor allergens was low which can be explained by geo-climatic situation. background: there are few studies of cutaneous sensitivity to gramineae in our region. mostly of them use allergens of foreign species. the study aims to estimate the prevalence of skin sensitivity to widespread grasses in our region. method: this is a retrospective observational study of patients with seasonal allergic rhinitis. patients were studied using skin tests with pollens extracts from pooideae, chloridoideae and panicoideae grass species. results: the prevalence of positive reaction to pollen from pooideae subfamily was . % (ic: . %- . %). in turn, prevalence of allergy to panicoideae subfamily pollens was . % (ic: . %- . %) and positive reaction to chloridoideae subfamily reach . % (ic: . %- . %). cochran test suggests that prevalence in those three groups is different (χ = . , p < . ). when comparing just the groups of allergens from pooideae and panicoideae differences are also significant (χ = . , p < . ). in particular, . % (ic: . %- . %) of patients were allergic to paspalum notatum. regarding cross-reactivity between subfamilies, we find a no crosscorrelation between pooideae and panicoideae (χ = . , p = . ). conclusion: in bahia blanca, patients with seasonal rhinitis are sensitive to pooideae, chloridoideae and panicoideae. paspalum notatum, belonging to panicoideae, has a significant prevalence, high reactivity and low cross-reactivity within the group of species studied. this last species is relevant because it is a native grass from the northwest region of our country, paraguay and the south of brazil. prevalence of grass positive skin tests in patients with seasonal rhinitis by species. allergen frequency percentage % ci results: correlation analyzes were performed between sige and spt and area results. the concentration with the highest correlation by diameter and area for blo t was μg/ml and for der f of μg/ml. in the case of der p the concentration with the highest correlation for the diameter was μg/ml and for the area of μg/ml. when evaluating the reproducibility of the results according to the area and the greater diameter of the spt, a strong agreement was observed for blo t in the concentrations of μg/ml and . μg/ml. results: among the patients, the majority of allergens-positive was t , accounting for . %, followed by f ( . %), f ( . %), ds ( . %) and ccd ( . %). the prevalence of plant-related allergens (t , w , f , f , w and u ) in ccd-positive patients were significantly higher than those in ccd-negative patients (all results: with our new point-of-care methods using a selected recombinant protein e other markers, we were able to detect the disease early as days post-infection and more than % of positive cases from chronic and low endemicity areas (which are characterized by hard to detect patients with extremely low parasite load, < eggs per gram of feces) were obtained. plus, chromatography poc-cca ® test was improved by our group with a urine concentration step that turned its sensibility from % to %. conclusion: monoclonal antibody and recombinant protein technologies allowed superior detection methods when comparing it to the conventional ones. in conclusion, data showed % of sensitivity of chronic patients and % of acute patients. marton c county hospital, oradea, romania background: allergic rhinitis is a disease that affects about a quarter of the population, a disease with an important negative impact on daily activities, both on learning and working ability, as well as spending leisure time or sleeping. in the western part of romania, the most popular and blamed allergen is ambrosia, in the late summer months. it is a plant of the compositae/asteraceae family, along with goldenrod, sunflower, dandelion, cocklebur, chamomile, wormwood, daisy, etc. allergen identification is important for applying prophylactic measures, but especially for determining the allergen to be desensitized. considering the possible cross-reactivity within the compositae plant family, as well as the possibility of co-sensitization, as well as the number of patients sensitized to these pollens, which is steadily increasing, i considered is necessary a broad screening for a more precise identification of the allergen and increase chances for a successful desensitization. method: the observational study includes patients who presented on october for testing with standardized allergen extracts, as recommended. criteria for inclusion: patients with specific symptoms of rhinoconjunctivitis in august and september, with or without asthma symptoms, who returned for allergic prick test after the end of treatment. criteria for exclusion: patients who disagreed with cutaneous testing, who did not discontinue antihistamine treatment or who had been treated for other diseases with drugs that influence skin testing. background: in recent years, cationic liposomes are thought to be the most effective and non-toxical nucleic acids`transport system, so most of gene therapy drugs are developed on their base. however, lipoplexes are quickly captured by reticuloendothelial system cells after the injection and taken out of a blood stream. there are many modification methods of liposomal surface for liposomes with prolonged pharmacokinetic properties production. addition of hydrophilic polymers (peg) is seemed to be the most promising approach, that is able not only to create steric barrier on the particle`s surface and prevent the interaction with blood plasma lipoproteins, but also inhibits the protein adsorption, opsonisation and subsequent degradation in human body. the aim of this study is the evaluation of liposomal surface modification by hydrophilic polymers influence on nucleic acids`lipoplexes conjugation and on their physico-chemical and biological properties. method: liposomes preparation (including peg-modified liposomes), size determination by photon-correlation spectroscopy, examination of transfection efficacy by luciferase assay. (c h ) ) were obtained. also the modified liposomes were produced by addition of % of peg (by mass) during thin lipid layer preparation step. the size distribution was analysed by photon-correlation spectroscopy. it was shown that peg addition does not increase the par- conclusion: it can be noted that addition of peg can change the lipoplex formation but the cationic liposomes still remain an effective rna delivery system. and peg modification will be able to impart prolonged properties for the vehicle in bloodstream. foundation (grant № - - ). ory c may cause a cross reaction with fel d (cat), can f (dog), equ c (horse), mus m (mouse) and rat n (rat). february eight patients that were treated at our institution were diagnosed with rabbit allergy. results: all eight patients with the diagnosis of rabbit allergy presented with signs of upper respiratory involvement. two patients had itching teary eyes, watery nasal discharge and sneezing while feeding farm rabbits. one of those also presented with dyspnea. four patients developed problems whenever in contact with domestic rabbits. one patient developed allergic rhinoconjunctivitis whenever she was home-her parents own a rabbit, but while away in her college room she had no problems. another patient had dyspnea whenever visiting his girlfriend's house. she owned a rabbit. two patients developed asthma-like symptoms, one also presented with angioedema. the other two had developed allergic rhinoconjunctivitis. two patients have problems in contact with cats, one of them also with cows, however skin prick tests were also positive to rabbit. three out of eight patients developed allergic asthma with a positive methacholine test. six patients had a positive house dust mite prick test. all patients were diagnosed with a positive prick tests to rabbit allergens. all were treated with a nasal steroid and antihistaminesic. they were also advised to avoid contact with the animal. conclusion: domestic rabbit-induced asthma and/or allergic rhinoconjunctivitis is possible, however it is still rare in our environment. it is very important to always ask the patient about their pets in general, not just focusing on cats or dogs. only with a thorough examination and history we can find the true cause of the patient's allergy where pets play an important role. korea. changes of protein and major allergen concentration were measured over one year by bradford assay, two-site elsia, and sds-page after reconstitution of the lyophilized allergen extracts in various buffer (normal saline, . % phenol saline, and or % glycerol with saline) and stored at room temperature (rt, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) or refrigerated ( °c). results: more than % of the initial protein concentration in all four extracts examined was detected over one year when % glycerol was added and refrigerated, whereas . %- . % remained in the extracts at rt. the addition of % glycerol to the storage buffer was found to prevent protein degradation at rt. all four extracts were found to be stable when reconstituted in % glycerol. amb a , a major allergen of ragweed, was almost completely degraded in weeks at rt when reconstituted in a buffer without % glycerol. however, . %- . % of amb a content was detected after one year of incubation at °c in all buffer conditions except . % phenol. conclusion: addition of % glycerol as well as refrigeration was found to be the important to increase the shelf-life of allergen extracts from pollens of allergenic importance. results: this is the first genetic study of the bulgarian hae patients. genetic defects were identified in hae families are: nonsense, splice-site defects, frameshift mutations, indel non frameshift, missense, and large deletion of exon . novel mutations, not previously reported in human gene mutation databases were discovered, and were predicted to be deleterious due to the expected effect on dna transcript and protein. descriptive statistics were used to summarize the eq- d-y descriptive system responses and vas scores by treatment and visit. results: twelve patients with hae type i and a median (range) age of . ( ) ( ) ( ) ( ) ( ) years were enrolled, ( . %) of whom were female. during bop, treatment with u c inh, and u c -inh, ≤ . %, ≤ . %, and none of the patients, respectively, reported having problems with mobility, self-care, doing usual activities, pain or discomfort, and feeling worried, sad or unhappy. the mean [sd] eq- d vas scores increased from . ( . results: overall, the model-derived median exposure and peak concentration across all weight ranges in paediatric patients is predicted to be higher with wb vs weight-based dosing (table) . the effect was most pronounced in patients aged - years, where the wb dosing achieved approximately % higher values than weight-based dosing for median auc - ( ng hour/ml vs ng hour/ml, respectively) and c max values ( ng/ml vs ng/ml, respectively). the wb levels are closer to those in adults receiving mg icatibant (median auc - ng hour/ml; median c max ng/ ml) but never exceed them. results: samples from patients were analysed. lanadelumab concentrations in plasma increased with higher doses and dosing frequencies. steady state was reached around week (range week to week as evaluated by predose concentrations). at baseline, mean (sd) chmwk levels were . % ( . ), . % ( . ), . % ( . ) and . % ( . ) for patients in the placebo and lanadelumab mg q wks, mg q wks and mg q wks treatment arms, respectively. by week , mean (sd) chmwk levels decreased to . % ( . ), . % ( . ), and . % ( . ) following treatment with lanadelumab mg q wks, mg q wks, and mg q wks, respectively, and remained reduced throughout the treatment period. conversely, chmwk levels remained elevated at . % ( . ) at week in patients who received placebo. patients in the placebo group had the highest attack rates over the -week treatment period (mean . attacks/month), whereas the rates were markedly lower in patients treated with lanadelumab mg q wks ( . attacks/month), mg q wks ( . attacks/month) and mg q wks ( . attacks/month). dose-and frequency-dependent manner. exposure to lanadelumab was associated with decreased chmwk levels (indicating inhibition of plasma kallikrein activity) and lower hae attack rates, corroborating the efficacy findings and utility of chmwk as a bioactivity marker in the help study. with cyklokapron (tranexamic acid) since she was years old and took the medication very irregularly due to lack of efficacy. one year before presentation at our clinic, she married and moved to vienna. we started a treatment with the bradykinin- receptorantagonist icatibant sc at the beginning of the menses and if needed a second time at the time of ovulation. she responded well until she got pregnant. during pregnancy, she developed weekly attacks with increasing severity. therefore, a weekly treatment with humanplasma-derived, pasteurized, nanofiltered c -inhibitor (inh)-concentrate, units iv once a week was started and had to be increased to twice per week after one month of therapy due to increasing number and severity of attacks. results: with this treatment attack frequency and severity attenuated. in january she had a normal delivery at term and gave birth to an otherwise healthy son. treatment had to be continued during year of lactation period and also thereafter due to persistent attack severity. conclusion: there are only limited data for the use of humanplasma-derived, pasteurized, nanofiltered c -inh concentrate during pregnancy and lactation period. this case confirms the safety and efficacy of the named drug during these periods. wheals are yet classified. the best characterized stem from hereditary or acquired c inhibitor deficiency (c -inh-hae and c -inh-aae) . last year, the french angioedema network (creak) joined the registry of angioedema without wheals (cloud-r hae). here we present the contribution of the grenoble alpes university hospital (chuga) to this disease registry. the study population is composed of patients with a proved diagnosis of c -inh-hae/aae. the following items are collected: patients' personal-demographic data, clinical/laboratory/genetic characteristics, major comorbidities, treatments (prophylaxis/acute attacks). data from existing registries at chuga are merged into cloud-r hae and missing data obtained at follow-up visits. as from cloud-r hae structure, patients can directly provide information on angioedema attacks and their treatment through a dedicated electronic app, web connection or paper support, which is then transferred into the registry at chuga. method: in a retrospective study, we included a total number of patients, suffering from a chronic skin disease, whose lesions did not improve or even worsened under immunosuppressive treatment ( chronic ulcers/pyoderma gangrenosum, bullous autoimmune diseases, skin lymphomas). ffpe tissue was examined for the presence of cmv dna by pcr. next, within the framework of a small prospective study (n = ) we analyzed the seroprevalence of cmv as well as the presence of cmv dna in lesional skin in patients that had been diagnosed with a chronic skin disease and in whom longterm immunosuppressive therapy had been initiated. results: in the retrospective study cmv dna could only be detected in / chronic ulcers/pyoderma gangrenosum ( . %), but not in bullous autoimmune diseases and skin lymphomas. / patients ( . %) of the prospective study group were seropositive for anti-cmv-igg, as compared to / patients ( . %) in an ageand sex-matched control group. anti-cmv-igm could be detected in method: in this study, we aimed at testing the diagnostic potential of skin function measurements in ss. sixteen patients with conformed diagnosis ss were enrolled in the study. skin fibrosis was assessed by conventional rss and involvement of inner organs and serum inflammation parameters were determined. four objective criteria, namely transepidermal water loss (tewl), corneometry, ph and elasticity, were assessed at nine predefined sites of the body. results were compared to patients with atopic dermatitis (n = ) and acne vulgaris (n = ). method: a multicenter prospective observational study was conducted to investigate the clinical significance of serum scca in children as a biomarker for ad. patients with ad younger than years old and age-matched healthy children without any allergic disease were enrolled in this study. the severity of ad was evaluated using the objective scorad (o-scorad). the serum levels of scca , tarc and total ige were also measured. results: in total, patients with ad and non-allergic healthy children were recruited. the serum levels of scca had the strongest significant correlation with o-scorad, compared with tarc and ige (r = . , and . , respectively). after standard treatment with topical steroids and emollients resulting in an improvement of symptoms, the serum levels of scca and tarc decreased significantly. the area under the curve (auc) for the roc curve was higher for scca ( . ) than for tarc ( . ) or ige ( . ). the difference in aucs between a single cut-off value and age-dependent cut-off values was not significant for scca , compared with that for tarc ( . and . , respectively). conclusion: scca is a more reliable biomarker than tarc for the diagnosis of ad and for determining the clinical severity of ad in children. challenges in predicting severity of atopic eczema patients results: before modeling, we checked for significant differences between patients and controls. these were detected for the levels of ccl , ccl , cxcl , ige and ldh. next, we assessed whether single serum proteins already explain disease severity by calculating correlations. twelve of the proteins, namely gcsf, il- , il- , il- , ccl , il- ra, cxcl , ifng, ccl , il- ß, ccl , and il- , significantly correlate with severity (r range: . - . ). finally, we built a model for the severity of ae based on all measured serum proteins. ten of the proteins are included in the best-fit model (adjusted r = . ). the overall correlation between original and predicted severity scores is high (r = . ) nevertheless the cross validation prediction error is substantial with %. conclusion: applied in daily practice, a prediction error of % translates to a possible miscalculation of scorad points in both directions and therefore the model is of no practical use. aside from using model-based quality measures like cross validation prediction errors to infer the usefulness of predictive models, testing them in independent cohorts could validate these models. collaborations among scientists working on similar approaches would lead to an increase in statistical power and ideally to more robust models. only robust and validated models are going to have the chance to take the step forward from being a result of computational modeling to being applied in the clinical practice of assessing disease severity in patients. jargosch m ; lauffer f ; pätzold k ; krause l ; garzorz-stark n ; schmidt-weber c ; eyerich s ; eyerich k preclinical studies in cell cultures, mice, guinea pigs and rabbits, comprising sterility, cytotoxicity, systemic toxicity, skin irritation, delay contact sensitization and phototoxicity tests, demonstrated safety of this therapeutic agent. we next conducted a single-blinded, intra-individually controlled, phased clinical trial on patients with keloids. the aim was to determine the effects of -month therapy on keloid volume and symptoms of pain and itch. two similar keloids on each subject were selectedone was treated with once-daily, self-administered application of triamcinolone-loaded ( . mg/patch) microneedles for weeks, while the other served as control with no intervention. outcome measures were (a) keloid volume using a -dimensional high-resolution ( . mm) scanner and (b) pain and itch scores on - numerical rating scales. evaluations were performed at baseline, and weeks. in phase of the trial, the whole process was repeated using microneedles loaded with a higher dose of triamcinolone ( . mg/patch). case report: a -year-old girl was admitted to our department with a single round-shaped lesion in the popliteal fossa which spread to extremities, trunk and face and persisted for several weeks and then faded slowly to residual hyperpigmented patches. courses of antihistamines, antibiotics, cyclosporine a, fluconazole, hydroxychloroquine, prednisolone and topical steroids were ineffective. also patient has had history of itchy urticarial rash and angioedema since -year-old, suffered from the flares triggered by physical exertion, stress, cold air and water, spicy food, which resolved within - hours. the patient's father and -year-old brother also had chronic urticaria induced by the same stimuli. the physical examination revealed multiple pink-to-red non-scaly, non-pruritic papules coalescing into annular, arcuate, polycyclic plaques ( - cm) with central clearing, centrifugal spread, indu- | the role of humoral immunity in the pathogenesis of psoriasis results: we found significantly increased levels of iga in the serum of treatment-naïve psoriasis patients correlating with disease score. however, iga was only observed in dermal vessels of skin sections. we next performed in-depth analysis of peripheral b cell subsets using flow cytometry. among all investigated subsets, we only found a moderate positive correlation of cd + plasma cells with iga levels and disease score in untreated psoriasis patients. however, in the group of treated psoriasis patients, neither did iga levels drop nor did plasma cells correlate with iga levels and disease score, rather hinting at an epiphenomenal finding. confirming our hypothesis that psoriasis can develop in the absence of proper humoral immunity, we present a patient who suffered concomitantly from both psoriasis and a hereditary common variable immune defect (cvid). conclusion: here, we provide new insights in the immunology of psoriasis, demonstrating the clear dominance of t cells over shifts in b cell subsets. conclusion: allergic diseases show an increasing incidence in geriatric age. this is partly due to the growing emphasis on a more accurate and careful diagnosis of the aging population. we must also take into consideration the influence of other factors, besides comorbidities and therapeutic regimens in elderly that might affects the immune response, such as environmental pollution as well as food contamination and changing dietary habits of elderly such as easy access to exotic food. one of the challenges in the decades to come is recognizing and fulfilling the need for accurate and timely diagnostics of allergic manifestations in elderly patients, as important part of achieving the best possible quality of life for this growing age group. method: sixty-eight patients with various forms of psoriasis and healthy subjects (healthy control group) were assessed after informed consent was obtained. all subjects were asked to complete a questionnaire including age, gender, duration of psoriasis, concomitant diseases and medications. in the group of patients psoriasis was with only skin involvement with skin plus joints involvement ranging from moderate to severe. psoriaticplaques were evaluated by a specialized medical team using the psoriasis area and severity index (pasi). all patients were seen by a dermatologist and clinical immunologist, who collected data considering the demographic, health status and any other relevant details. blood samples included serum levels of -hydroxycholecalciferol and tnf-α using an elisa kit (germany). method: % ethanolic extract of sp (sp etoh ) and its five major chemical constituents are prepared. to elucidate whether human orai modulated by sp etoh and its chemical constituents, conventional whole-cell patch clamp performed in horai -overexpressing hek t cell. we also assessed whether sp etoh and its constituents could inhibit mast cell degranulation and t cell activation. results: in jurkat t lymphocytes, we found that mg/ml sp etoh inhibited orai current (i orai ) by . ± . %, while one of its constituents (compound v (com v ); μm) inhibited i oria by . ± . %. investigation of human primary t cell proliferation induced by co-stimulation with antibodies to cluster of differentiation and , and of rbl- h mast cell degranulation following ige-antigen complex stimulation, revealed that μm com v inhibited both t cell proliferation (by . ± . %) and mast cell degranulation (by . ± . %); these effects were concentrationdependent, and no cytotoxicity was observed. conclusion: considering that most regional plants have not been investigated chemically or pharmaceutically, they remain as untapped potential sources of topical agents for drugs and other application. our findings suggest that com v , which derived from sp etoh , represents a promising candidate compound for the development of therapeutic agents for the prevention and treatment of allergic diseases. results: the cohort consists of caucasian patients. eight of them ( %) are women. the mean age (and range) at the clinical presentation of disease was years ( - years). the mean age at diagnosis for men was years and years for women. all patients have a positive history of recurrent and/or persistent lip swelling, of them ( %) report oral ulceration, cases ( %) have history of previous or current facial palsy and patients ( %) present tongue fissuring. concurrent cd has been diagnosed in one patient. biopsy reports were available for patients ( %); in cases ( %) non-caseating granulomas were seen. various therapeutic approaches have been described: intralesional corticosteroids had a good response in patients, infliximab was partially effective in cases; oral corticosteroids and/or methotrexate seem to cause a partial symptoms improvement. conclusion: this is the first attempt, in our knowledge, to (a) centralize all data of patients with ofg in a national registry with the aim of carrying out epidemiological data and (b) develop italian guidelines including a diagnostic-therapeutic flow chart, shared by the participating centers. the registry will guide the clinicians in the identification and management of the ofg patients, reducing the diagnostic delay and hopefully improving quality of life. case report: a -year-old girl without personal history of atopy, got a temporary tattoo with henna. after three days, she developed a local exudative, erythematous eruption with painful blisters lesions that followed the contours of the tattoo. she had neither fever nor other lesions. she was treated with topic methylprednisolone-gentamicin showing an important improvement days after. as a liquenoid scar remained in tattoo area, trofolastin ® (centella asiatica, αtocopherol, hydrolysed collagen, elastin) patch was prescribed to be placed on the scar. forty-eight hours later, the patch was removed and was newly observed an exudative, erythematous and painful wound that required oral treatment with amoxicillin-clavulanic. after three days, the girl developed on a maculopapular, generalized and itching rash. she was treated with dexchlorpheniramine and methylprednisolone with a complete resolution in days and she was referred to our allergy unit to be studied because of a suspicion of drug allergy to amoxicillin-clavulanic acid. an allergy workup was performed after obtaining an informed consent. case report: it may be sometimes difficult to find the causing allergen in allergic contact dermatitis. face is a region on which various materials contact. in this manuscript a woman case is presented who shows patch test positivity to her husband's shaving product. a years old woman applied because of allergic contact dermatitis on her face. it is learnt that lesions have been continuing for a long time, occasionally getting well with corticosteroid creams; but continuing again. patch test was performed with european standard series and cosmetic products she was using. negative result was observed. following, patch test was performed for the products her husband was using. positive results were obtained for the shaving cream of her husband was using. in detailed anamnesis, it is learnt that the lesions developed approximately month after her husband started to use this cream. it is advised not to use this product to her husband. the disease did not repeat again. it should not be forgotten that cases with allergic contact dermatitis could get in touch with allergenic materials via individuals in close contact. gül Ü akdeniz university faculty of medicine, department of dermatology, antalya, turkey case report: tnf-alpha plays role in etiopathogenesis of allergic contact dermatitis (acd). in mice which lack tnf-alpha, the response of late type hypersensitivity is spoiled. in addition, tnfalpha blocker are also used in some cases with acd. in this poster the results of european standard patch test is given in which acd is observed and tnf-alpha blocker are used without dermatological indication. cases who use tnf-alpha blocker applied because of acd: there was lesion in one case on face, in other case on face and hand, and in the last case only on hand. european standard patch test was performed to patients who were continuing to use tnf-alpha blocker. in one case no positive response was observed, while in two cases positive response to more than one allergen were obtained. in conclusion, tnf-alpha blockages cannot suppress the response of delayed type hypersensitivity. | case of allergy to nickel on the background of its intake in food peredelskaya m case report: nickel is one of the most commonly used metals; it is used for the manufacture of jewelry, plates and dishes, and medical products. a patient n, years old, female, complains of pruritic rash on the body skin with the itch intensity up to - points and the number of lesions more than . allergic background: for quite some time now the patient noted occasional eruptions on her skin after a contact with jewelry made of non-precious metals. previously patch skin tests with nickel showed a positive reaction. the patient sought emergency medical care with complaints of a number of itchy lesions erupted on her whole body during the last hours. on admittance: state of moderate severity, the patient was emotionally labile, focused on her body sensations, tearful. on the skin of face, upper and lower extremities and torso a punctuate purpura with lesions up to . cm diameter, prone to confluent. a physical status was within normal limits. in order to control the itching, as well as to sedate the patient, antihistamines of the first generation were administrated parenterally; but the eruptions kept to progress and to intensify; lesions were spread throughout the whole body, merged in gigantic areas. system glucocorticosteroids therapy was administrated, with mg of prednisolone, but then new lesions kept appearing in a large number, including after-meal rash. water, tea, bakery products, thin yoghurts did not impact the skin condition, whereas the intake of pasta, cereals, and similar products provoked intensifying of eruptions. the patient observation revealed a sharp increase in the rash after such manipulations as intravenous injections or blood sampling from the vein, the process spreading from the injection site to the entire arm. a detailed anamnesis of the disease: on the eve of the start of hives, the patient purchased a coffee machine (with metal nickel-plated parts) and started to use it. diagnosis: a systemic contact dermatitis. an allergy to nickel. the injection treatment was discontinued and a therapy with per oral gcs and antihistamines of the second generation was administrated. a recommendation was given to cook and to eat food using ceramic or wooden utensils. three days later marked positive dynamics of the skin process has been noted. the episode of systemic contact dermatitis has developed due to exposure to nickel from ingestion in food, as well as during the parenteral treatment. background: anaphylaxis reactions during anesthesia can have a mortality of %- %. / of the anaphylaxis in the operating room are due to the use of neuromuscular blockers. rocuronium is frequently involved because is oftenly used. we present a case of a years old man with an anaphylaxis shock due to the administration of rocuronium. method: years old man with no personal history of interest that is going to undergo vertebral surgery. minutes after anesthetic induction with fentanyl, propofol and rocuronium he started with lowering of oxygen saturation. orotracheal intubation is performed and, with the suspicion of anaphylaxis shock, adrenaline, antihistamines and corticoids were administered. after minutes without improvement, mg of sugammadex was administered, given the possibility that the condition was secondary to the use of rocuronium. tryptasa level was . results: skin test to fentanyl, propofol, látex and rocuronium were done weeks after and only rocuronium test was positive. conclusion: in summary, the occurrence of anaphylactic shock after neuromuscular blockers is widely described in medical literature. there are conflicting data about the use of sugammadex as coadjutant treatment in case of anaphylaxis due to the use of rocuronium. we believe is a good option when conventional treatment is not useful. case report: a -year-old woman with past history of allergic rhinitis and hypertension was admitted to the obstetrics service in labor of first child in april . epidural anesthesia with ropivacain and sufentanil was administered. as there was no labor progression, eighteen hours later she was admitted to undergo cesarean section and epidural anesthesia was re-administered. metoclopramide, ampicilin and ranitidine were given intravenously. during ranitidine perfusion, the patient presented general cutaneous erythema and pruritus, tongue, lips and eyelids angioedema and dyspnea. perfusion was suspended and hydrocortisone and supplementary oxygen administered. she denied any type of previous adverse reaction to drugs and any symptoms with use of latex-containing material. allergic evaluation revealed negative latex skin prick test (spt) and negative penicillin, amoxicillin and ampicillin specific ige assay. skin prick and intradermal tests with sufentanil, ppl, mdm, amoxicillin and ampicilin were negative. oral amoxicilin and metoclopramide provocation challenge were negative. spt and subcutaneous provocation challenge with ropivacain were negative. spt with ranitidine was negative but skin intradermal test proved to be positive. the patient was taught to avoid histamine h receptor antagonists and use as a safe alternative proton pump inhibitors. conclusion: anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. the identification of responsible drugs is a complex task. we report a case in which a commonly used and generally safe drug caused a severe reaction, which demonstrated that even the least obvious culprit should not be disregarded. epidemiologic data suggest that the number of cases of chx allergy appears to be increasing. background: chlorhexidine is a synthetic chemical with excellent antiseptic and disinfectant quality frequently used in everyday products and medical devices. the prevalence of allergic reactions towards chlorhexidine is rare, though there is increasing evidence for its allergenic potential. in this case we report about a patient with serious perioperative anaphylaxis. next to multiple potential allergens that he was exposed to, a chlorhexidine containing lubrication gel has been used for urinary catheterisation. within minutes post-exposure, the patient developed generalized urticaria, bronchospasm, tachycardia and hypotension. material and methods: we performed skin prick tests and intradermal tests with all substances documented in the anaesthesia chart, further we analysed specific immunoglobulin e (sige) antibodies and performed oral provocation challenges for exclusion. results: in the skin tests all substances except for chlorhexidine (spt: mm wheal diameter/ mm erythema) were negative. a sensitization for chlorhexidine was further corroborated by chlorhexidine-specific ige antibody ( . ku/l) in the patient's serum. in addition, the challenges for the drugs without sensitization (cefuroxime, lidocaine) were tolerated. considering all potentially relevant allergens that the patient was exposed to and the proof of specific sensitization, we diagnosed an immediate-type allergy towards chlorhexidine. conclusion: with the ubiquitous use of chlorhexidine an increase in hypersensitivity reactions including immediate-type allergic reactions is observed. anaphylactic reactions are rare, but potentially life-threatening, the diagnosis is crucial. as a warning declaration in medical devices is missing, the diagnosis of chlorhexidine allergy might be easily under-recognized or misdiagnosed. unfortunately, until now validated provocation tests are not existent, but the evaluation of combined skin tests and sige is sensitive and specific. | an approach to incidence of death due to anaphylaxis in spain ( spain ( - background: reports about death due to anaphylaxis are still scarce because of its rarity and limited information to few countries. also, data source analysis is usually not included. we report incidence of death due to anaphylaxis in spain using two databases. method: we used a hospital series of anaphylaxis deaths from the spanish hospital system and a series from the national institute of toxicology and forensic sciences (intcf) predominantly formed by extra-hospital deaths. deaths from the spanish hospital system were extracted using codes from icd- -cm, related to anaphylaxis among all deaths occured in the - period. for extracting deaths due to anaphylaxis at the intcf in the same period, two allergist researchers identified these deaths among cases with suspicion of anaphylaxis cause. a regression logistic was run to discriminate the probability of anaphylaxis death belonging to each database. incidence rates were calculated for the different groups (age, sex) using the spanish population as the denominator. temporal trends were calculated from the hospital database using poisson regression models with the number of cases of anaphylaxis detected each year as the dependent variable, and age and sex as covariates. results: there were four positive predictors of fatal anaphylaxis after the logistic model (usual allergen, positive specific ige, suggestive symptoms and previous reaction to the same allergen case report: we were informed that a girl was admitted to the pediatric endocrinology department due to early breast development. she had been diagnosed as central precocious puberty (pp). later, triptorelin acetate (ta) therapy had been started monthly. within minutes after first sc injection of ta at home, she had developed shortness of breath, decreased air entry, and coughing for ten minutes and lastly she had developed vomiting for minutes. her symptoms were accompanied by a pruritic blanchable maculopapular rash on her ears, cheeks, lips, and eyelids approximately for two hours. although they had applied emergency department of the local hospital. based on the diagnosis of anaphylaxis she was immediately treated with adrenalin. she was subsequently hospitalized for possible recurrence and discharged next day without any further events. treatment with another preparation, leuprolide aseptate(la-lucrin), as an alternative treatment was started with premedication against anaphylaxis risk only at first time and the patient did not develop any reactions. the patient is still on this treatment with no complications. anaphylaxis is diagnosed in the presence of a detectable allergen accompanied by symptoms of two systems. our patient had symptoms of the three systems as described above, that is, dyspnea with coughing, hives, nausea, and vomiting. main treatment of anaphylaxis is the epinephrine use. early usage maximizes the likelihood of survival. diagnostic tests with culprit drug were not performed in our hospital if the patient had the anaphylactic drug reaction and grouped as "physician diagnosed anaphylaxis". there has been only one report regarding anaphylaxis to ta treatment in cpp in turkey. in the literature, anaphylactic reactions against ta have been reported only in few pediatric cases. gnrh analogues are important to ensure the physiological growth in precocious puberty. because anaphylaxis can be lethal, and gnrh analogues are similar structure; the present case suggests that one should bear in mind the possibility of anaphylaxis in all patients who receive gonadotropin-releasing hormone and anologs and monitor such patients carefully as needed. furthermore, we must provide sufficient information of adverse reactions, including anaphylaxis, to patients. hence, managements against anaphylactic shocks should be recognized and treatment should be given immediately. | an anaphylactic shock induced by the rocuronium anesthesia: a case report cabrera v; barrios j; callero a; gonzález ce; pérez e; martínez ja hospital universitario nuestra sra de la candelaria, santa cruz, spain background: the anesthetic act is a unique pharmacological situation, where the patient is exposed to a multitude of substances.among them, neuromuscular blocking agents are the leading cause of preanesthetic anaphylaxis, with a frequency of between %- %.followed by latex in second place and antibiotics in third place. among the neuromuscular relaxants, most reactions are due to suxamethonium or succinyl-choline in . %, followed by atracurium, rocuronium and verocuronium.the one that produces the least reactions is cisatracurium. method: a -year-old woman presented a type iii anaphylaxis of the brown classification during the anesthetic induction in a surgery scheduled for laparoscopic cholecystectomy. for which adrenaline, dexchlorpheniramine, hydrocortisone, ranitidine and sugammadex was administered and was transferred with orotracheal intubation to the anesthetic resuscitation room. due to good evolution of the patient, she was extubated within three hours. the drugs involved in the reaction were: rocuronium, amoxicillin-clavulanic, fentanyl, propofol, midazolam, lidocaine and atropine. there was a high suspicion by the anesthesiology and resuscitation service that the abstracts reaction could have been due to the neuromuscular relaxant used, in this case rocuronium, since the reaction was reversed with sugammadex. the patient had undergone surgeries under general anesthesia previously without incidents. a specific allergy study was performed with laboratory tests with tryptase, skin tests with drugs and basophil activation test for rocuronium, sugammadex-rocuronium mixture and cisatracurium. • serial measurement of serum tryptase: . u/l, . u/l y . u/l there is no activation of basophils for sugammadex-rocuronium mixture and cisatracurium. the patient is diagnosed with rocuronium allergy. sugammadex not only acts as an antidote to reverse the neuromuscular block against rocuronium, but also has antiallergic properties by inhibiting mast cells. as an alternative for future interventions, the patient can use cisatracurium, as the skin tests and the basophil activation test are negative. unal d yedikule chest disease, istanbul, turkey case report: tetracycline hydrochloride may rarely cause hypersensitivity reactions. (hrs). immediate type reactions are at the level of case presentations and anaphylaxis is reported. we report a patient with late onset anaphylaxis caused by tetracycline. a -year-old woman referred to our allergy outpatient clinic because of urticaria due to an antibiotic that she does not remember the name of. the patient reported that many years before she had presented urticaria on her arms and legs one hour after taking the drug. to confirm drug allergy invivo and invitro testing have to performed. for many drugs there was no validated skin test. for all that invitro tests are often less sensitive and more expensive. therefore single blind placebo controlled drug provocation tests (sbpcdpt) is the gold standard in the diagnosis of drug hypersensitivity reactions. we did not know which group of antibiotics were allergy to the patient. because the patient had history of asthma and atypical pneumonia we were performed the allergy tests with clarithromycin and she had tolerated. it was necessary to use tetracycline because of patient had vaginal infection. skin tests have not yet been validated for tetracyclines. for skin prick tests of tetracycline that is only available as tablet, not in a soluble form. therefore, the tablet was smashed and diluted with . % nacl. it was also tested. healthy controls to exclude irritation. because of skin prick tests with tetracycline negative. sbpcdpt was planned. sbpcdpt was performed by progressively increasing four divided doses at minute intervals. two hours after last dose the patient experienced dyspnea, palpitations, and hypotension. as the reaction was considered to be anaphylaxis, she was given . mg of intramuscular epinephrine, intravenous mg of pheniramine, and mg of methylprednisolone. the reaction resolved within hours. blood tryptase level was . ug/l taken at the nd hour of the reaction approximately months after the anaphylaxis, serum tryptase level was . ug/l the serum tryptase level and the patient's clinic confirmed anaphylaxis due to tetracycline. we had proved late onset anaphylaxis due to tetracycline with the patient's clinic and serum tryptase level. anaphylaxis due to tetracycline is limited to case reports and small series but to our knowledge, there is no previous report of late onset tetracycline anaphylaxis. | case series of ige mediated anaphylactic shock due to polysorbate case : an -year-old male patient with hypertension, hypothyroidism and episodes of sustained monomorphic ventricular tachycardia (smvt), developed an anaphylactic shock after the administration of injectable amiodarone due to smvt. serum tryptase levels reached . μg/l during the reaction (baseline . μg/ l). skin tests were positive to injectable amiodarone (prick mg/ ml, intradermal . mg/ml) and polysorbate and (prick-prick). skin prick-prick to amiodarone and dronedarone tablets were negative. the patient tolerated oral amiodarone. we report an anaphylactic reaction during the first intravenous administration of amiodarone in a female patient being treated for supraventricular tachycardia. bat was positive, suggesting a direct effect on basophil activation, as the patient was not previously exposed to the drug. | anaphylaxis during labor: don't forget to think of an amniotic fluid embolism case report: a -year old primigravida ( weeks of gestational age) was admitted with signs of pre-eclampsia and labor was induced. benzylpenicillin and ropivacaine (epidural anesthesia) was administered > hours before the event. eighteen minutes after starting an infusion with oxytocin ( ml/h) and a vaginal toucher, the patient developed a decreased level of consciousness, generalized edema/erythema and thoracic pain, followed within minutes by fetal bradycardia and maternal collapse. after resuscitation, an urgent sectio was performed, and a baby girl was born. patient was extubated the same day. serum tryptase, hours after the event, was . μg/l (basal tryptase level . μg/l). allergy workup demonstrated negative specific ige and skin tests for latex and chlorhexidine, negative skin and provocation testing for ropivacain. however, skin testing was hampered by dermographism: intradermal (idr) testing of benzylpenicillin ( iu/ml, / - / ) and oxytocin ( ie/ml, / - / ) showed extensive erythema. idr testing of oxytocin in healthy volunteers showed pallor around the injection site (n = ). intravenous provocation with benzylpenicillin was uneventful. a basophil activation test with oxytocin (patient and control) was negative. an additional bone marrow evaluation showed no evidence for mastocytosis. although clinical criteria for anaphylaxis were fulfilled, a diagnosis of an amniotic fluid embolism (afe) was concluded. no drugs were prohibited. patient gave consent for publication. conclusions: afe is one of the most devastating conditions in obstetrics, occurring typically during labor and delivery or immediately postpartum. the pathogenesis remains incompletely understood, however, it has been suggested that afe involves an anaphylactic reaction to fetal tissue exposure associated with breaches of the maternal-fetal physiological barrier, supported by transiently increased serum tryptase levels. the diagnosis is primarily clinical, and generally one of exclusion. no specific antemortem diagnostic tests are available to confirm afe. postmortem identification of fetal squames in the maternal pulmonary circulation gives final diagnosis. differential diagnosis includes drug-induced anaphylaxis or mastocytosis, which were ruled out in our case. method: the patient presented after hymenoptera stings dyspnoea, generalized erythema with pruritus, edema of the face that required emergency therapy in episodes. results: an angio-ct was performed at the inferior limbs with optiray and minutes after the end of the investigation, the patient presented an anaphylactic shock requiring admission to the icu for days. conclusion: the patient's progression was slowly favorable. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. in % of the patients the suspect drug was withdrawn. thirty one patients ( %) received systemic anti-inflammatory treatment. twenty six patients ( %) received intravenous (iv) corticosteroids alone, ( %) iv corticosteroids plus ivig, ( . %) iv corticosteroids plus ivig, infliximab and colchicine, and ( . %) iv corticosteroids plus infliximab and cyclosporin. there were complications in cases ( %), and death occurred in the patient with overlapping ten/sjs who had received corticosteroids plus immunoglobulin. in this study, our aim was to evaluate severe ihr to icm. method: we retrospectively analysed patient who consulted to our allergy unit between july and july reporting symptoms within hour after icm administration. from a total of patients, we selected eight that had suffered an anaphylactic reaction. a written informed consent had been obtained for diagnostic procedures. introduction: immediate type hypersensitivity reactions to pemetrexed have been reported as very rare case reports. as limited availability of alternative therapies in chemotherapeutic allergy, desensitization plays an important role in ensuring reuse of the culprit drug. we report a case of pemetrexed anaphylaxis and successful desensitization. case: years old female patient with lung adenocarcinoma had been treated with cisplatin-pemetrexed as second-line therapy. during the th cycle within minutes after the end of pemetrexed infusion she had chest pain, shortness of breath, cough, swallowing difficulty, erythema on face and body, nausea and vomiting. she was diagnosed as anaphylaxis and adrenaline was administered besides antihistamine and methylprednisolone. symptoms and findings of the patient were improved within minutes. oncologists decelerated no suitable alternative therapy for the patient. although skin tests (prick test with / concentration, intradermal test with / - / concentration) were negative with pemetrexed, taking into account the severity of the reaction, pemetrexed desensitization was applied with the consent of the patient. no reaction was observed during the procedure result: desensitization is a successful and safe method of reusing the culprit drug. successful desensitization of pemetrexed with immediate type hypersensitivity reaction is described. the years old man was admitted emergency department with fever, rash (maculo-papular) and pain in joints. it was the th day of taking of amoxicillin. the hematological abnormalities were revealed -eosinophilia, increased erythrocytes sedimentation rate. the level of serum ecp was μg/l. the liver functional tests were increased too. hepatomegaly and cervical lymphadenopathy were observed. the patient was treated as a dress syndrome (infusion therapy, systemic steroids) and discharged after weeks with improvement. all hematologic parameters were in normal limits. lymphadenopathies were resolved. the level of ecp was retaken - μg/l. patient was prescribed oral steroids till normalization of limits of ecp. it lasted weeks after discharging. the serum level of ecp can play key role in the management of dress syndrome and in the making of diagnostic processes. until now, allergic or anaphylactic reactions to peg have been rarely reported. although patient with hypersensitivity to peg should avoid peg-containing drugs or products, patient who needs colonoscopy has few alternative bowel cleansing methods. no successful desensitization to peg has been reported to date. we report a case of successful desensitization and subsequent safe colonoscopic examination in patient with allergic reaction to peg. method: a -year-old woman developed generalized urticaria, pruritus, throat swelling, and shortness of breath immediately after taking a bowel preparation solution for colonoscopy. she had the first symptoms years ago, and has had more experiences so far. the symptoms appeared within - minutes of taking cleansing solution, and the endoscopy was no longer possible. seven years ago, she underwent endoscopy with no specific symptom. when the last symptom occurred a year ago, she was treated at emergency room because of severe dyspnea and dizziness. the patient came to our clinic for the proper diagnosis of allergy reaction and possible colonoscopic evaluation. objectives: to describe a successful desensitization to vedolizumab in one patient diagnosed with ulcerative colitis, refractory to infliximab and intolerant to azathioprine and sulfasalazine. methods: our patient was a year old woman receiving treatment with intravenous vedolizumab ( mg/cycle). cycles and were well tolerated, but in cycles , and she experienced hypotension and dyspnea, in spite of premedication with oral dexamethasone and metoclopramide. during cycle , she also showed facial angioedema, systemic urticarial reaction and oropharyngeal pruritus treated with methylprednisolone and ebastine. the results of prick (vedolizumab concentration mg/ml) and intradermal skin tests ( : and : ) with vedolizumab were negative in our patient and in ten healthy controls. total ige level was . ui/ml and specific ige against dermatophagoides were positive, being negative for hamster epithelium and latex. since vedolizumab was the only therapeutic alternative, the patient was planned to undergo vedolizumab desensitization according to an -step protocol. patient informed consent was obtained previously. premedication consisting of ebastine, acetylsalicylic acid, montelukast and methylprednisolone one hour before desensitization was administered. desensitization protocol was performed with a total duration of hours and minutes and a total dose of mg. dose steps were . , . , . , . , . , , and . mg. conclusions: our -step protocol desensitization to vedolizumab resulted safe and effective in our patient and it has allowed the continuation of treatment with vedolizumab for her ulcerative colitis. montelukast, anti h and h blockers were used for the pretreatment of desensitization. all procedures (skin and blood tests, desensitization) were carried out with the informed consent of the patient. we present an exceptional, non-immediate case of fever after cisplatin and etoposide infusion with positive skin test. case report: a -year-old man, recently diagnostic of lung cancer stadium iv, in first line of treatment with cisplatin and etoposide, started hours after finishing the nd infusion: facial erythema that becomes generalized after - hours from infusion. twelve hours later, developed warmth sensation, shivering and fever ( °c) that persisted despite the use of several oral antipyretics treatment. infectious disease was discarded, so he was referred to our department in order to assess further administration of cisplatin and etoposide. methodology: skin testing was performed days after the last reaction to minimize false-negative results, as follows (a) cisplatin prick test ( mg/ml) and intradermal tests ( . mg/ml); (b) etoposide prick test ( mg/ml) and intradermal tests ( mg/ml); with histamine as the positive control and nacl-diluent as the negative control. the results of skin test were negative for immediate reading. but two hours later, intradermal test for cisplatin turned into red and itchy and hours later, still associated a wheal. the patient was classified as high-risk (lung diseases, forced expiratory volume in second < l) and underwent programmed inpatient desensitization according to the standardized birmingham women's hospital protocol. desensitization was performed in the medical intensive care unit. the patient received only standard oncology premedication. he tolerated the final dose of cisplatin with no breakthrough reactions followed by etoposide standard infusion. two additional desensitization procedures were performed, with no breakthrough reactions. therapy ended when the disease worsened. the importance of this case, lies in the fact that fever has not been described as a clinical hypersensitivity reaction for cisplatin but for oxaliplatin. although a non-immediate reaction at the nd infusion of cisplatin could scarcely suggest a hypersensitivity reaction, the positive skin test and successful desensitization with this drug, could suggest it. introduction: propylthiouracil is commonly used as the first treatment option in patients with hyperthyroidism. although it is generally a well-tolerated drug, it may lead to some side effects including liver damage, leucopenia and skin rash. among skin rash findings, urticaria is considerably common. nevertheless, in cases that developed urticaria, a rapid desensitization protocol specific to propylthiouracil has not been encountered. we represented a case in which we applied successful oral desensitization via a scheme in accordance with general desensitization principles in a case that developed propylthiouracil-induced urticaria. case report: propylthiouracil at a dose of mg/day was initiated for a year-old female patient with diagnosis of hyperthyroidism in internal diseases clinic. the patient developed widespread itching and swelling in the body - hours after she took the first dose of the drug. she had experienced a similar reaction with use of propylthiouracil in . the patient who was breastfeeding a baby and did not have any treatment option other than propylthiouracil was referred to us with pre-diagnosis of drug allergy. the patient was thought to have propylthiouracil-induced hypersensitivity reaction and desensitization was planned. we prepared a desensitization scheme in accordance with general desensitization principles (table ). in accordance with this prepared scheme, we successfully applied the desensitization protocol with propylthiouracil for the patient. the patient gave informed consent before testing and desensitization. results: spt was negative, but idt reaction was positive at : method: we present a desensitization protocol to intravenous etoposide used in a -year-old male for non-hodgkin's lymphoma who was referred to the department of allergy at sotiria general hospital of athens. within minutes after receiving the first dose of the drug, the patient complained for flushing, retrosternal pain, difficulty in breathing and weakness. the infusion was ceased immediately and the patient received proper treatment with gradual recovery of the symptoms. the next day, skin prick test (spt) and intradermal test (id) were performed with etoposide at dilution : ( mg/ml). both of the tests, spt and id, were negative. histamine and nacl . % were also used as positive and negative controls, respectively. a desensitization protocol of three-day cycle with intravenous etoposide was conducted. premedication for days was administered including methylprednisolone, cetirizine, ranitidine, paracetamol and montelukast. results: the desensitization protocol of the first day consisted of steps of rapid pulses administered at increasing infusion rates every minutes, and step of drip infusion at a final rate of ml/hour ( mg/ . ml) until completion of the infusion. the following days, the patient received a modified rapid protocol consisting of the administration of the calculated dose of mg in only one step of infusion rate of ml/hour completing in only hours and minutes. the same protocol was applied in another three-day cycle with no adverse reactions. conclusions: hsrs to etoposide are rarely described in the literature. we propose a three-day modified rapid desensitization protocol to intravenous etoposide that could be particularly useful compared to other time-consuming desensitization protocols. case report: imatinib, a tyrosine kinase inhibitor, sometimes causes cutaneous reactions that can be of various severity. we present a case of a patient who was started on imatinib mg daily and after months developed diffuse mildly pruritic rash with some desquamation of palms of the hands. the dose of imatinib was reduced to mg daily and therapy with prednisone mg was started. after resolution of rash, the dose of prednisone was tapered to mg daily, but the rash reappeared, although milder in intensity. the dose of prednisone was increased and levocetirizine added and rash resolved. prednisone was slowly discontinued and rash did not appear. in the case of reactions to imatinib the dose of drug can be reduced and short course of oral corticosteroid given. milder reactions can be treated with antihistamine or topical corticosteroid. therefore, when adverse skin reaction to imatinib occurs, induction of tolerance to this important drug should be attempted. method: the exosomes were collected from in vitro primary human sinonasal epithelia cell, which derived from three different groups (normal control, chronic rhinosinusitis and chronic rhinosinusitis with asthma). generation of exosomes in epithelia was confirmed by nanosight, tem and western blot. the proteins of exosomes were identified by proteomics analysis. the cellular proliferation and ciliogenesis were analyzed by cck and qpcr.the ciliary beat frequency was detected by sava system. we found that epithelial cellular exosomes from chronic rhinosinusitis and chronic rhinosinusitis with asthma could reduce the multiplication rate of normal epithelial cell at a certain concentration (≥ μg/ml).we found that exosomes from chronic rhinosinusitis with or without asthma could interrupt the cellular ciliogenesis and ciliary beat frequency. using mass spectrometric analysis we demonstrated that the epithelial exosomes contained different proteins in different disease states. conclusion: our findings first identified that exosomes could be secreted by nasal epithelial cells. we also demonstrated exosomes from chronic rhinosinusitis with or without asthma could be a pathogenic factor in the remodeling of sinonasal mucosa. it could be considered as a significant biomarker for detecting the progress of chronic rhinosinusitis and a alternative therapy target. background: mucociliary transport (mct) is a major respiratory tract host defense mechanism and chronic exposure to allergen can deteriorate the these defense mechanism. the aim of this study was to investigate the effects common allergen (dp/df) on human nasal mucociliary transport in allergic rhinitis patients, and to determine the pathophysiology of ciliary beat frequency (cbf) during allergeninduced change method: allergic nasal mucosa cells of allergic rhinitis patients were exposed to common allergen (dp/df), and cbf was analyzed using an optical flow technique with the peak detection method results: the allergen(dp/df) exposed group showed a decreased cbf when compared to the control group. in the cytotoxicity assay, difference in survival rates was not found between the two groups. in the allergen(df/df)-exposed group, protein kinase c (pkc) activity was increased during a pkc activity assay. the broad pkc inhibitor, calphostin c abolished the allergen(dp/df)-induced decrease of cbf. the allergen-induced decrease of cbf was abolished by gf x, a novel pkc (npkc) isoform inhibitor, whereas the decrease was not attenuated by g€o- , a specific inhibitor of conventional pkc (cpkc) isoform. conclusion: allergen may inhibit cbf via an npkc-dependent mechanism. therefore, we have confirmed that chronic exposure to allergen could decrease cbf by increasing pkc activity. method: ova-alum allergic rhinitis mouse model (ar model) and poly(i:c) induced il- dominant mouse model (neutrophil dominant model) were used. both mouse models were exposed to tio particles for hours twice daily for days, while the controls (n = ) were not. sirius red staining for eosinophil infiltration, immunohistochemistry for neutrophil and il- a, serum immunoglobulin (ig) g and e were assayed by using enzyme-linked immunosorbent assay. in addition, the expression of interleukin (il)- , il- , and interferon (ifn)-γ in the nasal mucosa and cervical lymph nodes was measured by immunohistochemistry, and real-time reverse transcription-polymerase chain reaction (rt-pcr), il- monoclonal antibody (secukinumab) was administered in vivo to evaluate il- a dependency. results: tio exposure did not influence eosinophil infiltration in both ar and neutrophil dominant model. however, tio exposure increased neutrophil infiltration in both models and neutrophil infiltration was correlated with il- expression in the nasal mucosa. serum igg and ige levels were changed significantly in the tio exposed group. th cytokines (il- , il- ) and th cytokine, ifn-γ were not changed significantly in both models after tio exposure, however, il- were increased in tio exposure group. and these increased type pathway and neutrophil infiltration were reversed after il- monoclonal antibody administration. conclusion: exposure to airborne tio induced neutrophil infiltration in the nasal mucosa. the type response seems to play a dominant role in the nasal immune response following airborne tio exposure. | toll-like receptor ligands increase type i interferon induced b-cell activating factor expression in chronic rhinosinusitis with nasal polyposis results: first: paf-r mrna expression was very low in fibroblasts from nm and np (data not shown). paf-r mrna expression was detected in whole sinonasal tissue, submerged and ali epithelial cell cultures from both controls nm and np. paf-r mrna was also detected in peripheral blood eosinophils. although no differences were found between nm and np tissues and cultures, paf-r mrna expression was significantly higher (p < . ) in eosinophils than in upper airway tissues and cells. second: protein paf-r was found expressed in whole tissue (predominantly in the epithelium and submucosal glands), submerged and ali epithelial cell cultures from both nm and np. peripheral blood eosinophils also showed paf-r protein expression. conclusion: both paf-r mrna and protein expression was found in sinonasal nm and np tissues (epithelium and submucosal glands) and in peripheral blood eosinophils. these findings suggest the paf/ paf-r system could play a pathophysiological role in crswnp through the modulation of structural and inflammatory cell functions. "this study was funded with a research grant from uriach group". background: allergic rhinitis (ar) is an increasingly more common nasal inflammatory disease in which an antigen such as pollen or dust mites triggers symptoms such as itching, sneezing, and rhinorrhea, which can lead to nasal obstruction. ar is mediated by thelper type cells together with mast cells, eosinophils, and several inflammatory cytokines and chemokines. for example, recent abstracts | research indicates that hypoxia-inducible factor α (hif- α) is involved in the mechanism of ar development. the anti-heart failure drug digoxin has a specific inhibitory effect on hif- α, and thus, the aim of the present research was to explore the anti-hypertensive effect and mechanism of digoxin in ar. method: an animal model of ovalbumin-induced ar was established in guinea pigs. the experimental group was treated with digoxin through the tail vein. for the comparison of symptoms between the experimental and control groups, the incidence of sneezing was recorded, and the eosinophilic interleukin il- and il- levels in nasal secretions were measured by enzyme-linked immunosorbent assays. western blotting and reverse transcription polymerase chain reaction analyses were conducted to evaluated hif- α expression in guinea pig nasal mucosa. results: the ar symptoms of guinea pigs in the experimental group were significantly improved after administration of digoxin. specifically, the experimental group exhibited a significantly lower numbers of sneezing times(average . ± . vs . ± . , p < . ) and lower il- and il- secretion levels (p < . ) compared with the control group. moreover, guinea pigs of the experimental group showed less severe nasal mucosa edema, lower hif- α production, and reduced eosinophil infiltration in nasal mucosa compared with the control group. conclusion: the anti-heart failure drug digoxin may ameliorate the symptoms of ar by inhibiting hif- α production. campo p ; eguiluz i ; bogas g ; gomez f ; ariza a ; espino t ; torres mj ; rondon c allergy unit-regional hospital of malaga-ibima, malaga, spain; allergy laboratory_regional hospital of malaga-ibima, malaga, spain background: similarly to what has been described in allergic rhinitis, there is an important association of local allergic rhinitis (lar) with lower airway symptoms suggestive of asthma, being selfreported in . % of lar patients after five years of follow-up, and increasing to . % after years. however, clinical suspicion alone it is not enough for asthma diagnosis and could overstate its real prevalence. the aim was to evaluate the real prevalence of asthma in lar patients based on validated objective methods. method: seventy-five patients ( with lar, with non-allergic rhinitis (nar), with allergic rhinitis (ar)), and healthy controls (hc) were included. all patients had perennial history of rhinitis and bronchial symptoms suggestive of mild-moderate asthma for at least two years. non-specific airways hyperresponsiveness (methacholine challenge test, using tidal breath method following ats guidelines) was performed in all subjects. results: subjects were mostly young females, non-smokers. median μg/day of inhaled corticosteroids (budesonide/equivalent dose) was similar in all groups. median fev % in ar group ( . %) was significantly lower compared to lar ( %, p = . ), nar ( %, p = . ) and hc ( %, p = . ). in the lar group, / ( . %) had a positive methacholine, / ( %) in the nar, / ( . %) in ar group and / ( %) in hc. patients with lar had a significant lower percentage of confirmed asthma than ar (p = . ) and similar to nar (p = . ). no differences were detected between ar vs nar (p = . ). conclusion: presence of objectively demonstrated asthma was lower in lar compared to ar, and with better lung function. conclusion: ambient air pollution influenced the hospital visit of patients with rhinitis, even, the level of pollutants, below the national standard. so , o , no , and pm could increase an incidence of rhinitis and/or induce an aggravation of rhinitis symptoms. health care provider might expect upraising patients with rhinitis in the clinic with increase of air pollutants, even under the standard levels. results: during relapse of erosive oral lichen planus mononuclear cells obtained from peripheral blood of patients showed increased number of nk-cells cd + cd + in acute ( . ± . %) and chronic ( . ± . %) disease periods, and cd + grb cells in acute ( . ± . %) and chronic ( . ± . %) disease periods, p < . . in patients with the non-erosive forms of olp there were cd + cd + and cd + grb cells in acute ( . ± . %) and ( . ± . %) and chronic disease ( . ± . %) and ( . ± . %), p < . . the number of cd + cd + and cd + grb cells in the controls were ( . ± . %) and ( . ± . %), p < . . conclusion: acute relapse of erosive oral lichen planus, unlike nonerosive forms, is characterized by increases in the number of cd + cd + and cd + grb cells. chronic disease in patients with erosive oral lichen planus showed a steady increase in the number of cd + cd + killer cells and cd grb lymphocytes. bite", were observed in patients ( %). typical hyper-and hypopigmentation were observed in six patients mainly on the fingers and the cheekbones. fibrosis of the skin of the fingers often leads to flexion contractions, which we observed in patients. we were watching two-sided swelling of the fingers, but it was very pronounced in patients ( %). % of our patients have impaired motility of the esophagus. accelerated esr and c-reactive protein were found in patients as follows- intensively accelerated and moderate. in our patients with positive ana, we observed patients -at low titer : at and titration : in patients. the spectrum of ana found by us in raynaud's syndrome patients is closer to scleroderma than to lupus. we underline the importance of ana ( %) and anti-cc antibodies ( %) for the early diagnosis of raynaud's syndrome and scleroderma, which is also seen in our patients. anti-scl- antibodies were observed in patients coinciding with other publications describing about % of the patients. low levels of complement were observed in patients. low hemoglobin levels were observed in patient, with no iron deficiency. conclusion: . we observed a typical fibrinoid necrosis and polymorphonuclear infiltration, and collagen accumulation in the walls of small and medium-sized blood vessels. results: statistically significant increase of il level ( . pg/ml [ . ; . ]; . pg/ml [ . ; . ] respectively) was determined in patients with uc both in acute stage and remission compared to controls ( . pg/ml [ . ; . ] , (p = . ; . respectively). statistically significant increase of il a level ( pg/ml [ . ; . ] ); . pg/ml [ . ; . ] respectively) was also observed in patients both in acute stage and remission compared to controls ( . pg/ml [ . ; . ], p = . , p = . respectively). besides statistically significant increase of ifnγ both in acute stage ( . pg/ml [ . ; . ] ) and remission ( . pg/ml [ . ; . ]) compared to controls ( . pg/ml [ . ; . ], p = . ; . respectively) was revealed. background: the presence of antinuclear antibodies (ana) is commonly associated with a broad spectrum of connective tissue diseases. low titres might be detected rarely also in healthy individuals, especially in higher age. an indirect immunofluorescence (iif) detection of ana antibodies on hep- cells is the most frequently used laboratory method in this respect. the method is quite reliable regarding sensitivity, however the specificity of this test is lower. we would appreciate a biomarker for clinical discrimination of ana- other autoantibodies were tested in relation to basic diagnosis. results: a cohort of patients was divided into groups according to main diagnosis: immunodeficiency, connective tissue diseases, bronchial asthma and allergic rhinitis, recurrent infectious diseases, gastrointestinal diseases, endocrinopathy and others and the last group was generated from healthy subjects. the presence of anti dfs antibodies was highest in the group of recurrent infections, mostly in females. in these subjects homogenous pattern of ana antibodies by iif was also detected quite often, probably induced by non-specific activation of immune system. on the other hand, in a group of connective tissue diseases, we have not found any anti dfs positive patient. the clinical impact of anti-dfs antibodies is not yet finally confirmed, but their low frequency in connective tissue diseases and presence in %- % of healthy subject suggests their potential role as a new biomarker to be used as a negative predictive factor in non aard. confirmation of presence or absence of anti-dfs antibodies seems to be helpful to exclude potential diagnostic errors in iif ana positive patients. background: multiple sclerosis is a debilitating autoimmune and degenerative condition of the central nervous system, that predominantly affects young adults. both genetic and environmental factors are associated with increased risk for this disease. we propose that the effect of environmental factors, particularly latitude of childhood, is mediated through epigenetic mechanisms. specifically, we propose that unfavourable gene methylation predisposes individuals to multiple sclerosis, that this is set in childhood and adolescence, and transmitted from haematopoietic stem cells to progeny. method: cd + , cd + and cd + cell subsets were isolated from peripheral blood of healthy controls. libraries enriched for cpg islands and promoter regions were generated using modified reduced representation bisulfite sequencing and subjected to next generation sequencing. site specific methylation profiling of genome wide cpg islands, including ms susceptibility genes was conducted using methpipe software. results: genomic coverage was consistent with other published methylomes using modified reduced representation bisulfite sequencing. the methylation signature of peripheral blood derived subsets showed greater differences in methylation compared to buccal cells than with each other. individuals displayed differences in cd + methylomes, and these were recapitulated in the progeny cd + and cd + cells for those individuals. methylation of specific genes regions (e.g. prf ), were consistent with the known biological function of these genes and their potential contribution to ms risk. the vast majority of cpg islands interrogated show recapitulation of their methylation signature from cd + to progeny. however, individual differences and cell subset differences identified, likely reflect the known biological function of these genes in progeny cells. our preliminary results are consistent with the hypothesis that the epigenetic signature (that predisposes to ms risk) is set in childhood and adolescence. the physiological basis underlying the setting of this epigenetic signature is still to be elucidated, but may involve uv light and/or vitamin d, and may provide novel therapeutic targets, especially at a personalised level, for treatment of ms. background: auto-inflammatory diseases are rare disorders characterized by recurrent episodes of fever/inflammation affecting serosal surfaces, joints, eyes and skin without autoantibody production or an underlying infection. innate immunity is implicated in their pathogenesis and the underlying genetic defect has been identified in a fraction of the syndromes. during last years, the increased knowledge about auto-inflammatory diseases and the difficulty in their characterization aroused great interest to better understand these pathologies. the acidic soluble fraction of salivary proteome of patients and controls (hc) were analyzed by rp-hplc-esi-ms. known salivary proteins (salivary acidic proline-rich phosphoproteins (aprps), histatins (hst), salivary cystatins s, sn and sa, statherin, p-b peptide, α-defensins - , cystatins b, c, thymosin β- , s a , s a , s a , and s a proteins) and several derivatives (acetylated, glutathionylated, phosphorylated, and oxidized forms) were searched in the chromatographic profiles by xic (extracted ion current) procedure. adult patients (mean age ± sd: . ± . ; f, m) were enrolled and compared with sex/age matched healthy controls (mean age ± sd: . ± . ; f, m). patients are classified on the base of clinical manifestations as follows: patients with fmf (mean age ± sd: ± . ; f, m), and with unclassified fever syndrome (uc) (mean age ± sd: . ± . ; f, m). results: fmf patients showed low levels of α-defensins , and , this last was absent, with respect hc, and high levels of the glutathionylated proteoforms of cystatin b, and s a , and of antileukoproteinase (slpi). similar results were obtained on saliva of unclassified patients, which showed also levels of cystatin c higher than controls. interestingly, proteins and peptides typically secreted by salivary glands (cystatin c, histatins, statherin, aprps) were found more abundant in uc patients than in controls, and in some cases also than fmf patients (see table) . an evaluation of relative abundance of phosphorylation of phosphorylated proteins/peptides highlighted a significant hypophosphorylation of hst- , prp- and prp- in uc patients with respect to controls, probably due to a less active fam c kinase responsible for their phosphorylation conclusion: we show by a top-down proteomics approach a wide salivary modification, highlighting dysregulation in neutrophil-derived proteins and significant differences between fmm and uc patients. the control group consisted of healthy donors aged - years. immunological methods of investigation included determination of membrane antigens b cells: cd − cd + cd + , cd + cd + cd + , cd + cd + cd , cd + cd + cd + , cd + cd + cd + , cd + cd + cd + , cd + cd + cd l + cd + , cd + cd ra + cd + cd + , by flow cytometry. results: in the study subpopulation composition of lymphocytes in seropositive variant form of ra visceral a statistically significant increase in relative amount as b -cells with immunophenotype cd + cd + cd + ( . ± . % . ± . %) and b lymphocytes with the phenotype cd + cd − cd − cd + ( . ± . % and . ± . %). in the analysis of the processes of maturation and differentiation of b cells detected statistically reliable increase of the relative number of mature cd + cd − cd + naïve b cells cd + cd ra + cd number of mature cd + cd − cd + naïve b cells cd + cd ra + cd − cd + ( . ± . % and . ± . %) compared to the control group. in the study of surface markers b lymphocytes revealed an increase of expression of costimulatory cd + cd + ( ± . % and . ± . %) molecules and increasing the relative amount of cd l . ± . % ( . ± . %) ligand on cd + cd + cd + subpopulation of t-lymphocytes. analysis of surface antigenic receptor b cells in the visceral form of ra showed an increased expression of early markers of cd + cd + cd + ( . ± . % and . ± . %), cd + cd + cd + ( . ± . % . ± . %) activation in comparison with the control group. case: a year-old male patient who works as a dental technician with a history of lung silicosis and recurrent sinusitis applied to an orthopedics clinic for left hip pain and difficulty in walking. he has a history of keeping a dog during childhood. hip mri revealed a × cm sized mass on left iliac wing extended to gluteus muscle and subcutaneous tissue. incisional biopsy was reported as chronic granulomatous osteomyelitis. the lesion was considered as tuberculous abscess. despite anti-tuberculous (fourdrug regimen) treatment for one year, the lesion showed no regression. excisional biopsy was carried out by the same orthopedics clinic. chronic inflammatory reaction and fibrosis was considered to be due to cyst hydatid in the detailed evaluation. antiechinococcus igg and igm was performed with elisa and found positive. no other lesion was detected in lungs and liver. albendazole mg twice a day was initiated and substantial regression observed after three months. atypical and sustained infections made us think of primary immunodeficiency disorders. immunoglobulin subgroups were as follows: iga: < mg/dl ( - case description: year-old male was firstly admitted to gastroenterologist due to intermittent diarrhea, abdominal pain and reactive lymphadenopathy. celiac disease was suspected as genetic test showed hla dq (hla-dqa * and hla-dqb * ), histological evaluation of duodenum biopsy provided picture of lymphoid hyperplasia and marsh iiia variant. however, laboratory testing for celiac disease showed very low amount of antibodies against transglutaminase. gluten free diet for almost one year was ineffective as patient had a continuous problem of gaining weight due to chronic diarrhea. additional questioning revealed recurrent respiratory tract infections with a need of antibiotics more than two times/year during last decade. lymphocyte phenotyping by flow cytometry showed that cd , cd , cd , cd are in normal ranges, but amounts of all immunoglobulins are low: igm < . g/l, igg . g/l and iga . g/l. based on clinical symptoms and immunological evaluation diagnosis of cvid was confirmed, and replacement therapy with subcutaneous immunoglobulin ( mg/kg/month) was initiated. after six months of treatment patient affirmed reduction of gastrointestinal symptoms; he gained kg of weight, has no more infections and stable sufficient level of igg ( . g/l). conclusions: this clinical case shows the importance of immune testing for primary immunodeficiency in all subjects (despite age) with unusual symptoms of autoimmune and/or infectious disorders. cvid may have manifestation of various symptoms, which can lead to misdiagnosis, as well as inadequate treatment. results: in our sample, all patients who progressed to hypogammaglobulinemia were receiving lymphomas. there is no immunoglobulin dosage record prior to treatment. of the cases, mean age was years ( men and women), lost follow-up, and of them also presented neutropenia. seventeen patients who continued in followup required ivig replacement, due to infectious exacerbations, mainly pneumonia and sinusitis. the mean serum igg dosage at the time of onset of ivig replacement was g/dl. the mean time between the first dose of rtm and the need for ivig replacement ranged from to years, with an average of years. the iga dosage was used as a parameter for the recovery of hypogammaglobulinemia, and it was observed that only of the patients presented recovery of the condition up to the moment. conclusion: given the data, we considered the immunoglobulin dosage to be important before initiating rtm treatment and periodically, in order to indicate the replacement of ivig or igsc in a timely manner avoiding complications such as potentially serious infections. background: steinert's disease, also known as type myotonic dystrophy (md ), is the most common dystrophy of the adult. it is inherited with an autosomal dominant mechanism. it causes myotonia, progressive muscles atrophy, muscular weakness, and problems at the heart's conduction tissue and at the respiratory muscles. in patients with myotonic dystrophy, hypogammaglobulinemia is frequently described. the associations and the pathogenesis between those affections are not totally clear, but it is recognized an increased catabolism of the immunoglobulin in these patients. in most of the cases, hypogammaglobulinemia affects only the igg class and does not become clinically manifest. however, replacement treatment is not always successful in these patients. we report the case of a patient with myotonic dystrophy and hypogammaglobulinemia. case report: a -years-old man with md came to our attention for a history of recurrent infections of the upper respiratory tract and persistent infection by helicobacter pylori. at the laboratory tests, we documented low serum igg levels ( mg/dl), normal igm and iga levels and protective antibodies against tetanus consisting with the diagnosis of hypogammaglobulinemia. due to the recurrent infections, he started replacement therapy with ivig ( . g/kg/ months), switched one year ago to facilitated subcutaneous ig (fscig) with achievement of protective serum igg levels (> mg/dl) and significantly reduction of infectious episodes. conclusion: hypogammaglobulinemia is frequently reported in patients with md . in literature most of the cases described does not become clinically manifest, but in our case, the patient was symptomatic with recurrent infections. the replacement therapy with fscig showed both clinical effectiveness and safety. | real-world experience of a novel, highly purified % liquid iv human immunoglobulin for the treatment of antibody deficiencies guidelines for immunoglobulin use (july ). a highly purified % liquid iv human immunoglobulin (ig), with low levels of iga, anti-a and anti-b haemagglutinins, factors xia, xiia, kallikrein and aggregates (i e) was recently approved for use in the uk. here i report our centre's experience in using this novel % i e in three patients with antibody deficiencies. case presentations: a patient who presented in clinic with a first diagnosis of pid, was initiated on % i e at g infused every four weeks. after starting i e, they experienced a decrease in the rate and frequency of infections, in line with expectations for igrt. a young patient on home therapy with a % subcutaneous ig for pid presented in clinic with low trough igg levels. non-compliance was identified as the cause of these low trough levels and therapy was switched to % i e at g infused every four weeks in a clinical setting. both the rate and severity of infections reduced and trough igg levels normalised. an older patient on igrt for sad was reviewed in clinic due to discontinuation of their current igrt product. they were switched to % i e at g infused every four weeks. the efficacy and tolerability of i e was comparable to their previous therapy. a detailed analysis of patient, clinical and safety parameters associated with the initiation of % i e will be presented, including infection rates, white cell counts, c-reactive protein levels, tolerability and infusion-related adverse events. conclusion: these cases highlight the real-world use of % i e in two patients with pid and one patient with sad. they show that i e was well-tolerated and efficacious in one treatment-naïve, and two previously-treated patients. method: prospective study of families with one or more members with c -inh-hae followed in hospitals in the northern area of spain. a cohort of patients from families with c -inh-hae was evaluated for familiar diagnosis of c -inh-hae one or several patients from the same family were chosen and were given a questionnaire to identify the total family members from the family branch affected by c -inh-hae that had been already studied (members with diagnosis of c -inh-hae and healthy members) and those that had not been previously studied. we also register the difficulties for obtaining these data. family members not previously studied and that consent to be contacted were asked for study of c -inh-hae. for c -inh-hae screening we use c blood levels results: we have studied families with c -inh-hae, ( %) type and ( %) type ii; families had all their known members already studied for c -inh-hae ( %): families have all their members studied ( . %), families have % or their known members studied ( . %) and families had less than % of their total known members studied. we have identified members from unrelated families that had not been previously studied for hae, healthy, had low c levels and had presented symptoms of hae; had not presented symptoms of angioedema, had normal c levels, and low antigenic and functional c -inh levels. difficulties for a complete family testing study have been: family dispersion, scarce or no family relationship, do not wish to know their possible pathology conclusion: it is crucial to insist on the study of the relatives of patients with hae. we propose to include a questionnaire to identify all patient's relatives at medical reviews of hae patients. case: a- year old boy was admitted to our clinic with the history of recurrent respiratory tract infections. his all immunoglobulins were low (igg < mg/dl, iga < . mg/dl, igm < . mg/dl) associated with the absence of b cells. his aunt cousin also had xlaa missense point mutation, c c>t in exon of the btk gene was identified in both affected cousins. the patient was commenced on regular ivig treatment every weeks. at the age of , he suffered from intermittent fever attacks, abdominal pain and weight loss. tests for giardia lamblia, clostridium difficile and cryptosporidium, noro virus or parasites were negative. mr-enterography revealed intra-abdominal fluid and thickened walls of his jejunum and cecum. histopathological examination of the biopsy material obtained from terminal ileum, colon and cecum showed crohn disease. initially, he was treated with prednisolone and infliximab. because of the lack of response, infliximab treatment was switched to adalimumab. terminal ileum was resected to relieve obstruction complication. although he had been treated with adalimumab for year, a significant improvement was not observed. vedolizumab (entyvio ™ ), is a humanized monoclonal antibody α β integrin-receptor antagonist, was commenced. induction dosing was mg infusions at , , and weeks followed by a maintenance phase at week intervals. at the month of the treatment, fever and abdominal pain attacks reduced, while his weight and oral intake increased. no side effects were observed. discussion: vedolizumab is effective for inducing and maintaining remission in adults with inflammatory bowel disease (ibd); however, there is limited pediatric data. this is the first immunocompromised child treated with vedolizumab. the symptoms of the patient receded and no side effect observed during months of the treatment. results: louis-bar syndrome is a multisystem progressive disease with polymorphic manifestations which varies by age. the locomotor disability of these children is determined by neurological disorders, the exitus being caused by respiratory infectious and malignancies. the children involved in the study, had frequent episodes of respiratory infectious (bronchitis, pneumonia, atelectasis, empyema, lung abscess), ent infections (otitis, mastoiditis, sinusitis), chronic pulmonary disease (pulmonary fibrosis, bronchiectasis). index of death in this group is high ( . %). in one of the boy, the pulmonary ct showed lymphadenopathy, later was confirmed non-hodgkin lymphoma, with subsequent death. another child died from pulmonary and systemic infectious complications. results: in this paper we present the clinical and morphological analysis of children with nezelof syndrome diagnosed post-mortem. clinically were predominantly the generalized intrauterine infections or their development in the postnatal period. at macroscopic examination all patients had thymic hypoplasia. later on the microscopic study of the thymus specimens determined dysplastic changes, defined by the presence of concentrically arranged epithelial cells. in all patients, was determined the total lack of hassall corpuscles and its predecessors. besides the above-mentioned modifications in all specimens, there was no cortico-medullary segregation. thymic parenchyma outside pseudorrhagia was made up of a reticular stroma with total lymphocyte depletion. conclusion: nezelof syndrome is a severe primary immunodeficiency associated with thymic dysplasia and alymphocytosis, which is manifested early with generalized infections and major risk of death in neonatal and infant. background: the study was aimed to evaluate the cytokine profile in nasal secretion and blood serum in patients with seasonal (sar) and perennial allergic rhinitis (par) with a potential for additional sensitization with microbial allergens. method: the inclusion criteria for ar were as follows: a diagnosis of ar for more than years, the absence of nonallergic disorders of the nasopharynx, age of patients from years to years.control group: healthy volunteers at the age of - years without any allergic disorders at examination.in order to evaluate the innate and adaptive immunity, the cytokine profile of blood serum (il- , il- , and tgf-β) and nasal secretion (tslp, il- β, tnf-α, and gm-csf) was determined. to determine tslp, tgf-β, il- , and gm-csf concentrations, enzyme-linked immunosorbent assay kits were used (ebioscience, bender medsystems, r&d systems, mn, usa). we have noticed a significant correlation (r = , p = ) between the tslp concentration in nasal secretion and as-ige level to staphilococcus aureus enterotoxin (allergen component m ) in patients with par. there was a significant correlation conclusion: staphylococcal superantigens might be one of the stimuli of local tslp hyperproduction by the epithelium. there was a significant correlation between gm-csf concentrations in nasal secretion and the intensity of sensitization to a staphylococcal enterotoxin (seb) in the patients with ar. seb is one of the polyclonal t cells activators, which may account for increased concentrations of cytokines such as gm-csf locally within the system of mucosal immunity. the patients with ar and additional high sensitization to ses demonstrated a higher tnf-α production profile due to macrophage and tcell activation by these toxins. | evaluation of circulating osteopontin level as potential biomarker of allergic asthma in patients with caucasian and south-east asian ethnicity background: osteopontin (opn) is a pleomorphic cytokine known to influence a wide range of immune cells; allergic asthma was previously associated with high circulating opn levels. in the present study, we aimed to verify if opn may qualify as biomarker of activated immune response in allergic patients belonging to two different ethnic groups: caucasians and south-east asians. method: serum opn levels were measured by elisa test (human osteopontin duoset, r&d systems) in a series of italian adult patients affected by extrinsic asthma, allergic rhinitis, hymenoptera venom allergy, food allergy, allergic contact dermatitis and ige mediated hypersensitivity to beta lactams. healthy subjects served as controls. ethnic chinese subjects were recruited at the national university of singapore (nus) as cross-sectional cohort of an ongoing epidemiological study on the national prevalence of allergic diseases, and opn levels were detected by luminex (milliplex map, merck) and elisa assays (r&d systems). results: in the italian cohort, opn levels were significantly higher in cases compared to controls (p = . by the mann-whitney test). statistically higher opn levels were found in asthma (p = . ) and food allergy (p = . ) groups in comparison to controls. no significant differences were found (p = . ) between singaporeans with lifetime asthma and healthy controls, only the highest opn levels were heterogeneously found to correlate with asthma. however, a strong gender effect was shown, in both cases (p < . ) and controls (p < . ), with males presenting higher opn levels in comparison to females. consequently, we checked the mrna expression levels of opn gene (spp ) with illumina chips in whole blood of males and females, and no difference was found (p < . ). several experiments with western blots and different gel types were performed to verify if possible post-transcriptional/posttranslational modifications of opn could explain these findings. conclusion: opn seems to be a promising biomarker for current, active allergic asthma in caucasians even though technical difficulties, due to opn intrinsically disordered structure, the complex enzymatic metabolism, and the low circulating levels, significantly affect the experiments. further studies are needed to confirm these data. | mortality, intubation, and healthcare cost in patients with allergic bronchopulmonary aspergillosis in a hospital setting: a nationwide study fan x; luo y; yue b background: abpa is a complex hypersensitivity reaction to aspergillus fumigatus that colonize in airways, it is almost exclusively seen in patients with asthma or cystic fibrosis(cf). this study is to estimate hospitalization outcomes and healthcare cost of hospitalized patients with abpa. method: we conducted the study using data from national inpatient sample(nis) from to . diagnosis were identified using icd- -cm codes. hospitalization with a primary diagnosis of abpa and hospitalization with a primary diagnosis of acute respiratory failure/acute and chronic respiratory failure/respiratory distress/ asthma/cf and a secondary diagnosis of abpa were included. the study population was divided into groups including abpa with asthma, and abpa with cf. mortality and intubation rate were the primary outcomes; length of stay and total hospitalization cost(adjusted to cost in based on medical care cpi) were secondary outcomes. student t-test and chi-square were used for univariable analysis, linear and logistic regression were used for multivariable analysis. results: a total of hospitalizations with abpa were included, with hospitalizations with abpa and asthma, and hospitalizations with abpa and cf. the overall mortality rate was . % ( % ci: . %- . %), the mortality for abpa with asthma was . % ( % ci: . %- . %) and for abpa with cf was . % ( % ci: . %- . %). the overall intubation rate was . % ( % ci: . %- . %); the intubation rate for abpa with asthma was . % ( % ci: . %- . %) and . % were early intubation (< days); the intubation rate for abpa with cf was . % ( % ci: . %- . %) and . % were early intubation. the overall mean length of stay(los) was . ( % ci: . - . ) days, while the los for abpa with asthma was . ( % ci: . - . ) days and the los for abpa with cf was . ( % ci: . - . ) days. the overall total cost was million usd, the total cost for abpa with asthma was . million usd with a mean of , while the total cost for abpa with cf was million usd with a mean of . conclusion: mortality among hospitalized patients with abpa is low< %. intubation rate is relatively low, intubation, especially early intubation (< days), is more common in patients with asthma. although abpa is not a common disease in inpatient population, it does have a high health care cost and despite lower intubation rate, patients with abpa and cf generally have a longer hospital stay with a higher hospitalization cost. | frequent exacerbations of bronchitis with wheezing in adults: is it possible to predict and prevent asthma? case report: frequent episodes of bronchitis, accompanied by wheezing and dry with a prolonged duration in adults, the clinical course may be similar to bronchial asthma. the aim is to assess the risk of asthma in adult patients with or more episodes of acute bronchitis per year, had a prolonged duration and accompanied by a dry wheezing. for years in two regional clinical pulmonology centers were observed in patients ( men and women) with average age ± . years. each had at least episodes of acute bronchitis per year, which was accompanied by prolonged cough and presence of wheezes. average number of acute episodes per year was . ± . . in the course of the observation the patients were divided into equal groups. the first group consisted of persons treated in acute episodes of the disease symptomatic therapy, including inhaled β -agonists short-acting short course. in the second group to the corresponding treatment added montelukast mg per day lasting for month. in all cases of exacerbation had a viral nature. held in the period of remission of allergic sensitization, the survey revealed. starting from the first year of follow-up all patients were vaccinated against influenza annually. by the end of the fifth year of observation in the first group in cases was diagnosed of bronchial asthma- cases easy persistent asthma and case moderate. the diagnosis was exhibited in accordance with the gina criteria. in the second group, the diagnosis of bronchial asthma were exposed to patient (hazard ratio of . ). prospective observation suggests that the use of anti-inflammatory potential antileukotriene medicines in complex therapy of recurrent acute episodes of bronchitis accompanied by a dry wheezing in adults may be a factor preventing the development of asthma. for more conclusive results require more extensive research. background: chemokine receptors play an important role in regulating the migration of t lymphocytes, monocytes and neutrophils from the peripheral blood into inflamed tissue, such as lung. however, little is known about their expression on natural killer (nk) and natural killer t (nkt) cells in patients with chronic obstructive pulmonary disease (copd). therefore the aim of the study was to determine the chemokine receptor profile of peripheral blood nk and nkt cells of copd patients. method: for analysis of lymphocytes subtypes the flow cytometry method was used. the study population consisted of smokers with copd, healthy smokers and healthy non-smokers. results: we observed an increase in blood nk cells expressing cxcr receptors in smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). the percentage of nkt cells containing cxcr receptors was also significantly higher in blood of smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). copd smokers had significantly higher proportion of ccr + nk cells than smokers without copd (p = . ) and healthy non-smokers (p < . ). increased proportion of blood nkt cells expressing ccr on their surface was observed in smoking copd patients compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). there were no significant changes in the percentage of cxcr + and ccr + nk and nkt cells between healthy smokers and non-smokers. in addition, no differences were seen in the proportion of nk and nkt cells expressing cxcr , cxcr , ccr and ccr among all studied groups. method: patients with copd in stable condition (gold stage ) aged - years old, smoking history of ≥ pack-years, were studied. bmi of patients were divided into groups: obese (n = ) (bmi- . - . kg/m ) and non-obese (n = ) (bmi- . - . kg/ m ). ten subjects with normal lung function and bmi were the control group. the level of il- assessed in induced sputum (pg/ml) was measured using an elisa (raybiotech ® ). serum levels of crp were measured using the "vector-best" (russia federation). spirometry was performed according to american thoracic society and the european respiratory society (ats/ers) guidelines. results: obese copd patients had significantly increased concentrations of il- compared with healthy subjects and non-obese copd patients by . fold ( . ± . pg/ml vs . ± . pg/ ml) (p < . ) and . fold, ( . ± . pg/ml vs . ± . pg/ml)(p < . ), respectively. non-obese copd patients had higher levels of il- by . fold compared with healthy subjects ( . ± . pg/ml vs . ± . pg/ml) (p < . ). results: among these three groups, the level of cer in lung cancer patients ( . ± . g/l) was significantly higher than that in ild patients ( . ± . g/l) and healthy individuals ( . ± . g/l) (p < . ). meanwhile, the levels of c and c in healthy individuals, which are . ± . g/l and . ± . g/l respectively, were both significantly higher than that in lung cancer patients (c : . ± . g/l, c : . ± . g/l) and ild patients (c : . ± . g/l, c : . ± . g/l), (c : p < . , c : p < . ). results from optimal scaling demonstrated that lung cancer was closely associated with immune factors including crp, cer, c and c (cronbach's alpha = . %). conclusion: for ild patients, when the level of crp and cer is increased and the level of c and c is decreased simultaneously, the risk of the development of lung cancer should be considered for these patients. results: among pbmc subpopulations, endurance exercises impacted the number of nkt and activated t cells with nkt cell numbers greater in male bobsledders vs bullet shooting and biathlon ( . % and . %, respectively). the number of activated t cells (cd + ) was greater in bullet shooting and bobsleigh athletes vs the biathlon group ( . % and . %, respectively). in female athletes the number of cd + cells in the shooting and bobsled groups was greater by . % and . %, respectively vs the biathlon group (p < . ). increased il- occurred in bobsleds in comparison to bullet shooting and biathlon: % and % in male and . % and % in female, respectively (p < . ). the concentration of il- in male bobsledders and biathlon was % and % greater, respectively, compared with bullet shooting (p < . ). serum concentrations of ifnγ in male as well as female athletes showed an increase of . % and . %, respectively vs biathletes (p < . ). increased il- occurred in the male biathlon group by . % and %, respectively, vs the bullet shooting and bobsleigh athletes (p < . ). il- was increased in the male biathlon group, compared to bullet shooting and bobsledders by . % and . %, respectively (p < . ). conclusion: prolonged endurance exercises impacts secretion of pro-and anti-inflammatory cytokines in athletes of different sport specializations. concentrations of studied cytokines did not exceed reference values perhaps due to specialized sport nutrition, which may restore immune function during endurance exercises. background: oral immunotherapy (oit) is a promising therapeutic approach to treat food allergic patients. recently, we have shown that the use of a mixture of short-chain-and long-chain fructo-oligosaccharides (scfos/lcfos) improves the efficacy of oit in cow's milk and peanut allergic mice. however, concerns with regard to safety and long-term efficacy of oit remain and there is a need to identify novel biomarkers (panels) that predict, monitor and/or evaluate the effects of oit. here we present a method for the selection of candidate biomarkers by using the computational approaches bayesian networks (bn) and topological data analysis (tda). method: data were used from scfos/lcfos diet-supported oit studies performed in independent cow's milk allergy (cma) and independent peanut allergy (pna) experiments in mice. first, a subset of the data was used for learning the data structure and their interactions in terms of a bn. this bn was used to compare the key parameters in both experimental food allergy models. finally, the relations within the dataset in combination with the bn were explored to identify and rank candidate biomarkers for the effect of oit by applying tda. the bn was able to predict the efficacy of oit in the cma and in the pna model with % and % accuracy respectively, thereby identifying a set of parameters (allergen-specific ige and igg , body temperature, mmcp- , earswelling) being key in the mechanisms involved in both scfos/lcfos-aided oit food allergy models. the tda zoomed in on the full set of previously analyzed parameters and identified clusters of biomarkers closely linked to biologically relevant clinical symptoms but also unrelated and redundant parameters within the network. taken together, this enables the prioritization of candidate biomarkers. moreover, the tda indicated differences between pna and cma models in how the data are related to each other. here we provide promising bioinformatics methods to compare mechanistic features between two different food allergies and to determine the biological relevance of biomarker (panels) of oit for food allergy. we have shown that the key drivers that influence pna and cma are similar, but that these phenotypically similar diseases show mechanistic differences in their subnetworks. these new insights provide excellent starting points to generate new hypotheses to explain why cma has a different disease pattern than pna and to select biomarkers that are useful in future clinical studies. | functional and immunoreactive levels of igg correlate with clinical responses during the maintenance phase of house dust mite immunotherapy basophils were identified as ssc low cd high , and cd was used as an activation marker. reactivity was confirmed by anti-ige as a positive control. results: in patients, basophil reactivity and sensitivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a lower basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. conclusion: in patients, basophil reactivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a minor basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. reactivity of extract and the main sensitizing components correlated, while sensitivity did not. | in vitro assessment of hypersensitivity to allergen before and after allergen immunotherapy with whole blood basophil histamine release assay wbbhr assay in these patients was performed - days before and - days after ait. heparinized whole blood samples ( ml) of each patient after substitution of plasma with pipes buffer were incubated one hour at °c with different concentrations of birch pollen extract (t ) in u-shape -well micro-titer plates. after incubation plates were centrifuged and supernatants from each well of the plate were directly analyzed for histamine content by reversedphase high performance liquid chromatography with electro-spray ionization mass-spectrometry (rp-hplc-esi-ms). results were expressed as ng/ml released histamine. sensitivity (limit of quantification) was - ng/ml. to compare results of histamine release in patients before and after ait data were calculated as area under the curve (auc) values. results: in contrast to pre-immunotherapy activity of blood basophils there were significant decreases in hr induced by t extract after ait. according to auc values all patients demonstrated decrease in hr after ait in compare to hr before ait in a range of %- % demonstrating a decrease of hypersensitivity to birch allergens. analysis of basophil hr in patients received s.c. or s.l. the asthma and rhinoconjunctivitis symptom scores during and after pollination season decreased significantly and showed correlation with histamine release by t . | immunotherapy with the recombinant b cell epitope-based grass pollen allergy vaccine bm induces a biphasic allergen-specific igg and igg response background: immunotherapy with the recombinant b cell epitopebased grass pollen allergy vaccine has been shown to reduce symptoms of grass pollen allergy in a multicenter, double-blind, placebocontrolled study. aim of this study was to investigate the levels and kinetics allergen-specific igg responses in a double-blind, placebocontrolled phase iib combined field and exposure chamber trial studying the effects of three, four and five pre-seasonal injections of bm as compared to placebo. method: a quantitative elisa assay based on purified human monoclonal allergen-specific igg as well as igg antibodies as standards was developed to measure allergen-specific igg and igg concentrations induced by ait with bm . results: we found rises in levels of both tested allergen-specific igg subclasses in the actively but not placebo-treated patients. phl p -and phl p -specific igg levels up to μg/ml and μg/ml, respectively and phl p -and phl p -specific igg levels of up to μg/ml and μg/ml, respectively were measured in bm treated patients. five pre-seasonal injections induced the highest allergen-specific igg levels. interestingly, allergen-specific igg and igg antibodies showed a biphasic response with early rises of allergen-specific igg which declined quickly after the pollen season and a delayed but very sustained allergen-specific igg response. conclusion: treatment with bm induces a biphasic allergen-specific igg response consisting of an early igg and a sustained allergen-specific igg response which may be responsible for early and sustained protection against allergic symptoms. | t reg cd + cd high in peripheral blood in patient with grass pollen allergy during sublingual specific immunotherapy slit the aim of this study was to evaluate t reg cd + cd high in peripheral blood in patients with grass pollen allergy during sublingual immunotherapy slit. method: we examined adult patients, aged - , female and male. patients were qualified to slit after confirmation of allergy-by skin prick tests, specific ige and nasal provocation tests. we determined t reg cd + cd high from blood sampling of those patients (by flow cytometry method), before the slit, after reaching the maintenance dose, before the grass pollen season, during the grass pollen season, and after one year of slit. results: during slit the percentage of t reg cd + cd high increase after reaching the maintenance dose, then it decreased before and during the grass pollen season, and again increase after one year os slit. we observed, that in the group with significant improvement of symptoms, t regcd + cd high decreased during grass pollen season, comparing to group without clinical improvement. conclusion: slit as a method of immunotherapy influence on levels of t reg cd + cd high cells. the observed decreased levels of these cells during the grass pollen season might be consider as a prognosing marker of clinical improvement. | t reg cd + cd high from peripheral blood during subcutaneous specific immunotherapy (scit) for grass pollen hofman a; hofman j; hofman t centrum alergologii, poznan, poland background: specific immunotherapy is the only causal method for grass pollen allergic rhinitis. however, we don't observe in every patients satisfying clinical effects. because the treatment of allergic rhinitis takes - years, and is quite expensive, everyone is constantly looking for a perfect parameter, which may prognose the effectiveness of specific immunotherapy (sit). the aim of this study was to evaluate t reg cd + cd high lymphocytes from peripheral blood in patients during subcutaneous specific immunotherapy (scit) for grass pollen . method: we examined adult patients ( female, male), age - , who undergo scit for grass pollen allergy. we have done skin prick tests and specific ige in those patients. additionally, we confirmed the allergy by nasal provocation tests. we have determined lymphocytes t reg cd + cd high from blood sampling from those patients, with flow cytometry method: before immunotherapy, after reaching the maintenance dose of scit, before and during the grass pollen season, and after one year of scit. our control group was represented by adult healthy volunteers. after one year of scit we divided patients into two groups-with and without clinical improvement. results: in allergic patients we have observed decreased levels of t reg cd + cd high compared to control group before the start for scit. during immunotherapy, the percentage of t reg cd + cd high increased after reaching the maintenance dose, however it did not reached the level of healthy volunteers. again, levels of t reg cd + cd high decreased before and during the grass pollen season, and increased after one year of scit. we compared also patient with significant improvement of clinical symptoms, and without. and we observed that the level of t regs cd + cd high decreased during pollen season in improved group, and increased in the group without clinical improvement. conclusion: in patients with grass pollen allergy, during the grass pollen season, decrease of t reg cd + cd high cells might be con- results: in the group of patients treated with sit gene expression analysis revealed significant change in ifng expression (p = . ) (comparison between sample a and b). comparison between samples a and c showed significantly different expression in genes: afap l (p = . ), commd (p = . ), pik cd (p = . ), and twist (p = . ). duncan's multiple range test confirmed difference between sample a and c for commd (p = . ) and also revealed new significant difference in tbx in samples a and b (p = . ; in wilcoxon's test p = . ). k nearest neighbors algorithm was built based on ifng, pik cd, commd expression. the results of the study indicate, that there is a significant change in the expression of a few genes during the build-up phase of sit. it may be suspected, that this change contribute to the mechanisms involved in the building tolerance to allergen. k nearest neighbors algorithm may be useful for sit efficacy prediction. | regulation of cytokine thymic stromal lymphopoietin (tslp) in modulating tgf-ß induced interstitial inflammation and cellular fibrosis background: thymic stromal lymphopoietin (tslp) has previously been linked to allergic inflammatory diseases, tissue fibrosis and organ dysfunction. it remains unclear, however, whether tslp plays any role in the occurrence of renal fibrosis, so this study investigated that underlying mechanism. method: an in vitro fibrosis model was established by treating normal rat kidney fibroblast (nrk- f) cells with transforming growth factor-β (tgf-β ), after which the levels of various fibrogenic markers (e.g., fibronectin) and downstream fibrogenic signal proteins (e.g., smad ) were investigated. also, tslp shrna was used to silence the effects of tslp, while an elisa was conducted to evaluate the fibronectin secretions. results: the level of fibronectin in the nrk- f cells was doseand time-dependently increased by the administration of exogenous tslp (p < . ). tslp also significantly increased the level of fibrosis signaling, in addition to inducing a marked decrease in the down-regulation of smad . interestingly, the application of tslp shrna caused a dramatic reversal of the tgf-β -induced cellular fibrosis while simultaneously leading to the suppression of fibronectin and fibrogenic signal proteins. conclusion: taken together, these observations provide insights into how extracellular matrices develop and could lead to potential therapeutic interventions for the suppression of renal inflammation and fibrosis. abstracts | | effects of two years treatment with the recombinant b cell epitope-based grass pollen allergy vaccine bm on allergen-specific b and t cell responses background: bm contains recombinant fusion proteins of nonallergenic peptides from ige-binding sites of the four major timothy grass pollen allergens phl p , , and and pres protein from the hepatitis b virus as a carrier. in a multicentre, double-blind, placebocontrolled trial, grass pollen allergic subjects were treated for two years either with bm or placebo. here we investigated in detail the effect of immunization with bm on allergen-specific t and b cell responses. during the study from subjects treated in the vienna centre (bm : n = , placebo: n = ) were investigated regarding proliferation using h thymidine incorporation and cytokine production in response to various recombinant allergens at different time points. grass pollen allergen-specific ige, igg and igg levels were determined by immunocap and elisa. results: a significant increase of allergen-specific igg and igg levels was found in the bm -but not in the placebo group in both years (year > year ) after treatment. there was no difference regarding t cell proliferation in response to phl p and phl p after first grass pollen season between actively and placebo-treated patients whereas proliferation in particular of phl p -specific responses seemed to be blunted in the active group in the second year. no significant differences regarding allergen-specific th , th and tolerogenic (i.e., il- ) cytokines were observed between bm and placebo-treated patients. the findings indicate that the bm induces high levels of allergen-specific blocking antibodies which may reduce allergen-specific t cell proliferation but does not induce significant increases of regulatory cytokines in t cells. this study was supported by grants f , f and dk -b of the austrian science fund (fwf). hospital universitario ramón y cajal, madrid, spain; department of immunology iis-fundación jiménez díaz, uam, madrid, spain background: shiitake mushroom (sm) (lentula edodes) is an edible fungi native to east asia. it is traditionally cultivated and used in many asian countries and its consumption is increasing worldwide. direct skin exposure to sm can cause cutaneous reactions, including allergic contact dermatitis and urticaria, while its oral intake may prompt "shiitake flagellate dermatitis" (sfd), which is a distinctive itching linear erythematous eruption. sfd is usually considered a toxic reaction to lentinan, a thermolabile polysaccharide that increases interleukin- . we report cases (p , p , p ) of shiitake flagellate dermatitis studied in our centre. method: skin prick tests (spt) to environmental allergens-including moulds -, prick-by-prick and patch test with raw and cooked sm were carried out. total ige and specific ige to mushroom, white mushroom and environmental moulds were also determined. a raw and cooked shittake mushroom extracts were prepared. both extracts were analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: skin prick tests, prick-by-prick, patch tests and specific ige were all negative except for p , who had positive prick-by-prick to raw shiitake mushroom. sds-page ige immunoblotting assays with the patient's sera revealed ige-reactivity with proteins ranging from kda to kda for p , p and p . we report cases of shiitake flagellate dermatitis with demonstrated ige-sensitization. physicians should take into account that some cutaneous reactions considered as toxic might be allergic reactions. vorozhko i ; sokolnikov a ; sentsova t ; donnikov a ; ilyenko l ; denisova s background: allergic diseases such as asthma, rhinitis and food allergy have increased in recent decades in tropical countries. the tropics has climatic, environmental and ecological peculiarities that allow us to emit several hypotheses that could explain this phenomenon. in one of them, it is postulated that the increase of the sensitization to food, is due to the presence of lower serum levels of vitamin d, product of the adoption of a western lifestyle, with lower sun exposure, which in its turn diminishes the immunomodulatory action of this vitamin at intestinal level, favoring the sensitization against food antigens. we evaluate differences between the titers of serum antibodies against food antigens between two populations with african ancestry but different environment (rural vs urban) and investigate the influence of vitamin d levels. method: an observational, cross-sectional and descriptive study was carried out on afro-descendant children living in san basilio de palenque (rural) or in the city of cartagena, bolivar (urban). the sensitization was determined by a positive skin prick test to allergen extracts, including foods, and, specific ige, iga and igg to egg, milk and peanut extract, as well vitamin d, were measured by elisa. antibody and vitamin d titers were correlated by spearman's test and comparisons between groups were done using the wilcoxon rank sum test. a p < . was considered significant. results: atopy was more prevalent in the urban population ( % vs %, p < . ). however, none participant tested was positive for food allergens. regarding vitamin d levels, these were found to be higher in the rural population compared to the urban group (p < . ). among the antibodies analyzed, only ige against peanut showed differences, which were higher in rural population (p < . ) as well as those of iga to peanut, which were higher in the urban population (p < . ). we observed only a significant correlation between peanut specific ige (rho . , p < . ) and iga (rho - . , p < . ) response and vitamin d. conclusion: in our study, we found differences between the peanut specific ige and iga response in urban and rural populations. the correlation between the levels of specific ige and iga to peanut and vitamin d, suggest that this vitamin may influence peanut sensitization in this population, besides other components like diet and genetic and environmental factors. | evaluation of inhaled allergen sensitivity in patients with food allergies younger than two years of age kulhas celik i ; aldemir es ; buyuktiryaki b ; ginis t ; toyran m ; dibek misirlioglu e ; kocabas cn ; civelek e carbohydrates and pyruvate was observed in the severe group compared to the rest of allergic groups. in addition, an increment in lactate was noticed. these metabolites were closely associated with the energy metabolism. other metabolic changes included increased levels of fatty acids such as myristate, palmitate and laureate. these fatty acids might be precursors of arachidonic acid, a key molecule in inflammation. finally, alterations in some amino acids and adenosine were found method: to evaluate these critical processes, five-week old germ-free c h/hen mice were split into two groups; were intraperitoneally sensitized to the peanut allergen ara h and remained ns. upon reaching weeks of age, mice were intragastrically challenged with purified ara h . mice were harvested in two groups: -minutes and -minutes post-gavage. upon harvest, the left lobe of the liver was collected and sera were removed. sera and livers were evaluated for drp-ara h using an in-house quantitative sandwich enzyme-linked immunosorbent assay (elisa). a sample of the proximal small intestine was monitored for drp-ara h using immunohistochemistry (ihc) and for mast cell degranulation using toluidine blue stain. results: sensitization does not have a large effect on the concentration of allergen present in the sera or liver. however, s mice allowed to digest ara h for -minutes were more likely to display tissues positive for detection of drp-ara h than ns mice at the same time point. conclusion: there is drastic biological variation among mice in their capacity to absorb and transport allergens. the elisa used in these analyses proved effective in the quantitative detection of drp-ara h in both liver and sera samples, while ihc provided inconsistent results for the detection of drp-ara h in tissues. however, in positive ihc samples, staining was indicative of paracellular transport across the epithelial barrier. | eczema induces a high ovalbuminspecific ige/igg ratio and affinity maturation during the lactation period irahara m; kido h; shinahara w inst. for enz. res., tokushima university, tokyo, japan background: recent articles have revealed that ingestion of foods induces oral tolerance and cutaneous sensitization induces food allergy. relationships with levels of immunoglobulin subclasses, affinity of allergen-specific ige, and development of food allergy have also been indicated. however, relationships with levels and affinity of specific immunoglobulins and eczema during early infancy remain poorly understood. therefore, the present study aimed to elucidate these relationships. method: this study enrolled women who visited naruto hospital (tokushima prefecture, japan) in late pregnancy and their children. blood samples and information on skin condition were taken every months from neonate to months old. egg white and milk allergen-specific immunoglobulin subclasses and affinity of ovalbumin (ova)-specific ige levels were measured using the densely carboxylated protein (dcp) microarray with μl of serum. results: this study included infants whose parents agreed to join this study. of these, infants ( %) were diagnosed with eczema by months old. egg white (ew) and milk-specific igg were detected in a few subjects at months old. however, these specific ige and igg were detected in some subjects at that time ew-and ova-specific ige levels and ige/igg ratios were significantly higher in participants with eczema than in those without eczema at months old. moreover, subjects with high ova-specific ige/igg ratios showed higher affinity ova-specific ige antibodies than subjects with low ova-specific ige/igg ratios. these results were not reflected in milk-specific ige levels. the milk-specific ige level differed between breast feeding and formula-fed infants, with no difference in the ige/igg ratio. conclusion: eczema contributed to high ew-and ova-specific ige levels and ige/igg ratios. high ova-specific ige/igg ratios involved high affinity ova-specific ige antibodies. however, the milk source during early infancy had no effect on the specific ige/igg ratio with eczema. these results suggest different sensitization routes provoke different results in levels and affinity of immunoglobulins. | purification and characterization of naturally occurring post-translationally cleaved ara h , an allergen that contributes substantially to the peanut allergome background: the s albumin ara h is one of the most important peanut allergens. a post-translationally cleaved ara h isoform has been described in the past but had not been characterized in detail, nor had its relevance for peanut allergy been investigated. method: post-translationally cleaved ara h (para h ) and intact ara h (intact ara h ) were purified from virginia type peanuts and the cleavage site was mapped using high-resolution mass spectrometry. biochemical characteristics were determined by sds-page, uv absorbance spectroscopy, far uv cd spectroscopy, and immunochemical reactivity of both forms of ara h was compared by igg immunoblotting and ige-elisa using sera from individuals sensitized to peanut. reversed-phase liquid chromatography was applied to study the occurrence and abundance of para h in various peanut types. results: compared to intact ara h , para h lacks a -amino acid stretch, resembling amino acids - (uniprot accession number q g ) in the non-structured loop. consequently, para h consists of chains; a n-terminal chain of approximately kda, and a c-terminal chain of approximately kda, held together by disulfide bonds. intermediate post-translationally cleaved products, in which this stretch is cleaved but not removed, are also present. the secondary structure and ige-binding of para h resembles that of intact ara h , indicating that the loss of the non-structured loop is not critical for maintaining conformational ige-epitopes. both forms of ara h were reactive with several commercially available igg antibodies. the peanut cultivars runner, virginia, valencia, and spanish contained para h at equivalent levels, suggesting para h is a consistent and important constituent of the peanut proteome. conclusion: a post-translationally cleaved form of ara h is abundant in the main peanut market types, and has ige-binding comparable to intact ara h . this should be taken into account when ara h is investigated in peanut-containing products. | release of major peanut allergens from their matrix at various ph and at saliva conditions; ara h and ara h are quickly bioaccessible background: the oral mucosa is the first immune organ that encounters allergens upon ingestion of food. peanut is often consumed in solid form, and it is not known if peanut allergens are released from the food already in the mouth. we set out to investigate the solubility of individual peanut allergens at conditions that mimic the first exposure site, i.e. the mouth. method: light roast peanut flour was suspended in buffers of various ph mimicking saliva. protein concentration was measured in supernatant, and release of major allergens ara h , ara h , ara h , and ara h was assessed by sds-page. also, the allergen profile of un-dissolved material was assessed. results: peanut protein solubility is poor in the ph range - , while at low ph ( . ) and at moderately high ph (> ), the solubility is higher. at all conditions tested, there was a substantial amount of un-dissolved protein. this indicates that the ph range of saliva, between . and . in healthy individuals, may be critical for the release of peanut protein from its matrix. in this ph range from . to . , ara h and ara h are readily released, while ara h and ara h are poorly released. increasing the ph from . to . slightly increased the release of ara h and ara h , but still the recovery was low (approximately % for both ara h and ara h ) compared to that of ara h and ara h (approximately % and %, respectively). this remarkable difference in extraction kinetics suggests that ara h and ara h are the first allergens an individual is exposed to upon ingestion of peanut-containing food. conclusion: based on our observations, we conclude that the peanut allergens ara h and ara h are quickly bio-accessible in the mouth upon ingestion of peanut. this new insight may contribute to the understanding of the extraordinary allergenicity of ara h and ara h compared to other peanut allergens. background: in proven cases of non-ige mediated cow's milk allergy clinical response can be partial even when treated with amino acid formulae e.g pain in infants. residual intestinal symptoms can be related to ongoing nerve hypersensitivity, changes in microbiome or motility disturbance. mast cells are thought to play crucial role in non-ige mediated food allergy. ketotifen is a first generation h antihistamine which has mast cell stabilising properties with pain blocking and anti tnf-a effect. hence ketotifen could have important role in symptom resolution where diet elimination has not been successful. we aim to find out effectiveness of ketotifen to unresponsive/partially responsive symptoms such as pain in non-ige mediated cow's milk allergy infants. method: children who presented to single specialist centre over years had their case notes reviewed retrospectively. inclusion criteria were those children with confirmed non-ige mediated cow's milk allergy by elimination of cow's milk with improvement of symptoms and worsening of symptoms on reintroduction of dairy. where symptoms partially responded e.g pain, ketotifen was used at . - mg once at night for weeks and symptoms were reassessed. statistical analysis was performed using r v . . with significance was set at p = . . results: patients were identified with patients excluded due to unconfirmed non-ige mediated allergy. of the case ( males, age - months), atopic co-morbidities were found in % children. common symptoms were abdominal pain ( %), vomiting ( %), back arching ( %), constipation ( %), bloating ( %), food aversion ( %) and diarrhoea ( %). we compared the children who had symptom improvement on ketotifen and cow's milk elimination against children who improved on cow's milk elimination alone. significant difference of symptom improvement was found with abdominal pain; % using ketotifen compared to % who did not use results: a total of analysis for ttgiga have been performed for a total of patients during the study period ( , , , ) . patients showed at least once a positive ttgiga. among these, had a negative result at first testing, and were positive at the second (n = ) or third testing (n = ). despite an increasing number of ttgiga requests, the number of positive results decreased. wige were rarely requested but were positive in about % of tested sera (table a and b). the amount of laboratory requests for ttgiga has increased, while those for wige remains stable and is rare. wheat allergy seems to be rarely investigated in our center and may deserve more attention. case report: eosinophil-associated gastrointestinal disorders (egids), including eosinophilic gastroenteritis (eog), are a inflammatory diseases, characterized by gastrointestinal symptoms and eosinophilic infiltration. patients with eoe have an increased incidence of allergy, with increased ige mediated food and inhalant sensitivities. use of either a targeted food allergen avoidance approach (based on allergy testing) or untargeted approach (based on food allergen avoidance) results in the resolution of eosinophilia in the gastrointestinal tract of %- % of adult. we describe a case of a -year-old patient diagnosed with eosinophilic enteritis, associated to protein-losing enteropathy. the patient experienced severe diarrhea, nausea, vomiting and weight loss, that caused a severe dysproteinaemia and electrolytes abnormalities. an upper and lower endoscopy was performed, showing an ulcerative ileitis. the histological pattern was characterized by eosinophilic infiltration of ileum and duodenum> hpf. she presented also high levels of total ige ( k/ui), high serum tryptase ( μg/l, n.v. ≤ . ) and sensitization to the lipid transfer protein (ltp) of peach. the patient was prescribed to a six-food elimination diet (sfed) and underwent high doses of oral and intravenously corticosteroids, but a satisfactory therapeutic response was not achieved. we hypothesized that ige has a role in the mechanism of aeg and that blocking ige would have improved disease symptoms and reduced allergic inflammation, as measured by a decrease in intestinal tissue eosinophilia. we started off-label administration of omalizumab mg/month subcutaneously, the same dosage schedule used in allergic asthma and, by other authors, in eosinophilic gastrointestinal disease after achieving informed consent by patient. except for an exacerbation of symptoms occurred months after starting the therapy, when a further endoscopy, showing a gastrointestinal eosinophilic infiltration> hpf, was performed, a significant improvement of both gastrointestinal and cutaneous symptoms was observed during therapy, together with a normalization of laboratory parameters. after months a clinical remission of disease was obtained and administration was stopped. although a histological remission during the first few months of treatment was not obtained, in a subset of aeg patients, ige plays a role in the pathophysiology of the disease and that anti-ige therapy with omalizumab may result in disease remission. | fullerene c reduces the allergic inflammation in food allergy mouse model background: a food allergy (fa) is an abnormal immune response to food. the signs and symptoms may range from mild to severe. they may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. food allergy is becoming increasingly common. fullerene c has the unique electronic properties making it an attractive candidate for allergic diseases therapy. the main purpose of our research was to assess therapeutic effect of fullerene c in a mouse model of fa. method: new efficient method for producing a water-soluble fullerene c has been developed. fa experimental model was induced in balb/c mice by the intragastrical (ig) ova administration after subcutaneous (sc) sensitization. fullerene c was administrated ig once a week, or twice a week, or daily. ova-specific antibodies were assessed by elisa. splenocytes cytokine production upon ova in vitro stimulation was detected by elisa. samples of jejunum of the small intestine were removed for histological examination immediately after the last ig allergen administration. results: it was shown that ova-specific ige and il- level were significant decreased in groups treated with water-soluble fullerene c . the greatest effect was observed in mice receiving fullerene c daily. the ifn-gamma level was significantly higher in ig c treated groups. the histologic analysis of jejunum of the small intestine samples showed that c -therapy improved the histologic picture. the greatest effect was observed in mice receiving fullerene c daily too. conclusion: taken together, these results demonstrate that the water-soluble fullerene c exhibits a significant anti-inflammatory effect in a mouse model of fa, and possesses a high therapeutic potential. background: a -year-old male reported eight episodes of anaphylaxis after exercise. all the ingested food eight hours before each episode was analyzed. before each episode, he had always eaten chicken or turkey meat, and he tolerated these foods without exercising. in one of the episodes the patient had taken a tablet of dexketoprofen a few hours before. since several years, he referred chest tightness after eating some fish (emperor, salmon and whiff), however he tolerated others. the patient denied having eaten fish before any of the episodes of anaphylaxis. method: commercial skin prick tests (spts) and prick by prick tests (pp) with all food ingested and fishes were performed. tryptase, total serum ige (ige) and specific ige (sige) (immunocap. thermo-fisher scientific, uppsala, sweden) to the foods involved were determined. a controlled oral provocation test (opt) with dexketoprofen was performed. results: spt was positive to tuna extract ( mm) and negative ( mm) for the rest of fish extracts. it was also negative for chicken meat extract and other foods tested. pps were positive for raw and cooked turkey meat ( mm), raw and cooked tuna ( and mm), raw emperor ( mm), raw and cooked whiff ( and mm) and raw hake ( mm). pps were negative to raw and cooked chicken meat. ige was ui/ml and tryptase . ng/l. sige was slightly positive to hake, cod and chicken meat. dexketoprofen opt was negative. at that moment, we recommended the patient to avoid chicken and turkey, as well as the fishes which he had symptoms with. since then, he has not suffered any new episode of anaphylaxis despite exercising daily. protein extracts from turkey meat, tuna, emperor, salmon, hake and whiff were prepared and analyzed by sds-page. conclusion: recently, triosephosphate-isomerase ( kda) has been identified as a new chicken meat allergen. this allergen could be responsible for the cross-reactivity between bird and fish meat and the episodes of anaphylaxis after exercise in our patient. the triosephosphate-isomerase has not been implicated previously as a cross-reactive allergen involved in the fish-chicken syndrome. results: twenty-three patients were included, % male, median age years (iqr . ), % atopic, % asthmatic. non-specific lipid transfer proteins (nsltp) were implicated in % (n = ) and ω- -gliadin in % (n = ). eighteen ( %) patients referred anaphylaxis in the reaction with co-factor, ( %) urticaria/angioedema, had both depending on the co-factor. all patients in which ω- -gliadin was the allergen involved had anaphylaxis in the presence of co-factor, with tolerance to wheat without it. in patients in which nsltp was the allergen involved, ( %) had anaphylaxis in the presence of co-factor. reaction with co-factor was more severe than without in ( %) patients; patients had no previous history of reaction and subsequently tolerated the culprit food. only patient had anaphylaxis in the absence of co-factor; the remaining presented oral allergy syndrome and/or urticaria. exercise was the main co-factor, present in patients. nonsteroidal anti-inflammatory drugs (nsaids) were the only co-factor in patients; all of them had anaphylaxis, with allergy to ω- -gliadin, to nsltps. all subsequently tolerated the nsaids involved. conclusion: nsltps and ω- -gliadin were the most frequently involved allergens in cefa, with exercise being the most frequent co-factor. nsaids were relevant co-factors, even when ω- -gliadin was the allergen involved. several patients subsequently tolerated culprit foods and nsaids, difficulting the diagnosis and further emphasizing the importance of a correct cofactor evaluation. molecular allergens had an important role in the diagnosis, avoiding unnecessary ofc. information about co-factors must be included in all patients with allergy to nsltps and ω- -gliadin. | allergy to wheat-dependent exerciseinduced anaphylaxis (wdeia) proteins, without? -gliadins as responsible ferreira a ; castillo m ; martins s ; pineda f unidade de imunoalergologia hospital das forças armadas., lisbon, portugal; departamento de aplicaciones. diater laboratorios, madrid, spain background: the second well-characterized form of allergy to wheat proteins is wheat-dependent exercise-induced anaphylaxis (wdeia), with the ω -gliadins (part of the gluten protein fraction) being the major group of proteins which are responsible, but other forms of food allergy have also been reported, with the proteins responsible including gluten proteins, cm proteins and non-specific lipid transfer proteins. the patient was a -year-old man who visited the hospital with acute urticaria just eat bread before run ( minutes). according the components of bread. it was formed by a mixture of wheat, rye and barley. with a history (for several years) of episodes of severe urticaria after intake a mixture of cereals and/or different kinds of beer. results: prick test and specific ige with wheat, rye and barley were negative and the proteins from allergenic extract from these cereals, and also the gliadins and glutenins fractions were transferred onto a pvdf membrane to carried out a western blot technique with the patient's serum. the patient's serum recognized several proteins from wheat and millet gliadins not compatible in molecular mass with a ω -gliadins. the association of w gliadin as responsible for the symptoms produced after the intake of products containing wheat and exercise is well referenced but in the case of this patient could have other proteins involved as triggers of their symptoms. suksawat y phramongkutklao hospital, bangkok, thailand background: food-dependent, exercise induced anaphylaxis (fdeia) is an anaphylactic condition that develops in patients who ingest specific food followed by exercise. a variety of foods have been described to be the cause including shellfish, wheat and vegetables. the mechanisms of fdeia is believed that exercise increases allergen absorption or decreases threshold of mast cell. the investigations such as skin prick test or specific ige for food are useful because food sensitization is demonstrated. however, a challenge test including ingestion of suspected food followed by exercise is the only method to diagnose this disease. we report a case of fdeia in a -year-old adolescent male. result: he presented with generalized urticaria and hypotension after eating a barbecue buffet which was one hour followed by playing taekwondo. after treatment with intramuscular adrenaline, antihistamine and systemic steroid, his condition was improved. the barbecue buffet consists of many kinds of food including shrimp, squid, salmon and pork meat which were previously tolerated. he had no past history of anaphylaxis or drug allergy. he was referred to our allergy unit for investigation. we performed skin prick test with food allergens and many kinds of fresh foods that he ate on that day and the result was positive to shrimp ( mm. in diameter). three-day challenge protocol was set up a month after recovery and we used aspirin as a cofactor. on the first day, open challenge for gram of shrimp was administered and the result was negative. on the second day, exercise challenge test based on the american thoracic society guideline was also negative. however, on the last day, he developed generalized urticaria five minutes after the same exercise challenge test which was hour preceded by aspirin intake and gram of shrimp ingestion. but his vital signs appeared to be stable. the patient was administered intramuscular adrenaline and antihistamine with full recovery. he was strongly advised to avoid shrimp for - hours before exercise and carry an adrenaline autoinjector. the-three day challenge protocol is a definite tool to confirm the diagnosis of fdeia. a correct diagnosis is important to avoid unnecessary restricted diet. | food dependent exercise induced anaphylaxis in peach allergic patient-case report consumption of different types of food (pancakes with cream cheese and fruit, peach, chinese dish, sandwiches-all eaten on other occasions without symptoms) and co-occurring physical exercise (dancing, shopping, walking). during diagnosis we performed spt with inhaled and food allergens (allergopharma), prick by prick tests with peach, banana, apple, pear and bread. we established the concentration of allergen specific ige (peach, wheat flour, peanuts, hazelnuts) and the level of ige specific to allergen components (immunocap isac). we performed exercise provocation test and open food challenge with peach. results: spt were negative with all tested food and inhaled allergens (inc.egg; milk; cocoa; tomato; carp; apple; banana; strawberry; rye flour; wheat flour; peanuts; hazelnut; citrus, d. farinae; d. pteronyssinus; grass; weeds; clad. herbarium; alt. tenuis; dog; cat; poplar; hazel; alder; birch; mugwort). prick by prick tests were positive with fresh peach. concentration of peach specific ige was . ku/l. in immunocap isac we found elevated levels of ige specific to ltps from different allergen sources (jug r - . ; pru p - . ; pla a - . ; tri a - . [isu-e]). open food challenge with a medium size peach was negative. exercise provocation test without allergen exposition was negative. exercise provocation test after eating a medium size peach concluded with severe lip and eyelids edema, followed by whizzing, dyspnea and urticarial. patient received adrenaline . mg im, steroids and antihistamines with good clinical effect. conclusion: patient was diagnosed with food dependent exercise induced anaphylaxis (fdeia) due to ltp allergy. she was advised to eat peeled fruit and vegetables, avoid cofactors of allergic diseases and carry rescue set (adrenaline, steroids and antihistamines). cases reports: we report case of fdeia and cases of wdeia. case : -year-old woman with intermittent severe allergic rhinitis and food allergies since childhood. in the last years she registered weekly episodes of fdeia (urticaria, angioedema, wheeze, drop of bp) especially when during effort and after alcohol intake. prick tests were positive for grass pollen, mugworth, ragweed, dust mites, celery, soy, sesame, pistachio, mango, honey and shellfish. she followed years of subcutaneous immunotherapy for grasses pollen. the fdeia episodes frequency and severity diminished during it. provocation test for celery and mango were positive, for alcohol, soy, sesame, pistachio, honey and shellfish were negative. case : -year old man with a -year history of acute gluten induced urticaria, recently developed episodes of wdeia (flushing, severe urticaria and angioedema, wheeze) when he went for gym. skin test was highly positive for wheat flour and dust mites, in vitro tests for omega gliadin and wheat-specific ige were positive. food challenge for wheat was positive. he followed oral immunotherapy for wheat. the wdeia episodes were rare and mild. case : -years old female with mild allergic rhinitis and controlled asthma, with wdeia (urticaria, angioedema, wheeze, drop of bp) in the last years. skin tests showed positive results for wheat flour, dust mites and dog hair. omega- gliadin and wheat specific ige were high, but the provocation test for wheat was negative meanwhile combined wheat and effort provocation test was positive. -year-old female athlete, otherwise healthy, experienced three episodes of fdeia following running sessions. two reactions were preceded by intake of salad containing lettuce, tomato and sunflower seeds and the third one occurred after eating celery salad. the patient denied occurrence of any symptoms with physical exertion or food ingestion alone. physical examination and blood testing did not reveal any abnormalities. the differential diagnosis was performed. in skin prick test and specific serum ige antibodies sensitization to house dust mite, grass and mugwort were found. the spt and specific ige assay to culprit and most common food allergens were negative. the molecular diagnostic has been applied (faber, caam, rome, italy). the test scored positive for art v, blo t, der f, der p, eur m, lol p, phl p. no positive results for available food molecules including celery, tomato, sunflower seeds and lettuce were found. the detection of culprit food in fdeia is of crucial meaning as the syndrome can be life-threatening. the molecular diagnostic has been applied already in diagnosis of wheat-dependent exercise-induced anaphylaxis (wdeia) proving ω- -gliadin sensitization in the majority of the cases. as the presented case did not reveal sensitization to culprit food in traditional allergy tests the molecular diagnostic was performed. this test did not show sensitization to culprit food either. however, not all of the molecules are available in molecular assays yet. cross-reactivity reaction to mugwort and grass has to be considered. the pathophysiological components of physical exertion has to be taken into consideration as well. this could contribute to the assessment of reasonability of molecular approach in diagnostic work-up for fdeia and to the establishment of standardized protocols for diagnosis and management of that syndrome. case report: food allergy to wheat is rare in adults, often reported in exercise-induced anaphylaxis. food-dependent exercise-induced anaphylaxis (fdeia) is a form of food allergy induced by exercise. fdeia symptoms can include urticaria/angioedema, respiratory and gastrointestinal manifestations and hypotension/shock. a -year-old male patient presented to the emergency department, was admitted after an episode of hives, hypotension and loss of consciousness. his consciousness was restored after treatment with epinephrine, glucocorticoids as well as fluids, and thereafter, the patient reported that the anaphylactic episode occurred when he started rapidly walking hour after eating a slice of pizza. he mentioned that the offended food was tolerated always when it was not followed by a physical exercise. review of his past medical history and family one were non-contributory with respect to this episode. the allergy skin prick testing for common foods revealed a positive response only to wheat, while and other laboratory test values were within normal ranges. the patient is discharged after instructions on the use of epinephrine auto-injector. he was also advised to avoid wheat containing products up to hours prior to physical exercise. our case demonstrated that fdeia can be characterized by the onset of anaphylaxis soon after physical exercise, when preceded by the ingestion of the responsible food. avoidance of the combination of the exposure to respective allergen and exercise is the most efficient precautive measure toward subsequent fdeia episodes. | residual exercise-induced allergic reactions after successful rush oral immunotherapies for milk and wheat method: we conducted roit for children (median . years old) with milk allergy and children (median . years old) with wheat allergy during - . after - days of the rush phase in the hospital and a slow-increasing phase at home, patients consumed the maintenance dose ( . g milk protein or g wheat protein). after at least three months of the maintenance phase without allergic symptoms, we conducted an exercise provocation test (ept) after eating the target food. if the ept was positive, we repeated it after a couple of years to check for remission. the presence or absence of eiars was based primarily on the results of epts but also on the clinical history in some cases. results: as of december , milk-and wheat-allergic patients were able to continue ingesting the maintenance dose (desensitization). in these patients, milk-and wheat-allergic patients underwent the first ept at a median of ( - ) days after roit, and the result was positive in ( . %) and ( . %) patients, respectively. among these ept-positive patients, milk-and wheat-allergic patients conducted a second ept at a median of ( - ) days after the first ept. the result of the second ept was positive in milk-and wheat-allergic patients. in addition, clinical histories of eiars were subsequently observed in milk-and wheat-allergic patients after negative results on an ept. altogether, ( . %) milk-and ( . %) wheat-allergic patients still had eiars even after getting desensitization as of december conclusion: patients with persistent milk and wheat allergy often have residual eairs even after three to five years of desensitization due to the administration of successful roit. abstracts | | anaphylaxis caused by omega- -gliadin initially diagnosed as idiopathic anaphylaxis: a case report tziotou m ; syrigos k ; syrigou e ; sinaniotis a department of allergy,, athens, greece; gpp,, athens, greece case report: we report the case of a -year-old man who experienced two episodes of wheat dependent exercise induced anaphylaxis, initially diagnosed as idiopathic anaphylaxis. first episode: the patient woke up in the morning and drove to his resort. while driving, he ate a piece of cheese and ham pie. when he arrived, he walked some meters to the garden and started feeling pruritus and dizziness. he lost consciousness and recovered by himself. he was carried to hospital where his vital signs were normal. the patient has a history of atrial fibrillation and has been on flecainide bid and aspirin at noon for the last four years. a month after the first episode he visited an allergist. skin prick tests to aeroallergens and prick to prick tests to the ingredients of the pie were negative. tryptase levels were within normal limits and skin biopsy was negative for mastocytosis. an endocrinology workup was also negative. the patient was prescribed an epinephrine autoinjector and was asymptomatic for eight months. second episode: that morning he had a cup of milk and two slices of toast for breakfast and started working in the garden. two hours later he experienced pruritus and urticaria and fell unconscious. his wife had to administer two epinephrine autoinjectors before he regained consciousness. after the second episode it was decided to start treatment with omalizumab. two months later he experienced an episode of urticaria while working in the garden. he could not recall what he had eaten before. based on history, we thought that a cofactor might contribute to the occurrence of anaphylaxis. we performed skin prick tests with peach (ltp) and gliadin, allergens associated with food dependent exercise induced anaphylaxis in our region. the test to gliadin was positive. specific ige in serum to omega- -gliadin was also positive, while specific iges to all ltps tested were negative. the patient was advised to avoid wheat and has been asymptomatic ever since. cases diagnosed with idiopathic anaphylaxis may actually be cases in which the culprit allergen has not been identified. detailed history and extensive workup may contribute to the successful management of these patients. written informed consent has been obtained from the patient. | wheat-dependent exercise-induced anaphylaxis (wdeia) and nsaids: clinical history is crucial conclusions :we present a case clinically compatible with wdeia with nsaids intake as augmenting factor. this case emphasizes that a carefully and thoroughly taken medical history is of crucial importance, otherwise wdeia can easily be unrecognized. as a result, non-allergic hyperreactivity to nsaids could be excluded and the diagnose of selective allergy to arylpropionic acids was made. exercise challenge test could not be performed in our case. case report: kounis syndrome (ks) has been defined as an acute coronary syndrome that manifests as unstable vasospastic or non-vasospastic angina, and even as acute myocardial infarction. it is triggered by the release of inflammatory mediators following an allergic insult. a -year-old woman with type ii diabetes and hypertension, and unstable angina pectoris as cardiovascular risk factors, has consumed chamomile tea. thirty minutes later, she developed generalized itching, skin rash, swelling of the face and the throat, chest tightness, dyspnea and syncope. the patient was transferred immediately to the emergency department, and sodium chloride, mg prednisolone, mg dexamethasone, mg methylprednisolone, ui heparin, mg voltaren were intravenously administered along the subsequent minutes under simultaneous treatment with oxygen therapy. an ekg examination is performed based on the patient disease's history, showing a . - mm st-depression on d -d leads, mm on v , and . mm on the v -v ones. in addition, . mm st-elevation on the avr and mm on the v derivation was observed, associated by a negative t-wave on the v , v , and avr leads. blood tests revealed a normal troponin i level (of . ng/ml). five hours later in the ekg was noticed: isolined st-segments, and negative t waves on the d , avr, and v leads. ultrasound examination revealed normal heart kinetics and function. following the heart changes, the patient was administered sol. heparin ui twice i.v., nebivolol mg, plavix mg, atorvastatin mg, abstracts | monocinque mg, ordinary insulin ui s.c., glargine insulin ui s.c., and sol. furosemide mg i.v. the patient progressed favorably, and four days after the anaphylactic episode the ekg revealed a . mm st-depression on leads v , and v , negative t-wave on avl lead, and normalized one on the v one. this case emphasizes the role of serious allergic reactions as cause of acute coronary syndrome in patients with altered coronary arteries and food intake as cause of kounis syndrome. | recall urticaria in two young patients with alpha-gal-syndrome after tick bites case report: patient a (m, age ) had suffered from - anaphylactic reactions (hives, nausea, dyspnea and dizziness) within the past months. all episodes occurred - hours after ingestion of red meat, once with alcohol as a co-factor. all episodes started with a wheal measuring about . cm in exact the same spot where he had been bitten by a tick one year before. specific ige to galactose-alpha- , -galactose (alpha-gal) was positive ( . ku/l). skin prick testing using raw pork kidney suspension and intradermal testing with gelafundin ® % diluted : also showed positive reactions. we performed an oral challenge with cooked pork kidney under careful monitoring being able to reproduce the recall urticaria as described above with a cumulative dose of g pork kidney. we stopped the challenge and treated the patient with antihistamines and corticosteroids. patient b (m, age ) reported on several anaphylactic reactions within the past years with symptoms including abdominal pain, diarrhea, as well as dyspnea and loss of consciousness in one of the episodes. all episodes occurred several hours after ingesting food. furthermore the patient remembered a tick bite about years before the first anaphylactic reaction, which repeatedly became inflamed and only healed completely over months. every episode started with pruritus and a wheal in the area of the former tick bite (in loco). specific ige to galactose-alpha- , -galactose was positive ( . ku/l) as well as the skin prick testing with cooked pork kidney and intradermal testing with gelafundin ® % diluted : . this patient refused performance of oral challenge tests. an elimination diet of red meat for months resulted in the absence of the symptoms as described. the diagnosis of alpha-gal-syndrome with recall urticaria in loco was made in both cases. this symptom may also be useful in evaluating results of oral challenge tests as well as an important clinical sign in medical history. pali-schöll i ; meinlschmidt p ; purschke b ; hofstetter g ; einhorn l ; mothes-luksch n ; jensen-jarolim e ; jäger h background: insects have gained interest as alternative nutrient source for humans and animals. however, being a "novel food" in the industrialized part of the world, several safety aspects, like allergenicity, need to be thoroughly addressed. in the present work we evaluated the cross-recognition of ige from patients allergic to crustaceans, house dust mite or stable flies, using house cricket acheta domesticus (ad), desert locust schistocerca gregaria (sg) and mealworm tenebrio molitor (tm). we further investigated changes of immune-recognition in terms of ige-binding in differently processed insect extracts. method: migratory locust locusta migratoria (lm) was subjected to different extraction methods, enzymatic hydrolysis or thermal processing, whereas tm larvae (tml) were evaluated after different centrifugation modes and ph levels. results: we revealed that ige from patients with crustacean allergy shows cross-recognition of acheta domesticus, schistocerca gregaria and stable flies. ige from house dust mite allergic individuals binds to acheta domesticus and schistocerca gregaria. importantly, the cross-reactivity to lm can be deleted by enzymatic hydrolysis with different enzymes or heat treatment (cooking, autoclaving), but not by different extraction methods. changes of ph and varying centrifugation steps are not sufficient to reduce ige-binding to tml. our results show that patients allergic to crustaceans, house dust mite or stable flies-allergic patients cross-recognize desert locust and house cricket proteins, and crustacean-allergic patients also flies proteins. furthermore, we confirm that the appropriate food processing method of insect proteins can reduce the risk of cross-reactivity for crustaceans-and house dust mite-allergic patients. the study was supported by the austrian science fund fwf (grant sfb f -b to ejj). results: the mean age at diagnosis was years in children and years in adults, more frequent in males ( : ). in the pediatric group, three had first-degree relatives with eoe and three had celiac disease. two children had performed milk oral immunotherapy and five adults aeroallergens subcutaneous immunotherapy. most of them were atopics with sensitization to aeroallergens ( . % of children and . % of adults) and food allergens ( % of children and . % of adults), without statistically significant differences. the most frequent foods were fruits and nuts in both groups. we found significant statistical differences in fruits ( % of children abstracts | and . % of adults; p = . ) and cereals sensitization ( % of children and . % of adults; p < . ). in the clinical presentation we observed significant statistical differences in impaction ( . % of children and . % of adults; p < . ), dysphagia ( . % of children and . % of adults; p < . ) and abdominal pain ( % of children and . % of adults; p = . ). in the endoscopic findings children had more frequently exudates ( . %; p < . ) and adults had esophageal trachealization ( %; p < . ). significant statistical differences were found in the treatment with topical corticosteroids ( % of children and . % of adults; p < . ) obtaining a variable positive response. . % of patients in both groups received food elimination diet, % with four or more foods. conclusion: eoe presents differences in the sensitization profile, clinical manifestations and endoscopic findings according to the age of presentation. the response to pharmacological treatment is variable and a high percentage of patients receive food elimination diets. it is a pathology difficult to control, therefore new non-invasive techniques would be useful in order to facilitate its management. | modulation of gut microbiota in patients with nickel allergy and ibs after diet and probiotics supplementation mb ; garcía-figueroa be department of allergy department of allergy fang l united states | bcx improves health-related quality of life in hereditary angioedema with c -inhibitor deficiency bygum a fang l former yugoslav republic of; division of clinical immunology huissoon a bygum a ; panovska vg united states callejas fdb alobid i ; muñoz-cano r izquierdo i icahn school of medicine at mount sinai method: the case report form was developed by experienced allergists, and the web-based registry was established in cooperation with a professional medical software team. twenty-two departments from hospitals took part during the first year %), whereas in adults, drugs ( . %) were more common than foods ( . %). the most common food triggers were eggs ( . %), milk ( . %), and walnut ( . %) in children, and shrimps ( . %), wheat ( . %), and crab ( . %) in adults. among drug triggers in adults, antibiotics ( . %) were the most common cause followed by nsaids ( . %), and h -blockers ( . %). the onset time was≤ minutes in . %. in children, home was the place of occurrence in more than half of the cases, whereas adults experienced anaphylaxis in out-of-home settings more often than children. cofactors were present in %. among the cases registered via the emergency department of participating hospitals, epinephrine was administered in . % ( . % in adults, . % in children) and the route of administration was im in . %, iv in . %, both im and iv in . %, and subcutaneous in . %. the number of epinephrine administration was single in % conclusion: this multicenter prospective registry would provide a better understanding of anaphylaxis, and provide visionary modalities to improve the management and prevention of anaphylaxis in future a case of kounis syndrome after chamomile tea consumption characterized by symptoms related to esophageal dysfunction and esophageal mucosal infiltration by eosinophils objective: characterize patients (pts) with eoe diagnosis and analyze the differences between pts with diagnosis at pediatric (ch, < years old) and adult age epicutaneous tests(epict)], serum total ige and eos, findings in upper digestive endoscopy (ude) and biopsies. the correlation between food sensitization, clinical severity (visits to er services or hospitalization due to complications of eoe, sclin) or severe histology results: pts ( % male, average age ± years) ad and , respectively. % ch and % ad were atopics. the most frequent symptoms of eoe were dysphagia ( %) and gastroesophageal reflux( %) in ch; impaction( %) and dysphagia( %) in ad. % ch and % ad had aeroallergens sensitization. % ch and % ad had food sensitization. the most frequent positive tests were for ch: spt to milk( %) and shellfish( %), epict to shellfish( %) and meat( %); for ad: spt to milk( %), fresh fruits and nuts both %), epict to shellfish( %) and meat( %). ude showed: % striation and white plaques in % ch shist ( %) was associated with sclin ( %), p = . in ch; but this was not observed in ad group there was no correlation between food sensitization and sclin or shist in both groups(p > . ). the average values of serum total ige (kua/l) were in ch and in ad; eos were and , respectively in ch and ad allergy unit-fondazione policlinico universitario a. gemelli, università cattolica del sacro cuore conclusion: ltp with a fixed dose ( iu in ml) of ready-touse shp led to fewer severe attacks, a higher proportion of attack-free patients, and a clinically meaningful and statistically significant reduction in cumulative attack severity and daily severity in hae patients relative to placebo. background: c -inh-hae is a rare, potentially life-threatening disease characterized by episodes of subcutaneous and/or submucosal swelling. apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with a history of at least hae attacks per month were randomized to receive four different doses of bcx ( mg, mg, mg, . mg) or placebo for days. blood samples for bcx concentrations and kallikrein inhibition were obtained from patients before dosing and for hours post-dose on day . pk analyses and pk-pd modeling were done in phoenix winnonlin v . and sas v . . the pk population included , , , and subjects in the mg, mg, mg, and . mg groups respectively.after daily dosing achieved steady state, c max was reached at a median of - hours after dosing. there was a greater than dose proportional increase in exposure (auc tau and c max ) over the . -mg to -mg dose range, with an approximate -fold increase in exposure with a . -fold increase in dose. at doses ≥ mg, which showed statistically significant and clinically meaningful reductions in hae attack rates, geometric mean plasma trough concentrations (c tau ) were maintained at or above the minimum target concentration ( -fold ec ) estimated to be required for adequate plasma kallikrein inhibition. percentages of study subjects at steady-state with bcx plasma concentrations> -fold ec were %, %, % and % in the . , , , and mg dose groups, respectively. a -mg dose provided a mean c tau of slightly above . fold ec , with a corresponding reduction in hae attack rate of % (p < . ) compared with placebo. consistent with the exposure data, a dose dependent inhibition of kallikrein was observed with bcx treatment over the dose range. the drug effect on kallikrein inhibition was highly correlated with exposure (r = . ). in patients with c -inh-hae, bcx treatment at doses ≥ mg resulted in clinically meaningful reductions in the mean weekly hae attack rate. concentrations of bcx at doses ≥ mg were maintained at or above a c tau of -fold the kallikrein inhibition ec in most patients, and kallikrein inhibition was highly correlated with bcx plasma concentrations.background: c -inh-hae is a rare, life-threatening disease characterized by recurrent episodes of subcutaneous and/or submucosal swelling that lead to considerable morbidity and a poor quality of life (qol). apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with at least hae attacks per month were randomized to four different bcx doses ( mg, mg, mg, . mg) or placebo. subject-reported qol assessments were conducted at the start and end of treatment using the disease specific angioedema quality of life (ae-qol) questionnaire that measures domains (function, fatigue, nutrition, fear/ shame) and has minimal clinically important difference (mcid) of points. the changes from baseline in total and domain scores was compared between the treatment and placebo groups. modified angioedema activity score (aas) values across domains (daily activities, appearance, physical discomfort, overall severity) were calculated for each attack and a total score was derived for each subject by summing scores from each attack. total scores were compared to placebo using an ancova model with adjustment for qualifying attack rate. reduction of attacks was statistically significant for all top doses and there was a dose related increase in adverse events.results: in the mg dose group, qol assessed by ae-qol was significantly improved after weeks of treatment compared to placebo for ae-qol total score (- . , p < . ) as well as across all domains (function: - . , p = . ; fatigue: - . , p = . ; fears/shame: - . , p < . ; nutrition: - . , p = . ). all other treatment groups showed a trend towards improvement. qol improved the most in the mg group, and % of subjects in the mg group showed ae-qol reduction of more than points. disease activity as assessed by the aas was significantly reduced in the mg, mg and mg dose groups as compared to placebo, whereas there was no significant reduction in the . mg dose group. results: there were no marked differences in the age, sex, total ige titer, comorbidity of bronchial asthma and atopic dermatitis or the starting dose of rush oit among the groups. all patients in the low-bmfi group achieved ≥ % of the target dose, whereas . % of the middle-bmfi group and % of the high-bmfi group failed to achieve the target dose (p < . ). results: a total of infants were diagnosed with food allergy (ige-mediated and mixed type) at our center during the study period, of these patients underwent prick test for inhalant sensitivity, and ( . % male) of these were younger than years of age. conclusion: sensitivity to inhaled allergen were found in of ( . %) patients with food allergy. therefore, we believe that inhalant sensitivity should be evaluated in these patients. there is also a requirement for further studies to identify the influence of inhaled antigens on the disease activity of patients with allergic conditions. method: in this study, we aimed to perform the metabolic profiling of severe profilin mediated food allergic patients looking for biomarkers that might both, predict the prognosis of the disease and understand the molecular mechanisms of inflammation underneath. other allergic patients (mild and moderate) and non-allergic were recruited in the study as comparative groups. the allergic patients class was predicted using a mathematical algorithm from non-allergic vs severe model results: plasma samples from non-allergic subjects, mild, moderate and severe allergic patients were measured using gas chromatography coupled to mass spectrometry (gc-ms). the samples were from different hospitals in spain covering the areas with the highest pollen exposure. the metabolic profile was composed of metabolites for each sample. results after the statistical analysis showed differences between the groups. firstly, a clear reduction of several abstracts conclusion: we found, as expected, a predominance of males with eoe diagnosis. ch were more frequently atopic and had aeroallergen and food sensitization. impaction and esophageal stenosis were more frequent in ad than ch. shist was associated with sclin only in ch. method: three children with ee, boys aged . - years, were assessed over months to years. results: cases developed in infancy. one had dyspepsia and low weight gain in infancy soon after feeding began. another had symptoms in infancy but not diagnosed until age with dysphagia and esophageal stricture.. the third case was diagnosed at years old after episodes of food impaction in the esophagus beginning at age . all cases had allergic comorbid diseases including atopic dermatitis in all and allergic rhinitis in . skin prick tests were positive to several food allergens (cow's milk, egg protein) in , to dust mite in and to pollens in . serum total ige levels ranged from to iu/ml. eosinophils in peripheral blood were elevated in all , reaching %- %. treatment included restricted diet and topical budesonide - mg daily depending with periodic endoscopic biopsy.in all cases clinical improvement occurred by one month of treatment, with endoscopic confirmation. morphological improvement fol- the study aimed to evaluate the effects of probiotic supplementation, in addition to diet, in ibs and snas patients, in terms of modulation of faecal microbiota population, reduction of gi and cutaneous symptoms, increase of patient's quality of life and modification of gut dysbiosis.method: forty patients aged between and years, affected by ibs, ni sensitization and ltp sensitization were enrolled to evaluate gut dysbiosis. dna extraction method (next generation sequencing) with commercial kit (microbiopassport ® ) was performed on stool samples. ibs patients were divided in two groups, according a gluten free diet prescription or a low fodmaps diet prescription for three months. similarly, (suspected) snas patients (confirmed by % ni sulfate in petrolatum patch test) were prescribed a low ni diet ( μg/kg nickel content during the first four weeks and then up to μg/kg up to three months). two ltp (lipid transfer protein) sensitized patients underwent a ltp free diet.gut dysbiosis was re-assessed after a fixed probiotic supplementation. a sex-age matched group of individuals without history of ibs, snas or any gastrointestinal disease was considered as control.gastrointestinal symptoms were evaluated using the visual analogue scale before and after treatment. conclusion: our preliminary findings suggest that probiotic implementation could be useful in patients with snas on a low-ni diet to increase population diversity, which could contribute to restore the intestinal homoeostatic conditions. key: cord- - fz e k authors: henríquez, josefa; almorox, eduardo gonzalo; garcia-goñi, manuel; paolucci, francesco title: the first months of the covid- pandemic in spain date: - - journal: health policy technol doi: . /j.hlpt. . . sha: doc_id: cord_uid: fz e k background: : the covid- outbreak has led to an unprecedented crisis in spain. after italy, the spread of the virus was quick, and spain became the second epicenter in europe by number of cases and deceased. to tackle the outbreak and contain the spread, the spanish authorities undertook exceptional measures based on a generalized lockdown by which the majority of the economic activity ceased for several weeks. objectives: : the goal of this paper is to examine the spread of covid- in spain from february to may , as well as the public policies and technologies used to contain the evolution of the pandemic. in particular it aims to assess the effectivity of the policies applied within the different autonomous communities. cases and deaths are presented until august as well as the main changes in containment and mitigation measures. methods: : data was collected from various official sources, including government reports, press releases and datasets provided by national and international level institutions. results: : we show that the main measure to contain the spread of the pandemic was a stringent confinement policy enforced through fines. it resulted in a substantial reduction in the mobility and the economic activity. at a regional level, the negative consequences of the crisis affected differently across regions. the covid- outbreak has led to an unprecedented crisis in spain. after italy, the spread of the virus was quick, and spain became the second epicenter in europe by number of cases and deceased. although the first case diagnosed with covid- was registered at the end of january, the spanish health authorities did not undertake measures until one month later, moment when a systematic and exponential increase in registered cases and deceases was observed. to tackle with the outbreak and contain the spread, the management of public health policies were centralized within the ministry of health and the authorities undertook exceptional measures based on a generalized lockdown by which the majority of the economic activity ceased for several weeks. in this paper we describe and analyze the spread of covid- in spain and the policies and technologies used through the course of the unfolding of the pandemic. our focus consists of assessing the patterns within regions departments, autonomous communities (ac), to understand how the pandemic evolved across different parts of the country. this question is particularly relevant for the spanish case given the highly decentralized nature of the health system where ac manage most public health policies and are provided with different health resources. these different resource allocations across ac prior to the crisis could have been key determinants to understand the spread and impact of the virus throughout different parts of the country. we do so by exploiting official sources of epidemiological information and assessing the trends across ac. in particular, we study several indicators that include: registered cases, recovered, deceased, hospitalizations, icu cases by age and gender and comorbidity patterns. further, we pay special attention to the outcomes of the different policies and technologies. in particular, we evaluate the effectiveness of lockdown measures by comparing the evolution of a stringency index during the different stages of the pandemic and mobility. the rest of the paper is structured as follows. section provides an overview of spain and its health care system. section describes the main epidemiological trends. section presents the series of policies put in place. section outlines the health system response. section shows some economic and financial spillovers of the virus. section concludes. at the end of the document the references can be found. in , spain's population was million people, distributed among the acs that further divide into provinces. the health system is organized via a national health system typology, "sistema nacional de salud" (in spanish), and provides universal healthcare through , primary care facilities of general practitioners (gp), and hospitals ( ) . acs are the main managers of the health system coordinating the provider networks and purchasing resources. further, the ministry of health, dependent on central government, mainly acts in stewardship and coordination with the ac through the interterritorial council of the national health service. table contains an overview of the demographics and health system characteristics of spain, which we use as aid in contextualizing the epidemiological trends of covid- and changes in health resources. spain's life expectancy ( . ) is the highest amongst in the european countries and it is well above the average of oecd nations ( . ). as an ageing country, the share of population over exceeds other oecd countries ( . vs . ) as well as the old age dependency ratio ( . vs . ). alongside this longevity, spain presents a significant rate of morbidity having a . % of older than with two or more chronic conditions and a . % of diabetes prevalence (also higher than the . average in oecd countries). [insert table here] in a universal system, free at the point of use , the funding of the health system plays a key role. as a result of the financial crisis, over the period - the health budget shrank ( ) . these reductions resulted in decreases from . % to . % of the average participation in funding of the portion related to government compulsory schemes. at the same time, private expenditure on health, especially out of pocket spending rose, reaching . % currently. the existing proportion of health expenditure as a fraction of the gdp ( . %) is around oecd numbers ( . %), and higher than in ( . %), while per capita healthcare expenditure of , usd (ppp) in , was below the oecd average of , . in terms of health and long-term care resources such as doctors, nurses and beds per , population, spain falls above oecd levelsespecially regarding nurses and hospital beds. concerning long term care resources, despite not ranking among the top countries, spain has more beds in long term care residences than italy ( . ), and falls slightly above oecd average ( . ). ratio between those in working age with respect to those and above there are some exceptions such as pharmaceuticals. table shows the differences in health resources across the acs. andalucía is the biggest ac by population whilst the autonomous city of melilla presents the highest population density. other big acs by population are madrid and cataluña. cataluña, is also on top regarding number of hospitals and beds but not in the number icu beds, key to treat covid- severe patients, or primary care facilities important for tracking early cases. [insert table here] the covid- outbreak has modified the existing decentralized organization of health system. since the declaration of the state of alarm ( th of march), the main tasks and policies to tackle the crisis were temporarily centralized around the ministry of health. these included centralized purchase of necessary goods and services in order to meet three main purposes (according to the ministry): reinforcement of the ac purchasing processes, allocation of resources among the population and professionals and organization of the production at national and international level. only once the outbreak is under control its effects and the state of alarm will conclude ( st of june). this implies that the acs, at different speeds, will be regaining their competences in health. the ministry of health is the authority that sets and manages the protocol for reporting information related to covid- . using a notification form, the ac report to two bodies under the ministry of health: the national center of epidemiology (centro nacional de epidemiologia, cne) and the center for coordination of alerts and sanitary emergencies (centro de coordinación de alertas y emergencias sanitarias, ccae). another key institution, in charge of the management and release of the epidemiological information is the charles iii institute of health (instituto de salud carlos iii, isciii). the isciii, gathers the information through the national network of epidemiological surveillance (renave). the isciii is the official source of information and we will use it in the paper. until may, the isciii released daily information at regional level regarding confirmed cases (through different testing methods), hospitalizations as well as referrals to intensive care units (icu), deceased and recovered cases. since then, and currently, daily data only on daily cases is being released, and is available to download in an interactive website ( ) . further the isciii elaborates reports with relevant breakdowns of the information (i.e. demographic, clinical and epidemiological risk history characteristics). two main caveats in the data must be mentioned. first, in the initial stages of the pandemic, there was misalignment in the criteria applied by acs to classify new and hospitalized cases. since the th of april, a unified criterion was implemented to account for the number of confirmed cases. these criteria included positive cases under different testing methods (e.g. pcr and antibodies tests) ( ). second, data since the th of may is under review, and since then the same information as before hasn't been released. for this reason, we use information until may to capture the complete range of epidemiological indicators, while we update the data until august, capturing daily cases (the currently available information). there are other types of information available that are relevant for the purposes of this paper. in particular, information on existing health resources, reported by the ministry of health and information on new measures to mitigate the contagion. the first confirmed case of covid- in spain was reported on the st of january. it was an imported case corresponding to a german tourist visiting the island of la gomera (canary islands). after a month the number of confirmed cases increased to . [insert figure here] seroprevalence study ( ) detected initially that around % of the spanish population had antibodies, with a variability among regions and provinces ranging from . % to %. this would mean that around . million individuals got the virus, while official numbers (subject to underestimations due to testing criteria and the nature of the illness where people can be asymptomatic, among others) are around , . figure presents several snapshots of the fatality rates during the outbreak at province level. these data are released independently by different regional governments and collected by montera . the data used for the calculation of fatality rates are also affected by the change in the methodology mentioned above so are updated to the last record available before the change in the methodology. during the first half of april fatality rates reached their peak affecting several provinces located in the east of the country. a month after the worse parts belonged to provinces from ac of cataluña, extremadura, asturias, castilla-leon and madrid. indeed, deaths in the peak of the pandemic have been proved to be significantly above (around twice) the reported by the ministry of health compared to deaths registered in the daily mortality monitoring system ( ) and those informed by the national institute of statistics ( ), compared to the same dates in the previous year. [insert figure here] the cases of hospitalisations and referrals to intense care units (icu) have spread differently between different age ranges. as shown by figures and , the most affected groups have been individuals older than years old which have been classified as risky population. in addition, especially in patients within the former age range, there has been a significant gender gap in hospitalisations where men have shown higher number of hospitalisations and icu referrals. interestingly the trends remain in parallel between genders for individuals younger than years old. the epidemiologic information concerning diseases that may be related to covid- is presented at aggregate level without differentiation between acs in figure . despite registering a lower number of hospitalisations, women registered a higher of daily cases than men in several diseases that included cardiovascular, diabetes and respiratory. yet, trends across genders are fairly similar. amongst all diseases, the base disease and associated risk is the comorbidity that presents more registered cases. [insert figure here] to address the spread of the virus, typically countries will put in place measures to contain and mitigate the spread and also, due to the consequences those policies on the economy. as the peak of the pandemic has passed, it is necessary to cover two parts of the policies, their phase in, and their phase out. after who's notification of the existence of covid- , spain was quick to follow the advised instructions of the international organism in terms of epidemiological protocols and spread of information to the public. press releases showed a confident approach by the authorities but also, a non-alarming one. an example is a press note from the rd of january arguing for reduced risk as spain had no close links to the epicenter in china (wuhan had no directs flights to from spain, or china not being a frequented vacation destination). figure describes the full timeline of policies implemented to contain the spread of the virus. until the middle of february, only minor measures where implemented, and at the end of the month, the government opted to inform those with symptoms to stay home ( - ). some regional restriction where put in place after. since then, activities, gathering, sporting events started their suspension. the th of march, schools and universities were closed when community outbreak was declared, following the th of march, a flight ban to italy was imposed. it was only on the th of march, when , cases had been recorded and reported deaths, spain declared the state of alarm, limiting all people movement, with exception of grocery shopping, pharmacy and others. this came nearly a week after italy imposed a nationwide lockdown (the th of march), but at a comparable number of cases ( , ) , and around times less deaths ( ). despite this, cases continued an upward trend, and tightening of the lockdown was issued on the th of march, where all non-essential activities where stopped. [insert figure here] to assess the efficacy of the measures, figure shows the containment measure stringency index ( ) , which captures eight policy indicators on containment and closure policies (e.g. school closures and restrictions in movement) compared to the daily new cases (until august). it is observed how the measures started to grow in terms of containment while the pandemic was unraveling and stayed at their maximum from the start of april. in consequence, cases declined, and have remained low for may and june. it has become evident that after the spanish bumpy start, the restrictive measures that moved fast into extreme draconian ones paid the dividends. [insert figure here] several determinants can be related to the success of the measures, aside the broadness of the containment measures. two other key ones relate to the enforcement of the measure and their outcomes (e.g. mobility). regarding the first, the state of alarm allowed punishable measures to be imposed, with fines ranging between € and up to € , . the ministry of internal affairs ( th of april) informed that , fines had been issued since ( ) . moreover, as in other countries, drones have been operated by police forces to monitor the measures imposed (e.g. lockdown) and to inform individuals out in public about hygiene measures. this further reflects on the mobility of the spanish population. figure plots the percentage of mobility of the population per ac respect to the reference period - february. it can be observed how mobility was significantly reduced during the first week of the state of alarm, and was kept low during the lockdown period. [insert figure here] regional effects of the lockdown have been highlighted in amuedo-dorantes and co-authors ( ) , which show that regions that where at early stages of the contagion and were affected early on by confinement measures, reduced mortality rates. on the same basis, orea and Álvarez ( )) using a spatial econometric approach simulate different scenarios to assess the effectiveness of the lockdown measures. their results suggest that the lockdown reduced the covid- cases in about % especially in provinces close to the outbreaks. also, they conclude that the effectiveness of the lockdown could have improved by . % if the measures would have been implemented a week before. the reduced number in daily cases among others implied that gradually the country phased out the restrictions (see figure ). as of monday, th of april, working restrictions to non-essential workers were lifted, and thousands ( ) of workers returned to work, while citizens were still obliged to stay home until the th of april. two further policies were put in place: first, allowing minors (younger than ) to go outside, and second, in different timeslots, for those years and older to exercise outside. [insert figure here] the government has since agreed on a "plan of return to the new normality". different to how the state of alarm happened, applicable for the whole of spain, this plan will occur per ac in a process of co-governance with the ministry of health. some criteria have been put out by the ministry of health, but also, due to the fact that the government is in minority, political pressures from the ac will play an important role. when measures started to be consistently at lower levels, cases have started to slowly go up, and have now increased quite significantly to levels of april. moreover, mobility has increased substantially, and currently, probably due to the summer period, it is higher than in the reference period. this correlates too with the increases in cases observed. shutting down the economy, has meant that the government, to reduce the catastrophic impacts in businesses and individuals in terms of finances, have implemented several policies to push money into the country. legally, this have been published through several royal decrees. figure shows the timeline of the four main decrees that aimed at addressing the economic impact of covid- , and the two main restrictions imposed: declaration of the state of alarm and the closure of non-essential activities. [insert figure the decree / expanded measures related to an unemployment figure, temporary employment regulation known as erte, to protect employment, ranging from an extension of this figure due to major circumstances, and allowing those with erte to not contribute to social security. additionally, and not strictly related to covid- but highly influenced, was the implementation of the minimum vital income. the royal decree / , aimed at reactivating employment, protecting autonomous work and the competitiveness of the industrial sector. to address the needs associated to covid- , spain had to unravel an extraordinary response in regard to its health system, putting to the forefront technology interventions. the pandemic, has also had spillover effects on non-covid related health care and health problems which are necessary to address to comprehend the full picture of the efforts and impacts. initially, spain was not equipped to deal with the rapid surge in cases. as mentioned, not only the organization of the system (e.g. decentralized), had to be modified, but the delivery of care (e.g. telemedicine), and its capacity had to be increased significantly in all major areas. this ranged from testing (availability of pcr and rapid tests, as well as labs to analyze them), beds (in existing and new facilities, and of different levels of severitygeneral ward and icu), ventilators, medical staff to personal protective equipment (ppe). two main changes with respect to the delivery of care occurred: a move towards telemedicine, and the use of phoneapps to provide information about the illness. first, several private initiatives towards telemedicine, in the form of apps and in supplementary insurance plans added this type of consults and experienced a growth of their use ( ) . public use of telemedicine has been locally promoted, for example, the "hazlo" project, for the cardiac rehabilitation unit of the ramón and cajal university hospital (isciii and ramon y cajal university hospital) is a good example, while other types of consultations in the public system have been done through phone calls. second, the severity of the spread required information and services to alleviate calls to emergency rooms. phone apps where a key tool to provide information, self-diagnostic and monitoring of symptoms (e.g. apps like "stopcovid " in cataluña, "coronamadrid app" for madrid or "asistencia covid- " in canarias, cantabria, castilla-la mancha, extremadura, and asturias). in the pais vasco, "covid .eus", aimed additionally at prevention, follow up to possible cases in their homes, and analysis of the concentration of cases. capacity of the system was quickly upscaled. one area of specific importance was testing. as the emergency unraveled, to contain the spread testing had to be increased and testing criteria evolved. testing widely has become the cornerstone of the health policy specially, to be able to lift restrictions. to achieve that objective, the country has increased labs available and processing capacity and purchased significant amount of materials. a key actor in this regards, dependent on the ministry of health, is the national center of microbiology (centro nacional de microbiología), which has assessed testing facilities and performed testing analysis. a key component has been the use of technology. specifically, the use of robots (currently, ) in different institutions to automatize testing. this has been paired with the purchase of swabs (pcrs) and antibodies tests that have been distributed. table shows the testing criteria. in can be observed that a reduction of the initial restrictions in place occurred over time. [insert table ( ) . this has set the processing capacity around , daily pcr tests. since reporting started, on the th of april, the median days from symptoms to diagnostics was days ( - range), while on the report of the th of july, this number had been reduced to ( - ). nevertheless, the regions vary in their testing agility, as outlier is melilla, with days, and a range of - , until the th of july, while this value dropped to on the th of august ( ). news on the mentioned date with respect to tracing, the task has been given to the acs and a protocol has been elaborated by the ministry of health on that regards. as the regions have the autonomy to decide their tracing strategy, there is variation in the way they do so. a notable case that has been criticized is madrid, that hired a private company to do the tracing ( ) . tracing, as of the first report ( th july), managed to reach ( - ) close contact. until the th of august, the mean number of close contacts traced was ( - ). again, there is variance between the regions, as the highest median number of contacts identified per case in canarias is , while the lowest is castilla la mancha with provisional hospitals had to be opened. notable cases are ifema (feria de madrid) ( st march) that could have accommodated, if necessary, up to , beds (and up to icu beds) although it had a maximum of about , simultaneous patients; and in catalonia, fira de barcelona, which opened ready to admit patients although potentially they could have been increased to , . before the th of march, icu beds totaled , ( ). as observed in table , where the new icu and total beds are presented, an increase of % has been experienced to a total of , as of march th . despite some of the ac, previous to the virus, having the highest regional number of icu beds (e.g. madrid, ), the sharp increase in cases saturated the capacity. the ac that increased in the greatest percentage its icu capacity was país vasco ( . %), followed by murcia ( . %), and madrid and catalonia ( % and . %, respectively). [insert table here] a key resource to treat serious patients are ventilators (invasive and non-invasive types). there is no data regarding pre-covid- availability of ventilators to offer relevant comparisons. nevertheless, since data has been made public ( th [insert figure here] in an effort to increase work safety, the country had to significantly increase the delivery of ppe to the acs. by means of centralized purchasing, and a public formula for distribution based on population size and epidemiological data, the ac receive masks (see figure for the distribution over time compared to ), being madrid (more than . million) and catalonia (more than million) the cas receiving the highest amount. as of th of may, a new system was implemented combining the petition of the acs and the ministries calculation to meet a "reservoir amount" of masks. we must note that this does not consider the material purchased individually by each ac. to deal with the human resource shortages that covid- infection of medical staff and the general spread of the virus put in the system, a series of conditions previously in place related to contracting of medical staff, retirement, resident doctors, and graduation of health professionals had to be relaxed. the ministry of health informed that to the nd of april, it had increased the available for-hire health professionals to an extra , . the second group of measures has consisted of cross-regional hiring process of health professionals from regions with less demand of covid cases to regions with higher levels of demand as for example madrid or catalonia. the outbreak and focus on covid- has resulted in a quick transformation in healthcare processes and structures that have produced spillover effects on the delivery of other medical service, and health aspects. one important aspect is related to waiting times. latest reports (december ) ( ) , demonstrated an increase before and due to the pandemic effect on shifting the focus to treat covid- patients, they will suffer an increase. one specifically critical health service relates to transplants. the national transplant organization has released information stating that there has been a % decrease in donors and % decrease in transplants compared to the same period of the previous year ( ) . there is also record of a decreased participation in mandatory immunization programs during the first months of the pandemic ( ) . in short, many non-urgent health services were avoided by the population or postponed by the health services during the pandemic and will have to catch up when possible. in addition, other types of measures were implemented. pané-mena and pascual ( ) list three types of measures implemented on specialist services that included coordination and crisis management measures, support measures refocusing some services exclusively to covid- related cases and referring other series to other centers and logistic measures based on tackling with the lack of devices and materials to provide a suitable healthcare. the economy of spain has suffered increased hardship due to the pandemic. gdp has contracted by - . in the second quarter of , and is currently in technical recession ( ) , falling close to the worst projects of the international organizations by the spanish bank, between % and , % ( ) . moreover, the ibex- stock, has decreased significantly since january, with the lowest value being registered after the declaration of the state of alarm ( figure ). since then, the evolution has been positive, while still below levels of mid-february. the most significant increase was produced when the announcement of the credit loans for the tourist sector was made in mid-june ( ) , as this sector represents an important part of the spanish economy, that in accounted for . % of the gdp, and . million jobs ( ) . [insert figure here] unemployment rates in spain have gone up to . % in the second quarter of from . % in the last quarter of ( ) . in spite of this negative evolution, the unemployment rate is still much lower than in the first quarter of , during the earlier economic crisis, when it reached the peak of . %. however, this number does not consider those workers that have been subject to the temporary regulation of employment "erte" (for its name in spanish) (suspension of work or reduction in hours). at the same time, in the last months, the labor market has changed drastically, as full time job placements have gone down . percentage points ( ) . as a result, the affiliation to social security decreased in the month of july in the amount of - , individuals (most of them men, %) ( ) . whether the economic impact of the pandemic is as large as estimated or even greater, will depend on the speed at which economic activity returns to normal, and on the existence of a possible resurgence or second wave that would bring the economy to a standstill again, before a preventive vaccine or cure for covid- becomes available. spain was one of the first countries to be hardly hit by covid- in terms of cases and deaths. data shows that the country overcome the peak of the spread and intensity of the virus, greatly aided by the very stringent confinement policies that lasted for nearly months, aided by strict enforcement which implied fines reached all-time peak, and resulted in a significant decrease of mobility. having been an early epicenter, it struck the health system by surprise. the virus showed that the health system was not ready to confront a strain of this magnitude. nevertheless, the country managed to be quick in changing the necessary health system structures and increasing its resources to deal with the surge in cases. this encompassed from re-arranging the decentralized health system to a temporarily higher degree of centralization, to the significant roll out of ppe, beds, and medical staff to confront the emergency while it was unravelling. despite the measures to tackle with covid- have been centralized by the ministry of health and implemented homogeneously across the country, we have shown that the pandemic has had a different impact across spanish provinces. this situation has led to a relaxation of lockdown measures on a case-by-case basis. under this system, in order to lift mobility restrictions, ac have been required to submit bi-weekly reports to the health ministry to assess the suitability of their epidemic situation and more particularly their incidence rates. in some cases, provinces within the same ac showed different degrees of severity associated with the incidence rates. this was the case, for instance of the castilla león provinces closer to madrid (e.g. Ávila, segovia), which took longer to increase their mobility compared to others located more to the north. the current debate in terms of public health consists of how to design measures to contain the new wave of cases that are arising in different ac. these measures need to promote the primary care delivered in general practices. primary care plays a core role in prevention and detection of early cases. to enhance the quality of their delivery it is necessary to improve the set of resources available in the current gp premises as well as incentivize the promotion of gp staff. further, they need to increase their capacity to conduct tests. to this extent, there has been a generalized increase of tests in all ac. another key area to address public health measures consists of the redefinition in the organization of long-term care services. two thirds of covid registered deceased in spain occurred in a care home ( ) . these figures show deficiencies in the provision of long-term care under an epidemic crisis. to this extent, the implementation of coordinated protocols with a common framework as well as measures to increase the integration between long-term and primary care, may be two main elements to consider. . the data compiled correspond to the cumulative cases up to th of may . deaths are recorded as a person that has tested positive to covid- and has passed away. cases correspond to those with positive pcr tests. confirmed cases do not come from the sum of hospitalized, recovered and deceased, as they are not mutually exclusive. deceased and recovered could have been hospitalized and therefore be in the two groups. estadística de centros sanitarios de atención especializada situación de covid- en españa la inmunidad de la población española experimenta un leve incremento con una tasa del , % en la segunda ronda del ene-covid sistema de monitoreo de la mortalidad diaria estadística experimental -estimación de defunciones semanales durante el brote de covid- (edes) oxford covid- government response tracker, blavatnik school of government tantas multas propuestas en el confinamiento como impuestas en años de la ley mordaza timing is everything when fighting a pandemic: covid- mortality in spain how effective has the spanish lockdown been to battle covid- ? a spatial analysis of the coronavirus propagation across provinces notas de prensa el coronavirus impulsa la telemedicina en españa el % de los contagiados por coronavirus son trabajadores sanitarios informe sobre la situación de covid- en personal sanitario en españa sistema de información sobre listas de espera en el sistema nacional de salud. situación a de diciembre de covid- : impacto en la actividad de donación y transplantes covid- caida de las vacunaciones el desafio de la covid- para la atencióon especializada contabilidad nacional trimestral de españa: principales agregados cntr (avance) economic forecast for spain perspectivas económicas de la ocde macroeconomic projections for the spanish economy ( - ): the banco de españas contribution to the eurosystems el plan de sanchez para ayudar al turismo se basa en créditos a empresas primer trimestre sanidad estima en . los fallecimientos en residencias durante la epidemia, más de dos tercios con coronavirus población por comunidades y ciudades autónomas demography and population data extensión superficial de las comunidades autónomas y provincias, por zonas altimétricas health at a glance long-term care resources and utilisation: beds in residential long-term care facilities ciudades autónomas y provincias de colegiación, situación laboral y sexo mapa de recursos sociales y sanitarios renave; cne; cnm (isciii). informe. situación de covid- en españa a autonómica viajeros-km el mapa de la ocupación de las uci precios historicos ibex ministerio de educacion y formación. covid- key: cord- -pezm tnw authors: riccardo, flavia; ajelli, marco; andrianou, xanthi; bella, antonino; del manso, martina; fabiani, massimo; bellino, stefania; boros, stefano; mateo urdiales, alberto; marziano, valentina; rota, maria cristina; filia, antonietta; d'ancona, fortunato (paolo); siddu, andrea; punzo, ornella; trentini, filippo; guzzetta, giorgio; poletti, piero; stefanelli, paola; castrucci, maria rita; ciervo, alessandra; di benedetto, corrado; tallon, marco; piccioli, andrea; brusaferro, silvio; rezza, giovanni; merler, stefano; pezzotti, patrizio title: epidemiological characteristics of covid- cases in italy and estimates of the reproductive numbers one month into the epidemic date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: pezm tnw background in february , a locally-acquired covid- case was detected in lombardia, italy. this was the first signal of ongoing transmission of sars-cov- in the country. the outbreak rapidly escalated to a national level epidemic, amid the who declaration of a pandemic. methods we analysed data from the national case-based integrated surveillance system of all rt-pcr confirmed covid- infections as of march th , collected from all italian regions and autonomous provinces. here we provide a descriptive epidemiological summary on the first , covid- cases in italy as well as estimates of the basic and net reproductive numbers by region. findings of the , cases of covid- analysed, . % were reported from three regions (lombardia, veneto and emilia-romagna). all cases reported after february th were locally acquired. estimates of r varied between . ( %ci: . - . ) in toscana and ( %ci: . - . ) in lazio, with epidemic doubling time of . days ( %ci: . - . ) and . days ( %ci: . - . ), respectively. the net reproduction number showed a decreasing trend starting around february - , in northern regions. notably, , cases were reported among health care workers. of the , reported covid- associated deaths, % occurred in people aged years or above with an overall crude cfr of . %. male sex and age were independent risk factors for covid- death. interpretation the covid- infection in italy emerged with a clustering onset similar to the one described in wuhan, china and likewise showed worse outcomes in older males with comorbidities. initial r at . in lombardia, explains the high case-load and rapid geographical spread observed. overall rt in italian regions is currently decreasing albeit with large diversities across the country, supporting the importance of combined non-pharmacological control measures. introduction sars-cov- infection in humans causing clusters of severe pneumonia ( ) ( ) ( ) was first detected in the city of wuhan, china, in december . this pathogen was confirmed as a new virus by the coronavirus study group (csg) of the international committee on taxonomy of viruses. based on phylogeny, taxonomy and established practice, they designated it as severe acute respiratory syndrome coronavirus (sars-cov- ). ( ) although of probable zoonotic origin, human-to-human transmission is rapidly fuelling the spread of sars-cov- infections globally, with the main known routes of transmission being droplet and fomites. the infection spread within china and rapidly across countries, with cases in europe initially limited to small clusters in germany, france ( , ) and the uk ( ). on the th of february , the first case of locally acquired sars-cov- infection was diagnosed in northern italy in a critically ill, hospitalized young man with no travel history to known areas of viral circulation or link to a probable or confirmed covid- case. prior to this date, only three cases of covid- had been reported in central italy, all with a travel history to wuhan. following this unexpected finding, extensive contact tracing and testing of close contacts unveiled ongoing transmission in several municipalities of the lombardia region ( , ) . in subsequent days and weeks, case counts, and death tolls increased rapidly, at first in northern italy and then in the rest of the country. the italian government imposed increasingly strict physical distancing measures starting with the closure of municipalities in the lodi province (lombardia) and one in the padua province (veneto) on the rd of february . this culminated with a national lock-down on the th of march . ( , ) in this paper, we summarize key epidemiological findings from data on the first , confirmed covid- cases in italy, including , associated deaths, and initial findings on sars-cov- transmissibility across different regions. with the aim to increase the understanding of the disease dynamics in italy and support the planning of public health actions, a case-based surveillance system was established on the th of february , building on a previously existing surveillance system focused only on suspected and confirmed covid- severe respiratory infections ( ) . the system contains data on all laboratory confirmed cases of covid- as per the case definition published and regularly updated online by the european centre for disease prevention and control (ecdc) ( ) . laboratory confirmation by rt-pcr on nasopharyngeal swabs is performed at regional level, as previously described ( , ) . from the beginning of the outbreak until the st of march , all initially confirmed cases were sent for final confirmation at the national reference laboratory in the istituto superiore di sanità (iss) and re-confirmed according to the world health organization guidelines using rt-pcr protocols described by corman et al. ( ) and by the us-cdc ( ). due to the high concordance ( %) among confirmation results with the engaged laboratories, the policy was then changed allowing selected regions with demonstrated confirmation capacity to directly confirm covid- cases ( ) . data is collected daily using a secure online platform or, alternatively, received as individual datasets from the regions and two autonomous provinces (ap) of the italian territory, according to an increasingly harmonized track-record. data collected includes information on: demographics, clinical severity, comorbidities, date of symptom onset, date of diagnosis, outcome, region of diagnosis and province of residence. clinical severity was defined as follows: (i) asymptomatic -a person found positive for sars-cov- with no apparent signs or symptoms of disease, (ii) paucisymptomatic -a person found positive for sars-cov- with general mild symptoms (e.g. with general malaise, low grade fever, tiredness etc.) but no clear signs of disease, (iii) mild -a person found positive for sars-cov- with clear signs and symptoms of disease (e.g., respiratory disease) but not severe enough to require hospitalisation, (iv) severe -a person found positive for sars-cov- with clear signs and symptoms of disease (e.g. respiratory disease) and severe enough to require hospitalisation, and (v) critical -a person found positive for sars-cov- with clear signs and symptoms of disease (e.g., respiratory disease) and severe enough to require admission to an intensive care unit (icu). the surveillance system captures whether the reported subject is a health care worker (hcw). we have defined a hcw broadly as a person who has ever worked in the health care sector regardless of role, profession or current working status. the system also records whether the affected person has one of the following comorbidities: cardiovascular diseases, respiratory diseases, diabetes, immune-deficiencies, metabolic diseases, oncologic diseases, obesity, kidney diseases or other chronic diseases. we have defined covid- associated deaths as any person who has died and was confirmed to be infected with sars-cov- . data is harmonized in a single dataset, cleaned and analysed daily to produce an infographic with main surveillance outputs. a more detailed bulletin is published biweekly. these outputs are publicly available on the web portal of epidemiology of the iss ( ) . in total, , cases were included in the analysis (data extracted on march , ) . the data was summarized by age group and sex. epidemic curves were made by date of diagnosis and of symptom onset. cases were aggregated by region/ap of diagnosis and by province of residence for cases residing in the same region/pa of diagnosis. attack rates per , population by region/pa were calculated using population estimates for , available from the italian national institute of statistics (istituto nazionale di statistica; istat) and adjusted using the age distribution of the italian population as a reference. we classified the attack rates in each region as high, intermediate and low based on the inter quartile range (iqr) of the adjusted attack rates as follows: (i) high: . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org / . / . / attack rates higher than the upper limit of the iqr; (ii) intermediatewithin the iqr; (iii) lowlower than the lower limit of the iqr. case fatality rates (cfr), not accounting for delays, were calculated by age and sex and smoothed with the locally weighted regression method. cfrs by age were also calculated by calendar period of diagnosis (i.e., before th , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . a multilevel (clustered by region/ap) multivariable logistic model was applied to evaluate characteristics associated with death, including age group (i.e., ≤ , - , - , - , - , - , + years) , sex, hcw status, and week of diagnosis. adjusted odds ratios were estimated. the analyses were performed using stata (version ) and r (version . . ). the list of the r packages used for the analysis is available in the supplementary materials. as described previously ( ) , we define the basic reproduction number r as the average number of secondary cases that are generated in a fully susceptible population by a primary infector. this is an expression of the potential for transmission without any containment measure. however, once interventions are introduced or the susceptibility in the population decreases, the transmission potential at a given time t is measured as the net reproduction number rt. in this paper, we estimated both r and rt for italian regions in different epidemiological situations (high, intermediate and low age-adjusted attack rates), selected among those with highest data robustness. we used a previously described bayesian approach ( ) ( ) ( ) , informed by estimates of the serial interval from contact tracing data in lombardia ( ) . we defined the serial interval as the distribution of the time from symptoms onset in a primary infector and the symptoms onset in secondary cases and estimated it on average to be · days. details are reported in the supplementary materials. as of the th of march , , confirmed cases of covid- had been reported including , related deaths, and the number of reported cases was increasing ( figure ). locally acquired cases diagnosed at the end of february reported onset of symptoms from the th of january onwards, indicating undetected local transmission for at least three weeks before detection. the average delay between symptom onset and diagnosis in the first month of the outbreak was · days. by march , , all of italy's regions and aps had reported at least one locally acquired case of covid- . the country had high incidence areas with sustained local transmission (mainly in the north), low incidence areas with limited but growing numbers of locally acquired cases of infection and regions with intermediate incidence ( figure ). overall, % of , covid- cases diagnosed in lombardia, were among people residing in this region. among the remaining % for which the residence of the case was known, most ( cases) resided in the neighbouring region of emilia romagna. the index case of the outbreak was not found, and no clear chains of transmission were identified linking initial cases in newly affected regions/ap. age -adjusted attack rates per , were classified as high in lombardia (crude attack rate · and age-adjusted attack rate · per , ), valle d'aosta, trento, the region of emilia-romagna bordering lombardia and in the marche region in central italy. age -adjusted attack rates were classified as intermediate in bolzano/bozen, veneto, piemonte, liguria, friuli-venezia giulia, abruzzo, toscana, umbria, molise and puglia. in lazio, campania, sardegna, calabria, sicilia and basilicata age -adjusted attack rates were classified as low ( figure and table , supplementary material). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint most affected cases were male ( %) and the median age of cases was years. notably, , cases were reported among health care workers (median age years, · % male). among cases with known age, clinical severity was reported for , cases. as shown in figure , the proportion of severe cases in under years of age was below %. this proportion decreased to . % in the - year age group, then increased again gradually to · % in the age group - years. critical severity was reported in cases aged years and above, reaching % in the - year age segment ( table , supplementary material). among all cases, , ( · %) were reported to have been managed at home and , ( · %) were hospitalised. for , ( · %) cases this information was not available. as shown in figure (a), the proportion of hospitalised covid- cases decreased from . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org / . / . / - to - years of age and increased progressively from - to - years of age when it appeared to stabilize. figure (b) shows, among all reported hospitalised covid- cases with known unit of admission and age (n= , ) , the proportion of patients admitted in icu vs those admitted to any other hospital unit. overall, the icu admission rate was · % considering only cases for which admission hospital unit was reported. among all cases reported to have been hospitalised, the icu admission rate was · %. icu admissions were reported from the - age group onwards, increasing in proportion until ages - years. the proportion decreases in older age groups. of the , reported covid- associated deaths, % occurred in cases aged years or above with an overall crude case fatality rate (cfr) of · % (table , supplementary material). overall, deaths were reported in hcw. until march , , no deaths were reported among cases aged less than years. overall, % of the people who died were reported to have at least one co-morbidity. figure shows the cfr reported as of the th of march by single age of diagnosed cases stratified by sex smoothed using locally weighted regression curves. there was a strong association of the cfr with age. women had a lower cfr at each age point. when stratifying by age group and calendar period of diagnosis we confirmed the age effect on the cfr but also showed that cfr increases with time since diagnosis, with an overall cfr of % for people diagnosed with covid- before the th of march (table , supplementary material). after adjusting for age, sex, hcw profession, and calendar period of diagnosis, we estimated a higher adjusted odds ratios (aor) of death with increasing age decade and a higher aor for males compared to females. health care workers (hcw) diagnosed with covid- had lower aor of death compared to the non hcw (table , supplementary material). we performed additional models evaluating a possible interaction between sex and age group and between being a hcw and both age and sex. however, these did not provide a better fit to the data (p= · , p= · , p= . log-likelihood ratio test, respectively). similar results were found when restricting the analysis to cases aged - years old. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org / . / . . . doi: medrxiv preprint we estimated the transmission patterns for six italian regions (lombardia, veneto, emilia-romagna, toscana, lazio, and puglia) with adjusted ar classification ranging from low to high. these six italian regions are characterized by highly different epidemic trajectories. the variability is also clearly visible in terms of epidemic doubling time, which varies between · days ( %ci: · - · ) in emilia romagna and · days ( %ci: · - · ) in veneto (table ) , and basic reproductive numbers, which lie in the range · - · . in lombardia, we estimated the net reproduction number (rt) to be above the epidemic threshold since late january ( figure ). in february, the rt started to oscillate reaching maximum values around over the week from february to . starting from february , with the enforcement of a quarantined area around the most affected . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org / . / . / municipalities of the region, rt was estimated to follow a constantly decreasing trend. the second and third most affected regions in february (veneto and emilia romagna) show an increasing trend of rt until about february ( figure ). at that time a few tens of cases had been detected in those regions. the transmission patterns of toscana, lazio, and puglia are markedly different. in central and south italy, where tuscany, lazio, and apulia are located, the epidemic spread was largely undetected until early march. after an initial increase, rt remained nearly constant at values around · - until march - , when blanket physical distancing measures began being implemented at national level ( figure ). covid- emerged in italy with a similar clustering onset to the one described in wuhan, china ( ) with three major clusters around the cities of codogno, bergamo and cremona in the lombardia region in northern italy ( ) . subsequently, cases spread across the country with more sustained transmission in neighbouring regions in the north and in the central region of marche. we estimated r in the range of · - · in different italian regions with doubling time estimated between · and · days. this, alongside the short serial interval of covid- in italy ( · days on average) and the fact that the outbreak was detected amid ongoing transmission that had started at least three weeks earlier, explains the rapid case increase and geographical spread. it also explains the inability to identify the index case and clearly trace the initial spread of infection across the country. notably, in northern regions (lombardia, veneto and emilia-romagna), the net reproduction number rt shows a marked decreasing trend since the identification of the first cases in late february. the observed decrease of rt in northern regions is possibly due to increased population awareness and to the early effect of interventions. in other parts of the country, such as in central (toscana, lazio) and southern regions (puglia), transmission was largely undetected until the first days of march, with rt decreasing after the initial implementation of national blanket physical distancing measures. cases were for the most part detected in the same region/ap in which they reside. most initial cases that did not reside in lombardia resided in neighbouring emilia-romagna. this could be related to the fact that initial clusters occurred in industrial hubs with strong cross-border connections with neighbouring provinces in other regions, possibly favouring the rapid geographical spread of the infection in the north of the country. reported clinical severity was confirmed to be lowest among children, and in particular in the - years age group. the proportion of severe and critical cases increases with age until age or above. the slight decrease in the proportion of critical and severe cases, and of deaths, in the higher age groups might be due to the demographic structure of the population with a higher female to male ratio among older people ( ) . the proportion of hospitalized covid- cases appears to follow a similar trend with age. hospitalisation rates decreased from infancy to childhood and adolescence to increase again progressively with age among adults stabilizing from the - years age group. overall, the icu admission rate based on reported data ranged between . % and . % depending on the denominator used. both rates are much higher than the reported % in european union countries disclosed by the european centre for disease prevention and control (ecdc) ( ) . we are unable at this stage to speculate whether the reasons behind this difference are related with hospitalisation policies and practices or whether there are other factors at play. however, this observation confirms recent studies in lombardia that highlight the potentially catastrophic effects of an uncontrolled covid- epidemic on the healthcare system ( , ) . consistently with reported clinical severity, icu admissions were notified starting from the - years age segment, suggesting the potential for critical disease also among young adults. the proportion of covid- related icu admissions, increases until the - years age segment to decrease in older ages apparently more rapidly than the reported stabilization of more severe disease in the same age groups. this pattern, however, might simply reflect lack of completeness of the surveillance data available at this stage. further analysis on a larger number of records is required to confirm this finding. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org / . / . / as shown previously in china ( ), we also demonstrated worse outcomes in older males with comorbidities. male sex and older age are independent risk factors for covid- related deaths. the cfr of . % documented overall in italy, is higher than that observed in other countries. as recently described, this could be in part explained by the demographic structure of the italian population ( ) . however, other aspects such as testing policies and the surveillance system characteristics, including the choice in italy to count only laboratory confirmed cases and to define associated deaths in a very inclusive manner, may also play a role in making initial case fatality data poorly comparable across countries. it is however noteworthy to stress that the early phase of the covid- epidemic in italy is characterized by a large number of cases with a short follow-up time since diagnosis. this implies that the overall cfr is currently largely underestimated. this was confirmed when performing an analysis by period of diagnosis. we found that those diagnosed before march th, had an overall cfr of around %. future studies with longer follow-up will better clarify this aspect including studies evaluating overall population excess mortality, which will also be more comparable across countries. surveillance data shows clearly a very high number of covid- cases among hcw, underlining the fact that sars-cov- can be easily spread in health care contexts and the importance of strong infection prevention and control practices. in italy, as described in other countries ( ) , nursing homes and long term care facilities have emerged as particularly fragile environments in which infection can spread very rapidly with potentially more severe outcomes due to the vulnerability of the hosted populations ( ) . affected hcw, compared with the affected general population, are on average younger and more frequently female. considering the predominance of female professionals in working age in the italian health sector, this is the distribution that would be expected in professionally exposed groups. age and sex only explains in part the lower cfr, as a lower aor of death was observed among hcw also after adjusting for those variables and might be related to earlier detection and management. the data collected from the italian integrated covid- surveillance system during the initial phase of the emergency presents a number of limitations mainly due to completeness challenges. for this reason, some stratifications and analysis were not shown. the lack of completeness on the presence and type of comorbidities, did not allow us to include this in the multivariable analysis of deaths in order to assess, and/or adjust for, this factor. data on hospitalisation and icu admissions as well as cfrs are not adjusted for the expected time for disease evolution and might therefore be underestimated in the more recent period. finally, the estimation of r , rt and the doubling time were performed in regions selected on the basis of the robustness of data considering epidemiologically diverse settings. even in the presence of the mentioned limitations, our analysis suggests that the sars-cov- transmission potential in italy is decreasing, albeit with large diversities across the country. further, we observe that as of march , the rt it is still above the epidemic threshold. the progressively harsh physical distancing measures enacted since then may have enhanced the decreasing trend in transmissibility as happened in china [ , ] . the surveillance system will be key to monitor the effect of the implemented policies and guide the public health response as italy will enter the second phase of its outbreak. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org / . / . / evidence before the widespread sustained local transmission of covid- in italy was largely based on the experience shared by china ( , ) and specific other countries in asia, while evidence in europe was initially limited to small local clusters in germany, france ( , ) and the uk ( ). while some commentaries have been issued regarding the evolving situation in italy ( ) and initial studies are available on the epidemic in the first affected region lombardia ( , ) or based on different modelling approaches, there has been yet no communication to the scientific community of the italian epidemiological situation at national level based on surveillance data. in this paper, we summarize key epidemiological findings from data on the first , confirmed covid- cases in italy, including , associated deaths, and initial findings on sars-cov- transmissibility across different regions. the added value of this study is of providing an in depth review of the first month of the italian outbreak through descriptive and analytic epidemiology and an estimation of the r and rt taking into account the diversity of transmission across the country. we believe that the evidence collected in italy, with a demographic structure and health system organization that differs from those of other countries that had reported sustained disease transmission, can be of support to countries currently experiencing initial or escalating covid- transmission. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org / . / . / the basic reproduction number r represents the average number of secondary cases generated by a primary infector in a fully susceptible population. in general terms, when r is larger than the infection may spread in the population and the larger r the larger effort required to control the epidemic. once the number of susceptible individuals declines, the transmission potential of the disease at a given time t is measured in terms of the net reproduction number r(t). the net reproduction number is useful to track the effectiveness of performed control measures and other factors affecting the spread of the epidemic (e.g., the behavioral response of the population) over time. as soon as r(t) falls below , the epidemic starts to decline. to estimate r(t), we use the same methodology presented in reference [ ] [ ] [ ] . we assumed that the daily number of new cases (date of symptom onset) with locally acquired infection l(t) can be approximated by a poisson distribution according to the equation where  c(t), with t from to t, is daily number of new cases (date of symptom onset);  r(t) is the net reproduction number at time t;  ( ) is the distribution of the generation time (corresponding to the distribution of the serial interval) calculated at time s. from the analysis of observations of individual serial intervals in clusters, the distribution of the serial interval was estimated to follow a gamma distribution with mean . days (percentiles . th and . th of the distribution: . - . ) [ ] . the likelihood ℒ of the observed time series of cases from day to day t conditional on c( ) is thus given by where p(k; λ) is the probability mass function of a poisson distribution (i.e., the probability of observing k events if these events occur with rate λ). we then used mcmc metropolis-hastings sampling to estimate the posterior distribution of r(t). to estimate r , we assumed that during the period where the epidemic showed exponential growth r(t)=r and used the above described procedure. clinical features of patients infected with novel coronavirus in wuhan, china. the lancet epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study. the lancet a familial cluster of pneumonia associated with the novel coronavirus indicating person-toperson transmission: a study of a family cluster. the lancet severe acute respiratory syndrome-related coronavirus: the species and its viruses -a statement of the coronavirus study group. biorxiv first cases of coronavirus disease (covid- ) in france: surveillance, investigations and control measures transmission of -ncov infection from an asymptomatic contact in germany lessons for managing highconsequence infections from first covid- cases in the uk. the lancet potential short-term outcome of an uncontrolled covid- epidemic in the early phase of the covid- outbreak in disposizioni attuative del decreto-legge febbraio , n. , recante misure urgenti in materia di contenimento e gestione dell'emergenza epidemiologica da covid- ulteriori disposizioni attuative del decreto-legge febbraio , n. , recante misure urgenti in materia di contenimento e gestione dell'emergenza epidemiologica da covid- , applicabili sull first cases of coronavirus disease (covid- ) in the who european region case definition and european surveillance for covid- european centre for disease prevention and control whole genome and phylogenetic analysis of two sars-cov- strains isolated in italy in ministerial decree n. -covid- . aggiornamento della definizione di caso integrated surveillance of covid- : main national data ebola virus disease in west africa -the first months of the epidemic and forward projections measurability of the epidemic reproduction number in data-driven contact networks evolving epidemiology of novel coronavirus diseases and possible interruption of local transmission outside hubei province in china: a descriptive and modeling study. medrxiv demographic statistics -italian national institute of statistics -istituto nazionale di statistica istat rapid risk assessment: coronavirus disease (covid- ) pandemic: increased transmission in the eu/eea and the uk -seventh update european centre for disease prevention and control characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention case-fatality rate and characteristics of patients dying in relation to covid- in italy nursing homes are ground zero for covid- pandemic national survey on covid- spread in nursing homes and long term care facilities, first report world health organization ebola response team, ebola virus disease in west africa--the first months of the epidemic and forward projections measurability of the epidemic reproduction number in data-driven contact networks evolving epidemiology of novel coronavirus diseases and possible interruption of local transmission outside hubei province in china: a descriptive and modeling study the early phase of the covid- outbreak in lombardy, italy extended model formulas in r: multiple parts and multiple responses inspectdf: inspection, comparison and visualisation of data frames officer: manipulation of microsoft word and powerpoint documents rvg: r graphics devices for vector graphics output broom: convert statistical analysis objects into tidy tibbles with contributions from charles dupont and many others dates and times made easy with lubridate ggplot : elegant graphics for data analysis the split-apply-combine strategy for data analysis stringr: simple, consistent wrappers for common string operations forcats: tools for working with categorical variables (factors) scales: scale functions for visualization haven: import and export 'spss', 'stata' and 'sas' files readxl: read excel files tidyr: tidy messy data readr: read rectangular text data dplyr: a grammar of data manipulation eeptools: convenience functions for education data glue: interpreted string literals epidemic curves made easy using the r package incidence tibble: simple data frames purrr: functional programming tools the report package for r: ensuring the use of best practices for results reporting cartocolors' palettes simple features for r: standardized support for spatial vector data janitor: simple tools for examining and cleaning dirty data lattice: multivariate data visualization with r viridislite: default color maps from 'matplotlib' (lite version) _a package for survival analysis in s_. version . patchwork: the composer of plots epitools: epidemiology tools welcome to the tidyverse knitr: a general-purpose package for dynamic report generation in r table -distribution of diagnosed ) key: cord- - lhjfm authors: carsana, luca; sonzogni, aurelio; nasr, ahmed; rossi, roberta simona; pellegrinelli, alessandro; zerbi, pietro; rech, roberto; colombo, riccardo; antinori, spinello; corbellino, mario; galli, massimo; catena, emanuele; tosoni, antonella; gianatti, andrea; nebuloni, manuela title: pulmonary post-mortem findings in a series of covid- cases from northern italy: a two-centre descriptive study date: - - journal: lancet infect dis doi: . /s - ( ) - sha: doc_id: cord_uid: lhjfm background: covid- is characterised by respiratory symptoms, which deteriorate into respiratory failure in a substantial proportion of cases, requiring intensive care in up to a third of patients admitted to hospital. analysis of the pathological features in the lung tissues of patients who have died with covid- could help us to understand the disease pathogenesis and clinical outcomes. methods: we systematically analysed lung tissue samples from patients who died from covid- in two hospitals in northern italy between feb and march , . the most representative areas identified at macroscopic examination were selected, and tissue blocks (median seven, range five to nine) were taken from each lung and fixed in % buffered formalin for at least h. tissues were assessed with use of haematoxylin and eosin staining, immunohistochemical staining for inflammatory infiltrate and cellular components (including staining with antibodies against cd , cd , cd , cd , ttf , p , and ki- ), and electron microscopy to identify virion localisation. findings: all cases showed features of the exudative and proliferative phases of diffuse alveolar damage, which included capillary congestion (in all cases), necrosis of pneumocytes (in all cases), hyaline membranes (in cases), interstitial and intra-alveolar oedema (in cases), type pneumocyte hyperplasia (in all cases), squamous metaplasia with atypia (in cases), and platelet–fibrin thrombi (in cases). the inflammatory infiltrate, observed in all cases, was largely composed of macrophages in the alveolar lumina (in cases) and lymphocytes in the interstitium (in cases). electron microscopy revealed that viral particles were predominantly located in the pneumocytes. interpretation: the predominant pattern of lung lesions in patients with covid- patients is diffuse alveolar damage, as described in patients infected with severe acute respiratory syndrome and middle east respiratory syndrome coronaviruses. hyaline membrane formation and pneumocyte atypical hyperplasia are frequent. importantly, the presence of platelet–fibrin thrombi in small arterial vessels is consistent with coagulopathy, which appears to be common in patients with covid- and should be one of the main targets of therapy. funding: none. since the earliest reports of cases in china in december, , countries around the world have faced outbreaks of covid- , the disease caused by the novel coronavirus severe acute respiratory syndrome corona virus (sars-cov- ). italy was the first country in europe to document a large number of cases of covid- , and lombardy in particular was severely affected, with a total of people testing positive for sars-cov- and admitted to intensive care units between feb and march , . luigi sacco hospital in milan and papa giovanni xxiii hospital in bergamo were the first hospitals in lombardy faced with managing the epidemic crisis. sars-cov- is the seventh member of the coronavirus family identified to cause disease in humans. coronaviruses are enveloped, positive-sense, single-stranded rna viruses. two other members of this family, severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov), cause acute diffuse alveolar damage, pneumocyte hyperplasia, and interstitial pneumonia. [ ] [ ] [ ] at the mild end of the clinical spectrum, covid- can be asymptomatic or manifest as mild upper respiratory disease with fever and cough, while severe cases can result in pneumonia, leading to acute respiratory distress syndrome (ards) in around % of hospitalised patients. to the date of our last literature review (may , ), the only published reports of the pathological features of covid- lung involvement were from small case series or isolated cases, both from china and other countries. in those reports, the main histological fea tures comprised exudative diffuse alveolar damage with massive capillary congestion, often accompanied by microthrombi. [ ] [ ] [ ] [ ] we describe the lung histopathological findings from a large series of patients who died from covid- in northern italy, with the aim of reporting the main micro scopic pulmonary lesions associated with sars-cov- infection and severe respiratory failure. we histologically analysed lung tissue samples from consecutive patients who died from covid- between feb and march , , in two referral centres for the management of the covid- outbreak in northern italy: luigi sacco hospital in milan ( autopsies) and papa giovanni xxiii hospital in bergamo ( autopsies). all patients had sars-cov- infection confirmed by real-time pcr analysis of throat swab samples taken at the time of hospital admission, and all had undergone molecular tests for common respiratory viruses and bacteria by the microbiology laboratories at the respective hospitals, with negative results. the ethics committees of luigi sacco hospital and papa giovanni xxiii hospital approved the use of personal and sensitive patient data for scientific research related to the disease in this study. the study followed the italian general rules used for scientific research purposes (regulation n. - / / ). autopsies were done in airborne infection isolation autopsy rooms, with personnel using personal protective equipment in accordance with the italian recommendations. a team of pathologists (lc, as, an, rsr, ap, pz, ag, and mn) with extensive experience in the field of infectious diseases was involved in the autopsy procedures in both hospitals. a median of seven tissue blocks (range five to nine) were taken from each lung, selecting the most repre sentative areas identified at macroscopic examin ation. tissues were fixed in % buffered formalin for at least h. paraffin-embedded sections of -µm thickness were stained with haematoxylin and eosin. to better characterise the inflammatory infiltrate, immunohistochem ical staining was done on the most representative areas of randomly selected cases, and included staining with antibodies against cd (clones b and pd / ) for the identification of leucocytes, cd (clone gv ) for t lymphocytes, cd (clone kp- ) for mono cytes, and cd (clone ) for megakaryocytes. tissues were also stained with antibodies against ttf (clone g g / ) and p (clone bc ) to identify squamous metaplasia of pneu mocytes, and ki- (mib- ) to determine the proliferative index of epithelial cells. all antibodies were ready-to-use monoclonal antibodies (ventana, roche diagnostics, basel, switzerland) and staining was done with the benchmark ultra ihc/ish system (roche, basel, switzerland) in accordance with the standard protocols supplied by the manufacturer. masson trichome staining was applied to char acterise collagen and fibrin deposition, epithelial cells, and fibrosis. additionally, in cases with histological suspicion for bacterial or fungal infections, periodic acid-schiff staining and grocott methenamine silver staining were done to confirm morphological findings. additional samples from ten consecutive cases were assessed for the presence of viral particles with use of electron microscopy: two samples from each lobe were selected, fixed in glutaraldehyde, and examined with use of a zeiss em- transmission electron microscope (zeiss, cologne, germany) and an olympus megaview g transmission electron microscopy camera with an integrated imaging platform (item; olympus, munich, germany) evidence before this study we searched pubmed up to may , , using the search terms "autopsy" and "covid- ", with no language restrictions. the search revealed ten reported cases. lung morphological features of covid- in deceased patients were described in a few isolated case reports and in small case series, including some reports in chinese. histological descriptions of lung pathology were extremely concise, without any analytical report of morphological details, and lacking any highlighting of distinctive lesions compared with other forms of interstitial pneumonia. furthermore, as only quantitative and aggregate data were available, the possible clinical implications of the findings could not be determined. we histologically examined the lung tissues of patients who died from covid- -to our knowledge the largest post-mortem series so far reported-in two main hospitals providing care to patients with progressive breathing failure in a peak epidemic area in italy. we focused on the detailed analysis of histological features in these patients to elucidate any distinctive lesions associated with covid- . to our knowledge, these data represent the first relevant provisional information regarding tissue damage specifically induced by severe acute respiratory syndrome coronavirus (sars-cov- ), besides the previously described diffuse alveolar damage, a feature that characterises interstitial pneumonia regardless of infectious agent. although our observations are provisional, they were obtained in a large cohort of patients and revealed that histopathological lung damage was characterised by expected features of diffuse alveolar damage, as well as diffuse thrombotic vascular involvement. this latter finding could be relevant in the management and targeted treatment of patients infected with sars-cov- , with the potential to modify outcomes. histological evaluation was done independently by two pathologists from each hospital, from the same team involved with the autopsy, who were masked to patient characteristics, symptoms, and diagnoses. each pathologist analysed all the slides from both hospitals, and any discrepant results were jointly reviewed. the histological features of cellular and interstitial damage were described and graded on a semiquantitative scale on the basis of the percentage of tissue involved: absent ( %), rare (< %), focal ( - %), multifocal ( - %), plurifocal ( - %), or diffuse (> %). to quantify pulmonary intracapillary megakaryocytes, each tissue sample was scanned at low magnification to identify the hotspot area in which megakaryocytes were most easily recognisable, and cd -positive cells in these areas were counted. a high value was defined as the presence of more than four cd -positive cells per high-power fields, which is considered to be the average number of intracapillary megakaryocytes in the lungs of people without diffuse alveolar damage. this study had no funding source. the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. patients were men and five women, with a mean age of years (sd ; range - ). time spent in the intensive care unit or intermediate medical ward (subintensive care) ranged from day to days (mean days [sd ]). regarding past comorbidities, data were available for patients: nine ( %) had diabetes, ( %) had hypertension, four ( %) had past malignancies, ( %) had cardiovascular disorders, and three ( %) had mild chronic obstructive pulmonary disorders. at the time of hospitalisation, all patients had clinical and radiological features of interstitial pneumonia. of the patients with available d-dimer results, all had high values (> × the upper reference limit). mean time from symptom onset to death was days (sd ; range - ). upon macroscopic examination, the lungs of all patients were heavy, congested, and oedematous, with patchy involvement. in all cases, histological examination revealed features corresponding to the exudative and early or intermediate proliferative phases of diffuse alveolar damage (figure ). these features were also focally associated with patterns of interstitial pneumonia (presence of inflammatory lymphomonocytic infiltrate along the slightly thickened interalveolar septa), organising pneumonia (alveolar loose plugs of fibroblastic tissue), and acute fibrinous organising pneumonia (some alveolar spaces containing granulocytes and fibrin, with the formation of balloon structures). features indicative of the fibrotic phase of diffuse alveolar damage, such as mural fibrosis and microcystic honeycombing, were observed to be focal, suggesting that none of the patients had progressed to the fibrotic phase, possibly because of the short duration of the disease. histological examination of the main bronchi and bronchiolar branches revealed mild, non-specific alterations: focal squa mous metaplasia and mild transmural lymphocytic and monocytic infiltrates. lumina often contained residual dense mucoid material, and granulo cytes were present in ten cases. four ( %) patients also had bacterial abscesses (one or two per lung, < mm in diameter), and one ( %) had a single fungal abscess (< mm in diameter). the abscesses were presumed to have formed after hospital admission. morphological findings and their corresponding semiquantitative grades are reported in the table. the predominant histological pattern of the exudative phase of diffuse alveolar damage, which was observed in all cases, included capillary congestion, interstitial and intraalveolar oedema, dilated alveolar ducts and collapsed platelet-fibrin thrombi in small arterial vessels (< mm diameter) were found in ( %) cases. moreover, type pneumocyte hyperplasia, showing various aspects of cellular atypia, was present to some extent in all patients; interstitial myofibroblastic reaction was observed in ( %) cases and alveolar granulation tissue in cases ( %), whereas septal collagen deposition was found in ( %) cases and alveolar loose plugs of fibroblastic tissue in ( %). mural fibrosis was sometimes observed ( [ %] cases), as was microcystic honeycomb ing ( [ %] cases, most often with a focal pattern of distribution). although no clinical history of pre-existing fibrosing interstitial lung diseases was found in patients with mural fibrosis and microcystic honeycombing, the presence of mild fibrotic alterations not in continuum with other pre-fibrotic fea tures (myofibroblastic proliferation or organising pneu monia), as expected in a context of disease progression, might suggest that fibrosing interstitial lung diseases were pre-existing in some cases. the inflammatory component was represented by cd -positive and cd -positive lymphocytes infiltrating the interstitial space; a large number of cd -positive macro phages were also found, mainly localised in the alveolar lumina. immunohistochemistry with anti-cd antibodies identi fied an increased number of megakaryocytes in the lung capillaries in ( %) cases. ultrastructural examination (figure ) revealed particles suggestive of viral infection in nine ( %) of the ten cases analysed. the particles had a mean diameter of about nm and projection of about nm in length. the particles, assumed to be virions, were mainly localised along plasmalemmal membranes and within cytoplasmic vacuoles, as described for other corona viruses. infected cells were type and type pneumocytes; however, in two cases, particles were observed in alveolar macrophages, albeit scarcely. no particles resembling viruses were observed in multinucleated cells. ultra structural analyses of alveolar capillaries frequently showed platelet and fibrin plugs within the lumina, but no particles resembling virions were detected in endothelial cells. to our knowledge, we report the largest series of covid- autopsies focusing on pulmonary lesions. in all samples, a diffuse pattern of exudative and early proliferative phases of diffuse alveolar damage was alveolar multinucleated giant cells ( %) ( %) ( %) ( %) ( %) ( %) tissues were categorised on the basis of the percentage of tissue involved, as follows: absent ( %), rare (< %), focal ( - %), multifocal ( - %), plurifocal ( - %), or diffuse (> %). *absent was defined as fewer than four cells per high-power fields. found, while the fibrotic phase was rarely observed. the distinctive histopathological findings were atypical pneumocytes (reactive atypia) and diffuse thrombosis of the peripheral small vessels. sars-cov, mers-cov, and sars-cov- infections show many similarities in clinical presentation. sars-cov and mers-cov particles have been observed and described in pneumocytes, macrophages, and lung interstitial cells by electron microscopy, immunohistochemistry, and in situ hybridisation. , , , in two autopsy studies of patients who died from sars (eight cases from singapore and cases from toronto), the predominant pattern of lung injury was diffuse alveolar damage, including the exudative and proliferative phases. inflammatory infiltrate, oedema, pneumocyte hyperplasia, fibrinous exudate, and organisation were found. the toronto case series included a comparison group of matched control patients who presented with respiratory symptoms and signs, died in the same period as those with sars, and were negative for sars-cov. com pared with non-sars lung lesions, sars lesions were distinguishable by a prominence of vascular endothelial injury and extensive acute lung injury in varying stages of exudation and organisation. autopsy studies of patients who died from mers are limited. in the only complete report available, the authors described lung injury characterised by exu dative diffuse alveolar damage, pneumocyte hyperplasia, and septal inflammatory infiltrate. despite the relevance of lung involvement in patients with covid- , few data regarding lung pathology are available. in a case report of a patient who died from covid- in china, the histological findings in the lungs included desquamation of pneumocytes, diffuse alveolar damage, and oedema. in addition, tian and colleagues described the pulmonary pathology of early-phase covid- in two patients with lung carcinoma; both patients showed signs of the exudative phase of diffuse alveolar damage. in our study, fibrin thrombi in the small arterial vessels (< mm diameter) were observed in % of cases, around half of which had involvement of more than % of the lung tissue as well as high levels of d-dimers in the blood. these findings might explain the severe hypoxaemia that characterises ards in patients with covid- . vascular micro thrombi are often identified in areas of diffuse alveolar damage, and are associated with diffuse endothelial damage. these features, although not pathognomonic, were frequent in our series, widespread in the lung samples of the patients examined, and the predominant distinctive vascular component. our data support the hypothesis proposed in clinical studies that covid- is complicated by coagulopathy and thrombosis. furthermore, d-dimer values of greater than µg/ml have been associated with fatal outcomes in patients with covid- . for these reasons, the use of anticoagulants has been suggested to be potentially beneficial in patients with severe covid- , owing also to their anti-inflammatory properties, although their efficacy and safety are being closely monitored. [ ] [ ] [ ] in this study, we looked for virions in a subset of patients, and found particles resembling virions to be present, albeit rarely, in the cytoplasm of pneumocytes and macrophages. the morphology of the observed particles (about nm in diameter, enveloped, with spike-like projections, and an electron-lucent core with peripheral electron-dense granules of the sectioned nucleocapsid) and their intravacuolar cytoplasmic location are consistent with the reported ultrastructural features of coronaviruses, including sars-cov- . despite the low number of cases assessed, these findings might suggest that the virus remains in the lung tissue for many days, even if in small quantities, and might trigger the mechanism that leads to lung damage and causes it to progress. further histological and molecular analyses and extension of the case series are ongoing to better define the cellular and tissue distribution of the virus as well as inflammatory responses in different organs. although this report represents the largest european study of lung autopsy findings from cases of covid- to date and is based on the analysis of a large number of lung samples, it is limited by the absence of controls. future pathological studies should include an extensive analysis of cases of ards associated with other viral pneumonias. baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region overlapping and discrete aspects of the pathology and pathogenesis of the emerging human pathogenic coronaviruses sars-cov, mers-cov, and -ncov pulmonary pathology of severe acute respiratory syndrome in toronto histopathology of middle east respiratory syndrome coronavirus (mers-cov) infection-clinicopathological and ultrastructural study clinical features of patients infected with novel coronavirus in wuhan, china covid- autopsies pathological findings of covid- associated with acute respiratory distress syndrome histopathologic changes and sars-cov- immunostaining in the lung of a patient with covid- pulmonary pathology of early-phase novel coronavirus (covid- ) pneumonia in two patients with lung cancer management of the corpse with suspect, probable or confirmed covid- respiratory infection-italian interim recommendations for personnel potentially exposed to material from corpses, including body fluids, in morgue structures and during autopsy practice lung pathology of severe acute respiratory syndrome (sars): a study of autopsy cases from singapore megakaryocytes and platelet homeostasis in diffuse alveolar damage the intracellular sites of early replication and budding of sars-coronavirus immunohistochemical, in situ hybridization, and ultrastructural localization of sars-associated coronavirus in lung of a fatal case of severe acute respiratory syndrome in taiwan incidence of thrombotic complications in critically ill icu patients with covid- clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study anticoagulant treatment is associated with decreased mortality in severe coronavirus disease patients with coagulopathy anticoagulant therapy in acute respiratory distress syndrome thromboembolic risk and anticoagulant therapy in covid- patients: emerging evidence and call for action sarscoronavirus- replication in vero e cells: replication kinetics, rapid adaptation and cytopathology we declare no competing interests. key: cord- -z sz msj authors: fanoy, ewout b; van der sande, marianne ab; kraaij-dirkzwager, marleen; dirksen, kees; jonges, marcel; van der hoek, wim; koopmans, marion pg; van der werf, douwe; sonder, gerard; van der weijden, charlie; van der heuvel, jet; gelinck, luc; bouwhuis, jolande w; van gageldonk-lafeber, arianne b title: travel-related mers-cov cases: an assessment of exposures and risk factors in a group of dutch travellers returning from the kingdom of saudi arabia, may date: - - journal: emerg themes epidemiol doi: . / - - - sha: doc_id: cord_uid: z sz msj background: in may , middle east respiratory syndrome coronavirus (mers-cov) infection, with closely related viral genomes, was diagnosed in two dutch residents, returning from a pilgrimage to medina and mecca, kingdom of saudi arabia (ksa). these patients travelled with a group of other dutch travellers. we conducted an epidemiological assessment of the travel group to identify likely source(s) of infection and presence of potential risk factors. methods: all travellers, including the two cases, completed a questionnaire focussing on potential human, animal and food exposures to mers-cov. the questionnaire was modified from the who mers-cov questionnaire, taking into account the specific route and activities of the travel group. results: twelve non-cases drank unpasteurized camel milk and had contact with camels. most travellers, including one of the two patients (case ), visited local markets, where six of them consumed fruits. two travellers, including case , were exposed to coughing patients when visiting a hospital in medina. four travellers, including case , visited two hospitals in mecca. all travellers had been in contact with case while he was sick, with initially non-respiratory complaints. the cases were found to be older than the other travellers and both had co-morbidities. conclusions: this epidemiological study revealed the complexity of mers-cov outbreak investigations with multiple potential exposures to mers-cov reported such as healthcare visits, camel exposure, and exposure to untreated food products. exposure to mers-cov during a hospital visit is considered a likely source of infection for case but not for case . for case , the most likely source could not be determined. exposure to mers-cov via direct contact with animals or dairy products seems unlikely for the two dutch cases. furthermore, exposure to a common but still unidentified source cannot be ruled out. more comprehensive research into sources of infection in the arabian peninsula is needed to strengthen and specify the prevention of mers-cov infections. in , the middle east respiratory syndrome coronavirus (mers-cov) was isolated for the first time from the sputum of a -year-old man who presented with an acute pneumonia in kingdom of saudi arabia (ksa) [ ] . as of june , laboratory-confirmed cases of mers-cov infection have been reported to the who including ( %) fatal cases [ ] . following the first upsurge of cases in spring , a second wave occurred in , mainly in ksa [ ] . most cases so far either resided in or travelled to the arabian peninsula and neighbouring countries or were close contacts of these cases. furthermore, travel related cases have been reported from the united states of america (usa), the united kingdom (uk), germany, france, tunisia, italy, greece, algeria, egypt, the philippines and malaysia [ ] [ ] [ ] [ ] [ ] . so far, mainly sporadic cases are reported as well as a few hospital outbreaks, which is in line with a low reproduction rate (r ) of mers-cov, estimated to range from . to . [ ] [ ] [ ] . the median incubation period is estimated to be . days ( % ci . - . days) [ ] . for most non healthcare associated cases no clear source of infection could be identified, although camels are considered a reservoir as the virus and antibodies against mers-cov have been identified in camels (camelus dromedarius) and in their milk [ , ] . the exact modes of transmission of the virus to humans remain unclear [ ] [ ] [ ] [ ] , leaving the possibility for other yet unidentified sources of infection. to stop or reduce transmission of mers-cov and prevent new human infections, it is important to identify all potential sources of infections as well as risk factors and route(s) of transmission. in may , mers-cov infection was diagnosed in two dutch residents. these cases travelled with a group of other people, returning to the netherlands from pilgrimage to medina and mecca, ksa [ ] . we conducted a comprehensive epidemiological assessment of the travel group aiming to identify the likely source(s) of infection and presence of potential risk factors for these two cases. we compiled a questionnaire based on sample questionnaires originating from two who-protocols aimed to asses risk factors and investigate contacts of patients with mers-cov infection [ , ] . we adapted the questionnaire to the specific route and activities of the dutch travellers. our questionnaire covered human, animal and food exposures to mers-cov during the whole trip to ksa. the questionnaires consisted of open and closed questions, and it took approximately minutes to complete the face-to-face interview with the travellers (additional file ). nurses of the public health services administered the questionnaires approximately weeks after return to the netherlands. for the two cases the questionnaire was completed with data on the travel route and stay in ksa collected by the national coordination centre for communicable disease control. the patients were a -year-old man (case ) and his -year-old sister (case ), both having underlying cardiovascular co-morbidities and diabetes mellitus. the remaining travel group included persons ( % male) aged between and years (median age: years). seventeen ( %) of the non-cases did not report any comorbidities (table ). upon identification of case , throat swabs of all contacts were tested by pcr to assess other mers-cov cases. apart from case , who had reported mild respiratory complaints starting on the th of may (t = day ), all other travellers tested negative and did not develop symptoms. the group made a pilgrimage to medina and mecca, ksa ( figure ). they arrived on the th of april (day ) in medina, left by private bus to mecca on the th of may (day ) and returned to amsterdam on the th of may (day ). case started to feel feverish and had diarrhoea on the st of may (day ). respiratory complaints started on the th of may (day ). mers-cov was identified in case on the th of may (day ) and in case on the th of may (day ). detailed case reports of the two patients are described by kraaij et al. [ ] . during their pilgrimage, the whole group stayed in the same hotels and had breakfasts together. there was no fixed collective travel programme, but they had some joint visits to several mosques. the travellers also spent time alone or in smaller subgroups, visiting different mosques, markets and restaurants. the exposures for both the cases and asymptomatic travellers during their visit to saudi arabia are summarized in table . on the rd of may (day ), travellers (excluding the two cases) made a trip to the touristic valley wadi-e-jinn, and stopped when they came across a herd of camels laying behind an improvised razor fence. four travellers reported direct contact with the camels. eight travellers mentioned indirect contact, for example via the fences surrounding the animals. eleven travellers consumed unpasteurized camel milk, offered to them by the caretakers of the camels. besides contact with camels, two travellers reported that they spotted many pigeons in the cities and fed them. no other direct contact with animals was mentioned. page of http://www.ete-online.com/content/ / / as mentioned above, eleven travellers, excluding the two cases, consumed unpasteurized camel milk. furthermore, travellers, including case , visited one or more local markets in medina. seven of them, excluding case , bought and consumed a range of fruits such as prunes and dates. furthermore, travellers bought souvenirs, such as dates, perfume and clothing on these markets. case and his son visited two hospitals in medina on the th of april (day ) because of eye complaints of the son. as mentioned before, they spent minutes in a crowded waiting room of a general hospital where they were exposed to coughing patients. subsequently, the son was referred to a specialized eye clinic where they spent no time in a waiting room and did not notice any coughing patients. on the th of may (day ), case , accompanied by his son, visited an emergency department of a general hospital in mecca because of acute malaise, weakness, nausea and diarrhoea (without respiratory complaints). these symptoms started on may (day ). case and his son spend - minutes in the waiting room, though they had no specific exposure to coughing people. on the th of may (day ) case returned to another hospital in mecca, accompanied by his son, where he only briefly stayed in the waiting room, received antibiotic treatment and was observed for approximately three hours. four other travellers, including his son, accompanied him. two of them did not notice any coughing persons, while the other two did not answer this question. case did not visit a hospital during the pilgrimage or prior to her diagnosis in the netherlands. two travellers (case and his son) waited minutes in a crowded waiting room of a general hospital in medina ( th of april, day ) where they were exposed to coughing patients. one other traveller, who did not enter a hospital, reported coughing persons outdoors. the duration and intensity of this contact was not clarified in more detail. case and had been in close contact with each other during the entire trip, as they shared hotel rooms. all travellers had been in contact with both cases during the trip. seventeen travellers had minimal social contact with the two cases, for example only brief eye contact in the hotel lobby or in the bus. twelve travellers reported daily contact, such as visits to the hotel room of case while he was sick, or accompanying him while shopping. the son of case had the most intensive contact sharing a hotel room with both cases. nevertheless, his throat swabs tested negative to mers-cov by pcr during the follow-up after the identification of case . we found no indications that the two cases were infected via contact with specific animals or dairy products. infection during a hospital visit could be a source for case . sequence analysis of parts of the viral genome collected from both patients had shown that the strains were nearly identical, suggesting that the cases have infected each other, or that they were exposed to a common source. in the latter case, exposure during a hospital visit is unlikely because case did not visit a hospital before onset of disease. the possibility of asymptomatic infections and transmission among the accompanying travellers cannot be ruled out, but seems unlikely in view of the negative pcr results. subsequently, although considered unlikely, we cannot exclude the possibility of asymptomatic travellers being a source of infection for case and/or . no other common sources were identified although we cannot exclude the possibility of lack of accurate recall or indirect exposure to animal excreta. it might be possible that one or both cases were infected during non-specific contacts with the local population or the environment. if initial zoonotic introductions of mers-cov from camels have been followed by low level presence among the (asymptomatic) population or in the environment at large, this might result in an ongoing community-based outbreak, which, unlike sars, cannot be controlled by rigorous hospital hygiene alone. both patients were of older age and had comorbidities. in general, older age and comorbidity are considered risk factors for symptomatic mers-cov infections, although this was not the case in all outbreaks [ , ] . in this study, the distribution of symptoms towards higher age and comorbidity fits this assumption. ongoing serological analysis upon travellers and people exposed to the case in the netherlands may reveal to what extent asymptomatic infection has occurred. the remainder of the travellers did not develop symptomatic mers-cov and did not have positive pcr-test results despite exposure to camels, dairy products and the two cases. this could point to a low transmissibility of the virus, which is also illustrated by the limited number of secondary infections among contacts of import cases described elsewhere, with the reservation that asymptomatic infections among the remaining travellers cannot be excluded fully as final serologic results are not available [ , ] . currently, there is only limited epidemiological information published considering potential sources and transmission dynamics of mers-cov infection within the arabian peninsula. descriptive studies among a well-defined group of travellers can therefore provide relevant epidemiologic information, even when the number of travellers is too small to draw definite conclusions. more in depth epidemiological investigation of comparable travel groups will add to the body of evidence, although the diversity of activities during a relatively short trip makes accurate recall of potential exposure challenging. alternatively, prospective cohort studies among travellers to affected areas, whereby travellers are asked to keep a daily diary, are likely to be more informative and complete. due to the uncertainty about the source, the detailed questions of the who-questionnaire were a very useful guide to decide on the most relevant exposures to be explored, adapted to the specific route of travel. the exact source of infection remains difficult to identify. case could have been infected during his visit to a page of http://www.ete-online.com/content/ / / hospital and subsequently have infected case . however, exposure to a common source for both case and cannot be ruled out. besides, case may have been exposed to a yet unidentified source and subsequently have infected case , or vice versa. more research to relevant sources in the arabian peninsula is needed. the suggested role of underlying disease to develop mers-cov infection is in line with the age and comorbidity of the two dutch cases and the absence of symptomatic mers-cov infections among the younger and healthier travellers. additional file : the questionnaire. isolation of a novel coronavirus from a man with pneumonia in saudi arabia organization wh: coronavirus infections global alert and repsonse (gar) first confirmed cases of middle east respiratory syndrome coronavirus (mers-cov) infection in the united states, updated information on the epidemiology of mers-cov infection, and guidance for the public, clinicians, and public health authorities euro surveillance: bulletin europeen sur les maladies transmissibles = european communicable disease bulletin investigation of an imported case of middle east respiratory syndrome coronavirus (mers-cov) infection in a case of imported middle east respiratory syndrome coronavirus infection and public health response clinical features and viral diagnosis of two cases of infection with middle east respiratory syndrome coronavirus: a report of nosocomial transmission middle east respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: a comparative serological study geographic distribution of mers coronavirus among dromedary camels middle east respiratory syndrome coronavirus in dromedary camels: an outbreak investigation human infection with mers coronavirus after exposure to infected camels antibodies against mers coronavirus in dromedary camels middle east respiratory syndrome coronavirus (mers-cov) serology in major livestock species in an affected region in jordan middle east respiratory syndrome coronavirus (mers-cov) infections in two returning travellers in the netherlands world health organization: seroepidemiological investigation of contacts of middle east respiratory syndrome coronavirus (mers-cov) patients world health organization: case-control study to assess potential risk factors related to human illness caused by middle east respiratory syndrome coronavirus (mers-cov) al raiy b: clinical course and outcomes of critically ill patients with middle east respiratory syndrome coronavirus infection hospital-associated outbreak of middle east respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution medical centre haaglanden, the hague, the netherlands. isalaklinieken, zwolle, the netherlands. national institute for public health and the environment, epidemiology and surveillance unit, antonie van leeuwenhoeklaan , bilthoven, ma , the netherlands. the authors declare that they have no competing interests. all readers have read and approved the manuscript.authors' contributions ef compiled the questionnaires, analysed the data and drafted the manuscript. ms is in charge of the epidemiology department; she designed and coordinated the study and reviewed the manuscript. mk assessed travel data and reviewed the manuscript. kd coordinated interviews with travellers and reviewed the manuscript. mj was responsible for laboratory testing and reviewed the manuscript. wh is in charge of respiratory epidemiology department and reviewed the manuscript. mpgk is involved in laboratory testing and reviewed the manuscript. dw coordinated interviews with travellers and reviewed the manuscript. gs coordinated interviews with travellers and reviewed the manuscript. cw coordinated interviews with travellers and reviewed the manuscript. jh coordinated interviews with travellers and reviewed the manuscript. lg was involved in clinical care and interviewed a case. jb was involved in clinical care and interviewed a case. ag was leading the study, including the study design and analysis and she reviewed the manuscript. all authors read and approved the final manuscript. key: cord- - i jhvwn authors: maitra, s.; biswas, m.; bhattacharjee, s. title: case- fatality rate in covid- patients: a meta-analysis of publicly accessible database date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: i jhvwn a novel coronavirus was reported in wuhan, china in december to cause severe acute respiratory symptoms (covid- ). in this meta-analysis, we estimated case fatality rate from covid- infection by random effect meta-analysis model with country level data. publicly accessible web database worldometer (https://www.worldometers.info/coronavirus/) was accessed on th march gmt and reported total number of cases, total death, active cases and seriously ill/ critically ill patients were retrieved. primary outcome of this meta-analysis was case fatality rate defined by total number of deaths divided by total number of diagnosed cases. pooled case fatality rate ( % ci) was . ( . - . ) %. between country heterogeneity was . (p< . ). pooled estimate of composite poor outcome ( % ci) was . ( . - . ) % at that point of time after exclusion of countries reported small number of cases. pooled mortality rate ( % ci) was . ( . - . ) % amongst closed cases (where patients have recovered or died) with. meta regression analysis identified statistically significant association between health expenditure and mortality amongst closed cases (p= . ). a novel coronavirus was reported in wuhan, china in december to cause severe acute respiratory symptoms (covid- ) [ ] . subsequently, this viral outbreak was reported in countries and one international ship on th march . a wide range of mortality rate was reported from this viral illness and world health organization reported mortality rate of . % on rd march [ ] . in this meta-analysis, we estimated 'case fatality rate' from covid- infection by random effect meta-analysis model with country level data. publicly accessible web database 'worldometer' (https://www.worldometers.info/coronavirus/) was accessed on th march gmt and reported total number of cases, total death, active cases and seriously ill/ critically ill patients were retrieved. primary outcome of this meta-analysis was 'case fatality rate' defined by total number of deaths divided by total number of diagnosed cases. secondary outcomes were mortality rate amongst closed cases (where patients recovered or died) and proportion of composite poor outcome (defined by the number of patients died or critically ill). metaregression analysis was performed to identify association between population density, health expenditure (percentage of gdp) and percentages of patients over y age with mortality. between country heterogeneity (τ) was estimated by restricted maximum likelihood method and % prediction interval of pooled mortality were reported [ ] . countries reporting small number of cases (< on th march ) were excluded from analysis; however, sensitivity analysis was planned with including them. association between mortality and clinical characteristics of the patients were assessed by mixed effect meta-regression model. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . between country heterogeneity (τ) was . (p< . ). sensitivity analysis was performed by exclusion of one country at times and pooled estimates of crude fatality rate remained mostly similar. another sensitivity analysis was performed including countries where reported total number of cases were less than , and estimated case fatality rate ( % ci) was . % ( . - . ) % with i = . %. significant amount of publication bias was identified by regression test both with (p< . ) and without (p= . ) including countries will small number of cases. pooled estimate of composite poor outcome ( % ci) was . we have found a pooled mortality rate of . %, which was less than who reported death rate of . % but similar to the first published report of mortality from wuhan, china. [ ] our pooled estimate of composite poor outcome was around %, which was similar to the previous report from china. another important finding is that presence of a significant heterogeneity and publication biases in the pooled analysis. underreporting from different . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . proportion . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . clinical characteristics of coronavirus disease in china who director-general's opening remarks at the media briefing on covid- - march -world health organization cochrane handbook for systematic reviews of interventions version key: cord- -zdft q authors: cauchemez, simon; ferguson, neil m. title: methods to infer transmission risk factors in complex outbreak data date: - - journal: j r soc interface doi: . /rsif. . sha: doc_id: cord_uid: zdft q data collected during outbreaks are essential to better understand infectious disease transmission and design effective control strategies. but analysis of such data is challenging owing to the dependency between observations that is typically observed in an outbreak and to missing data. in this paper, we discuss strategies to tackle some of the ongoing challenges in the analysis of outbreak data. we present a relatively generic statistical model for the estimation of transmission risk factors, and discuss algorithms to estimate its parameters for different levels of missing data. we look at the problem of computational times for relatively large datasets and show how they can be reduced by appropriate use of discretization, sufficient statistics and some simple assumptions on the natural history of the disease. we also discuss approaches to integrate parametric model fitting and tree reconstruction methods in coherent statistical analyses. the methods are tested on both real and simulated datasets of large outbreaks in structured populations. data collected during field outbreak investigations are essential to better understand the clinical and epidemiological features of an infectious disease. they can also provide useful insights for outbreak management and control. for example, evaluating the risk factors governing transmission is important to design efficient control measures, and identify those individuals that are most at risk of infection or are the main contributors of infection and should therefore be targeted first. however, characterizing transmission from outbreak data can be challenging. first, the transmission process is usually imperfectly observed. for example, we may observe the date of symptoms onset of a case, but we rarely know where, when and by whom a case was infected. inference, therefore, requires integrating over 'missing data', which may quickly become cumbersome. over the last years, data augmentation methods have been used to tackle this problem: data are augmented with missing data (e.g. dates of infection) that are needed to write down the likelihood; in a bayesian setting, the joint posterior distribution of parameters and augmented data is explored usually via markov chain monte carlo (mcmc) sampling [ ] . this methodology is now well established in the field and has been successfully applied to analyse a range of complex datasets. however, for relatively large outbreaks with detailed data, this approach may require very long computational times. interested readers can, for example, read references [ - ] . the second challenge is that the type of dependency between observations that is typically observed in an outbreak (i.e. the risk of infection of an individual depends on the infection status of other individuals) is specific to communicable diseases and needs to be accounted for with dedicated methods. this usually requires that the statistical model used to analyse the data is explicitly based on a mechanistic model of disease spread [ ] . transmission parameters of interest, for example, the reproduction number (the number of individuals infected by a case), are usually mathematically defined in those models. fitting such parametric mechanistic models to outbreak data can give useful insights on transmission [ , [ ] [ ] [ ] , but is subject to the same limitations as parametric fitting in other fields. for example, although there are some exceptions [ ] , the approach usually requires to predefine time intervals on which transmission rates are constant. this can sometimes be difficult to achieve in a non-ad hoc way. an alternative approach that has become increasingly popular is to reconstruct the transmission tree and derive important summary statistics from it, for example, the temporal trends in the reproduction number [ - ] . this may give greater flexibility (for example, there is no need to specify time intervals with constant transmission rates), potentially at the cost of larger variance of the estimates [ , ] . however, since these methods generally only consider disease *author for correspondence (s.cauchemez@imperial.ac.uk). cases rather than the uninfected, but potentially susceptible bulk of the population, they can say little about the risk factors for infection or provide estimates of transmissibility in different contexts (e.g. households, schools or as a function of distance between a susceptible and an infected individual). overall, the two methodologies (fitting of a parametric mechanistic model and tree-reconstruction methods) are largely complementary. fitting a mechanistic model seems to be the only way to account for the depletion of susceptibles, the information on uninfected individuals leading to a quantification of relative risks; and it may ensure a better control of the variance of the estimates. tree-reconstruction methods can provide further insights on what effectively happened during the outbreak with summary statistics on who was infected by whom, when and where and temporal change in the reproduction number. they can also provide a framework to detect abnormal features in the data that are not initially accounted for in a mechanistic model. it is therefore important that the two approaches can be integrated in a coherent way. in this paper, we discuss strategies to tackle some of the ongoing challenges in the analysis of outbreak data. we present a relatively generic statistical model for the estimation of transmission risk factors, and discuss algorithms to estimate its parameters for different levels of missing data. we look at the problem of computational times for relatively large datasets and show how they can be reduced by appropriate use of discretization, sufficient statistics and some simple assumptions on the natural history of the disease. we also discuss approaches to integrate parametric model fitting and tree reconstruction methods in coherent statistical analyses. the methods are tested on both real and simulated datasets of large outbreaks in structured populations. assume that we observe the spread of a disease in a population of size n from day to day t. for each individual i ¼ , . . . , n, let y t i ¼ ; if individual i is infected between and t; otherwise. each individual i is characterized by a vector of q covariates z i (t) ¼ fz i (t), . . . , z i q (t)g such as age, gender, location, household id, etc . . . that may vary with day t. we want to quantify the transmission risk factors. we first consider the situation where day t i of infection of each case i is observed (by convention, . this assumption is relaxed in § . for a directly transmitted disease, the first step to estimate transmission risk factors is usually to propose a model for transmission hazard l i!j ðtjqÞ from case i to subject j on day t, i.e. define l i!j ðtjqÞ as a function of the individual covariates z i (t) and z j (t) and a set of parameters q. for example, the transmission hazard l i!j ðtjqÞ may depend on: -the time lag t-t i between day t and the day of infection t i of case i since infectiousness of a case may vary during the course of infection. the functional form between l i!j ðtjqÞ and t-t i will depend on the assumed natural history of the disease; -the individual characteristics of subjects i and j. for example, some subjects may be more infectious while others are more susceptible; and -the type of interactions that exist between subjects i and j. the contact rate might, for example, depend on whether the subjects live in the same household or go to the same school, etc. it could also depend on the spatial distance between them. examples of specifications for the transmission hazard l i!j ðtjqÞ are given in § § and . the force of infection exerted on individual j on day t is then the sum: l i!j ðtjqÞ: the contribution to the likelihood of case j is: where the first term is the probability of infection on day t, and the second term is the probability to escape infection up to day t (the link between the continuous time and discrete time transmission model is discussed in appendix a). the contribution of non-case j is: the log-likelihood is therefore: the number of pairs of farms to be considered per calculation of the likelihood is over [ ] . even with the recent increase in computational power, brute force exploration of the system, though feasible, is very time consuming. fast and efficient algorithms are necessary to provide real-time support to decision making. here, we explore the extent to which the discretization of the transmission risk factors can reduce the computational burden associated with the evaluation of equation ( . ). therefore, we now restrict our analysis to the situation where each transmission risk factor takes a finite set of values. we will then explore how the approach can be used to investigate continuous risk factors. assume that the transmission hazard between two individuals depends on k risk factors x ¼ fx , . . . ,x k g and that the k-th risk factor x k (k ¼ , . . . , k ) takes a finite number (¼c k ) of values fv k ; . . . ; v k c k g. the set c of possible values for risk factor vector x ¼ fx , . . . , x k g has size q k k¼ c k . for example, the list of risk factors might include the (discretized) distance between the individuals (either spatial or social, e.g. members of the same household), the time lag since infection or individual characteristics, such as age. we model the transmission hazard between a case and a susceptible individual in the population by: where the specific effect of x k on the transmission hazard is measured by function b k ðx k ; u k Þ ! , and u k ¼ fu k ; . . . ; u k l k g is a parameter vector of size l k . this expression makes the simplifying assumption that the effect of all risk factors on the hazard can be expressed as the product of the impacts of each factor. parameters of the model are remembering that z i denotes data available for individual i, we assume here that risk factors for transmission from case i to individual j on day t are a function of triplet fz i , z j , tg: x ði;j;tÞ ¼ fx ði;j;tÞ ; . . . ; x k ði;j;tÞ g, where for k ¼ , . . . , k, x k ði;j;tÞ ¼ g k ðfz i ; z j ; tgÞ. the transmission hazard l i!j ðt j jqÞ from case i to individual j on day t is therefore: l i! j ðtjqÞ ¼ bðx ði;j;tÞ ; qÞ: the total hazard of infection for individual j on day t is then: where here d a,b is the kronecker delta or identity function (¼ if a ¼ b and otherwise). m x counts the number of day-transmission events of type x, which might have occurred before time t but did not. equation ( . ) has important implications in terms of computational speed since it shows that the computational burden can be substantially reduced without loss of information. the first term of equation ( . ) only involves disease cases; the second term characterizes the probability of escaping infection up to time t. so, data needs for inference reduce to: -'case data'; -table fm x g x[c of sufficient statistics that characterize the interaction of cases with any individual of the population. it can be pre-computed and stored once, given they do not functionally depend on the parameters. tree reconstruction [ , [ ] [ ] [ ] is a useful complement to the likelihood-based estimates of the parameters derived from equation ( . ) . here, we present and discuss different strategies to perform tree reconstruction and parameter estimation in a coherent statistical framework. given parameter q and given that case j was infected on day t j , the probability that case j was infected by case i (t i , t j ) is simply (see appendix a): a natural way to integrate tree reconstruction and parameter estimation in a coherent setting is to proceed sequentially. for example, in a bayesian setting, a sample fq m g m¼ ;...;m can be drawn from the posterior distribution of q via mcmc sampling relying on equation ( . ) . then, for each parameter value in the sample m ¼ , . . . ,m, a source of infection r j can be drawn from its distribution f p i!j ðt j jq m Þg i for each case j. this gives a sample of m transmission trees drawn from their predictive distribution. for example, we used this strategy when analysing detailed data from an influenza outbreak in a school [ ] . here, we explore an alternative strategy where the two tasks are performed simultaneously. the method formalizes those introduced in work undertaken in on the uk fmd epidemic of that year [ ] . the idea is that the source of infection r j for each case j is considered as 'augmented' data. the augmented loglikelihood is: in many situations, where the force of infection exerted on individuals is relatively small, the likelihood simplifies to: the analysis of the augmented likelihood can be performed in a frequentist or in a bayesian setting. in the frequentist setting, it is straightforward to implement an expectation conditional maximization (ecm) algorithm [ , ] to both derive maximum-likelihood estimates of the parameters of the model and reconstruct the transmission tree. the pseudo-code for this algorithm is given in box . in the common situation, where one is interested in relative risks (i.e. comparison with a reference group) and where the force of infection exerted on individuals is relatively small, no maximization routine is needed since the maximum value is simply a ratio of two sums (appendix a) [ ] . confidence intervals can be obtained from the fisher information matrix derived at the maximum value for the incomplete log-likelihood (equation . ). the approach, therefore, requires that the second derivative of the log-likelihood with respect to q exists. alternatively, inference can be performed in a bayesian setting via mcmc [ ] , with a pseudo-code presented in box . the key difference is in the way missing data are handled: in the bayesian approach, one realization of the missing data is drawn from its expected distribution; by contrast in the em algorithm, the whole expected distribution of the missing data is used in the expression of the augmented likelihood. often, the day of symptom onset s j of case j is observed but not the day of infection t j . as a consequence, box . the em algorithm when the days of infection are observed. assume that at the beginning of iteration n, parameter vector is q n : -expectation step: (i) for each case j, compute probabilities f p i!j ðt j Þg i given q n (equation . ; see appendix a), and (ii) for x in c, compute the expected number of transmission events of type x : other parameters being fixed (see appendix a): bayesian algorithm when the days of infection are observed. at iteration n: -update missing data: (i) for each case j, compute probabilities f p i!j ðt j Þg i given q n (equation . ; see appendix a), (ii) for each case j, draw the source r j of case j from distribution f p i!j ðt j Þg i , and (iii) for x in c, compute the number of transmission events of type x: -update parameters: (i) for k ¼ , . . . , k, and (ii) for j ¼ , . . . , l k : mcmc update u k j relying on the augmented likelihood l c (see appendix a): methods to infer transmission risk factors s. cauchemez and n. m. ferguson likelihood as shown in equation ( . ) is no longer available. if the incubation period (time lag between the day of infection and the day of symptoms onset) has a known density f (s j jt j ), a common strategy to tackle the problem is to augment the data with the day of infection of each case. a particular computational burden is then that updating the day of infection of a single case may require re-calculation of the whole likelihood as the update may affect the risk of infection of all other individuals. in order to avoid this computational cost, we introduce the additional assumption: (h ) given the day of symptoms onset s j , infectiousness over time is independent of the day of infection t j . this is, for example, the case if infectiousness starts with symptom onset. this assumption seems acceptable for a relatively wide range of diseases since infectivity is often triggered or influenced by symptoms. under h , there is no need to re-compute the whole likelihood each time a day of infection is updated. it would be possible to extend the em approach to the situation when the days of infection are unobserved. inference would work as in the previous section except that one would have to take the expectation on both the contact tracing information and the day of infection. however, for this second application, it is no longer possible to easily derive the variance of the estimates. this is because, although maximum-likelihood point estimates could be derived from the likelihood for the 'complete' dataset, estimation of the variance of the estimates has to rely on the likelihood of the observed dataset (equation . ). this expression cannot be computed here since days of infection are not observed. the bayesian approach does not suffer from this limitation and makes it possible to easily obtain bayesian credible intervals (box ). we explore how the discretization of risk factors and the algorithms introduced in § can reduce the computational burden of inference. for simplicity, farms are partitioned into three groups on the basis of the number of cattle n c and the number of sheep n s : cattle (cattle farm: n c ! n s ), sheep (sheep farm: n s . n c ) and small (small farm: n c þ n s , ) [ ] . we assume that the latent period of fmd is days and that infectious farms remain so until the time of slaughter. the transmission hazard b between case farm i and susceptible farm j that is introduced in equation ( . ) is modelled as a function of the following characteristics: -the type (cattle, sheep or small) of case farm i. we estimate the relative infectivity of sheep farms ðg sh i Þ and small farms ðg sm i Þ relative to cattle box . bayesian algorithm when only days of symptom onset are observed. at iteration n: -gibbs sampling for missing data: (i) for each case j, compute probabilities f p j ðtÞg t for the day of infection of the case given q n (see appendix a), (ii) for each case j, draw the day t j of infection of the case from distribution f p j ðtÞg t , (iii) for each case j, compute probabilities f p i!j ðt j Þg i given q n (equation . ; see appendix a), (iv) for each case j, draw the source r j of case j from distribution f p i!j ðt j Þg i , and (v) for x in c, compute the number of transmission events of type x: -update parameters: (i) for k ¼ , . . . , k, and (ii) for j ¼ , . . . , l k : mcmc update u k j relying on the augmented likelihood. the augmented likelihood is slightly different from the case when days of infection are known (equation . ). in particular, since days of infection of cases change during the inference procedure, it is no longer possible to pre-compile and store the contribution of cases to matrix fm x g (i.e. number of day-transmission events of type x that could have occurred but did not); but one can still pre-compile and store the contribution fmm x g of non-cases, which is usually the key computational burden. the augmented likelihood is: farms. so the multiplicative term on the transmission hazard is g sh i ; if case farm is a sheep farm, g sm i if it is a small farm and if it is a cattle farm; -the type (cattle, sheep or small) of susceptible farm j. we estimate the relative susceptibility of sheep farms ðg sh s Þ and small farms ðg sm s Þ relative to cattle farms; and -the distance d ij between farm i and farm j. two models are considered: m : discrete model. we assume that the transmission kernel is a step function with k þ change points fd k g k¼ , . . . ,k and where the multiplicative term on the transmission hazard is g k d if d k , d ij d k . in practice, we take change points f , . , , . ð : Þ where qða; bÞ ¼ = Ð d¼ ð þ u=aÞ Àb du is a normalizing constant. here, we introduce a discretized version of this kernel. consider k þ change points fd k g k¼ , . . . ,k . we define d k ; the mean distance between farms i and j satisfying d k , d ij d k : the transmission kernel is the step function: in for the ecm algorithm, we consider that convergence is achieved at iteration n if the relative change in parameter values between iteration n and iteration n þ is smaller than for all parameters. in the bayesian implementation of the model, we specify the following priors for our parameters. parameters g sh i ; g sm i ; g sh s ; g sm s ; g d ; . . . ; g k d all have a gamma prior g(a, a) with a ¼ . we also do a sensitivity analysis for a ¼ , . for model m , we specify a uniform prior u [ , ] for kernel parameters a and b and a gamma prior g(a, a) for parameter c. the mcmc is run for iterations with a burn in of iterations. transmission parameters are estimated for time interval rd february (when the national ban on animal movements was introduced) to th october , conditional on the state of the epidemic on rd february. computation times are given for single threaded code running on an intel xeon x system. we first use the ecm algorithm (box ) to estimate model m (table ) . convergence is achieved in only iterations (figure ). total computational time is min s with most of the time ( s) spent reading the data and computing the table fm x g x[c of sufficient statistics (equation . ). in particular, there is no need to use maximization routines since there is an analytical solution to the conditional maximization step (see appendix a). computational times are also very short ( min s) for the bayesian algorithm (box ). estimates of transmission kernel m are obtained in min s (table ) . those computational times contrast with those needed through brute calculation of the likelihood (equation . ). replacing model m by the exact continuous parametric kernel (equation . ) and using equation ( . ) does not affect estimates (table ); but computational times move to a month for the same number of iterations of the mcmc, on the same machine and with no serious attempt to optimize the code. while algorithmic optimization and parallel programming allows this to be reduced to a few days [ ] , the algorithms presented here still give comparable estimates two orders of magnitude more rapidly than brute force approaches. we simulate an epidemic in a city that is structured in households and hospitals and where community transmission can happen. table summarizes the structure of the city. we consider a city of size with an average household size of . persons and with household demographics consistent with the french census [ ] . the city has three hospitals with staff members and beds each, a bed occupancy of per cent outside the epidemic period for a duration of hospitalization of days. we simulate the spread of a disease in this population and would like to assess how the techniques described above can be used to evaluate and monitor transmission in the different settings (community, hospital and household), infectivity and susceptibility of different types of individuals (here: children versus adults) along with the efficacy of the interventions that are put in place in the different settings. we are interested in a scenario like the severe acute respiratory syndrome (sars) rather than, for example, an influenza scenario; that is a disease for which it is possible to detect and identify a substantial proportion of cases. we assume that the incubation period of the disease has a geometric distribution (with probability . , truncated after days); that individuals start to be infectious on the day of symptoms onset with an infectivity profile following that time which has an exponential shape with mean days (truncated after days). we assume that per cent of cases are hospitalized with equal probability of hospitalization occurring or days after symptoms onset. we assume that children are . -fold more susceptible and more infectious than adults. following cauchemez et al. [ ] , we assume that the person-to-person household transmission rate is inversely proportional to the size of the household. the epidemic starts with five cases infected on day . control measures targeting community, household and hospital transmission each with an efficacy of reducing transmission of per cent are implemented on day of the outbreak. we consider different scenarios for the proportion of cases that are detected in the population. initially, we assume that all cases are detected. in alternative scenarios, we investigate the situations where or per cent of cases are randomly detected in the community/hospital, but where follow-up of households with detected cases is good ( %) and, last, the situation where detection of cases among household members is of the same quality as detection of cases in the community and in hospitals. the transmission hazard b between case i and individual j that is introduced in equation ( . ) depends on the following characteristics: -setting, i.e. whether individuals i and j are (i) members of the same household, (ii) have visited the same hospital or (iii) other (i.e. community transmission)-the multiplicative term on the transmission hazard is b hous /n (n: size of the household), b hosp /n hosp (n hosp : number of staff members plus average hospital occupancy outside an epidemic) and b com /n com (n com : size of the city). we specify a gamma prior g( , ) for b hous , b hosp and b com ; -infectivity profile from symptom onset of case imodelled with a normalized discretized exponential distribution with a mean to be estimated. we specify a uniform prior u [ , ] for the mean value; -whether or not case i is a child-we estimate the infectivity of children relative to adults. we specify a lognormal prior distribution with log-mean and log-variance for the relative infectivity of children g i . this ensures that g i has the same prior as /g i ; -whether or not individual j is a child-we estimate the susceptibility of children relative to adults, g s , assuming a lognormal prior distribution with log-mean and log-variance ; and -efficacy of interventions implemented in the different settings (i.e. household, hospital and community). after implementation of the intervention (day ), the transmission rate in the household, hospital and community is multiplied by parameter g hous , g hosp and g com , respectively; where g hous , g hosp and g com have the same prior as the relative infectivity and susceptibility of children. figure summarizes the data that would need to be collected during the outbreak with the age and dates of symptom onset of cases (figure a), a follow-up of households with cases and tracking of hospitalizations and more generally of hospital occupancy (figure b) and a follow-up of epidemics in hospitals (figure c). inference also requires having information on the age distribution of the population. in the simulated outbreak, there were a total of cases with ( %) child cases. in the scenario, where all cases are identified, figure shows how estimates change in real-time. on day , only cases have been detected and credible intervals of parameters are therefore wide. the credible interval includes the true value for all parameters except the relative infectivity of children. on day , with cases detected, posterior means are always relatively close to the true simulation value although credible intervals remain wide for some parameters like the relative infectivity and susceptibility of children and the mean generation time. on day ( cases detected), we would rightly conclude that children are more infectious and susceptible than adults although here again the credible intervals remain relatively wide. properly characterizing the infectivity profile requires substantially more data ( cases detected by day ). only days after control measures are implemented, fairly accurate estimation of the efficacy of interventions in different settings becomes possible. when only per cent of cases in the community and in hospitals are detected, performance of the approach remains satisfying although as expected credible intervals are wider and it takes longer for accuracy to be acceptable (figure ). when per cent of cases in the community and in hospitals are detected, precision of estimates starts to break down (electronic supplementary material, figure s ). although estimates of transmission rates in the community and the hospital are not strongly affected by under-reporting in those settings, this is not true of estimates of transmission rates in small closed settings such as households (electronic supplementary material, figure s ). the method also allows disaggregated monitoring of the reproduction number and the number of cases infected in different settings (figure ). in this paper, we have presented strategies to tackle some of the challenges associated with the estimation of transmission characteristics of infectious diseases and the risk factors affecting transmission patterns. the dependency that is typically observed in outbreak data (i.e. the risk of infection for an individual depends on the infection status of other individuals) can potentially lead to long computational times. we showed that if risk factors are discretized, the inferential problem can be simplified to the analysis of (i) a dataset on cases only and (ii) a pre-compiled summary table on interactions between individuals of the population and cases. in the fmd application, discretization reduced the computational time from few weeks to few minutes with no change in the estimates of the transmission kernel. it is likely that with substantial effort and parallel programming, we could have reduced the computation time of brute force approach by one or two orders of magnitude. even so, it seems unlikely that computational times could have gone much below few days. this has to be compared with the few minutes needed to run our algorithms on the fmd dataset. for small datasets, discretization may provide no computational gain if it takes longer to explore the set c of transmission risk factors than to sum over the pairs fcase i, individual jg. discretization may be difficult to implement on particularly complex transmission models [ , ] in which case brute force calculation of the likelihood may be needed. we presented two strategies to perform parameter estimation and tree reconstruction in a coherent way. the first one is a sequential approach that we used to analyse data from an influenza school outbreak [ ] . here, we implemented an alternative strategy where transmission parameters and the transmission tree are estimated simultaneously. there are pros and cons for each of those strategies. a nice feature of simultaneous inference is that the information on the transmission for situations when the dates of infection are unknown, we presented models which assumed that infectivity depends on the time elapsed since symptom onset, and is independent of the time of infection. this assumption reduces the computational burden since it implies that the infection hazard an individual is exposed to solely depends on measured quantities plus the parameters of the model, rather than on the unobserved days of infection of other cases. in practice, assumption h seems acceptable for a relatively wide range of diseases since infectivity is often triggered or influenced by symptoms. however, where the assumption is invalid, more computationally intensive methods accounting for the unobserved times of infection become necessary [ ] . in the simulation study, we considered an epidemic for which it would be possible to detect and identify a substantial proportion of cases; this would therefore be more applicable to a sars-like scenario rather than pandemic influenza. the simulation study showed that even in situations where under-reporting is substantial (e.g. %), it would still be possible to obtain informative estimates of key characteristics. we found that estimates of the transmission rate in the community and in the hospital were relatively robust to under-reporting in those settings. this can be explained by the fact that in a large population, the exponential growth rate of the epidemic is not affected by under-reporting. but estimates of transmission rates in small social units such as households were-as might be expected-strongly affected by under-ascertainment of cases. estimates of relative infectivity were particularly sensitive to underreporting, with large variance and sometimes important bias. estimating relative infectivity is in general quite challenging because it requires that one can compare the offspring of one group of individuals (e.g. adults) with that of another group (e.g. children) and this becomes very difficult as under-reporting increases. it is likely that estimates would be less robust to underreporting, if reporting rates changed over time, as probably happens in real epidemics. here, we have presented relatively simple approaches to reduce computational burden in the estimation of transmission parameters and to integrate parameter estimation and tree reconstruction in a coherent way. however, the analysis of outbreak data is subject to many other challenges. for example, it may be difficult to infer which parametric distribution should be used for the infectivity profile and the incubation period; data augmentation strategies may fail in a context when data are not missing at random or when there are false-positives or false-negatives [ ] . a particular challenge in outbreak data is that they are rarely informative about the incubation period of the disease. in the simulations study, for example, we made the assumption that the distribution of the incubation period of the disease was known. if it was not the case, one would require extra data to estimate it. for example, in the past, data from outbreaks in an aeroplane [ ] or in a bus [ ] were used to estimate the incubation period of influenza. a key practical challenge to implement the methods presented here in real time is the rapid collection and digitization of sufficiently detailed epidemiological data. however, recent experience demonstrates that it is possible to collect very detailed epidemiological data even during large outbreaks [ , [ ] [ ] [ ] , ] . cleaning and processing those data so that they are ready for analysis close to real-time remain a huge challenge, but the recent examples of the fmd outbreak in the uk [ , ] , the sars epidemic [ , ] and the h n pandemic [ ] show that this is increasingly feasible. however, reporting delays should always be expected and it will be important to account for those delays in future developments of the statistical method presented here. last, a key limit on the more widespread use of the type of methods presented in this paper is the relatively high technical hurdle to implement them, given there is currently no user-friendly statistical software package that allows easy implementation of this type of analysis. developing such tools is therefore a priority. we thank the mrc methodology programme, the nigms midas initiative, the eu fp emperie consortium and research council uk for research funding. we explain here the link between the continuous time and discrete time transmission models. at any (continuous) time point u during day t (i.e. u [ [t;t þ )), the instantaneous hazard of infection exerted on individual j is l à j ðuÞ ¼ l j ðtÞ for t u , t þ ; where l j (t) is defined in the main text. so, we make the assumption that the instantaneous hazard of infection is a step function with daily steps. conditional on the fact that individual j has not been infected up to day t, the probability that individual j is infected on day t is equal to in the continuous time model, conditional on the (continuous) time of infection u j of case j with u j [ [t j ; t j þ ), the probability that case i is the case source is: p à i!j ðu j jqÞ ¼ l i!j ðu j jqÞ p k:t k ,t j l k!j ðu j jqÞ ¼ l i!j ðt j jqÞ p k:t k ,t j l k!j ðt j jqÞ : and we note that this probability is constant for u j [ [t j ; t j þ ). conditional on the day t j of infection, the probability that case i is the case source given in equation ( . ) is: u j ¼t j p à i!j ðu j jqÞpðu j jt j Þdu j and p i!j ðt j jqÞ ¼ l i!j ðt j jqÞ p k:t k ,t j l k!j ðt j jqÞ ð t j þ u j ¼t j pðu j jt j Þdu j ¼ l i!j ðt j jqÞ p k:t k ,t j l k!j ðt j jqÞ : let consider the common situation where -we are interested in relative risks (i.e. comparison with a reference group). for example, the population is partitioned in c k groups fn k ; . . . ; n k c k g on the basis of risk factor k so that the multiplicative term associated with risk factor k in equation ( for the conditional maximization of the likelihood with respect to u k m in the ecm algorithm (box ), the log-likelihood can be re-written: markov chain monte carlo in practice stochastic epidemic models and their statistical analysis statistical studies of infectious disease incidence a tutorial introduction to bayesian inference for stochastic epidemic models using markov chain monte carlo methods analyses of infectious disease data from household outbreaks by markov chain monte carlo methods bayesian inference for partially observed stochastic epidemics role of social networks in shaping disease transmission during a community outbreak of h n pandemic influenza a bayesian mcmc approach to study transmission of influenza: application to household longitudinal data investigating heterogeneity in pneumococcal transmission: a bayesian-mcmc approach applied to a follow-up of schools temporal variability and social heterogeneity in disease transmission: the case of sars in hong kong statistical inference and model selection for the hagelloch measles epidemic infectious diseases of humans: dynamics and control transmission intensity and impact of control policies on the foot and mouth epidemic in great britain dynamics of the uk foot and mouth epidemic: stochastic dispersal in a heterogeneous landscape transmission dynamics of the etiological agent of sars in hong kong: impact of public health interventions estimating in real time the efficacy of measures to control emerging communicable diseases different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures transmission parameters of the foot and mouth epidemic in great britain maximum likelihood from incomplete data via the em algorithm (with discussion) maximum-likelihoodestimation via the ecm algorithm-a general framework estimating the impact of school closure on influenza transmission from sentinel data epidemiological inference for partially observed epidemics: the example of the foot and mouth epidemic in great britain an outbreak of influenza aboard a commercial airliner the early transmission dynamics of h n pdm influenza in the united kingdom. version transmission dynamics and control of severe acute respiratory syndrome key: cord- - euaaspo authors: li, xiaochen; xu, shuyun; yu, muqing; wang, ke; tao, yu; zhou, ying; shi, jing; zhou, min; wu, bo; yang, zhenyu; zhang, cong; yue, junqing; zhang, zhiguo; renz, harald; liu, xiansheng; xie, jungang; xie, min; zhao, jianping title: risk factors for severity and mortality in adult covid- inpatients in wuhan date: - - journal: j allergy clin immunol doi: . /j.jaci. . . sha: doc_id: cord_uid: euaaspo abstract background in december , covid- outbreak occurred in wuhan. data on the clinical characteristics and outcomes of patients with severe covid- are limited. objective the severity on admission, complications, treatment, and outcomes of covid- patients were evaluated. methods patients with covid- admitted to tongji hospital from january , to february , were retrospectively enrolled and followed-up until march , . potential risk factors for severe covid- were analyzed by a multivariable binary logistic model. cox proportional hazard regression model was used for survival analysis in severe patients. results we identified ( . %) of patients as severe cases on admission. elder age, underlying hypertension, high cytokine levels (il- r, il- , il- , and tnf-a), and high ldh level were significantly associated with severe covid- on admission. the prevalence of asthma in covid- patients was . %, markedly lower than that in the adult population of wuhan. the estimated mortality was . % in nonsevere patients and . % in severe cases during the average days of follow-up period. survival analysis revealed that male, elder age, leukocytosis, high ldh level, cardiac injury, hyperglycemia, and high-dose corticosteroid use were associated with death in patients with severe covid- . conclusions patients with elder age, hypertension, and high ldh level need careful observation and early intervention to prevent the potential development of severe covid- . severe male patients with heart injury, hyperglycemia, and high-dose corticosteroid use may have high risk of death. the sars-cov- virus, as a betacoronavirus, shares % of two bat-derived sars-like coronaviruses and distances from sars-cov (around %) and middle east respiratory syndrome coronavirus (mers-cov, around %). sars and mers epidemics posed threats to global health due to high mortality rates of . % for sars-cov and . % for mers-cov globally. , epidemiological data released by the chinese center for disease control and prevention showed that , confirmed cases have been identified in wuhan and , in mainland china except wuhan as of march , . the mortality rate of covid- patients was . % in wuhan, which was close to that in the world ( . %) and much higher than that in mainland china except wuhan ( . %). this study aims to describe and compare the epidemiological, demographic, clinical, laboratory and radiological characteristics as well as the complications, treatment and outcomes of hospitalized patients with nonsevere and severe covid- . potential risk factors for severe covid- and factors associated with death in severe cases were analyzed to provide scientific data for relieve severe cases and reduce mortality. this study was an ambispective cohort study of consecutive hospitalized patients with covid- enrolled at sino-french new city branch of tongji hospital, huazhong university of science and technology in wuhan from january , to february , . the final date of follow-up was march , . sino-french new city branch of tongji hospital is one of the major nationally designated hospitals only providing medical care for adult covid- patients in wuhan. all cases with covid- enrolled in this study were diagnosed based on the who interim guidance and the diagnostic and treatment guideline for covid- issued by chinese national health committee (version ). detection of sars-cov- nucleic acids was shown in text in the online repository. this study was approved by institutional review board of tongji hospital, huazhong university of science and technology. written informed consent was waived in light of the urgent need to collect data. the epidemiological and demographic data were obtained by face-to-face or telephone interview. clinical symptoms, laboratory, and radiological findings on admission as well as the complications, treatment and outcomes during hospitalization were extracted from electronic medical records. serum cytokines (il- β, il- r, il- , il- , il- and tnf-α) were measured on admission. patient data were cross-checked for consistency before final data entry and then entered into a computerized database. the presence of underlying comorbidities was identified based on the international classification of diseases and injuries- diagnostic codes. the complications of covid- after admission were assessed and the definitions were shown in text in the online repository. cardiac injury was one of the complications, which was defined as a serum hypersensitive cardiac troponin i level higher than . pg/ml without acute coronary symptoms or abnormal electrocardiogram. the clinical outcomes were classified into discharge from hospital, in-hospitalization, and death. severe covid- was defined according to clinical practice guideline from infectious diseases society of america and american thoracic society for diagnosis and treatment of adults with community-acquired pneumonia. based on whether or not requiring ventilatory support on admission, severe cases upon admission were divided into two cohorts, severely ill and critically ill cases. the descriptive statistics are median and interquartile range (iqr) for continuous data. a total of patients with covid- were enrolled, of whom cases were included in the study. one case not meeting inclusion criteria was excluded due to inclusion criteria. almost half of the patients ( . %, of ) were identified as severe cases and . % ( of ) were nonsevere cases on admission. . % ( of ) of cases were positive for sars-cov- nucleic acid test pre-admission. comparison of findings between nonsevere and severe cases in the patients with positive viral nucleic acid test pre-admission showed essentially the similar differences to that in the total patients (see table e in the online repository). the epidemiological and demographic characteristics are shown in table . ( . %) of patients got the infection in hospital. ( . %) of patients were health-care workers and ( . %) patients were family members of health-care workers. nonsevere cases had a higher proportion of health-care workers and family members than severe cases (p< . ). the date of onset of the first reported case with covid- was december , . the median time from december , to the onset of covid- was days, ranging from days to days. the median age of study population was years (iqr - ), ranging from years to years, of whom ( . %) were aged years or older. the patients aged years or older in severe cases were almost twice as nonsevere cases of the same age ( . % vs. . %, p< . ). slightly more than half ( . %) of all patients were male and the proportion of males in severe cases is higher than in nonsevere cases ( . % vs. . %, p= . ). . % of patients with severe covid- were smokers (table ) asthma ( . %) were identified in total population. ( . %) of patients regularly took angiotensin-converting enzyme inhibitors or angiotensin ii receptor blockers; no significant difference was found between nonsevere and severe cases. sore throat ( . %), cough ( . %), chest pain ( . %), dyspnea ( . %), chest tightness ( . %), dizziness ( . %), confusion ( . %), headache ( . %), myalgia ( . %), vomiting ( . %), diarrhea ( . %), abdominal pain ( . %). patients were asymptomatic and diagnosed by ct screening. duration of fever pre-admission was significantly longer among severe cases compared with that in nonsevere cases (p= . ). severe cases experienced longer duration from onset to outpatient visit and longer duration from onset to hospitalization compared with nonsevere cases (p= . and p= . , respectively). ( . %) of patients were treated with corticosteroids delivered by oral or intravenous pre-admission. ( . %) of patients had received at least one of the following antiviral medications: umifenovir ( . %), oseltamivir ( . %), lopinavir/ritonavir ( . %), and ribavirin ( . %). ct scans for patients were evaluated pre-admission, and showed multilobar pulmonary infiltrates in patients ( table ). the median time from onset to pneumonia diagnosed by ct scan was days. on admission, oxygen saturation (spo ) less than . % on room air presented in . % of all patients, of whom ( %) were severe cases. . % of all patients experienced lymphopenia (< cells per mm ) and . % of all patients had thrombocytopenia (< , cells per mm ). compared with nonsevere cases, inflammation-related marker levels (hscrp, esr, and ferritin) were significantly higher in severe cases the levels of procalcitonin, globulin, lactate dehydrogenase (ldh), nt-prob-type natriuretic peptide (nt-probnp), d-dimer, alanine aminotransferase, aspartate aminotransferase, total bilirubin, conjugated bilirubin, blood urea nitrogen, and creatinine were elevated in . %, . %, . %, . %, . %, . %, . %, . %, . %, . %, and . % of all patients, respectively. serum cytokine levels of il- r, il- , il- , and tnf-α were significantly higher in severe patients than those in nonsevere patients (all of the severe cases, were classified as critically ill for requiring respiratory support. compared with severely ill cases, the time from december , to onset was shorter and the time from onset to outpatient visit was longer in critically ill cases (see table e in the online high procalcitonin, high nt-probnp, high ldh, high d-dimer, low albumin, and high creatinine) were observed in critically ill cases compared with severely ill cases (all p< . ). . % of critically ill patients received systemic corticosteroids pre-admission, the proportion of whom was significantly higher than that in severely ill cases ( . %, p< . ). compared with nonsevere cases, systemic corticosteroid use pre-admission was more common in severe cases with larger cumulative dose and longer duration (p= . ; p< . ; p< . ; respectively). stratification of patients by corticosteroid exposure is presented in table e in the online repository. severe patients treated with corticosteroids had higher ldh level compared with severe patients without corticosteroid use pre-admission (p< . ). nonsevere cases were more likely to receive antiviral drugs pre-admission, including umifenovir and oseltamivir (p< . and p= . ; respectively). in severe case subgroup, the patients receiving umifenovir were younger than those without umifenovir use (p< . ). a comparison of baseline demographic and clinical characteristics between patients with and without antiviral drug use revealed no marked difference in spo or laboratory findings in both nonsevere and severe case subgroups (see table e and e in the online repository). in the final logistic regression model, variables such as age or older (or . ; % ci . - . ), hypertension (or . ; % ci . - . ), ldh > u/l (or . ; % ci . - . ), and d-dimer > mg/l (or . ; % ci . - . ) were significantly associated with severe cases with covid- ( figure ) . in the follow-up period, the complications of covid- were assessed , including acute respiratory distress syndrome (ards) ( . %), cardiac injury ( . %), liver dysfunction ( . %), acute kidney injury ( . %), bacteremia ( . %), diffuse intravascular coagulation ( . %), and hyperglycemia ( . %) ( this study provided a comprehensive data on the epidemiological, demographic, clinical, laboratory, and radiological characteristics as well as the complications, treatment, and outcomes of hospitalized patients with nonsevere and severe covid- in wuhan. almost half of the patients in this study were identified as severe cases, which may differ from the results of the previous studies. the proportion of patients aged years or older were higher in our study than in nanshan zhong's study ( . % vs. . %, respectively). the time from december , to the onset of most patients was longer than days. during mid-january to early february, wuhan experienced the highest peak of covid- outbreak, with a family cluster and high prevalence of covid- in older adults. longer wait for access to medical care was observed in severe cases compared with that in nonsevere cases. more than half of the patients experienced at least two hospital visits, which may increase the risk of nosocomial transmission events. diagnosis and treatment may be delayed due to the long wait for access to medical care. severe covid- patients would likely develop ards and died of respiratory failure. although there are currently no effective antiviral drugs for sars-cov- , prompt identification and early respiratory support would relieve severe cases and reduce mortality. the severity of disease in patients with initial positive nucleic acid test was similar to that of all covid- patients. we thus propose that urgent timely diagnosis is crucial, and that early intervention should not be delayed based on nucleic acid test. proinflammatory cytokine levels (inf-γ, il- β, il- , il- , il- , and tnf-α) and were associated with the development of ards. - in our study, severe covid- patients had ( . %) in our study was markedly lower than that reported in the adult population of wuhan ( . %). - we thus speculate that th immune response in asthmatic patients may counter the inflammation process induced by sars-cov- infection. further studies are required to characterize the immune response and inflammation features of the majority of severe patients showed rapid progression and multiple organ dysfunction. the to onset in critically ill cases than that in severely ill cases may reflect a higher virulence of sars-cov- , or earlier onset of the risk factors for severity identified in this study included age, high ldh level, and high d-dimer level, consistent with those in previous reports. , however, different from the findings of previous studies , hypertension was the only comorbidity associated with the severity of covid- after adjustment for age, sex and smoking status. the distinct features of pneumonia and high severity in patients with covid- in this study may lead to this difference from previous reports. ace , a gateway to sars, was reported to be a protective factor against sars-cov-induced lung injury. , the association between ace expression and hypertension was confirmed in a previous study. this fact may partly explain the high prevalence of severe covid- in patients with hypertension. ldh has been recognized as a marker for severe prognosis in various diseases, including cancer and infection. the high ldh level in covid- in severe cases suggested that ldh may be associated with lung injury and tissue damage, warranting an investigation for the potential mechanism. this study evaluated pre-admission medications for patients with severe covid- . although the proportion of nonsevere cases in patients receiving oseltamivir was higher than that in patients without oseltamivir use, stratification analysis showed that there was no significant difference in case subgroup. therefore, oseltamivir use may just be an indicator of disease severity. the patients receiving umifenovir were younger than those without umifenovir use, indicating that younger patients may have easier access to drugs or prefer umifenovir. older age, leukocytosis and high ldh level were reported to be risk factors associated with in-hospital death in previous studies. , , the present study also revealed that hyperglycemia was related with increased mortality in covid- patients. the prevalence of hyperglycemia may be associated with underlying diabetes and corticosteroid therapy. however, the localization of ace expression in the pancreas in sars was reported to damage islets, resulting in hyperglycemia ; this finding suggested that hyperglycemia may also be an indicator of severe this study indicated that corticosteroid use was more common in severe cases than in nonsevere cases and that high-dose corticosteroid use was related to high risk of death in severe covid- patients. high-dose steroid use may be an indicator of disease severity rather than a predisposing factor. in a previous study, treatment with methylprednisolone was shown to be beneficial for covid- patients who developed ards. however, critically ill cases had more signs of infection and abnormal laboratory findings, including high leukocyte, high procalcitonin, high d-dimer, low albumin, and high creatinine levels. high-dose corticosteroid use should be used with cautious in critically ill patients to avoid aggravating complications. a recent study by bin cao et al showed that lopinavir/ritonavir treatment offered no significant benefit over the standard care for hospitalized adult covid- patients. cao's study also reported that lopinavir/ritonavir led to a shorter median time to clinical improvement than the standard care (hr . ; % ci . to . ) in a modified intention-to-treat analysis. compared with cao's study, the severity of patients was more serious and lopinavir/ritonavir treatment was associated with a lower risk of death in severe covid- patients in this study. however, our study was an observational study; thus, the benefit of lopinavir/ritonavir for severe covid- patients needs to be further confirmed. there were limitations to the current study. firstly, epidemiological data were collected respectively and recall bias might have occurred. secondly, missing data on some variables, such as detailed information of ct scan, may cause bias in the estimation and reduce the representativeness of the samples. thirdly, laboratory findings were measured upon admission and may indicate the severity of covid- . the causal relationship between abnormal laboratory findings and severity could not be determined. fourthly, this study was an observational study with limitations in terms of evaluating the efficacy of corticosteroids and antiviral drugs. finally, the absence of comparative data from covid- patients not admitted or from other critically ill patients were limitations of this study. in conclusion, covid- outbreak caused widespread concern and has threatened the global clinical characteristics of patients infected with sars-cov- in wuhan an increased prevalence of self-reported allergic rhinitis in major chinese cities from ace links amino acid malnutrition to microbial ecology and intestinal inflammation cholangiocytes may cause liver damage after -ncov infection binding of sars coronavirus to its receptor damages islets and causes acute diabetes risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease comorbidity and its impact on patients with covid- in china: a nationwide analysis where n is the total number of patients with available data. p values comparing nonsevere cases and severe cases are from χ² test, fisher's exact test, or mann-whitney u test cov- nucleic acid test was performed pre-admission table . complications and treatment during hospitalization and clinical outcomes of covid- data are expressed as median (iqr), n (%), or n/n (%), where n is the total number of patients with available data. p values comparing nonsevere cases and severe cases are from χ² test, fisher's exact test ards=acute respiratory distress syndrome key: cord- -fvhq yud authors: skalet, alison h.; allen, richard c.; shields, carol l.; wilson, matthew w.; mruthyunjaya, prithvi; gombos, dan s. title: considerations for the management and triage of ocular oncology cases during the covid- pandemic date: - - journal: ocul oncol pathol doi: . / sha: doc_id: cord_uid: fvhq yud nan dear editor, sars-cov- , the virus that causes covid- , is a novel pathogen. it is spreading rapidly in the usa, and our understanding of its behavior, transmissibility, and best practices to reduce risk for spread remain limited. rationing of resources is already occurring in response to the covid- pandemic. the purpose of this document is to lay a basic framework for ocular oncology care during the current pandemic. however, it is important to recognize the complexity of ocular oncology care and the need for flexibility within any guidelines. exceptions will occur. patients will need to be evaluated on a case-by-case basis. treatment of ocular and adnexal malignancies is not considered elective. to the extent possible, ocular oncology surgical cases for malignant tumors and some visionthreatening benign tumors should proceed during the current covid- pandemic. it is important to recognize that there is risk for transmission of sars-cov- during patient care, even by asymptomatic individuals. therefore, risk to patients, physicians and staff, and the community at large, must be balanced with the necessity for urgent care. in some cases, the balance may shift to delayed care being more appropriate for safety and conservation of limited resources. clinicians faced with making these decisions should consider the severity of a negative outcome (death, loss of an eye, loss of vision) together with the probability of such an outcome. in ocular oncology, particularly with regard to retinoblastoma screening, events may be quite rare but consequences of delayed care devastating. the balance during a pandemic should favor the value of maximizing benefits to the population [ ] . the availability of local resources and perceived risk for covid- exposure asso-mruthyunjaya/gombos ocul oncol pathol doi: . / ciated with care given a region's burden of disease may also factor into decision-making. these decisions will not be simple, and in some cases, consultation with medical ethics may help with medical decision-making. in addition to the need to reduce the risk for virus transmission and preserve personal protective equipment (ppe), for ocular oncologists there may be competing obligations between patient survival, globe salvage, and vision. at this time, there is no recommendation to alter treatment algorithms to favor enucleation over globe salvage; however, patient survival must be prioritized. informed consent to include covid- risk is recommended. as the pandemic worsens, it is likely that prioritization of only the most urgent and emergent procedures may be necessary. there is precedent for such prioritization of surgical oncology cases by the american college of surgeons [ ] . in these situations, malignant tumors are prioritized over benign tumors, and the highergrade malignancies expected to more immediately lead to death and/or permanent disability are prioritized over less aggressive malignancies. lower risk and benign case may be amenable to deferred care via telemedicine. multidisciplinary discussions for urgent and semiurgent cases may facilitate institutional case allocation by or committees. in some cases, ophthalmic pathology resources may also be limited. telepathology may be an option in these circumstances. in march , the authors communicated with numerous experts within the usa as well as internationally, in both pandemic hotspots and in regions less impacted, to assist in creating this document. separately, multiple formal surveys were initiated to gauge current covidassociated practice patterns that reflect variations in practice focus and location. preliminary results from one such study, assessing practice patterns among north american ocular oncologist members of the collaborative ocular oncology group, have recently been made available online [ ] . strong pre-existing research networks and subspecialty societies have aided ocular oncologists in the rapid conduct of research, an often overlooked but critically important component of the public health response. the results of these studies will assist in the development of any future guidelines for ocular oncology care during a similar public health emergency. four levels of urgency in ocular oncology have been established: emergent, urgent, semiurgent, and nonurgent. − emergent cases should be performed within h or as soon as possible to preserve life and/or sight − urgent cases should be performed within the week, considering the availability of resources − semiurgent cases should be performed within - months, considering the availability of resources. it is important to note that while retinoblastoma care does not fall into an urgent category due to optimal timing for serial interventions, the continuation of retinoblastoma care including examinations under anesthesia is a critical need and should be prioritized − nonurgent cases should be deferred for at least - months or until improved availability of local and national operating room resources some surgical cases are believed to carry a higher risk for transmission of sars-cov- [ , ] . in ocular oncology, these higher-risk procedures are primarily in the oculoplastics domain and are indicated with an asterisk below. special precautions, including presurgical covid- testing and use of full ppe, should be considered when performing these surgeries in which aerosolization of virus may be more likely to occur. for these procedures, if covid testing is positive or unavailable and the case cannot be deferred, full ppe including powered air-purifying respirator is strongly recommended. the following procedures are considered emergent: − orbital biopsy for malignancy in a child (suspected rhabdomyosarcoma) − enucleation for intractable glaucoma/globe perforation from intraocular tumor (retinoblastoma, uveal melanoma) the following procedures are considered urgent: − examination under anesthesia for newly suspected retinoblastoma − enucleation for retinoblastoma − orbital biopsy for processes causing optic neuropathy and vision loss − * orbital decompression for impending visual loss (optic neuropathy or corneal perforation) secondary to orbital tumor the following procedures are considered semiurgent: real chemotherapy, plaque radiotherapy, cryotherapy, transpupillary thermotherapy, laser photocoagulation) must continue on necessary schedule to control disease, typically every - weeks − examination under anesthesia for retinoblastoma evaluation for patients with stable disease, who have received treatment within the past months − examination under anesthesia for children at high risk for retinoblastoma due to family history or known rb mutation − intraocular injection of chemotherapy agents for highgrade neoplasia − biopsy of suspected intraocular malignancy (fine-needle aspiration biopsy or other) − excision/drainage of iris cyst with pain or glaucoma orbital tumor − biopsy of suspected orbital malignancy (case by caserapidly growing tumor may need urgent biopsy; slowly growing suspected lymphoma is semiurgent) − biopsy of suspected orbital lymphoma (extended delay may be appropriate under certain circumstances) − * exenteration (case by case: rapidly growing tumor may need urgent biopsy; a slowly growing one could be semiurgent) the following procedures are considered nonurgent: fair allocation of scarce medical resources in the time of covid- american college of surgeons. covid- guidelines for triage of cancer surgery patients covid- pandemic: ocular tumor triage and careeyenet precautions for endoscopic transnasal skull base surgery during the covid- pandemic academy supports cms, offers specific nasal policy the authors wish to thank their colleagues from throughout the usa and around the world for their personal communications and contributions. they thank dr. robert macauley for discussions pertinent to the medical ethics considerations. the authors have no proprietary or commercial interest in the materials discussed in this article. dr. alison skalet is a consultant for castle biosciences inc. and immuncore inc. this work was supported by grant p ey from the national institutes of health (bethesda, md, usa) and by unrestricted departmental funding from research to prevent blindness (new york, ny, usa). a.h.s. and d.s.g. conceived the presented idea. a.h.s. and r.c.a. wrote the manuscript with input from all authors. a.h.s., r.c.a., c.l.s., m.w.w., p.m., and d.s.g. contributed substantively to the final paper. key: cord- -t edr gp authors: gershengorn, hayley b.; warde, prem r.; nguyen, dao m.; suarez, maritza m.; merchant, nipun b.; ferreira, tanira; shukla, bhavarth title: pre-procedural screening for covid- with nasopharyngeal polymerase chain reaction testing date: - - journal: br j anaesth doi: . /j.bja. . . sha: doc_id: cord_uid: t edr gp nan example, symptoms concerning for . the low test positivity rate precluded multivariable modeling. among cases with > test, we evaluated the predictive accuracy of the first test for the second test. irb approval was obtained from the university of miami (# ). our cohort consisted of , cases ( , patients in sum, we found that very few ( in ) cases had a positive covid- pcr within days preprocedure; this rate was substantially lower ( in ) if testing was specifically for "pre-procedural" indications. pre-procedural testing is intended to protect patients from morbidity and clinicians and staff from exposure. however, when prevalence is low, testing costs (i.e., financial, resources) coupled with procedural delays from false positive results cannot be ignored. the exact point prevalence of covid- active infection in miami during the study period is not known; yet, antibody testing of residual sera collected by a commercial laboratory from april - , estimated covid- prevalence of past j o u r n a l p r e -p r o o f infection in south florida to be . % ( % confidence interval: . %- . %). with % community prevalence, a positive result from a test with % sensitivity and % specificity will be found in likely uninfected people ~ in every times (supplemental figure ). our data are limited by their single-centre nature. we were unable to reliably assess the indication for covid- testing in all cases; however, ineffectively excluding symptomatic patients likely biases us towards overestimating screening positivity rates. our analysis shows that there is little role for obtaining more than test pre-procedurally. and, as we learn more about the incubation period, risk of asymptomatic transmission, and exposure potential of covid- , it will be important to reconsider policies advocating for testing every patient pre-procedurally, even once. all authors were responsible for the conception and design of the study, revising the article critically for important intellectual content, and final approval of the submitted manuscript. hbg, prw, and mms were responsible for data acquisition. hbg was responsible for data analysis and primary manuscript drafting. funding to support this project was provided by the university of miami through support for the uhealth-dart research group. no conflicts of interest exist for any author. j o u r n a l p r e -p r o o f vascular surgery ( . %) ( . %) ( . %) ( . %) iqr, interquartile range; pcr, polymerase chain reaction a p< . for comparison between "no positive test" and "≥ positive test" in full cohort; none of the comparisons in the subcohort of cases including only tests marked to be "pre-procedural" had p< . b comorbidities were determined from international classification of diseases, th revision codes from all patient encounters within our health system since based on the strategy outlined by elixhauser and colleagues. , the median number of patient encounters across cases for the full cohort was (iqr - ) with cases ( . % of cohort) with no prior patient encounters; for the subcohort of cases including only tests marked to be "pre-procedural", the median number of patient encounters across cases was (iqr - ) with cases ( . % of subcohort) with no prior patient encounters c includes diabetes mellitus with and without chronic complications d includes chronic pulmonary disease and pulmonary circulation disorders e cases on patients without prior encounters within our health system (n= , . % of full cohort; n= , . % of subcohort of cases including only tests marked to be "pre-procedural") were assumed to have comorbidities f "ambulatory" describes outpatients who come in for their procedure and are discharged following it (never admitted as inpatients); "direct-admit for case" describes outpatients who come in for their procedure and are admitted as inpatients post-procedurally g all other service lines: anaesthesiology (full cohort n/subcohort n) n= / ; cardiology, n= / ; cardiothoracic, n= / ; colorectal, n= / ; dermatology, n= / ; endocrine, n= / ; gynaecology, n= / ; gynaecology oncology, n= / ; gynaecology urology, n= / ; head and neck, n= / ; hepatology, n= / ; obstetrics, n= / ; oculoplastic, n= / ; ophthalmology, n= / ; oral surgery, n= / ; pain, n= / ; plastics, n= / ; podiatry, n= / ; pulmonary, n= / ; radiation oncology, n= / ; sports medicine, n= / ; thoracic, n= / ; and urology, n= / had no cases with ≥ positive tests; these service lines were included in chi-square testing clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid- infection surgical outcomes after systematic preoperative sars-cov- screening the impact of preoperative screening system on head and neck cancer surgery during the covid- pandemic: recommendations from the nationwide survey in japan early institutional head and neck oncologic and microvascular surgery practice patterns across the united states during the sars-cov- (covid ) pandemic seroprevalence of antibodies to sars-cov- in sites in the united states comorbidity measures for use with administrative data healthcare cost and utilization project (hcup) key: cord- -qfjet sa authors: paparini, sara; green, judith; papoutsi, chrysanthi; murdoch, jamie; petticrew, mark; greenhalgh, trish; hanckel, benjamin; shaw, sara title: case study research for better evaluations of complex interventions: rationale and challenges date: - - journal: bmc med doi: . /s - - - sha: doc_id: cord_uid: qfjet sa background: the need for better methods for evaluation in health research has been widely recognised. the ‘complexity turn’ has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. we argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear. main body: case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. this is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. the health sciences have much to learn from scholarship on case study methodology in the social sciences. however, there are multiple challenges in fully exploiting the potential learning from case study research. first are misconceptions that case study research can only provide exploratory or descriptive evidence. second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports. conclusion: whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences. the need for methodological development to address the most urgent challenges in health research has been welldocumented. many of the most pressing questions for public health research, where the focus is on system-level determinants [ , ] , and for health services research, where provisions typically vary across sites and are provided through interlocking networks of services [ ] , require methodological approaches that can attend to complexity. the need for methodological advance has arisen, in part, as a result of the diminishing returns from randomised controlled trials (rcts) where they have been used to answer questions about the effects of interventions in complex systems [ ] [ ] [ ] . in conditions of complexity, there is limited value in maintaining the current orientation to experimental trial designs in the health sciences as providing 'gold standard' evidence of effect. there are increasing calls for methodological pluralism [ , ] , with the recognition that complex intervention and context are not easily or usefully separated (as is often the situation when using trial design), and that system interruptions may have effects that are not reducible to linear causal pathways between intervention and outcome. these calls are reflected in a shifting and contested discourse of trial design, seen with the emergence of realist [ ] , adaptive and hybrid (types , and ) [ , ] trials that blend studies of effectiveness with a close consideration of the contexts of implementation. similarly, process evaluation has now become a core component of complex healthcare intervention trials, reflected in mrc guidance on how to explore implementation, causal mechanisms and context [ ] . evidence about the context of an intervention is crucial for questions of external validity. as woolcock [ ] notes, even if rct designs are accepted as robust for maximising internal validity, questions of transferability (how well the intervention works in different contexts) and generalisability (how well the intervention can be scaled up) remain unanswered [ , ] . for research evidence to have impact on policy and systems organisation, and thus to improve population and patient health, there is an urgent need for better methods for strengthening external validity, including a better understanding of the relationship between intervention and context [ ] . policymakers, healthcare commissioners and other research users require credible evidence of relevance to their settings and populations [ ] , to perform what rosengarten and savransky [ ] call 'careful abstraction' to the locales that matter for them. they also require robust evidence for understanding complex causal pathways. case study research, currently under-utilised in public health and health services evaluation, can offer considerable potential for strengthening faith in both external and internal validity. for example, in an empirical case study of how the policy of free bus travel had specific health effects in london, uk, a quasi-experimental evaluation (led by jg) identified how important aspects of context (a good public transport system) and intervention (that it was universal) were necessary conditions for the observed effects, thus providing useful, actionable evidence for decisionmakers in other contexts [ ] . the overall approach of case study research is based on the in-depth exploration of complex phenomena in their natural, or 'real-life', settings. empirical case studies typically enable dynamic understanding of complex challenges rather than restricting the focus on narrow problem delineations and simple fixes. case study research is a diverse and somewhat contested field, with multiple definitions and perspectives grounded in different ways of viewing the world, and involving different combinations of methods. in this paper, we raise awareness of such plurality and highlight the contribution that case study research can make to the evaluation of complex system-level interventions. we review some of the challenges in exploiting the current evidence base from empirical case studies and conclude by recommending that further guidance and minimum reporting criteria for evaluation using case studies, appropriate for audiences in the health sciences, can enhance the take-up of evidence from case study research. case study research offers evidence about context, causal inference in complex systems and implementation well-conducted and described empirical case studies provide evidence on context, complexity and mechanisms for understanding how, where and why interventions have their observed effects. recognition of the importance of context for understanding the relationships between interventions and outcomes is hardly new. in , canguilhem berated an over-reliance on experimental designs for determining universal physiological laws: 'as if one could determine a phenomenon's essence apart from its conditions! as if conditions were a mask or frame which changed neither the face nor the picture!' ( [ ] p ). more recently, a concern with context has been expressed in health systems and public health research as part of what has been called the 'complexity turn' [ ] : a recognition that many of the most enduring challenges for developing an evidence base require a consideration of system-level effects [ ] and the conceptualisation of interventions as interruptions in systems [ ] . the case study approach is widely recognised as offering an invaluable resource for understanding the dynamic and evolving influence of context on complex, system-level interventions [ ] [ ] [ ] [ ] . empirically, case studies can directly inform assessments of where, when, how and for whom interventions might be successfully implemented, by helping to specify the necessary and sufficient conditions under which interventions might have effects and to consolidate learning on how interdependencies, emergence and unpredictability can be managed to achieve and sustain desired effects. case study research has the potential to address four objectives for improving research and reporting of context recently set out by guidance on taking account of context in population health research [ ] , that is to ( ) improve the appropriateness of intervention development for specific contexts, ( ) improve understanding of 'how' interventions work, ( ) better understand how and why impacts vary across contexts and ( ) ensure reports of intervention studies are most useful for decision-makers and researchers. however, evaluations of complex healthcare interventions have arguably not exploited the full potential of case study research and can learn much from other disciplines. for evaluative research, exploratory case studies have had a traditional role of providing data on 'process', or initial 'hypothesis-generating' scoping, but might also have an increasing salience for explanatory aims. across the social and political sciences, different kinds of case studies are undertaken to meet diverse aims (description, exploration or explanation) and across different scales (from small n qualitative studies that aim to elucidate processes, or provide thick description, to more systematic techniques designed for medium-to-large n cases). case studies with explanatory aims vary in terms of their positioning within mixed-methods projects, with designs including (but not restricted to) ( ) single n of studies of interventions in specific contexts, where the overall design is a case study that may incorporate one or more (randomised or not) comparisons over time and between variables within the case; ( ) a series of cases conducted or synthesised to provide explanation from variations between cases; and ( ) case studies of particular settings within rct or quasi-experimental designs to explore variation in effects or implementation. detailed qualitative research (typically done as 'case studies' within process evaluations) provides evidence for the plausibility of mechanisms [ ] , offering theoretical generalisations for how interventions may function under different conditions. although rct designs reduce many threats to internal validity, the mechanisms of effect remain opaque, particularly when the causal pathways between 'intervention' and 'effect' are long and potentially non-linear: case study research has a more fundamental role here, in providing detailed observational evidence for causal claims [ ] as well as producing a rich, nuanced picture of tensions and multiple perspectives [ ] . longitudinal or cross-case analysis may be best suited for evidence generation in system-level evaluative research. turner [ ] , for instance, reflecting on the complex processes in major system change, has argued for the need for methods that integrate learning across cases, to develop theoretical knowledge that would enable inferences beyond the single case, and to develop generalisable theory about organisational and structural change in health systems. qualitative comparative analysis (qca) [ ] is one such formal method for deriving causal claims, using set theory mathematics to integrate data from empirical case studies to answer questions about the configurations of causal pathways linking conditions to outcomes [ , ] . nonetheless, the single n case study, too, provides opportunities for theoretical development [ ] , and theoretical generalisation or analytical refinement [ ] . how 'the case' and 'context' are conceptualised is crucial here. findings from the single case may seem to be confined to its intrinsic particularities in a specific and distinct context [ ] . however, if such context is viewed as exemplifying wider social and political forces, the single case can be 'telling', rather than 'typical', and offer insight into a wider issue [ ] . internal comparisons within the case can offer rich possibilities for logical inferences about causation [ ] . further, case studies of any size can be used for theory testing through refutation [ ] . the potential lies, then, in utilising the strengths and plurality of case study to support theorydriven research within different methodological paradigms. evaluation research in health has much to learn from a range of social sciences where case study methodology has been used to develop various kinds of causal inference. for instance, gerring [ ] expands on the within-case variations utilised to make causal claims. for gerring [ ] , case studies come into their own with regard to invariant or strong causal claims (such as x is a necessary and/or sufficient condition for y) rather than for probabilistic causal claims. for the latter (where experimental methods might have an advantage in estimating effect sizes), case studies offer evidence on mechanisms: from observations of x affecting y, from process tracing or from pattern matching. case studies also support the study of emergent causation, that is, the multiple interacting properties that account for particular and unexpected outcomes in complex systems, such as in healthcare [ ] . finally, efficacy (or beliefs about efficacy) is not the only contributor to intervention uptake, with a range of organisational and policy contingencies affecting whether an intervention is likely to be rolled out in practice. case study research is, therefore, invaluable for learning about contextual contingencies and identifying the conditions necessary for interventions to become normalised (i.e. implemented routinely) in practice [ ] . at present, there are significant challenges in exploiting the benefits of case study research in evaluative health research, which relate to status, definition and reporting. case study research has been marginalised at the bottom of an evidence hierarchy, seen to offer little by way of explanatory power, if nonetheless useful for adding descriptive data on process or providing useful illustrations for policymakers [ ] . this is an opportune moment to revisit this low status. as health researchers are increasingly charged with evaluating 'natural experiments'-the use of face masks in the response to the covid- pandemic being a recent example [ ] -rather than interventions that take place in settings that can be controlled, research approaches using methods to strengthen causal inference that does not require randomisation become more relevant. a second challenge for improving the use of case study evidence in evaluative health research is that, as we have seen, what is meant by 'case study' varies widely, not only across but also within disciplines. there is indeed little consensus amongst methodologists as to how to define 'a case study'. definitions focus, variously, on small sample size or lack of control over the intervention (e.g. [ ] p ), on in-depth study and context [ , ] , on the logic of inference used [ ] or on distinct research strategies which incorporate a number of methods to address questions of 'how' and 'why' [ ] . moreover, definitions developed for specific disciplines do not capture the range of ways in which case study research is carried out across disciplines. multiple definitions of case study reflect the richness and diversity of the approach. however, evidence suggests that a lack of consensus across methodologists results in some of the limitations of published reports of empirical case studies [ , ] . hyett and colleagues [ ] , for instance, reviewing reports in qualitative journals, found little match between methodological definitions of case study research and how authors used the term. this raises the third challenge we identify that case study reports are typically not written in ways that are accessible or useful for the evaluation research community and policymakers. case studies may not appear in journals widely read by those in the health sciences, either because space constraints preclude the reporting of rich, thick descriptions, or because of the reported lack of willingness of some biomedical journals to publish research that uses qualitative methods [ ] , signalling the persistence of the aforementioned evidence hierarchy. where they do, however, the term 'case study' is used to indicate, interchangeably, a qualitative study, an n of sample, or a multi-method, in-depth analysis of one example from a population of phenomena. definitions of what constitutes the 'case' are frequently lacking and appear to be used as a synonym for the settings in which the research is conducted. despite offering insights for evaluation, the primary aims may not have been evaluative, so the implications may not be explicitly drawn out. indeed, some case study reports might properly be aiming for thick description without necessarily seeking to inform about context or causality. we recognise that definitional and methodological plurality is not only inevitable, but also a necessary and creative reflection of the very different epistemological and disciplinary origins of health researchers, and the aims they have in doing and reporting case study research. indeed, to provide some clarity, thomas [ ] has suggested a typology of subject/purpose/approach/process for classifying aims (e.g. evaluative or exploratory), sample rationale and selection and methods for data generation of case studies. we also recognise that the diversity of methods used in case study research, and the necessary focus on narrative reporting, does not lend itself to straightforward development of formal quality or reporting criteria. existing checklists for reporting case study research from the social sciences-for example lincoln and guba's [ ] and stake's [ ] -are primarily orientated to the quality of narrative produced, and the extent to which they encapsulate thick description, rather than the more pragmatic issues of implications for intervention effects. those designed for clinical settings, such as the care (case reports) guidelines, provide specific reporting guidelines for medical case reports about single, or small groups of patients [ ] , not for case study research. the design of case study research in health care (descarte) model [ ] suggests a series of questions to be asked of a case study researcher (including clarity about the philosophy underpinning their research), study design (with a focus on case definition) and analysis (to improve process). the model resembles toolkits for enhancing the quality and robustness of qualitative and mixed-methods research reporting, and it is usefully open-ended and non-prescriptive. however, even if it does include some reflections on context, the model does not fully address aspects of context, logic and causal inference that are perhaps most relevant for evaluative research in health. hence, for evaluative research where the aim is to report empirical findings in ways that are intended to be pragmatically useful for health policy and practice, this may be an opportune time to consider how to best navigate plurality around what is (minimally) important to report when publishing empirical case studies, especially with regards to the complex relationships between context and interventions, information that case study research is well placed to provide. the conventional scientific quest for certainty, predictability and linear causality (maximised in rct designs) has to be augmented by the study of uncertainty, unpredictability and emergent causality [ ] in complex systems. this will require methodological pluralism, and openness to broadening the evidence base to better understand both causality in and the transferability of system change intervention [ , , , ] . case study research evidence is essential, yet is currently under exploited in the health sciences. if evaluative health research is to move beyond the current impasse on methods for understanding interventions as interruptions in complex systems, we need to consider in more detail how researchers can conduct and report empirical case studies which do aim to elucidate the contextual factors which interact with interventions to produce particular effects. to this end, supported by the uk's medical research council, we are embracing the challenge to develop guidance for case study researchers studying complex interventions. following a meta-narrative review of the literature, we are planning a delphi study to inform guidance that will, at minimum, cover the value of case study research for evaluating the interrelationship between context and complex system-level interventions; for situating and defining 'the case', and generalising from case studies; as well as provide specific guidance on conducting, analysing and reporting case study research. our hope is that such guidance can support researchers evaluating interventions in complex systems to better exploit the diversity and richness of case study research. abbreviations qca: qualitative comparative analysis; qed: quasi-experimental design; rct: randomised controlled trial complex systems thinking and current impasses in health disparities research evaluating health effects of transport interventions: methodologic case study the evaluation of complex interventions in palliative care: an exploration of the potential of case study research strategies using case studies to explore the external validity of 'complex' development interventions are rcts the gold standard? understanding and misunderstanding randomized controlled trials towards a critical complex systems approach to public health studying complexity in health services research: desperately seeking an overdue paradigm shift realist trials and the testing of contextmechanism-outcome configurations: a response to van belle et al adaptive designs in clinical trials: why use them, and how to run and report them effectivenessimplementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact process evaluation of complex interventions: medical research council guidance when and how do 'effective' interventions need to be adapted and/or reevaluated in new contexts? the need for guidance a critical examination of representations of context within research on population health interventions making trials matter: pragmatic and explanatory trials and the problem of applicability a careful biomedicine? generalization and abstraction in rcts integrating quasi-experimental and inductive designs in evaluation: a case study of the impact of free bus travel on public health the normal and the pathological theorising interventions as events in systems designing social inquiry: scientific inference in qualitative research diffusion of innovations in service organizations: systematic review and recommendations enhancing the quality of case studies in health services research challenges, solutions and future directions in the evaluation of service innovations in health care and public health taking account of context in population health intervention research: guidance for producers, users and funders of research complex systems, explanation and policy: implications of the crisis of replication for public health research strategies of causal inference in small-n analysis ruth boaden, et al. challenges, solutions and future directions in the evaluation of service innovations in health care and public health using qualitative comparative analysis to study causal complexity protocol for a systematic review of the use of qualitative comparative analysis for evaluative questions in public health research set-theoretic methods for the social sciences: a guide to qualitative comparative analysis five misunderstandings about case-study research craving for generality and small-n studies: a wittgensteinian approach towards the epistemology of the particular in organization and management studies the art of case study research ethnographic research: a guide to general conduct what is a case study and what is it good for? health technology assessment in its local contexts: studies of telehealthcare trading quality for relevance: non-health decision-makers' use of evidence on the social determinants of health we can't be % sure face masks work -but that shouldn't stop us wearing them | trish greenhalgh. the guardian what are case studies? in: what's wrong with ethnography the case study approach case study: a bridge across the paradigms case study research and applications: design and methods: sage methodology or method? a critical review of qualitative case study reports developing the descarte model: the design of case study research in health care an open letter to the bmj editors on qualitative research a typology for the case study in social science following a review of definition, discourse, and structure judging the quality of case study reports care guidelines for case reports: explanation and elaboration document publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable authors' contributions jg, mp, sp, jm, tg, cp and ss drafted the initial paper; all authors contributed to the drafting of the final version, and read and approved the final manuscript. this work was funded by the medical research council -mrc award mr/ s / hcs: case study, context and complex interventions (triple c). sp was additionally funded by the university of oxford's higher education innovation fund (heif). not applicable (article based on existing available academic publications)ethics approval and consent to participate not applicable the authors declare that they have no competing interests. key: cord- -dgysimh authors: al-jabir, ahmed; kerwan, ahmed; nicola, maria; alsafi, zaid; khan, mehdi; sohrabi, catrin; o'neill, niamh; iosifidis, christos; griffin, michelle; mathew, ginimol; agha, riaz title: impact of the coronavirus (covid- ) pandemic on surgical practice - part (surgical prioritisation) date: - - journal: int j surg doi: . /j.ijsu. . . sha: doc_id: cord_uid: dgysimh the coronavirus (covid- ) pandemic represents a once in a century challenge to human healthcare with . million cases and , deaths thus far. surgical practice has been significantly impacted with all specialties writing guidelines for how to manage during this crisis. all specialties have had to triage the urgency of their daily surgical procedures and consider non-surgical management options where possible. the pandemic has had ramifications for ways of working, surgical techniques, open vs minimally invasive, theatre workflow, patient and staff safety, training and education. with guidelines specific to each specialty being implemented and followed, surgeons should be able to continue to provide safe and effective care to their patients during the covid- pandemic. in this comprehensive and up to date review we assess changes to working practices through the lens of each surgical specialty. the rapid spread of covid- around the world ( . million cases and over , deaths brings new challenges for the international medical and surgical community [ ] ; the unprecedented strain it has put on units around the world has unfortunately been accompanied by an increasing number of covid- infections and subsequent deaths amongst medical colleagues [ ] . it is therefore important to follow the latest guidelines for surgical management of patients in order to reduce the risk of infection for patients and medical personnel. in part , the authors have reviewed the current evidence and offered general recommendations for changes to surgical practice to minimise the effect of the covid- pandemic on surgical units. prioritisation of surgical services during this pandemic must be a careful balance of patient needs and resource availability and the european association of urology guidelines office offer the following suggestions for factors that must be taken into account [ ] oncological surgery with the disruption of normal surgical practices due to workforce shortages as well as resource limitations due to covid- , it is important to rationalise all surgeries undertaken. this is especially important in cancer surgery where the surgeon must balance risk of potential viral transmission to the surgical team as well as of possible progression of cancer in the patient [ ] . in the first instance, patients should be transferred to hospitals with greater capacity to cover procedures, with the suggestion of setting up local 'covid- free' surgical hubs for the continuation of oncological surgery. in cancer patients, general considerations must also be taken into account. it is routine that most complex elective surgical procedures receive ward-based care post-operatively. occasionally, patients may develop postoperative complications requiring itu admission and/or re-operation, which may prove to be a challenge with the increasing numbers of covid- patients requiring level care. it is recommended that length of stay (los) be decreased to a minimum, especially in critical care [ , ] furthermore, the nhs has identified the cancer patients which are most at risk during the outbreak and who are likely to become seriously or critically unwell if they were to contract the virus. these include: patients on active chemo-or radiotherapy; immunotherapy or any antibody treatments; or immune system modulation therapy (eg. protein kinase inhibitors or post-transplantation immunosuppressants). this group also includes patients with blood or bone marrow cancers ie. leukemia, lymphoma or myeloma. further to the above, factors such as age above , pre-existing cardiovascular and/or respiratory disease have been associated with a worse prognosis. following a multidisciplinary team (mdt) discussion, clinicians are encouraged to clearly outline the risks and benefits with patients before commencing or continuing any cancer treatment [ ] . surgical teams are encouraged to offer telephone or video consultations when possible, cancel follow ups which are deemed non-essential in an attempt to minimise patient contact. in cases where patients must attend hospital appointments, time patients spend in services should be minimised. they should have a scheduled appointment time and should be advised not to arrive early [ ] . surgeons are encouraged to maximise breast conserving surgery when possible, as definitive mastectomy and/or reconstruction should be deferred when possible if radiotherapy options are available. surgeons should also consider alternative, non-surgical therapy where possible. suggestions for prioritisation are in table additionally, lu et al [ ] recommended prioritising breast disease care according to benign or malignant disease. for benign disease, they use the bi-rads grading score and advise that patients with score < are suitable for a -month deferral. patients grading ≥ should have a biopsy, reviewed in - weeks then re-assessed. for malignant disease, with a bi-rads grade ≥ and highly suspicious for malignancy, a core needle biopsy or fine needle aspirate should be arranged urgently. in hospitals in phase or , neoadjuvant therapy is given priority over surgical intervention and is to be administered in a day chemotherapy unit to avoid unnecessary admissions. they also recommend postponing follow-up adjuvant chemotherapy in patients who have recently had surgery for early stage breast cancer. for more at risk patients (such as the elderly or immunosuppressed) with a low tumour burden, a reduced dose (≥ % of the standard dose) is recommended. finally, where possible, adjuvant radiotherapy should be delayed by - months to avoid nosocomial transmission [ ] . for patients with stable remission, they recommend that reviews should be conducted every months instead of -monthly. in locally advanced resectable colon cancer, surgeons are urged to consider neoadjuvant chemotherapy and revisit the idea of surgery in - months. there should also be consideration of further chemotherapy in patients with rectal cancer which have shown a clear response to neoadjuvant chemotherapy. this may also be considered in locally advanced or recurrent rectal cancer requiring pelvic exenteration, in an attempt to delay the operation for a few months. diverting stomas should be utilised or give preference for stoma formation over anastomosis to reduce the risk of postoperative complications (e.g. anastomotic leak) [ ] . suggestions for prioritisation are given in table . guanyu et al [ ] note that sars-cov- has been identified in many faecal specimens and advise extra precautions during colorectal surgery where laparoscopically generated aerosols may mix with blood or intestinal contents during anastomoses. additionally, they note that whilst fever is a main sign of covid- , it is also a primary manifestation of anastomotic leak and advise surgeons to carefully consider this possibility depending on patient risk factors. in thoracic cancer, care must be taken to differentiate between the symptoms of covid- (which are predominately respiratory in nature) or severe acute respiratory distress syndrome and progression in lung cancer. furthermore, patient groups must be very carefully selected for surgery as any reduction in lung reserves may severely affect the risk of complications and morbidity and mortality should they later be infected with covid- . suggestions for prioritisation are given in table . trauma and orthopaedics is a key speciality where operations will be required to continue despite a patient's covid- status. for this reason, extensive planning is required to ensure that optimal injury care is provided regardless of a patient's infection status. trauma coordinators are required to plan for a potential surge in intensive care capabilities, where patients with suspected or confirmed covid- should be grouped in a separate area from patients without the virus, while ensuring optimal care is not compromised. policies should be decided in each centre regarding the restriction of elective appointments and procedures [ ] . some suggestions for case prioritisation are seen in table . examples of these patients include hip fractures and infected prostheses. these patients will require hospital admission and urgent surgical management that cannot be postponed. efficient treatment is essential to avoid prolonged hospital stay both before and after surgery. a lead attending physician must be allocated to coordinate the flow of patients from the emergency department through to operating room (or) scheduling. it is advised that daily trauma conferences should be held to update on problems faced and logistics of dealing with said issues. elective theatre capacity and rehabilitation services should be utilised to minimise preoperative delay and postoperative stay in hospital. elderly patients will be seen frequently in trauma and orthopaedics; therefore measures must be taken to shield these patients from covid- during their stay in hospital. anaesthetic guidelines must be developed for patients requiring surgery who may be covid- positive. examples of these patients include ligamentous injuries of the knee. non-operative management must be explored first to avoid hospital admission. a clinical decision must then be made when faced with a serious injury taking into account the availability of available clinicians and resources, as well as the potential impact on society. as resources become more strained, nonoperative care will be emphasised, where possible, to reduce the number of inpatients in hospital and resulting burden on the hospital system. this will also mean more beds are available for obligatory inpatients. many trauma patients may be clinically suitable for day-case surgery such as simple periarticular fractures. by utilising day-case trauma surgery, unnecessary admissions can be avoided thus reducing the likelihood of patients being exposed to a hospital environment while freeing up beds for obligatory inpatient cases. due to covid- , the only day-case procedures likely to take place are urgent cases therefore careful consideration and prioritisation of these patients is essential to ensure the necessary staff and theatre space is available. first contact and fracture clinics these patients will be outpatients therefore any hospital or clinic attendance must be kept to an absolute safe minimum. emergency departments are likely to be under immense pressure therefore trauma and orthopaedic surgeons may take pressure off the emergency services by utilising a fracture clinic. whilst the emergency departments may continue to care for patients who require resuscitation or a full trauma team, fracture clinics may be asked to take patients directly from ed triage with fractures, wounds and minor injuries prior to examination or diagnosis. surgery must not be scheduled by a junior clinician without approval from an experienced attending. managers can play to become fully integrated in regional and hospital planning. as mentioned previously, intensive care triage and resource allocation are essential when a surge in patients requiring urgent treatment is seen. regarding management of critically injured patients, it is advised that the standards of care for these patients is adapted in that the criteria for early triage to palliative care services is implemented for patients with low chances of survival [ ] . furthermore, senior staff such as trauma attendings should triage patients using a uniform triage policy rather than clinical judgement alone for trauma and icu patients. if resources in a care centre become sufficiently limited, exclusion from treatment may be decided based on the probability of the patient surviving to ensure resource allocation is efficient [ ] . an essential element of surgical service planning is the delivery of emergency general surgery. it is important to ensure that this continues as normal wherever possible for both patients infected with covid- or not [ ] . one suggestion is to set up dedicated 'clean' and 'dirty' emergency operating rooms to avoid nosocomial infections in covid-negative patients. operations or procedures should be performed if conservative management has failed, may cause harm to the patient, is likely to prolong hospital stay, or increase the likelihood of readmission at a later stage [ ] . surgeons should also be wary of a possible reduction in the availability of blood products. the uk has already seen resources beginning to deplete due to both increased usage as well as a reduction in blood donors due to social distancing and quarantine measures [ ] . it is therefore advisable for individual centres to monitor regional blood availability and if required, support a restrictive transfusion strategy both in ors and icu where necessary [ ] or intraoperative cell salvage [ ] . suggestions for prioritisation are given in table . incision and drainages should continue to be performed in cases of superficial soft tissue abscess, including perianal abscesses, under local anaesthesia where possible. in cases where infection is deep seated (ie. muscle involvement), incision and drainage should be performed in the or, in an attempt to avoid extension of the disease and shorten hospital stay. this classification includes, but is not limited to, perirectal abscesses (ischiorectal, intersphincteric, supralevator). if an operating room is not available, percutaneous drainage should be considered [ ] . spinelli et al. [ ] warn that cases of covid- may present with abdominal symptoms resembling acute pancreatitis. in fact, furong et al. [ ] suggest that high angiotensinconverting enzyme (ace ) receptor expression in the pancreas may be a cause of mild pancreatitis in patients infected with sars-cov- and advise clinicians to remain vigilant of this phenomenon. in cases of progression to necrotising pancreatitis during the covid- pandemic, percutaneous and interventional radiology (ir) drainage strategies should be favoured over endoscopy and laparoscopic or open operative methods [ ] . emergency operations should be performed in closed loop bowel obstruction and obstructions due to incarcerated hernias, bowel perforations and intestinal ischemia cases. conservative management should be attempted in bowel obstruction secondary to adhesions [ ] . appendicitis, if uncomplicated, may be treated with a trial of intravenous (iv) antibiotics with an aim to switch to oral alternatives. attention must be given to cases with an appendicolith present, or in cases where there is disease extension outside of the right iliac fossa. such cases have a - % failure rate and may constitute a longer than necessary hospital stay. this risk must be assessed against or availability. patients with complicated appendicitis should be treated with iv antibiotics followed by an oral switch. depending on the patient's clinical status, defined abscesses should be drained percutaneously or operated on. in cases where non-surgical management fails, surgery must be performed urgently [ ] . management of diseases of the biliary tree remain mostly unchanged. pain control is crucial in cholelithiasis and chronic cholecystitis. an elective cholecystectomy should be performed at a later stage. in cases of refractory pain, an emergency laparoscopic cholecystectomy should be performed. this is also true for acute cholecystitis cases; if the patient is fit and there is an emergency theatre available, they should be operated on in an attempt to minimise hospital stay. if there is limited operating room availability or the patient is not fit for a laparoscopic operation, then treatment should be with iv antibiotics. in cases where iv antibiotics have failed, a cholecystostomy may be performed. patients with choledocholithiasis who fail to pass their stone should undergo an endoscopic retrograde cholangio-pancreatography (ercp) with sphincterotomy. an elective cholecystectomy should be performed at a later stage [ ] . uncomplicated diverticulitis management remains unchanged ie. iv antibiotics followed by an oral switch. hinchey grade and cases should undergo percutaneous drainage as well as receive antibiotic treatment. hinchey and classifications should undergo a laparotomy with bowel resection and primary anastomosis or colostomy formation, as appropriate [ ] . transplant surgery covid- is having a significant impact on organ donation services world-wide. as the pandemic evolves, the transplant community faces various challenges, from allocation of resources and consenting patients, to optimizing immunosuppressive medication in patients with suspected covid- infections [ ] . currently, there is a limited amount of data to draw firm conclusions on the effect of covid- on organ transplantation. however, the immunosuppressive agents used may pose an increased risk of developing severe infections, placing these patients in an extremely vulnerable category. in the uk, transplant patients have been advised to stay at home and avoid face to face contact for weeks. additionally, transplant units should take measures to reduce the need for hospital attendance in these vulnerable patients by postponing nonurgent appointments or conducting them virtually as well as delivering immunosuppressive medication to a patient's home. it is important to note that levels of immunosuppression should be reviewed regularly. however, adjusting the level of immunosuppression should be undertaken with care as this could jeopardise the viability of the transplanted organ [ ] . guidance on acute transplantation during this pandemic is currently being developed and is adapting on a regular basis. transplant units are encouraged to take into account the availability of intensive care beds as this will affect feasibility and safety of undertaking organ transplantation. during the covid- outbreak, transplant decisions should be made on a case by case basis by balancing the risk of infection due to immunosuppression and hospital stay against the risk of organ failure. acutely however, recipients with an active infection or are recovering from an infection should not undergo transplantation. ultimately, if a unit has a significant number of covid- cases and has limited resources available, with a potential for negative impact on patient care, transplant services should be temporarily halted and reevaluated at regular intervals [ ] . alterations must be made to the consenting process during this pandemic with several additional factors needing to be taken into consideration when consenting patients for both living organ donation and solid organ transplantation. these include: • risk of transmission of sars-cov- from donor to recipient this should consider language barriers and disabilities to reduce the risk of miscommunication [ ] . local transplant services are taking drastic measures, making adaptations based on the resources available and the desires of donors and recipients. it is recommended that each centre should use their clinical judgement based on the circumstances of their individual centre. some kidney transplant centres have closed live donor programs due to the risk of patients contracting covid- and limited access to critical care beds, while others are conducting risk-benefit analyses on a case by case basis [ ] [ ] [ ] . there are a limited number of case reports relating to the effects of covid- on renal transplant patients [ ] [ ] [ ] [ ] [ ] . guillen et al [ ] report a case of a -year-old male who had undergone renal transplantation in . they expressed concern that sars-cov- may present in an atypical fashion in immunocompromised patients (diarrhoea, nausea and vomiting). there is also some discrepancy in the literature regarding the management of immunosuppression. zhu et al [ ] reported a case of a patient being successfully treated by initially stopping immunosuppressive medication followed by the introduction of a reduced regimen. similar findings were reported in two larger case series [ , ] . in contrast, wang et al [ ] successfully treated a patient without altering immunosuppressive therapy. a similar trend is seen in liver transplantation where clinicians should use their clinical judgement, taking into account resource availability in their respective centres. some centres in the uk are aiming to run a reduced service, accommodating those with severe disease (expected to die within the next months without transplantation or a united kingdom model for end-stage liver disease score > ) [ ] . decisions to perform heart and lung transplants should also be undertaken at a local level. routine surveillance such as biopsies and bronchoscopies should be postponed in patients who are more than months from transplantation, have not suffered previous episodes of rejection and are clinically stable. in heart transplant patients, it is recommended that non-invasive methods to assess rejection should be employed. such as gene expression profiling. for lung transplant patients, more emphasis should be placed on home spirometry data to be evaluated in virtual consultations. criteria should also be developed so that patients can notify the healthcare team if there is a significant decline in lung function [ ] . most patients who have undergone transplant surgery require immunosuppression to prevent graft rejection. however, this requires a careful balance as it can also result in an increased risk of developing covid- or severe complications. in suspected covid- cases, all other causes of symptoms such as fevers and cough should be excluded. this includes but is not limited to cytomegalovirus, pneumocystis, pneumonia and urinary sepsis. clinicians should also take into account atypical presentations of covid- and have a low threshold for testing. management is then categorised based on patients who do not require hospital admission, those who are unwell and admitted to hospital and patients who are progressively deteriorating and require ventilatory support (figure ) [ ] . cardiothoracic practice will be inevitably affected by covid- . in the uk and us all elective and non-urgent procedures have been postponed with resources being redirected to the emergency and urgent cardiothoracic service. furthermore, cardiothoracic surgeons possess generic skills which are mostly transferable to itu, making them prime candidates for redeployment. nhs england has issued guidance on management of cardiothoracic procedures based on the phase of the covid- pandemic [ ] . these phases include preparation, escalation, crisis (compensated and uncompensated), resolution, recovery and normal working ( table ). in summary, the elective cardiothoracic surgery service will be greatly reduced throughout the pandemic. surgeons are encouraged to use telephone and video conferencing to limit face-to-face appointments and to delay non-urgent referrals and follow ups. cardiothoracic surgeons can greatly support the itu service and attempts should be made to make senior staff available for redeployment [ ] . the vascular society of great britain and ireland have issued guidance for clinicians on the impact of covid- on vascular surgery services [ ] . these include general principles, outpatient appointments, elective and emergency vascular surgery, alongside trainee advice. regarding outpatients, only urgent cases should be seen, and virtual clinics considered. regarding surgical procedures, most arterial surgery is either classified as urgent or emergency and should therefore continue where possible. elective procedures, venous surgery, and asymptomatic conditions requiring intervention should be deferred. nhs england have classed acute & critical limb ischaemia, symptomatic aortic aneurysm & dissection and unstable carotid plaques as all still being emergency procedures and essential but the threshold for abdominal aortic aneurysm (aaa) should be weighed against the risk of rupture [ ] . where possible, ruptured aaas should be treated via endovascular aneurysm repair (evar) to reduce dependency on high dependency units (hdu). in patients with critical leg ischaemia or diabetic foot, urgent intervention is required in those with an immediately threatened leg(s), including an interventional radiological approach or amputation (as opposed to debridement). the american college of surgeons have similarly provided guidelines for the triage of vascular surgery patients (table ) [ ] . ahmed et al [ ] categorise urological surgeries into: oncological, emergency and benign and offer suggestions for prioritisation. these include the recommendation for liberal usage of local anaesthesia and day-case surgery wherever possible to minimise the impact on both resource usage and workforce shortages with anaesthesists being redeployed. furthermore, they suggested the setting up of parallel urological services with 'cold' hospitals dealing with oncological and emergency work and 'hot' hospitals operating on suspected covid- patients. additionally, whilst the extent of urinary viral shedding is not yet fully understood, there is some early evidence that sars-cov- viral rna is detectable in urine suggesting precautions must still be undertaken in urological services [ ] . moreover, there is some evidence that sars-cov- especially targets the cells of the urinary tract as they strongly express angiotensin-converting enzyme receptors -a known method of entry into the human host [ ] . this is one possible explanation for the recorded rates of acute kidney injuries in patients with covid- . additionally, sighinolfi et al [ ] warn urologists to consider covid- as a differential diagnosis in urosepsis as many of the symptoms (namely fever, leukopenia, tachycardia and tachypnoea) overlap. when prioritising patients, oncological surgeries must be a key priority. this is a major part of urological services with prostate cancer accounting for . % of all cancers [ ] , and recommendations are presented in table to be used in conjunction with guidelines issued by the eau guidelines office [ ] . due to the complex considerations that must be taken into account for these patients, a robust multidisciplinary team, consisting of urologists, oncologists, urological-specialist radiologists, anaesthetists and infectious disease clinicians, must be utilised for surgical prioritisation [ ] . the majority of benign surgeries may be delayed and where they should be prioritised, this is highlighted in table . principles for urological surgery during the covid- outbreak include as previously described in part , including the use of telephone triage and self-isolation prior to admission. simonato et al [ ] advise avoiding laparoscopy/robotic surgery where possible and where surgery is unavoidable, it should be performed only by experienced urological surgeons to decrease the risk of postoperative complications as well as reduce or time. additionally, they advise that enhanced recovery after surgery (eras) programmes be used to reduce length of stay in hospital as well as to reduce complications and admissions to already overstretched critical care units. furthermore, they advise regular correspondence with patients' relatives and to discharge patients who require catheters with video or photographic tutorials for catheter management in addition to virtual follow-up clinics. whilst there have been no publication of guidelines by any professional association for the management of stone surgery during the covid- pandemic, there have been some guidance published by proietti et al [ ] suggesting telephone triage of patients followed by prioritisation based on stone size and location, the presence of any obstructive uropathy, patient symptoms, presence of any stents or nephrostomy tubes and any other complicating factors such as renal failure or a solitary kidney. additionally, desouky [ ] suggests that despite reports in the media, nonsteroidal anti-inflammatory drugs (nsaids) should continue to be used as analgesia and as treatment for renal colic due to high effectiveness. similar considerations for prioritisation of surgery must also be undertaken for patients due to undergo robotic surgery. the eau robotic urology section have issued guidelines for both rationalisation and alterations to operative technique, with the aim of maximising protection for healthcare workers and minimising collateral damage to patients requiring treatment for non-covid- conditions [ ] . they also recommend that operations only be undertaken by the most experienced operators and that the minimum amount of staff necessary should be present in the or with all unnecessary personnel excluded (including fellows and students). there are specific recommendations for the prioritised ophthalmic operations (table ). when possible and safe, these operations should be performed as day cases. the surgical procedure with the less postoperative follow-up visits and the faster recovery period should be chosen. local anaesthetic is also preferred to general anaesthesia wherever possible [ ] . despite the cancellation of ophthalmic operations and outpatient clinics, all patients should be contacted to address any concerns they may have and to be given appropriate advice regarding management and awareness of red flag symptoms. patients should be stratified as low, medium or high risk and contacted by letter, by telephone, by through virtual clinics or remain face to face, depending on the severity and resources available in the eye department [ ] . moorfields eye hospital have also published guidance on ophthalmological risk stratification and implementation [ , ] . in order to further reduce the risk of acquiring covid- infection, patients should spend as little time in the department, and come into contact with as few patients and staff, as possible. necessary actions include reducing the number of anti-vegf injections per outpatients list and preference given to longer acting anti-vegf injections; no clinical review for ongoing anti-vegf injections; and stagger arrival times so that they do not occur at the same time. moreover, it is recommended that not all ophthalmology staff should be present. instead, staff could be reorganised into two teams, taking turns every two weeks. the team working from home should be on stand-by and be prepared to cover for any sick colleague from the active team. only senior-level clinicians capable of making decisions should see patients, and any administrative work should be undertaken from home where possible [ ] . the use of ppe in ophthalmology should follow local governmental recommendations. other specific recommendations are that surgical masks can be worn for multiple patients examined under the slit lamp, and that slit lamps can be modified with plastic breath shields to prevent droplet transmission of the virus. following these recommendations, reused masks should not be taken off between patients and there should be no contact between the mask and hands or clothes, to avoid contamination. it is also important to disinfect the plastic breath shields with alcohol before and after every consultation [ ] . plans for urgent elective cases should be made prior to surgery; neurosurgical teams should see if these plans can be delivered without access to icu. day case surgery and short length stay as routine are encouraged i.e. single night stay. critical care beds should only be reserved for patients who may require invasive monitoring or ventilatory support. for emergencies, the threshold for usual acceptance may change. due to the current situation, decision making will be challenging, hence ultimate decision should be shared by at least attendings, and multi-disciplinary teams should comprise of senior members only [ ] . the british neuro-oncology society offers suggestions for prioritisation of neuro-oncology (table ) . for outpatient referrals, only mri confirmed malignant brain tumour patients should be seen. for any mri confirmed non-malignant brain tumours, referral bodies should be followed up for confirmation. elective surgery for non-malignant brain tumour patients who are asymptomatic should be postponed. contact must be minimised during consultations. furthermore, chemotherapy and radiotherapy must be minimised and triaged for those who are most likely to benefit. if standard treatment is not offered, reasons must be outlined in the records [ ] . neuro-oncological treatment for glioma patients young adult patients with high grade malignant glioma should undergo maximal safe glioma resection; carmustine (bcnu) wafer may be used safely with no risks of contamination. radiological investigations alone should be used to generate treatment plans for the elderly and for patients with comorbidities [ ] . for low grade glioma patients, the bnos suggests a delay of - months [ ] . mohile et al [ ] suggested that only chemotherapy regimens which increase the interval between doses should be considered for patients with idh-wildtype gliomas, and the use of cytotoxic chemotherapy, immunotherapy and other tumour treatments should be evaluated against the potential risks of infection and immunosuppression. for patients with grade and grade idh-mutated gliomas, a similar decision-making plan to idh-wildtype patients may be followed and p/ q co-deletion glioma patients should delay therapy. mgmt methylated glioma patients may benefit from standard radiotherapy and chemotherapy courses hence temozolomide and radiation should be considered. on the other hand, mgmt unmethylated glioma patients are unlikely to benefit from temozolomide hence shorter radiotherapy courses with the aim of avoiding adjuvant and/or concurrent chemotherapy may be optimal for these cases [ ] . strict ppe must be followed by technicians involved in the care of patients undergoing chemotherapy and radiotherapy and toxicity tests should be done at the longest safe interval to reduce patient risks of covid- infections. cancer treatment must be stopped until recovery for any patients who test positive for covid- and treatment risk-benefit ratio should be evaluated for these patients. all malignant brain tumour patients should be followed up, preferably via remote tele-consultation at the surgeon's discretion. the following are adapted from guidelines published by the bnvg/sbns for the neurosurgical management of neurovascular conditions during the covid- epidemic [ ] . cta should be performed prior to transfer to neurosurgery, if possible. if no aneurysm is found and the patient has perimesencephalic sah, then an attending neuroradiologist should confirm perimesencephalic pattern and negative cta. it is encouraged to not transfer these patients or perform dsa. if no aneurysm is found and the patient has non-perimesencephalic sah, then good cta quality needs to be confirmed, which should be repeated if inadequate. an attending neuroradiologist should confirm the absence of an aneurysm and the adequacy of cta. a dsa should be done to address any concerns. otherwise, it is reasonable to repeat a cta at week locally. if an aneurysm is found: • world federation of neurological surgeons (wfns) grading score - : current provided guidelines should still be followed for transfer and treatment. • wfns - : neurosurgical treatment will still be beneficial for low grade patients. patients with poor prognostic factors are likely to undergo conservative treatment at their local hospital. • aneurysmal clot: this should be treated at the discretion of a senior neurosurgeon, although a higher treatment threshold may be followed. transfer patients to emergency surgery if they present with ich causing mass effect. those with ich but absent mass effect should undergo cta/mra: urgent treatment should be provided for ruptured or symptomatic cases from cortical venous reflux, and with regards to spinal fistulas, only cases with rapid neurological deterioration should be treated. treatments for unruptured aneurysms (also including giant aneurysm) should be postponed, unless there is cranial nerve iii palsy. all avms and davfs treatments should also be postponed. guidelines have been published by nhs england and nhs improvement for the management of neurotrauma patients during the covid- epidemic [ ] . categories to consider for neurotrauma patients include: national and local head injury guidelines should still be followed for these patients (fig ) [ , ] . treatment for emergency patients should be expedited. an anaesthetic guideline for covid- positive patients is required. contingency plans should be made for supply chain issues. this includes patients with easily reversible conditions e.g. extra-axial haematoma (extradural/subdural) with mass/clinical effect. during times of very limited care, withdrawal of treatment may occur earlier after decisions of futility are made for patients with brain injuries which are considered to be unsurvivable. overall, most neurosurgical spine and head procedures are safe to perform with strict ppe. if possible, pcr testing for covid- should be done for suspected patients prior to treatment. cranial and spinal drilling should be performed with slower speeds and more thorough irrigations of stationary drills should be done to reduce bone skull aerosol [ , ] . furthermore, to prevent blood splashing in a negative pressure operating room, surgeries should be performed as gently as possible [ ] . in addition, endonasal procedures should be avoided as they produce significant droplet aerosol; in wuhan, despite the use of n masks, ent surgeons were the worst affected by bone aerosol [ ] . oral and maxillofacial surgery nhs england and nhs improvement have published guidelines for the treatment of acute omfs and trauma patients (table ) [ ] . they suggest that senior members of the team should make decisions regarding patient care at the first point of contact with the patient, thus ensuring that unnecessary admissions are avoided, and nosocomial infections are minimised. additionally, a suggested model is that admission from the emergency room be directed to omfs clinics before any examination or treatment which is a divergence from normal practice where initial treatment is started by emergency physicians. in addition to this, they suggested the organisation of a temporary 'clean' minor operating theatre and dressings clinic within a triage clinic room to provide immediate services such as suturing of wounds and lacerations, abscess drainage and any urgent procedures that can be performed under local anaesthesia. non-operative care should be considered for patients with injuries which can be managed conservatively (this includes condylar fractures). for patients requiring surgical treatment, including mandibular and midfacial fracture patients and for cases involving cervicofacial infections, teams should work towards expediting the pre-operative and operative care. to reduce post-operative stay, elective rehabilitation services are suggested. the british association of head & neck oncologists (bahno) have also published guidelines for head and neck cancer management during the covid- epidemic [ ] . all non-malignant cancer treatments should be postponed, and tele-consultations should be done to assess the severity of any referrals of unclear urgency. priority should be given to malignant cancer patients and to those are older than years of age with/without comorbidities. ppe must be strictly followed during consultations and diagnostics work up should be kept to the minimum required to make informed and safe treatment plans. for any nasal endoscopy procedures, as per the advice of ent uk, aerosol generating procedure (agp) level of protection must be followed; theatre clothes and full ppe should be worn and endoscopy should be carried by remote video monitoring instead of eyepiece [ ] . with regards to surgical cancer treatment, it is encouraged to postpone surgical procedures which require itu admission at the discretion of senior surgeons. furthermore, day case surgeries should be prioritised, and their length reduced, if possible. with regards to nonsurgical cancer treatment, palliative chemotherapy should be delayed in asymptomatic patients. all patients should be followed up by telephone. however, it is suggested to minimise patient contact by delaying clinic appointments by the longest interval possible at the discretion of the senior surgeons. furthermore, caprioglio et al [ ] offer recommendations for the management of orthodontic emergencies which involve assessment of the patient over telemedicine devices then advising the patient step by step for self-management. although fever, cough and shortness of breath are commonly advertised as the symptoms suggestive of covid- , numerous reports emerged to reveal anosmia, an ent presentation, as a symptom of covid- and in some cases was present as an isolated symptom. hence, it was recommended that patients presenting with anosmia should be treated as a suspected case of covid- and healthcare workers should don ppe before making contact [ ] . ent surgeons were identified to be among those at an increased risk of contracting covid- from their patients due to working for prolonged periods of time in close proximity to their patients' faces as well as due to the presence of several aerosol-generating procedures (agps) in ent. the first hospital doctor fatality during this epidemic was an otolaryngologist and this highlights the risks faced by ent doctors [ ] . ent uk has generated a list of procedures that they consider to be agps. examination of the upper aerodigestive tract can be considered as an agp, especially if it triggers coughing, sneezing or pharyngeal reflexes, as well as operative procedures on the aerodigestive tract. it is recommended that all agps (e.g. nasal endoscopy, nasal cautery, foreign body removal, biopsies, tracheostomy tube changes and emergency care provided for acute tonsillitis, quinsy and epistaxis etc.) are carried out wearing full ppe, including ffp respirator, which could be substituted with ffp or n respirator in cases of unavailability of ffp respirator. it has also been recommended that all otolaryngeal examinations and operative procedures that are unnecessary are avoided [ ] . guidelines for the acute surgical care of quinsy, acute tonsillitis and epistaxis have been revised to minimise the risk posed to ent surgeons whilst providing uncompromising patient care. for example, revised guidelines recommend treating quinsy on history alone where possible, reserving oral examination for severe cases; it also recommends betadine gargles in the management of quinsy, reserving drainage for severe cases [ ] . tracheostomy guidelines have also been revised due to an anticipated increase in requests to perform tracheostomies on suspected or confirmed covid patients as well as due to tracheostomy being an agp which poses a considerable risk to the operator [ ] . additionally, rokade et al [ ] has described the innovative use of microscope drape in endoscopic sinus surgery while hellier et al [ ] has described the novel use of microscope drape in mastoidectomy, in both cases to reduce aerosolization in these operative procedures which are considered to be agps. suggestions for prioritisation are given in table . the british association of plastic surgery (bapras) and nhs england has provided advice to its members to help aid the management of plastic surgery patients during covid- (table ). the association has provided a plastic and reconstructive surgery escalation policy [ ] . this provides hospitals with recommendations on how to cope with an increase in covid- prevalence. with high prevalence, emergency surgery should be limited, and all elective surgery should be stopped. all emergency injuries should be triaged to outpatient clinics and minor operations should be performed in outpatient clinics. for the management of burns, breast reconstruction and melanoma specific guidelines have been formulated and to cope with the expected drastic reduction of clinical and surgical facilities advice has been created to guide local services. for patients with a suspected melanoma diagnosis, a referral letter is still required, which will be reviewed at a multidisciplinary team (mdt). the advice will be given on the basis of the photograph. the patient may then be sent directly for surgery to remove the lesion and phoned with the results once the pathology has been analysed [ , ] . nhs england have also set out specific guidelines for the management of burn injuries during the covid- epidemic [ ] . the recommendation guidelines for the management of patients with burns includes considering the burn patient into four categories. firstly, obligatory inpatients are those with large burns that will need continued admission and surgical management. however, treatment must be expedited to avoid pre-operation delay and minimize the length of stay. secondly, non-operative patients are those that can be reasonably managed without an operation. during the epidemic it is vital to consider non-operative care for burns to avoid unnecessary admissions. thirdly, day-case patients are those that can be undertaken for a large number of conditions. lastly, first contact and clinics patients are the outpatient attendances that should be kept to the safe minimum. the guidelines highly support non operative care to reduce the inpatient and operative burden on the nhs. many burn related procedures can be considered as day cases and should be considered. to avoid unnecessary admissions, senior presence is vital for the management of burn patients and will help reduce the ed workload as a whole, so the ed can focus on other medical patients. for facial plastic surgery, bapras have adopted the baoms guidance with their four main recommendations of ppe (full ppe including ffp mask for face to face exams and treatment), avoid (clinics, contact, transfer and surgery), restrict (visits, generation of aerosols and staff numbers) and abbreviate (time waiting in rooms and treatment) [ ] for breast reconstruction, the american society of plastic surgery has provided guidelines to manage breast reconstruction during covid- . all delayed breast reconstruction, planned secondary or revision breast reconstruction procedures should be postponed. for those patients who were considering immediate reconstruction, the society has advised plastic surgeons to err on the side of caution and delay reconstruction due to the potential risks and complications that may occur postoperatively. the decision to delay should take into account the age and comorbidities of the specific patient and the local-regional and individual institutional factors [ , ] . the american college of surgeons states that the principle of paediatric surgery during the covid- pandemic is to provide appropriate surgical care to children with urgent surgical issues (table ) while utilising patient care resources effectively in addition to protecting healthcare workers. non-urgent surgery should only be performed if necessary to avoid prolonged hospitalisation or further hospital readmissions [ ] . nhs england has also made a further recommendation to continue with elective paediatric surgeries only if patients are asa grade , with the exception of cancer cases [ , ] . paediatric surgical services should focus on the effective management of emergency cases with any elective procedures being postponed wherever possible. this will allow for better access to theatres and increase in the staff capacity, with the aims of decreasing the preoperative period and ensuring an early discharge. the paediatric surgical team should ensure continuous management of urgent surgical cases while minimising the risk of transmission of infection. such strategies could include the reorganisation into two groups, one that is active within hospitals, and one that works remotely in isolation, and the use of telemedicine. whenever possible and safe, the presence of parents during surgery should be considered [ ] . there is emerging evidence that paediatric patients suffer complications from preventable conditions due to late access to medical care. in response to this evidence, the royal college of paediatrics and child health has emphasised the importance of acute paediatric services and primary care forming agreed pathways for acute paediatric diseases. they also emphasised the importance of primary care workers having accessible and immediate advice from attendings in hospital and community-based paediatrics, to ensure prompt diagnosis and management [ ] . due to covid- , all surgical specialties have had to limit their surgical practices and rationalize the surgeries which are performed. selection of patients for urgent surgery during the pandemic is vitally important to ensure patients have postoperative reserves to combat any possibility of later being infected with covid- . surgeons from all specialties have been asked to consider non-surgical treatment where safe and possible to avoid unnecessary hospital admissions and to avoid patient harm. all surgery specialists have been asked to limit their follow up to telephone and video where possible. the delivery of emergency surgery during covid has become difficult due to a reduced workforce and hospital supplies. for example, all surgical specialties must carefully consider the need for postoperative supplements including blood transfusions. surgical consent has been tailored to minimize person to person contact, with written and online documentation being utilized where possible. due to evolving circumstances, guidelines for preoperative evaluation, intraoperative and postoperative management are subject to constant change. it is therefore advised to follow national guidelines to ensure the latest recommendations are implemented across centres. all surgical specialties have been affected by the covid- pandemic. all specialties have had to triage the urgency of their daily surgical procedures and consider non-surgical management options where possible. surgeons are having to adapt to new guidelines among covid- to continue to provide vital emergency surgery within their specialty. with guidelines specific to each specialty being implemented and followed, surgeons should be able to continue to provide safe and effective care to their patients during the covid- pandemic. • supratentorial symptomatic brain metastases. • hydrocephalus patients with rare brain tumours -suggestions of using endoscopic third ventriculostomy or ventriculoperitoneal shunt to delay surgery (except for germ cell tumours and pineoblastoma). • patients with low grade glioma who can reasonably be monitored with mri -a -month interval scan should be added to ensure no tumour progression in cases delayed by - months. • tumours of skull base in patients with minimal symptoms. • for high grade glioma patients, it has been suggested to consider reducing the course and fraction of radiotherapy and chemotherapy if there is no significant worse prognosis. oral therapy regimens are preferred, if possible, instead of iv administration. • for mgmt unmethylated glioblastoma patients, chemotherapy may be excluded; monitor patients for any deterioration. • whole brain radiotherapy patients. • stereotactic radiosurgery patients with brain metastasis. • patients with radiotherapy for other rare malignant tumours including anaplastic astrocytoma, pineoblastoma and primitive neuroectodermal tumour. • radiotherapy and chemotherapy patients with low grade glioma who can safely be monitored for an initial period. • patients with atypical meningioma or recurrent meningioma receiving radiotherapy. world health organization declares global emergency: a review of the novel coronavirus (covid- ) covid- and italy: what next? eau guidelines office rapid reaction group, an organisation-wide collaborative effort to adapt the eau guidelines recommendations to the covid- era management of cancer surgery cases during the covid- pandemic: considerations clinical guide for the management of noncoronavirus patients requiring acute treatment: cancer clinical guide for the management of cardiothoracic surgery patients during the coronavirus pandemic american college of surgeons, covid- guidelines for triage of breast cancer patients the treatment proposal for the patients with breast diseases in the central epidemic area of coronavirus disease urgent intercollegiate general surgery guidance on covid- american college of surgeons, covid- guidelines for triage of colorectal cancer patients several suggestion of operation for colorectal cancer under the outbreak of corona virus disease in china american college of surgeons, covid- guidelines for triage of thoracic cancer patients american college of surgeons committee on trauma, maintaining trauma center access & care during the covid- pandemic: guidance document for trauma medical directors clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic royal college of surgeons in ireland, royal college of surgeons of edinburgh, royal college of physicians and surgeons of glasgow, clinical guide to surgical prioritisation during the coronavirus pandemic covid- pandemic: perspectives on an unfolding crisis: covid- pandemic: perspectives on an unfolding crisis american college of surgeons, covid- guidelines for triage of emergency general surgery patients covid- outbreak in northern italy: viewpoint of the milan area surgical community emergency preparedness, resilience and response guidance for uk hospital transfusion teams clinical guide for the management of general surgical patients during the coronavirus pandemic highly ace expression in pancreas may cause pancreas damage after sars-cov- infection organ donation during the coronavirus pandemic: an evolving saga in uncharted waters covid- : information for transplant professionals transplant society guidance for clinicians on consent for solid organ transplantation in adults and living organ donation in the context of the covid- pandemic covid- ) guidance for patients with kidney disease the renal association, covid- : challenges for renal services bulletin number : organ and tissue donation and transplantation directorate case report of covid- in a kidney transplant recipient: does immunosuppression alter the clinical presentation? successful recovery of covid- pneumonia in a renal transplant recipient with long-term immunosuppression covid- in a kidney transplant patient identification of kidney transplant recipients with coronavirus disease coronavirus disease pneumonia in immunosuppressed renal transplant recipients: a summary of confirmed cases in guidance for cardiothoracic transplant and ventricular assist device centers regarding the sars cov- pandemic guidance on the management of transplant recipients diagnosed with or suspected of having covid triage considerations for patients referred for structural heart disease intervention during the coronavirus disease (covid- ) pandemic: an acc /scai consensus statement covid- virus and vascular surgery clinical guide for the management of vascular surgery patients during the coronavirus pandemic american college of surgeons, covid- guidelines for triage of vascular surgery patients global challenges to urology practice during covid- pandemic persistence and clearance of viral rna in novel coronavirus disease rehabilitation patients single-cell rna-seq data analysis on the receptor ace expression reveals the potential risk of different human organs vulnerable to -ncov infection covid- : importance of the awareness of clinical syndrome by urologists global cancer statistics : globocan estimates of incidence and mortality worldwide for cancers in countries covid- and urology: a comprehensive review of the literature network (run), pathways for urology patients during the covid- pandemic endourological stone management in the era of the covid- urology in the era of covid- : mass casualty triage eau robotic urology section (erus) guidelines during covid- emergency recommendations for tiered stratification of urologic surgery urgency in the covid- era triaging office-based urologic procedures during the covid- pandemic considerations in the triage of urologic surgeries during the covid- how to prioritize urological surgeries during epidemics: lessons learned from the toronto sars outbreak in the royal college of ophthalmologists, glaucoma management plans during covid- the royal college of ophthalmologists, management of ophthalmology services during the covid pandemic the royal college of ophthalmologists, management plans for children and young people with eye and vision conditions during covid- ophthalmological risk stratification & implementation guidance moorfields risk stratification for paediatric ophthalmology the royal college of ophthalmologists, protecting patients, protecting staff the royal college of ophthalmologists, ppe and staff protection requirements for ophthalmology sbns covid- bulletin # covid- treatment pathways and guidance sbns guide for the neurosurgical management of neurovascular conditions during the covid- pandemic clinical guide for the management of neurotrauma patients during the coronavirus pandemic clinical guideline [cg ], national institute for health and care excellence (nice) preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of coronavirus infection experiences of practicing surgical neuro-oncology during the covid- pandemic precautions for endoscopic transnasal skull base surgery during the covid- clinical guide for the management of patients requiring oral and maxillofacial surgery during the coronavirus pandemic maxillofacial trauma management during covid- : multidisciplinary recommendations approaches to the management of patients in oral and maxillofacial surgery during covid- pandemic british association of head and neck oncologists, bahno statement on covid- management of orthodontic emergencies during -ncov anosmia as a potential marker of covid- infection -an update practical aspects of otolaryngologic clinical services during the novel coronavirus epidemic: an experience in hong kong guidelines for changes in ent during covid- pandemic adult tonsillitis & quinsy guidelines bla covid- tracheostomy guidelines ioannidis, fess in the covid era: the microscope drape method to reduce aerosolization mastoidectomy in the covid era -the microscope drape method to reduce aerosolization clinical guide for the management of patients requiring plastic treatment during the coronavirus pandemic advice for managing melanoma patients during coronavirus pandemic clinical guide for the management of acute burns patients during the coronavirus pandemic asps statement on breast reconstruction in the face of covid- pandemic developing a virtual fracture clinic for hand and wrist injuries british society for surgery of the hand, covid- resources for members american college of surgeons, covid- guidelines for triage of pediatric surgery patients clinical guide for the management of paediatric patients during the coronavirus pandemic clinical guide for the management of paediatric critical care patients during the coronavirus pandemic british association of paediatric surgeons, covid- information for paediatric surgeons delayed access to care for children during covid- : our role as paediatricians -position statement the following additional information is required for submission. please note that failure to respond to these questions/statements will mean your submission will be returned. if you have nothing to declare in any of these categories, then this should be stated. please enter the name of the registry, the hyperlink to the registration and the unique identifying number of the study. you can register your research at http://www.researchregistry.com to obtain your uin if you have not already registered your study. this is mandatory for human studies only. . name of the registry: n/a . unique identifying number or registration id: . hyperlink to your specific registration (must be publicly accessible and will be checked): please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. others, who have contributed in other ways should be listed as contributors. the guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. please note that providing a guarantor is compulsory.corresponding author: ahmed al-jabir senior author: riaz agha key: cord- -s zv hr authors: narayanan, c. s. title: modeling the covid- outbreak in the united states date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: s zv hr the covid- contagion has developed at an alarming rate in the us and as of april , , tens of thousands of people have already died from the disease. in the event of an outbreak like such, forecasting the extent of the mortality that will occur is crucial to aid the implementation of effective interventions. mortality depends on two factors: the case fatality rate and the case incidence. we combine a cohort-based model that determines case fatality rates along with a modified logistic model that evaluates the case incidence to determine the number of deaths in all the us states over time; the model is also able to include the impact of interventions. both models yield exceptional goodness-of-fit. the model predicted a range of death outcomes ( k to k) all of which are considerably greater than the figures presented in mainstream media. this model can be used more effectively than current models to estimate the number of deaths during an outbreak, allowing for better planning. the first case of coronavirus disease , or covid- , a respiratory infection caused by severe acute respiratory syndrome coronavirus (sars-cov- ), was first identified in wuhan, china in late [ ] . subsequently, the outbreak has spread to [ ] countries, including the united states, where the first case of covid- was detected in washington state on january , [ ] . as of april , , the u.s has reported cases and deaths [ ] . as the pandemic progresses, determining its prognosis is essential to inform the adoption of adequate mitigation efforts. many have attempted to forecast the trajectory of the epidemic in the united states, and at the forefront is the white house dr. fauci suggested that the us would likely face , to , deaths, with millions of cases [ ] . however, on april he said the estimate had been revised down to , [ ] . moreover, a model by the university of washington, closely followed by the white house, projects , deaths as of april , [ ] , in line with dr. fauci's statement [ ] . it is well-known that there is a wide variance in the sizes of outbreaks between states as well as the resulting incidence of deaths. the primary reason for the variance is the uncertainty in the prediction of infections and the fatality rate of infected individuals. improved models to determine both the cumulative case incidence and the case fatality rate. we calculated the case fatality rate (cfr) for each state using a cohort-based approach, which has demonstrated greater accuracy than traditional methods [ ] . additionally, the number of cumulative cases in each state is predicted using a modified logistic model. combining the two, we are able to forecast the number of cumulative deaths by state. additionally, we analyze the drivers of deaths and discuss implications on policy formation. data sources the primary data for this study is publicly available and was obtained from the center for systems science and engineering (csse) at johns hopkins university [ ] . we obtained the data pertaining to daily new cases/deaths and cumulative cases/deaths for the period of january , , to april , . in addition, we obtained us state population data from the united states census bureau [ ] . the number of deaths is a product of the case fatality rate (cfr) and the population confirmed to have been infected [ ] . therefore, in order to determine cumulative fatalities due to covid- , it is necessary to first predict the cfr and the number of cases. cfr, case incidence, and deaths were evaluated for all fifty states as well as the district of columbia. calculating cfr there are three principal measures of disease lethality: the case fatality rate (cfr), infection fatality rate (ifr) and mortality rate (mr). the mortality rate is represented by the proportion of cumulative deaths to the total at-risk population. this is ultimately indicative of the probability of any individual's mortality among the total population. the cfr uses the same numerator (cumulative deaths) but instead divides it by the number of cumulative confirmed cases. the case fatality [ ] rate is the proportion of individuals who die from a disease among all individuals diagnosed with the disease within a specified timeframe [ ] . that is, it reveals the percentage of individuals that die among all individuals who test positive for the disease. the ifr is similar to the cfr, except it represents the ratio of deaths to the total number of people who are infected; it accounts for all infected individuals regardless of whether their disease is reported or not. in an ideal scenario, where zero individuals with covid- went unnoticed, and surveillance was faultless, the ifr and cfr would be equivalent. however, this is not truly plausible; testing is limited, asymptomatic infections commonly are not surveilled, and not all instances of the disease are accounted for in reality. as a result, the cfr that we calculate will be much higher than the ifr and the mortality rate. in this paper, we use a logistical function [ ] to describe the exponential growth and subsequent flattening of covid- cfr. the cfr depends on three parameters: the final cfr (l), the cfr growth rate (k), and the onset-to-death interval (t ) and is expressed as: using this model, we calculate the number of deaths each day for each cohort or group of individuals infected on the same day. next, we build an objective function that april , / minimizes the root mean square error between the actual and predicted values of cumulative deaths. we ran , simulations, using numerous values of the onset-to-death interval, the cfr, and the cfr growth rate. the cfr was kept in the range of . % to %, the slope was kept in the range of . and . , and the onset-to-death interval bounded between and days. we assigned these bounds because after in-depth explorations of the model, we were convinced the solutions would be within these parameters. we then identify the model parameters that best fit the data (top % of the best-fit rmse). with a kernel density distribution of case fatality rates, we determined the low cfr (the lowest value regardless of its frequency); the mode cfr (the most probable cfr); and the high cfr (the highest value regardless of its frequency). methods is the incorporation of the growth rate. in the sir model, this is r , the transmission rate-given that the population lacks immunity and there are no deliberate interventions to impede disease transmission. the number of infections will continuously rise in a population if r > , will remain steady if r = , and will decrease if r < . to explicitly account for the impact of mitigation efforts, models must support gradual changes in the shape of the case growth rate. the logistic model forecasts the slow initial rise, exponential growth, and eventual decay of cumulative cases, but cannot account for the changes that result from parameters: the terminal number of cumulative cases (c), the cfr growth rate (r), and the days to the inflection point (t i ). the inflection point indicates the day at which the number of daily cases reaches its maximum. this function that describes the change in case incidencei(t) over time can be expressed as: the modified logistic model has five parameters; however, the terminal number of cumulative cases (c) and inflection point (t ) remain unchanged. the set of equations that describe the incidence using the modified logistic model are: april , / . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . the parameter r m is the modified growth function that changes over time, and f is a smoothing function that determines how quickly the rate diverges around the point of inflection, as well as the magnitude of the transformation. using this model, we calculated the number of cases for each state. next, we built an objective function that minimizes the root mean square error between the actual and predicted values of cumulative cases, and ran numerous simulations by varying the four parameters. we held p constant at . in all our simulations. we ran , simulations, using numerous values of the days to inflection: t , the terminal number of cases, c, the growth rate, r, and the growth rate multiplier, k. the terminal number of cases was kept in the range of . % to % of the each state's penetration, the growth rate was kept in the range of . and . , and the number of days to inflection was bounded between and days. the growth rate multiplier was kept in the range between and %. the cumulative mortality is the product of the case fatality rate and the cumulative case incidence. with the low, mode, and high values of both cfr and cumulative case incidence, we evaluate the nine possible death tolls for each state by finding the product of each cfr value and each value of the cumulative case incidence. to determine cumulative mortality on the national scale, we add up the respective cells for all states. predicting case incidence we calculated the case incidence for each jurisdiction. fig shows the goodness-of-fit between the forecasted cases and the true number of cases for new york. the two sets of figures show the cumulative case incidence and new case incidence. it demonstrates that there is an excellent fit for both new and cumulative cases. we calculated the r for all the states and the fit was excellent (greater than % for all the states) for all states indicating that the modified logistical function does a great job of modeling the transition after the intervention. more information regarding the model's goodness-of-fit for the states is provided in the supplemental information (see s table) . s table) . however, new york is a substantial outlier: the model predicts , cases for the mode case. all the numbers we will quote in the rest of the document will be the mode case (unless otherwise specified), as it has the highest likelihood. even if the best-case scenario transpires, its case incidence will probably exceed the incidence of any other state by over . next, we evaluated the forecasted case incidence for the entire united states (fig ) . the total number of cases predicted is above . m, and the number of new daily cases april , / . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . forecasted case incidence for the top us states. the range of forecasted total case incidence for the top states that contribute % of all the deaths. the low, mode, and high cases are displayed. the low and high cases are determined as the low and high end of the % confidence interval. peaks at more than . as new york and new jersey contribute significantly toward the overall case incidence, the united states peak daily cases is strongly dependent on the peak of these two states. in order to understand whether the different states have a case incidence proportionate to their populations, we calculated the discrepancy between the projected cases per capita for individual states and u.s average projected cumulative cases per capita (fig ) . new york, new jersey, massachusetts, connecticut, and louisiana have much higher case incidence per capita. this means that the disease affected these areas disproportionately. in contrast, the states of california, texas, florida, and ohio did much better in controlling the spread of the infection. difference in forecasted case incidence between states. difference in forecasted case incidence between the top states that contributed % of all the deaths. this was calculated by subtracting the difference between projected cases per capita for individual states and the u.s average projected cumulative cases per capita. we previously calculated the case fatality rates for hubei province and showed that the goodness-of-fit was excellent [ ] . we used the same methodology and calculated the cfr for all the states. the model is able to fit the data extremely well showing that both the model and the methodology are sound. we provide the r value for all the states in the supplemental information (see s table) . we calculated the range of final case fatality rates for each state (fig ) . the cfr for most states is between % and %. compared to the case incidence, case fatality rates have far less variability. massachusetts, connecticut, new york, and maryland have relatively higher cfr's. in contrast, texas, california and georgia have much lower cfr's. we also provide supplemental information for all state (see s table) . in order to measure how well states are faring relative to each other, we calculate the difference between projected cfr's for each state and the average cfr for the us (fig ) . positive (negative) values indicate that the cfr is worse (better). it clearly shows that there is a wide disparity between states' case fatality rates. furthermore, the difference in cfr closely corresponds with projected cumulative deaths. this shows even more dramatically how much greater new york's and connecticut's outbreaks are compared to other states. april , / . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . fig . difference in forecasted case fatality rates between states. difference in forecasted case fatality rates between the top states that contributed % of all the deaths. this was calculated by subtracting the difference between projected cfr for individual states and the u.s average cfr. considering that cfr and case incidence are the factors of death, it is fitting now to discuss the projected incidence of deaths (fig ) . we calculated the number of deaths for each of the top states that contribute % of the deaths. this reveals the tremendous disparity between the size of outbreaks in different states (see also s table) . the majority of states will experience less than , deaths. new york is once again a significant outlier; the model returns a minimum of , deaths and a mode of , deaths, % of the u.s. total and more than the next five jurisdictions combined. this can be traced back to the state's relatively high projected case fatality rate and indicative of differences in cfr and case incidence. sources of variation include the chronology and success of mitigation efforts, the prevalence of testing, and the distribution of age [ ] and comorbidities [ ] within populations at risk of infection. fig . forecasted deaths for the top us states. the range of forecasted deaths for the top states that contribute % of all the deaths. the low, mode, and high cases are displayed. the low and high cases are determined as the low and high end of the % confidence interval. table summarizes the various possible death tolls under each of the conditions. there is a % likelihood that any of these results are possible. the lowest cumulative deaths the u.s. could experience is , , considerably higher than both fauci's predicted deaths tolls for the nine different scenarios. these scenarios are constructed using the low, mode, and high cases for cfr and cases. the low and high cases are determined as the low and high end of the % confidence interval. for the best-fit case in all the states, we calculated the number of deaths per day and the cumulative number of deaths (fig ) . this shows that the number of deaths will reach an asymptote in the end of june and the number of daily deaths will peak in early may. we used a cohort analysis approach to estimate cfr and a modified logistic model (that explicitly accounts for the impact of mitigation efforts) to forecast case incidence on the state level, and afterwards calculated mortality on the state and national levels. our model showed a wide range of mortality, with , deaths on the low end and a maximum of , deaths. every possibility predicted by the model exceeds the prognostications produced by both the white house and the university of washington model. our model also revealed the deep disparity in deaths among different states, which is attributable to differences in case fatality rate and case incidence. we postulate reasons for these variations. many states in the us northeast, including new york, new jersey, massachusetts, and connecticut are disproportionately represented in the cumulative death toll. this disparity is primarily because these states have much worse case incidence and case fatality rates. new york is forecasted to experience the largest outbreak, the greatest cfr, and the highest mortality of any state by far. one explanation for its high case fatality rate is the strain the epidemic has placed on its healthcare system. as a result of its high case incidence, more hospitalizations will be required, overwhelming the medical care system. this could result in diminished quality of medical care, resulting in a high case fatality rate. additionally, the disease has disproportionately impacted low-income, more vulnerable areas. [ ] the reason for the high case incidence itself is more perplexing. numerous factors are likely at play, such as the popularity of public transportation [ ] and the high population density of the new york city metropolitan area [ ] ] (where the vast majority of cases have been reported [ ]). however, it is difficult to find conclusive evidence that any of these factors are directly accountable for the outbreak. it is very likely that luck played a large role in determining where clusters appeared. there is ample evidence that super-spreading events, or sse's, can cause sizable outbreaks [ ] . for instance, officials in new york stated that as many as fifty infections could be traced back to a single man in westchester county [ ] . we propose two principal explanations for the discrepancy between the death tolls forecasted by the university of washington model and that of our model: the differences in both the procedure for calculating cfr and the procedure for calculating mortality. our cohort-based method to determining cfr's predicts case fatality rates more accurately at every stage of the outbreak than other models because it explicitly accounts for the onset-to-death interval. further, we forecast cumulative mortality by independently evaluating cfr and case incidence. in contrast, the university of washington model directly predicts deaths; this method is prone to greater errors. while both the cfr and case incidence models fit the data extremely well, there are several challenges with estimating the number of deaths accurately. our model assumes the scale and methods of surveillance do not significantly change between today and the future. any changes to the testing process will affect the number of confirmed cases. breakthroughs in leveraging telemedicine, for instance, would result in increased detection of infected individuals. in this case, the model's current forecasts for case incidence would be underestimates [ ] . additionally, if the shelter-in-place order is withdrawn from states too early, there will likely be an increase in both the case incidence and the mortality. the model itself has limitations; if our assumptions do not hold true, then our analysis will not hold true either. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . i would like to thank chandra narayanan for all his guidance on building the best case incidence model. first known person-to-person transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) in the usa who coronavirus disease first case of novel coronavirus in the united states who. coronavirus disease (covid- ) situation report - npr fauci estimates that , to , americans could die from the coronavirus npr the coronavirus crisis -fauci says u.s. coronavirus deaths may be 'more like institute for health metrics and evaluation. covid- projections a novel cohort analysis approach to determining the case fatality rate of covid- and other infectious diseases jhu novel coronavirus covid- ( -ncov) data repository by johns hopkins csse united states census bureau state population totals methods for estimating the case fatality ratio for a novel, emerging infectious disease how testing completely skews coronavirus case fatality rates case fatality rate the mathematics of infectious diseases estimating epidemic exponential growth rate and basic reproduction number estimation of the final size of the covid- epidemic clinical characteristics of coronavirus disease in china comorbidity and its impact on patients with covid- in china: a nationwide analysis data suggests many new york city neighborhoods hardest hit by covid- are also low income areas land area, and population density by county identifying and interrupting superspreading events-implications for control of severe acute respiratory syndrome coronavirus . emerg infect dis new york officials traced more than coronavirus cases back to one attorney virtually perfect? telemedicine for covid- key: cord- -fs rx q authors: blasius, bernd title: power-law distribution in the number of confirmed covid- cases date: - - journal: chaos doi: . / . sha: doc_id: cord_uid: fs rx q covid- is an emerging respiratory infectious disease caused by the coronavirus sars-cov- . it was first reported on in early december in wuhan, china and within three months spread as a pandemic around the whole globe. here, we study macro-epidemiological patterns along the time course of the covid- pandemic. we compute the distribution of confirmed covid- cases and deaths for countries worldwide and for counties in the us and show that both distributions follow a truncated power-law over five orders of magnitude. we are able to explain the origin of this scaling behavior as a dual-scale process: the large-scale spread of the virus between countries and the small-scale accumulation of case numbers within each country. assuming exponential growth on both scales, the critical exponent of the power-law is determined by the ratio of large-scale to small-scale growth rates. we confirm this theory in numerical simulations in a simple meta-population model, describing the epidemic spread in a network of interconnected countries. our theory gives a mechanistic explanation why most covid- cases occurred within a few epicenters, at least in the initial phase of the outbreak. by combining real world data, modeling, and numerical simulations, we make the case that the distribution of epidemic prevalence might follow universal rules. covid- is an emerging infectious disease caused by the coronavirus sars-cov- . it was first reported on in hubei, mainland china on december , and has spread well outside china in a matter of a few weeks, reaching countries in all parts of the globe within a time span of three month. as of march , the disease has arrived in countries, with more than confirmed cases and deaths worldwide. despite the drastic, large-scale containment measures implemented in most countries, chaos article scitation.org/journal/cha these numbers are rapidly growing every day-posing an unprecedented threat to the global health and economy of interconnected human societies. one of the most powerful tools to understand the laws of epidemic growth is mathematical modeling, going back to bernoulli's work on the spread of smallpox in . epidemiological models can be roughly divided into two classes. the first class of models is focused on describing the temporal development of the epidemic within a localized region or country. these models are often variants of the well-known susceptible-infected-recovered (sir) model , and have recently been adapted to the situation of covid- , taking into account non-pharmaceutical interventions (e.g., quarantine, hospitalization, and containment policies) and allowing first predictions of healthcare demand. , , , the second class of models is concerned with the geographic spread of the epidemic around the globe. for these aims, spatially explicit models have been developed that leverage information on the topology of transport networks. for example, the global network of cargo ship movements was used to model the dispersal of invasive species. similarly, for infectious diseases, in a pioneering study, the spread of sars in the global aviation network was modeled. based on these approaches, conceptual frameworks have been developed to estimate epidemic arrival times as effective distances. , at the same time, these models have been refined to highly detailed simulation frameworks for predicting the spread of disease and are able to include factors such as vaccination, multiple susceptibility classes, seasonal forcing, and the stochastic movement of individual agents. , reacting rapidly to the emergent pandemic, spatial epidemiological models have been developed to describe and anticipate the spread of covid- . , , , these models allow us to predict the incidence of the epidemics in a spatial population through time, permitting to study the impact of travel restrictions and other control measures. despite this theoretical progress, not much is known about the biogeography of covid- , neither from empirical studies nor from mathematical models. this is astonishing, as one prominent characteristic of the pandemic is the huge variation in the number of cases that have been reported from different countries of the world. as of april , some countries-the epicenters of the pandemic-were already badly affected by the pandemic, while others at the same time had just confirmed the first few cases. this geographic variation in covid- prevalence might be explained by several arguments: a first obvious possibility would be that the variation is caused by the idiosyncratic circumstances of the individual countries which differ largely in their geography and population size, but also in the way they are combatting the disease. alternatively, parts of the variation could simply be due to reporting errors, reflecting disparate national testing regimes, with countries such as china, japan, south korea, or germany having high testing rates, in contrast to other countries with much poorer testing. here, we argue, however, that a dominant part of this variation may be a direct consequence of the dynamics of the spreading process itself. thereby, the epidemic prevalence in a country should be directly correlated to the arrival time of the disease: countries that were invaded very early by the virus have accumulated many cases in time, while countries with a late invasion naturally still have smaller prevalence. to test this hypothesis, we use empirical data to compute the country-level distribution, p, of confirmed covid- cases, n, at the end of march worldwide and find that it is closely approximated by a truncated power-law, over five orders of magnitude. power-law distributions characterize a large range of phenomena in natural, economic, and social systems, which is known as zipf-or pareto law. , , , examples range from the number of species in biological taxa, the number of cities with a given size, the number of different words in human language, the frequency of earthquakes, the distribution of wealth, the number of scientific citations, , the step length in animal search patterns, and the popularity of chess openings. our study shows that epidemic prevalence, at least in the emerging stage of a pandemic, is another system that falls into this class, suggesting that the spatial distribution of covid- case numbers is a fractal. the appearance of a power-law distribution often points to the nature of the underlying processes. it might, for example, be an indication that the system operates close to criticality, , and it might hint at the presence of a multiplicative stochastic process with certain boundaries , or a rich-get-richer process. , here, we provide a conceptual dual-scale model that explains the emergence of the power-law distribution by the "superposition" of two concurrent processes: large-scale spread of the virus between countries and small-scale snowballing of case numbers within each country. assuming exponential growth on both scales, the critical exponent is simply determined by the ratio of large-scale to small-scale growth rates. we confirm this theory in numerical simulations in a simple meta-population model, describing the epidemic spread in a network of interconnected countries. by combining real world data, modeling, and numerical simulations, we make the case that the distribution of epidemic prevalence, and possibly that of spreading processes in general, might follow universal rules. our research builds on the covid- data repository operated by the johns hopkins university center for systems science and engineering (jhu csse). the database contains information about the daily number of confirmed covid- cases and confirmed deaths in various countries worldwide. using these data, we computed the distribution p c (n) of confirmed cases and the distribution p d (n) of confirmed deaths at a given date (see appendix a). the country-level prevalence distribution on march , is shown in figs. (a) and (b). on that day, countries were invaded by the coronavirus and countries already had reported fatalities. the number of confirmed cases varied between cases in china (followed by cases in italy) and case in countries. the number of confirmed deaths varied between in italy (followed by in china) and one or zero deaths in many countries. a broad, long-tailed distribution that in very good approximation can be described by a power-law, spanning five orders of magnitude for the confirmed number of cases and four orders of magnitude for the confirmed number of deaths. to illustrate the robustness of our hypothesis to spatial scale, in figs. (c) and (d), we depict the same analysis for the distribution of confirmed covid- cases in us counties on march , . on this day, counties were invaded by the virus and counties reported at least on death. epidemic prevalence varied between confirmed cases and confirmed deaths in new york city and one confirmed case in counties and one confirmed death in counties. again, we find that the distribution of confirmed cases follows a power-law over several orders of magnitude. thus, although the two datasets differ greatly in spatial scale and resolution [ invaded countries in figs , we obtain somewhat larger slopes of µ c = . and µ d = . . a more accurate estimation of the critical exponent is provided by a maximum likelihood estimation (see appendix a). applying this approach to the country-level covid- distribution yields critical exponents ofμ c = . ± . andμ d = . ± . . for the us-county distribution, we obtain the valueμ c = . ± . andμ d = . ± . . these exponents slightly deviate from those obtained from the regression analysis, but are still in the same ballpark. given an unbounded power-law distribution p(n), the cumulative distribution function c(n) = ∞ n p(n )dn should also follow a power-law c(n) ∼ n −µ . as shown in the insets in fig. , this is not the case for the distribution of covid- cases, for which the cumulative fraction c(n) = n m=n+ p(m) of countries, or counties, with case number m > n do not really follow a straight line in a double logarithmic plot. instead, they are better described by the cumulative distribution function eq. (a ) of a truncated power-law, that is, a power-law distribution with an upper bound n max for the number of cases, eq. ( ) (see appendix a and fig. ). this indication for the presence of a truncated power-law distribution also conforms with our theoretical analysis below. however, we note that although the shape of the empirically obtained c(n) overall follows the curve of a truncated power-law distribution, there is a considerable wavering around the theoretical curve (compare blue circles and black lines in fig. insets) . thus, a rigorous hypothesis testing with monte carlo simulations, , which does not take disturbances due to additional irregularities (e.g., heterogeneities in country sizes or containment measures) fully into account, will always reject the hypothesis of a perfect truncated power-law as the true underlying distribution. the presence of a power-law distribution means that global covid- prevalence patterns are characterized by a small number of countries with huge epidemic prevalence (the long tail of the distribution) and a large number of countries that are (yet) barely affected by the disease. in between these two extremes, there is a smooth transition and this transition is scale-free, that is, the amplification in the number of countries (or counties) with decreasing number of cases is the same at all scales. in general, the obtained critical exponents are rather small. while for most natural power-law distributions critical exponents are around µ ≈ , here we estimate exponents that are clearly below two, µ < , indicating a very broad distribution for which in the absence of an upper bound, the mean value diverges. while the present analysis considers the distribution of case numbers at a temporal snapshot, in reality the pandemic is a dynamic process successively invading countries worldwide. in fig. , we investigate the temporal development of the covid- distribution. the figure shows that the country-level distribution of confirmed cases is formed already within a few weeks from the start of the outbreak and remains roughly stationary over the considered time interval of days. a closer inspection (see inset in fig reveals that the critical exponents in fact are not constant, but in general are decreasing functions of time, indicating that the case distributions tend to broaden over the course of the pandemic. figure (b) further investigates the spatial spread of covid- across countries worldwide more systematically. the figure plots the number of countries that were invaded by the coronavirus (i.e., having the first confirmed covid- case) at a particular day in the time span from january to april , . on january , the first entry in the database, six countries (china, japan, south korea, taiwan, thailand, us) were already invaded by the virus. from this day, within roughly two months, the pandemic spread to nearly every country in the world. interestingly, the invasion speed was not constant. instead, fig. scitation.org/journal/cha distribution. a first group of countries was invaded by the disease in the end of january. in the first three weeks of february nearly no new arrivals were reported. starting from february , a second wave of invasions appeared which lasted until the end of march, after which the number of new arrivals began to fall again, probably reflecting the fact that the pandemic had reached basically all countries of the world. as of april , a total countries were invaded by the coronavirus. there are several possible reasons why the disease arrival is not more evenly distributed. one explanation for the bimodal shape is related to the lockdown of airline transportation in china in the end of january . according to this hypothesis, after the first pandemic bubble in january, the further spread of the pandemic came to a temporary standstill with the onset of travel restrictions, only to resurface in a second wave, starting end of february. alternatively, it may be that many arrivals of the virus in countries all over the world simply went undetected during the first weeks of february and were detected only later with the increasing awareness and increased testing. this hypothesis is corroborated by the observation that end of february is also the time when the first pcr based tests became available. in general, the strong irregularity in the arrival time distribution points to the high level of stochasticity of the worldwide spreading process. c. mechanistic explanation of the power-law distribution figure would suggest that the temporal development of the pandemic is characterized by two complementary processes: the successive invasion of more and more countries and the increasing number of cases within each affected country. here, we argue that the emergence of the power-law distribution could be related to the concurrent "superposition" of these two processes. thereby, on a large geographic scale, the pandemic is driven by the spread of the virus in the network of interconnected countries. on a small scale, case numbers are snowballing within each country, once it has been invaded, thereby further increasing the epidemic imbalance due to different arrival times between countries. in the simplest approximation, at the begin of the pandemic both of these processes developed exponentially in time. a straightforward calculation shows that the combination of the two exponential processes generically yields a truncated power-law distribution in the number of cases in countries: consider an epidemic outbreak that started (the first case reported in a country) at time t = . we are interested in the case distribution at time t > . let us first assume that at this day, the probability distribution for a country to have been invaded by the virus at some former time τ grows exponential in τ with spreading rate s, this exponential growth in the geographic distribution of the pandemic would be the expectation if one modeled the spread in a network where nodes are countries (neglecting saturation when the pandemic has reached most countries). note that the distribution is truncated from two sides because arrivals of the disease can only have occurred after the start of the pandemic, τ ≥ , and in the past, τ ≤ t. second, we assume that in each country, the number of confirmed cases has grown exponentially with the time since invasion t − τ with growth rate r (neglecting containment measures and saturation after the epidemic peak), combining these two equations, the probability distribution of confirmed cases p(n) can be calculated as which is a truncated power-law with critical exponent, thus, the critical exponent is simply determined by the ratio of large-scale to small-scale growth rates. in the symmetric case that both growth rates are identical, s = r, we would expect a powerlaw with µ = . in the limiting case that the large-scaling spreading process is linear in time, s = , we obtain a border-line distribution with critical exponent µ = . note that from the truncation of τ in the arrival time distribution, eq. ( ), the admissible range of case numbers in the power-law distribution eq. ( ) necessarily is restricted between the lower bound n = (the epidemic prevalence in a newly invaded country) and the cut-off value n max ∼ e rt (the epidemic prevalence at time t in the country with the first confirmed case)-justifying the observation of a truncated power-law in the empirical data as shown in fig. . obviously, this simple theory far from accurately describes a real-word pandemic. first of all, the theory is valid only in the initial phase of the pandemic, while both geographical spread and within-country epidemic growth are still exponential. as soon as saturation processes set in, the derivation of the power-law breaks down. next, as shown in fig. (b) , the arrival time distribution during the covid- pandemic is not exponential, as discussed above. in gross oversimplification, we may nevertheless fit an exponential function p(t) ∼ e st through the data, yielding an "average" spreading rate of s = . d − [black dashed line in fig. (b) ]. finally, epidemic growth rates during the covid- pandemic have not been identical in all countries (even in the initial stages). they have also not remained constant in time, but in most countries have fallen in the course of the epidemic. furthermore, most countries were invaded multiple times, leading to different epidemic foci within countries. neglecting all these observations, for the sake of argument, let us assume an average doubling time of case numbers of t / = . d in all countries, yielding an exponential growth rate of r = log( )/t / = . d − and a maximal case number of n max = e . * = . × after days. then, according to our simple theory equation ( ), we would expect a critical exponent of µ = + . / . ≈ . , in rather good agreement to the fitted exponents in fig. . to test the theory of sec. ii c, we developed a dual-scale metapopulation model (see appendix b). the first level describes the chaos article scitation.org/journal/cha large-scale stochastic spread of the virus in a network of n interconnected countries. the second level describes the small-scale increase in case numbers within a country; it is started in each country from the time point of invasion by the virus and follows a simple deterministic sir-dynamics. the motivation for this model design was not to predict the worldwide spread of covid- , but rather to quantitatively test the emergence of heterogeneous case distributions in a conceptual model framework that incorporates the ideas from sec. ii c. figure shows a typical model outcome. the large-scale spreading process is captured in the arrival time distribution, which exhibits a unimodal dependency on time [ fig. (d) ]. correspondingly, the number of invaded countries grows stochastically and roughly follows a sigmoidal shape. in accord to our theory, eq. ( ), this arrival time distribution starts to grow exponentially in the build-up phase of the pandemic. the highest invasion rates occur after about days, while after a simulation time of days, out of the n = countries are already invaded by the virus. combining the large-scale and small-scale model components allows us to simulate the epidemic prevalence in each country as a function of time. figures (a) and (b) show the resulting distribution of cases and deaths after a simulation time of days [vertical red line in fig. (d) ]. again, the distributions are well characterized by a truncated power-law. comparison with fig. shows that the model is able to describe the characteristics of the empirical distribution of covid- cases rather well. the log-likelihood estimation of the critical exponents yields values ofμ c = . ± . andμ d = . ± . . these exponents can be compared to our theory equation ( ) . from fig. (d) , we estimate a spatial spreading rate of s = . d − in the build-up phase of the pandemic. the initial growth rate of infected in the sir-model equals r = . d − (see appendix b). thus, according to eq. ( ), we would expect a critical exponent of µ = + . / . = . , in good agreement to the estimated value from the numerical simulation. we want to note that the nearly ideal power-law scaling in the case distribution holds only in the initial phase of the pandemic and is lost when the spatial spreading starts to saturate. this can be seen in the simulated case distribution p(n) for different time instances [ fig. (c) ]. while p(n) remains roughly stationary for the first - days of the simulation, a first plateau begins to emerge at the left end of the distribution for larger times. this plateau reflects the fact that when the number of newly invaded countries is reduced, these countries with just a few cases are missing in the left end of the case distribution [reminiscent to the behavior exhibited in the empirical case distribution, fig. (a) ]. additionally, the estimated critical exponents are decaying in time [inset of fig. (d) ], similar to that of the empirical data [inset of fig. (b) ]. thus, the first sign that the outbreak has reached most countries in the network is the reduction in the scaling range and a simultaneous broadening of the case distribution. eventually, in the limit of large time, when the epidemic has come to an end in every country, scaling is lost and the distribution of cases must converge toward a delta function p(n) = δ(n − fn pop ), with f the fraction of susceptible out of a population of n pop individuals in a country that will be infected (or it would approach the country size distribution in a meta-population with heterogeneously distributed country sizes). interestingly, in our numerical simulations, we still obtained power-law distribution when the contact rate β was set to a large value, so that the dynamics within a country rapidly reach a stationary state. in this case, with increasing β (and thus increasing initial epidemic growth rates r), the critical exponents tended to µ → . it is well known from the literature , that caution is in order when trying to identify power-law distributions in real data and, in particular, that a straight line in a double-logarithmic plot does not suffice to prove the existence of a power-law distribution. for this reason, the aim of this study is not to prove that the covid- case distribution is a perfect power-law, an undertaking that would require sophisticated statistical analysis and a much larger sample size. we also do not intend to rule out other likely candidate distributions (e.g., log-normal or stretched exponential distributions). instead, our claim is merely to demonstrate that the empirical data are highly consistent with the hypothesis that the number of reported cases are taken from a truncated power-law distribution of the form equation ( ) . nevertheless, the scaling relations in the distributions shown in fig. are remarkably constant over the whole range of case numbers, stretching several orders of magnitude with no obvious signs of saturation for either the range of small or large case numbers. one might argue that the bend in the cumulative distribution function is a sign that the growth in some countries (e.g., china, korea) had already become sub-exponential. however, this is contradicted by the observation that a similar bend is also exhibited by the cumulative distribution function obtained from the meta-population model (fig. ) . thus, the most likely explanation is that the case distribution follows a truncated powerlaw (see also fig. ) , suggesting the hypothesis that the spatial distribution of covid- cases is a fractal. this is further corroborated by our simple theory, which provides a mechanistic explanation for why we would expect a truncated power-law in the first place. our finding of power-law distributions in the number of reported cases has important consequences for epidemiology. most notably, the small values of the estimated critical power-law exponents are related to the strong inequality of case numbers that was frequently observed all over the world in the initial phase of the covid- outbreak. following a power-law distribution means that this pattern prevails even as numbers grew and the scale of infection expanded globally. in particular, during the course of the pandemic, most cases were reported to have occurred in a few countries, sometimes even a single country-the so-called epicenters of the pandemic. the distribution of cases within countries followed a similar pattern. often covid- was peaking in a few localized foci (local regions or cities), while other parts of the country at the same time had experienced only a moderate number of cases. our theory provides a mechanistic explanation why this might have been the case. a graphical representation for the inequality of a distribution is given by the lorenz curve, which in the case of the covid- case distribution is a plot of the fraction of the total number of confirmed cases in dependence of the fraction of the most affected countries. this is shown in fig. for the number of confirmed covid- cases and confirmed deaths on march , . the lorenz curve shows that on this day, . % of confirmed cases and . % of the confirmed deaths had been reported in the % most affected countries (while the top % most affected countries had accumulated . % of all confirmed cases and . % of all confirmed deaths). with out of confirmed cases on that day, china alone had accumulated a fraction of % of all cases. the two most affected countries, china and italy, together had accumulated a fraction of % of the worldwide reported cases. this inequality can also be measured by the gini-coefficient g, power-law distribution with µ < , one would theoretically expect a gini-coefficient of g = . the emergence of power-law distributions with a small critical exponent and the associated inequality of the distribution, with gini coefficients close to one is also observed in the developed meta-population model. consequently, also in the model case numbers are mostly concentrated in a few countries. in the simulations, these epicenters of the pandemic, i.e., the countries with most cases, are always the countries in which the diseases originated or which were first invaded by the virus. in other words, the prevalence rank order among countries remains unchanged during the course of the pandemic. this is akin to the "rich-get-richer process" or "firstmover-advantage," , a well-studied process to generate power-law distributions. in the real covid- pandemic, this was not the case. during the beginning of the pandemic, most cases were observed in china, later the "leading role" changed next to italy and finally to the usa. this reflects different mitigation strategies and circumstances in different countries, a factor that is not considered in the simple model. nevertheless, despite these changes in the rank order, the distribution of cases in the empirical data was always closely represented by a power-law. we would like to remark that the available database only provides information on the reported covid- cases in each country. in all likelihood, the real number of cases will be much larger. not much is known about the reporting rates, but first estimates indicate that a substantial fraction (possible %) of infections might go undetected. reporting rates probably vary strongly between countries and may change in time with the awareness of national health institutions and available testing capabilities. further uncertainties arise because the criteria by which a person is classified as active case (and even more so for being classified as recovered) vary between countries and not uncommonly have been modified during the course of the pandemic within a country. remarkably, we obtained power-law distributions in the absolute number of cases in each country. at first guess, one might have expected such scaling only after case numbers have been normalized by population sizes. our preliminary investigations show that such normalized case numbers become even more unequally distributed, robustness of the algorithm for estimating parameters of a truncated power-law. the same as fig. but for random numbers n i that were generated from a truncated power-law distribution with µ = . and cut-off value n max = × . the estimated distribution roughly follows a straight line on the double-logarithmic plot with equally spaced bins. note that even though only random numbers were drawn, the estimated probabilities vary over many orders of magnitude (which is numerically possible since in order to compute the probability distribution, the histogram counts are divided by the variable bin sizes). log-likelihood estimation of critical exponent (appendix a) yieldsμ = . ± . in good agreement with the actually used exponent. in contrast, the estimator for an unbound power-law, eq. (a ), yieldsμ = . ± . , strongly overestimating the true exponent. the estimation by a regression line, yielding µ = . , also is slightly too large. the inset shows that the cumulative fraction is well described by the cumulative distribution function c(n) of a truncated power-law with critical exponentμ and n max = . × , the maximal n i value of the sample. with even smaller estimated values of the critical exponent, and the distributed values do not line up any more so well on a straight line on a double-logarithmic plot. thus, "folding" the distribution of population sizes over the covid- case distribution does not flatten, but rather tends to further increase, the inequality of the resulting distribution. this indicates that absolute (non-normalized) case numbers may be the natural variables to describe the patterns of the pandemic in its initial stage. in all likelihood, the role of country sizes and population numbers will become increasingly important with the further spread of the pandemic. we have shown that a simple conceptual model yields an accurate description of the covid- prevalence distribution in the initial phase of the pandemic. this is remarkable because many important epidemiological aspects of the spreading process are not captured by the model. most notably, the model takes into account neither variability in country sizes, population numbers, testing rates, heterogeneity of intra-and inter-country connectivity, nor the corresponding changes due to social distancing, lock-down measures, closing of airline connections and shut-down of borders. these simplifications leave much room for future investigations and model improvements. obvious model improvements would be to consider a meta-population with heterogeneously distributed country sizes or to make the initial number of infected individuals a random number, as would be a better description of what happened in many countries. one basic assumption of the developed model is the separation of the pandemic into two spatial scales, the large-spatial spread over a rather small number (n < ) of interconnected countries and the small-scale growth within a population of much larger size (n = × ). this separation obviously is somewhat arbitrary. for the virus, countries are, of course, quasi-arbitrary entities. therefore, it would be important to check whether both the data analysis ( fig. ) and the mathematical model are robust to arbitrarily subdividing or lumping countries. the very similar scaling observed among us counties [figs. (c) and (d)] lends credence to the model's generality. similarly, one can readily ascertain that the model result is not an artifact of artificial lumping. suppose a virus that is spreading in an all-to-all, or randomly coupled, network of a number of n · n pop individuals. if we would artificially subdivide individuals into a small number n of classes (or countries), at the time point when the disease has spread to all countries, within each country, we would still have only a few cases (of the order of n n pop ). thus, the assumed simultaneous spread on both spatial scales requires a real physical separation in the network structure. it would be an interesting perspective for future research to study the spread in multi-scale hierarchies or in more realistic models of interconnected societies. one important model application would be the simulation of interim covid- lockdown or containment measures, as were introduced in many countries in the world in march and april . such measures might inhibit the increase of case numbers within local regions (the small-scale part of our theory) but they would not necessarily suppress also the large-scale diffusion of infections across regions. thus, under the guise of suppressed case numbers during the mitigation period, there could be a dangerous "invisible" homogenization in the spatial distribution of the virus. this would have tremendous implications in a scenario where the measures are suddenly lifted in many places. in this case, our theory would predict the emergence of a very different case number distribution than shown in fig. . instead of the previous power-law distribution resurfacing, the most likely situation would be the synchronous initiation of increasing in case numbers everywhere. thus, situations as they appeared only in the epicenters during the beginning phase of the pandemic could be the rule in most parts where mitigation measures are lifted. in this sense, the long tail of the case distribution, characterized by the many regions with only mild epidemic prevalence, that was observed in the initial phase of the pandemic, could create a false sense of security. finally, we would like to remark that the model's strong simplicity is at the same time a strength: being rather generic, it should be applicable to very different systems, to describe the spread of commodities as a process with two spatial scales. the fact that the distribution of covid- resembles a model where only the initial infection "counts" reflects the intrinsic difficulty in containing epidemics at global and local scales when unilateral measures (e.g., travel bans and lockdowns) are impractical or non-enforceable, i.e., where other countries or regions will step up and continue the spread. thus, assessing how a well simple dualscale model predicts the early spread of epidemics, despite the huge contrasts between countries, could help identify critical temporal and spatial scales of response in which to mitigate future epidemic threats. the author would like to thank christoph feenders, thilo gross, alastair jamieson-lane, cora kohlmeier, james mclaren, and alexey ryabov for helpful comments regarding the article. assume a truncated power-law (or pareto) distribution of the random variable n with upper bound n max . normalization p(n)dn = yields . the cumulative distribution function reads in the limit n max → ∞ (a power-law distribution without upper bound), the cumulative distribution function also follows a power-law c(n) ∼ n −µ . a synthetic sample of the distribution (a ) can be obtained by the formula where u i are random numbers taken from a uniform distribution in the range [ , ]. the inverse problem is to estimate the parameters of the distribution given a random sample n( , n , . . . , n n ) of n data points. the log-likelihood for the distribution eq. (a ) can be defined as , , then, an estimator for the cut-off value is obtained byn max = max(n i ) and an estimatorμ for the critical exponent is obtained by maximizing l(µ), yielding a standard error in these expressions, the "hat" means that we refer to an estimated value. the maximization of l(µ) must be computed numerically (here, we use brent's method from the julia package optim.jl ). in the limit of an unbounded power-law distribution n max → ∞, the maximization can be calculated analytically, yielding μ (a ) to estimate the distribution p(n) of case numbers that vary over many orders of magnitude, we used a histogram with logarithmic binning. that is, we placed a discrete number of bins, k, at positions of integer powers of two n k = k (i.e., , , , , , etc.) chaos article scitation.org/journal/cha and for each bin counted the number h k of countries (or us counties) that under the day of investigation reported a number n of cases that was falling into this bin (n k ≤ n < n k+ ). to obtain the probability distribution, the resulting histogram counts were divided by the varying bin sizes p(n k ) = ch k /(n k+ − n k ) and the normalization constant c fixed so that k p(n k ) = . for visualization, we plotted the distribution on double-logarithmic axes, excluding bins without entries. to confirm the robustness of the histogram estimation, we also used an alternative algorithm, where we first computed the histogram of log-transformed case numbers ν = log(n) using equally spaced bins, which, after normalization, yielded the distributioñ p(ν). next, we used the back-transform p(n) =p(ν)/n to obtain the probability distribution p(n) of non-logarithmic case numbers. this procedure also yields a distribution with bins that are equally spaced on a logarithmic scale and the resulting distributions, shown in fig. in appendix c, are very similar to that from the logarithmic binning method described above. we have checked that the resulting distribution is largely independent to the choice and number of used histogram bins and other numerical parameters. we also computed the cumulative fraction c(n) = n m=n+ p(m) of countries with case number m > n. this was obtained by taking a rank-plot of case numbers and inverting axes, i.e., sorting the array of case numbers in descending order and plotting for each country the rank as a function of the sorted case number on double-logarithmic axes. to describe the spatiotemporal evolution of epidemic prevalence during the course of a pandemic, we developed a conceptual dual-scale meta-population model. the large-scale model component allows us to simulate the spread of the virus in a network of n interconnected countries (with average network degree k). the state of a country is given as a boolean value, being either invaded by the virus or non-invaded. the model starts with a single invaded country. the geographic spread runs in discrete time, each step corresponding to one day of the time-continuous small-scale model. in each time step, a non-invaded country becomes infected by neighboring invaded countries in the network with the transmission probability p. as soon as a country has been invaded by the virus in this process, the small-scale model for this country is initiated. this large-scale model corresponds to the well-known siepidemic spread on a network. the number of invaded countries grows stochastically and roughly follows a sigmoidal shape. neglecting saturation effects (that is, in the initial phase of the pandemic) and assuming a homogeneous degree distribution, the expected number of invaded countries x(t) grows exponentially in time, x(t) = x exp(st), with x = and exponent s = kp. then, the rate of newly invaded countries is given byẊ = s exp(st) and thus also the probability distribution p(τ ) for a country to have been invaded at some former time τ ≤ t, eq. ( ), grows exponentially, p(τ ) = c exp(st). here, the normalization factor is given by c = s n exp(st)/(exp (st) − ), which is determined by the condition that the time integral t p(τ ) dτ = x(t)/n. in our simulation, parameter values were taken as follows: number of countries n = , degree k = (fully connected network), and invasion probability p = × − . the small-scale model is time-continuous and deterministically describes the epidemic dynamics within a country. the model determines the time course of susceptible s, infected i, recovered r, and dead d from a standard sir-model, here, n pop is the constant population size in the country, β is the contact rate, /γ the infectious period, and m the case fatality rate. the total number of cases is determined as c = i + r + d. in the small-scale model, countries are simulated independently from each other and are only coupled by the unique invasion event for each country, which starts the epidemic growth in that country with initial values s( ) = × , i( ) = and r( ) = d( ) = . all infection state variables in a country are zero before invasion by the virus, i = r = d = . the resulting well-known sir-dynamics in a single country is shown in fig. . with the chosen parameterization, it takes roughly days until the epidemic peak is reached. after this time, the assumption of an exponential increase, eq. ( ), breaks down. parameter values were taken as follows: country population size n pop = × , case fatality rate m = . , infectious period /γ = d, and contact rate β = . d − . this yields a growth rate r = β − γ = . d − , corresponding to a doubling time of t , = log( )/r = d and a basic reproduction number r = β/γ = . . alternative calculation of the distribution of covid- case numbers in countries worldwide and counties in the us. code for data analysis and numerical simulations was written in julia, ref. parameter estimation for the truncated pareto distribution a mathematical model for the spatiotemporal epidemic spreading of covid self-organized criticality: an explanation of the /f noise emergence of scaling in random networks réflexions sur les avantages de l'inoculation julia: a fresh approach to numerical computing zipf's law in the popularity distribution of chess openings the hidden geometry of complex, networkdriven contagion phenomena fractals and disordered systems the effect of travel restrictions on the spread of the novel coronavirus ( -ncov) outbreak power-law distributions in empirical data the role of the airline transportation network in the prediction and predictability of global epidemics fitting and goodness-of-fit test of non-truncated and truncated power-law distributions an interactive web-based dashboard to track covid- in real time impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand preparedness and vulnerability of african countries against importations of covid- : a modelling study variabilita e mutabilita frequency of earthquakes in california forecast and control of epidemics in a globalized world calculation of epidemic arrival time distributions using branching processes the complex network of global cargo ship movements modeling infectious diseases in humans and animals a contribution to the mathematical theory of epidemics substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) effective containment explains subexponential growth in recent confirmed covid- cases in china strong correlations between power-law growth of covid- in four continents and the inefficiency of soft quarantine strategies a brief history of generative models for power law and lognormal distributions optim: a mathematical optimization package for julia power laws, pareto distributions and zipf's law the first-mover advantage in scientific publication networks: an introduction cours d'economie politique novel coronavirus ( -ncov) early-stage importation risk to europe networks of scientific papers differential equations.jl-a performant and featurerich ecosystem for solving differential equations in julia how popular is your paper? an empirical study of the citation distribution the risk of marine bioinvasion caused by global shipping on a class of skew distribution functions critical phenomena in natural sciences evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease complexity in human transportation networks: a comparative analysis of worldwide air transportation and global cargo-ship movements coronavirus disease (covid- ) situation reports the gleamviz computational tool, a publicly available software to explore realistic epidemic spreading scenarios at the global scale levy flight search patterns of wandering albatrosses on estimating the exponent of power? law frequency distributions a mathematical theory of evolution based on the conclusions of human behavior and the principle of least effort key: cord- -jv qwjg authors: borthakur, arijitt; barbosa, eduardo m.; katz, sharyn; knollmann, friedrich d.; kahn, charles e.; schnall, mitchell d.; litt, harold title: radiology extenders: impact on throughput and accuracy for routine chest radiographs date: - - journal: j am coll radiol doi: . /j.jacr. . . sha: doc_id: cord_uid: jv qwjg interpretation of chest radiographs, although clinically highly impactful, entails a disproportionate amount of work relative to low reimbursement for these studies. increasing volumes of chest radiographs in the thoracic imaging division of an academic radiology practice led to incorporation of two radiology extenders (res) to draft reports of chest radiographs. we evaluated the difference in productivity and accuracy of the reports drafted by res versus radiology trainees. impact on throughput was analyzed by measuring flow rates (number of radiograph interpretations finalized per hour) for four subspecialist attending thoracic radiologists under three conditions: independent interpretation, reviewing re-drafted cases, and reviewing resident-drafted cases. improvements were calculated as change in flow rates for the latter two conditions compared with an independent interpretation. accuracy of re-drafted reports was compared with that of junior residents by evaluating their draft reports for the same chest radiographs (n = ). a blinded judging panel of three attending radiologists scored these reports using the -point radpeer scoring system; the original report dictated by an attending radiologist served as the reference standard. radpeer scores were compared between the res and residents. flow rates improved significantly (p < . ) by % for re-drafted cases versus a small improvement ( %) for resident-drafted cases compared with independently completed cases. re-drafted cases generated % greater efficiency for attending radiologists compared with resident-drafted cases (p < . ). there was no significant difference in accuracy scores between re-drafted and resident-drafted reports. re-drafted reports were finalized more rapidly by attending radiologists with insignificant differences in discrepancy rates compared with resident-drafted reports. thoracic radiographs are performed in patients in the intensive care unit primarily to identify placement of support tubes, catheters, and other devices. although highly impactful toward patient care, interpreting these radiographs entails a disproportionate amount of work (eg, retrieving patient history, completing standard dictation templates, and ensuring proper communication of important findings before finalization of reports). given low reimbursement rates for these studies, economic necessities push radiologists to provide faster interpretations, contributing to burnout. secondly, tasks that are characterized by low complexity and variability result in mundane work and a low sense of personal accomplishment, thus reducing job satisfaction for attending radiologists. although both high throughput and repetitive tasks lead to underperformance in any occupation [ ] , including medicine [ , ] , it has been particularly of concern in the field of radiology [ ] [ ] [ ] . we previously described method to improve radiologists' productivity by using a radiology extender (re) in a musculoskeletal radiology section [ ] . that experience motivated a trial of this concept in the department's cardiothoracic imaging division at our academic medical institute, which reports over , radiographs per week. the first experiment was to determine the impact of re on throughput by measuring the time taken by radiology attending radiologists to finalize examinations. the second experiment compared the accuracy of re-drafted reports to those from residents by comparing their dictation texts for the same chest radiographs. double reading of imaging examinations is an accepted method of assessing interpretation quality [ , ] . in this approach, examinations are submitted to different reader(s) after the initial reader and are reinterpreted with the same clinical information and prior examinations that were available at the time of the initial interpretation by an attending radiologist. a third set of readers then compared both re and resident-drafted reports and scored any discrepancies using the radpeer system [ , ] . major discrepancy rates were obtained by quantifying the highest score ( b) across res and residents. both res were recruited from an experienced pool of radiologic technologists through a formal interview process. interview candidates responded to an advertisement circulated internally in our hospital system. interviews were conducted over a period of a month by two radiology faculty, a clinical administration leader, and an operational business advisor. nearly all candidates exhibited desirable characteristics such as radiographic technical knowledge, intellectual curiosity, and ability to decide under ambiguity. however, the two best candidates additionally had concrete evidence of performing beyond their current job requirements in completing tasks. both res were trained over a period of months to interpret one-or two-view chest radiographs by a senior thoracic imaging radiologist with over years of experience as a faculty member. commensurate with previous re training efforts [ ] , these included one-on-one review of cases predrafted by the trainee and directed reading in both an online course designed to train radiographers in the uk to interpret images (http://eintegrity.org, ware, united kingdom), as well as standard radiologic texts. finally, the res were trained to dictate using standardized templates in our hospital's clinical reading rooms using standard reporting technology (ids pacs, sectra inc, shelton, connecticut; powerscribe reporting system, nuance, burlington, massachusetts). the res were deployed to the chest radiology section and drafted on average to cases each per day for a month period. this project was undertaken as a quality improvement initiative and thus was exempt from institutional review board review. four board-certified subspecialty-trained thoracic radiologists with at least years of experience as faculty volunteered for this study. all radiographs were read in one of our hospital's standard clinical reading rooms using the same reporting system utilized for training the res. examinations types were restricted to those routinely processed by the res as part of their normal workflow. these consisted of chest one-view anterior-posterior or two-view lateral and posterior-anterior radiographs corresponding to current procedural terminology codes or , respectively. examinations were not controlled for case variety or complexity, to replicate the realistic clinical scenario of the daily workflow. a single observer (a.b.) manually measured the time from examination opening in pacs to final signing in three categories: independently interpreted by the attending radiologist, redrafted reports, or resident-drafted reports. to reduce variability due to repeated stop-start events, the attending radiologists read out blocks of to or more cases under each category during each timing episode without interruption. these experiments were performed over several days to accumulate at least cases for each category for each attending radiologist. flow rate was defined as the number of radiographic examinations finalized per hour. a sample of attending radiologist-only finalized examination reports with current procedural terminology codes and were extracted from the radiology database mpower (nuance communications) to serve as the reference standard. only accession numbers, the unique record number in the local radiological information system for each diagnostic imaging examination, were supplied to the reporters who proceeded to dictate new reports using standardized templates without viewing the original attending radiologist's report. these reports were copied into a word (microsoft corp, redmond, washington) document and securely e-mailed to a single researcher (a.b.) for preprocessing, which involved automatically extracting report elements using custom-built code in python . programming language written in a jupyter notebook (jupyter.org), an open-source web application interface. all extracted examination reports were stored on a scoring template created using excel (microsoft corp) and saved using a coded file name to blind the reporter's identity. reporter's scoring template files were sent to a judging panel consisting of three attending radiologists with over years of specialist thoracic imaging experience each. judges were also provided the original attending radiologist reports to use as a gold standard. comparisons were restricted to text of the reports and no images were supplied. diagnostic discrepancies were classified according to acr's radpeer scoring system [ ] . this scoring system determines the significance of a discrepancy based on a point scale: ¼ concur with interpretation, ¼ discrepancy in interpretation or not ordinarily expected to be made (understandable miss), and ¼ discrepancy in interpretation or should be made most of the time. modifiers for scores and include a ¼ unlikely to be clinically significant and b ¼ likely to be clinically significant, resulting in five possible scores. radpeer scores of b were deemed a major discrepancy and their count was recorded in the excel spreadsheet for both res and residents. statistical analyses were performed in jmp pro (sas, cary, north carolina) and results graphed in excel. a p value of <. was assumed to be statistically significant for all hypothesis testing. for the flow rate measurements, average read time, defined as the time taken between opening the first case in a queue until finalization of the last case, was recorded within a fraction of a minute. analysis of variance was performed on flow rate measurements with three-level categorical dependent variables (ie, independently interpreted, resident, and re), resulting in a t test with pooled standard error. an ordered logit model [ ] was used to regress ordinal radpeer scores against the reporter category (ie, re or resident) and accession number of the cases to account for case mix. the model fits the cumulative response probabilities to the logistic function of a linear model using maximum likelihood. the value of the likelihood ratio c statistic and associated p value were recorded as the figure of merit for the corresponding effect. a low value of the statistic means that the null hypothesis should not be rejected. the res at our practice were formally recruited from a pool of x-ray radiologic technologists (rad techs or rts), whose qualifications vary by state but must have at least an associate's degree or a technical diploma. both of our res have bachelor's degrees in addition to being licensed radiologic technologists for at least years. one studied art history in college and served as a licensed medic, and another has an undergraduate degree in medical imaging, completed her rt training at our institute, and served as the lead inpatient tech for the preceding years. flow rate for the three categories of examinations finalized by the four attending radiologists that participated in the timing study are shown in figure . re-drafted cases were finalized more rapidly compared with resident-drafted cases as well as cases completed by the attending radiologists themselves. on average, the four attending radiologists finalized . cases per hour when reviewing re-drafted cases, . cases per hour when reviewing resident drafted cases, and . cases per hour performing independently, with a pooled standard error of ae . cases per hour. consequently, flow rates improved significantly (p < . ) by % for re-drafted cases compared with a smaller improvement of % for resident-drafted cases, which was within the error variance of flow rate of independently completed cases. re-drafted cases were also finalized % (p < . ) faster by the attending radiologists compared with resident-drafted cases, suggesting perhaps that more edits were necessary on resident compared with re reports. the distribution of radpeer scores across the reporters (fig. ) revealed no significant difference in scores between re-drafted and resident-drafted reports. the major discrepancy rate amounted to less than % of all cases and generated only by the res. modeling scores with reporter type and examination case mix (ie, accession number) showed a -fold greater contribution by the latter variable to the likelihood-ratio c ( table ) , regardless of whether the reporter was a resident or an re. combining these results suggested that the variability in scores was significantly (p < . ) related to case mix and indifferent to reporter type. the results of this project revealed baseline values for flow rate improvements, a key performance indicator for gauging flow rate, defined as the number of radiographic examinations finalized per hour, for the three categories of examinations finalized by the four attending radiologists that participated in the timing study. radiology extenderdrafted cases were finalized more rapidly compared with resident-drafted cases or cases completed by the attending radiologists independently. note: error bars indicate ae % confidence intervals using a pooled estimate of error variance. efficiency gains from incorporating an re in practice. previous work at our institute that graded trainee reports demonstrated that the rate of discrepancies as measured by major changes during attending radiologist review varied from . % to % among individual residents, modalities, and level of resident training [ , ] . hence the discrepancy rate of the res is within that expected of trainees. major discrepancy rates, although low and consistent with values measured previously at our institution, still merit a deeper evaluation to detect patterns of mischaracterizations or bias by the reporters. measured values will be leveraged to optimize the deployment of res into the reading rooms to synchronize their work schedules with fluctuating radiography volumes during the course of a day or a week. furthermore, the variability in the efficiency gains across radiologists could be utilized to redesign the processes of allocating cases into each of their queues. the re job role is controversial among some who consider res as a cost-effective replacement for radiology trainees. we respectfully disagree with their presumption. the incorporation of res had been a strategic decision to address recent mergers and acquisitions that have resulted in our radiology service providing care in multiple affiliated hospitals and diagnostic imaging centers located across our region and growth within those facilities, performing over a million cases annually. as with other academic hospitals, we have relied on trainees to share the burden of interpreting studies at lower cost; however, their supply has not kept pace with the increasing volume of work. regardless, as an academic medical center we hold training the next generation of radiology leaders at a higher priority than any revenue improving or cost control initiative. we are confident that the re job function makes more business sense if res are deployed in a strategic and meaningful manner. physician wellness is acknowledged as an essential goal in enhancing the safety and quality of health care [ ] . q although we are in the process of surveying radiologists' satisfaction with the new workflow, concerns in response to our earlier work on the role of res included the suggestion that reallocation of radiologists' tasks would devalue their work. we contend that the diagnostic responsibility remains with the radiologist in the reenhanced workflow while some of the technical tasks such as handling the computer software for speech recognition and text editing are taken over by support staff. our model does not reassign the intellectual contribution of the radiologist, but rather improves their professional stance by relieving them of some of the information technology tasks in a manner that fits the modern, fast-paced health care arena better than other methods such as tape-recording dictation models. we continue to manage the process improvement change proactively by tracking success with performance indicators such as average daily volumes by each re. over a typical month, each re predrafts upwards of cases per day, which at the activity time difference measured would free up min of a radiologist's time per day for higher value work. our experience in transforming our radiology practice required effective change management approaches to clearly articulate the business need and projected impact clearly. we relied on data from a variety of internal systems such as portable x-ray, radiologist, and resident schedules to optimize the work hours for the res and on external sources such as online courses for training. although the current res at our practice are licensed x-ray technicians with bachelor's degrees, as the role evolves and is adopted more distribution of radpeer scores from radiology extenders (gray bar) and residents (white bar). score of b is considered a major discrepancy in this study. these results suggested that the variability in radpeer scores was significantly (p < . ) related to case mix (ie, examination accession number) and indifferent to reporter type. df ¼ degrees of freedom, l-r c ¼ likelihood ratio c statistic. widely, we foresee additional licensing and certification requirements, most likely on a state-by-state basis. a limitation of our approach was that an ideal quality evaluation should also assess the accuracy of the initial report, independently verifying those findings with operative findings, pathology reports, or a consensus interpretation by experts. this would lead to a better understanding of the discrepancies observed in the current study and will be pursued in a subsequent study. another limitation for the timing experiments was that the differences in types of cases was not controlled as attending radiologists were timed finalizing cases each morning as part of their routine clinical workflow. there may also be a "hawthorne effect," sometimes described as the increase in human productivity when people are observed and measured in real time [ ] , and may be different for each radiologist. additionally, although these interpretations were performed as part of the radiologists' clinical work, they were completed and timed without interruption, which may not reflect a typical routine. as their medical colleagues have become more comfortable with their services, the res have taken on additional responsibilities in the reading room. a frequent complaint of radiologists is the many daily interruptions that impede one's ability to sustain a high rate of examination interpretations. fishman et al [ ] describe these interruptions to include telephone calls with referring physicians to communicate important results and working with technologists regarding protocoling or image acquisition. a recent publication from our institution on deploying a "call triage assistant" demonstrated improved workflow efficiency and reduced resident stress on call [ ] . at our practice, the res are routinely becoming the first to answer telephone calls and communicate previously reported findings to referring physicians, routing more difficult questions to senior house staff or attending radiologists as needed. finally, advances in artificial intelligence and machine learning techniques, particularly deep learning algorithms, have demonstrated significant success in image recognition [ ] . in thoracic imaging, these algorithms have been able to perform a variety of tasks such as automatically identifying and categorizing benign or malignant lung nodules in ct images, predicting long-term mortality from chest radiographs [ ] , and distinguishing covid- from other types of pneumonia from ct images [ ] . as artificial intelligence becomes more integral to patient care in radiology, radiologists who have leveraged its potential will likely become indispensable to the field [ ] . we foresee the re role evolving in conjunction to serve as a data curator, leveraging their technical expertise to assess image quality and guide reacquisition and performing hyperparameter tuning during model training to accelerate the adoption of machine learning algorithms in radiology workflow. -deployment of res in the thoracic imaging section of our academic radiology practice improved efficiency of chest radiography. -re-drafted reports were finalized more rapidly than resident-drafted reports by attending radiologists with insignificant differences in interpretation discrepancy rates. borthakur et al n radiology extenders a new strategy for job enrichment estimating the attributable cost of physician burnout in the united states changes in burnout and satisfaction with work-life integration in physicians and the general us working population between a call to action-our radiology chairs are burning out the road to wellness: engagement strategies to help radiologists achieve joy at work addressing burnout in radiologists improving performance by using a radiology extender radiology double reads added value of double reading in diagnostic radiology, a systematic review getting the most out of radpeer acr radpeer committee white paper with updates: revised scoring system, new classifications, self-review, and subspecialized reports regression models for ordinal data identifying benchmarks for discrepancy rates in preliminary interpretations provided by radiology trainees at an academic institution orion: a web-based application designed to monitor resident and fellow performance on-call the relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review radiologist productivity increases with real-time monitoring: the hawthorne effect evaluating the impact of a call triage assistant on resident efficiency, errors, and stress current applications and future impact of machine learning in radiology deep learning to assess long-term mortality from chest radiographs using artificial intelligence to detect covid- and community-acquired pneumonia based on pulmonary ct: evaluation of the diagnostic accuracy will machine learning end the viability of radiology as a thriving medical specialty? key: cord- - whai nr authors: nan title: esp abstracts date: - - journal: virchows arch doi: . /s - - - sha: doc_id: cord_uid: whai nr nan ofp- - intraoperative evaluation of breast cancer sentinel lymph node metastasis with an automated molecular detection method as an alternative to standard pathological evaluation f. beca * , e. rios, p. pontes, i. amendoeira * centro hospitalar de são joão, anatomic pathology, porto, portugal objective: one-step nucleic acid amplification assay (osna) from sysmex® is an automated system to detect sentinel lymph node (sln) metastasis in breast cancer patients. this assay is based on the detection of cytokeratin mrna amplification by reverse-transcription loop-mediated isothermal amplification. traditionally intraoperative evaluation of sln is accomplished by cytology and/or frozen section, accounting for heavy workload to pathology department. the objective of this study is to compare the osna assay with our standard processing for intraoperative sln evaluation. method: sln from patients with ck + and invasive primary carcinomas where simultaneously evaluated by cytology and/or frozen section and by osna assay. results where compared with gold-standard definitive h&e evaluation (serially sectioned at μm intervals). results: the sensitivity and specificity of osna assay was . % and . %, respectively with a positive predictive value (ppv) and a negative predictive value (npv) of %. for standard intraoperative evaluation, specificity was % and sensitivity was . %. conclusion: osna assay showed similar specificity and higher sensitivity than standard pathologic examination. these findings suggest it can be used as an accurate tool for intraoperative evaluation of slns metastasis and possibly contribute to reducing the need for re-intervention for axillary lymph node dissection. objective: antracycline-based chemotherapy represents a standard of care in breast cancer patients especially who overexpress her- . topoisomerase a has been considered a molecular target for antracyclines and its co-amplification with her- genes has been proposed. in our study we investigated if topoisomerase a overexpression can be used as a molecular marker on predicting response to antracycline-based chemotherapy. method: breast cancers tissues from patients underwent to antracycline-based neoadiuvantchemotherapy and treated with adiuvant therapy were collected into tissues microarrays, and classified according to pathological stage, er, pr, her- and topo a status. the expression of topoisomerase a has been correlated to response to chemotherapy. results: our results show that topo a expression is significantly higher in neoplasms with larger size, nodal metastasis, scant er end pr receptors, and amplification of her- gene (p < , , t-test). cancers in witch high level of topo a has been found exhibit a better clinical response to treatment with anthracycline (p < , , t-test). therefore topo a expression could be considered both as predictive and prognostic marker. conclusion: the employment of topo a as a predictive marker in clinical practice may be useful for the medical therapy of non-endocrine-responsive patients candidate to undergo treatment based on anthracycline, that is no free from adverse effects as cardiomyopathy and leukemia. ofp- - stem cells in triple negative breast cancer and associated in situ lesions m. comanescu * , m. dobre, g. bussolati * institutul victor babes, dept. of pathology, bucharest, romania objective: triple negative breast cancer (tnbc) (negative for expression of estrogen and progesterone receptors (er, pr) and her /neu protein) represent a subtype of breast cancer associated with poor prognosis and highly aggresive behaviour. genetic characterization of stem cell (cd , ....) in this type of carcinoma might provide important data concerning origin and evolution. data of the literature focused specifically on tnbc but, despite the interest shown to stem cells recently, there are no data concerning the genetic characterization of stem cells in the context of cell biology of tnbc as compared with associated dcis. method: we investigated, through immunohistochemistry, the expression and distribution of several stem cell/related antigens, exploring the association of tnbc with dcis and comparing the presence of stem cells in the invasive and in the in situ component. results: the multiplicity of parameters to be detected for characterising stem cells and of the diagnostic materials that are available would prevent a straightforward approach and a sequential combination will have to be planned. conclusion: optimization of detection, identification and characterisation of tumourigenic breast cancer stem cells might permit further identification of targeted treatment. over-and undergrading of breast cancer on core biopsies in comparison to surgical specimens t. decker * , c. focke, d. gläser * d. bonhoeffer medical center, dept. of pathology, neubrandenburg, germany objective: to evaluate the relevance of histological grading (hg) based on core biopsies (cb) for clinical decision making in breast cancer (bc) we evaluated the concordance with hg from surgical specimen (ssp) and the reasons for under-or overgrading. method: cb and related ssp of bcs were prospectively graded according to the nottingham grading system (ssp: g , g and g ). cb/ssp agreement rates and positive predictive values (ppv) of cb based hg were calculated. rates of over-and underestimation of glandular differentiation (gd), nuclear pleomorphism (np) and mitotic activity (ma) were calculated. results: cb/ssp agreement rates came out with % for g , % for g , and % for g . the ppvs of cb based hg were % for g , % for g and % for g . the overgrading and undergrading rates on cb were % and %, respectively. main causes for undergrading in cb were underestimated ma ( %) and a combination of underestimated np and ma ( %). conclusion: whereas overgrading on cb is an exception, undergrading derives largely from underestimation of proliferation. agreement of hg between cb and ssp ranges from almost perfect for g , moderate for g to slight for g tumours. ofp- - comparative histopathology of mammary alterations in women and dog v. deckwirth * , p. kronqvist, m. lintunen, a. sukura * university of helsinki, dept. of veterinary pathology, finland objective: companion animals such as dogs share the same environment with people. mammary tumours are the most prevalent spontaneous neoplasia in intact bitches. more animal models are needed for human mammary tumour research. our objective was to describe equivalent non-neoplastic and neoplastic mammary gland alterations in woman and dog. method: formalin-fixed, paraffin-embedded archived human and canine mammary gland tissue samples. epidemiological data were collected and analyzed from human (n= ) and canine (n= ) patients for the years - . histological comparison was performed with he-stained tissue sections and immunohistochemistry. applied antibodies included ck / , erα, pr, ki , her , p , sma, ecadherin and calponin. results: several comparable benign and malignant mammary gland alterations were identified, consisting of lobular, tubular and ductal as well as mesenchymal of origin. most of these have not been described previously. the epidemiological results show also shared characteristics. conclusion: although there are canine specific lesions there also exist equivalent entities. our results indicate the female canine as a suitable model for translational research. ofp- - st. gallen intrinsic subtyping of breast cancer: influence of proliferation assessment methods c. m. focke * , d. gläser, k. finsterbusch, t. decker * dietrich bonhoeffer klinikum, abt. pathologie, neubrandenburg, germany objective: the st. gallen conference strongly recommends intrinsic subtyping of breast cancer (bc) for therapeutic decisions. we analyzed the influence of different proliferation assessment methods on the bc subtype distribution. method: intrinsic subtyping was performed according to the st. gallen criteria on bcs. proliferation was assessed by mitotic activity index (mai) (area: , mm², cut-off ≥ ) and by several variants of ki -labeling-index counting any nuclear staining of ( ) tumor cells within the hot spot (ki - ), ( ) tumor cells in hpf in the tumor periphery, including the hot spot (ki - periphery), and ( ) tumor cells in hpf, including hot spot, cold spot and an intermediate area (ki - spectrum) using the recommended cut-off of < %. results: of carcinomas, % were triple-negative, % her +, % luminal b her +, and % special type. the rates of bcs after different proliferation assessment methods were: mai % vs. %; ki - spectrum: % vs. %, ki - periphery: % vs. % and ki - : % vs. %. conclusion: subtyping of luminal a and luminal b her neg bcs according to st. gallen is highly influenced by the method of proliferation assessment used. its biological relevance seems to be not unequivocal. ofp- - the utility of cytological smears allied to the osna method for intraoperative analysis of sentinel lymph-node metastasis in breast cancer patients s. foreid * , m. martins, h. pereira, m. oliveira * loures, portugal objective: one-step-nucleic-acid-amplification (osna) is a recently introduced pcr method to evaluate intraoperative sentinel lymph-node metastasis in breast cancer. it assesses the whole lymph-node in a -minutes protocol. many studies have reported it to be more sensitive than frozen section and/or cytology. yet, it is more expensive and takes longer to perform. method: between and at chlc, we have performed the intraoperative analysis of sentinel lymph-node using both osna and cytological smears in a group of patients. results: lymph-node evaluations were done. cases were osna positive ( micrometastasis and macrometastasis). of those, were also positive for tumor cells on cytological smears. cases were negative by both methods and cases were detected by osna but not on cytological smears. importantly, all macrometastasis diagnosed by cytology were confirmed by osna. of notice, in this series, % of the positive cases detected by osna were also detected by cytological smears. conclusion: like previously reported, osna showed a greater sensibility than cytology to diagnose sentinel node metastasis. however, the majority of metastasis can be detected by cytological smears alone. our results suggest that a less expensive and faster cytological analysis should precede osna, and if positive, the latter method could be disregarded. tuesday, september , . - . objective: tumor markers may be concentrated intraductally in early breast cancers. method: to test this hypothesis, her -ecd and ca - of the needle washout fluid from benign lesions, dcis, and invasive carcinomas of the breast were measured using chemiluminescence. the measuring limit for her -ecd ( . ng/ml) and that for ca - ( u/ml) were used as the cutoff values, respectively. results: the proportion of patients with any biomarker elevation was . % in cases of benign lesions, . % in dcis, and . % in invasive carcinomas. thus, biomarker elevation was most frequent in dcis, followed by invasive carcinomas (p< . ). her -ecd values over ng/ml or ca - values over u/ml were s een exclusively in dcis or invasive ductal carcinomas with an extensive intraductal component, supporting the hypothesis. conclusion: our approach may be useful to identify a subset of breast cancer patients who are suitable for intraductal molecular targeted therapy. ofp- - biological significance of proliferation and her overexpression in luminal/oestrogen receptor-positive breast cancer d. jerjees * , a. green, a. benhasouna, a. alshareeda, r. abduljabbar, f. barros, c. nolan, i. ellis, e. rakha * university of nottingham, dept. of oncology, united kingdom objective: in this study, we have compared the biological significance of proliferation; assessed using ki labelling index (ki -li), with respect to her expression in oestrogen receptor positive (er+) breast cancer to assess the impact on growth fraction and biological characteristics of luminal breast cancer. method: well-characterised er + breast cancers were assessed for expression of a large panel of biomarkers (no= ). results: % of the cases showed high ki -li (> %) and % showed her over-expression and both were positively associated with younger age, higher tumour grade, lymph node stage and shorter outcome. both markers were associated with up-regulation of er-coactivators (cd , carm , pi kca&tk ), p-cadherin, p and with lower levels of er expression and down-regulation of er-related genes (pgr, ar&gata ) and brca . neither of the two markers was associated with expression of basal-associated cytokeratins. high ki -li was associated with down-regulation of luminal enriched markers including luminal cytokeratins, muc , gcdfp- , fhit, and transcription and differentiation errelated genes (foxa and tff ). in contrast, her expression was associated with up-regulation of luminal cytokeratins, gcdfp- , fhit and e-cadherin. conclusion: unlike high ki -li, her overexpression is not associated with the down-regulation of luminal enriched genes. increased growth fraction in er + tumours may be driven by different mechanisms in her +&her -disease. ofp- - loss of drosha expression is associated with poor survival in breast cancer patients s. khoshnaw * , t. abdel-fatah, c. nolan, z. hodi, e. rakha, d. macmillan, i. ellis, a. green * university of nottingham, breast cancer pathology, united kingdom objective: drosha is a protein that plays a key role in the biogenesis of micrornas which are well known to be deranged in human breast cancer. the purpose of this study was to investigate the hypothesis that drosha is significant in the development and progression of breast cancer and has clinical relevance as a potential predictive and prognostic target. method: we have examined drosha protein expression, using microarray and immunohistochemistry, in a well-characterised series of unselected invasive breast cancer patients (n= ) with long-term follow-up and documented expression characteristics for a large range of biomarkers of known relevance in breast cancer. furthermore, a smaller cohort of selected breast cancer cases (n= ) was also investigated for differential drosha protein expression in distinct stages of tumour progression, including in situ (dcis), invasive and metastatic components. results: drosha cytoplasmic and nuclear expression was lost with cancer progression, and was associated with loss of brca expression. multivariate statistical analyses showed that drosha cytoplasmic expression was an independent predictor of breast cancer specific survival, tumour recurrence and metastases. conclusion: drosha cytoplasmic expression in breast cancer is an independent predictor of patient outcome, tumour recurrence and metastasis. these observations imply that alterations in mechanisms of mirna regulation can influence tumour behaviour. objective: determination of proliferation in breast carcinomas is highly prognostic and can have treatment implications. however, there is no consensus on issues such as counting area or cut-off values. our aim was to examine and compare ki- counts in various tumor areas, the novel mitosis marker phh , and standard mitotic count. method: we examined a nested case-control series (n= ) as part of the population-based norwegian breast cancer screening program. mitotic count (mitosis per mm ) was assessed on h&e-sections. the percentage of ki- positive nuclei among tumor cells was recorded for both hot-spots (hs; highest proliferation) and cold-spots (cs; lowest proliferation). phh counts (per mm ) were evaluated by immunohistochemistry. results: the upper quartiles for ki- -hs, ki- -cs, phh and mitotic count consistently showed the strongest associations with known unfavorable tumor features (high histologic grade, er negativity, her positivity, ck / +, p-cadherin+). univariate survival analysis showed comparable prognostic strength of ki- -hs, phh count and mitotic count. in multivariate analysis, mitotic count was the strongest prognostic factor among these. conclusion: by upper quartile, ki- -hs, phh and mitotic count all showed strong associations with various tumor features. in multivariate survival analysis, mitotic count was the strongest proliferation marker. objective: ki li is a good marker of breast cancer prognosis. we aimed at comparison of performance of ki antibodies. method: breast cancer cases were retrieved. immunohistochemical staining for ki clones ( - , b , mib , polyclonal, sp ) performed in tma-s in automated immunostainer. evaluation performed on digital slides utilizing linear - frequency score. objective: in breast cancer, classification systems are used to assess pathological response to neoadjuvant chemotherapy. biomarkers are still needed to better predict the efficiency of primary systemic therapy. dysregulation of connexin (cx) channels (gap junctions) is involved in carcinogenesis and tumor progression. method: we have correlated cx expression and the pathological response in neoadjuvant treated breast cancers. fifteen of the human cx isotypes were pre-screened. cx , cx , cx and cx were found widespread and tested in tissue microarrays of breast cancers prior to and after neoadjuvant chemotherapy. pathological response was characterized according to the ewgbsp, cps-eg, miller-payne, sataloff, and nsabp classification systems. results: only the cps-eg classification had prognostic relevance by score - cases presenting better overall survival (p= . ) than those scoring - . cx levels prechemo correlated with hormone receptor status pre-and post-chemo and had inverse correlation with her levels pre-chemo. reduced cx expression (< %) post-chemo correlated with better overall survival (p= . ). moderate or higher cx expression (> %) pre-and post-chemo was also associated with better survival in the ewgbsp tr b (ppre= . ), sataloff tb (ppre= . ; ppost= , ) and miller-payne g (ppre= . ; ppost= . ) subgroups. conclusion: classifications combined with testing for cx and cx expression can improve prediction of neoadjuvant chemotherapy in breast cancer. ofp- - atypical vascular lesions after radiation therapy for breast cancer: a clinicopathologic study and outcomes of cases h. gobbi * , c. fraga-guedes, m. mastropasqua, m. kneubil, e. botteri, g. viale * ufmg, dept. of anatomic pathology, belo horizonte, brazil objective: we assessed clinicopathologic features and outcomes of cases of atypical vascular lesions (avl) in patients submitted to radiation therapy for breast carcinoma. method: data from all patients were retrieved from the files of the european institute of oncology (eio), milan. histopathological review of all cases was carried out. results: all patients were women (median age: year, range: - year). median lesion size was . cm (range: . to . cm). median latency interval from radiation to avl diagnosis was months (range: to months). . % of cases presented as an erythematous unique papule confined to superficial/middermis with proliferation of thinwalled, vascular channels, lined by a single layer of bland endothelial cells. no prominent nucleoli, mitoses or blood lakes were seen. patches of chronic inflammatory infiltrate accompanied all avl. one patient ( . %) developed local recurrence, and two patients ( . %) developed angiosarcoma in the previous biopsy site, and months later. margin involvement was associated to unfavorable outcome. conclusion: our data suggest that post-radiation avl and angiosarcoma may represent a spectrum of the same disease process. the development of local recurrence and subsequent angiosarcoma indicate that avl must be completely excised, with free surgical margins, and patients must be accompanied by clinical exams and imaging. objective: gastric dysplasia is classified as gastric/foveolar and intestinal/adenomatous according to morphological (architectural and cytologic) features. the immunophenotypic classification of dysplasia, based on the expression of mucins and cd , recognizes three major types: gastric (muc ac and/or muc ); intestinal (muc and/or cd ); hybrid (gastric and intestinal markers). cdx is a transcription factor responsible for early intestinal differentiation. aldh is recognized as a stem cell marker in several organs. method: nineteen cases of dysplasia were classified as gastric/foveolar (n= ) or intestinal/adenomatous (n= ) and graded as low-grade (n= ) and high-grade (n= ). immunophenotypic classification showed gastric (n= ; %), intestinal (n= ; %) and hybrid (n= ; %) phenotypes. results: cases classified by morphology as gastric/foveolar-type displayed gastric ( %) or intestinal ( %) immunophenotype, whereas intestinal/adenomatous-type cases displayed gastric ( %), intestinal ( %) or hybrid ( %) immunophenotype (p= . ). high-grade dysplasia was identified in cases with gastric ( %), intestinal ( %) and hybrid ( %) immunophenotype (p= . ). cdx expression was significantly lower (p= . ) in gastric ( %) than in intestinal and hybrid immunophenotypes ( %). aldh expression was displayed only in gastric ( %) and hybrid ( %) immunophenotypes (p= . ). conclusion: gastric dysplasia is heterogeneous and morphology is insufficient to elucidate cell differentiation. high-grade dysplasia, decreased cdx expression and high aldh expression are associated with gastric immunophenotype. ofp- - tumor budding in pancreatic cancer: are we missing important prognostic information? d. born * , i. zlobec, m. montani, b. gloor, a. lugli, e. karamitopoulou-diamantis * universität bern, inst. für pathologie, switzerland objective: tumor budding is defined as single tumor cells or small cell clusters at the invasive front of gastrointestinal (including colorectal, gastric and ampullary) carcinomas and is linked to adverse prognosis. to date it has not been reported in pancreatic ductal adenocarcinomas (pdacs). we assessed the presence and prognostic importance of tumor budding in pdac. method: whole-tissue sections of pdacs with full clinico-pathological and follow-up information were stained with pancytokeratin. tumor budding was assessed in high-power fields (hpfs) by two pathologists and considered high-grade (hg) when an average of > buds was counted. measurements were correlated to the patient and tumor characteristics. results: inter-observer agreement was strong (icc= , ). hg-budding was found in . % of cases and was linked to advanced pt-stage (p= . ), lymphatic invasion (p= . ) and decreased disease-free and overall survival (p< , and p= , ). there was no association with pn, pm, r-stage or vascular invasion. in multivariate analysis the prognostic effect of hg-budding was independent of lymphatic invasion, pn and r-stage [p< , , hr ( % ci)= , ( , - , )]. conclusion: tumor budding occurs frequently in pancreatic cancer, is an indicator of worse outcome and adds independent prognostic information. routine use of tumor budding would help to better stratify patients into prognostic subgroups. ofp- - epstein-barr virus and p in the development of gastric cancer v. genitsch * , m. cathomas, l. terracciano, l. tornillo, a. lugli, a. marx, g. sauter, f. carneiro, f. hofstädter, n. willi, g. cathomas * kantonsspital baselland, abt. pathologie, liestal, switzerland objective: epstein-barr virus (ebv) is associated with a subset of gastric cancers (gc) . in this study, the prevalence of ebv and its presence in the development of gc were assessed. method: ebv was evaluated in gc by tissue microarrays using in situ hybridization for eber (n= ). non-tumorous, dysplasia, intramucosal and invasive carcinomas and metastasis of ebv positive gc were analyzed (n= ). p expressen was evaluated in ebv positive and a subset of ebv negative gc. results: . % of gastric cancers were positive for eber. all invasive cancers showed diffuse eber positivity and only lymph nodes revealed a focal loss of eber. in gc with foci of atypia/low grade dysplasia, no or only focal eber positivity was observed. p was overexpressed in of ebv negative but not in ebv positive gc ( . % vs. %; p= . ). conclusion: ebv is diffusely expressed in invasive gc and only occasionally lost in metastasis. in low grade dysplasia, however, ebv is often focal or missing, indicating that ebv infection may be associated with progression from low grade dysplasia to invasive cancer and this progression is p independent. ofp- - p x r attenuates colitis associated carcinogenesis p. hofman * , t. juhel, m. ilie, o. bordonne, o. boyer, x. hebuterne, s. adriouch, v. vouret-craviari * chu de nice, lpce, france objective: it is now well established that patients with inflammatory bowel disease presented a higher risk to develop a colon cancer. our previous works characterized the link that exists between bacterial infection and inflammation and highlighted the role of the microenvironment on the onset of chronic inflammation. here, we wished to understand the role of inflammasome, a complex of proteins that is activated by microbial motifs and the purinergic receptor p x and involved in the maturation of il- β. method: we treated p x r knockout mice to induce acute colitis ( % dss) or colitis associated colon cancer (aom and dss). results: we showed that p x r ko mice are more resistant than wild type mice to a dss-induced colitis. further, we demonstrated that p x r ko mice are highly susceptible to inflammation driven colon tumorigenesis. in addition, we showed that tumors from p x r ko contained more neutrophils (cd b+/ly g + cells) and less macrophage (cd b+/ly g-) than tumors obtained from wt mice. conclusion: we will present results on the characterization of the pro tumoral tumor associated neutrophils and the molecular mechanisms that are linked to the presence of such immune cells. ofp- - iel counts and distribution in normal duodenum, non-gse ielosis and gse: do we need a cut-off? b. a. karabork * , s. yuksel, b. savas, a. ensari * ankara university of medicine, dept. of pathology, turkey objective: intraepithelial lymphocytosis (ielosis) is a characteristic feature of gluten-sensitive enteropathy (gse), though, the cut-off is still debatable. we aimed to evaluate the number and distribution of iels in normal duodenum, and in non-gse ielosis and gse. method: the study group comprised of a spectrum of normal duodenal biopsies (n= ), non-gse ielosis (n= ), type (n= ) and type (n= ) serologically diagnosed gse cases. the number of iels/ enterocytes and distribution on h&e and cd -immunostained sections, were assessed for each group. chi square test was used for statistics. results: iels increased significantly through the spectrum ( , in normal, , , in type , , in type ) on h&e and cd , respectively (p< , ). iel counts ≥ on h&e and ≥ on cd had a sensitivity of , % and %, and a spesificity of , % and , %, respectively, for gse. iel distribution was diffuse in type ( , %), type ( %) but focal in non-gse ( %) (p< , ). conclusion: the current cut-off for iel counts seems to be sensitive for ielosis, though, not specific for gse and needs to be accompanied by the diffuse distribution of iels. ofp- - geographic analysis of the protein expression of metastasis suppressor gene rkip and its clinical relevance in colorectal cancer v. koelzer * , e. karamitopoulou, h. dawson, a. lugli, i. zlobec * university of bern, inst. of pathology, switzerland objective: loss of raf- kinase inhibitor protein (rkip) expression has been implicated in disease progression in several tumor types. the aim of this study was to evaluate rkip expression in colorectal cancer stratified by histological "zones" and to determine the zone responsible for its clinical relevance. method: immunohistochemical expression of rkip was assessed in colorectal cancers using whole tissue sections. four different areas were evaluated using highpower-fields (hpfs) each: normal mucosa, tumor center, invasion front and tumor buds. the average expression for each zone was assessed for its clinical relevance. results: expression of rkip was diffuse in normal mucosa and progressively lost towards the tumor center and front ( %, % and % rkip-positivity, respectively; p< . ). only % of tumor buds were rkip-positive. rkip loss in the tumor center only corresponded to more frequent lymph node positivity (p= . ), distant metastases (p= . ), lymphatic invasion (p= . ) and more advanced tnm stage (p= . ). rkip loss was highly prognostic (hr ( % ci): . ( . - . ); p= . ) independently of tnm and therapy. conclusion: the clinical relevance of rkip is restricted to the tumor center where it acts as an independent prognostic factor. its absence in tumor buds provides further evidence to support their hypothesized metastatic potential. ofp- - outcomes of neoadjuvant chemoradiation for rectal carcinoma g. ozgun * , f. oz atalay, n. ugras, o. yerci * uludag university, dept. of pathology, bursa, turkey neoadjuvant radiation and chemoradiation is currently the treatment of choise for patients with locally or advanced carcinoma of the rectum. patients treated with neoadjuvant chemoradiatheraphy with good clinical response and tumor regression present a controversial management dilemma. to assess the effects of chemoradiation on tumor regression and disease free survival, consecutive series of patients receiving neoadjuvant chemotheraphy or chemoradiation and a control series of patients without pretreatment were studied. the overall survivals and disease free survivals were compared in terms of variables such as tumor regression grade, stromal response in tumor bed, state of lymph node metastasis, and the localization of the tumor in between patients treated with chemoradiation and the control group. neoadjuvant treatment is one of the treatment modalities in rectal carcinomas. we want to present our experience between and in our institution. key words: rectal carcinoma, neoadjuvant treatment, pathologic complete response ofp- - identification of tissue microvascular invasion biomarkers in hepatocellular carcinomas by maldi imaging mass spectrometry n. poté * , t. alexandrov, j. le faouder, s. laouirem, j. belghiti, j. m. camadro, v. paradis, p. bedossa * paris, france objective: microvascular invasion (mvi), a major predictive factor of tumoral recurrence and mortality in patients with hepatocellular carcinoma (hcc), is only detectable on pathological examination. so far, there is no reliable tool to identify mvi prior to surgical procedures. maldi imaging mass spectrometry (ims) represents a new analytical tool to provide the relative abundance and distribution of the whole proteins expressed in a tissue section. the aim of this study was to compare, using maldi ims, the tissue proteome of hcc without and with mvi in order to identify surrogate biomarkers of mvi. method: a total of hcc samples obtained from surgical specimens, for which frozen samples were available, were retrospectively collected. two groups of tumors were defined ( hcc without mvi; hcc with mvi) and were analysed by maldi ims. a statistical comparative analysis of acquired mass spectra was then performed in order to identify protein peaks differentially expressed between the two groups. results: protein peaks were differentially expressed between the two groups, all overexpressed in hcc with mvi. protein characterization of some of these peaks is in progress. conclusion: these results highlight the potential of maldi ims to uncover new biomarkers in liver carcinogenesis. the identification of mvi biomarkers would be helpful in the therapeutic strategy of patients with hcc. ofp- - a histopathological scoring system can predict the recurrence of hepatocellular carcinoma in liver transplant patients treated with transarterial chemoembolization f. rosini * , f. vasuri, d. malvi, p. baldin, w. f. grigioni, a. d´errico-grigioni * university of bologna, dept. of anatomic pathology, italy objective: aim of this study is to define the histopathological features predictive of hepatocellular carcinoma (hcc) recurrence in patients treated with orthotopic liver transplantation (olt) after tumoral transarterial chemoembolization (tace), in order to establish a predictive "score" applicable by pathologists for recipient risk stratification. method: we retrospectively enrolled patients ( total neoplastic or necrotic nodules) who received tace for hcc downstaging before olt. the following data were collected: number of neoplastic/necrotic nodules, microscopic thrombosis, the residual neoplastic tissue (rnt), and dysplastic nodules. sizes, percentage of necrosis, edmondson's grade, clear cell features were also collected for each nodule. results: median follow-up was days: ( %) hcc recurrence cases were recorded. statistically rnt (best cutoff cm , p= . ), the total nodule number (best cut-off ≥ , p= . ), and the neoplastic thrombosis (p= . ) were the only variables predictive of hcc recurrence. scoring + each parameter, recipients with (n= ) had % recurrence rate; recipients with +/ + (n= ) had %; recipients with + (n= ) had % recurrence rate (p< . ). we were able to stratify olt recipients with tace-treated hcc in risk groups based only on histopathological analysis. ofp- - discovery of a new histopronostic factor in rectal adenocarcinoma treated by radiochemotherapy followed by surgical resection a. sannier * , j. lefèvre, f. bretagnol, d. cazals-hatem, y. panis, p. bedossa, n. guedj * paris, france objective: neoadjuvant radiochemotherapy (rct) followed by surgical resection became the treatment for locally advanced rectal cancer. pathological diagnosis is important for the prediction of prognosis and adjuvant treatment. study aim was to identify histopronostic factors in a consecutive series of patients treated by rct and surgery. method: patients were included, follow-up, tumor morphologic pattern and modified rectal cancer regression grade (m-rcrg) were assessed. univariate and multivariate analysis were used to assess predictors of disease-free survival (dfs). results: -years dfs was %. in univariate analysis, ypt, budding, calcifications, circumferential margin, node involvement, invaded margin, vascular emboles and perineural involvement were pronostic factors (p< . ). in multivariate analysis, presence of calcification in tumor bed (p= . ) and small circumferential margin (p= . ) were the only two independent factor of worse dfs. mrcrg was not correlated to dfs. among the mrcrg tumor, dfs was significantly better in patient with ypt than in other ypt stages (p= . ). conclusion: presence of calcification in tumor bed is a new major histopronostic factor described for the first time in rectal cancer. our results raised the question of whether ypt stage or histological tumor regression is more important in the prediction of patient prognosis. tuesday, september , . - . objective: the most widely used system for histological grading of colorectal cancer (crc) is based on the degree of gland formation, despite significant interobserver variability and low prognostic value. herein we analyzed the prognostic significance of a grading system based on the presence of poorly differentiated clusters in stage i crc. method: poorly differentiated cancer clusters were assessed by two independent pathologists in stage i crc characterized or not by disease progression. tumors with < , to , and > clusters were classified as g , g , and g , respectively. the prognostic value on disease-free survival and the association with other clinicopathologic characteristics of the conventional and novel grading systems were analyzed. results: k statistics for inter-observer variability in the assessment of histological grade based on poorly differentiated custers was . (good). high histological grade assessed with the novel system, but not with the traditional one, represented a negative significant prognostic factor for disease-free survival and it was significantly associated with venous invasion, lymphatic invasion, budding, invasive growth and nodal micrometastases. conclusion: we suggest that a tumor grading system based on the number of poorly differentiated clusters has a stronger power to stratify stage i crc patients by prognostic outcome than conventional grading. ofp- - cytokeratin : a marker for braf mutated colorectal carcinomas? s. gurzu * , z. szentirmay, i. jung * university of targu mures, dept. of pathology, romania objective: cytokeratin +/cytokeratin − (ck) is used as the characteristic immunophenotype of colorectal carcinomas (crc) . some new studies suggested that aberrant pattern ck /ck can be identified in colorectal cancer with microsatellite instability (msi). our aim was to establish which factors may determine changing in this immunophenotype. method: in crc, randomly selected, we performed immunohistochemical stains with ck and ck and analyzed the microsatellite status and braf mutations with real time pcr. results: from the crc, were msi and mss (microsatellite stable) cases. % of mss cases diffusely expressed ck without ck expression. from the msi cases, presented braf mutations. in msi cases with braf mutations, ck was focally expressed or negative and ck was diffusely expressed. conclusion: cytokeratin positivity may be used to select braf mutated msi colorectal carcinomas. both ck and ck should be used for differential diagnosis of colorectal cancer. ofp- - intratumoral budding in preoperative biopsies predicts local and distant metastasis in colorectal cancer patients a. lugli * , m. hädrich, d. inderbitzin, m. borner, i. zlobec * medizin. universität bern, inst. für pathologie, switzerland objective: in , the term "intratumoral budding, itb" was used to describe the presence of tumor buds within the main tumor body and was correlated to worse clinical outcome in colorectal cancer patients. here, we further elucidate the potential clinical role of itb in pre-operative biopsies using pan-cytokeratin stained tissues and a quantitative scoring system. method: pre-operative biopsies from patients with colorectal cancer underwent immunohistochemistry for pancytokeratin (ae /ae ). itb were counted in the area of densest budding ( ×) and classified as high-grade when > buds/hpf were observed based on receiver operating characteristic (roc) curve analysis. results: high-grade itb occurred in . % of cases and was associated with right-sided tumor location (p= . ), more advanced pt (p = . ) and pn (p< . ) classifications, distant metastasis (p = . ), higher tumor grade (p= . ) and lymphatic invasion (p= . ). the specificity and positive predictive value for lymph node metastasis was . % and . %, respectively. disease-free survival was significantly worse in patients with high-grade itb ( -year survival= %) in comparison to patients with low-grade itb ( -year survival= %) (p= . ). conclusion: the assessment of itb in pre-operative biopsies is predictive of local and distant metastasis in corresponding resections and should be considered in daily management of colorectal cancer patients. ofp- - alpha-methylacyl-coa (amacr) in gastric cancer -correlation with clinicopathological data and disease free survival a. mroz * , m. kiedrowski, z. lewandowski * cmkp, gastroenterology and hepatology, warsaw, poland objective: diagnostic and prognostic significance of alphamethylacyl-coa (amacr) has been established in many human cancers. its correlation with clinical and pathological data in gastric cancer has not been fully elucidated and its impact on surveillance has not been studied thus far. method: we analyzed consecutive gastric cancer cases in terms of amacr immunohistochemical expression and clinical/pathological characteristics and followed patients' postoperative history. results: amacr was expressed in / gastric cancers ( . %). we did not find correlation between amacr expression and gender, age, location, histological type, ptn staging, vascular and nerve sheaths invasion. overall disease-free survival tended to be worse in amacr positive patients (p= . ), and in adenocarcinoma subgroup it was significantly shorter (p= . ). conclusion: amacr expression might represent promising adverse prognostic factor in gastric cancer, particularly in adenocarcinoma histological type. ofp- - development of a rabbit monoclonal antibody for determining hent status and predicting response to gemcitabine in pancreatic ductal adenocarcinoma m. raponi * , j. isaacson, j. ranger-moore, j. clements, b. richardson, s. ormanns, k. winter, a. allen, r. andersson, v. heinemann, a. p. dicker * clovis oncology, san francisco, ca, usa objective: human equilibrative nucleoside transporter (hent ) is the primary membrane channel through which gemcitabine (gem) enters pancreatic tumor cells, and patients whose tumors have low expression of hent may derive little benefit from gem therapy. method: an analytically validated rabbit monoclonal antibody immunohistochemistry (ihc) in vitro diagnostic (ivd) for assessing the degree of hent expression in pancreatic adenocarcinoma using an automated ihc platform has been developed. results: using primary tumor samples (n= ) from a randomized controlled clinical adjuvant trial (rtog - ), we developed and verified a hent scoring methodology and cut-off for identifying patients least likely to benefit from gem (hent -low). the distribution of hent expression was similar between these samples and an independent set of pancreatic adenocarcinoma specimens from the aio-pk study of which were confirmed metastatic biopsies. overall, using this cut-off, approximately two thirds of pancreatic tumors displayed low-hent expression across the different data sets. conclusion: a robust hent ihc ivd has been developed using a rabbit monoclonal antibody and identifies two thirds of primary and metastatic pdac cases as having low expression of hent . ofp- - hypoxia activates pancreatic stellate cells: development of an organotypic culture model of thick slices of normal human pancreas v. rebours * , m. albuquerque, p. ruszniewski, p. lévy, a. sauvanet, v. paradis, p. bedossa, a. couvelard * beaujon hospital, pancreatology unit, clichy, france objective: pancreatic stellate cells (psc) promote oncogenesis by modulating cell proliferation. aim-to evaluate the early activation of psc in case of hypoxia in normal human pancreas. method: an organotypic culture model of thick sections of human pancreas has been developed and validated. slices of pancreas ( μm) were prepared from surgical specimens and cultured in hyperoxia conditions. half of the samples underwent an initial phase of culture in normoxia ( % o ) to reproduce hypoxia. the total duration of culture was h. cell viability, hypoxia, apoptosis and activation were monitored. results: sections per specimen were cultured. analysis was performed at baseline, h, h and h. morphological analysis showed gradual appearance of ductal/acinar dedifferentiation. at h, foci of necrosis were identified. hypoxia was confirmed by the expression of hif and ca at h ( % and % of labeled cells). apoptosis was limited, acinar cells expressed caspase at and h. analysis of proliferation using ki index showed significant activation of psc at h (× /baseline) and at h (× / baseline). activation of psc was confirmed by smooth muscle actin immunochemistry. conclusion: organotypic culture of normal human pancreas is possible with optimized cell viability at h. hypoxiainduced activation of psc occurs very early. objective: ipn are still poorly characterized precursor lesions of bile duct adenocarcinoma. we present a multicenter study with focus on morphology, subtyping and prognosis and provide a detailed molecular analysis in the stepwise progression from low-grade to high-grade lesions and invasive carcinoma. method: fourty-five patients with biliary ipn were included into the cohort, twenty-two patients with conventional adenocarcinoma of the bile duct served as control cohort. subtyping was performed based on histomorphology and expression profile of mucins and cdx expression. furthermore, low grade lesions (n= ), high-grade lesions (n= ) and invasive components (n= ) of ipn as well as conventional bile duct adenocarcinomas (n= ) were investigated individually for alterations of common oncogenic pathways using immunohistochemistry, real-time polymerase chainreaction and direct sequencing. results: ipn are mainly detected at preinvasive stage ( %), pancreato-biliary and intestinal type are the most common subtypes ( and %, respectively). detailed molecular analysis showed that p overexpression, k-ras mutation, loss of heterozygosity of p locus and nuclear ßcatenin expression are early events and loss of smad and overexpression of egfr and her are later events in the tumor progression of ipn. conclusion: stepwise alterations of common oncogenic pathways are required for progression of biliary ipn from non-invasive precursors to invasive carcinoma. ofp- - influence of braf mutations and rac b/rac mrna ratio or protein expression on outcome in patients with metastatic colorectal cancer (mcrc) treated with firstline chemotherapy m. cuatrecasas * , v. alonso-espinaco, p. jares, c. horndler, a. castells, j. j. lozano, j. maurel * hospital clinic, barcelona, spain objective: metastatic colorectal cancer (mcrc) patients with braf mutation v e present poor overall survival (os). rac b, a rac spliced variant, is overexpressed in crc and impairs apoptosis by activation of nuclear-factor-kb. we evaluated if rac b was an independent prognostic factor in mcrc. method: we examined braf (v e) mutational status, rac b by immunohistochemistry, rac b/rac expression ratio by mrna rt-pcr, and mismatch repair (mrr) deficiency by microsatellite instability (msi) analysis, in mcrc patients treated in firstline therapy with folfox or capox from three spanish institutions. we assessed whether these biomarkers were independently predictive of progression free survival (pfs) or os. results: % crc had braf mutations, % msi-h, % high rac b/rac ratio, and % rac b protein overexpression. five of crc ( %) with braf mutations had high rac b/rac ratio/protein vs / ( %) without braf mutation (p= . ). all braf mutated or rac b/rac high were mss. low rac b/rac ratio and braf wt had higher response rate ( % vs %; p= . ). multivariate regression analysis identified ecog ps as a significant variable for pfs and ldh levels, ps and high rac b/rac ratio for os. conclusion: high rac b/rac expression ratio or immunoexpression constitutes a marker of poor os and a potential marker of acquired chemo-resistance in mcrc treated with oxaliplatin-based therapy. objective: annually more than . new cases of papillary thyroid cancer, that is % of malignant tumors, are registered all over the world. method: there are clinical and morphologiсal methods: immunohistochemistry (mmp- , mmp- , timp- , timp- ), light, transmission, electron, probe and scanning microscopy with the trace element analysis. it was studied cases of thyroid cancer since. results: at the papillary thyroid cancer progression matrix metalloprotease and specific tissue inhibitors of metalloprotease (timp- ) increased in the cytoplasm of tumor cells, but the concentration of timp- decreased. tumors with low degree of ultrastructural differentiation were presented by cells with electron-dense dark cytoplasm and cells with poor cytoplasm organelles and differently formed nucleus with numerous deep invaginations. high level of some matrix metalloproteaseexpression (ММР- ) and low level of timp expression (Тimp- ) were observed in current cases more ( % and % respectively), than at more differential papillary thyroid cancer ( % and %). at performance of atomic force microscopy it was shown that connection between cells had become weak at the decreasing of malignancy degree. it was revealed the significant increasing of oxygen, magnium, potassium, calcium in tumor nodes. conclusion: conducted comlex morpho-chemistry analysis display diagnostic patterns of papillary thyroid cancer. objective: cytological features of btn-ph, sometimes interpreted as papillary carcinoma (pc) on fine-needle aspiration biopsies (fnab), have not been studied extensively. method: available material from btn-ph was reviewed retrospectively and compared with pcs. results: fnab diagnoses were: non-diagnostic (n= ), benign (n= ), aus/flus (n= ), suspicious for follicular neoplasm (n= ), suspicious for malignancy (s-pc) (n= ), and malignant (p-pc) (n= ). the extent of papillary hyperplasia on histology was higher in s-pc/p-pc diagnostic categories ( %; p= . ; range: - %). on cytology, papillary structures, present in % of bpn-ph cases, were more frequent and numerous in the s-pc/p-pc group ( %; p= . ). focal nuclear atypia was seen in all s-pc/p-pc cases, including rare grooves ( . %), enlargement/crowding ( %), chromatin clearing/rare pseudoinclusions ( %), but were less than in pcs (p< . ). nuclei were smaller in btn-ph than in pcs (mean diameter/range (μm): . / - vs . / - ; p= . ). all btn-ph tested (n= ) were immunonegative for hbme- , galectin- , and keratin- . conclusion: btn-ph diagnosed as s-pc/p-pc often show papillary structures and focal nuclear features of pc but they are significantly less than in classical pcs, stressing the need to apply strict criteria for pc diagnosis. ofp- - genetic alterations in glucagon cell adenomatosis t. henopp * , m. anlauf, s. biskup, g. klöppel, b. sipos * medizin. universität tübingen, inst. für pathologie, germany objective: glucagon cell adenomatosis (gca) was recently recognized by us as a multifocal neoplastic disease of the endocrine pancreas unrelated to men . multiple micro-and a few macrotumors are found on the background of a hyperplasia of glucagon cells. the disease may cause unspecific abdominal symptoms and only rarely a glucagonoma syndrome. recently a mutation in the glucagon receptor (gcgr) gene was described in one gca patient. method: the extracted dna of five patients with gca was sequenced and the gcgr gene analyzed for mutations. results: sequencing of the gcgr gene revealed germline mutations in three out of five patients. one patient shows two different heterozygous point mutations in the hyperplastic alpha cells as well as in the non-tumorous tissue leading to two premature stop codons. one patient harbors a homozygous stop mutation. the third patient shows two homozygous missense mutations of the gcgr gene that most likely also led to a dysfunction of the gcgr. in the two other patients no germ line mutations of the gcgr gene were detected. these variants were not identified in healthy subjects. conclusion: the finding of germ line and somatic "loss of function" mutations of the gcgr gene in three of five patients with gca suggests that a change in the signalling function of the gcgr may cause glucagon cell adenomatosis via glucagon cell hyperplasia. ofp- - timp- expression and hypoxia in papillary thyroid carcinoma: relationship to brafv e mutation and clinical behavior m. ilie * , s. lassalle, p. brest, c. bonnetaud, a. bozec, n. guevara, j. haudebourg, i. birtwisle-peyrottes, j. santini, p. hofman * chu de nice, lpce, france objective: brafv e causes up-regulation of timp- , promoting cell invasion in papillary thyroid carcinoma (ptc). hif- α is regulated by hypoxia but also by brafv emediated signaling pathway in ptc. we assessed the impact on clinical behavior in ptc of timp- , hif- α and the hypoxia-inducible caix and caxii. method: the protein expression was assessed by western blot in two cell lines, tpc- /brafwt and bcpap/ brafv e. tma-immunohistochemistry analysis was used to study protein expression in ptc samples. braf status was analyzed by pyrosequencing. data were correlated with clinicopathological variables of patients. results: higher expression of all proteins was detected in bcpap exposed to hypoxia. timp- expression displayed % sensitivity and % specificity for identifying braf mutation (p< . ), and was associated with pt-stage (p= . ), pn-stage (p= . ), and multifocality (p= . ). hif- α expression was correlated to pt-stage (p= . ). caix expression was related to pn-stage (p= . ), and both caix (p= . ) and caxii (p= . ) were highly associated with vascular invasion. conclusion: timp- protein expression is reliable surrogate of braf mutated status in ptc. timp- and hypoxiaregulated proteins have potential for future use as predictors of the malignant change in ptc, and warrant further investigation as new therapeutic targets for the treatment of highly aggressive form of ptc. objective: mtc are usually aggressive tumours which account for - % of all thyroid carcinomas. most of mtc are sporadic, the remaining tumours are due to hereditary forms with germline activating mutations of the ret proto-oncogene. the aim of this study was to assess the microrna profiling expression in both sporadic and hereditary forms of mtc. method: a total of frozen mtc from patients with welldocumented clinico-pathological parameters were used for microarray analyses ( hmtc and smtc) using human microrna mircoarray kit version (agilent technologies). after identification of a set of mirna of interest, validation was done using qpcr. results: when comparing hmtc harbouring germinal ret mutation with smtc, seven mirnawere significantly deregulated (mir- , − a, − c, − a, − - *, − b, − ). the most highly discriminative mirna in tumoral samples (> fold change) identify mir- , − - p, − , − c and − . moreover, mirna could segregate mtc with good prognosis and better clinical outcome (mir- , − , − , − and − ) . conclusion: a specific microrna signature in hmtc can be identified. moreover, detection of micrornas in tissue samples might be of interest for improved clinical management and treatment of patients with mtc. ofp- - focus on the follicular variant of papillary thyroid carcinoma: combination of the immunohistochemical markers ck , hbme and tpo is associated with histopathological diagnosis, better than molecular markers objective: the follicular variant (fvptc) is the major variant of papillary thyroid carcinoma (ptc), ranging from % to % of all ptc. it remains however a problematic entity. some consider that the encapsulated fvptc (enfvptc) have an excellent prognosis like follicular adenomas (fa); others showed that enfvptcs had potential for hematogenous spread like follicular carcinoma. its place in the spectrum the multivariate cox regression the flt -itd mutation (p= . ) was an independent poor prognostic factor, whereas the goodness-of-fit of the minkowski fractal dimension an independent favorable prognosticator (p= . ). the karyotype had no influence on survival. conclusion: flt -itd and chromatin fractal characteristics were more important as prognostic factors for overall survival than karyotype and gene methylation status. financial support: fapesp and cnpq. objective: the prevalence of cyclin d (cyd ) positive bcells with mantle cell lymphoma (mcl) phenotype in the mantle zones of reactive lymph nodes ("in situ" mcl/mclis). and related minimal mcl infiltrates in reactive lymphoid tissues of healthy individuals and in mcl patients are unknown. method: all . reactive lymph nodes from unselected consecutive surgical specimens of patients without a history of lymphoma obtained over a months´period were stained for cyd . additionally, all morphologically reactive lymph nodes and extranodal lymphoid infiltrates of mcl patients from to were studied. samples predating the lymphoma diagnosis for at least months were available from / ( . %) patients. results: a mclis was not identified. however, in four mcl patients, an early manifestation of mcl with mantle zone growth pattern was detected retrospectively, antedating the lymphoma diagnosis for - months. in six mcl patients, only small groups of cyd positive cells in morphologically reactive extranodal infiltrates were detected more than months before the diagnosis of mcl (range - months). conclusion: mcl "in situ" is an extremely rare phenomenon in morphologically reactive lymph nodes. in mcl patients, however, immunohistochemically detectable infiltrates of mcl cells antedating the lymphoma diagnosis were found in a significant proportion of cases ( / = %). ofp- - e f- 's relationship with tumor growth in hodgkin's lymphoma is regulated by p status e. georgiadi * , g. dimtsas, t. p. vassilakopoulos, v. g. gorgoulis, i. a. doussis-anagnostopoulou * larisa, greece objective: e f- is a member of the e f family group of transcriptional factors that play a major role in cell cycle progression and arrest, as well as in apoptosis. in different tumors e f can demonstrate opposing roles, acting either as an oncogene or as a tumor suppressor gene. method: we have previously established e f- 's immunohistochemical expression in hodgkin lymphoma (hl) and its correlation with p expression, although no relationship with either proliferation or apoptosis was demonstrated. a further investigation in a larger series of cases of primary hl with the addition of new apoptotic techniques and the use of p expression as an indicator of p functional status was undertaken. results: following stratification of our cases based on p functionality, e f- was inversely correlated with the proliferation marker topoiia. independently of p , high levels of e f- expression showed a linear trend with apoptosis and an inverse trend with proliferation (borderline p value in both cases). conclusion: both e f- and p activity is upregulated in hl, however it seems that p status is a major regulator of the relationship between e f- expression and tumor growth. alternatively, e f- may use p -independent pathways to induce apoptosis. objective: ptld represent a spectrum of usually ebv-driven lymphoplasmacytic proliferations in the settings of immunodeficiency associated with allograft. ebv infects cells in latent or lytic forms. although viral oncogenes are expressed in latency programs, lytic ebv replication is required to develop lymphomas in mouse models. the role of intratumoral ebv replication in ptld has never been addressed before. method: a series of ptld was reviewed and ebv latency genes were explored in all cases and included eber - , lmp and ebna . moreover, two early lytic genes involved in ebv replication, bzlf /zebra and ead were also analyzed. all clinical and pathological data were collected. results: the median age was years ( - ) with a male predominance ( m: f). ebv infection was observed in cases ( %). ebv replication was observed in % of the cases. these were more likely to be polymorphic ptld with latency iii in the context of stem cell transplantation. moreover these cases had atypical clinical presentations such as brain involvement or disseminated disease with aggressive behavior (os: months vs. months). conclusion: ebv replication occurs in tumor cells of ptld-patients associated with poor outcome and may be share common morphological and phenotypical features. in routine praxis, their differential diagnosis might represent a challenge requiring a specific work-up of immunohistochemical (ihc) and fluorescent in situ hybridization (fish) analyses. method: paraffin sections from cd +/cd + blastic b-nhl were examined for cyclin-d , cd , bcl- and mum- ihc expression together with fish method using probes for ccnd rearrangement and/or igh/ccnd translocation. the final diagnosis was established according to the criteria of who classification. results: / cases were diagnosed as bmcl showing cyclin-d positivity and ccnd rearrangement, other analysed ihc markers were negative. five of these cases were polyploid. / cases were diagnosed as cd + dlbcl in spite of coexpression of cyclin-d in of them, as they showed various cd , bcl- and mum- expressions and missed ccnd gene rearrangement. conclusion: cyclin-d positivity may appear in other than mcl lymphomas due to changes at transcriptional or posttranscriptional level. in spite of overlaping phenotypes, fish analysis of ccnd represents an effective tool to increase the diagnostic accuracy to distinguish cd + dlbcl from bmcl. supported by vega grant nr. / / and projects ceprii (imts: ) and mdcc (imts: ) co-financed by eu sources. ofp- - still's disease associated lymphadenopathy: report of two cases resembling malignant lymphoma with review of possible morphological findings k. kamarádová * , m. nova, m. kalinova, v. campr * prague, czech republic objective: still's disease (or systemic onset juvenile idiopathic arthritis, sojia) is a systemic inflammatory disorder characterized by fever, rash, and arthritis. it has a peak of incidence in early childhood with rare occurence in adulthood (adult-onset still's disease, aods). several other symptoms as hepatosplenomegaly, leukocytosis and lymphadenopathy may be associated possibly mimicking malignant lymphoma. method: we present two cases of still's disease associated lymphadenopathy in a child and in an adult simulating morphologically peripheral t-cell lymphoma and classical hodgkin lymphoma respectively. results: histological, immunohistochemical and molecular examination revealed non-neoplastic lymphadenopathy with atypical paracortical t-cell hyperplasia with immunoblastic reaction in the former and burnt-out histiocytic pattern in the latter, both falling into a broad spectrum of reactive lymph node changes associated with still's disease. the lymph node lesions in still's disease can be histologically divided into four major categories: ) simple atypical paracortical hyperplasia, ) burnt-out histiocytic pattern, ) exuberant immunoblastic reaction in paracortical hyperplasia and ) follicular hyperplasia. the second and the third pattern may closely resemble malignant lymphoma. extended and careful clinical examination with relevant laboratory findings and possible complex histochemical and molecular analysis are necesarry to rule out the suspition of lymphoma. objective: intravascular large b-cell lymphoma (ivlbcl) is a rare form of diffuse large b-cell lymphoma characterized by exclusive or preferential intravascular growth. ivlbcl often goes clinically unrecognized. we report three clinically unsuspected cases of classic variant ivlbcl. method: cases diagnosed as ivlbcl were collected from the pathology files of germans trias i pujol hospital. the diagnosis was reviewed in agreement with who criteria and immunophenotypic and clinical data were gathered. results: a -year-old male and an year-old-male showed neurological symptoms leading to progressive deterioration and death. a -year-old female presented with fever of unknown origin and died days after admission. at autopsy there were no gross findings suggestive of a neoplastic process in any instance. histologic study showed intravascular large b cells with vesicular nuclei involving predominantly the central nervous system in the first two cases and the adrenal glands, liver, and spleen in the third case. conclusion: the three cases of aggressive, advanced-stage lymphoma herein described illustrate how the clinical diagnosis of ivlbcl remains elusive due to its low frequency and variegated clinical presentation and how the pathologic diagnosis of ivlbcl continues to be highly dependent on autopsy examination. objective: the world health organisation (who) currently recognises four categories of ptld, which are lymphoid/ plasmacytic proliferations occurring due to immunosuppression after organ transplantation. the aim of this study was to examine the clinicopathologic characteristics of ptld occurring after renal transplantation in the republic of ireland. method: the national renal transplant registry from to (inclusive) was cross referenced with the national cancer registry to identify renal transplant recipients who had developed ptld up to the present day. review of pathology and chart review was conducted for each case. results: of , patients ( , allografts), cases of ptld were identified, with pathology review possible in cases. there were ( %) monomorphic ptld ( diffuse large b cell {dlbcl}, anaplastic large cell, burkitts-like, myeloma], hodgkin-type ptld, ( %) polymorphic ptld and ( %) early lesion. in addition, there was mantle cell lymphoma and lymphomatoid granulomatosis. the annual incidence of ptld was estimated as . % ( % ci . - . ). median time to diagnosis was . years (range to . years). conclusion: similar to other studies, monomorphic ptld is the most common type, with dlbcl representing the majority of cases. of interest, early onset ptld was very uncommon in this study. monday, september , . - . , forum hall ofp- oral free paper session head and neck pathology ofp- - human papilloma virus associated oropharyngeal carcinoma is strongly correlated with cancer of unknown primary s. ihrler * , g. assmann, p. zengel, m. mollenhauer * medizin. universität münchen, institut für pathologie, germany objective: human papillomavirus (hpv) associated oropharyngeal carcinoma has been identified as a distinct entity within squamous cell carcinoma of the head and neck and is preponderantly restricted to palatinal tonsils and base of tongue. these two primary locations have for long -and hpv-associated carcinomas have recently -been associated with the clinical situation of cancer of unknown primary (cup). method: to investigate the relationship between hpv and cup in detail, we studied consecutive patients who initially presented as cup and were finally diagnosed with carcinomas of these two locations. results: twenty-one carcinomas ( %) proved to be positive for high-risk hpv (p and polymerase chain reaction). they were frequently very small (smallest: . cm; cases: ≤ . cm; on average . cm) and located in a deep, submucosal position. conclusion: this demonstrates an overrepresentation of hpv-associated carcinoma in patients who were initially diagnosed with cup, supporting a strong causal relationship between hpv-association and cup. the frequent manifestation as cup presumably is caused by the unusual predisposition for small size and submucosal location, combined with frequent and early lymphatic metastization. in order not to miss these small, clinically occult carcinomas, consequent interdisciplinary cooperation and meticulous histological work-up is mandatory. ofp- - methylthioadenosine phosphorylase inactivation depends on gene deletion in laryngeal squamous cell carcinoma a. nadal * , l. conde, i. vilaseca, l. alos, m. bernal-sprekelsen, a. cardesa * hospital clínic barcelona, dept. of pathology, spain objective: methylthioadenosine phosphorylase is an essential enzyme for the methionine and adenosine salvage pathway in normal cells, frequently inactivated in many different human cancers. the mtap status could be important for tumor cell sensitivity to adjuvant chemotherapy. to date there are no reports on mtap status in laryngeal carcinoma. method: a series of laryngeal squamous cell carcinomas was investigated for mtap mrna expression through reverse transcription and quantitative pcr (qpcr) as well as for mtap gene deletion and/or promoter hypermethylation through qpcr and methylation-specific pcr respectively. results: low mtap mrna expression was found in % of cases, associated with mtap gene deletion in % (p< . ) but not to mtap promoter hypermethylation, indicating that in this tumors gene deletion is the main mechanism of mtap inactivation. neither low mrna expression nor gene deletion was associated with any of the clinicopathologic parameters investigated. conclusion: given the significance of mtap status for cell sensitivity to different chemotherapeutic regimes, our results suggest that determination of mtap inactivation could be useful for adjuvant therapy selection in laryngeal squamous cell carcinomas. ofp- - ercc , p and ki- immunohistochemical expression as predictive and prognostic markers in head and neck squamous cell carcinoma treated with platin-based induction chemotherapy h. roussel * , m. housset, h. tournat, p. ravel, s. hans, c. badoual * hegp, dept. de anatomie-pathologie, paris, france objective: ecc enzyme has been associated with resistance to platinum-based chemotherapy. the purpose of this study was to evaluate the role of ercc expression with p and ki- as predictive and prognostic markers in the response to platin-based induction chemotherapy in patients with head and neck carcinoma (hnscc). method: patients treated from to by an induction chemotherapy regimen for hnscc were included retrospectively. we assessed response to treatment, progression-free survival (pfs) and overall survival (os). results: % and . % of hnscc showed low expression of f and fl ercc . no correlation was found between the two clones (p= . ). in the patients treated with cisplatin- fu chemotherapy, a low expression of f ercc was associated with a better response (p= . ). over expression of p , ( . % of cancers of the oropharynx) was correlated with a better os (p= . ) and a better pfs (p= . ). conclusion: these results suggest that ercc expression might be a useful predictive marker of hnscc in patients treated by cisplatin-based chemotherapy. the f ercc clone appears to be the best for immunohistochemistry. our study confirms the prognostic value of the over expression of p in carcinoma of the oropharynx. objective: tumor-stroma ratio or proportion of tumor (pt) has been presented as a prognostic factor in colorectal and breast adenocarcinomas, but there is no information about squamous cell carcinomas (scc) and laryngeal carcinomas in particular. method: eighty-five laryngeal carcinoma cases were included in this series. five digital images of the tumor sections were obtained (h&ex ). percentage of epithelial tumor component was determined by software allowing the pathologist's selection of tiny areas as carcinomatous and stromal region for statistical analysis as a prognostic marker. results: median follow up was months (range - ). the mean pt was ( , + , ) . there was no difference for pt when tumor grade and stage were considered. although statistically insignificant, the mean pt was the lowest ( , + , ) for subglottic carcinomas and cases with perinodal invasion ( , + , ), and highest in pn cases ( , + , ) but there was no statistical significance. the over all and disease free survival analysis did not reveal significance for pt. only pathological stage was an independent factor for over all survival (p= , ). conclusion: although there might be an association with adverse prognostic factors and low tp, the findings in this series does not support pt as a prognostic marker in laryngeal carcinomas. ofp- - tumoral microvasculature in ameloblastoma subtypes c. h. siar * , k. h. ng * university of malaya, dept of. oral pathology, kuala lumpur, malaysia objective: angiogenesis is essential for tumoral growth and progression. the ameloblastoma is a benign but locallyinvasive odontogenic neoplasm with distinct behavioural characteristics of its subsets. whether angiogenesis contributes to a more aggressive course in these variants remains unclear. the aim here was to determine and compare the tumoral microvasculature in different ameloblastoma subtypes and to speculate on their significance. method: immunohistochemical staining for vascular markers (cd , cd , cd and vegf) was performed on archival tissues of cases solid/multicystic (sma), unicystic (ua), desmoplastic (da) and recurrent ameloblastoma (ra). mean microvessel density (mvd) at the tumour advancing front and centres were obtained. results: vegf was heterogeneously expressed in the tumoral epithelium in all ameloblastoma subtypes. protein localization was membranous/cytoplasmic. mean mvd was slightly higher in sma compared to ua but the difference was not significant (p> . ). mean mvds were not significantly different between primary and recurrent ameloblastoma; and between tumoral centre and advancing front of each subtype (p> . ). conclusion: although ameloblastoma subtypes are distinctive in their clinicopathologic presentations and behaviour, their tumoral microvasculature is not different. this suggests that angiogenesis is not a major factor influencing the progression of these ameloblastoma subsets. ofp- - an immunohistochemical study of e-cadherin and snail expression in laryngeal squamous cell carcinoma a. tanoglidi * , m. tsopanomichalou, c. barbatis, c. kostopoulos, o. pantzartzi, v. gorgoulis * hellenic red cross hospital, dept. of pathology, athens, greece objective: snail and (slug) are zinc-finger transcription factors, repressing the e-cadherin in epithelial tumors. published data in head and neck squamous cell carcinoma show either inverse relationship or unrelated co-expression, but e-cadherin reduction/loss and snail overexpression seem to confer an aggressive phenotype. method: thirty cases of laryngeal squamous cell carcinomas (lsccs) (gradei: , gradeii: , gradeiii: ) and one large cell neuroendocrine carcinoma (nec) were studied using double staining immunohistochemical method for e-cadherin (mab-dab) and snail + slug (pab-ap). the colocalization of both molecules was assessed and the expression was compared to the adjacent normal or dysplastic epithelium and the histological grade. results: normal squamous and dysplastic epithelium show strong nuclear snail expression and complete e-cadherin membranous positivity. reduction/loss of snail with or without e-cadherin membranous expression is observed in / ( %) lsccs with a tendency for inverse relationship with e-cadherin at the invasive front. / ( %) lsccs strongly express nuclear snail, without absolute relationship to the reduction/loss of e-cadherin, with a tendency for snail negativity in grade ii ( %). the nec is nuclear snail negative but cytoplasmic positive. conclusion: snail and e-cadherin may be retained, reduced or lost in lsccs, without a definite inverse relationship. these immunophenotypic combinations need further investigation. ofp- - non-sebaceous lymphadenoma of salivary glands: proposed development from intraparotid lymph nodes and risk of misdiagnosis c. weiler * , a. agaimy, p. zengel, s. ihrler * munich, germany objective: non-sebaceous lymphadenoma (nsla) is a recently described, rare benign salivary tumour composed of lymphoid and epithelial components, definitionally lacking sebaceous differentiation. method: nine cases of nsla were immunohistochemically stained for ck / , ck , ck , ck , p , and ki . results: all tumours ( males, females, mean age years) were located in the parotid gland and showed intimate intermingling of lymphoid tissue with islands of epithelium with a wide spectrum of histological differentiation. the immunohistochemical profiles mirrored the epithelial differentiation; tumours with basaloid or lymphoepithelial differentiation strongly expressed ck / , ck , p , while tumours with ductal differentiation showed strong positivity for ck /ck and ck / /ck /p in luminal and basal cell layers, respectively. a hilus structure with salivary inclusions or d - (podoplanin) positive marginal sinus were identifiable in and of the cases, respectively, confirming origin within intra-/periparotid lymph nodes. six cases were initially misdiagnosed as other benign (n= ) or malignant (n= ) tumours. conclusion: our study provides strong evidence that nsla belongs to the group of salivary tumours that pathogenetically develop from embryonic salivary inclusions in intra-/periparotid lymph nodes. knowledge of the wide histological spectrum of this rare tumour is important in order to avoid misdiagnosis. ofp- - crtc /maml fusion transcript in central mucoepidermoid carcinoma of mandible: diagnostic/ histogenetic implications d. bell * * md anderson cancer center, dept. of pathology, houston, tx, usa objective: mec typically arises from major/minor salivary glands. intraosseous salivary carcinomas are extremely rare ( - % of all mecs reported). the t( ; ) and its crtc / maml fusion transcript have been identified in mec at different sites and are associated with development of a subset of these tumors. we report examples of central mec of the mandible, including a case with a history of primary retromolar mec. method: rt-pcr and dna sequencing analyses used to study microdissected components of central mec and noncentral mec. of the central mec tumors, arose from ectopic salivary rests; others appeared to be of glandular odontogenic origins. results: we identified crtc /maml in central mec arising from ectopic salivary rests. this fusion transcript was not detected in non-central mec or in another central mec arising from a glandular odontogenic etiology. conclusion: central mec can manifest the fusion transcript in a subset of central mec originating from ectopic salivary rests, and may have diagnostic/histogenetic roles in the future analysis of this entity, given the absence of the fusion transcript in mec with glandular odontogenic precursors. since the initial clinical and radiological diagnosis in three central low-grade mecs was a benign odontogenic cyst, our findings support a future role for the fusion analysis in initial diagnostic efforts. ofp- - salivary duct carcinoma: morphological and immunohistochemical study of cases m. vazmitel * , a. dubrovskij, r. smoljakova, s. rjabceva * minsk, belarus objective: an evaluation of morphological and imunohistochemical features of salivary duct carcinoma (sdc). method: cases sdc were retrieved from tumor archives collected at belarusian cancer centre from to years. immunohistochemistry, fish. results: a man to women ratio was : ; median age , years (average . tumors arose in the parotid (n= ), submandibular (n= ) glands. sdc developed from pleomorphic adenoma (n= ) or de novo (n= ), there were foci of ductal carcinoma in situ (n= ), sialodochodysplasia (n= ) and pagetoid spread (n= ) additionally to usual features of sdc. as well, tumors demonstrated acinic cell carcinoma-like (n = ) and micropapillary growth patterns (n= ), oncocytic (n= ), clear cells (n= ), apocrine (n= ) and mucinous (n= ) changes. immunohistochemically, tumors were characterized by ar-expression (n= ), her /neu overexpression (n= ), of them score + in cases. ck and s- positivity, stat negativity was detected in one case with acinic cell carcinoma-like pattern. foci of sdc in situ were highlighted by ck and calponin. amplification of c-erb -gene was found in case, etv /ntrk gene was not identified in acinic cell carcinoma-like sdc. conclusion: salivary duct carcinoma, like breast cancer, is characterized by wide variability of morphological patterns and immunohistochemical features reflecting possible molecular heterogeneity, which need further investigation. sunday, september , . - . objective: quantification of protein expression based on immunohistochemistry (ihc) is an important step for translational research and clinical routine. however, routinely used eyeballing scoring systems are time-consuming and subject to significant intra-and interobserver variability. aim of our study was to explore, whether an image analysis software proves sufficient as an alternative tool to assess protein expression. method: prostate cancer specimens were stained with one nucleus specific marker (i.e., erg), one cytoplasmic specific marker (i.e., slc a ), and one marker expressed in both compartments (i.e., tmprss ). a pathologist visually quantified all stainings, applying a four-step scoring system. for digital quantification, an image analysis software (tissue studio v. . ) obtained a continuous spectrum of staining intensity. results: for each of the three antibodies we found a strong correlation of the eyeballing protein expression score and the score of the image analysis software (correlation coefficient of . , . , and . for erg, slc a , and tmprss , respectively, p< . ). conclusion: our data suggest that tissue studio is a powerful tool for the quantification of protein expression in ihc stainings. further, since the digital analysis is precise, it might help to overcome intra-and interobserver variability and increase objectivity of ihc based protein assessment. ofp- - is quality of histological and cytological slides a palatable issue?: the taste project m. comanescu * , g. bussolati, a. sapino, g. butur, f. schmitt, f. feoli, t. tot, e. ovcin * institutul victor babes, dept. of pathology, bucharest, romania objective: the taste (technological platform and repository of high quality images and slides) project aims at developing a novel tele-pathology system by means of modern icts (information and communication technology) and is addressed to technicians and doctors. method: histological and cytological preparations are the basis for pathological diagnosis performed in daily practice throughout europe in a number of several millions per year and correctness and reproducibility of such diagnosis are heavily dependent on the technical quality. yet, quality is variable in different places and countries, related to school level, technicians' dedication, standard of apparatuses and reagents. variation in technical quality of the preparations prevents their open circulation at european level and precludes optimal diagnosis. results: the taste project tackles these problems by building-up an ict environment taste system where professionals from different countries will submit, via web, "virtual slides" of their own preparations to a panel of internationally recognized experts who will give comments and suggestions on the quality of the preparation. conclusion: the present approach (unprecedented at world level) will fuel a web-based community, aimed to a levelling and improvement of histopathological and cytopathological preparations, thus leading to an innovative training and more reproducible diagnosis, a basic requisite for disease treatment. of the whole atlases. virtual microscope positions can be stored in the memory and users can navigate quickly back and forward similarly to web pages. all these features are available through any web browser without need to install any additional software. results: in addition to the current atlases (dermatopathology, fetopathology, pathology of the newborn and bone marrow), an interdisciplinary atlas of pathology for pregraduate students of medicine is under development. it will contain full size annotated virtual slides. the atlases are free of charge, but registration is required. in order to ease the access, the atlases are connected to national academic identity federations. the members of institutions connected to identity federations can use theirs home credentials without revealing them to the atlases. conclusion: the atlases can serve not only to the students as a source of information, but they can be used by teachers as a source of teaching material. proving experiment of international virtual slide telepathology, japan-vietnam and japan-china trial i. mori * , s. aida, y. osamura * international university of health, dept. of pathology, tokyo, japan objective: the communications between asian countries are growing. in the field of medical information and technologies, the necessity of communication is also required. in this work, as communication of pathology field, we tried to prove that international remote pathology diagnosis is possible using virtual microscopy (vs) telepathology. method: we put vs scanner and server to ) our hospital, tokyo, japan, ) cho-rai hospital, ho-chi-minh city, vietnam, and ) chinese rehabilitation research center, beijing, china. pathologists go and look the vs through leased optical line circuit and make diagnosis. discussion was made through teleconference system. results: the vs image maintained adequate quality for pathology diagnosis even looked cross-border. the diagnoses matched well between hospitals. the response of vs viewer was also good this time. when we use too much band width to the teleconference system or we sent too many data in the background, the response deteriorate, and was not good enough for diagnosis. conclusion: it was confirmed that the international vs telepathology diagnosis is now reached to a stage of actual use at least when connected by leased optical line circuit. challenges and solutions in the setup of a findings database for a large scale tissue collection r. reihs * , h. müller, s. sauer, k. zatloukal * medizin. universität graz, inst. für pathologie, austria objective: many medical centres have acquired through the last years huge data collections of great relevance for biomedical research. in order to utilize this knowledge it is necessary to analyse this records in a structured way. in our use case the starting point were approximately . million pathological findings of a non-selected patient group. method: we developed software tools for the classification of medical records using a phonetic a multi-level spell correction module and an ontology term extraction and decision tree text classification system. with the help of a visual editor a comprehensive decision tree ( nodes) was set-up by a team of bioinformaticians and medical experts. results: with our tool set we achieved in the icd- classification a f-score of , % (precession , % and recall , %) for the interpretation of the classification results we developed visualization tools and applied the whole software suite at several test cases, e.g. the analysis of a colon data-set with . findings over years. conclusion: we developed an automatic classification and visualization system and applied the results in a series of research projects. the software suite is currently used in several research projects and can be easily adjusted to specific phrases used in different institutions and languages. an image repository for decision support o. eichhorn * * aperio, vista, usa objective: pathology is a visual field, and pathologists make decisions based on visual information. an online repository of easily searched, well-categorized pathology images can be of immense use to pathologists, scientists, educators, and students. method: individuals and institutions all over the world have accumulated collections with thousands of slides representing a huge variety of pathologies. some collections are digitized and available online, while others remain libraries of glass slides, with a variety of formats for case information and other metadata. working with collectors to publish their slides and aggregating them together can yield an amazing decision support resource. results: long-term archival storage is a key issue for organizations adopting epathology. a cloud-based repository can provide an inexpensive and scalable solution. epathology is increasingly used for remote consultations. cases managed by online consultation networks can be de-identified and contributed to a common repository, increasing the value of the decision support tool while providing a long-term archive. conclusion: this talk will present concepts for an image repository for decision support, and discuss technical and business considerations for making it a reality, including ways to curate image metadata, organizational principles and search tools, relationships with users and contributors, access methods, and security and privacy considerations. ofp- - perfect diagnostic accuracy using pathomorphological diagnosis spectra constructed with the help of whole slide imaging k. furuya * , t. maeda, k. kito * ehime prefectural central hospital, dept. of pathology, matsuyama, japan objective: pathomorphological diagnosis (pd) is important for estimation of clinical trials and new medical equipment such as elastography. however, interpretation of pathomorphological findings is often subjective, and pathology publications show only a limited number of photographs. because pathomorphological changes occur in succession, we attempted to construct pd spectra to improve pd accuracy. method: pd spectra are defined as the series of pathomorphological images arranged in the order of disease progression or cell cycle procession. the images from the whole slide imaging (wsi) server were arranged in order in power point files at a fixed magnification, and pd spectra were constructed: chronic hepatitis staging, nuclear grading of hepatocellular carcinoma, nuclear grading of breast cancer, and ki- labelling index (li). the numbering of all images in the pd spectra corresponded with that of the wsi images so that the whole slides could be viewed alongside. next, these tools were tried out by people. results: these tools brought on perfect accuracy with regard to staging and grading, and very high precision of ki- li for breast cancer. conclusion: pd spectra are valuable not only for pd but also as learning tools and have a worldwide applicability for measuring pd online. ofp- - color correction of immunohistochemistry stained tissue section images by histogram transfer according to control tissues s. sarioglu * , s. seyrek, m. sakar * dokuz eylul university, faculty of medicine, izmir, turkey objective: for semiquantitative and quantitative analysis, previous normalization attempts of images of tissue sections are not satisfactory. in this study we evaluated, if color correction can be achieved by histogram transfer depending upon control tissue image (cti) differences. method: images from colon and placenta sections stained by anti-cd were used as cti and/or sample tissue images (sti). thirty-four but one (standard stained slide with images scti and ssti), was stained for different durations and dilutions than the standard procedures. digital images taken by a ccd camera connected to a light microscope without normalization was stored at a computer. software was prepared in order to find the histogram difference between two ctis and transfer the difference to the sti for achieving a corrected sti (corsti). ssti (one image) and sti and corsti ( images each) were semiquantitatively scored by two observers in blind fashion and the sti and corsti scores were compared with ssti score. results: the wkappa was , for two observers. the sti semiquantitative score was same as the ssti in , % of the sti but this was , % for corsti. conclusion: it seems histogram transfer depending upon ctis may be a valuable tool for color correction of tissue section images. sunday, september , . - . objective: there is a crucial need for identification of markers to choose the best treatment schedule and monitor the effectiveness of treatment in metastatic melanoma (mm) . the detection of circulating tumor cells (ctc) correlates with prognosis in different cancer subtypes. ctc can be detected by direct and indirect methods such as cytopathological approach, rt-pcr or immunomagnetic separation using the cellsearch (cs) method. method: from june to december , blood was drawn from patients with mm and controls patients and processed into h by the cs method. the primary end-point was the overall survival (os) of mm patients. results: enumeration of at least cmc was effective in . % of patients with mm (n= ) and in % of controls patients (n= ). nine patients ( %) had ≥ cmc. none of the controls patients had more than one cmc. mean os time was . months among patients with mm and < cmc (n= ) and mean os time was . months among patients with mm and cmc ≥ (n= ) (p= . ). conclusion: our results demonstrate that detection of cmc correlates with os in melanoma. thus, cmc monitoring should be developed to ensure the best treatment follow-up for patients with mm. ofp- - significance of circulating tumor cells (ctcs) detection using the cellsearch system in patients with locally advanced head and neck squamous cell carcinoma (hnscc) a. bozec * , m. ilie, e. long, o. dassonville, g. poissonnet, j. santini, e. chamorey, f. peyrade, k. benezery, a. sudaka, e. selva, p. hofman * centre antoine lacassagne, dept. of surgery, nice, france objective: the significance of ctcs in patients with hnscc is debated currently. we evaluated the potential detection of ctcs using the cellsearch (cs) assay tm (veridex, nj, usa) in hnscc patients and to identify the clinical factors predictive of the presence of ctcs in this population. method: forty-nine patients with locally advanced hnscc were included. the presence and number of ctcs were determined using the cs system in all patients prior to the initiation of therapy, in patients months after treatment, and in healthy individuals. results: the cs system was able to detect the presence of ctcs in of patients ( %) before therapy and in of disease-free patients ( %) after therapy. no ctc was found in the control group. when considering the presence of ctcs before or after therapy, the presence of ctcs was statistically associated with patients' age (p= . ; t-test) and n-stage (p= . ; fisher's exact test). conclusion: ctcs are identified in a relatively low proportion of patients with locally advanced hnscc and correlated with initial lymph node involvement. ctc detection could be a future useful prognostic tool to adapt the treatment intensity in hnscc patients. the diagnostic utility in identifications of an aneuploid chromosomal (ch.) pattern by using urovysion™: a fluorescence in situ hybridization (fish) commercial test, to improve the efficacy of cytology in peritoneal effusions l. baron * , m. postiglione, c. trombetta, f. quarto * p.o.s. leonardo, s.o.c. di anatomia patologica, castellammare di stabia, italy objective: the challenge in diagnosis of effusion is in differentiation of reactive and neoplastic mesothelial or metastatic cells and identification of primary neoplasia. the difficulties in this differential diagnosis derived from the low sensitivity (~ %) and specificity of effusion cytology. by identification of tumor associated aneuploidy fish could enhance the cytodiagnostic yield in effusions. method: we used urovysion™ (abbott), a fish commercial kit, designed for identifications of ch. , , polisomy and p loss in urothelial tumors. it has been applied to detect chromosomal aneuploidies as a marker of malignancy in effusions with or without known source primary tumors. also was evaluated reproducibility of molecular alterations with primary tumors and any their specific aneuploidies. results: fish positivity was observed in ( %) of cases, whereas were positive at cytology ( %). overall results of cytology and fish together rised to %. conclusion: urovysion™ test could be an useful tool to distinguish malignant cells in inconclusive effusions cytology but it doesn't seem to be used to provide definitive indications about primary neoplasia. ofp- - loss of imprinting of isulin-like growth factor (igf ) in colon carcinomas leads to the cell cycle genes activation -hints to intense proliferation d. belharazem * , j. kunanz, a.-k. henne, p. kienle, p. ströbel * inst. of pathology, university of medicine, mannheim, germany objective: the insulin-like growth factor (igf ) gene is regulated by imprinting in normal tissues. the loss of imprinting (loi) results in the bi-allelic expression of igf . its increased activity has been associated with many cancers including colorectal cancer (crc). to investigate the significance of igf in crc, normal tissue and tumor biopsies from patients were analyzed and correlated with clinical outcome and the kras and pik status. method: the igf g/a gene polymorphism and imprinting status were examined by restriction fragment length polymorphism of dna derived from normal tissues and tumors then of rna from heterozygous cases. igf protein analysis as well as an rna microarray were performed. results: % of the analysed cases were heterozygous. loi was detectable in both normal tissues and tumors in % of cases. tumors with loi had significantly higher igf protein levels. gene expression analysis revealed significance of cell cycle progression and mitosis genes in loi. conclusion: igf loi is a common and early change in patients with crc and in normal tissues, provides possibly a preneoplastic change. however increased igf protein levels as well as a different cell cycle specific gene expression profile were detected in tumors with loi. future studies must be performed to find out, whether such subsets of tumors differ in their response to chemotherapy or alternative therapies. objective: novel high-throughput technologies has revealed numerous genomic abnormalities in b-cell non-hodgkin lymphomas (nhl). this study aimed to detect point mutations involving ezh and cd b in a population of b-cell nhl by applying a multiplex mutation assay to minimal residual material from needle aspirates, and to determine the evolution of their mutational status overtime using all sorts of available samples from these patients. method: dna was extracted from residual cytological material stored on fta® cards as well as from archived cytological and histological specimens. the presence of point mutations was investigated by a specifically developed assay utilizing massarray spectrometry and confirmed by direct sequencing. results: all samples from b-cell nhl cases were successfully analyzed. mutations in ezh (y ) and cd b (y ) were detected in . % and % of the samples, respectively. mutational status varied in one third of the positive cases, with either gain or loss of mutations over the course of time. conclusion: minimal material from lymph node fine needle biopsy is a reliable source for high-throughput multiplex analysis for the detection of point mutation involving ezh and cd b. whenever possible, the most recent sample should be tested to verify the current status of the disease. ofp- - microrna expression profile identifies a distinct molecular signature between myc translocation-positive and negative burkitt lymphoma cases g. de falco * , a. onnis, f. morettini, f. fuligni, c. bellan, e. rogena, p. p. piccaluga, l. leoncini * university of siena, dept. human pathology and oncology, italy objective: the molecular hallmark of burkitt lymphoma (bl) is a dysregulation of myc oncogene, due to one of the three translocations leading to ig-myc fusion. however, about % of bl cases lack an identifiable myc rearrangement, although no significant difference of myc expression among cases has been observed. additional mechanisms alternative to translocations were explored by microrna profiling. method: ten myc translocation-positive and ten myc translocation-negative formalin-fixed and paraffin-embedded bl specimens were used for this study. for microrna and gene expression profile, the samples were hybridized on the mircury™ lna array and the illumina dasl whole genome assay, respectively. results: our results identified a panel of four micrornas which are differentially expressed between the two groups. importantly, these micrornas control relevant biological processes, such as the angiogenesis, apoptosis and cell proliferation, according to gene ontology categories. furthermore, the impact of microrna dysregulation on the gene expression pattern identified genes which more likely are regulated by the selected microrna. conclusion: using this approach, we showed a clear-cut microrna and gene signature between myc translocationpositive and negative bls. the identification of specific altered micrornas may represent an alternative molecular mechanism leading to myc over-expression in the absence of genetic alteration in cancer. ofp- - droplet digital pcr: a highly sensitive assay for b-raf, k-ras and egfr mutation detection j. frampton * , c. thorne, v. spivey, j. goodall, c. lowe * horizon discovery, dept. of diagnostics, cambridge, united kingdom objective: droplet digital™ pcr (ddpcr™) enables the absolute quantitation of nucleic acids in a sample. horizon discovery's patented gene editing technology enables it to manufacture reference material that is genetically defined and validated for the allelic frequency of the mutation. these reference standards were used to test the sensitivity of bio-rad's qx ™ droplet digital™ pcr platform. method: a panel of defined genomic dna allelic standards and formalin fixed paraffin embedded (ffpe) cell line samples were used in this study. this panel covered egfr (g s, t m, l r and l q), k-ras (codon ) and b-raf (v e and v k) mutations containing allelic frequencies between . % and %. droplet digital™ pcr was performed using mutation specific taqman custom snp assays. results: there was a strong correlation between the predicted and actual allelic frequencies even down to . %. the allelic frequency called by the ddpcr™ platform was highly reproducible between experiments particularly in the - % dilution range. conclusion: this study has demonstrated that the droplet digital™ pcr qx ™ platform can detect allelic frequencies down to at least . % using genomic dna purified from cell lines and down to at least . % using genomic dna extracted from ffpe cell lines. ofp- - chromothripsis and focal copy number alterations determine poor outcome in malignant melanoma t. gaiser * , d. hirsch, r. kemmerling, j. camps, t. ried * medizin. universität mannheim, inst. für pathologie, germany objective: genetic changes during tumorigenesis are usually acquired sequentially. however, a recent study showed that in - % of all cancers a single catastrophic event, termed chromothripsis, can lead to massive genomic rearrangements confined to one or a few chromosomes. method: in order to explore whether the degree of genomic instability and chromothripsis would influence prognosis in cancer, we applied high-resolution array comparative genomic hybridization to malignant melanomas (mm) that were, despite comparable conventional clinical and pathological parameters, defined by a profoundly different clinical course. results: we observed a striking association between both number and structure of chromosomal aberrations and outcome. mm associated with good prognosis showed only few chromosomal imbalances (average . alterations per case), predominantly presented as whole chromosome or chromosome arm gains and losses. mm with poor prognosis harbored significantly more chromosomal aberrations ( . per case; p= . ). these aberrations were mostly focal events, which culminated in two cases in a pattern consistent with chromothripsis. conclusion: here, we describe for the first time the phenomenon of chromothripsis in primary mm and reveal a link between focal copy number alterations and chromothripsis with poor outcome in mm patients (p= . ), providing a genetic approach to predict outcome in histopathologically indistinguishable mm. ofp- - targeting endometrial stromal sarcoma: histone deacetylase and pi k/akt/mtor signaling p. quan * , e. lederer, i. halbwedl, h. denk, k. zatloukal, j. haybaeck * institute of pathology, medical university of graz, austria objective: endometrial stromal sarcoma (ess) is a gynecological malignancy with few therapeutic options. up-regulated histone deacetylase (hdac) was observed in ess patients. the hdac inhibitor saha reduced ess cell growth by inhibiting mtor. the pi k/akt/mtor signaling cascade, vital to cancer growth is a critical target in cancer therapy. this study aimed at investigating if hdacs interact with the pi k signaling in ess pathogenesis and thus might serve as targets for ess therapy. method: tissue microarrays were used to determine hdac expression in ess specimens. western blots revealed protein expression levels of hdacs and pi k related molecules in two independent ess and one control cell lines (ess- , mes-sa and hesc). results: elevated hdac and levels were found in ess tissues and cell lines. increased cell growth and akt/mtor cascade hyperactivation were detected in ess cells. saha reduced growth of all cells, and induced cell death in ess cells. saha reduced phosphorylated ebp in all cells, but only inhibited activation of akt and p s k in ess- cells. conclusion: hdacs are linked to pi k signaling during ess pathogenesis. saha reduced cell growth via inhibiting pi k/akt/mtor components suggesting that a combination of saha with pi k inhibitors might be effective in treating ess. ofp- - usefulness of linking biobanking field and animal model: high successful rate of human primary non-small cell lung carcinoma (nsclc) xenografts in a model system separated by distance and time m. ilie * , l. blot, v. hofman, e. long, m. nunes, c. butori, e. selva, a. merino-trigo, n. vénissac, j. mouroux, p. vrignaud, p. hofman * chu de nice, lpce, france objective: with the ongoing need to improve therapy for nsclc, there has been an increasing interest in the development of reliable preclinical models to test novel therapeutics. the aim of this study was to evaluate the rate of establishment of patient-derived nsclc xenografts in the context of a long-distance research network. method: fresh surgically resected nsclc specimens were addressed from the human biobank hospital (nice) to the animal facilities (sanofi, vitry-sur-seine). shipment was performed in aqix medium at room temperature. within h post surgery, tumour fragments (~ mm ) were subcutaneously implanted in female scid mice. the growing tumours were passaged in new mice (≤ passages). the xenografts were histologically checked to eliminate human or murine lymphoma. results: overall, nsclc samples were implanted leading to ( %) nsclc xenografts. the rate of tumour growth was higher in non-adenocarcinoma specimens ( / ; %): / ( %) for squamous cell carcinoma, / ( %) for large cell carcinoma, and / ( %) for pleomorphic carcinoma, when compared to adenocarcinoma samples ( / ; %). conclusion: we report a high successful rate of xenotransplantation established from patient-derived nsclc tissues. our biobanking model system, regardless to extended time and distance, provides a stable and reliable animal model in human lung cancer research. monday, september , . - . objective: we tried to interpret "the job" of mf in different stages of tumor growth by monitoring the dynamics of their distribution. method: on a rat model of experimental tumorigenesis using bp fibrosarcoma cells injected intraperitoneally, we performed a semiquantitative analysis of the recruitment of mf in the tumor compartment (microenvironment) as well as in peripheral blood. results: we observed a slow increase of mf count in the initial phase of tumor growth followed by a slow decrease in the late phase within the tumor compartment. simultaneously peripheral blood showed constant increase throughout the experiment resulting in typical leukocytosis accompanying developed tumors. conclusion: increased mf in the initial phase could reflect their enrollment to "prepare a suitable microenvironment for tumor seeding". their decrease began after the tumor size was macroscopic, thus it was time for them to carry out a "different job". in the mean time their amount in peripheral blood started becoming significant, this is also the time when tumor -host interactions reach a systemic level. in futher experiments we will attempt to verify our assumption: when the tumor flourish in the host organism, it uses informed, transformed and recruited macrophages for growth and building construction of the tumor, and for communication with distant organs on a regulatory level. ofp- - wwtr and cyr are early markers of barrett's esophagus malignant progression m. mesquita * , j. cardoso, a. pereira, s. braga, m. bettencourt-dias, p. chaves, j. pereira-leal * ipolfg, dept. of pathology, lisboa, portugal objective: barrett's esophagus (be) is the major risk factor for esophageal adenocarcinoma (ea). be has a low risk of progression to ea, being imperative to identify markers to stratify the risk. our aim was to look for potential early biomarkers of be malignant progression. method: three available microarray datasets were analyzed with r statistical computing software complemented with bioconductor. biomarker prioritization included: ) expression barcode . ; ) filtering using differential expression analysis. candidate genes were validated by qrt-pcr on rna from paraffin embedded samples (rna-pes) of be patients with high-grade dysplasia/adc diagnosed during surveillance and of their index endoscopy dysplasia-free samples. as controls, we used samples from be patients who have not progressed. results: under conservative criteria, we identified upregulated genes that distinguish ea-progressed from nonprogressed be samples. a second filter, followed by qrt-pcr validation, trimmed the candidates to markers (wwtr and cyr ). qrt-pcr on time-series rna-pes of ea-progressed and ea-free be samples showed these genes are up-regulated years before the development of ea as compared to patients who did not developed ea. conclusion: wwtr and cyr were identified as early risk markers for be neoplastic progression and may have a potential role in be risk stratification. combined microrna in situ hybridization and immunohistochemical detection of protein markers b. nielsen * , t. møller, k. holmstrøm * bioneer a/s, dept. of molecular histology, hørsholm, denmark objective: micrornas are small noncoding rnas that constitute a novel group of biomarkers with exciting functions in cell differentiation, proliferation and apoptosis by mediating degradation or destabilization of target mrnas. mir- is highly prevalent in malignancies. previous reports on mir- in situ hybridization (ish) in colon and breast cancer identified expression in the stromal cell population that was related to recurrence and cell proliferation (nielsen et al., clin exp metastasis , : ; rask et al., apmis , : ) . here, we present a histological assay platform that allows parallel localization of micro-rnas and protein markers. method: routinely processed paraffin embedded breast cancer samples were analyzed. microrna ish probes were detected with fluorescent tyramine reagents and primary antibodies with compatible immunofluorescence. the reagents were introduced on a semi-automated platform, histoflex, which has a precise temperature control unit and utilizes continuous liquid flow. results: by combination of mir- ish and pdcd immunofluorescence we found differential expression in many but not all mir- positive cells. using the histoflex, the double fluorescence assay was reduced from to h without loss of sensitivity and specificity. conclusion: a -fold faster assay platform was developed and our in vivo findings support the assumption that pdcd is a target of mir- . the tnf-superfamily members april and baff and their receptors (baffr, bcma, taci) are differentially expressed in tumors and normal tissues and exert specific effects related to cell fate and differentiation v. pelekanou * , v.-i. alexaki, g. notas, m. kampa, e. stathopoulos, a. tsapis, e. castanas * university of crete, pathology, school of medicine, heraklion, greece objective: classically, tumor immune-related microenvironment was synonym of inflammatory cell infiltrate. recently, the detection of synthesis and secretion of immune mediators by tumor cells highlighted tnf-superfamily (tnfsf) members as key counterparts of cell fate-related signals. here, we assayed the synthesis-expression-function of a subset of tnfsf ligands and receptors (baff, april, baffr, bcma, taci) in normal epithelial tissues and tumors and resident adult mesenchymal stem cells. method: tissues (breast, cns, kidney, skin, adipose tissue) have been assayed by means of immunohistochemistry and real-time pcr. cell models were used for signaling, transcriptomics and functional assays. results: all tumors expressed this tnf-sf subset. baffr is absent, while its specific ligand baff is ubiquitously expressed; contrairewise, april, bcma and taci are expressed in tissue-specific manner. april relays on tumor evolution/grade and is involved in tumor proliferation/differentiation/apoptosis signaling through nfκb-related, or a novel pathway, implicating jnk/foxo a/gadd , triggering transcriptional events. conclusion: autocrine/paracrine effects of april and its receptors bcma and taci in normal/tumoral parenchyme and the recruitment/attraction of immune-related cells could orchestrate tissue response, regulating cell fate, differentiation, inflammation, tissue remodeling and cancer, with potential tailored-therapy application. objective: mutation analysis of kit and pdgfra genes is currently used in gastrointestinal stromal tumors (gist) as an important step in diagnostic protocol. method: dna samples obtained from parafin-embedded biopsy material of gist patients diagnosed in - were screened for mutations in exons , , and of kit and , and of pdgfra. results were tested for associations with clinical parameters of the tumor. results: causal mutations (according to in silico analysis with polyphen- predictor) were identified in . % of patients, most frequently in kit exon ( . %). the kit exon , pdgrfa exons and , kit exon , pdgfra exon and kit exon mutations appeared with frequencies . %, . %, . %, . %, . % and . % resp. genotype-phenotype correlation analysis revealed statistically significant association between intestinal localization of tumors and presence of kit exon p. - _dup mutation and gastric localization of tumors and presence of pdgfra exon p. d v mutation. conclusion: centralized and standardized gist diagnosis offers clinically and prognostically relevant informations and is necessary for the indication of appropriate targeted therapy of gist patients. supported by projects cepr ii (imts ) and mbcc (imts ) at cu jfm co-financed by eu and by grant novartis slovakia. objective: an association between cystic fibrosis transmembrane regulator (cftr) gene mutations and infertility may occur. this study investigated the frequency of mutations in the cftr gene, of a group of consecutive patients candidate for assisted reproductive techniques with the aim of identify subjects carriers of the most severe ones. method: we screened healthy subjects ( females and males) for cftr gene mutations and ivs -polit polymorphism utilizing the cftr inno-lipa amplification kit including both general and italian regional strips. results: cftr mutations were detected in . % of the patients, a percentage similar to that reported in the general population. the most common mutation was Δf /n observed in . % of patients. no difference in the gender distribution was evidenced. in the large group of patients analyzed . % were wt, . % carrier of one mutation, and interestingly . % compound heterozygous. conclusion: our data support the relevance of an accurate determination of mutations in the cftr gene in order to inform the couple of their carrier risk and the possibility on having affected child. moreover our findings highlight the potential of genetic screening as a tool to identify possible compound heterozygous subjects without cf-like symptoms. objective: a patient's response to cancer treatment can depend on their biomarker status. therefore it is important that laboratories perform their biomarker tests well. in an international external quality assessment scheme for kras mutation analysis on ffpe slides was set-up. method: this scheme was run for years by the coordination center, a medical and technical expert and scheme organizers under the umbrella of esp. participants received samples. genotype results were analyzed and labs with good performance were listed on the esp website. written reports of were evaluated in detail. results: in , % of participants identified all samples correctly. results seemed to improve over the years from . / to . / . genotype results from laboratories that participated for years appeared to improve overtime, although this couldn't be statistically proven. in the reports some important elements weren't always present. for example, the patient's name was only present in %, correct hgvs nomenclature in % and interpretation of results in less than %. conclusion: kras-eqa probably facilitates improvement of laboratory testing. the quality of reports of kras tests needs to be improved. a guideline for reporting molecular pathological results would be a good instrument for both participants and assessors. objective: microsatellite instability (msi) due to mismatch repair (mmr) deficiency is reported in a fraction of colorectal cancers (crcs) ( - %) complicating ibds (ibd-crcs). our recent findings argued for the existence of yet unknown mechanisms underlying mmr-deficiency in ibd-crcs, different from those involved in sporadic and hereditary msi crcs. here we hypothesized that over-expression of mir- and mir- , two inflammation-related mirnas that target core mmr proteins, could constitute a mechanism underlying mmr deficiency in ibd-crcs. method: we compared the expression of both mirs in ibd-crcs and non-ibd hereditary or sporadic crcs using nonneoplastic ibd and healthy mucosa samples as controls. results: overall, mir- and mir- were significantly over-expressed in both non-neoplastic and neoplastic mucosa of ibd patients as compared to healthy controls. mir- alone was preferentially expressed in msi vs. mss ibd-crcs. in contrast, mir- was poorly deregulated in non-neoplastic and neoplastic tissues of non-ibd msi or mss crcs. conclusion: mir- , alone or synergistically with mir- , may favor the emergence of msi ibd-ccrs. since its deregulation was not limited to neoplastic tissues but extends to non-neoplastic normal mucosa as well, the hypothesis of a mir- field defect promoting mmr deficiency and yet msi-driven transformation can be proposed. ofp- - pi k, akt and pten expression in enucleated brazilian uveal melanoma cases using tissue microarray g. freeman * , d. begnami, a. damascena, j. neves, s. nonogaki, f. soares * são paulo, brazil objective: in the world literature, little has been published on the molecular pathways in primary uveal melanoma or subsequent development of metastases. the pi k pathway has been implicated in regulation of apoptosis, cell cycle regulation, transcription and translation. method: we used immunohistochemistry with tma to investigate expression of pi k, akt and phos-akt, and pt in over formalin fixed paraffin embedded blocks of uveal melanoma from the a.c. camargo hospital, são paulo, brazil from to . fish was performed for pten copy numbers. results: in this study, neither immunohistochemistry nor fish results showed a statistically significant difference between the primary tumors and the tumors which metastasized. statistical analysis of all tumors together (tma) revealed only one molecular marker (pten), which gave results close to statistical significance. conclusion: this is the first large study of brazilian patients for pi k, pten akt expression by immunohistochemistry and pten using fish. expression values for molecular markers chosen did not reach statistical significance, although pten values were close. use of fish to distinguish metastatic from non metastatic cases also came close to statistical significance. these results suggest that the expression of pten in uveal melanoma may be a good topic to investigate further. objective: chronic antibody-mediated (camr) and chronic t-cell-mediated rejection (ctcmr) represent predominant reason for late graft dysfunction. both categories share similar morphological features. we ask the question whether there are differences between camr and ctcmr on the molecular level. method: graft biopsies (> m) were performed and evaluated according to the banff classification. biopsy specimens with camr (n= ), ctcmr (n= ) and from protocol biopsies with normal histology (n= ) were stabilized in the rna-later. using the taqman low density array, the intrarenal expressions of genes relating to immune response (b-cell activation, t-cell activation, chemokines, growth factors, immune regulators and apoptosis) were analyzed. results: both categories of chronic rejection were associated with up-regulation of many genes in comparison with the control group: chemokines (ccl , ccl , cxcl , cxcl , cxcl ), growth factor tgfb , mhc class ii (hla-dma, hla-dmb, hla-dr, ubd), and in t-cell dependent mechanisms (cd , cd , lag ), including cytotoxic t-cell associated transcripts (gbp , gzmk). in hierarchical clustering, camr and ctcmr gene expression profiles were similar. conclusion: chronic rejection very probably involves prolonged cooperation of innate immunity and allospecific immune response. our study showed that ctcmr and camr do not differ on the molecular basis. ofp- - podocyte loss and glomerulosclerosis in inducible mouse model of podocin mutation-related nephrotic syndrome i. simic * , m. tabatabaeifar, g. mollet, c. antignac, s. weber, f. schaefer * universitätskinderklinik, nephrologisches labor, heidelberg, germany objective: mutations in nphs gene, encoding podocyte specific protein podocin, cause hereditary nephrotic syndrome. knock-in mice carrying the r q mutation, murine analogue of the most common human mutation r q, show developmental arrest of podocytes and renal failure at neonatal age. the aim of this study was to quantify renal histopathological changes in mice with postnatally induced r q hemizygosity. method: c bl/ mice with nphs flox/r q, cre + genotype were injected with tamoxifen for days to induce hemizygosity for r q-mutant podocin. tissue samples were collected at defined intervals after induction. renal morphology was evaluated by quantitative histology, immunohistochemistry and electron microscopy. results: animals developed proteinuria within week that progressed into renal failure and advanced uremia at week - . the number of podocytes per glomerulus started decreasing at week ( ± vs. ± , p= . ), whereas glomerular sclerosis index increased from week ( . ± . vs. . ± . , p< . ). interstitial changes included fibrosis (up to % of section area in end stage renal disease), tubular atrophy and dilatation. conclusion: our results implicate that the expression of mutated podocin in induced r q-podocin mice leads to podocyte loss that precedes interstitial damage and glomerulosclerosis. quantification of histological changes will enable better evaluation of the efficacy of different pharmacological approaches directed to improvement of podocyte viability and attenuation of glomerulosclerosis. ofp- - heavy chain deposition disease in kidney biopsies a. vizjak * , j. mraz, j. lindic, d. ferluga * university of ljubljana, faculty of medicine, slovenia objective: heavy chain deposition disease (hcdd) is a rare and not yet fully explored monoclonal immunoglobulin-related disorder. method: we studied the histopathology in kidney biopsy cases of hcdd, representing a . % prevalence among native kidney biopsies. results: hcdd was diagnosed in kidney biopsies of women (mean age . years). light microscopy showed diffuse nodular glomerulosclerosis ( / ), associated with mesangial proliferation ( / ) and capillary aneurysms ( / ). immunofluorescence showed abundant mesangial deposits and ribbon-like deposits along glomerular, capsular, tubular and vascular basement membranes, positive for heavy chain igg ( / ) and igg ( / ), with deleted gamma ch domain ( / ). complement c and c q stained positive in all cases. by electron microscopy, punctate and powdery electron-dense deposits were found on the same locations. conclusion: immunofluorescence examination of kidney biopsies, including testing for immunoglobulin heavy and light chains, is crucial for diagnosis of hcdd. our study confirmed that hcdd is peculiar among monoclonal immunoglobulin deposition diseases not only because of its rarity but also because of uniform histomorphologic pattern of nodular glomerulosclerosis with pronounced capillary aneurysms and significant proliferation due to complement activation. deletion of the heavy chain ch domain and its significance in the pathogenesis has to be emphasized. ofp- - two cases of anca associated vasculitis with geographical necroses in the kidney tissue a. bartonova * , e. honsova, r. rysava * ikem, dept. of pathology, praha, czech republic objective: anca associated vasculitides (aav) are rare systemic autoimmune diseases affecting small to mediumsized blood vessels. in kidney biopsy samples, aav usually demonstrate pauci-immune necrotizing crescentic glomerulonephritis (gn). method: among cases of aav evaluated at ikem during years, had a very unusual pattern of renal involvement. results: the first patient had been treated for recurrent otitis media with unilateral hearing loss. he also suffered from artralgias and hematuria. an ultrasound study revealed a tumor-like mass in his kidney. during exploratory surgery, the lesion appeared to be infiltrative and a nephrectomy was performed. the second patient presented a granulomatous inflammation in a scar. a month later she developed multiple kidney and spleen "abscesses" with negative hemoculture, and underwent a nephrectomy with splenectomy. in both cases, the final pathological diagnosis was necrotizing granulomatous vasculitis of small and medium-sized vessels, with large geographical necroses of kidney tissue simultaneously with necrotizing crescentic gn. tests for anca antibodies were positive. no microbial pathogens including mycobacteria were detected. objective: polyomavirus nephropathy (pvn) is a common complication after renal transplantation. virus control is achieved by a reduction of immunosuppression allowing an effective t cell-mediated antiviral immune response. the morphology of resolving pvn has not been investigated. method: protocol biopsies of patients with pv viremia treated by reduction of immunosuppression only were included and scored according to banff criteria. the extent of interstitial inflammation was estimated as % of cortex. the number of tubular cross sections with sv + cells per mm of biopsy length was counted. findings were grouped as pre-, increasing, decreasing, and post-viremia. results: during the phase of decreasing viremia, we found a significant increase in the tubulitis score, the extent of tubules with intraepithelial lymphocytes, and interstitial inflammation (p< . ). these, to a lower extent, persisted after virus clearance. the number of sv + tubules correlated with the virus load in the serum, but sv immunohistochemistry was frequently negative ( / cases), especially if viremia was below geq/ml. conclusion: resolving pvn is characterized by a self-limiting acute interstitial nephritis. our findings are important because the diagnosis of interstitial rejection depends on the same morphological criteria. therefore, acute interstitial rejection cannot be diagnosed with certainty during pv viremia. ofp- - neural cell adhesion molecule and fibroblast growth factor receptor positive interstitial cells increase in interstitial fibrosis in different renal diseases j. markovic-lipkovski * , c. müller, s. cirovic, s. tatic, d. mitrovic, g. müller * university of belgrade, faculty of medicine, serbia objective: ncam + cells with dendritic morphology are rarely present in normal renal interstitium. the aim of this study was to evaluate presence of ncam + cells in kidney biopsies of different renal diseases with and without interstitial fibrosis (if). further immunophenotyping of ncam + renal interstitial cells was performed. method: kidney biopsies, after routine diagnosis, were stained applying antibodies against ncam clone c .d or cloneeric . for double immunofluorescence, antibodies against ncam cloneep y and fgfr , alpha beta integrin, alphasma, cadherin , cadherin were used. by rpcr, different ncam isoforms ( , , ) were detected using specific primers in renal tissues with and without if. results: ncam + interstitial cells were identified in cases: % lupus nephritis, % focal segmental glomerulosclerosis, % iga nephropathy, % membranoproliferative glomerulonephritis, % membranous glomerulonephritis. ncam + cells coexpressed fgfr and alpha beta integrin, and were increased in if. ncam + cells did not coexpress alphasma, cadherin and cadherin , although they were closely colocalised. all normal renal tissues tested for rpcr showed presence of all ncam isoforms, however ncam lacked in some tissues with if. conclusion: ncam + renal interstitial cells coexpress fgfr and alpha beta integrin and are increased in renal diseases with if, mostly in diffuse proliferative lupus nephritis. in contrast to normal kidneys, in renal tissue with if ncam is present in a lesser extent. reproducibility for c d immunohistochemistry in renal allografts: results from the banff trial m. mengel * , s. chan, j. climenhaga, p. randhawa, h. regele, y. kushner, r. colvin * university of alberta, laboratory of medicine, edmonton, canada objective: detection of c d is crucial for diagnosing antibody mediated rejection, yet formal reproducibility studies are limited. method: we conducted an international multi-center trial to assess the reproducibility for c d immunohistochemistry on paraffin-sections. a tissue microarray (tma) was constructed comprising kidney allograft specimens representing negative, focal, and diffuse c d positive cases. participants stained the tma slides, evaluated their stains and entered their scores online. stained slides were returned for centralized panel scoring. weighted kappa statistics were used to determine reproducibility. results: inter-institutional reproducibility, i.e. the product from variability between observers and staining methods was low (mean kappa . ). inter-observer reproducibility was fair (kappa . ), while inter-laboratory reproducibility was moderate (kappa . ). inter-observer reproducibility could be significantly improved by omitting the banff c d grading schema and only considering +/− calls (kappa . ). scoring only c d+/− inter-laboratory reproducibility improved considerably (kappa . ). higher dilutions of the primary antibody were associated with worse reproducibility. fixation < h or fixation in ethanol had significant negative impact on inter-laboratory reproducibility. conclusion: c d results reported from paraffin section are highly variable between institutions. simplification of the grading schema would improve reproducibility between observers. technical reproducibility between laboratories is acceptable but could further be improved by standardizing protocols. objective: heparanase is a predominant mammalian enzyme that cleaves heparan sulfate, the key polysaccharide found in the basement membranes and at cell surface. heparanase is overexpressed in the diabetic kidney; however, its role and mode of action in diabetic kidney disease remains largely unclear. method: applying heparanase-null mice we found that deletion of the heparanase gene protects diabetic mice from diabetic nephropathy (dn). recombinant heparanase enzyme and a specific heparanase inhibitor (sst ) were used to explore its mode of action in several in vivo and in vitro models. results: there is essential involvement of heparanase in the pathogenesis of dn. deleting the heparanase gene protects diabetic mice from dn and administration of specific heparanase inhibitor decreases the extent of albuminuria. in vitro, heparanase enhances macrophage activation by diabetic milieu components, and thus increases the kidneydamaging properties of macrophages. conclusion: our results validate the role of heparanase in dn and reveal the mechanism of heparanase action emphasizing its function in coupling chronic inflammation, macrophage activation and diabetic kidney injury. these findings will help in developing effective strategies to disrupt the heparanasedriven sequence of events in diabetic kidney disease, and in designing novel therapeutic interventions in dn. sunday, september , . - . , terrace ofp- oral free paper session neuropathology ofp- - microvascular angiogenesis occurs in a subset of only the arteriovenous types of vascular malformations and is more abundant in men than in women l. b. meijer-jorna * , c. m. van der horst, c. m. van der loos, a. c. van der wal * medical center alkmaar, symbiant pathology center, netherlands objective: episodic volume expansion may complicate the very slow growth pattern of congenital vascular malformations. we investigated the role of microvascular angiogenesis in this process of sudden growth. method: resection specimens of symptomatic vascular malformations were screened for presence and extent of sheets or clusters immature microvessels, interpreted as microvascular angiogenesis. microvessel density (mvd), mast cell density (mcd) and ki labelling index of endothelial cells (ec) were assessed immunohistochemically and quantified. extent of angiogenesis was correlated with the type of vascular malformation and clinical characteristics. results: of cases, were arteriovenous malformations (avm), were venous (vm), and were lymphatic (lm). microvascular angiogenesis was observed in % of all vascular malformations, of which % appeared to be avm. mvd, mcd and ki labelling indexes of ec were significantly higher in immature vessel areas. moreover, in affected patients these angiogenic responses were far more extensive (in terms of area involvement) in men than in women (p< . ). conclusion: microvascular angiogenesis appears a specific feature of the arteriovenous type of vascular malformations, and is much more extensive in men than in women. we suggest that these microvascular responses may contribute to onset of symptoms due to a mass forming effect. ofp- - the impact of ventricular assist device prior to transplantation on acute cellular rejection and antibody-mediated rejection in cardiac allografts with due consideration of seasonal behaviour: a prospective study k. wassilew * , e. potapov, c. knosalla, t. krabatsch, m. hummel, r. hetzer * deutsches herzzentrum berlin, germany objective: this study evaluated the impact of bridge-to-transplant ventricular assist device support on development of acute cellular (acr) and antibody-mediated rejection (amr) with due consideration of seasonal behaviour in cardiac allografts. method: we studied consecutive right ventricular endomyocardial biopsies (emb) between / and / prospectively. paraffin-embedded sections were evaluated for acute cellular rejection, endothelial cell swelling and capillary deposition of c d, c d and iga/m/g. the effects of vad (n= ) on acr and amr, classified according to the ishlt, were studied for seasonal effects and compared to results of emb harvested from patients without vad support (n= ). results: our results did not reveal significant differences between the two groups in any given parameter. a positive correlation was found for endothelial cell swelling and capillary c d deposition; the data failed to show a correlation between c d and c d deposition or c d deposition and endothelial swelling. complement and immunoglobulin depositions seemed to be more pronounced but without statistical significance in autumn and winter. conclusion: our results demonstrate only statistically insignificantly more pronounced capillary complement deposition in autumn and winter. the use of vad did not predict development of amr or acr. the c d staining does not add to the pathological diagnosis of amr. relevant changes of the molecular profile in the recurrence of glioblastomas with respect to the correspondent primary tumors m. idoate * , j. echeveste, r. diez valle, m. montanana, j. sola, t. labiano * university of navarra, dept. of pathology, pamplona, spain objective: in the literature, there is not enough information about changes of relevant molecular parameters in the recurrent glioblastoma. method: the study included a total of grade iv astrocytomas (oms) and their correspondent recurrences in a series of patients treated by -ala guided surgery. all patients received similar treatment. a comparative histologic and molecular study which included loh of pten region, egfr amplification sish, methylation of mgmt by msp-pcr and sequencing of egfr variant iii mutation on representative tumor samples was obtained. results: the recurrences appeared adjacent to surgical cavity in seven cases. the mean time between the diagnosis of primary and the recurrence was days ( - ). the primary glioblastomas showed loh q in % of cases, hypermethylation of mgmt in %, egfr amplification in % and egfrviii in %. in five cases ( %) the molecular profile of the recurrences was different to the primaries and most of them ( %) in the group of vaccines treated glioblastomas. the molecular profile change included one to several of the studied parameters. in one case all of the molecular parameters had changed. conclusion: the molecular profile change of the recurrences of glioblastomas in respect to the primaries is a frequent event that could be due to the selection of tumor cells due to both heterogeneity and treatment effect. objective: there is not literature reference on the prognostic significance of the proliferative activity in the border of tumor. a large series of patients with glioblastomas operated by fluorescence guided surgery with uniform treatment and enough follow-up have been studied. method: a total of samples of different fluorescence quality from glioblastomas, primaries and recurrences, were studied. for each tumor, the maximum value of ki- was determined by a semiquantitative counting by two observers and by an autoanalyzer. these values were compared with relevant oncologic parameters. results: the results of ki according both counting methods were concordant. the ki max values of red (center), pink (intermediate) and blue (border) fluorescence samples obtained by quantitative analysis were % % and %. in the cox regression analysis for overall survival, the ki value was an independent prognostic factor, stronger than other relevant clinical parameters studied (p= . ). in the kaplan-meier for a ki cut-off of %, the median overall survival was . months against . months (p= . ). for the patients with recurrent glioblastomas the overall survival according to ki values was also significant (p= . ). conclusion: the evaluation of the proliferative activity by ki- in the border of tumor defined by -ala fluorescence is a relevant independent prognostic marker of primary and recurrent glioblastomas. objective: according to the levels of estrogen receptor (er) expression, primary breast carcinoma (bc) cases are divided into two groups: er-positive and er-negative (godhirsch et al. ) . in metastatic bc, and especially in brain metastases (bm) of bc, the role of er expression is not clearly defined. aim: investigate er expression levels in brain metastases of bc and evaluate its prognostic significance. method: surgically obtained tumor specimens from sixty bc female patients (median age , ranges - ) with bm bc were stained with antibodies to er (dako). ihc expression was evaluated according to the semi-quantitative method. survival was estimated by means of kaplan-meyer curves. statistical analysis was performed using staitis-tica . software. results: er expression was detected in % of patients ( / ), and % ( / ) were er-negative. median time period between primary diagnosis and bm development was significantly (p< . ) longer in er-positive group compared to er-negative group ( and months, respectively). recurrent bm developed in both groups with a similar frequency ( % and %, respectively). general survival was significantly (p= , ) higher in er-positive patients compared to that of er-negative group. conclusion: er expression is considered to be an important prognostic factor for development of bmbc. nevertheless, further studies involving more patients with bmbc are required. ofp- - dopamine and alpha synuclein interplay in neurodegeneration: a rat animal model g. stoica * , g. lungu, n. bjorklund * texas a&m university, veterinary pathobiology, college station, usa objective: a spontaneous autosomal recessive rat model for neurodegeneration was developed in our laboratory. these rats demonstrate progressive increases in alpha synuclein (α-syn) in the brain mesencephalon followed by loss of dopaminergic terminals in the basal ganglia and motor impairments. method: histology, immunohistochemistry, transmission electron microscopy were used for morphological analyses. for α-syn assessment real-time pcr and western blot were used. dopamine measurements were performed by ion mobility mass spectral (imms). results: the severity of pathology is directly related to the overexpression of α-syn and parallel decrease in dopamine (da) level in the striatum (st) of affected rats. the neurodegeneration in this model is characterized by the presence of perikarya and neurites lewis bodies (lb) and diffuse marked accumulation of perikaryal α-syn in the substantia nigra (sn), brain stem, and striatum along with neuronal loss. light and ultrastructural analyses revealed that the process of neuronal degeneration is a "dying back" type. the disease process is accompanied by gliosis and release of inflammatory cytokines. conclusion: decrease dopamine and overexpression of α-syn in the brain mesencephalon may provide a naturally occurring animal model for parkinson's disease and other synucleinopathies that reproduces significant pathological, neurochemical, and behavioral features of the human disease. sunday, september , . - . objective: the mitotic index in thin primary melanomas replaced clark level in the staging system of the ajcc. however, the recommended quantification of proliferation by hot spots on he stains is criticized. an alternative may be the immunohistochemical proliferation marker phosphohistone h (phh ) visualizing all mitotic cells. and, when combined with the melanocytic marker mart , phh insures quantification of proliferating melanocytes, only. method: primary melanomas with a median follow-up of years for patients with event-free melanoma were included. phh /mart stains were performed by an indirect sequential immunoenzymatic technique. the number of phh /mart positive cells was counted in a fixed -mm frame in the dermal area with the highest concentration of positive cells (hot spots). results: in multivariate analysis, phh in hot spots was a strong independent prognostic marker for recurrent disease (hr= . , % ci, . to . ; p=. ) and melanoma-specific death (hr= . , % ci, . to . ; p=. ), when corrected for primary tumor thickness and ulceration. conclusion: cellular proliferation is an independent prognostic marker in primary cutaneous melanoma. however, accurate quantification is crucial for correct clinical staging. for this purpose, proliferation indices of the novel phh /mart double stains seem very promising. objective: some of the more common benign vocal fold lesions are polyps, nodules and polypoid corditis (reinke's edema). the majority of vocal fold pathology develops in the mucosal layer of the vocal fold, precisely in reinkes space. basic science and clinical research over past decades has led to advances in our understanding of benign laryngeal lesions. the aim of our study was compared contact telescopy findings with histological analyzes in a patients with reinke's edema. method: the our study included consecutive patients with clinical diagnosis of reinke's edema. videoassisted contact telescopy was performed in all cases under general anesthesia and mucosa was stained by methylene blue. tissue biopsies were taken from areas exhibiting visible pathological changes and sent to routine histopathology and immunohistochemical analyses. we analyzed expression of pancytokeratin antibodies, vimentin and cd . results: in the all case of reinke's edema, contact telescopic scans showed a change of direction or a disappearance of regular distribution and morphology of blood vessels (irregular shapes, positions, and patterns, apparently running in random directions) in vocal fold mucosa. marked pathological changes were noted by contact telescopic scans, confirmed with histopathology analyses. conclusion: contact telescopy is a useful additional diagnostic tool regarding reinke's edema. ofp- - volunteering in malawi: a snapshot of surgical pathology in sub-saharan africa s. berezowska * , t. tomoka, s. kamiza, d. a. milner jr., r. langer * universität bern, institute of pathology, switzerland objective: the breadth of material found in surgical pathology services in african countries significantly differs from the common spectrum of "the west". we report our experience in the pathology departments of blantyre and lilongwe, malawi. method: during a six-week period cases were processed ( histology, cytology). results: the vast majority of cases showed significant pathological findings (n= ; . %): ( . %) were non-tumoral conditions and ( . %) benign tumors or tumor like lesions. the large group of malignancies (n= ; . %) comprised pediatric tumors (e.g. rhabdomyosarcoma, small blue round cell tumors), and adult tumors. amongst women (n= ), squamous cell carcinomas (scc) of the cervix uteri predominated (n= ; . %), followed by breast carcinomas (n= ; . %), and esophageal scc (n= ; . %). males (n= ) most often showed scc of the esophagus (n= ; . %), and scc of the urinary bladder (n= ; . %). lymphomas (n= ) and kaposi's sarcomas (n= ) were less frequent. conclusion: providing pathology service in a low resource country may be handicapped by lack of personal, inadequate material resources, or insufficient infrastructure. rotating volunteers offer a bridge for capacity building of both personnel and the local medical service; in addition, the volunteer's horizons are broaden professionally and personally. objective: antinuclear antibodies (ana) are routinely tested by indirect immunofluorescence (if) and immunoblot. in this paper we aim to retrospectively analyze results of both methods. method: on two cohort groups: a (a total of samples), and b (a total of samples) we performed if on commercially obtained hep- cell, and immunoblot on (strips euroline). results: if revealed at least different morphological patterns of ana staining, which we grouped into easily distinguished categories: speckled nuclear fluorescence, homogenous nucleoplasmic fluorescence, multiple nuclear dots, nucleoli staining, and scattered nucleoplasmic dots. we compared these groups according to frequency, type of antibody and correlation with immunoblot resuts. we summed the characteristics of each if category, and noticed that both cohorts revealed . % and %, respectively of sera, which did not show positive if at an acceptable dilution (only by : ) or were fully negative in if test, but were clearly positive in immunoblot test. this was especially alarming with anti-scl- antibodies, which could be barely recognized in if test, but were clearly present in of positive stained strips (cohort a) and/ or out of positive stained strips (cohort b). ofp- - macrophages and their subtypes in tumorigenesis and growth o. el-hassoun * , l. maruscakova, z. valaskova, m. kopani, j. jakubovsky, i. hulin * alphamedical laboratories, dept. of pathological anatomy, martin, slovakia objective: it has been established that macrophages (mf) play a basic role in the tumor microenvironment. still, the definition of the function of mf with relation to tumors is still vague, mainly when mf are observed acting occasionally as pro tumor and elsewhere as anti tumor. method: in this paper we attempt to sum up the accumulating observations of mf function with respect to the microenvironment and the tumor entity. results: through the different stages of tumorigenesis and growth, macrophages are engaged in various signaling cascades that tame them to perform a certain function in a given microenvironment. this makes mf a multi-program cell with unique adaptivity. we assume that without the macrophages tumors cannot progress. conclusion: the available mf subtype analysis is still inadequate and doesn't bear into account the dynamics of tumorigenesis and growth. our presented mf schemes provide an insight on the tumor microenvironment with respect to stage. a complex view on the signaling cascades affecting mf is needed to formulate a novel classification of mf based on their programming. this consequently can be the basis of the development of "anti-mf therapy" or on a larger scale "anti-tumor microenvironment therapy". ofp- - lodox x-ray is an invaluable asset in autopsy procedures l. liebenberg * * university of cape town, dept. of forensic medicine, south africa objective: the field of autopsy performance has faced numerous challenges internationally. minimal background information on the deceased, various religious and personal objections regarding cutting a deceased body as well as health hazards face the pathologist regularly. lodox x-ray is a huge help for the pathologist. method: lodox x-ray (low dose x-ray) using the statscan has proven invaluable in busy forensic pathology laboratories in cape town, south africa. the digitally captured radiology images render a wealth of clear, recognizable, easily documented and user friendly images for use in diagnosis and court evidence. results: the use of the statscan has revolutionized the process of forensic autopsy procedures in cape town, south africa. the radiology images obtained in an unusually user friendly and time efficient way have improved efficacy, efficiency, accuracy and pro-active occupational health safety in our forensic laboratories. conclusion: lodox x-ray is a proven invaluable special investigation in forensic, and also academic, autopsy examination procedures. sunday, september , . - . objective: castration resistant prostate cancer (cr-pca) is the most aggressive form of prostate cancer (pca) posing a significant therapeutic challenge. our aim was to perform whole exome-sequencing on cr-pca/normal paired formalin fixed paraffin embedded (ffpe) samples using the solid next generation sequencing platform (ngs). we identified two promising genes-ywhaz and ptk , that could serve as novel potential therapeutic drug targets in pca. method: genomic dna was sequenced from cr-pca/ normal paired ffpe samples. a set of amplified/deleted genes were validated using fluorescence in-situ hybridization (fish) assays using a pca progression cohort consisting of cases for localized pca, patients with primary pca and corresponding ln metastasis, and samples for crpca. results: exome-sequencing identified regions of deletions/ amplifications, including nkx . , pten, cmyc and ar genes, known to play a role in pca. we identified several amplified genes as druggable targets such as ptk and ywhaz. for ywhaz we identified . % amplification in localized pca, . % amplification in ln metastasis and . % amplification in crpca. for ptk we % amplification for localized pca and % for both ln metastasis and cr-pca. conclusion: this is the first study to use exome-sequencing approaches on ffpe cr-pca to understand the biology of disease and its plausible treatment options. a study of d-np (p ) expression in tumours of stratified epithelium d. nonaka * * the christie hospital, dept. of histopathology, manchester, united kingdom objective: p can be expressed by a minority of adenocarcinomas. Δnp (p ), isoform of p , has recently been reported as more specific in lung squamous cell carcinoma (scc) than p , and it appears to be a more reliable marker for scc. there is no comprehensive study on p expression in tumours of different histotypes. method: tumours of various hisotypes were studied, including tumours of stratified epithelium such as scc ( cases) of the skin, head/neck, lung, cervix, and oesophagus, urothelial carcinomas ( ), cutaneous basal cell carcinomas ( ), thymomas ( ) and thymic carcinomas ( ), adenocarcinomas ( ) from multiple organs, germ cell tumours ( ), brain tumours ( ), lymphomas ( ), and sarcomas ( ). p immunostains were performed on tissue microarrays and staining extent was evaluated as focal ( - %) and diffuse ( - %). results: all but one tumours of stratified epithelium diffusely expressed p . the negative case represents spindle cell scc. other tumours except for basal/squamous component of two teratomas, one breast metaplastic carcinoma, and squamous component of adenosquamous carcinomas were all negative for p . conclusion: p is specific in tumours of stratified epithelium and its sensitivity appears comparable to p . p can serve as a marker for tumours of stratified epithelium. objective: although formaldehyde is the standard fixative used in routine histopathology, it is not considered an "ideal" fixative. formaldehyde presents carcinogenic properties, a slow fixation and produces cross-links with proteins and nucleic acids. formaldehyde-free fixatives are commercially available. method: from to we used glyo-fixx (thermo scientific, us), a glyoxal-based fixative, as formaldehyde substitute, analysing surgical pathology specimens and autopsies. all samples were processed and stained routinely. moreover we performed immunohistochemistry by an automated immunostainer and special stains with standard techniques, where needed. in tumoral cases we fixed cm sample in neutral buffered formalin and compared the results with gyo-fixx fixation. results: glyo-fixx fixation needed less hours than formaldehyde and not harden the tissues. on gross examination of the adipose tissue, lymph nodes were easily found, due to a more marked whitish appearance. morphologically we have not found differences between formalin and glyo-fixx, except for the eosinophils degranulation. special stains resulted similar to those with formaldehyde fixations. almost all antibodies not required pretreatment, but needed adjusts in the standardized protocol for formaldehyde. conclusion: our experience demonstrated glyo-fixx is a good non-toxic alternative to formaldehyde in routine pathology, capable to preserve morphology and protein integrity of the tissues. liposarcoma with solitary fibrous tumor-like dedifferentiated areas: clues on differential diagnosis m. aizpurua * * huvh/ics, dept. of pathology, barcelona, spain objective: well-differentiated liposarcoma (wdls) can undergo dedifferentiation to nonlipogenic sarcomas. solitary fibrous tumour (sft) characteristics have not been highlighted as a pattern of dedifferentiated liposarcoma (dls). however, this does occur and could be the cause of diagnostic pitfalls in atypical locations or partial tumoral resections. the aim of this comparative study is to demonstrate that some dls's may show morphologic features resembling sft's, and furthermore to describe the clue features supporting differential diagnosis. method: study comprised wdls-dls and sft ( malignant). histological features were systematically reviewed, and cd /cd /s /bcl immunostains and mdm fish-analysis were evaluated in all cases. results: there are many overlapping characteristics between dls and sft (table ). significant differences between both tumor types were observed in lipoblast-like cells (lpc); mature adipocitic cells within tumor (mac); stromal bands surrounding adipose tissue with atypical cells (sac); patternless (pa); keloidal-collagen (kcm) and haemangiopericytoid-pattern (hp). diagnostic accuracy of different features is shown in table . conclusion: the dedifferentiated component in some liposarcomas may resemble sft. in the dls/sft differential diagnosis, immunohistochemistry may be confusing. presence of wdls areas is the main diagnostic clue and mdm fish amplification is successful in distinguishing dls from sft. osteoblastoma and diagnostics pitfalls w. ouahioune * * ehs douera, dept. of pathology, algiers, algeria objective: osteoblastoma is a rare benign osteoblastic tumor with a potential for local bone destruction and aggressiveness. the most common site of osteoblastoma is the vertebral column particularly the posterior elements and the sacrum. method: in this study we present nine cases of osteoblastoma and the principal differential diagnosis. results: on a period of years, nine cases of osteoblastoma had been diagnosed including seven males and two females. the age of those patients ranged from to year old. the tumor was localized in the spine in five of the nine cases and the other ones in the long bones. the radiological diagnosis of osteoblastoma was made in just two cases. the diagnosis was made by histology in eight cases. all our patients had been treated with curettage. on the nine patients, just one of them had developed two successive recurrences. conclusion: osteoblastoma is a rare benign tumor which is rarely diagnosed by radiology alone. the pathologist should always suspect an osteoblastoma in front of a vertebral localization of any tumor. objective: congenital hepatic fibrosis (chf) is a developmental disorder of the portobiliary system. clinical findings usually include enlarged liver, well-preserved hepatocellular function and portal hypertension. chf is frequently associated with hepatorenal fibrocystic disease. method: a -year-old woman was referred to our hospital for further evaluation of hepatomegaly, and portal hypertension was found. laboratory tests were all negative. mri identified hepatosplenomegaly with hypertrophic left medial segment, high uptake nodular areas and homogeneous boundary liver. needle biopsy was performed. results: the biopsy demonstrated slight portal fibrosis and fibrous septa with proliferation of numerous biliary ducts, some of them containing inspissated bile. it was also noticeable the few number of portal vein branches. there was no inflammation or hepatocyte necrosis. therefore, our diagnosis was congenital hepatic fibrosis. we correlated these results with radiology. magnetic resonance cholangiopancreatography showed peripherally dilated biliary intrahepatic branches contrasting with preserved caliber of main intrahepatic branches. these findings were also diagnostic for chf. conclusion: the low prevalence of chf makes it hard to think about this entity in patients with portal hypertension and normal laboratory findings. the histological differential diagnosis must be done mainly with cirrhosis, but also with idiopathic portal hypertension and, in small biopsies, with biliary hamartoma. results: a total of cases of digestive tract lymphoma were reported ( males, females) with a sex-ratio of . . the patient age ranged between and years with a median age of years. stomach location was the most frequent with % of cases followed by intestine ( %) and colon ( %). among the digestive tract lymphomas, % were of marginal zone type (malt) and % were large b-cell lymphoma. according to the ann arbor staging system, % of patients were diagnosed at stage i and ii. conclusion: lymphomas of the digestive tract are still frequent in the centre of tunisia. the malt type lymphoma is main reported histological type. the association with the helicobacter pylori should be considered. collecting duct carcinoma in the west of ireland: a rare experience a. shalaby * , c. e. connolly * university hospital galway, dept. of histopathology, ireland objective: collecting duct carcinoma is a rare renal neoplasm arising from the epithelium of bellini's ducts in the distal part of the nephron. method: we describe our experience of this entity in university hospital galway with a series of four cases diagnosed between and . results: three patients aged between and years presented with either lymph node or bone metastases without evident abdominal mass. in each case the biopsy from the metastatic lesion showed adenocarcinoma with an immunohistochemical profile suggestive of renal origin and a renal mass was subsequently confirmed by radiology. the fourth patient was an year old male who presented with haematuria. abdominal ct scan revealed a . cm mass in the right kidney extending into the renal vein. biopsy of the renal mass in all cases confirmed adenocarcinoma with a tubular pattern with positive cytokeratin and vimentin staining and cd negative staining. one patient was treated with nephrectomy with post-neoadjuvant chemotherapy and died months after surgery. the other three patients died few months after their diagnosis. conclusion: collecting duct carcinoma is a rare renal neoplasm that can be difficult to diagnose on core biopsies, however, it can be identified based on radiological findings, gross, microscopic, histochemical and immunohistochemical features. objective: wilms tumors (wt) is the most frequent renal tumor of children. genetic alterations have been suggested as associated factors but the exact pathogenesis of wt is not fully characterized. tissue factor (tf) is a glycoprotein which happens to be a key receptor for factor vii/viia and a primary initiator of coagulation. tf has also been associated with angiogenesis. recent evidence pointed out an important role for tf in cancer progression and metastasis. method: in the present investigation the differential expression of tf in wt was assessed by real-time pcr of rna retrieved from paraffin sections using microdissection. results: different histological components of wt were analysed. the results revealed that tf was upregulated in blastema and epithelial components as compared to nonneoplastic tissue ( . and . -fold respectively, p< . ). stroma and non-neoplastic tissue presented low levels of tf expression. tf expression in wt metastatic lesions was also significantly upregulated as compared to non-metastatic wt. microvessel density was positively correlated with tf expression (r= . ). conclusion: as described in other tumors, tf seems to play a significant role in the behavior of wt. further investigations are warranted to better understand the pathways by which tf exerts its effects on tumor progression and its potential as a target for therapy. objective: biliary atresia (ba) is the most common neonatal cholestatic disorder and the prime indication for liver transplantation (ltx) in children. histopathological markers in liver biopsies emerge promise as indicator of early ltx in patients with ba. method: ductular proliferation, ductal plate malformations and type i, iii, iv and v collagen deposition were evaluated on kasai portoenterostomy (kpe) and liver transplantation (ltx) biopsies from children with ba. formalin fixed and paraffin embedded liver biopsies were stained with hematoxylin-eosin, picrosirius-polarization and immunofluorescence methods. there were analyzed liver histoarchitecture, biliary ductus and collagen deposition in hepatic compartments. pathologic findings were graded according to a -point semi-quantitative severity-based scoring system. impact of these markers was tested on ltx time (< year and > year). results: median age of kpe was weeks (range - ) and of ltx was months (range - ). in kpe liver biopsies, ductular proliferation, ductal plate malformations and collagen deposition were increased but these parameters presented no association with clinical evolution for early ltx. furthermore, collagen v prominent deposition was found along of hepatic sinusoids and type i, iii and iv were more frequent in portal compartment. conclusion: these results suggest that histopathological parameters evaluation presented may not determine early ltx in biliary atresia. the role of hofbauer cells on villous vasculature in early fetal losses e. Özer * , y. arman karakaya * dokuz eylul university, dept. of pathology, izmir, turkey objective: the aim of this retrospective study is investigate the role of hofbauer cells in early fetal losses. method: the slides obtained from archieval blocks of missed abortion (ma, n= ) and blighted ovum (bo, n= ) cases and unwanted pregnancies materials (control group, n= ) were stained by immunuhistochemical methods using cd and cd antibody to label hofbauer cells and endotelial cells, respectively. results: the mean number of vilous hofbauer cells was found to be significantly higher in both bo and ma in contrast to the control group (p= . and p<< . , respectively). however it was not significantly different between bo and ma (p= . ). chalkey method revealed no statisticaly significant difference in the control group in comparison with ma and bo in (p= . , p= . , respectively). higher microvessel scorring were found in ma in contrast to bo and the control group (p= . and p= . , respectively). however, there was no difference between the control group and bo (p= . ). conclusion: we think that hofbauer cells may be of biological importance in early fetal losses and play a role on defective vasculature formation in ma. placental vegf and its receptors expression patterns in preeclampsia k. pavlov * , e. dubova, a. shchegolev, g. sukhikh * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: placental angiogenesis anomalies play an important role in some complications of pregnancy development, including preeclampsia (pe). vegf and its receptorsone of the key placental angiogenic factor. aim: to evaluate patterns of vegf and its receptors (vegfrs , and ) expression in placentas from pe complicated pregnancies. method: we performed complex morphological and immunohistochemical study of term placentas from mild preeclampsia (mpe) cases ( st group), term placentas from severe preeclampsia (spe) cases ( nd group) and term placentas from uncomplicated pregnancies (control group). results: we revealed significantly increased syncitial vegf expression levels in preeclamptic placentas terminal villi and these changes were much prominent in spe. we also detected insignificantly increased endothelial vegf expression levels in preeclamptic placentas terminal villi. vegfr- syncitial expression levels in spe terminal villi were significantly higher in compare to the mpe and control groups. vegfr- endothelial and syncitial expression levels were significantly lower in both pe groups terminal villi and these changes were much prominent in mpe. patterns of vegfr- expression in preeclamptic and control groups were multidirectional. conclusion: revealed patterns of vegf and its receptors expression point on altered placental angiogenesis in pe and reflect different degree of such alteration in mild and severe pe. objective: chorionic villi vascularity disturbances, caused by abnormal expression of angiogenic factors could correlate with maternal and fetal complications in diabetic pregnancies. method: aim: to evaluate the patterns of vegf receptors (vegfr , vegfr and vegfr ) expression in placentas from gestational diabetes (gd) and type diabetes (d ) pregnancies and correlation between them and some clinical parameters in newborn (placental weight (pw), newborn weight (nw), placental/newborn weight index (pnwi), st day of life blood glucose test results ( bgtr)). term placentas from d (n= ) and gd (n= ) and term placentas from normal pregnancy (control group) were studied. results: in both d and gd group we revealed significantly higher level of vegfr (p= . ), vegfr (p= . ) and vegfr (p= . ) endothelial expression in terminal villi. difference in vegfr expression among d and gd groups was also significant (p= . ) as difference in its expression between d and control group (p = . ). among clinical parameters we only revealed significant increase in bgtr in diabetic groups (p = . ) with marked difference between d and control group (p = . ). we revealed multidirectional correlation between vegf and vegfr expression and nw in d and gd groups. conclusion: revealed changes reflect placental angiogenesis disturbances influence on intrauterine fetal development. microvillus inclusion disease (mvid) is a disorder of defective intracellular trafficking and disrupted epithelial cell polarity c. thoeni * * division of cell biology, medical university innsbruck, austria objective: mvid is a congenital enteropathy characterized by loss of microvilli and formation of microvillus inclusions (mi) in enterocytes. mvid is caused by mutations in the myo b gene, coding for the myosin vb (m b) motor protein involved in intracellular transport and maintenance of epithelial cell polarity. we examined the effects of loss of m b in enterocytes of mvid patient and in a caco- cell model. method: the expression and localization of cell membrane transporters (cd , na/k atpase) and various cell organelle markers : endosomal rab gtpases [rab , , , , ] ; early (eea ) and late endosome (lamp ), and golgi (giantin)) were analyzed using multilabel immunoflourescence and confocal microscopy of a duodenal biopsy from mvid patient and in caco- cells following m b si rna knock-down (hum mut : - , ). results: depletion of m b in both enterocytes and caco- cells resulted in disruption of epithelial cell polarity with loss of apical microvilli, formation of mi; mislocalization of transporters as well as aggregation of epitopes for different rab gtp ases, early and late endosomes. conclusion: m b plays a critical role in polarized organization of enterocytes in mvid -a disorder characterized by defective intracellular trafficking and altered endosomal sorting. caco- cells provide an excellent model to study the pathogenesis of mvid. ofp- - beta-catenin expression and mutational analysis of ctnnb gene in pediatic adrenocortical tumors (act) r. alaggio * , p. dall'igna, a. martines, e. lalli, r. boldrini, v. d´onofrio, g. esposito * università di padova, dipt. di pathology, italy objective: act have an unpredictable clinical behaviour, and no liable histological or molecular parameters are available to predict outcome. the activation of wnt/β-catenin pathway, involved in tumor growth and progression in adult act has been explored only in brasilian pediatric act. the aim of this study is the investigation of the possible prognostic role of β-catenin accumulation and/or ctnnb (β-catenin gene) mutations also in italian pediatric act. method: β-catenin immunostaining and mutational analysis of ctnnb gene at exons and , when possible, were carried on a series of act ( malignant and benign, according to wieneke classification), from patients enrolled in the italian pediatric rare tumor (trep) study. results: immunostaining for β-catenin showed membrane/ cytoplasmic staining in cases, benign and malignant, and nuclear staining in malignant. no mutations of ctnnb gene were found in the tumors analyzed. conclusion: ctnnb gene mutations do not appear to be involved in pathogenesis of pediatric act. the accumulation of protein might be related to different mechanisms. its presence in the majority of malignant act suggests a possible role in tumor progression. ofp- - neuroblastoma presenting like a wilms' tumor with thrombus in inferior vena cava: a case series h. sartelet * , g. gaetan, a. ouimet, c. lapierre, p. teira * chu sainte justine, dept. of pathology, montreal, canada objective: neuroblastomas and wilms' tumors are frequent pediatric solid tumors. the first is frequently detected in the adrenal gland and the second develops in the kidneys. the extension through the vena cava and the lung metastases are frequent in wilms' tumors and are rarely in neuroblastoma. we present the cases of three children with abdominal tumors with thrombus in the inferior vena cava and pulmonary metastases were discovered yet demonstrated a stage neuroblastoma. method: the three male patients were between and months old. they presented an abdominal mass, near the superior pole of the kidney. thrombus of the vena cava was evoked on imaging studies in all cases and pulmonary metastases were always found. catecholamine metabolites were present in the first case and negative in the two others. two out of three patients had a radical nephrectomy. results: the pathological analysis always found a neuroblastoma poorly differentiated or undifferentiated without mycn amplification and confirmed the tumoral thrombus in the second case. the evolution of the two first patients was unfavorable and the third is alive. conclusion: invasion of the inferior vena cava and pulmonary metastases in children with neuroblastoma is uncommon and can modify the surgical management. ofp- - epcam -a marker for tufting enteropathy (te) and a useful tool in the differential diagnosis of congenital enteropathies c. thoeni * * division of cell biology, medical university innsbruck, austria objective: congenital enteropathies (ce) are characterized by villous atrophy and disruption of apical microvilli in duodenal enterocytes. te is characterized by focal eptithelial tufts and mutations in the epcam gene, coding for epithelial cell adhesion molecule, important for cell-cell contacts. microvillus inclusion disease (mvid), shows loss of apical microvilli and formation of intracytoplasmatic microvillus inclusions. mvid is caused by mutations in the myo b gene, important for intracellular transport and organization of epithelial cell polarity. in this study, we identified a new epcam mutation in a patient with te and used anti-epcam antibody as a marker for the diagnosis of te and distinction from mvid. method: we used immunohistochemistry (ihc) with monoclonal epcam antibody (mouse monoclonal ab for epcam, ncl esa/leica microsystems) on routinely processed duodenal biopsies from patients with te, mvid and age matched controls. immunostaining for e-cadherin served as reference. results: epcam expression was completely absent in the biopsy from te patient homozygous for a novel epcam mutation (c c>g, ser x). e-cadherin showed normal expression and distribution pattern in the enterocytes. in mvid, expression and distribution pattern was comparable to controls for both epcam and e-cadherin. conclusion: loss of epcam is specific and a sensitive marker for confirmation of te. epcam antibody is useful in the differential diagnosis of ce. objective: in pulmonary adenocarcinoma egfr mutation analysis has become an important part of the diagnostic work-up. frequently the tissue of bronchoscopies is of limited diagnostic value. the aim of the present study was to evaluate the impact of rose on brochoscopy specimens with regard to egfr mutation. method: rose was used for adequacy of the specimen and for separating adenocarcinomas and carcinomas nos from other neoplasms in the lung. if it was not possible to retrieve material for histology, cytology and cellblock were made. if adenocarcinoma or carcinoma nos was suspected in rose, further two biopsies or two cell blocks were obtained. egfr mutation analysis was performed by pcr (light cycler ; egfr rgq pcr kit; qiagen). results: malignancy was diagnosed in of cases by histology or on cytology with and without cell blocks. adenocarcinomas (n= ) and carcinomas nos (n= ), scc (n = ), sclc (n = ), and rare tumors (n= ) were diagnosed, respectively. among the group of adenocarcinomas and carcinomas nos (n = ), egfr mutation analysis was performed in ( , %) cases and showed mutations in ( , %) and "wild type" in ( , %) tumors. no material was left in ( , %) cases. conclusion: rose supports bronchoscopic procedures to retrieve adequate specimens for tumor diagnosis and subsequent egfr mutation analysis. objective: patients with fibroblast growth factor receptor (fgfr ) amplified squamous cell lung cancers (l-scc) are treated in phase i clinical trials using small molecule inhibitors (smi). scc of the lung share common molecular alterations with squamous cell head and neck cancers (hn-scc). aim of our study is to assess if hn-sccs also harbor fgfr amplifications. furthermore, we aim to inhibit cell proliferation of fgfr amplified hn-scc cell lines using a smi. method: the cohort consists of patients suffering from hn-scc, of these suffering from metastatic disease. primary tumors and metastatic tumors were assessed for fgfr copy number status using fluorescence in-situ hybridization (fish). we tested cell lines for fgfr amplification status and inhibited these with smis. objective: the pulp of pequi has high levels of antioxidants properties. method: eighteen male balb/c mice divided: animals received by gavage , μl/mg/day of pequi oil (control + cbcoil= ) during days. after days, of these mices received two doses of , g/kg intraperitoneal of urethane (urethane + cbc oil= ). the other animals were only submitted to two doses of , g/kg intraperitoneal of urethane (urethane group= ). after days, groups were sacrificed. antioxidant activity was evaluated in the lung tissues by tbars (thiobarbituric acid-reactive substances), cat (catalase) and sod (superoxido dismutase) test. dna damage was estimated by comet test. results: the lung parenchyma from urethane groups without oil and with oil showed neoplasic formations induced by the chemical carcinogenesis in contrast with control + cbc oil group. the results of tbars test showed a significant decrease of lipid peroxidation in the urethane + cbc oil, than urethane group. the cat and sod test didn't show a significant difference. comet assay showed a significant decrease of dna damage in urethane + cbc oil when compared with urethane group. conclusion: the antioxidant components in the pequi oil diminish the oxidative stress status and dna damage in chemical carcinogenesis, suggesting that this type of strategies may have a greater impact in lung cancer treatment. financial support: fapesp. ofp- - an algorithm for gene mutation analysis in lung cancer m. comanescu * , c. iosif, m. dobre, l. buburuzan, g. bussolati, f. vasilescu, c. ardeleanu * institutul victor babes, dept. of pathology, bucharest, romania objective: somatic alterations of k-ras, egfr and alk which are increasingly requested in order to predict response to personalized therapies in lung cancer are mutually exclusive and are represented in over % of lung adenocarcinomas. the approach to be followed for planning analyses is not standardized in the literature. method: we have studied by molecular methods (pcr-rflp for k-ras, direct sequencing for egfr and fish for alk) formalin fixed, paraffin embedded cases of lung adenocarcinomas of different subtypes. results: based on rational, biological and economic considerations we started with k-ras analysis by pcr-rflp, which showed mutations in cases ( with mutation on codon and one case with mutation on codon ), the residual cases were all analyzed for egfr mutations. fish for alk translocation followed in egfr-wild cases. conclusion: the analysis for k-ras mutations allows to select the significant percentage (approximately % of adenocarcinomas) when egfr mutation analysis by direct sequencing can be postponed. k-ras and egfr wild cases will then undergo fish analysis for alk translocation. acknowledgements study conducted with the support of the following project: project persother -smis-csnr: / . ; with the support of sectoral operational programme "increase of economic competi-tiveness" priority axis : research, technological development and innovation for competitiveness. ofp- - gene mutation analysis in adenosquamous carcinomas of the lung m. comanescu * , g. bussolati, c. ardeleanu, l. daniele, g. gaina, c. luca, a. sapino * institutul victor babes, dept. of pathology, bucharest, romania objective: adenosquamous carcinomas of the lung constitute a rare and aggressive variant of lung cancers. the pressing interest in evaluating the mutational status in lung carcinomas for predicting responsiveness to targeted therapies is presently focused on adenocarcinomas (of different sub-types), which makes preliminary histological typing a crucial step in order to select cases to be genetically analyzed. hence the interest in deciding if adenosquamous carcinomas should be included among adenocarcinomas or, viceversa, if they should be interpreted as a variant of squamous cancers and excluded from the process of gene analysis. method: we have thus collected, from our two institutions a large number ( cases) of cancers showing the histological definition of adenosquamous carcinomas according to the who criteria and performed gene analysis for k-ras (codons , ) and egfr (codons , and ) mutations. the detection of rearrangements of the alk gene by fish was also performed. the results indicate that k-ras and, specifically, egfr mutations are detectable in a fraction of these tumors. in conclusion, adenosquamous carcinomas should not be denied the chance of genetic analysis eventually leading to a targeted therapy. acknowledgement project persother -smis-csnr: / . romania. ofp- - pathology of the lung progenitor cells and their niches in idiopathic interstitial pneumonias and lung sarcoidosis s. demoura * , e. kogan, v. tuong, o. kichigina * moscow, russia objective: the aim of the study was to investigate the morphological and the molecular-biological changes of the lung progenitor cells and their niches in idiopathic interstitial pneumonias (ipf) and lung sarcoidosis (ls). method: we performed an immunohistochemical study on open lung biopsies from patients (usual ipf - , desqvamative interstitial pneumonia- , nonspecific ipf - , cryptogenic ipf - , ls - , control - patients). immunochemistry was done on step paraffin sections with monoclonal and polyclonal antibodies: apo-cas, pcna, , , pdgf, fgf, igf ii, cd , mmp , , , , timp , cd , sma, ema. results: deep injury of clara cells together with pneumocytes ii and their nishes were found in usual ipf, sk with prominent ipf and desqvamative interstitial pneumonia. myofibroblast proliferation, neoangiogenesis, adenomatosis and fibrosis with high production of tnfα, tgf-β, pdgf, fgf, igf ii, cd , mmp , , , , timp accompanied proliferation of these epithelial cells. while in other variants of ipf pathological changes were localized in the interstitium, vessels and basal bronchiolar epithelial cells. conclusion: localization of injury and inflammation in progenitor cells niches results in pathologic reparation, sclerosis and precancer lesions. ofp- - a small immunohistochemical panel allows for accurate diagnosis of primary and metastatic lung cancer in biopsy specimens d. felizardo * , r. henrique, a. l. cunha * instituto de oncologia porto, dept. of pathology, coimbra, portugal objective: precise subclassification of lung cancer, mostly performed in biopsy or fine needle-aspiration specimens, is required for appropriate therapy. moreover, distinction between primary and metastatic carcinoma is critical. thus, the role of immunohistochemistry (ihc) has been emphasized, although an optimal ihc diagnostic algorithm has not been firmly established. herein, we evaluated the performance of the ihc panel used at our institution in subclassification of lung cancer and identification of metastatic carcinoma. method: cases of non-neuroendocrine lung carcinoma, diagnosed from march to april were selected. ihc was performed for ck , ck , ttf- and p . resection specimens were compared with the respective biopsy. results: of cases analysed, ( . %) were diagnosed as lung adenocarcinoma, ( . %) as epidermoid carcinoma, ( %) as other forms of nsclc, and ( . %) as metastasis. importantly, % of primary lung adenocarcinomas were initially suspected to be metastasis. in cases submitted to surgical resection, ( . %) were correctly diagnosed in the biopsy, revealing a substantial agreement (κ-value= , ). conclusion: our ihc panel allows for reliable subclassification of lung carcinomas in most cases and is decisive for appropriate diagnosis in patients suspected of lung metastasis, which is critical issue in a cancer institute. ofp- - rationale for treatment of metastatic squamous cell carcinoma of the lung using fgfr inhibitors f. göke * , a. franzen, a. schroeck, v. scheble, r. kirsten, r. menon, d. goltz, d. boehm, w. vogel, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: we previously identified amplified fibroblast growth factor (fgfr ) as a therapeutic target for small molecule inhibitor (smi) therapy in squamous cell lung cancer (l-scc), resulting in currently running clinical trials treating patients with stage iii disease. as most patients present with metastatic stage of disease, we attempt to demonstrate fgfr amplification in lymph node metastases of amplified primary tumors. our study aims to give a rational to include these patients in a targeted smi therapy. method: we assessed formalin-fixed paraffin-embedded (ffpe) primary l-scc samples. samples were primary tumours with corresponding ffpe lymph node metastasis. the biotin-labelled fgfr target probe ( p . to p . ) was used to determine the fgfr amplification status performing fluorescence in situ hybridization (fish). results: of assessable metastatic l-scc, samples displayed fgfr amplification ( %). all of these primary tumors also harbored fgfr amplification in their lymph node metastasis. non-amplified tumors never displayed fgfr amplification in corresponding metastases. conclusion: we found fgfr amplification not only in primary l-scc, but also in corresponding lymph node metastasis, suggesting that this genetic aberration is a clonal event in tumor genesis. our study provides data indicating new therapeutic possibilities for patients suffering not only primary, but also metastatic fgfr amplified scc lung cancer disease. kras mutation was a g to t transversion in % of the smoker nsclc population and a g to a transition in % of the non smoker nsclc population. mutations were noted at codon ( %), codon ( %) and codon ( %). a kras mutation was a negative prognostic factor with a hazard ratio for death of . ( % confidence interval, . - . ). a mucinous histological subtype was observed in more than % of kras mutated tumours. conclusion: kras oncogene substitution must be accurately determined in primary lung adenocarcinoma for correlation with tumour behaviour and clinico-pathological parameters. objective: there is an urgent need for diagnosis of nsclc at its early-stages and for improving the survival rate of patients. micrornas, small non-coding rnas, are frequently deregulated in nsclc. this study aimed to explore plasma micrornas for diagnostic value, and evaluated the correlation between expression profiles of plasma micro-rnas and disease-free survival (dfs) in nsclc patients. method: we selected eighteen most frequently expressed micrornas in nsclc. total plasma rna including micrornas was isolated and reverse-transcribed into cdnas. the level of micrornas was determined by quantitative real-time rt-pcr in resectable nsclc patients and matched cancer-free individuals. the correlation between the expression of micrornas in plasma and patient dfs were examined by log-rank and cox analysis. results: expression levels of mir- ,− ,− ,− a, − ,− ,− ,− ,− , and let- f in the plasma of nsclc including stage-i patients were significantly higher compared with controls (p< . ). the combination of these micrornas yielded % sensitivity and % specificity (auc= . ) in discriminating nsclc patients from controls. the levels of mir- , − , − a, − , − and mir- a were significantly associated with dfs (p< . ). conclusion: our results suggest that high expression of plasma mirnas signature would provide potential noninvasive blood-based biomarker for the prognosis of nsclc. monday, september , . - . objective: intratumoral disorganized neo-vasculature induces oxygen fluctuations which contribute to tumour growth and metastatic potential. although the activation by hypoxia of the carbonic anhydrases caix and caxii is well known, responses of these proteins under reoxygenation remain to be elucidated. method: in this study we evaluated the effects of hypoxiareoxygenation on caix and caxii expression and cell proliferation in a and h lung adenocarcinoma cell lines. we further investigated by immunohistochemistry on tissue microarray the value of the combined expression of these proteins to predict outcome in nsclc patients. results: caix expression was maintained at high level after reoxygenation in contrast of the rapid caxii downregulation, whereas the cell proliferation rate was significantly increased. survival analyses showed that high caix/ low caxii was associated with high cumulative incidence of relapse and with poor overall survival of nsclc patients (p< . ). conclusion: our results provide insight into understanding dynamic responses of caix and caxii expression under tumour cells reoxygenation and demonstrate a critical role for reoxygenation on caix and caxii levels that may select for aggressive lung cancer phenotype. these findings suggest that caix and caxii play selective roles in tumour progression and emphasize their significant prognostic and potential therapeutic value. ofp- - alk-gene rearrangement: a comparative analysis on circulating tumour cells (ctcs) and tumour tissue from lung adenocarcinoma patients m. ilie * , e. long, c. butori, v. hofman, c. coelle, v. mauro, k. zahaf, c.-h. marquette, j. mouroux, p. paterlini-bréchot, p. hofman * chu de nice, lpce, france objective: until now the alk status in ctcs isolated from lung cancer patients has not been characterised. we assessed the alk status in ctcs detected in lung cancer patients and correlated the results to the alk status defined in the corresponding tumour tissue. method: lung adenocarcinoma patients showing ctcs isolated using the isolation by size of epithelial tumour cell method were screened for their alk status both in tumour samples and in ctcs. alk break-apart fluorescence in situ hybridisation (fish) and immunochemistry using an anti-alk antibody were done on ctcs and compared with results obtained on corresponding tissue specimens. results: patients showed alk-gene rearrangement and strong alk protein expression in ctcs and corresponding tumour samples. negative results were found for patients in ctcs and corresponding tumour samples. conclusion: we demonstrate that the alk status can be determined in ctcs from lung cancer patients both by immunocytochemistry and fish analysis. a strong correlation was found for the alk status obtained from corresponding tissue specimens. these results favour non-invasive, alk-gene status pre-screening on a routine basis on ctcs isolated form lung cancer patients and open new avenues for real-time monitoring for adapted targeted therapy. ofp- - detection of egfr mutations and eml -alk rearrangements in lung adenocarcinomas using archived cytological slides e. imyanitov * , n. mitiushkina, a. iyevleva, a. poltoratskiy, a. ivantsov, a. togo, i. polyakov, s. orlov, d. matsko, v. novik * n.n. petrov institute of oncology, st. petersburg, russia objective: while the molecular analysis of egfr and alk in archival lung cancer tissues is relatively well established, the acceptability of genetic investigation of cytological material in clinical routine remains a subject of debate. method: islets of malignant cells were visually located on the archived cytological slides, lysed in situ by the drop of sds-containing buffer, and subjected to the standard dna and rna extraction. examination of paraffin-embedded tissue blocks from the same patients was done in parallel. results: cytological/histological lung adenocarcionoma sample pairs underwent the analysis for egfr mutation. cytological and morphological samples failed to produce dna. concordance for the wild-type and mutation status was observed in / and / informative pairs, respectively; pair was non-interpretable; and pairs had mutation only in the cytological or histological material, respectively. rna extraction followed by rt-pcr analysis for the eml -alk translocation was done for the pair; failures were observed for cytological and histological samples. / informative pairs were concordant for the norm, contained identical translocations, and were noninterpretable. pair demonstrated alk rearrangement in the tissue block but not in the histological slide. conclusion: archived cytological slides appear to be well suitable both for egfr and alk analysis. objective: non-small cell lung cancer (nsclc) represents a heterogeneous group of cancers consisting mainly of squamous cell carcinoma (scc) and adenocarcinoma (ad). increased sirtuin (sirt- ) expression leads to deacetylation of p that could be important in the pathogenesis of lung cancer. differences of the molecular mechanisms in nsclc subtypes may follow subtly different pathways to tumorigenesis. the aim of our study was compare sirt- expression in lung adenocarcinoma, squamous cell carcinoma and control group. method: patients with stage lung cancer were enrolled in the study. patients had adenocarcinoma, but patients had squamous cell carcinoma. lung tissue for control group were selected from autopsy cases. immunohistochemical and western blot methods were used to evaluate sirt- expression in lung tissue. results: obtained results showed that patients with lung cancer had increased sirt- expression compared to control group ( ± vs. ± cells/mm , p< . ). in addition, patients with squamous cell carcinoma had increased sirt- positive cells compared to patients with adenocarcinoma ( ± vs. ± cells/mm , p= . ). conclusion: lung cancer is characterized by an increased sirt- expression which ir more prominent in squamous cell carcinoma. objective: transplantation is the only treatment for several end-stage lung diseases but limited by chronic allograft dysfunction particularly obliterative bronchiolitis (ob) and its correlate bronchiolitis obliterans syndrome. the development of preclinical models is crucial to better identify immunological/non-immunological mechanisms leading to ob. [group b and c] post-transplant, animals were sacrificed. in animals from group c, cyclosporine was administered at sub-optimal dose. lung rejection was graded according to the working formulation of ishlt and the presence of circulating donor-specific (dsa) antibodies determined by flow cytometry. results: in group a, acute rejection (ar) or ob occurred in % and % of animals, respectively. ar occurred in - % of animals in group b and c respectively. ob was detected in % and in % of group b and c respectively. high levels of dsa igg were observed in cases with ar. conclusion: a novel model of pulmonary ob was developed in the rat. to obtain a reproducible onset of ob, shortterm and sub therapeutic cyclosporin administration appears indispensable, at least in our species combination. ofp- - epithelial dysplasia and lung cancer in end-stage idiopathic pulmonary fibrosis: padova experience n. nannini * , f. lunardi, e. balestro, e. rossi, m. loy, m. saetta, f. rea, f. calabrese * university of padova, italy objective: idiopathic pulmonary fibrosis (ipf) is associated with increased risk of lung cancer. the prevalence of high grade dysplasia/lung cancer was studied only in a small number of ipf patients. the aim of our study was to investigate the prevalence of precancerous/cancerous changes and their relationship with both metaplastic changes and clinical data. method: native lungs from ipf patients were studied. the degree of honeycomb changes and squamous, cuboidal and bronchial cell metaplasia were graded (score: - ). the presence or absence of precancerous/cancerous changes were also evaluated. results: three patients showed neoplastic transformation ( %) and nine high grade dysplasia ( %) ("cancer" group). the "cancer" group had similar smoking history, sex, age and duration of disease than the "no cancer" group. all lungs showed metaplasia, the score of squamous (p= . ), cuboidal (p= . ) and bronchial cell (p= . ) metaplasia was significantly higher in the "cancer" than in the "no cancer", while the honeycomb score was similar in the two groups. conclusion: advanced ipf patients have a high prevalence of high grade dysplasia/lung cancer, complex epithelial metaplasia, particularly squamous type, is more frequent in "cancer" group, independently from all clinical parameters, including smoking history. ofp- - primary pulmonary adenocarcinoma with enteric differentiation, morphologically indistinguishable from metastatic colorectal adenocarcinoma: case report with a history of metastatic colon adenocarcinoma s. percinel * , p. celepli, h. nalbant, y. yuyucu karabulut * ankara, turkey objective: according to a computerized medline search in the english literature, the present case is thought to be the first primary pulmonary adenocarcinoma with enteric differentiation, completely resembling metastatic colorectal adenocarcinoma morphologically, with a history of metastatic colon adenocarcinoma. results: a year old man with a history of colon adenocarcinoma which was detected in underwent radiologic evaluation. a chest computed tomography scan revealed a mm solitary nodule in the left lower lobe which enlarged in year. the patient underwent left lower lobe wedge resection. macroscopically, an irregular whitish nodule of . cm in greatest diameter was detected. microscopically, the nodule was entirely composed of glandular and papillary structures, some of which had a cribriform pattern, lined by tumor cells that were cuboidal to tall columnar with nuclear pseudostratification, eosinophilic cytoplasm, brush-border, luminal necrosis and nuclear debris. tumor cells were diffusely positive for cytokeratin (ck) and negative for thyroid transcription factor- , surfactant protein-a, cdx- and muc . only a very few tumor cells stained for ck . conclusion: enteric morphology with consistent expression of ck and a scattered positivity for ck helped in the distinction from metastatic colon adenocarcinoma and favored the diagnosis of primary pulmonary adenocarcinoma with enteric differentiation. expression of cxcr and cxcl in pulmonary carcinoids s. seiwerth * , l. brcic, a. sepac, a. zanko * zagreb school of medicine, pathology, croatia objective: cxcr and its chemochine ligand cxcl seem to play an important role in the process of tumor metastasis and, possibly, homing of metastatic tumor cells. the chemochine seems to be responsible for creating microenviromental predispositions for survival of metastatic cells, in a similar way it is done for developing immuno-competent cells. in contrast, expression of cxcl in primary tumor cells, is thought to be associated with lower metastatic potential. cxcr is expressed in a wide range of tumors, and is thought to be crucial for the metastatic process and tissue-specific spread firstly of breast and prostate cancer. the role of cxcr signaling has been poorly evaluated in carcinoids in general and not at all in pulmonary carcinoids. method: immunohistochemically we investigated the expression of cxcr and cxcl in pulmonary carcinoids. results: together tumors ( typical and atypical) where investigated. in there was a metastatic process (in typical and atypical). ligand cxcl expression was negative in all of the metastatic tumors and in two without known metastasis in contrast to only two non-metastatic tumors showing negative reaction. cxcr positivity was found in both metastatic and non-metastatic carcinoids. the other investigated parameters where present in both metastatic and non-metastatic tumors. objective: to evaluate col v and decorin expression in pulmonary tissue and to characterize biochemical profile of colv from lung fibroblasts culture from ssc patients. method: we evaluated col v and decorin expression and tridimensional reconstruction ( d) of patients with ssc without pulmonary hypertension that underwent surgical lung biopsy and as control was obtained lung fragments from normal individuals who died from trauma. col v amount in lung sections was evaluated with immunofluorescence. to biochemical characterization of col v from lung fibroblasts culture was used quantitative immunoblot. results: it was found that the structure of col v fibers was distorted and strongly thickened in lung tissue from ssc patients compared with thin fibers pattern in the healthy controls. decorin was distributed around col v fibrils in the bronchovascular interstitium and vascular walls. histomorphometric analysis of ssc lung demonstrated increased expression of both col v and decorin when compared to the control (p < . ). the semiquantitative imunoblot detected an increased high molecular weight colv fraction in patients when compared to the control. conclusion: the over expression and unusual organization of colv fibers with biochemical changes associated to increased decorin indicates that matrix signalization pathway is involved in colv fibrillogenesis process in ssc pulmonary fibrosis. objective: probe-based confocal laser endomicroscopy (pcle) is a new method used during bronchoscopy by means of special miniprobe alveoflex and based on the visualization of intraalveolar structures which possess autofluorescence. aim: to compare the visual signs of a healthy and pathologically changed lung tissue received at pcle in patients with infiltrative and local lung nodules with the diagnosis, delivered by light microscopy. method: an autopsy and surgical material was fixed in % neutral formalin solution and was analyzed by studying with a new method for visualization of structures. histological specimens were studied at that spaces, where the pcle was applied. we compared our results by using qualitative method. results: normal lung tissue structures include alveolar septum with the high light emission and light-negative spacesthe alveolar spaces. in case of pneumonia alveolar septum were saved, but the light density of alveolar spaces was higher in compare with the normal tissue. in case of alveolar proteinosis we observed unique globules, which had the highest light emission. we found out several authentic signs, which are representative for each kind of pathological feature. moreover, we revealed some other characteristics, which help us to distinguish some types of lung cancer. conclusion: pcle can be used as an additional method of noninvasive diagnostics in vivo. increased copy nember of alk gene is not associated with increased immunoreactivity of alk protein in lung adenocarcinomas t. balharek * , a. farkasova, z. kviatkovska, k. scheerova, p. tilandyova, z. hutka, l. plank * comenius university, dept. of pathology, martin, slovakia objective: anaplastic lymphoma kinase (alk) gene rearrangements represent an important predictive marker and promissing therapeutic target in small subset of non-small cell lung carcinomas (nsclc). immunohistochemical (ihc) screening of alk abnormalities in nsclc was reported to have variable reliability. we analyzed association between alk immunoreactivity and increased number of alk gene copies often seen in nsclc. method: we examined clinically selected egfr negative lung adenocarcinomas. alk protein expression was detected by ihc using antibody clone alk (dako). alk gene status was assessed by fluorescent in situ hybridization using lsi alk dual color rearrangement probe (abbott) and spec alk/eml tricheck probe (zytovision). results: increased alk gene copy number was identified in cases, of them showed cytoplasmic alk positivity. in of these cases we detected rearrangement of alk locus, once represented by alk-eml fusion combined with more complex cytogenetic abnormalities. remaining third alk + case was negative for alk rearrangement. conclusion: ihc seems to be useful method for initial screening of alk rearrangements in nsclc. there is no clear association between alk protein expression and number of alk gene copies. prognostic relevance of alk copy gains or amplification in lung adenocarcinomas remains to be determined, together with role of alk-inhibitors in those cases. expressions of egfr, ercc- , ß tubulin iii, rrm- in advanced non-small cell lung carcinoma n. bassullu * , e. namal, i. turkmen, r. yasar, p. y. korkmaz, z. akcali, g. demir, g. b. dogusoy * istanbul bilim university, dept. of pathology, turkey objective: egfr, ercc , rrm and βtubuliniii predicts sensitivity to therapeutic agents and provide prognostic information in nonsmall cell lung cancer (nsclc) which is the most frequent worldwide cause of cancer death. method: we investigated the expressions of egfr, ercc , βtubuliniii, rrm immunohistochemically in advanced nsclc cases and their correlations with other pathologic features. results: the age distribution was - with an average of , . male/female ratio was / . ercc protein was detected in nuclei of carcinoma cells in patients ( , %) (h score > ). Βtubuliniii expression was detected in cytoplasm of cancer cells in patients ( , %) (score ≥ ). ercc and βtubuliniii expression were not associated with pathological factors. rrm was negative (score< ) in ( %) cases and negativity was significantly correlated with male gender (p< , ). egfr was negative (score< ) in ( , %) cases and negativity was nearly correlated with absent necrosis (p< , ). no significant correlations were found between egfr, ercc , βtubuli-niii, rrm and the pathological parameters. conclusion: in our study, as a first step, egfr, ercc , βtubuliniii, rrm showed no significant correlation with pathologic features. we look forward to obtain further results in the next study consisting of correlations with follow ups. proliferative markers in idiopathic pulmonary fibrosis: clinical, radiological and functional significance e. parra * , m. cornati, v. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: natural course of idiopathic pulmonary fibrosis (ipf) could be predicted by proliferative markers of the fibrotic process, such as myofibroblasts and interleukins (il)- and il . our primary aim was to determine whether these proliferative markers influence the course of ipf course measured by a radiological/functional score. method: twenty-eight patients with biopsy-proven ipf disease, who underwent pulmonary evaluation by high-resolution computed tomography (hrct) fibrosis score and pulmonary function tests were studied. five normal lung tissues (nlt) were included biomarkers in lung tissues were detected by immunohistochemistry and quantified by histomorphometry for myofibroblasts alpha-smooth muscle actin (α-sma), anti-interleukin (il)- and il- . results: myofibrobalst amount, il- and il- expression were higher in ipf than in nlt (p< . ). myofibroblast expression of α-sma was positively correlated to il- and il- expression. lung tissue from patients with high hrct fibrosis scores expressed significantly greater α-sma+, il- and il- when compared with patients with low hrct fibrosis scores (p< . ). negative correlations were found between myofibroblasts α-sma + and vc and dlco. conclusion: proliferative markers, detected by immunohistochemistry, in lung tissue allowed recognizing a dichotomous distribution of hrct fibrosis course and influenced pulmonary function tests, suggesting that they may be promising markers of prognosis in these patients. objective: epithelioid mesothelioma is the most common histologic type of the diffuse malignant pleural mesothelioma, also having the best prognosis. although a great variety of histological patterns within epithelioid type has been described, a clear impact of histological subtyping on clinical outcome is unknown (kadota et al., .) . here we compared median survival of six histological subtypes of epithelioid mesothelioma. we examined hematoxylin and eosin-stained slides of patients diagnosed with epithelioid mesothelioma. according to previously described predominant histological features we grouped them into six subtypes: trabecular, solid, microglandular, tubulopapillary, micropapillary and pleomorphic. results: the median survival of all patients with epithelioid mesothelioma was . months. the best median survival was in trabecular and micropapillary subtypes (each months, n= and n= , respectively), followed by tubulopapillary ( months, n= ), microglandular ( months, n= ) and solid ( months, n= ) subtypes. the worst median survival was in pleomorphic subtype ( months, n= ). conclusion: epithelioid type of diffuse malignant pleural mesothelioma shows a great diversity of histological patterns that likely have an impact on the clinical outcome and patient's survival. further investigations of genetic variations among different subtypes may provide valuable information for better understanding of pathogenesis of these tumors. objective: genetic instability resulting in both aneuploidy and polyploidy are discussed to be involved in prostate cancer (pca) development and progression. aim of this study was to comprehensively characterize the ploidy status and proliferation levels in pca with regard to disease progression. method: using fish, we assessed localized pca, pca with corresponding lymph node metastases, and hormone-refractory distant metastases for losses and gains of all chromosomes. the proliferation rate was assessed using phh and ki immunohistochemistry. results: we observed significant increases in aneuploidy with advancing tumor stage (p< . ). chromosomes x, , y, , , and were most frequently numerically altered. increased levels of proliferation were significantly associated with the extent of aneuploidy and tumor stage (p< . ). combining aneusomy of chromosomes , , , and x with phh immunoreactivity resulted in a prediction model for lymph node metastases with a sensitivity of . % and a specificity of . %. conclusion: we present evidence that genomic instability leading to aneuploidy is an important factor in pca progression. furthermore, we demonstrate that increased ki- and phh expression are potential indicators of metastatic disease. lastly, we suggest a new approach to preoperatively determine lymph node metastasized disease in pca. ofp- - erg protein expression and genomic rearrangement status in primary and metastatic prostate cancer: a comparative study of two monoclonal antibodies m. braun * , d. goltz, z. shaikhibrahim, w. vogel, d. boehm, a. dobi, n. wernert, g. kristiansen, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: overexpression of the erg protein is highly prevalent in prostate cancer (pca) and most commonly results from gene fusions involving the erg gene. recently, an n-terminal epitope targeted mouse and a cterminal epitope targeted rabbit monoclonal anti-erg antibody have been introduced for the detection of the erg protein. here, we are the first to compare the mouse erg-mab to the rabbit erg-mab for their concordance on the same pca cohort. furthermore, we assessed if the erg protein expression is conserved in lymph node and distant metastases. method: we evaluated tissue microarrays of specimens containing localized pca, lymph node, distant metastases, and normal prostatic tissues. we correlated the erg protein expression with the erg rearrangement status using an erg break-apart fluorescence in-situ hybridization (fish) assay and ihc of both erg antibodies. results: erg protein expression and erg rearrangement status were highly concordant regardless of whether the mouse or rabbit erg-mab was used ( . % versus . %, respectively). conclusion: this is the first study to comprehensively compare the two erg-mabs. by demonstrating a broad applicability of ihc to study erg protein expression using either antibody, this study adds an important step towards a facilitated routine clinical application. ofp- - improved method of detecting the erg gene rearrangement in prostate cancer using combined dual-color chromogenic and silver in-situ hybridization m. braun * , j. stomper, d. boehm, w. vogel, n. wernert, g. kristiansen, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: the recently detected erg rearrangement revealed as a recurrent and prevalent prostate cancer (pca) specific event. to detect this alteration, fish is the method of choice. however, fish harbors disadvantages for widespread adoption in clinical practice. subsequently, the chromogenic in-situ hybridization (cish) and the enzymatic metallography silver in-situ hybridization (sish) emerged as promising bright-field alternatives. we aimed to develop a combined cish and sish (cs-ish) gene break-apart assay on the example of the erg gene. method: we assessed and compared pca and benign specimens for their erg rearrangement status applying a dual-colour fish and cs-ish erg break-apart assay on consecutive sections. results: we observed a highly significant concordance ( , %) between fish-based and cs-ish-based results (pearson's correlation coefficient . , p< . ). conclusion: we demonstrate that the erg rearrangement status can reliably be assesed by cs-ish. further, we confirm that the cs-ish technique combines the accuracy and precision of fish with the ease of bright field microscopy. we developed a tool which allows a broad spectrum of applicants to study the biological role and clinical utilization of erg rearrangements in pca. moreoever, our study is the first proof-of-principle for bright-field cs-ish gene fusion or break-apart assays. ofp- - rearrangement of the ets genes etv- , etv- , etv- and elk- is a clonal event during prostate cancer progression m. braun * , z. shaikhibrahim, w. vogel, d. boehm, r. menon, n. wernert, g. kristiansen, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: ets gene rearrangements are frequently found in prostate cancer (pca). recently, we observed that erg rearrangement in primary pca transfers into lymph node metastases, suggesting it to be a clonal expansion event during pca progression. here, we investigated whether this also applies to the less frequent ets genes, etv- , etv- , etv- and elk- . method: using break-apart fish assays, we evaluated the status of above mentioned ets gene rearrangements on a cohort comprising of primary pca, corresponding lymph node and distant metastases. results: etv- , etv- , etv- and elk- rearrangements were found in %, %, % and % of the primary pca, respectively, and in %, %, %, % of the corresponding lymph node metastases, respectively. rearrangements of etv- and etv- were not found in any of the distant metastases cases, whereas etv- and elk- rearrangements were found in % and % of the distant metastases, respectively. conclusion: our results suggest that rearrangement of the less frequent ets genes is a clonal event during prostate cancer progression. our findings provide insights into potential clonal expansion events during pca progression and may have significant implications in understanding the molecular basis of the metastatic cascade of pca. ofp- - comparative analysis of two prostate biopsy systems: a study of cases f. e. costa * , r. dias, j. r. vizcaíno * centro hospitalar do porto, braga, portugal objective: it's expectable that the higher the number of prostate biopsies the greater the probability of prostate cancer detection, presumably improving the diagnostic accuracy and treatment decision. method: under this assumption, since may/ , santo antónio's hospital implemented a prostate mapping system, increasing the number of biopsies performed from - to - and processing each core independently. we intend to establish a comparison between the traditional prostate biopsy system (ts) and the prostate mapping system (ms). for this study, all biopsy slides and corresponding surgical specimens from patients subjected to ms and patients subjected to ts were reviewed. gleason score, percentage of tumor present in prostatic tissue (expressed as small ≤ %, medium - % and large ≥ %) and presence of tumor in prostate apex and base were analyzed. results: comparing ms with ts, the correlation coefficient was , % and , % for gleason score and , % and , % for the percentage of tumor present in prostatic tissue, respectively. mapped biopsies were able to detect the tumor in the apex and base in % and % of cases. conclusion: these results suggest that prostate ms improves the diagnostic accuracy of prostate cancer and has a good ability to predict the presence of tumor in prostate apex and base. ofp- - frequency and prognostic significance of tmprss -erg gene fusion in lymph node positive prostate cancers a. fleischmann * , i. zlobec, t. visakorpi, g. thalmann * universität bern, inst. für pathologie, switzerland objective: tmprss -erg incidence and prognostic significance in lymph node positive prostate cancer are virtually unknown. method: a tissue-microarray was constructed from hormone-naïve nodal positive, surgically treated prostate cancers containing samples from all gleason patterns (gp) present in every primary tumor (pt) and corresponding lymph node metastases (met). tmprss -erg status was determined by fluorescence in-situ hybridization and correlated with various histomorphological tumor features (gleason score, stage, cancer volume, nodal tumor burden) and biochemical recurrence-free, cancer-specific and overall survival. results: tmprss -erg fusion was present in . % (homogeneous . %, heterogeneous . %) of the pt and in . % (homogeneous . %, heterogeneous . %) of the met. percentage of tmprss -erg in gp / / of pt and met were: %/ %/ % and %/ %/ %. concordance in tmprss -erg status between pt and met was poor (kappa . ) showing . % and . % of cancers with gene fusion solely in the pt and met, respectively. tmprss -erg fusion was not correlated with histopathological tumor features and predicted late biochemical recurrence independently (p= . ) when present in pt. conclusion: tmprss -erg fusion in pt is more frequent and its distribution more heterogeneous compared to met. the gene fusion in primary tumors independently predicts late biochemical recurrence. ofp- - wnt and shh pathways activation in penile carcinoma a. silva * , t. almeida, f. soares, m. buim * hospital ac camargo, investigative pathology, são paulo, brazil objective: penile carcinoma (pc) is rare in developed countries, accounting for less than % of all neoplasms in men, and biological characteristics of this tumor are poorly known. wnt and shh pathways are important for cell proliferation, differentiation and survival, and therefore, play a role in carcinogenesis of various organs. the goal of this study is to investigate the expression profile of wnt and shh pathway proteins in pc, characterizing the expression of target proteins from wnt (wnt- , wnt- , wnt- gsk β, β-catenin, d cyclin, mmp , c-myc, cd ) and shh (shh, smo, gli, egfr) pathways. method: for that, samples of pc were obtained from the files of anatomic pathology department from a.c. camargo hospital (brazil) and submitted to immunohistochemistry. results: we observed that wnt- and wnt- were expressed in and cases, respectively, out of the evaluated samples. strong shh expression was detected in / cases, whereas weak and negative expression was seen only in one case each. smo and gli- proteins were expressed in almost all cases ( / ), and also d cyclin, b-catenin and egfr were frequently expressed. conclusion: these preliminary results suggest that wnt and shh pathways may be active and participating in the progression of penile cancer. ofp- - expression of the multidrug resistance protein correlates with longer psa relapse free survival and androgen receptor and forkhead box a protein expression in prostate cancer m. montani * , g. kristiansen * medizin. universität bern, inst. für pathologie, switzerland objective: multidrug resistance protein (mrp ) a transmembranary transport protein has shown to be expressed in prostate cancer cell lines and cancer cell specimens and turned out to be among the highest upregulated genes in an arraybased transcription analysis. its expression is regulated in an androgen dependent manner, possibly modulated by forkhead box a (foxa), an androgen receptor (ar) co-activator. therefore, we investigated its expression in a large cohort of neoplastic and non-neoplastic prostate tissues (n = ) and evaluated its prediction of psa relapse free survival (rfs). method: tma (n= ) stained for mrp , foxa, ar, er, psa, ki- : radical prostatectomies (rpe) (n= ), castrate resistant prostate cancer (crpc) (n= ), metastases (n= ) and non-neoplastic (n= ). psa-rfs of patients; mean months. results: mrp expression decreases with tumor progression into castrate resistant disease, correlates with psa, ar and foxa expression and inversely correlates with gleason score. moreover, a strong mrp expression is significantly associated with a longer psa rfs in rpe patients. normal tissues from the transitional zone show a weak mrp expression compared to the peripheral and central zones. conclusion: mrp expression seems to predict psa relapse free survival in prostate cancer patients. since its expression is androgen dependent it decreases with tumor progression into crpc. ofp- - synchronous angiomyolipoma and renal tumors in patients without tuberous sclerosis: clinico-pathological study of cases f. j. queipo * , r. a. carías, Án. f. panizo, m. l. gómez-dorronsoro, f. j. pardo * clínica universidad de navarra, pathology, pamplona, spain objective: simultaneous existence of aml and renal neoplasia is frequent in tuberous sclerosis (ts) patients, but uncommon in non-ts cases. method: a total of cases of coexistent renal neoplasia and aml in non-ts patients were identified. clinico-pathological features were studied. results: patients: m/ f (mean age , year; range: - ) . mean aml size: , cm (range: , - , ). the main size of the renal neoplasms was , cm (range , - ). aml morphology: leiomyomatous, classic-triphasic, lipomatous, and epithelioid. three cases had multifocal aml. cases had ipsilateral tumors associated with aml: ccrcc ( sarcomatoid), chrcc, ro, tfe rcc, hybrid (ro-chrcc) renal-cell tumor, urothelial carcinoma, and case had tumors: mtsc-rcc and concomitant prcc. cases had contralateral tumours associated with aml: chrcc and ro. one patient had bilateral tumors associated with aml: an ipsilateral ro and a contralateral ccrcc. the median follow-up was , mths (range , - , ) : all patients were alive without disease. conclusion: the coexistence of renal tumors with aml is a rare event, usually incidental. if aml is found incidentally together with other renal tumors, it is important to exclude ts retrospectively. ofp- - primary renal synovial sarcoma: a clinicopathologic, immunohistochemical and molecular genetic study of cases j. schoolmeester * , j. cheville, a. folpe * mayo clinic, dept. of anatomic pathology, rochester, mn, usa objective: primary renal synovial sarcoma (r-ss) is a rare malignant neoplasm. approximately cases have been described, chiefly as case reports or as part of relatively limited small studies. we studied the clinicopathological, immunohistochemical (ihc) and molecular genetic features of well-characterized r-ss. method: all available slides for institutional and consultation cases of r-ss were reviewed. an ihc panel (tle , bcl , cytokeratins, s , cd , ini ) was performed. rt-pcr for ss -ssx / or fish for ss rearrangement was performed. follow-up was obtained. results: the patients ( m, f) ranged from to years (mean ). all tumors were of monophasic fibrous type. ihc results: all cases were strongly positive for tle and bcl ; focally positive or negative for cytokeratins; negative for s and cd ; and showed retained ini expression. molecular genetic results were: ss -ssx ( cases), ss -ssx ( cases), syt rearrangement ( case). follow-up ( cases): dead of disease, alive without disease. conclusion: our data show a striking overrepresentation of the ss -ssx fusion subtype among r-ss, in contrast to other ss, in which the ss -ssx fusion subtype accounts for two-thirds of cases. the reasons for this difference are unclear. the prognosis for r-ss appears similar to that of ss of more common locations. objective: new data related to the diagnosis and therapy of lung cancer have also affected the position of the pathologist in this area. principal changes in its classification have appeared in relation to adenocarcinoma and partly also in the large cell type of lung cancer. method: presented data represent a five-year retrospective study of a series of cases of lung cancers analyzed in our institute. besides routine he staining the following immunohistochemical reactions were used: antibody against ttf- , surfactant a, chromogranin, synaptophysin, ck , ae /ae , p , βe , cd and napsin a. results: using the who, classification of lung cancer, an unusual phenomenon of the return of squamous cell cancer (scc) prevalence over adenocarcinoma has been documented, which in the earlier years has equated the scc. the difference in obtaining the tissue samples, and changes in the geographical origin of certain patients of eastern slovakia may partly explain these differences. though the new travis classification (j thorac oncol, ) was not used, there prevailed mixed forms also in our series. conclusion: it is important to respect new information regarding the classification of lung cancer, especially in the category of adenocarcinoma. the constructive collaboration of pathologists with clinicians is recommended. objective: extranodal marginal zone lymphoma malt lymphoma and carcinoid are neoplasms occurring most frequently in the gastrointestinal tract and respiratory system. although each of them occurs relatively frequently and separately, the simultaneous appearance of these two neoplasms is exceptionally rare. method: we report an exceptional synchronous association of malt lymphoma and typical carcinoid in the lung. results: a -year-old male with sjögren's syndrome presented with cough and chest pain with no improvement after antibiotherapy. bronchial fibroscopy was normal. computed tomography showed a diffuse interstitial pneumopathy with a persistent left lower lobe nodule suspected of malignancy. a surgical resection of the nodule was achieved. histopathologically, it measuring . cm in diameter and was composed of association of malt lymphoma and typical carcinoid tumor which were focally admixed. immunohistochemical stains were strongly reactive to endocrine marker in carcinomatous component. tumor cells were diffusely cd positive in lymphomatous component. assessment of extent of lymphoma revealed a gastric location. the patient received chemoptherapy. he's still alive since months. conclusion: the best of our knowledge, this is the first report of such a collision lung tumor at the same anatomical site. the aim of this study is to describe the pathogenesis and clincicopathological feartures of such exceptional association. objective: primary mucoepidermoid carcinoma is rare comprise less than % of all lung tumors. it is characterized by the presence of squamoid cells, mucin-secreting cells and intermediate type. on the basis of morphological and cytological features, it is divided into low and highgrade types. method: we report a retrospective study of cases diagnosed during a -year period. diagnosis was made by histological examination of specimen obtained from lobectomy in cases and pneumonectomy in cases. no patient had history of salivary mucoepidermoid carcinoma. results: there were men and women ranging in age from to years. computed tomography showed a well circumscribed tumor arising in bronchus in all cases. a bronchial fibroscopy showed a main, lobar or segmental mass. bronchial biopsy revealed a non-small-cell carcinoma in only one case. histologically, tumors were classified into low grade mucoepidermoid carcinoma and high grade mucoepidermoid carcinoma. patients with low grade carcinoma remain alive after surgery alone. patients with high grade carcinoma received chemotherapy, four of them developed distance metastasis. conclusion: mucoepidermoid carcinoma is a rare primary malignancy of the tracheobronchial tree which is difficult to diagnose by limited biopsy. the prognosis is variable and depends upon the histological grade. objective: primary pulmonary malt lymphoma is considered to originate from malt of the bronchus secondary to autoimmune or inflammatory processes. although, it comprises more than two-thirds of all primary non-hodgkin's lymphoma of the lungs, it is a rare entity and accounts for less than % of all lymphomas. method: we report a retrospective study of cases of malt pulmonary lymphomas diagnosed during an -year period. diagnosis was made on surgical pulmonary biopsy in cases, bronchial biopsy in other cases and on lobectomy in one case. results: there were women and men ranging in age from to years. two patients had a history of sjoren's syndrome and one had a history of previous mammary carcinoma. computed tomography revealed bilateral nodules in patients, lung mass in patients and an area of consolidation in one patient. fiberoptic bronchoscopy showed bronchial stenosis in only cases. morphologically, the neoplasms had features typical of malt lymphoma. one patient was treated with surgery alone and received chemotherapy. five patients remained alive while one patient presented with recurrence. conclusion: pulmonary malt lymphomas are characterized by an important dissociation between clinical expression and radiological pattern. therefore, histological documentation is mandatory to ensure diagnosis. objective: malignant mesothelioma (mm) is an aggressive tumour with a poor prognosis. carbonic anhydrases and their inhibitors offer an opportunity for developing novel anticancer drugs, as well as diagnostic and prognostic tools. carbonic anhydrase ix (caix) is a membranous metalloenzyme involved in cell adhesion and ph homeostasis. it is a direct target of hypoxia-inducible factor and serves as a marker of hypoxia. this study was designed to assess systematically caix expression in mm of pleura and peritoneum, and their benign counterparts. method: mms of pleura ( epithelioid, biphasic, sarcomatoid) and peritoneum ( epithelioid), and normal or reactive pleural samples were analyzed. caix expression was determined using immunohistochemistry. membranous immunoreactivity was evaluated semiquantitatively. specimens were divided into five subgroups according to the staining pattern and intensity. results: , % ( / ) of mms expressed caix. all epithelioid mesotheliomas showed at least a weak focal ( , %, / ), but predominantly a strong diffuse ( , %, / ) staining with caix antibody, without any perinecrotic pattern. sarcomatoid mesotheliomas were negative. normal mesothelial cells were diffusely positive. conclusion: these data suggest that mechanisms of caix overexpression in mm are different than due to hypoxia and appear promising in prospective use of specific therapeutic caix targeting in advanced mesothelioma. objective: eml -alk crizotinib therapy needs validation at lower cost and rapid answer in pathology routine. method: histological/who and ck , ttf , ck . , cd /chromogranin and vimentin panel classifications with alk (clone a , novocastra laboratories ltd, newcastle, united kingdom) were applied to paraffin sections of bronchial-pulmonary carcinomas: adenocarcinomas, epidermoid carcinomas, pleomorphic carcinomas (mixed type adenocarcinomas with large/giant/fusiform cells), neuroendocrine carcinomas (nec) ( combined large cell nec with adenocarcinoma and with epidermoid carcinomas; sclc chromogranin positive combined with adenocarcinoma) and adenosquamous carcinoma. results: the applied antibodies specified bronchial pulmonary carcinomas subtypes clearly. in over years old nonsmoking females mixed type adenocarcinomas alk expression was over %: acinar, solid, micropapillary and microacinar patterns; one glandular mucinous pattern (mucinous ba pattern) and one ba pattern, all expressing ttf- . conclusion: in this study, / adenocarcinomas of older women had alk protein expression, only one with a mucinous pattern. as protein positivity cases comprise a lower number, fish described by s. lantuejoul seems to be the most appropriate method. it is now necessary to decide whether kras and egfr mutations have to be determined together and/or select ttf- positive adenocarcinomas (from terminal respiratory unit) raised by this approach. objective: the year survival of bronchial-pulmonary carcinomas remains poor, between % and %/men and % to %/women. treatment orientation is influenced by clinical staging and morphological classification in biopsies of % of the cases. method: this study comprised surgical specimens where we compared immunohistochemistry in-between adenocarcinomas ( ), epidermoid carcinomas ( ) and the heterogeneous groups of large cell neuroendocrine carcinoma ( ), small cell lung cancer ( ), large cell carcinoma ( ), adenosquamous carcinoma ( ) and pleomorphic carcinomas ( ) with max f-fluordesoxiglucose (fdg), a clinical parameter based in pet to preview diagnosis and prognosis. results: we found significant differences (p= . ) between ttf- positive and negative adenocarcinomas where the f-fdg capture was lower in ttf- positive cases, indicating lower metabolic activity. ttf- negative adenocarcinomas have similar and higher metabolic activity as epidermoid carcinomas. the other histological types have fdg capture similar in between the two defined groups. conclusion: immunohistochemical and f-fdg analysis correlate with clinical differences between adenocarcinomas and epidermoid carcinomas, where ttf- negative adenocarcinomas are biologically similar to epidermoid carcinomas, requiring a different medical approach as well as molecular pathology particular interpretation. these results strain the classification of bronchial ttf- negative adenocarcinomas because they are different from the terminal respiratory unit ttf- positive adenocarcinomas. objective: according to researchers pneumonias are characterized by increase number of alveolar macrophages population after increased migration of monocytes from bone marrow and blood into the alveolar space. method: we examined observations of pneumonia with bacteriological, histological and blood monocytes examination in all cases. bacteriological study was performed at the institute of antimicrobial chemotherapy. histological examination was performed in the smolensk regional institute of pathology. results: in the foci of pneumonias we discovered mainly mixed gram positive and gram negative microorganisms. ten observations were characterized by an increase in the absolute number of blood monocytes. fifty observations did not reveal excess levels of blood monocytes. in all cases with an increase in the number of blood monocytes, gram negative bacteria were isolated. in cases with normal number of blood monocytes some of the microorganisms were gram positive. conclusion: gram negative bacteria result in activation of the monocytes and their entry from the bone marrow into the blood more than gram positive bacteria. objective: bronchial carcinoids and schwannomas are uncommon, slowly growing, low-grade neoplasms. carcinoid tumors are thought to arise from neuroendocrine/kulchitsky's cells of bronchial epithelium. schwannomas are thought to originate from schwann cells. clinically they may be asymptomatic or present with non resolving recurrent pneumonia, hemoptysis, respiratory distress. conclusion: we present two cases of respiratory distress in two teenage patients. pulmonary hamartomas mimicking metastatic carcinomas h. erdem * , l. yilmaz aydin, a. k. uzunlat, m. oktay, a. n. annakaya, u. yilderim, f. basar * duzce university, dept. of pathology, turkey pulmonary hamartomas are usually found incidentally and they mimick metastic tumours. we report a case of a year-old man who admitted to chest disease service for cough. he had laryngectomy operation formerly and diagnosed as squamous cell carcinoma. chest-x-ray and computed tomography revealed pulmonary nodules. it was removed but there was not metastatic carcinomas. this case was presented because it can be difficult to make diagnosis when the patient has malignancy. objective: experimental models of pulmonary fibrosis (pf) has been proposed and its later phase tend to the resolution in different degrees depending on the drug/ strain/inflammatory-pattern. thus the maintenance of these mechanisms may participate in the pf-progression. our objective was to determine the immune-fibroticpattern in models of pulmonary fibrosis in the late stage ( d). method: distinct animal models were used, including balb/c, c bl/ and il ra-ko-c bl/ mice by bleomycin and paraquat. we analyzed the amounts of total peribronchiolar-interstitial collagen (tpc-tip) by picrosirius and col -col by immunofluorescence through the morphometric evaluation. these data were validated by rt-pcr. results: the tpc did not differ between the treated groups. tic was higher in the c bl/ strain, independent of the absence of il- ra. the col -immunoexpression was higher in control and blm-treated il ra-ko-c bl/ than in wild-mice and lower in blm-balb/c mice. the col immunoexpression was higher in blm-balb/c. likewise, the col gene expression was higher in the il ra-ko mice and lower in the blm-balb/c. conclusion: the perpetuation of fibrosis in pf-susceptiblemice can be modulated by il- -dependent col -hiperexpression and by col -subexpression. this suggests that col is an important component responsible for the development of pf. the prognostic role of filamin a protein expression in patients with non-small-cell lung cancer m. gachechiladze * , j. skarda * palacky university, pathology, olomouc, czech republic objective: an actin-binding protein filamin a (flna) serves as a scaffold in various signaling pathways. recently, it has been reported that flna interacts with brca protein and is required for efficient regulation of early stages of dna repair processes. as dna repair proteins are important prognostic markers for non-small-cell lung cancer (nsclc) patients, we aimed to investigate the role of flna protein expression in nsclc, as well as its correlation with brca protein expression. method: we performed a preliminary study of fnla and brca protein expression in nsclc patients. formalin-fixed paraffin-embedded tissue sections were stained by immunohistochemistry using antibodies against flna c-terminus (ep y, lsbio), brca n-termunus (ms ) and against phosphorilated forms of brca at ser and ser (abcam). staining intensity was estimated semi-quantitatively and correlated with all available clinico-pathological factors. results: flna expression was significantly higher in cancer, compared to normal lung tissue. positive correlation has been revealed between flna and brca phospho-ser expression. also, year overall survival rate was higher in patients with strong flna expression. conclusion: according to our preliminary study results the prognostic role of flna protein expression deserves to be a subject for further studies in patients with nsclc. ps- - pulmonary nodular lymphoid hyperplasia ("pulmonary pseudolymphoma") -the significance of increased numbers of igg positive plasma cells d. guinee * , a. gerbino, s. murakami, m. koss * virginia mason medical center, pathology, seattle, usa objective: pseudolymphomas of the skin, breast, and lacrimal glands show an increase in igg positive plasma cells. we hypothesized that a similar increase in igg positive plasma cells occurs in pulmonary nodular lymphoid hyperplasia (pnlh). method: immunohistochemical stains for igg and igg were performed in cases of pnlh, cases of balt lymphoma, cases of intraparenchymal lymph nodes (ipl) and case of follicular bronchiolitis (fb). the mean number of igg -and igg-positive plasma cells and the igg /igg ratio was obtained from a manual count of three separate high power fields (hpfs) of areas of highest cellularity. results: the average number of igg positive plasma cells and the igg /igg ratio was increased in pnlh (case : /hpf, ratio: . , case : /hpf, ratio: . ). in comparison, average igg positive plasma cells per hpf were much lower in balt lymphoma (range= - . /hpf, ratio= - . ), ipl (range igg / hpf= - , ratio= - . ) and fb ( /hpf, ratio= . ). conclusion: the increase in igg positive plasma cells and igg /igg ratio in pnlh aids in diagnosis and supports our current understanding of pnlh as a distinct form of reactive lymphoid proliferation. the relationship between pnlh and igg -related sclerosing disease requires further study. ps- - calretinin, ck / , ttf- , cea, ber-ep , and cd : a useful combination of immunohistochemical markers for differentiating pleural mesothelioma from pulmonary adenocarcinoma n. gursan * , m. calik, e. demirci, s. sipal, b. gundogdu, c. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: the distinction between pleural epithelial mesothelioma and peripheral lung adenocarcinoma involving the pleura is still an important diagnostic problem for surgical pathologists. the aim of our study was to identify the most specific and sensitive markers for the positive identification of mesothelioma. method: paraffin-embedded blocks from surgical material of pleural epithelial mesotheliomas and pulmonary adenocarcinomas were retrieved from the files in our department. the primary antibodies used in each case were the following: antibody anticalretinin, ema; cea, berep , ttf- and cd . results: of the mesotheliomas, % stained for calretinin, . % for ck / , . % stained for ema and ae /ae . of the lung adenocarcinomas, . % cases showed reactivity for calretinin, . % for ck / , . % for cd , all for ttf- , % for cea, . % for ber-ep , . % for ema, and all for ae /ae . conclusion: calretinin were the highly specific positive mesothelial markers, whereas ck / showed high sensitivity but low specificity. among negative markers, we advocate the use of ttf- , cea and cd which were the most specific in differentiating mesotheliomas from adenocarcinomas. cyclooxygenase- expression in nsclc i. kern * , e. sodja, m. rot * university clinic golnik, slovenia objective: overexpression of cox- correlates with aggressive disease of nsclc. aim of our study was to determine the cox- expression levels by two methods. method: analysis was done on consecutive surgical specimens of nsclc fixed in paxgene tissue system. relative quantification of cox- mrna expression was performed by quantitative rt-pcr using intron-spanning primer-probe set. cox- protein expression was assessed by immunohistochemistry (ihc). scoring was performed using an intensity-extent system, both parameters on the scale - and multiplied to give ihc index. results: there were cases of adenocarcinoma, cases of squamous cell carcinoma and one typical carcinoid. cox- mrna expression was detectable in all specimens. the median cox- mrna expression value, normalized against he internal reference gene gadph, was , (range , - , ). we observed cytoplasmic and membranous immunohistochemical reaction patterns. average ihc index was , . there was positive correlation between mrna and protein cox- expression (r = , ). adenocarcinoma cases had average relative mrna expression value , and ihc index , , while squamous cell carcinoma had average relative mrna expression value , and ihc index , . conclusion: cox- is expressed in nsclc with various ihc reaction patterns. adenocarcinoma and squamous cell carcinoma have different cox- expression levels. objective: the akt/mammalian target of rapamycin (mtor) pathway is up-regulated in many human cancers, and agents targeting the mtor pathway are in various stages of clinical development and application. method: expression of pakt and mtor was studied by immunohistochemical analysis of surgically resected nonsmall cell lung cancer (nsclc) specimens on a tissue microarray (tma). results: the results were correlated with clinicopathological features. expression of mtor showed a strong correlation with the expression of pakt (p< . ) and was significantly associated with female gender, tumor size ≤ cm, adenocarcinoma (adc), non-smoker status, and lower pathological stage. expression of pakt was correlated with older age (≥ ), adc, non-smoker status, and lower t stage. univariate survival analysis revealed that the mtor and pakt positive group had a significantly longer cancer-specific survival than the mtor and pakt negative group (p= . and p= . , respectively). coexpression of pakt and mtor correlated with better prognosis than either single or double negative pakt and mtor groups (p= . ). however, multivariate analysis proved that mtor and pakt expression are not independent prognostic factors for cancer-specific survival. conclusion: expression of pakt and mtor expression is more significantly associated with adc than squamous cell carcinoma (scc) and expression of these proteins is associated with better prognosis. ps- - pak immunohistochemistry marker in non-small cell lung cancer (nsclc) a. kucukosmanoglu * , o. d. İlara colakkadıoglu, k. bakir * university of gaziantep, pathology, turkey objective: pak is a member of p -activated kinase family. many human tumor express and activate this family. because of their role in cell transformation, they become therapeutic targets. they have important roles in cell survival, cell proliferation and cell migration. they affect cell growth and tumor invasion. method: cases with nsclc reported in gaziantep university pathology department between and , reviewed retrospectively. immunohistochemically nuclear and cytoplasmic pak stainings were considered positive and scored according to degree of staining. results: our cases included squamous cell carcinoma, adenocarcinoma, adeno squamous carcinoma and large cell carcinoma. there was no significantly associated between tumor types and pak staining. of patients showed recurrence and of cases showed nuclear staining but there were no statistically significance (p: , ). cases died from the disease and in of these cases nuclear stainig was very intresting, inspite of statistical results. conclusion: in this study pak staining patern and score were compared with tumor type, size, recurrence, mortality and lymph node involvement in nsclc. and we found no statistically significance. of case with nsclc stained with pak . these results suggest that pak was expressed in lung like prostat, plasenta and breast. pleural fibroelastosis is a similar spectrum of histopathology in chronic fibrosing lung disorders l. marcal * , e. r. parra, l. antonangelo, v. capelozzi, f. vargas, e. c. nascimento, v. teodoro, k. c. silva * lia junqueira marçal, são paulo, brazil objective: parenchymal fibroelastosis in chronic fibrosing lung disorders has been much investigated, but little attention has been directed at the visceral pleura (vp) participation in these situations. our aim was to verify whether elastic deposition accompanies collagen deposition in the repairing process of chronic lung injury. in this work we studied the distribution of these fibrous components of vp in bullous disease type i and ii, smoking-related interstitial fibrosis and usual interstitial pneumonia (uip). method: we employed histochemical methods on conventional histological slides. we measured, by image analysis, the content of fibres of the collagenous and elastic systems of the visceral pleura in histological slides sampled from surgical lung biopsies and bullectomy, using the picrosirius-polarization method and weigert's resorcin-fuchsin stain, respectively. results: four groups were studied: i, patients with spontaneous pneumothorax due to type i bullous disease; ii, patients with spontaneous pneumothorax due to type ii bullous disease; iii, smoking-related interstitial fibrosis; and iv, patients with idiopathic pulmonary fibrosis. the first two groups were used as controls. patient diagnosed with idiopathic pulmonary fibrosis ( ), in which experimental transplantation was performed of type ii pneumocytes, ingress to the hospital for further study groundmass of the right lung. in the postmortem study a gr. mass was identified, the mass was formed by sarcomatous cells habit, undifferentiated and pleomorphic, with the presence of multiple implants and adhesions in rib cage, diaphragm, pericardial fat. ihc profile was performed: vimentin (+), ema focally (+), wt , ck , ttf , ckae /ae , s , cd , cd and cd (−) and low proliferation index, the diagnosis undifferentiated malignant tumor. with inconclusive ihc profile, so blocks were sent to clinic barcelona hospital, for study. the estimated prevalence of idiopathic pulmonary fibrosis is cases per , population in men, with a mortality of % at years of diagnosis. cancer rate of in transplanted patients is within the range between % and %. could the appearance of this tumor be related either to transplanted pneumocytes or it is inmunosupression the main risk factor? current treatments for idiopathic pulmonary fibrosis are not effective, which requires the study and development of new therapeutic options, using fibroblast proliferation inhibitors, as well as prospective studies, in the long term, the evolution of these patients and the development of secondary entities to it. objective: mediastinal hemangiomas are rare tumors accounting for , % of all mediastinal tumors. these tumors are challenging because of the lack of clinical and radiologic specific signs. their diagnosis is mainly based on microscopic study. method: we report a -year-experience of a single institution. we describe cases of mediastinal hemangioma. results: our study contained men and women with a mean age of . years. symptoms consisted mainly in chest pain. neurologic signs were observed in patients. surgical treatment was performed in all patients dealing with a total resection in patients. the most used surgical approach was a posterolateral thoracotomy. video-assisted thoracic excision was tried in one patient and was converted into a median sternotomy. microscopic examination concluded to a mediastinal hemangioma in all cases. all the patients presented no complications after a follow up periods varying from months to years. conclusion: mediastinal hemangiomas are rare tumors whose diagnosis is based on microscopic findings. their surgical management may be challenging because of their connection to the adjacent structures. video-assisted thoracic excision is being more frequently used by experienced surgeons. these tumors are benign with a good behavior. objective: actinomycosis is an infectious disease caused by actinomyce israeli in % of the cases. it is mainly observed in alcoholic patients and affects mainly cervicofacial, abdominal and thoracic regions. pulomnary actinomycosis accounts for % of the localizations and is caused by the inhalation of septic particles causing granulomatous lesions, the extension to the adjacent organs and a cutaneous fistulae. it represents a real pitfall and mimics malignant lesions, tuberculosis or other infectious diseases. method: we report a retrospective study about cases of pulmonary actinomycosis diagnosed over a -year-period. results: we describe the cases of men aged between and years who presented with respiratory signs. radiologic investigations showed in all cases parenchymal masses with irregular margins mimicking malignant processes. positivie diagnosis was based on microscopic examination. the treatment was based on surgical excision associated to a medical treatment without complications after a follow up period ranging from months to months. conclusion: pulmonary actinomycosis shares usually the same clinical and radiologic features as malignant lesions. positive diagnosis is based on microscopic findings. it inducesusually surroundng organs and may affect, in some cases, the vital prognosis. over expression of hyaluronan syntehase- activity has impact in the remodeling process and survival evolution in patients with idiopathic pulmonary fibrosis e. parra * , v. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: the idiopathic pulmonary fibrosis (ipf) is a terminal illness characterized by unremitting extracellular matrix (ecm) deposition in the lung. in this regard, the myofibroblasts and the ecm components such as collagen and hyaluronan (ha) have an important role in the fibrosis. we analyzed the expression of has (ha synthase ), has , has and hyaluronic acid receptor (cd ) by epithelial and myofibroblasts cells in patients with ipf and we correlated with a survival. method: has- , has , has and cd epithelial and myofibroblast expression were evaluated in surgical lung biopsies from patients with ipf in minimal and severe fibrosis by the point-counting technique. impact of these markers was tested on pulmonary functional tests and follow-up until death from ipf. results: has and cd expression were significantly increased and directly associated with severe fibrosis. myofibroblast has activity was indirectly associated to dlo/va (r= − . ; p= . ). kaplan maier curves determined a higher risk of death for patient with high ha (> . %) expression than in low expression (log rank p= . , figure) . conclusion: the increased has- activity in epithelial and myofibroblast cells have impact in the remodeling process and the survival evolution, suggesting that strategies aimed at preventing the effect of this ecm component may have a greater impact in patient's outcome. financial support: fapesp, cnpq. ps- - viral antigens are more frequently observed in acute interstitial pneumonia than in other types of idiopathic interstitial pneumonias e. parra * , g. c. dos santos, f. weisshaupt stegun, c. dos santos cirqueira, m. i. seixas duarte, v. l. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: the etiology of idiopathic interstitial pneumonias (iips) remains unclear. many researches assumed that viruses can represent an important factor of aggression to the lung provoking fibrosis. in this regards, we researched the presence of virus infections in patients with iips. method: biopsy samples from patients with idiopathic interstitial pneumonia (ipf); patients with nonspecific interstitial pneumonia (nsip); patients with acute interstitial pneumonia (aip) and patients with idiopathic cetrilobular fibrosis (iclf) were used to investigate by microarray and immunohistochemistry the presence of measles virus (mv), hepatitis-c virus (hcv), adenovirus (adv), respiratory syncytial virus (rsv), epstein-barr virus (ebv), herpes i and ii viruses (hvi and hvii). results: we detected the epithelial alveolar infection by mv and cmv in . % and . % in aip, respectively. endothelial cmv infection was observed in % of iclf group. when we compared with the age of these patients, patients with ≤ of years old had more infection by mv and cmv than the group with ≥ years old. the other viruses were not detected in the different groups. conclusion: the viral infections observed in aip and iclf groups reinforce the possible viral participation in these pulmonary diseases. financial support: fapesp. abnormal up regulation of cyclooxygenase- is observed in idiopathic pulmonary fibrosis e. parra * , f. lin, w. teodoro, a. p. velosa, v. l. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: several factors modulate fibroblast proliferation and collagen deposition in pulmonary fibrosis diseases, including cyclooxygenase (cox). the main of this study was observed the relationship between cox and cox in surgical lung biopsies from patients with idiopathic pulmonary fibrosis (ipf). method: twenty four patients ( ± . year) were characterized with ipf. immunohistochemistry and histomorphometry were used to evaluate the amount of cox and cox expression in lung specimens. the expression of these markers was tested with their pulmonary function tests. results: significantly a higher amount of cox- was observed in ipf patients principally in normal and vascular areas (p= . ) when compared with control group (figure) , contrasting with similar amounts of cox- in both groups. an important negative correlation was observed between total lung cox- expression and dco/va (r= . , p= . ) in ipf patients. conclusion: higher vascular expressions of cox probably mediated the inflammatory reaction in patients with ipf and have an important impact with pulmonary function tests, suggesting that a participation in the pathway of ipf. financial support: fapesp. error barr shows the correlations between cox- expression in normal and vascular areas of ipf compared with control group ps- - multiplex ligation probe-dependent amplification (mlpa) as an ancillary method for the diagnosis of malignant pleural effusion e. parra * , d. rosolen, l. kulikowski, r. dutra, v. l. capelozzi, f. vargas, m. acencio, l. antonangelo * fmusp, dept. of pathology, são paulo, brazil objective: a definitive diagnosis provided by the finding of malignant cells in pleural fluid (pf) can be established in around % of patients with pleural malignancy. however, underdiagnosis risk in cytological suspicious cases is high, which makes the cytological diagnosis quite limited. this is an important clinical problem, especially if we consider that some patients, in bad clinical conditions, can not be submitted to a guided thoracoscopic biopsy. method: using multiplex ligation probe-dependent amplification (p -mrc-holland) we have studied sequence variations of egfr gene and amplifications/deletions of chromosomal regions frequently associated to tumors (atg b, pahs, pros, nsd , and cdgif genes). results: forty-three malignant pf samples from patients with different cancers were evaluated, even in those cases with scarce pellet cells. four benign pleural effusions were used as control. gene sequence changes were observed in ( . %) cases, while others copy number abnormalities were found in ( . %). conclusion: the findings suggest that mlpa could be considered an alternative tool to detect molecular genetic changes in malignant pleural effusions, since this technique is relatively low expensive and not time consuming. our next challenge is to find the best combination of probes capable to recognize malignant cells of any origin in fresh samples of pf. multiple primary pulmonary myopericytoma: case presentation n. petre * , f. pop, d. leonte, s. bedereag * medcenter bucharest, dept. of pathology, romania objective: myopericytoma is described as a perivascular myoid tumor which usually develops as a solitary mass in the subcutaneous tissues of the extremities, in adults. method: the chest radiography of a -year-old woman showed multiple, bilateral lung nodules. after the surgical excision of one of them, the histopathologic examination revealed a well circumscribed nodule, composed of fusiform or oval cells, with eosinophilic cytoplasm and ovoid nuclei, without atypia, in a concentric pattern, intimately associated with thin-walled vessels, within a myxoid stroma. results: the spindle cells were diffusely positive for vimentin, smooth muscle actin (sma) and occasionally for desmin. cd and cd were positive only in endothelial cells. ki was positive in less than % of neoplastic cells. conclusion: the histological and immuno-histochemical findings led to the diagnosis of multiple primary pulmonary myopericytoma. ps- - five cases of lung pneumocytoma: clinico-pathological, immunohistochemical and ultrastructural study i. rodriguez * , a. panizo, b. larrinaga, i. amat * c. hospitalario de navarra, dept. of pathology, pamplona, spain objective: lung pneumocytoma (lp), also called sclerosing hemangioma, is an uncommon tumor of uncertain histogenesis. method: we analyzed the clinical, morphological, immunohistochemical and ultrastructural features of lp. results: all patients were women, with median age of year (range: - ). mean size was mm (range - mm). all tumors were located within the right lung (upperlobe: ; middle-lobe: ; lower-lobe: ). all cases showed solid, papillary, sclerotic, and hemorrhagic patterns. the tumors were composed of cells types: pale polygonal and surface cells. ema, ttf , and pr were observed in both type cells. the surface cells showed also positivity for ck , napsin-a, and surfactant-a, whereas the polygonal cells for vimentin. surface cells had short microvilli and lamellar bodies in their cytoplasm. polygonal cells contained abundant microfilaments and rough endoplasmic reticulum. all patients were alive and well without recurrence at the last follow up. conclusion: lp is likely to be an epithelial tumor with a differentiation toward type ii pneumocytes, which exhibits various architectural patterns. the ihc profile provides useful clues for the diagnosis of this lung neoplasm when typical features are absent. all our cases had an excellent prognosis with no evidence of recurrence following surgery. rare tracheobroncheal lesions diagnosed by small bronchoscopic biopsies a. sasmaz * , s. yuksel, h. nalbant, p. celepli, e. kadan, s. percinel, s. dizbay sak * ankara, turkey objective: six different, rarely seen tracheobronchial lesions, taken by bronchoscopy as small fragments were discussed with an emphasis on morphological findings and differential diagnosis. results: six patients were men and two patients were women with an age range of to years. most of the lesions were symptomatic and discovered as small masses by bronchoscopy. the tracheobronchial lesions varied from polypoid, nodular, well-demarcated, fragile masses to nodular thickenings. microscopically, a polyp composed of a fibrovascular stroma with scattered mononuclear inflammatory cells was compatible with fibroepithelial polyp. mature adipocyte proliferation in two cases, s- and cd positive polygonal or ovoid cells with abundant eosinophilic, granular cytoplasm having small, hyperchromatic nuclei, smooth muscle actin and desmin positive spindle cells in interlacing fascicles within a myxoid and collagenous stroma with mononuclear inflammatory cells, cd and cd positive thin-walled vascular channels, filled with red blood cells and s- positive spindle cells having palisading of wavy nuclei in two cases, located in the submucosa were main findings of lipoma, granular cell tumor, inflammatory myofibroblastic tumor, cavernous hemangioma and schwannoma, respectively. conclusion: tracheobronchial biopsies, even with small fragments of lesions can allow to render rare specific histopathological diagnoses, some of which need to be confirmed by immunohistochemistry. objective: small cell lung carcinomas (sclc) are aggressive neoplasms that give very early distant metastases. matrix metalloproteinases (mmps) are a family of endopeptidases which degrade extracellular matrix and modulate cell adhesion, playing a crucial role in cancer cell invasion and metastasis. the aim of the present study is to investigate the immunohistochemical expression of mmp- , mmp- (type iv collagenases) and mmp- (interstitial collagenase) in patients with sclc. method: formalin-fixed, paraffin-embedded lung biopsy specimens from patients with sclc (m:f= : , median age= . ) were immunostained for mmp- , mmp- and mmp- (anti-mmp- polyclonal antibody, anti-mmp- kda collagenase iv antibody, anti-mmp- kda collagenase iv antibody, spring bioscience). results: immunohistochemical expression of mmps was detected in the cytoplasm of neoplastic cells. immunoreactivity was designated positive when > % of neoplastic cells were stained. overall, mmps were expressed in the majority of sclc. specifically, mmp- was positive in % ( / ), mmp- in . % ( / ) and mmp- in . % ( / ) of sclc. non-neoplastic lung parenchyma did not stain for mmps. conclusion: the majority of sclc express immunohistochemically mmp- , mmp- and mmp- . given the role of mmps in cancer progression and metastasis, their expression in sclc may contribute to their aggressive course. objective: number of pulmonary adenocarcinoma (adc) patients incresease. treatment of non-small cell pulmonary carcinoma depends of its histological type in era of target molecular therapy particulary of adc: diagnosis of adc is established on small-sized pulmonary biopsies obtained on bronchoscopy and by transthoracic needle pulmonary biopsy. the aim of this study was to evaluate optimal panel of monoclonal antibodies in diagnosis of pulmonary adc on small-sized biopsy pulmonary samples. method: analysis of small-sized biopsy pulmonary samples. diagnosis of adc was established on hematoxillyn-eosin stained (h&e) samples and confirmed immunohistochemicaly by thyreoid transcription factor- (ttf- ), napsin-a, surfactant b and cytokeratin (ck ). descriptive statistical method (%) was used. results: ttf- specificity was %( / ), napsin-a- %( / ), surfactantb - %( / ) and ck - %( / ) in adcs. two monoclonal antibodies were positive in % ( / ) adcs, one of them was necessary ttf- or napsin-a. three monoclonal antibodies were positive in %( / ) and in %( / ) adcs, respectively. there is not statistical significans in number of monoclonal antibodies for diagnosis of adc. conclusion: no one monoclonalantibody is specific for one histological type of carcinoma and its origin. ttf- , napsin-a, surfactantb and ck belong in optimal panel for diagnosis of pulmonary adenocarcinoma. ps- - expression of cd , e-cadherin and bcl- in lung cancer i. strumfa * , a. abolins, j. gekis, k. pavlovs, a. vanags, j. grusina-ujumaza, g. volanska, j. gardovskis * riga stradins university, dept. of pathology, latvia objective: lung cancer represents major problem in oncology as the incidence and mortality is high (parkin et al., ) . molecular studies could reveal additional targets for intervention or prognostic evaluation. however, the published data are controversial (renouf et al., ; leung et al., ; maraz et al., ; ko et al., ) . method: consecutive lung cancer cases ( ) were retrieved by retrospective archive search. the diagnostics has been performed systematically in accordance with who classification (travis et al., ) . the expression of cd , e-cadherin and bcl- was analysed by immunohistochemistry and evaluated semiquantitatively. results: the intensity of bcl- expression was highest in small cell cancer, reaching the mean value . . no or very low bcl- expression was found in adenocarcinoma, carcinoid and squamous cell cancer. the membranous expression of e-cadherin showed significantly higher mean intensity in adenocarcinoma ( . ) and carcinoid ( . ) than in small cell cancer ( . ) and squamous cell cancer ( . ). cytoplasmic e-cadherin expression was observed in small cell cancer. cd expression was widespread and frequent in non-small cell lung cancer. conclusion: the main histological types of lung cancer show different immunophenotype. bcl- expression is found in small cell cancer. the expression of e-cadherin is characteristic in adenocarcinoma and carcinoid. cd is expressed in non-small cell lung cancer. localized nodular pulmonary and thoracic cage amyloidosis i. strumfa * , a. abolins, j. gekis, k. pavlovs, a. vanags, b. strumfs, g. volanska, j. gardovskis * riga stradins university, dept. of pathology, latvia objective: localised amyloidosis represents a rare differential diagnosis of neoplasms. however, in some cases amyloid deposits are manifestation of tumour itself. to increase awareness about these uncommon but important differential diagnostic issues, we show here three well-characterised cases of thoracic cage or pulmonary localised nodular amyloidosis. method: the cases were identified by systematic retrospective archive search, - . congo red stain, polarisation microscopy and immunohistochemical analysis was applied. results: there were males and female among the patients diagnosed with thoracic cage or pulmonary amyloidosis. the patients were - years old and had no history of previous malignancy. clinically, either lung cancer or sternal osteochondroma was suspected. radiologically, - nodules measuring . - . cm were found in lungs ( cases, one of these being bifocal) or sternum ( ). surgical treatment was applied in all cases. amyloid deposits were identified by congo red stain and polarisation microscopy. al type of amyloid was confirmed. in case of bone lesion, the plasma cells were monoclonal justifying the diagnosis of multiple myeloma. conclusion: localised amyloidosis can involve lung or sternum as tumour-like mass. the lung lesions can be single or multiple. association with haematologic neoplasm is likely if bone is affected. clonality analysis of plasma cells surrounding amyloid deposits is mandatory. pleural localization of castleman disease: a rare entity e. tastekin * , f. oz puyan, e. isler, u. usta * trakya university, dept. of pathology, edirne, turkey objective: castleman disease (cd) comprises a heterogeneous group of disease with various clinical presentations and prognosis. by definition; cd is a lymphoproliferative disorder of the mediastinal lymph nodes and extranodal tissues with follicular and interfollicular abnormalities. pleural localization is an unusual presentation of cd. method: a -year-old man applied to the hospital because of cough. chest x-ray and ct images showed an irregular, × × mm sized intrapleural-extrapulmoner mass in the paramediastinal region. surgical specimen was consisting of a × × . cm sized, irregular-round shaped, gray colored calcified mass. microscopically, a lymphoid proliferation with distorted follicles and increased dendritic cells (with cd ) was detected. lymphocyte depleted germinal centers resembling "onion skin" appearance with penetrated sclerosing hyalinized blood vessels were also seen. interfollicular region was composed of proliferating blood vessels lined by plump endothelial cells and few lymphoplasmositer infiltration. there was heterogeneous positivity with cd and cd . expanded mantle zones showed diffuse bcl positivity. ki proliferation index was low. the mass was diagnosed as "castleman disease, hyaline vascular type". typical appearance of the follicular and interfollicular abnormalities allowed definitive differentiation from mesothelioma and solitary fibrous tumor of the pleura. conclusion: pleural cd is a rare lesion but should be considered especially on young patients in the differential diagnosis of pleural masses. objective: to evaluate foxp expression in bronchus-associated lymphoid tissue (balt) and correlate with the inflammatory process and collagen content in the lung tissue in an experimental model of scleroderma (ssc) after type v collagen (col v)-induced nasal tolerance. method: female new zealand rabbits (n= ) were immunized with mg/ml of col v in freund's adjuvant (im). after days, six immunized animals were nasally tolerated with col v ( νg/day), during days (im-tol). animals (n = ) only tolerated served as control (ct). foxp expression in balt and inflammatory cells in pulmonary interstitium were evaluated by point counting method. types i, iii and v collagen gene expression were evaluated by real-time pcr. results: im-tol when compared to im presented decreased lymphocytes, macrophages and monocytes and types i (p= , ) and v (p= , ) collagen mrna expression in pulmonary tissue. t lymphocytes foxp were expressed in % of im-tol and , % of ct (p= , ). additionally, balt was higher expressed in im-tol in relation to ct. conclusion: col v-induced nasal tolerance in ssc model induces foxp regulatory t cells in balt which can trigger an immune regulatory mechanism resulting in decreased inflammation and collagen expression. it suggests that col v tolerance could be a promising therapeutic for human scleroderma treatment. igg -related lung disease t. tichy * , h. hornychova, j. jankova, j. skarda, b. krajsova * university hospital olomouc, inst. of pathology, czech republic objective: igg -related lung disease is one of the manifestations of igg -related systemic disease. obliterative vasculitis is considered an organ specific feature of igg -related disease in the lung. we report a case of a -year-old man with multifocal subpleural consolidations in both lungs. histologic examination revealed igg -related lung disease with obliterative lymphoplasmacytic vasculitis. method: histological sections from paraffin blocks were used for hematoxylin-eosin and special stains (elastica-masson trichrome, pas, geimsa, grocott), for immunohistochemistry (antibodies against kappa and lambda light chains, cd , cd , igg, igm, iga, igg , lmp ) as well as for eber in situ hybridisation and pcr. results: the lung tissue was irregulary fibrotic with dense lymfoplasmacytic infiltration concentrated in the walls of pulmonary arteries. some arteries were obliterated by intimal fibrosis. infiltrating lymphocytes were small and without atypias. the majority of lymphocytes were cd positive, nearly all plasmocytes showed igg positivity. igg /igg ratio was %. eber in situ hybridisation was negative and monoclonal reaarangement of t cell receptor or immunoglobulin heavy chain genes were not detected. conclusion: igg -related lung disease is rare. obliterative vasculitis and high percentage of igg positive plasmocytes are main histological features of this entity. objective: primary lung carcinoma with heterotopic osteocartilaginous formation is exceedingly rare. to date only cases have been reported in the literature and the pathogenesis is not fully investigated. we report a case of pulmonary adenocarcinoma with osteocartilaginous formation with immunohistochemical staining of bone morphogenetic proteins (bmps). method: a -year-old man was admitted to our hospital for a lung tumor in his left upper lobe. an open lung biopsy followed a lobectomy was done. the resected tissue was fixed with % formalin and embedded in paraffin. sections, cut from paraffin blocks, were subjected to hematoxylin and eosin (he) staining and masson-goldner staining, in addition to immunohistochemical staining. results: the tumor was poorly differentiated adenocarcinoma with heterotopic ossification. some of the tumor cells were positive for bmp- , , and . some of mesenchymal cells in tumor interstitium were positive for osteoblast (ob)-cadherin or bmp receptor-ia. conclusion: we report a case of primary lung adenocarcinoma with heterotopic osteocartilaginous formation and reviewed previously published reports. to our best knowledge, this was the first case that not only bmp was expressed in tumor cells but also ob-cadherin or bmp receptor in some mesenchymal cells of tumor interstitium. expression of transforming growth factor ß and e-cadherin in lung adenocarcinoma j. yoo * , s. y. park * st. vincent's hospital, pathology, suwon, republic of korea objective: there is evidence supporting the concept of tumor progression from pulmonary adenocarcinoma in situ (formerly bronchioloalveolar carcinoma, bac) to adenocarcinoma with varying degrees of invasion. the aim of this study was to investigate the role of tgfß in tumor invasiveness in lung adenocarcinoma, and to determine the potential relationships between its expression and immunophenotypes of cell adhesion molecules. method: tumor samples (n= ) from adenocarcinoma in situ (n= ), minimally invasive adenocarcinoma (formerly bac with ≤ mm invasion, n= ), and lepidic predominant invasive adenocarcinoma (formerly mixed adenocarcinoma showing non-mucinous bac features with > mm invasion, n= ) were examined for the expression of tgfß , e-cadherin, n-cadherin, and h-cadherin proteins using immunohistochemistry. results: twenty-five tumors ( %) were positive for tgfß . the frequency of immunoreactivity in patients with adenocarcinoma in situ, minimally invasive adenocarcinoma, and lepidic predominant invasive adenocarcinoma was % ( / ), % ( / ), and % ( / ), respectively (p= . ). loss of e-cadherin expression was more frequently observed in invasive adenocarcinomas than in adenocarcinomas in situ (p= . ). tgfß expression showed a statistically significant correlation with h-cadherin expression (p= . ), but not with e-cadherin expression (p= . ). conclusion: these results suggest that tgfß and e-cadherin may play an important role in invasive progression of lung adenocarcinoma through regulating epithelial-to-mesenchymal transition. ps- - lin a expression as prognostic indicator in lung adenocarcinomas v. zolota * , v. tzelepi, g. psiouri, i. lilis, n. panagopoulos, c. sirinian, c. scopa * medical school of patras, dept. of pathology, greece objective: lin a is implicated in stem cell pluripotency by blocking let- mirnas and oct- is a transcription factor highly expressed in embryonic stem cells. the present study investigates the prognostic significance of both markers in lung adenocarcinomas. method: we evaluated, by immunohistochemistry, lin a and oct- a expression in formalin-fixed, paraffin-embedded tissues from lung adenocarcinomas. immunoreactivity was scored as +, < % positive tumor cells (ptc); +, - % ptc; +, - % ptc; and +, > % ptc and was compared with clinicopathologic features and overall survival. results: regarding lin a expression % of tumors were recorded as +, % as +, % as + and % as +. the stratification for oct- expression was % ( +), % ( +), % ( +) and % ( +). lin a and oct- expression was not significantly associated with age, gender and tumor grade or stage. lin a + expression predicted a shorter overall survival (p< . ) on univariate analysis. oct- was not associated with patients' prognosis. cox multivariate analysis showed that age, tnm and lin a + expression were independent prognostic factors of survival. conclusion: lin Α expression appears to be an independent predictor of poor outcome in lung adenocarcinomas. further studies are warranted in order to investigate its role in stratifying patients at increased risk for poor outcome. comparison of the mutation status of egfr and kras on pulmonary adenocarcinoma and corresponding brain metastasis objective: egfr and kras mutation statuses have been known associated with the sensitivity of tyrosine kinase inhibitor treatment in pulmonary adenocarcinoma. however, the mutation analyses were usually performed on the primary tumors only, due to the availability of the tumor tissue. method: to compare the kras and egfr mutation statuses between pulmonary adenocarcinomas and corresponding metastases, we performed direct sequencing, followed by scorpion arms method on wild-type cases for egfr analysis, and allele-specific real-time pcr for kras analysis, on the paired samples of pulmonary adenocarcinoma. results: thirty-one ( . %) pulmonary adenocarcinomas and ( . %) brain metastases out of the paired specimens have egfr mutations, and ( . %) paired specimens were concordant for the egfr mutation status between the primary and metastasis. in addition, ( . %) pulmonary adenocarcinomas and ( . %) brain metastases out of the paired specimens have kras mutations, and only ( . %) paired specimens were concordant between the primary and the metastasis. conclusion: the status of egfr mutation is relatively consistent between primary and metastasis comparing to that of kras mutation in pulmonary adenocarcinomas. however, discordance for the mutation statuses does happen. accordingly, repeat analysis is recommended if tissue from metastatsis or recurrence is available. objective: we tried to measure and analyze characteristics of neuroendocrine tumors in lung by image analysis and help to diagnose them. method: it was analysed that sixteen cases of typical carcinoid tumors, five cases of atypical carcinoid tumors, fifteen of small cell carcinomas, fifty one cases of large cell neuroendocrine carcinomas. we analyzed the nuclear area, perimeter, major axis and minor axis using i-solution image analyzer software package. results: the mean nuclear area was . μm in the typical carcinoid tumors, . μm in the atypical carcinoid tumors, . μm in the small cell carcinomas, and . μm in the large cell neuroendocrine carcinomas. after the statistical results, every method was effective to distinguish large cell neuroendocrine carcinoma from other tumors and the circumferences of nucleus was the most effective to distinguish among them. conclusion: pulmonary neuroendocrine tumors were the nuclear morphologic differences of each tumors. therefore, diagnosis that considers morphologic differences of pulmonary neuroendocrine tumors contributes to increase reproducibility and accuracy. sunday, september , . - . an abundant growth of lactobacilli may result in lysis of vaginal epithelial cells, named as cytolytic vaginosis. this cytolytic process may cause the symptoms as seen in candidiasis. we observed pap smears to evaluate if cytolysis has a relationship with infertility. method: in the pathology department of mardin maternity hospital, - period, we examined pap smear cases suffering from the similar syptoms as candidiasis. of the smears, were diagnosed as "cytolytic vaginosis". no growth was observed in cultures. results: the number of the cases suffering from the infertility was (% . ) among cases. in the cytolytic vaginosis group this ratio was % . (n= ). the ratio of the infertil cases of cytolytic vaginosis group over general population was significantly higher (p< . ). conclusion: our results are in favour of supporting the hypothesis of the relation between cytolytic vaginosis and infertility. lactobacilli are thought to have inhibitive role in fertility by changing the vaginal ph and adhering to the epithelial cells so inhibiting the sperm penetration. penicillium and aspergillus spp. on pap smears from the surprising origin i. i. akgun * , b. a. borsa * mardin maternity hospital, dept. of pathology, turkey objective: fungal organisms are commonly seen on smears. some unusual species as aspergillus and penicillium are so rare and generally seen via contamination. in this study, we investigated the origin of the many extraordinary fungal organisms seen on pap smears in series in only a few months. method: in pathology department of mardin maternity hospital, we observed both smear and vaginal discharge materials, came from the same hospital but different clinicians, for months. results: smears came from clinician a and smears from clinician b. curious fungal organisms with huge branching hyphas and macrochonidias were seen in smears among smears ( aspergillus and penicillium species were recognized morphologically). no growth was observed in cultures. interestingly, among all smears came from clinician b, there was no abnormal funguses. the smear samples with unusual fungal components all came from the same gynecologist. this made us strongly consider the probability of contamination. conclusion: penicillium and aspergillus spp. are extremely rare in vaginal smears. in our study, these funguses are thought to be airborne passed from the thick layer of the mold spreading on the ceiling of the office. objective: nearly all cervical cancers are related to human papillomavirus (hpv) infection. hybrid capture -hc (qiagen, hilden, germany) is the method to determine the presence of high risk hpv (hr hpv) in cytology samples with the best clinical sensitivity. method: in our study we compared the results of the hpv test in thinprep® cervical samples using first hc and secondly cervista (hologic, madison). samples were divided in two groups for the statistical analysis. the first group were hsil cases confirmed by biopsy (n = ) and the second group cytology samples reported as negative, asc-us or lsil (without biopsy or biopsy, not hsil) (n= ). results: overall, concordance between the two techniques was % ( / ). there were cases hc + cervista−, and cases hc −cervista+. the average hc viral load in discordant cases was . . in our series the hc sensitivity for ≥ cin was % ( / ) and the specificity was . % ( / ). cervista results were . % ( / ) and . % ( / ), respectively. in the hsil cases the coincidence was . % ( / ). conclusion: cervista results showed good clinical sensitivity and high concordance with hc , with a slightly lower specificity. in conclusion, according to our data the determination of hpv with cervista is comparable with hc . mammary analogue secretory carcinoma of salivary glands: cases including cytology, histology, ihc, em, rt-pcr and fish p. farrajota * , e. tani, c. carvalho, j. wejde, g. elmberger * centro hospitalar do porto, dipt. do anatomia patologica, portugal objective: mammary analogue secretory carcinoma (masc) of the salivary glands was described in by skálová et al. in a series of cases. we present new molecularly confirmed cases with focus on detailed cytomorphological features and correlation with special studies. method: a year old man and a year old female presented with history of slow growing parotid and submucosal buccal tumors, respectively. two fine needle aspiration biopsies (fnab) were performed in each case. the surgical resection specimens were routinely processed and special studies applied on paraffin tissue section. the fnab smears were retrospectively studied. results: all smears showed similar features of abundant proteinaceous background, moderate cellularity including macrophages and irregular and variable sized groups of cells with slightly enlarged round hypercromatic nuclei and abundant bluish vacuolated cytoplasm frequently containing small reddish granulations. the first fnab reports confirmed salivary origin and the second ones alert for possible neoplastic nature, advising surgical resection. electron microscopy performed in the parotid case caracterized the granules as mucigen. subsquent pathologic evaluation and molecular confirmation was carried out. conclusion: masc is a low grade malignant tumor capable of simulating a benign salivary gland process so it is important to know its cytological characteristics. adenosquamous lung carcinoma: the importance of cyto-histologic correlation d. felizardo * , a. l. cunha, r. henrique, c. lobo * instituto de oncologia porto, dept. of pathology, coimbra, portugal objective: adenosquamous lung carcinomas (asc) are uncommon and aggressive tumors. identification of a squamous component within a nsclc is critical as it excludes anti-vegf therapy. likewise, recognition of an adenocarcinoma component is also relevant because it prompts the search for egfr mutations. since % of lung cancers are diagnosed in small biopsies/cytological specimens, cytohistological correlation is crucial for correct diagnosis. thus, we aimed at determining the relevance of combining cytologic and histologic findings in initial diagnostic workup of asc. method: we searched for cases of asc diagnosed at our institution from march to april . cytologic and histopathologic findings were evaluated and their accuracy for diagnosing asc was assessed. results: of cases of lung cancer in biopsy, ( %) corresponded to probable asc and in cases cytologic examination was also performed. in cases, cytology was not conclusive, but in cases it demonstrated cytomorphological features of probable asc. we emphasize one case in which only the squamous component was valued by histology, but cytology provided clues that prompted immunohistochemical analysis which led to the diagnosis of probable asc. conclusion: cyto-histological correlation augments the diagnostic accuracy in asc of the lung, emphasizing the complementarity of both procedures. the impact of the bethesda system for reporting thyroid cytopathology (tbsrtc): a retrospective study of aspirates with emphasis on the prior "indeterminate" objective: the material of this study is consisted of selected fna biopsies performed in the last mounths period and followed by the endocrinology department. method: the bethesda system of reporting thyroid cytopathology was used. slides were stained with papanicolaou preparations. results: totally cases were examined, of which were female and were male. age of the patients varied between and . cases were diagnosed as nondiagnostic or nonsatisfactory. cases diagnosed as consistent with a benign follicular nodule. only cases were diagnosed as a consistent with lymphocytic thyroiditis in corelation with the clinical features. only case diagnosed as a granulomatous thyroiditis. diagnosis as "atypia of undetermined significance or follıcular lesion of undetermined significance "was made only in cases whereas "follıcular neoplasm or suspicious for a follıcular neoplasm" was diagnosed in case. "suspicious for malignancy" diagnosed in cases. cases were diagnosed as malignant. conclusion: although diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions are well established in the bethesda system, difficulty in categorizing the cases and underestimation or overdiagnosis are quıite frequent issues. to solve this problem, retrospective studies which include surgical and cytopathologic reports, to examine slides by at least two different pathologists in different times will be helpfull. metastatic pulmonary adenoid cystic carcinoma: report of a case diagnosed by fine-needle aspiration cytology p. karabagli * , s. ozbek * selcuklu medical faculty, dept. of pathology, konya, turkey objective: a rare case of adenoid cystic carcinoma of ceruminal gland with pulmonary metastasis presented with characteristic cytological and histological findings. method: the biopsy specimen of the patient, a year-old man with painfull, growing mass in his external auditory canal was interpreted as an adenoid cystic carcinoma. he was treated surgically and received post-operative radiotherapy. after years, a distant metastasis relapse was observed. computed tomography (ct) of the chest depicted multiple spiculated masses suggestive of metastases throughout both lung fields, the diameter of the largest measuring cm. ct guided percutaneous transthoracic fine needle aspiration biopsy was performed from the largest lesion. results: cytological examination of the aspirates revealed large spherical hyaline globules representing basement membrane material surrounded by neoplastic cells. the cells were cohesive, closely packed, and had uniform round to oval hyperchromatic nuclei with scanty cytoplasm. these features were suggestive of an adenoid cystic carcinoma. conclusion: patients with adenoid cystic carcinoma could be frequently encountered with disease recurrence confined to the lung. fine-needle aspiration cytology provided a conclusive diagnosis of adenoid cystic carcinoma. objective: often some of a fine needle aspiration (fna) sample is left behind in the hub of the needle when the specimen is ejected on the slides ( figure a) . method: we have designed a device that collects this material. it consists of a plastic adaptor that has a core of polyvinyl alcohol foam protruding from its lumen at one end ( figure b) . the other end of the adaptor then fits on to the syringe (figure c) . as the fna is being performed the sample material flows up the lumen of the needle's shaft and emerges into the hub of the needle where it is absorbed into the tip of the foam core ( figure d ). smears are made by ejected the specimen from the needle onto a slide by air pressure from an attached syringe. the air passes through the foam forcing some of the sample in the foam back down the needle but some remains behind. the device is then removed and placed in a formalin specimen pot. once fixed the core is pulled from the adaptor ( figure e ), processed and sectioned as for routine histology specimens ( objective: the presence of dcs has been studied histologically in ptc, but their presence and potential diagnostic value in thyroid fnas has not been evaluated. method: we assessed the presence of dcs in cytological samples of histologically confirmed ptcs (n= ) and benign thyroid nodules (btn) (n = ) using cd a. corresponding ptcs (n= ) and btn (n= ) from surgical excisions were stained with both cd a and langerin. results: cd a + dcs were identified in / ptcs on cytology ( %). they were either isolated in the background or more typically closely associated with tumor cell clusters. the ptc cases with the least dcs corresponded to the follicular variant on histology. in contrast, most btn ( %) lacked cd a + dcs. when dcs were present, they were primarily isolated in the background although / cases ( %) contained rare dcs among tumor cells. tumor-infiltrating dcs and background dcs were both higher in ptcs than in btn, but only the former was statistically significant (p< . and p= . respectively). similar findings were found on histology where all ptcs contained cd a + and langerin + dcs while only / btn ( %) contained rare dcs. conclusion: dcs are present in fnas of ptc, typically among tumor cell clusters, while they were absent or rare in fnas of btn. thus dcs may be useful as an additional diagnostic marker for ptc. significance of p immunostaining in postmenopausal women with atypical squamous cells a. repse fokter * , k. gornik kramberger, s. hutter Čelik, s. sramek zatler * celje general hospital, dept. of pathology and cytology, slovenia objective: the evaluation of postmenopausal pap smears can often be challenging. degeneration associated with atrophic vaginitis, hyperchromatic crowded groups, parabasal cells with organophilic cytoplasm or variations in nuclear size may be falsely interpreted as squamous atypia or even more severe lesion. method: the study included postmenopausal papanicolaou patients ( smears) with the initial cytological diagnosis of asc-us or asc-h. the smears were decolorized and immunostaining for p (ink a) was applied. in patients ( smears) tissue biopsy and histological examination was performed and four asc-us cases had cytological follow up only. results: among cases with histological examination positive p reaction was found in patients ( smears). the histological diagnoses were: cin ( ), cin - ( ), cin ( case), cin ( patients/ smears), ais ( case) and invasive squamous carcinoma ( patients). two p positive patients with three smears and initial negative histology had cin after years. among p negative patients there were two with cin and two with normal histology. four asc-us patients without histological examination had normal cytological follow up. conclusion: p is a useful marker in detecting of clinically significant cervical lesions in postmenopausal women. endoscopic-ultrasound guided fine needle aspiration cytology of intraductal papillary-mucinous neoplasms of the pancreas: report of two cases and review of the literature e. tejerina gonzález * , a. lópez garcía, c. gonzález lois, f. fernández garcía, a. herreros de tejada, e. sanz * hu puerta de hierro-majadahonda, dept. de anatomía patológica, spain objective: intraductal papillary-mucinous neoplasms (ipmn) of the pancreas are mucin-producing tumors recently recognized as a distinct entity among other mucinous pancreatic tumors. endoscopic-ultrasound guided fine needle aspiration (eus-fna) is a sensitive technique which can be very useful in the accurate diagnosis of these neoplasms. method: we present a case of a -year-old female with recurrent episodes of acute pancreatitis and a -year-old male with abdominal pain. tc showed a mm-cystic tumor at the uncinated process of the pancreatic head and cystic dilatation of the main pancreatic duct, respectively. in both cases eus-fna was performed. results: smears showed medium-to-large, cohesive groups and complex papillary clusters set in a clean, mucoid background, composed of cuboidal or columnar epithelial cells with abundant clear or mucinous citoplasms. a honeycomb arrangement was occasionally seen. although nuclei were predominantly medium-size and uniform, some groups showed some nuclear enlargement and pleomorphism with visible nucleoli. a diagnosis of "mucinous neoplasm with papillary pattern" was rendered in both cases, followed by partial pancreatectomy. the histologic examination was consistent with ipmn. conclusion: the cytologic features of intraductal mucinous papillary neoplasms of the pancreas, evaluated by eus-fna, seems to be quite characteristic of these tumors and allow to suggest a correct preoperative diagnosis. objective: the human igh locus at chromosome q is frequently involved in different translocations of non hodgkin lymphoma (nhl), and the detection of any breakage involving the igh locus should identify a b-cell nhl. the split signal igh fish-cish dna probe (ifcd) is a mixture of two fluorochrome-labeled dnas that binds the telomeric and the centromeric segments, on the igh breakpoint respectively. we tested the capability of the ifcd to detect igh translocations and diagnose b-cell nhl on cytological samples. method: fifty cytological specimens from lymphoproliferative processes were tested using the ifcd and the results compared to light chain assessment by flow cytometry (fc), igh status by pcr, and to clinical-histological data. results: ifcd analysis detected positive, negative and inadequate cases; there were true positive ( %), true negative ( %), false negative ( %) and false positive cases ( %). comparing the sensitivity of the ifcd with fc and pcr, the highest sensitivity was obtained by fc followed by ifcd and pcr. conclusion: the ifcd is effective in detecting any translocation involving the igh locus; it can be employed on different samples from different b-cell nhl whereas it is not useful to classify the specific entities. sunday, september , . - . objective: morphometric analysis of the glands and inflammatory cells proportions in colon mucosa may be crucial for distinction of subtle changes. the most important step is a recognition and proper segmentation of the separate glands, even branched, atrophic or distorted. method: new sequential algorithm has been proposed, based on mathematical morphology transformations, such as extended regional maxima, hit-or-miss, opening and closing operations. for lumen opened glands snake algorithm with closing has been applied to surrounding elements with sequential elimination of the closed contours under decreasing area criterion. proposed method has been used to evaluate cases of diversion colitis to compare specimens sampled from functional part of colon and defunctioned distal one. results: the appropriate results were obtained for specimens with different section planes with efficiency %. in comparison of the b to a was observed decreased participation of epithelium in the glands area measured in deep region (an average % instead %). in addition, the area of the gland was slightly reduced from % to % of the mucosa. conclusion: the proposed method can be useful to automatic morphometry analysis of the gland shape in colon mucosa. the recognition of the opened glands improves previously designed algorithms. objective: quantitative analysis of the immunohistochemical histological samples plays an important role in the diagnosis and prognosis of many cancers. the commercial and non-commercial software's to computerized image analysis of microscopic images based in several approaches. method: the advance segmentation scheme usually consists of preprocessing, nuclei extraction and classifier blocks. when the preprocessing step includes filtering and conversion to the most discriminative representation and the classifier can be realized by various tools, especially support vector machine as a state-of-art, nuclei extraction is the most crucial part of any algorithms. we compare single thresholding methods such as otsu, kurita, minimum error, entropy thresholding, with the sequential thresholding approaches combined with area criteria, local threshold value or extended regional maxima. all of them are accompanied by watershed method and filtration. results: for ki- stained meningioma specimens in the fields of view without overlapping nuclei the most advance methods are adequate. when increasing the cell number, only sequential thresholding with area criteria and extended regional maxima give acceptable results. the mean relative error is . ± . and . ± . % respectively. conclusion: the results confirm the efficiency of using sequential methods for segmentation of cell nuclei. for best results, use sequential thresholding with area criteria. ps- - nhs improvements: enhanced it project for histopathology f. mayall * * musgrove park hospital, dept. of cellular pathology, taunton, united kingdom objective: many histopathology laboratories are using antiquated software that hobbles their performance. we developed open source filemaker pro based histopathology reporting software with innovations based on lean principles to enhance work flow. these include: -colour coded visual workflow control -"one-click" extrawork requests with order tracking -user defined template reporting -reporting of complex cases using benchmark profomas -exportable data-sets using open database connectivity -easy local customisation and enhancement by the user. results: the software was used by staff to report more than histopathology specimens at two histopathology laboratories. many of these cases were complex cancer resection cases requiring key data capture. the histopathology staff using the software were surveyed on their experience of using the software. the key steps in lean it development: -start with a small idea -develop software with multiple plan, do, study, act (pdsa) cycles -ask users for more ideas for enhancements -recruit others into the project by allowing them to use the software and experience its benefits -standardise new reporting process by achieving agreement between users -design a project that requires minimal financial investment this open source software is available for download from www.freedp.org. sunday, september , . - . objective: myxopapillary ependymomas (mpe) often occur at the filum terminale but occasionally occur outside the central nervous system (cns). common site for these extraneural tumors is sacrococcygeal area. method: a cocygeal mpe with radiologic, gross and microscopic features will be presented. a year old female admitted neurosurgery department with painful coccygeal mass. magnetic resonance imaging revealed a coccygeal, well-demarcated, non-enhancing mass of × cm in diameter. the mass did not have any connection with the spinal cord. it was completely excised and grossly the cut surface of the encapsulated mass was soft. microscopically the tumor was comprimised of myxoid stroma with pseudopapillary structures around hyalinized vessels. the tumoral cells showed intracytoplasmic dot-like positivity with ema. there were no mitosis, and the ki labeling index was low. conclusion: extraspinal mpes are rare and the most common location is sacrococygeal area. these masses are often preoperatively misdiagnosed as pilonidal sinus. unlike the cns mpes, extraspinal mpes have a potential to metastasize even if they do not show any anaplastic morphological feature. long term follow-up is recommended as metastases can occur up to years after initial presentation. objective: cerebellar liponeurocytoma (cl) is a rare neoplasm with neuronal, astrocytic and lipomatous differentiation arising in adults. the entity is considered as a grade ii neoplasm in the last who classification of central nervous system tumours. we show two typical cases of this entity stressing the spectrum of histological changes and its differential diagnosis. method: patient is a -year-old woman with a history of headaches and instability. ct scans and mri showed a cm in diameter relatively ill-defined, poorly enhanced, round tumour mass in the left hemisphere. patient is a -yearold woman with a history of headaches and instability. mri showed a . cm in diameter well-defined triangular lesion in the right hemisphere. results: complete surgical resection was achieved in both cases. both tumours showed highly cellular neoplasms composed by round to polygonal cells with scant cytoplasm and round nuclei with fine chromatin pattern. mitoses were not seen. well differentiated lipomatous cells grouped in irregular nests were intermingled with the predominant neuronal component. conclusion: cerebellar liponeurocytomas are located in the cerebellar hemispheres and pursue a non aggressive clinical course, with local recurrences detected mainly after incomplete resections. the typical adipous tissue is the result of a lipidization process and not a true metaplasia. objective: giant cell tumor of bone is an uncommon neoplasm that accounts for about % of all bone tumors. it usually involves long bones and is very rarely encountered in the skull where it mostly involves the sphenoid and temporal bones. it is a benign neoplasm but can be locally aggressive. method: we present a case of a year old woman with history of multiple sclerosis whose routine ct scan revealed a mass with corrosive features and calcification situated at the petrous portion of her left temporal bone. a biopsy was sent to our laboratory. results: histopathologic examination revealed a neoplasm composed of sheets of oval mononuclear cells, with uniformly distributed nuclear chromatin, evenly intermixed with numerous giant cells that contain a variable number of nuclei with features similar to those of mononuclear cells. cytoplasm of either cell type was eosinophilic and cell borders were indistinct. mitoses were scarce and regular. foamy histiocytes, hemosiderin and microscopic nodules of cartilage formation were also noted. conclusion: although giant cell tumor is a benign neoplasm its' localization in this case posses a threat that should be managed surgically and by adjuvant radiotherapy if complete excision is unobtainable. leptin and leptin receptor expression in pituitary adenomas g. ayranci * , t. avsar, a. seker, t. kilic, s. bozkurt * marmara university, dept. of pathology, istanbul, turkey objective: leptin is a regulatory hormone which is mainly synthesized by adipocytes and regulates body fat mass. leptin also has regulatory function on anterior pituitary. in this study, we have investigated the expression levels of leptin (ob) and its receptor (ob-r) in various types of pituitary adenomas and normal anterior pituitaries. method: pituitary adenoma cases between and were selected. immunohistochemistry for leptin (ob) was performed for each cases of null cell, gh, acth, prolactin and fsh/lh secreting adenomas. western blot was performed for leptin receptor (ob-r) in cases consisting of all five subtypes. results: immunohistochemical staining showed greater immunoreactivity for leptin in normal pituitaries compared to adenomas. except for acth-secreting pituitary adenomas, all other four subtypes showed widespread and intense staining for leptin (p< . ). null and fsh/lh-secreting subtypes were mainly showed cytoplasmic and nuclear staining. western blot analysis showed leptin receptor expression in all types of adenomas except null cell. objective: primary malignant brain tumors often present local invasive growth. the study aimed to estimate the expression of kai protein, mmp- , cd v and their correlation in gliomas of different grade of malignancy. method: expression of mmp- , cd v and kai was evaluated on formalin fixed paraffin-embedded tissue blocks divided into: pilocytic astrocytoma (n= ), fibrillary astrocytoma (n= ), anaplastic astrocytomas (n= ), anaplastic oligodendrogliomas (n= ), glioblastoma multiforme (n= ) and normal brain tissue (n= ) using immunohistrochemistry. results: mmp- and cd v was observed frequently in gliomas with high grade of malignancy. kai immunoreactivity was mainly observed in specimens with low degree of malignancy. mmp- and cd v expression was significantly increased when the degree of malignancy of the gliomas increased (p< . ). whilst kai expression increased when the degree of gliomas malignancy decreased (p = . ). positive correlations between mmp- and cd v (p= . ) and inverse between kai and mmp- expression (p= . ) were found in gliomas. these results indicate that association between mmp- and cd v expression may increase dissemination of tumor cells. whereas, high expression of kai protein might suppress the function of mmp- in gliomas. pediatric glioblastoma: a case report a. barin * , s. ekici, c. altunkaya, s. yilmaz, g. s. yalcin, g. hatipoglu, m. caydere, h. ustun * ankara education hospital, dept. of pathology, turkey objective: glioblastoma is the most common malignant tumor of central nervous system in adults which characterized by malignant pleomorphic astrocytic cells with marked nuclear atypia, mitotic activity, necrosis and/or microvascular proliferation. glioblastoma may manifest at any age but usually affects adults especially older than years. in this case, we present a pediatric glioblastoma case because it has seen rarely under years and it is so important owing to its prognosis. method: an -year-old boy has had headache for days. according to radiological imagings × mm in diameter infiltrating mass has seen in temporal lobe contains × mm in diameter cystic component and contrast enhancement was noted. clinically grade astrocytoma has thought primarily and he has been operated. results: in microscopic examination nuclear atypia, mitotic activity and microvascular proliferation has seen without necrosis. objective: gliosarcomas are biphasic neoplasms composed of a glioblastoma admixed to a sarcomatous component with different lines of differentiation. histogenesis of these tumors is still discussed. our objective is to specify pathological characteristics of this neoplasm its related to or not to glioblastoma. method: cases of gliosarcomas diagnosed in our department of pathology. clinical, radiological, therapeutic and follow-up data were reviewed. histological features and immunohistochemical results were also established. results: female patients with a median age of years (ranging - years). intracranial hyperpressure and paralysis are main symptoms. the brain imaging showed frontal, fronto-parietal and intra ventricular expansive process, respectively. microscopically, a biphasic pattern, with anaplastic astrocytic cells alternated with malignant mesenchymal areas, demonstrating a fibrosarcoma pattern, in two cases and rhabdoïd pattern in one case. immunohistochemical stain confirmed the diagnosis of gliosarcoma in each case. patients were treated by surgical excision; one patient was lost on follow-up. one patient died by postoperative complications. conclusion: clinical, radiological and follow-up features of gliosarcomas share great similarities with glioblastomas. histopathological, histochemical and immunohistochemical studies are helpful in accurate diagnosis. cytogenetic and molecular data support a monoclonal origin for these tumors. objective: case of biphasic synovial sarcoma of nerve in a year-old female located between flexor muscles and radial diaphysis and adherent to median nerve and ulnar artery is presented. method: tissue was fixed in formalin, embedded in paraffin and stained with haematoxylin and eosin. periodic acid-schiff stain without diastase pre-digestion was obtained. ventana antibodies were employed: ttf- , er, ema, s , ck , ck and mnf . ss -ssx fusion gene transcript was detected with conventional rt-pcr and qrt-pcr. results: macroscopically nodule had smooth circumscribed borders, grey-yellowish colour and measured , × × , cm. histologically it was delimited by a dense sclero-hyaline capsule and constituted of numerous glands lined by one layer of cuboidal-columnar cells showing eosinophilic cytoplasm and round to ovoid nuclei with a single small nucleolus. they contained dense eosinophilic strongly pas and ema positive material. glands were immersed within tightly packed spindle cells. mitoses were scanty. necrosis was absent. ema strongly stained most of the glandular as well as scanty spindle cell elements. chromosomal reciprocal translocation t (x; ) with positive signal for ss -ssx transcript was seen. conclusion: synovial sarcoma of nerve is a rare condition that has to be distinguished from histologically similar lesions. rabdoid meningioma: presentation of a rare case i. dimitriadis * , a. heva, i. matzarakis, a. sekouli, p. sakellariou, l. sakkas * hospital of thessaloniki, dept. of pathology, greece objective: in , keppes and later perry suggested the term rhabdoid meningioma which was adopted into the who classification (grade iii) in . we present a rare case of a rabdoid meningioma and study the clinicopathological characteristics of the neoplasm. results: Α -year-old woman was submitted in surgical excision of an endocranial tumour (d: cm) in our hospital. the histological examination revealed entirely rabdoid morphology. the neoplastic cells expressed the following immunohistochemical phenotype: s +, vimentin+, ema+, gfap−, pr+, hmb −, a /ae +(focally), ck / +(focally), sma−, ki- (< )%. conclusion: rabdoid phenotype represents an indicator of malignant transformation regardless of the tumor's histogenesis. expression of ki- antigen correlates with recurrence even in meningiomas with minimal atypical features, which should prompt closer surveillance after excision. rabdoid meningiomas behave aggressively and have bad prognosis contrary to the classic meningioma. prognosis is influenced by it's complete excision and the expansion within the intracranial cavity. it has to be distinguished from glioma, melanoma and metastatic carcinoma. the patient after year is in generally good health, and is followed up by oncologists. atypical extraventricular neurocytoma (case report) s. ersöz * , u. yazar, a. reis, k. kuzeyli * karadeniz technical university, pathology, trabzon, turkey objective: central neurocytomas are rare intraventricular tumors with neuronal differentiation, typically located in the ventricles while tumors located outside the ventricles designated as ''extraventricular neurocytomas'' (evn). neurocytomas are classified as atypical if they exhibit a mib- labeling index > % or atypical features, like focal necrosis, vascular proliferation, and increased mitotic activity. we here report a case of atypical evn of the left frontal lobe. method: a -year-old woman patient admitted to hospital for headache. ct scan showed a large partially calcified cystic mass. mr imaging showed circumscribed, solid mural nodule within the cystic mass. the patient underwent a left frontal craniotomy. specimens were fixed in % formalin and stained with hematoxylin and eosin. for immunohistochemistry, sections were incubated with monoclonal antibodies to synaptophysin, neurofilament protein, map- , nse and gfap. the proliferative index was assessed with mib- . results: histopathological examination revealed a neuronal neoplasm composed of uniform cells in solid sheets. small necrosis areas and mitotic figures were evident. immunohistochemical examination revealed positive results for synaptophysin, neurofilament protein, map- , and nse. gfap staining was negative. mib- index was calculated as %. conclusion: in general, central and extraventricular neurocytomas have a good prognosis. atypical extraventricular neurocytomas are quite rare like this case with malignant histopathological properties. meningioma and schwannoma associated with neurofibromatosis type : a case report of rare genetic disorder o. e. gürer * , r. tuncer * akdeniz university, dept. of pathology, antalya, turkey objective: neurofibromatosis is a group of genetic disorders referred as phakomatoses. there are two main forms called nf and nf which have different incidence, molecular characteristics, and clinical exhibitio. both have higher risk for the development of certain rare malignant tumors that occur in the brain, nerves or spinal cord. method: here, we present a rare case in which multiple meningiomas and vestibular schwannomas diagnosed in the same operation. results: a year old woman presented with hearing loss clinically. she underwent surgical treatment for tumoral lesions in two different localization in the same session. one of them resected from pontoserebellar location was diagnosed as a schwannoma and the other one located on dura was diagnosed as a meningioma respectively. conclusion: nf is far less common than nf and strict diagnostic criteria have been described each of them. since difficulty to detect genetic abnormalities and no single criteria is pathognomonic, clinical characteristics much more valuable for differentiation. knowledge of associated clinical features will help to correct diagnosis and to predict much more devastating clinical course for nf . diagnostic confusion: central neurocytoma n. gursan * , e. demirci, m. calik, f. daloglu, c. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: central neurocytoma is a rare intraventricular brain tumor that affects young adults and presents with increased intracranial pressure secondary to obstructive hydrocephalus. they are usually located in the supratentorial periventricular region. because of some clinical and radiological findings cns neurocytomas were confused with other intraventricular lesions. method: a -year-old male was admitted with chronic headache with months duration on july , , when there were no neurological deficits or physical abnormalities. computed tomographic (ct) scans showed × mm a mixed density mass with amorphous calcification in the right lateral ventricle, which was irregularly enhanced by contrast medium. light microscopy showed sheets of monotonously neoplastic cells with uniform round-to-oval nuclei and inconspicuous nucleoli. the cytoplasm was clear or eosinophilic with indistinct border. capillary networks were well developed and divided the tumor cells into groups. no nuclear pleomorphism or mitosis was seen. we present a case of intraventricular neurocytomas confirmed by immunohistochemical studies. conclusion: this rare tumor causing diagnostic confusion, discussed by the literature. a case of oligodendroglioma with neuronal differentiation t. hirose * , s. nobusawa, y. nakazato, a. sasaki * tokushima pref. center hospital, dept. of diagnostic pathology, japan objective: we report a case of oligodendroglioma showing marked neuronal differentiation. method: a -year-old female visited an emergency room because of an attack of convulsion. imaging analyses disclosed a calcified, . × cm tumor in the right frontal lobe. results: the resected tumor was composed of a mixture of oligodendroglioma-like (olg) and gangliocytoma-like (gc) areas. in the former, fried-egg appearance and more cellular nodules were recognized. in the latter, there were numerous small neuron-like cells with basophilic cytoplasm. olg areas showed immunoreactivity for olig , gfap and mutant idh , while gc areas were positive for synaptophysin and neun. ki- labeling index was about % in cellular nodules of olg areas. at least one allelic loss of p/ q was detected in . / . % cells in olg areas and . / . % in gc areas with fish analyses. furthermore, an identical mutation of idh (g a, r h) was demonstrated in both olg and gc areas. conclusion: genetic abnormalities including p/ q loss and idh mutation indicate that this case is an oligodendroglioma associated with prominent ganglion cell differentiation. oligodendrogliomas with neuronal differentiation like our case may suggest a close relationship between oligodendroglial progenitor cells and neuronal cells. gemistocytic astrocytoma with granulomatous inflammation o. ipci * , e. atik dogan, t. ozgur, h. gokce, n. yilmaz, a. yilmaz * mustafa kemal university, dept. of pathology, hatay, turkey objective: the coexistence of granulomatous inflammation and astrocytoma is extremely rare. hemostatic agents are used to control intraoperative bleeding in many surgical subspecialties, including neurosurgery. there are occasional reports of granulomatous reaction to biomaterials. method: we aimed to present a year old female patient, who was operated because of the tumor at left frontoparietal region. tumor was histopathologically reported as oligoastocytoma. however, no granulomatous inflammation was detected beside the tumor. after months, patient was reoperated because of tumor recurrence, abscess and inflammatory necrotic tissue beside the tumor. histopathologically, gemistocytic astrocytoma with granulomatous inflammation and abscess formation was reported. no micro-organism had grown in any kind of cultures. at our neurosurgery department surgicel is used after craniotomy as hemostatic agent. it's raw material is cellulose and absorbed in about months. results: in the literature, germinoma accompanied by granulomatous inflammation have been reported. however, astrocytic tumors don't express such an association. the patient doesn't use any drugs forming granuloma reported in the literature. conclusion: we encountered that surgicel causing granulomatous inflammation in very few cases in the literature. the findings might be secondary to surgicel that used in the first operation. objective: astrocytic tumors show various molecular and genetic alterations in its development and progression. glioblastoma multiforme (gm) develops as either de novo or by progression from diffuse astrocytomas (da) or anaplastic astrocytomas (aa) by genetic alterations. method: loss of heterozygosity (loh) and microsatellite instability (msi) was investigated in cases of astrocytic tumors (das [n= ], aas [n= ] and gms [n= ]) with microsatellite markers and microsatellite markers harboring p and pten, respectively. the patients' age ranged from to years (mean, years). results: loh was statistically significant in aas and gms, compared to that of das (p= . ). loh for p and loh-h group for q were statistically significant in aas and gms (p= . and p= . ). msi rate in das, aas and gms was detected in . %, . %, . %, but it showed no significant correlation with prognosis factors. msi and msi-h rates were correlated with younger (〈 years) group (p= . , p= . , respectively). conclusion: alterations on pten and p may contribute to the development and progression of astrocytic tumors. especially, loh-h for q and p is considered as clinical application of discriminating the aas and gms from das. msi might be involved in the tumorigenesis of relatively young patients. objective: charcot-marie-tooth disease (cmt) iii or dejerine-sottas syndrome is a severe hereditary demyelinating motor and sensory neuropathy presenting in infancy or early childhood with delayed motor milestone and extremely slow nerve conduction velocities. method: among unrelated korean cmt patients, mutational screen for well known cmt genes reveals three patients with pmp de novo mutation showing dss. the histopathological findings of distal sural nerves are analyzed in all patients twice; cases and with years interval and case with years. results: on semi-thin transverse sections, all the remaining axons (thinly myelinated or demyelinated) are surrounded by classic or basal lamina onion bulbs (obs). the first biopsy of case ( years-old) shows obs ( , /mm ), which consists of , ( . %) mfs with obs and , ( . %) demyelinated axons with obs. the second biopsy shows obs ( , /mm ), consisting of ( . %) mfs with obs, ( . %) demyelinated axons with obs, and ( . %) obs with no discernible axons. cases and show similar histopathologic findings with main differences in numbers of obs. conclusion: although the differences noted in two biopsies are probably due to age of the patients, correlations with clinical symptoms will be helpul for management of the patients. objective: two mutations of the seipin gene (n s and s l) have been reported and known to cause neurodegenerative disorders. we performed whole exome sequencing in two charcot-marie-tooth families and identified three patients with two causative heterozygous mutations (n s and s w) and s w is a novel mutation. method: the histopathological findings of distal sural nerves are analyzed in two patients (cases and ) with s w novel mutation (fc ) and a patient (case ) with n s mutation (fc ). results: transverse semi-thin sections reveal increased numbers of myelinated fibers (mfs) ( , /mm ; , / mm ; , /mm ) with increased small mfs forming regenerative axon clusters and loss of large mfs. histogram shows unimodal distribution pattern. cases and show the similar ranges and average of diameter of mfs ( . . μm, . μm). case shows more numbers of small mfs ( . ~ . μm, . μm). ultra-structural examination reveals mfs with myelin abnormalities, pseudo-onion bulb formation including single axon or axon clusters, and thick mfs. conclusion: the findings are consistent with axonal neuropathy with features of demyelination. additional cases will be necessary to know the significance of differences between these cases. immunohistochemical subtyping of primary and secondary glioblastomas k.-s. lee * * seoul national university hospital, republic of korea objective: glioblastomas (gbls) may develop de novo (primary gbl; p-gbl) or through progression from lowgrade or anaplastic astrocytomas (secondary gbl; s-gbl). for subtyping of gbls, we tried immunohistochemical anaysis. method: we collected cases of gbls in snubh and snuh. the mean age at the time of the primary surgery was . years (range - ). immunohistochemical studies were performed for egfr, p and idh- . results: according to clinical history, gbls consisted of primary and four secondary gbls. however, egfr(+)/ p (−) immunohistochemical features of p-gbl consisted . % and egfr(−)/p (+) immunohistochemical features of s-gbl consisted . % among cases. egfr(+)/p (+) was noted in . % and egfr(−)/p (−) in . %. immunohistochemical expression of idh- was noted in cases ( . %) out of cases. expression of idh- and egfr(−)/p (+) showed positive correlations with young age. characteristic features of s-gbl were noted in . % of clinically p-gbl. conclusion: we analyzed immunohistochemical subtypes of korean glioblastomas. combination of egfr and p was unsatisfactory but combination of egfr, p and idh- can be a good tool for immunohistochemical subtyping of glioblastomas. (also known as erbb- ) is a -kd transmembrane glycoprotein with tyrosine kinase activity. her is expressed in some human malignancies and can be a potential target for therapeutic intervention with selective inhibitors. there are only a few studies on the relationship between meningioma and her expression, and the results are different as well. the aim of this study was to determine this relationship. method: seventy-two paraffin blocks of meningioma were selected randomly and immunohistochemical staining was then performed for each specimen. results: thirty-one of the meningiomas were her -positive. her expression was observed in ( %) of the grade ii/iii, and ( . %) of the grade i meningiomas. conclusion: consequently, her expression was detected in % of meningiomas. no significant difference was seen between grade i and ii/iii meningiomas, primary and recurrent tumors, and males and females from the point of view of her expression. objective: in our previous papers we studied accumulation of iron and proteoglycans in the brain. the aim of this analysis is to build on our previous results alongside other authors to investigate the reason for the presence of excessively accumulated iron observed in parkinson disease (pd). method: postmortem samples taken from the globus pallidus were prepared for light microscopy for iron and proteoglycans detection. patients had neither iron metabolism disorders nor had clinical signs of neurodegeneration. the samples were analysed using electron paramagnetic resonance (epr) to investigate the bounds between iron and proteoglycans. results: epr measurements confirm the presence of complex bounds between fe(iii) and proteoglycans. conclusion: previous data showed a possible dependance between accumulated iron, proteoglycans, ferrireductive alpha-synuclein and lewy bodies. we propose a mechanism of toxic iron accumulation in the brain in pd. this cyclic process of amplification is presented by onward steps. it is completed by our own observations into one cycle. the initiator of this vicious circle is probably an impirement of the equilibrium in the presence of useful amount of iron. understanding these relations could bring new insights to the neurodegenerative disease. role of pdgfr overexpression in schwannoma, and its diagnostic and therapeutic implications t. neuman * , y. fellig * hadassah medical center, dept. of pathology, jerusalem, israel objective: platelet-derived-growth-factor-receptors (pdgfr) are transmembrane tyrosine kinase receptors that function as relay points for signaling pathways. they play a key role in numerous processes that affect cell proliferation, tumor genesis, cancer invasion, metastasis, and modulation of apoptosis. recently, pdgfr has been demonstrated to be overexpressed in schwannoma in vivo, and in a small series of acoustic neuromas. however, its phenotypic expression in different variants of schwannoma remains largely unclear. method: immunohistochemical staining was used to detect pdgfr expression in archived formalin-fixed, paraffin-embedded schwannoma tissue samples (n= objective: pancreatic ductal carcinoma (pdc) has one of the worst prognoses. up to % of pancreatic cancers are diagnosed at the locally advanced or metastatic stage. however, brain metastases from pancreatic carcinoma are extremely rare since less than cases have been reported in the literature since . method: we report a case of a brain metastasis from pancreatic adenocarcinoma occurred in a years old women. results: -year-old woman developed severe neurological symptoms and progressively decreased consciousness. ct revealed cystic tumor in cerebral peduncle and medulla oblongata. stereotactic biopsy revealed metastasis of carcinoma. the patient died from of the twelfth day after stb because of recurrent hemorrhage. autopsy revealed well-differentiated papillary adenocarcinoma in the head of pancreas and with multiple metastases in liver and two metastases in medulla oblongata and cerebral peduncle. ihc staining for cytokeratins , and , mucin and ac types was strongly positive. ki labeling index was %. conclusion: we reported an autopsy case of brain metastases from pancreatic cancer, in which the patient initially developed symptoms of a neurologic disorder without exhibiting any symptoms of pancreatic disease. the use of bone morphogenetic proteins (bmp ) with nunostrucnure grey implant in reparation of bone tissue defect t. pavlova * , l. pavlova, a. nesterov, i. goncharov, d. kolesnicov * belgorod state university, dept. of pathology, russia objective: the matters of materials development of scull bones defect plastic are obviously necessary this time. the experience in use of nanocostructive titans, composites, bone morphogenetic proteins was accumulated. method: implant, made of nanoconstructed titan grey, covered by layer (gelatin, dextran), layers ( -gelatin, dextran, -hydroxyapatite, collagen, dextran) and by layers with use of bone morphogenetic proteins bmp- . the experiment was conducted on rat-males. in order to study the regeneration processes it were used light, fluorescence, probe and scanning microscopy with the trace element analysis. results: the most active changes were registered in the experimental group with use of composite from titan grey with layers of covering and bmp- . the covering compound increase the rate of regeneration processes due to creation calcium and phosphorus ion depot and perform support function for again-formed tissue. increase in the concentration of calcium, phosphorus, sodium, magnesium in trabeculae of bones in comparison with matrix bone at term of weeks testify about active regenerative processes; the mature smooth surface with structured relief of bone trabeculae and diploic veins were detected. conclusion: results can be used in neurosurgery, traumatology-orthopedics, dentistry, plastic and cosmetic surgery. alpha-synuclein (as) pathology of the peripheral autonomic nervous system (pans) in parkinson disease (pd) and other lewy body diseases (lbd) t. ribalta * , e. tolosa, j. navarro otano, e. gelpi * hospital clinic of barcelona, dept. of anatomic pathology, spain objective: pd and other lbd have been associated with as aggregates in the central nervous system (cns). however, autonomic dysfunctions may appear at any time in the course of the disease. our objective was to investigate the distribution of as in the pans in synucleinopathies. method: we examined pans structures obtained at post mortem from subjects ( female, age range - , mean ) at our brain bank with a diagnosis of pd ( ); lewy body dementia ( ); alzheimer's disease ( ); mixed dementia or other ( ). a complete neuropathological study of pans was performed, including dorsal spinal ganglia, vagus nerve, paraspinal sympathetic ganglia, mesentery, adrenals, digestive and genitourinary systems, heart, and skin. routine and immune stains for as and tyrosine-hydroxylase were applied. cases were semiquantitatively assessed. results: % of cases showed as pathology in the cns. of them, as aggregates were additionally present in the pans in %. a gradient in involvement was observed, being the paraspinal chain (particularly the stellate ganglion) the most constantly involved structure, followed by digestive system, adrenals, and gu system. conclusion: these findings indicate that as aggregates are extensively found in pans in synucleinopathies. the highest expression is found in the paraspinal ganglion chain and decreases in other pans regions. our results provide valuable information about potential development of new diagnostic and therapeutic strategies. objective: chordoid meningioma is an uncommon histopathological variant of meningioma. method: we report one case of chordoid meningioma occurring in adult patient. paraffin embedded tissue was stained with hematoxylin-eosin. we used immunohistochemical markers such as cea, ema, vimentin and tle . results: a -year-old woman was hospitalized with clinic of an intracranial hemorrhage. axial computed tomography (ct) of the brain revealed a . * . * . cm lesion with perilesional edema in the left temporoparietal region. foci of intratumoral hemorrhage were also seen. compression of the left lateral ventricle and midline shift to right side was seen. the patient underwent a left temporoparietal craniotomy for resection of the tumor and died days after surgery. histologically, sections revealed sheets, trabeculae and lobules of tumour cells scattered in a pale basophilic myxoid matrix. some of these cells exhibited characteristic cytoplasmic vacuolization. a typical focal meningiomatous pattern was also observed. the tumor cells were diffusely positive for epithelial membrane antigen, vimentin and a strong nuclear immunoreactivity for tle . these cells showed negative immunostaining for cea. conclusion: chordoid meningioma should be distinguished from chordoma, chondrosarcoma, metastatic mucinous carcinoma and other variants of meningioma. morphology of non-specified encephalopathy in cases of polymerase chain reaction proved presence of human herpesvirus- s. roga * , i. strumfa, s. kuleznova, s. chapenko, s. rasa, m. murovska * riga stradins university, teaching department, latvia objective: the morphology of non-specified encephalopathy is a complex medical problem. human herpesvirus- (hhv- ) infection can be discussed as a predisposing factor. the aim of the present study was to investigate the presence of beta hhv- in non-specified adult encephalopathy cases. method: the blood, meninges and brain tissue were obtained in adult (aged - years) autopsies including cases with encephalopathy and cases in the control group. tissues were submitted for routine histology including haematoxylin-eosin stain. the presence of hhv- genome (dna) was analysed by nested polymerase chain reaction (npcr), hhv- variants by restriction endonuclease analysis. results: the gross and microscopic structure did not reveal any specific changes. in the encephalopathy group, hhv- dna sequence was found in meningeal tissues ( / cases; p= . ), in brain tissues ( / cases; p = . ), and both in brain and meningeal tissues ( / cases; p= . ). in the control group, the viral dna was identified in meningeal tissues ( / cases), in brain tissues ( / cases), both in brain and meningeal tissues ( / cases). hhv- b variant was detected in all cases. conclusion: on the basis of the present study it can be concluded that hhv- is a pathogenic factor that can predispose to encephalopathy. pathological variants of brain metastases of breast carcinoma and their prognostic and predictive role in different age groups d. objective: it is extremely rare that the intramedullary spinal cord metastases (iscm) are the first manifestation of cancer. method: in database of neurosurgery biopsies from to two cases of iscm were found without preoperative signs of primary neoplasm. surgically removed tissue was stained with hematoxylin-eosin and immunohistochemically using following markers: ae / ae , ck , ck , mammaglobin, ttf- , gfap, s- and vimentin. results: one patient was male aged and another female aged . they presented with neck pain and rapidly progressive upper and lower limb weakness. imaging analysis showed contrast-enhancing mass at the level c -c in male and c -c in female, reported as an ependymoma. grossly, tumor tissue was of soft consistency and grey white color with yellowish foci of necrosis. histopathology revealed moderately differentiated adenocarcinoma with distinct border to surrounded glial tissue. in both cases, tumor cells were immunopositive for ae /ae , ck and ttf- indicating primary lung origin. postoperatively primary cancer was found in upper lobe of the left lung in both cases, without evidence of lymphadenopathy and other distant metastatic lesions in female. conclusion: diagnosis of iscm in both cases without preoperative signs of neoplasm in other organs was surprising. immunohistochemical analysis was essential for determination of cancer origin. objective: tetraspanin cd is a positive effector of cancer invasion and metastasis in many tumor types. method: we investigated the protein expression of cd in cases of who grade i to iv gliomas. additionally, we performed o -methylguanin-dna methyltransferase (mgmt) methylation analysis using real-time methylation-specific pcr in glioblastomas, and the prognostic significance of these biomarkers in glioblastomas was evaluated. results: cd was overexpressed in a significant proportion ( . %) of glioblastomas, while it was not deetected in most of grade i to iii glial tumors except for rare overexpression in anaplastic astrocytoma ( / , %) and oligoastrocytomas ( / , %). cd overexpression was closely associated with mgmt methylation (p= . ), and it was a prognostic factor for predicting worse overall survival (os; p= . ) and progressionfree survival (pfs; p= . ). combination of cd overexpression and mgmt methylation better stratified the patients' os (p= . ) and pfs (p= . ). in multivariate analysis, cd overexpression was an independent prognostic factor for predicting os over mgmt methylation (p= . ). conclusion: cd seems to have a critical role for high grade progression in astroglial tumors. cd is a good tissue marker for predicting worse prognosis in glioblastomas. results: a gross total resection of the tumor was achieved. histological examination revealed a paucicellular tumor with lobulated architecture and abundant myxoid stroma, containing stellate or spindle cells lacking mitotic activity. alcian blue and mucicarmin histochemical stains were diffusely and strongly positive. immunohistochemical analysis showed diffuse reactivity for vimentin and scattered cells positive for cd . stains for ema, gfap, s protein, cytokeratin and smoothmuscle actin were negative. conclusion: primary intracranial myxoma should be distinguished from other myxoid intracranial tumors such as myxomatous meningioma, epithelioid hemangioendothelioma or sarcoma through appropriate pathological and inmunohistochemical analysis. a metastasic cardiac myxoma should also be ruled out through cardiac evaluation including an echocardiography. the distinction between this entity and the reported neurothekeoma of the meninges needs to be reevaluated. holocord pylocitic astrocytoma associated to syringomyelia j. trillo-tinoco * , t. garibay-huarte, e. gómez-apo, m. a. rodríguez-florido, l. chávez-macias, j. e. olvera-rabiela * hospital general de mexico, dept. of surgical pathology, mexico city, mexico objective: spinal intramedullary tumors sometimes extend both superiorly and inferiorly along almost the entire cord, and those diagnosed as pilocytic astrocytoma are rare. the syringomyelia is an ependimary or periependimary cavitation of the spinal cord and is considered a suffering of degenerative and irreversible type, % of the cases is associated with intramedullars tumors. method: a three-year-old girl with history of headache, progressive weakness, months before, she was hospitalized for pneumonia, had impairment of neurologic functions and died of cardiac arrest. the autopsy was performed. results: the neuropathologic study revealed a intramedullary holocord tumor with secondary syringobulbia, cervical and lumbar syringomyelia. histopathological examination of all specimen resulted in diagnosis of a pilocytic astrocytoma. although no signs of atypia were present, an elevated proliferative activity of endothelial vessels was noted. conclusion: gross total resection of holocord and longitudinally extensive intramedullary spinal cord tumors can be achieved with preservation of long-term neurological function and also solved the syrinx. objective: epithelial cellular adhesion molecule (ep-cam) has been studied in many tissues and neoplasm, including thyroid and thyroid tumors. this is a preliminary study to assess the immunohistochemical expression of ep-cam in thyroid tumors using ber-ep . we examined the expression of ep-cam using the monoclonal antibody ber-ep in cases of thyroid tumors, including adenomas, papillary carcinomas, follicular carcinomas, medullary carcinomas, poorly differentiated carcinomas, and anaplastic carcinomas. we assessed the positivity as a predominantly membranous staining of the cells, and was scored according to the estimated percentage tumor cells in the total tissue section (negative: - %; positive: ≥ %). results: ber-ep expression was detected in normal thyroid tissue (perilessional), in all the adenomas, follicular carcinomas, and medullary carcinomas. papillary carcinomas showed in % lacking areas of expression, coinciding histopathologically one case with poorly differentiated component. all of the poorly differentiated and the anaplastic carcinomas were negative. conclusion: the expression of ep-cam, using ber-ep , was related to normal thyroid tissue and well differentiated neoplasms. our study suggest that lost of expression is associated to dedifferentiation. this results match up with the literature. in addition, clinical data and follow up are required to correlate focal areas of lost of expression of ber-ep with dedifferentiated areas of the tumor. the pathological effects of estradiol valerate on testis tissue: size and weight in male rat f. bidhendi * , r. ahmadi * imamkhomeini hospital, dept. of radiology, tehran, iran objective: studies show that estrogens can influence reproductive system differentiation. the main aim of this study was to determine pathological effects of estradiol valerate on testis histology and morphology in male rats. method: adult male albino wistar rats were divided to control and estradiol valerate ( μg/kg/day) receiving groups. estradiol valerate was applied subcutaneously. after weeks, testes were excised and studied morphologically and histologically. data were statistically analyzed and compared between groups using anova. results: our findings revealed that estradiol valerate injection resulted in reducing of testes weight and size (p< . ). semeniferous tubules were apparently deformed in estradiol valerate receiving animals and cellular density was also reduced. number of spermatocytes, spermatids and sperms was decreased in estradiol valerate receving rats compared with control animals (p< . ). conclusion: estradiol valerate has considerable pathological effects on testes morphology and histology in male rats. key words: estradiol, testes. are tumor-dimension, galectin- and cyclind useful to characterize oncocytic adenomas and carcinomas?: mutations in about % of cases. the first clinical manifestation of this tumour is often represented by lymphatic metastases. method: twelve cases of ptc and respective lymph node metastases were retrieved from our archive from to present. formalin fixed paraffin embedded tissue sections were stained with routine hematoxilin-eosin and representative tissue areas for both tumour and metastases were microdissected and dna was extracted. after pcr amplification the mutational status of braf and ras was determined by dna sequencing. results: seven cases of twelve ( %) showed a braf-v e mutation. interestingly, only in three these cases ( %) there was concordance in the mutational status between primary tumour and metastases. moreover, all metastase of wild type carcinomas were also wyld type. conclusion: even with an overall good prognosis, ptc is characterized by high incidence of lymph node metastases. as braf mutational status correlates well with prognosis and tumour progression, a correct molecular assessment is of paramount importance. our data may indicate that, because the possibility of discrepancy in the mutational status between primary tumour and metastases, molecular analysis should be performed on the primary tumour. objective: diabetes may cause chronic and non-healing diabetic foot ulcers (dfu) decreasing the welfare of patients. some neuropeptides, substance p and neurotensin (nt), may act as inflammatory modulators and improve wound healing. natural biopolymers, chitosan derivatives, are receiving great attention as powerful wound dressing materials for wound healing applications due to their favorable properties. the work aim was to use -methyl pyrrolidinone chitosan (mpc) as a platform for the delivery of nt. method: diabetes was induced by intraperitoneal injection of mg/kg streptozotocin. mice were anesthetized and two mm excision wounds were created dorsally. mpc alone, nt alone, mpc loaded with nt or pbs were placed daily on wounds. histological analysis of skin, at days , and , was done through h&e and masson´s trichrome stainnings. results: in diabetic mice, the healing process was slower, showing an engulfment of acute inflammatory cells that triggered macrophage activity when compared with controls. at day , mpc treatment leaded to a faster healing with retraction of the wound site, nt induced a slower noncontracting healing and combined application delayed inflammatory repair with persistent neutrophils. conclusion: at day , all treatments induced a total healing however, mpc + nt reduced neutrophils infiltration compared with mpc alone. acth producing nasal paraganglioma: case report j. cassis * , a. galzerano, m. chorão * hospital egas moniz, dept. of anatomy pathology, lisboa, portugal objective: female patient with chronic sinusitis and hypertension presents with lipothymia, dizziness, polyuria and polydipsia. laboratory studies showed hyperglicemia, leucocytosis, hypokalemia, hypercortisoluria and elevated serum acth levels. head mri revealed tumor in the right nasal cavity with implantation at the cribiform plate of the ethmoid bone. method: microscopically the tumor had lobular architecture with big, round cells and with eosinophilic granular cytoplasm. these cells were nse+, synaptophysin+, cd +, cd + and acth+. surrounding the tumor lobules were several spindle cells s- + (sustentacular cells). results: the lobular growth pattern, the presence of sustentacular cells (s- positive) , and the acth producing granules favours an acth producing nasal paraganglioma diagnosis. conclusion: head and neck paragangliomas account for , % of the tumors in this region, and are mainly located in the carotid bodies. paragangliomas arising in the nasal cavity are rare, only cases reported so far. they affect the middle or upper turbinates, and also the etmoid, maxillary and sphenoidal sinuses. we report the third case in literature of a acth producing paraganglioma in the nasal cavity. sporadic aggressive silent somatotroph pituitary adenoma in the young: report of two cases l. chinezu * , a. vasiljevic, s. achard peyregne, g. raverot, e. jouanneau, j. trouillas * emergency county hospital, pathology, tg. mures, romania objective: silent pituitary adenomas are infrequent tumors in adults and exceptional in young. we describe two cases of -year-old girls with pituitary adenoma without genetic history, revealed by visual field defects, with panhypopituitarism in one patient. in both cases, mri showed giant pituitary adenoma, with invasion of the cavernous and sphenoidal sinuses. hormone assays revealed normal gh, prl and igf plasma values. surgery was incomplete in both cases. results: both tumors presented a diffuse pattern. the cells exhibited large nuclei with prominent nucleoli. by immunocytochemistry, focal and low percentages of gh-and prl-immunoreactive cells were observed respectively in both tumors (gh= - % and prl= - %). cga was positive. cytokeratin and others antibodies against pituitary hormones were negative. both tumors had high proliferative indexes: ki- > % ( - %) and elevated mitotic number ( - mitoses). detection of p was also positive ( . - . %). the cases were diagnosed as atypical adenomas, according to the who classification. conclusion: the pathological diagnosis of these aggressive gh-prl tumors has to be taken into account by the clinician to choose the optimal therapeutic strategies. despite of the important side effects of the radiotherapy, this aggressive treatment might be proposed earlier, even for the young patients, to avoid the tumoral progression. intrauterine growth retardation with high fat diet in rats markedly disturbs islet morphology characterized by peri-islet inflammation, fibrosis and haemosiderosis j. dahlstrom * , v. delghingaro-augusto, l. madad, a. chandra, e. bean, c. simeonovic, c. j. nolan * act pathology & anums, dept. of anatomical pathology, garran, australia objective: pre-and post-natal factors such as intrauterine growth retardation (iugr) and high fat (hf) diet contribute to type diabetes (t d). our aim was to determine if iugr and hf diets interact in t d pathogenesis. method: a surgical model of iugr (bilateral uterine artery ligation) in sprague-dawley rats with sham (sh) controls was used pups were fed either hf or chow (ch) diets from weaning. serial measures of body weight and glucose tolerance were made. at weeks, rat pancreases were harvested for histological assessment. results: iugr vs sh pups weights were % lower. hf diet caused excess weight gain, dyslipidaemia, hyperinsulinaemia and mild glucose intolerance not further aggravated by iugr. markedly abnormal islet morphology was evident in / sh-ch, / sh-hf, / iugr-ch and / iugr-hf rats (chi-sq, p= . ). abnormal islets were characterised by larger size, irregular shape, peri-islet inflammation with cd positive cells and marked haemosiderosis. overall beta-cell mass was not altered by iugr, with a trend for it to be mildly increased in both hf-fed groups. conclusion: hf and iugr independently and together contribute to islet injury. the marked islet haemosiderosis associated with iugr and hf diets warrants further investigation as iron is toxic to β-cells. objective: adreno-hepatic fusion (ahf) is defined as adhesion of the liver and right adrenal gland with or without a fibrous capsule dividing both organs. we report a surgical case of ahf in which a virilising malignant adrenocortical tumour protruded into the liver mimicking a hepatic mass. method: a -years-old woman presented with mid-right abdominal pain and marked hirsutism. computed tomography (ct) revealed an apparently intrahepatic solid tumour suggestive of a giant hepatic adenoma. the right adrenal gland was not visible on ct and the right kidney showed marked downwards displacement. a radical right adrenohepatectomy was performed, with a satisfactory outcome. results: grossly, a giant, partially encapsulated mass was seen to protrude from the right adrenal gland into the liver. microscopically, the tumour was constituted by atypical clear cells with nuclear polymorphism, necrosis and moderate mitotic activity. tumour cells expressed vimentin and melan-a protein. conclusion: to our knowledge, this is the first description of a malignant adrenal tumour in the setting of ahf. as illustrated by this case, awareness of ahf as an entity and attention to its distinctive gross and histologic features are essential to avoid confusion between adrenal and hepatic lesions, especially when imaging studies have provided misleading findings. objective: cushing's syndrome (cs) is a rare disease, resulting in the majority of cases from acth hypersecretion. % is of pituitary origin, % of adrenal origin, and only % from ectopic acth production. method: we reported a rare cause of ectopic acth dependent cs, caused by a pheochromocytoma. results: a -year-old male was hospitalized for severe high blood pressure, depression and weight loss. biological investigation revealed serious hypokaliema, severe acth dependent hypercortisolism with elevated urinary free cortisol secretion, loss of diurnal variation, and excess plasma acth level. ct-scan revealed a nodular lesion in the right adrenal gland with hyperplasia in the left one. the nodular lesion was assumed to be a pheochromocytoma based on the elevated serum and urinary catecholamine and metabolites and local uptake in right adrenal gland in i-mibg scan. right adrenalectomy was performed. macroscopic examination revealed a cm, well-circumscribed, tan-brown tumor, associated with diffuse adrenocortical hyperplasia. histological examination confirmed the diagnosis of pheochromocytoma, without signs of aggressiveness. the tumor cells were immunopositive for chromogranin a, synaptophysin and acth. after surgery, catecholamine secretion returned quickly to normal level. biological and clinical cs regression was noted. conclusion: despite the rare association of cs with pheochromocytoma, preoperative diagnosis is required to an appropriate therapy. a rare case: extralobar pulmonary sequestration mimicking neuroblastoma g. emiroglu * , n. Özsan, s. tiryaki, a. Çelik, y. ertan * ege university, dept. of pathology, izmir, turkey objective: extralobar intraabdominal pulmonary sequestrations are rare congenital malformations which are characterized by disorganized and nonfunctioning pulmonary parenchyma. these lesions have no communication with the bronchial tree and pulmonary arteries. they receive their blood supply from the systemic circulation. method: we describe a days old male infant admitted to the hospital with a left subdiaphragmatic, × × mm, hiperechogenic and, solid mass that was identified during ultrasonography on the th week of gestation. results: abdominal computerized tomography demonstrated a × × mm, solid, vascularized, encapsulated, mostly cystic suprarenal mass with no calcification reported to be highly suspicious for neuroblastoma. the mass was completely excised. gross pathologic examination revealed a well circumscribed spongy lesion that mimicked a lung tissue. on microscopic examination, a disorganized lung tissue that was composed of alveoli, alveolar ductus and bronchioles was seen. normal adrenal tissue was not observed. later, we learnt that the lesion's arterial blood supply was from the abdominal aort. based on these findings, our diagnosis was intraabdominal extralobar pulmonary sequestration. conclusion: intraabdominal extralobar pulmonary sequestrations should be kept in mind in cases of the adrenal masses as the surgical resection is the adequate treatment method for these lesions. axillary lymph node metastasis of papillary thyroid carcinoma showing anaplastic transformation with cutaneous metastasis s. erkilic * , a. ozkur, u. elboga, f. celenk, m. kanlikama * gaziantep university, medical faculty, turkey objective: papillary thyroid carcinoma (ptc) rarely metastasizes to axillary lymph nodes. although anaplastic transformation (at) may occur in the cervical lymph node metastasis from ptc, it is rarely observed in the metastatic axillary lymph nodes. furthermore, cutaneous metastasis from anaplastic thyroid carcinoma (atc) is extremely rare. method: a -year-old male patient who had operated for multinodular goiter years ago presented with neck swelling on the right side. residual thyroid tissue was detected and the lesion was removed surgically in combination with a right neck dissection. histopathologic examination was consistent with ptc and metastatic lymph nodes. the patient received radioactive iodine therapy. afterwards, the patient presented with a right axillary mass years after the first operation and underwent surgical excision. results: histopathologic examination showed ptc with anaplastic transformation. histopathologically confirmed multiple skin metastases from atc emerged in thoracic and abdominal regions months after the last operation. patient died months after the diagnosis of anaplastic carcinoma. conclusion: although most ptcs show an indolent course and have a favorable prognosis, distant metastasis and anaplastic transformation of the metastatic lymph nodes may occur even more than many years after the primary treatment. local "bystander"effect of gene therapy on human tumor cells of medullary thyroid carcinoma in vivo l. feketeova * , m. poturnajová, l. kucerová, p. babál * comenius university, inst. of pathology, bratislava, slovakia objective: gene therapy acts on change of prodrug into cytotoxic drug inside tumor cells transfected by foreign enzyme. it uses also "bystander" effect on surrounding tumor cells without enzyme. we used yeast cytosine deaminase (ycd) in combination with -fluorocytosine ( fc) converted into -fluorouracil ( fu) and its metabolites. medullary thyroid carcinoma (mtc) is a malignant tumor often with therapy resistant distant metastases. patients with sporadic form have metastases at the time of diagnosis, mostly in bones, lungs and liver. the aim of this study was to evaluate the efficiency of ycd/ fc in mtc treatment using xenotransplants derived from model tt cell line in nude mice. method: tumors were immunohistochemically stained with polyclonal antibody anti-egfp (enhanced green fluorescence protein) and monoclonal antibodies anti-pcna and anti-ki . positivity was semiquantitatively evaluated. results: diffuse positivity for pcna was seen in untreated and treated tumors, respectively. positivity for ki- was diffuse in untreated and only sporadic in treated tumors. conclusion: diffuse pcna positivity in treated tumors suggests that the tumor cells stopped in s phase. scattered positivity of ki- after treatment document suppressed proliferation mediated by ycd/ fc gene therapy, which implies therapeutic application in patients with metastatic mtc. (itms , vega / / , vega / / ). ps- - e-cadherin/ß-catenin immunoexpression in thyroid carcinomas k. ivanova * , e. onal, j. ananiev, t. vlaikova, m. gulubova * trakia university, general and clinical pathology, stara zagora, bulgaria objective: the aberrant activation of wnt signaling pathway may be a common denominator for the development of thyroid tumorigenesis. it was announced that the loss of ecadherin rather than β-catenin mutation represents a crucial event in determining the degree of differentiation of thyroid carcinomas. the aim of the study was to evaluate the expression of e-cadherin and β-catenin in the thyroid cancer tissue and to correlate these data with some histological and clinical parameters of the tumors. method: we investigated patients, having thyroid tumorspapillary, follicular, anaplastic and oncocytic carcinomas immunohistochemically with antibodies against e-cadherin and β-catenin. survival analyses were done. results: e-cadherin expression was focally retained in the tumor cell membranes and in the tumor cell cytoplasm of the papillary, follicular and oncocytic thyroid cancers, weather in anaplastic cancers it was almost lost (p= . , and p= . , respectively, fisher's exact test). the expression of β-catenin in tumor cytoplasm and membrane in papilary cancers was higher as compared to that in the other tumors (p= . , and p= . , respectively). conclusion: not surprisingly, the presence of aberrant expression of e-cadherin and/or β-catenin in thyroid cancer has been associated with better patients' prognosis and more well differentiated tumor histology. correlation between estrogen receptor and progesterone receptor with some prognostic factors in papillary thyroid carcinoma m. jalali nadoushan * , r. amirtouri, a. davati * shahed university, dept. of pathology, tehran, iran objective: the more prevalence of papillary thyroid cancer in women shows the probability of the role of sex hormones in the cancer. the aim of this study was determination of relation between sex hormones receptors and some prognostic factors. method: we studied patients with pathology report of papillary thyroid carcinoma after thyroidectomy between and . the specimens were stained immunohistochemically for er and pr. the other informations such as sex, age, tumor size and lymph nodes involvement obtained from the patients documents. results: the average age of patients was . + , . . % t of samples were er positive while this was . % for pr. the percentage of lymph nodes involvement was . %. the size of tumors was . + . cm. there was a direct relationship between female sex and positivity of er (p≤ . ). but there was no significant relationship between er and pr with age, tumor size and lymph nodes involvement. conclusion: it seems to be that er is more prevalent in females but for showing of its role in prognosis, further studies are recommended. objective: type diabetes mellitus (t dm) treatment aims to control metabolic effects, preserve pancreatic function and reduce complications, such as nephropathy. this study intends to evaluate the effects of sitagliptin, a dipeptidyl-peptidase- inhibitor, in pancreatic and renal lesions in zucker diabetic fatty (zdf (fa/fa)) rats, an animal model of t dm. method: male obese diabetic zdf (fa/fa) rats, -weeksold, were treated with vehicle or sitagliptin ( mg/kgbw/ day) for weeks, and compared with lean control zdf rats (n= each). biochemical parameters as well as pancreatic and renal lipid peroxidation and histopathology profile were assessed. specimens we stained with haematoxylin-eosin and periodic acid of schiff, and examined by light microscopy. lesions were evaluated by a semiquantitative rating. endocrine/exocrine pancreas and renal glomerular, tubulointerstitial and vascular lesions were assessed and scored ( / - ). results are mean ± sem; anova and duncan's post-hoc analysis (p≤ . was considered as significant). results: sitagliptin improved metabolic parameters, reduced lipid peroxidation (p< . ) in both organs and significantly prevented major diabetic pancreatic and renal lesions in obese diabetic zdf rats. conclusion: sitagliptin seems to comply with the three main objectives of t dm therapeutic management. underlying molecular mechanisms deserve further elucidation, but could be related with metabolic improvement and reduction of oxidative stress. objective: thyroid tumors of uncertain malignant potential (tt-ump) include follicular and well-differentiated tumors of ump (ft-ump/wdt-ump), as it refers to the presence of questionable capsular/vascular invasion or incompletely developed papillary thyroid carcinoma (ptc)-type nuclear changes. however, a diagnosis of tt-ump is difficult in most cases. we aimed to investigate whether immunohistochemistry (hbme- , cytokeratin- , galectin- , cd and p ) provides additional information concerning such lesions. method: we performed an immunohistochemical analysis on wdts-ump and fts-ump. results: in the wdt-ump group, hbme- was positive in / ( . %) cases. cd , a marker whose expression is reduced in thyroid carcinoma, showed a "malignant" profile (no expression) in / ( . %) cases. / ( . %) cases were positive for both antibodies. one case showed the coexpression of hbme- , cd , galectin- and cytokeratin- . only one ft-ump case was positive for hbme- . the follow-up data revealed no distant metastases or persistent disease. conclusion: tt-ump demonstrated very heterogeneous immunohistochemical profiles. wdts-ump revealed a certain tendency toward a ptc profile, suggesting a possible pathogenetic link between these two entities. however, immunohistochemistry is to be regarded more as a supporting factor, while morphological criteria should always prime in the diagnostic decision. results: there was a positive correlation between tpcfv and hmwck, ck , hbme , galectin , fibronectin (p< . ), but there was no correlation with tpcfv and ret/ ptc (p> . ). hbme- and ck stained strong and diffuse positive in tpcfvs but weak and focal in fas. our study suggests that morphologic features combined with immunohistochemical panel of hmwck, ck , hbme- , galectin- and fibronectin can help to distinguish benign and malign thyroid neoplasms and tpcfv from follicular adenomas. ret/ptc expression has been nonspecific but its detection can be a useful tool combined with immunohistochemistry for diagnosing tpcfv. morphological features of the system mother-placentafetus during pregnancy on diabetes mellitus t. pavlova * , v. petrukhin, e. malutina, a. nesterov, l. pavlova, i. goncharov, d. kolesnicov * belgorod state university, dept. of pathology, russia objective: combination of diabetes mellitus and pregnancy has a special concern. method: it were studied pregnants with diabetes mellitus type and pregnant with gestational diabetes mellitus (gdm). the methods were used: light, transmission, electron, probe and scanning microscopy with microelement analysis. results: the pregnancy at diabetes mellitus type and gdm proceeds with complications: treat of pregnancy termination ( , % and , %), hydramnion ( , and , %), preterm birth ( , and , %). it was displayed decreasing of oxygen in mother's erythrocytes. at the diabetes mellitus in uterus of women in birth there are violations of spiral arteries as well as circulatory disorders (stasis, sludge, thrombosis and diapedetic bleedings), that is significantly expressed at gestosis. tendency to cell form changing is observed in erythrocytes at diabetes mellitus, especially at diabetes mellitus type . the frequency of placental insufficiency in pregnant with diabetes mellitus type were %, at gdm- %. the gestosis accession were resulted to birth's increasing of children with prenatal injury of central nervous system at diabetes mellitus type in mother and diabetic fetopathy at gdm. the clinical and morphological parallels of the system mother-placenta-fetus were presiced ad diabetes mellitus type and gdm. sclerosing mucoepidermoid carcinoma of the thyroid in a year-old female a. polónia * , l. santos, c. eloy, r. celestino, p. soares, m. jácome, c. lobo * ipo-porto, pathology, rio tinto, portugal objective: sclerosing mucoepidermoid carcinomas (smecs) are low-grade malignant tumours with both squamous and mucinous differentiation representing less than % of thyroid malignancies. smecs are usually associated to hashimoto thyroiditis and classically disclose eosinophilia. results: a year-old female with hashimoto thyroiditis presented a . cm nodule in the left lobe of the thyroid. the total thyroidectomy specimen disclosed a firm, well circumscribed, non-encapsulated tumour. microscopically, the tumour was composed by anastomosing clusters of squamoid cells in a sclerotic background without eosinophils. intra-cytoplasmatic pas/diastase positive material was focally found. the tumour cells expressed ae .ae , ttf- and p whereas no expression was observed for thyroglobulin, calcitonin and cd . the ki- labeling index was %. in the molecular analysis no mutations were detected in braf or (k-, n-, h-) ras genes nor ret/ptc or pax /ppargamma rearrangements. the remaining thyroid showed hashimoto-type thyroiditis. a cervical lymph node metastasis was identified. the patient was treated with radioactive iodine and is alive without signs of disease after months of follow-up. conclusion: smecs may not disclose the classical eosinophilia and represent rare low-grade tumours that can give rise to metastases. the most frequent molecular alterations found in thyroid tumours were not detected in this case. ps- - alk and bmp- overexpression as a cause of ossifying papillary thyroid carcinoma objective: ossification is an often encountered finding in papillary thyroid carcinoma (ptc). we hypothesized that osteogenic signaling may be related to osteogenesis of ptc. bone morphogenic protein (bmp)- is the most osteogenic subtypes among bmps. and as a cellular receptor, activin receptor-like receptor (alk) has been emphasized in bmp- induced osteogenic signaling. we investigated the expression of alk and bmp- and their correlation with ossification in ptc. method: alk and bmp- expression were investigated by immunohistochemistry in tumors and adjacent normal follicles of ptcs with bone formation and ptcs without bone formation. alk and bmp- expression were further verified by quantitative real time polymerase chain reaction in each group of cases of ptcs with or without bone formation. results: alk and bmp- immunoreactivity were increased in ptc with bone formation when compared to those without bone formation (p< . and p= . ). both mean values of alk and bmp- mrna expression were elevated in ptcs with bone formation compared with those without bone formation (p= . and p< . ). conclusion: alk and bmp- overexpression may be underlying the molecular alteration that accounts for osteogenesis in ptc. objective: thyroid is an extremely rare site of metastases. renal clear cell carcinoma (rccc) is one of the most frequent primary malignancies causing thyroid metastases as a single nodule ( %) or multiple nodules ( %). we report the case of a -years-old female patient affected by multinodular goiter, who was diagnosed with rccc, treated with nephrectomy. method: due to compressive symptoms, years after nephrectomy, the patient underwent thyroidectomy and the thyroid was sent for histology. results: histology showed multinodular goiter. in the largest hyperplastic adenomatous nodule (left lobe, diameter mm ), multiple solide yellow-orange areas were detected grossly. these areas were microscopically composed of sheets of large cells with clear cytoplasm and small hyperchromic nuclei, with a focally infiltrative growth pattern. at immunohistochemistry clear cells were negative for ttf , hbme , galectin- and positive for cd . conclusion: this is a rare case of multiple rccc metastases within an adenomatous nodule in goiter. clinical diagnosis of rccc metastases to thyroid is extremely difficult, even more if metastases grow in multinodular goiter. it should be always suspected in patients with a clinical history of rccc. objective: follicular carcinoma, oncocytic variant, is a rare type of thyroid carcinoma. we examined a case of oncocytic carcinoma misdiagnosed as medullary carcinoma on fineneedle aspiration (fna) because it was associated with amyloid material. method: a -year-old female rheumatoid arthritis (ra) patient had a . cm mass in the right lobe of her thyroid, which showed no enhancement effect on ct scan and was diagnosed as a "cyst". fna was performed, and she subsequently died of unrelated causes. an autopsy was performed. results: cytology: large and small round-shaped tumor cells were present with round nuclei with granular chromatin. double-or triple-nucleated cells and amyloid material were observed. histology: oncocytic round cells proliferated diffusely in the fibrous capsule. extra-capsular invasion and vascular infiltration by the tumor cells were recognized. electron microscopy: the cytoplasm of tumor cells was full of mitochondria. therefore, we diagnosed this as follicular carcinoma, oncocytic variant. amyloid deposition was also observed in several other organs. conclusion: amyloid deposition was caused by amyloidosis secondary to ra. narrowing of the tumor feeder artery due to amyloidosis may have prevented early enhancement on the ct image. objective: whipple's disease is an infectious disease caused by tropheryma whipplei, an ubiquitous gram-positive actinobacteria. the incidence of the disease is less than per milion. we report five new consecutive cases, four males and one female, diagnosed in our clinic from august to january . method: diagnosis was reached with the help of gastroduodenal endoscopy and histopathological examination of the duodenal biopsies, by lymph node biopsy and by electron microscopy. results: the main symptoms were arthralgia, weight loss and diarrhea. the endoscopic aspect of the small bowel mucosa varied from congestion, granularity of the mucosa to whitish plaques. all patients showed pas positive, diastase resistant, ziehl-neelsen negative macrophages in the lamina propria of the duodenal mucosa and, in one patient, suspected for lymphoma, in an abdominal lymph node. the diagnosis was confirmed by electron microscopy in all cases. classic whipple's disease was the diagnosis in all five cases, but one patient showed involvement of the endocardium and two patients showed lymphadenopathies. conclusion: clinical evolution was favorable under long-term antibiotics (cephtriaxone/trimethoprim-sulfamethoxazole) and follow-up biopsies in three patients showed a normal endoscopical mucosa and a reduced but persistent number of pas positive macrophages in the duodenal mucosa. results: eleven cases of nen of gastrointestinal tract were identified. they were men and women with a mean age of . years. the most common localization was the appendix ( cases). the other cases were localized in the small intestine, the ileo caecal valve, the fundus and the bulb. the mean tumor's size was . mm. mitoses were absent in the majority of cases ( , %). all the tumors were well differentiated classified as grade in cases and grade in cases. the tumor was aggressive in cases. the small intestine's net was multifocal infiltrating the subserosa with lymph node metastasis classified pt n . the ileo caecal valve's net was also aggressive with lymph node and hepatic metastasis classified pt n m . all patients underwent surgical treatment. conclusion: gastrointestinal nens are complex tumors whose incidence is rising and whose treatment requires precise classification and risk stratification. multiple duodenal stromal tumors associated with neurofibromatosis- g. benkhedda * , y. lamouti * chu frantz fanon, dept. of pathology, blida, algeria objective: gastrointestinal stromal tumors (gist), most commonly occur sporadically, but there seens to be some increased tendency for these tumors to develop in patients with neurofi-bromatosis (nf ). there is no histological difference between the nf assocaciated cases and the sporadic cases. however, tumors associated with nf frequently show multiplicity. method: a case of multiple duodenal gastrointestinal tumor arising in a year old mal with nf is reported. the abdominal exploration revealed multiple solid nodules in the duodenum, and the pancretecticoduodenectomy was performed. results: macroscopy: the resected segment of the duodenal showed seven suberosal solid masses. the largest mass measured , cm× cm× cm, and is coupled with the bors lower pancreas but remains limited by a capsule. the cut surface was smooth and white in appearance. microscopy: the tumors were composed of interlacing fascicles of the uniform spindle cells with elongated cytoplasm. the tumor cells lacked pleomorphism, and mitotic figures were absent. immunohistochechemistry: the tumors cells were diffusely positive for cd , cd , and negative for desmin, aml and ps . conclusion: gist are rarely noted in association with neurofibromatosis- . duodenal gist are most frequently diagnosed in the workup of symptoms not specific to these masses. duodenal resection is rarely indicated except in the case of duodenal gist and early-stage adenocarcinoma or if the tumor appeared involve the pancreatic parenchyma on preoperative imagings. periampullary adenomyoma: a true trap diagnosis g. benkhedda * , y. lamouti * chu frantz fanon, dept. of pathology, blida, algeria objective: adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. it is usually presented as biliary obstruction. most cases are misdiagnosed as adenoma or carcinoma by preoperative endoscopic or radiologic. therefore, it is frequently treated with extensive surgery. method: we report a case of a year-old man with an adenomyoma located in the ampulla of vater diagnosed by endoscopic piecemeal resection. results: on histologic examination, the lesion consisted of hyperplastic glandular lobules, mainly located in the muscle layers of the vaterian system. the lobular formations consist of small glands surrounded by myofifroblastic, fibroblastic proliferation, sparse capillaries and inflammatory cells. ihc: ki : rare cells with a positive nuclear staining were presenting in the epithelial and mesenchymal components aml: the myofibroblastic of most spindle cells was confirmed by a strong cytoplasmic expression. conclusion: real incidence of adenomyoma of the vaterian system is difficult to appreciate as different names (adenomyoma, adenomyomatosis, myoepithelial hamartome) are used to designate the same histological lesion. adenomyoma was diagnosed only in adult patients -mean age: y). the histogenesis is still a subject of controversy. the most widely accepted hypothesis is that the lesion may represent a form of incomplete heterotopic pancreas. adenomyoma is considered as benign and slow growing, but its potential neoplastic nature cannot be excluded. however, the histogenesis of these tumors is subject to further study. carcinosarcoma of the digestive organs has been reported to exhibit aggressive behavior. carcinosarcomas in digestive organs have been reportedly associated with a poor prognosis. , however, some cases that have been treated with a curative operation showed long-term survival. analysis of her expression level in gastric carcinomas m. bialas * , a. sinczak-kuta, a. lazar, k. urbanczyk, k. galazka, j. szpor, s. demczuk, d. adamek * jagiellonian university, dept. of pathomorphology, krakow, poland objective: the expression of her an oncoprotein belonging to tyrosine kinase family belongs to recently evaluated prognostic and predictive factors in gastric cancer. overexpression of her is observed in about - % gastric cancers. according to many authors, overexpression and/or amplification of her correlates with poor prognosis. the aim of our study was to analyze her expression in gastric cancer in material routinely examined in pathomorphology department, jumc. method: we have analyzed cases of gastric cancers. the material came from females and males, age: - . immunohistochemical reactions were performed automatically on benchmark bmk classic (ventana) using path-way her- /neu ( b ) antibody. scoring system for her expression was ranged from to + where: and + were regarded as a negative, + as equivocal and + as positive. results: most cases of gastric cancers were her -negative ( / ): including score ( patients) and + ( patients). three cases were equivocal and two cases showed + expression level. the lower level of her expression in the analyzed material in comparison with literature could be related to a relatively small group of cases but one cannot exclude that there exist some other factors that stand behind this and surely the investigations should be continued. ps- - mapkap kinase overexpression influences prognosis in gastrointestinal stroma tumors, associates with copy number variations on chromosome , and expression of p map kinase and etv p. birner * * medizinische universität wien, institut für klinische pathologie, austria objective: etv has been proposed to be activated by kitmutations in gastrointestinal stromal tumors (gists). aim of the study was to evaluate the role of etv and associated proteins in gist. method: expressions of etv , mapkap kinase (map-kapk ), phosphorylated p map kinase (pp ), phosphorylated msk , phosphorylated rsk , cop and kit were determined immunohistochemically in gists. sequence analysis of kit, pdgfra and mapkapk and fish of etv and chromosome was performed. results: prominent etv expression was seen in % of gists, but no correlation with clinical outcome was found. correlation of etv expression and kit mutation was seen in % of cases. mapkapk overexpression (n = / . %) correlated with pp expression (p= . ) and alterations of chromosome (p= . ). in one cases with high makapk expression, a mapkapk gene mutation was found. all relapsing gists with very low/low risk showed high mapkapk and kit expression. map-kapk overexpression was an independent prognostic factor for disease free survival (p= . ). conclusion: etv is not universally overexpressed in gist and seems to be induced also by other pathways than kit-mutation. mapkapk -overexpression is associated with shorter survival in gist. patients with low risk gists overexpressing mapkapk might profit from adjuvant tyrosine kinase inhibitor therapy. gastrointestinal stromal tumors: comparison of two risk stratification systems in a multicenter study of turkish cases g. bulbul dogusoy * * gayrettepe florence nightingale, dept. of pathology, istanbul, turkey objective: a nationwide database was performed for gastrointestinal stromal tumors (gists) in a large series of primary gists surgically treated at centers all around turkey. the aim of this multicenter study was to analyze and compare the performance of the national institute of health (nih) and armed forces institute of pathology (afip) risk criteria to determine the ideal risk stratification system. method: statistical analysis of a nationwide database is consisted of age, gender, location, risk groups, histopathologic features and the results of cd , cd , desmin, sm actin, s- protein, and ki immunohistochemistry. results: in cases registered in database, male to female ratio was . and mean age was . years. most common location was stomach ( . %) followed by small intestine, omentum-peritoneum, large intestine, and esophagus ( . %, . %, . %, . % respectively). comparison of the two risk-stratification systems demonstrated that proposed modified afip seems to be better when compared with nih system. many histopathologic and immunohistochemical findings showed significant correlation with risk groups of afip, even with 'not sufficient data' group (p< . ). the results of this multicenter study demonstrates that although follow up results are not provided, afip risk criteria seems to be more useful in prognostication for gists among the two systems. objective: her /neu overexpression or amplification is an important biomarker for identifying patients with intestinal-type gastric cancer who respond to therapy with trastuzumab. moreover, intestinal type gastric cancer shares many phenotypic and molecular genetic changes with colorectal cancer. in particular a progression from chronic gastritis to intestinal metaplasia, dysplasia, and finally malignant transformation is probably the sequence of gastric carcinogenesis. somatic mutation of k-ras gene is common in colorectal cancer, being found in more than one-third of cases, but it seems to have, mostly in intestinal-type gastric cancer, a low incidence ( - %). the purpose of this study is to assess her gene amplification and k-ras mutational status in a series of intestinal-type gastric carcinoma patients. method: twenty paraffin embedded gastric cancer specimens were tested for her amplification by chromogenic in situ hybridization (cish) and k-ras mutational status (codon e ) by pcr-rflp. results: six ( %) cases were her amplified. only one case ( %) was found to have k-ras mutation (codon ), but it was her not amplified. conclusion: the frequency of k-ras mutation and her amplification are in agreement with other studies on this topic. in our study, the two seem mutually exclusive events. objective: gastric carcinoma is related with cancer genetic susceptibility that can be investigated as single nucleotide polymorphisms (snps) and as cytokine genes are known to predispose to malignant disease, several polymorphisms of interleukin- (il- ) gene have been reported to in some may be associated with tumour progression including inhibition of malignant epithelial cells apoptosis and stimulation of angiogenesis. method: the aim of this study was to clarify the association between il- polymorphisms and the risk of gastric cancer and chronic gastritis development or maintenance. pcr-ssp genotyping for il- - c>g polymorphism was performed in biopsies of gastric carcinoma and in biopsies of chronic gastritis. results: there was association between il- - c allele (p = , ) and - cc, low producer, genotype (p = , ) and gastric carcinoma, whereas il- g allele (p= , ) and il- gg (p< , ), high producer, genotype was associated with gastritis. conclusion: we conclude that il- - , low producer genotypes, may have an important role in gastric carcinogenesis and the polymorphism study of this molecule could be a good marker for gastric carcinoma susceptibility when high grade dysplasia is seen in biopsies. objective: in helicobacter pylori gastritis, constant antigenic stimulation triggers a sustained b-cell proliferation. errors made during this continuous dna replication are corrected by the dna mismatch repair mechanism. failure of this mechanism has been described in hnpcc and results in a replication error phenotype. inherent to their instability during replication, microsatellites are the best markers of this replication error phenotype. we aimed to evaluate the role of defects in the dna mismatch repair mechanism and microsatellite instability (msi) in gastric mucosa-associated lymphoid tissue (malt) lymphoma. method: we examined microsatellite loci (bat , bat , d s , d s , d s , tgfb, bat , d s , d s and d s ) for instability in patients with malt lymphomas. in addition, these tumors were also immunostained for mlh , msh and msh , as well as screened for the presence of t( ; )(q ;q ) by real time polymerase chain reaction (rt-pcr). results: we found msi in / ( %) lymphomas, with one tumor displaying high levels of instability. msi occurred in both t( ; )(q ;q )-positive and -negative tumors. conclusion: our data suggest that a mmr-defect may be involved in the development of gastric malt lymphomas, and mutations in the msh mmr gene or hypermethylation of the msh promoter might be associated with msidriven gastric lymphomas. mitosis-specific marker phospho-histone h in the diagnosis of gastrointestinal stromal tumors a. dolzhikov * , a. tverskoi, k. hizhnyakov * regional pathology hospital, dept. of oncomorphology, belgorod, russia objective: the assessment of proliferative activity is one of the major parameters in the proper grading of gastrointestinal stromal tumors (gists). in the low level of mitotic activity it is difficult to calculate dividing cells correctly. phospho-histone h (phh ) is a recently introduced immunomarker for mitotic cells. method: immunohistochemical study of cases of gists of different malignant potential, statistical analysis. results: the count of phh -immunoreactive cells demonstrates the strong correlation (gamma , ; p< , ) with malignant potential of gists detected by standard parameters. it clearly separates true mitotic cells from apoptotic and piknotic nuclei. in all cases phh count was slightly higher than the mitotic index in h&e stained slides. we have found that pph demonstrated the two types of staining: nucleosomal dot-like type and mitotic homogenous type. the first type, probably, reflects the fraction of cells just before the prophase, which cannot be identified in h&e slides. conclusion: immunostaining of pph is a useful additional marker in detection of proliferative activity in gists, helping to identify true dividing cells correctly. ps- - her assessment in gastric carcinoma using ihc and fish p. drev * , b. gazic, j. contreras * institute of oncology, dept. of pathology, ljubljana, slovenia objective: her in gastric cancer (gc) should be assessed following guidelines -recommended testing algorithm employs ihc as a screening tool and is followed by ish to clarify equivocal cases. reported incidences of her + gc vary substantially and discordant results are frequent. in a series of gc her was assessed by ihc and fish to determine incidence of her + gc, concordance of the methods and reevaluate the recommended algorithm. method: her was assessed by both ihc (pathway b ™) and fish (pathvysion™) in gc samples. reactions were evaluated according to guidelines. her was considered positive in case of strong protein expression ( +) and/or gene amplification (ratio ≥ . ). frequencies of ihc and fish scores, incidence of her + gc and concordance (chi-square) of applied methods were analysed. results: ihc score distribution: neg ( ) objective: gastric glomus tumors are rare neoplasms originated from modified smooth muscle cells of the glomus bodies. such lesions present a diagnostic challenge in biopsy material. herein, we report a case of gastric glomus tumor in a -year-old woman. method: a -year-old woman presented with refractory epigastralgy. a gastrointestinal stromal tumor of the gastric antrum was suspected. the diagnosis was made after ultrasound-guided endoscopic biopsy, followed by an endoscopic submucosal resection. results: the biopsy showed tight convolutes of capillarysized vessels surrounded by collars of small, rounded cells set in a hyalinized, myxoid stroma. immunohistochemically, these cells were positive for smooth muscle actin and type iv collagen (pericellular pattern), synaptophysin (focal positivity) and negative for cd , cd , desmin, s and cytokeratins. the diagnosis of gastric glomus tumor was rendered. the resection specimen revealed a submucosal well-circumscribed × , × , cm nodule with identical histological features. the patient was disease-free months postoperatively. conclusion: visceral glomus tumors are rare neoplasms. when they arise in the gastrointestinal tract, the stomach (antrum) is the most frequent location. the differential diagnosis includes net, epithelioid gist and hemangiopericytomas. they usually behave in a benign fashion, although malignant cases have been reported. surgical excision is the standard treatment. immunohistochemical evaluation of replication protein-a in gastric cancer: clinicopathological associations h. gakiopoulou * , e. fourtziala, g. levidou, a. stofas, n. alexakis, p. korkolopoulou, e. patsouris * university of athens, st dept. of pathology, greece objective: replication protein a (rpa ) is required for stabilization of single-stranded dna at early and later stages of dna replication being thus critical for eukaryotic dna replication. in this study, we investigated for the first time the immunohistochemical expression of rpa protein in a series of gastric carcinomas in relation with clinicopathological parameters (age, sex, lauren's histologic classification, histologic grade, lymphovascular invasion, tumor size, depth of invasion (t), lymph node metastasis (n) and stage). method: a standard immunohistochemical method and a semi-quantitative evaluation for the detection of rpa labeling index (li) were applied. results: nuclear rpa immunoreactivity was seen in all carcinomas with a mean value of . %. statistical significant correlations emerged between: . rpa li and low tcategory (p= . ) . rpa li and absence of lymph node metastasis (p= , ). rpa li was higher in cases without lymphovascular invasion; however this association did not reach statistical significance. conclusion: the widespread expression of rpa in gastric carcinomas suggests that this protein is implicated in gastric cancer growth. the observed significant associations between rpa li and low t as well as n tumors could imply that rpa might offer a growth advantage in the early stages of gastric cancer progression. pigmented histiocytic "pseudotumoral" reaction due to endoscopic tattooing of the duodenum with india ink r. hadhri * , c. objective: india ink has been used for endoscopic tattooing to facilitate localization of a luminal abnormality at the time of surgery or repeat endoscopic examination. recognition of this phenomenon is important to prevent misinterpretation of this _nding as other cause of black tissue deposits. some of them can be easily excluded by microscopic examination; the others, however, necessitate special stains or, as illustrated by our observation, an adequate clinical information! method: a -year-old man was referred for enteroscopy for microcytic anemia. the procedure revealed a cm flat umbilicated lesion of the duodenum. endoscopic tattooing was performed to guide surgical excision. results: histologic examination of the surgical specimen revealed a tubulovillous adenoma with low-grade dysplasia. the submucosa showed numerous aggregates of large cells containing a heavy black pigmentation. special histologic stains were inconsistent with melanin or iron. this submucosal cellular infiltration was linked to the preoperative use of india ink when the notion of tattooing was "kindly" provided by the surgeon! conclusion: despite a striking and misleading appearance, the microscopic finding of such phenomenon does not represent a pathologic state. nevertheless, communication between enterologists, surgeons and pathologists are mandatory to assure prompt recognition and avoid unnecessary investigations. objective: gastritis cystica polyposa is a unique lesion found on occasion at the stoma of a gastrojejunal anastomosis. however, gcp is rarely found in an unoperated stomach. method: a -year-old woman with abdominal discomfort and vomiting. physical examination, routine hematological examination and biochemical tests were within normal limits, exept mild anemia. results: upper gi endoscopic examination revealed a pedanculated polyp, in the greater curvature. endoscopic ultrasonography revealed a polypoid heteroechoic mass with cystic area and × mm diameter in posterior wall of gastric body. polypectomy was performed without any complications. histological examination of the protruding lesion revealed some misplaced cystic glands were entrapped in dense disorganized bundles of smooth muscle of muscularis mucosa surrounded by a rim of lamina propria. these findings were consistent with gastritis cystic polyposa. objective: human papillomavirus (hpv) infection is a known risk factor for the development of squamous cell carcinoma (scc) of the cervix, the oropharynx and the anogenital region. the aim of our investigation was to assess the prevalence of hpv dna in patients with esophagus cancer in the western population. method: formalin-fixed paraffin-embedded blocks from consecutive patients who underwent esophageal endoscopic mucosal resection or esophagectomy for scc were tested for the presence of hpv dna by polymerase chain reaction using consensus primers gp +/gp +. viral genotyping was determined by type-specific primers. results: among the total of cases, no hpv dna was detected in cases ( . %). cases were tested hpv positive ( . %) , of which was hpv +, was hpv + and were non-high-risk hpv type. the non-high-risk hpvs were detected in patients with previously treated scc of the mouth (n= ) and the oropharynx (n= ). patients with high-risk hpvpositive tumors had no history of oropharyngeal cancer. conclusion: our study revealed the presence of oncogenic hpv genotypes in a subset of esophageal cancer. the low rates of viral infection detected suggest that hpv unlikely represents a significant etiologic factor in esophageal carcinogenesis. further studies are needed to confirm these data in larger populations. objective: gastric cancer is the second leading cause of cancer mortality in the world. amplification of her- /neu oncogene has become an important biomarker for identifying patients who will respond to her- targeting therapy. the rate of her positivity in gastric cancer is variable, ranging from % to %. objective: gastrointestinal stromal tumors (gists) are primary mesenchymal tumors that arise in the gi tract. only - % of gists occur in the duodenum. here, we report a rare case of duodenal gist with extramural growth that mimicked a pancreatic tumor. method: a years old male patient was admitted to our hospital for duodenal ulcer and gastrointestinal bleeding which was diagnosed in an another clinic by endoscopy. abdominal mr of the patient showed a × , cm necrotic mass in the uncinate process of the pancreas which was excised by whipple operation. results: macroscopically, the resected specimen consisted of solid mass that was connected to the patient's duodenal wall but not to the parenchyma of the pancreas. microscopic examination of the tumor showed spindle shaped and epithelioid cells with mild nuclear pleiomorphism. immunohistochemistry revealed that the cells are strongly positive with cd , with focal expression of cd and sma. conclusion: gists are low-grade malignant mesenchymal tumors of the gi tract and are believed to originate from the neoplastic transformation of the cajal cells, which are located between the longitudinal and circular layers of the muscularis propria. they most frequently arise from the second part of the duodenum where they push or infiltrate into the pancreas. in our case report, the patient's tumor exhibited extramural growth and mimicked a pancreatic tumor. mantle cell lymphoma (mcl) is relatively a rare subgroup of non-hodgkin lymphoma. we have experienced an uncommon case of mcl. a -year-old man was admitted to emergency service for upper gastrointestinal bleeding as melena. gastric corpus wall thickness found increased and splenomegaly determined at whole abdominal ultrasonography. endoscopic examination revealed subsequently, cm diameter polypoid lesion at corpus anterior wall and cm dimensioned elevated and vascularised lesion at corpus posterior wall. endoscopic biopsy had reported as active gastritis and mucosal reactive hyperplastic changes with ulcerative background. after than total gastrectomy and splenectomy specimens examined diffuse infiltration of monotonous medium-sized, atypical lymphoid cells with hyperchromatic nuclei. these cells were positive for cd , cd , cd , bcl- and cd a, but negative for cd , cd and bcl- . atypical lymphoid cells were present even in splenic hilus and lesser curvature lymph nodes. we reported this case as primary gastric mantle cell lyphoma according to morphologic and immunohistochemical staining features. we report a -year-old man who had been searched for bicytopenia (anemia and thrombocytopenia). bone marrow examination revealed extensive bone marrow metastasis of signet ring cell carcinoma. pas, d-pas and mucin histochemical markers performed to bone marrow sample which were all positive. immunohistochemical markers were positive with muc- , muc- ac, muc- (focal staining), ck , ck , ema, cea and negative with vimentin, cd , chromogranin. according to morphologic and immunohistochemical results we thought primarily gastrointestinal system malignancy, particularly stomach carcinoma. upper gastrointestinal endoscopy performed subsequently, hemorrhagic ulcerative lesion had seen and taken biopsies. endoscopic biopsy results showed metastatic signet ring cells origin from stomach. we report this case because bone marrow metastasis can be found commonly in some malignant tumors but diagnosing a nonhematologic malignancy from bone marrow is an unusual event. the pathological effects of salvia officinalis extract on serum level of alkaline phosphatase in male rats e. abdollahi * , r. ahmadi * tehran university, iran objective: studies show that there is association between salvia officinalis extract administration and liver or heart functions. the main aim of this study was to determine the effects of salvia officinalis extract on serum level of alkaline phosphatase in male rats. method: male wistar rats were randomly divided into control, normal saline receiving and salvia officinalis extract ( , or mg/kg/day) receiving animals of in each group. after a period of weeks, blood samples were collected using cardiac puncture method. following serum collection, serum alkaline phosphatase levels were measured by spectrophotometry method. data were statistically analyzed and compared between groups using anova. results: the results indicated that serum alkaline phosphatase levels were significantly increased in salvia officinalis extract ( , or mg/kg/day) receiving animals compared with control rats. conclusion: our findings show that salvia officinalis extract is enhancer of serum alkaline phosphatase according to which, impairing effect of the extract on certain tissues is conceivable. the pathological effects of waterpipe smoking on serum levels of cea, alkaline phosphatase or creatine kinase in male and female rats r. ahmadi * , m. mafi * islamic azad university, dept. of physiology, hamedan, iran objective: various studies show that smoking can influence serum levels of tumor markers such as carcino embryonic antigen (cea) and kinase or phosphatase enzymes. the main aim of this study was to determine the pathological effects of waterpipe smoking on serum levels of cea, alkaline phosphatase (alp) or creatine kinase (ck) in male and female rats. method: male and female wistar rats were randomly divided into control and waterpipe smoking groups of in each. after a period of weeks, blood samples were collected using cardiac puncture method. following serum collection, serum cea, alkaline phosphatase or creatine kinase levels were measured. intestinal tissue was also examined histologically. data were statistically analyzed and compared between groups using anova. results: the results indicated that serum cea, alp or ck levels were significantly increased in male and female waterpipe smoking animals (p< . , p< . or p< . , respectively). there was not gender effect on serum cea, alp or ck levels. there were also histological changes in intestinal tissue including increased tissue plasma cells infiltration and inflammation. conclusion: our findings show that waterpipe smoking is an enhancer factor of serum cea, alkaline phosphatase or creatine kinase levels, according to which, damaging effects of waterpipe smoking on various tissues, particularly intestine should be considered seriously. the effects of acute or chronic immobilization stress on serum level of creatine kinase and alkaline phosphatase in male rats m. alinavaz * , r. ahmadi, m. mafi * islamic azad university, nutrition, tehran, iran objective: studies show that immobilization stress has a variety of effects on serum levels of liver enzymes. the main aim of this study was to determine the effects of immobilization stress on serum level of creatine kinase and alkaline phosphatase in male rats. method: male wistar rats weighing ± g were randomly divided into control, acutely or chronically immobilized animals of in each group. animals were immobilized for h/day or h/day for a period of weeks or week in chronically or acutely immobilized groups, respectively. blood samples were collected using cardiac puncture method. following serum collection, creatine kinase or alkaline phosphatase level was measured by spectrophotometery method. data were statistically analyzed and compared between groups using anova. results: the results indicated that serum creatine kinase level was significantly increased in rats enduring acute or chronic immobilization compared with control animals (p< . ), however, there was not significant difference between serum alkaline phosphatase levels in immobilized animals compared with control rats. conclusion: immobilization stress may leave pathological effects in liver or other organs leading to enhanced serum creatine kinase level. immunoexpression of lactoferrin in bone metastases and corresponding primary carcinomas v. barresi * , a. ieni, g. giuffrè, g. branca, g. tuccari * university of messina, dept. of human pathology, italy objective: with reference to primary bone tumors, we previously found lactoferrin (lf) immunoreactivity in chondroblastomas, chondromyxoid fibromas, giant cell tumours and osteoid osteomas, while no immunoexpression for this protein was detected in chondrosarcomas and osteosarcomas. herein we aimed to analyze lf distribution in bone metastases from cancers of different sites. method: lf immunohistochemical expression was investigated in formalin-fixed and paraffin-embedded specimens of human bone metastatic lesions as well as in the primitive corresponding carcinomas. the primitive sites of carcinomas were: breast ( ), prostate ( ), kidney ( ), lung ( ), colon-rectum ( ), uterus ( ). a lf intensity-distribution (id) score was calculated for each case by multiplying the values of the area staining positivity and the intensity staining. results: lf immunostaining, with variable id scores, was encountered in / ( %) metastatic bone lesions. immunoreactivity for lf was found in primary carcinomas with a percentage of neoplastic cells ranging between tand %, although this positivity decreased in breast carcinomas ( . %) and was totally absent in lung cancers. the immunohistochemical concordant evidence of lf in bone metastases and corresponding primary carcinomas strongly supports the hypothesis of an autoctone production of this protein by the neoplastic elements themselves in order to get a greater availability of iron for their increased turnover. results: it was observed a negative correlation between il /il and il /foxp concentration in the sf as measured by fc, before the treatment. in the sm, il and mmp were strongly expressed in macrophages, fibroblasts, endothelial cells and the extracellular matrix of control cases, but reduced significantly in the treated cases (p< , ). il and foxp positive cells remained costantly in a reduced number in the ms. conclusion: as the proinflammatory cytokines decreased after the therapy, we can conclude that these are more efficiently influenced than some immune cells participating in the autoimmune process. histological evaluation of the spleen after acute bleeding followed by blood replacement with two different physiologic solutions m. cabral * , a. l. ortiz, c. venâncio, j. objective: chondromyxoid fibroma is a rare benign lesion accounting for less than . % of all primary neoplasms of bone. a study was conducted to assemble a national study group for rare entities and share the experience of different centers. method: the data was collected from the pathology archives of referral hospitals in turkey. results: among the cases enrolled in the study, . % (n= ) of them were male. median age was ± yearsold (range: - ). the most frequent localizations were tibia ( %, n= ), femur (n= , . %) and pelvic bones (n= , . %), followed by feet bones ( . %), fibula ( . %), humerus ( . %), hand bones ( . %), cranium ( . %), costa ( . %), radius ( . %), scapula ( . %), and vertebrae ( . %). although the cases with appendicular skeleton involvement was younger than the others (median age: . ± . vs ± . respectively) no significant correlation was found between age, gender and localization. conclusion: cases displayed a wide age-range with a slight male predominance. the most frequent localizations were tibia, femur and pelvic bones. rare localizations such as temporal frontal bones, vertebrae and scapula were also observed. the study, which may serve as a preliminary work for future studies was presented to share our experience on this rare entity. histological changes and granulocytes redistribution in adjuvant arthritis l. feketeova * , p. jancová, p. objective: surgical treatment options of malignant tumors of the knee includes reconstruction with incorporation megaprosthesis. inguinal lymphadenopathy due to the lymphatic uptake of metal debris has been described, and may be clinically confused with tumor metastasis. method: we report the case of a -year-old woman with inguinal lymphadenopathy caused by metallic debris from a knee mega prosthesis for malignant fibrous histiocytoma. results: the histopathological changes seen in lymph node were metal debris containing sinusoidal macrophages in a background with numerous epithelioid granulomata in the remaining lymph node. conclusion: the identification of regional lympadenopathy in patients with past history of malignancy usually indicates metastatic disease. post-prosthesis lymph node histiocytosis resembling metastatic disease is described, and that is why we need resect and examine lymph nodes with the use of polarized light microscopy to identify birefringent particles of prosthetic debris for an accurate histologic diagnosis. objective: chordoma is a slow-growing malignant bone tumor that exhibits notochordal differentiation. nearly % of cases occur in the sacrococcygeal region and in the base of the skull. the remaining cases develop in the mobile spine, predominantly in the cervical and lumbar vertebrae. we report a rare case of paravertebral mediastinal chordoma without bone destruction. method: case report. results: a -year-old japanese woman was admitted to hospital after a tumor was incidentally detected on a plain chest x-ray image. the tumor was located in the paravertebral region of the mediastinum and did not show any destruction of the thoracic vertebra radiologically. the tumor was clinically diagnosed as a benign neurogenic tumor and the tumor was easily removed surgically. microscopically, the tumor mainly consisted of tumor cells with extensively vacuolated cytoplasm, arranged in cord-and nest-like fashion in a myxoid matrix background. immunohistochemically, the tumor cells showed diffuse positivity for pancytokeratin (ae /ae ), vimentin. the tumor cell nuclei were positive for brachyury, which is a key transcription factor of notochordal development. conclusion: these results confirmed the tumor to be an extraosseous chordoma in the paravertebral mediastinal region, which is rather an extremely rare location for usual chordoma. ps- - testicular papillary mesothelioma: a case with borderline features s. mavropoulou * , z. tatsiou, p. nasos * general hospital, laboratory of pathology, xanthi, greece objective: well-differentiated papillary mesothelioma occurs rarely in the paratesticular region, with only a few published case reports. method: we describe a case of a -year-old man who initially presented with discomfort in the left testis and underwent resection of a hydrocele in the left testis. a hydrocelectomy was performed, during which a pedunculated mass, , cm in greatest dimension, was found attached to the testis. results: microscopically, the mass was composed of multiple branching papillary structures with fibrovascular cores covered by a single layer of low cuboidal to cuboidal cells with predominantly bland nuclear and cytologic features and rare microscopical necrosis. immunohistochemical staining for calretinin and cytokeratines / was positive and proliferative marker ki was < %. accordingly the diagnosis of a well-differentiated papillary mesothelioma was made. the patient has not received additional therapy and is disease free months after diagnosis. conclusion: in conclusion, we report a rare case of a welldifferentiated papillary mesothelioma of the tunica vaginalis of the testis. the combination of benign and semimalignant characteristics can make the diagnosis of such a lesion problematic and pathologic distinction from malignant mesothelioma is crucial, although it may be difficult because of the variability of associated histologic features. objective: lipoma of the bone is a rare benign adipocytic tumor that arises intraosseous and rarely on the cortex or on the surface of the bone (parosteal lipoma). parosteal lipoma affects the long bones diaphysis of adults over years old. method: we present the case of a years old female with clinical diagnosis of femoral exostosis. conventional radiographs shows the presence of a cm length area of lucency on the femoral metaphyseal surface with a periostal reaction at the base of the lesion. results: gross examination reveals a cm osseous tumor, whitish on the surface and yellow on the section. on microscopic examination there are mature adipocytes with small foci of bone scattered throughout the adipocytes and hyaline cartilage at the perifery of the lesion. the gross and microscopic examinations correlated with conventional radiographs led us to diagnosis of parosteal lipoma. conclusion: this case is interesting being a rare bone tumor, the young age of the patient and the location on the surface of the bone. application of scanning acoustic microscope to evaluate lymph node lesions k. miura * * hamamatsu university, school of medicine, japan objective: a scanning acoustic microscope (sam) is a device that uses ultrasound (frequency, > khz) to image an object or tissue. because it is known that the harder the tissue, the more the speed of ultrasound, sam can provide data on the elasticity of cells and tissues. method: we compared lymph node lesions between acoustic and light microscopic images to evaluate the usefulness of sam. results: sam system discriminated lymph node components and demonstrated distinct acoustic images of the lymph nodes such as cancer metastasis, lymphomas, granulomatous diseases, and deposition diseases such as amyloidosis. areas with desmoplastic reactions associated with cancer invasion or post-inflammatory fibrosis showed the greater speed of sound than normal lymph nodes. these results corresponded well to those obtained using the conventional microscope. conclusion: sam provides the following benefits: ( ) images are acquired in only few minutes without requirement for staining, ( ) imaging pattern is similar to that of light microscope, and ( ) speed of sound from each lesion is digital and statistical analysis is possible among diseases. although resolution of sam is little lower than that of light microscope, the sam can be an ancillary tool for histological diagnosis and clinical research. objective: parkinson's disease (pd) is considered one of the major neurological disorders of the population, and there is increasing data provides enough evidences confirming the involvement of free radicals and other reactive oxygen species (ros) in a number of physiological and pathological processes. the aim of the present study was to evaluate, the effect of therapy in patients with parkinson disease on biomarkers of oxidative stress, such as products of lipid peroxidation by two different methods: electron paramagnetic resonance and visible spectrophotometry. method: the study was performed in blood samples of patients with pd -with therapy, patients with pd -without therapy and healthy volunteers as controls. the products of lipid peroxidation were measured as malondialdehid (mda), spectrophotometrically by thiobarbituric acid (tba) method. the levels of lipid radicals were determinated ex vivo at room temperature on an x-band emx-micro spectrometer, bruker, germany. results: by the present study we reported higher levels of oxidative stress in pd patients without therapy compared to those with therapy. these results were comfirmed by the epr method. conclusion: the increase of oxidative stress, in pd patients' might be an additional reason for many secondary complications. objective: primary aneurysmal bone cyst (abc) is a histologically complex and mainly cystic lesion that accounts for % of all primary bone tumors. information regarding its clinical presentation and management in hands and feet remains sparse. method: the medical records abc in hands or feet in hospital la paz pathology department from to were retrospectively reviewed and compared with existing data. we also propose pathological criteria for differential diagnosis between abc and giant cell reparative granuloma (gcrg). results: ten abc in hands or feet were identified, out of ( . %), five tumors were in metacarpals, in metatarsals and in phalanx. radiographs showed expansile lytic lesions in metadiaphyseal region, sometimes with aggressive appearance. histologically, abc showed a mixture of blood-filled spaces with connective tissue septae containing osteoclast giant cells and foci of osteoid. scattered areas of so called "blue bone" were present in cases ( %). there were two solid variants. five patients underwent resection and curettage, three of which relapsed ( %). conclusion: abc should be considered in the radiologic differential diagnosis of hands and feet tumours because these lesions can even mimic malignancies. although clinicopathologically some authors consider gcrg is related to the abc solid variant, we believe they are different entities. carb- is the superior anti-cd monoclonal antibody in optimized protocol settings r. røge * , s. nielsen, m. vyberg * inst. of pathology, aalborg, denmark objective: immunohistochemical detection of cd is important in diagnosis of hodgkin lymphoma and may be relevant in classification of renal tumours. in four tests with - participating laboratories conducted by the nor-diqc external quality assessment scheme only - % of cd stains were sufficient, mainly because of too diluted primary antibody concentration, insufficient hier and less successful antibody clone. the purpose of this study was to evaluate three anti-cd antibodies based on vendor and inhouse optimized protocols. method: multitissue blocks with various malignant lymphomas, renal tumours and normal tissues (n= ) were stained with three concentrated (conc) antibodies (carb- , mma and by ) according to predetermined in-house optimized protocols on two staining platforms. ready-to-use (rtu) solutions of carb- and mma were also examined. extension and intensity of stains was scored using the h-score method. results: carb- conc with an in-house optimized protocol gave the highest h-scores in classical hodgkin lymphoma, renal tumours and normal kidneys. carb- rtu and mmaconc gave slightly lower scores, while mmartu and by conc gave the lowest scores and a large proportion of false negative reactions. all in-house optimized protocols gave better staining results than vendor protocols. conclusion: the importance of antibody selection and protocol optimization in immunohistochemical laboratories is emphasized. objective: studies show that there is association between stress and pathophysiological changes in reproductive system. the main aim of this study was to determine the pathological effects of immobilization stress on testes tissue and serum testosterone level in male rats. method: wistar rats were randomly divided into control, acutely or chronically immobilized groups of in each. animals were immobilized for h/day or h/day for a period of weeks or week in chronically or acutely immobilized groups, respectively. after weeks, blood samples were collected using cardiac puncture method. following serum collection, testosterone level was measured by radioimmunoassay method. the effect of immobilization stress on testes histology was also examined. data were statistically analyzed and compared between groups using anova. results: serum level of testosterone was decreased in acutely or chronically immobilized rats compared with control animals (p< . ). in histological study, semeniferous tubules were significantly deformed and cellular concentration was reduced in immobilized rats compared with control animals (p< . ). the number of spermatocytes, spermatids or sperms was also decreased in immobilized rats (p< . ) and this pathologic change was more prominent in acutely than chronically immobilized rats. conclusion: this report underlines the importance of studying the archive material in order to thoroughly comprehend a single museum object. this handling of matters will help to turn anatomical collections into a unique teaching tool for modern medical practice and a noteworthy documentation of scientific, artistic and historical value. objective: extramedullary plasmocytoma is an uncommon plasma cell tumor localized preferentially in the upper aerodigestive tract, with no evidence of underlying multiple myeloma. it accounts for less than % of head and neck tumours. method: we report a case of a -year-old male patient with reccurent left-sided epistaxis and nasal obstruction. ct-scan showed a left maxillary mass eroding the lateral wall of the nasal cavity. the tumor was surgically removed. results: histologic examination showed a diffuse infiltrate of neoplastic cells in the submucosa, arranged in a scant vascularized stroma. the neoplastic cells were large to medium-sized with amphophilic cytoplasm, irregular nuclei and proeminent, eosinophilic nucleoli. mitotic figures were frequent. imunohistochemical stains were performed in order to make a differential diagnosis: the tumor cells were positive for cd and cd and they expressed cytoplasmic immunoglobulin with kappa light chain restriction. most of the tumor cells were also cd and ema positive. conclusion: even though extramedullary plasmacytoma of the sinonasal tract is rare, it should be included in the differential diagnosis. the cooperation among the otorhinolaryngolists, pathologists and hematologists are required to manage the patients effectively in order to provide optimal treatment. objective: sinonasal malign melanoma is a rare antity, mostly arising from nasal cavity and accounting for < % of all sinonasal tract neoplasms. method: we report two patients complaining of nasal obstruction and epistaxis. endoscopy revealed partially haemorrhagic mass obliterating nasal passage. in one patient diagnosis was done as a plasmacytoma by pathologist in an another hospital. multiple biopsies were taken. microscopically, the tumour was consisted of medium sized cells, which had high nuclear to cytoplasmic ratio with pleomorphic nuclei containing eosinophilic nucleoli and intranuclear cytoplasmic inclusions. the cytoplasms contained variable amount of melanin pigment. mitosesincluding atypical forms-were easily detectable. there were mild inflammatory infiltrate against the tumour and rare tumour necrosis. one was showed pseudopapillary growth pattern and lymphovascular invasion. results: immunhistochemically, tumour cells showed immunreactivity for s- , vimentin, hmb- and melan-a(mart- ). tumour cells were negative for cd- , cd- , cd- , cd- , sma, pan-ck and desmin. submandibulary lymph node metastasis was observed in one patient. this patient has undergone chemotherapy of temozolomide and cures of regional radiotherapy. for the other patient, there were no metastasis detected by pet-ct. conclusion: sinonasal malign melanoma is a rare malignacy, but this entity could be kept in mind to avoid missdiagnosis with other tumors sharing similar morphology. objective: significant changes in the voice occur after years. vocal quality is dependent on the vocal fold (vf) tissue biomechanics that derive from the extracellular matrix composition and organization. we studied muscularlamina propria interface of human vf in the aging. method: two authors evaluated density of vessels and the thickness of the deep and muscle layer by he and ihc (collageniv) with semiquantitative score. these data were validated by point-counting morphometric method. results: with the aging of the vocal folds we identified increased of vessels density in the muscle and deep layers, increasing the matrix density and thickness of the deep layer, and "dissection" of muscle fibers by dense connective tissue. the progressive structural changes in musclelamina propria interface play a crucial role in the remodeling and vocal quality. the increased density of vessels and matrix in aging may contribute to the preservation of vocal function by the physiological repairing. ps- - "lymphoepithelioma-like" thymic carcinoma in parotid gland m. bugdayci * , g. atay, b. sozeri, g. guler tezel * hacettepe university, pathology, ankara, turkey objective: we report a -year-old woman presented with a slow growing painless mass beneath the right ear. a fineneedle aspiration revealed whartin tumour. the patient underwent parotidectomy and histopathological examination showed thymic carcinoma with areas of thymoma. method: histopathological examination was done according to conventional protocols. immunohistochemical stainings were performed using lsab methods. panck, cd , cd , ck / , ck , vimentin, ki- , cd , bcl- , cd a, s , sma, tdt antibodies were used. results: histopathologically, a well circumscribed, nodular, hybride neoplasm finely seperated from parotid gland had two components, uniform spindle cells in basaloid form lobulated by fibrous septae and large epitheloid cells with vesicular nuclei and meganucleoli, suggesting thymoma and thymic carcinoma, respectively. prominent lymphocytic reaction with germinal centers, high mitotic activity, small necrotic foci and microabcesses were also seen. immunohistochemisty revealed panck, vimentin, cd and cd a positivity. the diagnosis of "lymphoepithelioma-like" thymic carcinoma was made. conclusion: thymic carcinoma is a rare tumor most commonly located in the anterior mediastinum. thymic carcinoma which originates from ectopic rests of thymic tissue caused by defective migration of the embryonic thymus, is extremely rare. in the presented case a thymic carcinoma was found in parotid gland which is an unusual site. objective: recent in vitro and in vivo studies have shown that several malignant tumors express an alternatively spliced variant of the receptor of growth hormone -releasing hormone (sv ), which operates by a ligand-dependent and independent manner. method: nine ( ) adenocarcinomas, pleomorphic adenomas and warthin tumors were studied by immunohistochemistry for sv expression and visualized by diaminobenzidine staining. results: sv expression was cytoplasmic and was detected in / malignant ( %) and / ( %) warthin tumors. however, only / ( %) pleomorphic adenomas expressed sv (p< . , x -test). immunoreactivity ranged from mild to intense in all positive specimens, with the exception of warthin tumors at which only intense immunoreactivity was recorded. conclusion: our study, for the first time reports the presence of anti-sv immunoreactivity in tumors of the salivary glands. furthermore, the high association of sv expression with the malignant as opposed to the benign neoplasms implies a role of sv in the progression of the disease. a surprising finding of our study was the high positivity for sv exhibited by the warthin tumors that implies biological similarities between these histopathological entities of the salivary glands. these results imply that the use of antagonistic analogs of ghrh merit further investigation. objective: sialadenoma papilliferum (sp) is a rare, benign neoplasm of salivary gland origin which manifests as an exophytic papillary excrescence of the mucosa. indeed, sp is both an exophytic proliferation of papillary stratified squamous epithelium above the mucosal surface and an endophytic salivary ductal proliferation beneath the mucosa. it arises predominantly in minor salivary glands and usually affects patients in the age range of - years, with reports in young patients being exceedingly rare. method: we report a case of a previously healthy yearold man diagnosed with a nodular mass in the upper lip buccal mucosa. the tumour was excised and submitted for microscopic examination. results: histologic examination revealed a biphasic proliferation of papillary stratified squamous and salivary ductal epithelia, both underneath the mucosal surface. conclusion: in this unique case, as the classical sp, the tumour has a biphasic proliferation of squamous and ductal epithelia. however, unlike the classical sp, both epithelia grow under the mucosal surface. as a result, it didn't manifest as an exophytic proliferation, but as a nodule. we excluded squamous papilloma, inverted ductal papilloma, intraductal papilloma and mucoepidermoid carcinoma, the principal entities in the differential diagnosis of sp, and concluded it to be a sp with inverted pattern. interest of histopronostic classification in three grades in the therapeutic management of primary epithelial parotid carcinoma v. results: microscopic examination showed a biphasic tumor with a prominent myxoid stroma and tumor cells with clear cytoplasm involving pleural tissue. immunohistochemistry showed tumor cells positive for keratin, s protein, smooth-muscle actin, p protein, vimentin. histological and immunohistochemical features confirmed the diagnosis of epithelial-myoepithelial carcinoma. the patient underwent a right parotidectomy years earlier for removal of . cm mass diagnosed as emc. conclusion: epithelial-myoepithelial carcinoma of salivary gland is a rare low-grade malignant neoplasm with a potential for local recurrence and metastases. rare metastases for lungs, kidney and brain were reported. we described an additional case of pleural metastasis. objective: salivary defense system recognized as an important protective factor of the child oral environment. research data reveal that bacterial infection, dental caries and periodontal diseases have a higher incidence in cases of salivary glands dysfunction. the aim of present study was to find out the morphological peculiarities of the fetal parotid gland in cases of restrictions of its intrauterine growth (iugr) at late gestation. method: parotid gland of twenty human fetuses with iugr from the late spontaneous abortions material were compared with fifteen fetal glands in cases of induced abortions due to psychological reasons (control group). tissue samples were stained with hematoxylin and eosin. stereological examination was done to find out volume fractions of parotid gland structural components. results: results have shown the reduction of the area of acini, large collected ducts, striated and intercalated ducts in iugr group. the volume fractions of vessels were also lower than on controls. the foci of immature secretory lobes in cases of growth restriction occupied wider zones within loose, poorly cellular, fibrous stroma. conclusion: our study demonstrates the delay of the parotid gland structural maturation in pregnancies complicated with iugr. impaired growth and secretory gland's dysfunctions may cause pathological changes in oral ecosystem of a child. objective: dermal fillers are injectable products commonly used in aesthetic medicine. this type of treatment, which often replaces traditional surgical procedures provides satisfactory cosmetic results. it is known, however, that there is a risk of undesired effects at the site of injection of the product or even at a distance. literature reports numerous cases of orofacial injuries caused by dermal fillers. the aim of this study is to evaluate two of the most widely used facial dermal fillers for aesthetic purposes in an effort to identify adverse reactions they may produce. method: two of the most commonly used materials for aesthetic purposes by dermatologists and plastic surgeons, polymethylmetacrylate and hialuronic acid were injected in rat tongues: % polymethylmethacrylate (n = ) and mg/ml hyaluronic acid (n = ), compared to an inert solution for control (n= ). after , and days, local clinical and histological alterations were analyzed. results: the following factors were verified: intensity of the inflammatory response (h&e), amount of newly formed blood vessels (ihc) and macrophages and collagen fibers density (picrosirius). results showed that both filling materials triggered local inflammatory response to a greater or lesser degree. objective: the aim of this study was to compare clodronate and zoledronic acid regarding their influence on the repair of surgical wounds in maxillae (soft tissue wound and tooth extraction) and their relation to osteonecrosis. method: thirty-four wistar rats were allocated into three groups according to the treat-ment received: (i) animals treated with zoledronic acid, (ii) animals treated with clodronate and (iii) animals that were given saline solution. all animals were subjected to tooth extractions and surgically induced soft tissue injury. histological analysis of the wound sites was per-formed by means of hematoxylineosin (h&e) staining and immunohistochemical staining for receptor activator of nuclear factor-kb ligand (rankl), osteoprotegerin (opg), von willebrand factor, and caspase- . results: the zoledronic acid group showed higher incidence of non-vital bone than did the clodronate group at the tooth extraction site. at the soft tissue wound site, there were no significant differences in non-vital bone between the test groups. rankl, opg, von willebrand factor, and caspase- did not show significant differences between the groups for both sites of surgical procedures. conclusion: both of the bisphosphonates zoledronic acid and clodronate are capable of inducing maxillary osteonecrosis. immunohistochemical analysis suggests that the involvement of soft tissues as the initiator of osteonecrosis development is less probable than has been pointed out. objective: the aim of this study was to evaluate the expression of cd a, cd , cd , cd , caspase- , tryptase and basement membrane thickness in oral lesions of lichen planus (lp) and lupus erythematosus (le). method: oral lesions of lp (n= ) and le (n= ) were biopsied. after confirmation of diagnosis, the specimens were submitted to pas and immunohistochemistry. results: cd a expression was significantly greater in epithelium and connective tissue in lp. epithelial cd and cd did not differ between the diseases, but were greater in connective tissue in lp. cd expression was greater in both epithelium and connective tissue in lp. caspase- did not differ between the groups, whereas tryptase was greater in le epithelium. basement membrane thickness did not differ between lp and le. conclusion: cd a, cd , cd , cd , caspase- and tryptase expression and the basement membrane thickness are not definitive criteria for differential diagnosis of oral lichen planus and lupus erythematosus. objective: odynophagia may be caused by inflammatory/ infectious conditions and tumors arising within the oropharynx. we present an unusual case of a follicular dendritic cell sarcoma (fdcs) of the tonsil manifesting with odynophagia. method: an year-old man presented with odynophagia refractory to medical therapy; a . cm left tonsillar mass was noted on inspection. bilateral tonsillectomy was performed. a panel of antibodies was applied on paraffin tissue section. results: grossly, the left tonsil featured a . cm well circumscribed grey lesion. histologic examination showed a proliferation of spindle to ovoid cells arranged in fascicles with swirling qualities admixed with scattered lymphocytes. frequent mitoses and apoptotic bodies were seen but no "tumoral" necrosis was recognized. tumor nests were separated by thin stromal septi containing a prominent glioblastoma-like microvascular proliferation with focal formation of glomeruloid tufts. the tumor cells were immunoreactive for cd , cd and vimentin. objective: salivary gland tumors reveal a broad morphology and immunohistochemistry may be helpful. method: we examined mucoepidermoid (mec), adenoid cystic (adc), asinic cell (acc) and salivary duct carcinomas (sdc); myoepitheliomas (me), basal cell (bca), pleomorphic adenomas (pa) and warthin tumors (wt) for sma, calponin, s , cd , gfap, p , cea, gcdfp , glut , be , ck , ck , cd and galectin , using tissue microarray. results: tumors expressing myoepithelial markers were adc (sma, calponin), bca (sma, calponin, p ), pa (sma, calponin, s , cd , gfap, p ), me (s , cd , gfap), mec (p ) and wt (p ); pa being the only tumor expressing all of the markers in the panel. gfap, s , ck , p , ck / and galec-tin expressions were higher in benign and ck was higher in malignant tumors (p < . ). some of our findings helping in differential diagnosis are as follows: in differentiation of pa from adc: gfap, cd , gcdfp positivity; higher expression of s ; lower expression of ck and cd favors pa. in differentiation of pa from bca: gfap and cd positivity favors pa. in differentiation of mec from sdc: cd , ck , p and ck / positivity favors mec. conclusion: we conclude that salivary gland tumors may be well characterized by using distinct markers in each differential diagnosis. objective: lobulary capillary hemangioma (lch) is a benign, rapidly growing vascular lesion of the skin and mucous membrans. it may rarely present as a mass of considerable size and thus entirely fill the nasal cavity. it occasionally appears in the nasal region as a pedunculated or broad base mass. trauma and hormonal influences are the most common presumed etiologic factors. lch usually involves the gingiva, lips, tongue, and buccal mucosa. the most common symptoms are epistaxis and nasal obstruction. method: in this report; a case of years old boy operated surgically of lcd of the nasal septum, which occurred post delivery was described. results: on examination, a red pedunculated bloody swelling , * cm was noted arising from the posterior part of the nasal septum to nasopharinx. histopathologically lch has characteristics consistent with lobular prolifeation of capillaries in a fibromyxoid stroma. conclusion: we emphasise that rarely seen lch must be kept in mind in the differantial diagnosis of a rapidly growing mass, who is cured surgically. follow up months later showed no recurrance. although the head and neck is not an uncommon region, the nasal cavity is extremely rare sites for lch in children. objective: claudins are integral transmembrane proteins of tight junctions, critical for maintenance of cell adhesion and polarity. altered claudin expression has been detected in carcinomas and correlates with tumour progression. actinic cheilits is a pathologic condition that affects the lower lip, caused by chronic exposure to solar radiation; it corresponds to the early phase of squamous cell carcinoma. we investigated claudin patterns in phases of actinic cheilitis, as alterations in adhesion molecules are considered important during the progression of this process. method: immunohistochemistry against claudins − , − , − , − and − was performed in cases of actinic cheilitis/squamous cell carcinoma; results were analysed qualitatively. results: actinic cheilitis (low grade intraepithelial squamous cell carcinoma), and the invasive front of superficially invasive squamous cell carcinoma and in situ squamous cell carcinoma were negative for claudins − , − and − . claudin − was present on all epithelial layers in most cases evaluated. claudin − was present in all epithelial layers in actinic cheilitis, but negative in cases of superficially invasive and deeply invasive squamous cell carcinoma. conclusion: altered expression of claudins is present in ac from its incipient phase throughout the progression of the disease to invasive squamous cell carcinoma. objective: metastases to the jaw bones are uncommon and are most likely to arise from primary lung, breast, prostate or kidney tumours. jaw bone metastases from a primary oesophageal carcinoma are especially rare, with only seven reports published in the literature. method: here, we describe the case of a year-old male patient where years elapsed between the diagnosis and successful treatment of a poorly differentiated, stage pt n primary oesophageal adenocarcinoma and re-presentation with jaw pain due to a metastatic mandibular deposit. results: the morphological appearance of the metastasis and immunohistochemical positivity with ck , ck and cdx strongly supported an adenocarcinoma of upper gastrointestinal tract origin. conclusion: this case is of particular interest as there is an unusually long time between the detection of the primary oesophageal adenocarcinoma and diagnosis of metastatic disease. the longest period of time we have found for this reported in the literature is months, although it is known that some oral metastases may appear more than years following the primary tumour diagnosis. melanotic oncocytic metaplasia of the nasopharynx -a report of three cases and review of the literature j. s. lee * , j. y. na * chonnam national university, hwasun hospital, pathology, jeollanam-do, republic of korea objective: melanotic oncocytic metaplasia of the nasopharynx is a rare condition which is characterized by the presence of usually a small, brown to black colored pigmented lesion around the eustachian tube opening. although it is a benign lesion, it may be clinically misdiagnosed as malignant melanoma. microscopically, melanotic oncocytic metaplasia is a combination of oncocytic metaplasia of the epithelium of the gland and melanin pigmentation in its cytoplasm. method: in our present study, we report three cases of melanotic oncocytic metaplasia of the nasopharynx. results: all the three cases occurred in men and were presented as multiple black pigmented lesions around the torus tubarius. microscopically, mucous glands with diffuse oncocytic metaplasia and numerous black pigments were observed. no cellular atypia was observed. immunohistochemically, the scattering of s- proteinpositive, and hmb- -negative dendritic melanocytes was evident. conclusion: this is the first report of cases of oncocytic metaplasia of the nasopharynx in korea. objective: angiokeratoma is a rare cutaneous lesion. mucosal involvement is occasionally found as part of a more generalized cutaneous disease. isolated angiokeratoma in the oral mucosa is extremely rare with only a few cases reported thus far. method: we report the case of a -year-old female presented with a painless lesion on the left bucal mucosa, of months duration. on clinical examination, a solitary purple lesion of approximately mm in diameter was found. results: the lesion was excised and the histological examination revealed a tumour involving lamina propria, composed of large dilated vascular spaces, lined by normal appearing endothelium and filled with blood or with fibrin thrombi. the overlying epithelium showed variable degree of acanthosis and hyperkeratosis. accordingly the diagnosis of angiokeratoma was made. on clinico-laboratory examination no angiokeratomas were found anywhere on the skin as well as no other malformation or metabolic disorder. the patient received no further treatment and years later remains disease free. conclusion: in conclusion we report a case of a solitary angiokeratoma of the oral mucosa. although rare, it should be included in the differential diagnosis when evaluating any lesion in this location and further investigations should be performed to rule out a metabolic or systemic disease. results: histopathologically in macroscopy, the cystic lesion was determined as a small part of tissue in white -grey color, in sizes of , × , × , cm. in microscopic evaluation, the epithelial tumor cells were formed mostly tubular, partially in solid form and broadly making pseudopapillary pattern in stromal tissue. in the luminal structures formed by tumor cells, there has been mucin as dark basophilic stained with pas/alcian blue (ph: , ). the tumor cells are strong and have common positivity with ck , and have negativities with ck (b-sa method). in the focal area that the tumor cells got the solid pattern, synaptophysin and chromogranin to evaluate the neuroendocrine differentiation wasn't determined. conclusion: the lesion in the medial part of the tympanic membrane of the patient was reported as colesteatom and the lesion in the middle ear was reported as middle ear adenoma. histopathologic evaluation for helicobacter pylori as a possible etiopathogenic factor in chronic tonsillitis e. Özgün * , d. altinel, a. albayrak, a. tan, s. sayhan, n. bozlak * nevehir devlet hastanesi, dept. of pathology, turkey objective: helicobacter pylori is the major gastric pathogen which has an important role in the etiopathogenesis of chronic gastritis. we investigated the presence of helicobacter pylori as an extragastric reservoir in the tonsillectomy specimens to display if it is an etiologic factor in the development of chronic tonsillitis. method: in the current study, cases with chronic tonsilitis were examined in bilateral tonsillectomy specimens. objective: salivary duct carcinoma (sdc) is a rare, aggressive malignancy with poor prognosis. its histomorphology is distinctly reminiscent of the ductal carcinoma of the breast. method: a -year-old man was admitted with a mass of the right preauricular area. the mass had been enlarging steadily for the past months. computed tomography (ct) of the neck revealed × × cm contrast enhancing solid mass with irregular borders at the right parotid region. thorax ct, abdominal and thyroid ultrasonography were unremarkable. as the aspiration cytology was malignant right parotidectomy and right cervical lymphadenectomy was performed. results: histopathological examination showed a mixture of ducts, nests and cords of cells often embedded in a desmoplastic stroma with comedonecrosis of some ductal structures. the tumor cells were polygonal with vesicular nuclei, prominent nucleoli and eosinophilic, oncocytic cytoplasm. the tumor margins were lobulated and irregular with perineural invasion. mucin stains were negative. we noted high proliferative index and cerbb overexpression. the tumor was classified as a salivary duct carcinoma, oncocytic variant of parotid gland. the resection margins were negative and the lymph nodes were reactive. conclusion: as high proliferative index and cerbb overexpression are predictive factors, close clinical follow up is recommended for the risk of local recurrences and metastasis. immunohistochemical expression of bcl- and ki- in oral lichen planus and leukoplakia with different degrees of dysplasia f. pigatti * , l. a. de assis taveira, c. t. soares * university of são paulo, oral pathology, brazil objective: the oral lichen planus (olp) is a chronic inflammatory disease of unknown cause, and its malignant potential is a very controversial issue. therefore, the aim was to evaluate the immunohistochemical expression of apoptosis-related proteins and cell proliferation in olp and epithelial dysplasia in order to investigate changes related to carcinogenesis and emphasize the importance of long-term follow-up of patients with olp. method: for this purpose, we selected samples of olp, samples of leukoplakia with epithelial dysplasia, and samples of normal oral mucosa as controls. the evaluation of the expression of bcl- and ki- was conducted in accordance with the immunoperoxidase technique. results: there was also a high expression of blc- protein in inflammatory cells in olp lesions and leukoplakia with epithelial dysplasia. the expression of ki- marker was higher in all analyzed tissue levels in the lesions of olp and leukoplakia with epithelial dysplasia when compared with the control group. objective: pleomorphic adenoma (pa) is the most common benign salivary gland neoplasm of the major and minor salivary glands. pleomorphic adenoma was shown sometimes to undergo malignant transformation in its natural course. carcinoma ex pleomorphic adenoma (cpa) is a rare salivary gland malignancy that may develop from either a long-standing primary or a recurrent pa. the genetic mechanisms involved in the progression of adenoma to a carcinoma is still unclear. to identify the predictors of disease, more knowledge about their genetic profiles is necessary. this study aimed to characterize alteration in the dna copy number of pa and cpa. objective: leukoplakia is an oral premalignant white lesion. although its etiology may vary, smoking has been implicated as a possible risk factor. the p protein has been shown to inhibit kinases, and it is known that its expression is decreased during carcinogenesis. the reduced expression of p has been correlated with poor prognosis in carcinoma. in this study a role for the smoking habit in the expression of this protein was investigated. method: forty cases clinically diagnosed as oral leukoplakias and that presented a mild to intense degree of epithelial dysplasia and could not be diagnosed as any other disease were selected. twenty cases were from current smokers (more than cigarettes/day for at least year) and neversmokers. thirty-six cases of leukoplakia without dysplasia were used as controls. histological sections of each lesion were subjected to the estreptoavidin biotin immunohistochemical method for detection of p . results: a semi quantitative analysis was performed and the results showed that the expression of p was independent of the smoking status of the patient (p= , ), using kruskal-wallis and mann-whitney tests. although not statistically significant, due to the small number of cases, the results indicate that the counting of p in leukoplakia correlates inversely with degree of epithelial dysplasia. low-level laser therapy may influence on the akt/mtor signaling pathway in oral cancer cells f. sperandio * , f. giudice, l. correa, d. pinto jr., s. de sousa * university of sao paulo, dept. of oral pathology, brazil objective: distinct cells respond differently to low-level laser therapy (lllt), while the exact molecular mechanisms involved in cell proliferation or growth inhibition, after light stimulation remain poorly understood. although lllt has shown promising results in accelerating wound healing and preventing or treating oral mucositis, there is no evidencebased consensus of what this energy could cause in cancer cells. this should be highly pondered when an oral cancer patient is treated with lllt due to oral mucositis, for example. method: two tongue squamous cell carcinoma cell lines (scc and scc ) were utilized to find the effect of low-level laser irradiation on the akt/mtor signaling pathway. laser irradiation ( and nm) consisted on mw of power and energy densities of , and j/cm . after a single irradiation the most significant energy densities found with mts assay were employed to analyze akt/mtor signaling pathway related proteins through immunofluorescence and western blotting. results: beyond modifying the growing rates of cancer cells, low-level laser irradiation was able to induce different variations in the studied pathway, however a direct correlation among the proteins was not found. conclusion: lllt may act on akt/mtor/cyclin d signaling pathway, which has a widely recognized role in head and neck cancer progression. mucins as predictors of recurrent pleomorphic adenoma of salivary glands: an immunohistochemistry analysis of over cases t. teshima * , r. ianez, c. coutinho-camillo, s. lourenço * são paulo, brazil objective: pleomorphic adenoma (pa) is the most common tumor of salivary glands and, despite its benign behavior, the recurrence after primary surgery is significant. in attempt to find a marker capable to predict the recurrence of this lesion, this study aims to analyze the expression of mucins muc , , , ac and in cases of pa, considering that mucins have been related to tumour growth of some organs. method: this study was performed in cases in pa, which of them presented recurrence after the initial surgery. all the primary tumors were histologically processed and submitted to the immunohistochemistry reaction. the antibodies for muc , , , ac and were used and then analyzed with conventional optical microscope. results: muc was the only mucin significantly expressed in most of all cases ( %), being present within ductal lumen and cytoplasm. the other mucins showed a focal positivity in few cases, where muc , ac and were cytoplasmic, while muc was expressed in ductal lumen and blood vessels. objective: drug resistance remains a major problem in the treatment of nsclc cancer patients for both, conventional chemotherapeutic and novel biological agents. intrinsic or acquired resistance is caused by a variety of mechanisms, including increased drug elimination, decreased drug uptake, drug inactivation and alterations of drug targets. recent data showed that drug resistance mechanisms might also be regulated by micrornas (mirnas). method: we tested lung cancer samples. the total rna was isolated from individual specimens and then rt-pcr and pre-amplification were performed. we detected levels of mir- , mir- a, mir- b, mir- , mir- , mir- *, mir- , mir- - p, mir- p, mir- x, mir- - p, mir- p, mir- , mir- and mir- using taq-man® microrna assays by lightcycler® real-time pcr system. we assigned obtained results using statistical methods. results: our results suggest that mir- - p and mir- are involved in apoptosis. the higher levels of mir- - p correlate with bcl- positivity and pro-apoptotic protein bax seems to be regulated by mir- . the level of lrp protein responsible for drug resistance in lung cancer patients seems to be regulated by mir- . conclusion: within our cohort of nsclc patients we did not find any correlations between the expression profiles of the abovementioned mirnas and survival. the modified methacarn fixation as an excellent preservation of histology, protein immunoreactivity and rna integrity in paraffin embedded tissue specimens p. babal * , r. milcheva, p. janega, p. celec * comenius university, dept. of pathology, bratislava, slovakia objective: fixation techniques preserving morphological fidelity, immunoreactivity and integrity of nucleic acids may have a high impact on both basic and applied research and diagnostic pathology. we investigated the effect of formalin, absolute ethanol and methanol; ethanol supplemented with acetic acid and modified methacarn fixative on the tissue morphology and immunoreactivity of different types of tissues and the preservation of rna fragments of different lengths. results: the modified methacarn fixation provided a histomorphological quality comparable to the formalin-fixed tissue specimens. the immunoreactivity was superior in the buffered than in the untreated formalin and the preservation of protein antigenicity in normal and pathologically changed tissues tested with several antibodies was excellent with the use of alcohols with acetic acid. the acidic ethanol and the modified methacarn fixative showed the best preservation of the integrity of rna in satisfactory quantity and quality of fragments up to bp, which was reliable for relative evaluation of gene expression. objective: cflip prevents the apoptosis by caspase inhibition, its overexpression correlates with the progression of different tumors. thymomas and thymic carcinomas are thymic epithelial tumors, in which the regulation of apoptosis is still unknown. we investigated the role of cflip in regulating the viability of thymus carcinoma cell line c using an rna interference. the cell line hacat was used as a control. method: c and hacat cell lines were transfected with an established "short hairpin" pires/puro cflip-shrna expression vector. cflip suppression and its effect on pro and antiapoptotic molecules were analyzed using q-pcr and western blot. apoptosis was quantified using the flow cytometry. results: the c-shcflip, but not the shcflip-hacat, showed sensitivity to trail (tumor necrosis factor-related apoptosis-inducing ligand), accompanied by an overexpression of both the pro-apoptotic protein noxa (p< - ) and the anti-apoptotic proteins birc , birc and xiap compared to the non-transfected cells (p< - ). conclusion: cflip shrna seems to induce apoptosis in the thymus carcinoma cell line. simultaneously antiapoptotic proteins (aips) birc , birc and xiap were up regulated in order to protect the cell from apoptosis. could these aips provide the way to escape the cell death? aips selective inhibitions could represent a promising therapeutic approach for malignant thymic carcinomas. objective: nucleolin is a multifunctional dna-, rna-and protein-binding protein, involved in fundamental aspects of transcription, cell proliferation and growth. it is located in the nuclei/nucleolus, cytoplasm and on the cell surface. the present study aimed at optimizing the histological identification of nucleolin. method: mamary invasive ductal carcinoma μm paraffin sections were pretreatead with pronase at room temperature ( - min) to epitope exposure. biotinilated peptide against nucleolin was applied ( / . mm dilutions), incubated at room temperature for min/overnight at °c; after phosphate-buffered saline, peptide binding was identified by peroxidase-conjugated streptavidin and , -diaminobenzidine tetrahydrochloride applied according to manufacturer's instructions before haematoxylin counterstaining. results: pretreatment for min at . mm of biotinilated peptide showed only nuclear expression, as mm/ min pretreatment with overnight peptide incubation; positive cytoplasmic expression was obtained also after min incubation/room temperature. at . mm concentration for min epitope retrieval, cytoplasmic and nuclear positivity raised over % expression, independently of peptide exposure (overnight/room temperature). conclusion: for optimizing peptides/antibodies, we have to be aware that nuclear/cytoplasmic expressions depend on digestion and peptide concentration. histological morphology is also important and discordant results may be erroneously obtained. ps- - kras testing in clinical laboratory: optimizing targeted therapy l. cheng * , l. miravalle * indiana university, dept. of pathology, indianapolis, usa objective: activating mutations in the kras gene are found in more than % of colorectal tumors, where they are associated with a poor response to anti-epidermal growth factor receptor therapies. mutation testing techniques have therefore become an urgent concern. several methods for kras mutation detection have been described in the literature. most of these are laboratory developed tests and only a few commercial assays are currently available. method: we studied the performance characteristics of a kras mutation detection assay on the abi- xl genetic analyzer using a new commercial mutation detection kit. samples were analyzed in parallel by different reference laboratories using alternative methodologies. various sample types were used including formalin-fixed paraffin-embedded tissue, fine-needle aspirates, and cyst fluid specimens. results: a high level of agreement ( % correlation for formalin-fixed paraffin-embedded tissue and fine-needle aspirate samples and % correlation for cyst fluid specimens) was obtained despite the use of different methodologies. conclusion: shift termination assay is a simple, robust, and sensitive method for the identification of kras mutations in wide variety of specimen types. objective: micrornas (mirs) are small rnas that modulate protein expression via post-transcriptional regulation of mrna. they are related to malignancy in several tumors. deregulation of mirs expression has been described in high grade astrocytomas of adult patients, however there is scarce information in pediatric patients. in this work we quantified the expression profiles of mirs in pediatrics astrocytomas. method: total rna was extracted from astrocytomas and normal brain (nb) tissues, formalin fixed paraffin embedded. the expression levels of mir- , mir- - and mir- were quantified by using mirna-specific taqman mirna assays. results: the mir- - was more abundant in nb against to mir- and - (p< . ). mir- and mir- - were significantly down-regulated in all grades compared to nb (p< . ) but in grade iv was more decreased: -and -fold, respectively. in patients with recurrent tumor, the expression of mir- was lower (p< . ). live patients expressed high levels of mir- (p< . ) and mir- (p < . ) against deceased. conclusion: micrornas are differentially expressed between astrocytomas and nb. the low expression of mir- and - could be a potential marker in recurrent pediatric astrocytomas, and both are associated to less survival. embedded tissue is useful to describe and evaluate expression of molecular markers of malignancy. objective: isolation of genomic dna from formalin fixed paraffin embedded (ffpe) tissues is a critical step for molecular diagnostic assays. horizon diagnostics has generated ffpe cell line reference standards containing defined mutant allelic frequencies, enabling the quality control of both assay sensitivity and dna extraction. method: a panel of x-man™ (gene-x, mutant and normal) cell lines were developed using our patented gene editing technology (genesis™) including; b-raf v e, v k; egfr Δe -a , t m, l r, l q; k-ras g a, g c, g d, g r, g s, g v, g d; pi kα e k, e k, h r. ffpe blocks containing specific allelic frequencies including: %, %, %, % or % were generated and sections cut. dna was extracted using five different extraction methods and analysed using droplet digital™ pcr. results: mutant alleles could be detected using droplet digital™ pcr at each defined allelic frequency and the reproducibility of each test was very high. the allelic frequency was consistent throughout each block. the total dna yield from each section was consistent using the same extraction method but varied between methods. conclusion: this study has demonstrated horizon diagnostic's ffpe reference standards have a highly accurate defined mutation specific allelic frequency together with a consistent dna quantity. transcript variants and isoforms of the phosphatase subunit ppp ca and its regulatory binding partners in haematological malignancies g. grech * , c. saliba, b. shawn, r. avellino, p. j. m. valk, r. delwel * university of malta, dept. of pathology, msida, malta objective: the importance of feedback mechanisms involved in suppression of growth factor-induced signals is gaining importance both to understand molecular mechanisms of disease and also as potential therapeutic targets. our previous studies show that erythroid differentiation can be blocked by constitutive expression of the pp a inhibiting subunit, alpha . the aim of this study was to identify variants and transcript isoforms of ppp ca and the inhibiting subunits alpha and set, using ( ) cell lines derived from haematopoietic disease, and ( ) objective: epithelial cells grow by proliferation and adhesion, which will form an organ/tissue. stat is involved in cell proliferation and various cellular events. in the present study, we studied the role of stat in cell adhesion in hepatocytes. method: stat knockout cells (s ko cells) and liverspecific stat ko (l-s ko) mice were generated. cellular adhesion was analyzed by light/electron microscopy. expression of adhesion molecules was examined by immunohistochemistry and western blot analysis. protein expression and cellular adhesion were also examined in the pre-/post-hepatectomy liver tissue in control and l-s ko mice. results: mrna and protein of e-cadherin were not expressed in s ko cells. il- up-regulated e-cadherin in control cells but not in s ko cells, and induction of constitutively active mutant of stat restored e-cadherin level in s ko cells. interestingly, membrane-bound beta-catenin expression was not affected, but released to cytosol in s ko cells. s -ko cells showed almost normal proliferation but did not form cell cluster due to lack of e-cadherin. electron-micrograph confirmed lack of intercellular adhesion structures (desmosome) in s ko cells. also in l-s ko mice, hepatocytes lack desmosome structure and cell adhesion. objective: alk positive anaplastic large cell lymphoma (alcl) is characterized by anaplastic lymphoma kinase (alk) expression, most commonly associated with the t ( ; )(p ;q ), fusing the alk and nucleophosmin (npm) genes. however, in a significant proportion of cases the alk gene has a number of other than npm translocation partners. the aim of the study was to detect the npm/ alk fusion gene and the other possible fusion genes. method: npm/alk was detected by rt-pcr, npm/ alk negative lymphomas were analyzed by alk specific rapid amplification of ´cdna ends ( ´race). we prepared q-rt-pcr assay for quantification of Á lk mrna. molecular findings were correlated with i-fish. results: we analysed alk positive alcl. chromosomal breakpoints affecting the alk locus were detected by i-fish in all patients. the npm/alk was detected in / patients. ´race identified atic/alk in , cltc/alk in patients. other fusion genes (tpm /alk, tpm /alk, alo /alk) were found in one patient. in all specimens, overexpression of ´alk mrna suitable for the minimal residual disease (mrd) detection was found. objective: a year-old girl, presented with an osteolytic epiphyseal lesion of the distal ulna. based on histopathological examinations, the lesion was classified as giant cell tumor of bone (gct). four years later, the girl developed a second lesion at the same site. the histopathological examination revealed aneurysmal bone cyst (abc) with solid spindle celled and giant celled areas which raised a question of a recurrent gct or a primary abc. the aim of this study was to analyze the clonality of these two processes. determination of maternal and paternal x chromosome activation status is useful in the diagnostic analysis of nonrandom x inactivation patterns. method: the human androgen receptor (humara) gene polymorphism assay was used to identify the clonality of these two processes. results: the patient was identified as heterozygous for the humara allele. the gct and abc samples exhibited a monoclonal pattern, but one of them was with maternal and the other with paternal x chromosome origin. conclusion: the findings of this case report demonstrate the clonal behavior of both lesions with different clonal patterns. the above investigation proved to be helpful in distinguishing between recurrent gct and de novo abc in the field of previous surgical intervention. . in all specimens gen her /neu was quantifed agains reference gen by qrt-pcr method (lyghtcycler® ii, roche). results: the results of cytogenetic analysis have been showed in % that didn´t corespond with the results of qrt-pcr quantification. on the contrary the results of ihc was correlated with the results of qrt-pcr in %. methods sish vs fish has in % different of results. in regard to the quality of ish signals the sish is more preferable for determination her /neu. conclusion: a pilot study conducted on a group of patients showed that among the methods used in the process of determining her /neu amplification are significant differences, even in evaluation and interpretation of test results. regardless of the histological type of tumors (diffuse and intestinal type) as problematic for the evaluation of samples proved to be endoscopic route. the use of molecular methods in diagnosis of malignant melanoma of biopsy s. libor * , p. dundr, s. lísová, c. povýšil * general faculty hospital, inst. of pathology, prague, czech republic objective: distinction between benign and malignant melanocytic lesions commonly represents a big challenge for the pathologist. in this case it appears as a useful auxiliary method of fluorescence in situ hybridization (fish). the aim of this study was by using fluorescently labeled probes detection of numerical changes occurring in malignant melanoma and thus supply or confirm the diagnosis. method: the retrospective study included samples tissue with an established histological diagnosis ( x malignant melanoma, benign melanocytic lesions x). for detection was used probe vysis lsi rreb /lsi myb/lsi ccnd / cep (abbott molecular, usa), olympus ax fluorescent microscope (immersion lens x). in the area of the tumor were calculated signals of individual probes and evaluated according to the manufacturer's instructions. results: evaluable results were obtained in / cases ( %) of the melanomas were and benign melanocytic lesions. in all four cases of malignant melanoma have been burdened with genetic changes, mainly in the ccnd (in %) gene amplification and preb (in %) and myb (in %). in contrast, for all benign melanocytic been demonstrated normal findings. conclusion: dna abnormalities detected by fish occurr in the vast majority of malignant melanomas but are not seen in benign nevi. this fact make the fish test an important extra step in the differential diagnosis melanocytic lesions with ambiguous or borderline histological findings. objective: egfr is a receptor on the cell membrane with tyrosine-kinase activity and which is a regulator of proliferation, apoptosis, angiogenesis, tumor invasion. he is found to be overexpressed in some lung cancer histological subtypes. men is a tumor suppressor gene, with a role in cellular growth and differentiation, dna reparation, and apoptosis. method: surgically resected specimen from patients (men n= ; women n= , age ± ) with lung cancer were studied: carcinoid tumors (ct)- , small cell lung carcinomas (sclc)- , large cell neuroendocrine carcinomas (lcnec)- , adenocarcinomas (ac)- , and squamous cell carcinomas (scc)- . the histological subtype, ptnm stage, and gene expression of men and egfr in tumor and normal lung tissue were evaluated. results: overexpression of egfr was observed in %(scc- %, ac- %, sclc- %, lcnec- %, ct- %). decreased expression was observed in %(lcnec- %, sclc- %, ct- %, ac- %, scc- %) (p< . ). overexpresssion of men was observed in % of all tumors (sclc- %, ct- %, scc- %, lcnec- %, ac- %) (p> . ). significant correlation between overexpression of men and early stage scc was observed (p= . ). conclusion: egfr is a target for therapy with monoclonal antibodies, so the tumors that overexpress egfr can be considered for treatment with these drugs. men can eventually be a marker for good prognosis and a potential target for therapy. objective: homeobox genes encode transcription factors controlling cellular proliferation and differentiation. altered expression of prox homeobox gene is related to many cancers, including breast, esophagus, lymphatic and oral. method: after overexpression of prox gene in scc cell line, total rna was extracted from three overexpressing-prox clones (oc) and one control-transfection cell clone (cc). microarray analyses were performed using the whole human genome k according to the manufacturer's instructions. genes with a fold change of greater or lower than . in oc versus cc, were considered as increased or decreased, respectivelly. gene ontology (go) was used to assign biological process related to significantly differentially expressed genes. results: down-regulated genes mmp , timp and notch were further validated by qrt-pcr. comparative gene analysis of oc and cc revealed up-regulated and down-regulates genes. pathways induced upon prox overexpression in go terms included vascular development control, cellular adhesion, regulation of proliferation, among others. mmp , timp and notch expression by qrt-pcr showed reduced expression leves in oc. these genes are commonly overexpressed in oral squamous cell carcinoma and have been related with metastatic tumors and worse prognosis. objective: barrett´s esophagus is the unique known precursor for esophageal adenocarcinoma (eac), in a gradual progression to dysplasia. our objective is to determine the correlation between the hypermethylation in cpg islands of the promoter region of p tumoral suppressor gen in epithelial dna and the histopathological pattern, as possible biomarker for risk of progression. method: . a study was performed about the evolution of precursor lesions, in a group of patients diagnosed following the vienna classification. . p hypermethylation is analyzed in paraffin embedding samples, through laser microdissection, dna extraction, pcr amplification, pyrosequencing and quantification. results: . of cases with to biopsies remained as nd, id or lgd, and cases progressed to hgd and/or eac. . within the control group the methylation grade is . % and in the diagnostic groups is . % (nd), % (id), . % (lgd), . % (hgd) and . % (eac). conclusion: . % remained stable, but those reaching hgd all progressed to ace (only in % of the latter, hgd is recognized with h&e). . methylation´s grade is higher in all diagnostic groups comparing to the control group, progressively increased as the dysplasia grade found with h&e, so it may be a good biomarker for neoplastic progression. objective: in high risk hpvs the expression of oncoprotein e is responsible for the degradation of p , while e inactivates prb and causes the progression to s phase of cell cycle, both sustaining the conversion to and the maintenance of malignancy. the aim of this study is to compare the performance in the detection of the e and e mrna expression of hr-hpv using the nuclisens easy q test (biomerieux) or hpv oncotect (incelldx) a test based on flow cytometry-fish method. method: we enrolled patients positive for hr-hpv dna and/or pap smears. all subjects underwent a colposcopy histological evaluation and were tested both for the nuclisens easy q test and hpv oncotect. results: out of subjects resulted positive for rna expression. the patients were divided into two cohorts based on the histological diagnosis: low grade lesions (cin ) and high grade lesion (cin +). patients with cin were with nuclisens easy q test and with hpv onco tect, those with cin + were with either tests. conclusion: these preliminary results suggest that hpv oncotect have a better specificity than nuclisens easy q test, while more samples need to assess the difference in sensitivity. detection of pik ca/akt mutations in human meningiomas a. saetta * , g. tomara, i. chatziandreou, p. tsioli, e. el-habr, i. sakalidou, g. vretakos, e. boviatsis, p. korkolopoulou, e. patsouris * university of athens, st dept. of pathology, greece objective: the pi k/akt pathway is a major signaling pathway frequently activated in human cancer due to pik ca and akt gene mutations thus representing a potential therapeutic target and prognostic biomarker. in this study, we examined the mutational status of pik ca and akt in meningiomas. method: meningiomas were screened for activating mutations in "hot spot" exons , of pik ca using real time pcr and high resolution melting analysis. pik ca wild-type samples were analyzed for mutations in exon of akt . the mutations were verified by sequencing and/or pyrosequencing results: mutations were detected in out of samples ( %) in exon of pik ca and were identified as p.e k and p.s f. regarding exon , out of samples ( , %) showed the following mutations: p.r q, p.t t, p.h v, p.m i, p.h r ( cases), p.h t. finally, in exon of akt , mutant cases were detected ( %) all identified as p.e k. in % of the patients the activation of the pi k/akt pathway is due to mutations in the two examined genes. conclusion: aberrant activation of the pi k/akt pathway due to pik ca and akt mutations is commonly observed in human meningiomas and these genes could be considered as potential targets in new therapies for cancer. study of pi k/akt/mtor pathway in urothelial bladder carcinoma a. saetta * , n. prekete, e. trigka, g. levidou, m. karlou, p. pavlopoulos, p. korkolopoulou, e. patsouris * university of athens, st dept. of pathology, greece objective: deregulation of the pi kinase-akt/mtor pathway is a frequent event in tumorigenesis. we examined the possible significance of the components of this pathway in bladder urothelial carcinoma (uc). method: cases with bladder uc were screened for mutations in exons , of pik ca gene and exon of akt by pcr-sscp, hrma, sequencing and/or pyrosequencing. the expression of p-mtor, p- e-bp , p-p s k, p-akt, fgfr and p-erk was evaluated by immunohistochemistry. results: , % of the cases were mutant in pik ca gene and % in akt . cases with wild type akt displayed higher fgfr receptor expression (p= . ). p- e-bp expression was more frequent in low grade (p= . ) and in pta-t tumors (p = . ). furthermore, superficial tumors presented higher levels of p-p s k expression (p = . ) and lower levels of p-akt expression (p = . ). in multivariate survival analysis, p- e-bp immunoexpression emerged as an independent prognostic factor of adverse survival (hr = . , p= . ), along with tumor grade and t-category. conclusion: activation of pi k/akt/mtor pathway in bladder uc is not exclusively related to the presence of akt and pik ca mutations. expression of p- e-bp could serve as an independent prognosticator. comparison of dna extraction methods of formalin fixed, paraffin-embedded archival tissues b. senguven * , e. baris, t. oygur * gazi university dental faculty, dept. of oral pathology, emek, turkey objective: formalin fixed, paraffin-embedded (ffpe) archival tissues are valuable resources for many molecular studies. the goal of this study is identify the optimal method for dna extraction from ffpe tissues. method: human gingival tissues which has obtained from patients with gingival hyperplasia were used. serial sections of μm thickness obtained using a standard microtome. half of the sections were deparaffinized on glass, the other half collected directly to a , ml tube. in order to identify the optimal method for dna extraction, we compared phenol-chloroform protocol and dna extraction mini kit. the duration of proteinase k digestion were also compared. spectrophotometric evaluation of the yield and purity of dna was conducted. to deteminate the amplifiablity of extracted dna, three different bp fragment of the beta-globin gene were amplified using pcr. results: the phenol-chloroform method had the lowest yield and purity. deparaffinized specimens on glass, digested for h and isolated using mini kit had the highest yield. amplification of the bp fragment of beta-globin gene was successful in all samples. conclusion: according to our results deparaffinization on glass, increasing the time of proteinase k digestion and using commercial kits for isolation seems the best method to obtain amplifiable dna from archival specimens. microrna signatures associate with fallopian tubal implantation in humans r. shao * * gothenburg university, physiology and endocrinology, sweden objective: micrornas are small non-coding rna molecules that regulate a large number of cellular pathways and deregulation or altered expression of mirnas is associated with many disease states. the function of the fallopian tubes appears to involve orchestrated spatiotemporal alterations in transcriptome profiles, the regulation of tubal gene expression and function by mirnas may thus be of primary importance in tubal ectopic pregnancy. method: both implantation sites and non-implantation sites of fallopian tubes from women with ep and decidual biopsies from women undergoing therapeutic surgical termination of pregnancy were collected and analyzed by mirna array. the unique mirna profiling results were validated by taqman qrt-pcr, and bioinformatics' analysis was employed to further predict the mirna targets. results: a total of mirnas were differentially expressed in implantation sites compared with those in non-implantation sites of fallopian tubes after comparison of decidual mirnas, among which were up-regulated while are down-regulated. the mir- was significantly increased, whereas let- i, mir- , and mir- were significantly decreased. differentially expressed mirnas were predicted to be related with several signaling pathways in normal intrauterine implantation. conclusion: our findings establish an mirna signature associated with tubal implantation and provide the experimental basis for further understanding the molecular and cellular mechanisms of initiation and development of tubal ep in humans. lung is an organ that can sense any perturbation of the air, due to its constant interaction (long live) of the air. our hypothesis was that lung could be an organ sensor of climatic change observed today. method: this preliminary study analyzed the expression of isoforms of the genes of hsp . the cases were chosen from archive of autopsies from to , with different diagnosis, and were matched in sex and age with a same number of cases chosen from to . the expression was studied by rt-pcr from lung tissue embedded in paraffin, samples of each decade. results: the expression levels of hsp were normalized to β-actine. we found expression in six cases of - : five for hsp aa - , and for hsp ab , one case expressed both. their matched cases in - never expressed any isoform. the cause of dead in all cases doesn't fit with any pattern. conclusion: with these results we propose than the lung could be a sensor of global warming, and the expression of these genes could be molecular markers of this climatic change. apoptosis associated genes and their role in predicting responses to neoadjuvant breast cancer therapy d. tvrdík * , h. skálová, p. dundr, l. stanek, c. povýšil, l. petruželka * general university hospital, institute of pathology, prague, czech republic objective: neoadjuvant chemotherapy is used in the treatment of breast carcinoma because it substantially reduces the size of the primary tumor and lymph node metastases. this present study is aimed at the investigation of biomarkers that can predict a pathologic response to the therapy. method: the transcriptional profile of key apoptosis genes was evaluated in both pre-therapeutically obtained tumor tissue by core needle biopsy and in specimens removed by final surgery, using a pathway-specific real-time pcr assay. results: on the basis of a hierarchical cluster analysis of significantly changed genes, we divided patients into good and bad prognosis groups, which correlate well with progression-free survival. in the good prognosis group, we found a statistically significant downregulation of the expression of mcl and igf r genes after neoadjuvant treatment. we also found a statistically significant overexpression of bcl l , bcl af , casp , casp , casp , cideb, fadd, hrk, tnfrsf , tnfsf and cd genes. in contrast, we found upregulation of igf r after the treatment in the group with poor prognosis. conclusion: as we have shown, gene expression profiling after neoadjuvant chemotherapy is a valuable research tool for investigating molecular markers, which may better reflect tumor biology and treatment response than standard prognostic and predictive factors. objective: non-small cell lung carcinoma (nsclc) is one of the most serious cancers. identification of genetic changes (mutations, amplifications or rearrangements) within egfr, kras and alk oncogenes, associated with nsclc, allows choosing the patients, benefit from biological therapy with tyrosin kinase inhibitors. method: dna is isolated from formalin fixed paraffin embedded specimens or cytology specimens. mutation detection is performed by real-time pcr, fragment analysis, primerextension analysis and mutant-enriched pcr. wt-egfr patients (e.g. with no mutation detected) are tested for alk gene rearrangement and egfr gene polysomy or amplification using the fluorescence in situ hybridization (fish) method. results: since / till / , dna samples were analyzed. out of these, patients ( , %) were found to be positive for activating mutations within egfr gene. since / till / , patients were analyzed for alk gene rearrangement, egfr gene polysomy or amplification. alk gene rearrangement has been proven in ( , %) cases, alk gene amplification in ( , %) cases and egfr gene polysomy or amplification in ( , %) cases. conclusion: determination of genetics changes in tumor can provide powerful tool for setting up strategy and therapeutic protocols in nsclc patients. objective: a year old gentleman, ex-smoker with a history of asbestos exposure presented to the emergency department with a day attack of severe abdominal pain and bilious vomiting. history of abdominal pain, lethargy, and weight loss over the last months and years of recurrent pleural effusion. pleural aspirates and a videoassisted thoracic biopsy were negative. method: x-ray confirmed small bowel obstruction and an emergency laparotomy performed. the terminal ileum was intussuscepted into the caecum causing proximal obstruction. a right hemi-colectomy was performed. results: on gross examination there was intussusception of the terminal ileum secondary to a polypoid mass at the ileo-caecal valve. histology showed an oncocytic tumour with neuroendocrine features arising from the serosa of the small bowel. the tumour cells were positive for ck , calretinin, and vimentin but negative for ck , chromogranina, cd and ttf- . the features were in keeping with a malignant peritoneal mesothelioma infiltrating the small bowel wall. conclusion: peritoneal malignant mesothelioma is an uncommon tumour which rarely causes mechanical small bowel obstruction. to our knowledge this is the first case of localised primary peritoneal mesothelioma presenting with intussusceptions. giant mesenteric cystic lymphangioma in adult; rare tumor, unusual location and uncommon age of occurrence: a tunisian case report s. attafi * , w. ajouli, n. bouchiba, a. chouchene, m. h. balti, k. bellil * fsi hospital, dept. of pathology, marsa, tunisia objective: cystic lymphangioma is a rare benign neoplasm arising from the lymphatic system. it occurs as a result of congenital malformations of the lymphatics, leading to the obstruction of local lymph flow and the development of lymphangiectasia. lymphangioma is common in pediatric patients, but it is extremely rare in adults, with only about cases reported in literature. most lymphangiomas are found in the head and neck; intraabdominal and specially mesenteric locations are very unusual. the aim of this work was to study its clinical, histological and therapeutic features and their diagnostic difficulties. method: we report the case of a years-old woman, who presented a painful syndrome of the right iliac fossae (rif). the physical examination found a mass of the rif. abdominal ultrasonography and magnetic resonance image showed a mesenteric cystic formation. at laparotomy, a large cystic tumor of the caecal mesentery, measuring cm, was found. histopathology showed a fibrous and thin walled cyst, lined by flat low lying epithelium with surrounding tissue of scattered lymphoid cells. results: the diagnosis of cystic lymphangioma was retained. conclusion: mesenteric lymphangiomas are very rare, but they can cause acute abdomen that requires an emergent surgery. therefore, they should be included in the differential diagnosis of cystic intra-abdominal lesions raises several possibilities, including both malignant and benign soft tissue tumours. objective: the spleen metastases from colon cancer are rare conditions and usually associated with extensive disease. there are only eight reports in english-language literature of isolated splenic metastases from colorectal carcinoma, which generally metastasize to regional lymph nodes, liver and abdominal peritoneum. method: we report a case of multiple splenic metastases in a -year-old woman. results: in november , the patient had undergone right hemicolectomy, lymphadenectomy and chemotherapy for stage iii tubular adenocarcinoma of the ascendant colon with positive pericolic lymph nodes. in december , she was admitted in our hospital for diffuse abdominal pain and intestinal transit disorders. computed tomography of the abdomen revealed multiple metastases of different sizes in liver and spleen. during the surgery, which was performed with the goal of curing metastatic disease, there were found two nodular hepatic secondary tumors, and numerous spleen metastases, with diameters from . cm to . cm. the histopathological evaluation of splenectomy specimen revealed a metastatic tumor deposit, histologically similar to the primary tubular adenocarcinomas of colon. conclusion: this is the ninth documented case of splenic metastasis from colon cancer. previously reported cases of this type were isolated tumor, this one being the first reported with multiple splenic metastases. the role of fatty acid synthase in inflammatory bowel disease (ibs) e. bas bozkurtlar * , n. ozkan, a. e. kedrah, c. celikel * marmara university, dept. of pathology, istanbul, turkey objective: it was demostrated that fas expression increases not only in mucosa involved by active colitis but also in normal mucosa of ulcerative colitis (uc) patients. our aims were to evaluate the role of fas expression in differential diagnosis of ibd, to search for any possible change during the progression of the disease in patients with clinical and endoscopic follow-up. method: among colonoscopic biopsy samples of uc cases, samples were classified as remission, as resolution, and as active period; samples of crohn disease (cd) cases were classified as active period. fifteen cases with normal endoscopic and morphologic findings comprised the control group. results: between uc and cd active periods and control group, a significant difference was found (p= , ). there was a statistical correlation between fas expression of basal crypt of normal mucosa in uc active period and the disease duration (p= , ). conclusion: the increasing in fas expression in patients with ibd can not be explained only by the inflammation. fas expression can not aid us in the differential diagnosis of uc and cd, but it seems that it is related to the extent of inflammation in uc. the relation between the disease duration and an increase in fas expression active uc, might have a significant role in carcinogenesis in uc. micropneumatosis -an (un) usual finding in gastrointestinal specimen? k. blaue * , m. plauth, j. knolle * städtisches klinikum dessau, pathology, dessau-roßlau, germany objective: a rather rare disease, micropneumatosis describes the findings of cyst-like cavities devoid of lining epithelium in the gastrointestinal wall. micropneumatosis is often secondary to intestinal bacterial infection or mechanical factors. this study evaluates the incidence of micropneumatosis in our institute. method: we analyzed all cases of micropneumatosis obtained in our institute between and . available data were retrieved from patients' records. results: out of . specimens obtained between and , cases ( . %) presented with micropneumatosis ( female, male; mean age years, age range to years). most common site was the colon ( cases), followed by stomach ( ), small intestine ( ) and greater omentum ( ). conclusion: micropneumatosis represents a rare but harmless diagnosis in gastrointestinal specimen. due to the histological picture, which may be confused with dilated lymphatic vessels, submucosal lipomas, and, to the untrained eye, even with signet ring cell carcinoma, incidence may even be higher. in unclear cases, where there seems to be a endothelial layer, immunohistochemistry may be necessary to confirm diagnosis of micropneumatosis. this study shows that micropneumatosis should be considered in differential diagnosis in every age and sex. predicting lymph node metastasis in pt colorectal cancer -a meta-analysis providing rationale for therapy decisions s. bosch * , i. nagtegaal * radboud university nijmegen, pathology, netherlands objective: we conducted a meta-analysis of published reports on the predictive value of risk factors for lymph node metastases (lnm) in pt colorectal cancer in order to provide a rationale for choosing follow-up or radical surgery after local excision. method: local excision is an attractive treatment option for colorectal cancer, but is only safe in the absence of lnm. several pathological factors have been associated with lnm, however it remains unclear how to integrate these in clinical decision making. results: a pubmed search revealed studies totaling patients. strong predictors of lnm were lymphatic invasion (rr . [ % ci . - . ]), budding (rr . [ % ci . - . ]), and high grade histology (rr . [ % ci . - . ]). deep submucosal invasion was also strongly associated with lnm, however in a risk stratification model this factor was of limited added value. conclusion: the absence of lymphatic invasion, budding and high grade histology may justify withholding radical surgery. the independent role of submucosal invasion depth is probably limited. models for risk stratification based on these factors need to be validated. objective: dendritic s + cells in intestines have been described in more studies. their connection to s + fibres of nervous system is lesser of an object of interest. method: we have processed the samples of intestinal mucosa of people with crohn's disease and colitis ulcerosa by the means of form-paraffine technique and anti s antibodies. results: in lamina propria and in submucosa at crohn's disease were s + the fibres of various width and orientation. outside of them the diffusely scattered round s + mononuclear cells could be seen. contrary to colitis ulcerosa the granulation tissue at crohn's disease contains in the area around abscesses a thick accumulation of s + cells and this is similar also in the formed lymphoid tissue. conclusion: the positive fibres can be seen in submucosa at the edge as well as in lpm between the bases of the glands. in between the plexus/ring and longitudinal muscle there are massive bands of connective tissue which contains bundles s + of ganglion cells and nerve fibres. the fibres are present in ring as well as in longitudinal muscle. in this area s + fibres can also be seen in vessel walls. numerous bundles of granulatory tissue do not contain positively reacting substance. in the basal part lamina propria there are visible s + cells as well as long, smooth, positively reacting fibres. ps- - ncf -deficient mice with impaired oxidative bursthave a more agressive progression of dextran sulfate sodium (dss) -induced colitis l. carvalho * , t. rodrigues-sousa, a. alarcão, a. f. ladeirinha, m. souto-carneiro * amadora, portugal objective: intestinal inflammatory disease (iid) as a primary immunodeficiency depends on mutations in the nadph oxidase complex, responsible for the production ofreactive oxygen species (ros). one of the most common clinical patterns in iid is chronic colitis. ncf -mutation in mice leads to deficiency in ros, rendering them susceptible to autoimmunity. here we studies how ros-deficiency in ncf -mutant mice influenced the immune response to dss colitis, its recovery and answer to a second induction. method: colitis was induced in wild type (wt) and ncf mutant (ncf ) b .q mice by administration of . % dss in the drinking water for week. after week recovery, dss was administered for another week. mice were sacrificed at days , , and , the colon was removed and folded into a swiss roll. sections of the colon were stained with he, and monoclonal antibodies against b cells (b ), cd + t cells; and macrophages (mac /cd b) were applied. results: colitis was more severe in ncf than wt mice, with epithelial dysplasia, hyperplasia of peyer's patches and poor epithelium recovery (hyaline scars). at all time-points the amount and location of colonic b cells, t cells and cd b + cells was distinct between groups. these results suggest that ros are crucial for leukocyte recruitment and tissue-repair in dss-induced colitis. histopathological pattern of polypoid lesions of colon in albanian population g. cekodhima * , a. cekodhima, a. beqiri, g. andrea * university hospital maria teresa, dept. of pathology, tirana, albania objective: our aim was to study histopathologic pattern of the polypoid lesions in albania. method: we studied lesions, polypectomies and colorectal surgery in patients in tirana. results: there were observed polypoid lesions of large intestine in males and females. ( . %) were adenomatous polyps, ( . %) were hyperplastic, ( %) were inflammatory polyps with ulcerative colitis, ( . %) were inflammatory ( . %) were juvenile polyps, ( . ) non hodgkin's lymphoma and ( . ) was fibrolipoma. tubular adenomatous polyps were the commonest polyps. they were more common ( . %) in male population as compared to female ( . %). high grade dysplasia was present in ( . %) and malignant change in ( %). the size of the polyps range from . to cm. conclusion: adenomatous polyps were the most frequently found polyps in our study; the approximately % were advanced lesions. the role of cancer stem cells in biology and prognosis of colon cancers a. f. Çiçek * , Ö. Öngürü, m. gamsizkan, a. günal * gülhane military medical academy, dept. of pathology, ankara, turkey objective: this study was designed as a retrospective clinicopathological observation based on immunohistochemical and statistical findings to show the relationship between the disease progression and the intensity of the stem cell population within the tumor for colorectal cancers. method: for this purpose, we investigated colorectal carcinoma cases, retrospectively. paraffin embedded blocks was obtained from pathology archive and demographical patients' data from the patient's files of gastroenterological surgery department. immunohistochemically, we used cd and musashi- antibody to determine the stem cells within the tumor. we noted the age of the patients, histopathological diagnose, tumor location, grade, tnm status, clinical stage, disease-free-survival and the outcome. then we statistically compared all prognostic data with the immunohistochemical findings results: all of the cases were immunoreactive for both antibodies, furthermore we found a significant statistical correlation (p= . ) between cd expression value and patient outcome. when the value of cd expression was high, clinical outcome was poor. in addition, there was a relation between high musashi- expression and poor outcome. conclusion: based on these findings we reported that overexpression of both cd and musashi- antibodies may be a poor prognostic factor in colorectal cancers. immunohistochemical evaluation of vegf expression in colorectal carcinomas d. crisan * , m. florea, d. fodor * university of medicine and pharmacy, pathology, cluj-napoca, romania objective: vascular endothelial growth factor (vegf) is an important angiogenic glycoprotein secreted by the tumor cells and host cells which proved to be a powerful prognostic factor in various human cancers. the aim of our study was the evaluation of vegf expression in colorectal carcinomas using immunohistochemistry, in order to identify the relationship between the presence of the protein in the tumor cells and a series of morphological parameters. method: we analyzed consecutive surgically removed colorectal carcinomas. immunohistochemistry was done on formalin-fixed and paraffin embeded tissue sections, using the anti-human vegf-a monoclonal antibody (clone vg , dako). the extent and intensity of staining were graded and used to calculate the immunoreactive score for each case. statistical analysis was performed with spss (statistical package for the social sciences), using nonparametric tests. the level of statistical significance chosen was p < . . results: vegf was expressed in all tumors, with a heterogeneous distribution. the only parameters that correlated with high vegf positivity were the extent of the tumor necrosis and the presence of lymph node metastases (p = , ). conclusion: high levels of the vegf expression may be an indicator of poor prognosis in colorectal carcinomas. collision tumour of the appendix: mucinous cystadenoma and carcinoid -report of a case c. dastamani * , a. paraskeva, e. carvounis, t. theodosopoulos, a. kondi-pafiti * aretaieion hospital, dept. of pathology, athens, greece objective: appendiceal carcinoids are usually located at the tip of the appendix and occur as incidental findings. epithelial neoplasms of the appendix are uncommon and consist of mucinous adenomas, carcinomas and neoplasms with features of both carcinoid and adenocarcinomas. method: a case of dual mucinous cystadenoma and carcinoid of the appendix is reported. results: the patient, a -year old-asymptomatic female presented with a cystic right iliac fossa mass. the excised specimen was appendix cystically dilated measuring up to , cm in diameter. the luminal content consisted of viscid mucin. the base of the appendix was thickened (up to , cm) and firm. microscopically the cystic part of the specimen had features of mucinous cystadenoma with adenomatous epithelium extending as well over the thickened appendiceal wall. at that area the wall was involved by a well differentiated neuroendocrine neoplasm who gr i (carcinoid). the neoplastic cells infiltrated the entire thickness of the appendiceal wall, the mesoappendix and reached the serosal surface. the two neoplasms where separate and there was no transitional zone between them. conclusion: dual carcinoid/epithelial neoplasia is a rare occurrence in the appendix. the prognosis appears to be no worse than for either of the two components alone. gastrointestinal stromal tumor (gist) of the anal canal: a case report l. de carvalho * , p. a. teixeira, v. g. siqueira, m. pereira, t. or, e. pereira * centro universitário lusíada, dept. of pathology, santos, brazil objective: gastrointestinal stromal tumors (gist) are mesenchymal tumors derived from interstitial cells of cajal. they are found more frequently in the stomach, small intestine while colon and rectum represent unusual sites. gist's of the anal canal are extremely rare. method: -years-old woman who presented bleeding, pain and constipation for several months. the rectal examination revealed a well defined mass located within cm of the anal verge. the magnetic resonance imaging confirmed a well-circumscribed mural mass without adenopathy. the local excision of the tumor was performed for pathological study. results: gross examination showed a . × . cm fibrous mass. histological examination revealed a spindle cell tumor with moderate atypia and mitotic count of mitosis/ hpf. neoplastic cells showed marked positivity for c-kit and cd and negativity for muscular markers. a diagnosis of gist with intermediate risk of aggressive behavior was made. conclusion: gists of the anal canal are extremely rare with only few cases reported in the literature. we described an additional case of gist of the anal canal with histological and immunohistochemical study. intestinal graft versus host disease with giant cells b. doganavsargil * , a. vink, e. j. petersen, g. j. arnold offerhaus * ege university, school of medicine, izmir, turkey objective: graft-versus-host disease (gvhd) is a common complication of allogeneic bone marrow transplantation in which immune cells in the transplanted marrow attack the immunocompromised host. it can occur in either an acute or in a chronic form and may affect various organs. intestinal gvhd is particularly important because of its frequency, severity and its effects on the general condition of the patient. method: here we report a -year-old man who developed gvhd, months after receiving allogeneic non-myeloablative peripheral blood stem cell transplantation for refractory chronic lymphocytic leukemia. colonic biopsies revealed an edematous and congested lamina propria, dilated crypts lined by flattened epithelium, increased apoptotic figures and vanishing crypts. notably there were some giant cells in between crypts. however subsequent sections and special stains didn't show any granuloma formation or presence of an infectious agent. results: to our knowledge presence of giant cells in gvhd hasn't received proper attention before. although we don't know the actual importance or clinical consequences of the entity yet, we report this case to increase awareness of this feature within the context of gvhd. we have seen more cases with giant cell gvhd afterwards; comparison with other cases of gvhd without giant cells may help clarifying their significance. differential mutation patterns of kras and braf in adenomatous and serrated neoplastic sequences o. erdogan * , b. savas, a. ensari * ankara university, faculty of medicine, turkey objective: colorectal carcinomas develop through adenomatous or serrated neoplastic sequence. different molecular mechanisms underly these morphologic sequences which may be translated into different therapies. we aimed to assess adenomatous and serrated neoplastic sequences in terms of kras and braf mutations. method: the study group comprised of adenomatous polyps (aps, n= , . %), conventional adenocarcinomas (conca, n = , . %), serrated polyps (sps, n = , . %) and mucinous adenocarcinoma (mucca, n= , . %). kras mutation was assessed for exon and exon using pyrosequencing while braf v e mutation was analysed using allele specific pcr. chi square test was used for statistics. results: kras mutations were observed in . % of carcinomas and . % of polyps. kras mutation rate was significantly higher (p< . ) in conca ( %) than in mucca ( %), and in aps ( %) than in sps ( . %). braf mutation was found in one mucca ( . %) while all sps were mutated. tsas had the highest kras mutation rate ( . %) in comparison to ssa/ps ( . %) (p< . ) whereas ssa/ps and hps had significantly higher rates of braf mutation ( . %, . %, respectively) than tsas ( . %) (p< . ). conclusion: kras seems to take part in adenomatous sequence while braf, seem to play a significant role in serrated neoplastic progression of the colorectum. objective: quiescent ulcerative colitis (q-uc) is morphologically characterized by typical architectural and cellular mucosal changes that define the process as chronic. it is not clear which of these changes are more ubiquitous in q-uc. our aim was to evaluate which classical histological findings of q-uc are more prevalent in rectal samples. method: rectal biopsies were collected from patients with clinical and endoscopical q-uc. the biopsies were evaluated for mixed inflammation in the lamina propria, crypt architectural abnormalities, basal plasmacytosis, fibrosis, and paneth cell metaplasia as well as for features of active disease (cryptitis, lamina propria neutrophils and erosion). results: forty-five patients ( % female; median age years) were included. thirteen ( , %) biopsies showed focal activity and four cases ( , %) had criteria for active disease. epithelial distortion, chronic inflammatory infiltrate and basal plasmacytosis emerged as features present in , and % of biopsies. overall, biopsies were histologically normal (no chronic features, no active disease). conclusion: rectal mucosa from patients with clinical and endoscopical q-uc can show microscopic active disease, which illustrates that endoscopy alone may be insufficient to identify quiescent disease. in q-uc, the most frequent changes (present in over % of the biopsies) were epithelial distortion and chronic inflammatory infiltrate. vacuum-based preservation of colorectal cancer specimens: a comparison with formalin fixation j.-f. fléjou * , s. el-naderi, p. cervera * hôpital saint-antoine, dept. de anatomie pathologique, paris, france objective: in pathology, an alternative to immediate fixation in neutral buffered formalin (nbf) is vacuum sealing and cooling (vsc) ("tissue safe" system). there have been few evaluations of vcs. method: we assessed msi, kras, braf in colorectal cancers, conserved with vcs before fixation ( cases with surgery in a hospital distant from our centre), or immediately fixed in nbf ( cases with surgery during the same period in our hospital). dna was extracted from paraffin embedded tissue. msi was assessed by mlh and msh immunohistochemistry and pcr; kras and braf were screened by multiwell-plate based real-time pcr (lightcy-cler® , roche), confirmed by sanger sequencing. results: there was no difference regarding morphological analysis. immunohistochemistry was interpretable in all cases, with negative cases in the vcs group ( mlh ), negative cases in the nbf group ( mlh , msh ), and a % correlation between immunohistochemistry and pcr. dna extraction was possible in all cases. kras and braf mutations were detected in and cases in the vcs group and and cases in the nbf group, respectively. conclusion: we show that analysis of msi, kras and braf is feasible in surgical specimens after vcs. this procedure can be an alternative to formalin fixation. clinical significance of cd -positive m macrophage in colorectal cancer s. fushimi * , m. matsumoto, s. takahashi, t. ogino, j. itakura, t. ito, a. matsukawa * okayama university, dept. of pathology, japan objective: tumor-associated macrophages are divided into two phenotypes, termed m /m macrophages. m macrophages promote tumoricidal responses whereas m macrophages assist tumor progression and metastasis. in this study, we have analyzed a clinical significance of m macrophages in excised sections from patients with colorectal cancer. method: patients who had surgical resection for colorectal cancer between and were identified from a prospective database. tissue sections with adenocarcinoma in pt category were employed in this study. the sections were stained with anti-cd , a marker of m macrophages. the relation between the staining pattern and tumor budding or patient prognosis was examined. results: fifty-two patients ( male, female) with a median age of years (range - ) were studied. the tumors were classified into four subtypes according to the staining patterns of cd -positive cells, i.e. sparse type (n= ), invading-tip type (n= ), peri-nest type (n= ), and dense diffuse type (n= ). only a dense diffuse type was related to the high degree of tumor budding. the prognosis with a dense diffuse type demonstrated a poor prognosis as compared to the other types. conclusion: even the case with comparable tumor depth, cd -positive macrophages with dense diffuse distribution was related to the poor prognosis. objective: the treatment of locally advanced rectal cancer has shown a significant development over the last decade. the total mesorectal excision and the use of pre-operative radio (chemo)-therapy are leading the patients to a gradual improvement of local control of the disease. the aim of this study is to evaluate the pathological tumour response to pre-operative treatment through correlation between the clinical stage (ctnm) and the pathological stage (yptnm). method: since , patients with locally advanced rectal cancer, assessed by high resolution magnetic resonance imaging (hr-mri) and tnm staging system, have been evaluated by the colorrectal multidisciplinary team. pre-operative radio (chemo)-therapy was mandatory before undertaking standard surgery. surgical specimens were evaluated according to the vikingo project's protocol implemented by the spanish association of surgeons. results: patients completed the pre-operatory treatment. after evaluation of clinical and surgical study specimens, we observed variable degree of downstaging in ( , %) patients, of whom showed complete response. the ( , %) remainig patients were assessed as stable disease. no local progression of tumours was observed. conclusion: in this study, approximately % of patients, who were staged by hr-mri and underwent preoperative radio (chemo)-therapy for locally advanced rectal cancer, showed some degree of downstaging. we remark the fact that nearly % of patients reached complete response. the density of macrophages in colorectal cancer is inversely correlated to tgf-beta expression and patients' survival m. gulubova * , i. manolova, j. ananiev * trakia university, general and clinical pathology, stara zagora, bulgaria objective: the role of macrophages in colorectal cancer tumorogenesis is complex because they can both prevent and promote tumor development. we investigated cd infiltration in tumor tissue and its correlations with proteins ot tgf-beta signaling pathway. method: a nonselected panel of primary tumors of colorectal origin was investigated immunohistochemically with antibodies against cd , tgf-beta , smad , smad , tgfrii and levels of tgf-beta were measured by elisa. results: lower cd infiltration in tumor nests was associated with expression of tgf-beta (chi = . , р = . ) and smad (chi = . , р= . ) in tumor cells and with tgfrii expression (chi = . , р= . ) in tumor cells membranes. there was not correlation between cd cell numbers in tumor tissue and tgf-beta serum levels. we have found higher frequency of liver metastases in patients with lower infiltration with cd in invasive margin (chi = . , р= . ). the survival time was shorter for patients with low cd infiltration in tumor nests and invasive margin, compared with the survival time for patients, with higher cd infiltration in both tumor compartments (p< . ). conclusion: the increased levels of tgf-beta in the tumor have an immunosuppressive effect on cd infiltration. inflammatory myofibroblastic tumor of the colon: the th reported case s. gurzu * , t. bara, i. jung * university of targu mures, dept. of pathology, romania objective: inflammatory myofibroblastic tumor (imt) is a very rare tumor of the colon in which the diagnosis is especially based on immunohistochemistry. in the colon, we report the th case of imt. method: case presentation results: we report the case of a -year old male who presented with symptoms suggesting colon cancer. a mm protruded tumor was endoscopically described in the ascending colon. right hemicolectomy was performed. macroscopically the tumor was well defined, covered by normal mucosa with a central depressed area, suggesting a gist (gastrointestinal stromal tumor). microscopically spindle cells with fascicular arrangement admixed with mononuclear leukocytes were observed. the tumor cells expressed vimentin, sma, desmin and alk and were cd and cd negative. intense angiogenesis and cd expression in the endothelial cells were also observed. conclusion: in the imt of the colon, clinical endoscopic and gross feature can imitate a carcinoma or a gist. the ihc pattern of imt can offer informations about its histogenesis. based on the immunophenotype, we hypothesize that this tumor seems to occur from the the pluripotent stromal cells, cd positive which can be either differentiated in the interstitial cells of cajal (telocytes), which are also cd positive or, during differentiation, can loss cd positivity. objective: determining the fraction of tumor cells in colon carcinoma samples analyzed for kras mutation is important for choosing the proper testing modality. however, when asked to determine tumor cell fraction in tissue samples, different pathologists give considerably different estimations, possibly leading to erroneous interpretation of kras mutation analysis results and poor treatment choices. method: we developed a free, easy to use computer program that estimates tumor cell fraction on colon carcinoma slides that are immune-stained with anti-cytokeratin antibody. sixty samples were evaluated by the program and results were compared to actual measurement of tumor fraction. results: the tumor cell fraction estimated by the computer program showed highly significant correlation with the actual measurements (r= . , p< . ). additionally, we found that a short calibration step prior to beginning the computer estimation increased the accuracy of the results. in four cases ( %) there was some discrepancy between the computer estimation and the actual measurements, however, this was attributed to lower quality immunohistochemical staining. conclusion: in conclusion, we believe that this program can be used for standardizing the evaluation of tumor cell fraction in colon carcinoma, and that its use might aid in making better diagnosis and treatment choices for these patients. magnetic resonance imaging assisted tumour block selection in colorectal cancer c. hunter * , g. brown, l. temple, m. abulafi, a. arnaout * croydon university hospital, dept. of colorectal surgey, united kingdom objective: inadequate sampling may result in understaging in colorectal cancer. fat clearance techniques and whole mount sections are time consuming and costly. we hypothesise that high resolution magnetic resonance imaging (mri) of the colorectal cancer specimen may aid histological sampling and result in upstaging. method: patients undergoing resection are prospectively recruited, and randomised to "conventional histology" or "mri assisted histology". in addition to routinely selected tumour blocks, additional blocks and any additional lymph nodes are selected with the aid of specimen mri or visual inspection and palpation according to group. t stage, depth of extramural invasion, distance to resection margin, lymph node (ln) number and involved ln are compared between the two groups. results: to date, of patients have been recruited. we present the methods and preliminary results. there is a trend towards greater t stage and ln yield. no difference in n stage, extra-mural vascular invasion or involved non-peritonealised resection margin has yet been observed. conclusion: early results suggest that specimen mri may upstage colorectal cancer specimens by aiding tumour block selection. we will complete recruitment of colorectal cancer patients over the next months to determine whether observed differences are significant. diverticular disease of transverse colon is rare and perforation may occur in crohns disease c. hunter * , a. arnaout * croydon university hospital, dept. of colorectal surgey, united kingdom objective: diverticular disease commonly affects the sigmoid colon in the west and the right colon in asia. perforation is uncommon affecting / per year. perforated diverticular disease of the transverse colon is therefore very rare. we present a case of crohns disease complicating transverse diverticular disease that lead to perforation and unfortunate death. method: radiological and histopathological features are presented with a review of the literature results: to the best of our knowledge, this is the first reported case of crohns disease complicating diverticular disease of the transverse colon. we suggest that distal stricturing leading to increased intraluminal pressure or increased weakening of the colonic wall due to coincident crohns fissure and diverticulum are possible pathogenic mechanisms. conclusion: crohns disease complicating transverse diverticular disease is uncommon, but may be one pathogenesis leading to the rare event of transverse colon diverticular perforation. results: there were episodes in patients. they start between day and ( ± days). duration ranged from to days ( ± ). the three moderate and the three mild ar reversed with treatment. of the severe ar, caused the failure of the graft. five episodes de ar began as moderate or severe directly. severity in the course of each episode was fluctuating. sixteen indeterminate rejections were seen in grafts (did not reach definitive criteria). they lasted - days (mean: ± days). conclusion: -acute rejection is the most common cause of morbidity in the intestinal transplant ( % of the grafts). -it can develop at any time and relapse. -the duration and severity of the episodes are fluctuating. -in our series, % reversed, but severe rejection often lead to graft loss ( %). histopathological study of intestinal grafts lost in a series of adult transplants. hospital octubre. madrid. method: we studied explants and autopsy. the autopsy was not authorized in one death. results: seven grafts were lost in patients ( multivisceral). two types of failure were seen. a) local: severe acute rejections (ar) (days , , ) and lymphoproliferative syndrome (lps) in day ; b) systemic: sepsis (days , , ). ar showed types of morphology: ulcerative, pseudomembranous and with disappearance of the villi preserving the crypts. lps was a high-grade b lymphoma and affected the graft and the lymph mesenteric nodes with venous thrombosis that cause ischemic necrosis. the sepsis were due to acinetobacter, to adenovirus in the graft and pulmonary aspergillosis and to pseudomona aeruginosa with necrohemorrhagic pancreatitis. conclusion: -the incidence of igl was %. -the cause of igl was local (ar and lps) in % and sepsis in %. -severe ar was the most frequent cause of failure. -histological examination properly determine and document the causes of igl. cap polyposis: report of two cases r. ivanova * , d. kyoseva, g. trifonov, r. nikolov * hospital of endoclinology, laboratory of pathology, sofia, bulgaria objective: cap polyposis is a rare colorectal disease characterized by mucoid, bloody diarrhea associated with multiple inflammatory polyps covered by a cap of fibrinopurulent mucous. the disorder was first described in and up to date a small number of cases has been reported in the literature. method: we report two cases with multiple polyps of rectum and sigma, which were histologically diagnosed as cap polyposis. results: the cases were two males on age of years and years. in both cases there was a history of mucoid and bloody diarrhea. on the basis of colonoscopy findings, in the young patient there was a broad differential diagnosis including m. crohn, inflammatory pseudopolyps and cronkhite-canada syndrome. in the second case the clinical diagnosis was polyps of sigma. endoscopic biopsies and polypectomy were done. in both cases, the histology showed typical histological features of cap polyposis -polypoid lesions containing elongated, tortuous and often distended crypts covered by a cap of inflammatory granulation tissue. conclusion: the recognition of this rare disease is of practical significance because its clinical symptoms have some similarity with inflammatory bowel disease or irritable bowel syndrome. histopathological findings in consecutive appendectomies: a retrospective analysis j. jeruc * , z. dolenc stražar, v. jovic, a. cerar, n. zidar * university of ljubljana, faculty of medicine, slovenia objective: appendectomy is one of the most common surgical procedures. histology usually confirms the clinical suspicion of acute inflammation, but sometimes other clinically relevant diagnoses are made. the aim of our study was to audit the appendectomies at our institution and summarise atypical pathological findings with emphasis on benign and malignant tumours. method: we reviewed the histopathology results of consecutive appendectomies received in a -year period. results: excluding three cases of metastatic process, appendiceal tumour was found in cases ( . %), which is a higher rate than reported in the literature. there were four endocrine tumours, all g , three cases of classical adenomas, cases of low-grade appendiceal mucinous neoplasm (one associated with pseudomyxoma peritonei) and three cases of carcinoma (one mucinous adenocarcinomas, one intestinal type, one undifferentiated carcinoma). we also diagnosed one case of multicystic mesothelioma. endometriosis was diagnosed in seven cases. in cases appendicitis was associated with diverticula, in cases changes were suggestive for crohn's disease and in one case for cystic fibrosis. negative appendectomy rate was . % that falls within the range reported in the literature. conclusion: histopathological examination of appendectomy specimens may reveal many different conditions not previously suspected; therefore, it should be performed in all cases. results: cdx , muc , muc , muc ac, and muc expression was observed in . % ( cases), . % ( cases), . % ( cases), . % ( cases), and . % ( cases), respectively. while siac patients with cdx expression showed less nodal metastasis (p= . ), those with muc expression tended to have siacs with nodular or infiltrative growth (p = . ), poor differentiation (p = . ), and more lymphatic invasion (p= . ). muc ac expression was associated with siacs with well differentiation (p= . ) and frequent pancreatic invasion (p= . ). patients with cdx +/muc -had more polypoid (p= . ) and well differentiated (p= . ) tumors and a significantly better survival (median, . months, p< . ) than those with other immunophenotypes (cdx −/muc +, cdx +/ muc +, and cdx −/muc −). patients with cdx expression (median, . months) had a significantly better survival than those without cdx expression ( . months) by univariate and multivariate analyses (p< . ). conclusion: cdx expression is an independent good predictor of survival in surgically resected siac patients. small neuroendocrine tumor of appendix with metastasis in the ileocecal lymphnode: a case report g. kalan * , s. tušar, n. zidar * general hospital jesenice, dept. of pathology, slovenia objective: neuroendocrine tumors (net) of appendix are believed to behave less aggressively than nets at other sites. separate staging criteria have therefore been proposed, and tumor size > cm appears to be the dominant criterion for aggressive behavior in appendiceal nets. however, it is controversial whether radical surgery is indicated in tumors measuring > cm. we report a case of a -year-old girl with acute appendicitis in whom appendectomy and right-sided hemicolectomy were performed. method: surgical specimens were sampled and processed according to standard histological and immunohistochemical (ihk) procedures. results: in the base of appendix, there was a tumor measuring . cm in diameter, focally invading mesoappendix, with free resection margins. microscopically, tumor exhibited characteristic features of net g , with positive ihk for chromogranine and synaptophysin, and ki index < %. ihk for podoplanin revealed focal lymphovascular invasion. in the right-sided hemicolectomy specimen, there was no residual tumor, metastasis was found in one ilecoecal lymphnode. conclusion: our case shows that appendiceal net smaller than cm can metastasize to regional lymphnodes. ihk against podoplanin might be helpful in searching for lymphovascular invasion, helping to separate it from the retraction clefts, thus providing additional information concerning risk factors for a more aggressive behavior. lipomatosis of ileocaecal valve causing small bowel obstruction mimicking crohn´s disease m. kalman * , p. szépe, j. marcinek, t. balhárek, l. plank * university hospital martin, dept. of pathology, slovakia objective: lipomatosis of ileocaecal valve is a rare cause of small bowel obstruction. method: we describe a -year-old male treated for crohnś disease and clinical and imaging presentation of chronic small bowel stenosis and obstruction. results: a right hemicolectomy was performed, and hypertrophy of bauhin´s valve causing intestinal obstruction was found. microscopical examination of the specimen revealed morphological changes consistent with lipomatosis of the ileocaecal valve. the ileum and colon were macroscopicaly unremarkable and histomorphological features of crohn´s disease were absent. conclusion: many patients with lipomatosis of the ileocaecal valve are asymptomatic, or the lipomatosis gives causes insignificant symptoms only or rarely obstruction may occur. then, as in the presented case, the surgical resection with ileo-colic anastomosis is the only effective treatment. overexpression of cxcr in tumor buds is a strong predictor of lymphatic invasion and lymph node metastasis in colorectal cancer e. karamitopoulou-diamantis * , d. kassahn, i. zlobec, v. koelzer, h. dawson, a. lugli * universität bern, inst. für pathologie, switzerland objective: cxc chemokines enhance tumor cell survival and proliferation. especially cxcr promotes tumor development by stimulating angiogenesis and favoring metastasis. in contrast, cxcr is angiostatic and may exert an anti-tumor effect. since tumor budding is linked to vascular/lymphatic invasion and lymph node (ln) and/or distant metastasis in colorectal cancer (crc), here we explored the expression of cxcr + in relation to tumor budding. method: a multiple-punch tissue microarray of crcs with full clinicopathological information including therapy underwent immunohistochemistry for cxcr and cxcr . expression was evaluated in tumor-center, -front and -buds and correlated to clinical data. results: cxcr -expression was homogeneous throughout tumor-center, -front and -buds (average %) and was unrelated to clinicopathological features or survival. cxcr -expression was high in tumor-center and -front but reduced (p< . ) in buds ( %, %, and %, respectively). maintenace of cxcr -expression within buds was predictive of ln-positivity (p< . ) and lymphatic invasion (p< . ) but not of venous invasion or distant metastasis. cxcr -positivity in buds was associated to poor outcome (p= . ) in ln-negative crcs (p= . ). conclusion: maintenance of cxcr -expression in buds has a profound effect on tumor aggressiveness and prognosis in ln-negative crc-patients. this would help in establishing a tumor budding "profile" especially linked to lnmetastasis in crc. objective: cox- expression was investigated in colorectal cancer and colorectal precancerous lesions. its expression in adenomas is associated with increasing size and neoplastic potential. little is known about cox- expression in subtypes of serrated colonic polyps, which constitute substantial number of colon cancer precursors. the aim of the study was to assess cox- expression in serrated polyps of the colon and to investigate its potential discriminative role. method: consecutive serrated polyps were analyzed. they included: traditional serrated adenomas (tsa), sessile serrated polyps (ssp) and hyperplastic polyps (hp). cox- expression was assessed semi-quantitatively ( - ). kruskall-wallis test was used for the comparison of cox- expression between serrated categories (α= . ). objective: in colorectal cancer (crc), tumor buds represent a more aggressive tumor cell type at the invasive front with apparently low proliferation. the aim of this study was to determine the proliferation potential of tumor buds by comparing ki staining across different tumor areas and adjacent normal tissue. method: whole tissue sections from patients with crc underwent immunohistochemistry for ki . high-powerfields were evaluated for each of the following regions: normal mucosa, tumor center, tumor front and tumor buds. ki -positivity was correlated to patient outcome. results: average ki -positivity was . % in normal mucosa and significantly higher in the tumor center ( . %; p < . ) and invasion front ( . %; p < . ). strikingly, only . % of all tumor buds showed ki -positivity (p< . ). although ki -positivity in the tumor center or front was unassociated with clinicopathological features or patient survival, the greater the number of ki -positive tumor buds, the worse the prognosis. this effect was also found after adjusting from tnm stage (hr ( % ci): . ( . - . ); p= . )). conclusion: a marked absence of ki staining is found in most tumor buds, suggesting a substantially decreased proliferation rate. however, the association of ki -positivity with worse prognosis in % of cases points towards a heterogeneous population of tumor buds. kayexalate and intestinal necrosis: an underrecognised entity p. luís * , a. alves, c. ferreira * hospital de santa maria, dept. de anatomia patológica, lisboa, portugal objective: there are only few cases of intestinal necrosis secondary to administration of kayexalate described in the literature, most of them from postoperative patients, having the largest study only patients in years. we report our experience in the last years with a brief review of the pathophysiology and histologic aspects of the lesions induced by the kayexalate. method: between and march seven patients were diagnosed with ischemic necrosis related to kayexalate administration, five in colon biopsy and two in resection specimens. they're comorbidities and clinical evolution was extracted from the medical records. results: the patients' age ranged between and years. in one case we had the clinical information of chronic renal insufficiency. in three of them, there was no previous history of renal impairment. one patient developed symptoms after one single administration of kayexalate. the clinical presentation ranged from abdominal pain, gastrointestinal bleeding and three of them had a fatal outcome. the administration of kayexalate can have associated risks with different clinical impact in any patient. we must be aware of the related complications, as the histological identification of the kayexalate crystals indicates the etiology of the ischemic lesions to the clinicians and alerts them to the dangers of this therapeutic. objective: egfr plays an important role in colorectal cancer (crc) progression and represents a natural target for molecular anticancer drugs. in this study we evaluated consecutive crc aimed to analyze k-ras mutational status in relationship to: different clinical-pathological parameters, egfr immunohistochemical (ihc) expression, response to cetuximab treatment. method: k-ras mutations and egfr expression were determined by direct cycle sequencing and ihc respectively in surgical specimens and biopsies. ihc findings were evaluated using four different score systems. results: the distribution of k-ras mutations did not significantly vary between surgical or bioptic specimens or with respect to different anatomic tumor localization. in contrast, k-ras is more frequently mutated in egfr negative/low score tumors than in positive ones (p< . ). focusing on the surgical treated crc patients, we found a higher percentage of k-ras mutations in t crc (p= . ) and in younger patients (p= . ). finally, we observed that % of primary crc, concomitantly evaluated with their paired metastases, changed k-ras mutational status during progression. conclusion: our data showed that tumor size, patient age and egfr ihc expression significantly influenced k-ras mutations. interestingly, we observed that cetuximab treated patients, had a better clinical outcome when egfr presented a high ihc score. multiple immunohistochemical investigation of signaling pathways in colorectal cancer t. micsik * , l. kopper, t. krenács, z. nagy, o. horváth * semmelweis university budapest, st department of pathology, hungary objective: despite the recent advances in therapeutic armamnet colorectal cancer (crc) remains one of the leading cancer deaths worlwide. crc has a heterogenous molecular background with known prognostic and predictive markers, but the whole picture is rather complex with many unexplored connections. method: we performed multiple immunohistochemical stainings on tissue microarrays (tma) made of crc cases to study the correlations between egfr-ras, cell cycling, apoptosis, cell adhesion and tumor invasion pathways. we evaluated digitized slides using matrix scores considering both the frequency and positivity of cells and statistical analysis followed. results: we found strong linear correlation between positivity and (p- , p- ) phosphorylation of the egfr receptor and p positivity detected with different clones. furthermore, phospho-nf-kb p positivity was strongly linked to survivin-expression. conclusion: activation of egfr-related pathways including nf-kb is a key factor in crc-growth. the strong link between cancer promoting egfr signaling and the mutational lack of the p driven apoptosis suggests a deadly cooperation, which can be further aggravated by forced tumor survival through survivin. correlation of these markers potentially predict poor disease outcome but can be specifically targeted by the upcoming new molecules of tailored therapy. objective: kras mutational status is important in colorectal carcinoma (crc). it is unclear, however, which is the most informative tissue source for study in crc cases showing more than one tumor mass. to explore this issue we determined kras status in a series of primary (pt) and metastatic crcs. method: a total of tumors belonging to patients ( males and females) with ages ranging between and years (average, years) were studied. kras mutation hotspots in codon and were analyzed by polymerase chain reaction and sequentiation. wt-kras cases were confirmed with the kras stripassay tm. objective: lynch syndrome (ls), the most frequent form of hereditary colorectal cancer (crc), is caused by germline mutations in the mismatch repair system genes. a recently identified mechanism involving the epcam gene is responsible for . % of msh -negative ls cases. we herein explore epcam protein expression in ls-associated, msh -negative crcs to evaluate its potential value in the algorithmic approach to ls population screening. method: we studied a total of msh -negative crcs from different patients in whom we were able to perform a complete germline analysis. expression of both msh ( : dilution, clone g - , pharmingen) and epcam ( : dilution, clone ber-ep , dako) was evaluated by immunohistochemistry (ihc). results: nine patients showed a deleterious germline mutation that involved the msh gene in three instances and the epcam gene exon in six instances. all patients harbouring the epcam mutation belonged to the same family. of the crcs, epcam expression loss was seen in only five, all of them were from patients with a germline epcam deletion. conclusion: due to the high specificity of epcam protein loss for identifying ls patients with an epcam deletion, we recommend adding epcam ihc to the ls diagnostic algorithm in msh -negative crc cases. objective: colorectal carcinoma with signet ring cell component (crc-src) is a rare and distinct subtype with little molecular information. we investigated the frequency of braf mutation in crc-srcs and its relation with clinicopathologic parameters. method: we categorized tumors into groups - %, - %, - % and > % according to signet ring cell component. genomic dna was isolated from parafin blocks and analyzed for braf v e mutation by polymerase chain reactionrestriction fragment length polymorphism (pcr-rflp). results: eleven of cases showed braf mutation ( . %). the results were also confirmed with sequence. no statistically significant differences were found in clinicopatologic parameters between braf wild-type and mutant crc-src. on the other hand, when we adjusted age, gender, percentage of signet ring compenent and stage, we found a statistically significant increased risk in braf mutant group compared to braf wild-type in cox regression analysis (hr= . , % ci= . - . , p= , ) conclusion: braf mutation is frequent in crc-srcs. this finding may support its diverse molecular pathogenesis and could have important therapeutic implications for those patients. to clarify the relation of braf mutation with clinicopathologic parameters and prognosis in crc-src, studies with multi-instutional larger series are needed. coexisting lipomas and adenocarcinoma of the colon: case report g. orgun sonmez * , u. bayol, o. akman, s. cumurcu, m. olmez * tepecik research and training hospital, izmir, turkey objective: lipomas of the large bowel are rare, they are invariably submucosal and therefore may intussuscept. infrequently lipomas may also present in the form of multiple polypoid masses in the colon. we present a -years old female with submucosal lipomas and a coexisting adenocarcinoma of transverse colon. method: -years old female patient was admitted to hospital because of rectal bleeding for months. colonoscopic examination revealed mucosaly intact polypoid tumoral masses and an ulcerated tumoral mass in transverse colon. biopsy of the ulcerated mass was diagnosed as adenocarcinoma. extended right hemicolectomy was performed. results: grossly, ulcerated tumor was , × × , cm and there were polypoid tumors in cecal area of the right colon which were . - . - . cm in their greatest dimensions. polypoid tumors were yellow, lipomatous on cut surfaces. microscopically ulcerated tumor was composed of adenocarcinoma morphology and the other polypoid tumors were composed of submucosal mature adipocytes with a thin capsule around them. the diagnosis was colonic adenocarcinoma (pt n m ) and submucosal lipomas of colon. the patient had no additional therapy and she is healthy with no evidence of recurrence. conclusion: this case is presented to remind that there may be multiple lipomas of colon with coexisting malignant epithelial tumors. objective: primary liposarcoma of the small intestine is exceedingly rare. to our knowledge, only cases have been reported so far. we report a case of the primary myxoid liposarcoma of the ileum. method: the patient was -year-old woman. ct and mri revealed a -cm-intrapelvic mass, which was proved to be a tumor of the distal part of the ileum, and, therefore, partial ileectomy was performed. results: the tumor was . × . × . cm in size, relatively well circumscribed and located within the intestinal wall without invasion to the neighboring tissues. microscopically, the tumor had mixture of cellular and myxoid areas, showing proliferation of short spindle and stellate shaped cells in a delicate capillary vasculature. univacuolated tumor cells and a small number of lipoblast-like cells were also seen. immunohistochemically, these proliferating cells were positive for s- protein. according to these pathological findings, we diagnosed the tumor as myxoid liposarcoma. fish methods showed the tumor had chromosomal translocation t( ; )(q ;p ). conclusion: the differential diagnosis of this includes other spindle cell tumors such as gist and myogenic tumors. but we could arrive at the proper pathological diansosis following the above morphological features and the specific chromosomal translocation. we will also discuss the clinico-pathological features of the cases including ours. prognostic significance of selected immunohistochemical markers in colorectal cancer e. paltseva * , o. samofalova, y. gorbacheva, p. tsarkov * first moscow state medical university, pathology, russia objective: the aim of our study was to identify a combination of markers whose expression is predictive of invasion and metastasis of colorectal carcinoma. method: the expression of e-cadherin, β-catenin, tenascin c, kai- , epidermal growth factor receptor (egfr) and vascular endothelial growth factor (vegf) was studied immunohistochemically and correlated clinicopathologically in primary colorectal carcinoma cases ( with metastatic lymph nodes). patients ( %) developed haematogenous metastases at median , months postoperatively ( - ). results: expression of following markers significantly correlated with depth of tumour invasion: cytoplasmic accumulation of e-cadherin (p= , ), nuclear staining for β-catenin (p= , ), increased tenascin c expression (p= , ), and loss of egfr and vegf expression (p= , and , , respectively). decreased tenascin c and kai- expression associated with the presence of lymph node metastases (p= , and , , respectively). weak cytoplasmic e-cadherin expression correlated with distant metastases (p= , ). conclusion: our results suggest that abnormal expression of proteins involved in cell adhesion and migration (e-cadherin, βcatenin, tenascin c, egfr) and angiogenesis (vegf) may be related to the invasion of colorectal carcinoma. detecting the expression of e-cadherin, tenascin c and kai- probably possesses clinical significance in evaluating lymph node and distant metastasis and predicting the prognosis of colorectal cancer. objective: in colorectal adenocarcinomas (crcs) microsatellite instability (msi) can be documented by immunohistochemical detection of mismatch repair proteins (mmr). the aim of the present study is to identify the percentage of msi-positive crcs, in the epirus region of greece and compare it to the international data. method: a total of cases of sporadic crcs, adenomas and hyperplastic polyps, formalin-fixed paraffinembedded, were examined immunohistochemically using standard methods (en vision system), with the antibodies mlh (clone es ), msh (clone pu ) and pms (clone m r g) (novocastra-menarini). immunostained sections were evaluated semi-quantitatively, taking in account the percentage of neoplastic positive cells and estimating nuclear staining intensity, compared to the internal positive controls (normal epithelium, lymphocytes). results: all hyperplastic polyps and adenomas expressed the examined mmr. two out of crcs were negative for msh and pms , while one of them was also negative for mlh . interestingly, one of these two crcs had an adjacent adenoma, which also showed negative staining for msh and pms . conclusion: immunohistochemical staining for mmr is possible in archival material. loss of mmr varies, depending on the protein examined. in crcs from the epirus region the estimated loss of at least two mmr is %. objective: matrix metalloproteinases (mmps) are a family of zinc-dependent neutral endopeptidases collectively capable of degrading essentially all extracellular matrix (ecm) components. genetic alterations in mmp- and mmp- have been implicated to play an important role in colorectal carcinogenesis (crc). the aim of this study was to investigate the hypothetic correlations between the mmp- and mrna expression and the clinicopathologic variables of the crc. method: the expression of mmp- and - mrna was assayed by rt-pcr for tunisian sporadic colorectal adenocarcinomas. results: mmp- was highly expressed in the cases. mmp- was not detected in cases and moderately or highly expressed in cases. absence of mmp- mrna expression was significantly related to an advanced tumoral invasion stage (pt ) (p= . ). conclusion: our study suggests that the overexpression of mmp- could be the result of an imbalance in the system of transcriptional regulation of mmp- , which would involve the loss of expression or activity of its inhibitor: timp- . a variable expression of transcripts of mmp- could be explained by the hypothesis of hypermethylation of the promoter or degradation of its transcript after protein translation. relationship between matrix metalloproteinases and promoter polymorphisms and colorectal cancer risk objective: the carcinogenic schema of colorectal cancer (crc) follows a multistep process governed by mutational events that affect multiple micro-environmental factors, including matrix metalloproteinases (mmps). this present work aims to contribute to a better understanding of mmp- and - promoter polymorphisms involvements in the genesis and progression of sporadic crc in tunisian population. method: the mmp- and mmp- promoter genotypes were determined by pcr-rflp in tunisian patients with sporadic colorectal cancer and healthy control subjects. results: no significant associations were found regarding mmp- (- c/t) polymorphism and crc susceptibility. there was a connection between the mmp- - promoter polymorphism and gender (p = . ). the mmp- (− c/t) was significantly associated with crc (or= . [ . to . ]). no implication of mmp- - promoter polymorphism in the clinicopathological parameters of crc was evident. conclusion: our findings suggest that the mmp- promoter polymorphism was not a predictive factor for the crc occurrence while the mmp- - ct genotype was a risk factor for crc susceptibility. hodgkin's lymphoma in distal rectum in a patient with crohn´disease treated by biologic therapy -a case report r. sampaio * , f. costa, e. diane, j. palla garcia, j. r. vizcaino * anatomia patológica, valpaços, portugal objective: rare cases of hodgkin`s lymphoma have been reported in the setting of inflammatory bowel disease. method: we report a case of hodgkin`s lymphoma in a years old male patient with corticosteroid-dependent crohn´disease (cd) who had been medicated with azathioprine for many years. in the last years he began periodical therapy with infliximab, till the time when he complained of worsening of symptoms and the appearance of asthenia, tenesmus and weight loss. infliximab was withdrawn and replaced by adalimumab. a colonoscopy with several biopsies revealed the presence of a hodgkin lymphoma. results: the histological examination revealed granulation tissues where we identified atypical cells (reed-sternberg cells) with the following immunohistological staining: cd +, cd +, lmp + lca-, cd -, cd -, alk-. these results in conjunction with the morphological aspects and the clinical history of cd favored the diagnosis of hodgkin lymphoma in a patient with preceding cd. the patient was subjected to radical colectomy. postoperative pathological examination showed cd with involvement of the distal rectum by hodgkin's lymphoma. conclusion: the present report may serve as a reminder to clinicians of the possibility of occult lymphoma in patients with colonic cd treated with biological therapy. objective: dna mismatch repair (mmr) status in sporadic colonic cancers (ccs) had provided valuable prognostic and predictive information in the appropriate clinical setting; however there are no definitive guidelines for microsatellite instability (msi) testing. we evaluated the expression of mmr proteins and correlated them with outcome in a cohort of patients with sporadic colon cancer. method: we reviewed cases of sporadic stage ii colonic cancer from abril th to december th . clinical data including tumor grade, prognostic factors, therapy and outcome were searched for. tissue microarrays using a manual beecher system were constructed and stained with antibodies for mlh , msh , pms and msh . results: % ( ) of ccs had loss of expression of one or more mmr proteins, including defect in protein . % ( ), proteins , % ( ) and tree proteins , %( ). the mean overall survival was months with no significant differences in patients between microsatellite stable and unstable tumors. conclusion: we detected a fairly low prevalence of the loss of immunohistochemical expression of mmr proteins. this result might have influence our mean overall survival between microsatellite stable and unstable tumors. the pathological effects of orchidectomy on intestine tissue and serum level of carcino embryogenic antigen s. sattari * , r. ahmadi * azad university of iran, science dept., hamedan, iran objective: carcino embryogenic antigen (cea) is a wellknown tumor marker influenced by carcinogenic changes in intestine tissue. the purpose of this study was to determine the effects of orchidectomy on serum level of cea and histological changes of intestine in male rats. method: male wistar rats were randomly divided to control, sham, uni-orchidetomised and biorchidectomised groups of in each. weeks after operation, blood samples were collected using cardiac puncture method. serum cea level was measured using elisa method. the effect of orchidectomy on intestine tissue was also histologically studied. the results were statistically analyzed using anova. results: serum level of cea was significantly increased in orchidectomised rats compared with control animals (p< . ). the increase in serum cea level was more in biorchidectomised than uniorchidectomised rats (p< . ). there was also an enhancement in tissue lymphocytes, plasma cells and inflammation in intestine of orchidectomised animals. the results showed that orchidectomy results in pathological changes in intestine tissue leading to increased serum cea level. the plasma cells density in pararectal lymph nodes of patients with rectal cancer after neoadjuvant therapy m. sezak * , n. ozsan, b. pehlivanoglu, s. ozkok, t. yoldas, b. daganavsargil * ege university, dept. of pathology, izmir, turkey objective: neoadjuvant chemoradiotherapy (nt) is standard procedure for locally advanced rectal cancer. in this study, we compared the morphology of lymph nodes and the amount of plasma cells in the interfollicular region of lymph nodes in rectal tumour surgical excision material, between two groups who had received and not received nt prior to surgery. method: fifty cases with nt and forty cases without nt were included. the number and diameter of lymph nodes were recorded. the morphology of the lymph nodes were evaluated, and the percentages of interfollicular plasma cells were demonstrated immunohistochemically (cd ). tumor regression grade was assessed using mandard scoring system. results: average number and diameter of lymph nodes were greater in patients without nt (p< , ). atrophy of germinal centers was noted as % in nt group, versus %. the amount of plasma cells in the interfollicular region was found to be higher than fifty-one percent in % of nt group versus % (p< , ), as well. complete response rate (mandard's: ) was %. no significant association was found between the amount of plasma cells and tumor regression. conclusion: nt leads to a decrease in the volume of the lymph nodes and atrophy of germinal centers, conversely, causes stimulation of the proliferation of interfollicular plasma cells. adenomyoma of the ileum: pathohistological features with reference to pathogenesis b. snezana * , b. andrejic, n. solajic * clinical center of vojvodina, center for pathology, novi sad, serbia objective: adenomyoma is a rare benign non-neoplastic tumor-like lesion. it originates from abnormal embryonic buds but its pathogenesis has not been fully elucidated. method: a -year old man with severe pain, intussusception and ileus underwent a resection of a part of the intestine containing a tumor mass acting as a lead point. tissue was analysed using h&e, histochemical and immunohistochemical stains. results: lesion located in the mucosa, submucosa and muscularis propria consisted of glandular structures varying in size and morphology, the larger ones containing papillary projections and the smaller ones being similar to brunner's and peribiliary glands, both of them surrounded by smooth muscle bundles. the lesion was not accompanied by ectopic pancreas, and it indicated a diagnosis of adenomyoma of the ileum. glandular elements were ck + and ck − and cdx- −, opposite to intestinal mucosa. conclusion: adenomyoma is a mass lesion rarely found distal to the duodenum, which bares close clinical and morfological resemblance to a tumor and some non-neoplastic conditions. cytokeratin expression favors the heterotopic pancreas theory of pathogenesis, but abnormal interaction between the endoderm-and mesoderm-derived tissues can not be excluded. smoothelin in biopsies of colorectal carcinomas as marker of muscularis propria invasion p. stoemmer * , p. torres-galea * gemeinschaftspraxis pathologie, forschungslabor, augsburg, germany objective: staging of colorectal carcinomas is of eminent importance for prognostication and treatment; preoperative distinction between high grade dysplasia, invasion of submucosa (with permigration of the muscularis mucosae mm) and infiltration of muscularis propria (mp) is difficult in biopsies, due to similarities of smooth muscle cells in mm and mp. smoothelin is a robust marker of the mp in normal colon, not expressed in mm.we analysed it value for distinguishing mp and mm near carcinomas. objective: tuberculosis can affect any part of the gastrointestinal tract. anal localization, in particular, has a very low incidence ( , %). method: a year-old male presented, complaining of perianal pain, constipation, weight loss of kilos the last months and night sweating. physical examination was normal, except for an ulcerated lesion in the anal region. the patient was submitted to computerized tomography (ct) and incisional biopsy of the lesion. results: the ct of the chest revealed multiple, scattered, calcified nodules in the upper zones of both lungs and histological examination showed confluent, non-necrotizing, epithelioid granulomas with the presence of langhans' multinucleated giant cells. acid-fast bacilli were detected both within the anal lesion and in the sputum. mantoux test was positive. the patient had a history of pulmonary tuberculosis years ago. a diagnosis of anal tuberculosis was made and the patient was put on a four drug anti-tuberculous regimen. in months the symptoms improved and the perianal lesion healed. conclusion: a tuberculous origin must be considered when the cause of anal and perianal lesions is unclear. therefore histological and bacteriological confirmation is essential in order to avoid undue delay in diagnosis and treatment. the relation of braf v e mutation and microsatellite instability in colorectal carcinomas i. turkmen * , n. bassüllü, b. toptas, t. Öztürk, r. yasar, p. korkmaz, n. saygili, o. Öztürk, g. demir, g. dogusoy * istanbul bilim university, dept. of pathology, istanbul, turkey objective: colorectal carcinogenesis is associated with various morphological and molecular pathways. microsatellite instability (msi) pathway has familial and sporadic forms. among crc's % of the sporadic cases are associated with msi and these have hypermethylation of the mlh promoter associated with braf v e gene mutation. familial forms do not show braf v e mutation. method: we investigated the microsatellite instability (msi) by immunohistochemical study of mlh , pms , msh and msh together with the braf mutation presence and their correlation with standard histopathological parameters in sporadic crc cases. results: the age distribution was - with an average of , . immunohistochemical expression loss of mlh , pms , msh and msh was seen in , %, , %, , % and , % of the total cases respectively. msi was seen in , % of the cases. the braf v e gene mutation was seen in cases and among these cases ( , %) showed msi, while msi frequency was , in non-mutated group. and this was statistically significant (p < . ). msi was found significantly correlated with grade and lymph node number (p< . ). conclusion: our study confirmed that sporadic cases of crc with msi are associated with the braf v e gene mutation. msi is correlated with histologic grade and dissected lymph node number. colon biopsy diagnostics may reliably be performed using virtual microscopy objective: virtual microscopy using whole slide images (wsis) is a feasible alternative to optical microscopy, offering major advantages for pathology practice. the present study aims to prove reliability of this promising technique for colon biopsy diagnostics. method: colon biopsies (n= ) were assessed (into main diagnostic groups) using both glass slides and wsis by pathologists and residents. two of the pathologists having ample experience using wsis, scored the biopsies in a primary diagnostic setting. for each case the criterion standard diagnosis was defined based on glass slide diagnoses. accuracy was defined as the percentage of concordance with the criterion standard. kappa statistics were calculated as a measure of observer agreement. results: the overall concordance rates were . % for wsis and . % for conventional microscopy. the intraobserver (wsis versus glass slides) agreement was good to excellent, with kappa values ranging from . to . (mean . ) and was higher than the interobserver agreement for glass slides (mean . ). concordance with the criterion standard varied less between wsis and glass slides in the diagnoses of pathologists with virtual experience. conclusion: this study showed good diagnostic accuracy and reproducibility for wsis, indicating this technology may be used for colon biopsy diagnostics. intestinal occlusion due to colonic lipoma: a case report f. vukmirovic * * clinical center of montenegro, dept. of pathology, podgorica, montenegro objective: lipomas of the digestive tract are rare benign tumor and most often found incidentally during a colonoscopy, computed tomography scan, surgery or autopsy. lipomas of the colon were first reported by bauer in and are most often located in the ascending colon. the incidence of this lesion is estimated between . and . % and represents . % of the colonic benign lesions. we report a case of patient with symptoms of ileus due to colonic lipoma. method: a -year-old man patient was urgently admitted with symptoms of ileus. right hemicolectomy was performed, and clinical impression was that it was a malignant tumor. results: examination of the cecum we found polypoid whitish yellow tumor, size × , cm. on histology the tumor was composed of mature adipose tissue without cellular atypia. the tumor was located into submucosa. larger parts of the surface mucosa was eroded. the postoperative course was uneventful and intestinal passage was quickly established. conclusion: although colonic lipomas seldom cause severe symptoms in patients and are easily removed by endoscope while they are small, severe symptoms like abdominal fullness, intestinal obstruction, intestinal bleeding and intussusceptions may appear as a lipoma grows larger. in some cases lipoma may clinically mimic colonic carcinoma. prognostic impact of lymph node ratio outperforms positive lymph nodes and lymph nodes harvested: a time-dependent analysis in mismatch repair-proficient and -deficient colorectal cancers i. zlobec * , e. karamitopoulou, l. terracciano, d. inderbitzin, a. lugli * university of berne, inst. of pathology, bern, switzerland objective: we compare the prognostic strength of the lymph node ratio (lnr), positive lymph nodes (+lns) and collected lymph nodes (lncoll) using a time-dependent analysis in colorectal cancer patients stratified by mismatch repair (mmr) status. method: stage iii-iv patients were included. multivariable cox regression analysis and time-dependent receiver operating characteristic (troc) curve analysis were performed. the area under the curve (auc) over time was compared for the three features. results were validated on a second cohort of stage iii-iv patients. results: the auc for the lnr was . and outperformed + lns and lncoll by - % in both mmr-proficient and -deficient cancers. lnr and + lns were both significant (p < . ) in multivariable analysis but the effect was considerably stronger for the lnr [lnr: hr= . ( % ci: . - . ); +lns= . ( % ci: . - . )]. similar results were obtained for patients with > lncoll. an optimal cutoff score for lnr = . was validated on the second cohort (p< . ). conclusion: the lnr outperforms the + lns and lncoll even in patients with > lncoll. its clinical value is not confounded by mmr status. a cut-of score of . may best stratify patients into prognostic subgroups and could be a basis for the future prospective analysis of the lnr. prognostic value of tumor-stroma ratio in rectal adenocarcinomas s. zoidze * , r. scheer, j. klaase, m. elferink, a. baidoshvili * laboratorium pathologie oost, enschede, netherlands objective: recently, tumor-stroma ratio (tsr) has been identified as a strong predictor for survival in colorectal cancer. despite an identical biology clinical implications are quite different for colon and rectal cancer regarding to anatomical differences. method: tsr was estimated on h&e stained histological sections of patients who underwent resection for rectal adenocarcinoma between and . none of these patients had received neoadjuvant chemo-or radiotherapy. the tsr was determined, by two independent investigators, in different layers of the rectal wall at the point of highest tumor infiltration and at the border of the tumor. tsrs were categorized into three categories: tsr-low, tsr-moderate and tsr-high. results: patients with stage i and ii disease (t - n ) and tsr-high showed significantly better year survival rates for overall survival compared to tsr-low and tsr-moderate (p= . ) and a trend to a better disease specific survival (p= . ) and disease free survival ( . ). in a multivariate cox regression analysis the tsr remained an independent prognostic factor for overall survival, when adjusted for age, pt-status and grading. conclusion: tsr as a prognostic tumor characteristic can be used to identify patients with a good and a poor outcome in lymph node metastasis negative cases. objective: goblet cell carcinoid (gcc) of appendix vermiformis is a rare neoplasm that share histological features of both adenocarcinoma and carcinoid tumor. while its malignant potential remains unclear, gcc's particularly show transmural dissemination and are more aggressive than conventional carcinoids. patients usually present with acute appendicitis. they usually lack the formation of a well-defined tumor mass; thus, it is somewhat difficult to accurately assess their size. method: case presentation: fifty years old male patient applied to the emergency service with abdominal pain and laparatomy was performed with suspicion of acute appendicitis. grossly, conjestion and exudation on the distal edge of appendectomy material were seen. a × cm lesion which was spreading into peripheral adipose tissue was seen on the cut surface. microscopically, tumor was composed of goblet cell groups resembling "signet ring cells". tumor was infiltrated into muscularis propria and mesoappendix. immunohistochemically, chromogranin, synaptophysin, cytokeratin , mcea and p were stained positive. ki (mib ) proliferation index was %. conclusion: adenocarcinoid of the appendix is a rare tumor, which is very difficult to diagnose preoperatively and even macroscopically, making histological examination essential. immunohistochemical staining is required for definitive and differential diagnosis. here, we present this rare case with literature reviewed. normal colon tissue and colon carcinoma show no difference in heparanase promoter methylation d. hershkovitz * , y. peerless, e. simon, e. sabo, o. ben-izhak * rambam health care campus, dept. of pathology, haifa, israel objective: heparanase, the sole heparan sulfate degrading enzyme, has a role in cellular invasion. accordingly, a large number of studies have demonstrated an association between heparanse expression and tumor stage and patients' prognosis. in colon carcinoma, heparanase shows increased expression in tumor compared to normal tissue and its expression correlates with the presence of metastasis. one of the regulatory mechanisms of heparanase expression is methylation on its promoter. in the present study we evaluated the role of heparanse promoter methylation in colon carcinoma. method: analysis of heparanse promoter methylation was done on samples of colon carcinoma as well as sample of normal colonic mucosa. dna was extracted from ffpe tissue and subjected to bisulfite conversion. the relative fraction of methylated and unmethylated dna was evaluated with real-time pcr. results: the fraction of methylated dna was %± . in the colon carcinoma group, and . %± . in the normal colon group (p= . ). only one case in the normal group and one case in the tumor group showed more than % methylation in the heparanase promoter. conclusion: we did not find any difference in heparanase promoter methylation between colon carcinoma and normal colonic mucosa, suggesting that heparanase overexpression in colon carcinoma is mediated by other mechanisms. objective: among b-cell non-hodgkin's lymphomas, neural cell adhesion molecule/cd expression is exceptional. the aim of this study is to report unusual cd (neural cell adhesion molecule, ncam) expression on diffuse large b cell lymphoma (dlbcl). method: the panel of antibodies included cd , cd , cd , bcl- , bcl- , mum- and cd . results: a total of cases of dlbcl were identified and one case was also detected positive for cd . the subject was female, years old. the patient had presented generalized lymphadenopathy. she had not documented involvement of extranodal sites. the case is alive with disease year after diagnosis and chemotherapy treatment. objective: a case of mediastinal t-cell lymphoblastic lymphoma with indolent clinical course in a -yearold man was studied by immunohistology and molecular biology. method: formalin-fixed sample. histology with ematox-ilin&eosin and giemsa; immunohistochemistry by apaap method. t-cell receptor gamma rearrangement by biomed protocols. results: after one fainting episode the patient was found to have pericarditis caused by a xx-cm-diameter mediastinal mass. the first biopsies were unsuccessful and the third diagnostic one was done months later. in this time-period the patient was well without symptoms and the mass stable. after two mediastinal biopsies with unspecific features (castleman disease?), the diagnostic one showed fibrosis, abundant small reactive lymphocytes (cd +/cd +) and areas with diffuse small-medium size lymphocytes positive for cd , tdt, cd , cd , lmo and high ki . t-cell receptor gamma genes were monoclonally rearranged. conclusion: indolent t-lbl is exceedingly rare: for this reason in our case lmo was a key marker for the diagnosis which was delayed for the presence of fibrosis and reactive b cells. objective: granulocytic sarcoma (gs), also termed myeloid sarcoma or chloroma, is a rare malignant solid tumor resulting from the extramedullary proliferation of myeloblasts or immature myeloid cells. gs most frequently occurs in patients with acute myeloid leukemia, myeloproliferative neoplasms or myelodysplasia. gs rarely presents in the absence of systemic myeloid disease. gs most commonly occurs in the soft tissues of the head and neck, bone, skin and less often in the central nervous system and spinal cord. results: a year old woman presented with month history of weakness of both legs. mri of the thoracal spine showed cm diameter epidural mass compressing the dural sac in the spinal canal at the t - levels. decompressive laminectomy and tumor removal were performed resulting in neurological improvement. histologically neoplastic cells have round nuclei with finely dispersed chromatin and scant cytoplasm proliferating in a diffuse pattern. immunohistochemically, tumor cells were positive for mpo, cd , cd , cd . diagnosis was gs without bone marrow involvement. conclusion: we report the case of gs due to unusual localization and nonleukemic presentation. results: there were males and female with a median age of years ( - years). physical examination shows splenomegaly in all cases and hepatomegaly in cases, hematological parameters shows lymphocytosis with peripheral hairy cells in all cases. flow cytometric immunophenotyping was done in cases, and confirmed the diagnosis of hcl with cd c, cd +, cd +, cd +, and cd -, cd -, and cd -. bone marrow biopsy was done in all cases, showing massive infiltration with villous cytoplasmic projection cells that were cd positive. the treatment consists of blood transfusion in all cases, associated with splenectomy in cases, only patient was treated with ( cda: cladribine) with a complete remission after a follow up of months. conclusion: hcl has consistent cytologic histologic and immunologic features that make classification reliable and reproducible; it remains problematic because of the variety of the disorders and the differential diagnosis of splenic lymphoma of the marginal zone. objective: primary cns lymphomas (pcnsl) are uncommon tumors in immunocompetent patients, they represent up to % of non hodgkin lymphomas (nhl) and - % of all brain tumors. the majority of pcnsl are diffuse large b cell lymphomas, - % are t cell lymphomas, in rare instances low grade b cell lymphomas. we determine clinical characteristics, histological findings and treatment outcome of pcnsl. method: five cases of pcnsl occurring between and were retrospectively reviewed. results: they were males, female, median age years, range ( - ). most common symptom was neurological deficits ( cases). mri of the brain revealed an expansive tumor affecting the parietal bone in cases, the temporal bone in cases and the frontal bone in case. immunohistological finding showed large b-cell nhl in cases, anaplastic lymphoma in cases, and large-cell immunoblastic lymphoma in case. treatment consists on exclusive tumoral resection in cases, surgery and chemotherapy ( case), complicated by death in all these cases. surgery followed by high dose chemotherapy and radiotherapy ( case) with complete remission after a follow-up of years. conclusion: chemotherapy followed by involved field irradiation appears to be an adapted therapy. objective: primary cutaneous non-hodgkin's lymphoma (pcnhl) is defined as lymphoma limited to skin without extra-cutaneous involvement at presentation. we describe here epidemiological and histo-pathological aspects of pcnhl. method: retrospective review of clinical data of pcnhl patients diagnosed in hematology department, frahet hached hospital, sousse ( . results: fourty three patients with pcnhl, median age: years ( - ), sex-ratio was . . the site of cutaneous involvement was upper lumb in cases, lower lumb in cases and disseminated in cases. pcnhl was small t cell lymphoma in cases, large b cell lymphoma in cases, anaplastic, cd + cd + hematodermic neoplasm, and follicular type in case respectively. according to tnm classification cases were t bnxmx, cases were t n m . after first line therapy, patients in cr, pr was obtained in case and failure in cases, patients relapsed within to months (median months), all of them were disseminated cases. conclusion: our study indicate that the extend of cutaneous involvement at the time of diagnosis is a significant prognostic factor in pcnhl. objective: follicular lymphomas (fls) account for one third of non hodgkin lymphomas (nhls) in adults. the disease is characterized by a response to initial treatment, followed by relapses, sometimes associated with histologic transformation into high grade nhl. analyze epidemiological characteristics of patients with fl. method: retrospective study of of adult fls diagnosed in hematology department ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: median age was years ( - ), sex-ratio: . the most frequent clinical symptom at diagnosis was lymphadenopathy in cases. involvement of the spleen in cases. b symptoms were present in cases. performance status was more than in cases. according to the international prognostic index (flipi), patients have low index, have intermediate index, and have high index. grade fl was seen in the majority of cases. treatment modalities varied over time and according to the disponibility of drugs especially to anti cd monoclonal antibody. cr was obtained in cases, pr in cases; patients relapsed within - months. histologic transformation was seen in cases, we have noted deaths related to the disease in cases. conclusion: treatment results in fl might not only be improved by more effective induction regimens but also by maintenance treatment. objective: cd and fli- are widely used for their diagnostic utility in ewing sarcoma/peripheral neuroectodermal tumor (es/pnet). cd expression has been documented in a variety of tumors, including lymphoid malignancies of t cell origin. also fli- expression is common in different tumor types. however, few studies have investigated the cd and fli- immunoreactivity in diffuse large b-cell lymphoma (dlbcl). we aimed to determine the frequencies of cd and fli- immunohistochemical expressions in dlbcl which may lead to a misdiagnosis. method: cd and fli- expressions are retrospectively investigated by immunoperoxidase staining in prechemoterapy primary tumors of dlbcl cases. results: out of cases, cd and fli- expressions were observed in ( . %) and ( . %) tumors, respectively. concomittant expressions of cd and fli- proteins were found in / ( . %) cases. the present study revealed that cd and fli- are frequently expressed in dlbcl, thus dlbcl should be considered in the differential diagnosis of cd + and fli- + neoplasms. primary cutaneous marginal zone lymphoma with biclonality e. beretouli * , t. koletsa, a. bouzakis, s. mavropoulou, g. karkavelas, i. kostopoulos * ahepa hospital, dept. of pathology, thessaloniki, greece objective: primary cutaneous marginal zone lymphoma (pcmzl) represents a b-cell lymphoma which presents with papules, plaques or nodes. the presence of a monotypical light chain b cell population supports the diagnosis of pcmzl. we describe a case of pcmzl which showed different light chain restriction in two heterochronous lesions. method: Α year-old male patient presented in with a cutaneous nodule in the anterior surface of the tibia, which was totally excised. the patient did not show other lesions since , when a new cutaneous nodule located in the right ankle, was appeared. immunohistochemical analysis was performed in both biopsies. results: histological and immunohistochemical findings of both biopsies were consistent with marginal zone lymphoma of the skin with lambda light chain restriction in the biopsy of the first lesion and kappa light chain restriction in the biopsy of the second lesion. blood laboratory studies, chest and abdominal computerized tomography scans revealed no evidence of systemic involvement by lymphoma. conclusion: the finding of both kappa and lamda light chain restricted b cell populations in pcmzl is unusual. the monoclonal light chain switching in pcmzl is rare and its pathogenesis is discussed. objective: microvessel density (mvd) has prognostic significance in some malignancies. little information exists about angiogenesis in mantle cell lymphoma (mcl), although antiangiogenic drugs are used experimentally. prognostic factors of mcl are needed as outcome and therapy are heterogeneous and often unsatisfactory. the aim is to assess mvd in mcl and to evaluate its prognostic significance. method: mcl specimens (ffpe) were examined by immunohistochemistry with anti-cd antibody. mvd was quantified using systematic uniform random sampling and unbiased counting frames. clinical data were analyzed in kaplan-meier survival curves and log-rank test. results: median survival (ms) of all patients was months, median progression-free survival (mpfs) months. mean mvd was , microvessels/mm , median , /mm . dividing cases into quartiles: < , /mm , < , /mm , < , /mm and ≥ , /mm ( , , , cases), ms and mpfs did not differ statistically significantly between these groups (p= , ; similar for therapy groups). visible differences are only between the fourth quartile and the rest: objective: plasmablastic lymphoma (pbl) is a rare aggressive subtype of diffuse large-b-cell lymphoma which occurs primarily in the oral cavity of hiv-positive patients. it is extremely rare in immunocompetent patients. method: a total of cases of pb were retrospectively analyzed. all cases had tissue available for immunohistochemistry and in situ hybridization. results: the age range of the patients was - years (median ) and all were men. three patients were hiv negative. hiv + patients: tumors involved the oral cavity (n = ), and small intestine (n= ). hiv-patients: tumors were located in bone marrow (n= ) and lymph nodes (n= ). all tumors were composed of monomorphic plasmablastic cells. tumors were negative for cd and cd , while they showed diffuse positivity for cd , cd , mum and ema. by ish, monoclonal light chain restriction was detected. ebv (eber) was positive in all cases. the median overall survival was , months regardless of the intensity of chemotherapy. only one patient is alive month after diagnosis. conclusion: pbl may appear in non immunocompromised patients and other locations than oral cavity. any patient diagnosed with pbl should be tested for hiv. patients who had hiv-negative pbl have lower rates of oral involvement. spinal granulocytic sarcoma preceding clinical manifestation of acute myeloid leukemia v. cemerikic-martinovic * , n. drndarevic, n. andjelkovic, p. djordjevic, d. jovanovic, r. nikolic, t. martinovic * beo-lab, dept. of pathology, belgrade, serbia objective: granulocytic sarcoma is a rare malignant neoplasm of primitive myeloid cell origin, most commonly found in association with acute myeloid leukemia. granulocytic sarcomas generally occur in the soft tissues, bone, and skin. method: we report a case of a -year old man with spinal granulocytic sarcoma manifesting as rapidly progressive paraplegia preceding clinical manifestation of acute myeloid leukemia. results: magnetic resonance imaging revealed a tumor in lumbal spine (l -l ). baseline laboratory data were normal. he underwent emergent laminectomy and the tumor was totaly resected. histological examination of lesion demonstrated diffuse proliferation of large atypical cells with round nuclei with delicate chromatin and one or more prominent nucleoli. immunohistochemical studies revealed positive staining for lca, cd , cd , cd , lysozyme and cd while myeloperoxidase, lymphoid, neuroendocrine markers, s- and cd were negative. the final histological diagnosis was granulocitic (monoblastic) sarcoma. no chromosomal aberrations were detected by fish. a month later, acute myelomonocytic leukemia was diagnosed upon a peripheral blood and bone marrow examination showing an increased number of abnormal monoblasts. chemotherapy, with multiple regimens for leukemia in combination, did not affect the tumor and the patient died. conclusion: granulocytic sarcoma should be considered in the differential diagnosis of spinal tumors. objective: survivin, a member of the inhibitor of apoptosis family might play an important role in the pathogenesis of diffuse large b cell lymphoma (dlbcl). we investigate clinical and prognostic significance of survivin expression in nodal dlbcl. method: biopsy specimens obtained from patients with newly diagnosed nodal dlbcl treated with immunochemotherapy (r-chop) were immunostained for survivin. results: survivin immunoexpression (> % positive tumor cells) has been found in ( . %) patients. significant difference in immunoexpression was noticed between gcb and non-gcb subtype of dlbcl (p= . ). there was no significant association with ipi, "bulky"disease, ki- immunoexpression or other clinico-pathological parameters. univariate analysis showed that survivin expression was unfavorable factor for therapy response and shorter survival in patients with dlbcl (p= . and p= . , respectively). patients with survivin overexpression experienced relapse more often that the patients without expression of this apoptotic protein ( . % vs. . %), but this difference did not reach statistical significance (p= . ). the results of this study showed that disregulation of survivin expression had the important role in determination of course of disease in pateints with nodal dlbcl treated with r-chop. therefore, survivin represent potential therapeutic target in dlbcl. langerhans cell histiocytosis of the jaws: a report of ten cases with an analysis of the mechanism of eosinophilic infiltration y. objective: langerhans cell histiocytosis (lch) frequently presents eosinophilic infiltration. here we report ten cases of lch that involved the jaws and our investigation of the mechanism underlying eosinophilic infiltration in lch. method: we evaluated the ccl- /eotaxin- expression of lch cells via immunohistochemical staining. toluidine blue staining was used to inspect the densities of mast cells, with ten periapical granuloma specimens serving as a control group. results: every patient was classified as having single-system lch, even though acute lymphoblastic leukemia occurred in one patient during lch treatment. the ratio of mandible to maxilla lch was : . the jaw lesions were the earliest manifestation in seven patients with multifocal lch. toluidine blue staining revealed that the number of mast cells in lch lesions was not significantly higher than in periapical granulomas. however, upon immunohistochemical examination, most of the patients showed diffuse positivity for eotaxin- in lch cells, while few eosinophils/ t cells were immunoreactive. conclusion: we surmise that the eotaxin- expression of lch cells may be relevant to eosinophilic infiltration in lch. further studies of the eotaxin- functions including its influence on the immature state of lch cells may be needed to understand the pathogenesis of lch as well as the role of tissue eosinophilia in lch. method: we report a case of sant in years-old man presented with abdominal discomfort and pain in a left lumbal region. abdominal computed tomography scan revealed a massive haematoma extended from spleen to the enlarged left kidney and left retroperitoneal space. the patient also had a spontaneous rupture of right kidney years ago. results: macroscopically, the cut surface of spleen showed multiple well circumscribed red brown nodules. microscopically, sant consists of multiple well-circumscribed angiomatoid nodules showing plump endothelial cells and extravasated erythrocytes. nodular formations are surrounded by a variable lymphoplasmacytic infiltrate, spindle cells and collagenous stroma. immunohistochemical staining displayed endothelial phenotype that resembled splenic capillaries (cd +/cd +/cd −). expression of cd was also present. conclusion: the differential diagnosis of sant includes splenic hamartoma, inflammatory myofibroblastic tumor, littoral cell angioma and hemangioendothelioma. it has been postulated that sant represents a peculiar hamartomatous transformation of splenic red pulp in response to an exaggerated nonneoplastic stromal proliferation. sant has a benign clinical course and splenectomy has been supposed as curative. collision tumor of menningioma and non hodgin malignant lymphoma of cerebellum h. erdem * , a. k. uzunlar, u. yildirim, a. sav, m. dosoglu * duzce university, dept. of pathology, turkey primary central nervous system lymphoma (pcnsl) constitutes a rare group of extranodal non-hodgkin's lymphomas (nhls), primarily of b cell origin, whose incidence has markedly increased in the last three decades. immunodeficiency is the main risk factor, but the large majority of patients are immunocompetent. this report presents the case of a -year-old woman with a collision tumor of primary malignant lymphoma and meningioma in the cerebellum. collision tumor of primary malignant lymphoma and meningioma have not been described in the literature. the morphological aspect is interesting with regard to the problem of collision tumors. prognostic significance of immunohistochemical expression of the angiogenic molecules vegf-a, vegfr- and vegfr- in patients with classical hodgkin lymphoma e. georgiadi * , g. dimtsas, p. karakitsos, t. vassilakopoulos, i. thymara, p. korkolopoulou, e. patsouris, c. kittas, i. doussis-anagnostopoulou * larisa, greece objective: classical hodgkin lymphoma (chl) is characterized by the presence of a small percentage of malignant hodgkin and reed-sternberg (hrs) cells amongst a reactive background. the role of angiogenesis in chl is still unclear. the aim of the study was to evaluate the expression of vegf-a, vegfr- and vegfr- and their correlation with clinicopathological parameters and prognosis. method: the immunohistochemical expression of vegf-a (vg , dako), vegfr- (rb- , neomarkers) and vegfr- (sc- , santa cruz) was studied in a large cohort of patients with chl and the results were correlated with clinical characteristics and patient outcome. results: the neoplastic hrs cells expressed vegf-a, vegfr- and vegfr- in . %, . % and . % of the cases respectively and their expression levels were intercorrelated. expression of vegfr- and vegfr- was significantly and positively correlated with early disease stage, absence of b-symptoms, wbc < . , alb ≥ , ips ≤ . vegfr- was additionally positively correlated with male gender and esr < . all three molecules were statistically correlated with ramifications of blood vessels but not with microvessel density. conclusion: based on our results, we could speculate that, in contrast to solid tumours, the process of angiogenesis is probably an early event in neoplastic progression in the context of hodgkin's lymphoma. ps- - p upregulation is associated with proliferation and is not capable of inducing apoptosis in hodgkin's lymphoma e. georgiadi * , g. dimtsas, t. p. vassilakopoulos, v. g. gorgoulis, i. a. doussis-anagnostopoulou * larisa, greece objective: p is a tumor suppressor protein described as the "guardian of the genome". in a normal cell, p is inactivated by its negative regulator, mdm . once activated, p induces cell cycle arrest and apoptosis by activating various cell cycle related genes, like waf / cip encoding for p . although mutations that deactivate p are the most common genetic alteration found in cancer, they are rare in the context of hodgkin's lymphoma (hl). method: p immunohistochemical expression was investigated in a subset of cases of primary hl. the study of the p -downstream protein p was used as an indirect way of analyzing its functional status. p expression was correlated with proliferation, apoptosis, clinicopathological data and prognosis of the patients. results: p showed a median value of . %, suggesting an upregulation of the p gene in hl, and a significant correlation with p (p= . ) and the proliferation marker mib expression (p= . ). conclusion: although p overexpression is a frequent finding in hl and there is indication of its functionality, this upregulation does not lead to apoptosis. it can be speculated that this is possibly due to mdm -p interactions. ps- - simultaneous gastric adenocarcinoma and b cell lymphoma of the stomach f. gerin * , k. turkoz, b. kantarcioglu, c. ataizi celikel * marmara university, dept. of pathology, istanbul, turkey objective: the simultaneous association of gastric carcinoma with gastric lymphoma is a rare event. method: we describe a years old man, who had been diagnosed as marginal zone lymphoma in a cervical lymph node biopsy years previously.no endoscopic examination was evaluated then. there was no pathological appearance in the gastrointestinal system by ct scanning and patient was considered nodal marginal zone lymphoma. patient had taken cycles of chemotherapy which consisted of rituximab, cyclophosphamide, vincristine, and prednisolone. , years after completion of chemotherapy, a gastric wall thickening compatible with gastric lymphoma or linitis plastica was detected on ct and gastroscopic examination was indicated. endoscopic examination revealed an erosive, fragile, hemorrhagic, malignant-looking lesion with a diameter of . cm in the cardia. besides, rugae of fundus and corpus were severely rough and hyperemic suggesting a diffuse malignant infiltration. multiple biopsies were taken from cardia, fundus and corpus of the stomach. results: cardiac samples showed pancytokeratin positive signet ring cells which contain neutral and acidic mucine in microscopic examination. samples of corpus and fundus did not show similar carcinoma cells, instead, there was diffuse infiltration of atipical lymphocytic infiltration consistent with marginal cell lymphoma both morphologically and immunophenotypically. conclusion: co-occurrence of carcinoma and marginal zone lymphome is a rare event and dramatically exacerbates prognosis of a patient with such an indolent lymphoma. assessment of demographic data, staging and experesion of cd , cd , cd , bcl- in reed-sternberg cells of hodgkin lymphoma cases in their first admission in urmia imam komini hospital b. ilkhanizadeh * , p. mazlomi * imam komini hospital, dept. of pathology, urmia, iran objective: immunohistochemistry plays an important role in diagnosis of hodgkin lymphoma. beyond diagnostic importance of immunohistochemistry, so far many studies have investigated the correlation between cellular markers and the prognosis of patients with hodgkin lymphoma. amongst other markers, cd is one of the most studied marker with a lot of controversy around it. method: retrospectively eligible patients entered the study. clinical and laboratory data and immunohistochemistry findings analyzed for possible correlation between disease stage and other parameters. results: in our study . %, . % of cases respectively expressed cellular markers cd and cd while only . % of cases expressed cd . furthermore statistical analysis revealed that cd was inversely correlated with disease staging. (p= . ). in contrast we didn't find any relation between cd or cd positivity with disease staging. (p= . , p= . ). however in our study expression of cd was not related to stage or other parameters of poor prognosis which proposes that in our patients this marker possibly was not related to disease prognosis. conclusion: therefore we suggest that cellular marker cd is not beneficial beyond ips factors and its usage should be confined to diagnostic purposes. primary naturall killer cell lymphoblastic leukemia/ lymphoma of central nervous system g. karagkounis * , t. argyrakos, e. ronne, e. dimitriadis, d. papadopoulos, g. stranjzalis, d. rontogianni * athens, greece objective: a -year old woman with a -year history of a multifocal lesion occupying the cerebellum who periodically received cortisol and etoposide as it was considered tumor-forming multiple sclerosis. method: two years after initial clinical diagnosis a stereotactic biopsy was performed. immunohistochemistry and in situ hybridization were performed on the tissue sample. results: the perivascular (virchow-robin) space of microvessels was occupied by middle sized lymphocytes with blastic chromatin and scant cytoplasm. the neoplastic cells were negative for: . b-cell markers: cd , cd , cd , cd a, pax- , . myelogenous differentiation antigens: mpo, cd , cd , . plasmacytoid dendritic differentiation antigens: cd , tcl , . blastic cells markers: cd , cd . t-cell markers: cd , cd with restricted expression of cd and cd in a few cells, . cytotoxic enzymes tia- , granzyme-b and perforin. all cells expressed intensely cd and tdt and some of them cd . in situ hybridization for ebv virus (ebers) was negative. pcr analysis: t-cell receptor and immunoglobulin genes were in germ line. bone marrow was negative. objective: lymphomas constitute , cases on inhabitants annually, its frequency grows. method: this work presents epidemiological, morphological analysis of nodal/exstranodal lymphomas. analysis of data from izhevsk cancer center during - was carried out. results: lymphoma appeared in . % among first diagnosed malignant tumors. the panel of monoclonal antibodies was used for tumor immunophenotype identification. nodal lymphomas presented cases: -hodgkin lymphoma (hl), non-hodgkin lymphoma (nhl). exstranodal lymphomas presented cases, various variants of nhl were more frequent. small lymphocyte lymphoma - , diffuse large b-cell lymphoma (dlbcl) - , follicle center lymphoma - , mantle cell lymphoma - were frequent among nodal lymphomas. t-cellular nhl presented cases ( -peripheral t-cell lymphoma, -angioimmunoblastic tcell lymphoma). among other organs of lymphatic system lymphomas appeared in tonsils ( ), thymus ( ) and spleen ( ). exstranodal nhl were registered in stomach ( ), rarely in other organs -testis ( ), central nervous system ( ), nose ( ), breast ( ). as rule dlbcl was more frequent ( ). conclusion: results coincide with data on lymphoma's frequency and morphological characteristic in other regions. in situ mantle cell lymphoma in nasopharynx t. koletsa * , f. tsiompanou, c. poulios, g. karkavelas, i. kostopoulos * auth, dept. of pathology, thessaloniki, greece objective: the nasopharynx normally contains abundant lymphoid tissue and it can be the site of both lymphoid hyperplasia and lymphomas. we present the first case of the recently described in situ mantle cell lymphoma (mcl) in nasopharynx. a year-old woman presented with nasal obstruction in . a mass located in nasopharynx was found. biopsy was sent for histological examination. a new biopsy was taken years later. histological, immunohistochemical and fish studies were performed. results: histological examination of both biopsies revealed lymphoid hyperplasia, characterized by cd and cyclind positive cells of mantle zones, findings consistent with in situ mcl. the diagnosis of in situ mcl confirmed by fish analysis for t( ; ). the patient examined thoroughly and has remained free of an overt lymphoma to the present day. conclusion: pathologists and otorhinolaryngologists should be aware that in situ mcl may be observed in nasopharynx. it may be appropriate to perform cyclind immunostain, even in cases with clinical and histological findings compatible with lymphoid hyperpasia. the patients should be examined thoroughly, since in situ mcl may accompanied by an overt lymphoma in other sites or it may be a precursor of an overt mcl. multisystem langerhans' cell histiocytosis coexisting with metastasizing adenocarcinoma of the lung a. lovrenski * , m. panjkovic, z. eri * institute for lung diseases, dept. for pathology, sremska kamenica, serbia objective: langerhans' cell histiocytosis (lch) is an uncommon disease of unknown etiology characterized by uncontrolled proliferation and infiltration of various organs by langerhans' cells. to our knowledge, this is the first case reporting an association of multisystem lch with metastasizing adenocarcinoma of the lung. method: we present the case of a -year-old man, heavy smoker, with dispnea, cough, hemoptyses, headache and ataxia, who died shortly after admission to our hospital. on the autopsy, we found tumor in the posterior segment of the right upper pulmonary lobe as well as a right-sided occipito-parietal lesion which penetrated into the right ventricle resulting in internal and external hematocephalus. histologically and immunohistohemically, the diagnosis of primary lung adenocarcinoma with brain metastasis was made (tumor cells showed positivity for ck and ttf- which confirmed the diagnosis). light microscopic examination of the other organs showed lch involving the pituitary gland, hypothalamus, spleen, mediastinal lymph nodes, and lungs. immunohistochemical studies revealed cd , s- and cd a immunoreactivity within the langerhans' cells. conclusion: multisystem form of lch with extensive organ involvement was an incidental finding, while the metastatic lung adenocarcinoma to the brain, that led to hematocephalus, was the cause of death. langerhans cell histiocytosis associated with extramedullary hematopoiesis in a -year-old male patient l. lungoci * , l. elena, b. flavia, m. rodica * city hospital, pathology, timisoara, romania objective: langerhans cell histiocytosis is a rare disease histologically characterized by the proliferation of langerhans cells. method: a -year-old male came to our attention presenting with erythematous-squamous lesions all over the body, axillary and inguinal adenopathies and hepatosplenomegaly. we have taken a cutaneous and an axillary lymph node biopsy. results: microscopic examination of the cutaneous fragment revealed the presence of a dermal infiltrate of large cells with an eosinophilic cytoplasm and vesicular, nucleolated nuclei with an irregular nuclear margin, raising suspicion of a cutaneous lymphoma. immunohistochemical stains for cd , cd , cd a, cd , cd , cd , cd , and bcl- were negative, and the previous diagnosis was not confirmed. the microscopic examination of the axillary lymph nodes showed foci of extramedullary hematopoiesis, raising suspicion of a lymphoproliferative process, but the immunohistochemical stains and the paraclinical data didn't confirm it. based on the intense positive reaction for cd , s and ki- showed by the tumoral cells from the prelevated tissues, correlated with the clinical and paraclinical findings, a diagnosis of langerhans cell histiocytosis was established. conclusion: the particularity of our case consists in the presence of extramedullary hematopoiesis in the lymph nodes of a patient diagnosed with langerhans cell histiocytosis. unusual primary cutaneous presentation of b-cell chronic lymphocytic leukaemia s. mavropoulou * , z. tatsiou, g. xanthopoulidis, a. goutzouvelidis * general hospital, laboratory of pathology, xanthi, greece objective: b-cell small lymphocytic lymphoma/chronic lymphocytic leukaemia (b-cll) is a low-grade lymphoproliferative disorder and cutaneous lesions are rarely the presenting findings. method: we report the case of a -year-old woman who presented in winter with erythematous plaque on her nose, of months duration. laboratory data showed elevated white blood cell count ( . /mm ) with small mature lymphocytes predominance ( %). results: histopathologic examination of the skin lesion reveals infiltration of the reticular dermis and subcutis, consisting mostly of small lymphoid cells, without epidermotropism. immunohistochemical examination revealed positivity for cd , cd a and cd in the neoplastic cells. according to the laboratory and histopathologic findings the diagnosis was consistent with b-cll with a primary cutaneous presentation. a staging bone marrow aspiration and biopsy showed % infiltration by a clonal b-cell proliferation with typical cll immunophenotyping. ct-imaging was normal, so stage i according to binnet classification was confirmed. the patient received cycles of chemotherapy and remained in remission for year, when the skin lesion recurred in winter, at the same location. conclusion: in conclusion we report an extremely rare case of subclinical b-cll with cutaneous presentation. it is important to maintain a high index of suspicion for a lymphoproliferative process in skin lesions with atypical lymphocytic infiltration. myeloid sarcoma mimicking nasal polyp s. mungan * , u. cobanoglu, s. ersoz, g. guvendi, m. yilmaz * karadeniz technical university, pathology, trabzon, turkey objective: a myeloid sarcoma is a tumour mass consisting of myeloid blasts with or without maturation occuring at an anatomical site other than the bone marrow. every site of the body can be involved, skin, lymph node, gastrointestinal tract, bone, soft tissue and testis. % cases presents at multiple anatomical sites. method: the current case is year old woman presenting with nasal polyp and underwent polypectomy. the polyp was , cm in diameter and had a bloody appearance. by microscopic examination there was a diffuse infiltration of neoplastic cells under the cilliated epithelium. the mitotic index was high in neoplastic lymhoid cells. immunohistochemical study was helpful for the differential diagnosis. objective: the aim of this study was to describe the epidemiology and anatomo-clinical features of the ear, nose and throat (ent) lymphomas in the centre of tunisia. method: all ent lymphoma cases diagnosed in the pathology department, farhet hached hospital, sousse during a -year period were analyzed. results: a total of cases of ent lymphoma were reported ( males, females) with a sex-ratio of . . the age at diagnosis varied from to years with a median age of . years. the majority of ent lymphoma cases ( %) were of b cell type including large b-cell lymphoma ( %) and small-cell b lymphoma ( %). nasopharynx and tonsils were the most involved areas with % and % of cases, respectively. according to the ann arbor staging system, these lymphomas are diagnosed in the stage ii ( %) followed by stage i ( %). conclusion: the most frequent lymphoma developed in ent region was b cell lymphoma, especially located in nasopharynx and tonsils. results: a total of cases were reported ( males, females) with a sex-ratio of . . the median age was years (range: - years). lymph node lymphomas were the most frequent accounting for . %, followed by ent, mediastinum, and haematopoietic system ( . % each one); cutaneous and digestive location were less frequent ( . % each one). among the patients, ( . %) had had hodgkin's lymphoma and ( . %) had had non-hodgkin's lymphoma (nhl). diffuse large b-cell lymphoma was the most diagnosed ( %) followed by burkitt lymphoma ( . %) and t-cell lymphoma ( . %). according to the ann arbor staging system, . % of patients were diagnosed in an advanced stage. method: we present a case of composite ailt and diffuse large b-cell lymphoma (dlbcl) a -year-old woman with multiples lymph nodes. biopsy of inguinal node was performed. three months later the patient had enlarged cervical node which was removed. results: firstly, the inguinal lymph node was diffusely infiltrated by small-medium size lymphocytes with scanty cytoplasm. the nuclei were irregular. several large cells were observed in a background of prominent arborizing high endothelial venules. the small cells were cd positive. the large cells were cd a, cd positive. theses cells showed nuclear positivity for eber by ish. secondly, the cervical lymph node showed large areas of necrosis admixed with pleomorphic and medium size t lymphocytes. there were a population of neoplastic ebv + pleomorphic b lymphocytes; some of them with rs-like morphology. we performed b and t-cell clonality studies. we detected tcr-gamma t-cell and igh b-cell gene clonal rearrangement. conclusion: occasionally igh gene rearrangement has been detected but only a few cases have demonstrated, morphologically, composite ailt and ebv-associated diffuse large b-cell lymphoma (dlbcl). typhlitis as initial manifestation of granulocytic sarcoma of the appendix: a case report p. rohani doost * , b. ilkhanizadeh, f. noroozinia, a. objective: myeloid sarcoma is a localized mass of myeloblasts or immature myeloid cells involving any extramedullary site. reports in the literature documenting leukemic infiltration of appendix are uncommon and extremely rare when symptoms mimicking typhlitis. method: a -year-old man with a history of relapsed acute myelogenous leukemia (fab classification, m ) admitted for receiving induction chemotherapy. after days of chemotherapy, he presented with fever, nausea, vomiting, abdominal pain and severe neutropenia ( . × /l as absolute neutrophil count). this manifestation was attributed to typhlitis and he received antibiotic therapy, but he came back days later with acute abdomen prompting exploratory laparotomy which revealed inflamed appendix. results: histologic examination showed diffuse appendiceal wall infiltration of mononuclear cells with medium-to-large vesicular nuclei, conspicuous nucleoli and pale eosinophilic cytoplasm. immunostains showed the diagnosis of granulocytic sarcoma with myeloperoxidase, leukocyte common antigen, cd , cd and cd positivity and epithelial membrane antigen, keratin, cd , cd , cd , cd a and cd negativity. conclusion: our case declares that physicians and surgeons should be aware of granulocytic sarcoma in the differential diagnosis of mild tenderness on palpation of the abdomen as a complication of acute myelogenous leukemia. objective: angioimmunoblastic t-cell lymphoma (aitl), one of the most frequent entities among peripheral t-cell lymphoma, is characterized by lymphadenopathy, b-symptoms, and an aggressive behaviour. method: we reported cases of aitl during a period of years ( ) ( ) ( ) ( ) . results: the age of patients varied between and yearold. they hadn't any pathologic history. two patients presented with a multiple cervical lymphadenopathy, and weight loss. the other patient had fever and sweat. physical examination found multiple lymph nodes with hepatosplenomegaly in patients. abdominal ultrasound and ct-scan showed diffuse lymphadenopathy with features raising the possibility of lymphoma. the diagnosis of aitl was confirmed by a microscopic and an immunhistochemical study of lymph node or liver biopsy. patients received a cure of chemotherapy conclusion: angioimmunoblastic t-cell lymphoma (aitl) is an aggressive non-hodgkin t-cell lymphoma. aitl is frequently associated to immunological and hematologic diseases such as autoimmune hemolytic anemia, vasculitis, rheumatoid arthritis, and autoimmune thyroid disease. its natural history has been the subject of controversy, considered for many years to be a nonmalignant disorder or a dysimmune disease, until the clonal nature of aitl was proven by molecular studies. although patients are usually treated with corticosteroids, chemotherapy, and/or plasmapheresis, outcomes were dismal. objective: low grade lymphomas (indolent) are commonly located on extranodal sites. nodal location are relatively of low incidence. our aim is to describe the epidemiological status of nbcl and to assess their pathological features in the center of tunisia. method: we report cases of indolent nbcl diagnosed in the department of pathology, during a period of years ( - ) . clinical, pathological and immunohistochemical (large panel of antibodies), treatment and outcome data are collected. results: the mean age was year old ( and years). the sex ratio was . . nbcl was . % of all n h lymphomas and . % of indolent nbcl of any sites. nodal enlargement and hepatomegaly were the main symptoms. small lymphocytic lymphomas were the most frequent variant ( %), followed by follicular lymphomas ( %). mantle cell lymphoma and marginal zone b cell lymphoma were rare ( % and %, respectively). they were exclusively of b cell type. % of cases were in stage iii-iv. % of patients received chemotherapy. % of recurrence and % of death were found. conclusion: nbcl in the center of tunisia are relatively uncommon. small lymphocytic lymphoma is the most frequent in our population. they are still of relatively worse prognosis. objective: bone marrow metastases can be found in some malignant tumors, but diagnosing a nonhematologic malignancy from marrow is an unusual event. herein we present a case of metastatic signet ring cell carcinoma with an unknown primary site. method: a year-old woman admitted to the hospital with weakness and bone pain. positron emission tomography/computed tomography (pet/ct) revealed disseminated bone lesions showing increased metabolic activity. bone marrow biopsy and aspiration were performed. results: bone marrow biopsy revealed extensive necrosis and nearly total replacement of normal bone marrow elements by atypical tumoral cells. tumoral cells were arranged individually or in small clusters, having hyperchromatic, eccentric located nuclei and abundant cytoplasm with signet ring cell morphology. even after thourough investigation of all the systems, a primary site of malignancy could not be detected. she received nine cycles of chemotherapy. craial mri revealed multiple metastatic lesions. months after the initial diagnosis, she died of disseminated metastatic lesions. conclusion: even after thorough investigations, a primary site of malignancy could not be detected. in the literature, all the presented cases had very short survival varying from days to a few months. our patient lived for months with multidiciplinary approach. objective: approximately % of follicular lymphomas (fls) are bcl negative and - % of fls lack a translocation t( ; ). previously we have found that negative bcl staining in cases that do have a t( ; ) is caused by mutations in the epitope for the bcl- antibody, but this is never the case in bcl- negative, t ( ; ) negative cases. now that translocation detection is more commonly performed we noticed that many of the cases that were referred to us as translocation negative fl are actually often nodal marginal zone lymphomas (nmzls) with extensive follicular colonization. method: t( ; ) negative cases that on h&e sections look like fl were analyzed by morphology and immunohistochemistry, including antibodies against cd , bcl- , ki- , and cd . results: careful observation of the bcl- staining pattern revealed that follicles that appeared positive at low power contained negative cells at high magnification. the amount of negative cells varied from follicle to follicle and was associated with the extent of ki- positivity. conclusion: based on morphology and immunohistochemistry we reclassified many cases of bcl- positive, t( ; ) negative fl into nmzl. although there is presently no positive marker for nmzl, we believe that such cases are responsible for most t( ; ) negative fl. objective: recent studies do not provide a definite answer on the origin and pathogenesis of lichen planus (lp). histologic findings are the same, regardless of the area involved. electron microscopy is useful to confirm the diagnosis in atypical cases and monitoring lp development. this study aimed an ultrastructural characterization of keratinocyte degeneration in pemphigoides, hypertrophic, and follicular lp types correlating this with levels of gelatinolytic activity caused by metalloproteinase- (mmp- ). method: skin biopsies were processed conventionally and examined in a jeol transmission electron microscope. mmp- expression was detected immunohistochemically. results: lp pemphigoides demonstrated intact basal keratinocyte cell membrane, and the lamina densa lining blister cavity correlating with moderate basal mmp- expression of weak intensity. hypertrophic type demonstrated good preservation of keratinocytes and their junctions along with strong basal and suprabasal mmp- expression of moderate intensity. both types demonstrated diffuse and strong mmp- immunostaining in dermal lymphohistiocytic infiltrate. a hypertrophic type revealed an increase of expression within dermal sweat glands comparing with lp pemphigoides. a diffuse and strong epidermal and follicular mmp- staining was noticed in follicular variant of lp. conclusion: ultrastructurally keratinocyte involvement displays deviations in various types of lp, and these changes correlate with levels of gelatinolytic activity caused by mmp- . objective: clevudine is a recently introduced anti-viral agent that shows efficacy against hepatitis b virus related chronic liver diseases. however, it has been reported that certain patients who have received long-term administration of clevudine exhibit myopathy involving mitochondrial abnormalities. to make a differential diagnosis congenital mitochondrial myopathy and drug induced mitochondrial myopathy, we investigate ultrastructural findings of drug induced myopathy. method: we studied histopathological features of myopathy focused on the various ultrastructural mitochondrial abnormalities found in patients with long-term clevudine therapy. results: in every case, ragged red fibers and multinucleated fibers with eosinophilic granules were observed. additionally, type fiber atrophy was found in cases. mainly concentrated in subsarcolemmal or inter-fibrillar areas, the abnormal mitochondria were enlarged and swollen, showing a variety of morphological types. most of the abnormal mitochondria indicated structural abnormalities in cristae, including the apparent decrease in the number, concentric lamellar pattern, and structure that is branched or lattice-like. conclusion: from the overall analysis, clevudine-induced myopathy is characterized by ragged fibers showing proliferation of abnormal mitochondria with various forms of inclusion bodies and abnormal cristae. another particular feature of interest is the presence of multinucleated fibers, which, in most cases, are filled with abnormal mitochondria. ultrastructural features of human mature oocytes subjected to cryopreservation s. a. nottola * * university la sapienza, dipt. die anatomia histol., rome, italy objective: oocyte cryopreservation protocols have not been fully optimized yet. our aims were to evaluate and compare the ultrastructure of human mature oocytes frozenthawed (f/t) after slow freezing and vitrification. method: the oocytes, fixed at sampling (fresh controls) and after freeze/thawing, were processed for light and transmission electron microscopy (lm and tem) observations. results: by lm, both fresh and f/t oocytes were rounded cells surrounded by an intact zona pellucida (zp) and containing uniformly distributed organelles. by tem, numerous vacuoles were found in f/t oocytes after slow freezing. on the contrary, vacuoles were only occasionally detected in f/t oocytes after vitrification, and in fresh controls as well. amount and density of cortical granules (cgs) appeared abnormally reduced in f/t oocytes, irrespective of the protocol applied. conclusion: in conclusion, a) cryopreservation currently ensures a good overall preservation of the oocyte; b) however, vacuolization appears as a recurrent form of cell damage during slow freezing, whereas the quasi absence of vacuoles seems the most relevant marker of quality in vitrified oocytes; c) premature cg exocytosis -and the consequent hardening of the zp -seems a non-specific, ubiquitous phenomenon occurring during freeze/thawing, suggesting the appropriateness of the use of icsi as the preferred insemination method after cryopreservation. tuesday, september , . - . results: there were women and men with a median age of (range - years). symptoms were dominated by abdominal pain, jaundice, vomiting, and alteration of the general condition. radiologic investigation showed multiloculated cystic mass of the pancreas, associated to splenic thrombosis and bone metastasis in one case. in gross, we received multilocular cysts of to cm in wall, their wall was fibrous, and thick, the internal surface showed many papillary projections and mural nodules. there was no communication with the duct system. on histologic examination, cysts had a fibrous wall lined by mucinous atypical cells showing frank anaplasia, wall's cyst was invaded by anaplastic glands; the stroma was of ovarian type in all cases. conclusion: pmc are uncommon neoplasia, their diagnosis is based on the histopathologic exam, their diagnosis is better than duct carcinoma and depends on the extent of tumour invasion. heterotopic pancreas of the gallbladder associated with acute cholecystitis o. akman * , e. e. pala, u. bayol, m. emiroglu * tepecik training research center, dept. of pathology, izmir, turkey objective: pancreatic heterotopia is a rare entity, which is commonly found in the stomach, duodenum, jejunum and meckel's diverticulum. heterotopic pancreas is extremely rare in the gallbladder. despite being a congenital condition, it takes years to become symptomatic. it can be associated with cholecystitis or cholecystolithiasis. method: a -year-old female patient was admitted to emergency service with abdominal pain. on physical examination, right upper abdomen was tender without defense or rebound. abdominal ultrasonography revealed small sized gallstones and pericholecystic fluid. magnetic resonance cholangiography showed dilated intrahepatic and extrahepatic bile ducts. laparoscopic cholecystectomy was performed. results: cholecystectomy specimen was × × mm. on gross examination we noted a few milimetric yellow colored stones and mm yellow solid intramural nodule. the mucosa was covered with fibrinopurulent exudate. microscopic examination revealed acute cholecystitis and aberrant pancreatic tissue consisting of acini and ductules. the phlegmonous inflammation of the gallbladder infiltrated the aberrant pancreatic tissue. the patient recovered completely after cholecystectomy. conclusion: we found this case worth reporting because, pancreatic heterotopia of the gallbladder is a rare, clinically silent entity unless complicated with gallstones and acute cholecystitis. expressions of c-erb-b , egfr, p , pten, mtor, pi k in hepatocellular carcinomas and adjacent liver tissues method: fifty hcc cases were stained immunohistochemically with these markers. correlations between the markers and pathologic characteristics were analyzed. results: the cases had an average age of , . male/female ratio was / . hbv is more common in advanced stages and right lobe location (p< . ). tumor size is significantly larger in patients older than years (p< , ). no membranous c erb b staining was seen while cytoplasmic positivity was present in % and significant correlation was found with multiplicity (p< . ) and p positivity (p< , ). egfr membranous positivity was present in % and significantly correlated with stage (p< . ). p was negative in % and pten is reduced or absent in %. all markers were similarly expressed in adjacent noncancerous tissue. no significant correlations were found between pten, mtor, pi k and the pathological parameters. conclusion: in our study, as a first step, none of the markers among c-erb-b , egfr, p , pten, mtor, pi k was found significant in correlation with pathologic features. we look forward to obtain further results in the next study consisting of correlations with follow ups. the value of echo guided liver biopsy in the positive diagnosis of a rare primary liver tumorpathological approach g. becheanu * , v. herlea, v. serban-barbu, m. dumbrava, s. enache, g. smira, c. angelescu, a. pop, m. diculescu * bucharest, romania objective: hepatic angiomyolipomas are rare mesenchymal hepatic tumour. the most important problem about their diagnosis on biopsy specimens is to exclude a hepatocellular carcinoma. method: we present two cases of hepatic angiomyolipoma diagnosed in fundeni clinical institute, bucharest. both females patients, and years old, were imagistically diagnosed with a cm hepatic left lobe tumor in the first patient, respectively a . cm hepatic right lobe tumor in the second one. both tumors were echo guided biopsied. the biopsy specimens measured about mm, respectively mm. the tumors were surgical removed. the biopsy and resection specimens were analyzed in light microscopy, including immunohistochemistry. results: initial diagnosis on he stain was cell variant hepatocellular carcinoma, in the mm biopsy, respectively suspicious for angiomyolipoma in the second case. further immunohistochemical studies showed positivity for vimentin, hmb , melan a, s and actin, and negativity for och e , ck , ck / , cea, cd , ki and factor viii in both biopsy specimens, consistent with hepatic angiomyolipoma diagnosis, confirmed on surgical specimens too. conclusion: diagnosing a hepatic angiomyolipoma is not easy to do especially on a biopsy. the size of biopsy specimens plays a very important role in a correct diagnosis. results: a -year-old woman presented with a -day history of nausea, fever and diffuse abdominal pain. ct scan revealed a well circumscribed small lesion of the pancreatic body. on arterial phase imaging, the mass was of low density relative to the pancreas without marked contrast enhancement. based on these findings, the patient underwent surgical resection of this mass and a distal spleno-pancreatectomy was performed. microscopic examination showed a well circumscribed but non encapsulated soft tissue proliferation consisted of blood vessels lined by a single layer of uniform flattened cells, with dilated lumen filled with red blood cells and inflammatory cells. immunohistochemical staining confirmed the vascular nature of the lesion. the diagnosis of pancreatic hemangioma was made. conclusion: adult pancreatic hemangioma is an extremely rare tumor. the review of all published cases showed that this tumor often do not demonstrate the contrast-enhanced ct features typical of an hemangioma, so a poor arterial phase enhancement cannot rule out pancreatic hemangioma and the histological examination is very important in these cases. objective: hepatocholangiocarcinoma (hcc-cc) is an uncommon form of primary liver cancer with features of hepatocellular and biliary epithelial differentiation. it accounts for . - . % of all primary liver carcinomas. many of the demographic and clinical features of this tumor remain unclear. it was previously suggested that coexisting chronic liver diseases were rarely seen in patients with hcc-cc. method: we report a case of hcc-cc diagnosed in patient with cirrhosis. results: a year-old man presented with ascites, jaundice, vomiting and symptoms of portal hypertension. on abdominal ct scan the right hepatic segment was heterogeneous, hypervascular in the late arterial phase and low-attenuated on portal venous phase. based on a these clinicoradiological informations, diagnosis of infiltrating hepatocellular carcinoma was made and hepatic biopsy was performed. histopathologic examination showed, in addition to features of liver cirrhosis, the presence of malignant proliferation composed of tubular structures as well as microtrabecular and compact foci. on immunohistochemical stainings the tumor cells expressed cytokeratins and . cells lining the tubular structures reacted with cytokeratin allowing the diagnosis of hepatocholangiocarcinoma. conclusion: hepatocholangiocarcinoma is a rare primary liver cancer. preoperative noninvasive diagnosis with conventional radiography is often difficult especially when occurring in patients with liver cirrhosis or other hepatic chronic disease. the diagnosis is frequently made only after histological and immunohistochemical examination. morphological changes in different zones of the gallbladder in cholelithiasis m. bokhodir * , t. vervekina * tashkent medical academy, dept. of patological anatomy, uzbekistan objective: gallstone disease remains a serious problem of modern surgery. an important aspect of the problem is the question of the urgency of surgical intervention, depending on the condition of the gallbladder. method: it was carried out the analysis of case histories and excised gallbladder with different forms of cholelithiasis. . % were women in the age of - years. acute catarrh cholecystitis was found out in % cases, acute phlegmonousin % cases, acute gangrenous -in % cases, chronicin % and chronic relapsingin % cases. results: all forms of cholecystitis characterized by a maximum thickness of the body wall, minimal at the bottom of the gallbladder. in all forms adipose tissue inflammation in the connective tissue layer was increased and it was found out the atrophy of the mucosa. in the inflammatory infiltrate in acute forms of inflammation were found neutrophilic and basophilic leukocytes: with simple acute cholecystitis -in the bottom, and with acute phlegmonous and gangrenous cholecystitis -in the area of the body of the gallbladder. in the cases with chronic cholecystitis were dominated mononuclear cells in all areas, and in the cases with chronic relapsing -neutrophilic and basophilic leukocytes in the bottom and the body, and mononuclear cells -in the neck of the gallbladder. ps- - histological features of chronic hepatitis c in hemodialysis patients i. delladetsima * , a. kokkori, v. sypsa, m. psichogiou, s. sakellariou, j. boletis * athens university, st dept. of pathology, greece objective: chronic hepatitis c (chc) in hemodialysis patients has not been thoroughly investigated, despite its high frequency. the present comparative study aims to highlight the histological features of chc and its association with putative pathogenetic parameters in this specific group of patients. method: sixty-one biopsies of hemodialysis patients and biopsies from the general population with chc were comparatively evaluated for the severity and specific histological features of chc. results were examined in relation to age, time of dialysis, viral load and genotype. results: patients on hemodialysis were older than patients of general population (p= . ), showing a similar genotype distribution (p= . ) and lower viral loads (p= . ). chc on hemodialysis was significantly milder according to stage (p= . ), activity and its parameters (p< . ). significantly reduced was also the frequency of lymphoid aggregates (p< . ), bile duct damage (p< . ) and steatosis. (p= . ). severity of hepatits was not associated with time on hemodialysis. in multivariate analysis the differences were independent of age, which was associated with more severe disease. steatosis was associated with hemodialysis duration and age. conclusion: chc in hemodialysis patients is significantly milder than in general population. limited necroinflammatory activity and absence of immune mediated lesions are indications of defective immune response although involvement of low viral load cannot be overlooked. ps- - inflammatory (myofibroblastic) pseudotumor of the liver: case report e. demiralay * , s. altaner, h. Özdemir * baskent university, dept. of pathology, istanbul, turkey objective: inflammatory pseudotumor of the liver (ipt) is a rare, benign tumor-like lesion of which etiology is not fully known. it is confused with primary and metastatic malignant tumors as it seems as an occupying mass on radiologic examinations. method: thirtyeight-year-old male patient who had fatigue and dyspepsia was detected to have elevated liver enzymes and hepatomegaly. on computed tomography, two masses of which middle is mildly hypometabolic, measuring × mm in right liver lobe and × mm in left liver lobe were detected. biochemical tests were normal except elevated ast and alt levels. ultrasound-guided needle biopsy was done for two masses. results: on microscopic examination, a lesion composed of abundant fusiform fibroblastic cells and vascular structures among inflammatory cells composed of lymphocytes, plasmocytes, histiocytes and eosinophillic leucocytes and including sharp margins between regenerated liver tissue was observed. on immunohistochemical examination, sma was stained focal positive in fibroblastic cells. staining with desmin, s- , panck, cd , ki- and cd was not seen. conclusion: ipt does not have a specific radiologic finding and definite diagnosis is made with pathologic examination. this case is presented as it is rarely seen, radiologically resembles to malignant tumors and for review of pathological differential diagnosis. enhancer of zeste homologue (ezh ) expression in malignant and benign hepatic tumors k. dezso * , v. szabó, e. bugyik, k. schlachter, s. paku, z. schaff, p. nagy * semmelweis university, st dept. of pathology, budapest, hungary objective: the immunohistochemical demonstration of enhancer of zeste homologue (ezh ) proved to be a useful marker in several tumor types, including hepatocellular carcinomas.in order to recognize the diagnostic value of this protein in hepatic tumors we have investigated the presence of ezh in the most common liver neoplasms. method: the presence of ezh has been studied by standard immunohistochemistry in several formalin-fixed paraffin-embedded tumor samples (hepatocellular adenoma, hepatocellular carcinoma, cholangiocarcinoma, hepatoblastoma, metastatic liver tumors and primitive childhood tumors). results: forty of hepatocellular carcinomas, of cholangiocarcinomas, of hepatoblastomas and of metastatic liver tumors stained positively, but all the investigated hepatocellular adenomas (n = ) and proliferating biliary structures were negative. the other primitive childhood tumors that were examined all expressed ezh . conclusion: based on these results ezh is a sensitive marker of malignancy in hepatic tumors regardless of their histogenesis. in routine surgical pathology ezh could be helpful to diagnose hepatocellular carcinomas and it might be the first marker to distinguish transformed and reactive cholangiocytes. ps- - nuclear ploidy as a marker of intraductal papillarymucinous pancreatic neoplasms malignancy e. dubova * , o. mishnev, a. shchegolev * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: intraductal papillary-mucynous pancreatic neoplasm (ipmn) represents , to . % of all tumors of exocrine pancreas. our aim was to study nuclear ploidy of malignant and benign ipmns cells. method: we studied pancreatic surgical specimens from females and males. we performed histological, morphometrical and ploidy analysis of all specimens. results: ipmn cells nuclear perimeter and size was higher than in normal pancreatic duct cells. this parameters were higher in malignant noninvasive ipmn than in benign tumor. nuclear size and perimeter of invasive malignant ipmn were in intermediate position between benign and malignant noninvasive tumor. mean nuclear ploidy (mnp) of normal ductal pancreatic cells was . c. mnp of benign ipmns was . c, borderline tumors - . c. mnp of noninvasive malignant ipmns was . c, of invasive ipmns - . c. we also revealed that aneuploidy coefficient (ac) of benign ipmns was (there weren't aneuploid nuclei in its cells). ac of borderline ipmns was . . maximal level of ac was in malignant noninvasive ipmns whereas ac of invasive ipmns was lesser. conclusion: nuclear morphometric parameters and mean nuclear ploidy level as well as aneuploidy coefficient could be used as additional criteria for determining malignant potential of ipmns. ps- - an intraductal papillary mucinous neoplasm of the pancreas with concomitant neuroendocrine tumor: a case report j. garcia * , f. e. costa, r. sampaio, r. dias, a. duarte, j. ramon vizcaíno * lisbon, portugal objective: intraductal papillary mucinous neoplasms (ipmns) are a recently classified pancreatic neoplasm with an increasing incidence. ipmn of the pancreas is a lesion consisting of mucin-producing cells with neoplasic potential, characterized by papillary intraductal growth and varying degrees of cytologic atypia. neuroendocrine tumors of pancreas (pnet) are rare pancreatic neoplasms comprising - % of all pancreatic tumors. pnets express neuroendocrine markers, however the true cell or cells of origin are not fully understood. pnets are classified as functional or nonfunctional based on the presence or absence of a specific clinical syndrome associated with hormone oversecretion. intraductal papillary mucinous neoplasm of the pancreas with concomitant neuroendocrine tumor are a highly rare occurrence. method: a literature review of ipmns and pnet was made, as well as a review of the clinical data of a patient with ipmn and concomitant pnet. results: a -years-old caucasian female, underwent a laparoscopic distal pancreatectomy with splenectomy for ipmn. macroscopic examination revealed discrete dilatation of pancreatic ducts and nodule in the pancreas tail. hystologic examination revealed neoplasic lesion of intraductal papillary-mucinous in the body and tail of pancreas with moderate dysplasia (ipmn borderline) and neuroendocrine tumor grade (who ). conclusion: this case reports a highly rare occurrence. glypican and agrin expression in hepatocellular carcinoma and cholangiocellular carcinoma: a immunochemistry study n. gursan * , h. balta, b. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: glypican (gpc ), which plays a role cellular growth, differentiation and migration is one of members of glypican family. although gpc expression in the liver, glypican upregulation of the vast majority of tumors are available. agrin is found the surface on the cells and the extracellular matrix, the micro-vessels method: in this study, formalin-fixed, paraffin-embedded surgical specimens from patients with hepotocellular carcinoma and patients with cholangiocellular carcinoma diagnosed between and years in ataturk university, faculty of medicine, department of pathology were studied with immunohistochemistry agrin and gpc . results: we detected agrin in around bile ducts and blood vessels within the portal areas in the normal liver. İn the malignant hepatocellular carcinoma (hcc) is seen in a dramatic increase in the quantity of agrin. gpc immunpositivity showed in % of hcc and % of cholengiocellular carcinoma. agrin immunpositivity showed in % hcc and % of cholangiocellular carcinoma. conclusion: gpc and agrin, that is useful in early diagnosis of hcc cases; cholangiocellular carcinoma, or not enough was understood to be very limited. value of glypican , hep par and alpha fetoprotein in diagnosis of hepatocellular carcinoma n. gursan * , h. balta, b. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: glypican showed high expression of the embryonic liver and intestine, is silenced in normal adult tissues. it is an oncofetal protein. İn general, oncofetal proteins, while having a critical role in tumor progression or immunotherapy is a potent tumor marker used as a target. alpha fetoprotein, clone c localized, normally produced by gestational age, fetal liver and yolc salc, glycoprotein structure emerging marker for patients with hcc. hep par antibody was developed in using fixed liver as immunogen. method: İn this study formalin-fixed, paraffin-embedded surgical specimens from patients with hepatocellular carcinoma diagnosed between and years in ataturk university, faculty of medicine department of pathology were studied with immunohistochemistry gpc , heppar , and afp. gpc , heppar and afp expression was divided into categories negative (negative or weak under % tumor cells cytoplasmic staining) and positive (and % over of tumour cells) moderate or strong cytoplasmic with membranous accentuation. results: immunpositivity at gpc , hep par and afp were %, %, % respectively. objective: fibroblastic growth factor receptor (fgfr) family is known to be related to the development and progression of various types of cancers. the aim of this study is to determine the clinical implication of fgfr expressions in patients with hepatocellular carcinoma (hcc). method: immunohistochemical analysis was done in cases of hcc using tissue microarray. diffuse cytoplasmic staining for fgfr , , and in more than % of tumor cells were designated as positive. the results were analyzed in terms of various clinicopathologic parameters. results: on univariate analysis, the overall survival rates of patients with fgfr expression ( cases, . %) were significantly lower than those with no expression (hr . , % ci . - . , p< . ). however, the overall survival rates of patients with fgfr expression ( cases, . %) were significantly higher than those with no expression (hr . , % ci . - . , p< . ). there was no statistical significance between patients' overall survival rates and expressions of fgfr ( cases, . %) or fgfr ( cases, . %). on multivariate analysis, only fgfr expression is independently associated with reduced os (fgfr : hr . , % ci . - . , p< . ). conclusion: the fgfr expression can be used as an independent prognostic factor in patients with surgically resected hcc. objective: hurp (hepatoma upregulated protein) is a putative oncogene, overexpressed in many human cancers, including hepatocellular carcinoma. it has also been shown recently that high hurp protein levels correlate with resistance to chemotherapeutic agents. in the present study we investigate the expression of hurp and its correlation with pancreatic adenocarcinoma, prognosis and patient survival. pancreatic adenocarcinoma is one of the most aggressive types of cancer and represents the fourth most common cause of death, either in the male or in the female population of the united states of america. method: hurp immunoreactivity was assessed by immunohistochemistry in a series of primary pancreatic adenocarcinomas. in parallel, hurp expression was examined in normal pancreatic tissues. statistical analysis related hurp expression levels with clinicopathological characteristics and survival. results: results showed a positive correlation between hurp overexpression and grade as well as lymphovascular invasion. all non malignant biopsies were negative. furthermore, positive expression of hurp appeared to be an important independent prognostic factor too, related with poor survival rates. conclusion: our results showed that hurp overexpression is associated with poor prognosis in pancreatic adenocarcinoma and indicated a diagnostic potential of this protein. its role in the carcinogenetic process awaits further elucidation. hepatocellular carcinoma in patient with hepatic porphyria: a case report j. marcinek * , p. szépe, t. balhárek, m. kalman, l. plank * university hospital martin, dept. of pathology, slovakia objective: hepatocellular carcinoma (hcc) is frequently associated with liver cirrhosis or chronic hepatitis of various etiology, less often with other chronic hepatopathies, including hepatic porphyria. we present a case report of hcc diagnosed in patient with clinically unrecognized porphyria cutanea tarda (pct). method: a -year old male was admitted to hospital complaining of a pressure below low costal margin, anamnesis of a trauma year ago and clinical suspicion of a posttraumatic intrahepatic haematoma. by a surgery, a partialy necrotic and hemorrhagic tumor mass cm in diameter was removed. results: the mass corresponded histologicaly to moderately differentiated clear cell hcc, resembling renal clear-cell carcinoma. the surrounding parenchyme showed steatohepatitis with fibrosis and distinct intracellular porphyrin crystals. conclusion: development of hcc is a well documented complication of pct, a disorder of porphyrin biosynthesis. pct can be inherited (autosomal dominant trait), the acquired form (sporadic pct) is more common. known etiological factors of pct include toxins, alcohol abuse, estrogens or chronic viral hepatitis, or association with other hepatic diseases like iron overload (including hereditary haemochromatosis) or chronic hepatitis c, increasing the risk of malignancy. however, in the presented case none of these associations was recognized and its etiology remains obscure. objective: signet ring cell carcinoma is an extremely rare type of gallbladder carcinoma composed overwhelmingly ( %) of signet ring cells. only a few cases of this histologic type have been published and detailed knowledge of this disease is not available. method: we report a case of signet-ring cell carcinoma of the gallbladder in a -year-old woman who was admitted with epigastric pain. under the preoperative diagnosis of cholangiocarcinoma, which was based on findings of ct scan and ultrasonography. cholecystectomy was performed. results: microscopic examination revealed a signet ring cells tumor that arose from the sub epithelial layer of mucosa and involved all the layers of gallbladder. nuclear atypia and mitoses were present. periodic acid schiff (pas) stain highlighted the intracellular mucin in the tumor cells. lympho-vascular emboli were detected in the subserosal layer. the cystic duct surgical margins were invaded. conclusion: gallbladder adenocarcinomas are seen frequently, but signet-ring cell carcinoma is a rare entity. owing to the location of the gallbladder, dissemination of the tumour to the adjacent tissues is usually presented at the time of the diagnosis. it is necessary to exclude a gastric or colonic signet ring cell carcinoma secondarily involving the gallbladder. objective: gastrointestinal stromal tumors (gists) are mesenchyme neoplasms of the gastrointestinal tract which express cd . gists can occur in the entire length of gastrointestinal tract, but very seldom can also arise in omentum, mesentery and retroperitoneal space, kidney, urinary bladder etc. there they are located adjacent to stomach or intestine, but not originated from the latter. these tumors are designated as "extra-gastrointestinal stromal tumors" (egists). there are only description of the primary egists reported in the literature. method: we report a case of a pancreatic egist in a year-old female patient. results: ct scan showed a mass in the head of pancreas. grossly encapsulated tumor, cm in diameter, was found in the head of the pancreas (figure ) . histologically, tumor demonstrated spindle-cell pattern consisted of distinct fascicles and bands. the number of mitoses was - / high power fields in "hot-spot" areas. ihc revealed strong positivity for cd , cd in neoplastic cells and negative for sma, desmin, s- . ki labeling index was %. conclusion: we presented a rare case of pancreatic gist. the tumor has very good prognosis. hepatoblastoma is classified as epithelial ( %) or mixed epithelial/mesenchymal ( %). epithelial hepatoblastoma is further divided to pure fetal ( %), embryonal ( %), macrotrabecular ( %) and small cell undifferentiated ( %). aim: to increase the awareness regarding possibility of hepatoblastoma in adult age. method: we review four cases of hepatoblastoma epithelial type diagnosed in pathology department of fundeni clinical institute between and . immunohistochemistry was done in all cases: cea, vimentin, ck / , ck , ck , ki , ttf , cd , cd , cd , muc a, alpha-fetoprotein. results: two of the patients were males and two females with age ranging between and years. the tumors varying in size from to cm. on microscopic examination the tumor was composed mainly of epithelial elements. the pathological diagnosis was epithelial hepatoblastoma epithelial type. conclusion: hepatoblastoma is a rare tumor in adult age and epithelial type is the rarest from all type of hepatoblastoma in adult age. the pathological diagnostic is quite difficult even using immunohistochemistry because none of the markers are not specific for hepatoblastoma. submassive hepatic necrosis with regenerative nodules: a series of cases y. rodríguez-gil * , j. salazar, j. delgado sánchez, g. lópez alonso, c. ibarrola de andrés, f. colina ruizdelgado * hospital universitar de octubre, dept. of surgical pathology, madrid, spain objective: confluent hepatic necrosis is the morphological correlate of fulminant liver failure. a group of these livers develop a combination of areas of necrosis and regenerative macronodules (rmn). method: sequential biochemical and clinical data and tissues from two groups of patients were compared. group : cases of submassive necrosis associated with rmn; group : cases with total confluent necrosis without nodular regeneration. results: group : mean age was , years (ranged months- years); group mean age was , years (ranged months- years) (p> , ). a longer course ( , ± , days vs , ± , , p< . ) and higher maximum serum bilirubin levels ( , mg/dl ± , vs , mg/dl± , , p< . ) were observed in group . serum ast, alt and gamma-gt were lower in group (p> . ). morphologically livers from group showed well defined regenerative green-yellow nodules with large regenerative hepatocytes in acinar pattern without surrounding fibrosis. the remaining parenchyma showed confluent necrosis, haemorrhage, mixed inflammatory infiltrate and ductular proliferation. conclusion: a special anatomoclinical form of subacute liver failure was characterized by regenerative macronodules in a background of extensive confluent liver necrosis. illness duration was longer and had higher maximum bilirubin levels than those without rmn. immunohistochemical study of muc gene family in pancreatic cancer g. setdikova * , o. paklina * moscow, russia objective: investigation of the muc gene in pancreatic ductal adenocarcinomas (pda). method: in the present study, we examined the expression of muc , and ac types by immunohistochemical analyses in pda from patients. overall survival curves were drawn by the kaplan-meier method. for all analyses, p< . was considered to be statistically significant. results: in our cases most of the pda was presented as muc +/muc ac + phenotype - % cases ( / ). the group with intestinal phenotype mucin, which characterized by positive expression of muc and cdx , was only % ( / ). the group which characterized by positive expression only muc ac (gastric phenotype), was % ( / ). the survival rate of patient better in group with muc expression. cumulative survival at months after surgery was . and the median postoperative follow-up period was months. the most aggressive behavior was pda with expression only muc ("true pancreatobilliary type"). cumulative survival at months after surgery was . and the median postoperative follow-up period was months. conclusion: the mucin profile as a prognostic factor is important not only for intraductal pancreatic mucinous neoplasm, but and for ductal pancreatic adenocarcinoma. ps- - hepatocellular carcinoma microvessels density depends on tumor differentiation: radiologic-pathologic correlations a. shchegolev * , e. dubova, u. tumanova * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: prognosis and recurrence level in hepatocellular carcinoma (hcc) depends on microvessels density. method: we performed ct and pathological correlations in cases of hc ( cases of highly (h-hcc), cases of moderate (m-hcc) and cases of low differentiated hcc (l-hcc)). results: vessels number in w-hcc in compare to m-hcc was higher by . % (p< . ). total vessel area was higher in m-hcc and l-hcc than in w-hcc by . % and . % accordingly. we observed positive correlation between ct density of h-hcc and number and total vessel area. correlation between h-hcc ct density and mean vessel area was negative. we also revealed modest negative correlation between m-hcc density and the number vessels in all phases of ct. negative correlation between total and mean vessel area and m-hcc density was revealed in native and arterial ct phases in compare with venous and delayed phases where positive correlation was revealed. in all phases of ct we revealed strong negative correlation between l-hcc density and the number of vessels whereas correlation between l-hcc density and mean vessel area was strongly negative. conclusion: we revealed decreasing in angiogenic activity in hccs neoplastic progression and growth. ct signs correlate with hcc histological differentiation. ps- - primary sporadic liver schwannoma: an extremely rare diagnosis r. silva * , c. eloy, j. m. lopes * centro hospitalar de são joâo, serviço de anatomia patológica, porto, portugal objective: primary liver schwannoma (pls) is extremely rare. results: case report: a -year-old female with previous history of cholecystectomy, appendectomy, arterial hypertension and diabetes mellitus was admitted due to an intrahepatic nodular lesion identified in routine ultrasound examination. she was submitted to partial hepatectomy with postoperative uneventful evolution. macroscopically, the specimen disclosed a . cm nodular, well circumscribed, yellowish tumour. histologically, the tumour displayed an expansive growth pattern, comprising short bundles of spindle cells with mild atypia, without mitotic figures or necrosis. immunohistochemically, the tumor cells expressed diffusely vimentin, s- and gfap, in the absence of ae /ae , cam . , cd , and hmb ; ki- index was %. staging procedures did not disclose evidence of any other tumor. there was no personal or family evidence of neurofibromatosis. these features are consistent with sporadic pls. conclusion: schwannoma is a rare benign tumour in the gastrointestinal tract with few cases reported in the liver. the clinical presentation is usually an upper abdominal pain but they can be asymptomatic. secondary cystic degeneration and hemorrhage are common in large tumours. differential diagnosis by imaging evaluation includes several benign and malignant, namely metastatic, tumours. therefore, the pathological examination is crucial for the diagnosis of primary liver schwannoma. metastases of hepatocellular carcinoma to the costa and soft tissue: a very rare entity e. tastekin * , t. d. yalta, o. yalcin, t. ciftci * trakya university, dept. of pathology, edirne, turkey objective: hepatocellular carcinoma (hcc) is the most common primary tumor of the liver with a potential of metastasis primarily to the lung, abdominal lymph nodes and bone. however, metastases to the costa, soft tissue are rare. method: an -year-old man was admitted to hospital with weakness, anorexia. chest x-ray and ct-scan demonstrated a × cm sized, intrathoracic mass on the lateral-side of the left .costa and also infiltrating the axillary soft tissues.a secondary mass with the identical radiological features was also detected within the c -vertebra. whole-body ct-scan was planned.a × cm sized nodular, hipodense mass was detected in the upper segment of the liver. interestingly, none of these masses demonstrated a significant pathological fdg-uptake in the pet.a trucut biopsy was taken from the axillar. microscopically, large tumoral nests were observed in connective tissues. polygonal shaped tumoral cells were found to have granular cytoplasm, pleomorphic nuclei. immunohistochemistry results: positive cytoplasmic reaction with heppar, ttf- ; canalicular staining with polyclonal-cea, cd ; weak cytoplasmic staining with pankeratin, b . ; negative reaction with vimentin, afp, ck , ck . results: these histomorphological, immunohistochemical findings strongly supported to the diagnosis of hcc metastasis. conclusion: hcc that is, in general, morphologically similar to mesenchymal and epithelial tumors, should be considered among the differential diagnosis of unknown primary tumors. morphological justfication of using pulsed electric discharge in surgical treatment of echinococcosis m. tussupbekova * , d. kaliyeva, e. turgunov * medical university karaganda, dept. of pathological anatomy, kazakhstan objective: echinococcosis is characterized by lesions of internal organs, severe complications, often lead to disability and death. method: new method of processing of the residual cavity with impulsive electric discharge after echinococcectomy was experimentally developed and introduced into clinical practice. the effectiveness of the method is confirmed by morphological examination of operational bioptic of the liver tissue. results: patients underwent surgical treatment with the new method (patent of the republic of kazakhstan ¹ ). parasitic cysts with an inner germinal layer and protoskoleks, outdoor layer -chitinous shell with a productive reaction with lymphocytes infiltration, single eosinophils, separate groups of hydatid bubbles with their invasion in the liver tissue were detected in the histological examination of material taken intraoperatively prior processing of residual cavity with electropulse discharge. fibrinoid necrosis, destruction of germinal elements, single lymphoid infiltration, hyperemia of blood vessels, absence o inflammatory reaction were marked in the histological material after processing by impulsive electric discharge. the results showed that echinococcectomy with processing of the residual cavity with impulsive electric discharge is an alternative for pericystectomy and liver resection. objective: congenital peribronchial myofibroblastic tumor is a rare, solid mesenchymal tumor of the fetus and neonate, usually associated with nonimmune hydrops fetalis. we report the case with clinical, radiological and pathologic findings and review the other cases in the english language literature. method: we present a case of cpmt, whom a right lung mass was detected in intrauterine life. days after delivery by cesarean section, right lobectomy was performed. results: the tumor was limited to lung, and composed of spindle cells, proliferating around bronchial unit. central necrosis and - / hpf was present. patient is well months after surgery. conclusion: congenital peribronchial myofibroblastic tumor is a rare solid pediatric tumor of lung which was named differently in the past, such as congenital fibrosarcoma, congenital leiomyosarcoma, congenital mesenchymal malformation of the lung, neonatal pulmonary hamartoma. albeit it resembles sarcoma with high cellularity, mitosis and necrosis features microscopically, no additional therapy to tumor resection is needed. so it is important to keep in mind this scary looking, but innocent tumor both in prenatal and postnatal evaluation. morphologic alteration of metastatic neuroblastoma in bone marrow after chemotherapy g.-e. bae * * samsung medical center, dept. of pathology, seoul, republic of korea objective: the aims of our study are to evaluate the histologic features of metastatic neuroblastoma in bone marrow (bm) in comparison with those of primary neuroblastoma, and to compare the histologic characteristics of metastatic neuroblastoma in bm before vs. after chemotherapy. method: total biopsies from children diagnosed as stage neuroblastoma with bm metastasis were examined histologically; primary neoplasm biopsies, bm biopsies before chemotherapy, primary neoplasm excision biopsies after chemotherapy, and bm biopsies after chemotherapy. results: ) primary neoplasms were classified as neuroblastoma poorly differentiated (n= ), neuroblastoma differentiating (n= ), ganglioneuroblastoma intermixed (n= ) and neuroblastoma type unclassifiable (n= ). ) metastatic foci in bm before chemotherapy were composed of undifferentiated and/or differentiating neuroblasts but not ganglion cells, in neuropil but not schwannian stroma. ) metastatic foci of bm after chemotherapy showed differentiation such as ganglion cells and schwannian stroma, which was more prominent after more cycles of chemotherapy. ) metastatic neuroblastomas in bm after chemotherapy were as mature as or less mature than those in primary neuroblastomas after chemotherapy. conclusion: metastatic neuroblastomas in bm initially consist of more immature components than primary neuroblastomas, whereas they become differentiated as primary neuroblastomas after multi-cycle chemotherapy. morphometric evaluation and clinical correlations in malignant small round cell tumors c. bansal * , a. gupta, a. kumar, a. srivastava * csmmu, dept. of pathology, lucknow, india objective: nuclear size increases in malignant tumors and reflects dna content, ploidy and proliferation index. present study investigated; could nuclear morphometery differentiate histomorphologically similar paediatric malignant small round cell tumors in h & e stained sections for using in a poor resource country? method: morphometric analysis was done in confirmed but difficult to differentiate round cell tumors histomorphologically and were analyzed by cell images from different areas in each section, using leica q win images software. results: nuclear measurements were obtained for retinoblastoma ( ), hodgkin lymphoma ( ), wilms tumor ( ), medulloblastoma ( ), ewing's sarcoma ( ), alveolar rhabdomyosarcoma ( ), malignant hemangiopericytoma ( ), non-hodgkin lymphoma ( ) and neuroblastoma ( ). amongst the retinoblastomas, maximum mean nuclear area percent ( . ) was seen in cases with nerve involvement and metastasis, followed by cases with only nerve involvement ( . ) and smallest area ( . ) was in non-nerve involving, non metastatic cases. wilms tumor cases with metastasis had higher nuclear area ( . ) than non metastatic ( . ). non-hodgkin lymphoma nuclear area ( . ) was more than hodgkin's ( . ). amongst all tumors, minimum value ( . ) was seen in malignant hemangiopericytoma. conclusion: morphometric evaluation in paediatric malignant round cell tumors have generated useful data, and needs further multicentric confirmation for implementation. objective: survivin, a bifunctional protein that regulates cell division and suppresses apoptosis, may play an important role in tumorigenesis. the aim of this study was to determine survivin expression patterns in wilms tumor (wt) and to analyze it in relation to stage, prognostic category and histological type. method: immunohistochemical expression of survivin was analysed in cases of primary wt and in normal kidney specimens uninvolved by the tumor. results: fifty one out of cases of wt ( . %) showed decreased cytoplasmic survivin expression compared to the expression in normal kidney tissue. decreased cytoplasmic expression (in all components of wt) of survivin was found significantly more often in low stage compared to high stage wts ( . % vs. . %; p= . ). tumors of intermediate risk group showed more often decreased cytoplasmic expression of survivin in comparison to high risk group, but the difference was not significant. decreased survivin expression was found more frequent in wts with diffuse anaplasia and in epithelial wts compared to other histological types, but without statistically significant difference. conclusion: decreased survivin cytoplasmic expression may be associated with the favorable prognosis wt. objective: hepatic tumors accounted % of congenital neoplasms. mesenchymal hamartoma of the liver is a rare benign tumor of children. we report a case of hepatic mesenchymal hamartoma in a premature male neonate. method: a premature neonate born at gestational weeks from year-old mother, g p with non-consanguineous marriage; prenatal ultrasonography showed a fetal macrosomia, a highly vascularized abdominal mass occupying two-third of the abdomen and displacing the bowel loops associated with poly-hydramnios. the newborn examination showed abdominal firm lump. ultrasound found and anterior highly vascularized mass displacing the left lobe of liver. the infant died few hours later. a complete autopsy was performed. results: external examination showed a male neonate anatomically of - week having an increased periombilical diameter and a macrosomia, ascitis, pulmonary hypoplasia, cardiomegaly, pleuropericardial effusion, liver tumor developed in left lobe and dilation of renal vessels. histologically the tumor showed a mixture of normal liver tissues with blood or lymphatic vessels, bile ducts within an abundant edematous and myxoid stroma. conclusion: in neonate and fetus, prenatal diagnosis is possible by ultrasonography. large tumors can affect the viability of the newborn. adequate excision is curative in most of cases. ps- - ncam polysialylation as potential initiator of differentiation and proliferation of renal progenitors in human fetal tissue s. cirovic * , j. tadic, n. radunovic, c. müller, g. müller, j. markovic-lipkovski * inst. for pathology, nephropathology, belgrade, serbia objective: objective: neural cell adhesion molecule (ncam) is widely expressed on mesenchymal and early tubular epithelial cells during kidney development although with still undefined function. ncam can be polysialylated and as psa-ncam has been shown to be involved in proliferation and migration of neuronal cells during brain development. the aim of this study was to evaluate the presence of psa-ncam in nephron precursors in relation to the expression of renal progenitor and proliferation markers. method: human fetal and neonatal kidneys were analyzed using double-immunofluorescence (dif) staining and western blot (wb) analysis. specific antibodies against ncam, psa-ncam, epcam, cd and ki- were applied. results: on wb only fetal tissue samples have bands with ncam at to kda which suggest that ncam molecule is polysialylated; dif analysis of fetal tissue show psa-ncam + ki- + cells in all structures known as nephron precursors. while in neonatal tissue psa-ncam and ki- were positive only on rare single cells in intersticium. conclusion: psa-ncam expression appears to characterize a very early stage of induced nephron progenitors differentiating from ncam + epcam-mesenchymal cells. according to psa-ncam localization and coexpression with ki- during development and its practically absence in neonatal tissue, suggest that psa-ncam present potential initiator of proliferation and differentiation of renal progenitor. objective: cystic hygroma (ch) typically develops in utero, late in the first trimester to early in the second trimester of gestation. many of the fetuses with ch present additional malformations commonly associated with chromosomal anomalies. method: a review of fetal autopsies performed over a year period revealed cases of ch ( , %). the results of cytogenetic analysis and the prenatal ultrasound findings were retrieved and compared to the autopsy findings. results: fetal death was due to therapeutic abortion in / cases, intrauterine death in / cases, and spontaneous abortion in / cases. cytogenetic analysis was available in cases. the results showed an abnormal karyotype in cases ( cases of turner syndrome and cases of trisomy ). the mean size of ch was , cm. other findings suggestive of the cause of fetal death were diagnosed in / cases ( , %). the most common autopsy findings were hydrops and central nervous system anomalies. the autopsy findings were in agreement with the prenatal ultrasound findings in / cases, while in cases ( , %) additional findings were detected during autopsy. conclusion: our study is confirms the strong correlation between ch and chromosomal anomalies of the fetus. immunohistochemical expression of e-cadherin in primary and metastatic nephroblastoma cases i. franckevicha * , r. kleina * university children´s hospital, dept. of pathology, riga, latvia objective: in nephroblastoma cases association between decreased e-cadherin expression and higher stage of tumor (safford sd, ) and lower expression in metastatic tumors (alami j, ) was described. some authors considered that e cadherin is not likely to play tumor suppressor role in nephroblastoma ( shulz s, ) . purpose of this study was to compare the expression of e-cadherin in metastatic and primary tumor cases in latvia. method: cases of primary tumors, metastases and case of relapse were analyzed immunohistochemically using visualization system envision. the number of e-cadherin positive structures per field was assessed (magnification× ). comparison between primary tumors and metastatic/ relapse tumors groups was made using mann-whitney test. results: in primary tumor group the number of positive structures in the field ranged from to , average . , sd . . in the metastatic tumor group, the number of positive structures varied from to , average . , sd . . comparison of expression observed in both primary and metastatic tumors groups showed the decreased e-cadherin expression in metastatic tumor group (z= − . , p= . ). conclusion: expression of e-cadherin is lower in metastatic tumor group that may suggest about negative correlation between it and higher tumor grade. ps- - testicular fibrous hamartoma: a case report a. kilitci * , f. yilmaz, s. yanik, h. ozturk * abant izzet baysal university, dept. of pathology, bolu, turkey objective: fibrous hamartoma (fh) of childhood is uncommon benign tumor. they are generally seen in the head and neck region, gastrointestinal system and lung. as in the case we report, they may also occur in other unusual sites such as groin and testis. the clinical presentation is almost always a mass or swelling, however our case was admitted to our hospital because of a left testicular atrophy. we report a fh in the testis, which has a rarely location and clinical presentation. method: a -year-old male presented to department of pediatric surgery because of left testicular atrophy. left orchiectomy was performed. results: in macroscopic examination, testis dimension was . × . × . cm. its cut surface was smooth and dirtywhite. in microscopic examination, the tumor showed disorganized matur tissue that composed of fibrocollagen stroma, vessels, muscular and adipose tissue. by this findings, it was diagnosed as testicular fibrous hamartoma (tfh). conclusion: in conclusion, tfh should be always kept in mind with testicular atrophy not only testicular mass or swelling. and knowledge of this particular type lesion is important to distinguish the fh of childhood from other situations in testis such as testicular torsion, incarcerated hernia, malign neoplasm, etc. in order to allow a correct diagnosis and avoid inadequate treatment. placental pathologic features in diabetes and hypertension p. luís * , a. costa-silva, a. alves * hospital de santa maria, dept. de anatomia patológica, lisboa, portugal objective: the aim of this study was to evaluate the most frequent placental findings in diabetes and hypertension and their main differences. method: retrospective study of selected placentas from to weeks gestation, in a universe of placentas examined over the last years ( % associated with hypertension, , % with diabetes and , % with both diabetes and hypertension (dwh). results: in diabetes the most frequently found abnormalities were immature villi ( %) and infarction ( %). in dwh the most frequent lesions were the immature villi ( %) and inflammatory lesions (either acute or chronic) ( %). in the hypertension group the most frequently found lesions were infarction ( %) and accelerated maturation of the villi ( %). in % of placentas in diabetes, % in dwh and only % in hypertension, no lesions were found. the incidence of fetal death was % in diabetes, % in dwh and , % in hypertension. when evaluating placental weight, small placentas were more frequent in the hypertension group ( %), and large placentas were more frequent in diabetes ( %). conclusion: our findings may contribute to evaluate the consequences of diabetes and hypertension in fetal outcome. as inflammatory conditions are usually not directly attributed to diabetes or hypertension, placental examination may help in diagnosis of associated pathology like infection. placental villi morphometry in preeclampsia k. pavlov * , e. dubova, r. shmakov, a. shchegolev * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: terminal villi structure abnormalities could play an important role in preeclampsia (pe) and its complications development. our aim was to perform comparative morphometric study of the placentas from mild and severe pe pregnancies. method: complex morphological and morphometric study of term placentas from mild pe (mpe) cases ( st group), term placentas from severe pe (spe) cases ( nd group) and term placentas from uncomplicated pregnancies (control group) was performed. results: we revealed significant decreasing in terminal villi size in both preeclamptic groups in compare to control. this decreasing was much prominent in spe group. we also observed significant terminal villi perimeter decreasing in both pe groups without any difference between mpe and spe groups. morphometry of cd stained specimens revealed significant decreasing in mean capillary number in both pe groups. single capillary area and perimeter were significantly lower in mpe and spe groups and these changes were much prominent in spe group. total villous capillary area and perimeter were significantly lower in both pe groups with minimal values in spe group. degree of villous capillarisation was significantly lower in both pe groups. conclusion: revealed features reflect villous structure changes in preplacental hypoxia, caused by mild and severe preeclampsia. sudden intrauterine death: the usefulness of autopsy f. portelli * , e. orlando, e. di stefano, e. maresi * university of palermo, section of pathology, italy objective: we investigated in autopsies of stillbirths the usefulness of autopsy even in the absence of risk factors and/or apparent anatomical/clinical causes which could explain the death. method: from january to december (institute of pathology, paolo giaccone-palermo) autopsies on dead uterine foetuses were performed. cases were abortions (< weeks), were stillbirths (≥ weeks). in all cases the autopsy included a macroscopic and microscopic examination both of the foetus and the placenta. the final diagnosis of death was based on both the morphological and clinical data. of the stillbirths, cases were "risk factor pregnancies", non. results: the stillbirth mortality was classified as follows: -sudden intrauterine unexplained death (siud,"sine materia" and absence of risk factor autopsies), cases; -explained intrauterine death ("cum materia" with or without risk factor autopsies), cases; -borderline intrauterine death ("sine materia" and presence of risk factor autopsies), cases. conclusion: in the absence of autopsy in / cases it was possible to establish the cause of death based on the presence of risk factors. in the absence of risk factors the autopsy showed a certain anatomical cause in / , only in / it was "sine materia". the role of "traditional" and "tomography" autopsy in foetal congenital heart disease (chd) f. portelli * , f. p. busardò, l. gutsul, l. averna, e. orlando, e. maresi * university of palermo, section of pathology, italy objective: the role of systematic autopsy in foetal chd is to identify the morphology of cardiac and possible associated extracardiac malformations (ecm) and the correlation between morphology, suspected clinical etiology and genetics. we evaluated the role of autopsy in foetal chds with/without prenatal diagnosis. method: from january to december (institute of pathology, paolo giaccone -palermo), foetal autopsies were performed. the autopsy protocol used was "tomography" for abortions, the "traditional" technique was adopted for stillbirths. results: in cases chds were identified. in cases chd diagnosis was made only through autopsy, in after a certain ( ) or suspect ( ) clinical/genetic diagnosis. the etiology of chd associated to ecm ( ) was: chromosomic type ( ), syndromic/sequence type ( ), association type ( ). the etiology of chd without ecm ( ) was never syndromic. conclusion: "traditional" and "tomography" autopsy plays a key role in the diagnosis and counselling of chd, either when it represents the only diagnostic tool ( , %) or when it is preceded by a clinical/genetic study. in the latter cases, its value depends on the detection of ecm, useful to "consolidate" a suspect clinical diagnosis ( , %) and to "complete" a malformative picture etiologically known thanks to a clinical/genetic analysis ( , %). objective: deregulation of cell cycle control is a hallmark of cancer. we have examined protein expression and gene amplification of cyclin a in wilms tumor (wt) and to analyze it in relation to tumor stage, prognostic group and histological type. method: real-time quantitative pcr was used to detect gene amplification of cyclin a in tumor tissue from patients with wt, while immunohistochemistry was applied to detect protein expression of the same cyclin. results: cyclin a gene amplification was found in out of the ( . %) cases of wt. cyclin a protein overexpression was detected in all four cases, but was also found in . % of cases without detectable gene amplification. so, there was no significant correlation between cyclin a gene amplification and protein overexpression. all cases with amplification of cyclin a were of favorable histological type, intermediate risk group and three out of four cases were low stage wts. on the other hand, overexpression of cyclin a was found significantly more often in high stage wts compared to low stage wts (p= . ). conclusion: cyclin a gene amplification might be associated with the favorable prognosis of wt (low stage, intermediate risk group and non-anaplastic tumors). the gold standard to diagnose is lung biopsy or necropsy. up to % of cases have mutations or deletions in the gene foxf (cr q . ) who plays a crucial role in the development of the lung vasculature. method: we report a case of a term newborn female affected of acd/mpv who was diagnosed by a lung biopsy. she died at days of life. autopsy and molecular diagnosis were also performed results: in the biopsy and autopsy specimens a decline in the number of capillaries in the alveolar septa and detachment of the epithelial lining was observed. secondary proximal plexiform arteriopathy, muscularization of arterioles and venous-venular dilatation and proliferation were evident. a pathogenic mutation in the gene foxf (frame shift mutation in the first exon) confirmed our diagnosis. conclusion: acd is defined by a decrease in capillaries with alveolar septal thickening and hypertrophy of the middle muscular layer of arterioles. mpv suggests an imbalance of angiogenesis. the foxf mutation helps to prenatal diagnoses of high risk families and to give the diagnosis to patients who fail to perform biopsy or autopsy. objective: prognosis of rhabdomyosarcoma (rms) has improved significantly over the last years. overall survival (os) is> % in the majority of patients; even though, children with metastatic tumors have a dismal prognosis with an os < %. method: we analyzed in cases, the possible correlation of notch activation with histology, presence of metastasis and outcome. immunohistochemistry (ihc) was performed for the notch downstream effectors hes and hey . results: hes was strong or moderate in % of the cases. hey was positive in %. out of alveolar rms (arms) were positive for hes and was positive for hey . both stains were negative in the fusion-negative arms. in embryonal rms (erms), eight out the were hey positive and of the were hes positive. the patients whit metastases had staining for hes and hey . patients who died showed hes (+). of the patients in remission showed positivity for hes and for hey . conclusion: hes expression was found in the majority of rms while hey was more erms specific. is no correlation between pathway activation, metastasis or outcome. the blockage of the pathway with specific inhibitors could offer a new therapeutic option for this patients. a renal epithelioid angiomyolipoma in a young woman with tuberous sclerosis complex, cortical tubers by neuroimaging, facial angiofribromas and lung lymphangioleiomyomatosis j. trillo-tinoco * * hospital general de mexico, dept. of surgical pathology, mexico city, mexico objective: tuberous sclerosis (ts) is a genetic disorder affecting cellular differentiation and proliferation, which results in hamartoma formation in many organs like skin, brain, lung, kidney and heart. method: a seventeen-year-old female with history of facial angiofibromas a years before, right renal tumor diagnosed a year before as theratoid-rhabdoid tumor, with chemoradiation as adjuvant treatment, cortical tubers by neuroimaging a few months before, and diagnosis of lung lymphangioleiomyomatosis recently. after last diagnostics, we reviewed again the renal tumor, new orientation of tissue, with new histological sections were performed. (fig) results: at histological examination, the kidney showed an infiltrating tumor, very cellular, consisting mainly of polygonal cells with eosinophilic cytoplasm, other multinucleated similar to the ganglion cells, also small hamartomatous areas with smooth muscle, fat and blood vessels proliferation. the tumor cells expressed hmb , mart- , sma, vim and cd , ckae / were negative. (fig) conclusion: the majority of renal angiomyolipomas is sporadic and to % occurs as part of ts, and their partnership is more close with epithelioid variant, recently, a rare entity with aggressive behavior, difficult histological characterization and poor prognosis. pulmonary mast cells in sudden infant death syndrome (sids) c. zaharia * , c. loddo, p. schmidt, r. m. bohle * university of saarland, inst. of pathology, homburg, germany objective: several theories of the underlying mechanisms of sids have been proposed, one of them is focusing on shock including anaphylaxis. increased concentrations of mast cell tryptase in post mortem blood have been observed without increased mast cell numbers in lung tissue. the aim was to evaluate the age-related distribution of pulmonary mast cells in infants dying of sudden infant death syndrome and controls. method: infants (up to year of age) who died of sids and controls who died of other non-pulmonary causes were examined. peribronchial mast cells exhibiting tryptase immunoreactivity were evaluated and quantified in high power fields in lung sections. results: the number of mast cells in peribronchial regions amounted to , (± , )/mm in children aged month up to months. mast cells in sids cases were , (± , )/mm . the difference was not significant (p= , , student'st test). conclusion: it is unlikely that increased pulmonary mast cells are indicators of sids. the role of mast cells in sids remains controversial. trophoblast apoptosis in placentas from pregnancies complicated by preeclampsia s. zekic tomas * , i. kuzmic prusac, d. roje, i. tadin * clinical hospital centre split, pathology, croatia objective: to assess trophoblast apoptosis separately in cytotrophoblast, syncytiotrophoblast, total villous trophoblast and syncytial knots, as well as to investigate the expression of apoptotic factors fas ligand (fasl), bcl- and proliferation marker ki- in trophoblast of placentas from preeclamptic patients. method: the study included placental samples from preeclamptic and normal pregnancies. for the detection of apoptosis and proliferation antibody m and antibody against ki- antigen were used. expression of fas ligand and bcl- was assessed using semi quantitative hscore method. syncytial knots were expressed as the number of syncytial knots per individual villus and as the total number of syncytial knots in each placental sample. results: apoptosis in all stages of trophoblast differentiation, number of syncytial knots per individual villus and the total number of syncytial knots were significantly higher in preeclamptic placentas than in control group placentas. fas ligand expression was significantly less, and bcl- expression significantly greater in the villus trophoblast among the study subjects compared with controls. there was no difference in the trophoblast proliferation between groups. conclusion: our findings might suggests that increased apoptosis and syncytial knots formation combined with reduced fas ligand expression could be involved in pathophysiological mechanisms of preeclampsia. contribution of fetal autopsy for diagnosis of meckel-gruber syndrome m. jo * , i. guerra, g. perez de nanclares, p. morales, j. j. aguirre, z. s. quintero, c. gomez, n. t. villagra * hospital txagorritxu, pathology, vitoria, spain objective: meckel-gruber syndrome (mgs) is a lethal rare autosomal recessive malformation. the six implicated genes encode proteins involved in primary cilia function. groups of families in finland, india and north of africa have been identified. method: a fetus, xy, karyotype, therapeutically aborted at weeks with alobar holoprosencephaly in ultrasound. fetal autopsy was performed. genetic counseling was proposed to the family revealing moroccan origin and consanguinity, the parents were first cousins. results: a male fetus showing cyclopia, proboscis and a single opening with two rudimentary eyes was the external morphology. histological examination confirmed holoprosencephaly and also showed bilateral corticomedullary renal multicystic and periportal hepatic fibrosis with bile duct dilatation. the main diagnosis was mgs although other ciliophaties and non-ciliopathies conditions were considered, such as bardet-bield, joubert, smith-lemli-opitz syndrome and trisomy . however, the pathological characterization, parent's consanguinity and their north african origin makes mgs the likely diagnosis.a genetic study on paraffin-embedded material was requested, the poor quality of dna stopped definitive genetic diagnosis. conclusion: the pathologist may encounter atypical cases that require morphologic diagnosis to determine the type of underlying mutation and provide genetic counseling to parents.a meticulous autopsy is necessary to establish the diagnosis of mgs. fresh material would have to be frozen in order to make current diagnostic techniques of molecular pathology. mesenteric cysts in the pediatric age group r. jankovic * , j. sopta, m. stojanovic, b. lekic, b. jovanovic, z. stojsic * university of belgrade, faculty of medicine, serbia objective: mesenteric cysts are extremely rare lesions arising with an incidence of / , admissions in children. clinically, mesenteric cysts are generally comprehended as a unique diagnostic entity, although they exhibit histological diversity. the objective of this study was to determine the incidence and the histology of the mesenteric cysts in the pediatric age. method: all cases of mesenteric cysts operated at the university children's hospital belgrade over the -year period of to were reviewed using pathology reports from the files of the institute of pathology. histological slides were re-examined and immunohistochemistry was applied, when necessary. results: a total of cases of mesenteric cysts were identified. cysts of lymphatic origin (cystic lymphangiomas) were recorded in patients ( %), cysts of enteric origin -in patients ( %): duplication cysts and one isolated enteric cyst of the mesenterium. only one example of the cyst of mesothelial origin, i.e. benign cystic mesothelioma was diagnosed ( %). the most frequent site was mesenterium and mesocolon ( %), followed by omentum ( %) and the retroperitoneum ( %). conclusion: cysts of enteric origin are easily recognized. it is important to differentiate between cystic lymphangioma and cystic mesothelioma due to their different natural history. objective: myxoid liposarcoma belongs to the group of soft tissue sarcomas with lipomatous differentiation. breast is a rarely affected (only . % of breast sarcomas), and often misdiagnosed. method: a -years old woman presented with a painful timorous lump of the left breast. mammography showed oval, lobulated lesion between medial quadrants, while ultrasonography revealed hipoechogenic, inhomogeneous nodule. patient underwent core biopsy which was histologicaly inconclusive and followed by quadrantectomy with excision of both medial quadrants. results: a lump ( cm) was visible on the skin surface. serial sectioning revealed solid gray-white tumor with cystic and prominent necrotic areas. the tumor was located in the deep mammary tissue an it infiltrated the overlying dermis without involving the epidermis. it consisted of atypical stelate and spindle cells with infrequent mitoses and low ki- proliferative index. on the periphery mature adipocytes and lipoblasts were present. stroma was abundant, myxoid with plexiform capillary pattern. the myxoid substance stained slightly alcian-blue positive and tumor cells showed cytoplasmic immunopositivity for s . phylodes tumor was excluded because of absence of epithelial component. conclusion: myxoid liposarcoma has a distinct morphology, rarely confused with other soft tissue tumors, although on cytological smears or biopsy samples it may be unrecognized. objective: synovial sarcoma poses a difficult diagnostic challenge since it can be confused with other benign or malignant entities. method: four biphasic and one monophasic synovial sarcomas were studied. we used the break apart/split signal kit (vysis) to detect the t(x; ) translocation and we performed immunohistochemistry for tle- , ini- , d - , cd , cd , bcl- , ema, ck , cd , s- , desmin and claudin- . results: immunohistochemically we observed: tle- +( / ), ini- ( / ) with reduced nuclear and ( / ) with no expression, d - +( / ), cd +( / ), cd +( / ), bcl- +( / ), ema focal expression ( / ), ck −( / ), cd −( / ), s- −( / ), desmin−( / ), claudin- + ( / ). fish revealed the split signal between the centromeric and telomeric end of the syt gene. conclusion: t(x; ) translocation remains the diagnostic hallmark of synovial sarcoma. ini- which is typically negative in atypical teratoid/rhabdoid tumor, epithelioid sarcoma and myoepithelial carcinoma seems to be reduced or even negative in synovial sarcomas. the focal expression of d - must be considered when the differential diagnosis includes mesothelioma. finally tle- is a very sensitive marker for synovial sarcoma. ps- - "mixed aneurysmal bone cyst" and "simple bone cyst", represent a different group of cystic lesion e. ayhan cinar * , b. doganavsargil, m. sezak, f. oztop * ege university, pathology, izmir, turkey objective: there are some mixed cysts (mc) with overlapping histological features of aneurysmal bone cyst (abc) and simple bone cysts (sbc). method: we reviewed pure abc, sbc and "mixed cysts (mc)", and compared them by nonparametric tests. results: mcs, mainly showed two paterns as "type : sbc with secondary abc foci (n= )"and "type : cysts with fully developed sbc and abc areas (n= )". the median age for abc, sbc, and mc were ± . (range: - ), ± . (range: - ) and ± . years old (range: - ) respectively. mcs were more frequent in males than abc and sbc (p= . ) and the most frequently involved bones were humerus-femur-pelvic bones in descending order (p= , ). "type mc" showed more frequent cementum-like amorph material (p< . ), ectatic venules (p= . ), calcifications (p= . ), less cholesterol deposition, necrosis and no different fracture and osteoid matrix when compared with type mcs and sbcs. conclusion: cysts with overlapping features of abc and sbc are not uncommon. though they usually represent "sbcs with secondary abc component", they have dissimilarites with ordinary sbcs which needs to be further clarified with larger series. objective: percent of tumor necrosis after neoadjuvant chemotherapy, determined by detailed specimen mapping, has a high prognostic value. however both the mapping and grading systems has some practical problems. method: cases were reviewed for potential pitfalls in handling and reporting processes and correlated with radiological findings by nonparametric-tests. results: most of the tumors were osteosarcoma ( . %) and ewing sarcoma ( . %), located in femur ( %), tibia ( , %) and humerus ( . %). cortex, soft tissue and joint invasion was observed in %, . % and . % of the cases, respectively. a median of . tumor blocks ( - ± , ) were submitted for histology. tumors were totally necrotic in cases ( %) (huvos grade-hg-iv), hg iii in . %, hg ii in . % and hg i in . % of the cases. overall good (hg iii-iv) and poor responders (hg i-ii) correlated well with radiological findings (p< . ). discrepant cases showed extensive oedema and congestion enhancing contrast medium, patchy necrosis unabling accurate histologic evalation, or failure to prove tibiofibuler joint involvement because of sagittal sectioning (p< . ). conclusion: evaluating chemotherapy responce is a laborious work. radiologic orientation prior to grossing and applying morphometric technics may enhance more accurate evaluation. atypical ewing sarcoma/primitive neuroectodermal tumor with unusual melanocytic differentiation -a case report p. buzrla * , j. dvorackova, i. urbanovska, h. bielnikova * inst. of pathology, ostrava-marianske hory, czech republic objective: atypical ewing sarcoma/primitive neuroectodermal tumor with the melanocytic differentiation is a very rare, malignant tumor which occurs in infants and adolescents. it is localized mainly in soft tissues. its biological behavior is aggressive, but its response to the chemotherapy is prognostically good. method: a -month old male is presented with the × cm tumor of the soft tissue, localized in the right front over the cranial margin of the orbit. the tumor was surgically exstirpated and then sent to the histological investigation with the additional immunohistochemistry and the fish. results: microscopically, the tumor is hypercelullar and consisted of oval to polygonal cells with the vesicular nuclei, the prominent nuclei and the amphophilic cytoplasm. in other parts of the tumor, there are smaller neoplastic cells with hyperchromatic nuclei. some neoplastic cells contain the melanin pigment in the cytoplasm, which was positive in fontana-masson method. the immunohistochemical stains for vimentin, ae / , ck , cd , hmb- , fli- were positive. the fish investigation demonstrated the translocations (t ; , q ;q ) in % of neoplastic cells and (t ; , q ; ) of % ones. conclusion: in literature, the ewing sarcoma/pnet showing the myogennic differentiation is usual, but the melanocytic differentiation is rare and can be confirmed not only immunohistochemically, but also by fish investigation. objective: poly(adp-ribose) polymerase- (parp- ) is a nuclear enzyme involved in the repair of dna single-strand breaks. parp- inhibitors may be efficient in therapy of malignancies. this report evaluates the expression of parp- in primary testicular germ cell tumors and correlates expression patterns with histological subtypes and patient/ tumor characteristics. method: group of patients with testicular germ cell tumors were investigated for parp- expression by immunohistochemistry, scored by the multiplicative quickscore (qs) method and compared to parp- expression in normal testis. results: we observed higher expression of parp in testicular tumors compared to normal testis (mean qs= . vs. . , p< . ). the parp- overexpression (qs> ) was most often detected in intratubular germ cell neoplasia itgcn ( % of specimen with parp- overexpression), compared to . % of normal testicular tissue specimen. there was no association between parp- expression and clinical variables. conclusion: parp- expression is higher in tumor tissue than in normal testis. parp- could represent a novel treatment target in tgcts and the assessment of parp- expression in tumor samples may lead to the consideration of tgcts patients for parp inhibitor therapy. supported by / -nou- , vega / / and itms: cofinanced by european regional development fund. objective: gardner fibroma (gaf), a rare lesion, typically occurs in infants, children and young adults, with predilection for the trunk (particularly paraspinal region) and no gender predominance. gaf is an ill-defined plaque-like mass, with rubbery consistence, usually asymptomatic, ranging from . to cm. although benign, - % of the cases may be associated with apc mutations, familial adenomatous polyposis (fap) and/or gardner syndrome (gs). we report cases of gaf, which allowed the identification of families with gs. results: case : -month-old boy, with nodules in the left paraspinal region, the largest with . cm. case : month-old boy, presenting a . cm ill-defined deep right scapular mass. both lesions were infiltrative, paucicelular densely collagenized proliferations of bland spindle cells. a gaf diagnosis was made and clinical/genetic investigation advised. apc gene sequentiation revealed, in both cases, a frameshift germline mutation in exon . additionally, case presented a del( )(q q ). heredogram showed typical manifestations of gs: case : mandibular osteomas, epidermoid cysts, "soft-tissue tumours", colo-rectal carcinoma. case : hepatoblastoma, colo-rectal carcinoma. conclusion: given the high association with gs and the fact that it can be its first manifestation, gaf is considered a sentinel lesion for this syndrome. therefore, an accurate diagnosis is of the utmost importance. prognostic significance of bcl- , c-myc and survivin in synovial sarcoma d. demir * , b. yaman, y. anacak, b. keçeci, g. kandiloğlu, t. akalın * ege university, pathology, izmir, turkey objective: in this study, we evaluated synovial sarcoma cases, who had been referred to our tertiary tumor center during the last years. we applied bcl- , c-myc and survivin as immunohistochemical markers and evaluated the relation with conventional prognostic findings and prognosis for those patients who have follow-up. method: in this study; ten-year tumor free survival rate was % reflecting the agressive behaviour of synovial sarcoma. tumor grade was the most valuable prognostic input. progression free survival (pfs) was months for gradeii cases ( cases) and months for gradeiii cases ( cases) (p= , ). results: immunohistochemically, there was weak relation between bcl- staining intensity with prognosis. overall survival was months for weak or negative cases ( cases), months for focally intense cases ( cases) and months for diffuse and intense cases ( cases) (p= , ). there was also weak relation with c-myc staining pattern with prognosis. overall survival was months for c-myc negative cases ( cases), months for cytoplasmic positive cases ( cases) and months for nuclear positive cases ( cases) (p= , ). there was no relation between survivin and prognosis. conclusion: in conclusion; tumor grade is the most valuable prognostic parameter in synovial sarcomas. immunohistochemically c-myc and bcl- staining have weak relation with synovial sarcoma prognosis. immunohistichemical profile of primary and recurrent desmoids e. dubova * , t. sidorenko, a. shchegolev, a. adamyan * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: desmoids is a locally recurrent and invasive but not metastatic tumor. our aim was to study immunohistochemical profile of primary and recurrent desmoids. method: complex morphological study of abdominal desmoids. all the tumors were divided into groups: primary, first recurrent and second and more recurrent cases. we used antibodies against β-cathenin, cox- , apc, survivin and ki- for immunohistochemical study. results: nuclear and cytoplasmic β-cathenin expression levels were significantly higher in recurrent than in primary desmoids. apc cytoplasmic expression level was also significantly higher in recurrent tumors. we revealed only cytoplasmic cox- expression in desmoids, and its level was significantly higher in recurrent tumors with the activity increasing accordingly to the number of recurrences. survivin expressed both in nuclei and cytoplasm of the tumor cells and its expression levels were significantly lower in recurrent desmoids. conclusion: revealed immunohistochemical properties of primary and recurrent desmoids reflect tumor transformation and progression and could be used as additional prognostic markers in this disease. objective: many bone and soft tissue sarcomas (bsts) are aggressive tumors with fatal prognosis. the importance of angiogenesis for the growth and progression of solid bsts is now well recognized. a variety of chemokines have been described that either promote (angiogenic) or inhibit (angiostatic) angiogenesis. the aim of this study is to characterize the expression profile of some chemokines in a series of xenotransplanted human bsts. method: one ewing sarcoma (es), grade chondrosarcoma (chs), osteosarcoma (os), synovial sarcoma (ss), fibrosarcoma and gastrointestinal stromal tumor (gist) were xenotransplanted into the backs of nude mice (athymic balb-c nude mice). when the tumor size reached the cm, animals were sacrificed and tumors analyzed for the expression of cxcl / / , cxcl and cxcl , using two-color staining fluorescence on each slide under a confocal microscope (olympus fv ). results: we observed that angiostatic chemokines (cxcl and cxcl ) presented higher expression than angiogenic (cxcl / / ) chemokines in es, grade chs, os and gist whereas fibrosarcoma and ss were more positive for angiogenic chemokines. conclusion: the expression profile of angiostatic and angiogenic chemokines depends on the type of bsts and could be related to their different biological behaviour. other elements such as angiogenic or pro-inflammatory markers should also be considered. objective: the wide range of differential diagnostic possibilities of rhabdomyosarcomas (rms) shows the need for more specific and sensitive markers. low survival rates of high risk rms patients require new prospective therapeutic targets. method: archival material ffpe samples of rms ( embryonal -erms, alveolar -arms) and non-rms soft tissue tumors were evaluated by immunohistochemistry for myogenin, myod , egfr, vegf, cox- , p-akt and p-mtor expression. the presence of pax / -fkhr forming translocations, myogenin, myod , gamma subunit of fetal acetylcholine receptor (achr) and k-ras mutational state were determined by rt-pcr. results: / erms and / arms showed expression of myogenin, myod and gamma achr. non-rms tumors were negative. translocations were only found in arms. egfr expression was characteristic for erms, without the presence of activating k-ras mutation. strong expression of vegf was detected in all samples. p-akt and p-mtor showed overlapping expressions in , % rms. in most of the samples weak cox- positivity was demonstrated. conclusion: myogenin, myod and the fetal achr are specific and sensitive diagnostic markers of rms. rms subtypes are identifiable by pax / -fkhr detection and probably egfr expression. the results indicate vegf, egfr, cox- and akt-mtor pathway directed therapy to be considered in rms. supported by itms . immunohistochemical analysis of potential targets in desmoid tumor therapy a. janegova * , z. hlavata, p. babal, p. janega * comenius university, dept. of pathology, bratislava, slovakia objective: desmoid tumors (dts) are clonal fibroblastic/ myofibroblastic proliferations. although histologically benign, desmoids are locally invasive and often have an unpredictable clinical course. dts are infrequent lesions, but they have a high incidence in patients with familial adenomatous polyposis (fap). the treatment of dts needs to be individualized. method: to explore the molecular bases of potential pharmacologic targets in dts we evaluated the immunohistochemical expression of steroid hormone receptors (era, erb, pr) and cox- protein in sporadic (n= ) and fapassociated desmoid tumors (n= ) together with gi adenomas of fap patients (n= ). results: nuclear erb expression was found in / dts. all adenoma samples showed nuclear erb positivity, which was weaker than in the surrounding normal epithelial cell. era and pr expression were lacking in all samples. cox- was found in / dts. adenomatous polyps showed intense cox- expression compared to surrounding normal mucosa. conclusion: high incidence of erb positivity in dts supports the usage of hormonal therapy in these lesions. open question is the effect of anti-estrogen therapy in dt patients with adenomatous polyps, as in adenomas estrogen seems to have preventive potential. cox- expression suggests the benefit of anti-inflammatory treatment in dts adenomatous polyps. supported by itms: . retroperitoneal sarcomas: clinicopathological features in a series of cases e. kairi-vasilatou * , a. tsagkas, a. melloy, a. paraskeva, a. kondi-pafiti * aretaieio nosokomeio university, dept. of histopathology, athens, greece objective: retroperitoneum is the less common site of origin accounting for approximately % of soft tissue sarcomas. method: between january and december , our hospital's records of patients with retroperitoneal sarcomas were retrospectively studied. results: the patient median age was years and there was no sex predominance. median tumor size was . cm (ranging from to cm) with % of them being larger than cm. the most common histological type was liposarcoma ( / - , %), followed by leiomyosarcoma ( / - , %) and undifferentiated soft tissue sarcoma ( / - , %). the remaining tumors ( , %) included chondrosarcomas, well-differentiated fibrosarcomas, pecoma, hemangiopericytoma, ewing sarcoma and malignant peripheral nerve sheath tumor. of the sarcomas were high grade ( %) and ( %) low grade. -year recurrence rate was , %. the -and -year overall survival rates were , % and , % respectively. seven patients received adjuvant chemotherapy. conclusion: the most commonly encountered histologic subtypes are liposarcoma and leiomyosarcoma, which are consistent with the results of the present study. complete tumor resection at first operation is the only treatment factor that consistently predicts improved survival. abdominal desmoid tumor y. lorenzo mahia * , m. san martin alonso, b. iglesias rodriguez * hospital maixoeiro, anatomia patologica, vigo, spain objective: abdominal desmoid tumours are rare benign neoplasms. they are commonly found in the mesentery, while they are rarely found in the intestinal wall. most cases are sporadic, although there is a link with colonic polyposis, trauma, and oestrogen. they predominate in - year-old women. this present case is notable due to its location in the jejunal wall, possible relation with previous surgery, and the age and sex of the patient. method: we present a -year-old male patient previously operated for umbilical hernia years before. he came to the consultation on noticing an abdominal mass. since the initial suspicion was of jejunal wall gist tumour, surgery was performed. results: the histopathological and immunohistochemical findings, support the diagnosis of desmoid tumour. conclusion: desmoid tumours consist of fibroblastic monoclonal proliferation developed from aponeurotic muscle structures. some authors consider them non-neoplastic processes given their limited aggressiveness while others classify them within distinct low-grade sarcomas. their origin is not well established, although there are known factors involved such as mutations in the apc gene or beta-catenin and trisomy and . the originating cell, the myofibroblast, is involved in post-traumatic cellular regeneration. this explains why we find these tumours associated with previous surgery. treatment of advanced dermatofibrosarcoma protuberans with imatinib mesylate with or without surgical resection w. michej * * cancer centre institute of warsaw, dept. of pathology, poland objective: dermatofibrosarcoma protuberans (dfsp) is a rare soft tissue sarcoma of the skin characterized by the presence of specific col a -pdgfb fusion protein, which appears as a consequence of the t( ; ) (q ;q ) translocation. method: the aim of the study was to perform an analysis of patients with advanced dfsp treated with imatinib, with or without surgery. we examined patients ( male, female; median age years) with locally advanced/initially inoperable and/or metastatic dfsp treated with imatinib - mg daily between / and / . all diagnoses were ascertained cytogenetically (fluorescent in situ hybridization). median follow-up time was months (range: - ). results: metastases were present in cases (two lungs, two soft tissue, two lymph nodes). fibrosarcomatous transformation was confirmed in patients. after treatment with imatinib overall responses were: partial responses, stable diseases ( %) and progressive diseases ( %). seven patients ( %) after resection had residual disease confirmed by pathologic examination and remained free of disease. conclusion: we proved that anti-tumour effect of imatinib in dfsp with presence t( ; ) had in most cases good responses. imatinib therapy may in some cases leads to tumour resection because of lesser size. objective: at an estimated incidence of cases per million per year, osteosarcoma is the most common malignant primary bone tumor. method: we conducted a retrospective study to identify the osteosarcoma cases diagnosed at major tertiary care hospitals in turkey. results: our study group was made up of cases: men, women, aged - years (mean . year). all patients had been diagnosed with skeletal osteosarcoma between and at one of the tertiary care referral center. tumor was most frequently located in femur ( . %) followed by tibia. apart from the long bones, pelvic and gnatic bones were the next in location, . % and . % respectively. there were ( . %) secondary osteosarcomas, related to previous irradiation and various underlying diseases. for the histological types conventional osteblastic intramedullary tumors were most prevalent, making . .% of the cases. chondroblastic and telengiectatic osteosarcoma are the next common histologic types. surface tumors were detected in ( . %) cases. rare histological types like small cell, epitheloid, chondroblastoma like and fibrous dysplasia like were also reported. conclusion: this study is conducted as a preliminary work to form the basis of a pathologic database for the osteosarcoma cases diagnosed in our country. objective: kaposi's sarcoma is a rare disease likely associated with human herpes virus infection, and occurs predominantly in jewish, mediterranean and middle eastern men. since there is a paucity of reports on the pattern of its occurrence in tunisia, we here analysed the epidemiological pattern and anatomoclinical features. method: we retrospectively studied consecutive cases of kaposi's sarcoma diagnosed in the pathology department, farhet hached hospital, sousse during a -year period. results: kaposi's sarcoma represented % of soft tissue sarcomas. there were ( . %) females and ( . %) males (male-to-female ratio: . : ). median age at diagnosis was (range: - years). the age distribution showed that elderly (≥ years) were the most affected patients with a frequency of . %, followed by patients aged - years ( . %), and patients under years ( . %). the most common location was the lower limbs, particularly the distal lower extremity ( . %), followed by contiguous location ( %), and soft tissue, nos ( %). conclusion: kaposi's sarcomas were more frequently diagnosed in elderly. the distal lower extremities were more involved. objective: rhabdomyosarcoma is the most common soft tissue sarcoma in the first two decades of life. in this study, we analysed the epidemiological pattern and antomoclinical features of rhabdomyosarcoma in central tunisia. method: we retrospectively studied all cases of rhabdomyosarcoma diagnosed in the pathology department, farhet hached hospital, sousse during a -year period. results: there were ( . %) females and ( . %) males (male-to-female ratio: . : ). median age at diagnosis was (range: - years). rhabdomyosarcoma was more frequently diagnosed in childhood ( %) than in adults ( %). in children, the tumour size was higher than cm in % of cases, the embryonal subtype was the most frequent ( %) and the two most common sites of disease were the head and neck ( %) and genito-urinary tract ( . %). in adults, the tumour size was higher than cm in % of cases, the pleomorphic subtype was the most diagnosed ( %), and limbs were the most involved sites ( %). conclusion: rhabdomyosarcomas is more frequently diagnosed in children than in adult. head and neck locations were the most involved and embryologic type was the most diagnosed. in adults, rhabdomyosarcomas were more frequently localized in limbs and diagnosed as pleomorphic type. microarray-based dna methylation study in ewing sarcoma of bone h.-r. park * , y.-k. park * hallym university, sacred heart hospital, anyang, republic of korea objective: alterations in the dna methylation pattern are a hallmark of malignancy and also of ewing sarcomas. however, most epigenetic studies in ewing sarcoma have focused on the analysis of few candidate genes and comprehensive studies are required. method: here, we report for the first time a microarraybased dna methylation study of cpg sites of cancerrelated genes in ewing sarcomas. we used illumina's goldengate methylation cancer panel i microarray. results: using appropriate controls (n= ), we identified a total of cpg sites hypermethylated in ewing sarcoma. most of hypermethylated genes are related with cell adhesion, cell regulation, development, and signal transduction. we compared the methylation mean of each tumor according to the survival data. the methylation mean was significantly higher in the alive patient group ( . ± . ) compared to the dead patient group ( . ± . ) (p= . ). however, the methylation mean was not significantly correlated with age, sex, or tumor location. we selected the most popular hypermethylated genes, gdf , osm, apc, and hoxa , but, their methylation levels were not significantly correlated with the survival data. conclusion: we have characterized the dna methylation profile of ewing sarcomas and detected cpg sites that were significantly hypermethylated in ewing sarcomas. these might therefore play an important role in the development of ewing sarcomas. pleomorphic and dedifferentiated leiomyosarcoma associated with lynch syndrome: a case report h. quiceno * , f. j. queipo, r. carías, j. j. sola, f. j. pardo * clinic university of navarra, anatomical pathology lab, pamplona, spain objective: the lynch syndrome or hereditary non-polyposis colorectal cancer (hnpcc) is a hereditary syndrome that predisposes to different types of colonic and extracolonic cancer, mainly in endometrium, stomach, ovary, and hepatobiliary and urinary tract. occasional sarcomas have been reported in hnpcc patients. method: we describe a pleomorphic and dedifferentiated leiomyosarcoma of the gluteus in a patient with lynch syndrome. we study her clinical, pathology, immunochemistry and molecular alterations. results: we present a year old woman with previous colorectal, endometrium and breast cancers in a lynch syndrome with mutations in exons and of mlh , which appeared with a right gluteus mass. grossly, it was encapsulated, whitish-yellowish with necrotic areas and measured , cm. microscopically, the tumor was composed by a diffuse and polymorph spindle cells with fascicular pattern, focally myxoid and zones of necrosis and large hyalinization. the cells had large nuclei, sometimes giant multinucleated, with a brisk atypical mitosis activity. there was ihq variability: positivity to desmine, msa, calponin and negative to caldesmon and sm. there was loss of msh and msh repair proteins. conclusion: we must suspect a lynch syndrome relational sarcomas if we found one in a patient with hnpcc in order to test to mismatch repair proteins. immunohistochemical review of synovial sarcomas, including expression of tle : a "new" marker, with molecular confirmation in cases b. rekhi * , r. basak, s. desai, n. jambhekar * tata memorial hospital, dept. of pathology, mumbai, india objective: synovial sarcoma displays a wide clinicopathological spectrum and a specific translocation t(x; )(syt-ssx)(p . ; q . ). cost constraints limit molecular confirmation in every case. lately, tle has been recognized as a useful ihc marker. herein, we present ihc review of synovial sarcomas, including tle expression. method: forty-two synovial sarcomas included monophasic spindle-cell type ( ) ( . %), biphasic ( . %), calcifying ( ) ( . %) and poorly-differentiated type ( ) ( . %). tumors were confirmed with molecular analysis. tle immunostaining was graded from , +, +, +, with + or + grades interpreted as positive staining. results: on ihc, various synovial sarcomas were positive for ema ( / )( . %), ck ( / ) ( %), ck/mnf ( / )( . %), bcl ( / )( . %), mic ( / )( . %) and tle ( / )( . %), while negative for cd ( / ). among other tumors, tle was positive in schwannomas ( / ) ( %), neurofibromas ( / )( %), mpnsts ( / )( %) and pnets ( / )( %). sensitivity and specificity of tle for synovial sarcoma was . % and %. % of pnst ( % of schwanomas, % of mpnst and % of neurofibromas). in contrast, her positivity was observed in % of other mesenchymal tumors ( % uterine and % non-uterine leiomiomas, % uterine and % nonuterine leiomiosarcomas, % ups). conclusion: her overexpression is frequently found in pnst, including % of mpnst. due to the crucial role of her receptor in cell signalling as a main activator of the pi k pathway, these results support the rationale of developing new therapeutic approaches in mpnst. objective: nonneural granular cell tumour (nngct) is a rare neoplasm described in by leboit et al. till now, no more than cases have been presented in the literature, nearly all were limited to the skin. we report the first nngct of the breast and present its morphological and immunohistochemical characteristics. method: a year-old female underwent lumpectomy because of tumour of the breast. after routine histological examination, the immunohistochemical studies were performed using commercially available antibodies against cytokeratins (ae /ae ), cd , cd a, s , cd , smooth muscle actin, desmin, miogenin, inhibin, and ki antigen (mib ). results: microscopically, the tumour was composed of ovoid and polygonal cells with abundant granular, eosinophilic cytoplasm. the cells presented mild or moderate polymorphism and trace mitotic activity. they were arranged in diffuse sheets with no evidence of nesting or fasciculation. the histological texture of the tumour resembled that of classical granular cell tumour of abrikosoff. however, the tumour cells were strongly immunoreactive for cd and inhibin, whereas the reactions against s protein as well as other antigens studied gave negative results. the value of ki index did not exceed - %. conclusion: the differential diagnosis of granular cell myoblastoma (abrikossoff tumour) should include the nonneural granular cell tumour. low grade fibromyxoid sarcoma: a study of cases k. shelekhova * , a. konstantinova * petrov´s research institute for oncology, st. petersburg, russia objective: low grade fibromyxoid sarcoma (lgfms) is a specific type of fibrosarcoma with deceptively banal appearance and malignant behavior. method: a year retrospective study revealed lgfms cases. morphological and immunohistochemical analysis was performed. follow-up information was obtained for cases. results: all tumors occurred in adults (mean year). they developed in neck ( ), extremities ( ) and trunk ( ). beside classical morphology of lgfms following features were observed: necrosis ( ), rosettes ( ), areas of increased cellularity ( ), foci of epithelioid cells ( ), marked nuclear pleomorphism ( ), prominent myxoid change ( ), invasive border ( ), bone formation ( ), focal retiform pattern ( ) and sclerosing epithelioid fibrosarcoma-like areas ( ). immunoprofile was the follow: vimentin ( %), ema ( %), cd ( % focally), s ( ), sma( ), desmin ( ), ae /ae ( ). two patients were without evidence of disease, one developed lung metastasis after year. two patients developed secondary tumours in and years after initial diagnosis. there were differences in the location and histologic features compared with primary ones. secondary tumors were less cellular, without necrosis or epithelioid cells. behavior of secondary tumors did not fit to the classical concept of tumor progression that implies increase of malignancy. conclusion: lgfms is a distinctive but unusual type of soft tissue sarcoma demonstrating a wide histologic spectrum and behavioral range. immunohistochemical and mutational study of synovial sarcomas k. specht * , m. bettstetter, g. keller, h. rechl, r. von eisenhart-rothe, h. höfler, m. straub * technische universität münchen, inst. für pathologie, germany objective: synovial sarcomas are mesenchymal tumors of unknown histogenesis. their molecular signature is a specific t(x; )(p . ;q . ) translocation. no effective targeted therapies are currently available. the aim of this study was to evaluate the expression and mutational status of potential molecular therapeutic targets. method: molecularly confirmed cases of synovial sarcomas were included in this study. immunohistochemical stainings of the egf-r family (egf-r, her /neu, her ), and signaling molecules implicated in the mtor pathway (akt, mtor, pten), as well as e-cadherin and snail was performed. in addition, cases were screend for mutations in the egfr, pik c, b-raf, k-ras, and n-ras genes. results: egf-receptor family members as well as e-cadherin and snail are important for defining the tumor phenotype by determining epithelial-mesenchymal transition of synovial sarcomas. activation oft the mtor pathway is seen in a significant number of cases. mutations of the genes studied are an overall rare event in synovial sarcomas and other types of sarcomas studied. conclusion: egf-r expression is found in many synovial sarcomas, however, mutations of egfr or downstream molecules appear to be rare. activation of mtor pathway is frequently seen in synovial sarcomas. the benefit of targeted therapy against these genes in synovial sarcomas remains to be determined. collagen v induces differentiation of rabbit adipose tissue-derived stem cells in chondrocyte-like phenotype w. teodoro * , i. brindo da cruz, a. p. velosa, s. carrasco, c. goldenstein-schainberg, r. fuller, e. parra, v. capelozzi * faculdade de medicina da usp, disciplina de reumatologia, são paulo, brazil objective: stimulated mesenchymal stem cells (mscs) have capacity of differentiation in many cell types. it is being used in degenerative diseases treatment protocols. we evaluated the collagen v (col v) and collagen xi (col xi) influence in the differentiation of rabbits adipose tissue-derived mscs in a chondrocyte-like cell phenotype. method: mscs isolated of new zealand rabbits adiposetissue were maintained in culture by weeks. colv, colxi and colv/xi ( μg/ml) were added to culture during h. the cells aggregates were stained with toluidine blue, alcian blue and picrosirius. chondrocyte-like phenotype was confirmed by immunofluorescence to cd , vimentin and collagens i, ii and iii. results: mscs stimulated with colv expressed proteoglicans and collagen, when compared with colxi and colv/ xi and control. in the presence of colv, mscs was capable to increase collagen ii expression confirming its chondrocyte-like cell phenotype. in contrast, mscs cultured with colxi and colv/xi express collagen i and iii. conclusion: the data suggest that colv may facilitate the differentiation of rabbit adipose tissue-derived stem cells into a chondrocyte-like phenotype. further studies are urged in order to evaluate the influence of colv in the ability of chondrocytes to remodel osteoarthritic joint surface at ultra structural and molecular levels. objective: xrcc is essential for dna base excision repair, single strand break repair and nucleotide excision repair. method: we evaluated xrcc immunohistochemically in early stage breast (n= ), ovarian (n= ), gastric (n= ), colorectal (n= ) and pancreaticobiliary cancers (n= ). pre-clinically, we evaluated a panel of xrcc deficient and proficient chinese hamster ovary and human cancer cell lines. double strand break repair (dsb) inhibitors targeting atm (ku ), dna-pkcs (nu ) and atr (nu ) were evaluated for synthetic lethality and cisplatin alone or in combination with dsb inhibitors for chemopotentiation. results: in breast cancer, xrcc loss ( %) was associated with a -fold increase in risk of death and metastasis (p< . ). in ovarian cancer, xrcc positive tumours ( %) were more resistant to platinum chemotherapy (p= . ). xrcc positivity conferred a fold increase of risk of death (p= . ) and independently associated with poor survival (p= . ). pre-clinically, ku , nu and nu were synthetically lethal in xrcc deficient compared to proficient cells as evidenced by dsb accumulation, g /m cell cycle arrest and apoptosis. xrcc deficient cells were hypersensitive to cisplatin which was enhanced by dsb repair inhibitors compared to in proficient cells. conclusion: conclusions: xrcc deficiency in human tumours may be suitable for synthetic lethality application and exploited for cisplatin chemotherapy potentiation. analysis of bcl oncoprotein expressing breast cancer by molecular subtype a. abolins * , i. strumfa, z. simtniece, a. vanags, g. trofimovics, j. gardovskis * riga stradinš university, inst. of oncology, latvia objective: breast cancer is the most common malignancy in western women. despite the progress in morphological investigation, active research is devoted to potentially important targets for prognosis and intervention. bcl oncoprotein represents such factor. method: consecutive breast cancer cases were examined by routine protocol approach. the bcl oncoprotein expression was detected immunohistochemically. expression was considered positive if it was in more than % of tumour cells. the molecular subtype ( objective: breast cancer is the most common malignant tumour of latvian women (www.csb.lv). correct diagnosis, including identification of tumour histogenesis, is the prerequisite for appropriate treatment. method: consecutive breast tumour cases were selected by systematic retrospective archive search and were examined by breast cancer panel. if expression of oestrogen and progesterone receptors and her protein was negative, mammaglobin, cytokeratin ae /ae , vimentin, cd , cdx , cytokeratin , ttf- and melanosome protein hmb- were detected. results: five patients ( . %, % ci= . - . %) with secondary breast tumours were identified among cases. breast was affected by metastatic small cell lung cancer ( ), malignant neuroendocrine tumour of small intestine ( ) as well as by epithelioid melanoma metastasis in breast tissues ( ) or intramammary lymph node ( ). analysing medical records, multiple synchronous and/or metachronous metastasis, involving brain, kidneys and ovaries, were found in all patients with haematogenous tumour metastases in the breast. in contrast, the lymphogenic tumour spread was isolated. conclusion: . lymphogenic or haematogenous metastasis rarely ( . % of malignant breast tumours by morphology) can develop in breast tissues. it should be taking into account when planning the differential diagnostic approach, especially immunohistochemistry. . haematogenous metastases in breast are associated with a wide synchronous or metachronous extramammary tumour spread. the prognostic significance of tumor-associated stroma in invasive breast carcinoma objective: fibroblasts in the stromal component of a tumor may influence tumor progression in various organs. the prognostic significance of tumor-infiltrating lymphocytes is also frequently reported. however, the prognostic significance of the stromal component in breast cancers, particularly those of high grade, has not been established. method: in this study, we analyzed surgically resected specimens from patients with breast carcinoma, including high grade tumors, for tumor-stroma ratio, dominant stroma type (collagen (c), fibroblast (f) or lymphocyte (l) dominant type), and central fibrosis on hematoxylin-eosin stained histological sections. we correlated these features with clinical prognosis. results: among the specimens examined, ( . %) were of c type, ( . %) of f type, and ( . %) of l type. central fibrosis was found in tumors ( %). the dominant stroma type was a significant prognostic factor on univariate and multivariate analyses, together with t classification, nodal status and bloom-richardson grade. tumorstroma ratio and central fibrosis did not predict survival on multivariate analysis. even in high-grade tumors, relapse-free intervals differed significantly according to dominant stroma type. conclusion: conventional hematoxylin-eosin stained tumor slides may contain more prognostic information than previously thought; in particular, the dominant stroma type in invasive breast cancer may potentially be used to predict outcome. ps- - pathology in breast implants substitution l. alfaro * , j. serra, j. m. ibañez * valencia, spain objective: health alert concerning breast implants brand pip led to a review of patients harboring these prosthesis and in many cases replacement by new ones. anaplastic lymphoma described in these patients has been an additional problem to be faced by plastic-surgeons and pathologists. method: ninety two cases of women with breast implants were studied. most of them had pip implants (although no information of prosthesis type was available in all cases). eighty of them presented with ruptures of different size. after implant replacement, histopathologic analysis of fibrous capsules and liquid from seromas in periprosthetic cavities was carry out. following fda recommendations, immunohistochemical studies to rule out lymphoma was performed in cases. results: fibrous capsules showed synovial metaplasia in all cases. morphology was practically identical that in real articular synovial cells, and occasionally intracavitary nodules were seen detached from the surface in a process similar to synovial chondromatosis. no cases of lymphoma were seen and no expression of cd or alk markers occurred. a case of pericapsular ductal invasive carcinoma was discovered. conclusion: synovial metaplasia seems to be very common in capsules around breast implants. development of conventional breast carcinoma is probably much more frequent than lymphomas independently of the possible implant influence. post-radiation angiosarcoma of the breast: report of a case a. apostolaki * , m. sofopoulos, s. tsitsiou, e. pigadioti, n. mylona, n. arnogiannaki * agios savvas hospital, dept. of anatomical pathology, athens, greece objective: post-irradiation angiosarcoma generally occurs after breast conservation and radiation therapy. it affects the dermis of the breast within the radiation field. the incidence of post-radiational angiosarcoma is about . %. method: an -year-old woman who had undergone conservative surgery and radiotherapy for breast cancer years ago presented with multiple red-purplish papules on the skin of her right breast. excisional biopsy followed by simple mastectomy was performed. results: excisional biopsy revealed a neoplasm composed of highly pleomorphic cells with prominent nucleoli forming solid areas and neoplastic slit-like vascular channels. many mitotic figures and some individual apoptotic cells were also present. the tumor cells were positive for endotelial cell markers (factor viii, cd , cd ) and negative for ck . the gross inspection of the mastectomy specimen showed multiple reddish-purple papule-like lesions on the skin, spreaded in an area of × cm. sectioning showed numerous homogenous slightly hemorrhagic white nodules measuring from to mm located in the dermis. histopatology and immunohistochemistry findings were consistent to those of the excisional biopsy. infiltration of the subdermis was noted. conclusion: diagnosis was high grade post-irradiation angiosarcoma. simple mastectomy is the treatment of choice. adjuvant chemotherapy should be considered in high grade neoplasms like this one. prognostic factors in invasive lobular carcinoma of the breast g. askan * , g. ayranci, n. Özkan, h. kaya, u. ugurlu * marmara university, dept. of pathology, istanbul, turkey objective: determination of molecular features in breast carcinomas, such as hormone receptor expression, can guide clinicians to the optimal choice of therapy. in this study, the relationship between the histologic grade, pathologic stage and the prognosis of invasive lobular carcinoma of the breast, and the tissue expression levels of er, pr, her- /neu, p , bcl- , ki- and e-cadherin was investigated. method: cases of invasive lobular carcinoma of the breast, from to , were included in this study. a single best representative paraffin block was selected for each case and h&e staining and immunohistochemistry procedures were performed. ki-kare test was used for statistical method. results: of cases had classical lobular carcinoma, cases had tubulolobular, pleomorphic, signet ring cell, or apocrine features. the median age of patients was years. er and pr were positive in cases. all cases were negative for e-cadherin. ki- was greater than % in cases with pleomorphic lobular carcinoma. p positivity increased with grade. in cases p was negative and bcl- was positive. bcl- and p were positive in and cases respectively. conclusion: in contrast to the literature, there was no correlation between bcl- status and other molecular markers, including p . rapid immunohistochemistry in intraoperative sentinel axillary lymph node evaluation p. baldin * , m. c. cucchi, y. ishikawa, v. eusebi, m. p. foschini * university of bologna, dept. of anatomic pathology, italy objective: sentinel lymph node (sn) examination is the current procedure to establish the status of axillary lymph nodes in breast cancer. to avoid a two step delayed surgical procedure, a reliable and quick method of sn evaluation is advocated. rapid immunohistochemical technique (uich) for keratin has been only recently proposed. aim of this study is to apply keratin uich in frozen sections (fss) of sns. method: a consecutive series of (series a) sn cases was studied at fs level followed by two sections stained with keratin uihc. all procedure requires min. for comparison consecutive cases (series b) of sn were studied with fs only. all residual tissue from both series was paraffin embedded (ps). results: series a: sns showed tumour involvement in cases ( . %). in only cases ( . %), ps sections evidenced additional neoplastic cells (micometastases) not seen with keratin uihc, that led to a delayed axillary dissection. series b: ps sections revealed metastatic deposits (micrometastases) not seen in fs in . % of cases. conclusion: fs coupled with keratin uhic of all the entire lymph node accurately evidences carcinoma cells in sns. high concordance of her in situ hybridization methods with abbott fish j. boers * , l. krol, c. netjes, h. meeuwissen, c. prinsen, c. van krimpen, e. van der logt, j. bart, e. schuuring * isala klinieken, dept. of pathlogy, zwolle, netherlands objective: we conducted a comprehensive concordance study of ish methods with abbott fish in a large series of breast carcinomas. method: tissue micro arrays (tma) were constructed by taking tissue-cores from praffin blocks of primary breast carcinomas. up to cases were analyzable in ish assays. scoring was performed by two independent observers without knowledge of the other ish data according the asco-guidelines for her -testing. cases were considered positive when the ratio was ≥ . . discordant cases were reviewed and scores were reassigned on consensus of opinion. concordance and cohen's kappa score were calculated in relation to fish, abbott. results: in cases analyzable with abbott her fish, . % were her -positive. concordances (kappa-scores) of the other assays were: dako fish . % ( . ), dako duocish . % ( . %), zytovision fish . % ( . ), zytovision duocish . % ( . ), single probe sish ventana . % ( . ), dual probe sish ventana . % ( . ). conclusion: conclusion: concordance of her ish assays with abbott fish were shown to be . % or higher. in this study, dako assays had a lower kappa score with abbott fish than ventana or zytovision assays. which is the best method to measure multiple breast cancer? m. boros * , c. marian, o. pop, s. stolnicu * umph targu mures, pathology, romania the size of the breast tumor is relevant in a patient s management also affecting the prognosis. for unifocal lesions, tumor staging depends on the maximum diameter of the tumor, whereas in multiple lesions, this issue is not standardized. the aim of this paper is to study which is the best method in the assessment of the tumor size in multiple invazive carcinomas (multifocal and multicentric) in correlation with the lymph node metastases developement. two different assessments of the tumor size (diameter of the largest focus=ld, and combined, aggregate diameter of all the foci=ad) were used in primary invasive breast lesions ( multiple, unifocal) and compared with the nodal status (chi-test). the use of combined tumor focus upstaged ( . %) patients with multiple tumors ( upstaged from pt to pt and from pt to pt ). there was no difference in nodal positivity based on pt status between ld and ad. we observed a statistically significant difference in the mean diameter of the largest focus between the unifocal and multifocal group ( , vs , mm) (p= , ). aggregate diameter in multiple breast cancer is not correlated with an increase of axillary metasases and should not be used for staging. central nervous system metastases in women with invasive breast carcinoma, not otherwise specified, are associated with estrogen receptor status e. cambruzzi * , a. g. reginatto, c. g. zettler, k. l. pêgas, v. grings, j. m. venites, c. a. coelho * ulbra and ufrgs, dept. of pathology, porto alegre, brazil objective: central nervous system metastases (cnsm) from breast cancer (bc) are relatively common and can present as the first site of disease progression. lymph node status and tumor size are regarded as important prognostic indicators for disease-free and overall survival in bc. the aim of this study was to investigate prognostic/predictive pathological data in bc that could define a high-risk group to develop cnsm. method: the authors evaluated female patients with invasive breast carcinoma, not otherwise specified, previously submitted to setorectomy/mastectomy, in order to determine lymph node status, tumor size, histologic grade, estrogen receptor status (er) and immunoexpression of her /neu. of these cases, patients developed cnsm. results: the patients who developed cnsm were younger (median age . ± . years/p= . ) and more likely to have t n disease than patients with no cnsm. the presence of encephalic disease was associated with er (p= . ). lymph node status (p = . ), tumor size (p = . ), histologic grade (p= . ), and her /neu expression (p= . ) were not significant risk factors. conclusion: although the literature data discriminate that her /neu overexpression in bc is related with cnsm, the authors suggests that these lesions can be related to er too. efforts to determine other risk factor for development of cnsm may be warranted. androgen receptors and sex hormone serum levels in breast carcinoma: study of the ordet cohort l. cimetti * , s. sieri, a. m. chiaravalli, n. sahnane, f. sessa, c. riva, c. capella * university of insubria and ospedale di circolo, varese, italy objective: androgens and androgen receptors (ar) are involved in breast cancer (bc) pathogenesis. high testosterone serum levels increase the risk of developing mainly er + bc, especially after menopause, although androgen role in tumor progression is not clearly elucidated. method: correlations between serum sex hormones and clinico-pathological features of bc arisen among , women previously recruited for ordet study were investigated. prediagnostic estradiol, testosterone (free/total) and shbg serum levels were available. immunohistochemistry for ar was evaluated along with er, pr, her- and mib- . results: ar + was found in . % of bc. higher estradiol (p= . ), free testosterone (p= . ) and shbg (p= . ) were seen in premenopausal patients. in dead patients higher free testosterone was observed (p= . ). no correlation was found for hormone levels vs stage, histotype and grade. higher shbg was seen in pr-rich tumours (p= . ). her- +/er-cases showed a trend for a higher total testosterone (p= . ) and shbg (p= . ). testosterone, estradiol and shbg were similar in ar + and ar-tumors. among triple negative, ar + tumours showed higher free testosterone (p = . ). bc with few ar + cells showed higher total testosterone (p= . ) and a worse outcome (p= . ). conclusion: our results confirm the role of ar in bc and suggest the androgen involvement in tumour progression. mitotic count in metastatic breast carcinoma to lymph nodes: preoperative study a. córdoba * , l. gomez, f. vicente, i. amat, c. llanos, d. guerrero * hospital navarra, ap, pamplona, spain objective: axillary lymph node metastasis (alnm) is one of the most important prognostic factors in breast cancer. the reasons why tumours are capable to result in axillary metastasis remain unclear. the evaluation risk of alnm would improve the treatment planning. we study the metastatic breast carcinoma to the lymph node to obtain information about the metastatic risk. method: we study patients with metastatic breast carcinoma to the lymph node diagnosed preoperatively by needle biopsy. we study the mitotic average (× hpf), metastasis size, positive lymph nodes, total lymph node studied, lymph node ratio (nº of positive node/total nodes nº), primary tumour size and grade. results: all the cases with high mitotic count were associated with macrometastasis. we didn't find any relation between the mitotic rate or the metastatic size with the number of lymph node affected, and the lymph node ratio. breast carcinomas g , t , < mitosis/hpf lymph nodes showed - % of positive lymph nodes. conclusion: we tried to obtain information from the metastatic breast carcinoma to the lymph node to predict the axillary status. in our cases we couldn't predict the lymph node involvement based in the tumour size, grade, metastatic size, and metastatic mitotic rate. the preoperative study of a breast tumour and their lymph node metastasis don't allow predicting the lymph node status in our series. ps- - rassf a hypermethylation is associated to the presence of tumoral cells detected by one-step nucleic acid amplification (osna) a. córdoba * , f. vicente, n. perez janices, j. perez vizcaino, e. gochi, n. torrea, d. guerrero * hospital navarra, ap, pamplona, spain objective: one-step nucleic acid amplification (osna) is used in routine clinical use for sentinel lymph node biopsy (slnb). it consists of the molecular quantitation of a tumoral marker (cytokeratin-ck mrna). gene hypermethylation is one of the most common mechanisms of inactivation of suppressor genes. rassf a gene, is a region frequently hypermethylated in breast cancer. method: patients with breast cancer were included in the study, and a total of lymph nodes were analysed. results: %, . % and . % of the tumours were of low, intermediate and high-grade, respectively. in . % of the cases there are not tumoral cells, in contrast to . %, . %, . %, . % that showed low number of cells/itc (< copies/sample), micro-(< copies/sample) and macro-mtx, respectively. there is a very clear association between rassf a hypermethylation and the presence of tumoral cells (p= . ), being more frequent in macro-mtx compared to the rest of groups (p= . ). rassf a hypermethylation is also correlated to unfavorable histologic grade in the tumour (p= . ) and lymph node involvement at the diagnosis ( . ). conclusion: the analysis of rassf a hypermethylation could provide additional information to osna to detect tumoral cells in lymph nodes. the spare tissue material derived from osna could be good material to consider new molecular studies. results: of these, patients ( , %) had palpable tumor at presentation, ( , %) with palpable axillary adenopathy. in cases ( , %) the tumor diameter was over cm at the time of diagnosis. in cases ( , %) the histological type was infiltrative ductal carcinoma, with cases having high grade. most of the tumors expressed er and pr and were her- negative (none was triple negative). however, in cases ( , %) the ki- index was more than %. conclusion: young women with breast cancer have been shown to have a poorer prognosis because of the high grade and hormonal status. our study shows some similar aspects, but the hormonal status is totally different from the dates in the literature, revealing a possible better response to hormonal treatment and a better survival. immunohistochemical predictive markers for trastuzumab resistence a. cuesta diaz de rada * , e. honrado franco, m. baltasar moreira, f. m. izquierdo garcia * hospital de león, anatomía patológica, spain objective: her positivity defines a clinically challenging subgroup of patients with breast cancer with variable prognosis and response to therapy. the main aim of this study is to identify immunohistochemical markers to predict trastuzumab resistence. method: tumours from patients with invasive ductal carcinoma, who were previously treated with trastuzumab, were included in a tissue microarray and stained for er, ki , p , cyclin d , p and for her and sish (silver in situ hybridization). results: after years of follow up, % of patients with p negative tumours were disease free (p . ) and % were alive (p , ) and the patients cyclin d positive, % were alive (p . ) and % were disease free (p . ). among her +, % did not amplify (polysomy ). moreover, % of treated patients were her − + and did not amplify by sish. conclusion: the best immunohistochemical markers to predict a good response to trastuzumab treatment were p negative and/or cyclin d positive. all her positive + tumours should be confirmed by hybridization, since polysomy is found in %, and these tumours should not be treated with trastuzumab. variations in the immunostaining techniques could induce trastuzumab treatment to patients with her non amplified tumours. ps- - cd expression in breast carcinoma p. czapiewski * , j. szade, a. zaczek, m. welnicka-jaskiewicz, w. biernat * medical university of gdansk, dept. of pathology, poland objective: cd is a membraneous protein that is expressed widely among various soft tissue tumors. there is growing evidence that its expression in some carcinomas correlates with epithelial to mesenchymal transition (emt) and is a poor prognostic factor. its importance in the breast carcinoma remains unsettled. method: the analysis was performed on breast cancer samples from patients. tumors were graded histologically according to the nottingham system. cd expression was scored by grading system used for her- . only cases showing grade ( +) were regarded as positive. additionally, expression of estrogen (er) and progesterone receptor (pr), her- , e-cadherin, vimentin, twist, ki- , c-myc, cyclin d and topoisomerase alfa was performed. expression of the cd was correlated with all these markers and with clinical outcome. results: expression of cd was observed in patients and correlated significantly with negative pr status (p= , ), higher histological grade (p= , ), positive twist (p= , ) and topoisomerase alfa expression (p= , ). there was also a trend toward higher frequency of cyclin d positivity (p= . ). no impact on prognosis for cd expression was found. conclusion: expression of cd correlates with high histological grade, negative progesterone receptor status and expression of certain emt and proliferation markers, but it does not influence prognosis in breast carcinoma. primary plasmacytoma of the breast: a case report l. de carvalho * , g. g. monteiro, l. casagrande, t. ricci, t. lebrão, v. tarricone, p. dinamarco * centro universitário lusíada, dept. of pathology, santos, brazil objective: extramedullary plasmacytomas of the breast are extremely rare, especially those that are not associated with multiple myeloma and they can mimic mammary carcinoma. method: case report: -year-old woman presented a palpable mass in the left breast previously diagnosed as a lobular carcinoma by core biopsy performed in other service. in our institution a conservative surgery with lymph node dissection was proposed. results: frozen section was required and the gross examination showed a . × . × . cm firm-elastic nodule with surgical margins free of tumor and the microscopic examination showed tumor cells with abundant cytoplasm with hyaline appearance. the paraffin sections showed a proliferation of plasma cells with moderate atypia. the immunohistochemical study confirmed the diagnosis of plasmacytoma. there was no axillary lymph node involvement. there were no bone lesions in the additional investigation. conclusion: primary plasmacytomas of the breast are extremely rare and have to be included in the differential diagnosis with breast carcinomas especially in material of core biopsy. sentinel lymph node in breast cancer: form morphology to molecular examination l. di tommaso * , b. fernandes, b. fiamengo, c. navligu, p. spaggiari, s. manara, c. a. garcia etienne, g. masci, a. testori, c. tinterri, m. roncalli * irccs istituto clinico humanitas, dept. of pathology, rozzano, italy objective: sentinel lymph node (sln) examination is a standard in breast cancer treatment. it can be performed on formalin-fixed paraffin-embedded material (ffpe) or on frozen sections (fs). ffpe or fs suffer two drawbacks: ) partial examination; ) operator's dependence. to avoid these limitations, a molecular technique (osna) targeted to quantify a tumoral fingerprint (ck ), has been introduced. our aim is to compare the performance of ffpe, fs and osna. ps- - her assessment in invasive breast cancer using ihc and fish: results from consecutive cases p. drev * , b. gazic, j. contreras * inst. of oncology, dept. of pathology, ljubljana, slovenia objective: her in invasive breast cancer (ibc) should be assessed according to recommended algorithms employing ihc as screening tool and ish only in equivocal cases. therefore there is little data on possible missdiagnosis in discordant cases. method: her was assessed by both ihc and fish in consecutive ibc. distribution of ihc and fish scores, incidence of her + ibc, concordance and level of amplification in discordant cases were analysed. results: ihc distribution: neg( ) . %, neg( +) . %, equivocal( +) . %, pos( +) . %. fish distribution: nonamplified . %, amplified . %, equivocal . % of which in . % ratio was ≥ . . . % ibc were her + and . % were double-equivocal. . % of equivocal( +) were amplified. discordance was infrequent ( . %) (p< . ): among neg( ) and neg( +) , % and , % were amplified, while among pos( +) . % were nonamplified. ihc negative tumors, representing . % of all her +, were amplified, however in . % ratio was ≤ . . conclusion: % ibc are her +. application of two standardised methods results in excellent concordance and enables detection of all her + ibc, while recommended algorithms lead to missdiagnosis in % of her + ibc, but in these amplification is low-level. case report: unusual breast cystic lesion in a -yearold female p. farrajota * , p. cusati, d. esteves, c. dias, c. carvalho, g. falconieri * centro hospitalar do porto, dipt. do anatomia patologica, portugal objective: papillary carcinoma of the female breast may exhibit a broad phenotype. we present an unusual case of a pseudoencapsulated invasive papillary carcinoma featuring transitional cell features. method: a specimen of internal right female breast biquadrantectomy was routinely processed and a panel of antibodies applied on paraffin tissue section. results: grossly, the specimen showed a . cm cystic lesion with fibrino-hematic material and multiple pinkish-grey papillary structures, the largest measuring cm. the histological examination revealed a malignant epithelial papillary proliferation reminiscent of transitional cell carcinoma, with high nuclear grade, frequent mitotic figures, multiple areas of invasion and rare necrotic foci. tumor cells were immunoreactive for p , βe and ki- ( %) and negative for other stains including her /neu, estrogen and progesterone receptors. our differential diagnosis included a metastasis from a primary urothelial carcinoma, an intraductal papillary lesion, a metaplastic carcinoma and a papillary adnexal neoplasm, all reasonably excluded after careful clinico-pathologic evaluation. conclusion: metastatic involvement of the breast is uncommon but it should be considered if tumor phenotype is inconsistent within usual or "special type" breast carcinoma. yet, some rare primary misleading lesions are difficult to recognize. ps- - volume measurement of female sprague-dawley mammary tumors induced by n-methyl-n-nitrosourea: comparing ultrasonography and caliper a. faustino-rocha * , c. teixeira-guedes, j. pinho-oliveira, r. soares-maia, r. arantes-rodrigues, b. colaço, r. ferreira, p. oliveira, m. ginja * utad, dept. of veterinary sciences, vila real, portugal objective: n-methyl-n-nitrosourea (mnu) is a chemical carcinogen frequently used to induce mammary tumors in female rats, which experimental evaluation requires the monitoring of tumor's volume. for this purpose several methods are described, namely: caliper and ultrasonography measurement. the aim of this work was to compare data obtained by caliper and ultrasonography. method: twelve female sprague-dawley rats with . ± . g body weight were intraperitoneally injected with mnu ( mg/kg) at days of age. thirty-six weeks after mnu administration forty-one tumors volume was determined by caliper (vito®) and ultrasonography (logiqp ®, general electric healthcare) measurement. the tumor volume (v) was calculated according to the following formula v=π.〖s_ ^ 〗^.s_ ⁄ , being s_( ) and s_ the tumor diameters (s_( )<s_( )). results: the means tumor caliper and ultrasonography measures were . ± . cm and . ± . cm , respectively. the icc for scoring reproducibility was . ( % confidence interval, . to . ) and paired-sample t-test was significant (p< . ). conclusion: usually mammary tumors in rat are measured by caliper. however, our results showed that there are volume differences between both methods studied. ultrasonographic method is more accurate and more precise than caliper. therefore, we recommend the use of ultrasonography to rat tumor evaluation. objective: there is a significant percentage of patients with breast cancer and her receptor overexpression that do not respond to trastuzumab-directed therapy. the aim of this paper is to study the alterations of one of the her signalling pathways related to trastuzumab response in breast cancer. method: the study comprised cases of breast carcinoma in different stages of evolution with her overexpression (herceptest +) or gene amplification (fish). all patients were treated with trastuzumab. the assessment of pten and pakt expression was based on staining intensity and percentage of stained cells. we also determined the molecular alterations in pik ca. results: our series showed a statistically significant association between a positive expression of pten and the absence of pik ca mutations with better overall survival from treatment onset with trastuzumab (p= . and p= . , respectively). the association with the expression of pakt was statistically significant if survival is evaluated from the pathological diagnosis of the tumor (p= . ), pakt positive tumors had worse survival. objective: expression of mammaglobin a (mg-a) in breast cancer has been reported to be of prognostic value and to be associated to hormone receptor-positivity. mg-a is also useful in the diagnosis of metastatic breast cancer. the present study evaluates the differential mg-a expression in two subsets of primary breast cancer (metastasizing vs. non-metastasizing) and in their correspondent metastases. method: immunohistochemical analysis of mg-a (clone - a ) was performed in non-metastasizing primary breast tumors and paired primary and metastatic breast cancers. a percentage of % of stained tumor cells was considered positive. the expression of mg-a in the different groups, together with other clinicopathologic factors (grade, size, hormone receptors, her , etc.) was analyzed by t-test. results: expression of mg-a was significantly higher in estrogen receptor-positive (er+) tumors (p< . ). a trend was noted for er + metastasizing primary breast cancers to show a higher expression of mg-a, compared to those nonmetastasizing (p= . ). no significant differences were noted in the expression of mg-a between metastasizing primary tumors and their correspondent metastases, with a good correlation (p= . ). conclusion: these results suggest that mg-a might be of prognostic value in determining a subset of er + breast cancers prone to progression. larger series are needed to confirm these observations. concordance of st. gallen intrinsic subtypes in core biopsies and related surgical specimens of breast cancer c. m. focke * , t. decker * dietrich bonhoeffer klinikum, abt. pathologie, neubrandenburg, germany objective: to evaluate the relevance of intrinsic breast cancer subtyping (ibcs) on core biopsies (cb). results: samples were tested in . score was found in . % cases, + in . %, + in . %, + in . %. the amplification was revealed in . % of + cases, . % tumors were +/fish+. cases were tested in : score − . %, + . %, + . %, + . %. the amplification was seen in . % + cases and . % tumors became +/fish+. there was no significant distinction using % and % cells score system for + tumors, whereas for groups + and + it was. conclusion: asco/cap scoring criteria developed in have no effect on her -positive tumors detection but increases number of cases with equivocal result, what require retesting with ish. microvessel density in triple-negative breast cancer: characteristics and prognostic implications h. gobbi * , m. de brot, r. rocha, f. soares * ufmg, dept. of anatomic pathology, belo horizonte, brazil objective: we assessed topography and characteristics of blood vessels in triple-negative breast cancer (tnc) and examined their association(s) with clinicopathological features, basal-like phenotype and influence on patient prognosis. method: blood vessels were assessed in tissue sections from tncs stained for cd . slides were scanned using scanscope® xt and analysed with aperio image-scopetm, microvascular density v algorithm. microvessel density (mvd) was assessed in three areas: intratumoural (it), peripheral tumoural (pp) and peritumoural (pt), and correlated with clinicopathological features and prognosis. results: the majority of blood vessels were located largely at the peripheral tumoural and peritumoural areas. tumours with higher total mvd and pt-mvd were significantly associated with the presence of recurrence (p = . ; . ), distant metastasis (p = . ; . ), hematogenous metastasis (p= . ; . ); and shorter overall survival (os; p= . ; . ) and disease free interval (dfi; p= . ; . ). high pt-mvd correlated with a higher stage at diagnosis (iii and iv; p= . ), lymph node (ln) metastasis (p= . ), basallike phenotype (p = . ), high histologic grade (p = . ), presence of distant metastasis (p = . ), and shorter os (p = . ). conclusion: blood vessels are mainly located at the peritumoural and peripheral areas in triple negative breast cancers and seem to have a major role in tumour progression by representing means for disease dissemination. expression of cd and cd in primary ductal invasive carcinoma of breast and metastatic lymph nodes m. gudadze * , k. kankava, t. javakhishvili, m. sarishvili, g. burkadze * central university clinic, dept. of pathological anatomy, tbilisi, georgian, republic of georgia objective: cancer stem cells are believed to have certain role in progression, metastatic potential and outcome of ductal invasive carcinoma of breast. method: the archived materials of - years from the department of pathological anatomy, n. kipshidze central university clinic were used for the research. cases of ductal invasive carcinoma were chosen for the study. the cd , cd immunohistochemistry (biocare medical) was used for staining. evaluation was performed using spss software. results: the results showed: . % of grade ii cases and . % of grade iii cases were lymph node positive. cd positivity in grade ii tumors was seen in . % of primary site and . % of metastasis; in grade iii tumors- % of primary site and . % of metastasis. cd positive cases in grade ii- . % for primary tumor and % in metastasis, for grade iii- . % for primary tumor and . % for metastasis. the results show that cd positivity is significantly less frequently seen in metastasis than in primary tumor; cd positivity is more frequently seen in metastasis for grade ii cases. this indicates, that cells with stem cell phenotype decrease in metastasis reflecting heterogeneity between primary and metastatic sites, which should be taken into consideration for assessing progression and treatment. ps- - solid neuroendocrine breast carcinoma: three case reports b. ince alkan * , s. yuksel, e. kadan, s. percinel, s. dizbay sak * ankara university, turkey objective: it seems that neuroendocrine breast carcinoma (nebc) is underrecognized in routine practice. world health organization classification of tumors of the breast defined nebc as a subtype of invasive mammary carcinoma in which > % of the tumor cells express neuroendocrine markers. three cases compatible with solid nebc are discussed with an emphasis on identifying features useful in recognition of this tumor type. results: the patients were , and years old women. all patients presented with a palpable mass, two in the right and one in the left breast. microscopically, infiltrating, solid cohesive nesting pattern with delicate sinusoidal vasculature or peliosis and papillary pattern were observed. the tumor cells were round or polygonal with abundant granular, eosinophilic cytoplasm. the nuclei had hyperchromatic/vesicular or "salt and pepper" chromatin. two cases had ductal carcinoma in situ component. all cases were positive for synaptophysin and chromogranin a in > % of tumor cells. while a positive status for estrogen receptor was detected in all cases, progesterone receptor was observed in two cases. none of the tumors displayed her overexpression. conclusion: morphological clues suggestive of nebc must be recognized for immunohistochemical confirmation for appropriate classification of this clinically distinct subtype of invasive breast carcinoma. objective: automation of her fish may improve her gene testing. the aim of our study was to evaluate an automated her fish assay for assessing the her genomic status. method: core biopsies of invasive breast carcinomas were analysed in parallel using the manual pathvysion™ her- dna probe kit and the automated leica her fish system for the bond™ instrument. to assess intermethod agreement, concordance analysis was performed for various numerical and categorical parameters. results: carcinomas with all her immunohistochemical scores were included ( +: ; +: ; +: ; +: ). using either her /cep ratio > . or ≥ . as criterion for her amplification, high levels of concordance were observed between automated and manual fish (concordance rate %, k coefficient . ). high levels of inter-method agreement were also found for her copy number, cep copy number, her /cep ratio, the percentage of carcinoma cells with her /cep ratio > . , and the presence of her genetic heterogeneity, her clusters and cep polyploidy. conclusion: her testing using automated fish is feasible on breast carcinoma core biopsies. automated her fish using the leica her fish system for bond is an alternative to manual her fish in evaluating the her status of primary invasive breast carcinomas. myofibroblastoma of the breast: presentation of three cases e. kairi-vasilatou * , c. dastamani, a. tsagkas, a. paraskeva, a. kondi-pafiti * aretaieio nosokomeio university, dept. of histopathology, athens, greece objective: myofibroblastoma is a rare, usually solitary, benign spindle cell tumour composed of myofibroblasts. it affects both genders equally. method: three cases diagnosed in our laboratory are presented. results: two patients were postmenopausal females ( and years old) and one was male ( years old). the tumour was , cm in greatest diameter in the first case, cm in the second and cm in the third. microscopically, all neoplasms were circumscribed and consisted of uniform, bland spindle cells separated by broad bands of hyalinized collagen. the neoplasmatic cells had abundant eosinophilic cytoplasm, oval nuclei and were arranged in fascicles. cellular atypia was found only in one case and mitoses were scarce. immunohistochemically, all neoplasms were strongly positive for vimentin, cd and bcl- , while the expression of desmin and sma varied. s- protein was negative. the neoplasms of the female patients were strongly positive for er and negative for pgr. the stains for estrogen and androgen receptors were not carried out in the case of the male patient. conclusion: differential diagnosis can be complex. fibromatosis of the breast, nodular fasciitis, myoepithelioma, myofibrosarcoma, solitary fibrous tumor, inflammatory myofibroblastic tumour should be excluded based on the histological and immunohistochemical findings. method: using light-and transmission electron microscopy fragments of mammary gland tumors, received intraoperative, from patients - years with infiltrative ductal breast cancer were studied. results: most of the mast cells were localized in the areas of infiltrative growth, at a background of lymphohistiocyte infiltration and in peripheral part of the tumor. intratumourous mast cells were totally degranulated. the mast cells with intact structure at a background of cells and tissue destruction were also in mammary gland. in destructive mast cells the nucleus with electron-dense circle and chain of granules were observed. on transmission electron microscopy their deformations and the decrease of density were revealed. the mast cells were of elongated of rounded shape with large nucleus and invaginations of karyolemma. the nucleus occupies almost completely the cell's area. it has a ring of large but pale granules. small protuberances were observed on the surface of the cell membrane. their number decreased in direct proportion to the size of must cells and their remoteness from microvessels. such protuberances are necessary for mast cells in moving. destructively changed cells with the signs of swelling, vacuolization and clasmatosis were frequent in breast cancer. objective: determination of eligibility of breast cancer patients for treatment with anti-angiogenic drugs has been always considered as a challenge for oncologists. each mutation in the genes of proliferation phase enhances the angiogenesis of tumor. we aimed to determine the effect of concurrent mutations of her- and tp on angiogenesis. method: women affected by invasive ductal carcinoma (idc) sporadic breast cancer were included. immunohistochemical study was performed with her- , tp , ki- and annexinv markers. angiogenesis index was semiquantitatively calculated by mvd-cd technique. statistical associations between parameters were evaluated. results: prevalence of her- positive and tp positive cases were . % and . %, respectively. . % of patients showed concurrent mutation of these genes. concurrent mutation led to significant increases in both angiogenesis and proliferation and a significant decrease in apoptosis. there was no statistically significant association between concurrent mutation and tumor grade. conclusion: this study demonstrates that most of the tissue prognostic factors are poor in concurrent mutation of both genes. also, our study illustrates that the concurrent mutation correlates with a higher angiogenesis and thus an increased risk of recurrence. we can conclude that in priority setting for administration of anti-angiogenic agents, patients with concurrent mutations are more eligible. adenoid cystic carcinoma in male breast: a case report e. kimiloglu sahan * , u. karinoglu, a. akyildiz igdem, n. erdogan * taksim´s hospital, dept. of pathology, istanbul, turkey objective: adenoid cystic carcinoma of the breast is a rare variant of breast cancer that accounts for . % of all breast carcinomas and occurs commonly in women between the ages of to . in the literature, only a few examples have been reported in men. it is well-differentiated tumour with favorable prognosis and generally presents as a painful breast mass. method: here, we are presenting a years old male patient with a × mm diameter solid mass on left breast retroareolar region. on fine needle aspiration biopsy, there were 'atipical proliferating ductal epitelial groups'. then, hookwire localization and excision have been performed. microscopically, there were tubulary and cribriform islands composed of basaloid type cells with eosinophilic cytoplasm and myxoid material in the cribriform spaces at the center of the islands. we used immunohistochemical markers such as p , s , ck , cd , ck and smooth muscle actin for differential diagnosis. results: the diagnosis was 'adenoid cystic carcinoma'. the margins of the tumor were positive, so radical mastectomy was performed for treatment. conclusion: because adenoid cystic carcinoma of the breast in male is a very rare example, we present our case here. comparison between the bond oracle her immunohistochemical system, the polyclonal her dako antibody and chromogenic in situ hybridization in breast carcinoma h. kourea * , v. tzelepii, i. nikolatou, p. ravazoula, v. zolota * university of patras, dept. of pathology, greece objective: the sensitivity and specificity of immunohistochemical (ihc) methods for her testing are very important given the therapeutic implications. this study compares the concordance between oracle and the her dako polyclonal antibody (her ), in breast carcinomas (bcs) that were equivocal ( + or not evaluable/ne), by her staining, considering as gold standard the chromogenic in situ hybridization (cish). method: bcs (n= ), problematic by her staining ( − / + or ne), and studied by cish in our institution, and additional consecutive bcs were stained with her and oracle, and scored separately by three pathologists. consensus scoring for each ihc method and cish results were recorded. descriptive statistics and measurement of the cohen's kappa coefficient were performed. results: the overall agreement between the tests in a × analysis shows a concordance in % of cases (κ= . ). among the cases studied by cish, equivocal were and cases, for her and oracle, respectively. seventeen her equivocal cases were negative with oracle and cish. in problematic cases, using cish as gold standard, the sensitivity, specificity, positive and negative predictive values for her and oracle were , . , . , and , . , . , , respectively. conclusion: in problematic cases, oracle testing shows higher specificity and positive predictive value. stromal p and ki expressions of the mammary phyllodes tumors: are they the clues in determination of tumor grade? u. kucuk * , u. bayol, e. e. pala, s. cumurcu * tepecik training hospital, dept. of pathology, izmir, turkey objective: conventionally growth pattern, stromal overgrowth, stromal cellularity, stromal mitotic activity are the main parameters in grading of phyllodes tumors. recent studies revealed that p and ki expressions are both correlated with grade of phyllodes tumors of the breast. method: we searched for p and ki expression rates of benign and malignant phyllodes tumors in our archival data and correlated them with conventional parameters such as stromal cellularity and mitotic activity rates. benign, malignant phyllodes tumors were reevaluated as regards stromal cellularity (low/moderate and high), mitotic activity (low and high), p expression (low, moderate, high), ki expression (low and high) rates. statistical correlation amongst the whole parameters were searched with chi-square test. results: stromal cellularity, mitotic rate, p and ki expression rates were all closely correlated (p = . - . ) for benign and malignant histologic subgroups. ki expression was significantly correlated with histologic subgroups, stromal cellularity and mitotic rate (p= . - . ). similarly p expression was correlated with histologic subgroups, stromal cellularity and mitotic rate (p= . - . ). conclusion: both ki and p expression rates are statistically significantly correlated with grade of mammary phyllodes tumors, so they can be used in determination of tumor grade, especially for differential diagnosis of benign and malignant ones. quantitative measure proliferative markers by image analysis of invasive ductal carcinoma a. kudaybergenova * , s. kalantarli * rscrct, dept. of immunohistochemistry, st. petersburg, russia objective: we analyzed a total number of tumor cells) in invasive ductal breast carcinoma, proliferative activity (% ki -positive cells) and mitotic index (% phh positive cells) to establish absolute quantity tumor cells per sq.mm of histological slide and relations this measure with proliferation and mitosis. method: the study included patients diagnosed with breast carcinoma from baku oncology hospital during the - . after whole slide scanning by mirax scanner ( dhistech, budapest) of he, ki and phh stained slides we juxtaposed all three slides in one screen to the found area with maximal ki level in tumor and the corresponding area in other slides. morphometric analysis was performed using the pannoramic viewer software ( dhistech, budapest). for each case we analyzed a total number of tumor cells in mm , number of ki and phh positive cells. results: mean tumor cells in mm of histology slide was +\− cells, median - cells, +\− ( %) were positive for ki and +\− ( %) were in mitosis. there was moderate correlation between cell density and ki r= , (p= , ) and phh r= , (p= , ). conclusion: by analysis of breast cancer, was established a total tumor cell per mm and main proliferative characteristics for invasive ductal carcinoma. objective: adenomyoepithelioma of the breast is a very rare benign tumor with biphasic proliferations of epithelial and myoepithelial elements. it is morphologically and immunohistochemically identical to epithelial-myoepithelial cell carcinoma of the salivary gland. the histologic criteria of malignant ame is not well-established because of the rarity of ame. we report a case of malignant adenomyoepithelioma in a -year-old woman. method: on ultrasonography, a well-marginated and lobulated solid mass was found at liq of the right breast.. an ultrasono-guided core biopsy was performed. the diagnosis of core biopsy was myoepithelial lesion. she subsequently underwent a wide local excision of the lesion. results: microscopically the tumor mass was composed of biphasic patterns which showed formation of tubules lined by an inner layer of ductal epithelial cells surrounded by proliferation of myoepithelial cells that also formed solid nests. but this tumor had foci of infiltrating margins and proliferation of spindle cell components. also noted are numerous mitotic figures and increased mylepithelial ki- positivity ( - % of tumor cells). conclusion: breast lesions which have predominently myoepithelial cells can be divided into myoepithelial hyperplasia, adenomyoepithelioma and malignant adenomyoepithelioma. tavassoli divied ame into tubular, papillary, and solid subtypes. the criteria of malignant ame is not wellestablished but some criterias can apply to make a diagnosis of malignant ame. objective: neoadjuvant chemotherapy (nact) is available for patients with breast carcinoma. however, resistance to chemotherapy is still a main cause of mortality. method: differentially expressed genes were identified from previously published studies that examined chemoresistant and chemoresponsive cell lines or patients with breast carcinoma. the expression of selected gene products was assessed in tissue microarray slides comprising post-nact resection specimens from breast carcinoma patients using immunohistochemistry, and analyzed according to the molecular subtype and residual cancer burden (rcb) grade. results: most cases were positive for abcb ( . %) and myc ( . %), but negative for top a ( %). rcb-ii cases expressed much higher levels of muc (p= . ) and clu (p= . ) than rcb-iii cases. positive expression for calr (p= . ) and lgals (p= . ) was observed more often in triple negative types than in luminal types, and cytoplasmic cdkn b expression was observed more often in luminal types (p= . ). conclusion: positive expression of abcb and myc and negative expression of top a in the residual carcinoma after nact implies general resistance to nact. expression of calr, lglas and cytoplasmic cdkn b may be associated with resistance depending on the subtype. expression of muc and clu can be used to predict the rcb grade or response to nact. primary and metastatic melanoma of the breast-review of cases i. liepniece-karele * , l. osipova, m. sperga, s. isajevs, a. grjunbergs, j. eglitis * riga ecuh, dept. of pathology, latvia objective: primary breast melanoma is a very rare tumour accounting for < % of all malignant melanomas. the malignant melanoma can be with different manifestation in the breast (primary breast tissue or primary breast skin melanoma as well as metastatic melanoma). method: in this study cases of breast melanoma were identified from our records of the past years ( . % of all breast cancer cases). a histological and an immunohistochemical (ihc) study was performed using antibodies against ckae / , hmb- and melan-a on both the biopsy and operation material. results: obtained results showed that in cases pigmented, epitheloid and spindle cell melanoma, but in one case epitheloid cell amelanotic melanoma was found. by ihc the melanoma cells expressed hmb in three cases, melan-a and s in all cases. no expression of ckae / was observed. conclusion: careful histological and immunohistochemical examination of malignant tumour is essential for adequate diagnosis, follow-up and treatment of breast melanoma. stem cell expansion in ductal carcinoma in situ of breast c. lopes * , a. paula, o. marques, a. rosa, a. rema, f. carvalho * icbas, dept. of pathology, porto, portugal objective: the aim is to study the ability of a cell marker panel -aldh , cd and ki to identify breast stem cells in no malignant and ductal carcinoma in situ. method: double-color triple-immunohistochemistry -to aldh , cd and ki -was done in paraffin embedded tissue specimens from patients arrayed in tissue microarray blocks. statistical was done using chisquare probability test: differences were considered significant when p< . . results: significantly higher immunoreactivity was seen in dcis than in benign lesions of breast (p< . ) with used markers. in a total of specimens, cd +/aldh +/ ki -cells were identied in cases. the distribution was as follows: dcis ( / ); fibroadenoma ( / ), atypical hyperplasia ( / ); other benign lesions ( objective: data from in vitro and clinical studies suggest that casr expression can be associated with the development of bone metastases. most probably casr stimulates production and secretion of pthrp via egfr pathway. the aim of our study was to assess expression of casr in the primary breast cancer and correlate it with the risk of bone metastases. method: we have analysed patients with the breast cancer. bone metastases were diagnosed in cases, patients died without skeletal involvement (control group). casr expression was assessed in primary tumors using tissue microarray (tma) and immunohistochemical technique (polyclonal antibody pierce bio. pa - ). to evaluate cytoplasmatic casr expression we have used - point scale in which was defined as uniformly strong or medium staining in more than % of tumor cells. results: strong or medium staining in more than % was identified in most studied cases, however it was more predominant in patients diagnosed with bone metastases than in the control group ( , % vs , %), p= , . conclusion: expression of casr is common in primary tumors of patients with disseminated breast cancer irrespectively of the metastatic site. however, the patients with bone involvement have higher rate of expression, that is borderline significant statistically. as a result, a group of patients with very high risk of bone dissemination might be separated. bcl expression is associated with centromere alterations in luminal b breast cancer a. matsionis * , i. pavlenko, a. petrov * rostov refional institute, dept. of experimental pathology, rostov regional institute objective: bcl is an important established prognostic parameter in human breast cancer (bc) and chromosome centromere (cep ) copy number is proposed to be the same too. we evaluated bcl expression in different bc's molecular subtypes in relation to increased cep level (cep > per nucleus). method: immunohistochemistry for bcl assessment and fluorescence in situ hybridization for detection of cep alterations were used. statistical analysis was performed with fisher's exact test. results: a total of cases of female invasive bc's were analyzed ( ) ( ) . the tumour subtypes were as follows: luminal a (er/pr+, her /neu-, ki < %) - ; luminal b (er/pr+, her /neu-, ki > % or er/pr+, her /neu+) - ; her /neu+(er/pr-, her /neu+) - ; triple-negative - . in our study group, bcl -cases were preferentially er-in agreement with previous reports. however, , % tumours of luminal b subtype were bcl -too and all of them had increased cep copy number (p= , , rφ= , ). we therefore hypothesized that not only er had influenced bcl in luminal b bc but cep alterations also. conclusion: centromere alterations are associated to bcl downregulation in luminal b bc's. the mechanisms responsible for that remain to be established but the underlying cause could be promoter methylation or transcriptional repression. outcome of excision of radial scar diagnosed on core biopsy: a single centre analysis f. menezes * , m. caldas, n. coimbra, c. leal * ipo porto, dept. de anatomia patologica, portugal objective: radial scar (rs) is a sclerosing lesion of the breast which may be associated with a spectrum of epithelial proliferative lesions and carcinoma. it is frequently subject to biopsy when presenting as a mammographic abnormality. the need to excise rs diagnosed on core biopsy (cb) remains controversial. the aim of our study is to determine the frequency of upgrade in diagnosis after excision of rs. method: a retrospective study of rs diagnosed on cb in our department between / / and / / was performed. results: cases were retrieved, all women, with a median age of years. of these, pairs of cb/resection specimens were obtained. cb diagnosis was rs without atypia in cases, rs with atypia in cases and rs with in situ carcinoma in cases. after excision, / ( , %) cases diagnosed as rs without atypia were upgraded: to atypia, to in situ carcinoma and to invasive carcinoma. of those cases diagnosed on cb as rs with atypia, / ( , %) were upgraded: to in situ carcinoma and to invasive carcinoma. conclusion: our results support the excision of all lesions diagnosed on biopsy as rs. *fm and mc are joint first authors. outcome of excision of papillary lesions diagnosed on core biopsy: a single centre analysis f. menezes * , m. caldas, n. coimbra, c. leal * ipo porto, dept. de anatomia patologica, portugal objective: papillary lesions of the breast (plb) comprehend a spectrum of entities with different morphologies and malignancy risk, which present a diagnosis challenge on core biopsy (cb). although diagnostic accuracy has improved with immunohistochemistry, the need to excise benign plb remains controversial. the aim of our study is to determine cb diagnosis accuracy in plb, and subsequent need to excise all lesions. method: a retrospective study of plb diagnosed by cb in our department between / / and / / was performed. results: cases were identified, with a median age of years. cb diagnosis was benign in cases, some kind of atypia found in , and malignant lesions ('in situ' and encysted/invasive types of carcinoma) in . surgical excision was performed on cases, including all cases with carcinoma. following excision, / and / benign cb results were respectively upgraded to atypical and malignant; / with atypia were upgraded to malignant. overall, % ( / ) of benign and atypical plb cb diagnosis therefore missed malignancy. conclusion: our results show that, despite good correlation between cb and excision diagnosis, some cases of carcinoma are missed on cb, so the excision of all plb remains advisable. *fm and mc are joint first authors. myoepithelial carcinoma of the breast: a case report i. michalopoulou manoloutsiou * , b. christoforidou, p. xirou, v. bostani, e. goupou, i. themeli, f. patakiouta * theagenion hospital thessaloniki, dept. of pathology, greece objective: myoepithelial carcinoma of the breast is an extremely rare tumor, composed purely of myoepithelial cells, predominantly spindle, with identifiable mitotic activity. method: we report a case of a year-old female patient with a palpable, well demarcated lump in her left breast, measuring , cm in its maximal diameter. surgical excision and axillary lymph node dissection were performed. results: histologically, the tumor displayed an infiltrating growth pattern and consisted of spindle cells, that appear to emanate from myoepithelial cells of ductules entrapped in the center of the lesion. mitotic activity did not exceed mitotic figures/ hpf. immunohistochemically, the tumor cells revealed positivity for p , cytokeratin / , cytokeratin βΕ , smooth muscle actin, cd and s protein, whereas they were negative for desmin, cytokeratin , cd , hmb , estrogen, progesterone receptors and her- oncoprotein. approximatelly % of tumor cells showed nuclear positivity for mib- /ki- . all axillary lymph nodes were free of metastases. conclusion: myoepithelial carcinoma of the breast is a potentially highly aggressive neoplasm and its differential diagnosis is fairly broad, including metaplastic spindle cell carcinoma and a variety of myofibroblastic lesions. objective: we investigated the differential expression of several biological markers between primary invasive breast carcinomas and their paired lymph node metastasis analyzing separately epithelial and stromal components. method: representative samples of idc and paired compromised lymph nodes were arrayed in a tma and selected markers: hormonal receptors, her- , proliferation (p , pakt, pmtor, tgfβ ) , motility (cd and cxcr) and basal markers (ck , ck , c-kit) were evaluated by ic. results: in the primary tumor, p , mib- , tgfβ , cd and cxcr were more expressed in epithelial cells (p< . ), while pakt, pmtor, c-myc and c-kit showed a similar frequency in both components. hormone receptors, her- /her- and cytokeratins were not expressed in stromal cells. the proliferative biomarkers were concordant in the epithelial component. cd frequency was similar but cytoplasmic cxcr as opposite to nuclear was predominantly expressed in lymph nodes (p= . ). stromal cells from lymph node showed a reduced frequency of cd (p= . ) and c-myc (p= . ) when compared to the stromal component of primary tumors. conclusion: epithelial cxcr expression may facilitate lymph node metastasis whereas the low frequency of cmyc and cd in the lymph node stromal component indicated decreased proliferation enhanced motility of stromal cells in this site. expression of hypoxia-inducible factor- a and associations with vascular endothelial growth factor expression, high microvessel density and features of aggressive tumors in african breast cancer h. nalwoga * , j. b. arnes, h. wabinga, l. a. akslen * university of bergen, the gade institute, norway objective: breast cancer in africans is reported to have poor clinical outcome. whereas hypoxia-inducible factor- α (hif- α) expression has been linked to treatment failure and poor prognosis in breast cancer, there is a lack of reports about hif- α expression in africans. the aim of this study was to evaluate hif- α expression in relation to vascular endothelial growth factor (vegf) expression, angiogenesis, and other tumor characteristics in an african population. method: in total, we analyzed breast cancers by immunohistochemical staining. we determined microvessel density (mvd), proliferating microvessel density (pmvd), and vascular proliferation index (vpi) in the most vascularized areas as well as expression of hif- α and other biomarkers using tissue microarrays. results: expression of hif- α (in / tumors; %) was associated with vegf expression (p< . ), mvd (p = . ), high tumor grade (p= . ), high ki- proliferative rate (p< . ), and p expression (p= . ). conclusion: there is a high expression of hif- α in this series of breast cancer which is strongly associated with vegf expression and increased mvd. more studies are required to assess the therapeutic implications of hif- α expression in this population. the patient underwent lumpectomy. the gross specimen had a tan grey firm nodule of × × mm. histological examination revealed a proliferation made of signet ring cell and glandular structures, with islands of goblet cells. immunohistochemistry revealed strong positive staining with ck and ck , and a sparse positive staining with synaptophysin and chromogranin.er, pr and her were negative. the patient underwent appendicectomy with a final diagnosis of breast localization of a primary occult appendiceal gcc. conclusion: the differential diagnosis between primary carcinoid tumor of the breast and signet ring cell carcinoma metastatic to the breast is often controversial in surgical pathology. diagnoses need to be made correlating clinical and histological examination in difficult cases in which there is not a diagnosis of carcinoid tumor elsewhere. their histological appearance may mimic ductal adenocarcinoma of the breast. the distinction is important due to differences in management and prognosis. determination of her gene amplification by chromogenic in situ hybridization (cish) in breast carcinoma m. neagu * , c. ardeleanu, g. butur, a. florin * national institute of pathology, bucharest, romania objective: detection of her neu amplification is an integral part of breast carcinoma diagnostics to decide therapy. method: we study cases of breast carcinoma embended paraffin tissues, both cish and fish were performed on each case using (spot-light her ) for cish and both her- and chromosome probes for fish (vysis). sixty tumor cells were evaluated in each case. the scoring system and interpretation of cish -invitrogen. results: concordance between cish and fish was found in , % cases, considering fish as gold standard, sensitivity of cish was . % and specificity %. cish is more practical alternative due to lower cost, no requirement of fluorescence microscope, use of existing bright-field microscopy and techniques it s similar to ihc, archivable and quantitative results, it s easy to observe both the tissue morphology and the gene amplification evaluation of the cases analyzed, showed similar results for both methods. two cases were discordant. in these cases, low-level amplification was suggested by cish but nonamplification by fish. conclusion: our results, suggest that cish is a useful technique to determine her- /neu oncogene status, in breast carcinoma for paraffin embendded tissues, is a highly accurate, reproducible and practical technique, with a high sensitivity. usual ductal hyperplasia with central necrosis, microcalcifications and multiple foci of pseudoinvasion arising in a radial scar: a potential diagnostic pitfall a. nechifor-boila * , s. stolnicu * university of medicine and pharmacy, tirgu-mures, romania objective: the diagnosis of radial scar (rs) is often difficult, especially when associated with proliferative changes, pseudoinvasion and necrosis. method: a -year-old woman was referred to the surgery department for a palpable mass in her left breast, regarded as a possible fibroadenoma on ultrasonography. results: lumpectomy was performed and the macroscopy revealed a tan-white mm diameter lesion, with irregular margins and firm consistency. on light microscopy, a sclerosing lesion, with a stellate arrangement of ducts surrounding a central fibro-collagenous zone was identified. haphazardly arranged, distorted ducts associated with massive intraductal proliferation, highly suspicious of infiltrative were also present in the center of the lesion. the proliferating ducts showed slit-like, irregular, secondary lumens, several containing central necrosis and a heterogenous cell population. the presence of central necrosis and pseudoinvasion were, however, worrisome. immunohistochemistry for p demonstrated the presence of myoepithelial cells surrounding all the areas with pseudoinfiltrating features, while ck / displayed a heterogenous, mosaic-like positivity, characteristic for usual ductal hyperplasia (udh). conclusion: because pseudoinvasion in benign rs can easily be misinterpreted as invasive carcinoma, immunohistochemistry is mandatory to establish the presence of myoepithelial cells. although rare, central necrosis may occur in udh and should not be used as a single diagnostic criterion of malignancy. phenotypical and morphological heterogenity of breast cancer: our experience j. nieslanik * , j. dvorácková, m. uvírová, Š. laciok, r. ondruššek, d. Žiak * cgb laboratory a.s., dept. of pathology, ostrava, czech republic objective: breast cancer is the most frequent malignant tumor in women with a rising incidence. about new cases are diagnosed in czeck republic every year, up to % die on it´s account. in cgb laboratory are investigated of malignant breast tumors every year. we evaluate the morphology, grade of differentiation and phenotype properties-hormone receptors expression, overexpression and amplification of her- /neu gene. % of carcinomas posses significantly morphologically and phenotypically heterogenic tumor population in one and the same tumor leasion. results: the most often sign of phenotype heterogenity found is hormone receptors expression or overexpression of her- /neu gene. often we see two morphologically different tumor populations coexisting. the most interesting cases from our practice are on the poster. conclusion: as for now, studies about the origin of heterogenity inside the same leasions, did not find a single theory to resolve it. a possible answer gives the theory of tumor stem cells and the model of clonal evolution. our observations demonstrate and may explain the practical reason of different phenotype properties found in core cut biopsy where one population may be held, against the heterogenic properties of the tumor shown when resected as a whole. high grade infiltrating carcinoma with squamous features -a case report d. r. novac * , c. ardeleanu, s. taban, f. cadariu, a. dema * municipal clinical hospital, anatomical pathology, timisoara, romania objective: apocrine carcinoma is a rare and histologically distinct type of invasive breast carcinoma. method: the patient, a years-old woman was admitted to the hospital for a tumor mass in the upper internal quadrant of the left breast. tissue fragments from the quadrantectomy specimen were routinely processed by paraffin embedding. for the immunohistochemical (ihc) study we used the following antibodies: ck , androgen receptors (ar), estrogen receptors (er), progesterone receptors (pr), high molecular weight cytokeratin (hmwck), p , gross cystic disease fluid protein- (gcdfp- ), en vision system, visualization with diaminobenzidine. results: the gross examination revealed a nodular, well delineated mass of , / , / cm, firm, gray-beige with areas of necrosis on cut section. microscopically, the tumor had a predominantly solid, partially cystic and less tubular growth pattern. the tumor cells had abundant eosinophilic granular cytoplasm and pleomorphic high-grade nuclei. a small tumor contingent presented squamoid features. ihc stains showed the following profile: ck +, ar+, gcdfp- +, er-, pr-, p /hmwck + (focal/zonal). a diagnosis of high-grade infiltrating apocrine carcinoma with squamous differentiation was established. conclusion: there are only a few cases of apocrine carcinoma on record and our case is even more special because of his peculiar aspect, the squamous differentiation. the effects of treadmill exercise in the number and weight of mammary tumors chemically induced in female sprague-dawley rats: preliminary results j. oliveira * , c. teixeira-guedes, a. faustino-rocha, r. soares-maia, r. arantes-rodrigues, m. j. pires, m. ginja, p. oliveira, r. ferreira * utad, dept. of veterinary sciences, vila real, portugal objective: we hypothesized that moderate exercise in treadmill may affect the mammary tumor development. n-methyl-n-nitrosourea (mnu) is a commonly used carcinogen to induce mammary carcinomas. the aim of this study was to evaluate the influence of treadmill exercise in the development (number and weight) of female rat mammary tumors. method: in this experimental protocol were used female sprague-dawley rats. mnu was intraperitoneally administered at days of age in a dose of mg/kg. animals were randomly divided in two groups: sedentary (n= ) and exercised (n= ). the exercise program was started after carcinogen administration. animals were exercised in a treadmill control le ® after an initial period of familiarization. thirty-six weeks after mnu administration animals were sacrificed and tumors were counted and weighted. results: sedentary and exercised group presented and tumors, respectively. pearson chi-square value was not significant (p> . ). the mean tumors weight of sedentary group ( . ± . g) was lower than exercised group ( . ± . g). the difference between groups was not significant (p> . ). conclusion: we observed that exercised group showed minor number of tumors, however the lesions presented higher volume. future morphological and biochemical analysis of tumors will allow a better understanding of the relation between mammary cancer and physical exercise. objective: primary non-hodgkin's lymphomas is an uncommon disease representing approximately . % of all reported malignant mammary neoplasms. clinically they are mainly observed as solitary lesions but may also be seen as multiple foci. herein, we present a very rare case with the diagnosis of multifocal malignant lymphoma of the breast with a detailed clinicopathologic evaluation. method: a -year-old-female patient with a right palpable breast lump admitted to the hospital. mammography and ultrasonography findings showed different foci of hypoechoic solid mass forming lesion in the right breast. excisional biopsy has been performed. results: in the histopathological evaluation, both lesions demonstrated diffuse infiltration of mammarian tissue with foci of necrosis; mitotically active tumor cells with large nucleus and prominent nucleoli. the immunohistochemical analysis revealed diffuse and strong lca, cd , cd , focal cd positivity while pancytokeratin, ema, cd , sma were negative. the case was diagnosed as diffuse large b-cell lymphoma. conclusion: breast is an uncommon site for primary malignant lymphomas. we report a very rare case with a diagnosis of multifocal primary non-hodgkin's lymphoma of the breast. ps- - cytological, histopathological and clinical correlation at differential diagnosis of granulomatous mastitismalignancy t. ozgur * , e. atik, s. toprak, h. gokce, n. sengul, m. temiz * mustafa kemal university, medical faculty, antakya, turkey objective: idiopathic granulomatous mastitis (igm) is a rare disease that is difficult to diagnose by only radiological methods and clinical findings. method: first case; a years old woman with a well circumscribed mass of cm diameter at right breast applied to our hospital general surgery outpatient clinic. in the examination of fine needle aspiration biopsy (fnab), palisaded epitheloid histiocytes and scattered atypical cells have been seen on a bloody and inflammatory background. we suggested excisional biopsy. second case; a years old woman applied to our hospital general surgery outpatient clinic with a sore mass in her left breast. the mass has been excised for malignancy suspect. foci of abscesses, active chronical inflammation, areas of hemorrhage and numerous granulomas containing epitheloid histiocytes are observed microscopically. results: in microscobic evaluation of the excisional biopsy of the first case prediagnosed as granulomatous mastitis invasive ductal carcinoma has been our diagnosis. in the second case there have been numerous granulomas containing epitheloid histiocytes, microscopically. our diagnosis was granulomatous mastitis in this patient prediagnosed as malignancy. conclusion: especially fnab findings are easy to confuse with malignancy. we wanted to emphasize to clinician and pathologist to be more alert on distinction of granulomatous mastitis and malignancy. objective: triple-negative-breast-cancer (tnbc) that accounts for - % of all breast carcinomas is defined by the lack of estrogen receptor, progesterone receptor, her expression with agressive clinical behavior. tnbc is categorized into basal like subtype which is characterized by the expression of basal cell markers and normal breast subtypes. method: we studied on immunohistochemically tnbc patients to determine egfr, cytokeratine / (ck / ), p , ki , gcdfp expression patterns by immunohistochemistry, her /chromosome gene status by fish. results: most of the tumors ( , %) were invasive ductal carcinomas. p , ki , gcdfp mean positivity rates were , %; , %; , % respectively. gcdfp positivity was noted in cases of which were ck / (−). the cut-off value for ck / positivity was %. egfr immunoreactivity was grouped into , + as negative; +, + as positive categories. ck / was positive in , %, egfr was positive in , % of the patients. the relation between ck / and egfr expression was statistically significant (p < . ). her fish was negative in all cases. conclusion: as a result gcdfp alone is not a useful marker to detect the metastasis of basaloid type breast cancers. ck / and egfr coexpression can be used to diagnose basaloid tumors with % cut-off value. objective: lobular neoplasia (lns) of the breast include atypical lobular hyperplasia (alh) and lobular carcinoma in situ (lcis). because lns do not present typical clinical or radiologic findings, the diagnosis is incidental. many reports suggest that ln is not only a risk factor of invasive lobular carcinoma but also is as a precursor. it is important to know about the incidence of lns and associated disease in korea. method: a total cases of breast biopsy or excision from five major hospitals in daegu were reviewed independently by pathologists of the daegu breast pathology study group. the incidence of alh and lcis, associated disease, the presence of microcalcification and necrosis were reviewed. all suspected cases of lns were confirmed on e-cadherin immunohistochemical staining. results: only cases out of cases ( . %) revealed lns. associated disease were cases of invasive ductal carcinoma, cases of in situ ductal carcinoma, cases of invasive lobular carcinoma, cases o f other benign disease, and cases of florid ductal hyperplasia or columnar cell change. conclusion: the incidence of lns was similar to western women. incidental lns were frequently associated with invasive ductal carcinoma and further excision is suggested if it was present on the needle biopsy specimen. silver-enhanced in situ hybridization (sish) detection assay for her gene status determination in breast carcinoma: a four year experience in our laboratory f. patakiouta * , g. c. balis, v. theodorou, e. triantafillidou, c. fotiou, i. boukovinas, c. andreadis, g. sibilidis * "theagenion" cancer hospital, dept. of pathology, thessaloniki, greece objective: assessment of her status in breast cancer is important in the clinical management of patients and can be identified by a number of methods. in this study we present the results of the sish technique used in our laboratory in the last years. method: we analyzed cases of invasive breast carcinoma, including core biopsies, which were previously characterized immunohistochemically (cb ) as equivocal on a protein level (her +). all cases were evaluated by bright-field sish using the automated ventana benchmark xt machine. evaluation was independently performed by two pathologists (fp, gb) based upon the algorithms of the manufacturers and asco/cap guidelines. results: out of cases the her gene was amplified in cases ( . %), while in cases ( . %) there was no gene amplification. fourteen of the cases ( . %) were characterized as equivocal. the concordance between the two pathologists was high ( . %). conclusion: the sish method is new, fully automated and very rapid. furthermore the bright-field sish signal does not decay and can be visualized by any standard bright-field microscope even after long periods of time, making it particularly suitable for routine application in surgical pathology. objective: breast fibromatosis (bf) represents . % of breast tumours that simulate carcinoma. the aim of this study is to characterize the cases of bf diagnosed in our institution. method: bf cases diagnosed from to were evaluated with clinicopathological and immunohistochemical parameters. we also studied mutations in exon of the gene for β-catenin in cases. ultrastructural study (us) was performed in case. results: there were women between and years old. radiologically they showed deeply located hypoechoic irregular lesions. size ranged between and cm. histologically they were characterized by an ill-defined spindle cell proliferation without epithelial elements or atypia. immunohistochemical study was negative for ae /ae , ck / , p , cd and bcl . actin was diffusely positive in / , and s and desmin focally positive in / . β-catenin showed cytoplasmic( / ) and nuclear( / ) expression. the us showed double smooth muscle and myofibroblastic differentiation. three patients showed mutations in exon of the β-catenin gene ( with substitution at codon (t a) and deletion of base pairs (a _e del)). conclusion: focal desmin expression and us suggest smooth muscle differentiation in some bf. all cases showed cytoplasmatic positivity for β-catenin but nuclear expression was seen in only % of cases. % of the valuable cases showed genetic alterations of β-catenin. objective: breast cancer is a heterogenous disease consisting of distinct entities characterized by different gene expression patterns. gene expression profiling of breast cancer revealed major subtypes, including hormone receptor (hr) positive luminal a and b, her- positive and basallike breast cancer. most of the basal-like carcinomas are triple negative (hr and her- negative). as most triple negative breast cancers express egfr, mutations in the signal transducing cascade of ras/raf/map kinase might play a role in tumor progression. the aim of this study was to determine the incidence of kras and braf v mutations in triple negative breast carcinomas. method: total genomic dna was obtained from formalin-fixed, paraffin embedded, triple negative breast tumors. kras was analyzed by pyrosequencing of codon , , . braf (exon , v ) mutations were analyzed with autogenomics infiniti braf assay on the autogenomics infiniti analyzer. results: we found kras mutation in only one case ( . %), apocrine carcinoma which was gly asp (ggt> gat) mutation. the braf v mutations were not detected in all analyzed tumors. conclusion: we concluded that kras mutation was rare in triple negative breast carcinomas and high frequency of egfr overexpression in this subtype might be related to other pathways in egfr signaling. the pre-lymphatic system and the lymphatic network of the breast in menstruating and in menopausal women: a comparative study s. popovska * , i. ivanov, t. betova, t. dineva, z. ivanova * medical university hospital, dept. of clinical pathology, pleven, bulgaria objective: the pre-lymphatic system was initially described in the s by casley-smith and florey. it consists of cd positive fibroblasts lined stromal spaces communicating with the lymphatic capillaries. the aim of the following investigation was to compare the lympho-vascular density and pre-lymphatic network density of breast tissues in the context of the menstrual status of the patients. method: formalin-fixed, paraffin embedded tissue specimens from patients with primary breast cancer were studied. tumor-free tissue materials were selected. tissue processing and immunohistochemical staining with d - and cd antibody was performed in accordance to standard laboratory protocols. quantitative evaluation of the lymphatic and pre-lymphatic system was performed. the kruskal -wallies test was used to compare differences between the median values of the studied variables. statistical significance of the differences was considered if p< . . results: the pre-lymphatic network was found to be significantly more dense in menstruating, compared to menopausal women k-w= . ; p< . n= . lymphatic vascular density was higher in menstruating compared to menopausal women k-w= . ; p= . ; n= . conclusion: involution changes in the pre-lymphatic and lymphatic system of the breast were found to appear in postmenopausal women. this may be the explanation for the slow local progression of breast cancer observed often in elder patients. comperative study of herceptest and fluorescence in situ hybridization results in breast carcinoma: indeterminate ( +) group must not be a wide range uncertainty category y. saglican * , u. ince * acibadem maslak hospital, dept. of pathology, istanbul, turkey objective: herceptest is an exclusively used immunohistochemistry method for testing her /neu overexpression in breast carcinomas. the purpose of this study is to select the proper patients candidate to in situ hybridization, with an indeterminate her score. method: a retrospective analysis of cases with invasive breast carcinoma were evaluated for her status using immunohistochemistry and fluorescence in situ hybridization. İmmunohistochemistry of cases that had been previously evaluated by nine different pathologists in our department, were reviewed by two experienced pathologists. interpretation of the immunohistochemistry results was made without knowing the first results. results: compared to the first evaluation; cases with score , + and +correlated with the review of immunhistochemistry and none of score and + tumors were positive with in situ hybridization. gene amplification was detected in cases; of them with +score. three of + tumors and of + cases were negative with in situ hybridization. discordance was detected in cases in + score; of them were reclassified as negative and were technically unsatisfactory. conclusion: using a different cut-off value for indeterminate her results and training of pathologists to minimaze the interpretational differences, will maximize the accuracy, while not submitting to unnecessary molecular tests. objective: the excision repair cross-complementation (ercc ) enzyme plays an essential role in the nucleotide excision repair pathway and is associated with resistance to platinum-based chemotherapy in different types of cancer. the aim of the present study was to evaluate the clinicopathological significance of ercc expression in breast cancer patients. method: we used immunohistochemical to analyze ercc expression in a tissue microarray from breast carcinomas. ercc expression analysis was available for cases and was correlated with clinicopathologic factors and outcome data. results: ercc -positive was observed in ( . %) cases and was correlated with smaller tumor size (p= . ) and with positivity for estrogen receptor (p= . ). ercc expression did not correlate with overall and disease-free survival rates. the majority ( . %) of special histological types of invasive breast carcinomas was positive for ercc compared to invasive ductal carcinomas (ercc -positive in . % of the cases). similarly, triple negative breast cancers (tnbc) were more frequently negative for ercc ( . % of the cases) compared to the non-tnbc ( . %). conclusion: ercc expression correlated significantly with favorable prognostic factors, such as smaller tumor size and er-positivity, suggesting a possible role for ercc as a predictive and/or prognostic marker in breast cancer. a study of cd positive basal/myoepithelial cells in a consecutive series of in situ lobular neoplasia of the breast s. shousha * , g. forbes * charing cross hospital, dept. of histopathology, london, united kingdom objective: we have previously reported a few sporadic cases of in situ lobular neoplasia (iln) associated with marked proliferation of cd positive basal/myoepithelial cells. method: twenty consecutive cases of pure iln and dcis were studied. new sections were cut and stained for e-cadherin and cd . results: one out of the cases showed foci of invasive lobular carcinoma in the new cut sections. all iln cases showed increased proliferation of cd positive basal cells, varying from a focal mild increase to a marked proliferation surrounding or mingling with the lobular cells. cd positive cell proliferation was least observed in a case of iln with central necrosis and in foci of iln seen adjacent to the invasive carcinoma. the invasive tumour cells were cd negative. all cases of dcis had a thin layer of cd positive myoepithelial cells, that was incomplete or absent in some foci. conclusion: our findings confirm the presence of a unique relationship between excess proliferation of cd positive basal cells and iln; an association which is not seen in dcis or invasive carcinoma. this is particularly interesting as recent evidence indicates that cd is involved in the regulation of mammary stem and 'sphere forming' cells. objective: primary neuroendocrine carcinomas (nec) of the breast are defined by the who classification as a group of neoplasms that express neuroendocrine markers in more than % of the cells. these tumors can exhibit different morphologic appearances including solid, nested or alveolar pattern, papillary or mucinous differentiation or conventional ductal structures. the aim of this study is to identify histomorphological features useful in the recognition of this tumors. method: invasive breast carcinomas were reviewed, none of them previously typified as nec. were ductal carcinomas ( grade i, grade ii and grade iii) and lobullilar carcinomas. in all cases immunohistochemical staining for the neuroendocrine marker synaptophysin was performed. results: eight of the cases showed intense immunoreactivity for synaptophysin. all of them were predominantly composed of solid, confluent nests and cords of cells with medium-to high grade nuclear atypia. two cases showed intense desmoplastic or sclerotic stromal response. a colloid component was identified in another two cases. conclusion: due to its morphologic variability, mammary nec is frequently underrecognized. a predominantly solid pattern of confluent nests and trabeculae associated with a prominent sclerotic stromal response or colloid differentiation should prompt to perform additional immunohistochemical staining in order to exclude neuroendocrine differentiation. objective: association between centrosome abnormalities and response to chemotherapy has not been fully elucidated in breast carcinomas (bc). here we analysed the association between aurora kinase a (aurka) and gamma-tubulin (gt) and response to neoadjuvant chemotherapy (pst) in patients treated with bc. method: the immunohistochemical expression of aurka and gt was analysed in core biopsies of bcs taken before administration of pst. aurka expression was analysed using a modified allred-like scoring system (intensity and percentage of staining combined). cells containing one or two centrosomes as determined by gt were considered negative, whereas cells containing more than two centrosomes were regarded as positive. centrosome amplification was graded in each specimen as follows: negative ( - % of cells); weak ( - %); moderate ( - %); and strong ( %<). pathological response rates were assessed using chevallier's classification. results: centrosome amplification was significantly higher in patients achieving complete response when compared with the cases where partial remission or no response was defined (p= . ), whereas we found no significant correlation between the expression of aurka protein and response rate to neoadjuvant chemotherapy (p= . ). conclusion: bcs showing centrosomal amplification as determined by gt present higher response rates to neoadjuvant chemotherapy, but need further validation. breast granulocytic sarcoma with aleukemic presentation: a case report o. tzaida * , p. giagkazogloy, p. repousis, m. kotsopoulou, i. kasselaki, c. valavanis, i. iacovidou * anticancer hospital metaxa, peiraias, greece objective: granulocytic sarcoma (gs), a rare solid tumor of immature myeloid cells in exrtamedullary sites, usually occurs during the natural course of acute myelogenic leukemia (aml). rarely is presented without overt hematological disease. the breast is an uncommon site of localization. method: we report a case of breast gs with aleukemic presentation, condition that is extremely rare and requires a high index of suspicion for diagnosis. a year old woman, presented with a solitary, non-tender, palpable left breast mass. a lumpectomy was done. results: histopathology revealed breast parenchyma diffuse infiltration, in a targetoid pattern, by immature small cells intermingled with eosinophils. lobular carcinoma and lymphoma were considered in differential diagnosis. the myeloid origin of the neoplasm was established by immunohistochemical analysis that revealed lca, mpo, cd , hladr, cd (kp ) positivity. there was no evidence of leukemia in the peripheral blood and bone marrow. the patient was treated as aml with systemic chemotherapy and months after the diagnosis she is without evidence of disease. conclusion: breast gs is a challenging situation both for pathologists and hematologists. available evidence strongly favors the application of systemic chemotherapy despite the appeared localized nature of the disease. method: paraffin blocks of tumor tissue of breast cancer cases collected at our cancer centre for years. the immunohistochemical study was performed by standard techniques using following antibodies (dako): er, pr, her- , egfr, ck / , ck , ki . results: all cases were classified into the subtypes: luminal a (n = ; . %); luminal b (n = ; . %); her- -positive (n= ; . %); basal (n= ; . %); negative (n= ; . %). conclusion: luminal breast cancer phenotype predominates in our collection, predictive/prognostic value of molecular genetic subtypes is planned to be investigated. we recognized statistically significant differences (p< , ) in five-year survival rates between tumors of luminal (a, b) and basal subtypes. proliferating trichilemmal cyst with atypical cytological features r. g. wright * , c. gallivan, t. molden-hauer, r. liang * gold coast hospital, pathology queensland, australia objective: proliferating trichilemmal cysts are relatively common occurring within the scalp of elderly women. proliferating trichilemmal cysts of the breast, however, are rare. these cysts are benign with very few demonstrating malignant transformation. method: we report a case of proliferating trichilemmal cyst of the breast with atypical cytology which prompted excisional biopsy. cytological assessment was useful in this case as it indicated excisional biopsy rather than a more extensive excision. results: smears produced from the fna showed sheets of atypical epithelial cells with foamy histiocytes, multinucleate cells and fibrotic material with evidence suggestive of fat necrosis. a cell block was acellular. a specific diagnosis was not made. an excision specimen was advised and a proliferating trichilemmal cyst was demonstrated. objective: a large clinical value has determination of molecular subtype of breast cancer (bc). to clarify morphological and molecular biological similarities and differences between bc depending on age, we compared features between tumors of younger and older women. method: patients with bc are included in research: from till years, among them patients were till years. er, pr, her- /neu, p , p , ki , ck / , p , bag , mcl , ps , vegfr, her- were analyzed in all cases by immunohistochemistry. results: the younger patients with bc had higher expression of p , p , p , bag , mcl , ki- , vegfr, her- (p< , ) than older patients. there was a basal-like molecular subtype of bc -fold more frequent compared with older patients ( , % versus , %; p< , ). threeyears overall survival in patients till years was by , % and a five-year overall survival was by , % lower than in patients over years (p< , ). objective: breast her ish relies on correct enumeration of her /cep signal. however, as with immunohistochemistry, there are technical pitfalls which may render ish difficult/unreliable to interpret. the uk neqas has established a 'technical' ish module to provide feedback to laboratories using both chromogen and fluorescence based tehcniques. method: unstained slides consisting of breast cancer cell lines were distributed. laboratories were asked to demonstrate her gene amplification using their routine assay, and then return the slides for assessment. chromogen based methods were assessed around a multi-header microscope with assessors scoring each slides, whilst the fluorescent ish method was assessed by a single individual. assessors scored the 'readability' of each slide, without counting the probes, and provided feedback where the hybridisation technique could hinder interpretation. results: cish based methods showed acceptable staining in % (n= ) of cases. staining problems ranged from loss/poor her /cep signal, non-specific staining and morphological damage. the fish pilot assessment showed an acceptable rate of % (n= ), with the low pass rate being attributed to poor preservation/quenching of fluorescence signal. conclusion: greater emphasis needs to be placed on the 'readability' of an ish slide, prior to carrying out the process of enumeration. tuesday, september , . - . objective: intravenous leiomyomatosis is a very rare growth pattern variant of leiomyoma in which nodular masses of tumor grow within venous channels. occasionally the tumor can extend to vena cava and the right heart. method: we present a case of a -year-old woman, who was admitted in the emergency room with rapidly evolving exertional dyspnea. cardiac ultrasonography revealed a "big mass in the right chambers". she was submitted to a right atriotomy with resection of part of the tumor, which was sent for intraoperative consultation. results: grossly, the tumor was polypoid, firm, with a smooth surface. the frozen section showed a lesion composed of tortuous vessels and in some areas a fibrillar eosinophil extracellular matrix and others with spindle cells. no significant atypic or pleomorphic cells, mitosis or necrosis were observed. the diagnosis was deferred for definitive paraffin sections. in the definitive h&e and with immunohistochemical stains, the case was diagnosed as an intravenous leiomyomatosis, and the diagnosis was confirmed in the hysterectomy specimen. conclusion: intravenous leiomyomatosis with cardiac involvement is an extremely rare condition. clinical information is essential for the correct diagnosis in frozen section. characterization of a specific mechanism for late loss of cardiac allograft: the antibody mediated rejection (amr) as a major factor of cardiac allograft vasculopathy (cav) p. bruneval * , c. toquet, a. loupy, p. pouvier, a. cazes, j.-p. duong van huyen * france objective: the rational of this study was to investigate explanted failing grafts in the light of new concepts in rejection mechanisms, namely amr. method: this retrospective multicentric study collected explanted cardiac grafts failing ≥ year posttransplantation. the vasculature of the grafts was assessed from epicardial coronary arteries to myocardial microcirculation. immunohistochemistry was performed for c d complement fraction deposition and cd -positive macrophages in the explanted grafts and previous endomyocardial biopsies. donor specific antibodies (dsa) were retrospectively assessed using luminex sa technique. results: a pure classical coronary atherosclerosis pattern was observed in / ( %). a pure pattern of cav was present in / ( %) and a mixed pattern associating cav and atherosclerosis features in / ( %). interestingly the cav pure and mixed patterns were associated with vascular inflammation within the arteries and/or the microcirculation with c d deposits and macrophages ( / ) in the explanted grafts versus nil ( / ) in pure atherosclerosis pattern (p< . ). furthermore they were associated with previous amr episodes on endomyocardial biopsies ( / ) and by positive dsa ( / ) versus nil in pure atherosclerosis pattern (p< . and p= . , respectively). conclusion: in failing cardiac grafts cav lesions are associated with makers of amr. cav should be the consequence in coronary arteries of an ongoing amr process. results: in our cases increase in fibrous and adipose tissue concordant with age, indicating an age related nature, were detected. fibrous and fatty tissue infiltration appeared at the age of . fatty infiltration started at the age between and at sinoatrial node. in cases calcification and in cases inflammation was observed. amyloid accumulation was not present. in cases myocardial infarction not involving ccs was seen. in case fibroelastoma was detected. conclusion: in turkish population age related fibrosis and fatty infiltration in ccs appeared at the age of and increased with age. fatty infiltration in sinoatrial node started at a younger age than that of reported in the literature. in cases whom the cause of death could not be determined we could not detect lethal pathologic features. however we think that examination of the ccs will improve the quality of autopsy diagnosis. periadventitial adipose tissue in human coronary atherosclerosis: a neurotrophin study p. ghenev * , p. panayotov, g. chaldakov, l. aloe * medical university varna, dept. of pathology, bulgaria objective: recent evidence demonstrates that epicardial adipose tissue, including coronary periadventitial adipose tissue (tunica adiposa), are paracrine sources of bioactive mediators (adipokines, no, h s) which may be involved in coronary atherogenesis. because of the increasing interest for extra-neuronal effects (inflammation, wound healing, lipid and glucose metabolism) of the neurotrophins nerve growth factor (ngf) and brain-derived neurotrophic factor (bdnf), including in human coronary atherosclerosis in autopsy samples, the aim of the present study is to evaluate the expression of ngf and bdnf and their receptors (trka and trkb, respectively) in cardiosurgery biopsy samples of pericoronary adipose tissue. method: immunohistochemistry of ngf, bdnf and their trk receptors. results: ngf, bdnf, trk a and trkb expression was lower in periadventitial adipose tissue of atherosclerotic coronary arteries as compared to non-affected coronaries. conclusion: we provide the first evidence for a possible role of neurotrophins in the molecular remodeling of tunica adiposa in human coronary atherosclerosis. this study is dedicated to rd anniversary of rita levi-montalcini, the nobel laureate for the discovery of ngf. objective: in normal myocardium, apoptotic myocytes are usually absent, or if affected, with most of positive cells per million. method: the apoptosis was measured by the tunel method in patients with dilated cardiomyopathy (dcm) and myocarditis (mc), and expresed by apoptotic index (ai) in patients within both groups, and to correlated with ejection fraction (ef) and with different morphological stages of these entities. statistical analisys was performed, and p values ≤ . were considered statistically significant. results: ai in mc cases was , + , , and in dcm cases the value was significantly higher , + , (p= . ). in the group mc patients, we didn't found statistically significant correlation between ai and different values of ef (p= . ). the analysis of the value of ai between patients with different morphological stages of mc didn't show statistically significant correlation (p= . ), as well as in dcm (p= . ). conclusion: apoptosis play a significant role in dcm and mc but its significance in the progression to heart failure has still to be established. objective: cardiac lesions following blunt chest trauma are multiple and of various degrees of severity. "cardiac contusion" is a difficult diagnosis, especially antemortem and if signs of thoracic trauma are not evident on external habitus and on the underlying internal plans of cardiac area. is the contusion a cause of death per se? method: the authors present two cases of road accident male victims, aged and year-old, submited to complete postmortem examination with ancillary diagnostic methods. results: no traumatic lesions or underlying pathology was found at the autopsy. epicardial and myocardial haemorrhagic foci were histologicaly documented. toxicology was negative. conclusion: cardiac contusions are caused by one of the following mechanisms: ) heart compression between bone structures, ) sudden acceleration-deceleration movements and ) sudden thoracic/abdominal pressure increase. they may be asymptomatic or lead to rhythm disturbances responsible for unexpected death ( %) . they seem to be underdiagnosed, thus suspecting the entity "contusio cordis" is crucial, not only antemortem for correct surveillance and treatment, but also postmortem to adequately establish causality nexus in cases of post-thoracic trauma deaths. the influence of bone marrow-derived multipotent stromal cells on myocardial scar healing in experimental myocardial infarction l. kakturskiy * , t. fatkhudinov * institute of human morphology, central laboratory of pathology, moscow, russia objective: previous studies have shown the benefits of intracoronary infusion of bone marrow-derived multipotent stromal cells (bm-mscs) in heart disease. our aim was to study engraftment, differentiation of bm-mscs and its role in myocardial reparation. method: acute myocardial ischemia was produced by transient occlusion (total of min) of the proximal left anterior descending coronary artery and followed by reperfusion. bm-mscs were isolated, expanded by standard and labeled with pkh (sigma). cells were cd and cd positive. days after occlusion during cross-clamping of aorta the cells were administered into the cavity of the left ventricle at the concentration × in saline solution. in day, , and weeks after transplantation the labeled cells were detected in the cryosections and heart morphometry was performed. results: bm-mscs were detected only in the scar tissue and had a fibroblast-like phenotype. they neither differentiated into cardiomyocytes nor into the cells of blood vessels. in weeks after transplantation the scar thickness was higher in the group with cell transplantation (p< . ). conclusion: engrafted bm-mscs promote myocardial fibrosis only in the scar, but not in the perifocal myocardium, provided strengthening of the scar, remodelling of outflow tract, and improvements the myocardial function. objective: from january to december (institute of pathology and legal medicine, paolo giaccone -palermo) autopsies were performed on males and females who died of a massive pte. method: systematic autopsy. results: saddle pulmonary thrombosis in cases, in isolated in both the main pulmonary arteries. in all cases the transverse heart diameter was , - cm superior to the longitudinal one, the interventricular septum became rectilinear with a right ventricular dilation. the coronary artery anatomy was: critical stenosis through fibroatheromatous plaque of the dominant right coronary artery (rca, ), non dominant left coronary artery (lca, ); non critical stenosis of rca ( ), lca ( ); absence of stenosis ( ). histological ventricular examination showed hypoxic-ischaemic and/or reperfusion and overload lesions. in all cases, the lungs showed plurifocal occlusive thrombosis of intramural pulmonary arterial (ipa) vessels associated with adjacent infarctual necrosis ( ); acute partially haemorrhagic basal oedema ( ) and desquamative macrophagic alveolitis ( ). conclusion: in all cases of massive pte the thrombosis of ipa vessels associated with an adjacent infarction ( %) is constant. this suggests that death is nearly always preceded or triggered by one or more episodes (clinically silent or with non specific symptoms) of thromboembolism of ipa vessels. cardiac findings in routine fetal autopsies: more than it meets the eye? e. rios * , c. bartosch, c. ramalho, j. monterroso, o. brandão * centro hospitalar s joão, pathology, porto, portugal objective: congenital heart disease (chd) is the most common malformation in newborns. our aim was to evaluate the spectrum of chd in consecutively performed fetal autopsies and to correlate prenatal and postmortem diagnoses. method: a retrospective study of fetal autopsies was performed in a tertiary referral hospital. chd was classified in seven categories: left ventricular outflow tract obstruction-lvoto, right ventricular outflow tract obstruction-rvoto, septal defects, connection anomalies, conotruncal anomalies, complex anomalies and others. cardiac defects were also classified as isolated or associated with others anomalies. results: chd was identified in ( . %) fetuses. most common categories were septal defects and complex anomalies. associated anomalies were found in fetuses ( . %). in this group, septal defects were the most common chd, frequency being significantly higher than in the group of isolated cardiac anomalies (p= . ). comparison of prenatal and postmortem diagnoses ( cases) showed complete or partial agreement in and cases ( % and %, respectively) and complete disagreement in cases ( %). in the latter group, prenatal diagnosis had not been done by a pediatric cardiologist. conclusion: the high prevalence of chd in lost pregnancies highlights the importance of systematic fetal autopsy performed by a specialized pediatric pathologist. objective: the appearance of pathological calcification, which leads to significant changes of vascular wall, which underlie the development of atherosclerotic complications, has a great importance in the morphology of atherosclerosis development. purpose of the work is the study of pathological biomineralization in heart valves affected by atherosclerosis. method: the study was conducted on sectional material of mitral and aortic valves obtained during autopsy. the tissue of heart valves was studied by methods of histology, electron microscopy, x-ray diffraction, infrared spectroscopy. results: macroscopically mitral and aortic valves are thickened, opaque, dull whitish, sometimes with deformity and ulceration. histology observed the formation of atherosclerotic plaques, fibrous changes, and inflammatory infiltration. according to x-ray phase analysis biominerals in heart valves are represented by apatite crystalline phase. sizes of crystals have distinct age dependence. the results of infrared spectroscopy revealed absorption bands of carbonate apatite replacement; in all instances they correspond to the type of substitution b (co -replaces po -). conclusion: the study of pathological mineral formations on human heart valves by the range of morphological and physicochemical methods show that they are aggregates of interacting organic and mineral components, their ratio changes with "maturation": the organic component decreases and the mineral component, represented by carbonate containing hydroxyapatite doped with chlorine grows while improving, so the process is dynamic. relationship between myocardial injury, oxidative stress mechanism and sepsis/septic shock in infants submitted to surgery for congenital heart defects m. silva de oliveira * , e. medeiros floriano, p. henrique manso, r. nilsson sgabieri, j. guilherme klamt, e. zangiacomi martinez, w. vilella de andrade vicente, s. gusmão ramos * university of são paulo, dept. of pathology, ribeirão preto, brazil objective: a progressive ventricular dysfunction caused by ischemic myocardial injuries remains one of the leading causes of death during the postoperative course in congenital heart disease (chd). the aim of this study was to investigate the role of oxidative stress in these myocardial injuries. method: myocardial injuries and oxidative stress mechanisms were assessed by histopathology and immunohistochemistry and quantified by morphometrical analyses. results: myocardial injury was observed in pediatric patients submitted to surgery for chd with cardiopulmonary bypass, followed by lethal exit. oxidative stress mechanisms were directly related to these particular types of myocardial injuries. importantly, -hydroxynonenal ( -hne), a marker of lipid peroxidation, is strongly expressed, especially in irreversible myocardial lesions. although morphologically similar, myocardial injuries observed in patients who evolved with sepsis in the peri-operatory period exhibited a completely different set of oxidative stress mechanisms. increased concentrations of nitrotyrosine protein adducts were observed in these patients, suggesting that peroxynitrite-mediated protein nitration may be the predominant oxidative stress mechanism found in these situations. conclusion: the underlying mechanisms of these lesions seem to be related to the development of ischemia or ischemia/reperfusion followed by oxidative stress mechanisms that vary depending on whether sepsis was present. while the exact mechanism is not fully understood, it has been suggested that endogenous catecholamine release could have a role in this process. objective: a significant decrease of the mean cardiomyocyte dna content and increased numbers of diploid cardiomyocytes after ventricular unloading was demonstrated, suggesting a numerical increase of cardiomyocytes. the heart harbours several stem cells populations including c-kit (cd ) + cells and side population cells (spc), that might proliferate after unloading and generate diploid cardiomyocytes. it was tested, whether there is an increase of abcg + spc and cd + cells after unloading. method: in paired myocardial samples (before and after lvad), the number of cells with immunoexpression of abcg- , c-kit/cd and mef- was assessed by immunohistochemistry and morphometrically determined. results: a significant increase of spc and cells with coexpression of c-kit and mef- after unloading was observed (p= . ). a significant positive correlation between both spc and cells with coexpression of c-kit and mef- expression was observed (p= . and . ). no correlation was found between the number of spc and the mean cardiomyocyte dna content. conclusion: spc are significantly increased in the myocardium after ventricular unloading, suggesting a role of stem cell proliferation during "reverse cardiac remodelling". these cells might proliferate and commit to different cell lineages such as cardiomyocytes or endothelium, and thus ameliorate cardiac function. role of elastin gene polymorphism in ascending aorta aneurysm development in patients with essential hypertension v. zakharova * , v. dosenko, m. kostiv, e. rudenko * cardiovascular surgery institute, pathology, kiyv, ukraine objective: there is supposition about genetic propensity in the ascending aorta aneurysm (aaa) development. aim: to investigate role of elastin gene polymorphism (rs ) in aaa development in essential hypertension (eh). method: dna samples from persons with aaa and eh ( group), with eh only ( group) and healthy subjects ( group) were examined. polymorphism rs was studied with real-time pcr. histological examination of aaa walls was performed in group. results: distribution on genotypes a/a, a/g, g/g was the following: group - . %, . %, . %; group - %, %, %; group - . %, . %, . %. fragmentation of elastic membranes and media collagen component strengthening were revealed in persons with a/a, a/g, g/ g genotypes in . %, . %, . % respectively. persons with g/g genotype have more frequently ( . %) than others (a/a - . %, ag - . %) signs of inflammation, which promote aaa development parallel to eh. conclusion: we obtained evidence that elastin gene polymorphism (rs ) plays important role in eh and aaa development. in persons with allele a in rs risk of eh and aaa development is higher than in g/g genotype. mostly allele a in rs is accompanied with elastic membranes fragmentation and their substitution by collagen that decreases arterial wall elasticity. tuesday, september , . - . objective: our aim is to inform on the frequency, clinical aspects, and histopathological features of the tumor metastatic to the orbit. in adults, the most common tumor metastatic to the orbit are carcinomas, breast carcinoma the most frequent. less common are the metastases from gastrointestinal tract, kidneys, and prostate. cutaneous malignant melanoma is the most common nonepithelial tumor metastatic to the orbit. method: orbital metastatic tumors may occur at any age, but most often between and years of age. most reported statistics reveal a slight predominance of women, accounted for by the fact that breast carcinoma is causing metastases most frequently. a frequent finding in the cases of metastatic carcinoma is enophthalmos that is associated with scirrhous carcinomas. we present two cases of orbital metastatic tumors in which the primary tumors were a basal cell carcinoma and a cutaneous malignant melanoma. results: as to the metastasis from a basal cell carcinoma, the primary tumor was located in the external angle of the eyeball and metastasized the external / of the orbit. in the case of malignant melanoma, the primary tumor was located in the upper lid and invaded the orbital floor and fat. in both patients eyeball enucleation was performed. conclusion: we chose to present these cases given the differential diagnostic challenge and rarity of their location. uveal melanoma a. dumitriu * , s. dumitriu * umf iasi, dept. of neurology, romania objective: uveal melanoma which arises from melanocytes residing in the stroma is the most common primary intraocular cancer in adults. we report a case of uveal melanoma presenting as complicated cataract in a years-old male. results: the right eye was blind for months. the patient underwent extended enucleation and histopathology was consistent with uveal melanoma. conclusion: we present this case in order to provide the medical community a basic reference that would help to make further progress in this rare disease, which remains difficult to treat. results: there were more women than men ( % versus %). metastases developed in % (total group mean follow up of . year). mixed tumors were most common overall ( . %): for non metastasizing tumors there were . % mixed, . % fusiform and . % epithelioid types. for metastatic tumors there were . % mixed, . % epithelioid and . % fusiform types. the difference between cell type and metastatic development was significant in all but epithelioid compared with mixed tumors. epithelioid type had a relative risk of mortality of . and mixed had . compared to fusiform cell type. conclusion: our patients were younger, with larger tumors and different histological proportions from those of the collaborative ocular melanoma study. five year survival times were similar to those for europe. uveal melanoma between preserving vision and prolonging survival. pathological contributions to a better clinical management m. mera * , l. blaga * umf cluj-napoca, anatomic pathology, romania objective: uveal melanoma has a high metastatic potential which is invariably fatal. there is an ongoing debate on the impact of ocular treatment on metastatic disease and survival. improved prognostication is needed to identify cases that could avoid unnecessary loss of vision while avoiding unethical care. our study is aimed at contributing to the developing of reliable tools to assess the metastatic risk. method: an accurate prediction should include both clinical features and histologic parameters as biopsy techniques continuously advance. cases of uveal melanoma, either reviewed or prospectively managed in our pathology department, were included in a log-logistic multivariate survival model that we have considered would best accomodate our data. the performance of the model was assessed by bootstrap re-sampling. results: extravascular matrix patterns, optic nerve invasion, tumorinfiltrating lymphocytes, tumor cytomorphology, nucleolar size and the mitotic count together with initial visual acuity have been found to be the most important predictors, ahead of the traditional tnm stage. the results are provisional but encouraging. conclusion: there is still need for multidisciplinary approach and multicenter collaboration in an effort to elucidate the uncertainty related to the best management of one of the most traumatising types of cancer. orbital hemangiopericytoma: a case report e. omoscharka * , k. lankachandra * university of missouri, dept. of pathology, kansas city, usa objective: hemangiopericytomas are rare vascular tumors arising from zimmerman's pericytes, which ubiquitously surround blood capillaries and post-capillary venules. they rarely occur in the orbit, accounting for only % of all orbital neoplasms. in most cases the primary presentation is progressive proptosis. method: a -year-old female was first seen for the evaluation of a right orbital mass which has been causing proptosis. associated symptoms included peripheral vision loss in the right eye, persistent headache with occasional balance problems. a palpable, . × . cm well circumscribed mass with a smooth surface, resting on the inferior orbital wall was completely removed through right anterior orbitotomy. h&e stained histologic sections were studied. in addition, tissue sections were subjected to immunohistochemical stains for cd , cd , bcl , sma, desmin, ema and s- . results: the mass was composed of spindle cells with very low mitotic activity. staghorn vascular channels were evident, and in several areas the tumor cells invaded the pseudocapsule. the tumor cells were positive for cd , cd and bcl- supporting the histopathologic diagnosis of benign hemangiopericytoma. conclusion: orbital hemangiopericytoma is a slow growing tumor with a potentially malignant behavior, and a high local recurrence rate if incompletely excised. complete, intact removal prevents tumor recurrence and provides a good outcome. expression of sod family in rat lacrimal gland after intermittent light exposure c. l. zamfir * , f. e. zugun, e. cojocaru, r. o. temneanu, r. folescu, m. spataru * university of medicine iasi, dept. of histology, romania objective: any disturbance of chronobiological rhytms represents a potential stressor, acting like a strong oxidant trigger. sod family (cuzn-sod, mn-sod and ec-sod), is one of the most significant enzymatic complexes involved in antioxidant defense. monitoring local sod distribution in lacrimal gland after intermittent light exposure can be able to provide insights into the distinct links of antioxidant adaptative mechanisms.so long as lacrimal gland morphology and functions are dependent to a normal light exposure, mobilisation of its own antioxidant resources, especially sod, is an usefull starting point in antioxidant ophtalmic therapy. method: immunohistochemistry was performed in microscopic analysis of glandular fragments prelevated from male wistar rats, randomized in control/intermittent light exposed groups for days. there have been used specific antibodies for each enzymatic member of sod family. blood samples were prelevated to control sod levels. the study respected all imposed ethical criteria. results: lacrimal glandular tissue exhibits a strong cuzn-sod immunoreactivity, a moderate one for mn-sod and only a small ec-sod reactivity, while the level of sanguin sod is high, as a marker of oxidative aggression. conclusion: oxidative stress may be engagged in a deep alteration of lacrimal gland. mobilisation of sod, depending on their specific glandular location and tissular receptivity, should be regarded as a promising alternative for antioxidant therapy. tuesday, september , . - . objective: liposarcoma is the most commonly diagnosed soft tissue sarcoma in adults and occurs predominantly in the lower limbs and retroperitoneum. primary mediastinal liposarcomas are rare accounting for less than % of all mediastinal tumors. method: we report a retrospective study of cases of mediastinal liposarcoma during an -year period. diagnosis was made on mediastinal biopsy in cases and on resected specimen in the other cases. results: there were men and a women ranging in age from to years, explored for respiratory symptoms. radiological findings showed an anterior inhomogeneous mediastinal mass in all cases with extension to left hemithorax in one case. a surgical resection was achieved in only cases but was incomplete. histopathologically, tumors were classified into well differentiated lipoma-like liposarcoma, one myxoid liposarcoma and one mixed liposarcoma (sclerosing liposarcoma with myxoid liposarcoma). all patients received adjuvant radio or chemotherapy. one of them presented lung metastasis during the follow up and another died from respiratory failure. the two other are still alive. conclusion: mediastinal liposarcomas include a heterogeneous group of bulky tumours, the progression of which depends on the histological type. histopathologic examination is always necessary as much for diagnosis as prognosis. mediastinal epithelioid hemangioendothelioma with a highgrade clinical course a. konstantinova * , k. shelekhova, v. f. klimashevsky * st. petersburg state university, russia objective: epithelioid hemangioendothelioma (eh) is a rare neoplasm usually presenting in soft tissues. about twenty cases of eh have been reported in the mediastinum. most of these mediastinal eh exhibited an indolent course. results: a -year-old woman presented with focally encapsulated mass, . × cm in size, in the anterior mediastinum. the tumour of bone density was adhered to the lung tissue and occluded left subclavian vein. microscopically, the tumor consisted of foci of so-called blister cells typical for eh, anastomosing cords of small epithelioid cells embedded in myxohyaline matrix with haphazardly distributed metaplastic bone and hemorrhagic cellular stroma. spindling of the tumor cells was prominent. the tumor cells demonstrated moderate atypia, but mitotic figures were not found. immunohistochemically, cells of primary tumor were positive for fli , vimentin, cd and cd . focal staining with ema was observed. multiple metastases were subsequently found in the liver and lungs. metastatic deposits had the same morphology as a primary tumor. we present the case of rare mediastinum epithelioid hemangioendothelioma with peculiar histological features such as prominent spindling of neoplastic cells and abundant metaplastic bone formation in aggregate with aggressive clinical behavior that exhibited a profound metastatic poteintial. objective: thymic carcinomas comprise rare malignant epithelial neoplasms, which exhibit a disproportionately large variety of growth patterns. we present three cases of primary thymic carcinomas, including two squamous cell carcinomas and one papillary adenocarcinoma. method: all three patients were males, aged , and years, and presented with mediastinal masses measuring cm, . cm, . cm in maximal diameter respectively. results: microscopically the first two tumors were poorly differentiated squamous cell carcinomas, immunohistochemically positive for cd and cd , whereas the third tumor was a papillary adenocarcinoma, positive for cd and negative for cd and ttf- . immunohistochemical features of the tumors were supportive of thymic derivation. conclusion: primary thymic carcinomas are rare malignant tumors with clear-cut atypia, largely lack of organotypic features and a very diverse differentiation. squamous cell carcinoma is the most frequent subtype. they are often a diagnosis of exclusion, since metastases to thymus and anterior mediastinum, mainly from the lung, are far more common. immunoreactivity to cd , cd and cd may support the thymic origin of neoplastic squamous cells. treatment options include surgical excision, radiation and/ or chemotherapy depending on tumor stage and patient's condition. the prognosis is generally poor with squamous cell carcinomas having a slightly more favorable outcome. wednesday, september , . - . objective: surgical blood loss can lead to ineffective tissue perfusion of vital organs. physiologic solution chosen for blood volume replacement may be determinant for preserving renal integrity. our aim is to study kidney histopathological changes in a hemorrhagic model, followed by intravascular volume replacement with ringer's lactate or hydroxyethylstarch (hes) / . solutions. method: thirty one pigs under general anaesthesia with propofol and remifentanil underwent haemorrhage at a volume of ml kg- , over min. after a waiting period of min, intravascular volume was replaced using hes / . (g ) and ringer's lactate (g ). one hour after, pigs were euthanized with iv potassium chloride and sixty two renal samples were taken for histopathological examination, using pas staining. renal damage was assessed for glomerular, tubulointerstitial and vascular lesions. results: mean arterial pressure reached mmhg after bleeding, and recovered for values above mmhg in both groups after volume replacement. histopathological lesions observed in g were more frequent than those in g . conclusion: hes / . may reduce the incidence of histopathological lesions secondary to renal hypoperfusion after severe bleeding when compared with ringer lactate. results suggest that the reestablishment of intravascular volume with hes / . may preserve renal integrity secondary to blood loss. expression of aeg- , p and its clinicopathological significances in the malignant lesions of renal cell carcinomas h. erdem * , m. oktay, u. yildirim, a. k. uzunlar, m. a. kayikci * duzce university, dept. of pathology, turkey objective: astrocyte elevated gene- (aeg- also known as metadherin) is associated with various aspects of tumor malignancy. the aim of this study was to investigate p relationship between aeg- and prognostic parameters. method: this study was made paraffin blocks (tumoral samples), which were histopathologically diagnosed at department of pathology from to . subtypes of the cases were ( %) clear cell renal cell carcinomas (rcc) and ( %), non-clear rcc respectively. by immunohistochemical analysis, we investigated aeg- , p expression in carcinomas of kidney and we determined its relationship with clinicopathological parameters. results: there were significant relationship between increased aeg staining score and tumor capsule (p= . ), lymphovascular invasion (p= . ) and significant relationship between the increased diameter with the increase of p (p= . ). there were significant correlation between increased diameter of tumor and degree of increase the fuhrman (p= . ). conclusion: high aeg- , p expression correlates with prognostic parameters in the rcc. in addition, aeg- , p expression in rcc may be associated with tumor progression. relationship of cd , cox- and p in renal cell carcinomas with survival and other prognostic parameters: a tissue microarray study h. erdem * , u. yildirim, a. k. uzunlar, m. a. kayikci * duzce university, dept. of pathology, turkey objective: renal cell carcinomas (rcc) is the seventh most common human malignancy. rcc is now recognized to be a complex neoplasm consisting of several different tumor subtypes, each with distinct genetic and clinical features. the aim of this study was to investigate the expressions of cyclooxygenase- (cox- ), p and cd in rcc that has different clinicopathologic characteristics. method: this study was conducted on a total of paraffin embedded kidney samples (tumoral samples), which were histopathologically diagnosed at department of pathology from to . ihc stains for cox- , p and cd were performed on tissue microarray using standard procedures. results: there were significant correlations between cox- and subtype (p= , ), cox- and diameter (p= , ). significant relationships were found between p and age (p= , ), p and diameter (p= . ). besides, there were significant correlations between cd and furhman grade (p= , ). conclusion: cd , cox- , p expression correlates with prognostic parameters in the rcc patients. in addition, cox- , p , cd expression in rcc may be associated with tumor progression. objective: ebv related malignancies (skin cancers, lymphomas, kaposi sarcomas) complicates organ transplantation ebv-associated smooth-muscle tumors are rare. method: among kidney grafted patients, three developed ebv-smt. case . female y, with ebv-smt (generalized) case . female y, breast phylodes sarcoma, reviewed diagnosis: ebv-smt. case . male year, severe abdominal pain, gut tumor-like nodules were excised suspection of tbc. ebv-smt was microscopic diagnosis. results: progressive weight-loss all patients, chronic cough in patient , chest x ray multiple pulmonary lesions, on ct-scan paravertebral lesions. transthoracic biopsy: spindle cells proliferation with mixed cellularity eosinophilic cells intermingled fascicles resembling smooth muscle, mononuclear inflamatory cells and capillarie evoqued myofibroblastic tumor. no mitosis, mild nuclear atypia. negative immunohistochemestry: cd , cd , cd , ema, cytokeratin, s , cd . alpha-smooth muscle actin diffusely positive, evb-lmp negative. in situ hybridization : ebv + nuclei. ebv-smt was established. conclusion: smt in immunocompromised are ebv associated. primary target of ebv are b lymphocytes, may infect smooth-muscle through receptor for ebv cd mechanisms of ebv related-tumor genesis is integration of ebv-dna within alk locus in tumor cells. alkgene rearrangement and expression; associated with inflammatory myofibroblastic tumors, anaplastic large-cell lymphomas etc. clonally of multifocal ebv-smt using southern blot showed, multiple tumors constitute independent primary lesions. method: the degree of glomerulosclerosis was scored into - , mesangial proliferation was scored into (absent) and (present), and the degree of crescents was scored into - . glomerular injury score (gis) was obtained by adding the above scores and grouped into categories (group , score - ; group , - ; group , - ). results: serum creatinine level was significantly increased ( . ± . , . ± . , . ± . mg/dl, p= . ), estimated glomerular filtration rate (egfr) was significantly decreased ( . ± . , . ± . , . ± . ml/min, p= . ) and proteinuria was significantly increased as gis increased ( . ± . , . ± . , . ± . g/ h, p= . ). interstitial fibrosis of more than % of cortical area increased as gis increased ( . , . , and . %, p< . ). when a multivarate analysis was done, gis group was the most important predictive factor of egfr (p= . ) and proteinuria (p= . ). objective: the aim of the study is to evaluate the histopathological finding and the c d staining patterns of the patients who were biopsied due to graft dysfunction (gd) after initial well-function within month of deceased donor kidney transplantation (ddkt). method: histological analysis and c d immunostaining were performed on needle core biopsies. results: thirty-four patients (mean age: ± years, male: %) were included. histological analysis revealed acute rejection (ar) (n: ), acute tubular injury (ati) (n: ), allograft infection (n: ), borderline changes (n: ), normal morphology (n: ), and donor-related changes (n: ). c d staining was detected in % ( of ) biopsies; staining patterns were diffuse (n: ), focal (n: ) and minimal (n: ). diffuse (n: ) and focal (n: ) c d positivity accompanied of cases of ar. in remaining patients having non-ar histological picture, diffuse or focal c d positivity were detected in and cases, respectively. peritubular capillaritis was detected in . % ( / ) of biopsies, of which four had c d diffuse, one had c d focal positive. conclusion: beyond cold ischemia time-induced ati, immunological causes including antibody mediated process may play an important role in early impairment of graft function after ddkt. immunohistochemical analysis of the renal interstitial fibroblasts s. kostadinova-kunovska * , r. jovanovic, m. bogdanovska, v. janevska, l. grchevska, g. petrushevska * faculty of medicine, inst. of pathology, skopje, macedonia objective: renal fibrogenesis is a process common to all progressive kidney diseases. the main executive cell of this process is the fibroblast, by secreting and remodeling the extracellular matrix. the number of fibroblasts is minor in healthy kidney interstitium, but it increases during the process of fibrosis. their morphology and immunophenotype vary due to different intrinsic and extrinsic factors, thus making their identification and visualization, as well as determination of their origin, very difficult. method: we performed morphological and immunohistochemical analyses on kidney biopsies with primary glomerulopathy and interstitial fibrosis, using the following antibodies: vimentin, α-sma, s a , cadherin and cd . results: interstitial fibrosis with focal, rather than diffuse distribution, was present in all analyzed cases. the total interstitial fibroblast population was positive for vimentin, majority of the cells were positive for s a , and a smaller proportion of cells were positive for α-sma, cadherin and cd . furthermore, different cells in the fibroblastic population showed positivity for different markers. conclusion: the above stated observations contribute to the theory that different subpopulations of fibroblasts, with different origin, take part in the renal fibrogenesis. soluble epoxide hydrolase inhibition reduce blood pressure and organ damage independently of nitric oxide (no) in mice with goldblatt two kidney, one clip model ( k c) p. kujal * , l. kopkan, l. cervenka, z. vernerova * charles university, third faculty of medicine, prague, czech republic objective: investigate the role of no in the blood pressure (bp)-lowering effects of soluble epoxide hydrolase (seh) inhibition in k c model. method: the endothelial no synthase gene knockout mice and their wild-type controls were used. renal concentrations of epoxyeicosatrienoic acids (eets) and dihydroxyeicosatrienoic acids (dhets) were measured in nonclipped kidney. renal no synthase activity was determined by measuring the rate of formation of l-[ c]citruline. results: treatment with the seh inhibitor caused the same bp decrease that was associated with increase in daily sodium excretion in both types of mice. the ratio of eets/dhetes in the nonclipped kidney was increased and did not alter renal nos activity. seh inhibition reduced significantly glomerular and tubulointestitial injury. conclusion: bp-lowering effects of chronic seh inhibition in k c mice are associated with normalization of the reduced availability of biologically active eets in the nonclipped kidney and their direct natriuretic actions. total inflammation in -month surveillance renal transplant biopsies is associated with decreased renal function and de novo class donor specific antibody z. laszik * , s. chandran, f. vincenti * ucsf, dept. of pathology, san francisco, usa objective: the goal was to correlate inflammation and acute rejection (ar) with renal function and antibody status in -month renal transplant surveillance biopsies. method: relative risks of inflammation and ar in month biopsies was calculated by multivariable poisson regression. results: ar was seen in . % (n= ), borderline change in . % (n= ), and c d positivity in . % (n= ) of all biopsies. total cortical inflammation (ti), present in . % (n= ) cases, was associated with ml/min/ . m lower egfr at months ( % ci= − . , − . ). de novo hla class was identified in . % (n= ) and class dsa in . % (n= ), with most having mfi values < . increased risk of ar was seen with higher levels of de novo class (rr . , % ci= . , . ) or class dsa (rr . , % ci= . , . ). class (but not class ) dsa was associated with a higher risk of ti (rr . for ti-score ≥ , % ci= . , . ) at months. conclusion: both ti and ar in -month surveillance kidney transplant biopsies are strongly associated with de novo hla class dsa. total inflammation at months correlates with decreased kidney function. objective: tenofovir disoproxil fumarate has been used in the treatment of hiv patients producing occasional renal dysfunction and fanconi syndrome. method: a -year-old patient was referred with severe acute renal failure and important metabolic acidosis and glycosuria with normoglycemia in urine analysis, altogether with urinary alkaline ph and proteinuria with a protein/ creatinine ratio of . he was hiv and b positive diagnosed years earlier. his medication regimen consisted of lopinavir, ritonavir, tenofovir and lamivudine. the patient had a history of nausea, vomiting and some diarrhea with low fluid intake for a week. besides slight dehydration, the physical examination was unremarkable. renal ultrasound showed normal kidneys. with adequate fluid restoration, the renal function improved but other metabolic alterations like nephrogenic diabetes remained. results: renal biopsy revealed toxic acute tubular necrosis predominantly involving proximal tubules with prominent eosinophilic inclusions within proximal tubular cell cytoplasm, which represented giant, abnormal mitochondria, consistent with tenofovir toxicity. some histochemichal studies (cox and sdh) were performed. conclusion: although prospective clinical trials have demonstrated a low incidence of renal toxicity with tenofovir, there are several such reports in the literature. current recommendations suggest close monitoring of renal function after initiation of therapy with tenofovir, specially at the beginning and when used in combination with certain antiretroviral agents. objective: nutcracker syndrome (ns) is caused by compression of the left renal vein between the aorta and superior mesenteric artery. the main presenting symptom of this rare entity is haematuria, with various degrees of proteinuria. the diagnosis of ns syndrome is primarily by imaging and can sometimes be challenging. method: a -year-old male was referred to nephrology with a months history of intermittent gross haematuria. all blood test including blood cell count, biochemistry, immunoglobulin electrophoresis, antinuclear antibody were normal. urinary analysis revealed numerous red blood cells and a protein/creatinine ratio of . . a previous cystoscopic examination was normal. renal ultrasound revealed a diffuse increased echogenicity. results: renal biopsy showed a normal histology with no immunofluorescence deposits. ct scan revealed dilatation of the distal left renal vein with narrowing between the superior mesenteric artery and the aorta. conclusion: ns is a rare entity causing haematuria. there are few reported cases with histology, although it usually shows no abnormalities. the proposed mechanism for the haematuria is an abnormal communication between the submucosal venous plexus and the calyceal system presumably induced by renal venous hypertension. banff initiative for quality assurance in transplantation (bifquit): reproducibility for bkv immunohistochemistry in renal allografts m. mengel * , s. chan, j. climenhaga, h. regele, b. colvin, p. randhawa * university of alberta, laboratory of medicine, edmonton, canada objective: detection of bk virus associated large t-antigen is crucial for the diagnosis of polyomavirus nephropathy. method: in an international multi-centre trial we assessed the inter-observer and inter-laboratory variability for bk immunohistochemistry. a tissue microarray was constructed comprising specimens representative of the whole analytical spectrum from negative over mild to strong sv positive cases. participants at centers stained the tma slides using local protocols. participants evaluated their slides following a provisional banff grading schema. details regarding local staining protocols and evaluation scores were collected online. stained slides were returned for centralized panel re-evaluation. weighted kappa statistics were used to determine the variability. results: the bk inter-observer reproducibility was substantial (mean kappa . ), but inter-laboratory reproducibility was below chance (kappa − . ). separating components of bk evaluation schema into stain intensity and stain percentage showed no significant improvements in reproducibility. however, collapsing the proposed bk scoring schema into a simple positive/negative call improved bk inter-laboratory variability to . . conclusion: these results indicate a significant variability between laboratories for detecting the sv large-t antigen by immunohistochemistry in paraffin sections. any proposed grading schema for bk nephropathy, which is dependent on percentage and intensity of nuclear staining, will essentially not be reproducible between laboratories. objective: cryopyrin-associated periodic syndrome (caps) is a rare hereditary inflammatory disorder with three differents phenotypes: familial cold autoinflamatory syndrome, muckle-wells syndrome and neonatal-onset multisysten inflamtory disease caps results from a mutation of the nlrp gene ( q ) coding for cryopyrin, which forms intracellular protein complexes (inflammasomes). results: case report: year old women with chronic renal disease stage (creatinin , mg/dl and proteinuria mg/ h) who developed urticarial episodies since months old related to cold exposure. after years old patient describe associated to these episodios bilateral arthritis (knes, ankles and elbows), conjunctival inflammation, shivers, and asthenia, more frequently in winter and precipitated by cold exposure, air conditioning, stress and menstruatión. aditionaly the patient developed in last years bilateral hypoacusis a kidney biopsy showed a amorphous, acellular and acidophilic material congo red positive deposits at interstition, arteries and arterioles and less frequent at glomeruli. this material displays apple green birefringence by polarizad light microscopy. diagnosis: secondary renal amyloidosis conclusion: the clinico-pathologial findings of this case are compatible with muckle-wells syndrome. secondary amyloidosis is a severe complication which occurs in % of muckle-wells cases. amyloidosis is cause by increase of c-protein and a amyloid during the episodies before described and deposition of the a amyloid in differents tissues. glomerulocystic disease associated with thrombotic microangiopathy in two kidney allografts j. m. mosquera reboredo * , e. vazquez martul * complexo hospitalario universitario, dept. of pathology, la coruña, spain objective: glomerulocystic kidney disease (gckd) is a rare condition usually congenital and reported in infants and young children. only few cases of adquired gckd had been reported often following hemolytic uremic syndrome (hus). method: histological study of two kidney graft explants. results: we present two cases of kidney transplant who developed hus in allografts. both cases showed at the histological examination typical vascular and glomerular changes of thrombotic microangyopathy (tma). a cystic transformation with increase of urinary space and retraction of glomerular tuft was frequently observed. chronic transplant vasculopathy was found in the two cases. humoral active rejection was also demonstrate in one case with moderate peritubular capillaritis and glomerulitis and diffuse c d deposition at peritubular capillaries. conclusion: in a few cases gckd appear to develop after another kidney disease includes single case reports of gckd associated with mesangial glomerulonephritis, wegener's granulomatosis, progressive systemic sclerosis, after hus (include some case in adult patient). our two cases represent a initial stage of adquired gckd. the ethiopathogenetic relationship is not clear but some authors propous that cystic dilatation of the bowman's capsule associated to tma/ hus may be secondary to ischemic mechanism. case report: cytomegalovirus gastritis in renal transplanted man f. noroozinia * , k. makhdoomi, a. esmaeili, a. saffarifard * emam khomeini hospital, dept. of pathology, urmia, iran objective: cmv is an important pathogen in immunocompromised hosts, including patients with aids, neonates and transplant recipients. this infection develops in - % of transplant patients. upper gi symptoms in solid organ recipient are common ( %) and clinical signs are more serious in % of cases. method: we report a year old man with end stage renal disease underwent kidney transplantation from a cmv negative donor on june . after . months he admitted with fever, generalized body pain, oral aphtous ulcers and epigastric pain accompanied by malaise. endoscopic examination revealed multiple antral erosions with surrounding erythema. clinicopathological investigations revealed cmv viremia with a ig-m antibody titer and cmv gastritis confirmed by histopathological examination. results: the patient was started on intravenous (iv) ganciclovir mg/kg per day every h initially for weeks, afterwards the fever decreased; cell blood counts throwback to normal ranges and general condition of the patients improved. conclusion: cmv infection develops in - % of the transplant patients. the colon and stomach are the most common sites of gastrointestinal infection. though the rate of gi affliction by cmv is high, localization to the gastric antrum is not common. immunohistochemistry study of c-kit expression in renal cell carcinoma f. noroozinia * , f. abbasi, z. yekta, f. meisami, a. saffarifard * emam khomeini hospital, dept. of pathology, urmia, iran objective: renal cell carcinomas include about - % of adults neoplasms and - % of all renal tumors. in many cases, it is possible to distinguish. rcc subtypes on the basis of hematoxylin-eosin staining alone. however, overlapping morphologic features pose some difficulties in making a proper diagnosis. to render an accurate diagnosis, additional methods like immunohistochemichal staining against c-kit have been recommended. method: we reviewed cases of rcc diagnosed during years. formalin fixed, paraffin embedded specimens was available in cases. the expression of c-kit was evaluated using immunohitochemistry. results: six cases of clear cell type ( . %), of papillary type ( . %), and of chromophobe type ( %) were positive for c-kit that considering chi-square test there is significant relevation between rcc's subtypes and c-kit expression (p: . ). from cases with renal vein invasion, showed positive expression of c-kit ( . %) and in cases with no venous invasion, c-kit expression was detected in ( . ), so no significant relation was found between renal vein invasion and c-kit expression. conclusion: the expression of c-kit in rcc may have diagnostic significance. objective: igg -rsd shows abundant igg -positive plasma cells, diffuse fibrosis, and increased serum igg levels. although igg -rsd typically results in autoimmune pancreatitis (aip), any organ may be involved. thus, igg -rsd tin often goes unrecognized in the absence of aip. this is an igg -rsd tin case with mediastinal lymph node and pulmonary involvement. method: a -year-old male presented with rapidly progressive renal failure, hypergammaglobulinemia, hypocomplementemia, and enlarged mediastinal lymph nodes and bilateral pulmonary nodules on ct. renal and mediastinal lymph node biopsies were performed and igg ihc was done on both after standard techniques. results: the renal cortex and medulla showed diffuse interstitial fibrosis with tubular atrophy and abundant plasma cells ( igg -positive cells/hpf), numerous lymphocytes and some eosinophils. if showed igg, c , kappa, and lambda granular deposits in tubular basal membranes and bowmann capsules. lymph node follicular and paracortical hyperplasia with abundance of mostly igg positive plasma cells was seen. an igg -rsd diagnosis was rendered and high serum igg levels were demonstrated. steroid therapy resulted in lymph node and lung nodule reduction. conclusion: tin with abundant plasma cells and diffuse interstitial fibrosis, especially if accompanied by hypergammaglobulinemia, hypocomplementemia, or extrarenal involvement, should suggest igg -rsd and prompt serum igg level determination and renal igg ihc. objective: a -year-old woman was admitted for chronic renal failure. clinical examination was normal. biological explorations showed creatinin clearance around ml/min, tubular proteinuria with bence jones κ protein. serum immunoelectrophoresis identified abnormal monoclonal immunoglobulin g and κ-light chains (lc). bone marrow histology was normal. method: kidney biopsy revealed diffuse intracytoplasmic vacuoles in the proximal tubules resembling osmotic nephrosis. distal tubules, glomeruli, vessels and interstitial compartment were normal. immunofluorescence (including anti-κ and -λ staining) was negative. electronic microscopy (em) revealed intracytoplasmic immunoglobulinic crystals containing κ lc inside the vacuoles, leading to the diagnosis of light chain proximal tubulopathy (lcpt). results: lcpt is a rare complication of dysglobulinemia. it may be associated with crystals within the cytoplasm of proximal, less frequently distal, tubular cells, consisting more frequently in κ lc. rarely, diffuse tubular vacuolization is present, often indistinguishable from osmotic nephrosis. in our case, there was no proximal tubular dysfunction and immunofluorescence was negative. the first evocated diagnosis by light microscopy was "osmotic nephrosis". however, we failed to identify any causal factor. finally, the diagnosis was performed by immunoem. conclusion: in conclusion, before a picture of osmotic nephrosis without obvious cause, em and immunoem may be helpful for the diagnosis of lcpt, often revealing a dysglobulinemia. opportunistic infections in renal transplantation -a case series r. sampaio * , r. dias, p. farrajota, a. coelho, t. almeida, a. duarte, j. r. vizcaino * anatomia patológica, valpaços, portugal objective: oporto's hospital centre is one of the portuguese hospitals with more renal transplantation activity (performed since ). although increasingly rare, opportunistic infections (oi) in transplanted patients remain a major diagnostic challenge and are associated with high mortality rate. method: in order to evaluate the incidence of oi in renal transplant patients and to identify the location of infection, the respective techniques of diagnosis used and the survival time after infection, we conducted a retrospective study using the nephrology department's database on renal transplants. we consulted the registries from to . results: we investigated cases and found cases of oi caused by herpes virus (n= ), cytomegalovirus (n= ), polyomavirus (n= ), aspergillosis (n= ), alternaria (n= ), mucormycosis (n= ), candidiasis (n= ), tuberculosis (n= ), cryptococcus (n= ) and pneumocystis (n= ). the lung and urogenital system were the most affected systems. kidneys were affected in cases respectively by mucormycosis, tuberculosis and cryptococcus. of all the cases of oi, were diagnosed by the department of anatomic pathology ( by biopsy; by cytology; by biopsy and cytology). conclusion: in many cases the diagnosis could only be performed through histologic/cytologic examination. prompt diagnosis and treatment are necessary to avoid life threatening complications and may greatly improve prognosis. papillary renal cell carcinoma with osseous metaplasia and bone marrow elements: a case report l. l. santos * , a. polónia, r. henrique, c. lobo * ipo porto, dept. of pathology, viana do castelo, portugal objective: renal cell carcinomas might display foci of calcification and even ossification. this rare event has been reported mostly in the clear cell variant. herein, we present the case of a year-old man, previously diagnosed with colon cancer, incidentally found to have a calcified mass in the kidney, which was interpreted as non-characteristic for renal cell origin. results: radical nephrectomy was performed. a . × . × . cm tumor was found, with a heterogeneous brown cut surface, containing areas of necrotic tissue and extensive calcifications. histopathologic examination disclosed papillary structures covered by small cells with scant cytoplasm, dispersed among mature bone tissue enclosing marrow elements. epithelial tumor cells were imunorreactive for cytokeratins, cd and pax , and negative with hmb- . hale`s colloidal iron was negative. trisomy of p, p and p was detected by fish. a diagnosis of prcc type , fuhrman grade , with extensive osseous metaplasia was rendered. conclusion: ossification of renal cell tumors is rare, occurring mostly in clear cell type and the underlying mechanism is unclear. these tumors show atypical radiological features and might be confused with non-renal cell tumors. to the best of our knowledge, this is the first report of prcc with osseous metaplasia and bone marrow elements. the effect of doxycycline on glomerulosclerosis in / renal ablation s. sarioglu * , d. sonmez, a. celik, f. saglam, o. yilmaz, e. koraltan, z. cavdar, g. oktay * dokuz eylul university, faculty of medicine, izmir, turkey objective: the effect of matrix metalloproteinase (mmp) inhibitors in segmental sclerosis is unknown. the aim of this study is to investigate the effect of a mmp inhibitor, doxycycline, on glomerulosclerosis (gs) in renal ablation nephropathy. method: fourteen of the female wistar albinos were / nephrectomised. doxycyline was given to half of each group ( mg/kg/day total days). after sacrification, the gs, mmp- , mmp- , timp- expressions were analyzed histopathologically. pro and active mmp- and - were analyzed by gelatin zymography. timp- and timp- were measured with elisa assay. results: doxycycline administration to the / nephrectomy group improved gs, but did not inhibit glomerular mmp- or cortical pro-and active-mmp- and pro-mmp but increased timp- and timp- expression in all groups in cortical tissue. mmp- expression and gs were increased in all groups receiving doxycycline. conclusion: we have demonstrated improved gs in renal ablation model by doxycycline administration but also doxycycline has an unexpected adverse effect. the effect of doxycycline on the expression of mmp- and - cannot explain the improvement in gs, but increased cortical tipm- and - may be an important contributing factor for inhibition of mmps. digitally reinforced hematoxylin-eosine polarization in diagnosis of renal amyloidosis s. sen * , b. sarsik * ege university, faculty of medicine, izmir, turkey objective: systemic amyloidosis is a rare disorder, characterized by extracellular accumulation of congo-red (cr) positive fibrillar amyloid protein deposits. the kidney is the most commonly affected organ by systemic amyloidosis. cr staining which increases the positive birefringence of the weakly birefringent unstained amyloid. in this study we investigated potential power of digitally reinforced birefringence of routine hematoxylin-eosine (he) slides on the renal biopsies. method: we reviewed he stained slides for polarization. sixty five amyloidosis cases were diagnosed by renal biopsy from to at our laboratory. all biopsies were evaluated by light and immunofluorescence microscopy. slides were reevaluated blindly using a microscope (olympus bx ) attached polarization filter and connected to a digital camera (olympus dp , sal). depositions which show green birefringence on he with digitalized microscopy were considered as positive and results were confirmed using cr. results: of the cr confirmed amyloid positive biopsies, showed green birefringence with he. of the cr confirmed amyloid negative biopsies, two were considered as false positive. the sensitivity, specificity, positive and negative predictive values were estimated as %, %, % and %, respectively. conclusion: we concluded digitally polarized he sections can be used as a fast and first step diagnostic method for renal amyloidosis. sirolimus ameliorates cyclosporin-induced nephrotoxicity in a rat modelfocus on renal lesions, oxidative stress, inflammation, proliferation and angiogenesis j. sereno * , a. m. romão, m. teixeira, b. parada, c. mega, h. vala, e. t. lemos, f. teixeir, f. reis * ibili, medicine faculty, laboratory of pharmacology and experimental therapeutics, coimbra, portugal objective: sirolimus (srl) have been pointed as a feasible option for minimize the use of cyclosporin a (csa), especially because of putatively less nephrotoxicity. this study aimed to characterize the histological lesions and the molecular pathways implicated in csa-induced nephropathy and prevention when converted to srl. method: the following groups (n= ) were tested during weeks: vehicle, csa, srl and conversion (csa weeks + srl weeks). bp and hr were monitored. blood was collected and kidney gene expression of markers of inflammation, proliferation, angiogenesis and oxidative stress were assessed. histology: h&e, pas and gordon & sweets staining. statistics: anova and post´hoc tests (p< . ). results: after week of csa treatment, there was important kidney lesions, including glomerular, tubulointerstitial and vascular: mesangial expansion, atrophy, bowman capsule enlargement, hyaline cylinders formation, tubular calcification and vascular congestion, as well as arteriolar vacuolization and arteriolosclerosis. conversion to srl, ht and tachycardia were reduced, accompanied by amelioration of kidney dysfunction and lesions (glomerulosclerosis and tubulointerstitial fibrosis), together with reduction of oxidative stress, proliferation and angiogenesis. conclusion: in conclusion, srl ameliorates csa-induced nephrotoxicity in a rat model, which might be due to protection against oxidative stress, proliferation and angiogenesis, but these mechanisms deserve better exploitation. acknowledgements: fct(sfrh/bd/ / ). non-lupus "full-house" nephropathy in serbian population in last six years j. vjestica * , s. cirovic, s. tatic, r. naumovic, s. simic-ogrizovic, j. markovic-lipkovski * inst. for pathology, medical faculty, belgrade, serbia diffuse glomerular and sometimes focal mesangial staining of immune complex depositas (iga, igg, igm, c , and c q), also known as "full-house" pattern commonly indicates lupus nephritis. however, some non-lupus nephropathy also can be present with a "full-house" immunofluorescence pattern, mimicking lupus nephritis. the aim of this study was to define the clinicopathological spectrum of originally non-lupus "fullhouse" nephropathy. biopsies from january till december were analyzed in order to identify all renal biopsies cases showing "full-house" pattern. the study included "full-house" renal biopsy diagnosiss. from all analyzed cases ( %) had lupus nephritis expressing "full-house" pattern and ( %) cases had non-lupus "full-house" nephropathy. in the absence of clinical and/or serological evidence of systemic lupus erythematosus (sle), at the time of renal biopsy, in cases diagnose was membranous glomerulonephritis (gn), than mesangioproliferative gn, membranoproliferative gn, iga nephropathy, rapidly-progressive gn and membranous/membranoproliferative gn cases. nonlupus "full-house" nephropathy is present in broad spectrum of different types of gn, predominantly in cases of membranous gn. the possibility of "full-house" nephropathy preceding the emergence of overt sle remained to be clarified. objective: although the renoprotective effects of prostacyclin have been demonstrated in many studies, the protection mechanisms of prostacyclin in chronic kidney disease, especially at the terminal stage, are still remained unclear. in the present study, we performed pathological and pathphysiological analyses of prostacyclin renoprotective effects using a stable prostacyclin analogue, beraprost sodium, in the disease kidney of anti-gbm glomerulonephritis (gn) rats. method: beraprost was administrated from weeks after induction of gn. the condition of renal microvascular network and localization of apoptotic cells were examined using renal vascular corrosion casts, immunostainings and tunel-staining. the intracellular apoptotic signaling pathway was analyzed by western blot and qpcr. results: in the kidney of beraprost-treated rat, significantly high density of renal microvascular network was maintained, and apoptosis of vascular endothelial cells was suppressed even at the terminal stage of anti-gbm gn. pathophysiological analyses revealed that transcriptional and post-translational modifications of bcl and xiap, which were anti-apoptotic proteins in mitochondria dependent apoptotic pathway, were occurred in the kidney of beraprost-treated rat. conclusion: these results suggested that prostacyclin protects renal vascular network by inhibiting mitochondria dependent endothelial apoptosis, and it play an important role for preservation of renal function in the chronic kidney disease. wednesday, september , . - . objective: although villous adenomas commonly occur in the gastrointestinal tract villous adenomas of the urinary tract, including the bladder, are infrequently encountered. method: we report a case of urinary bladder villous adenoma in a -year-old man. the patient was undergone cystoprostatectomy because of diagnosis infiltrative urothelial carcinoma in the transurethral resection of bladder. results: histopathological examination of cystoprostatectomy specimen there was no urothelial carcinoma. a , cm polypoid mass was seen at the dome of the urinary bladder. histopathology confirmed that this tumor was a villous adenoma with a polypoid growth of the glandular epithelium consisting of small tubular glands, dilated cystic glands or papillary fronds lined by a columnar epithelium. the glandular epithelial cells displayed mild nuclear atypia and nuclear pseudostratification with some mucus cells admixed. the patient was diagnosed with a rare case of villous adenoma of the bladder. over the past months of follow up, the patient is alive and no metastasis. conclusion: patients with isolated villous adenomas in the urinary bladder have an excellent prognosis and surgical resection is curative. however, it is uncertain whether an untreated lesion might eventually develop into an adenocarcinoma. therefore, close follow up is recommended because of the possibility that this condition might be premalignant. caprin overexpression in urothelial carcinomas of bladder b. akkaya * , z. cetin, s. berker-karauzum, m. baykara * akdeniz university, school of medicine, antalya, turkey objective: caprin encoded by cytoplasmic activation/ protein- gene located in p chromosome region. it has been reported that caprin is associated with cell proliferation in various types of cell lineages. method: we researched whether caprin might be overexpressed or not in urothelial carcinoma of bladder and its overexpression could be correlated with clinicopathologic parameter (age, sex, invasion). fifty urothelial carcinoma of bladder ( infiltrative; non-infiltrative) were stained by immunohistochemically in tissue microarrays. results: the expression of caprin was observed in infiltrative urotelial carcinoma cases (% ) and non-invasive urothelial carcinoma cases (% ). age range was - . eight patients were female, patients were male. conclusion: in the literature caprin overexpression was reported in different types of tumors including esophageal, stomach, prostate, lung, liver. caprin overexpression might be correlated with the cellular proliferation potential. to determine of importance of caprin - overexpression new studies are necessary. objective: pseudohyperplastic squamous cell carcinoma of the penis (pscc) is a low grade tumor with specific clinical and pathological features. this very uncommon tumor occurs in association with lichen sclerosus, the main location is foreskin, and the high degree of differentiation may difficult its discrimination with pseudoepitheliomatous hyperplasia. method: a -year-old male presented a penis lesion involving glans and foreskin, clinically suspicious of malignancy. size was , × , cm and a conservative resection was done. pathological study was performed, and hpv detection with a commercially available kit: pcr amplification and reverse hybridization with probes to hpv types. results: the lesion showed a non-verrucous well differentiated squamous cell tumor. upper layers lacked any atypia but infiltrative growth was evident in basal layers, with atypical cells and mitosis. lichen slerosus changes were evident bordering the tumor. hpv was negative for all types studied. no further treatment was employed and after a months follow-up no recurrence has been observed. conclusion: pscc should be taken in mind when handling penis tumors. a correct differentiation from benign lesions and a knowledge of its low grade to avoid overtreatment will benefit patients. lichen sclerosus and not hpv seems to play a precancerous role. evaluation of sunitinib malate and meloxicam as single agents or in combination in bladder cancer cell lines r. arantes * , r. pinto-leite, c. lopes, l. santos, a. colaço, p. oliveira * utad, dept. of veterinary sciences, vila real, portugal objective: currently accepted for the treatment of advanced renal cancer, sunitinib malate is a small molecule inhibitor of the vegfr family, with ability to regulate tumor growth, progression, angiogenesis and metastasis. several reports have suggested that encouraging effects can be achieved by combining cox- inhibitors with anticancer agents. the goal of this work was to evaluate the effects of sunitinib malate and meloxicam isolated and combined on three human bladder cancer cell lines. method: t , and ht cells were treated with several concentrations of sunitinib malate and meloxicam, as single agents or in combined schedule. their influence on cell proliferation was determined by mtt method after h of treatment. control samples were processed in the same way as treated samples but in drug-free medium. absorbance values of each well were read at nm using an elisa plate reader. results: a reduction in cell proliferation rate was observed when all cell lines were treated either with sunitinib malate or meloxicam isolated. simultaneous exposure to both agents enhances the inhibition of cell proliferation. statistical significances were obtained when treatment groups were compared with control group. conclusion: these results suggest a potential clinical application of sunitinib malate in combination with meloxicam on bladder cancer. bcl- expression in prostate carcinomas b. balinisteanu * , a. dema, s. taban, c. lazureanu, d. herman, s. ursoniu, a. loghin, a. vaduva * municipal hospital, pathology, timisoara, romania objective: the disturbance of apoptosis represents an important event in the genesis of tumors with different localization. the study of anti-apoptotic protein bcl- expression from the perspectives of the prognostic and predictive value in prostate cancer has led to inconsistent results, even contradictory. method: expression of bcl- was analyzed in groups of prostatic carcinoma: localized, locally advanced and with distant metastases. for histological grading of carcinomas we used gleason score. classification of the tumors into prognostic subgroups was made according to nccn guidelines. for the immunohistochemical study we used anti-bcl- antibody (clone ), envision system, visualization with diaminobenzidine. the results of immunohistochemical reaction were assessed by evaluating the extent and intensity of immunostaining. statistical analysis was performed using stata . . results: of the analyzed cases of prostate carcinomas showed bcl- over-expression: , % localized carcinomas, , % locally advanced carcinomas and , % carcinomas with distant metastases (p< . ). although most of the bcl- positive tumors were poorly and moderately differentiated, the correlation between bcl- over-expression and tumor grade did not show statistical significance (p= , ). conclusion: bcl- overexpression in advanced prostate carcinomas suggests involvement of this marker in the progression of tumors in this location. urothelial carcinoma of the bladder: a clinicopathologic study of cases g. benkhedda * , s. khalifa, y. lamouti * chu frantz fanon, dept. of pathology, blida, algeria objective: urothélial carcinoma (uc) accounts for nearly % of urinary bladder tumors.a variety of histological variant of uc have been recently recognosed. some variants have prognostic and therapeutic implications. the aim to this study is to assess the pathological features from our series and to compare our results that of the literature. method: we retrospectively studied patients who were diagnosed histopthologically with urothelial carcinoma using the who classification system. results: the mean age of patients at diagnosis was (range, - years). , % were male ( h/ f). all tumors were classified as urothelial carcinomas: , % urothelial neoplasm with squamous differentiation, , % with glandular differentiation, , % urothelial tumors nested and % sarcomatoid. in this study most tumors were grade ( cases) and stage pt . conclusion: adult urothelium has the capacity to undergo several pathways of phenotypic cellular and structural differentiation as a result of the embryological origin of the bladder from the multipotent tissues of the cloacal endoderm and the mesodermal wolffian ducts. the clinical course of bladder cancer varies depending on the histological type of neoplasm, grade and stage of the tumor. hight-grade muscle-invasive urothelial cancers and tumors schowing variant microscopic morphology have in general hight mortality and poor prognosis. comparison of insignificant cancer detection rates in prostatectomies performed following and -core biopsy schemes u. berber * , a. haholu, i. yilmaz, z. kucukodaci, d. demirel * gata heh, dept. of pathology, istanbul, turkey objective: widespread use of extended biopsy protocols have increased the prostate cancer detection rates. besides this improvement, whether detection of clinically insignificant cancer detection rates are increased by extended biopsy protocols is not well documented. in the study, we aimed to compare the rates of insignificant cancers found in prostatectomy specimens performed following and -core biopsy protocols. method: retrospectively, we investigated the low volume/ low grade (lv/lg) prostate cancers in prostatectomy specimens. tumors volumes were calculated digitally as multiplying total tumor areas by mm for average block thickness, and corrected for tissue shrinkage by multiplying a factor of . . results: of the prostatectomies, were performed following sextant technique, and were performed after -core protocol. review of the h&e stained sections revealed insignificant cancers. number of lv/lg tumors found in and -core groups were ( . %) and ( . %), respectively. conclusion: when compared to sextant technique, detection of lv/lg tumors were significantly raised in prostatectomies performed following -core protocol, and this increase points out the need for new approaches in patient management to avoid overtreatment after extended biopsy protocols. ps- - impact of total core length for cancer detection in a lateral zone targetted -core prostate biopsy scheme u. berber * , a. haholu, z. kucukodaci, i. yilmaz, d. demirel * gata heh, dept. of pathology, istanbul, turkey conclusion: total core length is significantly associated with cancer detection rates and may be used as a reliable adjunctive tool in deciding repeat biopsies for patients with negative biopsy result. objective: primitive neuroectodermal tumors (pnets) are highly malignant tumors of neuroectodermal origin. we report a case of renal pnet in a -year-old male with a -month history of intermittent hematuria.. he underwent a right radical nephrectomy. macroscopically, the inferior pole was replaced by a multinodular, grey, glistening tumour measuring . / / cm, with foci of necrosis and hemorrhage. method: serial histological sections have been assessed using hematoxylin-eosin and van gieson stain and the indirect immunohistochemical analysis for antibodies: mnf , vim, cd , nse, mic /cd . results: histological examination revealed a uniform population of undifferentiated, small-to medium-sized tumor cells, arranged in alveolar-insular patterns, with round to oval nuclei, small nucleoli, numerous signs of mitosis and scattered apoptosis, geographic zones of necrosis. dispersed cells showed cytoplasmic vimentin positivity favouring the diagnosis of pnet. few tumoral cells appeared positive for mnf . expression of cd was positive in a large number of tumoral cells and an area of the tumour exhibit a milder reaction of positive nse. mic was positive with moderate staining in almost all tumoral cells. conclusion: diagnosis is based on histology and immunohistochemistry but pathological evaluation can be challenging because of the differential diagnosis with other small round cell tumors. nonamyloid fibrillary glomerulonephritis: presentation of two cases e. beretouli * , g. dimas, g. karayannopoulou, t. koletsa, d. grekas, g. karkavelas * ahepa hospital, dept. of pathology, thessaloniki, greece objective: fibrillary glomerulonephritis (fgn) is a rare disease, characterized by fibrillar deposits in the mesangium and the glomerular capillary loops. these deposits do not have an amyloidlike cross-β structure and are readily distinguishable from amyloid by the larger thickness of fibrils and lack of congo red staining. method: we report two cases of a -and -year-old women, who presented with severe nephrotic syndrome, rapidly progressive chronic kidney disease and lymphoproliferative disorders. glomerular crescents were present in about % of both renal biopsy specimens ( of and of glomeruli, respectively). immunohistochemical analysis, immunofluorescence and an electron microscopy (em) studies were performed. results: renal biopsy showed a deposition of an amyloidlike extraneous substance in the mesangium, as well as within the glomerular basement membranes. congo red staining was negative. the em examination revealed fgn. conclusion: fgn must be included in the differential diagnosis of rapidly progressive chronic renal disease. em confirm the diagnosis of fgn, which suggests a poor outcome. objective: urachal carcinomas represent less than % of bladder-related cancers. most are adenocarcinomas, but urothelial, squamous and small cell carcinomas may occur. there are pathological criteria for assessing an urachal origin. a specific staging system is lacking for these tumors. method: a mass of the bladder dome was found in two and year-old men. a year-old woman presented an urachal cyst. ct-scan revealed no other tumors and partial cystecomy was performed. pathological examination showed partially cystic adenocarcinomas, one enteric type g , and two mucinous type g . two tumors extended into the bladder mucosa and one was limited to the urachal cyst. surgical margins were negative. immunostainings were positive for ck , ck , cdx , cytoplasmic beta-catenin, and negative for p . results: with a follow-up of , months and years, all patients are free of disease. conclusion: no tnm classification exists for urachal carcinomas. specific staging systems have been proposed by sheldon, and more recently by the mayo clinic. two cases are sheldon iiia/mayo clinic ii, and one sheldon ii/mayo clinic i. since stage, grade and surgical margins are the main prognostic factors, a clear and relevant staging system is needed for these rare carcinomas. objective: renal cell carcinoma (rcc) with two different histologies must be included in the unclassified group (who classification). whether these cases should be included in this histological subgroup or be considered hybrid rcc is a matter of debate. we report one of such cases in which papillary and chromophobe phenotypes meet. method: a cm in diameter asymptomatic left renal mass was discovered incidentally in the radiological follow-up of a breast carcinoma diagnosed years before in a yearold woman. follow-up showed right adrenal gland metastasis. patient died months later. results: grossly, tumor well circumscribed, tan-yellow, with haemorrhagic and necrotic areas. the neoplasm showed two different histologies clearly defined: one showed solid nests of polyhedral cells, with eosinofilic cytoplasm, central and hyperchromatic nuclei, occasional mitosis recapitulating chromophobe rcc. the other component presented a well defined tubulopapillary growth pattern typical of papillary rcc. focally sarcomatoid transformation, with tumor necrosis and chronic inflammation. by immunohistochemistry, chromophobe and papillary areas retained their specific phenotypes. conclusion: hybrid renal carcinomas do exist, but they are most probably hidden in the unclassified group of renal tumors. however, the exact histological context for which a renal neoplasm deserves the name "hybrid" remains to be defined. objective: renal cell carcinoma with thyroid-like follicular pattern is a rare histological subtype of renal carcinomas that has been very recently described. method: a . cm in diameter asymptomatic left renal tumor was discovered during the study of a macroscopic hematuria in a years old man. the lesion was organconfined. results: grossly, the tumor was a well circumscribed, solid, brown and homogenous intraparenchymatous nodule. proliferating cells were arranged in a microfollicular pattern with colloid-like material resembling thyroid adenoma. cells displayed low grade nuclear features and had eosinophilic cytoplasm. some areas showed a solid pattern of growth resembling an oncocytoid neoplasm. by inmunohistochemistry, the tumor was negative for thyroglobulin and ttf , and positive for ema, ck , ae /ae , and ecadherin. conclusion: renal cell carcinoma with microfollicular thyroid-like features has been very recently identified in the literature. there is no agreement on the exact nature of this neoplasm so far, and the who classification of renal tumors still does not consider this phenotype as a distinct histological subtype. anyway, the tumor must be distinguished from metastatic thryroid carcinoma, another quite unusual condition. evidence for clonal fibroblast proliferation and autoimmune process in idiopathic retroperitoneal fibrosis l. cheng * , j. clevenger, a. lopez-beltran * indiana university, dept. of pathology, indianapolis, usa objective: we sought to determine if idiopathic retroperitoneal fibrosis is clonal process and if it is an autoimmune, or igg -driven, process. method: thirty cases of idiopathic retroperitoneal fibrosis, in whom known causes of retroperitoneal fibrosis were excluded and those for which paraffin blocks were available, were included in this study. we performed clonality analysis in female patients. genomic dna samples were prepared from formalin-fixed, paraffin-embedded tissue sections using laser capture microdissection. results: eight of information cases ( %) showed nonrandom x-chromosome inactivation, or a clonal process. of the patients for which igg analysis was performed, ( %) were positive for igg -positive plasma cells and all were negative for alk. of the patients, for which both clonality analysis and igg analysis were performed, were clonal and igg negative ( %), were clonal and igg positive ( %), were nonclonal and igg positive ( %), and were nonclonal and igg negative ( %). conclusion: our data indicate that a significant proportion ( %) of idiopathic retroperitoneal fibrosis cases in females is associated with a clonal expansion of fibroblasts. in addition, a subset of idiopathic retroperitoneal fibrosis cases could be classified in the igg -related sclerosing disease spectrum. although a conclusive association with malignancy, urologic disorder, or systemic disease has not been established, often the lesion carries a challenging clinical differential diagnosis that includes malignancy. we examined clinical and histopathologic characteristics in patients. medical records were assessed for presentation, clinical diagnosis, associated urothelial carcinoma, radiation treatment, tobacco use, immunologic/urologic disorder, and treatment strategy/outcome. results: the mean age was (range - years). presenting symptoms were: pain ( %), hematuria ( %), and dysuria ( %), in contrast to asymptomatic ( %). clinical diagnosis favored malignancy in % of cases. concurrent or subsequent urothelial carcinoma was present for five patients ( %), though none developed urethral carcinoma. histologic features included mixed hyperplastic urothelial and squamous lining, overlying a variably fibrotic, edematous, inflamed, and vascular stroma. invaginations of urothelium extending into the stroma were common ( %), showing rounded nests with cystic or glandular luminal spaces, similar to urethritis cystica/glandularis, without intestinal metaplasia. two lesions included an organizing thrombus, one with intravascular papillary endothelial hyperplasia. twenty patients were treated with topical medications without resolution. three lesions recurred ( %) after excision. conclusion: urethral caruncle is an uncommon lesion that may clinically mimic benign and malignant conditions, making tissue diagnosis critically important. human papillomavirus (hpv) is not involved in urothelial tumorigenesis l. cheng * , r. alexander, a. lopez-beltran * indiana university, dept. of pathology, indianapolis, usa objective: the purposes of this study were to investigate the possible role of human papillomavirus in the development of squamous cell carcinoma of the urinary bladder and to determine if p expression could serve as a surrogate marker for human papillomavirus in this malignancy. method: forty-two cases of squamous cell carcinoma of the urinary bladder and cases of urothelial carcinoma with squamous differentiation were investigated. hpv infection was analyzed by both in situ hybridization at the dna level and immunohistochemistry at the protein level. p protein expression was analyzed by immunohistochemistry. results: human papillomavirus dna and protein were not detected in cases of squamous cell carcinoma ( %, / ) or cases of urothelial carcinoma with squamous differentiation ( %, / ). p expression was detected in ten cases ( %, / ) of squamous cell carcinoma and nine cases ( %, / ) method: a review of clinical data from an adpkd patient with tcc admitted in our hospital and a review of current literature regarding adpkd and tcc were made. results: the patient is a year-old woman with chronic renal failure due to adpkd, on hemodialysis for years. she was admitted with left lumbar pain, hematuria and fever. radiological exams revealed various complex cysts with dense material that did not enhance with contrast, compatible with hematic cysts in the context of adpkd. the whole clinical findings suggested cystic infection complicated with sepsis, so nefrectomy was performed. macroscopic examination of the ressected kidney revealed a white granulous nodular formation with . cm diameter in the renal pelvis. histological examination confirmed a highgrade papillary tcc with parenchymal infiltration (pt ) and extense scamous differentiation. conclusion: the present case illustrates that tcc can occur in adpkd, despite its rarity. it can be difficult to successfully diagnose tcc on adpkd based on clinical-radiological findings. objective: carcinoid tumor is a very uncommon neoplasm in the kidney. we report the histopathologic and immunohistochemical (ihq) study of two new cases. method: case : year-old female with a cm asymptom-atic¨cystic¨mass discovered in a routine exam. the patient underwent tumorectomy. case : year-old female with a cm renal mass who underwent left nephrectomy. two months later a needle biopsy confirmed carcinoid tumor metastasis in the liver. both patients currently free of disease. results: both tumors showed similar histologic features. neoplastic cells were grouped in nests, ribbons, and pseudoglands with rosette-like appearance and showed eosinophilic granular cytoplasm and chromatic nuclei. low mitotic index. ihc: diffuse/intense cytoplasmic staining for cd , cd , ae /ae , chromogranin and synaptophysin. conclusion: primary renal carcinoid tumor is rare in the clinical practice. the histological findings correspond to a well differentiated neoplasm and are similar to carcinoid tumors in other locations, which makes the diagnosis feasible even without previous personal experience. ihc confirms the diagnosis. it usually behaves as a low grade neoplasm, but recurrences and metastases do occur. only single cases and short series have been published so far. there is no accumulated experience to establish long term prognosis. prostatic adenocarcinoma occurring simultaneously with large cell neuroendocrine carcinoma of the urinary bladder: an extraordinary collision tumor p. czapiewski * , m. sieczkowski, m. matuszewski, k. krajka, w. biernat * medical university of gdansk, dept. of pathology, poland objective: radical cystoprostatectomy is a standard surgical procedure for male patients with muscle-invasive urinary bladder (ub) carcinoma. vast majority of these tumors are urothelial carcinomas, while large cell neuroendocrine carcinoma (lcnec) is a very uncommon tumor with less than reported cases. invasive prostate carcinoma is incidentally detected in up to % of cystoprostatectomy specimens. it is usually well differentiated and shows low propensity for dissemination and local recurrence. method: clinical and pathological description of an extremely rare collision tumor composed of lcnec of the urinary bladder and a high grade acinar prostate carcinoma. results: a -year-old male patient was admitted to the urology department due to severe gross haematuria. cystoscopy revealed large tumor of the posteriorinferior wall of the ub with involvement of the left uretheral orifice. in the radical cystoprostatectomy specimen lcnec of the ub, involving bilaterally prostate and spermatic vesicle (pt a), was diagnosed. additionally both lobes of the prostate were involved by the acinar prostatic carcinoma (pt c, gleason score + = ). conclusion: high-grade prostate carcinoma may rarely coexist with ub tumors of uncommon histology. objective: despite of numerous researches in the field, data regarding immunohistochemical (ihc) expression of androgen receptor (ar) in prostate carcinomas, in terms of prognosis and therapy, are quite controversial. method: the ihc expression of ar was analyzed on groups, each of primary diagnosed prostate carcinomas: localized, locally advanced and distant metastasized. the anti-ar antibody (clone ar ) was used. for each tumor was determined the percentage of ar-positive nuclei, assigning a staining score ( to ). a value of % was considered to be discriminat o r y b e t w e e n t u m o r s w i t h h i g h a n d l o w a r expression. results: all the analyzed carcinomas showed ar. . % of tumors had high ar expression and . % showed low ar expression. / localized tumors (one tumor vanished during processing), / locally advanced and / distant metastasized tumors showed high ar expression (p= . ). / well-differentiated, of moderately differentiated and / poorly differentiated tumors showed high expression of ar (p= . ). conclusion: although not reaching statistical significance, the ar expression tended to correlate with the stage of disease and with the degree of differentiation in terms of an increased expression of ar in advanced, moderately and poorly differentiated tumors. objective: prostate lesions with atypical stromal component are rare and poorly characterized in terms of evolution and prognosis. method: we retrospectively analyzed cases of unusual prostate tumors diagnosed on prostate needle biopsy. the biopsies were performed due to an elevated serum psa and/ or phenomena of bladder outlet obstruction. for the immunohistochemical (ihc) diagnosis there were used the following antibodies: ck ae /ae , psa, psma, vimentin, sma, er, desmin, pgr, cd . results: two of the three patients, one and the other years-old, with serum psa level of ng/ml and . ng/ml respectively, were diagnosed with sarcomatoid carcinoma, the former presenting with liver metastases at diagnosis. in evolution, the death of the first patient occurred months after the diagnosis and the second patient refused surgery. the third patient, years-old, with a nodular prostatic mass of . cm, was clinically suspected to have an unusual malignant prostatic tumor considering that, despite his ng/ml of serum psa, he presented multiple bone metastases. the histopathological diagnosis was stromal tumor of uncertain malignant potential. conclusion: the prostate lesions with atypical mesenchymal component are rarities in urologic pathology. an accurate diagnosis relies on meticulous pathological examination techniques and supplemented, for rare cases, with other clinical and laboratory data. immunohistochemistery study in a case of nephrogenic bladder adenoma m. r. farzaneh * , a. safaei, a. amin shareefi * shiraz, iran objective: nephrogenic adenoma is a rare benign lesion of bladder that may be confused with malignant lesions. there is strong relation with urinary tract irritation and intravesicl instrumentations. nephrogenic adenoma was initially thought to originate from urothelial metaplasia however no solid proof is available. method: we present this years old lady with urinary problem. cystocopic examination show a sessile mass and biopsy show circumscribed proliferation of tubules, cysts, and papillae lined by cells with low cuboidal to columnar epithelial cell. nephrogenic adenoma can be a significant diagnostic pitfall as certain histological features, such as the presence of enlarged nuclei with prominent nucleoli results: immunohistochemistery study showed strong reactivity to ck , p s, cd , and ema but negative for ck , psa, and p . conclusion: we recommend that any lesion in cystoscopic examination should be followed and immunohistochmistery examination some times is mandatory to differentiate them from malignant tumors. regulators of apoptosis and the cell cycle are overexpressed in bladder cancer metastases and may predict survival a. fleischmann * , r. seiler, a. perren, t. george * universität bern, institut für pathologie, switzerland objective: expression of biomarkers and their prognostic relevance may differ between primary tumours (pt) and its metastases (met). there is little information about this phenomenon concerning apoptosis and cellcycle associated biomarkers in urothelial bladder cancer (ucb). method: nodal positive patients (n= ) with ucb underwent cystectomy and lymphadenectomy. immunohistochemical expression of bcl- , bcl- , mdm- , p and cyclind was quantified in tissue microarrays constructed from pt and corresponding nodal met. results: frequency of mdm- positivity increased from pt ( %) to met ( %, p < . ). this trend was not significant for bcl- (pt: %; met: %, p= . ) and bcl- (pt: %; met: %, p= . ). median percentage of p and cyclind immunostained cells increased significantly (p< . ) from pt ( %/ %) to met ( %/ %). mdm- and cyclind expression were positively correlated in pt (p< . ) and met (p< . ). p and mdm- positivity were inversely correlated in pt (p< . ). only high cyclind expression in the metastases predicted early death significantly and independently (p= . ). conclusion: biomarkers of apoptosis and cell-cycle associated are up-regulated in the metastases indicating differences in survival and proliferation of cancer cell compared to primary tumours. both tumor components may harbor different prognostic information and are not necessarily surrogates for each other. evaluation of histopathologic and histomorphometric changes of testicular tissue and gonadotropins levels following consumption of methylphenidate in male mice z. ghahri saremi * , s. fazelipour, z. tootian, m. shafii * tehran, iran objective: one of the most common psychiatric disorders in children is adhd (attention deficit hyperactivity disorder), which is treated extensively by methylphenidate. this study investigates the assessment of the effects of methylfenidate on histopathologic and histomorphometric changes of testes and serum level of gonadotropin in adulthood which produces gametes and has importance for future generations. method: in this study adult male mice (balb/c) were used. after determining the body weight, the animals were divided randomly into two experimental groups of and one control group. the experimental groups received ritalin via gavage as follow: the group received mg/kg/day and the group received mg/kg/ day for a period of days. after evaluation of body weight, general anesthesia was used for taking blood samples from the heart in order to measure gonadothropins levels in serum. then for the purpose of body weighing and measuring of diameter of germinal epithelium the testes were removed and the possibility of any pathologic changes was considered. results: the results showed that methylphenidate with different doses could decrease germinal epithelium and also body weight significantly. besides some significant changes in serum gonadotropins, without any pathological changes were observed. conclusion: our findings demonstrated that methylphenidate administration in adulthood due to influence of enhanced computed tomography and magnetic resonance imaging was characterized as × × cm sized welldemarcated left renal middle-superior polar mass with central necrosis and cystic changes. the contralateral kidney was normal. he underwent left radical nephrectomy by thoracoabdominal approach. gross examination of the specimen revealed yellowish white × × cm sized mass, with multifocal necrozis and cystic changes. histopathology of these resection specimens; scattered spindle cells and foam cells, fine vascular network and necrosis. immunohistochemistry revealed cd -positive xanthoma cells. the tumor also stained positive for vimentin, cd , but negative for cytokeratin, ema, desmin, sma and myod . a diagnosis of mfh was made. conclusion: mfh is a primitive mesenchymal tumor with some histiosytic and fibroblastic differentiation primary renal mfh is an extremely rare lesion. because this malign mesenchymal tumor is indistinguishable clinically and radiologically from renal cell carcinoma diagnosis and histopathology of this rare lesion are discussed. hyaline ring granulomas in the urinary bladder: a case report n. hammer * , n. gatt, j. de gaetano * swatar, malta objective: hyaline ring granulomas, or pulse granulomas, are rare inflammatory responses to vegetable matter, characterised by aggregates of hyaline rings and other inflammatory components around vegetable matter. the vast majority occur in the oral cavity and only a few specific extra-oral cases have been reported. we present a case of pulse granulomas in the wall of the urinary bladder, occurring in a year-old gentleman with a concurrent history of diverticulitis and colo-vesical fistula. pulse granulomas were recently described in the bladder in association with interstitial cystitis, in mesocolonic fat and mesocolonic lymph nodes in association with inflammatory bowel disease and in enterocutaneous and recto-salpingeal fistulas in association with diverticulitis. to our knowledge this is the first case reporting the direct association of the occurrence of bladder pulse granulomas in relation to diverticulitis. method: the tissue sections were fixed with % buffered formalin and stained with h&e. results: histopathological examination revealed several hyaline ring granulomas within the outer muscle layer and serosa of the urinary bladder, together with hyaline ring granulomata within the outer wall of the sigmoid colon associated with diverticula. conclusion: it is important to differentiate pulse granulomas from parasites, hyaline ring vasculopathy, granulomatous inflammatory disorders and even malignancy. objective: micropapillary carcinoma (mpc) is associated with poor prognosis, and may lead to immediate cystectomy irrespective of stage. we study mpc, with "classical" histologic features, to "stage-matched urothelial carcinoma (uca), not otherwise specified (nos)", and other uca with divergent differentiation to compare outcome. method: cases from patients with mpc, uca with squamous (sq) or glandular (gl) differentiation, small cell carcinoma (smca), and nested variant (neca) variant of uca were identified. histologic and clinical data including stage and outcome were collected. results: all groups show male predominance and similar age range. mpc showed the highest rate of nodal metastases (table ) . patients with mpc tumor volume of > % showed the highest rate of nodal metastases of all other subgroups. the majority of patients with mpc died, a large percentage from unknown causes. compared to mpc, sq showed similar presentation at higher stages and similar survival, but a lower propensity for nodal metastases. in our cohort, gl presented at lower stages, showed slightly better survival, and a lower rate of nodal metastases, when compared to mpc. our cohort included fewer cases of smca and neca. however, both patients with neca died of disease. conclusion: mpc, particularly when it represents > % of tumor volume, shows higher rate of nodal metastases than remaining subgroups, and is associated with a larger percentage of patient deaths. objective: müllerian-like stroma with er/pr expression is typical of renal mixed epithelial and stromal tumor and has been described in kidneys with obstructive pathology. wt overexpression is not reported in this setting. method: immunohistochemical study for er, pr and wt in autosomal dominant polycystic kidney disease (adpkd) (n= ), acquired cystic kidney disease (ackd) (n= ), xanthogranulomatous pyelonephritis (xp) (n= ), and renal lithiasis (rl) (n= ). controls: fetal (< w, n= ; > w, n= ) and adult autopsy kidneys (n= ). results: stromal er was found in % of adpkd, ackd, xp and rl; pr expression in % of adpkd, ackd and rl and % of xp, and nuclear wt in % of xp and rl. er were negative in % of controls. we found pr expression in % of fetal controls of second trimester. wt was negative in the stroma of adult controls ( %). % of fetal controls showed wt expression in the peripheral cortex. conclusion: er and pr expression is frequent in kidneys with chronic obstructive and inflammatory pathology. wt is expressed occasionally. more studies are needed to determine whether these findings are a consequence of renal obstruction or they are involved in its pathogenesis, as well as their potential therapeutic implications. telomerase expression in urothelial carcinomas of the urinary bladder: does it make sense for carcinogenesis or prognosis? d. kankaya * , s. kiremitci, k. zengin, c. tuygun, a. sertcelik * ankara university medical school, dept. of pathology, turkey objective: human telomerase reverse transcriptase (htert) has been reported as poor prognostic marker in several cancers. in the present study, we examined htert expression in urothelial carcinoma (uc) to investigate whether it has a role on the carcinogenesis or prognosis. method: immunohistochemistry was performed to detect htert protein expression in tisse microarray blocks consisting of cores of papillary uc (n = ) and infiltrating uc (n = ) cases. nucleolar staining was considered and staining scores (intensity × distribution) were determined. tumors were grouped as low or high in terms of histological grade, and as early (ta, t ), or late stage (t -t ) in terms of pathological stage. results: htert expression was significantly higher in the papillary uc group (p= . ). tumors in late stage were more likely to show low staining scores of htert (p= . ). no correlation was found with tumor grade and recurrence rate. no effect on survival.was detected. conclusion: these findings indicated an association of htert protein with early stage ucs as its expression significantly decreased with muscularis propria invasion. incidental multifocal renal cell carcinoma in graft nephrectomy with cellular rejection findings: concurrence of papillary renal cell carcinoma and renal carcinoma associated with xp . translocation d. kankaya * , s. kiremitci, a. ensari, a. sertcelik * ankara university medical school, dept. of pathology, turkey objective: malignancy represents the second main cause of death in renal transplant patients and increase markedly by years after transplantation. method: a year old male who has been on hemodialysis for months for chronic renal failure, underwent living kidney transplantation from his brother. he received immunosupressive therapy of siclosporin and prednisolon. twelve years later, due to the impairment of renal functions hemodialysis was started again and ultrasonography revealed chronic renal parenchymal disease. graft nephrectomy was performed with the pre-diagnosis of chronic rejection. results: macroscopic examination revealed two well-circumscribed tumor nodules with mm and mm in largest diameter. microscopically, both tumor nodules showed tubulopapillary organization. larger tumor consisted of clear cells with tfe positivity, whereas the small one showed eosinophilic cells with diffuse cytokeratin and amacr positivity, without any tfe expression. concurrence of papillary renal cell carcinoma and renal cell carcinoma associated with xp . translocation was reported. non-tumoral renal paranchyme revealed interstitial inflammation, tubulitis and transmural arteritis with fibrinoid necrosis compatible with type iii cellular rejection. conclusion: as far as we know this is the first case in the english literature demonstrating concurrence of papillary renal cell carcinoma and renal cell carcinoma associated with xp . translocation in a graft nephrectomy. the effect of postoperative intravesical bcg and mitomycin c therapy on recurrence in superficial bladder cancer d. kankaya * , k. zengin, a. sertcelik, c. tuygun, n. sertcelik * ankara university medical school, dept. of pathology, turkey objective: to evaluate the efficacy of two mostly used intravesical agent, bcg and mitomycin c, in case of tumor recurrence. method: between and , we performed tur-bt to patients whom pathology results were superficial bladder cancer. patients were treated with intravesical bcg once for week weeks then monthly up to one year beginning from . day postoperatively. patients were treated with intravesical mitomycin c, beginning from first h postoperatively and once a week for weeks. patients didn't get any further treatment, and excluded from study. results: for bcg group, expected disease free interval was . months, and . months for mitomycin c group. when two groups compared for expected disease free interval, statistically significant difference observed (p= . ). for bcg and mitomycin c group, recurrence was seen in and patients, respectively. for patients treated with bcg, and years disease free survival rate was % . and % . , respectively. in mitomycin c group and years disease free survival rate was % . and % . . conclusion: intravesical adjuvant bcg maintenance therapy is more effective for tumor reccurence than intravesical mitomycin c therapy. papillary cystadenomas of the epididymis: case presentation p. katafygiotis * , l. abou-asabeh, a. nomikos, s. chranioti * hospital of voula, dept. of pathology, athens, greece objective: papillary cystadenomas of the epididymis are rare, first described by sherrick in . they are considered hamartomatous lesions rather than neoplastic and may be seen as intrascrotal swellings in a wide age range. we report here the case of a -year-old male who presented with a swelling of the right testis over the past year. his past medical history was otherwise unremarkable. method: ultrasonography revealed the presence of an epididymal cyst. grossly the cyst had a cm diameter with a cyst wall of . cm thick attached to a part of epididymis measuring × cm filled with clear fluid. results: histologically the cyst showed pseudopapillary structures lined by monotonous clear cells. there was mild nuclear pleomorphism, no mitotic activity and no necrosis. immunostaining for ae /ae , ema, were positive, as well as focally for ck / whereas calretinin and cea was negative. similar pattern of staining was seen in the epididymal parenchyma. conclusion: papillary cystadenomas are benign neoplasms and there have been no reports of recurrence or metastasis in the recent literature. bilateral disease is often associated with von hippel-lindau syndrome. our patient received no further treatment and remains asymptomatic and well months after the intervention. effect of neoadjuvant sorafenib treatment on histology of clear cell renal cell carcinoma and occurrence of circulating tumor fragments g. kats-ugurlu * * umc st. radboud, dept. of pathologie, nijmegen, netherlands objective: clear cell renal cell carcinoma (ccrcc) generally presents with a micronodular phenotype (mp) due to high expression levels of vascular endothelial growth factor (vegf-a). earlier we have shown that mp is associated with shedding of multicellular tumor fragments (mtf) into the circulation and pulmonary metastasis. we hypothesized that vegf inhibition will destroy mp resulting in less mtf. method: ccrcc patients were treated for weeks by daily administration of sorafenib ( mg bid). three days after therapy, nephrectomy was performed and kidneys were perfused via the arteria renalis. venous perfundate was filtered and processed to agarcytoblocks for mtf. treatment effects were studied using immunohistochemistry. results: all tumors were ccrcc as demonstrated by high vegf-a expression. none of the tumors showed mp after sorafenib treatment. tumors showed large areas of necrosis and fibrinoid necrosis of the blood vessels, concomitant with profound perivascular inflammation. / ccrcc patients ( %) had mft vs % in a control group (p= . fisher's exact test). individual tumor cells in the mtfs showed increased mitotic activity. conclusion: sorafenib destroys mp in ccrcc, attacks tumor vasculature, causes extensive necrosis and inflammation. post-treatment mtf are increased in venous perfundate. care should therefore be taken with neo-adjuvant sorafenib treatment of ccrcc. objective: claudins are major transmembrane proteins of tight junctions. as the disruption of their function have important impact on tumorogenesis, invasion and metastasis. claudins became a focus of interest for targeting therapies. although their expression profiles have been studied in many organs, researches on claudin expression in bladder are in limited number. the aim of this study is to present the differential expression of claudins in invasive urothelial cell carcinoma (iucc), noninvasive papillary urothelial carcinoma (npuc), carcinoma in-situ (cis), papillary urothelial neoplasm of low malignant potentiall (punlmp) and control group (cg). results: cases ( iucc -further divided into: muscle invasive ucc, ucc with lamina propria invasion-, npuc, punlmp, cis and cg) were evaluated with claudin- , , . interestingly, high claudin- and - score in cg ( %, %), decreased significantly in all non-invasive lesions (mean %, %). claudin- expression appeared to decrease in iucc vs. others (% vs mean % ). conclusion: higher expression of claudin- in low-grade and non-invasive lesions may be used as a diagnostic tool. in terms of claudin- and - , their decreased expression in non-invasive lesions when compared to cg and their trend to show more increased expression in iucc needs to be studied further in larger studies. can we rely on alternative sampling method of radical prostatectomy specimens? t. d. kokenek-unal * , a. s. oguz-erdogan, m. alper * yb research and training hospital, dept. of pathology, ankara, turkey objective: prostatic adenocarcinoma is the most common cancer and second leading cause of cancer death in men. the incidence of prostate cancer has been increasing because of efficiency of modern cancer scanning programs and residual awareness of the patients. for that reason, there is a considerable increase in the number of prostatectomy specimens in the university and research hospitals.it is costly and time-consuming procedure and causes in turn increased workload. the aim of this study is to compare the results of total and alternative sampling methods and to delineate the differences if there are any. method: totally embedded radical prostatectomy specimens were randomly selected and evaluated for key pathologic parameters. these cases then were reevaluated with limited sampling. the limited sampling method was built to include similarly embedded apical margins, bladder neck margins and seminal vesicles. in addition to that new slices were selected by skipping every other slice as differently from totally sampling protocol. results: the % reduction was achieved in number of blocks. the concordance rates between two sampling methods were % , % . , % . , and % respectively for gleason scores, perineural invasion, extraprostatic extension and pathologic stages. conclusion: although the limited sampling protocol provides statistically significant results, because of critical role of pathological assessment in treatment of prostatic adenocarcinoma, they can be found unsatisfactory for many pathologists. objective: initially described in embryonic neuroepithelium, nestin is an intermediate filament involved in cell differentiation and transiently related to vimentin, keratin and glial fibrillary acidic protein (gfap). in tumoral and vascular proliferation, nestin is recognized in stem/progenitor cells. the octamer-binding transcription factor (oct- ) is a biomarker of this lineage. since there are few data concerning the presence of nestin in leydig cells and testicular tumors, our aim was to investigate a series of leydig cell hyperplasia and tumors. method: cases ( hyperplasia, adenomas, malignant leydig cell tumors and lymph node metastases) and controls were immunostained with anti-nestin, vimentin, keratin, gfap and oct- antibodies. results: twenty-six ( %) cases (tumors and hyperplasia) were nestin positive with mostly weak, finely granular cytoplasmic staining. four ( %) were negative, ( %) not interpretable. vimentin was expressed in twenty-seven ( %) cases. seventeen ( %) were focally keratin positive. only three ( %) showed oct- positivity. all were gafp negative. conclusion: in leydig cell hyperplasia, adenomas and malignant tumors nestin and vimentin are expressed frequently, sometimes with keratin. this would be a sign of epithelialmesenchymal transition. further investigations are needed to understand the relationship with the malignant potential of these tumors. morphological changes of testis in atherosclerosis n. krupnov * , a. astrakhantsev * bureau of forensic medical exp., ryazan, russia objective: up to now in the field of morphology of reproductive system of men the problems of testis involution and morphogenesis at atherosclerosis haven't been thoroughly investigated. we have investigated histologically testis of died patients aged - with general atherosclerosis and testis of men aged - with minimal manifestations of atherosclerosis died in an accident. results: the absolute volume rete testis of patients being ill with atherosclerosis decreases by - %. absolute volume of convoluted seminiferous tubules and interstitial tissue decrease by - %. in testis there are zones of focal sclerosis of seminiferous tubules, whose area goes as far as . % of shear section area. it was revealed that on the periphery of sclerosis zones there is a reduction of transaction area of seminiferous tubules by - % with sertolli cells quantity reduction by - %. it has been stated the downward changes in index of spermatogenesis in convoluted seminiferous tubules by - . %, accounted for the quantity reduction of all kinds of cells. conclusion: morphological changes of testis at general atherosclerosis characterize atherosclerotic testiculopatie, caused by chronic ischemia of testis. a leydig-cell tumor in a cryptorchid testis: report of a case e. lambropoulou * , a. datsis, p. morfaki, g. charalambopoulou * general hospital of messologhi, dept. of pathology, greece objective: leydig cell tumor is a rare form of testicular neoplasm, representing only - % of all testicular tumors. according to accepted medical knowledge, this type of tumor isn't linked to cryptorchidism, unlike germ cell tumors of the testicles. herein, a case of leydig cell tumor in a cryptorchid testis is described. method: a -year-old, unmarried man was admitted for surgical repair of inguinal hernia. his past medical history included untreated bilateral cryptorchidism first noted in childhood, as well as poliomyelitis that presented at age two. the past surgical history and review of systems were noncontributory. a ct scan of the abdomen and pelvis revealed two × cm testicles at the level of the inguinal canal. he underwent bilateral inguinal orchiectomy combined with surgical repair of his inguinal hernia. results: the right testis contained a solid, well-circumscribed, round, tan-colored tumor . cm in diameter. the histological appearance was that of a leydig cell tumor exhibiting no mitotic figure. there was no clinical or radiological evidence of metastatic spread. conclusion: although cryptorchidism is considered to be a risk factor for developing germ cell tumors, there have been a few reported cases of leydig cell tumors with a history of cryptorchidism. our case adds to the evidence that there may be a link between the two conditions. objective: cd , e-cadherin, β-catenin are "cell adhesion molecules" and appear to influence development, inflammation, cancer invasion and metastasis. we studied the expression of these cams in prostatic adenocarcinoma (pca), high grade prostatic intraepithelial neoplasia (hgpin) and nodular adenomatous hyperplasia (nh). method: specimens of radical prostatectomies were assessed. these cams were determined by immunohistochemistry. all sections included pca, hgpin, and nh. the expression of these markers was evaluated with three scores. the correlation of immunopositivity with gleason score and tnm stage was investigated. results: cd was strongly expressed in . %, . % and . % of nh, hgpin and pca, respectively. e-cadherin immunostaining was higly detected in . %, . % and . % of nh, hgpin and pca areas while β-catenin immunostaining was exclusively membranous in . % of nh and nuclear/cytoplasmic in . % and . % of hgpin and pca areas. all markers were unrelated to gleason score (p= . ). cd and e-cadherin immunopositivities were inversely associated with tnm stage (p= . and p= . respectively); such an association was not observed in β-catenin (p= . ). conclusion: cd and e-cadherin decreased expression is probably associated with invasive potential of prostate cancer. β-catenin staining pattern in neoplastic lesions differs from that in non-neoplastic prostate lesions. results: the loss of ecad expression was significantly higher at the tif when comparing with tscp and nnm. the loss of ecad was correlated with histological grade, infiltrative pattern, lymph node metastasis, perineural and vascular invasion. the vimentin expression showed association with histological grade, infiltrative pattern, t stage, lymph node metastasis, perineural and vascular invasion. conclusion: the loss of ecad and the gain of vimentin expressions occur more frequently at the tumor invasion front and are associated with classic factors of poor prognosis and low survival rates. prognostic value of immunohistochemical markers in bladder cancer i. m´sakni * , a. chaabane, f. bougrine, b. laabidi, a. bouziani * rades meliane, tunisia objective: the tumor stage and grade of bladder tumors are the major elements to define the prognosis. however, it is sometimes difficult to identify an infiltration of chorion or detrusor muscle. moreover, the evaluation of tumor grade is subjective and not reproducible. method: our objective is to study the prognostic value of the expression of proliferating cell nuclear antigen (pcna), ki antigen, the tumor suppressor gene p , the protooncogene c-erb b , the receptor for epidermal growth factor (egf-r), the apoptosis suppressor gene bcl , carcinoembryonic antigen (cea) and epithelial membrane antigen (ema). results: the study showed that the pcna expression was significantly associated with the early recurrence (p= . ) and the tumor stage (p= . ). the mib expression was correlated to the early recurrence (p= . ), and tumor progression in stage and/or grade (p= . ). the c-erbb expression showed significant association with the tumor grade (p= . ). the prognostic value of other markers has not been proven. conclusion: these findings may be useful providing better classification of bladder tumors thus the better management of patients. the c-erbb expression contributes to refine the tumor grading. pcna and mib can predict the early tumor recurrence; they could be relevant for the determination of endoscopic controls rhythms of patients. objective: primary urinary bladder neuroendocrine carcinoma (pubnec) is a rare tumor characterised by an aggressive behaviour and poor prognosis. method: we report five cases of pubnec diagnosed in the departement pathology of farhat hached hospital between and . results: our population is composed by four mens and a woman. all patient are heavy smokers. the most common presenting symptom is hematuria and dysuria in all cases. one patient presented a complete urinary retention. a cystoscopic examination with transurethral resection was performed in all cases. the pathological examination with use of immunohistochemical markers of neuroendocrine differentiation were consistent with a large cell neuroendocrine carcinoma in four cases and a small cell neuroendocrine carcinoma in a case. a cystoprostatectomy was made in two cases followed by chemotherapy. conclusion: the clinical presentation of pubnec is similar to other bladder cancers and is characterized by advanced stage at diagnosis and rapidly progressive disease. the diagnosis of poses several problems: a vesical metastasis has to be excluded and such lesions have to be differentiated from transitional cell carcinoma, lymphoma, paraganglioma and peripheral nerve neuroblastoma. there is no gold standard for the management of patients affected due to low disease frequency ps- - igg -associated inflammatory pseudo-tumor (ipt) of the ureter: a case report a. marando * , g. d´ambrosio, f. catanzaro, f. sessa * university of insubria, dept. of surgical, varese, italy objective: igg -associated inflammatory pseudo-tumor (ipt) is a novel clinico-pathologic entity characterized by intensive infiltration of igg -positive plasma cells, associated with systemic igg -related sclerosing disease. many reports described igg -related ipt in various locations such as pancreas, salivary glands, liver, breast, lung and recently also ureter. method: it is described a case of ureteral ipt with pathologic and immunohistochemical features of igg -related ipt, fibrohistiocytic type. results: the study case is a -year-old female with severe stenosis of the left ureter and hydronephrosis, who underwent to nephroureterectomy and endoscopic resection of multiple lesions in the bladder. the histological examination showed transmural fibrosing inflammatory lesion of the affected ureteral wall, with abundant plasma cells intermixed with many histiocytes, lymphocytes, fibroblasts and scattered eosinophils. the majority of infiltrating plasma cells were positive for igg . bladder lesions showed similar histological features. the diagnosis was igg -related ipt, fibrohistiocytic type. conclusion: igg -related ipt of ureter is extremely rare, with only few cases reported in literature. recognition of this entity is clinically relevant because this type of ipt can be treated with steroid therapy and may be associated with sclerosing autoimmune disease in other organs. a rare case of malignant fibrous histiocytoma of the urinary bladder s. mavropoulou * , z. tatsiou, i. amplianitis, p. nasos * general hospital, laboratory of pathology, xanthi, greece objective: malignant fibrous histiocytoma (mfh) is an extremely rare malignant mesenchymal neoplasm of the urinary bladder with only a few well-documented cases reported in the english literature. method: we report the case of an -year-old man who was brought to our hospital due to sudden massive haematuria. catheterization failed to obtain haemostasis so, a suprapubic incision and direct exploration of the bladder was performed. a large solid tumor was found with a shaggy haemorrhagic surface and biopsies were taken. results: histological examination revealed an infiltrating malignant neoplasm composed of variably pleomorphic ovoid neoplastic cells with eosinophilic cytoplasm, bizarre tumor giant cells and prominent stromal osteoclastic giant cell reaction. immunohistochemical examination was negative for cytokeratin, desmin, smooth muscle actin, psap, nse, s protein and hmb whereas it was positive for cd in a large number of tumor cells. accordingly, the diagnosis of undifferentiated pleomorphic sarcoma with histological features compatible with giant cell mfh of the urinary bladder was made. the patient died days after the diagnosis. conclusion: in conclusion, mfh of the bladder should be kept in mind when facing with an undifferentiated malignant tumor. despite the poor prognosis, early diagnosis and aggressive salvage therapy might offer the chance of long-term survival in selected cases. partial nephrectomy experience at a single tertiary-care oncology centre: a clinicopathologic study of cases s. menon * , g. bakshi, h. tongaonkar, v. noronha, a. joshi, k. prabhash, s. desai * tata memorial hospital, dept. of pathology, mumbai, india objective: partial nephrectomy (pn) is replacing radical surgery as a gold standard in the treatment of small renal masses. intra-operative frozen consultation for margin status is aimed at achieving a disease free state in order to reduce chances of recurrence. method: a retrospective clinicopathologic analysis of consecutive pns performed at our institute from to was undertaken. results: sixty cases of pn were analysed. male to female ratio was . : . median age was years. six cases were benign: oncocytomas ( ), angiomyolipoma ( ); while cases were malignant: renal cell carcinoma (rcc) -conventional ( ), papillary ( ), chromophobe ( ), mucinous tubular spindle cell carcinoma ( ) and one case of primitive neuroectodermal tumour. in patients, the renal tumour was a second malignancy. median tumour size was . cm with cases of stage pt . intra-operative margin was positive in cases. mean margin for all cases was . mm. median follow-up was of months. none of the tumours recurred or metastasized during follow-up. conclusion: conventional rcc is the commonest histology in pn cases. frozen section analysis has a definite role in achieving margin free status. pn is not associated with increased risk of local recurrence in small renal tumours. clear cell tubulopapillary renal cell carcinoma: a clinicopathologic study of two cases g. muñiz * , a. corominas, n. cerda, a. perez, v. caamaño, m. gonzalez, l. etxegarai, j. i. lópez * hospital universitario cruces, dept. de anatomía patológica, barakaldo, spain objective: cleal cell tubulopapillary renal cell carcinoma has been recently identified as a low grade renal cell tumor with distinct histological features. method: patient : year old female with a history of fibromyalgia and persistent loin pain. a right renal mass, . cm in diameter, was discovered in the rheumatologist's follow up. right nephrectomy was performed and the patient is free of disease months later. patient ; year-old female with a history of diabetes mellitus type , hypertension and renal failure grade with a . cm in diameter renal tumor in the routine studies. she underwent tumorectomy. results: grossly, both were cystic tumors with gelatinous fluid and white-yellowish solid areas. tumors showed a tubular and papillary architecture. proliferating cells displayed clear cell cytoplasm and hyperchromatic nuclei placed in the luminal side. ihc showed positive staining with e-cadherin, ema and ck . conversely, cd , cd and amacr were negative. conclusion: clear cell tubulopapillary renal cell carcinoma should be considered a distinct subtype of renal cell carcinoma according to its unique morphologic and inmunohistochemical features. the few cases reported so far behave in an indolent course. survivin expression in renal epithelial tumors: its usage in the differential diagnosis of eosinophilic renal epithelial tumors a. ozcan * , n. yigit, o. onguru, b. a. firat, s. ozaydin * gulhane military medical academy, dept. of pathology, ankara, turkey objective: the differential diagnosis of renal tumors can be problematic due to overlapping morphologic features. the purpose of this study was to assess the potential contribution of survivin expression in the differential diagnosis and determination of therapy modalities of these tumors. method: this study consisted of chromophobe (chrcc), clear cell (ccrcc) and papillary (prcc) renal cell carcinomas, and oncocytomas. sections were stained against survivin antibody. results: prccs and ccrccs showed diffuse and strong survivin expression. survivin expression was strikingly prominent in type prccs and cystic ccrccs. in ccrccs, survivin expression was more pronounced in low grade areas than high grade and sarcomatoid areas. in chrcc, survivin expression was more limited and weaker than that of oncocytomas and other malignant renal tumors. in non-neoplastic renal tissue, survivin expression was more pronounced in podocytes and atrophic tubules than other nephron parts. conclusion: our findings suggest that survivin may contribute to the differential diagnosis of renal tumors because of the partially unique staining patterns. it was purposed that knockdown of survivin reduced growth, induce apoptosis and enhance in vitro radiosensitivity of rcc cells. taken together, to be known different survivin expression patterns in renal tumors may help to determine new therapeutic strategies for rccs. objective: there are several tumor-like lesions and miscellaneous neoplasms of rete testis. we present a case with adenomatous hyperplasia of rete testis (ahrt). method: the patient was years old with undescended testis and referred to our hospital. there was no clinical or endocrin abnormalities. cryptoorchidism was unilateral and the other testis was normal. right orciectomy was performed and sent to pathology labarotory for examination. results: there was no tumoral lesion in gross examination but in microscobic examination there was gland like tubular structures. some of these were back to back position with little intervening stroma and mild to moderate atypia. ema and pancytokeratin immunohistochemistry findings with morphology confirmed the diagnosis of ahrt in this case. conclusion: ahrt is a rare proliferatif lesion and can be confused with malignancy. it is incidentally realised in microscobic investigation. it may present as a very small lesion detected in microscobic examination or solid-cystic mass lesion which is macroscobically evident. clinic history, localization, histologic features and immunohistochemistry are criterias for differentiating these lesions.we present this case for both surgeons and pathologists with its importance to be confused with malignancy. objective: prostate cancer is the second leading cause of death in men. the localized disease often responds to conventional therapies like androgen ablation via castration and/or administration of chemical inhibitors but advanced disease resistant to any curative therapies is still challenge for investigators. there are increasing efforts to enhance the possibility of finding positive and sensitive immune markers for diagnosing and treating prostate cancer. method: we applied immunohistochemical markers; amacr and inos. formalin-fixed parafin embedded tissues of prostate needle biopsy specimens diagnosed as prostate adenocarcinoma between and years were enrolled in the study. results: amacr expression has been found in ( . %) and inos expression in ( . %) of prostate adenocarcinomas.no significant relationship of amacr and inos has been obtained (p> . ). there was no significant correlation of histopathologic grade of the tumors with amacr and inos expression (p> . ). conclusion: the expression of amacr and inos might be important diagnostic immune markers for prostate adenocarcinomas especially in needle biopsies when the quantity and quality of tissue are limited. a tissue microarray study of napsin-a expression in renal tumors a. panizo * , f. j. queipo, j. j. sola, j. pardo * hospital de navarra, anatomia patologica, pamplona, spain objective: napsin-a is an aspartic protease present lung, renal, and thyroid cells. there are few studies evaluating napsin-a in renal neoplasms. therefore, we studied ihc expression of napsin-a in a wide spectrum of renal tumors. method: ihc for napsin-a (rabbit polyclonal antibody) was performed in a series of cases of primary and metastatic renal tumors on tma. cytoplasmic immunoreactivity was scored: intensity ( - +) and extent (% of tumor cells: - ). the scores were added: positive case: combined ihc score> ; negative if combined score of or less. objective: the diagnosis of prostatic carcinoma can be challenging on needle core biopsies. the aim of this study was to assess the utility of alpha-methylacyl-coa racemase (amacr/p ) antibody cocktail for prostate cancer diagnosis. a prospective analysis of consecutive radical prostatectomy specimens and prostate needle biopsy semples was performed to select histological sections showing foci of minimal prostatic carcinoma, high grade prostatic intraepithelial neoplasia (hgpin) and benign mimickers of prostatic carcinoma (atrophy, adenosis). method: serial histological sections were stained with hematoxylin and eosin, van gieson and immunomarkers: amacr and p using a prediluted antibody cocktail. results: the cocktail was very useful in highlighting prostatic carcinoma associated with hgpin (flat or cribriform) and distorted foci of minimal carcinoma. amacr was positive with moderate and strong staining in almost all cases for which the immunohistochemical result converted the atypical diagnosis to a final cancer diagnosis. the cases whose diagnosis was changed from "atypical" to cancer were all highly suspicious for cancer based on he histology and negative basal cell markers. conclusion: this cocktail would be of diagnosis utility when limited tissue is available for histopathological evaluation of small diagnostically difficult foci (prostate needle biopsy and surgical specimens). overexpression of cytokeratin , ki- and topoisomerase-ii-a can significantly stratify the recurrence risk in patients with bladder cancer after transurethral resection s. petrov * , k. malkhasyan, r. khasanov * kazan cancer center, dept. of pathology, russia objective: the current predictive models based on main clinical tumor features are not accurate for the biggest bladder cancer patient group, who underwent the transurethral resection (tur). method: overall patients with primary urocarcinoma after tur were included in this retrospective study. the follow up plan in all cases included cystoscopy and biopsy every months in the first years. the recurrence criteria were cystoscopical and pathological confirmation of the tumor growth. in all cases using tma technique (tma master, dhistech) there was done the ihc expression study of p , p , ck , e-cadherine, b-catenin, cd v , ki- ( % cut-off), topo-ii-a ( % cut-off) and her , as well c-erb-b amplification study (cish). results: there were no association found between the her expression and c-erb-b amplification in urocarcinoma patients. in multivariate regression analysis only ck , ki- and topo-ii-a showed the significant prognostic power in recurrence prediction. these markers were used to develop the powerful predictive index for bladder cancer patients after tur. conclusion: although the her overexpression is relatively common event in bladder cancer, c-erb-b gene amplification isn't main mechanism of its realization. the ck , ki- and topo-ii-a are promising prognostic markers for recurrence and should be validated in further prospective study. solitary fibrous tumor of the urinary bladder associated with a high-grade urothelial invasive carcinoma. a case report a. pitino * , s. squillaci, c. spairani, m. ferrari, m. f. cosimi, w. fusco, c. rossi, f. montefiore, g. l. bigatti, v. la paglia * san giacomo hospital, division of anatomic pathology, novi ligure, italy objective: solitary fibrous tumor (sft) is an unusual spindle cell neoplasm, which can exceptionally occur in the urinary bladder. method: we present a case of urinary bladder sft in a year-old man who complained of pelvic pain. cystoscopy revealed a large protruding, fleshy mass at the anterior wall of the bladder. a biopsy was first misclassified as inflammatory myofibroblastic tumor (imt). subsequent complete transurethral resection was performed. results: macroscopically, a × × cm greyish lobulated firm polypoid tumor was seen. microscopically, it consisted of uniform spindle cells with elongated tapered ends nuclei forming a patternless growth in a collagenous background. mitotic figures were rare. immunohistochemically, the neoplastic cells were positive for cd and bcl- , and negative for α-sma, desmin, ck ae / ae and alk- . the bladder urothelium showed foci of high-grade transitional carcinoma with lamina propria invasion. conclusion: initially, sfts were thought to be of mesothelial origin. then, these tumors have also been observed in extrapleural and extraserosal sites, which suggests a mesenchymal cell origin. the differential diagnosis should always include other spindle cells lesions such as sarcomatoid carcinoma, leiomyosarcoma and imt. to date, this is the first reported case of association of urinary bladder sft and high-grade urothelial invasive carcinoma. renal oncocytomas with unusual features: clinicopathological study of cases f. j. queipo * , h. d. quiceno, f. j. pardo, Án. f. panizo, m. l. gómez-dorronsoro, g. aisa, f. j. monzón, e. mejía, c. del agua, j. alfaro * clínica universidad de navarra, pathology, pamplona, spain objective: oncocytoma (ro) is a benign renal neoplasm, with a wide morphologic spectrum and excellent prognosis. recently, it has been described worrisome morphological features. method: ro treated in our centres were reviewed, and we focused on identifying the worrisome and the atypical features. results: we identified ro with at least one of the worrisome feature. patients: m/ f (mean age , year; range: - ). mean tumor size: , cm (range: , - , cm); right kidney: , and left: cases. invasion into the perinephric or renal sinus fat was the most frequent worrisome feature: tumors ( , %) and focal chromophobe carcinoma-like areas in cases ( , %). lymphovascular invasion, entrapped renal tubules-glomeruli, necrosis and mitosis were found in ( , %) respectively. all but two ros had at least worrisome features. followup was available for all cases (median months; range - ): all patients were alive without recurrence or metastasis. conclusion: ro is a tumor which often can show worrisome and atypical morphology. it is necessary to know and recognize the worrisome features to prevent diagnostic errors, if otherwise typical oncocytoma morphology is present. despite these atypical morphological data, the prognosis is excellent. ki and p expression in urothelial carcinomas and clinicopathologic correlation a. ribeiro * * chlc, epe, serviço de anatomia patológica, lisboa, portugal objective: the most important predictive parameter for the biological behaviour of urothelial carcinoma is histological grade, except for depth of invasion. the aim of this study was to investigate the expression of p oncoprotein and ki antigen in a series of transitional cell bladder carcinoma with papillary morphology (ptapapillary carcinoma and pt ) with histological grade and recurrence. method: this study included cases diagnosed with urothelial carcinoma with papillary morphology (pta, pt ). immunohistochemical expression of ki and p were examined in each case, and were graded accordingly to the percentage of cells stained, in low, moderate and high-expression groups. results: as described previously in other publications the expression of p and ki has a relationship with histological grade. we also noted that of the recurrences, were associated with moderate to high expression of either p or ki , or both. conclusion: we concluded that p and ki expression combined with histological grade and pathological stage may be helpful in assessing more accurately the biological behaviour of urothelial carcinoma. and the overexpression of p and ki are related with an unfavourable prognosis. objective: prostatic stromal hyperplasia with atypia is a rare lesion with fewer than cases reported worldwide. it can be mistaken for sarcoma because of the presence of atypical, bizarre cells. its malignant potential is uncertain. the follow up study of every case is important. method: a -year-old man with previously diagnosed atypical prostatic adenostromal hyperplasia with atypia of stromal cells was hospitalized with urinary obstruction after transurethral resection of prostate made years ago. repeat turp was performed and tissue specimens were investigated and compared with the initial biopsy. results: the second biopsy showed the benign hyperplastic prostatic glands with atypical, bizarre, frequently multinucleated giant stromal cells between them. they displayed intense immunoreactivity for actin, vimentin and androgen receptors. the microscopical picture was identical to that seen in the first specimens. the nuclear abnormalities looked like in an atypical symplastic leiomyoma of myometrium. no evidence of sarcomatous or carcinomatous transformation, mitotic index evaluation was noted. conclusion: this case maintains the viewpoint that the prostatic adenostromal hyperplasia with stromal cell atypia is a benign lesion. but it can recur and requires the repeat turp or radical surgery. cancer risk in patients with precancerous lesions of the prostate y. rogov * , v. zakharava, t. liatkouskaya, e. cherstvoy * belarusian medical academy, dept. of pathology, minsk, belarus objective: prostatic intraepitelial neoplasia (pin) and atypical small acinar proliferation (asap) has a high predictive value as markers for prostate cancer (pca). method: pca-risk in patients with precancerous lesions has been assessed on biopsy material in patients having morphological suspicious to pca. suspicious foci were estimated with use of cocktail amacr + hwc + p . results: according to our results revealing of precancerous lesions in biopsy specimens has been associated with pca identification in re-biopsies (f= , ). within the first- years the overall incidence of pca in re-biopsies made % in the group of precancerous lesions and %in the asap group. life-time-without-pca median made up -years with no reliable difference between pin and asap groups (ww= , ; p= , ). thus, the cumulative share of patients without pca in the asap group formed %- %- %- %- % at the end of the first-second-thirdfourth-fifth year of supervision respectively. conclusion: within the first years pca risk makes % in the general group of precancerous lesions of the prostate and % in asap group with no difference between asap and pin groups. Сumulative share of patients without pca in rebiopsy specimens decreased from % to % during these years. benign prostatic hyperplasia and prostate carcinogenesis after the chernobyl accident in ukraine a. romanenko * , a. chekalova, a. yurakh, p. harkonen, s. vozianov * institute of urology, kiev, ukraine objective: the prevalence as well as immunohistochemical (ihc) study of latent, incidentally found prostate cancer (lpc) as well as precancer lesions, in patients, who underwent surgery for bph were studied. method: bph samples were obtained by prostatectomy from ukrainian patients consisting of patients from areas without radio-contamination (control group ) and of patients living in cs contaminated areas of ukraine (group ). ki- , p , p kip- , p and bcl- proteins were ihc investigated in bph from all patients. results: the incidences of lpc (gleason score ), chronic prostatitis, pia and pin were . , . , , and . % in group ; . , . , . and . % in group , respectively. greatly elevated levels of p , ki- , bcl- associated with decreased levels of p kip- and p in areas of pia and less lpc and pin in group to compare with group patients were obtained with statistically significant differences. conclusion: our study suggests that chronic long-term lowdose radiation exposure might result in the increase of chronic inflammation and it is now found to be associated with increased incidences of pia and pin in bph accompanied by p , p kip- and bcl- alteration which in turn could lead to prostate carcinogenesis. eosinophilic globules in rete testis mimicking yolk sac tumor in a testicle with seminoma e. ronne * , t. argyrakos, d. rontogianni * evangelismos hospital, dept. of pathology, athens, greece objective: the recognition of a non-seminomatous component in an otherwise typical testicular seminoma changes the choice of adjuvant chemotherapy. method: a -year old male underwent orchiectomy for a testicular mass. serum tumor markers levels (β-hcg/afp/ ldh) were normal. results: macroscopical examination revealed a . cm white-yellow tumor. the tumor was composed of the characteristic for seminoma homogenous, clear cells arranged in nests and islands separated by septa and infiltrated by lymphocytes. immunohistochemically the tumor cells were positive for plap, oct / , cd and d - and negative for cd and ck . . there was also a regular pattern of tubular structures infiltrated by the seminoma cells while retaining a low columnar type epithelium. the presence of sphaerical eosinophilic globules (pas+/dpas+/afp−) within the tubular lumina was strongly reminiscent of the hyaline globules of yolk sac tumor. the tubular structures were positive for ck . and negative for afp, glypican- and oct / . conclusion: the presence of tubular structures with sphaerical eosinophilic globules creates a suspicion for a yolk sac tumor component. the absence of afp and glypican- expression, the regular pattern of the tubular structures and their continuity with rete testis excluded this suspicion. hyaline eosinophilic globules in rete testis should not be confused with the globules produced by yolk sac tumors. beta-catenin expression and ctnnb mutations in a series of wilms tumours r. santi * , p. pinzani, f. salvianti, g. baroni, m. pepi, g. nesi * university of florence, pathological anatomy section, italy objective: ctnnb mutations have been found in - % of wilms tumour (wt) cases. nuclear beta-catenin protein has been detected by immunohistochemistry in a higher proportion of wts, thus suggesting alternative genetic pathways leading to beta-catenin activation in these neoplasms. method: sixteen renal wts and secondary wt localizations were retrospectively investigated. the series included paediatric patients, females and males, with a mean age of . years and a year-old female patient. immunohistochemical analysis of beta-catenin was performed and findings were reported for each neoplastic component (i.e. epithelium, stroma and blastema). tumour dna was extracted for direct sequencing analysis. results: the majority of wts showed moderate to strong membranous staining for beta-catenin in the epithelial ( . %) and the blastemal ( %) components. nuclear betacatenin expression was observed in combination with cytoplasmic staining in the mesenchyma and/or the blastema of two primary renal tumours. in these cases the deletion of codon p.s del and the missense substitution p.t a were detected. conclusion: preliminary results of this ongoing study highlight beta-catenin cytoplasmic and membranous expression in the tumour cells of primary and metastatic wts, with few cases demonstrating nuclear expression. in our series, betacatenin nuclear expression was invariably associated to ctnnb mutation. a preliminary study on o -methylguanine-dna methyltransferase and type transglutaminase expression profile of renal cell carcinomas b. sarsik * , b. pehlivanoglu, d. tunali, a. simsir, e. gokmen, s. sen * ege university, faculty of medicine, izmir, turkey objective: o -methylguanine-dna methyltransferase (mgmt) repairs o -methylguanine in dna, therefore provides a tumor supressor effect. type transglutaminase (tgase- ) is a multifunctional enzyme involved in many biological processes. few data are available in the literature on their expression in kidney cancers. in this preliminary study, we evaluated immunohistochemical expression of mgmt and tgase- in renal carcinoma cases. method: forty cases of renal carcinoma including ten clear cell, ten chromophobe cell, ten papillary and ten urothelial carcinoma were randomly selected. thirty-one patients were male and average age was , . staining intensity and percentage of staining tumor cells were scored. total score was categorized as weak, moderate and strong. results: strong mgmt positivity was demonstrated in cases ( %). eight cases ( %) showed strong tgase- expression. fifty percent of clear cell carcinomas strongly expressed mgmt and tgase- . no correlation was found between mgmt and/or tgase- expression, tumor size and grade. eighty percent of urothelial carcinomas strongly expressed mgmt. conclusion: the prognostic value of mgmt and tgase- as well as their potential role in treatment response have been investigated recently. mgmt and tgase- may be prognostic factors in renal carcinomas. further investigation is required to verify our findings. three dimensional topographic analysis of cases of radical prostatectomy a. n. seo * , k. s. lee, g. choe * seoul national univ. bundang, pathology, seongnam-si, objective: prostate cancer is typically mutifocal, and there has been no report about the exact number of prostatic carcinomas in each case. we have performed topographic analysis using three dimensional mapping technique. method: we established data base including cases of radical prostatectomy consisting of individual adenocarcinomas, and performed comprehensive pathologic analysis. objective: tmprss -erg gene fusion is the most common genetic alternation in prostate cancer. it is associated with the expression of oncogene erg protein. recently, the immunohistochemical staining method that using anti-erg antibody was verified strong correlation with erg protein which is the product of genetic alteration. aim of this study is to declare that the relationship between erg expression and clinicopathological factor. method: otal cases of radical prostatectomy specimen were assessed. all cases were constructed tissue microarray and immunohistochemical staining was performed. results: erg-positive rate was . % ( / ) and significantly higher expression of erg expression was observed in the subgroup that has lower gleason score. (p< . ) analysis with the histologic pattern of prostate adenocarcinoma, tumors with discrete glandular unit (gleason pattern ) is shown higher frequency of erg expression (p= . ). conclusion: erg-positive case was smaller than that of western population (about %) and other factors including age, tumor volume, initial psa level, pathological stage and margin status were not significantly related with erg expression. in conclusion, positive rate of erg immunohistochemical staining is meaningful higher in the tumors with wellformed gland that is represented by lower gleason score. solitary fibrous tumour of the kidney mimicking renal cystic neoplasm t. tichy * , j. skarda * university hospital olomouc, institute of pathology, czech republic objective: solitary fibrous tumour (sft) can develop at any anatomic site, but in the kidney is described rarely. in general, sft forms an unencapsulated solid mass. we report a case of a -year old woman with benign sft of the left kidney. the tumour showed extensive pseudocystic change and mimicked renal cystic neoplasm. method: a nephrectomy specimen showed cystic tumour beneath renal capsule and in peripelvic adipose tisssue. histological sections were used for hematoxylin-eosin and for immunohistochemistry (antibodies against vimentin, smooth muscle actin, desmin, s- protein, cd , cd , bcl- , cd , ck , ae -ae , ema). results: microscopically the tumour showed uniform spindle cell proliferation with expansive tumour margins, without necrosis or hemorrhagies. mitotic activity was per high power fields. cystic spaces without epithelial lining contained eosinophilic proteinaceous fluid. imunohistochemically tumour showed difuse positivity for cd , cd , bcl- , vimentin and stained negatively for s- protein, cytokeratins, ema, smooth muscle actin, desmin and cd . conclusion: sft of the kidney is infrequent. some renal sft can undergo pseudocystic transformation and mimic renal cystic neoplasm both clinically and macroscopically. objective: renal angiomyolipomas are mesenchymal tumors that comprised of adipose tissue, smooth muscle like cells and abnormal thick walled blood vessels admixed in various proportions. epithelial renal angiomyolipomas are rare variants and may exhibit atypia. in the literature epithelioid renal angiomyolipomas with atypia are reported to have malignant potential. method: left radical nephrectomy was performed due to renal mass with flank pain and hematuria. results: in gross examination; . × . × cm gray white mass with occasionally necrotic areas at the middle portion of left kidney renal sinus and perinephritic fatty tissue, macroscopically. microscopic eveluation reveals; tumoral lesion comprised of adipose tissue, smooth muscle and blood vessels, showing areas of epitheloid morphology and moderate to severe degree of nuclear atypia. in addition to histomorphology positivity hmb- immunohistocemistry elaborated to the diagnosis of "epitheloid renal angiomyolipoma with atypia". conclusion: this case has been presented due to its infrequent occurrence and malignancy potential. correlation of minute focus of prostate adenocarcinoma on random multifocal needle biopsy with radical prostatectomy specimen a. urbanskiy * * russian research centre for ra, pathology, st. petersburg, russia objective: this work attempts to determine the importance of small foci of prostatic cancer in random multifocal needle biopsy specimens. method: patients with a microscopic focus confined to a single core specimen (which defined as tumor less than mm with a gleason score of or less) were identified from a retrospective review of needle biopsies of the prostate. twelve of these subsequently under went radical retropubic prostatectomy at our centre. clinically significant tumors were defined as those with volume greater than . cc. results: average tumor volume was , ± , cc (range , - , cc). in , % ( ) of the cases was less , cc (range , - , cc, mean volume - , ± , cc). there was ( , %) of patient with extraprostatic extension. conclusion: our data have shown high frequency of revealing insignificant tumours (mean ± %; Р= , ). however, about % of patients had clinically significant tumors warranting definitive therapy. the smallest focus of cancer on needle biopsy is not a guarantee of a clinically insignificant tumor. ps- - e-cadherin in mice: expression in normal urothelium, pre-neoplastic and neoplastic urothelial lesions c. vasconcelos nóbrega * , c. costa, r. arantes-rodrigues, a. henriques, h. vala, a. colaço, l. santos, c. lopes, p. oliveira * escola sup. agrária viseu, dzerv, portugal objective: e-cadherin is an adhesion molecule that promotes the integrity and stability of the urothelium. a decrease in its expression is associated with more aggressive tumour phenotypes, with the ability to invade and metastasize. our aim was to describe the expression of e-cadherin in normal urothelium and in urothelium with pre-neoplastic and neoplastic lesions of icr male mice. method: urothelial lesions were chemically induced by nbutyl-n-( -hydroxybutyl) nitrosamine in icr mice, and evaluated by immunohistochemistry in order to determine the staining pattern of e-cadherin. results: in normal urothelium, . % of e-cadherin expression was at the cellular membrane level. in simple hyperplasia, the same pattern was observed in . % of lesions. nodular hyperplasia exhibited a mixed pattern ( % membrane and % cytoplasmic pattern). in . % of dysplasia, a cytoplasmic pattern was seen. on invasive carcinoma the majority of invasive urothelial cells exhibited a pattern of membrane and cytoplasmic staining. on squamous metaplasia it was observed a membrane pattern on basal and intermediate layers, and a loss of immunoreactivity in the most superficial ones. conclusion: e-cadherin is a valuable tool for investigating the cellular adhesion status of the urothelium in mice. neoplastic lesions exhibited an abnormal, heterogeneous staining pattern. new potential prognostic and predictive factors in conventional clear cell renal carcinoma p. latalova * , p. flodr * fmd pu and fh olomouc, dept. of clinical and molecular pathology, czech republic objective: biological behavior of conventional clear cell renal carcinoma (ccrc) is associated with tumour stage and grade. cancer progression with metastasis is part of a process epithelial-mesenchymal transition (emt) and is joined with invasiveness due to adhesion and cytoskeleton change. the central role of the emt mechanism is attributed to snail factor. the intermediate filament expression is changed through the progression of many types of neoplasms. these changes are organ or tissue specific and depend also on the degree of malignant transformation (genome instability acceleration). the expression changes of cytokeratin (ck ) are signs of aggressive biological behaviour in some tumour types -e.g. colorectal and breast carcinoma (downregulation of expression) or ccrc (upregulation of expression). the expression of snail and ck molecules and mrna ck levels correlate to stage and grade of ccrc (according messai et al. ) . objective: study was based on the expression of immunohistochemical markers (ck , ck , vimentin, snail, cd ) in cases with evaluation of the primary tumour and its metastasis. results: the difference and similarity of intensity and percentage of positive neoplastic population between the primary and the secondary carcinoma will be presented. conclusion: snail and ck seem to be potential tumour progression factors and may be included in so called personalised medicine. objective: sarcomatoid carcinoma (sc) of the prostate is a rare variant of prostatic cancer representing less than % of prostate tumors. tumors are most commonly composed of an admixture of both malignant glandular and spindle cell elements. the sarcomatoid component can vary from % to %. method: we report the case of a -years-old patient with an invasive tumor of the prostate for which he had a radical prostatectomy. histopathological examination showed that the tumor was responding to an undifferentiated proliferation made of beaches and clusters of pleomorphic cells usually spindle-shaped, with eosinophilic cytoplasm, and elongated or oval nuclei, which are very irregular, sometimes monstrous, multinucleated, basophils with numerous mitotic figures. in some places, there were areas of glandular differentiation and foci of comedocarcinoma. immunohistochemical study showed immunoreactivity of spindle and pleomorphic cells with cytokeratin and vimentin. results: the diagnosis of sarcomatoid carcinoma of the prostate-grade gleason + was confirmed. conclusion: sc of the prostate is an exceedingly rare tumor. retrospective analyses render prostate sc as one of the most aggressive prostate malignancies. the prognosis is dismal regardless of other histologic or clinical findings. extra-uterine extension (figo stage ii-iv) were significant parameters of poor prognosis. no multivariate analyses were performed due series limitation. conclusion: detailed pathology evaluation, including histological subtype, and figo stage are essential in the adequate management decision/prognosis evaluation of u-lms. objective: over % of women with endometrial cancer show signs of uterine bleeding, so most cases are diagnosed at an initial stage. this study covers two patients who presented the first signs of this disease in an exceptional manner. method: case- a -year-old woman was afflicted with a six-month toxic syndrome. an omentum tumor was identified in the x-ray. eleven days after the excision, she demonstrated oliguria, dysuria, and scant uterine bleeding. the pelvic ultrasound revealed a uterine mass. case- a -year-old woman demonstrated disabling right inguinal pain. after an x-ray examination of her pelvis, a metastasis was suspected. a biopsy confirmed it. the immunochemistry pointed to a gynecologic, pancreatic or intestinal tumor. the computer tomography scan revealed a uterine mass. results: the first case only suggested an estromal gastrointestinal tumor or a mesothelioma, misdiagnosing and missing the endometrial carcinoma. the second case was uncommon as bone metastasis is found with solid tumors but seldom occurs with endometrial cancer and even less so as a first sign. conclusion: we must consider endometrial cancer at signs of uterine bleeding, however, further investigation is required in order to consider the % who do not show the common signs. extrapelvic endometriosis presenting as a retroperitoneal tumor a. alves * , p. luís, a. ribeiro, m. ferreira * hospital santa maria, servico de anatomia patologica, lisboa, portugal objective: endometriosis is a benign disease characterized by the presence of functional endometrial tissue in ectopic locations. retroperitoneal, liver or kidney involvement are extremely rare. method: we present a case of a -year-old woman, which was referred to surgical consultation because of a retroperitoneal mass that was found on a routine abdominal ultrasonography (us). a subsequent ct scan showed a cm tumor involving the liver, right kidney and adrenal gland. the gynecological us revealed ovaries with normal size and two probable uterine leiomyomas. she was submitted to a tumorectomy with segmental hepatectomy and nephrectomy. results: grossly, the tumor was × × cm, invaded the kidney, the liver and a segment of diaphragm. it was white, fasciculate and with hemorrhagic focus. histologically the tumor was composed of a biphasic proliferation of endometrial glands and endometrial stroma, both without atypia. the case was diagnosed as deep infiltrating extrapelvic endometriosis. with a years follow-up, the patient is doing well and without evidence of disease. conclusion: despite being an extremely rare presentation, endometriosis can involve retroperitoneal organs and simulate a malignant neoplasm, even without a previous history of pelvic involvement. objective: malignant melanoma of the female genital tract is a multifocal disease resulting from a disorder of melanocytes cotyledonoid dissecting leiomyoma is a benign smooth muscle tumor which can mimic a malignant lesion due to its alarming aspect. there are some variant forms of leiomyomas with an unusual infiltrative growth pattern. due to its worrying appearance of the gross specimen, it is often mistaken for malignant lesion and it is important to be aware of this entity not to over treat this benign smooth-muscle neoplasm. we report a case of a years old woman who underwent hysterectomy because of the suspect of a tumor growing from the right lateral uterine wall. on gross study the tumor measured mm in diameter and was nodular, brown in color and irregular on cut section. histological examination showed a nodular tumor composed of smooth muscle cells with a storiform pattern which dissects the uterine wall. the tumor was highly vascularized, included a myxoid component and showed some areas with invasion of vascular components. cellular atypia, mitosis and necrosis were absent. the patient has had a good clinical course, without relapses until the date, what supports the fact that these tumors have a benign clinical behavior, even though they may have a malignant appearance. uterine leiomyoma with lymphoid infiltration a. n. deger * , c. kocak * s.b. dpu. kec. ea hastanesi, patoloji bolumu, kutahya, turkey objective: although leimyomas of the uterus are common, lymphoid infiltration of leimyomas is a rare occurrence. we presented a case of a -year-old woman whose leiomyoma was diffusely infiltrated by lymphocytes. lymphoid infiltration was analyzed with immunohistochemical methods and infiltration was found to be polyclonal type. method: a -year-old woman with abnormal uterine bleeding was prediagnosed uterine leiomyoma and she was applied total abdominal hysterectomy and bilateral salphingo-oopherectomy. the analysis of the sample sent to pathology lab showed two leiomyomas. hematoxylin eosin -stained slides were prepared after sampling. ımmunohistochemical stains were applied. results: microscopic examination of leiomyoma in greater diameter revealed a lesion with well-circumscribed borders composed of interlacing fascicles of bland monomorphic spindle cells diffusely infiltrated by lymphoid cells. the infiltrate not extended into the surrounding myometrium. immunohistochemical analysis showed positive staining with cd , cd , cd . it was seen that inflammatory infiltration was polyclonal and involved t cells, b cells and histiocytes. leiomyoma with lymphoid infiltration was diagnosed. the postoperative course was uneventful within a month follow up period. conclusion: leiomyoma with lymphoid infiltration first described in by ferry et all. from that date on, the literature involves few cases. because it is rare and differential diagnose with malignant lymphoma is crucial, we presented the case and reviewed the literature. objective: vulvar intraepithelial neoplasia is divided into two groups: usual type and differentiated type. the differentiated vulvar intraepithelial neoplasia, which is frequently seen with invasive squamous cell carcinoma, can be confused with some benign lesions. the aim of this study is to analyse p , p , and ki- expression characteristics of different histological types of vulvar intraepithelial neoplasia, invasive squamous cell carcinoma, and benign lesions of the vulva. method: in this study, immunohistochemical analysis of vulvectomy cases with p , p , and ki- was performed. results: of patients who underwent vulvectomy, nine had invasive squamous cell carcinoma and nine had vulvar intraepithelial neoplasia. four additional vulvar intraepithelial neoplasia lesions were found accompanying the invasive squamous cell carcinomas. nine benign lesions were found accompanying the invasive squamous cell carcinomas and vulvar intraepithelial neoplasia. mean ki- proliferation index was . % in the usual type of vulvar intraepithelial neoplasia cases and . % in the differentiated vulvar intraepithelial neoplasia cases. no p expression was present in benign lesions. conclusion: ki- pi does not recognize the usual type or differentiated type of vulvar intraepithelial neoplasia. p positivity can be of value in distinguishing differentiated type vulvar intraepithelial neoplasia from benign lesions. an audit of surgical pathology reports of endometrial carcinoma: experience from a referral centre in india k. deodhar * , b. rekhi, s. menon, b. ganesh * tata memorial hospital, dept. of pathology, mumbai, india objective: the aim was to see, compliance to minimum data information in carcinoma endometrium reports, in a team of pathologists; and also to analyze these parameters e.g. tumor size, type, grade, depth of myometrial invasion, lymph node yield, ptnm stage etc. method: during the period of - , from the files of pathology department of our hospital, reports of operated carcinoma endometrium cases were retrieved and analyzed for various, above mentioned, parameters. results: the median age was . years and median tumor size was cm. endometrioid adenocarcinoma was the commonest type ( . %); followed by mmmt ( . %) and serous carcinoma ( . %). grade was the commonest tumor grade ( . %). less than half of myometrial invasion was seen in % of the cases, =/> half myometrial invasion was seen in . % of cases. (information-not available in cases). parametrial involvement was seen in . % cases. the ptnm stage was not mentioned in . % reports. the median lymph node yield was . conclusion: the compliance to adhere to minimum data information in carcinoma endometrium reports is generally good. lymph node yield is reasonable. parametrial involvement and mentioning of ptnm staging is to be done more meticulously. use of proformas/checklists is recommended. extraovarian granulosa cell tumor: a case report i. efstratiou * , s. pervana, e. pazarli, d. alataki * papageorgiou hospital, dept. of pathology, thessaloniki, greece objective: extraovarian granulosa cell tumor is a very rare neoplasm. we report a case of a tumor located in mesocolon. method: a -years-old woman presented with abdominal pain and fever. abdomen ct showed a mesocolic mass adherent to the left kidney and the spleen. she underwent resection of a cm long segment of the left colon with a circumscribed mesocolic tumor measuring × cm. the tumor was infiltrating the subserosa of the large intestine. intraoperatively normal ovaries have been identified. results: histologically the tumor is composed by monomorphous cells in solid nests developing cavities which contain serous or hemmorhagic fluid. the tumor cells have scanty cytoplasm and often grooved nuclei. mitoses are very rare. the tumor cells were immunoreactive for vimentin, inhibin and progesterone receptors. the postoperative course was uncomplicated and the patient is free of disease months later. conclusion: light microscopic and immunohistochemical features of the tumor are similar to those of ovarian granulosa cell tumors (gct). since the tumor was resected in toto and the mitotic activity of the cells is very low, we expect a favorable prognosis. extraovarian gct are very rare and only cases have been published during the last years. probably these tumors arise from residual tissue of the genital ridge (so-called secondary mullerian system). detection of amplification of terc and tert genes in cytology samples from cervical neoplasias by fluorescent in situ hybridization a. farkasova * , e. kudela, t. balharek, p. zubor, j. danko, l. plank * jfm cu, dept. of pathology, martin, slovakia objective: increased telomerase activity represents an early event in cervical carcinogenesis allowing cell immortality by recovering chromosomal telomeres. thus, detection of terc and tert gene amplification might represent a diagnostic and valuable prognostic biomarker of cervical neoplasias. method: cervical smears from patients classified according to bethesda as nilm (n= ), asc-us (n= ), l-sil (n= ), h-sil (n= ) and scc (n= ) were analysed for terc ( q ) and tert ( p ) gene amplification by fluorescent in situ hybridization (fish) in cells per slide using a four-color fish probe (fhact™). results: the numbers of terc and tert copies, average ratio of gene copies and average number of cells with ≥ terc gene copies were highest in scc, followed by h-sil, l-sil, asc-us and nilm cases. correlation between terc/tert amplification intensity and oncocytological findings was statistically significant (p< . ). conclusion: fish analysis of terc and tert genes could be effective tool for the diagnosis of cervical neoplastic lesions. using together with cytology and hpv dna testing it can achieve higher sensitivity and specificity to discriminate h-sil and invasive carcinomas from l-sil lesions. objective: ovarian stromal hyperplasia (osh) is characterised by non-neoplastic overgrowth of the ovarian cortical. mild hyperplasia of the cortical and medullary stroma is found in the ovaries of about one-third of perimenopausal and postmenopausal women. it is nearly always diffusely bilateral. we report a case of osh associated with endometrial carcinoma (ec). method: a -years-old caucasian woman, obese, smoker, with fatty liver, gilbert´s syndrome and cholelithiasis. she had endometrial curettage biopsy for dysfunctional uterine bleeding for month, which was diagnosed of complex atypical endometrial hiperplasia. a total abdominal hysterectomy whith bilateral salpingo-oophorectomy were performed. results: the diagnosis was well differentiated endometrioid ec and bilateral osh with focal stromal hypertecosis. conclusion: osh of moderate to severe degree may be found in women with disorders associated with androgenic and estrogenic manifestations including ec, obesity, hypertension, and glucose intolerance, but these findings are less frequent and less obtrusive than in stromal hyperthecosis. obese woman are at risk for developing endometrioid ec as a result of the increased capacity in adipose tissue to convert androstenedione to oestrone, and testosterone to oestradiol. a relationship in the origin of hormone-dependent endometrial pathology may exist between osh, blood androgen levels and ec. detection of micrometastases in para-aortic lymph nodes in patients with carcinoma of the uterine cervix after negative frozen section analysis l.-c. horn * , c. kellner, r. scherling, m. höckel, j. einenkel * medizin. universität leipzig, institut für pathologie, germany objective: previous studies considered the presence of micrometastases (mm) in pelvic lymph nodes as clinically relevant prognostic indicator. method: frozen section analysis was performed in all cases. after fs-examination nodes were examined by one h&e-stained slide. all nodes without metastatic disease after frozen section and permanent section examination were subject of the present study. patients and pan were enrolled and immunohistochemical staining using two cytokeratin-cocktail antibodies (ae /ae and kl-) was performed. results: in one case, one single node showed micrometastasis, representing an incidence of . % of the studied cases and . % of the examined lymph nodes. in three cases benign endosalpingiosis was seen. the patient with mm is alive without evidence of disease months after surgery. itc were not observed. conclusion: the frequency of mm in pan is very low. there are only limited data regarding their prognostic impact within the literature. after careful examination of all removed pan using h&e-staining (and step sectioning), immunohistochmeical ultrastaging cannot be recommend for routine use. serous tubal in situ carcinoma (stic) in tubal and primary peritoneal carcinomas l.-c. horn * , k. leonhardt, s. kafkova, j. einenkel * medizin. universität leipzig, institut für pathologie, germany objective: serous tubal in situ carcinoma (stic) has been defined as one important precursor of pelvic serous cancer. morphologically, stic is defined by are cytologic atypia, high proliferative index and strong staining for p . method: the present study evaluates the presence of stic and p -signature in consecutive cases of prophylactic salpingo-oophorectomy in women with brca- -mutaion (bso), macroscopically inconspicuous tubes of patients with primary tubal cancer (tc) and cases of primary peritoneal cancer (ppc) using immunohistochemistry against ki- and p (clone do- ). results: the frequency of p -signature and stic was % and % in cases of prophylactic surgery, % and % in tc and % and % in ppc. conclusion: stic and p -signature as precursor lesions of pelvic serous cancer is seen in macroscopically inconspicuous fallopian tubes in unilateral tc in patients with elective bso and patients affected by ppc. we propose that the sectioning and extensively examining the fimbria protocol be applied to all cases with ppc, tc and in women with prophylactic bso. objective: primary adenocarcinoma of the vulva is rare, and enteric differentiation is excepcional. only a few cases of neoplasms of pure intestinal-type in the low genital tract have been reported. they are considered to arise from cloacal remants or from intestinal heterotopia. method: we present the case of a year-old woman, with a histerectomy performed years before. on clinical examination a polipoid lesion in the vulvar vestibule was noticed. biopsy revealed a tubular adenoma of intestinal type with a focus of adenocarcinoma. the first histologic interpretation was a metastatic intestinal tumor. clinical examination, recto-colonoscopy and magnetic resonance imaging of the abdomen excluded this possibility. results: the immunohistochemical study showed reactivity with citokeratin but didn't with citokeratin . all this led to conclude that it was a primary intestinaltype adenocarcinoma of the vulva arisen from an adenoma. conclusion: on our knowledge there are less than reported cases of intestinal adenoma in the genital tract. they have been described also in the vagina and cervix but only a few developed an adenocarcinoma. it is important to be aware of this tumor type and to distinguish it from metastatic colorectal adenocarcinoma in order to plan appropriate treatment. ligneous cervicovaginitis and endometritis: case report m. koyuncuoglu * , e. dogan * dokuz eylul university, dept. of pathology, izmir, turkey objective: ligneous (wood-like) disease is a rare chronic pseudomembraneous inflammation of the mucous membranes which may also affect genital tract. the underlying pathogenesis is still unclear and an effective method of treatment has not yet emerged. method: here we present a years old female patient presented to our clinic with years of unexplained infertility. her diagnostic infertility work-up revealed no abnormality. however, at gynecologic examination there was a thick and hard granulation tissue at the cervix extending to the posterior vaginal wall. transvaginal ultrasound was unremarkable except for increased endometrial thickness. results: cervicovaginal and endometrial biopsy with diagnostic hysteroscopy was performed which demonstrated ligneous inflammation of both cervix and vagina. endometrial biopsy was reported as chronic non-specific endometritis with dense fibrin deposition. conclusion:. the disease may also affect other organs including oral cavity and eyes. this unusual condition is difficult to treat and lack of awareness makes the diagnosis also problematic. objective: differential diagnosis lm vs stump may be controversial, especially regarding necrosis evaluation; few studies address the relation between different treatments and their morphological effects. we aim to characterize a series lms and putative stumps harboring necrosis. method: consecutive putative stumps ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and a series of lms with necrosis diagnosed at chsj & ipop-porto. clinical files, particularly previous hormonal treatment (ht), gross specimen and histology features. results: putative stumps and lms with necrosis. lms mean age at diagnosis: years; mean size: . cm ( . - ); % with other lms; treatment: myomectomy ( %) and hysterectomy ( %); % peri-partum, . % post-uterine artery embolization; ( %) previous ht: progestin ( %), oral contraceptive-oc ( %), hormonal-iud ( . %), and medical assisted reproduction ( . %). stumps mean age at diagnosis: years; mean size: cm ( . - ); % with other lms; low mitotic index-mi (mean . ; median / hpf); slight cell atypia; variable ischemic/ tumor-type necrosis. treatment: myomectomy ( %), hysterectomy ( %) and radiotherapy ( %); ( %) previous ht: progestin ( %), oc ( %), hormonal-iud ( %); no recurrence in remaining cases (n= ): median follow-up: . months. conclusion: lms with necrosis and stump may display overlapping features. diagnosis of stump should consider previous ht, detailed morphology (necrosis type/atypia/mi), to prevent overdiagnosis of stump. positivity. plap and chromogranin were negative. ki- nuclear positivity was found in less than % of sertoli cells and in about % of leydig cells in hyperplastic areas. karyotype was xy. conclusion: although, surgical pathologists encounter tfs rare in a clinical practice, they should be aware of this condition, especially in lack of relevant clinical data, when it could be interpreted as a tumor. objective: frozen section (fs) diagnosis of ovarian mucinous tumors can be difficult due to the size of these tumors, heterogeneity and potential risk of metastasis from gastrointestinal (gi) neoplasms. method: we reported ovarian mucinous tumors submitted for (fs) evaluation between january and avril was conducted. results: fs and final pathology results were collected. the average tumor size was , cm ( - cm). the fs and final pathology diagnosis were concordant in , % ( / ) of the cases. of the ( , %) discordant cases, one ( , %) was downgraded and cases ( , %) were upgraded. of the tumors interpreted as borderline mucinous tumors (bmt) on fs, ( , %) were malignant at final diagnosis ( ovarian, gi), ( %) remain as bmt and ( , %) was benign. of the benign tumors on fs, cases ( , %) were upgraded to bmt at final diagnosis. tumors with a malignant diagnosis on fs ( cases) were % concordant with final diagnosis. conclusion: our study showed a , % rate of discordance between fs and final diagnosis. given that gi origin is a possible finding, intraoperative assessment of the appendix should be performed in all mucinous ovarian tumors. uterine müllerian adenosarcoma: a clinicopathologic study of cases a. nasfi * , l. charfi, k. mrad, s. sassi, r. sellami-dhouib, r. doghri, m. driss, i. abbes, s. nechi, w. jomaa, k. ben romdhane * salah azaiez institute, dept. of pathology, tunis, tunisia objective: müllerian adenosarcoma (ma) is a distinctive type of uterine tumor, traditionally regarded as a low-grade variant of mixed müllerian tumors. method: thirty one cases of adenosarcoma were examined during a period of years (may -february . results: thirty tumors were of the uterine corpus and one of the cervix. the mean patient age was , years (range: to year). the main clinical manifestations were vaginal bleeding and pelvic pain. physical examination showed cervical/vaginal mass or pelvic mass. treatment was known in cases: patients underwent hysterectomy with bilateral salpingo-oophorectomy in cases and lymphadenectomy in cases. tumor size ranged from , to cm (mean: . cm). microscopically, sarcomatous overgrowth was found in cases ( %), heterologous elements in ( %). eleven cases ( %) had myometrial invasion involving the internal half of the myometrial thickness in cases, and more than % in cases ( %). the cervical tumor presented as an endocervical polyp without invasion of the cervical wall. conclusion: uterine ma are low-grade neoplasms capable of local recurrence and much less commonly distant metastasis. surgical excision is the main treatment strategy with a good prognosis in the early stage disease. the most important adverse prognostic factors are deep myometrial invasion and sarcomatous overgrowth. spectrum of epithelium changes in adenomyosis n. nizyaeva * , e. kogan, t. demura * scientific center of obstetric, dept. of pathology, moscow, russia objective: adenomyosis (am) is a very common gynecological disorder. despite high incidence of the disease epithelial changes precise developmental events leading to the condition remain controversial. the aim of the study was to investigate and compare epithelium morphologicaly and markers expression of proliferation, apoptosis, invasion and neoangigogenesis in am foci. method: this study was done on biopsy samples of uterus taken from women with adenomyosis. immunohistochemical staining of tissues was performed with antibodies to apocas, ki- , mmp- , timp- , claudins , (cl , ), e-cadherin, cox- , egfr, vegf. results: four variants of epithelium changes were found in am foci such as proliferative type, hyperplastic type with and without atypia, and atrophic type. times during years and investigated using routine light microscopy and immunohistochemistry (ihc) to control the treatment response. results: in the course of progestin treatment the complex endometrial hyperplasia with intraepithelial neoplasia became histologically less complicated and than normal. ihc profiles and ki- expression had the same dynamics. in the youngest patient the unusual gland cell atypia with focal calcification was observed one time and hysterectomy was considered. conclusion: the study confirms that the repeated curettages with conservative treatment and histological studying can be successfully used in some cases of complex endometrial hyperplasia with intraepithelial neoplasia. value of ki , p and ck markers in differentiating cervical intraepithelial neoplasia and benign lesions a. safaei * , m. pourjabali, f. sari aslani, m. momtahan * shiraz university of medical sciences, iran objective: the cervical cancer is one of the most common cancers among women worldwide. diagnosis of cin affected by high rates of discordance among pathologists. therefore, we need to other adjunct methods for accurate diagnosis of cin versus benign lesions in equivocal cases. the aim of this study was evaluation of ki- (mib- ), ck and p ink a (p ) markers by immunohistochemical method in differentiating cin from benign cervical lesions. method: seventy-seven cervical biopsies that originally diagnosed as non-cin (n = ) and cin (n = ), were reviewed by three pathologists and re-classified as non-cin (n = ) and cin (n = ), based on agreement between at least two of three, to obtain a consensus diagnosis. consensus diagnosis was defined as the "gold standard". then immunostaining for ki , p and ck was performed on all cases and their results were compared with original and consensus diagnosis. results: the overall agreement between original and consensus diagnosis was . % (kappa = . , p-value < . ). the sensitivity and specificity of ki immunostaining were . % and . % and for p were . and . %, respectively. the sensitivity and specificity of ck negative staining for cin detection were . % and . % respectively. conclusion: we recommended using ki and p markers as complementary tests for differentiation between dysplastic and non-dysplastic lesions. ps- - wt expression in ovarian borderline and malignant surface epithelial tumors m. tahamtan * , f. sari aslani, a. safaee * shiraz, iran objective: wilms tumor gene product, a tumor suppressor gene, now is considered to have oncogenic functions. there seems to be differences in wt expression among surface epithelial ovarian tumor subtypes. method: immunohistochemistry for wt was done on serous & mucinous cystadenocarcinomas, borderline serous & borderline mucinous tumors, endometrioid ovarian carcinomas, clear cell carcinomas, malignant brenner tumor, metastatic adenocarcinomas and endometrial adenocarcinomas. a tumor was considered negative if< % of tumor cells were stained. positive reactions were graded : +, - %; +, - %; +, - %; +, - %. results: of serous cystadenocarcinomaes, ( . %) were positive, showed reactivity of< % of the tumor cells and one were negative. all borderline serous tumors were positive. all mucinous tumors, endometrioid carcinomas, clear cell carcinomas, metastatic adenocarcinomas and primary endometrial carcinomas were negative. the single malignant brenner tumor were positive for wt . conclusion: wt is a good marker to distinguish primary ovarian serous carcinomas from other surface epithelial tumors (especially endometrioid subtype) and metastatic carcinomas (especially endometrial serous carcinoma), other than malignant mesothelioma. degree of expression is not an indicator to separate high grade borderline serous tumors from low grade ones. objective: fatwo is a rare neoplasm originating from the mesonephric duct remnants that occurs predominantly in the broad ligament but also in the ovary. it is considered a lowmalignant potential tumor. however local recurrences and metastases have been reported. method: a year-old female, on routine gynecological physical examination, followed by pelvic ultrasonography and computer tomography was diagnosed with a mass at the right ovary. a salpingo-oopherectomy was performed. on gross examination a well-circumscribed, solid and focally cystic tumor measuring , × × , cm arose in the ovarian hilus. results: microscopically the tumor consisted of mediumsized, ovoid to polygonal cells arranged in a solid, tubular and sieve-like pattern. some cystic spaces were lined by low-cuboidal cells and contained amorphous, eosinophilic material. cellular atypia and mitoses were rare. the tumor cells were positive for vimentin, inhibin-a (focally), cd , cytokeratins / , and (focally) and negative for cytokeratin , epithelial membrane antigen, carcinoembryonic antigen and a-fetoprotein. conclusion: histopathological and imunohistochemical findings consistent with an ovarian fatwo. differential diagnosis includes endometrioid carcinoma, clear-cell carcinoma, sertoli-leydig cell tumors (retiform variant) and rete ovarii adenoma. surgical excision is the optimal treatment. radiation therapy, chemotherapy or even targeting molecular therapy is questionable. müllerian adenosarcoma is a rare mixed tumor of low malignant potential. usually presented as a large endometrial polyp in postmenopausal women. they are associated with tamoxifen or radiation therapy. microscopy shows a mixture of benign glandular epithelium and low-grade endometrial sarcoma is typically concentrated around the glands. the differential diagnosis is made with the adenofibroma, but now is doubted the existence of this tumor and is considered more of a distinct adenosarcoma. the treatment is total hysterectomy. sisters of and years with a history of dysmenorrhea. hysteroscopy was performed to the eldest one, in which multiple polyps are observed and partially resected. the pathological diagnosis was mixed mullerian tumor, adenofibroma/adenosarcoma. total abdominal hysterectomy was performed. histological examination showed a mixed tumor with glandular component and a low-grade sarcomatous, scarce mitosis, mild atypia and no necrosis. the diagnosis was: mullerian adenosarcoma. a year later, a hysteroscopy and endometrial biopsy was performed to the youngest sister, that showed endometrial polyps with stromal predominance, and no significant atypia. with the diagnosis of mullerian adenosarcoma, and taking into account family history, total hysterectomy was performed. adenosarcoma is a rare tumor whose family presentation is not described in the literature. gliomatosis peritonei is associated with frequent relapse but not affects overall survival in patients with ovarian immature teratoma n.-r. yoon * * samsung medical center, dept. of pathology, seoul, republic of korea objective: gliomatosis peritonei (gp) associated with ovarian teratoma has known to have no adverse prognostic effect. we investigated the clinicopathological features of ovarian teratoma associated with gp, and compared immature teratomas (its) with gp to its without gp. method: we investigated patients with ovarian teratoma with gp and patients with it without gp, who were diagnosed at samsung medical center (seoul) from january to august . results: six patients with it with gp ( . % of patients) had recurrence. when it with gp (n= ) was compared to it without gp (n= ), patient of it with gp showed larger tumor size (median, cm vs. median cm) (p< . ), more frequent relapse ( %, / vs. . %, / ) (p= . ), and frequently elevated pre-operative ca level ( %, / vs. %, / ) (p= . ). survival curves showed significantly shorter relapse-free survival in patients of it with gp (p= . ). two-year relapse-free survival rates were . % and . % in it with gp and it without gp, respectively. however, all patients except one case of it with gp alive. conclusion: ovarian it with gp was characterized by larger tumor size and frequent elevation of preoperative ca level, and gp was associated with frequent relapse in patients with ovarian it. corelation between histopathologic diagnosis with p and ki immunostaining, cytologic features in cervical neoplasia c. altunkaya * , s. yilmaz, a. barin, s. ekici, g. s. yalcin, m. caydere, h. ustun * s.b ankara e. a.h, pathology, turkey objective: frequency of cervical carcinoma decreases nowadays since cytologic screening methods have been using extensively. the incidance of cervical intraepithelial neoplasia increases. cytologic diagnosis og these lesions are substantially important. so we aim to identify the role of p and ki immunostainings for predictive factors of cervical neoplasia. method: the study was conducted january to january . ninety-three cases (mean age , ; range - years) diagnosed as squamous intraepithelial lesions were included, objective: there are several prognostic factors in melanoma. it was suggested that her- expression may influence the tumor behavior. the aim of the study was to investigate the relationship of her- expression with various prognostic factors. method: her- expression was evaluated in melanomas, without metastases and with lymph node and with distant metastases. membranous, cytoplasmic and nuclear her- expression was separately analysed. the staining intensity and percentage of positive tumor cells were evaluated. results: the cytoplasmic staininig was seen in all cases, with average intensity of and percentage of positive cells ranging from % to % (mean . %). the percentage of cytoplasmic her- positive cells was inversely correlated with clark and breslow stage (r=− . and r=− . ). cytoplasmic her- reaction was significantly stronger in cases with lymph node metastases ( . vs. . p< . ). in cases a dot-like cytoplasmic reaction was seen. membranous positivity was seen in cases ( %). conclusion: her- may play a role in melanoma progression. it may be involved in lymphatic dissemination. further studies of prognostic significance of her-expression in melanoma are needed. hypopigmented mycosis fungoides with unusual vitiligolike presentation in child h. erdem * , n. buyukbabani, h. turan * duzce university, dept. of pathology, turkey objective: mycosis fungoides (mf) is the cutaneous t cell lymphoma. classical, clinical and histopathological findings of mf are detected in most of the patients. however, some of the patients have defined atypical mf. hypopigmented mf (hmf) is one of the atypical forms. hmf could be misdiagnosed with clinical and histopathological examination. hmf is considered mistakenly vitiligo. therefore, it should be considered differential diagnosis. mf is usually seen in the middle aged and elderly. the occurrence of mycosis fungoides in children is very rare. method: an -year-old girl child attended dermatology clinic with complaints of pruritus and hipopigmented patches. lesions was performed punch biopsy and reported hmf. conclusion: herein, this case presented because it was considered vitiligo as clinically and diagnosed hmfas histopathologically. reducing block sampling in wide local excisions for melanoma c. fives * , c.c.b.b. heffron * cork university hospital, dept. of histopathology, ireland objective: it is established practice that wide local excision (wle) is undertaken for the further management of cutaneous melanoma, however, definitive guidelines for macroscopic sampling have not been established. our aim was to determine whether our sampling of wle specimens was adequate, inadequate or excessive and to establish guidelines for these specimens. method: cases which underwent initial biopsy and subsequent wle in were identified. we recorded the specimen size, macroscopic appearance, number of blocks sampled and margins of the original biopsy. results: there was wide variation in the number of blocks sampled (range - ). residual melanoma was identified in of the cases ( . %) which had clear margins on the original biopsy. of these, had evidence of a pigmented lesion on macroscopic examination. the remaining cases had margins of mm or less on the original excision. no subsequent surgery was performed on these cases. conclusion: our study has shown that in wle specimens with no evidence of a macroscopic lesion and in which margins of the original biopsy were clear by greater than mm, little is to be gained from extensive sampling. reduced sampling would result in saving laboratory resources with a predicted % block reduction in our laboratory alone. functioning oxyphil adenoma of parathyroid gland: a case report m. genadieva -yordanova * , s. hristova, a. vlahova, g. todorov, b. miserliovska, s. yordanov * alexandrovska hospital, dept. of pathology, sofia, bulgaria objective: the most frequent cause of primary hyperparathyroidism are adenomas of the parathyroid gland, the majority of which are composed of chief cells. oxyphil adenomas are uncommon and account for % of functioning parathyroid adenomas. up until year they have been considered non-functional. method: laboratory findings revealed calcium levels of . prior to operation. the serum parathyroid hormone level was . pg/ml. a ct scan of the neck showed normal size thyroid lobes with heterodense structure with an oval hypodense lesion in the lower right pole of the thyroid. results: at surgery a mahagony-brown mass measuring mm in diameter was removed and reported as oxyphil adenoma on frozen section. histopathological examination revealed encapsulated adenoma composed of oxyphil cells with abundant, granular pink cytoplasm and a rim of normal parathyroid tissue. mitotic figures were absent. postoperatively, a decrease of the serum calcium down to . mmol/l was declared. the followup period was unremarkable. conclusion: there appear to be a growing evidence that a big part of oxyphil adenomas of parathyroid gland can produce parathyroid hormone and contribute to the cases of primary hyperthyroidism. effectiveness of uvb phototherapy on mycosis fungoides using histologic guitart criteria in iranian patients a. ghanadan * , a.-h. ehsani, h. seirafi, m. khiabani * tehran university, razi hospital, iran objective: mycosis fungoides (mf) is the most common primary cutaneous lymphoma. mycosis fungoides often develops slowly over many years, presenting with a generalized erythroderma, skin patches or plaques. the diagnosis of mf requires the integration of clinical and histopathologic findings. narrowband uvb (nbuvb) is widely used to treat mf. to evaluate the effectiveness of therapy the histopathologic findings before and after nbuvb reviewed using guitart criteria. method: we enrolled patients ( women, men; age range, - years; mean age, . years) with clinically and histologically proven mf. the patients received nbuvb phototherapy three times a week. a biopsy was performed months after onset of the treatment and guitart criteria used to scoring mf before and after therapy. results: phototherapy was reduced the primary intraepidermal atypical lymphocytes (p value= . ), dermal atypical lymphocytes (p value= . ), epidermotropism (p value= . ), density of infiltration (p value= . ) and lymphocytic infiltrate without inflammatory features (p value = . ) in all patient. but the relationship between the reticular fibroplasia of papillary dermis and phototherapy was not proved (p value= . ). overall score of patients was significantly lower after phototherapy (p value= . ). conclusion: our data suggest that nbuvb therapy is reduces histiologic score of mf and is effective for the treatment of iranian patients. nodular colloid degeneration of the skin: report of three cases a. ghanadan * , k. kamyab-hesari, m. daneshpajouh, k. balighi, m. khosravi * tehran university, razi hospital, iran objective: nodular colloid degeneration (ncd) is a rare dermatological disorder and also a rare type of colloid milium. the degeneration may be related to sun exposure. method: three cases of ncd were enrolled from the archive of dermatopathology department of razi hospital during - . results: in this report, three cases, all presented with multiple plaques and nodules in the nose and the face, are depicted. histologically, these nodular masses were homogeneous, with eosinophilic clefted materials expanding the papillary dermis and extending into the deep dermis. histochemical review showed the reactivity of the colloid materials via the pas, crystal violet and methyl violet staining. all the three cases were finally diagnosed as nodular colloid degeneration. conclusion: ncd is a rare disease but it should be considered in any cases with a history of long exposure to the light. we suggest the long term exposure to the sun as an etiologic factor thus, sun protection would be the most preventive and available treatment. glypican- protein expression in melanoma: a immunocytochemistry study n. gursan * , h. balta, b. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: glypican- (gpc ) is a cell surface heparan sulfate proteoglycan. serum gpc was shown to be expressed in % of melanomas (ms) but gpc expression in melanoma tissues had not been investigated.in this study, immunohistochemical analysis of gpc protein expression was investigated in histologic sections from melanoma tissues. method: melanoma patients, twenty patients with insitu melanoma, twenty patients stage and stage i melanoma, twenty patients stage ii and stage iii melanoma. all cases were stained with anti-gpc antibody. gpc expression was divided into categories: negative (negative or weak cytoplasmic staining) and positive (moderate or strong cytoplasmic with membranous accentuation). results: gpc immunopositivity. showed in , % of melanomas. gpc expression at stage , i, ii, iii were . %, . %, . %, % respectively. method: we report the case of a year old man presenting with an erythematous plaque of the right hemithorax. results: macroscopically the lesion had irregular borders and was mildly infiltrative with a violet hue. microscopic examination revealed tumor cells within lymphatic spaces, without infiltration of the adjacent stroma. the histologic and immunophenotypic characteristics of these cells were compatible with a carcinoma of lung origin. ct scan revealed a lung mass as well as multiple liver and chest wall metastases. conclusion: malignancies originating from the breasts, lungs and large bowl are the most common to involve the lymphatic net of the skin. melanoma on the other hand is more frequently presenting with lymphangitic invasion, whereas inflammatory carcinomas may also affect lymphatic vessels and may be confused with erysipelas. the revelation of the primary origin is not always easy and differential diagnosis should also include gynecological malignancies, kidney and urinary bladder carcinomas. in our patient the diagnosis was established on the grounds of histology and immunohistochemistry, and was supported by the clinical and radiological findings. objective: inverted follicular keratosis (ifk) is almost always a solitary lesion occuring mainly in adult life. men are affected twice as often as women. pathologically, they can be confused with a variety of lesions, both benign and malignant. squamous carcinoma is the most serious differential diagnosis. method: we decribe a retrospective study about cases of ifk diagnosed over a -year-period ( - ) . results: we collected lesions, all treated by surgical excision. haemalum eosin sections were studied in all cases. all lesions were single. five, of them, were situated on the face and two on the scalp. all the patients were adults with a mean age of years, average between and years. they presented mostly as asymptomatic papules and all were small lesions. the different sections of the lesion showed skin well delineated endophytic epithelial proliferations with inverted papillomatous and acanthotic components containing several circumscribed squamous eddies. they was no atypia, mitotic activity necrosis or stromal invasion. conclusion: ifk pose very real diagnostic problems unless one is aware of this entity. in fact, they may mimic malignant lesions especially squamous cell carcinoma, both clinically and pathologically. primary cutaneous follicular lymphoma with prominent spindle cell areas. so called spindle cell follicular lymphoma. case report g. ivády -szabó * , t. strausz, e. tóth * national institute of oncology, dept. of surgical oncology, budapest, hungary objective: spindle cell type variant of cutaneous follicular lymphoma is a rare histologic variant of primary cutaneous follicular lymphomas. it is caracterised by the presence of spindle and bizarr cells. we present a case of a years old man who had a nodule on his scalp and two smaller nodules on his frontal region. we examined an excisional biopsy specimen of the forehead. method: he, stains all and immunohistochemical stains were used. results: histology revealed dense lymphoid infiltrate showing nodular pattern in the dermis and in the subcutis. the lymphoid infiltrate predominantly composed of large centrocytes. there were areas where the neoplastic cells show spindle cell morphology with bizarre nuclei and in these areas the stroma were myxoid, mucinous. with immunohistocemical stains the neoplastic cells were positive for cd , bcl- , and negative for cd , cd , vimentin, cd , s , actin, desmin, ae /ae . cd showed residual network of follicular dendritic cells in the background. conclusion: spindle cell lymphoma is a very rare variant of cutaneous follicle centre cell lymphoma and the presence of the spindled bizarre cells can cause differential diagnostic problems. the main differential diagnostic entities are primary or metastatic spindle cell sarcoma and spindle cell melanoma. careful morphological and immunohistochemical analysis are required to the correct diagnosis. the histopathologic and immunohistochemical features of mycosis fungoides b. a. karabork * , a. okcu heper, s. yuksel, i. kuzu * ankara university of medicine, dept. of pathology, turkey objective: the histopathologic diagnosis of early mycosis fungoides (mf) is often difficult. the lesions can mimic a variety of inflamatory dermatitis. we aimed to establish and draw attention to the most frequent histopathologic and immunohistochemical features of mf. method: we reviewed skin biopsies of clinicopathologically diagnosed mf cases at medical university of ankara. we looked for a) epidermotropism, atypical lymphocytes, morphologic features in the epidermis, dermoepidermal junction and dermis b) immunohistochemical staining ratios of cd , cd , cd , cd , cd and expression loss of cd , cd . results: atypical lymphocytes) ( %), dermal fibrosis ( %), epidermotropism ( % single cells, % linear arrangement, % pautrier's microabscesses, % 'haloed' lymphocytes), epidermal acantosis ( %), basal vacuolar degeneration (focally %, marked %) and a perivascular lymphocytic infiltrate were the most common and important features. dermal edema ( %) extravasated erythrocytes ( %), spongiosis ( %), eosinophils ( %) and necrotic keratinocytes ( %) were the less seen and non-specific ones. immunohistochemical results correlated with a ratio of % cd , % cd positive mf. expression loss of cd was seen in %, cd in % of cases. conclusion: diagnosis of early mf requires the correlation of morphologic, immunohistochemical and clinical features. also due to the disease's heterogenity, biopsies from different locations and rebiopsies will enhance the diagnosis. connexins of cutaneous melanocytic tumours g. kiszner * , z. buday, i. teleki, e. varga, i. b. nemeth, i. korom, t. krenacs * semmelweis university, st dept. of pathology, budapest, hungary objective: connexins (cx) form transmembrane channels that can transport ions and small regulatory molecules between adjacent cells. they also function as hemichannels and through protein interactions and are involved in the control of cell replication and maintenance of multicellular homeostasis. method: we have tested the expression of connexins in melanocytic tumours using immunohistochemistry in tissue microarrays of common and dysplastic nevi, and primary and metastatic malignant melanomas. results: cx was not found in melanocytic tumours despite expressed in the basal epidermis. cx . reaction showed punctate cell membrane staining in % of naevi in their superficial regions including atypical nests, and displayed cytoplasmic staining in % of melanomas. low levels of cx were revealed in the cytoplasm of > % of naevi and melanomas but only % and % showed membranous positivity, respectively. cx perinuclear/cytoplasmic immunostaining was observed in % of naevi and % of melanomas and as cell membrane reaction in % and %, respectively. punctate cx reaction was detected in vertical tumour nests in % of naevi, while only % of melanomas proved positive and showed cytoplasmic cx delocalization. conclusion: therefore, most tested connexins were significantly down-regulated in malignant vs. benign melanocytic tumours that possibly contribute to their malignant phenotype. quantitative follow up study of cd a, cd and cd positive cells in multiple basal cell carcinoma cases after combined treatment r. kleina * , i. truksane, j. kisis, i. franckevica * riga stradins university, dept. of pathology, latvia objective: in last years appear more cases with multiple basal cell carcinomas (bcc). skin immune system reaction is especially important in nonsurgically treated cases. aim of study is to evaluate the dynamics of cd a, cd , cd marked cells in bcc and in skin adjacent to tumour ( and mm) before and after the treatment with cryotherapy and imiquimodum. method: from bcc cases with multiple tumours investigated immunohistochemically, in dynamics we have characterized patients. antibodies for cd a, cd , cd + cells in derma and epidermis were used. they were evaluated in fields of vision ( ×) before and after treatment. % imiquimod cream and double freezing was used. control group: three normal skin samples. statistical analyses of results were done. results: after treatment were erythema, then crust and exfoliation. microscopically expressed fibrosis instead bcc was found. amount of immune cells before and after treatment were: cd ± , / ± , (also in epidermis), langerhans cells ± , / ± , , cd ± , / ± , . conclusion: all immune cells of skin react to the combined treatment of bcc in radius of mm. there is significant statistical difference between the numbers of langerhans cells in normal epidermis and in bcc cases treated with cryomethod and imiquimodum. regulatory t-cells in invasive and in situ squamous cell carcinoma of the skin and actinic keratosis h. kourea * , a. stravodimou, v. tzelepi, h. papaioannou, h. papadaki, c. scopa * university of patras, dept. of pathology, greece objective: regulatory Τ-cells (Τregs) participate in tumor tolerance and facilitate tumor growth and foxp transcription factor is necessary and sufficient for their development and function. we investigated the presence of t-regs in invasive (in) and in situ (is) squamous cell carcinoma (scc) of the skin and actinic keratosis (ak). method: tregs were identified using immunohistochemistry for foxp and recorded using image analysis in cases of inscc (and their adjacent is, ak or benign tissue (bn), when present), in cases of is and cases of ak (and their adjacent bn tissue). statistical analysis was performed using the paired t-test. p-values < . were considered statistically significant. results: in inscc cases, Τregs in the tumor were more numerous than the adjacent Βn (n= ) (mean vs. , p < , ). additionally, adjacent is had more tregs than adjacent ak (n= ) ( vs. , p= , ). significant differences between inscc, and is or ak were not observed. in is and ak cases, Τregs were more numerous than the adjacent bn ( vs. , p< , and vs. , p< , ), respectively. conclusion: treg infiltration of the skin increases early from the precancerous ak, indicating early involvement of tregs in the development of scc. objective: mastocytosis is a rare disorder and its true incidence is unknown. skin is most commonly involved, followed by the bones and the gastrointestinal tract. method: five men presented with many brown lesions in the trunk and one woman with multiple redish brown nonpruritic macules in the extremities. we used immunohistochemistry for c-kit and tryptase for the definite diagnosis. the expression of cd and cd were also evaluated. results: histology showed five cases of urticaria pigmentosa with severe diffuse infiltration of the papillary dermis by mast cells and one case of telangiectasia macularis eruptiva perstans (tmep) with scattered mast cells around dilated capillaries and venules of the papillary dermis. the mast cells were positive to c-kit and tryptase and only in one case there was a coexpression of cd and cd > % of the mast cells. in that case involvement of bone marrow was observed and the diagnosis of indolent systemic mastocytosis was established according to who criteria. conclusion: urticaria pigmentosa is the most common form seen in adults while tmep is an uncommon form that occurs exclusively in adults. the skin involvement in indolent systemic mastocytosis is a part of the spectrum of the disease. ps- - subvisual nuclear characteristics are different between keratoacanthoma and keratoacanthoma-like squamous cell carcinoma k. metze * , m. tabai, r. adam, i. watanabe, a. de moraes, m. cintra * university of campinas, pathology, brazil objective: the differential diagnosis between keratoacanthorna and keratoacantoma-like squamous cell carcinoma may be extremely diffcult. our objective was to study whether computerized image analysis could be helpful. method: in patients biopsies of keratoacantoma-like lesions were taken at admission. one month later surgical excision was performed in growing lesions, whereas regressing lesions were left untreated. a final diagnosis was established combining clinical and histological evaluation, digitalized images from ki- immunostained and hematoxylin counterstained sections of first biopsies were obtained. tumor nuclei were marked interactively. an inhouse computer program analyzed the geometric relations between the nuclei. nuclear gray values and their histogram entropy were calculated. results: keratoacnthomas and keratoacantomalike squamous cell carcinomas entered this investigation. basic variables of the geometric analysis did not differ between the two entities regardless whether all nuclei or only the ki positive ones had been examined. chromatin gray values were significantly lower and their histogram entropy higher in the keratoacantoma-like squamous cell carcinomas. conclusion: basic geometric variables do not seem to be different beteen both lesions, but a shift in the gray value histogram to lower values with increased entropy in carcinomas indicated important differences of the chromatin structure, supported by fapesp and cnpq. non-infectious erythematous papular and squamous lesions of the skin in our institute, with clinicopathologic correlation t. ozgur * , a. c. dogramaci, e. atik, s. hakverdi, m. yaldiz, z. a. tas * mustafa kemal university, medical faculty, antakya, turkey objective: non-infectious erythematous, papular and squamous lesions of the skin are basic lesions that pathologists differentiate in routine laboratory examinations. our aim has been to analyse these lesions by pathologic and clinical findings in our institute with determining clinicopathologic correlation. method: in our study cases prediagnosed as erythematous, papular and squamous lesion by dermatologists and evaluated in pathology laboratory between and have been reviewed. results: the lesions comprised % . of the total load of surgical pathology and . % of total number of skin biopsies. the highest percentage was in the - year age group ( . %) with a female predominance of . %. the limbs were most frequently involved ( . %). psoriatic lesions were the commonest ( . %), classic generalized plaque variant psoriasis ( %) being the most frequent. correlation with the histopathologic diagnosis was positive in . % cases and negative in . % cases. conclusion: the contribution of histopathology to the final diagnosis was significant. it confirmed the diagnosis in . % cases and gave the diagnosis in . % cases. ps- - vulvar lichen sclerosus: a misnomer for an entity with decreased fibrillar components and increased amorphous components in extracellular matrix remodeling e. parra * , c. a. pires de godoy, v. l. correia feitosa, w. teodoro, a. p. velosa, v. l. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: the hyalinization of subepidermal skin is one of the histopathological characteristics of the vulvar lichen sclerosus (vls). it was found that patients with vls present autoantibodies against the extracellular matrix protein (ecm- ) and the deficiency of this protein is responsible for the development of a different disease, the lipoid proteinosis. this disease shows a similar histology with vls and has better characterized morphology. method: we analyzed vls patients biopsies and the control group was composed by vulva samples from authopsy. the biopsies and control samples were analysed by immunofluorescence for collagen i, iii and v and th total collagen fibers by picrosirius staining. the elastic fibers were stained with verhoeff and the proteoglycans and glycosaminoglycans with periodic acid-schiff and alcian blue. collagen quantification was performed through image analysis. results: it was observed a significant reduction in all studied collagens as well as in the elastic fibers. on the other hand, the proteoglycans were increased in the vls biopsies. conclusion: this study did not found an increase in collagen sclerosis that would justify the term used for the ls. it was observed a predominance of the edema area probably caused by the increase of glycoproteins as in lipoid proteinosis. combined high-grade basosquamous carcinoma and malignant melanoma of the scalp (malignant basomelanocytic tumor) metastasizing to the breast. a case report a. pitino * , s. squillaci, c. spairani, f. ottelli zoletti, m. f. cosimi, m. ferrari, a. tropiano, p. c. rassu, f. tuo, p. maiocchi * san giacomo hospital, division of anatomic pathology, novi ligure, italy objective: background. basal cell carcinoma (bcc) is a very low grade, usually not metastasizing skin malignancy, which needs to be radically excised. methods. an year-old woman was treated for a × , cm multinodular mass in the scalp. one month later an ultrasonography of the left breast showed a , cm mass which was excised with clean margins. axillary lymph nodes were free of metastasis. results: results. the dermal tumor presented well demarcated basaloid epithelial nests with squamous differentiation focally connected with the epidermis. they showed peripheral palisading and high nuclear grade with pleomorphism, brisk mitotic activity and multiple prominent nucleoli. atypical cells, arranged as strips, nests or isolated elements, were observed at the tumor edge, separated by a grey-zone from the overlying malpighian epithelium. immunostains were positive for cytokeratins, melanocytic (s- /hmb- / mart- ) and neuroendocrine (cd /nse/cromogranin) markers. the , cm breast tumor corresponded to a high grade metastatic bcc with reactivity for epithelial markers, s- and cd . objective: pyoderma gangrenosum (pg) was described at first by brocq and named by brunsting et al. in . superficial granulomatous pyoderma (sgp) was described as a variant of pg in . we present three cases of this rare variant. method: there were two women and one man with age ranging from to years. all of them had a long history of a slowly enlarging, eritematous and ulcerative plaque in different areas including leg and breast skin. a biopsy was performed in all cases. results: the superficial dermis showed neutrophilic inflammation with an admixture of granulomatous inflammation and sinus formation. there wasn't vasculitis and fat tissue was not affected. conclusion: sgp is a rare variant of pg. diagnosis of this entity generally is made on the basis of skin biopsy results with all features mentioned previously and a typical clinical appearance. most of times, these lesions are diagnosed as granulomatous dermatitis, thinking in infectious pathology. this is the most important differential diagnosis, because sgp is responsive to corticosteroids. the pathogenesis of pg is unknown, though is now believed to altered neutrophil chemotaxis and some authors suggest that sgp may be a delayed-type hypersensitivity to an unknown antigen. pathergy is the inciting factor in several patients. high concordance in braf status between native-braf malignant melanoma and matched lymph node metastases a. santos briz * , e. godoy, l. arango, p. antúnez, m. yuste, c. roman, e. fernández, m. d. ludena * hospital universitario salamanca, dept. de anatomía patológica, spain objective: the discovery of selective v-raf murine sarcoma viral oncogene homolog b (braf) v mutation as an oncogenic mutation in cutaneous malignant melanoma (mm) has changed the treatment paradigm for melanoma. selective braf inhibitors have demonstrated response rates far higher than standard chemotherapeutic options. braf mutation analysis is usually performed on primary tumour tissue; however, no conclusive data are available on the concordance of test results between primary tumours and corresponding metastases. we assessed the concordance of braf mutation status in a study of primary brafnative tumours and their corresponding lymph node metastases. method: patients with histologically confirmed nonmutated braf mm who underwent surgical resection of the primary tumour and positive selective lymph node biopsy or lymphadenectomy were included. mutation status was determined by means of a realtime pcr assay (cobas braf v mutation test, roche molecular systems). results: there was a % concordance of the braf results in primary tumor and corresponding metastases in analyzed pairs. conclusion: our findings show total concordance in braf status between primary braf native tumors and their paired metastases, and suggest that acquisition of braf v mutation in metastases from primary native tumors is a rare event. dermatoscopic and histologic score correlation in atypical spitz/reed nevi m. saravia * , z. pellicer, j. m. martin, c. monteagudo * hospital clinic university valencia, dept. of pathology, spain objective: different dermatoscopic scores of pigmented skin lesions have provided a valuable tool in daily routine practice to differentiate malignant from benign lesions. however, these semiquatitative methods have a high rate of false positives in spitz/reed nevi. we have compared semiquantitative histopathologic and dermatoscopic findings in a series of spitz/reed nevi. method: we collected cases ( female and men) of atypical spitz and/or reed nevi. all cases were microscopically confirmed. a histologic index (hi) was constructed scoring the following findings: symmetry, sharp demarcation, architectural dysplasia, melanocytic atipia and nest size, and compared with validated dermatoscopic scores (abcd score, -point checklist and menzies score). distributions of these scores for the different dermatoscopic patterns were also analyzed. results: median age at presentation was years (range to ). the hi varied from to points. we found a strong positive correlation between the hi and menzies score (r= , , p= , ). in addition, hi values differed significantly when the multicomponent dermatoscopic pattern group was compared with the other patterns (u = , z =− , , p = . ). conclusion: menzies is the only dermatoscopic score which strongly correlates with histologic findings in spitz/reed nevi and may be useful in the diagnosis of atypical lesions. correlation of nonmolecular and molecular subtyping of inherited epidermolysis bullosa k. veselý * , h. bucková, l. fajkusová, m. veselá, b. jerábková * st. anne's hospital, dept. of pathology, brno, czech republic objective: inherited epidermolysis bullosa (eb) is a heterogeneous group of hereditary mechanobullous diseases with skin blister formation of variable severity and numerous extracutaneous manifestations. eb comprises three main groups and many subtypes and their recognition is important for prognosis and genetic counselling. method: we examined skin biopsy samples of patients with eb using transmission electron microscopy, immunofluorescence antingen mapping (am) and their peripheral blood samples by mutational analysis. results: in the total number of cases, concordant results of molecular and nonmolecular methods were found in cases ( %). in patients ( %) mutational analysis did not confirm the results of ultrastructural and am analysis. conclusion: strong correlation in the results obtained by different methods was observed. using combination of nonmolecular and molecular diagnostics methods high diagnostic accuracy can be achieved. granulomatous slack skin (gss): a case report with evidence of t cell clonality i. yilmaz * , h. baloglu, u. berber, z. kucukodaci, m. arcila * gata heh, dept. of pathology, istanbul, turkey objective: gss is a very rare variant of mf. we describe an additional case of this rare disorder in a yo female that has been approved by tcrb&g tcell clonality assay. method: a yo female with a single bulky skin lesion in the inguinal fold which had first appeared y before and enlarged up to cm, referred to plastic surgery for esthetics. h&e section of the deep skin biopsy of lesion showed a granulomatous infiltrate in the dermis. nuclear atypia and epidermotropism is not significant. but there is numerous multinucleated histiocytic giant cells. elastophagocytosis are present. tcrb&gt cell clonality assay showed a clonal rearrangement in tcr gamma gene. she was referred to dermatology for treatment and now she is getting uva phototherapy. results: the diagnosis of gss is difficult in early stages of the disease. clonal rearrangement of tcr genes can be a useful diagnostic tool in early stages of the disease. conclusion: - % of patients with gss carry a risk for the development of a second malignancy. gss may be associated with lymphoproliferative disorders. therefore, follow up of the patient is important. this case report supports that gss is an indolent variant of mf due to clinical, histological and t-cell gene rearrangement results. unusual occurrence of multicentric reticulohistiocytosis with systemic involvement in childhood s. zurac * , c. dobrea, a. diaconeasa, a. colita, c. solovan, c. arion, f. staniceanu * colentina university hospital, dept. of pathology, bucharest, romania objective: multicentric reticulohistiocytosis (mr) with systemic involvement is an extremely rare disease afflicting mainly adults. method: we report a case of sr arising in a year month old boy with concomitant celiac disease. results: since - months, he developed several brown to dark-red skin nodules (up to . cm) located mainly on face and arms; current episode include hemorrhagic syndrome, severe pancytopenia and massive hepato-splenomegaly. bone marrow aspirate ruled out acute leukemia and tezaurismoses; bone marrow biopsy and skin biopsy showed important infiltration with numerous large cells with abundant fine granular/ground glass eosinophilic cytoplasms in a reactive inflammatory stroma (lymphocytes, few plasma cells and few eosinophils); bone marrow cells were mononucleated, cutaneous cells were both mono&multinucleated; tumor cells immunophenotype was consistent with histiocytes (cd +, s- protein + (faint), cd a-, langerin-) both in bone marrow and skin biopsies; no hemophagocytosis was seen. mr with systemic involvement of skin, bone marrow, liver and spleen was diagnosed. cyclophosphamide therapy was instituted with initial diminishing of splenomegaly; latter on, despite adding cyclosporine and etoposide, no further impact on pancytopenia and hepatosplenomegaly was recorded. conclusion: complete hematologic examination is mandatory for patients diagnosed with cutaneous reticulohistiocitosis, irrespective of their age, in order to identify mr and institute proper treatment. primary cutaneous follicle centre lymphoma: a case report and review of literature k. diamantopoulou * , c. zorzos, c. eftychiadis, i. famellos, g. piagkos, g. karamanis, i. babalis, s. binder, h. mahera * general hospital kat, pathology, athens, greece objective: primary cutaneous follicle centre lymphoma (pcfcl) is an indolent, primary cutaneous b-lymphoma with an excellent prognosis but a high incidence of reccurence. apart from standard surgery and local radiotherapy, targeted strategies with anti-cd (rituximab) has introduced new treatment modalities. method: woman, aged , with solitary skin lesion on her face. after surgical excision, histo-and immunohistochemistry with the abc system on paraffin embedded tissue was performed. results: microscopically, a non-epidermotropic perivascular and periadnexal neoplastic infiltrate with a follicular growth pattern was observed. the lesion consisted of predominantly medium-sized centrocytes and several centroblasts enmeshed in a network of cd (+) dendritic cells. immunohistochemically, the neoplastic lymphoid cells were cd , cd a, bcl and bcl positive. cd , mum and ig were all negative. the patient received one cycle of rituximab and months later is free of disease. conclusion: primary cutaneous b-cell lymphomas (cbcl) account for % of cutaneous lymphomas. pcfcl is one of the three major categories of cbcl, recently classified by who, (the other two: pcmzl and pcdlbcl, leg-type). bcl- , except for systemic follicular lymphoma, it can also occur in pcfcl, as in our case. pcfcl, usually locally treated with surgery and radiotherapy, could possibly offer a candidate for anti-cd targeted therapy, especially in multifocal lesions. objective: thirteen and ten years old male patients admitted with months interval, having diffuse hemorrhagic papules on extremities and trunk. the first has not responded to methorexate previously. the second had varicella infection months before and, his rushes spreaded out recently. method: multiple punch biopsies of the first patient revealed epidermal necrosis, basal vacuolisation and subepidermal diffuse infiltrate composed of cd and mostly cd positive t cells showing a striking angiocentric distribution. there were cd positive large cells with vesicular nuclei both in epidermis and dermis. some of the vessels exhibited lymphocytic vasculitis with fibrinoid necrosis. punch biopsy of the second patient revealed subcorneal pustule, dyskeratosis and basal vacuolisation, papillary dermal edema, erythrocyte extravasation and severe lymphocyte-rich cellular reaction infiltrating the interface. lymphocytes were cd and mostly cd positive. in between, there were large cells with vesicular nuclei exhibiting cd positivity. results: diagnoses were pleva based on the vascular and interface changes in accordance with clinical findings. both patients responded to oral antibiotics. conclusion: pleva is among the reactive conditions that can simulate cd positive lymphoproliferative diseases. although cd positive lymphomatoid papulosis is defined in pediatric patients, no response was seen to oral antibiotics. are hmb- and mib results reliable for safe diagnosis of nevi? z. yusifli * , o. kurtulan, Ç. aydin, m. bugdayci, Ö. gököz * hacettepe university, pathology, ankara, turkey objective: melanocytic lesions having subtle features suspicious for malignancy create considerable difficulty in decision-making.process. lack of deep hmb- positivity and low dermal mib- index can be reliable tools in association with morphology. method: twenty-seven acquired melanocytic lesions in which hmb- and mib- have been performed are reviewed to determine the importance of these markers in routine diagnostic practice. asymmetry, focal loss of maturation, presence of mitoses, epidermal consumption and lymphocytic inflammation were the morphological features that have created difficulty especially when seen alone in a bland appearing nevus. results: all cases with epidermal consumption and/or mitoses and nearly half of cases with inflammation, asymmetry and focal loss of maturation was associated with.focal deep dermal hmb- positivity. thirteen cases had an mib- index of ≤ %. two of cases with mib- index of > % had also hmb- positivity and/or inflammation. the case with a mib- index of % was an acral nevus bearing of the evaluated morphological features. conclusion: focal deep dermal hmb- positivity goes parallel with epidermal consumption and dermal mitoses, mostly used prevailing criteria of malignancy in melanocytic lesions but it's expression is not adequate for diagnosis of melanoma. low mib index can be a reliable marker of benignity. objective: leptospirosis in humans usually courses with hypokalemia and hypomagnesemia, and the putative mechanism may be related to nitric oxide production. methylene blue is a known inhibitor of inducible nitric oxide synthase, and have beneficial effects on clinical and experimental sepsis. method: serum creatinine and ionic changes were evaluated at various time points ( , , and days) in hamsters. we also determined the effect of methylene-blue treatment when used as adjuvant therapy combined with a late start of standard antibiotic (ampicillin) treatment. results: rather than k and mg depletion, hyperkalemia and hypermagnesemia were observed during acute infection. these findings are probably associated with an accelerated progression to renal failure, since this model is not feasible to mirror the supportive therapy (including fluid expansion) that retards progression to the oliguric/hyperkalemic state. infected hamsters at day presented diffuse tubular cell swelling with mild or no nephritis. at days and they showed variable degrees of acute tubular changes, regeneration of tubular epithelia and nephritis. survival and renal pathology did not differ among different treatment groups. conclusion: adjuvant methylene blue had no effect on the survival, renal pathology or mg and k serum levels during acute-phase leptospirosis in hamsters. occupation of the striated muscle fibre by trichinella spiralis is associated with increased intracellular sialylation p. babal * , r. milcheva, d. ivanov, s. petkova * comenius university, dept. of pathology, bratislava, slovakia objective: the knowledge about glycoproteome in skeletal muscle is limited and most of the information come from studies on aberrant glycosylation in inherited muscle diseases. this work describes the intracellular changes in sialylation of skeletal muscle fiber during the process of its transformation into a nurse cell after occupation by the nematode trichinella spiralis. results: the study was performed at defined time points post infection. lectin histochemistry with tml, mal and sna detected increased production of sialylated glycoproteins within the affected fibers, and it was evaluated by acidic ninhydrin reaction in muscle homogenates. increase of total sialyltransferase activity was estimated by measurement of incorporated cmp-n-[ c]-acetylneuraminic acid, and immunohistochemistry showed higher expression of α- , -sialyltransferases ii and iv within the affected fibers. sna lectin affino-blots showed at least four protein bands with approximate molecular weight between and kda, which were more reactive to sna compared to their counterparts from the control samples. conclusion: it is evident that skeletal muscle injury induced by trichinella activates biosynthesis of glycoproteins bearing sialic acids, which are not present in the normal muscle fiber. however, the protein identity, function and the biological significance of these sialoglycoproteins remain to be elucidated. bg po objective: protozoal and helminthic infestations of the central nervous system (cns) are rare and their incidence is less than %. they are more common among children, the elderly and immunocompromised individuals and tend to follow a fatal course. method: we report cases of cerebral amebic abscess occurring in immunocompetent men. results: they were men aged of and years old. headache; altered mental status and fever were common presenting symptoms. in the cases the diagnosis of cerebral abscess was suspected on cerebral ct scan. histopathologic analysis revealed extensive areas of necrosis and hemorrhage with granulomatous lymphoplasmacytic inflammatory infiltrate. other conditions such as malignancy and tuberculosis. it occurs normally in the mouth and tonsils, however, it can sometimes occur in the chest, abdomen, pelvis or other areas of the body. method: we describe a retrospective study about cases of actinomycosis diagnosed over a -year-period ( - ) . results: the cases were divided in cervicofacial actinomycosis, genito-urinary tract actinomycosis, cutaneous actinomycosis, abdominal actinomycosis and cases occur in central nervous system. all patients were symptomatic. the most frequent symptom consisted in fever. the diagnosis was based on histologic study in all cases. tissue histologic studies show suppurative and granulomatous inflammatory changes, connective proliferation, in which bacteria form typical granular colonies composed of radiating gram positive filaments. conclusion: diagnosis of actinomycosis is usually made retrospectively by means of histologic examination of surgically obtained specimens, but rarely preoperatively. it is generally treated with long term antibiotics. expression of angiogenesis factors in placentas with intrauterine transmission of hiv a. kolobov * , e. musatova, v. karev, v. zinserling, d. niauri * st. petersburg, russia objective: placenta plays an important role in the prevention of the mother-to-child transmission of hiv during pregnancy. the purpose of this investigation was to study expression cd , bfgf and tgfβ in human placentas in cases of intrauterine hiv infection. method: group a - placentas from women and children with hiv infection. in control -group b, were placentas from women without hiv infection. on paraffin slices expression of cd , bfgf, tgfβ and p was evaluated. we counted the area of positive cells related to the square of the slice. results: in all placentas with hiv infection p has been found in placental macrophages and villi's vessels. in group a expression of cd in endothelial cells was , ± , % of the slice's square (in control - , ± , %) (p> , ). expression of bfgf in villi's stroma was , ± , % (in control - , ± , %) (p> , ). expression of tgfβ in villi's vessels was , ± , % (in control - , ± , %) (p< , ). conclusion: thus, placentas in cases with intrauterine transmission of hiv are characterized by increased expression of tgfβ the significance of this fact is still to be evaluated. objective: unilocular cystic echinococcosis which echinococcus granulosis causes is seen frequently in the animal husbandry practised underdeveloped countries. method: the unilocular cystic echinococcosis cases which were seen in the eastern part of turkey, in years between . . and . . , except faculty of medicine of atatürk university are presented. results: organ distribution: female: liver (sd: . ), lung (sd . ), spleen (sd . ), abdomen (sd . ), kidney (sd . ); male: liver (sd . ), lung (sd . ), spleen (sd . ), brain (sd . ), soft tissue (sd . ) . conclusion: the frequently seen organs in both gender are liver and lung. the rarely seen organs were spleen , brain , abdomen , kidney , vertebrae , soft tissue , pleura , bone , breast . the others were very rare: eye , gallbladder , thyroid , neck , ovary , testis . relation of the length of appendix and parasitosis: preliminary report a. kurt * , s. a. Özmen, i. erdem * bölge egitim ve arastirma hastanesi, dept. of pathology, erzurum, turkey objective: is there an effect of the length of appendix vermiformis on the settlement of the bowel parasites? we have decided to research. method: it was studied retrospectively for not to be under the influence. randomly chosen from the archives, parasitic appendix ( women + men) and appendix vermiformis ( women and men) lengths were compared. the last appendix materials of the appendixes which include parasites ( e.vermicularis, a.lumbricoides, t.saginata) and operated any causes were examined. placeholder conditions such as fibrous obliteration and tumour were excluded. the premeasured length of the appendix in the series ( + = ) were listed with the gender. results: appendix length in the control series: the length of appendix in men: . the length of appendix in women: . the length of appendix in both gender: . cm. the length of parasitic appendix: the length of appendix in men: . the length of appendix in women: . the length of appendix in both gender: . . objective: on the basis of recently detected receptors for erythropoietin on the surface of mscs we hypothesized that introduction of epo together with mscs may enhance their effect and improve the results of sepsis treatment. method: wistar male rats were randomized into groups with animals in each: group -the healthy controls, - groups were intraperitoneally introduced bacterial lps mg/kg. group - got × allogeneic mscs, group - . μg of recombinant epo-beta, group -mscs and epo in the same doses. the morphological study of liver, spleen, thymus, lung and kidney was performed. histological specimens were evaluated by qualitative, semiquantitative and quantitative methods. results: in lung tissue the thickness of alveolar septums progressivly reduced from group to .in kidney and liver tissue the dystrophy of hepatocytes and nefrocytes and a blood vessel's dilatation in studied groups also reduced.in lien tissue we observed hyperplasia of white pulp in groups and . structural features of thymus were connected with patterns of t-lymphocyte proliferation and differentiation. conclusion: combined treatment with epo and mscs can reduce acute lung injury and kidney damage, cause hyperplasia of lymphoid tissue and enhance the immune response more than separate treatment in an experimental model of sepsis in rats. mycobacterial spindle cell pseudotumor of the liver a. alves * , a. costa, a. fernandes, g. do carmo, i. tavora * hospital santa maria, servico de anatomia patologica, lisboa, portugal objective: spindle cell pseudotumors are rare manifestations of mycobacterial infections. we describe a case in the liver in an immunocompromised patient with tuberculosis. method: a -year-old man, with active substance dependency, hiv- infection known for years and acquired immunodeficiency syndrome for years, was receiving tuberculostatic medication for disseminated tuberculosis and investigated for persistent fever. a liver ultrasonography confirmed a moderate hepatomegaly and showed multiple dispersed nodules in both lobes, with to cm of greater diameter. results: a needle biopsy from one of the nodules showed a proliferation of spindle cells without atypia, grouped in intersecting bundles, with immunoreactivity to vimentin, cd and lysozyme and negative for cd , ps , sma and desmin; a ziehl-neelsen stain revealed several acid fast bacilli in the spindle cells. they were pas negative. conclusion: pseudotumoral lesions in hepatic tuberculosis usually correspond to granulomatous inflammation. a spindle cell proliferation, like that seen in other organs are more frequently associated with non tuberculous mycobacteria, is very rare. we found only another case in the literature of liver spindle cell pseudotumor associated with tuberculosis. this lesion must be differentiated from mesenchymal neoplasms. sixteen months follow-up in a treated case of whipple disease (wd) c. popp * , m. petre, g. micu, a. bastian, r. chirculescu, r. mateescu, f. staniceanu * colentina university hospital, dept. of pathology, bucharest, romania objective: wd is a rare, multi-systemic infection caused by a ubiquitous environmental bacteria -tropheryma whippleithat affects the duodenum and small intestine but also the brain, endocardium, skin, lungs and joints. method: we are presenting a years old man with a years history of diarrhea, malabsorption and weight lost (about kg). endoscopical examination revealed an unspecific, yet unusual pattern of lesions: small, yellow, multiple, slightly elevated patches involving duodenum and jejunum. histological examination revealed numerous foamy macrophages in lamina propria with pas (+), ziehl-neelsen (−) material in cytoplasm. results: treatment with trimethoprim/sulfamethoxazole was initiated with a spectacular response: after days of therapy the patient had normal stool and in months he already gained back kg. after year of treatment the biopsy confirmed a partial remission with fewer macrophages persisting in lamina propria of duodenum. after months of treatment (march ), very few macrophages with pas (+) material are still identified on duodenal biopsy. conclusion: wd is a potentially fatal disease with unspecific clinical and endoscopical signs that can be diagnosed on duodenal biopsies. histological follow-up is a useful tool of managing the treatment and histopathological confirmation of the absence of foamy macrophages is mandatory in discontinuing therapy. small cell urothelial carcinoma (scuc) comtherapy. method: we report two cases of scuc. both of them refer to year-old males, smokers. they presented with gross hematuria. transurethral resection bladder tumor (turbt) specimens showed scuc, followed by cystoprostatectomy and pelvic lymphadenectomy, confirming the initial diagnosis. immunohistochemistry was used on paraffin embedded tissue. results: microscopically, the tumor cells show a diffuse architectural pattern with occasional nesting, are small, uniform, with scant cytoplasm, nuclear crowding, nuclear molding, inconspicuous nucleoli and finely stippled chromatin. numerous mitoses, azzopardi phenomenon and foci of necrosis are present, as well as areas of urothelial carcinoma. tumor cells are strongly (+) with ker ae /ae , cam . (dot-like perinuclear pattern), cd (the most consistent neuroendocrine marker), p , ki- ( %), focally (+) with synaptophysin and (−) with chromogranin, ker βe , ker , ker , ttf- , lca. conclusion: pathologic and immunohistochemical data identify scuc. differential diagnosis includes metastasis of a small cell carcinoma from another site rare variant: primary renal malignant fibrous histiocytoma n primary leiomyosarcoma of the kidney: three cases b renal pelvic and ureteral dilatation was seen in the first case because of the mass effect. microscopically the alternating spindle tumor cells were detected which were positive with actin, desmin, caldesmon and negative with s , pan-ck, cd and cd congress hall foyer rd floor ps- poster session gynaecological pathology although rare, u-lms is the most frequent malignant gynaecological mesenchymal tumor, usually disclosing unfavorable prognosis. u-lms diagnosis may be controversial. in this study we evaluated clinical-pathological features/prognostic factors of u-lms. method: all consecutive u-lms diagnosed ( - ) at chsj and ipo-porto and with available material were reevaluated. the clinical files were reviewed, including demographic, clinical, imaging, surgical, staging, and follow-up parameters. the pathology features, including immunohistochemistry evaluation, were re-evaluated and the tumors staged according to most recent consensus criteria. results: the mean age at diagnosis of the cases was years ( - ); % were multiparous and % postmenopausal women. the majority ( %) had symptoms at diagnosis, mostly abnormal bleeding. histological classification displayed: % spindle, % epithelioid, % myxoid, . % pleomorphic, and . % mixed u-lms. treatment included surgery ( %), radiotherapy ( %), and chemotherapy ( %). overall median survival was months portugal objective: u-lms is the most frequent malignant gynaecological mesenchymal tumor, disclosing dm results: our series: ( . %) with metastasis; literature: with metastasis. global mean age at diagnosis: years ( - ); initial treatment: hysterectomy ( %), radiotherapy ( %), and chemotherapy ( %) pancreas, vulva/vagina, salivary gland, oral cavity, heart, mediastinum, adrenal, and breast; % with metastatic related symptoms. overall median time to first metastasis: months (ci % . - . ). pancreas, heart and mediastinum were the earlier metastatic sites microglandular adenocarcinoma (mga) of the endometrium, a rare subtype of endometrial mucinous adenocarcinoma, has histologic similarities to the microglandular hyperplasia (mgh) of the cervix. it should not be misdiagnosed as cervical mgh especially in a small endometrial biopsy specimen. method: eight cases of mga of the endometrium and cases of control mgh of the cervix were immunostained for ki- , cd , p , p , p , vimentin, estrogen receptor (er), progesterone receptor (pr) and pten. hpv dna analysis was performed using paraffin-embedded mga tissue by polymerase chain reaction amplification endometrial carcinoma (ec) displays variable outcomes. method: immunohistochemistry for p , ki , egfr, her- (%positive), pten, estrogen and progesterone receptors (er/pr), perk, pjnk (h-score results: ade: er/pr mean h-score from / to / , from g to g , for pten, and for perk and pjnk, two adeg > % p and one % ki . ads: % > % p and % > % ki , / for er/pr, for pten, and for perk and pjnk. adcc: none er/pr; , and for perk -regulated) compared to ulm and myometrium, several known to be involved in cell-cycle and/or apoptosis pathways (p , rb, e f, cyclin-d /e) and/or metastasis. conclusion: albeit some overlap, mirna expression profile of ulms is different from ulm but relatively similar to non-ulms. ulms and non-ulms share deregulation of several mirnas that may be linked to specific cell-cycle/ apoptosis pathways %) included rhabdomyoblastic ( ), cartilaginous ( ), adipocytic ( ) & sex-cord-type ( ). four cases had leiomyomas; alivewith-disease (mean, . months) and free-of-disease (mean, months). conclusion: adenosarcomas are uncommon endometrial endometrioid carcinoma is the most common malignant tumor of the uterine corpus usually developing in postmenopausal women. more seldom it occurs in young reproductive age and sometimes develops from an endometrial intraepithelial neoplasia (ein). the ein diagnosis and treatment in such patients have some difficulties. method: we have studied curettage tissue specimens from three women with ages , and , with abnormal uterine bleeding and obesity. the severe complex endometrial hyperplasia with low grade intraepithelial neoplasia was revealed in all cases polypoid glands with sarcatomatous stroma (phylloides-like pattern). b. periglandular condensation. c. sarcomatous overgrowth. d. decidualization. e. cartilagenous dedifferentiation. f. rhabdomyoblastic dedifferentiation (inset). g. vimentin positivity. h. desmin in rhabdomyoblasts. i. er positive glands. which were examined histopathologically, and in terms of cytologic features, p and ki immunoexpression. results: cervical smear samples from patients were diagnosed as agus, ascus, asc-h, hgsil, lgsil cases three types are generally acknowledged: circumscriptum (or capillary), cavernous, and cystic. -years-old female. method: case report: a -years-old woman presented to the department of obstetrics and gynecology at our hospital. for uterin myoma, she underwent total abdominal histerectomy and bilateral salpingo-oophorectomy congress hall foyer rd floor ps- poster session dermatopathology atypical spitz tumor or spitzoid melanoma: which morphological criteria ensure the diagnosis? method: thirty-one spitzoid lesions were reviewed by a scoring system based on seven selected criteria reported previously appreciating characteristics of spitzoid lesions. as a prevailing criteria, presence of deep mitoses had a score of ; ulceration, asymmetry, epidermal consumption, solid growth pattern, loss of maturation, pigment heterogeneity were scored as for each. final diagnosis was sm for scores - , ast for - , sn for . results: the most frequently seen criteria, loss of maturation was solid growth pattern and pigment heterogeneity were nearly equally seen in sm and ast. first diagnoses of sn switched to ast, to sm, and of ast to sm. conclusion: presence of deep mitoses is the single criteria present only in sm. loss of maturation, epidermal consumption and ulceration can be used to differentiate ast from sm basal cell carcinoma (bcc) of the skin is the most common form of human cancer. sometimes the histological appearances of benign adnexial neoplasm of hair follicle apparatus tumors (trichoepithelioma, trichoblastoma) are diffucult to distinguish from bcc. the aim of this study is to investigate the usefulness of cd and p in distinguishing bcc and benign adnexial neoplasm of hair follicle apparatus tumor. method: this study included bcc and benign adnexial neoplasm of hair follicle apparatus tumor. we used immunohistochemical stains for p and cd in all cases. results: in bcc cases the expression of cd was noted in tumor cells in cases objective: a widely accepted adequacy criteria for histopathologic evaluation of prostate core biopsy protocols has not been defined yet. selection of patients for repeat biopsies after a negative initial biopsy result is also a matter of debate. we aimed to evaluate the impact of total core length for detecting prostate cancer in a -core transrectal ultrasound guided biopsy scheme. method: retrospectively, we investigated the core lengths of patients underwent initial prostate biopsy by a lateral zone targetted -core protocol between and . results: cancer was identified in ( . %) patients. mean total core length for positive and negative patients were . cm and . cm, respectively. cancer detection rates in groups for total core length < cm, - cm, and > cm were . % ( / ), . % ( / ), and . % ( / ), respectively. when a threshold of cm was selected for total core length, overall cancer detection rates for < cm and ≥ cm groups were . % ( / ) and . % ( / ), respectively. conclusion: although molecular confirmation remains its diagnostic gold standard, tle , ema, bcl- , mic , cks and cd constitute an optimal for sy-novial sarcoma. awareness of tle expression in other tumors and its correct interpretation are necessary. objective: malignant peripheral nerve sheath tumors (mpnst) comprise - % of sarcomas. prognosis is poor and the search for new treatments is ongoing. her is a crucial receptor for neuregulin signalling in schwann cells but to date, has not been studied in sarcomas. our aim was to determine the prevalence of her receptor expression in soft tissue tumors, including mpnst. method: her expression was evaluated by immunohistochemistry in a total of benign and malignant mesenchymal tumors, including neurofibromas, schwanomas, mpnst and other lesion (uterine and non-uterine leiomiomas and leiomiosarcomas, synovial sarcomas, undifferentiated pleomorphic sarcomas (ups)). results: her overexpression was found in % of cases. significantly, her positivity was present in ps- - breast cancer in young czech women: an institutional review f. sobande * , a. ryška * dept. of pathology, hradec kralove, czech republic objective: breast cancer in young women poses unique diagnostic and management challenges however, very few large studies investigating clinico-pathologic and immunophenotypic characteristics within this group exist and varied, arbitrary age-limits are used to define 'young'. method: an institutional archive search was performed for breast cancer diagnosed in women < in [ ] [ ] . age at diagnosis, tumor histological type and grade, estrogen and progesterone receptor (er and pr), her /neu, ki- and p status as well as clinical course during the follow-up period were recorded. patients were sub-classified into agegroups of -year intervals for statistical analysis. results: ninety of carcinomas were diagnosed in women < . they frequently displayed aggressive morphology, high proliferative activity, increased expression of p and high incidence of lymph node metastasis. we found a statistically significant decrease in her /neu over-expression with increasing age using as the cut-off (< : %, ≥ : %; p= . , chi-square test). no significant age-related differences in er or pr expression were observed within the group of women < . conclusion: we show that should be used as the cutoff for defining young women; in whom breast cancer is most likely to over-express her /neu. the mechanisms behind this finding and its significance are yet to be elucidated. objective: osna is a molecular assay for lymph node in breast carcinoma (bc) based on m-rna detection of ck . the aim of this study is to evaluate the rate of negative o heterogeneous immunohistochemical expression of ck in bc. method: ck was assessed in consecutive samples. cases were categorized as positive, negative and heterogeneous. other parameters recorded where histological type and grade (nottingham) and molecular subtype (st. gallen ). results: cases ( . %) were ck +. ten ( . %) were ck -and ( , %) were heterogeneous. there were intraductal carcinomas, heterogeneous and ck -. among invasive carcinomas, there were ck -: ductal, papillary and metaplastic. three cases corresponded to g , g , g and t mi not available. five cases were luminal a(la), luminal b/her -(lb-), her + and triple negative (tn). among heterogeneous cases, were ductal, metaplastic, and atypical medullary carcinoma. eleven were g , and g . four were lb-and cases were tn. conclusion: all lobular carcinomas expressed ck ck was negative in . % and heterogeneous in . % of bc. they represent a heterogeneous group but half of these cases are either g or tn. % of heterogeneous cases were tn and % lb-with no la cases in this subgroup. case report of an extremely rare tumor of the breast: mucoepidermoid carcinoma f. staniceanu * , c. socoliuc, a. birceanu, e. gramada, l. nichita, r. andrei, a. croitoru * colentina university hospital, dept. of pathology, bucharest, romaniaobjective: staniceanu and socoliuc are first authors in equal proportions mucoepidermoid breast carcinoma, classified in category of purely epithelial metaplastic carcinomas, is rarely encountered with only a few female cases described in literature. it is composed by mucous, intermediate and epidermoid cells, similar to its salivary gland counterpart. method: we present the case of a years old man with a , / , cm breast tumor located under the nipple, poorly circumscribed, with increased consistency and central cystic area containing serous fluid. tissue samples were preserved using % formalin. all sides were stained using hematoxylin-eosin. immunohistochemistry was performed using labeled streptavidin-biotin method. results: microscopic examination reveals islands and sheets of polygonal cell with clear/pale cytoplasm, "signet cells" figures, areas of squamous metaplasia and centrally located hyperchromatic nuclei, some with visible nucleoli and rare mitoses. tumoral parenchyma contains ducts and cysts of varying sizes, with pale eosinophilic luminal accumulation pas, d-pas and alcian blue positive (mucin). immunohistochemical tests were performed. differential diagnosis was made among several benign and malignant lesions, the final diagnostic being mucoepidermoid carcinoma, low grade. conclusion: mucoepidermoid carcinoma of the breast is an extremely rare entity; however its specific morphologic and prognostic features (similar to its salivary gland counterpart) allow proper diagnostic. endomyocardial biopsy value in differential diagnosis of hypertrophic cardiomyopathy j. markovic * , i. ranisavljevic katuca, s. glumac, r. jankovic, j. d. vasiljevic * clinical center of serbia, dept. of pathology, belgrade, serbiaobjective: endomyocardial biopsy (emb) may be used to diagnose different types of cardiomyopathies, to monitor transplant rejection, evaluation of myocarditis, heart failure of unknown origin, arrhythmias, drug toxicity and heart neoplasmas. the aim of this case is to show how noninvasive cardiac investigations are sometimes not sufficiently conclusive for distinguishing between hypertrophic obstructive cardiomyopathy (hocm) and the other cardiac diseases.method: thirty-one representative left ventricle biopsies were obtained following suspected hocm. samples underwent routine standard and special staining procedures. five histologic parameters were used for assesment (disarray and hypertrophy of myofibers, myocardial short runs, perinuclear halo and bizarre nuclei and fibrosis) and graded from to , presenting in summary histological hocm index (hhi-ranging from to ). results: the histological findings in emb of thirty-one patients, in ( , %) patients hocm diagnosis was confirmed, in ( , %) patients hhi was under or equal to % ( ) so hocm diagnosis couldn't be confirmed, amyloidosis in one ( , %) patient, myocarditis in ( , %) patients, dilatative cmp in ( , %) patients and unspecific cardiac changes in ( , %) patients. conclusion: a definitive diagnosis can be obtained by means of a multidisciplinary approach including emb findings. morphometric study of structural changes in the heart of people who abused alcohol for more than years l. mitrofanova * , e. naumova * almazov federal heart, blood and cardiomorphology, st. objective: the information about structural changes in the heart of people abused alcohol (paa) is very contradictory. method: we studied hearts of paa (> g per day), hearts of patients with ischemic heart disease (ihd) and hearts of healthy persons. at the morphometric study of heart we measured the mean cardiomyocyte diameter (mcd), the relative areas of fatty infiltration (fi), fibrosis, cardiomyocytes. immunohistochemistry was performed using antibodies against cd -antigens to count the number of antigen-positive cells per mm². the average heart weight, the mcd of the paa were not significantly different compared to the ones of the control group. the average relative area of fi of rv for the group of paa was ± % and was significantly different compared to the one of both the control group and the group with ihd. the relative area of rv fibrosis in the group of paa was . ± . % and was not significantly different compared to the ones of the other two groups. the mean number of cd + lymphocytes/mm² of % of paa was more than . conclusion: the paa did not have myocardial hypertrophy. % of them had chronic myocarditis. marked fi in paa was significantly higher than the other two groups. objective: the aim of the study was to evaluate the expression of angiotensin-converting enzyme (ace- ) in left ventricular myocardium in the presence of chronic myocardial ischemia. method: heart specimens with persistent ischemia (n= , pre-infarction ischemic heart disease (ihd) group) and postinfarction scar (n= , post-infarction ihd group) from dissected males and heart explants (n= , end-stage ischemic heart failure group) were studied. heart specimens (n= ) selected at autopsy from individuals who died from accidents were used as controls. the slides of myocardium were incubated with polyclonal antibody against the ace- ( : , ab , abcam). results: ace- expression in cardiomyocytes of the preinfaction ihd and post-infarction ihd groups did not differ from the controls and was increased only in the end-stage ischemic heart failure group (p< . ). ace- expression in vascular endothelial cells, smoth muscle cells and macropages of the pre-infarction ihd group did not differ from the controls; but the number of ace- expressing cells in the post-infarction ihd and in the end-stage ischemic heart failure groups was greater, as compared with the pre-infarcion ihd group and the controls (p< . ). conclusion: expression of ace- is increasing in progression of ischemia-induced myocardial dysfunction. thrombotic occlusion of the peripheral pulmonary arteries: anatomical "trigger" of the massive pulmonary thromboembolism (pte) f. portelli * , f. p. busardò, l. gutsul, p. fleres, p. pugnetti, e. orlando, e. maresi * university of palermo, section of pathology, italy objective: tubulocystic carcinoma of the kidney (tcrcc) is a rare variant of renal tumor showing unique gross and microscopic features. several recent studies favour its inclusion within the papillary renal cell carcinoma (prcc) group. method: patient was a year-old man with a left asymptomatic renal mass incidentally discovered by sonography. patient was a year-old man with aortic estenosis and coronary disease. a right renal mass was discovered in the work up for aortic valve replacement and coronary bypass. results: both tumors were well circumscribed masses with "sponge-like" appearance. on light microscopy, the tumors were composed of ectatic tubules and cysts of variable size, lined by a single layer of tumor cells with eoshinophilic cytoplasm, apocrine appearance, rounded nucleus sometimes overlapping, and prominent nucleoli. ihc showed positive staining with ck , e-cadherin, cd , and amacr. conclusion: tcrcc has been recently recognized as a distinct subtype of prcc by some authors. in fact, some few cases reported have histological transition between tubulocystic and papillary phenotypes on routine histological sections. additionally, tcrcc shows trisomies of chromosomes and . the exact location of this tumor within the who classification is a matter of debate. objective: our purpose is to evaluate her protein expression in urothelial carcinoma of the bladder. her /neu is a tyrosine kinase receptor (family of human epidermal receptors), showing overexpression in a large variety of tumor cells. method: bladder biopsy and cystectomy specimens were included in this study. the age of the patients ranged from to (mean ). among them ( . %) were male and ( . %) female. all cases were reevaluated histopathologically according to who grading system. her protein expression was detected by immunohistochemistry (cb ) using the same criteria as for breast cancer. results: all bladder neoplasms were low-or high-grade urothelial carcinomas. her protein overexpression was observed in ( . %) cases ( +: cases and +: cases), while ( . %) cases were negative ( : cases and + : cases). among her positive cases ( %) were high-grade carcinomas, while ( %) was low-grade carcinoma. among negative cases ( %) were lowgrade carcinomas, while ( %) were high-grade carcinomas. conclusion: these findings indicate that her protein overexpression is predominately correlated with high tumor grade in urothelial carcinoma of the bladder and patients with these characteristics could be potential candidates for targeted therapy. mucinous adenocarcinoma of the renal pelvis: a case report and review of the literature m. otani * , t. tsukamoto, h. serizawa * tokyo medical university, division of diagnostic pathology, japanobjective: primary mucinous adenocarcinoma of the renal pelvis is extremely rare and about cases have been reported to date. we present a case of mucinous adenocarcinoma followed by renal cysts. method: the patient is a -year-old male. a renal cyst in the right upper region was found incidentally. he had no symptom at that time. after years, he came to the hospital because of hematuria and back pain. the examination revealed that the renal cyst was enlarged accompanied with solid lesion. the high serum level of cea indicated malignancy and tumorectomy was performed. results: macroscopically, a renal cyst ( × mm) in the right upper portion was adjacent to a solid mass ( × mm). the tumor showed papillary growth ( × mm) in renal pelvis. microscopically, the tumor was consisted of adenocarcinoma with tubular or papillary structure, spreading from cyst wall to pelvis. the tumor cells contained mucin and some showed signet-ring celllike feature. conclusion: clinically, high serum level of cea is a marker of mucinous adenocarcinoma originated from renal pelvis. in our case, the tumor has already from pelvis to cyst wall. we thought it originated form renal pelvis, however, the renal cyst is also a candidate for its origin. results: an cm tumour was revealed in douglas cavity, histologically, deciduoid morphology was predominant with abundant atypical mitoses and massive neutrophyls infiltration. immunohistochemical positivity: calretinin, cytokera-tin - , cam . , cytokeratinae ae , e-cadherin, vimentin, hmbe , ca and negativity: cd , cd a, melan-a, myod , wt- , cd , hmb , actin, thrombomodulin, desmin, alpha-fetoprotein, moc , cerb- , estrogen and progesterone. normal dna-repair proteins expression. conclusion: mdm is highly aggressive neoplasm, differential diagnosis includes: squamous carcinoma, gist, deciduosis pseudotumoral, anaplasic large cell lymphoma, trophoblastic tumour, oxyphilic variant of ovarian clear cell carcinoma. this case represent a rare variant of mesothelioma, in which, was possible a complete resection with a probably better pronostic unlike most of these cases. objective: we evaluated morphological features of male gonad in an adult patient with tfs with an accent on its immunohistochemical properties. method: our years old patient had a primary amenorrhea. external genitals were female, without pubic and axillary hair. us confirmed cystic formation of the left gonad and lack of uterus. tumor markers were normal but testosterone was high. cystic formation of the left gonad was surgically removed, initially specified as a left ovary, as well as the other gonad. pathohistological examination and karyotyping was done. results: immunohistochemical analyzes of the gonad sample reveal that sertoli cells showed positivity for inhibin α, vimentin, cd , ckae /ae and calretinin and leydig cells showed positivity for inhibin α, vimentin, cd , ckae /ae and calretinin, and weak positivity for s- , synaptophysin i nse. immunoreactivity for cd in hyperplastic areas of leydig cells showed the most intensive conclusion: we conclude that cd and p expression may be a useful adjunct marker in distinguishing bcc and benign adnexial neoplasm of hair follicle apparatus tumor. objective: pigmented purpuric dermatosis (ppd) comprises a group of vascular disorders of unknown etiology. histologically, it is characterized by lymphocytic capillaritis in the papillary dermis. method: a retrospective and monocentric study concerning the cases of ppd diagnosed in the department of anatomopathology la rabta over years (from to ). these cases were studied clinically and histopathologically. hepatitis c and b profile was carried out to evaluate a possible relation. results: cases of ppd have been diagnosed; men and women, aged from to years. only one patient tested positive for hepatitis c with an elevated viral load. she had a profuse eruption involving the trunk and the limbs of years duration, contrary to the other patients in whom only the lower limbs were affected. she has been treated by alpha interferon and ribavirin with a disappearance of the eruption within months. in the five other patients, the lesions resolved spontaneously within a period of to months. conclusion: hepatitis c may play a role in the pathogenesis of ppd especially when the lesions are profuse and longstanding. in our patient, the disappearance of lesions months after the onset of interferon alpha therapy with a significative decrease of viral load is an argument supporting our hypothesis. objective: fibrolipomatous hamartoma of nerve is a benign lesion, very rare in medical practice, occurring in children or young adults. case report: a year old woman, g. n., presented with a slowly growing plantar mass in the right foot that had been present for years. neither the patient nor members of her family had a history of neurofibromatosis or other soft tissue tumors. she had no pain at rest, but she had shooting pain while running or walking. physical examination revealed a mobile, tender mass located in the plantar soft tissue. method: after surgical excision, the lesion was well circumscribed, / / mm, white colour with yellow areas. tissues specimens were fixed in % buffered formalin, routinely processed and embedded in paraffin, sectioned at μm, then stained routinely by hematoxylin -eosin, than examined by light microscopy. results: the lession is characterized by proliferation of mature fatty and fibrous tissue within the epineurium of the nerve accompanied by prominent concentric perineurial fibrosis. the histopathological diagnosis was fibrolipomatous hamartoma of nerve. conclusion: the tumour usually affects nerves of the upper extremities, most commonly the median nerve. involvement of other nerves is rare. the lesion is benign and the recommended treatment is surgical excision. objective: leishmaniasis refers to the spectrum of diseases caused by leishmania species, which are protozoa of order kinetoplastida. clinically leishmaniasis is divided into visceral (kala-azar), cutaneous, mucosal, and mucocutaneous syndromes. the final diagnosis of the disease, lesions of the parasites, as well as shown smear'lerde factor confirmed by histopathological and clinical evaluation. method: in our study, patients with the diagnosis of leishmania cutaneous between and in department of pathology, ataturk university faculty of medicine were presented. results: four ( . %) cases were females and ( . %) were males. age ranging of cases was found from to years and median age . ± . years. the lesions were found on the face in patients. facial skin biopsy specimens were taken in all cases. giemsa-stained touch preparation of the skin biopsy revealed amastigotes inside macrophages, consistent with leishmaniasis. lesions of patients who have long been different from the rest of them were those who migrated to the cukurova region. conclusion: leishmaniasis is public health problem in southeastern anatolia region of turkey, especially in sanliurfa and Çukurova region. autoimmune blistering skin diseases in east anatolia n. gursan * , o. ceylan, h. bilen, n. akdeniz, m. atasoy * ataturk university, medical faculty, erzurum, turkeyobjective: autoimmune blistering skin diseases can be divided into pemphigus diseases and subepidermal bullous diseases. in pemphigus, the autoantibodies are directed against intercellular contact structures; in the pemphigoid diseases, the autoantibodies are directed against adhesion molecules of the basal membrane zone. method: a retrospective study of cases of autoimmune blistering skin diseases obtained over a period of years from st october to st december in the department of pathology, medical faculty of ataturk university was designed. results: in the present study, the mean age was years and male: female ratio was , . the most commonly affected sites were the buccal mucosa and the palate. % of cases, the oral cavity was the primary site of involvement. in histopathological examination we showed intraepithelial vesicle formation, subcorneal separation with acantholysis, and the presence of tzanck cells in biopsy specimens. conclusion: the incidence of autoimmune blistering skin diseases in our department increased in the past years. pemphigus vulgaris is the most common of these diseases. % of autoimmune blistering skin diseases was pemphigus diseases. objective: acute febrile neutrophilic dermatosis (sweet syndrome) is the most common neutrophilic dermatosis. a dense dermal neutrophilic infiltrate is the usual histological findings. the absence of histological image of vasculitis has been considered a characteristic of the disease and a distinctive feature of the other neutrophilic dermatoses. however, recent reports suggest that vasculitis should not exclude the diagnosis. method: this retrospective study examines cases collected over a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . we studied its clinical and histological characteristics. skin biopsy specimens were reviewed to determine the prevalence of vasculitis. results: sweet syndrome is significantly more common in women than in men (sex-ratio= / ). the patient's mean age was years. disease developed most often in autumn. atypical presentation was noted in patients. skin biopsy revealed a sweet syndrome pattern in all cases. the prevalence of vasculitis (vessel wall damage with fibrinoid necrosis) was % ( of the patients). conclusion: our series of patients is particular by the frequency of atypical clinical presentation and the presence of vasculitis in histologic examination, a feature that shouldn't exclude the diagnosis. it was suggested that vasculitis in sweet syndrome represents an epiphenomenon rather than a primary immune-mediated process. dermal lymphangitic carcinomatosis as a primary manifestation of lung carcinoma: report of an unusual case c. hadjileontis * , e. angelidou, a. kafanas * serres general hospital, dept. of pathology, greeceobjective: although dermal lymphangitic metastases are reported to range between and , % of all visceral carcinomas, their presence as a primary manifestation of the tumor is rather unusual. different structures (isolated or forming small clusters) with the morphological characteristics of amoeba trophozoites were identified in the areas of necrosis with and without an inflammatory reaction. the diagnosis of cerebral amebic abscess was then made. the patients received antibiotic treatment. conclusion: cerebral amebic abscess is rare but has poor prognosis. it should be considered as a diagnosis for any patient with subacute and/or chronic meningoencephalitis without evident bacterial etiology. more effective antibiotic drugs can be chosen for post-surgical treatment; furthermore, better survival may be achieved by diagnosing the disease in early stages. morphometric characteries of women placenta which can be different forms of syphilis m. bokhodir * , g. raimnazarova, z. parpiev * tashkent medical academy, dept. of patological anatomy, uzbekistanobjective: many literary information give us about getting down coefficient of fertitity -placenta at women which suffer from pregnancy with syphilis. method: verified data analysis about morphometric placentae and it's comparison with newly-born child at women which suffer from different forms of syphilis. results: research placenta with syphilis show us the area of placenta surface is decreased, it was formed primary syphilis − ,+− , sm, secondary − , ± . sm and with latent form of syphilis , ± . (at control . ± , sm p> o.l), at that time as a mass, placentary cell was been bigger and it formed (at primary- . ± . gr and at secondary- , ± , gr and at latent form of syphilis . ± . gr, then in control ( , ± , ) but all this different were been statistically unreliable (p> , ). comporision mass of placenta and mass newly born-child show us corfficient of fertitity-placenta is make up ( , ± , ) and actually it is not different at control fact group. conclusion: the change coefficient of fertitity -placenta was typifying for until penicillin era, that time. when actual condition, treatment syphilis with antibiotic to bring on development phathomorphism placentae with out different coefficient of fertitity -placenta. influenza b virus-associated pneumonia: report of one fatal case associated with sickle-cell trait l. de carvalho * , l. avila, h. camargo, c. torriso, r. penny, a. sementilli * centro universitário lusíada, dept. of pathology, santos, brazil objective: influenza virus pneumonia complicated with acute respiratory distress syndrome is rare and has a high mortality rate. patients with sickle cell trait are asymptomatic, however, complications with increased risk of thromboembolism can occur. method: case report: a -year-old woman with no preexisting medical conditions presented nonproductive cough and fever for days. for the next days, developed acute respiratory failure. she was treated for septic shock and acute respiratory distress syndrome without success with death. expectoration and blood cultures were negative and the real-time polymerase (rt-pcr) of the thracheal swab was positive for influenza b virus. results: the autopsy showed a diffuse necrotizing alveolitis and intra-alveolar hemorrhage with pulmonary infarction. there was no histological evidence of bacterial pneumonia. an evident blood cell sickling was observed associated with sickle cell trait. rt-pcr was also positive for influenza b virus in pulmonary tissue and the immunohistochemistry was negative for influenza a virus. conclusion: severe hypoxemia caused by the acute respiratory distress syndrome was a possible cause of the blood cell sickling and thrombotic events. objective: lupus vulgaris (also known as "tuberculosis luposa") are painful cutaneous tuberculosis skin lesions with nodular appearance, most often on the face around ears nose, eyelids and lips, cheeks. ıt is still a major health problem in developing countries. cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis. lupus vulgaris (lv) is the most common form of cutaneous tuberculosis. lv should make differential diagnosis other granulomatous disease. all three cases of old female patient. conclusion: herein, three cases were presented which they treatment with correlation clinical and histopathological examination. objective: actinomycosis is a rare, chronic, and slowly progressive granulomatous disease caused by filamentous gram positive anaerobic bacteria from the actinomycetaceae family. it is often misdiagnosed because it can mimic conclusion: the mean length of appendix in both series was about . cm. there were no important difference of the length of either parasitic appendixes or all cause appendectomy materials. in this study, it is concluded that there isn't an effect of the length of appendix on the settlement of bowel parasites. objective: cystic hydatid disease (chd) is an infection produced by larvae of the parasite platyhelminth echinococcus granulosus. living in a rural area is an important risk factor for this disease. it is still an endemic disease in some regions of the world, particularly in many mediterranean countries. the organs most commonly affected are the liver and the lungs. method: we present a new case of multiple thoracic hydatidosis. results: we present the case of a -year-old caucasian man who presented chest pain and dyspnea. chest-x-ray showed a well limited cardiac opacity of the upper lobe and of the right lung. chest-ct-scan showed a mediastinal cyst evoking a hydatid cyst in the left ventricle associated to a right pleural effusion. the patient underwent surgery that consisted in the drainage of multiple pericardial cysts, cystectomy of a left ventricle cyst and right pleural cystectomy. microscopic examination showed a pleura-pulmonary and cardio-pericardial hydatidosis. the patient was treated with albendazole and did not present complications or recurrences after year of follow up. conclusion: multiple thoracic hydatidosis is rare. cardiac location is the most challenging because it is difficult to manage and is life threatening. treatment modalities are mainly based on surgery. preventive measures are necessary to avoid disease recurrence. objective: lymphadenopathy is frequently present in hiv positive patients, especially in those with severe immune deficiency and consequently elevated risc of opportunistic infections and neoplasms. considering the large spectrum of possible differential diagnosis a thorough lymph node analyses should be performed. method: we examinated peripheral lymph nodes from patients from latero-cervical, axilar, inguinal and supraclavicular regions; nodes ( , %) had diameter less then cm. results: histopathological findings indicated mycobacterial infection in patients ( , %), reactive hyperplasia in patients ( , %), lymphoma in patients, metastasis from kaposi sarcoma in and supurative inflamation in . clinically suspected lymphoma was microscopically infirmed in all cases. cases of tuberculosis, of lymphoma and of kaposi sarcoma metastasis were identified, all of them without prior clinical suspicion we identified tuberculosis, lymphoma and metastasis in , % of nodes smaller then cm. conclusion: in % of cases lymph node biopsy identified tuberculosis or malignancy, and established a reliable diagnosis in various clinical suspicions. we consequently emphasize the importance of lymph node examination in the evaluation of lymphadenopathy in hiv positive patients, even is not prominent. stăniceanu and nichita are first authors in equal contribution. the importance of autopsy in hiv infected patients objective: nowadays possibilities of medical investigations offer miriads of accumulating data regarding hiv infected patients status. correlation and/or validation of these informations with pathological findings is mandatory to establish in order to ensure appropiate management of hiv infection. method: we performed a comparative study between clinical/paraclinical and autopsy findings in some of the most frequent afected organs in hiv infection; we studied in hiv positive patients autopsied between and ; all patients had no or incipient (up to year) antiretroviral treatment. results: patients presented lung pathology, clinico-pathological correlations revealing discrepancies, total concordances and partial concordances. most of these inconsistencies referred to opportunistic infections, clinically suspected and pathological refuted in cases and clinically unsuspected and pathological identified in cases. clinically suspected neurological alterations were microscopically infirmed in , % of cases, while cases presented unsuspected lesions. opportunistic infections were key: cord- -n epxwn authors: nan title: ecr – final programme: scientific and educational exhibits date: journal: nan doi: . /s - - - sha: doc_id: cord_uid: n epxwn nan contrast enhanced ultrasonography (ceus) of pancreatic masses m. d'onofrio, s. vasori, u. rozzanigo, s. caffarri, n. faccioli, c. procacci; verona/it purpose: to evaluate the role of ceus in the study of solid and cystic masses of the pancreas. materials and methods: masses of the pancreas, found on conventional us, were studied with ceus, by using sonovue (bracco) on a sequoia (acuson). a dynamic observation from the early contrastographic phase (during arterial enhancement), to the late contrastographic phase (after venous enhancement) was possible. all the lesions were cytologically/histologically proved. the results were compared with those obtained at spiral ct and/or mri. seven distinct enhancement patterns were observed: ) rapid intense enhancement in the early contrastographic phases with microbubble entrapment in the late phase [ neuroendocrine tumors, metastases from hypervascular tumors, poorly differentiated carcinomas]; ) moderate enhancement in the early contrastographic phase, resulting hypoechoic in the late phase [ poorly differentiated carcinomas, acinar cell carcinoma, neuroendocrine tumors]; ) capsular enhancement in the earliest phases [ solid and papillary epithelial neoplasm; neuroendocrine tumor]; ) no enhancement [ ductal adenocarcinomas and neuroendocrine tumor]; ) progressive enhancement [ solid and papillary epithelial neoplasm]; ) "parenchymographic" enhancement [ inflammatory masses]; ) parietal nodules and septas enhancement [ cystic tumors] . results: ceus correctly characterized / ( %) solid pancreatic tumors. in particular all ( / ) the ductal adenocarcinomas were correctly diagnosed. small nodules and septas of pancreatic cystic tumors, not visible at conventional us, were detected at ceus. conclusions: ceus can demostrate macrocirculation and microcirculation of solid pancreatic masses and can improve the characterization of cystic pancreatic lesions. is dual-phase spiral ct adequate for the confirmation of resectability and preoperative staging of pancreatic carcinoma? s. mylona, l. thanos, a. pagonas, v. kalioras, s. lyra, n. batakis; athens/gr purpose: to present the value of dual-phase spiral ct for the confirmation of resectability and pre-operative staging of pancreatic carcinoma. materials and methods: in a period of years patients with pancreatic carcinoma underwent dual-phase spiral ct for preoperative staging. ct scans after iv administration of contrast material with an electronic injector were obtained in the arterial (scan delay = sec) and in the portal venous phase (scan delay = sec) under a protocol with a total volume of ml, flow rate ml/sec. we have correlated the ct findings with surgical-pathologo-anatomic findings. results: dual-phase spiral ct was positive for pancreatic carcinoma in patients ( . %). in patients it was false-positive ( . %). in ( . %) out of patients it showed hepatic metastases, in ( . %) out of patients it showed lymph node enlargement, in ( %) out of patients vascular invasion, and in ( . %) out of patients peritoneal metastases. the accuracy of the method was up to %. conclusion: dual-phase spiral ct is a safe, noninvasive, and accurate method to investigate pancreatic carcinoma and should be considered as the standard preoperative method for assessing lesion resectability. assessment of resectability of pancreatic head cancer with ct imaging g.g. karmazanovsky, v.a. kubyshkin, a.v. kotchatkov; moscow/ru purpose: to investigate the value of preoperative ct in assessment of resectability of pancreatic head cancer. methods and materials: eighty-nine patients ( males and females; mean age ) with pancreatic head adenocarcinoma were investigated with spiral ct with bolus intravenous contrast enhancement. all of the patients were operated on. whipple procedures were performed on patients and palliative operations were performed on patients. results: tumors of patients were considered unresectable. patients (group ) had tumors that were encircling superior mesenteric or portal veins ( pts), superior mesenteric ( pts) or hepatic arteries ( pts) completely. no fat layer was identifiable between the tumors and the vessels. patients (group ) had ct appearances of tumors that partially (less than / of the circumference and in less than mm) circumscribed the vessels. tumors of all group patients were not resectable with a negative margin. among group , four patients ( . %) had unresectable tumors; six patients ( . %) had tumors that were difficult to dissect from the vessels; patients ( . %) had no evidence of vascular involvement and in fact went through curative surgery. conclusion: the ct findings predicted correctly surgical findings in of unresectable tumors ( . %). when the tumor partially circumscribed the vessels ct was not to be relied upon in predicting whether or not the tumor was fixed against the vessels. contrast-specific ultrasound (cs-us) imaging of the spleen: a pictorial essay of traumatic and nontraumatic disorders a. nunziata , o. catalano , m. mattace raso , i. matarazzo , a. siani ; naples/it, pozzuoli/it learning objective: to illustrate the appearance of several splenic lesions as shown during real-time, contrast-specific, harmonic imaging. background: contrast-enhanced, low-mechanical index us is a new technique allowing continuous, real-time assessment of splenic abnormalities. in our institution we use the technology named contrast tuned imaging (esaote, italy) and we employ a second-generation, sulfur-exafluoride based, microbubble contrast agent (sonovue-bracco, italy). the contrast agent, at a volume of . or . ml, in injected through a peripheral vein and a g needle, using a three-way stopcock and a -ml normal saline flushing. imaging findings: a wide spectrum of splenic disorders is depicted: injury, spontaneous hematoma, abscess, capillary and cavernous hemangioma, lymphomatous infiltration, metastasis, splenomegaly, and accessory spleen. several potential pitfalls are also shown. conclusion: contrast-specific us is being used with increasing frequency in the evaluation of the spleen. this is a superficial organ, with an almost homogeneous echotexture and with a dense and persistent contrast-enhancement; these characteristics make the spleen an optimal organ to be studied with contrast-specific us. radiologists should be aware of the typical and atypical appearance of splenic disorders as shown at contrast-specific us imaging. the spleen: normal variants and pathologies (imaging review) s. vessal, a. anbarasu, s.b. rai, w. shatwell, r. ramachandra; birmingham/uk learning objectives: to familiarise with the normal anatomy of the spleen. to further demonstrate common variations and splenic pathologies encountered in clinical practice. background: the spleen is the largest single mass of lymphoid tissue seen in the body. we familiarise with its normal image appearance using ct, uss and mri. the pattern of contrast enhancement of the spleen during the arterial and venous phases in ct can mimic disease by forming pseudomasses. normal variants such as splenunculus, splenic clefts/lobulations, liver wrap-around, wandering spleen as well as congenital heterotaxic syndromes will be discussed. a spectrum of splenic pathologies are demonstrated and the list of differential diagnoses that should be considered when seeing splenomegaly, cystic lesions, solid lesions and splenic calcification. examples of splenic trauma -laceration, subcapsular and intraparencymal haematoma will be discussed and complications such as splenosis demonstrated. image findings: images of the spleen on plain radiography, ct, mri, uss and radionuclide imaging from our institution are demonstrated along with imaging protocols. conclusion: there are several normal variants of the spleen which should be readily recognised. congenital abnormalities of the spleen such as polysplenia are rare, this should not be misdiagnosed as splenosis. it is useful to assess the presence and extent of splenomegaly. further classification of parenchymal lesions into cystic or solid can be made. solid lesions can be further subclassified into those with calcification. this poster demonstrates some splenic pathologies, a clear list of differential diagnosis is essential in interpreting any splenic lesion. non-traumatic acute splenic lesions: role of ct f. garibaldi, y. hetmaniak, b. gallix, j.-m. bruel; montpellier/fr learning objectives: -to illustrate a pictorial review of various acute splenic pathologies of non traumatic origin. -to learn characteristic imaging features of spontaneous spleen rupture or splenic infarction. -understand the pivotal role of abdominal ct when acute splenic pathology is suspected. background: splenic pathology is rarely suspected in patients with acute pain of the left upper abdominal quadrant. ct imaging is a well established tool for splenic injury of traumatic origin but ct features of non traumatic acute splenic pathology are less known. the purpose of this exhibit is to review the main causes of non traumatic acute splenic lesions and to describe their specific ct patterns. b d e f a g procedures: material consisted of patients with acute non traumatic splenic pathology who underwent multiphase contrast enhanced ct examination of the abdomen. the medical report of these patients were reviewed. cases were categorized according to the presence of the main ct patterns we found: spontaneous rupture, ischemic lesion, abscess or pseudo cyst or complicated tumoral involvement. conclusion: helical ct, in association with patients history and biology results is accurate to characterize the severity and the causes of acute non traumatic splenic injury. the new ultrasound who-classification for diagnosis, staging and follow-up of patients with cystic echinococcosis (ce) w.p. hosch, g.w. kauffmann, t. junghanss; heidelberg/de learning objects: the new who-classification provides, for the first time, a standardized sonomorphological staging of echinococcal cysts. we demonstrate the clinical value of this classification with examples from our cohort of patients. specific signs supporting the diagnosis of ce, and criteria for assessing cyst viability are presented. this allows staging of cysts relevant for treatment decisions (surgery, percutaneous drainage (pair), albendazole or "watch&wait") and treatment monitoring. background: ultrasonography plays a central role for diagnosis and follow-up of abdominal ce due to problems regarding sensitivity and specificity of clinical symptoms and serological tests. this technique allows the staging of cysts with respect to the involution process (spontaneous and treatment induced). the treatment options of ce have broadened in recent years with percutaneous drainage (pair), medical treatment and "watch&wait" as preferable strategies over surgery for specific cyst stages. in a standardized classification has been published by who allowing inter-observer comparison of treatment decisions and follow-up. procedure details: patients with a follow-up of up to years have been seen in our referral centre for ce since . apart from patients with pulmonary lesions and patient with a spinal manifestation, all other patients had abdominal cysts ( hepatic, spleen, kidney, peritoneal). we evaluated the value of the who-classification for diagnosis, therapeutic decision making and follow-up. conclusion: on the basis of the who-classification ultrasonography is not only an excellent tool for the primary diagnosis of ce but also very valuable for clinical decision making and monitoring treatment response. the spectrum of manifestations of metastatic malignant melanoma c.s. ng, v. kundra, m.j. jacobson, j. szklaruk, d.g. bedi; houston, tx/us learning objectives: . to gain an appreciation of, and be alert in clinical practice to, the wide range of sites, both common and uncommon, of metastases from malignant melanoma, including the lymphatic, central nervous, and musculoskeletal systems, thorax, abdomen and pelvis. . to become familiar with the radiologic appearances of metastatic melanoma on ct, mr, and ultrasound. background: malignant melanoma is a tumor that is increasing in incidence throughout the world, with a widely varying prognosis and distinctly capricious behavior. if, and when, the tumor metastasizes it can spread in an expected manner; however, frequently both the timing and sites of dissemination can be entirely unpredictable. imaging findings: this exhibit will present the wide range of manifestations of metastatic melanoma throughout the body, including the lymphatic, central nervous, and musculoskeletal systems, chest, abdomen and pelvis, and soft tissues, as identified by the major cross-sectional modalities of ct, mr, and ultrasound. the hypervascular and hemorrhagic tendency of the tumor, and its typical mr signal characteristics, will be illustrated. the exhibit will demonstrate the typical sites of metastases, namely lymphatics, brain, lungs, and liver; but will also illustrate the wide spectrum of more unusual sites of dissemination, including meninges, pleura, pancreas, gallbladder, gastrointestinal tract, genitourinary tract, peritoneal cavity, skeletal muscle and bone. the illustrative examples will be correlated with the tnm staging system. conclusions: metastatic malignant melanoma has an extremely wide spectrum of manifestations. practicing radiologists should be alert to these manifestations. malignancies in the aids affected population other neoplasms such as cervical cancer, hodgkin's disease and others have been observed with an increased incidence, probably because of the longer survival of aids patients. the aim of our exhibit is to describe ct and mr features of aids related neoplasms. procedure details: we reviewed ctand mr findings of aids patients examined between - , amongst which demonstrated pathologically confirmed neoplasms. ct's were performed by using spiral (plus, plus , siemens, erlangen, germany), and multislice ct equipment (lightspeed ge medical systems, milwaukee, usa); mr examinations were performed by using a . unit (vision; siemens medical systems, erlangen, germany) . we demonstrated nhls, hodgkin's disease, ks, cervical cancers, leukaemias, testicular, larynx, lung, breast, esophagus, stomach, liver, kidney, and adrenal carcinomas, intrahepatic multinodular cholangiocarcinoma and stromal tumors of the gastrointestinal tract. / nhl showed extranodal involvement to the liver ( / ), brain ( / ), lung ( / ), pleura ( primary effusion lymphomas with lymphomatous cells in the pleural effusion and no identifiable tumor mass) and gastrointestinal tract ( / ). ks involved the gastrointestinal tract ( ), lung ( ), liver ( ), larynx ( ), muscle ( ) , adrenal gland ( ), spleen ( ), pancreas ( ) . conclusion: ct and mr proved useful in the evaluation of the variegate pathologic findings of aids related neoplasms. abdominal imaging of post transplant lymphoproliferative disorders (ptld) k. burney, i. lyburn, r. hopkins; cheltenham/uk learning objectives: this exhibit will review the pathogenesis, staging and abdominal imaging findings of post-transplant lymphoproliferative disorders (ptld) seen in cardiac, lung, renal and liver transplant organ recipients. background: post-transplant lymphoproliferative disorders (ptld) are a complication of immunosuppression in solid organ transplant recipients. we reviewed the imaging of patients with a histologically proven diagnosis of ptld treated at our sub-regional oncology unit over the past years. conclusion: ptld is estimated to occur in between - % of patients. clinical manifestations are variable ranging from focal disease with graft dysfunction to systemic illness. ptld may be unsuspected or more extensive than expected and imaging plays an important role in diagnosis, staging and follow-up. ct (and to a lesser extent us) is the imaging modality of choice. does clinical examination of polytrauma guide properly ct evaluation? a. kalai, y.k. maratos, t. loeb, o. clément, g. frija; paris/fr learning objectives: to know the new definition of polytrauma patient based on the risk factor. to know that a whole body scanner is indicated in polytrauma patient. to know the ct protocol in polytrauma. background: the evaluation of the polytrauma patient is still most of time based on regional ct oriented with the clinical finding. based on our experience in patients this exhibit purposes a systematic evaluation with whole body scanner. major findings and pitfalls are illustrated. procedure details: whole body scanner includes: axial head ct, cervical spine helical ct with sagittal and coronal recontructions, helical ct with contrast iv with an arterial phase on the thorax and portal phase an the abdomen and pelvis, sagittal reconstruction on the dorsolombar spine. the severity of the lesions after the clinical evaluation were compared to the iss (index severity score) after the whole-body scan. % of the patients had at least one missed lesion when compared to clinical assessment .the average iss of these patients was higher and there was a surmortality. conclusion: whole-body scanning is highly recommended for polytrauma victims in order to enable prompt and early treatment of lesions which might have been missed at the initial clinical evaluation. radiological exploration of the embalmed cadaver of eva peron c. gotta, a. buzzi; buenos aires/ar learning objectives: to exhibit for the first time a medical document of eva perón's embalmed cadaver. background: eva perón was juan domingo peron's wife (he was president in argentina between argentina between and argentina between , and between argentina between and . for her political and social action she is known worldwide. she died of a cervix cancer in . when she died, she weighed less than kg, so many people doubt that her embalmed cadaver (small and consumed) belonged to her. the cadaver was embalmed by dr pedro ara, professor of anatomy at the school of medicine of the university of cordoba. he was born in zaragoza, spain, and he was established in argentina in the decade of . professor ara carried out excellent work with eva peron's cadaver. contrary to the classical technique, eva peron's embalmed body conserves its viscera. imaging findings: when the régime was overthrown in eva peron's cadaver was deposited in the general confederation of work ("confederacion general del trabajo", cgt). the new authorities doubted of the authenticity of the cadaver. radiological exams were made by dr guido gotta (father of one of the authors), who confirmed that the body corresponded to a human being, and that there was evidence of neoplasia (abdominal nodules, bone metastasis). conclusions: besides its medical use, thanks to its capacity to examine the interior of bodies, since their discovery x-rays were used for other purposes. in this case, they were used to determine the authenticity of eva peron's embalmed cadaver. imaging of complications of drug abuse s. van background: the material is culled from our databank of the emergency department of our institution. the age of the patients in our series ranged between and -years-old. imaging findings: complications of drug abuse in the drug addict will be classified according to their pathogenic mechanism or by their way of administration. pathologically, complications are usually due to their vasoconstrictive and thrombogenic effect on different organs, including the brain (stroke), heart (myocardial ischemia), the gastro-intestinal system (ischemic colitis), the nose (nasal septum perforation due to cocaine snorting). a direct toxic effect of drug metabolites is another pathogenic mechanism resulting in tissue necrosis, as typically seen in liver cell necrosis due to ecstacy. the route of administration (intravenously, orally, inhalation or smoking) may also reflect the radiological presentation. local abscess formation, septic thrombophlebitis, septic pulmonary emboli or bloodborn infections result from intravenous access, whereas inhalation and smoking may result in pneumothorax, pneumomediastinum and epidural pneumatosis. indirect complications, such as an increased risk for traffic accidents can be attributed to the additive effect of a cocktail of drugs and/or alcohol. complications related to smuggling are due to accidental rupture of packed drugs in the gastrointestinal lumen. the radiologist should be aware of the possible causal relationship with drug abuse, especially when those complications are encountered in a young population. abdominal background: there is a broad spectrum of neurogenic tumors that involve the abdomen. in this exhibit, we will describe the variable radiologic findings of abdominal neurogenic tumors. this study included patients with abdominal neurogenic tumors which were confirmed histologically by surgical resection (n = ) or us guided biopsy (n = ). two radiologists reviewed radiologic findings retrospectively and correlated with pathologic results. imaging findings: we categorized them into groups by cell of origin; nerve sheath origin (schwannoma in , neurofibroma in , plexiform neurofibromatosis in , malignant peripheral nerve sheath tumor in ), paraganglionic cell origin (paraganglioma in , pheochromocytoma in ), and ganglion cell origin (ganglioneuroma in , ganglioneurofibroma in , ganglioneuroblastoma in , neuroblastoma in ). conclusion: although abdominal neurogenic tumors show a broad spectrum, some neurogenic tumors revealed characteristic radiologic findings and correlated well with pathologic findings. familiarity with various neurogenic tumors in the abdomen is helpful in the approach of the diagnosis. purpose: to illustrate the broad spectrum of imaging findings (ct, us, urography and barium contrast studies) of patients with proven abdominal tuberculosis. we review between january and july , the typical and atypical imaging findings of patients that had a final diagnosis of genitourinary ( ), adrenal ( ), bowel ( ), peritoneal ( ), and hepatosplenic ( ) tuberculosis. results: most patients had been at increased risk because of drug abuse, alcoholism, aids and steroid therapy. radiological findings included low density lymph nodes, splenomegaly, hepatomegaly, intrasplenic and intrahepatic masses, ascities, diffusely thickened and enhanced peritoneum, mottled low density masses in the omentum, pleural effusion, thickening of the bowel, adrenal enlargement, atrophy and calcification, fallopian tube fibrosis, uterine atrophy and adhesions, ureteral and bladder fibrosis, and different patterns of renal hydronephrosis and calcification. conclusion: patients with aids had more severe form of involvement than those who did not have aids. sonography was the only imaging modality to demostrate septations within the tuberculous ascites, but showed the fewest morphologic details in renal tuberculosis. ct is the imaging modality that best determined the extent of intrabdominal tuberculosis. recognition of these manifestations should help optimize the correct diagnosis and management of tuberculosis in order to obtain a favorable outcome, biopsy is mandatory in almost all cases. predictive to develop a predictive model for the presence of esophageal varices (ev) in patients with hepatic cirrhosis (hc). this model would limit the endoscopic screening to the group of patients with high risk of bleeding from ev. methods and materials: consecutive patients with hc were included in this prospective study ( men, women; mean age . ). physical and laboratory examinations, upper gastrointestinal endoscopy and doppler ultrasonography were recorded. patients were divided in two groups: ) no ev or small ev, ) medium or large ev. the distribution of clinical, biochemical, and doppler ultrasonographic variables were compared in each group. the u statistic of mann-whitney was performed for the quantitative variables, whereas the chi-square or the fisher's exact tests were used for the qualitative ones. variables were also included in a multivariate stepwise logistic regression model. a roc-analysis was performed. results: in the stepwise logistic regression, presence of medium or large ev was independently predicted by splenomegaly, decreased platelet count, hcv infection and a decrease of the maximum portal flow velocity (mpv). the discriminating ability of the prediction rule was high, with an area under the roc curve of . ( % ci: . - . ). conclusion: patients with hc should be screened by upper gastrointestinal endoscopy only if splenomegaly, low platelet count, infection by hcv and decreased mpv are present, since these parameters confidently predict the existence of medium or large ev. premier experience of multiphasic contrast material-enhanced dynamic study on . tesla magnetic resonance (mr) imaging t.-j. hsieh, g.-c. liu; kaohsiung/tw purpose: to evaluate the accuracy and sensitivity of a dynamic contrast material-enhanced three-dimensional ( d) volumetric breath-hold hepatic magnetic resonance (mr) imaging examination on a . tesla machine. methods and materials: . tesla mr imaging with serial multiphasic contrast material-enhanced dynamic study was performed in patients with hepatocellular carcinoma (hcc). all patients had pathologic comfirmation by fine needle biopsy and followed angiographies were performed in . months. each test result was interpreted independently by two radiologists. separate reading sessions were performed for images from the multi-phases. sensitivity and positive predictive values were calculated for each reading session. results: one hundred twenty-nine early-enhancing lesions were detected in the patients on the . tesla mr images. the followed angiographies showed hypervascular tumor stains. all the lesions showed in the mr images were identified in the angiographies. the breath-hold dynamic examination on . telsa showed a overall sensitivity of . %. conclusion: multiphasic contrast material-enhanced dynamic study on . tesla magnetic resonance (mr) imaging . tesla mr imaging is insensitive for the diagnosis of hccs. role the insulinomas are rare functional pancreatic neuroendocrine tumours. the most common clinical presentations include hypoglycaemia (< . mmol/l), confusion, and loss of consciousness. diagnosis is difficult, and performed by computed tomography, magnetic resonance or selective angiography of the pancreatic arteries by digital subtraction angiography (dsa). the aim of the study was to analyse head-to-head the diagnostic value of pancreatic dsa, computed tomography and magnetic resonance in patients ( female, male; ± years) with insulinoma. the diagnosis was established by pathohistology after the surgical treatment in all patients. the tumours were localised in the pancreatic body in / patients ( %), in the pancreatic tail in / patients ( %) and in / patients ( %) purpose: to estimate variants in the anatomic structure of the gallbladder, the biliary and pancreatic ducts and to develop a technique of research. material and methods: patients underwent complex mri using a . t unit. t w haste, t w turboflash, including fs, and mrcp (single-slice turbose and multi-slice haste in different orientations) were acquired. patients also examined with ercp. results: in % of patients the merger of the hepatic lobar bile ducts was extrahepatic. % revealed an additional right hepatic duct, more than half running into the common bile duct (cbd) low. the low fusion of the cystic duct and cbd was revealed in % of the patients, and its left arrangement in %. anomalies in the form of the gallbladder are revealed in % and additional pancreatic duct in % of patients. in % patients the main pancreatic duct and cbd had a common ampoule, in more than % of cases they enter the duodenum parallel, in % cases separately. it is expedient to study the mutual relationships of ducts, parenchyma and vessels with application of t -w haste. general submission about bile and pancreatic ducts and gallbladder allows receiving single-slice tur-bose. for better analysis of details of anatomic structure it is necessary to study of source images multi-slice haste in different orientations. the results of research especially are useful for planning of operative treatment. conclusions: complex mri, especially reception of t -w images and realisation of mrcp, is an excellent tool for revealing variants in anatomic structure of the gallbladder and ductal system. the clinical utility of diffusion imaging out of the central nervous system y. murakami , k. imoto , n. aito , t. sakamoto , m. yamasaki , a. furukawa , r. ito , k. murata ; kohka/jp, shiga/jp the clinical utility of diffusion imaging out of the central nervous system is not yet clear. the purpose of this prospective study is to determine the role and the clinical usefulness of diffusion-weighted mr imaging combined with conventional mr imaging for the detection of visceral disease without of the central nervous system. material and methods: one hundred and thirty-four cases who were referred to our hospital for the examination of visceral disease without the central nervous system (including cases with neoplasms and cases with inflammatory disease, upper abdomen; , pelvis; , other organ; ) were investigated. mr imaging ( . t) was performed using a diffusion-weighted single-shot spin-echo echoplanar sequence, t -weighted fast spin-echo sequence, and t -weighted spin-echo sequence. an experienced reviewer evaluated the diffusion-weighted mr images for the presence of a high-signal-intensity lesion and compared with other mr sequences. imaging findings were correlated with findings from histological specimen in patients and with findings from clinical follow-up examination in other patients. results: diffusion-weighted mr imaging depicted high signal intensity lesions, including cases with malignancy and five cases with inflammation, and a case of castleman's disease. in three patients with lymphomas, high signal intensity lesions reflected the activity of the disease process. there was no high signal intensity lesion in cases with eight adnexal diseases. conclusion: diffusion-weighted mr imaging out of the central nervous system may possibly be useful for the extent or the activity of malignant or inflammatory disease. evaluation of computed tomography for assessment in lipodystrophy syndrome j.a.g.s. gallego, f.m.a.i. ardoy, s.p.u. padilla, f.g.r. gutierrez; elche/es purpose: lipodystrophy syndrome (peripheral fat loss and/or visceral fat accumulation) is a main problem in hiv-patients treated with antiretroviral therapy. the diagnosis is based on physical examination and/or standardized questionaires so there is a need for quantitative diagnostic tools. the aim of this study is to evaluate computed tomography (ct) to measure fat distribution in hiv patients. methods and materials: hiv-patients ( men) were included. lipodystrophy was diagnosed clinically on . subcutaneous limb adipose tissue area and their percentage were measured by a single slice at mid thigh and mid arm by ct. the subcutaneous (sat), visceral (vat), and total (tat) abdominal adipose tissue as b d e f a g well as the vat/tat, sat/tat and vat/sat ratios were calculated by a single slice at umbilical level. results: vat/tat and vat/sat ratios were significantly greater in lipodystrophic than in non-lipodystrophic patients: . vs . , p < . and . vs . , p < . respectively in men. . vs . p < . and . vs . p < . in female patients. sat/tat and mid thigh fat tissue percentage were significantly lower in lipodystrophic patients: . vs . p < . and . vs . p < . respectively in men. . vs . p < . and . vs . p < . in female patients. no significant differences were found at mid arm. a vat/sat ratio > . for men and > . for women had a sensitivity of % and % respectively and a specificity of %, to diagnose lipodystrophy syndrome. conclusion: computed tomography may be a useful technique to quantify lipodystrophy in hiv-infected patients. withdrawn by authors ultrasonographic assessment of body fat distribution in type ii diabetes mellitus of insulin resistant type and its relation to anthropometric measurements n. previous studies have shown that in subjects with type ii diabetes mellitus of insulin resistant type there is a relation between cardiovascular diseases and obesity, insulin resistance and body fat distribution. in these patients body fat distribution assessed with dexa and antrophometric measurements were correlated with ultrasonographic fat assessments. materials and methods: subjects ( male and female with mean age of . ± . ) in whom type ii diabetes mellitus of insulin resistant type was diagnosed with homa (homeostasis model assessment) were enrolled in the study. their weights, heights, abdominal diameters, and gluteal diameters were recorded. body mass index (bmi, kg/m²) and the ratio of abdominal diameter to gluteal diameter (a/g) were calculated. subcutaneous (fatsc), preperitoneal (fatpp), and visceral (fatv) fat thicknesses were ultrasonographically assessed. results: there was a significant correlation between bmi and fatsc or fatv (p < . ); and between total fat ratio and fatsc and fatv (p < . and p < . , respectively). there was no relation between a/g and fatsc, fatpp and fatv. conclusion: ultrasonographically assessed subcutaneous and visceral fat thicknesses in type ii diabetes mellitus patients of insulin resistant type may be used as prognostic factors of cardiovascular diseases. withdrawn by authors c- mri of the upper abdomen using a new free-breathing navigator triggered t -weighted tse-sequence (pace-tse) c. klessen, p. asbach, r. kirsch, b. hamm, m. taupitz; berlin/de purpose: to evaluate image quality of a new free-breathing navigator triggered t -tse sequence (pace = prospective acquisition correction) for magnetic resonance imaging of the upper abdomen in comparison to a established standard breath-hold t -weighted sequence. materials and methods: prospective evaluation of consecutive patients with various pathologies referred to our clinic for mri of the upper abdomen. all patients were examined at . t (siemens magnetom quantum) using the following sequences: pace-tse (work-in-progress sequence, x matrix, fov mm, axial slice orientation, tr ms, te ms, turbo factor , slices, mm slice thickness, n = excitations), breath-hold haste sequence ( x matrix, axial slice orientation, tr ∞, te ms, slices, mm slice thickness, n = excitation). three independent abdominal mri experienced radiologists reviewed all images and evaluated motion artifacts, liver-spleen contrast, depiction of intrahepatic vessels, depiction of the pancreas and the adrenal glands and overall image quality on a -point scale. in addition, to directly evaluate the influence of the respiratory trigger technique, in patients the t -tse sequence was repeated with the respiratory trigger function switched off. results: mean examination time of the pace-tse was . minutes. the depiction of anatomical details and contrast was significantly better (p < . ) using the pace-tse sequence compared to the standard haste sequence. the pace-t -tse sequence has the potential to significantly im-prove recognition of anatomical details and contrast compared to standard breathhold haste imaging. reactive lymph node hyperplasia: a diagnostic problem in the staging of hodgkin's disease (hd) l. ilic-todoric, b. lukac; belgrade/yu purpose: therapeutic approach to hd requires determination of the disease extent to supra/infradiaphragmatic lymph nodes (ln) . a problem appears when ln are of borderline size or only slightly enlarged. should such a finding on ct be considered as reactive hyperplasia or a pathological finding? the purpose of this report is to solve this dilemma. methods and materials: infradiaphragmatic spiral ct scan was performed in patients with histologically confirmed supradiaphragmatic hd. bipedal lymphography represented the gold standard for final staging. taking reactive hyperplasia into consideration, we estimated and statistically analysed ct's ability to differentiate benign and malignant conditions, and its value for staging. results: lymphography showed infradiaphragmatic disease in % of patients, % of whom had enlarged ln, while in % ln were of normal size or smaller. of the total number of patients, reactive hyperplasia and lymphographically normal findings were found in % and % of patients, respectively. ct detected enlargement in % of patients, and in % of these this finding concurred with the lymphographic one. ct could neither detect affected normal/reduced ln, nor differentiate reactive from malignant hyperplasia. postlymphographic restaging of the disease showed that % of patients would be understaged and % overstaged on the basis of ct finding only. conclusion: reactive hyperplasia represents a risk of up/downstaging if staging relies on ct only. errors can be partially assigned to the inadequate interpretation of the ct findings, which cannot be taken for granted when ln are of borderline sizes. in such cases additional diagnostic procedures are necessary. purpose: to compare the diagnostic accuracy of mr (magnetic resonance) images with msct (multislice ct) for preoperative t-staging in patients suffering from cardiac cancer. materials and methods: mr and msct were performed in cases of cardiac cancer diagnosed by biopsy prior to operation. mr and msct scans were performed on two different days. mr sequences included fset w, fset w, fse t w with fat suppression and dynamic enhanced fspgr with fat suppression; msct was applied with dynamic triphasic contrast enhancement. all these findings were prospectively analyzed by two doctors separately and correlated with the surgery pathological findings. statistic work was performed with spss. results: according to histopathologic staging, the accuracy for t -staging detected with mr and msct were % and % respectively, % and % for t staging, % and % for t -staging, % and % for t -staging. compared with msct, dynamic enhanced and delayed mr with fat suppression was superior for revealing the involvement of esophagus and aorta, early stage of invasiveness and providing more evidence in t from t or t from t staging (p < . ). among these mr plain scan sequences, t w with fat suppression was outstanding in depicting the gross features of the tumor, presence of ulceration, and adjacent lymph node swelling. diagnostic accuracy determined by roc analysis was marginally higher with mr scan than with msct scan in t-staging of cardiac cancer. conclusion: mr is superior in t-staging of cardiac cancer and can be used to optimize the therapeutic strategy, thus avoiding unnecessary operation. multidetector ct and virtual endoscopy of the esophagus s. mazzeo, d. caramella, e. neri, p. giusti, c. cappelli, r. bertini, a. belcari, c. bartolozzi; pisa/it purpose: to assess the diagnostic capabilities of multidetector ct in various esophageal pathological conditions. methods and materials: thirty-three patients underwent a multidetector ct study after esophageal distension by means of effervescent powder administered after induction of hypotonia. all acquired images were post-processed with d and d software tools. the ct data was compared with the results of conventional radi-ology ( ), endoscopy ( ), or surgery ( ) . follow-up ranged between and months. results: esophageal distension in the upper and middle third was classified as "good" in / cases ( %); in the lower third, esophageal distension was "good" in / cases ( %). final diagnoses were: leiomyoma ( ), squamocellular carcinoma ( ), adenocarcinoma ( ), esophageal infiltration by thyroid cancer ( ), benign polyposis ( ), chronic esophagitis ( ), post-sclerotherapy stenosis ( ) , no abnormalities ( ). when good distension was achieved, the thickness of unaffected esophageal wall was < mm (range between . and . mm, mean . mm). pathological wall thickening was observed in / cases ( %) with values ranging between . and mm (mean . mm). spiral ct demonstrated true positive cases and true negative cases. there were false negative cases and false positive case. sensitivity was %, specificity %, diagnostic accuracy %, positive predictive value %, negative predictive value %. conclusions: evaluation of the esophagus with multidetector ct proved to be a promising and easy to use technique, allowing panoramic exploration, virtual endoluminal visualization, accurate longitudinal and axial evaluation, and simultaneous evaluation of t and n parameters. (ibd) . to describe the technique of barium tagged dark-lumen mrc. to outline the advantages, disadvantages and limits of the method. background: conventional colonoscopy (cc) is the most widely used method for the assessment of the extension and the activity of ibd. however, cc is an invasive technique and requires long-lasting bowel preparation. furthermore, not infrequently the examination of the entire colon and terminal ileum wouldn't be possible due to severe pain or fecal residue. these disadvantages are eliminated with barium tagged dark-lumen mrc which makes this examination more tolerable and acceptable by patients. imaging findings: ten patients who present with symptoms of ibd underwent cc first and subsequently mrc. for fecal tagging, barium sulphate-containing contrast agent is given with meals, beginning hours before the examination. for mrc the colon was filled with ml of diluted barium. after intravenous administration of . mmol/kg gd-dtpa, coronal t -weighted three-dimensional gradient-echo sequence is performed. additional fat-saturated axial two dimensional gradient-echo and coronal true-fisp sequences are obtained. colon segments are interpreted seperately (rectum, descending, transverse, ascending colon, caecum) when assesing the extent of the disease. bowel wall thickening and congestion of marginal vascularity are considered as signs of the disease. out of sixty segments, of them had colonoscopic correlation. of these in ( %) the extent of disease correlated with cc. non-correlation of findings of mrc and cc was detected in ( %) patients. conclusion: barium tagged dark lumen mrc can be used for the assesment of the extent of ibd. evaluation of ct gastric virtual endoscope (ve) findings: comparison with real gastric fiberscope (gf) lesions k. inamoto, k. kouzai, k. hamada; osaka/jp learning objectives: to check ve findings compared with gf lesions in cases. to learn about images of ve and to consider possibilities to use ve clinically. background: gf is an invasive examination for patients. if ve can be used for checking pathologies of gastric diseases it will be beneficial to detect malignant changes of the stomach in their early stage. procedure details: md-ct images were obtained on the same day as gf with somaton sensation , siemens, erlangen, germany. thin slice ct images with mm thickness were reconstructed to ve images by surface rendering and volume rendering with advantage workstation . _ . with volume analysis voxtool . . e, ge, milwaukee, wi.usa. results indicated that ve images succeeded in showing subtle alteration of mucosal folds. gastric cancer, polyp, ulcer, erosion and gastritis were clearly visualized. by comparison studies between ve and gf, a sensitivity . %, specificity . %, positive predictive value . %, negative predictive value . % and accuracy . % were calculated. conclusion: d md-ct examination of the stomach is noninvasive except for radiation exposure. it will be expected as a new technique of the stomach examinations. gastrointestinal stromal tumor: current concepts and imaging characteristics j.h. lee, k. kim, c. park, w. jeong, j. lee, e. kang, i. cha, h. seol; seoul/kr learning objects: to provide an in-depth review of gastrointestinal stromal tumors (gist's) with their epidemiology, histopathology, clinical manifestations and the most up-to-date therapy. to describe radiologic features of gist's. to discuss differential diagnosis of gist's throughout the abdomen. background: gastrointestinal stromal tumors (gist's) are unique neoplasms that occur throughout the gastrointestinal tract, mesentery, omentum, and retroperitoneum. they are the most common mesenchymal neoplasm of the gastroin-testinal tract and are defined by their expression of kit (cd ), a tyrosine kinase growth factor receptor. the expression of kit is important to distinguish gist's from other mesenchymal neoplasms such as leiomyomas, leiomyosarcomas, schwannomas, and neurofibromas and to determine the appropriateness of kit-inhibitor therapy. imaging features of gist's vary depending on tumor size and organ of origin. since most gist's arise within the muscle layer of the gastrointestinal tract, they most commonly have an exophytic growth pattern and manifest as dominant masses outside the organ of origin. procedure details: the purpose of this exhibit is to provide an in-depth review of gist's with their epidemiology, histopathology, clinical menifestation and differential diagnosis. this exhibit will also reflect our experience in the radiologic evaluation of patients with gist's, with emphasis on the typical findings present on small bowel series, ultrasonography and ct (including d images using multidetector ct). examples of unusual gist's and pathologic correlation as well as the most up-to-date therapy will be included. conclusion: after interacting with this exhibit the radiologist will have an enhanced understanding of gist's including histopathology and radiologic features. imaging of jejunal and ileal primary tumors with pathologic correlation b. rodríguez-vigil, m. lamas, t. berrocal, j. fernández, v. tarín, a. alvarez; madrid/es learning objectives: to illustrate the spectrum of usual and unusual primary neoplasms involving the jejunum and ileum. to evaluate the efficacy of barium studies, us, ct and mr imaging in the management of these tumors. to understand the radiologic findings on the basis of pathologic correlation. background: preoperative diagnosis of jejunal and ileal neoplasms can be a challenge for both clinicians and radiologists. symptoms are nonspecific and endoscopy is commonly unsatisfactory. since early diagnosis is crucial for prompt therapy, imaging plays an essential role. tumors develop in all histologic components of the small intestine including epithelial cells, lymphoid tissues, lymphatics, vessels, nerves, and muscle. imaging findings: we retrospectively reviewed the imaging findings of jejunal and ileal neoplasms from our digestive pathology database. findings were correlated with pathology in all cases. specific neoplasms addressed include benign (adenoma, leiomyoma, lipoma, familial polyposis, hemangioma, lymphangioma and fibroma); and malignant neoplasms (adenocarcinoma, carcinoid tumor, lymphoma, leiomyosarcoma, direct extension to the small bowel from extraintestinal tumors, and metastasic lesions). enteroclysis is the primary and most effective radiologic modality in the evaluation of these neoplasms. ct should be the complementary radiologic modality and used for staging. mri may help in specific cases. pitfalls, diagnostic difficulties and differential diagnoses are emphasised. conclusions: evaluation of patients with small bowel neoplasms frequently requires multiple imaging modalities for diagnosis and treatment planning. because of the characteristic imaging appearances of many of these tumors, this exhibit will help the radiologist in training to better understand and recognise jejunal and ileal neoplasms. imaging findings of sigmoid diverticulitis: a pictorial essay of anatomy, pathology, differential diagnosis and radiologic treatment options m.c. freund, j. bodner, e.m. gassner, m. rieger, a. gschwendtner, w.r. jaschke; innsbruck/at learning objectives: to understand the anatomy and pathology of sigmoid diverticula and of the mesosigmoid. to be familiar with the typical findings of different imaging modalities in sigmoid diverticulitis and its complications and differential diagnosis. to be familiar with percutaneous and endovascular radiologic treatment options including abcess drainage and embolization for diverticular bleeding. background: sigmoid diverticulosis and diverticulitis represents a commonly encountered disease in western countries. an exact diagnosis is a prerequisite for further therapy. imaging findings: different imaging modalities are proposed for detection of self-limiting or complicated sigmoid diverticulitis e.g. abdominal radiography, contrast enema, ultrasound and even catheter angiography. during the last years ct has evolved to be a primary diagnostic imaging modality in patients with left lower abdominal pain. this pictorial essay will demonstrate the relevant anatomy of the sigmoid, mesosigmoid, and vascular supply as well as the typical pathology of the diverticula and its inflammatory complications including diverticulitis, peridiverticulitis, perforation, contained abcess in the mesosigmoid or rarely free intraperitoneal perforation with peritonitis, as well as fistula formation, obstruc- the learning objectives: to depict the ct imaging spectrum of the faeces sign, which is a consequence of small bowel occlusion, and to illustrate its causes. background: abdominal ct scan has been shown to be the most valuable technique, in confirming the diagnosis of small bowel occlusion and to depict the site, level and cause of occlusion. very few studies have focused on the contents of the bowel. particulate faeces-like material mixed with gas bubbles within the lumen of a dilated small bowel loop is always a pathological condition. it is the result of a delayed intestinal transit. to access prevalence, characteristics of this ct sign, and differential diagnosis, we have reviewed ct scans of small bowel occlusion over a period of two years. imaging findings: our analysis suggests that the small bowel faeces sign is probably more frequent than the previous reported studies, in demonstrating cases of small bowel faeces sign mainly observed in the ileal loops, and pointing to the site of occlusion. faeces sign appeared as tubular gas bubbles mixed with particulate matter with no capsule in dilated segments of small bowel loop, due to adhesions, closed loop, and tumours (adenocarcinoma, carcinoid). differential diagnosis of two phytobezoars is also illustrated and discussed. conclusion: small bowel faeces sign may not be confused with colonic segments leading to a failure to recognize the exact level of obstruction. moreover, it represents a sentinel sign in determining the site of occlusion and consequently the cause of the obstruction. imaging appearances and predictors of disease response in metastatic gastrointestinal stromal tumours (gist) treated with imatinib s. cox, b. lanka, m.b. taylor; manchester/uk learning objectives: to evaluate changes in radiological appearances in patients with metastatic gist treated with imatinib. to highlight any specific imaging features that can be used to predict disease relapse. background: imatinib (glivec, sti- ) is a kit tyrosine-kinase inhibitor drug, recently developed and found to be effective in the treatment of metastatic gist. we reviewed the pre-and post-treatment imaging findings on ct in ten patients. the duration of treatment varied from two to forty one months. the pre-treatment, eight and sixteen weeks scans were reviewed, along with the scans at the time of any relapse. the sites of metastases, size of lesions and cystic change were assessed. imaging findings: metastases were present in the liver and peritoneum in seven patients each; mesentery and retroperitoneum in four and two patients respectively; splenic, renal and subcutaneous in one patient each. one patient had progressive disease at eight weeks. nine patients responded to treatment. the maximum reduction in size of the metastasis was at eight weeks. most metastases underwent cystic change with treatment, particularly in the liver and peritoneum. two patients are known to have relapsed at fourteen and fifteen months. in both cases, cystic metastases developed more solid components prior to disease progression as indicated by an increase in the tumour volume. conclusion: ninety percent of the patients responded to treatment. cystic change in the liver and peritoneal metastases correlates with disease response to imatinib. an increase in solid components may be a useful predictor of disease relapse. ct appearances of neoplasms of the small bowel as a cause of obstruction s. sadiq, d. markham; swansea/uk learning objectives: this poster presents a pictorial review of the ct appearances of primary and secondary tumours of the small bowel in patients presenting with obstruction, including neoplasms that are the lead point of an intussusception. background: patients presenting with small bowel obstruction in two district general hospitals over the last twelve months and who were subsequently investigated by ct were selected. the imaging features of those with a neoplastic aetiology were reviewed. image findings: the imaging reflects recent studies examining the incidence of primary small bowel tumours. adenocarcinoma, non-hodgkins lymphoma, carcinoid and leiomyosarcoma comprise the majority. secondary tumour deposits also lead to small bowel obstruction. we demonstrate those that metastasize intraperitoneally (such as ovarian carcinoma), haematogenously (such as melanoma), or by local tumour extension (such as liposarcoma and bladder carcinoma). conclusion: it is well established that ct is a valuable diagnostic procedure in patients with acute small bowel obstruction. it is not only useful in distinguishing obstruction from ileus, but frequently establishes the cause of obstruction. small bowel neoplasms are rare but have a high mortality since tumour-related symptoms occur late and are non-specific. endoscopy is not feasible in most cases, as enteroscopy is limited to specialist centres. small bowel contrast studies do not reach the high level of accuracy obtained in the evaluation of the upper and lower gastrointestinal tract. ct not only allows tumour detection, but demonstrates possible complications and offers the possibility of pre-operative staging in the acute or elective situation. ct in adult intussusception: radiologic-pathologic correlation c. triantopoulou, p. maniatis, i. siafas, n. giannakou, c. avgerinos, c. dervenis, j. papailiou; athens/gr learning objectives: review the ct characteristics of bowel intussusception in adults through a wide variety of cases. emphasize the ability of ct imaging in narrowing the diagnostic possibilities and defining the cause of intussusception. stress the need for familiarization with the different aspects of this rare entity. background: intussusception is a relatively common cause of intestinal obstruction in children but is a rare clinical entity in adults. however, there is a lead point in % of adult cases. cases of adult intussusception were retrospectively reviewed. all ct examinations were conducted on a spiral unit with administration of both oral and intravenous contrast agent, using slice thickness of - mm anda pitch of . site, level, cause and degree of obstruction as well as signs of threatened bowel viability were evaluated and correlated with surgical findings and pathology examination. imaging findings: cases of ileocolic intussusception and of ileoileal were revealed. in patients findings included: cases of polypoid lesions, malignant neoplasms, lipoma, inflammatory diseases and in adhesions due to preceding surgery. in the other three cases no underlying pathology was proven so they were characterized as idiopathic conditions. all neoplastic lesions were correctly depicted before surgery while in the case of lipoma a specific diagnosis was made. ct is a powerful tool in adult intussusception, providing valuable information regarding the involved enteric segments, the underlying pathology and possible local complications, thus assisting in preoperative planning. diagnosis of perforation of stomach or duodenum on multislice computed tomography j.-i. nishimura, t. ohkoshi, y. yamamoto, t. inoue; yokohama/jp learning objectives: a review to determine the variety and relative conspicuity of findings in patients with perforation of the stomach or duodenum. background: multislice computed tomography (ct) gives us detailed information as thin-slice sagittal, coronal, and -dimensional images rapidly. a small volume of free air can be detected, and the perforation holes were predicted in some cases. during a -year period patients with perforation of the stomach or duodenum underwent preoperative ct scans. there were men and women averaging . ± . ( to ) years old. all patients underwent to surgical treatment, and all sites of perforation were confirmed. imaging findings: levels of perforation were the antrum of stomach (n = ), body of stomach (n = ), duodenal bulb (n = ), and descending limb of duodenum (n = ). ct images showed local extraluminal gas near the perforation sites in patients ( %), local ascites near the perforation sites in patients ( %), edematous wall of perforation sites in patient ( %), dirty increased density in the fat tissue in patients ( %), and a perforation hole in patients ( %). diffuse extraluminal gas and ascites were showed in , and patients respectively. in of patients ( %), we could predict the level of perforation. conclusion: multislice ct is a valuable method in the diagnosis of perforation in stomach or duodenum. the diagnosis can be established rapidly with high sensitivity. defecographic imaging of anorectal sphincter dyssynergia syndromes: our experience in subjects a. nunziata , a. salzano , p. de feo , a. de rosa , f. de rosa , m. covello ; naples/it, frattamaggiore/it, napoli/it learning objective: anorectal sphincter dysfunction can be responsible for evacuation difficulties and constipation; in addition, pelvic floor disorders can be associated. by using defecography associated with videoproctography, the evacuation time and the sphincters' opening time can be assessed, obtaining further information about the physiopathology of rectal empting and anal sphincter function. the aim of this study is to have functional radiological parameters of anal activity to detect anorectal sphincter dyssynergia syndrome. background: on a consecutive series of patients suffering from constipation we assessed by defecography combined with videoproctography cases of sphincter dyssynergia syndrome ( males and females with mean age of years, range of - years). all patients underwent clinical examination and endoscopy; patients were investigated by anorectal manometry. imaging findings: in all patients defecography with videoproctography provided a sphinter opening delay > s (normal values: - s) and increased evacuation time > s (normal values: - s). manometry revealed anal hypertonia in cases. conclusion: defecography associated with videoproctography is an accurate, simple and non-invasive method to approach anosphincteral pathology, permtting study of this particular type of terminal constipation, which is difficult to demonstrate using other techniques. background: gist are rare mesenchymal tumors of the abdomen, for which an effective, molecular-targeted therapy with imatinib mesylate has been recently developed. imaging findings: pts with advanced gist ( / with liver lesions and / with peritoneal involvement) undergoing therapy with imatinib mesylate. all pts had a baseline mr, and then at , , , months during treatment. pts responsive to therapy ( / ) showed: a) tumor decrease in size (with an in-crease in tumor volume at months from treatment start in some cases ( %) due to necrosis or bleeding): b) hypointensity of the lesions on t w images (lesion was hyperintense in rare case due to bleeding) and hyperintensity of the lesions on t w images (correlating with the amount of degenerative tissue or necrosis): c) hypovascularization of the lesions on contrast-enhanced t w images in comparison to pre-treatment assessment, due to the presence of degenerative tissue or necrosis: e) evidence of peritoneal fluid in all pts at the first months, reabsorbed in the following months. conclusions: mri is useful to identify tumor response to imatinib mesylate in advanced gist as from the early months of therapy with the following indicators of treatment activity: a) size of lesions; b) signal intensity; c) vascularization; d) amount of degenerative tissue or necrosis; e) presence of peritoneal fluid. crohn's disease: spectrum of findings on helical contrast enhanced ct enterography a.j. madureira, r. cunha, p. varzim, f. magro, i. ramos; porto/pt learning objectives: to illustrate the spectrum of imaging findings of smallbowel crohn's disease at contrast enhanced spiral ct after oral hyperhydratation with isotonic solution (ct enterography). background: spiral ct has become one of the most valuable methods in the assessment of parietal inflammatory changes and extraluminal involvement in small-bowel crohn's disease. the accuracy of this technique depends on the presence of well distended bowel loops. procedure details: after oral hyperhydration with ml of isotonic polyethylene glycol electrolyte-balanced solution, contrast enhanced ct of the abdomen and pelvis was performed with a collimation of mm and mm, respectively. the following ct findings were evaluated: wall thickening, parietal contrast enhancement, extraparietal anomalies (lymph nodes, vessels and mesenteric fat), and presence of inflammatory complications (abscesses, fistulas). the spectrum of findings of small-bowel crohn's disease is thoroughly illustrated and discussed based on our experience with over patients. conclusion: this method provides important information about the extent and activity of small-bowel crohn's disease and its extraluminal involvement and is a potential alternative to small-bowel ct enteroclysis. bowel intussusception in adults: an imaging review h.d. roach, j.m. hanson, r. bagree, c. evans, a. yong; cardiff/uk learning objectives:to outline the mechanism and causes of intussusception in the adult population. to provide a review of the imaging findings in intussusception using several imaging modalities. background: bowel intussusception is more commonly associated with the paediatric population, but can occur in adults, affecting virtually any part of the gastrointestinal tract. in adults there is more often an underlying structural lesion, which acts as a lead point. imaging findings: bowel intussusception has a classical appearance on barium studies and cross-sectional imaging and occasionally a lead point can be identified. due to the underlying structural causes, surgery is more often required in adults than children, resulting in the availability of histopathologic specimens for correlation. however within the small bowel even in adults it has been shown that the majority of cases are self-limiting. in this exhibit, we review the imaging findings of intussusceptions affecting various sites in the gastrointestinal tract using different modalities. conclusion: bowel intussusception is less common in the adult population, but is often associated with underlying structural lesions. the imaging findings are reviewed here. can double contrast barium enema exams incidentally detect terminal ileum tumoral lesions? c. gotta, s. merola, e. sanabria, m. landi, s. ballester, c.a. dominguez; buenos aires/ar learning objectives: to describe a number of radiological signs, found in barium enema double contrast exams in patients, that are specific or suspicious of terminal ileum tumoral lesions. background: since there have been few reports about radiological signs in double contrast barium enema exams that can help in the diagnosis of terminal ileum pathology. some of them use glucagon to improve the reflux of contrast material through the ileo-cecal valve in order to allow the visualization of the reviewing the available literature, there are no reports which describe specific radiological signs on this matter. procedure details: a total of cases of tumoral terminal ileum pathology were found. all lesions were seen for the first time at the double contrast barium enema, and lately examined and characterized by the follow through or small bowel enema. in most of them abdominal computed tomography was performed. cases had histological confirmation based on surgical specimens. of the remaining cases, were lipomas with typical densitometric values diagnosed by computed tomography, thus these patients did not undergo surgery. the other lesions described as polipoid did not have histological confirmation as the patients refused surgical resection. conclusion: double contrast barium enema can detect the presence of terminal ileum tumoral pathology even when not yet clinically suspected. there are a few radiological signs which allow the radiologist to recognize and diagnose it. background: magnetic resonance is a powerful diagnostic tool for abdominal imaging, particularly for extra-visceral tissue depiction. newer pulse sequences, such as single shot fast spin echo (ssfse) and steady state free precession (ssfp) with a water solution infusion via naso-jejunal tube can accurately depict the bowel lumen in a fashion similar to conventional double contrast enema. furthermore d and d fast t weighted sequences with iv contrast administration allows the evaluation of wall involvement. imaging findings: findings are summarized into lumen abnormalities, wall involvement and extra-luminal alterations. corresponding dcsbe are shown and compared. signs of disease activity at mre plus conventional mri are stressed. contribution of different pulse sequences is evaluated. conclusions: mre plus conventional mri is feasible in the diagnosis, staging and follow-up of crohn's disease. subtle mucosal lesions are still poorly depicted, compared to dcsbe. extra-luminal involvement is superbly showed, particularly by new ssfp sequences. disease activity signs seem to be the added value of magnetic resonance in crohn's disease assessment. diagnosis and staging of colorectal carcinomas using multislice ct colonography (msctc): pictorial essay with pathologic correlation r. iannaccone, a. laghi, c. catalano, a. lamazza, f. mangiapane, s. trenna, d. marin, a. schillaci, r. passariello; rome/it learning objectives: to assess the role of msctc in the detection and staging of colorectal carcinoma. background: patients affected by colorectal carcinoma underwent colonoscopy and msctc on the same day. patients free of colonic lesions were included as a control group. ct parameters were: collimation, x mm; effective mas, - ; and kvp, . msct colonography was performed before (prone position) and after (supine position) intravenous administration of contrast material with a -sec delay-time. msctc images were interpreted by two radiologists on a workstation. the results of msct colonography were correlated with colonoscopy and with the results of the histopathologic examination performed on the resected surgical specimen. intra-operative ultrasonography was used as the reference standard for the presence of liver metastases. sensitivity and specificity for tumor detection and staging accuracy (according to the tnm classification) of msctc were calculated. imaging findings: surgery revealed carcinomas ( primary and synchronous lesions) in patients. colonoscopy failed to visualize the entire colon in patients due to obstructive neoplasms and missed all synchronous carcinomas. msctc provided a complete evaluation of the colon in all cases, correctly identified all primary and synchronous carcinomas ( / ; sensitivity, %), and yielded three false-positive diagnoses (specificity, . %). msctc also detected polyps ( true-positives and three false-positives). overall, msctc correcly staged of primary tumors (overall tnm staging accuracy, . %). conclusion: msctc can be proposed as a comprehensive diagnostic test for the pre-operative evaluation of patients with known, or strongly suspected, colorectal carcinoma. gastrointestinal to present the characteristic features of malignant gist and correlated these with histopathologic findings. background: in our pathologic database from to , we found patients with gist and retrospectively reviewed their radiologic findings. thirty one ct, four us, and four barium studies were included. imaging findings: involved organs were as follows; in the small bowel ( %), in the stomach ( %), five in the rectum ( %), two in the mesentry ( %) and one in the colon ( %). on histochemical analysis, eight were classified as benign ( %), six as borderline ( %) , and as malignant ( %). mean tumor size was . cm ( . cm- cm): benign (mean; . cm, range; . cm- cm): borderline (mean; cm, range; cm- . cm): malignant (mean; . cm, range; cm- cm). multiplicity was demonstrated in one benign and one malignant tumour. six cases showed microscopic metastasis to the surrounding lymph nodes without evidence on radiologic imaging. ct features were relatively smooth margination and homogeneous enhancement of smaller tumors. poor margination with surrounding infiltration, central necrosis or ulceration was seen in larger tumors. no evidence of intestinal obstruction, peritoneal seeding or ascites was demonstated. barium examination showed a well demarcated, smooth marginated tumor with normal overlying mucosa. some ulceration was seen in larger masses (bull's-eye sign). us features were welldemarcated homogeneous hypoechogenicity of small masses, hyperechoic foci of ulcerated masses. the characteristic radiologic findings of immunohistochemically kitpositive malignant gist were large tumor size, poor margination, central necrosis or ulceration. the clinical significance of each feature and differential points from benign gist or other conditions will be discussed. learning objectives: to illustrate ct findings of common and uncommon duodenal diseases with pathologic correlation. to demonstrate a comprehensive ct anatomy of the duodenum and adjacent organs. to describe the pitfalls on ct interpretation of duodenal diseases. background: the duodenum may be involved by secondary process as well as primary pathology because it is close to adjacent organs including the stomach, pancreas, liver, gallbladder, hepatic flexure of the colon, aorta, ivc, right kidney and adrenal. duodenal pathology can be overlooked on ct interpretation but understanding of ct anatomy of the duodenum and adjacent organs may be helpful in the diagnosis of various duodenal pathology. procedure details: helical ct during the portal phase with water as an oral contrast agent was performed for better detail of duodenal lesions. we reviewed ct findings with pathologic correlation in patients with various duodenal diseases. duodenal diseases were classified as follows; congenital (duplication, malrotation, diverticulum, and annular pancreas), trauma (intramural hematoma, iatrogenic perforation by endoscopy), inflammatory (perforated peptic ulcer, secondary process by pancreatitis or cholecystitis), primary neoplasms (lipoma, adenoma, adenocarcinoma, lymphoma, and gastrointestinal stromal tumors), secondary invasion of adjacent neoplasms (pancreas, stomach, colon, and gallbladder), bezoar, and postsurgical afferent-loop syndrome. conclusion: helical ct during the portal phase with water as an oral contrast agent provided a comprehensive view of the duodenum and adjacent organs. understanding of ct anatomy and the pitfalls on ct interpretation was helpful in the diagnosis of various duodenal diseases. to investigate utility of mr volumetry for resectable rectal cancer before and after preoperative concurrent chemoradiotherapy. methods: patients with respectable locally advanced rectal cancer underwent preoperative concurrent chemoradiotherapy. among them, patients ( men and women; median age years; range, - years) who had mri before, and month after concurrent chemoradiotherapy were enrolled into this study. radiation of gy/ fractions was delivered to the pelvis, followed by a . gy/ fractions boost to the primary tumor. chemotherapy was administered concurrently with radiotherapy and consisted of cycles of -fu ( mg/m / day) and leucovorin ( mg/m /day) for five days during the first and fifth weeks of radiotherapy. surgery was performed - weeks after the completion of chemoradiation. mr volumetric examinations for tumor volume before and after chemoradiotherapy were perfomed in workstation software using t -weighted axial images. results: according to dworak grade, grade was present in . % ( / ), grade in . % ( / ), grade and in . % ( / ), respectively. primary tumor downstaging occurred in . % ( / ). the mean tumor volume was . cm ( . - . cm ) in mr volumetry before chemoradiotherapy and . cm ( - . cm ) in after chemoradiotherapy. when the tumor volume reduction rate was correlated with the dworak grade, mean tumor volume reduction rate was . % ( . - %) in grade , . % ( - . %) in grade and . % ( . - %) in grade and . the tumor volume reduction rates demonstrated statistically significant differences among dworak grades. conclusion: in mr volumetric evaluation for rectal cancer before and after preoperative chemoradiotherapy, tumor volume reduction rate is well correlated with histologic reduction grade. functional the rectum was insufflated with air. we used t -weighted haste sequences at rest, squeeze and strain, in the axial and sagittal planes. we also performed a dynamic study using a t -weighted haste modified sequence, acquiring a single mid-sagittal slice, repeated every second for seconds, starting with the patient at rest then in squeezing and finally in straining. mr findings were compared with evacuation proctography, considered as gold standard. rectocele and pelvic floor descensus were graded either with the standard reference values, and with modified values obtained from normal volunteers. results: mri vs evacuation proctography identified / rectoceles, / anorectal junction descents, / rectal prolapses, and / diskinetic pubo-rectalis syndromes. mri detected additional findings in % of patients ( enteroceles, uterine descents, cystoceles, perianal pathologies-abscesses, anal fistulas). mri, using specific reference values provided % sensitivity, % accuracy, % npv for the anorectal junction descent, while using conventional values provided % sensitivity, % accuracy and % npv. conclusions: defeco-mri requires a short examination time, is well accepted and gives reliable information for the diagnosis of posterior pelvic disorders. specific reference values should be used to correct the bias of the supine position. correlation between mr findings and pathology in evaluation of the affected bowel wall in crohn's disease f. maccioni, m. colaiacomo, a. bruni, a. cocco, s. parlanti, f. siliquini, m. marini, a. marcheggiano; rome/it purpose: to correlate mr findings with the corresponding pathologic specimens obtained at the level of the pathologic wall in patients with crohn's disease (cd). method and materials: patients with known cd underwent mri after oral administration of a superparamagnetic contrast, using t -weighted plain and fatsuppressed haste sequences, and gd-enhanced t -weighted flash sequences on axial planes. degree and pattern of wall signal, wall thickness and abnormalities of perivisceral fat were evaluated. disease activity was evaluated using standard clinical scores. endoscopic or surgical pathologic specimens were obtained in all patients (gs) . mr findings were inter-correlated and correlated with pathologic findings (gs) either prospectively or retrospectively, with a sideby-side analysis of results. results: high wall gd-enhancement and high t wall signal were observed in patients with active disease and diffuse transmural inflammatory cells infiltrates at gs (n. ). in patients with active disease a layered pattern of gd-enhancement was observed, associated with either submucosal oedema or fibrosis at gs (n. ); in this group of patients, however, t -weighted images showed high or low wall signal in presence of oedema or fibrosis, respectively. in patients with non active disease poor gd-enhancement and low t wall signal were observed and preoperative evaluation of early gastric cancer for laparoscopic gastrectomy by d-ct angiography using -row multislice ct angiography s. kumano , h. miki , t. mochizuki ; onsen-gun/jp, ehime/jp purpose: the purpose of this study was to determine the efficacy of d-ct angiography ( d-cta) using -row multislice ct (msct) in the pre-operative simulation of laparoscopic gastrectomy for early gastric cancer. method and materials: twenty patients with early gastric cancer underwent ct examination using -row msct ( . -mm x ). ml/kg of mgi/ml contrast material was intravenously injected at a rate of ml/sec. timing for the arterial phase scan was determined by using a test bolus injection. portal phase scan was performed s after the start of bolus injection. for d-cta, ct images of . mm thickness were reconstructed at . mm intervals. with a computer workstation, d-cta was produced using volume rendering and maximum intensity projection techniques. results: d-cta demonstrated the left gastric artery (lga), right gastric artery (rga) and left gastric vein (lgv) in all cases. d-cta also demonstrated the lga arising from the celiac trunk in cases and from common hepatic artery (cha) in one case; the left hepatic artery (lha) from the lga in two cases; an accessory lga from lha in one case; and the rga from the proper hepatic artery in cases, from the cha in five cases, and from the lha in one case. regarding the venous system, d-cta demonstrated lgv flowing into portal vein in cases, splenic vein in cases, and the junction of portal and splenic veins in one case. conclusion: -row msct d-cta clearly demonstrated the vascular anatomy in all cases that is necessary for laparoscopic gastrectomy, and was thought to be useful for the preoperative simulation of laparoscopic gastrectomy. douglas pouch hernias: evaluation with entero-colpo-defecography m. estienne , m. moretti , m. valle , p. meinero , o. brunetti ; lavagna/it, santa margherita ligure/it purpose: to assess the usefulness of entero-colpo-defecography (ecd) in the evaluation of douglas pouch hernias and to improve the technique by a simple and non-invasive method. methods and materials: female patients (mean age: years) with clinical symptoms of obstructed defecation underwent ecd. our standard technique includes: ml of diluted barium suspension given orally at least ½ hours before examination; a small gauze opacified with iodamide placed into the vagina; rectal filling with ml of thick barium paste. static and spot lateral radiographs of the pelvis are obtained at rest, during squeeze and push, and during and after evacuation. if widening of the rectovaginal space (rvs) is observed during the dynamic phase, in the absence of an enterocele, a barium sigmoid enema is performed and further lateral films are obtained at maximum straining. results: widening of rvs was observed during ecd dynamic phase in of the patients ( %). thirteen of these patients had small bowel loops prolapsing into rvs (enterocele). for the three remaining patients, in which the widening of rvs could not be explained by enterocele, we performed a sigma barium enema demonstrating the presence of a sigmoidocele. we did not find a peritoneocele without bowel contents. conclusions: douglas pouch herniations may account for symptoms of obstructed defecation. defecography alone is not able to evaluate the hernia contents and peritoneography is an invasive technique. visualization of douglas pouch hernias is improved by the use of our ecd technique allowing a correct identification of enteroceles and sigmoidoceles. were prospectively studied by mdctc and compared with colonoscopy. all patients were referred to ct immediately after colonoscopy. ct was performed with x . mm, kv and mas in both supine and prone positions after colonic air insufflation. this method was well tolerated for all patients. independently, two experienced radiologists interpreted axial, sagittal and coronal images and d endoluminal reconstructions (virtual colonoscopy). in cases of disagreement, the diagnosis was established by consensus. sensitivity, specificity, predictive values and kappa test were analysed. both methods were compared with chi-squared test. results: in our series, the prevalence of colorectal polyps was %. when polyps were mm in size or greater mdctc had a % sensitivity, % specificity, % pvp and % pvn. the agreement between colonoscopy and mdct was observed in %. no statistical differences were found between these methods. conclusion: ct colonography is emerging as a potential alternative to conventional colonoscopy in the screening of colorectal cancer. row mdctc represents a reliable imaging method to detection of colorectal polyps with a high accuracy, particularly when the polyp size is mm or greater. this suggests an improvement over single slice ct. a. kalogera-fountzila, c. kouskouras, a. lefkopoulos, n. fotiadis, d. karanikolas, i. tsifountoudis, a.s. dimitriadis; thessaloniki/gr purpose: to prospectively evaluate the characteristic spiral ct features of intestinal ischemia and necrosis in patients with acute abdomen. materials and methods: twenty patients, aged - (median ), were examined in a three year period, using helical ct without oral contrast administration and after intravenous injection of contrast medium. the clinical manifestations consisted of acute abdomen and/ or sepsis in all patients. the diagnosis of bowel ischemia was confirmed with surgery, where colonic and/ or small bowel resection was performed in patients within hours. one patient with the presence of portal gas was found to be normal at surgery and one patient died before surgery and had a confirmatory autopsy. results: the causes of critical intestinal ischemia were diverse, including superior mesenteric artery thromboembolism in ( %) patients, inflammation in ( %), intussusception in ( %), volvulus in ( %), adhesions in ( %), hiv infection in ( %) and unknown etiology in ( %). spiral ct identified necrosis of colon and small bowel in ( %) patients, necrosis of small bowel only in ( %), and of colon in ( %). suggestive findings included intramural air in ( %) patients, thickening of the bowel wall in ( %), thinning in ( %), double or concentric ring sign in ( %) and bowel dilatation in ( %). presence of increased density of mesenteric fat was noted in ( %), mesenteric vein dilatation in ( %), free intraperitoneal air in ( %) and peritoneal fluid or blood in ( %). conclusion: spiral ct can accurately demonstrate signs of bowel ischemia and is often helpful in determining the primary cause of ischemia or necrosis. a comparison of single and multi row ct colonography in the detection of colorectal polyps p. vagli, e. neri, s. picchietti, g. naldini, m. rossi, c. bartolozzi; pisa/it purpose: to compare the diagnostic accuracy of single and multi row ct colonography (ctc) for detection of colorectal polyps. materials and methods: between and , seventy-two consecutive patients with a moderate to high risk of developing colorectal cancer underwent ctc followed by complete cc within hours. ctc was obtained by means of single row ct (n = ) and multi-row ct (n = ). sensitivity and specificity of single and multi-row ctc for detection of colorectal polyps was determined by means of lesion location in four colonic segments (cecum-ascending c-a, transverse t, descending d, sigmoid-rectum s-r). results: all colonic segments were completely visualised in each patient both by single and multi row ctc study. ctc identified polyps (< mm) in pa-tients (c-a n = , t n = , d n = , s-r n = ) , and polyps ( - mm) in patients (c-a n = , t n = , d n = , s-r n = ) . ctc generated false positives (fp) for polyps smaller than mm and fp for polyps - mm. false negatives (fn) were for polyps < mm, and for polyps - mm. sensitivity of single and multirow ctc for detecting polyps were % and % respectively for polyps < mm, and % and % for larger polyps - mm (p < . ). overall sensitivity and specificity of ctc for small polyps (< mm) was % and % respectively. overall sensitivity and specificity increases for larger polyps ( - mm) at % and % respectively. conclusion: multi-row ctc demonstrated a higher diagnostic accuracy than single-row ct in detection of colorectal polyps. paring the two ct techniques, considering patient discomfort and respiratory artifacts. results were compared with double-contrast small bowel enema and evaluated by two experienced radiologists. the integrated diagnosis showed negative patients, with signs suggestive for crohn's disease, with reflux ileitis, with ischemic ileitis and with non-specific ileitis. ct detected positive loops (sensitivity %, specificity %, diagnostic accuracy %); conventional radiology showed positive loops (sensitivity %, specificity %, diagnostic accuracy %). ct-enteroclysis false positives were due to poor bowel distention and false negatives to proximal bowel localization of disease; conventional study false negative cases were due to unseparable loops. mild respiratory artifacts were present in % ( of patients) of sdct examinations vs % ( of patients) of mdct examinations. conclusions: mdct-enteroclysis in comparison with sdct-enteroclysis reduces scanning time, respiratory artifacts and patient discomfort, allows a better spatial resolution, more evident on mpr, and improves pathological pattern representation. detection and staging of gastric lesions combining axial ct and virtual endoscopy images s. visconti, v. panebianco, m. celestre, t. celano, d. tancredi, f. iafrate, r. passariello; rome/it purposes: the aim of our study was to develop a virtual endoscopy examination protocol for the stomach after co distention, and to identify agc lesions according to borrmann's classification based on tumor morphology. methods and materials: virtual endoscopy of the stomach was performed in patients with gastric lesions. the stomach was distended with g of top effervescent granules used for double contrast upper gi studies (duogas, bracco), after intramuscular injection of mg of scopolamine butylbromide. all patients underwent a spiral ct volume zoom examination ( / / mm/ mm/ mm/ .l sec kv/mas/slice-coll./slice-width/feed-rot/rot.time). in cases spiral ct was repeated in a prone position because of a limited gastric distension by air. real time endoscopy images were reconstructed using a volume rendering technique with a dedicated workstation and specific software (vitrea . -vital images), and evaluated combined with axial images by two radiologists. one week later a fiberoptic gastroscopy was performed in all patients. results: image quality was graded as optimal in cases. in cases the stomach was not distended. virtual endoscopy correctly showed gastric lesions (ulcerative lesions n = , vegetating lesions n = , benign lesions n = ). we found a good correlation with surgical specimens in cases. the actual role of virtual gastroscopy combining axial ct and ve images is to evaluate the locoregional and distant extension (perigastric tumor involvement, distant metastasis) of tumors. it's potential roles are replacing barium studies and examining patients with surgical gastric exclusion. traumatic bowel perforation after blunt abdominal trauma: analysis of the ct findings according to the perforation site and the elapsed time since the trauma h. kim, h. shin, s. park, s. park, h. kim, w. bae, i. kim; cheonan/kr purpose: to evaluate the efficacy of ct in predicting the perforation site and the differential findings according to the elapsed time from the trauma in patients with bowel perforation after blunt abdominal trauma. methods and materials: abdominal ct's of patients with bowel perforation after blunt abdominal trauma confirmed by surgery were retrospectively analyzed without knowledge of the surgical results. the interval from the trauma to ct was to hours (mean, hours). the ct findings of traumatic bowel perforation including extraluminal air collection, segmental bowel wall thickening, localized inter-mesenteric fluid, bowel wall discontinuity, and mesenteric hematoma were analyzed. the predicted perforation sites were classified as: duodenum, jejunum, jejuno-ileal junction, ileum, and colon. based on the mean elapsed time ( hours), the patients were divided into the early lapse group (n = ) and the late lapse group (n = ), and the differential ct findings were analyzed. results: diagnostic accuracy of predicting the perforation site was: duodenum ( %), jejunum ( %), jejuno-ileal junction ( %), ileum ( %), and colon ( %). extraluminal air collection was more frequently seen in the late lapse group ( %) than in the early lapse group ( %) (p < . ), whereas other ct findings showed no statistically significant difference in the incidence. contrast-enhanced magnetic resonance imaging of the terminal ileum in children with crohn's disease p. paolantonio, a. laghi, o. borrelli, c. miglio, m. celestre, d. marin, s. cucchiara, r. passariello; rome/it introduction: to evaluate the diagnostic value of gadolinium enhanced mri with polyethylene glycol solution as oral contrast agent (ce-peg-mri) in revealing inflammation of the distal ileum in children with crohn's disease (cd) and in differentiating them from other inflammatory bowel diseases. subjects and methods: seventy-five consecutive paediatric patients referred for suspected cd underwent ileo-colonoscopy with biopsy and ce-peg-mri. the distal ileal mucosa was assessed by endoscopic and histological scores. the cd activity was measured by means of paediatric crohn's disease activity index (pcdai). results: active cd was diagnosed in cases, active ulcerative colitis (uc) in , spondyloarthropathy and indeterminate ileo-colitis in . in all cd patients ce-peg-mri showed a high concordance with endoscopy and histology. of the uc patients the ce-pegmri was negative in and showed mild parietal contrast enhancement of the terminal ileum in of the patients with backwash ileitis. among the group of spa patients, ce-peg-mri was negative in and revealed mild parietal contrast enhancement in . no increase in wall thickness in any of the uc and spa patients was demonstrated. sensitivity and specificity of ce-peg-mri were % and %, respectively. the test optimally correlated with endoscopic and histological scores (r: . ; r: . , respectively) as well as with the pcdai in the cd patient group (r: . ). conclusions: high correlation of ce-peg-mri with ileal endoscopy, histology and pcdai makes this test of great interest as a tool for monitoring the clinical course and the effect of therapy in cd patients. small bowel sonography in celiac disease after oral administration of sonographic contrast medium p. mirk, r. foschi, i. de vitis, l. guidi, a. vecchioli-scaldazza, p. marano; rome/it purpose: to assess the usefulness of sonography in celiac disease after small bowel loop filling by sonographic contrast medium. materials and methods: consecutive patients with clinical suspicion or diagnosis of celiac disease were prospectively examined by us before and after ( '- ') drinking of - ml of an isosmotic water solution of polyethilene glycol. patients had celiac disease (positive histology or aga or ema antibodies); patients had previous celiac disease but were clinically negative, or had other benign disorders, and were considered as normal. results: after contrast administration intestinal loops were better or slightly better shown in / and / patients ( . % and . %), or unchanged in / ( . %). among celiac patients, observed intestinal abnormalities were: segmental dyskinesia; transient intussusception; reduced number of jejunal folds; increased number of ileal folds; hypotonic dilated fluid-filled loops; increased intestinal motility. extra-intestinal abnormalities in celiac patients were: spleen size reduction; mesenteric lymphadenopathy; liver steatosis; free peritoneal fluid. celiac patients had no detactable abnormalities (false negatives); there were no false positives. overall accuracy was . % (sensitivity: . %; specificity: %; ppv %; npv . %) conclusions: small bowel filling by sonographic contrast medium improves us evaluation of wall thickness, mucosal fold pattern, and intestinal motility. transient intussusception was the single most diagnostic sign, whereas other features were less specific and of limited value unless found in combination. preoperative mri and transrectal us in the staging, and post-irradiation therapy restaging, of rectal cancer i. miucin-vukadinovic; sremska kamenica/yu purpose: the goal of the study was to determinate and compare the value of mri and transrectal us (trus) in the staging, and post-irradiation therapy restaging, of rectal cancer. this study was designed to evaluate the down-staging effect of preoperative radiation. method and materials: patients (range, - ) with biopsy-proven rectal can-cer underwent imaging using a . t scanner and transrectal us ( . or mhz transducer) before, and after radiation therapy ( gy, a daily fracton of gy, days a week).tumors were staged according to the tnm staging system. two observers independently scored the tumor stage. the standard of reference was histopathology (after surgical resection). results: all patients underwent radiotherapy before surgery for rectal carcinoma. before radiotherapy mr examination detected . % t (b ), . % t (b ), . % t n (c ) and . % t / n (c ) tumors. down-staging of one or more t stages occurred in . % with tumor regression in . %. the mri tumor stage agreed with the histological stage in % of patients. trus correctly staged % of lesions. t category was correctly restaged after preoperative radiation in only . %. conclusion: preoperative radiotherapy is becoming the standard of care for resectable, locally advanced adenocarcinoma of the rectum. mri and trus enable selection of appropriate patients for preoperative radiotherapy. preoperative trus can establish the depth of penetration of a tumor and showed less sensitivity for lymph node staging. mri showed better diagnostic accuracy (with tendency for overstaging) then trus for interpretation of complete pelvic status in the pre-and post-irradiation period. echographic efficacy evaluation of gastric ulcer treatment s. pimanau, n. mikhailava; vitebsk/by purpose: the objective of this study was to investigate the possibilities of noninvasive abdominal echography in efficacy evaluation of chronic peptic ulcer pharmacotherapy. method and materials: patients with gastric ulcers in the exacerbation phase were examined before the course of pharmacotherapy and after it. ultrasound investigation was carried out after administration of - ml deaerated liquid. on echography a chronic gastric ulcer was visualized in cases. in the acute exacerbation phase the peptic ulcer was deep, filled with echogenic contents, the ulcer edge being sharp and overhanging. periulcerous infiltration was hypoechogenic, - mm long, - mm thick, and its area made up about - mm . the peripheral edge of periulcerous infiltration seemed sharp. in the course of effective treatment both ulcer dimensions and periulcerous infiltration area reduced on echograms. periulcerous infiltration reduction speed made up about mm /day. the reparative process was also accompanied by ulcer flattening. in cicatrization the ulcer was not visualized on echograms, a hypoechogenic stripe - mm thick generally remaining. in the absence of reparation, the echographic picture of the ulcer and periulcerous infiltration didn't change essentially. parallel endoscopic study of the stomach revealed either coincidence with echographic findings of qualitative characteristics of the reparative process positive dynamics or its absence. in cases the results of ultrasound and endoscopic investigations didn't coincide; echograms showed slight infiltration with a central small echogenic area at the site of ulcer regarded as ulcer reparation, while endoscopy revealed a red scar. conclusion: thus, abdominal ultrasound investigation of the stomach enables reliable evaluation of gastric ulcer dynamics in the course of conservative treatment. comparison of multi-slice ct-colonography in ultra-low-dose technique with high resolution video-colonoscopy in the detection of colorectal polyps m. cohnen, c. vogt, k. andersen, a. saleh, a. beck, s. vom dahl, v. aurich, d. häussinger, u. moedder; düsseldorf/de purpose: to prospectively compare msct-colonography using an ultra-low-dose technique (uld-msctc) with high-resolution video-colonoscopy (hr-vc) as the standard technique for detection of colorectal cancer and polyps. patients and methods: patients underwent msct-colonography (uld-msctc) after standardized oral bowel cleansing immediately before video-colonoscopy (hr-vc). patients were scanned with an ultra-low-dose msctcolonography protocol ( mas, ctdiw eff: . mgy). after noise reduction using an mathematical algorithm by dedicated software, uld-msct-colonographic images were analyzed by a team of two readers in a blinded fashion and the results were compared with the results of hr-vc. results: lesions were detected by hr-vc in patients. sensitivities for detection of polyps < mm, - mm, and > mm in size were % ( of polyps), % ( of polyps) and % ( of polyps) respectively. all colorectal tumors ( of , %) were prospectively diagnosed. the sensitivity to detect flat lesions was % ( of flat lesions). the overall specificity was calculated at %. the calculated effective dose ranged between . and . msv. conclusions: uld-msctc has an excellent sensitivity and specificity for the detection of colorectal lesions > mm despite a significant reduction in radiation exposure. defecographic the pelvic floor in straining state descended an average of . cm from the inferior margin of the ischial tuberosity, its broad range of position from - . cm to . cm implying a wide variation of anorectal angle and perineal descent. mild degree rectocele with less than cm of depth was found in out of cases. rectal intussusception was noted in six and rectal incontinence was seen in one. formation of rectocele and intussusception during defecation was common in asymptomatic young volunteers. the wide range of defecographic measurements warrants the necessity of other complementary studies on anorectal function to improve the diagnostic accuracy. therefore, the interpretation of defecographic findings should be made with caution and should not be used as the sole criteria for selection of a treatment modality. right-side colonic diverticulitis: sonographic and ct findings (differential diagnosis) e. blanc, m.j. martínez, t. ripollés, m. agramunt, c. soto, r. pastor; valencia/es purpose: to describe the sonographic and ct features in right-side colonic diverticulitis and to differentiate this entity from other right-side acute abdominal conditions. methods and materials: patients with a final diagnosis of diverticulitis of the ascending colon or cecum were retrospectively reviewed. sonography was performed in all patients and ct in . the following findings were evaluated: the presence of an inflamed right colonic diverticulum, pericolonic infiltration, focal colonic wall thickening and the identification of a normal appendix. the diagnosis was confirmed by surgery, clinical course, or barium enema. results: sonography and ct showed pericolonic inflammation and focal colonic wall thickening in all cases. the inflamed diverticulum was seen with sonography and ct in ( %) and ( %) patients respectively. the normal appendix was identified with sonography in ( %) and with ct in ( %) cases. the initial diagnosis was: right-side colonic diverticulitis (n = ), acute appendicitis (n = ), perforated colonic carcinoma (n = ) and an inflammatory mass (n = ). conclusions: right-sided colonic diverticulitis is a condition that can clinically mimic other causes of right abdominal pain like acute appendicitis, perforated colonic carcinoma, salpingitis, ileocecal inflammatory pathology, epiploic appendicitis and omental infartion. in this series the most common sonographic and ct findings included the presence of a right colonic diverticulum with thickening of the adjacent pericolonic wall and pericolonic infiltration. both ultrasound and ct can be extremely useful in the early diagnosis of this entity avoiding unnecessary surgery procedures, in a primarily benign and self-limiting condition that can be treated conservatively. an accurate scanning technique for detecting recurrent rectal cancer: enhancement of early-phase dynamic helical ct j. tanaka, s. tsukuda, a. heshiki; iruma-gun/jp purpose: to evaluate the usefulness of dynamic enhancement of helical ct in the detection of local recurrence of resected rectal cancer. in patients with a history of curatively resected t or t rectal cancer, follow-up plain ct indicated that they had a loco-regional recurrent tumor; consequently, they underwent follow-up pelvic helical ct providing accurate early-phase contrast enhancement in the lower pelvic region. the patients were divided into four groups according to grade of contrast enhancement of the suspected mass-like lesion before and after contrast enhancement, and correlation between groups and results obtained by biopsy and/or surgery was assessed. if no correlation was found, patients were followed up for a period lasting from days to two years. as of june , results had been obtained for patients; and correlation between these results and grouping by contrast enhancement ratio was analyzed. results: all patients in the highest-grade group (n = ) had local recurrence. when only the highest-grade group was considered positive, there were no false positives and only one false negative. conclusion: our results suggest that early-phase contrast enhancement is useful for accurately detecting recurrent rectal cancer. this can be easily achieved using smartprep function, and should be used to distinguish recurrent tumors from post-surgical scar tissue, because these two tissue types do not exhibit similar enhancement patterns. staging of gastric carcinoma by mr imaging in vitro c. sato , s. naganawa , h. kumada , t. miura , t. ishigaki ; nagoya/jp, toyohashi/jp purpose: to evaluate the accuracy of cancerous invasion to gastric wall with magnetic resonance imaging in vitro. twelve specimens of gastric carcinoma were examined with a . t mr using a small loop surface coil. they were fixed in formalin within days prior to imaging. the field of view was mm, a matrix size was x , and the section thickness was mm. the t -and t -weighted images were obtained. two radiologists evaluated the mr images independently, and consensus was obtained if there were any discrepancies between the two. findings on mr images were compared with histopathologic findings. results: mr images depicted the normal gastric wall as consisting of the layers clearly. cancerous invasion was detected in of specimens with mucosal invasion, with submucosal invasion, with the invasion to muscularis propria, with subserosal invasion, and the rest that extended into the serosa. the mr imaging-determined grade correlated with the histopathologic findings for of tumors. the overall accuracy was . %. conclusion: mr imaging has an accurate diagnostic capabilities for the evaluation of the cancerous invasion to the gastric wall in vitro. the results of the present study may encourage the further development of an endoscopic surface coil. role to investigate the value of mri in the overall assessment of crohn's disease (disease activity, disease extension, complications). method and materials: consecutive patients with crohn's disease underwent mri in the context of a clinical evaluation including biochemistry, endoscopy, histology and radiology. all patients underwent mri after oral administration of a superparamagnetic contrast agent, using standard sequences (haste t weighted, with and without fat-suppression and gd-enhanced t -weighted flash). two independent radiologists evaluated mr images on printed films. disease length, presence of strictures, fistulae, abscesses, phlegmons and any other abdominal complication were evaluated at the level of each segment. gold standard (gs) for morphological assessment were: barium studies, ct or us, and surgery when performed. at the level of the affected segments bowel wall thickness, t wall gd-enhancement, t wall signal, t fibro-fatty proliferation signal were evaluated and graded ( - ) to assess disease activity. gs for disease activity were endoscopy, biological activity and cdai. results: mri detected % of overall disease length, % of fistulae, % of strictures; adhesions were overestimated. in % of patients mri showed complications requiring surgery ( hydronephrosis, abscesses, phlegmons, pancreatic duct stone, enterovesical fistula, ovarian involvements). the following mri findings were statistically correlated with the clinical and biological signs of active disease: bowel wall thickness (r = . ), wall gd-enhancement (r = . ), t wall signal (r = . ), t fibro-fatty proliferation signal (r = . ). learning objectives: to recognize usual and unusual radiologic findings of pseudomyxoma peritonei with pathologic correlation. background: pseudomyxoma peritonei is a rare neoplastic condition in which gelatinous intraperitoneal fluid collections associated with mucinous disseminated implants are observed. although a ruptured appendiceal mucocele is the most common cause, pathologies arising from other origins may cause this condition with various imaging manifestations. imaging findings: the usual imaging findings were of mucinous, fluid-like material spread over the peritoneal cavity with organ scalloping observed in the liver, splenic and mesenteric margins, with central displacement of small intestinal loops. within the material, cyst-like round structures may be observed and clarified by the septal enhancement on contrast-enhanced images. punctate, annular, or curvilinear calcifications may be disseminated. dropping appendiceal mucocele or a rare urachal tumor located in the female pelvis may simulate an ovarian tumor and be misdiagnosed as gynaecological disease. demonstration of the continuity to the cecum or urachus was the diagnostic clue. localized disease in the female pelvis may simulate ovarian carcinomatous peritonitis, and scalloping of the uterine margin may suggest this condition. because synchronous mucinous tumors of the ovary and the appendix may occur, careful observation to detect the slight irregularity of the omentum adjacent to the cecum is necessary to avoid overlooking an occult primary appendiceal lesion. conclusion: to recognize various imaging findings is important to make the correct preoperative diagnosis. in particular occult appendiceal lesions must not be overlooked. multiplanar observation on ct and mri was important to recognize the complex organic-pathologic relationships to identify the primary neoplasm. retroperitoneal cystic masses: ct findings d. yang, h. kim, j. kang, t. seo, h. kim, s. kim, j. kim; incheon/kr learning objectives: to illustrate the ct findings of the different types of retroperitoneal cystic masses. background: retroperitoneal cystic masses, which arise within the retroperitoneal space but outside the major organs of that compartment, are uncommon. however, the widespread use of computed tomography (ct) for evaluating abdominal and retroperitoneal diseases has increased the detection rate of retroperitoneal cystic lesions. in this exhibit, we conduct a literature review and present the ct findings of our own patients to illustrate the ct appearance of different types of retroperitoneal cystic masses. imaging findings: a variety of ct features were identified in various retroperitoneal cystic masses. the disease entities include cystic lymphangioma, retroperitoneal mucinous cystadenoma, müllerian cyst, cystic change of paraganglioma, epidermoid cyst, cystic teratoma, tailgut cyst, mucocele of appendix, perianal mucinous adenocarcinoma, cystic change of leiomyosarcoma after chemotherapy, pancreatic and nonpancreatic pseudocyst, lymphocele, urinoma, and hematoma. conclusion: knowledge of ct findings of various retroperitoneal cystic masses may be helpful for differential diagnosis. learning objective: our purpose is to describe the ct and mr findings of cystic dystrophy of the duodenal and gastric wall in heterotopic pancreas (cdhp) which allows an accurate diagnosis of this pathology usually associated with chronic pancreatitis. background: cystic dystrophy in heterotopic pancreas is characterized by the development of cysts in heterotopic pancreatic tissue localized in the duodenal or gastric wall. cyst formation is related to cystic dilatation of an anomalous duct bordered by pancreatic excretory epithelium, or to pseudocysts caused by pancreatitis of the heterotopic pancreas. we reviewed ct and mr findings in five patients with cystic dystrophy in heterotopic pancreas (cdhp). they underwent spiral ct (n = ) and mr/ cholangio-mr (n = ). diagnosis was confirmed by endoscopic us in all cases. three cases were pathologically proven after surgery. imaging findings: the ct and mri findings of cdhp consists of cysts, (normally multiple), located in the inner wall of the second part of the duodenum and less frequently in the stomach. the duodenal or gastric walls affected are thickened and inflammatory changes are observed around the cysts. signs of chronic pancreatitis are frequently seen. mr/ cholangio-mr shows high intensity lesions corresponding to the cysts. conclusion: cdhp presents some ct and mr features which permit an accurate and reliable diagnosis. when a cystic lesion is found in the duodenal or gastric wall cdhp should be included in the differential diagnosis with other cystic masses such tumors or abcesses. , and thanks to its favorable influence on serum glucose and lipid profiles, this technique is the preferred treatment for patients with severe type i diabetes mellitus and end-stage renal disease (simultaneous pancreatic-kidney transplantation) . therefore an understanding of the anatomic configuration and the spectrum of postsurgical complications is needed. imaging findings: we retrospectively reviewed computed tomographic scans (ct), ultrasounds (us) and doppler studies of patients who had undergone pancreatic transplantation using portal-enteric drainage in our hospital between january and july . we review the usefulness, limitations and potential pitfalls of ct and us. acute postoperative complications, including acute rejection, transplant pancreatitis, peripancreatic collections and abscess, pseudocysts, vascular complications (thrombosis, pseudoaneurysm) and exocrine leaks, are depicted. furthermore, ct-guided percutaneous biopsy and drainage is a safe and an alternative method for obtaining tissue from the transplanted pancreas with graft dysfuntion, and collections. conclusion: knowledge of normal anatomic configuration and the radiologic appearance of normal pancreatic transplant will allow proper interpretation and early treatment of the spectrum of portsurgical complications in this kind of pancreatic allograft. the more common current gastric bypass procedures include the roux-en-y procedure and bilio-pancreatic diversion with duodenal switch procedure. the more typical complications of these surgeries include anastomotic leaks and stenoses, both of which have been reported in the current literature. more atypical complications, however, have not been comprehensively demonstrated. imaging findings: gastric bypass/gastric stapling is a common surgical procedure at our institution. we have encountered several atypical complications, documented with flouroscopic studies using water soluble contrast. we offer five unusual complications which include the following: internal herniation through the small bowel mesentery, internal herniation through the transverse mesocolon, external herniation through the abdominal wall incision, enterocutaneous fistulas, roux-en-y configuration with anti-peristaltic inversion of the gastroenteric roux limb, and incorrect anastomosis of the roux limb with the excluded stomach (resulting in a roux-en-o configuration). conclusion: our findings expand those of the current literature to include the more infrequent complications of gastric bypass surgery. in the fluoroscopic evaluation of post-operative gastric bypass patients, a thorough understanding of expected post-operative bowel configuration is essential. in addition to assessing anatomical abnormalities, it is equally important to assess for abnormalities of motility. in this study, we performed a retrospective review of the medical records and imaging studies of patients with proven fmf, diagnosed between - . imaging findings: the commonest clinical manifestation were recurrent peritoneal attacks with abdominal pain ( . %) and fever ( . %). abdominal imaging findings included ileus (n = ), focal peritonitis (n = ), ascitis (n = ), splenomegaly (n = ), and hepatomegaly (n = ). one patient developed fatal peritoneal mesothelioma, and . % of patients developed amyloidosis with sonographic findings of renal parenchymal disease or cardiomyopathy. arthritis was second in frequency occurring in . % of patients. radiographs were normal (n = ) or showed joint effusion and soft tissue swelling (n = ) due to synovitis. two patients developed seronegative destructive arthropathy. pleuritis was encountered in . %. polyarteritis nodosa (pan) was present in patients, multiple sclerosis in one, and autoimmune hemolytic anemia in one patient. conclusion: fmf predominantly involves abdominal viscera but can affect other organs. the majority of patients have nonspecific imaging findings and the radiologic diagnosis is rarely considered. amyloidosis, mesothelioma, and destructive arthropathy are potential serious complications of fmf. polyarteritis nodosa, multiple sclerosis, and autoimmune hemolytic anemia are rare associations or coincidence with fmf. mucosal associated lymphoid tissue lymphomas: imaging evaluation with pathologic correlation d. voultsinou, t. gerukis, n. staurogianni, k. anastasiadou, a. anagnostopoulos, p. palladas; thessaloniki/gr learning objectives: to identify the radiological features of extra nodal non hodgkin malt lymphoma. to illustrate the spectrum of appearance of the disease in its various locations in the human body. to list the various imaging strategies. to discuss the differential diagnosis. background: mucosal associated lymphoid tissue (malt) lymphoma arises in extranodal mucosal lymphoid tissue and has only been recognized recently. it affects several extranodal structures such as the stomach, the lung, the eye and the salivary glands. it is generally low grade and has an indolent course, as it remains long confined to the initial site. in this exhibit we describe and illustrate the most common radiological patterns of malt lymphoma. imaging findings: we retrospectively reviewed clinical and radiographic records in cases with confirmed low-grade gastric malt lymphoma. the study group consisted of men and women (mean age years). the predisposing factors of malt lymphoma, number and location of lesions, and course of the disease were evaluated. we determined the most probable diagnosis on the basis of the radiologic findings and correlated them to pathologic and immunohistochemical findings of endoscopy, biopsy and bone marrow examination. out of patients presented with malt lymphoma of the stomach, in the parotid gland, in the lung, in the large intestine (sigmoid colon, rectum), in ileocecal valve and in the orbit rectal malt lymphoma coexisted in one patient, and parotid gland and lung lymphoma in patients. all patients were treated with chemotherapy. the disease resolved in patients. the correlation of imaging, endoscopic and pathologic findings significantly contributes to diagnosis and follow-up of malt lymphomas, early diagnosis of which results in complete regression. to describe a new approach to ct colonography for detecting colo-rectal polyps with multidetector row ct (mdct). to display the results and to present the benefits provided by this technique. background: virtual dissection‚ (gems) is an original application to display the entire inner surface of the colon without the need for navigation. the method consists of displaying the straightened and flattened colon using surface rendering. we performed virtual colonoscopies with a ge lightspeed mdct. the acquisition parameter and each step of the imaging procedure will be described. procedure details: all patients underwent ct colonography in both supine and prone positions, the following parameters were used: kvp; - mas; . mm collimation; . -mm reconstruction intervals and rotation time, . - . sec. the colon was assimilated to a cylinder manually defined. time to display the straightened and flattened colon using surface rendering was about minutes. normal aspect, polyps and artifacts were displayed. polyp detection was faster and easier with this method compared to axial images and the usual virtual endoscopy mode with forward and reverse viewing fly-through volume rendered movies. conclusion: this method makes it possible to stretch the colon virtually and to cut it along its axis similar to a real dissection on the pathologist's ( ) and luschka duct ( ). ce-mrcp succesfully revealed the origin of the leak in patients. conclusion: contrast enhanced mr cholangiography with iv mangafodipir trisodium can accurately diagnose the presence and location of bile duct leaks in patients who have undergone laparoscopic cholecystectomy. internal hernia of the anterior part of the abdomen: imaging in the multidetector-row ct era n. hongo, h. mori, s. matsumoto, y. okino, a. adachi, a. kaku; oita/jp purpose: internal hernia of the anterior part of the abdomen (ihapa) is difficult to diagnose preoperatively because of its rarity and lack of imaging landmarks. the purpose of this study is to clarify the ct features of ihapa by ct, especially with multi-detector row ct (mdct). methods and materials: the ct scans in patients with surgically confirmed ihapa through a transverse mesoclolon (n = ) or an omentum (n = ) were retrospectively reviewed; furthermore, the transverse mesocolic type was classified into intramesenteric type (n = ) and transmesenteric type (n = ). special attention was paid to the herniated sac-like appearance, hernial orifice, running course of the omental fat and transverse colon. results: the closed loop of the small bowel was observed in all cases. a sac-like appearance, enclosed by transverse colon was identified in both cases with intramesenteric type, but was not observed in other types of ihapa. fatty continuation between the hernial orifice and omentum was identified in two out of four cases with omental type of ihapa. furthermore, the transverse colon passed above to the hernial orifice in all cases with omental type, while this finding was not observed in any of the transverse mesocolic type. conclusion: the relationship between the hernial orifice and transverse colon, and sac-like appearance enclosed by transverse colon are the diagnostic key of ihapa on ct. particularly, mdct would become feasible to diagnose the ihapa preoperatively, even though it lacks of vascular landmarks. contrast enhanced mri using oral peg solution in the follow-up of patients with known crohn's disease m. scettro, a. grasso, f. monetti, g. rescinito, g. rollandi, c. neumaier; genoa/it purpose: aim of our study was to analyze, in the context of an extensive evaluation, crohn's disease activity index (cdai), and conventional enteroclysis, the value of mri to identify disease extension and complications in patients with known disease. material and methods: abdominal mri of patients in a period of months with a diagnosis of crohn's disease were analyzed by two experienced gastrointestinal radiologists, in consensus, looking for any intestinal and extra-intestinal abnormality. mri studies were performed on a . t (intera nt, philips) with a phased array coil. mri was performed using a polyethylene glycol (peg) solution b d e f a g as oral contrast agent to distend the small bowel (ce-peg-mri), using standard sequences (ss-tse t and tfe t with fat saturation after gd-dtpa and buscopan mg i.v.) . results: mr imaging had an overall sensitivity of % and a specificity of % for active disease. bowel wall enhancement (ratio of signal intensity of abnormal to normal bowel > . : ), bowel wall thickening greater than / mm and increased mesenteric vascularity were useful in identifying active disease. the experience shows that the method is complementary to conventional enteroclysis in the detection of superficial and transmural abnormalities in patients with crohn's disease. in addition, ce-peg-mri can provide excellent information concerning mesenteric involvement, disease activity, and complications of crohn's disease. finally mri may become a gold standard in the identification of recurrant disease. withdrawn by authors the number of x-ray based examinations (using a contrast medium) of the oesophagus, stomach, and large bowel, decreased by %, % and %, respectively. x-ray based examination of the small bowel and plain radiography of the abdomen remained unchanged. endoscopies of oesophagus / stomach and the large bowel increased by nearly %. x-ray based examination of the biliary tract almost disappeared with us, ercp and mrcp taking over. the annual collective effective dose for the all gi tract examinations was reduced by %, from . mansv in to . mansv in . the shift in modalities used for diagnostic imaging of the gastrointestinal tract from x-ray examination to us, endoscopies and mri resulted in a significant reduction in exposure to ionising radiation of patient, and need to be considered when discussing further development and structure of diagnostic imaging in general. perfusional enhanced ultrasound in the diagnostic evaluation of sicca syndrome g. argalia, d. salera, g. giuseppetti; ancona/it purpose: sicca syndrome is a relatively common disorder especially among older women. it may be caused by an autoimmune disorder like sjogren's syndrome (ss) or by several other illnesses. our purpose is to evaluate the diagnostic possibilities of contrast enhanced ultrasound in the characterization of sicca syndrome. we studied consecutive patients with sicca syndrome, affected by ss ( with primary sjogren's syndrome, with secondary sjogren's syndrome due to connetivitis) and patients with a sicca syndrome not related to ss. all patients were selected according to the european community study group diagnostic criteria for sjogren's syndrome (the gold-standard of the study) and underwent contrast enhanced ultrasound examination with timeintensity curve analysis obtained before and during saliva stimulus, salivary glands scintigraphy and labial gland biopsy. results: ss patients had an echo contrast enhancement before and during saliva stimulus significantly lower (p < . ) than the non ss ones. the patients with primary ss showed a significantly lower enhancement during saliva stimulus than the secondary ss patients (p < . ); no statistically different enhancement was seen in basic conditions (p = . ). in the study group ( subjects with sicca syndrome) the enhanced ultrasound showed a sensitivity of . %, a specificity of % and an accuracy of . % on the diagnosis of ss. our experience confirmed the good diagnostic accuracy of salivary glands scintigraphy and labial biopsy. the preliminary results show this method is useful in the functional study of parotid glands in the characterization of sicca syndrome. fusion imaging of d angiographies of arteries and veins around the stomach by multiphase fusion technique under a single-breath hold using row multidetector row ct: its usefulness for preoperative simulation and intraoperative navigation of laparoscopy-assisted gastrectomy m. matsuki, h. kani, i. narabayashi; takatsuki/jp purpose: gastric arteries and veins can vary between patients; therefore, it requires much time to ligate arteries, and veins can be damaged during regional lymph node excision under laparoscopy-assisted gastrectomy (lag). we evaluate the efficacy of fusion imaging of three-dimensional angiographies of arteries and veins around the stomach by the multiphase fusion technique under singlebreath hold using row multidetector row ct (mdct) in the preoperative simulation and intraoperative navigation of lag. methods and materials: contrast-enhanced ct scan using das mdct was performed on patients before lag. images at both arterial and venous phases were obtained under a single-breath hold. three-dimensional ct angiographies at the arterial and venous phases were reconstructed using the volume-rendering technique and then fused. ) the detectability of the left gastric artery (lga), right gastric artery (rga), left gastric coronary vein (lcv), right gastric vein (rgv) and helens' gastrocolic trunk (gct) on the multiphase fusion images was evaluated in comparison with the surgical findings. ) in intraoperative navigation, the clinical usefulness of multiphase fusion imaging was evaluated. results: . in nine of ten patients ( %), the multiphase fusion images could demonstrate clearly, simultaneously and three-dimensionally the lga, rga, lcv and gct without a respiratory gap. . we could arrange and rotate a multiphase fusion image to correspond to the operative view, which was very useful in the intraoperative navigation of lag. the multiphase fusion imaging is considered to be very useful in the preoperative simulation and intraoperative navigation of lag. three-dimensional endosonographic guidance of needle positioning in interstitial brachytherapy a.f. christensen, m.b. nielsen, s.a. engelholm; copenhagen/dk interstitial brachytherapy is used in the treatment of anal carcinoma, so far without image guidance during needle positioning.the aim of the study was to describe a procedure for optimizing needle positioning guided by three-dimensional ( -d) endosonography. twelve patients who received external radiation therapy for anal carcinoma were referred for interstitial brachytherapy under -d endosonographic guidance. the procedure was initiated by anal endosonography performed with a mhz rotating endoprobe. cross-sectional images of the anal sphincters were stored on a -d system during retraction of the endoprobe. afterwards, any projection could be reconstructed. from this scanning the optimal positioning of the needles was determined. the needles containing radioactive isotopes were inserted through holes in an externally fixated disc. repeated endosonography assured that optimal tumor coverage was obtained by adjusting the number, loading or position of the needles. in all patients endosonography was able to visualize the extent of the tumor and the position of each needle so that both the distance from needle tip to upper tumor border, as well as the distance from the anal orifice to the lower tumor border could be determined. in patients endosonography showed a, at least clock-positions larger circumferential tumor size than manual examination. this made an increase in number of needles necessary. in patients endosonography influenced the extent of loading of the needles. in patients endosonography led to a change in positioning of the needles. -d endosonography guidance of interstitial brachytherapy in anal carcinoma seems possible, which may influence the radiation coverage. to determine ct criteria that allows accurate classification of interstitial hernias. methods and materials: ct scans of patients with surgically proved spigelian hernia (n = ) or interparietal inguinal hernia (n = ) have been retrospectively reviewed. ct assessment included: ) assessment of the hernial sac (anatomic situation, extension, content) and ) assessment of the fascial defect (anatomic situation, relationship to the inferior epigastric vessels). results: in all cases (n = ), the hernial sac was located between the internal and external oblique muscles. the fascial defect was located at the spigelian aponeurosis, above the inferior epigastric vessels in the seven cases of spigelian hernia, and at the internal inguinal ring, lateral to the inferior epigastric vessels in the six cases of interparietal inguinal hernia. conclusion: assessing only the hernial sac does not allow accurate classification of interstitial hernias. diagnosis is established by precise analysis of the anatomic situation of the fascial defect. the role of magnetic resonance cholangiography in patients with biliaryenteric anastomosis y.a. akhmetov; almaty/kz purpose: the study was aimed at investigating the role of mr-cholangiography (mrc) in the examination of patients treated with biliary-enteric anastomosis. methods and materials: mrc was performed in patients ( female and male, mean age: . years) undergoing biliary-enteric anastomoses ( hepatico-jejunostomies and choledocho-duodenostomies). mrc was performed with a non-breath-hold d turbo spin echo sequence (tr = msec, te = msec, etl = ) with an acquisition time from min to min. patients subsequently underwent percutaneous transhepatic cholangiography (ptc) in order to confirm the mrc findings and to perform a therapeutical procedure. patients with choledochoduodenostomy were examined with ercp. the remaining patients, with no evident symptoms or signs of bile duct dilation, were examined during their surgical follow-up without the performance of any invasive procedure. the degree of bile duct dilation was correctly evaluated with good panomaric assessment of the ducts and site of anastomosis in all patients. both dilated and non-dilated bile ducts were well depicted. mrc correctly showed stenosis of anastomosis in of patients, - mm stones in of patients and bile ducts irregularities in of patients with cholangitis. conclusion: mrc is a safe, noninvasive technique in the study of biliary-enteric anastomoses and can be used to the screening of symptomatic patients. mrcp images may serve as a guide for planning of interventional procedures. cystic duct imaging using both magnetic resonance cholangiography (mrc) and d learning objectives: to describe the indications and diagnostic limits of each procedure, to present the steps taken to perform each procedure as well as the possible complications, and potential pitfalls. background: the early diagnosis of breast cancer is a challenge in breast imaging work-up. to detect malignancy in non-palpable breast lesions without unnecessary open biopsies, percutaneous biopsy of the suspect lesion should be undertaken. percutaneous breast biopsy can be performed under sonographic or x-ray guidance. whatever method is used, certain principles apply. exhibit details: the exhibit will be divided into subsections focusing on the indications and diagnostic limits of each procedure, the necessary equipment for each method and the steps taken to perform each procedure through sample cases. we will focus on practical issues such as needle size, site of entry, number of tissue probes that we need to take according to the lesion type. also the avoidance of complications, and other useful tips will be presented. a special reference will be made to the histological findings that require surgical excision and the potential pitfalls in case of false negative samples. we will also present a short time follow-up diagram for the histologically confirmed benign lesions. conclusions: whenever a non-palpable breast lesion is considered for biopsy, either x-ray or ultrasound guided procedures are performed. each method has its indications, advantages and disadvantages, and the examiner should be familiar with those factors for proper procedure selection. the use of carbon marking after stereotactic -gauge vacuum-assisted breast biopsy and during advanced breast results: eleven cases were considered fn ( %). a) four cases were found after -g core biopsies: two architectural distorsions initially diagnosed as radial scars proved to be malignant after surgery, and one case of microcalcifications, first diagnosed as adenosis, underwent month follow-up corresponding to a ductal carcinoma in situ. also a ductal carcinoma in situ was found inside a fibroadenoma (first diagnosed as fibroadenoma). b) also seven cases were found after vacuum-assisted biopsies, all of them microcalcifications that were confirmed in the radiograph of the specimen: five cases were initially diagnosed as atipical ductal hyperplasia and corresponded to four ductal carcinomas in situ, and one infiltrating ductal carcinoma; the remaining two cases were first reported as ductal ectasia and interstitial microcalcifications, becoming two ductal carcinomas in situ (one of them was diagnosed months later after core biopsy). the average diameter of the lesion was . mm. none of the lesions were removed completely. conclusion: results such as radial scar, atypical ductal hyperplasia, interstitial microcalcifications and ductal ectasia may occult a carcinoma after needle core biopsies. the percutaneous triple sample (fnac, core biopsy, and cylinder smears) in breast cancer diagnosis: results in patients i. vizcaino, v. torres, s. picó, e. blanc, c. soto, s. isarria; valencia/es purpose: to evaluate a combined method to sample tumoral tissue in breast cancer. a prospective study using at the same time fnac, core biopsy and cylinder smears was performed in patients. we used a g needle ( - passes) and a thin-wall g needle ( - cylinders, mm/ cm sized). smears of core biopsy cylinders were systematically prepared to cytological examination. the lesions were targeted using palpation, ultrasound, coordinates plate, and a stereotactic device depending on the lesion. all patients had breast cancer. the results were evaluated regarding the sensitivity to breast cancer diagnosis. the overall sensitivity of three-way diagnosis was % (the false negative case was a non-palpable dcis that showed necrosis in cylinder and no tumoral cells in both, fnac and cylinder smears). the sensitivity of fnac was the same as core biopsy: %. the sensitivity of cylinder smears was %. benign tissue in cylinders with malignant cells in cylinders smears was seen in cases ( dcis, necrotic medullar carcinoma, intracystic carcinoma and idc). fibrous tissue was found in the cylinders of these cases. the combination of fnac, core biopsy and cylinder smears show a high sensitivity to breast cancer diagnosis. cylinder smears must be obtained systematically in core biopsy in order to prevent the false negative results. weak cohesion of tumoral cells can explain this phenomenon. purpose: mammographic follow-up of patients after conservative treatment for breast cancer by screen-film mammography is difficult and sometimes impossible due to the post-radiation and surgical changes. digital mammography (dm), with post-processing tools, might facilitate the reading. the purpose of this presentation is to evaluate the accuracy of dm and to describe the post-therapeutic changes in these patients. materials and methods: dm (senograph d, gems®) was performed in patients and months after conservative treatment (surgery and radiotherapy) for breast cancer. mammograms were indepedently read by two senior radiologists. both radiologists performed screen-reading, using commercially available post processing tools (magnification, zoom, contrast inversion, thickness compensation). they evaluated the overall image quality. the following features were also analysed: breast density (according to birads classification), skin thickening, parenchymal changes with glandular oedema ( grades), scar and microcalcifications. results: all dm were considered as of diagnostic quality by both radiologists. importance of glandular oedema was correlated to breast density (birads , n = ; oedema , n = ), (birads , n = ; oedema , n = ). analysis of skin and dermal thickness was facilitated by the algorithm of thickness compensation. visibility of scars (n = ) and microcalcifications (birads , n = ; bi-rads - - , n = ) was improved by digital magnification and digital contrast variations. conclusion: digital mammography due to the post processing tools seems to facilitate dramatically reading of mammography in patients with previous conservative treatment for breast cancer, and helps to delineate post-therapeutic changes. the conclusions: it appears that the achievable image quality of a system not only depends on detector characteristics but also on available combinations of target, filter and tube voltage. therefore image quality comparisons show different results using optimized spectra for each digital system, compared to using the same spectrum for all systems. to show a short way to present breast mr dynamic imaging obtained using -mm isotropic d acquisition and single-voxel proton spectroscopy. background: during a standard breast mr exam, including a precontrast shorttau inversion recovery (stir) or fast spin-echo t -weighted fat-sat and a dynamic gd-enhanced d sequence, at least native and subtracted images are produced. moreover, maximum intensity projections (mips) of a subtracted phase and dynamic curves must be shown. if performed, proton spectra could be given with localizing images, too. procedure details: seventy breast mr exams were performed at our department as follows: -slice axial stir; t -weighted d gradient-echo coronal -mm partitions ( x -mm field-of-view; x matrix; -mm voxel) with . mmol/kg gd-chelate and -s time resolution ( postcontrast phases), giving native and subtracted for a total of images; single-voxel spinecho (te ms) proton spectroscopy. we present firstly an axial mip of the first subtracted sequence similar to cranio-caudal x-ray mammography (xm) views, two lateral mips similar to lateral degrees xm views, and a coronal mip. then, only selected images are presented: stir, precontrast t -weighted, and postcontrast subtracted images (morphology); percent enhancement-to-time curves for regions of interest (dynamics); proton spectra with/without choline peak at . - . ppm and lipids peaks (metabolism). representative cases will be shown in correlation xm, ultrasound, and pathologic proof. conclusion: breast mr high-resolution imaging and proton spectroscopy can be effectively summarized in no more than images ( x -in-one films), % of the acquired/subtracted images. mr guided interventional procedures in breast pathology management i. herraiz, l. concepción, j. ballesteros, a. fernández-moscoso, j. gallego, m. garcía-franco; alicante/es; presented by s. lopez-celanda; alicante/es learning objectives: to descibe mri-guided core biopsy of mri-suspected lesion, hook wire placement or clip marking for excisional biopsy of non-palpable, mri-only visualized lesions. procedure details: all procedures were performed on a . t philips gyroscan intera unit. standard ce breast mri imaging protocol included a dynamic volumetric t -weighted acquisition prior and after gd-dtpa injection employing a bilateral surface coil. localization was achieved either by employing a stereotatic device or by triangulation methodology with external markers with a flexible unilateral surface coil. imaging acquisition was tailored to each case. titanium clips (inrad®) or nitinol (somatex®). g titanium coaxial needles (somatex®) and g automatic biopsy gun were employed (tsk acecut®,). our series includes patients with mri suspected lesions. reevaluation of them with conventional methods (mammography and sonography) allowed location of half of them resulting finally in a total of mri-guided interventional procedures. this includes mri-guided core biopsies in lesions measuring - mm, mriguided presurgical hook wire localization and clip placements to assist location of a mri visible single lesion. pathologic evaluation resulted in cases of infiltrative ductal carcinoma and benign lesions. the only biopsy false negative result was in the smallest lesion ( mm). conclusions: all mri-suspected lesions must be reevaluated by conventional methods. in mri-only visible lesions we favor clip marking or hook wire location if size is smaller than mm. in lesions highly suspicious for malignancy additional clip marking during core biopsy procedure is recommended. background: accuracy of pre-treatment diagnosis of breast carcinoma extension is essential in order to plan the most effective therapeutic approach. extension of carcinomas can be difficult to interpret on d images, especially if their distribution is segmental or irregular. also, additional multifocal or multicentric foci can be problematic to localize in respect to the main tumour and the anatomy of the remaining breast. it is furthermore important for breast surgeons to apprehend the extent of the disease in radiological images in order to plan the surgical approach. procedure details: t -weighted flash d pre-and post-contrast images were obtained in patients diagnosed with breast cancer on core biopsy. analysis of images was done with a dedicated software for breast mri (asymedâ). parametric images for maximum enhancement speed, maximum enhancement, multiplanar and d reconstructions, speed of enhancement curves and enhancement curves are analysed in each patient. d images were viewed as video clips with a degree rotation around both breasts. maximum tumor diameter was measured in all images and distribution was reported following surgical anatomy. all shown cases have been histopathologically proven in respect to size and extension. conclusion: besides analysis of morphology and speed of enhancement curves, maximum enhancement speed parametric d images stand as a useful approach to tumor extension, giving additional information and an overall view of distribution of the disease in respect to breast anatomy. background: the rate of breast cancer recurrence is - % per year. follow-up of patients after conservative surgery includes a periodic clinical examination and a mammography every months during the first years and every year thereafter. post-treatment changes may mimic or obscure recurrent cancer. diagnostic problems are encountered with conventional imaging and fine-needle aspiration cytology. increased vascularity and vascular permeability occurs in recent scars and inflammation; however majority of scars months after surgery do not enhance significantly at mrm while all malignancies do. imaging findings: in our series all cases of proved recurrence showed over % maximum signal intensity enhancement at minute and plateau or washout dynamic curve at mrm. only two cases of scar showed more than % maximum signal intensity enhancement at minute and the curve in all benign cases was gradual. the quantitative data should be always correlated with the morphology of enhancement curve. irregular shape or margins and inhomogeneous enhancement proved to be important criteria for recurrence assessment. conclusion: mrm appears a valuable tool to differentiate post-treatment changes from recurrent carcinoma and to guide the pathological confirmation. its high negative predictive value may have an impact on follow-up of treated breasts. the correlations between enhancement parameters and histopathological findings were analyzed using stepwise multiple regression analysis, student's-t test and spearman moments correlation coefficients. results: significant correlations were determined between the presence of lymph node metastasis and tumor size (r = . , p < . ), contour characteristics (r = . , p < . ), and edge characteristics (r = . , p < . ). a highly significant correlation was found between histological grades and qualitative enhancement patterns (r = . , p < . ). statistically significant differences were found between the groups with and without lymph node metastasis regarding enhancement in the st minute (p < . ) and tic slope (p < . ). a significant difference was found between the histological grades i and iii regarding all quantitative enhancement parameters, whereas no difference was found between the grades i-ii, and ii-iii. conclusion: dce-mri helps to predict prognostic factors of breast cancer by revealing qualitative and quantitative enhancement features of the primary tumor. additional morphological factors further improve our ability to predict lymphatic metastasis. we measured the number of vessels, the major systolic velocity (ps), the end diastolic velocity (ed), the resistance index (ri) and the glosing index (pi) appearing in all the slices we took. we noted the maximum and minimum values of all the above parameters that appeared in the same mass in different slices and calculated the differences. results: for the benign tumors the mean values for the differences between the maximum and the minimum number of vessels was (diffves) . (p < . ), the diffps was . cm²/sec (p < . ), the diffed was . cm²/sec (p < . ), the diffri was . (p < , ) and diffpi was . reliability of us-diagnosis of metastatically affected regional lymph nodes in the presence of female breast cancer e. shevchenko, a. zubarev; moscow/ru purpose: analysis of false-positive and false-negative results of us in diagnosis of metastatic lymph nodes (l.n.) in breast cancer. materials and methods: patients with breast cancer (stages t n -t n ) were examined on hdi atl philips with morphological verification. patients ( . %) had metastatic deposition in regional l.n. results: precision of us-diagnosis of unchanged l.n. was equal to . , specificity - . %, sensitivity - . %. false-negative results were found in cases ( . %). in b-mode the oval shape remained unchanged in all cases, cortical layer and core were differentiated. thickness of cortex: . - . cm, node size: . x . cm- . x . cm. in cases blood flow was located in portal region, cases - longitudinal vessel in center of the l.n. sizes of the l.n. with micrometastases were up to . cm. we had false-positive results in patients ( . %). round shape was found in cases, oval -in , in patients l.n. joined together in irregularly shaped node. in cases there was uneven thickening of cortex in one pole of node with size fluctuation. differentiation of cortex and core was absent in cases and echogenity was diffusely lowered. subcapsular vessels were located in cases, aberrant vessels -in , distortion of central vessel -in , local absence of perfusion -in . false-positive cases corresponded to sinus-histiocytosis, hyperplasia of lymphoid tissue. conclusion: only use of the full complex of us-symptoms of metastatically affected l.n. lets us improve the precision of diagnosis. inter-and intraobserver agreement in breast ultrasonography: significance of internal echoes at image interpretation j. tsutsumi, k. shimamoto, m. ikeda, a. sawaki, h. satake; nagoya/jp purpose: to evaluate the significance of internal echoes among diagnostic us criteria for breast lesions. materials and methods: breast masses ( benign, malignant) were interpreted by radiologists and radiological technologists using a four-point rating scale, and the kappa statistics were employed for analying interobserver agreement. to assess reproducibility in judgments, double reading was done in cases, and a total of cases were interpreted for each observer. us criteria included shape, border, boundary echoes, internal echoes (homogeneity and echo level), posterior echoes, lateral shadow, gland surface, depth-width ratio (d/w) and total impression in differentiating benign from malignant lesions. to evaluate the significance of internal echoes at us image interpretation, us images were modified to make the internal echoes invisible by painting with black color using the adobe photoshop. : roc analysis showed a significant difference in diagnostic performance between the original us images and modified us images (p < . ). the kappa value of posterior echoes was highest whereas that of boundary echoes showed the lowest value in both the original and modified us images. inter-observer agreement in shape, border, and category in the original images was significantly higher than that in the modified images (p < . ). reproducibility in boundary echoes and gland surface was fair, and that in posterior echoes and the d/w was good. can a mammogram dictate to you the diagnosis? a review of characteristic mammographic findings a.n. chalazonitis , j. tzovara , t. vrakatselis ; athens/gr, ioannina/gr learning objectives: participants will obtain an approach to various mammographic patterns and improve their diagnostic skills in breast imaging. background: mammography is considered by far the single most important imaging modality for breast diseases. except from radiologists with vast experience, many other physicians without specific knowledge are unable to discriminate normal from abnormal findings in the mammograms. imaging findings: the main aim of this exhibit is to provide a pictorial review of characteristic radiological findings in different mammograms. various examples due to different causes are illustrated and mammographic findings, as well as differential and final diagnosis are also discussed. all cases have been selected by reviewing our hospital teaching files. conclusion: our exhibit will allow participants to challenge their skills in the detection of both normal and abnormal mammographic signs. breast imaging and histopathologic correlation of fibroadenomas in patients with transplanted kidney: different features from usual fibroadenoma e. son , e.-k. kim , k. oh ; sungnam/kr, seoul/kr learning objectives: to analyze the imaging and histopathologic features of fibroadenomas in kidney transplanted patients and to compare findings of fibroadenomas in kidney transplanted patients with those in a control group. background: from to , , patients underwent renal transplantation at our institute. all patients received immunosuppressive therapy with cyclosporin a and steroid after renal allograft. we examined ten female patients who were diagnosed with fibroadenomas during chemotherapy, and compared the data obtained with that of fibroadenomas in the normal population. procedure details: twenty-two fibroadenomas developed in ten patients. eight of the patients had multiple fibroadenomas and had bilateral fibroadenomas. the mean diameter of the fibroadenomas was . ± . cm. by mammography the lesions were spherical in shape and had a well circumscribed margin with a high density mass. none of the lesions showed calcification or spiculation. sonographic findings of the masses showed relatively high echogenecity with higher l/t ratios than benign masses, however, features of homogeneous internal echo and well circumscribed margin were consistent with benign. conclusion: the fibroadenomas that developed in patients with renal transplantation showed a tendency to be multiple, bilateral and larger than those in the control group. these fibroadenomas also exhibited a more rapid growth, a more spherical shape and an unusually high internal echo and higher l/t ratio than usual fibroadenomas. to present mammographic and ultrasonographic (us) findings in various types of reconstruction using autogenous myocutaneous flap after mastectomy or breast conserving operation. background: breast reconstruction is an integral part of a woman's breast cancer management and yields positive psychological benefits for the patient. autologous tissue reconstruction has gained in popularity in part owing to adverse publicity regarding prosthetic implant safety. it can alter breast anatomy and architecture drastically. in this exhibit, we describe mammographic and us findings in the various types of reconstruction using autogenous myocutaneous flap after mastectomy or breast conserving operation. procedure details: mammography and ultrasonography obtained in patients who had undergone reconstruction mammoplasty using the autogenous myocutaneous flap procedure were reviewed to facilitate recognition of both normal and abnormal postoperative appearances of the various types of reconstruction using autogenous myocutaneous flap after mastectomy or breast conserving operation. normal mammographic and us findings include predominance of fatty appearance, surgical clips, and surgical scars. abnormal mammographic and us findings include fat necrosis, calcifications, and locally recurrent carcinoma. us findings of fat necrosis were cystic, complex and solid appearing masses with circumscribed or ill-defined margins in peripheral portions of flap. us finding of locally recurrent carcinoma was ill-defined heterogeneous hypoechoic lesions in reconstructed breast, similar to those of primary breast cancer. conclusions: breast reconstruction using autogenous myocutaneous flap has increased in popularity with various methods. mammography and sonography facilitated excellent visualization of normal and abnormal findings of various reconstructed breasts using autogenous myocutaneous flap. extramammary pathology mimicking breast disease e. rabanal, r. rosell, j. salvia, r. garcia; sabadell/es learning objectives: to present the imaging findings in cases suspected initially of breast disease which turned out to have extramammary pathology. background: we reviewed our records for the last ten years. during that time, , mammary studies were performed. all cases with extramammary pathology were selected. they were classified into two broad categories: those which had abnormal physical findings (palpable mass or skin thickening) and those with abnormal findings in the mammogram (calcifications, nodules and thickened lymphatics). imaging findings: cases were classified as follows: microcalcifications secondary to filariasis. we will see more of these cases due to increased immigration. it's important to know this entity to make the correct diagnosis and avoid unnecessary examination or biopsy. uniform skin thickening and/or oedema, secondary to systemic disease (sclerodermia), congestive heart failure or lymphoedema. palpable skin nodules (infected sebaceous cysts), simulating mammary abscesses. chest wall disease: empyema necessitatis draining into the breast. extramammary (chest wall) lipomas and dercum's disease. neurofibromas in von recklinghausen's disease. the imaging findings of these processes will be reviewed and their salient features described in order to suggest the correct diagnosis. conclusion: it is important to know the features of extramammary disease in order to make the correct diagnosis, avoiding further examinations and unnecessary invasive procedures. the reality of microcalcifications in breast tissues shown by synchrotron radiation imaging j. okamoto, y. kanemaki, k. imamura, n. ehara, y. inada, i. maeda, k. miyamoto, y. nakajima, m. fukuda; kawasaki/jp purpose: the aim of this study was to approach the reality of microcalcifications of benign and malignant diseases using synchrotron radiation imaging, and to make a comparison with conventional x-ray images. materials and methods: surgical and biopsied specimens fixed in wax blocks were imaged using synchrotron radiation (sr), and conventional mammography unit (conv) as well. studied were patients ( benign, malignant). sr imaging was performed at spring- in japan in refraction-enhancement mode. conv images were evaluated visually using a magnifying glass. sr images were inspected on a monitor without magnification. morphology of microcalcification was categorized to groups: small round, amorphous (am), and pleomorphic (pl). results: , calcifications were observed in conv images and , calcifications in sr images. , of , ( %) were invisible in conv images. sr imaging revealed that great numbers of specks were recognized collectively as a single calcification in conv images, and of , calcifications in conv images were found to consist of multiple specks. the incidence was especially higher in am and pl types ( / and / , respectively). comparing malignant with benign diseases, there was a striking contrast in am-type calcifications; majority of am-type calcifications in malignant diseases were found as collectives of fine specks ( / ), to the contrary / in benign (p < . ). conclusion: synchrotron radiation imaging showed that majority of amorphous and pleomorphic type calcifications, especially of amorphous type of malignant diseases, in conventional images were essentially collectives of multiple specks. psychological perceptions of women due to mammographic follow-up b. barreau , r. gilles , s. tastet results: women answered the questionnaire. all women were satisfied with the mammography and the medical staff except that the mammography was painful in cases. for women, the period between mammographic follow-up was too long. in women, the quality of life was altered. communications of the experience to a relative was frequent ( / cases) but satisfactory in only cases. for women, medical information was considered relevant. the median of the scale of stress was ( - ). there is two pickaxes, one at , the second at . "low-stressed" women could have an avoidance coping. "high-stressed" women could use a helplessness-hopelessness coping strategy. conclusion: women reported relevant medical information and comprehension of the short follow-up -mammography. they were reassured by the medical care, but the evaluation of the scale of stress was high, probably due to the diagnosis. mammographic density changes in postmenopausal hormone therapy: effects of various agents using a new scoring system s. orguc, c. göktan, g.y. ovali; manisa/tr purpose: to evaluate the changes of mammographic breast density due to postmenopausal hormone replacement with various agents using a new scale and to compare the new scoring system with the classical methods. materials and methods: women who received hormone replacement therapy in celal bayar university hospital between - were examined with baseline and follow-up mammograms. the effects of various hormone regimens, selected according to the gynecological status, were evaluated by two radiologists. wolfe classification and a new scoring system were used to assess the change of mammographic density. the new scale divides each breast into ten wedge shaped slices on the cc positioned mammograms. change of density is scored according to the number of slices, which have an increase of density in comparison with the baseline mammograms. the results were statistically evaluated to compare the effects of various hormone regimens using a control group of patients who did not receive any hormonal therapy. statistical analysis was also carried out to determine the effect of using different scales. results: tibolone effected breast density is less than preparations containing oestrogen. degree of mammographic change differs depending on the scale used. the new scale is more sensitive in depicting changes of breast density. conclusion: preparations containing oestrogen effect the mammographic density more than tibolone regimens. the new scaling system is highly efficient and objective in determining the changes of breast density. to evaluate sensitivity and specificity of positron emission tomography (pet) and -f-fluorodeoxyglucose ( f-fdg) in breast cancer diagnosis and to assess tumor dissemination. materials and methods: patients were examined: without mammary disease, with fibrous cystic mastopathy, and with breast cancer, which was hystologically proven. pet-scans (ecat exact ) in "whole body" mode were performed min after intra-venous injection of - mbq f-fdg. the t/ nt ratio for radiopharmaceuticals was evaluated. results: in all patients with malignant tumors the t/nt ratio for pet- fdg was higher than . (m ± m = . ± . ). it was shown that pet has a high diagnostic accuracy in breast cancer detection with sensitivity % and specificity %. pet scanning in the "whole body" mode was allowed to assess dissemination of tumor process with high accuracy. pet f-fdg sensitivity was around . % to % in diagnosis of regional and distant metastases. it was related to metastases localisation. conclusion: pet with f-fdg has high diagnostic accuracy in diagnosis of breast carcinoma and staging of tumor extent. results women aged between - were invited in three rounds in the mentioned period of time. bilateral mammography with double projection was performed, and read in a double blind manner, according to the strict, prescribed methods. if needed, additional mammographic x-ray, us, fnab and core biopsy was performed. results: the acceptance rate was low, around . % ( women were screened during five years). we called back around % of the screened patients for additional x-ray examination ( . %) or for us ( . %). we performed fnab in % of all cases ( women). cases were proven benign. the overall rate of hystopathologicly verified invasive cancers per women were ( patients). we could detect an increasing rate of small cancers and better lymph node state by the time, because around % of the examined women were already screened by us before, during the -year-period. number of interval carcinomas was nine ( . %). conclusions: comparing to european standards our screening program was the same, but the acceptance rate was lover. the high non-acceptance rates can be explained mainly by the cross-screening possibilities of budapest, hungary and because the high risk population is not informed well enough. however, due to the mental hygenic program running in hungary, we could detect an increased number of inquisitive women. tubular carcinoma of the breast: clinical, mammographic and ultrasonographic findings f. zandrino , m. calabrese , l.e. bacigalupo , f. musante ; alessandria/it, genova/it purpose: tubular carcinoma is a well differentiated invasive adenocarcinoma, with a prevalence ranging from to % of all carcinomas of the breast. the purpose of this presentation is to analyse its clinical, mammographic, and ultrasonographic features, with histopathological correlation. materials and methods: in a retrospective review of consecutive histologically proven carcinomas of the breast, pure (tubular component of at least %) tubular carcinomas were found ( . %) in women (age ± yrs). results: three lesions were palpable. on mammography, five were not detectable; the remaining presented as nodules with spiculated ( lesions) or irregular ( ) margins, spiculated nodules with microcalcifications ( ), distorsion ( ), or asymmetric density ( ). on us, lesion was not detectable; the remaining presented as hypoechoic lesions with irregular ( ) or well defined ( ) borders. for tumours, diagnosis of carcinoma was made with cytology; in cases core biopsy: in the first a complex sclerosing lesion with atypical cells was suggested, in the second differential diagnosis between tubular carcinoma and sclerosing adenosis was proposed. lesion size was . ± . mm. only in patient were metastatic axillary nodes found. conclusion: in our series, tubular carcinoma presented mainly as a non-palpable, small-sized lesion, with non-specific mammographic patterns and a hypoechoic ultrasonographic appearance. lymph node metastases are rare, as previously reported in the literature. dose distribution in tangential irradiation for breast h. ohtani, s. usui, y. jincho; tokyo/jp purpose: skin injury, lung disease and conservation radiation therapy for breast is reported. in a previous investigation, local management and survival rates were reported on the face of treatment effect's records, but the real irradiation doesn't become clear. this report is to measure the dose distribution of the effect on the critical organ by tangential irradiation of the left breast. materials and methods: measurement was performed with a semiconductor detector. irradiation was performed with x-ray beams at degrees. irradiation field sizes were established × cm to investigate influence by field sizes. irradiation was done on the wedge of degrees. results: dose equivalent was accurately measured with semiconductor detectors. from the results, breasts, thyroid gland, heart, both lung fields, kidney, ovary, and uterine doses become clear. the dose distribution at tangential irradiation of left breast was measured. consequently, the breast in which a radiation injury tends to be encountered, lung field, and the dose of important internal organs could be obtained. the necessity to confirm the dose distribution in the body for tangential irradiation in breast preservation treatment, refers to a radiation injury, and this study estimates these doses. the to assess the influence of days of repetitive hyperbaric simulations on the form and structure of single-lumen silicone gel-filled implants. materials and methods: new implants from different manufacturers and removed implants were submitted for simulated dives in a hyperbaric chamber, with an average of dives a day and with a maximal depth of m. a standard x-ray and mri were performed before, after and days of repetitive diving, and days after the experiment. mri was performed using a . -t superconductive magnet (symphony-, siemensag, erlangen, germany) with a body and spine coil, and a gradient echo t -w sequence ( d flash), slice thickness mm. the prostheses were checked for bubble formation, volume changes, integrity and morphological appearance. results: there were no significant changes in form, nor in shell integrity. after days of repetitive diving, there were some tiny bubbles in the implants, confirmed by x-ray and mri. after days, there were significant bubbles in of the implants (increase in implant volume up to %); in the other there was a slight increase in number and volume of bubbles. there was no significant change in the bubbles days after the last dive. the significant bubble formation in some single-lumen silicone gelfilled implants after days of repetitive diving, raises concern about the influence of repetitive stress on the lifespan of implants in correlation with the number and depth of dives. resection of non-palpable breast cancer using d imaging created by multislice helical ct: a new interventional technique to design resection lines in breast preserving surgery k. oda, t. kubota, h. satake, a. sawaki, t. ishigaki, y. nimura; nagoya/jp purpose: we report a new method for an adequate segmental resection of nonpalpable breast cancer employing an interventional technique using three-dimensional images of contrast-enhanced ct. materials and methods: eight patients with non-palpable breast cancer (dcis , invasive carcinoma ) were included in this study. diagnosis of carcinoma was made by cytology, but the extent of the lesion could not be clearly shown by us. one hour before the operation, contrast-enhanced helical ct was performed using a toshiba aquilion (toshiba corp. tokyo) with the patient in the supine position, following the insertion of vats (video assisted thoracoscopic surgery) markers (hakko, japan) under us guidance. ct scan was performed seconds after the injection of contrast medium. the detector row configuration was x -mm. maximum intensity projection (mip) was performed on three-dimensional reconstruction ( d-ct). using three-dimensional images of ct, anatomical relationship of vats markers, nipple and carcinoma demonstrated as a well-enhanced focal-clumped lesion or segmental lesion was evaluated and lines of resection with to cm surgical margin were designed. curative resection was confirmed in x-ray films of resected specimens based on the relationship between the lesion and the vats markers in preoperative three-dimensional ct images. results: in all cases, adequate segmental resection with cancer free surgical margins was accomplished and the cosmetic results of the surgery were satisfactory. conclusion: three-dimensional images of contrast-enhanced ct with this interventional technique is a useful method to design resection lines for non-palpable mammary carcinomas. european breast screening performance: does case volume matter? h.j. scott , a.g. gale , d. wooding , d. walter ; derby/uk, augsburg/de purpose: u.k. breast screening radiologists typically read over , screening cases per annum, whereas in europe this figure is much lower as in many countries national breast screening programs are in their infancy. the performs scheme in the u.k. permits radiologists annual self-assessment of their filmreader skills. as part of the eu funded european breast cancer network a number of german radiologists have now read the current performs assessment set. we investigated whether real-life case volume affects reading performance by the comparison of matched groups of radiologists from these two countries. we analysed the data from current sets of difficult recent screening cases. for each case individuals identified which key mammographic features were present, whether the case was abnormal and should be recalled or not. for this analysis the participants were matched on age, gender, film-reading protocols and years of experience. assessment of case volume was elicited by questionnaire data. the radiologists were compared on several key performance measures; cancers detected, correct recall and correct return to screen, signal detection performance statistics and real-life screening practice. results: it was found that whilst the performance of the german radiologists on the current test sets was excellent (correct cancer detection rate > %) on average they performed less well than their uk counterparts. we argue that this is closely related to the volume of cases read per annum by individuals within each country, and theoretically their performance will be equivalent as their case volume increases. the cytogenetic method of dosimetric control for screening mammography v. demin, e. djomina; kiev/ua purpose: it is advisable to study a degree of risk due to the unfavourable consequences of irradiation of the breast with screening mammography in ukraine after the chernobyls disaster. the correlation of cytological (cytogenetic) and physical findings were accomplished. the test-tubes with donor human blood were placed on upper and lower surfaces of breast of tissue-equivalent aldersons phan-tom. the test-culture of lymphocytes of human peripheral blood were used for biological dosimetry. physical dosimetry are realised with the thermoluminescent system alnor. the chromosome aberrations are becoming + . % on the upper surface of breast (normal control level is %) on mammography in two projections (upper-lower and lateral), the fragments of chromosome type are %, radiation markers -dicentric chromosome are . %; equivalent dose is . %. conclusion: there is a risk of radiation induced genetic lesions in breast tissue after mammography. instability genome is a basic radiation carcinogenesis. this is very real for women in ukraine after the chernobyls disaster. efficiency of the multidetector row ct in the diagnosis of breast cancer and evaluation of intraductal spreading h. kani, m. matsuki, i. narabayashi; takatsuki/jp purpose: the purpose is to analyse the efficiencies of multidetector row ct (mdct) in the diagnosis of breast cancer and evaluation of intraductal spreading. materials and methods: pathologically diagnosed breast lesions from patients were examined by mdct. the lesions included the following: invasive carcinomas, noninvasive ductal carcinomas, fibroadenomas, papillomas and other benign lesions. non-contrast ct and contrast-enhanced ct scans at , and sec after the start of enhancement were performed using row mdct. the imaging was performed under the following conditions: . -sec gantry rotation speed, . helical pitch, mm slice thickness and reconstruction intervals of mm. the items examined were as follows: ) in time-enhancement patterns during four phases, the early enhancement and plateau patterns were defined as a malignant tumor and gradual enhancement pattern was defined as a benign lesion. its ability in the diagnosis of malignant tumor was evaluated in the comparison with histopathologic findings. ) the abnormal enhancement continuing to the tumor at sec after the start of enhancement was estimated as intraductal spreading of breast cancer. the detectability of intraductal spreading was evaluated by the comparison with histopathologic findings. results: . the sensitivity, specificity and accuracy of the diagnosis of malignant tumor were . %, . % and . %, respectively. . the sensitivity, specificity and accuracy of the detactability of intraductal spreading of breast cancer were . %, % and %, respectively. conclusion: mdct is very useful for the diagnosis and preoperative estimation of breast cancer. an exploratory study about mammographic practice (acr from bi-rads) three months after a medical continuing education on breast cancer b. barreau , s. tastet , m. deghaye , v. picot , i. brault , p. marelle , l. ceugnart , d. aucant , s. haber ; paris/fr, bordeaux/fr objectives: evaluation of practices, three months after a medical continuing education, when abnormalities acr (probably benign) are detected on mammography. materials and methods: a questionnaire ( items) about these practices was sent to radiologists three months after medical continuing education (may-december ) . the answers were analysed with chi-square test. results: radiologists completed the questionnaire; radiologists practiced breast screening; used the bi-rads classification; radiologists followed-up the abnormality with a short interval, made a biopsy and overclassed the image; radiologists asked for advice from other radiologists, from an expert, submitted to a multidisciplinary committe and asked for a second reading. a short interval-follow-up disturbed radiologists about an eventual unfavourable evolution of the abnormality and radiologists about legal problems; had difficulty in explaining to patients the short interval-followup. the median of the scale ( to ) of the radiologists perceived stress is . conclusion: these french radiologists have consistent practices with the bi-rads classification and the anaes recommendations. they may have difficulties in explaining the procedure to patients. the radiologist's ethic is based on the "primum non nocere". c b d e f a g histopathological perspective on the first german mammography screening project: a two year review g. gohla , u. sauer , p. hanisch , w. boecker , h. junkermann , u. bonk ; bremen/de, münster/de purpose: the aim of this investigation was to critically review the role of the histopathologist in a mammography screening project. materials and methods: the first model mammography screening project in germany has been running in bremen for the last two years. all women between and years of age have been offered mammography and any suspect findings were investigated by core biopsy. these cases were reviewed in the pathology dept. of the university münster and discussed at a weekly multidisciplinary meeting. lesions were classified using the point b classification scale as recommended by the european union. results: in the first two years of the screening project, a total of women had mammography. suspicious areas were detected and core biopsies were obtained from of these women. % were classified b (malignant) % of these cases were classified b , (regular breast tissue, benign) and % of these cases were classified b and b (atypia probably benign, suspicious of malignancy). in % of all cases there was agreement amongst the reviewing histopathologists, but in % there was no interobserver consensus. these disagreements centered on flat epithelial atypia, atypically hyperplasia and papillary lesions. the consensus amongst experienced breast histopathologists is satisfactory in clearcut cases, but it should be improved in less well classified lesions. these lesions are more likely to be seen in a screening situation and in core biopsies. in this area it is certainly advisable to cooperate closely with the clinician and radiologist. usefulness of multi-slice ct for nonpalpable breast lesions with microcalcifications: correlation with mammographic findings h. satake, a. sawaki, k. shimamoto, s. ishigaki, k. oda, t. imai, t. ishigaki; nagoya/jp purpose: to evaluate the usefulness of multi-slice ct for nonpalpable breast lesions with microcalcifications, compared with mammographic findings. materials and methods: cases with nonpalpable microcalcification of the breast recommended for biopsy on mmg. they included malignant lesions (ductal carcinoma in situ, n = ; ductal carcinoma in situ with microinvasion, n = ) and benign lesions (mastopathy, n = ; intraductal papilloma, n = ; other, n = ). on multi-slice ct images, the presence of focal or segmental enhancement in the region consistent with microcalfications was regarded as positive diagnosis for malignancy. all mammographic and ct findings were assessed with a consensus between two radiologists. results: cases of benign lesions pathologically were assessed as "suspicious malignant" on mmg, while, in three of them, focal or segmental enhancement appeared on multi-slice ct. although seven cases of breast cancer were assessed as "probably benign" on mmg, six cases acquired focal or segmental enhancement on ct. for cancer diagnosis, the sensitivity of mmg and multi-slice ct were . % and . %, specificity was . % and . %, and negative predict value were . % and . %, respectively. breast conservation surgery with simulation using d ct images was performed successfully in cases of breast cancer. the sensitivity and the negative predict value of multi-slice ct for nonpalpable breast microcalcifications were superior to those of mmg. when biopsy is recommended according to mmg, additional examination of multi-slice ct enables the indication for biopsy to be more optimized and is useful for planning the treatment. the value of magnetic resonance imaging in the assessment of adult patients with corrected transposition of the great arteries s. shine, e. kavanagh, c. we fully illustrate the morphology, contrast enhancement and mobility of myxomas in rare locations such as the right ventricle and unusual attachment to the tricuspid valve. background: although benign myxoma is the most common primary cardiac tumor ( %), it remains a rare finding with an incidence of . per million population per year in the western world. myxomas are found in the left ( %) or right ( %) atrium and seldom in the ventricles. these pedunculated tumors typically arise from the atrial septum near the fossa ovalis and much less frequently from the mitral valve. intracardiac obstruction and systemic emboli are the major complications. imaging findings: myxomas in an uncommon cardiac location should be differentiated from other primary (malignant) and secondary (thrombus; metastasis) cardiac tumors. mri allows visualization of the narrow pedicle, its attachment and the changing tumor shape and mobility during the cardiac cycle, unlike most malignant processes. in contrast to most thrombi, myxomas have low signal intensity on cine gradient-echo images and show contrast enhancement. the water-rich myxomatous stroma, fibrous stroma, calcifications and hemorrhage account for the heterogeneous t -weighted se images. increased interstitial space in the myxoid region and inflammatory zones enhance after intravenous gd-dpta on t -weighted se images. lobular tumor surface and higher volume increase the pre-and postoperative risk for systemic emboli. furthermore, the exact location on mri is most helpful in planning the surgical access. conclusion: myxomas in uncommon locations can be differentiated from other cardiac tumors by evaluating tumor morphology, mobility and enhancement. how to study with cmr a patient submitted to ross procedure: a step by step follow-up protocol r. ribes , a. luna , j. vida , p. caro ; cordoba/es, jaen/es, cadiz/es learning objectives: to describe an adequate protocol to study patients submitted to ross procedure with mr. to identify and quantify postsurgical complications in this group of patients with mri. b d e f a g background: ross procedure is widely accepted as one of the best methods for aortic valve replacement, especially in children and young adults. ultrasound is usually used in their follow-up, but tit offers a limited evaluation of the right outflow tract, being important to discard homograft stenosis. mri overcomes the limitations of ultrasound and may replace the number of digital subtraction angiograms traditionally performed in the follow-up of these patients. procedure details: we describe step by step our mr protocol, to study patients submitted tothe ross operation. examples of the mr features of common presentations and complications are shown from our series of patients. our protocol consists of the following steps: • black-blood coronal and transverse turbo spin echo t -weighted images. • cinemr gradient-echo sequences allow functional qualitative assessment of themotion of valves and chambers, the detection of either valvular regurgitation orstenosis, and areas of altered myocardial contractility or relaxation. we perform gre-cinemr sequences in left two chamber, right two chamber, fourchamber, short axis (at several levels from the apex to the base), left ventricular outflow tract, right ventricular outflow tract, and aortic rootviews. • phase contrast images are performed to obtain quantitative data about magnitude anddirection of blood flow through the right and left ventricular outflow tracts. conclusions: cmr allows an accurate evaluation of patients submitted to ross procedure and identification of the postsurgical complications. the causes of focal outpouching of the left ventricle are as follows: ) true aneurysm; a chronic complication of myocardial infarction, which contains the endocardium, epicardium, and thinned fibrous tissue replacing the myocardium, ) pseudoaneurysm; a consequence of rupture of the ventricular free wall due to acute infarction and confined by the pericardium, ) diverticulum; a congenital outpouching of ventricular wall including all of three layers, and ) hibernating myocardium due to chronic ischemia with paradoxical outpouching at systole. mr imaging is useful in differentiating these causes by using variable imaging sequences to evaluate the myocardial contractility, perfusion and viability. in this exhibit, we will show the usefulness of mr imaging to differentiate these pathologies using various mr imaging sequences. imaging methods and findings: cardiac mr imaging methods include; ) cine imaging for wall motion analysis, ) first pass myocardial perfusion imaging, and ) delayed enhancement imaging. images were obtained along the short axis and horizontal long axis of the heart. by analyzing the shape, contractility, motion, perfusion, and contrast enhancement, it is possible to differentiate the causes of the outpouching lesion of the left ventricle. conclusion: cardiac mr imaging is useful in differentiating various causes of focal outpouching of the left ventricle. features of cardiac disease demonstrated on ct pulmonary angiography s. conclusion: ctpa is an increasingly frequently used investigation for the detection of pulmonary embolism. most patients investigated have pathology other than pe as a cause of their symptoms. frequently information about the heart is yielded that provides important clues to determine the cause for the presenting symptoms and signs or reveals co-existing pathology. with this investigation being used more frequently in daily practise in many patients with unexplained breathlessness or chest pain it is important to have a clear understanding of the features of cardiac disease as seen on a ctpa. mri has been done twice - - days and - months after surgery. mri was performed with a . t mr imager using ecg-gated t -se (or t -tse), bright-blood gre-cine-technique and phase-contrast mri. results: pts (of ) had a positive dynamic study of heart chambers dimensions and volumes in early postoperative stage. in the area of prostheses signal of low intensity was defined in all the patients (artifacts). narrow flow of low signal intensity along the prostheses leaflets corresponded to normal function of prosthesis ( of valves). pts had signs of mechanical valve dysfunction ( mitral paravalvular leaks, -aortic prosthetic valve stenosis). mri data were in agreement with the results of echocardiography. mri was able to diagnose such postoperative complications as atelectasis ( ), mediastinal haematoma ( ), pleuritis ( ). conclusion: mri could give an objective information about heart morphology (chamber dimensions, hypertrophy degree) and mechanic valve functioning (normal and abnormal flow) in patients after surgery. it can be safely performed in patients with artificial heart valves. negative calcium scoring: can it rule out severe stenosis? p.m. carrascosa , c. capuñay , p. garcia merletti , p. johnson , s. chandra , r. pissinis , j. carrascosa ; buenos aires/ar, cleveland, oh/us objective: to determine the presence of stenosis greater than % (in at least one coronary vessel) proved by digital angiography (da) in patients with a negative calcium score and correlate findings with ct angiography. methods: patients were evaluated. cts were performed with a -row ct scanner. the calcium score was calculated according to the agatston method. a calcified plaque was defined as a lesion of at least two adjacent pixels with signal intensity above hu. the second enhanced acquisition was performed following the administration of ml of non-ionic contrast with x mm collimation and . mm slice increment. das were performed on a digital angiographer. meas- car car car cardiac diac diac diac diac urements were done by means of qca. stenosis was considered positive if it was greater or equal than %. results: there were patients with high grade calcium score. eleven had positive da for at least coronary artery and in cases the da did not show severe stenosis. there were patients with negative calcium scores (grade ), had negative da findings, and had positive da findings. in these patients, the contrast ct acquisition revealed that the cause of the stenosis was due to soft plaques. conclusion: high grade calcium scores predict severe stenosis. negative results do not exclude them. in this study the % of the patients had negative calcium scores but significant stenosis due to soft plaques. a contrast ct acquisition instead of the calcium score will be necessary to rule out all the severe stenosis. positron emission tomography and n-ammonia application to evaluate myocardial blood flow in the asymptomatic patients with coronary artery calcification d.v. ryzkhova, i.e. itskovich, l.a. tyutin, l.a. kofal; st. petersburg/ru the purpose of this study was to assess myocardial blood flow (mbf) in the asymptomatic patients with coronary artery calcification (cac). methods: symptom-free patients with cac were included in study. all of them hadn't any symptoms of cad (chest pain, severe arrhythmia, heart failure) and myocardial infarction history. the patients with significant myocardial hypertrophy weren't included. the myocardial blood flow at rest (mbf rest) and during dipyridamole test (mbf stress) was evaluated by n-ammonia dynamic pet ("ecat exact ", siemens). the coronary calcium score (ccs) was measured by msct coronaroangiography ("somatom volume zoom", siemens) using the agatston method. results: myocardial perfusion abnormalities during stress test were revealed in patients with cac, there were patients with silent ischemia ( st group). we observed normal myocardial perfusion at rest and during stress test in the remaining patients ( nd group). the mean values of total ccs were less than units and close between the both group ( . ± . units vs. . ± . units, p = ns). mbf-values at rest didn't differ between the both patients' groups ( . ± . ml/ g/min vs. . ± . ml/ g/min, p = ns). mbf stress mean values were significantly decreased in the st group ( . ± . ml/ g/ min vs. . ± . ml/ g/min, p < . ). the ccs less than units isn't a reliable marker of flow-unlimiting stenoses in asymptomatic patients.soft lipid-laden plaques is a cause of myocardial ischemia in symptom-free patients with cac and low ccs. these patients should undergo stress studies to detect silent ischemia. detection and assessment of myocardial inflammation and fibrosis by echo-densitometry and ce-mri in patients with mild and medium myocarditis: validation by wbc-mibi spect m. deryugin, i. itskovitch, v. soukhov, s. boytsov, a. svistov; st.petersburg/ru background: echo-densitometry and ce-mri are novel methods for assessment of inflammatory myocardial infiltration (imi) and myocardial fibrosis (mf). the purpose of the current study was to validate these methods in patients with mild/medium myocarditis using wbc-mibi spect. methods: ce-mri was performed in patients using t -weighted turboflash inversion recovery. inflammation was evidenced by use of threshold method (signal intensity > + . sd). left ventricle echo-densitometry performed in long-axis views from left parasternal border at es/ed with following percentage cyclic variation indexes (cvi) calculation. spect was performed - hrs p.i. of mbq mtc-wbc and min p.i. of mtc-mibi. results: all patients were divided into groups based on scintigraphic data: first group - patients with diffuse leukocytes uptake that considered as imi; in second group there were patients with local leukocytes uptake and abnormal mp (imi+mf); third group consisted of patients with only mf. control group patients (n = ) had normal mp and no leukocytes uptake. cvi was ± % in controls; . ± % in st ; - . ± % in nd and - ± % in rd group. ce-mri was able to detect imi in % of patients. regression analysis revealed good correlation between imi by ce-mri and by wbc-spect (r = . , p < . ). furthermore, good correlation was found between cvi and mtc-mibi uptake (r = . , p < . ) both for imi and mf detection. conclusion: ce-mri enables exact detection of imi as compared to wbc-spect. the results of videodensitometry studies demonstrated that different types of imi were associated with definite cvi percentage, while cvi became negative with mf appearance. one-year ct evaluation of pulmonary veins following percutaneous cryoablation in patients treated for atrial fibrillation b. ghaye , d. szapiro , c. background: pulmonary vein isolation (pvi), using radiofrequency energy, for treatment of atrial fibrillation (af) has been associated with complications including pulmonary vein (pv) stenosis or thrombosis. the purpose of this study was to prospectively evaluate the pv morphology following cryoablation. method: patients underwent percutaneous pvi in academic centers. contrast-enhanced, single-slice or multi-slice spiral ct ( - . mm thick slices) was obtained before, and months following pvi. all examinations were read blinded to the location(s) of ablation. pvs were evaluated quantitatively and qualitatively: the diameter at ostium and at cm from ostium were measured. the presence and location of luminal irregularity or thrombosis was also assessed. the aims of this study were comparison of the local myocardial contraction between the myocardium with de and without, and evaluation of myocardial de's prognostic significance in patients with congestive heart failure due to nonischaemic dcm. materials and methods: delayed enhanced mri and myocardial tagged images were taken in patients ( ± yrs, male) referred for congestive heart failure due to nonischaemic dilated cardiomyopathy, whose left ventricular (lv) end-diastolic volume index > ml/m and lv ejection fraction < %. the patients were followed for a mean of ± months. results: myocardial de was present in patients ( %). in these patients, the average amount of myocardial de was ± % of lv myocardium ( - % of lv). myocardial axial thickening was ± % in the segments with myocardial de, and ± % without (p = . ). myocardial circumferential shortening was ± % in the segments with myocardial de, and ± % in without (p = . electron beam ct (ebct) in the detection of abnormal myocardial contrast enhancement in patients with recent and chronic myocardial infarctions t. vesselova, v. sinitsyn, s. ternovoy; moscow/ru purpose: of the study was to determine the occurrence of low-density areas in the myocardium of the left ventricle (lv) in patients with myocardial infarction (mi) seen during non-invasive ebct coronary angiography. material and methods: patients ( . ± . years old) with ischemic heart disease and mi were included in the study. in patients with first myocardial infarction (mi) ebct was performed during first weeks after coronary event. in patients ebct was done months after an mi. ebct angiography and venticulography were done with imatron c- imager. results: low-density areas in lv myocadium were seen on ebct images in all patients with mi. in % of patients these findings were accompanied by myocardial thinning and in % cases intracavitary thrombi were present. in . % patients with transmural mi low-density myocardial regions were visualized on non-contrast images. in . % patients with mi subendocardial low-density zones were seen. results of ebct were in agreement with myocardial scintigraphy. characteristics of hypodense areas (hu values) in patients with recent and chronic mi were similar. calcifications and significant stenoses of coronary arteries were found in all patients with old mi, the mean (sd) agatston score was . ± . . in patients with subacute mi the mean agatston score was . ± . (ns). four patients from this group had coronary score = . conclusion: during ebct coronary angiography most of the low-density areas corresponded to sites of previous myocardial infarctions. some of these areas may correspond to hypo-perfused areas of ischemic, but viable myocardium. progression of coronary artery disease in relation to coronary stenosis morphology: quantitative coronary angiography analysis j. saponjski, m. ostojic, b. beleslin, v. vukcevic, m. nedeljkovic, s. stojkovic, a. dordjevic/dikic, i. nedeljkovic; belgrade/yu objective: the aim of this study was to analyze progression and regression of coronary stenosis in relation to stenosis morphology. the study group consisted of patients ( male, female; mean age ± years). coronary stenoses were analyzed by quantitative coronary arteriography including percent diameter stenosis (%ds) and changes in obstruction diameter between two arteriographies. according to the ambrose angiographic lesion morphology groups were identified: group i (n = )-simple concentric lesion morphology, group iia (n = ) -simple eccentric lesion morphology, group iib (n = ) -complex lesion morphology, and group iii (n = ) with complex and multiple coronary stenoses. the follow-up period between first and second arteriography were similar for all groups (i, ± months; iia, ± months; iib, ± months; iii, ± months; p = ns). results: progression of coronary artery disease was identified in %, %, % and % of lesions in ambrose groups i, iia, iib, and iii, respectively. on the contrary, regression of coronary stenosis was documented in %, %, % and % of lesions in groups i, iia, iib, and iii respectively. however, comparing the lesions with non-significant and significant stenosis (cut-off point % ds), progression of coronary stenosis was higher for the lesions with ds < % for all groups (except group iii where all the lesions were with ds > %), reaching statistical significance in group i (i, + . ± . vs - . ± . mm, p < . ; iia, . ± . vs . ± . mm, p = ns; . ± . vs . ± . mm, p = ns). conclusion: coronary lesion morphology of simple type was associated with lower rate of coronary stenosis progression. noninvasive the aim of this study was to assess coronary microcirculatory function in postmenopausal women. methods: we measured myocardial blood flow (mbf) with a n-ammonia pet scan at rest, during cold pressor testing (cpt) for an indirect measurement of endothelium-dependent vasomotion, and during dipyridamole hyperemia (endothelium-independent vasomotion) in postmenopausal women without coronary artery disease. young healthy women served as controls. results: rest-mbf and hyperemic-mbf did not differ between the young and the postmenopausal women (rest: . ± . vs. . ± ,. and dipyridamole: . ± . vs. . ± . ml/ g/min; ns). coronary flow reserve was similar between the two groups (the young women: . ± . , the postmenopausal women: . ± . ; ns). cpt induced a similar increase of rate-pressure product in the young and the postmenopausal women ( ± vs. ± beats/min/mmhg), cpt-mbf was significantly decreased in the postmenopausal women ( . ± . ml/ g/min) compared with the young women ( . ± . ml/ g/ min; p < . ). conclusion: pet with n-ammonia during cpt is a noninvasive imaging technique to detect mbf abnormalities, which associated with endothelial dysfunction in postmenopausal women. contrast-enhanced magnetic resonance imaging at true end-diastole to quantify reproducible transmural extent of myocardial hyper-enhancement y.-j. kim, b. choi, k. choe; seoul/kr purpose: to determine feasibility of contrast-enhanced mri (ce-mri) at true enddiastole (ed) free from limitation of time for inversion-recovery and trigger window for quantifying transmural extent of infarction. methods and materials: mri was performed in patients with myocardial infarction. cine imaging and ce-mri with same registered slices in short axis were performed. to allow true ed ce-mri, ecg synchronization should use two rrintervals for one acquisition of a segment of k-space by setting the heart rate to half that of the true heart rate. trigger delay time was adjusted to the rr-interval for imaging at ed and to the sum of rr-interval plus the time between r-wave and the end-systole (es) determined in cine images for imaging at es. results: wall thicknesses of the ed and the es ce-mri were greater than those of the ed and the es cine images ( . ± . mm > . ± . mm, . ± . mm > . ± . mm respectively). subendocardial hyperenhancement was detected in patients. among them, systolic wall thickening was observed with cine imaging in patients and the transmural extent of hyperenhancement measured on ed ce-mri decreased by - % on es ce-mri proportional to the degree of systolic thickening of the epicardially nonenhanced myocardium. transmural hyperenhancement in patients showed no difference in thickness between enddiastole and end-systole. conclusion: ce-mri at ed is constantly possible by using two rr-interval per acquisition of a segment of k-space and useful to avoid the variation in infart sizing with irreproducible cardiac phase other than end-systole in case of subendocardial infarction. comparison of computed tomography (ct) and magnetic resonance (mr) for screening of pulmonary veins (pvs) complications of cryotherapy for percutaneous ablation of atrial fibrillation (af) b. ghaye , d. szapiro , l.-m. rodriguez , c. timmermans , r.f. dondelinger ; liège/be, maastricht/nl purpose: to prospectively compare ct and mr for evaluation of potential complications, including stenosis or thrombosis of pvs, of cryoablation for af. methods and materials: patients underwent percutaneous cryo-ablation of af. cardiac spiral ct and mr were performed before the procedure, at hours, and at months following af cryo-ablation. ct was performed with spiral ct (pq , phillips, eindhoven, the netherlands) using mm thick slices reconstructed every mm, -s rotation time, ma and kv per rotation following iv peripheral injection of ml of % iodinated cm. mr was performed on a . t symphony va system (siemens, erlangen, germany) using a multi-slice t -weighted dark-blood turbo-spin-echo pulse sequence and bright-blood cine trufisp sequence. all ct and mr examinations were quantitatively and qualitatively read blinded to the location(s) of ablation. results: for ct, the mean diameters at la-pv junction and at cm from ostium were . ( . ( . - - ) . associated cardiac and extracardiac anomalies were evaluated on fetal echocardiography. postnatal diagnosis or autopsy were correlated with fetal echocardiography. results: in fetuses with right aortic arch, combined congenital cardiac diseases were as follows, tof ( ), vsd( ), and dorv with pulmonary stenosis ( ) . associated extracardiac anomalies were oligohydramnios( ), arthrygryposis( ), splenic cyst ( ), and shortening of long bones( ). on postnatal echocardiography, previously non-diagnosed vsd were found on two neonates and tga without vsd in one neonate. overall incidence of combined cardiac defects is about . %. conclusion: right aortic arch associates variable cardiac defects and extracardiac anomalies in about half of fetuses. prenatal diagnosis of right aortic arch must be followed further echocardiography and targeted fetal sonography for exact diagnosis. potential myocardial iron content evaluation by mr in β β β β β-thalassemia major patients treated by deferoxamine or deferipron m. galia, m. midiri, t. bartolotta, a. maggio, r. lagalla; palermo/it purpose: to evaluate the usefulness of mri to assess myocardial iron content in patients with β-thalassemia major treated by deferoxamine b mesylate (df) or deferiprone (l ) chelation therapy. method and materials: consecutive patients with β-thalassemia major ( treated by df and by l ) underwent, at enrollment and after one year treatment, heart mri ( . t unit) with an electrocardiogram-triggered gradient-echo t weighted sequence. liver mri was obtained at the same time in all patients. measurements of the heart to muscle signal intensity ratio (hsirs) were compared between the two groups and with laboratory parameters, liver iron concentration (lic) and liver to muscle signal intensity ratio (lsirs). results: hsirs were significantly increased in df (t = - . ; p = < . ) and l group (t = - . ; p = < . ) after one year treatment. no statistically significant difference in the values of hsirs was present between the two groups at the beginning (p = . ; t = . ) and after one year treatment (p = . ; t = . ). hsirs were inversely correlated to lic (r = . ; p = < . ) but not to ferritin levels (r = . ; p = . ). a positive correlation was found between the variation of hsirs and that of lsirs (r = . ; p = < . ), and a mild correlation (r = . ; p = < . ) was found between the γ-glutamyltransferase levels and the hsirs values. conclusion: mri is usefull to detect hsirs variations during iron chelation therapy. moreover it is non-invasive and easily repeatable. application of -iodine labelled -iodinepentadecanoic acid for detection of myocardial viability in patients with chd and resting regional lv dysfunction v. soukhov, i. savicheva, a. partsernyak, a. svistov; st.petersburg/ru purpose of this study was to assess -iodine labeled -iodinepentadecanoic acid ( i-pda) -synthetic radiolabeled free fatty acid with the potence for detection of myocardial viability. methods: patients ( male and female, mean age ± yrs) who had history of myocardial infarction and resting regional left ventricular dysfunction were examined. blood supply, regional myocardial oxidative metabolism and regional metabolic substrate utilization were assessed by spect at - and - min after i.v. injection of mbq with i-pda. echocardiography with low doses of dobutamine was used for measuring inotropic reserve. results: early i-pda spect demonstrated high specificity in diagnostics of perfusion defects (up to %). the delayed images showed foci of remaining higher activity in regions of ischemic, but viable myocardium. of a total of myocardial segments had abnormal resting wall motion. in of them no oxidative metabolism and inotropic reserve were detected, that indicated scarred myocardium. of them were considered to be viable as they demonstrated both oxidative metabolism and inotropic reserve. conclusion: i-pda as an agent for simultaneous perfusion and oxidative metabolism evaluation may be used for identifying myocardial viability. diagnostic value of this method in combination with low doses of dobutamine echocardiography even in the cases of severe myocardial metabolic damage is nearly equal to pet with fdg and should be applied for detection of viable myocardium. comparison of mri and nuclear medicine in detection and analysis of left ventricular infarction r.m. macmillan , t. vakhtangadze , m.r. rees ; philadelphia, pa/us, bristol/uk aims: to compare standard spect perfusion imaging with last contrast enhanced mri for the detection of infracted myocardium. materials and methods: patients ( female, male) from two centres with proven myocardial infarction by ecg, clinical and echo criteria underwent stress/ rest tc sestamibi gated spect scanning with a dual headed gamma camera and late contract enhanced mri on identical . tesla scanners in each centre using a protocol which imaged minutes after injection of . mmol/kg iv gadolinium. analysis of segments used a segment system, with a total of segments analysed in both imaging methods. results: segments demonstrated scars on mri and segments demonstrated scars on isotope imaging. comparison of isotope imaging to mri showed that segments who had scars on isotope scanning failed to show on mri whilst scars on mri were not demonstrated on nuclear imaging. the majority of these scars were small or sub-endocardial. in some cases these scars had islands of functioning myocardium within them. some scars seen as completely non perfused defects on nuclear imaging were demonstrated to be partial thickness scars on mri. there was no significant difference in the findings from each centre indicating reproducibility and transferability of technique and findings. mri was able to detect smaller scars than nuclear imaging and viable myocardium in proximity to scar tissue. prenatal diagnostics of obstructive heart lesions g. spanovic , i. jovanovic , v. parezanovic , a. zvezdin ; novi sad/yu, belgrade/yu purpose: aim of prenatal diagnostics of obstructive heart lesion is to make right decision about the way leading further pregnancy, and decision about the time, place and way of labor. sensitivity and sensibility of fetal echocardiography are very high -between and %. methods and materials: fetuses were examined in period of seven years. fetuses with the diagnosis of some obstructive lesions of the heart were investigated. control group was made of fetuses with normal echocardiograms divided into four groups according to gestational weeks. echocardiographic techniques used: m-mode, d and doppler techniques. results: examination were made between and weeks of gestation. all cardiac structures show linear growth with progression of pregnancy. both halfs of the fetal heart are the similar size. obstructive lesions of the left heart and lesions of the right heart were diagnosed. there is statistically significant difference in size of the left and right structures in fetuses with obstructive lesions according to each other and also the same structure of the normal fetal heart. conclusions: obstructive lesions of the left heart were diagnosed much more frequently ( %) than the obstructive lesions of the right heart ( %) in the examination material. left heart hypoplastic syndrome was dominated lesion- % of obstructive lesions of the left heart and % of all diagnosed obstructive lesions. difficult obstructive lesions are progressive, have poor prognosis and present one of the indications for abortion. background: encouraged by beautiful cardiac multislice ct (msct) images presented at radiology and cardiology meetings, and by the favorable preliminary reports on high diagnostic value, more and more radiologists consider starting up their own cardiac msct program. the quality of the examinations initially obtained then, however, often does not live up to the high expectations. procedure details: a common cause for insufficent image quality is the poor attention to detail during image acquisition. in fact cardiac msct depends on the skill and dedication of the ct-technician. as an international training center for cardiac msct, we have noticed some common mistakes likely made by less experienced operators. generally, the basic procedures issues tend to go wrong: e.g., positioning the patient, placing the ecg-electrodes, choosing appropriate filtering, applying basic cardiac anatomy and physiology knowledge, etc. we will provide a step-by-step "how-to" pictorial with tips and tricks for successful cardiac ct imaging, illustrated by many examples of "right and wrong". issues addressed include handling of patient and workflow, data acquisition, and standardized image post-processing. conclusion: a step by step approach to cardiac msct scanning prevents scan failure. tomographic imaging of sinus venosus defects with multidetector ct angiography (mdcta) and magnetic resonance imaging-angiography (mri-mra) j.c. hellinger, a. napoli, f. chan; stanford, ca/us learning objectives: . describe tomographic imaging techniques for assessment of sinus venosus defects (svd). . illustrate intra and extracardiac anomalies during mdcta and mri-mra for svd. background: svd with associated partial anomalous pulmonary venous return (papvr), accounts for - % of congenital heart anomalies. clinical presentation is nonspecific and thus, diagnosis relies on imaging. transesophageal echocardiography (tee) and digital subtraction angiography (dsa) have been established as standard for this purpose. however, both are invasive and not without risk. mdcta and mri-mra are alternative noninvasive means to image these patients. mri offers the additional benefit to assess shunt ratios with cine phase contrast (pc) sequences. in this exhibit, we highlight our experience with mdc-ta and mri-mra in exams having surgically proven svd-papvr. procedure details: five exams were performed on or channel mdct. contrast was injected at cc/sec, employing bolus trigger technique. two of the -mdct were retrospectively ecg-gated with . mm thickness. non-gated studies were acquired at . mm, with a pitch of . - . and rotation time of . - . seconds. sequences employed in the four mri-mra exams included ecggated t , balanced steady state free precession, pc, and d-spgr angiography. d post-processing employed volume rendering and maximum intensity projection techniques. conclusion: anatomic defect size and location; number of abnormal veins) and dynamic evaluation for svd-papvr corroborated tee, dsa, and/or surgical findings. we identified on all mdcta, a jet of contrast crossing the defect into the left atrium (ct shunt sign). our preliminary experience indicates tomographic imaging is a reliable noninvasive alternative to tee and dsa for assessment of svd-papvr. to sensitize radiologists to the application of reformatting and d-reconstuctions in cardiac ct which depict the coronary arteries in a manner consistent with standard catheter angiography in routine clinical practice. to demonstrate a step by step approach to acquistion, optimized reconstruction techniques, and read-out algorithms in the evaluation of the coronary vessels. background: recent advances in the temporal and spatial resolution of mdct have opened the door to the use of ct in routine cardiac diagnostics, which is evolving rapidly as a noninvasive method. ct coronary angiography has compared favorably with conventional catheter coronary examinations, however new reconstruction and visualization methods are continuously being developed and are often lacking in meeting the demands of the routine clinical setting. it is crucial that radiologists become attuned to the standard approach to the coronary angiogram used in clinical cardiology so that advantage is not lost in the competition to provide services. procedure details: in this educational module, we present a step by step assessment of coronary vessels based on d-reconstructions of isotropic mdct datasets with special consideration to projections and visualization techniques which correspond with the standards of clinical cardiology. optimization of time consuming d renderings of ecg triggered datasets as well as read-out algorithms are demonstrated in examples for normal coronary vessels in addition to representative cases of coronary artery pathology. the resulting effective temporal resolution is - msec (depending on heart rate and reconstruction algorithm). larger volumes can be studied with isotropic spatial resolution and higher temporal resolution. the capability to scan larger volumes increases the feasibility and the accuracy of this technique in the visualisation of coronary artery bypass grafts (cabg). the scan protocol to evaluate cabgs with -row msct is described. different types of conduits (arterial and/ or venous), artefacts (surgical clips) and distal anastomoses of the graft are illustrated with dsa correlation. furthermore, atherosclerotic graft's disease (stenoses and occlusion) as well as native coronary artery disease is displayed with dsa. conclusion: ecg-gated -row multislice ct coronary angiography with . s gantry rotation time provide improved image quality in the evaluation of cabg. significance objective: to compare the msct and pet results in studying the condition of myocardial blood supply and to decide advisability of using them together. materials and methods: patients with suspected diagnosis of coronary artery disease were examined by msct and pet. msct data was obtained using siemens volume zoom ct scanner. retrospectively ecg-gating image reconstruction was conducted. pet was performed on ecat-exact- (siemens) with n ammonia at rest and during pharmacological test with vasodilatators (adenosine, dipyridamole). results: the first group comprised ( . %) patients without stenoses in coronary arteries according to the results of msct. pet also didn't detect reduction in perfusion of myocardial ischemic genesis in these patients. the second group included ( . %) patients with low-grade (< %) stenosis of coronary arteries. in these patients pet at rest and during stress didn't reveal a reduction in perfusion of myocardium. invasive coronarography was not performed for the and groups. the third group included ( . %) patients with different grades of stenosis in coronary arteries, according to the msct. there was reduction in perfusion in the corresponding myocardial segments revealed during at rest and/ or stress-pet. there was invasive coronarography done for these patients, which confirmed the existence of stenosis. methods and materials: ten volunteers (m:f = : , mean age ) without ischemic heart disease and consecutive patients (m:f = : , mean age ) with ischemic chest pain underwent ct coronary angiography (sensation , siemens, germany). reconstruction was done around - ms from r peak and multiplanar reformation and volume rendering were included. myocardial bridge was determined by demonstration of tunneled segment dip into myocardium. invasive coronary angiography was performed in patients. results: twelve tunneled segments in lad were detected in two volunteers ( %) (n = ) and patients ( . %) (n = ). nine were located in middle lad ( in volunteers, in patients) and in distal lad (in patients). with to mm in length, to . mm in greatest depth. the cross-sectional areas of tunneled segments were % smaller than those of the just proximal and % smaller than those of just distal to the tunneled segments. calcification in lad was detected in volunteer and patients with myocardial bridge but not in tunneled segment itself. significant stenosis was detected in proximal lad of two patients and mild stenosis in one patient which were confirmed by invasive coronary angiography. five patients showed only myocardial bridging in lad without coronary arterial stenosis. conclusion: msct directly visualizes tunneled segment within myocardium and gives useful information about myocardial bridging and neighboring coronary arteries. multi-detector row ct for the assessment of atrial septal defect and pulmonary venous drainage in adults g. morgan-hughes, a. marshall, c. roobottom; plymouth/uk purpose: to evaluate retrospectively ecg-gated multi-detector row computed tomography (ct) for the full evaluation of secundum and sinus venosus atrial septal defects (asd), in adults, in comparison to trans-esophageal echocardiography (toe). materials and methods: twelve patients undergoing toe for further assessment of presumed asd, as a prelude to definitive treatment, also underwent retrospectively ecg-gated multi-detector row ct. the multi-detector ct scans were compared to toe for defect and pulmonary vein visualisation. secundum asd sizing; measurements, before possible device closure, were compared, and virtual angioscopy of the right atrium was evaluated for direct, three-dimensional defect visualisation. results: larger secundum asds (greater than . mm) were well visualised with multi-detector row ct, but smaller defects and sinus venosus defects were not. for maximal secundum defect size there was a mean difference between the techniques of . mm (limits of agreement minus . to plus . mm). overall there was moderate agreement for the defect and rim sizing measurements. pulmonary venous drainage was universally fully and correctly evaluated with multidetector ct, which compared favorably to toe. virtual angioscopic visualisation of secundum defects was possible in patients, but the images produced were considered of limited clinical value. conclusions: retrospectively ecg-gated multi-detector row ct offers alternative imaging of asd in adults, allowing visualisation of significant secundum defects, pulmonary venous drainage and defect sizing. further investigation, to establish the accuracy of defect and rim sizing measurements and to re-explore direct defect visualisation with advanced post-processing tools, is required. detection of necrotic myocardial segments using multi-slice computed tomography: comparison with nuclear medicine p. . mm slice width, . mm slice increment and ml of non-ionic contrast ( mgi/ml) administered with a delay scan of seconds. nm and cts datasets were reoriented perpendicular to the left ventricle long axis. segmental analysis was performed on segments within the short axis planes ( basal, mid-ventricular and apical segments). a positive nm finding was defined as a perfusion defect within a segment at both rest and stress. a positive ct finding was defined as a hypo-intensive region within a segment. statistical analysis was performed using a % confidence interval calculated by the exact binomial method. results: segments were evaluated on both nm and msct. nm detected necrotic segments whereas msct detected . there were true-positive, true-negative, false-positive and false-negatives findings. the sensitivity was . %, specificity . %, positive predictive value . % and negative predictive value . %. conclusion: msct showed high sensitivity and specificity for the detection of myocardial necrotic segments compared with nm. evaluation of myocardial bridging by multislice computed tomography p.m. carrascosa , c. capuñay , m. vembar , p. johnson , r. pissinis , j. carrascosa ; buenos aires/ar, cleveland, oh/us to determine the usefulness of multiphase reprocessing msct coronary angiography in the identification of myocardial bridging (mb) and the detection of related ischemia. methods: patients were studied. cts were performed in a -row ct scanner with x mm collimation, . mm slice increment and ml of non-ionic contrast. ten patients with mb diagnosed with msct were evaluated with nuclear medicine (nm). rest and stress studies were performed with mci technetium m sestamibi. segmental analysis were performed on segments within the short axis plane ( basal, mid-ventricular and apical) in both methods. positives nm findings were defined as a perfusion defect within a segment at both rest and stress. positives ct findings as hypo-intense region within a segment. results: all the mbs were placed in the lad. da detected cases, whereas msct only . the sensitivity was . % and the specificity . %. in cases the mb of the lad had greater diameter in the % phase and they were compressed in the % phase. six cases showed ischemia in the nm studies. there were true-negatives, true-positives and false-negatives findings. the sensitivity was . % and specificity %, positive predictive value was % and the negative predictive value was %. conclusion: msct can detect the presence of mb in coronary arteries. it is essential for this identification a multiphase reprocessing of the ct data and can also detect the presence of myocardial perfusion defects. to predict the local, gonadal, thyroidal and eye dose with and without different protection devices in retrospective-gated multi slice ct of the heart. material and methods: radiation dose was measured with an alderson phantom and a digital dose meter with and w/o an infradiaphragmatic lead drape, a cervical lead protection and an eye shield. measurements were done with the ionization chamber placed over the heart, uterus, thyroid gland and eyes. helical ct of the heart was performed with an aquilion msct (toshiba). the dose was determined with slice collimation and pitch between and . using constant voltages and current-time-products for retrospective gated ct. results: local dose over the heart ranged from to µsv. gonadal dose was determined with to µsv w/o lead protection and to µsv using a circular infradiaphragmatic lead drape, meaning a gonadal dose reduction of up to %. with use of protection devices the dose to the thyroids could be reduced by . % and % in terms of using an eye shield. conclusion: radiation causing gonadal dose in cardiac ct is predominantly extracorporal radiation and only in a lesser degree due to scatter radiation from inside the body. an effective dose reduction of % can be achieved by consequent use of a circular lead drape closely adapted to the inferior helical range. the use of organ adapted shields covering the thyroids or eyes mainly results in a decrease of the surface dose and is recommended as well for all patients receiving cardiac ct. images were acquired using a -row spiral ct scanner with . s gantry rotation time. in all patients detailed clinical, ecg, us and scintigrafic (when available) data were collected in order to identify the presence of mi. when a patient with mi was found, mdcta images were analyzed on both axial and multiplanar reconstruction in order to confirm the presence of an infarcted area. results: our study population included patients who previously underwent coronary percutaneous transluminal angioplasty (pta) and stent placement (a total number of stents) and patients with previous by-pass surgery. after clinical assessment, mi was found in patient ( septal, apical, anterior wall of left ventricle, infero-septal). mdct was able to detect the presence of mi in / cases ( . %), showing a regional hypoattenuated area and wall thinning. in all cases, localization and extention of ischemic area were perfectly correlated with clinical known data. in two patients with sub-endocardial involvement, mi could was not detectable with mdct. in one patient the presence of motion artefacts affected image quality and myocardial scar wasn't visualized. the presence of mi is usually well depicted with retrospective ecg gated mdct. mdct coronary angiography: optimization of the image reconstruction phase y. nagatani, r. takazakura, n. nitta, m. takahashi, k. murata; otsu/jp purpose: to investigate the relationship between the heart rate and the optimal image reconstruction phase in mdct coronary angiography. material and method: patients underwent cardiac mdct ( das) (aquilion , toshiba, japan) to obtain coronary angiography. scan data were subsequently reconstructed at different kinds of phases in ecg wave. these methods can be classified as follows according to the used wave in ecg; ).the center of the reconstruction phase is positioned at the peak of t-wave (method t-p), the end of t-wave (method t-e) and the midpoint of descending curve of t-wave (method tm). ).the end of the reconstruction phase is positioned at the peak of p-wave (method p). ).the center of the reconstruction phase is positioned using nterval (method r , , , , , ) . all patients were classified into groups according to their heart rates (hr) (group ; hr < (n = ), group ; < hr; < (n = ), group ; hr < (n = )). two radiologists assessed image quality in blind fashion and scored as follows ( :good, :fairly, : bad). bonferroni/dunn test was performed for statistical analysis. results: in group , significantly better image quality was achieved in method p, rr , rr than other methods. among them, highest image quality was obtained by method p. the best result was obtained by method p in group and tm in group . conclusion: optimal image reconstruction phase in mdct coronary angiography shifts from late diastolic phase to late systolic phase as heart rate increases. assessment of aorto-coronary bypass grafts patency by detector rows computed tomography g. two out of five tumors (right atrium lipoma and aortic valve fibroelastoma) were discovered in a routine msct study of coronary arteries and left ventricle myxoma in an elective coronarography. atypical left ventricle myxoma with mitral stenosis and epicardial cyst were primary visualized in transoesophageal echocardiography. results: both methods allows to evaluate tumors size, localization and structure. the biggest advantage of echocardiography was aknowledged possibility of evaluation of lesions mobility while the biggest advantage of msct was possibility of both d and d imaging in arbitrary planes using multiplanar reformations with evaluation of tumor relations towards adjacent tissues and simultaneous visualisation of coronary arteries. conclusions: msct and echocardiography (tte and tee) are complementary methods in diagnosis of primary cardiac tumors. usefulness of -slice multidetector row computed tomography (msct) in assessment of dilated cardiomyopathy s. hosoi, t. mochizuki, t. haraikawa, j. funada; ehime/jp purpose: the purpose of this study is to show the potential benefits of -slice msct for the diagnosis of dcm. we studied consecutive patients, including dcm, coronary artery disease (cad), and patients with non-cardiac disease as a normal control. dcm was diagnosed on the basis of the clinical data by cardiologists. the msct system used in this study was a lightspeed (ge medical systems) with available gantry rotation speeds of . sec. all cardiac images reconstructed were divided into phase data sets in a r-r interval on ecg. end-diastolic (ed) and end-systolic (es) phase could be visually extracted, and the lv wall thickness and volume was measured. moreover, the segmental lv wall motion was evaluated by the cardiac movie image which was reconstructed using the phase data. results: image quality of mdct were considered sufficient for this analysis. concerning about the rate of coronary artery stenosis, dcm group were significantly less than cad group (p < . ). in dcm group, both lv wall thickness of ed and es were smaller than other groups (p < . ). lv volume between dcm and cad group had no significant difference. lv wall motion in dcm group had a tendency to be diffusely hypokinetic. conclusion: using -slice msct, lv function and coronary artery stenosis was able to be evaluated and distinguished the features of dcm and cad. this study revealed a potential ability of mdct as a useful method for the diagnosis of dcm. background: a variety of pulmonary complications occur in bone marrow transplant (bmt) recipients and are a major cause of morbidity and death. imaging findings: hrct is useful in detection of pulmonary abnormalities, but these findings are generally non-specific. these complications, which reflect the immunologic status of the patients, occur in three phases. this pattern can be used to interpret ct scans. the neutropenic phase (up to weeks after bmt) is characterized by fungal infections, alveolar haemorrhage, pulmonary oedema, and drug reactions. at ct, fungal infections like angioinvasive aspergillosis appear as nodules surrounded by a halo of ground-glass attenuation; alveolar haemorrhage and drug reactions, as bilateral areas of ground-glass attenuation or consolidation. the second phase ( weeks to days after bmt) is dominated by cytomegalovirus pneumonia, which appears as multiple small nodules with areas of consolidation or ground-glass attenuation, and pneumocystis carinii pneumonia again mostly as ground-glass attenuation. the late phase (more than days after bmt) is characterized by bronchiolitis obliterans revealing bronchial dilatation and a mosaic pattern of attenuation, bronchiolitis obliterans with organizing pneumonia (boop), the ct findings usually being patchy consolidation or ground-glass attenuation and chronic graft-versus-host disease. conclusion: if ct findings are considered in relation to the time elapsed after bmt, diagnostic options can be narrowed sufficiently to enable accurate diagnosis. small pulmonary nodules: an easy approach to the differential diagnosis j. rimola, x. gallardo, e. castañer, j.m. mata, a.m. quiles, p. bermúdez; sabadell/es learning objectives: to know the anatomy of the secondary pulmonary lobule, which is essential to the interpretation of high-resolution ct (hrct). to learn an easy way to approach the differential diagnosis of small pulmonary nodules. background: a wide variety of pathologies may present with small pulmonary nodules, which are defined as rounded opacities smaller than cm in diameter. differences in appearance, distribution and attenuation of nodules provide useful clues for correct diagnosis. helical ct and hrct enable correct identification and characterization of small nodules. imaging findings: we illustrate different examples of multinodular lung diseases in an easy-to-understand way. a simple algorithm is used to help in the differential diagnosis. we classify nodules according to distribution (centrilobular, perilymphatic or random) and show the most representative cases of each pattern. we present a wide variety of entities, including: infections such as tuberculosis (endobronchial spread or miliary tb), nontuberculous mycobacteria, fungus; sarcoidosis; tumors (lymphangitic carcinoma, hematogenous metastases); silicosis and coal worker's pneumoconiosis; hypersensitivity pneumonitis; cryptogenic organizing pneumonia; histiocytosis; etc. conclusion: an easy way to assess multiple nodular opacities in the lung is useful to reach an accurate diagnosis. differential diagnosis of unilateral hyperlucent lung m. nishino , k. hayakawa , h. hatabu ; boston, ma/us, kyoto/jp learning objectives: to review differential diagnosis of unilateral hyperlucent lung, understand pathological mechanisms causing the findings, and to be familiar with the imaging findings and clinical manifestations characteristic in each condition. background: unilateral hyperlucent lung on chest radiograph is seen with various pathological conditions. the conditions include both acute and chronic processes, and thus need accurate and prompt diagnostic evaluation. the findings on chest radiograph can provide clues to differentiate various causes of this condition and help to achieve proper management. imaging findings: we present cases of unilateral hyperlucent lung, emphasizing specific imaging findings along with characteristic clinical manifestations. the cases include proximal interruption of pulmonary artery, pulmonary hypoplasia, swyer-james syndrome, congenital lobar emphysema, foreign body aspiration, and bochdalek hernia. findings on chest ct which can confirm or support the diagnosis are also reviewed and discussed. conclusion: familiarity with the characteristic imaging findings of unilateral hyperlucent lung is essential for radiologists to make accurate diagnosis for appropriate patient management. multislice ct of primary and multisystemic pulmonary vasculitis: a patternbased approach to differential diagnosis k. marten , m. prokop , p. schnyder , e.j. rummeny , c. engelke ; munich/de, utrecht/nl, lausanne/ch . clinical and radiologic features of these tumors are often indistinguishable from those of malignant tumors. however recognition and early diagnosis of these lesions may allow for conservative treatment and excellent patient outcome. the aim of this study is to illustrate the ct findings of variable benign tumors of tracheobronchial tree and correlate with the pathologic findings. imaging findings: this study included patients with benign tracheobronchial tumors which were confirmed histologically by surgical resection (n = ) or bronchoscopic biopsy (n = ). the tumors were classified the anatomic locations of the lesions into trachea (n = ), bronchus intermedius (n = ), lobar bronchus (n = ), and segmental bronchus (n = ). pathologic diagnoses were hamartoma (n = ), leiomyoma (n = ), lipoma (n = ), schwannoma (n = ), amyloidoma (n = ), inflammatory polyp (n = ), and bronchial adenoma (n = ). ct demonstrated all tumors confined in the tracheobronchial lumen. of bronchial tumors occluded the bronchial lumen completely, resulting in distal parenchymal collapse. to enhance the limitations of chest x-ray and axial chest ct slices in estimating the volume of pleural effusions. this interactive presentation will allow the reader to test himself, comparing his own subjective estimation to the real volume computed from d shaded surface displays (ssd). to outline the usefulness and ease of post-processing with spiral ct to obtain a true assessment of the pleural fluid volume. background: assessment of the volume of pleural effusions is very imprecise both on chest x-ray and axial chest ct slices. the amount of fluid may be required by clinicians for therapeutic purposes. d ssd of the effusion provides rapid computation of its volume. in this exhibit we will recall the physiopathologic mechanisms involving the preferential locations of pleural effusions. we will show pleural effusions of various volumes on chest ct along with the corresponding chest x-rays and the precise volume of the effusion computed from d reconstruction. procedure details: various cases of free or collected pleural effusions on spiral chest ct (ct twin and mx idt), are presented, including coronal and sagittal reformations. ct images stand along with the corresponding chest x-ray, obtained in the upright and supine position, and with the computed volume of the effusion using d reconstruction. conclusion: pleural volumetry is readily available using spiral ct data recontruction. it should be more often used, to assess the amount of fluid to withdraw with thoracocentesis, before drainage or for monitoring in intensive care unit patients. lung consolidations in various clinical entities: clinico-radiologic correlation presented in an interactive cd-rom in html format s. mylona, s. tandeles, l. thanos, s. lyra, p. ellinas, n. mpatakis; athens/gr learning objectives: to present lung consolidations as found in ct and plain radiographs in various clinical entities. to give a differential diagnosis based on clinical and radiologic features. background: radiologists often encounter lung consolidations in plain radiographs and lung ct. there is a broad spectrum of clinical entities, which either present as lung consolidations or involve lung consolidations. clinical information and radiologic features help to approach the right diagnosis. procedure details: cases are presented in a question and answer format using html resources in an interactive cd-rom. reference is made to proper diagnostic work up and to other relevant clinical information. histopathological confirmation is presented where it is needed. conclusion: radiologists must be trained to deal with patients presenting with lung consolidations using clinical and radiological features. hrct patterns of cardiogenic pulmonary edema e. chambrier, s. zafatayeff, y. badachi, p.a. grenier, c. beigelman-aubry; paris/fr learning objectives: to be familiar with typical and atypical hrct appearances of pulmonary edema based on patients. to emphasize the role of hrct in suggesting this diagnosis in the setting of acute dyspnea, especially if pulmonary embolism is suspected. background: pulmonary edema, a frequent cause of acute dyspnea, can be clinically difficult to detect. hrct is crucial in suggesting this diagnosis, particularly when pulmonary embolism is suspected. actually, bolus intravenous injection of iodinated contrast in case of pulmonary edema may worsen heart failure and lead to patient death. imaging findings: the hrct signs of pulmonary edema are usually divided into interstitial and alveolar patterns, and both can be associated. classic signs of interstitial edema, which accounts for % of cases, are peribronchial and peribronchovascular thickening, septal lines, ground glass opacity, pleural effusion, cardiac enlargement and pulmonary veins dilatation. alveolar edema is characterized by bilateral, patchy or coalescent areas of airspace consolidation, predominantly basal and perihilar. butterfly pattern is found in % of cases. atypical patterns are due to preexisting lung or heart disease, such as right upper lobe edema related to mitral regurgitation, or heterogeneous distribution of edema due to preexisting lesions of emphysema or constrictive bronchiolitis. highly selected cases will be used to illustrate typical and atypical patterns. the varied hrct appearances of cardiogenic pulmonary edema have to be recognized in order to delay the performance of angioct of pulmonary arteries if pulmonary embolism is suspected. smoking-related interstitial lung diseases: radiologic-pathologic correlation a. hidalgo, t. franquet, a. giménez, r. pineda, m. madrid; barcelona/es learning objectives: . to review the radiological findings of smoking related interstitial lung diseases and their pathologic correlations. . to provide some radiological clues for the correct diagnosis. background: interstitial lung disease (ild) represent a heterogeneous group of lung disorders of known or unknown cause. recently, it has been appreciated that cigarette smoking is related to the development of several ilds including desquamative interstitial pneumonia (dip), respiratory bronchiolitis-associated interstitial lung disease (ribld), pulmonary langerhans'cell histiocitosis (plch) and idiopathic pulmonary fibrosis (ipf). procedure details: we reviewed the plain radiograph, ct, and hrct findings of four intersitital lung disorders that have been linked to smoking. several examples of the radiological forms of srild and their differential diagnosis are provided. we will also show how the radiologists can get the diagnosis through some clinical and radiological clues. the link between several interstitial lung disease and smoking has been recently indicated. radiologists have to be aware of these entities and to suggest a diagnosis as accurate as possible by the knowledge of clinical context and the radiological features. the spectrum of ct appearances in pulmonary amyloidosis a. aylwin, p. gishen, a. nicholson, s. copley; london/uk learning objectives: to review the ct appearances of pulmonary amyloidosis. background: amyloidosis has three main histopathological subgroups, with typical imaging characteristics: ) tracheobronchial disease with plaques, nodules or circumferential thickening of the trachea or segmental airways; ) nodular parenchymal disease with single or multiple nodules demonstrating sharp lobulated margins, spiculated masses simulating tumours, and a rare form associated with sjögren's syndrome and lymphocytic interstitial pneumonitis (nodules and lung cysts); and ) diffuse alveolar septal disease showing ground glass opacification, interlobular septal thickening, and traction bronchiectasis on hrct. it is often possible to divide cases into localized amyloidosis with tracheobronchial deposition or nodular disease, or the systemic type with diffuse parenchymal disease or lymphadenopathy on the imaging findings, but cases demonstrating overlapping features are not uncommon. procedure details: the ct appearances of cases of biopsy-proven pulmonary amyloidosis will be demonstrated. the spectrum of ct appearances of pulmonary amyloidosis of both localised and systemic types will be demonstrated. the ct features of localized and systemic disease may overlap. thoracic conclusion: incidence and imaging features of these complications will be illustrated. paraquat poisoning of the lung: a study of patients with paraquat intoxication for years a. ichinose , k. kimura , m. tsuboi , h. saito , t. ishibashi , s. takahashi ; miyagi/jp, akita/jp learning objectives: to analyze patients who had taken paraquat intoxication and to compare those with % paraquat intoxication to those with % paraquat-diquat intoxication, especially with respect to the change of their chest x-rays and ct. background: paraquat is a widely used herbicide that has toxic effects on the lungs, liver, and kidneys. paraquat has been known to induce acute pulmonary fibrosis, causing progressive respiratory failure and death. in japan, % paraquatdiquat product has been used since , in place of % paraquat product,. however, there is no report that compares the influence these products have on the lung. procedure details: there were patients from whom chest x-rays were taken, and of those ( . %) had abnormal findings, which were composed of ground-grass patterns, reticulogranular patterns, pulmonary edemas, cardiomegalies and pulmonary congestions, pneumothoraxs, and mediastinal emphysema. pulmonary edema was found only in the patients with % paraquat intoxication; in all cases, the plasma paraquat concentration was much higher than others. all reticulogranular patterns were found a few days later, and those in the patients with % paraquat-diquat intoxication were potentially reversible. conclusion: % paraquat product has more influence on the lung than % paraquat-diquat product. pulmonary fibrosis caused by % paraquat-diquat product is potentially reversible. thoracic parenchymal abnormalities, enlarged lymph nodes, pleural effusion, and pleural thickening were evaluated. in patients who underwent surgical biopsy or autopsy, the ct-pathological correlation was performed with the actual specimens. imaging findings: on the ct scans, abnormal findings were seen in patients ( . %). the ct findings consisted of ground-glass attenuation (n = ), centrilobular nodules (n = ), thickening of bronchovascular bundles (n = ), and consolidation (n = ). these abnormalities were predominantly seen in the peripheral lung parenchyma (n = ). pathologically, these findings corresponded with atypical lymphocytes infiltration along the interstitium and the alveolar spaces. pleural effusion and enlarged lymph nodes were found in patients and patients, respectively. conclusion: the ct findings in patients with adult t-cell leukemia/lymphoma consisted mainly of ground-glass attenuation, centrilobular nodules, and thickening of the bronchovascular bundles in the peripheral lung. these ct findings, though non-specific, are considered as suggestive of thoracic involvement in patients with adult t-cell leukemia/lymphoma. high resolution ct imaging of the lung for patients with primary sjögren's syndrome c. lohrmann, m. uhl, k. warnatz, n. ghanem, e. kotter, o. schaefer, m. langer; freiburg/de purpose: to assess pulmonary abnormalities in patients with primary sjögren's syndrome using high-resolution computed tomography (hrct). the hrct scans of patients over a ten-year-period with diagnosis of primary sjögren's syndrome were retrospectively reviewed regarding the presence, extension and distribution of pathological findings. results: patients ( . %) showed pathological findings and in ( . %) the hrct scan was normal. a predominance of abnormalities in the lower lobes and subpleural areas was detected. bronchiectasis, thin-walled cysts and small pulmonary nodules in patients ( . %), ground-glass attenuation and emphysema in patients ( . %), interlobar-septal thickening in patients ( . %), honeycombing in patients ( . %), bronchial wall thickening and tree-in-bud pattern in patients ( . %), mosaic perfusion in patients ( . %), and architectural distorsion in patients ( . %). airspace consolidation, air trapping, large nodules ( - mm) and masses (> mm), mediastinal lymph node enlargement (> mm) and free pleural fluid were seen each in patient ( . %). in of patients ( %) with thin-walled cysts areas of ground-glass attenuation were detected. conclusion: hrct seems to be contributive to the characterization of the wide variety of lung abnormalities in primary sjögren's syndrome. airway disease alone or in association with the presence of varying degrees of interstitial disease represent the main findings in accordance with earlier reports. unexpectedly, almost half of the patients have thin-walled cysts on the hrct scans, which etiology is unclear but could be associated with areas of ground-glass attenuation indicating lymphocytic interstitial pneumonia. investigation of the bulky hilum: how accurate are radiologists at detecting hilar pathology on the chest radiograph? s. desigan, d. murray; london/uk purpose: to determine the accuracy of radiologists in detecting hilar pathology on chest radiographs. materials and methods: a retrospective study was performed, analysing the chest radiograph and computed tomography (ct) findings of patients, all of whom had initially been referred for thoracic ct as part of the investigation for a "bulky hilum" as detected on chest radiography. radiologists, comprising consultants and specialist registrar trainees who were blinded to the initial ct findings, were asked to assess the chest radiographs for the presence or absence of a hilar mass and their recommendations for clinical follow-up in each case were recorded. they were then scored for accuracy as compared to the thoracic ct results. the results showed marked variation between observers in the two groups. the participants had an accuracy of %, sensitivity of % and specificity of %. positive predictive values of registrars and consultants were % and % respectively. negative predictive values were % for registrars and % for consultants.the group as a whole detected only out of hilar masses confirmed by ct. the wide range of responses demonstrates the very subjective nature of interpretation of the lung hila on chest radiographs, and the difficulty involved in correctly identifying or excluding hilar masses on chest x-rays. one of the most useful aspects of this study has been to provide feedback to individuals for educational purposes and personal audit. b d e f a g m. paslawski, w. krupski, k. krzyzanowski, j. zlomaniec; lublin/pl purpose: the aim of the study is to evaluate the diagnostic value of hrct in revealing small bronchiectases and bronchiolectases in patients with previously diagnosed pneumoconiosis. the study comprises a group of patients, men and women, aged between and years, with pneumoconiosis in which hrct was performed. hrct was performed in all patients in the prone position, from the level of the apices to the level of the diaphragm. the collimation of the scans was mm, with cm intervals between sections. the hrct examinations were assessed retrospectively by two radiologists, and the presence and character of bronchiectases were noted. results: bronchiectases were seen in patients ( %). in of them the "signet-ring sign" and "tram track sign" were seen, with lack of normal tapering. bronchi were visible in peripheral lung areas, within cm from the parietal pleura in patients. patients had varicose bronchiectases with the typical "string of pearls" appearance. in patients, cystic bronchiectases were seen, presenting with the picture of "cluster of grapes". conclusions: bronchiectases is very often seen in patients with pneumoconiosis, especially in advanced stages. hrct is the modality of choice to diagnose the presence of small bronchiectases and bronchiolectases. typical hrct patterns include "signet-ring sign", "tram track sign", lack of normal tapering, and visible bronchi in peripheral lung areas, within cm from the parietal pleura. in varicose bronchiectases, the "string of pearls" appearance, and in cystic bronchiectasis, the "cluster of grapes" appearance are typical. introspective background: spns occur on in chest radiographs with % being due to lung cancer. conventional imaging is fairly effective in determining the nature of the spn, although - % remain indeterminate following ct scan. the spn will often have needle biopsy either via bronchoscopy or percutaneously which have a recognised complication rate of - %. depreotide is a tc- m labeled analogue of somatostatin with affinity to receptors types , and . various tumours including lung cancer, breast cancer, lymphoma and neuroendocrine tumours express these receptors. we undertook a retrospective review of one years' referrals for depreotide imaging comparing the results with subsequent biopsy or surgical histology where available. additionally we assessed if the referring clinical question had been answered. results: depreotide studies performed, with showing increased uptake within the spn. patients ( %) with positive studies had had a previous indeterminate lung biopsy thus enabling planning of further biopsy or wedge resection with frozen section. depreotide and histology agreed in all patients who had subsequent histology of the spn ( malignant, benign). further biopsy was avoided in out of patients with negative studies. specific answers were given to the clinical referring question in cases. conclusion: depreotide effectively determined the nature of the spns with ability to avoid biopsies in the % of patients with benign disease and to prompt further invasive investigation following an indeterminate biopsy. pleural invagination in progressive massive fibrosis (pmf) in silicosis and mixed dust pneumoconiosis h. arakawa, k. honma, h. shida, h. mori, y. saito; tochigi/jp purpose: invagination of the pleura often accompanies progressive massive fibrosis (pmf) in pneumoconiotic lung. to elucidate the relation between pmf and the pleura covering them, we conducted a retrospective study comparing ct and autopsy findings in silicosis and mixed dust pneumoconiosis (mdp). the study group was an autopsy series of consecutive patients with complicated silicosis or mdp. ct images were examined to determine the location, shape, composition and size of pmf, distance between the lesion and the covering pleura, presence of pleural thickening, a band-like structure between the lesion and pleura, and pleural effusion. autopsy data were reviewed for the presence of pleural thickening and invagination and were compared with the ct findings. results: we identified pmf lesions. pleural invagination was found in ( . %) pmf and was always associated with pathologically determined pleural thickening. ct images showed pleural thickening in ( . %) and invagination in ( . %) lesions. lesions were associated with ipsilateral pleural effusion (p < . ). statistical analysis revealed pleural invagination was associated with pleural thickening (p < . ) and proximity of the lesion to the pleura (p < . ) but not with radiographic profusion of pneumoconiotic opacities, or the shape, composition, size of pmf (p > . ). pmf were radiographically identical to rounded atelectasis. conclusions: fibrous thickening of the pleura and invagination into the adjacent pmf are not uncommon in advanced silicosis and mdp. some lesions resemble rounded atelectasis. ct is beneficial in assessing these pathologic features. imaging the aim of this teaching exhibit is to illustrate a spectrum of usual and unusual cystic diseases involving the lung, and to evaluate the efficacy of plain radiographs and computed tomography (ct) imaging in the diagnosis and management of these conditions, with emphasis in high resolution ct (hrct). we retrospectively reviewed the imaging findings of patients with diffuse cystic lesions involving the lung from our data base of thoracic pathology. a cystic lesion was defined as an air-containing, well-defined space, variable in size. the pertinent embryology and pathologic basis of the radiographic findings are discussed. pitfalls, diagnostic difficulties and differential diagnoses are emphasised. results: specific topics addressed include diffuse cystic diseases of the infancy (bronchopulmonary dysplasia, pulmonary interstitial emphysema, types i, ii, and iii congenital cystic adenomatoid malformation, chronic eosinophilic pneumonia, and pneumatoceles), and diffuse cystic diseases of the adulthood such as honeycomb lung (secondary pulmonary fibrosis), langerhans cell histiocytosis, pulmonary lymphangioleiomyomatosis, tuberous sclerosis, and lymphoid interstitial pneumonia. we also include pulmonary diseases simulating cysts such as congenital diaphragmatic hernias, diffuse bronchiectasis, and emphysema. conclusions: hrct is an adequate imaging modality to assess diffuse cystic disease of the lung, allowing an excellent visualisation of the cysts as well as other secondary findings (distribution, size, location, and wall thickness). because many of these disorders have characteristic imaging appearances, this exhibit will help practising radiologist to better understand, recognise and differentiate cystic diseases involving the lung. beware the normal chest x-ray in suspected lung cancer: a pictorial review of the potential pitfalls a.k. basu, k. jeyapalan, j. entwisle, r. bhatt; leicester/uk purpose: to demonstrate that a standard pa chest x-ray can be falsely reassuring in patients where there is a high index of clinical suspicion for lung cancer. we reviewed the patients with suspected lung cancer whose chest x-rays were radiologically normal and had further ct cross sectional imaging. emphasis was placed on the hidden review areas on a standard pa chest x-ray, e.g. the mediastinum, the apices, behind the diaphragm and behind the heart. we present a pictorial review of these hidden areas and illustrate the potential lesions not seen on a "normal" chest x-ray. results: ct can often demonstrate lesions not visible on chest x-ray. conclusion: a normal pa chest x-ray may be falsely reassuring in patients suspected of having lung cancer. therefore in patients with a high index of clinical suspicion a ct should be carried out despite the normal pa chest x-ray with careful review of the hidden review areas. should a chest radiograph be requested in all cases of febrile neutropenia admissions? a study in a university hospital a.v. acharya, a.k. burnett; cardiff/uk purpose: to evaluate the clinical utility of obtaining chest radiographs, in the absence of chest symptomatology, in patients admitted with acute neutropenic sepsis. methods: prospective study of in patients with febrile neutropenia admitted to the haematology ward was carried out in this university hospital over a period of months. symptoms & signs, chest x-ray findings and changes in management because of these findings were assessed in these patients. we also conducted a questionnaire survey of haematologists of south wales regarding obtaining chest radiographs in these patients. results: chest radiographs were obtained in . % of the patients at the time of diagnosis of febrile neutropenia but only . % of the patients had chest signs/ symptoms. if chest signs/symptoms were present, . % had abnormal chest x-rays and this influenced change in clinical management. in the group where chest signs/symptoms were absent, radiographs were normal and no change in management resulted from a chest radiograph. the survey of haematologists suggested that majority of them ( %) requested chest radiographs in acute neutropenic sepsis irrespective of presence or absence of chest signs or symptoms. in neutropenic patients with no chest signs/symptoms, a chest radiograph on admission is not likely to be abnormal and is unlikely to change the management. on the basis of our study we suggest that the chest radiographs in these patients in the absence of clinical signs or symptoms, are of little value. this would however not exclude the possibility that other imaging approaches would be of clinical value. low to evaluate the usefulness of low dose thin-section ct by multidetector-row ct (mdct) for lung cancer screening in both the determination of malignancy or benignancy and the differential diagnosis. methods and materials: cases with pathologically proved solitary pulmonary nodules, which sizes were less than cm in diameter, were entered into this study. after the routine full dose thin-section ct ( . mm collimation, fov cm, pitch : , kvp, -ma/rotation, . second/rotation, high-spatial frequency algorithm), additional two kinds of low dose helical thin-section ct ( . mm collimation, pitch : , -(in initial cases), -(all cases), -(in remaining cases) ma/rotation) were scanned using a mdct scanner (lightspeed qxi, ge, milwaukee, wi). using roc analysis, an observer performance study, in which three observers indicated the confidence level for the determination of malignancy or benignancy for each nodule, was done. in addition, three observers recorded the final diagnosis of each case. accuracies of the final diagnosis were compared by mcnemer's test. in the determination of malignancy or benignancy, there was no significant difference among these four kinds of thin-section ct (full dose, -, -, and -ma/rotation; mean az = . , . , . , and . , respectively). accuracy of the final diagnosis by low dose thin-section ct ( -, -, and -ma/ rotation; %, %, and %, respectively) was significantly lower than that of full dose thin-section ct ( %) (p < . ). conclusion: efficacy of low dose thin-section ct by mdct is comparative to that of full dose thin-section ct in determining whether small nodules are malignant or not. lung cancer screening using low-dose spiral ct: preliminary results in asymptomatic smokers s. giunta, m. crecco, f. facciolo, l. carpanese, v. cilenti, m. caterino, p. visca, m. mottolese; rome/it purpose: to evaluate the feasibility of lung cancer screening using low-dose spiral ct and to present initial baseline data from a non randomized screening trial using low-dose spiral ct. methods and materials: asymptomatic smoker volunteers, aged years or older who had smoked packs-year or more, underwent baseline low-dose multislice spiral ct (volume zoom siemens) of the chest without contrast material enhancement following the elcap protocol. annual repeat screening was performed on participants. lesions up to mm were deemed non suspicious and low-dose ct was repeated after months. results: at baseline, non calcified nodules were identified in participants. nodules were larger than mm. biopsy of lesions revealed nsclc in cases ( adenocarcinoma, squamous cell carcinoma, large cell carcinoma, adenoid cystic carcinoma). of these were stage i ( . %); stage ii ( %); stage iii ( %) and one stage iv ( . %). were benign lesions ( hamartomas, lymph node, fibrosis). in cases the pet was negative, in cases the nodules resolved after antibiotics; participants refused biopsy. conclusion: low-dose spiral ct seems to be a promising method for screening lung cancer. our preliminary cancer screening results with low-dose spiral ct, demonstrated a prevalence of asymptomatic cancers in . % of a smoking population including a high proportion of early tumor stages. pathological mismatched findings of specimens between ct guided biopsy and resection in noguchi's classifications of small peripheral lung adenocarcinoma s. yoshida, h. ue, s. itou, y. murata; nankoku/jp purpose: we sometimes experience mismatched pathological findings of specimens between preoperative ct guided biopsy and resection in the noguchi's classification of small peripheral lung adenocarcinoma. in this study we discuss the mismatched pathological findings in each case and explored the possibility of reducing the incidence of mismatch. we selected cases, in which preoperative ct guided biopsy and consecutive resection were performed. tumors were peripheral lung adenocarcinoma of cm or less in diameter. the final diagnosis by resected specimen of these cases were type b, type c and type f peripheral adenocarcinoma. we compared hrct findings of them to identify the ct density in each tumor. results: though the final pathological findings show type c tumors, the specimen by ct guided biopsy show only type a or b tumors. further more, though the final pathological findings show type f, not having a replacement growth pattern, the specimen also show type a or b, having a pure replacement growth pattern. conclusion: pathological mismatched findings between ct guided biopsy and resection were observed. additional ct image comparison between mediastinal and lung window settings gave us probable information about the tumors having replacement growth patterns or not. before performing ct guided biopsies, image recognition about the solid density helped us choose the most suitable biopsy site. with more thorough information derived from hrct and biopsy on the types of tumors patients have, physicians can offer patients more accurate prognosis. purpose: to analyze high-resolution ct (hrct) findings in asthmatics and control subjects, and to evaluate the relationship between hrct findings and pulmonary function tests in asthmatic subjects. to try to evaluate the correlation between the bronchial wall thickening (bwt) with pathologic findings and reflect the thickness of epithelial basement membrane on basis of the hrct findings. materials and methods: using hrct, the author analyzed the ratio of bwt, the frequency of bronchial dilatation, the extent of air trapping and centrilobular nodules. in addition, the author assessed hrct findings of asthmatic patients for correlation with pulmonary function tests and then obtained bronchoscopic biopsy at the second divisional branch of patient among the asthmatics. the author measured the thickness of the epithelial layer and basement membrane after h-e stain and then statistically compared with bwt on hrct. results: among the total asthmatics, bwt on hrct showed significant correlation with fev (p = . ) and tlc (p = . ). pefr (p = . ) shows significant correlation with the air trapping on hrct statistically. among the patient of asthmatics, bwt on hrct shows statistically significant correlation with basement membrane thickness on pathology, but not with epithelial layer thickness on pathology (p = . , r = . ). the ratio of bwt between asthmatics and control subjects are significantly different on hrct. the grade of bwt shows significant different fev and tlc statistically, and that of extent of air trapping reveal significant different pefr statistically. the bwt on hrct reflect the thickness of epithelial basement membrane. computer-aided diagnosis: a shape classification of pulmonary nodules imaged on high-resolution ct s. iwano, t. nakamura, t. ishigaki; nagoya/jp purpose: the purpose of this study was to decide whether the computer image analysis could classify shape of pulmonary nodules like radiologists. materials and methods: based on the high-resolution ct (hrct) findings, two radiologists classified pulmonary nodules ( - mm in diameter) into types of shape: round (n = ), lobulated (n = ), polygonal (n = ), tentacle (n = ), spiculated (n = ), ragged (n = ), and irregular (n = ). on the other hand, an image processing computer software extracted several quantitative measures of the shape of each nodule from dicom data of hrct images. to identify the contour of the pulmonary nodules, - hu was used as the predefined threshold values. these quantitative measures were contrasted to the classification by radiologists. results: as quantifiable features to characterize nodule shape, the circularity (= π*area/ perimeter ) and the second moment were suitable. the combination of the circularity and the second moment could classify round, tentacle, spiculated, ragged, and irregular nodules. however, it was difficult to separate lobulated from polygonal nodules. conclusion: computer image analysis of hrct could classify round, tentacle, spiculated, ragged, and irregular pulmonary nodules like radiologists. this method may be useful for the differentiation between malignant and benign nodules. hrct of the lungs in cystic fibrosis: more sensitive marker of cf lung disease than lft m. polakovic, h. kayserová, p. boruta; bratislava/sk purpose: our study was aimed at determining the usefulness of hrct in evaluating pathomorphological changes of lung parenchyma, the reversibility of these changes, and correlation of these changes to pulmonary function and mutations in cftr gene. two hrct examinations of the chest were performed on cf patients ( males, females) with lft (maximal interval: two weeks) in the period of to . follow-up studies were evaluated by a modified bhalla scoring system and compared with initial studies. lung function testing was performed on a mir spiro-bank, using ers (zapletal) predicted values. in group with df /df genotype ( pts) the first examination mean score reached . (rl)/ . (ll), second . (rl)/ . (ll). lung function tests were: first examination -fvc %, fev %, mef % and second one fvc %, fev %, mef %. for groups with df /other genotype ( pts) and other/other genotype ( pts) similar results were obtained. conclusion: hrct is a more sensitive method of evaluating pathologic process in lungs of cf patients than lft. lft is a more complex examination, and the results of pulmonary functions are modified by the physical status of the cf patient (nutrition, strength of muscle, acute exacerbation) and his/her ability to cooperate with spirometry (age). severe mutations of cftr gene in genotype are accompanied by an increasingly high hrct score in spite of therapy applied and stable lung functions. high resolution computed tomography in the diagnosis of bronchiolitis obliterans syndrome after lung transplantation a.e. berstad, t.m. aaløkken, a. kolbenstvedt, Ø. bjørtuft; oslo/no purpose: to evaluate the clinical value of high resolution computed tomography (hrct) of patients after lung transplantation. materials and methods: hrct with insp-and expiratory scans was performed in patients ( women, single-and double lung-, including two heartlung transplanted) who had survived for months or more. the median followup time was months (range to months). air trapping was evaluated on expiratory scans constructed from two short spiral scans in two levels with minimum intensity projection (minip)-reconstruction. the degree of air trapping was classified on a to scale according to the affected surface area. a score of or more was defined as significant air trapping. results: patients developed the bronchiolitis obliterans syndrome (bos) as defined by reduction of pulmonary function test results to less than % of the best postoperative values after a median time of months. of these had an air trapping score of or more. among patients without bos (n = ), patients showed significant air trapping. the sensitivity, specificity and accuracy of a score of or more in the diagnosis of bos were , and % respectively. bron-chiectasis developed more frequently in bos than in non-bos patients ( and %, respectively). conclusions: hrct, including expiratory scans with minip-reconstruction, or development of bronchiectasis was of limited accuracy in diagnosing bos after lung transplantation. hrct indices and pulmonary function tests in patients with chronic bronchial asthma c. kalogeropoulou, d. kalampoka, p. zampakis, i. tsota, k. spyropoulos, t. petsas; patras/gr purpose: to quantitatively evaluate the presence and extent of low attenuation areas on chest high-resolution ct (hrct) in patients with chronic bronchial asthma and correlate such findings with the pulmonary function tests (pft). we examined patients (m: and f: , age . ± . yrs) with chronic bronchial asthma. all patients underwent inspiratory and expiratory hrct as well as forced spirometry, maximum voluntary ventilation, somatic plethysmography and cardiopulmonary exercise test. hrct images were evaluated for the presence and distribution of low attenuation areas. objective quantification of low attenuation areas was obtained by determining the relative area of pixels representing lung tissue with a density below - hu (pixel index). the resulting pixel index was determined for a single slice at the upper middle and lower zone. results: pulmonary function parameters correlated well with pixel index during expiratory scan. there was significant correlation between the upper part of the lung and forced vital capacity (fvc),%fvc, forced expiratory volume in sec (fev ), maximum voluntary ventilation (mvv) and total lung capacity (tlc). the middle part of the lung correlated with fvc, fev , fef - and resistance. the lower part of the lung was also correlated with fev , fef - , residual volume (rv) and total resistance. pixel index during inspiratory hrct scans did not correlate with pulmonary function tests. conclusions: expiratory hrct in asthmatics correlates well with pulmonary functions, which suggests that in asthmatics substantial gas trapping may occur during expiration because of severe airway narrowing and/or airway closure. thoracic imaging during treatment with pergolide r. dore, a. gervasio, m. braschi, v. vespro, g. meloni, c. nascimbene; pavia/it purpose: pergolide is a dopaminergic agonist widely used in the treatment of parkinson's disease. toxicity has been described in the form of fibrosis, inflammation of the pleura, retroperitoneal fibrosis, constrictive pericarditis and inflammatory lung infiltrates. we analyzed thoracic abnormalities in patients who have been taking pergolide long term and the possible differential diagnosis. hospital, "s.matteo" irccs, a group of neurological patients treated with pergolide underwent chest ct, because of clinical and chest x-ray abnormalities. we scanned each patients before and after intravenous injection of contrast medium; the lung parenchyma was evaluated with high resolution algorithm; three patients with pulmonary opacities also underwent fnab. results: all patients had round atelectasis associated either with pleural plaques of vary entity or with atypical and reactive pleural effusion. the thickest pleural plaques were located in the costovertebral angles, followed by the diaphragmatic pleura without effusion. in all the cases the pleural plaques in the parietal side were definetly irregular, linear in the lung side. association with lung interstitial septal thickening was inconstant. conclusions: although our cases are few in number and need further validation, pleural involvement, either fibrotic or inflammatory, always seem to be associated with pulmonary abnormalities. ct pleural signs are non specific; differential diagnosis may include tumors, asbestos exposure and inflammatory disease; however the association with relevant lung round atelectasis is significant. these ct findings must be held in mind and thought to be due to toxicity in patients treated with pergolide. the chest radiological appearances of severe acute respiratory syndrome methods and materials: patients with sars confirmed clinically had serial chest plain films, of whom also underwent chest ct scans. the radiological appearances and evolution patterns of sars were analyzed retrospectively. based on the extent and duration of the lesions on the chest plain films, the patients were classified into three types: simple type (type i) in which the lesions were limited, progressive type (type ii) in which more than three lungs fields were involved, and prolonged type (type iii) in which the lesions remained for more than six weeks. the follow-up chest plain films and ct scans were analyzed comparatively in patients of this group discharged from the hospital after clinical cure. results: in cases, on the chest radiography, cases showed predominately pulmonary parenchymal lesions in the form of ground-glass opacity and consolidation, cases showed predominately interstitial infiltration and cases showed both parenchymal and interstitial lesions. the radiological appearances were nonspecific with good patient prognosis in type i (n = ), and the radiological appearances were relative specific with high patient fatality rate ( %) in type ii (n = ). all of the patients ( %) in type iii (n = ) had residual lesions. ct was superior to the chest plain film on detecting residual lesions. the radiological appearances of sars were relatively specific. the exact diagnosis of sars must combine radiological appearances with the clinical, epidemiological and laboratory findings. hrct to identify hrct features that indicated predisposition to potentially fatal asthma and to evaluate serial follow-up hrct scans of patients with nearfatal asthma (nfa). abnormalities of the large airways (bronchial wall thickness) and small airways (centrilobular thickening and air trapping) were measured semi-quantitatively on hrct scans of non-nfa, nfa, and control subjects. in addition, these abnormalities were re-evaluated after intensive and relatively long-term (> -month) treatment with inhaled steroids. results: centrilobular thickening was observed in % of mild asthma cases, in % of moderate to severe asthma cases, and in % of nfa cases. centrilobular thickening, but neither bronchial wall thickness nor the area of air trapping, was significantly increased in nfa, as compared with mild or moderate to severe asthma (p < . , respectively). in the non-nfa and nfa patients who underwent follow-up hrct scans, only bronchial wall thickness was decreased significantly in the nfa cases (p < . ), while bronchial wall thickness and centrilobular thickening were significantly decreased in the non-nfa cases. these small airway abnormalities were partially reversible in the both groups. residual centrilobular thickening after long-term steroid treatment was significantly higher in nfa than non-nfa patients. the results of our study indicate that extensive small airway abnormalities may be associated with nfa, and that these abnormalities are partially reversible after the successful control of asthma symptoms. a. kalogera-fountzila, a. haritanti-kouridou, a. lefkopoulos, g. sevas, a. tzinas, a. sarafopoulos, a.s. dimitriadis; thessaloniki/gr purpose: we prospectively studied aids and non-aids immunocompromised patients with lung infection in order to evaluate the hrct findings, to characterize the infection and seek for differences in appearance of pcp in the two groups. methods and materials: hiv positive patients were referred to the special infectious diseases unit and non-aids immunocompromised patients were referred to the oncology unit of our hospital with a diagnosis of clinically suspected pulmonary infection. all patients were evaluated with hrct ( . mm collimation, mm interval, kvp, mas, and -s scan time). all non-aids immunocompromised patients had bronchoalveolar lavage, sputum culture, or ct guided biopsy as well as did of the hiv-positive patients which revealed pcp. in the rest of the patients pcp was confirmed after successful anti-pcp treatment. the data were calculated using the chi square test. results: all patients in both groups had the typical findings of pcp, such as presence of ground glass appearance (patchy or diffuse), consolidation (focal or diffuse), bronchiectasis or bronchioloectasies, septal thickening, cysts and nodules. the incidence of consolidation, especially diffuse, was a significantly higher finding in non-aids patients (p = . ). on the contrary, presence of ground glass in a central/perihilar distribution (p = . ), septal thickening (p = . ) and bronchioloectasis (p = . ) was significantly higher in aids patients. conclusion: hrct findings of pcp in non-aids immunocompromised patients are more aggressive, with diffuse consolidation as the cardinal sign and are associated with a more advanced disease. primary and secondary lung malignancies treated with percutaneous radiofrequency ablation: to describe the important ct findings to evaluate for therapeutic efficacy on follow-up ct after rf ablation for the lung cancer. the study group included lung cancers and metastatic nodules in patients. all patients underwent follow-up helical ct examinations immediately, one month later, and then every three months after percutaneous rf ablation. two reviewers interpreted the ct findings with consensus. the serial changes in the enhancement pattern, size, peripheral groundglass opacity, and other findings in the treated area were assessed on the follow-up ct. sensitivity, specificity, and the positive predictive value for evaluating the complete ablation using enhancement pattern on immediate follow-up ct were determined using the chi-square test. in the completely ablated group (n = ), the ablated lesions demonstrated absolutely no contrast enhancement on follow-up ct and the mean percentage of ablated lesion size decreased at , , , , and months ( . %, . %, . %, and . %, respectively) compared with immediate follow-up ct. in the partially ablated group (n = ), the ablated lesions demonstrated varying patterns of enhancement and the mean percentage of ablated lesion size showed a gradual increase after the -month follow-up ct scans. enveloped ground glass opacity surrounding the tumor was seen in ( . %) of lesions on immediate follow-up ct. conclusion: of the ct findings of lung malignancy after rf therapy, the enhancement pattern and the change in size of the ablated lesion are the most important factors in determining whether complete ablation can be achieved. (ip) is an uncommon benign lesion characterized by an irregular growth of inflammatory cells. the purpose of this study was to evaluate ct findings of the thoracic inflammatory pseudotumor. methods and materials: chest ct findings of pathologically proven seven thoracic ip were reviewed retrospectively. mean age of the patients was years old ( - years). pre-and post-contrast enhancement ct were performed in all patients. location and contour with margin of the lesion, pattern of contrast enhancement, calcification in the lesion, lymphadenopathy, associated parenchymal or pleural lesion were reviewed. clinical findings of the patients were also evaluated. results: six were in the lung parenchyma (five in peripheral, one in central; four in upper lobe, two in lower lobe), and one was in the anterior mediastinum. average size of the lesions was . cm ( - cm). of the six parenchymal lesions, three revealed as ill-defined mass-like consolidation, two as well defined masses, and one as speculated mass. one mediastinal mass showed ill-defined margin. all lesions showed heterogeneous contrast enhancement. three had eccentric calcification. none had satellite nodule. four cases had adjacent pleural thickening or effusion. lymphadenopathy was noted in one patient. they complained of mild fever (n = ), hemoptysis (n = ), coughing (n = ), weight loss (n = ). four patients had past history of pulmonary tuberculosis. conclusion: thoracic ip showed variable ct findings. however, when dealing with a peripheral pulmonary mass with heterogeneous contrast enhancement without remarkable lymphadenopathy, the radiologists should always include ip among the entities of the differential diagnosis. early to highlight the potential benefit of including fdg-pet in an early lung cancer detection protocol. materials and methods: from september to october , asymptomatic smokers (mean age . years, sd . , mean tobacco consumption . pack-years) were studied with ldct. repeat short-term high-resolution ct follow-up was done for non-calcified pulmonary nodules (ncpn) < mm to exclude growth. ncpn mm or more were considered as potentially malignant and complementary fdg-pet scanning was recommended. biopsy was recommended for ncpn found to be positive on the fdg-pet. results: ncpn were found in ( %) asymptomatic subjects. the diameter of the largest ncpn was: mm or less in ( . %) participants, > -< mm in ( . %) and mm or more in ( %). subjects underwent fdg-pet exam ( positive, negative). among the fdg-pet positive ncpn were resected (lung cancer), underwent fine needle aspiration cytology (fnac) (non-specific / necrosis). the remaining subject refused further work-up. ct follow-up was decided for the other ncpn. results will be updated after inclusion of more participants. this ldsct based screening programme demonstrated a prevalence of lung cancers in a population of ( . %) asymptomatic subjects at high risk, all with surgical stage t n m . addition of fdg-pet to the protocol may reduce the number of invasive procedures for histologically benign nodules. technical aspects postprocessing procedures after mdct for airway and lung diseases a.-l. brun, c. beigelman-aubry, y. badachi, p.a. grenier; paris/fr learning objectives: to be familiar with the postprocessing procedures after multi-detector row ct (mdct) which can optimize the assessment of airway and lung disease. background: axial slices are considered as the gold standard for analysis of airways and lung diseases. since the era of mdct, excellent reformations, and d reconstructions have become available and frequently used in case of airway disease. infiltrative and cystic lung diseases may also benefit from these techniques, provided that they are optimally used. procedure details: all d and d reconstruction techniques available were retrospectively applied on mdct volume data set from patients with airway and/or lung disease, using various parameters. optimized multiplanar volumetric reconstruction and d ct bronchography are particularly well adapted for assessing tracheobronchial stenosis and bronchiectasis. maximum intensity projection is recommended for assessing small nodular and mosaic perfusion patterns. minimum intensity projection is helpful: ) to detect and assess ground glass opacity; ) to visualize the airways within any lung parenchymal lesions, helping guide selective bronchial aspiration and bronchoalveolar lavage; and ) to depict bronchial adenolectasia in patients with copd or bronchiectasis. virtual endoscopy is particularly helpful in depicting tiny nodulation of the tracheobronchial mucosa in granulomatous and malignant diseases. highly selected cases will be used to illustrate the most striking additional information provided by postprocessing techniques in airway disease, infectious lung disease, and diffuse infiltrative lung disease. postprocessing procedures in addition to axial slices allow an excellent assessment of tracheobronchial and parenchymatous diseases, particularly concerning their depiction, characterization and extent assessment. volume rendering: less-time consuming and accuracy technique in diagnosis of rib fractures e. chavarri, c. trinidad, e. guerra, g. fernandez, c. delgado, p. moreno de la santa; vigo/es learning objectives: to asses the useful of volume rendering d images (vr) in the evaluation of rib fractures using a -slice multidetector ct. to compare vr and conventional images in determining the number and location of fractures. to describe the advantages of vr over conventional images. background: multislice ct has improved the resolution in evaluation of traumatic patients because it permits thinner slices and multiplanar reconstructions with near isotropic voxel. however, the number of images to be evaluated is greater and the diagnosis of rib fractures remains difficult due to the obliquity of costal arches in the axial view. we evaluated chest ct examinations in patients with rib fractures. in this exhibit, we describe ct technique, reconstruction parameters and the advantages of vr over conventional images to ensure number and location of rib fractures. procedure details: a -slice multidetector ct was performed using the following parameters: mas, kv, x . mm collimation, during a single breath hold. images were reconstructed with mm thickness, % overlapping and soft tissue kernel filter (b ). two experimented radiologists analysed axial, multiplanar and vr images. the number of fractures, location and part of arch fractured (anterior, medium and posterior) was described. conclusion: volume rendering is more accurate than conventional images in determining the presence and location of rib fractures, particularly when arches are fractured in more than one site. also, it is a less time consuming technique with better diagnosis confidence. we recommend its use in a routine practice for chest-ct in traumatic patients. c b d e f a g volume rendering d bronchography imaging of the airways with multidetector row ct c. trinidad, g.c. fernandez, m. rodriguez-castilla, c. martinez, e. guerra, f. tardáguila; vigo/es learning objectives: to describe the technique of d volume rendering bronchography (vr-b) with multidetector row ct. to evaluate the usefulness of vr-b of the tracheobronchial tree in clinical practices comparing with axial and multiplanar reconstructions. background: multidetector row ct allows superior imaging resolution in axial and multiplanar images, and also contributes to advances in d-volume rendering that can now be feasible in clinical routine practice. in this exhibit, we will describe the ct technique and vr-b parameters to obtain good quality d images for visualization of central and small airways. in addition, we will evaluate the role of this technique in clinical practice and in different pathologies of the tracheobronchial tree. procedure details: patients with airways pathology due to different etiologies were prospectively studied with -row multidetector ct. images were acquired at end-inspiration during a single breath-hold with x . collimation detector and reconstructed with - mm collimation, . - mm increment (overlapping %) and soft tissue kernel filter (b ). vr-b images were showed using - to - uh window with, - to - uh window level, % opacity and unshaped. conclusion: good quality vr-b images are feasible in daily practice. in patients with benign stenosis of the central airways additional information in assessing length and degree is provided. this technique improves confidence diagnosis in extrinsic compression by malignancies. however, no additional benefit in the evaluation of endobronchial lesions and bronchiectasis is shown. clinical procedure details: all scans covered from the vocal cords to the mainstem bronchi. ct parameters included a slice thickness of mm, a reconstruction interval of mm, a pitch of . mm, and a table speed of mm per rotation. data were obtained during a single-breath-hold acquisition in a craniocaudal direction. twodimensional reformation images including multiplanar reconstructions (mpr), multiplanar volume reconstructions (mpvr), and three-dimensional reconstructions (external and internal rendering) were obtained at a workstation (vitrea ; vital imaging). the main applications of msct in airways disease as well as its limitations and pitfalls are emphasized. specific topics addressed include congenital airways anomalies (anomalous origin of bronchi, vascular rings, tracheomalacia, bronchopleural fistula), extrinsic airways compression, tracheal and bronchial wall infiltration (bronchogenic carcinoma, angiosarcoma), intraluminal airways masses (carcinoid tumor), inflammatory diseases and posttraumatic and iatrogenic airways injuries. conclusion: msct provides very high-quality image postprocessing (multiplanar and three-dimensional images), overcoming limitations inherent to sdct. additional benefits include preprocedural planning for bronchoscopy and surgery, and a more comprehensive spatial anatomy for both radiologists and referring physicians. ultrasound: guided aspiration of supraclavicular lymph nodes in patients with suspected lung cancer m. kumaran, r. benamore, r. vaidhyanath, j. entwisle; leicester/uk learning objectives: to illustrate the utility of ultrasound-guided supraclavicular lymph node aspiration in the cytological diagnosis of lung carcinoma. we describe our preliminary experience in patients over the last months. background: lung carcinoma is the leading cause of cancer death in the uk. histological diagnosis traditionally requires invasive techniques to obtain tissue, such as bronchoscopy, mediastinoscopy or image-guided lung biopsy. we have introduced this technique in patients who have at least n disease on staging ct. if positive, this helps both to stage the patient and provide a cytological diagnosis. it may prevent the need for more invasive techniques, such as percutaneous lung biopsy or mediastinoscopy. procedure details: all patients were scanned and nodes over mm in size were aspirated under ultrasound guidance, using a gauge green needle. a capillary "coring" technique was employed, without suction and aspiration. the samples were then expelled from the needle into cytospin fluid, for cytological examination. the procedure could be performed without local anaesthetic and as an out patient. of the patients examined, had significant lymphadenopathy. of these, had positive malignant cytology, although had indeterminate cell type. samples showed no evidence of malignancy and pet confirmed no evidence of supraclavicular nodal involvement in case. conclusion: this is a promising non-invasive technique in the staging and diagnosis of patients with lung cancer. simulated low radiation dose ct angiography of pulmonary arteries d. tack , v. de maertelaer , c. suess , p. muller , p. scillia , w. petit , p. gevenois ; baudour/be, brussels/be, forchheim/de, charleroi/be purpose: to compare standard dose and simulated low-dose ct angiography of pulmonary arteries (ctpa). raw data of ctpa acquired in consecutive patients with pulmonary emboli (pe) were included. ct acquisitions (volume zoom, siemens) were: x mm, kv, effective mas. from the native raw data, four sets of simulated raw data were generated with , , and effective mas, respectively. from each raw data set, ct slices were reconstructed with . mm thickness and . mm increment, and with a soft tissue kernel. three readers who were blinded to the patients names and to the simulated mas levels analyzed the ct series twice, in random order. pe in central pulmonary arteries (pa) and segmental pa were graded with a four-point scale. agreements (kappa statistics) and readers performances using mas as the gold standard were calculated. results: all pe seen at mas were depicted at all lower radiation dose levels. intraobserver agreements were independent from the radiation dose but strongly depended on the reader's experience. agreements were good for central pe but only moderate for peripheral pa branches. accuracy of low-and lower dose ctpa ranged from to %, and were independent from the radiation dose (p < . ) but not on the reader. conclusion: reducing the radiation dose during ctpa is feasible with high accuracy, and may have less influence on ctpa interpretation than may have changing the reader or repeating a reading. receiver operator characteristic analysis of observer performance in virtual bronchoscopy p. maniatis, c. triantopoulou, h. labrakis, k. malagari, i. tsalafoutas, i. siafas, j. papailiou, d. kelekis; athens/gr purpose: to evaluate the observer performance with the combined interpretation on a workstation of vb, axial, coronal and sagittal images against hard-copy films of thin section ct in low grade bronchial abnormalities using receiver operating characteristic (roc) curves. patients and methods: bronchial sections in patients were evaluated in a prospective observer study using spiral ct data. exclusion criteria included occlusions, high-grade bronchial stenoses (> %) and tracheal lesions. all patients underwent a spiral ct acquisition with mm collimation. two reconstruction intervals were used: mm for virtual bronchoscopy and mm for thin section ct. both examinations were reviewed by two independent radiologists. the findings were correlated with those of flexible bronchoscopy and the statistical analysis was done with receiver operating characteristic curves. results: a total of lesions were identified by flexible bronchoscopy. areas under curves for virtual bronchoscopy and multiplanar reconstructions were . and . for the two observers respectively, while areas . and . were provided from thin axial ct images (by the two observers respectively). these results differed at statistical significant level (p < . for the first observer and p < . for the second observer). the combination of multiplanar reconstructions and virtual bronchoscopy in simultaneous viewing on a workstation is particularly useful for the evaluation of low grade bronchial abnormalities at statistical significant level when compared to thin section axial ct images alone. b d e f a g optimization of voltage combination for chest radiography in a new dualenergy subtraction system n. bandai , h. tagashira , m. yoshimoto , t. kiriyama , t. maruyama ; onsen-gun/jp, matsuyama/jp the new dual-energy subtraction system allows the fast ( millisecond) acquisition of two, high and low voltage images using csi:tl amorphous silicon flat-panel technology. the purpose of this study was to determine the best combination of the voltage for the soft tissue of the chest radiography. the dual-energy subtraction imaging increases the sensitivity and specificity of the pulmonary nodule detection in the chest radiography by reducing the contrast of overlying the bone structures. the range of the high voltage is from kvp to kvp and the low voltage is from kvp to kvp, respectively. the physical factor such as contrast, density and graininess and the anatomical factor such as visibility of the vessel were evaluated by five radiologists using the normalized-rank approach. all rank orders were transformed to the distance scale by the statistical method. the ranking in the low voltage was better in the order corresponding to kvp, kvp and kvp (p < . ). the ranking in the high voltage showed better in the order corresponding to kvp, kvp, kvp and kvp. there were significant differences (p < . ) except the distance scale between kvp and kvp. the best combination for the soft tissue of the chest in a new dualenergy subtraction system was kvp (high voltage) and kvp (low voltage). spiral low-dose ct of the chest: a "one-stop-shop" modality for early detection of the leading causes of death g. bastarrika, o. cosín, j.c. pueyo, Á. alonso, d. cano, j.j. zulueta; pamplona/es purpose: spiral low-dose ct (ldct) can identify very small lung cancers in high-risk individuals. the purpose of this study is to assess feasibility of quantifying coronary calcium using non ecg-gated ldct exams performed in individuals participating in an early lung cancer detection programme (elcdp). a comparative study was performed in asymptomatic smokers included in an elcdp ( male, female; mean age . years; sd . ). subjects consecutively underwent a ldct of the chest and an ecg-gated cardiac ct with a four-row msct scanner (volume zoom, siemens, erlangen, germany). standard parameters were employed: ldct: kv, mas, mm slice, mm coll., mm table feed, . mm rec. interval; ecg-gated cardiac ct: kv, mas, mm slice, . mm coll., . mm table feed, . mm rec. interval. retrospective reconstruction using the raw data from the ldct was performed reproducing the specific ecg-gated ct parameters. intraclass correlation coefficient (icc), paired-sample t-test and bland and altman plot were employed for the statistical analysis. the paired sample t-test showed there was not a systematic bias in the measures of calcium (p = . ). the icc for the overall calcium score and for the different main coronary arteries showed and excellent agreement (overall icc . , % ci . - . ). conclusion: a clear correlation when evaluating quantification of coronary calcium with both ct techniques is observed. a single ldct exam may be useful for early detection of leading causes of death: lung cancer and coronary artery disease. dual energy in digital chest x-ray: material and methods: patients scheduled to undergo routine chest ld-msct were examined either without ( mas, kv, . mm slice width fused to mm effective width, spiral acquisition, n = ) or with ecg-triggering ( mas, . mm slice width, axial incremental acquisition, n = , age-, sex-and bmi-matched) on a philips mx -row msct scanner. three independent radiologists scored axial slices at four different levels (carina, apical, mid-cardiac, basal), using a four-point scale for discrimination of pulmonary structures in the hilar region, the lung core and the subpleural region. mediastinal structures were scored on a three point scale. scores were compared using wilcoxon's test. results: for the more experienced ct radiologist, delineation of pulmonary structures did not improve significantly with ecg-triggering (p = . ), while improvement in the delineation of mediastinal structures was highly significant (p = . ). for the less experienced ct radiologist, there were no significant differences between ld-mscts with and without ecg-triggering for either pulmonary or mediastinal structures (p = . resp. p = . ). although not formally evaluated in this study, both radiologists reported a higher quality of sagittal and coronal mprs from non-triggered data due to lower susceptibility to breathing artifact. conclusion: results indicate that ecg-triggering improves delineation of moving structures (heart, mediastinum) in ld-msct of the chest. ecg-triggering improves delineation of pulmonary structures only in paracardial lung tissue. results: time-distance curves of the breathing-cycle using mri correlated highly significantly with spirometry (p < . ). vc calculated by the model was similar to vc measured in spirometry ( . l vs . l). tvc correlated highly significant with spirometry (p < . ). vertical parameters had a more profound influence on tvc change than horizontal parameters. conclusions: dynamic mri is a simple non-invasive method to evaluate local chest wall motion and respiratory mechanics. it widens the repertoire of tools for lung examination with a high temporal resolution. influence the aim of this study was to investigate influence of reconstruction filters on image quality in ct chest exams. methods: patients were examined with standard chest scanning protocol. after scanning, images were reconstructed with smoothing filter. both set of images were filmed under the same conditions. in blinded assessment, three radiologists independently rated films for overall image quality and chest anatomic details ( -unacceptable, -substandard, -acceptable, -above average, and -superior). for all exams and reconstruction filters image noise were measured in relation to the descending thoracic aorta. results: for all three readers overall image quality was higher for standard filter. image quality for standard protocol was . and for images reconstructed with smoothing filter . . average image noise for images reconstructed with standard filter was . and for images reconstructed with smoothing filter the noise was . . all three radiologists rated greater chest anatomic details for standard protocol images. for both protocols the best-rated detail was that of the trachea and main bronchi ( . standard, . smoothing), and the worst was that of the esophagus ( . standard, . smoothing). the greatest difference between rates of the two protocols was for paratracheal tissue ( . standard, . smoothing) and the smallest for carina and lymph node area ( . standard, . smoothing). conclusion: standard filter is better in visualization of all anatomic detail in general chest exams including mediastinal structure and lymph node area. greater image noise for image reconstructed with standard filters does not influence visualization of anatomic detail. usefulness new quality assurance systems for the evaluation of detectability of lung nodules on the digital chest radiograph y. fujiwara, k. higashimura, h. kimura, h. itoh; fukui/jp purpose: the goal of this study is to develop a new quality assurance system for evaluating detectability of lung nodule of the digital chest radiograph. method and materials: first, we made an oval shaped phantom, which simulated lung tissue such as muscle, fat, and pulmonary field. then several nodules with variable ct values were inserted into the center of the phantom. second, we took images of the phantom using ct and digital radiography (dr) with a flat panel detector.the contrast of the nodules relative to the pulmonary field were measured both on chest ct and dr. the relationship between contrast from ct and dr was analyzed in regression using rd order polynomial. finally, the same analysis was also performed on nodules from clinical cases with lung cancer (n = ), and clinical data was fitted into the same polynomial line. results: all nodules with the ct value less than in the difference between nodules and lung field could not be detected on dr. the relationship between the contrast from ct and dr in clinical cases was also regressed with the same rd order polynomial line from the phantom data. the current result is very useful for the evaluation of the detectability on chest dr. when one want to check it using variable nodules with known ct values, if the contrast of the nodules on dr is not regressed on above line, the assurance of dr might be problematic and/or dr system may need to be reconditioned. b d e f a g pulmonary thromboembolism: acute versus chronic (pictorial review) a. oikonomou , c.j. dennie , j.m. seely , f.r. matzinger , f.d. rubens , p.k. prassopoulos ; alexandroupolis/gr, ottawa, on/ca learning objectives: to present the spectrum of imaging findings that allow the differentiation of acute pulmonary embolism (ape) from chronic thromboembolic pulmonary artery hypertension (cteph) based on chest radiography and helical computed tomography (ct). background: patients with a prompt diagnosis of ape may recover completely following anticoagulation therapy. in a minority, pulmonary emboli do not completely resolve leading to organization, artery obstruction and ultimately to cteph. although the evolution process of ape to cteph has not been fully elucidated, the distinction of the two entities is critical since the treatment of ape is conservative, while cteph warrants pulmonary thromboendarterectomy. imaging findings: radiographic findings of ape are nonspecific and include atelectasis, peripheral consolidation and pleural effusion. localized lung oligemia with associated dilatation of a central artery is extremely rare. right ventricular and central pulmonary enlargement, patchy oligemia and peripheral scars may be seen in cteph. the cardinal signs of ape on ct angiography are central or completely occluding arterial filling defects, which may be associated with peripheral airspace disease and pleural effusion. eccentric filling defects adherent to the vessel wall, irregular intimal thickening, abrupt vessel narrowing or tortuosity are features of cteph. dilatation of central arteries, abrupt vessel cut-off and peripheral scars are more common in cteph than in ape but arterial webs, bands and mural calcifications are only observed in cteph. if arterial findings suggestive of cteph are present, the addition of mosaic oligemia on hrct is pathognomonic of cteph. conclusion: ct allows differentiation of ape from cteph. pulmonary hypertension: ct of the chest in pulmonary veno-occlusive disease a. resten, s. maître, m. humbert, f. capron, g. simonneau, d. musset; clamart/fr purpose: pulmonary veno-occlusive disease is a rare cause of pulmonary hypertension and often difficult to distinguish from severe primary pulmonary hypertension. unfortunately, medical treatment of the primary pulmonary hypertension by prostacyclin (pgi ) can be fatal in veno-occlusive disease and an early pre-therapeutic diagnosis of this uncommon condition is critical. so, the aim of the study was to evaluate ct of the chest as a non invasive approach of this disease. we reviewed cross-referenced records from to in our departments of radiology and pathology and identified patients with an initial pre-therapeutic ct and a pathologically confirmed pulmonary venoocclusive disease. ct scans were compared with the ct scans of consecutive patients with a pathologically confirmed primary pulmonary hypertension. results: ground glass opacities were significantly more frequent in pulmonary veno-occlusive disease (p = . ), abundant, with a random repartition, and a preferentially centrilobular distribution (p = . ). sub-pleural septal lines, and adenopathy were also significantly more frequent (p < . ). the association of these three findings appeared to be quite pathognomonic of pulmonary venoocclusive disease as the cause of pulmonary hypertension (specificity = %) with a % sensitivity. conclusion: on the initial pre-therapeutic chest ct, association of ground glass opacities (particularly with a centrilobular distribution), septal lines, and adenopathy are indicative of pulmonary veno-occlusive disease in patients displaying pulmonary hypertension. caution must be taken before initiating vasodilatator therapy in the presence of such radiological abnormalities. . x . mm ) was performed during and after a single injection of . mmol/kg body weight of gadomer. image data was compared to pre-embolism gd-dtpa-enhanced mri and post-embolism thin-section multi-slice ct (n = ). snr measurements were performed in pulmonary arteries and lung. results: one animal died after induction of pe. in all other animals, perfusion mri and mra could be acquired after single injection of gadomer. at perfusion mri, pe could be detected by typical wedge-shaped perfusion defects. while the visualization of central pe at mra correlated well with ct, peripheral pe were only visualized by ct. gadomer achieved a higher peak snr of the lungs compared to gd-dtpa ( ± vs. ± ). conclusion: contrast-enhanced d perfusion mri and mra allow the assessment of pe using a single injection of the blood pool contrast agent gadomer. c b d e f a g detection of pulmonary emboli with thin slice ( mm) maximum intensity projection reconstructions of multi-detector ct pulmonary angiography s.k. venkatesh, s. wang, p. goh; singapore/sg purpose: to compare thin-slice ( -mm) maximum intensity projection (mip) reconstructions with mm axial scans for detection of acute pulmonary emboli. materials and methods: multi-detector ct pulmonary angiography ( x mm, . pitch; . sec) was performed in patients. from each raw data set, axial mm and mm scans were reconstructed. thin-slice ( mm) mips in axial, coronal and rotational planes were reconstructed from mm axial data using a d workstation. the data sets were reviewed for evidence of embolus on a per vessel basis by radiologists with discrepancies resolved by consensus. emboli demonstrated on the axial mm images were taken as standard for comparison. results: pulmonary emboli were detected in vessels (mean of . emboli per patient) with . % in subsegmental arteries. the thin-slice mip images demonstrated more emboli as compared to axial mm images. axial and rotational mm mip images detected most of the emboli ( . % and %). significant advantage of axial and rotational mm mips over axial mm images was seen at subsegmental artery level ( . % and . % versus . %) (p < . ). among the mips, axial mips detected the most number of emboli in upper and middle lobes, whereas the rotational mip detected slightly higher emboli in the lower lobes. conclusions: thin slice mips are superior to axial mm for pulmonary embolus detection. the advantage of mips is most significant at the level of subsegmental artery level and beyond. we recommend routine use of axial mm mips in the detection of pulmonary embolus. primitive angiosarcomas of the pulmonary arteries: difficulties in ct diagnosis r. dore, m. mantelli, v. vespro, d. savulescu, g. digiulio; pavia/it purpose: primitive angiosarcomas of the pulmonary arteries are very uncommon tumors. the radiologist should consider them in the differential diagnosis with thromboembolic disease, in patients with clinical suspicion of pulmonary embolism, as early surgical treatment may be beneficial. between and , at our hospital, "s.matteo" irccs, we identified three cases of primitive angiosarcomas of the pulmonary arteries, subsequently confirmed at surgical examination, on chest cts of patients with clinical suspicion of thromboembolism. we used a single-slice spiral ct scanner ( sec., - mm collimation), with iv contrast injection at high flow rate. both pulmonary parenchyma and vasculature were evaluated, along with the enhancement pattern of the endoluminal lesions. results: in all cases, the left main pulmonary artery was affected (the distal segment in one case and proximal segments in two). in one patient, the right main pulmonary artery was also involved. all the vascular lesions were occlusive, without anterograde flow and extravasal diffusion. in two patients, contrast enhancement of the endoluminal mass was better detected in the delayed scan. in one patient, contrast enhancement had a periferical distribution. in all the patients, there were no parenchymal signs of thromboembolic disease. conclusions: primitive angiosarcomas of the pulmonary arteries are associated with occlusion of the main pulmonary artery and lack of parenchymal signs. as the differential diagnosis between massive thromboembolic disease and primitive angiosarcoma may be difficult with monophasic ct scan, the evaluation of the contrast enhancement of intraarterial lesion in the delayed phase becomes fundamental. purpose: to demonstrate the imaging features of chronic thromboembolic pulmonary hypertension (ctph) on chest ct scans and to evaluate the correlation between the extent of mosaic pattern of lung attenuation and hemodynamic measurements. methods and materials: chest ct scans of patients with ctph were reviewed to assess vascular and parenchymal changes. in all patients diagnosis was confirmed by surgery. the diameter of the main pulmonary artery (pa) and the ratio of the diameters of the main pulmonary artery to the ascending aorta (rpa) were correlated with mean pulmorary artery pressure and pulmonary vascular resistance. mosaic attenuation was quantitated by adding the number of abnormal lobes (including lingula, score - ). this score was correlated with the hemodynamic measurements. results were analysed by regression analysis and spearman's correlation. results: thrombi were observed in the central pulmonary arteries in % of cases. in all ct scans a mosaic pattern of lung attenuation was found. scars related to the pleural surface were identified in % of cases, bronchial artery collaterals in %. ct scans showed dilated pa in % and rpa ≥ in %. mean pulmonary artery pressure correlated more strongly with rpa than with diameter of pa. the score of mosaic attenuation showed a strong correlation with pulmonary vascular resistance (r = . ; p < . ). to be able to recall the most common ct and mr intrathoracic manifestations in patients with breast cancer. . to be able to describe the radiologic features of this entity. . to be able to recall helpful clues for narrowing the differential diagnosis and appropriately directing patient management decisions. background: breast cancer is a common cancer in women and is second only to lung cancer as a cause of cancer-related deaths in women. the thorax is a common site of metastasic disease and complications related to surgery, chemotherapy, radiotherapy and autologous bone marrow transplantation. imaging findings: the purpose of this exhibit is to review the ct and mr findings of the various intrathoracic manifestations occurring in patients with breast cancer. these include complications related to direct extension of tumor, to metastatic spread, and complications secondary to treatment. the complications can be divided into those that affect the chest wall (chest wall invasion, chest wall metastases, axillary and internal mammary lymphadenopathy, local recurrence, postradiotherapy sternal and costal tumors, surgical complications), mediastinal and hilar manifestations (lymphadenopathy, abscess formation, lymphatic obstruction), pulmonary manifestations (lymphangitic carcinomatosis, pulmonary metastases, endobronchial metastases, neoplastic emboli, lung infections related to immunosuppressive therapy, obliterative bronchiolitis post bone marrow transplantation) and pleural manifestations (pleural effusion, pleural metastases). conclusions: knowledge of the full spectrum of radiologic manifestations of the thoracic complications of breast cancer is useful in diagnosis and in preventing diagnostic errors. bronchogenic cysts: range of radiological appearances f. almolani, p.m. logan; dublin/ie learning objective: to review and illustrate the range of plain film, ct and mri appearances of bronchogenic cysts. background: bronchogenic cysts are one of the congenital cystic lesions in the chest. it has variable appearances on imaging and overlapping features with other mediastinal lesions. it is often identified incidentally. imaging findings: we reviewed the imaging on proven bronchogenic cysts. plain radiographs and ct images were available for all cases. mri images were available in cases. most of bronchogenic cysts have a classic mediastinal location and well defined margin on plain films, with homogeneous low density appearance on ct. however they can be found within the lung parenchyma, be cystic or cavitary, have thick walls and be seen to expand. on mri, fluid levels can be demonstrated. occasionally, they can be multiple or co-exist with significant unrelated pathology. conclusion: bronchogenic cysts have a wide range of imaging appearances and familiarization with these appearances is essential for appropriate inclusion of the diagnosis within a list of differential diagnoses. imaging appearances of mediastinal cystic lesions s.p. prabhu, k. burney, p. goddard; bristol/uk learning objectives: to illustrate the radiological appearances of various mediastinal cystic lesions using various imaging modalities. background: cysts of the mediastinum constitute a small but important diagnostic group, representing to % of all primary mediastinal tumors. mediastinal cysts can be classified based on their aetiology, and include bronchogenic, oesophageal duplication cysts of foregut origin, mesothelial derived pericardial and pleural cysts, cystic thymic lesions, and other miscellaneous cysts. neuroenteric cysts may develop by abnormal septation of the embryogenic germ cell layer, which closely associate with the vertebral column. in addition, mesothelial cysts, including pericardial and pleural cysts, and thymic cysts also occur in the mediastinum, as well as other rare cysts. imaging findings: characteristic location and internal architecture of different mediastinal cystic lesions are used to aid the clinician in formulating a diagnostic plan. plain chest radiographs can identify mediastinal cysts in a large proportion of cases. ct usually reveals well-circumscribed rounded masses of water density or a little higher and is useful in delineating the size, shape, and extent of the mediastinal masses. characteristic fluid signal on mri performed in selected patients differentiates the benign cystic lesion from solid mediastinal masses. mri has therefore succeeded in providing valuable pre-operative specific diagnostic confirmation in regard to mediastinal cysts in selected cases. in this pictorial review, we review the radiological appearances on plain radiographs and cross-sectional imaging for the entire spectrum of cystic lesions of the mediastinum. non-infectious radiographic manifestations of bone marrow transplantation: a pictorial review d. beckett, j. oliff; birmingham/uk learning objectives: to illustrate the radiological manifestations following stem cell transplantation for haematological malignancy. to outline the incidence, clinical presentation and role of imaging within this patient sub-group. background: bone marrow transplantation (bmt) is a critical therapeutic intervention for a variety of pathological conditions. the complications of bmt include chemotherapy and radiation toxicity, graft versus host disease, recurrent malignancy and miscellaneous conditions. complications of allogenic bmt manifest in a variety of clinical settings affecting all organ systems. plain radiography, contrast enhanced studies, sonography, ct, mri and interventional techniques are essential in diagnosing these complications and evaluating their response to therapy. imaging findings: pulmonary manifestations include drug and radiation toxicity, bronchiolitis obliterans, bronchiolitis obliterans organizing pneumonia, lymphocytic interstitial pneumonitis and diffuse alveolar haemorrhage. gastrointestinal presentation with veno-occlusive disease, typhlitis and pneumatosis intestinalis are also reviewed, as are central nervous, musculoskeletal and cardiovascular system manifestations. the spectrum of imaging findings following bmt is diverse. a firm understanding of the clinical presentations and incidence in combination with typical radiological findings is essential in the successful management of this patient sub-group. thoracic manifestations of chronic renal failure a.m. barnacle, p.g. gishen, s.j. copley; london/uk learning objectives: to review the radiological spectrum of thoracic manifestations of chronic renal failure, including the more unusual imaging appearances. background: the effects of chronic uraemia are evident in a multitude of organ systems, including the pulmonary, cardiovascular and musculoskeletal systems. imaging findings: the poster illustrates common thoracic manifestations such as pulmonary oedema and uraemic pericarditis. more unusual manifestations of chronic renal failure such as metastatic pulmonary calcification, renal osteodystrophy, amyloidosis and peritoneal dialysis fluid collection within the mediastinum are highlighted. plain radiographic and ct imaging findings of both these common and more unusual pulmonary manifestations are reviewed. the study illustrates the diversity of thoracic manifestations encountered in chronic renal failure patients and the less well recognised sequelae that should not be overlooked when imaging such patients. background: while the availability of bone marrow transplantation is improving and increasing numbers of adults and children are undergoing the procedure for the treatment of a wide variety of malignant tumours and haematological disorders, it remains a procedure which carries with it a very significant complication risk. despite prophylactic therapy, patients remain at particularly high risk for bacterial, viral and fungal infection in the post-procedure time period. infectious complications are diagnosed and monitored using plain radiography, ultrasound, ct, mri, image-guided biopsy and less often, nuclear medicine. other commonly encountered complications requiring radiological investigation include hepatobiliary complications, veno-occlusive complications and graft-versus-host disease. imaging findings: this educational exhibit demonstrates the radiological appearances of the spectrum of common and unusual complications encountered by patients who have undergone bone marrow transplantation, as depicted using a wide variety of imaging modalities. conclusion: while bone marrow transplantation is a life saving procedure it still retains a high degree of morbidity and unfortunately a wide range of complications can arise following the procedure. the role of the radiologist in using a number of imaging modalities to accurately diagnose and follow these complications remains an important one. air-space pattern lung metastasis l. herraiz, a. cima fernandez, s. dieguez, m. grande, m. sanchez nistal; madrid/es learning objectives: to identify and describe the imaging findings on air-space pattern in lung metastasis. background: lepidic pattern growth in lung metastasis is an uncommon manifestation of disseminated malignancies, mainly described in gastrointestinal adenocarcinomas. on ct, differentiation from other lung diseases as multifocal pneumonia, bronchiolitis obliterans organizing pneumonia (boop) and brochioloalveolar carcinoma (bac) may be difficult, and diagnosis of bac cannot be made with confidence if a primitive extrapulmonay adenocarcinoma has not been ruled out. imaging findings: we reviewed x-ray films and ct studies of patients with proven air-space pattern lung metastasis. metastasis was classified as air-space disease when it showed one or more of the following ct findings: air-space nodules, including cavitating and pseudocavitating nodules; parenchymal consolidation containing air bronchogram and focal or diffuse ground-glass opacities. the primary tumors were colorectal adenocarcinoma in patients; pancreatic adenocarcinoma in ; adenocarcinoma of the ampulla of vater in and infiltrating duct breast carcinoma in . in patient the diagnosis of pulmonary disease preceded the discovery of primary malignancy and was synchronous in other patients. cavitating nodules were seen in patients; parenchymal consolidation in ; ground-glass opacities were seen in ; pseudocavitated nodules in other patients; solid nodules in ; nodules with air bronchogram in two; mass with air bronchogram in and lymphangitic carcinomatosis in patient. conclusions: air-space pattern is an uncommon manifestation of lung metastasis. differentiation from boop, multifocal pneumonia and bronchioloalveolar carcinoma can be difficult because this can be the onset of the disease. imaging of chest wall disorders j. lee, k.-n. lee, s. kim, j. lee, m. roh; busan/kr purpose: to illustrate the radiologic features of a wide spectrum of chest wall disorders according to anatomic location. we have retrospectively reviewed the radiologic findings of patients with chest wall lesions pathologically proven by biopsy or surgery between january and july . we excluded cases of pleural effusion or thickening, chest wall invasion by lung cancer or mediastinal malignant tumor, and secondary metastatic lesions. all patients had plain films and spiral ct scan with intravenous contrast enhancement. several patients underwent supplementary mr with gadolinium enhancement. results: pleural lesions include empyema, tuberculous empyema, empyema neccessitatis, localized fibrous tumor of pleura, malignant mesenchymal cell tu-mor, malignant mesothelioma, pleuroblastoma, fibrosarcoma, angiosarcoma and asbestos-related pleural plaques. muscle and subcutaneous fat are involved in poland's syndrome, inflammation, abscess, tuberculous abscess, empyema neccessitatis, post-operative hematoma, epidermal cyst, intramuscular hemangioma, elastofibroma dorsi, pectoralis muscle fibromatosis, neurofibromatosis, malignant schwannoma, muscle involving nhl, subcutaneous t-cell lymphoma and extraskeletal ewing's sarcoma. rib lesions include chronic inflammation, osteochondroma, enchondroma, eosinophilic granuloma, and plasmacytoma. sternal lesions include chronic inflammation and pigeon breast. a case of chondrosarcoma of the t vertebral body is also included. a wide of spectrum of disease processes affect the chest wall. the ct and mr imaging has enabled precise localization and differential diagnosis of chest wall lesions. therefore, familiarity with these radiologic features will make accurate diagnosis possible and and allow for optimal patient treatment. standardized in all patients ml contrast-agent was injected with a flow-rate of . ml/sec, scan delay was sec. results: in ( %) of patients chest injuries were detected. the following posttraumatic thoracic injuries were revealed: in patients ( %) emphysema, in ( %) hematoma of chest wall; in patients ( . %) fracture of the thoracic spine, ( . %) fractures of the ribs, ( . %) of clavicle, ( . %) of sternum, ( . %) of scapula; ( %) patients had a pneumothorax, ( . %) a hematothorax, ( . %) a tension pneumothorax; patients ( . %) had a lung contusion, ( . %) a lung laceration; patients ( %) had a pneumomediastinum; ( . %) a rupture of thoracic aorta; ( . %) rupture of a supraaortal ar tery and ( . %) a rupture of diaphragm. no injuries of tracheobronchial system, esophagus or the heart were detected. conclusion: a standardized msct examination protocol represents the preferred screening method in the evaluation of patients who have sustained chest trauma. purpose:to find out important ct findings for the prediction of prognosis of thymoma with a survival analysis. materials and methods: patients with thymoma, who underwent surgical resection, were retrospectively analyzed. clinical data were collected from chart review. preoperative plain and contrast enhanced ct was performed in all patients. two independent chest radiologists evaluated ct images paying special attention to diameter, contour, shape, cystic or necrotic portion, calcification, mediastinal fat obliteration, invasion of adjacent mediastinal structure, thickening of adjacent pleura, infiltration of adjacent lung, infiltration of adjacent chest wall, pleural effusion, pericardial effusion, mediastinal lymphadenopathy, enhancement pattern, and degree of enhancement. kaplan-meier survival curves were generated. influence on survival for each ct finding was analyzed by logrank test. results: cystic or necrotic portion, calcification, mediastinal fat obliteration, invasion of adjacent mediastinal structure, thickening of adjacent pleura, infiltration of adjacent lung, infiltration of adjacent chest wall, pleural effusion, pericardial effusion, mediastinal lymphadenopathy, homogeneous enhancement pattern and high degree of enhancement were seen in %, %, %, %, %, %, %, %, %, %, % and % of patients respectively. the ct finding that were most predictive of survival was calcification (logrank test: p = . ). cystic or necrotic portion (p = . ), infiltration of adjacent chest wall (p = . ), and pleural effusion (p = . ) were independent predictors of long-term survival. there were no differences in survival for the other findings. conclusion: calcification, cystic or necrotic portion, infiltration of adjacent chest wall, or pleural effusion on ct suggest poor prognosis of thymoma. b d e f a g low attenuation splenic lesions found at chest ct: differential diagnosis and investigation a.k. choudhary, e.l. senior, n.j. screaton; cambridge/uk learning objectives: . to illustrate the causes of low attenuation splenic lesions. . to discuss clinical and imaging features which aid diagnosis in patients with known or suspected malignancy. background: abnormalities of the spleen are commonly encountered during ct of the thorax and abdomen in patients with suspected thoracic disease, posing diagnostic difficulty particularly in patients with otherwise operable malignancy. we present a pictorial review of low attenuation splenic lesions in patients with suspected thoracic disease. the most common causes are benign (including pseudocysts caused by trauma, infection or infarction), infections (mycobacterial, fungal, hydatid), sarcoidosis, haemangiomata, and lymphangiomatosis. malignant causes include lymphoma and metastases (lung, breast, melanoma, stomach, liver, colon). in patients with known malignancy, splenic metastases are rare in the absence of widespread metastatic disease. although the morphological pattern on ct may suggest malignancy (multiplicity of lesions, irregular margins, enhancement and splenomegaly), other imaging studies may be complementary. on ultrasound focal anechoic lesions are typical of benign cysts while multifocal or diffuse solid lesions are suggestive of malignancy. on mri heterogeneous lesion signal is suggestive of malignancy. in cases where morphological imaging is non-specific, fdg-pet may play an important role. the accuracy of splenic biopsy in indeterminate lesions approaches % but significant complications occur in . %. conclusion: isolated low attenuation splenic lesions must not be considered synonymous with metastases even in patients with known cancer. awareness of the differential diagnosis and further imaging permit accurate diagnosis and management. evaluation . whole-body msct scan were performed using the following protocol: ) native head and neck: mm slice thickness, um mode, reconstruction . mm; ) administration of - ml nonionic contrast media using automatic injector at flow rate of ml/sec and smart prep feature; ) thorax, abdomen and pelvis scan: . mm slice thickness, us mode, reconstruction . mm; ) scan time under minute; ) images were used for mpr and d-vr. results: in management of polytrauma patients, time is of the essence. in high-risk patients who were selected for msct examination following injuries were found: cranial (sub and epidural hematoma, contusion, fracture etc); thoracic (hematothorax, lung contusion, pneumothorax etc); abdominal (contusion and hematoma of parenchymal organ, retroperitoneal bleeding); aortic (rupture, dissection, periaortal hematoma); fractures (mostly ribs - [ %] and pelvis - [ %]) conclusion: in our hospital msct represents the major diagnostic tool in the management of high-risk polytrauma patients, reducing time spent outside of emergency unit. it is a fast and reliable method for diagnosis of skeletal trauma, parenchymal organs and aortic injuries. the radiologist becomes important member of the trauma team in management of acute polytrauma patients. learning objectives: to illustrate the fundamentals of digital imaging, the basic operations of image display and manipulation, the principles of image compression and filtering. backgound: radiological scanners generate digital images and image interpretation is performed using dedicated workstations. the knowledge of digital imaging, image compression and filtering is crucial to understand the new technologies and the post processing operations. procedure details: the structure of a digital image, the encoding algorithm, the operations for image display and manipulation, and the compression algorithms are described. a phantom and clinical cases are used to show the influence of these aspects on the quality and information of the images. conclusion: several aspects affect the information and the quality of digital images. the basic criteria for assessing image quality are defined. web-based radiology-teaching library for board examination of radiologists with object-oriented database system n. we have developed a web-based radiology-teaching library for a board examination of radiologists in japan. this library receives imaging cases from all of japan via the internet. the web-based radiology-teaching library is developed with an object-oriented database, and it is readily available with a simple operation to radiologists. the submission process makes full use of the internet. the reviewers, who are expert radiologists, carefully review the submitted cases. when the reviewed case is sent back to the submitter with the reviewers' comments, the submitter should correct their text and images according to the reviewers' comments in order to obtain the reviewers' approval. the computer assists these processes automatically, and it enables submitters and reviewers to do collaborative work in registering cases without temporal or spatial restriction. finally, approved cases can be registered to our library. results: up to august , our radiology-teaching library has collected imaging cases in all subspecialties. in these cases, cases have been registered. in august , the board examination of radiologists in japan has been performed with selected cases from this library in all subspecialties. conclusion: our library is readily available to radiologists who do not have much computer knowledge. our web-based radiology-teaching library will be useful for the education of all radiologists. pacs: ergonomic considerations c.l. arnoldus, c.j. zylak, m. flynn; detroit, mi/us learning objectives: ergonomic issues associated with picture archivial and communication systems (pacs) should be addressed during the early phase of incorporation in the radiology department. this reviews how a large tertiary care teaching hospital addressed these issues. background: existing computer and alternator workstations in the radiology department were observed for six months. the radiologists were surveyed on workstation issues related to space, noise, lighting, and repetitive motion. a pacs ergonomic work group consisting of radiologists, physicists, and administrators accepted the task of addressing these issues and recommending solutions. procedure details: on non-ergonomic workstations, repetitive strain occurred. of the forty-one radiologists on staff, four who used computer workstations extensively had elbow and shoulder tendinitis from extended periods of reach while manipulating images with the mouse. carpal tunnel symptoms, neck strain from periods of flexion or extension, and eye fatigue were also experienced. alternators placed near monitors reflected light and ghost images on monitor screens. eye level evaluation of films was not possible with fixed monitor height. crowded workstations and alternators were observed. based on the findings, adjustable workstations with articulating keyboards, mousing surfaces with gel wrist rests, flat screen liquid crystal display (lcd) monitors, and multi-adjustable posture support chairs were evaluated. placement of view boxes and ambient lighting issues were addressed. adjustable height workstations for small group consultation and conferencing will be strategically located. voice amplification is being considered. conclusion: ergonomic issues should be identified early before pacs transition to allow a workplace design to maximize workflow and minimize repetitive strain. withdrawn by authors in any single patient we use the same position during each scan to get proper images coregistration. during body scans patients were instructed to breath freely, but not deeply, and not to move. we used a dedicated system for image fusion that combines volumetric information from pet, ct and mri to get proper coregistration in all cases. conclusion: metabolic and anatomical information can be combined precisely to asses anatomic locations of lesions and artifacts with proper coregistration obtained with separate scanners using dedicated software. background: current limitations with regard to medical image quality control and consistency have been discussed previously. we have recently suggested proposals to several american industrial and scientific bodies aimed to improve image quality performance criteria for both clinical and diagnostic images. although some regional and national guidelines and regulations exist, practical universal standards have not yet been achieved. procedure details: this exhibit shows how international radiology and technical societies, regulatory groups, and standards agencies may collaborate in order to improve medical image quality performance and standards, including but not limited to ( ) performance criteria for softcopy and hardcopy, ( ) extending communication and control standards for the performance of output devices, and ( ) initiation and support for research into the relationship between display physical metrics and diagnostic performance, to assess clinical consequences of variations in image quality metrics, and to define what constitutes image quality from a diagnostic perspective. the exhibit has presented some initial steps that will improve the consistency and reproducibility of medical images in electronic imaging systems. the international medical community has an opportunity to build upon the work of many regional and national efforts in a collaborative effort to improve medical image quality with anticipated benefits to patient care, medical practitioners, and the medical industry. b d e f a g modeling and simulation of the blood flow using multi-slice ct: application of computational fluid dynamics s. yamamoto , s. hamada , t. johkoh , s. murai , s. yoneyama , s. maruyama , n. tomiyama , m. komizu , h. nakamura ; osaka/jp, tokyo/jp learning objectives: to understand the prediction based medicine model using computer fluid dynamics (cfd). to support the informed consent of the patient using four-dimensional display. to describe the technical procedure of ct scanning for blood flow analysis. background: aortic aneurysms or dissecting aneurysms are serious and lifethreatening conditions that requires early diagnosis and prompt surgical treatment. it is difficult to directly measure the blood flow and pressure without invasive examination. computer simulation is one of the solutions for non-invasive diagnosis, or for comparison of pre-and post-operative measurement of the blood flow and pressure. in this exhibit we will describe the application of cfd based on four-dimensional vessel reconstructions from multi-slice ct data. procedure details: the volume data ( . - mm slice thickness) was acquired from half-second multi-slice ct (aquilion, toshiba, tokyo, japan). segmented vessels were converted surface display by marchine cubes method. input parameters of blood were applied as an ideal incompressible fluid. steady and transient analysis of cfd was performed using commercially available software (acusolve, acusim software, mountain view, ca) by a finite element method. original program modules for image processing of both vector and medical (di-com) data was implemented on a commercially available workstation (amira . , tgs, san diego, ca). variable dynamic display of both steam line of blood and blood pressure was superimposed on the three-dimensional ct data (multi planer reformat, maximum intensity projection and volume rendering etc) conclusion: modeling and simulation applications to the blood flow could enable us to build rapid prototypes of the models for quick visual validations. using remote asp and internet- for integrating digital radiological images with a regionalinformation system in a new population-based purchasing system for public healthcare provision o. barbero , j. guanyabens , c. rúbies , j. fernández , j. maideu , i. cerdà ; sabadell/es, vic/es to learn about the improvements in health care management due to the implementation of several integrated his/ris and pacs in a regional area.to learn how new technologies like java, internet , asp and remote image archival can be used to improve health care management and provision. background: a pilot project to evaluate the possibilities of digital radiology in the improvement of health care is underway within the framework of the catalan health service's strategic plan to establish a system in the county of osona(*), not far from barcelona (spain). the sharing of information forms the backbone of the project, the aim being to enable all authorized healthcare personnel to have -hour-a-day access to all digital information and images from examinations performed in all healthcare centers in the county, whether private or public. procedure details: for the evaluation and analysis: . improvements brought about in healthcare services; . organizational impact; . cost-benefit analysis; . elements to take into account for the system's implementation and extension. from the technological point of view: . remote asp archive; . high-speed internet- links; . information systems integration based on web, java, xml and dicom. the analysis and evaluation of the results of this innovative project and health care provision strategy will be presented in ecr. (*) the health care ministry will pay a fixed amount of money per person and per year to all the health care providers of the area in exchange for public health care services. a new parameter enhancing breast cancer detection in computer aided diagnosis of x-ray mammograms k. murase , n. tanki , m. iinuma , h. kubota , m. nagao ; osaka/jp, matsuyama/jp purpose: to introduce a new parameter enhancing breast cancer detection in computer aided diagnosis (cad) of x-ray mammograms. we used the database of mammograms generated by japan society of radiological technology. this includes patients with benign masses and patients with malignant masses. the age ranged from to years ( . ± . years). the new parameter called -dimensional fractal dimension ( d-fd) was obtained from the slope of the graph with the logarithm of the cutoff value on the horizontal axis and that of the number of pixels with a gray level above the cutoff value on the vertical axis. in addition to d-fd, the conventional image features such as eccentricity (e) and curvature (c) were extracted. the conventional fractal dimension (c-fd) was also calculated using the boxcounting method. the artificial neural networks were used as a classification algorithm, and a receiver operating characteristic (roc) curve and the area under the roc curve (az) were calculated to evaluate the diagnostic accuracy in the task of differentiating between benign and malignant masses. results: when using e, c, c-fd and age as inputs, the az value was . ± . . on the other hand, when d-fd was added to inputs in addition to the above parameters, the az value was significantly improved to be . ± . . the d-fd is a new parameter which can enhance breast cancer detection in cad of mammograms, because it is effective for discriminating between benign and malignant masses. web computed radiography: a solution for x-ray examinations in africa d. soft tissue tumor distributed decision support system m. robles, l. marti-bonmati, j. garcía-gómez, c. vidal; valencia/es purpose: to provide distributed decision support services in soft tissue tumor (stt) to assist the radiologist. previous studies have shown the capability of pattern recognition techniques to classify between benign/malignant character and different histological groups. methods and materials: radiologist access to the stt distributed decision support services is achieved using a graphical interface, with four windows that offers the main system functionalities areas: . access to local or distributed stt registers that contain the features to study. new data can be imported from microsoft access formatted files or other databases. . statistical analysis that provides the graphical representation and reports of statistical and evaluation information like probability distributions per class, correlation studies, roc curves. . graphical representation of stt registers provides graphical representation of stt features from the protocol, using pca-transformation, or feature selection. . automatic classification access to stt classifiers distributed web-services, developed with pattern recognition technology. results: a location independent and multi-platform system has been developed to provided decision support services for radiologists dealing with stt diagnosis. the system architecture considers the access from hospitals using local or distributed data and connections to clinical decision support servers. the nodes maintenance and upgrade are automatically controlled by the architecture. conclusion: this system helps radiologists with novel and powerful methods in stt diagnosis and characterization. it provides access to distributed data, statistical analysis, graphical representation and pattern recognition classification. grid technology will incorporate more facility, security and powered communications to the stt distributed decision support services. integration of broadband teleradiology into picture archiving and communication system (pacs) y. zhao, k. chen, z. yao, d. wu, z. pan, b. guo; shanghai/cn purpose: the availability of broadband wide-area networks (wans) facilitates a range of new applications in healthcare. teleradiology is increasingly integrated into picture archiving and communication system (pacs). this paper introduces a broadband telemedicine system for transmitting interactive audio and video signals, and high-quality medical images directly acquired from a hospital-wide pacs. methods: a high-performance telemedicine system was developed over the existing metropolitan broadband multimedia network in shanghai to exploit the possibilities offered by internet protocol (ip) over synchronous digital hierarchy (sdh) technology to support real-time tele-consultation for medical imaging. a trial session was held with two channels of fiber-optic connection transmitting real-time duplex audio/video signals and high-quality dicom images between rui jin hospital and shanghai international convention center, kilometers apart. the system enabled direct retrieval of dicom images from the pacs, and allowed to use interactive telediagnosis tools for image visualization and processing. results: during the teleradiology session, dicom images archived at the pacs were readily accessed without any loss of information. a number of functionalities of visualization software were utilized and tested, combined with real-time videoconference session. the system was proven robust, efficient and providing for high performance. conclusion: the broadband telemedicine system under study has given us a useful insight about the potential of applying broadband technology in healthcare, especially the performance of videoconferences with telediagnosis of radiological images. with the close integration of teleradiology into a hospital-wide pacs, it yields sufficient sound and image quality for remote educational and clinical collaboration. performance assessment of a wavelet contrast enhancement method in dense parenchyma based on simulated lesions s. skiadopoulos, l. costaridou, p. sakellaropoulos, c. kalogeropoulou, e. likaki, g. panayiotakis; patras/gr purpose: evaluation of an adaptive wavelet-based contrast enhancement method in dense parenchyma based on simulated radiopaque lesions. methods and materials: sixty normal mammographic images of dense breasts were selected from the ddsm database. simulated radiopaque lesions of known image characteristics, such as low contrast ( . %- %) and unsharp contour ( %- %), were generated and superimposed in dense breast areas. this resulted in a case sample that is difficult to achieve and verify with real lesions. all images with simulated lesions were processed by the wavelet-based method. evaluation was carried out by an observer performance comparative study between the wavelet-processed images and original ones. the sample was presented to three experienced radiologists, classifying each simulated lesion with respect to contour type, using a five-point rating scale. a binormal roc curve was individually fitted to the scores of each observer with a maximum-likelihood procedure and the area under the roc curve (a z ) as well as the % confidence interval were calculated, for each technique. results: combining observers' responses, the a z values are . and . and their corresponding confidence intervals are ( . , . ) and ( . , ) for wavelet method and original one, respectively. this difference in a z values is statistically significant (students' t-test, p < . ), indicating the effectiveness of the wavelet method. conclusion: improved contour characterization of low contrast simulated lesions sample is achieved with the use of the wavelet-based contrast enhancement method. use of simulated lesions sample servers for verification purposes, required to assess the performance of various digital image post-processing techniques. estimating the arterial compliance in early stages of atherosclerosis: evaluation of a new index on the curve-fitted doppler sonograms n. erdogan, s. kara, f. dirgenali, m. okandan; kayseri/tr purpose: to develop a computational method to define a new index to estimate the arterial compliance in early stages of atherosclerosis. the doppler data was obtained from a nonstenotic arterial site (carotid artery) in patients with femoropopliteal atherosclerosis (n = ) and healthy volunteers (n = ) using the audio output of a commercial color doppler ultrasound unit. the signals were transferred to a personal computer and two dimensional sonograms were plotted by fast fourier transformation. smoothing and curve-fitting operation is performed on the sonograms. a moving average method was used for smoothing and interpolant-cubic spline was processed to make curve-fitting. the time interval between the first transmitted peak (t ) and the second compliance peak (t ) in the arterial waveform was evaluated as a new index. our preliminary data showed no significant difference between healthy subjects and the patients with regard to the acceleration, resistivity and pulsatility indices, although a significant difference exists for the new index ( . ± . msec for patients vs. . ± . msec for healthy people). the proposed new index on the the curve-fitted fast fourier transformation sonograms seems to be promising in assessing the cardiovascular risk by detecting the degree of compliance in atherosclerotic vessel walls before the overt clinical symptoms develop. however, its efficacy and prognostic implications need to be confirmed by large scale studies. the contribution of virtual endoscopy (ve), in the imaging of the upper airways and tracheobronchial tree a. morichovitou, a. manolitsas, s. stratilati, i. tsitouridis; thessaloniki/gr purpose: the purpose of our study is to demonstrate the contribution of virtual endoscopy in the imaging of the upper airways and tracheobronchial tree. we studied cases, ( male and female, aged to years old, mean yrs), with tracheobronchial diseases. the virtual endoscopy images were compared with those of actual endoscopy in patients. the examinations were performed using a picker pq spiral ct scanner and a picker voxel q visualization workstation. thickness: mm, pitch: . , overlap: % ( mm). results: ct virtual endoscopy depicted the anatomical structure of nasopharynx, larynx, trachea, and main bronchi in all patients as the actual endoscopy. the results show that virtual endoscopy can study the tracheobronchial tree as far as the segmental bronchi, and sometimes the subsegmental bronchi (in patients). in addition, it can evaluate the extraluminal location of the lesions. lesions in patients were shown by virtual endoscopy ( occlusions, stenosis, compressions) and in patients the examinations were negative. the findings were always in agreement with those of the actual endoscopy and surgical findings. we studied the results of the two methods and describe the advantages and disadvantages of each of them. conclusion: virtual endoscopy can be used in the primary evaluation of the patient before actual endoscopy is performed. it can be used for preparing, guiding and controlling actual endoscopy or in the postoperative follow-up when immediate biopsy is not necessary. pancreatic duct imaging using the curved thin-slab minimum intensity projection method t. ogura , t. ikari , t. tachikawa , a. kamei , k. takano , s. asahara , n. fujita , m. shimizu ; maebashi/jp, tokyo/jp purpose: the recent wide use of curved mpr was applied for pancreatic duct imaging, but curved mpr requires a great deal of skill for the trace of narrowed and tortuous pancreatic duct. mis-tracing on pancreatic duct has led to various artificial images such as false pancreatic stenosis. so novel curved thin-slab minimum intensity projection methods have been employed to obtain correct pancreatic duct image. the purpose of this study is to explain the protocol, reconstruction method, and describe the potential advantages and various problems of this method in the diagnosis of pancreatic diseases. materials and methods: pancreatic duct image was reconstructed from three dimensional volume data using multidetector-row ct (qx/i, gems) scans. axial images were taken with . -mm collimation, a table speed of . mm/rot and . mm image reconstruction intervals. image processing was performed with the virtual place (m.i.lab). results: this method was successful in depicting a wide range of tortuous pancreatic ducts. also the narrowed pancreatic duct is easily visualized, and even branch ducts. the characteristic of this method is that we can easily make a pancreatic duct image quickly and with little dependence on expert technique. in abdominal studies, this method enabled the visualization of the narrow, bending pancreatic duct, reducing false pancreatic stenosis, and also could be applied for screening examination for anomalous union of pancreaticbiliary ductal system in the future. evaluation of the optimal scanning protocol for ct virtual endoscopy using a -slice scanner w. wojciechowski , w. de wever , a. urbanik , g. marchal , r. chrzan , j. kozub ; krakow/pl, leuven/be purpose: the objective of this study was evaluation of optimal scanning protocol for ct virtual endoscopy using a -slice scanner in a phantom study. methods and materials: using the mdct scanner somatom sensation (siemens, germany), ct-images of a phantom were performed, with diferent combinations of slice-thickness ( . , , , , mm), pitch ( . , , . ), slice-collimation ( x . and x . ) and reconstruction increment ( % and %). the phantom consists of simulated round lesions of different size (diameter between and mm) placed into a thin-walled plastic tube of -cm diameter. quantitative analysis was assessed by evaluation of changes in size and shape of the lesions and calculation of sensitivities. qualitative analysis was perfomed by evaluation of lesion's blurring of stairstep artifacts and rippling artifacts. results: overall sensitivity was % with slice thickness . , and mm and not dependent on pitch. the smallest lesions (diameter mm) were not detected with slice-thickness of and mm. image quality of endoluminal images was graded as optimal for slice-thickness . mm and mm. there was no statistical significant difference in quality using a different pitch in these images. however mild rippling artifacts were documented together with an increase in pitch value. conclusion: slice-collimation and slice-thickness are the most important parameters in selection of on optimal scan-protocol for ve: slice-collimation of x . and slice-thickness of mm seem to be optimal. pitch and increment are less important, although values of and % seem to be optimal. selection of optimal parameters is also depended on lesion size. automatic methods and materials: fully automatic and manual methods were developed and compared using in vivo studies. this tool allowed automatic determination of a region of interest (roi) with background correction. by means of this technique, a roi was set, corrections performed and calculation of different parameters (flow, stroke volume and velocity) and flow curves made. this tool was designed using matlab . (mathwork, inc, natick, usa) with a friendly graphical user interface. comparisons were performed by means of intraclass correlations (icc). this model was validated in patients, men and women, age range: - years-old. mr examinations were performed on a . -t system (gyroscan nt intera, the netherlands) with a phase contrast sequence. image parameters were as follow x matrix; fov, mm; mm slice thickness; tr msec, te , excitations, flip angle ° and cardiac phases with use of peripheral retrospective gating. the automatic method performed significantly better than the manual analysis, icc of . - . and . - . , respectively. at the same time partial volume effect caused by inclusion of stationary tissue was corrected. conclusion: automatic setting of roi flow measurements at the cerebral aqueduct is feasible with an adequate reproducibility. it makes the measurements independent of the radiologist, generalizing the calculus of flow parameters. virtual duodenoscopy on the basis of high-resolution mrcp data for the simulation of ercp procedures t. yamagishi , k.h. höhne , k. abe ; tokyo/jp, hamburg/de purpose: ercp has been regarded as one of the most difficult endoscopic procedures for a trainee because of a high possibility of technical failures. therefore, it is considered useful to prepare a rehearsal of ercp. we present a virtual duodenoscopy for practical ercp simulation. the hr-mrcp data sets are imported into the voxel-man program (institute of medical informatics, university hospital hamburg-eppendorf, germany). an interpolated movie of the duodenal inner surface is computed by tracing where the endoscopic tip goes through to the duodenal papilla following the actual ercp procedure. three orthogonal radiological planes of the source mrcp are integrated into the movies, which are showing the conic extent of the endoscopic viewing field. the usefulness of making a prior simulation for a successful ercp was evaluated. the post-processed endoscopic view is precise and realistic enough to execute a practical simulation of ercp, following the actual procedures step by step, e.g., which angle and position of the endoscopic tip is best for the cannula insertion into the common bile duct. the movie created can indicate an ideal approach to the duodenal orifice in exactly the same way performed by ercp experts. the radiological planes are useful as external images like x-ray fluoroscopy. a practical simulation of ercp can be performed by a combination of hr-mrcp data and the voxel-man interactive visualization program. the presented method can provide useful information prior to actual ercp. to review the physics of the interaction between the us beam, the "bubble" and the corresponding us image of the liver and portal system. to estimate the degree of portal hypertension through better visualization of collateral pathways using usca. background: a short historical review of the evolution of usca is followed by a detailed presentation of the physics and technology of recent usca. the interaction between the "bubbles" and the us beam is explained with analytical drawings and real-time us videos. procedure details: the technique and the protocol of the hemodynamic examination of the hepatic veins and the portal system are explained. a detailed anatomical review of the portal venous system is presented with special attention to the main collateral pathways present in cases of portal hypertension. the findings of imaging methods (us, ct, mr) as well as endoscopic methods are presented and their limitations are underlined. new non-invasive hemodynamic us imaging of the main collateral pathways (gastric and esophageal varices, splenorenal, splenogastric, retroperitoneal anastomoses, recanalization of the paraumbilical vein) are described and presented in images and videos after administration of second generation usca. c b d e f a g the benefits as well as the limitations of usca, including those caused by artifacts, are thoroughly discussed so that an unbiased conclusion on new diagnostic possibilities in the study of the portal hypertension can be drawn. clinical impact of liver specific contrast agents in liver imaging a. ba-ssalamah, m. uffmann, s. mehrain, s. schweighofer, w. schima; vienna/at learning objectives: to illustrate the usefulness of liver specific contrast agents in identifying morphological and functional features of focal liver lesions. to educate radiologists about new mr liver specific contrast agents and mr imaging techniques. to demonstrate the value of the combined use of liver specific and non liver specific contrast agents as a problem solving tool. background: liver specific contrast agents used in combination with non-specific gadolinium chelates may serve as a problem solving tool in the diagnosis of focal liver lesions. hepatic focal lesions with atypical imaging appearances usually need further assessment, namely biopsy, particularly in patients with history of malignant disease. liver specific contrast agents offer new opportunities for liver imaging and provide information about the functional and morphological features of focal liver lesion. currently a variety of contrast agents, subdivided in different categories are available for clinical use in mri of the liver. procedure details: in this exhibition, we describe the use of reticuloendothelial system-specific iron oxide particulate agents, hepatocyte-selective agents, nonspecific gadolinum chelates and the combined use of these contrast agents for a large variety of liver diseases.we distinguish between specific imaging characteristics for various liver diseases and nonspecific imaging characteristics that may be found in both malignant and benign focal liver diseases. the combined use of liver specific and non liver specific contrast agents is a valuable tool for the diagnostic work up of special focal liver lesions and may replace the invasive biopsy in the vast majority of cases. doppler rescue: a review of the use of ultrasound microbubble contrast agents in the visualisation of the large vessels k. satchithananda, m.e.k. sellars, s.m. ryan, p.s. sidhu; london/uk learning objectives: understanding of the types of ultrasound contrast agents available and nature of enhancement. understand when these agents could be used to improve diagnostic images and cost effectiveness. an appreciation of the clincial appearances of "doppler rescue" in different areas of vascular imaging. background: ultrasound (us) assessment of the vascular system remains an accurate imaging modality despite the advancement of magnetic resonance angiography. us allows real-time, multi-planar and safe assessment of the vasculature which is convenient to both operator and patient. limitations of us, es-pecially in the vascular system are well documented. full diagnostic doppler assessment is not always possible for a variety of reasons. color doppler assessment greatly improves vascular imaging and recent technical advances have further improved the capabilities of doppler us. a further important development is the introduction of microbubble contrast, which allows previously non-diagnostic studies to become interpretable and avoids further imaging: termed "doppler rescue". image findings: the use of microbubble contrast will be illustrated in the cerebral circulation using trans-cranial us, the extra-cranial carotid system, the liver vasculature, renal artery and the peripheral arterial system. conclusion: both color doppler enhancement and low mechanical index b-mode non-linear imaging will be demonstrated. one learning objectives: initial work-up of trauma patients is time-critical. diagnostic demands require different examination techniques including unenhanced and several contrast enhanced scans for musculoskeletal, angiographic and parenchymal diagnosis. -channel mdr-ct overcomes previous technical limitations, which used to require thickening of slices or segmenting for whole body coverage. we therefore developed a multi-phase contrast protocol allowing acquisition of musculoskeletal, angiographic and parenchymal organ information in a single scan. ct technique and contrast protocol, advantages and limitations of this procedure are described and illustrated. procedure details: consecutive trauma patients were examined on a channel mdr-ct (philips, mx idt). after exclusion of cerebral hemorrhage application of iodine contrast media ( mg iodine/ml, imeron , altana, germany) was started with a bolus of ml at a flow of . ml/sec, followed by a pause of sec. subsequently, a second ml contrast bolus ( . ml/sec) is followed by a saline chaser. the ct-scan is initiated with a delay of sec using a collimation of x . mm, slice thickness of mm and an increment of mm. results: this protocol provides excellent diagnostic image quality covering all issues of trauma work-up. within a table time of less then minutes all relevant pathologies were assessed as proved by further clinical follow-up. all fractures including two petrosal ones were detected. parenchymal pathology included lacerations of liver, spleen, and kidneys. all arterial and venous hemorrhages were diagnosed without the need of additional diagnostic work-up. intravenous, oral and, rectal contrast media for abdominal spiral ct examinations: when to use, how much, how fast, and when to scan a.n. chalazonitis , j. tzovara ; athens/gr, ioannina/gr leaning objectives: to optimise the choice of contrast media initiation parameters for abdominal single slice spiral ct examinations, tailored to each specific organ and to the most common clinical conditions. background: introduction of multi-slice spiral ct permitted greater flexibility in abdominal examinations. however single slice spiral ct still remains a powerful tool in routine imaging practice. procedure details: the aim of this exhibit is to describe lesion or organ behaviour before and/or after contrast material initiation in order to help the participant to understand why, when and how these agents should be administrated for optimal abdominal single slice spiral ct evaluation. contrast volume, flow rate and scan delay before initiation, are discussed. the influence of patient weight and circulatory parameters such as cardiac output and inflow obstructions on contrast enhancement will be also analysed. special techniques in order to achieve optimum gi opacification will be also discussed. purpose: to compare hepatic signal intensity change using superparamagnetic iron oxide (spio)-enhanced mr imaging with scintigraphy using technetium- mgalactosyl human serum albmin ( mtc-gsa) and a visual grading score, in patients with hepatic dysfunction. methods and materials: forty-six patients with hepatic dysfunction who underwent spio-enhanced mr imaging and scintigraphy with mtc-gsa were examined prospectively. in terms of clinical cirrhosis severity, patients were classified into four group; patients were classified as non-cirrhotic, were classified as group a, as group b, and as group c (child-pugh classification). on mr imaging, t -fast field echo (t -ffe) images were obtained before and after the administration of spio. to assess the effect of spio, post contrast relative reduction in signal-to noise ratio (reduction-snr) was calculated. the findings of mtc-gsa-scintigraphy were classified into types according to visual grading score. the clinical cirrhosis severity, reduction-snr, and visual grading score were analyzed with nonparametric methods. the clinical cirrhosis severity was positively correlated with visual grading score (spearman rank test, p < . ). there were significant differences between the clinical cirrhosis severity and the reduction-snr on t -ffe and between the visual grading score and the reduction-snr (kruskall-wallis test, p < . , all comparisons). the index of blood clearance (hh ) was positively correlated and the receptor index (lhl ) was negatively correlated with the reduction-snr on t -ffe (spearman rank test, p < . , all comparisons). conclusion: to evaluate the reduction-snr on spio-mr imaging is helpful in predicting not only kupffer cell function but also hepatic function as assessed by mtc-gsa-scintigraphy. are efficient contrast agents available for use with ultra-high field mr imaging? r.n. muller, p.a. rinck, l. vanderelst, a. roch; mons/be purpose: molecular mr imaging requires specific markers exhibiting high relaxivities at ultra-high fields ( - tesla). although there are theories on the design of optimal paramagnetic centers, actual relaxivities are still below expectations. methods and materials: measurements of relaxivites s - mm - ) to establish nuclear magnetic relaxation dispersion profiles of existing and possible future contrast agents were performed on two field cycling relaxometers and on a . t mr research machine. results: at high field, r and r of small gadolinium complexes are low and decrease; high-field relaxivities can be increased through reduction of molecular motion. to some extent, it is possible to increase the r of small dysprosium complexes. nmrd profiles of superparamagnetic particles reveal a high r /r ratio at ultra-high fields. however, one particle of nm contains around , iron ions, whereas one macromolecular complex contains one or a few gadolinium ions. assuming equivalent relaxivites, the gd complex should carry approximately , ions to present, per molecule, the same relaxivity as the magnetic particle which leads to a molecular weight increase of , . conclusion: for small complexes of dy, r can be modestly increased at high fields. both r and r of gd complexes can be enhanced at high fields by an increase of the molecular size, however, only r keeps increasing. superparamagnetic particles seem clearly more efficient. this fact will be of paramount importance in the context of molecular imaging. they will act as negative agents. results: the contrast ratios of rat abdominal aorta and portal vein on the first to fifth contrast imaging were higher for nms than those for gd-dtpa with every injection doses. the peak contrast ratios of aorta and portal vein for nms were . - . and . - . times as high as those for gd-dtpa. the renal excretion of nms was as fast as gd-dtpa. conclusion: nms showed stronger contrast enhancement for the rat vascular system, especially the portal vein and provided mr angiograms of higher image quality when compared with gd-dtpa at the same injection dose. d-fspgr imaging was performed before and after , , , , min. delineation of popliteal lymph node (pln) and lymph duct (ld) (extremity region, iliac, para aorti, thoracic duct) was examined.on the evaluation of ld, visual evaluation ("good visualization": ++, "visualization": +, "poor visualization": ±, "no visualization": -) was carried out. on pln, snr was calculated as follows: snr = si (pln)/sd (noise). results: in gd-dtpa ( , , ), gd-eob ( , ) and gd-bopta ( , , ), grading of ld from lower extremity region to para-aortic region was "good visualization" or "visualization". in gd-dtpa ( ), grade of ld from lower extremity region to para-aortic region was "poor visualization". on the other hand, using gd-eob ( ), gd-bopta ( ), we could see ld from lower extremity region to iliac region.we found only ld of lower extremity region in gd-dtpa-dea ( , ).these grades were "good visualization" or "visualization". each concentration besides gd-dtpa ( ), contrast enhancement of plns were very well. the pln almost showed peak value after enhancement for most cases ( / ) in five minutes. we saw pln very well after enhancement minutes later, and, at the time of gd-dtpa ( ), gd-eob-dtpa ( , ), gd-bopta ( , , ), gd-dtpa-doa ( , ), snr value was more than . conclusion: using hepatobiliary agents and extracellular agent we were able to do good mr lymphography. optimized iv contrast administration protocols for diagnostic pet/ct imaging t. beyer, g. antoch, s. rosenbaum, l. freudenberg, t. fehlings, j. stattaus; essen/de purpose: we compared different iv-contrast injection protocols for pet/ct-exams (dual-slice) to assess their efficacy in avoiding high-density artifacts on ct and subsequent false positives on corrected pet. methods: four groups of pet/ct-referrals ( mbq fdg at min pi) each were investigated with/-out iodinated contrast ( mg/ml) application: (a) without, (b) multi-phase / ml ( / . ml - ) cranio-caudally with s delay, (c) / / ml ( / / . mls - ) cranio-caudally with s delay, and (d) / ml ( / . mls - ) caudo-cranially with s delay. ct-based attenuation correction (ac) of the pet was applied routinely. ct image quality (iq) was graded (very good), (good), or (insufficient) by three radiologists. image quality and artifacts were reported for head/neck, thorax, and abdomen. two nuclear medicine physicians reviewed the ac-pet images for potential artifacts from iv-contrast without knowledge of the ct, and reported lesion-to-background (l/b) values for potentially related uptake on pet. all reviewers were blinded to the contrast protocol and patient names. results: average ct iq was poorest ( . ) for protocol a across all regions, but improved to . (b), . (c), and . (d). high-density (> hu) ct artifacts were introduced only in the upper thorax in % (b) and % (c) of the patients. mean l/b in corresponding artificial lesions was . and . , respectively, thus resembling false positives. protocol d resulted in artifact-free images. pet/ct iq increased in the presence of iv-contrast agents. highdensity artifacts from bolus injection may lead to false positives on ac-pet. the artifacts can be avoided by alternative contrast administration protocols (e.g. d). contrast enhanced ultrasound in the evaluation of hepatic metastases treated using radiofrequency ablation: hours, and months follow-up assessment g.a. vorkas, i.a. chryssogonidis, c.a. papadopoulos, e. syndouka, k. lytras, l. grassos; thessaloniki/gr purpose: this study evaluates the importance of periodic follow-ups in the assessment of hepatic metastases treated with radiofrequency ablation (rf) using contrast-enhanced sonography. materials and methods: hepatic metastases in selected patients were included in our study. all lesions were studied with ce-us using real-time, continuous scanning with esaote esatune equipment with the cnti software, enabling non-destructive imaging at low mi, following intravenous bolus administration of . ml of a second-generation agent (sonovue-bracco). the enhancement patterns of lesions were assessed during the arterial, portal and late phases. the examination was conducted pre-ablation, hours, month and months after thermoablation. purpose: an up-to-date study showed that for high-risk patients the nonionic, dimeric radiographic contrast medium (rcm) iodixanol had less nephrotoxicity than the nonionic, monomeric rcm. the lower incidence of secondary effects is often attributed to the lower osmolality of the dimeric rcm. to compare the effect of dimeric iotrolan to monomeric iohexol and iomeprol independently of their osmolality, we have modelled the vascular activity of the rcm. in an organ bath, isolated segments of porcine renal arteries, uncontracted or precontracted by micromol/l phenylephrine, were incubated with increasing concentrations of iotrolan- , iohexol- , iomeprol- and mannitol solution iso-osmolal to the rcm. results: expressed in terms of concentration of iodine in the buffer as well as in terms of concentration of the rcm-molecule in the buffer, iotrolan induced a significantly lower relaxation than the monomeric rcm (p < . ). there was no significant difference between the two monomeric rcms iohexol- and iomeprol- (p > . ). the iso-osmolal formulation iotrolan- induced a smaller relaxation than the iso-osmolal formulation of iomeprol- (p < . ). precontracted segments were strongly relaxed by all the rcms as compared to mannitol (p < . ). iotrolan had no significant effect on the basal tone of the vessel whereas iohexol and iomeprol induced a small relaxation effect. conclusion: independently of its osmolality and dilution effect, dimeric iotrolan causes less relaxation of isolated, precontracted segments of porcine renal arteries than monomeric iohexol and iomeprol. this effect can be attributed to the different biological properties of the monomeric and dimeric rcm-molecules. ultrasound contrast agent in the study of traumatic splenic rupture g. caruso , g. salvaggio , g. bellissima , v. ricotta , g. ascenti , r. lagalla ; palermo/it, messina/it purpose: to evaluate the role of ultrasound contrast agent (uca) in the identification of traumatic splenic lesion. materials and methods: from may to july , consecutive patients were admitted to the emergency department for blunt abdominal trauma. ultrasound examinations were performed with an atl-hdi machine with a - mhz convex trasducer capable of fundamental and harmonic imaging. patients were studied before and after uca ( . ml of sonovue®). multi-detector computed tomography was used as the gold standard. all examinations were performed within hours. results: ninety seconds after uca administration, homogeneous contrast enhancement of the whole of the splenic parenchyma was observed in patients. in four patients, no contrast enhancement was observed in a subcapsular splenic area: inferior splenic pole (n = ) and mid-portion of the spleen (n = ). multidetector ct performed in the portal venous phase confirmed traumatic splenic rupture in four patients, and showed an unremarkable spleen in the remaining patients. conclusion: ultrasound after sonovue administration is useful in showing traumatic splenic rupture. contrast-enhanced, wide-band phase-inversion harmonic power doppler imaging of hepatocellular carcinoma j.r. janica; bialystok/pl purpose: to determine whether examination of hepatocellular carcinoma by wideband, pulse inversion sonography offers excellent accuracy in depiction of specific characteristics of these pathologies. b d e f a g eighteen patients were examined. the presence of hcc was confirmed by ultrasound-guided biopsy or surgical resection. all patients, prior to enhanced sonography, had undergone b-mode gray scale sonography, color doppler, and power doppler examinations. after injection of . g of levovist intravenously, analysis of contrast agent arrival was performed by wide-band, pulse inversion power doppler sonography. the b-mode gray scale sonography, color and power doppler sonography were non-specific for hcc in cases in our examination. however, based on the wide-band, phase inversion power doppler sonography findings, all patients with hcc were diagnosed. all typical anatomical features of hcc as chaotic appearance with irregular paths, breaks in calibre and arteriovenous shunts were clearly visible. in cases, computed tomography had failed to disclose pathology while pulse inversion sonographic images were completely suggestive, which was later finally confirmed by histologic examination. conclusions: our data demonstrates the usefulness of wide-band, phase inversion power doppler sonography in the diagnosis of hepatocellular carcinoma by visualizing all characteristic anatomical details. characterization of small liver lesions with contrast enhanced harmonic sonography (ceus) in patients with chronic liver disease p. cabassa, r. taranto human comparative study on zinc and copper excretion via urine after administration of magnetic resonance imaging contrast agents j. kimura, t. ishiguchi, j. matsuda, a. nakamura, s. kamei, k. ohno, k. murata; aichi/jp purpose: to evaluate the in vivo kinetic stability of magnetic resonance (mr) imaging contrast agents, excretion of zinc and copper via urine were studied for three gadolinium (gd) chelate complexes. methods and materials: urine samples were taken before, three hours, and six hours after intravenous administration of gd-dtpa-bma, gd-dtpa, and gd-dota at . mmol/kg to each of five patients who underwent contrast-enhanced mr imaging. five patients who had non-contrast mr imaging were evaluated as controls. urine was assayed for quantitative analysis of zinc and copper using atomic absorption analysis. results: gd-dtpa-bma caused the highest increase in zinc excretion among the three agents, ± µg at hours and ± µg at to hours. gd-dota did not cause a significant increase in zinc excretion, ± µg at hours and ± µg at to hours. gd-dtpa caused moderate increase in zinc excretion, ± µg at hours and ± µg at to hours. excretion of copper did not show a significant difference between the three agents. the difference in zinc excretion among the mr contrast agents reflects in vivo transmetallation of the gd chelate complexes and correlates with the respective stability of the contrast agent. gd-dota was found to be the most kinetically inert among the three agents tested. effect of contrast material pushed with saline solution using a dual injector on enhancement of abdominal aorta, portal vein, and liver parenchyma in multidetector row ct of the liver f. tatsugami low-high and high-low biphasic injection forms in ct examinations of the upper abdomen l. martí-bonmatí, e. tobarra, e. arana, s. costa; valencia/es purpose: our objective was to analyze the influence of different biphasic injection rate protocols in abdominal ct. a double-blind, randomized, parallel group study was designed and conducted in patients without differences regarding gender, age and weight. all of them were studied with the same ct helical protocol. patients were randomly distributed into three groups: a) monophasic ( ml at . ml/s); b) low-high biphasic ( ml, the first ml at a rate of ml/s and the other at . ml/s); and c) high-low biphasic ( ml, the first ml at a rate of . ml/s and the other at ml/s). all the patients were injected, through an antebrachial route, with mg i/ml non-ionic contrast media. all ct scans were obtained at the portal phase with a fixed delay time of seconds. contrast enhancement was evaluated by attenuation coefficients measurements at liver, inferior cava and portal veins, renal cortex, superior aorta and aortic bifurcation. results: the biphasic protocols obtained statistically higher enhancement at the aortic bifurcation (anova, p = . ). however, there was no other statistically significant difference (anova, p > . ) among the three protocols at the different levels. although non-significative, enhancements following monophasic protocol were always higher than those obtained with biphasic protocols, with the exception of aortic bifurcation. conclusion: monophasic injection of contrast agents on helical ct of the upper abdomen gives higher enhancement of parenchymal and venous structures. no significant difference was observed between low-high and high-low biphasic protocols. quantitative analysis showed a statistically significant difference between si of myometrium on plain and sinerem-enhanced mr images assessed by means of t-test. c/n between lesion and normal myometrium significantly increased following sinerem administration. in four patients sinerem-enhanced images provided additional information leading to more accurate t staging. conclusions: intravenous injection of sinerem provides a significant decrease of si of normal myometrium with higher c/n between neoplastic lesion and normal myometrium. sinerem-enhanced mri provides better evaluation of myometrial neoplastic invasion increasing the conspicuity of neoplastic lesions in patients with endometrial and cervical carcinoma. further studies are necessary in order to realize the physiologic mechanism of myometrial uptake of sinerem. purpose: verification of radiological methods with histology has always been difficult due to poor correlation of slice thickness, orientation and confinement to two dimensions. a method for a quantitative three-dimensional reslicing of histological sections is introduced (patent pending epa . ) permitting exact matching of slice geometry. this will enable proper correlation with radiological data. hacatras tumor (mouse) were examined by acquiring dynamic t -weighted mr images and mr microangiography. the tumors were subsequently serially sectioned ( ìm slice thickness) and vessels stained with immuno-fluorescence markers. slices were digitally captured with a microscope, assembled in the sectioning plane and co-registered in the vertical axis. a ray-tracing algorithm performed three-dimensional visualization allowing the virtual re-slicing of the histological sections to create thick-slices ( . mm) in accordance with mri slice geometry. thick-slices were processed as parameter-maps of marker volume density, giving information beyond the area density signal of immuno-fluorescence images. results: d-reconstructions of immuno-fluorescence images displayed diffuse angioarchitecture which is typical for malignant tumors. resliced images revealed the exact architecture of vessel structures seen on mra. also, large single vessels could be clearly delineated on reconstructions. parameter maps of vessel density in virtual thick slices matched well with mr-parameter maps. the quantitative d approach to histology essentially improves correlation of histological and radiological data due to proper matching of slice geometry. as this new method can be used with any histological stain, it provides a tool for verification of new molecular imaging techniques by means of histology. monitoring a human fibrosarcoma (ht ) was implanted in nude mice and grown up to a size of - mm. tumor bearing animals were intravenously injected with a vascular targeting agent (vta) inducing selective thrombosis of tumor neovasculature (treatment group) or saline (controls) respectively. mri ( . t) was performed using an ultrasmall superparamagnetic iron oxide agent (uspio, shu c, schering®) hours after initiation of treatment. iron oxide-induced change in r * (∆r *) was measured using a t w dual echo-epi sequence. ∆r * values of tumor tissue were calibrated by ∆r * of muscle for determination of the vascular volume fraction (vvf). parametric ∆r *-maps were calculated for visualization of tumor perfusion patterns. correlative immunhistochemistry was performed for assessment of the treatment effects in both groups. results: ∆r *-maps revealed a clear reduction of tumor perfusion in treated animals compared to controls. anti-angiogenic tumor treatment resulted in an approximate % decrease of iron oxide induced susceptibility effects. vvf was significantly reduced after injection of the thrombogenic peptide ( the in vivo detection of arthritis by autofluorescence using an antigen-induced arthritis (aia) model was investigated. material and methods: for autofluorescence investigations of joints, a mobile fluorescence-detector was designed consisting of a lens/mirror system attached to a conventional spectrofluorometer and of optimized fiber optic cables leading to and from the site of investigation. measurements were performed in arthritic and healthy mice. aia-and healthy mice were used for histological examinations. results: at the exudative stage (day ) of aia, a decrease of fluorescence signal intensities (arbitrary units, a.u.) for excitation wavelengths of nm (emission at λ = - nm; mean signal intensity . ± . a.u.) and excitation at nm (emission at λ = - nm; mean signal intensity . ± . a.u) were observed. signals increased on day (maximum of cellular infiltration; mean signal intensity . ± . for λ exc = nm and . ± . for λ exc = nm). chronic inflammation (day and ) led to a signal decrease again. signal intensities of nad(p)h differed significantly (p ≤ . ) from controls at days and . conclusion: arthritis influences autofluorescence signals in-vivo. the detected excitation/emission pairs can be assigned to collagen/elastin and nad(p)h. autofluorescence of nad(p)h can be a helpful tool for detecting arthritis noninvasive and in real-time. postpartum uterus: what is normal? what is pathological? evaluation with ultrasound and ct i. escape, j. martinez, f. bastart, l. ortega, c. solduga; barcelona/es learning objectives: to know the normal findings, mean diameters and evolutive changes in postpartum uterus and uterine cavity, in early, middle and late puerperium with ultrasound and ct. to differentiate them from pathological conditions. background: the majority of postpartum patients undergo an unremarkable clinical course. a small percentage of patients develop serious complications in the abdomen and pelvis. endometritis, the most common cause of fever in the postpartum period, complicates - % of vaginal deliveries and up to % of cesarean sections. post partum hemorrhage is most often caused by uterine atony and retained products of conception, and complicates - % of vaginal deliveries. imaging findings: in early puerperium, uterus is most often retroverted and empty with fluid and debris in the cervical area. intrauterine cavity increases on days - post partum with fluid and debris in the whole cavity and it may be normal to see an intracavitary echogenic mass. ap diameter of the uterus diminishes progressively in - weeks. endometrial gas is occasionaly visualized after normal vaginal delivery in the immediate puerperium and disappears within - weeks. it can be difficult to differentiate from endometritis, which can progress to pelvic inflamatory disease. endometrial stripe decreases during puerperium; if it remains thickened, complications such as retained products of conception or hypotonic uterus may be suspected. doppler us can be useful for differentiating between them. we describe these features with ultrasound and ct. conclusion: it is important to recognize normal postpartum uteral findings in order to differentiate them from pathological conditions. pelvic floor dysfunction: interest of mr imaging of ortheses and prostheses j. villeval , m. de graef , r. guillon , c. courtieu , a. maubon , j. rouanet ; montpellier/fr, limoges/fr learning objectives: to display the mri appearance in static and dynamic conditions of intra-vaginal device and post surgical procedures used for the treatment of pelvic floor dysfunction. background: we retrospectively analysed mr exams performed before and after surgical treatment and mr exams without and with intra vaginal device of patients with pelvic floor dysfunction: urinary incontinence (tension-free vaginal tape n = , artificial urinary sphincter n = , intra vaginal device n = ) and pelvic prolapse (intra vaginal device n = , promontofixation n = , prosthetic b d e f a g plaques permacol and polypropylène in recto-vaginal and uretro-vaginal wall n = ). mri consisted of t turbo spin echo, t turbo spin echo and dynamic single shot sequences. imaging findings: we will show the mri appearances of the devices in static and dynamic conditions. prosthetic plaques and tension-free vaginal tape appear as low signal intensity structures which are difficult to visualize compared to promontofixation, artificial urinary sphincter and intra vaginal device. mr imaging represents a good functional post operative evaluation for prosthetic plaques and intra-vaginal device in pelvic prolapse with dynamic studies especially in cases of suboptimal post treatment outcome. conclusion: a radiologist involved in pelvic mri should be aware of the various surgical treatments of pelvic floor dysfunction in order to avoid misinterpretation and evaluate their functional results. mri allows detection of complications for a better collaboration between radiologist and pelvic floor surgeon. pathologies of the uterine endometrial cavity: usual and unusual manifestations and pitfalls on magnetic resonance imaging m. takeuchi background: the endometrial cavity may demonstrate a spectrum of imaging manifestations ranging from normal, to that of a reactive, inflammatory, and benign and malignant neoplastic cause. imaging findings: thickened endometrium or endometrial mass included benign endometrial hyperplasia or polyps, endometrial carcinomas or carcinosarcomas, and gestational trophoblastic diseases. hyperintensity similar to the endometrium suggested rather benign hyperplastic lesions. hyperplasia or polyps associated with adjuvant tamoxifen therapy tended to be large masses with cystic changes and prominent stromal proliferation. myometrial thinning suggested malignancy but was occasionally overestimated because of the fragility of the myometrium with adenomyosis. submucosal leiomyoma with edematous change may mimic endometrial mass, and demonstration of the continuity to the myometrium was the clue to its myometrial origin. uterine sarcomas may involve endometrial cavity, and endometrial stromal sarcomas often showed endometrial masses with characteristic myometrial invasion. adenomyomatous endometrial polyp may simulate endometrial stromal sarcoma due to arborescent smooth muscle components which resemble the preserved bundles of myometrium within the tumor on t -weighted images. fluid collection in the cavity was well visualized on mri to distinguish between hydro-, pyo-, and hematometra. conclusion: to recognize various imaging findings of the uterine endometrial cavity; it is important to make a correct preoperative diagnosis to avoid unnecessary or excessive surgical intervention and to preserve the fertility of the patients. learning objectives: to demonstrate wide variations of the fluid collection in the female pelvis with pathophysiologic correlation and evaluate the diagnostic clues to the differential diagnosis. background: there are various situations with fluid collection in the female pelvis. although physiologic ascites is often observed in the reproductive era, other pathophysiologic fluid collection with both benign and malignant conditions may occur. imaging findings: mucinous ascites with organ scalloping in pseudomyxoma peritonei is characteristic. hemorrhagic ascites, which shows high attenuation on computed tomography (ct) and is well visualized on magnetic resonance imaging (mri) may be observed with malignant tumors, adnexal torsion or ruptured endometriosis. lactate detection on magnetic resonance spectroscopy (mrs) may suggest its malignant condition. non-neoplastic diseases such as ovarian hyperstimulation syndrome, pelvic inflammatory diseases, endometriosis, adnexal torsion and massive ovarian edema may cause accompanying fluid collection with adnexal enlargement. benign tumors may cause ascites, such as meigs' and pseudo-meigs' syndrome, and malignant tumors may cause carcinomatous peritonitis with fluid collection. ascites in postmenopausal woman is an unnatural finding and may suggest adhesion due to old inflammation or surgical procedure, or existence of hidden neoplastic disease. ascites in a tumor-bearing woman may suggest an advanced stage of disease with occult tumor implants. localized fluid collection like peritoneal retention cyst is observed in adhesive pelvis after surgery, inflammation or endometriosis with characteristic contour shape. conclusion: to evaluate the nature or biochemical components of ascitic fluid by mri and mrs may be helpful for the differential diagnosis. recurrent ovarian cancer: patterns and spectrum of imaging findings m. moon, s. kim, j. cho, y. lee; seoul/kr learning objectives: to illustrate the spectrum of imaging findings of the recurrent ovarian cancer. background: ovarian cancer is the most common cause of death among the gynecological malignancies. the treatment of ovarian cancer has traditionally been initial surgical staging and cytoreduction, followed by adjuvant chemotherapy. then, a second look operation is performed to reassess the tumor status after first line chemotherapy. once pathological complete response is defined, the management of ovarian cancer depends on non-invasive methods such as serology and cross sectional imaging. on the follow-up evaluation, identifying patients with minimal recurrent disease is important as it provides the best chance for complete clinical response and long-term survival following second-line chemotherapy. imaging findings: recurrent ovarian cancer usually manifests as local recurrence, peritoneal seeding and nodal recurrence. vaginal stump recurrence is the most common manifestation of the local recurrence. peritoneal seeding presents as ascites, peritoneal enhancement, peritoneal nodularity, and/or mesenteric infiltration on cross sectional imaging. nodal recurrence is most commonly seen in the external iliac group, which is not the presumed site based upon anatomic studies. although hematogenous dissemination is less frequently seen in the recurrent ovarian cancer, hepatic or pleuropulmonary involvement is a relatively common manifestation of hematogenous spread. the unusual manifestations of hematogenous dissemination include metastases in the extrahepatic abdominal solid organs, bone, central nervous system, and abdominal wall involving subcutaneous fat or muscle. conclusion: familiarity with the patterns and spectrum of imaging findings of recurrent ovarian cancer will facilitate accurate diagnosis and prompt treatment. ing of cervical carcinoma. the particular advantages of mri over ct include its multiplanar imaging capability and its superior depiction of soft tissue planes. accurate staging of cervical carcinoma at presentation is essential from the point of view of prognosis and also for management planning, as patients who present with stage iia or lower grade carcinoma proceed to surgery, and those with higher grade tumours are treated primarily with radiotherapy. recurrent disease is also best depicted using mri. patients can present with or develop a wide variety of complications as a result of their tumour and mri can be of particular advantage in the investigation of local complications. imaging findings: this educational exhibit illustrates the mr imaging findings of cervical carcinoma of all grades. we also demonstrate the mr imaging features of a wide variety of local and distant complications, including local invasion, fistula formation, small bowel obstruction and obstructive hydronephrosis. conclusion: mri is the imaging modality of choice for the diagnosis and staging of primary cervical carcinoma. it is also of benefit for the investigation of disease related complications and for the investigation of recurrent disease. the most common is serous papillary carcinoma. these tumors can show totally solid appearance, but mainly solid mass with some cystic portions is more common. they have unique imaging findings especially on mr in that papillary masses with branching pattern are frequently accompanied by peritoneal seeding masses. serous surface papillary carcinoma of the ovary, a distinct subtype of these tumors, is mainly located on the surface of the ovary. sometimes normal ovaries can be found inside papillary masses on mr, which is a very unique and striking appearance. brenner tumor and endometrioid carcinoma are another subtypes of epithelial tumors that can show solid appearance. extensive calcifications can be found in some solid brenner tumors. endometrioid carcinomas are sometimes accompanied by endometrial pathologies including endometrial carcinoma. conclusion: knowing these characteristics can help make correct diagnosis on ct and mr, especially differential diagnosis with metastatic tumors. wide spectrum of uterine leiomyomas mr imaging: radiologic and pathologic correlation h.k. kim; seoul/kr learning objective: to provide an in-depth review of uterine leiomyomas with their epidemiology, histopathology, clinical manifestations and the most up-todate therapy. to describe radiologic feature of usual and unusual appearance of uterine leiomyomas on mr image and histopathologic correlation. to discuss differential diagnosis of uterine leiomyomas from gynecologic and non-gynecologic disorder. background: leiomyomas are the most common uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue. imaging features of uterine leiomyomas vary depending on tumor size, location, degeneration and other histologic findings, and specific types of unusual leiomyomas. uterine leiomyomas are classified as submucosal, intramural or subserosal. the common types of degeneration are hyaline (> % of cases), cystic, myxoid, red and hemorrhage. degenerated leiomyomas have variable appearances on t -weighted and contrast-enhanced images. specific types of unusual leiomyomas include lipoleiomyoma and myxoid leiomyoma, which have characteristic mr findings enough to differentiate from other gynecologic and nongynecologic disease. the differential diagnosis of leiomyomas includes adenomyosis, solid adnexal mass, focal myometrial contraction, and uterine leiomyosarcoma. the purpose of this exhibit is to provide in-depth review of epidemiology, histopatholoy, clinical manifestations and differential diagnosis. this exihibit will also reflect our experience in radiologic evaluation of patients with leiomyomas, with emphasis on the typical and atypical findings on pelvic mri. examples of unusual uterine leiomyomas, pathologic correlation as well as the most up-to-date therapy will be included. after interacting with this exhibit the radiologist will have enhanced understanding of uterine leiomyomas including histopathology and radiologic features. experience of mri in women with suspected and known endometriosis: a pictorial review r. benamore, l. grosvenor, a. liddicoat; leicestershire/uk learning objectives: review of imaging features in women with endometriosis since introduction of a . t magnetic resonance (mr) scanner. women were referred when they did not wish to undergo laparoscopy or where surgical intervention and visualisation was difficult. background: endometriosis affects women during the reproductive years between and , with an estimated prevalence of - %. presentation range from pain (symptoms and severity do not correlate) to asymptomatic (diagnosed during infertility investigations). endometriosis (functional glands and stroma outside normal endometrium) is characterised by deposits, endometriomas (cysts) and adhesions, commonly ovarian but is documented to involve any site within the peritoneum and extraperitoneum. mr is noninvasive with high sensitivity and specificity, small foci appearing hyperintense on t and variable signal on t weighted images. endometriomas (> cm) appear hyperintense on t and hypointensity on t , with hyperintense foci on t dependant on age of haemorrhage. fat saturation sequences are essential to improve lesion conspicuity on t . we reviewed all women referred for investigation of suspected endometriosis, and for evaluation of disease extent and sites (notably recto-vaginal pouch) in known cases of endometriosis. procedure details: sequences used were axial t , sagittal t , axial oblique fat saturation (tirm) and narrow section coronal t imaging. mr identified endometriosis involving ovaries, bilateral thick walled and unilateral endometriotic cysts, extra-ovarian disease within peritoneum and soft tissue. fibroids and simple ovarian cysts were common, with evidence of concurrent endometriosis. conclusion: mr detected small foci of endometriosis outside of the ovaries. there was a high incidence of other gynaecological pathologies allowing early review and treatment. d transvaginal sonography in uterine leiomyomas with hysteroscopic and pathomorphological correlation v. gazhonova, k. sokolskaya, t. kurganskaya, a. zubarev; moscow/ru purpose: to determine the possibilities of d transvaginal (tv) sonography in preoperative assessment of uterine leiomyomas and to correlate the findings with hysteroscopic, laparoscopic and macroscopic data. method and materials: women with symptomatic uterine leiomyomas were evaluated before myomectomy and hysterectomy. multiplanar images of the uterus were created in d tvs. preoperative location of the leiomyomas, and interactions with uterine cavity, cervix and iliac vessels were assessed in each case. us results were compared with hysteroscopy in pts, laparoscopy in , open surgery in and pathomorphology data in pts. results: surgical management was changed after d tvs examination in cases. d coronal images allowed better location of the submucous and centripetal leiomyomas especially in multiple closely lying fibromyomas. d tvs results correlated with hysteroscopy in % ( / ) of cases vs. % ( / ). d power doppler tvs provided precise evaluation of the pedunculated submucous and subserous leiomyomas thus enabling adequate myomectomy. in comparison to macroscopic data of the uterus, d tvs were superior to d tvs in differentiation of the type of leiomyomas in % vs. % of cases, and in assessment of the interactions with the cervix in % vs. %. multiplanar reconstruction of the coronal planes on d tvs improved determination of the uterine cavity interactions with large subserous-interstitial leiomyomas before laparoscopic myomectomy. conclusion: d tvs is a useful complement to d tvs in preoperative assessment of leiomyomas. accurate evaluation of the leiomyomas on d mpr can decrease the possibilities of intraoperative hemorrhage and uterine trauma. b d e f a g treatment of the symptomatic large and multiple uterine fibroids by uterine artery embolization s. speca, a.m. costantini, c. di stasi, g. tropeano, v. summaria, p. marano; rome/it purpose: to evaluate the potential usefulness of uterine artery embolization as an alternative to traditional surgery (hysterectomy or myomectomy) for the treatment of symptomatic large or multiple fibroids. material and methods: premenopausal women, aged - years (mean age . ), who presented with menorrhagia, pelvic pain, and/or mass-related symptoms due to large (< or = cm) or multiple fibroids (> or = cm) and were unwilling to undergo surgery or had an increased surgical risk, underwent bilateral uterine artery embolization. before embolization all pts underwent to a complete clinical examination, a basal fsh and estradiol dosage, a vaginal and ureteral tampon, a papanicolau test, a trans abdominal and trans vaginal ultrasonography and color doppler flowmetry. for embolization we used polyvinyl alcool particles, embosphere or spongostan. detailed clinical and ultrasound follow-up were obtained at regular intervals ( - months). the procedure was technically successful in / patients. a mean clinical follow-up of months for pain, mass-related symptoms and menorrhagia was done. % of the patients treated reported a marked to complete symptomatic improvement. only patient experienced no changes in her symptoms. nobody had immediate or late complications. a median reduction of % in the uterine volume and a median decrease of % in the dominant fibroid volume were observed in patients who had follow-up ultrasounds for up to months. conclusions: in our experience artery uterine embolization may provide an important therapeutic alternative for women with symptomatic large or multiple fibroids who desire to avoid surgery. how to conduct quantitative evaluation of uterine neoplasms using gddynamic contrast-enhanced mri k. hayasaka, y. tanaka materials and methods: women with histopathologically proved cervical carcinoma underwent preoperative t -weighted fast spin-echo, dynamic imaging using gradient-echo and postcontrast t -weighted spin-echo mr imaging with a phased-array surface coil. the axial plans in each sequence were reviewed at separate sessions by three radiologists blind to the histopathologic data. results: for the conspicuity of tumor, dynamic and t -weighted images showed high detectability more than postcontrast t -weighted images. most appropriate enhancing time in dynamic study was seconds. in assessing parametrial invasion, the accuracy of t -weighted, dynamic and contrast-enhanced t -weighted mr imaging was . %, . % and %, respectively; no statistically significant difference was observed. conclusion: dynamic imaging is useful in assessing tumor visualization, and the most adequate enhancing time in dynamic study is seconds. but in diagnosis of parametrial invasion, the addition of dynamic mr images does not improve the accuracy compared with t -weighted images alone. ( ), on clinically progressive disease ( ) or patient death ( ). patients had undergone previous surgery ( radical hysterectomy, trachelectomy). patients had non-surgical treatment (chemo and/or radiotherapy). a recurrent mass was identified in patients (mean size cm, . - cm). on t w, the recurrence was hyperintense in %. in the post-surgical group, the recurrence was in the vaginal stump in patients ( %) with parametrial involvement in ( %). in the non-surgical group, the recurrence was in the cervix in patients ( %) with involvement of vagina in % and uterus in %. uterosacral ligament and/ or pelvic sidewall involvement was present in patients ( %). bladder invasion was suspected in % and rectal in %. nodal enlargement was seen in %. bone metastases were present in patients while had dxt changes ( sacral insufficiency fractures). recurrence in the pelvic muscles was also seen. conclusion: recurrent disease in patients with cervical carcinoma usually involves the cervix or vagina, however can present with varied manifestations. knowledge of the site and pattern of disease recurrence can help in early and accurate detection of recurrence. hysterosalpingography: is still useful in the diagnosis of peritubal pathology? s. deftereos, j. manavis, g. alexiadis, g. kafetzis, p. prassopoulos; alexandroupolis/gr purpose: to reevaluate the role of hysterosalpingography in the diagnosis of adhesions related to infertility and in patients managment. materials and method: consecutive patients with more than two years infertility underwent hysterosalpingography (hsg), followed by laparoscopy. patients with infertility related to uterine abnormality were not included. diagnosis of peritubal adhesions was based on the presense of the following six imaging findings: convoluted tubes, vertical tubes, loculation of contrast medium in peritoneum, halo effect, ampullary dilatation or fixed laterodeviation of the uterus. results: in total, tubes were delinated. no abnormality was detected in tubes on both hsg and laparoscopy. laparoscopy disclosed adhesions in tubes. diagnosis of adhesions was made in tubes ( correct, false positive), when the presence of one abnormal sign on hsg was considered as criterion; and in , when two or more signs are present ( correct, false positive). ten live births five to eight months after hysterosalpingography occured. conclusions: accurate diagnosis of adhesions on hsg requires the presence of at least two abnormal signs. the six-month interval between hsg and laparoscopy might be shortened when adhesive peritubal involvement is radiologically suspected. laparoscopy is less indicated when no abnormality is detected on hsg. withdrawn to illustrate ct-urographic patterns of neoplasia of the collecting system. background: conventional excretory urography and conventional computed tomography (ct) were considered the standard techniques used to examine patients with urinary tract neoplasia. multi-detector row ct offers high speed of acquisition and high resolution images, allowing axial and d urographic acquisitions. imaging findings: pts with transitional cell carcinomas were analysed. all patients underwent unenhanced and post-contrast ct axial scans, followed by a urographic acquisition in the excretory phase ( mm collimation, . mm reconstruction interval). d reconstructions of excretory phase images were created with on an independent workstation using a mip algorithm. neoplastic lesions were visualised as solid papillomas in / cases, as wall thickening of the collecting system in / cases and as solid tissue in the renal sinus in / case. lesions were more evident on the source axial images of the excretory phase urographic acquisition. in the post-contrast images, the lesions resulted quite vascularized. urinary tract dilation was evaluated in / patients. dilation was better evaluated on the d mip ct-urographic images in the case of normal renal excretory function and on the source axial images of urographic acquisition in the case of functionally excluded kidneys. conclusion: ct-urographic axial and d images combined with conventional ct imaging allowed good evaluation of urinary tract neoplasia. the more frequent pattern was the wall thickening of the collecting system ( % cases), associated to urinary tract dilation ( % cases). renal background: lc is a minimally invasive surgical technique for patients with small renal masses; mr provides an effective tool for imaging follow-up of renal lesions treated with lc. methods and materials: pts with renal masses underwent renal lc. all patients underwent follow-up mri hrs after surgery, and at , , and months. mr examinations were performed using gre t w, tse t w and ce fs-gre t w sequences. two radiologists reviewed mr images for i) signal intensity, ii) size, iii) vascularization, and iv) perinephric changes after treatment. imaging findings: a) t w images showed isointense cryolesions, and cryolesions isointense to renal parenchyma with hypo-or hyper-intense foci. on t w images all cryolesions were hypo-intense with iso-or hyper-intense foci; b) hrs after treatment all cryolesions were more than cm larger than the original masses; cryolesions decreased in size of an average of % at month, % at , % at , and % at months; c) ce-fs-gre t w images showed complete ischemia of cryolesions in cases; d) cases showed a perinephric haematoma at , and months. the more significant mr pattern in the follow-up of renal lesions treated with lc were the decrease in size of the cryolesions over time and the complete ischemia of the cryolesions. ( ), benign obstruction ( ), not obstructed ( ) and transplanted kidneys ( ). procedure details: we used ultrasound-guidance in cases and ct-fluoroscopy-guidance in cases. the technique was standard seldinger. most patients received -or f. nephrostomy catheters. we had access failures, usually in patients with nondilated systems. we encountered major complications (bleeding and two big urinomas) and only minor complications. catheter dislodgement was relatively frequent ( cases). conclusion: urinary diversion at renal level is necessary in the following clinical situations: as short-term palliation in a terminal case, as a temporary measure prior to definitive diversion, to relieve obstruction where immediate surgical intervention is not feasible and for prolonged drainage where surgical intervention is not indicated. since its first description in , percutaneous nephrostomy has developed into a technique that is now routinely used for a wide range of clinical applications. imaging of angiomyolipoma focused on the clinical issues k.-s. cho, y. jung, s. kim, j. kim; seoul/kr learning objectives: to discuss the role and findings of us, ct and mri in the detection and diagnosis of angiomyolipoma. to discuss the complication of angiomyolipoma and confusion in differentiation from other malignant neoplasm. to discuss the clinical issues of angiomyolipoma including the natural history concerning growth, efficacy of biopsy for diagnosis, and association with tuberous sclerosis. background: angiomyolipoma is the most common benign neoplasm of the kidney and consists of mature adipose tissue, smooth muscle and thick-walled blood vessels derived from perivascular epithelioid cells. although most angiomyolipomas are asymptomatic and cause no problem, some cases raise important clinical issues. ( ) angiomyolipomas may be complicated by risk of hemorrhage and cause confusion in differentiation from malignant neoplasm when they contain minimal amount of fat. ( ) angiomyolipomas are often related with the stigmata of tuberous sclerosis. ( ) the natural history of this benign neoplasm has been controversial, with regard to growth on follow-up images. ( ) the efficacy of biopsy for diagnosis is controversial when image findings are indeterminate. procedure details: in this illustration, we evaluate the role and findings of ultrasonography, computed tomography and magnetic resonance imaging in the detection and diagnosis of angiomyolipoma. discussion will be focused on the important clinical issues. conclusion: multi-detector row ct is the most accurate diagnostic modality for evaluation of angiomyolipoma especially in cases with minimal amount of fat in tumor or associated with complication. mr can differentiate minimal fat angiomyolipoma from small renal cell carcinoma. characterization to understand how to further characterize incidentally detected renal masses found on ct by using the appropriate modality with optimal techniques. backgrounds: due to advances in ct technology and its wide spread use for imaging a variety of abdominal conditions, small renal masses are being incidentally detected more frequently on ct. since at least half of renal cell cancers are detected incidentally by imaging, the cost and time for further imaging of small renal masses may increase. in addition, some renal cell cancers may be cystic and it is important to have a strategy for dealing with cystic renal lesions that do not meet the ct criteria for simple cysts. imaging findings: we will discuss and show a variety of small incidental renal masses detected on unenhanced and single phase contrast-enhanced ct. topics discussed will include the following: ct criteria for distinguishing lesions that do not need further imaging for characterization from lesions that require further imaging for characterization; technical considerations affecting imaging findings; updated bosniak classification for cystic lesions; pitfalls in interpretation; and an algorithmic approach for "indeterminate" masses by using ultrasound, dedicated renal ct, mri, or percutaneous biopsy. the majority of small renal masses incidentally found on ct can be characterized or managed through an appropriate diagnostic pathway. color-duplex imaging (cdi) and magnetic resonance angiography (mra) in reno-vascular disease l. olivetti , g. rozzi , p. pecchini , p. ravani , l. grazioli , e. botturi , i. laparoscopic cryoablation of small renal cell carcinoma: medium term outcome. g. cardone, p. mangili, a. cestari, g. balconi; milan/it purpose: to determine safety and efficacy of laparoscopic cryoablation in the management of small renal cell carcinoma and to assess its medium term outcome. methods and materials: patients underwent laparoscopic cryoablation of tumors between july and june . all treatments were delivered under laparoscopic us guidance. patients were followed up clinically, biochemically and by mr imaging hrs after surgery, and subsequently at , , , , and months. results: hrs after treatment all cryolesions were more than cm larger than the original masses; cryolesions decreased in size by an average of % at month, % at , % at and % at months following cryoablation. early post-procedure mr images showed complete ischemia of all cryolesions. follow-up (mean months) revealed no evidence of recurrence in / patients. one patient showed local recurrence at months, one patient demonstrated an metachronous nodule in the same kidney at months and another patient showed a pancreatic metastatic nodule at months. no significant rise in creatinine was noted post-procedurally. after surgery, retroperitoneal effusion was found in all cases; / cases showed an intralesional haematoma, / cases showed low signal intensity foci due to haemostatic material and / cases showed a perilesional haematoma at and month follow-up. conclusions: our medium term experience suggests that laparoscopic cryoablation is a safe, well tolerated and minimally invasive therapy for small renal cell carcinoma, and mr is an effective imaging technique in the follow-up of renal lesions treated with laparoscopic cryoablation. results: echographic findings postbiopsy were normal, or with loss of corticomedullary differentiation, enlargement and gross edema. clinical indication in transplanted kidneys was deranged renal function, and in native kidneys, nephrotic syndrome. acute rejection was the most frequent diagnosis in transplanted, and focal glomerulosclerosis in non transplanted kidneys. we observed cases ( % of all procedures) of postbiopsy complications ( haematomas, perirenal collections, decreased vascularization, arterio-venous fistulaes and deranged renal function), but none of them were significant. of them ( . %) were in native kidneys, and the remaining cases ( . %) were in renal allografts. we show an alternative way to perform the procedure in order to minimize patient risks and maximize results. we conclude that complications may be more frequent in renal allografts than in native kidneys. the complex preoperative assessment of patients with renal masses with complex mri-study i. platitsyn, e. zaytseva, a. zubarev, v.v. gazhonova; moscow/ru purpose: to study possibilities of complex mri-study in patients with renal masses in preoperative planning of renal surgery. material and methods: patients with renal masses detected by us were evaluated with complex mri-study. complex mri-study included mri before and after ce, d ce-mra and d ce-mru using fast d mra gre sequence were performed with . t system (magnetom harmony, siemens). dsa was used as diagnostic correlation as a gold standard. the obtained mr-data were compared with the results of surgical operation and histopathology. the renal tumors were identified with mri-study in patients; patients had cystic lesions. hypervascular masses were found in patients, hypovascular masses in patients. in one cases of cystic lesion detected with mri-study the patient had hypovascular cysto-solid masses. next, renal vascular variants were revealed: unilateral ara were detected with d mra in cases, with dsa in cases; bilateral ara -in and cases (consequently); triple unilateral ara -in and cases (consequently); multiple ara -in ( arteries) and ( arteries) cases (consequently); the sensitivity of d ce-mra was %. d ce-mru provided high-quality images of the urinary tract in all cases. mrstudy showed an almost complete correlation with results of operative treatment, histopathology and dsa. conclusion: complex mri-study allows noninvasive preoperative assessment of renal tumors localization, morphology and vascularisation, renal arterial system, renal parenchyma, urinary tract and perirenal region. it is valuable for planning of renal surgery. in all cases, the d free-breathing sequence was superior to the breathhold rare sequences in terms of spatial resolution, with equivalent contrast, and without significant motion artifacts. as a result, the level and length of stenoses were always better demonstrated with the d sequence than with the breathhold rare sequences. mip reconstructions allowed analysis of the entire urinary tract with different projections. the duration of the d sequence ( minutes) was comparable to the overall duration of the rare sequence, which requires several slice positioning to explore the entire urinary tract. less t -weighted sequences (haste and trufisp) were superior to d sequences to analyse the cause of obstruction, as they visualised the ureteric wall and the adjacent structures. the d turbo spin echo sequence is robust and especially useful in case of tortuous ureters. this sequence has now replaced the rare sequences in our protocol. haste and trufisp sequences remain useful to analyse the ureteric wall and the adjacent structures. prenatal ultrasonographic findings of multicystic dysplastic kidney: emphasis on cyst distribution m. moon, j. cho, m. song, y. lee; seoul/kr purpose: we retrospectively analyzed multicystic dysplastic kidneys to evaluate the prenatal sonographic characteristics, emphasizing the distribution of cysts. a total of cases was included in this study. the sonographic assessment included the site of the involved kidney, the size of the multicystic dysplastic and the contralateral normal kidney, the distribution of cysts, and associated anomalies. according to the distribution of cysts, multicystic dysplastic kidneys were categorized as subcapsular and random distribution, and interobserver agreement was determined using cross table analysis. the largest longitudinal diameters of the multicystic and the contralateral normal kidney were measured and data were plotted on the normal reference chart. results: multicystic dysplastic kidney was left sided in . %, right sided in . % and bilateral in . %. subcapsular distribution of cysts was observed in . % (n = ) for radiologist , . % (n = ) for radiologist . interobserver agreement was excellent (k = . ). the longitudinal diameter of the multicystic dysplastic kidney was above the % in % and that of the contralateral normal kidney was normal in %. there were major anomalies in cases and fetal karyotyping was offered in cases including cases with associated major anomalies. the results were always normal. conclusion: subcapsular distribution of cysts in multicystic dysplastic kidney is more common than random distribution, so the distribution of cysts may be helpful in the prenatal diagnosis of multicystic dysplastic kidney. tubular extraction rate of mag in patients with impaired renal function s. beatovic, e. jakšic, r. han; belgrade/yu purpose: to analyze whether clearance of mercaptoacetyltriglycine (mag ), which is equal to its tubular extraction rate (ter) could serve as a sensitive parameter of renal function impairment. methods and materials: investigation was carried out in patients, who were divided into nine groups, according to the diagnosis and the degree of renal failure. dynamic renal scintigtraphy was performed minutes after i.v. injection of - mbq of mag . ter was determined by single-sample, volume distribution method using the standard solution of labeled mag . results: results of ter were correlated with blood urea nitrogen (bun), serum creatinine (cr) and creatinine clearance (ccr). significant linear correlation between ter and ccr was found (r = . ; p < . ). correlation between ter/ bun and ter/cr was exponential (r = - . and r = - . , respectively; p < . ). conclusion: analysis of our results show that ter is a more sensitive parameter than ccr, cr and bun, especially in mildly deteriorated function. in advanced renal failure, the sensitivity of ter is similar to the sensitivity of bun and cr. daily we found some significant correlation between pulsatility indices (pi), resistance indices (ri) and renal volume (trv), with creatinine blood level (cr) in the patients with normal evolution, if we correlated the parameters using -day data. there was significant correlation between ri and cr in patients with nf ( days, p = . ). in the patients with atn there was significant correlation between trv and cr ( days, p = . ). significant correlation between trv and cr was found in rd evolution ( days, p = . ) and between pi and cr ( days, p = . ) in patients with rejection. these results confirm the findings obtained by dissection in five cadavers. the analysis of ct scans of retro-extraperitoneal pelvic processes demonstrates the inferior extension of the renal fasciae to the pelvis. these fascial planes serve as pathway for the spread of retro-extraperitoneal processes from the abdomen to the pelvis and vice versa. one can so explain, for example, the occurrence of an abcess in the prevesical space in case of sigmoid diverticulitis. to investigate the effect of alpha-blockers on prostatic blood flow and by means of power doppler image quantification. materials and methods: patients suffering from lower urinary tract symptoms (luts) were treated with alpha-blocker for weeks. transrectal power doppler ultrasound (trpdus) of the periurethral prostate as well as comparative cystometry were performed before and after therapy. for trpdus an acuson sequoia (acuson, mountainview, usa) fitted with a high frequency transrectal probe (ec -c ) was used at standardized machine settings. color pixel density (cpd) was calculated with computer assistance from transrectal power doppler images using scion image image analysis software. cpd and standard urodynamic parameters were recorded in each run at filling volumes of ml, ml and maximum cystometric capacity. in presence of nacl, mean cpd rose by % at ml and by % at full distension, whereas with kcl filling, mean cpd rose by % at ml and by % at full bladder capacity. after therapy, mean cpd was significantly increased at empty bladder by % compared to mean cpd before therapy. during nacl filling, mean cpd rose by % at ml and by % at full distension, while in the presence of kc , mean cpd rose by % at ml and by % at full bladder capacity. conclusions: using trpdus and cpd, relative changes of periurethral prostatic blood flow could be quantified. alpha-blocker lead to a significant increase of prostatic blood flow. these results may explain the therapeutic effects of alphablockers on luts. superselective results: using grey-scale trus, prostate tumors were hypoechoic before treatment. using d pd trus, tumors ( %) were hypervascular before treatment. during treatment the tumors' echogenicity increased gradually, focal fibrosis was detected; the degree of vascularity decreased gradually. in months the fibrosis was not revealed in ( . %) tumors and the hypervascularity was revealed in ( . %) patients that correlated with negative clinical response to hormonal treatment in patients. conclusion: d trus is an informative method in the assessment of the response to hormonal treatment of pc. methods: seven patients with adenocarcinoma of the prostate were scanned supine on a . t system. prior to imrt and during the -week treatment course, mm transverse, coronal and sagital haste-t -weighted images of the pelvis were acquired weekly. the bladder and rectal volumes, position of the prostatic margins, and center of prostate (cop) relative to the bony pelvis were measured. results: all pre-treatment positions were within a . mm range from the ontreatment mean position in each patient. the cop variability in the ap, cc and ml directions were . , . and . mm, respectively. the largest prostatic margin variability was . (posterior) and . mm (cranial and caudal). beyond a rectal volume of . , a strong correlation was found between rectal volume and anterior cop movement (p = - . ). a weak correlation (p = - . ) was found between bladder volume and cranial cop movement. beyond . ml, the mean variability of the cranial and caudal margins increased up to . mm, between and ml . mm, and above ml . mm. the pre-treatment prostate positions were representative of ontreatment positions. a . mm ctv expansion in any direction was sufficient to ascertain % coverage of the ctv within the ptv, assuming a rectal volume < . ml (rectal suppository) and bladder volume around ml (voiding followed by drinking ml of water to keep small bowel away from treatment field). local results: there was no significant difference between the number and severity of complications in the group with local anesthesia compared to the group without anesthesia. there were no significant side effects caused by the infusion of the anesthesic drug. however the infusion of the drug may cause a degradation of the trus image. air bubbles are sometimes infused with the drug causing a "fuzzy" image, which results in a degree of difficulty in guiding the needle. a thorough trus examination of the prostate prior to the anesthesia helps the radiologist in planning the biopsies in advance and thus guiding the needle to the appropriate area, even through a "fuzzy" image. conclusion: us-guided local anesthesia, before trus biopsy, is useful for assuring patient cooperation during this often painful procedure and essential if trus findings call for a large (more than ) number of biopsies. conclusion: conventional mr images combined with pyelo-urographic techniques allowed a good evaluation of urinary tract neoplasia. more frequent patterns were solid papillomas or wall thickening of the collecting system ( % cases), associated with collecting system dilatation ( % cases). there is a "difficult zone" located - cm below the iliac vessels. examination with mild compression is used to solve this problem. color doppler sonography is valuable to distinguish the ureter from vessels. conclusion: abdominal sonography is a cheap and informative method in the diagnosis of ureteral disorders and may replace traditional technologies. trauma of the urinary system: spectrum of findings at helical ct a.j. madureira, c. tavares, l. melao, i. ramos; porto/pt learning objectives: to review and illustrate the spectrum of imaging findings associated with blunt and penetrating trauma to the urinary system on helical ct. to discuss the importance of an appropriate technique and the major pitfalls encountered. background: injury of the urinary system is a common complication of major abdominal trauma. helical ct is a powerful imaging modality in the evaluation of patients with suspected injuries of the adrenal gland, kidney, ureter and bladder. the renal injury ct classification system is valuable and clinically important as it serves as a guide for patient management. procedure details: the authors present a comprehensive review of the imaging findings in common and rare traumatic lesions of the adrenal gland, kidney, ureter and bladder based on the experience of a level trauma center. the indications for helical ct are discussed and a special emphasis is placed in the use of an appropriate technique and discussion of the major pitfalls that may be encountered. conclusion: helical ct is a useful modality in the diagnosis, grading and followup of patients with trauma to the urinary system. helical ct protocols should be optimized and adapted to the clinical situation in question. characterization learning objectives: this poster will present the anatomical waxes dedicated to urogenital anatomy which are displayed at the museum "la specola" of florence. background: teaching gross human anatomy is traditionally based on demonstration and study of the different organs and systems directly on corpses. however, availability of specimens for this purpose can be difficult for a variety of problems and, at present, anatomical models made of plastic material and electronic files are used in most schools of medicine. these problems have been always present in the history of medicine. to overcome this, in , a special laboratory was established at the "imperial regio museo di fisica e storia naturale" of florence to create a collection of anatomical waxes, copied from anatomic dissections, to enable three-dimensional anatomic studies with schematic drawings and captions indicating anatomical details. imaging findings: from to , the laboratory prepared a large number of models, and the collection in florence consists of about pieces. in the collection there are over preparations, showing the complete urogenital system in the male and the female. special models have been created to demon-strate sectional anatomy, the internal structures of the kidney, the relationships of the prostate with the bladder base and the seminal vesicles, the penis, the vagina and the uterine cavity. many waxes depict the gravid uterus and the foetus, with its vasculature and its relations with placental vessels. conclusion: this allows the collection to be considered as the first d "textbook" of anatomy in medical history. characterisation of adnexal masses with magnetic resonance imaging a. saini; london/uk learning objectives and background: the accurate assessment of adnexal masses remains a challenge. to determine key differentiating features of adnexal masses, we retrospectively reviewed the magnetic resonance (mr) characteristics in patients and correlated their appearances with the findings at histopathology. imaging findings: benign solid lesions were characterised by fat, haemorrhage or fibrous components. mature teratomas (n = ) possessed high fat content. haemorrhage was a predominant feature of endometriomas (n = ) but also seen in some malignant tumours. fibromas (n = ), cystadenofibromas (n = ), benign brenner tumours (n = ) and fibrothecomas (n = ) that have a similar fibrous component shared a distinctive short t relaxation. benign cystic lesions comprised serous or mucinous cystadenomas (n = ), were recognised as thin walled uni-or multilocular cysts. borderline (n = ) and malignant epithelial tumours (n = ) were predominantly cystic and distinguished by papillary projections and the secondary features of malignancy, such as ascites, rather than their tissue signal intensity. malignant solid primary ovarian masses were less common. clear cell carcinomas (n = ) were recognised by a predominantly solid mass with more modest cystic elements. granulosa cell tumours (n = ) had variable amounts of cystic change and intratumoural haemorrhage. immature teratomas (n = ) contained circumscribed foci of variable signal-intensities. inflammatory masses (n = ) also presented as complex adnexal cysts. in these cases, the clinical history and examination was key in making the diagnosis. the ability to manipulate tissue contrast with mr imaging makes it an invaluable tool in the assessment of complex adnexal masses enabling characterisation and identification of features associated with less common pathology. to discuss the imaging features so that when this tumor is encountered the diagnosis may be considered. to correlate the pathologic characteristics with the imaging findings. to discuss the key elements to be included in the differential diagnosis and to provide examples of them. background: urachal adenocarcinoma is an extremely rare malignant neoplasm that develops from embryonic remnants and has a variable clinical course. clinical, pathologic and imaging findings were retrospectively evaluated for patients with urachal adenocarcinoma referred from centers. imaging studies (ct, n = ; mri, n = ) were reviewed for morphologic features, such as tumor size, homogeneity, margins and degree of enhancement. imaging findings: the mean tumor size was . cm. the tumors were heterogeneous in / patients, with irregular margins in / , calcifications in / and strongly enhanced in / . all tumors extended anteriorly from the bladder dome; endoscopy was normal in all cases. enlarged lymph nodes were visible in / patients. histologically proven invasion of the bladder dome was detected in / patients and invasion of the anterior abdominal wall in . d reconstructions in the sagittal plane (n = ) evoked a urachal mass and assessed its relationship with the urinary bladder, umbilicus and rectus muscles. all tumors were resected. conclusion: multimodality imaging is essential to obtain an early and accurate diagnosis of urachal adenocarcinoma. multiplanar ct and mr give the best assessment of the extent of tumor invasion. reduction of ionising radiation exposure to patients due to new imaging technology for medical diagnostics of the urinary tract: a retrospective study covering years in a norwegian referral hospital a. nyquist , i. børretzen , h. olerud , b. bjørnarå , t. gudmundsen ; drammen/no, oslo/no purpose: to examine possible changes in ionising radiation doses to patients (collective effective dose) undergoing diagnostic imaging procedures of the urinary tract over the last years in view of shift in modalities from conventional x-ray examination to ultrasonography (us). retrospective study of all patient files for the period from to . the number of plain radiographs, intravenous pyelography (ivp), ultrasonography (us), computer tomography (ct) and magnetic resonance imaging (mri) examinations were registered. for each type of examination the mean effective radiation dose were obtained from the norwegian radiation protection authority (nrpa) as published in . the number of plain radiographs of the lower abdomen covering the urinary tract increased by approximately %, ivps were reduced by %, and ct examination decreased by %. mri examinations did not play any significant role in examining the urinary tract. us of the urinary tract increased from in to in . this shift in modalities from totally x-ray based procedures, to nearly exclusively us often supplemented with one plain radiograph, caused a decrease in the annual collective effective dose for this group of patients with % from . mansv in to mansv in . the shift in modalities used for diagnostic imaging of the urinary tract from conventional x-ray to almost exclusive use of us, resulted in a significant reduction in exposure to ionising radiation of patients, and need to be considered when discussing further development and structure of diagnostic imaging. comparison of the adrenal vein sampling value between primary aldosteronoma and nonfunctioning adrenal adenoma: evaluation with receiver operating characteristic ( , voiding cystourethrography, urethroscopy and biopsy. combined retrograde and voiding sug with saline and echocontrast media levovist® were used in pts with urethral obliteration and chronic suprapubic catheters. the transperineal or transrectal ultrasound was performed to evaluate anterior and posterior urethra respectively. the images obtained allowed detailed morphology assessment of the urethra at different levels. results: compared with rug, the sug more accurately measured stricture length and diameter that was confirmed by measurements at optical urethrotomy ( pts) and urethroplasty ( pts). the introduction of contrast agents enhanced the visibility of the flow in the most strictured segment (less than . mm), which was diagnosed by rug as urethral obliteration in pts. the ce sug accurately diagnosed diverticula ( ), false passages ( ), which were confirmed by urethroscopy in all pts. conclusion: our preliminary results show, that the combined retrograde and the voiding power doppler sonourethrography with ultrasound contrast media might be an effective support in diagnostics and in the planning of treatment of patients with complex strictures and urethral obliteration. ce sug is an informative method in the differential diagnostics of patients with urethral obliteration and complex strictures. differentiation of adrenal adenomas from metastases with unenhanced ct using a scoring system h. gufler , g. eichner , a. results: attenuation values on unenhanced ct were significantly lower for adenomas than for metastases ( . ± hu versus . ± . hu, p < . ). the combined score parameter including all ct criteria showed the largest area under the roc curve. the highest predictive power suggested by the model was calculated with a cut-off point at . for benign lesions with a sensitivity of . and a specificity of . . at . points the scoring system yielded a sensitivity of . % and a specificity of . %. conclusion: compared to densitometry alone, diagnostic accuracy in the differentiation between adrenal adenomas and metastases is improved by including all ct criteria in the evaluation. the presented scoring system is simple but efficient and easy to use in the clinical routine. eswl of the unusually located stones in pediatric patients z. siric, m. radovanovic, a. slavkovic; nis/yu aim: to show the possibilities of lithotripsy in the treatment of bladder and urethral stones in pediatric patients. in a twelve year period, we treated pediatric patients, aged from months to years, by eswl. in children, stones were located in the urinary bladder, and in the urethra in another . all of them were male patients; we decided to use eswl instead of invasive methods of treatment. eswl procedures were performed under general anesthesia in and under sedo-analgesia in patient. during treatment, the patients were placed in the prone position (patients with bladder stones) or in a modified supine position (perineal approach for urethral stones). an average shock waves were applied per patient with a maximal energy of . kv. average duration of treatment was minutes. results: successful fragmentation was achieved during the first session in patients. in patient with a urethral stone, the fragmentation was not satisfactory and the treatment was repeated days later. complete elimination of stone fragments was achieved during the first days in the patients with successful first treatment, but was not achieved at all in the patient with repeated treatment. cystoscopy was performed and the stone was found within a urethral diverticulum. there were no complications in our patient group. conclusion: eswl in our experience seems to be useful as a non-invasive method in the treatment of stones with in unusual locations. it could be recommended in male patients without anatomical variations of bladder and urethra. methods: this is a retrospective study of helical ct of patients that showed iliopsoas abnormalities ( neoplasms, abscesses, hematomas, cases of atrophy and of calcifications). the study group included men and women, - years old (mean years). all studies were obtained over a -year period. final diagnosis were correlated with different ct features to determine findings that could be used to differentiate these abnormalities. these included enlargement of the iliopsoas muscle, irregular margins and fat infiltration, attenuation of the lesion, calcification, bone fracture and associated adenopathy. result: psoas pathology is more frequent in men (p < . ). low attenuation and heterogeneity are the most reliable ct features of iliopsoas abscesses (p < . ). the sensitivity and specificity of low attenuation for the diagnosis of abscesses are % and % respectively. the specificity of heterogeneity for the diagnosis of abscesses is %. bone fracture is useful for the diagnosis of hematoma (p < . ). bone fracture is % sensitive and % specific for diagnosis of hematoma. conclusions: low attenuation, heterogeneity and bone fracture are helical computed tomography features useful for differentiating iliopsoas pathology. results: all masses were classified correctly by both analysis. the mean percentage of signal intensity on subtraction images were ± (means ± sd) and nonadenomas ± (means ± sd), respectively. the difference between two groups was statistically significant (t test, p = . ). our results show that chemical shift subtraction imaging is an objective technique that allows the adrenal adenomas to be differentiated from the other tumors. the objectivity of the technique may help the unexperienced radiologists to improve their interpretation. patient ( %) had uretheral dilatation. the mru visualized the dilatation and determined the obstruction level in cases ( %). the excretory urography detected uretheral dilatation and determined the obstruction level in cases ( %). the mru detects with great accuracy the dilatation and also, obstruction level in patients with obstructive uropathy and could be used as an alternative to excretory urography in specific cases. oro objective: many congenital dysplasias of the osseous labyrinth have been identified. differentiation of these dysplasias is essential for patient management. the purpose of this study is to describe the imaging findings which can be found in anomaly of the inner ear. we retrospectively reviewed imaging findings of children with congenital sensory neural hearing loss ( male, female, mean age . years, age range - years) who had ct (n = ) and mr imaging (n = ). ct was performed on a ge hispeed/i scanner (general electric medical systems, milwaukee, wis, usa). . mm thick direct coronal axial sections were obtained with bone algorithms. mr was performed on a ge signa mr/i with temporal t fse thin section mm scan and routine brain axial, coronal, flair, fse t , se t , coronal fse t , sagittal se t weighted images. results: there were cochlear aplasia with large vestibule (n = ), cochlear hypoplasia (n = ), mondini malformation with large vestibular aqueducts (n = ), mondini dysplasia with large vestibule (n = ), large vestibular aqueduct and endolymphatic sac (n = ), small internal auditory canal (n = ) and large vestibule (n = ). four cases were involved unilaterally. seven cases had combined deformities. five cases had cochlear implant. conclusions: both ct and mr can be used to look at inner ear malformations, but often both techniques are complementary. ct is preferred when associated middle or external ear malformations must be excluded. mri is preferred when subtle changes in the membranous labyrinth or abnormalities of the nerves in the internal auditory canal must be visualized. purpose: benign paroxysmal positional vertigo (bppv) is probably the most common cause of vertigo and the most common peripher vestibular disorder. bppv has been postulated to be the result of freely floating debris of degenerative otoconia in the endolymph of a semicircular canal (sc), canalolithiasis or debris that becomes adherent to the cupula of the semicircular canal. the key in determining the diagnosis of bppv is still examination performing positioning manovers and the use of frenzel glasses. differential diagnosis can be difficult. the aim of this study was therefore to provide a new diagnostic approach by d-nmr technique. our special interest has been if there was a structural change in the sc or the cupula, which could be identified in patients with incurable vertigo compared to those with self-limited disease. methods and materials: we investigated normal and bppv subjects using a . t ge mri with d data set: tr , te , mm slices, x matrix, x fov, . nex. results: all bppv patients had pathological filling defect of the sc before therapy which must be considered as an anomaly canalolithiasis. we postulate there must be structural changes in its lumen which makes the endothelium adhesive which is recognizable in hr- d-mr as a filling defect. conclusion: a significant improvement in quality of high-resolution mri of the inner ear using ciss could be obtained at . t despite potential drawbacks. to obtain at . t, the same snr would require approximately double measuring time, optionally increasing the risk for an accidental head movement which may prove detrimental at high resolution. ( ), dysplasia of the vestibule with or without abnormality of the lateral scc ( ), mondini-deformation ( ), cochlear dysplasia and absence of cochlear nerve ( ) and dysplasia of the modiolus ( ). one patient showed labyrinth hemorrhage at the time of mri. ten cases presented typical clinical features of a progressive hearing loss. in patients a constantly moderate or profound sensorineural hearing loss was present since early childhood. one patient was deaf. one patient suffered from a pendred syndrome. conclusion: a large vestibular aqueduct is a common finding in patients with suspected inner ear malformation. nevertheless, especially in isolated lva, it is sometimes missed in routine work. even if there is no therapy, an early diagnosis is needed to explain to the patient, the cause of hearing loss, the prognosis and behaviour which can possibly delay progression. color digital radiography density measurements in differentiation of periapical granulomas and radicular cysts i.k. rozylo-kalinowska; lublin/pl purpose: the differentiation of periapical granulomas and radicular cysts is crucial for decision on conservative or surgical treatment and therefore influences the success and long-term results of the treatment. although radiograms are a valuable diagnostic tool, relying solely on the evaluation of these images may lead to mistakes in the choice of treatment. the aim of the study was determination of possibile applications of digital radiography density measurements in differentiation of periapical granulomas and radicular cysts of inflammatory origin. the material consisted of digital periapical radiograms obtained using digora, rvg and dixi digital radiography systems in patients aged to , divided into two groups: granulomas and radicular cysts. by means of digora . software, maximum and minimum densities were measured along a line and the difference between these densities was calculated. the largest dimensions of the lesions were measured both perpendicular and parallel to the root canal axis. results: the differences between the results for granulomas and cysts were statistically significant. when the difference of densities exceeded . , the lesion was a cyst and when it was below . , a granuloma was diagnosed. combined application of two criteria, namely the calculated difference between densities and the largest dimension, increased diagnostic possibilities of radiological differentiation of granulomas and radicular cysts. conclusion: it was proved that to some extent it was possible to differentiate granulomas and radicular cysts by means of digital radiography software. ameloblastomas d e f a g x-rays, ct and mri. the use of d-ct and dentascan proved especially helpful in determining tumor dimensions. histological examination of the lesions showed that were of the follicular type, presented as mural ameloblastomas, were squamous type, plexiform and was a malignant ameloblastoma. results: in patient the extension of disease was proven inoperable. in patients various types of mandibulectomies along with immediate reconstruction were performed. in cases of mural ameloblastomas local excision only was performed, whereas in patients the mandibular defect was reconstructed with a titanium plate. conclusion: in large monolocular lesions treatment can be conservative surgery, whereas in large multilocular lesions radical surgical treatment that includes segmental ostectomies with immediate reconstruction of either vascularized or autogenous bone grafting is the treatment of choice and produces the best post operative results. the interpretation of the d reconstruction images and the dentascan are of great importance when such an operation is decided upon. differential growth in vestibular schwannoma g.c. bockeler, v. nandapalan, t. lesser, h. lewis-jones; liverpool/uk purpose: mri plays a pivotal role in the management of patients with vestibular schwannoma (vs), yet there are no universally agreed guidelines on the use of this expensive investigation. this study analyses the site, size and morphology of vs referred for possible intervention. where clinically a wait-and-watch approach was chosen, growth of vs was determined on subsequent imaging. methods and material: mr images of patients with unilateral vs referred to a tertiary centre were classified according to the site of vs with respect to the internal acoustic canal. a variety of measurements were obtained to determine the most sensitive method of measurement. growth was expressed as absolute and relative change in the direction of the largest increase in size. results: vs showed growth in % of patients, % remained static and % regressed. growth was most frequent in vs with an intra-and extracanalicular component whereas purely intracanalicular vs showed no growth. the initial size did not predict growth. growth rates were largest in predominantly extracanalicular vs. conclusion: our findings confirm previous findings of infrequent and smaller growth in purely intracanalicular vs and more frequent and larger growth in predominantly extracanalicular vs. an incremental delay in follow-up imaging of the former vs appears justifiable in the absence of new symptoms. conversely most vs require close monitoring as even small changes in size may lead to symptoms necessitating invasive treatment. sonographic sialadenitis/sialolithiasis: ultrasound is accurate in the assessment of acute and chronic inflammation and abscess formation. it has replaced sialography in many centres for evaluating suspected stone disease and duct dilatation. granulomatous disease: sarcoidosis and sjögren's syndrome may both involve the submandibular glands. ultrasound is able to delineate the phases of disease progression in sjögren's and is also used in lymphoma surveillance in these patients. other lesions of the submandibular space: including adenopathy, cystic hygroma, brachial cleft cyst, ranula and lipoma may mimic submandibular gland lesions and are readily identified sonographically. conclusion: ultrasound represents a safe, widely available and accurate means of assessing the submandibular space and is able to delineate and characterize lesions. ultrasound can be used to guide aspiration or biopsy and reduce the need for surgical excision. ultrasound-guided core biopsy of the parotid gland: results of patients k.k. lewis , m. williams , d.c. howlett , g. manjaly , a.b. moody , n. violaris ; eastbourne/uk, brighton/uk purpose: to evaluate the role of ultrasound-guided biopsy in the management of palpable parotid lesions. materials and methods: one hundred patients were included in this prospective study over a -year period. initial ultrasound examination was performed using a - mhz high frequency transducer. guided biopsies were taken under local anaesthesia (single operator) with a spring loaded variable throw ( mm/ mm) biopsy gun using or g needles with an average of passes per patient. results: in patients, biopsy revealed benign neoplasms, malignant lesions (including primary and secondary lesions as well as lymphomas) and other pathologies including sarcoidosis, tuberculosis, reactive lymphadenopathy, sjogren's and actinomycosis. only lymphoma patients needed surgery for further histological grading. diagnostic accuracy was % for benign versus malignant pathology in the patients who underwent subsequent surgery. there was % correlation between biopsy and operative histology with only two non-correlates. these involved misdiagnosis of squamous cell carcinoma and mucoepidermoid carcinoma. these would have required further histochemical staining for differentiation. surgery was avoided in forty-six patients after biopsy diagnosis. there were no immediate complications of biopsy. conclusion: ultrasound guided biopsy gives % benign versus malignant pathological differentiation. it also has % correlation with operative histology. correct pre-operative diagnosis influences the decision to undertake conservative or radical surgery and unnecessary surgery can be avoided. a core of tissue allows histopathological analysis where assessment of tissue architecture, tumour grading and immunochemical staining is possible. this is invaluable for accurate diagnosis. contrast enhancement of the cochlear aqueduct in mr imaging: its frequency and clinical significance t. nakamura , s. naganawa , h. fukatsu , y. sakurai , i. aoki , a. ninomiya , t. nakashima , t. ishigaki ; nagoya/jp, tochigi/jp purpose: there have been no previous reports on contrast enhancement of the cochlear aqueduct in magnetic resonance (mr) imaging. the purpose of the present study was to evaluate the frequency and significance of this finding. methods and materials: thirty-one patients ( men and women; age range - years) with otologic symptoms (sudden sensorineural hearing loss, vertigo or tinnitus) were examined using contrast-enhanced imaging on a . t mr scanner. the normal ear served as the control. two radiologists evaluated contrast enhancement in the area of the cochlear aqueduct. result: forty-eight of ears ( . %) showed contrast enhancement of the cochlear aqueduct, but no significant differences in the frequency of contrast enhancement were observed between patients with and patients without vertigo, tinnitus, sensorineural hearing loss, cerebellopontine angle tumors or a highriding jugular bulb. in addition, no gender or age-related differences were noted. conculusion: contrast enhancement of the cochlear aqueduct was frequently observed, but the frequency of enhancement in symptomatic ears was not significantly higher than in control ears. the results of this study may prove helpful in avoiding unnecessary examinations and potential diagnostic confusion. high-resolution mr imaging of basaliomas of the facial soft tissue with a microscopy coil h. gufler, c. zörb, w.s. rau; giessen/de purpose: to correlate the tumor extension measured on high-resolution mr images with histology. patients and methods: five patients with basaliomas of the facial soft tissue were examined before surgery with high-resolution mri using a . tesla system with a mm microscopy coil. axial t -and t -weighted tse images were obtained from all patients before gd-dtpa application and additional axial and/ or sagittal t -weighted sequences with and without fat suppression after cm application (fov mm, matrix x , slice thickness . mm, acquisition time - minutes). qualitative analysis of mr images was performed by two radiologists who measured the extension of the tumor and decided whether bone erosion or infiltration of the orbit or of the nasal cartilage was present. results: t -weighted unenhanced axial images proved to be the most useful sequences in predicting the extension of the basaliomas. for the evaluation of b d e f a g orbital invasion, additional sagittal t -weighted unenhanced images were helpful. the extension of the lesions correlated well with the results on histology. in one case, however, nasal cartilage infiltration was not correctly diagnosed on the basis of high resolution mr. conclusion: high-resolution mr imaging using a microscopy coil is a promising method to predict the exact extension of basaliomas of the facial soft tissue. three orbit mri of the superior oblique muscles to measure the asymmetry in patients with iv nerve paresis m.a. eleta, f. shokida, f. seclen, j. gabriel, c. zanchez, f.a. eleta; buenos aires/ar purpose: to evaluate the section of the superior oblique muscles (so) in patients with unilateral congenital or acquired pareses to detect asymmetry and the relationship between the degree of vertical deviation and mri measurements. method and materials: from march to september , patients underwent orbits mri. seventeen patients had unilateral so muscle paresis: congenital and acquired. fifteen patients had normal so. the area of the superior oblique muscle in the section of maximun width was obtained in primary gaze position, supra and infraversion. asymmetry of the superior oblique muscles was defined arbitrarily as the difference between both so in the same patient and the measurement was compared with the values obtained in the normal group of patients. results: mean maximal difference was . ± . mm (p < . ) between the healthy and paretic eye. in the normal group of patients it was . ± . mm (p < . ). eleven out of the patients with congenital paresis showed asymmetry of the superior oblique ( . %). asymmetry determination of the superior oblique muscles disclosed . % sensitivity and % specificity. the relationship between vertical deviation and the maximal difference between the section of the normal versus the paretic eye was p > . . conclusion: imaging of the superior oblique muscles in patients with congenital iv nerve paresis showed significant asymmetry in the section area with regard to the contralateral muscle. however, no correlation was found between the degree of vertical deviation and interocular asymmetry. high resolution gray scale and color doppler imaging was performed in more than patients using a high frequency linear array transducer. various planes of imaging of the eye correlating with drawings of normal anatomy are shown. views are used to illustrate the complex anatomical relationships. an overview of the normal anatomy and pathologic conditions is presented with clinical correlation. results: evaluation with high resolution gray-scale and color doppler ultrasound can often determine diagnosis without further imaging procedures. us is sometimes insufficient to evaluating a deep structures of the orbit. paradigmatic us images from different pathologic entities of the eye (for instance: intraocular foreign bodies, haematoma, cataract, vitreal pathology and ablation of the retina etc.) are shown. conclusion: adequate knowledge of the anatomy of the eye and orbit is needed to correctly limit the differential diagnostic possibility of pathology of the eye and orbit. us is an available method for an accurate diagnosis of the eye with ct, and preferably mr, being reserved for cases which require additional information about deep structure, or those with in which there is discrepancy between the sonographic and clinical diagnosis. nasopharyngeal angiofibroma: the role of angiography in diagnosis and treatment a. szymanska, r. pietura, a. drelich-zbroja, m. szymanski, m. szczerbo-trojanowska; lublin/pl background: nasopharyngeal angiofibroma (na) is a rare, benign, unencapsulated tumour affecting adolescent males. surgery and radiotherapy are main treatment modalities. we evaluated typical angiography findings of na, its role in defining tumour blood supply and treatment planning. material and methods: forty patients with jna ( males and females aged to ) underwent angiography. we assessed tumour vascular composition, its location in relation to the maxillary artery (ma), feeding vessels and feasibility of preoperative embolization. relationship between stage of tumour, presence of intracranial extension and internal carotid artery (ica) blood supply were statistically evaluated. results: on angiograms, all tumours presented intensive inhomogenous blush. . % of tumours were supplied by ma, % by ascending pharyngeal and . % by the facial artery. in % of tumours, feeding vessels originated from the ica and in ( . %) case from the vertebral artery. the relationship between ica blood supply and tumour stage was statistically significant. ica blood supply had no correlation with the presence of tumour intracranial extension. two patients with abundant ica supply were disqualified from surgery and underwent irradiation. in patients with previous external carotid atery ligation, preoperative embolization of vascular recurrent tumour was not feasible. in % of cases ma was displaced by tumour lateral extension. conclusions: angiography shows typical features of na (nasopharyngeal, highly vascular tumour supplied by ma), confirms diagnosis of this tumour and enables preoperative embolization. analysis of tumour blood supply is useful in determining best therapeutic approach. angiography visualises displaced ma, which helps the surgeon identify and ligate it during tumour removal. is an increased capsular width a reliable indirect indicator of temporomandibular joint effusion? f. tognini , d. manfredini , v. zampa , g. tognini , m. bosco ; pisa/it, parma/it purpose: to establish the most accurate cut-off value of ultrasonographic (us) capsular width which consents to discriminate between temporomandibular joints (tmj) with and without magnetic resonance (mr) effusion. the study group consisted of patients who sought treatment for temporomandibular disorders (tmd). all the tmjs (n = ) were evaluated in order to detect the presence of effusion by means of us and mr. ultrasonographic examination allowed measurement of the capsular width, in the sagittal-oblique scans, as the distance between the hyperechoic lines representing condylar surface and the glenoid fossa. after capsular width was measured, roc curve analysis was performed to establish the most accurate cut-off value to discriminate between joints with and without mr effusion. results: diagnostic accuracy of us to predict mr evidence of tmj effusion was good (area under the roc curve = . ). us sensitivity was high for values lower than the cut-off value of . mm (true positive rate (tpr) = . %; false positive rate (fpr) = . %), while specificity was high for values higher than the cut-off value of . mm (tpr = . %; fpr = . %). conclusion: ultrasonography proved to be accurate in detecting the presence of effusion in the temporomandibular joint. analysis of receiver operating characteristic curve seems to reveal that the critical area of capsular width indicating effusion is that around the value of mm. patients were referred for ct angiography of carotid arteries in our institution. of these patients, were found to have carotid body tumors and were included in the study. all tumors were confirmed with several imaging modalities (us, msct, mr, digital subtraction angiography and somatostatin scintigraphy) and with histologic examination performed on the resected surgical specimen. imaging findings: the us (including power-and color-doppler scanning), msct angiography, mr angiography, digital subtraction angiography and somatostatin scintigraphy findings of carotid body tumors were reviewed. tumors were unilateral in eight cases and bilateral in the remaining two patients. all lesions were well-defined (ranging in size from . to . cm) and located within the carotid bifurcation, causing splaying of the carotid branches. all tumors were highly vascularized (mainly by branches of the external carotid artery) and no sign of malignancy was identified. after pre-operative embolization, all lesions were surgically removed with no complications and were confirmed to be carotid body tumors at histology. the diagnostic possibility of a carotid body tumor has to be considered when a solid mass is detected within the carotid bifurcation. imaging studies are essential to differentiate carotid body tumors from other masses of the neck (lymphadenopathy, tumors, cysts, etc). imaging background: evaluation of cervical spaces is an important procedure for patients with cervical pathology because it assesses the prognosis of the patients and helps to select adequate treatment. ultrasound, computed tomography and magnetic resonance play an important role in the imaging diagnosis of this area. however, before examination of pathology, a clear understanding of the anatomy of cervical spaces is essential. the neck is divided into eight regions, enabling the radiologist to examine all areas of the neck in a systematic way in order not to miss a lesion. procedure details: we have reviewed all the normal studies of the neck that were performed during the last year using at least one of the three techniques. we selected the most illustrated cases to describe the anatomy of the cervical spaces. the neck is a complex anatomic area. this education exhibit helps the radiologist to have a better knowledge of imaging of the cervical spaces. preoperatively, the thyroid nodules were assesed in terms of number, compressibility, texture, complexity, margins, volume, vascularity, interactions with great vessels and the presence of thyroid, parathyroid and cervical lymph nodes. d usa multiplanar reconstructions (mpr) reslicing thyroid nodules for virtual surgery were created. us results were compared with intra-operative findings and final pathomorphology. results: fifty-three patients had operations ( lobectomies, thyreoidectomies including with lympadenectomies and thyroid resections). six cancers, adenomas, colloid nodules, goiters and with thyroiditis were found. demonstration of the nodules in three orthogonal planes by d usa and assessment of the nodule's character and vascularity helped to change surgical management in cases; in cases post puncture morphological diagnosis and in cases operation was rejected. d usa was superior to conventional d in differential diagnosis of thyroid nodules. the preliminary decision to perform a lobectomy or a total thyroidectomy was based on variety of factors, many of which were delineated by detailed ultrasound examination. preoperative evaluation of thyroid vascular anatomy and mpr of the nodules were of value for changing surgical management for thyroid resections and in rejecting the necessity of operation. conclusions: d usa is a useful complement to conventional ultrasound that allows precise preoperative evaluation of thyroid nodules which influences surgical management. the value of mr imaging and mr angiography in the differential diagnosis of carotid space tumors p. virtual laryngoscopy: comparison with fiberoptic laryngoscopical findings z. celej , a. wygoda , c. przeorek , w. przeorek , j. baron , a. siemianowicz ; gliwice/pl, katowice/pl purpose: to evaluate the concordance between virtual and direct laryngoscopy in the estimation of laryngeal carcinoma staging. material and methods: multislice ct and direct laryngoscopy were used to examine patients with laryngeal carcinoma. ct data were obtained on a sixteen row detector ( . mm slice thickness, pitch factor ) during free breathing and "e" phonation both before and after contrast enhancement. the patients were examined before radiotherapy and surgical treatment. postprocessing was performed using multiplanar rendering (mpr) and virtual laryngoscopy (vl) as a surface rendering algorithm with boundary density of - ,- and - hu. all ct examination results (mpr and vl) were compared with fiberoscopy. virtual images created at boundary density of - hu revealed better concordance to direct laryngoscopy. every case of laryngeal carcinoma, even plain infiltration at t stage, was correctly diagnosed by virtual endoscopy. the disorder of vocal cord function was better demonstrated in fiberoscopy. virtual laryngoscopy is complementary to fiberoptic endoscopy and should be combined with axial slices and mpr images for the estimation of laryngeal carcinoma staging. ultrasound characteristics and histopathologic correlation in primary thyroid carcinomas c. to describe the technique and problems related to spect/ pet/ct/us image fusion in the neck region and to demonstrate the clinical relevance of the information gained by multimodality imaging on a series of patients with neck tumors, lymph node metastasis, graves disease and chronic ent inflammations. background: small tumors or subtle changes in inflammatory diseases cannot be detected in only one imaging series. multimodality imaging allows for a combination of functional and anatomical information in one dataset and therefore gives more detailed informations on distinct changes. procedure details: for reproducible immobilization of the patient, an individual mold of the patient's head, neck and shoulder was produced using the bodyfix vacuum device (medical intelligence, schwabmünchen, germany). up to modality-specific markers were reproducibly attached to the skin and to the mold. the data-sets were transferred to the treon stealthstation navigation system (medtronic inc.) and image fusion was performed based on the markers and anatomical landmarks. image fusion allowed precise correlation of suspicious tracer-enhancements to tumorous contrast-enhanced nodules on the ct images. in patients with graves disease and ent inflammations focal disease in homogeneous tissues was uncovered due to increased tracer uptake. us images were used for screening and to depict vascularisation. the presented method aids in the detection of tumors and lymph node metastasis in the neck area, influencing the surgical strategy in most patients. in patients with graves disease and chronic inflammations the real amount of inflammation can be determined. lemierre's syndrome (necrobacillosis): the imaging findings s. powell, m. powell, d. bakshi, j. evans; liverpool/uk learning objectives: the purpose of our poster is to demonstrate the imaging findings in the rare and interesting lemierre's syndrome (necrobacillosis), to heighten clinincal suspicion and therefore allow more rapid diagnosis. background: lemierre's syndrome is the triad of pharyngitis, internal jugular vein thrombosis and pulmonary infection. the causative organism is fusobacterium necrophorum. this is a commonly fatal disease requiring both the radiologist and clinician to keep an index of suspicion. the diagnostic findings include pharyngitis with direct local invasion into the lateral pharyngeal space and thrombophlebitis of the internal jugular vein. metastatic infection is common and the usual site is pulmonary ( %). imaging findings: the imaging findings include pharyngitis with direct spread of infection into the lateral pharyngeal spaces. internal jugular vein thrombosis and pulmonary infiltration leading to cavitation are the next most common findings.other findings include pleural effusions, spinal and brain abscesses, septic arthritis and ivc thrombosis. a variety of imaging modalities are employed to assess the patient with disseminated fusobacterial infection. conclusion: our poster aims to provide a comprehensive collection of imaging findings in lemierre's syndrome. lymph node staging in head and neck cancer: a pictorial review s. connolly, h. lewis-jones, r. hanlon; liverpool/uk learning objective: the purpose of this poster is to describe and show the anatomical location of the lymph node levels as described by the american joint committee on cancer. it will also cover some of the difficult diagnostic areas involved in reporting head and neck staging images. background: as a radiological department attached to a large head and neck unit, we have wide experience of head and neck cancer. the extent and level of cervical node involvement is probably the most important prognostic factor for patients with a primary squamous cell carcinoma. node level has also been shown to be a highly significant predictor of survival. procedure details: using anatomical drawings and cross sectional images of pathology that we have encountered in our department, we will show examples of nodes in the described levels. the pictorial review will include examples of normal reactive nodes as well as typical examples of extracapsular spread, squamous cell cancer metastatic nodes and lymphoma. we will also depict some of the more unusual cases we have experienced, such as histologically proven recurrent metastatic nodes, which on imaging grounds appeared benign and cystic, along with some examples of intraparotid nodal disease. the pictorial review will allow greater understanding of the staging process of head and neck cancer and its implication on patient prognosis and survival. ten patients with squamous cell carcinoma of the neck (t - , n - ) planned for primary radiochemotherapy were examined at several time points in the course of the weeks therapy (before, after beginning, and at and weeks). the examinations were performed with aplio us-system (toshiba) with . mhz broadband transducer. pd and adf (either d and d) were applied pre and post application of ultrasound contrast agent (intravenous bolus of . ml sonovue). the methods were compared by visual assessment. results: both ce adf and pd are sufficient to depict blood supply. while pd delivers better b-mode information, adf allows continuous examination due to the lower mi thus giving more time to acquire d data set and determining signal intensity time curve after one bolus application of contrast. adf showed less artifacts concerning blooming and cluttering in number and extent in almost all cases. in cases, we were able to demonstrate a perfusion after weeks of therapy but in it was only possible using ce techniques. conclusion: although pd delivers more b-mode information adf is the method of choice since it has the same sensitivity for detecting blood vessels but allows continuous examination and is less susceptible for artifacts. conclusion: percutaneous islet cell transplantation appears to be a simple and clinical promising radiological intervention and an alternative to surgical pancreas transplantation in patients with type diabetes refractory to insulin therapy. imaging findings and procedure details: diagnostic imaging and interventional minimally invasive percutaneous procedures in disk diseases are reviewed through an interactive hypertext-based teaching file with images and movie demonstrations. ct, mr imaging and discogram findings in disk pathology will be described including degenerative disk diseases, spondylosis, disk herniations, traumatic disk diseases, septic diskitis, and postoperative disk diseases. techniques, indications, contraindications, complications and results of percutaneous minimally invasive procedures of intervertebral disk diseases will be described and illustrated. these procedures include percutaneous periradicular and epidural steroids injection, percutaneous diskogram, diskal biopsy and drainage, percutaneous radiofrequency and laser nucleotomy. conclusion: for disk disease with appropriate indications, minimally invasive interventional radiologic procedures are able to relieve pain and to minimize the risk of disability. colonic stents in acute malignant colorectal obstruction: cases p. bermudez bencerrey, j. falco fages, j. perendreu sans, j. fortuño andrés, m. alcantara moral, d. gil bello; sabadell/es learning objectives: to illustrate our experience with colonic stents in the treatment of acute obstruction from colorectal cancer. to describe the results and complications of the procedure based on a series of patients. background: colorectal cancer is an important health problem with a high morbidity and mortality rate. between - % of patients with colon cancer present with acute obstruction. % of acute obstructions are in the left colon and rectum, and only % of left sided carcinoma colonic obstructions can be treated with intraoperative lavage and subtotal colectomy. the rest of the patients need a temporary or, more probably, permanent colostomy with an important impact on quality of life. in this exhibit we will describe the use of colonic stents as a temporary treatment prior to elective surgery of left sided colon and rectal cancer and as a palliative treatment in the unresectable colon cancer. between july and august , patients with acute colonic obstruction were treated with colonic stents in our department. the procedure, indications, contraindications, and the results are described and illustrated. procedure details: plain abdominal radiography and abdominal ct was performed to all patients prior to the procedure. two different types of colon stents were used: enteral wallstent (boston scientific) and hanarostent (mitech co., ltd.) conclusion: clinical resolution of the obstruction was achieved in %. anastomosis was successfully performed in % of the patients undergoing surgery. major complications developed in % ( perforations, obstructions and migrations). palliative treatment was effective in all cases. saline injection of solid tumours prior to radiofrequency ablation: our experience a.m. camenzuli, a. attard, j.c. evans; liverpool/uk learning objectives: . to outline the procedure we have adopted to instil saline into the tumour. . to describe the appearances of complete necrosis on the inital, early and late follow-up scans. . to describe the complications and patterns of recurrence of tumours after radiofrequency ablation. background: the injection of saline to potentiate the effects of radiofrequency ablation in solid organ tumours in experimental models is well described in the literature. we have injected saline prior to ablation into primary hepatocellular carcinomas, colorectal metastases to the liver and primary renal cell carcinomas. procedure and iimaging details: using either ultrasound guidance or ct and under general anaesthesia, we lace the tumour with ml of % saline via a coaxial needle. a radioablation probe is then placed along the needle -the latter is then removed prior to applying the rf pulse. we routinely ablate the track along which the probe has travelled to avoid seeding. routine follow-up with a dual phase abdominal ct scan is done at month and months. the appearances of ablated tumours, recurrences and complications are reviewed in this presentation. conclusion: saline infiltration is a safe and effective way of potentiating radiofrequency ablation of solid tumours in the liver and kidneys. percutaneous background: renal abscess is a collection of purulent material confined to the renal parenchyma. it is often life threatening leading to septicemia and is difficult to manage only with the use of antibiotics especially in immuno-compromised patients. ct is currently the most accurate modality in detecting and following renal abscesses. treatment with ct-guided percutaneous drainage and appropriate antibiotics can be very useful. in a period of two years we treated patients with renal abscesses. we demonstrate the technique and discuss the indications and complications of ct-guided percutaneous drainage of renal abscesses. the procedure is performed with the patient in prone position under local anesthesia supplemented with minimal sedation. initially a gauge chiba needle is passed into the renal abscess under ct guidance. on confirmation of an abscess we use a pigtail trocar catheter of to f for the drainage. conclusion: ct-guided percutaneous drainage is an effective and well-tolerated method for the therapeutic management of renal abscesses. the imaging features and percutaneous drainage of mediastinal abscesses secondary to oropharyngeal infection s. sadiq, s. owen, r. evans; swansea/uk learning objectives: oropharyngeal infection, such as dental abscess and acute pharyngitis, are recognised but rare causes of mediastinal abscess formation. we highlight the use of multimodality imaging and percutaneous image guided drainage. the hospital records of four such patients, including casenotes, microbiology data and imaging were reviewed. the clinical courses were followed in order to identify the causative pathogen and illustrate the imaging features and subsequent radiological interventional management. the patients presented over a two-year period. the age range of these patients was sixteen to forty seven. the primary aetiology in three patients was a dental abscess. the fourth patient had an acute pharyngitis. image findings: a combination of ultrasound (us), computed tomography (ct) and magnetic resonance imaging (mri) of the neck and thorax was used to define the anatomical compartments involved. radiological placement of an fpigtail catheter using us or ct avoided a major surgical procedure in all patients. the common pathogen isolated was streptococcus viridens. patients were treated with the appropriate antibiotics and all made an uneventful recovery. conclusion: an understanding of the anatomical spaces of the neck and their communication with the mediastinum is demonstrated and we recommend that in this condition, which has a high mortality when managed surgically, interventional radiology is an effective treatment option with a low complication rate. complications occurring after drainage are not uncommon and add to the morbidity of the procedure. the authors display their experience in handling complications (remedial procedures with appropriate images) that occurred in patients with malignant biliary obstruction, in whom ptbd and/or stenting was performed over a -year-period. the authors will also list precautions to be observed to prevent such complications. procedure details: severe hemorrhage was treated by catheter repositioning, angiographic embolization of pseudoaneurysm and coil embolization of a portal vein branch rent via a ptbd tract. cholangitis and bilomas required placement of additional drainage catheters. a migrated plastic stent was repositioned with vascular snare. a ring biliary catheter that broke during procedure, the proximal part lying in peritoneal cavity, was removed by image guided forceps, followed by replacement. blocked plastic stents were removed endoscopically or via the percutaneous route by canulation with a guidewire followed by replacement. ring biliary catheter and additional stents plastic/metallic stents were used for blocked metallic stents. pericatheter leaks responded to flushing, wire passage or larger catheter exchange. conclusion: it is important to be aware of complications that occur during ptbd and stenting, and how to deal with them before embarking on a full time biliary decompression program. intellectual property: development and protection c. cook , m. rees ; weston-super-mare/uk, bristol/uk learning objective: to discuss the different methods of intellectual property (ip) protection. to review the methods of interventional radiology device product development. background: there are many ways of protecting intellectual property. we discuss each of these in turn. we discuss the differences between the methods used in the united states and the european union. we also discuss the methods of product development. details: trademark, copyright, patents are all reviewed. we discuss the need for patent attorneys and specialist ip management units. we describe the different types and levels of protection available. we also discuss specific means by which an idea can be developed, then protected. we look at the methods available to link with development companies, leading to manufacture. all the principles are specifically discussed with respect to the development of a interventional radiological device. there are numerous ways of protecting ip, and we describe each of these in turn. in addition we look at the means of developing and ultimately manufacturing a radiological interventional device. purpose: ethanol injection (pei) and radiofrequency (rf) are the percutaneous radical therapies most frequently employed in europe to treat liver tumors in non surgical patients. we present our experience in these techniques over the last years at the hospital clinic in barcelona. since multisession pei was applied in patients with hepatocellular carcinoma (hcc) (uninodular ≤ cm or multinodular ≤ cm). rf was performed in patients since : hcc, metastasis and others. ct and us (with contrast agents in the later years) were used for efficacy assessment. results: pei: initial complete response (cr) = . %. extra and intratumoral recurrence = and %. one, and year survival rates in child a patients = , and % and in child b patients = , and % (mean follow-up = months). rf: cr in hcc patients = %. extra and intratumoral recurrence = and %. one, and years survival rates = , and % (mean follow-up = months). in patients with metastasis cr = %, with a recurrence rate = % (mean follow-up = months). major complications, that includes hemoperitoneum, liver abscess, needle-tract seeding and cardiovascular death are . % in pei and . % in rf. conclusion: pei and rf are effective local curative methods in liver tumors, with more frequent major complications in the rf group. and excellent ( - ). the efficacy was also evaluated with the days until the patients unable to move started to walk again after pvp. results: pvp was technically successful in all patients with three cases of minimal complications. the mean vas score for patients was . before pvp compared with . after the procedure. on the degree of improvement, the groups of ineffective, poor, effective and excellent consisted of . , . , . and . % of patients, respectively. patients ( . %) could walk the next day after pvp and the mean value until ambulation was . days. conclusion: pvp is a safe and effective treatment for relieving severe pain of osteoporotic vertebral compression fractures, leading to avoid various complications associated with prolonged immobilization in aged patients. effect of vessel size on creation of pulmonary radiofrequency lesions in sheep: assessment of the "heat sink" effect k. steinke , k.s. haghighi , k.k. hazratwala , d.l. morris ; basle/ch, sydney/au purpose: to evaluate the effect of vessel size on radiofrequency lesion creation in the lung with respect to potential for perfusion-mediated heat sink effect and for vascular and bronchial injury. methodology: radiofrequency lesions targeted to tissue encompassing a variety of vessels were created in vivo in the lung of cross-bred sheep. the access was either open after thoracotomy along the th intercostal space, or percutaneous. acute, subacute and chronic changes have been investigated, with immediate, hours and days sacrifice of the sheep post ablation. macroscopic and histopathologic analysis of the vessels and bronchi was performed. the degree of vascular and bronchial injury and viability of perivascular pneumocytes were recorded. results: heat sink effect, macroscopically indicated by invagination of the lung tissue between the vessel and the radiofrequency lesion, was not observed in vessels with a diameter less than mm. half of the vessels mm or smaller were thrombosed, while the arteries of the same size looked to be patent. macroscopically no vessel wall injury could be detected. all vessels mm and above showed a certain extent of invagination, no clots were visible. occasionally within the bronchial lumen small amounts of dark solid material was seen, macroscopically believed to be consolidated blood-tinged sputum. the histopathological results are expected soon. conclusion: as already shown for liver vessels, lung vessels seem to also have a perfusion-related heat sink effect, consistently seen in vessels above mm in diameter. peritoneal seeding of hepatocellular carcinoma after radiofrequency ablation: post-rf bleeding was detected in cases. two of these patients had hepatic arterial embolization performed due to severe bleeding. in terms of seeding pattern, massive perihepatic and ometal masses were seen in cases and multiple small peritoneal nodules were noted in a further cases. other cases showed small single mesenteric mass and gastrohepatic ligament thickening. the rate of peritoneal tumor seeding after rf ablation of hcc was . %. the capsular attachment, tumor bulging and post-rf bleeding seems to be risk factor of peritoneal seeding after rf ablation of hcc. r. marcello, l. broglia, m. castellana, g. gasparini, m. castrucci; rome/it purpose: the aim of our study was the evaluation of the spio contrast-enhanced mr pattern of malignant focal liver lesions treated with percutaneous radiofrequency ablation. methods and materials: focal liver lesions were evaluated with magnetic resonance ( . tesla philips, the netherlands), with spio (resovist schering, germany) contrast media after rf percutaneous ablation. lesions ranged in size from . cm. to . cm. mr examination sequences protocol was as follows: tfe t w and ffe dynamic study before contrast media injection and after and sec spio iv administration; tse t w and spir tse t w before contrast media injection and after - min after spio injection. all patients underwent mr imaging evaluation after days, days and months the procedure was carried out. the signal intensity appearance was examined in order to identify size, signs of absence, residual or recurrence of neoplastic tissue. the gold-standard was clinical and ct imaging follow-up. results: spio enhanced sequences were superior in conspicuity, presence or absence and residual or recurrence of tumoral tissue. in % of lesions a homogeneous pattern was observed within the lesion with a hyperintense peripheral rim; in % of cases inhomogeneity of lesions was observed in examinations performed at days. residual tumor was depicted at days examination as presence of hyperintense foci localized within the treated area. in this preliminary study spio appeared to be an efficacious contrast agent for detection and follow-up of percutaneous rf ablated focal hepatic lesions, especially on t w and the sec t w dynamic mr study. radiofrequency ablation of hepatic dome lesions g. papaioannou, l. thanos, a. nikita, e. alexopoulou, d. loggitsi, d.a. kelekis; athens/gr purpose: to present the additional difficulties and technical peculiarities of radiofrequency ablation (rf) for hepatic dome lesions. materials and methods: patients with focal subphrenic hepatic lesions ( hccs, metastases) underwent percutaneous ct-guided rf ablation. electrodes with or active tips were advanced under ct-guidance. although technically difficult due to the great needle angulation and penetration of a long hepatic portion, transhepatic route was followed in all cases. transpulmonary penetration was considered high-risk due to the large diameter of the electrode. results: all patients experienced mild discomfort during the procedure. three complications were noted: small subcapsular hematomas and pleural effusion, which were treated conservatively. % of the hccs and . % of the metastatic lesions showed signs of complete necrosis immediately post procedure. residual non-necrotic tumour was present in cases and repetition of the procedure was required. tumour recurrence was demonstrated in patients ( . %) on -year follow-up control and was treated with a new session of rf ablation. overall, rf sessions were performed. conclusion: hepatic dome lesions can be treated successfully with rf ablation. careful planning and technical skill are required due to their location. results: no treatment complications were noted. the patients recovered well post injection. ct performed in both children after three months showed ossification of the lytic lesions, allowing the cervical braces to be removed. conclusions: to our knowledge no prior experience in endosteal cervical steroid injection has been reported. these two cases confirm the improvement of osteolytic lesions in children with lch after treatment with endosteal infusion of steroids. stabilisation of the cervical spine was particularly beneficial, as the children were no longer in pain and removed the need for cervical braces three months after the treatment. the influence of radiofrequency ablation on hepatic vessels in porcine liver k. satoh, k. nakamura, m. hamuro, y. sakai, n. nishida, y. inoue, r. yamada; osaka/jp purpose: the objective of this study was to clarify the influence of radiofrequency ablation on hepatic blood vessels. hepatic rfa was performed on swine (mean body weight: kg). the livers were removed either immediately following ablation, week or weeks after ablation. the patency of vessel was determined by ct, and the extent of endothelial disorder with diameter less than . mm was determined histopathologicaly. the portal vein patency rate of immediately, or weeks after rfa were: . ± . %, . ± . % (less than . mm), . ± . %, . ± . % ( . mm and more). hepatic vein patency rate were: . ± . %, . ± . % (less than . mm), . ± . %, . ± . % ( . mm and more). the patency rate was higher for larger vessel diameters. the patency rate of the portal and hepatic veins with diameters less than . mm was found to decrease with time. at weeks after ablation, the patency rate for vessels with diameters of . mm and over were significantly higher (p < . ) compared to those of diameters less than . mm. endothelialization were found in patent vessels from week to weeks after ablation. conclusion: endothelization was confirmed from week to weeks after rfa in patent vessels. blood vessels with diameters of . mm and over maintain high patency even after rfa. it is therefore possible to maintain blood flow in the distal area of hepatic parenchyma following ablation for hepatic tumors, thus rfa has a limited impact on hepatic function. in three cases, a successful second trial after an initial failure was performed. the procedure was performed by means of a transhepatic (n = ) or a transperitonea l (n = ) access route. during procedure, the seldinger technique was used (transhepatic approach, n = , transperitoneal approach, n = ) in patients, while in the remaining patients the procedure were performed using a trocar technique with a transperitoneal approach. chiba needles ( g, mdtech, denmark, n = ), jelco needles ( g, johnson & johnson, usa, n = ) and secalon catheters ( g, ohmeda, uk, n = ) were used for initial puncture of gb. only minor complications such as abdominal pain (n = ), hemorrhage (n = ), referred pain (n = ) occurred in cases ( %). abdominal pain is more frequent in transhepatic approach ( %) than in transperitoneal approach ( %), but not statistically significant (p = . ). overall complication rate is lower in transperitoneal approach ( %) than in transhepatic approach ( %)(p = . ). according to puncture needle, there is no significant difference in complication rate between the chiba needle ( %) and the g needle (jelco needle and secalon catheter, %). conclusion: percutaneous cholecystostomy has proved to be safe and effective treatment for patients with acute cholecystitis. t.v. bartolotta, t. angileri, m. midiri, f. sorrentino, g. sparacia, a. carcione; palermo/it purpose: to evaluate the ct role in treatment of lumbosciatalgia through chemonucleolysis with oxygen-ozone (o -o ) mixture with periradicular and periganglionic technique. materials and methods: from january to june , patients ( women, men; age range: - years) with lumbosciatalgia, underwent intradiscal, periradicular and periganglionic treatment with o -o mixture, corticosteroids and anaesthetics. the analysis of the results was made by visual analogue scale (vas) day before treatment (t ) and, respectively, weeks (t ), months (t ), months (t ) later. all the procedure was performed in a step-wise fashion and controlled by ct scans: from positioning the needle in the centre of the nucleus polposus to mixture administration within the nucleus and in periradicular and periganglionic sites. results: in / ( . %) patients a partial remission of the complaints just after the first treatment (vas at t ) was observed; vas was at t and at the last evaluation, six months later (t ), it was . in / ( . %) patients vas was at t and another treatment was performed, with an improvement of vas at t and t respectively of and in / cases. the remaining / patients did not show any improvement even after the second treatment and vas ranged from to at t . conclusions: chemonucleolysis with o -o mixture with periradicular and periganglionic technique under ct guidance is a reliable and competitive method in treatment of lumbosciatalgia. multiple in patients with malignant biliary obstruction of the hilum and unavailable bilateral access, drainage of biliary tree was obtained with one percutaneous access through which multiple stent deployment was performed with a cross-positioning technique. the first self-expandable endoprosthesis was positioned in the common bile duct. thereafter a balloon catheter was inserted along a previously introduced guide wire to dilate the mesh of the stent. after having removed the catheter, a second stent was implanted through the dilated wall of the first stent, across the hilum. overall stents have been cross-implanted. in patients stents have been inserted, in patient stents, in another patient cross-positioning of stents was required. results: no relevant complications have occurred. patient survival and stent patency rates were comparable with those of multiple-access stenting technique. the procedure is generally more protracted implying an increased radiation exposure for both the patient and the operator. conclusion: biliary stenting with one percutaneous access and cross-positioning technique is a useful procedure in all cases in which bilateral access in not possible. it reduces the risks connected to multiple passages of liver parenchyma though at the expense of a longer time of exposure for both the patient and the radiologist. results: in ( %) patients pain relief was complete within one to two days after injection. one ( %) patient with multilevel hemangioma failed to respond. we did not observe any complications. conclusion: percutaneous vertebroplasty is a promising therapy for patients with painful vertebral hemangiomas. this method is effective, with low risk of complications, and may be appliciable to asymptomatic cases as a preventive treatment. percutaneous a retrospective analysis was performed of percutaneous nephrostomies in patients ( male, female; age range: days- years). twenty patients had bilateral nephrostomies and patients were recatheterized. the procedures were performed with sonographic and fluoroscopic guidance under sedation or general anesthesia. the catheters ( . - fr) were placed either with a seldinger technique or an accustick introduction system. results: percutaneous nephrostmy catheters were placed due to up junction obstruction in patients, uv junction obstruction in patients, posterior urethral valve in patients, neurogenic bladder in patients, congenital anomalies in patients, trauma in patients, stones in patients, tumor in patient and renal insufficiency in patients. pyonephrosis was detected in patients. nine dislodged catheters were replaced percutaneously. all procedures were carried out successfully. no procedure related mortality was seen. one patient arrested right after the procedure because of methemoglobinemia due to local anesthetic and treated with methylene blue. no other major complications were detected. catheter dislodgement and infection were detected in and patients, respectively. duration of catheterization was between and days. all the catheters were removed after medical, surgical or percutaneous treatments. conclusion: image guided percutaneous nephrostomy in pediatric population is a safe and effective procedure with low mortality, morbidity and high success rates. percutaneous ct-guided facet screw fixation in lumbar spines: technical aspect h.y. kang, s.h. lee; seoul korea/kr purpose: to report our experience of the technique of percutaneous ct-guided facet screw fixation of cases in lumbar spines. the ct gantry has an angle tilt limitation of approximately . degrees, but the z-axis (coronal) angle of facet joints is about - degrees. thus under local anesthesia, positioning was head first, prone with cephalad elevation of upper body to compensate for the facet angle. after selecting the route of the procedure, the guide wire and fixed screws were inserted, after measurement of the size of fitting screw. this procedure was performed in patients, with combination of anterior lumbar interbody fusion (alif, patients) and cases of discitis ( patients). results: all procedures of facet screw fixation with alif were performed successfully, there were no definite malpositioning of screw or segmental instability on postoperative images at one month follow-up. in cases of discitis, the procedure were performed also successfully, but with more slightly decreased disc height on image at one month follow-up. the controlateral translaminar facet screw fixations were performed at the levels of l - and l - , and ipsilateral transfacet screw fixations were done at l -s level. conclusion: percutaneous ct-guided facet screw fixation in lumbar spines was a safe and reliable procedure for a method of spinal fusion. minimally invasive management of benign biliary diseases a. doros, v. weszelits, a. peter, a. nemeth; budapest/hu purpose: report our experience in treating percutaneously benign biliary strictures, fistulas, post-operative leakages, residual stones/sludge, bilomas and abscesses. in the last five years, patients ( women, men, - years) with benign biliary diseases were referred to our interventional radiology unit. twenty patients underwent laparoscopic or open cholecystectomy, six had residual stones, three had biliary fistulas. twenty patients had hepatico-or duodeno-jejunostomy stenoses, four had cholangitis-induced liver abscesses, and three had chronic pancreatitis. results: forty percutaneous biliary interventions were performed with good longterm results. strictures were dilated times. six metallic stents were placed into three patients. two plastic stents were placed in one patient with a rendez-vous maneuver. two fistulas were treated with drainage and glue. five stones were removed percutaneously with balloons or dormia baskets. one patient with chronic pancreatitis was treated with a metallic stent. another patient underwent insertion of three metallic stents for intrahepatic stenosis. of the four abscesses, two were surgically and one was percutaneously drained. one patient had two small abscesses treated with iv antibiotics. conclusions: percutaneous management is useful in selected benign biliary diseases. dilatation, stone extraction, and abscess drainage can be performed successfully. in difficult cases combined surgical, endoscopic and percutaneous approach must be chosen. role of aspiration-lavage in the treatment of abscesses in the gallbladder bed after laparoscopic cholecystectomy a.b. stoian, z.a. sparchez, r. badea; cluj napoca/ro purpose: the evaluation of the efficacy of ultrasound guided aspiration followed by lavage with antibiotics in the treatment of gallbladder bed abscesses after laparoscopic cholecystectomy. materials and method: patients with gallbladder bed abscesses were treated percutaneously between - . the abscesses were located in gallbladder bed with extension into subhepatic area % ( / ). the volume of aspirated pus was - ml (average ml). the first step of the treatment was the abscess puncture by a transhepatic % ( / ) or another approach % ( / ) using an g needle ( . mm). after pus aspiration, the cavity was washed - times with a metronidazol + ampicillin solution, the amount of antibiotics once injected being half the amount of the aspirated pus. oral or iv antibiotics (corresponding to antibiogram) were administrated for - days. in the case of fluid reaccumulation the treatment was repeated. background: ptpe is a reliable tool to induce liver regeneration of the nonembolized lobe. this facilitates extended right resection in e.g. klatskin tumor, hcc or liver metasases. between and we performed ptpe. in three cases we noted a failure in regeneration of segment ii + iii but a growth of segment iv after right lobe embolization. in portal vein ligations which regularly spare segment iv the regenerative outcome was significantly reduced compared to ptpe including segment iv. procedure details: in / patients we use a subxiphoidal access to puncture the left portal vein under us-guidance, otherwise a transhepatic right intercostal access. via f guiding catheters a . f microcatheter is placed in each segmental branch in order to apply - ml histoacryl-lipiodol solution in total. segment iv branches are difficult to reach because of the configuration of the rex recessus anatomy. since the left lateral segments lie adjacent, the emolization of segment iv is critical and has to be performed with the utmost care to prevent spill over of embolzation material. conclusion: segment iv turnes out to be the key for optimal portal vein embolization results. although bearing the risk of embolization material displacement to segment ii and iii the better results clearly suggest application of this technique. . palliation of duodenal obstruction via trans-oral route (n = ) and trans-gastric route (n = ). procedural details and results: for group and , and the trans-oral route in group , the technique is essentially an extension to the well established technique of oesophageal stenting of malignancy (except longer wires and catheters are used when more distal stenting is required). as more distal lesions are tackled, the intrinsic difficulty of manipulating long wires and catheters increases and gives way to the more direct transgastric route approach of group . this is also an extension to the well established technique of radiological insertion of gastrostomy using t-bar fixation. failure of insertion occurred in patients in the duodenal obstruction group via the trans-oral route. there were no immediate or delayed complications and no re-interventions were required. five patients ( %) returned to normal diet, patients managed semi-solid diet ( %) and patients ( %) had no significant improvement post stent insertion respectively. the mean survival for groups ( ) and ( ) (i.e. primary carcinoma) was days (range to days). conclusion: radiological placement of gastroduodenal stents is effective for palliation of upper gi malignancies. impact of multi-detector-row-ct ( x) prior to angiographic intervention m.s. juchems, s. pauls, h.j. brambs, a.j. aschoff; ulm/de learning objectives: to demonstrate the additional impact of contrast enhanced multi-detector-row-ct angiography (mdr-cta) compared to digital subtraction angiography (dsa) for planning of angiographic intervention. backround: in selected cases a pre-interventional cta can be useful to facilitate angiographic intervention. we selected four patients with different disease entities (pulmonary av malformation; bleeding caused by hepatic aneurysmosis and from renal pseudoaneurysm after partial renal resection; hepatocellular carcinoma (hcc) prior to transarterial chemoembolization (tace) with aberrant arteries) from our collective who underwent cta prior to angiographic intervention. procedure details: all ct scans were performed using a channel multi-detector-row-ct (philips mx idt). both multiplanar reconstructions (mpr) and slab maximum intensity projections (slab mip) were performed. after cta, patients underwent angiographic intervention (coil embolisation in the first three, tace in the last case). mdr-cta can demonstrate the exact extent and localize multiple vascular malformations, as demonstrated in the first case. in addition, mdr-cta can not only find the cause of hemorrhage but also demonstrate the exact localization of the specific vascular pathology ( nd and rd case). these findings facilitate the intervention, resulting in decreased in three children, a renal artery stenosis between and % due to fibromuscular dysplasia was discovered. in two of these three, the stenosis was unilateral and in one bilateral. in the remaining child, a long stenosis of unknown etiology was discovered. procedure details: in all patients, ptra was performed after having exactly defined the morphology and the hemodynamics of the renal artery stenoses. in three children we have achieved very good. results: ptra was successful resulting in an increased diameter of the arterial lumen. ptra was repeated and unsuccessful in one child with a severe stenosis and an emphasised "recoil" phenomenon. autotransplantation was therefore performed. reference is made to current controversies on this issue. background: endoluminal repair is an acceptable treatment modality for abdominal aneurysms. implant selection is based on the aneurysm's neck anatomy, resulting in two main implant groups; those fixed above the level of the renal arteries, and those fixed below this level. each group presents advantages and disadvantages that should be considered in the selection process. type i endoleaks are the most common complications derived from implant selection. procedure details: in order to select the implant, the patient should undergo a contrast-enhanced abdominal ct scan with coronal reconstructions to image in detail the abdominal aorta, and measure the size of the aneurysm, the distance from the renal arteries to the upper border of the aneurysm, and several other measurements needed. alternatives are abdominal aortic dsa and mra. the two main features that will determine the fixation site are the neck's shape and distance. sealing is always infrarenal. suprarenal devices provide better fixation, although some series report small renal parenchyma infarcts, due to emboli. infrarenal devices are easier to handle, provide for small corrections one placed, but cannot be placed in tortuous necks. conclusions: two main implant groups are used in endoluminal abdominal aneurysm repair, the suprarenal and infrarenal fixation devices. proper patient selection is needed to decide which device is to be used, in order to minimize post-procedural complications. in-vivo transcatheter implantation of a new aortic stent-valve for the temporary relief of acute aortic insufficiency m. hashimoto , t. kaminou , p. haage , y. ohuchi , k. nakamura , k. sugiura , y. noishiki , r.w. günther , t. ogawa ; yonago/jp, aachen/de, yokohama/jp purpose: acute aortic regurgitation is a life-threatening condition, particularly when associated with type a aortic dissection or aortic ectasia. the aim of this animal study was the evaluation of a novel temporary stent-valve as a potential temporizing measure to prevent progression to sudden death until conventional surgical repair can be performed. an umbrella-shaped highly porous polyester mesh valve was placed in the subcoronary portion with the attached metallic stent fixed in the ascending aorta. the prosthesis (stent-valve) was implanted in pigs via the right carotid artery through an fr introducer. the efficacy of the valve was assessed by aortography, pressure measurement and electrocardiography. hour after the implantation, the animals were killed and the stent-valve was subjected to macroscopic examination. results: a severe peri-prosthetic leak and cardiac arrest due to the deep implantation of the stent-valve were seen in case. although, a few premature ventricular complexes were seen in and slight blood stagnation in the valsalva sinus was seen in two, excellent performance of the mesh valve was demonstrated in of cases. there was no significant thrombus formation inside the umbrella valve. the presented new temporary stent-valve shows promise for possible future clinical application. further studies are necessary to assess valve thrombogenicity and coronary flow. percutaneous ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) with hepatic posttransplantation biliary complications who required treatment with interventional radiology techniques. were pediatric patients and were adults. diagnostic percutaneous transhepatic cholangiography (ptc) was performed in all patients, followed by placement of an internal-external biliary drain in the same procedure. in patients presenting with stenosis in the area of the anastomosis, dilatation with balloon angioplasty was also carried out. in patients with biliary calculi, lithotomy was performed followed by expulsion of the calculi to the digestive tract. one patient presented with a massive biliary leak that did not respond to percutaneous drainage and required implantation of a metal prosthesis. results: the transhepatic approach was used for the diagnostic study, for locating the cause of the complication and to carry out the therapeutic maneuvers required for its resolution. in the patients studied, the initial outcome of percutaneous treatment was satisfactory ( % technical success) and in of them ( %) it was the definitive therapeutic measure. among the remaining patients, underwent surgical re-anastomosis and re-transplantation. drainage placement was beneficial in all patients, allowing elective surgical treatment once the infectious-obstructive complication was resolved. conclusion: interventional radiology plays an important role in the therapeutic management of hepatic post-transplantation biliary complications. ptc allows precise early diagnosis of the complication. the interventional technique reduces the need for reoperation, thereby reducing associated morbidity and mortality. a comparative study of transjugular intrahepatic portosystemic shunt and transcatheter sclerotherapy for gastric varices t. ninoi , k. nakamura , n. nishida , y. sakai , t. kitayama , m. hamuro , r. yamada , y. inoue , t. kaminou ; osaka/jp, yonago/jp purpose: the rupture of gastric varices (gv) is a serious complication in patients with portal hypertension. transjugular intrahepatic portosystemic shunt (tips) and transcatheter sclerotherapy (ts) are effective treatments of gv. the effects on the portal pressure completely differ in tips and ts. however, to our knowledge, no comparative study of the two treatments for gv has been reported. the purpose of this study was to compare tips with ts on gv bleeding and survival. materials and methods: a total of cirrhotic patients with gv underwent endovascular treatment. of the patients, without hepatocellular caricinoma were enrolled in this study; patients were treated by tips, and patients by ts. gv bleeding and survival rates were compared between the tips and ts groups. multivariate analysis was used to identify the prognostic factors for gv bleeding and survival. results: the cumulative gv bleeding rate at year was % in the tips group, and % in the ts group (p < . ). the prognostic factor associated with gv bleeding was the treatment method. the cumulative survival rates at , , and years, were %, %, and %, in the tips group, and %, %, and %, in the ts group, respectively (p < . ). the prognostic factors for survival were the treatment method and the child-pugh classification. conclusion: ts may be more useful for gv than tips in consideration of gv bleeding and survival. results: tpsae was technically feasible in all patients without procedure-related complications. despite significant higher injury grade ( . vs ), higher rate of active contrast extravasation ( % vs %) and higher amount of hemoperitone-um on ct, secondary bleeding rate requiring splenectomy was lower in the tp-sae group ( . % vs %). conclusion: tpsae is a feasible and safe procedure in the treatment of splenic injury. tpsae allows a non-operative management despite a selection of severe splenic injuries with one of the lowest reported secondary splenectomy rates. recanalization of acute vertebro-basilar occlusion by a coronary waterjet thrombectomy device t.e. mayer, g.f. hamann, h. brueckmann; munich/de purpose: with a death rate of more than %, vertebrobasilar thromboembolism still remains a dangerous disease. this high rate can be mainly attributed to the overall failure of recanalization of %, depending on the extensiveness of the clot. this is especially in multisegmental occlusions, where the recanalization rate is very low and mortality is about %. we investigated the feasibility of using a coronary mechanical device based on the bernoulli effect (angiojet) for rapid recanalization. methods: ten patients with acute vertebrobasilar occlusion were included in the pilot study. inclusion depended on the presence of multisegmental intracranial ( patients) or any extracranial occlusions and coma lasting no more than hours. local intra-arterial fibrinolysis had failed in two patients before the angiojet was used, and thrombolysis was administered to two patients afterwards (rt-pa). five patients underwent additional intracranial balloon or stent angioplasty, and five received platelet inhibition by tirofiban. results: treament was primarily done with the angiojet and succeeded in complete recanalization in % of the patients ( % of the vessel segments). addition of fibrinolysis resulted in success in % of patients and segments. three hemorrhages were associated with additional thrombolysis, tirofiban, or both. seventy percent of the patients survived, and % had moderate to excellent outcome. the use of the coronary angiojet in the vertebrobasilar system is feasible. a success rate of % recanalization was achieved in a pilot study. compared to historical data of multisegmental thrombosis, the death rate was cut in half and good neurological outcomes increased. experience of transradial and transulnar abdominal angiography and intervention t. sato, m. kajikawa; hiroshima/jp purpose: in coronary angiography and angioplasty, transradial and transulnar approach has currently been accepted as an alternative catheterization method to transfemoral or transbrachial approach. the purpose of this study was to report practical and clinical applicability of these methods in abdominal angiography and intervention. methods and materials: between february and august , abdominal examinations were tried transradially or transulnarly in cases. cases were for liver or gall bladder tumor, cases were for other abdominal tumors, cases were due to gastrointestinal bleeding, cases were for renal or superior mesenteric arterial thrombosis and case was for ulcerative colitis. examinations were with further intervention. cases were examined twice, cases were examined times, case was examined times, cases were examined times, case were examined times and cases were examined times during this period, transradially. results: radial puncture was failed in examinations ( . %) and changed to brachial puncture. in cases with weak radial pulsation, ulnar puncture was tried. in cases of hepatocellurar carcinoma, superselective catheterization was also available and transarterial chemoembolization was done. in cases of abdominal branch aneurysm, successful coil embolization was done in cases and a femoral approach was needed on another occasion for complete embolization in one case. no puncture site hematoma was seen. radial arterial stenosis was found in cases at the next examination. no cerebrovascular problems were noted. conclusion: transradial and transulnar approach are alternative catheterization methods even in abdominal angiography and intervention. pre-and post-operative ct scans before discharge, at , , months and biannually thereafter were performed; pla and pima were evaluated in each followup scan and the number of pla was counted.these data were correlated with the frequency of el-ii. pre-and postoperative volumes of the aneurysmal sacs were measured from ct data. results: median follow-up was months (range - months).in total ct scans were performed and analyzed. six months after stent-graft implantation pima and/or at least pla were seen in patients ( . %); patients ( . % of the study cohort) had an el-ii. no el-ii was seen in patients without pla/ pima. three groups were identified and compared: patients without pla/pima/ el-ii and patients with pla/pima with/without el-ii. a tendency to minor mean volume loss in patients with pla/pima and a significant trend to volume increase in patients with el-ii in later follow-ups was seen. conclusion: there is a high incidence of pla/pima in patients after evr. persistent lumbar and inferior mesenteric artery perfusion is associated with significantly higher el-ii rates after evr of aaa. significant differences in volume changes in later follow-ups were seen between patients with or without el-ii. chemoembolization of hepatocellular carcinoma in candidates for orthotopic liver transplantation: histopathologic findings s. terraz, p. majno, l. rubbia, p.-a. schneider, c.d. becker; geneva/ch purpose: to evaluate the effects of selective transarterial chemoembolization (s-tace) in patients with suspected hepatocellular carcinoma (hcc) before orthotopic liver transplantation (olt). materials and methods: candidates for olt, with viral or alcoholic cirrhosis and a total of nodules suspected to be hcc ( - nodules of . - . cm), underwent s-tace with doxorubicine/lipiodol in - sessions. catheter position was segmental or subsegmental in % and unilobar in %. particles were added unless complete stasis was observed. the delay between s-tace and olt was ( - ) days. histologic findings of the explanted livers was correlated with all clinical, biologic and radiologic parameters. results: based on the final diagnosis, nodules were hcc, five were regenerative nodules and one was focal nodular hyperplasia. we observed total or neartotal necrosis (> %) in ( . %) hcc nodules and no dissemination was present. twenty-three hcc ( . %) nodules were partially necrotic; in of these, capsular and/or vascular invasion were present. one patient developed a pseudoaneurysm at the puncture site; no other complication was observed. conclusion: s-tace leads to complete necrosis in the majority of hcc nodules. olt candidates with a long waiting period should be followed by repeated imaging studies, in order to be able to prevent tumor regrowth or spread by repeating s-tace when necessary. kasabach merritt syndrome: treatment with transarterial embolization k.s. malagari, d. antonopoulos, d. loggitsi, d. danassi, a. rigopoulou, a. sissopoulos, a. nikita, g. papaioannou, d. kelekis; athens/gr aim: kasabach merritt syndrome is a rare life threatening condition characterized by consumption coagulopathy, most often associated with liver hemangiomas. we report on the value of transarterial embolization in the treatment of this condition. material and methods: two patients are included in the study (mean age yrs, range - ). both were women. kasabach merrit was the first manifestation of the liver lesion in one patient and a complication of a known cavernous liver hemangioma in the second. hct values were % and %, plt , and , / mm , fibrinogen and mg/dl respectively. spiral ct of the liver showed typical hemangiomas with a lace-like enhancing pattern (mean diameters and cm respectively). patients were infused with platelets, fresh plasma, cryoprecipitates, aprotinin and antithrombin prior to embolization. one patient required also units of packed red blood cells. selective hepatic angiography was performed prior to embolization, followed by superselective injection of the feeding vessel(s). microspheres of - microns were injected under fluoroscopic guidance until cessation of flow. the procedure was uneventful in both patients. partial restoration of plt cell count was observed from the following day and within a week fibrinogen levels and plt levels were completely restored in one patient and partially to the other. conclusions: transarterial embolization may be life saving in kasabach merritt since it can safely control coagulation abnormalities and allows planning for more definitive treatment including surgical resection or liver transplantation for non operable hemangiomas. in vivo characteristics of microspheres injected into the hepatic arteries of rabbits: angiographic and microscopic comparison of embosphere and beadblock m. takahashi, y. saida; tsukuba/jp purpose: the authors presently utilize non-resorbable microspheres (ms) for the transarterial embolization (tae) of hepatocellular carcinoma (hcc). to correlate their clinical features and in vivo characteristics, two different types of industrially-produced ms, injected into the hepatic arteries of rabbits, were microscopically compared. eight japanese-white rabbits were divided into four groups. hepatic arteries were selectively catheterized by the femoral approach. in each group, lipiodol, embosphere ( - and - µ) or beadblock ( - µ) were injected. ms were prepared as a ml suspension with contrast material, in which ml ms were contained. animals were sacrificed immediately after the injection. the liver was excised with ligation of all major vessels. sections were made in the radiate plane along with hepatic arteries. results: lipiodol spread into the hepatic sinusoid and reached the central veins. they were found also in the peribiliary plexus (pbp). ms reached maximally glisson's sheath but was not found around the pbp nor the sinusoids. embosphere occluded the artery after an injection of some milliliters. microscopically they were often clustered and compressed but their spherical shape was maintained. smaller embosphere penetrated deeper than larger one. beadblock once occluded the artery with a smaller amount of suspension than embosphere. after a few minutes, however, the arterial flow resumed and additional injections were possible. microscopically they formed casts and tend to reach deeper tissue than embosphere of the same size. conclusion: embosphere is elastic but robust, while beadblock is plastic, forming casts in the vessel. these characteristics explain much of their features at the time of injection. the at another patient hours after the implantation the rupture of common femoral artery aneurysm was stated. there were also observed certain post-hospitalization complications which included: a) clotting of stent-graft leg in cases b) leak type i which demanded implantation of additional element of stent-graft in one case c) small leaks type i in cases and type ii in cases which did not demand any further intervention-the type ii leaks were observed in cases months after the operation d) the increase of parietal circular thrombus inside the main part of the stent-graft in two cases e) complaints connected with the internal iliac artery occlusion were declared by patients. the catheter has four microsurgical blades that cut directly into the stenotic plaque during inflation. recently they were proposed for the use in peripheral arterial system using a balloon diameter raging from up to . mm. material and methods: seven consecutive patients (mean age years) were treated with cutting balloon pta (cb-pta) from june until september . all of them had severe multiple, calcified stenosis of the femoro-popliteal artery, maximum cm in length, never treated before. all patients had important associated risk factors such as insulin-dependent diabetes mellitus, hyperlipoproteinemia and smoking. results: cb-pta was technically successful in all patients, with lumen diameter improvement at least of % or residual stenosis less than %; moreover we never observed major dissection of the intimal plaque and we never required stent placement. conclusion: cb-pta in lower limb calcified stenoses is a promising technique that seems to be superior to pta alone, without requiring stenting in femoropopliteal arteries. aneurysm diameter in all patients were > cm (average diameter were . cm, range, . - . cm). the mean follow-up was months. average hospital stay after the intervention was - days. results: the stent-grafts were successfully deployed in all patients. control spiral ct hours after the procedure revealed endoleak in patients ( . %). spiral ct follow-up on th day following the intervention showed that in patients endoleak spontaneously stopped and in one patient small endoleak was seen, but it also stopped within a month following the intervention. in two patients ( . %) acute thrombosis of iliac graft extensions was diagnosed a month after the intervention. in both cases successful endovascular thrombolysis was performed with good clinical outcome. in one patient ( %), progression of atherosclerotic disease resulted in migration of the stent-graft two years after the placement of the graft. reintervention was done with successful deployment of additional aortic extension of the stent-graft. average reduction of aneurysm diameter was . mm (range, - mm). conclusion: endovascular treatment of aaa with talent stent-graft is a safe and effective procedure. in patients with well defined indication it is safe alternative to open surgery procedure. direct thrombin injection for non-femoral pseudoaneurysms r. corso, m. solcia, m. castoldi, r. vercelli, m. intotero, a. rampoldi; milan/it purpose: percutaneous thrombin injection under sonographic guidance has been shown to be an effective and well tolerated treatment for a iatrogenic femoral pseudoaneurysms. for these reasons some authors suggest thrombin injection as alternative treatment also in other body districts. we illustrate our experience, techniques and results in the ablation of pseudoaneurysms of different etiologies and locations whit direct thrombin injection. materials and methods: from june we treated six patients, age range - years, affected with pseudoaneurysms developed after iatrogenic trauma in three patients (arising from radial, posterior tibial and thoraco-acromial arteries), post-pancreatitis (splenic and superior mesenteric arteries) in two patients and in one patient after spontaneous rupture of renal angiomyolipoma in tuberous sclerosis. two patients were anticoagulated. the diameter of pseudoaneurysms varied between . - . cm. after disinfection of the entry site, we slowly injected bovine thrombin ( u/ml of solution) percutaneously under ultrasound guidance in four cases, while in two cases we injected directly the thrombin in the pseudoaneurysm cavity with a fluoroscopically guided endovascular angiographic catheter. results: all interventions were successful and showed no immediate or late complications. doses of thrombin needed varied between - units ( . - ml of solution). a complete thrombosis of the pseudoaneurysm sac was accomplished within minutes of thrombin injection. no recurrence was seen at the follow-up. conclusion: in selected cases, direct thrombin injection may be useful in treating non-femoral pseudoaneurysms resulting in rapid and persistent occlusion. in our limited experience it represents a safe and effective minimally invasive technique and an alternative to surgical repair. the purpose: bronchopulmonary sequestration is a combined lung and vascular anomaly witch is usually surgically treated. in those cases witch the anomaly is mostly vascular, coil embolization is a safe alternative to surgery. method and materials: coil embolization of intrapulmonary sequestration was performed in three adult patients, two of them admitted with hemoptysis and the third one with low left thoracic pain and fever. the initial diagnosis was made by ct and confirmed with angiography. we embolised the feeding arteries using coils (from to mm, cook). angiography after embolization indicated almost complete occlusion and all patients were discharged the next day. results: there were no immediate nor long term complications. follow-up ct was performed six months and one year later, at witch time there was complete occlusion of the anomalous artery. all patients are asymptomatic at present. conclusion: arterial embolization of intrapulmonary sequestration with a predominant vascular component, is a less invasive method of occluding the anomalous artery in selected patients and is a safe alternative method to surgery. emergency endovascular repair of ruptured hepatic artery pseudoaneurysm with coronary stent-graft: two cases a. park; pusan/kr purpose: to report two cases of successful emergent endovascular treatment of ruptured pseudoaneurysm from the hepatic artery using balloon expandable coronary stent-grafts. materials and methods: case . a -year-old male underwent whipple's operation for a cholangiocarcinoma in the distal common bile duct, but his postoperative course was complicated by serious blood loss from a ruptured pseudoaneurysm in the common hepatic artery. using premounted coronary stent-grafts (jostent, jomed, germany), the neck of the aneurysm was completely excluded. case . a -year-old male underwent surgical treatment of a klatskin's tumor and hepaticojejunostomy. four weeks later, an episode of gastrointestinal bleeding prompted celiac angiography. active bleeding from a small pseudoaneurysm in the right hepatic artery was controlled with endovascular deployment of a premounted coronary stent-graft (jostent, jomed, germany). the final angiogram demostrated a total exclusion of the aneurysm with preservation of the arterial lumen. results: transcatheter embolization using a variety of embolizing materials has been considered the treatment of choice for true or false hepatic artery aneurysms. however stent exclusion of the hepatic artery bleeding in an emergent situation has been reported only in few cases. for patients with a compromised blood supply due to portal vein occlusion or exclusion of important collateral pathways by surgical operation, a stent-graft may become the procedure of choice. in emergent situations of hepatic artery bleeding, endovascular implantation of a stent-graft may be an alternative procedure to transcatheter embolization or surgical repair. materials and biomaterials for interventional radiology t. hasebe , a. shimada , t. suzuki , y. matsuoka , h. yoshimura , s. kuribayashi ; tokyo/jp, sagamihara/jp, hiyoshi/jp learning objectives: . to describe the most often used interventional devices (id) benefiting from the recent intensive research activity to improve their functionality or their biocompatibility. . to provide an update on the current status of new materials and biomaterials available in the field of vascular and non-vascular interventional radiology, including our original experimental data . to discuss the importance and the safety issues related to the use of biomaterials and coating materials concerning id. background: in the past decade, interventional radiology has allowed percutaneous access devices and therapeutic implants to be more reliable and effectively used due to the availabiliity of new materials. currently, there are several passive or active stent coatings commercially available with good results in preliminary studies. these materials more often result from industrial research and less frequently from medical research. procedure details: in this paper, we discuss biomaterials currently available for use, together with new biomaterials for the vascular or non-vascular id, such as, for example, the drug-eluting stents, coils for embolization, and biliary/ureteral catheters or stents. finally, we discuss the future of biomaterial use in interventional radiology with the original data in our laboratory (e.g., antithrombogenic and biocompatible stent coating: diamond-like carbon). conclusion: biocompatible issues are very critical for id in order to coexist with living tissue without causing harm. considering the recent advances in new materials with biological effects, we believe the biomaterials will soon constitute a new core of interventional radiology. the radiologists should establish new research domains and complete new and effective products. clinical usefulness of a unified multidetector-ct we can always generate a control image during intervention without repositioning the patient. we have performed highly integrated imaging diagnosis and interventional therapy with this system in more than patients. procedure details: angiography assisted multidetector-ct was performed for the diagnosis and the target therapy of hepatic, pancreatic, adrenal and renal tumors and uterine myomas. in addition, multidetector-ct assisted angiography and interventional therapy was performed for vascular recanalization, such as aortic and peripheral vascular stent therapy; for endovascular treatment of aneurysms and for percutaneous therapy of varices, with a variety of three-dimensional reformatting techniques. we also performed several interventional procedures, such as percutaneous biopsy, biliary and abscess drainage, with this system. conclusion: we introduce our highly integrated intervetional ct system with technical merits to clinical use. background: ct is the imaging method of choice to evaluate hemodynamically stable patients with significant blunt abdominopelvic trauma. contrast enhancement is essential for the diagnosis of many visceral injuries in these patients. it has been demonstrated that contrast-enhanced ct is valuable in the detection of active extravasation of contrast material. the detection of contrast extravasation is critical because it indicates an ongoing, potentially life-threatening hemorrhage. imaging findings: the purpose of this exhibit is to review our experience with active contrast extravasation in patients with blunt trauma to the abdomen and pelvis. findings of contrast-enhanced ct are correlated with those of conventional angiography. the role of angiography and transarterial embolization in patients with active extravasation on contrast-enhanced ct will be discussed. conclusion: contrast extravasation on ct can be used to localize anatomic sites of hemorrhage and to guide immediate angiographic or surgical intervention in patients with abdominopelvic trauma. state-of-the-art ct enables a more detection of contrast extravasation than is possible with conventional and single detector helical ct. for the presented in vitro study, peas (mean diameter . mm) were embedded within a gel-phantom in order to simulate small target lesions. positional data of the patient and of the needle guide mounted to the robot arm were acquired via an optical tracking system (ndi polaris). a preliminary ct calibration procedure allowed assignation of d coordinates to each d pixel of the particular ct scan for fast and accurate intervention planning. the best needle trajectory was defined graphically by simply selecting skin entry point and target point -appropriate position and angulation of the robotic arm were calculated and sent to the robot controller. after confirmation of the planning, the robot moved to the start position using different modes of motion. the coaxial biopsy was performed manually using a -gauge puncture needle, combined with an -gauge biopsy needle and an automated biopsy device. the complete intervention could be monitored and documented by means of superimposed information on the actual ct scan. to prove efficacy of biopsy the length of the harvested specimen, as well as the distance between actual needle tract and centre of the lesion was measured. results: biopsy specimens were successfully obtained from all targets with only one needle pass necessary. radial distance between needle trajectory and centre of the target was surpassing clinical requirements. conclusions: robotic assisted biopsies with high accuracy were feasible using ct guidance. a new laser guidance device for ultrasound guided percutaneous biopsy a.e. samir, j. koukounaras, p. u, a. moorhouse, m. brooks; melbourne/au introduction: ultrasound guided needle placement is usually performed by inserting a needle along a path in the plane of the ultrasound beam. this permits visualisation of the needle in "real time", allowing accurate needle placement. a novel laser guidance device that facilitates needle placement during ultrasound guided biopsy is presented. methods: a laser module was constructed by mounting a laser diode in a nylon tube. a lens was used to transform the pencil laser beam into a linear alignment beam. the laser module was mounted on an ultrasound probe using a customdesigned clip that consisted of two polycarbonate half shells. the linear laser beam was calibrated to be coplanar to the ultrasound beam. no probe modifications were necessary. fourteen biopsy operators performed eight free hand and eight laser guided biopsies each of capsicum-stuffed olives suspended in gelatine phantoms. endpoints measured were: ( ) time to biopsy, ( ) sample quality and ( ) perceived usefulness. the laser beam was visible on the surface of needles ranging from to gauge in size. when the needle was inserted colinear to the laser beam it was visible on the ultrasound image. a significant difference in procedure time or sample quality was not observed. however, % of operators stated that laser guidance had a positive effect on the procedure, and % said that they would use it in the future. conclusion: a probe-mounted laser guidance device is perceived to facilitate accurate ultrasound guided needle insertion by the majority of operators in a pilot study. planning of the intervention is on basis of ct-imaging data sets acquired immediately before an intervention. spatial relation between imaging space and targeting device is either established by using of an optical tracker system or via robot registration based on a ct data set. after graphically selection of the target point and manual pre-positioning of the device, correct needle angulation will be set automatically by the system. during the intervention, the robot kinematic holds the needle guide in a defined position/ orientation to the patient's body -needle insertion will be performed manually by the physician. results: the developed system is easy-to-use and does not interfere to the clinical work-flow. system accuracy and clinical relevance currently is being tested in a series of in vitro tests. the designed and realized prototype of a modular automated needle guide allows positioning of a biopsy needle based on an intra-operatively planning with good cost/benefit ratio. effect of radiotherapy and ischemia on rat liver z. vigvary, p. kupcsulik, a. szijartó, o. hahn; budapest/hu aim: the aim is to create a model of a liver resection combined with intraoperative irradiation for micrometastases. this combined ischemic-reperfusion and irradiation injury of the liver has not yet been investigated. methods: normothermic segmental liver ischemia were created on - g male wistar rats. rats were divided into four groups for , , and minutes of ischemia. hepatic microcirculation was studied by laser doppler flowmeter. histological alterations were followed. i, ii, iv lobes were exposed to , and gy of cs- ã-radiation. alp, alt, ast, ldh, bilirubin and tnf-á tests were performed. results: reperfusion was assesed by post-ischemic flux plato maximum (pm), by area under the curve (rt) and by the time to maximum flux level (rmi). flowmetery showed a nonlinear fashion of reperfusion according to ischemic period. after and minutes ischemia the rate of the reperfusion is almost the same. minutes of ischemia represents an intermediate lesion in term of recovery. after minutes, minirapid deterioration of flux (below % of control) was observed. survival is rather determined by the length of the ischemic period, than the irradiation dose. low dose irradiation ( gy) with short-term ischemia ( min) did not result in increased liver enzymes and resulted only in minimal histological changes. the group of gy irradiation with normotherm, short-term ischemia seems to be tolerable for the tumor-free liver. conclusion: liver toleratse irradiation injury suprisingly well and preconditioning promotes restitution of liver circulation after ischemic injury. purpose: the aim of the study was to assess radiation exposure to the radiologist incurred with ct fluoroscopy. the spectrum of indications and radiation exposures for the radiologist were assessed for an -month period. scatter exposures were measured with and without radiation protection devices: without and with placement of a lead drape on the patient, with and without use of thin rubber radiation protection gloves. in addition, scatter radiation was determined for a combination of lead drape and radiation protection gloves. results: there is a wide variety for the use of ct fluoroscopy ranging from diagnostic biopsy procedures to therapeutic interventions such as radiofrequency ablation of liver metastases and ct fluoroscopy-guided osteosynthesis of fractures. scatter exposure rates to the hand of the radiologist ranged from to micro sv per case without use of a lead drape and radiation protection gloves. the lead drape reduced the scatter exposure to the hand of the radiologist by percent. radiation protection gloves reduced scatter radiation by percent. the combination of both radiation protection devices was most effective in decreasing the dose by percent. conclusion: ct fluoroscopy is a useful targeting method with a wide variety for interventional procedures. however, significant radiation exposures may occur. therefore, the radiologists should be aware of different techniques of ct fluoroscopy guidance and the methods to reduce scatter radiation. purpose: workforce planning, deskilling scenarios and risk containment are generating a need for interventional training processes remote from patients. fixed models lack ultimate realism, and animal models lack pathology with political problems in the uk. virtual environments for interventional needle puncture training require accurate haptics, based on force relationships between tools and tissues, and visualization. to achieve this demands advancements in tissue segmentation, assignment of tissue properties and generation of synthetic images from abnormal patient anatomy and pathology. these challenges require wideranging expertise and will probably take over a decade to achieve fully. no existing simulator model covers interventional radiological needle access procedures (eg: targeted biopsy, nephrostomy, biliary and abscess drainage). thus a substantive collaboration is essential to develop appropriate virtual training environments. internet search highlighted key development areas and, together with conventional networking, relevant departments and individuals were located with major involvement in medical simulations. results: the craive collaboration was established and comprised interventional radiologists, computer scientists, physicists, clinical engineers and psychologists. the key challenges of interventional procedures have driven specific proposals for accurate representation of haptics, from measured in vivo forces, within imaging-derived, immersive, simulated environments. conclusion: achieving effective simulator modeling for training and rehearsal requires research advances and further development in the underlying technologies. while currently beyond the scope of any research group or individual company, a substantive new collaboration, craive, aims to develop interventional radiological simulator models, initially based on a spectrum of interventional needle access procedures. and % (on low dose mode) reduction. image quality measurements were consistently superior ( % higher resolution in fluoroscopy and % in dsa) with significantly more low contrast iodine targets and moving wires detected and a larger dynamic range or working thickness range. the results of our first clinical investigations give further evidence for superior image quality. conclusions: on all modes, dose monitoring and image quality of the digital flat panel system compared favorably to the conventional image intensifier system. the results of our first clinical investigations on image quality based on our routine daily practice will be presented. differential diagnosis of femoral head bone marrow edema pattern i. kalaitzoglou , p. papadopoulou , a.s. dimitriadis ; thessaloniki/gr, kavala/gr learning objectives: to present the imaging features which help in the differential diagnosis of the femoral head "bone marrow edema pattern". background: bone marrow edema of the femoral head is a non-specific mri finding associated with various painful conditions of the hip like osteonecrosis, idiopathic transient osteoporosis, transient bone marrow edema syndrome, migratory osteoporosis and stress fracture. a total number of approximately hip mri examinations were performed in three different diagnostic centers from january to july . bone marrow edema was present in cases. procedure details: mri units used ranged from . to . tesla and the examination protocols included t se and t fse fat-sat or stir axial and coronal images, while sagittal images and contrast administration were reserved for specific cases. patients with typical findings leading to the diagnosis of osteonecrosis or fracture were excluded. the remaining patients had non-specific bone marrow edema of the femoral head which was demonstrated as diffuse, ill defined, low signal intensity on t w images, high on t w and stir images, and extended to the femoral neck region. in half of the patients follow -up examinations were also available. we selected and present the imaging criteria, at presentation and follow -up, which can lead to an early specific diagnosis. conclusion: bone marrow edema of the hip has to be correctly interpreted in order to avoid overtreatment in transient and self-limiting conditions. the presence of subtle subchondral lesions and the temporal evolution are usually key to diagnosis. periosteal reactions: the spectrum of radiological appearances with histopathologic correlation i. pinilla, d. bernabéu, c. martín-hervás, a. alvarez, a. bravo, f. lópez-barea; madrid/es learning objectives: the aim of this exhibit is to illustrate the spectrum of imaging features of periosteal reactions with plain radiography, computed tomography (ct) and magnetic resonance imaging (mri) with emphasis in pathologic correlation. imaging findings: patients with histologically proved diagnosis of benign and malignant lesions in our institution between january and december were identified from the pathology data base. imaging findings with plain radiography, ct and mri were retrospectively reviewed and correlated with key pathologic features. the various patterns of periosteal reaction are arranged into the following categories: continuous (smooth, lobulated, and ridged shells, solid, single lamella, laminated or "onion skin", and parallel spiculated or "hair on end" reactions), interrupted (buttres, codman triangle, lamellated, and spiculated reactions), and complex (divergent spiculated or "sunburst", and combined reactions). the most representative cases of each form of periosteal reaction are displayed. specific topics addressed include benign and borderline bone tumors (osteoid osteoma, osteoblastoma, periosteal chondroma, aneurysmal bone cyst, giant cell tumor, langerhans cell histiocytosis, and adamantinoma), primary malignant bone tumors (osteosarcoma, chondrosarcoma, ewing's sarcoma and non-hodgkin's lymphoma), skeletal metastases, and non-neoplastic conditions such as osteomyelitis and myositis ossificans. the changes in the periosteum are common and important imaging features of bone diseases. recognizing and understanding the different radiological patterns and underlying histopathologic changes help the radiologist to narrow the differential diagnosis. this teaching exhibit gives an overview of the wide spectrum of radiological appearances of periosteal reactions together with histopathologic correlation. in mr images, spin-echo (se) t -weighted images (t -wi) and t -wi were obtained and gd-dtpa contrast enhanced images were obtained in cases. in these cases, the location, the radiographic findings, signal and enhanced pattern on mri were analyzed. imaging findings: in cases, the tumor located in epiphysis ( . %), in cases in apophysis ( . %), in cases in apo-metaphysis ( . %), in cases in epimetaphysis ( . %). in all cases, the tumor was depicted as radiolucent area and in cases, the sclerotic margin was recognized. in all cases, the tumor was revealed as iso-intensity comparing with surrounding muscle on t -wi. on t wi, in cases, the tumor revealed as iso-intensity with bone marrow and in the other cases, it revealed as low intensity. on t -wi, in cases, high intensity area was included which corresponds to the cystic degeneration. in all cases, the tumor was moderately enhanced on contrast enhanced t -wi. in cases, t -t -prolonged lesion which is considered to be the reactive inflammatory change were shown in the bone marrow around the tumor. conclusion: to analyze the image characteristics of chondroblastoma is important to approach the exact diagnosis of bone tumor. chondrosarcomas background: parosteal osteosarcomas represent only - % of all osteosarcomas, and have better prognosis than the classical osteosarcoma.they are frequently low-grade tumors, which may rarely dedifferentiate into high grade sarcomas. imaging findings: mr images performed on - . t mr system of histologically proven cases of parosteal osteosarcoma were retrospectively analyzed for the bones involved, location and the relationship between the signal intensity and the grade of the tumor.there were females and males. ages ranged from to (mean . ). most commonly affected bone was femur, on its distal end, posterior aspect ( ). histological grading was described as follows:grade i: hypocellular stroma with subtle atypia; grade ii: mild increase in stromal cellularity and more prominent cytologic atypia, grade iii: marked pleomorphism with high cytologic atypia and mitotic rate, also called dedifferentiated type. regarding the described grading above, of our cases were grade i (low), were grade ii (intermediate) and were grade iii (high). on mri, all of the parosteal osteosarcoma cases were of hypointense signal intensity on t -weighted images and were hyperintense on t -weighted images with no exception. on gadoliniumenhanced images, heterogeneous contrast enhancement was observed. conclusion: in our study, mri signal intensity was the same in all of the cases; hypointense on t -weighted images and hyperintense on t -weighted images; regardless of the grade of the tumor. giant cell tumor of knee: imaging findings of the most common site v. zampa, s. giusti, c. spinelli, s. ortori, c. bartolozzi; pisa/it learning objectves: . to describe imaging findings useful for an effective diagnosis . to discuss the main differential diagnosis with giant cell tumor (gct) of knee. background: gct is a relatively common skeletal tumor. it is a benign but locally aggressive and destructive lesion composed of primitive histiocytes and large, multinucleated giant cells. the most frequent symptom is pain, local swelling, limited range of motion and pathologic fracture ( %). location of gct and age of patients suggest the diagnosis. it usually affects long tubular bones and, in particular around the knee, the most common site is distal femoral and proximal tibia ( and % of all tgc). the main differential diagnoses include osteosarcoma (teleangectatic or fibrogenic), malignant fibrous istiocytoma, chondromyxoid fibroma and aneurysmal bone cysts. treatment of choice is surgical resection but recurrence is frequent. imaging findings: on radiography gct appears as an eccentric and geographic bone lysis, associated with a narrow zone of transition and lacking surrounding sclerosis. ct is superior to conventional radiography in outlining the extent of the tumor and in demonstrating cortical invasion but mr is currently the best imaging modality in determining extra-osseous extent, articular surface involvement and tumor recurrence with optimal definition of either osseous sclerosis or pseudocapsule. the signal characteristics of the lesion on the different mr sequences will be described to find out if they can help in differential diagnosis. conclusion: radiologic appearances of gct is important in allowing prospective diagnosis, guiding therapy, and facilitating early detection of recurrence. superscans: a pictorial review s.a. o'keeffe, t. geoghegan, w.c. torreggiani; dublin/ie learning objectives: the objective of this poster presentation is to pictorially describe the causes, findings and interpretative pathways of patients undergoing radionuclide bone scintigraphy resulting in a superscan. background: a superscan is a radionuclide bone scan which demonstrates markedly increased, homogenous skeletal radioisotope uptake relative to soft tissues and is usually associated with absent or faint renal images. a retrospective analysis of all whole body radionuclide bone scans performed over a fiveyear period was performed to identify the presence of superscans. analysis was based on review of reports identified on a computerised radiology information system (ris). images were reviewed in association with other relevant imaging and in select cases, with laboratory data and clinical notes. a variety of cases were then selected for this pictorial review. imaging findings: a total of whole body bone scans were performed in our institution in the last five years. superscans were selected for inclusion in this pictorial review. the vast majority of superscans identified were related to metastatic disease of which prostate cancer dominated. superscans were also identified secondary to hyperparathroidism, metabolic bone disease including osteomalacia and pagets disease. conclusions: in this pictorial review, we describe the patho-physiological pathways resulting in the appearances of a superscan. in addition, we pictorially demonstrate a variety of causes resulting in superscan. finally, interpretative pathways of analysis and helpful signs are suggested. usefulness of d reformations in the assesment of spondylolisthesis and spondylolisis of the lumbar spine e. vilar bonacasa, p. sanchez santos, j. torres nuez, g. martinez sanz; teruel/es learning objectives: to obtain images that provide a full and direct view of the pars interarticularis in order to determine the isthmal affectation in lumbar spondylolisthesis. background: nine patients with spondylolisthesis of the lumbar spine among sent to our department for ct study during the last year were performed a volumetric acquisition from l or l to s instead of the conventional axial scanning. later, a d image was obtained and modified in the work station, to achieve a view of the pars interarticularis from the vertebral canal. procedure details: using this method, we obtained images wich allowed us to asses the isthmal affectation in a direct way in all patients. moreover, it permits the study of the repercussion of vertebral bodies slide over the vertebral canal and the intervertebral foramina. conclusion: convencional ct has some limitations to determine exactly the type and degree of isthmal affectation in spondylolisthesis as well as its repercussion on intervertebral foramina. helical ct, using volumetric acquisition with three-dimensional reformations can resolve those limitations. morphology in these cases, the improvement of the skeletal pain were scored in five-levels by patients' interview from = marked improved to = worse and the duration of the symptom's improvement was monitored. results: a total of taes (mean . times) were performed. all procedures were technically successful. skeletal pain was relieved in patients ( %) between = slightly and = markedly improvement. in of patients with malignant lesions, the duration of pain relief ranged from one to months (mean months). no serious complications were observed except for a case with transient neurogenic bladder. conclusion: tae using sap-ms was a safe and effective treatment for the pain control with long duration of unresectable bone tumor. bone marrow edema at mri: diagnostic clue to the underlying cause of knee pain a. blanco, m. martinez, e. parlorio, m.a. corral, s. torres; murcia/es purpose: bone marrow edema (bme) is usually associated with traumatic injuries of the knee but there are other conditions, often unsuspected, that can cause this pattern. our purpose was to evaluate the patterns of distribution of bme in patients with knee pain and try to correlate them with their possible underlying cause. we retrospectively reviewed mri examinations of patients referred for knee pain, with or without history of trauma, during a month period. the examinations were performed in a . t unit using our standard protocol which included fluid-sensitive sequences. in some cases intravenous gadolinium was used. results: patients ( . %) showed bme with variable distribution, resulting from: acute trauma ( ), stress fracture ( ), degenerative disease ( ), spontaneous osteonecrosis ( ) and osteochondritis dissecans ( ) of the femoral condyle, soft-tissue infection ( ), excesive lateral pressure syndrome ( ), iliotibial-band friction syndrome ( ), transient bme ( ), tumor ( ), and nonspecific ( ). in many cases associated with trauma, the distribution of edema allowed to explain the mechanism of injury and predict with accuracy the soft-tissue abnormalities that may be present. conclusion: bme patterns at mri can help to establish the possible cause of knee pain. when there is a history of acute trauma, edema shows typical features that can give the clue to a possible mechanism of injury. on the other hand, if clinical data is not clear, the distribution of edema can orientate to other unsuspected pathologic conditions. appropriate recognition is necessary for an accurate diagnostic and therapeutic orientation. percutaneous percutaneous thermoablations was performed with radionics cool tip rf generator system by using probes with or cm unprotected tip applied for minutes in the center of the lesion. the procedure consisted of localizing the osteoid osteoma on ct imaging and positioning within the lesion a kirschner wire, rigged on a hand-drill device. once the nidus was engaged we proceeded to exchange the thread of kirschner for a rf probe and emit the radio waves. results: at a mean follow-up of months the treatment has been considered effective in % of the cases. in four patients pain has subsequently recurred; one of these cases has been treated for a second time with success. in two cases procedural complications of minor degree, represented by limited cutaneous burns have occurred. conclusion: in our experience ct-guided percutaneous radiofrequency treatment of osteoid osteoma proved to be effective in % of the cases. deprived of severe complications it may represent an uncomplicated, minimally invasive, rapidly effective procedure, alternative to the surgical treatment. order to obtain the load-to-fracture, the specimens were tested destructively at side impact. results: in the standard regions of interest, correlations between fracture load and bmd (bmc) ranged from r = . to r = . , p < . (r = . to . , p < . ). for the newly defined roi in the upper neck of the proximal femur, significantly higher correlations between bmd, bmc and fracture load (r = . and . , respectively; p < . ) were obtained. only a weak statistical relationship between fracture load and fnal was found (r = . , p < . ). normalization of fracture load with respect to fnal of the specimens did not significantly improve results. the mechanical competence of the hip highly depends on the bmd and bmc of the proximal femur. of all the regions of interest analysed in this study a newly defined roi in the upper neck showed the strongest correlation with fracture load. under in-vitro conditions, only a weak association between mechanical strength and fnal was observed. or secondary (n = ) diagnostics were analysed visually. the final diagnosis based on histology, imaging and follow-up. results: histologically the primary lesions were es (n = ), pnet (n = ) and osteomyelitis (n = ). the sensitivity and specificity of fdg-pet for disease (presence of et, and/or its metastases) were and % respectively. fdg-pet and/ or other imaging modalities detected altogether focal lesions. sensitivity and specificity regarding focal lesions were and %. this lower sensitivity is due to small lesions. wbs detected all primary bone lesions present at wbs investigation, but only of bone metastases in four patients, while fdg-pet detected both the primaries and metastases. conclusion: fdg-pet investigation is a valuable method in case of et-s. concerning the detection of bone metastases of et-s fdg-pet is superior to wbs, while for the depiction of small lesions mainly represented by pulmonary metastases fdg-pet is less sensitive than helical ct. the determination of the role of whole body fdg-pet in the diagnostic algorithm needs further investigations. the role of an optimized mr protocol in the detection of osteomyelitis neighbouring metallic bone implants g. michailidis , n. economopoulos , c. kontopoulou , s. argentos , n.l. kelekis ; piraeus/gr, athens/gr purpose: osteomyelitis presents as a complication in a percentage of patients after metallic bone-implant placement. early and accurate detection is crucial for proper treatment. conventional mr images are usually severely degraded from intense artifacts, rendering interpretation often impossible. we report our results using an optimized mr imaging protocol in detecting foci of osteomyelitis near metallic bone implants. materials and methods: during the last year we examined patients ( men and women, age range - ) with metallic bone implants and clinical suspicion of osteomyelitis. the mr protocol consisted of t -weighted stir and single shot turbo spin echo sequences. for t and t contrast-enhanced images we employed turbo spin echo sequences with slice thickness of mm, echo train length > , minimum echo spacing and minimum te. diagnosis of osteomyelitis was based on the detection of one or more of the following findings: subperiosteal fluid, bone sequestrum, fistula and abscess. results: all mr examinations were of diagnostic quality with minimal artifacts present. in patients one or more of the above mentioned findings were present and were diagnosed with osteomyelitis. in the remaining patients no findings suggestive of osteomyelitis were observed. confirmation was obtained by followup and clinical outcome. conclusion: with the use of an optimized scanning protocol mri may overcome its limitations caused by metallic artifacts and is able to detect foci of osteomyelitis in patients with metallic bone implants. primary methods and materials: patients were included, aged to years old. flat bones (pelvis = , sternum = ) were involved as well as metaphysis of tibia (n = ) and femur (n = ). pathologic diagnosis was obtained in all cases. results: in long bones, tumor originated from the medulla, excentered and metaphyseal in location. in all cases, agressive patterns were present such as osteolysis, cortical break and tumoral extension in surrounding soft tissues, lack of peritumoral reactional osteocondensation. periosteal reaction was present in one case. no calcification was noted. on mr imaging, tumors demonstrated intermediate signal intensity on the t -weighted images with heterogeneous enhancement following gadolinium injection. pathological findings included smooth muscle cells with interlacing fascicles of spindle cells, without osteoid production or cartilagineous matrix. despite adequate surgical resection, metatastatic diseases appeared in cases. conclusion: primary leiomyosarcoma of bone is a rare tumor which must be included in the diagnostic possibilities in case of agressive purely osteolytic lesion. results: patients included females and males (aged from to years) with pain in extremities. osteogenic sarcoma was diagnosed in patients, ewing sarcoma - , chondrosarcoma - , bone lymphoma - . in cases on plain film bone damage wasn't detected. on bone scintigraphy, the majority of lesions showed greater than mild uptake, in cases showed no uptake. at mr imaging isointense or low t w signal and increased t w signal was present in all cases. specific cellular constituents (e.g. fibrous, chondroid, blastic or teleangiectatic components), can modify signal characteristics. lesions that are primarily blastic, and, therefore, sclerotic on plain film radiographs, demonstrate low signal intensity on both t -and t -weighted sequences. edema characterized by indistinct margins, is a poor indicator of malignancy. conclusion: study shows that there is overlap in the radiological appearances of primary malignant bone tumors especially in the early stages. magnetic resonance imaging is shown to be a useful and sensitive modality in the detection and evaluation of bone tumors. mr imaging accurately assesses soft tissue and synovial involvement, as well as marrow infiltration, which may be radiographically silent. in patients with extremity pain mr imaging is necessary and mri data wasn't correlated with conventional radiology. all of them were underwent lateral flexion-extension radiography and lumbar mr imaging. differences of interspinous distances at flexion-extension radiography were analyzed at upper, lower, and spondylolisthetic segments. the mr features of the interspinous ligament were divided into groups according to their signal intensities: group , with inflammatory type presented as high signal intensity at t -weighted image and low signal intensity at t -weighted image, and group , fibrotic or fatty type. the incidence of the interspinous ligament with the inflammatory type was analyzed on the spondylolytic segment and the upper and lower segment without spondylolysis, respectively. results: spondylolysis at l , l and l levels were , and , respectively. of patients, the inflammatory type of the interspinous ligament was ( %) on the spondylolisthetic segment and ( %) on the upper segment without spondylolysis (p < . ). the mean difference of interspinous distance on the spondylolisthetic segment and the upper segment were . mm and . mm, respectively (p < . ). in patients of isthmic spondylolisthesis, the upper segment without spondylolysis showed more inflammatory type of the interspinous ligament on mr imaging than spondylolisthetic segment probably due to interspinous hypermobility. advantages of multislice ct in the diagnosis of traumatic osseous disease c. remaining cases, to assess the articular surface involvement and the real extension of the fracture. the isotropic mpr reconstructions carried out with the multislice ct scanners allow us to scan the patient in only one position, usually the axial plane, saving time and using less radiation dose. the mpr reformats takes an important role in the final diagnosis of many cases. the consideration of positioning in radiography for the waist of the scaphoid bone fractures s. matsubara; hiroshima/jp purpose: the most common type of scaphoid bone fracture is the transverse fracture of the waist (central / ). however, traditional positioning in radiography frequently fails to visualize bone fracture line. this may be caused by the fact that x-rays cannot be irradiated perpendicularly onto the scaphoid long axis. in this study, we searched optimal limb position for visualizing the waist of the scaphoid bone. method: in volunteers, the scaphoid bone was taken in the ulnoradial direction at °ulnar deviation (group a) and ° ulnar deviation with the fist clenched (group b). images measured the angle between the cassette plane and long axis of the scaphoid (c-s) and the angle between the cassette plane and the volar tilt (c-v). result: the c-s angle in group a was . ± . ° and in group b was . ± . °. the c-v angle was . ± . °. we devised new positioning that lift distal side of forearm upward at about ° in group a, at about ° in group b. these positioning make the long axis parallel to the cassette plane. especially, the later view was able to visualize the ulna-scaphoid joint more clearly without overlap of radius and scaphoid bones as compared to traditional method. conclusion: in fractures of the scaphoid, in which early diagnosis is critical, optimization of first-choice x-ray imaging is a key factor, and an additional image involving a ° scaphoid waist view will be useful. background: mri imaging is a very powerful tool in the evaluation of the acl, with higher sensitivity than the clinical examination of the knee. some of its lesions are well known and easily identifiable, but others require careful interpretation and familiarity with the spectrum of acl pathology. over knee mri examinations performed in three different diagnostic centers from january to july were reviewed retrospectively. acl lesions were found in approximately knees. procedure details: mri units ranged from . to . tesla, and various imaging protocols were used, with t and t coronal and sagittal images obtained in all cases. traumatic tears were the most common lesions identified. tears were classified as acute or chronic, complete or partial. we illustrate and discuss the primary and secondary findings of acl tears, as well as the imaging criteria in the evaluation of the postoperative acl. we also present fractures of the anterior tibial spine with acl avulsion, acl ganglion cysts and mucoid degeneration, which are less commonly seen. in the examination of the acl pathology the radiologist should evaluate multiple signs and be aware of some less common pathologies in order to effectively contribute to the clinical management. ultrasound and x-ray findings in painful shoulder involvement in rheumatoid arthritis l. rutkauskiene; vilnius/lt learning objectives: to illustrate and compare conventional x-ray and ultrasonography diagnostical possibilities of painful shoulder in ra. background: up to percent of rheumatoid patients have shoulder pain. a rational decision on the treatment of shoulder disease in rheumatoid arthritis depends on an accurate assessment of its cause and the extent of rheumatoid involvement. imaging details: a group of ra patients, who reported a pain in the arm and/ or limitation of the active movement, were examined first with conventional anterioposterior and obligue -outlet -view with - angulation x-ray of both shoulders. the most common findings were: joint space narrowing, erosions, subchondral cysts, irregularities of greater tuberosity, deformity and flattening, superior migration of humeral head, erosions in acromioclavicular joint, sometimes soft tissues swelling. ultrasonography study was performed with a . results: clinical signs and symptoms (pain and swelling) due to foot involvement were present in ( %) of the patients while frequency of involvement was ( %) with mr imaging assessment. the most common involved anatomical region was the hindfoot ( %) following by midfoot ( %) and ankle ( %). the mr imaging findings were bone erosions, achilles tendinitis, para-articular enthesophyte, joint effusion, plantar fasciitis, joint space narrowing, subchondral sclerosis, soft tissue edema, bone marrow edema, enthesopathy of the achilles attachment, plantar fascia attachment, and plantar ligament, subchondral edema, retrocalcaneal bursitis, subchondral cysts, subchondral fissures, and bone ankylosis. conclusion: mr imaging may detect bone, soft tissue, cartilage, tendon, and joint abnormalities in as patients, even if as patients did not have clinical signs and symptoms of foot involvement. this imaging modality may be of importance especially early diagnosis of inflammatory changes in the foot. additionally, familiarity of the typical mr appearances of foot involvement in as patients may be helpful in narrowing the wide differential diagnosis of spondyloarthropathies. mr handle meniscal tear using the following criteria: a) bow tie sign; b) double posterior cruciate ligament sign; c) coronal truncation sign; and d) displacement of the free meniscal fragment. results: in / cases a bucket-handle meniscal tear was identified. in of these latter an infero-medial displacement of a free fragment of the medial meniscus was identified. in all cases a lesion of the posterior horn involving the inferior articular surface was observed on axial plane. on coronal plane was observed the truncated triangle aspect of the peripheral, not displaced, meniscal portion. on all planes the displaced free meniscal fragment was identifiable as a little hypointense formation, medially to proximal tibial extremity, inferiorly to meniscal plane and deep to tibial collateral ligament. in all cases diagnosis was confirmed by arthroscopy. conclusions: mri allowed the detection of the infero-medial displacement of a free meniscal fragment thus helping the arthroscopic approach. high-resolution mri of ulnotriquetral ligament injury and its anatomical variations with a microscopy coil t. ueno , h. yoshioka , t. tanaka , y. kujiraoka , m. shindou , k. ooyama , y. saida ; tsukuba-shi, ibaraki/jp, boston, ma/us purpose: to demonstrate ulnotriquetral ligament (utl) injury and its anatomical variations using a microscopy coil. materials and methods: patients ( males and females with age ranging - year-old), who suffered ulnar side wrist pain and suspected triangular fibrocartilage complex injuries, were investigated in . t mri system with a microscopic coil ( -mm in diameter). axial and coronal t *-weighted images, sagittal and coronal proton density-weighted images, coronal stir images were obtained with a -mm fov and a - . mm of slice thickness for all patients. result: utl was identified in patients and its injuries were found in patients. regarding anatomical variations, in proximal side, utl always connected to volar radiocarpal ligament and disc proper. however, there were many variations of the attachment to triquetrum bone. in patients, bands attached to triquetrum at different site: one attached to the distal aspect of triquetrum, and another attached to a notch which was found at volar aspect of triquetrum. in patients, one attached to proximal side of the notch. patients showed separate utl bands. conclusion: high-resolution mri with a microscopy coil is a promising method to demonstrate utl injury. it would be useful to know normal anatomical variations for understanding the mechanism of utl injury. pictorial review of diagnostic imaging techniques in hip arthroplasty follow-up j. rimola, p. melloni, r. valls, p. bermúdez, d. gil, a. massuet; sabadell/es objective: to evaluate the spectrum of findings for plain-film radiography and other imaging techniques in patients with early or late complications of hip prostheses. we describe the usefulness of each imaging technique in follow-up. background: over the last years more than hip replacements have been performed in our hospital annually. all patients are followed up immediately after surgery, at months and then yearly or when necessary, using plain films and sometimes sonography (us) and/or computerized tomography (ct). us and ct are used to confirm or rule out osteointegration of the prosthesis and complications such as periprosthetic abscess and/or hematoma. imaging findings: we analyzed radiological features of the normal and pathological evolution of hip prostheses. we describe early complications (affecting . % of patients), such as infection, cement extrusion, and periprosthetic fracture, as well as late complications (affecting . % of patients), including aseptic loosening, osteolytic lesions, heterotopic calcifications, migration of the acetabular component, femoral diaphysis fracture, and dislocation of the prosthesis. conclusion: plain films are essential for evaluation and detection of hip arthroplasties. us is usually used to guide percutaneous aspiration of soft tissue. ct enables correct assessment of osteointegration of hip prostheses. results: with wrist arthroscopy as the standard of reference, average sensitivity and specificity of non-enhanced mri, for tears of the tfcc were . and . respectively and . / . / for arthroscopy. conclusion: mr imaging-plays a major role in evaluation and management of traumatic wrist injuries, improves clinicians diagnostic accuracy and reduces the need for arthroscopy. these preliminary results illustrate the ability of mri to assess the integrity of the tfcc and suggests its use as the first imaging method following plain radiography in the evaluation of patients with chronic posttraumatic pain on the ulnar side of the wrist. wrist arthroscopy is a more valuable technique in determining the location, size, and extent of ligament injuries within the wrist. high patients ( women, men; mean age: years) referred from e.r. for a suspect traumatic dislocation of the a-c joint. all patients underwent plain x-ray examination (conventional projections integrated by "outlet" view and stress projections) and hrus scan (longitudinal and axial scan planes of interested ligaments) of both the interested and contralateral a-c joint. ultrasonographic criteria of lesion were considered the absent recognition of the ligament and strong echostructural inhomogeneity a-c joint. measures of a-c and coraco-clavicular (c-c) distances were drawn by means of both methods. dislocation's degree was defined according with rockwood's classification. results: in / cases of indirect trauma, diastasis of the a-c joint ( - mm), was observed, whereas c-c joint was not involved and c-c ligaments were normal. in / patients with direct trauma, distracting lesion of the a-c ligament was observed in cases, and involvement of both a-c and c-c ligaments with diastase of both joints was observed in the remaining cases. a complete correspondence of the two methods was observed. conclusion: hrus enables early anatomical-structural changes detection and lesion's degrees assessment in acute traumatic lesions of the a-c joint, and could be considered more than complementary to x-ray exam in the emergency clinical setting, mantainig its role in the follow-up. ligaments and ac joint soft-tissue morphology, acromioclavicular distance and coracoclavicular distance were evaluated. sonographic findings were correlated with the results of conventional radiographic examination, which was performed in all cases with anteroposterior projections, taken with and without weights, and with "outlet" projection. sonographically, all patients presented lesion of ac ligament with high amount of sero-hemorrhagic fluid inside and outside the joint. in / patients, which had indirect trauma, we observed ac joint dislocation with ac ligament lesion that was not associated to involvement of cc joint and ligament. in / patients, which had direct trauma, we observed lesions of ac and cc legaments with associated joints dislocations. conclusions: ultrasonography, if performed with appropriate technique and adequate transducer, is accurate in the evaluation of acute traumatic ac joint lesion and dislocation, integrating and correlating well with the informations offered by conventional radiography. study of the mr imaging of the posterolateral structures of the normal knee c. yu, k. li; beijing/cn puropse: through the study of the mri appearance and localization of the posterolateral structures (pls), to provide a practicable method for intactly displaying them. methods: thirty tibial bone specimens were observed to establish the bony landmark for localizing the knee. in cadaver knees, the angles between lateral tibial plateau and the long axis of the individual structure of pls were measured. then we can determine the scan methods of the oblique mr images based on above results. the routine and oblique scans of t wi were performed in normal knees. the display effect and appearance of the pls were observed in mri. the lateral tibial plateau is a stable bony landmark for measuring and localizing of the knee. in the pls, the fibular collateral ligament can be intactly displayed on ° posterior coronal oblique images in cases ( %). the popliteus can be better seen on either ° posterior coronal oblique in cases ( %) or ° medial sagittal oblique planes in cases ( %). the popliteofibular ligament can be intactly appreciated on both ° posterior coronal oblique in cases ( %) and ° lateral sagittal oblique images in cases ( %). although the arcuate ligament and the fabellofibular ligament can occasionally be seen on routine and oblique images, their presence rate is low. the oblique mr imaging can intactly display the main structures of pls, and can be an useful tool in diagnosing these structures' injuries. patients are also asked for the presence of their prolonged physical activity in their life. results: patients had type ii, patients had type i and of them showed type iii patellar shapes, out of . patients had patella alta whereas all others stayed in normal range as patellar position. in patients' case no other abnormalities were seen apart from the signs of iliotibial band friction syndrome and three of them had shown type iii patellar shape. conclusions: no apparent correlation was found between iliotibial band friction syndrome and patellar position. as it is much more rare in the normal population wiberg type iii patella showed considerably high prevalance in our study. shoulder to assess by mri the potential benefit and efficacy of selective meniscectomy combined with radiofrequency ablation in cystic degeneration of the lateral meniscus treatment. materials and methods: sixty-one patients entered this study. patients underwent arthroscopic selective meniscectomy and patients underwent arthroscopic selective meniscectomy and radiofrequency treatment (arthocare, sunnyvale, ca) of the meniscal remnant. all of them were submitted three months later to mri and clinical evaluation. in case mri examination was performed before and after the surgical treatment. mri examination was performed using a dedicated . t (artoscan esaote italy) and a . t superconductive unit (ge signa horizon usa) employing se t -w, se t -w and ge t -w sequences on axial and longitudinal scan planes. in case arthro-rm was also performed. clinical evaluation included physical examination and questionnaire. results: clinical evaluation did not show statistically significant discordance between the two groups. mri follow-up after months demonstrated a very clear decrease of the degenerative spots inside the meniscal remnant in the group with combined treatment respect to the group treated only with selective meniscectomy. conclusion: in conclusion our experience considers mri the method of choice in the evaluation of post surgical treatment of degenerative cystic diseases of the lateral meniscus of the knee. high-resolution ultrasonography of the extrinsic carpal ligaments: examination technique and performance d.v. guntern, n. favarger, p. schnyder, n.h. theumann; lausanne/ch purpose: to develop an examination technique to visualize the extrinsic carpal ligaments by ultrasonography and to assess the performance of high resolution ultrasonography in the visualization of different parts of these ligaments. the extrinsic carpal ligaments of wrists of healthy volunteers were examined with a mhz linear array transducer by two muskuloskeletal radiologists in consensus. an examination technique was developed for each extrinsic carpal ligament (radioscaphocapitate, radiolunotriquetral, palmar scaphotriquetral, dorsal scaphotriquetral, palmar ulnotriquetral, dorsal ulnotriquetral, dorsal radiotriquetral and radial collateral ligaments). delineation of the proximal attachment, the body and the distal attachment of each ligament was evaluated as good, poor or absent. results: with a profound knowledge of the anatomy, especially of the osseous landmarks, an easy and fast examination of the extrinsic carpal ligaments by high resolution ultrasound is possible. the more superficial ligaments such as the dorsal scaphotriquetral and the dorsal radiotriquetral ligaments are well visualized by high resolution ultrasound whereas ligaments in a deeper position, such as the proximal and distal insertion of the palmar scaphotriquetral and the distal insertion of the radioscaphocapitate are less well visualized. high resolution ultrasonography is an accurate method to visualize the extrinsic ligaments of the wrist. direct mr arthrography of the glenohumeral joint with capsular distension using a posterior approach r. drescher, j. ludwig, f. rubenthaler, o. köster, g. schmid; bochum/de purpose: evaluation of the clinical use of direct mr arthrography of the glenohumeral joint with maximum distension of the joint capsule in patients with glenohumeral instability using a posterior approach. patients and methods: direct mr arthrography of the shoulder joint was performed on a . t system in patients ( women, men, mean age years). right and left shoulders were evaluated. all patients had anterior or bidirectional instability ( posttraumatic, constitutional). using a fluoroscopically guided posterior approach, ml iopamidol m and ml . % mepivacaine were injected, followed by a % dilution of dimeglumine gadopentetate in . % sodium chloride until full capsular stretching was achieved. mr sequences were t -weighted spin-echo axial and oblique-coronal, fat-saturated t d axial and oblique-coronal, and axial t flash- d. results: arthrography was possible in all patients. the total amount of intraarticularly injected fluid was - ml (mean ml). no complications occurred. mr imaging showed significant capsule distention in patients ( %) and ventral capsule defects in patients ( %). labral lesions ( anterior, posterior), bicipital tendon lesions ( complete, partial ruptures) and partial ruptures of the rotator cuff were noted. patients underwent surgery. regarding labral lesions, sensitivity of mri was . %, specificity was %, and diagnostic accuracy was . % compared with surgical results. conclusions: glenohumeral direct mr arthrography allows accurate detection of labral and tendinous lesions. maximum capsular distension allowed preoperative evaluation of capsular laxity as a source of shoulder instability. anterior talofibular ligament injury: evaluation with mr imaging j. ishida , j. yoshigi , h. okizuka , k. ooae , m. takao , t. yoshizako , k. izaki , n. uchida , h. kitagaki ; izumo/jp, himeji/jp purpose: inversion stress is most frequent injury of all ankles. atfl is the weakest of lateral collateral ligaments and first to rapture. the purpose of this study is to evaluate the usefulness of high-resolution mri for diagnosis of atfl disruption divided into acute and chronic phase. method and materials: patients suspected atfl disruption underwent mri ( . t). cases were in acute phase (< days) and cases were in chronic phase (> month). axial spin-echo (se) t -wi (tr/te = / , fov cm, mm/ . mm, x , nex,) and axial fast se t -wi (tr/te = / , etl , fov cm, mm/ . mm, x , nex,) were obtained with an extremity coil. atfl disruption was diagnosed when either finding is positive:discontinuity, irregularity, non-visualization of aftl, and high signal intensity lesion in atfl on t -wi. results: arthroscopy confirmed atfl disruption in cases in acute phase and b d e f a g cases in chronic cases. in acute phase, sensitivity was %, specificity was %, and accuracy was %. only false negative was seen. in chronic phase, sensitivity was %, specificity was %, and accuracy was %. / was false negative. conclusion: in acute phase, mri was accurate for evaluation of aftl disruption. however, in chronic phase, mri was less accurate because granulomatous tissue after disruption cannot be detected with mri. ct arthrography of the shoulder a. gligorievski, z. temelkovski; skopje/mk purpose: to present ct arthrography (cta) as a new method in our practice in order to point out its advantages and to compare the results with conventional arthrography and mr arthrography. we describe the technique of the examination in detail, performed at the institute of radiology in cooperation with an orthopaedic surgeon and radiologist that form the diagnostic-therapy team. cta performed with patients, aged to , men and women. conventional arthrography was performed in and mra in patients. results: patients presented with lesion of the glenoid labrum, with rotator cuff lesion, with a frozen shoulder, with a hill-sachs lesion, with biceps brachi tendon subluxation and case with slap lesion. we report our first experiences and the results gained are compared to similar recent studies as well as to the conventional radiologic techniques. cta is a method of choice in case of frozen shoulder and glenohumeral instability, but mra is better in case of rotator cuff lesion. we can conclude that cta is a sophisticated method of extreme diagnostic value in the evaluation of the humeral joint especially in case of glenohumeral instability. the invasiveness of the method is small, no complications have been noticed and compared to mr it is significantly cheaper and more available for the medical centers equipped with a ct scanner. mr imaging of the metatarsophalangeal joint with standard mr imaging: evaluation of six patients with clinical suspicion of plantar plate disruption p. hauser; lausanne/ch purpose: to report the mr imaging findings of painful injured metatarsophalangeal joints (mtpj) in case of clinical suspicion of plantar plate (pp) tear. a series of patients with clinical suspicion of pp rupture of first (mtpj ) or second (mtpj ) ray underwent mr studies with . tesla units with use of an extremity coil. the patients lay on their back with the ankle in plantar flexion and the toes in extended position. the standard mr imaging protocol performed in all specimens consisted of t weighted spin echo sequences in sagittal and coronal plan and t fse fat satured sequences in sagittal, coronal and transverse plan. the examinations were interpreted separately by two musculoskeletal radiologists assessing whether or not a pp rupture and associated lesions were present. after the imaging study all the patients underwent surgical revision in a mean delay of one month. results: tears of the pp were visualized in cases, degenerative lesions of the pp were visualized in two cases and two other cases showed no lesion. the mr imaging results concerning pp rupture although allowed depiction of several associated lesions including injuries of the extensor hood, the collateral ligament complex, ostechondral lesions and joint deformities. conclusion: although surgical treatment is generally the rule for hallux valgus deformities, surgical repair is also often required in cases of traumatic injuries of the mtp joints. the force of accord between radiologists and surgical observation of pp ruptures is good. mrt monitoring of autologous hyaline cartilage grafts c. müller, e. grönewäller, c.d. claussen, f. schick; tübingen/de purpose: seven different mr sequences were compared to localize cartilage defects in knee and to evaluate the stage of maturation of the hyaline cartilage graft. methods: mrt was performed in patients aged - years with autologous transplantation of a hyaline cartilage tissue graft after a knee trauma. examination dates were: before transplantation to localize the defect, and weeks, , and months after transplantation to control the morphology and the maturation of the autologous graft. standard t -and proton-density weighted turbo spin echo (tse) sequences, t -weighted spin echo (se) sequences, gradient echo (gre) sequences with and without magnetization transfer (mt) pulses as well as experimental diffusion weighted gre sequences (psif) were used. results: for depiction of the graft short time after surgery t -weighted tsesequences showed the best results, to identify potential secondary damages before transplantation pd weighted sequences were superior. and months after transplantation spoiled d-gre-sequences displayed the graft in high spatial resolution. from the diffusion measurements no statistically significant discrimination between cartilage and graft was obtained at any time, whereas, different images from gre-sequences with and without mt pulse provided high contrast between cartilage and surrounding tissue. the quantification of the mt effect showed an assimilation of the graft to the original cartilage within months. conclusion: mrt should be performed before every transplantation because cartilage defects and secondary damages can be detected clearly. after transplantation mrt can easily identify the graft and detect hypertrophy or debonding in early stage. quantitative macroradiographic study with fractal signature analysis measures bone loss in the rheumatoid arthritis hand l. disini , m. foster , j. buckland-wright ; london/uk, loughborough/uk purpose: fractal signature analysis (fsa), a computerised method of textural analysis, permits the separate measurement of changes in vertical and horizontal trabeculae based on the fractal dimension over a range of trabecular widths (fractal signature). we determined whether the fsa of high definition macroradiographs (x magnification) quantified differences in trabecular organisation at sites of osteopenia and erosion formation in the rheumatoid arthritis (ra) hand. methods: sixty-seven ra patients had macroradiographs of the left hand. the distal radius was scored and grouped from very mild (ra ) to moderate (ra ) disease. macroradiographs were digitised and fsa of horizontal and vertical trabecular organisation were measured in the radius at sites of osteopenia, erosion formation and a mid-shaft site. the fractal signatures were compared to healthy non-arthritic subjects using the t-test. results: compared to the non-arthritics, fsa at the distal radius in groups ra to ra measured a significant reduction (p < . ) in fractal signature at the osteopenic and mid-shaft sites, affecting small to large sized vertical trabeculae, and at the erosion site, involving small and medium sized horizontal and vertical trabeculae. the reduction was smallest in ra and greatest in ra . conclusion: fsa quantified the trabecular bone loss in the distal radius of ra patients of increasing radiographic severity based on a proportional reduction in fractal signature. disease related bone loss involved varying trabecular widths with vertical trabeculae at the osteopenic site and both vertical and horizontal trabeculae at the erosion site. potentially, fsa can distinguish changes consequent to bone-mediated ra drug treatment. the results: the value of d ct reconstructions in external projections was the highest in revealing of the osteophytes of anterior margins of vertebral bodies; the anterior osteophytes were found in ( . %) patients on d ct images. the d ct reconstructions cut off in sagittal plane along the spinous process were the best imaging modality in evaluation of the osteophytes of the posterior margin of the vertebral body, which were seen in cases ( %) and in evaluation of narrowing of the intervertebral foramens ( cases - %). conclusions: d ct reconstructions are valuable in determining the localization and the extent of the cervical spine osteophytes. they are the imaging modality of choice in assessment of the degenerative narrowing of the intervertebral foramens. d ct reconstructions should be the integral part of ct examination of patients with the neck pain. purpose: the aim of our study was to determine the incidence of jspa in croatian population in the last years in relation to other rheumatic diseases and the presence of hla -b in children with jspa. as the cause of jspa is still unknown, the strong association with hla -b suggests genetically determined mechanism. methods and materials: the patients from to years of age diagnosed during the period - at department of paediatric rheumatology, university hospital zagreb following strict criteria of european spondyloarthropathy study group. we identified newly diagnosed patients with rheumatic disease using hospital and outpatient records. results: were identified as having jspa ( . %) amongst , patients with rheumatic disorders. sex ratio was females against males, mean age of . years. patients had undifferentiated spondyloarthropathy ( . %), patients had reiter's syndrome ( . %), had arthritis of inflammatory bowel disease, i.e. crohn's ( . %), two patients had psoriatic arthritis ( . %), and two had ankylosing spondylitis ( . %). ocular complications were present in patients ( . %), enthesitis in ( . %), sacroileitis in ( . %) and peripheral arthritis in all patients ( %), diagnosed radiologicaly. hla -b was present in patients ( . %). conclusion: our epidemiological study showed similar incidence of jspa among other rheumatic diseases in childhood and adolescents ( . %) compared to results of american, canadian and british studies in which this incidence is . - . %. however, the presence of hla -b antigen is lower ( . %). postprocessing optimization of computed tomography data of acetabular fractures v. moschenko, t. shamova, a. sklyarenko, i. bobkova; kharkov/ua purpose: to study diagnostic opportunities of postprocessing programs -multiplanar (mpr) and d shaded surface display (ssd) reconstruction of ct data on acetabular fractures. methods and materials: patients aged - with acetabular fractures in various terms since the moment of trauma (from days to months) were examined. plain radiographs and ct with the subsequent application of programs mpr and ssd were conducted. the acetabular fractures classification by judet -letournel was used. results: use of postprocessing programs allowed in ( . %) cases to specify a type of fracture and character of deformation of acetabulum, therefore in ( . %) -the originally prospective conservative treatment was replaced by operative. considering complexity of choice certain reformations mpr and ssd for analysis and documenting of views, we used standard projections: for mpr - ) along anterior column, ) along posterior column, ) along both columns; for ssd - ) anteroposterior view of the pelvis; ) direct projection (lateral view) of the acetabulum; ) obturator oblique view of the pelvis; ) iliac oblique view of the pelvis. in ( . %) cases use of only these projections was enough to establish the type of acetabular fracture. conclusion: use of mpr and ssd in ct data postprocessing allows establishing the type of acetabular fractures that defines a choice of treatment tactics. our standard protocol of mpr and ssd reduces analysis time of research results and creates conditions for uniform perception of injuries by all participants of diagnostic process. conclusion: routine x-ray projections prove insufficient to establish a diagnosis in / th of the cases. confusion is caused by overlaying of fracture edges and pelvic bone in the direction of x-ray beams. the latter makes hardly visible the small posterior fragment, too. therefore, ct scanning is required for the diagnostic protocol of displaced femoral head fractures. is learning objectives: to describe us and mr imaging findings of nerve infiltration by extrinsic masses, including lipomas, hemangiomas, non-hodgkin lymphomas and ganglion cysts. to learn to differentiate between these pathologic conditions. to emphasize the role of us and mr imaging in the management of these lesions to further delineate the nature and extent of the process. background: in addition to peripheral nerve sheath tumors (e.g. neurofibromas, schwannomas and malignant peripheral nerve sheath tumors), there are softtissue masses, such as hemangiomas, lymphomas and ganglion cysts, which do not originate from the nerve itself but may occasionally infold among the nerve fascicles and expand into the neural tissue. the intraneural growth of these masses is rare, may cause nerve dysfunction and local symptoms and should not be confused as the more common nerve sheath tumors. imaging findings: - mhz us and . t mr imaging findings for a series of eight retrospectively collected cases of masses infiltrating nerves are illustrated with emphasis about the different pathogenetic mechanisms of intraneural infiltration. hemangiomas involved the median and ulnar nerves, ganglion cysts the peroneal nerve, non-hodgkin lymphomas the sciatic and median nerves. correlation of imaging findings with gross surgical views is provided in / cases. conclusion: high-resolution us and mr imaging can detect nerve infiltration by extrinsic masses. knowledge and recognition of the characteristic imaging features can aid in the proper diagnosis and treatment of these lesions. mri of lipomatous soft tissue tumors: radiologic pathologic correlation m. pilavaki, d. chourmouzi, g. boulogianni, a. drevelegas; thessaloniki/gr purpose: to study the mr imaging findings for each type of lipomatous soft tissue tumors and to correlate them with the pathological findings. we studied retrospectively the mr examinations of patients with histological proven lipomatous soft tissue tumors. the histological types of the tumors were: lipomas, fibrolipoma, lipoblastoma, lipomatosis and liposarcomas ( well-differentiated, myxoid, and mixed type) t -, t -, and fat-suppressed and t -weighted images after administration of gadopentetate dimeglumine were obtained. the signal intensity on different sequences, the internal characteristics, the presence of septa and other nonadipose component, revealed on the mr images and the degree of contrast enhancement of septa and nonadipose component were evaluated. results: from the group of benign lipomatous lesions lesions were without a recognizable nonadipose component. lesions had thin septa without contrast enhancement. in case of fibrolipoma areas of nonadipose component correlated with fibrous tissue. in the group of well-differentiated liposarcomas had thin septa and thick septa with mild contrast enhancement. the remaining liposarcomas had thick septa with of them having a nodular and globular non-fatty component with enhancement after the administration of paramagnetic agent. conclusion: statistically significant imaging features favoring a diagnosis of liposarcoma included the presence of thick septa, enhancement of septa and the presence of nodular or patchy nonadipose components. imaging features suggesting benignancy included thin septa with no enhancement relative to muscle and no recognizable nonadipose component. guidelines for diagnosis of soft tissue lipomatous masses (stlm) g. chave, d. ranchere-vince, p. meeus, p. thiesse; lyon/fr learning objectives: to clarify the steps of pretreatment diagnostic procedures in case of soft tissue lipomatous masses (stlm). to describe the mri findings for lipomas and liposarcomas. to develop the principles of percutaneous biopsy. background: differential diagnosis between lipomas and liposarcomas, especially atypical lipomas is not always easy. despite similarities, differential diagnosis can be reliably established employing image parameters. nevertheless, the staging process of stlm culminates in biopsies, allowing to manage the proper treatment. biopsies can be performed percutaneously using imaging guidance. an open biopsy with the resection of the entire mass is disputed when the stlm is composed essentially of fat on mri imaging to avoid the misdiagnosis of benign lipoma. each procedure must be carefully planned: an inadequate biopsy may fail to allow proper diagnosis, have a negative impact on survival, and ultimately necessitate an amputation to accomplish adequate margins of resection. procedure details: after the description of characteristics and different histological subtypes of lipomas and liposarcomas, we will describe the mri findings for each diagnosis, according to a review of the litterature by illustrating with mri imaging of patients followed in our center. we will develop the principles of percutaneous biopsies according to litterature and our experience. conclusion: accurate diagnosis of stlm is based on three factors: clinical presentation, radiological features and pathologic evaluation. the importance of careful planning and performance of biopsies cannot be overemphasized because errors may have a negative impact on survival and impede proper diagnosis. high background: clinical assessment of extensor tendon injuries is not straightforward because of the peculiar anatomy of these tendons made of several interconnecting layers and different attachment sites in the fingers. the development of very high-frequency "footprint" transducers has improved the ability of us to scan the extensor tendon complex in the fingers, allowing accurate depiction of the central and lateral slips of the extensor tendon, and the sagittal and lateral bands of the extensor hood. imaging findings: paradigmatic - mhz and - mhz us images from a series of retrospectively collected cases with a variety of extensor tendon injuries in the fingers are illustrated, including partial and complete rupture of the central slip (boutonnière deformity), tears of the lateral slip, avulsion injury of the terminal tendon (mallet finger), injury of the sagittal band over the metacarpophalangeal joint with tendon instability (boxer knuckle). dynamic us is essential to diagnose injuries of the extensor hood mechanism. correlations of us findings with schematic drawings and the results from . t mr imaging are also provided. conclusion: high-resolution us is promising for evaluating the extensor tendons complex in the fingers. it can identify and characterize a variety of abnormalities. by providing unique information on these tendons, us has potential for major impact on treatment planning. high-resolution us of tenosynovitis in the wrist and hand a. picotti , l.e. bacigalupo , r. podestà , g. succio , f. pugliese , s. bianchi , c. martinoli ; siena/it, genoa/it, geneva/ch learning objectives: to describe the spectrum of tenosynovitis of flexor and extensor tendons in the wrist and hand by means of high-resolution us. to correlate us findings with clinical features and mr imaging. to emphasize the role of us in the management of these lesions to further delineate the nature and extent of the process. background: tenosynovitis of wrist and hand tendons are common and account for a high percentage of orthopaedic consultations. they can be related to local causes, particularly overuse due to sport or occupational activities or may be the result of systemic musculoskeletal disorders. imaging findings: paradigmatic - mhz and - mhz us images from a series of retrospectively collected cases with a variety of tenosynovitis in the wrist and hand are illustrated with emphasis on the pathogenetic mechanism of tendon disease, including de quervain disease, intersection syndrome, extensor pollicis longus, extensor carpi ulnaris, flexor carpi radialis and flexor digitorum tenosynovitis. the main findings in infectious and hypertrophic tenosynovitis are also described and a spectrum of unusual causes producing them is reported, including foreign bodies and conflict with fracture residuals and osteosynthesis material. conclusion: due to its widespread availability, low cost and high spatial resolution, high-resolution us is an excellent tool for investigating a variety of tenosynovitis of the wrist and hand. background: the patients with inflammatory myopathies (inclusion-body myositis (ibm) = , polymyositis (pm) = and dermatomyositis (dm) = ) underwent whole-body mr muscle screening examination. mr examination is performed at six different levels: neck, shoulder, abdomen, pelvic girdle, and upper and lower leg. t -and t -weighted images with and without fat suppression were performed for each level. signal intensity of muscles, volume and the symmetry of involvement were quantified in individual muscles on each side. imaging findings: ibm, dm and pm are rare diseases with clinical and histopathological similarities. ibm usually does not respond to immunosuppressive therapy. therefore, it is necessary to distinguish these entities correctly. ibm is characterized by more frequent fatty infiltration, atrophy, inflammation, a distal predominance, and anterior group involvement. the finding of selective involvement of the medial gastrocnemius and of the vasti with sparing of rectus femoris is typical for sporadic ibm. the selective involvement of flexor digitorum profundus is also highly suggestive for ibm. t , t and fat-sat images contain different but complimentary information. pm and dm predominantly affect muscle groups of the shoulder girdle and the thighs. a newly introduced mr technique provides an excellent overview of all diseased muscles in the body. moreover, it helps us to distinguish ibm from other iims. mri may help establish the diagnosis, suggest appropriate sites for biopsy, and enable assessment of disease progress or regression over time. background: elastofibroma dorsi is a rare, typically slow-growing, often bilateral, para-neoplastic formation. it's composed by fibro-elastic and adipose tissue and is selectively localized along the postero-lateral side of thoracic wall, under the scapula. the certain diagnosis is cyto-histological. mri was the hitherto elective diagnosis. all cases of elastofibroma in our series were studied with us; some of them also with ct and mri; in a retrospective analysis us allowed to suspect presence of elastofibroma in all patients: of them underwent surgery that confirmed the diagnosis. procedure details: in our series the us examination, performed with . - mhz linear probe, showed solid masses, sometimes in both sides, with badly visible margins, hypoechoic with inside hyperechoic stripes, obliquous from the transducer plan. conclusions: in all cases us and clinical findings allowed the diagnosis of elastofibroma dorsi. the mri, performed in patients that underwent surgery, confirmed the us findings. the remaining patients are undergoing follow-up with us. so, us findings, within site, slow growth and possible presence of bilateral masses, allow the diagnosis of elastofibroma dorsi, avoiding costly mri. a comparison between ultrasound, echo-color-doppler, and mri in the evaluation of achilles enthesopathy in psoriasis: preliminary results f. maggi, f. di gregorio, c. de simone, c. pagliarello, m. politi; rome/it purpose: psoriasis is often associated with achilles enthesopathy. this study compares the efficacy of ultrasound, echo-color-doppler and mri in the evaluation of early signs of achilles enthesopathy in psoriatic patients. methods and materials: consecutive psoriatic patients, men, women, mean age years (age range - ), mean pasi score , entered the study. all patients underwent sonography of the achilles tendon and peritendinous structures with aplio (toshiba) equipped with a linear multifrequence ( - mhz) transducer; the study was completed with color-doppler analysis. an mri study, before and after gadolinium, was then performed using e-scan xq (esaote), . tesla superconducting magnet. axial and sagittal t and t weighted, sagittal ge and stir sequences were obtained. after gadolinium, axial and sagittal t weighted sequences were obtained. results: the more frequent us findings were microcalcifications inside the achilles tendon ( % of cases) and signs of bursitis ( %), while uncommon there were degenerative lesions and signs of peritendinitis. completion with echo-color-doppler did not add significant data to us study. mri imaging showed degenerative lesions and peritendinitis as well as us, but was not able to identify any microcalcification. all the alterations were identified in the basal study; administration of gadolinium did not allow any additional pathological finding. conclusion: our preliminary results show that mri, especially with low magnetic field, is not sensitive compared to us in detecting early changes of achilles enthesopathy in psoriatic patients, while echo-color-doppler and enhanced mri sequences had limited utility in diagnostic imaging of early stages of this pathology. characterization high resolution us and mri in the evaluation of plantar fibromatosis i. gallesio, s. parodi, r. pastorino, d. schettini, m. falchi, e. silvestri, g. garlaschi; genoa/it purpose: plantar fibromatosis is a benign fibroproliferative disorder of the plantar fascia clinically presenting subcutaneous nodules in the foot sole. this study aimed to evaluate the application potential of us and mri performance in detection of these lesions. material and method: patient with palpable nodules suspected plantar fibromatosis were evaluated. the us examination was performed by means of a high resolution transducer through tranverse and longitudinal scans along with evaluation of intra-nodular vascularization by power-doppler. mri was performed by means of a . t unit with axial and sagittal planes. t weighted mri images after administration of iv contrast medium were acquired from two patients. results: nodules were, overall, detected, most of them located in the medial plantar fascia. all nodules were oval-shaped, hypoechoic at us and hypointense at mri. considering number and size of nodules, us and mri overlapped (were strikingly similar). moreover, nodules showed hypervascularization at power-doppler, confirmed at mri with paramagnetic contrast medium. this pattern might suggest a different pathoanatomical condition of these lesions, as hypervascularization is a sign of an early stage lesion, featuring a large fibrovascular proliferation. no correlation was found between vascularization degree and symptoms the latter resulting from the neurovascular structures disorder. conclusions: us associated with power-doppler is the first choice method in the evaluation of plantar fibromatosis, able to detect number, size and activity pattern of nodules, leading to a pre-surgery diagnosis. in severe plantar fibromatosis mr is to be considered a complementary method in evaluation of the extent. purpose: conventional mri is a well-accepted technique in evaluating soft tissue tumors. however it is not specific in differentiating benign and malignant lesions. in this study the differential value of the dynamic contrast enhanced mri (dce-mri) was investigated. methods and materials: turbo flash dce-mri was performed on subjects ( - yrs) with soft tissue tumors. enhancement in the st min (e ), nd min (e ), maximum enhancement (emax), and time-signal intensity curve (tic) slopes were calculated. discriminant analyses were performed to reveal parametric differences of the benign and malignant lesions. results: histopathological diagnosis of benign (n = ) tumors were hemangioma (n = ), neurogenic tumor (n = ) lipoma (n = ) and desmoid (n = ), whereas malignant lesions (n = ) were classified as liposarcoma (n = ), osteosarcoma with soft tissue component (n = ), malignant fibrous histiocytoma (n = ), synovial sarcoma (n = ) and giant cell tumor (n = ). for malignant lesions mean values for e , e and emax were %, %, and %, respectively. mean tic slope was . . for benign lesions the above mentioned values were %, %, %, and . , respectively. anova based discriminant analysis was correctly classified % of the lesions to benign and malignant groups using e , % of the lesions using e or emax, and % of the lesions using tic slope. the combination of the above mentioned parameters had resulted a % accuracy (p < . ). conclusion: dce-mri parameters are the surrogate markers of tumoral microcirculation and tissue perfusion. these parameters may be used as key factors when deciding proper treatment alternatives and to reveal malignant transformations. the relation of flexor retinaculum laxity with age, gender, and hand dominance t. altinok, h.m. karakas; malatya/tr purpose: carpal tunnel syndrome (cts) is an entrapment neuropathy involving the median nerve within its fibroosseous tunnel at the wrist. one of the main radiologic parameters in diagnosing cts is the palmar displacement (pd) of the flexor retinaculum in this study, possible physiologic factors that may affect the palmar displacement and decrease the sensitivity of this criterion were investigated. materials and methods: normal wrists of male and female with ages between and (mean: . ; sd: . ) were ultrasonographically investigated with - mhz linear transducer. pd values obtained were correlated with with age, gender, and hand dominance was analyzed. results: there was no significant difference between different genders and between dominant and non-dominant hands regarding palmar displacement. when considering all subjects this parameter was varied between . and . mm (mean: . ; sd: . ). palmar displacement exhibited a very strong correlation with age (p < . ; r = . and r = . , for dominant and non-dominant hand, respectively). when considering all subjects, linear regression between both factors was found to be . (p < . ). the sensitivity of pd in diagnosing carpal tunnel syndrome was variously reported to be lower than other radiologic criteria. we have found this relative insensitivity to be originated from the age dependent laxity. the cut-off value of . mm given in the relevant literature must therefore be considered normal for the paients older than years of age. the use of the normalization data presented may help to improve the sensitivity of the palmar displacement. vascular soft tissue tumor discrimination with mr image findings by pattern recognition techniques c. vidal, j. garcía-gómez, l. marti-bonmati, m. robles; valencia/es purpose: to discriminate within soft tissue tumors (stt) those with a vascular origin from other histological groups by using pattern recognition techniques with mr image findings. a total of consecutive patient with confirmed musculoskeletal stt from different european centres were examined with mr. t and t -weighted fat-suppression or stir images were obtained in all subjects. the recorded variables were: age, clinical presentation, localization, size, shape, mr signal intensity, margins, homogeneity, edema, t -hyperintense tracts, mul-tiplicity, target appearance, muscular atrophy, intratumoral hemorrhage, calcification, intratumoral fat, fibrosis, fascial relationship, bone alterations, vessels. the k-nearest neighbour (knn), support vector machine (svm) and decision trees (dt) were used to classify vascular from cystic, fatty, nervous, synovial and fibrous origin. the sample was splitted with % of cases used as test. results: efficacy of vascular in front of each histological group using knn was high (nervous . , cystic . , fibrous . , fatty . and synovial). vascular vs. all other stt gave an efficiency of . with dt, . with svm and . with knn. conclusion: discrimination of vascular from nervous and cystic origin was easier than from fatty, synovial and fibrous stt. however, the overall values were very high. the computer assisted diagnosis in the discrimination of the vascular histological group from the others in stt diagnosis is possible by using pattern recognition techniques. spring ligament chronic injury on mr imaging a. iovane, m. midiri, m. galia, t. bartolotta, r. lagalla; palermo/it purpose: to evaluate the usefulness of mr to depict spring ligament (sl) and to visualize its chronic abnormalities even when associated to injury of the posterior tibial tendon (ptt). materials and methods: mr images from patients ( female and male; age range - years), with clinical suspect of injury of the ptt, were retrospectively examined for sl normal appearance and abnormalities. all exams were performed by a . t mr using t weighted spin-echo and t weighted fast spinecho sequences on the axial plane. asymptomatic control patients ( female and male; age range - years), were examined in the same interval time using t weighted spin-echo and t weighted fast spin-echo sequences on an oblique plane ( °), parallel to sl. we evaluated if sl was totally or partially visualized, sl thickness and signal intensity. results: in all control patients sl was completely visualized, - mm thick and homogenously hypointense. / patients had injury of ptt. among these patients sl was visualized in its medial portion in patients of which had chronic abnormalities of ls. at standard mr examination was not possible to visualize the inferior portion of sl in almost all patients. conclusions: mr seems to be an important diagnostic technique to evaluate sl abnormalities. the high association of sl lesions with ptt injury has to be known and considered when studying patients with proved advanced ptt injury in order to plan correctly the mr study to sl whole examination. primitive muscular hydatidosis: a pictural review of cases a. konan, h. rajhi, n. mnif, m. karray, m. zlitni, r. hamza; tunis/tn purpose: soft tissue involvement by hydatid disease remains unusual even in endemic areas. in this report our aims are to review the imaging findings of muscular hydatidosis and underline possible peculiarity. we review retrospectively patients ( men, women) who underwent surgery for primitive muscular hydatid disease. imaging technique used included ultrasonography (n = ), ct scan (n = ) and magnetic resonance imaging (n = ). results: ultrasonography found multiple anechoic and hypoechoic cystic lesions (n = ), necrozing tumor-like lesion (n = ). ct scan showed evidence of multivesicular cysts in all cases. mri showed typical liquid lesions (n = ), heterogenous signal due to scraps (n = ) and evaluate accurately the extent of involvement. conclusion: in our experience multivesicular cysts is the main lesion showed in primitive hydatidosis soft tissue. ultrasound is still in routine relevant to detect muscular hydatidosis; ct scan and mri confirme the diagnosis and are helpful to demonstrate the relation between cysts and adjacent structures and evaluate extent of involvement before surgical management. results: mri showed degenerative signs. in % disc enhancement was peripheral, parallel to the end plates.the disk enhancement was at l -l in % and l -s in %. it was found in % of end plates inflammation and in % of fatty changes. it was found in % of stage ii and iiia normal or earlier degenerative stages, % of stage iiib and % of iv stage latter degenerative stages. biopsies were performed avoiding disc infection. of the mri of patients with ankylosing spondylitis showed large contrast enhancement parallel to the end plates without end plates inflammation. mri of operated patients showed linear uptake parallel to end plates associated with enhancement in the posterior part of operated disc. mri of patient with infectious spondylitis showed central disk enhancement with end plates inflammation in % and vertebral abscess in %. conclusion: disc enhancement parallel to end plate is a disc degenerative sign in operated and non-operated disc. it may be present in inflammatory conditions as ankylosing spondylitis. central disk enhancement appears to be an infection sign. effectiveness of us-guided core needle biopsy in the diagnosis of musculoskeletal lesions i. lecumberri, j.l. del cura, o. gorriño, i. lópez, a. legorburu, d. grande; bilbao/es purpose: to evaluate effectiveness and accuracy of ultrasound (us) guided core needle biopsy in musculoskeletal lesions. material and methods: us guided core needle biopsies were performed in patients with musculoskeletal lesions imaged by us. all lesions were tumors on us exam, except two that appeared as ill-defined alterations in soft tissues. twelve were arising from or involving bone. location of the lesions was axial in and in extremities in . results of core biopsy were correlated with the final diagnosis, that was based on the exam of surgical specimen in patients who were operated on, and in clinical course in the rest. results: no complications occurred. core biopsy was considered diagnostic in cases. fifty-two lesions were finally diagnosed as malignant and were benign. in cases final diagnosis was different from that of core biopsy. two lesions with non-diagnostic result were finally diagnosed as malignant and another one as benign. five lesions, benign in core biopsy, were diagnosed as a different benign entity after surgery. three lesions, considered benign after core biopsy, were finally diagnosed as malignant. us-guided core needle biopsy achieved % sensibility, % specificity, % positive predictive value and % negative predictive value to detect malignancy in musculoskeletal lesions. in us-visible musculoskeletal lesions, us-guided core biopsy can establish a diagnosis with great accuracy and frequently can avoid other explorations. thus, it should be considered a stable technique in the management of musculoskeletal pathology. extra-abdominal desmoid tumours in the post-partum period: diagnosis and staging with ultrasonography and mri l. dogliotti , m. bazzocchi , n. gandolfo , f. pugliese , f. prefumo , g. serafini ; pietra ligure/it, genoa/it purpose: the extra-abdominal desmoid tumour (eadt) is a rare disease more common in young females. this study describes the ultrasonographic features of eadts, and compares them with mri in the diagnosis and staging of the disease. a total of lesions of the anterior abdominal wall and perineum have been assessed with ultrasonography and mri. six of them were subsequently diagnosed as eadts at histology. of these, were located in the anterior abdominal wall and one, the largest, was embedded within the perineal muscles. all patients were female and reported being pregnant in the year preceding the diagnosis. three had delivered by caesarean section. the ultrasound examination were performed with a - mhz multifrequency transducer. mri imaging employed tse-t w sequences with and without gadolinium, and tse-t w sequences with and without fat suppression. results: in the cases of eadt ultrasonography showed solid homogeneous masses, slightly hypoechogenic compared to the adjacent fibromuscular structures. in the anterior abdominal wall cases, the margins were clearly identified on a transversal plane but spiculated and irregular along the longitudinal plane in out cases. the large perineal lesion (diameter cm) appeared dyshomogenous, but margins were regular and clearly identifiable. at color doppler exami-nation, all lesions showed a rich vascularisation. mri confirmed the fibrous nature of the lesions and helped in the differential diagnosis with endometriosis. conclusion: eadts appear as solid, homogeneous, clearly delimited lesion at ultrasonography. mri is useful for excluding endometriosis in case of dyshomogeneous lesions. retrospective analysis of ultrasound guided core biopsy in the diagnosis of soft tissue masses f.j. perks, i. beggs; edinburgh/uk purpose: to assess the accuracy of ultrasound guided core biopsy of soft tissue masses. we reviewed soft tissue biopsies in consecutive patients. diagnoses were compared to the post excision diagnosis in patients. all core biopsies were performed by the same radiologist using ultrasound guidance. biopsies were performed as outpatient procedures. results: biopsies repeated. ( %) biopsies diagnostic of a wide range of benign and malignant disease. of ( %) biopsies accurately representative of post excision histology. biopsies diagnosed disease that did not warrant excision. false negative biopsies when sampling liposarcoma, lymphoma, chondrosarcoma and metastasis. overall sensitivity and specificity was . % and % respectively. there were no complications. the purpose of this exhibit is to describe the imaging features of sapho in adults. this retrospective study included patients ( women, men). all imaging procedures, radiographs, ct, mri and scintigraphy, were reviewed. background: sapho (acronym for synovitis, acne, pustulosis, hyperostosis and osteitis) is a syndrome of obscure cause, commonly considered to represent a seronegative spondylarthropathy, affecting especially young adults and children and leading to osteoarticular and skin manifestations. osteosclerosis, cortical thickening, enlargement of bone, arthritis are the predominent radiologic pattern, but periostitis and soft tissue swelling also may be seen and these findings can simulate osteomyelitis, sarcoma, lymphoma. imaging findings: of the patients, topographic localizations were the upper anterior chest wall ( %), spine ( %), periphral bones and joints ( %), pelvis ( %), mandible ( . %). the main radiologic findings correlated with hyperostosis, osteitis and synovitis. the radiologist plays a major role in the diagnosis: this exibit reviews the radiologic appearance of this syndrome and illustrates difficulties in differential diagnosis. erdheim-chester disease: detection and staging with multimodality imaging a. miquel , e. dion , c. graef , y. menu , p. grenier , j.-d. laredo ; le kremlin-bicêtre/fr, paris/fr learning objectives: to illustrate the clinical, radiological and histological spectrum of findings in erdheim-chester disease. to be able to recognise the disease in a patient with elementary symptoms. to describe the imaging modalities that are necessary for a precise staging of the disease. background: erdheim-chester disease is a multisystemic histiocytosis associated with characteristic skeletal abnormalities. bone (bone pain), skin (xanthomas), orbits (exophthalmos), pituitary gland (diabetes insipitus), retroperitoneum (hydronephrosis) and lungs may be affected by the disease. the relashionship of the disease with langerhans cell histiocytosis is still unclear. seventeen patients with erdheim-chester disease were evaluated between and , using conventional x-rays, us, ct, bone scintigraphy and mri. radiological-pathological correlations were available in cases. imaging findings: osteosclerosis of long bones in lower limbs is the most common feature ( / cases) and should be a trigger for the diagnosis. mri demonstrates replacement of the high signal of the bone marrow by a decreased signal on t and t -weighted images. atypical osseous manifestations include involvement of ribs, skull and pelvis; focal lytic lesions are seldom encountered ( / ). visceral involvement may affect pituitary gland, orbits, pericardium, lungs, kidneys and retroperitoneum. pathologic study shows accumulation of lipid-laden histiocytes and fibrosis. conclusion: bone lesions are rather specific and should suggest the diagnosis of erdheim-chester disease. detection of visceral involvement, sometimes asymptomatic, requires imaging of brain, lung and retroperitoneum. histological analysis is necessary to assess the diagnosis and differentiate the disease from other cases of histiocytosis, especially langerhans cell histiocytosis. the learning objective: we aim to highlight the manifestations of myeloma using referrals from such specialities as haematology, orthopaedics and general medicine. the classical appearances of myeloma are presented with aids to enable the radiologist confirm the diagnosis and differentiate from other pathologies of similar appearance. background: multiple myeloma is the commonest primary malignant neoplasm and therefore as pathology the radiologist should be mindful of its many appearances. imaging findings: through a pictorial review we show not only the classical appearances of myelomatosis on plain film and bone scans but we also present its' appearance on ct scan and mri. the limitations and benefits of each modality are discussed. furthermore we highlight the recent findings which show that not only is mri better at staging multiple myeloma but compared to the dated "durie and salmon" criteria it negates the need for repeat blood and urine samples. conclusion: multiple myeloma may not always present with classical appearances and therefore it is paramount that a radiologist be aware of some of the unusual forms. through an assortment of imaging modalities we present not only the characteristic appearance but also atypical varieties. vertebral development: normal and abnormal aspects-interactive a. marinescu, a. pavel, h.c. ionescu, g. iana; bucharest/ro learning objectives: the program is conceived as an interactive lesson for those who wants to easy understand the vertebral development and also the pathology of an inadequate development. it is addressed to any radiologist in training. background: the vertebral development consists in three stages: mesenchymal, cartilaginous and bony. during this development appear many centers of the future vertebrae (mesenchymal, chondrifications and ossifications centers).o:p> procedure details: using a graphic presentation (originally and schematically) of the vertebrae for any stage and a color convention (the mesenchimal stage is represented in orange, the cartilaginous stage in blue and the third -the bony stage in pink); you can follow all the steps of the vertebral development. the program is interactive, meaning that you can follow the graphic presentation of the steps of the vertebral development, but also: • if you want to know more about the elements on the graphics, you can use the left button of the mouse clicking on the red sign. • before "details" and you will get the information and explanations. then, you can come back to the slide with the marks ü "details". • you can see, for each type of pathology which can occur in different steps of vertebral development, a graphic presentation and radiography (you press the left button of the mouse on the red sign before "pathology". conclusion: all the radiology trainees in our department have been satisfied with the program, instead of reading some arid pages for this topic. nevoid background: nevoid basal cell carcinoma syndrome (nbccs) is a rare autosomal dominant inherited disorder with complete penetrance but variable expressivity. although many radiologists are familiar with typical findings (e.g. major criteria) of this disease there are also findings that are only rarely demonstrable (e.g. minor criteria). imaging findings: we present nbccs-findings of patients. they include numerous pathologies such as multiple cutaneous basal cell carcinomas, odontogenic jaw cysts, ectopic calcifications of the falx cerebri as well as palmar or plantar pits. characteristic images of the patients faces as well as bifid or fused ribs, vertebral anomalies, bridging of the sella turcica, flame shaped pseudocysts of the hands, lymphomesenteric cysts as well as increased frequency of tumors particularly medulloblastomas and ovarian fibromas that are also very important to recognise will be shown. the radiological findings are specific for this disease and may confirm the diagnosis in combination with the clinical presentation. furthermore early diagnosis as well as periodical follow-up examinations is very important since the nevi after puberty turn out to be aggressive. imaging with pathological correlation of sacral and presacral lesions s.a. o'keeffe, t. geoghegan, w.c. torreggiani; dublin/ie learning objectives: the objective of this poster presentation is to pictorially review the imaging of a series of patients with sacral and presacral lesions and to correlate these with pathology. background: presacral tumours are extremely rare accounting for less than in , hospital admissions. there are many pathological causes as this is an anatomical area of embryologic fusion. a review of reports on the radiology information system (ris) was undertaken to identify those patients who had pre- in this pictorial review, we describe the anatomical contents of the presacral space and correlate this with the possible pathological causes of a lesion in this area. in addition, the imaging and pathology of a selection of sacral and presacral tumours is presented and methods of analysis of imaging are suggested. diagnosis background: chordomas are very rare tumors, for which standard medical therapies are lacking. following detection of pdgf-r expression in tumor samples, it was decided to treat some patients with advanced chordoma with imatinib mesylate on an individual basis. these patients were treated at the istituto nazionale tumori, milano, italy, as from august . imaging findings: five pts with advanced disease ( with sacral, one with clivus chordomas) undergoing imatinib mesylate were evaluated with mri at baseline, and then every months. four pts showed hints of tumor response. these were: i) minor and slow decrease in size in the pt with the longest follow-up, following a transient initial increase in size, which was seen in all pts; ii) hypodensity of lesions on t w images and hyperintensity on t w images; iii) hypovasculature of lesions on contrast-enhanced t w images in comparison to baseline assessment. conclusion: actual responsiveness of chordomas to molecular-targeted therapy with imatinib mesylate is left to be determined. however, preliminary observations suggest that mri may be useful to assess tumor response. signs of response may be subtle, likely depending on changes in tumor tissue rather than (or before) decrease in size. groin pain in athletes: mri findings f. idoate saralegui; pamplona/es learning objectives: this exhibit reviews the rmi findings in athletes with groin pain. background: groin pain is a common complaint in athletes, particularly prevalent among soccer players. this condition is frequently multifactorial, and the differential diagnosis can cover a rather broad area of entities, mainly involving adductor muscle and tendinous group, pubic bone even inguinal hernia. between january and august , athletes with groin pain were examined at our institution. the mri findings of the possible causes of groin pain in athletes are described and illustrated. imaging findings: the examinations were performed in a tesla imaging system (magnetom impact expert, siemens) with a surface coil. t -weighted spin echo and t -weighted fat suppressed turbo spin echo images were obtained in axial plane; stir a t -weighted turbo spin echo sequences were performed in coronal plane. the pathological findings observed were: osteitis pubis, stress fracture of pubic bone, muscle tears (adductor, obturator, rectus abdominis, pectineus, iliopsoas, gracilis and rectus femoris groups), abdomino fascial abnormalities, inguinal hernia, bursitis and inflammation conditions of the spermatic cord. conclusion: mri depicts adequately the numerous pathologic entities related to groin pain in athletes. infection background: prosthetic, graft or catheter infection, irrespective of location, invariably equates with a poor outcome. modern aseptic technique, in addition to the use of antibiotic-coated prostheses, have dramatically reduced the incidence of such infection. aggressive antibiotic suppression is effective in fewer than % of cases, the remainder requiring removal of the infected prosthesis, with associated morbidity, and occasionally, mortality. clinical signs and symptoms are frequently non-specific, including lethargy, pyrexia and anorexia. it is for this reason that quite often the task of locating a causative factor relies upon the expertise of the radiologist. imaging: using a pictorial review we depict the numerous pitfalls in the radiological diagnosis of prosthetic and endovascular graft infections. in addition, a guide to radiological imaging of less frequently encountered infections, such as those of breast and penile prostheses, ventriculo-peritoneal shunts, intra-ocular lens, cardiac pacemakers and valves, will be provided. the limitations and benefits of conventional radiography, digital subtraction angiography, computed tomography, ultrasound, magnetic resonance imaging and radio-isotope scintigraphy with respect to the site of infection will be explored in turn. the radiological diagnosis of infection of synthetic materials is notoriously difficult. the use of these materials for therapeutic, cosmetic and palliative purposes is ever-increasing. it is therefore of vital importance that the radiologist be aware of the advantages and disadvantages of available imaging modalities in arriving at a confident, swift diagnosis. a new method for radio frequency of lumbar disc in treatment of chronic low back pain n. azulay , m. forgerit , a. moumouh , e. alava , p. vandermarq , j.-p. tasu ; poitiers/fr, niort/fr, barcelona/es purpose: treatment of chronic low back pains remains a challenge for physicians. recently, radio-frequency heating of inter vertebral disc has been proposed, as an alternative to surgery. we propose here a new method of discal radiofrequency in which heated water is used to spread the thermal energy. materials and methods: seventeen patients were included prospectively according to the criteria used in previous intra discal radiofrequency studies. the catheter is placed in the nucleus and heated water is used as thermal conductor to burn the annulus nociceptors. intra discal pressure and impedance measurements were used to control the energy delivered during the procedure. clinical results were evaluated by the oswestry score. the treatment was scored as a success with at least a % pain reduction on global perceived effect on oswestry score. the global oswestry before treatment was . points and points b d e f a g after corresponding to a . % improvement. on the patients, were successfully treated ( %). we have shown that injection of heated water is sufficient to spread thermal energy to the anular nociceptor. this method is technically more simple than previous techniques using anular needle, avoiding navigation of the catheter through the anulus. ultra low dose ct in navigated closed reduction and percutaneous screw fixation of pelvic ring fractures h.g. staedele, r. huegli, s. meckel, a.l. jacob, h. roser, p. messmer, j. roth; basle/ch purpose: to reduce radiation doses in image-guided pelvic closed reduction and percutaneous fixation crpf without compromising guidance quality and procedural outcome. prospective study including patients with pelvic ring fractures treated with ct-guided crpf. patients received screws which were navigated over guide pins. imaging modality used was a single slice scanner (general electric, usa). tube current was reduced by % with every step starting with routinely used scan parameters for diagnostic and interventional procedures ( ma). if the image quality was good the next control scan was performed with % reduction of ma again. results: patients with fractures underwent crpf. were males, females, with a mean age of years (range . - . ). dose reduction was possible in all patients in to steps ending up in ma (n = ), ma (n = ) and ma (n = ) respectively. ma is the lowest current provided by the ct. number of misplaced screws was . number of additional correction of guide pin was . number of fallbacks to the next dose level was . conclusion: by lowering scan doses no relevant morphological information needed for safe guidance of instruments and implants was lost. scan protocols can be changed to lower ma values without compromising the safety of crpf. immediate procedural outcome was not affected. withdrawn by authors pelvic painful syndrome in athletes: diagnostic imaging evaluation l. zugaro, f. iannessi, a. catalucci, a. barile, c. masciocchi; l'aquila/it purpose: to describe the imaging features of the anterior and posterior painful syndrome in athletes. materials and methods: athletes ( males, female) suffering from pelvic pain (groin pain = and hamstring syndrome = ) underwent mri after plain film and ultrasound preliminary evaluation. in patients ct evaluation was also performed. mr examination was performed using a . t unit (ge medical system). proton density, t weighted and t weighted sequences on axial and coronal planes were employed. in one case mri was also obtained after surgical treatment. in all cases mri demonstrated pathological findings: anterior painful syndromes were related to osteitis pubis, bursitis, inguinal hernia, post-traumatic muscular lesions and stress fractures. hamstring syndrome was related to insertional pathology of hamstring tendons, inflammation disease of regional bursae and fibrotic changes of fatty tissue surrounding the ischial tuberosity. conclusion: anterior and posterior pubic painful syndromes are painful conditions often affecting athletes. mri provides a correct evaluation of these syndromes enabling an adequate therapy. the value of qualitative and semiquantitative ultrasonographic findings in the differential diagnosis of superficial lymph node enlargements o.o. okten , n. tuncbilek , h.m. karakas ; edirne/tr, malatya/tr purpose: the value of the gray-scale (gsusg), color doppler (dusg), and power doppler (pdusg) ultrasonography in the differential diagnosis of superficial lymph node enlargements were evaluated. the study group was consisted of males and females ( - yrs old, mean age . yrs) in whom physical examination had revealed superficial lymph node enlargement(s). all patients were investigated with power doppler usg (sonoline elegra advanced, siemens, germany) using . mhz linear transducer. longitudinal/transverse dimensions (l/t), edge characteristics and hilar echogenecity of lymph nodes were evaluated with gsusg. pulsatility (pi) and resistivity (ri) indexes were calculated using cdusg. vascular pattern described as hilar or non-hilar were determined by pdusg. above parameters were analyzed to determine their differential diagnostic values using anova based discriminant analysis. results: when clinical data and histopathological findings were combined, subjects were diagnosed as lymphoma, and cases were classified as lymphadenitis. multiple comparison analysis of qualitative gsusg and pdusg features consisting of edge characteristics, hilar echogenecity and vascular pattern was able to differentiate lypmhomatous lymph nodes and lymphadenitis with % accuracy (p < . ). in contrary, semiquantitative features (ri, pi and l/t) were not able to classify lymph nodes ( % accuracy, p < . ). conclusion: semiquantitative rdus parameters are not valuable in the differential diagnosis of superficial lymph node pathologies. qualitative usg and pdusg features, on the other hand, may be used as an alternative work-up to cytological studies in patients in whom diagnostic surgical procedures cannot be performed. modern imaging in langerhans cell histiocytosis a. geoffray, k. oudjhane, l. lau, s. weitzmann; toronto, on/ca purpose: to review imaging features of pediatric langerhans cell histiocytosis (lch) with particular attention to cross-sectional imaging and aggressive cases. we reviewed retrospectively the imaging database of all the cases treated in our institution for lch during a years period (january to december ). there were patients, boys, girls, with an age range of weeks to years. results: patients had no imaging anomalies and were excluded. among the with anomalies, had a solitary bone lesion (skull , orbit , spine , iliac , long bones ), had multiple bone lesions associated with other organ involvement in (lung , liver and spleen , thymus ), patients had no bone lesions ( cervical adenopathy, abdominal involvement, abdominal and lung, pituitary gland, middle ears), patient had lch associated with neuroblastoma, and presented with lymphadenopathy, mediastinal and sacrococcygeal masses. imaging modalities were conventional radiography in %, nuclear scans %, ct %, mr %, us %. conclusion: lch in children is characterized by a wide spectrum of organ involvement. cross sectional imaging is useful in assessing the diagnosis and managing the most aggressive cases. can calcaneal spur help in the evaluation of a painful heel? n. sabir, s. demirlenk, b. yagci, n. karabulut; denizli/tr purpose: to determine the value of presence of calcaneal spur in evaluating painful heels. materials and methods: heels of female and male patients with a mean age of . ± . years and mean body mass index (bmi) of . ± . complaining of bilateral (n = ) and unilateral (n = ) heel pain were studied. lateral radiographs of the symptomatic and asymptomatic heels were obtained to assess presence of calcaneal spur. mr imaging of the symptomatic heels was performed using . t superconductive system. the images were taken and reviewed for presence of plantar fasciitis (pf). heel pad thickness was also measured. results: calcaneal spur was seen in of ( %) symptomatic and in of ( . %) of asymptomatic heels. mr has revealed pf in of ( . %) painful heels and calcaneal spur was present in of the cases with pf. calcaneal spur was significantly correlated with weight (p < . ), bmi (p < . ), age (p = . ), heel pain duration (p = . ) and pf (p < . ). no correlation was seen between calcaneal spur and both height and heel fat pad. conclusion: although calcaneal spur is not the cause of pain, it may provide an objective assessment of the changes due to chronic repeatitive trauma to plantar fascia secondary to obesity or age. on the other hand foot radiography should be part of the initial diagnostic methods as it helps in excluding different causes of heel pain. purpose: the positive areas in scintigraphy of sentinel lymph nodes are sometimes difficult to be anatomically identified. we have examined the usefulness of bone scintigraphy performed together with lymphoscintigraphy for identification of the anatomical positions of the positive area in lymphoscintigraphy. materials and methods: sixteen patients, cases of malignant melanoma and cases of squamous cell carcinoma were examined by lymphoscintigraphy. nine patients, cases of malignant melanoma and cases of squamous cell carcinoma, were examined by bone scintigraphy together with lymphoscintigraphy. the patients were divided into three groups. in the first group, lymphoscintigraphy was performed alone. in the second group, the patients were first injected intravenously with tc- mhmdp or tc- mmdp and then lymphoscintigraphy was performed after intradermal administration of tc- m sulphur colloid. three hours after injection of tc- mhmdp or tc- mmdp, bone scintigraphy were taken. in the third group, lymphoscintigraphy was performed minutes after bone scintigraphy. result: anatomical identification of the positive areas in lymphoscintigraphy was difficult when used alone, whereas their identification became easier when used together with bone scintigraphy. when bone scintigraphy was performed after lymphoscintigraphy, evaluation of lesions in the bones near the original focus was sometimes not easy. however, evaluation of lymphoscintigraphy was not affected by prior performance of bone scintigraphy. conclusion: identification of the anatomical positions of the positive areas in lymphoscintigraphy was easier when used together with bone scintigraphy than in lymphoscintigraphy alone. in cases of the joint use, lymphoscintigraphy should be operated after bone scintigraphy. ultrasonographic detection of iatrogenic foreign bodies in an in vitro study i.k. rozylo-kalinowska, l. barczewski, e. szczepanik, r. lenard; lublin/pl purpose: sometimes foreign bodies being parts of surgical appliances remain in soft tissues as a result of iatrogenic faults. their presence is dectected clinically or radiologically, when the objects are radiopaque. nevertheless, radiolucent or faintly radiopaque objects often are a diagnostic challenge as their presence is difficult to diagnose on the basis of conventional radiograms. the purpose of the study was application of ultrasonography for detection of radiolucent and faintly radiopaque foreign bodies in an in vitro model. examples of radiolucent and poorly radiopaque foreign bodies such as plastic fragments of syringes, intravenous catheter, different cotton and gauze swabs, were embedded in containers filled with gelatine, which served as a model of soft tissues as well as played the role of a stand-off pad. the ultrasound scanning was performed by means of atl hdi machine with a high-frequency broadband linear transducer. results. there was determined the possibility of detection of various types of foreign bodies. there were described ultrasonographic image patterns of different objects. image findings: all types of used materials were well visible and hyperechoic in ultrasound image. plastic objects caused appearance of reverberation artifacts. the swabs produced characteristic patterns of internal structure. variations in ultrasonographic image patterns of foreign bodies studied in vitro allowed differentiation of various types of the examined materials. conclusion: ultrasonography may become a useful, widely available and costeffective tool in detection and localisation of foreign bodies of iatrogenic origin that otherwise remain undetected. spectrum of mr findings of herniation pit of the femoral neck m. ferrer, r. dominguez, m. romera, e. castella, x. merino, l. casas; barcelona/es background and purpose: herniation pit of the femoral neck has been considered a normal variant. this lesion is located in the superior aspect of the femoral neck, below the anterior cortex of the femur. the aim of this study was to describe the spectrum of magnetic resonance imaging (mri) findings associated with herniation pit of the femoral neck. material and methods: we retrospectively reviewed the mr studies in patients with hip pain performed in our hospital over the last years. a total of patients presented herniation pit. the features analyzed included: type of herniation pit (unilateral/bilateral), iliofemoral ligament thickening and asymmetry, iliopsoas muscle/femoral head relationship, acetabular coverage angle, cervicodiaphisary angle, femoral anteversion angle, and associated imaging findings (synovitis). results: in patients with hip pain and herniation pit, the following data were found: no other apparent cause of the pain ( %), iliofemoral ligament thickening ( %), decreased acetabular coverage angle ( %), altered cervicodiaphisary angle ( %). the elevated incidence of alterations in acetabular coverage and cervicodiaphisary angle in herniation pit, together with other alterations in stabilizing elements, lead us to suggest that, rather than a separate entity, herniation pit can be considered a component of the spectrum of adult hip dysplasia. b d e f a g high resolution ultrasound of the peripheral nerves of the lower limb: technique of examination and normal us appearance x. montet , s. bianchi , c. martinoli , j. fasel ; geneva/ch, genoa/it objective: to present the basic normal us appearance of peripheral nerves evaluated in vitro and in vivo. to describe the examination technique, the normal us findings and the main anatomic variations of the nerves of the lower limb. materials and methods: us images were obtained with commercially available equipment utilizing two linear probes ( - , - mhz). the normal us appearance of a peripheral nerve was evaluated by in vitro examination a human sciatic nerve. sonograms were then obtained in normal volunteers and correlated with mri and images from anatomic textbook. results: the in vitro us appearance of the a normal peripheral nerve correlates well with the internal nerve structure. fascicles appear as hypoechoic bundles embedded within the hyperechoic connective tissue. the normal anatomy of the sciatic, peroneal, tibial nerve is first briefly described. then for each nerve the scanning technique is presented with emphasis on patient position, probe orientation and dynamic maneuvers. to improve the understanding of us images, correlative drawings showing the adjacent anatomic structures and diagrams showing the position of the probe are presented. high frequency transducers allow a detailed analysis of even smaller peripheral nerves. we present a practical manner to realize a us examination of the nerves of the upper extremity as well as us images of normal nerves and of their main anatomic variants. withdrawn by authors radiologic and sonographic examinations in patients with heterotopic ossifications j. nagy; budapest/hu purpose: to evaluate the diagnostic capability of radiologic and ultrasonographic examinations in patients (pts) with heterotopic ossifications (ho). during the last four years we have examined pts ( women, men; age: / - / years) in case of the clinical suspicion of ho. dynamic conventional radiologic and ultrasonographic ( . mhz linear transducer) examinations were performed. results: in the background of ho, spinal cord injury ( pts, %), brain injury ( pts, %), limb damage ( pts, %), orthopedic surgery ( pts, %) or limb amputation ( pts, %) were found. the most frequent localizations of ho were as follows: one side ( pts) or on either of the sides of the hip ( pts), elbow ( pts), knee ( pts), hip + knee ( pts) or rare localizations (around the femoral stump) ( pts). more than one localization was found in half of the pts. when the clinical suspicion of ho was not proved by radiology, dynamic ultrasonographic examinations were positive in each cases ( pts, %). conclusions: ( ) ho can occur in more than one localization after cns or limb injuries, ( ) the most frequent localization was around one or both hip joints, ( ) sonographic examinations showed earlier positivity compared to conventional radiology, ( ) rare localizations of the ho can induce differential diagnostic problems in clinical practice. ultrasonographic experiences of spine-related lesions in patients with back pain: correlation with mri w. jin; incheon/kr purpose: multiple paraspinal lesions or spine-related lesions have been overlooked on transabdominal ultrasonograhic examination. therefore, we correlated transabdominal ultrasonographic findings with mri findings in spine-related lesions. materials and methods: patients were underwent transabdominal ultrasonographic examinations for routine check prior to surgery. they were men and women aged to (average, ) years. all patients also were checked with mri. in transabdominal ultrasonographic examination, compression of abdominal wall and inner contents were done. after this, we observed closely the contour of body, the height of body, disc height, and paraspinal lesion. results: in patients, there were ) compression fractures or burst fractures; patients, ) spondylitis; patients, ) bone tumorous condition; patients, ) abscess formations in paraspinal muscle; patients, ) ankylosing spondylitis; patient, and ) disc herniation; patients. in these patients, transabdominal ultrasonographic findings were relatively correlated with mr findings, but lesions in posterior and middle elements of spine could not be evaluated with transabdominal ultrasonographic approach. conclusion: despite of many limitations of transabdominal ultrasonographic examination for detection of spine and paraspinal lesion, when spine and paraspinal structures or lesion are visible on transabdominal ultrasonography, ultrasonography suggested to be a screening method in patients with back pain. in particular, ultrasonography was superior to mri in detecting the minimal change of anterior disc, prediscal space, or anterior longitudinal ligament of spine. creation of a radiological musculoskeletal database (db) for statistic referrement, differential-diagnosis and didactic use (stuart project) s. trupiani, e. baldan, r. stramare, c. saccavini, l. bacarini, g. feltrin; padua/it purpose: to create a radiological db, with normal and pathologic cases, to be used for statistic endings, differential-diagnosis and for consultation. the db is available to everyone who as investigation or consultation needs or else for cases submission; for this reason is necessary to follow some fixed criteria unless the case is not accepted. the submission modalities have a starting schedule that contains: patient's anagraphic data, documentation source, sequence of technical-methodological procedures used, a description of every semeiological aspect contained in every single image, gamuts criteria-based diagnosis and final diagnosis. the cases are resumed by acr code. the definitive diagnosis, that contain a synthesis of anatomical-clinical and diagnostic aspects about the pathology observed, is open to critical observations by everyone that is consulting the db. every db consulter is able to introduce his opinion in a special window. the case report ends with a bibliographic correlation that contains the latest literature articles about the argument. the db contents can be utilized as a cases archive for clinical research (for this aspect, very important is the acr code), or as a support in the diagnostic report making, or as a didactical archive. moreover the db users can exchange their opinions, modify or add informations for every case by the web. ment was present in cases ( . %) and discal involvement was present in case ( . %). patients had soft tissue involvement and abscess was present in patients. all cases showed vertebral and discal enhancement. patients showed diffuse involvement of vertebral corpus and patients showed endplate involvement. cases showed both vertebral corpus and endplate involvement. intervertebral space narrowing was present in cases, height loss in vertebral body was observed in cases and cases showed end plate deformities. we detected epidural extension in cases, posterior longitudinal ligament (pll) elevation in , spinal cord compression in and root compression in cases. conclusion: spondylodiscitis is a rare complication of brucellosis and it can cause permanent neurologic deficits and spinal deformities. mri is a very sensitive and non invasive imaging technique which must be firstly preferred for the early diagnosis of spondylodiscitis. imaging findings: a total of aneurysms in patients were evaluated. all were proved at surgery. five small aneurysms were not depicted at d-cta-ssd (three were less than mm, two were less than mm). but only three small aneurysms were missed in d-cta-vrt (two were less than mm, one was less than mm). in ( %) of the patients, d-cta-vrt gave additional informations: orientation (n = ), defining exact neck anatomy (n = ), incorporation of vessels into aneurysm (n = ), lobulation (n = ), and blebs of aneurysms (n = ). conclusion: d-cta-vrt is superior to d-cta-ssd in the detection of very small aneurysms and evaluation of complex anatomy of intracranial aneurysms. gadolinium enhanced ultra-fast mra: a primary diagnostic tool in the recognition and follow-up of dural sinus thrombosis s. gaudino, t. tartaglione, f. molinari, v. valentini, c. colosimo; rome/it dural sinus thromboses (dst) are not extremely rare, they still account for % of ictus in young adults. they need an accurate diagnosis at the onset of symptoms, and during the follow-up, to reduce the risks related to prolonged thrombolytic therapy. digital subtraction angiography (dsa) and, in the last years, phase contrast mr angiography (pc mra) with conventional mr sequences have become the methods of choice for dst diagnosis. our purpose was to evaluate the usefulness of gadolinium-enhanced ultrafast mra (ge-uf mra), routinely employed in supra-aortic vessel evaluation, in the diagnosis and follow-up of dst. materials and methods: we retrospectively evaluated patients with diagnosis of dst, studied using . t magnet, conventional se, tse and ge-uf mra sequences. we could compare ge-uf mra images with dsa in patients and pc mra in patients. results: in all dsa controlled patients, we found a complete agreement between ge-uf mra and dsa concerning location and extent of dst. in all patients with both ge-uf and pc mra, the overall dst diagnosis was identical, even if the diagnosis of minimal dural sinus involvement was easily and definitively assessed with uf-ge mra, which allows a superior diagnosis confidence. conclusions: our preliminary experience suggests that ge-uf mra is a very fast modality, is easily obtained and analyzed and has a superior diagnostic confidence compared to pc mra. in our opinion ge-uf mra should be proposed as the primary diagnostic tool in the recognition and follow-up of dst. imaging imaging appearances: the images were obtained using unenhanced ct and routine mri sequences for brain imaging (ie sagittal t , axial t and coronal proton density weighted sequences). fat suppression sequences were sometimes used for further clarification. the characteristic ct and mri appearances of intracranial fat and the anatomical location of the lesion allow the provision of a narrow differential diagnosis using routine imaging protocols. this facilitates decisions on the need for further imaging modalities. background: vascular dementia represents a very heterogeneous diagnostic category. utilizing the ninds-airen criteria and a centralized imaging rater to determine eligibility for enrollment in recent large-scale clinical trials testing new treatments for vascular dementia has provided increased consistency in the diagnosis of vad. the diagnostic criteria for probable vascular dementia include the development of dementia temporally related to stroke with neuroimaging confirmation. the criteria include a table listing brain imaging lesions associated with vascular dementia. in this study, patients have been screened for the presence of cerebro-vascular disease using brain ct or mri. imaging findings: the wide spectrum of neuroradiological features that are associated with vad may result from cerebral small-vessel disease with extensive leukoencephalopathy or lacunes (basal ganglia or frontal white matter), or may be the consequence of single strategically located infarcts or multiple infarcts in large-vessel territories. it may also be the consequence of global cerebral hypoperfusion, intracerebral hemorrhage or other mechanisms such as genetically determined arteriopathies. conclusion: neuroimaging is required for confirmation of cerebrovascular disease in vad and provides information about the topography and severity of vascular lesions. neuroimaging may also assist with the differential diagnosis of dementia associated with normal pressure hydrocephalus, chronic subdural hematoma, arteriovenous malformation or tumoral diseases. imaging spectrum of cerebral complications after cardiac surgery e. testempassi, g. katsou, v. vantali, m. kolios, d. exarchos, d. chondros; athens/gr learning objectives: to present a systematic approach to imaging findings of cerebral complications caused by cardiac surgery. to review and understand the mechanisms and pathophysiology of cerebral involvement after cardiac surgery. background: a wide spectrum of neurologic complications may occur after cardiac surgery, such as motor, sensory or visual disturbances, stupor or depression of consciousness. the role of imaging in differentiating a variety of conditions that may cause the above neurologic symptoms is very important. morphology and patterns of cerebral lesions also enables an assessment of the pathophysiology and hemodynamics of brain complications after cardiac surgery. we retrospectively reviewed the brain ct images of symptomatic patients, who previously had cardiac surgery performed. imaging findings: a variety of common and uncommon findings on ct and mr images of neurologic complications after cardiac surgery are illustrated. acute infarctions involving a vascular territory, hemorrhagic infarctions, multiple infarctions, watershed infarctions, bilateral infarctions, braistem and cerebellar infarctions, uncal herniation, brain edema and inflammatory processes are depicted. preoperative cerebral ct or mr images are helpful in diagnosing new lesions in patients with old infarctions, lacuna or ischemic leucoencephalopathy. the radiologist must be familiar with the imaging appearance of complications that affect the brain after cardiac surgery. imaging findings of an ethmoidal dural arteriovenous fistula with venous drainage in the vein of galen v.t. skiadas, a. prasouli, p. mitseas, g. kottas, s. laxanis; athens/gr learning objectives: to illustrate the mri, mra and angiographic findings of an ethmoidal dural arteriovenous fistula (avf) in the anterior cranial fossa. background: ethmoidal avfs are rare vascular anomalies. only cases have been presented since , when they were first described by lepoire. they can be either congenital or acquired lesions. ethmoidal arteries are the main feeding vessels. the vast majority drain to the superior sagittal sinus and to the cavernous sinus. the presenting symptom is intracranial hemorrhage, mostly subarachnoid or intracerebral. their propensity for hemorrhage justifies immediate surgical removal of the lesion. imaging findings: an mri scan was performed demonstrating an abnormal region of signal void, suggesting a vascular anomaly involving the base of the left frontal lobe. for further evaluation, the patient underwent an mra examination. a vascular linear lesion, probably a vein, at the base of the left frontal lobe and enlargement mainly of the left, as well as of the right ocular artery was discovered. a digital subtraction angiography (dsa) was performed and an edaf on the left ciribriform plate supplied by bilateral ethmoidal arteries was revealed. it drained via a dilated abnormal vein to the left vein of galen. so far, only one other case has ever been reported with venous drainage to the vein of galen. conclusion: specific mri and mra imaging findings should arouse the suspicion of an edaf and dsa can effectively demonstrate the nidus of the lesion, as well as the feeding and draining vessels and confirm the diagnosis. functional based on the hypothesis of focal cortical inhibition, low-frequency transcranial magnetic stimulation (tms) was used, resulting in a slight reduction of hallucinations in some patients. in this case study, functional magnetic resonance imaging was employed to image blood oxygenation level dependent (bold) effect changes in the temporal lobes under tms-therapy. methods: in a curative attempt, a -year old schizophrenic patient (dsm-iv) with medication resistent acoustic hallucinations was treated with low-frequency tms (fstim = hz) over a four week period. fmri was performed in a . t clinical scanner using the standard head coil and a ge-epi sequence. the tmseffects were detected based on the event related bold-fmri of auditory hallucination and auditory hallucinations rating scale. fmri was performed prior to and after the tms series to visualize possible cortical activation changes in the stimulated area. data analyses were performed with spm (http:// fil.ion.ucl.ac.uk.spm). results: after the third week, the patient presented a reduced frequency of acoustic hallucinations of approx. %, while the loudness of the hallucinations remained unchanged over the weeks of stimulation. fmri demonstrated a bold effect activation reduction after tms in speech related areas, which exceeded the local stimulation area. discussion: fmri data revealed an activation reduction in temporal and temporo-parietal areas after tms corresponding to the clinical recovery. the combination of tms and functional imaging is promising, allowing an insight into neuro-biological mechanisms during tms intervention, which may help to improve treatment success. went immediate hyperbaric oxygen (hbo) therapy and the initial result was excellent. he was discharged with subtle weakness in the right lower extremity. the second woman didn't undergo hbo therapy and was discharged with left hemiparesis. imaging findings: mr imaging with diffusion-weighted images (dwis) and adc maps were performed at admission. the first man showed high signal intensities bilaterally of the perirolandic cortex and occipital cortex on t -weighted images (t wis) and dwis. these areas showed dark signal intensities on adc maps, suggesting cytotoxic edema. the second woman showed high signal intensities bilaterally of the perirolandic cortex, bilateral globus pallidus and left occipital periventricular white matter on t wis and dwis. these areas also showed dark signal intensities on adc maps. conclusion: mr imaging findings are similar to co poisoning in that cytotoxic edema involves the globus pallidus bilaterally. but we experienced some different mr imaging finding to co poisoning in that cytotoxic edema involves the perirolandic area bilaterally, which can be seen in profound perinatal asphyxia in term infants. computed tomography angiography ( volumic acquisition of the brain with multislice detector ct at arterial phase is analyzed systematically with d maximum intensity projection (mip). in most cases, volume rendering reconstructions are also performed. all patients with negative cta have a conventional cerebral angiography to visualize entire intracranial circulation. cta and conventional cerebral angiography are performed by senior neuroradiologists. imaging findings: multislice detector cta explores all the locations of intracranial aneurysms. cta is a quick and reliable technique for the detection and therapy planning of intracranial aneurysms. rarely, cta depicts arteriovenous malformations. in some cases, hemorrhage suggests cerebral venous thrombosis that is also diagnosed on cta. we present selected cases emphasizing the utility and the limits of the technique. conclusion: cta is a non invasive, reliable tool to explore patients with non traumatic intracranial hemorrhage. the use of cerebral cta by expert neuroradiologists allows a significant reduction of the number of emergency diagnostic angiography required. brain activations during bi-script reading in chinese: a direct comparison of alphabetic and non-alphabetic reading using functional magnetic resonance imaging (fmri) y. li , x. feng , y. chen , w. tang ; shanghai/cn, oxford/uk learning objectives: a direct comparison between reading alphabetic and nonalphabetic scripts was done using fmri during bi-scripts reading of chinese characters and its alphabetic sound symbols known as pin yin. background: six mandarin speakers and skilled readers of chinese participated in this study. all the subjects were right handed. experiments were performed on ge mri scanner at the huashang hospital. sixteen slices covering the whole brain were collected with blood oxygenation level dependent (bold) sequence. the anatomical images were obtained in the transverse plane during the same scan session with d fspgr sequence after the functional measurements. the four types of stimuli were distributed equally in two main conditions i.e. chinese and pinyin. in each condition, half stimuli were words and half were non-words. data analysis was carried out using feat, the fmrib easy analysis tool, an extension of medx. imaging findings: the activations in the right inferior frontal gyrus, the left fusiform gyrus, the bilateral cuneus and the bilateral superior frontal gyrus were stronger for chinese character reading than for pinyin reading. the activations in the bilateral supramarginal gyus, the bilateral superior parietal gyrus and the bilateral middle frontal gyrus, however, were stronger for pinyin reading than for chinese character reading. different parts of the middle temporal gyrus were also activated for reading these two scripts. the low hemispheric lateralisation for both chinese character and pinyin reading indicate an important role for both hemispheres in reading. conclusion: fmri is one of the best methods of illustrating difference of brain activations during alphabetic and non-alphabetic reading. mri of the brain in inherited neurometabolic disorders: a pictorial review s.p. prabhu, s.a. barnard, n. stoodley, s.a. renowden; bristol/uk learning objectives: to illustrate typical mri appearances of the brain of patients with inborn errors of metabolism and toxic inherited white matter disease. a simple algorithm to unravel the possible cause of imaging findings is incorporated as part of this presentation. background: the diagnosis of a neurometabolic disease is usually suggested by clinical history and physical findings and is confirmed by appropriate special studies, which may include neuroradiological investigations. when the patient is referred with a nonspecific diagnosis, such as delayed development, the aim is to suggest the possibility of a neurometabolic disorder and initiate further evaluation including possible therapy and genetic counselling. on occasion, routine neuroradiological studies may incidentally produce results suggestive of a neurometabolic disorder. imaging findings: disorders including glutaric aciduria, pyruvate dehydrogenase deficiency, leigh's encephalopathy, maple syrup urine disease, methylmalonic aciduria, adrenoleukodystrophy, metachromatic leukodystrophy, krabbe's leukodystrophy and pelizaeus-merzbacher disease are illustrated. a pattern approach based on which part of the brain is affected is used to provide an aid to the diagnosis. conclusion: magnetic resonance imaging plays an important role in the identification, localisation and characterisation of underlying white matter abnormalities in affected patients and is also extensively used to monitor the natural progression of such disorders and the response to therapy. background: to compare d-dsa with d-dsa and d multi-detector ct angiography (cta) with vrt in the detection and evaluation of intracranial aneurysms. imaging findings: a total of aneurysms were evaluated. seven very small aneurysms (diameter less than mm) and two small aneurysms (less than mm) that were not depicted at conventional d-dsa and d-cta-vrt were depicted at d-dsa and all were proved at surgery. in ( %) of the patients, d-dsa gave additional informations: orientation (n = ), defining exact neck anatomy (n = ), incorporation of vessels into aneurysm (n = ), lobulation (n = ) and blebs of aneurysms (n = ). conclusion: d-dsa is superior to d-dsa and d cta-vrt in the detection of very small aneurysms and evaluation of complex anatomy of intracranial aneurysms. low background: dwi is a useful diagnostic tool that improves our background understanding to pathology. the b-value choice has a significant repercussion on signal-to-noise ratio, dwi contrast and t shine-through phenomenon. we have created a straightforward animated microsoft power point presentation showing diffusion physical principles and its imaging consequences. the dwi studies from normal subjects and patients (including brain tumours, encephalitis, demyelinating and cerebrovascular diseases) were further analyzed. all studies were b d e f a g carried out with three different b-value ( , , s/m ). exponential images and apparent diffusion coefficient (adc) maps were subsequently computed. in normal individuals, the signal and adc in the hemispheric white matter, basal ganglia and brain cortex were measured. lesions' signal with different bvalues, and their contrast rate on computed maps, were subjectively compared. imaging findings: when we visualised some acute lesions, higher b-values improved contrast compared with lower b-values. other lesions, like tumours, showed mixed dwi intensities and their contrast also improved with high b-value images. exponential and adc maps were useful for discarding t shine-through effects, moreover with low b-values, but contrast rate was significantly dismissed. conclusion: high b-value dwi provides a better contrast and a reduced t shinethrough phenomenon but it does not display more lesions than low b-value dwi. as computed maps add useful information to that provided by dwi, it seems that the b-value choice depends on each group preferences. utility of mr spectroscopy, diffusion and perfusion mr imaging in the evaluation of brain lesions in aids patients l. . diffusion weighted imaging were performed using a diffusion gradient of sec/mm applied in three axis planes. mr perfusion was performed using tr ms and te ms, following bolus infusion of intravenous contrast material, obtaining relative cerebral blood volume maps (rcbv). to determine metabolites a mr spectroscopy (mrs) was performed with single-voxel press- sequence. we classified the brain lesions in two majors groups: one with brain lesions that cause mass effect (n = ) and the other with infiltrating white matter lesions (n = ). three patients did not have any lesion. mass effect lesions could be inflammatory/infectious diseases: toxoplasmosis (n = ), tuberculosis (n = ), cryptococcosis (n = ) and neoplasic lesions: lymphoma (n = ). as infiltrating white matter lesions, we included progressive multifocal leukoencephalopathy (n = ), hiv encephalopathy (n = ), cmv infection (n = ) and hsv infection (n = ). brain infarct (n = ) is an important condition in aids patients and is more prevalent than in the general population. the mrs, diffusion and perfusion mri have been shown to be extremely useful in characterizing and making the correct diagnosis of brain lesions in aids patients. "string-knot shape" enhancement: a presenting feature of cerebral sparganosis in mri c. shuguang; shanghai/cn learning objectives: to describe the mri character of cerebral sparganosis. background: the cases of cerebral sparganosis have shown a trend of increased frequency with the change of eating habits, especially eating under-cooked products of snake or frog. there is sparse literature available which illustrates nonspecific findings of cerebral sparganosis in mri including nodular lesions, white matter degenerations or haemorrhages. mr imaging of six patients with cerebral sparganosis were reviewed retrospectively in our exhibit. imaging findings: all six cases of cerebral sparganosis showed a single lesion. the location of lesions were superficial with three in the parietal lobe, one in the frontal lobe, one in the temporal lobe and one in the posterior part of brain stem. five lesions were irregular in shape and about cm diameter with moderate hypointensity on t wi and hyperintensity on t wi. a presenting feature of the parasitic granuloma was a "string-knot shape" enhancement, which was demonstrated in cases. one case showed a cystic lesion with peripheral enhancement. there was slight hyperintensity surrounding the nodular lesions which corresponded to edema. no white matter degenerations or hemorrhages were revealed which had been described by previous studies. diagnosis of sparganosis was made on the basis of characteristic enhancement in mri for cases and one was diagnosed as parasitic infectious disease. during surgery, live larvas of sparganum were successfully removed in five cases with "string-knot shape" enhancement lesions. in the case with a cystic lesion, only fragments of worm body were obtained. conclusion: "string-knot shape" enhancement is a characteristic mri finding which has a high value in diagnosis of cerebral sparganosis. cystic lesions of the brain: a pictorial essay with mr imaging s. cakirer, m. basak, e. serin, i. ince, m. birinci; istanbul/tr learning objectives: to illustrate the spectrum of intracranial cystic lesions. to clarify the underlying reasons for specific mr appearances. to define the role of additional mr sequences for differential diagnosis of cystic lesions with similar appearances. background: intracranial cystic lesions are common in radiological practice. the differential diagnosis of intracranial cystic lesions includes a wide spectrum of diseases and is much easier with the use of standard and advanced mr imaging techniques including diffusion and perfusion-weighted studies and mr spectroscopy. between january and august , patients with intracranial cystic lesions were studied in our institute. mr imaging characteristics of the lesions, the underlying reasons for the specific mr appearances and the role of additional mr sequences for the differential diagnosis were defined following the categorization of the lesions. imaging findings: intracranial cystic lesions can be categorized into five groups. they include cystic components of primary and secondary neoplasms (glioblastoma multiforme, pilocytic astrocytoma, pleomorphic xanthroastrocytoma, ependymoma, ganglioglioma, central neurocytoma, hemangioblastoma, macroadenoma, craniopharyngioma, metastases), benign developmental cysts (arachnoid cyst, colloid cyst, epidermoid cyst, dermoid cyst, pineal cyst, rathke cleft cyst, choroid plexus cyst), post-infectious and inflammatory cysts (abscess, parasitic cysts including cystisercosis and hydatid cyst, multiple sclerosis, adem), post-traumatic or post-infarct cysts (porencephalic cyst, encephalomalacic cyst, leptomeningeal cyst) and normal variant cysts (enlarged tumefactive perivascular spaces, cavum septum pellucidum, cavum vergae). the underlying reasons for mr appearances of cystic lesions, role of additional sequences for their diagnosis and differential diagnoses between lesions with similar appearances have been evaluated. cta was performed on a single-slice spiral ct scanner (hispeed lxi, ge) with slice thickness mm, reconstruction interval . mm and pitch . an area from base of the skull to above the clinoid processes was covered. a non-ionic contrast medium was injected in cubital vein ( mgi/ml, ml/ s, ml) and scanning started after delay of - s. corresponding d image reconstructions (maximum intensity projection (mip) and volume rendering (vr)) were produced at accompanying workstation (aw . , ge). conclusion: intracranial aneurysms were visualized in of patients, but only were further evaluated. although intra-arterial dsa is still regarded as "gold standard" in diagnostic evaluation of the sah, cta can serve as guidance for intervention. proton mr spectroscopy of the brain: patterns and pitfalls in diagnosis of brain tumors c.c.t. lim, h. parmar, h. yin, v.g.e. chua; singapore/sg learning objectives: to review typical spectral patterns of brain tumours and non-neoplastic lesions and to understand the potential mimics and pitfalls in using proton magnetic resonance spectroscopy (mrs). background: mrs provides metabolic information that is independent of conventional mr imaging. mrs has been applied to distinguish brain tumors from other diseases and is available on many clinical scanners. post-processing of single-voxel and multi-voxel studies may be presented either as metabolic spectra or parametric maps in the latter. imaging findings: in brain tumours, there is elevation of choline (a marker of cell membrane turnover) and decreased n-acetyl aspartate (a neuronal marker) and creatine (an energy substance). lactate and mobile lipids are sometimes present. conversely, non-neoplastic lesions typically do not show increased choline. lactate is sometimes detected in ischemia, abscess and demyelination. toxoplasmosis and tuberculomas typically show a dominant lipid peak. bacterial breakdown products including acetate, alanine and succinate are detected in abscesses. occasionally, increased cellular infiltrates and reactive astrogliosis may result in elevated choline levels, mimicking tumour. conclusion: with increasing clinical application of mrs, radiologists should be familiar with common spectral patterns of brain disease as well as the potential pitfalls in interpretation. decreased signal intensity on t -weighted mri in the basal ganglia in patients with white matter disorders p. arguis, s. capurro, j. berenguer, t. pujol, m. olondo, j.m. mercader; barcelona/es learning objectives: to describe some aspects of brain iron metabolism which can be studied by mri. to learn how decreased signal intensity on t -w images in the basal ganglia can be seen in several white matter disorders. background: the iron is taken up by capillary endothelial cells in basal ganglia and then is transported axonally to projection sites where it is used in local metabolism, there the iron is stored in oligodendroglia cells. interruption of normal axonal transportation of iron caused by white matter abnormality might lead to increased accumulation of iron at the basal ganglia since it could still be taken up but not be transported. it is generally accepted that there is a correlation between the accumulation of iron in the extrapyramidal system and the degree of hypointensity observed at this site on t -weighted images. imaging findings: low signal intensity on t -w images were observed in the basal ganglia in patients with different white matter disorders (congenital, multiple sclerosis, postradiation toxicity, ischemia, aids-related and tumoral). mr studies were performed with a . t scanner. conclusion: decreased signal intensity on t -w images in the basal ganglia can be seen in several white matter disorders. typical background: wernicke encephalopathy (we) is a severe neurologic disorder caused by thiamine deficiency related to malnutrition or malabsorption of b vitamin that occurs mainly, but not exclusively, in alcoholic patients. we reviewed the risk factors as well as the usual and unusual clinico-radiological features including two cases in non-alcoholic patients (one with gastroesophageal reflux and other with pyloric stenosis secondary to biliogastric reflux). a third of patients with acute we present with the classic clinical triad: opthalmoplegia, ataxia and confusion. other initial manifestations are hypothermia, hypotension, coma, nutritional polyneuropathy, cardiovascular involvement. early diagnosis is crucial because of non-specific clinical findings, a high mortality rate but a possible complete recovery with immediate thiamine replacement. imaging findings: typical mr findings include symmetrical signal changes in medial thalami, tectum and periaqueductal region. in the acute stage, enhancement after contrast injection may be visible in these regions as well as in the mamillary bodies, but at chronic stages atrophy is the main finding. atypical features described include signal changes in the cerebellum, dentate nuclei, pons, red nuclei, basal ganglia and central and precentral sulci. massive haemorrhages are rare whereas microscopic foci are frequent. differential diagnosis includes de/dysmyelinating disorders, infarctions and creutzfeldt-jakob variant but symmetrical distribution of findings rules out most of them. conclusion: we is a reversible, severe disorder and a high index of suspicion is recommended to diagnose it, even in non-alcoholic patients. to determine whether functional mr imaging sequences (diffusion tensor, tractography, perfusion, spectroscopy, blood oxygenation level dependent-bold), can help add new information to the pre-surgery approach to brain tumors. to determine the efficiency and efficacy of these news tools in evaluating brain tumors. during the period of months, mr exams of patients with brain tumors ( men, women; mean age . years) were performed in a . t clinical scanner (siemens, germany) , using mr clinical standard protocol and functional sequences (diffusion tensor imaging, perfusion, spectroscopy and bold sequence). all the patients had their histopathology diagnosis confirmed by brain biopsy and surgery; glioblastoma multiforme (n = ), anaplastic astrocytoma (n = ), low grade glioma (n = ), gliomatosis cerebri (n = ) and metastases (n = ). high grade glioma and metastases had hyperperfusion, high picks of choline and low n-acetylaspartate (naa). low grade glioma and gliomatosis cerebri had low relative cerebral blood volume, low naa, high choline and myoinositol. diffusion tensor imaging showed alterations of the main tracts within and nearest the high grade tumors. low grade tumors had main tracts dislocated but not interrupted. the white mater tract were preserved in gliomatosis cerebri. bold sequence identified the sensory-motor and language activating areas. mr imaging has been used to evaluate brain tumors. with new neuroimaging advanced tools, we can do this analysis in a more accurate and precise way and it takes less time than it was thought to. it is a huge contribution to the evaluation and management of patients, providing a type of diagnosis close to histopathology diagnosis. individual approach to recanalization treatment of acute ischemic brain contrast-enhanced mra were obtained three to five days after the insult. we retrospectively reviewed the mr findings and clinical courses of patients with anterior circulation territorial infarction. those with ica and mca lesions were divided into six and five groups respectively, according to the level and mechanism of the occlusion. pwi findings can be another factor in the management planning. here, we will present representative cases of each group and discuss the management with thorough consideration of various factors, such as pattern and type of arterial occlusion, the extent of dwi/pwi mismatch, the duration of the ischemia, age of the patient, the severity of neurologic deficits, or use of other anticoagulants, etc. we believe that mr imaging is very helpful in the evaluation and management planning of patients with hyperacute stroke. the treatment should be individualized to enhance the effectiveness and safety of the various treatment modalities. similarities and differences in functional connectivity of the prefrontal cortex: task in episodic memory (em), task-and item-related processes have been postulated to contribute to asymmetries in cortical involvement with the prefrontal cortex (pfc) being of particular interest. this study demonstrates task-and itemrelated differences in functional connectivity of pfc in verbal vs non-verbal em. methods and materials: twelve healthy volunteers performed visual non-verbal (line drawings of known objects) and verbal (abstract words) em tasks undergoing o- -butanol-pet to measure regional cerebral blood flow. using correlation analyses, functional connectivity of item-related (verbal vs non-verbal) processes during episodic encoding and retrieval was assessed. results: across all tasks/items we observed strong prefrontal interactions regarding the dorsolateral (dl) and frontopolar (fp) pfc. during encoding we found bilateral but left dominant pfc interactions with any material, right dlpfc showed no interactions during the abstract word condition. during retrieval of pictures we found an increase of right fppfc interactions and a symmetrical increase of dlpfc interactions. during retrieval of abstract words we observed an increase of left fppfc interactions, while right dlpfc showed no interactions. memory performance was higher for pictures vs words. conclusion: firstly, our results support the idea of a common bilateral pfc involvement across different stimuli and mnemonic operations. secondly, item-related processes point to a left lateralized pfc involvement for words and a bilateral pfc involvement for pictures. these data support the "dual coding" hypothesis, introduced by paivio (paivio, ; paivio ) , postulating a double (verbal and non-verbal) processing pathway for pictoral stimuli, hence a supplementary mnemonic strategy to increase memory performance. perfusion weighted dynamic susceptibility ( method: fifteen patients with unilateral - % carotid artery stenosis were studied with dsa and perfusion-weighted dynamic susceptibility (dsc) mri and were compared to age/sex matched controls. regional cerebral blood volume (rcbv) and mean transit time (mtt) values were calculated in the middle cerebral artery (mca) and borderzone (bz) territories. all patients underwent tea within one week from mri and were re-examined one month after surgery. results: there was no significant difference in rcbv and mtt values between the hemispheres in the symptomatic patients. there was a significant difference in mtt values in the borderzones between patients and controls. after tea we found a decrease of mtt of both hemispheres in bz territories while the remaining hemodynamic parameters persisted unchanged. the decrease in mtt values after tea lead these values to be similar to those of normal subjects. the results of our study suggest that there is an adequate compensation of unilateral stenosis when it is less than %. a hemodynamic compensation mechanism between the two hemispheres, particularly for the distal border zone territories that tend to have a slower mtt with respect to the control subjects before tea, and the restoring of mtt values in the bz after surgery, seems to be demonstrated as well. parkinson's disease: pre-and post-apomorphine perfusion evaluation with dynamic susceptibility contrast (dsc) mri f. gaudiello, s. marziali, a. ludovici, e. ferone, r. floris, g. simonetti; rome/it purpose: our aim was to study whether dsc-mri perfusion method may detect an altered pattern of regional cerebral blood flow (rcbf) in parkinson's disease (pd) patients in comparison to normal subjects and whether this altered pattern may be normalised by apomorphine. material and methods: twenty subjects affected by idiopathic pd according with the brain bank criteria were enrolled for this study. nineteen normal subjects were included as controls. ten of them performed a retest procedure. pd patients, after at least days of therapy withdrawal, were submitted to perfusion dsc-mri. sixteen of them were retested after apomorphine injection at least hours. relative regional blood flow was evaluated by using regions of interest (roi) of pixels manually placed in different region of basal ganglia. results: pd patients showed a significant inter-hemispheric asymmetry due to a higher perfusion in the more affected side (< . ), while normal subjects did not. pd exhibited an abnormal "asymmetry index" in the measured nuclei. dsc-mri performed after subcutaneous apomorphine injection did not show any significant asymmetry in pd patients. retest in normal subjects did not show any significant variation. conclusion: dsc-mri of basal ganglia confirms the asymmetry observed in pet studies of pd, suggesting this method as a promising technique in neurodegenerative diseases. b d e f a g steeper (r = . , p < . ) comparing to wm (r = . , p < . ) and almost negatively linear. conclusion: our study shows that ageing effects on metabolite concentrations are more pronounced in the gm regions of the brain. determination of absolute metabolite concentrations, rather than use of ratios only, is essential for characterizing age-related changes in brain metabolites. diagnosis of cerebral vascular malformations with ct angiography in patients with subarachnoid hemorrhage s. stathopoulou , c. kokkinis , n. makris , a. petinelli , k. vassiou , m. vlychou , p.j. papadaki , g.m. zavras , j.b. fezoulidis ; athens/gr, larissa/gr purpose: to evaluate the diagnostic accuracy of spiral ct angiography in patients with subarachnoid hemorrhage due to vascular malformations. methods and material: one hundred and fifty-eight patients suffering from subarachnoid hemorrhage (sah) underwent ct angiography (cta) as well as intraarterial digital subtraction angiography (ia-dsa). cta was performed using spiral ct with ml of intravenous contrast at ml/sec, after a delay of sec. slice thickness . mm and a reconstruction index of . was used. axial slices and multi-planar reformatting (mpr), maximum intensity projection (mip) and d surface shaded display (ssd) reconstructions were reviewed. ia-dsa followed in all patients. there was comparative study between two methods. results: twelve cases of vascular malformations were diagnosed by cta and these comprised arteriovenous malformations and venous angiomas. in cases, the cause of sah was vascular malformation and in cases was an incidental finding. in comparison with ia-dsa, cta missed only a small dural arteriovenous malformation but diagnosed a small venous angioma missed by ia-dsa. these two malformations appeared without hemorrhage. conclusion: cta is a useful non-invasive method in detection of cerebral vascular malformations causing sah, with similar results to ia-dsa. even though ia-dsa offers more anatomical detail in the evaluation of supplying and draining vessels, cta can be a useful diagnostic tool as the tridimensional aspect offers additional information in the therapeutic planning of these vascular malformations. material and methods: ct angiography (cta) was performed using spiral ct with ml of intravenous contrast at ml/sec, after a delay of sec. a slice thickness of . mm and a reconstruction index of . were used. axial slices and multi-planar reformatting (mpr), maximum intensity projection (mip) and surface shaded display (ssd) reconstructions were studied to evaluate aneurysm characteristics. then the image data was analyzed using volumetric d rendering technique to succeed endoscoping imaging. this technique extracts ct numbers in the boundary region between the vessel wall and contrast media within the vascular lumen. results: forty cases of cerebral aneurysms were detected by cta. with the technique of ct virtual angioscopy, we assured an excellent visualization of the inner contours of the vessels including the neck and the dome of the aneurysm (fly through). also d morphology of the internal structure of the aneurysm was demonstrated (fly around). the size of the sac (true lumen) and the neck were exactly estimated. blood vessels flowing into and out of aneurysms were visualized. in patients with ruptured aneurysms that were operated, virtual angioscopy showed the site of rupture, wich was confirmated by operation. conclusion: virtual angioscopy following spiral cta is a very useful technique supplementary to cta in non-invasive evaluation of cerebral aneurysms and selection of the most appropriate therapeutic modality. serial mri in adult-onset rasmussen's encephalitis reveals two main radiographic and clinical variants n. danchaivijitr, r. nicholas, t. smith, i. hart; liverpool/uk purpose: rasmussen's encephalitis (re) is a rare autoimmune disorder that classically affects one cerebral hemisphere. it is characterized by intractable epilepsy with progressive neurological deterioration and usually presents in childhood. adult onset re was believed to have a more benign clinical course and imaging features are less well described. here, we characterize the mri brain findings of a series of adult onset re patients and correlate with the clinical progression. we retrospectively reviewed the serial mri brain scans of patients with pathologically confirmed adult onset re ( scans in total). five patients had complete series of annual mri studies from their onset. clinical data including neurological signs, cognitive deficits and functional disability were recorded prospectively. results: we recognized patterns of imaging findings; patients had focal increase signal on t w in subcortical white matter of the temporal lobe. later, these were followed by ipsilateral hemispheric atrophy. these patients had a rapidly progressive clinical course in which neurological deficits occurred within months after onset. the second group ( patients) had initial focal cortical atrophy followed later by diffuse atrophy of affected hemisphere without evidence of high signal changes. in addition, bilateral involvement and caudate atrophy were more frequent than childhood variant. conclusion: adult re can be difficult to diagnose because the early mri findings can be subtle and physicians may be unaware of the possible presentation of one hemisphere atrophy without inflammation. pattern of initial mri features may help to predict clinical course of the disease. radiofrequency neurotomy for the treatment of headache associated with the third occipital nerve g.b. marshall, c. siwak, b. frizzell; calgary, ab/ca purpose: to assess the efficacy of a fluoroscopically-guided neurotomy technique in patients with cervicogenic headache associated with the third occipital nerve. methods: retrospective analysis of patients ( women and men) who underwent third occipital neurotomy for cervicogenic headache. these patients had failed conservative treatment and were selected based on response to facet joint injection and medial branch block. neurotomy procedures were completed by two radiologists. a chart review of pre-and post-procedural pain levels was undertaken in addition to follow-up patient interview to determine whether they had improvement in their activities of daily living and recreation. results: all patients reported a reduction in the frequency of their headaches. pain levels reported on a visual analog scale dropped from a pre-procedural mean of . / to a post-procedural mean of . / . the mean duration of pain relief was . months, with of the patients describing ongoing relief of symptoms. all patients reported restoration of activities of daily living, albeit for varying lengths of time. no significant complications were encountered. this radiofrequency neurotomy technique may be a useful means of providing symptomatic relief from cervicogenic headache associated with the third occipital nerve. the study justifies proceeding to prospective evaluation of the technique. functional magnetic resonance imaging (fmri) study of memory functions in elderly and young healthy controls and alzheimer's disease (ad) patients a. urbanik, m. binder, b. sobiecka, j. kozub, m. kuniecki; krakow/pl purpose: the aim of the study was to assess differences in the neural correlates of nonverbal memory functions in pathological and normal ageing. methods: thirty-six volunteers were examined in a . t mr scanner. three groups of twelve subjects were examined: young and elderly healthy controls, and patients with probable ad diagnosis. subjects were required to memorize complex geometrical figures. after the scanning session, they were all asked to redraw these figures. their performance was scored. image data were analysed with spm statistical package. results: both control groups copied drawings more accurately than the ad group. in all groups, the most prominent differences were seen in frontal regions and the occipital lobes, extending to the temporal. for each group this pattern was dissimilar. for the ad group moderate activation in the occipital lobe was observed, but no activation in frontal lobes. in turn, the elderly group revealed quite weak activation in occipital lobes and strong bilateral activation in the frontal lobes. finally, in the young adults group there was very prominent activation in occipital lobes, as well as in the frontal lobes, with apparent left-hemispheric dominance. we have succeeded in revealing differential patterns of brain activation in the studied groups during nonverbal memory encoding. our results suggest that a successful encoding requires an involvement of frontal lobes, that are probably responsible for the strategic aspects of memory functions. as was shown in the elderly control group, frontal lobes can compensate for the deteriorated visual memory which is known to decline over time. the special features of cerebral hemodynamics were studied in patients with chiari malformation (cm) with the help of magnetic resonance angiography (mra) and transcranial dopplerography (tcd). mra data analysis ( ) revealed the frequent presence of vertebrobasilar system (vbs) maldevelopment and embryonic type of circle of willis. tcd data analysis ( ) discovered vertebrobasilar insufficiency and bilateral blood flow increase in the intracranial part of the internal carotid arteries giving evidence of the compensated blood flow from the carotid system to the vbs. % of patients with cm and communicating hydrocephalus had tcd signs of intracranial hypertension. the most significant changes in cerebral hemodynamics were found in patients with marked pathology and older than years. conclusions: . changes of cerebral hemodynamics in patients with chiari malformation are conditioned by a complex of various causes; vertebrobasilar system underdevelopment, extravasal compression of the vbs arteries, rombencephalon hernia (cm) compensated blood flow from internal carotid system to vbs and the presence of intracranial hypertension. . the role of vascular factors in pathogenesis of the clinical signs of chiari malformation is confirmed. acute disorders of cerebral ischemic circulation in vbs and syncopal conditions were mainly found in patients with the nd / rd degree chiari malformation above years of age, that correlates with the greatest changes of cerebral hemodynamics by transcranial dopplerography findings. routine mr imaging in parkinsonian syndromes m. cosottini, r. ceravolo, g. lazzarotti, u. bonuccelli, m. michelassi, c. bartolozzi; pisa/it purpose: to assess the usefulness of routine mri in the differential diagnosis of parkinsonian syndromes such as multiple system atrophy type p or c (msa p and msa c), supranuclear palsy (psp), and corticobasal degeneration (cbd) from idiopathic parkinson disease (pd). we retrospectively evaluated patients with extrapyramidal signs and symptoms that had been followed for five years until a definitive clinical diagnosis. ninety five patients had pd, msa p, msa c, psp, cbd. mr examinations were obtained with . and . t equipment in cases and cases, respectively. axial dp-t and sagittal t -weighted images were evaluated considering the most frequently abnormal findings reported in parkinsonian syndromes. pd mr examination was supposed to be normal. results: using the reported radiological criteria, imaging by mri revealed a sensitivity and specificity of % and % in psp, % and % in msa p, % and % in msa c, % and % in cbd. a correct diagnosis of atypical parkinsonian syndrome was made in % of patients with extrapyramidal signs and symptoms. conclusions: several features on brain mr imaging may improve the diagnosis of atypical parkinsonian syndromes and pd in a substantial proportion of patients. brain with done by pc mra and the intracranial circle was evaluated with d tof mra. dsa was then performed to confirm the grading of stenosis and to depict the presence of collateral intracranial compensatory circles. patients were divided into two groups on the basis of the presence (group ) or absence (group ) of a regional or hemispheric perfusion defect detectable at visual inspection of mtt map. results: in group (six patients) there was a prolonged mtt, a reduced cbf and an increased cbv in two cases. a poor depiction of mca with mra and a significant reduction of mbf in the mca homolateral to ica stenosis ( ml/ min), as well as an angiographic impaired willisian compensation with a recruitment of vessels arising from the external carotid artery and from superficial collateral supply was detected in group . conclusions: pwi reveals oligemic abnormalities in only some patients with ica stenosis. increased mtt and reduced cbf are associated with an impaired willisian collateral supply. probably, bolus dispersion may influence the pwi-detected oligemia in ica stenosis. specificity results: statistical differences were found between the dementias group (ad and vd) and the non-demented group (depression and mci). the ratio choline/ creatine (cho/cr), myoinositol/creatine (mi/cr) and n-acetylaspartate/creatine (naa/cr) showed differences between the studied pathologies, only in ppgm, without significant differences in rtl. naa/mi and mi/cr distinguished between ad and the other pathologies, in ppgm, with the best area under the roc curve for naa/mi, showing the higher sensitivity ( %) and specificity ( %) for the diagnosis of the ad. conclusion: h mrs is a non-invasive tool for the study of ci, showing biochemical information to differentiate ad, vd, depression and mci. the metabolical alterations observed contribute to the differential diagnosis with a high sensitivity and specificity in pathologies with ci, in particular for the diagnosis of ad. value of transcranial doppler (tcd) measurements and "hyperdense middle cerebral artery" sign on ct for acute ischemic stroke prognosis y.t. efendiev, l.b. khalilova; baku/az methods: ct examination was carried out on the first day of stroke for patients (age range to ), who had ischemic infarcts in the middle cerebral artery (mca) territory and repeated on the rd , th and th days. "hyperdense middle cerebral artery" sign reflecting active intraluminal thrombosis was found in patients. the same patients had tcd on the st day. results: symmetric blood flow velocity (bfv) in both mcas was revealed in % of the patients. in this group, clinical course was rather auspicious in more than % of patients. infarcts area in these patents had limited, cortical ( %) and subcortical ( %) localization. no lethal outcome was noted. asymmetric blood flow with decreased mca bfv by more than % on the affected side was noted in % of the patients. in this group, the infarctions had cortico-subcortical localization on final ct. the clinical course was more severe and complicated than in the first group.one lethal case occurred. in %, tcd demonstrated signs of hyperperfusion of hemodynamics with increased of mca bfv by more than %, on the affected side, combined with high peripheral resistance index. infarcts had mainly deep basal location, and lethal cases occurred. later ct detected hemorrhagic transformation of necrotic area ( cases, %). conclusion: "hyperdense middle cerebral artery" sign on ct is significant for early diagnosis of stroke, whereas the tcd measurements in mca is important to predict the clinical course and possible impairment at the early stage of the disease. b d e f a g imaging of brain parenchymal and leptomeningeal metastases from lung cancer: significance of contrast enhancement mri m.p.i.m. jakimovska, t. markoski, m. grunevski, s. jakimovska, s. jovanoska; skopje/mk purpose: to estimate significance of iv application of paramagnetic contrast in mr imaging in diagnosis of parenchymal brain metastases, especially leptomeningeal carcinomatosis seeding from lung cancer. next purpose is to compare sensitivity between ct and mr imaging. material and methods: thirty-six patients with lung cancer were evaluated radiographicaly to determine the present of metastases in cns. we used ct as a screening tool and mr after i.v. application of gddtpa. results: our series with patients included or % with non small-cell lung cancer and patients or % with small-cell lung cancer. three patients ( %) of with small-cell lung cancer had occult metastatic disease to the brain. eight patients ( %) of with non small-cell lung cancer had metastatic disease to the brain parenchyma. in this series, leptomeningeal metastases were not found. ct scans were performed in all patients, mri was performed in cases, some with i.v. application of gddtpa, and in patients brain metastatic disease was found. post contrast mr imaging presents leptomeningeal carcinomatosis as thin linear enhancement along the cortical surface, which follows the gyral pattern of the cortex. conclusion: all patients with lung cancer have to be investigated for brain metastases because of a great percentage (about %) of occult metastatic disease. contrast enhanced mr of the brain is a superior method compared to ct because of excellent contrast resolution, is safer and has multiplaner abilities. to demonstrate meningeal seeding, contrast enhanced mri is the modality of choice. evaluation of the uselfulness of high b-value diffusion-weighted mr imaging in patients with acute cerebral infarction h. hirota , e. shimosegawa , k. takahashi , m. mineta , t. yamada , w. yamamoto , k. nagasawa , h. sato , t. aburano ; asahikawa/jp, akita/jp, iowa, ia/us purpose: we occasionally encounter cases without distinct abnormal findings on conventional diffusion-weighted mr imaging despite there being obvious clinical findings of acute cerebral infarction. our purpose was to evaluate positive predictive value of high b-value diffusion-weighted mr imaging in subjects with acute cerebral infarction. we prospectively assessed subjects with acute cerebral infarction within hours from the onset. all examinations were performed with . t unit using single-shot echo planar diffusion-weighed mr imaging at three different b values of , and s/mm . seven days later from the onset, we re-examined the subjects with t weighted image for confirming the final diagnosis. four experienced neuroradiologists assessed each diffusionweighted images for the presence of cerebral infarction and then compared the findings of each images with those of t weighted images. we divided the findings of each diffusion-weighted images into five categories by location of abnormal signal intensities and calculated true positive rate in each categories. purpose: arterial visualization of intracranial d-cta is difficult in the area of the skull base. this is due to the close proximity of the internal carotid artery and skull base and the fact that they both have almost the same ct values. accordingly, subtraction artifacts due to misregistration are unavoidable using the conventional subtraction method. even a slight difference of the start position in data between pre-and post-contrast ct may lead to the production of considerable artifacts. nowadays, subtraction of two sets of volume data has become possible on a workstation. we assessed whether this technique was useful in intracranial d-cta. methods and materials: subtraction was performed in both phantom and patients and the accuracy was tested. results: precise measurement was shown to be possible in the phantom experiment. following this, several clinical cases were applied. conclusion: subtraction is effective due to being almost free of misregistration. does an interpolated high resolution matrix improve the detection of brain hyperintensities on flair images in multiple sclerosis? f. sardanelli, a. fausto, g. spadaccini, b. cotticelli; milan/it purpose: to test whether an interpolated high resolution matrix improves the detection of brain hyperintensities on flair images in multiple sclerosis (ms). materials and methods: seven ms patients ( male, females, - years old, median ) underwent brain mr at . t using a fast-flair para-axial sequence (tr/te/ti = / / ms; fov mm; no-gap -mm slices; matrix x ; pixel size = . x . mm; time ' "). the sequence was repeated changing only from the standard matrix to an interpolated matrix with a pixel size of . x . mm. the two sequences were read on a remote console in a random blinded fashion, using a one-in-one format and free windowing, grading them as certain (c) or probable (p); for confluent plaques, only the lesions with more than half the contour detectable were counted. wilcoxon test was used. results: a total of hyperintensities (c/p = / ) with and of ( / ) with were counted. they ranged in total - (median = ) with and - ( ) with ; c hyperintensities - ( ) and - ( ); p hyperintensities - ( ) and - ( ), respectively. data were similar in / patients; in the remaining patient (female, years old) total hyperintensities were ( ) and ( ), with a c/p of / and / , respectively. in spite of this outlier, no significant overall difference was found between and for total, c, and p hyperintensities (p > . ). conclusion: interpolated matrices do not significantly improve the detection of brain hyperintensities on flair images in ms. a method for reducing radiation exposure in cerebral perfusion study using multi-detector row ct t. nanjo , k. murase , y. sugawara , m. hirata , t. mochizuki ; osaka/jp, onsen-gun/jp purpose: radiation exposure during ct perfusion study is a serious problem. the purpose of this study was to devise a method for reducing radiation exposure in cerebral perfusion studies using multi-detector row ct. methods and materials: nine patients ( males and females; mean age . years) participated in this study. following a standard protocol for ct perfusion study, continuous (cine) scans ( . - . sec/rotation x sec) consisted of four -mm-thick contiguous slices performed after an injection of iodinated contrast material ( - ml) using a multi-detector row ct scanner (light speed qx/i, ge). new image data were generated by thinning out the original images thus acquired. the thinned-out images were interpolated by linear or cubic interpolation. the functional images of perfusion parameters such as cerebral blood flow (cbf), cerebral blood volume (cbv) and mean transit time (mtt) were generated from these images by applying deconvolution analysis based on singular value decomposition pixel by pixel. we calculated the correlation coefficients between the perfusion parameters obtained from original and thinned-out images for regions of interest in the grey and white matter. results: when using continuous images with a scan time of . - . sec and the thinned-out images with a scan interval of . - . sec, the radiation exposure could be reduced to . - . %, with the correlation coefficients of cbf, cbv and mtt being kept greater than . . conclusion: this method can reduce radiation exposure while keeping the accuracy of perfusion parameters equivalent to that obtained from original images. dynamic scanning. the data acquisition conditions (analysis algorithm, analysis matrix, contrast medium injection rate, image reconstruction algorithm and exposure dose) were optimized while maintaining high quantitative analysis capabilities. cerebral blood flow was then measured in volunteers in their s, in their s, in their s, in their s, in their s, and in their s. none of the subjects had cerebral blood flow disorders. results: the use of optimized data acquisition conditions provided high reproducibility while permitting the exposure dose to be reduced by % or more. a decrease in cerebral blood flow with advancing age was confirmed in ct dynamic perfusion studies. the use of optimal data acquisition conditions allows the exposure dose to be reduced and provides high reproducibility while permitting acceptable quantitative cerebral blood flow analysis. this has made it possible to determine age-specific normal values for cerebral blood flow in dynamic ct perfusion examinations. it is expected that dynamic ct perfusion analysis will prove clinically useful for the assessment of diffuse cerebrovascular diseases and chronic-stage blood flow disorders, as well as for the diagnosis of acute-stage cerebral infarction. diffusion weighted imaging (dwi) epi on low field mr system ( . t): comparison with . t and preliminary report on clinical use in brain ischemia p. purpose: this study assessed the diagnostic value of low field dwi in brain stroke. the secondary goal was to compare apparent diffusion coefficient (adc) values obtained in high and low systems. methods: dwi were performed in groups of volunteers, on . t and . t systems. dw images at b = and mm /s were recorded. adc values from regions of interest (roi) were compared. forty patients with acute symptoms of cns stroke were examined by ct and mr, - h after symptoms onset. dwi-epi images were obtained. follow-up mr weeks later were set as a reference. results: statistical analysis showed significant differences of adc values dependent on roi location within the brain hemisphere. there was no difference between right and left hemisphere. adc values for low and high field systems were similar. in patients, ischemic lesions were found in the first examination. follow-up confirmed infarcts. four patients out of with negative dwi revealed infarction in follow-up mr. sensitivity, specificity, and diagnostic accuracy were . %, %, and %, respectively. conclusions: low field systems are capable of diffusion weighted imaging. for the same b value, adc values at . t and . t are similar. in clinical practice dwi on low field mr systems can be used as a fast and reliable tool for detection of acute ischemic lesions in the brain. advantages of a d multislab t turbo spin echo magnetic resonance (tse mr) sequence for high resolution brain imaging b. it is feasible to scan the whole brain with t contrast in mm³ isotropic resolution with high snr and cnr using a multislab d tse sequence. postoperative multidetector-row ct angiography ( ( ), hemimegalencephaly( ), bilateral perisylvian syndrome( ), lissencephaly( ) and focal cortical dysplasia( ). all were the subject of conventional brain mr imaging studies using the mp-rage (magnetization-prepared rapid gradient-echo) sequence and the resulting -d data sets were processed on a commercially available workstation. abnormal gyral configurations were reviewed. results: abnormal gyral patterns were seen of patients. the configuration and orientation of affected gyri were clearly evaluated in the brain surface-rendering image. in two cases of the schizencephaly (involved the frontal lobe), there were wheel shaped broad gyral pattern of the superior, middle, and inferior frontal lobes. in two cases of the hemimegalencephaly, there were thick gyral pattern and enlarged ipsilateral brain. in two cases of the lissencephaly, the frontoparietal cortex was not delineated and showed a markedly thick and smooth gyral pattern. in two cases of the bilateral perisylvian syndrome, there were opened insular cortex and a thickened gyral pattern. in the focal cortical dysplasia, there were irregular serrated or thick and enlarged gyri. in patients with cerebral cortical dysplasia, brain surface-rendering mr imaging detects a detail gyral pattern and involvement site of abnormal gyri. it can create difficulties in the differential diagnosis and can therefore cause problems in choosing the appropriate therapy. this is especially true in cases with alzheimer's versus lewy-body disease ((dlb), which require different therapeutical approach. we applied h-mrs to assist the diagnostic process and to look for specific differences in the metabolic content of the brain tissue in these two entities. methods: h-mrswas performed using . t scanner in t -weighted images in orthogonal planes in elderly subjects with consensus criteria dlb (n = ), nincds-adrda ad (n = ), and normal control subjects (n = ). h-mrs was performed with single-voxel (svs) technique using steam sequence (tr ms, te ms). voxel was positioned in the temporal, occipital lobe and centrum semiovale. results: in both alzheimer's and lewy-body group, h-mrs showed changes in the metabolite pattern in all voxel locations, with the most distinct expression within temporal lobes. naa and creatine peaks were lowered in both patients groups, comparing to the controls. in spectra of lewy-body patients myoinosytol peak remained unchanged as opposite to the alzheimer's where it was increased. conclusions: h-mrs can be an additional, very important tool in dementia studies and differential diagnosis of this group of diseases. in dlb patients h-mrs is feasible but there are difficulties in scanning patients in the later stages of the illness due to tremor and the degree of brain atrophy. the activation tasks consisted of left finger movement, sensory stimulation, listening to comprehension (for sensory language area), word generation (for motor language area) and working memory. the reference function was boxcar waveform. activation maps were thresholded at uncorrected p = . . the thresholded activation maps were placed into talarach's space. results: cerebellar activation was observed in the motor, the word generation and the working memory tasks. in the hot sensory and listening comprehension tasks, there was not any visible activation in the cerebellum. left and right posterior cerebellar (declive) activation was observed in the left motor task. ipsilateral cerebellar activation was more prominent than contralateral cerebellar activation during the left motor task. left posterior cerebellar (declive) activation was observed in the working memory task. left posterior cerebellar (declive) and both anterior cerebellar (culmen) activations were noted in the word generation task. conclusion: cerebellar activation was observed in the afferent actions of the brain including motor, motor language and working memory tasks. there was no activation of the cerebellum in the efferent action of the brain including sensory and sensory language tasks. the cerebellum is involved in a variety of functional tasks including motor, word generation and working memory. the brain smell centres: comparison of localisation and activation in male and female subjects using functional mr imaging (fmri) m.d. marchwicka-wasiak, b. goraj; lodz/pl the study was conducted in order to determine and to compare the location and activation of smell brain centres in females and males brains using olfactory nerve-mediated (geraniol) and combined olfactory and trigeminal nervemediated (patchouli) stimulants. methods: ten normal volunteers (five women and five men), right-handed, nonsmokers, without any cns diseases were examined to determine the activated cortex areas during stimulation by geraniol and patchouli. mr brain scans were obtained using a . t clinical scanner, with the head-neck coil. the imaging was performed in each subject using se and epi sequences with a blood-oxygenlevel-dependent (bold) effect. the individual inhaled odorized air during the seconds period and alternating room air over the same period. the mean pixel intensity of activated images was substracted from the mean pixel intensity of preactivated images. results: the olfactory system-mediated stimuli (geraniol) evoked bilateral activation of female brain smell centres compared to right hemisphere centre activation in male brains. the exposure to the olfactory and trigeminal nerve-mediated stimuli (patchouli) showed more activated regions in both sexes than to the olfactory nerve-mediated stimuli. conclusion: fmri proved to be a useful method to compare the location and activation of male and female brain smell centres. we compared the group of psp patients with that of control subjects and found a highly significant difference in antero-posterior midbrain diameters (mann-whitney test: p < . ), absolute midbrain volumes (p < . ) and naa/ cr ratios (p < . ), as well as a significant difference in total intracranial volume-normalized midbrain volumes (p < . ). we also found out a significant correlation between naa/cr ratios and antero-posterior midbrain diameters in psp patients (spearman's rank correlation test: rs = . , p < . ). the aim of this study was to compare the diagnostic accuracy of t fast spin echo (t fse), fluid attenuated inversion recovery (flair) and inversion recovery (ir), in evaluating hippocampal sclerosis and to determine a costeffective protocol for this disease process. in this prospective study, patients (aged months- years) with drug-resistant temporal lobe epilepsy (based on clinical symptomatology and electroencephalographic (eeg) registrations) were evaluated by mri with a . tesla unit. the protocol consists of axial t and pd/t se, and flair, t fse and ir in a coronal plain perpendicular to the long axis of the hippocampus. whenever necessary, we applied t + gd se in axial and coronal planes. films were interpreted by two experienced neuroradiologists. sequences were statistically analyzed in pairs using wilcoxon sign ranks test. results: there were patients ( . %) with mr and eeg findings suggestive of hippocampal sclerosis. eight of them underwent therapeutic surgery and there was histopathologic confirmation of the diagnosis. flair detected hyperintensity of the hippocampus in / ( %) and was much more sensitive than t fse ( / p = . ) and pd/t ( / p = . ). reduced hippocampal size ( / ), atrophy of hippocampus ( / ) and enlarged temporal horn ( / ) were better detected with ir than t ( / p = . ). conclusion: a mr protocol using thin coronal sections angled perpendicular to the hippocampus with flair and ir sequences is cost-effective for mesial temporal sclerosis because it is highly sensitive, inexpensive, quick and easily applicable in most units. reversibility of the brain white matter changes in adults with late diagnosed and treated phenylketonuria m. gizewska, l. cyrylowski, d. koziarska, p. nowacki, a. walecka, m. walczak; szczecin/pl purpose: phenylketonuria (pku) is an autosomal recessive disorder related to absent or reduced activity of phenylalanine hydroxylase what leads to increased plasma phenylalanine (phe) concentration. because screening the whole newborn population for pku in poland began in the late s, many pku adults have been diagnosed and treated very late. patterns and extent of the brain white matter changes in these patients is described. in this paper, late diagnosed and treated adults with pku, including males and females, is presented. the mean age at diagnosis was . y (range - ). microcephaly was present in , seizures in , aggressive behavior in ; all but one had speech difficulties, including total mutism in . mri of the head was performed on . t unit with fse and flair sequences without contrast medium administration. results: mri of the head detected white matter changes, hyperintense on t weighted images, in all but one patients. all but one of them had changes in parietal and/or occipital regions. the treatment with low-phe has been introduced in with improvement in all of them. the follow-up mri were performed after mean . months, revealing decreased severity of the white matter changes in all, from mean (according to cleary's scale) on the initial mri to . on the follow-up. our results indicate the possibility of white matter changes reversibility in late diagnosed and treated pku adults. conclusion: dwi is thought to be useful in the diagnosis of cns infections. in our experience, dwi may allow the differentiation of brain abscess from necrotic or cystic brain tumor. dwi is also a useful tool to differentiate subdural and epidural empyemas. detection . coronal views were performed for flair imaging, and coronal and axial views for dp and t -weighted imaging. images were reviewed by two seniors radiologists in consensus for localisation of the signal abnormalities. results: lesions of the olfactory system were observed in patients ( %). signal abnormalities were localised in the temporal lobe in cases ( % with cases of unilateral lesions and cases of bilateral lesions) and in the orbito frontal cortex in cases ( % with cases of bilateral lesions and cases of unilateral lesions). with flair, dp, and t weighted imaging, lesions was detected respectively in %, % and %. olfactory bulb signal abnormalities were diagnosed in cases ( % with cases of unilateral lesions and cases of bilateral lesions). for this localization, the accuracy of flair, dp and t sequences was respectively %, %, %. in post-traumatic anosmia, coronal flair and coronal pd imaging is required to detect respectively signal abnormalities in the parenchyma and in the olfactory bulbs. t weighting imaging seems to be inferior. cerebral hydatid disease: ct and mr imaging findings y. bükte, s. kemaloglu, h. nazaroglu, a. uyar, c. akgül, m. simsek; diyarbakir/tr purpose: cerebral hydatid disease is very rare, representing only % of all cerebral space occupying lesions, even in the countries where the disease is endemic. the aim of this study was to describe the discriminative computed tomography (ct) and magnetic resonance (mr) imaging features of cerebral hydatid disease. we retrospectively reviewed the imaging findings of patients with pathologically confirmed cerebral hydatid disease over a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . among these patients, there were cases of echinococ-b d e f a g cus granulosis and case of echinococcus multilocularis (alveolaris). they were male ( . %) and female patients ( . %), ages ranging from to years with an average age of . years. results: common ct and mr imaging findings of e. granulosis lesions were well-defined, smooth thin-walled, round or spherical, homogeneous cystic lesions with no contrast enhancement, no calcification and no surrounding edema. the lesion seen in e. multilocularis showed a well-defined multiseptated mass consisting of solid and cystic components with calcifications of solid portions. cystic lesions with surrounding hyperintense area of perifocal edema, complete and incomplete rim of contrast enhancement were seen in two patients and were labeled as complicated and infected cysts. conclusion: although the cystic cerebral hydatid disease could be equally well demonstrated on ct and mr examinations, ct is superior in detecting calcification of the cyst, when present. mr is better in demonstrating cyst capsule, detecting multiplicity and defining the anatomic relationship of the lesion with the adjacent structures and helps in surgical planning. ct it may be used to identify regional differences within a patient. qualitatively, single scan cbv maps were noisier than maps using the dynamic method. conclusion: cbv estimates from a single contrast-enhanced scan may identify abnormal areas. however, differentiation between normal and abnormal regions is not as pronounced as when using quantitative, dynamic methods. virtual endoscopic imaging of cerebral ct angiography (veccta) in selecting patients for neurosurgical intervention or endovascular treatment r. prpic-vuckovic, m. rados, m. batinica, j. papa, m. seronja-kuhar; zagreb/hr purpose: to assess the usefulness of virtual endoscopic cerebral ct angiography data analysis in patients with aneurysm rupture before making a decision between neurosurgical intervention or endovascular treatment. materials and methods: during a one-year period, mscta was performed in patients after a conventional ct proven subarachnoid hemorrhage. images were acquired using msct lightspeed ultra, ge. helical data acquisition followed after rapid i.v. administration of contrast material ( . ml/sec), with - sec delay. data was postprocessed on ge advantage workstation ultra v . using reconstruction protocols mip (maximum intensity projection), ssd (shaded surface display), vr (volume rendering) and ve (virtual endoscopy). results: detailed analysis of aneurysmal neck, dome, vessel of origin and surrounding vascular or bone structures was acquired by ssd, mip or by high-accuracy vr protocol. modified surface rendering and ve protocol were used for endoscopic mode viewing to visualize neck shape, accessibility from the parent vessel, presence of thrombotic clots or calcifications inside the aneurysm and vessel of origin, as well as to define orifices of branches arising from the dome. conclusion: accurate characterization of morphology of the aneurysm, especially depiction of orifices and aneurysmal neck are essential for choice between neurosurgical intervention or endovascular treatment. when endovascular treatment is an option, it is useful to know angulation between parent vessel and neck and real volume of aneurysmal dome for proper estimation of coil size and shape. vr and ve imaging of the aneurysmal sack and surrounding anatomy may provide additional useful information for endovascular treatment or neurosurgical intervention. we have demonstrated the existence of non-monoexponential diffusion in the human csc that can be approximated by fast and slow diffusion components. our results are within the limits of human brain and full dti data for the rat spinal cord. the aim of this study is to review the embryology and the development of this structure. to describe the normal ct and mr appearances and to show the neuroradiological findings of pathology that can effect the craniocervical junction. background: the craniocervical junction is an anatomical crossroads with characteristic pathologic entities, mainly malformative and traumatic in origin. we illustrate the normal anatomy of the craniocervical junction and a wide spectrum of pathological conditions involving this structure through a selection of cases from a retrospective review of the ct, mr and plain-film examinations carried out in our centre over the last five years. imaging findings: normal anatomy and a wide spectrum of pathologies affecting the craniocervical junction are illustrated by ct and mr examinations. we group the findings according to etiology: malformation, trauma, infection, inflammatory and tumor, placing emphasis on the radiological features and the differential diagnosis. conclusion: ct depicts the bony structures of the craniocervical junction superbly while mri shows the neurological components better, enabling excellent characterization of lesions and recognition of all potential types of disorders that need to be recognized by general as well as neuroradiologists. the spectrum of t hyperintensities of the sellar region f. with the introduction of high field strength it is expected to overcome the limited signal to noise ratio and subsequently decreased spatial resolution in routinely used standard field strength . - . tesla mr scanners. this would have clinical impact in the preoperative work up of patients with sellar processes. imaging findings: in this exhibit we present a large variety of sellar diseases using tesla mr imaging with emphasis on detection of microadenomas and visualization of anatomic structures. furthermore, the differentiation between infiltration or just compression of the medial wall of the cavernous sinus in case of macroadenoma is illustrated. the excellent visualization of normal anatomy and tumor topography makes this technique a very valuable tool for planning neurosurgical operations. cns manifestations following stem cell transplantation: a pictorial review d. beckett, a. banerjee, j. oliff; birmingham/uk learning objectives: to illustrate the spectrum of radiological manifestations in the central nervous system and head and neck following stem cell transplantation for haematological malignancy. to outline the advantages and limits of plain film radiography, cross-sectional imaging, interventional radiology and radionuclide imaging. background: bone marrow transplantation (bmt) is a critical therapeutic intervention for a variety of pathological conditions. the complications of bmt include chemotherapy and radiation toxicity, graft versus host disease, recurrent malignancy, infection and miscellaneous conditions. complications of allogenic bmt manifest in a variety of clinical settings. the neurological system is commonly affected. in this presentation we will review the incidence, clinical presentation and the radiographic findings of cns involvement following stem cell transplantation. plain radiography, contrast material enhanced studies, sonography, ct, mri and interventional techniques are essential in diagnosing these complications and evaluating their response to therapy. imaging findings: findings may be broadly classified into either infective, cerebrovascular or treatment induced. common infective manifestations include human herpes virus , invasive mucormycosis and central nervous system tuberculosis. classical image findings of haemorrhage and infarction are seen in addition to graft versus host disease cerebrovascular angiitis. infarcts, diffuse white matter disease and cortical atrophy are seen following total body irradiation. the imaging findings of posterior leukoencephalopathy in cyclosporin toxicity is illustrated. the spectrum of imaging findings in the central nervous system is diverse. a firm understanding of the clinical presentations and incidence in combination with typical radiological findings is essential in the successful management of this patient sub-group. b d e f a g background: diffusion weighted imaging has been widely used in stroke patients to detect early acute cerebral infarction and find out ischemic penumbra. however, we often unexpectedly encounter restricted diffusion on dwi of nonvascular origin mimicking hyperacute or acute infarction in clinical practice.we reviewed nonvascular diseases with restricted diffusion on dwi for past three years by retrospective selection. imaging findings: the characteristic findings mimicking hyperacute or acute infarction are high signal intensity and low apparent diffusion coefficient values, mainly distributed in the white matter and incompatible with arterial territory with no stenoocclusive lesion on mr angiography or conventional angiography, and are reversible. these findings may increase possibility of nonvascular diseases such as infection, inflammation (viral or bacterial encephalitis), hemorrhage, leukodystrophy, toxic (anti-cancer drugs, co poisoning), metabolic origin and tumors. conclusion: we present various diseases, under certain clinical settings, and systematically discuss the mechanism of restricted diffusion in a limited number of specific diseases. background: in patients with vitamin b deficiency, symptoms related to the spinal cord may often help to find the diagnosis. however, in patients with atypical symptoms mri shows typical findings often diagnostic for scd. beneath a general discussion, we present cases of scd in whom mri findings were leading to the diagnosis of b -deficiency. patient presented with tingling in her extremities. neurologic examination showed a subacute loss of proprioception and profound loss of vibration sense. vitamin b serum levels were normal. t w-mri showed increased signal in the posterior columns of the spinal cord. dwi showed disturbance of diffusion in the same location. patient , who practiced a vegan alimentation, was admitted with incomplete paraplegia with signs of spasticity. vibration sense and proprioception were impaired as well. mri revealed the typical findings of severely increased signal within the posterior columns of the spinal cord. both patients presented in very early stages of the disease. in summary, the mri findings showed typical signal hyperintensities in t w images in the posterior columns of the cervical and/or thoracic myelon-segments. conclusion: even in patients with subtle atypical symptoms, mri with its typical findings often allows the diagnosis of scd even in the rare case of normal levels of vitamin b . fiber tracking and tensor metrics in diffusion tensor mr imaging c.c.t. lim, h. yin, m. xu, f. hui; singapore/sg learning objectives: to review anatomical patterns and distribution of white matter tracts in the brain and to understand the potential uses of diffusion tensor imaging (dti), including pathological disruption and destruction of fiber tracts. background: dti is a new mr imaging technique that non-invasively visualizes white matter fiber tracts and may have potential to assess demyelination and other brain disorders. using single shot echo planar imaging (tr - /te - ms, mm section thickness, b value - s/mm in - non-collinear directions at . and t) and offline post-processing of diffusion tensor metrics (fractional anisotropy, mean diffusivity and principal eigenvector) and fiber connectivity images (using fast marching tractography) could be studied. imaging findings: in normal patients, the fractional anisotropy (fa) maps clearly visualized white matter tracts as areas of high fa compared to gray matter. the corticospinal tracts, corpus callosum and optic radiations could be consistently identified. abnormalities such as brain neoplasm, cerebral infarction and multiple sclerosis lesions showed decreased fractional anisotropy and elevated mean diffusivity. principal eigenvector maps of water diffusion showed deviation in the direction of the white matter tracts surrounding benign brain neoplasms and malformations. conclusion: quantitative in vivo information on water diffusivity, degree of directionality and directional vector in space, that are not available on conventional mr imaging, can be measured in dti studies. with a potential new clinical application of dti, radiologists should be familiar with anatomy and pathology of the white matter fiber tracts. neuroimaging of background: multiple gliomas are rare findings with variable incidence ( . to %). they can by classified according to: a) time of presentation as early = synchronous (at initial diagnosis) or late = metachronous (diagnosed during the treatment); b) the imaging characteristics as multicentric (arise independently in different sites, there is absence of macroscopic connections or way of dissemination) or multifocal (they spread from primary tumor to other areas in the brain, with evidence of routes of dissemination). we reviewed documentations of patients with diagnosis of glial tumor who grade iii-iv who underwent surgery between january and december . in all patients radiological and histological diagnosis was performed and cases were established as multiple glioma. imaging fingings: most of the patients had one bigger lesion and or smaller ones. the lesions were usually hyperintense on t -weighted images and hypoor isointense on t wi with strong postcontrast enhancement. most of them had moderate edema. we recognized multicentric and multifocal gliomas, were synchronous and one metachronous. conclusion: multiple gliomas are often radiologically reported as metastasis, sometimes as lymphomas or infectious diseases. the differential diagnosis of multiple masses in the brain is very important for therapeutic consequences and multiple glioma should considered because of suggested increasing frequency of this entity. if strong postcontrast enhancement and moderate edema around the lesions are observed, this diagnosis should be suggested. role background: gks is a method of treatment allowing the delivery of a conformal radiation dose to a stereotactically defined target. the significant development of interest in the role of gks as an alternative or adjunct to the neurosurgical management of many brain disorders, requires accurate and reliable methods of acquisition of image modalities for the stereotactic planning. imaging and procedures: between december and august , we treated patients for a large variety of indications (metastases %, vascular malformations %, trigeminal neuralgia %, pituitary adenoma %, primary brain tumor %, other tumors %, vestibular schwannoma %, meningioma %, other functional < %). all patients had an mri combined with ct in stereotactic conditions. some patients also benefited from stereotactic dsa (n = ) or pet (n = ). in all cases, mr was used to delineate a target before radiosurgery. ct was always used as a control for mr distorsion. dsa was used in combination with angiomr for all arteriovenous malformations. when the tumor was ill-defined, we anticipated some limitation of target definition (infiltrative lesions, recurrence of metastases, pituitary adenomas) and also used stereotactic pet. we present a pictorial review illustrating the role of neuroimaging for appropriate targeting in gks. these images are also critical for the evaluation of the potential risks and complications. the complementary information provided by the combination of various imaging modalities allows appropriate and accurate delineation of a target volume before stereotactic irradiation. to familiarize non-greek radiologists with the definition of greek eponyms and to emphasize on those terms and words that have been derived from greek mythology. background: medical eponyms serve as mnemonics, add color to medical writing and are useful shorthands in medical communications. a long catalogue with the most representative greek medical terms is listed. the exact definition and meaning of each word is explained and a short narrative of the relative myth is presented for the neuroanatomical terms which gained their name from greek mythology. conclusion: accurate knowledge of the meaning of these words will help the radiologist to remember the terms and make their learning fun. preoperative to present the potential of diffusion tensor imaging (dti) and colored coded fractional anisotropy (fa) maps in identifying the anatomy of white matter tracts for pre-operative planning. materials and methods: dti data were acquired using dw-se-epi sequences and a . t mr-unit, with the following parameters: tr - , - slices, mm slice thickness, . mm intersclice gap, x matrix and gradients encoding in directions, b- sec/mm . data were acquired in normal subjects and patients with brain tumors, avm's or seizure foci being considered for surgery. fa images and corresponding colored coded maps were generated. also, fse t or flair images were acquired in identical locations for comparative use. results: major white matter tracts (intrahemispheric, interhemispheric, and brain stem) were readily visualized, including the following: superior longitudinal fasciculuus, superior fronto-occipital fasciculus, inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, uncinate fasciculus, corpus callosum, cingulum, optic radiations, anterior commissure, corona radiata, internal capsule, pyramidal tracts, medial lemniscus, medial longitudinal fasciculus, cerebellar peduncles and gracile and cuneate fasciculi. the spatial relationships of these tracts and resectable lesions were analysed, with particular attention to the risk of a postoperative deficit. all results were correlated with the pre-and post-operative deficits. conclusion: white matter anatomy can now be imaged using dti/fa and access to pre-operative eloquent white matter mapping has great potential to improve the outcomes of neuro-surgical candidates. the future management of neuro-surgical patients will be impacted by future refinements and developments of this technique. to present a retrospective analysis of our experience in the endovascular coil trapping for ruptured vertebral artery (va) dissecting aneurysms. materials and methods: we treated patients who presented with acute subarachnoid hemorrhage due to rupture of a vertebral artery dissecting aneurysm. embolization of the entire segment of the dissected site with detachable platinum coils (internal trapping) was performed in all patients. in one patient with posterior inferior cerebellar artery (pica)-involved va dissecting aneurysm, internal trapping of the aneurysm followed by occipital artery-pica bypass was performed by a neurosurgeon. results: coil embolization was successful in all patients. there were no procedure-related complications. there was no sign of infarction in the pica territory in all patients. there was no recurrent bleeding or ischemic symptoms during the follow-up periods. follow-up angiography showed complete occlusion of the aneurysm without recurrence in all patients. conclusion: endovascular coil embolization is a safe and highly effective treatment of ruptured va dissecting aneurysms. high-grade stenoses of the carotid artery were treated with stent implantation. dw mr imaging of the brain was performed a day before and after the endovascular treatment. all patients underwent neurological examination before and after the procedure. results: dw mr images showed a total of new hyperintense lesions in ( %) of the procedures performed. eight lesions were ipsilateral to the treated vessel and lesions, in patients, were contralateral. these patients with contralateral lesions also had new ipsilateral lesions. the lesions were located in parietal lobe (n = ), periventricular (n = ), occipital lobe (n = ), frontal lobe (n = ) and corona radiata (n = ). all lesions measured < mm in diameter. none of the patients had neurological symptoms. results: angiographic occlusion was complete in ( %) and ( %) aneurysms in groups a and b, respectively. mean percentage of volumic occlusion in these groups was . and . %, respectively. perioperative morbidity and mortality rates were and %, respectively in group a, and were respectively similar in group b. no significant difference between the two groups was observed. however, percentage of volumic occlusion correlated with sac-to-neck ratio smaller than . (p = . ) and with sac size (p = . ), except when or more threedimensional coils per aneurysms were used (p = . ). the better the percentage of volumic occlusion, the better the percentage of angiographic occlusion (p = . ). percentage of volumic occlusion was an independent predictor of angiographic complete occlusion (p = . ). wfns grade was an independent predictor of perioperative mortality (p = . ). the use of three-dimensional coils improved the coil-packing and angiographic and volumic occlusion of aneurysms with a neck greater than mm at the time of treatment, provided the sac-to-neck ratio was . or greater and the largest number of three-dimensional coils were positioned first. minimum apparent diffusion coefficient: a quantitative parameter for prediction of malignancy of gliomas preoperatively x. yun; sendai/jp introduction: in gliomas, choline signal (cho) correlates with total membrane metabolism, apparent diffusion coefficient (adc) inversely with cell density, cho*meanadc with each cell's metabolism. we examined which parameter is the most reliable in prediction of malignancy of gliomas. methods: twenty-three pathologically proven glioblastomas (gbm) and anaplastic gliomas (ag) were retrospectively evaluated with preoperative mri with mr spectroscopy (mrs) and dwi. ki index was counted to evaluate pathological malignancy. to evaluate clinical malignancy, we selected cases in which at least enhancing lesions were removed and classified into progressed and stable groups. the minimum adc (madc) of gbm was shown to be significantly lower than ag (p = . ). the highest value of madc in gbm was . , and the lowest in ag was . . using this threshold, subjects were divided into groups; a: gbm with madc < . (n = ); b:gbm and ag with . < madc < . (n = ), c: ag with madc < . (n = ). six cases in group a were classified as progression ( pathologically proven recurrence, two dissemination) and all cases in group c were stable. six cases in group b showed progres-sion ( recurrence, dissemination). fisher test showed significance (p = . ). in group b, the madc of progressive gbms was significantly lower than stable gbms (p = . ). the ncho and ncho*meanadc showed no difference between gbm and ag (p = . , p = . ). inverse correlation was found between ki and madc (p = . ), no correlation was found between ki and ncho (p = . ) and meanadc*ncho (p = . ). the madc suggestive of cell density was the most reliable in prediction of malignancy of gliomas preoperatively. usefulness methods: forty-one cases of skull base lesions ( meningiomas; petroclival, clinoidal, olfactory, in foramen magnum, spheno-petro-clival, in the planum sphenoidale, in posterior pyramid and in pca; acoustic schwannomas, epidermoids, pituitary adenomas, craniopharyngiomas, posterior fossa aneurysms, trigeminal schwannoma, dermoid and juvenile angiofibroma) have been evaluated. data was collected, fused, integrated and reconstructed by a dedicated stealthstation system for neuronavigation. ct images were acquired on axial non-overlapping slices, - mm thick; mri images were obtained with . t device, same field of view and thickness. results: neuronavigation was possible in all cases and was successfully applied in pre-operative planning and during surgical procedures. we calculated some data to check the efficacy of the method, having a mean fiducial error of . mm and an accuracy value at cm of depth . mm. discussion and conclusion: imaging fusion for pre and intra-operative neuronavigation provided, in all cases, great advantages in the choice of the best approach, placing of bone flap, early identification of deep normal or distorted anatomic or pathologic structures and their eventual encasement or involvement by the pathologic primary process, correct definition of tumor boundaries and meningeal implant and relationship with functional areas. neuronavigation appeared ideal for skull base meningiomas making surgical maneouvres safer, more effective and less invasive. a study of mr diffusion changes in normal appearing white matter (nawm) of patients with relapsing remitting multiple sclerosis (ms) f. gaudiello, s. marziali, a. ludovici, e. ferone, r. floris, g. simonetti; rome/it background and purpose: the aim of our study was to monitor water diffusion changes over time in nawm of patients with relapsing-remitting ms and to monitor water diffusion changes in patients with different disability status (edss) and with different clinical status (poussè). methods: we selected subjects who had completed a month follow-up. the mr scans were obtained at baseline, at months and at months. two regions of interest (roi) were placed in each hemisphere in the nawm in each mr study and the apparent diffusion coefficient (adc) value were calculated in patients and in healthy controls. results: tadc in nawm in patients was significantly higher then in controls (controls mean tadc ± sd = . ± . mm /sec x - ; patients mean tadc ± sd = . ± . mm /sec x - ; p < . ). in nawm in patients with higher edss, tadc was significantly higher then in patients with lower edss (patients with higher edss: mean tadc ± sd = . ± . mm /sec x - ; patients with lower edss: mean tadc ± sd = . ± . mm /sec x - ; p < . ). tadc in nawm in patients with poussè was significantly higher then in patients without poussè (patients with poussè mean tadc ± sd = . ± . mm /sec x - ; patients without poussè mean tadc ± sd = . ± . mm /sec x - ; p < . ). purpose: evaluation of uveal melanoma imaging characteristics in ultrasound, computed tomography and magnetic resonance imaging and correlation of those findings suggestive of melanoma. material and methods: eleven patients ( men, women, age - years) with possible diagnosis of uveal melanoma were evaluated. the patients underwent ophthalmoscopic and ultrasonographic examination followed by ct and mr examination. ct imaging was performed with mm axial pre-and post-contrast and coronal post-contrast sections. axial and coronal mm t and t images were obtained, followed by post-contrast t images in axial and coronal direction. additional t fat-sat post contrast images were also obtained depending on the relative position of the melanoma in order to evaluate possible extra-orbital extension. results: of the melanomas, six were located in the left globe, ranging from mm to mm in size and most commonly on the lateral wall. the tumors appeared as hyperechoic lesions on us with a reflectivity range of - %, suggestive of melanoma. retinal detachment was detected in four patients. on ct images the melanomas appeared as homogenous slightly enhancing lesions, while in two patients, the tumor was less obvious due to the retinal detachment. on mr images the tumors appeared as homogenous hyperintense lesions on t wi in five patients. characteristic signal void on t wi due to melanin deposition was noted in three patients. conclusion: ultrasonography appears to be a valuable tool in tissue differentiation of uveal melanoma although magnetic resonance, and to a lesser degree, computed tomography are more specific in evaluating the extra-orbital extension. purpose: gadobenate dimeglumine (gd-bopta: t relaxivity in blood = . mmol - s - ) was evaluated to determine whether the high relaxivity offers advantages over other agents for cns imaging. methods: preliminary studies evaluated gd-bopta at cumulative doses up to . mmol/kg to ascertain the optimal dose for mri of cerebral metastases. two phase iii controlled trials were conducted to compare gd-bopta at cumulative doses up to . mmol/kg with gadodiamide (gd-dtpa-bma) at cumulative dose up to . mmol/kg. two intra-individual, blinded, fully randomized comparative studies were conducted in patients with cerebral gliomas or metastases to determine differences in quantitative (tumor contrast, cnr ratios) and qualitative (lesion contrast, delineation, internal morphology, structure) enhancement parameters versus gadopentetate dimeglumine (gd-dtpa) and gadoteric acid (gd-dota) at a dose of . mmol/kg. in patients with metastases a dose of . mmol/kg gd-bopta proved sufficient for most situations while a cumulative . mmol/kg dose provided additional information in certain cases. comparative studies revealed that . mmol/ kg gd-bopta offers improved performance compared to . mmol/kg gd-dtpa-bma and that cumulative . mmol/kg gd-bopta is equivalent to cumulative . mmol/kg gd-dtpa-bma. the intra-individual comparative studies revealed superior qualitative enhancement performance for gd-bopta compared to both gd-dtpa and gd-dota for all evaluations. the subjective assessments were confirmed by the objective measurements of signal intensity and cnr which were significantly higher for gd-bopta (p < . ). discussion: gd-bopta is a safe and valuable contrast agent for the assessment of cns neoplasms offering statistically significant advantages over gd-dtpa, gd-dota and gd-dtpa-bma for brain lesion enhancement. the in cases the examinations were performed before the treatment, in patients as an assessment of drug treatment. in cases the efficacy of stereotactic effect (se) was assessed on the suitable target structures. results: a metabolism decrease (md) in the right caudate head (ch) was noted in two patients before drug treatment. in two patients hypermetabolism was observed in the anterior cingulate (ac). follow-up examinations revealed a md in the ac and an metabolism increase (mi) in the right ch in these patients. in one case an mi in both dorsal thalami (dt) was observed. a md in both dt before drug treatment was seen in two cases. a bilateral mi was noted in dt by followup examinations in these patients. in all cases of se, it revealed a md in suitable structures. in cases, a md was observed in ac and both the ch. in two cases, a md was seen in the ac, in a bilateral md in the dt. changes of glucose metabolic rate were associated with severity of clinical manifestations in all cases. this data proves participation of limbicostriatal system in forming aod. our results demonstrate the possibility to use f-fdg pet for aod diagnosis and estimation of treatment efficiency. b d e f a g magneting resonance imaging in patients with intractable partial seizures: a preoperative assessment a. lefkopoulos, a. kalogera-fountzila, c. kouskouras, n. fotiadis, g. spanos, e. papadopoulou, a.s. dimitriadis; thessaloniki/gr purpose: the aim of this study was to assess the prevalence of detected structural abnormalities in medically intractable epilepsy, especially those who are amenable to a surgical therapy, and also to evaluate the sensitivity of different dedicated mr sequences. materials and methods: one hundred and twenty patients (aged months- years) with medically intractable partial seizures underwent an mri examination in a . t unit, with t and pd/t se in an axial plane and fluid attenuated inversion recovery (flair), t fse and inversion recovery (ir) in a plane perpendicular to the long axis of the hippocampus. whenever necessary, we applied t se + gd dtpa in axial and coronal planes. results: seventy-nine of the patients had a pathological scan ( . %). abnormalities were hippocampal sclerosis (hs) in patients ( %), cerebral tumors in patients ( %), vascular malformations in patients ( . %), cortical infarcts in patients ( . %), cerebral infections in patients ( . %) and patients with developmental disorders ( cortical dysplasias, pachygyrias, polymicrogyrias, subcortical heterotopias and patient with tuberous sclerosis). all patients with cerebral tumors and eight patients with hs were operated and there was a pathologic confirmation of the diagnosis. patients with vascular malformation underwent a therapeutic embolization. flair had higher sensitivity in detecting hippocampal sclerosis and cerebral infarcts while ir was particularly useful in detecting developmental disorders. conclusions: mr imaging, with an epilepsy dedicated protocol, plays a cardinal role in locating and characterizing anatomic epileptogenic foci in patients with refractory epilepsy and helps in defining the type of treatment. the purpose: the aim of this study was to evaluate the possibilities of combined pet/ct imaging in detecting glioblastomas and in estimation of efficiency of their surgical treatment and radiotherapy. materials and methods: seven patients ( men, women, age between - years) with biopsy-proven glioblastomas were scanned before and/or after treatment by pet/ct (biograph, siemens). a dose of to mbq fluorine- fluorodeoxyglucose (fdg) was administered for each pet scan with an acquisition time of minutes for bed and interactive reconstruction. acquisition time for ct was seconds, bringing the total acquisition of combined pet/ct study to minutes. results: three patients with high-grade astrocytomas demonstrated hypometabolic fdg nodules without contrast enhancement at ct scan before surgery. two patients showed nodules with hypermetabolism of fdg (suv - ) and intensive enhancement of contrast medium due to the recurrence of tumor after combined therapy. in one patient, after radiation therapy, the region of treatment had decreased uptake of fdg and increased enhancement of contrast medium at ct because of radionecrosis. conclusion: it was confirmed that combined pet/ct study could effectively determine whether a lesion was malignant and provide evidence of tumor recurrence. the collection of prominent medullary (white matter) veins appears like a "medusa head" on mr angiographic images and gadolinium-enhanced d-tof sequences; this sign is considered pathognomonic. conclusion: mri is of great value in the accurate identification and morphologic specification of vascular abnormalities. traditionally, these cases required invasive diagnostic imaging. va correct identification is very important because this anomaly is asymptomatic but the ablation can induce venous infarctions. abdominal imaging findings: gastrointestinal tract (gi), hepatobiliary system and the pancreas are involved in cf. the gi complications include obstructive (distal intestinal obstruction syndrome, intussusceptions, fibrosing colonopathy, post surgical adhesions) and non-obstructive conditions (pneumotosis intestinalis, gastroesophageal reflux, duodenitis, and rectal prolapse). liver pathology includes steatosis, cirrhosis, and portal hypertension. the pathological mechanism of cirrhosis may be due to obstruction of the biliary ductules with thickened secretions and secondary inflammation producing fibrosis. biliary tract abnormalities include gallstones, micro gallbladder, and sludge. excessive loss of faecal bile acids due to pancreatic insufficiency is associated with increased lithogenicity of the bile. the pancreatic abnormalities include fat infiltration, fibrosis, atrophy and occasionally cysts and calcification. the primary problem is the plugging of the intralobular ductules by inspissated viscid mucus. conclusion: abdominal symptoms in patients with cf may be due to the various causes related to cf or may be due to coincidental pathology e.g. appendicitis, renal disease. the radiologist should keep an open mind and not restrict his thought process only to the conditions related to cf. neck masses in infants and children: a pictorial review j.r.a. turkington, a. paterson, l.e. sweeney, g. thornbury; belfast/uk learning objectives: this poster presents a pictorial review of pediatric neck masses and their imaging features. particular emphasis is applied to the anatomical site of the mass to aid in differential diagnosis. background: infants and children with neck masses frequently present to the radiologist for further evaluation. the most common aetiologies include congenital lesions and their complications, lymphadenopathy and malignant masses. the role of the radiologist is to differentiate between these conditions using im-aging modalities such as ultrasound and colour doppler, ct and mri. where appropriate, the radiologist will also stage lesions for management purposes, and aid in guiding aspiration or biopsy. imaging findings: the radiological appearance of congenital lesions such as thyroglossal duct cysts, branchial cleft cysts, cystic hygromas, haemangiomas, dermoid cysts and sternomastoid "tumours" are discussed. cervical lymphadenitis and abscesses, and neoplastic masses such as neurogenic tumours, rhabdomyosarcoma, neuroblastoma and lymphoma are also described. lastly, lesions of the thyroid and salivary glands are evaluated. it must be emphasised that the radiological findings should always be interpreted in conjunction with the patient's age, the clinical history and the findings on physical examination. conclusion: neck masses are common in children and a frequent cause of attendance at a&e departments. identifying the anatomical site and radiological appearance aids the differential diagnosis. conclusion: a typical osteoarticular lesion in a typical site can alert you to the diagnosis of sapho, but an unusual site or a primary presentation with no skin lesions will make diagnosis harder or there may be misdiagnosis. children may be seen in a number of specialties, which can lead to unnecessary delays in diagnosis and possible incorrect treatments. this makes the radiologist pivotal in the diagnosis of sapho, although the differential diagnosis should always be considered. to demonstrate the problems which can be caused when trauma x-ray films are incorrectly marked when using the red dot system. background: many radiographs are returned to accident and emergency departments without formal radiological reports, and the red dot system, whereby radiographers attach a red dot to radiographs which they suspect to be showing a fracture, is a widely practised system, used throughout the national health service. it is acknowledged that whilst this system can be beneficial to accident and emergency departments it is not without its problems. procedure findings: our poster examines the problems which can arise in children where normal variants are often highlighted as "fractures" by radiographers. most of the common misinterpretations occur in the appendicular skeleton, e.g. normal variants of epiphyseal ossification or accessory epiphyses, especially of the metacarpal and metatarsal bones. other common "errors" include the pisiform, or os trigonum and accessory ossification centres for the medial and lateral malleoli. in the axial skeleton, vascular markings in the skull, facial bone sutures and end plate ossification centres for the vertebral bodies are some of the commoner areas of concern. conclusion: issues are raised for both accident and emergency departments and for radiology departments if these "errors" are not minimised, including patient complaints of over-diagnosis and potentially unnecessary treatment and follow-up visits. the radiology of pediatric extracorporeal membrane oxygenation: normal appearances and complications a.m. barnacle, m.p. hiorns; london/uk learning objectives: to demonstrate the normal appearances of the pediatric chest during extracorporeal membrane oxygenation (ecmo). the spectrum of radiological abnormalities arising from the complications of ecmo is illustrated, including cannula position and anticoagulation complications. background: ecmo is a means of cardiopulmonary bypass therapy used in patients with cardiorespiratory failure who are unresponsive to conventional intensive care interventions. there is a range of indications for ecmo therapy in the pediatric population, which include congenital diaphragmatic hernia and cardiac disease. there are a number of complications associated with the use of ecmo, many of which are related to the high levels of anticoagulation required during therapy. radiological assessment prior to the commencement of treatment and sequential imaging during therapy are mandatory, and appropriate imaging protocols are discussed. imaging findings: the normal radiological appearances of the chest during ecmo therapy are demonstrated, including the correct positions of both va and vv ecmo cannulae. several technical points are highlighted, to avoid the misinterpretation of certain radiographic appearances. the radiological manifestations of a wide range of complications are illustrated. these include intracranial haemorrhage and extra-axial collection, haemothorax, peritoneal collections and vascular complications. inappropriate cannula positions are also reviewed. the radiologist must be familiar with both the normal and abnormal imaging appearances during ecmo therapy and should be aware of the range of potential complications. the importance of sequential imaging is highlighted and appropriate imaging protocols discussed. acute disseminated encephalomyelitis or multiple sclerosis: what tips the balance? s. avula, a. ghatak, n. wright, r. appleton; liverpool/uk learning objectives: to identify the imaging features and clinical parameters which help to distinguish between acute disseminated encephalomyelitis (adem) and multiple sclerosis (ms) in children. background: both adem and ms are disseminated inflammatory disorders affecting the central nervous system. distinction between the two is difficult, especially at the initial presentation when the prognosis and risk of relapse is an important issue. this exhibit will highlight the salient distinguishing features stated in the literature and illustrate cases of adem and ms which presented over a three year period. procedure details: literature review of childhood adem and ms was carried out and a retrospective review of cases presenting over a three year period with a subsequent diagnosis of adem or ms was performed. there is a considerable overlap between the imaging and clinical features of adem and ms. though there are a few features that predominate in either condition, the temporal progression of the disease with presence of new lesions with or without relapse of symptoms as noted in ms, is the most important factor in distinguishing the two. mri in assessment of fetal renal anomalies j.l. hughes, w. jan; london/uk introduction: in patients with renal anomalies causing severe oligohydramnios, the lack of fluid around the fetus significantly degrades the ultrasound image, making assessment of the fetal abdomen difficult. the presence of renal anomalies has great postnatal significance and successful antenatal counselling depends on the availability of the most complete information. the advent of fast mr sequences has allowed the acquisition of high signal to noise ratio images of the fetus even in the absence of amniotic fluid. we discuss the technique of mr of the fetal renal tract. we describe the normal appearances fetal kidneys on mr and present data on illustrative cases where mr provided additional information over and above a detailed ultrasound examination. methods: t w single-shot rapid acquisition with relaxation enhancement (rare) and t w d fast low angle shot (flash) were obtained of the fetal kidneys in the three orthogonal planes. all images were acquired without fetal sedation with the mother in the supine position within minutes. comparison ultrasound and mr images are presented. results: mri is able to diagnose and assess a variety of renal anomalies such as renal aplasia, dysplastic renal tissue, polycystic kidney disease, congenital hydronephrosis, and ectopic renal tissue. conclusions: fetal mr offers further information over ultrasound examination and hence allows appropriate ante-natal counselling. pediatric urethral anomalies a. sharma, s. maroo; glasgow/uk imaging evaluation of neonatal cystic pelvic masses v.v.t. mascarenhas, a. duarte, l. lobo, j. fonseca-santos; lisbon/pt learning objectives: to describe imaging features of cystic pelvic masses (cpm) in the newborn. to outline main differential diagnosic pitfalls. to emphasise the role of imaging evaluation in treatment and follow-up orientation. background: neonatal cpm are among the most common abdominal masses in the neonate and usually first suspected during fetal ultrasonography. a more precise diagnosis in the neonatal period is essential to an adequate orientation in treatment and follow-up. on this regard, imaging evaluation, particularly us and mri as the main techniques, undertake a pivotal role. we describe diagnostic imaging features, differential diagnosis limitations and a systematic diagnostic approach to cpm among selected cases in our department. imaging findings: we reviewed the referred cases based on sex, location, relation to adjacent anatomic structures and morphological features. main diagnostic entities considered were pre-sacral (sacrococcygeal teratoma and myelomeningocele) and non pre-sacral masses (genitourinary related namely hydrocolpos, ovarian cyst, bladder diverticulum; digestive tract related e.g. duplication cyst; others, particularly lymphangioma). morphological imaging findings according to their uni-or multilocularity, simple or complex components and the presence of specific findings were considered. ultrasound was the first and sometimes the only imaging modality performed. selected cases were further evaluated with other imaging modalities such as conventional contrast studies (e.g. cystography) or mri. conclusion: although there is a wide range of entities presenting as a cpm in the neonate, a systematic imaging approach allows a more precise diagnosis or at least a considerable narrowing of diagnostic possibilities in the majority of cases, which is essential for therapeutic orientation. normal sonographic appearance of kidneys and adrenals in neonates and young infants: unique distinctive features m. vakaki, g. pitsoulakis, h. manoli, c. koumanidou; athens/gr learning objectives: to familiarize residents in radiology or pediatric radiology with the sonographic characteristics of neonatal and infantile kidneys and adrenals. backround: the kidneys are the most commonly sonographically examined abdominal organs during the first months of life. the adrenals, due to their position adjacent to kidneys, are almost always clearly visualized during the renal sonogram. their sonographic appearance is quite different from that in older children and adults and often causes misleading incorrect diagnoses. imaging findings: examples of various normal sonographic findings of the kidneys and adrenals in neonates and young infants are presented and embryologically, anatomically or functionally explained. they include the hyperechogenicity of the renal cortex, the "enlarged" hypoechoic pyramids, the fetal lobulation, the inter-renicular septum, the transient neonatal renal medullary hyperechogenicity, the papillary projections in the pyelocalyceal system, the renal pyelectasis, the large and hyperemic neonatal adrenals and even more. these sonographic interpretations are often misdiagnosed as abnormal conditions, which are also provided. conclusion: this exhibit will allow an interesting way for young radiologists and pediatric radiologists to learn the common, but also the rare sonographic appearances of neonatal and infantile kidneys and adrenals. this knowledge is essential in order to prevent misdiagnoses and needless further investigation. background: difficulties with blind corticosteroid injection of the subtalar joint are commonly encountered in children with jra. ultrasound (us) guidance can make the puncture more accurate by directly showing the needle tip within the joint. procedure details: twelve consecutive patients with jia who had clinical signs of active arthritis and intraarticular fluid or synovial proliferation in the subtalar joint detected at us received either a blinded injection (n = ) or a us-guided (n = ) injection with free-hand technique using high resolution ( - mhz) us. patients were assessed at hours, months and months of follow-up to compare the level of clinical response and the frequency of complications between the two treatment groups. conclusion: although significant improvement was documented in both groups of patients with respect to baseline, those injected under us-guidance had a lower clinical dysfunction score at hrs and months follow-up. no major complications were noted. our preliminary results indicate that intraarticular corticosteroid injection of the subtalar joint in children with jia is more accurate and successful when performed under us guidance. background: doppler sonography is a well-established technique to evaluate a number of pediatric abdominal conditions, but the field of diagnostic applications is now on the brink of major changes. many contrast-specific modalities have been developed in recent years by academic researchers, ultrasound scanner manufacturers, and pharmaceutical companies. our aim is to update the diagnostic value of conventional doppler modalities, and to analyse potentially useful applications and indications for the more recently developed techniques. imaging findings: specific entities will be used to illustrate clinical principles that can be applied to multiple clinical situations. topics addressed include: vascular patency (arterial or venous thrombosis or stenosis, biliary atresia, liver and bowel transplantation, and surgical shunts); anomalous vessels and tubular structures (dilation of the biliary tree vs. blood vessels, pulmonary sequestration, varicocele); and evaluation of hyperemic and ischemic lesions (appendicitis, intussusception, pyelonephritis, orchitis / testicular torsion). conclusion: b-mode sonography, as well as doppler techniques, have a key role in pediatric diagnosis for several reasons (non-invasivity, lack of ionizing radiation, sonographic access is better than in adults, no need for anesthesia or sedation). understanding the physical principles that govern doppler imaging is essential for its successful clinical application. symptomatic cases: n = . mean onsd right eye = . mm (sd = . ), mean onsd left eye = . mm (sd = . ). a wilcoxon signed ranks test showed no significant difference between these results. using the largest reading for each eye when well and symptomatic: mean asymptomatic onsd = . mm (sd = . , n = ), mean symptomatic onsd = mm (sd = . , n = ). a wilcoxon signed ranks test showed a significant difference in these results (p = . ). conclusion: onsd increases in acutely raised icp. our results suggest that children with spina bifida and shunted hydrocephalus cannot be assumed to have onsd within the normal range even when clinically well. in the long term we aim to compile new onsd reference ranges for children with shunted hydrocephalus. withdrawn by authors hyperechoic foci in the kidney: an incidental sonographic finding in neonates and infants m.a. pourbagher, a. pourbagher, f. tiker, z. koc, e.a. niron; adana/tr purpose: the purpose of this study was to determine the incidence and significance of non-shadowing hyperechoic foci in the kidney and to evaluate metabolic disturbances in these patients. in a period of years abdominal ultrasonography (us) was performed as a screening procedure in neonates and infants. a followup us was performed in of ( female and males) patients with hyperechoic foci in the kidney approximately - months after the initial examination. all patients underwent metabolic evaluation, including serum electrolyte measurement and -hour urine collection. results: non-shadowing hyperechoic foci were detected in ( %) patients ( kidneys). the size of foci were - mm (mean mm). the foci were located in the lower pole calix in %, upper pole calix in % and middle zone calix in % kidneys. sixty kidneys had single, had and had or more foci. at - months follow-up the clearance for foci was %. size and site of foci has no relation with foci clearance. urinalysis showed elevated urinary calcium in and hematuria in patients. in patients foci were passed without intervention, and uric acid was the dominant foci composition in both patients. serum electrolyte measurement were normal in all patients. the incidence of hyperechoic foci in our study was %. that is usually discovered incidentally during sonography of the abdomen and generally resolve spontaneously. follow-up of the patients is advocated with us and urinalysis. germinal matrix morphology in antenatal ventricular dilatation k.m. koprivsek , t. vanderheyden , s. counsell , j. allsop , a. stonebrige-foster , s. kumar , n. fisk , m.a. rutherford ; sremska kamenica/yu, london/uk purpose: the germinal matrix (gm), a densely cellular zone lining the lateral ventricles, and give rise to the developing cortex. the mri appearance of gm during fetal development has been well-documented, but data about gm morphology in pathological conditions is sparse. antenatal ventricular dilation (vd) is associated with significant neurological morbidity. we used antenatal magnetic resonance imaging (mri) to measure the gm in fetuses with and without vd. methods: retrospective analyses were conducted of fetal mr images acquired over a -year period, using fast t weighted sequences. in fetuses (normal ventricles in , vd in cases), we evaluated the signal characteristics and the maximum germinal matrix diameter (gmd) at three sites: the anterior and posterior ventricular horns and the caudothalamic notch (ctn). between-group comparisons of gmd in normal and fetuses with vd were made using a students t-test. results: gm had the same low signal intensity regardless of ga and/or ventricular volume. none of the infants with vd had evidence of gm haemorrhage. the mean gmd in controls showed a linear decrease with brain maturation. in fetuses up to weeks of ga with normal ventricles the gmd was greatest at the ctn. the similar pattern of changes in gmd was measured in vd group, where the mean gmd at the tcn were slightly, but not significantly lower then in controls (t = . : p > ( . )). conclusion: gm diameter decreased with increasing gestational age. we did not detect any significant difference in gm morphology in the group of fetuses with antenatal vd. contrast enhanced color doppler ultrasonography in diagnosis of scrotal lesions in children u. zaleska-dorobisz, e. czapiga, k. moron; wroclaw/pl purpose: to investigate the usefulness of ultrasound with contrast agent levovist-schering (usca) for the detection scrotal lesions in children. between - , boys with scrotal masses were examinated. mean age was . years and ranged from - . diagnostic assessment included in all cases conventional us, color doppler and power doopler before and after the adminstration of contrast agent keeping the same methodology in every examined patient. focal testicular lesions (cystic and solid tumor) and extratesticular structures were documented regarding size, localization, range, vascularity and ultrasound diagnosis. in testicular tumors, the degree of tumor vascularity was subjectively graded from to iv. the ultrasound diagnoses were compared to the final diagnoses based on clinical tests, surgical and histological examination. results: testicular and extratesticular tumors showed more enhancement than adjacent testicular parenchyma, seen between to s (mean s) and to s (mean s) after injection. the duration of enhancement was to s (mean s). cross sections and adjacent vessels were only seen in: teratoma, embryonal carcinoma and yolk sac tumor. conclusions: usca is an important and significant aid in the diagnosis of scrotal diseases, in the assessmentof of degree of vascular change and is predictive of malignancy. mr features of the preterm children with athetotic cerebral palsy k. hayakawa, t. kanda, y. yamori; kyoto/jp purpose: the recent development of the neonatal intensive care medicine has caused not only a dramatic decrease in the incidence of kernicterus, but also marked improvement in the survival of premature babies. consequently, the incidence of pure athetotic cerebral palsy has decreased, whereas the incidence of spastic cerebral palsy associated with athetosis, termed mixed cerebral palsy, has increased. the purpose of this study is to evaluate the brain mr features of this condition and to assess the frequency of basal ganglia injury. the subjects consisted of boys and six girls diagnosed with mixed cerebral palsy. their gestational age range from to weeks (average = weeks) and the birth weight ranged from g to g (average = g). mr brain scans were assessed with particular attention to the basal ganglia. imaging of pancreatic disorders in pediatric patients y. herrero, t. berrocal, c. prieto, j. fernández, m. parrón, r.r. lemos; madrid/es purpose: the aim of this teaching exhibit is to illustrate a wide spectrum of usual and unusual disorders involving the pancreas in children, and to evaluate the efficacy of ultrasound (us), duplex and color doppler sonography, endoscopic retrograde cholangiopancreatography (ercp), computed tomography (ct) and magnetic resonance (mr) imaging in the diagnosis and management of these conditions. methods and materials: the imaging findings of patients with disorders involving the pancreas were reviewed from our database of pediatric pancreatic pathology. ultrasound was performed in all cases, while ct, and mri were performed in all tumors and whenever us and doppler images were not conclusive. ercp was used to study the pancreatic ducts. the embryologic and pathologic bases of the imaging findings are discussed in appropriate cases. the key findings at each imaging modality are shown and compared with the underlying pathologic features when available. pitfalls, diagnostic difficulties and differential diagnoses are emphasized. results: specific topics addressed include congenital anomalies (pancreas divisum, annular pancreas, ectopic pancreas, pancreatic cysts, cystic fibrosis, shwachman-diamond syndrome, von hippel-lindau syndrome, and nesidioblastosis); acute and chronic pancreatitis; pancreatic cyst and pseudocysts; primary neoplasms (insulinoma, cystadenoma, and papillary cystic carcinoma); metastasis of burkitt lymphoma; and miscellaneous (hemochromatosis, cushing's disease, steroid and cytostatic therapy, and parenteral nutrition). conclusion: evaluation of patients with pancreatic disorders frequently requires multiple imaging modalities for diagnosis and planning surgical correction. because many of these disorders have characteristic imaging appearances, this exhibit will help practicing radiologist to better understand and recognize pathologic processes affecting the pancreas. imaging congenital vertebral disorders in pediatric patients m. fernández -velilla, t. berrocal, a. royo, a. fernández, j. gutierrez, n. gómez-león; madrid/es purpose: to illustrate a wide spectrum of usual, unusual and exceptional congenital anomalies involving the vertebrae, and to evaluate the efficacy of plain radiographs, computed tomography (ct) and magnetic resonance (mr) imaging in the management of these conditions. methods and materials: we retrospectively reviewed the imaging findings of patients with congenital abnormalities involving the vertebrae from our database of spinal pathology. abnormalities were divided into isolated vertebral anomalies and anomalies associated with systemic diseases or syndromes. plain radiographs were performed in all patients. ct or mr were performed whenever plain radiographs were inconclusive. the embryology and pathologic basis of the radiographic findings are discussed. pitfalls, diagnostic difficulties and differential diagnoses are emphasized. results: specific topics addressed include anomalies in number (vertebral agenesis, sacral agenesis, omovertebral bone); anomalies in size and shape (vertebral and sacral hypoplasia, hemivertebra, occipitalization of c , os odontoideum, lumbarization, sacralization); anomalies of fusion (blocked vertebra, klippel-feil abnormality, spina bifida, butterfly vertebra, coronal cleft vertebra); anomalies of alignment (spondylolisthesis, spondilolysis, scoliosis); neural arch defects (absence of the pedicle and lamina); caudal spinal anomalies with anorectal and urogenital malformations (terminal mielocystocele, caudal regression syndrome, vacter association, oeis complex, currarino triad); and skeletal dysplasias (achondroplasia, thanatophoric dwarfism, chondrodysplasia punctata, spondyloepiphyseal dysplasia, and mucopolysaccharidoses). conclusion: evaluation of patients with vertebral abnormalities frequently requires multiple imaging modalities for diagnosis and planning treatment. because many of these disorders have characteristic imaging appearances, this exhibit will help trainee radiologist to better understand and recognize pathologic processes affecting the vertebral spine. defecography in chronically constipated children a.d. yang, m.-t. cheng, k. lee; changhua/tw purpose: to evaluate the defecographic findings in children suffering from chronic constipation. between may to august , we performed a prospective study of children ( boys, girls) with an age range of - years old who fit the criteria for chronic constipation in our institution. defecography was performed using flouroscopy with radiographs were taken during different phases of defecation; the whole study was video recorded. results: of the children studied ( ) children were found to have abnormal defecographic findings: partial relaxation to non-relaxation of the puborectalis muscle on defecation was found in patients; anterior rectocele in , posterior rectocele in , rectal intussusception in , mucosal prolapse in , rectal prolapse in ; sigmoidoceles in : grade i ( ), grade ii ( ), grade iii ( ). conclusion: . the defecographic findings that are seen in adults could also be found in children. . defecographic evaluation could be a potentially valuable and simple radiologic study which could be used in the evaluation of children suffering from chronic constipation. evaluation of the usefulness of d ct reconstructions of multifragmented fractures in children m. wozniak, e. dybiec, p. wieczorek; lublin/pl purpose: the aim of the study was the evaluation of the usefulness of d ct reconstructions in the imaging of post-traumatic alterations of the bones in children. the analysis was based on three dimensional ct reconstructions of the fractured bones. there were cases of extensive, complex bone fractures, when evaluation based on conventional radiographs was insufficient. all examinations were performed on a shimadzu sct tx scanner. surface and volume rendering were employed in the processing. the results of the study show that d reconstructions allow very precise evaluation of post-traumatic alterations, especially in the bones of complex anatomical structures. they enable the imaging of small fracture fissures invisible on conventional radiographs and ct. in the cases of bone indentations d reconstructions allow very detailed evaluation of the depth of indented fragments, their displacement and rotation. results: ct examinations were performed over the nine month study period. examinations using tube current of more than % greater than protocol were noted. these reduced from % of examinations prior to the introduction of the protocol to % following its introduction. reductions were most noticeable in helical examinations of thorax, abdomen and pelvis. conclusion: weight related protocols reduce the tube current used and thus the radiation dose in a large percentage of paediatric ct examinations. this has proved to be an effective method of reducing dose both in this study and in previous studies. bone sarcomas as a second malignancy in children c. renal dysplasia and intrarenal reflux in boys with posterior urethral valves: high resolution sonographic findings m. vakaki, g. pitsoulakis, h. manoli, c. koumanidou; athens/gr purpose: voiding cystourethrography (vcug) is considered the gold standard for the diagnosis of the posterior urethral valves (puv) and the accompanying vesicoureteral reflux (vur) in boys. however, its contribution to the characterization of intrarenal pathology, which is considered to be of great prognostic value, is minimal. it is only with recently introduced high resolution ultrasonographic equipment that details of disturbed renal architecture can be visualized. materials and methods: infant boys with puv, aged day to months were examined sonographically with - mhz convex and - mhz linear transducers. the presence of puv was confirmed with vcug in all cases. results: apart from the classic sonographic findings of puv, which were also demonstrated, findings specific to the kidney included: a) bilaterally increased renal parenchymal echogenicity and loss of corticomedullary differentiation ( / ), which with b) small cortical cysts ( / ) imply renal dysplastic lesions, c) increased medullary echogenicity, cupping of dilated calyces, which is attributed to intrarenal reflux ( / ), d) hypoechoic lines pointing towards rounded calyces, corresponding to the pelvotubular backflow of urine ( / ), e) small subcapsular urinomas ( / ), f) urinoma and urine ascites ( / ) and g) intrarenal abscesses ( / ) and fungal balls in the collecting system ( / ), due to post-surgical candidiasis of the urinary tract. conclusion: ultrasonography with high-resolution transducers is able to visualize underlying renal pathology and to image the parenchymal architecture, contributing not only to the diagnosis but also to the definition of the prognosis in boys with puv. meningiomas within the vertebral column are even rarer. we present the imaging characteristics of meningiomas ( intracranial and intracanal) in girls and boys, aged . - years (mean age . years). these meningiomas were diagnosed during year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . none of the studied children had previously been treated with radiotherapy. both children with vertebral meningioma suffered from neurofibromatosis. the imaging studies included brain ct ( / ) and mr of the brain ( / ) and vertebral column ( / ) before and after intravenous administration of gd-dtpa. the histologic examination after the surgical tumor resection showed meningioma of the transitional type in children and co-existing malignant elements in the th child. following tumor resection, children were free of symptoms and no other treatment was required. in contrast, the patient with the meningioma with malignant elements was treated with chemotherapy and radiotherapy, after subtotal tumor resection. conclusion: imaging of meningiomas (intracranial and intracanal) provides essential information for surgical planning, demonstrating the extraparenchymal nature of the neoplasm, its location, its dimensions, possible calcifications, as well as its effects on adjacent anatomic structures. rare hepatic vascular anomalies in pediatric patients z. harkanyi, g. balazs, g. tasnadi; budapest/hu purpose: to present a selection of rare cases of hepatic vascular anomalies in pediatric patients. us, helical ct and mr were used in the diagnosis and in the follow-up of these lesions. various venous anomalies were detected including intrahepatic arterio-portal and porto-hepatic shunts. a case of porto-caval shunt was also identified. the most frequent anomaly was portal cavernoma due to portal vein thrombosis. one case of caval web has been followed up for years. another case of budd-chiari syndrome has been followed up for two years. several cases of hepatic and portal vein anatomic variations are also documented. d and color doppler us was used as the first line examination in the diagnosis and follow-up different congenital hepatic vascular anomalies. helical ct, cta and, more recently, mra has been used for further analysis of these lesions. conclusions: us is still the first method for the evaluation of the pediatric liver and the hepatic vessels. color doppler is the modality of choice for functional evaluation of the vascular anomalies and is also useful in the follow-up of the patients. contrast-enhanced mra and cta is helpful in selected cases to demonstrate the extent of the lesions and other associated anomalies, such as development of systemic collaterals. acute [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , (n = ) children with septic sacroiliitis and/or acute osteomyelitis of the pelvic bones were imaged by our radiology department. other laboratory tests were already performed and in ( / ) young patients, material from needle aspiration had been sent for cytological examination. the imaging initial approach included plain film study and triple-phase tc radiophosphate scan. in addition, ( / ) patients underwent mri examination and ( / ) children had ct. the laboratory results confirmed the diagnosis of osteomyelitis and/or that of septic sacroiliitis. the retrospective study of the imaging examination results indicated the superiority of scintigraphy and of mri in the diagnosis of these entities. plain film radiographic signs of disease were observed only in patients ( / ) though the bone scintiscan was positive in all patients ( / ). the ct examination was positive in young patients ( / ) while mri's sensitivity was % ( / ). at the end of therapy all patients recovered completely. conclusion: a bone scan is warranted in every case of clinically suspected osteomyelitis and/or septic sacroiliitis in which the radiographs are unrevealing. however, mri is a useful adjunct in the evaluation of the bone edema, the detection and localization of abscess and in the demonstration of the soft tissue extent of the infectious process. the results: hrct showed that / of the cases had bronchiectasis, with cystic fibrosis as the underlying cause in cases. cases had bronchiolitis obliterans and cases had macleod's syndrome. cases with aspiration pneumonia had gastroesophageal reflux, and a intrabrochial foreign body was detected in one case. one case had bronchopulmonary dysplasia, and had tb lymphadenitis compressing bronchi. chest radiography revealed findings of bronchiectasis only in of the cases. hyperaeration was detected in the chest radiographs of only cases out of , whose hrct revealed air trapping. hrct showed peribronchial thickening in cases, however, chest radiography showed the same finding in patients. hrct made it possible to observe linear densities caused by linear atelectasis / scars in cases. hrct showed the underlying pathology and consequent pulmonary lesions in out of cases, and linear densities in . conclusion: hrct has a significant role in detecting the underlying abnormalities and consequent lesions in children with recurrent pulmonary infections. compared to chest radiography, hrct gives much more information. analysis of doppler signals: application for detection of fetal movements a. kribeche, s. benderbous, m. berson, d. kouame, l. pourcelot; tours/fr the objective is to develop and validate a new doppler ultrasound system allowing the imaging of fetal movements in real time. we describe the prototype of new ultra-sound sensors and present the results obtained in pregnant women. the apparatus enabling us to acquire the signals coming from fetal activity consists of ultrasonic sensors, a doppler module and a computer provided with a chart of acquisition of the signals. after suitable recording and signal processing, fetal heart rhythm (fhr) and the fetal breathing movements (fbm) are extracted. study of the doppler signals after fast fourier transform enables us to characterize the fetal movements in term of the amplitude, displacement and frequency. estimate of displacement is obtained by calculating the phase of the signal resulting from the analytical filtering of the doppler signal and to separate the direction from the doppler signals. results: twenty recordings were carried out on four women in their last quarter of pregnancy. during the last quarter of pregnancy, the fhr is approximately beats.min - . however, the fhr that we detected is about beats.min - . we are thus in the presence of the fetal heart rhythm. conclusion: this is the first time that parameters giving the fetal movements are extracted. as a first approach, the fft gives satisfactory results. assesment of skeletal age with hand and wrist sonography: could a standardised method replace radiography? s. megremis, g. cavallo, m. michalakou, e. kehagias, n. segkos, e. agianniotakis, e. sfakianaki; iraklion/gr purpose: to investigate the capability of hand and wrist sonography in skeletal age assessment, and to propose a technique that could be commonly used. materials and methods: forty-two children, aged months to years, underwent a left hand radiograph for skeletal evaluation. they were also sonographically examined on the same hand, with focus on distal epiphyses of radius and ulna, carpal ossification centers, adductor sesamoid bones of metacarpophalangeal joint of the wrist and the cartilage of the third's finger distal phalange. scanning and measurements were obtained in both transverse and longitudinal planes, and the images were digitally recorded for further evaluation. results: all areas of interest were identified both in the left hand radiograph as well as in the sonographic examination, for each individual. furthermore by dorsal and palmar scanning of the carpal ossification centers, accurate mapping and measurements were feasible. gaining experience, and developing a common procedure, we were able to progressively minimize most technical difficulties. conclusion: hand and wrist sonography promises an accurate, safe and cost effective assessment of skeletal age. detailed knowledge of hand and wrist anatomy, and familiarization with a standardized method, as the one we propose, in acquiring and interpreting images is indispensable. in addition, the designation of sonographic charts for the evaluation of skeletal age could be possible in the future. the role of hepatobiliary scintigraphy in the differential diagnosis of neonatal hepatitis, intrahepatic cholestasis, and biliary atresia e. palócz, t. györke, k. bártfai, l. balogh, l. szönyi, i. máttyus, É. kis, t. verebély, e.k. makó; budapest/hu purpose: biliary atresia (ba), intrahepatic cholestasis (ihc) and neonatal hepatitis (nh) are the main causes of neonatal direct hyperbilirubinaemia (ndh). the distinction of ba needing early surgical intervention from nh and ihc syndromes is essential, but difficult. the impact of hepatobiliary scintigraphy (hsc) in the differential diagnosis of ndh was evaluated. methods and materials: hscs of patients (age: days- months) with ndh were included in our retrospective study of a five years period. after administration of . mbq/kg (min.: mbq) mtc-brida serial abdominal images were performed up to hours. the scintigraphic diagnoses (sd) of ba, ihc, nh and indeterminate (ind) were defined based on visual scoring of liver uptake, intrahepatic radiopharmaceutical transport and bowel activity. sds were compared with clinical diagnoses (cd), which were based on laboratory, histological or operative findings and/or clinical follow-up. results: the cds were: ba, ihc, and nh. the sds were: ba, ihc, nh, ind were correct in and false in cases, while the cd in the ind cases was ba. regarding the shortage of bowel activity as a basis for sd of ba the sensitivity and specificity of hsc in the diagnosis of biliary atresia were and % respectively. conclusion: our results suggest that hepatobiliary scintigraphy is a useful tool in distinguishing ba requiring urgent surgical intervention from other kinds of pathologic conditions causing ndh, but that it is unreliable in further narrowing of the differential diagnosis. various radiologic findings of wilms' tumor y.-w. kim , w. kim , i.-o. kim , k. yeon ; busan/kr, seoul/kr purpose: wilms' tumor is the most common pediatric renal mass. although it usually manifests as a solid intrarenal mass with a pseudocapsule and distortion of the renal parenchyma and collecting system, some atypical radiologic findings may produce diagnostic confusion. the purpose of our exhibit is to illustrate various radiologic findings of wilms' tumor. we retrospectively reviewed radiologic findings of cases, which were pathologically proven from to (the age of patients; between months and years). results: this exhibit includes: ) typical intrarenal wilms' tumor (n = ), ) wilms' tumor with vascular invasion (n = ; renal vein , ivc , right atrium ), ) wilms' tumor with perirenal extension (n = ; psoas & ln , perirenal hematoma , subcapsular hematoma ), ) wilms' tumor with extension into the urinary tract (n = ; renal pelvis , ureter & bladder ), ) wilms' tumor with metastasis (n = ; lung , bone , pleura , mediastinum , scrotum ), ) bilateral wilms' tumor (n = ), ) wilms' tumor in a horseshoe kidney (n = ), ) atypical wilms' tumor (teratoid wilms'; n = , cystic wilms'; n = , extrarenal wilms'; n = , intrapelvic wilms'; n = ). the knowledge of these various radiologic findings of wilms' tumor can be helpful in the diagnosis and management of the tumor. extracorporeal shock wave lithotripsy monotherapy for pediatric urinary tract calculi z. siric, a. slavkovic, m. radovanovic, m. mrvic; nis/yu purpose: to show the safety and efficacy of extracorporeal shock wave lithotripsy (eswl) for the urolithiasis in the pediatric age group and to evaluate the complications encountered after the treatment. material and methods: children (age range months to years) with stones underwent eswl. kub were taken on the day after treatment. if stonefree status was achieved, the patient was followed with ultrasonography and urinalysis every six months. if fragments < mm were present, follow-up was repeated every months. results: stone size ranged from . to . cm. kidneys, ureters and bladers underwent eswl sessions. retreatment was required in % patients. the mean number of sessions per child was . . mean fluoroscopy time per session was . min. the overall success rate was %, but the stone -free status was achieved in % of children. the composition of the stones were struvite and calcium oxalate in the majority of the patients. auxiliary procedures (jj stents) were used in % children. transient hematuria, ecchymoses and colic p p p p pedia edia edia edia ediatric tric tric tric tric were the complications encountered after treatment in % of children. perirenal haematoma was identified in one patient. ( %) children developed obstruction and required nephrostomy. conclusions: eswl is non-invasive procedure suitable for stones in all locations in the pediatric patients. it may be the first-line treatment for all pediatric urinary tract calculi, although the long-term effects of lithotripsy on the kidney are unknown. imaging to meckel's diverticulum (n: ), small bowel tumour (n: ), duplication enteric cyst (n: ), postoperative (n: ) and bowel wall hemorrhage (as in henoch-schonlein purpura (n: ). the enema failed to reduce the intussusception in all cases. all children underwent definitive surgery rather than inappropriate treatment by attempted radiological reduction. conclusion: abdominal sonography is the most efficient examination for the diagnosis of intestinal intussusception. various pathological lead points in intussusception can now be defined by ultrasound. secondary intussusception treatment is surgical. diagnostic value of diffusion weighted mr imaging in pediatric cerebral neurological diseases y. oksuzler, h. cakmakci, s. kurul, m. oksuzler, e. dirik; izmir/tr purpose: to detect the diagnostic value of diffusion weighted (dw) magnetic resonance (mr) imaging in different diseases involving the cerebral white and gray matter and to compare the diffusion properties with age matched normal children. conventional and dw mr imaging was performed in children with neurologic disorders, and normal control subjects. neurological disorders included neurodegenerative brain diseases (n: ), anoxic encephalopathy (n: ), acute disseminated encephalomyelitis (adem) (n: ), encephalitis (n: ), subacute sclerosing panencephalitis (sspe)(n: ). apparent diffusion coefficients (adc) were measured from the brain lesions and normal appearing white and gray matter areas in study group. normal appearing areas were also measured in the control group. results: adc values obtained from the normal subjects were similar to values described in the literature. adc values of study groups were significantly different from the control subjects. adc values for the neurodegenerative disease group, anoxic encephalopathy group, adem group, encephalitis, sspe group, were respectively between . x - - . x - cm /s, . x - - . x - cm /s, . x - - . x - cm /s, . x - - . x - , . x - - . x - cm /s. conclusion: although this study is limited due to population size and disease heterogeneity dw mri provides useful and complementary information regarding the degree of involvement in different pediatric neurological disorders. clinical presentation and mri findings in non-accidental trauma in children under two years of age p.c. sundgren , m. petrou , j. jennings , j. ksar , j. smythe , b. foerster , p. maly , p. eldevik ; ann arbor, mi/us, lund/se purpose: to describe the clinical presentation and illustrate the mri findings in suspected non-accidental brain trauma in children under two years of age. we reviewed the hospital charts and the mr reports of patients examined due to clinical suspicion of non-accidental brain trauma. we noted the clinical presentation and the mri findings in each case. both the radiological diagnoses and the final diagnoses were extracted and compared, and the impact of the mri examination on the clinical course of the patient was evaluated. results: subdural hematoma was the most common finding seen in of the patients, petechial hemorrhages and brain edema was other common findings in these patients. discussion/conclusion: non-accidental brain trauma is not uncommon and in most cases ct of the brain is the method of evaluation. mri is only performed in a limited number of cases, for example, when dating the abnormalities is crucial, and to evaluate for additional findings of axonal shearing injury. examples of this will be illustrated. congenital hip dysplasia: mri after reduction of the femoral head e. svedström; turku/fi purpose: in the treatment of developmental dysplasia of the hip, maintenance of the correct position of the reduced femoral head is very important. many modalities such as conventional x-ray images, tomography, ct and us have been used in the evaluation of the femoral head position after reduction. these techniques either use ionizating radiation or require an experienced examiner. they might even be subject to technical limitations or sometimes be inaccurate. this poster describes the use of mri in the assessment of femoral head position after closed or open reduction. mri studies with an open-configured . t mr-imager were performed on four children. some of these children ( - months of age) were studied multiple times during the follow-up. no sedation was used. coronal and axial sequences were used. position of the femoral head, appearance of the limbus and formation of the pseudoacetabulum were noted. results: all mri studies were successfully performed without any sedation. the plaster did not reduce image quality in any of the studied hips. in four still-dislocated hips mri showed correct diagnosis. in two of these hips an inverted limbus could correctly demonstrated. conclusions: accurate diagnosis is very important after reduction of the femoral head. these children commonly require multiple imaging studies during followup. therefore, mri and us, which do not use ionizating radiation, are the preferred modalities. after reduction, mri findings are easily reproduced and are accurate. even other findings like inverted limbus in interposition and formation of pseudoacetabulum can be demonstrated. b d e f a g practical experience with the application of the "digital addendum of the european protocol for quality assurance in mammography" h. bosmans , f. rogge , a.-k. carton , k. young , r. van engen , m. thijssen , g. marchal ; leuven/be, guildford/uk, nijmegen/nl learning objectives: to teach different aspects of the digital addendum (da) to the european protocol for quality control in mammography: • the purpose of the tests as described in the document. • the test methods. • the applicability of the test methods and the discussion of the first measurement results. background: digital mammography is a new imaging modality for mammographic applications. in order to assure sufficiently high quality standards, new test protocols had to be developed. a group of european medical physicists has cooperated under the coordination of the european breast cancer network and euref. the first publication is expected for october . the (pre-released) version (aug. ), work in progress, has been evaluated on different full field digital mammography (ffdm) systems and is the basis of the present teaching session. procedure details: following systems were included: senographe d (ge), senoscan (fischer), ma (fuji), ac (fuji), embrace cr (agfa) and embrace dr (agfa). the tests as described in the protocol included direct performance tests, contrast detail analysis, patient dose measurements and physical measurements such as mtf and dqe. for these last measurements, acceptable and achievable levels have not yet been defined. the help of a service engineer was necessary in most systems to get access to raw data. the tests as proposed in the protocol could then be performed. contrast detail analysis is the most critical part and should be automated to reduce interobserver variability. patient doses were comparable or lower than doses in conventional mammography. the acquisition of mtf and dqe requires a further standardization of the method. the digital addendum in its current phase was applicable to all systems tested so far. practical experience is growing and will add to the applicability and value of the document. anisotropic resolution in helical cone-beam ct reconstruction d. heuscher , s. utrup , f. noo ; highland heights, oh/us, salt lake city, ut/us learning objectives: to describe how the different aspects of helical cone-beam reconstruction affect spatial resolution in all three dimensions. to demonstrate that depending on the radial and angular position of a voxel, this resolution can be anisotropic. to describe appropriate filtering and interpolation steps that can be taken to reduce these effects. background: a number of methods have been described recently that provide either exact or near-exact reconstructions of helical cone-beam scan data. in this exhibit, we will describe key aspects of the implementation of these reconstruction algorithms that affect spatial resolution. we will show how the anisotropy of in-plane resolution can be related to the corresponding effect in single-slice d reconstructions. alternative filtering and interpolation steps will be suggested. procedure details: fwhm slice-sensitivity profile and in-plane resolution measurements were performed on helical reconstructions of a phantom consisting of seventeen . mm diameter spherical beads located at , , and mm radii. the scans used an mx -idt x . mm detector configuration with a . pitch factor. single-slice d reconstructions were performed on the same phantom using both fan and parallel convolution-backprojection algorithms to produce comparative in-plane measurements. alternative hi-order interpolation and voxel-dependent filters were investigated to produce nearly isotropic resolution. conclusion: significant spatial variation in resolution can be observed in exact or near-exact helical cone-beam reconstructions. a more uniform and isotropic result can be achieved by using hi-order interpolation to produce parallel projection data along with longitudinal voxel-dependent filtering. comparison in pet/ct studies iv contrast agents increased the suv of the mediastinum to . ( . ) and the liver to . ( . ). these increases in suv were coincident with changes in ct density from hu to hu (mediastinum) and from hu to hu (liver). suv values in the colon wall seem unaffected by positive oral contrast compared to pet: . ( . ) vs . ( . ). conclusions: physiologic suv from pet/ct appear somewhat higher than suv from standard pet when the ct is acquired with standard volumes of iv contrast media. adventures in non medical radiography a.a. alhajeri, d. mckenna, b. tuohy, c. roche, p. mccarthy; galway/ie learning objectives: to demonstrate the non-radiological use of familiar imaging modalities and show how far we have come since the first x-rays of mrs. roentgen's hand. background: today, x-rays technology has a wide application and is presently in use in fields as diverse as engineering, art, forensic pathology and security. procedure details: through a pictorial review we show how x-rays have a role in non-medical applications. we demonstrate how law enforcement agencies have adapted x-ray technology to screen luggage at airports, sometimes even using ct. furthermore newer technology in use in europe has been developed, termed "back scatter", which makes possible the detection of illegal immigrants and contraband material concealed within trucks. the characterisation of the bony skeleton with the aid of x-rays is not only helpful in identification but sometimes can also indicate to the forensic pathologist the mode of death. industrial engineers are able to evaluate the integrity of a structure with the aid of x-rays. examples include the examination of airplane engines and pipes for hairline fractures, unidentifiable to the unaided eye. in the art world, x-rays have been used to detect forgeries and even to create original art works. conclusions: this poster reaffirms the benefits of different imaging modalities showing how technology developed for medical imaging has been adapted for use in non-medical areas. radiation-induced temporary hair loss after cerebral perfusion studies with multi-detector ct y. imanishi, a. fukui, h. niimi, s. nakaji, k. nozaki, y. furuya, m. uzura, s. hashizume, y. nakajima; kawasaki/jp learning objectives: learning presence of complications by a cumulative or multiplier effect of radiation exposure from multiple diagnostic techniques. background: as various imaging technologies become increasingly advanced, they make it possible to get various kinds of information and large amount of imaging data. in some imaging technologies, the radiation dose increases with the ability to obtain better images or more detailed information. imaging findings: we encountered cases of temporary bandage-shaped hair loss, which was caused by perfusion studies of the head by multi-detector computed tomography (mdct) for evaluation of blood flow in the brain. in all of the , digital subtraction angiography of the head was performed within a period of the ct perfusion studies. this suggested the possibility that radiation exposure from angiography performed in serial examinations, combined with the perfusion studies effectiveness of a new dual-energy subtraction system using csi:tl amorphous silicon flat-panel technology h. tagashira, n. bandai, m. yoshimoto, y. yasuhara; ehime/jp learning objectives: to describe the theory of the new dual-energy subtraction system. to demonstrate the system with chest radiology cases. background: lung cancer is the current leading cause of cancer death and continues to be increasing. chest radiography has been shown to have relatively low sensitivity and specificity for the detection of the pulmonary nodules. this new dual-energy subtraction system allows the fast ( millisecond) acquisition of two, high and low voltage images and provides soft tissue and bone structure image of the chest with relatively low dose. procedure details: the radiologists' performance for reporting chest radiographs was evaluated by use of receiver operating characteristic (roc) analysis. the performance of radiologists was improved significantly when the dual-energy subtraction image was used (p < . ). conclusion: diagnostic accuracy will be improved by using this dual-energy subtraction system. longitudinal filters for uniform cone-beam resolution d. heuscher, s. utrup; highland heights, oh/us purpose: this presentation demonstrates the non-uniform longitudinal resolution inherent in today's cone-beam reconstructions and how, through the appropriate use of longitudinal filtering, improvements in image quality can be achieved. simulations and scans for acquisition geometries of or more detector rows were evaluated. a circular half-scan (hs) and a helical scan (pitch factor . ) were performed on an mx idt using a x. mm detector configuration. a phantom consisting of steel beads was used to measure longitudinal resolution at angles and radii. simulations were performed using the same phantom geometry, including a x. mm helical scan. a voxel-dependent filter was used to achieve uniform longitudinal resolution and compared to projectionbased filtering. both real and simulated thorax phantoms were used to evaluate the effects on image quality. results: resolution measurements demonstrate an angular variation in longitudinal resolution for large-pitch helical and circular hs cone-beam scans. the fwhm ssp measurements varied by over % and % at and mm radii respectively. reconstructions with projection-based filters did not reduce this variation. similar results were observed for helical scans with the larger cone angle ( x . mm detectors), wherein the resolution pattern varied at half the frequency along the longitudinal direction. applying voxel-dependent longitudinal filtration achieved uniform resolution, demonstrating improved image quality in both real and simulated scans. conclusion: there is an inherent non-uniformity of longitudinal resolution for cone-beam scans, particularly for large-pitch helical and circular half-scans. uniform resolution can be achieved using voxel-dependent filters. potential of phase contrast in x-ray imaging p. monnin , r. meuli , j. hoszowska , j.-f. valley , f.r. verdun ; lausanne/ch, grenoble/fr purpose: one of the limitations of conventional radiology is that small or weakly absorbing structures cannot be detected on images. coherent properties of an x-ray beam produce phase contrast images where a change of the refraction index of tissues translates into an edge enhancement phenomena on the images that allows the detection of weakly contrasted structures. this study shows the feasibility of implementing the in-line holography principle with an aim to imaging very small structures. material and methods: phase-contrast images were obtained using synchrotron radiations at esrf (grenoble, france). images of to micrometer nylon wires, immersed in different media, were recorded with a ccd camera ( . micrometers pixel size) in different imaging conditions. images were compared with the results obtained by means of fresnel diffraction theory. the coherent x-ray beam and the defocusing distance between the structures to be imaged and the detector produced phase contrast images of the wires. the comparison of the recorded images with the predicted image formation from the fresnel diffraction theory revealed the performance of this technique in terms of sensitivity, geometrical and energy requirements. images of a biological sample (i.e. pork kidney, cam's) were also produced where very fine low contrast structures, unnoticed in pure absorption contrast, appeared. the potential of the technique in neo-vascular process imaging will also be discussed. the potential of in-line holography techniques to improve image contrast of biological tissues has been demonstrated. experimental the aim of the present study was to evaluate y al o :ce (yag:ce) phosphor for radiographic and mammographic imaging. yag:ce, which has never been previously used in diagnostic radiology, emits green light with very short decay time ( ns). it is expected to match the spectral sensitivities of most photodetectors. radiographic test screens of various coating thickness ( - mg/cm ) were prepared in laboratory employing yag:ce phosphor in powder form with . µm median grain size. luminescence emission efficiency (emitted light over x-ray exposure) and light emission spectrum were experimentally evaluated as a function of x-ray tube voltage employing both tungsten and molybdenum target x-ray tubes. in addition, the spectral compatibility of yag:ce emission spectrum with orthochromatic films, photocathodes, ccd arrays and amorphous silicon photodiodes, used in both conventional and digital radiography, was determined. results were compared with other phosphor materials (gd -o- s:tb, csi:tl) currently employed in medical imaging. results: maximum yag:ce emission efficiency was observed for mg/cm screen at - kv using tungsten target x-ray tube. emission spectra peaked at nm. the spectral compatibility with amorphous silicon photodiodes ( . ) and ccds ( . ) was found to be very high, better than the corresponding compatibility of csi:tl, as mostly used in digital radiography detectors currently. conclusion: considering the yag:ce performance, its short emission decay time and its spectral compatibility with amorphous silicon detectors and ccds, this phosphor material is appropriate for use with digital radiography detectors. b d e f a g reduction of eddy current artifacts in echo planar diffusion tensor imaging with a stimulated echo preparation g. steidle, f. schick; tübingen/de purpose: diffusion-tensor-imaging (dti) using se-epi in tissue with short t values, such as kidney or skeletal muscle, suffers from a poor snr for higher bvalues. using a stimulated-echo diffusion preparation, sufficiently high b-values can be obtained by increasing the mixing time (tm) rather than te. a diffusionweighted stimulated-echo epi sequence is proposed which minimizes the influence of eddy currents (ec) without any increase in the minimum te or acquisition time. methods and materials: assuming a monoexponential decay for the ec with time constant λ, gradient pulses can be implemented within the tm interval such that eddy current effects proportional to exp (-λ x t) will vanish. in-vivo dti measurements were performed in human calf musculature on a . t siemens sonata unit. measurement parameters were te = ms, tm = ms, tr = ms, b = resp. s/mm , matrix x , fov mm, nex = , slice thickness mm. diffusion weighting was applied in six directions in order to calculate the diffusion tensor. results: diffusion images were acquired with and without ec correction. images without ec correction showed obvious scaling and shearing distorsions whereas in images obtained with ec correction no significant distorsions were observed. conclusion: diffusion-weighted mr imaging using epi is very sensitive to image distorsions caused by eddy currents. inserting additional gradient waveforms in a stimulated-echo epi sequence drastically reduces these artifacts and allows a calculation of the diffusion tensor in various tissues with low t /t ratios without significant misregistration. rf-induced artifacts due to aneurysm clips in mrt at . t u.a. lauer, h. graf, f. schick, c.d. claussen; tübingen/de purpose: metallic implants such as aneurysm clips may cause enlarged artifacts at higher magnetic field strengths, not only due to susceptibility effects. aneurysm clips made of ti-alloy were investigated with special respect to mr-imaging results and possible rf-induced artifacts. materials and methods: aneurysm clips were measured in gd-dtpa doped water at . t and . t with adapted se-sequences. additionally, two models made of copper were investigated at . t. to separate rf induced effects, the transmitter voltage was bisected stepwise to verify the rf-induced deviation of the local flip angle near to the implant. this was also done with d-tse sequences. results: in comparison to . t, more pronounced hyperintense zones were found at . t. they were independent of the exchange of phase-and frequency-encoding direction (swap) and became more pronounced at reduced transmitter voltage. comparative investigation of two cu-models and one selected ti clip at reduced transmitter voltage revealed rf induced effects depending on inductive and capacitive structures of the clip. conclusion: metallic implants have to be considered carefully at . t due to the electrical conductivity. rf-induced artifacts can appear not only for longish objects but also on smaller devices. in the case of aneurysm clips, a slight rfinduced effect could be detected. potential patient endangering due to a local enhancement of the secific absorption rate (sar) can be estimated as negligible. optimum is currently recommended as a consistent image display function. however, while the cielab function is still in use in europe, comparative evaluation of these two functions for optimum display function has not yet been reported. the purpose of the present study was to identify which of gsdf and cielab is the optimum display function for thoracic ct imaging by means of visual contrast analysis (vci), i.e. the ratio of luminance contrast to ct value contrast. methods and materials: monochromatic m lcd monitor and photometer of luminance calibration tool kit (data ray corp, westminster, usa) were used. the luminance contrast of this monitor was measured by a photometer displaying gsdf and cielab. luminance change and digital driving level (ddl) that corresponded to ct value (hu) were tabulated. ct value was represented by window setting of thoracic ct imaging, i.e. for mediastinum (ww: ~ , wl: ) and lung (ww: ~ , wl:- ) using gsdf and cielab. the ratio of luminance contrast to ct value contrast was calculated as visual contrast index (vci). the vci of gsdf and cielab was evaluated using t-test. result: using t-test, vic of cielab was significantly higher than that of gsdf in window setting of thoracic ct imaging (p < . ). based on visual contrast index analysis, cielab was more useful than gsdf as a monitor display function of thoracic ct imaging. we suggest that cielab is the optimum monitor display function of thoracic ct imaging because it intrinsically has excellent luminance contrast characteristics. follow-up of patients subjected to high skin radiation dose as a consequence of repeated interventional cardiology procedures r. padovani, g. bernardi, e. quai, m. signor, h. toh; udine/it purpose: as part of a quality assurance program, to retrospectively evaluate cumulative skin dose (csd) received by patients subjected to repeated interventional coronary procedures and to detect radiation induced skin injuries in patients who have received the highest dose. materials and methods: from april to february , cardiac procedures, coronary angiography (ca) and percutaneous transluminal coronary angioplasty (ptca) have been performed on patients. mean dap was . gycm . patients with a cumulative dose-area product (dap) higher than gycm have been extracted. they were patients ( . %), female and male, mean age years, who underwent a mean number of . procedures resulting in a mean cumulative dap of gycm and a maximum value of gycm . from dap, csd has been estimated adopting . and . - cm - as conversion factors for ca and ptca, respectively. clinical follow-up has been performed adopting the lent-soma methodology and scale. results: the highest csd estimated was . gy and only patients ( %) exceed a skin dose of gy. no skin injuries were detected at clinical follow-up. these results allow to estimate a frequency for skin injuries of less than . - in patients undergoing repeated cardiac procedures. the results of this study implies that the frequency of skin injuries may be very low when a quality assurance programme, including regular patient dose monitoring, periodic evaluation of procedure protocol, quality control of equipment and operator training, is established. ultrasound purpose: ultrasound is the most frequently used diagnostic imaging modality. the main problem of ultrasound, however, is interobserver variability. the intention of the development of ultrasound computer tomography was to increase the reliability of ultrasound imaging and to supply standardized images similar to other cross section imaging procedures. methods and materials: instead of a manually-controlled linear transducer array, we used ultrasound computer tomography (usct) to image a volume directly. a few thousand ultrasound transducers were arranged in a cylindrical array around a tank containing the object to be examined coupled by water. every single transducer was small enough to emit an almost spherical sound wave. while one transducer was transmitting all other transducers worked as receivers simultaneously. afterwards a different transducer emitted the next pulse. for volume reconstruction each transmitted, scattered and reflected signal was used. in an experimental set-up a phantom containing nylon filaments, straws, and a cadaveric forearm were investigated. results: nylon filaments with a diameter of . mm were visualized. the skin and soft tissue of the cadaveric forearm were clearly detectable but the bone structures could not be delineated sufficiently. usct supplied reproducible image sequences. conclusion: usct promises to supply standardized high quality three-dimensional images without ultrasound shadowing artifacts and without interobserver variability. furthermore, the tissue is not deformed, in principle offering multimodal image fusion with other cross section imaging modalities. prior to clinical set up extended development especially of large transducer element tubes and improvement of software is necessary. multicentre assessment of a complexity index for ptca procedure a. peterzol , e. quai , r. padovani , g. bernardi , j. kotre , a. dowling ; udine/it, newcastle/uk, dublin/ie purpose: multicentre assessment of a procedure-severity-based complexity index (ci) for the introduction of reference levels (rls) in percutaneous transluminal coronary angioplasties (ptca) as a function of procedure complexity. materials and methods: , and ptcas performed at three different centres were investigated. multiple linear stepwise regression analysis, including clinical, anatomic, and technical factors, was performed in order to obtain fluoroscopy time (ft) predictors. based on the regression coefficients of the emerging model a scoring system was defined, and a ci was obtained by adding up the single scores for each individual procedure. since a good correlation (r = . ; p < . ) was found between the dose-area product (dap) and the resulting ci, the latter was used to classify dose values into three groups. ci groups were determined by means of an anova test: different sets of groups were explored until the matrix of pairwise comparison probabilities reached a minimum value (p < . ). the resulting dap and ft third quartiles corresponding to each ci group are suggested as preliminary rls in ptca as a function of procedure complexity. results: ptca preliminary rls: (i) for dap values: , and gycm , and (ii) for ft: , and min, respectively for the three ci groups: low, medium and high complex procedures. the possibility to introduce rls as a function of procedure complexity, as confirmed by this multicentre study, can improve the process of patient dose optimisation in interventional cardiology. investigation of the radiation detection properties of lu sio :ce and gd o s scintillators for applications in medical imaging d. nikolopoulos, p. liaparinos, d. margetis, d. linardatos, p. mellisaropoulos, k. kourkoutas, g. panayiotakis, d. cavouras, i. kandarakis; athens/gr purpose: the aim of this study was to use monte marlo techniques to examine the detection efficiency of three ce-doped fast emitting scintillators, yap (yalo : ce), lso (lu sio :ce) and gos (gd o s:pr, ce, f) when used with photon energies and coating thicknesses employed in medical imaging. a general monte carlo code has been generated for tracking photons in the energy range covering all medical imaging applications (diagnostic radiology, nuclear medicine). simulated scintillator materials were selected to be in blocks and arrays of dimensions equal to those usually employed in medical imaging. the results for the yap scintillator, showed that the fraction of the incident photon energy which was totally absorbed decreases very rapidly for energies higher than kev (e.g. from % at kev to % at kev for . mm coating thickness). lso was better than yap, its absorption efficiency being significantly higher (p < . ) at - kev (mammography), - kev (x-ray imaging), kev (gamma ray imaging) and at kev (positron imaging). gos was also found to exhibit significant detection efficiency in the whole energy range examined (e.g. from % at kev to % at kev for . mm coating thickness), however its applications are limited due to its longer decay time. conclusion: lso was found to be of adequate efficiency for most imaging applications, while yap could be considered most suitable for x-ray mammography applications. analyses of physiological kinetic functions in dynamic chest radiography by the use of time series spectroscopy y. tsuchiya , y. kodera , m. tsuchiya , a. fukui , s. itou , y. machida ; shizuoka/jp, nagoya/jp purpose: the purpose of this study was to distinguish between movement of diaphragm and heart wall, and to evaluate the kinetic function of these structures in dynamic chest radiography with computer aided diagnoses. we obtained a dynamic chest radiograph of one healthy volunteer during respiration to assess the distinction between structures and another radiograph of a patient during a left ventriculogram to evaluate heartbeat calculation using an image intensifier system. we performed fft and band pass filter processing to obtain an intensity curve of the spectrum of dynamic chest radiography and detected the "change-point" of the phase by using characteristic analysis. fifty-five kinds of band pass filters were used to compare "detection rate of change-point", "matching rate of heartbeat" and "heartbeat error". results: movement of diaphragm and heart wall could be extracted selectively by the use of an extreme low pass filter ( . ~ . cycle/mm) and middle frequency pass filter ( . ~ . cycle/mm). we obtained % of matching rate, when detection rate was % with these two kinds of filters. there was correlation significantly between them (r = . , p < . ). improvement of detection rate decreased heartbeat error. but there was no significant difference between them by the non-repeated measures anova (p = . ). conclusion: our method was effective in analysing the dynamic chest radiograph in order to evaluate precise kinetic function, when suitable filters were used. therefore it is expected to apply for computer-aided diagnoses. reduction of ionising radiation exposure in patients as a consequence of new imaging technology for medical diagnostics of the spine: a retrospective study covering years in a norwegian referral hospital a. nyquist , h. olerud , b. bjørnarå , l. borgen , t. gudmundsen ; drammen/no, oslo/no purpose: to examine possible changes in ionising radiation doses to patients (collective effective dose) undergoing diagnostic imaging procedures for spinal problems over the last years in view of the shift in modalities from conventional x-ray examination and myelography to computed tomography (ct) and later on to magnetic resonance imaging (mri). retrospective study of all patient files for the period from to . the main modality groups for each of the three parts of the spine (cervical, thoracal, lumbar) were: conventional radiographs, myelography, ct, and mri. for each type of examination the mean effective radiation dose were obtained from the norwegian radiation protection authority (nrpa) as published in . the number of conventional x-ray examinations performed was nearly unchanged. use of myelography reduced by %, %, and % for the cervical, thoracal and lumbar regions, respectively. ct usage increased steadily, remained nearly unchanged, and was reduced by nearly % for the cervical, thoracal, and lumbar regions, respectively. the annual collective effective dose from examinations the spine was reduced by % in our hospital from . mansv in to . mansv in . the shift in modalities from conventional x-ray and myelography to ct and mri resulted in a significant reduction in patient exposure to ionising radiation. the results may be explained by our intended policy to select mri insted of ct whenever possible, and is an overture to the discussion of the further development and structure of diagnostic imaging in general, and for the spine in particular. dose evaluation for clinical proton beam with standard dosimetry h. ohtani , t. hiraoka , h. saitoh , t. irifune , t. katoh ; tokyo/jp, chiba/jp purpose: the standard dosimetry was revised on august in japan; it had calling standard dosimetry of absorbed dose in external beam radiotherapy (standard dosimetry ). the purpose of standard dosimetry are the establishment of traceability for dose of radiotherapy and quality assurance / quality control, according as we measure the dose of high-energy radiation using the standardized international method. we explained the dosimetry of absorbed dose with the standard dosimetry for proton beams and the depth dose was measured with the reference ionization chamber and the parallel plate ionization chamber. the maximum energy of the proton beam used in this study was mev. electric separation induced radicals were calibrated for squarer field of × cm with some ionization chambers. the absorbed dose to water calibration factor is obtained by the reference ionization chamber calibrated co gamma rays. the remainder range in water calibrated the beam quality conversion factor for proton beam. using these coefficients, the absorbed dose was calibrated. the absorbed dose used the parallel plate ionization chamber was relatively decided by the results for the reference ionization chamber. conclusion: the absorbed dose for proton beam was calibrated at each depth. dosimetry in water was recommended on the standard dosimetry . however, it is difficult that we have the waterproof dosimeter. we suggested that the method and problem for proton dosimetry using the standard dosimetry . b d e f a g kinetic analysis of the temporomandibular joint with computer-aided detection system n. bandai , s. sanada , k. ueki , s. funabasama , s. tsuduki , y. otani , t. matsui ; onsen-gun/jp, kanazawa/jp, otsu/jp purpose: the purpose of this study was to develop a method of kinetic radiography and a computer-aided detection (cad) system for quantitative evaluation of the temporomandibular joint (tmj). methods and materials: dynamic images of the tmj were obtained from one healthy volunteer by digital fluoroscopy in the lateral view on the right and left sides. the accumulated image subtraction technique extracted the condyle in each image. a sequential similarity detection algorithm (ssda) was employed to trace the movement path and the velocity of the condyle. results: there were no significant differences between by manual and computer analysis. the shape of the path of the right condyle was smoother than that of the left condyle. the size of the maximum vertical and horizontal movements of the condyle were . ± . mm and . ± . mm, respectively. the velocity of the movement of the condyle was higher in the area close to the articular eminence than in any other area during the opening and closing of the mouth. conclusion: our cad system will contribute to the kinetic analysis of the tmj for screening, follow-up study, and informed consent, providing speed, quantitation, and cost-effectiveness. assessment of fetal dose in x-ray examinations of pregnant patients a.j. servomaa , a. kettunen ; helsinki/fi, oulu/fi purpose: when a pregnant woman undergoes examination of the lower abdomen or pelvic area, the fetus is directly irradiated. determination of the absorbed dose to the fetus is therefore of interest as a basis for risk estimates. in finland, the practice with regard to both estimation of the dose to the fetus and recording of the examination in patient records varies considerably. the fetal dose calculated by means of various dose calculation methods are compared and the results presented. methods and materials: using the "fetdose" and "pcxmc" programs, the normalized fetal dose was calculated for abdominal and pelvic examinations of various radiation qualities, esd and conceptus depths. the doses obtained were compared against those reported in the literature. the calculated nuds (normalized uterus doses) obtained for various parameters by means of various calculation methods agree, with reasonable accuracy. the nud occurring in a pelvic ap examination ( kv, mmal filtration, fsd cm) is about . for a gestational age of - weeks and for a fetal depth of cm. the dose to the ovaries differs slightly from the dose occurring to the uterus during the same examination. detailed data about the nuds in various common radiography examinations are presented. the results of calculations obtained with different programs show the same nud with reasonable accuracy. normalized fetal doses and radiation risks corresponding to the european esd recommendations in conventional radiography examinations may help the radiological staff to assess the significance of the exposure to the fetus. withdrawn by authors quality advances via noise reduction in laser imaging t.r. lindquist; oakdale, mn/us purpose: noise sources in medical imaging and printing can limit diagnostic accuracy but are often not assessed quantitatively. a method is described for objectively quantifying noise by means of a film digitizer and analysis software. a second method, based on human perception of simulated nodules on films with varying amounts of noise, is also described. in the first method, a film digitizer scans a print of a constant gray level image. the scanned digital image file is then processed by software that: ( ) extracts and averages density data from narrow horizontal and vertical strips, and ( ) performs one-dimensional fast fourier transform (fft) processing to yield a noise power spectrum (nps) for each horizontal or vertical strip. in the second method, a computer program is used to synthesize a test image with very low contrast dots ("nodules") superimposed on a gradually changing background. in timed experiments, prints of these images are placed on a light box, and an observer is asked to mark the locations where the dots are believed to be present, after which the true and false positives are counted. results: prints were made on a variety of medical imagers, using film with a variety of quality levels. prints made with the latest laser imager and film yielded lower measured noise and higher perception scores than prints made with prior technology. conclusion: measurable progress has been made in reducing the noise level of medical imaging printers. this is further demonstrated by improved perception of subtle details. estimation of maximum skin dose and average lung dose in coronary angiography procedures a. karambatsakidou, p. tornvall, n. saleh, p.-o. löfberg, a. fransson; stockholm/se purpose: a comparison of phantom and patient based techniques to estimate the maximum skin dose (mesd) and average lung dose from coronary angiography procedure is described. conversion factors for the dose to the skin and lung, normalized to the dose-area-product (dap), have previously been obtained from measurements using an alderson phantom. in this study, measurements on patients using slow radiographic film and diodes were used in combination with the software winods to evaluate the impact of different operators, and of variations in patient size, on these factors. the transmission ion chamber integrated into the angiographic unit was used to measure dap. the conversion factor for mesd from the phantom simulation was reported as . msv/gycm . the corresponding value for measurements on patients in this study was . ± . msv/gycm ( sd; patients). no significant difference in conversion factor between the operators was found. the lung dose varied with the body mass index (bmi). in slightly overweight patients (bmi: - ), the lung dose was about % lower than in normal sized patients (bmi: - ) for the same dap-value, while for overweight patients (bmi > ) this difference increased to %. conclusion: measurements on phantoms and on patients yield similar conversion factors for mesd in coronary angiography procedures. the bmi-value seems to be a robust indicator of the variation in dose to internal organs from such procedures. with film/diode measurements, the differences in techniques (geometry; projections) between operators can be easily verified, and as such be integrated into the training of new angiography operators. radiation doses in a newly installed flat-panel digital system in interventional cardiology department v. tsapaki, s. kottou, n. kollaros, p. dafnomili, v. neofotistou; athens/gr purpose:the purpose of the study was to investigate the radiation doses of the newly installed flat-panel fluoroscopy (fpf) system in an interventional cardiology (ic) department and to examine possible methods of technique optimization regarding the new digital system. materials and methods: fifty coronary angiographies (cas) and percutaneous transluminal coronary angioplasties (ptcas) were investigated. patient data were: sex, age, weight, height, dose area product (dap), fluoroscopy time (t) and total number of frames (f). further more, dose rates in all fluoroscopic and cine modes were measured. image quality was assessed using a dedicated test tool. results: median values of dap, t and f were: . gycm , . min and in ca and . gycm , . min, in ptca. our results are comparable with those found in the recent literature. regarding the technical characteristics of the digital system, the high contrast resolution (hcr) is not affected by fluoroscopic mode, whereas low contrast resolution (lcr) is slightly decreased in the lowest mode. the results of the study concerning the fpf system lead to the conclusion that the lowest fluoroscopic mode and the lowest frame rate should be used routinely for dose optimization and that the new digital technology has comparable radiation dose to the conventional technology. purpose: an earlier study using the mte scanner enabled us to register in vivo wave-like activity of the skin electrical landscape (sel), which is supposedly macroscopic manifestation of intercellular communication. the present study of the chaotic sel activity was done to try to find out distinctive dynamic features between melanoma and adjacent tissues. methods and materials: mte is a new functional, non-invasive digital imaging modality, which enables dynamic visualization of the skin and underlying tissues in terms of spectral electroimpedance and electropotential parameters, with high spatial and temporal resolution (~ . mm). non-thermal mm-emf ( min) and weak mf (< . t) were used as test influences. initial and induced sel dynamics have been graphically and statistically analyzed. specifically, the throughimage-sequence analysis resulted in detailed dispersion maps of the scan-area. the sels of (i) healthy and allergic subjects, and (ii) those with cutaneous melanoma were investigated. results: primary melanoma manifested not only as a sharp electro-abnormality, but also as a distinctly stable/hyposensitive zone (sigma = . - . %) in all measurement parameters.this hyposensitive zone(s) was surrounded by islet areas of marked hypersensitivity (sigma is up to %). dispersion range of the more distant environment had intermediate values. in cases of allergy, strongly pronounced dependence of the mm-emf response upon time of investigation was observed at the same subject, i.e.: from sharply marked reactions at the stage of sensitization to practically indistinguishable ones during remission. in healthy subjects, in most cases, significant trigger reversible changes of histograms were registered in response to both tests. intracranial elastance analysis using mri in normal-pressure hydrocephalus t. miyati , m. mase , m. onoguchi , h. kasai , m. hara , k. yamada , y. shibamoto , s. matsunaga , t. kasuga ; kanazawa/jp, nagoya/jp purpose: in order to assess the state and dynamics of the intracranial system in normal-pressure hydrocephalus (nph), intracranial elastance (ice) was measured with magnetic resonance imaging (mri). the ice index, which is the ratio of pressure to volume change, was obtained with alperin's method; intracranial volume and pressure changes during the cardiac cycle were calculated from the net transcranial blood and cerebrospinal fluid (csf) flow measured with phase-contrast (pc) cine mri. ice indices were determined in patients (n = ) with nph, brain atrophy or asymptomatic ventricular dilation (vd), and in healthy volunteers (control group; n = ). concurrently, a time constant of the integral of the csf response function, which represents the intracranial mechanical property was determined with pc cine mri. the changes in ice indices were also analyzed after intravenous injection of acetazolamide. these values were then compared with the volume-pressure response (vpr) during the shunt operations. results: the ice index in the nph group was significantly higher than in the control or vd group, but no difference was found between the control and vd groups. the ice index increased in all groups after an acetazolamide injection because of an increase in cerebral blood volume. there were significant correlations between the ice index and the time constant. a positive correlation was noted between the ice index and the vpr. conclusion: ice analysis measured by pc cine mri makes it possible to noninvasively obtain a detailed assessment of intracranial state and dynamics in the nph and to assist in diagnosis of the nph. quantification of magnetization transfer by sampling the transient signal using mt-prepared single-shot epi g. helms , g.e. hagberg , c.d. claussen , f. schick ; tübingen/de, rome/it purpose: using trains of mt-pulse and epi readout, the transition to steady state can be measured with higher accuracy than the steady state. a novel quantification method based on sampling transitions at different repetition periods (pr) is introduced. gaussian mt-pulses of . ms duration and flip angle of degrees were repetitively applied at khz offset at pr = , , , , ms. an axial slice through the centrum semiovale of the brain was measured by single-shot se-epi ( ms te, mm thickness, cm fov, x matrix). in brain tissue, the signal dependence was described by analogy to progressive partial saturation, where the direct saturation is increased by pr-dependent mtcontribution proportional to macromolecular content and differential saturation. macromolecular content, kinetic and relaxation parameters and the saturation were estimated by a global non-linear least-square fit of the signal equation for rois in cortical grey matter (gm) and central white matter (wm). results: the macromolecular content was ( . ± . )% in wm and ( . ± . )% in gm, the apparent relaxation rates ( . ± . ) /s and ( . ± . ) /s. the apparent transfer rates were ( . ± . ) /s and ( . ± . ) /s. macromolecular saturation of a single mt-pulse was ( . ± . )% in wm and ( . ± . ) in gm; the direct effect on water less than %. signal correction for csf contributions was necessary. conclusion: quantitative mt-mapping of the whole brain may become feasible in vivo at higher field strengths by means of permutation of the slice order. b d e f a g the concept of radiography in health sciences: a concept analysis s. sorppanen , a. servomaa ; oulu/fi, helsinki/fi learning objectives: to clarify the content and uses of the concept of radiography in health sciences and to compare it to the concept of radiography in physics and technology. background: in the field of radiography, theoretical research related to concepts has so far being rare. nevertheless, the concept development is an important part in constructing theories and clarifying the identity of a discipline. in finland, the discipline of radiography started in at the university of oulu, and since then it has offered radiographers academic education in their own field. for being able to build its own knowledge base and theories to be used in developing the profession and education of radiographer, and for being able to stand for its position as an independent academic discipline, the young discipline of radiography needs systematic conceptual clarification and development. procedure details: the concept of radiography was analysed using so-called evolutionary method of concept analysis (presented by rodgers). the contents and uses of the concept were studied by determining the concept's characteristics and by observing these characteristics in the cross-disciplinary comparison. the data consisted of literature and internet pages, and were analysed using deductive-inductive content analysis. conclusion: the concept of "radiography" in health sciences can be determined as "dual, dynamic, social and situation-related expertise of radiographers in the use of radiation, which is based on a versatile synthesis". it seems to be wide and complex in nature, and radiographer-centered. the content and the use of the concept varies according to the discipline. measurement of distribution of horizontal dose amount to chest x-ray by gafchromic film k. nishikiori , m. miyazawa , a. otonashi ; habikino/jp, itabashiku/jp, suita/jp learning objectives: to illustrate horizontal dose distributions of human diagnostic level in the chest phantom by gafchromic film and glass dosimeters. to point out the characteristics of horizontal dose distributions by materials in ten shots and in fluoroscopy. background: in general, we use an ionization chamber dosimeter or tld to measure dose distribution of diagnostic level. however tld can not indicate horizontal and consecutive dose distributions, because it has only scattered dose data. consequently, we used gafchromic film to obtain a horizontal consecutive dose distribution of human diagnostic level. imaging findings: . first, we placed a gafchromic film and glass dosimeters in the specific place of the chest phantom. then we irradiated the chest phantom with diagnostic level x-rays. the dose distribution which was acquired by the film and glass dosimeters was then analyzed. . next, we examined the result of fluoroscopy. . the results of the first method were compared with the result of the fluoroscopy and the difference between the distributions in (gafchromic film and glass dosimeters) and (fluoroscopy) examined. the characteristic dose distributions of the incidence dose in diagnostic level were confirmed by both horizontal dose distributions. . horizontal dose distribution which was specific and consecutive data could be obtained from the gafchromic film. . horizontal dose distribution which was specific and scattered data could be acquired by glass dosimeters. we obtained almost the same as results in fluoroscopy. horizontal dose distribution of fluoroscopy showed a sharp reduction on the subcutaneous tissue of the chest phantom. barium enemas: are radiographers up to it? p. vora, a. chapman; leeds/uk aim: to determine the types and rates of complications encountered by radiographers when performing double contrast barium enemas. a similar complication rate to those encountered by radiologists will reassure those who have adopted this new skill mix and encourage its further development whereas an increase in complications may point to areas where radiographer training needs to be improved. materials and methods: questionnaires were posted to radiographers who had in the last years attended one of the biannual leeds barium enema training courses. results: of questionnaires posted ( . %) were returned completed. approximately, , barium enema examinations had been performed. radiographers reported complications, including intraperitoneal and extraperitoneal perforations. there were five deaths (mortality rate - in , ). the five deaths included two of the twenty-four ( %) perforations, two of the forty-five ( %) cardiac events and one cva that occurred during an examination. conclusions: radiographers have been regularly performing dcbes for almost a decade. the mortality rate for radiographer performed double contrast barium enemas is similar to that reported for radiologists. a slightly higher than expected rate of perforation is noted in this study and so this is an area where radiographer training should be targeted. the level and incidence of the fear in patients subjected to radiological examinations e. czekajska-chehab, m. makara-studzinska, a. koczynasz, i. nowak, a. drop; lublin/pl purpose: analysis of incidence and intensity of fear in patients subjected to diagnostic procedures. methods: an anonymous survey concerning the occurrence and level of fear connected with radiological examinations was conducted among individuals: patients attending for various contrast examinations and women before mammography, using the questionnaire prepared by the authors. the level of fear was evaluated according to the adopted scale in relation to the obtainable maximum values. results: out of individuals ( %) reported their fears before planned radiological examinations. the frequency of fear was extremely high for mammography ( %) and lower for contrast procedures ( %). the strongest fear was associated with the uncertainty of diagnosis and length of waiting for results ( - %). the fears of patients before contrast examinations were mostly related to results and harmful effects of radiation. the fears concerning allergic reactions were reported by almost a half of patients before ct, urography and barium enema. in patients before contrast procedures the highest fear level was related to the uncertainty of results ( - %). the lower level ( %) was associated only with urography. the fears about the examination itself, allergic reactions or harmful effects of radiation showed similar intensity ( - %), irrespective of the kind of examination. conclusions: fears before radiological examinations are common and concern over a half of patients subjected to contrast procedures and almost all of those before mammography. the most common causes of fear include: uncertainty about diagnosis, exposure to harmful effects of radiation and length of waiting for results. audit of adequacy of inpatient ct requests: implications and consequences w. chooi, p. heath, m.j. bull; sheffield/uk purpose: vetting of ct requests ensure that the examination is justified in accordance to local guidelines and also allow the radiologist to select the most appropriate ct protocol. however the provision of poor clinical information severely limits this step. this audit aims to determine the prevalence of inadequate clinical details in ct request forms and also identify trends that result in poor referring technique. methods and materials: for a two week period all inpatient electronically generated ct request were prospectively monitored. outpatient & out-of-hour requests were excluded. results: out of a total of requests, were successfully audited ( %). the types of examinations included ct head ( %), abdomen ( %), thorax ( %), abdomen and thorax ( %), and musculoskeletal ( %). problems were encountered with requests ( %). the most common problem encountered was that of inadequate or misleading information (n = ). others issues included better alternative examination (n = ), undisclosed renal impairment (n = ), failed examinations due to agitated patients (n = ), ward cancellations (n = ), requests without contact details (n = ), and wrong ward details (n = ). as a result of these requests were not performed. the majority of these requests are completed by junior doctors. conclusion: vetting of ct requests is an essential first step towards a successful ct examination. the provision of inadequate clinical information is prevalent and junior doctors require closer supervision when completing ct requests. to determinate whether use of high iodine concentration contrast medium offers more complete information. diagnosis and follow-up of aortic dissection with multislice computed tomography y. herrero, m. martí, j. echeveste, m. fernández-velilla, g. garzón, n. gómez-león; madrid/es purpose: to assess the utility of multislice computed tomography (msct) in the diagnosis and follow-up of aortic dissection. materials and methods: seventy-one patients referred to rule out aortic dissection underwent msct following a standardised protocol. the volume of interest was the entire aortoiliac system, ml of non-ionic iodinated contrast were administered at a flow rate of ml/sec. a collimation of mm, table speed of mm per rotation, pitch of and reconstruction interval of mm were used. multiplanar (mpr) and three-dimensional reconstructions (external rendering) were obtained in a workstation (vitrea ; vital images plymouth, minn). aortic dissection was diagnosed when an intimal flap separating the true and false lumen was observed. patients diagnosed with aortic dissection underwent an endovascular repair (stentgraft placement). follow-up ct examinations after endovascular repair were acquired with the same msct protocol, after performing a basal nonenhaced study. complete closure of the entry site, and both stent-graft and visceral arterial branches patency were considered as adequate stent-graft function signs. results: nine of the patients were diagnosed with aortic dissection (six acute and three chronic dissections), two of which involved the ascending aorta and seven the descending thoracic aorta. follow-up demonstrated in all cases a residual abdominal aortic dissection with progressive decrease in size of the false lumen. conclusion: msct determined the exact anatomy of the dissection flap, the location of the entry and reentry sites, and the major branch vessels that were supplied by the true lumen. endovascular stent-graft placement for treatment of thoracic aortic aneurysms m. fernández -velilla, g. garzón, i. acitores, f. ibáñez, l. riera; madrid/es learning objectives: to assess the safety and efficacy of endovascular stentgraft placement for repairing descending thoracic aortic aneurysms in high-risk patients. to analyse the major associated complications. to show our experience in the management of these patients over a six-year period. background: by helping patients avoid open surgery, endovascular aneurysm repair minimises the perioperative derangement of pulmonary, renal, cardiac, and gastrointestinal function. the greatest potential benefit is in high-risk patients who have large aneurysms and who are poorly suited to any of the current alternatives. procedure details: endovascular aneurysm repair was performed in highrisk patients who could not undergo conventional repair. the feasibility of endovascular treatment and the prosthesis' size was determined based on preoperative spiral ct and intraoperative angiography findings. stent-grafts were surgically inserted through exposed femoral arteries with fluoroscopic guidance. the anaesthetic technique was either epidural or general. endovascular grafts were constructed with gianturco stents and polytetrafluoruroethylene (ptfe) graft. stent-grafts were placed in disecting, atherosclerotic, five traumatic, and one post-coarctation descending thoracic aortic aneurysm. % of them were chronic. we analysed the results obtained in both stable patients, in which an elective treatment was performed of sacular, fusiform, traumatic and chronic dissection aneurysms, and in emergency patients (intramural bruise, penetrating ulcer, and aortic dissection). conclusion: endovascular treatment of thoracic aortic aneurysms offers considerable benefits. long-term follow-up is needed to ascertain the durability of the procedure especially in dissecting aneurysms. an interdisciplinary and experienced team is needed to manage endovascular and surgical treatment. radiologic appearances of thoracic outlet syndrome: evaluated by pat optimized d contrast enhanced mr angiography and intraarterial dsa Ö. Özsarlak, o. d'archambeau, f. delrue, p.m. parizel; antwerp/be learning objectives: thoracic outlet syndrome: pat optimized contrast enhanced (ce) mra and intraarterial digital subtraction angiography. background: seventeen patients clinically suspected of having a vascular thoracic outlet syndrome were retrospectively reviewed. the patient population consists of women, and men with an age range between and . in eight patients, ce-mra was performed in . t mr system. gre flash d mr angiography with care bolus technique was used with a pat acceleration factor of two. the remaining nine patients were examined by intraarterial, and intravenous dsa of the upper extremity. all examinations, including mra were performed both in neutral and in adson positions with abduction of arms. imaging findings: none of the patients showed abnormality during neutral position. examinations repeated during adson position revealed subclavian artery lesions in patients: occlusions, high-grade stenoses, and mild-grade stenoses. in patients, the lesion was located on the left side, in patients on the right side, and remaining patients' lesions were bilateral. conclusion: a review of the functional anatomy, clinical symptoms, ce-mra and dsa findings are presented with illustrative cases. the advantages of patoptimized ce-mra are highlighted. mri evaluation of patients with peripheral vascular malformations g. calabrese, g. falda, g. lucchini, a. cazzulani; garbagnate milanese/it learning objectives: to define a mri protocol to study patients with angiodysplasia in order to evaluate soft tissues and bone involvement and to demontrate the appearance of the vascular malformations. background: imaging studies must show all the abnormal vessels and provide information on the degree of surrounding tissue involvement. in this exibit we describe the mri findings in patients with angiodysplasia of the lower or upper limbs. procedure details: t weighted fse sequences and t weighted fe sequences in the sagital and coronal planes were acquired. a sagital t fse sequence b d e f a g with echos and fat-saturation was used to demonstrate vessels with slow flow. dsa and dsv were performed to proceed to embolization or operation. t images gave good morphological demonstration of muscle involvement. on t fe images the presence of small vessels within the subcutaneous fat or within the bones was easily shown. images acquired with the echos t sequence were processed with the m.i.p. function to show the abnormal vessels; this sequence was especially useful in the venous malformations and in some cases the draining veins were also identified. conclusion: mri is the technique of choice to demonstrate the anatomic extent of the lesions and their relationship to the adjacent soft tissues. even if mra is improving from the technical point of view, still it remains quite complex and time consuming. in our protocol a simple t sequence showed to be a good method to demonstrate abnormal vessel with slow flow. occlusion background: thrombosis of the ivc and its tributaries is most commonly associated with malignancy, resulting from direct invasion by carcinoma of the kidney, liver or adrenal gland. thrombosis of the ivc secondary to benign causes is less common. predisposing factors include pregnancy, connective tissues disorders and coagulation abnormalities. recognition of caval thrombosis on ultrasound may be difficult. however, depiction of the ivc on both contrast-enhanced computerised tomography and mri is more accurate. although non-contrast mri is useful for demonstrating ivc occlusion, contrast-enhanced mr venography offers the opportunity for rapid evaluation in a single breath-hold. imaging findings: the normal appearance of the ivc as demonstrated by mri is illustrated, along with examples of ivc occlusion associated with both benign and malignant pathology. simple rules for differentiating bland versus tumour thrombus are presented and illustrated. a method for optimising the timing of data acquisition for ce-mra is presented. the merits of "indirect" versus "direct" ivc mr venography are also discussed. finally, artefacts that may mimic ivc thrombus are described. conclusion: mri/mra accurately evaluates the ivc. the multiplanar imaging capabilities, lack of ionising radiation, coupled with the added benefit gained from the use of intravenous gadolinium based contrast agents in mra, makes mri the modality of choice in evaluating patients with suspected ivc occlusion. the swollen leg: the various etiology and its ct venography findings w. jun, w. lee, j. chung, j. park; seoul/kr learning objectives: to illustrate the various causes of swollen legs. to recognize the characteristic imaging findings of various causes of swollen legs. to evaluate the accuracy of ct venography in the differential diagnosis of the etiology in patients with swollen legs. background: the swollen leg is a common clinical problem that complicates many medial and surgical disorders. clinical applications of computed tomography (ct) venography have increased with the improved technology of multidetector ct systems. ct venography showed the diagnosis of dvt and other soft tissue disease in patients with swollen leg. for the past two years, ct angiography of lower limbs was performed in patient (age - years) with swollen legs. the various causes and imaging findings of swollen legs are described and illustrated. imaging findings: the characteristic imaging findings of acute deep vein thrombosis (dvt) are a definite intraluminal filling defect, venous distension and muscle compartment enlargement. findings of chronic dvt are small, thick-walled, poorly enhancing veins and presence of collaterals. findings of lymphedema are skin thickening, subcutaneous tissue thickening, fat infiltration: lines parallel to skin and perpendicular to skin. findings of cellulitis including necrotizing fasciitis, are fascial thickening, fat infiltration, focal fluid collection, soft -tissue gas and muscle involvement. conclusion: ct venography showed promise for the diagnosis of dvt and other soft tissue disease in patients with swollen legs. ct venography is the modality of choice when clinical and other imaging findings are indeterminate. the aorta revisited: spectrum of findings on helical ct a.j. madureira, j.p. jesus, j. loureiro, i. ramos; porto/pt learning objectives: to review the imaging findings of the anatomical variants and disease processes that may affect the aorta from the aortic valve to the bifurcation. to describe the pitfalls that may be encountered. background: helical ct is a frequently used method in the evaluation of diseases affecting the aorta. it provides invaluable information in the assessment of acute aortic syndromes and is often employed in diagnosis and follow-up of dissection, aneurysm and bypass surgery. procedure details: the imaging findings of the diseases that may affect the aorta are presented based on the experience of our tertiary care hospital and level trauma center. the anatomical variations of the aortic arch vessels, acute aortic syndromes, aneurysmal disease and aortic bypass surgery are discussed and illustrated thoroughly. conclusion: helical ct is a firstline imaging method in the evaluation of aortic disease due to it's widespread availability, good spatial resolution and speed. learning objectives: to illustrate the mr findings that differentiate severe carotid artery stenosis with a tiny residual distal lumen from patients with total carotid artery occlusion. background: due to the small but substantial stroke risk in patients undergoing digital subtraction angiography, contrast enhanced magnetic resonance angiography (m.r.a.) has become the standard for evaluation of carotid occlusive disease in many centres. m.r.a. is highly accurate in differentiating significant stenosis ( %- %) that requires carotid endarterectomy, from insignificant (< %) disease. m.r.a. is also highly accurate in differentiating severe stenosis from occlusion. however, demonstration of a string sign depends on careful interrogation of the source images as the residual patent lumen may not be visualised on standard maximum intensity projections. given the clinical importance of differentiating between these two groups, we present and contrast the imaging findings of patients with significant carotid stenosis and those with total carotid artery occlusion. imaging findings: we describe the varied findings in both patients with total carotid artery occlusion and those with severe stenosis. we present a simple algorithm for rapid evaluation of patients referred for differentiation of severe stenosis from occlusion. background: anomalies of ivc and renal veins occur with a prevalence of . % to . %, and are easily identified on ct, frequently incidentally. if unidentified, they can be misinterpreted as pathology (adenomegaly, retroperitoneal masses, normal venous structures and/or collaterals during acquired obstruction) or can lead to morbidity during radiologic and surgical procedures (positioning ivc filters, varicocoele sclerotherapy, renal venous sampling, shunt placement for portal hypertension, liver or kidney transplantation, ivc ligation for thromboembolic disease, abdominal aortic aneurysm repair). we describe the ct findings in cases of anomalies of the ivc and the lrv. imaging findings: female and male patients, aged - years, were studied. we found anomalies of the suprarenal segment (interrupted ivc with azygos continuation), anomalies of the renal segment ( circumaortic lrv, retroarotic lrv), and anomalies of the infrarrenal segment ( retrocaval ureter, transposition of the ivc, and duplications of the ivc). one patient with agenesis of the ivc with azygos continuation had profound venous thrombosis, and another had bronchiectasis. in any other case the anomaly was responsible for the patient's symptoms. results: mean size of the ascending aorta in these patients at initial presentation was . cm (range . to . cm). dissection of the ascending aorta occurred in %. median size of ascending aorta at time of dissection was . cm. all patients underwent surgery for their aneurysms. the postoperative mortality was . %. we have compared the two groups of marfan's syndrome patients whom had dissections: with an aortic-root diameter from . to . cm ( %) and with an aortic-root diameter from . to . cm ( %). there is correlation between the aortic-root diameter and the probability of aortic dissection. analysis to isolate risk factors for dissection revealed that size larger than . cm increased the probability by %. the incidence of dissection increased with aneurysm size and the radiological criteria for surgical intervention in marfan's syndrome are aneurysm diameter of . cm. maximal information about size and dissection of aneurysms in marfan's syndrome patients are obtained from analysis of angiography data. an evaluation of internal carotid artery and cerebral blood flow volume using color duplex sonography in patients with vertebral artery hypoplasia m. acar, b. degirmenci, a. yucel, r. albayrak; afyon/tr purpose: vertebral artery hypoplasia (vah) may be defined as va flow volume below ~ to ml/min using color duplex sonography. the aim of this study was to evaluate the effect of va hypoplasia on internal carotid artery (ica) flow volume and cerebral blood flow (cbf) volume. materials and methods: in this study, patients with va hypoplasia and control subjects with normal va flow volume were enrolled. the patients and control subjects were - years of age. the ica and va flow volumes were determined by using color duplex sonography. cerebral blood flow volume was calculated as sum of flow volumes in the ica and va of both sides. the ica and cbf volumes of patients with va hypoplasia were compared with control group flow volumes. results: in va hypoplasia and control group, there were no significant differences between ica flow volumes of right and left sides ( ± versus ± ml/ min; p = . on the right side, ± versus ± ml/min; p = . on the left side) or sum of flow volumes of both ica ( ± versus ± ml/ min; p = . ). however cbf volume tended to be lower in patients with va hypoplasia than control group. conclusion: evaluation of cbf using color duplex sonography is noninvasive and easily applicable to all patients and provides valuable diagnostic data. to the best of our knowledge, this is the first study demonstrating lower sbfv and normal ica flow volume in patients with va hypoplasia. the floating layer: a new sonographic sign of ruptured abdominal aortic aneurysm a. nunziata , o. catalano , m. mattace raso , f. sandomenico , a. siani ; naples/it, pozzuoli/it purpose: in patients with ruptured abdominal aortic aneurysm we have occasionally seen a floating layer, similar to the intimal flap recognizable in patients with aortic dissection but slightly thicker. we reviewed our series to assess the overall prevalence, specificity and diagnostic significance of this finding. materials and methods: in a year period (from january to december ) we have evaluated with us, consecutive patients with abdominal aortic aneurysm (larger axial diameter of the aorta > mm). twenty-nine aneurysms were proven to be ruptured (sonographic and/or ct diagnosis) and were surgically confirmed. the remaining patients were not symptomatic and were proven to have a non-ruptured aneurysm at follow-up. results: a floating membrane was found in out of patients with ruptured aneurysm ( %) and in none of the subjects with non-ruptured aneurysm. the image appeared as a thick layer floating within the aneurysm lumen, clearly detached from a more or less eccentrically placed luminal thrombosis (present in all cases), with a paradoxical movement unrelated to overall vessel pulsation. the floating layer is an uncommon but specific sonographic sign of abdominal aortic aneurysm rupture. recognizing this findings should lead to prompt surgical treatment, without need for further imaging (contrast-enhanced ct). color duplex measurement of cerebral blood flow volume in patients with polycystic ovary syndrome m. acar, a.s. cevrioglu, b. degirmenci, a. yucel, r. albayrak, m. yilmzer; afyon/tr purpose: polycystic ovary syndrome (pcos), one of the commonest endocrinopathies in the human, is known to be associated with risk factors for cerebrovascular disease. we want to determined whether there is a change in cerebral blood flow volume in pcos. we reported women with pcos and healthy women with similar body mass index (bmi). both groups of women were aged to years. we detected internal carotid (ica) and vertebral artery (va) flow volume using color duplex sonography. cerebral blood flow (cbf) volume was determined as the sum of flow volumes of internal carotid and vertebral arteries of both sides. results: there were no significant differences between patients with pcos and control group in cbf volume or the bilateral sum of flow volumes in the ica and va. but bilateral mean velocity of va was significantly lower in patients with pcos compared to control group. correlation between age of patients and mean velocity of va and ica were assessed with pearson correlation analysis. in control group, mean velocity of va and ica was inversely correlated with age (r = . , p = . versus r = . , p = . ). however no correlation was found for patients with pcos. conclusion: this is the first study demonstrating normal cbf volume using duplex sonography in pcos. it is known that the increased risk factors for cerebrovascular disease does not increase stroke mortality in pcos. normal cbf volume and absence of decrease in va and ica mean velocity by aging may be protective mechanisms. thoracic aortic calcification in the elderly g.s. karlsdottir, t. aspelund, s. sigurdsson, g. eiriksdottir, l. launer, t. harris, v. gudnason, r. detrano; kopavogur/is purpose: though demographic associates of coronary and abdominal aortic calcification in elderly persons are known, similar information about the thoracic aorta is not available. we developed a protocol for scanning the thoracic aorta from the aortic bulb to the descending aorta at the level of the cardiac apex. methods and materials: computed tomographic images were acquired with a siemens sensation scanner, using sequential mode and prospective ecg gating. the ct images were processed using calcium scoring software for coronary arteries, which is modified in order to label areas and quantify calcium in the thoracic aorta. the thoracic aorta is divided into three segments: arch, ascending, and descending. these segments are labeled and calcium within them quantified and results expressed in agatston scores. results: agatston scores were acquired from individuals ( men, women) with an age range of - (mean ) years. there was a % increase ( %ci: %- %) in the total agatston score for every years of age for men, and % ( %ci: %- %) for women. there was no significant difference between men and women in the age group - and, men in the age group + had significantly lower scores than women. conclusion: a robust method for quantifying calcium in the thoracic aorta has been established. age and gender distributions of thoracic aortic calcification in the elderly show strong age dependance for both genders but significantly stronger for women than for men. b d e f a g materials and methods: ct scans of fourty patients (mean age years, female: previous aortic repair (n = ), atherosclerosis (n = ), trauma (n = ), other (n = )) with aortic or supraaortic emergency were reviewed for aortic rupture (ar), aortic or supraaortic fistula (af), covered aortic perforation (cap) with transection (at), dissection (ad), or ruptured ulcer (rau), and rapid aortic aneurysm expansion (raae). morphological findings were correlated by dsa, surgery or post-mortem. results: there were ar, af ( tracheobronchial, oesophageal, duodenal), cap ( at, ad, rau) and raae. cta was diagnostic in all cases except five af: four were diagnosed by dsa, one at post-mortem. in cases, cta correctly determined the decision of patient management. one separate vertebral artery origin was missed. two patients died before surgery. patients underwent emergency repair ( surgical, endovascular); two were observed. five thoracic af were treated by endovascular repair, two by surgery, one infradiaphragmatic af by surgery. conclusion: cta is valuable for diagnosing aortic and supraaortic emergencies and determining their treatment. however, in suspected af complementation by dsa is usually required. low materials and methods: seventy-five patients with peripheral arterial disease, divided into three groups of , underwent mdcta. mdcta scanning protocol was: collimation x . mm, thickness mm, gantry rotation time . s, kv , delay time s. the only variable among the three groups was mas, respectively , and , with a resultant ctdiw of . , and . mgy. all patients underwent dsa within hours from cta. the volume of contrast medium ( . gi/ kg of iomeprol mgi/ml), injected at . ml/s, was flushed with ml of saline. d real time interaction approach on a dedicated workstation was performed in all cases, with different reconstructions algorithms. image quality and degree of stenosis were independently evaluated by blinded readers. results: regarding image quality no significant difference was found among three protocols. slight artefacts related to beam hardening were present in the pelvis with the lower mas protocol without impairment of diagnostic quality. interobserver agreement was substantial to almost perfect in all cases. the sensitivity, specificity and accuracy resulted of , and %, independent of the mas value. conclusions: low-dose mdcta provides qualitatively acceptable images. it also appears accurate in the assessment of patients with peripheral arterial disease providing results comparable to higher dose protocols. image noise on native lowest dose protocol can be reduced or eliminated by thickening mip or mpr images. diseases had lymphadema, ( . %) had superficial venous thrombosis, ( . %) had popliteal vein or artery aneurysm. nine ( . %) limbs had pseudoaneurysms ( femoral and located at the tibial-peroneal trunk), ( . %) had avf ( detected to be femoral and at the level of the external iliac artery). four ( . %) had either abscess, or enlarged lymph nodes in the groin, compressing the veins, and ( . %) had some kind of musculoskeletal problem (muscular tear). conclusion: complete venous evaluation with duplex imaging can be very helpful in the determination of the underlying cause of leg swelling. dvt is the commonest. sonographic assessment of intima-media thickness (imt) and plaque morphology of the carotid system: a comparative study a.a. kotis , p. brestas , l. guindaglia , g. chatzakis , k. papanastasiou ; rhodes/gr, athens/gr purpose: to investigate the potential association of increase in imt with carotid artery disease extension, plaque morphology and formation of carotid bifurcation stenosis. materials and methods: patients females and males referred for color duplex ultrasound were included. risk factors for cerebrovascular disease were recorded. measurements of common carotid (cca) imt adjacent to the bulb and carotid bifurcation plaque characterization and classification were realized. coefficients of variation and k-statistics were used for assessment of variability in imt measurements and plaque characterization respectively. controversy cases underwent shu a contrast agent injection. results: significantly higher imt values were measured a) in men than in women (p < . ) b) on the left side compared with the right (p < . ). mean imt measurements showed positive linear relationship with age. we identified plaques in of carotid bulbs and stenosis (> %) in of them. echogenic us plaque appearance ( / ) predominated in comparison with echolucent ( / ) and relationship of lumen stenosis with the presence of echolucent plaques (p < . ) was found. multiple regression model revealed significantly higher imt values in patients with plaques at any side (p = . ), with more evident difference in those with stenosis (p < . ). the magnitude of plaques correlated significantly with imt. there was no relationship between plaque echogenity and imt (p > . ). we realize the existence of correlation between increase in imt in cca and extent of carotid bifurcation atherosclerotic disease. color doppler ultrasonography is accurate and reproducible for assessment of imt and detection of carotid plaque morphology and evolution. to emphasize the role of mr angiography in the evaluation of renovascular disease, and to discuss the performances, advantages and limitations of different mr angiography techniques. materials and methods: more than mr angiograms of renal arteries were reviewed for the presence of any anatomic variations, the number of renal arteries, the presence of renal artery stenosis, occlusion, or other arterial diseases together with the limitations, artifacts and pitfalls of the technique. more than examinations were performed after applying parallel acquisition technique with acceleration factors up to , using a -channel phased array body coil. influence of pat on slice thickness, image matrix, total examination time, and image quality are discussed. results: phase contrast acquisitions are extremely helpful in evaluating flow patterns in the renal arteries, and offer unique information about the flow velocity patterns. pat using sense reconstruction algorithm leads faster d mra acquisitions. this results in, not only shortening the examination time, but also shortening the breath-hold time, and providing better image quality due to decreased motion artifacts. pat-optimized d contrast enhanced mr angiography is unique among noninvasive imaging modalities in that it offers a comprehensive d evaluation of renal anatomy, and renal vascular territories in a very short acquisition time. the main challenge in the evaluation of renovascular hypertension is the detection of hemodynamically significant renal artery stenosis. a combination of different techniques (phase contrast and contrast-enhanced mra) yields the best results, comprising both morphologic and functional information. possibilities results: pathologic changes in the visceral arteries were revealed in cases, including findings with various grades of stenosis of the coeliac trunk, with stenosis of the sma, -occlusion of the splanchnic arteries. causes of visceral ischemia were: atherosclerosis (the main cause), found in patients, aorto-arteriitis -in , coarctation of abdominal aorta -in , extravasal compression-in . high correlation between conventional angiography and ce-mra was determined in patients. the functional phase-contrast mra was done in patients with stenoses of small and middle degree; it gave an opportunity to acquire information on flow parameters and to elaborate the grade of stenotic changes. the ce-mra with pc-mra gives a chance to determine the grade of stenosis with high accuracy, visualize colateral vessels, to get information on flow parameters in damaged splanchnic arteries. b d e f a g imaging findings: all degrees of local vascular damage were seen. various imaging modalities may be employed in characterising such lesions, including ct, mri and conventional angiography and venography. an addict may injure any vessel during injection and the superficially placed femoral vessels are particularly susceptible to damage. septic vascular complication is common. arterial injury resulting in haematoma formation, arterial dissection and thrombosis, arteriovenous fistula and mycotic aneurysm formation is shown. a case of torrential haemorrhage from a ruptured pseudo-aneurysm treated with coil embolisation is demonstrated. deleterious effects secondary to the injected substance, including distal ischaemia and tissue necrosis, are demonstrated. venous thrombosis is common and can be shown by multiple imaging modalities. infected venous pseudo-aneurysms with secondary septic embolisation may occur. conclusion: it is important for radiologists to become familiar with the appearance of vascular complications occurring in the setting of injection drug use. early imaging to define disease extent and possible complication is important in this difficult patient group. carotid intima-media thickness ( the aim of the study was to investigate the probable association of atherosclerotic disease with endothelial cell adhesion molecule icam- , vcam- and e-selectin levels. carotid imt was measured by high resolution ultrasonography of the common carotid arteries in predialysis patients with esrd, patients on chronic haemodialysis (hd) and controls. compared with controls, esrd and hd patients had increased imt (p < . and p < . respectively), as well as serum icam- (p < . and p < . respectively) and vcam- (p < . and p < . respectively) levels. imt was correlated with age in controls, esrd and hd patients (p = . , p = . and p = . respectively). no correlation was found between imt and other cardiovascular (cv) risk factors such as gender, lipid levels, mean arterial blood pressure, ca x p products or hd duration in hd patients. in univariate analyses, imt was correlated with history of cv events, logcrp and icam- both in esrd (p = . , p = . and p = . respectively) and hd patients (p = . , p = . and p = . respectively). moreover, compared with patients with normal imt, esrd and hd patients with increased imt (> . mm) had increased icam- (p = . and p = . respectively). multivariate analyses showed that icam- was a strong independent correlate of imt values both in esrd and hd patients (p = . and p = . respectively). vcam- and e-selectin levels failed to be a significant contributor to imt. in conclusion, chronic uraemia is associated with advanced atherosclerosis. in patients with esrd, both on conservative treatment and on hd, icam- levels are potentially a useful surrogate marker of the extent of atherosclerosis. evaluation of tumor microvessels using monochromatic x-ray after administration of angiogenesis inhibitor t. yamashita, s. imai, n. maehara, a. yamamoto, m. kobatake, y. kajihara; kurashiki/jp purpose: to quantitatively evaluate changes in tumor microvessels using synchrotron radiation in vivo after fr- administration as an angiogenesis inhibitor. the fr- agent (using propylene glycol as a solvent) was continuously infused subcutaneously to rabbits with vx carcinoma implantation at auricles. the rabbits were divided into six groups: control- and control- received only propylene glycol for three or seven days, fr- - and fr- - received mg/day/kg of fr- for three or seven days, fr- - and fr- - received mg/day/kg for three or seven days. microangiograms using a synchrotron radiation system were obtained to evaluate the tumor microvessels and tumor size. results: compared to control- group, fr-x- groups showed no significant tumor size difference (fr: diameter = . ± . mm, volume = . ± . mm , control- : . ± . mm, . ± . mm ), but microangiologically fewer vessels were observed. fr-x- groups presented significant difference (fr: diameter = . ± . mm, volume = . ± . mm , control- : . ± . mm, . ± . mm ), and many irregular vessels, findings similar to control- . there was no significant difference in tumor size and microangiographic findings between fr- -x and fr- -x. conclusion: our study demonstrates the application of new technique to examine antiangiogenic effects in vivo. the growth of the vx carcinoma were sup-pressed remarkably in the fr- -day-groups, and the microangiographic findings were similar to those of control- . the synchrotron radiation microangiogram is a useful tool to evaluate antiangiogenic agent. early atherosclerotic changes in hiv positive patients treated with protease inhibitors m. cristofaro, n. petrosillo, l. rovighi, c. bibbolino; rome/it purpose: antiretroviral therapies with protease inhibitors (pi) produce derangement of lipid metabolism with possible occurrence of early atherosclerotic changes. aim of this study is to evaluate onset of early atherosclerotic changes of epiaortic vessels in hiv positive patients, treated with pi. purpose: hematoporphyrin (hp) accumulates in arteriosclerosis selectively and shows specific fluorescence spectrum change in accordance with the stages of the sclerosis, and this fact is under discussion as to its availability to diagnosis and therapy. we paid our attention to the fact that hp accumulates in the interface of swollen collagen type iv and lipid. we assumed such a model of atheroma, and we examined the possibility of a photodynamic therapy for arteriosclerosis using collagen type iv and phosphatidyl choline liposome. material and method: we added hp to collagen type iv, then the liposome containing cholesterol to the mixture, and examined the agglutination state of the protein-lipid complex. afterwards, we irradiated that complex with led pulse of nm for one hour, and examined scattered spectroscopy, interference spectroscopy using nm semiconductor laser and high sensitivity ccd in order to observe the hp and the agglutination state of complex, and, then, analyzed the alteration of protein-lipid complex in terms of fourier analysis. result: hp gave influence to the various state of assembly of protein-lipid complex. in addition, protein-lipid integration state was changed by the irradiation of light pulse and the change of scattered light that signifies the state of dispersion was observed. conclusion: this study suggested that the molecule composition of the proteinlipid complex in the plaque was changed by the irradiation of light pulse after the addition of hp, and that the photo stimulation could contribute to the decomposition of the cumulated lipid and the stabilization of plaque. depiction of arterial branches in the abdomen using multidetector-row ct n. terayama , o. matsui , k. ueda , t. kobayashi contrast medium ( mgi) was administered intravenously at a rate of ml/sec. parameters of data acquisition were as follows: a slice thickness of . mm, reconstruction intervals of . mm, a pitch of . , and fov of cm. axial images were transferred to advantage workstation . (ge medical systems) and multi-projection volume reconstruction (mpvr) images were obtained. if the origin of each arterial branch and the route until the target organ was depicted, we regarded that the branch was visible. results: coeliac, superior and inferior mesenteric, renal, intercostal, lumbar, right and left hepatic, and anterior and posterior pancreaticoduodenal arteries were visible in all cases. cystic, right gastric and dorsal pancreatic arteries were visible in cases ( %), in cases ( %) and in cases ( %), respectively testicular arteries were visible in cases ( %), and in cases ( %), respectively. conclusion: reformation images of mdct can visualize thin arterial branches in the abdomen experimental lung injury prior to the ct examinations. in addition, segmental and subsegmental pulmonary embolism was artificially induced in four healthy pigs. scanning was performed using a -slice msct protocol using contour finding and adaptive thresholding, both plain and enhanced ct volumes were separated into lung parenchyma, vascular structures and airways. the high contrast information was used to locally match and align sub-volumes. the matched parenchymal volumes were low pass filtered, subtracted and normalized to the enhancement level in a major vessel. results: scanning was successfully performed during a total ~ s scanning time in all pigs. post-processing was technically feasible, even in underlying experimental lung injury. in pe, filling defects corresponded to areas of decreased enhancement. conclusion: it is expected that this imaging technique will increase the sensitivity and specificity of msct determination of arterial input function for measurement of brain perfusion index with tc- m compounds using a solid-state gamma camera y. uenishi, k. murase, m. nagayoshi, m. kawamata, m. takasawa, n. oku, a. takahashi, j. hatazawa; osaka/jp purpose: cerebral blood flow (cbf) can be non-invasively quantified using the brain perfusion index (bpi) determined from radionuclide angiography (ra). for measurement of bpi, accurate determination of arterial input function (aif) is necessary. we have developed a method for the automatic extraction of aif using fuzzy clustering and a solid-state gamma camera (digirad). methods and materials: ra was performed using tc- m hmpao for sec with a digirad placed on the heart and a -head spect (spect h). for comparison, the data were also acquired using a conventional gamma camera (rc- i). the aifs were obtained using fuzzy clustering (aif a ) and manual drawing of a region of interest (roi) (aif m ) from the region of aortic arch. the rois were also drawn over the left and right cerebral hemispheres. the bpi values were calculated using spectral analysis (bpi a : bpi obtained using aif a , bpi m : bpi using aif m ). the deadtimes of digirad and rc- i were measured using the reference source method. results: the mean and sd of bpi m became larger with increasing roi size, while the bpi a was almost constant regardless of roi size. the sd of bpi a was smaller than that of bpi m . the deadtime of digirad ( . ± . µsec) was much less than that of rc- i ( . ± . µsec). furthermore, the deadtime of digirad was almost constant regardless of the volume of phantoms, while that of rc- i increased with increasing volume. the proposed method appears promising for calculation of the bpi, because it allows automatic and objective determination of aif. spectroscopic imaging of radiation-induced effects in the brain after brachytherapy g. bajzik , j. julow , i. repa ; kaposvar/hu, budapest/hu purpose: the effect of brachytherapy, characterized by rapid dose fall off from the radiation source, is different compared to external radiation. we used proton mr spectroscopic imaging to investigate brain tissue response to brachytherapy. methods and materials: twenty glioma patients treated with surgery and/or brachytherapy were studied with mr imaging (t weighted images and post contrast t weighted images) and d proton mr spectroscopy (tr: ms, te: ms, voxel size . cm ). brachytherapy resulted in central necrotic zone, surrounded by an enhancing rim (demarcation zone) and an outer edematous zone on mr images. in each patient sample, spectra of the three zones and the normal appearing white matter were analyzed. results: in demarcation zone, choline/creatine (cho/crea) ratio ( . ± . vs. . ± . , p = . , two-tailed unpaired student's test) and choline/n-acetylaspartate (cho/naa) ratio ( . ± . vs. . ± . , p = . ) was increased compared to normal white matter. in edematous zone cho/crea ratio was increased ( . ± . vs. . ± . , p = . ), cho/naa ratio was not different ( . ± . vs. . ± . , p = . ) compared to normal white matter. in demarcation zone we found elevated cho/crea ratio ( . ± . vs . ± . , p = . ) and cho/naa ratio ( . ± . vs . ± . , p = . ) compared to edematous zone. in the central necrotic zone we could only detect lipid and/or lactate peaks. conclusions: mr spectroscopy demonstrates significant spectral differences in the brain following brachytherapy. tumor recurrence can be suspected in cases where focal choline accumulation is detected. does ct-perfusion imaging based on parametric deconvolution permit prediction of infarct volume in acute stroke? g. bohner , a. förschler , c. zimmer , r. klingebiel ; berlin/de, leipzig/de objectives: suitability of quantitative ct-perfusion (ctp) imaging for assessing the early as well as final infarct volume in acute stroke patients. material and methods: twenty-two patients with acute cerebral ischemia underwent ctp on admission. parameter maps of cerebral blood perfusion (cbp), cerebral blood volume (cbv) and mean transit time (mtt) were generated using a parametric deconvolution algorithm. additional diffusion weighted imaging (dwi) was performed in seven cases. volume of diffusion abnormality was compared with the infarct volumes as assessed by two blinded neuroradiologists for each of the perfusion maps. in addition, final infarct volumes were determined on the basis of follow-up studies. results: mean volumes of ischemia as assessed by cbp, cbv and mtt were . , . and . ml respectively. amongst the patients in whom dwi was performed, six showed perfusions deficits in all perfusion images. in one patient, who had no dwi abnormality, perfusion deficits only were found on cbp and mtt images. mean volume of dwi changes was . ml. the most significant correlation was found between the extent of cbv reduction and dwi infarct volume (r = . , p < . ). mean final infarct volume was . ml for all patients. cbv reduction showed the best correlation (r = . , p < . ) with final infarct volume. conclusion: our findings suggest that cbv maps based on the ctp technique applied in this study permit prediction of infarct volume in early stroke, so ctp would deliver information about the ischemic penumbra. hepatic encephalopathy in alcoholic and non-alcoholic subjects: correlation of magnetization transfer ratio, apparent diffusion coefficient and critical flicker frequency m. cohnen, g. kircheis, h.-j. wittsack, f. miese, f. wenserski, a. saleh, d. häussinger, u. moedder; düsseldorf/de purpose: to correlate quantitative changes of water content in brain parenchyma using magnetization transfer imaging (mti) with different stages of hepatic encephalopathy (he). materials and methods: forty-three patients with hepatic encephalopathy and age-matched control subjects underwent mr imaging ( . t vision, siemens) including mti, mr-spectroscopy (mrs) and diffusion weighted imaging (dwi). liver cirrhosis was due to alcohol in patients whereas non-alcoholic disease was found in . patients underwent assessment of critical flicker frequency (cff) as test for he with a frequency under hz considered pathologic. magnetiza-tion transfer ratios (mtr) and apparent diffusion coefficient (adc) values were determined in basal ganglia, posterior white matter and pons using roi-measurements. single-voxel mrs was performed using a steam sequence (te = ms, tr = . s) assessing basal ganglia and posterior white matter. results: mrs showed typical findings with decreased myo-inositol combined with increased glutamine/glutamate with increasing degree of he indicated by a reduced cff. compared to controls, mtr showed a significant decrease both in the basal ganglia as well as in the posterior white matter. in alcoholic subjects, this was independent from the degree of he, whereas in posthepatitic cirrhosis a correlation was found. a non-significant increase in adc was noted with a decrease of cff in both groups. conclusion: the results may indicate an increase of free protons in the brain parenchyma of patients with he possibly supporting the hypothesis of a lowgrade cerebral edema. the differences between alcoholic and non-alcoholic subjects may hint at a general brain damage due to alcohol independent of hepatic failure. assessment of cerebral blood flow values obtained from dynamic perfusion computed tomography: a comparison with positron emission tomography h. yokote, k. nakayama, t. okamura, n. tsuyuguchi, k. kitamura, n. ozawa, s. minamikawa, t. tashiro, y. inoue; osaka/jp purpose: among imaging modalities measuring regional cerebral blood flow (cbf), dynamic perfusion computed tomography (ct) studies are easy to perform and readily available without specialized equipment. however, quantitative studies comparing perfusion ct with positron emission tomography (pet) have been few. we assessed the correlation of cbf values obtained from perfusion ct and pet. methods and materials: eleven patients with various cerebrovascular diseases underwent perfusion ct and pet. the perfusion ct studies were performed with a four-channel multi-detector row ct scanner. four contiguous -mm ct sections were cine-scanned during a ml bolus of intravenous contrast medium at a rate of ml/s, with a total acquisition time of s. cbf maps were obtained from perfusion ct data by central volume principle and deconvolution method. on cbf maps of both perfusion ct and pet, multiple regions of interest (roi) were drawn independently, including frontal, temporal, parieto-occipital territories, caudate nucleus, thalamus and white matter in both hemispheres. rois were visually matched by agreement of three radiologists. mean cbf values of multiple rois with both ct and pet were compared through linear regression analysis. results: correlation coefficients for individual analysis ranged from . to . , overall . . linear regression analysis showed moderate correlation between perfusion ct and pet values (slope = . , intercept = . ). conclusions: our study has shown moderate correlation of cbf values between perfusion ct and pet. despite the various alterations of cerebral blood flow in our cases, perfusion ct studies were validated to be an easy-to-perform imaging technique to assess cbf values. ageing of the cerebrum: assesment with quantitative proton mr spectroscopy j. ostojic, r. semnic, d. kozic, d. bogdanovic, m. prvulovic; sremska kamenica/yu introduction: aging is recognized to originate from a diversity of mechanisms that blur the limits between normal and pathologic processes. the purpose of this study was to determine the early effect of normal aging on the regional distribution of brain metabolite concentrations, including n-acetylaspartate (naa), choline (cho) and creatine (cr). methods: seventy nine volunteers, ages to years, were examined by localized single-voxel proton mr spectroscopy at . t using press sequence.voxels x x cm were placed in the middle white matter (wm) of the centrum semiovale in the left hemisphere and in the occipital gray matter (gm) of posterior parietal lobes. the ratio of naa/cho were calculated, as well as absolute concentrations of naa, cr and cho.quantification was performed using method of external standard. results: absolute concentrations (mm/kg) of cho increased with age both in wm (r = . , p < . ) and in gm (r = . , p < . ). cr concentrations were much higher in gm than in wm and significantly higher in the old than young subjets (r = . , p < . ). the change of wm cr with age failed to meet p < . criteria. naa concentration was higher in gm than in wm and did not differ between young and old subjects. the age dependency of gm naa/cho ratio was technical inadequacies of plain films in an emergency department b. rajashanker, f. jabeen, r.w. whitehouse; manchester/uk purpose: . to assess the diagnostic quality of radiographs performed in the emergency department in a major referral hospital. . to determine the type and number of inadequacy encountered most often. materials and methods: two specialist registrars (trainees) in radiology, reviewed plain films performed in a busy emergency department. films were examined for inadequacies, which impair the diagnostic quality of the examination. despite artefacts or exposure problems, if a reasonable diagnostic conclusion could be made, the film was considered to be adequate. if a film was found to be inadequate, clinical details (that could have contributed to the poor quality) were looked at, and taken into consideration. artefacts obscuring the area of interest, inadequate collimation, incomplete examinations and improper exposure factors were considered as inadequate. the number and the type of inadequacy, the type of examination were noted. results: . the study showed that about % of the total films performed were inadequate. there are no national figures we could find to compare our results with to evaluate the performances on our emergency department. . the type of inadequacy encountered most often was the presence of jewellery obscuring the area of interest ( %), followed by artefacts caused by clothing ( %). chest radiograph was the most frequently encountered inadequate examinations ( %). conclusion: national guidelines regarding target quality radiographs that need to be achieved in institutions need to be published. the inadequacies were pointed out for better performance in future. drug courier pays a high price for easy money b. szabó, z. mocsári, s.o. farkas, p. magyar, Á. takács, k. karlinger, e.k. makó; budapest/hu purpose: the aim of this study is to show the most common methods for examining drug couriers and their results. method: native abdomen ct scans and native abdomen x-rays and us examination were performed on probably positive patients. in the year until now we examined patients. four positive cases were found. one of them after the ct examination died in the hospital, because leakage of a capsule. conclusion: swallowers before traveling swallow - cm long, cm diameter capsules, which they hope to retrieve after traveling. stuffers insert drug filled corpus alienums into the rectum or vagina. the danger of this type of drug smuggling is the braking or bursting of the capsules, leading to potential fatal drug overdose. steps to european union from europe: reforms of education of hungarian radiographers a. maléta, z. mocsári, s.o. farkas, Á. mester, k. karlinger, e.k. makó; budapest/hu purpose: the aim of this presentation is to show a short summary of the education of hungarian radiographers currently and in the future. method: assessment based on the bologna contract new education system with the cooperation between the society of hungarian radiographers and hungarian ministry of education according to the european directives. results: the base of the modular education system is already laid down. the construction and edition of the new scientific books and the preparation of the teachers and professors has already commenced. conclusion: since the hungarian educational system of radiographers has a history of nearly ninety years we need to use the lessonst of the past into the new system. since the result of the reforms requires a long time, well-organized feedback mechanisms is needed to ensure the effectiveness of the reforms. origin of military radiology: first use of x-rays in ottoman empire a. tunaci, n. yildirim, y.i. ulman, e. yekeler, h. genchellac, m. tunaci, g. acunas; istanbul/tr x-ray usage as a diagnostic device was realized in turkey first time at the military medical school in by esad feyzi, who was an intern and physics assistant. this new invention attracted attention so much that dr. salih and rifat osman also joined him and they started to work in a small unit, where they practiced radiographic examination.the following year, yildiz portable military hospital was reserved for wounded patients from the battlefield of the ottoman-greek war. this mobile hospital, which was activated in , was exported from germany and comprised duquer system pavilions that were reassembled within hours. they took away the x-ray equipment from the military medical school to yildiz and began to produce images of bullet and shrapnel pieces from the patients sent from the battlefield. kuttner and nasse from german red cross came to istanbul in . they were surprised to see that this new invention was already being used there. on the greek side english physicians used two x-ray devices that were transferred from england to pire harbour on may . therefore the ottoman-greek war took its place in medical literature as the first war that radiographic images were taken, first by the turkish and soon after by german and english physicians. references stated that english physicians took x-ray images of wounded greek soldiers and there is no record about greek physicians taking part in this work. turkish physicians continued to work on radiographic images during the war which they had started shortly after the discovery of x-rays. to demonstrate how to perform a numeric flow simulation in patient-specific vessels based on isotropic ctdatasets. to illustrate the possibilities of this promising tool on clinical cases. background: cfd was introduced recently to investigate the behaviour of blood flow. different studies determined cfd as a valuable method to demonstrate the flow and pressure. most studies use simplified standard models for the simulations. this exhibit explains methodological aspects of cfd and how numeric flow simulations are performed in patient-specific vessels based on high-resoloution ct datasets. possible applications of cfd in the cardiovascular field are discussed. procedure details: isotropic ct-angiography data are used to segment the vessels. after generation of a surface mesh using the marching cube algorithm, the model is transferred into a volume mesh and the different entities and walls were defined. specific parameters as velocity at the inlet boundary, flow parameters, and material specific parameters have to be assigned in a next step.the simulation itself provides detailed information about flow-behaviour and pressure. this helps to identify possible zones for development of artherosclerosis or, especially in aneurysms, locations for a possible rupture. furthermore, blood flow can be quantified and e.g. effects of stent-graft implantations or the benefit of a coronary bypass can be demonstrated. conclusion: cfd in combination with patient-specific patient-data is a promising method to visualise flow-effects. in the near future cfd will also gain increased importance for pre-interventional planning of vascular procedures. background: evaluation of the central veins is easily achieved with contrastenhanced mr angiography. "indirect" ce-mrv, a technique where the veins are evaluated during the "venous" phase has been largely replaced by "direct" ce-mrv, a technique whereby dilute contrast agent is injected into the upper extremity veins and imaging is performed during the first-pass. imaging findings: in order to overcome t *-induced susceptibility-effect commercial strength contrast-agent is diluted with saline. in our institution we use a % solution ( cc of contrast agent in cc saline). - cc of contrast is injected over the duration of the breath-hold scan (tr/te/flip msec/ msec/ deg, matrix x , fov - mm x - mm. - slices, mm interpolated to mm). mask subtraction of a pre-contrast scan is performed. the spectrum of findings in normal and diseased veins is illustrated. examples of thrombosis, stenosis and occlusion of the central veins will be illustrated. common pit-falls and artefacts will also be emphasised. conclusion: "direct" ce-mrv is an effective modality for evaluating the central veins. a simple robust method is presented, along with examples of the appearance in normal and pathological states. multidetector row ct angiography of the lower extremities for the assessment of traumatic vascular injury e.e. williamson, j.c. hellinger, a. napoli, g.d. rubin, d. fleischmann; stanford, ca/us learning objectives: . to describe the ct angiographic (cta) technique used in the evaluation of traumatic lower extremity (le) vascular injury. . to illustrate the spectrum of vascular and nonvascular pathology found during le-cta in the setting of trauma. background: digital subtraction angiography (dsa) has long been considered the imaging standard for traumatic vascular injury. cta is a more readily available, noninvasive imaging alternative which is less expensive, less resource intensive and can be used to assess bone and soft tissue injuries without the need for additional imaging tests. in this exhibit we highlight our experience with cta in trauma patients.procedure details: all examinations were acquired using or -channel multidetector-row ct (mdct). contrast media was administered at - cc/sec using bolus-tracking technique. thin section images were obtained from one vascular segment above the level of trauma through to the foot with collimation of . and pitch of . - . . table feed and gantry rotation speed were adjusted to optimize scan duration to match the peripheral delivery of iv contrast. all studies were reformatted in -dimensions using volume rendering, maximum intensity projection and curved planar reformation techniques. conclusion: the spectrum of direct vascular injuries included large and small vessel occlusions, pseudoaneursyms, active extravasation, and vasospasm. nonvascular pathology with indirect effects on the vascular system included complex fractures, open soft tissue wounds, hematomas, and joint effusions. ct angiography of the extremities is a promising technique in the evaluation of traumatic le arterial injury with the ability to assess nonvascular injuries without the need for additional studies. there is a wide range of imaging techniques available for mrv evaluation of the central chest veins, including conventional non-contrast time of flight imaging and contrast enhanced methods such as the newer vespa (venous enhanced subtracted peak arterial) sequences. imaging findings: examples of common central venous pathologies will be illustrated from our database of over patients, who underwent mr at . t using various sequences including non contrast time-of-flight, and post gadolinium true fisp, t -weighted vibe and d flash sequences. typical scan parameters included matrix x , fov - x - mm, - slices, mm interpolated to mm. common pathologies demonstrated included thrombo-embolic disease, central venous obstruction due to local tumour extension, congenital and acquired venous stenoses, av fistulas and infected venous pseudo-aneurysms. conclusion: mrv is a robust, highly accurate and non-invasive technique for assessment of central venous pathology. accuracy of automated centerline approximation algorithms for lower extremity vessels in a cta phantom a. la cruz , m. straka , a. köchl , m. Šrámek , e. gröller , d. fleischmann ; vienna/at, stanford, ca/us purpose: the accurate determination of the central vessel axis is a prerequisite for automated visualization (curved planar reformation) and quantitation. the purpose of this work was to assess the accuracy of different algorithms for automated centerline detection in a phantom simulating the peripheral arterial tree. materials and methods: six algorithms were used to determine the centerline of a synthetic peripheral arterial vessel (aorto-to-pedal arteries, diameter - . mm) dataset ( x x , voxel size . x . x . mm). they are ray-casting/ thresholding (rct), ray-casting/maximum gradient (rcmg), block matching (bm), fitting to ellipse (fe), center of gravity (cog), and randomized hough transform (rht). gaussian noise with a sigma: , and was used to observe the accuracy of the method under noise influence. the accuracy of automatic centerline determination was quantified by measuring the error-distance between the derived centerlines, and the known centerline course of the synthetic dataset. results: bm demonstrated unacceptable performance in large vessels (> mm) when the shift used was less than voxels. rcmg demonstrated a greater error (mean of the error . mm) in large diameter (> mm) vessels than in small diameter (< mm) vessels (mean of the error . mm). because rht and fe use canny edge detector preprocessing, both are sensitive to noise. cog and rct keep the mean of the error-distance significantly smaller ( . mm and . mm respectively) than all other algorithms. conclusion: cog and rct algorithms provide the most efficient centerline approximation over a wide range of vessel diameters. detection of the adamkiewicz artery by subtraction magnetic resonance angiography h. hyodoh, r. shirase, h. akiba, m. tamakawa, k. hyodoh, k. aratani, n. kawaharada, k. morishita, m. hareyama; sapporo/jp purpose: to assess the ability of magnetic resonance angiography (mra) to depict the adamkiewicz artery. materials and methods: fifty-one patients with thoracoabdominal disease underwent mra of the bypass graft region. subtraction maximum intensity projection (mip) images and cine-mode displays were produced to identify the adamkiewicz artery, its side of origin and branching level, and the drainage vein. for statistical analysis, signal intensity ratio (snr) and contrast noise ratio (cnr) were also calculated. results: in ( . %) of the patients, at least one adamkiewicz artery was seen to arise from an intercostal artery. two adamkiewicz arteries were identified in ( . %) of the patients. spinal drainage veins were visualized in ( . %) of the patients, a single drainage vein in of the ( . % of the total patient group) and two drainage veins in the remaining ( . % of the total patient group). in of the patients, both the adamkiewicz artery and the drainage vein were detected during the early phase. conclusion: subtraction mra depicts the adamkiewicz artery in a high percentage of patients. -row multislice computed tomography of pulmonary veins: assessment before and after cryothermal energy ablation r. maksimovic , f. cademartiri , m. scholten , l. jordaens , p.m.t. pattynama ; belgrade/yu, rotterdam/nl purpose: electrical isolation of the pulmonary veins (pvs) with radiofrequency ablation in treatment of patients with paroxysmal atrial fibrillation is associated with pv stenosis. cryothermal ablation (ca) is a new promising method in treatment of these patients. although initial experience of ca showed no associated pv stenosis, results at follow-up have not been reported. the aim of the study was to assess pvs for the presence of stenosis three months after ca by contrast enhanced angiography on -row detectors multislice computed tomography (msct). materials and methods: twenty four patients (mean age . ± . years, males) with symptomatic atrial fibrillation underwent ca in pvs. all patients underwent complete clinical work-up, electrophysiological study, ultrasonography and msct angiography before ca. msct pulmonary angiography was performed three months after the procedure to evaluate ostium and the proximal mm of all pvs. results: dimensions of the treated pvs remained unchanged: the coronal ostial diameter was . ± . preprocedural vs. . ± . mm at follow-up, p < . , ratio of coronal and axial diameter . ± . vs. . ± . , p < . , respectively and the coronal diameter of the proximal mm from the ostium . ± . mm vs. . ± . mm, p < . , respectively. conclusions: ca of pvs in atrial fibrillation has not been associated with stenosis at the orifice and proximal mm of the pvs after three months follow-up. msct pulmonary venography is a reliable, noninvasive method for assessment of pvs in a three-dimensional manner prior to ablative treatment and during the follow-up period. magnetic resonance venography without contrast media for patients with lower extremity varicose veins j. koizumi , m. wada , t. horie , e. kimura , i. muro , k. myojin , t. niibori , y. imai ; isehara/jp, wako/jp purpose: to compare three different sequences of magnetic resonance (mr) venography without contrast media for patients with varicose veins below the knee. materials and methods: for patients with lower extremity varicose veins, mr-venography using time-of-flight (tof), fat suppressed t -weighted turbo spin echo (tse) and balanced turbo field echo (btfe) were compared.the original images on . tesla gyroscan (philips) were transferred to a workstation (m quadra, ziosoft inc.) and d images were reconstructed using maximum intensity projection (mip), multiplaner reformation (mpr), and volume rendering (vr) techniques. for analysis, the veins were divided into superficial, deep venous systems, perforating and varicose veins, and were evaluated using three points scale by a radiologist and a surgeon.results: superficial, deep venous systems and perforating veins were best visualized on btfe (p < . ), while varicose veins were equally visualized on tse and btfe. tof provided poor visibility except in popliteal veins. coexisting arterial system seen on btfe could be discriminated from the deep venous system especially on axial reconstructed images. the varicose veins connected with the superficial venous systems and perforating veins on the surface of the muscle were easily recognized on vr only using btfe. conclusions: mr-venography using btfe displays the best images of the whole venous system in patients with varicose veins below the knee. magnetic resonance angiography in potential live renal donors: a joint radiological and surgical audit a. mizzi, g. roditi, m. subramaniam; glasgow/uk purpose: to assess the impact of joint surgical and radiological audit on the accuracy of mra reports in the evaluation of potential live renal donors. materials and methods: we analysed the case records of live renal donors who underwent gadolinium enhanced mra as part of pre-operative evaluation to assess renal vasculature between august and july . in cases of discrepancy between mra reports and surgical findings, studies were retrieved to the mri workstation and subjected to detailed joint clinical and radiological review. scan quality was assessed and sources of discrepancy were identified. results: there were donors, men and women. reported mra findings were fully confirmed at surgery in of cases. these scans were not analysed further. in donors, the findings at surgery were discrepant with the radiological reports. there were cases of "missed" early branches and cases of "missed" accessory arteries. in the first year of audit there were discrepant cases out of ( %), all of which were radiological reporting errors. the number of discrepant cases in the second year dropped to out of cases ( %). neither of these was a radiological reporting error. there was one "missed" early renal artery branch in the third year of audit, which was visualised on mra review. conclusion: the accuracy of preoperative mra in potential live renal donors is high. radiological reporting of mra examinations is improved through careful clinical feedback, audit and interdisciplinary co-operation. d contrast-enhanced mr portography to scan the entire volume of upper abdomen with maximal spatial resolution using parallel acquisition techniques: preliminary experience d. horák, m. herman, j. bucil, j. klein, j. nekula; olomouc/cz purpose: to assess the feasibility and to evaluate the benefit of a d contrastenhanced (ce) mr portography (mrp) covering the entire volume of upper abdomen with maximal spatial resolution using grappa (generalized autocalibrating partially parallel acqusitions). materials and methods: patients were examined before or after surgical creation of porto-systemic shunt. t -weighted d angiographic sequence with d centric reordering optimized using a grappa factor of was performed at a . t scanner (siemens symphony maestro class) in three phases after administration of - ml of . -molar or ml of -molar gadolinium-dtpa followed by ml saline solution into the canula in antecubital vein. anatomical postcontrast t -weighted d spoiled gre with fat saturation was added. parameters of hires d-ce-mra sequence: in-plane resolution = . x . mm, number of partitions = , slice = . mm, partial-fourier = / , fov = , tr/ te/fa = . / . / , ta = sec. results: large evaluated volume hires mrp sequence is suitable for detailed postprocessing (subvolume mips) in any plane, imaging borderline vessels like recanalized umbilical vein or retroperitoneal collaterals, usually best seen in portal phase. robust protocol can be very easily adapted for uncooperative patients covering the same evaluated volume. functional information (flow direction) can be added with phase contrast mra flow quantification sequence. conclusion: our preliminary results show that the application of grappa allows to capture the whole portal vascular system without missing any important collateral with high spatial resolution in cooperative patients and with sufficient spatial resolution in non-cooperative ones. it's possible to image the flow in surgically placed porto-systemic shunts. gadobenate dimeglumine (multihance®) in contrast-enhanced mr angiography m. kirchin , r. la ferla , m. daprà , g. pirovano , a. spinazzi ; milan/it, princeton, nj/us purpose: gadobenate dimeglumine (gd-bopta) has high t relaxivity in blood (r = . °mm- s - ) compared to other gadolinium agents. this review is aimed at defining the usefulness of gd-bopta for ce-mra. methods: preliminary intraindividual, crossover studies were conducted in healthy volunteers to compare gd-bopta and gd-dtpa at the same dose and injection rate for mra of the abdominal aorta and run-off vasculature. subsequently, phase ii multicenter trials were performed in the renal/abdominal arteries (n = patients), the pelvic arteries (n = patients) and the carotid arteries (n = patients) to establish the optimum dose of gd-bopta for ce-mra. standard unenhanced and contrast-enhanced sequences were employed and images were evaluated by independent, off-site blinded radiologists on the basis of segmental and overall diagnostic quality scores per patient and dose. the crossover studies demonstrated significantly greater signal intensity enhancement after gd-bopta compared to gd-dtpa both in the abdominal aorta and run-off vasculature. the phase ii studies revealed dose-related trends for the contrast-enhanced images in each territory and good correlation between readers. the greatest increase in diagnostic quality from unenhanced mra to ce-mra occurred at . mmol/kg bw while a higher dose of . mmol/kg bw provided little or no additional benefit. ce-mra led to an increased number of patients with lesions detected and increased reviewer confidence for lesion characterization. conclusions: ce-mra with gd-bopta is more efficacious than unenhanced mra and appears superior to ce-mra with conventional gadolinium chelates. the optimum dose for ce-mra of vascular disease is indicated to be . mmol/ kg bw. influence of ct scanner and observer on volume measurement: five glass phantoms filled with diluted contrast material underwent one single-detector row ct (sdct) and two multi-detector row ct (mdct) examinations. for each ct scanner the clinical protocol for ct angiography of the abdominal aorta was used. in a first step the resulting volumes were measured using a special software with automatic outline detection without need of manual segmentation and thus without intra-and interobserver variability to evaluate differences between the ct scanners. in a second step the volumes were measured by three observers using a standard software for manual outline detection to assess inter-and intraobserver variability. results: there was no statistically significant difference between the ct scanners with the corresponding standard protocols (p = . ). inter-and intraobserver variability was . and . ml and lead to significant difference in volume measurement between the observers (p = . ). conclusion: volume measurement does not seem to be influenced by the used ct scanner. the interobserver variability is significant, but slight. consequently, changes of the volume of abdominal aortic aneurysms in follow-up ct angiography after endovascular repair can be considered as true change and not as scanner related. -slice multi-detector ct angiography in the assessment of stenoocclusive disease of the carotid artery bifurcation and vertebral artery origin s. lee, h. roh, h. byun; seoul/kr purpose: to determine the accuracy of -slice multi-detector ct angiography ( -mdcta) in the assessment of steno-occlusive disease of the carotid artery bifurcation and vertebral artery origin. materials and methods: in patients, carotid arteries and vertebral arteries were evaluated with -mdcta and conventional digital subtraction angi-ography (dsa). standardized -mdcta acquired from the circle of willis to the aortic arch. -mdcta data were displayed with maximum intensity projection (mip) for carotid and vertebral arteries and with volume rendering (vr) for carotid artery. the percent diameter stenoses of the carotid artery bifurcation and vertebral artery origin were measured separately on mip, and/or vr ct images and dsa. the carotid stenosis was graded as no, mild (< %), moderate ( - %), severe (> %), and occlusion with nascet criteria. the vertebral artery stenosis was also assessed with the same five-grade scale. the results of -mdcta were correlated with the gold standard of dsa. results: all carotid and vertebral arteries were assessable on mip and/or vr ct images. correlation between stenosis measured with -mdcta and that measured with dsa were good (pearson correlation: on carotid mip images, c = . , < . ; on carotid vr images, c = . , < . ; on vertebral origin mip images, c = . , < . ). the aggrement rate of stenosis grading between -mdcta and dsa was also high ( . % on carotid mip; . % on carotid vr images; . % on vertebral origin mip images). conclusion: -mdcta has a high accuracy for the evaluation of carotid and vertebral artery stenosis and provides multiplanar information preoperatively. does high iodine concentration contrast agent improve arterial enhancement in mdct angiography of the run off vessels? comparison of three different iodine concentration contrast agents f. venditti, c. catalano, m. francone, f. fraioli, a. napoli, v. votta, r. passariello; rome/it purpose: to evaluate whether a high iodine concentration contrast agent may determine a greater arterial contrast enhancement in the visualization of aortoiliac and peripheral vessels. materials and methods: sixty-six patients, randomly divided into two groups, a and b, were studied with a multi detector-row ct (mdct) scanner. both groups were divided in three subgroups (a = , a = and a = mgi/ml; b = , b = and b = mgi/ml) in which different iodine concentrations were injected. in group a variable flow rates were used. in group b the flow rate was kept constant at . ml/s. quantitative and qualitative analyses were performed at predefined fixed vascular segments. results: in both groups a greater density value was achieved using the high concentration contrast agent, in particular at the level of the superficial femoral artery for subgroup a and at the level of the popliteal artery in subgroup b . for all vascular segments the best enhancement was visualized for group b . no statistical significant differences were achieved between the two different groups in the visualization of sub-popliteal vessels. conclusion: our study demonstrates that the use of a high iodine concentration contrast agent increases arterial enhancement of the peripheral arterial tree using mdct scanner. multidetector ct angiography in arterial occlusive disease of the lower extremities: a step forward in vascular diagnostic procedures? m. maggi, s. alborino, e. paci; ancona/it purpose: multidetector computer tomography (mdct) angiography is a new available technique for studying arterial disease of the lower limbs. in this study we report our experience with mdct angiography in evaluating atherosclerotic lesions of peripheral arteries. materials and methods: patients ( / male/female, age ± , in and in rutherford category) were investigated by mdct between april and march , patients underwent digital subtraction angiography (dsa) of the lower extremities within days from mdct angiography. we used a - channels ge medical system ct-scanner, needle-cannula, flow rate ml/ sec, ml iodinated contrast medium / mgi/ml, bolus tracking program (smart prep). mip and volume rendering reformations were used. dsa and mdct angiograms were blindly evaluated by two vascular radiologists according to the following parameters: stenosis (lumen reduction - %), occlusion (> %), absence of lesion (< %) in arterial segments, for each patient. therapeutical implications of mdct angiography were also evaluated. results: concordance between mdct angiography and dsa was . % in detecting and . % in excluding lesions, . % in defining stenosis and . % for occlusions. in / patients percutaneous approach was modified according to ct images. conclusions: mdct angiography could be considered as the first step in diagnostic procedures of peripheral arterial disease and could also modify therapeutical strategy and vascular radiologist's performance. further studies are needed value of long-term routine ultrasound assessment of hemodialysis fistulae in comparison with clinical parameters a. wojciechowski, m. golebiowski, m. grzeszczyk, w. kania; warsaw/pl purpose: the aim of the study was to correlate the results of clinical and ultrasonographic long term follow-up of hemodialysis fistulae. the utility of routine ultrasound examination was discussed. materials and methods: patients underwent doppler ultrasound evaluation of dialysis fistulae. patients were randomly assigned for evaluation. in addition routine tests for blood cell count, hematocrit, kt/v, urr and blood pressure in the venous line were available in all patients. all patients had native fistulae. a single unit (atl ultramark hdi) was used for ultrasound examinations. results: results of laboratory and clinical parameters were abnormal in almost % of patients. low levels of hematocrit (< %) were observed in . %, albumin (< . g/l) in . %, elevated pressure in venous line (> mmhg) in . %. abnormal kt/v (< . ) and urr (< %) in . and . % respectively. us revealed: pseudoanerysms in . % of patients, hematomas adjacent to the fistula . %, arterial steal syndrome in . %, stenosis in . % and mural thrombi in . %. in . % of patients brachial artery blood flow was less than ml/min and in % of cases dialysis fistula flow was greater than ml/min. conclusion: only . % patients had no abnormal either clinical, morphological nor flow parameters. . % of patients had abnormal clinical and us morphological parameters. colour doppler ultrasound is more sensitive than clinical or laboratory methods in detection of hemodialysis fistula dysfunction. it is strongly recommended to start regular ultrasound examinations of all dialysed patients. material and methods: patients with brescia-cimino-shunts were examined by independent examiners with i. a. dsa and vascular ultrasound. all patients had a shunt-volume of less than ml/min., an angiographical stenosis of the anastomosis of at least % or changes of the venous portion of the shunt were examined. studies were performed with the aid of a multifrequency ultrasound probe ( - mhz, logic , , ge) using b-mode, color coded duplex (ccd) and b-flow, first of all in the brightness modification. results: in the group of anastomotic stenosis measurements of intrastenotic diameter gave for i. a. dsa values of (average: . mm), for b-mode (average: . mm), for ccd (average: . mm), for brightness mode of b-flow (average: . mm) and for b-flow with b-mode information values of (average: . mm). the best agreement with dsa was achieved by brightness mode of b-flow. while in b-flow in cases of anastomotic lesion or venous stenotic lesions, hypoechogenic vessel wall alterations were detected, they were not seen in b-mode in any case and not reliably in ccd due to blooming artifacts. in cases of venous aneurysm and vascular elongation a flow detection free of artifacts was only demonstrated by b-flow. conclusion: ultrasound b-flow detects anastomotic stenosis of hemodialysis fistula better than other ultrasound modes. the visualization of hypoechogenic vessel wall alterations and the degree of stenosis is also better appreciated by this mode. ultrasonographic assessment of internal mammary artery in the screening of radiotherapy induced coronary artery disease n. tuncbilek , o.o. okten , h.m. karakas ; edirne/tr, malatya/tr purpose: radiotherapeutically treated breast carcinoma patients are prone to the development of iatrogenic fibrosis and plaque formation in coronary vasculature. in this group of patients, early changes in the diameter and the flow characteristics of internal mammary artery, hypothesised as the surrogate markers of the coronary artery disease, were ultrasonographically (usg) investigated. the study group was consisted of breast cancer patients with ages between and (mean age . yrs) and age-matched control subjects. all patients were radiotherapeutically treated to month ago. internal mammary arteries were ultrasonographically investigated with . mhz linear transducer in longitudinal planes. diameters of the arteries were measured in m-mode; resistivity indices (ri), pulsatility indices (pi), peak systolic and end diastolic values were measured with color doppler usg. mean values of the above mentioned parameters were statistically compared among patient and subject groups. results: mean diameter of the internal mammary arteries were found to be . mm in patients and . mm in control subjects. there was a statistically significant difference between two groups regarding the stated parameter (p < . ). in contrary, the difference of ri, pi, peak systolic and end diastolic values were not statistically significant in two groups studied. conclusion: shortly after radiotherapy the diameter of the internal mammary artery significantly decreases but its flow spectrum does not change. ultrasonographically performed simple diametric measurements may be used as rapid and noninvasive screening tests to predict the development of coronary artery disease. assessment and follow-up of endovascular repair of aortic aneurysm with multislice computed tomography m. fernández -velilla, m. martí, y. herrero, j. echeveste, g. garzón, n. gómez-león; madrid/es purpose: to evaluate the usefulness of multislice computed tomography (msct) after placement of endovascular stent-grafts for treatment of aortic aneurysms. matrials and methods: seventy-six patients underwent msct angiography following treatment of thoracic or abdominal aortoiliac aneurysm with endoluminal stent-grafts. msct was performed from the supracoeliac aorta to the femoral artery bifurcation in patients with aneurysm affecting the abdominal aorta (n = ), and from the thoracic inlet to the femoral bifurcation in patients with thoracic aneurysm (n = ). the standardized protocol consisted of a nonenhanced ct ( mm collimation, pitch of , reconstruction interval of mm, table speed of mm per rotation and a single-breath-hold acquisition), followed by a contrast-enhanced ct. all images were postprocessed in a workstation (vitrea ; vital images, plymouth, minn). the image postprocessing included multiplanar reformats, mip, shaded-surface display, and volume rendering. the studies were assessed for stenosis, thrombosis, perigraft leakage, migration, angulation of graft, and enlarging sac size without visible endoleak (endotension). follow-up ct was performed prior to discharge and at six and twelve months after intervention. results: after stent-graft placement in the patients, ct demonstrated graft permeability in ( %), perigraft leaks in ( %), angulation of the graft in ( %) and endotension in ( . %). conclusion: msct was able to study the entire aorta with a maximal and homogeneus opacification. the msct technique allowed fast scanning, great anatomic coverage during a single breath hold, few motion artefacts, and high spatial resolution in the longitudinal plane, improving the diagnostic accuracy of the examinations. evaluation of vertebral artery using color duplex sonography: comparison of vertebral artery velocity and flow volume measurements for diagnosis of vertebrobasilar insufficiency m. acar, b. degirmenci, a. yucel, r. albayrak; afyon/tr purpose: the aim of this study was to compare the measurements of vertebral artery (va) flow velocity and flow volume for diagnosis of vertebrobasilar insufficiency. matrials and methods: we examined patients referred for evaluation of vertebrobasilar insufficiency. net va flow volume and mean systolic flow velocity were determined by using color duplex sonography. we grouped the patients into three: group consisted of patients with severely damped va flow volume (< ml/min), group moderately damped ( - ml/min) and group , normal (> ml/min). the mean systolic flow velocities in each group were compared by one-way anova. results: damped va flow volume was determined in of patients, of these patients had severely damped, had moderately damped, had normal va flow volume. mean va systolic flow velocities of group , and were ± , ± and ± cm/sec, respectively. mean va systolic flow velocity in group was significantly lower than that of group (p = . ). however there were no significant differences between va systolic flow velocities in group and group (p = . ). conclusion: according to our findings, measurement of va velocity is enough for diagnosis of vertebrobasilar insufficiency in patients with severely damped va flow volume but may not always be helpful in differentiation of moderately damped flow volume from normal. therefore we conclude that for the diagnosis of vertebrobasilar insufficiency, measurement of volume in addition to velocity is necessary in detection of moderately damped va flow volumes. rotational angiography of femoropopliteal arteries after percutaneous transluminal angioplasty (pta): preliminary results f. pozzi-mucelli, m. belgrano, g. tona, r. pozzi-mucelli; trieste/it purpose: to report our experience in rotational angiography (ra) after pta of the femoropopliteal arteries and to compare this modality to standard anteroposterior (ap) projection. materials and methods: forty patients underwent pta of the femoropopliteal arteries in the last months. twentysix were stenoses (lenght: - cm) and occlusions (lenght: - ). in all cases pta was successful and the result was checked with ap projection and with an ra acquisition. the procedure were performed on the philips integris allura system providing the ra tool. results: ra after pta was successful in all cases. in % of cases there was no difference between the static ap projection and ra, whereas in % the static acquisition, compared to ra, underestimated the degree of residual stenosis by - %. in about % of these cases a disagreement on the presence and extent of subintimal flaps between static and rotational acquisition was identified. in another % of cases there was substantial agreement on the residual stenosis but not on the pta-induced dissection which was always better identified on ra. conclusions: ra allowed optimal evaluation of all cases improving the information on the conventional technique based on one or two projections. in our experience this information modified our therapeutic approach leading to repeated balloon angioplasty or stenting in % of cases. all the diagnosis were confirmed by digital angiography or surgical treatment. in the first group (endoluminal repair), the complications were: a) periprosthetic hematoma (n = ); b) neointinal hyperplasia (n = ); c) partial stent-graft thrombosis (n = ); d) total stent-graft thrombosis of an iliac branch (n = ); e) endoleak type ii (n = ); f) endoleak type iii (n = ), separation of the stents' components (n = ). in the second group (surgical repair) we observed: a) periprosthetic infections (n = ); b) supraprosthetic aneurysm (n = ); c) pseudoaneurysm (n = ); d) aortoenteric fistula (n = ). conclusion: cta is accurate, fast and minimally invasive imaging method in the evaluation of complications after abdominal aortic aneurism repair. interobserver agreement in the ct evaluation of carotid artery stenosis p.m. carrascosa , f. meli , c. capuñay , t. sampere , e. martin lopez , d. smith , s. chandra , j. carrascosa ; buenos aires/ar, cleveland, oh/us objective: to determine the usefulness of ct angiography (cta) in the detection and quantification of carotid stenosis in comparison with da. materials and methods: thirty-eight carotid arteries were evaluated in patients with transient ischemic attacks. ctas were performed with a helical ct scanner (pq ; picker). images were evaluated by two radiologists, who were blinded to the percentage of stenosis determined by da. the stenosis were considered positive if they were ≥ %. different methods of stenosis quantification (nascet(n), esct (e) and area quantification (a)) were performed on the same vessel to determine the sensitivity and specificity of each one in comparison with da. interobserver variability of the three methods was evaluated. statistical analysis: kappa coefficient was performed to determine the interobserver variability. results: observer : sensitivity: n: %, e: % and a: % and specificity: %, . % and . % for each method, respectively. observer = sensitivity: n: %, e: % and a: % and specificity: %, . % and % for each method, respectively. kappa: . , and . for n, e and a respectively. conclusion: cta showed high s and sp in the carotid stenosis quantification, specially with the nascet method. emergency multislice ct angiography (mscta) in patients with suspected aortic dissection r. stern padovan, m. lusic, b. oberman, k. potocki; zagreb/hr purpose: the purpose of the study was to evaluate positive msct-angiography findings in patients with spontaneus-nontraumatic aortic dissection. mscta is a noninvasive, time-saving radiological procedure for patients with aortic dissection because they need prompt and accurate diagnosis and treatment. aortic dissection is defined as a separation of the inner aortic wall layers. it is divided by stanford classification into type a that involves the ascendent aorta and type b involves distal to the origin of the left subclavian artery. materials and methods: mscta was performed in patients ( ( . %) female and ( . %) male age - ) with clinically suspected aortic dissection over a period of months on lightspeed ultra slices, ge. slice thickness was . mm with % overlap of reformatted images. we injected - ml of nonionic contrast material at a flow rate of ml/sec with smart prep feature. mip and mpr were usually used. results: aortic dissection was found in ( . %) patients. ( . %) had acute aortic dissection and ( . %) chronic type. acute aortic dissection stanford type a was found in ( %) and type b in ( %). in patients we did not find aortic dissection but other ct findings could explain the symptoms: aa, rupture of aa, mesenteric ischemia, pericardial effusion. conclusion: mscta is noninvasive, rapid and relatively comfortable radiological procedure for patients with suspected acute aortic dissection in cardiovascular emergency. this technique enables correct and detailed diagnostic information and obviates catheter aortography. diagnosis of aortic and supraaortic emergency with ct angiography: how does aortic morphology influence the choice of treatment? c. engelke , k. marten , a. chavan , j.f. reidy , a.-m. belli , e.j. rummeny ; munich/de, hannover/de, london/uk objective: ct angiography (cta) is the imaging method of choice for diagnosis of aortic and supraaortic emergency. in this retrospective evaluation of patients with aortic or supraaortic emergency undergoing intial cta at four european centres diagnosis and determination of treatment are reviewed. the assessment of diagnostic value of vmax, vmin, pi, ri measurements in the diagnosis of coeliac trunk stenosis before and after levovist injection -roc curves analysis a. drelich-zbroja, t. jargiello, w. krzyzanowski, p. kurczab, m. szczerbo-trojanowska; lublin/pl purpose: to assess the diagnostic value of vmax, vmin, pi, ri measurements in the diagnosis of coeliac trunk stenosis before and after levovist injection. in patients doppler examination of coeliac trunk before and after levovist injection was performed measuring vmax, vmin, pi, ri. in conventional doppler and after levovist administration stenoses were diagnosed. number of diagnosed stenoses in relation to number of normal coeliac trunks was representative enough to perform the statistical analysis using roc curves. results: . the areas under curves (aucs) for vmax, vmin, pi, ri, before and after levovist. a. before levovist: aucvmax = . *, aucvmin = . *, aucpi = . ns , aucri = . ns . a. after levovist: aucvmax = . *, aucvmin = . *, aucpi = . ns , aucri = . ns . *p < . when compared with auc = . ; ns-not significant when compared with auc = . . the comparison of aucs for vmax and vmin before and after levovist. aucvmax after levovist -aucvmax before levovist = . ns , aucvmin after levovist -aucvmin before levovist = . ns , aucvmax before levovist -aucvmin before levovist = . *, aucvmax after levovist -aucvmin after levovist = . *. *p < . ; ns-difference not significant conclusions: only vmax and vmin are useful in the diagnosis of coeliac trunk stenosis. the diagnostic value of vmax is significantly higher than diagnostic value of vmin. the use of levovist has no an effect on diagnostic value of vmax and vmin. the effect of body mass index on the ultrasonographic measurements of the portal venous system n. tuncbilek , o.o. okten , s. guldiken , h.m. karakas ; edirne/tr, malatya/tr purpose: the effect of body mass index (bmi) on portal venous diameter and pulsatility index was investigated. the study group consisted of obese and control subjects with normal bmi. inferior vena cava (vci) and portal vein (pv) diameters and their pulsatility indices (pi) were prospectively evaluated with . mhz convex transducer. diametric measurements were employed in m-mode imaging. the difference between obese and normal subjects regarding above mentioned parameters and their correlations with pi are investigated. results: bmi varies between . and . kg/m in control, and between . and . kg/m in obese subjects. in control subjects, mean pi is . for pv and . for vci. in obese patients, these values are . and . , respectively. pi for pv significantly differs between two groups (p < . ) whereas vascular diameters for vci and pv, and pi for vci are not statistically different. in both groups there is a negative correlation between pi and bmi (for control subjects: r = - . , p < . ; for obese subjects r = - . , p < . ). conclusion: pi of the portal venous system is regarded as the surrogate marker of right cardiac function. however factors such as inspiratory and expiratory intraabdominal pressure changes are known to affect this parameter. when considering pi as a marker of right cardiac function, attention must be paid to the relation of pi and bmi, proved by this study to be one of these factors. significance of patent pyloric branch in hepatic arterial infusion chemotherapy s. yoshioka, y. yasuhara, t. murakami, s. kumano, t. mochizuki; ehime/jp purpose: to investigate the clinical significance of the patent pyloric branches after right gastric artery (rga) embolization for arterial infusion chemotherapy. materials and methods: sixty-six patients who received catheter placement in the hepatic artery for arterial infusion chemotherapy were retrospectively recruited from the pool of clinical records between and . two interventional radiologists reviewed the digital subtraction angiographies (dsas) and clinical records of these patients. they assessed the following items by consensus: ) location of the rga, ) frequency of the patent pyloric branchs after coil embolizaton of the rga, ) outcome of arterial infusion chemotherapy through the catheter. results: the location of the rga could be determined in patients. rga-coil embolization was performed in patients. in patients, fine pyloric branchs were patent after embolization. they were too fine to be embolized by the catheter technique. in of these patients, the catheter was successfully placed to avoid the drug infusion into the pyloric branch. the clinical outcome of the other patients were as follows: one patient received the arterial infusion chemotherapy without any complication. one patient experienced transient abdominal pain in the course of arterial infusion chemotherapy. two patients received replacement of the catheter because of abdominal complication. the last patient received surgical ligation of the rga because of reopening of the rga. conclusion: the frequency of abdominal complication in arterial infusion chemotherapy was not negligible in the cases with patent pyloric branchs after rga embolization. erdheim-chester disease: imaging features c. graef, e. dion, p. cluzel, r. renard-penna, j. haroche, b. wechsler, c. beigelman-aubry, p.a. grenier; paris/fr learning objectives: to be familiar with the radiologic features of erdheim-chester disease, a rare form of non-langerhans cell histiocytosis of unknown etiology. background: the disease is characterized by tissue infiltration with lipid-laden foamy histiocytes, polymorphic granuloma of inflammatory cells and collagen fibrosis. the patients have a mosaic of infiltrative involvement of various organs. bone involvement is almost always present but often clinically asymptomatic. the prognosis depends on the severity of cardiovascular, renal or cerebral involvement. imaging features of histologically proven cases were reviewed. imaging features: radiological bone involvement was present in all cases, characterized by bilateral and symmetrical spongy bone densification, cortical thickening and periostosis of long bones from the metaphysis to the diaphysis associated with scintigraphic tracer uptake. renal and perirenal involvement seen on ct scans consisted of bilateral and symmetrical perirenal tissue infiltration (hairy kidney) (n = ), extended to the adrenal fossae, the renal sinuses, and the proximal ureters. cardiovascular involvement consisted in ) thoracic and abdominal circumferential periaortic tissue infiltration (coated aorta) with extension to the coronary, supraaortic and pulmonary arteries, and abdominal branches, ) stenosis of renal or mesenteric arteries (n = ), ) involvement of pericardium (n = ) and myocardial mass (n = ). tissue infiltration involved pituitary in one case and orbits in another one. conclusion: a diagnosis of erdheim-chester disease should be considered in patients who demonstrate bilateral and symmetric densification of the long bones with increased uptake on scintigraphy in association with perirenal fat infiltration and/or a periaortic fibrosis. human nk- cells were labeled with ferumoxides and ferucarbotran using simple incubation, lipofection and electroporation techniques. incubation times were varied from - hours and added contrast agent concentrations were varied from - microgram fe/ cells. pellets of labeled cells and non-labeled controls were evaluated by mr imaging. the cellular iron oxide uptake was proven by prussian blue stains and spectrometry as a standard of reference. in addition, cell viability was tested with the trypan blue exclusion test. differences between labeled cells and non-labeled controls were tested for significance using the t-test. results: nk- cells could be labeled with ferucarbotran and ferumoxides by lipofection and electroporation, but not simple incubation. lipofection had to be performed for h, but resulted in only minor, not significant impairment of cell viablility ( - %) compared to controls ( - %), while electroporation caused cell labeling within seconds, but reduced the viablility of the cells significantly ( - %), thereby necessitating additional cell culture time for cell recovery. the intracellular iron oxide uptake was proven histologically and quantified by spectrometry. ferucarbotran and ferumoxides-labeled cells could be depicted by a significant signal decline on t *weighted mr images. conclusion: human nk- cells can be labeled with ferucarbotran and ferumoxides by lipofection and electroporation. optimized labeling techniques allow a subsequent cell depiction with a standard . t mr scanner. which temporal frame rate is necessary in quantitative dynamic ³he-mri? c. heussel , a. dahmen , f. lehmann , m. salerno , k.k. gast , h.-u. kauczor , j.p.i. mugler , e.e. de lange , w. schreiber ; mainz/de, charlottesville, va/us purpose: dynamic ³he-mri permits regional analysis of distribution ventilatory kinetics. dedicated post-processing offers image-based lung function parameters. sliding window reconstruction of interleaved-spiral acquisitions provides high temporal rates, but do functional parameter values depend on the temporal frame rate? methods and material: single-slice coronal dynamic ³he-mri was acquired continuously for s during free respiration. image reconstruction was performed using sliding window technique with . ms data sampling-time (repetition-time ms). post-processing was performed using a self-written software with linear motion correction for calculation of: rise time (tr, interval of lung-signal from % to % of peak signal), delay- time (td , interval of trachea-signal % and lung-signal %), amplitude (peak lung-signal), and peak flow (pf, maximum signal slope). analysis was done for rois using a temporal resolution of ms, ms, and ms ( nd , th , and th image). this study included exemplary patients (asbestosis, x asthma, copd) so far. results: post-processing of the data-sets lasted to mins at an actual pc ( . ghz p , gb ram). tr ranged from to ms (median ms), td ranged from to ms (median ms), amplitude ranged from to a.u. (median a.u.), pf ranged from to a.u. (median a.u.). no relevant difference was detected in the evaluation of different temporal frame rates for all patients or within an individual patient. conclusion: since these preliminary data suggest a limited effect of high temporal frame rates, improvement of spatial rather than temporal resolution might be the emphasis in the future. to determine the compensatory mechanisms involved in recovery of motor function following resection of the supplementary motor area (sma) and their relation to the clinical characteristics of recovery. subjects and methods: thirteen patients referred for surgery of low-grade gliomas located in the sma were compared to nine healthy controls using fmri before and after surgery during self-paced movements of both hands, successively. activation within regions of interest (rois) (primary sensorimotor cortex (smc), premotor cortex (pmc), sma) were compared and tested for correlation with anatomical characteristics of the tumor and resection, and clinical data. interaction analysis between rois was performed using partial correlation. results: tumor growth induced preoperative underactivity in the adjacent sma and overactivity in the opposite sma. postoperative recovery was associated with recruitment of the lateral premotor cortex in the healthy hemisphere. in the affected hemisphere, pre-and postoperative correlations between sma, pmc and smc were decreased. in the healthy hemisphere, postoperative correlations between pmc and sma or smc were increased. shortened onset and duration of recovery was associated with preoperative changes in sma activation. conclusions: these findings suggest that tumors induced a dysfunction in activation and connectivity of the ipsilateral sma, which was partially compensated by a recruitment of the sma in the healthy hemisphere. this preoperative remodeling of sma activity did not prevent the occurrence of the postoperative deficit but was associated with shortened recovery. sma resection was compensated by the recruitment of an ipsilateral premotor circuitry. the use of internet filters to build a radiology education and teaching resource p. davison, j. revell, m.r. rees; bristol/uk purpose: to develop a resource for radiology undergraduate and postgraduate education from a series of research projects dealing with internet filter aided search. supported by a research and education grant from the ear. materials and methods: two independent research projects into internet search were examined for their application to radiology education and these methods were compared to conventional image search protocols. this experience was translated into constructive advice for undergraduate students undertaking special study modules in radiology. the two internet filters developed were designed to improve accuracy of text search and to improve the search results from image search enquiries in radiology and medical subjects. a second iteration of the image search filter was developed to produce a web crawler that selected images from previously carried out text searches. the text and image based filters were tested with other search engines over a preset number of criteria. results: both the text based search facility and the image based facility showed advantages when compared to conventional search methods. the image search facility was successful in handling medical searches compared to common search engines and the web-crawler was efficient at producing a large number of images from selected sites. these methods were used to develop medical students skills in the use of the internet and has been used in the construction of radiology image based special study projects. conclusion: web based filter programmes and education in search techniques can result in improving the efficiency of internet based material for radiology education. single breath-hold subtraction: novel approach to diagnosing pulmonary embolism by multi-slice ct (work-in-progress) j.e. wildberger , a.h. mahnken , h. ditt , m.u. niethammer , e. spüntrup , e. klotz , r.w. günther ; aachen/de, forchheim/de purpose: in the work-up of pulmonary embolism (pe), ct allows for direct visualization of emboli. in addition, perfusion defects permit direct assessment of the extent of pe, using color-coded lung densitometry. this new image processing technique has been deployed for a -slice multi-slice ct (msct) system. for further improvement, a subtraction technique within a single breath-hold will be mandatory. materials and methods: three healthy pigs underwent lung lavage to induce c- assessment of the angioarchitecture and hemodynamic characteristics of cerebral avms by contrast enhanced static and non enhanced dynamic mr angiography m. essig; heidelberg/de purpose: the aim was to improve the definition of the angioarchitectural components of the avm based on a dynamic mra (dmra) and a high resolution d multi-bolus and multi-phasic contrast-enhanced mra (ce-mra). both techniques will be compared with d-tof-mra and transfemoral high resolution plain film angiography performed for treatment planning. materials and methods: dmra will be performed by tracking a blood bolus through a vessel structure using the spin labeling technique star (signal targeting with alternating radiofrequency sequences). time-resolved ce-mra will be acquired with an ultrashort d fast low-angle shot (flash) sequence (tr/te . / . msec) using asymmetric k-space sampling in readout, phase-encoding, and partition directions. results: all used sequences were successful in the assessment of patients' cerebral avms. the integration of acquired images into the treatment planning protocol was possible for all modalities. the different avm compartments, feeding arteries, avm nidus, and draining veins were detected easily and best on the dmra. the method also allowed to hemodynamically assess the malformations: small avms generally showed shorter shunt times, however, a short shunt-time was associated with a higher risk of bleeding. ce-mra also proved to be superior than tof-mra in the assessment of the angioarchitecture, however, the time resolution of the dynamic varient was too slow to achieve a substantial hemodynamic characterisation. discussion: dmra and ce-mra are better suited than tof-mra to assess avm angioarchitecture. the differentiation of different compartments of the malformation and the hemodynamic assessment is best seen with dmra. diagnostic investigations in relation to determination of paramagnetic centres and free radicals in the model of testicular tumor metastases m. kekelidze, f. todua; tbilisi/ge purpose: to assess the possible connections between diagnostic imaging (spiral ct, mri) of retroperitoneal metastases of testicular tumor and the detection of paramagnetic centres and free radicals in the resected lymph node tissue after retroperitoneal lymph node dissection (rplnd). materials and methods: patients with stage i morphologically confirmed nonseminomatous testicular tumors were subjected to rplnd. diagnostic imaging included abdominal spiral ct with iv contrast and mri. specific tumor markers (afp, cgt) were detected. highly sensitive ( - spin/gas) electron paramagnetic resonance (epr) of resected lymph node tissue was performed to detect the presence of paramagnetic centres and free radicals (fe + , mn + , n ) signals. ct or mri scans were judged as positive or negative for rp metastases on the basis of size, contrast enhancement criteria and compared with morphological and epr data. results: in patients estimated as n on ct and mri the increased signals of free radicals were revealed in tissues. among patients (n ) with resected lymph node tissue, showed low signals of fe + mn + n and material (morphologically confirmed as metastatic) high signals of free radicals, while the increased presence of paramagnetic centers were not detected in these tissues. spiral ct and conventional mri fail to detect micrometastases in cases. there exists real correlation (p < . ) between the increased signals of free radicals (fe + , mn + , n ) and low stage metastatic lesions of rp lymph nodes, which can reflect the connection between particular molecular events and malignant degeneration. diagnostic accuracy of gadolinium-enhanced mr-angiography vs. contrastenhanced helical ct in the diagnosis of pulmonary embolism in the presence of lung infiltrate: an animal study t. franquet, s.e. kalloger, a. oikonomou, s.l. macdonald, e.m. baile, r.j. mayo; barcelona/es purpose: to compare gadolinium-enhanced mr angiography with contrast-enhanced spiral ct for the detection of small pulmonary emboli in pigs with and without pneumonia. materials and methods: ten female juvenile pigs were anaesthetized, intubated and ventilated. sub-segmental sized pulmonary emboli were introduced by injecting . mm methacrylate beads into the external jugular vein. lung infiltrates were simulated by intra-bronchial injection of human plasma. animals were imaged in the supine position at suspended inspiration with cm h peep. contrast media was injected via brachial vein. dual gradient (twinspeed) . t mr images were acquired using dimensional spoiled gradient-echo time of flight sequence; tr . msec, te . msec, * flip angle, mm section thickness, cm fov, x matrix, one average. two mra sets, pulmonary arterial and venous, were acquired in seconds. contrast enhancement was provided by ml of gd dimeglumine followed by ml of normal saline, injected at ml/sec. non-contrast and contrast enhanced ct images were obtained using an track spiral ct; . mm detector aperture, ml contrast at ml/sec. subtraction perfusion images were calculated by subtracting contrast enhanced from non-contrast ct images. after imaging the pig was euthanized and a methacrylate cast of the pulmonary vasculature was obtained and used as a "goldstandard". cta, cta with subtraction perfusion images and mr images were independently interpreted by two observers in a blinded fashion. results: no significant difference (p > . ) was seen between cta, cta with subtraction perfusion images and mr for mean sensitivity ( %, % and %) or mean specificity ( %, % and %), respectively. no significant difference (p > . ) was seen in sensitivity or specificity between pigs with and without infiltrates. a prospective power analysis based upon this preliminary data indicates that the addition of two more readers (n = ) would yield significant differences (p£ . ) between cta and cta with subtraction perfusion images compared to mra for sensitivity and specificity. conclusion: preliminary results indicate that cta and cta with subtraction perfusion images provide improved detection of sub-segmental sized pe in comparison to gadolinium-enhanced mra. key: cord- -wycj imc authors: saini, varinder; garg, kranti title: case finding strategies under national tuberculosis elimination programme (ntep) date: - - journal: indian j tuberc doi: . /j.ijtb. . . sha: doc_id: cord_uid: wycj imc case finding, an important parameter in fight against tuberculosis (tb) has always remained a challenge despite advances in diagnostic modalities, access to health care and administrative commitment. we are still far from reaching the goals so set as per end tb strategy and national strategic plan - , and case finding is of paramount importance for achieving the said targets. this article, after identifying the obstacles faced in case finding, explores the various case finding strategies in the perspective of diagnostics, feasibility, resource utilization and current recommendations. need for prioritization of case finding in different settings with involvement and active participation of one and all has been discussed. role of health education in an individual, general public and health care worker in the context of case finding has been highlighted. research areas to strengthen case finding have been enumerated. the review concludes by bringing out the need for heightened efforts for case finding in tb as the resources are significantly diverted as the world is facing the corona virus disease (covid- ) pandemic. tuberculosis (tb) has been present in humans and causing suffering to the mankind since ancient times. despite various measures being carried out continuously at every possible level to eliminate this disease from the world, we have been far from successful. it still remains either undiagnosed or untreated and underreported in a significant section/proportion of the population all over the globe. the goal of the end tb strategy devised by the world health organization (who) is to end the global tb epidemic by the year . an effective step in this direction is prompt diagnosis so that the treatment may be initiated before that person transmits infection to others in the society. to meet this goal, who has proposed early diagnosis of tb and systematic screening of contacts and high risk groups, and calls for achieving zero catastrophic cost for tb-affected families by the year . india is a high tb burden country and efforts are continuously being undertaken for elimination of this disease. in the indian national strategic plan (nsp) for tb elimination - , it was announced that the national goal was to work towards elimination of tb in india by the year and achieve zero catastrophic cost for affected families due to tb by the year . as with any other infectious disease, finding those suffering from the disease early in the course of illness, and treating them effectively is of paramount importance. a person suffering from tb, if left undiagnosed and untreated, can infect - individuals in his close contact over the course of one year. tb thus affects the individuals, their families and also the society, directly or indirectly. even after diagnosis and initiation of treatment, the long duration of chemotherapy and its tolerance and issues with compliance are obstacles to successful treatment outcomes. in addition, the problem of drug resistance has added significantly to the troubles of the tb control programs. breaking the chain of transmission is the key component of any tb elimination program. treating only those patients who themselves present to the health care facilities with symptoms of the disease and are subsequently diagnosed with tb is not enough as this leaves out a large chunk of patients who don't report for a variety of reasons and are free to spread the disease to their contacts. measures to find these 'missing tb j o u r n a l p r e -p r o o f cases', who are infectious but not presenting to the health care facilities, is the need of the hour, to curtail further spread. nsp for tb elimination has also taken a call on this very important phenomenon. previously, the strategy of passive case finding (pcf) i.e. investigating only those who themselves reported to health care facilities was considered good enough to control tb. the initial objectives of revised national tb control program were to achieve and maintain detection of at least % of the estimated new sputum positive people in the community. , but now, in the nsp for tb elimination, the importance of case finding has been highlighted, with particular emphasis on the need to shift from pcf to active case finding (acf). keeping in view the difficulties involved while dealing with such a huge population, certain more vulnerable target groups have been identified for the purpose of acf. it has also been proposed that % of the identified targeted key affected population should undergo acf by the year . however, we are still far away from our goals. tb is associated with an indolent course. despite efforts, lack of awareness, stigma, apprehension and distrust persists amongst general public and those suffering from the illness. people avoid coming forward for the diagnostic workup, and prefer to suffer in silence, spreading the disease further to their close contacts and in the community. also, in a country like india, where a significant percentage of population relies on daily wages for livelihood, going to a health care facility is regarded as wastage of productive time because of poor transport options and difficult accessibility of health care centers in many cases. on top of that, these individuals usually being below poverty line, and living in congregate settings, spread the undiagnosed disease like a wild fire. these issues, even at the administrator level, are not easy to deal with, while formulating policies for tb elimination. resource mobilization for decreasing the diagnostic delays in such areas is quite challenging, and not an easy task. there is also an evidence that some patients suffering from tb may be completely asymptomatic. so they may never present to the health care facility, or present after a significant delay after continuing the chain of transmission as super spreaders. , sometimes, because of overlapping of it is a well known that children under years of age, elderly, people living with human immunodeficiency virus (plhiv), diabetics, smokers, alcoholics, care takers, family members, co workers and home visitors of the index case, monks, nuns, slum dwellers, prison inmates, refugees, migrant workers, etc are more vulnerable to get infected as compared to the general population. , [ ] [ ] [ ] [ ] [ ] [ ] early case finding in these groups particularly will decrease the transmission and hence decrease the secondary cases in the community. the nsp for tb elimination has also proposed acf in such vulnerable groups and even sub-classified them into urban, rural as well as tribal areas, as per requirements of that specific area. passive case finding (pcf): is defined as diagnosis of tb at health facilities among individuals who are aware of their symptoms and present for evaluation of the same on their own. it accounts for the major chunk of patients diagnosed with tb and is the backbone of any tb control/ elimination program. however, by the time the patient is diagnosed, he has undergone suffering and might already have infected a number of people who came in contact with him. for tb in individuals who are at high risk of developing the same. interventions for acf may encompass a variety of strategies, ranging from household or social contact tracing, door to door screening, facility based case finding, targeted screening of high risk groups or retrospective contact screening. [ ] [ ] [ ] as a general rule, acf has been found to be helpful as it has added to the case notification rate, in whatever subgroup/ setting it has been conducted. [ ] [ ] [ ] [ ] j o u r n a l p r e -p r o o f any type of the acf strategy, whatever resorted to, will help to identify active tb patients at an earlier stage than during the natural course of their illness. looking from the programmatic point of view, with the pre-defined targets set for tb elimination, acf seems to be an attractive option for early case finding and subsequent treatment, particularly during first years after exposure, when the chances of developing active disease and spreading the infection are the highest. however, the application of any modality of acf has to be carefully assessed for its actual feasibility in the existing real life case scenarios. in a high tb burden country like india, with limited resources and the disease being extensively present in the community, indiscriminate mass screening of the whole population is a tedious and practically impossible task. at the same time, if we aim to screen a specific subgroup of vulnerable individuals, the process needs to be continuous and has to be repeated periodically. a study in an indian setting has found that patients diagnosed with tb through acf were of older age, predominantly from rural background, poorly educated, financially constrained and stayed away from the designated microscopy centers. another study from peru has found that acf was particularly helpful in women. the identification of the cases while screening hence should be guided by local epidemiology, requirements of the particular area and behavior of the people and the staff working there. , contact tracing should start from household contacts, followed by close and then remote contacts. also, the issue of 'missed cases' in the population left unscreened, after acf needs attention and should be considered at every point during analysis. the advantages and contribution of acf are obvious as evidenced by a number of studies. , it has been found to decrease the time interval between first onset of symptoms and first access to health care services, especially when compared with pcf. however, even in acf, a considerable time wastage has been observed in acquisition and transfer of data as the decision regarding diagnosis and initiation of treatment is taken at the higher levels. , hence, there is an urgent need for decentralization of diagnostic services by use of mobile units and training of hcw's at the peripheral level. interventions to frame patient friendly policies for provision of j o u r n a l p r e -p r o o f diagnosis and treatment at the door step, with minimal logistic delays is hence urgently required. it is pertinent to note that before more evidence is generated, patients diagnosed with tb through acf should be particularly monitored for treatment outcomes when compared from those diagnosed by pcf, as studies in the past had reported variable treatment outcomes. [ ] [ ] [ ] in the indian context, a variety of health care setups are available to which the patient first presents, and this opportunity to diagnose tb through acf in such patients during their first health care visit should never be missed, irrespective of the complaints. the implemented throughout the country, nucleic acid amplification test (naat) is to be used. , but for acf, it has been observed that various agencies have used a variety of diagnostic algorithms depending on the population being screened, local prevalence, feasibility and logistics. symptom screening, chest radiography, sputum smear microscopy and cartridge based nucleic acid amplification test (cbnaat) in various combinations have been used by various researchers in different settings. , , , , , , despite having given promising results, such a use of varied algorithms in different subgroups has resulted a variable yield. rather than relying on different combinations of diagnostic modalities in different algorithms, we need to have a rapid, convenient and j o u r n a l p r e -p r o o f resource saving point of care screening/ diagnostic tool for better acf. , innovative ways like the use of mobile units, thus bringing the health care facilities at the door step, have already been proposed and can be of immense help in scaling up testing and decreasing diagnostic and treatment delays. , framing clear cut recommendations for acf, and testing the vulnerable population on priority, without any diagnostic dilemmas which are currently prevailing, is bound to serve as a major leap in our efforts to tb elimination. so far as the patient is concerned, immediate benefit of pcf is apparent, in terms of improvement in day to day symptomatology and overall morbidity. mortality and other long term indicators are also known to show improvement. however, immediate benefit of acf is difficult to quantify, as these cases may be apparently healthy, with minimal or no restrictions in their day to day activities. we need very specific indicators and the benefit over long term needs to be particularly measured for a broader vision and better planning of strategies for the coming future. tb has a devastating financial impact, in terms of direct as well as indirect costs. rationale use of resources becomes a major concern, as we diagnose and treat people in their natural course of disease either by pcf, or even earlier by acf. acf is associated with huge expenditure and resource utilization. however, pcf also doesn't come for free and has its own costs. comparative cost analysis of acf vs pcf in the long run is urgently required, as contradictory literature on its cost effectiveness in different sub groups, from different parts of the world is available. , neither acf nor pcf can be totally discarded. rather it is required that both the strategies complement each other. as we shift our focus to acf, strengthening of the traditional pcf is also simultaneously required as acf cannot cover the entire population. acf in vulnerable groups should be integrated with various other national level activities/ programs. integration with national program on prevention and control of diabetes, national acquired immunodeficiency syndrome (aids) control program, national tobacco control program etc is destined to improve the case finding in patients j o u r n a l p r e -p r o o f with these co-morbidities and thus help in management of the patients in totality. role of non government organizations (ngo's) also needs a special mention here, as they can serve as a huge pool of easily available resources. close monitoring and rapid evaluation of innovative interventions, long term follow up of existing campaigns and carrying out randomized controlled trials in different epidemiological settings for studying the impact of different approaches for effective screening/case finding is urgently required, as we struggle to meet the goals so set forth in the end tb strategy. , universal health coverage and social protection with a patient centered approach for one and all should be the prime concern. standardization of protocols and tailored approaches as per local needs need to be worked up. collective efforts in this direction will ultimately help us in formulating clear cut guidelines for case finding, which can be confidently relied upon and thus help us in taking another giant leap towards tb elimination. as we deal with the index case, it is generally noticed that there is very limited participation of the contacts. it is understood that contact tracing in such situations may lead to considerable anxiety. formal focused health education should routinely be a part of pcf as well as acf. understanding the psychology of the patient and the community is indispensable to the development of education strategies. intensive education to inculcate awareness and health seeking behaviors amongst tb patients and general public needs to be carried out. special attention should be given to cough etiquettes, respiratory hygiene and ventilation. patients should be counseled to bring their contacts for screening, and for diagnosis and treatment if screened positive. proper sessions on diagnosis, treatment and the accompanied dangers if left untreated, need to be conducted time and again targeting for a final behavioral change amongst masses. training and mobilization of patients, their contacts and socially active persons in the community as peer educators may work wonders in case finding and tb elimination. at one end, when we focus on the role of patients and the general public, we should be fully aware that the role of a health care worker (hcw) is equally important. generally, at administrative levels, there is staff shortage, poor infrastructure and diagnostic equipments. poor knowledge, attitude and practices of hcw's add to the problems. the whole hearted active participation and alertness of the hcw needs special attention, and needs to be emphasized during their training sessions. they should focus on health education during household visits, and at every point of contact with the patient and/or general public. the approach of the hcw should be sensitive enough to counter the apprehension and psychosocial barriers so encountered at different steps. covid- was declared a global pandemic on th march, , by the who. strict nationwide lockdown in india was announced on th march, as a preventive measure to mitigate the spread of the virus. except for the essential services, there was a complete closure of the work, with activities of day to day living and social interactions coming to a sudden standstill. the focus of the health care shifted entirely to deal with the pandemic, rest all health related issues going to an unexpected and unprecedented backdrop. the nation still continues to be going through different phases of the lockdown, with anxiety and panic in the minds of the patients as well as the hcw's. routine out-patient departments (opd) in many institutes still remain closed, with partial closure of the private sector as well. the in-patient services earmarked for drug sensitive and drug resistant tb patients at many health care facilities have also been converted temporarily to covid- patient care wards. as far as the case finding in tb is concerned, since there was a complete shutdown of the public transport, with multiple restrictions to move out of the houses, there is a possibility that except for emergencies, even the symptomatic patients stayed indoors, suffered silently and avoided consulting a health care facility, thus adversely affecting j o u r n a l p r e -p r o o f the pcf. either there was a total non-availability / highly restricted availability of the opd services in public and private sector or the hcw's were busy in dealing with the pandemic and the tb related services suffered badly as a result. the quantum of spread of infection due to such a scenario is hard to measure, and its long term implications are yet unknown. the effect on acf is expected to be even graver. every hcw, starting from the grass root level, to the topmost in hierarchy, is busy in addressing covid- problem. even the laboratory services dealing with testing of tb are channelized to meet the demands of the pandemic. under such circumstances, there is hardly any possibility of acf in the community, or door to door tracing till the pandemic is over as there is a complete reallocation of manpower, finances and nationwide resources towards fighting the covid- . the pandemic seems to have significantly decreased the access of tb patients for medical care, and achieving the targets so set, seems far from reality. the long term impact on tb case finding, both passive and active, needs particular attention. though various agencies have warned regarding the serious implications on tb control, yet, strategic measures are yet to be taken to prevent a surge in active tb infections in the community. interrupting the chain of transmission by early case detection and prompt treatment is the cornerstone to achieve tb elimination. ongoing pcf needs to be strictly complemented with acf, especially in the vulnerable population and predefined subgroups according to local epidemiology, at least till the time we strengthen our health care system to be capable of mass screening. in a resource constrained setting like ours, a clear cut line of action for acf, with the use of novel approaches, is urgently needed to screen, diagnose and subsequently treat these patients in the minimum possible time frames, with due consideration to cost effectiveness and optimal utilization of resources. in addition, a sensitive and patient centered approach, with formal focused j o u r n a l p r e -p r o o f health education for the general public inculcating awareness, positivity and preventive behaviors is expected to give long term dividends. in the existing nationwide fight against covid- , when the health care system is grossly diverted to meet the needs of the pandemic, we need to diligently continue and strengthen our efforts for tb case finding at every level, to avoid a sudden unexpected surge in patients with tb. slightest of the inattentiveness in tb case finding in these testing times is bound to be extremely detrimental in realizing our goal of tb elimination in the near future. j o u r n a l p r e -p r o o f prediagnostic loss to follow-up in an active case finding tuberculosis programme: a mixedmethods study from rural bihar, india national strategic plan for tuberculosis elimination lid= last accessed on st technical and operational guidelines for tb control in india last accessed on st active case finding for tuberculosis through touch agents in selected high tb burden wards of kolkata, india: a mixed methods study on outcomes and implementation challenges improved detection of tuberculosis and multidrug-resistant tuberculosis among tibetan contact screening and risk factors for tb among the household contact of children with active tb: a way to find source case and new tb cases communitybased active case-finding to reach the most vulnerable: tuberculosis in tribal areas of india improving detection of tuberculosis among household contacts of index tuberculosis patients by an integrated approach in myanmar: a cross-sectional study intensified household contact tracing, prevention and treatment support versus enhanced standard of care for contacts of tuberculosis cases in south africa: study protocol for a household cluster-randomised trial role of communitybased active case finding in screening tuberculosis in yunnan province of china patient-led active tuberculosis case-finding in the democratic republic of the congo world health organization: assessing tb-case finding the role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in nepal contact tracing versus facility-based screening for active tb case finding in rural south africa: a pragmatic cluster-randomized trial (kharitode tb) the yield of community-based "retrospective" tuberculosis contact investigation in a high burden setting in ethiopia impact of advocacy, communication, social mobilization and active case finding on tb notification in jharkhand, india active and passive case-finding in tuberculosis-affected households in peru: a -year prospective cohort study patient characteristics, health seeking and delays among new sputum smear positive tb patients identified through active case finding when compared to passive case finding in india active tuberculosis case finding in india: need for introspection are treatment outcomes of patients with tuberculosis detected by active case finding different from those detected by passive case finding? active versus passive case finding for tuberculosis in marginalised and vulnerable populations in india: comparison of treatment outcomes treatment outcome of tuberculosis patients detected using accelerated vs. passive case finding in myanmar yield of household contact tracing for tuberculosis in rural south africa training modules for programme managers and medical officers (ntep) active tuberculosis case finding in india -the way forward bringing state-of-the-art diagnostics to vulnerable populations: the use of a mobile screening unit in active case finding for tuberculosis in palawan, the philippines cost-effectiveness of a new strategy to detect pulmonary tuberculosis in household contacts in myanmar active casefinding for tuberculosis by mobile teams in myanmar: yield and treatment outcomes how much is tuberculosis screening worth? estimating the value of active case finding for tuberculosis in south africa, china, and india contact investigation for tuberculosis: a systematic review and meta-analysis factors affecting tuberculosis health message recall years after active case finding in blantyre, malawi timeline of who's response to covid- highlights: . early case finding and prompt treatment is of paramount importance for elimination of tuberculosis but has always remained a challenge ongoing passive case finding (pcf) needs to be strictly complemented with active case finding (acf) especially in the vulnerable population till we are ready for mass screening efforts for case finding in tb should not be neglected despite the present corona virus disease (covid- ) pandemic key: cord- -vy ohgia authors: adamik, b.; bawiec, m.; bezborodov, v.; biecek, p.; bock, w.; bodych, m.; burgard, j. p.; krueger, t.; migalska, a.; ozanski, t.; pabjan, b.; rosinska, m.; sadkowska-todys, m.; sobczyk, p.; szczurek, e. title: estimation of the severeness rate, death rate, household attack rate and the total number of covid- cases based on polish surveillance records date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: vy ohgia background: estimating the actual number of covid- infections is crucial for steering through the covid- pandemic crisis. it is, however, notoriously difficult, as many cases have no or only mild symptoms. surveillance data for in-household secondary infections offers unbiased samples for covid- prevalence estimation. methods: we analyse polish surveillance records to obtain key figures of the covid- pandemic. we propose conservative upper and lower bound estimators for the number of sars-cov- infections. further, we estimate age-dependent bounds on the severe case rate, death rate, and the in-household attack rate. results: by maximum likelihood estimates, the total number of covid- cases in poland as of july nd, , is at most around times larger and at least . times larger than the recorded number. the lower bound on the severeness rate ranges between . % for the - year-old to . % for older than , while the upper bound is between . % and . %. the lower bound on the death rate is between . % for the age group - to . % for the oldest. overall, the severeness and death rates grow exponentially with age. the in-household attack ratio is . % for the youngest group and . % for the oldest. conclusions: the proposed approach derives highly relevant figures on the covid- pandemic from routine surveillance data, under assumption that household members of detected infected are tested and all severe cases are diagnosed. the covid- pandemic has led to dramatic changes in the everyday life worldwide. the most appropriate countermeasures are sought against a further spread. to this aim, key disease characteristics need to be described, such as the severeness and attack rates. mounting evidence indicates that many infected with sars-cov- show no or only mild symptoms and remain undetected. , , the lack of accurate knowledge of the actual number of infected highly complicates epidemic control. computational approaches to estimating both severity of covid- disease and the unknown total number of infected range from statistical and machine learning to model-based. , , , , , , with more detailed data, these approaches gain more statistical power and need to make less educated guesses. the report by bi et al. proved contact tracing and surveillance data to be useful in characterizing epidemiology and transmission of sars-cov- in china. to our knowledge, such detailed case data has not been reported in europe, and has not been used for the estimation of the total number of cases. here, we rely on detailed covid- surveillance data in poland, recording the source of transmission, household contacts and hospitalization status for cases. these data allow to differentiate from the cases that were first detected in each household from the secondary cases that were infected in the household. while the former cases are often diagnosed based on their symptoms and are biased towards worse disease progression, the latter can be considered unbiased samples of the susceptible population. using this unbiased sample, we derive upper and lower bounds on the age dependent rates of severe progression, death rates and in-household attack rates. we show that the severeness rates grow exponentially with age. unlike easily obtainable case fatality rates, our bounds on death rates give insight into the actual lethality of covid- . based on these estimates, we further provide bounds on the total number of sars-cov- cases. our results pave the way for utilizing surveillance data in the covid- spread for unbiased estimation of its key characteristics and the unknown total number of infections. in the following, we analyze covid- surveillance data, with each case assigned to a household. for each household, the first detected case in this household is referred to as an index case. the index cases may be subject to some bias, since they may be diagnosed due to the severity of their disease, different kinds of ex-ante social activity or other exposure factors. all remaining household members (all apart from the index cases) are referred to as the susceptibles. the number of susceptibles is equivalent to the sum of the household sizes reduced by the number of the index cases, and is denoted n * . in contrast to the index cases, it is plausible that the infections among the susceptibles are unbiased with regard to clinical progression, severeness rate and attack rate. those remaining infections in the household are called secondary household infections. let i * denote the number of the known (recorded in the data) secondary household infections. denote by t * the true total prevalence of secondary household infections (including undetected cases). let i * ,sev be the number of severe cases among these infections, and assume that all severe cases among the susceptibles are observed. there is a close relation between the rate of severe disease progression, household attack rate and the undiagnosed fraction of covid- infections, as they can all be estimated using the above-mentioned quantities. below, we first derive estimators for the bounds on covid- severeness and attack rates, as well as the total number of infected, without taking account for such factors as age or sex. next, we extend the derivation to consider these factors. we considered two alternative definitions of severe cases. first, we assumed severe cases are those hospitalized for days and more or dead, and second we assumed they were hospitalized for days and more or dead. finally, we describe how the susceptible population size can be estimated from external census data in the absence of records of household sizes for the index cases. given the true total number of secondary household infections t * and the number of severe secondary infections i * ,sev , the severeness rate is easily estimated as σ = i * ,sev t * . ( ) i * ,sev can easily be obtained from the existing data records, since severe cases are likely found in a functioning healthcare system. contrarily, e.g. due to asymptomatic cases, t * may be unknown. we hence derive upper and lower bounds on the severeness rate, which are derivable from the observed quantities. first, denote the observed severe case rate α by α := i * ,sev i * . ( ) if all infected persons were diagnosed, i * = t * and α would be the true severe case rate among the infected. in common case, when only some of the infected are diagnosed, i * is the minimum of secondary infected in the observed households. hence, α defines an upper bound on the severe case rate. this rate is lower bounded by as n * is the maximum number of possible infected in the observed households. in section . we compute different bounds on severeness rates, separately for different values of other factors, such as age. finally, smooth estimates on the functional dependence of the severeness bounds on the age are obtained using restricted cubic splines. further details are depicted in section a of the supplementary online material (som). the exact same equations as for the bounds on the severeness rates can be used to estimate the death rates, but inserting for i sev the number of deaths instead of the number of severe cases. let t sev be the total number of severe cases in the entire population and t be the unknown true total number of sars-cov- cases. assuming that the severeness rate among secondary infected individuals, σ, is the same as it is in the entire infected population, we have from which we obtain the estimate of the total prevalence t . since σ is often not directly obtainable from the data, we can use it's lower bound β and upper bound α to derive the conservative maximum likelihood upper and lower bounds on t , respectively aŝ andt if the secondary infections in the households are diagnosed precisely, this lower bound ( ) will be near the expected number of infected. a gap between officially recorded infections and the estimated lower bound could stem from a poor testing of secondary infections. if this can be ruled out, the gap indicates the expected minimum of additional undiagnosed infections. conservative one-sided % lower confidence bound on β (denoted β q ), and % upper confidence bound on α (denoted α q ), are derived using and extension of the clopper-pearson interval method (som b). based on this, the one-sided % upper confidence interval bound for the upper bound of infected is given by while he one-sided % lower confidence interval bound for the lower bound estimator of infected is given by for a rapidly growing number of infections, which was not the case of the polish epidemic as of july nd, , one would have to adjust for a time delay from infection to the recording of severe cases. in som c we describe how to correct for this time lag. . accounting for population strata to estimate of the total number of infections above we assumed that the rate of severe disease progression among infected individuals is the same. it is known, however, that this rate depends on factors like age, sex, and the comorbidity status. , , , when stratifying the population according to these factors, the between-class variance is removed from the total variance. hence, the estimate becomes more efficient. we thus adapt the approximation to account for these strata. again, we make use of the fact that the secondary infected in the households constitute a severeness-rate-unbiased sample. instead of calculating the rates α and β over all units in the sample, they are calculated in the classes known to affect the severity of infections. let us number the classes of all combination of age, sex, comorbidity values consecutively with l = , . . . , l . note that the resulting classes, as in anovas, have to be big enough such that some severe cases s * ,sev l in the l-th class are observed. the severe case rates in class l yield . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint therefore, for obtaining an upper bound estimator of the upper bound of infected we sum up this figure over all classes. accordingly, the estimators t q post , t post , and t post can be obtained. in poland and other countries, neither the negative tests nor the household sizes are recorded. in that case it is necessary and possible to estimate n * based on external data. here, we obtain the household size distribution conditioned on demographic characteristics of the index cases from census data. via this information a distribution of n * is derived by bootstrapping, as described in som d. the bootstrap draw of a household size was conditioned on the age of an index case, minimal household size information and residing voyvodship. adjustment for the estimation of the confidence bound for the lower bound β on the severeness rate is described in som b. there are two natural ways to define the household attack rate. the first is a probability Λ * of an infected household member to infect a non-infected household member. we refer to this quantity as the attack probability. Λ * is estimated based on the secondary case data, taking into account the fact that the infections proceed consecutively within a household (som e). the second is the ratio of the expected total number of infections t * to the expected number of susceptibles n * , given Λ * and the distribution of the household size (som e). we refer to this quantity as the attack ratio and denote it g(Λ * ). arguably, in contrast to the attack probability, the attack ratio is not a medically-relevant intrinsic characteristic of the disease. it is, in particular, dependent on the household size distribution. thus, for example, for the same attack probability, the attack ratio would be different for countries with different typical household size. an estimator of the attack ratio is then given by: since the true number of secondary infections t * is unknown, as we instead compute the lower bound on . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; the attack ratio as g(λ * ) = i * /n * . g(λ * ) depends on the probability λ * , which in turn constitutes a lower bound on Λ * . since the upper and lower bounds on the severeness rates depend directly on the i * and n * , respectively, one can associate attack probability λ * directly with the upper bound α on the severeness rate, and an attack probability with the lower bound β. furthermore the relation α · g (λ * ) = β between attack rate, rate of severe progression and the g -function holds. analog computations can be performed for age-dependent attack probability and ratio (som e). in these computations, we assume that the probability and ratio depend on the age of the susceptible (the person acquiring the disease). the analyzed data was collected as part of routine covid- surveillance in poland, which was implemented based on a data collection system functioning for other notifiable infections. the mandatory reporting was ordered both for clinical diagnoses of covid- and positive laboratory tests of sars-cov- . the notifications were sent to the local public health departments, which were responsible for conducting epidemiological investigation, contact tracing and, if necessary, -ordering quarantine. according to the protocol, all quarantined cases were tested in case of symptoms. testing of all individuals in the quarantine was optionally applied. the results of the epidemiological investigations were documented in the epidemiological reports registration system (srwe). the data was to be updated once the case outcome was known. however, given the strain on the public health system, this information could be missing or delayed. the srwe database includes basic demographic and clinical information, exposure category, hospitalization history and use of mechanical ventilation and moreover detailed information on established links between cases. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the total number t sev of the severe cases the polish population was computed as the number of all such defined severe cases in the analyzed households (including the index cases), multiplied by a factor d/c , where d was defined as the total number of officially diagnosed cases in poland (as of july nd, ), and c the total number of all diagnosed in the analyzed database ( = . ). the factor is intended to scale up the database level estimates to a national level of the entire polish population. we characterized a total of covid- surveillance records (table ) , out of which ( . %) were the index cases and ( . %) were the secondary cases. the patients were divided into four age groups, including a group of - years old ( . % of all records). this wide age group was formed to reliably estimate per-group severe case rate, as there were no or only a few severe cases among children. the proportion of females was slightly larger ( . %) than of males, and similar in both index cases ( . %) and secondary cases ( . %). the index cases can be regarded as detected based on their symptoms and the secondary cases as an severeness-rate-unbiased sample of the population. the index cases were more often hospitalized (with hospitalization rate . %) than the secondary cases ( . %). in addition a larger fraction of hospitalization for longer than days is observed ( . % for index cases vs . % for secondary cases) . on / / , the final outcomes were known for out of cases, with deceased and recovered. again, for the index cases, the death fraction was larger than for the secondary cases. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; to estimate upper and lower bounds for the covid- severeness rate in poland, we focused on the secondary case data ( table ). the expected number of susceptibles n * , i.e., the estimate for the number of all inhabitants of the analyzed households, except for the index cases, was computed using the polish census data (som d) as . first, we obtained the bounds on the severeness rate for the different age groups using the maximum likelihood estimators, in equation for the lower bound, and in equation for the upper bound, respectively. for the definition of severity, we used two alternative thresholds of hospitalization, and days respectively. for the days threshold, the young population ( - year old) had the smallest lower bound on severe case rate ( . %). the bound increases for older age groups, reaching . % for the group older than . across the age groups, the upper bound on the severeness rate α is roughly an order of magnitude larger than the lower bound β and also increases for older age groups. next, we obtained smooth estimates of the severity rates and death rates among secondary cases as a function of the age together with the % bootstrap intervals (figure ). the death rate is presented only for people over years, because number of deceased among secondary cases among younger people was too small to get credible intervals. to get estimates at this resolution we estimated mortality with logistic regression model with age transformed with tail linear restricted cubic splines (som a). overall, severity and mortality depend exponentially on the age (note figure is a semilog-plot). this finding is . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint in agreement with the fact that severe cases are more likely among the elderly patients. the estimate for β is roughly x higher than the estimate for α. from the maximum likelihood estimate of the lower bound on the severe case rate β and from the number of severe cases t sev we obtain the maximum likelihood estimator for the upper bound of the total number of infectionst β (equation ). we found an overall upper bound of on covid- infections in poland (corresponding to . % of the polish population), using a days threshold for the severe cases (table ) . this upper bound is around times larger than the cumulative recorded number of cases. the percentile of this upper bound estimator is (corresponding to . % of the population). using the days threshold the upper bound is ( . %) with a percentile of ( . %). the lower bound estimate for the total number of covid- cases in poland (t α ) is using a days threshold for the severe cases. this lower bound is . times larger than the recorded number of cases. the percentile of the lower bound was equal to and the -percentile was equal to . . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . figure : partial dependence profiles for lower (beta) and upper (alpha) bound for the severity rate and death rate estimated with a linear tail-restricted cubic spline function. filled regions show % bootstrap intervals. the subscript stands for: -severity calculated for days, -severity calculated for days, d -death rate. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint for this analysis, we split the before considered age group − into − and − and show that attack probability in the − age group was . , around half as high as in the oldest two age groups ( . for the + group). the attack probability estimate for all secondary cases (age-independent) was λ * = . . how significantly the data supports the hypothesis that the attack probability is age dependent is discussed in som e. the maximum likelihood estimate for the lower bound on the household attack ratio for the entire set of secondary cases was %, while the age dependent estimates ranged from . % for the youngest to . % for the oldest age group, respectively ( table : age-dependent attack probability and attack ratio estimation with corresponding known and expected numbers of infected and susceptibles in the age groups. we propose a new method for the estimation of severeness and attack rates, as well as the unknown total number of sars-cov- infections, including diagnosed and undiagnosed cases. the estimation is based on routine surveillance data, i.e. the residence address of the case and the indication of severity of the disease course. in contrast to approaches based on seroprevalence testing, it does not require expensive population studies. compared to model-based approaches, it is data-based and introduces only minimal assumptions. the assumption that severe cases or deaths are likely to be diagnosed and registered was made previously by other authors, e.g., flaxman et al. these approaches, however, were limited by the lack of precise . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint information on the expected infection fatality rate or, more generally, the expected fraction of the severe cases. the assumption that secondary infections in households constitute an unbiased sample of the infected, with similar severeness rate to the entire population, was considered also by hernandez-suarez et al. this work, however, relied on asymptotic approximations, did not account for problems encountered in real data, such as unknown household sizes, and finally, did not apply their method to any case dataset. we estimate that from % up to % of all cases in poland were actually detected. as at the time of the study the strategy was to test all quarantined individuals, we consider higher detection rates and thus also the lower bound estimates of the total prevalence to be the more likely. the low estimated prevalence bounds are in agreement with the seroprevalence below % measured in a population sample in czechia, which has a similar detection rate as in poland. up to date, there are no published seroprevalence results in poland that we could compare the estimates to. however, a study in cracow reports % seroprevalence in this city [personal communication k. pyrć]. importantly, even the unlikely upper prevalence bound estimate . % of the whole population (for severity defined as days) is not enough to provide any effect of herd immunity. , to our knowledge, we are the first to derive the household attack probability, also in different age groups, and show how the attack ratio depends on this quantity. since the household attack ratios depend on household distribution, it is recommendable to report attack probability instead, which is rather an intrinsic parameter of the disease. the approach has several limitations. the results depend on the definition of the severe case and how accurately the severe cases are recorded in the data. on top of that, precise recording of the household sizes and their age distribution would lower the variance of our estimations. in conclusion, the method is easily applicable using surveillance data and provides useful information on the severeness and attack rates, as well as the total number of infections and the undiagnosed fraction. in the future, it could be used to continuously monitor the effectiveness of the testing strategy and the proportion of individuals who have already passed the infection. in the example of poland we show that only a minor part of individuals were already infected and recovered. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint [ ] carlos m hernandez-suarez, paolo verme, and efren murillo-zamora. "estimation of the infection fatality rate and the total number of sars-cov- infections". in: medrxiv ( is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint i * ,sev x ∼ bin(i * x , α(x)). if groups i * x are large enough then we can estimate α(x) in each group independently with the procedure described in equation . such estimates for four age groups are presented for example in table . if we want to have a continuous form of the function α(x) then we can treat this problem in the same way as in the classification problem. we assumed that α(x) can be approximated by some family of functions. a simple logistic regression with a linear link may be too rigid. we compared the gradient boosting approach and logistic regression with restricted cubic splines [ ] . both leads to similar results thus only the one with splines, as more smooth, is presented below. for age, we used four knots places in percentiles , , , . this corresponds to age breaks at , , , . between knots, the function α(x) is approximated as cubic polynomial while outside knots it is approximated as a linear function. additional restrictions are put to get smooth approximation in knots. the exact formula of three cubic polynomials is hard to read so to visualise this relation we used the partial dependence profiles implemented in the dalex [ ] library for r [ ] . the relation is presented in figure . note that due to the behaviour of α(x) and β(x), the log-linear axes are used in the plot. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint x ∼ bin(n * , θ). therefore the one-sided q% upper confidence interval bound for the upper bound of infected is given by in the case when the household size distribution is unknown, we extend the idea of the clopper-pearson interval by searching for the value of β q = θ ∈ [ , ] with q = ∞ n * = p (x n * ≤ i * ,sev )p n * (n * = n * ) where x n * ∼ bin(n * , θ). since p (x n * ≤ i * ,sev ) is monotonic in θ for each n * also ∞ n * = p (x n * ≤ i * ,sev )p n * (n * = n * ) − q is monotonic as a convex combination. we then use the bisection method to find the single root of this function. analogously, the one-sided q% lower confidence interval bound for the lower bound estimator of infected can be derived by obtaining the α q = θ with p (x ≥ i * ,sev ) = q, where x ∼ bin(i * , θ) in the case without observed severe cases in the secondary infections, the rule of three by eypasch et al. can be used to approximate a % confidence interval bound instead. let p(k) be the probability of developing a severe progression after k days after infection, conditionally on developing the severe progression at some point in time. denote as before byα the severe case rate and let ϕ(t) be the cumulative number of severe cases discovered at day t. further, we denote by δ(t) be the number of new severe cases manifesting themselves at day t, and by ∆(t) the number of all new infections (not only the discovered) at day t. for the following considerations we assume that the daily reported number of severe progressions is reported without delay. however, if there is a delay in reporting, then the estimated number of infected have to be shifted backwards by this delay. in particular, for the k-th day the amount of new severe cases among the previously infected is where the β is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; immunity is not complete and a second infection is possible, these probabilities may change for the second infection. then the probability of developing a severe progression in the second infection may be lower, and the estimated figures will tend to underestimate the total amount of infected. at day s, ∆(s) persons get infected. the probability to exhibit a severe progression at day k conditionally on developing a severe progression at some point is p(k − s). in expectation the number of severe cases at day t, starting at day t , is then given by recall that δ(k) is a sum of independent bernoulli random variables. define µ := eδ(k). by applying the chernoff bound (see e.g. theorems . and . in mitzenmacher and upfal ), we get for λ > and for a single realization r of δ(k) we get and for obtaining a lower -significant estimate on µ from ( ), we take λ = r/µ − , that is r = ( + λ)µ, and find the solution to the constrained optimization problem the solution to ( ) is the smaller root of the equation with unknown µ so µ = r + | ln | − r| ln | + ln . iv . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint similarly, by taking λ = − r/µ in ( ) we can find an upper -significant estimate on µ by solving the constrained optimization problem the solution to ( ) is the greater root of hence so µ = r + | ln | + r| ln | + ln . take now = − . (t −t ) , and let r k be the realizations of δ(k) that we observe. set and then by ( ) and ( ) p µ u k ≤ r k + | ln | + r k | ln | + ln for all k = t + , . . . , t hence µ u k , k = t , . . . , t defined by ( ) give us upper . -significant estimates for ∆(k), k = t , . . . , t , in the sense that, assuming eδ(k) = µ k , similarly, µ k , k = t , . . . , t defined by ( ) provide lower . -significant estimates for ∆(k), k = t , . . . , t . v . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint we can rewrite ( ) as we see that the coefficient matrix is a triangular matrix and thus the system can be solved by forward substitution. in particular, . . . denote by f t , f t + , . . . , f t +t − the solutions to ( ) as linear functions of eδ(t + ), eδ(t + ), . . . , the lower and upper boundaries of a . -significant confidence interval for ∆(t), t ∈ {t , t + , . . . } are given by similarly, the cumulative number of infected i(t) = t ≤s≤t ∆(s) can also be expressed as a linear function is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; remark. from the numerical point of view the method outlined here works well if is the mode of the distribution p, or at least if p( ) is close to the max{p(k)}. otherwise the elements of the inverse matrix may take very large values, and dependence of ∆ on δ is very sensitive, making the approach not numerically stable. additionally, if the aim is to obtain a confidence interval only for the total number of infected i(t), a narrower confidence interval can be designed. d estimation of the susceptible population size n * under unknown household sizes unfortunately, the information on the household size of the index patients has not been recorded in poland and thus has to be estimated. for the estimation we used the data from census. a representative study was done on a random sample of approx. % (approx. ) households in poland, out of the total number of . million registered households. the data was successfully collected directly from inhabitants of households. based on the data described above, we estimate the average household size to be . . a ( − ) % confidence interval can be obtained using hoeffding's concentration inequality in the form . ± q , where q solves exp − q nc = with c = being the maximum household size. in particular, a % confidence interval is . ± . , and a % confidence interval is . ± . . in figure we give the distribution of mean household size given the age of a randomly chosen individual along with the standard deviation in the population of poland. note, that we use the household size in terms of the number of people living together. this is in contrast to the majority of publication defining the household as economic unit. for the economical unit the mean household size was . in the census . vii . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; for each index case, we sampled a household h from "national census of population and housing " inhabited by a person of the same age a and sex as the index case, and calculated the number of household members within each considered age group g in g = { − , − , − , + years old}. for each household h we hence obtained |u * h | as the sum of the number of household members in all age groups g∈g |u * h,g |. this bootstrapping procedure was repeated times. in each iteration w of the procedure, after all index cases had been processed, the numbers of household members in each age group were totalled, n * g,w = h |u * h,g |. we estimate the size of the susceptible population in each age group n * g as the th percentile of all obtained n * g,w , and the total size of the susceptible population as viii . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; d. estimation of the household size with partial information on the household size the above procedure yields mean household sizes when no household size information is known, i.e. under the assumption that for each h the total household size |u * h | + is at least . however, in cases when other household members, but possibly not all of them, were infected and these links were reported in the srwe data, we are able to determine the minimal size of these particular households. based on the srwe data, we calculated a minimal household size k + for each index case as the number of all infected people living in the same household. thus, for an index case of known age a, sex, and minimal household size k + we sampled only from households satisfying all three conditions. for people younger than years old, who legally cannot live alone, we set max(k + , ). in the srwe database, the exact address of the residence of each case is reported. since household size distributions may vary across voyvodships and, moreover, the distribution of household sizes at the voyvodeship level is available in the census data, we included the voyvodship information in the bootstrap procedure. thus, for each index case, in addition to the age, sex, and the minimal household size conditions, we conditioned the household sample on a voyvodship. the only exception from this condition was made for podlaskie voyvodship, for which very few households are provided in the census data. for this particular voyvodship we used the household size distribution of poland. figure illustrates the differences in the distributions of the number of susceptibles in each age group obtained by the three bootstrapping procedures mentioned above. the procedure that served as a basis for the results presented in table and table , was the third procedure that takes into account both the minimal household size and spatial data, due to its richest usage of available data. ix . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint figure : distribution of the number of susceptibles in each age group based on the results of the bootstrapping procedure. in figure we compare empirical cumulative distribution functions (ecdf) of age within reported index cases and secondary case to the ecdf of age within the general population of poland. the index cases population is clearly older than the general population, whereas the distribution of age of secondary cases resembles the distribution of age in the general population. further, the distribution of age within susceptible population, obtained from the bootstrapping procedure, indicates that this population is younger than the general population. x . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; figure : empirical cumulative distribution functions of age in the population of secondary household infected (based on the srwe data), in the population generated by the bootstrapping procedure (based on census data), in the general population of poland (based on official . statistics), and of index cases (from srwe data). all four ecdfs illustrate the cumulative probability of age among people younger than years old. in figure , the frequencies of household sizes of an infected population are given. in case the source of infection is known and the circumstances are classified as "household contact" we make the assumption that all household members were infected and use this assumption to calculate their household size. in case the source of infection is from the outside of the household or is unknown, then we take the average household size given the age of a person. xi . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; figure : ecdf of household sizes (with less than inhabitants) in the general population of poland and within the population of secondary cases. in case the source of infection is known and the circumstances are classified as "household contact" we make the assumption that all household members were infected and use this assumption to calculate their household size. in case the source of infection is from the outside of the household or is unknown, then we take the average household size given the age of a person. we describe here in detail how to get a lower bound on the attack rate within a given age cohort. assume we have n index patients enumerated from to n. for the attack rate we will use as index patients the first infected patient in a household , that is the patient whose source of infection was outside the household or the patient where the source is not known. we assume a constant attack rate λ ∈ [ , ] which is defined as the a priori probability of an index patient to infect a given member of the household . let is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint size . then the actual number i of infected in the susceptible population is given by where the random variables y i are independent but not identical distributed . due to the concentration properties of sums of bounded independent random variables, i is concentrated around the expectation ei. since the household-size distribution depends on age we have to group the index patients into age classes [a] corresponding to the age cohort a . clearly let further p k (a) be the probability that an index patient from age class [a] lives in a household of size whereμ (a) is the expected number of secondary household infected for index patients in a age class [a]. we have finally (we can make the errors explicitly by using concentration inequalities). clearly g (λ) -the fraction of true case in the secondary household population -is a continuous and strictly monotone increasing function in λ and has an inverse. in figure we give the obtained g (λ) for λ ∈ [ , . ]. given the observed number of secondary household infectionsÎ we get under the assumption thatÎ is xiii . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the true number of cases as an estimator for the attack ratê furthermoreλ defines a lower bound on the true attack rate since we assumed thatÎ is the the true number of cases. note that there is a close connection to the upper and lower bounds on the severeness rate estimated in the main text. the lower bound severeness probabilities (β ) were obtained by assuming that all of the susceptible population n * is infected, which corresponds to the case λ = . the upper bound on the severeness rate was obtained by assuming that the observed number of casesÎ is the true number of cases, hence this corresponds to the attack rateλ. on the other side, if the true value of λ ∈ λ , of the attack rate would be known and is independent of age we could estimate the severeness rate τ (a) in age group a as follows. the number of cases i (a) in age group a is given by where y i (a) is the number of infected in households h i in age group a. let ν k (a, b) be the expected fraction of secondary household members of age class a in an household size k of an index patient i from age class b. then note that the age classes for a and b in the above formulas need not to be the same (usually we take the age class b for the index patients to consist of a single year, whereas the a cohorts are taken to be much larger). again by the law of large numbers i(a) ei(a) ∼ and the maximum likelihood severeness rate based on an observed numberÎ sev (a) of severe cases in age class a reads aŝ the numbers ν k (a, b) can be computed with arbitrary precision by bootstrapping from the census household population. the adaptation of the above consideration to the case of age dependent attack rates is straightforward. xv . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint we first discuss the situation when the attack rate depends on the age of the susceptible but not on the age of the index patient (that is the source of the infection in the household). let k be a partition the age classes of the the susceptibles into k age cohorts. for the index patients we assume usually a finer partition a into age classes (usually one class per year). let λ = (λ , λ ..., λ k ) ∈ [ , ] k be the vector of attack rates for the different age cohorts from k. let µ l (λ, a) = µ and for the expectation where p l (a) as before is the probability that an index patient of age a lives in a household of size l + . contrary to the age independent case, µ l (λ, a) might depend on the age a of the index patient since the age composition of households matters here. again by the multivariate law of large numbers we have where g : [ , ] k → [ , ] k is a strictly monotone increasing mapping and hence as a well defined inverse. given the vectorÎ = Î , ...,Î k of observed infected in the different age groups and in the susceptible population. we get the estimationλ for the attack rates in the age groups from k. instead of the normalization by en * one could also scale the different components of i respectivelyÎ by the expected size en * (b) of the susceptible population in an age cohort b. this might look from an epidemiological point of view more natural but would only change the definition and form of g and give in the end the same (at least asymptotically) estimatorλ. note that there is no easy analytic way to compute the values of µ l (λ, a) . here one has to rely on numerical approximations for instance by monte carlo simulations. the case when the attack rate depends also on the age of an index patient is more complicated and will be discussed elsewhere. xvi . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint figure : empirical cumulative distribution functions of true secondary infected vs simulated secondary infected e. estimating the age-dependent attack rate from data we consider attack rate for five age groups: - , - , - , - , and +. thus, λ is a vector in five-dimensional space, where each dimension corresponds to a respective age group. we start with a search interval of [λ l, , λ u, ] = [ . , . ] . the search is performed by repeatedly bisecting the hypercube defined by these values and then selecting the sub-hypercube in which the bootstrapped mean number of infected equals the observed number of infected within each age group. the algorithm begins with drawing a household for each index case from the census data so that age, sex, minimal household size and voyvodship matches those of the index case; the household selection is repeated times. in the next step, we perform iterations of hypercube bisection and in each iteration we take the center of a current sub-hypercube as a λ vector. for each household configuration, i.e. the vector of the number of susceptibles within each age group in this household, and for the current λ vector we calculate the probabilities of infection for each age group and "infect" household members accordingly. for each age group we check whether the mean number of bootstrapped infected is higher or lower than the observed number of secondary infected within this age group and, depending on the result, the next iteration is performed on an interval [λ l,i , λ i ] or [λ i , λ l,i ], respectively. xvii . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint e. discussion of uniform versus age-dependent attack rate we further attempted to test the hypothesis that the attack probability is age independent. to this end, we compared the numbers of known infected individuals to the numbers expected given the lower bound uniform attack probability λ * . by the definition of the attack ratio, the expected total number of infected individuals should depend on the attack ratio and on the expected household size as in the case when the λ * was indeed age independent, the recorded numbers of infected individuals in the corresponding age groups should at least be inside the percent confidence bounds of with generated number of secondary infections (based on the estimated uniform attack probability). the expected numbers of infected individuals in different age groups with their % confidence bounds, obtained for the estimated uniform, age-independent λ * = . , computed according to the estimation procedure described in section e. are presented in table . in the youngest age cohort ( − years) the actually recorded number of infections is smaller than the lower bound of the % confidence interval for the number of infected, while for the age group above years old the recorded numbers are above the confidence bounds. hence, we would reject the hypothesis that the attack rate does not depend on age if we could be sure that the observed number of cases i * is really the true number of cases. to illustrate the age dependence of simulated versus recorded number of infections -assuming a uniform attack probability -we show additionally in fig. the cumulative empirical distribution function for secondary household infections as a function of age. finally we still give a uniform lower bound on the attack probability. to get such bound we estimated the largest uniform attack probability λ * such that all observed numbers of infections in the corresponding age groups are larger or equal to the percent upper bound values of expected infections given the value of λ * . we estimate this λ * to be . and the corresponding values of secondary infections are given in table . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint f pre-processing of the surveillance data first, we extracted the case clusters of size at least two with documented household transmission (the infected households). only cases for which clear epidemiological links were registered as household transmission together with their source cases were included. cases in social care units and households of minimum inhabitants were filtered out, as an initial analysis revealed that those were not representative for the overall population, due to over-represented comorbidities and severe cases. this filtering left cases (summarized in table ). in each infected household, the index case was identified as the one with the earliest date of diagnosis, since this case was the most likely to trigger the contact tracing. other cases in each of the infected households were regarded as secondary cases and included in the estimation of the severe case rate. xix . cc-by-nc . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint herd immunity-estimating the level required to halt the covid- epidemics in affected countries individual variation in susceptibility or exposure to sars-cov- lowers the herd immunity threshold regression modeling strategies dalex: explainers for complex predictive models in r" r: a language and environment for statistical computing. r foundation for statistical computing probability of adverse events that have not yet occurred: a statistical reminder probability and computing: randomization and probabilistic techniques in algorithms and data analysis national census of population and housing warunki mieszkaniowe gospodarstw domowych i rodzin key: cord- -iz l i d authors: o’gorman, c.; mchenry, e.; coyle, p. v. title: human metapneumovirus in adults: a short case series date: - - journal: eur j clin microbiol infect dis doi: . /s - - - sha: doc_id: cord_uid: iz l i d this study was carried out to further the available information on adult cases of human metapneumovirus (hmpv), a recently described cause of respiratory infection. among a cohort of symptomatic patients tested since , the virus was diagnosed in six adults using reverse transcriptase polymerase chain reaction. of the six, two were from the community, two were hospital inpatients with chronic obstructive pulmonary disease and two were immunocompromised patients, both of whom required ventilation and later died. this report discusses the clinical features, epidemiology and diagnosis of hmpv, highlighting that this infection may be associated with death in high-risk adults. for adults presenting with respiratory symptoms and a background of pre-existing respiratory disease or who are immunocompromised, nucleic acid-based techniques are a cost-effective means of making the viral diagnosis in a clinically relevant time frame. acute respiratory tract infections are a major cause of morbidity and mortality worldwide, and they account for a high percentage of hospital admissions. however, up to % of cases of community-acquired pneumonia in adults and - % of cases of bronchiolitis and pneumonia in children are of uncertain aetiology [ ] [ ] [ ] . it is clear that respiratory viruses are the principal pathogens in a proportion of such cases [ ] . hmpv is a recently described respiratory pathogen of the subfamily pneumovirinae, which is divided into the pneumovirus genus, containing respiratory syncytial virus, and the metapneumovirus genus, containing hmpv. in young children and elderly patients hmpv is most commonly associated with a clinical diagnosis of bronchiolitis or bronchitis, respectively, whereas in middle-aged adults, it may produce an influenza-like illness, which can be complicated by pneumonitis in the presence of immunocompromising factors [ ] . hmpv has been detected as the sole pathogen in the nasopharyngeal aspirate of a haematopoietic stem cell transplant recipient who subsequently died of respiratory failure following an upper respiratory prodrome [ ] . the regional virus laboratory in belfast carries out viral diagnostics for northern ireland, a region with a population of , , . it began routine use of a multiplex reverse-transcriptase polymerase chain reaction (rt-pcr) method for virus detection from respiratory samples in july of [ ] . the samples were from three sources: adult hospital inpatients ( . % of total processed), paediatric hospital inpatients ( . %) and general practitioners participating in a sentinel influenza surveillance program ( . %). the laboratory tested any specimens of respiratory tract material including bronchoalveolar lavage, nasopharyngeal and tracheal aspirates, and sputum, nose and throat swabs. this retrospective observational study reviewed all cases of hmpv detected in patients over years of age, from the time the rt-pcr method was adopted in july through to january . we selected adult cases for review as there is less data in the literature pertaining to hmpv infection in this age group. the routine assay used to detect respiratory viruses in the regional virus laboratory is a multiplex, nested rt-pcr for common respiratory pathogens: influenza a (h and h ) and b; parainfluenza virus types , and ; respiratory syncytial virus a and b; adenovirus; human rhinovirus; coronavirus e; and hmpv. the pcr target for hmpv was the fusion gene. sensitivity was determined at × copies per ml using an hmpv amplicon cloned from a clinical specimen during the preliminary development of the c. o'gorman (*) . e. mchenry . p. v. coyle regional virus laboratory, royal group of hospitals trust, belfast bt ba, northern ireland e-mail: ciaran.ogorman@bll.n-i.nhs.uk tel.: + - - fax: + - - molecular strip assay. direct comparison of the assay with an alternative was not possible because of the lack of specimens containing hmpvor alternative tests; virus identification was confirmed by selected amplicon sequencing [ ] . following ethics committee approval, we obtained written consent from the living patients in whom hmpv was detected. we reviewed their clinical case notes, noting presenting symptoms, significant medical and drug histories, results of other infectious investigations, chest radiograph findings, and clinical outcomes. a total of respiratory samples from adults were tested over the winters of / and / . six were positive for hmpv, accounting for a period prevalence in the population assayed of . %. in all cases, hmpv was the only virus detected. unless otherwise stated, bacterial culture and serology for atypical respiratory pathogens were negative. the clinical characteristics of these six patients are summarised in table . of the six cases, five were female and one male. their ages ranged from to years (mean . years). two cases presented to sentinel general practitioners with selflimiting influenza-like illness (cases and ). neither had a background respiratory disease or any other significant aspect of their medical history. two cases were diagnosed while admitted for acute exacerbations of chronic obstructive pulmonary disease (cases and ). they presented with dyspnoea, decreased exercise tolerance, cough and lowgrade pyrexia with a background of respiratory disease requiring home oxygen and nebulised corticosteroids. both had been smokers, had received prednisolone as inpatients, and were discharged on maintenance oral steroids. sputum culture of case revealed serratia liquefaciens, which was treated with intravenous ertapenem; for case , hmpv was the sole pathogen isolated. two cases ( and ) were fatal. the fatalities occurred in individuals receiving immunosuppressive therapy for rheumatological conditions. case had rheumatoid arthritis for which she received prednisolone and methotrexate. she presented in a collapsed and unresponsive condition following a -week history of cough, nausea and increasing dyspnoea. within h of admission she was intubated, ventilated and admitted to the intensive care unit (icu). hmpv was the sole pathogen isolated. she died with multiorgan failure days after admission. case six was admitted in an acute confusional state attributed to the oral steroids she was taking for polymyalgia rheumatica. she had been an inpatient for days when she became acutely dyspnoeic with hypoxia, hypothermia and hypotension requiring intubation and admission to the icu. she was found to have bacteremia caused by escherichia coli and was treated with piperacillintazobactam, fluconazole and pulsed methylprednisolone. on the first day of her icu stay, having been an inpatient for days, she was found to have hmpv. this patient made no significant progress while receiving maximal inotropic and ventilatory support and she died after weeks in the icu. whilst our detection of hmpv in symptomatic patients does not establish causation, it is possible that the virus may be associated with serious sequelae in high-risk adults as reported previously [ ] and supported by the fact that two of our six cases required icu admission and ventilation. we cannot be sure that case represented nosocomial acquisition as our assay may detect hmpv up to weeks after clinical infection. the clinical syndrome associated with this virus is probably too indistinct to be of diagnostic value. treatment is principally supportive; at present there are no antiviral agents active against hmpv, nor any available vaccine. effective diagnosis of viral respiratory pathogens is necessary to elucidate their epidemiology and assess their clinical impact. moreover, such data is crucial for effective infection control in hospitals and may ultimately allow more rational prescribing of antibiotics and corticosteroids [ ] . defining the assay sensitivity by comparison with a gold-standard detection system is a growing problem for viruses such as hmpvor human rhinovirus, for which pcr is becoming adopted as the diagnostic test of choice [ ] . we recommend the routine use of rt-pcr or other nucleic acid-based techniques for adults presenting with respiratory symptoms and a background of pre-existing respiratory disease or immunocompromise. the tucson children's respiratory study ii. lower respiratory tract illness in the first year of life etiology of community-acquired pneumonia: impact of age, comorbidity, and severity prospective comparative study of viral, bacterial and atypical organisms identified in pneumonia and bronchiolitis in hospitalized canadian infants virological features and clinical manifestations associated with human metapneumovirus: a new paramyxovirus responsible for acute respiratorytract infections in all age groups a newly discovered human pneumovirus isolated from young children with respiratory tract disease human metapneumovirus in a haematopoietic stem cell transplant recipient with fatal lower respiratory tract disease a touchdown nucleic acid amplification protocol as an alternative to culture backup for immunofluorescence in the routine diagnosis of acute viral respiratory tract infections prevalence and clinical symptoms of human metapneumovirus infection in hospitalized patients acknowledgements the royal group of hospitals trust (royal research office, grosvenor road, belfast) has agreed to act as sponsor for this study. ethical approval for this study was obtained on january from the office for research ethics committees northern ireland (orecni); rec reference number: /nir / . written consent was obtained from case patients as required by the research ethics committee. key: cord- - g om sf authors: isakbaeva, elmira t.; khetsuriani, nino; beard, r. suzanne; peck, angela; erdman, dean; monroe, stephan s.; tong, suxiang; ksiazek, thomas g.; lowther, sara; smith, indra pandya; anderson, larry j.; lingappa, jairam; widdowson, marc-alain title: sars-associated coronavirus transmission, united states date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: g om sf to better assess the risk for transmission of the severe acute respiratory syndrome–associated coronavirus (sars-cov), we obtained serial specimens and clinical and exposure data from seven confirmed u.s. sars patients and their household contacts. sars-cov was detected in a day- sputum specimen from one case-patient and in five stool specimens from two case-patients. in one case-patient, sars-cov persisted in stool for at least days after symptom onset. the highest amounts of virus were in the day- sputum sample and a day- stool sample. residual respiratory symptoms were still present in recovered sars case-patients months after illness onset. possible transmission of sars-cov occurred in one household contact, but this person had also traveled to a sars-affected area. the data suggest that sars-cov is not always transmitted efficiently. laboratory diagnosis of sars-cov infection is difficult; thus, sputum and stool specimens should be included in the diagnostic work-up for sars-cov infection. s evere acute respiratory syndrome (sars) was recently described as the clinical manifestation of infection by a novel coronavirus (cov), the sars-associated cov (sars-cov) ( ) ( ) ( ) ( ) ( ) . this syndrome was first recognized in february in vietnam, but it was later realized that the first cases occurred in southern china in november ( , ) . subsequently, the infection rapidly spread throughout the world, and by july , when the world health organization declared that the outbreak was contained, , cases and deaths in countries had been reported ( ) . as the outbreak developed, epidemiologic evidence suggested that sars-cov was transmitted by respiratory droplets or direct contact with infected patients and possibly by fomites ( ) ( ) ( ) ( ) . in certain circumstances, transmission of sars-cov was particularly efficient and resulted in individual patients infecting large numbers of people (referred to as "super-spreading events"), whereas in other situations, no secondary transmission was observed ( ) . a better understanding of the duration of sars-cov shedding and virus quantities in respiratory secretions, stool, urine, and other body fluids and of the risk factors for spreading illness to close contacts is critical to accurately assess the risk for transmission and to develop effective control strategies. to that end, we obtained serial biologic specimens and clinical and exposure data for to weeks after onset of illness from seven laboratory-confirmed u.s. sars patients and their household contacts. we targeted patients who met the centers for disease control and prevention's (cdc's) surveillance case definition for probable sars ( ) . of these patients, ( %) with laboratory-confirmed sars-cov infection (antibodies to sars-cov were detected) were enrolled; ( %), including confirmed sars case-patient, declined participation; and ( %) were excluded for various reasons (negative for sars-cov antibody at ≥ days after illness onset, a confirmed alternative diagnosis, or foreign citizen not residing in the united states). the household contacts of seven laboratory-confirmed casepatients were also enrolled. household contacts were defined as persons who had lived in the same household with sars case-patients during their illness. all participants provided informed consent. follow-up visits were scheduled twice a week for the first weeks after illness onset and then once a week for weeks. if a case-patient was first enrolled after week of illness, then a follow-up visit was made as soon as feasible after enrollment. some case-patients were enrolled at > weeks after illness onset and, therefore, were followed up for > weeks. for household contacts, visits were scheduled once weekly for a period of weeks after initial exposure to the case-patient. a single follow-up visit was scheduled if the household contact was enrolled > weeks after initial exposure to the case-patient. at the initial visit with the sars case-patients, we collected data on demographics, date of illness onset, clinical symptoms, and exposure history. at the initial visit with household contacts, we gathered data on any illness they had had since their exposure to the case-patient and on the types and patterns of exposure (e.g., sleeping in the same room at night, daily contact within < feet, and direct skinto-skin contact, such as kissing or hugging, with casepatients). at each subsequent visit, we collected information on any symptoms experienced by case-patients or household contacts since their previous visit, including symptoms during the current visit. specimens collected as a part of the diagnostic work-up were available for this investigation, and at each postenrollment visit, participants were asked to provide wholeblood, serum, stool, urine, nasopharyngeal, and oropharyngeal swab specimens. we obtained - ml of blood from adults and . - ml of blood from children < years old by venipuncture or finger stick. clotted blood was centrifuged, and serum was separated before being shipped to cdc for testing. similar volumes of whole blood were collected in a tube containing edta. nasopharyngeal and oropharyngeal samples were collected by use of a single dacron swab with a nonwooden shaft; the swab was then placed in a sterile vial containing ml of viral transport medium. stool specimens were collected in a sterile con-tainer and sealed. participants provided a -ml cleancatch collection of urine in a sterile urine cup. specimens were processed and stored according to cdc laboratory biosafety guidelines ( ) . all specimens were stored at °c for a maximum of h and shipped on ice to the cdc laboratory. if shipping within h was not feasible, specimens were stored at - °c and then shipped. to detect sars-cov in stool, urine, and respiratory specimens, we performed reverse transcriptase-polymerase chain reaction (rt-pcr), using primers targeted to the polymerase and nucleocapsid genes of the sars-cov genome, as described elsewhere ( , emery et al., unpub data). stool samples were prepared as % extracts in tris-hcl buffer before isolation of total nucleic acid for rt-pcr testing. to quantify the virus load in respiratory and stool specimens, quantitative rt-pcr was performed using the taqman assay and standard curves generated from synthetic rna transcripts (s. s. monroe and r. s. beard, unpub. data). previously described culture techniques ( ) were used to isolate sars-cov from specimens. to determine the s and n gene sequences of sars-cov, a set of overlapping rt-pcr products, which cover the entire open reading frames of the s ( products) and n ( products) genes, were generated by using the superscript one-step rt-pcr with platinum taq (invitrogen, carlsbad, ca) and sequenced by using (s gene) or (n gene) sequencing primers (s. tong et al, unpub. data). serum specimens were tested for sars-cov-associated antibodies by use of an enzyme-linked immunosorbent assay and an indirect fluorescent antibody test, using previously described methods ( ) . serum specimens were considered positive only if results for both tests were positive using predetermined cut-offs ( ). five of seven enrolled case-patients provided data on residual symptoms. three case-patients reported shortness of breath that persisted at least until days , , and , respectively, after onset of fever. two case-patients reported residual coughing: case-patient reported a dry cough until day and case-patient reported a productive cough until day after onset of fever. these symptoms had been reported during the acute phase of each case-patient's illness. wheezing developed in one case-patient without a previous history of respiratory disease at day of illness and persisted at least until day . no data were available to characterize the progression of symptoms over time. of respiratory specimens obtained from seven casepatients (table ) , ( %) were sputum samples from two case-patients ( from case-patient and from casepatient ). sars-cov was detected by both rt-pcr and viral culture in the sputum sample of case-patient , which was collected at day after illness onset (figure) . all other respiratory specimens, including seven nasopharyngeal and oropharyngeal swab samples collected during the first weeks of illness from five case-patients, tested negative by rt-pcr. a total of stool specimens were obtained from seven case-patients: two patients provided samples each, one patient had samples, and four had sample each. sars-cov rna was detected in five specimens, all of which came from two case-patients (one specimen from casepatient and four specimens from case-patient ) (figure) . the single positive stool specimen from case-patient was obtained days after onset; his subsequent stool specimens (collected at days , , and ) tested negative for sars-cov by rt-pcr. the first stool specimen from case-patient was collected on day of illness; viral rna was detected in all four of his stools, including the last one, which was collected at day . sars-cov was not isolated by culture from any of the rt-pcr-positive stool specimens. the highest concentrations of sars-cov were detected in sputum from case-patient ( million copies per gram of specimen) and in the day- stool from casepatient ( million copies per gram of specimen) ( table ). after day of illness, the concentration of virus in stool specimens from case-patient dropped by -fold or more. of note, this case-patient reported moderate diarrhea from days to of illness. case-patient had only mild diarrhea during the first days of illness, and the amount of virus in his stool sample that was collected on day (i.e., weeks after the resolution of diarrhea) was approximately -fold lower than the amount in the day- stool sample of case-patient and approximately -fold lower than that found in subsequent specimens from case-patient . no evidence was found that the virus mutated in casepatient during the infection: genomic sequences of s and n genes of sars-cov from all positive stool specimens of this case-patient were identical. no viral rna was detected by rt-pcr in any of the eight urine specimens collected from the seven casepatients. sars-cov antibody was first found as early as days and after illness onset in three of seven casepatients. adequate specimens were not available to characterize the time of first detectable sars-cov antibody in the remaining four case-patients ( : respiratory specimens (include np, nasopharyngeal swab; nw, nasal wash; a, nasal aspirate; op, oropharyngeal swab; sp, sputum). : stool. : urine. blocked symbols denote sars-cov-positive specimens by rt-pcr. ten household contacts of five of the seven sars casepatients were enrolled. case-patient had four household contacts, case-patients and had one such contact each, and case-patients and had two household contacts each. of the household contacts, were female, were smokers, and reported previous history of respiratory problems (sarcoidosis in household contact and pulmonary embolus in household contact ). household contact (who was also case-patient ) was the only such contact who tested positive for sars-cov antibody. the remaining nine household contacts were negative for sars-cov antibody in specimens collected > days after their initial exposure to a case-patient. the infected household contact was the wife of confirmed sars case-patient . the couple had visited hong kong together in early march and stayed at hotel m, which was subsequently linked to the initial spread of sars ( ), where they had multiple opportunities for exposure. casepatient became ill days after returning to the united states from hong kong. symptoms developed in household contact some days after returning to the united states and days after onset of illness in her husband. sars-like symptoms did not develop in any of the three other household contacts of case-patient , nor did any have laboratory evidence of sars-cov infection. the analysis of household exposures and protective measures in this household indicated that household contact had more frequent unprotected contact with the index patient compared with three other household contacts ( table ). the remaining six uninfected household contacts reported close contact (e.g., contact within feet and unprotected skin-to-skin contact) with case-patients. the exposure of four household contacts of two case-patients with stool specimens positive for sars-cov was limited by isolation of the case-patients in a separate room with a private bathroom during the first week of illness. both case-patients also wore surgical masks during this period, as did three of their four household contacts. case-patient was hospitalized from day to day of illness, the period during which the highest amounts of virus were detected in his stool, and continued to be positive for sars-cov in stool after discharge. neither case-patient nor his two household contacts wore surgical masks after being discharged from the hospital. case-patient , who was never hospitalized, had low-level shedding of sars-cov in stool on day , but no virus was subsequently found in his stool specimens. one of his two household contacts wore a mask until days after the resolution of fever in the case-patient. in this investigation of u.s. sars-cov-infected persons and their household contacts, we identified probable transmission of sars-cov to only of such contacts. we detected sars-cov in fecal and respiratory specimens and found that sars case-patients may have high concentrations of virus in stools during the nd week of illness and continue to shed the virus in feces until at least days after onset of symptoms. the amount of sars-cov in stool from a case-patient with moderate diarrhea was similarly high to the quantity seen in a sputum specimen collected from a different case-patient at the same interval after illness onset. however, no virus could be cultured from any stool specimens that were pcr-positive for sars-cov, suggesting that sars-cov in feces may be present in the form of either nonviable viral particles or antibody-coated virus. the one household contact who became infected was the person who had more contact with the potential source case-patient during the first week of illness than did other members in the household. this contact was also exposed in hong kong along with her husband; however, she became ill > days after returning to the united states ( ). previously reported data suggest that the incubation period for sars ranges from to days ( , ) , but in some cases, the incubation period may be as long as days ( ) . therefore, the possibility remains that this contact may have been infected in hong kong. the remaining uninfected household contacts included four contacts of two case-patients with positive stool specimens in whose households simple infection-control procedures were implemented during the acute phase of illness in the index patient. the lack of widespread household transmission of sars found in our investigation is similar to findings in reports of the outbreak in toronto, where ( %) of household contacts were infected despite unprotected contact with a sars case-patient ( ) , and from the philippines, where < % of nonhospital contacts were reported to be infected ( ). this finding supports the idea that in certain circumstances, sars-cov is not easily transmitted. transmission may also be more likely to occur at the time when patients are shedding higher amounts of virus, and this period may coincide with their hospitalization, thus decreasing the degree of exposure for household contacts. we were unable to detect sars-cov in specimens of our case-patients before day after illness onset. we only detected virus in three case-patients: in a sputum sample of one patient at day and in stool samples of two patients at day > . all upper respiratory specimens in the first weeks after onset were negative for sars-cov by rt-pcr; this finding differs from a report in hong kong, where viral rna was detected in nasopharyngeal aspirates of % of case-patients at day ( ) . our inability to detect the virus in early respiratory samples may be associated with the type (nasopharyngeal and oropharyngeal swabs versus nasopharyngeal aspirates) of collected specimens, as well as with low amounts of virus generally seen in such specimens ( ) . sputum samples may have a higher concentration of virus than upper respiratory specimens ( ), consistent with our findings. stool specimens have been found positive more frequently than upper respiratory specimens during the nd and rd week of illness, which is in accord with the limited results of this study. the inability to detect sars-cov in urine may be the result of a late collection of urine specimens (> days after illness onset). a wider use of steroids in treatment of persistent respiratory symptoms that were reported up until at least months after onset by most of our casepatients were similar to symptoms observed by avendano et al. ( ) in a study of canadian healthcare workers who were followed for weeks after illness onset, suggesting residual illness in sars case-patients. however, the progression of these symptoms over time is difficult to interpret without a better appreciation of the pre-illness symptoms. antibody to sars-cov in some case-patients was documented as early as day after illness onset. we did not have an adequate number of early serum specimens from other case-patients to determine when sars-cov antibody is first detectable. results of this investigation should be interpreted in light of several limitations. the small number of participants does not allow for accurate estimation of the risk for transmission to household members. irregular and long intervals between collections of specimens do not permit a clear picture of the natural history of sars-cov infection, including documenting the precise timing of the first appearance of sars-cov antibody. we also may have missed the presence of shedding in stools of other casepatients who had reported diarrhea during the acute phase of illness. possible variations in specimen collection and handling techniques could also have affected sars-cov detection rates in respiratory and stool specimens. our results suggest that sars-cov is not always transmitted efficiently. routine collection and testing of stool and sputum specimens of probable sars case-patients may help the early detection of sars-cov infection. a follow-up of recovered sars case-patients over several months would also help to better assess possible waning of antibody titers and long-term sequelae of the disease and, thus, improve our understanding of the true illness associated with sars-cov infection. identification of a novel coronavirus in patients with severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome coronavirus as a possible cause of severe acute respiratory syndrome a major outbreak of severe acute respiratory syndrome in hong kong identification of severe acute respiratory syndrome in canada acute respiratory syndrome. china, hong kong special administrative region of china, and viet nam communicable disease surveillance and response (csr) world health organization. cumulative number of reported probable cases of sars. communicable disease surveillance and response (csr) cluster of severe acute respiratory syndrome cases among protected health care workers-toronto a cluster of cases of severe acute respiratory syndrome in hong kong outbreak of severe acute respiratory syndrome (sars) at amoy gardens, kowloon bay, hong kong: main findings of the investigation severe acute respiratory syndrome-singapore updated interim surveillance case definition for severe acute respiratory syndrome (sars)-united states interim laboratory biosafety guidelines for handling and processing specimens associated with severe acute respiratory syndrome (sars) investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong clinical course and management of sars in health care workers in toronto: a case series clinical progression and viral load in a community outbreak of coronavirus-associated sars pneumonia: a prospective investigation address for correspondence: elmira isakbaeva we thank all patients and their family members who participated in this investigation. we also thank d. vugia, g. the international conference on women's health and infectious diseases, sponsored by the centers for disease control and prevention (cdc) and partners, will be held at the marriott marquis, atlanta, georgia, february - , . intended for clinicians, scientists, women's health advocates, health educators, public health workers, academicians, and representatives from all levels of government and from community-based, nonprofit, philanthropic, and international organizations, the conference will promote prevention and control of infectious diseases among women worldwide.featured sessions will include women and hiv/aids, perinatal infectious diseases, immu-nizations, links between infectious and chronic diseases, and the impact of globalization. other topics include infectious disease disparities, gender-appropriate interventions, and effective health communication.speakers will include, julie l. gerberding, cdc director, who will speak about the impact of infectious diseases on women; carol bellamy, executive director, united nations children's fund (unicef), who will speak about globalization and its effect on infectious diseases among women; and mirta roses periago, director, pan american health organization (paho), will speak about prevention of infectious diseases among women globally. for information, about cost and registration, contact the office of minority and women's health, national center for infectious diseases, cdc, at web site: www.womenshealthconf.org; email: omwh@cdc.gov; or phone: bejaye roberts, - - . key: cord- - kmd ds authors: carneiro, arie; wroclawski, marcelo langer; nahar, bruno; soares, andrey; cardoso, ana paula; kim, nam jin; carvalho, fabricio torres title: impact of the covid- pandemic on the urologist’s clinical practice in brazil: a management guideline proposal for low- and middle-income countries during the crisis period date: - - journal: int braz j urol doi: . /s - .ibju. . . sha: doc_id: cord_uid: kmd ds this letter to the editor aims to provide suggestions and recommendations for the management of urological conditions in times of covid- crisis in brazil and other low- and middle-income countries. it is important to highlight that one of the main characteristics of this pandemic is the oversaturation of the health system capacity, mostly due to a high demand for personal protective equipment (ppe), hospital/icu beds, as well as ventilators. in places with limited resources and where the health care systems are already saturated, such consideration is even more worrisome. therefore, most worldwide authorities are recommending to avoid, as much as possible, patient’s elective visits to hospitals, as well as a judicious use of the operating room in order to mitigate the strain put on the health system. while efforts should be directed to the care of covid- patients, other conditions (especially urgencies and oncological cases) must continue to be assisted. thus, through a panel of experts, we have prepared a practical guide for urologists based on the recommendations from the main urologic associations, as well as data from the literature to support the suggested management. we will try to follow the standard guideline recommendations from the american urological association (aua) and european association of urology (eau), with the aim of pursuing the best outcomes possible. however, some recommendations were based on the consensus of the panel, taking into consideration the reality of developing countries and the unprecedented situation caused by the covid- crisis. most importantly, all recommendations on this manuscript are based on the expectancy of a maximum -month duration of the crisis. if this period shall extended, these recommendations will be revised and updated. the format of the text will be given through questions and answers. similar to other specialties, the pandemic has drastically changed the routine of the urologists. elective clinic visits are being canceled, postponed or, in some situations, replaced by remote care through telemedicine, recently regulated and temporarily authorized by the brazilian ministry of health ( ) . we believe that tele-screening, test reviews and follow-up evaluations that do not require physical examination are the ideal situations for this type of care, especially when the patient is in the high-risk group and must be socially isolated ( ) . in regard to surgeries, all postponable procedures must be rescheduled, in order to reduce the exposure of the surgical team and the patient to a potential contamination. furthermore, cancelation of surgeries collaborates with social isolation and save resources (such as ppes) for the care of patients with covid- infection. the main question is how to define which operations can really be postponed, especially in urologic oncology, without interfering with the patient's outcomes. the most important recommendation at this point is that elective surgical procedures should be postponed. the diagnostic, therapeutic and human resources of the health care facilities must be available to fight the pandemic ( ) . some considerations should be made: a) we must consider all cases as suspect, until proven otherwise. ideally, every case should be tested by rrt-rna-crp for sars--cov- prior to surgery, but unfortunately this is not feasible in most developing countries. negative confirmed cases should be kept in a separate environments. b) surgeries for covid- negative patients should ideally be performed in a surgical center different from the location where patients with positive covid- are being treated. if it is not possible to separate an entire surgical block, we suggest designating specific rooms for the care of patients with covid- that will not be used for regular cases. c) a trained and dedicated multidisciplinary team should be available for the management of suspected and confirmed patients for covid- . it is preferable that this team does not assist co-vid- negative cases. d) whenever possible, we should prioritize surgeries with local anesthesia or spinal blockade. e) always obtain a consent form, as recommended by the brazilian society of medical and bioethics law. patients are at risk of contracting covid- infection during their hospital stay and major surgeries in asymptomatic infected patients during the incubation period appear to predict worse outcomes, with a mortality rate up to % ( ). f) after the procedure, covid- positive patients should be admitted to the designated areas for suspected and / or confirmed patients with covid- , if the institution in question provides such area. -if available, we recommend testing all patients for rrt-rna-pcr for sars-cov- hours before performing the procedure. -if it is impossible to test everyone with the resources available, all cases should be considered suspect. for everyone in the room: caps, personal protective glasses, n mask (pff or pff ), protective gowns for contacts, procedure gloves and shoe covers. for those who will perform procedures: cap, personal protective glasses, face shield, n mask (pff or pff ), sterile waterproof apron, sterile gloves, shoe covers and waterproof disposable boots whenever secretions (when urine, stool or blood are expected, such as in endourological procedures) are expected. -in the setting of n masks rationing, the face shield is important in order to prevent soiling of the mask, that can be further reutilized. -increased care should be taken when handling patient's stool. studies have shown that even in patients with negative airway crp, the clearance of the the viral rna is longer in the stool ( ). thus, surgeons should take extra precautions with surgeries that include bowel manipulation and trans-rectal prostate biopsies. a) on the corridor: -hand hygiene; -put on the n mask and goggles or face shield for anesthetists, in the case of intubation. -perform surgical hand antisepsis. b) in the lobby -put on a surgical gown. -put on sterile gloves (surgical team); -the anesthesiologist should use pairs of gloves and after intubation the second pair should be changed as soon as possible. what is the correct order to remove the surgical ppe? a) inside the room: -remove gloves; -hand hygiene; -remove disposable gown; -hand hygiene. b) outside the room: (leave a side table with an oxivir® drum and procedure gloves). -remove glasses; -remove the n mask and place it in an identified plastic bag; -remove the cap; -hand hygiene; -put on procedure gloves and clean and disinfect the glasses and support surface (use disinfectant detergent -oxivir® or optigerm ®); -remove the gloves; -hand hygiene. after removing protective equipment, remember not to touch your hair or face before hand washing. some studies have suggested transmission of some pathogens (coryneobacterium, papillomavirus and hiv) by the pneumo peritoneum through the release of smoke generated by the laparoscopic electrocautery ( ) ( ) ( ) . a parallel situation may be extrapolated to the coronavirus. therefore, additional care in these procedures must be performed: a) as mentioned earlier, it is important to test all patients before the procedure, if possible. b) additional protection in relation to aerosol dispersion: always keep materials clean, assistants must have additional care when placing and removing trocars, do not use trocars with air leakage, avoid using monopolar energy and give preference to bipolar, keep settings of the electrocautery to minimum in order to reduce smoke formation. c) handling of pneumoperitoneum: keep it as low as possible, minimizing the trendelenburg as much as possible. if possible, use devices that are able to aspirate and filtrate the smoke from the pneumoperitoneum. d) during disinflation, the co gas and smoke should be captured with an ultra-filtration system. a disinflation mode should be used on your insufflator if available. e) if available, use filters on vacuum cleaners, there are different models and brands. f) use drains only when extremely necessary because post-operative care in the presence of organic fluids demand extra-caution and additional ppe. g) favor the open approach in cases where minimally invasive surgery has not shown considerable benefit. when should we go into isolation? urologists, like other physicians, should be isolated only when they become suspected or confirmed cases of covid- . in suspicious cases, the sars-cov- rt-rna-crp should be collected and physicians should be kept isolated until the result. physicians with the following symptoms should be considered highly suspicious for co-vid- : fever, respiratory symptoms (cough, runny nose, nasal obstruction, sore throat, shortness of breath, loss of smell), in addition to body aches, fatigue, diarrhea and nausea ( ) . healthcare professionals should always be tested when symptomatic. the duration of the quarantine is days, starting on the day of onset of symptoms. individuals should be asymptomatic at the end of this period. otherwise, they should remain isolated until symptoms are resolved, and only return to activities hours after the resolution of all symptoms. the center for disease control and prevention (cdc-usa) recommends the utilization of rt-rna-crp for control and only release physicians to work after a negative result. however, due to the lack of tests in most of the country, this is not mandatory by the brazilian ministry of health ( ). in cases of patients with urinary lithiasis all surgeries to treat urolithiasis should be suspended, unless these are emergencies. in the presence of ureteral lithiasis associated with fever or other signs of infection, there is an absolute indication for antibiotic therapy and urinary drainage. preferably, we opted for the passage of a ureteral stent (i.e double j stent) under spinal anesthesia (or even with local anesthesia). as an alternative, bedside ultrasound percutaneous guided nephrostomy might be considered in centers with the necessary expertise ( ) . in addition to lithiasis associated with urinary tract infection, ureteral obstruction in a solitary kidney or bilateral ureteral obstruction, acute impairment of renal function and pain refractory to clinical treatment should not be postponed. unlike other recommendations( ), our position is that, once the surgical procedure is indicated, we should be as resolutive as possible, in order to reduce the number of visits to the hospital for new surgeries to the emergency department. thus, instead of just draining the urinary tract, our tendency is to perform ureterolithotripsy whenever possible and safe, keeping the double j stent with a string externalized by the urethra to be removed on an outpatient basis. the remaining cases of renal colic should preferably be managed clinically, with medical expulsive therapy and pain control. however, it is important to note that, invariably, cases initially conducted in this way may evolve into emergency situations, such as those previously mentioned. patients who are already with a double j stent may remain with the stent for as long as possible. surgery may be indicated in cases of extreme ureteral stent discomfort. otherwise, clinicians must keep strict control of all cases in order to avoid the forgotten double j syndrome. patients with benign prostatic hyperplasia should not be operated at this time of a pandemic, unless they develop complication that will require hospitalization and possible surgery, such as massive hematuria and clot retention. in this scenario, we believe that the evacuation of clots and / or cauterization of the prostate should already be accompanied by resection, vaporization or endoscopic enucleation of the prostate ( ) . in all other cases, even if there is urinary retention, we recommend postponing the procedure. if necessary, indwelling urinary catheter placement or percutaneous cystostomy with local anesthesia are indicated for preservation of renal function ( , ) . the investigation of hematuria through imaging tests during covid- pandemic should be limited to cases of macroscopic hematuria, especially if there are clots or hemoglobin decrease. greater attention should be given to patients at higher risk for urothelial carcinoma, such as men, over years of age and with a history of smoking and exposure to known carcinogenic agents. the gold standard test for investigation of the upper urinary tract is uro-tomography, but in times when we need to consider the use of resources, ultrasound could potentially be used since many imaging services are overloaded due to the frequent indication of thoracic cts for the diagnosis and follow-up of patients with sars-cov- . these data are extrapolations from recent evidence that ultrasound could replace tomography in the investigation of microscopic hematuria ( ) . however, once the outbreak is resolved or if the resource is available, uro-tomography should be performed. regarding the lower urinary tract, flexible cystoscopes are not widely avaliable in brazil. thus, diagnostic cystoscopies should initially be postponed avoiding hospitalization for cystoscopy in the or. ultrasound could also be used to evaluate the lower urinary tract during this time of pandemic. in addition to the procedures previously mentioned, non-urologic oncology conditions that deserve urgent treatment are testicular torsion, scrotal abscess and / or fournier's syndrome, infection of penile prosthesis or artificial sphincter, priapism and urological trauma. we should consider postponing surgical treatment for all other urological conditions, such as urinary incontinence, prolapses, urethral stenosis, prosthetic implants, infertility-related operations (including vasectomy) and genital procedures such as circumcision or hydrocele correction ( ) . urodynamic study: we suggest that urodynamic study programs should be suspended during the crisis period. whenever possible, cystoscopies should be postponed. if indispensable, priority should be given to outpatient procedures, using a flexible cystoscope. it's well known that most programs in developing countries do not have flexible cystoscopy, so it is necessary to perform it in the operating room. this should be postponed whenever possible. as a rule, prostate biopsies should be postponed, since delaying the diagnosis of prostate cancer for - months will not interfere with survival outcomes in the vast majority of cases. it's worth discussing prostate biopsy in highly suspicious cases of patients with symptoms related to advanced / metastatic disease, such as bone pain or urinary retention. given that most medications for metastatic prostate cancer (such as androgen deprivation therapy) are not approved/released without histological confirmation of prostate adenocarcinoma, we recommend to biopsy the most easily accessible site, which may be the prostate (often the most quickly available resource) or some metastasis focus. however, if clinical signs of metastatic disease are evident, a shared decision should be made with the patient and additional efforts should be performed to expedite the release of these medications even without the biopsy. we believe this exception should be highly considered in selected patients, especially in times of crisis. if indicated, the biopsy should be performed under local prostatic block, avoiding sedation. as mentioned earlier, additional care must be taken, given the high prevalence of covid- in the stool of infected patients. -in case of small bladder tumors, consider a single-dose intravesical chemotherapy within hours of turbt (not immunotherapy). the most commonly used agents are: mitomycin and gemcitabine, in brazil just gemcitabine isavaiable ( ) . -in intermediate-risk and high-risk non--muscle-invasive bladder cancers: clinically fit patients with no major comorbidities should receive induction therapy followed by at least -year maintenance bcg. in selected cases we can consider postpone one dose during the maintenance. in the case of bcg shortage supply, gemcitabine can be used ( , ) . patients with d'amico low-risk prostate cancer -treatment: active surveillance is recommended for all patients with grade group . -follow-up: follow-up tests as well as confirmatory and control biopsies should be postponed. -treatment: treatment of these patients should be postponed until the pandemic is over. we have robust evidence to support that postponing treatment in these patients for months do not impact cancer-specific mortality (protect, pivot, spcg trials). afterward, local treatment should follow the current recommendations in the guidelines ( ) ( ) ( ) . -follow-up: patients who have already been treated should ideally be followed via telehealth. in-person consultations should only be carried out if they are really necessary. the first post-operative psa can be performed after months, because no early adjuvant therapy would be initiated in this scenario. -treatment: we recommend initiation of hormone deprivation therapy immediately and, after months, discuss the most appropriate local therapy. there is good evidence supporting this approach, particularly when associated with radiation therapy and, less common, as neoadjuvant for surgery. while no survival benefit was seen with neoadjuvant studies, pre-operative androgen deprivation therapy reduced positive margin rates as well as extra prostatic extension without compromising cancer control ( ) . -follow-up: patients who have already been treated should undergo additional tests and visit after the pandemic. in-person consultations should only be carried out if they are really necessary. the first post-operative psa can be performed after months, because no early adjuvant therapy would be initiated in this scenario. no adjuvant radiation therapy may be indicated during covid- pandemic. all cases, even in the presence of unfavorable features, can be managed later with salvage radiation therapy if necessary. we recommend use of adt in a -month formulation ( ) in association with apalutamide mg vo daily or enzalutamide mg vo daily ( ), when indicated. if apalutamide or enzalutamide is not available, an alternative option is abiraterone mg vo daily associated with prednisone mg vo daily. the use of low dose prednisone should be considered since the impact of corticoid usage during the covid- pandemic are not well known ( ) . chemotherapy associated with adt should be indicated only in extremely selected cases. when indicated, it can be postponed until days after initiation of adt ( ) . use of colony stimulating factor is recommended in cases of chemotherapy. we recommend the use of adt in semiannual formulation ( ) associated with preferably mg of enzalutamide vo daily (if not previously received) ( ) or alternatively abiraterone mg vo daily associated with prednisone mg vo daily (if not previously received). alternatively, in patients with isolated bone metastases, the use of radium adt may be considered ( ) . alternatively, docetaxel with reduced dose every weeks can be considered. it's important to emphasize that colony stimulating factor is highly recommended when chemotherapy is administered ( ) . zoledronic acid should be used in patients with bone metastases every months ( ). asymptomatic ct a patients should have their treatment postponed, unless there is a rare risk that a nephron-sparing procedure becomes not feasible with the delay of surgery. asymptomatic ct b or ct patients, eligible to partial nephrectomy, should be operated to avoid losing the window of a nephron sparing surgery. if the indication is radical nephrectomy, it may be postponed. patients with ct - disease and/or with symptoms such as gross hematuria should be operated, especially those with thrombus in the renal vein and / or vena cava. what is the role of cytoreductive nephrectomy in the current scenario? should we always try systemic treatment first? we should proceed with cytoreductive nephrectomy whenever this is the best short-and medium-term treatment option for symptoms control. asymptomatic patients with low and intermediate risk who can wait months to start treatment should wait. patients with indications of immediate systemic treatment should start treatment despite nephrectomy, especially in cases of intermediate and poor risk ( ) . regarding the choice of first line treatment, we favor, if available, the combination of a tyrosine kinase inhibitors (tki) with immunotherapy, such as axitinib with pembrolizumab ( , ) . we also suggest adjusting the dose intervals to less frequent (pembrolizumab to mg every weeks). if not available, the choice between the combination of immunotherapy with ipilimumab and nivolumab versus tki should take into account the risk of complications and potential readmissions ( ) . it is relatively safe to start systemic therapy with tyrosine kinase inhibitors (tki) and immunotherapy, although it might have a hypothetical detrimental effect on the immunological response to covid- . nonetheless, no reliable evidence regarding therapy with immunotherapy or tyrosine kinase inhibitors has been identified but the landscape is changing rapidly, and we should be attentive to any evidence that could show the opposite ( ) . in general, turbt should be performed whenever possible. it is important to highlight that we recommend performing a cold-cup biopsy of the base of the lesion to ensure representation of the detrusor muscle and avoid the need for repeat turbt due to undersampling ( ) . elderly patients with multiple comorbidities and asymptomatic patients with radiologically small and superficial tumors can have the procedure postponed. virads staging system may play an important role in selecting such cases. repeat turbt is the standard of care for non-muscle-invasive high-risk bladder tumors ( ) . however, during the pandemic, some exceptions can be considered. if the initial procedure was performed by an experienced surgeon who is confident that the entire lesion was completely removed and there is presence of muscle layer in the pathology, the repeat turbt may be postponed. in patients with high-grade pta, repeat turbt can also be delayed, even if no muscle is represented. muscle invasive bladder cancer is an aggressive disease with great potential to be curable. in this scenario, surgical delays might represent a loss on the window of treatment. in general, we recommend performing neoadjuvant chemotherapy and, after finishing, assess the conditions of the hospital to decide on the need for a cystectomy vs bladder preservation protocol (if indicated). of note, neoadjuvant chemotherapy with cisplatin and gemcitabine before cystectomy can be delayed for up to - weeks from diagnosis ( ) . cystectomy after neoadjuvant chemotherapy can also be safely delayed for up to weeks post chemotherapy ( ) without jeopardizing oncological outcomes ( ) . patients who have undergone cystectomy should consider adjuvant chemotherapy with cisplatin and gemcitabine. this approach still offers survival benefits even days after surgery ( ) . we should always consider using colony stimulating factor when chemotherapy is recommended. for patients who wish to preserve the bladder, or who are not eligible for surgery, or the hospital does not have adequate resources, trimodally therapy should be considered. (tur-bt followed by hypo-fractionated radiotherapy associated with weekly chemotherapy with gemcitabine mg/m ). for cisplatin eligible patients we recommend first line of treatment ( ) : -cisplatin mg/m on days and and gemcitabine mg/m on days and every weeks ( ). -consider colony stimulating factor in all patients. for cisplatin ineligible pd-l negative patients we recommend the first line of treatment: -carboplatin, auc . - and gemcitabine , mg/m² on day and day , every weeks ( ). -consider colony stimulating factor in all patients. radical orchiectomy should be performed as soon as possible because it is an outpatient procedure and will guide further treatment. we recommend surveillance for most patients with stage i over any adjuvant treatment, despite unfavorable features ( ) . -for low volume stage ii patients (iia and iib) we recommend radiotherapy instead of chemotherapy for seminomas ( ) . -for high volume stage ii seminomas: cycles of ep(etoposide mg/m iv on days - and cisplatin mg/m iv on days - , every days), considering using g-csf ( ); -for non-seminoma stage iia with normal markers: retroperitoneal lymph node dissection might be considered to avoid use of chemotherapy ( ) . -for non-seminoma stage iia with significant elevation of tumor markers and stage iii (for both seminoma and non-seminoma): in case of favorable risk, we recommend cycles of ep. we do not recommend cycles of bep. in case of intermediate or unfavorable risk, cycles of vip (etoposide mg/m iv on days - ; ifosfamide mg/m iv on days - with same protection and cisplatin mg/m iv on days - , every days) are preferable or alternatively, cycles of bep, (with strong recommendations of g-csf use), because of the bleomycin pulmonary toxicity ( ) . portaria número cancer guidelines during the covid- pandemic clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid- infection persistence and clearance of viral rna in novel coronavirus disease rehabilitation patients microbiologic activity in laser resurfacing plume and debris risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. an in vitro study clinical features of patients infected with novel coronavirus in wuhan coronavirus disease (covid- ). . available at endourological stone management in the era of the covid- covid- and urology: a comprehensive review of the literature surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: aua guideline urology practice during covid- pandemic can renal and bladder ultrasound replace computerized tomography urogram in patients investigated for microscopic hematuria? canes d considerations in the triage of urologic surgeries during the covid- pandemic european association of urology guidelines on non-muscle-invasive bladder cancer (tat and carcinoma in situ) - update alternative therapies to bacillus calmette-guérin shortage for nonmuscle invasive bladder cancer in brazil and other underdeveloped countries: management considerations radical prostatectomy or watchful waiting in early prostate cancer -year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer follow-up of prostatectomy versus observation for early prostate cancer the survival impact of neoadjuvant hormonal therapy before radical prostatectomy for treatment of high-risk prostate cancer a -month clinical study of la- ( . mg): a new -month subcutaneous delivery system for leuprolide acetate for the treatment of prostate cancer apalutamide for metastatic, castration-sensitive prostate cancer abiraterone plus prednisone in metastatic, castration-sensitive prostate cancer chemohormonal therapy in metastatic hormone-sensitive prostate cancer increased survival with enzalutamide in prostate cancer after chemotherapy alpha emitter radium- and survival in metastatic prostate cancer docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer effect of longer-interval vs. standard dosing of zoledronic acid on skeletal events in patients with bone metastases: a randomized clinical trial renal cell carcinoma: eurpean association of urology immune checkpoint blockade plus axitinib for renal-cell carcinoma. reply pembrolizumab plus axitinib versus sunitinib for advanced renal-cell carcinoma nivolumab plus ipilimumab versus sunitinib in advanced renal-cell carcinoma clinical rationale and safety of restaging transurethral resection in indication-stratified patients with high-risk non-muscle-invasive bladder cancer gakis get al. muscle-invasive and metastatic bladder cancer: european association of urology a retrospective analysis of the effect on survival of time from diagnosis to neoadjuvant chemotherapy to cystectomy for muscle invasive bladder cancer delaying radical cystectomy after neoadjuvant chemotherapy for muscle-invasive bladder cancer is associated with adverse survival outcomes survival benefit persists with delayed initiation of adjuvant chemotherapy following radical cystectomy for locally advanced bladder cancer a phase i/ii study of gemcitabine and fractionated cisplatin in an outpatient setting using a -day schedule in patients with advanced and metastatic bladder cancer first-line pembrolizumab in cisplatinineligible patients with locally advanced and unresectable or metastatic urothelial cancer (keynote- ): a multicentre, single-arm, phase study randomized phase ii/iii trial assessing gemcitabine/carboplatin and methotrexate/carboplatin/ vinblastine in patients with advanced urothelial cancer who are unfit for cisplatin-based chemotherapy: eortc study testicular cancer: european association of urology arie carneiro and marcelo langer wroclawski contributed similarly as first author. none declared. key: cord- -j authors: itoyama, satoru; keicho, naoto; quy, tran; phi, nguyen chi; long, hoang thuy; ha, le dang; ban, vo van; ohashi, jun; hijikata, minako; matsushita, ikumi; kawana, akihiko; yanai, hideki; kirikae, teruo; kuratsuji, tadatoshi; sasazuki, takehiko title: ace polymorphism and progression of sars date: - - journal: biochemical and biophysical research communications doi: . /j.bbrc. . . sha: doc_id: cord_uid: j abstract we have hypothesized that genetic predisposition influences the progression of sars. angiotensin converting enzyme (ace ) insertion/deletion (i/d) polymorphism was previously reported to show association with the adult respiratory distress syndrome, which is also thought to play a key role in damaging the lung tissues in sars cases. this time, the polymorphism was genotyped in vietnamese sars cases, with healthy controls who had had a contact with the sars patients and controls without any contact history. sars cases were divided into either non-hypoxemic or hypoxemic groups. despite the small sample size, the frequency of the d allele was significantly higher in the hypoxemic group than in the non-hypoxemic group (p = . ), whereas there was no significant difference between the sars cases and controls, irrespective of a contact history. ace might be one of the candidate genes that influence the progression of pneumonia in sars. the severe acute respiratory syndrome (sars) spread worldwide as an emergent pneumonia [ ] . typical clinical features of sars are high fever, myalgia, and other symptoms caused by systemic inflammation and the subsequent atypical pneumonia [ ] [ ] [ ] . approximately % of sars cases developed hypoxemia [ ] and further advanced cases were presented as acute respiratory distress syndrome (ards). pathological analysis of the lung at autopsy in cases of sars revealed diffuse alveolar damage, characterized by desquamation of pneumocytes, inflammatory infiltrates, edema, and hyaline-membrane formation [ ] [ ] [ ] . such pathological feature of the lung in sars cases was consistent with that in ards. the early reports showed that higher age, diabetes mellitus, and heart disease are risk factors for the prognosis of sars [ , ] , whereas there has been so far little discussion on contribution of genetic factors for the development or progression of sars [ , ] . to in ards as well [ , ] . in the present study, we focused on the angiotensin converting enzyme (ace) deletion (d) allele that was once reported to be associated with poor outcome in ards [ ] . ace is a metallopeptidase that converts angiotensin i (at-i) to angiotensin ii (at-ii), acting as a vasoconstrictor, and it also degrades bradykinin, acting as a vasodilator. ace is a prototype of angiotensin converting enzyme, which is distinct from its human homologue ace also known as a sars receptor [ ] . it is well known that ace is rich in microvascular endothelium and is likely involved in angiopathy of the lung. the human ace gene on chromosome q consists of exons, and has insertion (i) or deletion (d) of a -bp alu repeat sequence in intron [ ] . although the function of this polymorphism remains unclear, the genotype or allele frequency of this polymorphism has been often reported to be associated with pathological status including the development of myocardial infarction and deterioration of the renal function in diabetes mellitus in humans [ ] . in the present study, we explored the possibility of this polymorphism, based on the assumption that it might be associated with progression of sars in vietnamese cases. although vietnam experienced the outbreak of sars in february , they successfully controlled sars and vietnam was removed from the list of the affected areas just nine weeks later. consequently, in vietnam, there were probable cases of sars; % was nosocomial infection in a single hospital and the community-acquired infection was only % [ ] . study population. this study was reviewed and approved by ethics committees in ministry of health of vietnam as well as international medical center of japan. out of cases fulfilling the world health organization case definition of probable sars [ ] , five cases died, three were not vietnamese, such that they were excluded from this study. in the remaining , written informed consent was obtained from individuals, who were enrolled in this study as cases. furthermore, staff members who came in contact with sars patients in the hospital a without development of sars, and individuals reflecting general vietnamese population who had no contact history participated in this study. peripheral blood sample of all the subjects was taken, blood cells were separated from plasma by centrifuge method, and genomic dna was subsequently extracted by a method described elsewhere [ ] . genotyping of ace i/d polymorphism. ace i/d genotype was determined by three-primer polymerase chain reaction amplification method that was described previously [ ] . briefly, primers ace and ace were chosen outside the insertion sequence and another primer ace was placed on the insertion sequence. reactions were performed with pmol of each primer ace and ace , and with . pmol of primer ace in a final volume of ll, containing . mm mgcl , mm kcl, mm tris-hcl, ph . , . % (w/v) of gelatin, . mm of each dntp, and u taq polymerase (ampritaq gold dna polymerase, applied biosystems). nucleotide sequences of primers were as follows: ace : -catc ctttctcccatttctc- , ace : -tgggattacaggcgtga tacag- , and ace : -atttcagagctggaataaaatt- . after the initial denaturation at °c for min, the reaction mixture was subjected to cycles of °c for min and °c for min. this method yields amplification products of bp for the d allele and bp for the i allele, and products were electrophoresed and visualized on % agarose gels with ethidium bromide. clinical profiles and backgrounds of the subjects. clinical profiles and backgrounds of all subjects were extracted from medical records and questionnaires taken by trained interviewers. information about age, sex, degree of contacts with sars patients, and requirement of supplementary oxygen was obtained. chest radiographs of sars cases on the acute phase were also available. entire lung field on the chest xray films was divided into six zones, which were right upper, middle, and lower zones and left upper, middle, and lower zones. the number of affected zones on the film where the lung is most severely inflamed during the clinical course was counted in each case. two different chest physicians judged the number of involved zones in the entire lung field independently. statistical analysis. disease associations were assessed by the v test. inter-observer variability for the number of involved zones in the lung was assessed with the spearman rank correlation coefficient. logistic regression analysis was performed to identify predictors of hypoxemia or progression of sars. the p values less than . were considered significant in all the tests and data analysis was carried out using the sas system for windows version . (sas institute, cary, nc). demographic information of sars cases and healthy contacts in this study is shown in table . of the cases, were male and were female. their mean age was . years old. two cases had hypertension but they had neither diabetes mellitus nor heart disease. of the healthy contacts, were male and were female. their mean age was . years old and this was comparable with that of sars patients. one case had hypertension. individuals who faced sars patients directly were defined as ''direct contacts.'' health care workers working in the hospital a during the outbreak but did not come in direct contact with sars patient were described as ''indirect contacts.'' based on the requirement of supplementary oxygen when pneumonia deteriorated, cases were separated into two groups. oxygen was supplied to maintain a partial pressure of arterial oxygen of higher than mm hg, or arterial oxygen saturation of more than % at room air on the basis of provisional guidelines issued by ministry of health in vietnam. half of the cases did not require supplementary oxygen and were defined as ''non-hypoxemic'' group and the other half required supplementary oxygen and constituted ''hypoxemic'' group ( table ). five cases of the hypoxemic group further received mechanical ventilation because they could not keep spontaneous breathing. serial chest x-rays were taken in all cases during the acute stage. we compared the number of involved lung zones with requirement of supplementary oxygen ( table ) . assessment of the number of involved lung zone correlated well between two medical observers (spearman rank correlation coefficient, r = . , p < . ). the number of involved lung zones was significantly associated with requirement of supplementary oxygen (v value = . ; df = ; p < . ). in out of cases with hypoxia, more than three zones of the lung were involved on chest x-rays, whereas in out of cases without hypoxia, only one zone was involved. genotypic distribution and allele frequency of the ace i/d polymorphism in sars cases and controls with or without contact history to sars patients were compared (table ). genotypic and allele frequencies of ace i/d polymorphism were not different among those groups. roughly, one-third of the alleles were d in the vietnamese population, which were comparable with the previous data from asians including japanese and chinese, but quite different from those in british population, where a half of them were d allele. as shown in table , frequency of the d allele of the hypoxemic group was significantly higher than that of the non-hypoxemic group ( of alleles versus of alleles; v value = . , df = , p = . ). in a univariate logistic regression analysis, the number of ace d allele in sars cases was a significant risk factor for hypoxemia of sars cases (odds ratio . ; % ci . - . ; p = . ) ( table ). even when age, gender, and contact status were added to the ace allele to carry out multivariate logistic regression analysis, contribution of the d allele as a risk factor for hypoxemia was still robust (table ). age did not contribute to this parameter. however, the mean age of hypoxemic cases that received mechanical ventilation was . and obviously higher than . of hypoxemic cases that did not require mechanical ventilation ( table ). comparison of parameters between survivors and non-survivors was not possible, because no dna samples were available from non-survivors. in vietnam, % of sars cases were medical staff members, in-patients with another disease or visitors to the hospital in question [ ] . although a standard precaution was taken, this nosocomial infection was neither modified by isolation of patients nor protected by measures such as wearing n masks against the new pathogen, because the cause of this atypical pneumonia was unknown in the early phase of the outbreak [ ] . all the infection spread originally from one case from hong kong within months. it implies that natural course of nosocomial infection of sars was observed in vietnam. this was an unfortunate event but was a major advantage for us to assess genetic risk factors, minimizing other confounding factors. moreover, the study population was limited to be vietnamese ethnicity for genetic analysis. questionnaires taken by trained interviewers and chest radiographs of all cases in this study, and clinical records of most of the cases were available to evaluate clinical status in detail. as a result, out of accessible cases of ethnic of vietnamese were enrolled and this achieved high coverage of this study. although the number of cases is not enough to reach a definite conclusion in a case-control design, we were able to extract an attractive candidate gene in this study. herein, % of the cases required supplementary oxygen. this was comparable with a report by others [ ] . oxygen was given on the basis of local guidelines, when hypoxemia was detected at room air. there was a close correlation between the number of involved zones of chest radiography and status of supplementary oxygen; therefore, we considered that progression of sars in the lung is reasonably evaluated by the requirement of supplementary oxygen. in the sars cases, the frequency of d allele in hypoxemic group was higher than that of non-hypoxemic group with statistical significance, despite the small sample size. this indicates that ace gene could be one of the candidates which influence the progression of sars, although another gene that is located close to the gene may be responsible for the disease. the frequency of d allele of sars cases was not different from that of the healthy contacts, and the d allele did not appear to influence development of sars itself. there was also no difference in the frequency of d allele between healthy contacts and non-contacts. in other words, contact history did not affect the genotype distribution. most severe cases of sars show diffuse alveolar damage. this pathological status is characterized by increased permeability of alveolar-capillary barrier, which consists of two separate barriers, microvascular endothelium and alveolar epithelium [ ] . when these barriers are damaged, the permeability of alveolar-capillary barrier increases and protein-rich edema fluids flow into alveolar spaces from blood vessel [ ] . a previous report indicated that at-i increased vascular permeability in rat [ ] . another report showed that at-ii induces apoptosis of human alveolar epithelial cells [ ] . the degree of epithelial injury seems to influence the outcome of ards [ ] . the serum ace levels of individuals who have genotype dd are almost twice as high as that of genotype ii [ ] . it is conceivable that d allele might influence the activity of renin-angiotensin system via ele- vation of serum or local ace level, and then this may lead to damage of endothelium or epithelium of the lung. in this study, neither higher age nor underlying disease was found to be risk factors for hypoxemia in sars. one of the reasons might be that sars cases in vietnam were mostly nosocomial infection among relatively young medical staff members who did not have underlying diseases. this situation may be different from ones in other countries. however, as described above, the number of cases that had specific underlying diseases, which may influence the prognosis of sars, was too few to conclude the role of underlying disease as a risk factor in our cases. although no case of sars had cardiovascular disorders or diabetes mellitus in vietnam, it is interesting that heart disease and diabetes mellitus have been reported to be risk factors in the prognosis of sars cases in other countries where incidence rates of these life-style related diseases are rather high [ , ] . the ace insertion/deletion polymorphism has also been reported to be a risk factor of the diseases mentioned above [ ] and this might be associated with systemic angiopathy and influence progression of sars in the lung. the reason why we used hypoxia as a parameter of disease progression and did not use other parameters such as requirement of mechanical ventilation or outcome of death was that there were only cases which required mechanical ventilation in our samples tested and no samples were obtained from the fatal cases. autopsies were not performed in vietnamese sars patients for religious reasons. it would promote further studies to clarify genetic predisposition of infection, development or progression of sars in the near future in other countries where a larger number of cases were reported. in conclusion, we showed that ace insertion/deletion polymorphism was statistically associated with hypoxemic status in sars cases of vietnam. genetic predisposition may be one of the risk factors for the progression of sars. world health organization, consensus document on the epidemiology of severe acute respiratory syndrome (sars the severe acute respiratory syndrome clinical description of a completed outbreak of sars in vietnam hku/uch sars study group, clinical progression and viral load in a community outbreak of coronavirus-associated sars pneumonia: a prospective study lung pathology of fatal severe acute respiratory syndrome lung pathology of severe acute respiratory syndrome (sars): a study of autopsy cases from singapore pulmonary pathological features in coronavirus associated severe acute respiratory syndrome (sars) clinical features and short-term outcomes of patients with sars in the greater toronto area short term outcome and risk factors for adverse clinical outcomes in adults with severe acute respiratory syndrome (sars) association of hla class i with severe acute respiratory syndrome coronavirus infection association of human-leukocyteantigen class i (b* ) and class ii (drb * ) genotypes with susceptibility and resistance to the development of severe acute respiratory syndrome angiotensin converting enzyme insertion/deletion polymorphism is associated with susceptibility and outcome in acute respiratory distress syndrome polymorphisms of human sp-a, sp-b, and sp-d genes: association of sp-b thr ile with ards angiotensin-converting enzyme is a functional receptor for the sars coronavirus an insertion/deletion polymorphism in the angiotensin i-converting enzyme gene accounting for half the variance of serum enzyme levels new aspects on angiotensin-converting enzyme: from gene to disease world health organization, global surveillance for severe acute respiratory syndrome (sars) purification of genomic dna from human whole blood by isopropanolfractionation with concentrated nal and sds polymorphisms of the angiotensin-converting-enzyme gene in subjects who die from coronary heart disease deletion polymorphism in the angiotensin i converting enzyme (ace) gene as a genetic risk factor for sarcoidosis association of the angiotensin-converting enzyme gene polymorphism with chronic heart failure in chinese han patients angiotensin converting enzyme gene polymorphism in korean patients with primary knee osteoarthritis lack of sars transmission among public hospital workers the acute respiratory distress syndrome mineshita, pulmonary edema induced by angiotensin i in rats human lung myofibroblast-derived inducers of alveolar epithelial apoptosis identified as angiotensin peptides the authors thank dr. nguyen key: cord- -ytpofa b authors: sujath, r.; chatterjee, jyotir moy; hassanien, aboul ella title: a machine learning forecasting model for covid- pandemic in india date: - - journal: stoch environ res risk assess doi: . /s - - - sha: doc_id: cord_uid: ytpofa b coronavirus disease (covid- ) is an inflammation disease from a new virus. the disease causes respiratory ailment (like influenza) with manifestations, for example, cold, cough and fever, and in progressively serious cases, the problem in breathing. covid- has been perceived as a worldwide pandemic and a few examinations are being led utilizing different numerical models to anticipate the likely advancement of this pestilence. these numerical models dependent on different factors and investigations are dependent upon potential inclination. here, we presented a model that could be useful to predict the spread of covid- . we have performed linear regression, multilayer perceptron and vector autoregression method for desire on the covid- kaggle data to anticipate the epidemiological example of the ailment and pace of covid- cases in india. anticipated the potential patterns of covid- effects in india dependent on data gathered from kaggle. with the common data about confirmed, death and recovered cases across india for over the time length helps in anticipating and estimating the not so distant future. for extra assessment or future perspective, case definition and data combination must be kept up persistently. as of date confirmed covid- cases across the globe are , , and mortality approximately . %. gradually the mortality rate is increasing and it's an alarming factor for the whole world. transmission is categorized into stages based on the mode of spread and time. every nation imposed different methodologies starting from staying in-home, using masks, travel restrictions, avoiding social gatherings, frequently washing hands and sanitizing the places often in the case of a common effort to combat the outbreak of this disease. many countries imposed a lockdown state that prevents the movement of the citizens unnecessarily. due to this social distancing factor and movement restrictions, the wellbeing and economy of the various nations are being under jeopardy. gpd of the entire world dropped drastically. when the person is found infected, he is isolated and treatment is given for recovery. but based on the severity it will cause death and also people left with a higher level of depression. in india, the outbreak of coronavirus as disturbed the functioning of life as a whole. all were pushed to stay back to safeguard from the dreadful transmission. in the initial stages, the confirmed cases are those returned from oversees followed by transmission via local transmission. more caution is given to the elderly and immunity fewer people. the demographic of the infected people in india indicates that years is the median. comparatively, people between and years are being affected more. the everyday predominance information of covid- from january , , to april , , was gathered from the website of kaggle. weka . . and orange is utilized to decipher the information. lr, mlp, and var are applied on the kaggle dataset having instances for anticipating the future effects of covid- pandemic in india. forecasting is the need of an hour that helps to device a better strategy to tackle this crucial hour across the globe because of this infectious disease. as mentioned by the visual capitalist, the human race as crossed several outbreaks because of the several microbes that were invisible and invincible. covid- is the current threat in the highly sophisticated twenty-first century. figure is a snapshot of the visual capitalist. artificial intelligence (ai) can assist us in handling the problems that need to be addressed raised by the covid- pandemic. it isn't simply the innovation, however, that will affect yet rather the information and inventiveness of the people who use it. without a doubt, the covid- emergency will probably uncover a portion of the key shortages of ai. machine learning (ml), the present type of ai, works by recognizing designs in chronicled training information. people have a preferred position over ai. we can take in exercises from one situation and apply them to novel circumstances, drawing on our dynamic information to make the best speculations on what may work or what may occur. computer-based intelligence frameworks, conversely, need to gain without any preparation at whatever point the setting or assignment changes even marginally. the covid- emergency, hence, will feature something that has consistently been valid about ai: it is a device, and the estimation of its utilization in any circumstance is dictated by the people who structure it and use it. in the present emergency, human activity and development will be especially basic in utilizing the intensity of what ai can do. one way to deal with the novel circumstance issue is to assemble new training information under current conditions. for both human leaders and ai frameworks the same, each new snippet of data about our present circumstance is especially significant in advising our choices going ahead. the more viable we are at sharing data, the more rapidly our circumstance is not, at this point novel and we can start to see a way ahead. ai can assist us in handling the problems that need to be addressed raised by the covid- pandemic. it isn't simply the innovation, however, that will affect yet rather the information and imagination of the people who use it. to be sure, the covid- emergency will probably uncover a portion of the key setbacks of ai. machine learning, the present type of ai, works by recognizing designs in verifiable training information. people have a preferred position over ai. we can take in exercises from one setting and apply them to novel circumstances, drawing on our theoretical information to make the best theories on what may work or what may occur. simulated intelligence frameworks, interestingly, need to gain without any preparation at whatever point the setting or undertaking changes even somewhat. the covid- emergency, along these lines, will feature something that has consistently been valid about ai: it is an apparatus, and the estimation of its utilization in any circumstance is dictated by the people who plan it and use it. in the present emergency, human activity and development will be especially basic in utilizing the intensity of what ai can do. one way to deal with the novel circumstance issue is to accumulate new training information under current conditions. for both human chiefs and ai frameworks the same, each new snippet of data about our present circumstance is especially important in illuminating our choices going ahead. the more compelling we are at sharing data, the more rapidly our circumstance is not, at this point novel and we can start to see a way ahead. sujatha and chatterjee ( ) proposed a model that could be useful to foresee the spread of covid- by using linear regression, multilayer perceptron and vector autoregression model on the covid- kaggle data to envision the epidemiological example of the malady and pace of covid- cases in india. yang et al. ( ) introduced dynamic seir model for anticipating the covid- pestilence pinnacles and sizes. they utilized an ai model prepared with respect to past sars dataset additionally shows guarantee for future expectation of the scourges. barstugan et al. ( ) presented early stage location of covid- , which is named by world health organization (who), by machine learning strategies actualized on stomach computed tomography pictures. elmousalami and hassanien ( ) presents a correlation of day level guaging models on covid- influenced cases utilizing time series models and numerical detailing. rizk-allah and hassanien ( ) acquainted another guaging model with examine and gauge the cs of covid- for the coming days dependent on the announced data since jan . rezaee et al. ( ) introduced a mixture approach dependent on the linguistic fmea, fuzzy inference system and fuzzy data envelopment analysis model to ascertain a novel score for covering some rpn inadequacies and the prioritization of hse dangers. navares et al. ( ) introduced an answer for the issue of anticipating every day medical clinic confirmations in madrid because of circulatory and respiratory cases dependent on biometeorological markers. cui and singh ( ) created and applied the mre hypothesis for month to month streamflow prediction withspectral power as a random variable. torky and hassanien ( ) introduced a blockchain incorporated structure which research the chance of using peer-to peer, time stepping and decentralized storage points of interest of blockchain to construct another framework for confirming and distinguishing the obscure contaminated instances of covid- infection. ezzat and ella ( ) a novel methodology called gsa-densenet -covid- dependent on a hybrid cnn structure is proposed utilizing an optimization strategy. in statistics, linear regression (lr) is a direct way to deal with demonstrating the connection between a dependent variable and at least one independent variable. lr was the main kind of regression analysis to be concentrated thoroughly and to be utilized widely in useful applications (yan and su ) . lr shows the connection between two variables by fitting a straight condition to based information. one variable is viewed as an independent and the other is viewed as a dependent. an lr line has a condition of the structure: here x is the independent and y is the dependent variable. the slope of the line is b and a is the intercept (the value of y when x = ). a multilayer perceptron (mlp) is a type of feedforward artificial neural network (fann). the term mlp is utilized vaguely, now and then freely to indicate any fann, now and then carefully to allude to systems made out of various layers of the perceptron. an mlp is a perceptron that is generally used for complex issues. the formula for mlp is: here w is for the vector of weights, x is for the vector of inputs, b is for bias and phi are the non-linear activation function. a vector autoregression (var) is a prediction calculation which is utilized when at least two-time series impact one another, i.e., the connection between the time arrangements included is bi-directional. the formula for var is: where a is the intercept, a constant and b , b till bp are the coefficients of the lags of y till order p. order 'p' means, up to p-lags of y is utilized and they are the predictors in the equation. the e t is the error considered as white noise. the structure of data based on date, confirmed, recovered and death are shown in fig. with the boxplots, and it's very clear that several cases are in so primitive stages. as mentioned by who, right now india is in the second phase indicating very few cases and forecast of this same is the potential work that is required at this juncture (tareen et al. ) . sieve diagram provides the visualization of the dataset along with that showing the sieve rank. figure illustrates attributes that have a strong relationship with the dark shades. the interestingness of the pair of attributes is represented via this contingency table. it's a very graphical way of frequency visualization. correlation plays a great role in finding the dependency among the features of the dataset. our dataset revolves around the confirmed, recovered, and death of cases because of the covid- outbreak over the time frame of around months in india. from the spearman correlation, it's very evident that based on progressive of the day (date) the possibility of getting prone to sickness is very high and that is given with the? . correlation value. figure provides a glance at the correlation between pearson and the spearman process. appreciably the date attribute is holding a higher level of importance and that's is reason globally the measures have been taken for social distancing (mu et al. ; gautheir ) . normally the spread happens just in contact with the person by a handshake is the big brother in case of covid- . correlation provides the signal about the impact and necessary countermeasures to be taken into consideration. across the globe, leaders of the nation are carrying out various trial and error methods to combat the seriousness of the disease. forecasting gives pertinent and consistent input about the past, present, and future happenings with certain statistical and scientific approaches. helps in string decision making in all perspectives. broadly classified into qualitative and quantitative approaches. steps involved in forecasting is the deciding factor of the task. initial understanding of the problem with complete analysis, making a strong foundation, collecting data based on the previous two steps followed by future estimation. comparison between actual and estimated with followup actions. various applications like economic and sales prediction, budget, census and stock market analysis, yield projections and many more fields. the medical field also a potential area to deploy the forecast and predication to serve the number of people in need (hajirahimi and khashei ; yamana and shaman ). our work carried out with linear regression, multilayer perceptron, and var model over the time series dataset to provide the forecast. var model is a more suitable analysis model in the multivariate time series. it helps in inferencing and analysis of policy. it is used more in a practical forecasting scenario but it is hading superior forecasting performance. technically narrating about the var, it is an m-equation, mvariable model in which individual variable explains on its own based on current, past values. various parameters of var begins with maximum auto-regression order. various information criteria that help in optimize autoregressive order are akaike's information criterion (aic), bayesian information criterion (bic), hann-quinn and final prediction error (fpe). by adding and varying trends from constant, linear, and quadratic with forecast steps ahead and confidence intervals (billio et al. ; portet ; zhang and krieger ) . the formula for calculating aic, bic and hq is as follows: where n is the number of attributes in the system, x is the sample size, and r is an estimate of the covariance matrix r. in our forecast work the maximum auto-regression order of followed by an average of information criterion is used for visualization. the trend of constant, linear, and quadratic along with step ahead and % confidence interval (ci) is introduced (tapia ). in figs. , , , and , , , and ) the x-axis shows the days and the y-axis shows the number of cases. figure shows the covid- predicted confirmed cases; death cases and recovered cases based on actual confirmed, death and recovered data with a % ci with lr.the graph can be interpreted that cases are going to be increased in future as per the existing case data. stochastic environmental research and risk assessment figure shows the covid- predicted confirmed cases; death cases and recovered cases based on actual confirmed, death and recovered data with a % ci with mlp. the graph using mlp can be interpreted that cases are going to be increased in future as per the existing case data. figure shows the predicted confirmed cases based on the actual confirmed case data with a % ci with lr. the graph using can be interpreted that confirmed cases are going to be increased in future as per the existing case data by utilizing lr. figure shows the predicted confirmed cases based on the actual confirmed case data with a % ci with mlp. the graph using mlp shows prediction of confirmed cases in a incremental range based on the existing data of days. figure shows the predicted impacts of covid- based on the actual data of confirmed, death and recovered cases with % ci via lr. in this figure also it is showing that the confirmed cases will be increasing day by day based on the input data, system shows this prediction. figure predicts the impacts of covid- based on the actual data of confirmed, death and recovered cases with % ci through mlp. this graph shows the confirmed cases will go down with a very slow rate and the recovered and death records will fluctuate (i.e. some times more some times less) as per prediction with mlp. figure shows the predicted impacts of covid- death based on the actual data of death cases with % ci through lr. the graph can be interpreted that cases are going to be increased in future as per the existing case data. figure shows the predicted impacts of covid- death based on the actual data of death cases with % ci through mlp. the fig. can be interpreted that cases are going to be increased in future as per the existing case data. figure shows the predicted impacts of covid- recovered based on the actual data of recovered cases with % ci through lr. by analyzing the figs. and we can understand the cases are going to increase in future. figure shows the predicted impacts of covid- recovered based on the actual data of recovered cases with % ci with mlp. figure shows the forecast of next days in the var model, where auto regression order is , with aic optimize information criteria with constant and linear trend vectors and ci of % for the confirmed, recovered and death cases are illustrated in perfect manner. we have given data of cases till the th day i.e. th april . table shows the predicted values of cases (confirmed, death, recovered) by using the lr method from the st day i.e. th april for the next days, i.e. th june .these are the predicted values as per the actual values given in the system as an input. the figs. , , , , are generated based on the predicted values of table . we have given data of cases till the th day i.e. th april . table shows the predicted values of cases (confirmed, death, recovered) by using mlp method from the st day i.e. th april for the next days, i.e. th june . these are the system predicted values as per the actual values given as an input. figure gets its waves of the different cases from the table values for the next days. it depends on the various parameters mentioned in the var model part. information and communication technology help in the decision-making process based on the past data with the data analytics and data mining perspective. the size of data available is huge and gathering information and getting an interesting pattern out of the cumulated data is a challenging task. with the prevailing data about confirmed, recovered and death across india for over the time duration helps in predicting and forecasting the near future. the correctness of the model could be increased by introducing related attributes like several hospitals, the immune system of the infected person, age of the patient, gender of the patient, steps taken to combat the proliferation of the virus, and so on to make it completely informative. as of now, it's very prudent that yards to carry needs to be stringent and vigil in nature to handle this crucial situation by social distancing, lockdown, curfew, quarantine, and isolation to prevent the transmission. by seeing the predicted values and matching with cases from john hopkins university data we can conclude that the mlp method is giving good prediction results than that of the lr and var method using weka and orange. in future we can work with some deep learning methods for forcasting time series data for getting better predictions. e? . e? . e? * , . , . * . e? , . e? e? . e? . e? e? . e? . e? e? . e? . e? * coronavirus (covid- ) classification using ct images by machine learning methods bayesian nonparametric sparse var models application of minimum relative entropy theory for streamflow forecasting day level forecasting for coronavirus disease (covid- ) spread: analysis, modeling and recommendations gsa-densenet -covid- : a hybrid deep learning architecture for the diagnosis of covid- disease based on gravitational search optimization algorithm detecting trends using spearman's rank correlation coefficient hybrid structures in time series modeling and forecasting: a review a pearson's correlation coefficientbased decision tree and its parallel implementation comparing arima and computational intelligence methods to forecast daily hospital admissions due to circulatory and respiratory causes in madrid a primer on the model selection using the akaike information criterion risk analysis of health, safety and environment in chemical industry integrating linguistic fmea, fuzzy inference system and fuzzy dea covid- forecasting based on an improved interior search algorithm and multi-layer feed forward neural network jm ( ) data envelopment analysis with estimated output data: confidence intervals efficiency descriptive analysis and earthquake prediction using boxplot interpretation of soil radon time-series data covid- blockchain framework: innovative approach a framework for evaluating the effects of observational type and quality on vector-borne disease forecast modified seir and ai prediction of the epidemics trend of covid- in china under public health interventions appropriate penalties in the final prediction error criterion: a decision-theoretic approach conflict of interest the authors declare that we don't have any conflict of interest. key: cord- -hquc v c authors: gupta, rajan; pal, saibal kumar; pandey, gaurav title: a comprehensive analysis of covid- outbreak situation in india date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: hquc v c the outbreak of covid- in different parts of the world is a major concern for all the administrative units of respective countries. india is also facing this very tough task for controlling the virus outbreak and has managed its growth rate through some strict measures. this study presents the current situation of coronavirus spread in india along with the impact of various measures taken for it. with the help of data sources (till th- th april ) from various state units of india and ministry of health and family welfare, government of india, this study presents various trends and patterns. this study answers six different research ques-tions in a comprehensive manner. it has been reported that growth rate of infected cases has been controlled with the help of national lockdown, however some uncontrolled mass level events had negatively impacted the infected cases. with the help of exponential and polyno-mial regression modelling, the predictions of up to cases have been done by the end of april . it has also been seen that there are some prominent clusters and patient nodes in the network of patients which are the major influencers for covid- spread. also, death rate case predictions have been done through multi-class classification models with an accuracy of %. at the end, strategies for continuation for lockdown has been discussed and presented. it appears that only essential services should be open for the citizens of india and the national lockdown should be carried on for next - weeks. this study will be useful for the government of india and various states of india, administrative units of india, frontline health workforce of india, researchers and scientists. this study will also be favorable for the administrative units of other countries to consider various aspects related to the control of covid- outspread in their respective regions. united kingdom. with respect to the recovered patients list, china is at the top of the list followed by spain, germany, italy, iran and the united states of america. india was placed comfortably out the list of infected nations by huge margins, but recent events led to its rise to th position which is a point of concern. the mortality rate is controlled at less than % right now, which is better than the ~ . % mortality rate of world, but the model of spread is slowly moving towards an exponential trend which can lead to massive loss of lives and infrastructure. india is being looked upon by various nations now as a world leader and even who acknowledged that world is looking towards indian strategies to contain the outbreak of this epidemic [ ] . india accounts for almost one-fifth of the world's population and is second leading country in terms of population in the world. india contributes heavily to the world's gdp and is amongst the most prominent developing country in the world with fairly strong economic growth percentages [ ] . india's good camaraderie with majority of the nations in the world and its helpful nature makes it a perfect ally for other countries. therefore, the analysis of covid- outbreak in indian region is closely watched and monitored by the world and there is a need of comprehensive analytical studies based on different strategies taken by indian administrators from time to time. india has been following a nationwide lockdown since -march- , which was a one-day lockdown, followed by a -day lockdown after two days. every activity in india since then has been happening with permission from various administration units and almost all the domestic and international travels have been either banned or monitored closely. india is yet to get into the third phase of covid- outbreak i.e. the community outbreak as seen by various countries around the world, but the cases have been rising continuously. india's lockdown period has been impacted by two major events in the recent days which were related to the mass exodus of laborers and workers from one state to other states (especially from delhi to neighboring states) and conduction of a religious event in delhi which led to spike in the number of cases in various states of india. during this time, the indian prime minister has been trying to connect with indian citizens through innovative strategies and coming up with various engagement activities which are impacting the whole nation. with so much happening in india right now, it becomes imperative that we study the current situation and impact of various such events in india through data analysis methods and come up with different plans for future which can be helpful for the indian administrators and medical professionals. the current study explores various aspects associated with the covid- outbreak in india and the various regions situated in india. the specific research questions (rq) explored in this study are as follows.  rq : how has the situation changed in post-lockdown period in india i.e. what is the outbreak situation after -march- in india as compared to pre-lockdown period?  rq : what are the short terms predictions for the number of infected cases in india for the next - weeks based on current situation?  rq : has the lockdown been followed by the indian citizens after -march- ? has the social distancing worked for indian citizens? what are the mobility changes in the various regions of india?  rq : whether the community outbreak spread started in india with the conduct of a religious event in delhi? how is the outbreak different for citizens related to event and for citizens not related to the event?  rq : which are the prominent clusters which were formed in the last few weeks with respect to covid- outbreak in india? does network analysis provide influential points in the infected patient network?  rq : whether the national lockdown should be opened after th april in india or should it continue? are there any partial regions for which lockdown can be removed? which all essential services should be opened in india after one week under restricted lockdown? the current study is divided into five sections. first section has laid the context of the study. the second section discusses various literature review and analytical techniques followed by the different researchers across the world. the third section presents the methodology and research variables of the study. the fourth section presents the results and findings of the study along with the discussion of the achievement of the various research questions explored in this study. and finally section five concludes this study and present limitations and future directions for this research work. as per different papers available in literature, there are a few studies that focus on the trend analysis and forecasting for indian region. the studies [ ] [ ] on indian region presents long term and short term trend, respectively. these studies use time series data from john hopkins university database and present forecasting using arima model, exponential smoothing methods, seir model and regression model. however network modelling and pattern mining are not attempted in these versions of the studies and that too at the regional level, hence the current study attempts to do that. also, the studies in indian region from the past are more focused on presenting time series analysis based on the overall data for indian region rather than covering other sources of information apart from just considering the number of infected patients, so the need to analyze the patients background and information is required for the authorities to get better insight about the situation. similarly, there are other mathematical models that were developed for analyzing the trends of covid- outbreak in india. a model [ ] for studying the impact of social distancing on age and gender of the patients in india was presented. it compared the country demographics amongst india, italy and china and suggested the most vulnerable age categories and gender groups amongst all the nations. the study also predicted the rise of infected cases in india with different lockdown periods. similarly, a network structure approach was used by one of the study [ ] to see whether any specific node clusters were getting formed. but only travel data nodes were considered by the authors to check which the prominent regions are affecting indian travelers coming back to the india. also, the study presented the sir model to see the rate of spread of the corona virus amongst patients in india. analysis on the testing labs and infrastructure was also presented by earlier authors. work of medical doctors and frontline health workers was also presented by some studies [ ] . it was found that in india, the role of health workers was less stressed as the spread stage of corona virus was still in phase two or the phase of local transmission rather than the community transmission as compared to other nations like italy, spain and usa. however, it was also claimed that indian healthcare infrastructure is not very strong as per the who guidelines and in case of community spread, the indian government may find it difficult to manage the spread. some detailed discussion on the nature of the corona virus was also presented by some studies [ ] [ ] . apart from india, a few models are also available for other countries primarily for china, italy and usa as the number of infected patients was high. studied like [ ] [ ] [ ] [ ] [ ] worked on various mathematical models to determine the spread of the disease, predict the number of infected patients, commenting on the preparedness for each country in tackling covid- spread and finding the patterns of flattening curve in different conditions. a lot of researches are still in preprint stage for the world level and are yet to be peer reviewed. with respect to the research activities conducted in the indian region, the studies are yet to work on the impact of different policies working towards containment of the corona virus. even in the preprint databases, there are fewer evidences available which worked in the indian region with more granularities and came up with analysis that can support the decision making of the various administrators in india to curb the lockdown and work on future strategies. therefore, this study attempts to work on a comprehensive level to analyze the covid- spread in india and impact of various strategies imposed by the government at both state level and central level. to answer the different research questions, specific methodologies have been used which covers up different data set, data sources, modeling techniques and outcome variables. the overall variables covered up in the study are shown in figure . for the first research question, the time series data from the time period of th january till th april has been covered from the indian database of covid- [ ] . this dataset was divided into three parts of th january to th march , th march to nd march and rd march to th april . trend analysis and average number of infected cases were compared at both the national level. on the same dataset, the second research question has been answered using the exponential modelling to predict the short term trends for the next three weeks. the exponential modelling can be done using equation . where, n and n are the total cases at time t and t, respectively, and γ is the growth rate. by definition [ ] , n = n needs the doubling time (α) that is expressed as α = ln( )/γ through ln(n/n ) = ln( ) = γt. if the growth rate evolves with time, depending on the effective prevention strategies, then the doubling time changes with time. thus, the time-dependent growth rate γ(t) causes the time-dependent doubling time α(t), defined as α(t) = t ln ( ) for the third research question, the mobility data set [ ] from google has been considered after nd march to see the patterns in mobility of indian citizens at prominent places in . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint india. also, the number of operational places and events conducted during lockdown data has been analyzed through news reports and channels. based on the news reports, the major events were traced and people getting infected due to such events have been covered from the indian data repository created using crowdsourcing channels [ ] . the patients were categorized as infected from the event as compared to other patients who were not related to the event. the trends and patterns were analyzed after conduction of this event i.e. in the first week of april . the data was also confirmed from various news reports in india. to understand the patterns existing in the patients of covid- in india, their demographic details were studied in detail since th january from the crowdsourced database in india [ ] and rules were generated for the patients with potential probabilities. network analysis [ ] was also conducted on the patients and node centralities [ ] were calculated the patients. based on the patient database and number of infected cases along with the various secondary reports from the news media and consulting firms, the success of engagement activities and lockdown strategies have been analyzed, which answers the research question . the findings of the different types of data analysis conducted on various types of datasets are presented in the current section as follows. the national lockdown for one day was announced on nd march by the central government of india, before which majority of the schools, colleges, markets, cinema halls, etc. were already shut down by respective state governments. merely, two days after this one day curfew, a -day lockdown was announced by the central government banning all the movement and restricting the indians to stay at home. the citizens were allowed to step out only in emergency situations and that too with prior permissions from the local administration. all these instructions were given in the hope of flattening the curve of infected cases and to restrict the exponential growth of the patients in india. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint there are almost confirmed cases reported in india as on the morning of th april with more than % cases being active. the death rate has been keeping under % at all the stages of the covid- spread. looking at the graph in figure , it is clearly evident that a spike has been reported in india after nd march i.e. the time when lockdown was announced. it clearly shows that indian authorities were quick enough to sense the spread rate in indian region and taking necessary steps of maintaining social distancing by announcing a rigid step of lockdown. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. looking at the growth rate of infected cases on daily basis (blue line) and the trend line of expected growth (red line) in figure , it appears that in early days of infection the growth rate was quite high due to low number of cases. the growth rate has been calculated as the difference in number of cases between two consecutive days divided by the count of infected cases on the previous day of the two days under consideration multiplied by . since, in the early days the count was in single digits, so the growth rate was pretty high. hence ignoring that period, considering the second phase of time period from th march to nd march i.e. exactly before the lockdown, the growth rate has been hovering around % with trend line forecasting it to be maximum around %. however, for the time period after lockdown i.e. from nd march onwards, the growth rate slightly increased, but it remained around a similar mark of %. and the trend line also predicted the growth rate on per day basis to be around maximum of %. therefore, it can be said that the national lockdown has been able to contain the growth of the number of cases of covid- patients. without lockdown, the growth might not have been contained in india and may have gone into the exponential zone too quickly. this gives all the state level and national level administrators and health workers to get prepared for the rising number of cases. exponential modelling has been used to predict short term predictions at national level. first, the growth for doubling days was calculated, i.e. the number of days to double the number of infected cases have been calculated. as seen from figure , the first image shows that prior to the lockdown period average number of days to double the cases was majorly above four, while the average period drop down near to three after lockdown. as per the predictions . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint (trend line in red) the average number of days is constantly decreasing when the number of cases is rising in india. based on the exponential model, the predictions for the next weeks were made for the infected cases in india. considering that doubling rate is going as per the historical evidences, the number of predicted cases in india is shown in table . based on the exponential modelling based growth of the number of covid- cases in india, polynomial regression line was plotted with different degree values. a total of degrees were checked between to and root mean error (rme) was checked for all cases. the lowest rme reported was . for . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the model with degree . thereafter, the prediction model of polynomial regression of degree was built and used for the prediction values. for training set, data for days was considered starting from -march- to -april- . this was due to the fact that prior to rd march, only cases were reported in indi within days which was impacting the prediction model. for evaluation, data from a short time period of -april- to -april- was used. other train and test sets were also considered and predictions were similar. with these prediction values, it is estimated that the values for infected cases may rise near to , in india which may not be a really good situation in india. the concept of social distancing was suggested by a lot of health experts around the world as it was important that the chain of physical interaction between humans must be broken. the major step in this direction was to announce lockdown at national level. indian government took this suggestion seriously and started with the one-day implementation of lockdown on nd march and then announcing a -day lockdown till th april . it was welcomed by a lot of citizens in india. the same was suggested by google through its mobility report as shown in figure . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint as per the google's method of calculation, every day changes for the number of visits and length of stay at different places were compared the baseline values. the baseline value was considered as the median value for the corresponding day of the week. there were six different categories which were considered important for social distancing and there was a significant drop down seen in five of these categories. graph shows a % decline as compared to the baseline in the visits at retail and recreation places like restaurants, cafes, shopping centers, theme parks, movie theatres, etc.; % decline as compared to the baseline in the visits . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint to the grocery & pharmacy places like markets, food shops, farmer places, drug stores, pharmacies, etc.; % decline as compared to the baseline in the visits to the parks like public beaches, dog parks, marinas, national gardens, public gardens, etc.; % decline as compared to the baseline in the transit stations like bus stations, public transports, metro stations, train stations, etc.; and % decline as compared to the baseline at the workplaces like private and government offices. it was seen that a % increase as compared to the baseline was observed at the residential places which implies that more indians are now staying at their homes. all these numbers cannot be % as a lot of frontline health workers, administrators, pharmacists, grocery store and people involved in other essential services were on duty during the lockdown as well. however, the basic purpose of lockdown to maintain social distancing has been achieved to good potential. citizens are spending more time at their homes as compared to crowded places. so it can be said that indian citizens have been able to follow the lockdown effectively. during the lockdown period, there were two mass events reported in india. one was related to the exodus of the laborers to their respective states in india [ ] and the other was a religious event which happened in new delhi at a mass level [ ] . there are around % citizens living below poverty line and have to depend on the daily wages to feed their families. once the lockdown was announced, the fate of these . billion people was under scanner and that is why even the government of india came up with a package of more than billion usd to help these workers and laborers. all the respective state governments also came up with the different infrastructural setup for providing food and money to the needy citizens. some agencies reported that in providing food security, india and the neighboring nations depending on india may fall short of food [ ] while the others reported loss of millions of job [ ] during the lockdown due to such mass exodus. however, the numbers of infected cases were not impacted much by this mass movement as majority of workers were not carrying any infection with them during their movements from workplaces to their native places. as seen from figure , the average number of days to double the infected cases from corona virus without any cluster event was estimated to be . as per the health ministry, while it is . after delhi's religious event took place [ ] . this event resulted in formation of clusters in the whole country as people who attended this event went to different parts of the country without following any rules of getting quarantine. some of them even came from out of india to attend this event and no rules were followed by them regarding covid- protection. this resulted in a sharp spike in the number of infected cases after st march . as per the figure , at least % of the total infected cases reported on th april were linked to the religious event in delhi [ ] . out of over cases reported, a minimum of cases were suspected to be due to the religious event in delhi. this event took the graph sky high in a week's time with growth slowly moving towards exponential path and india entering into the third phase of community transmission for covid- virus. many regions of india which were totally isolated with the infection of corona virus, also reported their first case in the first - days of the conduction of the event. therefore, it can be said that religious event that happened in delhi has really pushed the bars higher for infected cases from coronavirus in india. it has far more serious consequences than it seems right now and authorities needs to be really alert as people linked to this event have gone back to different parts of the nation. based on the data available from crowdsourced database at covid- -india dot org [ ] , network of the patients and their demographic details was created. the patient id, the countries of travel, and any mass events were considered as the nodes and connection between each patient and his travelling history or event attending history was considered as edge in the network. presenting the visualization of the network consisting of nodes was out of scope for this paper; however degree centrality of important nodes was calculated and is presented in table . degree centrality of the nodes is calculated as the number of connections with that particular node divided by the total number of edges present in the network. the top nodes based on their nodes centralities were religious event in delhi, italy, gulf countries, united kingdom, mumbai, saudi arabia and the first patient. it was found that these were the major hotspots responsible for the rapid spread of coronavirus in india. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint based on the patient database, classification model was developed to check that on the basis of the demographic features, can a patient have the probability to be deceased. other patterns were mined for the rules for covid- patients; however rules were not significant enough for the positive cases as data for negative cases was not available. based on the age group of covid- infected patients, it was found that majority cases are in the age group of - years in india, as shown in figure . the deceased patients are majorly above years of age group and majority people who are infected either travelled back from italy or attended the religious event in delhi. [ ] there was a classification model developed around patients who lost their lives after getting infected from the coronavirus. decision tree classification model [ ] was used to classify that out of the given covid- infected patients, whether a patient will be deceased or not. three features were found to be significant which were the age of the patient, gender of the patient, and the state/region of the patient. although a total of patients have been infected from covid- virus so far, but demographic details of all the patients is not known. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint there were living patients and dead patients modelled on the dataset. out of , only patients had complete demographic details available for the modelling, however for rest of the patients, relevant data imputation techniques [ ] were used and missing values were filled up scientifically. accuracy and precision values were computed based on the confusion matrix generated from decision tree classifier model. the model generated a % accuracy as the data points were too less for the model to be trained and tested. moreover, the three-variable model was not sufficient enough to make an significant relevance out of the model. however, the deaths have found to be more prevalent in the age group of or more years and males were more prominent to getting deceased. also, infants were least impacted by coronavirus in terms of life and death. the state of maharashtra and madhya pradesh were found to be the significant regions for the dead cases. not major inferences can be drawn from the classification model as numbers of cases were low, but as per the records of deceased patients, a hint can be taken by the medical and administrative authorities as in which type of patients need extra critical care. considering the numbers in previous sections, there are five major reasons due to which the national lockdown will be difficult to be abolished. firstly, the growth rate of infected cases is continuously increasing. secondly, the doubling time for number of infected cases in india is declining very fast making it a dynamic spread. thirdly, majority of the indians are following the social distancing fairly well with mobility rates going down for public places in india. this is due to the combined efforts of the administrative authorities, engagement activities by the office of prime minister and citizen's will to stay away from social events. fourthly, the sudden mass events are ruining the efforts of the indian authorities to contain the spread of coronavirus. and lastly, the penetration of the people infected from religious event has been really deep in india currently. there is a lot of tension created in india due to spread of infected people and the numbers are rising with each day. thus, it is very difficult for india to completely ban the national lockdown after th april. in extreme conditions, the state wise rate of infection spread needs to be considered and then decision over lifting the lockdown may be taken. table shows the current number of infected cases in different states of india and the associated growth rates for the last days for each state, respectively [ ] . it can be seen that majority of the states have witnessed more than % of growth rate in last one week, which is worrisome situation for all the state authorities. in fact, the national growth has also been towards % mark which is very in the last seven days. the administrators for the regions with less than infected cases can consider the uplifting of ban on lockdown in their respective regions, however uplifting national lockdown looks difficult. the social distancing must be followed for next few weeks so that curve flattening process can continue for some more time. with respect to transportation services, only intra-state travel may be allowed in states where population density is less and reported cases are less than right now. no inter-state domestic travel should be allowed for the time being as it may result in transferring the covid- carriers from one region to another region. international travel flights must not be activated as the number of cases in majority of the regions of the world is very high. european and us region are already facing most of the turmoil, while other parts of the world are seeing rapid rise in number of infected cases. starting inbound international flights to india may disturb the covid- action plan in india. only essential services should be open for the citizens of india and lockdown should be carried on for next - weeks. this study presented a comprehensive analysis of the covid- outbreak situation in india. the cases are rising very fast and they need aggressive control strategies from the administrative unit of india. there are six different aspects covered up in this study and six research questions have been answered comprehensively. they are related to presenting the growth trends of infected cases in india, predictions for the number of infected cases for next few days, impact of social distancing on the citizens of india, impact of mass events on the number of infected cases in india, network analysis and mining of patterns on the patients suffering from coronavirus, and analyzing the strategies for uplifting lockdown in india. the current study implemented various techniques to present the analysis and the results are in sync with few limited studies available in the literature. this study will be useful for the govern-. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint ment of india and various states of india, administrative units of india, frontline health workforce of india, researchers and scientists. this study will also be favorable for the administrative units of other countries to consider various aspects related to the control of covid- outspread in their respective regions. coronavirus disease (covid- ) pandemic, who novel coronavirus (covid- ) cases, provided by jhu csse india's swiftness in dealing with covid- will decide the world's future, says who, quartz india india is now the world's th largest economy, world economic forum trend analysis and forecasting of covid- outbreak in india seir and regression model based covid- outbreak predictions in india. medrxiv age-structured impact of social distancing on the covid- epidemic in india network structure of covid- spread and the lacuna in india's testing strategy. available at ssrn covid- : how doctors and healthcare systems are tackling coronavirus worldwide a review of coronavirus disease- (covid- ). the indian journal of pediatrics world health organization declares global emergency: a review of the novel coronavirus (covid- ) early dynamics of transmission and control of covid- : a mathematical modelling study. the lancet infectious diseases the effect of travel restrictions on the spread of the novel coronavirus real-time forecasts of the covid- epidemic in china from critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response risk assessment of novel coronavirus covid- outbreaks outside india covid- tracker doubling time tells how effective covid- prevention works see how your community is moving around differently due to covid- india covid- tracker centrality and network flow visual analysis of network centralities india: coronavirus lockdown sees exodus from cities, aljazzera news channel coronavirus: search for hundreds of people after delhi prayer meeting, bbc news will coronavirus lockdown cause food shortages in india? bbc news india lost more jobs due to coronavirus lockdown than us did during depression, the print . days doubling time for coronavirus worrisome, deccan chronicle coronavirus: , cases liked to tablighi jamaat event, total crosses , , india today news a new decision-tree classification algorithm for machine learning a comparison of imputation techniques for handling missing data key: cord- -n lg tr authors: chang, luan-yin; lu, chun-yi; shao, pei-lan; lee, ping-ing; lin, ming-tai; fan, tsui-yien; cheng, ai-ling; lee, wan-ling; hu, jen-jan; yeh, shu-jen; chang, chien-chih; chiang, bor-luen; wu, mei-hwan; huang, li-min title: viral infections associated with kawasaki disease date: - - journal: j formos med assoc doi: . /j.jfma. . . sha: doc_id: cord_uid: n lg tr background/purpose: kawasaki disease (kd) is a disease of unknown cause. to investigate the infectious etiology of kawasaki disease, we initiated a prospective case-control study to investigate possible links between common viral infections and kawasaki disease. methods: we enrolled children with kd and age- and sex-matched healthy children from february to march . throat and nasopharyngeal swabs were taken for both viral isolation and polymerase chain reaction (pcr) for various viruses. results: the mean age of the kd cases was . years, and the male to female ratio was . ( boys to girls). their mean fever duration was . days with a mean peak temperature of . °c. in addition to the typical symptoms of fever, neck lymphadenopathy, lip fissure and/or strawberry tongue, skin rash, nonpurulent bulbar conjunctivitis, palm/sole erythema, and induration followed by periungual desquamation, these kd cases also exhibited cough ( %), rhinorrhea ( %), and diarrhea ( %). cases of kd had a significantly higher positive rate of viral isolation in comparison with the control group ( . % vs. . %, p = . ). compared with the control group, cases of kd were more likely to have overall positive rates of viral pcr ( . % vs. . %, p < . ) and for various viruses including enterovirus ( . % vs. . %, p < . ), adenovirus ( . % vs. . %, p = . ), human rhinovirus ( . % vs. . %, p < . ), and coronavirus ( . % vs. . %, p = . ). conclusion: we found that some common respiratory viruses, such as adenoviruses, enteroviruses, rhinoviruses, and coronaviruses, were associated with kd cases. kawasaki disease (kd) is an acute systemic febrile illness of unknown etiology which predominantly affects children under years of age. initially described in by tomisaku kawasaki, it is now the most common cause of acquired heart diseases in children in the developed world due to the less frequent occurrence of rheumatic heart disease. there have been reports of differing incidence rates in different countries. asian countries are supposed to have higher incidences of kd ( e /per , children under years of age) than most of the western countries ( . e /per , children under years of age). e the etiology of kd is still controversial and infections are considered to be one of the predisposing factors. the infectious evidence of kawasaki disease includes temporal clustering and marked seasonality, geographic clustering, family clustering, a high association between kawasaki disease and infectious disease surveillance, and age distribution, for which the highest incidence rates are seen among monthe -year-old children who have low maternal antibodies and are most susceptible to infections in general. e we hypothesize that infections with certain viruses may elicit systemic inflammation, and further small and median sized vasculitis, so-called kawasaki disease, in certain hosts because we found a higher incidence of kd among males, young children, and asian populations. we thus carried out a prospective case-control study to investigate the association of common viral infections with kawasaki disease to test the above hypothesis. we enrolled kawasaki disease cases that had fever for over days and at least four of the following five manifestations: neck lymphadenopathy, lip fissure and/or strawberry tongue, skin rash, nonpurulent bulbar conjunctivitis, palm/sole erythema, and induration followed by periungual desquamation. the onset of kd illness cases was defined as the st day of fever onset. after informed consent was obtained from the parents, a questionnaire-styled interview was carried out to solicit clinical symptoms and previous contact history with ill household members or with ill people from outside of the household. the illness included sore throat, rash, fever, conjunctivitis, cough, rhinorrhea, abdominal pain, and diarrhea. clinical laboratory data and coronary arterial lesions were collected from the participants, and all received intravenous immunoglobulin g per kg plus low-dose aspirin ( e mg per kg). if fever persisted for days after use of intravenous immunoglobulin, retreatment with intravenous immunoglobulin was administered. two-dimensional echocardiography was performed in all patients during hospitalization and was repeated at convalescence, weeks, and weeks after discharge. coronary arterial lesions were defined as coronary arterial dilatation/ectasia, aneurysm, and increased echogenecity, irregularity of vascular wall, or coronary artery aneurysm. a coronary artery aneurysm was defined as having a lumen diameter (inner border to inner border) of ! mm in kd cases less than years old and ! mm in cases less than years old, and giant aneurysm was defined as a lumen diameter of ! mm for any one echocardiography. we took nasopharyngeal swabs and throat swabs from kd cases on the st day of hospitalization. these swabs were processed for both viral isolation and polymerase chain reaction (pcr) for various viruses. for the healthy control group, we enrolled children who were age-and sex-matched with the kd cases, and who did not have preceding illness for the weeks prior to enrollment. the preceding illness included sore throat, rash, fever, conjunctivitis, cough, rhinorrhea, abdominal pain, and diarrhea. these children were kindergarteners or children who visited our baby wellness clinics for vaccination. informed consent was obtained from parents of all children in the control group. we also took throat swabs and nasopharyngeal swabs from the control children for viral isolation and viral pcr. throat or nasopharyngeal swabs were submitted for virus isolation. samples were inoculated into human embryonic fibroblast, llc-mk , hep- , and rhabdomyosarcoma cell cultures. when a cytopathic effect involved more than % of the cell monolayer, cells were scraped and subjected to indirect fluorescent antibody staining with specific antibodies or typed by specific methods according to the suspected types of viruses. rna and dna extraction from throat swabs, and nasopharyngeal swabs were performed using magna pure lc . system and magna pure lc total nucleic acid isolation kit (roche applied science, roche diagnostics, indianapolis, in, usa). the primers and probes for enterovirus, adenovirus, influenza b, rhinovirus, metapneumovirus real-time pcr, and coronavirus pcr are presented in table . primers and probes for pan-enterovirus were selected based on highly conserved regions in the -untranslated region of the enterovirus genome, and design of primers of other viruses are also based on their most conserved regions. the detection limitation of each virus was copies for enterovirus, for adenovirus, for influenza b virus, for rhinovirus, for metapneumovirus, and , for coronavirus. if the samples had positive viral isolation or pcr, further molecular typing was done. the detailed method of the viral molecular typing is in the supplementary material online. this study was conducted in taiwan only and institutional review board (irb) approval was obtained from national taiwan university hospital (irb number ). written informed consent was obtained from the parents of all participants. the c test was used to compare the rates of viral isolation and pcr of various viruses between kd cases and the control children. a p value < . was considered statistically significant. in total, kd cases as well as age-and sex-matched control children were enrolled. the demographic characteristics of the kd cases and the control children are shown in table . the mean age of kd cases was . ae . years, the median (range) was . ( . e . ) and the male to female ratio was . ( to ). their age distribution is shown in figure ; about % were younger than years old. the demographic characteristics of the control children were comparable to those of the kd cases. table shows the clinical manifestations. their mean (sd) fever duration was . ( . ) days with mean peak temperature of . c. for the typical clinical features of kd, rash was found in % of the cases, bcg scar erythema and induration in %, palm and/or sole erythema and induration in %, desquamation in % ( % of periungual desquamation and % of peri-anal desquamation) and bulbar conjunctivitis in %, red lip with fissure and/or strawberry tongue in %, and neck lymphadenopathy in % of cases. kd cases also had other clinical features including cough ( %), rhinorrhea ( %), and diarrhea ( %). during the acute stage, ( . %) children required intravenous immunoglobulin retreatment, ( %) patients had coronary arterial lesions, and ( %) patients had coronary arterial aneurysm. for the contact history and the rate of household transmission, . % of the cases had positive contact history: . % of cases had contact with ill household members and . % had positive contact with extra-familial ill people e days prior to their kd illness. in ( %) of the families, at least one of the other family members had an illness after the onset of disease in the kd cases. table shows the results of viral isolation and table shows the results of viral pcr between the kd cases and the control participants. kd cases had significantly higher rates of viral isolation ( . % vs. . %, p z . ) than the control children. they also had significantly higher positive rates of pcr ( . % vs. table . as for further typing, only one case of echovirus and one case of ev were identified among the enteroviralpositive kd cases and the other enterovirus serotyping failed due to low viral titer. for adenovirus, six cases of ( ) data are presented as n (%), unless otherwise indicated. kd z kawasaki disease; sd z standard deviation. a coronary arterial lesions were defined as coronary arterial dilatation/ectasia, aneurysm, increased echogenicity or irregularity, and coronary artery aneurysm. b a coronary artery aneurysm was defined as having a lumen diameter (inner border to inner border) of ! mm in kd cases < years old and ! mm in cases ! years old. serotype , five cases of serotype , three cases of serotype , one case of serotype , and one case of serotype were identified in kd cases, whereas two cases of adenovirus serotype , one case of serotype , and one case of serotype were identified in the control children. for coronavirus, cases of human coronavirus nl , three cases of human coronavirus e, and one case of human coronavirus oc were identified in kd cases whereas two of human coronavirus e were identified in the control children. for rhinovirus, serotypes were identified and type c was the most common ( cases) in the rhinoviruspositive kd cases whereas serotypes were identified and the antwerp rv / type was the most common ( cases) among the rhinovirus-positive control children. overall, ( . %) kd cases had positive viral results by either viral isolation or pcr. however, kd cases with positive viral results did not have significantly higher percentages of needing intravenous immunoglobulin retreatment ( % vs. %, p z . ), coronary arterial lesions ( % vs. %, p z . ), or coronary arterial aneurysm ( % vs. %, p z . ) than kd cases without positive viral results. this was a prospective study to investigate the association of common viruses with kawasaki disease. we found that cases of kd frequently had a cough ( %), rhinorrhea ( %), and diarrhea ( %) in addition to the typical symptoms of kd; several common respiratory viruses were also more frequently detected in cases of kd than in the control children. we propose that heterogeneous infectious agents, such as common viruses found in our study, may trigger kawasaki disease in young children with certain genetic backgrounds or susceptibility. the leading theory of kd etiology is that a ubiquitous infectious etiologic agent, that usually results in asymptomatic or mild infection in most people, causes kd in a small subset of genetically predisposed children. in our study, approximately % of kd cases had a preceding contact history with people of febrile, respiratory, or gastrointestinal illness, and kd cases frequently had cough ( %), rhinorrhea ( %), and diarrhea ( %), which supported certain kinds of viral infections. a winterespring predominance of kd cases in non-temperate climates also suggests the association of kd with some kinds of viral infections, particularly a respiratory infection, and this theory is supported by the two articles which reported a preceding history of respiratory illness in some kd patients. , the other infectious evidence of kawasaki disease includes geographic clustering, family clustering, high association between kawasaki disease and infectious disease surveillance, and age distribution, with the highest incidence rates among children aged from months to years old who have low maternal antibodies and are most susceptible to infections in general. e many studies worked on a certain single pathogen to be associated with kd. various infectious agents including bacterial (staphylococcus aureus, group a streptococcus, yersinia pseudotuberculosis, klebsiella pneumoniae, pseudomonas aeruginosa), viral (parvovirus b , eps-teinebarr virus, cmv, hhv , retrovirus, rotavirus, para-influenza virus, new haven coronavirus, measles, chickenpox, dengue fever), chlamydiae pneumoniae, mycoplasma pneumoniae, rickettsial organisms, and so-called kd agent, a viral etiology characterized by intracytoplasmic inclusion bodies, have been found to be associated with kd. e however, at present, links between any of these individual agents and kd have not been irrefutably established. although kd had temporal clustering, different seasonality was found in different countries. for example, studies from europe and canada reported a higher incidence in winter, whereas taiwan and korea have the highest incidence rates of kd during the summer, , beijing and hong kong in the spring and summer, and japan in january and summer. , , such seasonality and temporal clustering of kd suggests that different infectious diseases in different countries might trigger this clustering presentation. in the summer, enterovirus infection was one of the most common infections in young children in taiwan. we also detected enterovirus most frequently in kd cases, which links enterovirus with kd in the summer. other respiratory viruses, such as adenoviruses, may play an important role during other seasons because adenoviruses circulate all year-round in taiwan. we proposed that it was not the same infectious etiology, but rather heterogeneous infectious agents in different areas and different seasons, which trigger kd; there was no single pathogen reported to be associated with kd worldwide. that is to say, different pathogens might be responsible for kd in different countries or different seasons. this may explain why no single pathogen was consistently found in cases with kawasaki disease. for example, jordan-villegas et al reported that . % of kd patients had documented respiratory viral infections including rhinovirus, adenovirus, influenza, parainfluenza, and respiratory syncytial virus. a recent article also reported a case of kd associated with parainfluenza type viral infection, and another article reported adenovirus detection in some kd cases. however, kim et al reported that there was no significant association between the presence of any of the respiratory viruses and the incidence of kd. new tests or techniques for specific microorganisms may help us find the etiology of kd. , in conclusion, we found that common respiratory viruses, such as enteroviruses, adenoviruses, rhinoviruses, and coronaviruses, were associated with kd. heterogeneous infectious etiologies may be responsible for kd in different countries as well as during different seasons. pediatric acute febrile mucocutaneous lymph node syndrome with characteristic desquamation of fingers and toes: my clinical observation of fifty cases epidemiologic pictures of kawasaki disease in japan: from the nationwide incidence survey in and epidemiologic study on kawasaki disease in beijing from kawasaki syndrome hospitalizations in the united states kawasaki syndrome hospitalizations and associated costs in the united states incidence of henocheschonlein purpura, kawasaki disease, and rare vasculitides in children of different ethnic origins epidemiologic study of kawasaki disease in korea, e : comparison with previous studies during e kawasaki disease in australia kawasaki disease in sweden: incidence and clinical features kawasaki disease in finland in e epidemiological features of kawasaki disease in taiwan from changes in epidemic patterns of kawasaki disease in japan validity of the infectious disease surveillance system on comparison of nationwide surveys of kawasaki disease during a -year period temporal and geographic clustering of kawasaki disease in japan the pathogenesis of kawasaki disease and superantigens lack of association between kawasaki syndrome and chlamydia pneumoniae infection: an investigation of a kawasaki syndrome lack of association between kawasaki syndrome and infection with parvovirus b , human herpesvirus , tt virus, gb virus c/hepatitis g virus or chlamydia pneumoniae kawasaki syndrome: description of two outbreaks in the united states an epidemic of kawasaki syndrome in hawaii mucocutaneous lymph node syndrome (kawasaki disease) in israel. a review of cases: is pseudomonas infection responsible? staphylococcal scalded skin syndrome, toxic shock syndrome, and kawasaki disease coronary aneurysms in a patient with atypical kawasaki syndrome and a streptococcal infection trial of isolation of a virus from sera of patients with kawasaki disease kawasaki syndrome: a controlled study of an outbreak in wisconsin epsteinebarr virus genome-positive t lymphocytes in a boy with chronic active ebv infection associated with kawasaki-like disease kawasaki syndrome: issues in etiology and treatment human herpesvirus infection and kawasaki disease prevalence of antibodies to human herpesvirus in different age groups, in children with exanthema subitum, other acute exanthematous childhood diseases, kawasaki syndrome, and acute infections with other herpesviruses and hiv epsteinebarr virus and other herpesvirus infections in kawasaki syndrome adenovirus infection in patients with kawasaki disease possible role of streptococcus pyogenes in mucocutaneous lymph node syndrome. xii. variable responses of platelets in mcls seem to be explainable by streptococcal pyrogenic exotoxin kawasaki disease and epstein-barr virus viruslike particles with reverse transcriptase activity associated with kawasaki disease toxic shock syndrome toxin-secreting staphylococcus aureus in kawasaki syndrome kawasaki disease associated with streptococcal infection within a family serologic evidence that streptococcal superantigens are not involved in the pathogenesis of kawasaki disease kawasaki syndrome associated with group a streptococcal and epsteinebarr virus co-infections lack of association between kawasaki syndrome and infection with rickettsia conorii, rickettsia typhi, coxiella burnetii or ehrlichia phagocytophila group cytoplasmic inclusion bodies are detected by synthetic antibody in ciliated bronchial epithelium during acute kawasaki disease kawasaki syndrome hospitalizations in ireland kawasaki disease in korea kawasaki disease in hong kong seasonality and temporal clustering of kawasaki syndrome concomitant respiratory viral infections in children with kawasaki disease kawasaki disease associated with parainfluenza type virus infection human adenovirus infection in kawasaki disease: a confounding bystander detection rate and clinical impact of respiratory viruses in children with kawasaki disease a highly specific elisa for diagnosis of influenza a (h n ) virus infections seroprevalence of hepatitis virus infection in men who have sex with men aged e years in taiwan supplementary data related to this article can be found at http://dx.doi.org/ . /j.jfma. . . . key: cord- -ouykx g authors: puig-barberà, j.; díez-domingo, j.; arnedo-pena, a.; ruiz-garcía, m.; pérez-vilar, s.; micó-esparza, j.l.; belenguer-varea, a.; carratalá-munuera, c.; gil-guillén, v.; schwarz-chavarri, h. title: effectiveness of the – seasonal influenza vaccine in preventing confirmed influenza hospitalizations in adults: a case–case comparison, case-control study date: - - journal: vaccine doi: . /j.vaccine. . . sha: doc_id: cord_uid: ouykx g introduction: we estimated influenza vaccine effectiveness (ive) to prevent laboratory-confirmed influenza-related hospitalizations in patients years old or older during the – influenza season. methods: we conducted a prospective case-control study in five hospitals, in valencia, spain. study subjects were consecutive emergency hospitalizations for predefined conditions associated with an influenza-like illness episode < days before admission. patients were considered immunized if vaccinated ≥ days before influenza-like illness onset. cases were those with a real time reverse transcriptase polymerase chain reaction (rt-pcr) positive for influenza and controls were rt-pcr positive for other respiratory viruses. adjusted ive was estimated as × ( − adjusted odds ratio). to account for indication bias we computed adjusted ive for respiratory syncytial virus related hospitalizations. results: of eligible hospitalized patients, ( %) were influenza positive and considered cases, and ( %) were positive for other respiratory viruses and considered controls. adjusted ive was % ( % confidence interval, – %). by subgroup, adjusted ive was % ( – %) for those with high-risk conditions, % ( – %) for those ≥ years of age, and, % ( – %) for those ≥ years of age with high-risk conditions. no influenza vaccine effect was observed against respiratory syncytial virus related hospitalization. conclusion: influenza vaccination was associated with a significant reduction on the risk of confirmed influenza hospitalization, irrespective of age and high-risk conditions. yearly seasonal influenza epidemics are associated with excess morbidity and mortality [ ] . vaccination against influenza is considered the most effective strategy for preventing influenza [ ] . as a consequence of antigenic drift, influenza vaccines are to be a produced every year [ ] . despite this achievement, vaccine effectiveness varies from season to season and can be very low one in four influenza seasons [ ] . this is due to the unpredictable antigenic distance between vaccine's and the circulating strains [ ] . as a consequence, evidence on influenza vaccine effectiveness has been difficult to obtain and is disputed [ , [ ] [ ] [ ] . the reappraisal of the evidence on influenza vaccine effectiveness is possible by the availability of reverse transcriptase polymerase chain reaction (rt-pcr) to diagnose influenza infection [ ] . rt-pcr has allowed the development of the test-negative approach for measuring influenza vaccine effectiveness. in test-negative case-control studies, cases are rt-pcr positive for influenza, and controls those negative for influenza. this approach has been advocated for its practicability, comparability between cases and controls, and the use of laboratory confirmed outcomes [ , ] . various authors have used the test-negative casecontrol study [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . under conditions of concurrent circulation an appropriate test-negative control group are patients testing positive for other respiratory viruses, ensuring similarity on quality of sample collection and specificity of outcomes [ , , ] . using a prospective case-case comparison approach, we have estimated seasonal influenza vaccine effectiveness (ive) to prevent laboratory confirmed influenza-related hospitalizations in adults. during the - influenza season, we performed a prospective case-control study in five hospitals in valencia, spain. the five hospitals provided care to , inhabitants years of age or older. the influenza season was defined by the weeks with positive specimens for influenza on enrolled patients. it began on december (week ) and ended on march (week ) . patients with confirmed influenza by a rt-pcr test were considered cases and patients with an rt-pcr confirmed infection for other respiratory viruses were considered controls. influenza vaccines were offered free of charge to health district inhabitants older than months of age with high-risk conditions and to years old or older. three vaccine formulations were used. subunit trivalent non-adjuvanted vaccine (influvac ® , abbot-solvay, illinois, usa; batch numbers v , v , v ) offered to subjects less that years of age, virosomal trivalent subunit vaccine (inflexal ® -v, crucell, leiden, the netherlands; batch numbers , , ) offered to subjects years old or older, and an mf tm -adjuvanted trivalent subunit vaccine (chiromas ® , novartis vaccines and diagnostics, massachusetts, usa; batch numbers , , , ) offered by licensure requirements to those years old or older. subunit trivalent non-adjuvanted was offered in the five health districts included in the study; virosomal vaccine was used in two, and the mf tm -adjuvanted vaccine was used in three. the strains included in the influenza vaccine for the - season were a/california/ / (h n )-like, a/perth/ / (h n )like, and b/brisbane/ / -like [ ] . we established an active surveillance system. full-time field researchers identified, monday to saturday, patients who were hospitalized, coming from the emergency department, in the previous - h. patients whose indications for admission were any of a predefined set of conditions, described as possibly associated with a recent influenza infection [ ] , were invited to participate. patients were excluded if institutionalized, not permanent residents, with reported egg allergy, had been hospitalized in the previous days, or if they had had a previous laboratory confirmed influenza infection. patients were included if they reported an ili episode, defined as at least one of these four systemic symptoms (fever or feverishness, malaise, headache, myalgia) and at least one of these three respiratory symptoms (cough, sore throat, shortness of breath), sudden onset was not a requisite for inclusion [ ] , less than days preceding their arrival at the emergency department. the ethics research committee of the centro superior de investigación en salud pública (csisp) approved the study. all study subjects gave written informed consent before enrollment. a nasopharyngeal and a pharyngeal swab were obtained from each included patient. samples were introduced into vials with viral transport medium and kept at − • c until sent to the reference laboratory. four multiplex real-time rt-pcr/pcr qualitative amplifications were performed: multiplex # for influenza virus type a [ ] and influenza virus type b [ ] ); multiplex # for coronavirus, metapneumovirus, and bocavirus [ ] [ ] [ ] ; multiplex # for respiratory syncytial virus (rsv), adenovirus and parainfluenza virus [ ] ; and multiplex # for rhinovirus [ ] . negative results for viruses were only considered if human ribonucleoprotein gene amplification was positive. laboratory procedures to prevent pcr contamination were followed and a series of multiplex assays # to # negative controls without sample nucleic acid were included in all runs. information was obtained on age, sex, indications for inclusion, hospitalization date, time elapsed from symptoms onset to swabbing, presence of major underlying medical conditions, long-term treatments, contact with children, smoking habits, occupation, number of physician encounters in the last three months, number of hospitalizations in the last year, prescription of antivirals, intensive care unit admission, death in hospital and length of stay. functional status, measured by barthel index [ ] , was obtained in study subjects years old or older. social class was assigned according to occupation [ ] . influenza vaccination status was obtained by asking the patient if he or she had received the current season's influenza vaccine, on which month, and if the vaccine had been administered at least two weeks before the onset of symptoms. in addition, vaccination status was independently ascertained by a researcher blinded to patient characteristics, who consulted valencia's population-based vaccine information system. a patient was considered immunized with the - influenza vaccine if the vaccine was registered as administered or more days before the date of ili onset or if the patient recalled the month when the vaccine was administered and if it had been administered more than two weeks previous to current ili episode onset. information related to the administration of the - seasonal influenza vaccine, the a(h n ) pandemic vaccine and previous -valent polysaccharide plain pneumococcal vaccinations was obtained from the vaccine information system. ive was defined as × ( − adjusted odds ratio [or]) [ , ] . the adjusted or was obtained using a logistic regression model using stepwise background selection of the variables, with a criterion of p < . to remain in the model, starting with a fully saturated model, including being immunized with current season's vaccine, sex, age (in years of age intervals), socioeconomic class, number of high-risk conditions, obesity (imc ≥ ), smoking antecedents, number of physician encounters in the last three months, hospitalizations in the last year, pneumococcal vaccination, antiviral prescription, epidemiological week and time from symptoms onset to swabbing. we defined four groups for ive estimation: (a) all cases and controls enrolled (overall group); (b) all cases and controls with high-risk conditions regardless of age; (c) cases and controls years old or older and (d) cases and controls years old or older with high-risk conditions. to validate our estimates, we computed ive against rsv-related hospitalization following the same design and analysis strategy followed for influenza-related hospitalization, but in this instance cases were those positive for rsv and controls those positive for the other respiratory viruses, including influenza. the significance in differences in the distribution of covariates, between cases and controls, was estimated using the chi-squared, or fisher's test, for categorical variables; and the t-test, or kruskal-wallis test, for continuous variables; p < . was considered significant. all probabilities were -tailed. all analyses were performed with stata . (statacorp, college station, tx). we identified eligible patients, complied with all inclusion criteria, ( %) were positive for influenza and considered cases; ( %) were positive for other respiratory viruses and considered controls (fig. ) . swabs were performed days or less after onset of symptoms in % of study subjects. time from onset to swabbing was similar between cases and controls, median was in both instances four days, p = . . hospitalization rate associated with any of the respiratory viruses assessed was per , years old or older. by age group, hospitalization rate associated to respiratory viruses was , , , and per , - , - , - , and years old or older, respectively. influenza-related hospitalization rate was , , , and per , - , - , - and years old and older. type and number of virus identified were: h n pdm , ( %); rsv, ( %); rhinovirus, ( %); coronavirus, ( %); influenza b, ( %); parainfluenza virus, ( %); mixed infections, ( %); h n , ( %); and human metaneumovirus, ( %). including mixed infections, influenza accounted for % (n = ) of all respiratory viruses identified. influenza subtypes identified were h n pdm (n = ; %), influenza b (n = ; %), and h n (n = ; %). influenza viruses circulated concurrently with rsv, rhinovirus and coronavirus (fig. ). there were no differences regarding emergency admission diagnoses between cases and controls; with the exception of heart failure, that was % in cases compared to % in controls (p = . ) ( table ). in % of influenza patients the presenting complain was not for a respiratory condition (table ) . the duration of symptoms previous to admission was evenly distributed between cases and controls, p = . (table ). there were no differences in the percentage of sudden onset of symptoms, malaise, myalgia, headache, sore throat or shortness of breath; the only significant difference was the frequency of fever in influenza cases, p = . (table ) . when compared to controls, cases were younger, had fewer high-risk conditions, were of higher social class, more frequently smokers, and consulted their general practitioners or had been hospitalized in fewer occasions (table ). there were no differences between cases and controls aged years or more in their barthel index scores (table ) . when restricting the comparison, between cases and controls, by the presence of high-risk conditions, the differences that remained significant were age, -valent pneumococcal vaccination, and having been vaccinated with the previous or current season influenza vaccines (table ) . when restricted to those years old or older, age and influenza vaccination with the previous or current seasonal influenza vaccine remained as significant differences between cases and controls ( table ). compared to . % cases, . % controls were immunized with the influenza seasonal vaccine; p < . (table ) . controls also had more often been vaccinated with the -valent pneumococcal polysaccharide vaccine (p = . ), seasonal influenza (p < . ), and pandemic (p = . ) vaccines (table ) . when high-risk conditions or age were taken into account, no differences were observed in the percentage of cases and controls vaccinated with the pandemic vaccine, and only in those with table cases and controls a characteristics and vaccination history by group: overall, highrisk conditions, and years old or older. high-risk conditions, irrespective of age, there was a difference (p = . ) in pneumococcal vaccination ( % cases vs. % controls) ( table ) . this difference was not observed between cases and controls years old or older ( table ). according to the presence of high-risk conditions or age, the percentage of controls who had been vaccinated with the vaccine compared to cases remained significantly higher (table ) . current influenza season vaccination was highly associated with previous influenza-seasonal vaccination (p < . ) and age or older (p < . ). adjusted vaccine effectiveness to prevent confirmed influenzaassociated hospitalization was % ( %ci, - %) ( table ) . for the subgroup analysis, in those with high-risk conditions influenza vaccine effectiveness estimate was % ( %ci, - %); for those years old or older, it was % ( %ci, - %); and for those years old or older with high-risk conditions it was % ( %ci, - %) ( table ). the overall adjusted or of rsv-associated hospitalization of seasonal influenza vaccination was . ( %ci, . - . ); for those with high-risk conditions it was . ( %ci, . - . ); for those years old or older, . ( %ci, . - . ); and for those years old or older with high-risk conditions, . ( %ci, . - . ). subjects vaccinated experienced a risk of influenza-related hospitalization two times lower compared to the unvaccinated. the vaccine preventive effect was specific for influenza. three recent systematic reviews of studies reporting influenza vaccine efficacy or effectiveness [ , , ] reach the conclusion that evidence on ive to prevent influenza in older adults is scarce, elusive or non-existent. osterholm et al. [ ] looked for studies published between january and february with outcomes confirmed by rt-pcr or viral culture, as estimates based on serologic outcomes [ ] overestimate inactivated vaccine efficacy [ ] . they identified only two observational studies in older adults [ , ] . talbot et al. [ ] studied three consecutive seasons ( - ), using a test-negative case-control design, and reported a pooled adjusted ive of % for influenza-related hospitalizations; however, these estimates were only significant when pooled over three seasons. more recently, castilla et al. [ ] conclude that ive for preventing laboratory-confirmed influenzarelated hospitalization in adults years of age or older, during the - influenza season, is % to %. influenza vaccine effectiveness depends closely on the match of the vaccine strain to the circulating strain [ , ] . during the - influenza season, % of hospitalized subjects with confirmed influenza had been immunized with the seasonal vaccine. this was in clear contrast to what was observed during the - autumn pandemic wave, when, in presence of a good match between the circulating and the vaccine strain, vaccine failures were rare [ ] . the percentage of vaccine failures observed during the - influenza season can be interpreted considering that % of specimens collected in europe showed a reduced activity against the a/california/ / vaccine virus strain [ ] . we tried to minimize selection bias by an enrollment strategy based on an active surveillance system, the use of broad eligibility requirements for inclusion, completeness of inclusion, and enrolling subjects without previous knowledge of their vaccination or case-control status. we reduced classification bias by the use of two independent sources to ascertain vaccination, performing rt-pcr for influenza diagnosis, and by the case-case comparison. patients' recall is considered a valid source of influenza vaccination status [ ] , but is limited by recall bias and uncertainty on date of vaccine administration, or type of vaccine administered. record of vaccination reliably indicates immunization, but absence of record is not informative. we estimate electronic vaccine information system sensitivity as %, and specificity as %, during the - autumn pandemic wave [ ] . with the data collected in the present study, and using a capture recapture method [ ], completeness of ascertainment was % for electronic vaccine information system, % for patient recall, and % for both sources. we aimed to reduce classification bias considering a study subject as vaccinated or non-vaccinated adding the information provided by both sources. rt-pcr is the preferred diagnostic test for influenza [ ] ; but, case status misclassification may contribute to underestimation of ive because of false-negative rt-pcr results [ , , ] . to maximize rt-pcr sensitivity, we included patients with onset of symptoms seven or less days before hospitalization. pcr positivity is, with a similar swabbing strategy, % and %, at and days after symptoms onset [ ] . a non-differential misclassification of true positives as negatives cannot be ruled out and underestimation of vaccine effectiveness is to be expected if a test-negative design is used. this was minimized by case-case comparison [ , ] . although nasopharyngeal aspirate is considered the best specimen for detection of influenza viruses [ ] , we opted for pharyngeal (throat) and nasopharyngeal swabbing to reduce patients discomfort and performance easiness. in children nasal swabs are comparable to that of nasopharyngeal aspirates for the detection of all major respiratory viruses, except rsv [ ] . in adults, swabbing has been used to study respiratory virus disease [ , ] , and ive [ , , , , ] . we obtained a yield of positives similar to other studies on hospitalized adults [ , ] , and the timing of the epidemic wave and types and subtypes we identified were consistent with those reported by spain's surveillance system [ ] . swabbing is a reliable and convenient alternative to obtain specimens for rt-pcr testing [ ] , and accounting for days elapsed from symptoms onset to swabbing, should limit the effect of misclassification of true positives as negatives [ , ] . the case-case analysis approach design assures comparability of controls to cases [ , ] . in a case-case comparison approach, cases and controls should mainly differ in the exposure (and its correlates) associated to the outcome of interest [ ] . all this is even more plausible if influenza and other respiratory viruses cocirculate concurrently (fig. ) . . . impact of age as a confounder and age-related protection due to previous exposure age effect was taken into account by adjustment, and by performing an analysis restricted to those years old or older. vaccine effectiveness could be explained in the elderly by acquired protection due to distant exposure to similar h n strains. we consider this pre-existing protection bias in our results as debatable. first, we observed the third h n pdm wave, this repeated circulation levels exposure to h n pdm over the age range [ ] . second, age-specific h n pdm influenza-related hospitalization rates were in our population two to seven times higher in the years or more age group. third, seroepidemiology studies [ ] [ ] [ ] have described the persistence of protective antibody titers against h n pmd only in a small fraction of subjects years old or older [ ] [ ] [ ] . fourth, when t cell epitopes are compared between h n pdm and seasonal h n , % and % for cd + and cd +, respectively, are conserved [ ] , hence a less dependent on age protection for severe episodes should be expected in those years old or older [ ] . fifth, vaccine effectiveness did not differ when age was considered. the main weakness of our study was the number of influenzarelated hospitalization. although we were able to assess adjusted ive on large groups, this was done with broad confidence intervals, and we did not attain a sufficient number of cases to provide robust ive estimates by virus strain or vaccine type. we report ive estimates with a low probability of bias and the current vaccines provided a significant health benefit. any single ive study results are difficult to generalize. variability of the factors involved, such as circulating strains, vaccine types and composition, match between vaccine's and circulating strains, population characteristics, and outcomes measured are limitations to generalizability. future studies should be planned, after taking into consideration the strengths and limitations exposed, to attain the necessary statistical power to obtain robust ive estimates by virus antigenic subtypes, comparing the different vaccines available, and for relevant high-risk groups. the impact of influenza epidemics on hospitalizations influenza vaccines. who position paper the annual production cycle for influenza vaccine efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis influenza vaccine: the challenge of antigenic drift influenza vaccination: policy versus evidence a systematic review of the evidence on the effectiveness and risks of inactivated influenza vaccines in different target groups estimating the effect of influenza vaccines efficacy studies of influenza vaccines: effect of end points used and characteristics of vaccine failures influenza seasonal vaccine, preliminary mid-season effectiveness estimates: reason for concern, confounding or are we following the right track? effectiveness of inactivated influenza vaccines varied substantially with antigenic match from the - season to the - season association between the - seasonal influenza vaccine and pandemic h n illness during spring-summer : four observational studies from canada cyceva study team. estimating the influenza vaccine effectiveness in elderly on a yearly basis using the spanish influenza surveillance network -pilot case-control studies using different control groups and pandemic vaccines, to prevent influenza hospitalizations during the autumn influenza pandemic wave in castellón, spain. a testnegative, hospital-based, case-control study vaccine effectiveness against laboratory-confirmed influenza in healthy young children: a case-control study effectiveness of seasonal vaccine in preventing confirmed influenza-associated hospitalizations in community dwelling older adults effectiveness of h n / monovalent and trivalent influenza vaccines against hospitalization with laboratory-confirmed h n / influenza in australia: a test-negative case control study vaccine effectiveness in preventing influenza hospitalizations in navarre, spain, - : cohort and case-control study case-case comparisons to study causation of common infectious diseases recommended viruses for influenza vaccines for use in the - northern hemisphere influenza season influenza surveillance influenza case definition rapid multiplex reverse transcription-pcr typing of influenza a and b virus, and subtyping of influenza a virus into h typing (a/b) and subtyping (h /h /h ) of influenza a viruses by multiplex real-time rt-pcr assays clinical disease in children associated with newly described coronavirus subtypes evaluation of a new rapid antigen test using immunochromatography for detection of human metapneumovirus in comparison with real-time pcr assay real-time pcr for diagnosis of human bocavirus infections and phylogenetic analysis increased detection of respiratory syncytial virus, influenza viruses, parainfluenza viruses, and adenoviruses with real-time pcr in samples from patients with respiratory symptoms new molecular detection tools adapted to emerging rhinoviruses and enteroviruses effectiveness of the mf -adjuvanted influenza vaccine in preventing emergency admissions for pneumonia in the elderly over years of age proposal for a social class measure, working group of the spanish society of epidemiology and the spanish society of family and community medicine proportion of disease caused or prevented by a given exposure, trait or intervention what does the odds ratio estimate in a case-control study? vaccines for preventing influenza in the elderly the efficacy of influenza vaccination in elderly individuals. a randomized doubleblind placebo-controlled trial i-move towards monitoring seasonal and pandemic influenza vaccine effectiveness: lessons learnt from a pilot multi-centric case-control study in europe community network of reference laboratories (cnrl) for human influenza in europe. influenza virus characterisation, summary europe evaluation of selfreported and registry-based influenza vaccination status in a wisconsin cohort validez del registro de vacunas nominal para conocer el estado de vacunación frente a la gripe en adultos ingresados en hospitales de la comunidad valenciana. • congreso de la asociación española de vacunología (aev) capture-recapture methods in epidemiology: methods and limitations viral loads and duration of viral shedding in adult patients hospitalized with influenza laboratory diagnosis of influenza comparison between pernasal flocked swabs and nasopharyngeal aspirates for detection of common respiratory viruses in samples from children respiratory syncytial virus infection in elderly and high-risk adults human metapneumovirus infections in adults: another piece of the puzzle the diagnosis of viral respiratory disease in older adults estimates of pandemic influenza vaccine effectiveness in europe, - : results of influenza monitoring vaccine effectiveness in europe (i-move) multicentre case-control study vigilancia de la gripe en españa, temporada - . (desde la semana / hasta la semana / ) incidence of pandemic influenza a h n infection in england: a cross-sectional serological study serologic survey of pandemic (h n ) virus, guangxi province high frequency of cross-reacting antibodies against pandemic influenza a (h n ) virus among the elderly in finland preexisting immunity against swine-origin h n influenza viruses in the general human population the authors thank the staff of the hospital la plana, in vila-real; arnau de vilanova, in valencia; la ribera, in alzira; san juan, in alicante; and hospital de elda, in elda. as well, we thank all the study participants and their families.we wish to express our recognition to prof juan garcía-de-lomas for his support and contribution on the laboratory methods section. we also acknowledge the dedication and commitment of researchers in the field begoña escribano-lópez, verónica alcarria-garcía, ester huet-trujillo, Ángela lópez-doménech, montserrat cano-armenteros m and consuelo calvo-mas.funding: the study was funded in part by contract code grt between sanofi-pasteur and centro superior de investigación en salud pública (csisp). sanofi-pasteur did not participate in the design or conduct of the study, collection, management, analysis, or interpretation of the data, writing the report, and the decision to submit the report for publication. key: cord- -pkwxlydz authors: liu, yang; funk, sebastian; flasche, stefan title: the contribution of pre-symptomatic infection to the transmission dynamics of covid- date: - - journal: wellcome open res doi: . /wellcomeopenres. . sha: doc_id: cord_uid: pkwxlydz background: pre-symptomatic transmission can be a key determinant of the effectiveness of containment and mitigation strategies for infectious diseases, particularly if interventions rely on syndromic case finding. for covid- , infections in the absence of apparent symptoms have been reported frequently alongside circumstantial evidence for asymptomatic or pre-symptomatic transmission. we estimated the potential contribution of pre-symptomatic cases to covid- transmission. methods: using the probability for symptom onset on a given day inferred from the incubation period, we attributed the serial interval reported from shenzen, china, into likely pre-symptomatic and symptomatic transmission. we used the serial interval derived for cases isolated more than days after symptom onset as the no active case finding scenario and the unrestricted serial interval as the active case finding scenario. we reported the estimate assuming no correlation between the incubation period and the serial interval alongside a range indicating alternative assumptions of positive and negative correlation. results: we estimated that % (range accounting for correlation: – %) of transmissions in shenzen may have originated from pre-symptomatic infections. through accelerated case isolation following symptom onset, this percentage increased to % ( – %), implying that about % of secondary infections among symptomatic cases have been prevented. these results were robust to using reported incubation periods and serial intervals from other settings. conclusions: pre-symptomatic transmission may be essential to consider for containment and mitigation strategies for covid- . since its emergence in early december , sars-cov- has spread rapidly despite multiple layers of interventions designed to prevent a pandemic . in less than two months the covid- outbreak progressed from fewer than cases across four countries to more than , cases in over countries , . covid- infection in the absence of clinical symptoms has been frequently described [ ] [ ] [ ] [ ] alongside anecdotal evidence for potential asymptomatic or pre-symptomatic transmission or transmission while symptoms were suppressed by fever-reducing and prescription-free medication [ ] [ ] [ ] [ ] . in combination with highly non-specific and generally mild symptoms in most cases , pre-symptomatic transmission of covid- would substantially hinder control and mitigation efforts, which typically focus on rapid syndromic identification and isolation of cases , . we thus estimated the possible extent of pre-symptomatic transmission to help inform infection control and mitigation plans. multiple estimates for the covid- incubation period and serial interval have been reported to date. while estimates for the incubation period are relatively similar, the serial interval is dependent on the local context, in particular local contact patterns and the presence of interventions, active case finding with subsequent isolation, in particular, that may right-censor the serial interval. as our base case, we used the estimates provided by bi et al. derived from cases and their contacts as identified by the shenzen centre for disease control . this study currently includes the most extensive investigation of the infector-infectee transmission dynamics in a single setting. the probability of pre-symptomatic transmission can be expressed as the probability of onward transmission during one's incubation period. ideally, this probability could be estimated from individual-level observations on exposure, onset of symptoms and the transmission to others. however, such data remains largely unavailable and is inherently difficult to generate. instead, we approximated this quantity from population estimates of the density distribution of the incubation period and the serial interval. we did so by first using the incubation period density distribution to calculate the probability of having developed symptoms on each day since infection and then using this to stratify the serial interval distribution, assumed to be a proxy for the generation time, into likely pre-symptomatic and symptomatic onward transmissions. the observations of the incubation period and the serial interval may be correlated. in other words, individuals with a long incubation period may not have a serial interval of typical length but may be exactly those who have a long serial interval, or alternatively, exactly those who have a short serial interval. to account for this, we also calculated the proportion of pre-symptomatic transmission by randomly drawing from the incubation period and serial interval distributions and pairing samples not randomly, but aligning them either both in ascending or one in ascending and the other in descending order (rank ordering), before calculating the proportion of draws with a shorter serial interval than the incubation period. we report the estimates assuming no correlation accompanied by a range indicating estimates that assume positive and negative correlations. we consider two scenarios: transmission with and transmission (largely) without active case finding to accelerate case isolation. for the no active case finding scenario we use the serial interval reported based on cases that were only isolated at least days after their symptom onset; i.e. . days ( % empirical confidence interval (eci): . - . ). for the active case finding scenario we used the overall serial interval; i.e. . days ( % eci: . - . ) ( figure ). the incubation period in this study was on average . days ( % eci: . - . ). we also included sensitivity analyses. we used the reported mean incubation period ( . days ( % eci: . - . )) and serial interval )) from the first cases in wuhan province as an alternative scenario for a setting with no or limited active case finding . further, nishiura et al. provide estimates of the serial interval from published reports across all affected countries, mostly including attempted rapid case finding and isolation . we use their mean serial interval estimates based on high certainty transmission pairs ( . days ( % eci: . - . )) in combination with either the incubation time reported by bi et al. or li et al. . we implemented all density distributions to match reported estimates and their distributions . we then calculated the effectiveness of case isolation in reducing the number of secondary cases during the symptomatic period (φ) let x be the proportion of pre-symptomatic transmission in the absence of active case finding, and y the same proportion in the presence of active case finding. then, y can be expressed as a function of x while accounting for a reduction φ in the symptomatic cases: solving for φ: all analyses were done in r . . ; codes and data are available online . in the scenario of no active case finding and isolation before six days after symptom onset, and assuming uncorrelated serial interval and incubation period distributions, we estimate that % (range accounting for correlation: - %) of onward transmissions in shenzen have occurred during the pre-symptomatic period ( figure and table ). . ( . - . ) * a summary table of the parameters used and the underlying assumptions regarding the probability distributions used is publicly available . the uncertainty ranges above are those of the simulated distributions of serial interval and incubation periods (instead of the mean or median of these parameters), and thus may be different from what is reported in the original articles. note that serial intervals sampled for with and without active case finding scenarios were independent, i.e., based on separate sets of parameters. active case finding and subsequent accelerated isolation right censors the serial interval and thereby reduces the number of symptomatic onward transmissions. in shenzen, the presence of active case finding increased the percentage pre-symptomatic among all transmissions to % ( - %). therefore, case isolation in shenzen has on average reduced the number of secondary cases during the symptomatic period by % ( - %) and hence the total number of secondary cases by % ( - %). both the sensitivity analyses for the scenario of limited to no active case finding and for the scenario of real-world effects of active case finding and isolation during the containment phase of the outbreak response are similar to the estimates in our main analysis (table ). we estimated that without active case finding to accelerate isolation in shenzen to % of transmissions occurred during the pre-symptomatic period. we further estimated that active case finding reduced the number of secondary infections after symptom onset and thereby increased the percentage of pre-symptomatic transmissions to to %. this implies that in shenzen accelerated case isolation has prevented - % of secondary cases among symptomatic infectees. these results were similar when alternative settings with and without accelerated case isolation were considered. in addition to the mostly-mild and non-specific symptoms of covid- , a high contribution of pre-symptomatic cases to the transmission dynamics of covid- could be part of the reason why controlling covid- has been challenging and seems to have failed in many countries . it implies that control and mitigation of covid- may be substantially improved if also targeting pre-symptomatic infections. this may be achieved via social distancing interventions that do not rely on the identification of symptoms. having - % pre-symptomatic transmission also suggests that immediate isolation at symptom onset can at best prevent - % of cases. however, immediate case isolation on the day of symptoms onset is unlikely. we also find that, based on parameters estimated under no active case finding scenarios, case isolation on days , or after symptom onset reduces the proportion of or preventable onward transmissions by syndromic case finding and isolation to approximately %, % and less than %, respectively (figure ). we find that in shenzhen syndromic identification and isolation has prevented - % of secondary cases from symptomatic infectees, which is in line with previous model-based estimates . even for well-studied pathogens like influenza, there is a substantial amount of uncertainty in the contribution of asymptomatic and pre-symptomatic infections to the transmission dynamics. for influenza, - % of infections have been found to be asymptomatic but shedding, although at lower viral loads , . for sars, . % of exposed and seroconverted health care workers were found to not have displayed symptoms although it is unclear if those were also effectively transmitting . for covid- the proportion of pre-symptomatic or asymptomatic infections is likely much higher. during an outbreak aboard a cruise ship, % of passengers who tested positive were asymptomatic at sample collection and therefore may or may not have developed symptoms at some point later on . whether asymptomatic carriers are also infectious has not yet been clearly established. our work is based on observations of eventually symptomatic cases and hence we implicitly assume that only those who will eventually become symptomatic can effectively transmit. if there is an additional role for asymptomatic individuals in the transmission of covid- this will further decrease the proportion of secondary infections attributable to symptomatic cases. hence, our estimate that among those coivd- cases who eventually will develop symptoms the pre-symptomatics substantially contribute to transmission is a conservative approximation for the contribution of individuals without symptoms to covid- transmission. a key limitation for this study is that we had to use populationlevel estimates rather than individual-level estimates for the incubation period and the serial interval. we address biases potentially arising from the correlation of the two estimates on the individual level by estimating the sensitivity of estimates to the assumption of positive or negative correlation. additionally, our estimates are in essence estimating the proportion of pre-symptomatic transmission from the amount of overlap of the incubation period distribution and the serial interval distribution. if the heterogeneity observed in either distribution was originated in measurement bias rather than in actual between individual heterogeneity of the infection process, then we would overestimate the role of pre-symptomatic transmission. in our sensitivity analyses, we find similar estimates for other settings indicating that the observed heterogeneity in shenzhen is unlikely to be purely an observation artefact. however, our study supports the world health organization's prioritisation for epidemiological studies, ideally individual-level observations, to further enhance the evidence base around the role of pre-symptomatic transmission for covid- . in summary, we find that pre-symptomatic transmission may play a key role in the epidemiology of covid- . given the relevance of pre-symptomatic transmission for control and mitigation efforts, additional studies are urgently needed to reduce the uncertainty in the role of pre-symptomatic transmission. source data this project does not involve any primary data collection. all data used are based on references , , and . more specifically: i have only few remarks listed below. remarks: table : it would interesting if the authors could give some insight on "fully anti-correlated" si and incubation period. under which circumstances, may this happen? i could imagine uncorrelated and fully correlated cases, probably, partially anti-correlated, but it was difficult for me to imagine the setting of fully anti-correlated cases. typos, etc: page , sixth line from above: probably, the authors could specify that it was the diamond princess cruise ship docked in japan. figure : i would recommend to make the lines grey and a bit transparent, so the reader would be figure : i would recommend to make the lines grey and a bit transparent, so the reader would be able to distinguish between individual lines. github repo (very optional): the author could improve their readme.md file, so to make it as a graphical abstract of their paper. this may help to ease the access to the repo for the readers. is the study design appropriate and is the work technically sound? yes if applicable, is the statistical analysis and its interpretation appropriate? yes . variability/uncertainty through sensitivity analyses. figure is difficult to read, can you use semitransparency to distinguish the density of simulated lines? do you have any estimate of how early people might become contagious before symptom onset? in figure you show infectivity is persisting for up to a week after onset, but how many days before onset did infectiousness start? is the study design appropriate and is the work technically sound? yes are all the source data underlying the results available to ensure full reproducibility? yes no competing interests were disclosed. reviewer expertise: infectious disease epidemiology i confirm that i have read this submission and believe that i have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. cmmid ncov working group: temporal variation in transmission during the covid- outbreak cmmid repository reference source . world health organization: novel coronavirus( -ncov), situation reference source . world health organisation: novel coronavirus ( -ncov) situation report - reference source a well infant with coronavirus disease (covid- ) with high viral load radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study field briefing: diamond princess covid- cases, feb update reference source epidemiologic features and clinical course of patients infected with sars-cov- in singapore version july reviewer report https://doi.org/ . /wellcomeopenres. .r © lee e. this is an open access peer review report distributed under the terms of the creative commons attribution , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is license properly cited. department of epidemiology, johns hopkins bloomberg school of public health, baltimore, md, usa this report by liu is a clean and straightforward analysis that brings together early data on the et al. incubation period and serial interval of covid- to provide important insight into the contributions of pre-symptomatic individuals to onward disease transmission. the authors' analysis is strengthened by the inclusion of sensitivity analysis on assumptions about the incubation period and serial interval as well as scenarios that account for the impact of active case finding on the relative contribution of pre-symptomatic infections to onward transmission. i would like a more explicit description of how the pre-symptomatic transmission percentages were estimated. as is, i'm not sure why there are only point estimates presented in table , unless only a single set of draws were performed for each category.can the authors comment on the sufficiency of follow up time for the studies that informed the serial interval estimates? are the authors reasonably confident that there is limited right censoring for individuals that were non-symptomatic and positive at identification (i.e., to see whether they may have instead been pre-symptomatic). this seems an important consideration that would bolster the validity of the authors' estimates.since this paper was originally posted, i am wondering whether there have been additional estimates of the serial interval under conditions of active case finding. presumably locations outside of china may have had time to prepare their surveillance systems so that serial interval estimates would directly reflect scenarios with active case finding (as opposed to making a cutoff assumption). are all the source data underlying the results available to ensure full reproducibility? yes no competing interests were disclosed. this is a nice simple analysis of the incubation period distribution and the serial interval distribution, showing that substantial pre-symptomatic transmission has likely been occurring.there is fairly good consistency in published estimates of the incubation period distribution, but relatively less consistency in published estimates of the serial interval distribution. authors deal with this variability/uncertainty through sensitivity analyses. key: cord- - s st authors: che, xiao-yan; di, biao; zhao, guo-ping; wang, ya-di; qiu, li-wen; hao, wei; wang, ming; qin, peng-zhe; liu, yu-fei; chan, kwok-hong; cheng, vincent c. c.; yuen, kwok-yung title: a patient with asymptomatic severe acute respiratory syndrome (sars) and antigenemia from the – community outbreak of sars in guangzhou, china date: - - journal: clin infect dis doi: . / sha: doc_id: cord_uid: s st an asymptomatic case of severe acute respiratory syndrome (sars) occurred early in , during a community outbreak of sars in guangzhou, china. this was the first time that a case of asymptomatic sars was noted in an individual with antigenemia and seroconversion. the asymptomatic case patient and the second index case patient with sars in the – outbreak both worked in the same restaurant, where they served palm civets, which were found to carry sars-associated coronaviruses. epidemiological information and laboratory findings suggested that the findings for the patient with asymptomatic infection, together with the findings from previously reported serological analyses of handlers of wild animals and the index case patients from the community outbreak, reflected a likely intermediate phase of animal-to-human transmission of infection, rather than a case of human-to-human transmission. this intermediate phase may be a critical stage for virus evolution and disease prevention. suggested that sars-cov was reintroduced to humans from animals [ , ] . although it was reported that none of these patients were involved in the secondary spread of symptomatic sars-cov infection [ ] , we describe a patient with asymptomatic sars-cov infection who was identified from contacts of the index case patients in this community outbreak. this asymptomatic case of sars-cov infection was confirmed by a sensitive method of viral antigen detection and by serological tests. the asymptomatic case also highlights some issues associated with disease prevention. the present study was performed retrospectively. seventeen serum specimens were collected from index case patients who exhibited recurrence of sars with laboratory-confirmed sars-cov infection in guangzhou city, china, from december through january . an additional serum specimens were collected from contacts of the index case patients with sars. to identify the nucleocapsid (n) protein of sars-cov in serum specimens, antigen-capture assays were performed: an n antigen-capture elisa and an n antigen-capture chemiluminescent immunoassay (cia). the development of these assays was based on the detection of monoclonal antibodies directed against the n protein of sars-cov, as described elsewhere [ ] [ ] [ ] . serum igg and igm antibodies to sars-cov were detected using commercially available indirect elisa kits (bgi-gbi; biotech) according to the manufacturer's instructions [ ] . the sensitivity and specificity of elisa for the detection of igg antibodies to sars-cov were %- % and %- . %, respectively, and the sensitivity and specificity of elisa for the detection of igm antibodies to sars-cov were . % and . %, respectively [ ] [ ] [ ] . an indirect immunofluorescent assay (ifa) for the detection of igg antibodies to sars-cov was performed using a commercially available ifa kit (euroimmun), according to the manufacturer's instructions [ ] . this ifa has a specificity of % (with detection of igg antibodies to sars-cov in healthy blood donors) and a sensitivity of %- % (with detection of igg antibodies to sars-cov in serum specimens obtained, at least days after the onset of symptoms, from patients with sars). in-house ifas for the detection of igg specific to human coronaviruses e and oc were performed as described by us elsewhere [ ] . a microneutralization assay was performed according to procedures described elsewhere, with modifications [ ] . in brief, a -well microtiter plate that contained confluent fetal rhesus kidney- cells in ml of maintenance medium was prepared. two-fold dilutions of patient serum samples ( ml), which started at : and increased to : , were premixed with ml tcid of sars-cov (the hku- isolate) and were incubated at Њc for . h. then, ml of the virus-serum mixture was inoculated in duplicate wells with fetal rhesus kidney- cells and was further incubated at Њc. a cytopathic effect was observed at and h. the neutralization titer was determined to be the reciprocal of the highest serum dilution that produced % cytopathic effect on cells. a neutralizing antibody titer of у was considered to be positive for sars-cov. all serum specimens were tested for the n protein of sars-cov by use of both n antigen-capture elisa and n antigencapture cia. the findings of these assays had been validated previously with the use of serum specimens obtained from patients with serologically confirmed sars, and the sensitivity and specificity of the n antigen-capture elisa were documented [ ] [ ] [ ] . although the characteristic of the n antigencapture cia was shown to be equivalent to that of the n antigen-capture elisa (data not shown), the n antigen-capture cia seemed to be more sensitive than n antigen-capture elisa in the present study. both n antigen-capture assays detected n protein in serially obtained serum specimens that were collected from patients - days after the onset of symptoms; cia was also able to detect n protein in serum samples collected from the second index case patient on the ninth and th days after the onset of symptoms, although these samples had negative results according to the n antigen-capture elisa (table ) . this result was not surprising, because enzyme-amplified chemiluminescent chemical analysis is generally more sensitive than conventional elisa [ ] . for index case patient , the first serum sample was obtained on day after the onset of symptoms, and n protein was not detectable in serially obtained serum specimens during this patient's illness. of the serum specimens obtained from the contacts of the index case patients, specimen, which was collected on january , was from a female contact of the second index case patient, who experienced onset of symptoms on december . this female contact was found to be positive for the n protein by means of n antigen-capture cia, and the presence of sars-cov infection was further confirmed by serological tests (table ) . ifa detected a -fold increase in the sars-cov antibody titer in paired serum samples collected over a -week period. igm and igg antibodies to sars-cov were also detected by elisa. antibodies to sars-cov were also detected in the convalescent-phase serum sample obtained from this female contact case patient weeks later, and the results of the sars-cov microneutralization assay were also found to be positive, with a titer of determined for the convalescent-phase serum sample obtained from this female contact case patient. the serological results were verified by the center for disease control and prevention of guangzhou, which is one of the sars reference laboratories in china. to exclude the possibility of a false-positive result, serum specimens from the contact case patient were tested for antibodies against the human coronaviruses e and oc , by use of ifa. paired serum samples showed no increase in the titer of antibodies to either e or oc . these tests were also performed for serially obtained serum specimens from the index case patients (table ) . although the paired serum samples obtained from the first and second index case patients did show an increase in the titers of antibodies to e and oc , no neutralizing antibodies against e and oc were detected in these index case patients during a previous study [ ] . although none of the index case patients showed evidence of secondary spread of the infection [ ] , the direct detection of sars-cov n protein by the highly sensitive cia a serum samples in a serial -fold dilution (from -fold to -fold). b the highest ratio of acute-phase to convalescent-phase absorbance values at the same serum dilution tested. illness, her case is the first confirmed and documented asymptomatic case of sars in this outbreak. this asymptomatic case of infection occurred in a -year-old woman who was working as a service chief in the local restaurant tdlr [ ] , where the second index case patient worked as a waitress [ , ] . although the asymptomatic case patient had only indirect contact with the second index case patient, she had a history of clear and close animal (i.e., palm civet) contact. she often showed the wild animals to customers who were ordering exotic food. subsequently, sars-cov n protein was detected, by use of n antigen-capture elisa, in of a total of palm civet serum samples obtained during the same period from the restaurant tdlr; results revealed a high level of n protein, with a mean od value of . , compared with the cutoff value of . . viral rna was also detected in all throat and rectal swab specimens obtained from palm civets, by use of rt-pcr for the detection of polyprotein and n genes of sars-cov, and full genome sequences and complete s gene sequences of sars-cov were identified in the specimens obtained from of palm civets [ ] . when this information is considered together with the viral genomic information from the palm civets that was collected from the same restaurant during the same period [ ] [ ] , the clear conclusion is that the palm civets used for exotic food in the restaurant must have been heavily contaminated with sars-cov. with the limited samples available, the kinematics of the antigenemia and antibody responses of the second index case patient were compared with those of the asymptomatic case patient. the asymptomatic case patient had antigenemia (i.e., detection of n antigen in serum; antigenemia was detected in the asymptomatic case patient on january ) disappear at almost the same time as it disappeared in the second index case patient (who had detectable antigenemia up to january ). meanwhile, the second index case patient had seroconversion occur on january , whereas the asymptomatic case patient had a positive antibody result from january ; however, because serum samples were unavailable before this date, the exact date of seroconversion cannot be determined. nevertheless, because the mean incubation period for sars is days [ ] , it seems that the asymptomatic case patient was unlikely to have acquired infection directly from the second e • cid : ( july) • che et al. index case patient. combining the epidemiological information regarding the contact history with the molecular diagnostic profiling of either the animals (the palm civets) or the human (the second index case patient), we infer that this asymptomatic case of sars was more likely to have resulted from an animalto-human infection (likely due to sars-cov carried by the palm civets from the restaurant) than from the second index case patient. sars is a zoonotic disease. sars-cov evolved consistently and rapidly within its animal and human hosts, while both the infectivity of the virus and the severity of the disease varied, along with the variation/adaptation of the virus to its hosts [ , ] . it is particularly significant that even in the "early phase" of the - sars epidemic [ ] , human-to-human transmission of infection was observed, and the symptoms were so severe that the disease was eventually named after its primary symptomatic characteristics. however, in the - community outbreak of sars, none of the index case patients with confirmed sars had severe illness, and they all seemed to have acquired infection with sars-cov directly from animals. although sars-cov-specific antibodies previously had been detected at a relatively high rate among the population handling wild animals or had been observed in health care workers [ ] [ ] [ ] , it was impossible to correlate serological results with the corresponding onset of clinical symptoms in these retrospective screenings. therefore, the asymptomatic case patient described in the present article is the first patient with asymptomatic sars-cov infection with detectable antigenemia and seroconversion caused by animal-to-human infection. this finding, together with the previously reported findings of serological analysis of the handlers of wild animals and the index case patients from the community outbreak of sars in , reveals that there likely is an intermediate epidemiological phase, which might be critical for genetic adaptation of the virus to its new hosts before critical mutation enables it to eventually cause severe symptomatic sars, as was seen in early . although it is usually difficult to observe the virus in the intermediate phase, sars-cov is one of the rare viruses for which both genotypes [ , ] and the antigen/antibody corresponding to the intermediate phase were detected. this finding may also be significant for the prevention of sars epidemics. although the most contagious human epidemic strain of sars-cov from the middle and late phases of the - pandemic has not been seen in nature since june [ ] , the risk of asymptomatic or mildly symptomatic infection with sars-cov should not be ignored. to date, molecular epidemiological data have indicated that, although it might take decades for sars-cov to evolve into a contagious strain for human infection, it would not be too difficult for sars-cov to reach the stage in which it might cause infection either without symptoms or with mild symptoms in humans. this process could be accelerated if appropriate susceptible animal hosts, such as palm civets, were largely present together with the human population. on the other hand, if the highrisk population with infection can be properly monitored at the asymptomatic stage and the disease can be promptly controlled at the mildly symptomatic stage (both objectives are technically feasible now), future threats of a reemerging sars epidemic could be much lower than once was surmised. laboratory diagnosis of four recent, sporadic cases of community-acquired sars cross-host evolution of severe acute respiratory syndrome coronavirus in palm civet and human sars-cov infection in a restaurant from palm civet nucleocapsid protein as early diagnostic marker for sars sensitive and specific monoclonal antibody-based capture enzyme immunoassay for detection of nucleocapsid antigen in sera from patients with severe acute respiratory syndrome detection of the nucleocapsid protein of severe acute respiratory syndrome coronavirus in serum: comparison with results of other viral markers evaluation by indirect immunofluorescent assay and enzyme linked immunosorbent assay of the dynamic changes of serum antibody responses against severe acute respiratory syndrome coronavirus anti-sars-cov immunoglobulin g in healthcare workers novel immunofluorescence assay using recombinant nucleocapsid-spike fusion protein as antigen to detect antibodies against severe acute respiratory syndrome coronavirus antigenic cross-reactivity between severe acute respiratory syndrome-associated coronavirus and human coronaviruses e and oc comparison of chemiluminescent assays and colorimetric elisas for quantification of murine il- , human il- and murine il- : chemiluminescent substrates provide markedly enhanced sensitivity the severe acute respiratory syndrome the chinese sars molecular epidemiology consortium. molecular evolution of the sars-coronavirus during the course of the sars epidemic in china isolation and characterization of viruses related to the sars coronavirus from animals in southern china asymptomatic sars coronavirus infection among healthcare workers mild illness associated with severe acute respiratory syndrome coronavirus infection: lessons from a prospective seroepidemiologic study of health-care workers in a teaching hospital in singapore potential conflicts of interest. all authors: no conflicts. key: cord- - dn at k authors: portillo, aránzazu; ruiz-arrondo, ignacio; oteo, josé a. title: arthropods as vectors of transmissible diseases in spain() date: - - journal: med clin (engl ed) doi: . /j.medcle. . . sha: doc_id: cord_uid: dn at k different aspects related to globalization together with the great capacity of the arthropod vectors to adapt to a changing world favour the emergence and reemergence of numerous infectious diseases transmitted by them. diptera (mosquitoes and sandflies), ticks, fleas and lice, among others, cause a wide spectrum of diseases with relevance in public health. herein, arthropod-borne disease are reviewed, with special emphasis on the existing risk to contract them in spain according to different parameters, such as the presence of arthropod and the circulation or the possible circulation of the causative agents. infectious agents. most avs belong to insecta and arachnida classes (table ) . to review the broad subject of arthropod vector-borne diseases (avbd) in spain is a complex task. just listing the arthropods that transmit diseases in our environment, such as dipterans (culicids and phlebotominae sand flies), fleas, lice, bed bugs and ticks, among others, and the diseases they transmit, or that they can transmit at any given time, would be a reason for one or several treatises. in any case, before discussing the subject, it should be remembered that the infections that they transmit are usually included in the socalled zoonoses. in this regard, the world organization for animal health estimates that at least % of infections that affect humans have a zoonotic origin and, according to the pandemic emerging threats program of the american agency for international development, almost % of current threats also have this origin. one of the many known routes for the acquisition of zoonoses, apart from direct contact with animals or their products, faecal-oral or respiratory routes, bites or scratches, the consumption of undercooked - /© elsevier españa, s.l.u. all rights reserved. products or the intake of milk, is av transmission. it is difficult to limit this issue to our country, since the setting is global and very dynamic, and diseases do not understand political borders. only a few months ago new threats appeared, such as the re-emergence of yellow fever in brazil or the epidemic of plague in madagascar. however, in this review we will put the focus on avbd with greater risk to humans in our environment, without losing the "one health" perspective. avbd are subject to complex interactions (demographic, social and cultural changes, climate change, wars and famine or evolution of microorganisms) among which, undoubtedly, global transport systems and the consequent invasion of exotic species stand out. generally speaking, travel, migration and globalization contribute to the emergence of infectious diseases. its importance has been debated for many years and, possibly, dates back to ancient times. humans carry their usual microbiota, pathogens, ectoparasites and other possible vectors, the immunological history of past infections and vaccines, the genetic load (greater or lesser susceptibility), cultural preferences, behaviours, habits and customs, as well as luggage (pets, goods and others). in the case of avbd, the equation for the appearance of a certain disease would be the following: the presence of competent vector arthropods plus susceptible population, together with the presence of reservoirs and/or intermediate hosts (sick people), could give result an epidemic. the introduction of the tiger mosquito (aedes albopictus) and the threat of its expansion could be a good example. it is thought that a. albopictus was introduced in europe in through albania, by the trade of used tyres, although the first publication on its introduction in the european continent dates back to in italy. since then, a. albopictus has expanded throughout the mediterranean area. in spain, this aggressive mosquito is well established in catalonia, levante, in the coastal area of murcia and andalusia. it has also been detected in guipúzcoa, and little by little it is introduced in other non-coastal areas such as aragon, extending through travel routes (for example, motorways). the last detection was carried out in the community of madrid (fig. ) . a few months ago, the first specimens of this species were also identified in the north of portugal. this mosquito has been incriminated as a vector of numerous arboviruses in different parts of the world, including europe. a. albopictus, is the chikungunya virus vector. in this regard, most of the cases in europe are imported, although in the last two decades there have been different epidemic outbreaks in italy and, recently, in france. in spain, only imported cases have been reported. this mosquito (next to aedes aegypti which, as will be detailed later, has been detected in a timely manner in europe) can act as a vector of the dengue virus and with less effectiveness of the zika virus. in france, a. albopictus was responsible for the first autochthonous cases of dengue and of those reported in the same country during the following years, one of them with a history of travel to madeira, where a large outbreak had been reported (more than a thousand cases) between and . in , the occurrence of autochthonous cases of dengue in croatia were also attributed to a. albopictus, establishing the transmission by this mosquito in europe. in spain we are only suffering from their annoying bites, for now. table shows arbovirus infection and table shows other infections transmitted by dipterans worldwide, with the risk of transmission in spain. we have evaluated the risk of emergence and/or re-emergence of these diseases in spain according to the existing studies for each pathogen, the experience according to other diseases, previous immunity and other criteria, some of them subjective, that do not appear in the text. a. aegypti is the main zika vector and also a transmitter of yellow fever, dengue and chikungunya. in principle, this species is not a problem because it is not settled in europe, although it has been detected in some areas, such as in an airport in the netherlands and, more recently, in fuerteventura (canary islands) (fig. ) . in view of the zika epidemic in the americas, the ministry of health, social services and equality, in collaboration with the carlos iii health institute and the autonomous regions, has established a zika virus disease surveillance in spain. to date (last update in july ), confirmed cases have been reported, all imported, except congenital cases whose mothers were infected in the risk zone and autochthonous cases of sexual transmission. it should be noted that it is not necessary to resort to invasive or exotic species to refer to avbd. thus, anopheles atroparvus is present in spain, a good malaria vector. the official map of the distribution of this mosquito is not updated; however, although the risk of a malarial outbreak is low in our country, recent events have involved this species in the two cases of autochthonous malaria registered in the north of the peninsula. spain was an endemic country of malaria until , when who declared it a the risk of emergence/re-emergence is calculated based on three factors: (a) presence of cases of the disease in humans in the last years in europe, mediterranean, central and south american countries with a significant relationship with spain; (b) presence of the vector in spain; (c) pathogenicity of the virus for humans. each factor is scored with one point (presence in the first two factors and low pathogenicity in the third factor) or with zero points (absence in the first two factors and high pathogenicity in the third factor). the first two factors are added and the third is subtracted. the total score can range between and , with being: low risk; : moderate risk; : high risk. free zone. in europe, after the eradication of malaria, most cases are imported, although sporadic cases have recently been reported in many mediterranean countries such as france, italy, greece. the emergence of autochthonous cases in greece between and has raised doubts about the real situation in europe as a malaria-free zone. other diptera present in spain which we cannot ignore are phlebotominae sand flies. the species phlebotomus perniciosus and phlebotomus ariasi, are the competent vectors of the leishmaniasis agent (leishmania infantum). there are also other potential vectors of l. infantum in spain, as they are phlebotomus papatasi and phlebotomus sergenti. leishmaniasis is endemic throughout the mediterranean basin in europe and its geographic scope is spreading. usually, the epidemiology of leishmaniasis was linked to the rural habitat with the presence of dogs. the great epidemic outbreak of fuenlabrada with a high number of cases in an urban area, in which leishmaniasis was not common, showed the dangers of changing the urban model in spain. many houses were built in rural agricultural areas with gardens and peri-urban green spaces where wildlife was present. in these places the concentration of phlebotominae sand flies was high, and, in their environment, there were not only dogs but also other l. infantum reservoirs, such as hares and rabbits. this fact together with mild temperatures in recent years, decreasing the mortality of the vector, seems to be what caused the great outbreak. [ ] [ ] [ ] undoubtedly, the presence of phlebotominae sand flies throughout the iberian peninsula is a great threat, since not only do they transmit leishmania, but they are also toscana virus vectors, which is causing numerous cases of meningoencephalitis in some areas of spain and other phleboviruses such as the granada virus (without proven pathogenic power), the naples virus or the sicily virus. another species of mosquito to which special attention is to be paid is culex pipiens. this species, which is distributed and well represented throughout the iberian peninsula, is capable of transmitting the west nile virus (wnv). west nile fever is becoming a serious problem in some areas of europe, as in greece, where there has been an outbreak with numerous neuroinvasive forms, and in cases have been reported in france, italy, romania, hungary, croatia, serbia and austria. in spain, according to the data from the situation report and wnv risk assessment, published in , there are several species of mosquitoes capable of virus transmission. for example, culex modestus, culex perexiguus and culex theileri show a high vector competence, while c. pipiens and a. albopictus have a moderate vector competence. the first human case of neuroinvasive disease due to wnv in our country was identified, retrospectively, in a patient diagnosed with meningitis in september who, in the days before the onset of symptoms, visited a village in badajoz, extremadura (spain). in , the ministry of the environment reported the detection of wnv in equine farms in the provinces of cádiz, sevilla and málaga. through this active surveillance, suspected cases were investigated and two human cases of wnv meningoencephalitis were confirmed. between and , virus activity was detected in equines, suggesting that the virus is endemic in our country. in addition, there was previous evidence about its circulation in birds that were considered for the development of a predictive virus circulation model in our country. another factor that clearly influences infections transmitted by arthropod vectors is climate change. in the international conference on climate change and health was held in atlanta, which revolved around the idea that: "health is the human face of climate change". following this meeting, a special article was published in the new england journal of medicine which stated that the distribution of infectious diseases such as lyme borreliosis, rickettsiosis or west nile fever are expanding at the same rate as their avs. we know that climate variations and extreme weather events have a profound impact on avbd. mosquitoes and ticks are devoid of temperature regulation mechanisms and, for this reason, fluctuations in temperature greatly affect their reproduction and survival. in our country, it is more than possible that the great increase in the number of ticks in recent years is due to the fact that winters, in general, are much milder than years ago. just to mention an example, ixodes ricinus, the tick that most frequently bites people in the north of spain, is very sensitive to climate warming. this, among other factors, is increasing its survival. this species of tick transmits very prevalent diseases in europe, such as lyme disease or tickborne encephalitis, or others such as rickettsia monacensis infection, human anaplasmosis, and babesiosis. , in spain, human cases of all of them have been described, except for tick-borne encephalitis. although there is a high suspicion of the circulation of the virus in spain, the molecular screening of hundreds of ticks has been carried out in our laboratory, with negative results. in addition, other pathogens have been detected in i. ricinus specimens collected in spain, such as rickettsia helvetica, candidatus neoehrlichia mikurensis or borrelia miyamotoi, which leads us to be alert to the possible occurrence of human cases. [ ] [ ] [ ] as a consequence of climate change, the hypothesis about the probable changes in the distribution of another species of tick, hyalomma marginatum, which is the crimean-congo hemorrhagic fever (cchf) vector in europe, has also been established. under warmer climate conditions, according to prediction models, it is expected that the distribution of this tick species will extend to new areas which were previously free of the vector. in relation to this issue, the epidemiology of mediterranean spotted fever seems clearly associated with climate change, especially with low rainfall values and it has been shown that warming causes greater aggressiveness in its avs. table shows the tick-borne diseases throughout the world, with the prediction of risk for spain (subjective assessments). to be able to show a perspective on the avbd, it is essential to monitor and identify microorganisms in vertebrates and arthropods, designing strategies before their transmission to humans. early detection and implementation of control strategies allow minimizing the impact on the population. between and , % of emerging infections spread from a wild-type focal point. occasionally, the infection is spread directly from reservoirs such as bats, rats or chimpanzees to domestic animals, which amplify the infection, or to people; other times, infection dissemination (spill-over) occurs through av such as ticks, fleas or mosquitoes. in any case, it is essential to carry out a surveillance and to know the microorganisms carried by av. a recent example in spain is the detection of cchfv in ticks of the species hyalomma lusitanicum collected in deer a few years ago in the province of caceres and the explanation of one of the possible ways of the arrival of the virus to our country. detection of the disease that appeared in as, to some extent, it was predictable. on september , , the ministry of health issued a press release reporting the death of a man by cchf and the contagion of the nurse who had taken care of him in the icu of the vallecas hospital where he had been treated. the first two autochthonous cases of cchf in spain were confirmed (fig. ) . in the last cchfv situation report and transmission risk assessment in spain, the diagnosis of tick-borne diseases is not always easy. we must bear in mind that a tick bite history is usually absent in at least half of the cases and that incubation periods can be very long. depending on the size of the tick, they can be very difficult to see (they can simulate a small mole), and their bite is painless. unless there is awareness or a high index of suspicion when faced with certain signs and/or clinical symptoms, who is going to think of a tickborne disease? it is clear, "what is not sought, is not found". in , who revised the list of emerging pathogens that could cause serious epidemics in the future and those that need to be investigated, including cchfv, ebola/marburg virus, zika virus, middle east respiratory syndrome coronavirus (mers-cov), severe acute respiratory syndrome coronavirus (sars-cov), lassa virus, nipah virus and rift valley fever virus. in addition, this year the list is completed with disease x, referring to an international epidemic that could be caused by a pathogen whose pathogenic potential and route of transmission is unknown at the moment. this list takes into account the transmissibility between humans, the severity of cases and the percentage of mortality, the difficulty of control and diagnosis and the context of public health and global expansion. in addition, there are other diseases that need more attention as soon as possible: hemorrhagic fevers by other arenaviruses, chikungunya virus, diseases by other highly pathogenic coronaviruses or by emerging enteroviruses and febrile syndrome with severe thrombocytopenia. many of these diseases are avborne. high high debonel/tibola: dermacentor-borne necrosis, erythema and lymphadenopathy/tick-borne lymphadenopathy; lar: rickettsiosis associated with lymphangitis. a in spain, borrelia hispanica relapsing fever. the risk of emergence/re-emergence is calculated based on two factors: (a) presence of cases of the disease in humans in the last years in europe, mediterranean countries and central and south american countries with a significant relationship with spain; (b) presence of the vector in spain. each factor is scored with one point (presence in the two factors) or zero points (absence in the two factors) and both are added. the total score can range between and , with being: low risk, : moderate risk and : high risk. another av that is said to have killed more people than all wars together is the body louse (human pediculus), transmitting exanthematic or epidemic typhus (rickettsia prowazekii), endemic recurrent fever (borrelia recurrentis) and the trench fever (bartonella quintana). body lice have been a serious public health problem until recently. they live in the seams of clothes and multiply in cold weather, lack of hygiene and war conditions. a person can be infested with thousands of lice, and each specimen is capable of biting an average of five times a day. it is said that body lice were one of the main problems during the russian revolution, where three million people affected by exanthematic typhus died. thus, vladimir ilyich lenin ( - ) stated: either socialism defeats the louse, or the louse will defeat socialism". here in spain, it was also a problem during the post-war period and was used as propaganda by franco's regime. we can ask ourselves: is there a risk of an epidemic or an epidemic outbreak of exanthematic typhus? it could happen, as it occurred in burundi in , when a large epidemic affected more than one hundred thousand patients. all the alarms went off when a red cross nurse was diagnosed after returning from work in the affected country. body lice are not seen on the body surface but live in the seams of clothing, in ± • c temperatures. parasitism by body lice should be suspected in persons with signs of scratching and lack of hygiene, more frequently in cold times of the year. at present, body lice have reappeared in refugee camps in europe, as in the second world war. in november , the european center for disease prevention and control reported the emergence of cases of recurrent fever due to body lice at different points along the route followed by refugees arriving in italy from the syrian war. in western europe, although we have not experienced any epidemic since the post-war period, and the fact that the condition had been eradicated, occasionally, there are r. prowazekii and b. quintana infection reports in homeless people parasitized by lice and cases of brill-zinsser disease have been described in people who have suffered from exanthematic typhus which could lead to an epidemic outbreak in certain conditions. fleas are other bloodsucking insects of worldwide distribution with an impact in public health. rickettsia can be transmitted to humans by at least two species: the rat flea (xenopsilla cheopis), which is the endemic or murine typhus vector (caused by rickettsia typhi), and the cat flea (ctenocephalides felis), which is the key vector of rickettsia felis and, occasionally, of r. typhi. as far as we know, rickettsias are not transmitted by the human flea (pulex irritans). in europe, murine typhus is a common avbd in mediterranean countries such as greece, cyprus, croatia and spain, including the canary islands. it develops as a non-specific febrile disease, with or without rash, which is often underdiagnosed. in clinical practice, murine typhus should be included in the differential diagnosis of any patient with fever of intermediate duration, that is, in a patient with fever (more than • c) of more than and less than days of progression, without focality to guide the diagnosis, which remains without a diagnosis after an initial evaluation that includes a complete clinical history, physical examination, complete blood count, chest x-ray and biochemical blood and urine tests. r. felis infection is another rickettsiosis with characteristics similar to murine typhus, of which cases have also been published in spain and that should be considered in patients with fever and/or rash, with a history of contact with cats or flea bites. despite the fact that there have been no reports of autochthonous yersinia pestis infection transmitted by the rat flea (x. cheopis) in spain, there is an alert for travellers at the time of writing this manuscript due to an epidemic outbreak in madagascar that has affected several thousand people. finally, we should remember the phrase written by hans zinsser in in his book entitled: rats, lice and history: "nothing in the world of living creatures remains constant. infectious diseases are constantly changing, new ones are in the process of development and the oldest ones are changing or disappearing". currently, ticks are considered the most dangerous avs in the world, because of their ease in moving from animals to people, because of their ubiquitous nature (they are present on all continents, including antarctica) and because of their capacity to agglutinate inside them a host of pathogenic microorganisms potentially transmissible through their hematophagous habits. the human tampering of ecosystems (deforestation, erosion of geographical limits to facilitate travel, etc.) or climate change are some of the factors that are favouring a greater contact between wild animals (with their ticks and the diseases they transmit) and people, facilitating the expansion of ticks to new previously unoccupied areas. diptera, ticks or other av may play the leading role in the next pandemic. therefore, anticipating the next public health crisis is in our hands. the authors declare no conflict of interest. biology of disease vectors ecology of zoonoses: natural and unnatural histories agency for international development) recreational infections disease outbreak news challenges in predicting climate and environmental effects on vector-borne disease episystems in a changing world travel and the emergence of infectious diseases aedes albopictus in italy and possible diffusion of the species into the mediterranean area updating the known distribution of aedes albopictus (skuse, ) in spain direct evidence of adult aedes albopictus dispersal by car aedes (stegomyia) albopictus (skuse, ) (diptera, culicidae) primera cita para la comunidad de madrid chikungunya is back in italy preliminary report of an autochthonous chikungunya outbreak in france enfermedad por virus chikungunya en españa zika virus: an updated review of comp or naturally infected mosquitoes first two autochthonous dengue virus infections in metropolitan france european centre for disease prevention and control. dengue outbreak in madeira, portugal autochthonous dengue fever in croatia initial distribution assessment of aedes albopictus (diptera: culicidae) in the barcelona, spain, area identificación del mosquito aedes aegypti en fuerteventura casos diagnosticados en españa informe de situación y evaluación del riesgo para españa de paludismo. centro de coordinación de alertas y emergencias sanitarias (ccaes), ministerio de sanidad fauna de mosquitos (diptera, culicidae) presentes en el humedal de la grajera (logroño) y sus implicaciones en salud pública really malaria-free europe? re-emergence of leishmaniasis in spain the role of indigenous phlebotomine sandflies and mammals in the spreading of leishmaniasis agents in the mediterranean region subdirección de promoción de la salud y prevención. dirección general de atención primaria phlebotomine sand-fly-borne pathogens in the mediterranean basin: human leishmaniasis and phlebovirus infections acute viral infections of the central nervous system informe de situación y evaluación del riesgo para españa de virus del nilo occidental. centro de coordinación de alertas y emergencias sanitarias (ccaes), ministerio de sanidad west nile virus in spain: report of the first diagnosed case (in spain) in a human with aseptic meningitis west nile fever outbreak in horses and humans epidemiology and spatio-temporal analysis of west nile virus in horses in spain between risk mapping of west nile virus circulation in spain preventive medicine for the planet and its peoples vector-borne diseases and climate change: a european perspective impact of regional climate change on human health driving forces for changes in geographical distribution of ixodes ricinus ticks in tick-borne rickettsioses in europe the risk of introducing tick-borne encephalitis and crimean-congo hemorrhagic fever into southwestern europe (iberian peninsula). in: virology ii -advanced issues role of birds in dispersal of etiologic agents of tick-borne zoonoses detection of tickborne 'candidatus neoehrlichia mikurensis' and anaplasma phagocytophilum in spain in borrelia miyamotoi: should this pathogen be considered for the diagnosis of tickborne infectious diseases in spain? boutonneuse fever and climate variability crimean-congo hemorrhagic fever virus in ticks, southwestern europe crimean-congo hemorrhagic fever virus in ticks from migratory birds autochthonous crimean-congo hemorrhagic fever in spain informe de situación y evaluación del riesgo de transmisión de fiebre hemorrágica de crimea-congo (fhcc) en españa. ministerio de sanidad fiebre hemorrágica de crimea-congo: «lo que no se busca no se encuentra list of blueprint priority diseases outbreak of epidemic typhus associated with trench fever in burundi rapid risk assessment: communicable disease risks associated with the movement of refugees in europe during the winter season ectoparasitism and vector-borne diseases in homeless people from marseilles zinsser disease in moroccan man fever of intermediate duration: new times, new tools and change of spectrum cluster of cases of human rickettsia felis infection from southern europe (spain) diagnosed by pcr we wish to thank jorge garcía labeaga, of urbe ingeniería, for his collaboration in the preparation of fig. . key: cord- -hyod n authors: laxmipriya, s.; narayanan, r.m. title: covid- and its relationship to particulate matter pollution – case study from part of greater chennai, india date: - - journal: mater today proc doi: . /j.matpr. . . sha: doc_id: cord_uid: hyod n it is well known that atmospheric contamination, especially the particulate matter (pm), causes severe human diseases. yet, presently air pollution levels have dropped primarily attributable across the nation lockdown forced in the wake of the novel coronavirus outbreak. in this study, we have attempted to establish a conceivable relationship between covid and pm – . , obtained from eleven airquality monitoring stations in chennai city, india for both pre and during covid situations and its influence over covid positive cases. the observations of the materials (+ve cases, pm , pm . ) collected proved that during precovid regime less polluted areas are indicated with less than infection cases reflecting the healthy people and they are less vulnerable to covid except the few occurrence of foreign source indicating no community spread whereus most polluted spots of precovid regimes are indicated with more than % cases and indicated that people in pollution zones are succumbed to get infected quickly. however, during covid the lockdown has considerably reduced the particulate suspension and the results revealed that the +ve cases are of the nature of community spreading through primary and secondary contacts as reported from the media. if covid is a visible, brutally virulent, incredibly contagious pandemic that kills rapidly and mercilessly, air pollution is its unseen evil twin. under the radar, but even ruthlessly, if covid and pm paired together lead to murder without delay. this is a non-communicable disease (ncd) slow-motion pandemic, equivalent-if not exceeding-the catastrophic wrath of sars-cov- . air pollution has emerged as an increasing cause of concern worldwide, especially in developing nations such as india [ ] . india saw financial development, a quick extension of urban areas, industrialization, and quick-paced improvement of the foundation since progression during the s. at the same time, the degree of air pollution in india has expanded to a significant wellbeing danger and reason for massive untimely mortality [ ] . around one million individuals kicked the bucket in because of the encompassing particulate issue (pm) contamination alone in india [ ] . indian urban communities have been continually making into the best most contaminated urban areas of the world for as far back as hardly any years and surpassing the surrounding air quality gauges suggested by the world health organization and central pollution control board (cpcb). air pollution can exacerbate a broad scope of respiratory ailments, and coronavirus seems, by all accounts, to be no particular case. in the first four months, the outbreak of coronavirus disease (covid ), initially identified in china's wuhan, has resulted in more than one million cases worldwide.the pandemic situation has brought about lockdown in numerous countries around the world. though india's first confirmed case was on january th , the cases were multipled to , , as on today ( th july ). from march th , the country was cut off from all places of mass gatherings such as schools, shopping malls, and theatres through the lockdown. further, the lockdown imposes limitations and measures of self-isolation which diminish emanations from transport and businesses. the researchers, based at several universities across italy, propose the virus could be scattered all the more generally on air pollution particles [ ] . harvard researchers suggest their results are especially important for vulnerable minority groups, which will be slowly exposed to air pollution in general, leading to the likelihood of coronavirus being genuinely sick. for every small increment in air pollution, there's a generous increase in death [ ] . based on epha study comprising people's ability to fight off infection resulted with weakening of immune system by airpolloutants, [ ] . one recent study found that even little increments in fine particulate matter of only microgram for every cubic meter related to a % expansion in covid- passings [ ] . further the relations between pm and communicable diseases were also recorded in more recent studies revealed inhalation may transmit pm concentrated into the lungs, and particle-attached viruses may directly conquer the inferior respiratory tract, thus raising infection induction [ ] . if this is true that novel coronavirus remains active on various surfaces from a few hours to several days [ ] , it is reasonable to conclude the same might appear when adsorbed or absorbed by the particulate matter in the atmosphere, which can also possibly bring the viruses into the respiratory epithelium a spatial distribution for pre-covid pm . and positive corona cases between the stations is geographically heterogeneous, and it is presented in figure . and/or contact with contaminated surfaces [ ] , the veracity of covid- occurrence (table . ) observed in most of the highly polluted areas withcompared to that of low, also suggested to consider possible route of transmission by airborne route. the pre covid particilate matter pollution zones revealed that less polluted areas are indicated with < +ve cases with < . % of distribution and might be resulted from foreign source and indicating that there is no community spread however while most polluted areas has more than +ve cases and max of +ve cases with percent distribution and started carried away through atmospheric medium by means of particulate suspension. the lockdown brought numerous anthropogenic (human-made) supporters of a halt. chennai, one of the most critically polluted cities, also reported a significant reduction in air pollution. the contamination levels of pm . during covid was found to be µg/m larger particles (> μm) appear to settle on the upper respiratory tract surfaces of nose breathers, and occur with deposition on the upper respiratory tract. exposure to pm is associated with increased bronchiolitis in infants with respiratory syncytial virus hospitalisations [ ] . the pre covid particulate matter pollution zones revealed that less polluted areas are indicated with < +ve cases with < % of distribution and might be resulted from foreign source and indicating that there is no community spread however while most polluted areas has more than +ve cases to the maximum of +ve cases with . percent distribution and might be resulted from transportation of particulate suspension through atmospheric medium . the contamination levels of pm has significantly decreased during the lockdown period. there was about to % reduction rate. the variation of covid positive cases also showed significant change. from figure .(d) it was observed that areas under the range ( to µg/m ) has more positive cases( percentage ) than other areas. during covid particulate matter pollution zones revealed that less polluted areas are indicated with < +ve cases with < % of distribution and might be resulted from community spread or pimary contacts however while most polluted areas has only +ve case with < percent distribution and has no significant role in spreading due to atmospheric medium by means of particulate suspension. the air pollution might be clearing in chennai due to lockdown; however, the harm has just been done to human wellbeing and individuals' capacity to ward off disease. governments ought to have handled ceaseless air contamination quite a while in the past. however, it has organized the economy over wellbeing. science articulates epidemics like covid- will occur with increasing rate of recurrence [ ] . incredibly contagious pandemic that kills rapidly and mercilessly, air pollution is its unseen evil twin. under the radar, but even ruthlessly, if covid and pm paired together lead to murder without delay. this is a non-communicable disease (ncd) slow-motion pandemic, equivalent-if not exceeding-the catastrophic wrath of sars-cov- .the hypothesis could exploit ways to connect atmospheric particulates is a challenging point which we believe deserves more, immediate and in-depth experimental work. it is to be expected that steps to clarify the dynamics involved in the current pandemic will be taken promptly. esri india ltd in preparation of gis maps. we also thank the er a.c.s. arunkumar president, dr m.g.r educational and research institute for providing the necessary facilities and for their constant motivations to carry air pollution monitoring network using low-cost sensors, a case study in hanoi the relationship between indoor particulate matter and home ventilation field calibration of low-cost air pollution sensors particulate matter air-pollution a familial cluster of covid- indicating virus can be transmitted by asymptomatic carriers familial cluster of covid- infection from an asymptomatic beijing smog chinese bicycl. body power chernobyl years later mex. coral reefs battling deforestation honduras outbreak desertif. chile india's e-waste ecotourism phil novel coronavirus: how atmospheric particulate affects our environment and health covid- asymptomatic infection estimation impact of urban expansion on the air pollution landscape: a case study of hanoi recent increase of surface particulate matter concentrations in the seoul metropolitan area q&a: the novel coronavirus outbreak causing covid- a novel coronavirus (covid- ) outbreak covid- -a timeline of the coronavirus outbreak the authors are thankful to those who helped in placing the airsampler in the prescribed hotspots for obtaining the results during field observations and the technical support rendered by the observations of the materials (+ve cases, pm , pm . ) collected proved that during precovid regime less polluted areas are indicated with less than infection cases reflecting the healthy people and they are less vulnerable to covid except the few occurrence of foreign source indicating no community spread whereus most polluted spots of precovid regimes are indicated with more than % cases and indicated that people in pollution zones are succumbed to get infected quickly. however, during covid the lockdown has considerably reduced the particulate suspension and the results revealed that the +ve cases are of the nature of community spreading through primary and secondary contacts as reported from the media. if covid is a visible, brutally virulent, incredibly contagious pandemic that kills rapidly and mercilessly, air pollution is its unseen evil twin. under the radar, but even ruthlessly, if covid and pm paired together lead to murder without delay. this is a non-communicable disease (ncd) slow-motion pandemic, equivalent-if not exceeding-the catastrophic wrath of sars-cov- . the hypothesis could exploit ways to connect atmospheric particulates is a challenging point which we believe deserves more, immediate and in-depth experimental work. it is to be expected that steps to clarify the dynamics involved in the current pandemic will be taken promptly. key: cord- - ibswt authors: kim, jong-hyun title: infectious diseases in children and adolescents in the republic of korea; past & recent status date: - - journal: korean j pediatr doi: . /kjp. . . . sha: doc_id: cord_uid: ibswt compared to the past decades, in recent decades, environmental and hygienic conditions in the republic of korea have improved along with socioeconomic developments, and the incidence of most infectious diseases, especially vaccine-preventable diseases, has greatly decreased due to active immunization with the developed level of health care. however, the incidence of some diseases has been increasing, and new diseases have been emerging. to cope with such changes actively, the government put the "law for control and prevention of infectious diseases" into effect; this law was entirely revised on december , . in this report, i review the past and recent status of infectious diseases in the republic of korea, following the introduction of this law, on the basis of data in the "national notifiable disease surveillance system", which had been accumulated between the years and . in the republic of korea (rok), the "prevention of contagious diseases act" was first enacted in the year and this law laid the foundation of the "national notifiable disease surveillance system (nndss)", by designating infectious diseases for mandatory reporting. the first major revision of this law in provided the current structure of the nndss, which collects individual patient information using an electronic reporting system. as of august , this system covered infectious diseases ) . recently, as of december , , the "prevention of contagious diseases act" and "parasite diseases prevention act" were merged and completely revised to the "law for control and prevention of infectious diseases" and "quarantine act". major changes in the "law for control and prevention of infectious diseases" included a nndss ) . the range of infectious diseases is too broad; therefore, the analysis was limited to significant infectious diseases that fall under categories i, ii and iii of the currently revised law. category i infectious diseases include diseases that can spread through water or foodstuff, requiring immediate control measures upon outbreak, and require immediate reporting by a health care provider upon occurrence. six diseases, cholera, typhoid fever, paratyphoid fever, shigellosis, entero-hemorrhagic escherichia coli, and hepatitis a, are included in this category (table ) ) . according to data from , the number of reported cholera cases was in , , in , and in , and the incidence remarkably decreased thereafter. however, there were intermittent outbreaks, in , in , and in ) . since then, less than cases have been reported every year, and in , cholera was epidemic nationwide, centered on the gyeongsangdo province, and cases (including confirmed cases) were reported. with the exception of and cases reported in and , respectively, less than cases were reported, and with the exception of cases in and case in , all were imported cases ( fig. ) ) . for the past decade ( to ), the total number of reported typhoid fever is one of the indigenous infectious diseases in rok, and , to , cases had been reported yearly before the s, but to cases have been reported every year thereafter ( fig. ) ) . according to the infectious diseases surveillance yearbook ) , out of cases in were laboratory-confirmed cases and tended to occur year-round. as an example of a regional trend, the cases were reported in gyeongsangnamdo, gyeonggido, seoul, and busan, in descending order in terms of frequency, and were imported cases. although they were distributed across all ages, the incidence was markedly higher in patients in their s ( . %) and s ( . %). for the past decade, the total number of reported cases was , , and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . ) paratyphoid fever paratyphoid fever is an infectious disease, showing sporadic outbreaks of dozens of patients every year. however, in the epidemic event centered in busan in , cases were reported. since then, just a few cases hepatitis a was included in category i notifiable infectious diseases under the "law for control and prevention of infectious diseases" in the version revised on december , ) . since hepatitis a was officially followed up from , exact data enabling us to examine the previous incidence do not exist. however, according to a published report ) , among all patients who had been hospitalized in the department of pediatrics over years from to , patients with hepatitis a accounted for . % ( . to . %) on the average. a similar trend continued until the early s, and sharply decreased thereafter, and increased again in ) . according to the sentinel surveillance system started from , hepatitis a incidence showed a sharply increasing trends for several years, with less than cases (table ), but the actual incidence is expected to be several folds higher ) . moreover, there was huge difference in incidence between regions, such that the incidence was to % in seoul, gyeonggido and incheon areas but the incidence was much lower in gyeongsangbukdo and gyeongsangnamdo areas, including daegu and busan ) . regarding the age of cases, most occurrences were reported in patients in their s and s, and few cases occurred in patients in their s in s. however, most occurrences during to were reported in patients in their s, followed by those in their s and s, and the order of the ages of occurrence was the s, s, s, and s after ) . hepatitis a vaccine has still not been included in the national immunization program, but since its first use in the end of , it is currently expected to be vaccinated in about % of infants and toddlers. the category ii infectious diseases are vpds, and once a case have been reported again ( fig. ) ) . in , a total of cases were reported and of these, were laboratory-confirmed cases. the cases occurred in all age groups year-round, and were imported cases ) . for the past decade, the total number of reported cases was , and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . hundreds of cases of shigellosis were reported in the s, less than cases were reported between and . one to two hundred cases were reported between and , less than cases were reported thereafter, and then its incidence increased abruptly as , to , cases were reported between and . since then, to cases have reported yearly ( fig. ) ) . among the cases reported in , were laboratory-confirmed cases, and in cases, the infection acquired during an overseas trip. more cases were reported in january and november ) . for the past decade, the total number of reported cases was , , and patients aged < years and to years accounted for . % ( , cases) and . % ( cases), respectively ) . data on entero-hemorrhagic e.coli infections has been collected since it was designated as a notifiable infectious disease in . one case in , in , and in were reported, and the incidence has increased since , when surveillance of hemolytic uremic syndrome was implemented and the monitoring was reinforced. except for cases in , about cases have been reported yearly ( fig. ) ) . among the cases reported in , cases were men and women, indicating that there was no significant difference between genders, and cases ( . %) were reported between june and august ) . for the past decade, the total number of reported cases was and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . occurs, it is required to be reported by a health care provider without delay. ten diseases, diphtheria, pertussis, tetanus, measles, mumps, rubella, polio, hepatitis b, japanese encephalitis, and chicken pox, are included in this category (table ) ) . in the s, to , cases were reported every year with a peak of , cases in . since the diphtheria, tetanus, and whole-cell per tussis (dtwp) vaccine was introduced in , to , cases were reported in the s and to cases by the end of the s. less than cases had been reported since , and with use of the diphtheria, tetanus, and acellular pertussis (dtap) vaccine from , and with the vaccination rate maintained at % or more, no occurrences have been reported after (fig. ) , ) . fifteen to twenty thousand cases of pertussis were reported in the s, , to , cases were reported between and , and to thousands of cases had been reported every year from to . after introduction of the dtwp and dtap vaccines in and , the vaccination rate has been maintained at % or more, and the incidence of pertussis has significantly decreased. just dozens of cases have been reported yearly from , until now ( fig. ) ) . for the past decade, the total number of reported cases was , and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively, and in patients < years old, most were aged < months ) . tetanus data has been collected since it was designated as a category ii infectious disease in . in , the dtap vaccination rate exceeded % and few neonatal tetanus cases were reported, and after the s, about cases have been reported yearly. however, in the s, to cases have been reported yearly (fig. ) . for the past decade, the total number of reported cases was , and the number of cases patients aged < years and to years was and , respectively. few cases occurred in the pediatric age group, and those aged years or more accounted for . % ) . ten to twenty thousand cases of measles were reported every year, but since the measles vaccine was introduced in , the incidence had continuously decreased, except for an epidemic at an interval of to years. an average of , to , cases was reported yearly by the beginning of the s, but with continuation of the immunization program, the incidence decreased to , to , cases per year after . there was a nationwide epidemic event during to . compared to the period between and , during the above mentioned period, the epidemic occurred more often in those aged years or more, and thus in , the korean pediatric society temporarily recommended that those aged years should be revaccinated with the measles, mumps, and rubella (mmr) vaccine, in addition to vaccination at the recommended age of months. since , the government has reduced the time of primary mmr vacci- nation to to months and adjusted the immunization schedule for revaccination in those aged to years , , ) . from the latter half of to the first half of , a large epidemic event occurred with about , cases reported, and the incidence has greatly decreased since in may , the measles catch-up immunization program was executed in all school-aged populations ) . except cases in and in , just to cases were reported every year (fig. ) ) . according to reports in and , patients aged < years and to years accounted for . % and . %, and . % and . %, respectively. the age difference between two outbreaks might be dependent upon the age of the first case as the source of infection ) . before introduction of the immunization program, mumps had occurred mostly in elementary school-aged population, but since the program was introduced, those incidence in patients aged years or more has tended to increase in all years. in the beginning of , , or more cases of mumps were reported and then gradually decreased thereafter, and to less than , cases in the middle of the s. however, it started to increase thereafter and , or more cases have been reported for in the past years (fig. ) , ) . this phenomenon not only might result from an actual increase of incidence, but also from increased reporting through the consolidated report system. according to data collected in , mumps occurred year-round, but occurred mostly in april through september ( . %), and occurred more frequently in men than in women ) . for the past decade, the total number of reported cases was , and patients aged < years and to years accounted for . % ( , cases) and . % ( , cases), respectively ) . rubella was designated as a category ii infectious disease in ; therefore, it is difficult to estimate the before . in , a small outbreak was reported in seoul, and from a mass outbreak in the middle of s, "rubella warning" was issued by the ministry of health & welfare in march . one hundred seven cases were reported in , in , and to cases yearly thereafter (fig. ) . before the vaccine program was introduced, it occurred mostly in children aged to years, but after it was introduced, the incidence tended to increase in young adults. the incidence is reported on a yearly basis, and it is higher in late winter and early spring , ) . for the past decade, the total number of reported cases was and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . polio occurred in , to , patients between and , to cases had been reported thereafter until . only several to dozens of cases were reported between and , and since cases were reported in , wild poliovirus infections have not been reported, thus far (fig. ) ) . according to a study of polio cases between and , those aged year were most common and those aged years or more accounted for %. inactivated vaccines for injection were used in , oral live attenuated vaccines were added in , and improved inactivated vaccines for injection have been used from , , ) . in the s, hepatitis b surface antigen (hbsag) positive rate was shown to be . to . % in all populations ) . however, since hepatitis b vaccine was first introduced in , and then subsequently included in the immunization schedule table of the korean pediatric society in , and also in the national immunization program in , hbsag positive rate has significantly decreased , ) . according to the national health and nutrition survey in korea, it has significantly decreased to . % in populations aged years or more (fig. ) ) . specifically, hbsag positive rate in those aged to years was found to be . % ) from a study with nationwide sampling in . this data could be a basis for certification from the who that hepatitis b has been well-controlled in the rok. since it was first reported in an american soldier in the rok in , , cases occurred in and of these, , died. in , , cases occurred and of these, , died in a large epidemic. since then, , to , cases had occurred between and , and to cases died every year. since the vaccine was first introduced in , the incidence has sharply decreased, and after the last epidemic in , when , cases occurred and of these, died, or less cases have occurred yearly, nearly reaching an elimination level (fig. ) , , ) . in the past epidemic period, most of the cases were aged to years, but for the most recent years, the total number of reported cases was and the number of cases aged < years and to years was and , respectively, indicating that few cases were reported in children or adolescents, and rather those aged years or more accounted for most occurrences ( . %, cases) ) . since it was designated as a category ii notifiable infectious disease in , , cases of chicken pox were reported in , , in , , in , , in , and , in ) . such an escalating trend of cases might result from the increased reporting through improved educations and public relations after its designation as a notifiable infectious disease. according to a report in , those aged to years accounted for most cases at %, and those aged under years accounted for % ) . according to data from the "health insurance review and assessment service" between and , the number of cases of chicken pox was as low as , in , but as high as , in . although there have been no exact data about chicken pox vaccination rates in the rok, according to a nationwide head-tohead interview of about , parents of children aged ≥ months to ≤ years in , the vaccination rate was . % , ) . category iii infectious diseases involve possibilities of intermittent outbreak; therefore, surveillance of occurrence should be performed and control measures need to be taken. once a case occurs, it should be reported by a health care provider without delay. nineteen diseases, malaria, tuberculosis, hansen disease, scarlet fever, meningococcal meningoencephalitis, legionellosis, vibrio vulnificus sepsis, epidemic typhus, murine typhus, tsutsugamushi disease, leptospirosis, brucellosis, anthrax, rabies, hemorrhagic fever with renal syndrome (hfrs), influenza, acquired immune deficiency syndrome (aids), syphilis, and creutzfeldt-jakob disease (cjd) or variant cjd (vcjd), are included in this category (table ) ) . as a typical re-emerging infectious disease, it had not been reported from the latter half of the s since it was epidemic in the beginning of the s, and then the occurrence of cases was reported again from . in the s, , to , cases were continuously reported every year (fig. ) ) . according to the infectious diseases surveillance yearbook ) , among , cases, , were local cases, were imported cases, and were soldiers and veterans, indicating that military-related cases accounted for . %. the number of cases in july and august was and , respectively, indicating that . % of total cases occurred in the middle of summer, and cases were men and for the past decade, the total number of reported cases was , and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . in the s, the total registered number of treated cases for tuberculosis was , or more yearly, and tuberculosis tended to decrease gradually thereafter. however, after , , to , new cases have occurred yearly, not showing a decreasing trend any more (fig. ) ) . the total number of tuberculosis cases reported in was , ( . / , populations). the number of new cases was , ( . / , populations), and of these, the number of pulmonary tuberculosis cases was , ( . / , populations), and the number of sputum acid fast bacilli -positive cases was , ( . / , populations). the number of extra-pulmonary cases was , ( . / , populations), accounting for . %. those aged < years and to years accounted for . % ( cases) and . % ( , cases), respectively ) . according to a study by medical institutions on pediatric tuberculosis between and , the prevalence of tuberculosis in decreased to about a tenth of that in , and, in particular, central nervous system and miliary tuberculosis cases decreased to about / th. on the other hand, pulmonary tuberculosis cases decreased just to about / th during the same period ) . reports on scarlet fever have been made on a full scale from , and the incidence was highest in , with about cases, and to cases have been reported yearly after ) . such numbers might result from the fact that many patients who contracted the disease were not reported properly because its severity was mild ) . for the past decade, the total number of cases reported was , and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . about cases were reported yearly in the s, under in the s, and to after the s. there were small outbreaks, cases were reported in , cases in , and in (fig. ) . for the past decade, the total number of reported cases was and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . since legionellosis was designated as a notifiable infectious disease in , less than cases were reported yearly in the beginning of the s and to cases have been reported after (fig. ) . for the past decade, the total number of cases reported was and the number of those aged < years and to years was each , and it mostly occurred in patients in their fifties or over ) . ) v. vulnificus sepsis since v. vulnificus sepsis was designated as a notifiable infectious disease in , about cases have been reported yearly (fig. ) . for the past decade, the total number of cases reported was and just cases were reported in those aged to years, and it mostly occurred in patients in their forties or over ) . less than cases had been reported by the middle of the s and no cases have been reported thereafter ) . few cases had been reported by the end of the s, the cases started to increase in the s, and to cases were reported yearly in the s (fig. ) . for the past years, the total number of patients reported was and the number of those aged < years and to years was and , respectively, and it mostly occurred in patients in their fifties or over ) . since it was included in the korean nndss in , , to , cases were reported yearly in the end of the s and the early s, and , to , cases have been reported yearly after (fig. ) ) . according to data in ) , . % of the cases were reported in october to november, and . % were in patients in their fifties or over, and female cases were . -fold higher than male cases. for the past years, the total number of reported cases was , and patients aged < years and to years accounted for % ( cases) and . % ( cases), respectively ) . since it was included in the korean nndss in , to cases were reported yearly after , and the incidence decreased to less than cases from (fig. ) ) . according to data in , % of the cases were reported in september to november, and those in their forties or over accounted for %, and it occurred . -fold more often in men ) . for the past years, the total number of reported cases was , , and the number of those aged < years and to years was and , respectively, and most occurrences were in patients in their forties or over ) . since brucellosis was designated as a notifiable infectious disease in , to cases were reported between and but less than cases have been reported yearly thereafter (fig. ) . for the past years, the total number of reported cases was , and the number of cases aged < years and to years was and , respectively, and it mostly occurred in patients in their forties or over ) . since anthrax was designated as a notifiable infectious disease in , no cases have been reported yet ) . in and , and cases, respectively, were reported, and few cases were reported after . no cases had been reported after , when just case was reported. however, rabies patient and patients with suspicious rabies were reported in , or cases were reported yearly between and , and no cases have been reported thereafter (fig. ) . for the past years, the total number of reported cases was , and the number of those aged < years and to years was each , ) . since about , hfrs cases occurred in the united nations forces and hundreds of them died during the korean war between and , scholars became interested in this condition ) . since it was designated as a category iii notifiable infectious disease in , the incidence has increased from the latter half of , and to cases were reported yearly in the s (fig. ) ) . according to a report in , . % of the cases were reported in october to december, those aged in their forties to sixties accounted for . %, and male cases were more than female ones ) . for the past years, the total number of reported cases was , and patients aged < years and to years accounted for . % ( cases) and . % ( cases), respectively ) . since it was designated as a category iii notifiable infectious disease and the korea influenza surveillance scheme consisting of clinical sentinel surveillance and laboratory sentinel surveillance was started in , the domestic prevalence of influenza has been reported ) . except the seasons of to , when an influenza a (h n ) pdm epidemic occurred, the domestic weekly prevalence of influenzalike illness (ili) for the seasons from to usually started to increase from around november, reached the peak from the end of december to the beginning of january, and tended to decrease, and then showed an increased trend once more between march and may of the following year. the peak ratio of ili was to / , cases in the winter, and was generally lower in the spring (fig. ) , ) . for aids, since the first human immunodeficiency virus (hiv)infected case was reported in , the accumulated number of hivinfected cases was about , by . in , infected cases were newly reported and the accumulated number of infected cases by the end of was , . among infected cases in , occurrences in men were -folds higher than in women, those aged twenties to forties accounted for . %, and the identified route of infection was always sexual contact ) . regarding syphilis, the sentinel surveillance system was established in , and private medical institutions and health centers were involved in . other venereal diseases tended to decrease after , while the number of reported syphilis cases increased, to , in and to , in ) . since cjd was designated as a notifiable infectious disease in , the total number of diagnosed cases of cjd or vcjd in the past years was , and to cases have been reported yearly. the malefemale ratio was close to : and the mean age of the patients was ± years ) . category iv infectious diseases are newly emerging cases in the rok or likely to be imported, and once a case occurs, it should be reported by a health care provider without delay. seventeen diseases, plague, yellow fever, dengue fever, viral hemorrhagic fever (marburg fever, lassa fever, ebola fever, etc.), small pox, botulism, severe acute respiratory syndrome, avian influenza, new h n influenza, tularemia, q fever, west nile fever, newly-emerging infectious diseases syndrome, lyme disease, tick-borne encephalitis, melioidosis, and chikungunya fever, are included in this category (table ) ) . category v infectious diseases are parasitic infectious diseases, requiring periodic investigation. once a case occurs, it should be reported by a health care provider within days. six diseases, ascariasis, trichuriasis, enterobiasis, clonorchiasis, paragonimiasis, and intestinal trematodiasis, are included in this category (table ) ) . for designated contagious infectious diseases, any epidemic events are required to be investigated, and once a case occurs, it should be reported by a health care provider within days. seventeen diseases, hepatitis c, hand-foot-mouth disease, gonorrhea, chlamydiosis, chancroid, genital herpes simplex, condyloma acuminatum, vancomycinresistant staphylococcus aureus infections, vancomycin-resistant enterococcus infections, methicillin-resistant s. aureus infections, multidrug-resistant pseudomonas aeruginosa infections, multidrugresistant acinetobacter baumannii infections, carbapenem-resistant enterobacteriaceae species infections, enteric infectious diseases, acute respiratory infectious diseases, imported parasitic diseases, and enterovirus infectious diseases, are included in this category (table ) ) . as described above, there have been huge circumstances changes in infectious diseases in the rok. in particular, changes in vpds were remarkable. such changes might result from a combination of multiple factors, such as environmental improvements with socioeconomic developments, improvements in the reporting system with consolidated administration of the government, increased collaboration in the private medical fields, and increased vaccination rate in infants and toddlers. to maintain and improve the current situation of infectious diseases in the rok, high coverage rate of vaccines in the national im munization program need to be maintained. moreover, vaccines that are not included in the national immunization program should be added, and surveillance and control of emerging or re-emerging diseases, especially imported infectious diseases, should be performed properly. besides, the governmental and medical associations should coordinate their efforts to build an efficient and practical nndss. timeliness of national notifiable diseases surveillance system in korea: a cross-sectional study immunization policy in korea trends in imported cases of infectious diseases in korea disease web statistics system communicable diseases surveillance yearbook clinical observation of type a hepatitis in children recent epidemiological status and vaccination of hepatitis a in korea the korean pediatric society. immunization guideline centers for disease control and prevention (cdc) epidemiology and prevention of vaccine-preventable disease current status of liver diseases in korea: hepatitis b impacts of vaccination on hepatitis b viral infections in korea over a -year period the office for health and medical care policy in the ministry of health & welfare, division of chronic disease surveillance in korea serosurvey of measles, mumps and hepatitis b. seoul: korea centers for disease control and prevention an analysis of varicella incidence in korea evaluation for the usefulness of bcg vaccine: a survey study for the incidence trends of patients with disseminated tuberculosis in children after year . seoul: korea food and drug administration rapid increase of patients with scarlet fever and of group a streptococcus isolated patients from the pharyngitis laboratory surveillance animal bite cases in high-risk region of rabies current status of hiv/ aids in korea current status of laboratory diagnosis for creutzfeldt jakob disease ( - ) and introduction of the active surveillance system for cjd patients the authors would like to thank ms. chris lee for english translation of this article. key: cord- - bd adip authors: nepal, gaurav; rehrig, jessica holly; shrestha, gentle sunder; shing, yow ka; yadav, jayant kumar; ojha, rajeev; pokhrel, gaurab; tu, zhi lan; huang, dong ya title: neurological manifestations of covid- : a systematic review date: - - journal: crit care doi: . /s - - -z sha: doc_id: cord_uid: bd adip introduction: severe acute respiratory syndrome coronavirus (sars-cov- ) is responsible for the global spread of coronavirus disease (covid- ). our understanding of the impact this virus has on the nervous system is limited. our review aims to inform and improve decision-making among the physicians treating covid- by presenting a systematic analysis of the neurological manifestations experienced within these patients. methods: any study, released prior to may , , that reported neurological manifestations in patients infected by sars-cov- was systematically reviewed using the prisma (preferred reporting items for systemic review and meta-analysis) statement. results: our systematic review included data from articles: twelve retrospective studies, two prospective studies, and the rest case reports/series. the most commonly reported neurological manifestations of covid- were myalgia, headache, altered sensorium, hyposmia, and hypogeusia. uncommonly, covid- can also present with central nervous system manifestations such as ischemic stroke, intracerebral hemorrhage, encephalo-myelitis, and acute myelitis, peripheral nervous manifestations such as guillain-barré syndrome and bell’s palsy, and skeletal muscle manifestations such as rhabdomyolysis. conclusion: while covid- typically presents as a self-limiting respiratory disease, it has been reported in up to % of patients to progress to severe illness with multi-organ involvement. the neurological manifestations of covid- are not uncommon, but our study found most resolve with treatment of the underlying infection. although the timeliness of this review engages current challenges posed by the covid- pandemic, readers must not ignore the limitations and biases intrinsic to an early investigation. coronavirus disease is caused by the novel virus, severe acute respiratory syndrome coronavirus (sars-cov- ) [ ] . since its recent discovery in wuhan, china, coronavirus disease has spread across the world, leaving physicians challenged by its variable clinical manifestations. most patients infected by sars-cov- have presented with a mild clinical course: beginning with fever and dry cough, progressing to a form of mild or moderate respiratory disease, and resolving without specific treatment [ ] . serious complications of the infection, however, remain a central concern. acute respiratory distress syndrome, acute heart injury or failure, acute kidney injury, sepsis, disseminated intravascular coagulation, and lifethreatening metabolic derangements have all been reported in covid- patients, particularly among those with underlying comorbidities or advanced age [ , ] . as knowledge of sars-cov- and its clinical appearance continue to grow, the literature has shown a significant number of infected patients exhibit neurological symptoms [ , ] . in this systematic review, we evaluate various neurological manifestations reported in covid- patients and hypothesize their underlying pathophysiology. we deem the timeliness of this systematic review relevant, given the state of the covid- pandemic, but encourage readers to consider the implications of early review and analysis in the clinical setting. our systematic review utilized the prisma (preferred reporting items for systemic review and meta-analysis) statement in conjunction with the prisma checklist and flow diagram for manuscript format development [ ] . the following databases were reviewed for published studies prior to may , : pubmed, google scholar, and china national knowledge infrastructure (ckni). we also searched pre-print servers including research square, medrxiv, ssrn, and chinaxiv. boolean logic was used for conducting database search and boolean search operators "and" and "or" were used to link search terms. the following search strategy was adopted: covid- or sars-cov- or -ncov or ncov or novel corona and neurological or neurologic or brain or cns or nervous and manifestation or symptoms or presentation. titles, abstracts, and full text were screened to ensure they met eligibility criteria. two authors (gn and jhr) screened, retrieved, and excluded reports. additional investigators were consulted if uncertainty arose during the review process. we included any study, published in any language, which reported neurological manifestations in patients infected by sars-cov- . this included case reports and pre-print publications. we excluded all review articles, hypotheses papers, and papers reporting neurological symptoms in mers-cov and sars-cov patients. data was manually extracted from eligible studies by the research investigators. the following variables were included: first author, type of design, site of study, year of publication, published journal or pre-print server, sample size, and reported neurological manifestations. our outcome was to elucidate the neurological manifestations of covid- reported in the medical literature. the results were divided into three categories: central nervous system manifestations (e.g., headache, encephalopathy, and stroke), peripheral nervous system impairment (e.g., dysfunction of taste, dysfunction of smell, neuropathy), and skeletal muscle manifestations (e.g., myalgia). in total, our literature search yielded articles. after excluding duplicates and those not meeting inclusion criteria, papers were included in our systematic review. figure displays the results of our literature search and selection. the characteristics of each study are summarized in table . there were twelve retrospective studies [ , , , , - , , ] , two prospective studies [ , ] , and the rest were case reports/series. one article was a multicenter study [ ] , were from mainland china, six from the usa [ , , , , , ] , five from iran [ , , , , ] , four from italy [ , , , ] , and one each from japan [ ] , switzerland [ ] , and spain [ ] . out of all included studies, one was published in a premier news agency of china [ ] , eight were unpublished scientific articles deposited in pre-print servers [ , , , , [ ] [ ] [ ] [ ] , and the remaining were journal publications. eight retrospective studies reported covid- patients presenting with headache. we found that an overall average of . % of patients experienced headache (fig. ) . mao et al. reported that some of covid- patients with neurologic manifestation initially presented with fever and headache only. however, several days later, they developed cough, throat pain, lymphopenia, and a ground-glass appearance on their respective chest computed tomography (ct) images. real-time reverse-transcription pcr (rt-pcr) analysis of nasopharyngeal swabs confirmed covid- infection in these patients [ ] . a retrospective study from china reviewed cases of covid- , of which ( . %) developed hypoxic encephalopathy which progressed to death in ( . %) and recovery in ( . %) [ ] . a separate study from china reported encephalopathy in ( . %) out of cases, out of which one was obtunded, one was delirious, and six were comatose [ ] . among the deceased cases in both studies, there were high rates of acute respiratory distress syndrome (ards), respiratory failure, heart failure, and sepsis. three other case reports of covid- encephalopathy have been documented, one each from the usa [ ] , iran [ ] , and italy [ ] , with an age group spanning - . all three cases presented with symptoms of fever and cough for a duration of approximately days before the onset of confusion and asthenia. ct and magnetic resonance imaging (mri) of the brain were unremarkable. electroencephalogram (eeg) was employed in the usa and italy case which revealed diffuse slowing consistent with encephalopathy [ , ] . chloroquine, lopinavir, and ritonavir were administered in the first two cases. at the time of the report, the first patient was critically ill and the second had complete resolution of her symptoms [ , ] . the third patient showed dramatic response to high-dose steroids and with slightly more than a week of therapy, he was back at baseline mentation with a normal neurological examination [ ] . a retrospective observational study from wuhan, china, reported that six ( . %) patients, out of the reviewed covid- cases, developed ischemic stroke. of these six patients, two arrived at the emergency department owing to sudden onset of hemiplegia without any fever or upper respiratory tract symptoms. five of the six patients were severe cases of covid- . d-dimer levels were high in patients with severe disease, compared to non-severe, as well as in those with cns manifestations, compared to those without [ ] . a retrospective observational study from a different center in wuhan, china, found eleven ( . %) patients, out of reviewed covid- cases, developed acute ischemic stroke. those who had covid- infection with new onset of ischemic stroke were more likely to have a severe sars-cov- presentation, an advanced age ( . ± . years versus . ± . years), and preexisting cardiovascular risk factors including hypertension, diabetes, and previous cerebrovascular disease. an increased inflammatory response and hypercoagulable state, typified by raised crp and d-dimer levels, was also more common among these patients [ ] . three other cases of ischemic stroke were reported in china among covid- patients aged - . each of them initially presented with a dry cough. at least week later, they developed limb weakness, dysarthria, and tongue deviation. a ct scan of the brain revealed basal ganglia infarction in one case; normal findings were reported in the other two cases. laboratory studies showed elevated d-dimer, decreased fibrinogen level, prolonged prothrombin time (pt), and activated partial thromboplastin time (aptt). additionally, serum cytokine levels including il- , il- , and il- , were markedly elevated. all three patients recovered with good functional outcomes after stroke treatment and supportive therapy [ , ] . oxley et al. reported five cases of large-vessel stroke in patients younger than years of age from the usa. only three cases were symptomatic for covid- . the mean nihss score was at admission. ct brain, ct angiography, and/or mri revealed severe large-vessel stroke in all patients. all but one underwent mechanical thrombectomy. among these patients, d-dimer, ferritin, pt, and aptt were raised while the fibrinogen level was reduced. one was discharged home, two were transferred to a rehabilitation facility, and two were in the icu/stroke unit at the time of the report [ ] . a retrospective observational study from wuhan, china, reported one ( . %) patient, out of reviewed covid- cases, who developed intracerebral hemorrhage. he was a -year-old male cigarette smoker who presented to the hospital with a severe case of covid- . about a week later, he developed an intracranial hemorrhage and died. of note, his blood pressure averaged / mmhg during treatment [ ] . there are two case reports from iran, one of a year-old male with no medical history of hypertension or anticoagulation therapy [ ] and another of a year-old lady with a history of hypertension [ ] . both presented with an acute loss of consciousness preceded by fever and dry cough. initial glasgow coma scale (gcs) for them was seven and ten, respectively. coagulation studies were normal for both. the ct brain revealed massive intracerebral hemorrhage in the right hemisphere accompanied by intraventricular and subarachnoid hemorrhage for the former, and bilateral subacute basal ganglia hemorrhage in the latter, and a lung ct scan showed bilateral ground-glass opacities in both cases. the respective authors suspected the intracranial hemorrhage was secondary to infection with sars-cov- in both cases. six cases of encephalitis have been described to date; two from china [ , ] , two from switzerland [ ] , one from japan [ ] , and one from america [ ] . their ages range from early s to late s. all of them had preceding symptoms of fever and cough followed by a rapidly deteriorating level of consciousness. meningeal irritability in the form of nuchal rigidity, kernig's, and brudzinski's was reported in two out of the six cases [ , ] . where lumbar puncture (lp) was performed, it showed lymphocytic pleocytosis typical of a viral meningo-encephalitis [ , , ] . sars-cov- was detected in the cerebrospinal fluid (csf) in only one chinese patient [ ] and japanese patient [ ] . for one of the switzerland patients who presented with psychosis and focal status epilepticus, an eeg was done which showed abundant bursts of anterior low-medium voltage irregular spike and waves superimposed on an irregularly slowed theta background. this was managed with intravenous (iv) clobazam and valproate, and she had a marked improvement h after admission with the resolution of her symptoms [ ] . ct brain was normal in all but the case of the american whose scan demonstrated symmetric hypoattenuation within the bilateral medial thalami. she had a follow-up mri brain which revealed hemorrhagic, rimenhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions. in her case, a presumptive diagnosis of covid- -associated acute necrotizing hemorrhagic encephalopathy was made, and she was thereafter started on intravenous immunoglobulin (ivig) [ ] . the mri of the patient from japan revealed right lateral ventriculitis and encephalitis mainly involving the mesial temporal lobe and hippocampus [ ] . mri brain performed for the switzerland patients were normal [ ] . at the time of writing, the chinese and switzerland patients recovered completely with supportive therapy [ , , ] , and the outcome of the patients from america and japan is not known. one case of acute disseminated encephalomyelitis (adem) has been reported in new jersey, america [ ] . the case was a female in her early s who presented with a -day history of dysphagia, dysarthria, and encephalopathy preceded by headache and myalgia. covid- nasal swab rt-pcr was positive. a lumbar puncture (lp) showed a csf with normal cell counts, protein, and glucose. ct brain showed multifocal patchy areas of white matter hypoattenuation and mri brain showed extensive patchy areas involving bilateral frontoparietal white matter, anterior temporal lobes, basal ganglia, external capsules, and thalami. she was treated with hydroxychloroquine, ceftriaxone, and a -day course of ivig. improvement was noted at the -day mark of therapy. one covid- case from wuhan, china, came with the presentation of acute myelitis. a -year-old male, with a -day history of fever, was admitted to the hospital after outpatient oral moxifloxacin hydrochloride and oseltamivir failed to improve his symptoms. ct scan of the chest found patchy changes in both lungs, and nasopharyngeal swab tested positive for sars-cov- . after a night of high fever, he developed bilateral weakness of his lower limbs, with urinary and bowel incontinence, rapidly progressing to flaccid lower extremity paralysis and paresthesia and numbness below t . planters were down going bilaterally. a clinical diagnosis of post-infectious acute myelitis was made. he received treatment with ganciclovir, lopinavir/ritonavir, moxifloxacin, dexamethasone, ivig, and mecobalamin. his bilateral lower extremity paralysis ultimately improved, and he was discharged to a rehabilitation facility [ ] . five studies assessed the prevalence of smell disorder. an overall average of . % of patients experienced olfactory disturbance (fig. ) . additionally, four studies assessed the prevalence of taste disorder. an overall average of . % of patients experienced taste disorder (fig. ) . a multicenter prospective study by lechien et al., reported time course of the aforementioned disorders. the olfactory dysfunction appeared before, in unison, and after the appearance of general symptoms in . , . , and . % of the cases, respectively. this olfactory abnormality persisted after the resolution of other symptoms in . % of cases [ ] . in an iranian study by moein et al., majority of patients with olfactory dysfunction reported that the onset of the olfactory dysfunction occurred at the same time or immediately after the onset of their other covid- symptoms [ ] . in china, a -year-old woman was admitted to the hospital for a left facial droop preceded by a -day history of pain in the mastoid region. there was no preceding fever, cough, or respiratory symptoms. physical examination showed a left lower motor neuron facial nerve paralysis. mri brain showed no abnormality. however, a throat swab rt-pcr turned positive for sars-cov- virus and the ct chest revealed ground-glass shadows in the right lower lung. the left facial paralysis was relieved after antiviral treatment with umifenovir and ribavirin [ ] . toscano et al. reported cases of guillain-barré syndrome (gbs) in covid- patients. the interval between the onset of viral illness and the first symptoms of gbs was between and days. the first symptoms of gbs were lower limb weakness and paresthesia in four patients and facial diplegia followed by ataxia and paresthesia in one patient. generalized, flaccid quadriparesis or tetraplegia evolved over a period of h to days in four patients; three received mechanical ventilation. csf analysis showed raised protein levels in two patients and raised lymphocytes in all five patients. csf rt-pcr for covid- was negative in all patients. neurological examination and nerve conduction studies were consistent with a demyelinating neuropathy in two patients, while the others were diagnosed as axonal variants of gbs. all five patients were treated with ivig; two received a second course of ivig and one required plasma exchange. four weeks after treatment, two patients remained in the icu and were receiving mechanical ventilation, two were undergoing physical therapy, and one was discharged without any residual symptoms [ ] . four other case reports of gbs, one in america [ ] , iran [ ] , italy [ ] , and china [ ] , respectively, were reported. age ranged from mid- s to s. all but the chinese patient presented with flu-like symptoms preceding weakness and/or numbness of the lower limbs with a progressive ascending paralysis; the chinese patient presented with neurological symptoms first and respiratory symptoms only on day of admission [ ] . in all cases, neurological examination and nerve conduction studies were consistent with a demyelinating neuropathy [ , [ ] [ ] [ ] . where lp was done, an albuminocytologic dissociation was revealed [ , ] . ivig was administered in the above case reports with variable response. two gbs variants have been described in a case series from spain. specifically, one case of miller fisher syndrome and one case of polyneuritis cranialis associated with covid- was described. the former case was a -year-old man who presented with anosmia, ageusia, right internuclear ophthalmoparesis, right fascicular oculomotor palsy, ataxia, areflexia, albuminocytologic dissociation, and positive testing for gd b-igg antibodies. five days prior, he had developed a cough, malaise, headache, low back pain, and a fever. the latter case was a -year-old man who presented with ageusia, bilateral abducens palsy, areflexia, and albuminocytologic dissociation. three days prior, he had developed diarrhea, a low-grade fever, and a poor general condition. the oropharyngeal swab for covid- by rt-pcr was positive in both patients and negative in the cerebrospinal fluid. the first patient was treated with ivig and the second with acetaminophen. two weeks later, both patients made a complete neurological recovery, except for residual anosmia and ageusia in the first case [ ] . an overall average of . % of patients reported experiencing myalgia in seven retrospective studies (fig. ) . the character and course of myalgia was not detailed in any of those studies. mao et al. reported that out of covid- patients, skeletal muscle injury occurred in ( . %). compared with the patients without muscle injury, patients with muscle injury had significantly higher levels of creatine kinase (median u/l [range . to , . ] versus median . u/l [range . - ]; p < . ). in addition, patients with muscle injury had higher c-reactive protein (crp) levels and d-dimer levels-manifestations of increased inflammatory response and associated coagulopathy. furthermore, patients with muscle injury showed more signs of multiorgan damage, including more serious liver and kidney abnormalities, than patients without muscle injury [ ] . a case report by jin et al. described a -year-old man in wuhan who presented with a -day history of fever and cough and a ct chest which showed bilateral ground-glass opacities. rt-pcr analysis of the patient's throat swab specimen indicated sars-cov- infection. he was treated supportively and with antivirals and antibiotics. on day of admission, the patient complained of pain and weakness in his lower limbs, and tenderness was noted on examination. urgent laboratory reports indicated raised myoglobin (> , . μg/l), creatine kinase ( , u/l), lactate dehydrogenase ( u/l), alanine aminotransferase ( u/l), and aspartate aminotransferase ( u/l). the patient's kidney function and electrolytes were normal. urinalysis revealed a lightyellow color of the urine, with positive occult blood and positive urine protein. these results indicated the onset of rhabdomyolysis. in addition to ongoing supportive therapy, the patient was treated with hydration, alkalization, plasma transfusion, and gamma globulin. the patient improved subsequently [ ] . coronavirus contains four structural proteins, including the spike protein (s), envelope protein (e), membrane protein (m), and the nucleocapsid protein (n). among them, the s protein plays the most important role in virus attachment, fusion, and entry. sars-cov- , like sars-cov, recognizes the angiotensin-converting enzyme (ace ) as a host cell entry receptor [ ] . high expression of the ace receptor is seen in type ii alveolar cells of the lung, intestine, esophagus, cardiomyocytes, proximal tubular cells, and urothelial cells [ ] . glial cells and neurons have been reported to express ace receptors, making the brain a potential target of covid- infection [ ] . how the virus enters the central nervous system is still a subject of debate. one plausible route of entry is through the olfactory nerve. retrograde transfer into the axon, whether through synapses, endocytosis, or exocytosis, could explain viral migration into the brain [ , ] . experimental studies using transgenic mice suggest that sars-cov and mers-cov may enter the central nervous system intranasally through the olfactory nerve. once in the brain, they have the potential to spread to the thalamus and brain stem, two regions highly involved in coronaviridae infections [ ] [ ] [ ] . a study evaluating specific receptors in the nasal mucosa, however, suggest sars-cov- may reach the brain through mechanisms independent of axonal transport via olfactory sensory nerves [ ] . another theory suggests if sars-cov- gained access to the general circulation, it could potentially invade the cerebral circulation and continue viral spread [ ] . slow movement in the cerebral microvasculature may promote interaction of the sars-cov- s protein and capillary endothelium ace receptor. once bound, the virus would have the potential to infect, damage, and bud from the capillary endothelium, thereby facilitating viral entry into the cerebrum [ , ] . sars-cov- could also cause damage to the central nervous system indirectly. viruses do not have to enter the brain to cause damage; they can activate an immune response that triggers subsequent damage within neuronal tissue. sars-cov- has been reported to cause a massive release of cytokines, a syndrome known as "cytokine storm"-downstream effects of this immune response include endothelial damage, disseminated intravascular coagulation, and disrupted cerebral autoregulation [ , ] . common symptoms elucidated from our systematic review include myalgia, headache, altered sensorium, hyposmia, and hypogeusia. acute viral respiratory tract infections have already been shown to cause the aforementioned neurological symptoms [ ] . peri-and postinfectious hyposmia and hypogeusia is hypothesized to be secondary to olfactory nerve and/or apparatus damage from direct insult of viral infection [ ] . according to the multicenter prospective european study by lechien et al., it appears that a large number of covid- patients experience olfactory and gustatory symptoms. in their study, olfactory and gustatory dysfunction occurred in . and . % of patients, respectively, with a majority of patients ( . %) experiencing abnormalities in olfaction after the appearance of their general symptoms [ ] . we found that in covid- patients, altered sensorium and encephalopathy were not uncommon. the basic pathological change seen in this disease is cerebral edema, with key clinical features being headache, confusion, delirium, loss of consciousness, seizure, and coma. covid- patients with encephalopathy were, by large, older male patients with cardiovascular comorbidities and severe infection with systematic inflammation and multi-organ dysfunction. early identification of covid- patients with altered sensorium is critical, as underlying potential reversible causes, including impending respiratory failure, require timely intervention [ ] . the pathophysiology behind the cerebral dysfunction is hypothesized to be in part inflammatory-mediated [ ] . this is supported by the fact that the encephalopathic italian patient had a dramatic response to high-dose steroids [ ] . ischemic stroke is another clinical entity which can present in patients with covid- infection. this presentation may arise secondary to a cytokine storm syndrome [ ] , which can cause endothelial damage, disseminated intravascular coagulation, and disrupted cerebral auto-regulation [ ] . through the ace receptor of the vascular endothelium, the virus's extensive invasion of the vascular endothelium obviously may cause extensive endotheliitis, increasing the risk of thrombosis leading to ischemic stroke. critically ill patients with severe sars-cov- infection often show elevated levels of d-dimer, a fibrin-degraded product which serves as a marker of dysfunctional activation of the coagulation system, such as in acute ischemic stroke [ , , ] . however, it is observed that the stroke prevalence in covid- patients and non-covid- patients are similar. two retrospective studies in wuhan, china, reported prevalence rates of between . - . % of acute ischemic stroke [ , ] which is consistent with the stroke prevalence in northeast china prior to the outbreak [ , ] . although the biochemistry suggests an association of covid- with disorders of the coagulation system, further studies are warranted to establish a relationship. for the three cases of covid- -associated intracerebral hemorrhage, a few potential explanations exist. it is known that the expression and the ability of ace receptor to lower blood pressure is reduced in patients with hypertension. in sars-cov- infection, the presence of s protein could further reduce the expression and function of ace proteins. this could potentially lead to uncontrolled hypertension, arterial wall rupture, and cerebral hemorrhage in infected patients [ ] . moreover, if the virus disseminates within the cerebral microvasculature, subsequent damage of capillary endothelial cells could result in a tear of the vasculature sufficient enough to cause parenchymal hemorrhage [ ] . additionally, covid- patients have been reported to have thrombocytopenia and coagulopathy, both of which are contributory factors for secondary brain parenchymal hemorrhage [ , ] . it is still unknown how covid- causes encephalomyelitis. it is thought that once viral particles gain entry into the milieu of the neuronal tissue, their interaction with the ace receptors in neurons could initiate a cycle of viral budding accompanied by neuronal damage. this can occur without substantial inflammation [ ] . in other cases, it may cause an acute inflammatory demyelination resulting in adem, which was described in one covid- case [ ] , and previously in mers-cov [ ] . covid- is also thought to cause acute hemorrhagic encephalitis through the mechanism of a cytokine storm [ ] . acute hemorrhagic leukoencephalitis is a rare demyelinating disorder that is usually fatal; icu care, use of high-dose corticosteroid therapy, immunoglobulins, plasma exchange, and dehydrating agents have led to survival in only some patients [ ] . this has been seen in one covid- case thus far [ ] . three neuro-immunological entities related to covid- infection surfaced in our systematic review: acute transverse myelitis, gbs and its variants, and bell's palsy [ , , ] . the time course of the disease is alike what is known for other viruses known to cause the above in that the symptoms of respiratory or gastrointestinal infection usually precede that of the neuroimmunological phenomena [ ] . this was seen in all cases in this report with the only exception being the gbs case report from china [ ] . this suggests that the underlying mechanism of such neuro-immunological phenomena in covid- patients is likely to be grounded by the hypothesis of molecular mimicry, where mimicry between microbial and nerve antigens is thought to be a major driving force behind the development of the disorder [ ] . there are a number of limitations in our study. most of the studies included in this systematic review are case reports/series and retrospective observational studies. the larger retrospective studies included were limited to the documentation of common neurological symptoms, such as headache, myalgia, and a loss in sense of taste and/or smell. furthermore, the timeliness of our systematic review presents potential for premature analysis of data trends in the literature. given the current pandemic, the authors of this study felt that the benefits of systematic data retrieval and review outweighed current risks of inaccurate predications. our aim was to synthesize data to aid physicians currently treating the novel covid- , knowing time constraints inhibited their own analysis of the evolving literature on neurological manifestations. our systematic review comprehensively detailed the neurological manifestations of covid- known to date. respiratory symptoms remain the hallmark of early identification, cohorting, and treatment of covid- , bearing in mind that in a number of cases it has been observed that neurological manifestations may precede it in the course of the disease. clinical characteristics of coronavirus disease in china clinical features of patients infected with novel coronavirus in wuhan covid- in critically ill patients in the seattle region-case series neurologic complications of coronavirus infections neurologic manifestations of hospitalized patients with coronavirus disease the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration acute cerebrovascular disease following covid- : a single center, retrospective, observational study guillain-barré syndrome associated with sars-cov- guillain-barré syndrome associated with sars-cov- infection: causality or coincidence? miller fisher syndrome and polyneuritis cranialis in covid- covid- -associated acute hemorrhagic necrotizing encephalopathy: ct and mri features beijing hospital confirms nervous system infections by novel coronavirus the impact of covid- on ischemic stroke: a case report covid and intra cerebral hemorrhage: causative or coincidental neurological complications of coronavirus disease (covid- ): encephalopathy. cureus acute myelitis after sars-cov- infection: a case report. medrxiv frequent convulsive seizures in an adult patient with covid- : a case report clinical characteristics of deceased patients with coronavirus disease : retrospective study clinical and epidemiological features of children with coronavirus disease (covid- ) in zhejiang, china: an observational cohort study clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan clinical infectious diseases: an official publication of the infectious diseases society of america a first case of meningitis/encephalitis associated with sars-coronavirus- rhabdomyolysis as potential late complication associated with covid- the novel coronavirus disease with secondary ischemic stroke: two cases report encephalitis as a clinical manifestation of covid- . brain, behavior, and immunity coronavirus disease complicated with bell's palsy: a case report steroidresponsive severe encephalopathy in sars-cov- infection. medrxiv preprint covid- -associated acute disseminated encephalomyelitis -a case report two patients with acute meningoencephalitis concomitant to sars-cov- infection guillain-barré syndrome following covid- : new infection, old complication? guillain barre syndrome associated with covid- infection: a case report guillain-barré syndrome associated with sars-cov- infection self-reported olfactory loss associates with outpatient clinical course in covid- olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid- ): a multicenter european study smell dysfunction: a biomarker for covid- basal ganglia involvement and altered mental status: a unique neurological manifestation of coronavirus disease large-vessel stroke as a presenting feature of covid- in the young new onset acute symptomatic seizure and risk factors in coronavirus disease : a retrospective multicenter study characterization of the receptor-binding domain (rbd) of novel coronavirus: implication for development of rbd protein as a viral attachment inhibitor and vaccine angiotensin-converting enzyme (ace ) as a sars-cov- receptor: molecular mechanisms and potential therapeutic target evidence of the covid- virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms axonal transport enables neuron-to-neuron propagation of human coronavirus oc rapid nipah virus entry into the central nervous system of hamsters via the olfactory route lethal infection of k -hace mice infected with severe acute respiratory syndrome coronavirus middle east respiratory syndrome coronavirus causes multiple organ damage and lethal disease in mice transgenic for human dipeptidyl peptidase severe acute respiratory syndrome coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ace non-neural expression of sars-cov- entry genes in the olfactory epithelium suggests mechanisms underlying anosmia in covid- patients. biorxiv preprint neurotropism of sars-cov : mechanisms and manifestations preventing covid- -induced pneumonia with anticytokine therapy inflammatory cytokines and ischemic stroke risk: the regards cohort aneta nitsch-osuch and ls. pathophysiology of clinical symptoms in acute viral respiratory tract infections hypogeusia, dysgeusia, hyposmia, and dysosmia following influenza-like infection covid- : icu delirium management during sars-cov- pandemic nervous system involvement after infection with covid- and other coronaviruses surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease (covid- ) prevalence of stroke and associated risk factors: a population based cross sectional study from northeast china prevalence, incidence, and mortality of stroke in china: results from a nationwide populationbased survey of adults coagulopathy and antiphospholipid antibodies in patients with covid- severe neurologic syndrome associated with middle east respiratory syndrome corona virus (mers-cov) acute hemorrhagic leucoencephalitis guillain-barré syndrome publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations none we received no funds for conducting this study. ethics approval and consent to participate not applicable. not applicable. none of the authors has any conflict of interest to disclose. we confirm that we have read the journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. key: cord- -fmy zrim authors: lim, jue tao; dickens, borame l; cook, alex r; khoo, ai leng; dan, yock young; fisher, dale andrew; tambyah, paul anantharajah; chai, louis yi ann title: the costs of an expanded screening criteria for covid- : a modelling study date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: fmy zrim objectives: nosocomial infection is an ongoing concern in the covid- outbreak. the effective screening of suspected cases in the healthcare setting is therefore necessary, enabling the early identification and prompt isolation of cases for epidemic containment. we aimed to assess the cost and health outcomes of an extended screening strategy, implemented in singapore on february , which maximizes case identification in the public healthcare system. methods: we explored the effects of the expanded screening criteria which allows clinicians to isolate and investigate patients presenting with undifferentiated fever or respiratory symptoms or chest x-ray abnormalities. we formulated a cost appraisal framework which evaluated the treatment costs averted from the prevention of secondary transmission in the hospital setting, as determined by a branching process infection model, and compared these to the costs of the additional testing required to meet the criteria. results: in the base case analysis, an [formula: see text] of . and incubation period of days, an estimated ( % ci: - ) cases could be averted over days within the hospital setting through esc. a corresponding $ . ( – . ) million usd costs could be averted with net cost savings of $ ( % ci: - – ). in the sensitivity analyses, when positive identification rates (pir) were above %, regardless of [formula: see text] and incubation period, all scenarios were cost-saving. conclusion: the expanded screening criteria can help to identify and promptly isolate positive covid cases in a cost-saving manner or within acceptable cost margins where the costs incurred from the testing of negative patients could be negated by the averted costs. outbreak control must be sustainable and effective; the proposed screening criteria should be considered to mitigate nosocomial transmission risk within healthcare facilities. since its emergence in wuhan, hubei province, china, the coronavirus disease has continued to spread with an escalating numbers of cases and countries affected. to prevent ongoing transmission, effective screening of suspected cases is necessary which enables the early identification and prompt isolation of cases for epidemic containment. these screening measures for testing have been largely guided by the world health organization's (who) case definitions, which serves as a valuable epidemiologic tool for public health officials to track the disease and is regularly updated with the changing epidemiology and demographics of the disease. this definition includes the presentation triad of fever, chest symptoms as well as a positive contact with an active infection or travel to an area with confirmed local transmission. covid- shares many clinical similarities to other respiratory and febrile illnesses, creating significant uncertainty at the point of testing as to whether cases should be treated as a potential positive infection. although symptom case reports have emerged over the ongoing outbreak, [ ] [ ] [ ] the case definition is dynamic, being continually updated using clinician feedback through research or policymakers who collate and publish. both pathways however have an inevitable time delay in information dissemination. this affects clinicians and healthcare workers (hcws) at the front line who rely on the case definition to screen and triage patients, where this epidemiologic case definition lag can lead to problems of case misclassification. the screening process should therefore maximise sensitivity to minimise the number of missed cases and risk of nosocomial transmission, which occurred in singapore during another coronavirus outbreak of severe acute respiratory syndrome (sars) in . during this outbreak, frequent inadequately protected patient-to-hcw interactions among untested and unidentified cases , led to hcws becoming infected. due to the presence of nosocomial transmission, clinicians at the national university hospital, singapore (nuhs) quickly responded with a revised testing protocol. they screened patients with a substantial expansion of the admission and isolation criteria to quickly identify and isolate infected individuals whose symptom profiles were too mild to be considered for testing , or for patients who sought medical attention with atypical disease presentations, especially in the pediatric or geriatric population. the implementation of this expanded screening criteria (esc) placed all patients with undifferentiated fever or respiratory symptoms or chest x-ray abnormalities in isolation until all symptoms and fever were resolved or an alternative diagnosis was proven, regardless of travel history or confirmed previous exposure. using esc, nuh clinicians were able to identify and isolate patients who did not fit the who sars criteria but were eventually confirmed to have sars, who would have otherwise been potential spreaders (the number of positive and negative cases for sars are presented in supplementary table .) clinicians responded to the covid- crisis similarly, implementing esc on th february , which was approximately three weeks after the first imported case. with widespread concerns raised regarding the low detection rate of infected travellers where most present j o u r n a l p r e -p r o o f mild symptoms ( . % with no fever, . % with cough) and high asymptomatic rates an estimated . % ascertainment rate in wuhan. a wider screening policy for covid- and future novel respiratory viruses requires assessment in terms of its efficacy and costs. the clinical management and costs of a large proportion of negative outcomes comes at the expense of resources which can be invested in other parts of the healthcare system. the efficacy of the esc in long term should thus be assessed in terms of its prevention of nosocomial transmission which may not only negate these costs but also save resources for the healthcare system. this paper therefore assesses the practicality of esc through a cost-effectiveness analysis by estimating the number of cases that can be averted through esc, and calculating the associated costs from the testing of negatives and cost savings from potentially averted cases. the first case definition used by the ministry of health, singapore for the testing of suspect covid- cases was based on who and other international bodies recommendations. this centered on the presence of fever, respiratory illness or pneumonia, and recent travel to wuhan, china (namely, regions with reported infections) or close contact with a case of covid- patient (table ). recognizing the limitations of these case definitions and extending from our experience from sars, , we proposed an expanded screening criteria (esc) simplified for execution at the hospital triage, which was then implemented on february with immediate effect. any patients with undifferentiated fever or respiratory symptoms or chest x-ray abnormalities are placed into isolation on admission with respiratory precautions, investigated until symptoms and fever resolve or an alternative diagnosis was determined (table ) we used our institution in singapore, a , -bed tertiary hospital, as a study example. as of february to february , cases have been identified through esc which would have otherwise been missed. we determined the total number of infected cases that could occur from each non-identified admitted covid- cases in a hospital setting using a branching process infection model (figure ), which estimates the number of new infections at each generation. each day, a set of imported cases is designed to be able to start multiple generations of transmission. the model characterizes this influx of cases into the hospital and subsequent infections that may occur. the baseline generation represents the first covid- positive case which is not deemed to be a suspected case under the non-esc criteria (who criteria until january or ministry of health criteria until january ) but would otherwise have been isolated under esc. under non-esc screening, the daily influx of symptomatic and positive cases is parameterised by a binomial distribution with a probability determined by the positive identification rate (pir), otherwise referred to as the proportion of confirmed symptomatic cases observed out of the total number of observed respiratory illness cases . all symptomatic and asymptomatic cases are assumed to be able to transmit the infection due to the closed environment within the hospital setting so are not distinguished. the number of importations in the hospital facility is therefore, the number of infections incurred from these daily incoming non-isolated cases is determined by a poisson distribution with a rate of infection λ, and the incubation period length which determines the infectiousness period . therefore the total number of infections at time , to time and incubation period , is defined as, where , denotes the size of the generation descending from ancestor , and determined by, after each newly infected person's incubation period, the individual is assumed to be in the process of being identified and have a decreasing rate of infectiousness of % until their end point at days. after the period + , an individual's infectiousness is consequently greatly reduced, where a person is expected to have follow up with the development of new symptoms or unexpected ongoing symptoms from the new infection of covid- and is consequently isolated, or if asymptomatic, is discharged. therefore, is updated to, for the main analysis, we ran simulations with a set of parameters taken from literature; a rate of infection ( ) of . and incubation period (ip) of days, and pir rate . % which is based on the upper bound for case identification in the sars epidemic in . [ ] [ ] [ ] [ ] [ ] [ ] the full analysis was run for different parameter distributions (table ) . for each independent combination, simulations were run where the incubation period was varied between to days, the rate of infection λ from . - . increments, and the rate of influx from . % to . % in . % increments based on a range of positive identification rates (pirs) from literature on covid- , cov-sars and cov-middle east respiratory syndrome. [ ] [ ] [ ] [ ] [ ] [ ] all simulations were run across days (approximately months) and performed in r version . . . after determining the number of new cases occurring within healthcare facilities, we assessed the healthcare system costs and outcomes of implementing the proposed esc and followed the consolidated health economic evaluation reporting standards (cheers). the cost framework examined the impact of the esc on hospitalization and testing costs while considering the transmission dynamics and importation rates of covid- cases in a hospital setting. a constant daily influx of patients was assumed across days based on general ward patients being admitted across days ( february to february , supplementary table ). the total number of patients being admitted to the isolation wards for undifferentiated fever or respiratory infection or an abnormal chest x-ray according to the esc was taken to be . % ( isolated out of admitted patients, supplementary table ) . a proportion of these, according to the pir, will be covid- positive. all costs presented are in us dollars with no discounting for the year . the net cost of esc is calculated as the total hospitalization costs for the isolation of negative patients subtracted from the total hospitalization costs averted from the isolation of positive cases which would have otherwise been missed by a non esc criteria. for the former, the total hospitalisation cost for the isolation of negative cases was the total number of negative diagnoses at the cost of $ each, as all patients receive coronavirus polymerase chain reaction (pcr) tests and a respiratory isolation room cost (supplementary table ). this represents the costs to the healthcare system which should be minimised as they require no further isolation measures. for the latter, the total costs averted from the isolation of positive cases under the esc was determined by the branching process model with an associated testing and treatment cost each. these covid- positive patients inherit the same initial costs as negative patients at the testing phase and have subsequent treatment costs depending on whether they require intensive care unit (icu) stay with a probability of . % based on patient outcome profiles from literature. table ). patients who required icu received an additional cost for days of intensive care management, followed by the standard respiratory isolation procedures for a non-icu patient at a total of $ (supplementary table ). the sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. at an of . and incubation period (ip) of days, approximate to estimates by wu and colleagues for wuhan, an estimated ( % ci: - ) cases would be prevented over days through esc by isolating patients presenting fever or respiratory symptoms such as cough with their travel and exposure profile not considered (table ) . with an observation of patients being admitted per day into hospital and a corresponding total of across the -day period (supplementary table ), patients would be expected to enter respiratory isolation of which ( % ci: - ) to ( % ci: - ) would be covid- positive, depending on the ( table ) . a total cost between $ . million ( % ci: . - . million) to $ . million ( % ci: . - . million) could be potentially averted from the isolation of these patients. a corresponding cost saving at an of . or greater can be achieved with $ ( % ci: - - ) to $ ( % ci: - ) saved. of note, if the proportion of positive cases is taken to be . %, which represents the upper bound of sars patient identification during the testing period for the epidemic, - the total cost of testing for negative patients is $ . million at this pir. figure a) . a higher causes esc to yield larger cost savings with this difference in cost savings being more pronounced at higher pir values. at a pir of . %, having an of . versus . increases the cost savings by $ with more infections averted ( figure b ) but at a pir of . %, this difference widens to $ . million ( figure a ) with more infections averted ( figure b ). however, provided that the pir is above . %, regardless of , cost savings can be achieved through esc implementation. notably, less than a . % difference was recorded in net cost savings across the of − . at a pir of . %, with the largest change being a -$ decrease in net cost savings at the of . . across all and pir values, changing the ip from to days decreased the net cost savings of esc by an average of -$ . j o u r n a l p r e -p r o o f discussion among the lessons learnt during the sars epidemic of - was the importance of adapting official case definitions to provide effective triage and screening, especially as the definitions are expected to rapidly evolve for a new disease. for the current covid- outbreak, all early diagnosed patients had travelled from china but by the th feb , suspected local transmission was evident therefore negating the usefulness of this travel history . furthermore, as symptom profiles were identified as being very heterogeneous with the two dominant symptoms fever and cough at . % and . % prevalence among patients in mainland china, the expanded screening criteria (esc) was designed to capture all of these patients to reduce the risk of nosocomial transmission. as of february , esc was implemented as an emergency response to operate alongside intense contract tracing. the results demonstrate that provided the positive identification rate (pir) is sufficiently high at % or greater, costs-savings can be created across the values . − . , making the screening strategy sustainable for the healthcare system in the long term. at lower pir vales and low values, the strategy should still be considered by policymakers during the initial part of the epidemic to ensure the majority if not all cases are captured at healthcare facilities. nosocomial transmission should also be prevented through the isolation of these cases at the point of admission during testing with the costs accounted for. the prevention of - covid- infections in a hospital at an of . and incubation period (ip) of days can also prevent transmission within the community and relieve the need for ppe resources which are already under strain. the branching process shows the rapidity of infection spread and highlights the urgency of enhancing hospital surveillance to detect any potential transmission chains when a case is identified, which is already carried out for all atypical pneumonias, some upper respiratory illnesses and hospitalized acute respiratory illnesses. our findings are relevant to cities and highly urbanized regions with well-developed healthcare infrastructure and resources to undertake considerable epidemiological investigation for suspected cases. the costs for areas with fewer resources or different health systems however are likely to be considerably lower but potentially at the cost of a lower pir. a total of cases have been confirmed in singapore to date ( th march ; a full case listing is provided by gov.sg ) with limited local transmission currently suspected. elsewhere, ~ million cases and over deaths have been confirmed across who regions. the analysis performed here can be utilised for all countries regardless of outbreak stage as it can prevent nosocomial transmission at hospitals with incoming cases of local transmission and prevent imported cases from establishing transmission chains altogether. it also supports the general body of literature highlighting the importance of a highly sensitive standardised criteria for case identification in an epidemic involving a new infectious pathogen. for covid- , this has been particularly challenging as it shares symptoms with many respiratory illnesses, making it difficult for practitioners to distinguish positive cases. similar issues already exist for influenza between national and regional surveillance programmes where most use measured or reported fever with cough and/or sore throat. during the initial wave of the influenza a h n pandemic in singapore, serological surveillance on patients from june to october demonstrated that the revised who definition had the highest reported positive predictive value (ppv) in comparison to three others. this variety in case definition across institutions demonstrates the ongoing challenges in place for both diagnosis and surveillance, which can be difficult for practitioners to interpret and implement. for covid- , complete case finding is being prioritised where possible in singapore as ppv will substantially change with increasing disease prevalence. provided the case definition is highly sensitive, it can continue to be rapidly updated with greater specificity over time as symptom profile data continues to be shared and assessments carried out on missed cases, therefore sensitivity at the initial phases should be greatly prioritised. the model can be used by policy makers to estimate the costs saved using esc within the hospital setting for the ongoing covid- pandemic. esc is cost-effective in the long term, especially at higher and pir values, preventing undiagnosed cases from infecting other individuals, which is especially important during the initial outbreak phase or where the epidemic is suppressed from lockdown measures. it should be noted however that there are several limitations in our analysis, primarily due to the ongoing uncertainties regarding the parameters of covid- infection profile and differing operational procedures in hospitals. firstly, the pir is currently unknown and the is likely to vary considerably in space and time across singapore. infectiousness will also vary between hcws and patients which may not be fully explained by the branching process. second, the asymptomatic rate has yet to be determined as part of the continually evolving symptomatic profile. , third, we only considered the hospital costs for the institution and did not account for the productivity and economic losses from unnecessary isolation or those saved from averting of nosocomial cases. this also includes the excess manpower costs from hcws who are currently working long hours to ensure patient wellbeing. fourth, revisions may be required to make these findings applicable to other countries or cities through adaption of the isolation and testing procedures. lastly, the potential for superspreading events, as witnessed in sars, has not been accounted for as the movement patterns of hcw were not modelled. esc should be implemented in the early phase of an epidemic where local community transmission is suspected or where imported cases are being repeatedly recorded. cost-savings or relatively minor costs are expected to occur whilst reducing the risk of uncontrolled outbreaks occurring in nosocomial settings. this is critical considering the ongoing anxiety and strain on healthcare systems worldwide, which are reflected within the public and impossible to fully quantify , . measures such as esc, which can aid national control efforts, should be considered in order to relieve this pressure through the exhaustive testing and isolation of individuals which have good potential to be positive. contributors jtl, bld, lyac designed the experiments, jtl, bld, arc created the models, bld, jtl, lyac, arc, alk, yyd, daf, pat interpreted the results, bld, jtl, lyac, arc wrote the manuscript, alk and lyac performed data collection for the models. singapore population health improvement centre (nmrc/cg/c / _nuhs) to bld and arc. clinician scientist award (csa) funded by the national medical research council to lyac. ethical approval was not required incubation period - days lauer linton [ ] [ ] [ ] [ ] [ ] [ ] all costs are rounded to the nearest ten is greater than , nearest hundred if greater than , thousand if greater than , and hundred thousand if greater than a million. costs are also in usd. an interactive web-based dashboard to track covid- in real time surveillance case definitions for human infection with novel coronavirus clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical characteristics of coronavirus disease in china sars transmission and hospital containment occupational health aspects of emerging infections -sars outbreak affecting healthcare workers mild severe acute respiratory syndrome severe acute respiratory syndrome: lessons from singapore diagnosis and treatment recommendations for pediatric respiratory infection caused by the novel coronavirus an expanded screening criteria may be requisite for novel coronavirus: lesson learnt from sars world health organisation estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship estimating clinical severity of covid- from the transmission dynamics in wuhan, china global surveillance for moh | updates on novel coronavirus ( -ncov) local situation nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study features discriminating sars from other severe viral respiratory tract infections transmission characteristics of mers and sars in the healthcare setting: a comparative study a comparative study of clinical features and outcomes in young and older adults with severe acute respiratory syndrome epidemiological, demographic, and clinical characteristics of cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study predictors of mers-cov infection: a large case control study of patients presenting with ili at a mers-cov referral hospital in saudi arabia comparative study of patients with and without sars who fulfilled the who sars case definition the incubation period of covid- from publicly reported confirmed cases | annals of internal medicine | american college of physicians incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study -the lancet nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study highlights: confirmed cases of local transmission of novel coronavirus infection in singapore investigation of three clusters of covid- in singapore: implications for surveillance and response measures rational use of personal protective equipment (ppe) for coronavirus disease (covid- ) world health organisation revision of clinical case definitions: influenzalike illness and severe acute respiratory infection performance of case definitions for influenza surveillance eurosurveillance | pattern of early human-to-human transmission of wuhan novel coronavirus ( -ncov) the rate of underascertainment of novel coronavirus ( -ncov) infection: estimation using japanese passengers data on evacuation flights indirect health care costs. in: weintraub ws, ed. cardiovascular health care economics indirect costs and cost-effectiveness analysis we declare no competing interest the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.j o u r n a l p r e -p r o o f key: cord- -tm kesum authors: lemos, daniele rocha queiros; d’angelo, sarah mendes; farias, luis arthur brasil gadelha; almeida, magda moura; gomes, ricristhi gonçalves; pinto, geovana praça; cavalcante, josafa nascimento; feijão, levi ximenes; cardoso, ana rita paulo; lima, thaisy brasil ricarte; linhares, pâmela maria costa; mello, liana perdigão; coelho, tania mara; cavalcanti, luciano pamplona de góes title: health system collapse days after the detection of covid- in ceará, northeast brazil: a preliminary analysis date: - - journal: revista da sociedade brasileira de medicina tropical doi: . / - - - sha: doc_id: cord_uid: tm kesum introduction: covid- emerged in late and quickly became a serious public health problem worldwide. this study aim to describe the epidemiological course of cases and deaths due to covid- and their impact on hospital bed occupancy rates in the first days of the epidemic in the state of ceará, northeastern brazil. methods: the study used an ecological design with data gathered from multiple government and health care sources. data were analyzed using epi info software. results: the first cases were confirmed on march , . after days, , cases reported in . % of ceará’s municipalities, with , deaths. laboratory test positivity reached . % at the end of april, a period in which more than daily tests were processed. the average age of cases was (< - ) years, most occurred in a hospital environment ( . %), and % required hospitalization in an icu bed. the average time between the onset of symptoms and death was ( - ) days. patients who died in the hospital had spent an average of six ( - ) days hospitalized. across ceará, the bed occupancy rate reached . % in the wards and . % in the icu. conclusions: the first days of the covid- epidemic in ceará revealed a large number of cases and deaths, spreading initially among the population with a high socioeconomic status. despite the efforts by the health services and social isolation measures the health system still collapsed. the novel coronavirus sars-cov- , the etiological agent of covid- , emerged in wuhan, china in december and quickly spread to other countries , . due to the rapid increase in the number of cases, on march , , the world health organization (who) declared it to be a pandemic . one month after the declaration, more than two million people worldwide had been infected and , deaths had been registered across countries . worldwide, health systems faced the need to adapt to a critical overload on services, and a shortage of health care professionals and personal protective equipment , . in brazil, the first case of covid- was confirmed on february , , and the first death on march , both in the state of são paulo . community transmission was officially recognized in brazil on march , . through may , , there were more than , confirmed cases and approximately , deaths, with a mortality rate of . %. the three most affected states were são paulo ( , deaths), rio de janeiro ( , deaths), and ceará ( , deaths) . the state of ceará in northeast brazil was one of the first to confirm sustained transmission. within days of confirmation of its first case, ceará had registered the third highest number of deaths in the country. the exponential increase in cases and deaths imposed a series of challenges to meet the demand for care, with a real possibility of a collapse of the health services system. the brazilian government enacted social isolation regulations on march (decree , ) and a lockdown on may (decree , ). considerable effort was put into expanding the capacity of emergency services, emergency department care, and laboratory testing, as well as the increasing the number of intensive care (icu) beds . we describe the epidemiological scenario of cases and deaths from covid- and their impact on hospital bed occupancy rate in the first days (february to april , ) of the epidemic in ceará, northeastern brazil. the study used an ecological design to compare confirmed covid- cases and deaths to bed occupancy rates in ceará. in addition, we describe the actions implemented during the first days of the epidemic. data were collected from six different sources: . redcap -database in which all suspected and confirmed cases of covid- were recorded from the beginning of the epidemic until april , ( days after the first known case occurred). surveillance information system that records all cases of severe respiratory infections and related deaths. . e-sus notifica -a system developed specifically to meet the high demand for notifications of covid- , recording mild and moderate cases of the disease that have undergone laboratory investigation. ceará state civil registry -the number and cause of verified deaths. laboratory of public health of ceará -confirmatory laboratory testing results. . unified health system, ceará regulation center -hospital admissions. we followed the case definitions below for suspected cases of covid- : ) an acute respiratory condition characterized by a fever or feverish sensation, even if only reported, accompanied by cough or sore throat or runny nose or breathing difficulty. in the case of children, nasal obstruction was also acceptable in the absence of another specific diagnosis. in the case of the elderly, a reported or diagnosed fever was optional. ) specific worsening criteria such as syncope, mental confusion, excessive sleepiness, irritability, and loss of appetite. ) dyspnea / respiratory discomfort or persistent pressure in the chest or o saturation less than % in room air or bluish color of the lips or face. ) in children, in addition to the previous items, nasal flaring, cyanosis, intercostal circulation, dehydration, or lack of appetite. we followed the case definitions below for a confirmed case of covid- : a suspected case with molecular biology (rt-pcr in real time) detection of the sars-cov- virus or a positive immunological test for antibody detection (rapid or classic serology) or a history of close or home contact with a laboratory-confirmed case for covid- within seven days before the onset of symptoms, and for which it was not possible to perform laboratory testing. the variables used in this study were sex, age group, date of onset of symptoms, whether the subject had been hospitalized, place of hospitalization (public or private), date of hospitalization, the time between first symptoms and hospitalization, whether the patient had been admitted to an intensive care unit, the time between the first symptoms and admission to the intensive care unit, laboratory diagnosis, outcome (discharged with resolved symptoms or death), date and place of death (if occurred), municipality of residence, preadmission signs and symptoms, the ward occupancy rate, and the number (total and occupied) of icu beds on the day the patient was admitted. all data were analyzed using epi info software version . (u.s. centers for disease control and prevention, atlanta, georgia). all ethical principles provided for in the resolution of the national health council (cns-translated) no. , of december , , were respected. the study design was approved by the state secretariat of health of ceará. the first confirmed cases of covid- in ceará were diagnosed on march , , with onsets of symptoms on the th (two cases) and the th (one case). within days of the country's first known case, , cases had been confirmed in . % of brazil's municipalities (figures and ) . of the confirmed cases, , ( . %) were laboratory-confirmed, another , were under investigation and , were confirmed covid- -related deaths. epidemic week had the highest number of reported cases and the peak of deaths. the distribution of cases was initially the most widespread in fortaleza, ceará's capital city, later overtaken by metropolitan municipalities in which the highest incidences were identified (over cases per , inhabitants). the virus also spread through municipalities in the northern region, which also had incidences above cases per , inhabitants. during the -day period, the central laboratory of public health of ceará (lacen-ce) processed more than , molecular biology exams, reaching tests in a single day (april ). the lowest positive rate among the examinations was registered on march ( . %) and the highest on april ( . %). in the first days, the average positivity was . %, increasing to . % and . % over the next and days, respectively (figure ). the first death in ceará was confirmed on march ; within four days another had been confirmed. ten days after that, more deaths had been confirmed. subsequently, the number of confirmed deaths doubled approximately every seven days, reaching the highest single day occurrence on may st ( deaths). females made up a higher percentage than males of reported and confirmed cases ( . %) but deaths occurred in a greater proportion in males ( . %) ( table ) . the same pattern occurred in age groups where a predominance of cases were in people aged to years ( . %), but the percentage of deaths was highest for those over years of age ( . %). the average age of the cases that progressed to death was ( - ) years old, with more than half ( . %) occurring in people table ) . the first days of the covid- epidemic in ceará showed an explosion in the number of cases and deaths, reaching more than , confirmed deaths. in the first days after the detection of the first cases, infections spread most rapidly in the city of fortaleza and municipalities with higher hdi, mainly among users of the supplementary health network. in the following month, infections began to spread to the interior of the state, reaching the periphery of large cities and the most vulnerable social and economic populations. these populations have a higher prevalence of comorbidities, and often have living situations that make effective social isolation unfeasible . this likely contributed to the early exponential increase in the number of cases and deaths. the symptoms described in this study were similar to those reported for the pandemic for other countries . our findings show a predominance of male deaths, as was also reported in china . a recent survey of more than , people in ceará showed that a significant percentage of females perceive themselves to be at risk of covid- , while males reported greater difficulty adhering to social isolation practices . these observations could, in part, explain our findings. at the beginning of the epidemic, due to concerns about the simultaneous increase of seasonal influenza and the possibility of a new dengue epidemic, the ceará health department advised that medical care should only be sought for severe symptoms such as shortness of breath, difficulty breathing, or cognitive impairment , . this initial guidance, together with fears in the population of acquiring infection from attending a health facility, probably contributed to the increase in the number of home deaths. by the beginning of april, there were widespread notices by the ceará health department that everyone, especially those with known risk factors, should seek basic care at the first sign of symptoms. this change reduced the number of home deaths, but also generated a large demand for basic health centers, contributing to the collapse of the outpatient care network. this study had several limitations. we relied on secondary databases from local surveillance systems. further, not all cases with laboratory confirmation were by rt-pcr, but those limitations don't invalidate the results. the brazilian ministry of health published decree . at the end of january, reactivating the interministerial executive group on public health emergency of national and international importance (gei-espii). among other duties, the gei-espii is responsible for implementing preparation measures and the official health surveillance response to the covid- epidemic , . it is noteworthy that despite extensive efforts by health services, social isolation measures were not effective in reducing the speed of disease spread to the pace at which the health care network was expanding. this imbalance led to the collapse of the health system , . development and implementation of effective health service responses to covid- has been challenging, especially in poor countries . in this scenario, it is essential to identify effective drugs for early stages of the disease and to develop an efficient vaccine . a novel coronavirus from patients with pneumonia in china first case of novel coronavirus in the united states coronavirus disease (covid- ) . situation report - . geneva: who; coronavirus disease (covid- ) situation report - the italian health system and the covid- challenge depression, dependence and prices of the covid- -crisis how brazil can hold back covid- portaria nº , de março de . declara, em todo o território nacional, o estado de transmissão comunitária do coronavírus (covid- ) secretaria de vigilância em saúde. sistema nacional de vigilância em saúde - boletim epidemiológico especial coe covid- : brasilia decreto nº . , de de março de . intensifica as medidas para enfrentamento da infecção humana pelo novo coronavírus distribuição espacial do índice de desenvolvimento humano, da infecção pelo hiv e da comorbidade aids-tuberculose: brasil clinical features, laboratory characteristics, and outcomes of patients hospitalized with coronavirus disease (covid- ): early report from the united states severe acute respiratory syndrome coronavirus (sars-cov- ) and corona virus disease- (covid- ): the epidemic and the challenges covid- in the state of ceará: behaviors and beliefs in the arrival of the pandemic deep impact of covid- in the healthcare of latin america: the case of brazil translating transmissibility measures into recommendations for coronavirus prevention covid- in brazil: advantages of a socialized unified health system and preparation to contain cases decreto nº . , de de janeiro de . dispõe sobre o grupo executivo interministerial de emergência em saúde pública de importância nacional e internacional -gei-espii intervenções não farmacológicas para o enfrentamento à epidemia da covid- no brasil modeling and forecasting the covid- pandemic in brazil the covid- epidemic the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak lpgc is recipient of a fellowship for research productivity granted by the brazilian national council for scientific and technological development (cnpq/brazil). the authors declare there are no conflicts of interest. key: cord- - s kbs authors: malhotra, rajesh; gautam, deepak; george, jaiben; goyal, devansh; ansari, mohammed tahir title: conducting orthopaedic practical examination during the covid- pandemic date: - - journal: j clin orthop trauma doi: . /j.jcot. . . sha: doc_id: cord_uid: s kbs background: as the coronavirus disease (covid- ) pandemic is expected to stay for a longer time, educational activities including residency training have gradually resumed with the aid of virtual tools. in addition to continuing the residency education during covid- , it is also important to conduct their examination so that the graduations of final year residents are not delayed. the conventional exam pattern involved clinical case presentations and required resident interaction with a number of patients. however, in view of the covid- pandemic we conducted a “zero-patient contact virtual practical exit examination” for orthopaedic residents. methods: in order to replicate the conventional exam case-scenarios, clinical cases were prepared in a digital presentation format. the candidate used n- facemasks and gloves, and adequate social distancing was maintained in the examination area. we also designed a - item questionnaire aimed at assessing the quality and satisfaction with the exam pattern. results: the mean score for overall satisfaction with the virtual pattern was . (out of ) in examiner group while it was . in examinee group. higher scores were also reported for questions related to safety of the exam, relevance and quality of the virtual cases, etc. the mean total feedback score for the examiner and examinee group was and . respectively (out of ). conclusion: orthopaedic residency end-of-training examinations can be successfully conducted during the covid pandemic, and we hope our experience will be helpful to other residency programs. introduction the coronavirus disease (covid- ) pandemic has affected the lives of millions of individuals globally . in india, a nationwide lockdown was implemented towards the end of march leading to disruption of routine hospital services and residency training curriculum. despite continued efforts to stop the spread of covid- , the number of covid- cases continue to rise in the country, as a result of which there has been a paradigm shift from "living after covid" to "living with covid- " . since it is difficult to predict an end to the pandemic, many services including educational activities have gradually resumed taking into account the covid- situation [ ] [ ] [ ] [ ] [ ] [ ] [ ] . like many other residency programs, our department continued the majority of educational activities during the pandemic through online portals , , . we also successfully conducted the end-training evaluation of the graduating residents. in this article, we would like to share our experience in conducting the orthopaedic residency exit examination during this pandemic. the conventional examination pattern involved clinical case presentations and viva voce. each candidate was traditionally allotted clinical cases on the day of examination including one long case and short clinical cases. the candidate was expected to elicit history, perform clinical examination and present the cases to the examiners following which there was a table viva. however, the covid- pandemic posed a few challenges that made conducting the practical exams in a conventional manner unseemly, difficult and impractical. a total of seven candidates completed the tenure of residency training and were appearing for the examination in june and therefore clinical cases were needed. so, the first challenge was to arrange a relatively large number of patients with varied diagnoses who could be kept for examination. with the out-patient department shut since last two and a half months and with various travel restrictions in place, arranging cases was difficult. the second challenge was to ensure the safety of both the examinees and the examiners who would be coming in close contact with their patients. to overcome both these challenges, our department planned to conduct a "zero-patient contact virtual practical exit examination" for orthopaedic residents. in order to replicate the conventional exam case-scenarios, clinical cases were prepared by were prepared, each consisting for one major case and short cases. an attempt was made to include at least one common type of short case in each group. the collection was mailed to the external examiners in a password protected file. the external examiners selected sets out of the available sets, to be kept for examination. each set was given a numeric code and random allocation of the sets to the candidate was ensured by chit-pull system on the day of exam. a mock test was conducted two weeks before the date of the exam so that the candidates (figure a&b) . the case discussions carried marks and were followed by table viva for marks on x-rays, osteology, orthopedic instruments, and, orthoses & protheses, which were conducted in a conventional manner but with use of hand sanitizers, gloves and adequate social distancing measures. after each candidate, the used instruments or materials were sanitized before the other candidate entered the examination room to avoid fomite transmission. if a candidate is from a hotspot or containment zone, the virtual examination can also be conducted using web applications like zoom™ or webex™ so that candidates can take the exam from home (we have conducted the examination in similar fashion for the fellows at our institution in arthroplasty, arthroscopy and musculoskeletal oncology). to evaluate the quality of examination pattern and level of satisfaction amongst the examinees and the examiners, we designed a questionnaire aimed at assessing the feeling of the study has a few limitations (table ) . first, it is a pilot study and the number of participants from examiner as well as examinee group is small. a study with larger number of participants across the different states is needed to establish its reproducibility and value. we believe that the proforma designed by us could help capture the relevant data to that end. secondly, good quality photographs and/or videos may not be available at other places. in x-ray (e) along with the potential questions that can be asked by examiner (shown in the notes section which will only be visible to the examiner when the slide is in presenter mode). a video file was used to demonstrate telescopy test (c) and interactive tools were used to draw bryant's triangle (d) and describe x-ray findings (e). who. who director-general's opening remarks at the media briefing on covid- - evaluation of the orthopedic residency training program in saudi arabia and comparison with a selected canadian residency program residency programs and diversity: dilemmas and challenges, an international perspective use of standardized patients in clinical assessments: recent developments and measurement findings external examiners were sent the collection as password protected file with instruction to select each group (long as well as short) given number to as per the number of candidates appearing in the exam random allocation of the group numbers by chit-pull method for major and short cases separately to each candidate . were you comfortable with the seating arrangement made for you in the exam room? . do you think that the case details given in the digital presentation was sufficient enough to make differential diagnoses? . do you think that the clinical photographs were good enough to elicit the clinical findings? . do you think that the radiological pictures were good enough to reach up to a provisional diagnosis? . do you think that the interactive touch screen was helpful in compensating the absence of actual clinical examination? . do you think that the examination pattern was relevant to the type of academics that you had received/given in your institute?("received" for the examinee; "given" for the examiner) . would you like to recommend such type of examination pattern in similar situations like pandemics? . do you think a mock test helps/helped in preparing for this pattern of examination? * ("helped" for examinee; "helps" for examiner) . rate your overall satisfaction in ( to ) for the 'zero-patient contact virtual practical examination' key: cord- -h r jpy authors: wang, tsung-hsi; wei, kuo-chen; jiang, donald dah-shyong; chiu, chan-hsian; chang, shan-chwen; wang, jung-der title: unexplained deaths and critical illnesses of suspected infectious cause, taiwan, – date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: h r jpy we report years’ surveillance data from the taiwan centers for disease control on unexplained deaths and critical illnesses suspected of being caused by infection. a total of cases were reported; the incidence rate was . per , person-years; and infectious causes were identified for cases ( %). i n , the outbreak of severe acute respiratory syndrome (sars) demonstrated that the world has become a global village in which human risk for exposure to different kinds of biological hazards is increased through frequent travel and commercial activities ( ) ( ) ( ) ( ) ( ) . historically, emerging diseases occur abruptly in outbreaks of unknown cause. although various efforts have been proposed and conducted to analyze secondary data periodically ( ) ( ) ( ) ( ) , they generally provide information for the less urgent decision making in health policy and may not be in time for infectious disease control. thus, a task force is needed to provide timely and accurate diagnosis for early control of any potential epidemic infection, especially in a newly developed country like taiwan, where the healthcare resources may not be evenly distributed and autopsy for diagnosis is not widely accepted culturally. in , the taiwan centers for disease control collaborated with academic institutions, medical examiners, local health authorities, and experts from different fi elds to establish a nationwide surveillance center for outbreak and unexplained death investigation due to unknown infectious causes (counex) (figure) . this effort was to build local health authorities, hospitals, or clinics report suspected infection-related cases through the "notifiable infectious disease surveillance system," "syndromic surveillance system," and toll-free notification hotline figure. flow of information and decision making for reported cases of unexplained death or critical illness. *if unexplained infectious causes were suspected, counex mobilized an investigation team including experts, fi eld epidemiology training program members, public health workers from the local branch of taiwan centers for disease control (tcdc), and public health authorities to proceed with further fi eld investigation. tcdc was in charge of the investigation. †cases were categorized into > of the following clinical syndromes: acute neurologic (encephalitis, meningitis), acute respiratory (pneumonia), acute hemorrhagic, acute diarrhea, acute jaundice (hepatitis), acute heart (myocarditis, pericarditis, endocarditis), and acute kidney-related. for every reported case, counex investigators usually selected diagnostic tests relevant to a particular syndrome (www.cdc.gov.tw). additional tests were prescribed if needed. the hospital laboratories were requested to save all remaining clinical specimens, including biopsy specimens, obtained from clinical management and send them to our reference laboratories, if indicated. ‡if an autopsy was performed, whenever possible tissue specimens were examined by pathologists of tcdc-designated medical centers and the forensic department of the ministry of justice to ensure the accuracy of the fi nal diagnosis. specimens were also sent for microbiologic cultures and tests as well as toxicologic examination for trace toxic chemicals, if needed. §all laboratory results and clinical, epidemiologic, and pathologic data were sent to the expert committee to determine if the etiologic agent could fully or most likely explain the disease. otherwise, cases were categorized as unexplained. in general, histopathogic examination was the major evidence for determining cause. if casepatients could not be autopsied within hours of death, laboratory results would be the most useful information for identifi cation of cause of death. taiwan's capacity for detecting and responding to uncommon and unrecognized pathogens, which was conceptually the same as that of the study of hajjeh et al. ( ) . we defi ned the surveillance case-patient as a previously healthy resident who died or was admitted to a hospital with a lifethreatening illness possibly caused by infection of unidentifi ed etiology. usually the death occurred within days of the patient's admission. patients were excluded if the cause of death was noninfectious. a life-threatening illness was defi ned as any illness requiring admission to an intensive care unit or reported as being critical. an infectious disease is generally suspected if the case-patient has > of the characteristics such as fever, leukocytosis, histopathologic evidence of an acute infectious process or more specifi c symptom patterns, or infection precipitating adult respiratory distress syndrome, renal failure, or sepsis. a total of cases were reported during - , for an annual average rate of . cases per , persons. the annual incidence rates varied by year and among branches of taiwan centers for disease control (table) . the highest rate was in the eastern branch, where surveillance was conducted in a well-defi ned population of ≈ , persons. ninety-fi ve ( %) of the case-patients died. for ( %) of those who died, an autopsy was performed, a rate much higher than the national autopsy rate of < % ( ). the mean age of case-patients was . years. the incidence rates varied by age group; it was highest in those - years of age, followed by those < - years, and then - years, with . , . , and . per , person-years, respectively. men had a higher incidence rate than women ( . vs. . per , person-years). approximately % of case-patients and % of patients with cases of infection had a history of animal contact; % of case-patients and % of infection casepatients had a history of travel outside taiwan within the previous months. the most common initial syndromes were acute respiratory ( %), acute neurologic ( %), and acute diarrhea-related syndrome ( %). initially, patients had acute heart-related syndrome, and had acute kidney-related syndrome; both of these syndromes had a % case-fatality rate. the online appendix table ( www.cdc.gov/eid/ content/ / / -appt.htm) lists all the infectious pathogens and noninfectious causes identifi ed among fatal cases. one third were related to bacterial infection and one fourth to viral infection; remained unclassifi ed. the proportion of explained cases was lower among patients who survived ( %) than that among patients who died ( %). the proportion of explained cases was also higher for patients who underwent autopsy ( %) than for nonautopsied patients ( %) but not statistically signifi cantly so. explained cases were similar to unexplained cases in terms of patient age and interval between dates of disease onset and report (median . and . days, for explained and unexplained cases, respectively). although the overall case-fatality rate was %, patients were more likely to die if they had multiple organ system involvement. we have established the infrastructure needed to detect critical and fatal cases of unknown causes; such a surveillance system is essential to identify early potential infectious threats in a period of globalization and increasing travel between countries. the contributions of our surveillance system are demonstrated by early detection and control of at least outbreaks of serious viral diseases: hantavirus pulmonary syndrome, rabies, and sars. in , a family cluster occurred in huanlian city; dyspnea, cough, leukopenia, and pulmonary edema developed in both parents, who died. their -year-old daughter was also ill, but she survived. counex quickly intervened, and hantavirus pulmonary syndrome was confi rmed by positive serologic test results, which led to an early control of local rodents and spread of the disease. taiwan has been free of human and animal rabies since . however in , a -year-old woman from mainland people's republic of china was admitted to a hospital because of diffi culty in swallowing, fear of wind (aerophobia), and numbness of the arms. her condition was reported to the surveillance system as suspected rabies. our emerging infectious diseases • www.cdc.gov/eid • vol. , no. , october ( ) and approximately the midpoint of this study period, included all people in the age groups under surveillance at the various sites and were used to calculate the incidence rate. personnel quickly confi rmed the diagnosis by reverse transcription-pcr and dna sequence analysis of the samples from cerebrospinal fl uid, saliva, and trachea while the patient was still alive ( ) . the patient had been bitten by a domesticated dog in mainland china months earlier. during the sars outbreak in , the surveillance system received reports of cases; autopsies were performed on patients. as a result, the correlation between clinical course and pulmonary pathology at different stages of the disease was possible, and corroborative evidence for control measures was provided ( ) . had the surveillance system for unexplained death and critical illness not functioned normally during these outbreaks, more people in taiwan would have been ill and died from the diseases because of the high population density on this island. this system was particularly useful for infection control at remote regions with limited resources. most physicians in the rural eastern part of the country have less access to consultation and referral to other specialties in medical centers and teaching hospitals. thus, they rely more on this kind of surveillance system for early detection of potential infectious threats. this was especially important for acute unexpected deaths, as was demonstrated by a higher incidence and autopsy rates in eastern taiwan. throughout this project, we have increased the autopsy rate and established a population-based bank of specimens for future research. this collection could provide a better opportunity for corroboration or refutation of any previous diagnosis of infectious disease. this improved decision making in regard to control of infections was demonstrated in november , when infl uenza virus (h n ) was diagnosed in a patient who had a previous misdiagnosis of sars ( ) . because emerging and reemerging infectious diseases may quickly travel between different countries, the system is becoming more crucial for early detection and control of potential health hazards. the system depends on close cooperation among different disciplines and staff from different agencies. thus, education, empowerment, and good feedback incentives should be continually offered to keep this system sustainable. this work was supported in part by taiwan centers for disease control grant no. doh -dc- . dr t.-h. wang is the head of the public relations offi ce of taiwan cdc. she was the previous coordinator of counex and conducted investigations for infectious disease outbreaks. her research interests include governmental strategic planning and for-mulation and evaluation of response measures for public health disasters. control measures for severe acute respiratory syndrome (sars) in taiwan update: outbreak of severe acute respiratory syndrome⎯worldwide severe acute respiratory syndrome-singapore evidence of airborne transmission of the severe acute respiratory syndrome virus optimizing severe acute respiratory syndrome response strategies: lessons learned from quarantine addressing emerging infectious disease threats: a prevention strategy for the united states. atlanta: us department of health and human services unexplained deaths due to possibly infectious causes in the united states: defi ning the problem and designing surveillance and laboratory approaches. the unexplained deaths working group the role of postmortem examination in medical education retrospective validation of the prospective surveillance of unexplained illness and death due to potentially infectious causes surveillance for unexplained deaths and critical illnesses due to possibly infectious causes institute of forensic medicine. mobilization of forensive medicine business molecular-biological analysis of the fi rst imported rabies case in taiwan evolution of pulmonary pathology in severe acute respiratory syndrome fatal infection with infl uenza a (h n ) virus in china all material published in emerging infectious diseases is in the public domain and may be used and reprinted without special permission; proper citation, however, is required.use of trade names is for identifi cation only and does not imply endorsement by the public health service or by the u.s. department of health and human services. key: cord- -re w d authors: sanville, bradley; corbett, rebecca; pidcock, wesley; hardin, kaitlyn; sebat, christian; nguyen, minh-vu; thompson, george r; haczku, angela; schivo, michael; cohen, stuart title: a community transmitted case of severe acute respiratory distress syndrome due to sars cov in the united states date: - - journal: clin infect dis doi: . /cid/ciaa sha: doc_id: cord_uid: re w d nan the current novel coronavirus (sars cov ) outbreak, which was identified in december in wuhan, hubei, china has spread rapidly causing a significant public health crisis worldwide . the focus of public health measures in the united states has been on individuals with known at risk travel or contacts with at risk individuals . while person-toperson transmission without clear exposure has been observed in other countries , we present a case of the first community transmission of sars cov in the united states. a patient in their s presented to an outside facility with - days of flu-like symptoms. chest x-ray upon admission showed a right upper lobe consolidative process with airbronchograms ( figure ) . computed tomography revealed a dense consolidation with airbronchograms in the right upper lobe with minimal areas of ground glass, primarily in the right middle lobe. the remaining lung parenchyma was normal in appearance. within hours of admission, her respiratory status deteriorated, and she required intubation. followup imaging showed bilateral dense alveolar filling. she progressed to develop the acute respiratory distress syndrome (ards) with refractory hypoxemia requiring a fraction of inspired oxygen (fio ) as high as % with a positive end expiratory pressure (peep) of despite intermittent neuromuscular blockade. she developed septic shock requiring large volume crystalloid resuscitation and high dose norepinephrine. antibiotics were expanded to linezolid, piperacillin-tazobactam, and azithromycin. she underwent bronchoscopy with report from the treatment team of negative bacterial cultures after two days. a respiratory viral panel was in process at time of transfer. the patient was transferred to our facility for consideration of extracorporeal life support (ecls) given refractory hypoxemia on hospital day . upon arrival the patient had a heart rate of beats per minute and a temperature of . °c. the blood pressure was / , which was maintained by a norepinephrine drip at . mcg/kg/min. peripheral saturation of oxygen was % on an fio of %, respiratory rate of breaths per minute, a peep of the patient was immediately placed on droplet and contact precautions, and a respiratory viral panel, respiratory culture, and blood cultures sent. she underwent prone positioning and therapeutic paralysis with cisatracurium to maintain ventilator synchrony for treatment of her severe ards. a vasopressin infusion was started for further blood pressure support. given her critical condition in light of the current outbreak, a suspicion for a potential sars cov infection was raised. but the patient had no travel to high-risk countries and no contact with an individual with high-risk travel thus, as she did not meet the current centers for disease control (cdc) criteria, testing was not pursued by public health officials. a sars cov infection was therefore low on our initial differential diagnosis and a typical bacterial infection was thought to be more likely. to date, no source of exposure has been identified for this patient. therefore, we conclude that she must have had community acquired disease. although her course was complicated by acute renal failure, dialysis was never required and she did not require ecls. she improved clinically following a week of therapy, with a significant reduction in ventilator support and interval improvement in her oxygenation and chest radiograph findings ( figure ). she was successfully extubated days after her hospital transfer and is currently in as a result of the positive sars cov test, healthcare workers who were exposed to the patient were required to undergo home quarantine with symptom and fever monitoring. two healthcare workers in contact with the patient at the outside hospital have subsequently tested positive for sars cov . no transmission has been noted to healthcare workers at our institution. while the majority of covid- cases were identified within our patient's age group years), only . % of severe cases were from this age group. those over the age of comprised . % of severe cases , . in a large review of , cases from china the authors reported % of all cases meeting critical illness (i.e. shock, respiratory failure, and/or multi-organ failure) with a case-fatality rate of % in that subgroup . health care personnel that became infected suffered a similar amount of severe and critically ill cases as the general population. overall, these reviews note a case fatality rate of . - . %, though this may be considerably lower when accounting for a likely large number of mild or asymptomatic patients that were not tested , , dewit and colleagues from the nih, gilead, and columbia university successfully treated rhesus macaques against a model of mers . whether remdesivir is effective against human covid- is not known. the ability to provide early testing and diagnosis would certainly accelerate clinical trial efforts to investigate this compound. as will any novel infection, our knowledge evolves over time as more data from affected individuals is collected and analyzed. given changes in epidemiologic risk and potential for atypical presentations, the challenge for clinicians to identify whom to test becomes more difficult. this virus has a prolonged incubation time ( . - . days in the most optimistic estimate of chinese patients) with a wide range of disease severity . as we have reviewed, its radiographic appearance can be quite varied both in time from symptom onset and overall appearance. a wide variety of symptomology and radiographic appearances create difficulty for providers to identify covid- and differentiate it from other more common respiratory infections. it has also been shown that human coronaviruses persist on inanimate surfaces for up to days, thus, can be picked up without close contact to an infected person . as noted in a recent editorial, diagnosis becomes even more difficult considering the likelihood of a large number of mild or asymptomatic patients who are not formally identified with a sars cov infection , . because there are individuals in the community that are not manifesting severe enough symptoms to warrant presenting to healthcare providers, we should expect community spread to occur more frequently, challenging our ability to adequately contain the spread of sars cov . our case has influenced national health policies for revising screening criteria. nonetheless, to tackle the outstanding burning issues (true prevalence and mortality rate, impact on update and interim guidance on outbreak of novel coronavirus ( -ncov) a locally transmitted case of sars-cov- infection in taiwan evaluating and reporting persons under investigation (pui) ct imaging features of novel coronavirus ( -ncov) clinical characteristics of coronavirus disease in china time course of lung changes on chest ct during recovery from novel coronavirus (covid- ) pneumonia covid- ): relationship to duration of infection characteristics of and important lessons from the covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention unique epidemiological and clinical features of the emerging novel coronavirus pneumonia (covid- ) implicate special control measures the novel coronavirus outbreak -a global threat epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study prophylactic and therapeutic remdesivir treatment in the rhesus macaque model of mers-cov infection coronaviruses -drug discovery and therapeutic options the nucleoside analog gs- strongly inhibits feline infectious peritonitis (fip) virus in tissue culture and experimental cat infection studies incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents covid- -navigating the uncharted presumed asymptomatic carrier transmission of covid- key: cord- - hn wui authors: nor, mohd basri mat; richards, guy a.; mcgloughlin, steve; amin, pravin r. title: pneumonia in the tropics: report from the task force on tropical diseases by the world federation of societies of intensive and critical care medicine date: - - journal: journal of critical care doi: . /j.jcrc. . . sha: doc_id: cord_uid: hn wui abstract the aetiology of community acquired pneumonia varies according to the region in which it is acquired. this review discusses those causes of cap that occur in the tropics and might not be readily recognizable when transplanted to other sites. various forms of pneumonia including the viral causes such as influenza (seasonal and avian varieties), the coronaviruses and the hantavirus as well as bacterial causes, specifically the pneumonic form of yersinia pestis and melioidosis are discussed. in general, community acquired pneumonia (cap) is caused by pathogens that are common to all geographical areas; s. pneumoniae, viruses, chlamydia, mycoplasma, legionella and less commonly s. aureus and k. pneumoniae. however some organisms are endemic to specific regions and early recognition and awareness of these is critical to the diagnosis and to a favourable outcome. this is no less the case in residents of or travellers to tropical regions. this review discusses those that are most prevalent and which can cause potentially lethal infections. in adults, respiratory viruses account for % to % of cap and the most common of these are influenza, parainfluenza, adenovirus and respiratory syncytial viruses (rsv) [ , ] . influenza viruses which are classified by their core proteins (i.e. a, b or c) and belong to the family orthomyxoviridae, cause predominantly respiratory disease in humans. influenza type a and b account for n % of viral pneumonia in adults whereas influenza c infections generally cause mild respiratory disease and are not thought to cause epidemics [ ] . the close contact between humans and animals in tropical areas may enhance the genetic reassortment of influenza viruses which when disseminated into the human population may result in pandemics [ ] . other important respiratory viruses in the tropics that can cause severe pneumonia are influenza a h n , avian influenza viruses (h n , h n ), severe acute respiratory syndrome associated coronavirus (sars-cov) and the middle east respiratory syndrome coronavirus (mers-cov) [ , ] . standard, droplet and contact precautions are recommended for these selected acute respiratory infections and whenever possible patients should be placed in airborne infection isolation rooms. influenza viruses have been associated with annual epidemics and intermittent pandemics throughout the world. despite the absence of a winter season in the tropics, consistent seasons of infection have nevertheless been observed. the composition of the antigenic surface glycoproteins of the influenza virus, hemagglutinin (h) and neuraminidase (n) are used for subtyping, resulting in names like h n and h n . antigenic drift represents the minor changes of h and n side chains and is responsible for seasonal epidemics. influenza pandemics occur less frequently and these result from major changes in antigenic structure in the envelope glycoproteins (antigenic shift) resulting from reassortment of various viruses such as swine, equine and human varieties. contemporary geographic distributions show that east, south and southeast asia influence unduly the evolution of seasonal influenza a (h n ), exporting most of the evolutionarily strains that ultimately spread globally. the obvious role of asia in h n 's evolution has been ascribed to the seasonal nature of influenza in temperate climates [ ] . seasonal influenza is an acute respiratory illness caused by influenza a or b viruses. given that these infections including the pandemic variety h n now occur in all parts of the world they will not be discussed in any detail in this treatise. avian influenza viruses (e.g. h n and h n ) have emerged relatively recently and cause disease in humans and currently remain a potential threat, particularly in the southeast asia [ , ] . the first association of avian influenza h n with clinical respiratory disease was in in hong kong, as a human infection transmitted from birds. later h n re-emerged in humans in as a highly pathogenic virus resulting from antigenic drift to which a larger number of species were vulnerable and conferring resistance to adamantine antivirals [ ] . as yet, human to human transmission is rare and the vast majority of cases are related to contact with birds. travellers who have a history of recent exposure to birds in affected areas and who present with otherwise unexplained ards should be screened. h n has been reported from countries and is currently most prevalent in egypt [ ] . as of august , from laboratory confirmed cases of influenza a h n , ( %) patients have died [ ] . . . . . clinical. following exposure, the incubation period is seven days or less. clinical characteristics include fever, respiratory illness, pneumonia, diarrhoea and encephalopathy. laboratory abnormalities may include leukopenia, lymphopenia, thrombocytopenia and elevated serum aminotransferases. complications include multi-organ failure, pulmonary haemorrhage, pneumothorax and pancytopenia. radiographic findings include diffuse or patchy infiltrates and segmental or lobar consolidation. progression to respiratory failure is associated with diffuse bilateral ground-glass infiltrates. . . . . diagnosis. a comprehensive travel and epidemiological history is critical in suspected cases. patients who meet clinical and epidemiological criteria should be tested for h n avian influenza infection. diagnosis can be established by rrt-pcr or viral culture of respiratory specimens. serological testing is not helpful in the acute setting but useful for retrospective diagnosis [ ] . . . . . introduction. another avian influenza virus, h n , derived from reassortment of at least four avian influenza viruses, has caused severe pneumonia in some patients. it emerged in and originated from eastern china [ ] . additional cases have been detected in mainland china, hong kong, macao, taiwan and malaysia. similar to h n this virus occurs primarily in bird handlers or following recent exposure to live poultry or potentially contaminated environments. to date, there is no evidence of sustained human-to-human transmission. the incubation period has been estimated to be from to days, but can be as long as days. presenting signs and symptoms may include fever, cough, dyspnoea, headache, myalgia and malaise. patients present with lrti which may progress rapidly to pneumonia and potentially acute respiratory failure, ards, septic shock, multi-organ failure, rhabdomyolysis and encephalopathy. severe illness and fatal outcome have been frequently observed in pregnant women, older persons and those with chronic illnesses [ , ] . as of mid-august , a total of laboratory-confirmed cases have been reported to who including ( %) deaths [ ] . real-time reverse-transcriptase polymerase reaction (rrt-pcr) for avian influenza a h n is the preferred diagnostic test, since rapid antigen tests may be insensitive for novel or avian influenza strains. nasopharyngeal swabs or aspirates should be obtained for testing [ ] . vaccination is the best method of protection during a pandemic however if not available or if a patient contracts influenza then antiviral therapy is indicated in certain circumstances. currently two classes of antiviral drugs are available for the treatment and prevention of influenza: the neuraminidase inhibitors (oseltamivir, zanamivir and peramivir) and the adamantines (amantadine and rimantadine) [ ] . the adamantines block m protein channels and inhibit the uncoating of the influenza virus after it enters the host cells. they are only active against influenza a not b viruses and due to a marked increase in resistant isolates, many countries do not recommend that they be used except in combination with neuraminidase inhibitors in selected case. therefore, adamantines are not recommended for treatment of novel influenza a virus infections [ ] . neuraminidase inhibitors are recommended to treat patients hospitalised with seasonal influenza, inclusive of h n , and avian influenza (h n and h n ) infections. in adults, the dose of oseltamivir is mg orally twice daily; inhalational zanamivir is mg (two inhalations) twice daily; and peramivir is mg iv once daily. in patients with severe influenza, there are insufficient data to recommend the use of inhaled zanamivir or iv peramivir as empirical therapy. as such empirical treatment with oseltamivir should be started as soon as possible for all hospitalised cases associated with severe disease, and for confirmed and probable outpatient cases. early therapy (especially within h of illness onset) can shorten the duration of the symptoms in high-risk patients and reduce secondary complications associated with influenza. the recommended duration of antiviral therapy is five days for uncomplicated disease. in severely ill hospitalised or immunocompromised patients, longer courses of treatment (e.g. days) should be considered. in these circumstances, a higher dose of oseltamivir has been recommended by some experts ( mg twice daily) in adults with normal renal function. however, oral oseltamivir has been reported to be adequately absorbed in critically ill patients and higher dosing may not provide additional clinical benefit. in obese patients, studies have demonstrated adequate exposure to oseltamivir carboxylate (active metabolite of oseltamivir) with the mg twice daily dosing regimen. limited data suggest that oseltamivir administered by oro/naso-gastric tube is well absorbed in critically ill patients, including in those on continuous renal replacement therapy and ecmo [ ] . for patients who cannot absorb or tolerate oral oseltamivir, the use of iv peramivir or investigational iv zanamivir should be considered. it is possible that novel influenza a viruses may become resistant to oseltamivir and peramivir during treatment but remain susceptible to zanamivir. in resistant infection, zanamivir is the preferred agent and can be delivered by inhalation or by the intravenous route. corticosteroid treatment is controversial with some reports showing benefit and others harm. in all cases of severe influenza whatever the type bacterial coinfection is possible and as such, appropriate antimicrobial treatment directed toward those organisms causing bacterial acute community acquired pneumonia, and mechanical ventilation as required can reduce the mortality rate. extracorporeal membrane oxygenation (ecmo) has been utilised in some patients with ards and one study showed a possible mortality benefit in patients who were referred to a specialised ecmo centre [ ] . ongoing monitoring for antiviral resistance among avian influenza a viruses is crucial. some evidence of antiviral resistance has been reported in highly pathogenic avian influenza (hpai) "asian h n viruses" and "asian h n viruses". future treatment strategies may make use of new generation broadly reactive monoclonal antibodies. in addition, a viral rna polymerase inhibitor, favipiravir is registered for the treatment of pandemic influenza in japan [ ] . potentially life-threatening coronavirus infections are caused by the severe acute respiratory syndrome associated coronavirus (sars-cov) and the middle east respiratory syndrome coronavirus (mers-cov) [ ] . cases of sars were first noted in guangdong province, china in november . the illness spread to countries in north america, south america, europe and asia before the outbreak was contained. sars-cov is a novel coronavirus that jumped the species barrier from civet to man. based upon clusters of cases in hong kong and canada, sars-cov is transmitted by means of close person-to-person contact via droplets or fomites. it has been suggested that airborne and faecal-oral transmissions is also possible [ ] . the incubation period is two to seven days and approximately % will develop symptoms by days. this is followed by an influenza like (ili) prodrome (stage ) of high fever (n °c), malaise, headache, myalgia and chills without upper respiratory tract symptoms. about % to % of patients have diarrhoea. the prodrome may last for three to seven days after which involvement of the lrt (stage ) occurs and this begins with a non-productive cough and dyspnoea. this may progress to acute hypoxaemia with radiologic progression to pneumonia. about % of patients progress to stage and develop features of ards that may require mechanical ventilation. the chest radiograph shows diffuse interstitial infiltrates characteristics of ards. risk factors for poor outcomes include older age, underlying comorbidities such as diabetes, atypical symptoms and elevated lactate dehydrogenase on admission [ , ] . the diagnosis is based on clinical, epidemiological and laboratory criteria and case definitions have been developed by the centers for disease control and prevention. the reverse transcriptase polymerase chain reaction (rt-pcr) and serum antibodies as measured by enzyme-linked immunosorbent assay (elisa) testing, are two reliable tests for diagnosis. however serologic testing during the acute illness has limited value since antibodies typically develop several weeks into the illness. there is no specific treatment recommended except for supportive care. the benefit or otherwise of antiviral drugs or glucocorticoids has not been established for treatment of sars [ ] . mers is a newly recognized highly lethal respiratory illness caused by mers-cov. mers-cov is a zoonotic virus and studies have shown that humans are infected through contact with infected dromedary camels or infected people. the disease was first reported in saudi arabia in june [ ] . so far, all cases have been linked through travel to, or residence in, countries in and near the arabian peninsula. outside the arabian peninsula, the largest known outbreak of mers occurred in the republic of korea in which was also linked to a traveller returning from the arabian peninsula. a total of confirmed patients with mers-cov infection across hospitals were identified. eightytwo ( . %) of the cases were patients exposed in hospitals, ( . %) were caregivers, and ( . %) were hospital staff [ ] . a total of . % of the cases were linked to five super-spreaders, all of whom presented with pneumonia and were in contact with hundreds of people. since , although countries have reported cases of mers-cov, % have been reported by saudi arabia. mers-cov can infect anyone and patients have ranged in age from b to years old. the incubation period for mers is usually about to days, but can range from to days. most patients present with a severe acute respiratory illness manifested by shortness of breath but preceded by fever, cough, myalgia and arthralgia. rapid progression to pneumonia may occur within the first week, often requiring mechanical ventilation and other organ support such as renal dialysis [ ] . patients in the korean outbreak had fever and chills as the most common symptoms but gastrointestinal symptoms including diarrhoea and nausea/vomiting have also been reported. as of august , % of laboratory-confirmed mers-cov cases reported to who have died. studies have shown that older age and pre-existing comorbidities are important risk factors for death [ , ] . those with mild symptoms (such as cold-like symptoms) or no symptoms at all usually recover. case definitions have been developed by who, the centers for disease control and prevention (usa) and the ministry of health of saudi arabia. confirmation of the diagnosis is by rrt-pcr performed on respiratory secretions. currently, there is no vaccine to prevent mers-cov infection and no proven antiviral therapy. management includes preventive daily hygiene measures and travel precautions. thereafter symptomatic and supportive therapy is required [ ] . the hantavirus is a member of the bunyaviridae family and the genus includes n different viruses that manifest with a wide spectrum of clinical illnesses [ ] . the pathogenesis of hantavirus is related to the targeting of vascular endothelial cells, alveolar macrophages and follicular dendritic cells, as well as the renal tubular epithelium [ ] . the induction of vascular or capillary leak is a key component of the pathogenicity [ ] . transmission to humans is via contact with, or inhalation of aerosolised urine, saliva or faeces of the rodent host (family muridae). as it is predominately a rural disease, risk factors include farming, land development and camping, however due to the method of inoculation, it is usually acquired indoors [ ] . person to person transmission has been documented previously in some subtypes so respiratory precautions are recommended for health care workers. it is estimated that over , cases of hantavirus occur globally each year, with the majority in asia [ ] . it causes two major clinical syndromes namely hantavirus pulmonary syndrome (hps) and haemorrhagic fever with renal syndrome (hfrs) with the former occurring predominately in the americas [ ] . reports have indicated that there is an increasing incidence of hps in south america [ ] . the case definition of the hps as per the centers for disease control and prevention (cdc) is: 'a febrile illness with bilateral diffuse interstitial edema that may resemble the acute respiratory distress syndrome, with respiratory compromise requiring supplemental oxygen developing within hours of hospitalisation, in a previously healthy person' [ ] . the incubation period is two to three weeks followed by a number of phases that include [ ] ; a prodrome with nonspecific viral symptoms however also with thrombocytopenia, lasting for to days; and the pulmonary phase in which symptoms of respiratory failure predominate progressing extremely rapidly (over to h), to shock, coagulopathy, pulmonary oedema, bronchorrhea, arrhythmia and death. lastly in the recovery phase patients often have a period of significant diuresis as endothelial function recovers and fluid redistribution occurs, with urine outputs of to ml per hour for h [ ] ; thereafter there is a convalescent phase which can be prolonged over weeks to months [ ] . hantavirus is diagnosed by serology, with hantavirus igm positive by the time symptoms are present. if an appropriate history of exposure is obtained, the presence of thrombocytopenia, hemoconcentration, n % immunoblasts and a lack of toxic granulation has a high sensitivity and specificity for hantavirus [ ] . chest radiograph abnormalities consistent with interstitial oedema are usually present on admission which worsen as respiratory function declines [ ] . advanced respiratory and haemodynamic monitoring and support, may be necessary, inclusive of mechanical ventilation and extracorporeal membrane oxygenation (ecmo) which is often a challenge in lics [ ] . it is recommended that intravenous fluids are minimised with the early institution of vasopressor and inotropic support as aggressive fluid resuscitation has been shown to increase the risk of respiratory failure [ ] . unfortunately, no specific antiviral therapy has been demonstrated to be effective. burkholderia pseudomallei is a gram negative pathogen endemic to south east asia, northern australia, india, south china and taiwan and cases have been documented in brazil and elsewhere in south america, papua new guinea, fiji, and new caledonia [ ] . despite being the most common cause of fatal community acquired bacteremic pneumonia in north east thailand and darwin, it is seldom recognized when imported to areas where it is not endemic [ ] . the prevalence varies in affected regions and may be related to climactic conditions, being particularly influenced by rainfall, having reached record rates ( . cases per , people) after heavier than usual precipitation in - in northern australia [ ] . global mortality estimates are extremely high, similar to deaths from measles and much higher than leptospirosis and dengue, infections that receive considerably more attention. in fact the mortality may be even higher, as diagnosis is low in endemic areas primarily due to the low resource settings in which it occurs, as laboratory facilities are generally poor to non-existent [ ] . infection occurs from inoculation from contaminated soil or water, through abrasions, ingestion or inhalation with subsequent haematogenous spread. those with chronic diseases such as diabetes, renal failure and cystic fibrosis or those on immunosuppressive agents appear to be more susceptible [ , ] . most of the infections in endemic areas are asymptomatic with a significant number having antibodies but no history of disease [ ] . however at least % of cases present with pneumonia of varying severity ranging from a nodular infiltrate with septic shock which has a mortality of up to %, to a lobar consolidation presenting with less florid features. the former often has little in the way of respiratory symptoms, presenting with fever, hypotension and organ dysfunction [ ] . the more indolent form may mimic tuberculosis radiologically, most commonly involving the upper lobes, however it may also occur in the lower lobes in which case pleural effusions and empyema may occur [ , ] . pulmonary and diffuse metastatic abscesses (involving spleen, kidney, prostate and liver), osteomyelitis, and arthritis may also occur [ ] . the diagnosis is dependent on obtaining a positive culture. melioidosis must be considered in the differential of all febrile patients that have visited endemic regions, as antibiotics used routinely for community acquired pneumonia are not effective, and inappropriate therapy in severe disease increases mortality. although b. pseudomallei grows readily, laboratories may misidentify the organism as a pseudomonas which may lead to confusion and potentially incorrect therapy prior to the availability of the antibiogram. certain specific culture media may enhance growth however these are not always available outside of endemic areas [ ] . serological tests are available and a positive indirect hemagglutination test (iha) or enzyme-linked immunosorbent assay (elisa) in a traveller may raise the suspicion of melioidosis but definitive diagnosis is based on culture positivity [ , ] . treatment for severe disease is administered as an initial intensive intravenous phase with combinations of ceftazidime or meropenem/ imipenem with cotrimoxazole for at least days as recommended in thailand or days as recommended in australia. thereafter an oral eradication phase consisting of cotrimoxazole or amoxicillin/ clavulanate is administered for - weeks (thailand) or months (australia) [ ] . yersinia pestis is a gram negative coccobacillus and is notorious historically as the cause of 'the black plague'. y. pestis is likely to have caused three major pandemics which led to significant loss of life. in the first in the th century ad it is thought that in some regions, between and % of the population may have perished [ ] . according to the who, currently there are high rates of plague in the democratic republic of congo, madagascar and peru. the disease has three clinical syndromes: bubonic, pneumonic or septicaemic [ ] . pneumonic plague leads to purulent, exudative bronchopneumonia that is usually fatal if untreated [ ] . the yersinioses are zoonotic infections in which humans are accidental hosts via contact with an infected animal, usually with the flea as the vector. the infection can be acquired via a bite from a flea, scratches or bites from infected animals or rodents or inhalation of infected respiratory secretions. the infecting organisms are carried via lymphatics to the local lymph node which and this is followed by a severe inflammatory reaction [ ] . there were cases of plague reported to the who between and with deaths with % of cases from africa. areas affected by plague include north america, the former soviet union, africa, asia and south america [ ] . the majority of cases are of the bubonic form ( to %) which manifests with fever, chills, malaise, dizziness and associated lymphadenitis causing intense pain and swelling in a lymph node region. if untreated, dissemination occurs to the lungs or meninges in % of cases causing pneumonia or meningitis. septicaemic plague can occur without the bubonic illness in to % of cases and is a severe illness that can lead to profound multi-organ failure [ ] . pneumonic plague can either be primary or secondary. the former develops from aerosol exposure to y. pestis, with symptoms developing to days after inoculation [ ] . this can be caused by person to person spread via exposure to respiratory droplets and is the cause of outbreaks in extended families. secondary pneumonic plague is due to dissemination of y. pestis into the lungs during either the bubonic or septicaemic phases and occurs in approximately % of patients [ ] . recent data suggested that pneumonic forms are increasing in incidence accounting for % of global plague cases [ ] . a high index of suspicion is important in order to make the diagnosis, which is then confirmed by serology or culture or by more recently developed rapid diagnostic tests [ , ] . a high percentage of blood cultures are positive in septicaemic plague and gram stain and culture of sputum or lymph node aspirate is the usual means of diagnosis demonstrating small gram negative coccobacilli [ ] . the mortality rate of plague if untreated is between and % with pneumonic plague having a mortality of % if untreated and % if treated. previously streptomycin was the preferred antibiotic however in most cases gentamicin is now preferred. alternative agents include doxycycline and tetracycline. fluoroquinolones are the preferred agents for post-exposure prophylaxis [ ] . cap is usually managed according to national guidelines that are directed toward those organisms seen most frequently in each region. the conditions described above may not be seen frequently if at all in other parts of the world and as such may not be treated appropriately and may also result in considerable spread. all intensivists should be aware of these conditions and make sure that a good travel history is obtained in each and every case. management of infections in critically ill returning travellers in the intensive care unit-i: considerations on infection control and transmission of resistance viral infection in community-acquired pneumonia: a systematic review and meta-analysis influenza-a model of an emerging virus disease community acquired pneumonia in the tropics community-acquired pneumonia explaining the geographical origins of seasonal influenza a (h n ) community-acquired pneumonia cumulative number of confirmed human cases of avian influenza a(h n ) reported to who monthly risk assessment summary. influenza at the human animal interface interim guidance for specimen collection, processing, and testing for patients with suspected infection with novel influenza a viruses associated with severe disease in humans human infection with a novel avianorigin influenza a (h n ) virus human infection with avian influenza a h n virus: an assessment of clinical severity clinical findings in cases of influenza a (h n ) virus infection optimizing antiviral therapy for influenza: understanding the evidence interim guidance on the use of antiviral medications for treatment of human infections with novel influenza a viruses associated with severe human disease extracorporeal membrane oxygenation for ards in adults severe acute respiratory syndrome severe acute respiratory syndrome sars: systematic review of treatment effects centres for disease control and prevention. centres for disease control and prevention. middle east respiratory syndrome (mers) middle east respiratory syndrome coronavirus outbreak in the republic of korea epidemiological, demographic, and clinical characteristics of cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study mortality risk factors for middle east respiratory syndrome outbreak, south korea middle east respiratory syndrome hantavirus infection: a global zoonotic challenge hantavirus pulmonary syndrome hantavirus cardiopulmonary syndrome hantavirus infections for the clinician: from case presentation to diagnosis and treatment hantaviruses and cardiopulmonary syndrome in south america case definitions for infectious conditions under public health surveillance centers for disease control and prevention burkholderia pseudomallei and burkholderia mallei: melioidosis and glanders melioidosis: a review predicted global distribution of burkholderia pseudomallei and burden of melioidosis the epidemiology and clinical spectrum of melioidosis: cases from the year darwin prospective study management of infections in critically ill returning travellers in the intensive care unit-ii: clinical syndromes and special considerations in immunocompromised patients development of antibodies to burkholderia pseudomallei during childhood in melioidosis-endemic northeast thailand comparison of ashdown's medium, burkholderia cepacia medium, and burkholderia pseudomallei selective agar for clinical isolation of burkholderia pseudomallei workshop on treatment of and postexposure prophylaxis for burkholderia pseudomallei and b. mallei infection pneumonic plague: the darker side of yersinia pestis early emergence of yersinia pestis as a severe respiratory pathogen clinical problem-solving. sick as a dog development and testing of a rapid diagnostic test for bubonic and pneumonic plague fast and simple detection of yersinia pestis applicable to field investigation of plague foci practice guidelines for the diagnosis and management of skin and soft tissue infections: update by the infectious diseases society of america none. none declared. key: cord- -djp onk authors: verma, v. r.; saini, a.; gandhi, s.; dash, u.; koya, d. m. s. f. title: projecting demand-supply gap of hospital capacity in india in the face of covid- pandemic using age-structured deterministic seir model date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: djp onk background: due to uncertainties encompassing the transmission dynamics of covid- , mathematical models informing the trajectory of disease are being proposed throughout the world. current pandemic is also characterized by surge in hospitalizations which has overwhelmed even the most resilient health systems. therefore, it is imperative to assess supply side preparedness in tandem with demand projections for comprehensive outlook. objective: hence, we attempted this study to forecast the demand for hospital resources for one year period and correspondingly assessed capacity and tipping points of indian health system to absorb surges in demand due to covid- . methods: we employed age- structured deterministic seir model and modified it to allow for testing and isolation capacity to forecast the demand under varying scenarios. projections for documented cases were made for varying degree of mitigation strategies of a) no-lockdown b) moderate-lockdown c) full-lockdown. correspondingly, data on a) general beds b) icu beds and c) ventilators was collated from various government records. further, we computed the daily turnover of each of these resources which was then adjusted for proportion of cases requiring mild, severe and critical care to arrive at maximum number of covid- cases manageable by health care system of india. findings: our results revealed pervasive deficits in the capacity of public health system to absorb surge in demand during peak of epidemic. also, continuing strict lockdown measures was found to be ineffective in suppressing total infections significantly, rather would only push the peak by a month. however, augmented testing of , tests per day during peak (mid-july) under moderate lockdown scenario would lead to more reported cases ( , , - , , ), leading to surge in demand for hospital resources. a minimum allocation of % public resources and % private resources would be required to commensurate with demand under that scenario. however, if the testing capacity is limited by , tests per day under same scenario, documented cases would plummet by half. coronavirus disease (covid- ) is a contagious disease caused by a novel strain of coronavirus (sars-cov- ) which was first informed as the cluster of viral pneumonia cases of unknown etiology detected in wuhan city, hubei province, china. coronaviruses are enveloped, positive single-stranded large rna virus that infect humans, but also a wide range of animals ( ) . amongst humans, they have known to cause myriad of illness with varying degree of severity ranging from relatively benign common cold to more severe forms like sars (severe acute respiratory syndrome) and mers (middle east respiratory syndrome). however, illness onset among rapidly increasing number of people and mounting evidence human-to-human transmission suggests that sars-cov- is more contagious than its predecessors ( ) . following the outbreak of covid- , the who emergency committee declared it a global health emergency on january , and a pandemic on march , . within a short span of time, a localized outbreak evolved into pandemic with three defining characteristics: a) speed and scale-the disease has spread quickly to all corners of the world, and its capacity for explosive spread has overwhelmed even the most resilient health systems b) severity-overall, % cases are severe or critical, with a crude clinical case fatality rate currently of over %, increasing in older age groups and in those with certain underlying conditions c) societal and economic disruption-shocks to health and social care systems and measures taken to control transmission having deep socio-economic consequences ( ) . currently, approximately , , confirmed cases of covid- has been reported including an estimated , deaths in countries and territories as on may , . around three months have elapsed since the first case of covid- was reported in india on january , . since then, the number of cases have surged to , with , deaths as on may , . as part of the pandemic preparedness, in the absence of vaccines or antivirals, india adapted gamut of nonpharmaceutical interventions such as lockdown, quarantining and tracing and testing concomitantly to alter the trajectory of pandemic. these interventions encompassed two types of strategies a) suppression, which aims to reverse epidemic growth, by minimizing the effective reproduction number (average number of secondary cases each case generates), r, to below and thus, reduce case numbers to low levels and maintaining that indefinitely b) mitigation, which aims to slow the spread of epidemic with the rationale of preventing significant overload on health system and gradually allowing the population to develop herd immunity ( ) . who enforced a binding instrument of international health regulation (ihr) in to prevent, detect and respond to public health emergencies. the ihr monitoring and evaluation framework includes state party annual reporting tool (spar) which underscores capacity indicators to gauge the preparedness of nations to mitigate the effect of public health emergencies, including the emergence of novel pathogen (who, ) . in , although india's spar composite score ( . ) was above the international average ( . ), albeit, the scores for indicators pertaining to health service provisioning and laboratory capacity were incongruous as india had only half the average readiness in these indicators as compared to international scores. therefore, it is imperative to unravel the supply side readiness especially, with regards to infrastructural capacity of india to handle the surge of hospitalization cases. demand for hospitalization services for covid- can be estimated by analyzing the interface between transmission curve, age-structure, contact patterns and morbidity status of population. disease progression is characterized by myriad of uncertainties and the trajectory of an epidemic is defined by some key factors and parameters. specifically, for a novel infection whose disease dynamics are still unclear, mathematical models are thus, pertinent to understand the mechanics of transmission. deterministic compartmental models such as susceptible-exposed-infectious and recovered (seir) are widely used to provide insight into disease progression and can be chosen over complex models due to minimum number of assumptions. yet, there is a caveat in using the baseline seir model as it doesn't incorporate the testing capacity in the model which punctuates the dynamics in two ways. firstly, in basic model, the undetected yet infectious individuals are not accounted in determining probability of infection and potential transmissibility and secondly, there's reduced transmissibility from confirmed positive cases which no longer transmit the disease once they are tested and isolated. modelling exercises allowing for testing and isolation capacity and undetected cases are rather scarce. further, covid- has differential impact on different age groups and additionally, heterogeneities in contact networks have a major effect in determining whether pathogen can become epidemic or persist at endemic levels. consequently, mathematical models of disease transmission incorporating age and social contact structures are more congruous to the reality. therefore, in this study we have attempted the short and long term prediction of transmission of covid- using age-structured compartment based model allowing heterogeneities in contact networks and simulating for varying assumptions and scenarios around containment and mitigation strategies. drawing from international experience and literature on covid- , we determined the proportion of high-risk population with underlying conditions in india who are more vulnerable to progress into severe condition upon infection that can guide triage and targeted intervention decisions. further, we assessed the capacity and tipping points of indian health system to absorb surges in the number of people that will need hospitalization and critical care because of covid- based on varying scenarios. the objectives of the study can be elucidated as follows: -a) estimate the projected demand for hospital resources under various mitigation strategies of reduced social mixing and varying levels of testing capacity in india. b) analyze the hospital surge capacity of the indian health system to absorb the surge in demand under different scenarios. the spread of any virus is incumbent upon the infectivity of pathogen and the pool of susceptible population. we formulated the transmission dynamics model for the outbreak of covid- in a heterogeneously mixing population. compartmental disease models divide population into groups (or compartments) based on each individual's infection status and track the corresponding population sizes through time. seir model in which the population was divided according to infection status into susceptible(s), exposed (e), infected (i) and removed(r) was employed in the study. susceptible individuals become infected at a given rate when they interact/contact with an infectious person and enter the exposed state. these exposed pool transition to infectious state after a latency period and later either recover or die. however, it is crucial to consider host age structure to enable realistic modelling for disease prevention policy. also, the spread of an infectious disease is sensitive to the contact patterns in the population as person-to-person transmission is largely driven by who interacts with whom. the agespecific mixing patterns of individuals in age group i alter their likelihood of being exposed to the virus given the extent of infections in the group. the assumption of homogenously mixing population can lead to an overestimation of the final epidemic size and magnitude of interventions needed to stop an epidemic ( ) . contrarily, including contact patterns that vary across age and locations (e.g. home, work, and schools) as predictors in transmission dynamic model improves the model's realism. thus, we investigated the impact that different mixing assumptions have on the spread of covid- in an age structured seir model with infectivity in both latent and infectious period described by a system of ordinary differential equations. our model incorporates two sections as illustrated in figure where left part represents the classic seir model with additional post latency node accounting for infections in the terminal stage of incubation period. the transmission dynamics is further branched out into asymptomatic, symptomatic, severe and critical on the right-hand side constrained by the testing coverage. following equations represents the dynamics of the model. where β' is the probability of infection upon contact with infectious people, n is the total number of considered age groups, cij is the number of age wise interaction between infectious and susceptible population. where si, ei, li, ii and rui are the susceptible, exposed, post latency, infectious and undocumented recovered group of people of age group i. rate constant k = t_latency is defined by time from exposure to onset of infectiousness (latent period), k ' and k ' are rate for testing, k is defined by part of incubation time after latent period and k is rate at which undocumented infectious people recover or die. documented cases in the model are determined and constrained by the testing. positive cases can be presymptomatic, symptomatic and asymptomatic. pre-symptomatic and symptomatic may progress to severe and critical state before either recovery or death. whereas true asymptomatic positives recover without exhibiting any symptoms over the course of illness. where tpi is tested positive, asi is asymptomatic, ssi is symptomatic, svi is severe, cri is critical, di is dead and rdi is documented recovered for age group i. rates of progression are given as follows . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . to account for the mitigation factor such as social distancing, the contact matrix is divided into household contacts, workplace contacts, school contacts and other contacts using the following form where tw, ts and to can range from to allowing various degree of interactions of contacts delineating the impact of same on progression of the epidemic. main parameters of the model are surmised in table which were extracted/estimated from various sources. population age distribution for india was obtained from website of population pyramid ( ) and social contact matrices were adapted from state-of-the-art compilation by prem et. al in which matrices were projected by bayesian hierarchical model for countries using contact surveys and demographic data ( ) .time parameters were extracted from a recently published systematic review which synthesized parameters using meta-analysis of studies on covid- ( ) . further, age-distributed data from u.s. was used to estimate the epidemiological parameters in the study. as reported in table , age wise fractions of transition from one state to another and case fatality ratio (cfr) was calculated from the report published by u.s. center for disease control ( ), as currently in india (as of nd may), cfr is analogous to that of usa when cdc carried out the study. also, we collated the data on confirmed positive cases, hospitalizations, recovery and deaths from publicly available time series data of usa published by u.s. cdc ( ) to estimate the probability of infection β'. remaining model parameters such as latency rate, testing rate and rate of recovery/death were estimated using crowdsourced indian data ( ) from th march till nd may, while incorporating mitigation strategies of lockdown starting from th march to rd may and current social distancing guidelines based on the zones which is issued by indian government starting from rd may to th may. three scenarios of mitigation measures were modeled -(a) full lockdown (assuming closure of schools, workplace and community spaces and doubling of contacts in households) (b) social distancing measures and moderate lockdown (assuming closure of schools, staggered opening of workplace and community spaces with half strength and social distancing of vulnerable population including aged above years and people with at-least one underlying high risk chronic condition with % compliance) post th may, and (c) no lockdown (assuming % contacts in schools, workplace, community spaces and households). the model is augmented to incorporate the testing coverage and test to positive (ttp) ratio of % till may nd in india. the underlying set of assumptions characterizing the transmission dynamics are elucidated as followsi) india was assumed to be a closed system with constant population size of . billion (s+e+l+i+r= . billion) throughout the course of epidemic. ii) different inflows and outflows and imbalance by demographics, migration etc. is not considered. iii) seasonal effects, weather conditions like temperature and humidity and mutations not included in the model. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint iv) heterogeneous mixing in the contact networks is assumed and interactions at four spheres are considered: home, work, school and other locations. v) infectivity from latency period is considered, a latent individual can transmit the disease to the susceptible, i.e., individual has force of infection in both latent and infectious period. vi) asymptomatic transmission from truly asymptomatic cases is accounted in the model. vii) positively diagnosed cases are documented and isolated from rest of the susceptible pool, thus, less likely to spread the infection. viii) the recovered individuals develop the immunity and do not revert back to the susceptible pool. multi country evidence suggest that there are certain underlying conditions most associated with severe and critical cases of covid- . in conjunction with elderly, younger and working population group with chronic health conditions are also vulnerable and can be classified as high risk for developing complications. u.s. center for disease control and prevention in its morbidity and mortality weekly report ( )divulged that as of march , , % hospitalized non-icu cases and % icu cases had one or more precondition. similarly, evidence from italy ( ) affirmed that in a sample of deaths in italy, . % patients had some pre-condition(s). overall, among dead, . % had single disease, . % had diseases and . % had or more underlying diseases in italy. therefore, analyzing the prevalence of highrisk underlying condition associated with covid- is germane to understand the progression of cases from mild to severe/critical stage and identify the vulnerable population to design more effective interventions. hence, we used the information on burden of chronic diseases from a study conducted by london school of hygiene and tropical medicine ( ) therefore, we used the information on prevalence of these underlying conditions in india (table ) by culling out information from above-mentioned study to estimate proportion of population with at-least one underlying condition. data on indian health infrastructure was coalesced from different sources. information on beds in public hospitals (phc+chc+dh) and medical college hospitals was extracted from national health profile, ( ) . however, there was missing information in this data source for some states and colleges, which was then scrapped individually from websites of the colleges. beds under ayush, defense, railways and esi corporation are also incorporated in the analysis as india is likely to rope in beds from these institutions during surge in demand. the data for bed availability in these institutions was taken from national health profile, ( ) . further, due to absence of veritable data available on private sector, approximations using utilization rates for hospitalizations in private hospitals from recently released national sample survey organization th round ( ) was used and crude estimations were made based on proportion of . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint inpatients treated in private hospitals. further, there is major lacunae in credible data availability for icu beds and ventilators required for critical care. henceforth, another assumption was made that only % of total beds are icu beds and % icu beds are equipped with ventilators in india. health system's capacity to accomodate the increasing number of covid- patients was computed using an open access tool developed by giannakeas et al ( ) ( ) . this tool enables the modelling of steady state patient flow dynamics that can guide the tipping point of health care system in terms of the availability of hospital beds, icu beds and mechanical ventilators. entire dynamics of supply side readiness is explained in figure . the left-hand panel in the figure is representative of the current health capacity with total number of hospital beds, icu beds and ventilators. average length of stay determining the daily turnover rates for mild, severe and critical cases were set as . days, . days and . days respectively (parameter values from model). using population-weighted age-stratified probabilities, number of cases requiring hospital beds, icu beds and ventilators was estimated. further, the daily turnover of each of these resources was measured by dividing the number of available resources with average length of stay for that resource. thereafter, the daily turnover rates were divided by the proportion of cases requiring mild, severe and critical care to arrive at the maximum number of covid cases manageable by health care system of india. three distinct cases based on the allocation of resources were made to discern the surge capacity for each of these cases. in all three cases, we assumed that public health facilities dedicate fixed % of their hospital beds, icu beds and ventilators for covid- patients since existing bed occupancy rate of public hospitals in india is around % ( ) . however, for private sector hospitals, varied assumptions pertaining to allocation was made. under case , the provision of private infrastructure was assumed to be . whereas, the allocation of hospital beds, icu beds and ventilators in private hospitals was % under case and further expanded to % under case- main findings of the study are presented in this section. figure encapsulates various transmission curves under the scenario of ramping up of testing coverage (number of individuals tested daily) and increased ttp from % to % when the pandemic reaches final stage of community transmission. the impact of other non -pharmaceutical interventions like social distancing and lockdown is also explicated in the figure. while the lockdown was effective in slowing down the infection rate and shifting the peak to later months of the year , it perpetuated heavy socio-economic costs in india. therefore, it is pertinent to compare how continuing with moderate lockdown or lifting the restrictions completely would impact the number and spread of total covid- cases in india. the detailed representation of our modelling results is exhibited in figure . our modelling exercise revealed that with the current testing rate of , individuals tested daily on an average in india from th march, till nd may and % ttp ratio, the estimated total documented covid- infections in india would not exhibit any significant difference ( , to , in an year) across the scenarios of no lockdown, full lockdown and moderate lockdown guidelines. lifting the lockdown completely after th may would hasten the surge in demand to th july as compared to rd august if the full lockdown . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . continues for one year. although, moderate lockdown would push the peak to early august, total number of infections will not plummet by this intervention. current ttp ratio in india is around % which is exiguous as compared to ttp in usa of %. there could be plethora of reasons for low ttp in india such as absence of widespread-community spread, untargeted testing or less sensitivity of diagnostic kits. however, we estimated the number of total infections and peak time for surge in demand for expanded testing coverage of , and , tests per day at current % ttp as well as for % ttp modelling for worst case scenario. assuming no/limited community spread with ttp of % and augmenting the testing to , , in the absence of lockdown, our model estimated the peak to be around mid-july with total documented cases ranging from , to , during peak time. however, continuing moderate lockdown (with % contacts in schools, workplaces and others), estimated number of documented cases would be around , at the peak time of th july. with this increased testing of , individuals per day, surge in demand would be highest (~ , , ) if stringent lockdown measures are imposed after th may. this is because complete lockdown will delay the overall community spread and more people will be diagnosed and tested positive during peak time. under the worst case scenario of widespread community spread in india with ttp of %, peak will be witnessed around early july to mid-august . total documented infections under moderate lockdown scenario will range from , , to , , around rd july if , individuals are tested daily. however the total documented infections will increase with higher testing rate of , individual per day ranging from , , to , , cases around peak time on th july. in a no lockdown situation during worst case scenario with ttp %, number of cases will peak a week ahead around th july with similar number of infected cases in moderate lockdown. our analysis indicated paucity of resources in india to handle surge in demand during the peak time for both mild infections and severe cases. the capacity of indian healthcare system to absorb increases in caseload is constrained by availability of beds and ventilators. india has a total (public +private) bed capacity of , , which can be allocated for covid- infections according to existing bed occupancy rate and government guidelines. the availability of health care infrastructure which is collected from multiple sources is presented in table . according to case- where no allocation is made by private sector and only % resources are dedicated in public infrastructure, actual availability of hospital beds, icu beds and ventilators is , , , and , respectively. the estimated inflow/outflow of mild, severe and critical cases per day are , and . under this scenario, india has the capacity to accommodate only , mild cases, , severe and critical new covid cases every day. however, leveraging upon expansive private health care system in india can bolster the capacity. the tipping point for beds and ventilators increases significantly when % (case ) and % (case ) private health care resources were assumed to earmarked to accommodate covid- patients. for example, under case- , we found that the surge capacity of health system for mild, severe and critical care is distinctly higher than case as can be seen in figure and figure . moreover, when the allocation of private infrastructure increases by %, the capacity to manage new covid cases doubles. we computed the surge capacity, which is determined by trajectory of cases and infrastructure dedicated to covid- patients by accessing the time period around which indian hospitals will face serious crisis in terms of availability of beds and ventilators. the demand-supply gap during peak time if the moderate lockdown is continued after th may for mild, severe and critical cases is presented in the form of heat map ( figure ). green coloured boxes are indicative of the availability of infrastructure during peak time in respective scenarios, whereas non-green coloured boxes suggest the extent of health infrastructure that has to be upgraded to meet the real demand during peak time. as mentioned earlier, surge capacity is likely to vary across different testing scenarios. for example, when the partial lockdown is considered with increased testing coverage of , and , per day and ttp of %, our demand and supply side projections indicate that the indian health care system is likely to face a huge deficit in terms of the availability of health care infrastructure, especially for severe and critical case. assuming the community spread and scaling up of testing to , tests per day with ttp of %, under case- , india will have to increase the availability of icu beds by more than five times ( %) and availability of ventilators by . times( %) before th july . however, under current scenario where ttp is %, if we increase testing to , cases per day, we will have to ramp up the availability of icu beds by . % and ventilators by . % before th july . under case- , where % of capacity in public facilities and % in private facilities is apportioned for covid- , and testing coverage is , per day with ttp of %, the estimated demand for severe and critical cases can only be met if supply of icu beds and ventilators is increased by . % and . % before th july . however, increasing the testing even further to , , number of icu beds must double, and supply of ventilators must be increased by . % before th july. therefore, necessary steps must be made to include private-sector hospitals in the treatment of covid- patients in order to be prepared for the widespread community transmission and increase in detected cases due to aggressive testing. time to surge in capacity or tipping point will occur much earlier than the peak. hence, this analysis delineates an urgent need of procuring the ventilators and upgrading the capacity in this months window. our study calibrated the model to preliminary data arising from outbreak in india in order to project the demand for hospital resources under three transmission curve scenarios: no lockdown, moderate lockdown and full lockdown across varying testing coverage. we also evaluated the extent to which the full lockdown and moderate lockdown delays the peak of outbreak, thereby, prolonging the window of time to augment the health-system capacity in order to accommodate the surge in demand during peak period. our analysis of indian healthcare system's preparedness to absorb surges for infected cases exhibited pervasive deficits. there was a substantial variation in tipping points of supply side capacity across the assumptions on resource allocation in private sector to accommodate covid- patients. one of the important finding of our analysis is relative ineffectiveness of further extending the strict lockdown measures, as full lockdown is likely to push the surge in demand for hospital resources by a month without suppressing the total number of cases significantly. india was amongst the countries to implement lockdown early with highest stringency in the world which is also indicated by the stringency index of lockdown ( % for india) prepared by university of oxford ( ) . due to the high costs of lockdowns, there's a policy conundrum if the countries should quarantine everyone at a large social cost or test everyone and apply quarantine in a more directed fashion. the increase in documented cases with augmented testing in our study suggests that lockdown should be replaced gradually with more thrust on public health intervention of testing, tracing and isolating in conjunction with surveillance and real time data. more targeted sequestering of infected case(both symptomatic and asymptomatic) aided with increased random testing, along-with the social distancing measures for containment zones with higher incidence of cases and isolating vulnerable with underlying conditions and aged population is recommended rather than stringent lockdown in order to prevent the negative shock from deepening further. our analysis underscored the absence of surge capacity for severe and critical cases under all of the transmission and testing scenario. there is some capacity available for mild cases, provided documented cases are constrained by testing capacity, albeit, in an event of expanded testing and community transmission, mild cases will also be subjected to deficit of beds. the shortage of beds for even mild and asymptomatic cases can be corroborated with the recent reports from indian cities of chennai ( ) and mumbai ( ) where government hospitals are running out of beds due to explosion of cases. many countries are resorting to home isolation of mild and asymptomatic cases, a measure which union health ministry of indian government has also announced recently. however, we recommend to ramp up institutional capacity to isolate infected cases under institutional care as india's congested housing conditions are not conducive to quarantining at home. the national sample survey office data ( ) reveals that for % indians, per capita space available is less than a single room leading to unprecedented challenges for effective home isolation. our model didn't consider the potential staff shortages in transmission dynamics and capacity readiness due to uncertainty around their predictions and unavailability of quality data. age-distributed data on severe, critical and recovered cases is rather sparse in india, therefore, we adapted/estimated some parameters from detailed data released by other countries. modelling is rather a necessary input to guide policy decisions, however, a more comprehensive approach incorporating stakeholder's analysis, case studies and triangulating information across multitude of sources should be adapted for nuanced decision making. the study can be further extended to map the geographical accessibility of facilities providing covid- care, specifically spatial accessibility for critical care needs to be explored. also, rapid health facility assessments for covid- preparedness unravelling mean availability of tracer items for emergency response should be conducted for targeted interventions at hospital level. finally, study can be extended at more granular level to inform demand-supply gap so that resources can be mobilized in commensuration with demand at more local level, thereby enabling local government systems to combat covid- in india. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . the covid- epidemic method study design [internet]. cdn.onb.it mise à jour de la stratégie covid- impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand mathematical models of mixing patterns between age groups for predicting the spread of infectious diseases. pdfs.semanticscholar.org [internet projecting social contact matrices in countries using contact surveys and demographic data epidemiological characteristics of covid- ; a systemic review and meta-analysis . medrxiv.org [internet preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease -united states covid- india tracker case-fatality rate and characteristics of patients dying in relation to covid- in italy. jamanetwork how many are at increased risk of severe covid- disease? rapid global, regional and national estimates for . medrxiv.org [internet directorate general of health services m of h and fw. national health profile directorate general of health services m of h and fw estimating the maximum capacity of covid- cases manageable per day given a health care system's constrained resources utilization pattern and financing of public hospitals: a report ^ variation in government responses to covid- bed-medical-personnel-shortage-as-cases-rise/story/ .html . ministry of statstics and programme implementation. drinking water, sanitation, hygiene and housing condition in india updated rapid risk assessment from ecdc on the novel coronavirus disease (covid- ) pandemic: increased transmission in the eu/eea and the uk. ncbi.nlm.nih.gov key: cord- - ou ubb authors: weiss, martin m.; weiss, peter d.; mathisen, glenn; guze, phyllis; henderson, donald a.; inglesby, thomas v.; o'toole, tara title: rethinking smallpox date: - - journal: clin infect dis doi: . / sha: doc_id: cord_uid: ou ubb the potential consequences of a competently executed smallpox attack have not been adequately considered by policy makers. the possibility of release of an aerosolized and/or bioengineered virus must be anticipated and planned for. the transmission and infectivity of variola virus are examined. arguments for and against pre-event vaccination are offered. the likely morbidity and mortality that would ensue from implementation of a mass pre-event vaccination program, within reasonable boundaries, are known. the extent of contagion that could result from an aerosolized release of virus is unknown and may have been underestimated. pre-event vaccination of first responders is urged, and voluntary vaccination programs should be offered to the public. two defenses against a vaccine-resistant, engineered variola virus are proposed for consideration. methisazone, an overlooked drug, is reported to be effective for prophylaxis only. the extent of reduction in the incidence of smallpox with use of this agent is uncertain. it is useless for treatment of clinical smallpox. n- respirators (face masks) worn by uninfected members of the public may prevent transmission of the virus. conventional wisdom holds that smallpox presents an unlikely threat to the public health [ ] [ ] [ ] [ ] . that wisdom asserts that the virus is sequestered in secure sites [ ] and that, even if it somehow released, vaccine will abort any potential epidemic [ ] . moreover, conventional wisdom holds that promising drugs are in development to treat smallpox [ ] [ ] [ ] [ ] and that the virus is not highly contagious [ ] . such considerations could prove to be overly optimistic and do not take into account the many uncertainties regarding transmission and infectivity of the smallpox virus. in addition to the possible existence of more-virulent "weaponized" strains, further advances in genetic engineering may permit construction of strains able to evade the current vaccine. australian workers markedly increased mousepox virulence by splicing a mouse il- gene into a laboratory strain [ ] ; similar constructions might be assembled using human smallpox virus (variola major) or another pox virus (e.g., monkeypox virus) and human genes [ ] . this article critically examines some of the current tenets of public health policy and highlights the uncertainty of much of the data. we also examine potential defenses against a release of smallpox virus and make recom-mendations regarding immunization and the development of prophylactic medications. smallpox may be transmitted via respiratory droplets or via fine-particle aerosol. the distinction between the two has critical public health implications. respiratory droplets (i.e., sputum and saliva) have a range likely no more than m (∼ ft) and are therefore a threat only to persons in the immediate vicinity of the affected patient. epidemiological studies support the finding that respiratory droplet spread is the prime route of transmission; the geographic locus of transmission is described as being almost always at the bedside, rather than public areas [ , ] . freefloating aerosolized virions, on the other hand, would have a considerably more extensive range. in , dixon [ ] reviewed the evidence for the alternative mode-aerosolized spread-and concluded that true airborne infection was extremely rare. nonetheless, epidemiological evidence suggests that transmission by means of aerosolized particles may be a real occurrence. in , persons on floors of a german hospital developed smallpox, despite isolation of the coughing, smallpox-infected patient in a single room [ ] . seventeen cases of smallpox developed; none of the patients had direct contact with the initial patient. subsequent "smoke" testing demonstrated air flows consistent with an aerosol spread [ ] . the last recorded death due to smallpox, according to world health organization investigators, was likely associated with virus that had been transmitted by aerosol [ ] . in , janet parker, a medical photographer at the university of birmingham medical school in england, became ill with smallpox and subsequently died. her darkroom was story above and several rooms down the hall from the laboratory of dr. henry bedson, a prominent smallpox researcher. smallpox virus can also be transmitted by fomites, such as clothing and bedding [ ] . laundry workers have developed smallpox. one study found a much higher recovery of smallpox virus from pillows and bedclothes than from air samples of the patient's coughs [ ] . the length of time that these objects remain infectious is unclear, but on the basis of the historical pattern of epidemics, it is likely no more than a few days. current wisdom holds that smallpox, contrary to its popular reputation, is not a highly infectious disease [ , ] . examinations of outbreaks in india and pakistan in the s showed that each case of smallpox gave rise to only new cases during the infectious (dry) season and to new case during the humid season [ ] . such observations-along with the long incubation period of smallpox (mean, - days; range, - days)suggest that there would be adequate time to vaccinate the public and prevent a more widespread outbreak. not revealed in these reports is the extent to which the affected public had already been vaccinated. if the percentage of the population that had been vaccinated was high, the aforementioned findings may merely reflect the population's immune status, rather than a low attack rate. another report placed the vaccination level in india at that time at % [ ] . if accurate, this would support the reason for the low attack rate as being a consequence of a public protected by immunization, rather than due to a virus with low inherent infectivity. indeed, there are data that smallpox is highly contagious. during the period of endemic smallpox, in field studies in africa, % of susceptible contacts became infected [ ] . other sources report attack rates of anywhere from % to % among unvaccinated contacts [ ] . potentially fatal reactions to smallpox vaccination include encephalitis, progressive vaccinia, eczema vaccinatum, and myopericarditis. postvaccinial encephalitis or encephalomyelitis has been reported to occur at an incidence of case per , vaccinations [ ] . in recent data from an ongoing department of defense (dod) study, there was case of encephalitis reported among , vaccinations [ ] ; the patient recovered. there was no evidence by either viral culture or pcr for vaccinia being the etiology. progressive vaccinia (a postvaccination viral dissemination with subsequent shock and localized gangrene) occurs in persons with immunodeficiencies, and eczema vaccinatum (a generalized spread of vaccinia to skin beyond the vaccination site) occurs in persons with atopic dermatitis; neither was reported in the dod study [ ] . fifty cases of contact transfer of vaccinia occurred, primarily in spouses and adult intimate contacts [ ] . the lower-than-expected incidence of adverse events may reflect more-careful screening of vaccination candidates for immunosuppression and eczema (for whom vaccination is contraindicated), the generally healthy status of the population being vaccinated, the previous vaccination in up to two-thirds of vaccine recipients, and covering of the vaccination site, which reduces inadvertent inoculation of contacts. (in previous vaccination campaigns, the vaccination site was left exposed.) an unexpected finding in the dod study above was the occurrence of cases of myopericarditis [ ] [ ] [ ] . there was death among these cases [ ] . other than for that fatality, in all cases for which there was follow-up cardiac testing, there was normalization of electrocardiograms, echocardiograms, exercise testing, and functional status [ ] . there was no increased incidence of coronary events in the dod program [ , ] , but in the much smaller civilian vaccination program (involving , vaccinees), the number of myocardial infarctions observed ( cases) was higher than would have been expected ( cases) [ ] . plaque-purified tissue culture vaccines are in clinical trials and may have a lower incidence of adverse reactions than does the standard calf lymph vaccine [ ] . in addition, attenuated and dna subunit smallpox vaccines are under development [ ] and may prove to be safer for immunocompromised persons. there have been attempts to answer the question of how many deaths would arise from preemptive mass vaccination of the public. depending on the percentage of the population vaccinated, the number of deaths is estimated to be in the range of - [ , , ] . the likely deaths and morbidity that would ensue from a vaccination program must be weighed against the likelihoodand consequences-of a smallpox attack. the conventional wisdom, as noted above, is that smallpox "does not spread rapidly under natural conditions" and, in fact, spreads at a "leisurely" pace [ , p. ]. transmission usually requires "close prolonged contact" for spread [ , p. ]. each case of smallpox "gives rise to (only) about three new cases" [ , p. ]. the long incubation period of - weeks "provides the time to intervene and limit secondary spread" [ , p. ]. we can "readily stop outbreaks within two infective generations (about weeks) after recognition of the initial cases" [ , p. ]. there is a problem in basing public policy on these principles. even if the above is an accurate representation of the contagiousness of smallpox, this paradigm reflects the spread of natural smallpox. unfortunately, any future smallpox epidemic would likely be an unnatural, man-made event. the natural history of an unnatural event may not be natural. a second misconception regards vaccination. contrary to the widely held belief that vaccination is equally successful after implantation of the variola virus, "postexposure vaccination is at best of limited effectiveness" [ , p. ]. the most optimistic report on postexposure vaccination, plotting efficacy against time, utilized a presumed average incubation period. it concluded that postexposure vaccination reduced the clinical case rate by % when administered up to days postexposure [ ] . concerns over the effectiveness of postexposure vaccination have been raised by others [ , ] . bozzette et al. [ ] calculate that there would be , deaths in a "high-impact airport attack," despite the presence of an aggressive postevent immunization program. it could be argued that his calculation may be an underestimation. in their model, bozzette et al. [ ] used a pattern of spread based on outbreaks that occurred after world war ii in a largely smallpox-immune population. vis-à-vis smallpox, the immune status of the older portion of our population is uncertain. it was generally accepted that the immunity provided by vaccination deteriorates with time. two-thirds of persons with smallpox in the s had preexisting vaccination scars [ ] . however, hammarlund et al. [ ] found substantial humoral and or cellular immunity against vaccinia persisting in persons who had been vaccinated - years earlier and cite epidemiological studies that argue for long-term protection. regardless, the immune status of our younger population (i.e., those aged ! years), with regard to smallpox, probably resembles the status of the aztec, inca, and th century american indian populations, rather than that of a vaccinated people. it is possible, therefore, that each index case would give rise to considerably more than just the secondary cases in the outbreaks that occurred after world war ii. as is reported in a consensus statement by smallpox authorities, "a clandestine release of smallpox, even if it infected only - persons to produce the first generation of cases, would spread rapidly in a now highly susceptible population, expanding by a factor or - times or more with each generation of cases" [ , p. ]. this pattern of spread likely occurred in the population of central mexico, which, according to aztec tribute rolls taken before their exposure to smallpox in the early s, was million. the spanish, in , estimated that the population was . million, but other factors, including measles, also probably played a role in the decline [ ] . bozzette et al. [ ] ascribe a mortality rate of . % to the unimmunized population. however, there are data showing a mortality rate of % in an unvaccinated population [ ] . the same long incubation period that some authorities hold to be an advantage in control of the disease [ ] could actually prove to be our achilles' heel. even within the limits of the shortest possible incubation period ( days), high-impact attacks could be repeated-at the same site or at different sites, with no one aware that attacks were taking place. to make a cogent assessment of the consequences of a smallpox attack, several questions must be answered. otherwise, we are engaged in no more than guesswork. the questions are these: ( ) can smallpox virus be aerosolized? ( ) if it can be aerosolized, for how long does it remain viable, and how far can it be carried? ( ) even if it can remain aerosolized and viable for a prolonged period of time, just how infectious is it by this route? smallpox virus can be aerosolized [ ] . however, the current opinion on how long the virus can remain viable in this state is that the viability rapidly decreases after min ("no more than %- % survived" [ , p. ] ), implying that there is nil viability left soon thereafter and, thus, that aerosolization does not represent much of a threat [ ] . unfortunately, closer scrutiny of the science underlying that assertion shows less reason to be sanguine. the great majority of the loss in variola virus viability was already present when first measured min into the study. thereafter, there was but modest further decline over the remaining -min length of the study [ ] . the virus may therefore persist at a relatively stable level of viability for hours. how long the virus can actually remain aerosolized is unknown, as is its infectivity in this mode. if one extrapolates from the results of studies of vaccinia, aerosolized variola virus that is protected from uv light survives for h [ ] . a critical caveat that was not addressed above is that the discussion has been limited to natural smallpox in a natural setting. the soviet union is known to have engaged in an active program to aerosolize bioweapons, including smallpox, for use in bioweapons [ ] . if modified or attached to the appropriate carrier, variola virus could possibly remain suspended and infectious for a considerable period. on the other hand, dissemination of variola virus into the air (e.g., via crop dusters or bomblets) subjects the virus to variables such as uv light, thermal factors, humidity, and wind. the virus might not survive, or it might be dispersed in the atmosphere into such low concentrations that it is no longer infective. because the minimal infective dose has not been determined, the efficacy of such dissemination is unknown. the current bush administration sought widespread preevent vaccination of the public over concern as to whether an effective vaccination program could be implemented after an attack on an unvaccinated public [ ] . the public health com-munity, however, citing safety issues, has opposed immunizing the public [ ] . animal studies demonstrate that cidofovir (vistide; gilead) has activity against poxvirus infections [ ] [ ] [ ] [ ] , but only when it was administered either concurrently or, in one study, within days after the initial challenge with the virus. if its effectiveness extends to humans, this drug would have a prophylactic effect only. it would not be of benefit for treatment of established clinical smallpox. cidofovir has been modified to render the drug bioavailable by the oral route. this modification (adding a lipid tail to produce hexadeclyoxypropyl-cidofvir [hdp-cidofovir]) resulted in a new drug, which, in vitro, is times more effective against variola than is unmodified cidofovir [ ] . methisazone, a thiosemicarbazone, has been reported to be effective for smallpox prophylaxis. a clinical trial in india in the s involving contacts claimed a % reduction in the incidence of the disease ( ) [ , ] . however, p ! . this study has been criticized elsewhere [ ] . treatment and control groups were incompletely randomized, with a possible bias in favor of methisazone. a subsequent fully randomizedbut considerably smaller-trial reported favorable but lessimpressive results (the incidence of smallpox in the control group was almost double that in the methisazone group) [ ] . this finding did not reach statistical significance. methisazone was stated to be effective prophylaxis in the eighth edition (from ) of harrison's principles of internal medicine [ ] , but it is doubtful that many made note of it. by then, smallpox had essentially been eradicated, and there was little reason to pay much attention to the entry. later editions of harrison's virtually eliminated the smallpox chapter, along with discussion of the drug. the agent has since fallen off of our radar screens [ ] . a panel of smallpox authorities assessed methisazone and determined that it had only modest benefit, probably reducing the incidence of smallpox by only %- % [ ] . this reduction should not be dismissed as inconsequential. in the event of a smallpox attack with an engineered virus, even such modest efficacy could prove critical. not addressed, however, is the question of just how effective methisazone would be without coadministration of vaccine. (vaccine could be useless in an attack with a modified virus.) in all of the aforementioned studies, contacts simultaneously received postexposure vaccination and methisazone. one study, on a related poxvirus, suggests an answer to this question. methisazone was investigated as prophylaxis for variola minor (alastrim), where contacts were not vaccinated, and was found to be effective for the prevention of alastrim at a significance level of . [ ] . methisazone is not without side effects. nausea and vomiting have been reported in one-tenth to two-thirds of persons who receive the drug [ , ] . for prophylaxis, the drug must be given within days of the initiation of infection with variola major [ ] . methisazone has a significant weakness: without patent protection, it is essentially an orphan. a pharmaceutical company is unlikely to expend research effort or promotion on such a drug. that weakness, however, is also a strength: in the public domain, it would likely be inexpensive to produce. the smallpox virus is - nm in size. n- respirators, with ulpa (ultra-low penetration air) filters, are . % efficient in filtering particles of у nm in size [ ] . the retail cost of these masks is $ . n- respirators, which are less effective respirators, have been reported to be protective in preventing transmission of severe acute respiratory syndrome coronavirus (size, nm) in health care workers [ , ] , but use of these respirators failed to prevent a cluster of cases in one hospital [ ] . concerns have been raised over leakage around the mask, especially in the absence of fit testing [ ] . nonetheless, these masks, if distributed to the public, could prove to be critical for the control of a smallpox epidemic that was overwhelming our health care system, and they might also prove to be effective in limiting contagion of smaller viruses, such as influenza virus (either natural virus, as in , or engineered virus [ ] ). additionally, an aerosolized smallpox attack would likely paralyze our cities. availability of masks might allow some measure of confidence for essential services to continue. a focus on the hazards of smallpox vaccination without consideration of the potential consequences of a competently executed smallpox attack may lead to skewed analyses and flawed decisions. in particular, the use of a more virulent, "weaponized" strain of smallpox virus could mean that the epidemic would outrun the currently planned postevent vaccination/isolation measures. although conventional wisdom suggests that smallpox, in its natural state, is largely limited to spread via respiratory droplets, concern about the potential for aerosol transmission is real and might be a greater problem in a developed society with large urban populations. despite the potential hazards, we believe that greater efforts should be made to promote pre-event immunization-especially in emergency providers and health care workers. furthermore, consideration should be given to allowing the public voluntary access to the vaccine. with proper informed consent and careful screening to minimize the risk of adverse side effects, such a program could reduce the risk of a runaway epidemic. because of the possibility of an attack involving bioengineered smallpox virus that is resistant to the current vaccine, methisazone should be reexamined, and research should be continued on other antiviral agents. also, an adequate supply of masks should be assured. although unlikely at the present time, the possibility of a future bio-engineered attack using smallpox should not be arbitrarily rejected. because of scientific advances (the polio virus has recently been synthesized de novo) [ ] and ready access to those advances (complete genomes for viruses, including variola, are available on the internet), we face a potential vulnerability. although that threat may not be immediate (variola would be a complex genome to synthesize, and its dna requires the activity of associated proteins to be infectious) [ ] , it may not be long in coming. board on health promotion and disease prevention, institute of medicine. review of the centers for disease control and prevention's smallpox vaccination program implementation: letter report # evaluation of st-century risks of smallpox vaccination and policy options smallpox vaccine policy is bad science harrison's principles of internal medicine bio-terrorism, nih-cdc grand rounds us hunting antiviral drug to use in case of smallpox ammo for the war on germs in vitro activity of potential anti-poxvirus agents expression of mouse interleukin- by a recombinant ectromelia virus suppresses cytolytic lymphocyte responses and overcomes genetic resistance to mousepox smallpox: anything to declare? a different view of smallpox and vaccination smallpox and its eradication. geneva: world health organization the recent outbreak of smallpox in meschede, west germany the demon in the freezer the recovery of smallpox virus from patients and their environment in a smallpox hospital transmission potential of smallpox in contemporary populations in: office of the surgeon general, department of the army. virtual naval hospital. textbook of military medicine: medical aspects of chemical and biological warfare diagnosis and management of smallpox smallpox as a biological weapon us military smallpox vaccination program experience department of defense smallpox vaccination program. smallpox vaccination safety summary myocarditis following smallpox vaccination among vaccinia-naive us military personnel incidence and follow-up of inflammatory cardiac complications with smallpox vaccination update: cardiac-related events during the civilian smallpox vaccination program-united states smallpox vaccine: problems and prospects. immunol smallpox vaccine: looking beyond the next generation expected adverse events in a mass smallpox vaccination campaign the case for voluntary smallpox vaccination smallpox and smallpox vaccination the smallpox outbreak in khulna municipality, bangladesh can postexposure vaccination against smallpox succeed? smallpox vaccination after a bioterrorism-based exposure a model for smallpoxvaccination policy duration of antiviral immunity after smallpox vaccination the greatest killer smallpox in europe, - assessment of aerosol mixtures of different viruses the looming threat of bioterrorism rough and tumble behind bush's smallpox policy cidofovir in the treatment of poxvirus infections cidofovir protects mice against lethal aerosol or intranasal cowpox virus challenge treatment of aerosolized cowpox virus infection in mice with aerosolized cidofovir cidofovir in the therapy and short term prophlyaxis of poxvirus infections oral drug and old vaccine renew smallpox bioterror debate prophylactic treatment of smallpox contacts with n-methylisatin b-thiosemicarbazone prophylaxis of smallpox with methisazone smallpox and its eradication. geneva: world health organization field trial of methisazone as a prophylactic agent against smallpox harrison's principles of internal medicine smallpox and smallpox vaccination the research agenda utilizing variola virus: a public health perspective methisazone in prevention of variola minor among contacts remington's pharmaceutical services is the n respirator appropriate for occupational protection against sars? ecmaj effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) sars among critical care nurses cluster of severe acute respiratory syndrome cases among protected health-care workers-toronto, canada interim domestic guidance on the use of respirators to prevent transmission of sars influenza as a bioweapon active poliovirus baked from scratch a not-so-cheap stunt key: cord- -a yrtuwf authors: burke, r. m.; balter, s.; barnes, e.; barry, v.; bartlett, k.; beer, k. d.; benowitz, i.; biggs, h. m.; bruce, h.; bryant-genevier, j.; cates, j.; chatham-stephens, k.; chea, n.; chiou, h.; christiansen, d.; chu, v.; clark, s.; cody, s. h.; cohen, m.; conners, e. e.; dasari, v.; dawson, p.; desalvo, t.; donahue, m.; dratch, a.; duca, l.; duchin, j.; dyal, j. w.; feldstein, l. r.; fenstersheib, m.; fischer, m.; fisher, r.; foo, c.; freeman-ponder, b.; fry, a. m.; gant, j.; gautom, r.; ghinai, i.; gounder, p.; grigg, c. t.; gunzenhauser, j.; hall, a. j.; han, g. s.; haupt, t.; holshue, m.; hunte, title: enhanced contact investigations for nine early travel-related cases of sars-cov- in the united states date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: a yrtuwf background coronavirus disease (covid- ), the respiratory disease caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), was first identified in wuhan, china and has since become pandemic. as part of initial response activities in the united states, enhanced contact investigations were conducted to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. methods close contacts of nine early travel-related cases in the united states were identified. close contacts meeting criteria for active monitoring were followed, and selected individuals were targeted for collection of additional exposure details and respiratory samples. respiratory samples were tested for sars-cov- by real-time reverse transcription polymerase chain reaction (rt-pcr) at the centers for disease control and prevention. results there were close contacts who underwent active monitoring in the response jurisdictions; had at least basic exposure data, of whom had at least set of respiratory samples collected and tested. across all known close contacts under monitoring, two additional cases were identified; both secondary cases were in spouses of travel-associated case patients. the secondary attack rate among household members, all of whom had at least respiratory sample tested, was % ( % ci: - %). conclusions the enhanced contact tracing investigations undertaken around nine early travel-related cases of covid- in the united states identified two cases of secondary transmission, both spouses. rapid detection and isolation of the travel-associated case patients, enabled by public awareness of covid- among travelers from china, may have mitigated transmission risk among close contacts of these cases. , the respiratory disease caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), was first identified in wuhan, china and has since become pandemic. as part of initial response activities in the united states, enhanced contact investigations were conducted to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. close contacts of nine early travel-related cases in the united states were identified. close contacts meeting criteria for active monitoring were followed, and selected individuals were targeted for collection of additional exposure details and respiratory samples. respiratory samples were tested for sars-cov- by real-time reverse transcription polymerase chain reaction (rt-pcr) at the centers for disease control and prevention. there were close contacts who underwent active monitoring in the response jurisdictions; had at least basic exposure data, of whom had ≥ set of respiratory samples collected and tested. across all known close contacts under monitoring, two additional cases were identified; both secondary cases were in spouses of travelassociated case patients. the secondary attack rate among household members, all of whom had ≥ respiratory sample tested, was % ( % ci: - %). the enhanced contact tracing investigations undertaken around nine early travel-related cases of covid- in the united states identified two cases of secondary transmission, both spouses. rapid detection and isolation of the travel-associated case patients, enabled by public awareness of covid- among travelers from china, may have mitigated transmission risk among close contacts of these cases. in late december , a cluster of patients with pneumonia of unknown etiology was identified in wuhan, china. this disease, now termed coronavirus disease (covid- ) , spread rapidly within china and quickly became pandemic. phylogenetic analyses of severe acute respiratory syndrome coronavirus (sars-cov- ), the causative agent of covid- , suggest zoonotic origin, with subsequent rapid spread indicative of person-toperson transmission. , on january , , the first case of covid- was confirmed in the united states; through the end of january, nine more travel-related cases were identified. to interrupt transmission and facilitate early identification of secondary cases, public health authorities at the state, county, and local levels, in consultation with subject-matter experts from the u.s. centers for disease control and prevention (cdc), mobilized rapidly to place the patients under appropriate isolation and identify contacts exposed to these patients. enhanced contact investigations were conducted centered on nine patients, and included in-depth interviews to better characterize exposure type, exposure duration, and contact medical history, in addition to collection of respiratory specimens to identify asymptomatic or pre-symptomatic infections. this report summarizes results from these nine enhanced contact investigations, including information on exposures, active monitoring, laboratory testing, and secondary attack rates among close contacts. these investigations included the close contacts of nine travel-related covid- patients (hereafter referred to as "travel-associated case patients") first identified as suspected covid- patients between january and january , , and represent collaboration among state and local health department staff, cdc personnel, and healthcare facility staff (hereafter referred to as "covid- outbreak response teams"). the aims of these investigations were to interrupt transmission, investigate risk factors for transmission, and identify both symptomatic and asymptomatic infections among contacts of travel-associated case patients. after diagnosis confirmation, these nine travel-associated case patients were interviewed to determine the date of symptom onset and to collect information on movements and interactions with other individuals during the presumed infectious period of the travel-associated case patient. individuals with potential exposure to a travelassociated case patient were contacted by covid- outbreak response teams to determine their exposure risk level, whether they met the definition of a close contact, and whether they met criteria for active monitoring (terms defined below in "classification of contacts and exposures"). individuals not meeting the definition of a close contact are not included in this report. to better understand sars-cov- transmission, covid- outbreak response teams selected a convenience sample of the close contacts who met active monitoring criteria to target for collection of additional, detailed exposure and demographic information using standardized forms; some sites were able to collect information on all close contacts, while others collected information only on those close contacts they classified as having had high-or medium-risk exposures. to understand the prevalence of asymptomatic or pre-symptomatic infection, a convenience sample of actively monitored close contacts was selected from whom to request respiratory (nasopharyngeal [np] and oropharyngeal [op]) samples outside of diagnostic specimen collection procedures (i.e., while contacts were asymptomatic or, in some cases, symptomatic with ≥ previous negative sars-cov- result); some sites were able to request at least one set of samples from all close contacts, but most sites targeted sample collection mainly to close contacts determined to have had high-risk exposures, such as household members. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint definitions of the infectious period, close contact, and exposure risk, as well as decisions regarding which types of contacts to monitor and how to manage their movement, were made at the site level by the covid- outbreak response teams. in one site, the presumed infectious period began on the date of symptom onset in the travel-associated case patient; however, in other sites, investigators also considered between one and three days before symptom onset in the travel-associated case patient. in all sites, the presumed infectious period ended when the travel-associated case patient was released from isolation. generally, close contacts were defined as persons having frequent or more than brief contact (> - minutes within ft) with a travel-associated case patient during the travel-associated case patient's presumed infectious period. most sites also considered persons sharing the same airspace as the travel-associated case patient for more than ten minutes to be close contacts. for persons whose exposure occurred in the healthcare setting, the definition of close contact also depended on usage of personal protective equipment (ppe) by the exposed person during their interaction with the travel-associated case patient. close contacts were grouped by type. close contacts were classified as "household contacts" if they were family members or friends of a travel-associated case patient who spent at least one night in the same residence as the travel-associated case patient during the presumed infectious period. close contacts were classified as "healthcare personnel" (hcp) if they were healthcare or public health personnel working in healthcare settings who had the potential for exposure to a travel-associated case patient or to infectious materials from a travel-associated case patient. close contacts who were defined as neither household contacts nor hcp were classified as "community contacts"; this category was broken down into contact occurring in a healthcare setting (e.g., waiting room close contacts) and contact occurring outside a healthcare setting (e.g., coworkers). "community contacts" also included flight-related close contacts of travel-associated case patients whose infectious periods included plane travel; these were defined as passengers seated in the same row as the travel-associated case patient, or in the two rows in front of or behind the travel-associated case patient. for the purposes of analyses of hcp ppe data, "all recommended ppe for airborne and contact precautions" is defined as gloves, gown, eye protection (goggles or a disposable face shield that covers the front and sides of the face), and a powered air-purifying respirator (papr) or n filtering facepiece respirator (ffr) with fit-testing in the past year"; "all recommended ppe for droplet and contact precautions" is defined as gloves, gown, eye protection, and a face mask. any encounter during which an hcp was wearing any combination of ppe not meeting either of the above definitions was considered to be "less protected." risk stratification varied by site, but all sites considered household contacts as well as hcp who provided patient care without all recommended ppe to have had high-risk exposures. close contacts meeting criteria for active monitoring were contacted daily via phone, text message, email, or in person, and were asked to report temperature and any symptoms. close contacts selected for collection of detailed exposure information were interviewed using forms that were standardized within but not across jurisdictions. information collected included dates of exposure to the travel-associated case patient; basic demographics; duration and types of exposure (e.g., face-to-face contact, direct physical contact); and, among hcp close contacts, use of ppe and interactions with or procedures performed on travel-associated case patients. information was entered into standardized forms, spreadsheets, or databases maintained by the covid- outbreak response teams. close contacts selected for biological sample collection agreed to provide np and op samples for sars-cov- testing. samples were collected by trained personnel. most sites aimed to collect samples from close contacts with high-risk exposures every - days through days following last exposure to the travel-associated case patient. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . close contacts living outside the response jurisdictions were forwarded to their respective health jurisdictions for assessment and monitoring. some flight-related close contacts were forwarded to cdc's division of migration and quarantine for follow-up. close contacts meeting criteria for active monitoring were monitored through days following their last exposure to a travel-associated case patient. close contacts not meeting criteria for active monitoring were asked to self-monitor and to contact the local health department if they developed any symptoms. close contacts who developed new or worsening symptoms that covid- outbreak response teams deemed possibly consistent with covid- (e.g., fever, cough) were considered to be suspect covid- patients and had respiratory samples (and serum samples, when possible) collected and sent for testing at the time that determination was made, regardless of whether previous samples had been collected. household contacts of some non-hospitalized travel-associated case patients were quarantined in the same home with their respective travel-associated case patient following the travel-associated case patient's diagnosis; this quarantine lasted through the period of case isolation. this situation is hereafter referred to as "co-habitation during case isolation." to prevent household transmission, the travel-associated case patients were instructed to stay in a separate bedroom, use a separate bathroom if possible, and to wear a face mask if they had to be in the same room as cohabitants . all specimen samples were collected according to cdc guidance then packaged and shipped to cdc . specimens were refrigerated at - °c before shipping on icepacks. cdc performed real-time reverse transcriptase-polymerase chain reaction (rrt-pcr) to detect three separate genetic markers of sars-cov- in the n , n , and n regions. respiratory specimens were considered positive if all three genetic markers were positive by rrt-pcr. demographic, clinical, exposure, and testing results for contacts are summarized and described. because the exact information that was collected varied by site, denominators are presented throughout. collection of respiratory specimens is described by sample type and days since last exposure to the travel-associated case patient. the secondary attack rate by close contact type was calculated as the percent of close contacts with at least one positive sars-cov- test result among close contacts for whom ≥ set of respiratory samples was tested; % confidence intervals were calculated using the wilson score interval. differences in continuous variables were tested by the mann-whitney u test given non-parametric distributions. data were entered into access, excel, or redcap databases. data were merged and analyzed using the r environment for statistical computing. these activities were reviewed by cdc's human research protection office and deemed to be non-human subjects research because they were conducted as part of a public health response. a total of (range to close contacts per case) individuals were identified as close contacts of the first nine patients with travel-related covid- in the united states (figure ) . four hundred and four ( %; range: to per confirmed case) met criteria and participated in local active monitoring. most of the close contacts who did not participate in local active monitoring were determined to have had low-risk exposures that did not for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint require active monitoring. other close contacts who did not participate in local active monitoring were either unable to be reached or were managed by other jurisdictions. among those close contacts actively monitored, ( %) had either limited demographic and exposure type information (hereafter referred to as "at least basic exposure data") or demographic plus detailed exposure information collected; the type and amount of information for different types of close contacts varied by study site depending on their protocol. of these close contacts, ( %) were household contacts, ( %) were hcp, ( %) were community contacts exposed in a healthcare setting, and ( %) were community contacts exposed in another setting (table ; figure ). among the actively monitored close contacts with demographic information, the majority were female (n= / ; %) and aged - years (n= / ; %). of these close contacts, only nine ( %) were exposed prior to symptom onset in the travel-associated case patient, including seven household members who were also exposed while the travel-associated case patient was symptomatic (data not shown). a total of actively monitored close contacts with at least basic exposure data ( %) developed new or worsening respiratory symptoms and had a set of diagnostic respiratory samples collected; of these ( %) had additional respiratory samples taken as part of enhanced contact investigations or case follow-up. there were ( %) actively monitored close contacts with at least basic exposure data who remained without new or worsening symptoms, of whom ( %) had at least one set of respiratory samples collected and had more than one set of respiratory samples collected (figure ) . a histogram of samples collected by type, contact category, and days since last exposure is shown in supplemental figures and . the nine travel-related travel-associated case patients had a total of household contacts, of whom all were actively monitored. two household contacts, both spouses of travel-associated case patients, became symptomatic and tested positive for sars-cov- ( table ). the secondary attack rate among all household members of travel-associated case patients was % ( % ci: - %). the secondary attack rate among significant others of travel-associated case patients was % ( % ci: - %). there were two couples ("a" and "b") in which secondary transmission occurred; neither spouse shared a travel history with their respective travel-associated case patient. in couple a, the travel-associated case patient developed symptoms one day after returning from travel and enrolled in active monitoring with the local health department; the spouse, who had no reported comorbidities, developed symptoms three days after the travelassociated case patient's symptom onset. couple a reported the use of some isolation precautions during the period of exposure: the travel-associated case patient wore a face mask and used a separate bedroom and bathroom even prior to developing symptoms, although the couple did share a meal and spent extended time in the car together. both persons in couple a were diagnosed with covid- at the same time and were instructed to co-isolate at home until released by public health officials; however, eight days after symptom onset in the travel-associated case patient, couple a had to be hospitalized due to worsening conditions in both patients. in couple b, as in couple a, the travel-associated case patient's symptoms began the day after returning from travel. six days after symptom onset, the travel-associated case patient was hospitalized; the next day, the travelassociated case patient was identified as having suspect covid- , and the spouse entered active monitoring. symptom onset in the couple b spouse could not be precisely determined, as this person has underlying conditions, but could have been as early as three days after the travel-associated case patient's symptom onset. couple b did not report any isolation precautions prior to the diagnosis of the travel-associated case patient (which occurred days after symptom onset), and had frequent unmasked face-to-face and direct contact. in both couples, the spouse tested positive in the first respiratory samples collected. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . in general, the length of exposure to the travel-associated case patient was lower among the household contacts who did not develop covid- . among these , eight (including significant others) were completely separated from the travel-associated case patient once the patient was diagnosed and isolated; these persons maintained separate living space throughout the period of case isolation. two ( %) had < hours of exposure to the symptomatic travel-associated case patient before isolation, five ( %) had - days of household exposure to the symptomatic travel-associated case patient before isolation, and one ( %) had eight days of household exposure to the symptomatic travel-associated case patient before isolation. among these eight, three household members of two travel-associated case patients shared a travel history with the travel-associated case patient. all eight household members who were separated from the travel-associated case patients following diagnosis had serial specimens collected (median: . sets; range: - ), and all persistently tested negative; the date of last specimen collection ranged from five to days following last exposure. five household members (including significant others) across four households co-habited with the travel-associated case patient during the period of case isolation; none shared a travel history with the travel-associated case patient. none of these travel-associated case patients were hospitalized at any time. when following up with these four co-habiting households via phone and in-person visits, the covid- outbreak response teams noted moderate to very high adherence to recommended home isolation procedures: in two out of four households, the travel-associated case patient was able to use a separate bathroom, and in only one of four households did the covid- outbreak response team ever directly observe or learn of the travel-associated case patient spending time in the same room as their household member(s). all five household members undergoing co-habitation had multiple respiratory samples collected for testing (median: sets; range: - ) and remained sars-cov- -negative throughout the period of co-habitation, with the last samples collected within seven days of the end of case isolation or the end of cohabitation. these samples are shown in supplemental figure . the nine travel-related travel-associated case patients made a total of visits to healthcare facilities ( outpatient clinics, urgent care clinic, hospital visits), resulting in hcp contacts who met criteria for active monitoring. there were hcp ( %) for whom data were available to describe patient contact and ppe usage in more detail. among hcp who provided care to or came into contact with the infectious fluids of travelassociated case patients and who had at least one set of respiratory samples collected and tested for sars-cov- , the secondary attack rate was % ( % ci: - %). two hcp (< %) reported performing a possibly aerosol-generating procedure on a travel-associated case patient (nebulizer therapy: ; spirometry: ); both reported using all recommended ppe during the procedure. laboratory personnel reported using recommended ppe when processing samples from travel-associated case patients. fourteen hcp ( %) reported collecting diagnostic respiratory specimens, of whom ( %) reported always using all recommended ppe for airborne and contact precautions, ( %) reported always using all recommended ppe for droplet and contact precautions, and ( %) reported using less ppe than recommended on at least one occasion (i.e., ppe meeting neither airborne/contact nor droplet/contact precautions; table ). among the hcp using less ppe than recommended, reported the details of their ppe use: all five wore gloves, one wore a gown, one wore eye protection, and one wore only a face mask; one wore an ill-fitting n ffr. all occasions during which "less-protected" hcp collected respiratory specimens from a travel-associated case patient were at the travel-associated case patient's first presentation to care-before covid- was confirmed. there were ( %) hcp who reported providing patient care, touching the patient, or coming into contact with the patient's infectious fluids ( table ) . of these hcp, ( %) reported always using all recommended ppe for airborne and contact precautions, ( %) reported always using all recommended ppe for droplet and contact precautions, and ( %) reported using less ppe than recommended on at least one occasion. among hcp using less ppe than recommended, described ppe usage in detail. eye protection was most frequently missing ( ; %), followed by gown ( ; %), and less commonly ffr or mask ( ; %). all but three of these less-for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint protected encounters occurred before covid- was suspected in the travel-associated case patient. during all but seven of these less-protected encounters, the patient wore a mask for source control and removed it only for specimen collection and temperature measurement. there were community contacts ( exposed in a healthcare setting and exposed in another setting) for whom information was sufficiently detailed to classify at least one specific type of exposure ( table ). the secondary attack rate for community contacts of travel-associated case patients was % ( % ci: - %) among the contacts with some detailed exposure information and at least one set of respiratory samples tested. for community contacts exposed in the healthcare setting, some exposure information was missing as the patient was not always identified to these persons. out of who provided information, only one ( %) recalled having face-to-face contact with the travel-associated case patient. as compared to community contacts in the healthcare setting, community contacts exposed outside the healthcare setting had more interaction with the travel-associated case patient, and included airport quarantine station screeners, workplace contacts, flight contacts, four rideshare drivers, and three friends. of those with data, many reported having face-to-face contact ( / ; %) with the travel-associated case patient or spending time within feet of the patient ( / ; %), and nearly all ( / ; %) could remember being in the same room as the travel-associated case patient. fewer ( / ; %) reported being within feet of the patient while the patient was coughing. the enhanced contact tracing investigations undertaken by the covid- outbreak response teams around nine early travel-related covid- cases in the united states resulted in identification of two transmissions from two travel-associated case patients to their spouses. we did not find evidence of secondary infection with sars-cov- among the other actively monitored close contacts who developed symptoms suspicious for covid- nor among the close contacts who submitted respiratory specimens for virologic testing and who did not develop new symptoms during the -day active monitoring period. the results of these investigations suggest that the risk of secondary covid- infection is high among close household contacts of confirmed covid- patients, especially significant others. additional detail on one of these transmissions has been previously published. overall, the average exposure durations among household contacts were longer among those who developed covid- compared with those who did not. the higher transmission risk observed for household contacts is consistent with published research on other coronaviruses as well as sars-cov- . , , interestingly, we did not detect any sars-cov- infections among household members who were co-habiting with their confirmed sars-cov- -positive household members during the period of case isolation. since the majority of these co-habiting case patients and close contacts adhered very well to home isolation precautions, it is possible that careful adherence to isolation protocols mitigated the transmission risk to household members co-habiting with travel-associated case patients during the period of case isolation. we did not detect any symptomatic secondary cases of covid- among the non-household contacts who completed active monitoring, including hcp contacts and community contacts from whom respiratory samples were tested for sars-cov- . this finding is similar to findings from early contact investigations in europe and asia, [ ] [ ] [ ] [ ] but in contrast to other data suggesting a much higher secondary attack rate. it is possible that asymptomatic secondary cases could have developed in persons from whom respiratory samples were not collected, , or that secondary cases could have developed without being detected in respiratory samples (for instance, if the timing of shedding did not align with the timing of sample collection); follow-up serology could help to rule out some of these possibilities. the low number of secondary cases could also be related to the quick for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . isolation of most of these travel-associated case patients, as found in studies of mers-cov. , . out of hcp with higher-risk exposures to a travel-associated case patient, all but three reported these exposures to have occurred prior to confirmation of the patient's diagnosis. once the patients were classified as suspected covid- cases, contact and transmission-based precautions were begun and maintained by the majority of hcp throughout the patient's care. in contrast to the first community-acquired cases identified in the united states, it is also important to consider that most if not all of these first travel-related cases were likely cognizant of the possibility that they were infected, and engaged in practices such as wearing face masks, practicing social distancing in some cases, and seeking care; , , these practices have the potential to have reduced secondary transmission from these cases. further, these investigations were taking place at a very early stage in the u.s. outbreak, and many sites employed a low threshold for defining close contacts, potentially inflating our denominator. this report is subject to several limitations. because individual covid- outbreak response teams were operating out of distinct locations with unique considerations, the procedures of the investigation were heterogeneous across sites: different teams made different decisions regarding how to define close contacts, how to categorize exposure risk, which close contacts to actively monitor, which types of exposure information to collect, and how often (and from whom) to attempt collection of respiratory samples. although available information was standardized across sites for the purposes of analysis, this heterogeneity led to missing data, limiting our ability to assess certain types of exposure in this population. relatedly, only % of actively monitored close contacts provided any respiratory specimens, and fewer provided serial respiratory specimens. incomplete sample collection could have biased secondary attack rates, and also raises the possibility of a missed asymptomatic infection. symptomatic infections occurring after the end of the -day monitoring period also could have been missed. although some sites attempted to reach individuals with close contact prior to symptom onset in the travel-associated case patient, many of these exposures occurred during the travel of the travelassociated case patient and therefore were managed by other jurisdictions. as a result, only nine such persons are included in the present analysis (of whom seven were household members with continued exposure). thus, secondary transmissions occurring prior to symptom onset in the travel-associated case patient may have been missed. missed transmissions (either asymptomatic infections, transmissions occurring outside the presumed infectious period, or transmissions with an incubation period outside the -day active monitoring period) may have contributed to community spread, as suggested by some genetic analysis of sars-cov- circulating in washington. lastly, although all sites endeavored to interview and sample the close contacts with the highestrisk exposures, the selection of the sample for interview and respiratory specimen collection was not systematic or consistent across sites. this may have introduced bias in the characteristics of the close contacts described as well as in the secondary attack rates. the findings of these enhanced contact investigations, consistent with other research, suggest that household members of covid- patients, particularly significant others, who are likely to have prolonged close contact with the patients, are at excess risk of developing covid- . , further, the lack of observed transmission to hcp underlines the importance and effectiveness of rapid identification and isolation of suspected cases of covid- and appropriate use of ppe in caring for these patients , . careful adherence to infection prevention procedures within the home and the healthcare setting may help to reduce the risk of transmission of covid- , while monitoring and quarantine of household contacts may help interrupt transmission. close contacts with highrisk exposures (such as household contacts or hcp providing patient care without ppe) should continue to be quarantined and actively monitored, as data from covid- clusters have raised the concern of transmission from asymptomatic or pre-symptomatic individuals infected with sars-cov- , , , , which may be contributing to the widespread community transmission that is currently occurring in the united states. it is important for hcp and public health professionals to remain vigilant to the possibility of sars-cov- transmission from confirmed cases to household, community, and hcp contacts, and continue to emphasize isolation and other precautions. , further, individuals exposed to sars-cov- should self-quarantine, and all for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . persons should practice everyday behaviors to limit the spread of covid- such as proper hand hygiene, covering coughs and sneezes, wearing cloth face coverings, and social distancing. , this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . *includes healthcare or public health professionals providing patient care or directly interacting with a covid- patient in healthcare setting; cleaning personnel who potentially had contact with bodily fluids of a covid- patient in a healthcare setting; and laboratory personnel who processed samples without recommended ppe. **contacts were asked about any non-cancer immunosuppressive conditions or therapies (e.g., therapy for autoimmune conditions such as rheumatoid arthritis), as well as about whether cancer chemotherapy had been received within the last months. † all persons reporting a history of diabetes specified type diabetes. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . *does not include household member who was concurrently diagnosed following co-isolation with their spouse, who was a suspected case. **these persons inhabited the same house as the travel-related covid- patient throughout the period of case isolation, but were instructed to have the case patient stay in a separate bedroom and use a separate bathroom if possible, and to have the case patient wear a face mask if they could not avoid being in the same room. † these persons maintained separate living quarters from the travel-associated case patient throughout the period of case isolation. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . ( . ) *a total of community contacts exposed in the health care setting and exposed in other settings had information sufficiently detailed to classify at least one specific type of exposure. sample sizes within each exposure do not sum to these totals because data was either not collected by the covid- outbreak response team or was not reported by the participant. **zero samples tested positive for sars-cov- . for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. excludes specimens from five household contacts with ongoing household exposure after the diagnosis of the travel-associated case patient, one household member diagnosed concurrently as the travelassociated case patient, and four community contacts without a known exposure period or date of collection. specimens from contacts submitting only a single set of respiratory specimens are shown in navy, while specimens from those submitting multiple sets of respiratory specimens are shown in lighter blue. household contacts (hh) are shown in the first row (excluding who were co-habiting with the case patient following diagnosis and who was concurrently diagnosed), healthcare personnel (hcp) contacts are shown in the second row, and community contacts are shown in the bottom row. the first column shows the number of nasopharyngeal (np) swabs collected and tested, and the second column shows the number of oropharyngeal (op) swabs collected and tested. some hh members and hcp have specimens collected at negative days from last exposure-these represent specimens collected during a period of ongoing exposure to the covid- patient. samples collected relative to the first day of exposure are shown in supplemental figure . only the initial specimens are shown for the secondary cases, as these specimens tested positive. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . collected from contacts with known exposure periods are shown by the days following first exposure to the confirmed covid- patient on the x axis. excludes specimens from five household contacts with ongoing household exposure after the diagnosis of the travel-associated case patient, one household member diagnosed concurrently as the travel-associated case patient, and four community contacts without a known exposure period or date of collection. specimens from contacts submitting only a single set of respiratory specimens are shown in navy, while specimens from those submitting multiple sets of respiratory specimens are shown in lighter blue. household contacts (hh) are shown in the first row, healthcare personnel (hcp) contacts are shown in the second row, and community contacts are shown in the bottom row. the first column shows the number of nasopharyngeal (np) swabs collected and tested, and the second column shows the number of oropharyngeal (op) swabs collected and tested. only the initial specimens are shown for the secondary cases, as these specimens tested positive. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . specimens (n = ) collected from contacts who were co-habiting with a covid- patient following the travel-associated case patient's diagnosis are shown by the days following first exposure to the confirmed covid- patient on the x axis. the first column shows the number of nasopharyngeal (np) swabs collected and tested, and the second column shows the number of oropharyngeal (op) swabs collected and tested. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . covid- ): situation report - a pneumonia outbreak associated with a new coronavirus of probable bat origin a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia first case of novel coronavirus in the united states interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid- ) in healthcare settings if you are sick or caring for someone interim guidelines for collecting, handling, and testing clinical specimens from persons under investigation (puis) for research use only -novel coronavirus ( -ncov) real-time rt-pcr primer and probe information first known person-to-person transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) in the usa middle east respiratory syndrome coronavirus transmission in extended family, saudi arabia case management team kcfdc, prevention. early epidemiological and clinical characteristics of cases of coronavirus disease in south korea case management team kcfdc, prevention. coronavirus disease- : summary of , contact investigations of the first cases in the republic of korea investigation of three clusters of covid- in singapore: implications for surveillance and response measures first cases of coronavirus disease (covid- ) in france: surveillance, investigations and control measures serological and molecular findings during sars-cov- infection: the first case study in finland secondary attack rate and superspreading events for sars-cov- presumed asymptomatic carrier transmission of covid- asymptomatic and presymptomatic sars-cov- infections in residents of a long-term care skilled nursing facility clinical and epidemiologic characteristics of spreaders of middle east respiratory syndrome coronavirus during the outbreak in korea transmission of middle east respiratory syndrome coronavirus infections in healthcare settings initial public health response and interim clinical guidance for the novel coronavirus outbreak -united states cryptic transmission of sars-cov- in washington state escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease (covid- ) due to sars-cov- in hong kong risk of nosocomial transmission of coronavirus disease : an experience in a general ward setting in hong kong public health responses to covid- outbreaks on cruise ships -worldwide presymptomatic transmission of sars-cov- mmwr morb mortal wkly rep . . situation summary how to protect yourself & others social distancing, quarantine, and isolation the authors would first like to acknowledge the covid- patients and close contacts described in this manuscript. we also gratefully acknowledge the assistance and contributions of glen abedi, sharad aggarwal, olivia almendares, alison binder, catherine bozio, nakia clemmons, aaron curns, rebecca dahl, connor hoff, michelle kautz, marie killerby, lindsay kim, stephanie kujawski, steven langerman, jessica leung, allison miller, christine miner, ruth n. moro, florence whitehill, and rebecca woodruff of cdc; and meredith haddix of santa clara county public health. no authors have any conflicts of interest to disclose.for use under a cc license. key: cord- - coxz l authors: souris, m.; gonzalez, j.-p. title: covid- : spatial analysis of hospital case-fatality rate in france date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: coxz l when the population risk factors and reporting systems are similar, the assessment of the case-fatality (or lethality) rate (ratio of cases to deaths) represents a perfect tool for analyzing, understanding and improving the overall efficiency of the health system. the objective of this article is to estimate the influence of the hospital care system on lethality in metropolitan france during the inception of the covid- epidemic, by analyzing the spatial variability of the hospital case-fatality rate between french districts. the results show that the higher case-fatality rates observed in certain districts are mostly related to the level of morbidity in the district, therefore to the overwhelming of the healthcare systems during the acute phases of the epidemic. however, the magnitude of this increase of case-fatality rate represents less than per cent of the average case-fatality rate and cannot explain the magnitude of the variations in case-fatality rate reported by country by international organizations or information sites. these differences can only be explained by the systems for reporting cases and deaths, which, indeed, vary greatly from country to country, and not attributed to the care or treatment of patients, even during hospital stress due to epidemic peaks. since the beginning of the epidemic, the case-fatality rate of covid- and the differences between countries have been the subject of many questions about national pandemic response policies and patient treatment. most studies on the lethality of the case-fatality rate (or lethality rate) is the ratio between the number of closed cases (i.e. recovered or dead) and the number of deaths due to the disease, it is estimated by the healthcare system based on the reporting of these two values. the case-fatality rate should not be confused with the mortality rate, which is the ratio of the number of deaths to the total population, or also with the morbidity rate, which is the ratio of the number of cases to the total population. mortality and morbidity rates depend on the extent of disease in a population, unlike case-fatality rates, which are normally calculated independently of the number of infected persons [por ]. the case-fatality rate of a disease in a population is an index of severity of the disease in that population, and of the capacity of the healthcare system to reduce mortality. in principle, this allows to compare the effectiveness of healthcare systems across regions or countries. the aim of this article is to analyze the effectiveness of the healthcare system in france in the context of the covid- epidemic. based on spatial differences in lethality, this study ultimately show that the case-fatality rates published by the international agency by country (may ) do not allow to compared the country one to the others. lethality depends on the intrinsic virulence of the virus but, unlike morbidity, it does not depend on its contagiousness. virulence comes from the reproductive capacity of the virus in the cell, its capacity for cellular degradation, and its ability to induce or not an innate or specific immune response. virulence is of purely biological origin and once the virus has entered the target cell where it will cause its pathogenic effect does no longer depends on environmental conditions outside the host. virulence is independent of the host population, but may change over time and space if there is a risk of natural mutation/selection of the pathogen. contagiousness characterizes the biological capacity of the virus to reach the target cell system of its host, and the ability to be transmitted from one individual to another. the efficiency of transmission depends largely on environmental conditions (e.g., climate, urbanization, population density, mobility), which can vary greatly from one country to another. in addition to the virulence of the virus, the case-fatality rate depends on biological risk factors and on population vulnerability (age structure, genetic factors, prevalence of co-morbidities, healthcare accessibility, etc.) as well as other factors related to the health system (equipment, capacity, staff, management, care of patients, effectiveness of therapies, patient management in a critical phase of the disease), and factors related to the detection and registration system for cases and deaths (clinical cases definition, detection, surveillance systems, case and death reporting). the evaluation of the case- fatality rate normally requires the detection and counting of all infected persons, irrespective of their level of symptoms (i.e. disease severity). when the population risk factors and reporting systems are identical, case-fatality rate evaluation represents an excellent tool for analyzing, understanding and improving the overall performance of the health system, particularly at the level of hospital units. studying the magnitude of differences in case-fatality rates between units also makes it possible to assess the impact of the quality of the health system on case-fatality. there are large differences in the case-fatality rates of covid- published by country (table ) or calculated directly from who data. these rates vary considerably, from less than . (thailand, australia, chile) to more than . (france, belgium, uk), with a mean at . and a standard deviation of . (who, may , , figure cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . in europe, the characteristics of populations (in terms of risk factor for covid- ) and health systems are quite similar, but the definition, detection and reporting of cases and causes of death can differ greatly from one country to another. some countries conducted significantly more detection tests and hospitalizations than others (table ) , resulting in differences in the protocols for patient management. the rate of testing performed (policy) and mortality rates (reporting) vary mainly according to the geographical extent of the epidemic within each country. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . the virulence of the covid- pathogen (sars-cov- virus) is assumed to be identical in all countries. in order to compare case-fatality rates across regions or countries (and thus analyze the effectiveness of healthcare systems), it is necessary, when calculating rates, to standardize population-related risk factors and to use the same definitions and enumeration methods to record cases and deaths. this is not the case for the current pandemic and discrepancies exist among the country systems. the objective of this article is not to estimate the actual lethality of covid- in france based on the rates published by the health authorities, but to estimate the influence of the healthcare system on lethality by analyzing the spatial variability of the hospital case-fatality rate (confirmed hospitalized cases and hospital deaths) in metropolitan france between districts (i.e. french départements). this analysis, limited to metropolitan france, makes it possible while it remains within the framework of the same system for defining and counting cases and deaths. we thus assume that this system of definition and enumeration was identical throughout france during the period ( march to may) corresponding to the first wave (inception) of the covid- epidemic in france. therefore the study focuses on the extent of spatial differences in the case-fatality rate in metropolitan france, and enable to highlight the relative differences between districts, as well as to analyze the causes independently of the system of definition and enumeration of cases and deaths, and also independently of the main biological risk factor of severity (age) after standardization on this factor. estimating the variability of the case-fatality rate attributable exclusively to hospital care of patients will then allow us to compare the case-fatality rate observed in metropolitan france with the one calculated for other countries. it will allow us to estimate whether the variability of the case-fatality rate due to the management of . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint patients in the acute epidemic phase can exclusively explain the significant differences in case-fatality rates observed between countries. this study is based on daily hospitalization and death declaration data by district in france and is accessible on the "santé publique france" website. (www.data.gouv.fr/fr/datasets/donnees-hospitalieres-relatives-a-lepidemie-de-covid- ) from march to may , , corresponding to days lockdown (i.e. quarantine) and the spread of the covid- epidemic in france. we also obtain demographic data by districts (source: population by age, insee, ), as well as data on the distribution of hospitalized cases according to age group ( -year age group) (santé publique france). this analysis was carried out on the districts of metropolitan france (figure ), while the french overseas districts and territories were excluded from the analysis for reasons of spatial analysis and mapping. the data were integrated into a geographic information system (savgis, ww.savgis.org) for analysis and mapping. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . severe and asymptomatic forms (which a fortiori do not cause deaths) -it is estimated that only . % of infected persons were hospitalized [sal ] -this overall lethality is necessarily much lower than hospital lethality, but it will be accurately calculated only at the end of the epidemic when the total number of positive cases (i.e. seroprevalence survey) will be available and the total number of deaths outside hospital due to covid- will be accurately assessed. all identified and hospitalized cases were tested positive (by rtpcr). all deaths counted were covid- associated. as of may , , not all hospitalized cases are closed since the epidemic is still ongoing: deaths counted at the beginning of the study period correspond to cases hospitalized but were not included in the study, and cases counted at the end of the period were not closed and no deaths from these cases were included in the study. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . belfort) (figure ) . the hospital mortality rate (not age-standardized) has the same spatial distribution. it varies from . per , (tarn-et-garonne) to . per , (territoire de belfort), with a mean of . (median . ) and a standard deviation of . . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . from the calculation of age-specific case-fatality rates, the slr is between . and . , with the mean at . and the median at (figure ) . in the following, we will consider only the slrs calculated with age-specific case-fatality rates that do not take into account the ile-de-france and grand-est regions. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . the spatial distribution of standardized morbidity rate (hospitalized cases) shows a significant spatial autocorrelation (moran index: . , p-value < - ), and this is expected for an infectious disease. the case-fatality rate shows also significant spatial autocorrelation (moran index: . , p-value < . ), and this is no expected. the analysis of the clusters clearly shows a clustering of high case-fatality rate values in regions of high morbidity (particularly the grand-est), and shows some cases of districts with high case-fatality rate values isolated in areas with low rates. the breslow & day significance test shows districts where the slr is statistically significantly different from , corresponding to districts with abnormally high (slr > , red) or abnormally low (slr < , green) case-fatality rates. the individual significance threshold is set at . , and for all districts at . to account for multi-testing ( figure ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. there is a correlation between the standardized hospitalization rate and the standardized case-fatality rate (bravais-pearson index= . ) (figure ), a correlation which increases ( . ) if we limit the calculation to districts whose slr is significantly different from (p-value < . ). to illustrate the increase of case-fatality rate with hospitalization rate, table gives the mean of the standardized case-fatality rate over the districts according to their standardized hospitalization rate. the average case-fatality rate varies from . for . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . the mapping of the hospitalization rate and the hospital mortality rate with the slr shows the spatial correspondence of these values ( figure ) . a typology combining hospitalization rates and case-fatality rates is proposed: low rates (values below the mean by less than one standard deviation), high rates (values . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . above the mean by more than one standard deviation), so as to represent four classes (low-low, low-high, high-low, high-high). the hatched areas represent those for which the slr is not significant (p-value > . ) (figure ). figure . combination of standardized hospitalization and case-fatality rates in four classes. the ratio between the rate of patients in intensive care and the rate of hospitalization gives in principle an indication of the severity of the patients in hospital. this hospitalization rate and severity rate show a weak negative correlation (r=- . ), indicating a decrease in the intensive care rate when the hospitalization rate is high. this trend may be due to the saturation of intensive care units. the relationship between hospitalization and severity could also be interpreted as a decrease in less severe hospitalizations in order to be able to manage more severe cases when the healthcare system is overloaded, which would result in an increase in lethality. nevertheless, in both cases, there is no correlation between the severity rate and the case-fatality rate (r=- . ), indicating that globally, the intensity of reanimation does not impact the case-fatality rate. finally, the severity rate does not have a spatial distribution corresponding to the increase in the hospitalization rate ( figure ) . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the standardized case-fatality rates (slr) of the districts in france ( . for tarn- et-garonne to . for the vosges district) remain in a ratio of . to . compared with the national average of . , calculated by excluding districts under stress in order not to take account of possible saturation of the care systems. the relationships between morbidity rates and standardized case-fatality rates in france show a correlation between these two indices, the average case-fatality rate for all districts being about % higher than the average rate calculated in the % of districts with the lowest hospitalization rates. it is therefore very likely that the increase in hospital tension over the period under consideration has increased the hospital case-fatality rate: for the districts with the highest hospitalization rates (essentially located in the grand-est and ile-de-france regions), the average case-fatality rate is per cent higher than the average for all districts, and per cent higher than the average for all other districts alone. it can be concluded that hospital case-fatality rates have increased the national average case-fatality rate by district from . to . . it can therefore be estimated that , deaths (out of the , deaths due to covid- in hospital in france from march to may , i.e. % of the total number of deaths) are due to the saturation of the health system in the grand-est and ile-de-france regions. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint there are clearly two risk profiles: / the districts where a high rate of hospitalization is coupled with a high case-fatality rate, and / the districts where a low rate of hospitalization is coupled with a high case-fatality rate. the first category probably results from an increase of lethality due to saturation of the health care system. the second category is probably linked to the opposite phenomenon: a low hospital case-fatality rate which would have led to an increase in lethality due to a local lack of healthcare access (e.g. medical deserts, poor hospital lethality preparation). it has also been noted that all these late districts are located in essentially rural areas. some districts in the south of france have both a very low rate of hospitalization and a very low case-fatality rate (gironde, dordogne, gers, pyrénées orientales), as a result of the low circulation of the virus and the effective response of the health system. another particular case, is the one of the bouches-du-rhône, which appears with a high hospitalization rate ( french average is therefore very significantly higher than the world average (p-value < - ). even if we consider only the average case-fatality rate calculated only for the french districts with the lowest hospitalization rates (thus not causing saturation of the health care system), this average is still very significantly higher than the international average (and the rates of most european countries, such as spain, . , greece, . , germany, . , etc.) (table ) . taking into account the quality of the healthcare system in france (table ) , it can be concluded that the difference between the case- . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . fatality rate calculated for france and the case-fatality rates presented using international who data is highly probably the result of a difference in the registration of cases and/or deaths and not due to the quality of health care. these differences in the counting of cases and/or deaths may be due to the hospitalization and screening policy specific to each country as well as the ability or willingness to hospitalize more non-severe forms, to the differences in case definition, or to insufficient quality of the system for detecting and reporting cases and deaths. this study shows that the higher case-fatality rates observed in france in certain districts during the first wave of the covid- epidemic (data from march to may ) are mostly linked to the level of morbidity in the district, and therefore to the congestion of the healthcare systems during the acute phases of the epidemic. when the hospitalization rate is low, high case-fatality rates concern rural districts and could be linked to health care access in these districts. however, the increase in the standardized case-fatality rate due to exceptional situations during epidemic peaks represents less than % of the average case-fatality rate per district in france, and the hospital case-fatality rate without these districts would be reduced from . to . . this increase cannot therefore explain the extent of the difference observed between the average case-fatality rate in france and the average of the rates reported for all countries by international organizations or information sites (who, wordometer, etc.). these differences probably stem from the reporting of cases and deaths, which is uneven from one country to another, and not from the care or treatment of patients during hospital stress due to epidemic peaks. real estimates of mortality following covid- infection [mor ] morteza abdullatif khafaie, fakher rahim. cross-country comparison of case fatality rates of covid- /sars-cov- . osong public health and research por ] porta m. a dictionary of epidemiology. th ed an empirical estimate of the infection fatality rate of covid- from the first italian outbreak using early data to estimate the actual infection fatality ratio from covid- in france estimating the burden of sars-cov- in france key: cord- -q qgps authors: knobbe, rebecca b; diallo, abdallah; fall, amary; gueye, aida d; dieng, assane; van immerzeel, tabitha d; ba, abou; diop, amadou; diop, abdoulaye; niang, mbayame; boye, cheikh sb title: pathogens causing respiratory tract infections in children less than years of age in senegal date: - - journal: microbiol insights doi: . / sha: doc_id: cord_uid: q qgps introduction: while acute respiratory tract infections are the main cause of paediatric mortality and morbidity worldwide, pathogen patterns shift due to factors such as hygiene, vaccinations, and antibiotic resistance. knowledge about current cause of respiratory infections is lacking, particularly in low- and middle-income countries. the aim of this study was to identity the various respiratory pathogens causing acute respiratory tract infections in children below years of age visiting a sub-urban primary care clinic in senegal. methods: a case-control study was performed in september and october . oropharyngeal swabs were collected from cases; infants with fever and respiratory symptoms, and controls; children involved in the vaccination programme. viral identification was conducted by polymerase chain reaction for different viruses; bacteria were identified by culture studies. associations between microorganisms, acute respiratory infection and severity of disease were calculated by multivariate regression adjusting for confounders such as age, sex, and living area. results: overall, cases and controls were included. microorganisms were detected in . % of cases and . % of controls (p < . ). influenza virus a (including h n ), influenza virus b, respiratory syncytial virus (rsv), and streptococcus pneumoniae were independently associated with acute respiratory tract infections. co-detection of two or more pathogens was present in . % of cases; . % of cases had a pneumonia and . % was treated with antibiotics. conclusions: this case-control study in a primary care setting in sub-saharan africa found influenza virus a and b, rsv, and s pneumoniae to be the main causes of acute respiratory tract infections in children below years of age. we recommend evaluation of antibiotics prescription behaviour in this setting. worldwide, the leading cause of paediatric mortality and morbidity in the postneonatal period remains lower respiratory tract infections (lrtis). the who (world health organization) estimated that more than of the . million total deaths in children less than years old were caused by lrtis in . a meta-analysis found a hospital-based case-fatality ratio of . % in children in lowincome countries with severe lrti, compared with . % in high-income countries. children with lrti can present with a highly variable package of symptoms including cough, tachypnoea, dyspnoea, fever, rhinitis, chest pain, abdominal pain, vomiting, diarrhoea, headache and lethargy. the who guidelines states tachypnoea as the main diagnostic criterion for pneumonia requiring an antibiotic. however, distinction from upper airway infections and other illnesses such as asthma/bronchiolitis, anaemia or malaria can be challenging when minimal diagnostic tools are available. furthermore, in many low-and middle-income countries, treatment policies are empiric or based on foreign guidelines, due to a lack of local causal studies. these could be reasons why research has discovered an overdiagnosis and overprescription of antibiotics to treat pneumonia in low-income countries. one of the biggest public health problems of this century is antimicrobial resistance. it threatens the effective treatment of major infections and is induced by an overuse and inappropriate usage of antibiotics. this phenomena has major consequences: higher health-related costs because of the necessity of more expensive antibiotics, rising mortality rates due to pathogens causing respiratory tract infections in children less than years of age in senegal microbiology insights untreatable infections and an increasing danger for the immunosuppressed patient. , moreover, viral causes of lrtis have become seemingly more important. ancient studies in mostly western countries frequently described haemophilus influenza b (hib), streptococcus pneumoniae, and moraxella catarrhalis as major causative pathogens of lrtis. , nonetheless, while in , s pneumoniae was responsible for deaths in children, in , this number dropped to children. recent developments, such as the implementation of the pneumococcal conjugate vaccine and the hib vaccine, are responsible for a reduction in the burden of these respiratory bacteria but may also have induced a shift in the pathogens causing lrtis. , recent research in senegal indicated viruses as main pathogens of all acute respiratory tract infections (artis), both upper and lower. the frequency of virus detection was even higher than those found in several other countries. , viruses most commonly found in senegal were respiratory syncytial virus (rsv ), adenovirus, rhinovirus, influenza virus a, enterovirus, human bocavirus, and parainfluenza viruses. furthermore, there are indications that nowadays artis are more often caused by the sequential or concurrent interaction of different pathogens and that the presence of multiple organisms is linked with the existence of a lrti and with severity of disease. , to reduce paediatric mortality caused by lrti, while fighting antibiotic resistance, more knowledge about the cause of respiratory infections, especially in low-and middle-income countries, is essential. case-control studies have been conducted in africa, investigating the association between different pathogens and pneumonia. these studies found strongest associations for s pneumoniae, bordetella pertussis, rsv, influenza virus a, and human metapneumovirus. [ ] [ ] [ ] [ ] [ ] [ ] however, these studies were conducted in hospitalized settings while most children with lrti are treated in primary care clinics. to the best of our knowledge, no case-control studies investigating artis in primary care have been conducted in sub-saharan africa. therefore, the aim of this case-control study was to investigate the prevalence of the different viruses and bacteria colonizing the airways and their association with the occurrence of artis and severity of disease in children less than years of age, visiting a sub-urban primary care clinic in dakar, senegal. an unmatched case-control study was performed at the institute de pédiatrie sociale (ips), a primary care clinic in dakar, senegal, during september and october . institute de pédiatrie sociale is a free government health care clinic for children and pregnant women based in pikine, a sub-urban area. children with respiratory infections were enrolled using convenience sampling at the paediatric outpatient ward. controls were enrolled during the vaccination programme, which took place once a week. exclusion criteria for controls were fever and respiratory symptoms. standardized forms were used to prospectively gather information concerning patient demographics, medical history, clinical signs, and symptoms at enrolment and treatment. oropharyngeal swabs and bloods samples were taken in cases. one week after enrolment, symptoms and signs were evaluated by phone call in all cases. every case was called a minimum of times when parents did not respond. when a child had to be admitted to a hospital, daily follow-up of signs and symptoms was conducted. data were imported in the data management software, excel. databases were anonymized. this study has been approved by the ethics committee for research of the cheikh anta diop university of dakar. data were gathered after an informed consent statement had been signed by parents or a legal guardian. children aged less than years old with an acute respiratory infection defined as (antecedents of ) fever and at least one respiratory symptom were found suitable for inclusion. cases were excluded if the symptoms began > days before enrolment and/or if antibiotics were taken within hours before enrolment. exclusion criteria for controls were signs of fever or respiratory symptoms. fever was defined as a rectal or ear temperature of ⩾ . °c or an axillary temperature of ⩾ . °c. antecedents of fever had to occur within hours before enrolment. respiratory symptoms included cough, thoracic pain, sore throat, dyspnoea, chest indrawings, tachypnoea, cyanosis, and rhinorrhoea. tachypnoea was defined using the who definition of a respiratory rate > breaths/min in children < months of age, > breaths/min in children to months of age, and > breaths/minute in children ⩾ year of age. tachycardia was defined as > beats per minute (bpm) for infants < years of age and > bpm for children to years of age. elevated c-reactive protein (crp) suggestive for severity of disease was defined as ⩾ mg/l. , leucocytosis was present if leucocytes are increased to more than /mm . pneumonia was defined using the who guidelines as tachypnoea with cough and/or dyspnoea. alarming signs were defined as tachypnoea, chest indrawing, or hypoxemia. in all cases and controls, oropharyngeal samples were collected. all samples were analysed by the biotechnology unit of the laboratory of bacteriology of university hospital aristide le dantec and by the virology unit of pasteur institute. the samples were stocked and transported following the protocols. for bacterial samples, bacteria were isolated from appropriate culture media. morphological, cultural, and biochemical or antigenic characters were studied. strains were determined and knobbe et al considered for infection if the bacterial load was at least cfus/ml. all samples were tested using polymerase chain reaction (pcr) with a bio-ras cfx- thermo cycler and the ftd respiratory pathogens (fast-track diagnostics), capable of detecting viruses and bacteria (supplement ). in addition, blood samples were collected in cases and crp and leucocytes were determined by the laboratory of ips. c-reactive protein was determined using the crp latex kit a (lorne laboratories, berkshire, uk). based on g*power . . . version, a sample size of was yielded, when using logistic regression, an alpha of . , and a small-to-medium effect size with an odds ratio (or) of . . therefore, a sample size of is sufficient to detect microorganisms as a predictor of acute respiratory infection. baseline characteristics were compared between cases and controls. continuous variables were expressed as medians and ranges. they were compared using the mann-whitney u test. categorical variables were expressed as frequencies and proportions and were compared using the chi-square test. to identify potential predictive factors, a univariable logistic regression was used. thereafter, established predictors of the outcomes (occurrence of respiratory infection and severity of disease) (p < . ) were included in multivariable logistic regression. data were presented as ors and % confidence intervals (ci). p < . was considered significant. epi info was used for analysis of the data. of eligible children, cases and controls were analysed ( figure ). ten cases were excluded from analysis, due to an onset of disease of more than days before enrolment, missing month of birth, or an age of more than months. approximately % of all assessed controls declined to participate in the study, mainly based on fear of discomfort for their child or possible disapproval of the other parent. none of the cases declined. overall, ( . %) children were male, and the mean age was . (± . ) months. overall vaccination coverage was . %. table shows a summary of baseline characteristics of the included cases and controls at enrolment. a significant difference of means was found in mean age among case and control group, respectively, . (± . ) and . (± . ) with a p value of <. . furthermore, cases more often lived in other areas in and outside of dakar, whereas more controls than cases lived in the neighbourhood near the pikine clinic, respectively, ( . %) and ( . %) with a p value of <. . among all cases, . % had a pneumonia based on who criteria. the main respiratory symptoms were rhinitis and cough, in ( . %) and ( . %) of cases, respectively. in all, . % had a tachycardia and . % a tachypnoea. none of the children had a hypoxemia during consultation. on physical examination, ( . %) cases had abnormal lung sounds of which rhonchi were the main type. an elevated crp was seen in . % of cases with a mean crp of . (± ). in all, . % had a leucocytosis with a mean number of leucocytes of . (± . ). malaria rapid diagnostic tests were performed on only cases, but all were negative. data on treatment were available in cases. antibiotics were prescribed in . % of those. data on follow-up were only available in cases. in . % of those, symptoms had passed within week. none of the children had to be hospitalized. table shows a summary of clinical signs and symptoms and management of cases. for detection of bacteria, only culture was used, because when using pcr, equal amounts of bacteria were found in cases and controls. the reason for this is that a better differentiation between bacterial colonization and infection can be made using cultures. at least pathogen was detected in . % of cases and . % of controls. bacteria were detected in . % of cases and % of controls, of which s pneumoniae ( . %) and h influenzae b ( . %) were the most prevalent. viruses were detected in . % of cases and . % of controls and influenza virus a ( . %), rsv ( . %), and influenza virus b ( . %) were most common. in . % of cases, or more pathogens were detected. univariate analysis shows that s pneumoniae, rsv, influenza virus a (including h n ) and b were significantly associated with the occurrence of arti (table ) (continued) . , ci: . - . ). respiratory syncytial virus was only significantly related to illness in children less than years of age. likewise, the prevalence was higher in this age group. legionella pneumophila, b pertussis, chlamydia pneumoniae, coronavirus , coronavirus oc , coronavirus hkui, piv (parainfluenza virus) , piv , piv , human metapneumovirus, and influenza virus c were investigated, but not detected in cases or controls. the prevalence of pathogens in cases and controls is illustrated in figure . table shows the prevalence of different co-detections. streptococcus pneumoniae was found in most of the co-detections ( . %). it was most frequently found in combination with influenza virus a, in cases. associations between all possible specific co-detections and illness were analysed, but no additional relationship was found, other than a cumulative association of the present pathogens. analysis of cases. treatment with antibiotics was not significantly related to alarm signs: tachypnoea (or: . , ci: . - . ), withdrawals (or: . . ci: . - . ), and hypoxemia (or: undefined). none of the pathogens was significantly associated with those alarm signs or an elevated crp or leucocytosis. no difference in elevated crp or leucocytosis was found between bacteria and viruses. this case-control study investigates the prevalence of the different viruses and bacteria colonizing the airways and their microbiology insights association with the occurrence of artis in children visiting a sub-urban primary care clinic in senegal. dieng et al studied pathogens in children with arti in senegal and found a total of bacteria in children. they found a lower prevalence of s pneumoniae ( % of cases) in comparison with our study ( % of cases) and a prevalence of m cattharalis of % where we did not detect this pathogen. dieng et al used different swab sampling techniques (bronchoalveolar lavage, sinus fluids, and throat swab) depending on the site of infection. moraxella cattharalis causes otitis media and sinusitis rather than lrti, possibly explaining the higher detection rate. furthermore, their study covered a full year, including all seasons. although our study was conducted during months, it covered the rainy season, which is known for its respiratory infections. streptococcus pneumoniae was the most prevalent bacteria in our sample. recent case-control studies in low-income countries found similar prevalence in cases and controls, even though those countries have lower vaccination coverages. , , , in western countries with a similar vaccination coverage to senegal, s pneumoniae rates in children with arti are evidently lower than we detected. possibly, disease burden of s pneumoniae is high in senegal due to serotype replacement following the introduction of the pneumococcal vaccine, as has occurred in many other countries. staphylococcus aureus is a bacteria frequently detected in these studies. , , they used nasal/nasopharyngeal swabs, but the literature does not mention major differences in detection of s aureus between nose or throat. another explanation is the use of pcr for detection of bacteria. numerous studies in sub-saharan africa have been conducted studying the prevalence of viruses in children with an arti. equal total amounts of viruses and a similar prevalence of rsv and influenza viruses were detected when comparing with our results, but these studies, including some recent senegalese studies, found significantly higher percentages of adenovirus, enterovirus, and rhinovirus. , , , results from case-control studies conducted in low-and middle-income countries show a similar prevalence of all viruses in healthy children, except that the average prevalence of rhinovirus in those studies is approximately %, whereas we found rhinovirus in . % of controls. , [ ] [ ] [ ] [ ] the most obvious possible reason for the differences in virus prevalence is our short study period, given that virus prevalence is highly seasonal. this study did not find an association between different pathogens and alarm signs (tachypnoea, tachycardia, hypoxemia, or an elevated crp). concordant to our findings, no association was found between alarming signs and specific pathogens in previous research. both viral and bacterial infections can cause either mild or severe infections in children. other studies found an association between viral or bacterial aetiology and an elevated crp too weak to rule out bacterial infection in clinical practice. , , we did not find this association, presumably because of a small number of severely ill children. colonization by more than one pathogen is believed to influence the occurrence and severity of illness, by stimulating each other's adherence and decreasing clearance. co-detections were seen in . % of cases and . % of controls. most of the co-detections in our study were caused by s after adjusting for pathogens significantly related to illness, no relation was detected between the presence of a co-detection and illness in our study, which means that we did not detect a synergic effect in co-infection, possibly due to a small sample size. in investigating the cause of arti in low-income countries, most studies are done in hospital setting and case-control methods are rarely used. nevertheless, in these studies, similar pathogens were found with similar significant associations with illness compared with our study. [ ] [ ] [ ] [ ] [ ] [ ] , this could mean that the same pathogens are responsible for both upper and lower artis. furthermore, it confirms a generally shifting pattern towards viruses of pathogens causing artis. some pathogens were more prevalent in other settings, such as human metapneumovirus, piv, and mycoplasma pneumoniae. , , , , low prevalence of these pathogens was found in our study, possibly due to seasonality or their possible higher prevalence in severe infections. notable is the overprescription of antibiotics in our population. approximately % of cases have been treated with antibiotics, whereas only . % had a pneumonia and should have been treated as such following who criteria. moreover, most of the antibiotic treatments concerned broad-spectrum antibiotics, whereas a narrow-spectrum penicillin is recommended in the primary care setting. literature confirms that practices are similar in other low-income countries. [ ] [ ] [ ] the main strength of this study is the inclusion of all artis within a primary care clinic. this gives insight into the pathogens causing the infections. other strengths are the large number of pathogens tested for, with pcr and culture testing for bacteria, and the inclusion of treatment methods. an additional strength is that all data were gathered by one researcher, hereby decreasing the risk of variation in swabbing technique. there are also limitations to be mentioned. we could not properly adjust for some factors such as social status due to few data on these subjects. furthermore, selection bias could have occurred, because no matching was done. the average age of controls is lower than the average age of children with a respiratory infection, probably due to the young age of children enrolled in vaccination programmes. however, we did not discern significant heterogeneity regarding pathogens in different age groups (except for the mentioned differences in prevalence of rsv ) or living areas. another limitation is the use of only throat swabs. the nasopharyngeal swab is found to be superior in detecting influenza virus, s pneumoniae, and moraxella species, but oropharyngeal swabs are superior for the detection of m pneumoniae and h influenzae. [ ] [ ] [ ] [ ] it is preferable to use both techniques, but limited resources inhibited that. there was a lack of a gold standard such as chest x-ray for pneumonia. by taking a clinical definition of arti, there is possible overlap with other feverish diseases such as malaria and gastrointestinal illnesses. other limitations are the short duration of the study and a lack of follow-up data of patients due to nonresponse to phone calls. we might have missed data on severity of illness and hospitalizations. this case-control study conducted in senegal investigates the cause of artis in children less than years of age in a primary care setting. in this population, illness was mainly caused by influenza virus a and b, rsv, and s pneumoniae, which confirms a generally shifting pattern towards viruses in pathogens causing artis. we suggest continuation of this case-control study for a full year, and further research on serotypes and resistance patterns of bacteria present in children with arti. these findings could lead to improvement of vaccinations against respiratory pathogens. we recommend reduction of antibiotics prescription, especially broad-spectrum antibiotics, for children with an arti visiting a primary care clinic. rbk, adg, ad and tdvi contributed to the design and implementation of the research. samples were analyzed by af, adg, amb, abd and mn. rbk analyzed the data and wrote the manuscript with consultation from all authors. adiallo supervised the project at the clinic. csbb supervised the study. rebecca b knobbe https://orcid.org/ - - - amary fall https://orcid.org/ - - - tabitha d van immerzeel https://orcid.org/ - - - abou ba https://orcid.org/ - - - estimates developed by the un inter-agency group for child mortality estimation estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in countries: a systematic analysis for the global burden of disease study world health organization. revised who classification and treatment of childhood pneumonia at health facilities -evidence summaries british thoracic society guidelines for the management of community acquired pneumonia in children: update viral etiology of hospitalized acute lower respiratory infections in children under years of age -a systematic review and meta-analysis can we distinguish pneumonia from wheezy diseases in tachypnoeic children under low-resource conditions? a prospective observational study in four indian hospitals antimicrobial resistance: a global multifaceted phenomenon antibiotic resistance threats in the united states childhood pneumonia: the role of viruses burden of disease caused by haemophilus influenzae type b in children younger than years: global estimates burden of disease caused by streptococcus pneumoniae in children younger than years: global estimates burden of streptococcus pneumoniae and haemophilus influenzae type b disease in children in the era of conjugate vaccines: global, regional, and national estimates for - invasive disease potential of pneumococci before and after the -valent pneumococcal conjugate vaccine implementation in children children under five years of age in senegal: a group highly exposed to respiratory viruses infections viral and bacterial etiologies of acute respiratory infections among children under years in senegal enteroviruses and rhinoviruses: molecular epidemiology of the most influenza-like illness associated viruses in senegal community-acquired pneumonia in children -a changing spectrum of disease respiratory viruses detected in mexican children younger than years old with communityacquired pneumonia: a national multicenter study microorganisms associated with pneumonia in children < years of age in developing and emerging countries: the gabriel pneumonia multicenter, prospective, case-control study viral and bacterial causes of severe acute respiratory illness among children aged less than years in a high malaria prevalence area of western kenya aetiology of childhood pneumonia in a well vaccinated south african birth cohort: a nested case-control study of the drakenstein child health study association of respiratory viruses with outcomes of severe childhood pneumonia in botswana a preliminary study of pneumonia etiology among hospitalized children in kenya etiology and factors associated with pneumonia in children under years of age in mali: a prospective case-control study national health care provider solutions. paediatric advanced life support: provider handbook the utility of serum c-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of children diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review a flexible statistical power analysis program for the social, behavioral, and biomedical sciences nucleic acid amplification tests for the diagnosis of pneumonia moraxella catarrhalis, a human respiratory tract pathogen community-acquired pneumonia requiring hospitalization among u.s. children serotype replacement in disease following pneumococcal vaccination: a discussion of the evidence multi-site and nasal swabbing for carriage of staphylococcus aureus: what does a single nose swab predict detection of non-influenza viruses in acute respiratory infections in children under fie-year-old in cote d'ivoire viral etiology of respiratory tract infections in children at the paediatric hospital in ouagadougou (burkina faso) seasonal variations of respiratory viruses and etiology of human rhinovirus infection in children the value of clinical features in differentiating between viral, pneumococcal and atypical bacterial pneumonia in children differentiation of bacterial and viral pneumonia in children a three-step diagnosis of paediatric pneumonia at the emergency department using clinical predictors, c-reactive protein, and pneumococcal pcr viral bacterial co-infection of the respiratory tract during early childhood the contribution of viruses and bacteria to community-acquired pneumonia in vaccinated children: a case-control study aetiological role of common respiratory viruses in acute lower respiratory infections in children under five years: a systematic review and meta-analysis care seeking behaviour and aspects of quality of care by caregivers for children under five with and without pneumonia in ibadan the effect of rapid diagnostic testing for influenza on the reduction of antibiotic use in paediatric emergency department an under-recognized influenza epidemic identified by rapid influenza testing a comparison of nasopharyngeal and oropharyngeal swabbing for the detection of influenza virus by real-time pcr comparison of the prevalence of common bacterial pathogens in the oropharynx and nasopharynx of gambian infants comparison of four different sampling methods for detecting pharyngeal carriage of streptococcus pneumoniae and haemophilus influenzae in children comparison of oropharyngeal and nasopharyngeal swab specimens for the detection of mycoplasma pneumoniae in children with lower respiratory tract infection key: cord- -q f d ig authors: zhao, pengcheng; zhang, nan; li, yuguo title: a comparison of infection venues of covid- case clusters in northeast china date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: q f d ig the world has been suffering from the covid- pandemic since late . in this study, we compared various types of infection locations in which covid- cases clustered, based on the data from three adjacent provinces in northeast china. the collected data include all officially reported cases in this area until march . we explored the associations between the cases and the frequency of infection locations. the covid- epidemic situation was worse in heilongjiang province than in liaoning and jilin provinces. most clustered cases occurred in individual families and/or between relatives. the transmission in public venues served as a hub for transmitting the disease to other families and results in new clusters. the public transport spread the infection over long distances by transporting infected individuals, and most infections did not seem to occur within vehicles. this field study shows the effect of indoor environments on sars-cov- transmission and our data may be useful in developing guidance for future disease prevention and control. a novel coronavirus pneumonia (covid- ) emerged in wuhan, hubei province, china in late , and has swept around the world [ ] [ ] [ ] . its transmissibility between people has been reported to exceed that of sars-cov- [ ] [ ] [ ] and mers-cov [ , ] . several studies have investigated sars-cov- transmission by the statistical analysis of outbreaks on large scales, such as entire countries [ , [ ] [ ] [ ] or by case studies of a family [ ] [ ] [ ] [ ] [ ] [ ] or a specific group of people, such as the elderly [ ] and healthcare workers [ ] . however, few studies have focused on the characteristics of sars-cov- transmission for a regional epidemic situation in a medium-scale area, with an analysis accounting for local policy and government actions. thus, we propose choosing a region with a sufficient number of covid- cases and their detailed case reports to illustrate the role of different types of location in person-to-person transmission of this disease. in the covid- outbreak, the chinese health authorities made their case investigation data publicly available [ , ] . these data present a good opportunity to investigate the roles of various infection locations in sars-cov- transmission. previous viral outbreaks have reportedly involved transmission in various types of location, such as sars-cov- in a residential estate [ ] , mers-cov in a hospital [ ] , norovirus on mass transport [ ] and influenza virus a in a market [ ] , with various transmission routes, including the fomite [ ] , large droplet [ ] and airborne [ ] routes. sars-cov- , as a novel coronavirus, has also been reported to be transmitted in various locations, such as a shopping mall [ ] , a cruise ship [ ] , healthcare settings [ ] and homes [ , ] , with various possible transmission routes [ ] . however, direct determination of the exact infection location is difficult in most situations when there is no complete and detailed record of a newly infected patient's itinerary before the case was confirmed [ ] . only when we know the details of a patient's movement can we effectively determine the infection source [ ] . for some cases, the infection source cannot be identified during initial tracking of the case's activities, unless trajectories of all individuals are tracked in public places, such as buses, restaurants and shops. in this study, we analysed the reported cases in liaoning, jilin and heilongjiang, which are three adjacent provinces in northeast china. the travel records of all confirmed patients in these three provinces have been posted online by local health authorities via official websites, social media or newspapers. for details, please refer to table s . this provides an opportunity to analyse the reported cases within a city or over provinces. the population inflow from southern china before the lunar new year ( january) is known to have mainly come to these three provinces [ ] , which helps in identifying the imported cases into the studied area. we first summarised all covid- cases in the three provinces before march , and identified the relationships among the reported cases based on case reports. we also clustered the cases according to meeting locations of the involved individuals. based on the collected and deduced information, we compared the epidemic situations between cities and/or provinces and enumerated the cases for the various location clusters. we collected personal information (surname, age, sex, infection source) and itinerary reports of all cases confirmed before march in the three provinces of northeast china. these cases were reported daily by the local health authorities of cities via their websites, with a few cases published via social media or online newspapers, as listed in table s . the cases in each city (large city or prefecture regionalised by the state council [ ] ; the administrative region containing counties, cities, municipal districts and townships) were sequentially numbered according to the timing of notification (or the original order in the city's report, usually according to the date of confirmation). a total of cases were collected in the three provinces (liaoning, cases; jilin, cases; heilongjiang, cases). we determined any related cases, including family members, relatives, friends and strangers in close contact [ ] . note that the total number of cases in this study was based on the governments' daily reports. in some cities, we observed that the final reported number of confirmed cases was less than the sum of the daily reported cases. this occurred as some of the cases were later identified to belong to other regions outside the three provinces. in other situations, a few asymptomatic cases had been originally counted in the daily report, but were finally excluded from the statistics. when determining the potential relationships among cases, we noted that some cases had the same address and detailed itinerary, but their potential relationships were not directly noted in their case reports. we identified those cases as possible clusters in families. for any case pairs with a relationship (directly collected from case reports or identified by searching the report details) to the existing cases, the relationship is specified in table s . we also listed the locations where each case stayed and was likely to meet an infection source (in table s ). we summarised the frequently visited locations and categorised them according to the involved activities between people from an estimated high infection probability to an estimated low infection probability, as shown in table , by assuming that dining activities and long-term or repeated close contact between people can increase the probability of the disease transmission [ , ] . we summarise each of the cases and identify their relationships in figure , based on the information summarised in table s . icons of the cases are located in the three provinces in figure , differentiated by colour according to their reported cities with their serial numbers in the cities. the cases were categorized into four groups: (i) imported from hubei province (black solid edge); (ii) imported from anywhere outside the three provinces other than hubei, including other countries (dashed edge); (iii) locally infected cases who had contact with an unknown covid- source (thin-dot edge); and (iv) locally infected cases with no report of contact with any covid- sources (no edge). in addition, the cases were clustered and connected by five types of line corresponding to the five categories of clustering location in table . figure specifies all locations outside the home where case clustering occurred, and all train or flight numbers are marked along with the cases' travel date. note that clusters solely within families in public locations (i.e., the locations of the last four categories in table ) are not marked on figure , because the potential infection within families was more likely to occur at home, so family itineraries outside the home may be assumed to play an insignificant role in investigating the location of infection clusters. further statistical operations were performed according to the information in figure . to further understand the characteristics of the cases in the three provinces, a series of parameters were defined and counted as follows. first, the daily increase in the number of cases was searched for each province during the period between january and march . these statistical data were obtained from each provincial health commission (websites are listed in table s ), as not all collected case reports had the confirmation date. second, to compare epidemic prevention and control between administrative regions, the case density (number of cases per million people) and the imported ratio (ratio of the number of imported cases to the total number of cases) were calculated for each city and province [ ] . the population in each city and province was obtained from the household registered population [ ] . to compare the frequency of case clustering between locations, the clustering cases were counted for each of the specific types of infection location listed in the third column in table . the number of cases connected in figure was determined for each type of location. note that the cases that connect multiple clusters were counted for each type of location. as a reference, the total exposure time of all reported cases for each type of location were also quantified. on traditional trains, electric multiple units (emus; a series of high-speed trains) or aeroplanes, the case's total exposure time was calculated by searching for and summing all travel durations. for each of the other location types, the total exposure time was estimated by the product of the total number of visits to the location and the average duration of stay per visit. in the types of location, the average duration of stay per visit was assumed to be , and h for home, bus/metro and taxi/private car, respectively [ ] ; and those for the other nine types of location were estimated by averaging the durations of stay per visit in the corresponding type of location mentioned in the case reports. we compared the clustering frequency of cases of different distances, i.e., contacts between cases whose home locations were separated as follows: inter-province contacts (connections between cases from different provinces in figure ), inter-city contacts (connections between cases from different cities in the same province in figure ) and intra-city contacts (connections between cases from the same city in figure ). however, a case could be clustered with cases from the same and other cities simultaneously. for this reason, we cannot associate every case with merely a single contact event. thus, we assumed a series of rules, set out below, to enumerate the contacts between cases as a parameter to quantify the clustering frequency of cases of different distances. we introduced a definition, named effective contact, as the minimum number of contacts required for one source case to infect all the others in a cluster. for a cluster of n people that includes one infection source, the number of effective contacts equals n − . the contacts counted in this study refer only to effective contacts, because extra contacts do not contribute to infection. we first set a case as the initial infection source of covid- for each cluster following the principles below. for a case in a cluster, if a case is imported from hubei, it is considered to be the infection source of the first order. ii. if no cases are imported from hubei but one is imported from outside the three provinces of northeast china, it is considered to be the infection source of the second order. iii. if no cases are imported from outside the three provinces of northeast china, but a case is imported that has been in close contact with some cases confirmed in other provinces, it is considered to be the infection source of the third order. iv. if there are multiple possible infection sources of the same order, or if there are no possible transmission sources, the first reported case (usually the case with the lowest serial number) among the cases of the highest order is considered to be the infection source. in addition, we set the priority order of contact between cases. for each infected case in the clusters in figure (i.e., for all cases except the assumed source cases), we selected an upstream case as its most likely contacted case following the principles below: the disease spreads from the source case to the other cases step by step. ii. the case upstream from an infected case is only selected from direct-connected cases (without an intermediate case). iii. for an infected case with connected cases from different cities or provinces, the infection is first found from the cases of the same city, then from different cities in the same province, and then from different provinces. iv. for any two cases with more than one type of contact, we assume that the infection occurs in the category of contact with a smaller order in table . thus, for each cluster in figure , we assumed one case to be the initial source of infection and determined an upstream contacted case for each of the other cases. the number of contacts was then counted respectively for each category of location (in table ) based on the rules introduced above. the contacts were further sub-categorised into inter-province contacts, inter-city contacts and intra-city contacts. the number of contacts in each sub-category was also counted. note that the assumed contact network in each cluster can be considered as a possible transmission chain for each case cluster. however, the number of contacts, as our target parameter, is related only to the set priority order of effective contact, but independent of the choice of source cases and the consequent possible transmission chains. the assumption of a source case is made only for the convenience of counting the number of contacts. table s . the locations for the clusters outside the home and the flight and train numbers along with the cases' travelling dates are specified on the diagram. in general, figure shows that the epidemic situation varies by province and by city. the total number of cases, the number of clusters and the average scale of the clusters in heilongjiang are generally greater than those in the other two provinces. in all three provinces, most cases had recorded contacts with other cases and were therefore grouped into case clusters. inter-city and inter-province contact events occurred frequently. five hundred and twenty-six of the cases were clustered due to family gatherings at home. most clusters have a simple structure with a single location of occurrence, but there are also some clusters in which multiple clustering events are connected to each other via several case nodes to form a larger cluster in which the exact infection sources are difficult to identify. the regional epidemic situations for all cities are shown in figure . figure a depicts the daily increase in cases in each province. the first case was reported on january in each of the three provinces. the peak of the daily increase in cases occurred later in heilongjiang than in the other two provinces, but the peak was significantly higher than in the other two provinces. in terms of the absolute number of cases, harbin became the worst affected city, with the darkest red area in figure b , and its cases comprised . % of all cases in heilongjiang and . % in the three provinces. figure c shows obvious differences in epidemic severity among cities and provinces. cities on the horizontal axis (y = ) received no imported cases and thus had a light epidemic burden, and cities on the line of y = had no locally infected cases and thus showed good performance in disease prevention and control. the epidemic situation in some cities in heilongjiang (red areas), such as shuangyashan, jixi and harbin, is significantly more serious than in the other regions. the situations of liaoning and jilin were relatively better. furthermore, a higher imported ratio was found in liaoning than in jilin (imported cases/total cases: liaoning, / ; jilin, / ; heilongjiang, / ), which indicates a lower ratio of local community infection in liaoning and thus a better effect of covid- prevention and control. the risk of infection in various locations is compared by counting the number of clustered cases in each type of location (in figure a ) and the contacts between cases of different distances (in figure b ). as shown in figure a , . % of total cases were clustered in a home, apartment or residential estate. considering the lack of detailed information in the case reports, it is believed that some cases in the same apartment or residential estate could be from the same family. some clusters also occurred in restaurants ( . %) and public buildings ( . %), such as hospitals, shops and malls. the risk of infection in various locations is compared by counting the number of clustered cases in each type of location (in figure a ) and the contacts between cases of different distances (in figure b ). as shown in figure a , . % of total cases were clustered in a home, apartment or residential estate. considering the lack of detailed information in the case reports, it is believed that some cases in the same apartment or residential estate could be from the same family. some clusters also occurred in restaurants ( . %) and public buildings ( . %), such as hospitals, shops and malls. however, a high frequency of infection in a type of location could be due to long exposure times in such locations, rather than the infection being particularly efficient. in figure a , the total exposure time of the cases in each type of location is also displayed as a reference to compare with the number of cases clustered in the location. apart from the location of home/apartment/residential estate, the cases also exposed themselves for a long time in hospitals, hotels, offices and the coaches of traditional trains. figure b , the number of contacts also varies by province. the number of contacts between cases in public buildings in heilongjiang was significantly higher than those in the other two provinces ( , and events in liaoning, jilin and heilongjiang, respectively). table . each bar is a stack of cases from all three provinces. as a reference, the cases' total exposure time (× h, grey bars) and unit exposure time (hours) are listed for each type of location. three important types of public vehicle are underlined. the unit exposure times estimated from experience are marked with an asterisk. (b) number of contacts between cases in five types of location. the contact events in each category were subcategorised into the provinces in which the contact occurred, and each bar is a stack of inter-province, inter-city and intra-city contacts. table . each bar is a stack of cases from all three provinces. as a reference, the cases' total exposure time (× h, grey bars) and unit exposure time (hours) are listed for each type of location. three important types of public vehicle are underlined. the unit exposure times estimated from experience are marked with an asterisk. (b) number of contacts between cases in five types of location. the contact events in each category were subcategorised into the provinces in which the contact occurred, and each bar is a stack of inter-province, inter-city and intra-city contacts. figure b , the number of contacts between cases of different distances (i.e., inter-province, inter-city and intra-city) varied by location category. in general, . % of the contacts occurred between cases from the same city. the inter-city and inter-province contacts occurred mostly on public vehicles ( . %). however, a few inter-province and inter-city contacts still occurred at home or in public buildings, as cases received friends or family from other cities or provinces. in each category of location in figure b , the number of contacts also varies by province. the number of contacts between cases in public buildings in heilongjiang was significantly higher than those in the other two provinces ( , and events in liaoning, jilin and heilongjiang, respectively). figure lists all public vehicles, including traditional trains, emus and flights, that were taken by cases from different families. the trains g and t , both of which departed from wuhan, suffered from the most severe epidemic situation and transported a number of cases to all three provinces. on the public vehicles, contact occurred frequently between cases of each category of distance (inter-province, inter-city and intra-city contacts). however, only eight groups of cases were observed in the same coach of a train or on the same flight, as enclosed by dashed lines in figure , and three groups of cases involved train staff. overall, most cases had a history of residence in hubei but travelled in different coaches or on different dates. of distance (inter-province, inter-city and intra-city contacts). however, only eight groups of cases were observed in the same coach of a train or on the same flight, as enclosed by dashed lines in figure , and three groups of cases involved train staff. overall, most cases had a history of residence in hubei but travelled in different coaches or on different dates. during the period up to march, the daily increase in cases in all three provinces reached its lowest point, and no new cases were confirmed from to march. the daily increase in cases rose again after march, due to imported cases from overseas. we mainly analysed the effect of intervention in various regions and focused on the frequency of case clusters in various locations. the epidemic situation significantly varied by city and province. the case density and the imported ratio were calculated for comparing the regional epidemic situations, as shown in figure figure . diagram of cases clustering on trains (black, traditional trains; purple, emus) and aeroplanes (orange), in reference to the train and flight numbers and the travel date. each ribbon with one or multiple colours shows the provinces of the cases source. the case cluster corresponding to each train or aeroplane can be found in figure . the characteristics and the numbering of the icons are also consistent with those in figure . the cases on the same coach/flight are enclosed by a dashed line. grey shadows represent trains/flights that should have departed from wuhan that were cancelled on that day (or the previous day for overnight trains). during the period up to march, the daily increase in cases in all three provinces reached its lowest point, and no new cases were confirmed from to march. the daily increase in cases rose again after march, due to imported cases from overseas. we mainly analysed the effect of intervention in various regions and focused on the frequency of case clusters in various locations. the epidemic situation significantly varied by city and province. the case density and the imported ratio were calculated for comparing the regional epidemic situations, as shown in figure c , in which the cities and provinces to the upper left of the graph have lower case densities and local infection rates (i.e., a high imported ratio among the cases), which means that these cities are considered least affected; in contrast, the cities to the lower right of the graph encountered a heavier epidemic burden due to the higher case density and local infection rate. we mark all areas with a population of more than million in figure c , including six cities (shenyang, dalian, changchun, harbin, qiqihar and suihua) and the three provinces. most of these cities' positions in figure c are very close to their provinces (except for dalian, in which some cases did not have specified itineraries and were thus not counted as imported cases), which means that the epidemic situation in each province was highly related to that in these metropolises. we believe that this relationship was due not only to the cities' large percentage of their provinces' population, but also to their status as the transport hubs for the surrounding areas. the differences in the epidemic situation between cities and provinces may be due to differences in government actions and in public awareness of epidemic prevention and control. all three provinces initiated a level i emergency response to the public health emergency on january . however, several clustering events occurred in public buildings in heilongjiang after that date ( figure ). considering the similar natural environment, culture and economic development level in the three adjacent provinces, it may be hypothesized that local government actions and the efficiency in intervention played a major role in the epidemic among regions [ ] and that the early implementation of social distancing, testing and diagnostics can have a significant impact on epidemics [ , , ]. in addition, as shown in figure , significantly more large-family clusters (involving relatives from different estates) were found in heilongjiang, which means that people continued visiting relatives during this severe epidemic, indicating an absence of public awareness of epidemic prevention relative to the other two provinces. case clusters mostly occurred at home between families or relatives. in general, infection events on vehicles and in families were difficult to avoid at the beginning of the covid- outbreak. the outbreak overlapped with the lunar new year holidays ( january to february), for which people travelled home to reunite with their families [ ] . some imported cases were quarantining themselves at home with their families before their diagnosis. however, the high prevalence of cases in some cities in figure c was mainly due to the occurrence of several local outbreaks in public buildings, as cases who had been newly infected in public buildings could then act as a source to infect their families. infection in public buildings usually occurred between non-associated individuals or friends from different families. once infection occurred, it could further lead to an outbreak in new families via the newly infected cases [ , ] . some cities had a significantly large case density, such as harbin, jixi, suihua, shuangyashan and changchun (figure c) . we have observed large scale of clusters in public buildings in all these cities. for instance, seven cases from harbin and suihua, in heilongjiang, were staff or shoppers from toulong mall (a heilongjiang cluster with red and blue icons in figure ); some were also members of family clusters, which indicates that the cases from toulong mall could be the second-generation infection sources of their family clustering infections; similar local outbreaks were also found in qiqihar first hospital (a heilongjiang cluster with grey icons in figure ), the easyhome company's annual party (a jilin cluster with red icons in figure ) and three fruit markets in shuangyashan (a heilongjiang cluster with green icons in figure ). thus, public buildings showed a great effect on the spread of covid- . in some cases, the patients went to the same hotels or pharmacies or took the same buses or cars, but very few cases were confirmed from those categories of locations because the summarised case clustering in those locations all occurred between families or relatives, so we believe that their infection is more likely to have occurred at home. clustering occurred far less often in clinics than in hospitals, possibly due to the shorter average unit exposure time (shown in figure a) , as clinics usually have no long-term inpatients. in addition, no cases were found to have been infected in offices, except for staff working in hospitals and clinics. some cases were clustered in public transport ( . %). as shown in figure b , contacts on public transport led to more connections between cases from different cities or provinces than contacts in public buildings or at home. this means that contact between people as they travel by (or queue for) public transport could result in infection, spreading the disease to a new area. passengers on vehicles have a high risk of infection, but the risk still varies by the vehicle type. a higher infection rate was seen on traditional trains than on emus and aeroplanes. the case reports included trips on traditional trains, and we found clustering cases; the ratio of the number of clustering cases to the total number of reported trips was thus . %. this ratio was . % on emus and . % on aeroplanes, possibly due to the long average unit exposure time on traditional trains ( . h; shown in figure a ) compared with emus ( . h) and aeroplanes ( . h). in addition, the direction of seats (and beds) may also influence the infection risk. passengers in aeroplane cabins and most emu coaches face forward, whilst the seats and beds on traditional trains face each other [ ] . although figures and show a significant number of clusters on public vehicles, the number of actual infection events on trains and aeroplanes may have been far lower than the number of contacts quantified in figure b . figure shows that a significant proportion of cases on the clustering trains and aeroplanes had a residence history in hubei (icons with black solid edge), the site of the initial outbreak. figure further summarises the trains and aeroplanes in which cases from different families clustered. eleven of the trains or flights had cases from different provinces. the two trains, g and t , departing from wuhan included patients from all three provinces. some cases on the two trains travelled on the same day (enclosed with thin-dot line in figure ), which means that the infection could have occurred in the train coaches or in the trains' waiting rooms. however, we found only eight groups of cases in figure (enclosed with dashed line), each as a cluster with cases from different families clustering in the same coach of a train or the cabin of the same flight. there was a high probability of close contact between the cases in each group. in contrast, most cases had a residence history in hubei province and travelled on different dates, which means that the cases that departed from hubei may have been infected before they boarded the trains or aeroplanes. thus, we still believe that public vehicles are risky locations where cases tend to cluster, but not all cases were infected during their trips. public vehicles play two roles, as the locations in which infection occurs and as the agents that transport cases to a new area. some cases were truly infected during the trips, whilst most cases were purely clustered by the trains or aeroplanes with no infection occurring during transportation to a new area [ ] . in addition, cases or case clusters in figure had no connection to any imported cases or contact with any known covid- sources. in addition to the incomplete nature of the itinerary report, we believe that the absence of a possible infection source for a locally infected case (or case cluster) is due to the presence of asymptomatic cases [ , ] . for example, the case fuxin- in liaoning province was reported to have had contact with a relative who took the train g , one of whose on-board staff became a covid- confirmed case (shenyang- ), but the relative of fuxin- was not reported as a confirmed case. if we assume that each case (or case cluster) with no connection to any imported sources was infected via an asymptomatic case [ ] , then there should be about asymptomatic cases, which yields an estimated ratio of asymptomatic cases to all cases of /( + ) = . %. this ratio is higher than the corresponding ratio of . % in beijing [ ] , which indicates that potential asymptomatic cases in the crowd might have not been detected and confirmed. furthermore, some cases had family members who were not named as infection sources in the case reports but may have been asymptomatic carriers, despite being officially excluded as confirmed cases. thus, we suspect that the ratio of the number of asymptomatic cases to symptomatic cases might be actually much higher than . %, which is also evidenced by some recent reports [ , , ] . this study analysed the epidemic situations in various areas in the three provinces of northeast china and the effects of various types of infection location on identified covid- clusters. in general, the epidemic situations varied significantly by city and province. most infections occurred between family members and relatives at home, and their contacts usually involved dining activities. case clustering in public buildings might play a hub role in regional epidemic, such as in heilongjiang, because clustering events could cause infection between different families, which could cause further clusters of infection in more families. some case clusters occurred on trains and aeroplanes, which transported the cases to new areas, and this situation also increased the risk of infection during the trip. the timely closure of public buildings and efforts to raise public awareness may help to significantly relieve regional epidemics in the future. supplementary materials: the following are available online at http://www.mdpi.com/ - / / / /s , table s : statistic result of cases. author contributions: p.z. collected the data, drew the figures, conducted analyses and drafted the manuscript. n.z. and y.l. provided critical comments during the conceptualization and revision of the manuscript. all authors have read and agreed to the published version of the manuscript. virology, epidemiology, pathogenesis, and control of covid- the covid- epidemic characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention the reproductive number of covid- is higher compared to sars coronavirus can we contain the covid- outbreak with the same measures as for sars? what caused the outbreak of covid- in china: from the perspective of crisis management a study of the probable transmission routes of mers-cov during the first hospital outbreak in the republic of the sars, mers and novel coronavirus (covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned? incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china spatial transmission of covid- via public and private transportation in china preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak a familial cluster of infection associated with the novel coronavirus indicating possible person-to-person transmission during the incubation period a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster transmission of covid- in the terminal stage of incubation period: a familial cluster covid- transmission within a family cluster by presymptomatic carriers in china investigation of three clusters of covid- in singapore: implications for surveillance and response measures familial cluster of covid- infection from an asymptomatic covid- and the consequences of isolating the elderly reasons for healthcare workers becoming infected with novel coronavirus disease (covid- ) in china the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak multi-zone modeling of probable sars virus transmission by airflow between flats in block e airborne or fomite transmission for norovirus? a case study revisited human infection with influenza virus a(h n ) from live poultry markets physical factors that affect microbial transfer during surface touch short-range airborne transmission of expiratory droplets between two people evidence for airborne transmission of norwalk-like virus (nlv) in a hotel restaurant indirect virus transmission in cluster of covid- cases estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship the sars-cov- outbreak: what we know presumed asymptomatic carrier transmission of covid- transmission of influenza a in a student office based on realistic person-to-person contact and surface touch behaviour administrative division infection spread and high-resolution detection of close contact behaviors evolving transmission network dynamics of covid- cluster infections in south korea: a descriptive study a human behavior integrated hierarchical model of airborne disease transmission in a large city covid- infection epidemic: the medical management strategies in heilongjiang province impacts of social and economic factors on the transmission of coronavirus disease (covid- ) in china an investigation of transmission control measures during the first days of the covid- epidemic in china closed environments facilitate secondary transmission of coronavirus disease (covid- ) indoor transmission of sars-cov- turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid- assessing the impact of reduced travel on exportation dynamics of novel coronavirus infection (covid- ) characteristics of covid- infection in beijing covid- : four fifths of cases are asymptomatic, china figures indicate covid- : what proportion are asymptomatic? available online this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord- -pbfi c e authors: lyngse, f. p.; kirkeby, c. t.; halasa, t.; andreasen, v.; skov, r. l.; moller, f. t.; krause, t. g.; molbak, k. title: covid- transmission within danish households: a nationwide study from lockdown to reopening date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: pbfi c e background the covid- pandemic is one of the most serious global public health threats in recent times. understanding transmission of sars-cov- is of utmost importance to be able to respond to outbreaks and take action against spread of the disease. transmission within the household is a concern, especially because infection control is difficult to apply within the household domain. methods we used comprehensive administrative register data from denmark, comprising the full population and all covid- tests, to estimate household transmission risk and attack rate. results we studied the testing dynamics for covid- and found that the day after receiving a positive test result within the household, % of potential secondary cases were tested and % of these were positive. after a primary case in , households, % of potential secondary cases were tested within days, of which % tested positive as secondary cases, implying an attack rate of %. among primary cases, those aged - were underrepresented when compared with the total population. we found an approximately linearly increasing relationship between attack rate and age. we investigated the transmission risk from primary cases by age, and found an increasing risk with age of primary cases for adults, while the risk seems to decrease with age for children. conclusions although there is an increasing attack rate and transmission risk of sars-cov- with age, children are also able to transmit sars-cov- within the household. in late , increased numbers of severe respiratory infections were reported in the wuhan region in china caused by the sars-cov- virus (coronaviridae study group of the international committee on taxonomy of viruses, ). since its emergence, the virus has spread rapidly throughout all five continents affecting millions of people (world health organization, ) and causing massive economic losses (fernandes, ) . the effective reproduction number was estimated in different studies with different methods to range from . to . (boldog et al. ( ) ), revealing a high transmission potential. person-to-person transmission is a major transmission mode of sars-cov- , including transmission through aerosols or droplets on surfaces (chan et al., ; leclerc et al., ) . quantifying the transmission risk in different settings is essential for improving our understanding of the viral transmission dynamics, to implement effective preventive measures, to minimize economic damage, and to avoid overloading the healthcare system. close person-to-person contact is one of the main risk factors and transmission within the household is thus a major setting for virus transmission (prem et al., ; davies et al., ; cauchemez et al., ; leclerc et al., ) . furthermore, infection control and isolation are challenging in the (often crowded) household domain. quantifying the extent of transmission within the household can help improve our understanding of the effects of implementing quarantine for household members, physical distancing and improved hygiene. furthermore, these estimates are useful in constructing reliable prediction models for the spread of sars-cov- from households to the community. data from contact tracing and monitoring of individuals have been used to investigate household transmission of sars-cov- (he et al., ; jing et al., ; liu et al., ; li et al., ; madewell et al., ) . contact tracing is laborious and requires large resources when there are many new cases, as in the case of the sars-cov- pandemic. thus, these studies have been limited to include a maximum of a few hundred primary cases, selected mainly due to history of hospitalization or clinical disease (see a systematic review by madewell et al. ( ) ). the relatively small sample size as well as the selection and recall bias caused by contact tracing may limit the generalizability of these studies. in this study, we exploit national register data from denmark to investigate transmission patterns within households. to our knowledge, this is the first nationwide study that uses estimates of household attack rates and transmission risks that exploit sars-cov- test data from an entire population. the epidemic in denmark on february , , the first case of sars-cov- was diagnosed in denmark (reilev et al., ) . shortly thereafter, the number of cases began to rise with an estimated effective reproduction rate (re) of about . (statens serum institut ( )). on march , a comprehensive lockdown of the public sector was implemented by the government. moreover, the private sector was encouraged to work from home as much as possible. in figure a. (panel a) , key indicators of the epidemic are shown: number of tests, positive test results, hospitalized cases, and deaths for the early stage of the epidemic, the lockdown period and the two following stages of reopening. the figure shows a clear reduction in the number of positive test results, hospitalized cases and deaths over time. panel b shows a summary of the main measures for controlling the epidemic over time, including test and contact tracing strategy, and restrictions on public and private workplaces, education and childcare institutions, as well as in the community in general. all danish residents have access to tax-paid universal health insurance, and a test for sars-cov- is free of charge. furthermore, denmark has comprehensive social welfare insurance, and sars-cov- sick leave is fully reimbursed by the state. thus, financial reasons are not a major obstacle to obtaining a test. the test capacity has increased throughout the epidemic, and in the study period, the number of tests has been fairly stable since late april (figure a. ) . in the beginning of the epidemic, all suspected cases of covid- were tested and their contacts traced. however, soon after, due to capacity constraints on testing, only cases with severe symptoms (i.e., admitted to hospital) were tested and the overstretched contact tracing was halted. during reopening testing again became generally accessible, so that all residents could obtain a test without a referral (panel b of figure a. ) . in the current study, we used danish administrative register data. all residents in denmark have a unique personal identification number that allows a completely accurate linkage of information across different registers at the individual level. all microbiological data in denmark is registered in the danish microbiology database, from where we obtained individual level data on all national tests for sars-cov- for the period february , (the first positive test in denmark) to july , . information on the reason for being tested (e.g., symptoms, potential contact with infected persons etc.) was not available. from the danish civil registry system, we obtained information about the sex, age, and home address for all individuals living in denmark. all data management and analyses were carried out on the danish health data authority's restricted research servers with project number fseid- . we constructed households by linking all individuals living at the same address, and only considered households with six or fewer members, in order to exclude e.g., institutions. the data set captured . % percent of the danish population. person level data, which included information on the test result and date and time of sampling as well as time of the result, were linked to individuals within households. for each household, we identified the first positive test for sars-cov- ; this case was defined as the primary case and referred to as such throughout this paper. we considered all subsequent tests from other members in the same household as tests taken in response to the primary case. we defined secondary cases as those who had a positive test within days of the primary case being tested positive. primary examination of the data revealed that this cutoff provided a stable proportion of potential secondary cases (see figure b ). in addition, we assumed that the secondary household members were infected by the household primary case, although some of these secondary cases could represent co-primary cases. a longer cutoff time period could result in misclassification of cases among household members with somewhere else being the source of secondary infections. in order to investigate potential bias in our results in relation to time, due to changing test strategy and capacity over the epidemic period (see figure a . for an overview of test strategy and capacity), we separated the data into three data sets representing the three time periods based on the test date of the primary case, and analyses were performed separately on these data sets. the defined periods were: lockdown: march -april ; early reopening: april -may ; and late reopening may -july (see figure a . ). during lockdown, educational institutions were kept closed and the public sector with non-essential functions stayed at home. children's daycare was limited to children of employees in essential functions, such as doctors, nurses and police. employees in the private sector were encouraged to stay home if possible, and international travel was minimized by closing the borders except for essential activities. in the early reopening phase, children's daycare became available again, and schools were re-opened for classes up to th grade. in the late reopening, systematic contact tracing was resumed, schools ( - th grade) and higher educational institutions reopened, along with restaurants and smaller bars (with physical distancing). . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint to determine the probability that an additional household member would test positive after the primary case in the household was tested positive, we used all records for potential secondary cases within the household. we defined the attack rate as the proportion of additional household members that tested positive, whereas the transmission risk was the proportion of secondary cases per primary case. we did not exclude any potential co-primary cases in the main analysis. we further conducted a sensitivity analysis for the robustness of the time cutoff of transmission from the primary case to potential secondary cases. we used sas . to manage and analyze the data (sas, ) . in order to reach sufficient sample sizes, we separated all records into age groups of five-year intervals. to investigate the testing dynamics, we took an event study approach (ball & brown, ) . following this method, we used the date of diagnosis of the primary case in each household as an event and observed all other household members for five days before until days after the event. in the case of two or more primary cases detected on the same date, we randomly assigned one of them as the primary case. we estimated the probability of being tested (β τ ) for each day relative to the first positive test result within the household, using the following equation: where y i,t is a binary variable for individual i being tested at time t. τ is days relative to the date of the primary case's positive test result. i τ =t denotes indicators for time since the primary case's positive test result. β τ represents parameters estimating the probability of being tested on day τ relative to receiving the primary case's test result in the household. ε i,t denotes the error term, clustered on the household (event) level. we used the same equation to estimate the probability of y testing positive conditional on being tested. furthermore, to estimate the proportion of potential secondary cases that had been tested on day τ or previously, we estimated the absorbing probability, using the following equation: where i τ ≥t = if individual i was tested on day τ or previously, and zero otherwise. we also used the same equation to estimate the probability of y ever being tested positive. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint to investigate the proportion on positive tests originating from households, we defined new cases that live in a household with another case that tested positive within the preceding days as a case originated from the household domain. we used a seven day rolling average in order to take account of variation in testing rates across the weekdays. to estimate the attack rate, we estimated the proportion of potential secondary household members who received a positive test within days after the test date of the primary case. we estimated attack rates using the following equation: where y i,t = if the individual had a positive test within the days after the primary case, and zero otherwise. γ denotes a vector of fixed effects for the three periods. female is a binary variable for sex. β measures the day attack rate. ε i,t denotes the error term, clustered on the household (event) level. to investigate the age structure of the attack rate for potential secondary cases and transmission risk from primary cases, we used a non-parametric approach. we separated the data into five-year age groups. we estimated the attack rate using the following equation: where y i,t = if the potential secondary case i had a positive test within the days after the test date of the primary case, and zero otherwise. agegroup s is five-year age groups of the potential secondary cases. α is a vector that measures the age structured attack rate. ε i,t denotes the error term, clustered on the household (event) level. we estimated the transmission risk using the following equation: where agegroup p is five-year age groups of the primary cases. β is a vector that measures the age structured transmission risk. we estimated the age structured interaction between the attack rate and transmission risk using the following equation: . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . where γ is a vector that measures the age structured interaction between attack rate and transmission risk. to quantify the effect of age on attack rate, we estimated the approximately linear relationships between attack rate and age using equation: where β measures the probability of being infected as a linear function of age. φ is a vector of fixed effects for each time period (see "robustness of estimates over time" in section . ). δ measures the differential age gradient for each period. π measures the effect of sex for each period. in order to investigate the potential difference between male and female cases, we explored the age dependent attack rate separately for each sex. we also separated the data into households where the primary cases were children (below years of age) and adults (above years of age). these thresholds were chosen to ensure the primary cases were either children or adults. we estimated the attack rate stratified by the number of household members for households with one to six members. furthermore, we estimated the proportion of households with n number of positive cases, conditional on the size of the household being greater than or equal to n (with a maximum household size of six). in total, we obtained positive test results from , household primary cases and , positive secondary cases, see table . further summary statistics are presented in appendix b. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint appendix figure a. presents the probability of being tested and testing positive over the epidemic for five-year age groups. we found that all age groups are being tested, though children generally had a lower probability. the increase in test capacity over time was approximately equally distributed across ages. in late june, we saw an increase in the probability of children being tested. appendix figure b. shows summary statistics of the primary cases compared to the overall danish population. panel (a) shows the age distribution and panel (b) shows the household size distribution. there were proportionally fewer children as primary cases than in the total population. the household sizes of the primary cases generally matched the household sizes of the population. in this section, we focus only on the testing dynamics during the late reopening, where test capacity was stable. (in appendix d, we illustrate changes over all three periods.) figure panel (a) shows that after receiving a positive test result in the household (t = ), % of potential secondary cases were tested (blue) the day after the positive test result (t = ) of the primary case was available and % of these % were positive (red). on the day preceding the test result (t = − ), % were tested and % of these tests were positive. panel (b) shows the proportion of individuals that were tested (blue) and those that tested positive (red), daily up to days after the primary case was tested (t = ). % of potential secondary cases were tested on the same day as the primary case and % of potential secondary cases tested positive on that day. within days after the primary case was tested, % of the potential secondary cases were tested and % tested positive. there were % who tested positive on the same day (t = ) as the primary case. these may represent co-primary cases, and therefore do not represent household cases. under this assumption, in order to estimate the attack rate, one should exclude these cases (by subtracting percentage points (pp) from %), thereby resulting in an attack . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint rate of %. similarly, cases detected within one day of the primary case may represent co-primary cases (t ≤ ). this leaves an attack rate of % (by subtracting pp from %). (appendix f provides robustness analysis on the definition of co-primary cases.) on the day preceding the result (t = − ) % were tested and % of these tested positive. the day after the households received their first positive test result (t = ), % were tested and % of these tested positive. in panel b, t = denotes the time the first positive test was taken (not when the test result was given). % of all potential secondary cases were tested on the same day as the primary case (t = ) and % of all potential secondary cases tested positive. this implies a % probability of testing positive conditional on being tested on the same day as the primary case. days after the day of the first positive test, % had been tested and % tested positive. shaded areas show the % confidence bands clustered on household level. figure shows the proportion of positive tests originating from households within the days after the primary case tested positive. after a rapid decrease immediately after lockdown, there was an increasing proportion of new cases originating from households during lockdown, and a decreasing proportion after reopening. the last day of school was june , and many families start their vacation at that time. after this date, the proportion started to increase again. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint we found an approximately linearly increasing relationship between attack rate and age. panel a of figure shows the probability of having a test (blue) and the probability of having a positive test (red) (unconditional on being tested) across -year age groups. the shaded areas show the % confidence bands. panel b shows the transmission risk from primary cases by age group, i.e., the probability of infecting others. the figure shows an increase with age for adults, while the risk seems to decrease with age for children. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint notes: panel a illustrates the probability of having a test (blue) and the probability of having a positive test (red) (unconditional on being tested) across -year age groups. panel b illustrates the transmission risk from primary cases by age group, i.e. the probability of infecting others. the shaded areas show the % confidence bands clustered on the household level. as figure shows an approximately linear relationship between attack rate and age, we estimated the linear relationship using equation (see table e . , column i). the results show that individuals had a baseline risk of . % of testing positive. the risk increased by . percentage points for each year of age. thus, a -year-old had a risk of . %, a -year-old had . %, and a -year-old had . %. the estimates were robust to different specifications, including period and sex covariates, table e . , column ii-iv. the attack rates conditional on the primary case being a child or an adult are presented in figure c. . when the primary case is a child (under years old), the attack rate seemed uniform, regardless of the age of the potential secondary case. when the primary case is an adult (over years old), the attack rate increased (linearly) with age. the attack rates by sex are presented in appendix c. . the results indicated no difference in attack rates between males and females. the interaction between the attack rate and transmission risk for each combination of age groups is presented in figure c . . the age range of the primary case is depicted on the horizontal axis and the age of potential secondary cases on the vertical axis. panel a shows the probability of being tested (for each age group combination); panel b shows the probability of obtaining a positive test result. the probability for potential secondary cases of being tested was generally highest when the primary case was a child (below years old). the probability of being tested was also high when the age difference between the primary case and the potential secondary case was small. the attack rate was highest when the primary and potential . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint secondary cases were above years of age. when children were the primary case, an increased attack rate was observed for all age groups. figure illustrates the proportion of cases by the number of household members for households with one to six members. for instance, in a household with two members (red), % of the households had one positive case, while % had two positive cases. similarly, in a household with three members (green) % of the households had one case, % had two cases, and % had three cases. (table e . .) this implies that in a three-person household, % have an attack rate of , % have an attack rate of %, and % have an attack rate of %. this amounts to an overall attack rate of % ( % × % + % × % + % × % = %). once a primary case was found within a household, the probability of at least one secondary case was %, regardless of household size, and consequently % of the primary cases do not generate any additional cases. in particular, the primary cases had a % probability of generating one additional case, % of generating two additional cases, % of generating three additional cases, and % of generating four additional cases. this pattern was consistent regardless of the number of persons in the household, showing a transmission pattern that was exponentially decreasing with the number members within the household. the pattern was consistent over the three phases of the epidemic examined here, indicating that it is not a result of the change in the testing strategy (figure d is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint the epidemic in denmark changed over time, both due to changes in policy response (e.g., lockdown), and changes in test capacity and strategy (see appendix a for an overview). in this section, we investigate the robustness of the previously described results over the three defined periods of the epidemic (see appendix d). the analyses show that despite the substantial changes in probability of being tested, the estimated attack rates were consistent over the epidemic. in appendix f, we investigate the sensitivity of the estimated attacks to the definition of co-primary cases. the analysis showed that the estimated age structured attack rates did not change noticeably by excluding secondary cases found within the same day, one day or two days of the primary case. we estimated an overall attack rate within households of % (table e . ), ranging from % during lockdown, % during early reopening, and % during late reopening (figure d. ) . this suggests that attack rates estimated early in the danish epidemic underestimated the true attack rate. this bias likely comes from the limited testing capacity . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint early on. these estimates are in line with the estimates from the literature; madewell et al. ( ) conducted a meta-analysis of household transmission of sars-cov- from studies and found an overall attack rate of . %, which is very close to our estimate. we studied the testing dynamics for covid- and found that the probability of obtaining a test relative to a primary case positive test result within the household peaked on the day after the primary case received the result, where % of all potential secondary cases were tested and % of these were positive (figure a) . interestingly, % of the potential secondary household cases were tested one day preceding the test result of the primary case, and % of these were positive. this could indicate that these individuals were tested for a reason other than the primary case result, e.g., for having symptoms themselves. the probability of being tested after a primary case in the same household increased from % on the same day as the primary case until it flattened out at around % on day six (figure b) . % of the secondary cases were found during the first three days after the primary case ( % / % = %). this highlights the importance of fast contact tracing, as most secondary cases are found in the first couple of days after the primary case, which is also concluded by moghadas et al. ( ) . the proportion of positive cases originating from households ( figure ) increased during the lockdown until the late reopening period when the borders reopened. thereafter, it increased again after the school holidays started. in other words, the school holidays (which also include three-weeks of annual leave for most parents) essentially functioned as another lockdown period, because families tend to stay together during the holidays. we suggest that this may have contributed to a low incidence of community transmission over the summer. when the testing capacity was relatively stable (from late april ), the proportion varies between % and % of total cases. this indicates that many cases originate within the household domain, and this should be taken into account when monitoring the epidemic as well as in national guidelines for covid- prevention. evidence from other countries also finds a substantial proportion of cases originating from households, as for instance, in israel, where % of all infections were found to have been originated at home (jaffe-hoffman, ). we estimated the age structured attack rate and transmission (figure ) and found a (linear) relationship between age and both the attack rate and transmission risk from primary cases. this suggests that susceptibility to infection increases with the age of the susceptible person. however, children (younger than year of age) also have an elevated transmission risk, likely due to closer contact with parents ( figure c. ), indicating that children may represent an overlooked risk. our findings correspond well with findings in the literature: madewell et al. ( ) found that susceptibility to infection increased with . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint age, and a large seroprevalence study in spain also found an increasing linear relationship with age (pollán et al., ) . similar findings were found by li et al. ( ) and bi et al. ( ) . we further estimated the attack rates conditional on the primary case being a child or an adult (figure c. ) . when the primary case is a child (under years old), the attack rate seemed to be uniform, regardless of the age of the potential secondary case. when the primary case is an adult (over years old), the attack rate increased (linearly) with the age of the potential secondary case. this suggests that transmission from children is fairly constant, and depends on close contact with susceptible cases, whereas transmission from adults is more effective the older the potential secondary case is. one could think that if a child is sick, caregivers are likely to have more even close contact with the child -and more so the younger the child is. the opposite may be true for adult cases, indicating that the susceptibility to covid- increases with the age of a person, reflecting immunological properties. although there is agreement that transmission from and between children is not the main driver in this epidemic (ludvigsson, ) , transmission from sick children to parents in the household domain may represent a hitherto overlooked risk factor. we also estimated the age structured attack rates by sex and found no difference in attack rates between males and females, corresponding to the findings of jing et al. ( ). we used a large administrative data set to investigate the attack rate and transmission risk from lockdown to reopening, comprising , primary cases and , potential secondary cases. exploiting this rich nationwide data, we were able to address several concerns regarding the sensitivity of our results. as the testing capacity and strategy (and hence access to obtaining a test) has changed remarkably over the epidemic, robustness of results are a primary concern when comparing positive test cases over the covid- epidemic. we addressed this by dividing our sample into three periods with different testing capacities (appendix d) and found that the probability of obtaining a test did increase remarkably across the periods. our results were, however, relatively consistent over time, suggesting that the findings are not due to changing testing strategies. there are no formal guidelines for defining co-primary cases. madewell et al. ( ) provided a review on household transmission of sars-cov- : most of the studies included in madewell et al. ( ) did not describe how co-primary cases were handled, several studies stated they assumed all secondary cases were infected by the primary case, one study excluded secondary cases if they developed symptoms before exposure to the primary case, . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint and another study randomly selected one primary case as the source of infection. we addressed this important question by showing the sensitivity for different specifications. we found that the attack rate is strongly dependent on the definition. for instance, in figure b we show that if one defines co-primary cases as individuals tested on the same day as the primary case, the secondary attack rate is reduced by % ( % / % = %). increasing the period for co-primary cases further caused the estimated attack rate to decrease even more. therefore, it is important to further investigate the dynamics of sars-cov- in homes, schools, workplaces and major places in the community in order to quantify their impacts on virus transmission and develop effective control measures. mathematical modeling is a widely used tool for researchers in order to understand and predict the spread of disease; and policy relies on proper results from these models when making decisions such as choosing between keeping some parts of society open and other parts closed. closing of childcare and schools has been widespread in most countries. the results from this study can be used as direct input in parameterizing such mathematical models in terms of virus transmission at home. furthermore, we estimated the age structured attack rate and transmission risk, as well as the interaction of these, which are important inputs in mathematical models, for instance, for contact matrices between age groups (davies et al., ; zhang et al., ) . when modeling the spread of covid- , many researchers assume that each contact has the same probability of transmission (conditional on time and distance of contact), i.e., a binomial process (e.g., jing et al. ( ); kucharski et al. ( ) ). our results, however, suggest that this should be modelled as a two-step procedure when simulating contacts between individuals: first, it should be determined whether a case is infectious or not (i.e., a bernoulli process), and second, conditional on being an infectious case, a binomial process should be used to represent actual transmission. this allows replicating the transmission dynamics of the virus more realistically and hence allows more realistic predictions from these models. in conclusion, to the best of our knowledge, this study presents the results of the first nationwide register-based study on household transmission of covid- . these results are important as they show differences in transmission pattern with the age of both the primary case and the potential secondary cases within households. a large proportion of transmission was found to occur within households, highlighting the severity of covid- transmission, and that preventative measures within households are urgently needed in order to prevent transmission. moreover, monitoring the proportion of positive cases originating from households may be an important tool for public health authorities to measure community transmission. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https: //doi.org/ . //doi.org/ . / appendix a is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint - - - - - - - - - - < - - -< -< - ---- - ---- ---- notes: this table provides summary statistics on the potential secondary cases included in the study. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint appendix c age structured attack rate notes: panel a shows the probability of being tested and panel b the probability of having a positive test. the age of the primary case is depicted on the x-axis and the age of potential secondary cases on the y-axis. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . appendix c. age structured attack rate by sex is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . appendix d dynamics over the epidemic appendix d. testing dynamics over the epidemic figure d . panel a-c presents the testing dynamics for the three periods of the epidemic. panel a shows that during lockdown only few percent of the other household members were tested and that there was a high positive rate of the ones tested. panel b shows that during the early reopening, more household members were being tested and the positive rate declined accordingly. lastly, panel c shows that in the late reopening even more household members were being tested and the positive rate declined further. panel d-f shows the proportion of household members ever being tested and ever being positive. during lockdown % of secondary household members were tested after days, during early reopening % were tested, and during late reopening % were tested. similarly, % had tested positive after days during lockdown, % during early reopening and % during late reopening. another aspect of testing is how long a person has to wait for the result after obtaining the test. table a . shows that % of all cases received the result within day during lockdown, within days during early reopening, and within day during late reopening. notes: shaded areas are % confidence bands clustered on the household level. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint appendix d. age structured attack rate over the epidemic figure d . illustrates the age structured attack rate separately for the three periods of the epidemic. the testing rate clearly increases during the epidemic, while the rate of positive test results is relatively constant. both rates increase with age of the case. notes: this figure illustrates the age structured attack rate separately for the three periods of the epidemic. figure shows the estimates for the pooled analysis. the testing rate clearly increases during the epidemic, while the positive rate is fairly constant. shaded areas are % confidence bands clustered on the household level. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint notes: the estimates are calculated from households with at least one potential secondary case, i.e., households with two to six members. the estimate for two secondary cases is calculated from households with at least two potential secondary cases, i.e., households with three to six members. estimates are in percentages. standard errors in parenthesis, clustered on the household level. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint notes: this table provides estimates on the robustness of the estimates for the attack rate depending on the definition of co-primary cases. column (i) corresponds to column (ii) in table e . . in column (ii) we exclude secondary cases that test positive on the same day (t = ) as the primary case. in column (iii) we exclude secondary cases that test positive within one day (t ≤ ) of the primary case. in column (v) we exclude secondary cases that test positive within three days (t ≤ ) of the primary case. standard errors in parenthesis, clustered on the household level. *p< . , **p< . . . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint notes: this figure illustrates robustness for the definition of co-primary cases with respect to the age structured attack rate. panel a has no restrictions and is the same as figure . panel b excludes secondary cases testing positive the same day as the primary case (t = ). panel c excludes secondary cases testing positive within day of the primary case (t ≤ ). panel d excludes secondary cases testing positive within days of the primary case (t ≤ ). . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint an empirical evaluation of accounting income numbers epidemiology and transmission of covid- in cases and of their close contacts in shenzhen, china: a retrospective cohort study. the lancet infectious diseases risk assessment of novel coronavirus covid- outbreaks outside household transmission of pandemic influenza a (h n ) virus in the united states a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster the species severe acute respiratory syndrome-related coronavirus: classifying -ncov and naming it sars-cov- age-dependent effects in the transmission and control of covid- epidemics economic effects of coronavirus outbreak (covid- ) on the world economy temporal dynamics in viral shedding and transmissibility of covid- early dynamics of transmission and control of covid- : a mathematical modelling study. the lancet infectious diseases what settings have been linked to sars-cov- transmission clusters? the characteristics of household transmission of covid- secondary attack rate and superspreading events for sars-cov- . the lancet children are unlikely to be the main drivers of the covid- pandemic-a systematic review household transmission of sars-cov- : a systematic review and meta-analysis of secondary attack rate the implications of silent transmission for the control of covid- outbreaks prevalence of sars-cov- in spain (ene-covid): a nationwide, population-based seroepidemiological study projecting social contact matrices in countries using contact surveys and demographic data coronavirus disease (covid- ): situation report changes in contact patterns shape the dynamics of the covid- outbreak in china : robustness for definition of co-primary cases key: cord- -kx x g authors: colmenero, i.; santonja, c.; alonso‐riaño, m.; noguera‐morel, l.; hernández‐martín, a.; andina, d.; wiesner, t.; rodríguez‐peralto, j.l.; requena, l.; torrelo, a. title: sars‐cov‐ endothelial infection causes covid‐ chilblains: histopathological, immunohistochemical and ultraestructural study of paediatric cases date: - - journal: br j dermatol doi: . /bjd. sha: doc_id: cord_uid: kx x g background: chilblains ("covid toes") are being seen with increasing frequency in children and young adults during the covid‐ pandemic. detailed histopathological descriptions of covid‐ chilblains have not been reported, and causality of sars‐cov‐ has not been established yet. objective: to describe histopathological features of covid‐ chilblains and explore the presence of sars‐cov‐ in the tissue. methods: we examined skin biopsies from paediatric patients presenting with chilblains during the covid‐ pandemic. immunohistochemistry for sars‐cov‐ was performed in all cases and electron microscopy in one. results: histopathology showed variable degrees of lymphocytic vasculitis ranging from endothelial swelling and endothelialitis to fibrinoid necrosis and thrombosis. purpura, superficial and deep perivascular lymphocytic inflammation with perieccrine accentuation, oedema, and mild vacuolar interface damage were also seen. sars‐cov‐ immunohistochemistry was positive in endothelial cells and epithelial cells of eccrine glands. coronavirus particles were found in the cytoplasm of endothelial cells on electron microscopy. conclusions: although the clinical and histopathological features were similar to other forms of chilblains, the presence of viral particles in the endothelium and the histological evidence of vascular damage, support a causal relation of the lesions with sars‐cov‐ . endothelial damage induced by the virus could be the key mechanism in the pathogenesis of covid‐ chilblains and perhaps also in a group of patients severely affected by covid‐ presenting with features of microangiopathic damage. acral purpuric lesions identical to chilblains are being seen with an exceedingly high frequency in children and young adults during the coronavirus disease- (covid- ) pandemic worldwide. [ ] [ ] [ ] they have been subject of numerous mentions in the non-specialized media usually under the designation "covid toes". most patients have been negative for severe acute respiratory syndrome-coronavirus- (sars-cov- ) when tested by pcr of nasopharyngeal and oropharyngeal swabs, and less than % have a history of exposure to positive household contacts or previous history of mild upper respiratory or gastrointestinal symptoms. all the biopsies were assessed on multiple serial sections stained with hematoxylin & eosin (h&e), mowry's colloid iron and periodic acid-schiff (pas). the following histological features were recorded: vacuolar changes of the basal layer, exocytosis of lymphocytes, necrotic keratinocytes, erosion/ulceration of the epidermis, parakeratosis, spongiosis, oedema of the superficial dermis, perivascular superficial inflammatory infiltrate, perivascular deep inflammatory infiltrate, perieccrine lymphoid cell infiltrate, lymphocytic lobular panniculitis, fibrinoid material within the vessel walls, thrombi in papillary dermal vessels, thrombi in reticular dermis/subcutis vessels, lymphocytic infiltration of dermal vessels, purpura, dermal mucin, and basal membrane thickening. in each case, these features were scored as absent (-), mild/focal (+), moderate (++) or marked/extensive (+++). immunohistochemical stains with antibodies against cd , cd , cd , cd , cd and cd (dako, glostrup, denmark) were performed in all the samples. for sars-cov / sars-cov- immunostains the tissue was cut from paraffin blocks in μm sections using a microtome and stretched on a water bath at °c, mounted on glass slides and incubated at °c for hour. the slides were deparaffinized in xylene and hydrated in ethanol. antigen retrieval was performed with mm citrate buffer (ph . ) in a pt link (agilent technologies, santa clara, ca, usa) at °c for min. we used a monoclonal antibody ( a , dilution : , genetex inc., irvine, ca, usa) against the spike protein of sars-cov / sars-cov- . the staining was visualized with -amino- -ethylcarbazole substrate-chromogenic (envision system-hrp/aec, dako, k , santa clara, ca, usa) for minutes, counterstained with mayer's hematoxylin, and mounted with commercially ready to use dako ultramount aqueous permanent mounting medium. the staining was carried out with a dako autostainer link link (agilent technologies, santa clara, ca, usa). negative controls (tonsils from non-covid- patients) were included together with each sample. the antibody was previously optimized using sections of covid- lungs from autopsies as positive controls and different inflammatory skin conditions as negative controls. we evaluated the relative proportion of t and b cells, the proportion of helper to cytotoxic t cells and the presence of activated lymphocytes. the presence and location of the virus was recorded as present (+) or absent (-). cd was done to highlight the presence (+) or absence (-) of intravascular platelet thrombi. this article is protected by copyright. all rights reserved transmission electron microscopy (em) examination was performed in case . all the morphologic, histochemical, and immunohistochemical parameters were assessed by of the authors (ic & at) and sars-cov / sars-cov- stained slides were seen by (ic, at, lr & cs). our patients ( male, female; - years old) had skin lesions on the toes and lateral aspects of their feet and heels consistent with chilblains ( figure ). they were minimally painful or pruritic. the hands were also affected in one patient who had associated lesions of erythema multiforme on the elbows and knees. of note, no patient had a history of rheumatic disease, lupus erythematosus, raynaud's phenomenon, acrocyanosis or previous chilblains, and of them were on treatment with methylphenidate hydrochloride for more than year at the same dose for attention deficit hyperactivity disorder (adhd). the lesions had been present to days before the biopsy procedure. in all patients, the lesions had a benign outcome, with no significant systemic complaints and gradual spontaneous resolution was achieved in all of them after weeks of follow up (table ) . sars-cov- pcr from nasopharyngeal and oropharyngeal swab was negative in all cases tested ( / ). pcr tests were performed between and days (median ) from the beginning of the skin lesions. coagulation studies were normal in patients tested. d-dimer levels in serum were measured in cases and were minimally elevated in one case ( ng/ml; normal < ng/ml), but this abnormal result had no clinical significance, with the patient showing good health, no systemic symptoms and other coagulation tests within normal limits. full blood count was normal in all tested cases. the biopsies showed similar findings with variable intensity ( table ). all showed a mild interface dermatitis featuring vacuolar degeneration of the basal epidermal layer. exocytosis of lymphocytes was seen in cases and scattered necrotic keratinocytes in . lymphocytic vasculitis was demonstrated in all biopsies. lymphocytes infiltrated the wall of dermal venules and arterioles. endothelialitis, defined as swollen endothelial cells separated from the underlying basement membrane by subendothelial lymphocytes, was frequently observed this article is protected by copyright. all rights reserved ( figure ). indirect features of vascular damage such as red cell extravasation and dermal oedema were present in all cases. fibrinoid necrosis of vessels was seen in biopsies and microthrombosis in . these thrombi were noted in papillary dermal capillaries as well as involving reticular dermis vessels ( figure ). transmural lymphocytic infiltration of a large subcutaneous vessel, not associated with fibrinoid necrosis or thrombosis, was noted in one case. a superficial and deep angiocentric and eccrinotropic lymphocytic infiltrate was seen in all samples. inflammation extended to the subcutaneous fat in the biopsies where subcutis was represented and involving mostly the fat lobule. the inflammatory infiltrate was predominantly composed of small lymphocytes. large activated lymphocytes were noted only in cases (cases and ) with more severe inflammation. plasma cells were only focally seen in these biopsies showing more dense inflammation. the inflammatory infiltrate was predominantly composed of mature t cells (cd +) with a predominance of helper t lymphocytes (cd +) over cytotoxic t lymphocytes (cd +). only this article is protected by copyright. all rights reserved lymphocytic vascular damage was the hallmark feature in biopsies from our patients with covid- related chilblains. the intensity of the vasculitic damage ranged from minor findings, such as endothelial cell tumefaction and mild lymphocytic infiltration of the walls, to more severe signs like fibrinoid necrosis and thrombosis. the spectrum of histopathological features did not correlate with the duration of the lesions. vasculitis is defined as inflammation directed at vessels, which compromises or destroys the vessel wall leading to haemorrhagic and ischemic events. the spectrum of vascular reaction to injury is variable. moderate to severe lymphocytic inflammation of vessels walls was noted in half of our cases, and inflammation was mild in the rest. in all of them, even in those with mild inflammatory infiltrate, indirect evidence of vascular damage and leakage was present in the form of extravasation of erythrocytes and dermal oedema. the overall clinical and histopathological features in our cases are entirely in keeping with chilblains. biopsies of chilblains show a moderate to dense superficial and deep perivascular lymphocytic infiltrate with exocytosis to the epidermis and acrosyringia and perieccrine accentuation. a few necrotic keratinocytes and mild vacuolar degeneration of the basal layer can be observed occasionally. pronounced papillary dermal oedema and spongiosis are often present. lymphocytic vasculitis is a common feature, and superficial thrombosis is present in some cases. chilblains may be classified as primary (idiopathic, cold-related) or secondary to underlying conditions. some authors consider that primary and secondary chilblains cannot be reliably differentiated based only on microscopic features. perieccrine inflammation and marked dermal oedema have been described as features favouring idiopathic chilblains over chilblains associated with connective tissue diseases, particularly lupus erythematosus, which is favoured by more prominent changes of interface dermatitis. , immunohistochemistry for lymphoid markers is not useful in the differential diagnosis of primary and secondary chilblains, as both show a predominance of mature t cells with only a minor proportion of b cells and some histiocytes. increased numbers of large cd + cells have been described in some cases of idiopathic chilblains with no clinical significance. , secondary causes of chilblains include connective tissue diseases (lupus erythematosus, behçet this article is protected by copyright. all rights reserved disease, antiphospholipid syndrome, rheumatoid arthritis, sjögren syndrome); cryopathies; haemoproliferative or neoplastic diseases; blood hyperviscosity states; genetic diseases (familial chilblain lupus, sting-associated vasculopathy of infantile onset (savi), aicardi-goutières syndrome, and irak deficiency); and anorexia or other disorders causing weight reduction. [ ] [ ] [ ] none of these causes of secondary chilblains was present in our patients. moreover, cold exposure was unlikely to be the trigger in our cases, since all lesions appeared during the mild spring climate in madrid. a causal relationship with covid- has been considered doubtful in this outbreak of cases of chilblains. however, we are not surprised by the high rate of negative pcr tests in our cases considering the reported low rate of positive pcr tests in children with suggestive symptoms of covid- . we have demonstrated the presence of viral particles within endothelial cells in lesional skin biopsies from patients presenting with chilblains during the covid- pandemic. the positive immunohistochemistry was confirmed by the presence of viral particles in one case using transmission electron microscopy. our results strongly support a pathogenetic role for sars-cov- in chilblains presenting during the pandemic. covid- should be included in the list of secondary causes of chilblains, and we think these lesions can be denominated from now onwards as covid- chilblains. it has been proposed that sars-cov- uses angiotensin converting enzyme (ace ) expressed by pneumocytes in the epithelial alveolar lining to infect the host cells and cause lung injury. , it is likely that sars-cov- uses ace to enter vessels, as ace is widely expressed by endothelial cells. , ace is also present in epithelial cells of eccrine glands, explaining the positive immunolocalisation of sars-cov- we have observed in these cells. vascular injury and thrombosis could explain the clinical features of chilblains and related acro- this article is protected by copyright. all rights reserved of the pathophysiologic importance of complement in covid- and could suggest targets for specific intervention. histological features of covid- related chilblains have been only scarcely described. , kolivras et al has been shown to infect endothelial cells in the skin and other organs in a few cases. , , our study has some potential limitations. we acknowledge that the number of patients is small; furthermore, evidence of sars-cov- infection by pcr and serology could not be obtained. also, the use of immunohistochemistry for sars-cov/sars-cov- is still restricted and larger studies are necessary to assess with accuracy the role of immunohistochemistry in the diagnosis of covid- . finally, we only carried out electron microscopy in one case; even though the virus was detected, more cases are needed to further support our conclusions. this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved chilblains in children in the setting of covid- pandemic chilblain-like lesions: a case series of patients during the covid- pandemic classification of the cutaneous manifestations of covid- : a rapid prospective nationwide consensus study in spain with cases covid- ) infection-induced chilblains: a case report with histopathological findings chilblains-like lesions in children following suspected covid- infection erythema multiforme-like lesions in children and covid- endothelial cell infection and endotheliitis in covid- accepted article this article is protected by copyright. all rights reserved electron microscopy of sars-cov- : a challenging task -authors' reply electron microscopy of sars-cov- : a challenging task renal histopathological analysis of postmortem findings of patients with covid- in china collapsing glomerulopathy in a covid- patient a novel coronavirus from patients with pneumonia in china post-mortem examination of covid patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings of lungs and other organs suggesting vascular dysfunction ultrastructural characterization of sars coronavirus the histological assessment of cutaneous vasculitis idiopathic perniosis and its mimics: a clinical and histological study of cases a histologic and immunohistochemical study of chilblains perniosis: clinical and histopathological analysis cd positive atypical lymphocytes in perniosis: a potential histopathologic pitfall in a benign condition comparative analysis of chilblain lupus erythematosus and idiopathic perniosis: histopathologic features and immunohistochemistry for cd and cd clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of patients at mayo clinic chilblains accompanying interleukin- receptorassociated kinase (irak)- deficiency chilblains and antiphospholipid antibodies: report of four cases and review of the literature screening and severity of coronavirus disease (covid- ) in children in madrid severe respiratory sars-cov infection: does ace receptor matter? cell entry mechanisms of sars-cov- exploring the pathogenesis of severe acute respiratory syndrome (sars): the tissue distribution of the coronavirus (sars-cov) and its putative receptor, angiotensin-converting enzyme (ace ) tissue distribution of ace protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis complement associated microvascular injury and thrombosis in the pathogenesis of severe covid- infection: a report of five cases chilblains are a common cutaneous finding during the covid- pandemic: a retrospective nationwide study from france this article is protected by copyright. all rights reserved key: cord- -onr ue authors: sciubba, daniel m.; ehresman, jeff; pennington, zach; lubelski, daniel; feghali, james; bydon, ali; chou, dean; elder, benjamin d.; elsamadicy, aladine a.; goodwin, c. rory; goodwin, matthew l.; harrop, james; klineberg, eric o.; laufer, ilya; lo, sheng-fu l.; neuman, brian j.; passias, peter g.; protopsaltis, themistocles; shin, john h.; theodore, nicholas; witham, timothy f.; benzel, edward c. title: scoring system to triage patients for spine surgery in the setting of limited resources: application to the covid- pandemic and beyond date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: onr ue abstract background as of may , , the covid- pandemic has affected over . million people and touched every inhabited continent. accordingly, it has stressed health systems the world over leading to the cancellation of elective surgical cases and discussions regarding healthcare resource rationing. it is expected that rationing of surgical resources will continue even after the pandemic peak, and may recur with future pandemics, creating a need for a means of triaging emergent and elective spine surgery patients. methods using a modified delphi technique, a cohort of fellowship-trained spine surgeons from academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-priority elective, or low-priority elective scheduling. results the devised scoring system included independent components: neurological status, underlying spine stability, presentation of a high-risk post-operative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. the resultant calculator was deployed as a freely-available web-based calculator (https://jhuspine .shinyapps.io/spineurgencycalculator/). conclusion here we present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. we believe that our scoring system, while not all-encompassing, has potential value as a guide for triaging spine surgical cases during the covid pandemic and post-covid period. every inhabited continent. accordingly, it has stressed health systems the world over leading to the cancellation of elective surgical cases and discussions regarding healthcare resource rationing. it is expected that rationing of surgical resources will continue even after the pandemic peak, and may recur with future pandemics, creating a need for a means of triaging emergent and elective spine surgery patients. methods using a modified delphi technique, a cohort of fellowship-trained spine surgeons from academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high- priority elective, or low-priority elective scheduling. results the devised scoring system included independent components: neurological status, underlying spine stability, presentation of a high-risk post-operative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. the resultant calculator was deployed as a freely-available web-based calculator (https://jhuspine .shinyapps.io/spineurgencycalculator/). conclusion here we present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. we believe that our scoring system, while not all-encompassing, has potential value as a guide for triaging spine surgical cases during the covid pandemic and post-covid period. in acute respiratory distress syndrome (ards) and/or death. , since that time it has spread rapidly to affect nearly every country, placing significant stresses on the global healthcare system. in order to mobilize resources to combat this pandemic, the centers for medicare and medicaid services (cms), the centers for disease control and prevention (cdc), and multiple professional organizations , recommended the cancellation of elective surgical procedures. in spite of this, it was recognized that there were cases, many of them neurosurgical, which required urgent or emergent intervention to minimize patient morbidity and maximize the chances of an optimal outcome. in response, several centers have presented frameworks for the management of neurosurgical patients presenting during the covid- pandemic. [ ] [ ] [ ] [ ] additionally, a triage scoring system has been previously developed in an attempt to guide spine surgery consults. , however, to date, there has not been a systematic, multi-institutional scoring system that includes resource availability and disease burden to aid in triaging spine surgery patients during this crisis. though certain symptoms referable to chronic spinal conditions may not necessarily be life threatening, these can cause significant pain and disability prompting the challenge of determining who and when to operate in times of crises. it is recognized that effective triaging of these cases in the post-covid era will be essential to prevent the healthcare system from being overwhelmed by the backlog of elective spinal cases that have been deferred because of the covid- pandemic. [ ] [ ] [ ] recently, a scoring system aimed at triaging such cases has been published in the general surgery literature, however no comparable system has been described for spine patients. here we present an applicable example of such a system assembled based upon input by a multi-institutional collaboration. this scoring system is designed to assist in two ways. first, it may assist spine surgeons and administrators with triaging surgical patients during the covid- pandemic. second, the scoring system may help health systems triage elective cases in the post-covid crisis, which is likely to also see a relative shortage of surgical resources and has been described by some as a potential collateral pandemic. methods scoring system development to generate this scoring system, the first author proposed an a priori scale highlighting those elements thought to be pertinent to the triaging of an operative spine patient in the setting of limited resources. the elements applicable to the spine patient included the patient's current neurological status (rapidity of progressive, severity), the presence of underlying spinal instability, and radiographic evidence of neural element compression. several general elements were added that could be used to triage any surgical patient, including general patient health/comorbidities, expected resource utilization, current resource availability, and local disease burden. medical comorbidities were pulled from the charlson comorbidity index and from previously published series describing comorbidities associated with increased symptom severity in patients infected with the sars-cov- virus. , [ ] [ ] [ ] [ ] [ ] after identifying these elements, weights were initially assigned based on input from surgeons at the lead institution using a modified delphi approach that included both neurosurgical and orthopaedic spine surgeons. component weighting of the preliminary scale was tested using ten example spine patients, testing the assessed urgency of the patient as determined by the scoring system against the consensus opinion of the group of surgeons. after identifying a preliminary scoring system, a multi-institutional group was convened, including neurosurgical and orthopaedic spine surgeons from multiple institutions with varying levels of experience. a modified delphi approach was again used to alter the weights assigned to the categories to refine the preliminary score. three rounds of written communication, polling, and electronic teleconferencing sessions were used to solicit input. example cases were again devised to test the degree of agreement between the scoring system and the consensus opinions regarding the urgency of the hypothetical patient's issue (supplemental data). the final scoring system was then deployed as a freely available, web-based calculator (figure ; https://jhuspine .shinyapps.io/spineurgencycalculator/). details of the multi-institutional panel the study group was comprised of spine surgeons representing the degree of impairment that their deficit causes in ambulation or the ability to perform activities of daily living (adl). the scoring system runs from - (lowest priority elective case) to (highest priority emergent case) and classifies cases as "emergent," "urgent," "high-priority elective," or "low-priority elective" as identified in table . additionally, in they have not provided an algorithm for the prioritization of such cases in the setting of potential resource shortages. here we present a scoring system devised by a multi-institutional collaboration that aims to assist with these triage issues. the ability to assist with both populations is a strength of this scoring system, which we feel may be a useful tool for health systems both during the covid pandemic and in the post-crisis period, as they struggle to accommodate the large volume of non-emergent surgical cases. additionally, though we hope such a need does not arise, the present scoring system could also have value in the triaging of patients if a "second wave" of the coronavirus pandemic occurs, which may lead to further resource limitations. such a wave occurred during the spanish influenza pandemic and many experts have speculated that a similar phenomenon could occur during the present pandemic. , furthermore, the framework of the proposed scoring system could apply to future pandemics where healthcare resources are similarly stretched as the current covid- pandemic. prior examinations of triaging in neurosurgery there have been several broad descriptions of triage strategies presented in the neurosurgical literature, , and guidelines from the american college of surgeons (acs) currently divide surgeries into five levels based upon apparent acuity. however a large proportion of spinal cases require emergent or urgent addressal in addition to a perceived lack of granularity, neurosurgical triage systems published in the pre- covid era have predominately focused on emergent surgical issues. triage amongst non- emergent cases has been largely overlooked. one exception to this is the "accountability for reasonableness (a r)" framework described by ibrahim and colleagues to emphasize scheduling fairness and minimize operating room downtime at an academic center seeing a mixture of emergent and elective cases. unlike the present scoring system however, their framework was purely qualitative -triaging was performed by a single stakeholder without an obvious means by which surgical cases were ranked. another exception is the calgary spine severity score proposed by lwu et al. that assessed spine referrals based on the clinical, pathological, and radiological aspects. similar to the a r framework, however, this score was not intended for implementation in the setting of a crisis or the acute resource shortages that are expected in the post-covid era. constituted an urgent case, namely a surgical issue requiring treatment within weeks that was not identified in the emergency list. elective cases were similarly identified as all cases that did not fall into the above two categories. unlike the system presented here, however, no formalized system was identified for the prioritization of cases within the urgent or elective categories. neuro-oncology (sno) made recommendations to prioritize adjuvant therapies (e.g. chemotherapy and radiotherapy) over earlier surgical intervention for spinal and intracranial malignancies, as this will decrease the risks posed by hospitalizing oncologic patients in the same facility as covid- -positive patients. however, the groups acknowledge that this is not always possible, and that care deferral may cause some elective cases to progress to the point of requiring urgent operative management. the european association for neurosurgical societies has attempted to address the question of how to prioritize elective neurosurgical cases through an "adapted elective surgery acuity scale." unfortunately, while this scale provides some guidance, the three tiers it employs are quite broad and there are no guidelines for prioritizing cases within a category or a given diagnosis (e.g. "degenerative spinal pathology"). consequently, we feel the need for a means of triaging both emergent and elective spine cases remains unmet. while there have been several general frameworks highlighting those cranial pathologies requiring emergent management, , , there has only been one description of a framework for triaging emergent spine surgeries. derived from the experiences at a single italian center tasked with treating cord compression and spinal instability, the framework of giorgi and colleagues is a care pathway intended to expedite the identification, treatment, and safe discharge of patients with spine emergencies. priority within the system was based upon american spinal injury association (asia) grade and radiographic evidence of instability. though good results were described for the patients treated under the framework, the pathway is non-quantitative and seemingly lacks the granularity to prioritize between two or more emergent patients. similarly, it is not equipped to triage non-emergent cases. a more quantitative approach was described by jean and colleagues based upon nearly respondents to an internet survey, asking respondents to assign an urgency score to each of nine hypothetical cases. the authors found mild-to-moderate agreement regarding the extent of surgical urgency for each case (range . - . %), however, their "acuity index" was simplistic in that it was based solely upon the perceived case risk and case urgency assigned to it by respondents. case risk was graded on a to scale ("no risk" and "cannot postpone") and case urgency on a to scale ("leave until after the end of the pandemic" and "case already done"). the scale itself did not incorporate neurological status, patient comorbidities, or local resource limitations, all of which are likely to influence the timing of operative management. because of this lack of granularity, it is unclear that this "acuity index" can be generalized to other case scenarios, thus limiting its potential utility relative to the multidimensional scoring system described here. limitations as with scoring systems published in other domains of neurosurgery, the present scoring system is not intended to be prescriptive in its guidance. rather, we present it as a potential tool to aid surgeons and healthcare systems when triaging patients in times of national crisis or global resource shortages. as with the triage frameworks presented to date, the present scoring system is derived from expert opinions. consequently, the scoring system is limited by the biases of the surgeons recruited and their respective institutions. we attempted to address this by recruiting surgeons at multiple levels of training, at academic centers spread across a large geographic region subjected to varying covid- burdens. furthermore, by only including surgeons into the decision-making process of the urgency of spine patients, there is potential that additional points from the non-surgical and administrative personnel could have altered the final scoring system. additionally, in an effort to maximize the usability of the scoring system, it was necessarily simplified and is consequently not all encompassing. for example, the broad term of "new neurologic deficit" was included under the "high-risk postoperative complication" category, however, this leaves it up to the treating surgeon whether this new deficit is "high- risk". therefore, while it can assist in determining surgical priority, final disposition should be based upon the clinical judgment of the treating surgeon and institution. nevertheless, we believe that it can be an effective tool for informing clinical stakeholders as to how each patient's case may be triaged at peer institutions. our scoring system is also limited by the fact that it operates on the assumption that the patient desires surgery at the same time recommended by the treating surgeon. this is not always the case and the ultimate timing of surgery must therefore rely on an in-depth discussion between provider and patient. finally, the present scoring system was devised with the covid- pandemic in mind. consequently, it could be argued that it may not be applicable to other resource challenging situations, and future pandemics may limit resources in a manner not assessed in the current work. however, we feel that the modular structure employed could easily be adapted to other crises that cause a shortage of medical resources. therefore, the present system may have utility beyond the present crisis and any "second wave" that may arise. conclusion here we present a scoring system for the triaging of spine surgery patients during times of crisis and severe resource scarcity. our system was developed by a multi-institutional panel using a modified delphi technique and has the potential to assist surgeons, hospital administrators, and other clinical stakeholders in assigning priority to both emergent and non-emergent spine surgery patients. while not intended to be prescriptive, this scoring system may prove useful as a guide during both the covid crisis and the post-covid period to help prioritize patients with the greatest surgical needs, though determining the urgency of an individual procedure should be left to the operating surgeon. additionally, we believe the modular structure of the scoring system implies that it may potentially be adapted to other crises resulting in an acute shortage of medical resources. tables table : spine surgery urgency scoring system table : proposed timeframes for surgical treatment based upon urgency score figure . screenshot of web-based calculator deployed based upon scoring system identified (https://jhuspine .shinyapps.io/spineurgencycalculator/) key: adl -activity of daily living; asc -ambulatory surgery center; d -day; hrhour; mo -month; snf -skilled nursing facility; wk -week †whether the complication requires surgical intervention or can be treated with nonoperative management is made at the discretion of the attending surgeon ‡vital structures include spinal cord, esophagus, trachea, aorta, lung, §medical comorbidities included: active malignancy, age > , congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, current cigarette or vape use, diabetes mellitus, history of myocardial infarction, interstitial lung disease, moderate-to-severe liver disease. urgent (e.g. within weeks) - high-priority elective (e.g. within weeks) < low-priority elective (e.g. delay until after covid- crisis) key: covid- -coronavirus disease a novel coronavirus from patients with pneumonia in china clinical characteristics of coronavirus disease in china fair allocation of scarce medical resources in the time of covid- coronavirus disease (covid- ): healthcare facility guidance covid- : recommendations for management of elective surgical procedures. acs: covid- and surgery. published . accessed nass guidance document on elective, emergent, and urgent procedures letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital model letter: adaptation under fire: two harvard neurosurgical services during the covid- pandemic a scoring system for elective triage of referrals: spine severity score validation of the calgary spine severity score how to risk-stratify elective surgery during the covid- pandemic? letter: collateral pandemic in face of the present covid- pandemic: a neurosurgical perspective editorial. covid- and its impact on neurosurgery: our early experience in singapore medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid- pandemic a new method of classifying prognostic comorbidity in longitudinal studies: development and validation covid- in critically ill patients in the seattle region -case series clinical characteristics of covid- in new york city clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study covid- and neurosurgical practice: an interim report the management of emergency spinal surgery during the covid- pandemic in italy beware of the second wave of covid- a year of terror and a century of reflection: perspectives on the great influenza pandemic of - first-wave covid- transmissibility and severity in china outside hubei after control measures, and second-wave scenario planning: a modelling impact assessment assessment of a triage protocol for emergent neurosurgical cases at a single institution protocol for urgent and emergent cases at a large academic level trauma center is case triaging a useful tool for emergency surgeries? a review of trauma surgery cases at a level trauma center in south africa priority setting in neurosurgery as exemplified by an everyday challenge inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the covid- pandemic: general guidance for neuro-oncology practitioners from the aans/cns tumor section and society for neuro-oncology triaging non-emergent neurosurgical procedures during the covid- outbreak the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study key: cord- -xes g authors: patwardhan, j. title: predictions for europe for the covid- pandemicafter lockdown was lifted using an sir model date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: xes g i analyze a simplified sir model developed from a paper written by gyan bhanot and charles de lisi in may of to find the successes and limitations of their predictions. in particular, i study the predicted cases and deaths fitted to data from march and its potential application to data in september. the data is observed to fit the model as predicted until around days after december , , after which many countries lift their lockdowns and begin to reopen. a plateau in cases followed by an increase approximately . months after is also observed. in terms of deaths, the data fits the shape of the model, but the model mostly underestimates the death toll after around days. an analysis of the residuals is provided to locate the precise date of the departure of each country from its accepted data estimates and test each data point to its predicted value using a z-test to determine whether each observation can fit the given model. the observed behavior is matched to policy measures taken in each country to attach an explanation to these observations. i notice that an international reopening results in a sharp increase in cases, and aim to plot this new growth in cases and predict when the pandemic will end for each country. the novel sars-cov- coronavirus, first appearing in wuhan, china at around december , , has caused an ongoing worldwide pandemic. it differs from the initial sars-cov virus strain in a multitude of ways, from its only percent similarity to the original [ ] , to a wider range of mortality rates. while the sars-cov strain had about a . percent mortality [ ] , this new coronavirus has death rates ranging from . percent in italy to . percent in the us [ ] . despite this, it appears to have a more favorable transmission rate and a prolonged latency period. since the onset of a global lockdown earlier in the year, many countries throughout the world have begun reopening, albeit not in full. nonetheless, the measures taken by governments during quarantine have significantly eased, although many countries continue to encourage proper social distancing measures, from wearing masks to staying feet apart. around days after december , , an sir model [ ] was created to model the flow of this novel coronavirus in the european countries of the netherlands, denmark, sweden, norway, the uk, spain, germany, italy, and france [ ] . the lack of a common policy amongst the world has led to different responses and outbreaks in different countries, as we will come to see. varying reopening policies between each country has resulted in varying levels of success in virus containment, with some countries almost entirely shutting down the virus and other countries seeing a plateauing and subsequent growth in cases. in my study, i focus on the two differential equations modelling the s and i part of the sir model, meaning susceptible and infected, respectively. this uses the variables x , denoting s, x , denoting i, α, the transmission rate (number of infections per day per contact), γ, the rate at which individuals leave the infected population, n, the total individuals in an interacting pool of susceptibles, δ, the fraction of individuals who die after being infected, and p, the maximum value of x . the fits for the amount of deaths are found by scaling the cases by δ and shifting the graph forward by a certain amount of days. all of the relevant equations used to build the model are taken from the paper that develops the model [ ] . the primary equations used to graph the curves are: finding the residuals themselves is an easy enough equation: if r = the value of the residual, x = the observed number of cases or deaths at a point in time, and x = the predicted number of cases or deaths at a point in time using the main curve, then the associated error bars to each residual are found from subtracting the observed number of cases or deaths from the predicted number of cases or deaths at a point in time using each value of the error bar curve. to each point in time, i also associate a p value denoting the probability of finding the observed data result if the model was true. this is a matter of a simple hypothesis test. the standard deviation is found by using its formula and the values x u and x l representing the upper and lower bounds from the estimation model: using the formula, we can then find the corresponding z score and the area under the curve representing the p value using alternatively, using the pnorm function in r yields the same results. reasons for data analysis tools. in this exploration, both residual plots and p value plots (at the α = . level corresponding to a percent level of confidence) are utilized to find results. we can observe both the advantages and drawbacks to each tool, which provide a need for the other. with a residual plot, we can better analyze how far each data point falls from the predicted value on a linear scale. this clears up the confusion of distances on the log scale, as the model may show an overprediction of to be miniscule in comparison to an overprediction of based on the data point's location on the y axis. we also gain a better understanding of both how well the data fits the model and when the data starts and stops fitting the model. the drawback, however, is a lack of knowledge of whether a certain residual is expected from the data for the same reason . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint that there is a distinction between the aforementioned difference of and . the error bars expand as time goes on, encompassing a larger expanse of area, but deceptively accounting for a less inclusive interval of error. it is useful to gather whether an observed data point's deviation from the model is expected or not. a statistical analysis into the probability of observing such an extreme or more extreme data point tells us that even a large difference of can be expected given a large standard deviation as dictated by the error bars. a problem, however, arises when the r value derived from the model [ ] increases. as r increases, the fit becomes tighter and tighter, decreasing the standard deviation, potentially making even a deviation of seem probabilistically impossible. this is where a look at the residuals clears up the problems caused by small standards of deviation. in other words, residuals are particularly useful when studying smaller values, while p values are more useful when studying larger values. a final useful note is that all labeled days represent days starting after december , (january , is day ). analysis of the case model. in general, the model matches the observed data points well until around day . we note an initial almost linear climb in log space, accounting for an exponential growth of the virus. we note a maximum point at a median of about days after the first case detected in the country, followed by a more gradual drop in cases. instead of seeing a continuous decrease in cases, we observe a plateau, sometimes followed by a small drop in cases, and then a rise which on occasion exceeds the initial peak. this plateau starts at different locations, most after an initial drop in cases, but some at the peak itself. the peaks of each country vary, and we can see a clear relationship between a country's population and their number of cases. looking at the number of cases per million population, however, does not show any such relationship, suggesting that this factor depends more on federal action rather than just population and population density. we notice that both the uk and sweden plateau immediately after peaking, making the model mostly inaccurate for both countries. for this reason, we can't do a p value analysis. along a similar vein, the observed drop in cases for italy didn't match the model as the drop was much more gradual than expected, and for that reason the model is mostly inaccurate for this country as well. for every other country, the data points began to deviate from the model at about day ± days. these plateaus lasted for about . ± days, with the exception of norway, with an day plateau. given the relatively small size of the outbreak in norway, it is expected that there would be a thickly shaped plateau in cases due to the smallness of the numbers involved. it can also be argued that france doesn't have a plateau at all, instead going from a decrease in cases to a sudden increase. another interpretation would be to observe a wide plateau akin to the shapes of norway and denmark, followed by a rise in cases. we notice an increase in cases in every country, with most increases being sharply exponential (with the exception of sweden). we also observe a small decline in cases right prior to the aforementioned increase (with the exception of spain and germany), suggesting that many countries had the potential to drop their cases once again before whatever event caused them all to grow so suddenly. finally, we observe this rise in cases to occur roughly in the same timeframe: from day to day . we can likely attribute this to a policy either made by the eu or by each government in close proximity to the other regarding reopening. we'll explore this in a later section. the residual plots were useful when attaching a rough start date to the plateau, as it roughly corresponds to a deviation from the covid model. a point and its error bars not intersecting with whose future points also do not intersect with is thus marked as a starting point to locate these plateaus. as time went on, the model predicted the virus to be gone in most countries before day [ ] , with the exception being the uk at around day . after around day , the model predicts small x values with small standards of deviation, so observed residuals at this point mostly represent the growth of the virus itself during that time. we can clearly see an exponential increase both in the model and in the residual plots at nearly . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint identical times for this reason. similarly, we mark the date in which the observed data points are first statistically improbable given the model curve and continue to be (mostly) improbable as the date at which point the model becomes obsolete using our p value plots. this also matches quite well with the start date of the plateau. analysis of the death model. we can observe a similar shape for each death graph as that of the cases graph, but with the values on the y axis scaled down by whatever fraction δ was found. we notice almost consistently that the model underestimates the total death rate after its peak, with the exception of the netherlands, which the model surprisingly overestimates. the model accounts for deaths to be at around days for each country, but instead we see that there are still deaths after the predicted end date, albeit very few. we can see this in our residual plots, in which the graphs stabilize around after around day . this stabilization, however, is not an indicator of the accuracy of the model, which is proven by the p values dropping below the α = . level after roughly the same date, but because the deaths have also fallen to fairly small numbers, usually around - . the model fails around days after cases plateau, because we expect cases and deaths to decrease continually until they reach , but instead we get a stagnation of the virus. it wouldn't be apt in most cases to call this persistence of the virus a plateau, but rather the failure of the model to graph a much less steep falling curve. we notice that the uk and italy almost immediately deviate from the expected curve after reaching its peak, and we can see a much more gradual decrease in cases in both countries. in almost every residual plot, we see a shape resembling a damped harmonic oscillation curve as the residuals approach . as x approaches and beyond, we can say that if the residuals don't go to and stay at , there's an anomaly. we observe this in the uk and in sweden. in the uk, we notice a fluctuation between and from days onwards, indicating a stagnation in deaths. each stagnation occurs during a period of increased cases. while we may expect an increase in cases to signify an increase in deaths, it might be useful to consider the possibility that the lethality of the virus itself has decreased, or hospitals have adapted and become better equipped to help patients survive the virus. we know that the virus takes a long time to mutate [ ] , and that its mutations are mostly inconsequential, so we could choose to focus our analysis on hospitals. during the peak of the virus, hospitals were mostly swabbing and testing severely symptomatic patients, arguably skewing the lethality of the virus. considering that case rises could be associated with increased numbers of both moderately and severely symptomatic patients instead of just mostly severely symptomatic patients, we can infer that the number of deaths wouldn't have increased [ ] . in addition to this, younger people are getting the virus, leading to a greater survival rate, and hospitals themselves have become better at preventing deaths, due to the efforts of medical researchers. all of this has continued to keep deaths down. in fact, since we don't see a surge in deaths as we see a surge in cases, it could be predicted that deaths would increase after day in order to compensate for the rise in cases, but it is also entirely probable that the persistence and "plateau" that we see prior to day is due to the surge of cases in each country. it is also probable that it takes longer to die now with the virus than it did before. finally, an examination of the date of the first deaths in each country compared to the days until the model began to deviate from its expected behavior yields no relation, indicating that any failure of the observed data points to conform to the model is most likely due to the policy measures taken in each country. policy measures taken in each country. we have seen almost uniform behavior amongst all of the countries in the shape of their growth, but the days for each significant change in shape vary. this begs the question, what changed? we know that it takes about . days for a person who gets infected to be recognized as infected and to get removed from the population, so we can . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint infer that any action taken will have repercussions about days later. however, seeing as this number was recorded when mostly severely affected people were being diagnosed, it can be assumed that it'll take less time in the months of july and august to get diagnosed. after about days since december (july , ) , the eu began lifting restrictions on nonessential travel for some countries. this has caused a direct increase in the number of cases for italy, germany, spain, norway, denmark, the netherlands, france, and to a much lesser extent, sweden. we can see these effects in the rise in cases in each country from days to . the uk announced around days since december that restaurants, bars, hotels, hairdressers, cinemas and museums would reopen, causing a surge in cases almost immediately. sweden, which imposed a more voluntary lockdown, has experienced a more protracted outbreak than other countries, which we can see by the plateauing of cases in sweden, with the exception of a sudden spike and drop in cases over the span of just a few days. in addition to this, every country on the list launched some phase of reopening in july and august, further compounding the issue caused by opening the borders [ ] . this still begs the question, why did cases rise in this scenario but plateaued in prior days? this is likely because countries initially began lifting lockdowns internally during the day -day period, launching their initial phases of reopening. these reopenings were largely internal, allowing for mobility inside the country. in germany, smaller shops began to reopen, and the travel ban was lifted for eu member states. italy ended travel restrictions, bars, restaurants, shops as well as other public activities such as tourist locations opened. such changes happened to essentially every country, with restrictions being lifted in mid may (day -day ). a smaller scale reopening coupled with falling cases likely contributed to a smaller growth of the virus causing a plateau, whereas larger scale reopenings in later months almost uniformly caused a significant rise in cases. spain in particular has been hit hard, with many cases in aragon [ ] , the most heavy hit county, due to infections with wandering seasonal fruit pickers. nonetheless, while cases continue to increase, only about percent of cases need hospital treatment, and the mortality rate is as low as . percent in some areas. this provides a cause for hope, but also indicates an inaccuracy in the covid model in both its measurements of the fraction of cases that result in deaths and in the time it takes for an infected person to die. a new model to chart the post lockdown case growth. we then sought to chart the new growth of covid- using the same equations as before. using the times indicated by our analysis, we charted the new wave of cases. we found that the time before a person removes him/herself from the population ( /γ) increases dramatically, as well as the infectivity rate α. however, we notice no upward trends in deaths as of yet, and any increase in deaths is slow and not profound as of yet, suggesting that while cases are indeed on the rise, the death rate has stabilized. this can be linked to younger people getting the virus, as older age patients are more susceptible to receiving the virus [ ] . an appropriate residual graph analysis shows that the residual cases have mostly dropped, with some exceptions. we can't do a p value analysis due to the tightness of the graphs in addition to the flatter shape of the incline and the odd rises and falls due to the peculiarities of each country's reopening format. we plot the best case scenario for each of these countries, as we see a general easing of the growth and a parabolic curve in each plot. we were unable to do so for sweden due because we failed to observe a sharp rise in cases akin to the initial growth. the assumption thus is that the trend will continue downwards as it is predicted, which will likely require a continuation of the current reopening phase without the introduction of more radical changes that may shift the data. studying the parameters, we observe that not only has the value for gamma significantly decreased for all of the countries, the value for alpha has too. in the netherlands, the value for gamma drops from . to . , in denmark from . to . , in norway from . to . , in the uk from . to . , in germany from . . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint to . , in italy from . to . , in canada from . to . , in france from . to . , in the usa from . to . , and in spain from . to . . similarly, in the netherlands, the value for alpha drops from . e- to . e- , in denmark from . to . e- , in norway from . to . , in the uk from . e- to . e- , in germany from . e- to . e- (increasing slightly in this scenario), in italy from . e- to . e- (also increasing slightly here), in canada from . e- to . e- , in france from . e- to . e- , in the usa from . e- to . e- , and in spain from . e- to . e- . a decrease in gamma indicates that each infected person is taking more time to remove himself/herself from the population, suggesting that the symptoms and harm to them is significantly less. a lower alpha value indicates a lesser transmission rate, which aligns with the prediction that younger people are getting the virus. younger people have a lesser history with preexisting conditions and are generally stronger and in better shape to fight the virus. if younger people are stronger in general and show less symptoms, it follows naturally that they would take longer to go to the hospital. taking x < to be the day that the pandemic ends, we conclude that it will end in the netherlands on day (july , ), in denmark on day (may , ), in norway on day (january , ), in the uk on day (march , if we take as our parameter), in germany on day (january , ), in italy on day (august , ), in canada on day (december , if we take as our parameter), in france on day (january , ), in the usa on day (june , if we take as our parameter), and in spain on day (february , ). while this is the expected fit, we hope for a vaccine to be found, or the development of herd immunity, which may reduce the time for the virus to be removed from the population. this paper thus aims to provide a general shape to the future of the covid- virus, and an examination of which policy measures resulted in a growth in cases. in almost every european country, we see the case model begin to fail at around day , at which point the cases stagnate, then increase starting at around day . this increase in cases is nowhere close to reaching the peaks of the initial outbreak, even though we see a sudden increase in the case count. this owes to the deceptive nature of space in the log scale, where a sudden increase from to is seen as more dramatic than an increase in the thousands. spain, however, is dealing with another major outbreak, with cases approaching that of its first peak. the model also largely underestimates deaths and the continued persistence of deaths after day . it also overestimates the lethality and underestimates the time to die in later months after around june. the deviation of the observed data points from the expectations set by the model of the model can be understood to be due to its inability to account for reopening, instead assuming that each country would remain in a state of total lockdown until deaths go to . it also fails to account for the outbreak amongst younger people, and thus overestimates the survival rate. nonetheless, before the lifting of lockdown, the model fits the data quite well. an attempt to extrapolate the results of this model to asian countries was attempted, but many countries there are still fighting the virus, seeing a growth in cases. others observed a small peak around april, and are suddenly seeing a dramatic resurgence in august, akin to the peaks of the european countries in april. while the model could be adapted to the cases in august, an analysis of the data wouldn't be appropriate until much after cases have subsided. nonetheless, this paper aims to change the notions of the general public as to the situation of the covid- virus, that contrary to popular opinion, it is still at large, and affecting a younger crowd. it also aims to provide an answer to what forms of reopening are still acceptable to reducing net cases, to which mostly internal reopenings are suggested. it finally looks to model the new growth of covid- in the european countries in addition to two new north american countries. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint disclosure statement. the author has no conflicts of interest to declare. declaration regarding data and software. the data used in this paper were all derived from public sources. links to these data are included in the paper. the main data source is taken from https://ourworldindata.org/coronavirus-source-data. the r code used to analyze the data along with all data files will be provided on request -email: jaypatwardhan @gmail.com. ) using the ode solver ode in r. the mean values of the parameters obtained (inset) are from the solid black line and the error bars are from the two red lines. the next plot is the residual plot for the cases, found by subtracting the observed value from the fit value, with an error estimation taken from the values of the fits in the error bars. we can observe the error getting smaller as the expected data from the fits fall below the case mark. the final plot is a measure of the p value for each observed data point given a mean of the middle fit and a standard deviation calculated from the values of the error bars. the horizontal blue line indicates an α = . level of significance, leading us to reject any values below that line as expected. this is replicated for all european countries. observed data (red dots) for the number of deaths per day (x (t)) and fits (solid lines) obtained by solving ( . ) and ( . ) using the ode solver ode in r. the mean values of the parameters obtained (inset) are from the solid black line and the error bars are from the two red lines. the next plot is the residual plot for the deaths, found by subtracting the observed value from the fit value, with an error estimation taken from the values of the fits in the error bars. we can observe the error getting smaller as the expected data from the fits fall below the case mark (unless the peak is really small, in which case the error gets smaller as the expected data falls below the case mark). the final plot is a measure of the p value for each observed data point given a mean of the middle fit and a standard deviation calculated from the values of the error bars. the horizontal blue line indicates an α = . level of significance, leading us to reject any values below that line as expected. this is replicated for all european countries. figure : observed data (blue dots) for the number of cases per day (x (t)) and fits (solid lines) obtained by solving ( . ) and ( . ) using the ode solver ode in r. the mean values of the parameters obtained (inset) are from the solid black line and the error bars are from the two red lines. this graph contains the model fits for after reopening starts. data was obtained by ending the first curve at a certain date (found using the residual and p plot analyses) and starting the second curve around that date. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint figure . new plot of cases after the lockdown was lifted . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint incidence, clinical characteristics and prognostic factor of patients with covid- : a systematic review and meta-analysis coronavirus: why spain is seeing second wave coronavirus disease (covid- ) in the eu/eea and the uk -eleventh update: resurgence of cases predictions for europe for the covid- pandemic from a sir model update: severe acute respiratory syndrome -worldwide and united states coronavirus: how lockdown is being lifted across europe genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding a contribution to the mathematical theory of epidemics key: cord- -m xba g authors: macintyre, chandini raina; costantino, valentina; kunasekaran, mohana priya title: health system capacity in sydney, australia in the event of a biological attack with smallpox date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: m xba g planning for a re-emergent epidemic of smallpox requires surge capacity of space, resources and personnel within health systems. there are many uncertainties in such a scenario, including likelihood and size of an attack, speed of response and health system capacity. we used a model for smallpox transmission to determine requirements for hospital beds, contact tracing and health workers (hcws) in sydney, australia, during a modelled epidemic of smallpox. sensitivity analysis was done on attack size, speed of response and proportion of case isolation and contact tracing. we estimated clinical hcws and public hospital beds in sydney. rapid response, case isolation and contact tracing are influential on epidemic size, with case isolation more influential than contact tracing. with % of cases isolated, outbreak control can be achieved within days even with only % of contacts traced. however, if case isolation and contact tracing both fall to %, epidemic control is lost. with a smaller initial attack and a response commencing days after the attack, health system impacts are modest. the requirement for hospital beds will vary from up to % to % of all available beds in best and worst case scenarios. if the response is delayed, or if the attack infects people, all available beds will be exceeded within days, with corresponding surge requirements for clinical health care workers (hcws). we estimated there are public health workers in sydney with up to , contacts to be traced. at least million respirators will be needed for the first days. to ensure adequate health system capacity, rapid response, high rates of case isolation, excellent contact tracing and vaccination, and protection of hcws should be a priority. surge capacity must be planned. failures in any of these could cause health system failure, with inadequate beds, quarantine spaces, personnel, ppe and inability to manage other acute health conditions. smallpox is a category a bioterrorism agent, despite being declared eradicated in [ ] . the virus is retained in high security biosafety level laboratories in the united states and russia [ ] . the variola genome is fully sequenced and could be synthesized in a laboratory [ ] . this a a a a a to determine the capacity of the health system in sydney, a city of . million people in australia, during an epidemic of smallpox. specifically, we aimed to determine hospital bedcapacity for isolation, public health workforce capacity for contact tracing and health care worker (hcw) personal protective equipment (ppe) requirements under different attack scenarios. we also aimed to test a worst case scenario among the range of possible attack scenarios and identify modifiable factors which would prevent a worst case scenario. we constructed a modified seir model for smallpox transmission based on a model published in our previous study [ ] . model parameters and their estimation have been previously described [ ] . we assumed that the virus has not been genetically modified and that there is minimal residual immunity in the population from previous vaccination, as described in our previous study [ ] . we assumed an initial attack size of , or , infected. case isolation was assumed to reduce transmission to zero [ ] . given antivirals would be commenced after diagnosis and isolation, we assumed this effect would only apply in the healthcare setting and would not add to interruption of transmission above the effect of isolation alone, with the main transmission risk being in the community for undiagnosed or early cases prior to hospitalisation. we assumed that antivirals would therefore have no effect on community transmission, acknowledging that they would likely reduce morbidity and mortality for treated cases. we estimated number of hospital beds needed to control the epidemic, ppe requirements for clinical hcws and public health workers required for contact tracing, under different scenarios. we constructed a modified model for smallpox transmission. population residual immunity and contact mixing are based on assumptions used in our previous study [ ] . using ordinary differential equations as described in s file, the population moves through the disease compartmental epidemiological states of being susceptible, exposed, infected and recovered (seir) from smallpox. once infected, people move into the next state following disease duration rates. euler's approximation was used to estimate age-specific force of infection, assuming contact would be similar to observed patterns in the uk [ ] [ ] [ ] . different infectivity levels were based on the reproduction number for hemorrhagic, flat, ordinary and modified smallpox as previously described [ ] . the force of infection was multiplied by a parameter (α , α , α , α ) to account for different population susceptibility levels. model parameters and their estimation are described in our previous study [ ] . the model runs for days. the model assumptions are shown in table . to test the preparedness of the health system we assumed the base case response would be case isolation and treatment, contact tracing and ring vaccination. as the study was examining health system factors, ring vaccination was kept constant in the model at % with assumed adequate vaccine supply and trained vaccinators, and - % vaccine efficacy for uninfected people and - % for latent infected [ , [ ] [ ] [ ] as described in s file. hospital bed requirements. we estimate the number of hospital beds in sydney using data published for - in nsw [ ] . in nsw for - there were beds available from public hospitals ( . per population) and beds available from private hospitals ( . per population). this was resized for the sydney population. the number of hospital beds needed for case isolation was then modelled under different scenarios based on variation of response time (t), the percentage of infected cases isolated each day and how many contacts were traced. we tested if the number of available hospital beds in sydney will be enough to isolate up to % of all new infected cases every day, under different scenarios. clinical health workforce and ppe requirements. the clinical health workforce was estimated by the number of hcws in sydney for / , including aboriginal and tsi health practitioners, chinese medicine practitioners, dental practitioners, medical practitioners, radiation therapists, nurses and midwives, occupational therapists, pharmacists and ambulance services workers [ ] . the total estimated health workforce number was for nsw, with a total population of . million in [ ] . we applied the same percentage adjusted for the sydney population from the same year, . million [ ] . hcw distribution by age average number of contacts per case [ ] proportion of contacts traced around an infected case %, sensitivity analysis with % and % [ ] [proportion of cases that get isolated once infected and symptomatic %, sensitivity analysis on with % and % [ ] group was estimated using national and global health worker data [ , ] . we estimated, based on epidemic size and duration, the amount of respiratory ppe (n respirators) required for sydney clinical hcws assuming two respirators per shift per hcw. this is based on recommendations that disposable respirators should not be re-used, and the fact that a standard shift for a hcw would include at least one break, after which a new respirator would need to be used. public health workforce for epidemic control. there are no published data to estimate the public health workforce, comprising trained public health officers working in health departments and capable of conducting contact tracing and outbreak investigation, as public health workers are not registered health practitioners. the only uniform qualification in public health is a master of public health (mph) and similar degrees. whilst there are a large number of mph graduates in australia, the number working in government public health roles would be a minority. it should also be noted that a mph does not equip people with the skills for field response to an epidemic. there are approximately alumni of the national field epidemiology training program (fetp). in addition, there is a medical specialisation in public health medicine for a relatively small number of medical doctors, with an estimated full time equivalent public health physicians nationwide in [ ] . based on discussions with national experts we estimated there are approximately skilled public health officers in australia, although the actual number may be lower. the public health workforce was calculated using estimates of mph graduates currently working in government, fetp graduates or current fetp trainees and public health physicians. an optimistic assumption of public health officers nationally was used to estimate the number working in sydney. contact tracing requirements. in the base case, we assumed % of contacts would be traced and % infectious people would be isolated. we used age specific contacts rates, with an average of contacts per case based on european social mixing data [ ] . we estimated the number of public health workers required to conduct contact tracing under different scenarios. given contact tracing may require complex communications and travel over large geographic distances, we assumed one public health officer could trace contacts per day. australian guidelines for management of smallpox state that isolation is needed for nonimmune category a (high risk) contacts, in individual rooms with supervision by vaccinated staff [ ] . we conservatively assumed at least % of contacts traced would be category a, and would require supervised quarantine. data from tuberculosis studies [ ] as well as estimated social contact matrices suggest one person [ ] , on average, has - contacts at reasonable risk of infection. the closest of these contacts would include household contacts (about - people), plus - others in work or friendship circles. this would be about half of the - contacts. the number of contacts needed to be traced and managed was estimated based on attack size, time to response (t) and the percentage of infected cases isolated each day. a contact tracing day was defined as one day entirely spent tracing contacts per public health worker. sensitivity analysis. a sensitivity analysis was conducted on attack size, the proportion of infectious cases isolated and contacts traced, as well as time to commencing the response. to illustrate the difference in epidemic size between a single index case of smallpox imported from overseas, compared to a primary attack which results in or simultaneous firstgeneration cases, we modelled the epidemic resulting from , or initial first generation cases. the size of an attack is unknown, and would depend on the technical sophistication of aerosol dispersion of variola. to account for this uncertainty, we explored the influence of attack scenarios of , and initial infected as a wide range of possible attack sizes, to determine the impact of attack size on epidemic control. delays in diagnosis and time to obtaining laboratory confirmation could vary the time of onset of the response. we therefore varied the time of the response commencing between t = , and t = days following virus release. given an average incubation period of days for smallpox [ ] , this corresponds to day , and after the onset of symptoms of the index case. we estimated public hospital beds and private hospital beds in sydney. we estimated there are clinical hcws in sydney, the majority ( %) aged - years old, % nurses and % doctors [ ] . we estimated a public health workforce of nationally, with approximately public health workers in sydney. fig shows the relative epidemic size of a deliberate release scenario with or initial infected compared to a single importation of smallpox from an epidemic overseas, to illustrate the potential scale of the required public health response. the higher the initial number infected, the more rapid and severe the epidemic. without intervention, the death rate will reach an incidence (number of new infected people per day) rate of deaths per population per day. the overall reproductive number was estimated to be . . fig shows the influence on infections and deaths by varying time to response and case isolation rates. both timing and isolation rates of infected cases are highly influential in outbreak control. with infected initially, when isolation decreases, the deaths increase from a maximum of , and per day in the best scenario with % isolation (for t = , and respectively), to . , . and per day with only % of cases isolated (fig ) . fig shows the influence of varying time of starting the intervention and varying percentage of contacts traced on the incidence of infections and deaths with case isolation constant at %. with a high proportion of cases isolated, outbreak control can be achieved within days even with only % of contacts traced. fig shows the effect of varying both case isolation and contact tracing rates, with the intervention commencing at days-case isolation is more influential, with epidemic control severely impacted when isolation and contact tracing falls to %. in table we show the impact of the epidemic (total cases and contacts needed to be traced) by varying case isolation rates. the total number of cases range from to , ; and contacts that need to be traced between and in the best-and worst-case scenarios respectively. we estimated public hospital beds and private hospital beds in sydney. the modelled maximum number of people isolated at the same time is about . and . times the initial number of infected if we start intervention respectively at t = and at t = and peaks days after the response commences. therefore, if the initial number of infected is or , the available beds will not be completely exhausted, but treatment capacity for other illnesses may be impacted. in the case of initial infected, the maximum beds usage will reach . % and . % of sydney public available beds, if the response starts at time t = and t = days from the virus release respectively. if the initial number of infected is , the maximum beds usage will reach . % and . % of sydney public available beds days after the response commences, if the response starts at time t = and t = days from the virus release respectively. however, in the case of initial infected, the available hospital beds will be all used in the first few days of the response. fig shows the hospital bed usage in the worst-case scenario of initially infected, with varying start times of the response. maximum number of beds needed at the same time and day shown in the square windows. with initial infected if we start the intervention at t = from virus release, beds will be used the first day, the second day. at and days after commencing the intervention (at day and ) more than % and % of the total beds in sydney hospitals will be needed. at day post-attack, days after starting the intervention, % of all public and private beds will be used. if the intervention is delayed to day t = , almost % of the available beds will be used in the first days, % at day of response will be used and at day of the response (t = after the attack) all available public and private beds will be used. table https://doi.org/ . /journal.pone. .g results showed for % of new infected isolated. % % % maximum number of beds used in the same day (% of the total) initial infected shows the time to occupancy of all available hospital beds at levels of % or greater. whilst an attack of initial infections does not reach % of beds under any scenario, in the worstcase scenario (response commencing at day ) % of beds will be used by day . the number of hcws required and the ppe they need will be proportionate to the number of cases requiring treatment (table ). in scenarios described above where cases (beds) exceed % of available beds, staffing requirements will increase %, unless reduced staff/patient ratios are implemented. estimating a minimum of disposable respirators a day per hcws for days, over million respirators will need to be stockpiled for all clinical hcws in sydney. this number can be used to estimate requirements based on the estimated percentage of the clinical workforce needed for the epidemic, which will be proportionate to the number of cases requiring treatment ( table ). if % of clinical hcws are involved in care of smallpox patients, over million respirators will be needed. if the epidemic is not controlled within days this number will be doubled. the public health staff (phs) required to conduct contact tracing will depend on how many contacts one person can trace per day and the number of available phs, estimated to be in sydney. if one phs can trace contacts a day, then in the best-case scenario of contacts, over contact tracing days are required, based on the number of contacts in table above. in the worst-case scenario, , contacts and , contact tracing day are required. in the worst-case scenario, phs would work over days each doing contact tracing. if half of contacts are high-risk, quarantine spaces will be required for to , contacts. in the case of a smallpox release in sydney, a high-income, well-resourced city of over . million people, health system impacts may be substantial under some scenarios as shown in our model. we showed if smallpox arises overseas and is imported as a single case into australia by travel, control will be far easier than under an attack scenario. we showed that influential factors on epidemic impact are the size of the initial attack, time to commencing the response, case isolation rates and contact tracing for ring vaccination. whilst both are influential, case isolation is more influential than contact tracing. these public health interventions depend on physical and human resources, including clinical and public health workforce. whilst the size of an attack may not be within our control, other the influential factors are modifiable and potentially within our control. if the initial attack size is - and the response is rapid, an outbreak of smallpox can be controlled with case isolation, contact tracing and vaccination. however, if the response is delayed to days or longer (which equates to about weeks after the first symptoms occur), or if the attack infects people, epidemic control will be much more challenging, and the health systems impacts will be substantial. in the worst-case scenario, available hospital beds will be exceeded in less than days. the requirement for hospital beds for isolation of cases will vary from up to % to % of all available beds depending on the size of initial release and speed of response. even in the mid-range scenario of initial cases, up to % of all available hospital beds will be required for smallpox control. this does not account for the facilities required for quarantine of contacts, which must additionally be planned for, and in the worst-case scenario would require over , high risk contacts to be quarantined. quarantine and isolation capacity are critical to epidemic control. planning for surge bed capacity using available guidelines should be undertaken [ ] , and back up plans such as the use of community halls, school buildings, hotels or other large buildings should be made to ensure that that other viable isolation sites are pre-designated as smallpox treatment centres and available. during the pandemic of influenza, which was reportedly not as severe as expected, studies reported a tripling of patient presentations to hospital [ ] . plans for managing hospital bed capacity in the event of a large initial attack should also be made, including designation of specific treatment facilities, cancellation of elective surgery and decanting of patients with non-urgent other conditions into private hospitals or other facilities. the capacity for hospital beds for non-smallpox patients who require urgent hospitalisation must also be considered, and in some scenarios, the care of patients with urgent non-infectious conditions such myocardial infarction or stroke, may be compromised by lack of hospital capacity and staffing shortages. rapid response time is critical and becomes even more critical when the initial infected number is higher. responding more than days from the virus release (which means commencing the public health response within days of symptom onset, given an average day incubation period) will result in a more severe outbreak. whether it is feasible to commence response within the best-case scenario of days post-release (or days after symptom onset) is unknown, but unlikely. a rapid response depends on very early detection and diagnosis, as well as prompt commencement of case finding, isolation, contact tracing and vaccination. practically, the target for reducing the time to response is in early diagnosis, which depends on awareness first, followed by diagnostic test. delays may occur if the diagnosis is missed in the index case. recent examples of serious emerging infectious diseases where the diagnosis was missed include ebola in nigeria and the us, both of which occurred during the height of the west african epidemic when media reports were at a peak and awareness should have been high [ , ] . the largest epidemic of mers coronavirus outside the arabian peninsula occurred in south korea following a missed diagnosis and failure of triage in a patient with a relevant travel history and a respiratory clinical syndrome [ ] . the last european epidemic of smallpox in also involved a missed diagnosis, when a traveller to the middle east returned to yugoslavia, which had been free of smallpox for years. the patient had haemorrhagic smallpox, which was misdiagnosed as a severe adverse reaction to an antibiotic, and smallpox was not suspected until second generation cases began occurring, resulting in an outbreak of cases [ ] . excellent surveillance systems and triage protocols for early detection of low probability, high impact outbreaks such as smallpox is recommended. improving diagnosis requires triage protocols and rapid diagnostics, the latter being useful only if the diagnosis is suspected clinically in the first instance. other avoidable delays in response could include having pre-vaccinated first responder teams, pre-designated isolation and quarantine facilities, and rapid human resources and surge capacity scale up plans [ ] . we have showed that epidemic control is highly sensitive to case isolation rates, which need to be maintained at high levels. identifying and isolating less than half the new infected cases and tracing only half of all contacts will result in a blow-out of the epidemic. space and human resource requirements for case finding, isolation, contact tracing, vaccination and quarantine are therefore essential for preparedness planning. physical space requirements extend beyond isolation of smallpox cases, to quarantine of contacts. in the worst-case scenario, almost one million contacts need to be traced and there will be a lack of physical space for quarantine of high-risk contacts. plans for home quarantine and surveillance of contacts should also be undertaken and will require adequately trained personnel. the speed and effectiveness of contact tracing is also critical to the success of ring vaccination and will require an adequately trained critical mass of public health workers and epidemiologists, separate from the clinical workforce. in australia, as a federation, this will rely on state and territory capacity, and cross-border mobilisation of jurisdictional capacity in the event of a smallpox epidemic, and estimation of the current and required capacity for such an event. the fact that public health personnel are not registered as health practitioners or documented in any other centralised way, makes it more challenging to rapidly mobilise suitably qualified and experienced personnel for a large-scale epidemic response. this is a policy consideration that could be addressed as part of pandemic and health emergency planning, which may strengthen response. contact tracing may need to rely on community volunteers, as the available public health workforce will be inadequate in a large epidemic. staff surge requirements would track parallel to bed requirements and would be over % in some scenarios. the need for a clinical health workforce to treat smallpox will be high, with case numbers in the s to , s in many of the scenarios modelled, and just over , clinical hcws in sydney. limiting the number of hcws working in designated smallpox facilities is a sensible strategy. a possible approach to such a scenario would be a reduction of staff to patient ratios, as well as using trainee hcws. protection of these clinicians is key, with vaccination being the mainstay. up to , doses of vaccine will need to be reserved for clinical hcws and plans in place to commence vaccination. ppe will not be an alternative to vaccination, but an additional protective measure for hcws. today, work health and safety requirements would dictate that paprs or disposable respirators with a hood and coveralls be available to clinicians treating smallpox cases. perceived lack of protection during a serious emerging infection outbreak may result in refusal to work or industrial action by hcws [ ] . hcw may be well protected by ppe, but there is large uncertainty around effectiveness of ppe. studies of other viruses transmitted by the respiratory route suggests good effectiveness of respirators against smallpox [ ] . it should be noted that surgical masks are unlikely to offer protection to hcws based on available data [ ] . stockpiling may provide a short duration of supplies. the modelled epidemic may run for - days or more, depending on the scenario. a very large quantity of respirators may need to be stockpiled, depending on the percentage of hcw involved in direct care of smallpox patients. given the likely duration of an epidemic, plans should put in place for rapid procurement of ppe supplies beyond the stockpiled capacity. strategies to minimise the number of hcw treating each case of smallpox, including using designated smallpox hospitals, will reduce the quantity of ppe required. early identification of the epidemic, high rates of case isolation, excellent contact tracing and vaccination, and protection of hcws are the key influential components of epidemic control. failure in any of these could severely compromise the capacity of the health system. australia has a detailed plan for smallpox response, [ ] and we have outlined key influential parameters for disease control which can add further guidance on mitigating severe outcomes in both the planning and response stages. excellent surveillance systems and triage protocols for early detection of low probability, high impact outbreaks such as smallpox can make a difference, given the criticality of timing of the response and better prospects of epidemic control in the early stages. planning for the health system should consider rapid surge capacity for beds, strategies to create and staff make-shift designated smallpox treatment facilities, and protection of hcws at all levels of care. requirements for contact tracing are substantial and may require mobilisation of community volunteers and additional space for quarantine and surveillance of high-risk contacts. designated surge smallpox facilities and plans for management of other urgent health conditions should be considered. we have outlined several modifiable factors which, with good planning, can ensure adequate health system capacity in the event of a smallpox epidemic. general fact sheets on specific bioterrorism agents smallpox and its eradication: the pathogenesis, immunology, and pathology of smallpox and vaccinia the de novo synthesis of horsepox virus: implications for biosecurity and recommendations for preventing the reemergence of smallpox. health security how canadian researchers reconstituted an extinct poxvirus for $ , using mailorder dna biopreparedness in the age of genetically engineered pathogens and open access science: an urgent need for a paradigm shift development of a risk-priority score for category a bioterrorism agents as an aid for public health policy influence of population immunosuppression and past vaccination on smallpox reemergence who (world health organizazation). smallpox. geneva, switzerland: world health organization smallpox vaccines: past, present, and future public health and health reform in australia respiratory protection for healthcare workers treating ebola virus disease (evd): are facemasks sufficient to meet occupational health and safety obligations? planning for smallpox outbreaks modelling disease outbreaks in realistic urban social networks containing bioterrorist smallpox modeling the effect of herd immunity and contagiousness in mitigating a smallpox outbreak planned and unplannedfutures for the public health physician workforce in australia. a labour market analysis for the australasian faculty of public health medicine: australasian faculty of public health medicine:sydney hospital resources - : australian hospital statistics canberra: australian institute of health and welfare social contacts and mixing patterns relevant to the spread of infectious diseases transmission potential of smallpox in contemporary populations effectiveness of postexposure vaccination for the prevention of smallpox: results of a delphi analysis smallpox in europe ambulance service of nsw. workforce statistics staff turnover counting health workers:definitions, data, methods and global results. geneva: world health organization annual report / : melbourne. australian health practitioner regulation agency smallpox response plan and guidelines (version . ). archive-use only for research purposes preventability of incident cases of tuberculosis in recently exposed contacts. the international journal of tuberculosis and lung disease a survey of emergency department pandemic influenza a (h n ) surge preparedness office of the chief health officer. public health workforce surge guidelines transmission dynamics and control of ebola virus disease outbreak in nigeria ebola us patient zero: lessons on misdiagnosis and effective use of electronic health records hospital outbreaks of middle east respiratory syndrome smallpox as actual biothreat: lessons learned from its outbreak in ex-yugoslavia in . annali dell'istituto superiore di sanita exercise mataika: white paper on response to a smallpox bioterrorism release in the pacific uncertainty, risk analysis and change for ebola personal protective equipment guidelines the efficacy of medical masks and respirators against respiratory infection in healthcare workers. influenza and other respiratory viruses smallpox cdna national guidelines for public health units. communicable diseases network australia key: cord- -ekw oxw authors: lin, gary; strauss, alexandra t; pinz, maxwell; martinez, diego a; tseng, katie k; schueller, emily; gatalo, oliver; yang, yupeng; levin, simon a; klein, eili y title: explaining the bomb-like dynamics of covid- with modeling and the implications for policy date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ekw oxw using a bayesian approach to epidemiological compartmental modeling, we demonstrate the bomb-like behavior of exponential growth in covid- cases can be explained by transmission of asymptomatic and mild cases that are typically unreported at the beginning of pandemic events due to lower prevalence of testing. we studied the exponential phase of the pandemic in italy, spain, and south korea, and found the r to be . ( % cri, . - . ), . ( % cri, . - . ), and . ( % cri, . - . ) if we use bayesian priors that assume a large portion of cases are not detected. weaker priors regarding the detection rate resulted in r values of . ( % cri, . - . ), . ( % cri, . - . ), and . ( % cri, . - . ) and assumes nearly % of infected patients are identified. given the mounting evidence that potentially large fractions of the population are asymptomatic, the weaker priors that generate the high r values to fit the data required assumptions about the epidemiology of covid- that do not fit with the biology, particularly regarding the timeframe that people remain infectious. our results suggest that models of transmission assuming a relatively lower r value that do not consider a large number of asymptomatic cases can result in misunderstanding of the underlying dynamics, leading to poor policy decisions and outcomes. the spread of covid- has become a global pandemic, with confirmed cases of the disease growing exponentially on every inhabited continent [ ] . despite the rising numbers of cases and deaths, there are still important questions about the dynamics of the spread of the disease. understanding the transmission of covid- is essential to developing policy to contain the spread of the disease. the most important question in understanding the dynamics is how to explain the "bomb-like" dynamics of the disease; in most countries/states/cities, the number of confirmed cases remained low for weeks and then suddenly exploded, with the number of confirmed cases exponentially increasing in a matter of days ( figure ). these dynamics have been consistent across europe and many states in the united states. they are also characteristic of the early infection period in china. the major question is whether these dynamics are due to missed cases of asymptomatic/mild disease or extremely rapid spread of the disease. understanding the percentage of the population that is actually infected is critical for developing policies. as many countries have instituted extended shutdowns to try to contain the disease, there remain significant questions about the effectiveness of these policies in the short-and longterm. the most prominent countries to have contained or slowed the spread of disease include china, singapore, hong kong, taiwan, and south korea [ ] [ ] [ ] [ ] [ ] . through comprehensive strategies such as early detection, extensive testing, shelter-in-place orders, and isolation of infected individuals (among other measures), these countries have demonstrated that a combination of control measures can effectively slow transmission from affected individuals whether they are severely sick or asymptomatically infected. in contrast, isolated measures like broad travel restrictions or enforced quarantine have proven less effective, as the ability to achieve "zero risk" through these measures are virtually unattainable in most contexts. moreover, the effectiveness of these strategies are even more questionable in light of research showing asymptomatic and mildly symptomatic carriers as important vectors for community transmission of covid- [ ] [ ] [ ] [ ] . in this analysis, we aim to elucidate the parameters related to transmission, specifically the reproductive number. in epidemiology, the reproductive number of a disease describes the average number of additional infections each infected individual contributes within a totally susceptible population. at the outset of a disease, or time , the reproductive number is r . if r is greater than the disease will spread; if it is less than the disease will die out. estimates for the r of covid- range widely. initial estimates suggested it was quite high [ , ] , but most models that have been highly cited in the literature have assumed an r in the - range [ ] [ ] [ ] [ ] . capturing the magnitude of this value is critical to understanding how fast the disease will spread, how much of the population will be infected, and how quickly they will become infected. in simplest terms, the reproductive number of a disease is a function of its transmission rate and the duration of infectious period. transmission rate is a function of both the number of social contacts an individual has and the probability that a contact results in a transmission. therefore, either a greater number of contacts or a higher probability per contact, such as when someone is shedding more virus or the virus is more transmissible, can increase the transmission rate. thus, governments have opted for widespread quarantines (thereby reducing contacts) to reduce the transmission rate of covid- regardless of its infectiousness. on the other hand, a long infectious period in one individual can result in a high number of resultant infections. recovery, death, and isolation of an individual all result in a halt in that individual's ability to transmit a virus (though all such options are not equally desirable). a high transmission rate and short infectiousness period or vice versa can result in the same r , but the implications for disease spread are different; a longer infectiousness period would result in a much later peak relative to a high transmission rate (though the number of infected people at the peak is comparable). understanding the transmission patterns of covid- can help policymakers predict critical moments in its progression, such as peak infection and the point when herd immunity has been reached and restrictions can be lifted or whether to worry about a second peak later. emerging evidence from china [ ] , germany [ ] , taiwan [ ] , and iceland [ ] suggests a larger fraction of the population may actually be asymptomatically or mildly infected than previously thought. even the first report of genomic differences in the virus from washington state in the united states suggested there may have been widespread community transmission as early as late january [ ] , which presumably generated asymptomatic or mild enough cases that they were missed. given that the spread of the disease coincided with peak influenza season, it is reasonable to assume that a mild covid- infection could have been misdiagnosed. in addition, data on the disease's effect on children have been almost entirely lacking in the numbers of cases and hospitalizations reported [ ] . evidence suggests they are likely getting infected at the same rate as adults, albeit with lesser severity [ , ] , implying that, at a minimum, at least % of the population in many countries may be asymptomatic when infected; the numbers are likely much higher. here we use a bayesian approach to estimate the parameters of a disease transmission model of covid- that includes both recognized and unrecognized infections. we examine the fit of the model to confirmed cases of covid- across several countries. to estimate transmission dynamics, we adapted the kermack and mckendrick compartmental model to the reported disease dynamics of covid- . specifically, we assumed that, (i) there is an incubation period for susceptible individuals that become infected; and (ii) a fraction of individuals are asymptomatic or only have mild/moderate symptoms and would be missed in the official count of confirmed cases. the model is described by the following set of ordinary differential equations, where s is the population of susceptible individuals and e are exposed individuals incubating the disease, and who eventually become infected. after the incubation period, /μ, we assume individuals will either be asymptomatic or mildly infected and will not be detected, c, or will have moderate to severe symptoms, i, which would result in detection. the parameter θ, . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . describes this unknown value. finally, we assume that individuals will either recover, die, or remove themselves from transmission through self-quarantine until they recover at rate γ. our goal was to estimate the ranges of parameters that would fit the data of the beginning of an outbreak in a country, assuming that initially the effects of distancing and other measures to control the disease are largely absent and thus the data are largely representative of the transmission dynamics but that some proportion of the infected population is not observed. data on outbreaks in italy, spain, and south korea were obtained from the center for systems science and engineering at johns hopkins university [ ] (figure ) . we fit the model to the observed data assuming that the first observed case was in the more severe group. we constrained our fit to the early part of the outbreak in each country, before widespread quarantines or extensive testing altered the path of the disease. for italy this was from january , to march , , for spain this was from january , to march , , and for south korea this was from january , to march , . to estimate the credibility of parameters, we used monte carlo (mc) to sample the parameter space with a uniform prior density with bounds and used acceptance and rejection sampling to approximate a posterior distribution of the parameters. the error between the results of the model yielding the expected number of observed cases and the observed number of cases is considered to be normally distributed with norm ( , σ). the variance ( ) is estimated as the difference between the model with the optimal parameter set and the observed number of cases. reported parameter estimates are the medians of the posterior distributions, and % credible intervals from quantiles of the posterior distribution. the goal of the bayesian parameter estimation is to approximate a posterior probability density function of the parameter. mc sampling of the parameter space was based on the number of reported active cases, recoveries and deaths. specifically, we fit projected cases in the i compartment to active cases (confirmed cases minus recovered cases and deaths) and the r compartment to the sum of recovered and deaths. while traditional unbiased curve-fitting methods yield a set of parameter estimations that capture observed data, they do not account for known prior belief on parameter ranges. a bayesian approach to parameter estimation allows us to quantify the credibility of one set of model parameters. this approach is extremely powerful as it provides a range of credible parameters in which the model can fit the observed data. parameter bounds were based on disease dynamics literature and expert judgement (table ) . to assess the biological relevance of the parameters, we calculated the of model, based on the dominant eigenvalue of the next generation matrix. the infection subsystem of the model can be described by equations ( ). we use a linearization of the infection subsystem, similar to the formulation outlined by diekmann et al. [ ] , . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . ( ) where the matrix represents the transmission matrix that captures the number of transmissions from the susceptible compartments. the matrix m represents the transition between compartments within the infection subsystem. specifically, is equal to from this formulation, we can mathematically construct the next generation matrix , which is defined as = − − , which would equate to r is equal to the dominant eigenvalue of w (highlighted in red), which is equal to to assess fit, determine model parameter priors for the model fits, and provide context for the analysis, we conducted a search of all literature already published on the biology and transmission of covid- . the majority of this literature was on pre-print servers such as medrxiv, biorxiv and ssrn's first look (table ) , and most data estimates were reliant upon small studies with wide variability. from this literature, we found an estimate for the incubation period, defined as the time from exposure to onset of illness, of . ± . days [ ] . the proportion of the population with no/mild/moderate symptoms was estimated to be as high as % of the population [ ] . the infectiousness period, γ, was estimated to be . days ( % cri: . - . ) based on the dynamics of earlier coronaviruses, though symptomatic and hospitalized cases likely have a longer recovery time than mild/asymptomatic cases [ ] . finally, we estimated the transmission rates, β and β , based on calculations of the basic reproduction number, , of covid- and clearance estimates. values for in the literature range from . to . [ , [ ] [ ] [ ] ; given these values we assumed that the transmission rate for β was likely between . and . . we first fit the data assuming only that transmission from our unobserved group (β ) was lower than from the symptomatic observed group (β ), as mild/asymptomatic cases are likely to shed fewer viruses and thus be less transmissible. thus, we constrained β and β to be between . - . and . - . , respectively. we then refit the data by constraining our symptomatic fraction, θ, to be % or less. the main results are presented as the fitted values and the relative relationship to the known biology. as the process is stochastic, we were interested in the local maxima obtained from this procedure to guide understanding of the parameters and to assess the ability of the model to fit actual data with biologically plausible values. assuming a uniform prior with no constraint on the fraction of the population that was symptomatic, θ, the parameter estimation from our mc sampling resulted in a posterior mean for the symptomatic rate of . table . the overall fit of the model to the data was generally better in the unconstrained case, in which only a small fraction of the population is missed due to unobserved asymptomatic/mild infection ( figure ). variation between the two estimated scenarios was primarily governed by differences in the length of the infectiousness of the symptomatic group. in the high symptomatic case, the fit of the parameter produced mean infectiousness periods of - days, while in the constrained case the infectiousness period was estimated to be about days. as covid- spreads through the united states, questions remain as to the rate of disease spread, the extent of people infected, and the implications for policies regarding quarantines. we conducted this analysis to contribute to available disease models, which play an integral role in defining the policy choices of government officials. accurate evidence that conforms to observed data is needed to aid those decisions. our results suggest that there appear to be two dichotomies. the first assumes that most cases are discovered and the r of the disease is more than . the second assumes a lower r , but a large fraction of the population is asymptomatically infected and excluded from official estimates of the disease spread. given these scenarios, we . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint believe the more likely case is that a large fraction of the population is asymptomatically infected, and the only question is what percentage. if the proportion of individuals that are asymptomatically infected is actually higher than initially assumed, waiting for the emergence of observed cases to impose travel restrictions is not a productive policy, because (i) there are likely far more infected individuals than are observed, and (ii) due to the long dynamics of the incubation period, there is a large proportion of people who are already infected but not yet infectious. evidence from china suggests that the observed data trail reported infections by about two weeks. in other words, despite dropping transmission dramatically between january and january , the rate of newly confirmed cases did not begin to level off both country-wide and within each local city until two weeks later (figure ) . assuming a large fraction of the population is asymptomatically infected has important implications for policy because of herd immunity. while there have been some potential second cases, the vast majority of the evidence suggests that infected individuals develop immunity to circulating strains. as more of the population gains immunity, disease spread will slow. when transmissibility between contacts falls because of widespread immunity, the effective reproductive number is reduced, the disease spreads more slowly, and the threat posed by widespread numbers of infected individuals fades away. such widespread immunity would allow restrictions to be lifted sooner, as most individuals would not pose a transmission risk to the general public and would abrogate the possibility of a second peak in the future. understanding the potential risks requires serological surveys to be conducted as soon as possible in areas with high and low numbers of cases to understand how much the disease has been spreading and to inform better policies regarding quarantines. finally, the troubling implication of these results is that asymptomatic rates are estimated to be ~ %. based on the fits from the model, this would suggest that the r of covid- may be higher than . . a high r combined with large numbers of asymptomatic and mildly infected individuals could account for the "bomb-like" dynamics of covid- . in new york city, the rate of confirmed cases has been doubling roughly every days. this is faster even than italy where the rate of doubling was approximately every three days. recent data on mortality in the nyc region suggests that this rapid increase in cases is not just the effect of rapid increased testing, as the number of deaths is growing at a similar rate as the case load with an approximate two-week lag ( figure ). this mortality rate is, at least for the moment, substantially higher than the rate in italy (figure ). this suggests that densely populated urban areas may facilitate more rapid spread of the disease and have even higher reproductive numbers. given the strong connectivity between china and nyc, it is likely the first cases of covid- arrived in nyc by late january, yet the first case was not observed until late february and there was no "explosion" until mid-march. this should be a cautionary tale to other cities that are not as connected to international travel as nyc or are in the southern hemisphere, where potential seasonal differences may have led to lower transmission rates in february and march [ ] . postponing policy action until the outbreak is well underway, as nyc and italy did, is thus much less effective in containing the virus. only by extensive and early restrictions can the bomb-like dynamics of the disease be averted. in south korea, the dynamics initially appear similar, but the introduction of widespread testing likely led to the discovery of much larger numbers of less severe cases, which bent the curve. however, as the case of hong kong demonstrates, relaxing these policies before the disease has spread widely enough to provide herd immunity leads to rapid growth in cases within a couple of weeks [ ] . without a vaccine, cities and countries will need to manage the spread of the virus so that the number of hospitalized individuals will not exceed capacity. this is a difficult option but the only rational policy until more progress is made in vaccine development or therapeutics. the explosive nature of covid- disease dynamics is likely the result of large fractions of asymptomatic and mild cases leading to rapid and silent spread throughout the community. however, even this cannot explain the dynamics of disease spread alone in certain areas, such as nyc, without assuming that the reproductive number, or r , is higher than the reported values based on severe symptomatic cases. . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . using monte carlo (mc) methods, we were able to generate parameter samples from a prior distribution with acceptance-rejection sampling. in the figure, each set of sampled parameters of three countries, italy, south korea, and spain, were generated which allow us to calculate the , basic reproduction number, and display those values against the symptomatic rate ( ). the probability distribution for and are displayed on the right and top, respectively. the size each point represents the relative inverse sum of square errors for each country, with larger sized points being a better fit. the ellipses encircle % of simulation runs for each scenario. the triangular points represent priors for that were bounded (constrained) between . - . , while the circular points represent priors (unconstrained) that were bounded between . - . . . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . figure . based on the sets of parameters that were obtained from mc sampling, the severe infection outcomes are of each run for italy are displayed in color, while the observed active cases are displayed in black. the left side show the mc sampling for priors for θ (symptomatic rate) that were bounded uniformly between . - . (constrained), while the right side represent priors that were bounded between . - . (unconstrained). although, unconstrained parameters have a better fit to observed data, the constrained priors may capture the true dynamics of cases which will result in a relatively steeper increase. . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure . the confirmed cases by localities outside of hubei, china are shown for january nd , to march th , . we can see similar exponential increases in cases were observed after the population is rescaled with respect to population inside hubei province. . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure . confirmed cases and deaths in nyc. there appears to be a consistent lag, but similar rate of increase in deaths compared to cases, suggesting that the increase in confirmed cases is not due primarily to testing changes, but to actual disease dynamics. . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure . per capita death rate in nyc compared to italy. . cc-by-nc . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint an interactive web-based dashboard to track covid- in real time response to covid- in taiwan: big data analytics, new technology, and proactive testing lessons drawn from china and south korea for managing covid- epidemic: insights from a comparative modeling study assessment of covid- mass testing: the case of south korea impact assessment of non-pharmaceutical interventions against covid- and influenza in hong kong: an observational study real-time monitoring the transmission potential of covid- in singapore estimating the asymptomatic proportion of novel coronavirus onboard the princess cruises ship high transmissibility of covid- near symptom onset high incidence of asymptomatic sars-cov- infection presumed asymptomatic carrier transmission of covid- early in the epidemic: impact of preprints on global discourse about covid- transmissibility early dynamics of transmission and control of covid- : a mathematical modelling study preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak estimation of the reproductive number of novel coronavirus (covid- ) and the probable outbreak size on the diamond princess cruise ship: a data-driven analysis substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) transmission of -ncov infection from an asymptomatic contact in germany a locally transmitted case of sars-cov- infection in taiwan iceland lab's testing suggests % of coronavirus cases have no symptoms cryptic transmission of novel coronavirus revealed by genomic epidemiology. cryptic transm characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention epidemiological characteristics of pediatric patients with coronavirus disease in china covid- in children: the link in the transmission chain the construction of next-generation matrices for compartmental epidemic models time-varying transmission dynamics of novel coronavirus pneumonia in china characteristics and associations with severity in covid- patients: a multicentre cohort study from jiangsu province epidemiology and transmission of covid- in shenzhen china: analysis of cases and , of their close contacts data-based analysis, modelling and forecasting of the covid- outbreak the reproductive number of covid- is higher compared to sars coronavirus covid- outbreak progression in italian regions: approaching the peak by march th will coronavirus pandemic diminish by summer? hong kong records new cases in biggest daily jump yet. . available at projecting the transmission dynamics of sars-cov- through the post-pandemic period nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study key: cord- -o rchhw authors: el qadmiry, m.; tahri, e.; hassouni, y. title: on the true numbers of covid- infections: behind the available data date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: o rchhw in december- china reported several cases of a novel coronavirus later called covid- . in this work, we will use a probabilistic method for approximating the true daily numbers of infected. based on two distribution functions to describe the spontaneous recovered cases on the one hand and the detected cases on the other hand. the impact of the underlying variables of these functions is discussed. the detected rate is predicted to be between . % and , %, which means that there would be about million infected until now ( -may ), rather than the officially declared number of . million worldwide cases. since the outbreak of the novel coronavirus covid- and its spread around the world, several published works were concerned with the analysis of the available data to extract information that characterizes the daily evolution of this new pandemic. among the concerned information, there are the incubation period [ , ] , the reproduction number [ ] , mortality rate [ ] , and the asymptomatic proportion as in [ ] , where was used the data of the diamond princess cruise ship; which means that the study is done on a closed population, a fact that is worthy to mention. our aim in this work is to approach the true number of infected cases, and to develop an analytical method in order to allow the simulation of different scenarios that can occur if we modify the underlying variables of two special medkadmiri@hotmail.fr hassanfa@yahoo.com y-hassou@fsr.ac.ma probabilistic functions. these probabilistic functions control the numbers of the infected as well as the numbers of the detected cases. to predict the evolution of the true number of cases; which escapes from the official counting, we take into account the reproduction number. the importance of this investigation lies in the fact that the important part of the infection comes from people who are not in hospitals or not isolated, i.e., that the virus transmission occurs in general before symptoms appear [ ] . then, we think that the numerical simulation achieved here can be helpful to estimate the consequences of different strategies adopted at the governmental level, such as social distancing, strict-confinement for a short period, mass testing, and other measures that aim to stop the evolution of the pandemic. in this section, we will introduce the distribution functions that describe the spontaneous outcome cases and cases detected. in addition to the reproduction number responsible for exponential growth. when there is no medical intervention in favor of the infected, the biological defending system has to withstand alone as a natural solution. therefore, eventually the cases end by either recovering disability or death. thus, for a closed population initially infected, the number of infected keeps steadily decreasing since the illness onset until the end of infection, concerning many factors including age, health status, viral load, immunity, etc. considering these facts, we will suggest a suitable distribution function to lower the amount of the infected population through time. it is denoted as ps(t) -(s)-subscript as survival-and its analytical expression is chosen so as to be compatible with the empirical observation taken from the data available in [ ] based on control patients, so it is given as follows: . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint where ( ) is the heaviside step function equals to if ≤ and to otherwise, it ensures here that the function vanishes if the time exceeds the period of -days since the illness onset. this is because there is no remaining infected after this period, which after all, we will see that it does not have a significant impact on the results. let us note also that we do not use the polynomial regression to describe ps(t), because it demands a greet polynomial degree. in fig: ( ) , we show the behavior of the ps(t) function. the real curve can be extracted from the data concerning the control patients under the drug treatments experiment as for example in [ , ] , here we use the data of the first one as we mention above. the comparison is shown in fig: ( ), where we take the initial number of infected to be . thus, we plot the expected survival cases -at every day-given by the product × ps(t), with the real survival cases following the data. the standard error equals to , which means that we have a good approximation. days since the ilness onset survival probability . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint there is no doubt that the cases counting is not perfect, because there are many factors that may affect the results, such as test accuracy; viral load; medical protocol; testing strategy... nevertheless, we can estimate another cumulative distribution function (cdf), which describes the probability to detect the infected cases among the entire population. this function is wellknown used for several precedent epidemics (see [ ] ), e.g., sars coronavirus; rhinovirus; influenza b... the logistic distribution is useful to recognize this cdf, it is characterized by two parameters: the first one, denoted by m, represents the maximum absolute accuracy of testing and the second one is denoted by δ and represents the incubation period of covid- , which is estimated to be between . and . days (see [ ] ), e.g. it has fixed to . days in [ ] and . days in [ ] . let us denote this distribution function by pd(t) -(d)-subscript as detected, and "t" as time representing days since infection-and write its explicit expression in the following manner: in what follows, we will choose the value of the incubation period as δ = . -days following the result of the reference [ ] (where it was chosen for the accuracy of the data used in the analysis). concerning the testing days since the admition survival cases . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint accuracy, we take the maximum equal to m = %, which is a widely varied quantity regarding the testing strategy and the asymptomatic proportion estimated in [ ] to be . %. in fig:( ) we show the evolution of pd(t) cdf with respect to the above conditions, from which we get the probability to detect . % after days; % after days; % after days. the reproduction number is an important index to evaluate the spread of an epidemic. it is defined as the number of infected caused by an infectious person during the infectious period, denoted by r . what interests us in this work is the infection-producing contacts per one day, which is described by a function of time denoted by r(t), obtained simply as the ratio of the reproduction number r to the infectious period τ (neglecting the latent period). this quantity is sensitive to the confinement measures and always lower with respect to time. we suppose that r(t) follows an exponential evolution, which we could justify by the fact that at early times it is much easier to reduce the infected-healthy contacts than at a late time. therefore, we can write it as: days since the illness onset detection probability . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . where r = r /τ is the initial value calculated from the value of the reproduction number r , which itself is estimated according to several considerations as . -days in [ ] or . -days in [ ] . here, we will use the last one as a precaution to prevent bad decisions, thus r = . . the parameter d is the number that characterizes the isolation strategy, which is -by definition-the number of days required to reduce the initial value r by /e ≃ . . in our case, we must choose it as d = -days to get the simulation of detected cases compatible with the worldwide data of confirmed cases. let us first start with a simulation to see what happens if we have a semiclosed infected population, where it is only possible to lose the infected without any gain. therefore, let us fix the initial population to be n = infected and extract every detected case following the pd(t) cdf. to do so, every time tn= n-days, we recalculate the numbers of infected and detected cases, where t = is the moment of illness onset for the entire population. the number of infected n(t) at tn is then given by: where we introduced a new distribution function p(t) written as follows: the number of detected cases Ñ(t) among the infected cases is given by: where ̃( ) is a cdf function defined by: the behavior of these two numbers n and Ñ with respect to time -since the illness onset-is given in fig: ( ) . it is noteworthy that the detected cases . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint reach its maximum value near the incubation period and decrease afterward. the accumulation of detected cases is less than the initial number of infected n by a rate of % (the majority of infected are not detected). in the following section, we shall consider each "new cases" as a semiclosed population. remark that after only -days there is no infected stay free, they are either isolated or recovered. for the last reason, we know that the period from the illness onset to death does not play a significant role in the detection mechanism. now, to apply the method to the worldwide status, the infected population must be considered as an open population where it is possible to gain and lose the infected. in essence, every day we must recalculate its remain cases as the following: where we suppose that the new cases are given through the exponential growth [ ] . explicitly, if we suppose that the latent period [ ] is zero so as days since the illness onset daily number of cases . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint to be able to multiply by r(t) since the first day of infection, we can then write it as: new cases(tn) = r(tn− ) * (remains cases(tn− ) ). in general, we can write the true number of infected cases by a recurrence relation as: where n(tn−i) = if n <i. the first term represents the new cases, the second term (formed by the sum of -terms) represents the cases that have not recovered spontaneously from the previously generated cases, and the last term represents the cases that have not recovered spontaneously from the initial number of infected (which of course is equal to zero if tn> -days). likewise, the number of detected cases (confirmed) can be expressed as a recurrence relation as follows: where the first terms under the summation symbol represent the detected cases from the previously generated cases and the second term represents the detected cases from the initial number of infected (which is equal to zero if tn> -days). thus, using the above equations ( ) and ( ) by taking an initial number of infected cases as n = . note that there were cases at -dec according to [ ] , and a detected rate claimed to be %. thus, we can realize the simulation showing the evolution of the true infected cases and that of the detected one. the result is given by the two curves in fig: ( ) . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : the evolution of the true infected cases n(t) (blue) and detected cases Ñ(t) (orange) in function of time by looking at the two curves, we observe a great difference between them: the confirmed cases appear very smaller than the true infected cases. with a detection rate increasing across time (fig: ( ) ). beginning with an average of . % in the first -days and ending by an average of % in the final -days before the disappearance of the pandemic. these results are well-matched with the results of the studies achieved in [ ] , [ ] . in fig: ( ) we can see the daily evolution of the detection rate is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint worldwide data [ ] . this is what we do in fig: ( ) , indeed, we compare the theoretical curve (dashed) with the real curve (continued) up to the present time. figure : the graphs represent real (continued) and theoretical (dashed) curves of daily-confirmed cases. furthermore, we can deduce a numerical comparison between the simulated and the real accumulated -confirmed-cases ∑ Ñ( ) which are . m and . m respectively (up to -may [ ] in the other side, the true accumulated cases ∑ ( ) give about . m cases rather than . m. across this work, we developed a new method to simulate the true evolution of the covid- pandemic. this method consists of three concepts modeled by three analytic functions: the spontaneous outcome, the detected cases, and the well-known exponential growth. the results show in particular that the simulated curve of the true infected cases gives a large number in comparison with the confirmed one. the method is presented in a way that can be extended for use to other pandemics and/or to a given country. furthermore, this simulation may help in predicting the impact of various measures taken to tackle the epidemic. days since the outbreak . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application the reproductive number of covid- is higher compared to sars coronavirus real estimates of mortality following covid- infection. the lancet infectious diseases estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship feasibility of controlling covid- outbreaks by isolation of cases and contacts. the lancet global health association of treatment dose anticoagulation with in-hospital survival among hospitalized patients with covid- hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial incubation periods of acute respiratory viral infections: a systematic review. the lancet infectious diseases the incubation period of -ncov infections among travellers from wuhan incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china the reproductive number of covid- is higher compared to sars coronavirus estimation of the transmission risk of the -ncov and its implication for public health interventions transmission potential and severity of covid- in south korea averagethe following experimental design was used: ... detection rate of sars-cov- infections is estimated around six percent substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov- ) key: cord- -xi un kc authors: saadat, s.; mansoor, s.; fahim, a. title: covid- seidrd modelling for pakistan with implementation of seasonality, healthcare capacity and behavioral risk reduction date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: xi un kc introduction: december saw the origins of a new pandemic which would soon spread to the farthest places of the planet. several efforts of modelling of the geo-temporal transmissibility of the virus have been undertaken, but none describes the incorporation of effect of seasonality, contact density, primary care and icu bed capacity and behavioural risk reduction measures such as lockdowns into the simulation modeling for pakistan. we use above variables to create a close to real data curve function for the active cases of covid- in pakistan. objective: the objective of this study was to create a new computational epidemiological model for pakistan by implementing symptomatology, healthcare capacity and behavioural risk reduction mathematically to predict of covid- case trends and effects of changes in community characteristics and policy measures. methods: we used a modified version of seir model called seidrd (susceptible - exposed latent - diagnosed as mild or severe - recovered - deaths). this was developed using vensim ple software version . . this model also incorporated the seasonal and capacity variables for pakistan and was adjusted for behavioural risk reduction measures such as lockdowns. results: the seidrd model was able to closely replicate the active covid- cases curve function for pakistan until now. it was able to show that given current trends, though the number of active cases are dropping, if the smart lockdown measures were to end, the cases are expected to show a rise from th august onwards reaching a second peak around th september . it was also seen that increasing the icu bed capacity in pakistan from to will not make a significant difference in active case number. another simulation for a vaccination schedule of vaccines per day was created which showed a decrease in covid cases in a slow manner over a period of months rather than days. conclusion: this study attempts to successfully model the active covid- cases curve function of pakistan and mathematically models the effect of seasonality, contact density, icu bed availability and lockdown measures. we were able to show the effectiveness of smart lockdowns and were also to predict that in case of no smart lockdowns, pakistan can see a rise in active case number starting from th of august . december saw the origins of a new pandemic which would soon spread to the farthest places of the planet. several efforts of modelling of the geo-temporal transmissibility of the virus have been undertaken, but none describes the incorporation of effect of seasonality, contact density, primary care and icu bed capacity and behavioral risk reduction measures such as lockdowns into the simulation modeling for pakistan. the aim of this study was to create a new computational epidemiological model for pakistan by implementing symptomatology, healthcare capacity and behavioral risk reduction mathematically to predict of covid- case trends and effects of changes in community characteristics and policy measures. to achieve this we propose a novel sir-type metapopulation transmission model and a set of analytically derived model parameters. the objective of this study was to create a new computational epidemiological model by implementing symptomatology, healthcare capacity and behavioral risk reduction mathematically to predict of covid- case trends and effects of changes in community characteristics and policy measures. real world covid- data utilized for this study can be found on the following repository maintained by the center for systems science and engineering (csse) at johns hopkins university and "our world in data" website page "coronavirus pandemic (covid- )" https://github.com/cssegisanddata/covid- https://ourworldindata.org/coronavirus we used a modified seir model with slight modifications in the compartmentalization and parameterization of an existing example ( ) . we call this model seidrd for the presence of susceptible, exposed-latent, infectious, detected-symptomatics (mild or severe), recovery and deaths compartments ( table ) . following is detailed look into these compartments: figure . basic compartmental modeling setup with seidrd compartments arranged as above. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . this represents the population set which is susceptible to covid- . any exposure to presymptomatic infectious (pi), mild symptomatic (ms) or severe symptomatic (ss) populations can lead to a conversion of susceptible persons to an exposed-latent (e) patient with a probability of beta (β) ( table ). the transition equation for this population's conversion into exposed-latent population is given as: ∂s/∂t = (fs.br.rcd).(pi(β) + ms(β)( −ief) + ss(rβ)( −ief)) in this equation, fs represents fraction susceptible, br is behavioral risk factor while rcd represents relative contact density ( table ) . each of these parameters are additional controlling levers which can either increase or decrease the rate of conversion into exposed-latent population. a decrease in fs reflects less susceptibility to infection, low br reflects better hygienic and social isolation behaviour while a low rcd reflects sparse population density when number of susceptibles decreases, thus naturally low contact between the remaining susceptibles as they are far apart. decrease in any or all of these parameters can slow down the rate of conversion into the next compartment. the second part of the equation represents the ability of pi, ms and ss to infect a susceptible person with the probabilities of β, (β)( −ief) and (rβ)( −ief) ( table ) respectively. β reflects the probability of getting infected from a pi population, rβ represents the relative change in probability of getting infected if the infection is coming from a severe case to a susceptible, while ( −ief) is a measure of isolation effectiveness (table ) . isolation effectiveness (ief) is a measure of effectiveness of isolating total symptomatic patients. it is one if every symptomatic patient is completely isolated and cannot infect any other susceptible person. it does not cover the pi population as they are usually not identified unless symptomatic thus does not have a huge impact. this population represents the patients who have acquired the disease but are neither showing any symptoms nor able to transmit the disease. this population converts into presymptomatic infectious population. the transition equation is given as: here, niϵ represents non-infective-epsilon which represents the probability of transmission from exposed latent to presymptomatic infectious state. these are the patient population who have acquired the disease and are infectious to others but have not developed any symptoms yet. thus, they usually remain under the healthcare radar and are usually the most common source of disease spread. they transition into either mild symptomatic cases of severe symptomatic ones. the transition equations is as follows: here ∂pi(mc_t)/∂t represents the rate of change of pi into mild symptomatic cases while ∂pi(sc_t)/∂t represents the transition into severe symptomatic cases. the probability of conversion from pi into the next compartment is represented by iϵ (infective-epsilon) while out of this converted population, the probability all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . of converting into severe symptomatic population is given by ps. the probability of detection / diagnosis is given by pdxm and pdxs for mild and severe cases respectively (table ) . this compartment represents the patients who have now developed mild symptoms and are most likely to either recover or a minority could still die. being mildly symptomatic, they can also infect the susceptible population with a rate of (β)( −ief) if isolation effectiveness is not one as described above. the transition equations for this compartment are as follows: here ∂ms(mr)/∂t represents the rate of change of ms cases into recovered population with a total probability of μ x -pdm while ∂ms(md)/∂t represents the conversion of ms cases into the cases who die with a total probability of μ x pdm (table ). mu (μ) represents the probability of transitioning from any symptomatic case into any next compartment. this represents the severe cases compartment which are converted from pi compartment. this compartment then transitions into either recovered cases or deaths as given by following equations respectively: here, ∂ss(sr)/∂t represents the rate of conversion of ss population into recovered ones with a probability of ( -pds) while ∂ss(sd)/∂t represents the rate of conversion of ss population into deaths with a probability of pds (table ). the probability of deaths in severe cases (pds) is in turn calculated as combined mortality rate (cmr) ( table ). this cmr variable is in effect determined by minimal rate of mortality (as in mild cases) plus any additional mortality risk imparted by the lack of hospital capacity. thus, if hospital strain (severe cases / available hospital capacity) is high, there is additional mortality risk imparted and thus the mortality in severe cases will be at-least the same as in treated mortality plus an additional risk. its maximum value can get as high as the untreated mortality (table ) . this compartment represents all those who have recovered after being mildly or severely symptomatic. this represents total deaths observed as converted from either mild or severely symptomatic compartments. behavioral , time in days when first and the first detected cases were found on all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . second (smart lockdown) episode of behavioral risk reduction measures are started / / but the disease must have reached pakistan before it. the time to first lockdown was days after the first case was reported. we take the total time (real start time + time from st detection) to be days as it produces the most representative curve of active cases. similarly, the second set starts with initiation of smart lockdowns at day . note: above we imply that during the lockdown phase, apply the maximum behavioral reduction but apply a negative value of it when lockdown lifts. for the second set of lockdowns (smart lockdowns) we imply a half of its negative value thus second time around, people go to their socialization half as much probably because of learned behaviors. reflects the effect of social smooth ( -step(behavioral risk all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . note: time mentioned above in days is based on the simulation time and begins when the simulation starts. change in susceptible population which are transitioning into exposed population over the given time period t exposed-latent (e) e_t -i_t patients exposed to covid- but have neither yet developed the symptoms nor can they spread the disease. infecting (i_t) ∂e/∂t = e.niϵ change in exposed populations which are transitioning into the presymptomatic infectious population. after experimenting with the values, we assumed that during lockdown phases, people have a reduction in spread of active cases by a factor of behavioral risk reduction (brr) value but non lockdown periods, people often go back to socialization and spread of disease activity is increased by the brr value. time to react we assume that it takes around days for people to properly respond to any risk reduction measures like lockdowns hospital capacity we assume that beds needed for severe cases equates to itu beds available. everyone who gets infected is removed from the population either through recovery or death. the population is large, fixed in size and it is confined geographically. recovered individuals cannot be reinfected, although the only evidence so far is for rhesus macaques (ota, ) and who is still investigating the issue. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . note: the root mean squared error for above table equals . this is high for the early phase of the disease but relatively small when total cases get to a hundred thousand mark. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint above in table , we present the parameters chosen for the model. these have been derived after literature review and represent either the best estimates mentioned in the literature, or most plausible values by the authors based on the epidemiological knowledge on sars-cov- and other viruses. we split the total time between a person gets infected and develops symptoms into non infective latent period (ni) and infective (i) latent periods. we then calculate the parameters niϵ and iϵ, using the estimates of average latency period (lp) ( ) and non infective latency period (lpni) (wallinga & teunis, ) as given by the formulae in table . we chose to use korean proportion of "severe" to diagnose cases as a base for the probability of developing the severe condition (ps), and we set it to . . among other important parameters were β, rβ and μ which represent the effective contact rate, reduction in contact rate in severe cases and rate of transitioning from symptomatic cases. β can be calculated from previous parameters as: there are widely varying estimates for r in literature with values ranging from . to . ( ) ( ) ( ) ( ) ( ) we decided to choose the r of . reflecting a relatively higher rate of spread which is well within the range of - , modelled for sars ( ) . we derive μ from a safe quarantine period for diagnosed cases equal to days ( ). we assumed /μ to last on average for days from symptoms development to recovery. the sum of / μ and previously estimated lpi (presymptomatic infectious period) results in . days which represents the total duration from becoming infectious till recovery after a person acquires the disease. using μ and ( /lpi), we can now calculate β which comes equal to . . we also selected rβ to be . following the assumption for this parameter used in the influenza outbreak ( ) . this is because patients who have severe disease are mostly admitted, thus isolated and have reduced rates of transmission. the probability of death or mortality rate varies widely from values around . to . based on age and other parameters ( ) , ( ) , ( ) . for rate of mortality in mild cases (pdm), we chose a value on the lower spectrum of . , based on the results obtained from early wuhan studies ( ) . for severe cases admitted in itus, the mortality rate spectrum ranges from . to . depending on the age group with an average of . ( ) . in one study, the mortality rate in icu patients was reported as high as . ( ) . in order to calculate the combined rate of mortality in severe cases (cmr) ( table ) , we used two types of mortality estimates: . untreated mortality rate, which was chosen to be . being on the higher end of the spectrum, . treated mortality rate, which was set at . , assuming it to be on the lower end of the spectrum but still representing an average value. in order to analyse the model for pakistani population we choose the parameters based on the most recent available literature as given in table with references. we choose the total population to be , , . based on a report from the world bank, the total bed capacity for pakistan was calculated to be . per thousand ( ) . we chose this value to represent the total public health capacity as in the ideal case scenario, all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . any symptomatic case will be admitted and isolated for the disease duration. for the purpose of hospital capacity variable, we selected the total number of ventilators ( ) as a surrogate for the total icu beds in pakistan ( ) . we use vensim ple software version . (http://www.vensim.com) for the model development and numerical integration. vensim, the ventana simulation environment, is an integrated framework for conceptualizing, building, simulating, analyzing, optimizing and deploying models of complex dynamic systems ( ) for our purpose, we use first order euler integration technique to solve the equations numerically which is built into the software ( ). the simulation period was selected to be months. in order to simulate the covid- curve of pakistan, some of the assumptions in table were made. we then used the constants and variables as defined in table and to come up with the most similar curve of total symptomatic (reported) cases in pakistan. we divide the derivation into following experimental stages: experiment creates a base model with seasonal variation incorporated and shows the expected curve if none of the lockdown measures or risk reduction methods were implemented. in experiment , we implement the first set of lockdown measures and see their effect without the subsequent smart lockdowns. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . in the third experiment, we fully implement the smart lock downs as well and observe the similarity between actual case number and our predicted ones. in the fourth experiment, we test two assumptions; . what if the smart lockdown measures end? . what if some form of smart lockdown measures persist. finally, in the fifth experiment, assuming that covid- returns, we observe the effect of varying hospital, public health capacity and possible vaccination and its impact. before reviewing the following experiments, it's important to note that the simulation time starts days before the first cases were officially reported in pakistan (table ), thus any of the day references mentioned below are from the simulation timescale. in this experiment, we run the simple base model consisting of seidrd compartments as explained in the methodology section. this run was under the assumption that none of the lockdown measures have been imposed and the cases are spreading at a natural rate. this model also incorporates the seasonality adjustment ( table ) . as per this model, the cases start rising around day to simulation time. the cases peak at around day with a maximum of around cases being reported each day. the numbers then start to decline but very slowly. as this model assumes no behavioral risk reduction measures, this would have been the worse case scenario were it not for the timely lock downs. the second experiment assumes the implementation of the st set of lockdown measures. it mimics the timings on which the first lockdown was started around day and stopped after days simulation time. this model represents the scenario when only a single down is put in place only to lift it later as happened in pakistan from march to may , (table ) . this model mimics the initial rise of cases in pakistan closely peaking at around cases on day and then plateauing subsequently for some time. this model shows a better case then the base model but it predicts a subsequent rise from day if no further lockdown measures are put in place. figure . shows the experiment curve for total symptomatic cases against the simulation time period. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . this model represents the implementation of the second set of lockdown measures also known as the "smart lockdowns". since in our model, we assume the population to exist in a single geographic area homogeneously, the concept of smart lockdowns is implemented as the one before. it is evident that the cases follow a similar curve until day but then after a brief plateau, they start to decrease as happened in pakistan (table ). since this model assumes the second set of lockdown measures to start around day and persist up to days, the cases start to rise again around day after reaching the lowest case report number of per day. as per this model, if the smart lockdowns are completely lifted, the cases will rise again and eventually reach a maximum of cases per day around day simulation time ( september , ). here we also present the other compartmental graphs as below: (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint experiment (sustained smart lockdowns): continuing from above, if the smart lockdown measures are kept in place with maximum effect, the total number of active cases are shown to drop to less than by day (october th, ). this model assumes that the lockdown measures don't lose their efficacy and are kept in place indefinitely which can be difficult in a real world scenario. any compromise in efficacy of sustained lockdown measures will result in a curve which is intermediate between experiment and . figure . shows the experiment curve for total symptomatic cases against the simulation time period. finally, we take the model from experiment , assuming that a sustainable option of smart lockdowns is impossible and implement some of the possible solutions into the future. . we observe the change in mortality per day by increasing the total number of available itu beds from an available (table ) to . as in the graph below, the observed change is not much even though there is a definite decrease in mortality because of better respiratory support. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . figure . shows the experiment curve for deaths per day against the simulation time period comparing scenarios with vs icu bed availability in pakistan. it shows no significant difference between both scenarios. . as part of a second predictive analysis, we increase the number of available public health beds (includes all available hospital beds and social care services). we increase it from an available number of to million ( table ) . as shown in the graph below no significant change in total symptomatic cases was observed. figure . shows the experiment curve for total symptomatic cases against the simulation time period comparing scenarios with vs million public health capacity units / beds availability in pakistan. it shows no difference between both scenarios. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint . as part of final analysis, we introduce a vaccination schedule of vaccines per day starting from day simulation time (when a rise in cases is expected). as shown in the graphs below, there is an evident decline in the number of active cases per day and in deaths per day though the rate of decline is slow. it shows that without any complementary social distancing / behavioral risk reduction measures, mere act of vaccination would take years for the disease to come under control if the vaccination starts after the second peak is achieved. figure . shows the experiment curves for total symptomatic cases and deaths per day against the simulation time period comparing scenarios with none vs vaccinations per day starting from day simulation time. it shows a visible decline in the incidence of new cases in both curves after the start of vaccination schedule. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . our study shows the implementation of the seidrd model for predicting the incidence of active covid- cases in pakistan. it tests several experimental scenarios with or without conventional or smart lockdowns, with improvement in bed capacity and with vaccination. it was shown based on the seidrd model that after the end of smart lockdowns in pakistan, the covid- active cases in pakistan are expected show a rise at the start of september and if no risk reduction measures are taken, they are expected to achieve a second peak around th september . we also observed that increasing the itu bed capacity to a time current value will not have a significant impact on the number of active cases or mortalities per day. finally, a vaccination schedule of vaccines per day started after the second peak of covid- will cause a drop in active cases and mortality per day but the effect will be observed over a period of few years without any risk reduction measures. based on above findings, we recommend to put in place minimum risk reduction measures (smart lockdowns in high risk areas) at least until the availability of any form of vaccination. from a single host to global spread. the global mobility based modelling of the covid- pandemic implies higher infection and lower detection rates than current estimates the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures covid- pandemic in pakistan -wikipedia people) | data characteristics and outcomes of critically ill patients with covid- in washington state study in icu finds . % mortality rate from covid- -futurity pakistan plans another covid- lockdown. will it work? -the diplomat covid- pandemic in pakistan -wikipedia who international health regulations emergency committee for the covid- outbreak. epidemiol health statement on the second meeting of the international health regulations ( ) emergency committee regarding the outbreak of novel coronavirus ( -ncov) early in the epidemic: impact of preprints on global discourse about covid- transmissibility an updated estimation of the risk of transmission of the novel coronavirus ( -ncov) viral dynamics in mild and severe cases of covid- virological assessment of hospitalized patients with covid- modeling the spatial spread of infectious diseases: the global epidemic and mobility computational model covid- : death rate is . % and increases with age, study estimates covid- death rate by percentage, sex, pre-existing condition | disabled world fact check: cdc estimates covid- death rate of . % [internet estimating clinical severity of covid- from the transmission dynamics in wuhan, china study in icu finds . % mortality rate from covid- -futurity reference manual > the vensim modeling language > integration key: cord- -duvzwxv authors: džiugys, algis; bieliūnas, martynas; skarbalius, gediminas; misiulis, edagaras; navakas, robertas title: simplified model of covid- epidemic prognosis under quarantine and estimation of quarantine effectiveness date: - - journal: chaos solitons fractals doi: . /j.chaos. . sha: doc_id: cord_uid: duvzwxv a simplified model of covid- epidemic dynamics under quarantine conditions and method to estimate quarantine effectiveness are developed. the model is based on the daily growth rate of new infections when total number of infections is significantly smaller than population size of infected country or region. the model is developed on the basis of collected epidemiological data of covid pandemic, which shows that the daily growth rate of new infections has tendency to decrease linearly when the quarantine is imposed in a country (or a region) until it reaches a constant value, which corresponds to the effectiveness of quarantine measures taken in the country. the daily growth rate of new infections can be used as criteria to estimate quarantine effectiveness. the - coronavirus outbreak has started since december th, in wuhan, hubei province, people's republic of china, and has progressively expanded through almost all countries. this ongoing pandemic of coronavirus disease (covid- ) caused by severe acute respiratory syndrome coronavirus (sars-cov- ). in order to prevent the spread of the disease, many of the countries affected by the disease has been put under quarantine, which has led that , billion people ( % of whole world population) around the globe faced some form of lockdown [ ] . however, the remaining problem of the current covid- disease is that second wave of the epidemic is expected after imposed quarantine is discontinued in each country. on the basis of epidemiological data provided by european centre for disease prevention and control [ ] and estimation that the number of infections can be four times higher than the number of confirmed cases [ ] , it can be evaluated that for most countries only less than % of the population of the infected country/region will acquire the immunity after first wave of epidemic controlled by the effective quarantine. that would require next - similarly controlled waves to achieve herd (population) immunity of - % in order to stop further spread of disease. such scenario is improbable as it would require a significant amount of time, during which the individual immunity could be lost because even today, when more than . million people have been infected in more than countries and territories ( may , [ ] ), it is not clear for how long time the recovered patients have the immunity. however, hope for sars-cov- antiviral vaccine or sufficiently effective antiviral drugs, or sars-cov- virus mutation to less aggressive strain [ ] gives us chance to survive through the course of the controlled epidemic. therefore, forecasting the spread of the pandemic on the basis of mathematical models are extremely important for decisions how to prepare countries in order to avoid overloading of health system and manage other related problems. valuable information that could be obtained from modelling is forecast of the expected time and number of most active infected cases and the effectiveness of applied infection control measures. it is current global trend, that the experience and available data from already affected countries are used to model the pandemic dynamics in other countries before the epidemic has reached the peak or to estimate effectiveness of various scenario of the next wave management [ ] . most popular epidemic dynamics models of covid- are based on transmission model for a directly transmitted infectious disease, such as standard compartment models of disease sir [ , ] , or more advances derivates, such as seir and similar models [ ] [ ] [ ] [ ] . many of the models, which are used to forecast the covid- epidemic, do not accurately capture the transient dynamics of epidemics; therefore, they give poor predictions of both the epidemic's peak and its duration [ ] , because calibration of parameters are based on dynamics of such non-reliable epidemiological data as number of active infectious cases. we propose to build epidemic analysis and model on the dynamics of rate of new infection cases as more reliable epidemiological data together with an assumption of effectiveness to isolate registered infectious during imposed quarantine. other epidemiological parameters, such as numbers of active infectious, deaths, recovered, severe patients and others, can be forecasted from the forecasted dynamics of the rate of new infectious cases. the proposed approach is based on sir model. the simplest sir model consists of three compartments: s for the number of susceptible, i for the number of infectious, and r for the number of removed (recovered, deceased or immune) individuals. these variables (s, i, and r) represent the number of people in each compartment at a particular time. we denote the total population size by . the dynamics of the simplest sir system (excluding birth and death) can be described by the following set of ordinary differential equations [ ] : where γ is the rate of recovery or mortality, β is the infectious rate controlling the rate of spread that represents the probability of transmitting disease from infectious individual to susceptible individual. the disease transition rate β/ni is defined as a product of β and a probability of disease transmission during a contact between an infectious individual and a susceptible individual. in that case, is the average number of contacts per person per time unit and can be defined by the typical time between contacts = ⁄ . the transition rate between i and r defined by γ and is estimated from typical time until recovery = ⁄ . in case of isolation or self-isolation, γ can be defined by the average number of days that a person is infectious (before they are isolated or self-isolate), = ⁄ . the dynamics of the infectious class depends on the following ratio: the so-called basic reproduction number (or basic reproduction ratio) of an infection and represents the average number of infections generated by one individual over the course of the infectious period. the estimation model parameters and , as well as , may vary depending on country due to methodological issues, including different assumptions and choice of parameters, utilized models, used datasets and estimation period. in addition, during the spread of the sars-cov- virus infection, it was found that the model parameters are varying according to the dynamics of transmission of the novel coronavirus outbreak as well as the case reporting rate, which requires to build up more sophisticated and complex models [ ] .the model parameters are constantly calibrated according to the last epidemiological data because forecast is constantly refreshed. the wide and rapid spread of the disease forced many countries to impose quarantines, entry bans and other restrictions during the pandemic to reduce the movement of population and recent travellers in most affected regions [ ] . global restrictions that apply to all foreign countries and regions have also been imposed in other countries preventing their own citizens to travel overseas. these measures, especially quarantine, helped to suppress the spread of the disease within the population of various countries with different effectiveness. other important property of the pandemic is that total number of infected cases is much smaller than population size of infected country or region due to quarantine measures: this assumption allows to simplify epidemiological models used to simulate codiv- disease spread under quarantine. consequently, on the basis of eq. ( ), the parameter of sir model can be estimated as the number of new registered cases of infection to number of active cases ratio: where is the rate of new infected cases the number of daily new infected cases is defined as so, expected number of new cases in next day could be predicted by the today number of active infected individuals multiplied by the infectious rate in general, the infectious rate is time dependent and usually can be described by a complex function with additional parameters that must be daily calibrated according to last epidemiological data. behaviour of the infectious rate during quarantine may differ in different countries, which reduces possibilities to build correct model of the infectious rate on the basis of epidemiological data from other countries. furthermore, there is no clear criteria to relate influence of quarantine actions with the infectious rate . as illustration, the dynamics of the parameter estimated from active infected individuals and new cases by eq. ( ) is demonstrated in figure [ ] . in order to damp daily and weekly fluctuations, , and estimated the parameter were smoothed by moving average, where each average is calculated over a sliding window of length = days: where is any parameter to be smoothed. as can be seen, the dynamics of the parameter demonstrates similar non-linearly decreasing behaviour after the start of the quarantine for almost all countries. in addition, an estimation of the number of active infected individuals depends on the number of recovered active cases of infections , which in turn depends on testing protocols, tests number, delays in testing and other circumstances, which are different in each country. consequently, this makes = − unreliable parameter for model calibration. for example, in lithuania the first pool consisting of recovered cases of total cases was reported only after days from the first infection registration [ ] , which can be explained only by troubles in recording of recovered cases and can be also expected in other countries. in contrary, the number of daily new infected cases , despite of countries specificity, is still the most reliable parameter allowing to estimate disease spreading. in addition, other epidemiological parameters, such as numbers of active infectious, deaths, recovered, severe patients and others, can be forecasted from the forecasted dynamics of the number of daily new infectious cases. in order to build model of covid- disease spread during quarantine, we make simplifying assumptions, that:  registered infected individuals do not spread virus to health individuals, because of an effective isolation of the registered infected individuals;  no imported infections. new cases of infectious individuals are generated by previously infectious individuals until they are registered; therefore, the number of new cases of the day is dependent on the number of new cases generated during previous day and the effectiveness of imposed quarantine actions: ) restriction of social contacts and mobility, ) identification of infectious individual and his contact tracing as soon as possible, ) isolation of infectious individuals. let us analyse hypothetical simplified case. the averaged time period, during which an infected individual is registered and isolated after infection, is denoted . during this time period, the infected individual is infectious and infects individuals. in the end of this period, the infected individual is isolated and does not take more participation in the process of the epidemic spread. during the time period [ − , ], new infected cases are generated, from which ( − , ) are registered and isolated. these new registered infected cases will then generate more cases and the number of new registered infection cases for next time period [ , + ]: where is the growth rate of new cases and can be associated with the effective reproduction number [ ] . the parameter is time dependent and > means that number of new cases is increasing, while < -decreasing. according to eq. ( ), the parameter can expressed as follows: it is evident that in limits of → , we have which, together with eq. ( ), gives differential equation for disease dynamics during quarantine: keeping in mind eqs. ( ) and ( ), the parameter can be related to the infectious rate as follows let us define as the growth rate of new infection cases when epidemic starts and spreads without control. because of > , the number of new cases is exponentially increasing. it is expected that the population in any country would start to behave more safely even though no official quarantine actions were taken; consequently, the growth rate of new cases is expected to slowly decrease before strict quarantine rules are imposed. the growth rate of new infected cases can be defined as = ( = ) > at the quarantine start time = . because of > , the number of new cases is still increasing. let us assume that the imposed quarantine is ideally effective, which means that all infected individuals are isolated until the end of the time span and do not have contact with other individuals during time span [ , + ]. furthermore, no new cases will be generated for the next time period [ + , + ]. in such case, the growth rate of new cases becomes constant and equal to after the quarantine starts: ( > ) = = (figure (a) ), which means that the supposed effectiveness of the quarantine is equal to and epidemic is stopped immediately. if the quarantine is less effective, then the growth rate of new cases is non zero constant ( > ) = > , which leads to slower spread of the disease in case of > > and suppression of the epidemic in case of > > (figure (b) ). consequently, quarantine effectiveness can be measured as the zero effectiveness = means that the growth rate of new cases during quarantine remains the same as before: = . therefore, in order to suppress the disease, the growth rate of new cases must be below , which means that quarantine effectiveness must be greater than − ⁄ . in realistic scenario, the growth rate of new cases does not change sharply at the time because of time lag due to incubation period, infections generated by non-registered infected individuals and so on. in addition, it takes a time for people to adjust to the quarantine requirements after the beginning of the quarantine; therefore, there is a time lag before people start to strictly follow the rules. consequently, the growth rate of new cases decreases from initial value until reaches constant value satisfying the effectiveness of applied quarantine at the time ( figure ). − depends on the properties of covid- disease, such as incubation period and time span of individual being infectious, and how quickly quarantine actions are implemented. as a result, the angle = − (( − ) ( − ) ⁄ ) depends on − and the effectiveness of applied quarantine actions, because the case of = corresponds to situation when applied measures does not improve quarantine effectiveness and remains constant. the case of approaching to demonstrates exceptional effectiveness of the applied measures. negative corresponds to increasing the growth rate of new cases , what signalizes about critical state of broken quarantine. in addition, for a big country with heterogeneous population distribution across the country, it is expected to have several infection clusters and, therefore, wider time period − will be for decreasing stage (and consequently sharper φ) due to different start time of disease in each infection cluster. so, angle φ depends on the quarantine effectiveness, durations specific for the disease and homogeneity of the infected country or region. the proposed parameters and together with analysis of the population mobility and social contacts [ ] can be used to estimate effectiveness of country or region lockdown measures. in this paper we will analyse only . in order to predict covid- disease spread in infected country or region with imposed quarantine, a model of the growth rate of new cases needs to be developed. it is possible to build up such model speculatively in general; however, it is reasonable to analyse dynamics of in various countries. we analysed covid- pandemic data from various countries [ , ] . the daily growth rate of new infection cases was estimated on the basis of the registered daily new infection cases , ( ) (defined by eq. ( )) and smoothed by moving average according to eq. ( ) with sliding window of length = days in order to damp daily and weekly fluctuations: in this case, the parameter ( ) can be interpreted as the average daily reproduction number [ ] . as illustration, the dynamics of ⟨ ⟩, obtained as the parameter smoothed by moving average according to eq. ( ) with sliding window of length = days, is demonstrated in figure as can be seen, that despite of fluctuations, the scenario described in figure can be identified in the dynamics of the parameter : chaotic behaviour of before quarantine demonstrates linear decreasing until some certain value after quarantine. let us analyse some examples in greater detail. ) is presented in figure (b) by solid blue line. if to average fluctuations over supposed straights, the daily growth rate of new cases was almost constant or slowly decreasing before quarantine, started to decrease sufficiently after quarantine had been imposed and had somewhat linear dependency on time during quarantine time, which allowed to approximate by descending straight line ( figure consequently, the model of the daily growth rate of new cases can be described as follows: where = . is value in the beginning of the quarantine occasional new infections occurring during last weeks demonstrate that efficiency of applied quarantine actions was sufficient to suppress substantially the epidemic in the country, but the effectiveness is still not enough to decimate the infection. let us note, that small numbers of daily new infection cases ( < ) are registered after ′ = days, and therefore, the proposed method cannot not be used for such small numbers, because of too casual nature of new infections. consequently, the epidemic end cannot be forecasted accurately. we will shortly overview some other countries demonstrating applicability and possible shortcomings of the proposed approach. the next example of the similar scenario is switzerland. the government of switzerland announced that no lockdown would be implemented; however, some restrictions were implemented [ ] . on march , the federal council decided to cancel classes in all educational establishments until april and banned all events (public or private) involving more than people. furthermore, the borders were closed, and border control was enacted. on march , the federal council announced further measures and a revised ordinance. measures included the closure of bars, shops and other gathering places until april , but leaved open certain essentials, such as grocery shops, pharmacies, (a reduced) public transport and the postal service. since march , all events or meetings over people were prohibited, and economic activities would continue including construction. the daily growth rate of new cases began decreased before first official restrictions of social contacts (figure (b) ) while daily numbers of new cases were relatively small. during three following weeks after the restrictions initiation, continued to decrease from . on march until . and it is expected for to remain constant until the end of the epidemic ( figure ). [ ] and the calculated growth rate of new cases are presented in figure . the modelled was overestimated (figure (b)), because was approximated by one straight in the time interval from (corresponding to march ) to = + days (figure (a) ). to improve the model of , the change of alert level from to on fifth day after the beginning of the quarantine must be considered. accordingly, must be approximated by straights in the time interval [ , ] . the similar scenario is demonstrated in iceland, where universities and secondary schools were closed on march . furthermore, public gatherings of over were banned on the same day [ ]. the same quarantine conditions were applied for the whole quarantine period. nevertheless, there were three stages during the time interval [ , ], = + days (figure (b) ). the first stage of decreasing lasted for days since the beginning of the quarantine. then the next stage followed up for days, in which the fluctuates around ≈ . the third and the final stage of decreasing took place for days, during which reached value of = . . therefore, model for the whole period of days, which describes the behaviour of by one decreasing line the similar scenario to australia and switzerland cases developed in austria (figure ) , where the epidemic started on february , and the quarantine was imposed on march [ ] . however, slight increase of the daily growth rate after one month of quarantine may be related to the easter celebration, which started after good friday, april . after the easter, the number of daily new cases fluctuates around cases per day. the case of poland illustrates the scenario when the proposed method to predict epidemic dynamics under quarantine does not work straightforward, because of country specificity. strict rules of the country lockdown were implemented on march [ ], and it was expected, that quarantine effectiveness would be the same as in the cases described above. however, during four following weeks after the beginning of the quarantine, decreased from . only to . and then stayed fluctuating around ≈ till now ( may ) (figure ) , what shows the low effectiveness of the taken quarantine actions. as in austria case, the most reliable reason is the easter celebration. during the expected next wave of the covid- , such specificity of the country can be taken in to account. italy has been under quarantine since march , [ ] . it seems that italians are too tired of the country lockdown, that they have strong intentions to finish the lock-down as soon as possible. therefore, italy celebrated the easter more quietly without visible breaks of the quarantine restrictions ( figure ). however, a high value of the daily growth rate of new infection cases during the imposed quarantine = . suggests that quarantine actions are not sufficient and, there is little hope to reach the end of epidemic as fast as australia having = . . denmark is an example in which the proposed model cannot be applied to predict the epidemic dynamics, and clarification of the reasons for such discrepancy requires more detailed analysis of epidemic situation in the country ( figure ) . however, the last days is below , what demonstrates that social distancing helps to reduce infection rate. situation in russia serves as an example of ineffective quarantine actions for at least first two weeks of the country lockdown. this can be explained by huge size of the country and heterogeneous distribution of the population across the country, which is reason for sequence of arising infection clusters in different locations/regions at different times, despite that national quarantine was imposed on march, . consequently, the daily growth rate of new infection cases = . remained above for days with almost zero angle of inclination = − ( ) ≈ (figure (b) ), what demonstrates that effectiveness of the quarantine actions was insufficient during this period. for example, only from may, moscow's residents will be required to wear face masks and gloves in public transport and public places [ ] , while face masks in public places are one of the most important obstacles for virus spread [ ] . consequently, the daily growth rate crossed critical value = only after days from the national lockdown start, but it gives hope that eventually the epidemic reached peak of the daily new infection cases . because of heterogeneous distribution of the population, analysis and forecasting of epidemic situation must be done at region level to generate results with practical value. like russia, united states of america is another huge country by the population number and size. the dynamics of the new cases and the daily growth rate of new infection cases fluctuating around ≈ till now in usa show that quarantine is not effective enough ( figure ) and suggested emergence of new clusters of infection. the forecast, made on the basis of the current dynamics of the epidemic, shows that epidemic will not be defeated in the usa until the end of this year. it should be taken into account, that differences of covid- statistics across various states are huge: cases per people are varying more than times [ ] . therefore, overall us data can suffer from too high level of generalisation. again as in russia, analysis and forecasting of epidemic situation should be done at state level to generate results with practical value. scenario realised in sweden, where the quarantine started on march, [ ], is specific. due to soft conditions of the quarantine (technically most of eu countries would not attribute swedish regime a quarantine, just a gradual restriction of some social activities), it seems that the new cases is achieved maximum only in weeks days after the lockdown start and then the stabilised at = (figure ). further dynamics of the epidemic is still unclear because no country has experience of such situation. the experience gained in sweden is very important and will be used by other countries for the second wave management in the future. the experience gained during the first wave of covid- pandemic could help countries to be better prepared for the next wave, which is expected to take place in the autumn of . we proposed the simplified approach, which allows to quantifiable estimate effectiveness of the imposed quarantine conditions/restrictions and compare between countries, forecast the epidemic spread and take appropriate decisions. the proposed approach is based on the time series data of registered daily infection rate as most reliable epidemiological data together with the following main assumptions:  total number of infections is much smaller than a population size of the infected country or region;  registered infected individuals are effectively isolated during the imposed quarantine. the observed dynamics of the pandemic in examined countries shows that the daily growth rate of new infection cases has a tendency to decrease linearly during the imposed quarantine period until reaching a constant value, which corresponds to the effectiveness of taken quarantine measures in the country. the proposed parameters , and together with the analysis of the population mobility and social contacts can be used to estimate the effectiveness of the lockdown measures. on the basis of these parameters, the countries experiencing ongoing epidemic can use the proposed approach to study effectiveness of taken quarantine measures in other countries yet affected by the covid- disease. the proposed approach has a limitation because it cannot be directly applied for a country with large population size, which might have several epidemic clusters due to the heterogeneous population distribution across the country. in this case, each cluster must be analysed separately. also, the approach cannot be applied when the daily infection cases is too few because of casual nature of emerging new infections. consequently, the epidemic finish cannot be forecasted accurately. on the basis of the proposed approach, more complex models of epidemic forecasting can be developed. a demographic scaling model for estimating the total number of covid- infections on the origin and continuing evolution of sars-cov- quantifying the effect of quarantine control in covid- infectious spread using machine learning the sir model and the foundations of public health modelling the covid- epidemic and implementation of population-wide interventions in italy an seir infectious disease model with testing and conditional quarantine nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study the mathematics of infectious diseases stability of epidemic models with waning immunity dynamics of covid- epidemics: seir models underestimate peak infection rates and overestimate epidemic duration an updated estimation of the risk of transmission of the novel coronavirus ( -ncov) joint european roadmap towards lifting covid- containment measures novel coronavirus (covid- ) cases data n svarbiausia informacija apie koronavirusą (covid- ) n.d different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures see how your community is moving around differently due to covid- n Частичное возобновление работы, масочный и перчаточный режим wearing face masks in the community during the covid- pandemic: altruism and solidarity n tracking the pandemic: how quickly is the coronavirus spreading state by state? n data availability the data used to support the findings of this study are available from the corresponding author upon request. data for the infected cases count from various countries is obtained from the data we also would like to thank tadas markūnas and aušra džiugytė for collecting of covid- epidemiological data. ad developed the method, analysed data and post-process data. mb proposed the conception of the model and analysed data. gs, em and rn performed data processing. all authors wrote and approved the manuscript. we declare no competing interests. correspondence and requests for materials should be addressed to ad.declaration of interests + the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- -ujsqshjg authors: dexter, franklin; epstein, richard h; shi, pengyi title: forecasting the probability that each surgical case will either be ambulatory or the patient will remain in the hospital overnight versus having a length of stay of two or more days date: - - journal: cureus doi: . /cureus. sha: doc_id: cord_uid: ujsqshjg when the hospital census is high, perioperative medical directors or operating room (or) managers sometimes need to review with surgical departments as to which surgical cases scheduled to be performed within the next three days may need to be postponed. although distributions of hospital length of stay (los) are highly skewed, a surprisingly effective summary measure is the percentage of patients previously undergoing the same category of procedure as that scheduled whose los was zero or one day. we evaluated how to forecast each hospital's percentage of cases with los of < days, segmented by category of surgical procedure. the large teaching hospital studied included several inpatient adult surgical suites, an ambulatory surgery center, and a pediatric surgical suite. we included , cases in a training dataset to predict , cases in a test dataset. for each category of procedure, we calculated the cumulative count of cases among quarters, from the most recent quarter, second most recent quarter, and so forth up to the quarter resulting in at least cases. if every quarter combined had fewer than cases for a given category of procedure, we included all cases for that category. for each combination of category and quarter, we used the cumulative counts of cases and cases with los of < days, excluding the current quarter. then, for each category of procedure, and for each of the preceding quarters included for the category, we used the cumulative counts to calculate the asymptotic standard error (se) for the proportion of cases with los of < days. if all preceding quarters combined provided a sample size such that the estimated se for the proportion exceeded . %, we included all preceding quarters. the observed absolute percentage error was . % (se: . %). this error was nearly -fold smaller than the percentage of cases to which it would be used (i.e., . % versus . % with los of < days). the principal weakness of the forecasting methodology was a small bias caused by a progressive reduction in the overall los over time. however, this bias is unlikely to be important for predicting cases’ los when the hospital census is high. when performing these time series calculations quarterly, a reasonable approach is to perform calculations of both case counts and ses for each category of procedure. we recommend using the fewest historical quarters, starting with the most recent quarter, either with at least cases or an estimated asymptotic se for the estimated percentage no greater than . %. applying our methodology with local los data will allow or managers to estimate the number of patients on the elective or schedule each day who will be hospitalized for longer than overnight, facilitating communication and decision-making with surgical departments when census considerations constrain the ability to run a full surgical schedule. in scenarios where hospital census is high, perioperative medical directors or operating room (or) managers may sometimes need to review with surgical departments as to which surgical cases scheduled to be performed within the next three days may need to be postponed, if clinically appropriate. this scenario has arisen at hospitals in regions with large increases in admissions due to coronavirus disease (covid- ) and hospital administrative or governmental mandates to reserve available beds for such patients. previously, we examined summary measures for hospital length of stay (los), as could be used to guide the or manager when deciding which cases may need to be postponed [ , ] . distributions of los are highly skewed, complicating the decision-making process. we used data from all hospitals and ambulatory surgery centers in florida to study all surgical cases that included at least one major therapeutic procedure, with procedures classified using clinical classifications software (ccs) from the agency for healthcare research and quality (ahrq) [ , ] . the first summary measure compared was the percentage of patients previously undergoing the same category of procedure as that scheduled whose hospital los was zero (i.e., ambulatory surgery) or one day (i.e., overnight stay) [ , ] . the percentage of cases with los of < days, being a single number, is simple to compute and easy to understand. the second set of summary measures compared were the mean and standard deviation of los for each category of procedure [ , ] . student's t-test with unequal variances is robust to deviations from a normal or lognormal distribution [ ] . however, for interpreting los, only considering the mean is insufficient because standard deviations differ markedly among procedures [ ] . consideration of both the mean and the standard deviation can be too challenging to be practical to assist decision-making related to case postponement. the third measure compared was the probability that a patient undergoing one category of procedure would have a smaller los than a patient undergoing another category [ , ] . that probability is the area under the receiver operating characteristic curve, calculated by the wilcoxon-mann-whitney test. although this approach is distribution-free, it does not summarize each case as needed by the or manager; rather, it provides pairwise comparisons among all cases [ , ] . the statistical power to compare cases of different categories of procedures was at least as large by comparing percentages of patients with los of < days than versus student's t-test with unequal variances or wilcoxon-mann-whitney test [ ] . we recommended applying the first measure because it is the easiest of the three to implement and interpret [ , ] . one application of our finding is for bed management during the covid- pandemic when the hospital census is high and the number of beds available for elective admissions is being rationed [ ] . the or manager will have many issues in addition to los to consider with surgical departments when determining which cases to postpone, including, but not limited to, the patients' medical conditions, their residential locations and travel times to the hospital, and surgeons' availability. the implication of our results is that when balancing multiple competing objectives and making decisions for scores or hundreds of cases per week, the manager and surgeons can include in the deliberation of which cases to postpone the simple statistic of whether there is a high probability that the patient will remain in the hospital for two days or longer. although the mode or median of the los for a given procedure may be known, this is insufficient to provide information about the tails of the distribution (i.e., the outliers) necessary for decision-making. for example, at the hospital studied, most patients undergoing nephrectomy had a los of two days (i.e., the mode was two days), and % of the patients had a los of ≤ days (i.e., median was two days), but % had a los of ≥ days. the or manager contributes to the assurance of enough bed capacity for medical patients requiring admission (e.g., with respiratory failure from covid- ). in practice, applying our scientific results [ , ] would require that the hospital estimates for each category of procedure the percentage of cases that have los of < days. for example, the preceding cases could be used for each category of procedure, and the percentage of those cases with los of < days calculated. this forecasting is a time series prediction problem. the advantage of using n = is that the cases will be recent, thereby reflecting current discharge practices. alternatively, the last cases could be used. the advantage of using n = is that the percentage of the cases with los of < days will be estimated more accurately. however, such thresholds are arbitrary. alternatively, for each category of procedure, the smallest number of preceding cases possible could be used for which the standard error (se) of each percentage estimate is less than some threshold (e.g., . %). the advantage of an approach based on the se is that to estimate the percentage of cases with los of < days, many fewer cases are needed to estimate the percentage within approximately . % when the raw percentage is approximately % than when the raw percentage is close to %. a further advantage is that consideration of the se balances the desire to use the most recent cases (i.e., favoring current practice), and the desire to obtain greater precision (i.e., larger sample size). in this study, we analyzed five years of data from a large teaching hospital to compare methods of estimating the percentages of cases with los of < days for each category of procedures. the university of iowa institutional review board determined on september , , that this project (no. ) does not meet the regulatory definition of human subjects research since it involved the analysis of previously collected and de-identified data. table shows the progressive process of selecting cases for the training and testing datasets. the surgical cases were performed in the main adult surgical suites, the ambulatory surgery center, or the pediatric suite ors at the studied hospital, all located within a five-minute indoor walk of one another [ ] . the cases were limited to those that were elective, defined by the organization as the surgeon having specified that the patient could wait safely at least three days for surgery (i.e., from friday to monday). the start date, october , , was selected because that was the change date in the united states when all inpatient procedures were required to be coded using the international classification of diseases version procedure coding system (icd- -pcs). we therefore only needed to use the ccs categories obtained from icd- -pcs and for current procedural terminology (cpt) codes [ , ] . the last date of cases was june , , the end of the last full quarter in before data analysis. los was estimated with discharge data through august . there were four-week periods available for testing during the final year. table shows that the distribution of included cases among surgical specialties was similar between the two periods. the sample sizes are explained in table for assigning a ccs category to each case, the vast majority of cases had only one procedure, or when more than one procedure was performed during the case, all procedures performed were of the same category. when a case included more than one procedure and the procedures mapped to more than one ccs category, we used data from the state of florida [ ] . for each ccs category of major therapeutic procedures, we have previously used the percentage of patients in florida in who had los of < days [ ] . the ccs assigned to the case at the study hospital was the ccs with the smallest percentage of patients with los of < days [ ] . the most common of the observed ccs categories are listed in table . all estimation for cases performed during each quarter corresponding to the test dataset was done based on the los percentages from cases performed before the start of that quarter ( table ) . we applied this approach because we expect that many hospitals would not update computer tables more frequently than on a quarterly basis. for example, estimates of the percentage of cases with los of < days for all cases in the th quarter were forecast using workdays in one or more of the preceding quarters. from each quarter, the data used were the count of elective cases for each of the categories and the count of such cases with los of < days. estimation for each quarter proceeded as described below. for each category of procedure, we calculated the cumulative count of cases among quarters, from the most recent quarter, second most recent quarter, and so forth up to the quarter resulting in at least cases. if all preceding quarters combined had fewer than cases, we included all previous cases. among the observed ccs categories of procedure, there were with fewer than cases in total. the choice of cases was based on the results as described in the below paragraphs. for each combination of category and quarter, we used the cumulative counts of cases and cases with los of < days, excluding the current quarter. for each category of procedures, and for each of the preceding quarters included for the category, we used the cumulative counts to calculate the asymptotic se for the proportion of cases with los of < days. that equaled the square root of three terms: the proportion multiplied by the quantity one minus the proportion then divided by the count of cases among the included preceding quarters. if all preceding quarters combined provided a sample size such that the estimated se for the proportion exceeded . %, we included the cases from all preceding quarters. for each combination of the category of procedure and quarter, we determined the smallest number of preceding quarters needed to be included for the preceding count of cases to be at least . we also determined the smallest number of preceding quarters needed to be included for the estimated se of the proportion to be ≤ . %. we used whichever of the two that permitted the use of fewer preceding quarters of data. as noted in the legend of table , there were n = included four-week periods during the final year, comprising the test dataset. for each of the four-week periods, we calculated the count of elective cases, the count of elective cases for each of the categories of procedures, as well as the count of such cases with los of < days for each of the categories. applying the training dataset as described in the preceding section, we also had for each case performed during the training dataset a forecasted probability that the case would have los of < days. we summed the forecasted probabilities to give an estimate for the count of cases with los of < days during the period. we summed the forecasted probabilities because the expected value of the sum of independent bernoulli trials equals the sum of the individual probabilities. the quality of the estimates was calculated for each four-week period. for each period, the observed percentage of cases with los of < days was subtracted from the estimated percentage of cases with los of < days. the absolute value of the difference was taken. the sample mean and sample se of the mean of the absolute values were calculated among the periods. all statistical inference was performed using two-sided one-group student's t-tests based on the sample size of n = independent four-week periods. data are reported as mean (se) except for data from florida [ ] , which were reported as percentages and se. the studied hospital averaged [ ] elective cases per workday. among all hospitals and ambulatory surgery centers in florida, . % ( . %) of cases had los of zero or one day [ ] . at the studied hospital, the percentage was . % ( . %) (i.e., no different from that in florida, p = . ). thus, we believe these findings can be generalized, even though the data in this study are from a single large teaching hospital. we varied the threshold sample size in increments of historical cases and the threshold se of the percentage of cases with los of zero or one day in increments of . %. the minimum observed absolute percentage error was . % ( . %), achieved by using the minimum number of quarters of the year of data providing for either a minimum of historical cases or a maximum . % se (see materials & methods). table shows that there were multiple, near-equivalent, and suitable choices for optimal parameter choices. the means are reported with the standard errors (ses) of the means among the test period of n = four-week periods (see table ). the parameter values described in the section materials & methods and used in table are noted with an asterisk. the negative numbers for bias in the third column show that the historical data (i.e., from the training period) underestimated the percentages of cases with los < days during the test period. this indicates that, overall, the studied hospital's los was declining progressively over time there were ccs categories of procedure with at least one case among the test periods. for each category, we calculated among all periods the absolute difference between the estimated and the actual count of cases with los of zero or one day. we calculated the contribution of each category to the mean. our primary result was that an average absolute percentage error of only . % can be achieved for the percentage probability of patients having los of < days. this error is nearly -fold smaller than the percentage of cases to which it would be used (i.e., . % versus . %). furthermore, tables , show that most of this small bias was caused by progressive reductions in the overall los over time (i.e., there was a consistent underestimation of the percentages of cases with los of < days). for the application of predicting cases' los when the census is high, such underestimation would be preferred because it is conservative. in other words, the number of patients staying in the hospital for ≥ days would be slightly less than predicted. one limitation of our study is that we used data from one large teaching hospital. however, there was no difference in its percentage los of < days than among all hospitals and ambulatory surgery centers in florida. thus, we believe these findings can be generalized. a second limitation is that we used two criteria for selecting historical quarters of training data for each category of procedure, while there are other potential predictive models (e.g., linear changes in percentages over time). however, we doubt that this is important. table shows that there were multiple, nearly equivalent choices for the optimal parameter choices. what matters is that our conceptual strategy worked well, with the precise value of the parameters being of minimal importance. when estimating percentages of cases with los of < days, a decision needs to be made as to how much historical data to use. including too many cases would increase the predictive error because of reductions in los over time for many procedures. including too few cases would increase the predictive error because of imprecision (i.e., wide prediction intervals). in this study, we show that when performing these time series calculations quarterly, a reasonable approach is to perform calculations of both case counts and ses for each category of procedure. we recommend using the fewest historical quarters, starting with the most recent quarter, either with at least cases or an estimated asymptotic se for the estimated percentage no greater than . %. the application of our methodology with local los data will enable or managers to estimate the number of patients on the elective or schedule each day who will be hospitalized for longer than overnight, thereby facilitating communication and decision-making with surgical departments when census considerations hamper the ability to run a full surgical schedule. human subjects: all authors have confirmed that this study did not involve human participants or tissue. animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. monte carlo simulations comparing fisher exact test and unequal variances t test for analysis of differences between groups in brief hospital lengths of stay policy implications for the covid- pandemic in light of most patients (≥ %) spending at most one night at the hospital after elective, major therapeutic procedures clinical classifications software (ccs) for icd- -pcs (beta version clinical classifications software for services and procedures a review of analysis and sample size calculation considerations for wilcoxon tests wilcoxon-mann-whitney test for data that are not normally distributed many us hospital-affiliated freestanding ambulatory surgery centers are located on hospital campuses, relevant to interpretation of studies involving ambulatory surgery key: cord- -flb wwzg authors: garcía, inés suárez; lópez, maría josé martínez de aramayona; vicente, alberto sáez; abascal, paloma lobo title: sars-cov- infection among healthcare workers in a hospital in madrid, spain date: - - journal: j hosp infect doi: . /j.jhin. . . sha: doc_id: cord_uid: flb wwzg aim: the aim of this study was to describe the epidemiological and clinical characteristics of covid- among healthcare workers (hcws) between february (th) to april (th), in a hospital in madrid, spain. methods: we designed a retrospective cohort study. cumulative covid- incidence was calculated for all hcws and categorized according to presumed level of covid- exposure (high, medium and low). results: among , hcw, ( . %) had covid- during the study period. cases increased gradually from march (th), peaking in march (th) and declining thereafter. the peak of cases among hcws was reached days before the peak in admitted covid- cases in the hospital. there were no significant differences in the proportion of covid- cases according to level of occupational exposure (p= . ). there were departments and professions in which more than % of the workers had confirmed covid- . we identified temporal clusters in three of these departments and one profession, with most of the cases occurring over a period of less than days. the prevalence of comorbidities was low and . % of patients had mild or moderate symptoms. eleven patients were admitted to the hospital and patient needed intensive care. none of the patients died. the median time of sick leave was (iqr: – ) days. conclusions: our results suggest that hcw-to-hcw transmission accounted for part of the cases. in spite of a low prevalence of comorbidities and a mild clinical course in most cases, covid- caused long periods of sick leave. the virus sars-cov- is the causal agent of the acute respiratory tract infection known as covid- ( ) . it is estimated that by may th , covid- had caused , , infections and , deaths( ). the first covid- case was declared in spain in january st, ( ) and since then, spain has been one of the most affected countries by the pandemic ( ) . healthcare workers (hcws) are especially vulnerable to infection by sars-cov- . in the first published series of patients from wuhan, china, % of the cases were hcws( ). the proportion of hcws was much lower ( . %) in a later case series from china including , covid- cases ( ) . in spain, % of all the covid- cases have been among hcws ( ) , and in italy, % of responding hcws were infected ( ) . very few studies have focused on sars-cov- infection among hcws. moreover, the scarce data available to date have focused on the proportion of hcws infected but have not sufficiently described epidemiological and clinical characteristics of the affected workers. there are important implications of covid- among hcws. firstly, there are consequences for their health: in the previously mentioned series from china, . % of the cases among hcws were classified as severe or critical and of the patients died ( ) . secondly, infected hcws could also transmit the infection to vulnerable patients if they are not properly and timeously isolated. thirdly, high rates of infection among hcws could cause problems due to understaffing in the health system. lastly, the workers may transmit the infection to close family contacts ( ) , other hcw ( ) , and the community. due to the important implications of covid- among hcws, and the lack of detailed information published about this issue, it is important to better characterize its epidemiology and clinical characteristics in order to inform decision-makers on appropriate prevention and management strategies. therefore, we designed a retrospective cohort study whose aim was to describe the epidemiological and clinical characteristics of sars-cov- infection among hcws in a hospital in madrid, spain. the study was performed in hospital universitario infanta sofía, a public tertiary hospital in madrid, spain. all hcws that were working in the hospital between february th to april th were included. workers from the laboratory, radiology department, security services, maintenance services, kitchen facilities, cleaning workers and porters were also excluded as they are contracted by external companies and are not employed by the hospital. variables and data collection all data were gathered retrospectively. the number of hcws according to their profession and department for the study period was obtained from the human resources department. data for covid- cases were extracted from the clinical records of the occupational health department and recorded in an anonymized database. during the study period, hcws experiencing symptoms consistent with probable covid- were instructed to present at the occupational health outpatient clinic, where they were managed according to the hospital protocol: a nasopharyngeal swab was collected and analysed with polymerase chain reaction (pcr) for sars-cov- . for symptomatic hcws with negative pcr, this test was repeated after - hours if symptoms persisted. according to the hospital protocol, hcws with positive sars-cov- pcr remained on sick leave until a negative follow-up pcr was obtained. follow-up pcrs among patients with a previous positive pcr were obtained between day and after symptom resolution and repeated thereafter until a negative pcr result was obtained. workers were allowed to return to work when they fulfilled two criteria: symptoms had resolved, and they had a negative follow-up pcr. a case of covid- was defined as any hcw presenting to the occupational health outpatient clinic with symptoms consistent with covid- and with positive sars-cov- pcr. the date of the case was defined as the date of presentation to the occupational health outpatient clinic. the following variables were obtained from the clinical records: age, sex, profession (head of department [i.e., a physician in charge of a medical or surgical department], physician, nurse supervisor, nurse/auxiliary nurse, other), department, date of presentation at the outpatient clinic, date of symptom onset, duration of sick leave, admission to hospital, presence of comorbidities (arterial hypertension, diabetes mellitus, current tobacco consumption, cardiovascular disease, and chronic obstructive bronchopulmonary disease or asthma). nine patients had no information on the day of symptom onset: for these patients, the date of symptom onset was assumed to be the date of presentation to the outpatient clinic. clinical course was divided in the following categories: mild symptoms (including myalgia, ageusia, anosmia, headache, sore throat, cough, or temperature < o c, plus no need to stay in bed), moderate symptoms (including fever ≥ o c, or need to stay in bed, with or without any of the mild symptoms), and unilateral or bilateral infiltrates in chest x-ray. hcws were stratified in three categories according to their presumed level of occupational exposure to covid- cases: high risk (hcws with usual contact with covid- patients: accident and emergency, internal medicine, intensive care, and pneumology departments), moderate risk (hcws with occasional contact with covid- patients: other medical and surgical departments not included in the high or low risk groups) and low risk (including administrative workers, social workers, hospital management, and pharmacy, pathology, and preventive medicine departments). for nurses working in the hospital wards and haemodialysis unit, the department was not available and therefore they were included in a separate category for the purpose of risk of occupational exposure. in addition to these variables, information was collected about the training in covid- prevention, and use of personal protection equipment (ppe,) in the hospital during the study period. total numbers of notified covid- confirmed by pcr were obtained from the madrid autonomous region website ( ) . statistical analysis covid- cumulative incidence during the study period was calculated for all hcw, stratified by presumed level of occupational exposure, and stratified by department and profession. for departments and professions with more than hcws, of which more than % were diagnosed with covid- , date of presentation was analysed in detail to detect possible transmission clusters. descriptive analyses were carried out using frequency distributions or median and interquartile range (iqr), as appropriate. the proportions of hcw acquiring covid- among the three categories according to risk of occupational exposure were compared with χ test. statistical analyses were carried out with stata version . (stata corporation, college station, tx, usa). the study was approved by the ethics committee of hospital universitario "la paz" (pi- ). informed consent was not required. by april th , , there were , hcws in our hospital that fulfilled inclusion criteria. among these, presented to the occupational health outpatient clinic with symptoms consistent with covid- and were tested with at least one pcr during the study period. a total of workers, which account for . % of all hcws included, had microbiological confirmation of covid- . median age was (iqr: - ) years, and cases ( . %) were women. figures a and b show the number of confirmed cases among hcws per day, along with the number of patients admitted in the hospital with covid- (figure a) and the total number of cases notified in the madrid autonomous region (figure b) during the study period. the first case among hcws was diagnosed in march th and cases increased gradually, reaching a peak in march th and declining thereafter. the peak of cases among hcw was reached days before the peak in admitted covid- cases in the hospital, which occurred on march st (figure a), and days before the peak in the notified cases in the madrid autonomous region, which occurred in march th (figure b). as expected, cases among hcws very rarely presented during weekends. the median delay between the date of symptom onset and the date of presentation to the outpatient clinic was (iqr: - ) days. the first date of symptom onset was february th and then increased gradually, reaching a peak on march th and gradually declining thereafter. the proportion of cases among hcws according to level of occupational exposure is shown in table i. there were no significant differences in the proportion of covid- cases according to level of occupational exposure (high, medium, or low) (p= . ). there were departments of more than hcws in which more than % of the workers had confirmed covid- : dermatology ( the proportion of cases according to profession are shown in table ii. there were professions in which more than % of the workers had confirmed covid- : medical heads of department ( . % with covid- ) and nurse supervisors ( . %). the number of cases according to date of presentation for the departments and professions in which more than % of the hcws had covid- are shown in figures a and b, respectively. the cases in the oncology, dermatology and neurology departments seemed to be clustered in time, with all cases presenting in a period of and days in the oncology and dermatology departments, and out of cases presenting in a period of days in the neurology department. according to work category, there also seemed to be a temporal cluster among heads of department, with out cases presenting over a period of days (figures a and b ). regarding comorbidities, workers ( . %) had arterial hypertension, ( . %) had asthma or chronic obstructive bronchopulmonary disease, ( . %) were active smokers, ( . %) had cardiovascular disease, and worker had diabetes mellitus. regarding the clinical course, ( . %) had mild symptoms, ( . %) had moderate symptoms, ( . %) had unilateral lung infiltrates in chest x-ray, and ( . %) had bilateral lung infiltrates. in addition, patients with unilateral lung infiltrates also had thromboembolic disease: patient had deep venous thrombosis and the other had pulmonary embolism. the majority of cases were managed in their home, but cases ( . %) needed admission to the hospital for a median of (iqr: - ) days. one of the patients with bilateral pneumonia needed icu admission and orotracheal intubation because of severe respiratory failure. none of the patients died. among the workers, were still on sick leave at the end of the study period. the median time of sick leave among the hcws who had returned to work was (iqr: - ) days. after symptom resolution, the median number of pcrs performed per hcw was (iqr: - ), and the median time to obtain a negative pcr result (and therefore to allow the hcw to return to work) was days (iqr: - ). training in infection control practices and use of ppe was provided by the occupational health department from february th to march th for the intensive care unit, hospitalization wards, surgical rooms, daycare hospital, obstetric ward, nurse supervisors, and the internal medicine, anaesthesia, general surgery and emergency departments. in addition one training session was provided in the pharmacy department on april nd . there were a total of training sessions involving a total of ( . %) hcws. this study has analysed the epidemiology of sars-cov- infection among hcws in a public hospital in spain during the height of the covid- epidemic. we found that . % of the hcw had microbiologically confirmed covid- . the peak of cases preceded the peak of admitted patients with covid- , with a lag of weeks. the risk of covid- did not differ significantly among three groups with different levels of occupational exposure to covid- patients, and a few clusters were detected in specific departments and professions: these facts suggest that a considerable proportion of the transmissions occurred from hcw-to-hcw, rather than from patient-to-hcw. infected workers had low prevalence of comorbidities and the clinical course was mild in most cases; in spite of this, covid- caused long periods of sick leave. the sources of hcw infection include patients with covid- , other hcws, and the community. during the covid- pandemic several reports have identified factors increasing the risk of patient-to-hcw exposure, mainly excessive workload( ), shortage of personal protection equipment (ppe), lack of training in infection control measures, or use of ppe that does not fulfil safety requirements ( , ) . also, hcws can become infected outside their workplace if there is ongoing transmission in the community( ) (community-to-hcw). however, it has been pointed out that there is potential for transmission between hcw (hcwto-hcw), with potential occasions such as clinical meetings, clinical handovers, lunchbreaks and shared use of small work spaces ( ) . nevertheless, the transmission of covid- between workers has not been sufficiently studied: we are only aware of a study in singapore that identified a cluster of intrahospital hcw-to-hcw transmission ( ) , and an anecdotal recent report from newspapers that described an outbreak in madrid, where hcws acquired covid- after a lunch that took place in a hospital with over participants, who were not wearing masks during the event ( ) . in our study, the fact that cases peaked well before the peak in admitted covid- patients and the peak of diagnosed cases in the community, the lack of differences on the risk of infection among groups with different levels of exposure to covid- , and the identification of several temporal clusters among certain groups suggest that transmission among hcws account for part of the cases. it is possible that several hcws became infected during the first days (either from undiagnosed covid- cases in the hospital, or from the community) and then in turn transmitted the infection to other hcws. three departments (oncology, dermatology and neurology) had most of the cases diagnosed in a short period of time, suggesting transmission in shared facilities or clinical meetings. there was also a temporal cluster among the heads of department, and a high proportion of the nurse supervisors affected, although the latter were not temporally related. these two groups were having daily meetings every day and also doing daily night shifts, and it is possible that there had been transmissions during the meetings or through fomites in the staff rooms or the emergency phone. in our hospital, workers were instructed to wear adequate ppe when contacting patients with confirmed or suspected covid- . however, at the time of the study the use of face masks was neither recommended by health authorities for the general population (their compulsory use was only instituted for public transport on may rd ( ) and closed spaces on may th ( )) nor specifically recommended for hcws that were not having contact with patients( ). during the period of february th to march th , training about covid- transmission and ppe was provided to hcws by the occupational health department. however, the training focused on the contact with covid- patients and did not specifically recommend wearing face masks when not interacting with patients. until approximately march th to th , hcws did not systematically wear face masks when being in contact with other hcws in the hospital facilities. after noting an increase in cases, most departments started systematically wearing face masks at all times in the hospital; shared meals during the night shifts were stopped, instructing workers to keep a distance of at least metres in the refectory; and ward rooms were disinfected on march th and th . we cannot precisely determine the influence of these measures on covid- transmission in the hospital, but we presume that they were effective since the cases in hcws started declining after march th despite an increasing number of patients admitted to the hospital with covid- . it is unlikely that a better training on the use of ppe could explain the decrease in cases among hcws, as this training was not continued after march th (except for one additional session in the pharmacy department on april nd ). the prevalence of comorbidities was low and the clinical course was mild in most of the cases; our hcw were in general healthier and had a less severe clinical course than the series published in the general population ( , ) and can probably be explained by a healthy worker effect, along as a younger age. also, the spanish ministry of health recommended that hcws with vulnerability to covid- complications (such as hcws aged over years, pregnant women, and those with certain comorbidities) who could not be relocated to avoid covid- exposure should be preventively kept away from work ( ): this was the case for hcws in our hospital. nevertheless, some cases did experience severe complications such as bilateral pneumonia, thromboembolic disease or severe respiratory failure. in addition, cases had to stay away from work for a long time, for a median time of days; this long sick leave, along with the workers preventively kept away from work, in a time of increasing healthcare demands due to the pandemic can have important effects due to understaffing, which entails an increase in workload and can produce additional stress on the already overworked staff that remains in the hospital( ). our study has two main limitations. first, we did not systematically test all the hcws in the hospital, but we limited our tests to symptomatic hcw presenting to the occupational health outpatient clinic. thus, we could have missed a proportion of workers with asymptomatic infection. second, the only available diagnostic test during the study period was sars-cov- pcr in nasopharyngeal swabs, which can have false negatives even in symptomatic cases: a recent review found a sensitivity of % (ci %: - ) ( ) . therefore, our study has probably underestimated the percentage of affected hcws. during the covid- pandemic health services had the challenge of ensuring sufficient ppes and that these were adjusted to quality standards. spanish health institutions had difficulties in providing adequate ppe to all healthcare workers during these times and we cannot exclude that some transmissions could be attributed to lack of adequate ppes or their suboptimal use. however, our results suggest that hcw-to-hcw transmission accounted for at least part of the covid- cases found in our hospital: this is a transmission route that is rarely mentioned in other studies ( ) . we believe that this possibility should be further explored in other settings, and suggest preventive measures such as the systematic use of face masks at all times in the workplace, ensuring adequate working spaces to avoid overcrowding, and keeping a safety distance in meetings, clinical handouts, and work meals that could reduce the transmission of covid- in healthcare settings. also, surveillance of potential clusters could potentially be useful for contact tracing and prompt identification of transmissions ( ) . in this study in a public hospital in spain, . % of the hcws had symptoms consistent with covid- and microbiological confirmation of infection. the facts that cases among hcws peaked weeks before the peak of admitted patients, that the risk of covid- was similar among three groups with different levels of occupational exposure, and that several temporal clusters were detected in specific departments and professions, suggest that hcw-to-hcw transmission accounted for part of the cases. in spite of a low prevalence of comorbidities and a mild clinical course in most cases, severe complications were diagnosed in some hcws and covid- caused long periods of sick leave. hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china world health organization. coronavirus disease . situation report- euro surveillance : bulletin europeen sur les maladies transmissibles = european communicable disease bulletin characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention informe sobre la situación de covid- en personal sanitario en españa covid- : protecting health-care workers asymptomatic sars-cov- infection in household contacts of a healthcare provider containment of covid- cases among healthcare workers: the role of surveillance, early detection, and outbreak management comunidad de madrid. informe diario de situación covid- risk factors of healthcare workers with clinical infectious diseases : an official publication of the infectious diseases society of america covid- : a new work-related disease threatening healthcare workers covid- : the daunting experience of healthcare workers in sardinia rapid assessment of regional sars-cov- community transmission through a convenience sample of healthcare workers, the netherlands beyond the assistance: additional exposure situations to covid- for healthcare workers. the journal of hospital infection un almuerzo de despedida celebrado en el gregorio marañón causa un brote de coronavirus en el hospital orden tma/ / , de de mayo, por la que se dictan instrucciones sobre la utilización de mascarillas en los distintos medios de transporte y se fijan requisitos para garantizar una movilidad segura de conformidad con el plan para la transición hacia una nueva normalidad orden snd/ / , de de mayo, por la que se regulan las condiciones para el uso obligatorio de mascarilla durante la situación de crisis sanitaria ocasionada por el covid- procedimiento de actuación para los servicios de prevención de riesgos laborales frente a la exposición al nuevo coronavirus (sars-cov- ). de marzo de procedimiento de actuación para los servicios de prevención de riesgos laborales frente a la exposición al sars-cov- . de marzo de infectious diseases society of america guidelines on the diagnosis of covid- we thank all the nurses, physicians and occupational risk prevention technicians that took care of the hcws in the occupational health outpatient clinic during the study. all authors declare that they have no conflict of interest. this study was not funded. isg asked the research question, designed the study, analysed the data and wrote the first draft of the paper. mjm gathered the data. as gathered the data. pla designed the study and gathered the data. all authors were involved in interpretation of the data and commented on interim drafts. all authors have read and approved the final version of the article. key: cord- -s do cb authors: lara-reyna, jacques; yaeger, kurt a.; rossitto, christina p.; camara, divaldo; wedderburn, raymond; ghatan, saadi; bederson, joshua b.; margetis, konstantinos title: “staying home” - early changes in patterns of neurotrauma in new york city during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: s do cb abstract objective new york city is the epicenter of the novel coronavirus disease (covid- ) pandemic in the united states. traumatic brain injury accounts for a significant proportion of admissions to our trauma center. we sought to characterize the effect of the pandemic on neurotraumas, given the cancellation of non-essential activities during the crisis. methods retrospective and prospective review were performed from november to april . general demographics, clinical status, mechanism of trauma, diagnosis, and treatment instituted were recorded. we dichotomized the data between pre-covid- (before march st) and covid- periods and compared the differences between the two groups. we present the timeline of events since the beginning of crisis in relation to the number of neurotraumas. results a total of patients composed our cohort with a mean age of . years (sd+/-: . ), and % male. more males sustained neurotrauma in the covid- period compared with the pre-covid- ( . % vs . %, p= . ). the most common mechanism of trauma was mechanical fall, but it was observed less frequently compared to the pre-covid- period ( . % vs . ; p= . ). subdural hematoma, traumatic subarachnoid hemorrhage, and intracerebral contusion accounted for the most common pathologies in both periods. non-operative management was selected for most patients ( . vs . %, p= . ) in both periods. conclusions a decrease in the frequency of neurotraumas was observed during the covid- crisis concomitant with the increase in covid- patients in the city. this trend began after the cancellation of non-essential activities and the implementation of social distancing recommendations. on march of , the world health organization declared the infection with the novel coronavirus disease (covid- ) as a pandemic, after the initial outbreak in wuhan, china in december . - , by february , the first cases in the united states (u.s) were confirmed. since then, there has been an exponential growth in disease incidence, and the u.s. became the world's epicenter. , new york city (nyc), in particular, saw the most significant impact, reaching an overwhelming number of , new cases diagnosed in a single day, on april th. since the outbreak began in the city on march rd, there have been , confirmed cases, and , confirmed deaths by april th. . as a result, healthcare systems throughout the city had to divert significant resources and staff to newly created covid-specialized units. in an attempt to slow the progression of covid- pandemic, new york state and city governments enacted strict social distancing policies starting on march th, which included a progressive restriction and cancellation of non-fundamental activities, like the closure of schools, restaurants, bars, and business; as well as the cancellation of all elective surgical procedures. . according to the last new york state trauma registry report, for discharges between and , there was an average of , trauma incidents with a . % case fatality rate, with falls accounting for % of the total leading cause of trauma followed by motor vehicle accidents (mva) in . % of the cases. . we hypothesize that the social distancing and restrictive policies have changed the typical neurotrauma patterns throughout the city, given that fewer people were working, less transportation, and less interpersonal contact. to assess these possible changes, we reviewed all neurotrauma admissions to our trauma center during the early covid- period, and assessed changes in frequency, demographics, and mechanisms, in order to highlight any changes due to social distancing policies. mount sinai morningside is located in the upper west side of manhattan, is a level- trauma center accredited by the american college of surgeons, and is the centralized trauma facility in our system. institutional data on neurotrauma admissions were queried between november st, (one month prior to the disease outbreak in china) until april , . the start date for our query was selected based on the first confirmed cluster of pneumonia associated with the novel coronavirus (sars-cov- ), which was documented in china on december , . data analysis was done both retrospectively and prospectively, after institutional review board approval [irb # - ] was obtained. the data were dichotomized in pre-covid (before march , when the first case in new york city was confirmed) and covid groups (after march st). general demographics (age, sex), date of the encounter, mechanism of the trauma, injury severity score (iss), glasgow coma scale (gcs), radiological diagnosis, length of stay (los) in the intensive care unit (icu), days intubated (if applicable), total in-hospital los, and treatment instituted were obtained. additionally, we recorded specific information during the pandemic, such as covid- status (reported positive or negative by nasopharyngeal swab polymerase chain reaction (pcr), and unknown cases -if no test was obtained), presence of respiratory symptoms, known close contact with covid- patients, and radiological signs suggestive of active infection. we excluded patients who presented with neurosurgical conditions other than related to trauma (i.e spontaneous intracerebral hemorrhage, stroke, aneurysmal subarachnoid hemorrhage, central nervous system tumor). descriptive and comparative analyses of data were performed using chi-square, fisher's exact test, or a -sample t-test, depending on the variable type and observed values of the variables. the significance was set to alpha = . . we used r version . . in rstudio interface (rstudio integrated development for rstudio, inc, boston, ma). during the study period, patients with neurotraumas with a mean age of . years (sd+/- . ) and male prevalence of % presented to our institution, in the pre-covid- era and in the covid- period. figure shows the monthly frequency of neurotrauma cases during the study period. an average of . cases was observed in the pre-covid- period, and . cases in the covid- time. an average of case/day was observed in march and a decrease to . patients/day in april. figure shows a timeline of events during the covid- crisis. an inverse relationship was noticed between the number of positive cases and the frequency of neurotraumas since march st. by the third week of march, a drop in the frequency of neurotraumas was noticed, especially since the cancellation of non-essential activities (march th). an increase in the frequency of cases was noticeable in the second week of april, which was observed concomitant with the decrease in the number of new covid- cases in the city. during the covid- crisis, patients with a mean age of . years (sd+/-: . years) and . % male distribution were evaluated by our service. the most common neurotrauma was caused by mechanical fall ( . %), unknown mechanism ( . %), and mva/transit-related injuries ( . %). the most common diagnoses were subdural hematoma (sdh), traumatic subarachnoid hemorrhage (tsah), and intracerebral contusion in . %, . %, . % respectively. medical management accounted for . % of treatment instituted, and . % required surgical intervention. from this cohort, patients ( . %) were tested positive for covid- , ( . %) negative, and ( %) with unknown status at the time of evaluation. two patients ( . %) had a recognized contact with a positive person, and ( . %) unknown contact. five patients ( . %) had positive clinical symptoms on arrival (cough, dyspnea, fever) and ( . %) patients had positive radiological findings consistent with covid- pneumonia. table summarizes the comparative findings between pre-covid- and covid- groups. no significant difference between the groups regarding age was noticed ( . vs . years, p= . ). in both groups, most of the traumas were observed in males, with an increased male gender predominance in the covid- period ( . % vs . %, p= . ). the most frequent mechanism of trauma in both cohorts was mechanical fall, with a higher frequency in the pre-covid- period ( . % vs . %, p= . ). unknown mechanism ( . % vs . %), mva/transit-related ( % vs . %), and violence-related/inflicted traumas ( . % vs . %) increased in frequency in the covid- period with significant difference (p= . ). subdural hematomas were the most frequent diagnosis between both groups, with a decrease in numbers of cases in the covid- period ( . % vs . %). traumatic subarachnoid hemorrhage ( . % vs . %), intracerebral contusion ( . vs . %), and epidural hematoma ( % vs . %) experienced a relative increase in frequency during the covid crisis with a non-significant difference (p= . ). medical management was the most common treatment modality in both groups, ( . % vs . %, p= . ). among the non-surgical interventions, the frequency of conversion to dni/dnr status, and poor surgical candidacy increased in the covid- period from . % to . % (p= . ). overall, neurotraumas requiring surgical management decreased during covid- ( . % vs . %) but the difference did not reach statistical significance (p= . ). healthcare institutions in nyc witnessed an exponential growth of covid- cases since march , with the highest peak of , diagnoses on april th, and a peak of deaths on april th. during this time period, we observed a decrease in the frequency of neurotrauma at the early phase after the strict limitation of non-essential activities in the city, compared to the pre-covid- period. overall, we noticed a significant increase in males who sustained neurotrauma, with a nonsignificant tendency to be younger in the covid- period. mechanical fall accounted for the majority of cases in both periods, but the frequency decreased during the covid- crisis. interestingly, transit-related neurotrauma, as well as tbis related to violence (direct head trauma with an object) increased in frequency in the covid- period showing significant difference. subdural hematomas were the most frequent pathologies in both periods, and surgical management was observed less frequently in the covid- period, but these differences did not reach significance. in the past, several classic public health strategies have been implemented in a pandemic crisis. these include isolation, quarantine, social distancing, or community containment. . in order to decrease the spread of the virus, social distancing is defined by spacing ft away between individuals. other related activities include avoiding public transportation, working remotely to decrease the number of possible contacts, and staying home as much as possible. by encouraging all these measures, the expectation is to decrease the community transmission of the disease and ensure the separation between healthy and infected people. ahmed et al found a reduction of % of the influenza attack rate and a delay in the peak of the influenza rate with the institution of social distancing strategies. . we hypothesized that under these unique circumstances in which social interaction is expected to be limited, the frequency of traumas will decrease accordingly. overall, the incidence of tbi has been reported to be per . persons, as well as . cases per million in case of spinal cord injury (sci) in the u.s. , , , . we found that a significant increase of males sustained neurotrauma compared to the pre-covid- era ( . vs . %, p= . ). as previously reported, males are more likely to incur in tbi compared to females, especially between the age range of to years ( . cases per , persons for females and . per . for males), but this tendency disappears by the age of ( . per , for females, . per , for males). the increased incidence of tbis in males could be attributed to the increased risk-taking behavior and high-risk activities, most commonly engaged by men. . in the setting of a pandemic and "lockdown", we can presume that males are more prone to be involved in activities that increase the risk of trauma even while social distancing policies are in place, such as exposure to violencerelated/inflicted trauma, mva, falls associated with alcohol use. we noticed that the frequency of neurotraumas decreased the same week the social distancing and cancellation of non-essential activities were instituted (figure ). this trend was observed until the fourth week after the first case was reported and the second week after the executive order was implemented. the weekly maximum peak of covid- cases was observed between march th and march st, three weeks after the first case was reported in nyc, and one week after the executive order started. this progressive increase in the incidence of new covid- cases was observed inversely with the frequency of neurotraumas. this trend may be explained by the mandatory restriction of non-essential activities and the recommended social distancing policies that require avoidance of people crowding and limitation in public transportation in the city. experiences from italy, one of the most impacted countries, reported a preliminary impression that public "lockdown" during the pandemic has diminished the number of traumatic cases, which eased the number of surgical cases. similarly, christey et al reported an overall reduction of % of all-injury related admission in new zealand during a short period of lockdown due to covid- . . fall-related brain injury comprises % of all tbis in the elderly. . it is believed that this is due to increases in falls-related arrhythmias and the high intake of medication for chronic diseases. we noticed the same tendency in our cohort, having mechanical fall in . % of the cases overall. once dichotomized, we found that this mechanism was evident in . % of the cases in the pre-covid- period and . % of the neurotrauma cases in the covid- crisis. although we observed a significant decrease in the frequency of this mechanism compared to the pre-covid- period, it remained the most frequent etiology. this may be explained by the fact that falls can still happen irrespective of the location of the patient and can not necessarily be modified by the policies about the restriction in mobilization, especially in the elderly. following mechanical falls, the reported remaining leading causes of tbi are struck by an object ( . per . persons), mva ( . per . persons), and those related to assaults ( . per . ). we were expecting that the frequency of the aforementioned mechanism may be more common in an environment in which social interaction and personal mobilization are not limited. interestingly, in our cohort, we noticed a significant increase in mva/transit-related accidents and those related to violence. this tendency would not be expected during quarantine or lockdown, due to the theoretical restriction of interpersonal relationships and mobilization. recent reports mentioned an increase in the frequency of traffic-related fatalities during the pandemic, probably related to the decrease in transit that allows drivers to exceed speed limits and the fact that more people choose to walk or bike while there is a limitation in public transportation. [ ] [ ] [ ] . on the other hand, several reports have mentioned the increased risk and vulnerability to suffering domestic violence, specifically associated with the isolation requirements during the pandemic. - the possible factors that may lead to domestic violence in these circumstances have been associated with economic stress, exposure to previous exploitative relationships, disaster-related instability, and reduced support. , medical management accounted for the majority of treatment modalities implemented in both time periods, with a decrease in numbers of surgical cases between the pre-covid- and covid- period, which was not statistically significant. even though it did not reach statistical significance, it is worthy to note that the tendency to convert neurosurgical patients to a dni/dnr status increased in the covid- period from . % to . %. dnr decisions are made after a conjoined evaluation between trauma and neurosurgery. if both teams agree that aggressive care is not warranted based on the severity of injury and prognosis, a goal of care discussion is scheduled with the health care proxy or an appropriate surrogate. palliative care is often but not always involved in these discussions. the role of palliative care was definitely expanded during the covid- crisis. in our institution, the dnr form must be signed by an attending physician (trauma surgeon, intensivist or neurosurgeon depending on the primary service). the second physician can be a fellow or resident. in the case of a patient without capacity and surrogate, two attending physicians must agree that dnr is appropriate and complete the required dnr forms. during this crisis, it was of utmost importance to discuss advance care planning for adult patients. overall, the reported rate of advance directive completion is less than % in adults of years-old. several factors may influence this decision during the covid- crisis, especially the predicted life expectancy. by the moment this report is been written on may th, the national death count due covid- was , and , if limited to nyc; with an overall estimate of by august. , , interestingly, just . % of our cohort tested positive, and % had an unknown status at the time of evaluation. we may infer that the decision to change the status was based on the overall assessment and prognosis of the trauma, and not exclusively limited to the covid- status. this pandemic is affecting almost all levels of care in a health system. the relocation of staff, including neurosurgeons and neurointensivists to cover covid- units has been necessary during this crisis to ensure proper coverage to the infected patient population. under normal circumstances, neurosurgery responds to and evaluates all trauma codes. the "trauma code" is the hospital's designation for the highest-level activation for a trauma patient who is brought to the ed. for lower level trauma activations (trauma alerts), neurosurgery consults are obtained if there are positive findings on clinical assessment or imaging. in addition, all injured patients with positive ct findings are evaluated by neurosurgery, regardless of activation level. all neurotrauma patients are initially admitted under the trauma service for a minimum of hours. in isolated neurotrauma cases, the patient is then transferred to neurosurgery no sooner than hours after admission. this allows the trauma team to complete a tertiary survey and safely transition of the patient to care of a single service. regarding sci, the spine call schedule is shared by neurosurgery and orthopedics. there were no changes in the schedule during the covid crisis, so this shared call does not interfere with the reported results. we have modified our triaging process and admitting steps. as reported in other institutions worldwide, all transfers within our system and from outside hospitals (osh) are being restricted to life-rescue surgical cases and/or impending irreversible neurological deficits. , , each consult is evaluated by the on-call attending neurosurgeon. in case a transfer is indicated, the attending then discusses and obtains approval from a designated neurosurgeon that oversees all transfers, admissions, and surgical cases within the entire system. when the patient is not transferred, we provide a direct line to our neurosurgery service, this allows direct communication between services for the further management of the same patient. we are recommending the covid- test for all patients before initiating the transfer. in case the patient was not tested or the result is not yet available, we treat the patient as a person under investigation (pui). the pui policy includes the implementation of contact, droplets, respiratory precautions, isolation of the patient, and the use of proper personal protective equipment (ppe), as well as radiographic and clinical screening for covid- infection. one of the biggest limitations that we encountered is the single-center nature of the data, which may limit the generalizability of the results. the relatively small size of the cohort may lead to observational bias. we only explored the results of neurotrauma and not the total number of traumas, which may vary during the installment of social distancing policies. the type of trauma may vary between institutions, with some other hospitals having more inflicted traumas compared to ours due to the location in areas in which violence can be more prevalent. the total number of spine traumas may be underestimated due to the possible overlapping of more severe conditions because we used the primary diagnosis for the analysis. the true incidence of mild cases of neurotraumas may be underestimated, because patients may have preferred to stay at home and avoid hospitals due to the fear of getting the infection. also, the system triage policy table : comparison groups between the pre-covid and covid period. iss: injury severity score, tbi: traumatic brain injury, mva: motor vehicle accident update: public health response to the coronavirus disease outbreak -united states the lancet infectious diseases. covid- , a pandemic or not? the covid- epidemic the origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak -an update on the status the who just declared coronavirus covid- a pandemic who declares covid- a pandemic johns hopkins coronavirus resource center covid- : data -nyc health new york state trauma registry -statistical wilder-smith a, freedman do. isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus ( -ncov) outbreak epidemiology of traumatic brain injury blue book) | concussion | traumatic brain injury | cdc injury center global prevalence and incidence of traumatic spinal cord injury people with spinal cord injury in the united states the epidemiology of traumatic brain injury variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level lockdown for covid- in new zealand motor vehicle fatality rates up percent in march, despite covid- --occupational health & safety the roads are quieter due to coronavirus, but there are more fatal car crashes family violence and covid- : increased vulnerability and reduced options for support ; : . . pandemics and violence against women and children covid- era and beyond: ethical considerations regarding older adults covid- : projections of mortality in the us rise as states open up letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of coronavirus infection protein chain reaction tbi: traumatic brain injury sci: spinal cord injury mva: motor vehicle accident dni/dnr: do not intubate/do not resuscitate pui: person under investigation ppe: personal protective equipment osh: outside hospital disclosures and conflict of interest disclosures: none conflict of interest: lara-reyna: none yaeger: none rossitto: none camara: none wedderburn: none bederson: contractual relationship and has received financial compensation from brainlab conceptualization, methodology, formal analysis, investigation, data curation, writing -original draft, writing -review & editing, supervision, project administration yaeger: investigation, data curation, writing -review & editing rossitto: investigation, data curation, writing -review & editing camara: writing -review & editing wedderburn: writing -review & editing ghatan: writing -review & editing bederson: writing -review & editing margetis: methodology, formal analysis, data curation, writing -review & editing, supervision acknowledgments: we appreciate the contribution of gina maria arena, ma (regulatory approval), lindsey heacook, cstr and deborah travis, rn (data acquisition).this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. key: cord- -idbmh uo authors: raza, ali; khan, muhammad tariq iqbal; ali, qamar; hussain, tanveer; narjis, saadia title: association between meteorological indicators and covid- pandemic in pakistan date: - - journal: environ sci pollut res int doi: . /s - - - sha: doc_id: cord_uid: idbmh uo this study was designed to investigate the impact of meteorological indicators (temperature, rainfall, and humidity) on total covid- cases in pakistan, its provinces, and administrative units from march , , to august , . the correlation analysis showed that covid- cases and temperature showed a positive correlation. it implies that the increase in covid- cases was reported due to an increase in the temperature in pakistan, its provinces, and administrative units. the generalized poisson regression showed that the rise in the expected log count of covid- cases was . times for a °c rise in the average temperature in pakistan. second, the correlation between rainfall and covid- cases was negative in pakistan. however, the regression coefficient between the expected log count of covid- cases and rainfall was insignificant in pakistan. third, the correlation between humidity and the total covid- cases was negative, which implies that the increase in humidity is beneficial to stop the transmission of covid- in pakistan, its provinces, and administrative units. the reduction in the expected log count of covid- cases was . times for a % increase in the humidity per day in pakistan. however, humidity and covid- cases were positively correlated in sindh province. it is required to create awareness among the general population, and the government should include the causes, symptoms, and precautions in the educational syllabus. moreover, people should adopt the habit of hand wash, social distancing, personal hygiene, mask-wearing, and the use of hand sanitizers to control the covid- . the public health and global economy faced difficulties due to the outbreak of novel severe acute respiratory syndrome coronavirus (sars-cov- ), which is responsible for coronavirus disease (covid- ) (briz-redón and serrano-aroca covid- spread . in china, both relative humidity and temperature significantly influenced the transmission of covid- (wang et al. a) . sajadi et al. ( ) also mentioned the nexus between temperature, humidity, and respiratory viruses. the variations in the temperature and humidity also influenced the covid- mortality . prata et al. ( ) stated that it is hypothesized that variations in average temperature could significantly affect the covid- . jahangiri et al. ( ) wrote that ambient temperature could be a crucial transmissibility factor behind covid- . tosepu et al. ( ) explored the correlation between the covid- pandemic and weather indicators (minimum temperature, maximum temperature, average temperature, and rainfall) in jakarta, indonesia. spearman-rank correlation confirmed a significant correlation between covid- and temperature. in korea, the transmission of influenza was associated with relative humidity and low temperature. studies also highlighted that covid- was linked with meteorological factors . Şahin ( ) explored the linkages between covid- , population, and meteorological indicators (temperature, wind speed, dew point, and humidity) in turkey. the spearman's correlation confirmed the highest correlations score for population, temperature, and wind speed. bashir et al. ( ) revealed the link among climate indicators (average temperature, average humidity, rainfall, air quality, and wind speed) and covid- in new york, usa. correlation statistics confirmed a significant link between climate conditions and covid- . however, no study explored the association between meteorological indicators and covid- in pakistan. the contribution of this study is (a) it first time examined the relationship between meteorological indicators and covid- in pakistan, (b) it first time examined the relationship between meteorological indicators and covid- in four provinces and three administrative units in pakistan, and (c) it used the generalized models to investigate the impact of average temperature, rainfall, and humidity on covid- cases. therefore, this study explored the impact of meteorological variables (temperature, average rainfall, and humidity) on coid- cases and infection rate. this study was designed to examine the link between meteorological variables and covid- cases in pakistan. pakistan ranked among top countries, which were affected by the covid- . pakistan is the th most populated country and ranked th according to the area in the world. pakistan is an agriculture-based developing country, having usd per capita income per annum (hussain et al. ) . pakistan is situated between longitudes °e- °e and latitudes °n- °n (ali ) . pakistan has four provinces such as punjab, sind, khyber pakhtunkhwa, and baluchistan; and three administrative units such as gilgit-baltistan, islamabad capital territory, and azad jammu and kashmir. pakistan has . (hussain et al. ) . pakistani climate shows regional diversity from arid to humid. pakistan is blessed with the monsoon rainfall in summer and western systems rainfall in winter. the climate of pakistan showed variations in the temperature (ali ). this study used covid- data (government of pakistan (gop) a) in the case of pakistan from march , , to august , . the data of meteorological indicators like temperature (°c) and rainfall (mm) was obtained from the pakistan meteorological department (government of pakistan (gop) b). the humidity (%) data was obtained from world weather online (world weather online ). the infection rate shows the speed of the covid- transmission, which was calculated as (ahmadi et al. data analysis the non-parametric tests (spearman's and kendall's rank correlations) were used to investigate the association between two variables. these tests were computed on ranks and depicted a monotonic association (hamadeh et al. ). spearman's rank correlation coefficient was used to investigate the correlation between meteorological variables and covid- cases and infection rate. it used a monotonic function to analyze the association between two variables. spearman's rank correlation coefficient is estimated as (Şahin ): where n shows the number of alternatives, and d i shows the gap among ranks of two parameters. the coefficient of kendall's rank correlation (τ) was estimated as (kocsis and anda ) : where s shows trend and d shows data pairs using n members of dataset (kocsis and anda ) : regression analysis a generalized linear model was found useful to assess the link between covid- cases and different factors (prata et al. ) . the generalized additive model (gam) established a univariate response variable y, to predictor variables xi. the exponential family of distribution was specified for y like poisson, normal, and binomial (goswami et al. ) . the relationship between meteorological variables and covid- cases was explored using gam, to fit equations and splines. the gam fitted for parametric and nonparametric regression and smoothing. it was used to estimate the linear and nonlinear association between meteorological factors and health indicators ). an additive and semiparametric polynomial model was expressed as (prata et al. ) : where y shows the covid- cases in pakistan, its provinces, and administrative units on day t, β represents the intercept, s(•) shows a spline function with two degrees of freedom to control over-fitting wang et al. ) , β shows the parameter of x, and x shows the days since the first outbreak, at represents average daily temperature (°c), rf shows the average rainfall (mm), and hum shows the average humidity per day (%). the explanatory variables were controlled for confounding using expression s(•). the smoothing spline function could control the effects of confounding factors . ma et al. ( ) used gam to explore the relationship between meteorological variables (temperature and humidity) and covid- death in china. the gam model used both linear and nonparametric trends to optimize the linear model. however, prata et al. ( ) mentioned the statistical significance of a linear association between meteorological variables and covid- , which was expressed as (prata et al. ) : a dose-response function f connected several explanatory variables (dose x), with a probability of infection (response f(x)) (brouwer et al. ) . the dose-response association was normally expressed graphically and showed different mathematical distributions to express a clear relationship (sullivan et al. ) . mathematically, a dose-response relationship showed the expectation of potential loss as a function of different environmental indicators (ye et al. ) . chuang et al. ( ) used gam to explore the dose-response association between the daptomycin dose and mortality. in the present study, the gam was applied to establish a dose-response function, which connected different dose variables (outbreak days, average temperature, rainfall, and humidity), with a probability of covid- infection (response variable). li et al. ( ) used the poisson model to explore the association between total cases and meteorological variables. poisson regression is a commonly used classical model, which was based upon the classical assumptions. it was further assumed that the dependent variable had poisson distribution, as the random variable showed a value , , , , … n. it explained the distribution of y i or the expected value y i by the explanatory variables x i , as expressed below (cupal et al. ) : the count data models assumed that the count variable y i for given x i had a poisson distribution. where y! shows y factorial. substituting the appropriate functional form for λ i produced expressions for the probabilities used to construct the log-likelihood function for this model, called the poisson regression model. the generalized poisson regression was capable to explain the count data with any type of dispersion. it incorporated both positive and negative correlation between response variables (consul and famoye ; famoye ) . the generalized poisson regression was beneficial in the presence of over-dispersion (var(y i ) > e(y i )) and under-dispersion (var(y i ) < e(y i )). according to the generalized poisson distribution, the probability density function of y i was expressed as (famoye ; maxwell et al. ) : where x i shows a (k- ) dimensional vector of covariates such as driving habits, demographic factors, and medication use, and β shows (k- ) dimensional vector of regression parameters. it assumed that: the generalization of standard poisson regression was called generalized poisson regression (maxwell et al. ). this study also used generalized poisson regression to assess the link between meteorological variables and covid- cases. the empirical analysis was performed using r software, stata , and eviews . the trend of covid- and meteorological indicators in pakistan figures , , , , , , , , , and show the trend of meteorological indicators (temperature, rainfall, and humidity), day-wise covid- cases, and total covid- cases in pakistan from march , , to august , . figure shows that the day-wise trend showed a continuous increase in pakistan up to june , . after that, the reduction in the day-wise covid- cases was reported in pakistan. the covid- cases were on august , . however, there were some fluctuations in the day-wise confirmed cases. figure shows the daywise cases in provinces and administrative areas. it was cleared that the day-wise increase was more in punjab and sindh provinces. it might be due to the higher population and population density in punjab and sindh. figure shows the trend of total covid- cases in pakistan. it showed a rapid increase in the total covid- cases from march , , to june , . after that, covid- cases were increased at a decreasing rate. figure shows total covid- cases in provinces and administrative areas. it is cleared that the total covid- cases were higher in sindh province followed by punjab, khyber pakhtunkhwa, islamabad capital territory, baluchistan, gilgit-baltistan, and azad jammu and kashmir. it was cleared that punjab and sindh provinces were mostly affected by the covid- . figure shows the trend of average temperature in pakistan. there are fluctuations in average temperature in pakistan. however, there was an increasing trend in average temperature from march , , to may , . after that, there was no significant increase in temperature, but it shows fluctuation in average temperature. figure shows the average temperature in provinces and administrative areas. the average temperature was higher in sindh province followed by punjab, baluchistan, islamabad capital t e r r i t o r y , a z a d j a m m u a n d k a s h m i r , k h y b e r pakhtunkhwa, and gilgit-baltistan. the average temperature also showed fluctuations in provinces and administrative units. figure shows the trend of average rainfall per day in pakistan. there was no specific trend in the rainfall per day in pakistan due to the presence of fluctuations between march , , and august , . figure shows the average rainfall per day in provinces and administrative units. average rainfall per day also showed fluctuations in all provinces and administrative units. however, average rainfall per day showed upward spikes after the covid- outbreak in pakistan. the trend of humidity (fig. ) shows a decreasing trend from march , , to june , . after that, there was an increasing trend of humidity in pakistan. figure shows the humidity in provinces and administrative units. the humidity also showed fluctuations in all provinces and administrative units between march , , and august , . an increasing trend of humidity was found in sindh province. however, other provinces and administrative units showed a minor reduction in humidity up to the first week of june . after that, the increasing trend of humidity was observed in provinces and administrative units. however, fluctuations in humidity were also observed in provinces and administrative units. tables and show the spearman's and kendall's rank correlation analysis. the five meteorological variables like temperature (minimum, maximum, average), rainfall, and humidity were used in correlation analysis with total covid- cases (table ) and covid- infection rate (table ) . both spearman's and kendall's rank correlation shows the same direction between selected variables. tosepu et al. ( ) used weather-related indicators in the case of jakarta. but this study used these variables for the country level (pakistan) as well as provincial l e v e l ( p u n j a b , s i n d h , b a l u c h i s t a n , k h y b e r pakhtunkhwa, islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir). the results showed that temperature (minimum, maximum, and average) has highest correlation coefficient. therefore, average temperature is closely linked with the covid- cases. it implies that the covid- cases increased in pakistan due to an increase in average temperature, which was in line with the results of tosepu et al. ( ) in the case of jakarta, indonesia. a positive correlation was also observed between total cases and average temperature in new york, usa, which was badly a f f e c t e d b y c o v i d - ( b a s h i r e t a l . ) . temperature is an environmental factor behind covid- spread in china . contrarily, Şahin ( ) reported an increase in covid- cases due to a reduction in average temperature in turkey. sobral et al. ( ) also reported a reduction in infections due to an increase in temperature. in past studies, bi et al. ( ) also reported an inverse correlation between sars cases and temperature in beijing and hong kong. the diversified results between temperature and covid- cases were due to the fact that the impact of temperature on human health may vary between different regions or countries (hajat and kosatky ; sobral et al. ( ) . the literature highlighted that influenza and sars-cov viruses survived only under specific climatic conditions and their transmission rate was sensitive to increasing temperature (chan et al. ; jaakkola et al. ) . second, correlation between average rainfall and covid- cases was negative and significant in pakistan, which implies the reduction in covid- cases due to rainfall in pakistan. however, those findings were not in line with findings of tosepu et al. ( ) in the case of jakarta, indonesia. it seems that weather and covid- behavior was different in pakistan and indonesia. another study (bashir et al. ) showed an insignificant correlation between rainfall and covid- cases in new york, usa. contrarily to tosepu et al. ( ) , correlation between humidity and the total covid- cases was negative in pakistan, which implies the reduction in covid- cases due to an increase in the level of humidity in pakistan. the reduction in covid- cases due to a rise in the level of humidity was also reported in turkey (Şahin ) . it means that pakistan and turkey showed similarities with respect to covid- and humidity. it was also noted that the absolute value of negative correlation between humidity and covid- cases was higher in pakistan ( . ) as compared to turkey ( . ) (Şahin ). moreover, ma et al. ( ) also indicated a reduction in covid- cases due to higher humidity in china. chan et al. ( ) pointed out that higher relative humidity eliminated the virus viability, which supported the findings of the present research. along with environmental factors, population (zu et al. ) , population density, medical care (wang et al. b ), people's endurance, social distancing, and health facilities (bashir et al. ) were also possible reasons behind spread or control of covid- . a higher correlation coefficient was observed between temperature (minimum, maximum, and fig. humidity in provinces and administrative areas environ sci pollut res average) and covid- cases for all provinces and administrative units (punjab, sindh, baluchistan, khyber pakhtunkhwa, islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir). the correlation between rainfall and covid- cases was significant and negative in the case of khyber pakhtunkhwa and baluchistan. it implies that the increase in rainfall was linked with a reduction in covid- cases. a positive correlation was reported between rainfall and covid- cases in gilgit-baltistan. in general, humidity had a negative correlation with covid- cases in punjab, baluchistan, khyber pakhtunkhwa, islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir. however, sindh province showed different behavior due to a positive correlation between humidity and covid- cases. to control the covid- , it is required to reduce the infection. the results (table ) showed that temperature (minimum, maximum, and average) has highest correlation coefficient. therefore, average temperature was linked with the infection rate. it implies that the covid- infection increased due to an increase in average temperature. second, correlation between average rainfall and the covid- infection rate was negative in pakistan. a negative correlation was observed between humidity and covid- infection rate. this study also explored the correlation between meteorological indicators and the covid- infection rate in the case of provinces. the positive correlation coefficient was observed between temperature (minimum, maximum, and average) and covid- infection for all provinces and administrative units. the correlation between rainfall and the covid- infection rate was significant in sindh and azad jammu and kashmir. in general, humidity had a negative correlation with covid- cases the gam explored the association between meteorological variables (temperature, rainfall, and humidity) and the covid- cases in pakistan, its provinces, and administrative units. figure explains the dose-response link between average temperature and covid- cases using the gam. initially, there was a direct association between temperature and covid- cases, but the curve showed a flatter shape when average temperature lies between and °c. the rise in the covid- cases was also observed when average temperature was more than °c. the temperature was positively linked with the covid- cases in jakarta, indonesia (tosepu et al. ) , and new york, usa (bashir et al. ) . in punjab, the covid- -temperature curve showed a positive slope initially, but it was flattered when average temperature was more than °c. there was an inverse link between covid- and temperature in gilgit-baltistan, and azad jammu and kashmir. temperature and the covid- cases were positively associated in sindh and baluchistan. in khyber pakhtunkhwa and islamabad capital territory, the covid- cases increased when the temperature was low, but there was a reduction in the covid- cases when the temperature was higher. figure explains the dose-response link between rainfall and covid- cases per day, showed an increase in covid- cases due to rainfall initially, but the curve was flattered when the rainfall was more than mm per day. an insignificant association between rainfall and covid- cases was reported in jakarta, indonesia (tosepu et al. ) and new york, usa (bashir et al. ) . the dose-response curve between covid- and rainfall was positively sloped in sindh, baluchistan, and khyber pakhtunkhwa, but it was not much steeper. the curve between covid- cases and rainfall seemed like a flatter curve in islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir. figure explains the presence of an inverse dose-response curve between humidity and covid- cases in pakistan. the curve was steeper when humidity was more than %. the inverse relationship between covid- cases and humidity was also reported in turkey (Şahin ) and china ) because higher relative humidity eliminated the virus viability (chan et al. ) . the dose-response curve showed a reduction in covid- cases due to a rise in humidity in islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir. the curve was downward sloped between covid- and humidity in punjab, baluchistan, and khyber pakhtunkhwa, but it showed a positive trend in the presence of a higher level of humidity. table shows the impact of average temperature, rainfall per day, and humidity using time-series generalized poisson regression in pakistan, its provinces, and administrative units. yuan et al. ( ) also used regression analysis to reveal the impact of temperature, wind speed, and relative humidity on sars transmission. temperature and humidity were significant factors in the seasonal spread of coronaviruses (sajadi et al. ) . results showed that the increase in the expected log count of covid- cases was . times for a °c rise in average temperature in pakistan. it implies that the increase in temperature was favorable to control the covid- in pakistan. the regression analysis of provincial and administrative units showed that the increase in expected log count of covid- cases was . times in sindh, . times in khyber pakhtunkhwa, and . times in baluchistan for °c rise in average temperature. the rise in the covid- cases due to an increase in average temperature was also reported in jakarta, indonesia (tosepu et al. ) , and new york, usa (bashir et al. ) . xie and zhu ( ) also considered that temperature was a factor in covid- transmission. wu et al. ( ) described that the increase in new cases was . % for a °c rise in temperature. however, coefficient of average temperature was insignificant in punjab, azad jammu and kashmir, islamabad capital territory, and gilgit-baltistan. the impact of rainfall on covid- cases was insignificant in pakistan. it implies that the increase in rainfall per day was not a significant factor behind the covid- transmission in pakistan. the increase in expected log count of covid- cases was . times in punjab and . times in khyber pakhtunkhwa for mm increase in rainfall per day. however, coefficient of rainfall was insignificant in sindh, baluchistan, azad jammu and kashmir, islamabad capital territory, and gilgit-baltistan. on the other hand, a reduction in the expected log count of covid- cases was . times for a % increase in humidity per day in pakistan. it implies that the increase in humidity was beneficial to stop covid- transmission in pakistan. the provincial and administrative units also showed that the reduction in expected log count of total covid- cases was . times in punjab, . in islamabad capital territory, and . times in azad jammu and kashmir for % increase in humidity. however, an insignificant link between covid- cases and humidity was observed in sindh, baluchistan, khyber pakhtunkhwa, and gilgit-baltistan. wu et al. ( ) described . % reduction in covid- cases for a % increase in relative humidity. chan et al. ( ) pointed out that the higher relative humidity eliminated the virus viability, which supported the empirical results. however, some other meteorological indicators (air quality and wind speed) could also affect the transmission of infectious diseases ). public health and the global economy faced huge problems due to covid- . this study was designed to investigate the impact of meteorological indicators (temperature, rainfall, and humidity) on total covid- cases and covid- infection rate in pakistan from march , , to august , . the correlation analysis implies that the covid- cases increased due fig. the dose-response curves between average temperature and covid- cases to a rise in average temperature in pakistan, its provinces, and administrative units. the dose-response relationship showed a direct association between temperature and covid- cases but the curve was flattered when average temperature lies between and °c in pakistan. the increase in covid- cases was also observed when average temperature was more than °c in pakistan. the results of generalized poisson regression showed that the increase in the expected log count of covid- cases was . times for a °c rise in average temperature in pakistan. second, correlation between average rainfall and covid- cases was negative in pakistan. the dose-response curve showed an increase in covid- cases due to rainfall initially but the curve was flattered when the rainfall was more than mm per day. third, correlation between humidity and the total fig. the dose-response curves between rainfall and covid- cases covid- cases implies the reduction in covid- cases due to an increase in humidity in pakistan. the dose-response curve between humidity and covid- cases showed the presence of an inverse relationship between humidity and covid- cases in pakistan. the downward slope curve becomes steeper when humidity was more than %. the reduction in the expected log count of covid- cases was . times for a % increase in humidity in pakistan. it implies that the increase in humidity was beneficial to stop the covid- transmission. this study also had some limitations like (a) total covid- cases also included those pakistani citizens, which were affected abroad and moved to pakistan with covid- symptoms, (b) it is also important to include some other factors like virus resistance, population mobility, and immunity, (c) the spread of covid- also depends upon some precautionary measures such as hand wash habits, social funding this research has no funding from any organization. availability of data and material data will be available on request. conflicts of interest the authors declare that they have no conflict of interest. ethical approval this article does not contain any studies with human participants or animals performed by any of the authors. consent to publish not applicable investigation of effective climatology parameters on covid- outbreak in iran climate change and associated spatial heterogeneity of pakistan: empirical evidence using multidisciplinary approach correlation between climate indicators and covid- pandemic weather: driving force behind the transmission of severe acute respiratory syndrome in china? a spatio-temporal analysis for exploring the effect of temperature on covid- early evolution in spain dose-response relationships for environmentally mediated infectious disease transmission models community pharmacists and communication in the time of covid- : applying the health belief model the effects of temperature and relative humidity on the viability of the sars coronavirus roles of meteorological conditions in covid- transmission on a worldwide scale daptomycin versus linezolid for the treatment of vancomycinresistant enterococcal bacteraemia: implications of daptomycin dose generalized poisson regression model the poisson regression analysis for occurrence of floods urbanization and humidity shape the intensity of influenza epidemics in u restricted generalized poisson regression model a multivariate generalized poisson regression model assessing the impact of climate change on vector-borne viruses in the eu through the elicitation of expert opinion projections for covid- pandemic in india and effect of temperature and humidity accessed date: oct government of pakistan (gop) ( b) pakistan meteriological department effect of weather on covid- spread in the us: a prediction model for india heat-related mortality: a review and exploration of heterogeneity using correlative data analysis to develop weather index that estimates the risk of forest fires in lebanon & mediterranean: assessment versus prevalent meteorological indices regional and sectoral assessment on climate-change in pakistan: social norms and indigenous perceptions on climatechange adaptation and mitigation in relation to global context decline in temperature and humidity increases the occurrence of influenza in cold climate the sensitivity and specificity analyses of ambient temperature and population size on the transmission rate of the novel coronavirus (covid- ) in different provinces of iran noor-ul-huda zm ( ) is pakistan prepared for the covid- epidemic? a questionnairebased survey parametric or non-parametric: analysis of rainfall time series at a hungarian meteorological station the relationship between meteorological factors and the risk of bacillary dysentery in hunan province impact of meteorological factors on the covid- transmission: a multicity study in china effects of temperature variation and humidity on the death of covid- in wuhan modelling count data; a generalized linear model framework temperature significantly changes covid- transmission in (sub) tropical cities of brazil impact of weather on covid- pandemic in turkey temperature and latitude analysis to predict potential spread and seasonality for covid- impact of temperature on the dynamics of the covid- outbreak in china association between climate variables and global transmission of sars-cov- climate change. how climate change affects extreme weather events chapter -living with the risk of polluted water. the environmental science of drinking water estimation of the final size of the covid- epidemic in pakistan correlation between weather and covid- pandemic in jakarta a time-series study of the association of rainfall, relative humidity and ambient temperature with hospitalizations for rotavirus and norovirus infection among children in hong kong high temperature and high humidity reduce the transmission of covid- temperature significant change covid- transmission in cities world health organization (who) ( ) world heath organization effects of temperature and humidity on the daily new cases and new deaths of covid- in countries association between ambient temperature and covid- infection in cities from china quantifying livestock vulnerability to snow disasters in the tibetan plateau: comparing different modeling techniques for prediction a climatologic investigation of the sars-cov outbreak in beijing, china association between ambient temperature and covid- infection in cities from china coronavirus disease (covid- ): a perspective from china publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -udtoutew authors: furuse, yuki; sando, eiichiro; tsuchiya, naho; miyahara, reiko; yasuda, ikkoh; ko, yura k.; saito, mayuko; morimoto, konosuke; imamura, takeaki; shobugawa, yugo; nagata, shohei; jindai, kazuaki; imamura, tadatsugu; sunagawa, tomimasa; suzuki, motoi; nishiura, hiroshi; oshitani, hitoshi title: clusters of coronavirus disease in communities, japan, january–april date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: udtoutew we analyzed , cases of coronavirus disease in japan and identified case-clusters in healthcare and other care facilities, restaurants and bars, workplaces, and music events. we also identified probable primary case-patients for the clusters; most were – years of age and presymptomatic or asymptomatic at virus transmission. we analyzed , cases of coronavirus disease in japan and identified case-clusters in healthcare and other care facilities, restaurants and bars, workplaces, and music events. we also identified probable primary case-patients for the clusters; most were - years of age and presymptomatic or asymptomatic at virus transmission. functions; and ( %) transportation-related incident in an airplane. most ( / ; %) clusters involved - cases ( figure , panel b). the largest cluster involved > cases in a hospital, including nosocomial infections and staff infections. the largest non-healthcare-related cluster we observed was among > persons who attended a live music concert, including performers, audience members, and event staff. healthcare and care facilities accounted for > % of clusters at epidemiologic weeks and ( figure , panel c). we identified probable primary case-patients who had symptoms develop before they had contact with other case-patients in a cluster or who had prior epidemiologic links before contact with a cluster. we did not identify probable primary cases for nosocomial clusters. we believe these case-patients contributed to the incidence of clusters. demographic data show that ( %) probable primary case-patients were female and ( %) were male. the most frequently observed age groups among probable primary cases were - years (n = ; %) and - years (n = , %) ( figure , panel a). for clusters, we determined the date of transmission from probable primary case-patients to other case-patients in a cluster and found % ( / ) of probable primary casepatients were presymptomatic or asymptomatic at the time of transmission; only had a cough at the time of transmission ( figure , panel b). of the probable primary case-patients, % ( / ) had cough at the time of diagnosis. of the probable primary case-patients with the determined date of transmission, transmission occurred one day before illness onset for ( %) case-patients and on the same day of illness onset for ( %) case-patients ( figure , panel c). all age groups demonstrated presymptomatic or asymptomatic transmission. we investigated clusters of covid- cases and probable primary cases in japan during january -april , . we found that healthcare facilities, such as hospitals, and care facilities, such as nursing homes, were the primary sources of clusters, some of which had > cases. japan experienced waves of imported cov-id- cases, after which local transmission occurred and the epidemic grew ( ) . of note, clusters of covid- cases at healthcare and care facilities predominated at epidemiologic weeks (march - ) and (march -april ), which corresponds to ≈ weeks after the waves of imported cases (figure , panel c) . healthcare and care facilities might be located at the end of the local transmission chain because clusters in those facilities only became evident several weeks after community transmission persisted. we noted many covid- clusters were associated with heavy breathing in close proximity, such as singing at karaoke parties, cheering at clubs, having conversations in bars, and exercising in gymnasiums. other studies have noted such activities can facilitate clusters of infection ( , ) . japan's prime minister's office and the ministry of health, labour and welfare announced situations that could increase the risk for covid- cases and advised the population to avoid the "three cs": closed spaces with poor ventilation, crowded places, and close-contact settings ( ) . among the probable primary covid- cases we identified from non-nosocomial clusters, half ( / ) were - years of age, which is younger than the age distribution of all covid- cases in japan (figure , panel a) . we do not know whether social, biological, or both factors play a role in the difference in transmission patterns between the younger and older persons. we also noted probable primary covid- case-patients appear to transmit the virus and generate clusters even in the absence of apparent respiratory symptoms, such as cough. our study has some limitations. the epidemiologic investigation mostly relied on voluntary cooperation. because some case-patients could not disclose contact history, epidemiologic links and clusters of cases might have missed. recall bias is likely because japan did not use digital devices for contact tracing and information was obtained only through interviews. in addition, we could not calculate a secondary attack rate from probable primary cases because data were unavailable for denominator, such as the number of persons present in the places where clusters of cases were detected. active case finding and investigation are key to establishing links to other cases or transmission events. detecting clusters of cases can lead to effective quarantine of close contacts and to the identification of risk factors for the formation of such clusters ( ) . our findings provide further information and insight on clusters of covid- cases in communities that can aid in the ongoing efforts to curb the global pandemic. age ranges of probable primary covid- cases in clusters. age distribution among all covid- cases in japan is provided as reference. b) proportions of symptoms among probable primary cases of covid- clusters at transmission (n = ) and among at laboratory confirmed diagnosis (n = ). , asymptomatic; , fever; , fatigue; , cough; , sore throat; , headache; , arthralgia or myalgia; , runny nose; , diarrhea; , difficulty breathing. c) distribution of probable primary cases of covid- clusters by time of transmission compared with illness onset by age groups (n = ). six cases were excluded because the time of transmission was undetermined. nin, kota ninomiya, yukiyo nitta, akiko sakai, kazuaki sano, asako sato, akiko sayama, ayaka takeuchi, hiroto tanaka, fumie tokuda, shogo yaegashi, yoko yamagiwa, lisa yamasaki, and fumi yoshimatsu. this study was supported in part by grants from the ministry of education, culture, sport, science and technology in japan (no. ) and the japan agency for medical research and development (no. fk h ). china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china clinical features of patients infected with novel coronavirus in wuhan world health organization. who director-general's opening remarks at the mission briefing on covid- - world health organization. who director-general's opening remarks at the mission briefing on covid- - investigation of three clusters of co-vid- in singapore: implications for surveillance and response measures transmission potential and severity of covid- in south korea about coronavirus disease (covid- ) press conference epidemiology of covid- outbreak in japan coronavirus disease cluster associated with fitness dance classes, south korea. emerg infect dis high sars-cov- attack rate following exposure at a choir practice prime minister's office of japan; ministry of health, labour and welfare. avoid the "three cs identifying and interrupting superspreading events-implications for control of severe acute respiratory syndrome coronavirus dr. furuse is an assistant professor at institute for frontier life and medical sciences and hakubi center for advanced research, kyoto university, japan. his primary research interests include the public health, epidemiology, bioinformatics, and molecular biology of viral diseases. key: cord- - krbrj w authors: koh, wee chian; naing, lin; wong, justin title: estimating the impact of physical distancing measures in containing covid- : an empirical analysis date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: krbrj w background: epidemic modelling studies predict that physical distancing is critical in containing covid- . however, few empirical studies have validated this finding. our study evaluates the effectiveness of different physical distancing measures in controlling viral transmission. methods: we identified three distinct physical distancing measures with varying intensity and implemented at different times—international travel controls, restrictions on mass gatherings, and lockdown-type measures—based on the oxford covid- government response tracker. we also estimated the time-varying reproduction number (r(t)) for countries and tracked r(t) temporally for two weeks following the th reported case in each country. we regressed r(t) on the physical distancing measures and other control variables (income, population density, age structure, and temperature) and performed several robustness checks to validate our findings. findings: complete travel bans and all forms of lockdown-type measures have been effective in reducing average r(t) over the days following the th case. recommended stay-at-home advisories and partial lockdowns are as effective as complete lockdowns in outbreak control. however, these measures have to be implemented early to be effective. based on the observed median timing across countries worldwide, lockdown-type measures are considered early if they were instituted about two weeks before the th case and travel bans a week before detection of the first case. interpretation: a combination of physical distancing measures, if implemented early, can be effective in containing covid- —tight border controls to limit importation of cases, encouraging physical distancing, moderately stringent measures such as working from home, and a full lockdown in the case of a probable uncontrolled outbreak. coronavirus disease is an emerging respiratory infectious disease caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), which was first detected in early december in wuhan, china. as of may , , it has affected . million people and resulted in more than , deaths globally (who ) . in the absence of effective therapeutics or vaccines, containment measures rely on the capacity to control viral transmission through non-pharmaceutical interventions (npis) (kissler et al. ) . current evidence suggests that the effectiveness of case isolation and contact tracing strategies can be enhanced when combined with physical distancing measures in public settings (chu et al. ; kucharski et al. ) . governments worldwide have implemented various forms of physical distancing measure with varied stringency level and timeliness. the measures include school and workplace closures, cancellation of public events, restrictions on mass gatherings, public transport closures, stayat-home orders, restrictions on internal movements, and international travel controls. due to the potential for socioeconomic disruptions caused by these measures, it is therefore important to quantify their impact on disease spread to inform policymaking, which has thus far relied primarily on epidemic modelling studies (ferguson et al. ; prem et al. ) . as cases accumulate, it has become possible to use empirical data derived from real-world observations to validate the model-based estimates of the effectiveness of policy interventions. in this paper, we assessed-at a normalized point on the epidemic curve-the impact of physical distancing measures on viral transmission measured by the time-varying reproduction number, rt, which represents the expected number of secondary cases generated by a primary case at time t. a value of rt greater than one indicates that a sustained outbreak is likely. the goal of policy intervention is to bring rt below one, suggesting that the outbreak is under control. data on physical distancing measures were obtained from the oxford covid- government response tracker (oxcgrt), which collects information, starting from january , , on a range of government policies, assigns a stringency score for the measures, and aggregates the data into a common index for countries (may version). we used the stringency index as an aggregate measure, which has a score between and , with a higher index indicating increased stringency. we further examined the impact of specific measures: (i) school closures; (ii) workplace closures; (iii) cancellation of public events; (iv) restrictions on size of gatherings; (v) public transport closures; (vi) stay-at-home orders; (vii) restrictions on internal movements, and (viii) restrictions on international travel. these measures have an ordinal scale of severity or intensity. further details on the oxcgrt database are provided in hale et al. ( ) . we normalized the stage of disease spread to minimize the confounding effect of increased caseload on transmission: the impact of interventions is expected to be different at and , cases. we used total cases as the starting point for all countries to indicate an outbreak (hartfield and alizon ) . we estimated rt for countries that have reported at least cases as of may , . the estimation covered the whole period from the first reported case to may using a weekly sliding window based on the methods developed by cori et al. ( ) . we used data on new daily cases and the distribution of the generation time (time between infection of an index case and infection of a secondary case). we incorporated uncertainty in the generation time distribution with a mean of . days (sd: . days) and standard deviation of days (sd: . days) and used a gamma prior for the reproduction number with mean . and standard deviation . these parameter estimates were obtained from the covid- epiforecasts project by the centre for the mathematical modelling of infectious diseases at the london school of hygiene and tropical medicine (see abbott et al. ) . data on daily reported cases were obtained from the european centre for disease prevention and control and from the johns hopkins university centre for systems science and engineering covid- data depository. rt was estimated using the epiestim package in r version . . (r foundation for statistical computing). an important feature of examining rt, instead of cumulative case numbers, is that, if the proportion of cases that are unreported remain constant throughout an outbreak, estimates of rt are unaffected by underreporting (thompson et al. ) . as countries have implemented and subsequently relaxed measures in response to the outbreak, establishing causality from such measures to a change in rt is challenging. to address possible reverse causality, we examined the measures that were in place at the time when cases have been reported. we then tracked the median rt temporally over the next days. the lagged measures thus controls for the endogenous response to viral transmission. we regressed rt on physical distancing measures and other covariates. the control variables used were income level (log of gdp per capita at current us$), population density (log of population per square kilometre), age structure (proportion of population aged years and above), and air temperature ( day average after the th case). these socioeconomic and environmental factors have been postulated to influence disease spread qiu et al. ) . data on gdp per capita, population density, and population above years old were obtained from the world bank's world development indicators, supplemented by the central intelligence agency's the world factbook. data on temperature were collected from the air quality open data platform and other online weather resources. the empirical specification takes the following form: is the average reproduction number of country over the days following the date of the th case; is country 's physical distancing measure of type on the date of the th case; represents the country characteristic (income level, population density, age structure, and temperature) of country ; is a constant term, 's are the regression coefficients, and denotes the error term. a schematic of the methodology is outlined in figure s in the supplementary materials. we also conducted ex-post predictions on the date of the th case using equation ( ) to make comparative assessments on how rt would be predicted to evolve relative to what has been observed in reality. all regression analyses were performed in stata (statacorp llc). j o u r n a l p r e -p r o o f we conducted a series of robustness checks to validate our results. we explored a shorter time horizon of seven days to address the possibility of new measures implemented after the th case that could affect rt. we also used the growth in total cases instead of rt as the dependent variable. to examine actual behavioural changes instead of de jure government policies, we used a de facto measure of physical distancing using mobility data from google community mobility reports. we first take a cursory look at the nature of the relationship between physical distancing measures and rt, and then proceed to estimate the magnitudes using regression models. the average timing of implementation of the physical distancing measures is summarized in table s in the supplementary materials. the earliest policies to be implemented, on average, were restrictions on international travel, about days before the detection of the first case. cancellation of public events and school closures were the initial responses during the onset of an outbreak (about a week after the first case), followed by restrictions on the size of gatherings and more stringent measures such as workplace closures, restrictions on internal movement, stay-at-home orders, and public transport closures. on average, all these measures were implemented before the occurrence of the th case. since several measures were implemented very close to one another, and due to the similar nature of some the measures, it is difficult to relate the observed changes in rt to a specific measure. we addressed this identification issue by grouping the measures, taking into account the implementation timing and correlation ( [ figure here] j o u r n a l p r e -p r o o f the time-varying reproduction number rt is the expected number of secondary cases generated by a primary case at time t. the specific measures on international travel restrictions are detailed in table . each bubble represents a country, and the size of the bubble is proportional to the total number of reported cases as of may , . [ figure here] the time-varying reproduction number rt is the expected number of secondary cases generated by a primary case at time t. the specific measures on mass gathering restrictions are detailed in table . each bubble represents a country, and the size of the bubble is proportional to the total number of reported cases as of may , . table . each bubble represents a country, and the size of the bubble is proportional to the total number of reported cases as of may , . we first examine the impact of the stringency index on rt. the results are reported in column ( ) of [ table here] to validate our results, we conducted several robustness checks. we tracked rt over seven days and used the growth of total cases instead of rt as the dependent variable. we also used a de facto measurement of physical distancing using google mobility data-as opposed to de jure government announced measures-to examine the actual observed behaviour changes on rt. the findings are largely unchanged, as reported in columns ( ) to ( ) in table and the supplementary materials (tables s and s , figure s ). we conducted ex-post predictions using the regression model in column ( ) of table to retrospectively assess how rt would be predicted to evolve over the following two weeks, given the case history and physical distancing measures implemented on the date of the th case, along with specific country characteristics. the predicted rt of the countries are displayed in table s in the supplementary materials. some countries had a lower rt over the two weeks following the th case than predicted by the model, such as japan, brunei, iceland, and vietnam. by contrast, others, such as turkey, italy, and the united states had a higher rt. we assessed, at a standardized stage of the outbreak at cases, the impact of physical distancing measures on covid- transmission, measured by rt, and found that, on average, they have been our study provides empirical support to findings from modelling studies that highlight the role of physical distancing measures in containing covid- . we identified three distinct measures, implemented at different times-restrictions on international travel prior to the first reported case, restrictions on mass gatherings during the onset of an outbreak, and lockdowns at later stages. our analysis suggests a hierarchy of physical distancing measures that are effective in outbreak control. we found that lockdown-type measures had the largest effect on limiting viral transmission, followed by j o u r n a l p r e -p r o o f complete travel bans. these measures have to be implemented early to be effective-based on our definition of early implementation using the observed median timing across countries worldwide, lockdown measures are considered early if they were instituted about two weeks before the th case and travel bans a week before detection of the first case. this accords with the findings in other studies that severe travel restrictions have been critical in slowing down infections in china and around the world (keita ) , and also corroborates studies showing that lockdowns limited disease spread in wuhan (fang et al. ) , italy and spain (tobias ) , and california (friedson et al. ) . importantly, our findings suggest that lockdowns measures should not be viewed in a binary approach. there is a wide range of lockdown-type measures from less stringent forms such as working from home up to complete movement restrictions, and all were shown to be effective in suppressing viral transmission. if implemented early, work from home and stay at home recommendations reduce rt by . ( % ci: - . , - . ); a partial lockdown reduces rt by . ( % ci: - . , - . ); and a complete lockdown reduces rt by . ( % ci: - . , - . ). across these three grades of lockdown-type measures, the % ci of their effect sizes overlap suggesting no significant difference in effectiveness across these measures. this finding is replicated even when assessed against other indicators of outbreak control, such as the increase in cumulative cases. as such, we suggest that early on in the outbreak, complete lockdowns may be unnecessary to control viral transmission, given the availability of other equally effective and more sustainable approaches. this is particularly important for the poorest countries. more than four-fifths of low-and lower-middle income countries have imposed complete lockdowns at the time of reported cases (compared to three-fifths in upper-middle income and less than one-third in high-income countries), with potentially severe socioeconomic consequences, having already been hit by the slump in global economic activity, including sharp declines in remittances, tourism receipts, and commodity revenues (world bank ). measures that recommend workplace closures or staying at home have been effective, implying that voluntary physical distancing has played an important role. in the united states, the decrease in mobility has been found to be largely voluntary, reflecting greater awareness of risk (maloney and taskin ). japan has achieved success without the need for a complete lockdown. clear public health messaging and voluntary practice of physical distancing shaped by cultural norms such as mask wearing, avoiding handshakes, and keeping silence when taking public transport and during events such as funerals, have been critical in limiting disease spread (sposato ) . overall, our analysis suggests that a combination of physical distancing measures may yield the most beneficial outcomes: international travel restrictions to limit imported cases from high-risk regions, encouraging voluntary social distancing, moderate forms of lockdown-type measures such as working from home and only leaving the house for necessary activities, and complete lockdowns in areas or provinces with more severe outbreaks. the implementation timeliness of these measures invariably depends on the country-specific context, including public acceptance and institutional capacity. countries that have been relatively successful share these common elements. despite an international travel hub and its close proximity to wuhan, early border control and the practice of personal protective behaviours, including the use of face masks, contributed to hong kong's success in controlling viral transmission (wong et al. ) . taiwan and brunei responded quickly by instituting border control and reassured the public by delivering timely information on the epidemic (wang et al. ; wong et al. ) . targeted lockdown-type measures in vietnam, coupled with mask wearing and consistent public health messaging, helped to contain disease spread (duc huynh ) . our study has several limitations. first, although we controlled for several country characteristics, our model could suffer from omitted variable bias as behavioural variables, such as mask wearing, were unaccounted for due to lack of data. second, beyond physical distancing measures, other npis such as j o u r n a l p r e -p r o o f early case isolation and aggressive contact tracing and quarantine are critical elements of a successful containment strategy (ferguson et al. ) , which we could not control for, again due to the lack of data. third, although a significant amount of effort has been put into the construction of the oxcgrt database with a global coverage and a systematic classification of government policies, there could be some reporting errors or data quality issues. moreover, our country-level analysis may miss the variation of policies implemented at the city/county/province level. nonetheless, the database is the most comprehensive to date. physical distancing measures have been applied in arguably every country that is fighting covid- . although modelling studies have shown the importance of physical distancing in stemming disease spread, few empirical studies have validated this finding. we provide empirical support and quantified the impact of physical distancing measures in lowering the reproduction number, particularly lockdowntype measures and border closures. moreover, we found that less stringent lockdown-type measures, such as encouraging working from home and staying home unless necessary were as effective as complete lockdowns in reducing transmission. however, all these measures have to be implemented early to be effective. as many countries are in the midst of de-escalating, we suggest that some combination of these measures-empirically justified-should be considered in containing subsequent waves of covid- . j o u r n a l p r e -p r o o f and jw wrote the manuscript with critical feedback from ln. all authors contributed to and approved the final manuscript. this research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors. not required. pandemic ? cmaj ; ( ) : the dependent variable is the average rt over the days since the date of the th case. rt, the timevarying reproduction number, is the expected number of secondary cases generated by a primary case at time t. the physical distancing measures are those that are in place on the date of the th case; refer to table for the specific measures. standard errors are in parenthesis. ***, **, and * represents statistical significance at the %, %, and % level respectively. n/a denotes not available. estimating the time-varying reproduction number of sars-cov- using national and subnational case counts covid- : cross-country heterogeneity in effectiveness of nonpharmaceutical interventions physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and meta analysis. the lancet a new framework and software to estimate time-varying reproduction numbers during epidemics the effect of containment measures on the covid- pandemic the covid- containment in vietnam: what are we doing? human mobility restrictions and the spread of the novel coronavirus ( -ncov) in china. nber working paper report -impact of nonpharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand did california's shelter-in-place order work? early coronavirus-related public health effects. nber working paper variation in government responses to covid blavatnik school of government working paper / . university of oxford introducing the outbreak threshold in epidemiology air passenger mobility, travel restrictions, and the transmission of the covid- pandemic between countries projecting the transmission dynamics of sars-cov- through the postpandemic period early dynamics of transmission and control of covid- : a mathematical modelling study impact of meteorological factors on the covid- transmission: a multi-city study in china determinants of social distancing and economic activity during covid- : a global view the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study impacts of social and economic factors on the transmission of coronavirus disease (covid- ) in china japan's halfhearted coronavirus measures are working anyway. foreign policy improved inference of time-varying reproduction numbers during infectious disease outbreaks evaluation of the lockdowns for the sars-cov- epidemic in italy and spain after one month follow up response to covid- in taiwan: big data analytics, new technology, and proactive testing coronavirus disease (covid- ) situation report - . geneva: world health organization journal of global health. . th case; rt, in column ( ) is the average rt over the days following the date of the th case; g in column ( ) is the growth rate of total cases between the date of the th case and the date days later. the stringency index is a composite index of physical distancing measures with a range of to mobility (from google community mobility reports) is the average percent change in visits to retail and recreation, grocery and pharmacy, parks, transit and workplaces on the date of the th case compared to the median baseline value of the corresponding day of the week during standard errors are in parenthesis. ***, **, and * represents statistical significance at the %, %, and % level we thank dr ying-ru lo, head of mission and who representative to malaysia, brunei darussalam and singapore, for useful comments and suggestions.j o u r n a l p r e -p r o o f all authors have no conflict of interest to declare. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- -ekhwb xb authors: mash, bob title: primary care management of the coronavirus (covid- ) date: - - journal: s afr fam pract ( ) doi: . /safp.v i . sha: doc_id: cord_uid: ekhwb xb south africa is in the grip of a novel coronavirus pandemic (covid- ). primary care providers are in the frontline. covid- is spread primarily by respiratory droplets contaminating surfaces and hands that then transmit the virus to another person’s respiratory system. the incubation period is – days and the majority of cases are mild. the most common symptoms are fever, cough and shortness of breath. older people and those with cardiopulmonary co-morbidities or immunological deficiency will be more at risk of severe disease. if people meet the case definition, the primary care provider should immediately adopt infection prevention and control measures. diagnosis is made by a rt-pcr test using respiratory secretions, usually nasopharyngeal and oropharyngeal swabs. mild cases can be managed at home with self-isolation, symptomatic treatment and follow-up if the disease worsens. contact tracing is very important. observed case fatality is between . % and %, but may be overestimated as mild cases are not always counted. primary care providers must give clear, accurate and consistent messages on infection prevention and control in communities and homes. severe acute respiratory syndrome coronavirus (sars-cov- ) was first detected in december . as i write this, the coronavirus disease (covid- ) pandemic is hitting south africa and events are unfolding fast as new measures are taken on a daily basis to contain its spread within communities. this article does not attempt to keep up with the latest announcements and news, but to share what we know about the virus and its clinical management. the article is targeted at primary care providers, general practitioners and family physicians. it is clear that containing the virus will require an all-of-society response and that the pandemic will impact multiple sectors such as health, business, tourism, education, and trade. our response is intended to contain the spread of the virus and slow the growth of the epidemic in order to allow the health system to cope. there is a risk of stigma for those infected and a plethora of misinformation, panic and anxiety. facilities and healthcare practices should adequately prepare themselves to cope with the epidemic, and a checklist, along with other resources, has been provided on the national institute of communicable diseases (nicd) website at http://www.nicd.ac.za/diseases-a-z-index/ covid- /covid- -resources/. the incubation period appears to be - days, with a median of days. the four most common symptoms are , : • fever ( %) • cough ( %) • difficulty breathing ( %) • fatigue and myalgia ( %) the most common presentation is myalgia, malaise, cough, and a low-grade fever. difficulty breathing may develop in the second week (average days) due to viral pneumonia. symptoms such as sore throat, runny nose, headache, chest pain, confusion, diarrhoea, nausea and vomiting are also possible, but much less common. most patients ( %) have more than one south africa is in the grip of a novel coronavirus pandemic . primary care providers are in the frontline. covid- is spread primarily by respiratory droplets contaminating surfaces and hands that then transmit the virus to another person's respiratory system. the incubation period is - days and the majority of cases are mild. the most common symptoms are fever, cough and shortness of breath. older people and those with cardiopulmonary comorbidities or immunological deficiency will be more at risk of severe disease. if people meet the case definition, the primary care provider should immediately adopt infection prevention and control measures. diagnosis is made by a rt-pcr test using respiratory secretions, usually nasopharyngeal and oropharyngeal swabs. mild cases can be managed at home with self-isolation, symptomatic treatment and follow-up if the disease worsens. contact tracing is very important. observed case fatality is between . % and %, but may be overestimated as mild cases are not always counted. primary care providers must give clear, accurate and consistent messages on infection prevention and control in communities and homes. keywords: coronavirus; covid- ; sars-cov- ; primary care; continuing medical education; clinical management. read online: scan this qr code with your smart phone or mobile device to read online. symptom, but only % have fever, cough and shortness of breath together. the cough is most often a dry cough. laboratory findings are not that helpful. the most consistent finding is a lymphopaenia, while c-reactive protein is unreliable. abnormalities are seen on x-ray in about % of patients and bilateral pneumonia is the commonest finding. the most consistent finding is a ground glass appearance due to interstitial infiltrates. it should be emphasised that the majority of people will have a mild self-limiting illness ( %), while % may be more severe with hypoxia and dyspnea. around % may become critically ill with respiratory failure, septic shock or multiorgan dysfunction. co-infection with another virus is uncommon and secondary bacterial infection is also less common than with influenza. patients should be treated in a separate room, although not necessarily an airborne infection isolation room, as measures to prevent contact and surface contamination are most important. the current case definition for a suspected case or person under investigation is : • person with acute respiratory illness (sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever irrespective of severity) this in combination with: • at least one of the following epidemiological criteria in the days prior to onset of symptoms: ß was in close contact with a confirmed or probable case of sars-cov- infection. ß had a history of travel to areas with presumed ongoing community transmission of sars-cov- . ß worked in, or attended, a healthcare facility where patients with sars-cov- infections were being treated. anyone admitted with a severe pneumonia of unknown aetiology should also be regarded as a possible case. the main diagnostic is a real-time reverse transcriptase polymerase chain reaction (rt-pcr) test on respiratory secretions. secretions are typically obtained by a nasopharyngeal (box ) and oropharyngeal swab (box ) placed in universal transport medium and kept cool (between °c - °c). the test can also be performed on sputum or tracheal aspirate if available. in hospital, bronchoalveolar lavage can also be used to collect a sample. serological testing on acute and convalescent serum samples can confirm infection, but is not useful for immediate diagnosis. all cases are notifiable as per the nicd: http://www.nicd. ac.za/notifiable-medical-conditions/. if someone meets the case definition given above then infection prevention and control measures should be immediately adopted and specimens taken for a diagnosis. mild disease can be managed at home (box ) with symptomatic treatment and self-isolation (box ). self-isolation can be ended when the patient's symptoms have improved or resolved and they have two consecutive negative rt-pcr tests at least - hours apart. if severe or critically ill, take or send them to an emergency or resuscitation area, keep waste in a designated area and do not share equipment with other patients. consult a more senior doctor. there is no specific treatment for covid- and treatment is supportive. treat fever and myalgia with paracetamol and offer oxygen if there is difficulty breathing. collecting a nasopharyngeal swab. • use only nylon or rayon flocked swabs with perforated, flexible plastic shaft. cotton-tipped, calcium alginate swabs or swabs with wooden shafts should not be used as residues present in these materials may inhibit pcr assays. • gently insert nasopharyngeal flocked swab into the nostril aiming backwards, along the floor of the nasal cavity, until the nasopharynx is reached. be careful not to insert swab upwards. if resistance is encountered during insertion of the swab, remove it and try the other nostril. the distance from the nose to the ear gives an estimate of the distance the swab should be inserted. • gently rotate the swab and hold in place for a few seconds. • slowly withdraw swab. • unscrew and remove the cap from the tube with transport medium. • insert the swab directly into a vial containing universal transport medium (utm). • break plastic shaft at the break point so that it can fit in the utm tube. • close the tube with the lid. • refrigerate at °c - °c. collecting an oropharyngeal swab. • keeping the same pair of gloves on, and holding the universal transport medium (utm) with the nasopharyngeal swab in, take a second flocked swab and open it at the plastic shaft. • ask the patient to tilt their head back and open mouth wide. • hold the tongue down with a tongue depressor. • have the patient say 'aahh' to elevate the uvula. • swab each tonsil first, then the posterior pharynx in a 'figure ' movement. • avoid swabbing the soft palate and do not touch the tongue with the swab tip as this procedure can induce the gag reflex. • insert the swab directly into the same utm vial containing the nasopharyngeal swab. • break plastic shaft at the break point so that it can fit in the utm tube. • close the tube with the lid. • refrigerate at °c - °c. differential diagnosis would include other viral pneumonia, such as from seasonal influenza, bacterial pneumonia (conventional and atypical organisms) and, in the hiv immunocompromised population, pneumocystis jirovecii pneumonia. critically ill patients may need intubation and ventilation and treatment in a high care or intensive care unit. once someone is diagnosed with covid- , contact tracing must start immediately. contacts are divided into two groups: • close contacts: a person having had face-to-face contact (≤ m) or was in a closed environment with a covid- case; this includes, amongst others, all persons living in the same household as a covid- case, and people working closely in the same environment as a case. a healthcare worker or other person providing direct care for a covid- case, while not wearing recommended personal protective equipment (ppe) (e.g. gowns, gloves, niosh-certified disposable n respirator, eye protection). a contact in an aircraft sitting within two seats (in any direction) of the covid- case, travel companions or persons providing care, and crew members serving in the section of the aircraft where the index case was seated. • casual contacts: anyone not meeting the definition for a close contact, but with possible exposure. close contacts should self-quarantine at home and be monitored by daily telephonic follow up for days for the development of symptoms. casual contacts should ensure social distancing and avoid non-essential contact and selfmonitor for days. if symptoms develop, they should be investigated as already described. observed case fatality rates may be higher than reality as it is difficult to count all of the mild cases making up the denominator. most observations place the overall case fatality rate as less than % (range . % - %) and modelling suggests between . % and . %. this is probably more than seasonal influenza, on a par with swine flu or measles, and considerably less than spanish flu, severe acute respiratory syndrome (sars) or middle east respiratory syndrome (mers). figures from china suggest that case fatality increases with age from . % in young adults to . % ( - years), % ( - years) and % (≥ years). in china, the overall mortality for males ( . %) was higher than females ( . %). people with cardiopulmonary co-morbidity (e.g. cardiovascular disease, diabetes, structural lung damage, tuberculosis or chronic obstructive pulmonary disease) have a higher morbidity and mortality. in south africa we can postulate that immunocompromised patients, particularly those with poorly controlled hiv, will be at higher risk, as might tobacco smokers. it is estimated that an infected person on average infects between and other people. this is on a par with the common cold, and far less than chickenpox or measles. infection is mostly by respiratory droplets contaminating surfaces and being passed by hand to one's own respiratory tract. infection is less common by airborne spread of droplets that are breathed in, although some hospital procedures may generate an aerosol (e.g. bilevel positive airway pressure machines). transmission is most likely when the person is symptomatic. transmission may be possible between asymptomatic people in the incubation period, but the extent of this is not known. viral shedding can be detected for - weeks after symptoms resolve, but the extent of infectivity is not known as particles detected may not be viable. • patients should stay in a specific room and use their own bathroom (if possible). patients should avoid unnecessary travel and unnecessary contact with other people. • where contact is unavoidable, the patient should wear a surgical mask, and maintain a distance of at least m (preferably m) from other people. • patients should clean their hands frequently with soap and water. alcohol-based sanitisers may also be used, provided they contain at least % alcohol. • patients should practise good cough and sneeze hygiene, by using a tissue, and then immediately discarding the tissue in a lined trash can, followed by washing hands immediately. • patients should not have visitors in their home. only those who live in their home should be allowed to stay. • if they live in shared accommodation (university halls of residence or similar) with a communal kitchen, bathroom and living area, they should stay in their room with the door closed, only coming out when necessary, wearing a face mask if they do so. • patients should avoid sharing household items such as dishes, cups, eating utensils and towels. after using any of these, the items should be thoroughly washed with soap and hot water. • all high-touch surfaces such as table tops, counters, toilets, phones, computers, etc. should be cleaned both appropriately and frequently. • if patients need to wash laundry at home before the results are available, then they should wash all laundry at the highest temperature compatible for the fabric using laundry detergent. this should be above °c. if possible, they should tumble dry and iron using the highest setting compatible with the fabric. disposable gloves and a plastic apron should be used when handling soiled materials, if possible, and all surfaces, as well as the area around the washing machine, should be cleaned. laundry should not be taken to a laundrette. the patient should wash their hands thoroughly with soap and water after handling dirty laundry (remove gloves first if used). • patients should know who to call if they develop any worsening symptoms, so that they can safely be reassessed, as % - % of patients may worsen. older patients (> years) or those with co-morbidities are most likely to worsen. • provide a patient information sheet. when handling a suspected or confirmed case you should isolate them in a single room or separate them from other patients by at least m and put a surgical mask on the patient. all staff providing clinical care should wear a surgical mask, apron and gloves. if you are going to perform a procedure that creates an aerosol then wear a fit-tested n respirator during the procedure instead of a surgical mask and eye protection as well as the apron and gloves. such procedures include taking nasopharyngeal or oropharyngeal swabs, sputum samples or tracheal aspirates. the single room should be adequately ventilated. medical equipment, including stethoscope or blood pressure cuffs and thermometers should be cleaned and disinfected before using on another patient. in the community, people should avoid infection by: • regularly washing hands for seconds with soap and water or hand sanitiser -particularly after visiting the bathroom, before and after eating, after blowing your nose, or coughing or sneezing. • avoiding touching the face or nose with uncleaned hands. • avoid close contact with sick people, stay at least m away from someone that is coughing. people should avoid spreading the infection: • social distancing, staying at home and avoiding contact with groups of people. • self-isolation if you are a contact of a case, a person under investigation or a confirmed case. • cough or sneeze into the crook of your elbow or into a tissue, which is disposed of immediately in a closed container. wash hands. • do not share with other people items such as clothing, bedding, towels, cell phones, uncovered food, books and magazines. • close the lid when you flush the toilet. • wipe frequently touched areas regularly with a disinfectant. • hand hygiene. • it is not useful to wear a surgical mask unless you are a suspected or confirmed case. the covid- epidemic may put even more pressure on healthcare workers who already feel overstretched. doctors and nurses who are caring for people with covid- will also be anxious about infecting themselves and taking the infection home to their families. the epidemic may be with us for several months and we will need to pace ourselves. mindful awareness of levels of stress and one's need to take a break is important in order to recharge during the day. we are not superhuman and also need to ensure sufficient sleep and food to continue working effectively. self-compassion and compassion for those around us in our teams is important. acknowledging and witnessing one another's experiences may help the team to cope with what can feel unreal. if necessary, make use of psychological support services. importation and human-to-human transmission of a novel coronavirus in vietnam epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study clinical features of patients infected with novel coronavirus in wuhan novel coronavirus pneumonia emergency response epidemiology team -ncov quick reference for health workers guidelines for case-finding, diagnosis, management and public health response in south africa clinical management of suspected or confirmed covid- disease clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected i declare that i have no financial or personal relationships that may have inappropriately influenced me in writing this article. i declare that i am the sole author of this research article. the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the authors. key: cord- -fmgsp authors: mu, di; gao, naiping; zhu, tong title: cfd investigation on the effects of wind and thermal wall-flow on pollutant transmission in a high-rise building date: - - journal: build environ doi: . /j.buildenv. . . sha: doc_id: cord_uid: fmgsp the solar radiation can heat the building outer surface, and then cause the upward natural convection flows adjacent to the wall. this phenomenon is especially obvious on a windless sunny day. the near wall thermal plume can drive gaseous pollutants released from lower floors to upper floors. combined with the effect of ambient approaching wind, the transmission routes will be very complicated. the paper aims to investigate the airflow patterns and pollutant transmission within a building under the effects of wind and thermal forces. a hypothetical twenty-storey slab-shape high-rise building in shanghai with single-sided natural ventilation is set as the research object in the present study. the intensity of solar radiation on a typical day during transition season is theoretically analysed. the temperature difference between the heated building envelope and the ambient air is calculated by a simplified heat balance model. finally, the tracer gas method is employed in the numerical simulation to analyse the influence of the wind and wall thermal plume flow on the inter-flat pollutant transmission characteristics. the results show that, the temperature difference between sunward and shady side wall is about k at noon on the designate day. when the source is set as a point with steady intensity and the buoyancy is stronger than or approximately equivalent to the wind, the reentry ratio of the flat immediately above the source can be around %. the environmental and public health issues are quite important concerns worldwide. understanding how contaminants continue to pose a significant threat to human health is highly emphasized. the airflow can carry hazardous air pollutants moving within a room or between rooms even buildings to influence the residents' health [ ] . such long-distance routes of transmission are called airborne transmission, which is reported to be one of the major respiratory syndrome transmission routes by numerous engineering and epidemiological studies [ ] [ ] [ ] [ ] . a lot of researches involving airflow patterns and aerosol-transmitted scenarios in multiscale area have been done by onsite full-scale measurements, reduced-scale wind/water tunnel experiments and computational fluid dynamics (cfd) techniques [ ] [ ] [ ] [ ] . for urban scale, the airflow is complicated because of the interaction with the inhomogeneous underlying surfaces [ ] . for street scale or building arrays, the microclimate in the street canyon or a neighborhood area will influence the natural ventilation process of buildings. the pollutants from vicinity, like traffic exhaust, dust and atmospheric aerosols, can easily penetrate into the indoor environment [ ] [ ] [ ] . for indoor circumstance, studies about the travel of airborne infectious pathogens in hospitals, schools, offices, homes, aircraft cabins and other indoor environment have been performed to illustrate the pollutant behavior and help to guide the air distribution design [ ] [ ] [ ] [ ] . li et al. [ ] reviewed over multidisciplinary studies and demonstrated the evidence of interconnection between building ventilation and the transmission of airborne infections. regarding the isolated building environment, a special transmission mode called vertical cross-floor contamination has been detected, the cooking fume from lower floor to upper one is a very telling example for such physical phenomena. the airborne fine droplets can be carried upwards by buoyancy-forced air convection flow [ ] . thus, the upward contaminant flow can take the potential health issues to the neighbor upstairs. this inter-flat infection path is firstly identified and explored after the severe acute respiratory syndromes (sars) clusters occurred in several high-rise residential buildings in hong kong, where the most affected occupants dwelled along the same vertical blocks on different storeys [ ] [ ] [ ] . li et al. implemented a study for the largest sars outbreak in ward a at prince of wales hospital [ ] and in block e of amoy garden [ ] . they also verified the probability to reduce airborne infection by optimizing the ventilation performance in the hospital wards [ ] . pressure control methods have been considered as an effective technology to control the transmission of infectious virus in hospital environment [ ] . nevertheless, such strategies are not feasible for those residential buildings without centralized ventilation systems. therefore, the process of pollutant interflat transmission in residential buildings is generally elaborated in the light of the mechanisms of natural ventilation. as to the contaminants in residential buildings, the proliferation and accumulation of harmful components or odors such as second hand tobacco smoke and volatile organic compounds (vocs) may also cause a health concern. several studies revealed that the passive tracer gas method can be used for reflecting the movement and distribution of gaseous pollutants or fine particles [ , ] . based on the above facts and work, niu et al. [ ] first proposed a possible airborne re-entry behavior of inter-flat cross-contamination driven by indoor/outdoor temperature difference under the condition of single-sided natural ventilation through open windows. previous onsite tracer gas tests and numerical simulations on buoyancy-forced inter-flat dispersion well explained and quantified the vertically upward transport of gaseous pollutants [ , ] . subsequently, a series of wind tunnel tests [ ] [ ] [ ] [ ] [ ] and numerical calculations [ ] [ ] [ ] were carefully carried out to explore the inter-flat transmission dominated by wind force. mao et al. [ ] reviewed the mechanisms and evaluation indexes for the airborne transmission and dispersion between flats by single-sided natural ventilation in high-rise residential buildings. in general, it has been revealed from the previous studies that in the single-sided ventilation mode, the airflow exchange and migration of contaminants within the building are normally driven by wind effect, buoyancy effect, or combined wind and buoyancy effect. the synoptic wind speed and direction have an essential impact on the strength of wind effect [ , ] . for the buoyancy effect, one inducement is the difference between indoor and outdoor temperature, the other one can be the thermal plume along the high-temperature walls heated by the solar radiation during the daytime, especially in windless or breezy sunny day [ ] . fan et al. [ ] measured boundary layer structure along the sunward surface of a sixteen-storey building in guangzhou, and concluded that the maximum velocity in the boundary layer at a height of m is about . - . m/s with absent wind and a wall/air temperature difference of - k. such strong thermal flow should not be neglected since the most common wind speed in the urban environment is in the range of . - . m/s [ ] . hence the buoyancy forces basically generated by solar radiation will be a particular consideration in this paper. over the past dozen years, several literature published about the combined wind and thermal flow patterns in urban region. xie et al. [ ] calculated a set of cfd simulation cases to investigate the impact of solar radiation on pollutant dispersion in different street layouts and estimated the relative strength of thermally/ mechanically induced flow using the ratio of gr/re . it was found that solar calefaction of a windward surface in a street canyon would give rise to an increase in pollutant concentration of the canyon. richards et al. [ ] performed wind tunnel measurements to simulate the thermal effects within the vicinity of a onefold building with leeward facade heating with the same parameter gr/re . they concluded that compared with the isothermal condition, the leeward recirculation lengths were shorter for both cases of gr/re = . and . (non-isothermal conditions). the velocity field and temperature distribution within the recirculation area were obviously different between two non-isothermal cases. larsen and heiselberg [ ] carried out a group of wind tunnel tests to create a scene of single-sided natural ventilation driven by wind pressure and temperature difference. they gave the velocity profiles and air-change rates in the openings, which greatly varied from wind force dominating to buoyant force governing. bangalee et al. [ ] set four different open window modes to investigate the flow structures of fluid-driven natural cross-ventilation. they found that a larger volumetric flow rate did not always ensure better replacement of the indoor air, and vice versa. dama and angeli [ ] designed three cases on the wind and buoyancy induced natural ventilation in double skin facades and compared two flow patterns derived from a simplified building simulation model and cfd. their results showed that cfd analysis can provide a deeper insight on surface-level heat transfer. most of the studies mainly paid attention to the heat and mass transfer around a single building block or building arrays, but there is a lack of research work on the cross-contamination mechanism through outer window flush driven by the combined buoyancy and wind effect. according to the wind-driven airflow around a bluff body under normal wind direction [ ] , there is a stagnation zone formed at the / height of the building on the windward side. the airflow above the stagnation zone goes toward the building top, while the airflow below the stagnation zone goes downward to the ground. the wall thermal plume can drive the gaseous pollutants released from lower unit to go to upper ones, especially in high-rise buildings. when the heated wall is on the windward side, the near wall airflow direction will change with the variation of the relative force of buoyancy and wind, notably in the approaching wind downward flow region in front of the building (fig. ). if the buoyant force is stronger, the flow patterns at the window opening should be inflows at the lower part and outflows at the upper part. when the wind force is stronger, the flow direction at the window opening can be downward. the purpose of the present work is to quantitatively explore the aforementioned phenomenon, namely the airflow field and pollutant transmission under effects of wind and thermal forces. a hypothetical twenty-storey high-rise building with single-sided ventilation is modelled as the research object. to quantitatively clarify the effect of solar radiation on the exterior wall surface of the building, the intensity of solar radiation on a certain day is calculated. since the single-sided natural ventilation is usually used in transition season, we select a typical day from transition season as representative. then the temperature difference between the heated wall and the ambient air is calculated using a simplified energy balance model of the building envelop. finally, to analyse the influence of the wind and wall thermal plume flow on the pollutant transmission characteristics, the tracer gas method is employed in the numerical simulation. the results of present work are helpful for a profound understanding of how solar radiation and near-wall flow affect the vertical inter-flat contaminant transmission routes, and the results also reveal the combined effect of wind force and buoyancy lift on the pollutant dispersion near the building. to quantify the strength of the natural convection adjacent to the wall, the temperature difference between the building surface and the ambient air should be clarified. the solar radiation intensity has a strong influence on the wall heating process, which needs to be quantified first. the wall temperature can be obtained by the heat balance calculation afterwards. the parameters of meteorology and building envelope refer to those of shanghai, a city of hot/humid climate zone in china. based on the method given by yan and zhao [ ] , the solar radiation intensity (w/m ) in the selected typical day on the horizontal plane and two vertical surfaces are calculated. the atmospheric transparency is set as . [ ] [ ] [ ] . the results are shown in table . during : to : , the solar radiation intensity on the sunward side is in a small range of - w/m , while that of the opposite side is about w/ m . for both the sunward and shady side vertical walls at noon, the received solar radiation intensity changes in a very small range, which can be seen as a steady-state condition for the following calculation. the temperature of outer wall surface increases after receiving the solar radiation. there is heat conduction between outer and inner wall surfaces, heat convection and radiation heat exchange with the ambient environment (fig. ) . because of the wall thermal inertia, the external wall will not reach the highest temperature when the solar radiation is the strongest, as well as the internal wall. in the present study, the timeaverage states are concerned. so the thermal lag on the temperatures of wall surfaces and indoor air is neglected in the theoretical calculation. for an isolated building in a relatively open terrain, suppose the temperature distribution on the outer wall surface is uniform, which means no vertical and horizontal temperature difference. the steady-state heat balance can be described as eq. ( ), q solar represents the solar radiation absorbed by the outer wall surface, w/m , the equation is as eq. ( ), where α w is the wall absorption. i sv is the received solar radiation by vertical outer wall, which includes the direction solar radiation, diffuse sky radiation and ground reflected solar radiation. q conduc represents the heat conduction from the outer wall surface to inner, w/m , the equation is as eq. ( ), where t wout is the temperature of outer wall and t win means the temperature of inner wall. δ w represents the wall thickness and λ is the thermal conductivity. δ w /λ is the thermal-conduction resistance, set as . m k/w [ ] . q convec is the heat convection exchange between the outer wall surface and the ambience, w/m , see eq. ( ), where t aout is the ambient air temperature, h out represents the convective heat transfer coefficient, w/(m ·k). according to ref. [ ] [ ] [ ] , the value of h out can be calculated by eq. ( ), when the coming wind is below m/s, the wind speed near the windward wall u w has a reference value of . m/s [ ] , so h out = . w/(m ·k). q lw is the longwave radiation heat exchange between the outer wall surface and the surroundings, w/m , here only the atmospheric longwave radiation to the sky is considered, see eq. ( ), where σ is the stephen boltzmann constant, . × − w/(m ·k ). ɛ w represents the system emissive of the outer wall surface longwave radiation, which is . . x sky is the angle factor between the vertical wall and the sky, which is . . t sky is the sky effective temperature, see eq. for the inner wall surface, suppose the temperature difference between surfaces is small, then the radiation heat transfer can be neglected. the heat balance equation is as following eq. ( ), q conducin represents the heat conduction received by the inner surface, w/m , the value is equal to q conduc . q convecin is the heat convection exchange between the inner wall surface and the indoor air, w/m . the convective heat transfer coefficient h in is set as w/(m ·k) [ ] . since a change of k for the indoor air temperature t ain only causes a . k variation of t wout , the value of t ain has a very small influence on the result of t wout . the given value of t ain is k higher than t aout in the calculation. based on the above equations and variable values, the temperature values of vertical sunward and shady side outer wall surfaces at noon can be calculated. the results are shown in table . the solar radiation intensity is an average value of : - : . it is observed that the temperature of the sunward outer surface is k higher than the shady side, and k higher than the outdoor air temperature. the calculation results are compared with the experimental data from wang et al. [ ] . note: the atmospheric transparency is . [ ] [ ] [ ] . during : to : , the south face is sunward, while the north face is shady side. they selected a m height rectangular student dormitory as the target building and measured several parameters including external wall temperature, wind speed, solar intensity and air temperature in april th and th in . during their test process, the solar radiation received by the south wall at : - : was in the range of - w/m , the wind speed was below m/s and the ambient temperature was - k. the temperature on the sunward surface varied with height. the largest difference between bottom and top was . k. the measured average temperature difference between the external south wall and ambient at : - : was - k. the calculation result in the present work is relatively small compared with the aforementioned measurements. in view of the other influence factors such as the wall thermal conductivity and radiation heat transfer, a k temperature difference can be considered as a reasonable value. in the following numerical simulation, considering the computation accuracy for airflow on the windward side and the mesh quantity, the heated sunward and shady side walls are placed at the windward side in different cases separately. that is, in some cases the windward wall is sunward and in some cases it is shady side. the cfd method is adopted by using a commercial program, fluent . . the building model and computational domain are shown in fig. . a hypothetical twenty-storey high-rise building is set as the research object. the whole building dimensions are m height(y), m length(z), m width(x). thus the building model is a slab one with the length-width ratio of . six rooms in this building are focused on, which fall into three groups and each group contains two neighboring units, respectively the nd, rd, th, th, th and th floors along the middle column of the building windward facade, which are located at the lower, middle and upper positon of the building separately. the dimensions of the concerned rooms are . m height(y), m length(z), . m width(x). the window dimensions of each room are height (y) × width(z) = . m × . m. the bottom of the window frame is . m above the room floor. the dimensions of each room and window are in accordance with our previous wind tunnel tests [ , ] . the computational domain for the concerned cases is a rectangular zone surrounding the objective building. the domain size is carefully designed, considering both efficiency and accuracy. according to franke et al. [ ] , the blockage ratio of the domain should be below %, which is about . % in the present study. as for the boundary condition, the windward surface is set as a heated wall with constant temperature listed in table . the other walls of the building are assigned with adiabatic surfaces. three different mesh systems of . , . , and . million grids are created and compared. the mesh refinement multiple is over . [ ] . the medium one is selected because the latter two mesh systems generate similar values for air velocity and temperature at several specific locations in the computational domain. the near wall mesh on windward side is refined and y + < , as shown in fig. . for the other surfaces, the value of y + is satisfied with < y + < . . the wind profile at the inlet of the computational domain is determined by the following power law eq. where h is the building height and u ref is the reference wind speed at the building height. the turbulence on the inlet boundary is characterized by turbulence intensity and length scale, which are % and m [ , ] , respectively. the turbulent effect is simulated by the renormalization group (rng) k-ɛ model [ ] with enhanced wall treatment. the pressure-velocity coupling algorithm is simple. the pressure interpolation method is a staggered scheme named presto. the discretization scheme used for the other variables except the pressure is second order upwind to ensure the computational precision. as to the pollutant transmission, a × − m tiny cube at the middle of the window is assigned as the source, located at the nd, th and th floor respectively in each case. propane (c h ) [ ] [ ] [ ] , as a tracer gas of gaseous pollutants, is generated at a constant mass flow rate of mg/ s [ , ] . it takes more than iterations for every simulation to reach the convergence. the calculations are terminated when the residuals do not show any further reduction and maintain at a reasonable level. the convergent values of residuals are as following: − for continuity, − for k, ɛ, x-, y-and z-velocity, − for concentration and − for energy. the solutions, such as the air velocity, temperature and concentration at specific points, are stable or appear steady quasi-periodic variations with acceptable fluctuation amplitudes. the amplitudes of velocity and concentration values at specific points show significant ones in the buoyancy driven windless case, which are all below %. considering the effects of window active status, wind speed, temperature difference and source location, totally cases are calculated. table shows sets of configuration based on the airflow field without the influence of source, and these cases are divided into four groups according to the window condition and the temperature difference. "c" means close window mode and "o" means open window mode. a k temperature difference represents that the building windward wall faces the sun, while a . k temperature difference means that the windward wall is the shady side. a dimensionless number, richardson number, is adopted to represent the relative strength of buoyancy lift and wind. the equation is as following eq. ( ), where β is the thermal expansion coefficient, ((t aout + t wout )/ ) − , k − , g is the gravity acceleration, . m/s and ν is the kinetic viscosity, . × − m /s. gr is the grashof number reflecting the intensity of natural convection and re is the reynolds number characterizing the forced convention flow patterns. the building height is selected as the characteristic length since the flow direction along the windward heated wall is one of the biggest concerns. according to the parameters shown in table , these cases contain the processes from natural convection to forced convection. the model involving pure wind driven inter-flat transmission has been validated in our previous paper [ ] . since the formation of airflow field around the present objected building is contributed to the combined effect of approaching wind and buoyancy, the mechanism contains the natural convection and wind driven airflow around a bluff body. the following two correlative cases are done to validate the accuracy of the numerical configuration. betts and bokhar [ ] carried out a series of experiments to investigate the natural convection of air in a tall cavity. a portion of results are selected to certify the applicability of the numerical methods to predict the natural convection flow adjacent to the wall. the experimental cavity was . m height (y), . m width (x) and . m depth (z), with a cold wall of . °c and a hot wall of . °c (fig. ) . thus the temperature difference between these two vertical walls was . °c, corresponding to a rayleigh number of . × . a k-type thermocouple was used for measuring the temperature distribution in the cavity and the accuracy was about . °c. the velocity field was measured by a laser doppler anemometry (lda) system. in the simulation configuration, the rng k-ɛ model including low-reynolds number effect is employed to solve the flow pattern. the enhanced wall treatment combining a two-layer model is used for improving the prediction of the boundary layer flow and the heat transfer in the near wall area. as shown in fig. , the wall-adjacent grids are refined with y + below . the profiles in fig. illustrate the comparisons of the temperature and velocity distribution results between the experiment and simulation at three different heights of the central x-y plane. it can be seen that the temperature rises up from the cold wall to the hot wall. the temperature profiles have two changes of gradient along the width direction, and the variation of temperature on each gradient is not exactly linear. for the velocity profiles, the positive values mean the airflow direction is upward, while the negative ones mean downward. thus the airflow moves upward near the hot wall and downward near the cold wall. the velocity magnitude near the walls is relatively larger than that at the central section of the cavity except the confined wall-adjacent regions where the airflow is adhered by the walls. there are some tendencies in common between the corresponding temperature and velocity lines. the first thing is that the gradient near walls is relatively higher than that at the central part. the next one is that at the upper height (y/ h = . ), the gradient near the hot wall is lower than that near the cold wall, and the simulation results at the middle part are slightly smaller than those at the near wall part. whereas at the lower height (y/ h = . ), the gradient near the hot wall is larger, and the simulation results at the middle part are mildly higher than at the near wall part. another one is that high quality of anti-symmetry shows in the midheight test line (y/h = . ) across the cavity. in general, although there are deviations between simulation and experimental results, the coincidence rate is acceptable enough. jiang et al. [ ] performed several sets of wind tunnel tests to measure the airflow patterns around a building-like cubic model with the dimensions of mm height (y) × mm length (x) × mm width (z), and the wall thickness of mm. the model had an opening on the windward side wall and the size was mm (y) × mm (z), resulting in wind-induced single-sided ventilation. the mean and fluctuating velocity distributions along vertical lines at the middle x-y plane, ranging from to mm in height, were measured by a onedimensional lda with a resolution of ± . m/s. the mean velocity fig. . the near wall meshes of the building model are locally densified with the minimum grid width of . mm. the rng k-ɛ model combined with enhanced wall treatment is used again for reproducing the airflow field feature. fig. shows the streamlines at the middle x-y section obtained by numerical simulation. the comparisons of four velocity profiles at the middle x-y section between simulation and experiment are shown in fig. . the positive value of u/u ref means the airflow direction is the plus x direction, and the negative one means the airflow move to the minus x direction. it can be seen that the backflow vortex at the bottom before the cubic model in fig. (a) (line -h/ ) and fig. (b) (line -h/ ), the reverse flow on the roof in fig. (c) (line h/ ) and the recirculation zone in the downstream region in fig. (d) (line . h) are captured by the present simulation. the simulated velocity distributions are satisfactory compared with the measurement except along the line . h behind the model. the minus simulated velocities at the lower section of the line . h mean that rng k-ɛ model predicts a mildly larger separation region in the wake flow of a bluff body. despite the slight inaccuracy of rng k-ɛ model in the prediction of the vortexshedding effects in the building wake, the calculations of the airflow field inside the cubic model and in the upstream areas near and beside to the windward façade agree well with the experimental results. it is sufficient to justify the application of rng k-ɛ model in the present main concern of inter-flat pollutant transmission on the windward side and the qualitative pollutant distribution behind the building. the work in this section contains two parts. for the isolated building scale, concerning the comprehensive performance of combined wind and buoyancy effect, part . gives the airflow streamlines and tracer gas mass fraction distribution around the building in the close window mode. since the heated wall is on the windward side, the thermal plume generated by natural ventilation is adjacent to the windward surface. part . firstly shows the concentration distribution along the windward wall in the open window mode. then for the room scale, part . illustrates the mean temperature and air exchange rate (ach) of each room. furthermore, an evaluation index, reentry ratio, is introduced in to analyse the inter-flat transmission characteristics. so this part mainly concerns the situations within the objective building. to compare the airflow patterns around the building in different cases, the velocity magnitude distribution on a portion of middle x-y plane for four representative close window mode cases are shown in fig. . in fig. (i ) , ri = . , the buoyancy lift is dominant. the thermal plume along the windward surface can be observed distinctly and the flow over the building roof moves downstream toward the high sky. the wall thermal flow velocity at the building height is up to . m/s. the airflow near the leeward surface is upward. since the thermal air from upstream flows to the upper space of downstream, the air density and pressure of the upper zone are smaller than those of the lower zone. that should be one of the main reasons for the upgrade airflow on the leeward side. in fig. (i ) , the coming wind speed at the building height is . m/s, the corresponding ri is . . it can be seen that the wall flow scope is weakened due to the suppression effect of the approaching wind. the airflow above the roof and behind the building is more likely to go to the downstream rather than to the higher altitude. a reverse vortex can be observed behind the building. in fig. (i ) , the corresponding ri is . . the airflow closely adhering to the windward wall still tends to go upward. the velocity magnitude near the windward wall is below . m/s. a small backflow vortex forms at the windward bottom area. as the approaching wind speed goes up, and the temperature difference is constant, a stagnation zone shows between th and th floor on the windward side, as shown in fig. (i ) . the downward flow below the stagnation zone has a velocity magnitude of about . m/s. the near wall upward thermal flow is severely restrained. the recirculation vortexes on the leeward side can be observed. because of the relatively high wind speed, the airflow pattern in this case is almost the same with the pure wind driven airflow around a bluff body [ ] . as to the pollutant dispersion characteristics, the tracer gas is released as a point source at a constant mass flow rate from one windward unit in each case. to observe the pollutant transmission routes and compare the concentration distributions, fig. gives the tracer gas in case i , the ri number is reduced from . to . , the infected area on the windward side reflects a peach-like shape around the source unit. both the vertical and horizontal transmissions are limited. part of tracer gas can be taken to the front of building because of the backflow at the windward bottom region, and then spread to the lateral side. in case i , the upward transmission on the windward side is totally suppressed by the downward coming wind, the tracer gas spread toward the ground and to the downstream with airflow, which means the buoyancy lift is weaker than the approaching wind at lower height. in case i , the infected area is mainly restricted at the bottom in front of the building, which is influenced by the bottom airflow vortex when the approaching wind is ruling. for the region behind the building, the concentration magnitude is mostly below − . in case i , although the thermal plume is dominant, the gentle wind still takes a part of tracer gas bypassing the lateral side to the leeward side during the upward transmission process along the windward surface. in case i and case i , where the ri number is . and . respectively, the affected phenomenon is relatively more obvious due to the horizontal dispersion from the windward side and the upward near wall airflow on the leeward side. when the ri number decreases to a relatively low value of . , in case i , the tracer gas mainly moves to the upstream with the bottom backflow and then to the lateral. when the source location is at the windward th floor, the vertical coverage area of − - range along the windward wall is from the source floor to above the building top and still shows a symmetric shape in case i . since the thermal flow speed is faster at the upper height of the building, the windward tracer gas is brought to high altitude quickly, so the leeward space is barely affected. in case i , the wind speed is higher than in case i , the effect of the near wall thermal flow is weakened. the tracer gas still goes up to the top of the building and the vertical coverage area is smaller than that in case i , while wider in horizontal direction. part of tracer gas can cross the building roof moving to the downstream and the upper space on the leeward side is affected. in case i , due to the low velocity along the windward wall, the tracer gas tends to spread in a small region around the source on the windward side. the region behind the building also suffers. as the ri number reduces to . in case i , the wind effect is dominant, the windward covered area seems like raindrop going downward because of the vertical downward airflow. the leeward space is affected, but slightly less than the former case. when the source location is at the windward th floor, the tracer gas wouldn't disperse downward since the thermal plume and the airflow above the stagnation zone are both upward. the units on the leeward side are softly affected in case i . overall, in the buoyancy lift governing cases (ii-ii ), the tracer gas mainly spreads from source unit to the upper ones on the windward side. in the two forces equivalent cases (ii ), the tracer gas mainly disperses horizontally from windward side to leeward side. in the wind force ruling cases (ii -ii ), the tracer gas mainly moves from the source unit to the lower ones on the windward side. fig. illustrates the tracer gas mass fraction distributions along the windward wall in each case of group ii and group iii. the overall tendency of group ii is similar with that of group i, the close window mode. in the windless case ii , the velocity of vertical upward flow adjacent to the wall increases with height. so compared with the source location at nd floor, the tracer gas releasing from the th floor moves upward faster and has a longer vertical coverage. when the source is located at the th floor, the tracer gas covers a wider range at the horizontal direction in case ii where the wind force is ruling than that in ii under buoyancy lift dominated condition. in group iii, the temperature difference is . k. under the same breeze condition, the vertical upward transmission in case iii is weaker than case ii due to the smaller thermal plume. in case iii and iii , the ri number is less than , the wind force is predominant. with the source releasing from the th floor, the shape of tracer gas coverage is like raindrop as mentioned above and the breadth of the raindrop decreases from case iii to iii , while the raindrop length increases. the reason is the growing downward airflow speed below the stagnation zone. for each room in the objective building, open window mode means single-sided natural ventilation. there's inside/outside heat transfer and air exchange through openings, resulting in inter-flat transmission. the mean indoor air temperature in each room of group ii is shown in fig. . since the heat conduction from the building envelope is neglected in the simulation, the indoor air temperature can be slightly underestimated. one common thing can be observed from the profiles that for two neighbor flats, the mean indoor air temperature in the upper one is higher than that in the lower one. as for the differences, the profiles of eight cases can be divided into three classes according to the variation tendencies of rd → th and th → th. class one contains three cases under the condition when the approaching wind speed is in the range of . m/s - . m/s and the buoyant lift dominates the near wall airflow. in this class, the mean indoor air temperature in the concerned room increases with height, which should contribute to a stronger thermal plume at a higher height. for a certain flat, the temperature level increases with ri number. the reason is that a higher approaching wind can take away more heat by convection, so less heat enters in the room, resulting in a relatively lower indoor temperature. class two refers to cases with the wind speed of . m/s and . m/s. the slope from rd to th floor is negative, while from th to th floor is positive. the reason might be that the thermal flow is suppressed below the stagnation zone, whereas it still exists at the higher region. class three contains three wind force dominated cases. the slopes of both rd → th and th → th are negative. since the downward airflow is strong at the lower half part of the building height, the wall heat also transfers downward. in general, the indoor/ambient air temperature difference is in the range of ke k. the ach (air exchange rate) is calculated by an integral method [ ] , see eq. ( ), where the u x is the velocity normal to the window, m/s, a represents the window area, m and vol is the room volume, m . since the airflow from outside is likely to form a small circuit at the opening window and the effective depth of fresh air is limited, the calculation result by this method is considered to be slightly higher than the tracer gas decay method, but the value is testified very close to the empirical models [ ] . the ach values of six concerned units in different cases are listed in fig. . in general, the ach values change in a big range of . - . when the ri numbers are approximate, the ach values in group ii are mostly higher than those in group iii. take case ii (u ref = . m/s, Δt= k, ri = . ) and iii (u ref = . m/s, Δt= . k, ri = . ) as an example, the ri numbers in these two cases are very close, while the ach value in the former case is . - . times that of in the latter case for the same room. the reference coming wind speed in the former case is twice that of in the latter one. the temperature difference between the outer windward wall and the ambient in case ii is higher than in case iii , so the thermal plume in case ii is stronger. these phenomena also appear in other corresponding conditions, such as case ii and case iii , case ii and case iii . this might be concluded that under the coupling effect of wind force and buoyancy lift, the relative magnitude of wind and thermal plume is quite crucial for ach value of the room. another thing can be found from fig. is that in the wind force predominant cases when ri < (ii , ii , iii , iii , ref , ref ), the ach values are lower than those in the buoyancy lift governing conditions or the two forces equivalent cases (ii -ii and iii -iii ), except for the th floor. to evaluate the potential inter-flat pollutant transmission, the quantifying method proposed by niu and tung [ ] is used for analyzing the possibility of reentry. the reentry ratio, r, is defined as the fraction of the exhaust air from a source unit i which reenters another unit j, which can be calculated by eq. ( ): m i-j represents the mass fraction of air that originates from the source room i and is present in another room j. in the present work, the pollutant concentration in a unit is represented by the mean ii ii ii ii ii ii ii ii iii iii iii iii iii iii iii ii ii ii ii ii ii ii ii iii iii iii iii iii iii iii ii ii ii ii ii ii ii ii iii iii iii iii iii iii iii concentration on the plane at the height of . m above the floor (human respiration plane), which is near the source height. m i-j can be directly calculated from the predicted average concentration values of the tracer gas on the two corresponding planes, m i-j = c j /c i . the calculated reentry ratios are shown in fig. . each column contains the results for a certain case. the six grid boxes along a column represent six concerned rooms in the objective building. the number in each grid box is the reentry ratio value for the corresponding room. the color of the grid box indicates the magnitude of the reentry ratio in this room. a high reentry ratio means a high cross contamination risk. only the infected units are discussed according to the figure. when the source is located at the windward nd floor, the rd floor is the most vulnerable. the reentry ratios for the third floor are almost or above % when the buoyancy force is stronger (case ii -case ii and case iii ), and then reduces to near or below % when the two forces are approximately equal at lower height (case ii , caseiii and case iii ). in case ii , ri = . , the reentry ratios for the middle units, the th and th floors, are around %, and the magnitude for the upper units are . %. when the ri is . , the reentry ratios for the middle units are in a range of . %- . %, and for the upper units are at a magnitude of . %. when the ri decreases to . , the reentry ratios for the middle units are below . %. in the isothermal cases, the tracer gas cannot go upward. when the source is released from the th floor, the reentry ratios for the th floor are over % once the ri numbers exceed . as to the lower units, the affected risk exists when the ri numbers are below , and the reentry ratios are generally below . %. in two isothermal cases, the values of r for the bottom two floors are close to ones in the wind effect dominated cases, ii , ii , iii and iii . for the upper two units, the reentry ratios are around % in case ii -case ii and case iii when ri > , while it is around . % in case iii when ri = . . and the values are below . % in case ii and case iii . comparison work has been done between the present work and anterior study by gao [ ] . in the previous numerical simulation of cascade effect, the indoor/outdoor temperature difference was k, and the ach values were both . in the two concerned rooms under windless condition. the pollutant was generated by a point source in the room with a constant mass flow rate of mg/s. it was found that in a windless day, around . % of the exhaust air from lower unit can re-enter into the upper one, while it's around % in the present work. different mechanisms can be one of the main reasons for the differences on reentry ratio values. in the indoor/outdoor temperature difference driven mode, cold flow enters from the lower part of the window and thermal flow exits from the upper part. the outflow from indoor will not go upward exactly along the wall but have a certain distance with the wall. in the present study, the upward thermal plume is adhering to the wall, so the tracer gas moving with airflow is easier brought into the upper floor, causing a higher reentry ratio. besides, the source locations and sampling methods of mean concentration may also have influences on the different values of reentry ratio. when the source location is at the th unit, only the th floor among the concerned rooms is influenced. the reentry ratios are all over %, especially when ri numbers are below , the r values can be up to % or even %. one thing should be noticed that, for two isothermal cases, both of the reentry ratios exceed %, more than twice those of buoyancy lift ruling cases (ii -ii , iii -iii ). compared with the buoyancy force dominant cases, the ach values in the isothermal cases are much smaller, which means the tracer gas is easier to stay in the source room rather than exhaust to another room. so the specific values m i-j are lower in the isothermal modes. according to eq. ( ), the reentry ratio is closely related to the concentration ratio and air exchange rate ratio of two units. take the buoyancy forced case i and isothermal case ref as the comparison objectives. in case i , the concentration ratio between th and th is about / while the ach ratio is almost . thus the reentry ratio is close to %. in case ref , the concentration ratio between th and th is about / while the ach ratio is approximate . so the reentry ratio is up to %. similarity rules can be found between isothermal cases and combined wind and buoyancy effects forces cases. in general, the upstairs residents should pay more attention to the intervention measures on the control of contamination risk. concerning the inter-flat pollutant transmission phenomenon, the impact of solar radiation has not been taken into account before. the present work pays attention to this factor, and also the coupling effect of approaching wind and near wall thermal plume originating from solar radiation. the different influences between the sunward surface and shady side surface are compared. richardson number is adopted to represent the combined effect of buoyancy lift and wind. the pollutant dispersion routes on the windward side under different ri number cases are analysed. for a m high building at noon of a typical day of transition season in shanghai, the near wall thermal plume speed at the building height is up to . m/s. for the pollutant transmission, the source is released from a point at a constant intensity. the following conclusions can be obtained: ( ) in a gentle breezy day, the tracer gas can spread vertically upward driven by thermal flow, from bottom to top in a high-rise building. the reentry ratio of the flat immediately above the source is around %. however, for the isothermal condition, the vertically upward transmission is only possible above the stagnation zone, and the reentry ratio can be up to more than %. for source location below the stagnation zone conditions, the pollutants disperse from the middle of the building to bottom with the downward flow in the isothermal cases. ( ) as to the comparisons between the sunward and shady side, both of two surfaces are placed at the windward side. take the gentle breeze cases as contrast objects, the results show that when the source is released from the bottom flat of the building, the vertical upward coverage length of tracer gas on the shady side surface is nearly half of that on the sunward surface. both of the reentry ratio values of the flat immediately above the source are almost %. ( ) in terms of the combined effect of wind and buoyancy forces, multiple cases are set for relevant analysis and investigation. the assigned dimensionless number, ri, is helpful for summarizing the results. when the source location is above the stagnation zone, the pollutant always goes up with the rising airflow. under the conditions of the source location below the stagnation zone, as the ri number decreases, the effect of force convection strengthens, so the pollutant spread from lower floor to upper ones is weakened. as the source located at the nd floor, the vertical upgrade transmission is suppressed once ri is lower than . when the source is released from the th floor, the vertical upward transmission is restrained once ri is smaller than . overall, the vertical upward transmission driven by wall thermal plume and the affected risks of leeward units from a windward source should not be overlooked in a high-rise building. there are still many limitations in the present study. the airflow patterns around an isolated building under different meteorological conditions are diverse. the direction of approaching wind has been proved as one of the main influencing factors, which is not considered in this paper. besides, the near wall flow features are distinct in daylight and night, also in different seasons. in addition, the calculations in this paper are based on steady-state simulations without considering the effect of time-dependent dynamics on heat and mass transfer. the selection of more applicable dimensionless numbers can be another issue, since a global ri number has limitations to reflect a local pollutant dispersion phenomenon for a large scale problem, such as in the high-rise building. further investigations are worthy to be done on the above matters. factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises spread and prevention of some common viral infections in community facilities and domestic homes improving the health of workers in indoor environments: priority research needs for a national occupational research agenda toward understanding the risk of secondary airborne infection: emission of respirable pathogens review of aerosol transmission of influenza a virus ventilation performance prediction for buildings: a method overview and recent applications dispersion of air pollutants around buildings: a review of past studies and their methodologies flow and dispersion in urban areas influence of regional pollution outflow on the concentrations of fine particulate matter and visibility in the coastal area of southern china indoor/outdoor relationship of fine particles less than . μm (pm . ) in residential homes locations in central indian region influence of atmospheric fine particulate matter (pm . ) pollution on indoor environment during winter in beijing risk assessment guidelines for infectious diseases transmitted on aircraft dispersion of exhaled droplet nuclei in a two-bed hospital ward with three different ventilation systems role of ventilation in airborne transmission of infectious agents in the built environment -a multidisciplinary systematic review field and wind tunnel investigations of plume dispersion around single surface obstacles evidence of airborne transmission of the severe acute respiratory syndrome virus role of air distribution in sars transmission during the largest nosocomial outbreak in hong kong multi-zone modeling of probable sars virus transmission by airflow between flats in block e, amoy gardens an evaluation of the ventilation performance of new sars isolation wards in nine hospitals in hong kong positive-pressure isolation and the prevention of invasive aspergillosis. what is the evidence? numerical investigation of particle diffusion in a clean room the airborne transmission of infection between flats in high-rise residential buildings: particle simulation on-site quantification of re-entry ratio of ventilation exhausts in multi-family residential buildings and implications numerical simulation of inter-flat air crosscontamination under the condition of single-sided natural ventilation the airborne transmission of infection between flats in high-rise residential buildings: tracer gas simulation investigation of indoor air pollutant dispersion and cross-contamination around a typical high-rise residential building: wind tunnel tests local characteristics of cross-unit contamination around high-rise building due to wind effect: mean concentration and infection risk assessment analysis of concentration fluctuations in gas dispersion around high-rise building for different incident wind directions wind tunnel tests of inter-flat pollutant transmission characteristics in a rectangular multi-storey residential building, part a: effect of wind direction wind tunnel tests of inter-flat pollutant transmission characteristics in a rectangular multi-storey residential building, part b: effect of source location numerical investigation of wind-induced airflow and interunit dispersion characteristics in multi-storey residential buildings a study of inter-unit dispersion around multi-storey buildings with single-sided ventilation under different wind directions large eddy simulation of wind-induced inter-unit dispersion around multi-storey buildings the airborne transmission of infection between flats in high-rise residential buildings: a review numerical simulation of dispersion around an isolated cubic building: model evaluation of rans and les ten questions concerning modeling of near-field pollutant dispersion in the built environment thermal energy balance analysis of the tokyo metropolitan area using a mesoscale meteorological model incorporating an urban canopy model natural convection flows along a -storey high-rise building experimental investigation of air flow and temperature distribution in deep urban canyons for natural ventilation purposes the impact of solar radiation and street layout on pollutant dispersion in street canyon wind tunnel experiments modelling the thermal effects within the vicinity of a single block building with leeward wall heating single-sided natural ventilation driven by wind pressure and temperature difference flow visualization, piv measurement and cfd calculation for fluid-driven natural cross-ventilation in a scale model wind and buoyancy driven natural ventilation in double skin facades american society of heating, refrigerating, and air-conditioning engineers building thermal process the state of atmospheric transparency over china analysis on the characteristics of atmospheric transparency in shanghai, annual meeting of the china meteorological society analysis on atmospheric transparency and direct solar radiation at noon practical design manual for heating and air conditioning procedure for determining heating and cooling loads for computerizing energy calculations, algorithms for building heat transfer subroutines ashrae a survey of wind convection coefficient correlations for building envelope energy systems' modeling field experiment study on the convective heat transfer coefficient on exterior surface of a building numerical study of a passive solar still with separate condenser experimental study of temperature distribution and heat transfer coefficient of vertical exterior surface of a building best practice guideline for the cfd simulation of flows in the urban environment perspective: a method for uniform reporting of grid refinement studies numerical heat transfer development of turbulence models for shear flows by a double expansion technique experiments on turbulent natural convection in an enclosed tall cavity natural ventilation in buildings: measurement in a wind tunnel and numerical simulation with large-eddy simulation this research is funded by the natural science foundation of china (no. ) and the fundamental research funds for the central universities of china. key: cord- -shmpfnrj authors: massad, eduardo; amaku, marcos; wilder-smith, annelies; costa dos santos, paulo cesar; struchiner, claudio jose; coutinho, francisco antonio bezerra title: two complementary model-based methods for calculating the risk of international spreading of a novel virus from the outbreak epicentre. the case of covid- date: - - journal: epidemiol infect doi: . /s sha: doc_id: cord_uid: shmpfnrj we present two complementary model-based methods for calculating the risk of international spread of the novel coronavirus sars-cov- from the outbreak epicentre. one model aims to calculate the number of cases that would be exported from an endemic country to disease-free regions by travellers. the second model calculates the probability that an infected traveller will generate at least one secondary autochthonous case in the visited country. although this paper focuses on the data from china, our methods can be adapted to calculate the risk of importation and subsequent outbreaks. we found an average r( ) = . (ranging from . to . ) and a risk of spreading of . latent individuals per travellers. in addition, one infective traveller would be able to generate at least one secondary autochthonous case in the visited country with a probability of %. given the extent of global travel patterns [ ] [ ] [ ] , newly emerging diseases can rapidly spread globally. in general, respiratory pathogens spread faster [ ] than vector-borne viruses [ , ] or those that require very close contact such as ebola [ ] or lassa [ ] . in late , a novel coronavirus, severe acute respiratory syndrome coronavirus (sars-cov- ) emerged in wuhan, china, which rapidly spread globally [ ] and caused epicentres of covid- disease in multiple countries. sars-cov- has a high reproduction rate and is easily transmitted via respiratory droplets among humans [ ] . population flow data between wuhan and other major cities in mainland china were clearly correlated with the number of cases exported from wuhan to other city clusters in mainland china before the lock-down [ ] . the potential for rapid international spread via air travel was enormous, and indeed first exportations followed high travel volumes to thailand, hong kong and singapore [ ] . as of june , more than million cases and more than deaths due to covid- have been reported in more than countries. the speed of spread depends on the air passenger volumes, the basic reproduction rate as a measure of transmissibility and the incubation time [ , ] . in this paper we present two complementary methods for calculating the risk of international spread of a new virus from an epicentre. the first method aims to calculate the number of cases that would be exported from an endemic country to disease-free regions by travellers. the second method calculates the probability that one of the infected travellers will generate at least one secondary autochthonous case in the visited country. the calculation for disease exportation is simpler than the calculation for infection importation. one difference is that in the case of disease importation travellers to endemic areas return infective to their home country, whereas in the case of disease exportation travellers depart from their endemic home country in a latent state. this latter assumption is based on the conjecture that symptomatic individuals do not travel. for asymptomatic travellers, their disease will manifest itself either during the flight or after arrival in the visited disease-free country dependent on the time of infection and incubation time. in the case of disease importation, the key parameter is the force of infection of the disease in the visited endemic country. in the case of disease exportation, the key parameter is the latency duration of the disease in the travellers' home country. in the case of disease importation latency is not too important and the model considers only susceptible, infected and removed individuals. on the other hand, in the case of disease exportation latency is important because it is assumed that infected and symptomatic individuals are either so sick that they do not manage to travel or are not allowed to board the plane due to exit screening. the models model . calculating the number of exported cases from an endemic country in this section we consider the case of infective travellers from an endemic country visiting a disease-free country, and so exporting the infection to the visited country. once arriving in the visited disease-free country those infective visitors may trigger an outbreak that can establish itself depending on the value of the basic reproduction number r of the infection in the disease-free country. if r is greater than one, the disease will spread. we will approach the problem with a deterministic formulation. the model is a classic susceptible-exposed-infected-removed (seir) model given by the following set of equations: where s h (t) is the number of susceptible individuals, e h (t) is the number of incubating and asymptomatic individuals, who have the disease but do not transmit it, i h (t) is the number of infectious individuals, r h (t) is the number of individuals recovered from infection and n h (t) = s h (t) + e h (t) + i h (t) + r h (t) is the total population. the parameters are β, the potentially infective contact rate, δ h , the inverse of the incubation (or latency) period, γ h , the duration of infectiousness and μ h and α h are the natural and disease-induced mortality rates, respectively. hence, the number of new infections per unit of time corresponds to the infection incidence, denotedλ(t) = βs h (i h (t)/n h (t)). the basic reproduction number, r , that is, the number of secondary infection produced by an infectious individual in an entirely susceptible population along his/her infectiousness period, associated with system ( ) is deduced in appendix a: for exportations, our interest is the prevalence of latent infections in the local population, from which, some individuals will travel already infected but not yet symptomatic. we estimated the disease prevalence in the population, that is, the number of infected individuals at each instant of time, i h (t), by integrating the third equation of equation ( ) to obtain [ ] : dividing i h (t) by the size of the local population, n h , we obtain the prevalence, that is, the proportion of infectious individuals, p i (t), in the endemic country as follows: on the other hand, multiplying the number of visitors to a given disease-free country by the prevalence of latent (infected but not infectious individuals), p e (t), generates the number of infected visitors or exportations of infections. integrating the second equation of ( ) yields the following quantity e h (t), exposed or latent individuals: dividing e h (t) the total population n h , yields the prevalence of infected but not yet infectious individuals in the home country as follows: to obtain this prevalence, the force of infection of the disease, that is, the number of new cases of infection per time unit, β (i h (t)/n h ), in this endemic region is a necessary input variable. the best information normally available is the notification rate of infectious individuals, δ h e h (this term is the number of individuals that evolve from the latent to the infectious state), provided by disease surveillance systems. equation ( ) will be used later in the paper. in this section we calculate the probability that an infected traveller (index case) from an endemic country arriving infective in a disease-free country generates a secondary autochthonous case. on arriving in the disease-free country each infected visitor will trigger an outbreak that will establish itself depending if the value of the basic reproduction number r of the infection is greater than one. since we are dealing with a low number of travellers, we need to approach the problem with a stochastic formulation. this model assumes that a density of one infected individual, i h (t ), arrives at t = t and remains infective for a period of (μ h + γ h + α h ) − days, that is where μ h , γ h and α h are the natural mortality rate, the recovery rate from infection and the disease-induced mortality rate, respectively. if the region where these infected travellers arrive had an area a the number of them is i h (t )a. eduardo massad et al. the total number of new cases infected by these travellers, Δ weeks after its introduction, new cases, is given by where β is the potentially infective contact per unit time between infected and one susceptible individuals, and s h and n h are the susceptible and total population, respectively. the risk of new cases invasion of a previously unaffected country, risk new cases , can be defined as the probability that at least one autochthonous case be produced by the arrival of one single infected individual at the area during his/her infectiousness period. for calculating this risk, we assumed a non-homogeneous simple birth process [ ] , which describes the propagation of the disease. let p n (t) be the probability of n cases. the probability generating function of such process is p(x, t) = n p n x n . after some calculation, we obtain the probability of x cases at time t [ , ] : we have assumed that the region to be studied has an area a, the number of infected travellers that arrived at t = t is a = i h (t ) a. we set a = from now on, that is, a single index case arrives at the non-affected area. expanding ( ) in powers of x we find that the risk, that is, the probability of having n infected individuals at time t, denoted risk new cases (n, t) as the risk (probability) of having no infected individuals is in equations ( a) and ( b) the probability of at least one autochthonous case in a previously unaffected region can be calculated as the tail probability, that is, the probability of the infection invading the previously non-affected area: for m = , equation ( ) to illustrate the models' performance, we consider the case of the outbreak of covid- in the province of hubei, china. at the time of writing, this province was responsible for approximately % of the total number of covid- cases in the world. we used data from the who website [ ] . as we use the case of hubei outbreak only to illustrate the models, we calculated the incidence of cases in that province by multiplying the total world number of daily cases of infections by . . as china modified the diagnostic criteria along the course of the outbreak, we used incidence data only until february . we begin by fitting a continuous function to the daily number of reported cases, that is, the incidence of new cases per time unit, δ h e h (t). we assume here that new cases are symptomatic cases. this assumption is probably very reasonable for the hubei epidemic because tests were developed only at the end of the hubei outbreak. the function has the bell-shaped form: where c i , (i = , …, ) are the fitting parameters and t is the time. the fitting of reported new cases per time unit to equation ( ) is shown in figure . note that equation ( ) fits the hubei covid- cases reasonably well. if equation ( ) is inserted into equation ( ), the covid- prevalence at each instant of time i h (t) is obtained. on the other hand, we can fit the initial exponential phase (e ϕt ) of the prevalence curve obtained in figure . it is then possible to estimate the value of r according to (see appendices a and b): where w is the rate of the exponential growth and m h , a h , g h and δ h as in equation ( ). the parameter values used to calculate r are shown in table . the value of the estimated r resulted in an average of . (ranging from . to . ) for the outbreak in the province of hubei. figure shows the fitting of data from hubei province to an exponential function. it is possible, in principle, to fit the parameters of system ( ) in order to retrieve the prevalence curve. the parameters then can be used to estimate the number and the prevalence of latent individuals (equations ( ) and ( )). alternatively, taken the covid- average latency period of days (i.e. δ h = ( / ) per day), e h (t) can be calculated by simply dividing equation ( ) by δ h , that is, from which it is possible to estimate the prevalence of asymptomatic latents in the population: the result for the case of covid- in the province of hubei is shown in figure . as an example in a cohort of travellers that depart from hubei at week the relative number of latent individuals carrying the covid- virus is of . individuals per travellers, which is much higher than ebola, for instance [ ] . in other words, out of travellers from that region, would be infected. next, we assume that one individual traveller from an endemic country (index case) visits a disease-free country and remains infective for a period of (μ h + γ h + α h ) − days. to calculate the probability of a secondary autochthonous case generated by each infected traveller, we used the incidence curve described above to calculate the probability generating function according to equation ( ) where the incidence is represented by the parameter λ(t). next, we calculate the values of parameters π and σ from equations ( a) and ( b) to estimate the probability that the infected traveller who imported the virus to his/her home country would generate at least one secondary case, according to equation ( ) . the result is %, that is, one single infective traveller would be able to generate at least one secondary case along his/her infectiousness period, with probability of %. note that the expected number of secondary case is the average value of the basic reproductive rate, that is, . . in this paper we propose two complementary models for calculating the risk of international spreading of the novel coronavirus sars-cov- from the initial epicentre of covid- in wuhan, china. one model addresses the case of disease exportation from the epidemic outbreak and considers a certain number of travellers leaving the epidemic region during the incubation period, thereby importing the virus into another country. the model is deterministic and was illustrated with the data from the initial outbreak in the province of hubei in china. the first model's simulation resulted in an average r = . (ranging from . to . ) and a risk of spreading of . latent individuals per travellers. if we consider the monthly number of travellers from the city of wuhan described by wu et al. [ ] to other asian countries of around , we should expect almost cases of the infection to these countries. the second model addresses the case of the probability of disease introduction in a disease-free country by an index case from the epidemic epicentre. the model considers the situation in which a single infected traveller from an epidemic region, acquires the infection and travels to a disease-free country where he/she can trigger a local outbreak. as we consider a single traveller we approach the case with a stochastic formulation. we simulated the model with the same case of the province of hubei in china and the results show that one single infective traveller would be able to generate at least one secondary autochthonous case in the visited country, along his/her infectiousness period, with a probability of %. this probability should be contrasted with the average number of secondary cases the traveller would generate at his/ her home country of . . the latter is the average basic reproduction number of covid- in the community of hubei and should not be essentially different elsewhere when the population is immunologically naïve and there is a homogenously mixing pattern of contact. in a stochastic context, even when r is greater than , there is a probability of extinction of the infection. moreover, the % risk of exportation means the probability that one traveller when arriving in the infectious condition would generate at least one secondary autochthonous case of covid- . some important limitations are worthwhile mentioning about our approach: our model assumes that only latent individuals travel. however, it is possible that some mildly symptomatic cases can escape from the screening measures at the moment of the travel. moreover, for example, a number of the earliest known exported cases travelled when sick. there are reports of travellers taking antipyretics to mask their fever, and then board the plane. however, the number of patients who travel with mild symptoms is likely to be very small when compared to the non-symptomatic latent individuals and this should not interfere with our results. furthermore, our results will depend on the incidence of covid- in the departing country. for example, during the peak of the covid- outbreak in europe, about − % of air passengers were sars-cov- positive on repatriation flights [ ] . from the modelling perspective an important limitation is the homogeneously mixing assumption. we are well aware of the many heterogeneities involved in transmission of a directly transmitted pathogen like sars-cov- . in addition, the deterministic approach of the exportation model is an approximation of the real dynamics involved in transmission. however, both limitations above do not invalidate the qualitative results of the models. considering the large number of people involved in the current epidemic the deterministic approach and the homogeneously mixing assumption can be considered as a good first approximation of the problem. however, heterogeneities can be introduced in the model using the techniques described in [ ] , and these heterogeneities could have significant influences in the quantitative results of our model. for instance, if variation in infectiousness would be included, the risk of spread could be lower on average, and the speed of the infection spread could be affected as well. equation ( ) assumes that only infected individuals, i h , are infectious. in fact, at least a fraction f of the exposed individuals, e h , may be infectious. so i h in the first and the second equations of system ( ) should be replaced with i h + fe h . equation (a ) in appendix a shows that e h ( ) and i h ( ) are related. this artificial feature can be removed by adding to equations (a ) and (a ) the initial infection terms e h ( )e −(m h +dh)t and i h ( )e −(m h +ah+g h )t , respectively, and solving them [ ] . another limitation of our approach concerns the data upon which we exemplify our application. we have access only to the global number of cases from the who website on covid- and in order to apply the model for the province of hubei we assumed that that region represents % of the global cases. hence, we assumed a direct proportionality of the cases to simulate the model on these data. in addition, we simulate the model until february because china modified the diagnostic criteria along the course of the outbreak. the incidence curve, however, had already started to wane at that time. moreover, we used the incidence data for the province of hubei only to exemplify the models, which could be applied, in principle, to other situations related to the spread of pathogens from outbreak epicentres. finally, it should be commented that the model assumes that the potentially infective contact rate β in the receptive country of the index cases is the same as in the province of hubei. in fact, β has a remarkable seasonality, being higher during winter time, declining throughout spring time into summer time. therefore, the probability of autochthonous cases is superestimated for receptive countries during the summer season. we believe that the models presented here may present a significant step forward in estimating the risk of importation of the novel coronavirus sars-cov- . financial support. this work was partially supported by the project zikaplan, funded by the european union's horizon research and innovation programme under grant agreement no. , by lim -hfmusp, cnpq andfapesp and fundacao butantan. global travel patterns: an overview global trends in air travel: implications for connectivity and resilience to infectious disease threats mapping global variation in human mobility pandemic preparedness and response − lessons from the h n influenza of imported dengue in spain: a nationwide analysis with predictive time series analyses severe dengue in travellers: pathogenesis, risk and clinical management ebola virus outbreak in north kivu and ituri provinces, democratic republic of congo, and the potential for further transmission through commercial air travel fifty years of imported lassa fever − a systematic review of primary and secondary cases potential for global spread of a novel coronavirus from china the reproductive number of covid- is higher compared to sars coronavirus the positive impact of lockdown in wuhan on containing the covid- outbreak in china estimating the probability of dengue virus introduction and secondary autochthonous cases in europe modeling importations and exportations of infectious diseases via travelers nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study high prevalence of sars-cov- infection in repatriation flights to greece from three european countries modelling heterogeneities in individual frailties in epidemic models ethical standards. not applicable (this is a purely theoretical work with no human subject involved). finding the basic reproduction number given by equation ( ) linearising the second and the third equations of the system ( ) assumingthe above system has non-trivial solution if the determinant of the unknown c and c are different from zero. we then obtain is greater than . thus, r is the basic reproduction number. also, now we relate the basic reproduction number (equation (a )) to the rate w of new cases n c (t) given by equationthe rate w is obtained by fitting equation (b ) to the initial exponential growth shown in figure .using equation (a ) we have that the number of new infected cases at t = is given bysince e h (t) and i h (t) are given by equations (a ) key: cord- -y jwu r authors: bao, changjun; dworkin,; ni, daxin; jiang, renjie; li, xian; wang, zhongze; shi, zhiyang; li, liang; wang, hua title: possible spread of adenovirus type from poultry to humans: indirect evidence from an outbreak in china date: - - journal: journal of nanjing medical university doi: . /s - ( ) - sha: doc_id: cord_uid: y jwu r abstract objective to explore the epidemiology and etiology for an outbreak of acute respiratory tract infection that occurred in one county of jiangsu province, china . methods only cases meeting the case definition were included in the study. we reviewed the medical records of the cases who were admitted to the local hospitals, interviewed cases by a standard questionnaire, and then described the epidemiologic features and analyzed risk factors by means of a case-control study. we collected pharyngeal swab specimens and sent them to different laboratories for isolation and culture. the laboratory used different detection methods such as dif, pcr, electron microscope examination and microneutralization assay, to identify and then type the positive specimens. results a total of cases were reported during the period from april to july , . the distribution of onset times presented two peaks, one in late may and another in middle june. the epidemic occurred mainly in the elementary and junior high schools in ten townships of one county, and the mean age of the cases was years (range months to years). the course of the disease was acute, and was characterized by fever accompanied with sore throat and tonsillitis. the wbc count of cases was normal or elevated. the mean duration of illness was days (range to days). no fatalities from illness were reported. a case-control study indicated that the possible risk factors were close contact with a case and/or poultry before onset and sharing of towels among members of the family. the typical cpe was observed through inoculating pharyngeal swab specimens into the hep- cell cultures in different laboratories. an infection of adenovirus type was verified by detecting positive specimens in different methods. conclusion this investigation demonstrated that the acute respiratory infection in cases was caused by adenovirus type . cases occurred in over schools in ten townships in , and the route of transmission was possibly close contact with cases or droplet transmission. adenovirus infections in humans are ubiquitous. adenovirus can cause coryza and pharyngitis in infants, upper respiratory, pharyngoconjunctival fever, diarrhea and haemorrhagic cystitis in children, acute respiratory disease and pneumonia in young adults, and epidemic keratoconjunctivitis in adults. adenovirus is a non-enveloped icosahedral dna virus. over serotypes have been discovered since the first successful adenovirus isolation in the s. at least fifty-one serotypes belong to the human adenovirus group and can be divided into six different subgroups (a-f). various clinical syndromes may result from infection depending on the viral serotype causing disease and the immunologic status of the host. we describe an outbreak of acute respiratory infection due to adenovirus type that occurred in one county of jiangsu province, china, during the period from april th to july th . cases experienced fever, cough, sore throat (pharyngitis) and tonsillitis. despite the mildness of the illness, it was characterized by high transmissibility and rapid spread. the clinical case definition: persons lived in the initial and neighborhood townships with illness onset after april and displaying the following symptoms: fever(axillary temperature over ), accompanied by manifestations of upper respiratory tract infection such as cough, headache, and sore throat, plus one or more of the followings: a. pharyngitis, tonsillitis, or conjunctivitis; b. normal or slightly increased wbc count; c. thickening lung veins by chest x-ray. students who were reported as having a fever (temperature measured by local hospital doctors) were required to report to the local county cdc and then were determined whether meeting the clinical case definition by epidemiologists. the clinical records of some cases who were admitted to the local township health care hospitals were reviewed. local public health personnel interviewed the cases with a standard questionnaire. pharyngeal swab specimens from children and adolescent patients who were diagnosed with acute upper respiratory tract infections at township a health care hospital during the outbreak from april through july were cultured for adenovirus. swab specimens of healthy children in the nanjing area, china were also included in the virological analysis were used as a control group during the same time period. acute and convalescent serum specimens collected from patients admitted to the local health care hospital were tested for adenovirus antibodies. other serum specimens were collected randomly from healthy students as control serum from the same schools and same grade but in different classes where no cases were reported. in addition, specimens from healthy animals such as swine, sheep, poultry, duck and five flies were collected randomly to test for adenovirus. nested polymerase chain reaction(pcr) was used to detect adenovirus dna [ ] . after amplification two times, the length of the amplificatory objective fragment was bp through % agarose electrophoresis to the amplification products, by using the ptc- pcr instrument. real-time pcr was also used to detect adenovirus dna [ ] using the rg- fluorescence quantitation pcr instrument. all the primers and probes needed in pcr detection were synthesized by shanghai bio-engineer biology company. enzyme-linked immunosorbent assay(elisa) was used to detect igm antibody in the patient s acute serums, using euroimmun company lot: kit. the enzyme standard equipment/instrument from sunrise company was used to measure the value of a with double waves(measurement wave nm, reference wave nm). test designed ru/ml, ru/ml, and ru/ml three adjust standard samples and the a value of sample was among the allowance scope. a sample with a value equal to or greater than ru/ml of standard sample a value was considered positive. pharyngeal swab specimens were inoculated into human esophageal type (hep- ) monolayer cell cultures(kindly provided by prof. wen-bo xu, institute for virosis control and prevention of national center for diseases control and prevention) [ ] . these cell cultures were maintained in eagle s minimum essential medium with % inactivated calf serum and % co at for days. the media were changed every days. the cell cultures were observed for ~ weeks under the inverted microscope for confirmation of characteristic cytopathic effect(cpe) by indirect immunofluorescent antibody assays. the cell cultures were examined for characteristic cytopathic effects(cpe) every day. after to days, the cell cultures with cpe continued to passage and the cell cultures without cpe stopped blind passage after generations. three continuous and stable generations with cpe was judged as adenoviral culture positive, and a blind passage for generations without cpe or that cell cultures coud not passage continuously and stably was considered negative. after a -fold dilution, the new isolate viral suspending fluids were inoculated into the hep- cell cultures. each dilution was divided and inoculated into four tubes and cultured with and % co . the tcid of the isolate viral strains was calculated according to the highest dilution degree with cpe present. the positive specimens were frozen and thawed repeatedly and then centrifugated for minutes with r/min. supernatant samples from positive specimens with typical cpe, after negative staining, were observed and filmed under the h- a type transmission electron microscope. adenovirus serotypes were determined by use of neutralization assay with type-specific reference antiserum (anti-adv serum, provided by prof. jing-ming zhao, capital paediatric institute, beijing) and hep- cells, and the neutralization antisera concentration was against -fold tcid . in addition, multi-primer real time pcr was also used to identify the serotype of isolated adenovirus with adenovirus type (ad ) and adenovirus type (ad ) as primers according to the methods used in reference [ ] . a microneutralization assay was used to detect the titer of patients paired (acute and convalescent period, interval of to weeks) serum with the identified adenoviral strains isolated from the patients admitted to the local health care hospital. a -fold or greater rise in titer between the acute and convalescent serum was considered diagnostic for a recent adenovirus infection. to identify risk factors for illness, a case-control study was performed. risk factors evaluated included contact with a case, contact with poultry, sharing towels in the family, egg and milk consumption, and hand-washing (frequent classified three grades as over times per day, ~ times per day and never). fifty cases and fifty-eight controls were randomly selected from two schools for the unmatched case-control study. a standardized questionnaire was administered to the cases and controls by face-to-face interview. data obtained form the epidemiologic investigation and review of clinical records was entered into microsoft excel , and spss . was used for statistical analysis. some of the pharyngeal swabs of the acute patients were sent to the laboratory of national centers for diseases control and prevention, beijing and key laboratory of public health safety, school of public health, fudan university, shanghai. as shown in the attack rate in school students in the townships was . %, but the attack rate in township a was . %, and township b was . %. for individual schools, the highest attack rate( . %) was one kindergarten in township c, and the second highest attack rate( . %) was the township a elementary school. for individual classes, the highest attack rate( . %) was class one, grade three in the township a elementary school. from epidemiologic analysis of one class in the junior high school and three elementary schools in township a, we found that the cases aggregated within classrooms, and the mean secondary attack rate in the classes ranged from . % to . %. the index patient had onset of illness on april , . most of the case onsets were from mid may through middle june. the first peak occurred in late may, and the second one occurred in mid june. after june , the cases began to decrease, and the reported number was less than cases per day in all ten townships. epidemiological surveys showed that there was no significant association and assembly among the new cases. initially, the epidemic was limited to township a, but township b was implicated on may , and township c on june , township d on june , township e and township f on june , township g and township h on june , township i on june , and township j on june . most of the cases were students and children under the age of years. the age of cases ranged from months to years, and most cases were between and years of age( . %)(shown in tab ). the median age of cases was years. the outbreak happened primarily in the elementary and junior high school although some pre-school children were involved. no adult cases were reported. the male to female ratio of cases was . to , and the similar ratio of students in schools was . to (rr= . , %ci: . ~ . ). the average incubation period was days(range to days) based on cases who had a definite history of having contact with other patients before onset. the clinical course in patients with acute respiratory infection characterized fever and cough as the first symptoms. the temperature fluctuated between . and . , and the mean duration of fever was . . days(range to days). most of the cases presented with a pattern of remittent fever or irregular fever and a few presented with a pattern of continued fever. case-control study significant factors for illness included contact with other cases, contact with poultry, and sharing towels among the members of a family. significant risk factors which were protective against illness were frequent hand-washing, egg consumption and milk consumption. (shown in tab ) stratification of data analysis was performed to evaluate confounding and interaction between the risk factors of contact with a case and contact with poultry. the results indicated that contact with poultry was still a significant risk factor despite removing the effect of contact with other cases. (shown in tab a total of pharyngeal swab specimens were collected from acutely ill patients admitted to the local health care hospital. nested pcr was used to test pharyngeal swab specimens collected from the patients and specimens from controls. the positive rate was %( / ) and %( / ), respectively. the difference between the two groups was statistically significant( = . , p < . ). real time pcr was also used to test another pharyngeal swab specimens from the acutely ill patients, and the positive rate was . %( / ). the detection rate between the two pcr methods to detect viral dna displayed no significant statistical difference. in addition, using the two same pcr test methods, other pathogens which can cause acute respiratory diseases(ards) such as influenza, parainfluenza, rsv, sars,coronavirus, enteric virus, mycoplasma pneumoniae had also been tested and been ruled out as the cause of illness. twenty acute period patient sera and ten control sera were tested for anti-adenovirus igm antibody. the positivity rate was %( / ) and %( / ), respectively. the detection rate of anti-adenovirus igm antibody in cases was higher than that in controls, but the results were not significant(fisher exact p-value equal to . ). eighteen viral strains were isolated from pharyngeal swabs through inoculating specimens into hep- cell cultures, and the isolation positivity rate was . %. the icid of isolated viral strains was between - and - . the typical cpe characters of adenovirus was observed under inverted microscope, where infected cells began swelling, became round, and developed into a grape cluster appearance in the end (fig , ) the typical cpe, presented with a crystal lattice array of many adenovirus-like particles in the cell nucleus observed under negative staining electronic microscope. this cpe occurred in ( . %) of pharyngeal swabs by means of hep- cell cultures in the laboratory of the school of public health, fudan university, but no cpe occurred in the cultures of mdck( th generation), llc-mk , vero e and mrc- ( th generation). the presence of adenovirus was further confirmed by direct immunofluorescence(dif) and polymerase chain reaction (pcr). the diameter of the isolate virus under the electron microscope was about nm with non-enveloped particles, which had an icosahedral cubic symmetric structure. the virus presented the typical morphology of adenovirus with a regular array of particles on the surface of triangle, two penton bases located on both sides and four hexon monomers located in the center of every line of the triangle(see fig ) . multi-premier pcr was used to test isolated viral strains using ad and ad primers, viral strains were detected as adenovirus type and no viral strains were detected as adenovirus type . an infection caused by adenovirus type was verified by entire gene sequence testing to nested pcr amplification products of positive specimens (from nine patients) in the laboratory of the national cdc of china. eighteen paired patient serums(acute and convalescent) were used to test neutralization titer with the isolate adenovirus type viral strain simultaneously. four-fold or a greater increase of neutralization titer in the acute period compared to the convalescent period occurred in pairs, and the conversion rate was . %. complement fixation tests were also used to detect the adenovirus neutralization titer of paired patient sera. for three paired specimens there was a four-fold or more rise in adenovirus neutralization titer, for three paired specimens there was a two-fold rise, for three paired specimens the titer rise was less than : , and for one paired specimens a four-fold decrease was found. adenovirus type (ad ) and ad have usually been associated with outbreaks of acute respiratory tract infections. the common types of adenovirus, which can lead to acute pharyngoconjunctival fever in children, have been type , , and [ ] . ad and ad are responsible for most epidemics or outbreaks of lrtis in children [ ] [ ] [ ] . three outbreaks caused by respiratory adenovirus infection were reported in taiwan, china from through . the epidemic viral strains isolated from the first outbreak that occurred from november through january was ad and ad . the second outbreak that occurred from september to october and the third outbreak that occurred in september were primarily ad [ ] . outbreaks caused by adenovirus have been reported in china and other counties in recent years [ ] [ ] [ ] . three pharyngoconjunctival fever outbreaks caused by adenovirus type were reported in china in [ ] [ ] [ ] . research has shown that ad is isolated more frequently than other adenovirus serotypes in subgroup b. in japan, isolation of ad from infants and children with acute gastroenteritis increased rapidly from . % in to % in [ ] . a survey of successive adenovirus outbreaks in children during an -year period indicated that mortality was . % [ ] . this investigation demonstrated that acute respiratory infection caused by adenovirus type caused the outbreak that occurred in over seventy schools in ten townships in . the outbreak was very unusual because of the large number of children affected and the wide geographic areas involved. the most common manifestations resulting from adenovirus infection involved the respiratory and gastrointestinal tracts, but cardiac, neurological, cutaneous, urinary, and lymphatic manifestation also occurred [ ] . in this outbreak, most of the cases had only signs and symptoms of respiratory diseases, some had manifestations of gastrointestinal tract diseases, but almost all of the cases had no extrapulmonary manifestation such as conjunctivitis, otitis media, lymphadenopathy, bleeding diathesis, anemia, hepatomegaly, splenomegaly, exanthema, neurologic signs and renal signs [ ] . the results of the epidemiological study indicated that contact with a case, sharing towels among members of a family, and contact with poultry before onset was the main risk factors. infection was probably transmitted through close contact and or droplet transmission, but fecal-oral transmission can not be excluded with evidences. a large poultry farm with a hennery was located in township a, the first township to be infected. the number of poultry was estimated at over million in total. most of the poultry houses were constructed near human residences and the poultry manure was piled on the road. adenovirus infection can be seen in people, poultry, cattle, dog, rats, pigs and monkeys and be classified as mastadenovirus and aviadenovirus. aviadenovirus or fowl adenovirus(fav) was once thought impossible to infect mammals including hu-man beings for the reason of strict host specificity [ ] . the results of the case-control study identified contact with poultry as one of the risk factors even after the effect of contact with cases was removed.(or adjust = . , % ci: . - . ). however, we did not detect out viral dna from animal specimens and five flies specimens using the fluorescence quantitation pcr assay. the lack of identifying virus in the poultry specimens could have been due to an insufficient number of poultry in our sample. also possibly, an outbreak had occurred in the poultry population but was over by the time when investigators began testing poultry. if infection in humans did result from close proximity to poultry farms, this has implications for avian influenza transmission as well. determining what specific kinds of contact with poultry put humans at greatest risk for such infections is very important for prevention. the etiologic agent causing the outbreak was verified by three different laboratories, but some risk factors are still unknown. a single infectious source was not identified through field epidemiological investigation and not enough evidence supports the idea that cases from all other townships were infected from township a. each adenovirus serotype can be further divided into genome types based on the patterns of digestion of their dna with restriction enzymes, and ad has been shown to have at least seven genome types with dna restriction analysis [ ] . among genome types of ad that have been identified to date, ad p are the prototype, and there are ad a through ad x and their variants. in china from to , the dominant genome types were ad a , with occasional isolates of ad a , ad a , and ad a [ ] . the viral etiology study of an acute conjunctivitis outbreak that happened in shenzhen areas in the summer of was performed by he yaqing, et al [ ] and also demonstrated that the main viral strain was ad a . in many outbreaks, the adenovirus viral strain can not be isolated and the genome type can not be identified [ ] . genome types may be useful for epidemiological studies. it is important to identify the variability in epidemic viral strains on time and relate specific strains with clinical manifestation and severity. analysis of genome types may be of clinical as well as epidemiological importance. future studies of adenovirus in poultry should examine if unique or similar strains circulate in that population. initially, a bacterium, such as streptococcus was suspected as the etiologic agent in this outbreak. support for a bacterial etiology included fever, sore throat, redness and swelling of the tonsil. also the majority of cases admitted to hospital had a white blood count presentation of normal to elevated(mainly neutrophils) and some of the cases presented aso rise in convalescent period( positive of specimens) compared to acute period(only positive of specimens). furthermore, streptococcus a( -hemolysis) was cultured and isolated from all pharyngeal swab specimens collected on may , . another three persons were cultured positive for streptococcus viridans by means of blood plate culture in the laboratory of shanghai fudan university. therefore, use of oral antibiotics as prophylaxis was suggested for the key population in early june. however, cases occurred in people who were given antibiotics. we eliminated streptococcus as a cause of illness based on the carrier rate of aso of % in healthy people, no cases had signs of rash, %~ % of cases had a recurrent fever some time after recovery, and streptococcus would be a very unusual cause of a large community outbreak [ ] . also the course of illness for most cases was still over days after use of antibiotics. concurrent infection of adenovirus and other pathogens has been reported [ ] . prevention measures included screening the students every morning and surveillance in clinics to identify patients as early as possible. patients were then isolated for at least two days after their symptoms disappeared and temperature returned to normal ranges in a hospital or at home and the epidemic was under control. before using antibiotics as prophylaxis the cause of illness should be verified through laboratory testing. before the confirmation of pathogen through viral culture, pcr detection of relating viral dna and serology methods, it was very difficult to distinguish adenoviral diseases from a bacterial diseases based on clinical manifestation, white blood cell count, and chest x-ray findings. although normal wbc count or leucopenia may be seen after a viral infection, the wbc count may be normal or may be elevated leukocytosis consisting mainly of neutrophils in the adenovirus infection. progression of the clinical course despite antibiotic therapy and presence of a normal or elevated wbc count suggests the possibility of adenovirus infection [ ] . in conclusion, the big outbreak caused by adenovirus type was confirmed first based on epidemiological characteristics and laboratory test results as performed in jiangsu province, china. our finding that contact with poultry may be one risk factor is possibly important because of our increased awareness of avian influenza and the risk of transmission from poultry. rapid typing by a general pcr combined with restriction endonuclease analysis rapid and quantitative detection of human adenovirus dna by real-time pcr typing specific identification of human adenovirus , , and by a multiplex pcr assay rapid subgenus identification of human adenovirus isolates by a general pcr respiratory adenoviral infections in children: a study of hospitalized cases in southern taiwan in - evolution of an adenovirus outbreak in a multidisciplinary children s hospital he ya-qing, zhang shao-hua, ning hao-ding. outbreak of children pharyngo conjunctivitis caused by adenovirus type a two decade survey of respiratory adenovirus in taiwan:the reemergence of adenovirus type and outbreak of adenovirus type in a neonatal intensive care unit the etiology study on the outbreak caused by respiratory tract adenovirus type in children etiology study on the pharyngo conjunctivitis caused by adenovirus type . huanan prevention outbreak of pharyngo conjunctivitis caused by adenovirus type in children molecular epidemiology of adenovirus infection among pediatric population with diarrhea in asia genome type analysis of adenovirus types and isolated during successive outbreaks of lower respiratory tract infections in children comparision of clinical characteristics of adenovirus and non-adenovirus pneumonia in children correlation between serum interleukin and c-reactive protein concentrations in patients with adenoviral respiratory infection practice of infectious diseases molecular epidemiology of adenovirus types and isolated from children with pneumonia in beijing viral etiology study of acute conjunctivitis report on the outbreak caused by adenovirus in children in indoor pool an etiology study on the outbreak of acute respiratory disease(ard) serological analysis and detection of multi-virus during the prevalence of flua in beijing severe adenovirus infection in children dong-tai county health bureau and dong-tai county center for diseases control and prevention are thanked for assisting in investigation and questionnaire data collection. national center for diseases control and prevention and shanghai medical university are thanked for assisting in viral culture and serotype.dr. austin, and michele mcgee, from the illinois department of public health(idph), we thank for their assistance with the review of this manuscript. key: cord- -tv nhojk authors: eltoukhy, abdelrahman e. e.; shaban, ibrahim abdelfadeel; chan, felix t. s.; abdel-aal, mohammad a. m. title: data analytics for predicting covid- cases in top affected countries: observations and recommendations date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: tv nhojk the outbreak of the novel coronavirus disease (covid- ) has adversely affected many countries in the world. the unexpected large number of covid- cases has disrupted the healthcare system in many countries and resulted in a shortage of bed spaces in the hospitals. consequently, predicting the number of covid- cases is imperative for governments to take appropriate actions. the number of covid- cases can be accurately predicted by considering historical data of reported cases alongside some external factors that affect the spread of the virus. in the literature, most of the existing prediction methods focus only on the historical data and overlook most of the external factors. hence, the number of covid- cases is inaccurately predicted. therefore, the main objective of this study is to simultaneously consider historical data and the external factors. this can be accomplished by adopting data analytics, which include developing a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. the viability and superiority of the developed algorithm are demonstrated by conducting experiments using data collected for top five affected countries in each continent. the results show an improved accuracy when compared with existing methods. moreover, the experiments are extended to make future prediction for the number of patients afflicted with covid- during the period from august until september . by using such predictions, both the government and people in the affected countries can take appropriate measures to resume pre-epidemic activities. by january , the covid- outbreak that originated in china has spread globally, with the number of infected persons rising to , , and a fatality of about , persons (https://www.worldometers.info/ coronavirus. last accessed june ). with the global spread of this infectious disease, the world health organization (who) designated it as a pandemic. besides the personal tragedies and casualties brought by this pandemic, the economic implications of this pandemic are significant. most of the affected countries locked their borders and ordered closure of factories, restaurants, big malls, and clubs. consequently, the world is suffering from an economic recession as the global economic losses are estimated to approach usd trillion (the economist, "covid carnage," march ). this dire situation motivates researchers to conduct research on covid- focusing on two main areas: medicine and engineering. of the narx neural network-based algorithm is described in section . sections and present the results of the experiments and conclusions of the study, respectively. before investigating the literature on covid- , we conducted a brief bibliographic search about covid- for two purposes. firstly, to find out the number of research works published on covid- and secondly, to identify the different research areas focusing on covid- . for those purposes, we used some keywords like covid- , novel coronavirus, and hubei pneumonia. it was found that more than research documents have been published on this topic. figure shows the different types of research documents published on covid- . by looking at figure , it can be observed that the vast majority of published works are in the form of journal articles, whereas a small number of research works have appeared as conference papers. this is because most conferences have been canceled due to the outbreak of the covid- pandemic [ ] . before investigating the literature on covid- , we conducted a brief bibliographic search about covid- for two purposes. firstly, to find out the number of research works published on covid- and secondly, to identify the different research areas focusing on covid- . for those purposes, we used some keywords like covid- , novel coronavirus, and hubei pneumonia. it was found that more than research documents have been published on this topic. figure shows the different types of research documents published on covid- . by looking at figure , it can be observed that the vast majority of published works are in the form of journal articles, whereas a small number of research works have appeared as conference papers. this is because most conferences have been canceled due to the outbreak of the covid- pandemic [ ] . bibliographic search is then continued to identify the different research areas focusing on covid- . the findings are presented as a pie chart in figure . as covid- is a novel disease, it is noticed that the majority of these research works (around %) has focused on medicine, whereas the rest are distributed in different areas, like biochemistry, social sciences, and engineering. these research areas are discussed in the next section. bibliographic search is then continued to identify the different research areas focusing on covid- . the findings are presented as a pie chart in figure . as covid- is a novel disease, it is noticed that the majority of these research works (around %) has focused on medicine, whereas the rest are distributed in different areas, like biochemistry, social sciences, and engineering. these research areas are discussed in the next section. in this section, we discuss the different research areas that have considered covid- , including medicine and engineering. in the field of medicine, most of the early research on covid- is focused on understanding the symptoms of the disease [ ] , characterizing it [ ] , and finally estimating its incubation periods [ ] . in addition, wang et al. [ ] have reported that the elderly are more likely to die from covid- , because of their underlying comorbidities [ ] . however, the virus attacks not only the elder people but also children [ ] . this means that everybody can be infected by covid- . moreover, zhuang et al. [ ] have showed that people infected with covid- are asymptomatic in many cases. in this section, we discuss the different research areas that have considered covid- , including medicine and engineering. in the field of medicine, most of the early research on covid- is focused on understanding the symptoms of the disease [ ] , characterizing it [ ] , and finally estimating its incubation periods [ ] . in addition, wang et al. [ ] have reported that the elderly are more likely to die from covid- , because of their underlying comorbidities [ ] . however, the virus attacks not only the elder people but also children [ ] . this means that everybody can be infected by covid- . moreover, zhuang et al. [ ] have showed that people infected with covid- are asymptomatic in many cases. covid- has a long incubation period of to days, and in many cases, patients are asymptomatic [ ] ; thus, it has a high infection rate. therefore, it is of great importance to predict and estimate the number of people affected by covid- . this motivates researchers to focus on the engineering aspect of this disease, that is, the prediction of covid- cases. usually, prediction can be conducted using traditional statistical methods. for example, remuzzi and remuzzi [ ] and tuite et al. [ ] have utilized the statistical methods to predict the number of covid- cases in italy. similarly, the number of covid- cases has been predicted in different countries/territories such as, iran [ , ] , spain, and france [ ] . beside the statistical methods as mentioned above, the mathematical modeling and simulation including logistic growth and susceptible-infected-recovered (sir-model) have been utilized to predict the new covid- cases in china [ ] and saudi arabia [ ] . moreover, papastefanopoulos et al. [ ] have investigated and compared the accuracy of six time-series forecasting approaches, namely, arima, holt-winters additive model (hwaas), tbat, facebook's prophet, deepar, and n-beats, in predicting the progression of covid- . in a similar work, hernandez-matamoros et al. [ ] have developed an arima model to predict the spread of the virus. the developed model consists of arima parameters, including the population of the country, the number of infected cases, and polynomial functions. ivorra et al. [ ] have proposed a new mathematical model for predicting the spread covid- outbreak in china. the proposed model, θ-seihrd model, considers a fraction θ of detected cases over the realized total infected cases. there are other studies that focus on collecting and analyzing posts related to covid- from social media sites. this is because keyword search trends related to covid- on search engines proved tremendously helpful in predicting and monitoring the spread of the virus outbreak. qin et covid- has a long incubation period of to days, and in many cases, patients are asymptomatic [ ] ; thus, it has a high infection rate. therefore, it is of great importance to predict and estimate the number of people affected by covid- . this motivates researchers to focus on the engineering aspect of this disease, that is, the prediction of covid- cases. usually, prediction can be conducted using traditional statistical methods. for example, remuzzi and remuzzi [ ] and tuite et al. [ ] have utilized the statistical methods to predict the number of covid- cases in italy. similarly, the number of covid- cases has been predicted in different countries/territories such as, iran [ , ] , spain, and france [ ] . beside the statistical methods as mentioned above, the mathematical modeling and simulation including logistic growth and susceptible-infected-recovered (sir-model) have been utilized to predict the new covid- cases in china [ ] and saudi arabia [ ] . moreover, papastefanopoulos et al. [ ] have investigated and compared the accuracy of six time-series forecasting approaches, namely, arima, holt-winters additive model (hwaas), tbat, facebook's prophet, deepar, and n-beats, in predicting the progression of covid- . in a similar work, hernandez-matamoros et al. [ ] have developed an arima model to predict the spread of the virus. the developed model consists of arima parameters, including the population of the country, the number of infected cases, and polynomial functions. ivorra et al. [ ] have proposed a new mathematical model for predicting the spread covid- outbreak in china. the proposed model, θ-seihrd model, considers a fraction θ of detected cases over the realized total infected cases. there are other studies that focus on collecting and analyzing posts related to covid- from social media sites. this is because keyword search trends related to covid- on search engines proved tremendously helpful in predicting and monitoring the spread of the virus outbreak. qin et al. [ ] developed a prediction technique based on the lagged series of social media search indexes to forecast the number of new suspected covid- cases. the considered social media search indexes include common covid- symptoms such as dry cough, fever, pneumonia, etc. in another study by li et al. [ ] , the daily trend data related to specific keyword search such as "coronavirus" and "pneumonia", has been acquired from google trends, baidu index, and sina weibo index search engines to investigate and monitor new covid- cases. li et al. [ ] have collected data on the posts related to covid- that are posted by chinese users on weibo using an automated python programming script. the collected data have been analyzed quantitatively and qualitatively in order to recognize trends and characterize key themes. other applications using social media to predict covid- cases have been reported by shen et al. [ ] and ayyoubzadeh et al. [ ] the major drawback of statistical methods and mathematical modeling is their inability to consider massive amounts of data. this leads to poor prediction of the number of covid- cases. this drawback can be avoided by using data analytics, which is explained in the next section. data analytics is one of the efficient tools in discovering the relationships, trends, and other useful information existing in a body of data. the number of data analytics tools is large. among these tools, the neural network is one of the most efficient tools in uncovering the relationship between an output (i.e., response) and multiple inputs (i.e., indicators) [ , ] . this efficiency has been applied in handling different applications, including stock price forecasting in the financial industry [ ] , flight delay prediction in aviation industry [ ] [ ] [ ] , organ prediction in healthcare sector [ ] , and demand forecasting in the railway industry [ ] . these previous studies reveal the importance of data analytics for prediction purposes. this motivates researchers to adopt data analytics in the domain of covid- . for example, chen et al. [ ] utilized data analytics to predict the number of covid- cases to avoid overwhelming hospital capacity in taiwan. the pitfall of this research work is that it has only focused on historical data of the number of covid- cases while considering a limited number of factors, like travel and occupation. another research work by zhou et al. [ ] coupled geographic information system (gis) and data analytics together to identify the infection network of covid- . additionally, machine learning and artificial intelligence tools have been utilized by many studies to develop covid- prediction approaches. wieczorek et al. [ ] have developed a forecasting model for covid- new cases based on the deep architecture of neural network using nadam training model. however, the pitfall of this study is the focus on one dataset, called total number of confirmed covid- cases, while overlooking many other factors. magesh et al. [ ] have proposed an ai-based algorithm for predicting covid- cases using a hybrid recurrent neural network (rnn) with a long short-term memory (lstm) model. the authors have conducted their experiments while considering some demographic factors like sex, age, and temperature. indeed, many other social factors were not considered in their model. pinter et al. [ ] have developed a hybrid machine learning approach to forecast covid- cases in hungary. the proposed hybrid approach encompasses the adaptive network-based fuzzy inference system and multi-layered perceptron-imperialist competitive algorithm. a machine learning-based approach for predicting covid- new cases has been proposed in the study by tuli et al. [ ] , who have used an iterative weighting for fitting generalized inverse weibull distribution. for extensive study and more details about the forecasting approaches for covid- , the interested readers are referred to the work by bragazzi et al. [ ] who have reviewed the potentials of applying artificial intelligent and big data based approaches in predicting and managing the covid- pandemic outbreak. these previous studies show successful application of data analytics in multiple areas. therefore, it is reasonable to use data analytics in this study. from the above, it is clear that most of the data analytics studies have focused on historical data of confirmed covid- cases, while some studies have considered some factors like temperature and patient sex. indeed, many other important external factors that affect the spread of the disease have been completely ignored. these important factors include population, median age index, public and private healthcare expenditure, air quality as a co trend, seasonality as month of data collection, number of arrivals in the country/territory, and education index. this results in a poor prediction of the number of covid- cases. a thorough examination of the literature reveals some observations, which can be outlined as follows. first, there is no previous study that simultaneously considers the historical data of the number of covid- cases and most of the external factors that affect the spread of the virus. secondly, there is no research work that provides future prediction of the number of covid- cases using data analytics techniques. therefore, efforts of the government to improve the healthcare system in the affected countries are greatly hampered. consequently, in this research work, we have tried to fill this gap by proposing a data analytics algorithm, in which all the aforementioned features can be simultaneously considered. this paper has the following contributions. firstly, in contrast to the existing approach [ , ] , which only focuses on the historical data of persons infected with covid- , we propose a more robust approach. our approach simultaneously considers the historical data of covid- cases alongside most of the external factors that affect the spread of the disease. these external factors include population, median age index, public and private healthcare expenditure, air quality as a co trend, seasonality as month of data collection, number of arrivals in the country/territory, and education index. to consider all those massive number of factors, we develop a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. this algorithm is developed because it is the most appropriate one to handle time-based factors, like the number of covid- cases. moreover, narx algorithms have been successfully applied in different research areas, as shown in section . . second, instead of predicting the number of covid- cases in one or two countries [ ] [ ] [ ] , we use our algorithm to predict the number of covid- in multiple countries, including top five affected countries in each continent. this is fruitful as it gives wide information about the spread of covid- in different parts of the world. lastly, it has been observed in the literature that most research papers have not provided future prediction of the number of covid- cases. as opposed to these previous research papers, we use the trained data produced from our algorithm to make future prediction of the number of covid- cases. by using such predictions, both the government and people in the affected countries can take appropriate measures to resume pre-epidemic activities. in this section, we present how data analytics can be used in predicting the new daily cases of covid- . instead of using the traditional approaches, which either focus on historical data or assume a normal distribution for the number of daily cases, we use a data analytics approach. in particular, this approach has the ability to consider a massive amount of data, including historical data of daily cases besides other external factors. the proposed methodology includes a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. the main steps of this algorithm are presented as follows: step : collecting the data. the data have been collected from online websites, including "worldometers" [ ] , "our world in data" [ ] , "world bank open data" [ ] , and the official website of the world health organization (who). besides, human development reports have been used to pick other kind of information, like median age and education index [ ] . the scope of this study includes collecting data for about countries/territories by focusing on two types of data: main data and other external factors. the main data include considering the number of confirmed coronavirus disease cases/day, the number of deaths due to coronavirus disease/day, and the total number of confirmed cases [ , ] . the external factors, on the other hand, include considering the factors that affect the spread of coronavirus disease. note that the data have been collected for about days, from december until august . this leads naturally to set the size of data at . step : preprocessing the data. while collecting the data, it was observed that data were not always available for the whole countries/territories. to alleviate this situation, a refinement was performed by ruling out any countries/territories that suffer from data unavailability. this results in cancelling around countries/territories, so that only countries/territories have been considered. our preliminary goal is to predict the new cases for all countries/territories. however, this is not reasonable for two reasons. firstly, it is not possible to present all the results in a single study due to page limitation. secondly, it is computationally expensive to run this algorithm for countries/territories. for the above reasons, we have limited our scope to considering the most affected countries in each continent. by doing so, the top five affected countries/territories have been considered from each continent. more details are presented in section . step : identifying the input sets. these sets contain historical data of some information alongside the external factors. these sets can be outlined as follows: i. main set, which includes two main information: the number of deaths due to coronavirus disease/day and the total number of confirmed cases; ii. external factor set that comprises the factors that affect the spread of coronavirus including population [ ] , median age index [ ] , public and private healthcare expenditure [ ] , air quality as a co trend [ ] , number of arrivals in the countries/territories [ ] , and education index [ ] . there is another factor that should be considered, called seasonality. before incorporating this factor in the model, it should be clarified here that, in most countries, we can find cities with different seasons. for example, iran has four seasons in its different cities [ ] . other examples include usa, china, saudi arabia, and egypt. this observation indicates that, to consider the seasonality using seasons as a factor, the cities should be the scope of the study. since the scope of this study is not cities but the countries, seasonality factor using seasons themselves cannot be considered in our algorithm. to find a compromise for this situation, the month of collecting data is selected to capture the seasonality in the proposed algorithm. it should be noted that the main data for the daily covid- cases have been collected from the website "our world in data", corrected through the website "worldometers". next, the data have been doublechecked and refined by the data from the official website of who. in addition, because the considerable predictors are diverted, and they are not available on one database, their data have been collected from several websites. in further details, the data that have been collected from the website "world bank open data" are the median age, number of arrivals, and health expenditure as a percentage of gdp [ ] , while the education index has been collected from united nations development programme [ ] . step : test of hypothesis using regression analysis. since our study goal is to accurately predict the number of covid- cases, we should focus on the most influential external factors. to do so, test of hypotheses using regression analysis should be conducted for each external factor. these hypotheses can be outlined as follows: after outlining the test of hypothesis, the regression analysis has been conducted, in which the p-value is calculated. if the p-value < . , which is the significance level in this study, we reject the null hypothesis h and go in favor of the alternative hypothesis h . if p-value ≥ . , we cannot reject the null hypothesis h . by doing so, the significant factors have been picked, including all the previous external factors except public health expenditure and air quality as a co trend. more details about test of hypothesis using regression analysis are shown in section . . step : designing the neural network structure. we have utilized the feedforward time-delay neural network as this structure has been commonly used in the literature due to its efficiency [ ] . this network is composed of three main layers: input, hidden, and output. regarding the activation function, the sigmoid function has been selected because it is efficient in reflecting the non-linear relationship among multiple factors. step : training the neural network. to achieve this goal, the supervised learning method has been adopted. in this method, % of the data have been used for training purposes, whereas the rest have been reserved for validation and testing purposes. step : predicting new cases of covid- . the trained data, known as the output of the network, have been used to predict the new cases of covid- in the period from august until september . figure represents diagrammatically the structure of the neural network. it should be noted that neural network is a common artificial intelligence technique. indeed, this technique uses the idea of information flow between brain neurons, which is represented as a network via arrows and nodes. arrows represent the input details and the output information, whereas nodes stand for the neurons. usually, the nodes or neurons receive the input data, then analyze it to give suitable outputs. this straightforward movement of data from several input points is the simplest way to obtain an output. such network structure is called feedforward neural network (ff), which has been used in our algorithm. usually, feedforward neural network is either single layer feedforward neural network, as shown in the left-hand side of figure , or multiple layers feedforward neural network, as shown in the right-hand side of figure . in multiple layers feedforward neural network, the input layer is indirectly connected with the output layer by means of hidden layers (i.e., each layer in the network is in connection with the next layer). in particular, the input is connected to the first hidden layer, and this layer is connected to the next hidden layer. these connections move forward in this sequence until reaching to the output layer. as mentioned earlier, the neural network structure adopted in this research is feedforward neural network with multiple layers. the type of the neural network is narx neural network. the analysis of this network is based on the time-series modeling [ ] . this means that it uses data obtained at successive times in the past in order to predict data in the future. therefore, it is commonly used as a predicting tool in different fields, such as predicting the solar radiations per day [ ] , predicting electricity price of day-ahead [ ] , and the prediction of bearing life [ ] . as any neural network, input data are processed in the narx neural network through the nodes using the following function: where a(t) is the output of the narx neural network at time t. on the other hand, the values a(t − ), a(t − ), . . . ., a(t − n) are the outputs of the narx neural network in the past, whereas n a is the number of delays in the output. the values b(t − ). b(t − ), . . . , b(t − n b ) are the inputs of narx neural network, and n b is the delay in the inputs. from this equation, it is clear that, in order to get an output a(t) at time t, not only the input data is used but also the output data of the past should be used as well. for example, in order to predict the number of covid- tomorrow a(t), the input data besides, the predicted data of today and the past few days a(t − ), a(t − ), . . . ., a(t − n a ) will be used as well. as mentioned earlier, the neural network structure adopted in this research is feedforward neural network with multiple layers. the type of the neural network is narx neural network. the analysis of this network is based on the time-series modeling [ ] . this means that it uses data obtained at successive times in the past in order to predict data in the future. therefore, it is commonly used as a predicting tool in different fields, such as predicting the solar radiations per day [ ] , predicting electricity price of day-ahead [ ] , and the prediction of bearing life [ ] . as any neural network, input data are processed in the narx neural network through the nodes using the following function: after presenting the algorithm, some questions might be asked. one of these questions is "is seasonality a factor that might have an impact on the results?". before answering this question, it should be clarified here that, in most countries, we can find cities with different seasons. for example, iran has four seasons in its different cities [ ] . other examples include usa, china, saudi arabia, and egypt. this observation indicates that, to consider the seasonality as a factor, the cities should be the scope of the study. since the scope of this study is not cities but countries, we have considered the month of data collection as a measure of seasonality to overcome the above situation. the proposed algorithm deals with variable population size, meaning that countries with higher population size impact more on the algorithm than lower population size countries, which can induce a high uncertainty in the predictions. the question here is "how this fluctuation was accounted for in the algorithm?" indeed, to avoid the high fluctuation in the predictions, the best parameter setting input layer output layer output layer hidden layers single layer multiple layers after presenting the algorithm, some questions might be asked. one of these questions is "is seasonality a factor that might have an impact on the results?". before answering this question, it should be clarified here that, in most countries, we can find cities with different seasons. for example, iran has four seasons in its different cities [ ] . other examples include usa, china, saudi arabia, and egypt. this observation indicates that, to consider the seasonality as a factor, the cities should be the scope of the study. since the scope of this study is not cities but countries, we have considered the month of data collection as a measure of seasonality to overcome the above situation. the proposed algorithm deals with variable population size, meaning that countries with higher population size impact more on the algorithm than lower population size countries, which can induce a high uncertainty in the predictions. the question here is "how this fluctuation was accounted for in the algorithm?" indeed, to avoid the high fluctuation in the predictions, the best parameter setting for the algorithm should be used, while adopting the proposed algorithm in prediction [ ] . for this purpose, the taguchi method has been adopted, as shown in section . . after presenting the narx neural network-based algorithm that helps in predicting the new cases of covid- , it is necessary to present the effectiveness of the algorithm. for this purpose, some experiments are conducted while considering the top five affected countries from each continent, as shown in table . note that the experiments of this case study have been performed using an intel i cpu and . ghz clock speed laptop. the memory is gb ram and runs the windows software. in addition, the algorithm is coded in matlab a. the results of experiments are presented in the following subsections. before conducting the experiments of this study, we have collected the external factors that seems to affect the spread of coronavirus. these factors include population, median age index, public and private healthcare expenditure, air quality as a co trend, seasonality as month of data collection, number of arrivals in the countries/territories, education index, and the month of collecting data. since our study goal is to accurately predict the number of covid- cases, only the most influential external factors should be considered. towards this goal, the test of hypothesis using regression analysis has been adopted using minitab software [ , ] , in which the number of covid- cases and their related external factors have been collected for about countries/territories. note that the regression analysis has been conducted with a significance level of % [ ] . the results of hypothesis test are summarized in table . by looking at the results presented in table , it is noticed null hypothesis h related to hypotheses # , , , , , and is rejected, and the alternative hypothesis h is picked. this means that the external factors like population, median age index, private healthcare expenditure, number of arrivals, education index, and month of collecting data have a significant effect on the number of covid- cases. this is because p-values of these factors, which appear in boldface, are lower than the significance level, which is % in this study. in contrast, the null hypothesis h related to hypotheses # and cannot be rejected, meaning that alternative hypothesis h is rejected. this indicates that external factors like public healthcare expenditure and co trend do not have significant effect on the number of covid- cases. based on the above test of hypothesis, our experiments are further conducted while considering only the significant external factors, meaning considering all the factors except public healthcare expenditure and co trend. after selecting the most influential factors, it is the time for conducting the prediction experiments. however, before doing so, the best parameter setting of narx neural network-based algorithm should be determined. towards this end, the most influential parameters are selected, and their corresponding levels are determined [ , , ] , as shown in table . to select the best parameter settings, taguchi method has been utilized as it is one of the effective tools in determining the best parameter settings by applying an orthogonal array and signal-to-noise (s/n) ratios [ , [ ] [ ] [ ] . the orthogonal array approach can be defined as an economic approach that is commonly adopted with an objective of minimizing the number of conducted experiments. the s/n ratio can be described as a performance indicator that indicates the quality of each conducted experiment. since our taguchi experiment includes four parameters with three levels, the orthogonal array l should be selected in our experiments, which have been conducted using minitab software. figure illustrates the average s/n ratio of the selected parameter at each level, while using our proposed algorithm. since our algorithm aims at predicting the covid- cases, the objective in this study is to minimize the error between the predicted and real values. based on this observation, the parameter level should be selected based on the smaller is better criterion. this means that the level with small average s/n ratio is better than the level with higher average s/n ratio. by applying this criterion in figure , the best level for the parameters , , , and should be set at are levels , , , , respectively. these levels appear in a boldface in table . in this section, we report the performance of the narx neural network-based algorithm. it should be noted that the performance of the algorithm has been evaluated using a commonly used performance indicator, called root mean square error (rmse) [ ] . the rmse is used to reflect the error between real and predicted values of covid- cases. besides, the correlation has been calculated to indicate the closeness of the predicted data to observed data. to select the suitable correlation test, the normality of the observed and predicted covid- cases should be checked. by doing so, it has been noticed that both the observed and predicted covid- cases are not normally distributed. this observation naturally leads to using spearman correlation test [ ] [ ] [ ] . to measure the model uncertainty, the error standard deviation has been calculated [ ] . details of the results are presented in table . by looking at table , it is noticed that the value of the rmse is low in most african and asian countries. this is because the values of predicted and real cases are a bit low if compared with other countries. it is also observed that that the value of the rmse is a bit large in some countries like usa, spain, and china. for instance, rmse = while considering usa. at a first glance, an rmse value of can give the impression of a large difference between predicted and real values, implying a poor performance of the proposed algorithm. indeed, is not that big at all, because predicted or real values reach up to , . thus, is not a big figure if compared with , , meaning that the performance of the algorithm is still reasonable, while handling a large number of covid- cases. to summarize, we can say that the proposed algorithm produces large rmse when the real and predicted values are large, and vice versa. this indicates the consistency and robustness of the proposed algorithm. in this section, we report the performance of the narx neural network-based algorithm. it should be noted that the performance of the algorithm has been evaluated using a commonly used performance indicator, called root mean square error ( ) [ ] . the is used to reflect the error between real and predicted values of covid- cases. besides, the correlation has been calculated to indicate the closeness of the predicted data to observed data. to select the suitable correlation test, the normality of the observed and predicted covid- cases should be checked. by doing so, it has been noticed that both the observed and predicted covid- cases are not normally distributed. this observation naturally leads to using spearman correlation test [ ] [ ] [ ] . to measure the model uncertainty, the error standard deviation has been calculated [ ] . details of the results are presented in table . regarding the correlation, it is observed that the correlation factor is larger than . in all countries with p-value of zero. this means a strong positive significant correlation between the observed and predicted data, which indicates a closeness of the predicted data to the observed data. this reflects the high accuracy of the proposed algorithm. by looking at the error standard deviation, it indicates low error variability in countries characterized with low number of covid- cases and vice versa. this confirms the stability and reliability of the proposed algorithm. after presenting the performance of the proposed algorithm, there is a question that might be asked here, "what is the advantage of the proposed algorithm over the existing traditional method in the literature?". to answer this question, our experiments have been further extended to make a comparison between our proposed algorithm and the traditional method that can be represented in the study by chen et al. [ ] . note, both studies have the same objective, which is predicting the number of covid- cases. however, both studies are different in their considered factors. the study by chen et al. [ ] has only focused on historical data of the number of covid- cases while considering a limited number of factors, like travel and occupation. in contrast, our study has the same focus as the study chen et al. [ ] , besides, it has considered many external factors that overlooked in their study. these factors include population, median age index, public healthcare expenditure, private healthcare expenditure, air quality as a co trend, education index, and seasonality as month of collecting data. the experiment results obtained from both approaches are summarized in table . by looking at table , the results show that the narx neural network-based algorithm is more accurate than the traditional method. this outperformance is due to considering more factors that affect the spread of covid- , such as the external factors like the population, the health expenditures, and others. this results in an accurate prediction for the proposed algorithm. in contrast to the proposed algorithm, the traditional method only focusses on the historical data and neglect many external factors. hence, some important factors that affect the spread of the virus are neglected, leading finally to a poor prediction of the number of covid- cases. this section establishes that the proposed algorithm gives improved results when compared with the traditional method. thus, the significance of utilizing this algorithm in real practice is further affirmed. so far, we have presented the performance of the proposed algorithm and its advantage over the existing methods. it is fine, but still, there are some questions that have not been answered like "what next in the future?", "how can we benefit from the algorithm in predicting future cases of covid- ?", "when will coivd- end?". answering these questions necessitates extending our experiments, in which we use the trained data to predict the number of future cases of covid- . in the experiments of the previous sections, we observe that in the countries that control the spread of covid- , the peak in the number of daily cases appeared after - months. this observation has been taken as a reference to predict future covid- cases in the countries where the disease is yet to peak. it is interesting to recall that the future prediction has been done for about two months, in the period from august until september . the results of these experiments are presented in figures - , which represent the future predictions in europe, north and south america, asia, and africa, respectively. after presenting the future prediction of covid- cases in european countries, we have some observations, which are outlined as follows: • in most european countries, like italy, uk, and russia, the number of cases has already reached its peak before our future prediction. based on this observation, we predict that the number of future coivd- cases will decrease gradually during the period from august until september . it is worth to mention that our predicted reduction in the number of covid- cases appear during august . the abovementioned reduction is because of strict compliance with the precaution guidelines established by who. in contrast to most of european countries, the situation in spain and france is quite similar, as the number of cases has raised recently and formed another peak. in spain, the second peak has been already formed, therefore, our algorithm predicts a gradual decrease during the period from august until september . in france, the algorithm predicts a slight increase followed by a gradual decrease in the number of cases during the same period. by looking at figure , some observations can be summarized as follows: • in the case of usa, the number of covid- cases has already formed its second peak by mid of july . therefore, we have predicted a slow reduction in the number of future covid- cases. this prediction, in terms of reduction, appears in the usa during the first half of august . it should be noted that this slow reduction is because of the dysfunction experienced in the healthcare system of the usa [ ] . in the case of brazil, we observe that the peak has been reached. then, we predict that the number of future covid- cases will experience a wavy reduction during the period from august until september . it is important to mention that the predicted slow reduction in future covid- cases agrees with the actual reduction realized during august . this wavy reduction is due to overlooking the social distancing instructions by most of brazilian residents [ ] . in case of canada, the number of covid- cases has reached its peak since beginning of may . therefore, it is reasonable to predict a gradual decrease in the number of cases during the period from august until september . in the case of peru, we observe an increase in the number of covid- cases by july . then, we predict that, during the period from august until september , this increase will continue a bit before a decline in the number of future covid- cases. this increase is due to the bad behavior of the people, so that the situation becomes even worse during those days [ ] . • in the case of ecuador, we predict the number of future covid- cases will keep its wavy motion, meaning that the number will tend to zero and increase again. this wave appears because there is no transparency in the reported number of covid- cases, meaning that the government has not disclosed the real number of covid- cases [ ] . reached the peak. our algorithm predicts a gradual reduction in the number of future covid- cases, which has been realized during august . the situation in india is completely different compared to the rest of asian countries. this is because india is yet to reach its peak. based on this observation, we predict that the increase in the number of covid- cases will continue during the period from august until september . after presenting the future prediction of covid- cases in european countries, we have some observations, which are outlined as follows: • in most european countries, like italy, uk, and russia, the number of cases has already reached its peak before our future prediction. based on this observation, we predict that the number of future coivd- cases will decrease gradually during the period from august until september . it is worth to mention that our predicted reduction in the number of covid- cases appear during august . the abovementioned reduction is because of strict compliance with the precaution guidelines established by who. in contrast to most of european countries, the situation in spain and france is quite similar, as the number of cases has raised recently and formed another peak. in spain, the second peak has been already formed, therefore, our algorithm predicts a gradual decrease during the period from august until september . in france, the algorithm predicts a slight increase followed by a gradual decrease in the number of cases during the same period. by looking at figure , some observations can be summarized as follows: • in the case of usa, the number of covid- cases has already formed its second peak by mid of july . therefore, we have predicted a slow reduction in the number of future covid- cases. this prediction, in terms of reduction, appears in the usa during the first half of august . it should be noted that this slow reduction is because of the dysfunction experienced in the healthcare system of the usa [ ] . in the case of brazil, we observe that the peak has been reached. then, we predict that the number of future covid- cases will experience a wavy reduction during the period from august until september . it is important to mention that the predicted slow reduction in future covid- cases agrees with the actual reduction realized during august . this wavy reduction is due to overlooking the social distancing instructions by most of brazilian residents [ ] . in case of canada, the number of covid- cases has reached its peak since beginning of may . therefore, it is reasonable to predict a gradual decrease in the number of cases during the period from august until september . in the case of peru, we observe an increase in the number of covid- cases by july . then, we predict that, during the period from august until september , this increase will continue a bit before a decline in the number of future covid- cases. this increase is due to the bad behavior of the people, so that the situation becomes even worse during those days [ ] . in the case of ecuador, we predict the number of future covid- cases will keep its wavy motion, meaning that the number will tend to zero and increase again. this wave appears because there is no transparency in the reported number of covid- cases, meaning that the government has not disclosed the real number of covid- cases [ ] . after presenting the results of asian countries, we have the following observations: • china is one of the few cases that has fully controlled the situation. this is apparent as the number of future covid- cases is almost zero. thanks to the chinese government and medical system, strict typical quarantining measures have been implemented, thus, leading finally to overcoming this hard time. the situation in turkey, iran, and saudi arabia is like other european countries that have reached the peak. our algorithm predicts a gradual reduction in the number of future covid- cases, which has been realized during august . the situation in india is completely different compared to the rest of asian countries. this is because india is yet to reach its peak. based on this observation, we predict that the increase in the number of covid- cases will continue during the period from august until september . by looking at figure , we can draw the following observations: • most of african countries are quite similar, except morocco, as the peak of covid- cases has already appeared. it is predicted that the future number of covid- cases will decrease gradually, during august and september . so far, the trend of our predicted graph has been realized in the aforementioned african countries. in contrast to the above-mentioned african counties, in morocco, the peak of covid- cases has not yet appeared. therefore, the future number of covid- cases will continue its increase during august and september . it is important to mention that this increase has been realized during the first half of august . based on the above observations, we outline some recommendations, which are as follows: • it is recommended for the people living in the usa, brazil, ecuador, peru, and india to strictly follow the precautions instruction recommended by who. this includes quarantining infected people, whereas healthy people should stay home to avoid covid- infection, and when they go out, they should follow the rules of social distancing. it is recommended for the government and healthcare system of countries like the usa and brazil to raise their private and public health expenditures to control the number of future coivd- cases. in addition, penalties may be applied to the people who violate the instructions recommended by who. it is recommended for the government of ecuador to release the correct number of covid- cases so that the people can understand the severity of the situation and obey the health guidelines released by who. in the countries that fully or partially control the covid- like china, it is recommended for the people to keep following the medical instructions. otherwise, covid- may come back in a mutated form causing another global pandemic. this study investigates how new covid- cases can be predicted while considering the historical data of covid- cases alongside the external factors that affect the spread of the virus. to do so, data analytics was adopted by developing a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. the effectiveness and superiority of the developed algorithm are demonstrated by conducting experiments using data collected for top five affected countries in each continent. the results show an improved accuracy if compared with the existing methods. moreover, the experiments are extended to make future prediction of the affected covid- cases during the period from august until september . the predicted covid- cases help in providing some recommendations for both the government and people of the affected countries. this study provides a novel way for predicting the number of covid- cases. however, there are some venues that might be suitable for future directions. for example, predicting the number of deaths could be one direction. another direction might be predicting the number of recovered people. one of the fruitful ideas is predicting the number of covid- cases in the top affected cities, while considering the seasonality factor. clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in diagnosis, treatment, and prevention of novel coronavirus infection in children: experts' consensus statement the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china covid- and italy: what next? estimation of covid- outbreak size in italy estimation of coronavirus disease (covid- ) burden and potential for international dissemination of infection from iran preliminary estimation of the novel coronavirus disease (covid- ) cases in iran: a modelling analysis based on overseas cases and air travel data estimation of covid- prevalence in italy, spain, and france estimation of the final size of the covid- epidemic predicting the epidemiological outbreak of the coronavirus disease (covid- ) in saudi arabia covid- : a comparison of time series methods to forecast percentage of active cases per forecasting of covid per regions using arima models and polynomial functions prediction of number of cases of novel coronavirus (covid- ) using social media search index retrospective analysis of the possibility of predicting the covid- outbreak from internet searches and social media data data mining and content analysis of the chinese social media platform weibo during the early covid- outbreak: retrospective observational infoveillance study big data integration and analytics to prevent a potential hospital outbreak of covid- in taiwan covid- : challenges to gis with big data neural network powered covid- spread forecasting model covid- pandemic prediction for hungary how big data and artificial intelligence can help better manage the covid- pandemic covid- " or "covid- " or "hubei pneumonia" or updated understanding of the outbreak of novel coronavirus ( -ncov) in wuhan novel coronavirus (covid- ) epidemic: what are the risks for older patients? novel coronavirus infection in hospitalized infants under year of age in china mathematical modeling of the spread of the coronavirus disease (covid- ) taking into account the undetected infections. the case of china using reports of symptoms and diagnoses on social media to predict covid- case counts in mainland china: observational infoveillance study predicting covid- incidence through analysis of google trends data in iran: data mining and deep learning pilot study neuro-adaptive cooperative tracking control with prescribed performance of unknown higher-order nonlinear multi-agent systems adaptive synchronisation of unknown nonlinear networked systems with prescribed performance a deep increasing-decreasing-linear neural network for financial time series prediction data analytics in managing aircraft routing and maintenance staffing with price competition by a stackelberg-nash game model robust aircraft maintenance routing problem using a turn-around time reduction approach cascading delay risk of airline workforce deployments with crew pairing and schedule optimization a healthcare analytic methodology of data envelopment analysis and artificial neural networks for the prediction of organ recipient functional status neural network based temporal feature models for short-term railway passenger demand forecasting pervasive computing in the context of covid- prediction with ai-based algorithms predicting the growth and trend of covid- pandemic using machine learning and cloud computing covid- coronavirus pandemic our world in data. the covid- pandemic slide deck world bank open data united nations development programme country of four seasons: iran a world inside a country long-term time series prediction with the narx network: an empirical evaluation time series prediction based on narx neural networks: an advanced approach a nonlinear autoregressive exogenous (narx) neural network model for the prediction of the daily direct solar radiation on the importance of the long-term seasonal component in day-ahead electricity price forecasting with narx neural networks the use of md-cumsum and narx neural network for anticipating the remaining useful life of bearings joint optimization using a leader-follower stackelberg game for coordinated configuration of stochastic operational aircraft maintenance routing and maintenance staffing a regression-based approach for testing significance of "just-about-right" variable penalties robust design of multilayer feedforward neural networks: an experimental approach optimizing the parameters of multilayered feedforward neural networks through taguchi design of experiments modelling three-echelon warm-water fish supply chain: a bi-level optimization approach under nash-cournot equilibrium temperature and precipitation associate with covid- new daily cases: a correlation study between weather and covid- pandemic in oslo impact of weather on covid- pandemic in turkey correlation between weather and covid- pandemic in jakarta a model with a solution algorithm for the operational aircraft maintenance routing problem heuristic approaches for operational aircraft maintenance routing problem with maximum flying hours and man-power availability considerations why the us has struggled to tackle a growing crisis. the guardian coronavirus: brazil records third-highest covid- infection level peru's coronavirus response was 'right on time'-so why isn't it working? the guardian covid- numbers are bad in ecuador. the president says the real story is even worse this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors wish to acknowledge the support of king fahd university of petroleum and minerals. the authors declare no conflict of interest. int. j. environ. res. public health , , key: cord- -zp k k z authors: brunner, carolyn m.; horwitz, david a.; shann, mary k.; sturgill, benjamin a.; davis, john s. title: clinical and immunologic studies in identical twins discordant for systemic lupus erythematosus date: - - journal: the american journal of medicine doi: . / - ( ) - sha: doc_id: cord_uid: zp k k z abstract middle-aged female identical twins, one of whom had systemic lupus erythematosus (sle), were evaluated for immunologic reactivity to previous antigenic challenges, including primary immunization with a foreign antigen, keyhole limpet hemocyanin (klh). these two women had lived together for all of their years and neither was receiving anti-inflammatory or immunosuppressive drugs at the time of these studies. both twins demonstrated comparable s and humoral antibody response to klh, as well as similar viral antibody titers. however, the twin with sle was anergic to common antigens, streptokinase-streptodornase, trichophyton and candida; furthermore delayed hypersensitivity to klh did not develop after immunization. this observed discrepancy between humoral and cellular immunity in genetically similar subjects may be significant in the pathogenesis of sle. the patient (fo, ) was a year old mentally retarded white woman, born in a rural area of southwestern virginia. in july she was referred to the university of virginia hospital (uvh) because of edema of the legs and facial swelling of recent onset. she admitted having arthralgias but denied having recent rash, pleurisy or hair loss. previous medical history revealed that a systolic heart murmur had been heard in . a hemogram and urinalysis at that time were normal. in june she had been admitted to her local hospital with congestive heart failure attributed to mitral insufficiency. laboratory studies included a positive lupus erythematosus cell preparation, and she received a brief course of prednisone therapy. a pruritic rash of her neck and trunk was recorded in june . family members included a healthy twin sister (case ), who was identical in appearance. the sisters shared the phenotype gm ( , , , ) ; inv(-l)* and common red blood cell groups (type , dce/ dce). their histocompatibility lymphocyte typing against serums was identical, being hl-al and hl-a and te positive.? on physical examination the patient had a left pleural effusion and pitting edema of both legs. there was no skin rash or joint abnormalities. urine sediment showed to white blood cells and to red blood cells/high power field, with many doubly refractile fat bodies under polarized light. other laboratory data included a hematocrit value of per cent, white blood cell count , /mm , blood urea nitrogen mg,iloo ml and creatinine clearance ml/min. serologic studies were as follows: latex nucleoprotein +, lupus erythematosus cell preparation positive, hemolytic complement (c'h ) units (normal range to units) and rheumatoid factor (rf) negative. hypoproteinemia (serum albumin . g/ ml) and abnormal urine sediment were considered to be secondary to active lupus glomerulonephritis. in addition a urine culture showed infection. the patient was treated with diuretics, prednisone and antibiotics. in december the patient and her twin sister were moved to a nursing home. the following month the patient was rehospitalized with bilateral pulmonary infiltrates, a left pleural effusion and edema extending from both feet to the iliac crests. microscopic hematuria. proteinuria ( g/ hours), and depressed serum complement ( to c'h units) were consistent with active sle, and the dose of prednisone was increased to mg/day. her course was complicated by progressive azotemia (blood urea nitrogen reaching a maximum of mg/loo ml), which was gradually reversed by increasing intravascular volume. the dose of prednisone was tapered and then discontinued in late march . clinically, the patient's condition sta-*courtesy of a. g. steinberg, m.d., department of biology, case western reserve university, cleveland, ohio, who tested forgm ( , , , , , , . ) and inv ( ) bilized (blood urea nitrogen mgilo ml). and she remained asymptomatic. blood pressure ranged from to _l / to mm hg. and there was no peripheral edema. her urine continued to show -l-protein, numerous white cells (cultures usually positive), hyaline and granular casts, and doubly refractive fat bodies. both twins were hospitalized in june in the clinical research center for concurrent immunologic evaluation. neither twin had specific complaints. one (case l), however, had decreased renal function, documented by a blood urea nitrogen level of mg/loo ml, serum creatinine of . mg/loo ml, and hour protein excretion of . to . g. although antinuclear factor remained positive, a lupus erythematosus cell preparation was negative, and serum complement was normal. serum deoxyribonucleic acid (dna)binding activity (performed subsequently on serum stored from this hospitalization) was per cent (normal controls less than per cent) [ ] . glucose tolerance test was also abnormal (blood sugar mg/ ml, fasting mg/loo ml at hour, mg/loo ml at hours and mg/loo ml at hours). during late the patient's condition deteriorated. in early october a urinary tract infection developed with gram-negative sepsis, and although her condition improved temporarily, she died in december. at autopsy extensive chronic polyserositis was found, with fibrous pleural, pericardial and peritoneal adhesions, particularly over the spleen and liver. the heart was moderately enlarged due to left ventricular hypertrophy ( g). but the coronary arteries were free of significant disease. except for focal calcification jn the mitral valve ring, the valves of the heart were normal; libman-sachs endocarditis was not seen. the spleen was slightly enlarged ( g), congested and firm. the liver was unremarkable. the kidneys were pale and diffusely granular. the right kidney also contained a large ischemic scar and weighed only g as compared to the left kidney, which weighed g. histologic sections of the kidneys showed diffusely thickened glomerular basement membranes, glomerular hypercellularity and adhesions of some glomerular tufts to bowman's capsule. many glomeruli were hyalinized, with associated atrophy and interstitial infiltrate of lymphocytes. sections of lung contained evidence of multiple small old pulmonary emboli. the remainder of the examination was noncontributory. case . this patient (fe) is the identical twin sister of the patient just described (case ). she spent her entire life with her sister in a remote cabin until december when they moved to the nursing home. she was examined at uvh for the first time in august . she denied having any previous illnesses, as well as photosensitivity, rash, arthralgias or pleurisy. blood pressure was / mm hg, and other than the mental retardation physical examination revealed no abnormalities. laboratory data obtained during two outpatient visits (august and april ) were normal (hematocrit per cent. white blood cell count , /mm , blood urea nitrogen mg/loo ml) except for slight hypergammaglobulinemia ( . to . g/l ml). routine urinalysis showed an occasional white blood cell and no proteinuria. there was no serologic evidence of sle. this patient was hospitalized with her sister (case ) in the clinical research center in june so that her immunologic status could be evaluated. blood pressure was to / mm hg, and there was thyroid enlargement with irregularity in the left upper lobe. serum thyroxine levels, chest roentgenogram and electrocardiogram were normal. c;hest roentgenogram and electrocardiogram were normal. glucose tolerance test was abnormal (blood sugar fasting mg/loo ml, mg/loo ml at hour, mg/ ml at hours, mg/loo ml at hours). the patient was last seen by us in january when there was still no clinical or laboratory evidence to suggest sle. sle as the etiology of the patient's nephritis (case ) was first suggested by the positive lupus erythematosus cell preparation in . subsequently the presence of antinuclear factor, anti dna, decreased serum complement, cryoglobulins and, at autopsy, polyserositis and histologic changes in the kidneys, supported the diagnosis of sle. the healthy identical twin at age (case ) has never had any symptoms suggestive of sle. multiple blood samples tested for lupus erythematosus cells, antinuclear factor, anti dna, rheumatoid factor and cryoglobulins (table i) delayed hypersensitivity to common antigens was assessed by the intradermal injection of . ml of : streptokinase-streptodornase (sk-sd), (varidasew, lederle, pearl river, n.y.), : trichophyton (hollister stier, yeadon, pa.) and :loo candida albicans (hollister stier). response was measured as millimeters of induration after , and hours. klh immunization. response to a foreign antigen was evaluated after immunization with klh. klh was obtained as an ammonium sulfate precipitate from the pacific biomarine supply company, venice, calif. this material was prepared in the associated form by a method modified from campbell and co-workers [ ] . it was filtered through a . p millipore@ filter, and merthiolate@ ( : ) was added. klh mg was injected subcutaneously and serum samples were obtained frequently for several weeks. antibody to klh was measured by the tanned cell hemagglutination micromethod [ ] . formalinized sheep red blood cells were tanned and then coated with . mg klh/ml of packed red cells. agglutination was read after hours in plastic microtiter trays. sucrose gradient centrifugation was performed on selected serums (positive for anti-klh) to measure relative amounts of antibody in s and s fractions. sucrose was layered in concentrations from to io per cent (ph sphate buffered solution, ph . ) and . ml aliquot of a : dilution of serum was placed at the top. bromphenol blue was used as a marker for albumin. centrifugation at , x g was carried out for hours. five-tenth milliliter fractions were taken from the bottom of the tubes and reassayed for anti-klh by hemagglutination and double diffusion in agarose. skin tests for delayed hypersensitivity were performed on the th and th days after immunization, with observations recorded after , and hours. biopsy specimens from the areas injected .with pg klh were obtained hours after the second skin tests were performed. studies. the proliferative response of the twins' lymphocytes to klh and phytohemagglutinin (pi-ia) was determined using previously described technics [ ] . in brief, x lo washed (case ) which increased in size when injections of and pg were given (table i i ). in contrast, there was no cutaneous response to the injection of or pg of klh in the twin with sle (case ), and after the injection of pg only a by mm site of induration was observed. biopsy of the mm sites confirmed the difference in response of the twin sisters; there was a paucity of lymphocytes near blood vessels and surrounding dermis in the section from the twin with sle (case ), whereas a round cell infiltrate typical of delayed hypersensitivity was apparent in the dermis of the healthy twin (case ). lymphocyte blastogenic response (table ii) : prior to immunization, neither twin's lymphocytes could be stimulated by pg/ml klh. the healthy sister (case ) demonstrated sensitization of her lymphocytes to klh days after immunization at this time. htdr uptake by stimulated cells were . times control values. by days after immunization this response had increased to times control values. in contrast, lymphocytes from the twins with sle (case ) failed to respond to klh. htdr uptake of her stimulated cells was never greater than two times control values. the kinetics of the day response to klh are reported elsewhere [ ] . the main observations which emerge from these case studies include: first, sle developed in only one member of a set of genetically and environmentally similar twins, and second, the affected twin showed a marked difference between humoral and cellular response to an administered antigen. titers represent averages of tubes , and ( s), and , and ( s). another difficulty has been the lack of uniform criteria in establishing the diagnosis of sle. in two patients, in separate reports, the diagnosis was made solely on clinical grounds [ , ] . in addition to fulfilling the criteria for the diagnosis of sle recommended by the american rheumatism association [ ] , the serologic and postmortem findings confirmed the clinical impression in our patient. our twins are the oldest in the series of previous studies (ages to ), lessening the likelihood that the disease will develop in the healthy twin. these patients are also unusual in that they shared the same environment into adult life and that similar antibody titers to multiple viruses developed. although in these twins there was remarkable correlation between the antibody titer and the antibody response after klh immunization, their cellmediated responses were different. delayed cutaneous reactions and lymphocyte proliferative responses to antigens were decreased in the twin with sle (case ) suggesting that she had impaired delayed hypersensitivity. when these stud- hereditary hypergammaglobulinemia and systemic lupus erythematosus. i. clinical and electrophoretic studies familial systemic lupus erythematosus disseminated lupus erythematosus in identical twin sisters associated with diabetes mellitus in one case disseminated lupus erythematosus in identical twins identical three-year-old twins with disseminated lupus erythematosus: one with nephrosis and one tiith nephritis progressive systemic sclerosis (pss) and localized scleroderma (morphea) with positive le cell test and unusual systemic. manifestations compatible with systemic iudus ervthematosus (sle) complement and its role in disease for sle-brunner et al ies were in progress the twin with sle (case ) was not receiving any steroids or other drugs that are potentially capable of modifying immune responses. because cellular responsiveness is often impaired in azotemic patients [ , ] , however, it is not possible to conclude that the differences observed are exclusively related to sle. however, subsequent studies from this laboratory indicate that nonazotemic patients with newly diagnosed sle also show impaired delayed hypersensitivity to common antigens [ . this demonstration of a discrepancy between humoral and cellular immunity in the twin with sle is in some ways analogous to recent obser- key: cord- - nrhl t authors: brumit, ryan; daily, bethany; levine, wilton c title: surgical case deferment during a global pandemic date: - - journal: j med syst doi: . /s - - - sha: doc_id: cord_uid: nrhl t nan in march of , hospitals across the united states began deferring elective surgical procedures in response to the rapidly escalating sars-cov pandemic. on march , , the massachusetts department of public health (dph) issued a directive that all non-essential surgery be deferred [ ] . massachusetts general hospital (mgh) needed to quickly evolve surgical scheduling guidelines that were clear, reasonable and fair to meet the needs of our patients and balance the evolving needs of our hospital and healthcare system. on march , , the american college of surgery (acs) published guidance for triage of non-emergent surgery [ ] . a method was needed to quickly draw-down our operating room (or) schedule to be in line with the acs guidelines and more detailed guidelines that we developed. this was necessary given the rising need to conserve space, staffing and ppe resources. we describe a method for case deferment that empowers a large swath of surgical specialties to make safe and quick decisions that result in a dramatic reduction of the or schedule and hospital census. the following rules and methodology have applicability for our current pandemic as well as during other emergency situations such as blizzards, hurricanes or massive power outage. surgical and perioperative leadership determined a set of focused criteria to guide types of patient care deemed essential during the global pandemic and during the dph mandate to defer all non-essential surgery. mgh evolved the acs guidelines to specifically include the following patient/disease states to have ongoing surgery: beyond those directly involved in the process of deferring surgical cases, nursing and anesthesia must be kept well informed of significant drops in or volume, as their staff are crucial in times of crisis and will be needed for redeployment to support other critical care needs within the hospital. beyond the operating room, mgh used this method to defer scheduled cases in all procedural areas including endoscopy, electrophysiology, cardiac cath and interventional radiology. the framework of this method starts with generation of a report containing upcoming or cases. key data points include: date of surgery, patient name, service, surgeon, procedures, pre-op diagnosis, and patient contact information. decisions must then be made on which cases can be deferred. a set of strategically ordered update queries was created to provide rudimentary deferability recommendations based on keywords found in the procedure booking code and pre-op diagnosis ( fig. a ). in the first weeks, scheduled cases evaluated by these queries. % of them were determined by the logic and automatically marked with a deferability recommendation of high (easy to defer), medium or low (case must proceed). for example, the word arthroplasty automatically establishes a high deferability recommendation, whereas the words malignant or cancer automatically establish a low deferability recommendation. based on the order of the update queries, a low deferability cancer case converts to medium deferability if the word prostatectomy is found. inpatients are always automatically marked as not deferrable. as to not get too far ahead of the pandemic's trajectory, weeks of upcoming scheduled case data is exported from the ehr every weeks and run through the query logic. after generating the initial recommendations, the file is then divided into service-specific case lists and distributed to chiefs and administrators for formal review. instructions are to ) indicate which cases can be deferred and resubmit the updated file within h, and ) contact all deferred patients to let them know that their surgery has been postponed within h. rather than canceling en masse, deferrable cases are removed from the or schedule grid and placed back into a scheduling depot to make rescheduling easier when the hospital returns to normal operations. a far future date was selected as the new "date of surgery" for all cases being deferred. in our case, we chose / / , so that that cases can be easily tracked and isolated from any non-deferrable cases ( fig. b) . the work of processing all deferred cases has been centralized in order to maintain consistency and ensure that all deferrable cases are removed from the schedule in a timely and organized manner. with a significant reduction in surgical volume, the need to decrease the number of daily rooms running became quickly apparent. blocked operating rooms open and available on the or scheduling grid meant there was no visual guidance for where non-deferrable cases should be placed. this created unnecessary work for or leaders and the central scheduling team, as they had to actively consolidate rooms and surgical services throughout the day to effectively manage operating room resources. to rectify this issue, the or schedule was reduced first to blocked rooms per day and over subsequent weeks ultimately down to blocked rooms per day for both scheduled necessary surgery as well as urgent/emergent surgery. our normal or schedule is mostly comprised of blocks assigned to specific surgeons, which was simply not practical to maintain at this time. the reallocation of blocks to servicelevel assignments was based upon a service's anticipated nondeferrable case volume. within our ehr, the normal or block schedule recurs indefinitely. when permanent block changes are made, the new assignment overwrites the old by beginning on a specific date and recurring indefinitely. as case deferment occurs in two-week windows, the temporary block schedule can be set in the ehr to coincide, protecting the normal block schedule from being deleted. an improvement to the framework was the inclusion of a formal process for scheduling any new non-deferrable cases. knowing that certain patients need their surgeries to occur before the end of the crisis is reached, all new nondeferrable cases must go through a service-based review carried out by the surgical chief (or designee) prior to scheduling. a schedule change report was also created so that the or medical director can conduct a daily review of all new cases that have been added to the schedule and follow-up with individual surgeons and surgical leadership as needed. it was also found that the pre-procedure evaluation (ppe) program had fallen out of synch with the or because the twoweek cadence of the deferment method did not align with the -day scheduling window of the pre-procedure phone a b c fig. interviews. nurses were calling patients and conducting interviews for noticeably deferrable cases, simply because they were scheduled for a date of surgery beyond the two-week deferment window. to address this, an or schedule report was built for the phone nurses, which is populated by surgical cases scheduled over the next five business days and ignores the ppe appointment date and time, ensuring that the phone nurses are only calling non-deferrable patients. as of / / , mgh's surgical case deferment method has been employed for three two-week windows. in this time, the deferment rate has dropped from % (weeks & ) to %, leaving only non-deferrable cases on the schedule across days (weeks & ) ( fig. c) . considerable curtailing of or volume has had a significant positive impact on hospital operations. limiting the flow of or patients to the icus and inpatient floors increases the available capacity for covid-positive and covid-risk patients and provides flexibility with covid floor consolidation. reduction in our or schedule has allowed re-deployment of our nursing and anesthesia teams to help staff and support new icus that have opened and allowed our surgeons to help staff emerging respiratory clinics. decreasing the staff and ppe required for the operating room has helped our hospital to remain stable during these uncertain times. funding no funding was received in support of this work. conflict of interest mr. ryan brumit declares that he has no conflict of interest. mrs. bethany daily declares that she has no conflict of interest. dr. wilton c levine declares that he has no conflict of interest. ethical approval this article does not contain any studies with human participants or animals performed by any of the authors. elective procedure order [mass.gov web site covid- : guidance for triage of non-emergent surgical procedures key: cord- -moligska authors: wong, justin; chaw, liling; koh, wee chian; alikhan, mohammad fathi; jamaludin, sirajul adli; poh, wan wen patricia; naing, lin title: epidemiological investigation of the first covid- cases in brunei: implications for surveillance, control, and travel restrictions date: - - journal: am j trop med hyg doi: . /ajtmh. - sha: doc_id: cord_uid: moligska studies on the early introduction of sars-cov- in a naive population have important epidemic control implications. we report findings from the epidemiological investigation of the initial covid- cases in brunei and describe the impact of control measures and travel restrictions. epidemiological and clinical information was obtained for all confirmed covid- cases, whose symptom onset was from march to april , . the basic reproduction number (r ), incubation period, and serial interval (si) were calculated. time-varying r was estimated to assess the effectiveness of control measures. of the cases detected, ( . %) were imported. the median age was (range = . – ) years. forty-one ( . %) and ( . %) were presymptomatic and asymptomatic cases, respectively. the median incubation period was days (interquartile range [iqr] = , range = – ), and the mean si was . days (sd = . ; % ci: . , . ). the reproduction number was between . and . , and the doubling time was . days. the time-varying reproduction number (rt) was below one (rt = . ; % credible interval: . , . ) by the th day of the epidemic. epidemic control was achieved through a combination of public health measures, with emphasis on a test–isolate–trace approach supplemented by travel restrictions and moderate physical distancing measures but no actual lockdown. regular and ongoing testing of high-risk groups to supplement the existing surveillance program and a phased easing of physical distancing measures has helped maintain suppression of the covid- outbreak in brunei, as evidenced by the identification of only six additional cases from april to august , . the global spread of covid- and the lack of an effective vaccine or therapeutic options pose challenges for disease control and travel health. importation events in a country with no cases can lead to an exponential increase in case numbers within a short time period. as such, countries have implemented travel restrictions in response to the global rise; however, their effectiveness is debatable. , studies on the early introduction of the virus in a naive population can provide insight into the natural history of the disease and have implications for control measures. brunei darussalam (pop. , ), a well-connected country vulnerable to multiple importation events, detected its first covid- imported case on march , linked to an international super spreading event in kuala lumpur, malaysia: the sri petaling mosque tablighi jamaat cluster. this -day event (february -march , ) was attended by more than , members of the tablighi, an apolitical islamic group, from various parts of the world, including brunei. , given the absence of widespread community transmission and a slowing in the trajectory of spread since the th confirmed case, brunei's response to this first wave of the pandemic has been generally successful. to maintain this, a number of questions need to be addressed. first, what were the epidemiological characteristics of the cases observed so far? second, what was the role of travel-related cases in driving the disease? third, how infectious were the cases and how effective were the approaches to reducing transmission? here, we report findings from the first covid- cases, detected within the first weeks of the local epidemic, along with their epidemiological, clinical, and transmission characteristics. as jurisdictions that have implemented lockdowns begin to bring the epidemic under control, our findings will be important to calibrate detection and response efforts in potential future waves of the pandemic. case identification and contact tracing. the brunei surveillance and contact tracing strategy has previously been described. since january , clinical and laboratory surveillance has been implemented across the country, and testing criteria have progressively expanded in scope (supplemental table ). a confirmed case is someone who tested positive for sars-cov- through real-time reverse transcriptase-pcr (rt-pcr) test on nasopharyngeal (np) swab. all laboratory-confirmed covid- cases with symptom onset from march to april , were included in this study and followed up until recovery or death. epidemiological investigation was conducted for each confirmed case, and information was collected on demographic characteristics, clinical symptoms, travel history, activity mapping days before the onset of symptoms (or swab date for asymptomatic cases), and contact history. a close contact was any person living in the same household, or someone within m of a confirmed case in an enclosed space for more than minutes. all close contacts underwent rt-pcr testing. those who tested negative were quarantined at home for days from last exposure, and those who later developed symptoms were retested. all confirmed covid- cases were treated and isolated at the national isolation centre. cases were discharged following two consecutive negative sars-cov- np swabs collected at ³ -hour intervals. we categorized cases into two groups: imported cases (defined as individuals presumed to have acquired the infection outside brunei) and locally transmitted cases (defined as those without a travel history). statistical analysis. an epidemic curve was constructed based on the date of symptom onset (for symptomatic and presymptomatic cases) or the date of np swab collection (for asymptomatic cases). the duration between symptom onset to diagnosis date was calculated. the exposure period for imported cases and their close contacts was calculated as the duration between their return date to brunei and their diagnosis/swab collection date. the incubation period was calculated as the duration between the known exposure date of confirmed cases and their symptom onset dates. the serial interval (si) was calculated as the duration between the symptom onset dates for the primary case and that of a secondary case. only symptomatic or presymptomatic infectorinfectee pairs with clear epidemiological links were included in the si calculation. group comparison was performed between the imported and local contact cases, using chi-square, fisher's exact, or mann-whitney's tests as appropriate. the estimation of the reproduction number (r ) (defined as the expected number of secondary cases infected by a primary case) was performed using two methods. the basic r was estimated from the mean si and the exponential growth rate of the cumulative number of cases in the epidemic λðtÞ = lnðy½tÞ=t, using the formula r = + siλ + fð À fÞðsiλÞ , where f is the ratio of the infectious period to the si. this assumes an exponential distribution, allowing for a range of reported values. the exponential growth phase between march and was chosen for the r estimation because it represents the initial growth of the epidemic curve (see figure ), and also because control measures were enhanced after march . thus, this -day period represented more accurately the nature of sars-cov- transmission, in the absence of heightened measures. the epidemic growth rate and doubling time were also calculated, based on established formulas. we also estimated the time-varying reproduction number (rt) to assess the effectiveness of epidemic control measures, based on methods proposed by thompson et al. and using the epiestim . package. this rt estimation uses case incidence data and si distribution, and distinguishes between imported and locally transmitted cases. following studies that use a nonnegative si distribution to approximate the distribution of the generation time, , we used a gamma distribution and incorporated uncertainty in the parameters (sd of mean = , sd = . ). the median rt and % credible intervals for each day were estimated jointly from incidence data and from the posterior si distribution, using a -day sliding window. this -day window reduces the bias associated with early estimations of rt, as at least one average si has passed. all analyses were conducted using microsoft excel (microsoft corp., redmond, wa) and r (ver. . . , r core team, vienna, austria). a p-value < . was considered as statistically significant. ethics approval was granted by the university research ethics committee, universiti brunei darussalam (ref: ubd/oavcr/urec/apr - ). a total of cases were detected in the first weeks, comprising ( . %) imported and ( . %) locally transmitted cases ( table ). the median age was years (ranging from months to years). fifty-three ( . %) cases were female. locally transmitted cases were significantly younger (p = . ) than imported cases and tend to be females (p = . ). eighty-one ( %) cases developed symptoms, reported either during or before np sample collection. notably, we observed high proportions of presymptomatic and asymptomatic cases- ( . %) and ( . %), respectively. in total, . % of the cases were detected within days of symptom onset or np swab date. among them, . % (n = ) were detected on or before the day of symptom onset. no significant differences were observed between the imported and locally transmitted cases ( table ). the most common reported symptoms were fever ( . %), sore throat ( . %), and cough ( . %) (supplemental table ). among these cases, three subsequently died from covid- complications, giving a case fatality rate of . %. all three deaths were in men, aged , , and years, respectively. impact of travel restrictions. since late-january, travel restrictions were progressively implemented in response to the emerging regional and later global situation. initially, travelers from hubei province, china, were restricted, whereas those from other parts of mainland china underwent days home quarantine. these restrictions were gradually tightened, first to travelers from iran and italy (the emerging epicenters) and then mandating quarantine for travelers from china and south korea. these restrictions had a considerable impact on arrivals into brunei. immigration data indicate a . % decrease in arrivals from january to march ( , people), compared with the same period in ( , , people). outbound travel was restricted for all brunei residents on march , and a ban on all foreign citizens entering the country was enacted on march . beginning on march , all the origin country of imported cases changed over time. cases were initially from malaysia ( cases), and, as the epidemic progressed globally, and overseas brunei citizens were returning, imported cases were identified in travelers and returning residents from indonesia (n = ), united kingdom (n = ), thailand (n = ), the united states (n = ), austria (n = ), cambodia (n = ), australia (n = ), and the philippines (n = ). figure shows the epidemic curve, by the date of symptom onset or np swab date for asymptomatic cases. detection of positive cases among local close contacts occurred very early in the epidemic. coupled with the early detection of further generations (supplemental figure ), this suggests a short time interval for transmission within the community. epidemic characteristics over time. the mean duration from symptom onset to diagnosis for local transmitted cases decreased from days in the first week to − . days in the fifth week of the epidemic (figure a ). among imported cases, this reduction occurred between the third and fourth weeks of the epidemic (from . to . days, respectively), coinciding with implementation of quarantine and testing of all arrivals beginning march (figure a) . this demonstrates the impact of increasingly stringent travel restrictions. there were no local infections linked to imported cases in the last weeks of the epidemic. using the known return dates from imported cases (n = ), the median duration in the exposure period to other contacts was days (iqr = ), ranging between and days. the reduction in the median exposure period between imported cases and their close contacts from their return to diagnosis was apparent between the third ( . days) and fourth weeks ( . days; figure b ). summary statistics and distribution remained unchanged when the local contact cases with known exposure dates were included. among local contact cases, of them ( . %) had known dates of exposure to confirmed imported cases. using these dates, the median incubation period was . days (iqr = ), ranging between and days. based on symptomatic and presymptomatic infectorinfectee pairs, the mean si was . days (sd = . ; % ci: . , . [approximated using normal distribution]). the range for the si was between − and days ( figure c ). four pairs ( . %) had negative si values. the median si was relatively constant throughout the weeks of the epidemic ( figure d ). using the calculated mean si and the -day growth phase of the epidemic, the growth rate was . /day, and the r in the early phase of the epidemic ranges between . and . . the doubling time was . days. figure shows the estimated rt and the timing of the control measures implemented after march . the initial median reproduction number was estimated to be . ( % credible intervals: . , . ) on the seventh day of the epidemic (march ). the time-varying reproduction number gradually decreased after several control measures were put in place and was below one on the th day (march ) and the bold values indicate findings with p-value is < . . * cases were classified as follows: ) symptomatic, if symptoms were reported on or before np swab collection day; ) presymptomatic, if symptoms were reported after np swab sample was taken but during admission; and ) asymptomatic, if no symptoms were reported since np swab collection day until the date of hospital discharge. † this includes the asymptomatic cases, from whom the symptom onset date was replaced by the date of swab collection. ‡ severity was classified as ) asymptomatic, for those with no symptom throughout their disease; ) mild, for patients who had uncomplicated upper respiratory tract infection symptoms and no radiological changes; ) moderate, for patients with radiological changes but did not require supplemental oxygen; ) severe, for patients who showed signs of severe pneumonia including tachypnea > /minute, spo of £ % on room air, or abnormal arterial blood gases, as well as patients showing signs of sepsis with evidence of organ dysfunction; and ) critical, for patients who developed septic shock, that is, persistent hypotension requiring vasopressors support to maintain mean arterial pressure ³ and those who developed acute respiratory distress syndrome requiring ventilatory support. reached . ( % credible intervals: . , . ) on the th day (april ). however, because these control measures were implemented quickly over a short time period, it is difficult to attribute the observed reduction in rt to a specific intervention. key findings. a total of cases ( imported and locally transmitted) were reported from the start of the epidemic on march until the first week of april. all locally transmitted cases could be traced to an importation event, and there were no cases detected without a clear epidemiological link. brunei managed to successfully control the first wave of the covid- pandemic. the r was between . and . , and the epidemic had a doubling time of . days during the exponential phase. there was a rapid decline such that by day , the rt was under one. estimating the reproduction number. assuming the ratio of the infectious period to the si (f) is . , the r was . , higher than those estimated by the who ( . - . ), but within those estimated in other studies from china [ ] [ ] [ ] and europe. our observations of negative sis pose challenges for specifying f. hence, we reported r as a range covering all plausible values of f, using the mean si value from our data and with assumption of exponential growth. then, rt was estimated from the th to the th day. the % credible intervals of the initial rt value ( . - . ) are consistent with those of the r estimate. test, isolate, and trace. we observed that the approach of isolation of confirmed cases, as well as tracing and quarantine of their contacts, was associated with a significant reduction in the effective reproduction number. by the time the early physical distancing measures had been implemented, the rt had reduced from . (ranging between . and . ) at the start to . ( % credible bands: . , . ) by the seventh day (march ). our findings on the importance of the test, isolate, and trace approach are consistent with observational studies from hong kong and singapore. we highlight three characteristics of the approach implemented in brunei. first, testing was conducted on a significant scale. even before detection of the first case, testing was already conducted for all inpatient pneumonia cases, in addition to those who met the suspect case definition; -hour testing centers were established within days of the detection of the first case (march ) , and all contacts were tested regardless of symptom status. the relatively high proportion of asymptomatic ( . %) and presymptomatic ( . %) cases identified demonstrates both the breadth of testing and the speed at which cases were identified. second, all confirmed cases (regardless of disease severity and symptom status) were isolated in a dedicated isolation facility and remained isolated until two negative results were obtained from rt-pcr specimens at -hour intervals. this reduced the chance of household transmission, which could not be excluded if cases were allowed to isolate at home. finally, contact tracing was conducted for each case, using a variety of tools including case interview, workplace assessment, and mobile phone data. contacts were placed on -day home quarantine, and inperson spot checks with penalties for noncompliance were also conducted. travel restrictions and other non-pharmaceutical interventions. we report several characteristics of sars-cov- that make effective isolation and contact tracing challenging, including high transmissibility, a relatively short si (mean si = . days), and a high proportion of asymptomatic and presymptomatic cases suggesting the potential for silent transmission. as such, the test, isolate, and trace approach was supplemented with physical distancing measures to increase the likelihood of achieving sustained control. restricting travel is one measure by which countries have responded to the covid- pandemic. by the time brunei implemented an exit travel ban and restricted the entry of foreign citizens in the country, the rt was already decreasing and had neared one. nonetheless, we suggest that reducing ongoing vulnerabilities to importation events, through restrictions on incoming travelers, and requirements for testing and quarantine for all arrivals in the country limited additional spread, consistent with a reduction in mean time from symptom onset to diagnosis observed for imported cases following implementation of mandatory quarantine and testing for all arrivals. modeling studies suggest a role for travel restrictions in containing the epidemic, with one model estimating that travel restrictions in wuhan reduced case importations elsewhere by nearly % through mid-february. although various other physical distancing measures were implemented in brunei, including school closures; prohibition on mass gatherings, cinemas, and religious services; and dine-in restrictions, importantly, no lockdown was implemented, and there were no generalized stay-at-home orders. most businesses and government agencies were able to operate. these suggest that effective test, isolate, and trace approaches were able to control the epidemic with moderate levels of physical distancing. this finding corroborates the experience of other countries. in hong kong, case isolation and contact tracing were combined with other physical distancing measures (but no lockdown), which resulted in an estimated effective reproduction number near for weeks. in south korea, testing and tracing have been combined with school closures and remote working. even with the best efforts at testing, case identification, and quarantine, the potential for widespread community transmission of covid- is clear. once the disease is established, suppression may require the implementation of severely disruptive social distancing measures. , limitations. our study had several limitations. first, although we can be reasonably confident of having identified most cases since march, given more restrictive testing criteria in january and february, we were unable to account for potential importation events that may have occurred before detection of the first case. second, the generalizability of our results are limited because of lack of community transmission, small number of cases, and a lack of cases in settings such as residential care facilities and dormitories. third, due to the potential for presymptomatic infection of sars-cov- , using the si distribution to approximate the generation time distribution is problematic. we had not accounted for negative sis with the use of the gamma distribution, and thus may have overestimated rt to fit incidence data. one way to account for negative si is to use a deconvolution approach using the incubation period distribution to recover the generation time distribution. however, this assumes that the generation time and incubation period distributions are independent, which may not be appropriate. finally, given the limited data available and the analytic methods used, we could not directly estimate the effectiveness of other non-pharmaceutical interventions, such as face mask wearing, personal hygiene practices, and voluntary reductions in mobility. swift control of covid- in brunei was achieved through a combination of public health measures, focusing on a testisolate-trace approach supplemented by travel restrictions and general physical distancing measures, but no actual lockdown. as of august , , brunei has recorded a total of confirmed covid- cases, with the last case reported on may . on may , brunei commenced its de-escalation plan in a stepwise approach including reopening of mosques, schools, and other indoor facilities in phases, while still maintaining its border control and enhancing the surveillance program (including testing of high-risk groups such as those working in residential institutions, healthcare workers, and also individuals at relatively high risk of developing severe complications). in conjunction with easing of physical distancing restrictions, a mobile application was rolled out on may to speed up the process of contact tracing. its public uptake among the general adult population was > %. along with timely reimposition of physical distancing measures, if necessary, these can help maintain suppression of a second wave in brunei. e-mail: sirajul.jamaludin@moh.gov.bn. wan wen patricia poh, department of dental services, ministry of health covid- : what is next for public health? can we contain the covid- outbreak with the same measures as for sars? first-wave covid- transmissibility and severity in china outside hubei after control measures, and second-wave scenario planning: a modelling impact assessment the effect of human mobility and control measures on the covid- epidemic in china covid- : travel health and the implications for sub-saharan africa a single mass gathering resulted in massive transmission of covid- infections in malaysia with further international spread sars-cov- transmission in different settings: analysis of cases and close contacts from the tablighi cluster in brunei darussalam. medrxiv responding to covid- in brunei darussalam: lessons for small countries suppression of covid- outbreak in the municipality of vo transmission dynamics and control of severe acute respiratory syndrome an introduction to infectious disease modelling improved inference of time-varying reproduction numbers during infectious disease outbreaks estimation of the time-varying reproduction number of covid- outbreak in china evolving epidemiology and transmission dynamics of coronavirus disease outside hubei province, china: a descriptive and modelling study a new framework and software to estimate time-varying reproduction numbers during epidemics r: a language and environment for statistical computing estimation of the transmission risk of the -ncov and its implication for public health interventions effects of media reporting on mitigating spread of covid- in the early phase of the outbreak modelling the epidemic trend of the novel coronavirus outbreak in china. biorxiv monitoring transmissibility and mortality of covid- in europe suppressing covid- transmission in hong kong: an observational study of the first four months evaluation of the effectiveness of surveillance and containment measures for the first patients with covid- in singapore feasibility of controlling covid- outbreaks by isolation of cases and contacts early dynamics of transmission and control of covid- : a mathematical modelling study estimating covid- outbreak risk through air travel the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak reduction in effective reproduction number of covid- is higher in countries employing active case detection with prompt isolation impact assessment of non-pharmaceutical interventions against coronavirus disease and influenza in hong kong: an observational study flattening the curve on covid- -how korea responded to a pandemic using ict only strict quarantine measures can curb the coronavirus disease (covid- ) outbreak in italy the positive impact of lockdown in wuhan on containing the covid- outbreak in china estimating effective reproduction number using generation time versus serial interval, with application to covid- in the greater toronto area this is an open-access article distributed under the terms of the creative commons attribution (cc-by) license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. key: cord- -kjx z hc authors: rubio-pérez, inés; badía, josep m.; mora-rillo, marta; quirós, alejandro martín; rodríguez, julio garcía; balibrea, jose m. title: covid- : key concepts for the surgeon date: - - journal: nan doi: . /j.cireng. . . sha: doc_id: cord_uid: kjx z hc abstract in view of the current pandemic by sars-cov- it deems essential to understand the key concepts about the infection: its epidemiological origin, presentation, clinical course, diagnosis and treatment (still experimental in many cases). the knowledge about the virus is still limited, but as the pandemic progresses and the physiopathology of the disease is understood, new evidence is being massively published. surgical specialists are facing an unprecedented situation: they must collaborate in the er or medical wards attending these patients, while still needing to make decisions about surgical patients with probable covid- . the present narrative review aims to summarize the most relevant aspects and synthetize concepts on covid- for surgeons. the current pandemic of severe acute respiratory syndrome coronavirus (sars-cov- ) is an unprecedented situation for healthcare systems. the high incidence of cases has saturated these systems, leading to the reorganization of hospitals and the availability of all resources for the treatment of patients with covid- . this has had a significant impact in the field of surgery, as many elective surgical procedures have been suspended, operating rooms closed for the use of the ventilators in intensive care units, and surgical staff redistributed to other medical services. both the spanish ministry of health and numerous scientific societies have published guidelines and recommendations for medical professionals. the surgical infection division of the spanish association of surgeons (asociación española de cirujanos, or aec) and the specific surgery-aec-covid- workgroup have reviewed the scientific evidence and available guidelines, synthesizing key concepts about covid- in order to facilitate the transfer of this knowledge to surgeons. methods a review of the literature has been conducted using pubmed and platforms with specific covid- resources: litcovid, cochrane library, lancet resource center, springernature, biomed central and jama network. likewise, for other specific aspects, we have consulted updated information and documents from the spanish ministry of health, the world health organization (who), centers for disease control (cdc), as well as the recommendations of surgical societies including: aec, american college of surgeons, society of american gastrointestinal and endoscopic surgeons, european cancer organization and the association of surgeons of great britain and ireland. the co-authors conducted the bibliographic search, reviewed the selected articles, and adapted the content for synthesis. the most relevant topics were grouped in an orderly manner to facilitate accessibility and consultation of this document. the authors have provided a narrative review of the literature available for certain key aspects of covid- epidemiology, clinical presentation, diagnosis and treatment, which are of special interest to the readers of the journal. specific concepts related to surgery have also been included, based on available evidence. the new coronavirus responsible for severe acute respiratory syndrome (sars-cov- ) was first detected in december in the city of wuhan (hubei province, china). several cases of atypical pneumonia of unclear origin were detected. as the first infected patients had been to the huanan market (wuhan), this site was the suspected ground zero of the epidemic and was closed on january , . the disease is considered a zoonosis, although it still has not been determined in which animal the disease originated. based on the genetic sequencing of the virus, either bats or the pangolin would be the most probable animal of origin. the virus was sequenced in early january , which identified it as a new type of coronavirus. on january , , china openly shared the gene sequencing of the new coronavirus on the gisaid.org platform. on january , the first case outside china was detected in thailand, which was an individual who had traveled to wuhan. in the following days, cases were detected in japan, korea and other asian countries. on january , the usa reported the first positive case, a traveler who arrived in washington state that had also come from wuhan. the first case in europe was reported by the french ministry of health on january th . on january , , the who declared a public health emergency of international concern (pheic), and the number of cases continued to rise in several countries, including iran, italy and spain. on march , , the who declared covid- had progressed to pandemic status. s i t u a t i o n i n s p a i n table shows the chronology of the most relevant events in spain in terms of the start and evolution of the epidemic. by april , , a total of cases had been registered in spain, with deaths and cured patients (currently, these numbers are still rising). however, the estimates of undiagnosed cases are much higher. the community of madrid has been one of the most affected, with the highest number of confirmed cases (> on april , ). c h a r a c t e r i s t i c s o f t h e v i r u s coronaviruses are a broad family of viruses first described in the s. they are spherical, encapsulated viruses that contain single-stranded rna surrounded by a protein coat. protein s 'spikes' cause the characteristic structures giving it its crown-like appearance, and they are what determine the tropism of the virus and its fusion with host cells. there are several known coronaviruses circulating in animals and humans. an interspecies 'jump' can sometimes occur, as in the case of sars in (which originated in civets) or mers in (originating in dromedaries), causing serious novel respiratory diseases in humans. the main difference between these and the current sars-cov- is the transmissibility between humans that the latter has shown. on february , , the official nomenclature was established for the virus as sars-cov- , and the disease it causes as covid- . it is a highly transmissible virus. the main form of transmission is droplets (large particles > m, moving - m) that are produced when an infected person sneezes or coughs. transmission by contact with surfaces or fomites contaminated by these droplets is also relevant, with subsequent entry of the infection by touching the nose, eyes or mouth. transmission by aerosols (small particles < m, moving more than m) is also possible and has stirred up controversy. this factor is especially relevant in the healthcare setting. in the operating room, the possibility of aerosolization when performing intubation or any airwayrelated maneuver is of concern. aerosolization also seems possible when using electrocoagulation or laparoscopy (if the patient is infected) when performing these techniques on infected tissue, mainly the respiratory tree. in vitro studies have shown that the virus can survive on multiple types of surfaces (metal, plastic or glass), where it can remain for up to days. disinfection of surfaces is therefore essential to minimize the contagion risk. thorough hand washing (with soap and water) is recommended as a preventive measure, using either soap (due to the ability of the soap to disintegrate the viral lipid capsule) or hydroalcoholic gels. likewise, solutions of %- % alcohol (ethanol), . % hydrogen peroxide and . % sodium hypochlorite are highly virucidal (time of around one minute), which should be used in surface disinfection. other biocides such as . % chlorhexidine gluconate or . %- % benzalkonium chloride are less effective. , the who has made available formulations to for individual/institutional/local production of alcoholic solutions in case of shortages or distribution problems. p r e v e n t i o n o f t r a n s m i s s i o n a n d i n f e c t i o n as the specific mechanism of transmission of the virus is known, it is essential to establish preventive measures. in the case of transmission by droplets, the basic measures are: -cover mouth/nose when sneezing, or use a disposable tissue and throw this away immediately. -symptomatic patients should cover their nose and mouth with a mask, one without a valve to avoid the dispersion of droplets. -wash hands with soap and water or hydroalcoholic solution. -maintain interpersonal distance (some studies even recommend . - meters). -avoid touching your face (eyes, nose and mouth). -follow pertinent recommendations made by health authorities (local/national/international). in the situation of an epidemic, it is essential to adopt a series of public health measures for the population, which will depend on the evolution of the epidemic and the local context: -vigilance: rapid detection of cases in order to establish pertinent isolation measures as early as possible during the containment phase. -screening at entry points: detection of imported cases and adequate information to persons coming from affected areas. -contact studies of confirmed cases to quickly identify infected individuals, and isolation (at home) of positive patients to avoid new contacts for weeks (in the containment phase). -social distancing measures: these may include avoiding crowds or large gatherings or public events, and even mandatory quarantine of the population (mitigation phase). -healthcare authorities should inform the public about the measures implemented, number of cases and status of the epidemic; health education measures are also necessary. the clinical presentation is highly variable, and different conditions have been observed, from mild (catarrhal symptoms) to very severe (adult respiratory distress syndrome). there are asymptomatic patients who pose an epidemiological problem due to their ability to transmit the virus unnoticed. the average incubation period is about days (ranging from to days), and . % of patients develop the disease in the first . days of incubation. the most frequently described clinical symptoms have been fever, cough (with/without expectoration) and general malaise. other symptoms have been described with varying frequencies, including dyspnea, headache, asthenia, myalgia, odynophagia, nasal congestion/discharge, anosmia, ageusia, syncope, confusion, neurological symptoms, ophthalmological symptoms (conjunctivitis and dry eye) and cutaneous (rash skin eruptions). a percentage of patients report the presence of diarrhea, vomiting and abdominal pain as relevant symptoms. sars-cov- rna has been identified in stool samples from infected patients, and the viral receptor ace has been found with high expression in gastrointestinal epithelial cells, indicating that the virus could easily infect and replicate in the gastrointestinal tract. it has also been observed that the virus continues to be eliminated in the feces after the initial symptoms have passed. however, fecal-oral transmission has not been confirmed at this time. preliminary data obtained mainly from studies carried out in the chinese population seem to indicate that elderly patients with associated comorbidities (htn, cardiopathy, diabetes, cancer, obesity, etc.) are at increased risk of serious presentations. it is estimated that more than % of total cases are mild/moderate, but % are severe and % critical. patients with the highest mortality in the chinese retrospective studies were males with a mean age years older than survivors ( vs. years) who had some type of underlying pathological process (htn, diabetes, cardiovascular disease or copd). furthermore, the presence of various associated comorbidities also increased the risk of poor progress. table shows some serious risk factors and laboratory abnormalities that have been associated with poor clinical outcomes. it has been observed that cases with poor present sudden worsening (usually in the second week of illness), with the appearance of dyspnea and respiratory failure that usually lead to the need for oxygen therapy and occasionally intubation and icu care around days to . , the usual cause of death is uncontrolled sepsis and respiratory failure. this poor evolution seems to correlate with the development of a 'cytokine storm' on the th day, which occurs as a result of the virus's interaction with the patient's immune system. the molecular diagnosis is based on rt-pcr techniques that study specific sequences of the virus genome. when the sars-cov- genome was openly shared, several groups began working to develop diagnostic rt-pcr tests based on genomic regions. in general, it is recommended to detect a less specific area for screening (the envelope gene or e gene) and another more specific one for confirmation (rna-dependent rna polymerase, or rdrp). there are different combinations of sequences according to the protocol developed by several laboratories. despite having high sensitivity and specificity, these tests can present false negatives. generally, these are due to the sample being insufficient or unrepresentative, taken too early or too late in the course of the disease, or degraded during transport or handling. in negative cases where suspicion or symptoms persist, it is recommended to repeat the rt-pcr in a few days. although nasopharyngeal or oropharyngeal samples are the easiest to obtain, bronchial samples (for example, bronchoalveolar lavage) are more effective for diagnosis yet more complex to obtain and require a higher level of biosecurity for personnel during extraction. the virus has also been detected in other biological samples (blood, feces, and saliva). serological techniques are able to detect igm and igg antibodies. there is evidence that these techniques begin to detect antibodies from day after the onset of symptoms, and they can be useful for population-based seroprevalence studies. there are already commercially available serological tests (immunochromatography) performed with whole blood that may be useful in diagnosis. cell culture is used for research. it takes several days, so it is not useful for clinical diagnosis, but it enables us to study the cytopathic effect of the virus on cell lines and to obtain virions. in this instance, biosecurity facilities (minimum bsl iii) are necessary. in the initial stages of the disease, changes may not be observed on plain radiography, or even on ct scan if performed during the first days of symptoms. however, as the condition progresses, the sensitivity of ct increases, especially after the th day, when almost all patients with covid- will present some type of alteration. when the radiological image is abnormal, certain common patterns are seen. asymmetrical areas of alveolar or interstitial opacity (patches or diffuse) are identified on simple chest radiograph. the most common pattern is bilateral pneumonia, with subpleural ground glass opacities, poorly defined margins and a slight predilection for the right lower lobe (figure ) . the most characteristic findings on thoracic ct are multiple ground glass opacities with peripheral lung consolidations. if these atypical findings are identified (even in asymptomatic patients), the diagnosis of covid- should be considered. ct stratification has been used to assess severity and is the most sensitive diagnostic test, detecting lesions that are sometimes not identified on plain chest radiography. this may be especially relevant in the early identification of cases, for example preoperatively in patients with suspected disease requiring surgery. regarding lab results, increased c-reactive protein (crp) levels with normal procalcitonin and lymphopenia (< cells/l) are characteristic. it should be noted that severe cases (compared to moderate ones) more frequently presented intense lymphopenia, hypoalbuminemia and higher levels of alt, ldh, pcr, ferritin and ddimer, as well as il- r, il- , il- and tnf-. current evidence suggests that the exaggerated immune response mediated by the cytokine storm leads to acute lung injury and acute respiratory distress, which, without treatment and support, lead to death in a large proportion of patients. in severe cases, it is recommended to rule out coinfections with other respiratory pathogens (influenza a and b, pneumococcus and legionella) and to extract blood for cultures. in the first series published in china, % of the deceased presented a second infection during hospitalization. t r e a t m e n t to date, there is no known effective treatment for covid- . however, several molecules have demonstrated in vitro activity against sars-cov and they are being investigated and used off-label. there are currently various clinical trials underway from different initiatives, public and private, national and international, to try to establish which treatment may be effective for covid- . the who has proposed an international clinical trial (solidarity trial) to evaluate the efficacy of the different therapeutic modalities proposed in affected countries, which have been used empirically or based on limited evidence. it is an adaptive, open, randomized trial that allows the study branches to be modified as more data become available. currently, the molecules under evaluation are: j o u r n a l p r e -p r o o f ) remdesivir (initially developed and previously evaluated for the ebola virus) ) lopinavir/ritonavir (enhanced antiretroviral therapy used for hiv) ) lopinavir/ritonavir in combination with interferon  ) chloroquine or hydroxychloroquine (cq/hcq) (antimalarial drugs that have been used successfully in china) ) all of them will be compared with standard support treatment without any molecule with potential antisars-cov action the spanish ministry of health frequently updates the drugs proposed for treatment as data and new therapeutic options are registered. currently some of the drugs being considered in the protocol are: cq/hcq, lopinavir/ritonavir, remdesivir, tocilizumab, sarilumab, interferon beta- b and interferon alfa- b. cq/hcq has demonstrated an antiviral effect in vitro, and it therefore has been considered a possible candidate for treatment and has been widely used empirically. when administering any of these off-label treatments, it is essential to evaluate the pharmacological interactions with the patient's current medication and potential toxicity. serious interactions can occur (such as qt prolongation with cq/hcq) and occasionally there are relevant contraindications (in cardiac or hiv-positive patients, etc.). web portals such as www.hiv-druginteractions.org provide for quick consultation of interactions. the utility of plasma from convalescent patients is being tested for the treatment of critically ill patients with covid- , and several laboratories around the world are investigating the development of a possible vaccine. the aec, as well as other national and international scientific societies, have issued clinical guidelines and recommendations to try to standardize practices at this critical moment, aimed at protecting both patients and healthcare professionals. [ ] [ ] [ ] around the world, the available evidence has been used to dynamically update treatment guidelines in moderately and critically ill patients, diagnostic testing, tracing contacts, as well as the necessary protective measures for healthcare workers depending on the type of care or procedure to be carried out. any procedure with increased exposure to respiratory secretions (intubation, tracheostomy, ent examination, etc.) is considered high risk. other body fluids that may present viral load, such as saliva, feces and blood, in which viral load has been detected to a greater or lesser extent, are also considered a risk. regarding the possibility of aerosolization in surgical procedures (electric scalpel and other electronic devices, laparoscopic smoke, etc.), various studies have been carried out by surgical teams, and specific proposals have been made to reduce this aerosolization (smoke filtration with a water seal and bleach, suction of smoke from the electric scalpel, etc.). in any case, and given the possibility of this infection route, it is essential that all operating room personnel have adequate and complete personal protective equipment, especially face protection (ffp /ffp /n masks, closed goggles and shields when needed). after the experience in china and italy, some important measures have been proposed for laparoscopy: minimize the dispersion of aerosols, avoiding uncontrolled leakage of gas/fluids through trocars or incisions; use closed filtration and evacuation systems for smoke; use the lowest possible gas pressure and the lowest intensity programs for electrocoagulation. it is also essential to adequately train and instruct operating room staff in this regard. under the circumstances of a pandemic, the high number of patients affected simultaneously saturates healthcare services. in the case of covid- (due to its ability to produce severe respiratory symptoms), there is an increased demand for ventilators and hospital or icu beds for these patients. therefore, in anticipation of the need for these resources, it has been proposed to delay all elective surgical procedures when possible, always considering the local epidemiological situation and the resources of each hospital. patients with a benign pathological process and/or with a low risk of complications may be postponed without a problem. in other elective cases in which there is some risk of complication due to not performing the intervention, the urgency of each case will be assessed individually (considering the benefit/risk), but postponing is recommended as long as possible until the current epidemiological situation is normalized. , o n c o l o g y p a t i e n t s oncology patients can be especially affected during the pandemic period for several reasons: -greater susceptibility to infection due to the baseline disease or secondary to immunosuppression of adjuvant treatments (chemotherapy). -alteration of their treatment regimens (chemotherapy and radiotherapy) or inability to conduct scheduled surgical procedures, which may affect the course of their disease and/or prognosis. -complications of oncological disease that require urgent treatment or hospitalization and increase the risk of sars-cov- infection (bleeding, perforation or obstruction due to untreated stenosing tumors, thrombosis, other infections, etc.). in case of suspicion and symptoms compatible with covid- , multiple international societies, such as the european cancer organization, advocate the prioritization of sars-cov- detection tests in these patients. decisions on whether or not to proceed with elective surgery in cancer patients currently depend on the local epidemiological situation, availability of operating rooms j o u r n a l p r e -p r o o f and icu at the corresponding hospital, disease status and the risk of progression or complications (individualized), assessment of surgical risk and potential complications of the procedure. in addition, specific assessment is necessary of possible pre/postoperative covid- infection as well as the individual risk in terms of the comorbidities of the patient, who must also be informed. individualized decisionmaking is promoted by multidisciplinary committees, and the creation of 'clean' hospitals where cancer patients can be referred has been proposed in high-incidence areas. in some cases, and depending on the type of tumor, even alternative treatments (such as extra cycles of chemotherapy) are proposed to control progression and/or delay surgery. u r g e n t s u r g e r y disease requiring urgent surgical management cannot be delayed or canceled despite the pandemic situation. in cases of pathological processes requiring surgery that cannot be postponed (appendicitis, peritonitis, etc.), several aspects must be evaluated when making decisions: -patient covid- status: does the patient present a concomitant viral infection in addition to the surgical disease? this determination is essential for the patient's prognosis and surgical risk as well as for the surgical team, who must be adequately protected. -is there sufficient protective material (personal protective equipment [ppe])? are the facilities satisfactory to operate safely? -are there any alternative treatments other than surgery that would be safe for the patient? for this reason, medical societies like the aec and the american college of surgeons suggest determining the patient's covid- status before proceeding with the surgical intervention in order to act in the safest way. all available means will be used to make this determination, ideally including rt-pcr and chest radiology (preferably ct scan). when it is not possible to determine covid- status, or in uncertain cases, proceed with surgery under the assumption that the patient is positive, providing adequate protection for operating room personnel with complete ppe. some extra measures have also been suggested, such as delaying the entry of staff into the operating room as much as possible, that the procedure be carried out by the most experienced surgeon available and that all non-essential personnel leave the operating room before extubation. as already mentioned, the use of the laparoscopic approach has generated great controversy because of possible aerosolization with the use of pneumoperitoneum. h e a l t h p e r s o n n e l a n d i n d i v i d u a l p r o t e c t i o n the availability of adequate material and sufficient ppe has been one of the most relevant issues since the start of the pandemic because of the global shortage and the many infections (and deaths) occurring among front-line healthcare workers. the experience in italy has been especially important in this regard, since a much higher number of infections was detected among healthcare personnel than in china, even leading to the closure of hospitals due to lack of personnel and the death of doctors. , unfortunately, the situation in spain has developed in a way similar to italy, and we are currently the country with the most infected health personnel (around %), which in many cases is secondary to the lack of adequate protection. it is essential for any surgeon working with covid- to have sufficient, quality ppe available. the current sars-cov- coronavirus pandemic is the greatest challenge that contemporary medicine has ever experienced. it directly affects all surgeons, requiring their role within health institutions to be redefined and their usual therapeutic strategies to be rethought, while having to adapt to unfavorable working conditions in which surgeons may be seriously affected. the very high incidence of sars-cov- infection requires surgeons to have an indepth understanding of the disease, including daily tasks and medical treatments with which they are not familiar. likewise, they need to adapt their practice to a critical situation, prioritizing safety in the work environment and care for the most serious patients, while considering options they usually do not consider, especially in emergencies. the need to know and implement strategies aimed at patients whose surgeries cannot be delayed, especially cancer patients, is essential to avoid what are called secondary and tertiary victims of the pandemic: infected healthcare workers and, above all, patients who ultimately receive suboptimal treatment. it is essential to highlight that the current situation has made decision-making necessary in a scenario full of uncertainties, where the scientific evidence to support these decisions is scarce. thus, although the effort of the health community continues to be intense, it is essential to constantly reevaluate each of the measures adopted. being a surgeon in the era of covid- requires maximum versatility, which means accepting that today's decisions may not be tomorrow's. again, this is an opportunity to renew deaver's aphorism that a surgeon is always more than just a doctor, yet never anything less. the authors have no conflict of interests to declare. the novel coronavirus resource. yi chuan identifying sars-cov- related coronaviruses in malayan pangolins aerosol and surface stability of sars-cov- as compared with sars-cov- pubmed central pmcid: pmc . -world health organization. guide to local production: who-recommended handrub formulations the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application covid- and the digestive system characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention china medical treatment expert group for covid- . clinical characteristics of coronavirus disease in china an update on covid- for the radiologist -a british society of thoracic imaging statement thailand joins the who "solidarity trial": global testing of effective treatments of covid- across countries -an aggressive effort to save lives from the pandemic (press release) could chloroquine /hydroxychloroquine be harmful in coronavirus disease (covid- ) treatment? covid- : fda approves use of convalescent plasma to treat critically ill patients management of critically ill adults with covid- -rosenbaum l. facing covid- in italy-ethics, logistics, and therapeutics on the epidemic's front line key: cord- -sfr x ob authors: röst, gergely; bartha, ferenc a.; bogya, norbert; boldog, péter; dénes, attila; ferenci, tamás; horváth, krisztina j.; juhász, attila; nagy, csilla; tekeli, tamás; vizi, zsolt; oroszi, beatrix title: early phase of the covid- outbreak in hungary and post-lockdown scenarios date: - - journal: viruses doi: . /v sha: doc_id: cord_uid: sfr x ob covid- epidemic has been suppressed in hungary due to timely non-pharmaceutical interventions, prompting a considerable reduction in the number of contacts and transmission of the virus. this strategy was effective in preventing epidemic growth and reducing the incidence of covid- to low levels. in this report, we present the first epidemiological and statistical analysis of the early phase of the covid- outbreak in hungary. then, we establish an age-structured compartmental model to explore alternative post-lockdown scenarios. we incorporate various factors, such as age-specific measures, seasonal effects, and spatial heterogeneity to project the possible peak size and disease burden of a covid- epidemic wave after the current measures are relaxed. a cluster of pneumonia cases of unknown origin was detected in wuhan city, the capital of hubei province, china, with a population of million in december . on december china alerted the world health organization (who) china country office [ ] . on january the causative pathogen of the pneumonia outbreak was identified as a novel coronavirus, and, on february, the who officially named the novel coronavirus as sars-cov- and the disease it causes as covid- . sars-cov- infection quickly spread from china, where it emerged in december , to europe, where the first cases were confirmed on january in france (where, later in april, covid- was retrospectively confirmed for a patient hospitalized in late december ) [ , ] . around the same time, on january, the first infection in germany was confirmed in bavaria that led to a local outbreak. by february , subsequent cases have been confirmed and high-risk contacts have been identified via agile contact-tracing [ ] . the first epidemic in europe started in the lombardy region of italy with the first detection on february [ ] . the who director-general declared the covid- outbreak a public health emergency of international concern under international health regulations ( ) on january [ ] and then a pandemic on march [ ] . by that time, the number of daily new cases of covid- was over in several countries, including italy, france, and germany. manipulation and shiny version . . . [ ] for creating an interactive dashboard to carry out epidemiological analyses online (available in hungarian [ ] ). the full source code of this dashboard and related analysis is available at [ ] . effective reproduction number (r t ), the average number of secondary cases per primary case for those primary cases who turn infectious on day t, was tracked in real time based on the daily number of reported new cases using the methods of cori et al. [ ] and that of wallinga and teunis [ ] , among the several methods aimed to estimate r t [ , ] . in brief, the method of cori et al., is based on calculating the ratio of the actual number of infections on a day to the total infectiousness of all past cases on that day. thus, it measures r t by assuming that infected individuals will infect in the future as if conditions remain unchanged. in contrast, the method of wallinga and teunis makes no such assumption; it uses a likelihood-based inference on the possible infection networks underlying the epidemic curve. the fundamental difference is that the method of cori et al., solely uses past information ("backward looking approach"), due to which the result is sometimes called instantaneous reproduction number, while the wallinga-teunis method more closely corresponds to the concept of the usual definition of effective reproduction number; however, it requires future information in exchange ("forward looking approach"). for a discussion on the relative merits of these two approaches, see [ , ] . the wallinga-teunis method was used with the addition of cauchemez et al., who aimed to provide real-time estimation capability [ ] . both methods require-in addition to incidence data-information on the serial interval. depending on the used dataset, different estimations of the serial interval have been published: a mean of . days was found in [ ] , and . days in [ ] . here, we assume an intermediate value following [ ] , where the mean and standard deviation (sd) of the serial interval were estimated at . days ( % cri: . , . ) and . days ( % cri: . , . ), respectively. (the serial interval is assumed to follow gamma distribution.) they also concluded that the serial interval of covid- is close to or shorter than its median incubation period, which is coherent with our choice of parameters in the transmission dynamics model. the estimation was carried out using r packages r version . - [ , ] and epiestim version . - [ , ] . case fatality rate (cfr) is defined as the (conditional) probability of death from a disease for those contracting the disease (for diseases where asymptomatic state also exists, infection fatality rate (ifr) is defined analogously) and is estimated as the ratio of cumulative deaths and cumulative cases. this definition, i.e., where c t and d t are the daily, c t and d t are cumulative number of cases and deaths, respectively, on day t is however biased when used during the epidemic (thus the name crude/naive cfr or ncfr). the reason for this is that a proportion of cases counted in the denominator will die (in the future), thus they should have been counted in the numerator as well, but, as they're not, the ratio underestimates the true value [ , ] . fortunately, it is relatively easy to correct for this bias using information on the distribution of the diagnosis-to-death time [ , ] . the likelihood that the cumulative number of deaths on day t is d t is given by where f i denotes the (conditional) probability that death happens on day i after onset (for those who die) and π stands for the true value of the cfr. this observation allows both maximum likelihood and bayesian estimation for π using the observed series of c i and d i , the latter of which was employed in the present study, using a beta( , ) (i.e., uniform) prior. it was assumed that diagnosis-to-death time follows lognormal distribution with a mean of days and a standard deviation of . days, as found by linton et al. [ ] . the bayesian estimation was manually coded using the r package rstan version . . [ ] . a markov chain monte carlo approach was used to carry out the estimation with no-u-turn sampler, using chains, warmup iterations and iterations for each chain. the cfr mentioned in the previous subsection is still not the true value of the fraction of fatal outcomes of all infections, as there is another source of bias, but this time leading to overestimation: the underascertainment of cases. this is a substantial issue now as a-precisely not yet known, but epidemiologically significant-fraction of the covid- cases are asymptomatic or mildly symptomatic. since in many countries testing was extended to contacts (and in a few instances, even random sampling was carried out), the confirmed cases include some asymptomatic cases as well. however, the value of the estimated (corrected) ifr can also be used to estimate the ascertainment rate: by assuming that the ifr in reality takes a benchmark value (one derived from large-sample, well-designed studies accounting for underascertainment or sero-epidemiological surveys) and-crucially-assuming that the difference of the actual estimated ifr from that value is purely due to underascertainment. then, the ascertainment rate can be obtained by simply dividing the assumed true value of the ifr with the actual estimated cfr [ ] . note that this might be a strong assumption, as it rules out that there is a real difference in the country's ifr from the benchmark value; in particular, it rules out different virulence of the pathogen, different age-and comorbidity-composition in the country and different effect of the healthcare system on survival. mathematical models have been developed to better understand the global spread [ ] and the transmission dynamics of covid- for many countries, including australia [ ] , france [ ] , germany [ ] , uk [ ] , and the usa [ , ] . such models have been used to project the progress of the outbreak and to estimate the impact of control measures on reducing disease burden. the two most common approaches are compartmental models formulated as systems of ordinary differential equations, and agent based models used to generate an ensemble of stochastic simulations for possible outcomes. here, we establish a compartmental population model, adjusted to the specific characteristics of covid- , considering the following compartments. we denote by s the susceptibles, i.e., those who can be infected by the disease. latents (l) are those who have already contracted the disease but do not show symptoms and are not infectious yet. in accordance with studies indicating that viral shedding peaks before the onset of symptoms [ ] , in our model, we have introduced the presymptomatic infected compartment i p for those who do not have symptoms, but who already are capable of transmitting the disease to susceptibles. we divided the latent period into two compartments l and l , thus, together with i p , the incubation period follows a hypoexponential distribution, having a shape matching empirical observations [ , ] . since a large fraction of infected shows only mild or no symptoms, after the incubation period, we differentiate these individuals from those with symptoms. we assume a gamma-distributed infectious period with erlang parameter m = , similar to the sars study [ ] , hence, we have three classes for both asymptomatic and symptomatic infectious individuals (i a, , i a, , i a, and i s, , i s, , i s, , respectively). individuals from the i a, compartment will all recover and hence proceed to the recovered class r. immunity is assumed for those who have recovered from the disease, at least for the time scale of this modeling. individuals from i s, may either recover without requiring hospital treatment (and thus move to r) or become hospitalized. it is of crucial importance to project the number of hospital beds and intensive care unit (icu) beds needed; thus, in the model, we further differentiate symptomatically infected individuals who need hospital care and critical care, denoted by i h and i c , respectively. we operate with the assumption that the healthcare system will not be overwhelmed, and thus disease-induced death is only considered from critical care that fits with the data obtained from nphc. hence, individuals from i h will proceed to r after recovery. those from i c with fatal outcome transit to the d compartment. those who are out of icu and on the path to recovery are collected into the i cr , from where they eventually recover and move to the r class. to take into account the different characteristics of the disease in various age groups, we stratified the hungarian population into seven groups, corresponding to the available choices in the hungarian online questionnaire for the assessment of changes in the number of contacts following the lockdown [ ] . the compartments listed above corresponding to the different age groups are denoted by an upper index i ∈ , . . . , . accordingly, all of our parameters can be calibrated age-specifically. the transmission rates from age group k to age group i are denoted by β (k,i) j , with j ∈ {p, a, s}, where the three subscripts p, a, s stand for presymptomatic, asymptomatic, and symptomatic infected, respectively. the parameters described in the following all have an upper index i which stands for the corresponding age group. a fraction p i of exposed people will not show symptoms during his/her infection, while ( − p i ) will develop symptoms. the average length of the incubation period is (α i l, ) − + (α i l, ) − + (α i p ) − days, with the transition rates α i l, , α i l, , α i p , respectively. similarly, the average infectious period of asymptomatic and symptomatic infected individuals are with the corresponding transition rates, respectively. a fraction h i of the infectious compartment i i s, will be hospitalized, the remaining fraction − h i will recover without hospital care. out of those who need hospitalization, a fraction ξ i needs intensive care. for the hospitalized classes i i h , i i c , i i cr , the average time spent in these compartments is given as (γ i h ) − , (γ i c ) − and (γ i cr ) − , respectively. a fraction µ i of those leaving the i i c compartment will die due to the disease, while the remaining fraction will proceed to the i i cr class. the transmission dynamics of our model for one age group is illustrated in figure . . reproduction numbers are calculated using the next generation matrix method in section . . . we discuss the application and, then, some limitations of this model in sections . . and . . , respectively. the codes were implemented in wolfram mathematica and are available at [ ] . the governing equations of the transmission model described in section . take the form where the index i ∈ { , . . . , } represents the corresponding age group. next, we add the spatial locations of the population to the previous model. the population is divided into patches, where each patch represents a separate geographic region. within each region, we use the same compartmental model (but possibly with different parameters), and we also include spatial movement of individuals between the patches. the governing equations of such a metapopulation model, where p ∈ { , , . . . , #patches} are we have chosen our model parameters based on comprehensive literature review and present them here, except the transmission rates β (k,i) s,_ which are left for section . . . for the incubation period, we assume hypoexponential (generalized erlang) distribution with parameters ( . , . , ). this way, the average incubation period is . days: the same length and very similar shape of the probability distribution function was estimated in [ ] , and this distribution has the observed concavity properties as well (see [ ] ). in addition, this estimation is consistent with [ ] , and such values have been used in [ , , , ] . the first . days are the latent period [ ] and the past two days are the presymptomatic period [ ] , when transmission is already possible with similar rate as at symptom onset [ ] . therefore, we use the same transmission rates for the presymptomatic and symptomatic infectious periods. for the transmission rate of asymptomatic infected individuals, we use a reduction factor . [ , , ] . for the length of infectious periods (both symptomatic and asymptomatic), we assume a gamma distribution with erlang parameter (coherent with the sars study [ ] ), and an average length days of infectivity. although full recovery and viral shedding may take much longer, the infectiousness throughout the course of infection is mostly concentrated to this period [ , ] . the choice of days is also justified by [ , ] , who estimated that around % of transmissions occur during the presymptomatic period, and it is also within the range of infectious periods used by [ , ] . the average stay in hospital is assumed to be days, in accordance with the seven days median reported in [ ] using over , patients' data in the uk. similarly, the average duration of critical care is assumed to be days, in accordance with the intensive care national audit & research center (icnarc) report [ ] . very similar numbers were reported in the us [ ] , and were used in other modeling studies [ , , ] . for those who recover from intensive care, we assumed a -day hospitalized rehabilitation period. the periods above associated with the average time an individual spends in each compartment over the course of the infection are age-independent and summarized in table . table . age-independent epidemiological parameters of covid- . assumed to be valid for all age groups. references and explanations are in section . . . incubation period (α i l, ) − + (α i l, ) − + (α i p ) − . days latent period (α i l, ) − + (α i l, ) − . days presymptomatic (infectious) period (α i p ) − . days infectious period of i i a (γ i a, ) − + (γ i a, ) − + (γ i a, ) − . days infectious period of i i s (γ i p, ) − + (γ i p, ) − + (γ i p, ) − . days hospitalization (γ i h ) − presymptomatic vs symptomatic β next, we discuss the age-specific parameters, which are mostly related to the outcome of infections. we stratified the population into the following seven age groups: - , - , - , - , - , - , + years old. using the data from the hungarian central statistical office (ksh), we obtain the division shown in table . according to [ ] , a fraction . of infected children (under years old) are asymptomatic or mild cases. this value was used in [ ] as well. we set the probabilities of the infection following mild or asymptomatic course in an individual according to weitz et al. [ ] . the probabilities of hospitalization given infection h i and of requiring intensive care in addition ξ i are based on the work of moss et al. [ ] . the ratios of fatal outcomes µ i are derived from the icnarc report [ ] comprising icu case reports from uk. all these age-dependent parameters are listed in table . for creating our contact matrix m cont , we have utilized the work by prem, cook, and jit [ ] , where the estimated matrices are written for age groups, namely - , - ,. . . , - , +. as we have divided the hungarian population into seven age groups, see table , we aggregated the higher resolution data. first, we derived a symmetric matrix m total with elements where m = [m i,j ] is the original contact matrix and [p i ] is the age distribution of hungary for the same age groups as in [ ] . thus, m total contains the total number of contacts among age groups in its upper triangular part (with values relative to the contact pattern in m). the total number of contacts, w.r.t. the age distribution used in our work, is then obtained by summing up the corresponding elements of this matrix of size × resulting in m total cont of size × . finally, dividing element-wise each column of m total cont by the aforementioned population vector given in yields the following × contact matrix: for more insight, we include its heatmap in figure . additional technical details are to be found in our source code available at [ ] . recall that we have assumed presymptomatic patients, which are members of classes i i p , to be as infectious as symptomatic patients. in addition, patients with no or mild symptoms (those in i i a ) possess a transmission coefficient half of the baseline. thus, our task is to give reasonable estimates for the rates β (k,i) s,_ corresponding to the transmission rate of the symptomatic individuals from age group k to group i. to that end, we follow the terminology and techniques of [ ] to compute the next generation matrix (ngm) and the baseline transmission rate β . finally, the desired coefficients are obtained by taking into account the relative contact rates between age groups via the contact matrix presented in section . . . we note that the probabilities p i have a special role during ngm computations as their effect is what ultimately specializes the resulting transmission rate matrix for covid- . first, let us consider the infectious subsystem of ( ), namely, equations describing l i . . , }. linearizing this w.r.t. the disease free equilibrium yields the linearized infectious subsystem: where the matrices t and Σ are referred to as the transmission part and transitional part, respectively; the state is described by recall that the transmission matrix t has the form on the other hand, the transitional matrix Σ is block diagonal with blocks then, the ngm with large domain is given by follows with the, again, block diagonal e with e i = [ ]. the baseline transmission rate β may be factored out from k as β hence, k = β ·k, wherek may be readily constructed and we can compute its spectral radius ρ(k). then, we obtain the baseline transmission rate using the assumed basic reproduction number r as for other scenarios, the final steps are altered to align with the desired reproduction number r, resulting in an appropriate β and then the scaled transmission rates β (k,i) s . we omit presenting all transmission matrices but give the computed baseline transmission rates in table . we use the compartmental model described above to explore possible future scenarios, assuming widespread transmission in the population. in particular, we investigate the disease dynamics when different levels of general reductions of transmission, compared to the baseline, are in place. by manipulating the contact matrix, we investigate the effect of age-specific interventions, such as school closures and special measures aimed to protect the elderly. seasonality of respiratory viruses can be attributed to a combination of factors, including the survival of the virus in different environmental conditions, changes in contact patterns (such as school holidays), less time spent in closed spaces where the highest number of transmissive contacts are made, and potentially seasonal changes in the health conditions of the population as well. to express this behavior, we define a time-dependent parameter by which we scale the transmission rate β. parameter c denotes the magnitude of the effect of seasonality on the number of contacts. using such a time-dependent transmission rate, we compare possible disease dynamics generated by the interplay of control measures with different degrees of seasonal behavior. spatial heterogeneity is also considered using our patch model, where the country is divided into distinct geographic regions (patches). the transmission dynamics is described within each patch by our compartmental model (but potentially with different parameters and age group composition), and individuals may move between those patches. for obvious reasons, individuals in compartments i i h , i i c , i i cr and d i do not travel. let travel p,q denote the number of travels from patch p to patch q. to derive travel rates t p,q for each age group i, we divide the number of travels with the population of the appropriate patch numerical simulations for such situations show the differences in the transmission dynamics, healthcare demand, mortality, and overall disease burden. these scenarios are summarized in table . our work has several limitations. due to limited testing and the large number of asymptomatic and mild cases, there was a huge uncertainty in the number of true cases, especially in the early weeks. now, with the help of [ ] , we have a good estimation of the overall ascertainment rate over this period, but it is still unclear how this rate evolved in time. the transmission model has the same weaknesses that all compartmental models have: we assume a homogeneous population with random mixing, apart from the age structure. we added some further heterogeneity in space (patch model) and time (seasonality). in our scenarios, we assumed a constant reduction in transmission, while in reality the control measures and the behavior of the people were continuously changing. hence, such scenarios cannot be considered as predictions, as we cannot expect such unchanging circumstances for months. the role of children in this pandemic is still not clear, in our modeling, we assumed that they are equally susceptible, and equally infectious once they develop symptoms, but we used an age-specific probability for developing symptoms. since our transmission model is deterministic, it is suitable only when there is significant spread in the population. for very low case numbers, the development of the epidemics is largely influenced by random events. stochastic effects are important when considering extinction or resurgence of the disease, and possible case importations after travel restrictions are lifted. however, these issues are not in the scope of the present work. the model has a large number of parameters, many of those have uncertainty. the most important ones in regard to the burden on the healthcare system are hospitalization rates, probability of intensive care need, mortality, all of those depending on age. we do not have too much data for this from hungary, hence we used parameters taken from the literature. a full sensitivity analysis is beyond the scope of this study, but we present a sensitivity chart for a crucial output of an outbreak, see section . , which is of concern in many countries: the peak icu demand, including the need for mechanical ventilators, to assure that all patients receive the necessary care, and no additional excess mortality is caused by an overwhelmed healthcare system. this was one of the key questions in other modeling studies. the sensitivity analysis was conducted by running many simulations, sweeping through a two-parameter plane, and retrieving the icu peak from each individual run. the code can be found in [ ] . the first hungarian covid- cases were reported during the first week of march through the hungarian notifiable disease surveillance system operated by nphc which is the source of data described in this section (for the most recent information, see [ ] ). the first case, an iranian -year old man (studying and residing in hungary) who recently returned from tehran, was reported on march . by may , the cumulative number of reported confirmed covid- cases were ( . cases per , population), including deaths (crude cfr . %), see figure for the daily reported numbers. out of the cases, . % ( , cases) occurred in the + age group, . % ( cases) in the - age group, . % ( cases) in the - age group and . % ( cases) among people under -years old. age specific morbidity was highest in the + age group ( . cases per , population) and more than twice of the overall in the - age group ( . out of deaths, . % ( deaths) belonged to the + age group. as seen in figure , the highest crude cfr was observed in the + age group ( . %), followed by the - age group ( . %) and the - age group ( . %). no deaths were reported under years of age, see figure . additional details are provided in table . out of the cases, . % ( cases) were female and . % ( cases) male (gender is unknown for two cases). the morbidity among women was higher ( . vs. . cases per , population), so men were . ( % ci . - . ) less likely to become ill. however, men aged years and older had a . ( % ci . - . ) higher risk to die than women aged years and older ( . cases vs. . cases per , population). out of cases, at the stage of data consolidation as of may , , we have information about the symptoms of . % ( cases). out of cases, . % ( cases) had no symptoms, . % ( cases) had mild symptoms, and . % ( cases) had severe disease (including cases required intensive care and/or ventilation). most of the cases were reported from the central part of hungary, from the capital ( cases) and the surrounding pest county ( cases). see figure for a comparison of the capital region with the rest of hungary. the morbidity (per , population) was also the highest in budapest ( . ). the epidemic curve ( figure ) reflects a propagated source epidemic especially when we consider only those cases that cannot be connected to outbreaks in closed communities (like long-term care facilities or hospitals) or to health care associated infections. out of cases, . % ( cases) were associated with health care and/or outbreaks in hospitals, contributing to the daily reported new cases since mid-march. health care workers had . times ( % ci . - . ) higher risk to become a confirmed covid- case in comparison to the general population ( . cases vs. . cases per , population). out of cases, . % ( cases) were reported from long-term care facilities (nursing homes and other closed communities like homeless shelters) contributing to the daily reported new cases since early april. at the peak of the epidemic curve, . % ( cases) of cases on april were reported from the same retirement and assisted living facility. figure shows the results for the real-time estimation of the reproduction number. it showed a steady decline-apart from an outlying effect in early april-and became close to, or even below by mid-april, and remained at that level since then. this conclusion is robust to the chosen methodology. results for the real-time estimation of cfr are shown in figure . note that-as the outbreak is coming to its end-the naive method converges to the final value that was readily well estimated almost a month earlier by the corrected technique. (the naive estimator is increasing as deaths still occur, but case count is already low at the end of the epidemic.) the final cfr to characterize this phase in hungary is about %. various ifr estimations have been published, for example . % for china [ ] , . % for uk [ ] . recent serological studies found ifr values spanning from . % in a german town [ ] , to . % in milan [ ] . note that the testing intensity-and therefore the ascertainment rate-may very well change over time, e.g., with the increase of testing intensity. this analysis is based on the data from the early phase as a whole and, therefore, it is considered as an estimation of the average. the results for the estimation of the ascertainment rate are shown in table , where we explore a reasonable range of ifrs from . % to . %. note that earlier estimates based on [ , ] are consistent with the preliminary results of a large-scale hungarian sero-epidemiological study [ ] . most studies concerning the early growth-rate of the epidemic in wuhan estimated the value of the basic reproduction number to be around . - . (see e.g., [ , ] ), also later studies regarding the spread in other countries [ , ] used similar values. our estimations given in section . shows that in hungary the highest value of the effective reproduction number was . , by the wallinga-teunis method. hence, we choose r = . for the basic reproduction number (comparable with a similar reproduction number for germany in the early phase [ ] , . for italy [ ] ). modeling studies [ , , , ] highlighted that the worst case, i.e., "do nothing" scenarios lead to an outbreak when the healthcare demand substantially exceeds the capacities at the peak and the overall mortality reaches severe levels. given the current level of preparedness, we do not consider a "do nothing" scenario, and our most pessimistic case assumes that, even in the absence of any control measures, a % reduction in transmission is realized due to population awareness and behavior. on the other hand, the best case is the continuation of the current suppression scenario with r ≈ , resulting in very small case numbers. however, it is questionable whether it can be sustained until a vaccine is developed and deployed. below, we consider three scenarios illustrating the loss of control for suppressing the outbreak, and assuming a wide community spread of the disease. the efficacy of the mitigation efforts is expressed by a percentage in the reduction of transmission. the primary tool for this is the decrease of contact numbers, but other preventive measures such as hand hygiene or mask wearing may also have an effect in the reduction of transmission. first, let us consider a weak control of the epidemic assuming there is no centralized control measure introduced, but the number of transmissions is reduced by % following a level of behavioral response due to social awareness. such a reduction decreases the reproduction number to r = . . the first column of figure shows the hospitalization and icu demand on the top row and the daily incidences on the bottom row as a function of time with the application of this weak control. according to the simulations, in this case, there would be approximately . million infections with about , deaths by the end of the outbreak. this suggests that we can expect % of the population to gain immunity against the virus and this number is slightly larger than the threshold of herd immunity (that is ( − /r ) ∼ . % with r = . for the "do nothing" scenario). at the peak, there would be a need for more than icu beds and for , hospital beds with such a weak measure. we remark that there is a -days window when the daily incidences exceed , , and during this period more than . million people ( % of the population) get infected. in other words, % of all the infections occur during these three weeks. for further details, see table . we perform similar simulations for the case of a moderate control, assuming that the reproduction number is decreased to r = . as a result of the control measures. the simulations (second column of figure ) show that the number of hospital beds and icu beds needed is significantly reduced to and at the peak, respectively. meanwhile, the daily incidence at the peak is around , . we expect almost . % percent of the population to be infected throughout the epidemic and gain immunity upon recovery. this is less than required to reach herd immunity. for further information, we refer to table . finally, we consider a stronger control achieving a % reduction of transmission. this results a decrease of the reproduction number to r = . . the outcome of this strong control is shown in the third column of figure . a control of such strength significantly reduces the number of all infected and hospitalized cases and of those needing intensive care treatment. the number of required intensive care beds (around ) is far below the available capacity even at the peak of the epidemic and also the number of hospital beds needed is reduced to a rather low level-around at the peak. the total number of fatalities in this scenario is about . meanwhile, the epidemic would last for more than a year and the cumulative number of all infected remain far below the level of herd immunity threshold, so we can expect further outbreaks when the measures are relaxed. several key parameters of the model are highly dependent on age. intervention strategies and the relaxation of various measures have to take into account the fact that different age groups have different risks and different roles in the transmission. although the number of children infected with covid- has been reported worldwide relatively small in comparison with other age groups [ ], some evidence shows that children and adolescents may become infected and spread the disease as other age groups [ , ] . moreover, children and adolescents usually have a high number of contacts. thus, school closures can be expected to be an efficient tool to reduce the contacts and transmissions. besides school closures, it is important for younger individuals to avoid meeting older and other high risk people. elderly people have a higher chance of developing symptoms, and a higher percentage of them needs hospitalization and intensive care, hence these groups need more protection. age-specific interventions include avoiding contacts with elderly by providing special time slots for shopping, in post offices, etc., or closing/reopening schools. the introduction of various age groups in our model enables us to study such age-specific interventions and analyze their direct and indirect effects on all groups. on the stacked diagrams of figure , we present the contributions of the age groups to the mortality and the number of recovered individuals. columns of this figure show the effect of the weak, moderate, and strong control that we previously discussed in details in section . and table . here, we would like to emphasize that, in the case of each control measure, the most vulnerable age groups are the groups of elderly ( - , - , +) people as they suffer most of the fatalities; meanwhile, they are predicted to produce only a small fraction of the cases in the population. figure . age-specific mortality and recovery. the figure shows the effect of the weak, moderate, and strong control ( %, % and % general contact reduction, respectively). every age group covers at most one decade except the group of "middle aged" that represents three decades. according to our model, elderly people ( +) are predicted to produce most of the fatality cases in each scenario. the legend on the bottom applies for all figures. we consider two school closure scenarios: an optimistic and a pessimistic one (with respect to the outcome of the outbreak); both use the weak control scenario ( % general decrease in transmission, cf. section . ) as a starting point. the optimistic case is comprised of omitting the school component of the contact matrix and halving the other contacts [ ] of children and young adults (between age - ), which provides a new global contact matrix for this intervention. in the pessimistic scenario, we omit the school component of the contact matrix as well, but, instead of halving, it considers a % increase in the other contacts of children and young adults. arguably, the students might replace some school contacts by new other contacts, due to other activities. however, many of such contacts are lost as well: for example, they do not use public transportation to/from the school, and extracurricular activities also drop. since the exact balance is difficult to estimate, our two closure scenarios serve as a boundary to explore this regime of possibilities. note that, by school closure, we mean the closure of educational institutions from preschools to universities. as a reference, we also incorporate the weak control scenario to this analysis. figure shows that this measure decreases the peak hospital bed and icu needs to approximately % compared to the case when we only apply weak control in the optimistic scenario and by % in the pessimistic one. moreover, closing schools postpones the peak of the epidemic (by about one month in case of the above setting), suggesting that children may play a significant role in transmission due to their large number of contacts, even though they give negligible contribution to the overall mortality, cf. top row of figure ). note that this conclusion is based on the assumption that all age groups are equally susceptible, and symptomatic children are equally infectious to adults, and age specific difference appears only in the probability of developing symptoms, which is much smaller for children in our model (see parameters p i in table ). school closure in addition to the % contact reduction (pessimistic approach) school closure in addition to the % contact reduction (optimistic approach) figure . effect of school closure. simulations suggest that school closures-if maintained for a long period-effectively decrease peak hospital bed and icu needs and significantly postpone the peak of the epidemic. the effect of school closure combined with the % general reduction in transmission is comparable, in the optimistic case, with the effect of moderate control ( % reduction in transmission, cf. section . ) regarding the peak hospital bed and icu need, but not as significant in decreasing the mortality (figure middle column). however, to achieve this, schools need to be closed for an extended period of time, which may not be feasible. we also point out that a standalone closure of preschools and primary schools is not sustainable without a certain amount of home office of the parents, but this opens up sociological and economical questions that we do not address here. the elderly being the most vulnerable group of the population, when it comes to relaxation of measures introduced against the spread of covid- . most countries handle these age groups separately from the rest of the population, e.g., separate time slots for shopping continue to exist and elderly are encouraged to keep the same level of social distancing [ , ] . to include these effects in our model, we manipulate the entries of the contact matrix involving older age groups separately from the remaining parts. figure illustrates that, in addition to the weak control, if % and % reduction of the outside household connections of elderly people is applied, then we can expect about % and % reduction in the hospital, icu bed needs, and mortality. the epidemic curves only slightly shift to the right suggesting that elderly people do not play an important role in the transmission of the disease due to their low number of contacts. in addition, % reduction of contacts outside the household is again not feasible, as this would mean the complete isolation of a large sub-population. we plotted this scenario only to show the theoretical limits of this approach. general % contact reduction (weak control) % contact reduction for elders outside of households + weak control % contact reduction for elders outside of household + weak control figure . protection of the elderly. the figures show the effect of an additional contact reduction of elderly people in case of a weak control. the figures suggest that the selective protection of elderly people can successfully reduce the peak icu need and the overall mortality, yet it has a theoretical limit. in this section, we investigate the epidemic curves in case of the weak, moderate, and strong control with seasonality of various strengths expressed by parameter c ∈ { , . , . , . }, see ( ) . during the summer, these values of c eventuate a %, %, and % further decrease in transmission as that is when the seasonality curve attains its minimum. the case c = means that there are no seasonal effects at all, while c = . is a strong seasonality, which is similar to h n [ ] . see the top left image of figure for the seasonality functions ω(c, t) corresponding to the different c values. as we have seen in section . , decreasing the reproduction number decreases and postpones the peak of the epidemic curves. seasonality causes a similar delay in the peak of the epidemic due to decreased transmission rates in the summer months. counter-intuitively, it cannot be said in general that stronger seasonality leads to a smaller peak (cf. bottom left image of figure ). the reason for this is that the impact of seasonality is not only determined by the decrease in the transmission rate, but the temporal relation between the peak of the epidemic and the minimum of the seasonality function is also an important factor. this phenomenon is well illustrated in figure where three scenarios (weak, moderate, and strong control) are presented along with the assumed seasonality functions for the aforementioned values of c. in the upper right image of figure , corresponding to a weak control, one can observe that increasing the effect of seasonality first decreases the peak, but, after a certain value (c = . in our example), the epidemic is so much suppressed in the summer months that the peak shifts to the right and even slightly increases in winter months compared to the c = . scenario. for the case of moderate control, shown in the lower left figure, this effect is much more significant. note that the peak of the epidemic (without seasonality) is so far from summer (the minimum of the seasonality curves) that increasing the effect of seasonality results in a significantly higher peak. it can be seen that strong seasonality eventuates a long "plateau" phase when the epidemic curve does not increase in a period of six months. during this time, only a small fraction of the population goes through the infection and a massive number of susceptibles remain in the system, only to get infected a few months later. this phenomenon is responsible for the increased peak of c = . compared to the c = . case. the lower right figure shows that the reduction of transmission during the warm months together with a strong control can decrease the number of infected in such an extent that the peak, even if arriving in the winter months, is significantly smaller. a general observation is that seasonality has the largest impact on the epidemic curve if the peak time is close to the summer months. of course, this is highly dependent on the starting time of the outbreak. hungary is a relatively small country; however, significant differences were observed between regions in the reported case numbers. the capital, budapest, has . million inhabitants and a further . million people live in its surrounding pest county. budapest and pest county are highly connected by commuters with connections to other regions as well [ ] . the high connectivity of the capital with other countries contributed to the earlier appearance of the disease in budapest, and most of the cases were reported from this central region of the country. to address the role of spatial heterogeneity in the evolution of the epidemic curve, we considered a metapopulation model as in ( ) . hence, the population is distributed among patches, representing geographic regions of the country. for the sake of simplicity, here we only present results from a two-patch model, separating budapest and pest county (patch , population of approx. , , ) from the remaining parts of the country (patch , population , , ). we assumed different transmission parameter β for each patch. based on hungarian mobility data on commuters [ ] , we assumed , daily travels between the two patches in the case of normal circumstances and investigated the effect of the lockdown of budapest and the surrounding pest county by decreasing the number of daily travels to , . we considered the contact matrix for both patches to be the same as in the uniform model described in section . . . the biological and medical parameters are assumed to be the same in each patch, but the local reproduction number may differ, as well as the age structure of the population. the left-hand side of figure illustrates that the two-patch model reproduces the uniform model in case we use the same r = . for both patches as well as for the uniform model and we assume , daily travels between the patches. the middle figure shows that the uniform model slightly overestimates the size of the epidemic as the peak of the aggregated two-patch model is smaller than that of the uniform model in case r = . remains the same, and we reduce the daily travels to , corresponding to the separation of budapest and pest county from other regions. although the epidemic curves of the patches are shifted, the aggregated result shows that this setup does not provide significantly different dynamics. lastly, on the right-hand side of figure , we further investigate the scenario of , daily travels, and choose the local reproduction numbers of the patches to vary around r = . , namely, we take r budapest = . and r other regions = . . these values were selected to reflect the higher population density of the capital, proportionally to the population in the two patches. due to the difference in the local reproduction numbers, we may observe an increased number of cases in budapest with an earlier peak and fewer infections in other regions. figure . epidemic curves of the regions: sum of the infective compartments (i p , i a, , i a, , i a, , i s, , i s, , i s, ). first, we consider identical reproduction numbers r = . for both patches (budapest with pest county and other regions). without any travel reductions, the two-patch model gives identical results to the one-patch version, as seen in the left figure. next, if travel reductions are put in place, the one-patch model overestimates slightly the size of the epidemic for equal r values. finally, assuming different reproduction numbers and large reduction in travel, the peak occurs earlier in the patch with larger r (budapest and pest county); furthermore, the one-patch model and the aggregated two-patch model differ in both time and size of the peak. for an uncontrolled epidemic in the uk, ref. [ ] estimated a peak in icu bed demand more than times greater than the maximum capacity in these countries. in a study for the united states, ref. [ ] projected that, at the outbreak peak, three times more icu beds would be needed than the total number of icu beds in the us, and % isolation of cases reduces the demand for icu beds to the normal capacity. in the Île-de-france region, ref. [ ] estimated that the peak number of icu beds needed would exceed more than times the regional capacity if no strategy is implemented after lockdown, and only efficient case-finding and isolation applied parallel with social distancing could decrease icu demand below the maximum capacity throughout the epidemic. for australia, ref. [ ] studied three capacity expansion scenarios ( , and times expansion, respectively), and, even in mitigated scenarios, demand is estimated to be higher than the number of available beds. additional social distancing measures were shown to reduce the epidemic to a level where a reasonable expansion of icu capacity can be sufficient. the peak icu demand crucially depends on two factors: the probabilities of developing severe disease, and the shape (in particular the peak size) of the epidemic curve. we plotted a heatmap of the peak icu demand in figure , compiled from hundreds of numerical simulations. transmissibility (vertical axis) is expressed by the reproduction number r. disease severity, for simplicity, is expressed by the ifr. in fact, here we used a scaling factor for the probability of hospitalization, with the baseline corresponding to the parameters in table . in our weak control scenario (section . ), the ifr is . %, which is a bit lower than the finding of [ ] . however, during the first wave in hungary, the schools were closed and covid- disproportionately affected the vulnerable population. in our scenarios, we assume a widespread community spreading, hence younger generations appear in higher numbers, thus the ifr is expected to be smaller. in any case, by the scaling of the hospitalization rate (while leaving the probability of intensive care and fatal outcome given hospitalization intact), we explored a wider range of ifrs. we found that indeed the peak icu demand can vary across a large interval. from the shape of the level curves in the heatmap, we can conclude that the peak icu demand is more sensitive to r than to the ifr, hence flattening the curve is indeed of utmost importance to avoid exceeding healthcare capacities. [ ] . the white dot is our most pessimistic scenario (weak control). the most important implemented measures are summarized in table . to assess their impact, we compared the reported case numbers adjusted by the ascertainment rate : to the simulated outbreak curve with r = . ( figure on the left, logarithmic scale). here, we assumed that the ascertainment rate did not change in time, which may not be the case. one can see that the epidemic was on the r = . trajectory, which could have resulted in substantially more infections. the data shows a clear deviation from this scenario early april, two weeks after strict social distancing started. the slope of the epidemic curve further decreased mid-april, following the stay at home measures by two weeks. overall, due to the compliance of hungarian society with the social distancing measures, around half million infections were averted by the end of april, compared to the "do nothing" scenario, which could have reached - million in may if further doublings would have been allowed. the first covid- case was detected, the laboratory confirmed, and then reported through the hungarian notifiable disease surveillance system on march . well tailored, effective, combined non-pharmaceutical control measures have been introduced promptly in hungary in the very early phase of the outbreak (see table ), accompanied with a high level of compliance for social distancing. online surveys [ ] , polling, and indirect data (such as traffic data, passenger volumes on public transportation, etc.) all showed a drastic reduction in the number of contacts and mobility. in particular, the online questionnaire maszk [ ] showed a - % decrease (depending on the locality) in the daily number of physical contacts as well as in the number of closed contacts per capita, based on the replies of , respondents by may , constituting a non-representative, but rather large sample. accordingly, the hungarian epidemic curve was strongly suppressed. as of may , the cumulative number of reported confirmed covid- cases were ( . cases per , population), including deaths. the epidemic peaked on april with newly reported cases. sars-cov- was not able to sustain long transmission chains in the community; however, it was able to cause outbreaks mostly in healthcare institutions and long-term care facilities: nearly two thirds of the reported cases are connected to such institutions. the proportion of cases in health care workers gradually increased during the epidemic. they had tenfold risk to become confirmed covid- cases compared to the general population. due to effective measures, the virus could not spread significantly from closed communities and health care workers to the wider population. the age specific cfr showed a similar pattern to other countries: of the deaths reported by may, ( . %) belonged to the + age group. we tracked the temporal variation of the effective reproduction number in real time, which showed a steadily decreasing trend, interrupted by an outlying outbreak in a long-term care facility. we identified the time intervals when the effective reproduction number was below or around the critical threshold . the adjusted cfr was also estimated real-time, and predicted the eventual cfr one month in advance well. benchmarking the cfr to other countries, we estimated underascertainment rate to be - times, and the true cumulative number of covid- cases to be between , and , . these results are consistent with data from the preliminary results of a large scale seroepidemiological survey, carried out in hungary in may , where the seroprevalence of sars-cov- infection was estimated to be between , and , [ ] . based on these data and the number of reported cases, underascertainment is likely to be between . - . , and the true cfr may be lower than . %, and the ifr is roughly half of that. as control measures are being successively relaxed since may , we established an age-structured compartmental model to investigate several post-lockdown scenarios, and projected the epidemic curves and the demand for critical care beds assuming various levels of sustained reduction in transmission. special measures designed to reduce the contact number of the elderly population as well as school closures can reduce the peak hospital bed demand and the overall mortality; however, these measures also have their limitations. a metapopulation version of the transmission dynamics model has also been studied, and we reported some results for a two-patch case, where the budapest region is considered separately from the rest of the country. due to the high connectedness, the epidemic curves of the two-patch system are not much different from the spatially uniform case. to achieve a noticeable reduction in the overall peak size due to spatial heterogeneity (where the local peak times are shifted in the regions), a large reduction in the mobility rates is necessary. since the majority of the population is still susceptible (over %, according to [ ] ), a weak or even a moderate reduction in the transmission, compared to the baseline, could result in a large second outbreak with significant mortality and high peak icu demand. therefore, a high level of alertness needs to be maintained to avoid such scenarios. the seasonal behavior of sars-cov- is not completely understood yet [ , ] , thus we considered a range of possibilities from the absence of seasonality to a strong seasonality, which is similar to h n . the interplay of seasonal effects with the post-lockdown contact numbers can generate a variety of disease dynamics; thus, a confident forecast of the timing and the size of a potential second wave is not possible at the moment. the effectiveness of strict social distancing measures, such as school closures and stay at home measures with good compliance is likely to be very high; however, such interventions have negative consequences on the society and on the economy and are thus not sustainable in the long term. modeling results [ , ] suggest that combined multiple interventions, including moderate contact decrease, high covid- detection rate, effective contact tracing, and good compliance with personal protective instructions, may have substantial impact on transmission, and are able to keep the reproduction number around one. situation reports; world health organization france: surveillance, investigations and control measures cov- was already spreading in france in late investigation of a covid- outbreak in germany resulting from a single travel-associated primary case: a case series covid- epidemic in italy: evolution, projections and impact of government measures who. statement on the second meeting of the international health regulations ( ) emergency committee regarding the outbreak of novel coronavirus director-general's opening remarks at the media briefing on covid- ; world health organization covid- ) in the eu/eea and the uk-ninth update multiple sars-cov- introductions shaped the early outbreak in central eastern europe: comparing hungarian data to a worldwide sequence data-matrix covid- announcements of hungary r: a language and environment for statistical computing; r foundation for statistical computing elegant graphics for data analysis table: extension of 'data.frame'. r package version . . shiny: web application framework for r real-time epidemiology of covid- in hungary (a magyarországi koronavírus járvány valós idejű epidemiológiája-in hungarian) real-time epidemiology of covid- in hungary (a magyarországi koronavírus járvány valós idejű a new framework and software to estimate time-varying reproduction numbers during epidemics different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures how generation intervals shape the relationship between growth rates and reproductive numbers the effective reproduction number of pandemic influenza: prospective estimation association of public health interventions with the epidemiology of the covid- outbreak in wuhan effective reproduction number estimation estimating in real time the efficacy of measures to control emerging communicable diseases serial interval of covid- among publicly reported confirmed cases epidemiological characteristics of covid- cases in italy and estimates of the reproductive numbers one month into the epidemic serial interval of novel coronavirus (covid- ) infections the r package: a toolbox to estimate reproduction numbers for epidemic outbreaks r : estimation of r and real-time reproduction number from epidemics. r package version . - estimate time varying reproduction numbers from epidemic curves. r package version . - . methods for estimating the case fatality ratio for a novel, emerging infectious disease assessing the severity of the novel influenza a/h n pandemic early epidemiological assessment of the virulence of emerging infectious diseases: a case study of an influenza pandemic real-time estimation of the risk of death from novel coronavirus (covid- ) infection: inference using exported cases incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data rstan: the r interface to stan using a delay-adjusted case fatality ratio to estimate under-reporting ( ). cmmid risk assessment of novel coronavirus covid- outbreaks outside china modelling the impact of covid- in australia to inform transmission reducing measures and health system preparedness expected impact of lockdown in Île-de-france and possible exit strategies a first study on the impact of current and future control measures on the spread of covid- in germany report -impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand projecting hospital utilization during the covid- outbreaks in the united states covid- epidemic risk assessment for georgia temporal dynamics in viral shedding and transmissibility of covid- early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia effects of latency and age structure on the dynamics and containment of covid- appropriate models for the management of infectious diseases hungarian data supply questionnaire (maszk-magyar adatszolgáltató kérdőív-in hungarian) code basis for covid modelling in hungary contact tracing assessment of covid- transmission dynamics in taiwan and risk at different exposure periods before and after symptom onset quantifying sars-cov- transmission suggests epidemic control with digital contact tracing features of , hospitalised uk patients with covid- using the isaric who clinical characterisation protocol report on covid- in critical care incidence, clinical outcomes, and transmission dynamics of severe coronavirus disease in california and washington: prospective cohort study children with covid- in pediatric emergency departments in italy projecting social contact matrices in countries using contact surveys and demographic data the construction of next-generation matrices for compartmental epidemic models preliminary results of the h-uncover study estimates of the severity of coronavirus disease : a model-based analysis infection fatality rate of sars-cov- infection in a german community with a super-spreading event sars-cov- seroprevalence trends in healthy blood donors during the covid- milan outbreak pattern of early human-to-human transmission of wuhan covid- outbreak in italy: estimation of reproduction numbers over two months toward the phase . medrxiv ministry of health, welfare and sport, netherlands. children and covid- an analysis of sars-cov- viral load by patient age covid- and the consequences of isolating the elderly seasonal transmission potential and activity peaks of the new influenza a (h n ): a monte carlo likelihood analysis based on human mobility the salient targets of commuters social distancing strategies for curbing the covid- epidemic temperature, humidity, and latitude analysis to estimate potential spread and seasonality of coronavirus disease (covid- ) cmmid covid- working group. effects of non-pharmaceutical interventions on covid- cases, deaths, and demand for hospital services in the uk: a modelling study cmmid covid- working group. effectiveness of isolation, testing, contact tracing, and physical distancing on reducing transmission of sars-cov- in different settings: a mathematical modelling study the authors declare no conflict of interest. key: cord- -gf a f authors: nan title: b scientific sessions (ss) date: journal: eur radiol doi: . /s - - - sha: doc_id: cord_uid: gf a f nan this icon indicates a pre-selected scientific paper to be judged by the subcommittee chairmen. the final winners of the best paper within one topic will be announced at the closing ceremony and presented with a diploma and their prize (€ .-) in (a)symptomatic high-grade internal carotid artery (ica) stenosis, ultrasound and digital subtraction angiography (dsa) are the established techniques for grading ica stenosis; contrast-enhanced magnetic resonance angiography (cemra) is replacing dsa. aim of this study was to evaluate the diagnostic accuracy of cemra in studying the carotid arteries and to compare cemra with dsa findings. two mra protocols, differing in acquisition voxel size, were used to assess whether intravoxel dephasing effects could modify diagnostic accuracy of cemra. patients were studied: (group ) underwent a cemra protocol with an acquisition voxel size of . mm and (group ) with a voxel of . mm . dsa was perfomed in all patients. morphology and degree of stenosis were evaluated, and a qualitative analysis comparing cemra and dsa findings was obtained. diagnostic accuracy and correlation with dsa results for ica stenosis were calculated in all patients and, separately, in the two groups. cemra diagnostic accuracy and agreement with dsa were respectively % and k = . ; no significant difference was found among the two groups. qualitative analysis revealed a better correlation between cemra and dsa images in group than in group . these data suggest that cemra could be a powerful tool for the non-invasive evaluation of atherosclerosis of neck vessels. stenosis overestimation of cemra is confirmed; reduction of voxel size, decreasing the dephasing intravoxel effect, allows to minimize it, with a better correlation of cemra and dsa findings; yet, no diagnostic gain is obtained in the patients' classification according to nascet criteria. mri perfusion changes in unilateral symptomatic internal carotid artery stenosis: evaluation of middle cerebral artery and border territories f. gaudiello, g. manenti, f. garaci, r. floris, a. bozzao, g. simonetti; rome/it background and purpose: to determine, with dynamic susceptibility contrast magnetic resonance imaging (dsc-mri), the hemodynamic changes occurring in patients with unilateral internal carotid artery stenosis (icas). methods: patients with symptomatic unilateral icas (over % by nascet criteria) as assessed by digital subtraction angiography and age and sex matched control subjects underwent dsc-mri. on a separate workstation rcbv and rmtt were calculated on the basis of signal decay rate during the passage of gadolinium bolus through the sampled. middle cerebral artery (mca) and distal border territories (mca to posterior and anterior circulation) were evaluated in all patients. results: patients with unilateral icas did not showed statistically significant hemodynamic changes (rcbv and rmtt) between the two hemisphere both considering mca and border territories. comparing patients and controls statistically significant differences were found only for rmtt values in the border territories (increased, p = . ). conclusions: dsc-mri is a valuable tool for measurement of hemodynamic changes in the presence of carotid disease with hemodynamic impairment. based on our data no significant perfusion changes occurs between the two hemispheres in patients unilateral symptomatic icas. this indicates compensatory mechanisms between the two hemispheres in the cerebro-vascular reserve distribution. only rmtt values changes (increased) in the border territories (of both hemispheres) differentiate patients with icas from normal controls. correlation of doppler-and duplex ultrasonography based grading of unilateral internal carotid artery stenosis and blood volume flow quantification in brain supplying arteries using d cine phase-contrast mr imaging k.w. neff, a.k. kilian, s. meairs, a. schwartz, c. düber; mannheim/de purpose: correlation of unilateral internal carotid artery (ica) stenosis grading based on doppler-and duplex ultrasonography and the hemodynamic changes in brain supplying arteries. methods and materials: patients with unilateral ica stenosis at the level of the bifurcation between % and % and age-matched normal controls were examined using a d cine phase-contrast mr technique. blood volume flow was measured in both icas and the basilar artery (ba). the ultrasonography based grading of stenosis was compared to the changes in blood flow in the stenosed ica and to the changes in the contralateral ica and the ba. results: ica stenoses greater % were hemodynamically relevant. with increasing stenosis, a decrease of blood volume flow in the ipsilateral ica was determined with a high linear correlation of r = . . normal controls showed a blood volume flow in an ica of . ± . ml/min. in patients with % stenosis a mean blood volume flow of . ± . ml/min; with % stenosis . ± . ml/min and patients with % stenosis a reduction of mean blood flow in the stenosed ica to . ± . ml/min. with decreasing blood flow in the stenotic ica an increasing blood volume flow in the contralateral ica was found. in patients with unilateral ica stenosis greater than % a significant increase in ba blood flow was documented. the comparison of ultrasonography based grading of unilateral ica stenosis and blood volume flow determination in patients with hemodynamically relevant ica stenoses demonstrates a high correlation between increase of stenosis, decrease of ipsilateral blood flow and collateralization of brain supplying circulation. doppler ultrasound, multidetector ct and gd-mra in the assessment of carotid artery stenosis e. ferone, c. pistolese, s. fabiano, r. floris, a. spinelli, a. bozzao, g. simonetti; rome/it aim of the study was to prospectively compare gadolinium-enhanced magnetic resonance (mr) angiography, computed tomographic angiography with multidetector capabilities (md-cta) and doppler ultrasound for use in detecting atheromatous stenosis and plaque morphology at the carotid bifurcation. conventional angiography was available in all cases; surgical specimens were also available in many cases. methods and materials: carotid arteries (in patients) were analyzed by using md-ct, enhanced mr angiography, and dsa. the following features were analyzed: degree of stenosis on the basis of north american symptomatic carotid endarterectomy trial criteria, luminal surface and presence of ulcers. results: there was significant correlation between md-cta, enhanced mr angiography, and doppler for degree of stenosis. with enhanced mr angiography and ct angiography, degree of stenosis was underestimated in two of cases ( mild and moderate). no case of overestimation with enhanced mra and md-cta was found. severe internal carotid artery stenoses were detected with high sensitivity and specificity: % and %, respectively, with ct angiography; % and %, respectively, with enhanced mr angiography. luminal surface irregularities were most frequently seen at md-cta as demonstrated by surgical specimens. conclusion: there was a significant correlation between md-cta, enhanced mr angiography and dsa in evaluation of carotid artery stenosis. cta was however slightly better than mra in detecting surface alterations. fucan, a natural polysaccharide from algal origin, inhibits intimal hyperplasia after stent implantation in normocholesterolemic rabbits we tested the hypothesis that fucan, a sulfated polysaccharide inhibitor of smcs proliferation in vitro, may reduce intimal hyperplasia in vivo. we performed a pharmacokinetic study on a rat model and a restenosis study on a rabbit model. a single dose of fluorescent fucan and heparin were administered to rats and serum and urine were collected over time. serum and urine concentration and pharmacokinetic parameters were calculated. ten normocholesterolemic rabbits were treated with daily intramuscular injection of fucan ( animals) or saline ( animals) after stent implantation in both iliac arteries. fourteen days after injury animals were sacrified and histomorphometric analyses were performed. blood samples were systematically collected. results: fucan exhibited high plasma levels and a prolonged half-life ( h min) compared to heparin ( h) after intravenous and intramuscular administration. fucan reduced intimal hyperplasia by approximately % after stent implantation in rabbits ( . ± . vs . ± . mm , p < . ). intimal hyperplasia inhibited was associated with a better longitudinal organization of cells layers. no toxic effect was noted in treated animals. blood samples showed no anticoagulant activity. conclusion: fucan, a natural polysaccharide of algal origin, reduces markedly intimal hyperplasia in a rabbit restenosis model without anticoagulant activity. methods: endovascular treatment was performed in patients with aneurysms presenting with an unruptured aneurysm either of the anterior (n = ) or posterior circulation (n = ). patients had a previous sah from another aneurysm and had neurological symptoms due to the aneurysm. in patients the aneurysm was an incidental finding. aneurysm size was small in ( mm). occlusion rates was divided into complete ( %), subtotal ( - %) and incomplete (< %). results: endovascular treatment was technically feasable in / aneurysms. complete or nearly complete occlusion was achieved in / aneurysms. in four aneurysms of the ica only incomplete obliteration could be achieved. procedural complications included one case of thrombembolic vessel occlusion with narrowing of the parent artery due to coil protrusion, resulting in anterior cerebral infarction. with the exception of one patient with a mild deficit, all had a good recovery according to the glasgow outcome scale, resulting in a morbidity of . % and a mortality of %. conclusion: endovascular treatment in patients with unruptured aneurysms is an effective alternative with low morbidity and mortality and should be considered the first option for treatment. we designed three chains of calcium made from small cortical chicken bone fragments. before the fragments were fixed with glue onto tape, volume measurements using water displacement and mass measurements using a precise balance (mettlar h ar) were performed. during open-heart surgery the chains then were sutured to the pig heart (n = ) covering the coronary bed of each major epicardial artery as lad, cx, and rca in order to simulate real coronary motion. in each pig we performed a series of prospectively gated sequential and retrospectively gated half-scan and multisector helical scans (lightspeed plus, gems, milwaukee, wi) using a range of scanning parameters (ma, kv, slice thickness). we evaluated the agatston score as well as the volume and a mass score for each chain and each pig. results were compared to water displacement volume measurements and balance mass measurements. the cortical bone frag-purpose: electron beam computer tomography (ebct) and multislice computer tomography (msct) are used to evaluate the amount of sclerotic plaque in coronary arteries in clinical practice. to investigate the potential of both ct techniques to identify calcified coronary lesions, we compared the results of ebct and msct with intravascular ultrasound (ivus) and histology. methods: five human autopsy coronary arteries were fixed in a saline perfused bath with vessel side branches and sutures defined as landmarks: a total of vessel cross sections (vcs) were randomly assigned to undergo all investigative steps. ivus was performed with an automated pull back system ( . mm/s). vessels were scanned with ebct (imatron, mm slice thickness, mm increment) followed by msct (siemens plus volume zoom, × mm spiral mode, mm slice thickness purpose: to evaluate the reliability of ca-score measurements of identical multislice ct (msct)-derived raw data obtained by the traditional agatston method and a volume score using different software systems. methods and materials: asymptomatic patients with known or suspected coronary heart disease were scanned on a multidetector ct system (somatom volume zoom, siemens) with retrospectively ecg-gated -slice spiral scanning. data was acquired with a × . mm collimation. continuous volume data sets were reconstructed in the enddiastolic phase with mm slice thickness. for each patient reconstructions without ( mm non-incremental -ni) and with a % overlap ( . mm incremental -i) were performed. two observers independently performed calcium-scoring using the agatston (as)-and volume-score (vs) on two software systems, the calcium-scoring (siemens) and the accuimage-scoring-system. replicated ca-scoring was performed by each observer. the data was categorized into score groups ; - ; - ; - ; > . results: intra-and interobserver reliability was . - . for both scoring methods (as i/ni and vs i/ni). when ca-scoring measurements were repeated on different scoring software systems, the kappa statistics were found to be . for as i, . for as ni, . for vs i, and . for vs ni, resulting in different risk stratifications in up to % of the patients. conclusion: intra-and interobserver agreement was excellent using the same software. the two different softwares do not yield the same calcium quantities. there were significant differences with regard to interobserver reliability, resulting in different risk stratifications. the interpretation of calcium quantities should acknowledge which type of software was used. thirteen patients with heterozygous fh (mean ± sd; age . ± . a) and controls were studied. endothelium-dependent, flow-mediated dilation (fmd) and endothelium-independent, nitroglycerin-induced dilation (nmd) were assessed in the brachial artery using high-resolution ultrasound. in addition, fh patients were evaluated for coronary calcium using ecg triggered multidetector ct. results: fmd was significantly reduced in heterozygous fh patients compared to controls ( . ± . % vs. . ± . %; p = . ). in contrast, nmd values were similar in both study groups ( . ± . % vs. . ± . %; p = . ). on multiple stepwise regression analysis, a significant correlation was found between fmd and total cholesterol (r = − . ; p = . ) as well as between fmd and vessel size (r = − . ; p = . ). calcifications of the aortic root or the major epicardial coronary arteries were not detected. conclusions: endothelial dysfunction is present in the brachial artery of heterozygous fh already in the second and third decade of life without evidence of calcification of the aortic root and the coronary artery tree and is independently related to total cholesterol. thus, altered vascular function precedes morphological evidence in the course of atherosclerosis. therefore at this early age endothelial function testing seems to be more appropriate to evaluate fh patients developing atherosclerosis and to assess the short-term effects of therapeutic interventions. the association between electron-beam ct detected coronary calcification and mri detected cerebral white matter lesions j.c. de groot , r. vliegenthart , j.c.m. witteman , m.m.b. breteler , a. hofman , m. oudkerk ; groningen/nl, rotterdam/nl purpose: coronary calcification is associated with angiographically detected coronary artery disease. cardiovascular risk factors are associated with cerebral white matter lesions (wml), which in turn play a role in cognitive decline. we investigated whether coronary calcification is associated with wml. materials and methods: participants were recruited from a population-based study of elderly patients aged - years. during - , cerebral mri ( . t) scans of subjects (response %) were obtained on which the severity of deep subcortical wml (scwml) and periventricular wml (pvwml) was estimated using a semi-quantitative scale. during - thoracal electron-beam ct scans were obtained and coronary calcium scores (according to agatston) are available for of these subjects. wml was dichotomised in severe (upper quintile) versus mild to moderate (other quintiles) and the calcium score was dichotomised in severe (upper tertile) versus mild to moderate (other tertiles) for additional analyses. results: mean age was . years ( % women). mean severity of scwml was . (range - . ) and of pvwml . (range - ). median calcium score was . (interquartile range . - . ). subjects with higher calcium scores had more scwml (rho = . , p = . ) and tended to have more pvwml (rho = . , p = . ). when adjusted for age and sex, severe calcium scores were associated with the presence of severe scwml (or = . , p = . ) but not with severe pvwml (or = . , p = . ). conclusion: preliminary analyses show that coronary calcification is associated with cerebral scwml and as such may be indicative for a generalised vascular disease process. coronary calcification detected by electron-beam computed tomography is associated with mortality r. vliegenthart , , h.-h.s. oei , a. hofman , j.c.m. witteman , m. oudkerk ; groningen/nl, rotterdam/nl purpose: coronary calcification is closely related to the amount of coronary atherosclerosis, but its predictive value for cardiovascular disease and mortality has not been well established. we studied the association between coronary calcification and mortality in the population-based rotterdam coronary calcification study. materials and methods: from - , rotterdam study participants were invited for electron-beam ct scanning to detect coronary calcification. calcifications were quantified according to agatston's method. calcium scores of scanned subjects ( % men, mean age (standard deviation, sd), ( . ) years) were used in the analyses. the rate ratios of mortality between categories of the calcium score were calculated. results: % of men had a calcium score above , while % had a calcium score above . corresponding percentages for women were and , respectively. during a mean follow-up period (sd) of . ( . ) years, subjects died ( men, women). the age-adjusted relative risk for death was . ( % confidence interval (ci), . - . ) for men with a calcium score above compared to men with a calcium score of - (reference category). men with a calcium score above had a . times increased risk ( % ci, . - . ) compared to the reference category. in women, the relative risks were . ( % ci, . - . ) for calcium scores above , and . ( % ci, . - . ) for calcium scores above , compared to the reference category. conclusion: the amount of coronary calcification detected by electron-beam ct is predictive for all-cause mortality. methods and materials: consecutive patients ( men and women; mean age years) with surgically treated mitral valve disease underwent preoperative contrast-enhanced, retrospectively ecg-gated mdct. two readers assessed visibility of the mitral valve annulus, mitral valve leaflets, tendinous cords, and papillary muscles using a four-point grading scale. abnormal findings of the mitral valve, such as thickening of the mitral valve leaflets, presence of mitral annulus calcification (mac) and calcification of the valvular leaflets, were compared to preoperative echocardiography and intraoperative findings. results: visibility of mitral valve annulus and mitral valve leaflets were good or excellent (grade and ) in patients ( %), and in patients ( %) for papillary muscles; visibility of tendinous cords was inferior. mdct yielded a - % agreement with echocardiography and surgery with regard to thickening of mitral valve leaflets and presence of calcification of the mitral valve annulus and mitral valve leaflets. conclusion: retrospectively ecg-gated mdct allows good to excellent visualization of anatomical details of the mitral valve and its apparatus except for tendinous cords, and demonstrates high agreement between echocardiography and surgery with regard to the diagnosis of mitral valve abnormalities. with increasing experience a diagnostic niche may open up for preoperative assessment of mitral valve pathology using mdct, especially for patients for whom echocardiography is of limited use, e.g., for patients with suspected perivalvular abscess. conventional parathyroidectomy is a difficult operation and unsuccessful in % to % of cases. to improve the efficacy, preoperative (mibi) spect scintigraphy and intraoperative radio-guided localization of parathyroid adenomas with γ probe and a quick pth assay were used. methods: forty patients with the diagnosis of primery hyperparathyroidism were studied with (mibi) spect scintigraphy. we combined the preoperative administration with the intraoperative γ probe examination to identify the exact localization of parathyroid adenomas. the intact parathyroid hormone was measured by irma method (schering cis bio international). results: in all cases parathyroidectomy was performed successfully and the preoperative localization was always confirmed. after five minutes parathyroidectomy pth concentrations decreased more than % compared with the highest preexcision value. at follow-up, serum calcium and pth levels were normal in all patients. in hyperparathyroidism, the combined use of preoperative imaging mibi-spect and intraoperative γ probe examinations improved the success rate of parathyroidectomy. the most helpful use of quick pth in patients is its ability to give the surgeon quantitative assurance that all the hyper functioning parathyroid tissue has been removed. d ultrasound technology for the calculation of thyroid volume and the evaluation of benign cystic, nodular disease v. osti, l. cova, l. solbiati, m. tonolini, d. della chiesa; busto arsizio/it purpose: to assess whether three dimensional sonography ( d-us) can permit reliable and easily calculated volumes of the thyroid and nodules. methods and materials: patients, aged - , underwent d-us of the thyroid gland. ten patients had prior hemithyroid resection for multinodular disease and presented with goitre relapse. after examination, all had surgical resection. the surgical specimen volume at pathology was compared with the volumes calculated using d-us. the remaining patients had either single or multiple, cystic nodules. following d-us, these nodules underwent percutaneous needle aspiration of the fluid content with measurement of the aspirated volume prior to ethanol injection. us examinations were performed using linear, mhz probes (voluson d and d, kretztechnik, austria). volume acquisitions were automatically achieved by transverse scans, with the addition of coronal oscillations of the transducer crystals. subsequently, both automatic [n = ] and/or manual [n = ] d reconstructions were performed, including volume calculations, for either the entire gland [n = ] or the nodules [n = ] . results: comparison between surgical specimen volumes and in-vivo volumes calculated by d-us demonstrated a restricted margin of error of % for automatic reconstruction, and % for manual reconstruction. the quantitative assessment of the fluid aspirated from cystic nodules was identical to the d-us calculation (margin of error < %). conclusions: d-us allows easy and accurate estimation of the volume of the thyroid gland and of nodular, cystic thyroid lesions. these measurements will undoubtedly provide both surgeons and interventional radiologists additional potentially useful information prior to procedures. role of color-doppler sonography in graves' disease diagnosis and follow-up after i therapy v. summaria, a. costantini, v. rufini, m. garganese, g. maresca, s. speca; rome/it purpose: to assess the usefulness of cds in evaluating activity of graves' disease and the response to i therapy. methods and materials: several cds patterns: thyroid volume (tv), parenchymal hypoechogenicity (ph), parenchymal vascularity (pv), peak systolic velocity (psv) in inferior thyroid arteries (ita), were evaluated in patients with graves' disease divided in groups: pts at first diagnosis; pts during antithyroid drug treatment; euthyroid pts after withdrawl of therapy; pts who relapsed into hyperthyroidism. all pts in the latter group underwent radioiodine therapy (rt) and cds was performed , , months after rt. healthy subject were included as control group. results: all pts with hyperthyroidism showed an increase of tv, pv and psv in ita, compared with patients in remission and with control subjects. in pts within group , cds values were lower, but not significantly different from those in group . ph was found in / pts, without a statistically significant difference between pts with hyperthyroidism and pts in remission. in pts within group , a significant decrease (p < . ) of tv and psv mean values in ita was observed in / ; the others pts, with residual signs of hyperthyroidism underwent further rt. materials and methods: forty two patients with nodules were prospectively enrolled in this study. the nodules were studied in a transverse plane with conventional high frequency b-mode imaging and with sono-ct (atl hdi , l - linear probe). the data were transferred on a pc (hdi lab). after selecting two comparable images in both modes, three parameters of quantification were measured using region of interest: the difference of contrast between the nodule and the adjacent thyroid (db), the slope of the transition between the nodule and the adjacent tissue (db/cm). the nodule heterogeneity was evaluated as the standard deviation of the mean signal intensity normalized with the mean signal intensity (linear units). the contrast between the nodule and the adjacent thyroid was systematically greater with sono-ct (mean . db). the transition slope was higher with sono-ct. the average difference between the sono-ct slope and the conventional b-mode slope was . db/cm. the heterogeneity index was superior in % of cases with this modality. however, sono-ct imaging exhibited a blurring artifact when the probe was moved too fast, despite the use of a unique focal zone. conclusion: the objective evaluation using appropriate quantification technique showed a significant improvement in the visibility of thyroid nodules with both sono-ct when compared to conventional b-mode imaging when the linear probe was moved very slowly. pre-biopsy investigations included scintigraphy and thyroglobulin levels. then we examined the us characteristics of the nodule (low reflectivity, irregular margins, thick-irregular halo, intranodular blood flow pattern, hypervascularity, invasion of vessels and adjacent structures, vessel encasement). in patients the nodule was solitary and not palpable and in patients the disease was multinodular with a nodule having characteristics suspicious for malignancy. we performed us guided fna biopsy using g needle. we used negative pressure on the syringe to obtain material through the needle. it is important to allow the pressure to equalize before removing the needle. the cytological specimen obtained was examined by cytopathologist. a post biopsy us was performed to exclude complications. the following results were obtained: follicular ca (n = ), papillary ca (n = ), undiferentiated ca (n = ), hashimoto thyroiditis (n = ), colloid and bening follicular cells (n = ), blood (n = ), nodular hyperplasia (n = ), colloid and activated lymphocytes (n = ), colloid and histiocytes (n = ). conclusion: us guided fna is safe, fast and low cost method to determine the nature of thyroid nodules and exclude malignancy. papillary stenosis: differential diagnosis with mr-cholangiography using a cholecystokinetic drug m. di girolamo , l. azzarri , r. di nardo , c. rende , g. brughitta , v. david ; rome/it, grottaferrata/it purpose: to differentiate with mr-cholangiography (mrcp) inflammatory papillitis from functional papillary stenosis, using a cholecystokinetic drug. methods and materials: patients with papillary stenosis diagnosed with ercp underwent mrcp before and minutes after i.v. injection of ceruletide (takus, farmitalia, italy) . this drug stimulates the activity of the gallbladder and promotes the relaxation of oddi's sphincter. mrcp was performed by using -d non-breathholding, fat-suppressed turbo se sequence (tr: ms; te: ms; n.ex.: ; etl: ; matrix: × ; acq. time: min s) on coronal planes with . t superconductive magnet (gyroscan t iii, philips medical system). the d coronal images were post-processed with mip algorithm. results: in patients mrcp diagnosed fibrotic papillary stenosis while in patients detected functional papillary stenosis that in cases was confirmed by ercp with manometry. the diagnosis was based on the evaluation of the mbd calibre after drug administration: a partial reduction of the calibre is typical of functional papillary stenosis while the persistence of the same calibre allows the diagnosis of fibrotic papillary stenosis. mrcp could also exclude choledocholithiasis whose clinical symptoms can simulate papillary stenosis. conclusions: it is possible to differentiate with mrcp between fibrotic and functional papillary stenosis, without performing invasive procedures like ercp with manometry. this differential diagnosis is very important: in fact, fibrotic stenosis should be treated with sphinterectomy while functional papillary stenosis does not need any particular treatment. methods and materials: patients ( women, men) with confirmed psc were examined with mri at . t comprising: t -weighted spoiled gradient echo (sge), t -weighted fat-suppressed turbo spin echo, haste, and serial postgadolinium t -weighted sge sequences without and with fat-suppression. two radiologists reviewed retrospectively all images independently and in a consensus reading. the evaluations comprised: the imaging pattern of the liver parenchyma; the presence and grade of intrahepatic biliary ductal dilatation; the presence of areas of parenchymal atrophy or abnormal signal and/or gadolinium enhancement. results: a "diffuse pattern" of liver cirrhosis was observed in of patients ( %). a "large macronodular pattern" (regenerative nodules ≥ cm) was observed in of patients ( %) with nodules showing low signal on t -and t -weighted images and low gadolinium enhancement. intrahepatic biliary ductal dilatation was observed in of patients ( %) with a "general distribution" in patients ( %) and a "segmental distribution" in patients ( %). peripheral wedgeshaped areas of abnormal parenchyma showing atrophy were observed in patients ( %) and without atrophy in patients ( %). the signal intensity on t -/t -weighted images was usually low/high. gadolinium enhancement was typically late in areas with atrophy and early in areas without atrophy. conclusion: the spectrum of mri appearances of psc is diverse and comprises distinct patterns. large regenerative nodules are a frequent finding and may help to establish the diagnosis. for months, patients were diagnosed to have incomplete pancreas divisum on ercp and six of them underwent mrcp after secretin stimulation. the maximal diameter and length of pancreatic duct (ventral, dorsal, and main duct) and the angle between the main pancreatic duct (mpd) and the communicating channel (cc) were measured on ercp. morphologic changes of the pancreatic duct, the presence of santorinicele, the shape of cc, and associated bile duct anomaly were analyzed on ercp and mrcp. results: ercp showed dominant dorsal duct and foreshortened ventral duct with a small communication between the two ducts. the mean caliber of dorsal, ventral, and main duct was . mm, . mm, and . mm, respectively. the angle between the mpd and the cc was acute in patients, right angle in , and obtuse in . the cc was classified into short (n = ) and long (n = ) types. the morphologic features of pancreaticobiliary duct included: santorinicele in , beaded appearance of pancreatic duct in , pancreaticoliths in , and bile duct anomaly in . mrcp successfully demonstrated the presence of the cc and associated morphologic features of the pancreaticobiliary duct in all patients. purpose: since evaluation of bile ducts in mrcp can be complicated by other fluid filled structures as pancreatic or bile duct cysts superimposing the region of interest and the clinical relevance of a dilated bile duct regarding functional stenosis may be unclear we investigated the hepatobiliary contrast medium gd-bopta as a positive contrast enhancer for intra-and extrahepatic bile ducts in mri. material and methods: patients were investigated on a . t scanner (magnetom vision, siemens, erlangen) using unenhanced t an t w breathhold sequences as well as d-and d-mrcp. to evaluate contrasted biliary structures to min after cm administration (gd-bopta, . µmol/kg bodyweight) a d gre sequence as well as t w axial images were applied. results: in the majority of the patients ( / ) bile duct structures could be delineated by the mrcp sequence. however the identification of the common bile duct in the region of the pancreatic head was not possible in patients. in patients following pancreatitis or cholelithiasis a dilatation of the common bile duct was observed with unclear functional relevance, in patients following resection of the pancreatic head the anastomosis of the common bile duct could not be displayed in detail in mrcp. ce mrcp was able to delineate the bile duct in of the unclear cases, functional relevance of dilatation could be evaluated in of patients. conclusion: in unclear cases gd-bopta can be helpful for a better delineation and functional evaluation of bile duct structures. follow-up of suspected pancreatic intraductal papillary mucinous tumours (ipmt) of collateral branches: preliminary results g.m. carbognin, a. guarise, e. dalla chiara, n. pagnotta, c. procacci; verona/it purpose: to verify the evolution of suspected collateral branches ipmt assessed as benign at the first imaging control. methods and materials: patients with a presumptive diagnosis of benign branch duct ipmt formulated by ercp (# ) and/or mrcp (# ). diagnosis on the basis of the following criteria: ( ) no previous pancreatitis; ( ) one/multiple cystic lesion/ s, homogeneous liquid content, thin wall, no parietal proliferation; ( ) maximum diameter of the lesion < cm; ( ) normal main pancreatic duct (mpd). the patients were submitted to mrcp follow-up every months. two observers reviewed all the mrcp examinations. results: mean duration of the follow-up: . months (range: - months). / ( %) lesions with the requisite for benignity reported in literature, did not show any morpho-structural modification during the follow-up. in case the lesion manifested rapid growth after months, along with what seemed to be a small parietal nodule. at intervention, it was a retention cyst in a mild focal pancreatitis. in the other case, multiple apparently benign lesions were present, which demonstrated slight growth over months of follow-up. nevertheless, the patient was submitted to strict mrcp monitoring, since a total pancreasectomy would have been warranted. conclusion: among those considered, lesions of different nature could be present. however, the evolution of all these lesion, when the sign of malignancy are absent, is so slow to justify the follow-up in the elderly, in the presence of high surgical risk or whenever the multiplicity of the lesions would require a largely demolitive intervention. results: mrt and mrcp were false positive in a patient with a benign stricture due to an inflammatory pseudotumor and false negative in two patients (suspected granulation tissue after prior surgery and contrast enhancement of the wall of the bile duct after interventional therapy). except for one false negative patient mrcp revealed stenosis of central bile ducts in all patients. in patients a well demarcated mass was seen while patients revealed circumferential tumor spread along the bile ducts. most lesions appeared hyperintense on t -weighted images (n = ) and hypointense on unenhanced t -weighted images in all cases. contrast enhancement was either lower (n = ) or higher (n = ) than normal liver parenchyma. t -weighted images and gadolinium-enhanced fat-suppressed t weighted images showed best lesion conspicuity and tumor margins in and patients respectively. combined ercp, us and ct suggested hilar cholangiocarcinoma in / ( %) patients. mrt with mrcp appears to be the most sensitive imaging modality for detection of hilar cholangiocarcinomas and may replace us, ct and ercp in the evaluation of suspected malignant bile duct obstruction. information supported by mrcp: consistency and repeatability t. gorycki, b. bobek-billewicz, m. studniarek, p. jagodzinski, k. grabska; gdansk/pl purpose: to compare decisions of radiologists watching mrcp images in order to find the strongest features on mip reconstructions which characterise biliary strictures. materials and methods: mrcp mip reconstructions ( . t gyroscan nt) from cases of biliary stricture had undergone estimation by three independent observers who performed linear measurements on mrcp images concerning morphology of the biliary stricture including stricture length, proximal ductal dillatation and distance from stricture to hepatic ducts junction. last of the measurements has introduced information about stricture localisation along the biliary tree. measurements were compared in two stages: between two observers as well as counting their mean values against third observer. the analysis included change, consistency and repeatability values with relative repeatability coefficient (rrc). results: repeatability counted with rrc presented values from . % to . %, consistency did not exceed . mm when stricture length or proximal biliary dilatation were measured and . mm when stricture was localised along biliary duct. conclusion: mrcp mip reconstructions are valuable and easily understood images in radiologists' every day practice when morphology and localisation of biliary stricture is discussed. the most reliable conditions seem to be stricture length and stricture localisation. assessment of the role of translabial perineal ultrasonography (tpus) to evaluate urinary stress incontinence in females c. roy, d. pfleger sr., e. castel sr., h. lang sr., c. saussine sr.; strasbourg/fr purpose: assess the usefulness of translabial perineal ultrasonography (tpus) in the evaluation of the two mechanisms (hypermobility of bladder neck and intrinsic sphincter deficiency) of urinary stress incontinence (usi). method/materials: women (mean age: . ) underwent us with translabial perineal approach ( . mhz transvaginal probe) located on the perineal floor, behind urethral meatus. examinations performed in sagittal and coronal, in decubitus and standing positions, at rest, and during pelvic floor contraction and straining. bladder was filled with - ml of urine. morphology of the bladder neck (funneled) was evaluated to diagnose isd. to evaluate hbn, position and displacements of bladder neck was evaluated calculating the distance using inferior border of the symphysis pubis as reference according an orthogonal system, in sagittal plane. the diagnosis of hbn was based on a displacement up to . cm. correlation was made with clinical evaluation and urodynamic testing results. results: among patients with the clinical diagnosis of hbn, tpus confirmed a displacement and depicted in cases an additional isd in front of funneling of bladder neck at rest and straining. among patients with diagnosis of isd; us confirmed an abnormal bladder neck. an association with bladder neck hypermobility was found in cases of this group. for the diagnosis of cystocele ( cases), correlations were excellent, but without additional findings for tpus. conclusions: tpus is easy to perform and no time consuming. it provides a perfect assessment of bladder neck during static and dynamic studies. it allows the diagnosis of associated mixed types of usi with a better classification of these disorders. dynamic fast mri of pelvic floor dysfunction in females using a t -w turbo spin echo technique: value of knee flexion lateral position in comparison with conventional supine position c. roy, f. mayer sr., j. pfeiffer sr., e. castel sr., c. saussine sr.; strasbourg/fr purpose: evaluate organs displacements due to patient position by using a knee flexion lateral versus supine position and its role in the quantification of abnormalities. materials and method: women symptomatic for pelvic floor descent and asymptomatic were explored with dynamic sagittal mri ( . t) using a t w tse sequence (tr/ete: / ms) at rest, pelvic floor contraction, maximal straining and two series: supine and lateral position with knee flexion. distances from bladder base, cervix and anorectal junction perpendicular to the pubococcygeal line were measured in the sagittal plane. in symptomatic patients, correlations with clinical evaluation and colpocystorectography was performed. results: at rest and contraction, there was no significant difference. during straining; for asymptomatic patients mean descent differences of bladder base, cervix and anorectal junction between the two positions were . cm (± . ), . cm (± ), cm (± . ), respectively and for symptomatic patients . cm (± ), . cm (± . ) and cm (± ), respectively. the lateral position revealed rectoceles and additional cystoceles with enteroceles associated to rectal prolapse. the highest displacements in lateral position were better correlated with clinical findings. conclusion: dynamic mri in lateral position is easy to perform, is more reliable to assess pelvic floor prolaps and to detect associated defects of other compartments. role of translabial perineal ultrasonography in females after surgical treatment of urinary stress incontinence by tension vaginal tape (tvt): a prospective study c. roy, d. pfleger sr., e. castel sr., h. lang sr., c. saussine sr.; strasbourg/fr purpose: the efficiency of tvt unknown. to assess the morphologic and dynamic modifications of bladder neck in order to better understanding its action. method/materials: females (mean age: . ) underwent translabial perineal us ( . mhz transvaginal probe located on the perineal floor behind urethral meatus) in sagittal, decubitus and standing positions, at rest, during pelvic floor contraction and straining, before and after surgery. bladder was filled with - ml. position, morphology, and displacements of bladder neck were calculated using inferior border of the symphysis pubis as reference according to an orthogonal system. correlation was made with clinical findings and urodynamic results. results: tvt was always perfectly seen as linear hyperechoic structure; against lower third ( ), middle lower third junction ( ) and upper third ( ) of urethra, respectively. before surgery, cases had funneling of bladder neck in addition to hypermobile bladder base. after surgery, all bladder necks were closed, located at rest above the inferior portion of symphysis. in decubitus position, displacements before and after tvt were - mm (m = . ± . ) and - mm (m = . ± . ) at pelvic floor contraction and straining respectively. in standing position, they were - mm (m = . ± . ) and - mm (m = . ± . ) respectively. among cases of dysuria, tvt was located against the middle ( ) or upper part ( ) with angulation. conclusions: tvt procedure limit excessive movement of bladder neck. it must be located against the lower third of urethra. us examination is reliable to detect malpositions. in patients with symptomatic uterine fibroids cemra (symphony-siemens; . t) of the pelvic and uterine vessels combined with conventional mr imaging was performed. we used a breath-hold d flash cemra (tr/te . / . , fa °) and injected gadolinium ( . mmol/kg b.w.) at a rate of . ml/s. clinical value of the arterial and venous cemra for the planning of the uae was evaluated. after the mr-imaging biphasic uae was performed. the selective and superselective dsa sequences were compared with a vessel by vessel technique with the cemra. results: all cemra were technically successful and all topographically relevant segmental/subsegmental arteries could be evaluated. the common iliac, external iliac, internal iliac and uterine artery could be identified in all cases. the vascular d information of mra provides additional information for the planning of the intervention and the superselective catheter placement. the arterial cemra phase allowed an exact demarcation of the hypervascular fibroids in patients, thus defining the primary access site for the intervention. the venous phase did not provide an additional diagnostic information. the time for the interventions and the radiation could be reduced by using the diagnostic information of cemra in of the patients. cemra combined with mri of the pelvis appears to be an important diagnostic tool for analysing the volume and location of the fibriod and planning of the vascular access. withdrawn by author b- : clinical stage i carcinoma of the uterine cervix: value of preoperative mr imaging in assessing parametrial invasion s. sironi; milan/it purpose: the purpose of this prospective study was to assess the efficacy of different mr imaging techniques in the evaluation of parametrial tumour invasion in patients with early stage cervical cancer. methods and materials: consecutive patients, clinically considered to have stage b tumour (confined to the cervix), underwent mr imaging studies at t, according to the following protocol: fast spin-echo (fse) t -weighted, gadoliniumenhanced se tl-weighted, and fat-suppressed gadolinium-enhanced se tlweighted sequences. images obtained with each sequence were evaluated for parametrial invasion with the use of histopathological findings as the standard of reference. results: in the assessment of tumour infiltration into the parametrium, with fse t -weighted images accuracy was %, with se tl-weighted gadolinium-enhanced images was %, and with se tl-weighted gadolinium-enhanced fat-suppressed images was %. the difference between the accuracy rate achieved with fse t -weighted images, and those obtained with the other two mr sequences was statistically significant (p < . ). the high negative predictive value ( %) for the exclusion of parametrial tumour invasion was the principal contributor to the staging accuracy obtained with fse t -weighted imaging. conclusion: unenhanced fse t -weighted imaging is a reliable method in determining the degree of tumour invasion in patients with early stage cervical cancer. our data suggest that contrast-enhanced sequences, even with the use of fat suppression technique, have a limited value in the assessment of tumour extension. methods and materials: mri of the pelvis was performed h after i.v infusion of uspio ( . mg fe/kg b.w.) in patients (mean age years) with gynecologic tumours ( cervical, endometrial carcinomas, malignant mixed mullerian tumour) who were scheduled for surgery. axial t w se, t w fse (fatsat), fspgr, sagittal and oblique t w fse sequences were acquired on a . t system. next to the primary tumour, lymph nodes were staged prospectively using newly established criteria and results correlated with histology. results: mri correctly diagnosed the primary tumour as stage i in cases and stage ii in case respectively. in case preoperative diagnosis of stage iv led to a change in the therapeutic approach and chemotherapy was given. in this case, multiple malignant iliac nodes were demonstrated. no surgical proof was available. / of the lymph nodes detected on mri, in which a histological correlation was available, were correctly staged (accuracy %). node was false positive; micrometastasis < mm were missed. conclusion: according to our preliminary results, uspio-enhanced mri of the pelvis has the potential to become an important tool for preoperative assessment of uterine tumours. the prognostic significance of high-resolution ct morphology compared to a histological diagnosis in usual interstitial pneumonia (uip) and nonspecific interstitial pneumonia ( in idiopathic pulmonary fibrosis (ipf) both histological and ct features are known to predict outcome. the aim of this study was to compare the prognostic significance of the histological diagnosis (uip vs nsip) and ct findings. materials and methods: biopsy proven cases of uip and nsip were diagnosed by consensus by two histopathologists. the hrcts were scored semiquantitatively by observers with regard to the proportion of ground glass opacity to reticulation ( = predominantly ground glass, = mixed ground glass and reticulation, = predominantly reticulation). in addition the exact proportion of ground glass opacity was recorded. results: / cases were classified as uip and of the / classified as nsip / were cellular and / fibrotic. at follow up (median months) there were / deaths. both an increasing extent of ground glass opacity and a lower semiquantitative ct score were associated with a better outcome (p = . , p = . respectively). the histological diagnosis of nsip was also associated with lower mortality (p = . ). on bivariate analysis hrct provided the more powerful prognostic information. conclusion: in terms of prognosis hrct features in ipf provide much information with little added value from the histological diagnosis. correlation between histologic features and ct morphology in idiopathic pulmonary fibrosis (ipf) s.m. ellis , s.r. desai , d.m. hansell , a.g. nicholson , t.v. colby , r.m. du bois , a.u. wells ; london/gb, scottsdale, az/us purpose: there is increasing evidence that the profusion of fibroblastic foci seen at histology in ipf is predictive of mortality. the aim was to determine whether high-resolution ct appearances correlate with prognostically important histological features. the hrct scans of histologically confirmed cases of ipf were scored by two observers according to the proportion of macro (≥ mm) and microcystic (< mm) honeycombing, fine reticulation and ground glass opacity. their relationships to histological scores of fibroblastic foci and macrophages were examined. results: there was a positive correlation between the proportion of combined hrct score of macro and microcystic honeycombing and the number of fibroblastic foci on histology (p = . ). a further positive correlation was found between the extent of ground glass opacity and the macrophage score (p < . ). there was no correlation between any histological feature and the extent of fine reticulation on hrct. purpose: to describe the radiological (thin section ct) findings correlated to activity and remission in anca associated pulmonary-renal small vessel vasculitis (svv) material and methods: we used retrospective analysis of cts, in disease activity ( first manifestations, relapses) im remission of patients with pulmorenal syndrome ( wegener, microscopic polyangiitis-mpa, churg-strauss-syndrome, idiopathic crescentic glomerulonephritis following the chapel hill classification) women, men, median . years ( - ). the diagnosis was established by clinical presentation (cough, dyspnoea, hemoptysis and/or fever associated with significant hematuria or progressive renal failure), anca titers ( c-anca, p-anca, anca negative) and renal biopsy in all patients. results: pulmonary involvement defined by pathological ct occured in all patients. nodules with (n = ) or without (n = ) cavitation, ground glass opacity (n = ), air space consolidation with (n = ) or without (n = ) cavitation and interstitial septal thickening (n = ) were detected. local interstitial infiltration and nodules in wgs, diffuse interstitial alveolar infiltration in mpa and css, neither lower versus upper lungfield involvement nor side preverence were evident. radiological course of pulmonary involvement was the best indicator for therapeutic success after immunosuppression, occured earlier compared to renal symptoms and was a stronger indicator in first manifestations then in relapses for disease activity. conclusion: thin section ct as the most sensitive radiological examination detects and classifies efficiently the extent of pulmonary involvement of svv, most likely air space consolidation and ground glass opacity, it proves to be the most efficient therapeutic monitor indicating remission. traction bronchioloectasis on hrct in simple pneumoconiosis d. ryu; kangnung/kr objective: traction bronchioloectasis and focal pericicatrical emphysema in p type pneumoconiosis have been well known in pathologic report. however, traction bronchioloectasis, earlier finding of p type pneumoconiosis has not been yet radiologically reported. therefore, we describe traction bronchioloectasis on hrct in p type pneumoconiosis and assess its incidence among small rounded opacities (p, q, r). we retrospectively analyzed the hrct scans of patients that showed small rounded opacity less than centimeter. the study group had a history of occupational exposure to dust and was comprised of all men, - years old (mean age ). type p, q, r rounded opacity consisted of , , patients respectively. two radiologists assessed with consensus whether traction bronchioloectasis was present or not, and its incidence at three levels (aortic arch, carina, and between carina and diaphragm). the degree of traction bronchioloectasis was classified as follows: score : - traction bronchioloectasis were visible at each scan level; score : - traction bronchioloectasis; score : over traction bronchioloectasis. the total score was the sum of three level score. result: all patients showed traction bronchioloectasis. the degree of traction bronchioloectasis decreased with increase of nodule size; p type . ; q type ; r type . . conclusion: traction bronchioloectasis is an early finding of pneumoconiosis with centrilobular dot or branching structure on hrct. such findings could be helpful to differentiate pneumoconiosis from other diseases showing centrilobular nodule. viewing efficiency of soft-copy reading of high-resolution ct of the lungs s.m. ellis, x. hu, l. dempere-marco, g.-z. yang, d.m. hansell; london/gb purpose: soft-copy ct reading is increasingly common and offers the radiologist a choice of many viewing formats. using eye-tracking data we have assessed the efficiency of reading high-resolution ct of the lungs comparing two fundamentally different viewing formats. the eye movements of experienced radiologists viewing hrct's demonstrating diffuse lung disease (n = ), airways disease (n = ) or normal appearances (n = ) displayed on a single monitor were recorded. the time taken to view each case, the number and duration of fixation points, the number of movements between sections and the proportion of these leading to fixation were calculated. the viewing formats used were sections displayed simultaneously ( × ) and single sections displayed at full screen size (stack mode). sections in both formats were viewable by sequential scrolling. results: the number, duration of fixation points, and the number of movements between sections were greater in the × mode (p = . , p = . and p < . respectively. however, the proportion of movements between sections leading to a fixation point was greater in stack mode (p < . ). there was no significant difference in the overall time taken on each case. the viewing efficiency of soft copy reading of lung hrct is greater with sections presented in a × format compared to a stack mode, despite the tendency towards non-fixation movement between sections in the × format. the group of most severe cases (parasitemia > %, presence of complication) included pts ( %). radiographic pulmonary examination was performed in pts. results: pulmonary radiographic changes were founded in pts ( %) with severe malaria. pts ( %) had solitary or multiple pulmonary infiltration. one patient had hospital acquired pulmonary infection during artificial ventilation, while noncardiac pulmonary oedema with fatal outcome was noted in one patient. the therapy in this group of patients was based on quinine/arthemeter parentally. in pts ( %) tetracycline, erythromycin or clindamycin was added as second antimalarial drug. all pts who suffered from pulmonary complications received also various antibiotics parenteral (ampicilin/ceftriaxon/cefotaxim/imipenem, ciprofloxacin, aminoglycoside, vankomcin) according to severity of pulmonary changes, bacteriological findings (blood, sputum) and up to date therapetutical recommendations. conclusion: severe malaria is often connected with pulmonary manifestations, which implies prolonged course of healing and even fatal outcome (noncardiac pulmonary oedema). the value of post-contrast flair in the detection of brain metastasis a. patsalides, j.a. butman, n. patronas; bethesda, md/us in this study we assessed the value of post-contrast flair in the detection of brain metastasis. brain mri studies were performed in patients with melanoma and renal cell carcinoma. fluid attenuation inversion recovery (flair) and t -weighted (t -w) scans were obtained before and after contrast administration in each patient. each of these techniques was evaluated blindly by two radiologists who diagnosed the presence of metastatic tumors by consensus agreement. follow up studies were available in patients with positive studies and the temporal changes of the lesions were used to confirm the diagnosis. cases. at one month the mean serum creatinine level had decreased from ± mmol/l to ± mmol/l, blood pressure was reduced in all the patients from / ± / mmhg to / ± / mmhg and drug therapy was reduced from . ± . drugs to . ± . drugs. results were maintained at months. conclusions: in cases of renal impairment, renal ptra/s using gadolinium chelates as radiographic contrast agents can be performed using standard digital subtraction angiography (dsa) equipment. gd-dota ( . mmol/kg) can be administered intra-arterially without any effect on renal function up to a total volume of ml. carotid artery stent implantation with cerebral protection: multicenter experience of procedures f. castriota , b. reimers , n. corvaja , r. manetti , c. cernetti , c. di mario , p. pascotto , a. cremonesi , a. colombo ; cotignola/it, mirano/it, milan/it background: distal embolization of debris during percutaneous carotid artery stenting may result in neurological deficit. methods/results: consecutive procedures ( patients) of elective carotid stent implantation with cerebral protection performed in different centers were included in a prospective registry. cerebral protection was performed using filter devices ( . % of procedures), occlusive distal balloons ( . %), and endoluminal clamping of the common and external carotid artery ( . %). all lesions were > % diameter stenoses (mean ± %). mean age of the patients was ± years, % were males, and . % of patients had had a previous stroke or transient ischemic attack. in procedures ( . %) it was possible to position a protection device. in of procedures using distal balloon protection, this was not tolerated by the patient ( . %). in procedures ( . %) a stent was successfully placed. neurological complications during the procedure, in-hospital and during days of follow-up, occurred in patients ( . %). these were major stroke ( . %; amaurosis of ipsilateral eye), minor strokes ( . %), and transient ischemic attacks ( . %). protection device related complications, all without neurological symptoms, occurred in procedures ( . %). these were distal dissections ( required additional stents and lead to occlusion of the internal carotid artery) and filter entrapment requiring surgical removal. major adverse cardiac events during the days of follow-up occurred in patients ( . %). conclusions: routine use of cerebral protection during carotid artery stenting appears feasible. in this study the incidence of neurological complications was low. fresh dwi lesions after stenting of the internal carotid artery v. moeller; homburg a. d. saar/de purpose: our aim was to reveal the number of thrombembotic events after stenting of the carotid artery. methods: patients underwent stenting of the carotid artery. afterwards patients were neurologically examined and underwent mr imaging. stenting was performed without protective devices. systemic anticoagulation was started three days in advance. in cases predilatation of the stenotic vessel was performed. results: stents were succesfully placed. patients developed neurological deficits, had a minor stroke, a transient ischemic attack. retrospectively anticoagulation was found to be insufficient in one of these cases. months after the intervention none of the patients had developed neurological deficits. diffusion weighted mr imaging detected fresh lesions in patients. the medium degree of stenosis was . %, this being significantly higher than the . % among those without new lesions on dwi. furthermore the mean age of the first group was thromboembolic events -a challenge in interventional neuroradiology i.q. grunwald, v. möller, w. reith; homburg a. d. saar/de purpose: thromboembolic events are the most frequent complication in the endovascular treatment of intracranial aneurysms with gdcs. at the moment diffusion-weighted imaging is the most sensitive method for their early detection. our aim was to evaluate the number of ischemic events by using diffusion-weighted mri. method: before and within hours of endovascular treatment with gdcs patients with asymptomatic aneurysms were studied with diffusion-weighted images. during positioning of the coils and for another days the patients were heparinised. a neurological examination took place before and after coiling as well as on discharge. results: occlusion of the aneurysm was achieved in all cases. dwi showed small, fresh hyperintense areas in cases. they were all located in the vascular territory of the aneurysm and have to be seen as intervention-related. none of the patients had clinical symptoms. occurance of thromboembolic events did not correlate with the number of coils used. conclusion: regarding the frequency of thromboembolic events, even though they are mostly silent, dwi monitoring should follow intervention. we assume that the thrombembolic lesions are due to embolic fragments that migrate from the aneurysm as well as due to ischemic events of other origin (vasospasm, arteriosclerosis). therefore we think that in the endovascular treatment of asymptomatic aneurysms systemic anticoagulation should be performed. purpose: for most of the pregnant women who underwent an obstetric flow study using color doppler imaging, we calculated low velocity values from the foetal middle cerebral artery in comparison to literature. the aim of this study was two-fold: to define the normal flow values of the foetal and maternal arterial systems and to compare the results with the literature. methods and materials: healthy pregnant women of various gestational age who underwent a color doppler examination were studied after having an uncomplicated pregnancy and labour. pulsatility index (pi), resistance index (ri), peak systolic/end diastolic ratio (s/d ratio) values were calculated for the foetal aorta (fa), foetal middle cerebral artery (fmca), umblical artery on the maternal (mua) and foetal (fua) side and the maternal uterine artery (uta). the results were compared with the published literature. results: to forty week pregnancies were divided into different groups, each group represented a period of weeks of gestational age. for each group, the studied parameters were defined and presented in a diagram. flowmetric values are helpful in defining the existing or potential abnormalities in the foetus. the published literature was used to compare patient flowmetric study results. in our study, we found significant differences for fmca and ua values compared with the published data. to study the relationship of uterine artery impedance measured as pulsatility index (pi) and resistance index (ri) on the outcome of in vitro fertilization -embryo transfer cycles. methods: women in the age group between - a were studied on the day of embryo transfer by performing tranvaginal color doppler sonography. uterine artery pulsatiliy index, resistance index and endometrial thickness were calculated. subsequently pregnancy rates were calculated. results: the pregnancy rate was % in patients with a pulsatility index . ± . and resistance index . ± . . in patients with a pulsatility index higher than . and resistance index higher than . the pregnancy rate decreased significantly to %. purpose: in addition to histologic evaluation of the effect of antiangiogenic treatment with anti-vegf receptor antibodies, a functional investigation of tumour vascularisation was performed using contrast enhanced, intermittent power doppler sonography in tumour bearing nude mice. methods and materials: thymus-aplastic nude mice with hacat-ras-tumours were examined weekly for weeks after i.v.-bolus injection of levovist with intermittent power doppler sonography. this further developed method allowed statements about the quantification of blood flow and volume by varying the time delay between doppler imaging sequences to be made. besides other vascularisation parameters like time of arrival, slope of the curve, maximum and plateau phase of the colour pixel density (pcd) and mean colour value were measured. five mice were treated with a vegf-receptor antibody during the examination period. results: while without contrast agent nearly no blood flow was visible, the tumours showed clearly visible enhancment of doppler signal after injection of levovist. tumours without therapy showed an increase in pcd signals during the tumourgrowing phase. mice with antiangiogenic treatment showed a signal decrease in the first monitoring examination, even in growing tumours. there was a limitation of doppler signals to the periphery of the hacat-ras-tumours whilst untreated tumours showed a homogenous enhancement except in necrotic areas that were found in later phases. conclusion: contrast enhanced sonography enables vascularisation measurements of hacat-ras-tumours and the monitoring of antiangiogenic therapy. therapeutic effects could be visualized before a macroscopic change of tumour size was observed. furthermore intermittent doppler sonography enables objective perfusion parameters in ultrasound. we prospectively examined the va origin with cds using a - mhz endovaginal transducer in vas in consecutive subjects referred for evaluation of carotid and vertebral arteries. we also evaluated va origins of the same subjects using a - linear transducer and compared the visualization rates of both transducers. the criteria for visualization of va origin was identification of origin of an artery arising from the subclavian artery and entering the transverse foramen at the c level. angle-corrected peak systolic velocity (psv), end diastolic velocity (edv), and resistive index (ri) were determined. angiography was available for comparison in vas of subjects. results: two aplastic right vas of subjects were excluded. the va origin was visualized in ( . %) of vas ( right and left vas) with the endovaginal transducer and ( . %) of vas ( right and left vas) with the linear transducer. psv, edv, and ri of vas were . ± . cm/s, . ± . cm/s, and . ± . (mean ± sd), respectively. angiography revealed stenosis (> %) of the va origin in vas (psv > cm/s at cds) and normal patency in vas. in the only one of vas missed at cds with the endovaginal transducer, the va was shown to arise directly from the aorta at angiography. conclusion: cds with an endovaginal transducer was a very useful and efficient method to visualize the va origin. doppler sonography of sympathetic vasomotor response in patients with diabetic foot syndrome a. hlawatsch , j. bauer , v. kuhl , s. mink , m. eicke ; mainz/de, heilbronn/de purpose: neurophysiological assessment of the peripheral autonomic system is limited. continuous wave doppler sonography of the radial artery can be used to measure the sympathetic vasomotor response (svr). we studied patients (mean age a) with diabetic foot syndrome. the data from mhz cw doppler sonography before and after sympathetic stimulation by coughing (leading to a temporary disappearance of diastolic flow) were compared with normal controls. correlation was made with nerve conduction studies and the extent of radiologically visible media sclerosis. results: under baseline conditions, the mean flow velocity was similar in diabetics and controls, but the resistance index (ri) was significantly higher in diabetics ( . vs. . ). after coughing no significant difference in the ri or the duration of the response was noticed between patients and controls, but the onset of the response was significantly delayed in the study group ( . vs. . s). no correlation was found with nerve conduction studies and radiologic results. conclusion: radial artery svr is an independent and sensitive marker for autonomic function. : - : room i interventional radiology liver tumor ablation -metastases purpose: to evaluate in vitro and in vivo the use of mr-guided interstitial thermotherapy with rfitt in bipolar technique and to compare electrodes with active and non-active tips. material and methods: a newly designed internally cooled rf probe (∅ mm) was used. both electrodes were mm in length, the inserted insulator between both electrodes was mm in length. for cooling, distilled water was used at flow rates between and ml/min and the power was between and w. three patients with a liver metastases were treated under local anesthesia. in vitro studies were done to compare electrodes with an active tip with electrodes with a nonactive tip. during mr measurements the rf generator was switched off. results: mri allowed a reliable visualization of the electrodes and the insulator in between. the experiments documented that a rf power of w with an irrigation rate of ml/min results in the largest possible area of coagulative necrosis with a diameter of mm × mm. the treatment of the patients was performed without any complications. the advantage of the active tip is that subcapsular lesions can also be treated using this bipolar rf technique with the active tip as the distal electrode. conclusion: mr-guided rfitt using a internally cooled, irrigated bipolar rf electrode results in a coagulative necrosis which is comparable to those of mr-guided laser induced thermotherapy (litt) . with the active tip as the distal electrode subcapsular lesions can also be treated with the bipolar system. to determine the value of multiplanar and d post-processing techniques for guidance of the ablative probe to an optimal position before radiofrequency treatment of liver lesions. methods and materials: patients with malignant hepatic tumors (hcc n = , metastases n = ) underwent radiofrequency ablation. following conventional ctguided (siemens volume zoom©, biopsy mode) positioning of the ablative device, its position was re-evaluated using multiplanar (mpr) and volume rendering dreformations. the position of the ablative device was characterized qualitatively based on the following scale: central -probe is localized within the central % of the tumor; marginal -probe is lateralized towards the periphery of the tumor; outside -probe-position outside of the tumor. suboptimal positioning was corrected following initial ablative therapy to assure complete ablation of the tumor and imaging was repeated. results: multiplanar and d renderings proved superior over imaging in the axial plane in determining the position of an ablative device within liver tumors (p = . ). in out of patients the probe position was considered to be central on axial images whereas multiplanar and d renderings only revealed marginal probe localisation. axial, multiplanar and d renderings yielded identical results in the remaining patients. comparing multiplanar and d reformative techniques, no significant difference was shown in determining the ablative device position. conclusion: mpr and d renderings aid in optimising the probe position for ablative therapy in a substantial number of patients. as a correct probe position is crucial for the success of an ablation procedure, these viewing techniques should be implemented without delay. clinical diagnosis was always underestimated at initial presentation. imaging modalities were requested for cerebral ischemic attack ( / ), cephalalgia, photophobia and tinnitus ( / ). initial imaging diagnosis was delayed (> days) in all cases, as patients were referred for brain evaluation and carotid artery disease. follow up clinical and imaging examination demonstrated: a death (n = ) serious brain damage (n = ), complete recovery after antiobiotherapy and anticoagulotherapy (n = ). conclusion: delayed diagnosis of septic thrombosis of the lateral sinus is probably related to its non-specific clinical symptoms. therefore, in patients with an history of diabetes immunodepression or of infection of the face or of the temporal bone, a careful examination of the skull base should be performed to determine the permability of the brain venous sinuses, the status of the mastoid cell pneumatization of the temporal and occipital bones and the normality of the related fatty spaces. objective: conventional or digital d dacrocystography and ct dacocystography is usually carried out after the catheterization of a lacrimal canaliculus. we tried to evaluate the quality of opacification on ct scans after simple instillation of contrast medium, without any catheterization. patients and methods: patients ( nasolacrimal ducts) were explored for lacrimal pathways obstruction by ct scans after instillation of diluted water soluble contrast medium instillation. a complementary ct acquisition after catheterization was performed when the first ones did not show any opacification. results: ct dacrocystography after instillation is a well tolerated and safe technique. in our study, it allowed detection all pathologic lacrimal canals; normal lacrimal pathways (after catheterization) were not opacified after instillation (false positives). the sensitivity of the method was %, its specificity %. conclusion: ct dacrocystography after ocular instillation is an easy, physiologic and sensitive method to evaluate lacrimal obstruction. we propose it as the first step test, the catheterization being used only when there is total absence of opacification after instillation. results: inflamatory causes are responsible of lacrimal duct obstruction. we found no post-traumatic lesions, dacryolithiasis or nasolacrimal neoplasms. dcg evaluated lacrimal ducts and the nasal meatus. dct was performed only in patients with simple intubation or endoscopic dacryocystorinostomy to exclude all postsurgical complications of the surrounding nasolacrimal duct tissues or an inflammatory process of paranasal sinuses. discussion and conclusion: dcg and dct have almost the same sensitivity and specificity in a morphological study of nasolacrimal ducts. crystallin dosage is . to . msv in dcg and . to . msv in dct. dct with d reconstruction gives good spatial and anatomic details (orbital, etmoidal and nasal bone). dcg is always the gold standard in the imaging of the lacrimal ducts, but we propose dct to check possible post-surgical complications. purpose: poag is an ocular disease based on a progressive optic neuropathy, visual-field defects and elevated intraocular pressure. our purpose was to compare with color doppler the blood flow of the main orbital arteries of normal, atherosclerotic and glaucomatous subjects. methods and materials: we evaluated with color doppler (atl hdi ) the blood flow of ophthalmic artery (oa), central retinal artery (cra), nasal and temporal short posterior ciliary artery (spca). peak systolic velocity, end diastolic velocity and resistive index (ri) of each artery were considered. we examined group of patients: normal subjects (group a), patients (> years) with positive risk factors for atherosclerosis (smoking, hypertension) (group b) and patients affected by poag (group c). inclusion criteria in group c were: iop > mmhg, visus > / , pseudoexfoliatio presence. results: all the arteries of group b showed higher ri than group a, with low end diastolic velocities. spca ( . ± . ) and cra ( . ± . ) of group c showed significantly higher ri than group a, but no significant ri differences were found in oa of group c ( . ± . ) and group a ( . ± . ). conclusion: normal, atherosclerotic and glaucomatous subjects can be distinguished by color doppler evaluation of the blood flow of the main orbital arteries. orbital color doppler can be useful in the diagnosis of poag and in the monitoring of these patients. which parameter should be used for rapid assessment of extraocular muscle enlargement in patients with graves' ophthalmopathy? z. szücs-farkas, j. toth, l. galuska, e. balazs, e.v. nagy; debrecen/hu purpose: to find the most accurate, easy-to-measure parameter that can be used as a substitute for extraocular muscle volume assessment in patients with graves' ophthalmopathy. subjects and methods: orbits of patients were examined in a conventional t mr scanner and the rectus muscles evaluated. the diameter at the largest extent of the muscle belly, as well as the long and the short diameters and the cross sectional areas in a preselected coronal scan were measured for each muscle and compared with the corresponding muscle volume measured on contiguous t w transverse slices. results: the measured coronal area correlated well with the volume of the superior (r = . ) and inferior (r = . ) recti. the largest transverse diameter showed strong correlation with the volume of the lateral (r = . ) and medial (r = . ) recti. for the latter muscle, the coronal area also exhibited a high correlation with the volume (r = . ). coronal cross-sectional areas can be well estimated by measuring both the short and long coronal muscle diameters (r values were between . and . ). p was less than . for every above mentioned correlations. conclusions: in graves' ophthalmopathy, the volume of three of the rectus muscles seems to be well estimated by measuring their cross sectional area on a single coronal slice, while the largest transverse diameter of the lateral rectus is suitable for the same purpose. purpose: a prospective study was performed to determine the accuracy of unenhanced, enhanced and early delayed ( ') enhanced ct densitometry in differentiating adenomas from non adenomas and to evaluate the usefulness of absolute and relative percentage of washout. methods and materials: oncology patients with undetermined adrenal masses were all studied by unenhanced, enhanced and minutes delayed enhanced helical ct scans. attenuation values of all adrenal masses on each type of scan was measured by mean of a region of interest and then used to calculate absolute and relative percentage wash-out. proof of diagnosis was ct and/or mr follow-up ( - months) in patients; percutaneous ct guided biopsy in patients; surgery in patient. results: on unenhanced ct scans, with attenuation threshold of hu, specificity and sensitivity for the diagnosis of adenoma were % and % respectively. on minutes delayed ct scans, with an attenuation threshold of hu, specificity and sensitivity for the diagnosis of adenoma were % and % respectively. moreover, all adrenal masses were correctly characterised as benign or malignant on delayed scans with a relative percentage washout of % and an absolute percentage washout threshold of %. conclusion: unenhanced and early delayed enhanced ct attenuation values can characterise an adrenal mass as a benign adenoma with high specificity and acceptable sensitivity. the percentage change in washout of contrast media can be a useful adjunct to absolute ct attenuation values in differentiation of adrenal adenomas and nonadenomas. ct adrenocortical carcinomas and pheochromocytomas: assessment of wash-out at delayed contrast-enhanced p.i. reittner , m. korobkin , p. wehrschütz , k.w. preidler , d.h. szolar ; graz/at, ann arbor, mi/us purpose: to measure the changes in washout of contrast material on contrast medium-enhanced computed tomographic (ct) scans in patients with adrenocortical carcinomas and pheochromocytomas. materials and methods: fifteen patients with proven adrenocortical carcinomas and patients with pheochromocytomas underwent helical ct. unenhanced ct was followed by enhanced ct at seconds and minutes. adrenal masses ( adenomas and metastases, respectively) in patients served as reference data. results: the adrenocortical carcinomas and pheochromocytomas enhanced significantly lesser than the adenomas at seconds (p < . ). at minutes, both the absolute and relative percentage loss of enhancement were significantly greater for the adenomas than for the adrenocortical carcinomas and pheochromocytomas (p < . ), respectively. delayed-enhanced ct at minutes (sensitivity, %; specificity, %) was more accurate for differentiation of adenomas and adrenocortical carcinomas and pheochromocytomas than unenhanced ct (sensitivity, %; specificity, %) conclusion: adrenocortical carcinomas and pheochromocytomas exhibit similar wash-out than do adrenal metastases, but significantly lesser than do adrenal adenomas. the percentage change in washout of contrast material is a useful adjunct to absolute ct attenuation values in differentiation of adrenal adenomas and adrenocortical carcinomas and pheochromocytomas. incidence of malignancy in complex cystic renal masses (bosniak category iii): should biopsy precede surgery? m.g. harisinghani, k. jhaveri, d.a. gervais, p.f. hahn, j. varghese, p.r. mueller; boston, ma/us purpose: we sought to determine the incidence of malignancy and to assess a possible role for image guided biopsy of this category of renal masses materials & methods: of the renal biopsies performed at our institution between and ; a total of patients with category iii lesions, were identified for analysis. there were men and women with age range from to . the incidence of malignancy, based on surgical pathology or imaging follow up, and percentage of lesions proceeding to surgery, among these lesions, was determined. the surgical results were correlated to the biopsy findings results: of the biopsied category iii lesions, were malignant ( renal cell carcinoma, lymphoma) and were benign ( hemorrhagic cyst, oncocytoma, inflammatory cysts, adenomas, focal glomerulosclerosis). seventeen of the ( . %) lesions ( renal cell carcinoma, inflammatory cyst) had surgical resection following the biopsy. all lesions proceeding to surgery had pathological diagnosis identical to the pecutaneous image guided biopsy results. non-surgical patients had radiological follow up for minimum year conclusion: the incidence of malignancy in bosniak category iii is . % ( % confidence interval). presurgical renal biopsy and radiological follow up is useful in identifying non-malignant lesions in this category, thus avoiding unnecessary surgery in up to % of patients method and materials: prospective analysis of patients with histopathologicaly proved rcc included enhanced mdct studies in arterial and corticomedullary phase (detector configuration: × mm, rt . ). we compared reconstruction protocols (slice width/reconstruction interval: . / . mm, / . mm, / . mm). in addition, multiplanar reconstructions (mpr) in , and . mm coronal planes were assessed. finally, low-dose ct urography (delay min) with mpr reconstructions was performed in the excretory phase. image data of all reconstructions were analysed for the size of the lesion, tnm staging, morphological, and enhancement characteristics by two radiologists. histopathological data were used to determine the efficacy of the different ct reconstruction protocols. results: different reconstruction protocols ( , and . mm) have no influence on the evaluation of tumour size and t-staging. however, assessment of lymph node size was improved in % of the patients by using thinner slice width and . mm mpr reconstruction. vertical tumour size and v. cava infiltration was more precisely assessed by evaluation of mpr-than axial reconstructions. in all patients ct-urography demonstrated sufficient opacification of the collecting system. conclusion: axial reconstruction protocols are equally suited for the t-staging of rcc. a mdct protocol using additionally . mm mpr reconstructions and lowdose ct urography appears effective as a "one-stop" protocol for a proper staging of rcc and eliminates further investigations such as iv urography. b- : . ( % ci: . - . ) for the n-stage. the average tumour size was . cm. all accessory arteries and veins were correctly described. the renal pelvis was opacified in %, the proximal ureter in %, and the distal ureter in %. distant metastases were found in cases and patients showed tumour extending into the renal vein. conclusion: isotropic multislice ct of the kidneys with a modified injection protocol provides good correlation with pathological tumour stage, allowing cta and ct-urography calculation from the same dataset and, thus, may represent a universal imaging technique in renal cancer staging. histopathological correlated, staging of renal carcinomas by multislice ct and high performance mri p.j. hallscheidt, s.o. schoenberg, g. riedasch; heidelberg/de aim: to evaluate the accuracy of multislice-computed tomography (ct) and magnetic resonance imaging (mri) in staging renal carcinoma and planning of nephron sparing surgery. material and methods: in a prospective study renal carcinomas were preoperatively examined for tumour staging by multislice ct and mr imaging and correlated with histopathological staging. triphasic ct imaging was performed with a siemens volume zoom with a reconstructed slice thickness of mm. d and coronal reconstructions were used to improve planning of the surgery. in mr imaging (siemens vision) additional to the transversal t -weighted ge sequence with and without gdtpa, and a transversal t weighted respiration triggered tse, a coronal t -weighted ge sequence with gdtpa and fat saturation were acquired. in addition a multi phase d angio after gdtpa injection was performed. results: in early stage renal carcinoma ct and mr imaging provide similar staging accuracies. in all cases multi slice ct allowed us to identify all renal masses, especially in multifocal renal cell carcinomas. accessory arteries could be identified in all cases, too. multiphase mri allows detection and differentiation of renal masses, especially in caval infiltration. conclusion: multislice ct and d reconstruction integrate essential information from angiography, venography, urography and d ct in a single imaging modality. in multislice ct all tumours in multifocal renal cell carcinoma were detected. in advanced renal carcinoma mri was superior to ct imaging, especially in diagnosing tumour thrombus. consequently the extent of tumour thrombus may be assessed by mri which therefore may replace conventional cavography. small renal masses: value of contrast-enhanced colour doppler imaging a. klauser, g. janetschek, g. helweg, r. peschel, l. pallwein, d. zur nedden, f. frauscher; innsbruck/at purpose: we assessed the value of a microbubble based ultrasound (us) contrast agent for blood vessel enhancement in colour doppler imaging (cdi) of small renal masses. methods and materials: patients with "indeterminate" small renal masses (< cm in diameter) underwent prospective cdi before and after intravenous administration of the contrast agent levovist® (schering ag, berlin, germany). the degree of tumour vascularity was subjectively graded from to iv (indicating an increasing vessel count) and the peak systolic velocity (psv) was measured. cdi findings were compared with those obtained at histopathological examination. results: intra-and/or peri-tumour vessels were detected in lesions ( %) by unenhanced cdi and in lesions ( %) by enhanced cdi. the detection of vascularity was increased by contrast administration (p = . , mcnemar test). higher grades of tumour vascularity (grade iii and iv) were found more often in malignant renal masses (p < . ). psvs higher than cm/s were found only in malignant lesions. based upon receiver operating characteristic analysis, enhanced cdi (az = . ) is more accurate than unenhanced cdi (az = . ) for differentiating benign from malignant renal masses (p < . ). conclusions: enhanced cdi is superior to unenhanced cdi in the detection of tumour vascularity, and in the discrimination between benign and malignant small renal masses. assessment of renal masses with contrast enhanced sonography using pulse inversion imaging and fso j.-m. correas , m. claudon , a. lesavre , a. méjean , l. bridal , o. hélénon ; paris/fr, nancy/fr purpose: to evaluate the efficacy of contrast-enhanced sonography of renal masses using a fso (optison®, mallinckrodt, usa), with quantification of the signal intensity. materials and methods: renal masses were studied with pulse inversion imaging (pii) at baseline and following a bolus injection of fso ( , , and ml, randomised dose, patients per dosage group, atl hdi , c - probe). cineloops were transferred to a pc for quantification with hdi lab. the cortical and solid mass enhancement was calculated as the difference between the signal intensity of a region of interest located upon the normal cortex and the mass before and after injection (db). the final diagnosis was obtained by ct, mri and/or surgery (adenocarcinomas , complex cysts ; hamartomas ). results: cortical enhancement was correlated with the dose (r = . ) and was consistently greater when the mechanical index was lower than . . the detection of normal and atypical cysts was improved and was correlated with ct and mri features. renal mass delineation was improved except when the enhanced mass signals matched with the normal surrounding cortex ( cases). the visibility of the necrosis within the lesion was comparable to the ct and mr appearance. the peak enhancement was: . db ± . db for the cancers, . db ± . db for the hamartomas and . db ± . db for the complex renal cysts. conclusion: pii of renal masses following fso injection improved the detection and the characterization of renal masses, particularly in small tumours and complex cysts. purpose: combined inhibition of the synthesis of nitric oxide and prostacycline predisposes rats to renal injury from radiographic contrast media (rcm). the reliability of these pharmacological manipulations was investigated. methods and materials: adult male sd rats were injected with l-name ( mg/kg), indomethacin ( mg/kg) and rcm (or normal saline) minutes apart. serum creatinine (cr) was measured prior to and post these pharmacological insults. results: a significant increase in serum cr (from . ± . to . ± . µmol/l and from . ± . to . ± . µmol/l, n = /group) was observed hours after injection of ml and ml of high osmolar rcm diatrizoate respectively. the increase in serum cr recovered spontaneously days after the injection. no significant change in renal function was observed in the control group receiving ml/kg of normal saline (n = ) or after injection of ml of diatrizoate (n = ). the increase in serum cr observed with ml of diatrizoate was significantly higher (p < . ) in comparison to the rise induced by equivolume of the low osmolar iopromide (serum cr was . ± . µmol/l pre contrast and . ± . µmol/l hours post contrast, n = ). the calcium channel blocker diltiazem ( mg/kg i.p., min prior to contrast injection) prevented the rise in serum cr observed with ml of diatrizoate. the protective effect was less with lower doses of diltiazem. conclusion: the used animal model is reliable and capable of reproducing previously established observations. the protective effect of a calcium channel blocker has also been shown. purpose: aim of the study was to evaluate the efficacy of gadobutrol as contrast agent for diagnostic chest and abdominal ct compared to iodinated contrast media in a porcine animal model. methods: in pigs spiral cts of the chest and abdomen were performed using ml/kg bw gadobutrol (gadovist, schering, germany) given by single intravenous injection (siemens somatom plus ; slice: mm, table feed: . mm, reconstruction increment: mm). one week later the same animals were examined under the same protocol using iopromide (ultravist ; schering, germany; ml/kg bw). in additional animals serial cts were performed using gadobutrol on day and iopromide on day to detect contrast media kinetics, peak enhancement and time enhancement-product in important vascular regions and parenchymal organs. peak enhancement (net increase compared with native baselines) were measured in houndsfield units (hu) in defined regions of interest. additionally, diagnostic quality and accuracy of the cts were evaluated on a two-step scale by three independent blinded investigators. results: in vivo, the mean peak enhancement , , , , and seconds in the abdominal aorta after injection of ml/kg bw gadobutrol and iopromide was , , , , , hu and , , , , , hu respectively. all cts using gadobutrol were classified as diagnostic with excellent differentiation of vascular and parenchymal structures. conclusion: computed tomography with mol gadobutrol resulted in an excellent contrast peak enhancement. computed tomography using gadobutrol is feasible and a possible alternative to iodinated contrast material. use of artificial neural networks in predicting adverse drug reactions in patients receiving contrast media e. grossi , m. buscema , a. seeberg ; milan/it, rome/it, constance/it neural networks (anns) are mathematical algorithms tools are able to determine the existence of subtle correlations between series of data and a particular outcome, and once "trained", can predict output data on the basis of the input data. although neural networks have been applied in various areas of medical research, they have not been previously applied to the prediction of adverse events to contrast media. materials and methods: anns (provided by semeion research centre, rome, italy) were used to predict adverse events occurring in over patients receiving iomeprol ( mg i/ml) within a large observational clinical study performed by bracco-byk gulden in german radiological centres. the database consisted of independent variables obtained from the case report forms. during an optimising process based either on linearity criteria or specific evolutionary algorithms, just independent variables resulted as best predictors of the prognostic target. the sample size was divided into two random subsamples: the training one (the only one containing the dependent variable) and the testing one. in the testing phase the overall prediction accuracy ranged from . to . %. these values were reproducible along ten consecutive experiments with independent networks of the same type trained in different random subsamples. these results indicate that neural-network analysis can be used to predict adverse effects of contrast media within a given class. mr imaging of atherosclerotic plaque with new ultrasmall particles of iron oxide ( ) compared to sinerem® in hyperlipidemic rabbits c.u. herborn , t.c. lauenstein , f.m. vogt , c. corot , j.f. debatin , s.g. rühm ; essen/de, aulnay-sous-bois/fr purpose: to evaluate a new uspio compound , compared to sinerem® (both guerbet, france) as a marker of macrophage activity in atherosclerotic plaques. materials and methods: experiments were conducted on heritable hyperlipidemic rabbits aged - months. imaging was performed on a whole body scanner using the transmit/receive head coil. after initial d mr angiography of the thoracic aorta with conventional paramagnetic contrast agent (gd-dota), animals were injected once with either (n = ) or sinerem® (n = ) at equal doses. d mr angiography was repeated daily over days. on day the rabbits were euthanized for histopathologic evaluation of the aorta. results: d mras with gd-dota revealed no abnormal findings in any of the animals (n = ). luminal signal intensity at different days was comparable between both compounds with no significant differences regarding the time-evolution of t * effects. susceptibility effects within the aortic wall became evident on day in both groups reaching the maximum after days. these changes were more pronounced in the group without amounting to a statistical significance. histopathology proved slightly increased fe uptake in macrophages of atherosclerotic plaques of the two rabbits injected with compared to those who received sinerem®. conclusion: both uspio agents cause susceptibility effects within atherosclerotic plaques detectable by d gre sequences. since phagocytosis of seems to be superior to sinerem® it can be assumed that lower doses of this compound are suited to allow better visualization of active plaque in atherosclerotic disease. a.r. rudisch , c. kremser , w. judmaier , h. zunterer , j. griebel , a. de vries , w.r. jaschke ; innsbruck/at, neuherberg/de aim: this study aimed to compare perfusion-index-values (pi) of gadolinum-dtpa (gd-dtpa) obtained in malignant tumors with pi's of normal tissue (muscle). material and method: perfusion data were obtained in histological proven primary rectal carcinoma and in left sided gluteus maximus muscles (n = ). perfusion data were obtained by magnetic resonance imaging (mri) measurements using a specially ultrafast t -mapping sequence in a . t whole body scanner. t -maps were acquired in intervals of s or s before, during and after constant rate infusion of gd-dtpa. in order to investigate the relevance of spatial heterogeneities of microcirculation in tumors and muscles, relative frequency distributions of pi's were computed with equal class intervals of . ml/min/g. not only the mean pi but also the relative fraction of pi £ . ml/min/g between tumor tissue ( . ml/min/g ± . ; . %; ± . ) and muscle tissue ( . ml/min/g ± . ; . %; ± . ) was statistically significantly different (both p < . , mann-whitney-u-test). discussion: our results can offer additional information about higher nurtrients supply, e.g. chemotherapeutic agents, to tumor tissue than to muscle tissue caused by high pi's and a higher relative fraction of high intratumoral pi's. the presentation was supported in part by grants from schering, germany and austria. can necrosis avid-mr-imaging with metalloporphyrins differentiate between stunned and infarcted myocardium: results of an experimental study in dogs p. reimer , j. bankert , c. bremer , k.-u. jürgens , t. filler , t. weber , b. tombach ; karlsruhe/de, münster/de purpose: to investigate whether stunned myocardium may be differentiated from infarcted myocardium by metalloporphyrin-enhanced-mri. materials and methods: open-chest anesthetized dogs underwent reversible ( min; n = ) and permanent (n = ) pneumatic occlusion of the left anterior artery (lad) to induce myocardial stunning and myocardial infarction, respectively. mri was performed at . t obtaining ecg-triggered short and long axis t -w tse at baseline and every min following injection of gadophrin- ( µmol/kg bw) up to hours. postmortem, needle biopsies were taken from the lad-perfused and a remote area. ex vivo, mri (t -w tse) and ttc staining were performed. results: gadophrin- enhancement was slightly higher in stunned myocardium than in remote regions but significantly higher than in infarcted areas when measured in the long axis. all regions showed highest signal intensity min following injection followed by a decrease over time. conclusion: gadophrin- enhanced mri may serve as an additional tool besides functional measurements such as tagging or perfusion to differentiate stunned from infarcted myocardium. assessment of angiogenic tumor burden by susceptibility mri using long circulating iron oxide nanoparticles c. bremer , m. mustafa , a. bogdanov jr. , v. ntziachristos , a. petrovsky , r. weissleder ; münster/de, boston, ma/us purpose: to evaluate iron-oxide enhanced mri for the assessment of the angiogenic burden of various tumors methods and materials: a variety of tumors ( l-gliosarcoma, du -breast cancer, ht -fibrosarcoma and eoma-hemangioendothelioma) with various angiogenic potential were implanted into nude mice. tumors were imaged at . t using a pd-w ge sequence before and after i.v. injection of magnetic iron oxides nanoparticles (mion). ∆-r * maps were calculated for all tumors and the relative tumoral blood volume was determined by roi-analysis. tumors were stained for cd for quantification of the microvessel density (mvd). moreover, vegf expression was analyzed for each cell line by western blotting and elisa. a subset of animals was injected with a tc-labeld intravascular tracer for measuring the blood volume distribution in vivo. results: blood volume maps generated by mri revealed a significantly higher tumoral blood for eoma-( . ± . %) and ht -( . ± . %) compared to du -( . ± . %) and l-tumors ( . ± . %). mvd correlated well with the mr-data with eoma-and ht -tumors revealing a higher mvd ( ± and ± counts per field) compared to du -and l-tumors ( ± and ± counts per field). moreover, mri data closely correlated with tc-blood volume maps and the vegf expression patterns conclusions: mri with long circulating iron oxides can be utilized to assess tumoral angiogenesis. since iron oxide based particles are widely available, this technique can be readily adapted for clinical use. ) . a -month clinical follow-up was obtained in all patients who were not anticoagulated. results: for a longer mean z-axis coverage (group : mm; group : mm; p < . ), the mean duration of data acquisition was shorter with msct (group : s; group : s; p < . ). examinations devoid of respiratory and cardiac motion artifacts were more frequent in group than in group (p < . ). in the absence of significant difference in the quality of vascular enhancement, the porportion of examinations interpretable down to the subsegmental arteries was higher in group ( . %) than in group ( %) (p < . ). the benefits of msct were more marked for patients with underlying respiratory disease and did not lead to a higher detection rate of peripheral pe. the negative predictive value of ssct and msct were % and %. conclusions: improvement in image quality on msct scans accounts for the improved diagnostic accuracy of scta, especially for patients with impaired respiratory function. incidental detection of pulmonary emboli on routine multislice ct of the chest c. ciccotosto, m.l. storto, f. guido, a. di credico, a. guidotti, l. bonomo; chieti/it purpose: to determine the prevalence of pulmonary embolism (pe) incidentally detected on routine multislice ct (msct) scans of the chest and to assess the influence of window width and level on pe detection. methods and materials: between january and august , , routine contrast-enhanced ct scans of the chest were performed in patients using a msct scanner ( × mm or × . mm collimation; mm slice width). ct angiographic studies performed for suspected pe or evaluation of the thoracic aorta were excluded. ct scans were retrospectively reviewed by chest radiologists for the presence and site of pulmonary emboli using a cine-view mode on a dedicated workstation and different widow settings: w = hu, l = hu (standard) and w = - hu, l = - hu (wide). results: unsuspected pe was present in / ( . %) patients, with an inpatient prevalence of . % ( / ) and outpatient prevalence of % ( / ). most patients ( / ; . %) with unsuspected pe had cancer. the proximal extent of pe involved the main pulmonary artery in patients, a lobar artery in , a segmental or subsegmental artery in . use of a wide window setting allowed detection of pe in more patients than did the standard one. unsuspected pe was found in as many as . % of patients undergoing a routine study of the chest with msct, with a higher prevalence among patients with malignancy. the use of a wide window setting is recommended when interpreting routine msct of the chest in order to improve unsuspected pe detection. low kvp settings improve contrast enhancement and reduce radiation exposure in spiral ct of pulmonary emboli c. weidekamm, m. prokop, c.j. herold; vienna/at purpose: higher contrast of iodinated contrast material at low kvp settings may be used to compensate for increased image noise at lower exposure dose. we evaluated this concept for spiral ct of patients with suspected acute pulmonary embolism. we compared a standard protocol using kvp, mas (ctdi vol = . mgy) to a protocol using kvp and mas (ctdi vol = . mgy). we evaluated two groups of consecutive patients, for whom identical scan parameters ( mm collimation, mm feed, mm increment) and contrast injection protocols were used ( ml, ml/s, s start delay). we measured the enhancement of the pulmonary artery in an roi at the level of the pulmonary trunk. for the enhancement of small arteries, we measured the maximum ct number in peripheral pulmonary arteries at the level of the aortic arch and at the lung bases. we determined the percentage of segmental and subsegmental arteries with sufficient quality for pe evaluation. to test the influence of observer experience on the accuracy of ct venography (ctv) for diagnosis of acute deep thrombosis (dvt) and to identify potential sources of misinterpretation. methods and materials: patients with clinical suspect of pulmonary embolism (pe) underwent combined ct pulmonary angiography and ctv, using a multislice ct scanner. ctv was performed in the caudo-cranial direction, minutes after administration of ml of contrast material ( mg i/ml). scan parameters were: × . mm collimation, mm slice width, and mm reconstruction increment. ctvs were analyzed independently and in a blinded fashion for the presence of acute dvt by three readers: (a) an experienced radiologist in body ct, but without experience with ct imaging of pe; (b) a fellow in ct; (c) a third-year resident without any formal experience with ct imaging of pe. ct scans were scored on a -point confidence scale and different causes of interpretation errors were analyzed. the gold standard was lower extremity sonography. results: interobserver agreement was moderately good (k = . ; % confidence interval), whereas interobserver disagreement occurred in ( %) cases. the two observers with ct experience were more accurate than the less experienced one (p < . ) who made a higher number of false-positive diagnoses. the most frequent causes of misinterpretation were chronic thrombosis and arterial thrombosis. no clear differences were found among the readers for the error type. conclusion: ctv in addition to ctpa is a relatively accurate method for evaluation of dvt. ct diagnosis of acute dvt improves with general ct experience. conclusions: a pre-therapeutic hr-ct should always be done before medical treatment by epoprostenol. if poorly defined nodular opacities, septal lines, pericardial effusion, pleural effusion, and adenopathies are found, the pre-therapeutic strategy should be discussed again, in order to prevent patients from the risk of a paradoxical aggravation under medical treatment by epoprostenol. purpose: surgical repair of ventral hernias has been changed during the last years. this is due to new biomaterials as expanded polytetrafluoroethylene soft tissue patch (eptfe), which lets a transabdominal preperitoneal technique. this laparoscopic hernioplasty has a lower morbidity and recurrence rate, whereas it needs an accurate follow-up to assess complications which require readmission. in this prospective study we considered eight patients who underwent a laparoscopic repair of ventral hernia with an eptfe mesh between march and june at our institution. in all cases ct of the abdomen was performed after days to evaluate the position of the mesh which is visualised as an higher density bandlike structure. results: in one patient after days ct scan showed a fluid collection; one patient became syntomatic after days and a new ct scan was performed with iv contrast medium which showed an infected fluid collection whith enhancing. conclusion: ct scan is a useful technique to assess post-operative complication of laparoscopic repair of ventral hernias, such as sieromas, abscess, hematomas, bowel obstructions and recurrences and is a great advantage to an accurate follow-up evaluation. methods: patients admitted with acute abdominal pain for which no immediate surgical intervention or ct was indicated, were randomised to "early ct" (within hours of admission) or to follow "standard practice". diagnoses and confidences (on a -point scale) were documented by surgeons on admission and again after hours. the admission, hour, and final diagnoses (established at surgery and/or months follow-up) were assessed by two reviewers for changes (to more serious, or less serious conditions, or "no change"). results: patients were randomised to "early ct" and to "standard practice". early ct reduced the length of hospital stay by . days, but this reduction did not reach statistical significance (p = . ). only % ( / ) of admission diagnoses proved to be correct on follow-up, improving to % ( / ) after hours (both independent of the randomisation arm). although early ct was not associated with a significant change in diagnostic confidence at hours, comparison with the final diagnosis revealed that early ct missed significantly fewer serious diagnoses (p = . ). there were in-patient deaths, all in the "standard practice" arm. conclusions: ct undertaken early during an admission for acute abdominal pain may have favourable effects on length of hospital stay and mortality, and it is able to identify unforeseen diagnoses and complications, particularly those of a potentially serious nature. objective: to correlate isolated blunt spleen, and liver injury in children with presence and amount of free-fluid on ct scan. methods: paediatric patients (range months to years) with isolated solid organ injury (liver or spleen) was confirmed with enhanced ct scan and graded according to the asst guidelines. the presence, location and amount of free-fluid was recorded. free-fluid was quantified as = no fluid, = small amount, = moderate, = large for each of the anatomic areas. results: paediatric patients with an isolated spleen (n = ) or liver (n = ) injury from blunt trauma were identified. free-fluid was noted in injuries overall ( %), more commonly with spleen ( %) than liver ( %) injuries. as injury grade increased, so did the frequency of free-fluid (grade % to grade %) and the total volume of free-fluid in the three quadrants (grade . to grade . ). the total volume of free-fluid was greater for splenic injuries ( . ) than liver injuries ( . ). the pelvis was the most common location for free-fluid (liver %, spleen %) and had the greatest mean amount of free-fluid (liver . , spleen . ) of the anatomic areas evaluated. ( ) there is a direct correlation between the severity of the isolated injury and the frequency and amount of associated free-fluid. ( ) the pelvis was the most common location to detect free-fluid and had the greatest estimated volume. whole body spiral ct in trauma patients -part i: assessment of cervical, thoracic and abdominal soft tissue and organ injuries t. albrecht, j. von schlippenbach, k.-j. wolf; berlin/de purpose: to assess the accuracy of standardized "whole body" spiral ct in the initial work-up of cervical, thoracic and abdominal soft tissue and organ injuries in trauma patients. method: patients with potentially life-threatening injuries underwent a spiral ct of the neck (unenhanced; / / ), the chest, abdomen and pelvis ( ml contrast agent, / . / ) immediately after resuscitation. the ct findings were compared with the final diagnoses at discharge or death. in patients abdominal sonography and ct were also compared. the final diagnoses were: cervical haematoma (n = ), haemothorax (n = ), pneumothorax (n = ), pulmonary contusion (n = ), mediastinal haematoma (n = ), aortic dissection (n = ), retroperitoneal haematoma (n = ), renal haematoma/laceration (n = ), hepatic haematoma (n = ), splenic haematoma/rupture (n = ), mesenteric laceration (n = ), and isolated intraperitoneal haemorrhage (n = ). spiral ct showed all these injuries with the exception of a delayed splenic rupture. in the patients with sonography available, ultrasound missed hepatic, splenic and renal injury. furthermore sonography produced two false positive findings: haemopericardium and renal contusion. conclusion: the initial standardized "whole body" ct used provided fast, comprehensive and accurate diagnosis of cervical, thoracic and abdominal soft tissue injuries in trauma patients. it is superior to sonography in assessing abdominal injuries. it should be preferred over a targeted approach with selective ct of certain body areas according to sonography results and the clinical situation since it is time efficient and often reveals unsuspected injuries. part ii: b- (ss a) b a c d e f single-phase helical ct protocol in the evaluation of patients with suspicion of pancreatic carcinoma m. imbriaco, l. camera, m. romano, p. mainenti, e. soscia, a. puzziello, m. salvatore; naples/it purpose: to evaluate the diagnostic accuracy of single-phase (sp) helical ct in the detection and assessment of resectability of patients with suspicion of pancreatic carcinoma (pc). methods and materials: (mean age: ± years) patients with a suspicious pc were studied. unenhanced scan was followed by one set of scans ( mm beam collimation, mm reconstruction intervals, pitch . , kv, - ma) in the caudo-cranial direction, from the inferior hepatic margin to the diaphragm, with a scan delay of s after i.v. contrast administration. results: a final histopathological diagnosis based on surgical findings was obtained in patients, in the remaining fine needle aspiration biopsy followed by years clinical follow up showed no evidence of malignancy. final diagnosis was pc in cases and chronic pancreatitis in . of the tumors, patients had surgically resectable disease and were unresectable. sp helical ct showed a diagnostic accuracy for assessment of tumor detection of % with sensitivity and specificity of % and % and positive and negative predictive value of % and %, respectively. the overall accuracy of sp helical ct to determine resectability or unresectability of pc was %. conclusion: sp helical ct is an effective technique for the detection and assessment of resectability of patients with suspicion of pc. due to the lower radiation burden and to the lower cost a sp of acquisition in a caudo-cranial fashion might be considered the protocol of choice when evaluating patients with suspicion of pc. secretin assisted ct of the pancreas: is it of benefit for pancreatic tumour staging or diagnosis? s.m. lyon, t. fotheringham, p. o'sullivan, m.f. given, m.j. lee; dublin/ie purpose: to determine the effect of secretin assisted ct on contrast material delivery to the pancreas. methods: patients (mean age ; range - ) were enrolled. triple phase helical ct of the pancreas was performed on successive days. unenhanced and enhanced ct in the pancreatic phase and pv phase was performed without (day )and with (day ) secretin ( iu) given at t = s (n = ), t = s (n = ), t = s (n = ), t = s (n = ), t = s (n = ), t = s (n = ). percent enhancement of the pancreas and pv system was calculated using roi's obtained from studies with and without secretin. two radiologists scored the images using a five point scale for: pancreas/tumour contrast, pv, smv and duodenal mucosal enhancement. results: overall mean pancreatic enhancement was % without secretin and % with secretin. no significant difference in pancreatic enhancement was noted when secretin was given at t = , t = s, and t = s. however, significantly increased pancreatic enhancement was noted (secretin vs no secretin) at t = s ( %), t = s ( %) and t = s ( %) (p < . ). pv/smv enhancement was significantly increased in the pancreatic phase in all secretin studies (p < . ). qualitatively scores for pancreas/tumour contrast, pv/smv and duodenal mucosal enhancement were all increased on secretin studies. conclusion: secretin administration increases pancreatic enhancement which aids tumour identification. early enhancement of duodenal mucosa and pv/smv is helpful for staging. for optimal results secretin should be given - minutes before iv contrast administration. further patients are being recruited and study completion is estimated for november . high resolution multislice spiral ct in pancreatic cancer: preoperative detection and assessment of resectability f. fraioli, c. catalano, f. pediconi, a. laghi, a. napoli, s. vagnarelli, m. danti, r. passariello; rome/it purpose: to prospectively evaluate multislice ct (msct) in the preoperative diagnosis and assessment of resectability in patients with clinical suspicion of pancreatic carcinoma. material and methods: patients referred for suspected pancreatic carcinoma underwent msct. immediately prior to the examination, patients were given - ml of tap water; i.v. scopolamine ( mg/ml) was administered to reduce intestinal peristalsis. unenhanced volume was first acquired, followed by the postcontrast acquisitions, during arterial and portal venous phases. the post-contrast volumes were acquired afeter injection of ml of non ionic c.a. at ml/s. images were evaluated using a real time interactive d approach by two observers, in terms of lesion identification and conspicuity, infiltration of peripancreatic fat, vascular involvement of major peripancreatic arterial and venous vessels, adenopathies and liver metastases. results: pancreatic carcinomas were identified in of the referred patients; in cases no abnormalities were detected. tumors were located in the head in cases, the isthmus in cases and in the tail in cases. peripancreatic spread was seen in cases. vascular involvement was identified in cases. adenopathies were present in cases, while liver metastases in patients. d real time interaction with multiplanar reformations appeared particularly useful in the evaluation of vascular involvement and above all in the detection of liver metastases. conclusion: high resolution msct with multiplanar reformations is a very accurate technique in the identification and staging of patients with suspected pancreatic carcinoma. to develop, test, and evaluate an automatic brain contour segmentation technique for multispectral mri data of the human brain based on radial basis functions (rbf) neural networks. methods and materials: healthy male volunteers (aged - years) were examined employing a standardized mri sequence protocol (t w mp-rage, t w/ pdw se, ir, anatomically correct image registration) on a . t system. automatic brain tissue classification was performed by a -layer feed-forward rbf neural network: image data were transformed to a -dimensional feature space with spatial and gray level coordinates of each voxel and its neighborhood. for comparison, manual interactive brain contour tracing was performed by two neuroradiologists on each data set. five data sets served as training data. the procedure was tested on the remaining data sets. contingency tables were calculated w.r.t. results of human interactive contour tracing and compared to interobserver variability of manual segmentation. results: computation time for automatic brain segmentation was ± min on a sun ultrasparc workstation. mri acquisition time was . min for the sequence protocol. manual processing time for interactive contour tracing of the training data was ± min. the ratio of voxels classified differently in manual and automatic segmentation was . ± . %. this is comparable with the interobserver variability for manual brain segmentation ( . ± . %). conclusion: automatic tissue classification by rbf neural networks is a powerful method for brain segmentation from extracerebral anatomical structures. although comparable w.r.t. segmentation quality, the rbf approach is considerably less time-consuming than manual contour tracing by human operators. purpose: for medical applications in the field of computer assisted surgery it is essential to complement human visual systems. in order to develop new ultrasound based minimally invasive therapy systems in the head and neck region we combine both mr and d ultrasound data. materials and methods: mr and ultrasound datasets from the head and neck region were prealigned manually and filtered using adaptive filtering techniques. the prealigned data were matched for the first time using our biomechanical model based on a linear elasticity model recently developed for nonrigid registration of mr datasets of the brain. in order to reduce the computational effort this model uses as input parameters a sparse deformation field estimated from the images as well as predefined homogeneous tissue parameters. results: mr acquisition technique leads to rigid nondeformed datasets. ultrasound techniques offer resolution capacity of higher quality specially for soft tissue diagnostics and therapy. but ultrasound volume datasets show distorted and deformed anatomical structures. in order to prealign the data all images need to be resampled using both global affine transformation and interpolation. after being carefully prealigned an edge enhancement was carried out using adaptive filter techniques. it is shown in some cases of the neck region, that it is possible to match both data types using a linear elasticity model. the resulting images show clearly that the method can be used with slightly deformed ultrasound data. up to now the model is limited to high quality image data with a highly optimized data acquisition. using mri and ct data with the nasa virtual glovebox; a simulation system for life science experiments aboard the iss s. wildermuth , j. smith , c. bruyns , n. teodorovic , r. boyle , p.r. hilfiker ; zürich/ch, moffett field, ca/us purpose: the international space station will provide an orbiting research facility for addressing fundamental questions on the long-term effects of microgravity on living systems. many of these life science experiments will require the use of the space station glovebox facility, a contained reach-in environment where astronauts will handle animals and collect biological samples. to aid in this endeavor, virtual environment technologies are being developed to assist astronauts in training and performing complex experiments in the space station glovebox. this "virtual glovebox" (vgx) is designed to integrate ultra-high resolution imaging technology and force-feedback devices with highfidelity graphics and real-time computer simulation engines to provide a realistic immersive environment. here, we describe the prototype vgx system and its initial simulation environment using ct and mri datas. material, methods, and results: the virtual glovebox was designed and developed for three main applications: engineering evaluation of operational efficiencies for glovebox equipment, experimental design for on-orbit life animal research and simulation for training astronauts to perform biological experiments in space. different animal models are built based multidetector-ct (mdct) and mri datasets. we present high resolution mdct data to reconstruct anatomy of small animals and represent them as deformable objects within a linear mass-spring simulation system. the vgx combines elements of aerospace flight simulator technologies with new imaging techniques (high resolution ct and mri datasets) and medical simulation systems to provide a versatile, state-of-the-art virtual environment for training astronauts in biology research tasks. development of the function of the high speed virtualized bronchoscopy system and it's medical significance h. natori , m. mori , h. takabatake , k. mori , j. toriwaki ; sapporo/jp, nagoya/jp purpose: we previously developed the virtualized bronchoscopy system which enables us to do intrabronchial high speed free navigation with special functions for clinical application and education in the medical school. we report the medical significance of the developed system. materials and methods: chest helical ct data were stored with dicom format. on the onyx (silicon graphics inc), bronchial air space was extracted and three dimensionally reconstructed with surface rendering. this bronchial tree was used a c d e f as the virtual environment of this system. external view of the bronchial tree with the view point marker and its trace, ct image at the view point, intrabronchial view for navigation were displayed on the crt. the system had the anatomical database of the bronchial tree for automatic display of the bronchial name and for the bronchial name quiz. the system had interactive artificial cough as a sonic alert against wall irritation by the virtualized bronchoscope. results: even faster speed than real bronchoscopy was obtained for navigation conducted by the mouse. the system enables navigation into the peripheral bronchus for example b bi. navigation into the peripheral intrabronchial space was possible beyond the narrowing portion. the system displayed proper bronchial names. its accuracy was dependent on the spatial resolution of thin slice ct data. conclusion: a high speed virtualized bronchoscopy system with special feature based on the ct data was developed. this system is useful for anatomical education for students, training to get their bronchoscopic skill for residents, and for preliminary examination simulator of real bronchoscopy. concept of a ct based orthopaedic simulation enviroment for movement analysis and osteotomy planning t.c. mamisch , j. kordelle , p. everett , m. das , f.a. jolesz , r. kikinis , r.m.m. seibel ; mülheim a. d. ruhr/de, gießen/de, boston, ma/us purpose: the goal of the presented study was to investigate the relation between the proximal femur and the orientation of the epiphysis, to determine if the acetabular development is influenced by the femoral neck orientation, and to simulate reorientating osteotomy. material/methods: three-dimensional reconstructed models based on ct data sets of patients scfe were reviewed. measurement of the hip joint geometry was performed by using a newly developed interactive software to determine projected angles. a phantom scan was performed to validate the accuracy of the tool. a computer program for simulation of movement based on cartilage filtering techniques and osteotomy developed by the authors, served for study execution. results: we found a significant positive correlation between the femur version and the version of the femoral epiphysis. furthermore, there was a highly significant positive interdependence between the shaft-neck-angle and the shaft-epiphysis-angle. there was no correlation between the epiphyseal orientation and the anteversion and inclination of the acetabulum. conclusion: the study of the hip geometry demonstrates a significant correlation between the femoral orientation and the epiphyseal alignment. in response to these results, we suggest that there is an interrelation between the development of the proximal femur and the epiphyseal growth plate, wich influences the planning of reorientating osteotomy purpose: in addition to tumour size, the therapeutic effect after neo-adjuvant chemotherapy is histopathologically described by regressive changes. the aim of this study was to evaluate whether regressive changes affect the accuracy of preoperative mri tumour measurement. in an ongoing study initial and preoperative mri was performed in patients with advanced breast cancer. beside t- w flash d pre-and post contrast mri, a fast turboflash sequence was used for the dynamic examination. the time-intensity curves were parameterised by a pharmacokinetic two compartment model and colour-mapped. in consideration of the conventional mri, tumour diameters were measured using the colour-mapped images and compared with the histologically determined tumour size. regarding sclerosis, cytopathic effects and invasive residuals the histological regression was classified between and . results: in cases without regressive changes (grade ), the correlation (spearman rank test) between mri and histopathological tumour measurement was . (p < . ). in patients with regressive changes grade - the correlation was . (p < . ), without any tendency for systematic over-or underestimation (p = . ). compared to tumours without regressive changes, those with grade - were associated with a distinct decrease of pharmacokinetic parameters (amplitude and distribution constant rate) derived from time-intensity curves (p < . resp. p < . ). in two cases without residual tumour (grade ), a complete response was observed by mri. conclusion: histological regression of breast tumours after neo-adjuvant chemotherapy leads to an inaccuracy of preoperative mri tumour measurement. in addition to the lost tumour continuity the decrease of contrast uptake complicates the demarcation of residual tumour. (axial t d ffe, axial and sagittal t * ffe, axial and sagittal t tse) . two experienced radiologists analysed the lymph nodes regarding size, morphology, and signal intensity before and after sinerem®. the results were compared with histopathologic findings. results: a total of lymph nodes were detected equally by pre and post-sinerem® mri. lymph nodes were diagnosed by histology. a node-by-node correlation between mri findings and histology could be achieved in lymph nodes. / lymph nodes were true positive, / true negative, / false negative, / false positive. sinerem®-enhanced mri revealed a node-by-node sensitivity, specificity, and accuracy of %, %, and %, respectively. however, in the overall lymph node assessment for each patient sinerem®-enhanced mri did not miss any lymph node metastases. conclusion: sinerem®-enhanced mri is an accurate method in the assessment of lymph node metastases in patients with breast carcinomas and is superior to plain mri. in our institute we performed breast mri examinations for different clinical queries. we used a d-dynamic contrast-enhanced fspgr sequence and a . t mr unit. before the examination patients underwent a careful clinical-anamnestic evaluation; in fertile women mri was carried out between th and th day of menstrual cycle; previous mrx and/or us examinations were reviewed; patients were recommended for the highest compliance in order to reduce motion and breathing artefacts. results: among cases with an histological equivalent we observed false results. the false negative cases were performed before the th day of menstrual cycle ( in situ carcinomas, small fibroadenomas, sclerotic adenosis). false positive results were : due to a hormonal therapy recently suspended or still active, due to the presence of the so-called ubos (unidentified bright breast objects), in which examination was performed after the th day of menstrual cycle. in literature breast mri diagnostic accuracy varies from and %. this large variability is mostly due to pitfalls in cases selection and examination timing. we recommend an optimal examination timing ( th - th day of the menstrual cycle); a months interval after hormone or radiotherapy. purpose: this study was designed to investigate the relationship between greater tuberosity irregularities, subacromial space, age and rotator cuff tears in the subacromial impingement syndrome. methods and materials: sonographic examination of symtomatic shoulders (age range of patients from to years) were performed. the rotator cuff, greater tuberosities and subacromial space were evaluated. full and partial thickness rotator cuff were given equal significance. supraspinatus degeneration was graded according to the neer classification. the sonographic finding of tears was confirmed surgically. a student's t test, and logistic regression analysis were used to analyze the data. results: sonography showed the greater tuberosity to be irregular in % of shoulders with a rotator cuff tear and in % of shoulders with supraspinatus degeneration. the thickness of supraspinatus outlet ranged from . mm to mm in shoulders with rotator cuff tear and from mm to . mm in shoulders with supraspinatus degeneration. subacromial space: with tihckness < mm was found in % of rotator cuff tears and a thickness > mm was found in % with supraspinatus degeneration. statistical significance was detected (p < . ) for the association of greater tuberosity irregularity and rotator cuff tear and for the association of subacromial space thickness < mm and rotator cuff tear. patients and methods: the study population comprises randomly selected patients suffering from rheumatoid arthritis. a radiograph of the left hand was acquired for each patient and subjected to a new automated method for estimating bone mineral density (bmd) from a plain hand radiograph using the pronosco x-posure system™. this system digitizes a radiograph with a scanner and derives subsequently a bmd, a metacarpal index (mci) and a porosity index (pi) from automated radiogrammetrical measurements of the three middle metacarpal bones. the severity of the decease was graded by two radiologists using the larsen score. a third radiologist reviewed the incongruent scored cases. results: the x-posure system was capable of providing a bmd estimate in all cases. mean value of bmd decreased from . ± . (score )g/cm to . ± . (score ) g/cm . mean mci-values decreased from . ± . to . ± . . no significant change of pi was observed. correlation of bmd, mci, pi and severity score was - . , p < . ; - . , p < . and - . , n.s., respectively. conclusion: the new densitometric system based on radiogrammetry seems to be able to detect differences of bone mineralization depending on the severity of rheumatoid arthritis. with suitable normative data, the new technology may be able to reduce additional radiation exposure in the future, especially in patients receiving a radiograph of the hand for e.g. diagnostic purposes. and normal subjects (n = ) with equal mean age and sex ratios underwent electron-beam ct of the thoracic spine. images were acquired using the single slice mode (slice thickness . mm, scan time . s, matrix number × , field of view cm). for bone density analysis, cortical, transitional, and medullary zones were semi-automatically segmented on four consecutive images of the vertebral bodies. averaged histograms were acquired according to zones and proportions of five density intervals (a: , d: > , e: - - ) were measured by custom-made software. firstly, the feasibility of this method was evaluated by comparing normal and osteoporotic groups. secondly, verification was performed by measuring the "coefficient of variance". thirdly, the feasibility was compared with quantitative ct using intervals c and e in medullary zone, since the interval e in medullary zone was used on quantitative ct. results: in the medullary zone, intervals a-d showed significant differences between osteoporotic and normal subjects, while analysis of whole density measurements (interval e) could not reveal a significant difference between both groups. intra-and inter-observer errors of intervals c-e were lower than % in all zones. in the normal subject group, inter-subject variability of interval c was exclusively lower than %. therefore, interval c in all zones became the region for the histographic bone density analysis method. conclusion: bone density analysis using histographic intervals was feasible to diagnose osteoporosis and superior to quantitative ct. purpose: micro-ct may offer a worthwhile opportunity to analyse so called patterned injuries in bone. in the field of forensic science, it has not been possible until now to non-destructively document such damages to bone. materials and methods: based on a real murder case, porcine pelvic bones were experimentally stabbed with multiple knives. afterwards these bone samples were examined with a micro-ct system developed at the imp erlangen. this cone beam scanner can achieve an isotropic resolution from to µm for sample diameters from to mm. resolution in the specific bone samples is to µm depending on the sample size. so far analysis has been performed by visual inspection of double oblique slices of the reconstructed volume to optimally display the plane cut by the knife using impact view (vamp gmbh, erlangen, germany). additionally the stabbing wounds were quantitatively evaluated by measuring distances and angles. results: the micro-ct datasets of the injured bone samples were used to obtain those d slices that optimally showed the stabbing wounds inside. based on the measured distances and angles it was easily possible to uniquely identify the size and shape of the injury-causing knife in straight stabs. in the field of forensic pathology micro-ct provides a new and advantageous tool for the non-destructive examination and analysis of patterned tool marks in bones. by using the micro-ct technology new horizons are opened for matching a possible injury-causing instrument against the patterned lesion in the bone. a bone defect (diameter mm) was generated in the calvaria of adult rats in general anaesthesia. this defect was filled with a threedimensional extracellular matrix gel inoculated with osteoblasts, marked with lipophilic tracer components, latter to proof viability. implants were covered by gore-tex patches. the cells phenotype was determined by antibody staining. ms-ct examinations were performed hours, , , , and weeks after implantation in short anaesthesia using a siemens somatom volume zoom unit (siemens, erlangen, germany). acquisition parameters were: collimation × . mm, tube current to mas at to kv, reconstructed slice thickness/increment . / . mm. thin sagittal multiplanar reformations (slice thickness . mm, overlapping . mm) out of coronar acquisition were performed. the rats were sacrificed, the implants histologically examined, and correlated with ct findings with respect of defect size and ossification. results: in all cases there was an absolute correlation between ct-findings and histological findings concerning the size of the defect and the presence of mineralised bone matrix. conclusion: ms-ct is a very sensitive and specific diagnostic tool for this and similar studies. with respect to refinement and reduction of animal experiments following the directive / /eec of the council of the european union ms-ct allows tremendous reduction of the number of animals to be sacrificed (in this study two-thirds). d-navigation with an infrared-based camera system for biopsies using spiral-ct datasets -initial preclinical results c.r. krestan, s. grampp, p.l. peloschek, m. pretterklieber, c. czerny, h. imhof; vienna/at purpose: to assess the accuracy and feasibility of biopsies with a novel d-navigation system (ct-sightline: philips medical system, best, netherlands) which is based on spiral-ct datasets. methods: this navigation system uses an infrared based camera, which can track the biopsy needle and the patient position by infrared light reflected from mounted passive spheres. the spiral ct dataset (philips, secura tomoscan ) gained during the procedure can be linked with the position of the instruments and the patient position. we used needle-marked water melons for biopsy purposes. after scanning the object, target and entry point are located by the physician. the accuracy of the simulated biopsies with and g standard coaxial biopsy systems was determined by a target scan. the table position of the target scan and the gantry tilt are given by the navigation system. results: we performed biopsies (targeting of needle-tip) using water melons. the mean distance between the biopsy needle tip and the target needle tip was . ± . mm (range: . - . mm). the average time for the procedure after set-up of the navigation-system was minutes on average. conclusions: our preliminary results suggest that this navigation system allows accurate targeting of biopsy needles at defined regions of interests within a reasonable procedure time. the advantage of this system is the potentially safer and more accurate positioning of the biopsy needle at different targets. further studies and clinical evaluation will determine the value of this system in performing minimally invasive procedures. to explore the novel application of a methodology known engineering as pq diagrams to characterise the evolution of ischaemic stroke. methods: five acute stroke patients were imaged with diffusion tensor imaging (dti) at presentation, week and months on a t magnet using a previously described dti data acquisition scheme. each dataset was then processed on a voxel-by-voxel basis, and each tensor was decomposed on into its p (isotropic) and q (anisotropic) components. when p and q are taken as axes of a cartesian plane, the evolution of tissue (e.g. due to pathology) can be visualized as characteristic trajectories or signatures in this plane. in this study, p, q, and the standard indexes relative anisotropy (ra) and fractional anisotropy (fa), were computed for the lesion (l) and contralateral control (c) regions, for each patient at each time point. results: all patients showed the same characteristic trajectories consisting of: an acute (pl < pc, ql < qc), subacute (pl ≈ pc, ql < pc), and chronic (pl > pc, ql < qc) stages. percentage acute changes in q, ra and fa for the five studies were: ∆q = %, %, %, %, %. ∆ra = %, %, %, − %, − %. ∆fa = %, %, %, − %, − %. conclusion: ra and fa are less sensitive than p and q to detect diffusion changes associated with early ischaemia. in particular, q seems to be the most sensitive parameter to detect early loss of anisotropy in tissue; pq diagrams provide a powerful analytical and visualization tool to investigate the evolution of stroke. advances in diffusion imaging using sensitivity encoding (sense) r. bammer , f. fazekas , m. auer , s.l. keeling , m. augustin , r.w. prokesch , m.e. moseley ; stanford, ca/us, graz/at purpose: diffusion-weighted single-shot epi (sshepi) is currently one of the most important tools for the diagnostic assessment of stroke patients, however it suffers from well known artifacts. sensitivity encoding (sense) was employed to greatly enhance the quality of diffusion-weighted echo-planar imaging (epi) in stroke imaging and for diffusion tensor imaging (dti). methods and materials: eight healthy volunteers and a consecutive series of stroke patients (n = ) were examined with diffusion-weighted sense-sshepi using different reduction factors ( . < r < . ). moreover, in eight volunteers the potential of sense to improve dti was investigated. dti scans were carried out with regular ( × ; r = . ) and high resolution acquisition matrices ( × ; r = . ). to further improve the image quality, new reconstruction and co-registration algorithms were applied. results: derived maps of the trace of the diffusion tensor and of fractional anisotropy were of high quality. measured direction-dependent diffusion-coefficients and isotropic diffusion values were comparable to previous findings but showed less fluctuation. overall, the geometric distortions were substantially removed and the resolution enhancement was remarkable. all patient examinations were diagnostic and of better quality than conventional sshepi. the efficient use of thrombolysis requires robust algorithms for patient selection in acute stroke. intracranial vessel status and properties of brain tissue perfusion are predictive of cerebral ischemia. we present first clinical results using a multimodal multislice ct concept. material and methods: sixteen patients (age to years) with suspected cerebral ischemia and onset of symptoms within hours (mean . h) were included in this prospective study. we performed noncontrast ct (ncct) followed by perfusion ct (pct) and ct angiography (cta). at the level of basal ganglia pct data were acquired using a × mm collimation after injection of ml of cm (flow ml/s). two consecutive slices of mm slice thickness were reconstructed. cerebral perfusion maps (cbf, cbv, ttp) were calculated using ctp software. the size of the ultimate cerebral infarction was measured by follow-up ct or mri. results: in nine patients significant perfusion deficits were noted in one (n = ) or both (n = ) slices. four patients with normal pct showed small supra-or infratentorial infarctions outside the section levels. no false-negative pct results were seen. cta revealed major vessel occlusion in five patients. ncct showed early signs of infarction only in three individuals. conclusion: pct improves the sensitivity for the detection of cerebral ischemia in the section levels compared to ncct and can estimate the ultimate size of infarction. cta might localize the underlying pathomorphology. the presented multimodal ct concept is an accurate and reliable method for the assessment of acute stroke. the preliminary study of ct perfusion imaging in tias k. li, j. lu, x. du; beijing/cn purpose: to evaluate the application of ct perfusion imaging on transient ischemic attacks (tias). methods: conventional ct and ct perfusion imaging were performed on a group of tias and control group of normal adults. cerebral blood flow, cerebral blood volume, and time to peak enhancement were measured within specific regions of the brain on ct perfusion imaging. quantitative analysis was used for these images and comparative analysis was performed on these two groups to evaluate the differences on perfusion images between tia patients and control group. results: a gradient of perfusion between the gray matter and the white matter was shown on the ct perfusion images of normal adults and tia patients. persisting abnormal perfusion changes of decreased cerebral blood flow were found on about % ct perfusion images of tia patients. abnormalities were detected on time-to-peak images of all tia patients with diffuse or regional prolonged time to peak enhancement. conclusions: perfusion ct can provide valuable hemodynamic information and depict abnormalities of perfusion in the patients with tias. prognostic value of admission perfusion ct in acute stroke patients: comparison with admission mr m. wintermark, j.-p. thiran, p. maeder, s. binaghi, p. schnyder, r. meuli; lausanne/ch purpose: comparison between perfusion-ct and dwi-/pwi-mr in acute stroke patients at the time of their emergency evaluation methods and material: acute stroke patients underwent perfusion-ct and dwi-/pwi-mr on admission. were treated with thrombolytic agents. the size of infarct and ischemic lesion (infarct + penumbra) on the admission perfusion-ct was compared to that of the mr abnormalities on the adc map and on the relative cerebral blood volume (rcbv), cerebral blood flow (rcbf), time-to-peak (rttp) and mean transit time (rmtt) maps extracted from pwi studies. the most significant correlations were found between the infarct size on the admission perfusion-ct and the abnormality size on the admission adc map (r = . ; p < . ) and between the size of the ischemic lesion (infarct + penumbra) on the admission perfusion-ct and the abnormality size on the rmtt map calculated from admission pwi-mr (r = . ; p < . ). information provided by both imaging techniques about cerebral infarct and total ischemia (infarct + penumbra) are similar, with slopes of . and . , respectively. conclusion: perfusion-ct and dwi-/pwi-mr are equivalent in the identification of cerebral penumbra in acute stroke patients and in their selection for thrombolytic therapy. perfusion-ct takes advantage from its availability and from its feasibility in acute stroke patients, as part of their admission imaging survey. a novel ct brain perfusion algorithm for improved measurement of low flow regions: clinical results a.j. cook ii. , s. pohlman , s. lin , p.c. johnson , a. cook ; ravenna, oh/us, highland heights, oh/us purpose: accurate quantitative measurements of ct perfusion studies will make a significant impact on patient care. low flow regions, associated with minimal contrast enhancement and poor signal to noise ratios, are susceptible to difficulties using traditional perfusion calculations. we propose a novel signal enhancement algorithm for analysis of low flow regions. methods: ct brain perfusion cases were acquired. a low flow improvement technique, which works by clustering similar tissue types, was applied to each case. gray matter and white matter regions were manually segmented. for quantitative measurements, perfusion values and ratios were calculated for each region before and after the low signal correction. for qualitative evaluations, four radiologists reviewed the corrected and uncorrected images. the corrected images were found to be visually superior to the uncorrected images, particularly in terms of reduced noise and improved distinction between gray and white matter. perfusion values for the corrected images (gray matter: . ml/ g/min, white matter: . ml/ g/min) were closer to physiological norms than uncorrected images (gray matter: . ml/ g/min, white matter: . ml/ g/min). the gray/white matter ratio, typically reported in the literature to be approximately : , improved from . : for the uncorrected images to . : for the corrected images. regions with no blood flow, such as the ventricles, were also more accurately depicted on the corrected images. conclusion: initial results using our approach for low signal enhancement is very promising and could potentially provide more accurate quantitative measurements using ct perfusion. to evaluate the effect of dose reduction on diagnostic performance, using a digital chest imaging system in which amorphous selenium serves as the x-ray detector. material and methods: patients were examined with the selenium system. three sets of images were made in each patient: one set with a standard x-ray dose, one set with % of the standard dose, and one set with % of the standard dose. all images were read by two radiologists. the diagnostic value of each set of images for detection of pulmonary, mediastinal and pleural pathology was analyzed with receiver operating characteristic (roc) methodology, using computed tomography (ct) as the reference standard. we also assessed the effect of the sex, height and weight of the patients on the diagnostic performance of the readers. a c d e f conclusion: we found no statistically significant difference between the radiologists' performance in detecting abnormalities with standard x-ray dose images, and the performance with images made with % and % of the standard dose. sex, height and the weight of patients had no influence on diagnostic performance. withdrawn by author b- : flat panel x-ray detector: reduced radiation exposure for the detection of simulated interstitial lung disease, nodules and catheters u. rapp-bernhardt, t.m. bernhardt; münster/de purpose: evaluation of a flat panel detector (fd) using amorphous silicon with respect to detection of simulated interstitial lung disease, nodules and catheters and reduction of radiation exposure compared with an asymmetric screen-film system. materials and methods: an experimental model was used to determine the detection of reticular, micronodular, linear, ground glass patterns, nodules and catheters which were superimposed over an anthropomorphic chest phantom. observation fields were evaluated using the fd with the simulated speed of , and and compared with the asymmetric screen-film system with the speed of . five radiologists performed receiver operating characteristics (roc) for a five-level confidence scale. the areas under the roc-curves showed no statistically significant differences between the two detector systems at the same speed with respect to the detection of all simulated lesions (p > . ). the fd with a digital speed of yielded in decreased diagnostic performance compared with the asymmetric screen-film system, however, these results were not statistically significant (p > . ). using the fd with a digital speed of lead to statistically inferior results in the detection of catheters and nodules over obscured lung (mediastinum) as well as micronodular lesion over lucent lung (p < . ). conclusion: these results suggest that a dose reduction up to the digital speed of is possible for fd. image quality of computed radiography and flat panel detector radiography: evaluation of simulated subtle lung abnormalities h. tagashira, k. arakawa, m. yoshimoto, j. ikezoe; shigenobu/jp purpose: to evaluate the image quality of computed chest radiography (cr) and flat panel detector radiography (fpd) for diagnosing subtle lung abnormalities. materials and methods: we studied the differences of observer performance among computed radiography (new type computed radiography (fcr d, pixel size µm, dual side (front and back) read out by laser beam of imaging plate) and flat panel detector radiography (indirect type with screen, canon cxdi- , pixel size µm). simulated nodule, ground-glass opacity and reticular shadow were made of acrylic resin, sand ground down and softened gauze with urographin (contrast material), respectively. a simulated abnormality was placed on the back of the thorax of each volunteer (n = ) in order to overlap the right or left lung parenchyma and each volunteer was examined with three different modalities with the same exposure condition. so, total of unilateral lungs were obtained, and of these unilateral lungs, lungs had one of the simulated abnormalities, and the remaining lungs were normal. five chest radiologists evaluated these unilateral lungs with roc analysis with continuous confident scale. the area under the roc curve (az) was used to evaluate the results. results: for all simulated abnormalities, dual read-out type cr (fcr d) showed the best result (az = . ), followed by fpd (az = . ). however, in case of reticular simulated abnormalities, fpd showed the best result, followed by dual read-out type cr. conclusion: dual read-out type cr and fpd showed extremely high image quality. first experiences with a detector-based dual energy system for thorax radiography j. ricke, f. fischbach, u. teichgraeber, t. freund, r. felix; berlin/de purpose: to assess the influence of dose on the image quality of subtracted soft tissue and bone images generated by a dual energy system based on a flat panel detector. materials and methods: patients were randomized in groups. one group received a dual energy examination at a xqi revolution (ge medical systems, usa) with an intended approximative speed pair of / for high and low energy shot, the other group with an intended approximative speed pair of / . for data analysis, subgroups were specified according to additional dose measurements at the detector. image quality indicators were noise, residual bone structures, motion artefacts of pulmonary vessels, heart and aorta, display of retrocardiac ribs or other bone structures, display of lung apex or retrocardiac lung. image review was performed blinded by two experienced radiologists in consensus applying a rating score of to . linear regression and chi square tests were performed for statistical analysis. results: overall image impression was rated good with no significant improvement of image quality with increasing dose. however, a trend for decreased noise in soft tissue and bone images was noted with higher dosage as well as increasing residual bone structures. conclusion: increased dose did not improve image quality significantly. dual energy thorax imaging at a flat panel detector proved potential as a future routine application. digital bedside chest radiography with and without antiscatter grid: impact on image quality and display of low contrast details m. uffmann, k.s. exter, i.m. nöbauer-huhmann, c. balassy, j. sailer, c.j. herold, c. schaefer-prokop; vienna/at purpose: use of an antiscatter grid also for bedside chest radiographs improves image quality however at the expense of increased dose requirements. image processing in digital radiography offers the option for optimising detail contrast. purpose of the following study was a) to test whether contrast enhancing processing compensates for increased scatter radiation if no grid is used and b) whether further dose reduction is feasible. materials and methods: routine chest films with storage phosphor plates (st vn, fuji) were performed on icu patients on consecutive days using an antiscatter grid and an acquisition dose approximating speed system, without grid and an optimised image processing, and without grid and additional dose reduction of one third. all images were overlaid by a element matrix with small fragments of various catheter types (n = ). readers evaluated the hardcopies for the presence of catheter fragments and diagnostic image quality. results: areas under the roc curve for the detection of catheter fragments were statistically equivalent for all images irrespective of the use of a grid or reduction of acquisition dose ( . , . and . , resp.). visualisation of lung parenchyma and monitoring lines was rated comparable for all image types. visualisation of mediastinal and retrocardiac areas, however, was rated significantly poorer in images obtained without grid and reduced dose. conclusion: digital bedside chest radiographs can be obtained without an antiscatter grid by using optimised image processing. however, further dose reduction results in significant loss of image quality in high absorption areas. detection of simulated chest lesions using soft-copy reading: comparison of an amorphous silicon flat-panel detector system and a storage phosphor system j. goo, j.-g. im, j. kim, m. chung, j. seo, h. kim; seoul/kr purpose: to compare observer performance using soft-copy images produced by an amorphous silicon flat-panel detector system and a storage phosphor system for the detection of simulated chest lesions. materials and methods: to test the diagnostic performance of these two systems, we used four types of simulated lesions (nodules, micronodules, lines, and reticular opacities) that were superimposed over an anthropomorphic chest phantom. digital chest radiographs were acquired by amorphous silicon flat-panel detector radiography ( k matrix, bits) and by storage phosphor radiography ( k matrix, bits). six board-certified radiologists evaluated soft-copy images on a high-resolution video monitor ( × × bit). a total of observations were analyzed in terms of receiver operating characteristics (roc). results: averaged performance in terms of the detection of nodules was significantly better (p < . ) on the flat-panel detector system than on the storage phosphor system (area below roc curve [az] values: . ± . and . ± . ). for micronodules, lines, and reticular opacities, no significant detection differences in averaged performance were found between the flat-panel detector and storage phosphor system (az values: micronodules, . ± . and . ± . ; lines, . ± . and . ± . ; reticular opacities, . ± . and . ± . ). in the evaluation of soft-copy images, the amorphous silicon detector system appears to be superior to the storage phosphor system for the detection of pulmonary nodules. the total realistic examination time in multi-slice-ct is min s faster than in single-slice-ct. due to shorter scanning time a reengineering of preparation and post-processing phase enables to increase the number examinations per day with multi-slice ct. process simulation showed to be superior to cpm/pert due to higher flexibility and ability to consider cycle overlap and determine cycle times. evaluation of a new patient transfer board (ptb) for diagnostic er-/icupatient-management in diagnostic ct t. schroeder, s. ruchholtz, s.g. rühm, s. heistrüvers, h. kuehl, j.f. debatin; essen/de purpose: multislice ct has vastly reduced scan times. rather than data collection, patient transfer and positioning has thus become the rate limiting step particularly for polytraumatized er-and icu-patients. to speed transfer to and positioning onto the ct table, we developed a patient transfer board (ptb) enabling the "en-bloc"-transfer of patient and life-support equipment. the ptb was assessed on acute trauma-patients and icu-patients. patients were placed on the ptb directly in the er/icu before transfer to the ct room. transfer-times between patient arrival in the er and completing of the radiological diagnostic procedures (er-patients) and the in-roomtimes in the ct (er-and icu-patients) were measured by stop-watch and compared to those determined in matched populations ( acute trauma, icu) examined without the ptb. results: the ptb enabled the "en-bloc transfer of er-/icu-patients and support equipment". the handling of the ptb was easy, and intuitive. the ptb had no adverse effect on image quality. transit-times between arrival of trauma patients in the er and completing the radiological diagnostic procedures including ct were reduced from to minutes ( %, p < . ). the in-room-times in the ct (er-and icu-patients) were reduced from to minutes ( %, p < . ). the ptb was well accepted by the medical staff. conclusion: the ptb is a simple device capable of vastly shortening patient transfer and positioning times onto ct-tables. the ptb accelerates the diagnostic management of er-and icu-patients and hence increases ct patient throughput. iliocaval thrombi were simulated using clotted bovine blood. four experimental set-ups were performed with interventions each. thrombus particles and distribution were measured in the effluent. mechanical thrombectomy (mt) was performed using the ptd alone. secondly, a newly developed vena cava filter was inserted before and removed immediately after the intervention without manipulation within the filter. in a third procedure, the filter was filled with thrombus and closed without any fragmentation. finally, the filter was completely filled with thrombus material and mt was performed within the filter using the ptd. results: running the ptd in the flow circuit led to a maceration of . % of clots into particles below µm. in the second set-up, additional placement of the filter safely prevented embolization of particles above µm. closing the filled filter within the flow circuit macerated . %, while additional mt within the occluded filter led to a dissolution of . % of the initial clot weight. the ptd proved as an effective and safe device for clot fragmentation in this experimental set-up. the use of a cava filter is mandatory to prevent embolization of thrombus fragments. even large clot burdens can be further macerated easily by the ptd within the filter basket before removal. clinical evaluation of these two devices in iliocaval thrombosis is promising. cost effectiveness assessment of port devices chemotherapy implant in m breast cancer patients: radiological versus surgical placement evaluation p.y.r. marcy sr. , c. bailet , n. magne , e. chamorey , j.c. machiavello , j.c. gallard ; nice/fr, caen/fr purpose: to report the feasibility and cost effectiveness of two venous chemotherapy port implantation techniques in m -breast cancer patients. material and methods: radiological venous arm port (r) and surgical subclavian (s) implantation techniques were retrospectively evaluated in an homogeneous set of m breast cancer patients treated with adjuvant/neoadjuvant chemotherapy. mean age was . a [ . a, n = (r); . a, n = (s)] and the f/m sex ratio was . . initial feasibility was evaluated for both techniques. procedure related direct costs and outcome were respectively evaluated. results: initial technical failures rates (r/s) were % and %. mean implant duration time was / days, the overall complication rate (r/s) was %/ % (chi test p = . ) ( . - . / patient-days). mean implant duration time without any complication or death was d vs d. median number of chemotherapy courses was (r = s). %/ % of the devices had to be removed prematurely. complications included device-related sepsis (n = vs ), skin dehiscence (n = ), deep venous thrombosis (n = vs ), catheter occlusion (n = vs ) and fissuration migration (n = . vs . ) of the catheter. direct costs (r/s) were respectively . vs . • . conclusion: both techniques are successful and safe, with a % higher relative cost for r placement. both are indicated for breast cancer adjuvant chemotherapy. b a c d e f balloon angioplasty and stenting of subclavian and brachiocephalic benign venous obstruction b. guadagni, m. cariati, g. cittadini, g. de caro, c. ferro; genova/it purpose: report our clinical experience of the treatment with balloon angioplasty and/or stent placement of subclavian or brachiocephalic benign venous stenosis or obstruction in patients undergoing hemodialysis. materials and methods: among patients with subclavian (n = ) or brachiocephalic (n = ) venous stenosis or obstructions, were treated with pta alone and with pta and stent placement. technical success and primary and assisted primary patency rates were calculated. results: technical success was %. the ten patients treated with pta alone had good immediate results. primary patency rates at months, year and years were respectively %, % and %. two patients required additional procedures with repeated pta and stent placement (wallstent) with an assisted patency rate of % at years. wallstents were inserted immediately after failed angioplasty in patients because of early restenosis and unsuitablility for angioplasty. primary patency rates at months, year and years were respectively % ( / ), % ( / ) and % ( / ). eight patients required multiple reinterventions for restenosis or thrombosis with additional angioplasty and/or stent placement. assisted patency rates at months, year and years were respectively % ( / ), % ( / ) and % ( / ). conclusion: endovascular treatment of subclavian and brachiocephalic benign venous stenosis or obstructions with pta alone and/or stent placement can provide prolonged use of a hemodialysis access site. close clinical surveillance and multiple reinterventions are usually necessary to maintain stent patency. follow-up was available in patients over months. in this period / patients ( . %) had another treatment: pta of intra stent stenosis in cases; stenting of restenosis after pta in cases; positioning of a second stent in cases. results: in total we performed procedures, with a full technical success in ( . %), ( . %) were technically unsuccessful and complication ocurred ( . %): rupture of the treated vein. primary patency rates were % at months, % at , . % at and . % at months. secondary patency rates were % at months, . % at , . % at and . % at months. conclusion: interventional procedures allow treatment of stenoses with a high grade of technical success but the high incidence of restenosis requires continuous monitoring and frequent re-intervention to maintain the functionality of the hemodialysis vascular access. mechanical thrombectomy to preserve vital venous access in patients with subclavian vein thrombosis p.m. vos, h.j. baarslag, j.a. reekers; amsterdam/nl purpose: deep venous thrombosis is one of the most important catheter related complications in patients with central venous lines. preservation of venous access may be vital for these patients. feasibility of percutaneous mechanical thrombectomy of subclavian vein thrombosis in patients with central venous lines was evaluated. materials and methods: patients ( male; female) with a mean age of years were included. all patients had central venous catheters in the thrombosed subclavian vein. catheters were placed for chemotherapy , nutrition and dialysis . before the procedure venography was performed to evaluate the level and extent of the thrombosis. if there was extensive thrombosis with extension in the brachial veins, patients were not included. mechanical thrombosuction was performed using a or french hydrolyser catheter (cordis j&j, psi, ml/s). prior to the procedure u of heparin was given intravenously. all patients were treated with anti-coagulants after treatment. re-establishing flow with or without wall adherent thrombus was defined as a clinical success. results: in cases, percutaneous mechanical thrombectomy was successful. in these patients the central venous line could be preserved. in patients re-canalization of the subclavian vein thrombosis could not be established due to wellorganized (longstanding) thrombus clots. in one patient with a clinical success, reocclusion occurred months after the procedure. conclusions: percutaneous mechanical thrombectomy of subclavian vein thrombosis in patients with central venous lines is feasible if the thrombosis is acute and not too extensive. factors that influence the results of percutaneous transluminal angioplasty for hemodialysis access dysfunction k. maeda, a. furukawa, m. yamasaki, m. onishi, k. furuichi, t. nagata, s. aoki, m. takahashi, k. murata; otsu shiga/jp purpose: to evaluate factors that influence the initial success rate and long-term results of percutaneous transluminal angioplasty (pta) for hemodialysis access dysfunction. methods and materials: a total of pta procedures were performed in hemodialysis shunts with stenosis ( procedures) or occlusion ( procedures) in patients between and . initial success rates were compared between patients with stenosis and occlusion. in cases where initial success was obtained, cumulative rates of shunt-patency (crp) were evaluated to assess whether the following three factors may influence the long-term results; length of stenosis (≤ . cm vs > . cm), length of patent period of the primary shunt (≤ months vs > months) and diameter of the balloon used for angioplasty (≤ mm vs > mm). results: overall initial success rate was . % (stenosis: . % vs occlusion: . %). overall crp at , , and months were . %, . %, and . %, respectively. crp was significantly higher in patients with shorter stenosis compared to patients with longer stenosis ( . %, . %, and . % vs . %, . %, and . %, respectively, p < . ). crp was significantly higher in patients with longer patent period of the primary shunt compared to patients with a shorter period ( . %, . %, and . % vs . %, . %, . %, respectively, p < . ). conclusion: pta is technically highly successful in patients with shunt stenosis (not occlusion) and a better prognosis is expected in patients with shorter stenosis and patients with a longer patent period of the primary shunt. long-term follow-up of vena cava filters: clinical and radiological findings s.c.a. herber , t. knodel , j. schneider , c. düber , m. thelen , m.b. pitton ; mainz/de, mannheim/de purpose: to evaluate the clinical efficacy, mechanical stability and safety of vena cava filters (vcf) in patients for prophylaxis of pulmonary embolism. material and methods: retrospective analysis of patients undergoing vcf for thrombosis (dvt) in / and pulmonary embolism (pe) in / patients. filtertypes were inserted ( lgm; antheor; cook tulip) using a femoral approach in / and a jugular approach in / patients. follow up included ultrasound, conventional x-ray and ct-scans. results: no periinterventional complications occured. / patients were anticoagulated ( / marcumar, / heparin). mean follow-up was . months (range - months). patients are still alive. mean survival was months (range - months). patients died (tumour progression n = , others n = ). there was no evidence of further pe, but dvt recurred during long-term follow-up. in / cases correct filter deployment was achieved including a suprarenal position (n = ). technical problems with filter deployment occured in of : incomplete opening (n = ), non-opening of filters (n = ), filters tilted > ° (n = ). follow up demonstrated significant filter migration in / with a mean migration of mm (range - mm), / within days and / showed late filter dislocations (> months). fractures of filter struts occured in cases ( lgm, antheor) and perforation of struts through the venous wall occured in (antheor). conclusion: vcf has a low periprocedural complication rate but significant migration, some filter fractures and strut perforations were seen. due to the low incidence of re-thrombosis under anticoaglation, vcf is restricted to very selected cases. patients and methods: patients underwent percutaneous implantation of a snf from through to . patient reports were retrospectively analysed for complications during and after implantation and deep venous thrombosis and pe before and after implantation. helical-ct with contrast media and plain abdominal radiography were performed on patients, helical-ct alone on patients. we checked the position and configuration of the snf and looked for perforation of the filter legs through the wall of the inferior vena cava (ivc). the ivc and deep pelvic veins were analysed for patency. results: during implantation / ( %) patients had minor complications, major complications were reported in . % ( / ). pulmonary re-embolism was documented in / ( . %) patients. there was no significant increase in thrombosis of the deep pelvic veins or the ivc after implantation. / ( . %) examined patients showed a single strut fracture of the snf. tilting more than ° was seen in / ( %) patients. dislocation of the snf more than mm occurred in / ( . %) patients and perforation through the wall of the ivc in all patients. we found no occlusion of the ivc. the snf is easy and safe to implant. in our investigation, complication rates during and after implantation were low. the snf effectively prevents pe. (june to september . the estimated period of protection against pulmonary embolism was less than days. before insertion, color duplex sonography was performed in all patients. all filters were implanted and retrieved through a femoral approach. the position and condition of the filters was assessed immediately and days after insertion. results: there were no placement complications in any patient. no clinical manifestations of pulmonary embolism occurred during the filtration period or during removal. implantation time was to days (mean days). there were no filter thrombosis at the time of retrieval in patients. one patient required reinsertion of a gunther temporary vena cava filter days after the first insertion because thrombus was captured. in two patients, permanent filtration was subsequently requested, in one due to an ongoing contraindication to anticoagulation whilst in the other due to sizable clot captured in the gunther temporary filter. one other patient died of causes unrelated to the procedure. there were no complications of retrieval. no damage was detected at the insertion site. clinical and imaging follow up of the patients did not demonstrate any pathology. conclusions: gunther temporary vena cava filters are easy and safe to use and effective in protecting against pulmonary embolism in high risk patients. tips creation using self-expandable stent-graft covered with eptfe (viatorr): first experience and short-term follow-up v. chovanec, a. krajina, m. lojik, j. raupach, p. hulek; hradec kralove/cz purpose: to evaluate technical success of tips dedicated stent-graft implantation and short-term patency. materials and methods: between february and september , patients ( female, male) aged - years with end stage liver disease underwent tips procedure. liver cirrhosis was due to alcohol abuse ( / ), hepatitis ( / ), liver fibrosis ( / ), unknown cause ( / ) and mixed etiology ( / ; patient with hepatitis c and wilson disease). the shunt was created using eptfe covered selfexpandable nitinol stent-graft (viatorr, w.l. gore), which was placed from the portal vein to the ostium of the hepatic vein. the cm non-covered part of the stentgraft was placed into the portal vein branch which remained patent. tips procedure was done using a standard technique and with antibiotic prophylaxis. the tips patency was assessed by doppler us at discharge and then at and every months. the follow-up period ranged from to months (mean months). results: all tips were technically successful with a significant decrease in the portosystemic gradient (from . mmhg to . mmhg) without clinical complications and all were fully patent. in one patient ( . %) two stent-grafts had to be results: due to technical failures patients were excluded from the evaluation. in the remaining patients the exam rendered diagnostic image quality from the carotid arteries to the tibial vessels ( segments). apart from the clinically suspected pvd, additional clinical relevant disease was found in %. patients had a renal artery narrowing, in patients a carotid arterial stenosis was detected, and patients showed an aaa. conclusion: noninvasiveness, three-dimensionality, extended coverage and high contrast conspicuity are the characteristics of the applied whole body d mra approach allowing for a quick, risk-free, and comprehensive evaluation of the arterial system in patients with atherosclerosis. the impact of cardiovascular and colorectal disease processes can be diminished if recognized and treated at an early stage or pre-stage. inherent noninvasiveness and lack of harmful side effects make mri ideal for preventive imaging. the goal of this study was to assess the impact of a screening mr examination, encompassing depiction of the brain, the arterial system, the heart and the colon. materials and methods: healthy subjects (mean age . a, range: - a) were evaluated. using a high performance mr system (siemens sonata) equipped with a rolling table platform (angiosurf), mri of the brain (t w, t w and tof sequences), whole-body mr-angiography (five contiguous d gre acquisitions), cardiac mri (truefisp cine and ir-turbo flash) and eventually mr-colonography ( d gre imaging following administration of a water enema) were performed. paramagnetic contrast was administered i.v. prior to mr-angiography and for mrcolonography. all examinations were evaluated by two experienced radiologists. results: the compound mr examination was well tolerated by all patients. mean examination time amounted to (± ) minutes. a total of unsuspected pathologies were detected: colorectal polyps ( ), cerebral aneurysms ( ), aortic aneurysm ( ), stenosis of renal arteries ( ), stenosis of femoral arteries ( ), reduced myocardial ef ( ) and mitral regurgitation ( ). conclusion: multi-organ screening with mri within a short time is possible. a considerable number of disease pre-conditions requiring subsequent treatment were identified. further work will be required to determine the true value of such an approach. the use of diluted contrast media in equipment with co software t. moreno sánchez, e. lopez jimenez; huelva/es objective: to determine the cost-effectiveness and efficiency of angiography of the abdominal aorta and lower extremities using diluted contrast media and co postprocessing software for obtaining diagnostic images. subjects and methods: forty patients with peripheral vascular disease were evaluated by co software-digital substraction angiography with diluted iodinated contrast material (ioversol , diluted at %). results: diluted contrast was well tolerated by all patients with no complaints despite the severity of the vascular disease. good image quality was achieved for the aorta and iliofemoral arteries in all cases. the popliteal artery and distal tree images were of good quality in patients. for the remaining five, it was necessary to use pure contrast along with the co software. conclusion: contrast diluted angiography with co software can be used as an alternative to pure iodinated contrast material for obtaining arteriograms of the abdominal aorta and lower limbs. the diagnostic quality is equivalent to that obtained with conventional methods. the lower dose of contrast reduces the risk of adverse reactions, increases the cost-effectiveness of the procedure and is more comfortable for the patients. the use of the co software produces good quality diagnostic arteriographic images with more comfort for patients, less secondary effects and less cost. the time for completing the study is similar to the conventional one and less time consuming than co lower extremities angiography. material and methods: cduv was performed using manual injection and digital substraction angiography in consecutive patients ( upper limbs). images were read on a k high brillance digital workstation. the international anatomic nomenclature was used to divide the superficial venous network into segments per limb. two senior radiologists independently assessed the patency of all segments according to the following grading: absent or non-opacified (grade ), poor quality (grade ), small calibre (grade ), good quality (grade ). in the case of discrepancy, a consensus was reached by reviewing the images. the kappa-test was used to assess the inter-observer correlation in each of the different venous segments. results: overall, grade was seen in %, grade in %, grade in % and grade in %. mean κ was . (p < . ) for the right side and . (p < . ) for the left side. the worst correlation (k = . ) was obtained for veins at the elbow level. conclusion: cduv allows satisfactory imaging of the upper limb venous network with good agreement between the observers. special attention must be paid to obtain good images at the elbow level. intraarterial digital subtraction angiography with carbon dioxide and nonionic gadodiamide in incomplete renal failure h.-p. dinkel, h. hoppe, i. baumgartner; berne/ch purpose: to evaluate the benefit of gadolinium for intraarterial use in diagnostic and therapeutic angiography in patients with incomplete renal failure. methods: patients with planned peripheral or renal vascular interventions ( iliac, femoral, renal, transplanted kidneys) and renal insufficiency underwent digital subtraction angiography with intraarterial administration of gadolinium ( gadolinium-dtpa, gadodiamide). gadolinium was used selectively after peripheral catheter placement, usually as an adjunct to carbon dioxide (co ) if the quality of co -angiography (n = ) was insufficient to assess the distal run-off vessels or did not sufficiently characterize stenotic lesions. in of cases gadolinium yielded good or satisfactory results that were superior to those of co -angiography in each case. this applied to the calf and femoropopliteal region in patients with femoropopliteal occlusions, but at times also to the aorto-iliac vessels and the renal arteries. mean serum creatinine level after angiography ( µmol/l) was not significantly different from the initial level ( µmol/l), p > . . conclusion: gadolinium is a viable alternative contrast agent in digital subtraction angiography and percutaneous transluminal angioplasty (pta). it enhances the diagnostic evaluation of stenoses and run-off vessel. non-ionic gadodiamide is preferable to hyperosmolar gadolinium-dtpa. for economical reasons and since the maximal applicable dose of gadolinium is currently restricted to . mmol/kg bodyweight ( - ml) its combined use with co -angiography is recommended. evaluation of the aorto-iliac and renal arteries: intraindividual comparison of d mr angiography and mdct angiography j.k. willmann, p.r. hilfiker, t. pfammatter, j.e. roos, b. marincek, d. weishaupt; zürich/ch purpose: to compare contrast-enhanced d mr angiography (mra) and multidetector row spiral ct angiography (cta) in the assessment of the aorto-iliac and renal arteries, using digital subtraction angiography (dsa) as the standard of reference. methods and materials: dsa, mra and cta were performed in consecutive patients with suspected occlusive arterial disease. two readers assessed all mra and cta data sets independently; a third reader evaluated the dsa images. all reviewers were unaware of the results of the other imaging modalities. for data analysis, the arterial system was divided into segments, and a -point grading system was applied to assess arterial luminal stenosis. time for post-processing and reading times of mra and cta data sets were noted. results: for readers / sensitivities of cta were %/ % and specificities %/ %; mra had sensitivities of %/ % and specificities of %/ % for detection of hemodynamically significant stenosis (> %). interobserver agreements for both mra and cta were good (kappa = . and . ). intermodality agreement between cta and mra for readers / were . / . . post-processing of cta data sets was significantly more time consuming (mean minutes) compared to post-processing of mra data sets (mean minutes) (p < . ). similarly, reading time for evaluation of cta was longer than reading time of mra ( versus minutes). conclusion: both mra and cta demonstrate a similar diagnostic performance compared to dsa in the assessment of occlusive disease of the aorto-iliac and renal arteries. due to shorter post-processing and reading times, mra seems to be more suited to clinical routine. correlation of spatial resolution in multislice ct and angiography in kidneys p.j. hallscheidt, c.c. cardenas, j. boese; heidelberg/de aim: the aim of this study was to evaluate the maximum spatial resolution of multislice ct in comparison to digital subtracted angiography. material and methods: kidneys were catheterised with a french straight catheter and under went mulitslice-ct in an early arterial phase with a reconstructed slice thickness of . mm. the data were evaluated in mip and d reconstruction and the resolution was compared to conventional dsa angiography, which was performed after the ct scan. results: in reconstruced multislice ct with isotropic voxels all segmental and subsegmental arteries could be delineated. the reconstructed ct data allowed similar spatial resolution to dsa, but additionally the segmental anatomy could be evaluated. discussion: reconstructed multislice ct gives similar spatial resolution, with delineation of subsegmental arterial branches, as angiography. but the d data allows additionally the delineation of the segmental anatomy which is essential for the planning of nephron sparing surgery. material and methods: patients with a clinical or ultrasound suspicion of renal artery stenosis were examined with mscta after a bolus injection of ml of non-ionic c.a. at ml/s. in most cases the renal artery study was part of a run off examination for patients with peripheral arteriopathy. a fixed time delay of to (in presence of abdominal aortic aneurysm) seconds was used in all cases. images were interpreted by blinded radiologists either on axial or reconstructed images. in all patients dsa was performed within hours and considered the gold standard. sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) for the assessment of degree of stenosis and evaluation of supernumerary arteries were calculated. results: we evaluated renal arteries. mscta provided good to excellent diagnostic quality in all cases; all supernumerary arteries were correctly demonstrated. regarding the degree of stenosis the values of sensitivity, specificity, ppv and npv were respectively %, %, % and . %. cta was superior to dsa in the delineation of calcification. in cases with ostial calcified plaque the stenosis, moderate at dsa, was overestimated with mscta and considered severe. multislice spiral cta provides excellent arterial delineation in patients with suspected renal artery stenosis. the limited amount of contrast agent used lends itself to use in patients with partially impaired renal function. to evaluate the utility of mri for the assessment of angiodysplasia compared to conventional duplex us, venography and arteriography. methods and materials: patients ( male, female; age range, - years) with clinically diagnosed angiodyplastic abnormalities of the extremities were examined on a . t whole body scanner (magnetom sonata, siemens, germany). based on a localizer sequence axial/coronal t -, heavily t -weighted (stir) as well as axial t -weighted sequences post contrast were acquired to determine the extent and type of the arteriovenous malformation. in addition dynamic contrastenhanced ( . mmol/kg gd-bopta, multihance, bracco, italy) d gradient echo sequences were collected. a board certificated radiologist as well as an angiologist analysed the mr data sets for lesion depiction, determination of extent and involvement of neighbouring structures as well as characterisation of the malformation. results were compared to findings from duplex us, conventional venography and intraarterial arteriography. results: all mr examination were of diagnostic quality. a total of arteriovenous malformations (venous malformation: n = , arteriovenous fistulae (avf): n = , posttraumatic avf: n = ) were depicted. the stir sequence was helpful in the determination of the extent of the vascular malformation which was often underestimated by d mra alone, whereas dynamic d mra was mandatory for the classification of the lesion. these findings correlated well with the combination of conventional venography (n = ) and duplex-us (n = ). conclusion: mri appears to be valuable in the assessment of angiodysplastic lesions of the extremities. the protocol should combine dynamic contrast-enhanced d gre-sequences with heavily t -w (stir) sequences. material and methods: all procedures were done on a multislice-spiral-ct (siemens somatom plus vz) using a standardized ct-fluoroscopy technique. robot assisted punctures were executed using a remote-controlled robotic system (unitedrobotsystems, evolution ) with unrestricted flexibility of movement. interventions performed were either punctures of contrast-media filled capsules, placed in a soft-tissue-phantom, or interventions within the spinal column of human bodies, such as vertebroplasty or discography. evaluation parameters were accuracy and application of the system, access to the patient and procedure time for the intervention. results: using robotic assistance high accuracy was achieved for all interventions. each lesion within the soft tissue phantom was punctured precisely ( / ). interventions on the spine ( ) and the intervertebral discs ( ) were performed without significant deviation from the approach determined initially. though application of the system was simple, free access to the patient was often aggravated by the scanner and robotic design. a marked learning curve was observed, thus leading to a significant reduction in intervention time in the course of all procedures ( %) conclusion: a robotic system may be useful for ct-interventions in the spine, significantly reducing the radiation dose to the radiologist. as examination time is still markedly increased and patient access remains difficult, the system configuration has to be further optimized for the clinical setting. purpose: percutaneous vertebroplasty is used to strengthen the pathologic vertebral body and reduce pain in some diseases involving the spine. the purpose of this study was to evaluate segment stability and clinical status in patients who received vertebroplasty after radiofrequency ablation of spinal tumors. methods and materials: vertebroplasties with polymethylmethacrylate were performed in patients who had been treated with radiofrequency ablation of inter-or paravertebral tumors in the thoracic and/or lumbar spine. vertebroplasty was indicated due to presence or imminent tumor related vertebral fractures and presence of imminent neurological deficits. operations were carried out under ct/ fluoroscopy guidance under local anesthesia and on an out-patient basis. at follow-up, preoperative mr images were compared with follow-up mr-images in addition to clinical examination. follow up ranged from to months. results: at follow-up, mr images of treated vertebral bodies showed no signs of sintering or refracture. clinical examination showed improved mobility of the spine in patients ( . %). in none of these patients was the presence or progression of neurological deficits diagnosed. patient ( . %) was restricted in motion due to a new tumor in another segment. no intra-or postoperative complications were reported. our results indicate that image-guided percutaneous vertebroplasty seems to be a safe and effective, minimally invasive method to stabilize pathologic vertebral bodies in patients who have received radiofrequency ablation of spinal tumors. purpose: frequent complications of osteoporosis are fractures, especially in the vertebral bodies of the thoracic and lumbar spine. the purpose of this study was to ask whether percutaneous ct-/fluoroscopy-guided vertebroplasty can cause pain reduction in patients with fractured osteoporotic vertebral bodies. methods and materials: verebroplasties were performed on patients with osteoporotic vertebral body fractures. patients suffered from superior or inferior endplate fractures, combined end plate fractures without loss of height and combined end plate fractures with loss of height. inclusion criteria were new osteoporotic vertebral body fractures with acute pain as well as older fractures with persistent pain. exclusion criteria were fractures causing a narrowing of the spinal canal and neurological deficits, tumors, cement allergy and haemorrhagic diathesis. the procedure was carried out on an outpatient basis under local anesthesia and was performed under combined ct/fluoroscopy-guidance. follow up examinations were carried out after an average of days and after months. pain was assessed with the help of a visual analogue scale. results: at the time of the first follow up, patients reported on an average relative pain reduction of . %. after months the patients obtained an average of . % relative pain reduction according to the visual analogue scale. conclusion: ct/fluorscopy-guided percutaneous vertebroplasty of osteoporotic vertebral body fractures is a gentle, effective and minimally invasive method to reduce symptomatic pain in the affected region. it can be carried out on an outpatient basis under local anesthesia, which results in direct mobilization and rehabilitation. steroid injection in sciatica due to lumbar disk herniation: technical aspects and clinical results ( patients) d. krause, f. cognet, m. dranssart, d. ben salem, s. chapuy, j. lerais, j. cercueil, j. couaillier; dijon/fr purpose: to assess the feasibility and efficiency of foraminal or intracanalar steroid injections in cases of sciatica due to disk herniation. materials and methods: between january and january , patients presenting with typical sciatica, resisting usual medical treatment (four weeks), underwent a prospective protocol of pain treatment. a percutaneous approach was performed using ct guidance under local anesthesia. in foraminal lateral herniation ( %), the g needle tip was positioned through the soft tissues. in intracanalar herniations ( %), the needle tip was advanced directly into contact with the posterior part of the root, through the ligamentum flavum (homo-lateral or contra-lateral approach in case of a narrowing lumbar tendency). in all cases the steroid injection (dexamethasone acetate mg) was rigorously epidural. the procedure was possible in all cases, without any complications or side effects. the analysis of the results was based on a multi-factorial analysis: analogue visual scale for pain intensity measurement; family g.p questioning; professional activity recovery; stopping medical treatment. the mean follow-up was more than nine months. good or excellent clinical results were observed in % of cases, poor results (without surgical intervention) in % of cases and failures in %. conclusion: this less aggressive and non expensive technique, performed under very precise ct guidance, is particularly adapted to ambulatory patients with encouraging results. effect of ct-guided lumbar facet joint infiltration on lower back pain r. knapp, a. glück, j. lukasser; kufstein/at purpose: ct-guided lumbar facet joint infiltration is a valuable tool in treating lower back pain. the duration and quality of pain relief is evaluated. methods and materials: patients suffering from lower back pain caused by osteoarthritis of the facet joints underwent ct-guided lumbar facet joint infiltration with bupivacain and hydrocortisone. only one facet at one lumbar level was treated. evaluation of pain relief and change in medical treatment over a period of one year was performed with a questionaire. results: patients ( %) felt a complete relief of pain after a mean time interval of . days after the infiltration. after one year patients ( %) remained free of pain. patients ( %) improved markedly or reported rarely any pain, whereas in patients ( %) the pain recurred to the same extent as before the infiltration. the pain free interval after infiltration was a mean of days. before infiltration of the patients ( %) took one or more different oral analgesic drugs. one year after infiltration patients ( %) still needed analgesics. in patients ( %) who took two or more different drugs before treatment this was reduced to patients ( %) after one year. no adverse effects of the infiltration were seen during the study interval. conclusion: ct-guided lumbar facet joint infiltration is a save and effective treatment for patients with lower back pain caused by osteoarthritis of the facet joints. purpose: offical recommendations for obtaining informed consent for operative or ir procedures are that the patient is consented by the operator. the purpose of the study was to identify the proportion of european interventional radiologists who conform to these guidelines. materials and method: a questionnaire was designed and consisted of thirteen questions on current working practice and opinions on informed consent. the questionnaire was distributed to european interventional radiologists who were members of irish or british societies of interventional radiologists and members of cirse. the anonymous replies were then entered into a database and analysed. results: ( . %) questionnaires were returned. institutions were classified as academic ( . %), . % non-academic ( . %) and private ( . %). . % of responders do not use specific consent forms and % have patient information leaflets for procedures. although . % of radiologists consent patients for some procedures, junior medical staff (house officers or senior house officers) consent patients in % of replies. over half ( . %) did not feel that their current policy was adequate. comments from responders indicated that there is insufficient time for radiologists to consent all patients. suggestions to improve current local policies included radiology outpatient clinics and radiology nurses visiting patients on the wards or in outpatient clinics. conclusion: only . % of european interventional radiologists follow current guidelines for obtaining informed consent. the causes identified were resource limitations and in particular constraints on time. optimizing material management in interventional radiology departments methods and materials: after compilation of a comprehensive stock list of all disposable materials necessary for interventional radiology an abc-analysis was performed with focus on high quality and high volume materials (a-articles). based on ordering frequency, all a-articles were subjected to xyz analysis, which is based on predicting the probability of requirement of the article. on this basis capital binding costs were considered with an annual interest rate of % assumed. results: current inventory control reveals an annual capital binding for all articles of $ mainly due to a-articles, which accounted alone for $ . if articles are bought in a just-in-time (jit) mode instead of mid term, stock costs could be reduced by $ , thus storage time is shortened and capital binding is reduced and $ can be saved. with a stock turnover of the remaining material of months, which matches our experience, jit-buying of articles can lead to an additional cost reduction of $ . altogether $ could be saved, which means a relative cost reduction in stock of %. besides this, there are lower costs for renting space and expiration dates of articles can better be controlled. late improvement of regional myocardial wall motion in the area of infarction after acute ptca in a -month follow-up study using delayed contrast enhanced magnetic resonance imaging: is "bright" really "dead"? purpose: acute recanalization in myocardial infarctions (mi) has shown to be of benefit with respect to global myocardial function and prognosis. the aim of our follow-up study was to investigate late effects of acute coronary angioplasty (ptca) on regional wall motion after the subacute phase of mi. patients and methods: patients underwent mr imaging at . t after acute ptca in the subacute phase of mi and a second time months later. corresponding short axis slices encompassing the left ventricle (lv) were acquired with standard cine and delayed contrast-enhanced magnetic resonance imaging (cemri). target parameters were the percentual size of infarction (psi (%)) and percentual wall thickening (pwt (%)) in the infarct area (ia) and the remote area (ra). results: psi was similar in the subacute phase and at month's follow-up ( . and . %, respectively; n.s.). pwt improved significantly in ia ( . and . %, p < . ) in contrast to ra ( . and . %; n.s.), whereas global myocardial function did not change significantly. this late improvement was only observed in transmural mi. patients with subendocardial myocardial infarction did not show any further improvement. conclusion: pwt improved in ia after acute ptca even after the subacute stage of transmural mi in this -month follow-up study. this phenomenon could be explained by a prolonged stunning in transmural infarctions and contradicts the hypothesis that "bright" in delayed cemri represents nonviable tissue in all cases. contrast-enhanced (ce) mr can clearly depict definitive necrotic areas after myocardial infarction: the high resolution of mri permits discrimination of subendocardial versus transmural infarction. follow-up with cine mri allows documentation of functional recovery of both subgroups. methods: patients ( males, mean age years) underwent emergency ptca ± stent for ami. mr controls were done on day , , and after ami using a . t unit (siemens, sonata) with the following protocol: ( ) multiple truefisp (tr . ms, te . ms) along the short axis to assess lv volumes and wall motion abnormalities; ( ) d inversion recovery sequence (tr to rr, te . ms) - min after administration of gd-dtpa to visualise infarcted myocardium ("late enhancement"). results: patients showed transmural infarction in late enhancement. all of these patients had wall motion abnormalities in the same segments which persisted over the observation period of days. patients had myocardial segments with non-transmural enhancement in late enhancement. improvement of the wall motion abnormality was shown in / patients. the transmural group showed a decrease of ef ( - %) and the non-transmural group an increase ( - %). conclusions: transmural infarction with late enhancement has a worse functional outcome in the involved myocardial segment and the entire ventricle than nontransmural infarction. longer observation periods than days may be required for monitoring the outcome of non-transmural infarction. b a c d e f combined first-pass and delayed contrast enhanced mri in the assessment of myocardial viability after acute infarction l. natale , a. meduri , , a. lombardo , a. giordano , r.m. razmi , p. marano ; rome/it, birmingham, al/us purpose: to define the role of mri in the assessment of myocardial viability we compared mri, rest tc sestamibi spect and dobutamine echocardiography (de). methods and materials: consecutive patients with first ami ( . a, anterior, inferior, primary ptca, thrombolysis) underwent mri, spect and de within the first week after onset of symptoms. mri was performed with a . t scanner (ge signa horizon echospeed); short axis single slice first pass (iv ml gd-dtpa, ml/s) and multi-slice delayed t imaging were performed. using a segments lv model, both segmental analysis and percent infarct area were analyzed. segments were classified as: ( ) normal first-pass, absent or delayed hyperenhancement; ( ) hypoenhancement at first-pass, delayed hyperenhancement; ( ) hypoenhancement both at first-pass and delayed imaging. in delayed images, segments out of first-pass slice were classified at delayed imaging as normal, hyperenhanced and hypoenhanced. patterns and and patterns hyper-and hypo-were considered non viable. results: segmental analysis results were poor, particularly if compared with de (sensitivity %, specificity %); infarct area analysis (at least viable segments) was better (vs de and spect respectively: sensitivity % and %, specificity % and %). conclusions: patterns and respectively identify viable and non viable tissue. pattern or delayed hyperenhancement is less specific as % viability was demonstrated at de and/or spect. first pass plus delayed imaging are superior to delayed imaging alone (sensitivity and specificity with de and spect respectively % vs %, % vs %, p > . ), but multislice first pass is mandatory. comparison of magnevist™ and gadophrin- for the assessment of acute and chronic myocardial infarction j. barkhausen , w. ebert , c. heyer , j.f. debatin , h.j. weinmann ; essen/de, berlin/de purpose: to investigate whether the area of hyperenhancement using extracellular contrast agents is larger compared to the region demarcated by a necrosisspecific contrast agent. methods and materials: rabbits underwent thoracotomy and permanent occlusion of a branch of the left coronary artery. two animals died prior to imaging, animals were examined hours following occlusion and animals were imaged six weeks following induction of the infarction. all animals received mmol/kg of a necrosis-specific contrast agent (gadophrin- , schering, berlin/germany) hours prior to the mr examination. continuous short axis views were collected on a . t mr scanner using an ecg-triggered ir-turboflash sequence. imaging was repeated minutes after additional injection of mmol/kg of magnevist (schering, berlin/germany). the area of hyperenhancement demarcated following gadophrin- injection was compared with hyperenhancement seen on gadophrin- plus magnevist enhanced images and with ttc staining. results: in animals with acute myocardial infarction hyperenhancement was detected in slices. the mean difference in the size of hyperenhancement seen on the two different in-vivo mr scans was − . ± . mm (p > . ). both measurements showed excellent agreement with ttc-staining. chronic infarctions showed no enhancement following gadophrin- injection, whereas application of magnevist resulted in hyperenhancement. conclusion: in acute myocardial infarction the area of hyperenhancement following gd-dtpa application does not exceed the area of hyperenhancement seen on gadophrin- enhanced images. the combination of gadophrin- and magnevist can distinguish acute and chronic infarction because chronic myocardial infarctions do not enhance with gadophrin- . multi-slice first pass myocardial perfusion imaging: first results comparing saturation recovery (sr) truefisp d und sr turboflash d pulse sequences s. miller , m. fenchel , o. simonetti , u. kramer , u. helber , n.i. stauder , j. finn , c.d. claussen ; tübingen/de, chicago, il/us purpose: to compare two different pulse sequence techniques for multi-slice first pass myocardial perfusion imaging. methods: using . t (magnetom sonata, siemens, erlangen) patients and volunteers were examined using both sr truefisp d and sr turboflash d pulse sequences. t -weighting was enhanced applying a ° saturation recovery preparation pulse. sequence parameters were tr . ms, te . ms for truefisp d and tr . ms, te . ms for turboflash imaging with a - mm field of view and × matrix. contrast injection was standardized to ml ( ml/s flow rate) resulting in a dose of . - . mmol gd-dtpa/kg per injection. data evaluation included signal intensity (si) over time analysis and determination of baseline and peak signal and contrast to noise ratios (s/n, c/n). an automated post-processing software (argus, siemens) was used to derive perfusion parameters simax, slope, time to peak and area under curve. results: with diastolic ecg-triggering - slices/rr-interval were acquired. values of s/n baseline were comparable (truefisp . ± . , turboflash . ± . , p > . ), but superior results of s/n simax ( . ± . vs. . ± . , p < . ) and c/n ( . ± . vs. . ± . , p < . ) could be obtained with truefisp. additionally, analyzing individual myocardial segments, absolute and dynamic ranges of slope and area under curve were - fold higher (slope . ± . , area under curve . ± . , p < . ) using sr truefisp compared to sr turboflash imaging. conclusion: superior results for multi-slice first pass perfusion imaging can be obtained using sr truefisp d imaging compared to sr turboflash d. myocardial perfusion assessment with dynamic p enhanced mri compared to tc-sestamibi-spect: phase ii european multicenter trial j. bremerich , m. friedrich , b. wintersperger , f. brunotte , j. piek , n. al saadi , t. schindler , s. friedrich , m.f. reiser ; basle/ch, berlin/de, munich/de, dijon/fr, amsterdam/nl purpose: to compare mri enhanced with the new rapid clearance blood pool agent (rcbpa) p with the gold standard tc-sestamibi-spect for the assessment of myocardial perfusion. materials and methods: by september patients with subacute myocardial infarction were included in european centers. dynamic first pass and delayed equilibrium phase mr images were acquired after injection of . or . mmol/kg p (guerbet, france) at injection rates of ml/s or ml/s. mr was conducted at . t with phased array coils. mr images were acquired in the short axis during first pass of p with a dynamic saturation recovery turboflash sequence (magnetom vision/symphony; siemens, germany or cvi; general electrics, usa). subsequently equilibrium phase inversion recovery mri were acquired and min after contrast injection to assess late enhancement. ∆si and si-upslope were calculated. results were compared with tc-sestamibi spect as gold standard. results: p was well tolerated by all patients. with . mmol/kg infarction was readily detected on dynamic first pass mr images as hypointense areas. with . mmol/kg infarction was not visible in all patients on dynamic images, but upslope and delta si were attenuated. location and extent correlated well with tc-sestamibi-spect. infarction was also visible on inversion recovery mr images. the results from this study exhibit the potential interest of a new gadolinium based intravascular contrast agent in assessing qualitatively and quantitatively hypoperfused myocardium on p enhanced mr images during first pass and equilibrium phase. this study was supported by guerbet, france. quantitative first-pass myocardial perfusion mri in patients with coronary artery disease after successful revascularization v. gramovitch, v.e. sinitsyn, m. gordin, o. stukalova, e. noeva, s.k. ternovoy, e. chazov; moscow/ru purpose: to determine the potential value of quantitative myocardial perfusion mri in the assessment of successful coronary intervention. method and materials: we studied pts ( men, age ± years, weight ± . kg) with - vessel cad and normal left ventricular (lv) function before and after ( nd day to month) coronary intervention. all pts underwent either ptca ( / , stent / ) or cabg ( / ). mri was performed using a . t siemens magnetom scanner with snapshot-flash sequence. perfusion was assessed by injecting the contrast agent gd-dtpa-bma (omniscan, nycomed amersham) via the antecubital vein before ( st bolus ml) and after dipyridamole ( . mg/kg, nd gd bolus ml). myocardial and blood si were converted to concentration of gd according to the in vitro calibration curve and fitted by one-compartment model by saturday b a c d e f the use of a custom written program. eleven normal and segments supplied by stenotic coronary arteries (³ % diameter stenosis) with successful intervention afterwards (residual stenosis < %) were included in the final analysis. results: myocardial blood flow was similar in normal and "stenotic" segments at base line ( . ± . and . ± . ml/min/g of tissue) but significantly lower in "stenotic" segments during hyperemia ( . ± . vs. . ± . ml/min/g, p < . ). coronary vasodilator reserve (the ratio of flow during hyperemia to flow at base line) was significantly lower in "stenotic" segments than in normal ( . ± . vs. . ± . , p < . ) and normalized completely after successful revascularization ( . ± . ). conclusion: quantitative mr perfusion assessment may be useful for the follow-up of patients with cad after coronary intervention. myocardial perfusion in the human heart: quantitative assessment using a spin-labeling technique at t f. fidler, c.m. wacker, p.m. jakob, w.r. bauer, a. haase; würzburg/de purpose: the aim of this study was to determine myocardial perfusion of the human heart using a spin-labeling technique without exogenous contrast agent. method and materials: an ecg-gated fast saturation recovery flash sequence was implemented using a t scanner (bruker) with a homebuilt quadrature surface coil for signal reception. t measurements were performed after global and slice-selective saturation under resting conditions and adenosine-induced stress. exams were obtained breathing room air (air) and pure oxygen (oxy). ecgtriggered enddiastolic midventricular short axis views were acquired in a single breathhold of about s in healthy volunteers. results: myocardial perfusion was calculated as p = . ± . ml/g/min (rest, air), . ± . ml/g/min (stress, air) and . ± . ml/g/min (rest, oxy). t of lv (rv) blood was ± ms ( ± ms) (air) and ± ms ( ± ms) (oxy). the presented spin-labeling method is a robust alternative for quantitative perfusion evaluation and allows repeated measurements without contrast agents. oxygen induced changes of t (myocardium and blood) are detectable and may therefore become important in patients with coronary artery disease. purpose: in small larynx tumors (t , t ) the presence of spread is crucial in determining adequate surgical or laser-surgical treatment. therefore, the purpose of the study was to determine sensitivity and specificity of preoperative multi-slice helical ct (msct) for the infiltration of various glottic laryngeal structures. material/methods: patients with suspected laryngeal cancer were investigated on a msct scanner (siemens plus volume zoom) with × mm collimation, . seconds rotation time in a single breathhold. multiplanar reconstructions (mpr) in sagittal and coronal planes were reconstructed in all patients and rated in consensus. all findings regarding tumor spread into the glottic fat, crossing the anterior commissure, infiltration of the arytenoids and the extension along the vocal cords were compared to surgery and histology. the sensitivity and specificity of msct regarding the infiltration of the glottic region were %, %. regarding infiltration of the anterior commissure sensitivity and specificity were %, %, respectively; regarding the infiltration of the anterior part of the vocal cords % and %, and regarding the infiltration of the arytenoids % and %, respectively. sagittal mprs were especially helpful regarding the surfaces of the arytenoids and the anterior commissure, and coronal mprs were most helpful in the evaluation of the vocal cords. the detection of spread of supraglottic laryngeal tumors is crucial in determining best treatment, as the preoperative assessment decides to what extend surgical therapy can be offered. thus, the purpose of the study was to determine sensitivity and specificity of multislice helical ct (msct) for the identification of infiltration of supraglottic laryngeal structures. material/methods: investigations on a msct scanner were performed in patients with suspected supraglottic laryngeal cancer, with two entire acquisitions; one in breathhold and one in phonation. multiplanar reconstruction's (mpr mm thickness) in sagittal and coronal plane were reconstructed in all patients. the findings were separately evaluated regarding tumor spread into the pre-epiglottic fat, the anterior commissure, the laryngeal and the superficial side of the epiglottis and the piriform sinus, and were compared to surgery and histology. results: regarding infiltration of the piriform sinus sensitivity and specificity were % and %, regarding the infiltration of the laryngeal side and the superficial side of the epiglottis % and %, and regarding the anterior commissure % and %, respectively. the cumulative sensitivity and specificity of msct regarding the infiltration of the entire supraglottic region were % and %, respectively. while the mprs were felt to be of general benefit, sagittal mprs were especially helpful regarding both surfaces of the epiglottis, and coronal mprs were mot helpful in the evaluation of the piriforme sinuses. the extend of supraglottic laryngeal tumor spread can be depicted with high accuracy using msct. referred pain in oropharynx carcinoma: a clinical symptom finds its anatomical correlate in mri h.c. thoeny, k.t. beer, r.h. greiner, p. vock; berne/ch purpose: is there a correlation between mri and the prognostic symptom of referred pain to the ear in patients with oropharynx carcinoma? method/materials: irritation in the region innervated by the glossopharyngeal nerve can be transmitted as pain to the ear due to connections between the glossopharyngeal nerve and the tympanic nerve. in a prospective study consecutive patients, median age (range, - years) with oropharynx carcinoma underwent mri before radical radiotherapy. patients had referred pain to the ear, did not. the protocol included axial pd/t -weighted tse sequences, axial, coronal, and sagittal t -weighted se sequences before and/or after contrast medium administration. examinations were performed on two . t mris (magnetom vision, siemens, or signa, ge). two independent, blinded radiologists analyzed the mri studies for alterations of anatomical structures (effacement, signal alteration, or contrast medium enhancement) of the oropharynx and adjacent regions. a twosided test was used to compare variables. results: patients with referred pain to the ear showed significantly more alterations of the following structures innervated by the glossopharyngeal nerve: palatoglossus (p < . ), stylo-(p < . ) and palatopharyngeus (p < . ), and constrictor pharyngis (p < . ) muscles; hard palate (p < . ), tonsil (p < . ), pre-epiglottic space (p < . ), and posterior soft palate (p < . ). no difference could be observed for structures innervated by different cranial nerves. conclusions: alterations of structures innervated by the glosso-pharyngeal nerve showed a significant association with referred pain to the ear in patients with oropharynx carcinoma. the symptom of reflex-otalgia has, therefore, an anatomical correlate in mri. virtual laryngoscopy with multislice ct enables grading of upper airway stenosis h. hoppe, h.c. thöny, h.-p. dinkel, p. zbären, p. vock; berne/ch purpose: to compare the efficiency of noninvasive virtual laryngoscopy in depicting and grading upper airway stenosis with multislice ct versus fiberoptic laryngoscopy. methods and materials: multislice ct and fiberoptic laryngoscopy were used to examine upper airway sections (supraglottis, glottis, subglottis, trachea) from patients (n = malignant upper airway pathology, n = benign upper airway pathology, n = control group without upper airway pathology). ct data were obtained on a toshiba asteion multislice ct in × mm collimation, pitch . / and mm reconstruction interval. postprocessing was performed using surface ren- a c d e f dering and multiplanar reformats (mpr). ct images were independently interpreted by two radiologists. fiberoptic laryngoscopy was the gold standard of reference. results: virtual laryngoscopy and mpr accurately demonstrated upper airway stenosis caused by intraluminal tumor growth. there was a close correlation (r = . ) between virtual laryngoscopic and fiberoptic laryngoscopic grading of stenosis. virtual laryngoscopy was limited in the differentiation of mucus and appositional tissue folds from tumor, which was more reliable with mpr and axial ct slices. furthermore, subtle mucosal irregularity could not be defined. conclusion: virtual laryngosopy with multislice ct enables high-resolution endoluminal imaging of the upper airways with a short scan time despite thin collimation, but should be combined with axial ct-slices and mpr readings. virtual laryngoscopy was especially useful for evaluation of subglottic and tracheal stenosis, which may be difficult to assess with fiberoptic laryngoscopy. it is a reliable non-invasive method for the assessment of upper airway stenosis as a complement for fiberoptic laryngoscopy. purpose: to evaluate the potential of mr-guided laser-induced thermotherapy using a high power irrigated laser application system for the treatment of recurrent head and neck tumors. materials and methods: recurrent tumors in the head and neck tumors (recurrent squamous cell carcinoma n = , recurrent pleomorphic adenoma n = ) were treated using mr-guided laser-induced thermotherapy and a newly developed irrigated power application system which allows power settings times higher than the conventional system. a total of laser applications were performed using laser applicators. mr thermometry was performed using a temperature sensitive t -weighted gradient echo sequence for monitoring thermal induced changes in signal intensity. follow up studies were performed using plain and contrast enhanced mr. results: all procedures could be performed under local anesthesia. laser applicators with an active length of or cm were used with or w respectively ( w/cm active length of the laser applicator). the application time was between and minutes. all lesions showed a very rapid heat distribution. we were able to induce coagulative necrosis in all patients. clinical relevant improvement of clinical symptoms was observed in lesions. the treatment of lesions resulted in no improvement of clinical symptoms. conclusion: mr-guided litt using a high power irrigated laser application system proved to be an reliable and effective method to treat recurrent tumors in the head and neck region. mr-thermometry allowed monitoring of laser induced temperature changes during litt. fat suppressed t sequences in the evaluation of "t" factor in carcinoma of the tongue s. cappabianca, a. barberi, l. pasqualetto, g. colella, r. grassi; naples/it purpose: comparison between se t , dp and t sequences and t fat-suppression sequences in staging of lingual carcinoma methods: patients with lingual carcinoma underwent mri exam using a t superconducting scanner. in all cases se sequences dp-t w were obtained; t w and t w with selective fat suppression before and after intravenous administration of gd-dtpa were also acquired. two different groups of radiologists evaluated independently the dp-t and t sequences, and the dp-t and t -fs sequences, in order to define the extension of the neoplasm ("t" factor). mri findings were compared with pathological staining. results: dp-t and t : tumour not detectable n = ; t n = , t n = , t n = , t n = . dp-t , t and t -fs: tumour not detectable n = ; t n = , t n = , t n = , t n = . surgery/pathology: tumour not detectable n = ; t n = , t n = , t n = , t n = . dp-t w and t w sequences diagnostic accuracy . %; dp-t w, t w t -fs sequences diagnostic accuracy . %. conclusion: our data suggests that in the local staging of lingual carcinoma the use of se-t sequences with selective fat suppression can improve diagnostic accuracy of mri in evaluation of tumour volume. withdrawn by author ultrasonographic detection of iatrogenic accessory nerve palsy p. kovacs, g. bodner, a. gardetto, h. piza-katzer, w.r. jaschke; innsbruck/at purpose: to report the ultrasonographic findings of cases of iatrogenic accessory nerve palsy after lymph node biopsy and neck dissection and to demonstrate feasibility of ultrasonography (us) in detecting the accessory nerve in three cadaveric specimens. methods and materials: patients (range - years) presented with neck and shoulder pain after surgical intervention in the neck region ( after lymph node biopsy, after neck dissection). us was performed with a linear broad-band transducer ( - mhz) working on a hdi (atl). in fresh cadavers the accessory nerve was detected by means of us and marked with blue ink. following, the accessory nerve was exposed carefully. results: in the right lateral cervical region of two patients, who underwent lymph node biopsy, we found a hypoechoic mass, in which a tubular structure ended. we suspected a cut accessory nerve. in two patients with unilateral neck dissection us revealed a tubular structure ending in a hypoechoic scar measuring cm in length. in all cases the trapezius muscle showed hyperechoic texture, suggestive of muscular atrophy. us findings were confirmed by electroneurographic testing and surgical nerve inspection. on us the accessory nerve appears a small tubular structure (diameter . mm) lying just under the superficial layer of cervical fascia. in all specimens the nerve was correctly marked by means of us showing blue stained accessory nerves after dissection. conclusions: the capability of high resolution us allows detection of the normal accessory nerve and of iatrogenic accessory nerve palsy. saturday materials and methods: to date, small (< cm) and large (> cm) solid renal tumours and cystic complex renal masses (< cm) were evaluated by ultrasound (us), color doppler (cd) and pihi. pihi was performed after levovist injection by high mi ( . - . ) intermittent manual triggered stimulation every - seconds, during vascular ( - seconds) and late phase ( - seconds). helical ct pattern and/or histologic findings were considered as the reference procedures. results: reference procedures classified small solid tumours and large solid tumours as renal adenocarcinomas, small solid tumours as angyomiolipomas and cystic complex renal masses as cystic papillary tumours. small solid renal adenocarcinomas were hypoechoic (n = ) or hyperechoic (n = ) on us with a basket arterial pattern on cd. large solid adenocarcinomas appeared inhomogeneous with no vascular pattern, while angiomyolipomas appeared hyperechoic with peripheral venous flows. cystic complex renal masses revealed thick septa and a peripheral solid portions on us with a basket arterial pattern on cd. on pihi small solid renal adenocarcinomas appeared hyperechoic on vascular phase and isoechoic (n = ) or hypoechoic (n = ) on late phase. large renal adenocarcinomas revealed increased conspicutiy of necrotic intratumoural zones and inhomogeneous enhancement. renal angiomyolipomas revealed dot-like enhancement. cystic renal adenocarcinomas revealed peripheral enhancement limited on septa or solid portion. during a -month period, variable renal masses including renal cell carcinoma (n = ), transitional cell carcinoma (n = ), acute pyelonephritis (n = ), angiomyolipoma (n = ), and traumatic renal contusion (n = ) were evaluated with cha us (logiq expert series; ge medical systems) using microbubble contrast agent. us images were obtained before contrast administration and with a bolus injection of g of microbubble contrast agent ( mg/ml of levovist; schering) in every - s for min. the contrast enhancement patterns of variable renal masses were assessed. result: renal cell carcinomas showed more enhancement than adjacent renal parenchyma was seen between to s (mean, s) and to s (mean, s) after injection. the duration of enhancement was to s (mean, s). one angiomyolipoma showed heterogeneous enhancement from s to s. all transitional cell carcinomas showed no definite enhancement. three acute pyelonephritis and one traumatic renal contusion showed focal perfusion defects that were not apparent on pre-contrast scan. conclusion: cha us with microbubble contrast agent is an effective us technique in the evaluation of both tumour vascularity and renal perfusion abnormality. withdrawn by author ( ). all patients were followed-up clinically, biochemically and by ct both early (< days) and at monthly intervals. results: one patient demonstrated a minor internal injury to the psoas muscle. no significant rise in creatinine was noted post-procedurally in / patients (mean rise: . µmol/l; range − . to . µmol/l). one patient with von hippel-lindau syndrome had tumours treated in a single kidney. there has been a gradual post-treatment rise in creatinine, from to µmol/l. early post-procedural ct demonstrated complete tumour necrosis in / tumours. two tumours ( . and . cm) required additional ct-guided treatments of residual crescents of viable tumour. follow-up (mean . months, patient months, range - months) revealed no evidence of local or distant recurrence. conclusions: early experience suggests rfa is a safe, well-tolerated, and minimally invasive therapy for renal cell carcinoma. in the era of nephron-sparing surgery rfa may have a role in the management of small problematic rcc. drug-induced mr-pyelography in the evaluation of renal collecting system malformations, tumours, renal calculi and obstructed renal ureters m. di girolamo , a. grossi , a. roncacci , r. di nardo , l. azzarri , v. david ; rome/it, grottaferrata/it purpose: drug-induced mr-pyelography (dimrp) is a diagnostic technique for the evaluation of obstructed and non-obstructed renal collecting systems. a c d e f method and materials: normal volunteers and patients underwent dimrp. the examination was performed with a -d non-breath-holding fat-suppressed turbose sequence (tr: ms; te: ms; n.ex.: ; etl: ; acq.time: min) on coronal planes. these acquisitions were post-processed with a mip algorithm. to obtain maximum filling of the collecting system, the diuresis was pharmacologically induced by administering i.v. ml of saline solution together with mg i.v. of furosemide. one mr acquisition was performed minutes after diuresis induction. normal volunteers and patients had undergone ivu and ascending pyelography was performed in cases. results: we always obtained an excellent anatomical evaluation of the renal collecting system that was considered comparable to that obtained with ivu. it was always possible to study the renal collecting system malformations, even in patients with known contraindication for i.v. administration of contrast media. renal calculi larger than mm were always identified by the analysis of d coronal scans. dimrp is particularly important for the detection of ureteral stones. patients had non-functioning kidneys on ivu: in cases with obstructive uropathy the site of the obstruction was determined and using conventional mri, abdominal plain radiograph and urinary cytology, the cause was always determined. conclusions: dimrp is recommended for patients with contraindications for i.v. administration of contrast agents; in non-functioning kidneys is considered the best diagnostic imaging modality to perform after us, especially in case of ureteral obstruction. filling defect artefacts in magnetic resonance urography g. girish, w.k. chooi, s.k. morcos; sheffield/gb purpose: ( ) assessing the prevalence of filling defect artefacts (fda) in magnetic resonance urography (mru). ( ) presenting the characteristic features of fda, that can differentiate them from true filling defects (tfd). method/materials: mru's of patients with neurogenic bladder dysfunction were reviewed to assess the prevalence of filling defects within the pelvicalycyal system (pcs) and ureter. heavily t weighted fast spin echo techniques with fat saturation were used. these included axial images mm (thick)/ mm (gap), slab images ( mm thick) of retroperitoneum and volume coronal imaging of kidneys and retroperitoneum with d and maximum intensity projections. dilatation of pelvicalyceal system as well as features of filling defects (central, eccentric, complete) were graded. clinical course and plain films were reviewed to determine significance of filling defects. results: filling defects were present in pts ( %). prevalence of filling defect artefacts amounts to / ( %) and that of true filling defects was %. the following are the characteristic features of fda that differentiate them from true filling defects: ( ) vast majority of fda occurred in axial t weighted images and very rarely in slab and maximum intensity projection images. ( ) fda's were usually small, centrally placed ( %) and noted mostly in pelvicalyceal system ( . %) and the upper third of the ureter ( . %). ( ) true filling defects were bigger in size and seen in two or more image sequences. conclusions: ( ) awareness of these artefacts will avoid misinterpretation and prevent further unnecessary investigations or interventions. ( ) when in doubt, correlation is suggested with other mri sequences, plain abdomen radiograph and clinical presentation. purpose: differentiation of healthy kidneys from those with haemodynamically significant stenosis or those with renoparenchymal disease. methods and materials: in kidneys with suspected renal artery stenosis (confirmed stenosis n = , no stenosis found n = ) or parenchymal disease (n = ) renal flow and perfusion measurements as well as mr angiography were performed. flow measurements were done using an ecg gated cine phase flash sequence, perfusion was measured using an arterial spin labeling fair sequence. contrast enhanced mr angiography was done with a fast d gre sequence in a single breath hold. data was compared to that from healthy volunteer kidneys and correlated to serum creatinin levels. results: substantial differences in mean renal artery flow and perfusion were found in kidneys with renal artery stenosis or parenchymal disease compared to healthy kidneys. in addition perfusion measurements showed significant agreement to tc renal scintigraphy. using the discriminant analysis we were able to achieve a specificity of % and a sensitivity of % in terms of separating healthy kidneys from those with either vascular, parenchymal or combined disease. on the contrary, renal volume measurements did not show any significant differences. the combination of mr angiography, flow measurements and mr perfusion measurements offers a comprehensive way for assessment of both renovascular and renoparenchymal disease. it offers a non invasive way to separate normal individuals from either those with haemodynamically significant stenosis or those with underlying renoparenchymal damage. functional imaging of the kidneys using pure o inhalation r.a. jones, n. grenier, m. ries, c.t.w. moonen; bordeaux/fr purpose: because of its paramagnetic effects, pure o reduces the t of lungs. our purpose was to investigate the intra-renal signal intensity changes induced by the dissolved molecular oxygen in blood. materials and methods: nine volunteers were imaged while breathing normal atmosphere and pure o alternatively with an inversion prepared, segmented, half fourier tse sequence for t measurement and a multiple echo gradient echo sequence for t * measurement. roi were positioned on the cortex, the medulla, the liver and the spleen. subtraction and cross-correlation images were also obtained after dynamic t w acquisitions during three successive phases (air-o air) results: the only significant intrarenal change was the reduction of t within cortex while o breathing ( ± ms vs ± ms, p = . ) and a reduction of t within the spleen. neither significant change of t within the medulla and the liver nor significant change of t *, in all organs, were observed. the effect was not related to flow because no change was noted between selective and nonselective inversion pulses. the observed t change induced by pure o within the cortex is related to the high arterial blood volume without o consumption. the absence of change within the medulla is probably related to the high o consumption and shunting effect. is to distinguish it from other entities for prognostic and management purposes. it is the unusual cases of lch that often create a particular diagnostic dilemma. however, careful analysis of the radiographs including the site of involvement and behavior, coupled with a detailed demographic and clinical history, can be suggestive of the diagnosis. methods and materials: consultation cases, including skeletal sites, submitted to the armed forces institute of pathology, were analyzed for unusual manifestations of lch. five unusual manifestations were evaluated including cortical involvement, disease at birth, presence of fluid levels, circumferential "pencilling", and involvement of the mandibular inferior cortex. results: unusual demographics included non-caucasian cases. unusual sites of involvement were the epiphysis ( ), apophysis ( ), cervical spine ( ), posterior elements of the spine ( ), soft tissues ( ), cortical involvement ( ), and atypical locations (sternum, middle and distal phalanx). unusual manifestations included crossing the physis ( ), crossing calvarial sutures ( ), fluid levels ( ), erosion of the inferior mandibular cortex ( ), transforming from sclerotic to lytic ( ), brain invasion ( ), circumferential "pencilling" ( ), sequestrum in noncalvarial sites ( ), unusual size of a lesion ( ), and bone expansion ( ). these unusual appearances may mimic other diseases including paget disease, fibrous dysplasia, ewing sarcoma, coxa vara, and metaphysitis. conclusion: recognition of the spectrum of unusual manifestations of lch is helpful in allowing distinction from other differential diagnoses. the imaging of patients ( female, male; age range - a, mean age . a) with biopsy-proved subperiosteal aneurysmal bone cyst was reviewed. radiologic studies inculuded radiographs (n = ), ct (n = ), and mr images (n = ). evaluation included patient demographics, lesion location and size, radiographic features, and intrinsic characteristics on ct and mr images. review of histologic specimens was carried out by an experienced musculoskeletal pathologist. results: all lesions were located at the surface of long tubular bones (femur , tibia , humerus ); three involved the diaphysis, two the dia-/metaphysis, and one exclusively the metaphysis. lesion size ranged from . to cm in maximum diameter. radiographs and ct images always showed a superficial bone defect, which on radiographs demonstrated irregular margins in four cases. all lesions caused an interrupted periosteal reaction (shell , trabeculated shell , codman angle ). mr images always showed a multicystic appearance with hypointense rim, contrast-enhancing cyst walls, and fluid levels. edema of adjacent soft tissues was present in all cases. conclusion: aneurysmal bone cysts in a subperiosteal location can demonstrate an aggressive radiographic appearance. mr imaging appears to be most valuable in differential diagnosis, since it can demonstrate typical morphological features of the underlying process. rib sonography: can we obtain more information than with conventional radiologic studies? s.h. paik, m. chung, y. yoon, j.-g. im, j. ahn; seoul/kr purpose: we performed this study to evaluate whether high-resolution ultrasonography can give more information concerning rib lesions than plain radiography or bone scintigraphy. method: we selected patients with high uptake rib lesion on bone scintigraphy. plain radiography and rib ultrasonography were performed on these patients. ultrasonography was performed using linear . mhz transducer. we analyzed cortical disruption, mass, callus formation, hematoma, deformity and bone destruction by rib ultrasonography. we considered radiologic findings and clinical information in the diagnosis. purpose: innovative therapeutic protocols of musculoskeletal tumors include neoadjuvant and antiangiogenic approaches. functional tumor imaging including dynamic contrast enhanced (dce) mri and fdg-pet seem to be capable techniques to evaluate ongoing response during therapy. aim of this study is to assess the clinical utility of dce-mri in such cases. materials and methods: within a therapeutic phase i protocol, dce-mri was included as a surrogate marker to assess the tumor prior and during therapy. after neoadjuvant treatment, surgical resection was performed with histological correlation as well as detailed micro-array analysis. mri was performed on a . t clinical system using optimized fast d gradient echo sequences. standard gd-chelates were given at . mmol/kg bw and the studies post processed using a pc based environment facilitating quantification and visualization. results: dce-mri could be performed and quantified in all cases. the enhancement patterns observed revealed a wide variability with areas of high uptake and rapid washout correlating to active tumor areas and regions of contrast agent trapping seen in less vascularized, necrotic areas. areas with decreased enhancement correlate with response to therapy. in more than / of the cases, active tumor areas were only detected by functional imaging, not seen otherwise and confirmed histologically. conclusion: functional imaging is an essential tool to assess ongoing therapy in musculoskeletal tumors, it is robust and can be used as surrogate marker in therapeutic trials. whole body mr imaging with a rolling we assessed a single whole-body mri examination for detection and staging of metastases and compared the results with findings of nuclear bone scintigraphy and ct examination. materials and methods: patients with known primary malignancies were included in this study. patients were examined on a mr system (siemens sonata) equipped with a rolling table platform (bodysurf) allowing the swift movement of the patient through the magnet bore as well as through a phased array surface coil. t w d vibe data sets were collected in five stations following the intravenous application of paramagnetic contrast covering the body from skull to the knees. the chest and abdomen were imaged with t haste and t flash before contrast. mean examination time amounted to (± ) minutes. mri findings were compared to results obtained with skeletal bone scintigraphy and ct-scans of the abdomen and chest. results: all pulmonary and hepatic metastases > mm detected by ct were identified by whole-body mri. skeletal scintigraphy detected bone metastases in nineteen patients. in eighteen patients mri confirmed these lesions. in one patients presenting with bone metastases in the ribs mri failed to reveal the osseous lesions, whereas in four other patients mri detected bone metastases missed by scintigraphy and eventually confirmed by biopsy. conclusion: vibe whole-body mri screening for metastases correlated well with ct and scintigraphy. use of the rolling table platform provides the basis for a comprehensive whole-body exam in merely minutes. early therapeutic evaluation of bone metastases from breast cancer: histopathology, mr imaging and ct i. ciray, g.k.o. Åström, h. lindman, h. nordgren, j. bergh, h.k. ahlström; uppsala/se purpose: evaluation of early therapeutic changes in breast cancer bone metastases using various parameters of mri, ct and histopathology. materials and methods: metastatic bone lesions in breast cancer patients were examined with mri and ct, and were subsequently biopsied under ct-guidance before initiation of chemotherapy and courses later (median). the changes in size and signal intensity (si) on t -weighted and long te inversion-recovery turbo-spin-echo (long te ir-tse) mr sequences and in density on ct were measured. the histopathological changes in the amount of tumor and fat cells, in the density of fibrosis and in the trabecular bone were evaluated. results: the amount of tumor cells was decreased in (responding) and was increased in lesions (progressive). si could not be measured in one responding lesion. there was no change in the tumor size and si on t -weighted sequence in of responding lesions. there was an increase in si on long te ir-tse sequence of of responding lesions. two progressive lesions remained unchanged, one increased in size and the other in si on t -weighted sequence with no alteration on long te ir-tse sequence. density increased in of responding lesions and in of the progressive lesions on ct images. conclusion: an increase in si in metastatic lesions on long te ir-tse sequence may indicate an early therapeutic response while a t -weighted sequence is of limited value. an increased density on ct can be measured in both responding and progressive lesions. belgian soft tissue neoplasm registry (bstnr) j.l. gielen, p.m. parizel, a.m.a. de schepper; antwerp/be introduction and objectives: based on epidemiological data from the usa, the total number of new cases of malignant soft tissue tumors in belgium is estimated at per year. this low incidence and the overmedicalization with numerous university hospitals and large general hospitals with mr-equipment available limits the number of cases seen in each hospital and per year and hampers the gaining of expertise in this field. to cope with these disadvantages, the department of radiology of the university hospital of antwerp in cooperation with all mr centers ( ) in belgium created a belgian soft tissue neoplasm registry ("bstnr"), starting the registration on january , . material and methods: internationally accepted standard procedures are used in the development of the electronic database in order to guarantee future and systematic availability of the data. a clinical and statistical indexing of biomedical imaging and image-related information based on the attributes of image acquisition procedures and on the diagnostic image obeservations is applied. in this way, an electronic image data selection by image related, acquisition related as well as disease related criteria will be possible. results: until now cases of soft tissue tumor sent by the cooperating centers have been registered. the bstnr achieves objectives: ( ) to provide the referring radiologist with a second opinion about diagnosis and differential diagnosis within hours; ( ) to create a digital archive at the disposal of national or foreign researchers; ( ) to obtain epidemiological information about the prevalence of stt in belgium. the vascularity in malignant lesions was significantly greater than in benign (benign: . m%cda, malignant: . m%cda, p < . ). vascular heterogeneity (sd%cda) showed similar results, albeit less significant (p < . ). there was a monotonic linear relationship between m%cda and sd%cda with increasing tumor grade. best separation was achieved between benign, intermediate and high grade (p < . ). there was a clear correlation between increasing tumor grade and higher vascularity (m%cda). separation between benign and low grade was possible, but less significant (p < . ). this correlates to histopathology, where vascular markers are low -similar to benign -for this group. conclusions: qpd shows the potential to differentiate benign from malignant softtissue tumors. it can measure increasing vascularity and vascular heterogeneity and reliably predict higher-grade malignancy. qpd therefore is a promising new non-invasive method both diagnostically and prognostically. after gd administration there was no significant enhancement of the nodules. our findings were then confirmed in all cases with the exception of one patient in whom arthroscopy did not find the lesion as it was located outside the synovial membrane. conclusion: mr provides a good and detailed evaluation of the different recesses of the knee and demonstrates high diagnostic accuracy in the evaluation of pvns enabling lesion characterization. to verify the benefits introduced by a new cr system for digital mammography, using a dual-side reader and transparent imaging plates. methods and materials: two kinds of breast phantom have been used to compare the performance of two different cr systems employed in digital mammography. they are the high resolution imaging plate hr-v coupled with the fcr -r reading unit and the last fuji cr system including transparent ips and a dual-side reader. this detects also the laser-stimulated light propagating toward the back of the plate, which was previously removed from the hr-v plates. consequently, the detection efficiency and the signal-to-noise ratio are increased, resulting in a better image quality. phantom images have been taken for different values of entrance dose. the images produced by the two cr systems have been scored by three expert observers and the results compared in terms of both contrast-detail curves and detail visibility. the benefits of the new cr system are emphasized by the contrastdetail curves and the cirs phantom scoring. the new system permits a dose reduction of about %. the spatial resolution is heavily better and exceeds lp/mm for the new system, while is slightly lower than lp/mm for the previous. the contrast-detail analysis shows a gain of % in disk size and % in contrast. saturday purpose: dry and conventional laser printers have become an equipment for producing images from digital mammography. purpose of our study was to compare image quality of a dry versus a conventional laser imager for digital mammography. materials and methods: two view mammograms of patients with different breast composition (pattern i -iv) and mammograms of patients with pathologic lesions were printed on a conventional wet laser imager (agfa scopixlr ) and a dry laser imager (kodak dryview laserimager ). all examinations were performed on a full field digital system (senographe d, ge). two radiologists independently scored images side by side on the following aspects: delimitation of the skin, subcutis, musculature, glandular tissue, fat, and calcification. each comparative aspect was rated by using a five-level scale. in case of a breast lesion (masses n = , calcifications n = ) lesions characteristics and resulting birads-classification were assessed. additionally, artefacts were noted. objective comparison was performed in accordance to instructions of the producers. results: a total of digital mammograms were assessed. breast parenchyma of different composition and pathologic lesions were equally displayed by dry and conventional laser imagers. dry laser images showed significantly more artefacts at the film surface ( . % vs. . %, p < . ). however, these artefacts did not influence image interpretation. conclusion: compared to a conventional wet laser imager, a dry laser imager is capable of producing images of equal quality. the dry laser imager offers advantages with regard to handling, installation, maintenance, and environmental criteria. full-field digital mammography and patient dose reduction g. gennaro, c. di maggio, e. bellan; padova/it purpose: to estimate the dose reduction factor allowed by the full-field digital mammography. methods and materials: exposure parameters and breast characteristics have been collected from screen-film (ge senographe dmr) and digital mammograms (ge senographe d) randomly distributed. from the track/filter combination, kv and mas values and breast thickness we estimated the entrance skin dose by using the ipem (institute of physics and engineering in medicine) data. results: data analysis shows a mean dose reduction of % for the digital system. it is mainly due to the larger dynamic range of the digital detector, which permits the use of rh/rh combination in almost % of considered cases without image quality degradation. in screen/film the mo track was needed in most cases, while the rh/rh choice was convenient only for %. moreover, by analysing data as a function of breast thickness, the digital system shows an extra dose reduction for each track/filter combination due to its higher quantum efficiency compared with the screen/film system. conclusion: the digital system delivers an entrance skin dose % lower than the screen-film system. a quality control phantom for full field digital mammography: first experience p. baldelli , c. di maggio , m. gambaccini , g. gennaro , d. giannopoulou , a. taibi ; ferrara/it, padova/it purpose: to verify the usefulness of a simple phantom to monitor some quality control parameters in full field digital mammography. methods and materials: a phantom has been developed for periodic quality control measurements on a full field digital mammography system ge senographe d). the phantom allowed us to verify the detector linearity, uniformity, contrast and spatial resolution and the reproducibility and stability of both the detector and the automatic exposure control system (aop). the system stability was daily controlled by using four different exposure settings. the raw images have been used for data analysis. results have shown that the presented phantom is able to give information on the detector characteristics and can detect any problem related to the system stability. the collected data have verified that the detector response is linear with a high correlation degree, for both the mo/mo and rh/rh combinations. the non-uniformity was lower than a few percent. the detector response variability was lower than % when manual exposure is employed while the fluctuation in the aop choices was less than % for the three available settings (std, cnt and dose). the phantom used was found useful to check the key detector performance parameters and the system stability. it is fast and easy to use, as required for a quality control. full-field digital mammography -comparison of hardcopy versus softcopy reading s. obenauer, s. luftner-nagel, k.-p. hermann, u. fischer, e. grabbe; göttingen/de purpose: to evaluate the feasibility of using a mammography workstation for the interpretation of digital mammography images in comparison to the results of hardcopy reading. materials: mammograms performed on a digital full-field mammography system (senographe d, ge) of patients were evaluated as softcopies and hardcopies by readers. of the patients had histologically proven carcinomas, the remainder showed no malignancies after a follow-up of years. the softcopies were displayed on a . × k monitor, the hardcopies were printed on a laser printer (scopix, agfa). the mammograms were evaluated with respect to image quality, artefacts, presence of masses and microcalcifications. all detected lesions were categorized according to the bi-rads classification. the time for this evaluation was written down. post-processing in softcopy evaluation (windowing and levelling, zooming, inversion) and additional views like spot views in both methods were also timed. results: diagnostic accuracy of the classification of the malignant lesions according to the bi-rads categories showed no significant differences between soft-and hardcopy. more time was needed for the evaluation of softcopies than for hardcopies. additional views were recommended in hardcopy more often than in softcopy evaluation ( versus for reader , versus for reader ). postprocessing was used in cases by reader and in all cases by reader . the evaluation of softcopies needs more time than those of hardcopies, especially when post-processing is performed. however, it seems that softcopy reading reduces the need of additional views without change of diagnostic accuracy. full-field digital mammography (ffdm): intrapatient comparison of direct magnification versus monitor zooming u. fischer, f. baum, s. obenauer, s. luftner-nagel, d. von heyden, e. grabbe; göttingen/de purpose: our goal was to compare digital magnification mammograms with images zoomed from the digital contact mammogram in patients with microcalcifications. materials and methods: patients with microcalcification clusters were evaluated with a ffdm system (senographe d, ge). in addition to a digital contact mammogram, a digital magnification mammogram (factor . ) and two images zoomed from contact mammogram with magnification factors of . and - were obtained in each patient. the image quality ( = perfect to = inadequate) and the characterisation of microcalcifications (bi-rads™ - ) were evaluated by readers. the results were compared to histopathologic findings in patients ( lesions) and follow-up in patients. in patients with mammographic microcalcifications, monitor zooming of the digital contact mammogram is equivalent to direct magnification ffdm. therefore, monitor zooming allows a reduction of the radiation exposure and an optimization of the work-flow. b a c d e f full-field digital mammography -comparison of different exposure protocols s. obenauer, k.-p. hermann, e. grabbe; göttingen/de purpose: to evaluate the potential of radiation dose reduction in full-field digital mammography (ffdm) compared to screen-film mammography (sfm). materials and methods: ffdm was performed by using an amorphous silicon detector with a cesium iodide scintillator layer (senographe d, ge). sfm was performed by using a state-of-the-art system (senographe dmr, ge) combined with a dedicated screen-film. an anthropomorphic breast phantom with superimposed egg shell fragments ( - µm) was used to evaluate the detectability of microcalcifications. contact mammograms and magnification views (m = . ) performed with both the digital and the screen-film system were compared. images were exposed automatically (aec mode) by using a molybdenum/ molybdenum (mo/mo) anode-filter-combination, kvp and mas (protocol a, dose ~ %). dose reduction in digital mammography was achieved by using protocol b with mo/rh and kvp (dose ~ %) and protocol c with rh/rh and kvp (dose ~ %). the detectability of microcalcifications was assessed by well-experienced readers with a confidence level ranging from to . a receiver operating characteristic (roc) analysis was performed. results: in protocol a the area under the roc-curve (az) for contact views performed by the screen-film system was . and for those performed with the ffdm system . . for the conventional and digital magnification views az was . and . , respectively. for the protocol b/c the az value reached . / . for the contact views, and . / . for magnification views. conclusions: compared to screen-film mammography the digital mammography system allows an equivalent detection rate of microcalcifications at a slightly lower radiation exposure. comparison between analogue and digital reading performance in screening mammography a.a.j. roelofs , s. van woudenberg , j.h.c.l. hendriks , a. boedicker , c.j.g. evertsz , n. karssemeijer ; nijmegen/nl, bremen/de purpose: to investigate the use of a digital reading station for screening mammography and to compare results with analogue reading. materials and methods: cases, screen-detected cancers, interval cancers, and non-cancers, were collected from the dutch breast cancer screening program. for each patient, mammograms from two prior screening rounds were collected in addition to diagnostic mammograms. diagnostic mammograms and pathology reports were used to establish ground truth. all mammograms were digitised and processed by a cad system (r imagechecker, los altos, ca). experienced screening radiologists participated in a study in which each of them read one film the two prior screening mammograms of all cases in randomised order and blinded to the detection results. the readers were asked to annotate potential abnormalities, and estimate the likelihood of malignancy of each finding they reported. a subset of cases with visible cancers on the prior mammograms and non-cancers were randomly selected. this subset was reread on a dedicated workstation we are developing for screening mammography, by a subset of radiologists . years after their first reading. the workstation was has two highresolution monitors (barco). results were evaluated using roc analysis and compared to the results obtained with analogue reading. results: no significant difference in screening performance between analogue and digital reading was found, provided cad was available for microcalcification detection. conclusion: using a dedicated reading station for mammography, soft-copy reading of digital mammograms in screening is possible without loss of quality. management through pacs and digital telemammography a. grueva, m. mahesh; baltimore, md/us purpose: digital telemammography (dtmg) is rapidly developing into a mature technology due to advances in digital image acquisition, database design and communications infrastructure. current film-screen mammography has a number of inherent limitations, which can be overcome effectively with dtmg. since acquisition display and storage can be optimized independently, screening sensitivity is increased. the initial goal was to provide dtmg in a screening environment with radiologist teleconsultation. technical issues in planning the establishment of dtmg screening infrastructure include network design, image compression, archiving, and special viewing station. displays, picture archiving and communications systems (pacs), image storage and processing architecture are examined, all at a concrete functional level of dtmg. a component-based approach to software development is described and is validated for each of the abstract system requirements for future breast screening computing environments and information management. research approach is telediagnosis, teleconsultation, and telemanagement. results: the implementation of this architecture is described and analysed from image and clinical data. workstations and comprehensive database development is the most difficult and expensive technology for teleimaging and information management. full-field dtmg with technical components, study protocols, and preliminary results of a study are analysed. conclusion: the study shows the dtmg system to be successful in fulfilling the goals, dtmg is also considered in the general context of an integrated regional health telematics network, emphasizing its role and its interaction with other information and networking services for decision treatment strategies. dtmg standard needs to be further evaluated for quality of telemammography and for cost effectiveness. material & methods: seventeen subjects affected by drug resistant cryptogenic partial epilepsy underwent long-term computer assisted video-eeg monitoring and dsc mri in the same day. mri data were compared with eeg findings, and accuracy of perfusional mri was analyzed considering the spiking rate and the type of epilepsy. results: dsc mri showed a relevant asymmetry in a region compared to the contralateral areas in ( %) out in patients, suggesting the presence of a relative focal hyperperfusional pattern. this area corresponded to the epileptogenic focus or to the hemisphere involved. in the genesis of epileptic discharges in ( . %) out of patients showing a higher spiking rate (hsr) conversely, all patients with a low spiking rate (lsr group) did not show significant asymmetry indexes in perfusional pattern. moreover we found that dsc-mri seems to be very sensitive for detection of epileptogenic focus in patients affected by temporal lobe epilepsy (tle). in ( . %) of hsr-tle patients dsc-mri showed a relative hyperperfusion region concordant with eeg focus or hemisphere involved in the genesis of epileptic discharges. conclusion: perfusional mri is a noninvasive procedure that provides useful additional information to better localize the epileptogenic zone, when the interictal epileptiform activity is sufficiently elevated. saturday materials and methods: eleven patients ( females, males), affected by intractable epilepsy were included. brain lesions were: mesial sclerosis, brain tumors, cortical gliosis, encephalomalacia, cortical displasia. mri studies were performed on a . t scanner. fmri volumes were acquired according to a block paradigm of alternating (rest-task) phases, including scans for each phase. bold contrast images were obtained by echo-planar fid sequences (fov = , tr = . ms, te = ms, thickness mm). high resolution mprage sequence, covering the whole head, served as basis for the integration of anatomical, meg and fmri data. magnetic field recordings were performed using a whole head meg system, equipped with integrated squid magnetometers. the location of magnetic field source during intercritical activity identified by meg was found to be in close proximity to the lesion in cases. a displacement of the source with respect to the lesion was found in two cases. in three cases meg was not able to reliably locate a source. functional markers (sensory areas identified by meg and motor areas identified by fmri) where in accordance with the known cortical organization. conclusion: these preliminary results are encouraging toward the use of morphological mri, fmri and meg in the identification of the functional areas within the affected region. quantitative h mrs investigations of the regional and age dependences of metabolite content in the human brain v.a. rogozhyn, z.z. rozhkova; kiev/ua purpose: the aim of our work is a quantitative study of the age and regional dependences of cerebral metabolism using primary spectral parameters of main metabolites. materials and methods: healthy volunteers (age range - ) were examined by . t magnetom vision (siemens). spectra were obtained in two locations of each brain hemisphere: in the occiput (gray matter), and in the forehead (white matter). all spectra were recorded with the steam sequence: tr/te / ; / , ms; voi = × × cm . results: for the normal brains the peak areas of h mrs signals from n-acetylaspartic acid (naa), total creatine (cr) and choline (cho) were obtained. we define the metabolite concentration as the ratio of the peak area to the sum of all the peak areas. we have found a "fine structure" of the average metabolite concentrations which depends on the relative values of peak areas. to describe this fine structure we introduce the triad t* = {a, b, c}, where a, b, and c are the unequal peak areas of the signals from naa, cr and cho, respectively. we believe that each of the three peak areas takes three values: , and , to represent symbolically six possible spectral configurations: t = { *, *, / , *}. the triads * = { , , } and * = { , , }denote the most frequent configurations in the spectra. metabolic variations with age are especially noticeable in the left forehead for them. we have built spatial maps of the age dependences of metabolite content in the normal brain. our results serve as the background for the description of brain pathologies. mrs data for the quantitative description of the brain metabolism in patients with brain tumors v.a. rogozhyn, z.z. rozhkova; kiev/ua purpose: the aim of our study is to propose the quantitative indicators of metabolic changes in the human brain and brain pathologies. methods and materials: patients with gliomas (of various grades of anaplasty) or meningiomas, together with healthy volunteers were examined using a . t magnetom vision (siemens). all spectra were recorded in brain locations with the steam sequence: tr/te / ; / , ms, voi = × × cm . the peak brain areas of h mrs signals from n-acetylaspartic acid (naa), total creatine (cr) and choline (cho) were obtained for all subjects. we introduce the metabolite concentration as the ratio of the peak area to the sum of all the peak areas. we describe the metabolic state of the brain in each voi by the triad t* = {a, b, c}, where a, b and c are the unequal peak areas of the signals from naa, cr and cho, respectively. each of the areas takes three values: , and , to give six symbolic spectral configurations: * = { , , }, * = { , , }, * = { , , }, * = { , , }, * = { , , } and * = { , , }. the frequency of appearing each of the triads in spectra depends on the brain state. the triads * and * denote the most frequent configurations in the spectra. and the triads * and * we observed only in the pathological brains: both in the tumor location and in the intact tissue. we give a quantitative classification of the brain state by creating spatial triad maps. this essentially amplifies mri examinations of patients with brain pathologies. proton mr spectroscopic imaging and fdg-pet in irradiated glial brain tumors h.-p.w. schlemmer , m.p. lichy , m. henze , p. bachert , s. sammet , a.a. maudsley , j. debus , g. van kaick ; heidelberg/de, san francisco, ca/us purpose: to assess the clinical utility of proton mr spectroscopic imaging ( h mrsi) for evaluating suspicious brain lesions after radiotherapy of glial brain tumors. methods and materials: in this ongoing study patients with irradiated gliomas (who grade , n = ; grade , n = ; grade , n = ) were examined by h mrsi and positron emission tomography with [ f]- -fluoro- -deoxy-d-glucose (fdg-pet) to evaluate suspicious brain lesions. the mr protocol included multiplanar t w turbo spin echo mri, h mrsi (press, tr/te / ms; spatial resolution . × . × . mm ), and pre-and post contrast t w-spin echo mri. relative signal intensity ratios of choline-containing compounds (cho), total creatine (cr), and n-acetyl-aspartate (naa) were determined both in lesions and in contralateral normal tissue using the program sitools. fdg-standard uptake values of the lesions were obtained from pet examinations and were related to normal gray (suvgr) and white matter (suvwm). lesions were classified as neoplastic (p) and non-neoplastic (np) based on mri follow-up or biopsy. results: significantly enhanced intensity ratios cho/cr and cho/naa were observed in p compared to np (p = . for both ratios) and compared to the contralateral normal tissue (p = . and p = . , respectively). in all patients cho/naa and cho/cr correlated with fdg-standard uptake values, e.g., cho/cr and suvwm: r = . , p = . . conclusion: parameters from h mrsi are helpful for differentiating neoplastic from non-neoplastic lesions after brain tumor radiotherapy. moreover, the correlation with glucose metabolism indicates that mrs parameters may also indicate tumor grade. proton magnetic resonance spectroscopy ( h mrs) of brain meningiomas at long echo time c. majós, j. alonso, c. arús, c. aguilera, m. serrallonga, j.j. acebes, j. cabiol, j. gili; barcelona/es purpose: to assess the utility of h mrs in the categorization of meningioma with especial emphasis in their differentiation with respect to other brain tumors. methods and materials: single voxel "in vivo" h mrs at an echo time of ms was carried out in patients with meningioma. a data-set of spectroscopic exams of brain tumors acquired under identical conditions was used for comparison. this data-set included low-grade astrocytomas, anaplastic astrocytomas, glioblastomas and metastases. fitted area of seven resonances of interest (lipids at . ppm, lact at . ppm, ala at . ppm, nac at . ppm, glx at . ppm, cr at . ppm and cho at . ppm) was calculated. we searched for the resonances that better discriminated meningioma from every other tumor type. an empirical algorithm for bilateral discrimination between meningioma and the other tumors was produced on the basis of these findings. the performance of the algorithm was assessed by means of the leave-one-out method. results: high ala, low or absent lipids, high glx, low cr and high cho were found to be the most characteristic trends of meningioma. when applied in pair-wise discrimination with the other tumors, these findings produced % successful classification outputs, % unsuccessful and % "unclassifiable". conclusion: single voxel h mrs provides biochemical information from meningioma that can be satisfactorily applied in its categorization. according to our results, high ala, glx and cho, as well as low lipids and cr are characteristic spectroscopic signatures of meningioma. a c d e f materials and methods: patients who underwent supratentorial cortical/subcortical infarction were studied, months after the onset of clinical symptoms of ischemic stroke the mr studies were performed on . t system. the results of spectra approximation (presented as metabolite ratios: naa/cr, naa/sum, chol/cr, chol/naa, lac/naa, lac/sum, lip/naa and lip/sum were subjected to statistical analysis. mr spectra were recorded from a tissue adjacent to area of infarction and normal appearing brain region: contra and ipsilateral internal capsule. spectra from stroke patients were compared with control group from healthy volunteers recorded with the same techniques. results: the statistical analysis revealed significant differences between data obtained from the various regions in the patients who had undergone ischemic stroke and between the infarcted and control groups. proton mr spectroscopy detects changes in cerebral metabolites levels also in apparently normal regions. in contralateral brain regions, as well as in the internal capsule we have noticed significant reduction in choline, creatine and naa; we found correlation between clinical outcome and mri/mrs findings. conclusions: proton mrs is a very useful tool for evaluating major changes in cerebral metabolite levels in infarcted patients. our preliminary results of h mrs, mri and clinical data support the idea that metabolic leasions distant from the infarcted tissue can be responsible for clinical course and have predictive value. fingerprinting of the etiological agent in brain abscesses using proton mr spectroscopy m. garg jr., r.k. gupta, m. hussain, k.n. prasad, s. chawla, r. kumar, n. hussain; lucknow/in purpose: in vivo proton mr spectroscopy data was analyzed from cases of proven brain abscess(s) to look for the possible metabolites that may act as marker for the specific group of bacteria. methods and materials: data from patianets with proven brain abscess by pus aspiration, bacterial culture, and histopathology of the wall were analyzed to look for spectral pattern relationship with the bacterial culture. in vivo data was obtained using single voxel steam (te = ms) and se (te = ms) sequences. results: the in vivo spectra show the following patterns: • abscesses in patients showing only lipids ( . ppm, . ppm) and without amino acids ( . ppm) and showed m. tuberculosis on smear and culture. • abscesses in patients showing succinate ( . ppm) and/or acetate ( . ppm), along with lipid/lactate ( . ppm) and amino acids ( . ppm) and showed anaerobic bacterial growth namely peptococci, peptostreptococci, and bacteroides. • abscesses in patients showing only lipid + lactate ( . ppm) and amino acids ( . ppm). orgainsms seen on culture in these were either aerobes (pseudomonas, nocardia) or facultative anaerobes (staphylococcus, proteus, and escherichia coli). two patients with this pattern also showed anaerobic bacterial growth (peptostreptococci). • abscesses in the remaining patients were found sterile on culture. these patients were on treatment with broad spectrum antibiotics at the time of spectroscopy and show lipid + lactate ( . ppm) and amino acids ( . ppm) only. conclusion: our data suggests that it may be possible to group the brain abscesses on the basis of metabolite pattern seen in vivo and may be of value in improved management of these cases. subclinical cerebellar neuropathy as a result of chemotherapy in proton magnetic resonance spectroscopy b. ciszkowska-lyson, l. krolicki, a. janowicz-zebrowska, a. teska, e. tacikowska, m. krzakowski, s. budrewicz; warsaw/pl purpose: of our study was to evaluate the central neurotoxicity of chemotherapy using mri and mrs, in patients with lung cancer who were treated with cisplatin and vinca alkaloids. we expected to find a reduction in n-acetylaspartate, as a result of the neurotoxicity of chemotherapy. methods: patients aged to years underwent before and after chemotherapy: clinical examination; mri of the brain, mrs (press, tr ms, te ms) voi of ml localized in centrum semiovale (cs) and hemisphere of cerebellum. each patient's naa/cr and cho/cr ratios have been analyzed statistically. analysis was carried out separately for cs and cerebellum. none of the patients demonstrated clinical manifestation of cns neurotoxicity. mri did not reveal any abnormalities caused by chemotherapy. analysis of naa/cr and cho/cr ratios in cs did not show significant differences before and after chemotherapy. analysis of the cerebellar spectra showed significant decrease of naa/cr ratio (p < . ) and time dependent decrease of cho/cr ratio (p < . ) after chemotherapy. analysis of pearson's correlation showed very strong linear relationship between naa/cr and cho/cr ratios (p < . ), both at cs and cerebellum. conclusion: decreased naa/cr ratio can indicate the neuronal loss caused by chemotherapy. decreasing cho/cr ratio could be associated with damage of myelin. the mrs results suggest presence of subclinical selective cerebellar neuropathy caused by chemotherapy. the mrs revealed different reaction to chemotherapy at cs and cerebellum. these initial results indicate that proton mr spectroscopy is a potentially useful modality for detecting early stage of the cns neurotoxicity caused by chemotherapy. the liver and splenic parenchyma were surveyed and evaluated before and after embolization with plain helical ct, including volumetry of the liver and spleen. results: dsa examinations revealed a dilated splenic artery (n = ) or gastroduodenal artery (n = ) combined with slightly decreased perfusion of the hepatic arteries, while immediately after successful embolization normal perfusion of the hepatic arteries was noted. volumetric measurements before and after embolization showed no significant changes in liver parenchyma ( % - %, mean, %), and an alteration in spleen volume ( % - %, mean, %) in comparison with initial measurements. clinical follow-up examinations revealed a normalization of the previously elevated hepatic enzymes and a normalization of the liver function tests after successful embolization. complications were observed in patients (infarction of the spleen). the preliminary results reveal that in liver transplant candidates with splenohepatic and gastroduodenal steal syndrome, successful embolization of the splenic artery results in a improvement in organ perfusion with normalization of function tests. were noted after sessions ( . %). the number of sessions of tace, pancreatic location of primary tumour, extent of hepatic involvement and use of tace as a first line non-surgical treatment were significant for response rates in an univariate as well as a multivariate analysis. when survival from date of tace was considered, previous resection of primary and number of tace sessions were significant on univariate and multivariate analysis, while location of primary, histopathological grading and extent of hepatic involvement were significant only on univariate analysis. the digestive location of the primary tumor appears to be the strongest positive prognostic indicator for both response to tace and survival. use of at least tace sessions per patient is recommended. poor prognostic indicators are presence of extra-hepatic lesions (nonresected primary and/or extra-hepatic metastases), poor histological differentiation of the tumor and more than % involvement of liver. ( ), kidney ( ), spleen ( ), brain ( ). mostly there was an asymptomatic clinical course postprocedure. in six cases there were serious complications ( × pneumonia, × renal failure, × cholecystitis) which resolved after two weeks. without evidence of displacement of lipiodol, there was one renal failure, one abscess of the liver and one case of hepatic encephalopathy. post-embolization syndrome (pes) with abdominal pain, nausea and vomiting, subfebrile temperature and pleural effusion was seen in % ( / ) for a period of a few days. no rupture of an embolized hcc and no reflux embolization was observed. conclusions: unexpected displacement of embolisation material is not seldom, but mostly clinically inapparent. in cases with complications, symptomatic therapy is sufficient and successful. the frequent postembolization syndrome is transient and can be easily managed. transcatheter arterial chemoembolization (tace) as a first line treatment for liver metastasis from digestive neuroendocrine tumors a.j. roche, b.v. girish, v. kuoch, t. de baère, e. baudin, m. ducreux; villejuif/fr purpose: to report the outcome in patients who underwent tace as a first line non-surgical treatment methods and material: from jan. to dec. fourteen patients with progressive unresectable liver metastases from digestive neuroendocrine tumor were treated with tace (mean of . sessions) before any non-surgical treatment (somatostatin analogue, chemotherapy or interferon). liver involvement was less than % in patients. the size of the largest lesion ranged from . to cm. the number of lesions was more than in patients. ten patients presented with carcinoid symptoms. tace was performed with doxorubicin emulsified in lipiodol® and gelatin sponge particles. results: a symptomatic response relating to flushes and/or diarrhea was complete in / cases and partial in / . an objective morphologic response was noted in / cases. one patient developed transient renal failure and hypertension after the first tace. there was no procedure-related mortality in the series. the and -year survival from diagnosis was respectively % and %. six patients were alive at the end of the study after to months from first tace and to months from diagnosis. three of them were successfully palliated for , and months with only tace as treatment (they received , and sessions respectively). the control rate of carcinoid syndrome with tace is comparable to somatostatin analogues. long term clinical, as well as morphological palliation, is possible in unresectable liver metastases from digestive neuroendocrine tumors with a few sessions of tace as early and exclusive treatment. material and methods: tace in consecutive patients with hcc. sequential tace (interval: weeks) was performed using a suspension of mg mitomycin c and ml iodized oil (lipiodol). follow-up included pre-and post-interventional ct scans and laboratory measurements (liver-function parameters; afp). the number of lesions and tumour size were investigated using spiral ct. results: mean follow up was months (range to ). patients are still alive (mean survival months, range - months). lesions were detected on the initial ct scans. size of individual lesions was < mm (i), - mm (ii), and > mm (iii) in . %, . % and %. over all median change of tumour size was - . % (range - % to + %). median change depending on the initial lesion size was - . % (i), - . % (ii), and - . % (iii). stable disease was noted in / patients. / patients had significant tumour regression and liver transplantation was successfully performed. tumour progression was noted in patients with multilocular hcc and tumours > mm. complications occurred in patients, pancreatitis in one and dissection of the hepatic artery in two. there were no periinterventional deaths. conclusion: sequential tace in primary hcc is an effective therapy in patients with small tumours. because of tumour size control and avoidance of new tumour lesions, tace is a promising method to bridge the time to liver transplantation or to change patients into a transplantable condition. hybrid mri: transarterial chemoembolization of liver metastases using interactive mr guidance t.j. vogl, j.o. balzer, s. zangos; frankfurt a. main/de purpose: to evaluate the effectiveness of mr guided transar terial chemoembolization (tace) of liver metastases by employment of a hybrid mri system. in a newly built suite with fully interactive high field ( . t) mri and c-arm angiography units, elective tace was performed in patients. an interactive table was positioned between the mri and angiographic unit, and allowed repositioning of the patient on a carbonfibre-plate within seconds. arterial access was successfully achieved by employment of the dsa-unit and a mr compatible angiography catheter was superselectively positioned in the tumor feeding artery. the patient was then positioned in the mr unit and gd-enhanced dynamic mri (turboflash) via the catheter revealed the regional perfusion and verified the correct catheter position prior to tace. results: in / patients immediate embolization of the tumor bearing liver segments was performed. in patients repositioning of the catheter and in patients a change of vascular access was necessary. therapy monitoring using mri therefore resulted in the repositioning of the catheter tip in % of the embolization maneouvers. dsa control immediately after tace revealed successful tace of the appropriate liver segments. conclusion: the presented hybrid system optimizes complex tace procedures in patients with liver metastasis. mri guidance enables the exact identification of the tumor bearing liver segments and correct catheter placement. uterine artery embolisation for symptomatic fibroids: results in women w.j. walker, j.-p.j. pelage; guildford/gb purpose: to evaluate the mid-term efficacy, adverse events and complications of uterine artery embolisation (uae) in women with symptomatic fibroids. to assess reduction in uterine and dominant fibroid volumes using ultrasound imaging and magnetic resonance imaging (mri). methods and materials: four hundred women were treated between december and february . indications for treatment were menorrhagia, menstrual pain, abdominal swelling or urinary frequency. imaging was performed before embolisation and at regular intervals thereafter. clinical evaluation was made at regular intervals after embolisation to assess patient outcome. results: bilateral uae was achieved in women whereas women had a unilateral procedure. with a mean clinical follow-up of . months, menstrual bleeding was improved in % of women and menstrual pain was improved in %. the mean changes in uterine and dominant fibroid volumes were and % using ultrasound (performed at an average of . months after embolisation) and and % with mri (performed at an average of . months). three ( %) infective complications requiring emergency hysterectomy occured. ( %) patients had clinical failure or recurrence and nine ( %) had a hysterectomy. ( %) of women had permanent amenorrhea after embolisation including patients under the age of . thirteen pregnancies occurred. % of women were pleased with the outcome. conclusion: uterine artery embolisation is associated with a high clinical success rate and good fibroid volume reduction. infective complications requiring hysterectomy and amenorrhea under the age of are rare but major complications. embolization of bleeding arteries from pelvic trauma n.-e. klow , a. riise , m. brekke , o. roise ; oslo/no, fredrikstad/no purpose: to study the effects of arterial embolization after pelvic trauma in hemodynamically unstable patients. material and methods: from to , patients were included, three women and men, mean age years (from to years). all patients were admitted with trauma to the pelvis, but freqently multiorgan trauma was present. the pelvic fractures were bilateral in five, a sacral fracture was present in seven and diastasis of the symphysis pubis in seven. over the hours immediately before embolization the need for whole blood transfusion was ± units (range - ). results: all patients were successfully embolized. fourteen had embolization of one internal iliac artery (iia), one both iia and a lumbar spinal artery, one a lumbar spinal artery, and one a superficial femoral artery branch. in patients coils were used exclusively, in one gelfoam and in one coils and gelfoam were combined. the total need for blood transfusion after the embolization was . ± . units (range - ). three patients died during the hospital stay, and no deaths were related to the procedure or rebleeding from the pelvic arteries. conclusion: embolization of arteries bleeding from traumatic injuries of the pelvis is a life saving procedure with a high procedural success rate. the procedure can be done on call, in hemodynamically unstable patients, and should probably be performed in an early stage of bleeding. intraarterial chemotherapy of malignant pelvic tumors under tourniquet occlusion of the femoral vessels p.d. niggemann , s. murata , h. tajima , y. okajima , k. ichikawa , h. kawamata , t. kumazaki ; aachen/de, tokyo/jp purpose: to evaluate the possible benefit of intraarterial chemotherapy in malignant pelvic tumors under tourniquet occlusion of the femoral vessels. methods and materials: the difference in contrast enhancement of regions in malignant pelvic tumors was evaluated with and without tourniquet occlusion of the femoral vessels. in nine patients (group a) two ct scans of the pelvis, one and five minutes after starting an intraarterial contrast medium injection under tourniquet occlusion, were performed and then two ct scans after injection of the same dose without tourniquet occlusion were performed. in the remaining patients (group b), the study was done in the opposite order. results: in group a, a mean change of the contrast enhancement of all tumors was . hounsfield units (hu) after one minute and − hu after five minutes. in group b, a mean change in contrast enhancement of . and . hu at one and five minutes respectively was observed. in patients with prostate tumor, the results were . and . hu respectively in patients from group a and . and . hu in patients from group b. the average of both groups together showed an increase of . and . hounsfield units respectively. conclusion: an increase in the contrast enhancement of malignant pelvic tumors due to tourniquet occlusion of the femoral vessels has been observed only in patients with prostate cancer after one and five minutes. therefore intraarterial chemotherapy under tourniquet occlusion of the femoral vessels only seems to yield a benefit in poorly vascularized tumors. purpose: to establish a high resolution mri (hr-mri) protocol for precise and repeated non-invasive analysis of selected atherosclerotic vessel segments in vivo and to compare the results with intravascular ultrasound (ivus). materials and methods: patients with atherosclerotic disease of the superficial femoral artery were examined on a magnetom vision, siemens using axial t -w, fat-saturated contrast enhanced t -w, t -w and d-tof sequences. contrast enhanced mra was used to display the detailed vasculature for precise orientation. maximum matrix size was × , minimum voxel size . × . × . mm. ivus ( . f, mhz) images were recorded with a standardized motorized pullback system (pullback speed . mm/s). parameters analysed were minimum and maximum luminal diameter and cross sectional lumen area. vessel wall calcification was determined by steps. results: / segments were available for comparison between hr-mri and ivus. intra-and interobserver repeatability for exact assignment of vessel segments was high (r = . , r = . ). there was a good correlation for luminal parameters (correlation coefficients ranging from . to . depending on the plaque burden). no correlation was found for cross sectional vessel area. calcification could be classified with a sensitivity of %, a specificity of %. accuracy was %. conclusion: our hr-mri protocol is highly accurate for non-invasive assessment of atherosclerotic lesions in human femoral arteries. the results are comparable with ivus as known reference standard in vivo. purpose: to evaluate ultrasonography as a method of characterizing plaque surface configuration and plaque internal structure in comparison to in vitro angioscopy and pathological specimens. the carotid plaque specimens of patients were examined by in vitro angioscopy and histopathological examination after carotid endarterectomy (cea) in a comparative study with preoperative ultrasonography. colorcoded ultrasonography was obtained with a . mhz linear transducer (logic , ge). transverse and longitudinal sections were recorded from the bifurcation area as well as from the proximal internal carotid artery. the plaque surface was characterized as smooth if the plaque surface did not show any disruptions. further, the echogenic structure was recorded by grey scale analysis. after cea the inner surface of the plaque was visualized by a . mm angioscope. the results were compared with histopathological findings. results: peak flow velocity (mean: . m/s, range . - . m/s) demonstrated a > % stenosis in all cases. the median of gray scale analysis (gsm) was with a high correlation between both investigations (p < . ; r = . ). in comparison to pathological findings there was a correct detection of plaque surface in . %. pathological classification of plaque composition revealed no correlation to computer-assisted analysis (p = . ; r = - . ). conclusion: detection of an ulcerated plaque surface by ultrasonography is difficult with a wider degree of variation when compared with direct visualisation of the surface and pathological examination. computer-assisted analysis of the morphology provides a high interobserver correlation, however, there was no correlation between the gsm and histological findings in this series. common carotid artery intima-media thickness (cca-imt) and carotid plaque echogenicity: correlation with cardiovascular risk factors in patients with acute ischemic stroke g. terzis, a. chrysanthopoulou, g. gioldasis, a. kalogeropoulos, c. paschalis, j.a. dimopoulos; patras/gr purpose: to correlate the cca-imt and the echogenicity of the carotid plaques with the main cardiovascular risk factors in patients with acute ischemic stroke. methods and materials: consecutive patients (male , female , mean age . years) with acute ischemic stroke were studied with b-mode and color doppler ultrasonography during may to july . cca-imt was evaluated and four types of plaques were defined by their echostructure. type i: uniformly echolucent, type ii: predominantly echolucent, type iii: predominantly echogenic and type iv: uniformly echogenic. cardioembolic and undetermined strokes were excluded. all patients were evaluated for a history of smoking, hypertension, diabetes or hypercholesterolemia. smoking, hypertension and diabetes were all significantly associated with an increased cca-imt (p < . for all subgroup comparisons). hypercholesterolemia had no significant effect (p = . ). smoking was associated with an increased cca-imt (p = . ) independently of other risk factors. hypertension was significantly associated with diabetes (p = . ) as a risk factor. smoking, hypertension and diabetes had no significant effect on the type of the plaque (p = . , p = . , and p = . respectively). hypercholesterolemia was significantly associated with type i plaques (p < . ). a trend for advanced echogenicity was observed among smokers (p >> . ). smoking, hypertension and diabetes but not hypercholesterolemia were significantly associated with an increased cca-imt in patients with acute ischemic stroke. smoking, hypertension and diabetes were not associated with a specific type of plaque, but hypercholesterolemia was clearly associated with type i plaques. high-resolution mr of carotid atheroma: a non-invasive tool for assessing plaque morphology and potential risk? j.h. gillard , m.t. gaskarth , m.j. graves , r.a. coulden , h. wilson , n.m. antoun , m. goddard , p.j. kirkpatrick ; cambridge/gb, papworth/gb purpose: whereas current imaging techniques provide excellent structural information including the quantification of vascular stenosis, they provide no information of the degree of functional plaque stability. risk of rupture is more closely related to plaque composition and macrophage content than size. thus angiographic appearances are an inaccurate predictor of risk; even large atherosclerotic lesions may not produce a significant stenosis at angiography. we aimed to use highresolution mr to evaluate plaque morphology in patients being evaluated for carotid endarterectomy. methods: blood-suppressed fast spin echo imaging was performed using a dedicated surface coil (t , t , proton density, and chemical shift selective fat suppression; spatial resolution . × . . × mm) in patients with symptomatic carotid disease. gadolinium-enhanced elliptic centric mra was also performed and compared with conventional digitally subtracted angiography (dsa). histopathological examination was carried out on specimens. results: plaques were identified, of which were eccentric, extending outside the limit of the "normal" vessel wall. there was no significant difference in the degree of stenosis (using nascet criteria) assessed with dsa and gd-enhanced mra (p = . ). high-resolution axial mr measurements, however, demonstrated more severe stenoses than was apparent from projection dsa (mean difference ± %, p < . ). mr correctly identified plaque constituents (fibrin, lipid and focal hemorrhage). conclusion: high-resolution carotid mr appears to be a useful tool in evaluating plaque morphology and effectively assesses plaque volume and degree of arterial narrowing. it may be an effective tool in evaluating plaque risk and the effects of pharmaceutical interventions. in patients with btm (mean age . ± . year, . % male, mean hemoglobin . ± g×dl - , mean serum ferritin ± ng×ml - , % on optimal chelation therapy) without cardiac disease or diabetes mellitus and healthy control subjects, flow-mediated dilatation (fmd) was measured as a percentage change of the post-ischemic right brachial artery (ba) diameter. endothelial-independent, nitroglycerin-induced vasodilatation (nid) and cca imt were also assessed. the study groups were matched for age, gender, body surface area, blood pressure and smoking habits. serum cholesterol levels were lower in the patient group ( ± versus ± mg⋅dl − , p = . ). the brachial artery diameter was . ± . mm in patients and . ± . mm in healthy subjects. post-ischemic increase in the brachial artery blood flow was ± % (p < . ) for patients and ± . % for healthy subjects. fmd was . ± . %(p < . ) for patients and . ± % for healthy subjects. nid was . ± . % for patients and . ± . % for healthy subjects. cca imt was . ± . mm for patients and . ± . mm for healthy subjects. fmd and thickness of the carotid arterial wall did not correlate with serum ferritin levels. conclusions: in patients with thalassemia major, endothelial function of conduit arteries is impaired and cca imt is increased. our findings suggest a proatherosclerotic milieu with reduced bioavailability of nitric oxide, probably due to the iron-induced, high oxidative stress in these patients. functional imaging of the aortic wall by ecg-gated multislice-ct: an ex vivo experiment m.-k. ganten , j. boese , d. leitermann ; heidelberg/de, prague/cz purpose: ecg-gated multislice-ct (msct) allow imaging with increased temporal resolution. the aim of this study was to evaluate the possiblity of obtaining functional information determining aortic-wall-elasticity in an ex-vivo experiment. elasticity is a piece of clinically relevant information not yet widely accessible. methods & materials: samples of porcine aortas were examined ex-vivo. to imitate physiologic circulation an artificial heart phantom emitting an ecg signal was used to perfuse the samples with pulsatile flow and varying pressures. aortic wall elasticity can be determined by dividing the relative change in vessel area by the corresponding pressure change. as a reference, the wall distension was measured using an optical system with high temporal and spatial accuracy. ecg-gated ct images were acquired with a standard ct-angiography protocol applying specially developed reconstruction algorithms. this allowed us to obtain images with improved temporal resolution of about ms. the aortic cross-section was determined from the images by manual segmentation. the accuracy of the crosssectional changes measurements was evaluated by comparison between the optical and the ct data. results: determination of aortic wall elasticity was possible in all samples. elasticity, expressed as mean compliance, was . × − /pa. precision of the manually determined values was in the order of % compared to a precision of about % for the reference optical method. cross-section changes obtained from the ct images were in line with the error bounds obtained from the optical measurements. conclusion: our study shows that aortic wall elasticity determination using ecggated ct is feasible. this allows functional information about the aortic wall to be obtained. patient studies are required to investigate the in-vivo applicability. detection of atherosclerotic plaque using gadofluorine enhanced magnetic resonance imaging j. barkhausen , w. ebert , c. heyer , j.f. debatin , h.j. weinmann ; essen/de, berlin/de purpose: to visualize atherosclerotic plaques independent of luminal narrowing using t -w contrast enhanced mri. methods and material: watanabe heritable hyperlipidemic rabbits ( - months) and age-matched controls (white newseeland) underwent magnetic resonance imaging of the aortic arch using a . t mr system (magnetom symphony, siemens ag, erlangen, germany) before and h after injection of mmol gadofluorine (schering ag, berlin, germany). a haste sequence (tr ms, te ms) and a t -weighted inversion recovery turboflash sequence (tr ms, te ms, ti ms) were used for data acquisition. immediately following the mr examination the animals were sacrificed and the aorta was stained with sudan. ex vivo imaging of the stained aortic specimens was performed. additionally, the gadolinium concentration in plaques and normal aortic wall was measured by means of inductively coupled plasma atomic emission spectrometry. results: plain mr imaging revealed no plaques in the aortic arch in either animal group. enhancement occurred in the aortic wall of all whhl rabbits but not in the vessel wall of the control group. sudan staining demonstrated multiple plaques in the aortic arch of the whhl rabbits and using ex vivo imaging the area of hyperenhancement matched the area of plaques stained with sudan. the gadolium concentration was ± nmol/g for normal aortic wall in the control group and ± nmol/g for plaques. conclusions: gadofluorine enhances atherosclerotic plaques thereby permitting the detection of plaque independent of luminal narrowing. vessel wall mri of the descending aorta: comparison with transesophageal ultrasound n. abolmaali, m. langenfeld, c. schick, r. kraforst, v. schächinger, t.j. vogl; frankfurt a. main/de purpose: to evaluate the validity of high-resolution contrast-enhanced mri of the aortic wall and to prove comparability of plaque morphology detected by transesophageal ultrasound (teus). is there additional information in mri? methods and materials: we performed mri in five patients (median age: years) in whom aortic wall thickening and plaques of varying morphologies were detected by teus. after sequence optimisation in cadaver studies, all mr-examinations were performed with a . t scanner (magnetom symphony quantum, siemens) with the cp-spine surface coil (supine position) using ecg-triggered t weighted tse-sequences with dark-blood-preparation and fat-suppression before and after iv-administration of . mmol/kg bw gadolinium-dtpa (gd). slice thickness was mm, in-plane-resolution using a matrix was . × . mm . the heart-frequency dependent acquisition time for slices was - minutes. roi-measurements of the aortic wall before and after contrast enhancement were performed and mri was correlated with the teus findings. results: thickened wall segments and plaques of the descending aorta detected by teus were visualized by mri. different morphologies with evidence of fatty deposits were detected. unaffected aortic wall revealed two layers and signal isointensity compared to striated musculature. after iv-administration of gd most parts of the aortic wall did not enhance (< %) while wall thickening and plaques showed considerable enhancement ( - %) solely of the inner layer of the aortic wall. conclusion: high-resolution mri of the aortic wall provides similar morphologic information as teus does. additionally the distinct enhancement of the inner aortic layer may correspond to an inflammatory process of the vessel wall. , metastases (n = , mainly colorectal), carcinoid (n = ) and two benign liver tumours. patients were excluded from follow-up. results: mean survival for all patients was . months, with an adjusted mean survival of months for hccs and . months for metastases. there were three major and five minor post-procedural complications but no deaths. an average of % of tumour was ablated as assessed by per-procedural thermal mapping, with an average of . % of tumour ablated assessed by pre and post ablation gadolinium-enhanced mris. average tumour size was unchanged after ablation. in patients with multiple liver tumours ablated tumours grew significantly less than untreated tumours over the same time period ( % compared to % growth over an average follow up period of . months). conclusions: mr guided laser thermal ablation of primary and secondary liver tumours is safe and feasible and produces a better survival in patients with hcc than would be expected in untreated patients, as well as a mean survival in patients with metastases at least equal to the longest median survival in untreated patients. percentage viable tumour was decreased by a mean of . % per lta session. contrast enhanced harmonic sonography (ceus) used in the interventional room (ir) during radiofrequency (rf) ablation treatments: how to save time and reduce patients' discomfort l. solbiati, t. ierace, m. tonolini, l. cova, v. osti, p. marelli; busto arsizio (va)/it purpose: to evaluate usefulness of ceus performed during rf ablation procedures to assess the therapeutic result prior to ending the treatment session. materials/methods: patients with - hcc in liver cirrhosis ( patients) or - metastases from colorectal ( ), breast ( ), gastric ( ) and endocrine ( ) cancers underwent single session percutaneous rf ablation with cool-tip electrodes, under general anesthesia, in the ir. before and - minutes after ending each treatment session, continuous mode, low mechanical index, ceus with a second generation contrast agent (sonovue, bracco) was performed. a total of lesions were examined. when, residual enhancement was detected within treated tumors, a second targeted electrode insertion was carried out. when complete tumor avascularity was demonstrated, general anesthesia was terminated. contrast-enhanced helical ct (cect) was performed in all cases - days after ablation. results: in / ( . %) lesions no post-ablation residual enhancement was found with ceus. subsequent ct showed unablated portions of tumors in / ( . %) lesions (all larger than cm) and complete necrosis in the remaining saturday in / tumors in patients, ceus showed either single or multiple intralesional areas of residual enhancement in arterial and/or portal phase, - . cm in size. all these likely viable portions were immediately targeted with - electrode insertions, until no residual areas were demonstrated. on subsequent cect, only in / ( . %) of these tumors, - . cm residual areas were found requiring new rf treatment. to prove the hypothesis that t w thermal mapping is reliable and achievable in mr guided laser tumour ablation. methods & materials: mr guided laser thermal ablations (lta) of liver, kidney and uterine tumours were studied. after laser fibre placement, near real-time grey and colour scale thermal maps are produced. previous work showed t signal is inversely proportional to temperature below °c (the point of irreversible tissue necrosis). measurements included: (i) percentage (%) of cases in which the thermal map provided sufficient information to control the procedure (ii) ability of grey and colour scale maps to demonstrate size (centimeteres) and conspicuity ( point scale) of thermal lesions (iii) factors causing thermal mapping failure. results: (i) thermal mapping was successful in % uterine, % hepatic, and % renal ablations. (ii) for hepatic/uterine tumours, size and conspicuity of thermal lesions were significantly greater on the colour than grey scale mapping. for uterine ablations, mean lesion size was . cm (colour) and . cm (grey, p = . , paired student's t-test), while mean conspicuity was . (colour) and . (grey, p = . ). for liver ablations mean lesion size was . cm (colour) and . cm (grey, p = . ) while conspicuity was . (colour) versus . (grey, p = . ). (iii) patient movement (n = ), fibre charring (n = ), magnetic field distortion & reconstruction errors (n = ) caused mapping failure. in hepatic & uterine thermal maps the colour scale produced significantly greater sized lesions with significantly greater conspicuity than the grey scale. t w signal thermal mapping was reliable and successfully achieved in . % of procedures. the most important challenge on the follow-up of radiofrequency treated hypovascular liver metastases: the differentiation of coagulative necrosis from viable tumor. is there a role for contrast enhanced sonography? l. solbiati, m. tonolini, l. cova, d. della chiesa, v. osti; busto arsizio/it purpose: to assess if contrast enhanced harmonic sonography (ceus) can be useful for the differentiation of radiofrequency-induced coagulative necrosis from viable hypovascular liver metastases. materials and methods: metachronous colorectal liver metastases (mean size . cm) in patients treated - months beforehand with rf ablation and systemic or intraarterial chemotherapy underwent conventional us and continuous mode, low mechanical index, ceus with a second generation contrast agent (sonovue, bracco) due to suspicion of local recurrence. triphasic contrast-enhanced helical ct (in all cases) and fnab ( cases) were performed to confirm recurrence. results: usind ceus in arterial and very early portal phases, / metastases showed intense, predominantly peripheral enhancement. in full portal phase, complete disappearance of the enhancement was observed, with homogeneously hypoechoic appearance. the same arterial ct demonstrated enhancement, although less evident than with ceus, in only of these metastases ( %). us-guided fnab was performed in at least one metastasis for each patient, with diagnosis of viable adenocarcinoma cells. in the remaining / lesions no enhancement was found with either ceus or ct and fnab (in / nodules) did not yield viable tumoral cells. conclusions: differentiation of coagulative necrosis from unablated or recurring hypovascular tumor is a diagnostic challenge. ceus demonstrates marked arterial enhancement of the viable tumor portions, better and with higher sensitivity than with ct. this finding could represent a quick and valuable tool for post-ablation follow-up. such arterial enhancement (more intense than that observed before ablation) raises a suspicion of more active neovascularity in uncompletely ablated tumors there was no effect on survival by tumor size, number of tumor nodes or the grading. however, the survival of % of the patients with a child c cirrhosis or with afp levels > ng was less than months with nobody living longer than months. in patients with child a cirrhosis and/or normal afp levels the mean survival was and months, resp. % of these patients lived more than months. conclusion: tace is an effective therapy that may prolong the patients survival in patients with non-resectable hcc. however, child class in cirrhotic patients and elevation of afp levels have to be considered as prognostic factors for a life extending tace therapy. purpose: to evaluate a neoadjuvant treatment protocol for large sized liver metastases performing repeated transarterial chemoembolization (tace) and litt (laser induced thermotherapy) in patients with unresectable liver tumours initially unsuited for litt material and methods: patients with different malignant liver tumours were evaluated between january and september . tace was performed with mg/m mitomycin c, ml/m lipiodol and microspheres. the tumour volume was measured by mr-imaging. lipiodol retention and perfusion of the tumours were evaluated by ct and angiography. after response to tace and reducing the tumor size patients ( patients with hcc, patients with metastases of colorectal cancer, patients with metastases of breast cancer and patients with metastases of different primary cancer) could be treated with mr-guided litt to weeks post embolization. these patients received to (mean: . ) tace before litt. results: repeated tace enabled a significant reduction in tumour size and/or tumour perfusion in patients, forming the basis for the performance of mrguided litt procedure for a complete ablation of the tumour. in tumors lesions laser interventions archived a complete tumour ablation. the initial tumour volume pre-litt presented with a mean of . ml, the resulting necroses was . ml. the local tumour recurrence rate was % in the month control, the rate of side effects %. conclusion: repeated tace alteres the size and structure of primary unresectable liver metastases and expands the indication for mr-guided litt. results: tace treatment were performed successful in . %. only in cases sondage of celiac trunk and performing tace was not possible. during the tace procedure in cases an occlusion of the a. hepatica was evidenced with good collateral arteries, so that tace could performed. in one case perforation of a. hepatica propria resulted in a small subhepatic bleeding. no therapy associated mortality was observed. only minimal side effects like pain ( . %), nausea ( . %), vomiting ( . %), fever ( . %) and apokamnosis ( . %) were associated with the tace, which could be managed by oral medication easily. in patients aszites was documented after tace treatment. in patients intrahepatic abscess cavities were evidenced and treated with percutaneus drainages. conclusion: tace in liver tumors proved to be a safe oncologic treatment in an outpatient setting. side effects must be treated fast to reduce failure. extrahepatic recurrences after radiofrequency ablation treatment of hepatocellular carcinoma: spectrum of imaging findings m. tonolini, l. solbiati, t. ierace, v. kirn, p. marelli; busto arsizio/it purpose: to describe diagnostic aspects and particularly ct findings of extrahepatic relapses observed after treatment of hepatocellular carcinoma. materials and methods: during a six-year span, patients (aged - years) with chronic hepatitis or cirrhosis were diagnosed with hepatocellular carcinoma confined to the liver and treated percutaneously with radiofrequency (rf) ablation. a total of treatment sessions were performed. post-therapeutic follow-up is based upon serum alpha-fetoprotein levels and ct examination. results: mean duration of follow-up was months. after successful treatment, actuarial probability of neoplastic relapse is . % after year and . % after years. patients had recurrence of hepatocellular carcinoma after a variable time interval (mean . months). extrahepatic neoplastic relapse was observed in patients, half of these without active hepatic disease. distribution of extrahepatic sites of recurrence was as follows: abdominal lymph nodes ( cases), bone ( ), peritoneum ( ), adrenal ( ), lung ( ). five patients ( . %) had a second primary extrahepatic neoplasm. conclusion: extrahepatic hepatocellular carcinoma is considered rare and occurring in advanced stages, but may represent a modality of post-treatment relapse. the distinctive hypervascularity of this tumor histology may be observed in adenopathy and adrenal metastases. second primary neoplasms should be considered in the differential diagnosis of lesions observed during follow-up. radio-frequency (rf) ablation of liver tumors: postprocedural appearances on multiphasic spiral ct p. cabassa, l. romanini, d. guidetti, f. simeone, a. maggi, l. grazioli; brescia/it purpose: to describe the spectrum of ct findings of liver malignancies treated with rf. materials and methods: histologically proven malignant liver lesion ( hcc, methastasis, size range . - . cm) in patients ( male, age range - years) were treated with rf (using either internally-cooled electrode or le veen needle electrode). multiphasic spiral ct at , , , months (and every months after year) was performed for follow-up. spiral ct included unenhanced and enhanced arterial and portal venous phase images. absence of contrast enhancment within the lesion was considered as complete ablation. the location (local intrahepatic, remote intrahepatic) and morphology of tumor recurrence were rewiewed. any other findings (perilesional hyperemia, thad etc) were recorded. results: complete necrosis was described in lesions ( . %) at month, partial necrosis in the remaining lesions ( . %). local tumor recurrences (persistence) appeared in three patterns: nodular, halo or gross enlargement. / lesions ( . %) tumor-free at month showed tumor persistence at months. analysis of these cases showed that residual disease was probably masquerade by perilesional hyperemia, a common finding at month. any lesion considered complete ablated at month didn't show tumor recurrence in the following controls. cases showed remote intrahepatic recurrence. pseudolesions as thad or a-v fistula were common findings expecially in early controls. the median follow-up was months (range - months). conclusion: knowledge of any ct findings after rf ablation is important but correlation with timing of follow-up is mandatory to avoid misdiagnosis. ct-guided aspiration and drainage of suppurative residual cavities after hydatidectomy a.i. ikramov, n.m. djouraeva; tashkent/uz purpose: to evaluate the efficacy of ct controlled intervention procedures in infected residual cavities after hydatidectomy. material and methods: ct-guided drainage was conducted on patients with infected residual cavities after hydatidectomy. age varied between and years (mean . ). size of cavities ranged from . cm up to cm. . % of cavities were located in the right lobe. in homogenous low density collections (+ ± hu) with thin walls an fna procedure was used to allow aspiration. in other cases ( ) with high density collections (+ ± hu) we performed percutaneous drainage with - f pigtail catheters. in cases when cavity sizes were more than cm we performed drainage via two catheters. results: in . % of patients ct-guided interventions allowed us to achieve a full recovery. repeated aspirations (from up to ) were conducted in cases. one complication occurred (partial lung collapse). in cases with ineffective drainage surgical conversion was needed. conclusion: ct-guided drainage procedures can be an effective method of treating suppurative residual cavities after hydatidectomy and may be an alternative to surgical treatment. in none of the patients was contrast material administered for mri. patients also underwent cardiac catheterization within two months after mri examination. all patients were examined with percutaneous echocardiography. the results were compared to the anatomical situs and functional parameters. patients with abnormal coronary arteries were excluded from this study. results: in of patients ( %) cardiac catheterisation and mri examinations provided results which led to the same clinical decisions. discordance between the two methods occurred in the assessment of pulmonary stenosis, in the evaluation of spongy myocardium, and straddling of mitral or tricuspid valves. overall there was no significant difference between mri and cardiac catheterisation in the pre-and postoperative evaluation of congenital heart disease (chd). conclusion: mri can be more beneficial in difficult patients especially with complex postoperative situs. cardiac catheterisation should only be performed when mri is questionable. percutaneous echocardiography still remains the first diagnostic tool in the evaluation of chd. saturday methods: patients with an established echocardiographic diagnosis of tricuspid valve insufficiency grade ii or grade iii and planned combined reconstruction of tricuspid and mitral valve were prospectively included and examined with mri. sequences included continuous short axis truefisp cine sequences of the whole heart for volumetry of atria and ventricles, phase contrast (pc) through-plane flow measurement and cine sequences for assessment of valvular function. patients were randomized and treated either by devega annuloplasty or by carpentier ring implantation. in patients, postoperative results were obtained - months after surgery. results: of patients examined had an absolute arrythmia, thus impairing diagnostic quality especially for flow measurements. atrial volumetry in these cases showed no discernible contraction, and through plane flow measurement in the valvular plane showed no a-wave. in all patients, the degree of insufficiency was established with pc-flow correlated with chamber view cine sequences and echocardiographic findings. in the follow-up-studies, no significant differences between the surgical treatment groups could be detected. conclusion: cardiac mri with pc-flow measurement and cine sequences seemed to be well suited for evaluation of atrial function and valvular morphology and function before combined valvular reconstruction. atrial volumetry is less useful than valvular flow measurement. cine sequences in the valvular plane allowed for sizing of the valvular ring. purpose: severe pulmonary regurgitation late after total correction for tetralogy of fallot leads to progressive right ventricular dilatation and an increased incidence of severe arrhythmias and sudden death. mri was used to assess the effect of pvr on rv function and pr. materials and methods: adult patients who underwent pulmonary valve replacement in our institution between and were studied. mean age at initial repair was . ± . years and mean duration of follow-up was . ± . years. cardiac mri was performed . ± . months before and . ± . months after pvr. pulmonary regurgitation (pr), rv end-diastolic volume (rvedv), right ventricular end-systolic (rvesv) and rv ejection fraction (rvef) were measured. results: preoperative pr was % (range from to %). after pvr, out of patients ( %) showed no residual pr. rvedv decreased from ml ± ml to ml ± ml (p < . ) and rvesv decreased from ± ml to ± ml (p < . purpose: retrospectively ecg-gated d volume data from multislice spiral ct (msct) coronary angiography enables image reconstruction in diastolic and systolic phase of the cardiac cycle. thus, the objectives of our study were to determine lv ejection-fraction (lv-ef) from msct data set and to compare the results to cine magnetic resonace imaging (mri). materials and methods: patients ( . ± . a) with coronary artery disease (cad) underwent msct coronary angiography (somatom volume zoom, siemens ag; × mm slice thickness, kv, ma; ml nonionic cm, flow ml/s). an additional cine mr study was performed at a . t mr unit (breath-hold flash d sequence, tr ms, te . ms, flip angle °, slice thickness mm). from msct data set retrospectively ecg-gated axial images were reconstructed in systolic and diastolic phase (acv reconstruction algorithm). enddiastolic and endsystolic lv volumes were determined from multiplanar reformations (slice thickness mm) in short-axis image orientation ( d volumetry) to assess lv-ef. cine mri data was analyzed by using the implemented argus™ software in shortaxis image orientation. multiplanar reformations from msct data set allowed good delineation of endocardial and epicardial contours. systolic reformations showed slight motion artifacts in patients with a heart rate above b.p.m. enddiastolic (r = . ), endsystolic (r = . ) lv-volumetry and lv-ef determination (r = . ) from msct data set demonstrated good correlation to cine mri. conclusion: in patients evaluated for cad, retrospectively ecg-gated d volume data set from msct angiography provides lv volumetric and functional data in good correlation to cine magnetic resonance imaging. after intravenous administration of contrast media ( ml, mg/ml iodine, flow ml/s) scanning was initiated by bolus tracking and performed using a ecg-gated protocol at mas and kv, collimation of × . mm, pitch of . : and . s rotation time. the raw data was reconstructed with % reconstruction pitch every % of the r-r interval. images were transferred to external workstations for diagnostic interpretation of the chest (easy-vision, philips) as well as the cardiac data (alato-view, toshiba). studies were evaluated with regard to image quality. left ventricular function parameters were calculated and were compared with echocardiographic measurements using pearson's correlation coefficient and student's t-test for paired samples. results: diagnostic interpretation of the images was feasible in all patients without recognizable reduction in image quality. the radiation dose of the modified protocol did not exceed the exposure of a routine chest ct. retrospective reconstruction of diastolic and systolic cardiac images succeeded in all patients, only minor motion artifacts occurred in cases due to cardiac arrhythmia. comparison between msct and echocardiographic measurements revealed no significant differences in the mean values of the function parameters (p < . in all cases) and a good correlation between both modalities: diastolic/systolic wall thickness r = . / . ; diastolic/systolic diameter r = . / . and ef r = . . conclusion: using a modified protocol for routine chest scanning, msct allows a reliable, fast calculation of heart size and function without additional radiation exposure. b a c d e f value and reproducibility of multidetector-row ct in the assessment of cardiac function c. herzog, a. mehtap, n. abolmaali, j.o. balzer, s. schaller, t.j. vogl; frankfurt a. main/de objective: to explore the value and accuracy of multislice-cardiac-ct in the assessment of functional cardiac parameters. materials and methods: patients prospectively underwent multislice-ct (siemensplus vz, germany) and invasive angiocardiography. using retrospective ecg-gating scanning parameters were × mm collimation, pitch . and ms rotation time. based on a proportional reconstruction algorithm two datasets were obtained from the endsystolic, endiastolic phase respectively. effective slice thickness amounted to mm, increment to mm. measurements were performed in mm thick slices cut orthogonal to the short axis of the heart. functional parameters determined were endiastolic (edv) and endsystolic ventricular volume (esv), segmental wall thickening and ejection fraction (ef). all measurements were performed using a mri-proved evaluation software (argus . wip, siemens, germany). invasive angiocardiography served as a reference measuring method using centerline analysis for functional evaluations. results: concerning evaluation of the ejection fraction, the wilcoxon test for matched pairs did not reveal significant differences between the two methods (tukey confidence interval: p = . ). however ca tended to overestimate ef by . %. the limits of agreement between ct and ca in ef were ± . %. significantly higher differences between both methods were found for edv rather than for esv, again values being overestimated by ca. the best correlations for edv, esv and ef were obtained in patients with dcm. hypokinetic wall areas were detected with a sensitivity of . % ( / ), hyperkinetic regions with . % sensitivity ( / ). conclusion: multislice-cardiac-ct provides precise evaluation of functional parameters such as ejection fraction, wall thickening or endiastolic and endsystolic volume. to evaluate left ventricular volumes and systolic function using multirowdetector spiral computed tomography (mdct) with retrospective ecg gated biphasic data reconstruction in comparison to left ventriculography (lvg). methods and materials: patients underwent routine mdct coronary angiography using retrospective ecg-gating. dedicated algorithms allowed for a temporal resolution of ms. contrast enhancement was provided by administration of ml of iopromid. to assess lv volumes and systolic cardiac function biphasic reconstruction at end-diastole (ed) and end-systole (es) was performed. data reconstruction timing was based on the ecg trace with placing the ed window at − ms before the r-wave and the es window to cover the t-wave. short axis views were reconstructed from ed and es data sets and the simpson rule used for calculation of ed volumes (edv), es volumes (esv), stroke volumes (sv) and ejection fractions (ef). data were compared to results of lvg. results: edv (r = . ) and sv (r = . ) showed good correlation with lvg, whereas esv (r = . ) and ef (r = . ) showed very good correlation. mdct significantly overestimated edv (md: ± ml; p = . ) and esv (md: ± ml; p < . ) whereas sv (md: − ± ml; p = . ) and ef (md: − ± %; p < . ) were significantly underestimated. mdct intraobserver variability ranged between % and %. conclusion: ecg orientated biphasic reconstruction of coronary mdct data sets allow for estimation of lv volumes and systolic function without the need for additional scanning. however, with current possible temporal resolution cardiac volumes are consistently higher in mdct and therefore sv and ef are underestimated in comparison to ventriculography. r. rienmüller, g. reiter, u. reiter, n. gagarina, a. ryabikin, b. schröttner; graz/at purpose: comparison of left ventricular volumes and muscle mass studied by electron beam tomography (ebt) and magnetic resonance (mr) evaluated by a geometry-based model as well as d methods in patients with suspected or known coronary heart disease. materials and methods: patients were studied by ebt (ecg gated, multislice mode, ms exposure time, intravenous contrast agent application) in long axis view and by mri ( . t field strength, mt/m gradients, cine-truefisp) in chamber view. enddiastolic (edv) and endsystolic (esv) volumes as well as left ventricular muscle masses (lvmm) were evaluated by a single-plane ellipsoid model. in addition mri short axis scans were performed in patients to use simpson rule (argus software) to determine the above parameters. results: correlation between ebt and mri ellipsoid model is r = . ( %-confidence interval is . to . ) for edv, r = . ( . to . ) for esv and r = . ( . to . ) for lvmm. correlation between ebt and mri simpson approach is r = . ( . to . ) for edv, r = . ( . to . ) for esv and r = . ( . to . ) for lvmm, respectively. relative standard deviations of the differences of single paired measurements varied in the range of % to %. conclusion: both ebt and mr methods may be used to determine left ventricular volumes and mass. the differences of standard deviations implicate the need to determine ranges of normal values for all evaluation approaches in clinical routine. background: several tumor-host biological factors seem to be valuable predictors for the prognosis of patients with squamous cell carcinoma (scc) of the head and neck, such as the peritumoral lymphocytic infiltration (pli) or a sharp tumor border. in particular, significant associations have been reported between the presence of pli and the absence of cervical adenopathy. preoperative biopsy specimens are often insufficient for an evaluation of these criteria. therefore, this study was performed to examine whether an elevation of peritumoral ct-values correlates with the presence of pli. moreover, correlations with present cervical adenopathy were obtained to check whether an elevation of peritumoral ct-values can be regarded valuable in predicting a prognosis. methods: in total, patients with primarily resected scc were involved (pt = , pt = , pt = , pt = ); patients were pn-positive. all tumors were histopathologically analyzed regarding the presence of pli and a sharp or infiltrating tumor border. based on standardized ct examinations, repeated roi-based density measurements were obtained in vital parts of the tumor boundary. statistics were performed to find dependencies between pli, pattern of tumor invasion, cervical adenopathy, t classification, and ct densities. results: our results show that an elevated peritumoral ct-density is a highly specific and sensitive sign for the presence of pli. moreover, there were significant statistical correlations of present pli and elevated peritumoral ct-values with absent regional lymph node metastases. our results show that the evaluation of peritumoral ct-values appears to be a valuable prognostic co-factor, useful in the majority of patients (especially in patients without clinically detectable cervical metastases). clinical trial of the accuracy of a freehand and sensorless three-dimensional power doppler ultrasound system measuring the diameters, volumes and vascularity of malignant primaries of the neck m. keberle, m. jenett, d. hahn; würzburg/de purpose: the diameters, volumes, and vascularity of malignant primaries of the neck have substantial impact on staging and prognosis. the purpose of this study was to determine the accuracy of a novel freehand and sensorless three-dimensional power doppler ultrasound ( d pdus)technique in the assessment of these parameters. saturday method: patients with squamous cell carcinomas of the neck underwent conventional ultrasound in b-and power doppler-mode (us), d pdus, and computed tomography (ct). diameters (sagittal, longitudinal, and transverse) and volumes of the tumors were correlated with hand-segmentated ct images, and tumor vascularity with us. results: d pdus and ct were highly correlated regarding diameters and volumes (correlation coefficients r = . /p < . and r = . /p < . , respectively). d pdus and us highly correlated regarding vascularity (r = . /p < . ). conclusion: although d pdus is based on a freehand and sensorless data acquisition, it appears to be as accurate as ct or us for measurements of diameters, volumes, and vascularity of neck malignancies. in spite of the excellent results it has to be noted that this technique requires a lot of training and its general use has to be employed with caution. prognostic significance of the revised tnm staging in patients with locally advanced nasopharyngeal carcinoma (ncp) a. kalogera-fountzila, c. kouskouras, n. fotiadis, e. vakali, g. sevas, c. christoforidis, l. papadopoulou, a.s. dimitriadis; thessaloniki/gr purpose: to evaluate the prognostic significance of specific anatomical structure involvement related to the revised tnm staging ( ) in patients with locally advanced npc. materials and methods: ct images of patients, who were treated in our hospital with radiation or chemotherapy and radiation, were retrospectively reviewed. we analyzed, the ct scans performed prior and after the completion of treatment. results: there were men and women (median age a). histology was undifferentiated carcinoma in patients and scc in . the paranasopharyngeal space was found to be involved very commonly ( %). degree (d ) of paranasopharyngeal extension included % of the patients, d %, and d %. the incidence of osteolysis was % (clivus %, foramen rotundum %). cavernous sinus involvement was present in % and carotid sheath in %. retropharyngeal nodes were found in % of the patients. t b ( %) and t ( %) as well as n ( %) and n ( %) were more frequent. after the completion of treatment patients demonstrated complete response. after a median follow up of months complete responders have relapsed. median time to progression for all patients was months and the median survival months. cox univariate analysis revealed, age, t , t , paranasopharyngeal extension and cavernous sinus involvement, as significant prognostic factors for survival. the revision of tnm staging, in our study, was useful in the prognosis of npc. the degree of extension of the tumor into the paranasopharyngeal space has to be considered in future tnm staging revisions. the prognostic value of mri in nasopharyngeal carcinoma s.s.a. lingawi, y.f. ragab, m. mansour; jeddah/sa purpose: to evaluate the role of mri in the prediction of nasopharyngeal carcinoma (npc) response to radiotherapy. material and methods: npc patients had mri before and after radiotherapy to the local disease and to the nodal involvement. the mri assessed the size, site, signal intensity, enhancement pattern and extension of the regional disease in anatomical sites. radiotherapy was delivered using x-rays of - mv linac. purpose: head and neck tumors show considerable variation in perfusion pattern and biological behavior as well as response to chemoradiation. the high frequent acquisition of multislice ct data after a contrast medium bolus allows quantification of tumor perfusion. the aim of this study was to assess therapy-induced changes of tumor perfusion early after initiation of treatment. methods and materials: dynamic msct was performed in patients with histologically proven head and neck cancer before and weeks after initiation of chemoradiation. after bolus injection of ml contrast medium, two mm-sections through the largest tumor region were scanned for s (siemens somatom volume zoom). the arterial input function was derived from the largest arterial vessel in the field of view. perfusion values were calculated using graphical analysis and displayed as parametric color coded images. standardized circular regions of interest were drawn on the area displaying highest perfusion. the tumor area was determined by the product of the maximum perpendicular diameters. results: at baseline, all tumor lesions were visible in parametric images by enhanced perfusion values ( . ml/min/ml ± . ), however the perfusion pattern was very inhomogeneous. the tumor area was mm ± . three weeks after initiation of chemoradiation, tumor perfusion increased to . ml/min/ml ± . , whereas tumor area decreased to mm ± . there was no correlation between perfusion and tumor size changes (r = . ). these results indicate that chemoradiation induces significant changes of tumor perfusion. standardized assessment is possible by perfusion msct. evaluation of radiation response with dynamic gadolinium-enhanced mri for head and neck cancer: correlation of hemodynamic changes with pathology n. tomura, k. omachi, k. kato, s. takahashi, i. sakuma, k. sato, j. watarai, m. sageshima; akita/jp purpose: to assess the diagnostic value of dynamic gadolinium-enhanced mr imaging in the evaluation of response to radiation therapy for head and neck cancer, and to correlate hemodynamic changes after radiation therapy with pathology. methods and materials: mr imaging was prospectively performed before and after radiation therapy in patients with various head and neck cancers. a dynamic gd-enhanced study was performed using a fast spgr sequence. the maximum slope of increase (msi) on the time-intensity curve was displayed as a colorcoded image. ratios were obtained for peak time of enhancement (tpr) and intensity of maximum enhancement (mer), as well as the msi (msir) between the a c d e f tumor and normal muscles. tpr, mer, and msir after therapy were compared with those before therapy. pathologic specimens after radiation therapy were acquired in patients. histological grading of radiation changes was divided into grades i -iv. tpr, mer, and msir after therapy were compared with histological grades. results: a significant difference (p < . ) was observed in msir before and after therapy. although only of patients with grade ii (viable tumor cells present) or iii (only non-viable tumor cells) showed a msir < . , all patients with grade iv (no tumor cells) showed a msir < . . conclusion: msi quantitatively reflects the treatment response of radiation therapy for head and neck cancer. color-coded msi display is feasible for depicting hemodynamic changes following radiation therapy. scintigraphic prediction of resistance to radiation and chemotherapy in patients with head and neck tumors k. sato, n. tomura, o. watanabe, k. sasaki, j. watarai; akita/jp purpose: tc-sestamibi (mibi) spect was compared with tlcl spect for prediction of multidrug resistance and radioresistance in patients with head and neck tumors. materials and methods: eighteen patients (age range: - a, mean a) with tumors in the head and neck region (larynx in , oropharynx in , hypopharynx in , oral cavity in , maxillary sinus in ) were evaluated with dual-isotope spect imaging using tc-mibi ( mbq) and tlcl ( mbq) at (early) and (delayed) minutes after the injection. quantitatively, tumor-to-background (t/b) ratio of tracer uptake was calculated in the early and delayed phases of each tracer, and retention index was calculated as follows: [(delayed ratio − early ratio)/early ratio] × (%). using radiation and chemotherapy concurrently, the patients were classified into partial remission (pr) and no change (nc) groups. the relationship between therapeutic response and tracer uptake was analyzed. the detectability of resistance to radiation and chemotherapy was examined. results: the delayed ratio for tc-mibi in the nc group was significantly lower (p < . ) than that in the pr group. there was no significant correlation between t/b ratio and tumor response using tlcl. there were no significant differences in the early ratio and the retention index with respect to the tumor response in both tlcl and tc-mibi spect images. conclusion: tc-mibi spect may be more effective than tl spect for prediction of multidrug resistance and radioresistance in patients with head and neck tumors. purpose: to evaluate the need for doubling the effective mas in obese patients when performing low dose multi-row detector ct (ldmrdct) for the assessment of ureteric lithiasis. materials and methods: consecutive patients with known body mass index (bmi), and clinical suspicion of renal colic were referred for a ldmrdct with the volume zoom (siemens) and kv, mas, × . mm collimation, . s/rotation, pitch of . . a second acquisition limited to the region with artefacts, using the same parameters but mas, was obtained if necessary. slice thickness and increment were of and mm respectively. workstation based assessments of ureteric lithiasis were later performed by radiologists who were unaware of the final results, and compared all clinical, surgical and radiological results available. effective dose was computer simulated and correlated with bmi. results: intra and interobserver agreements were greater than . . the prevalence of ureteric lithiasis was % and the accuracy of ldmrdct ranged from to %. effective doses for males and females were . and . msv respectively at mas and . and . msv respectively in patients with focused acquisitions at mas. a bmi of was found to be a threshold over which all patients needed mas. conclusions: ldmrdct with mas in patients with normal weight and with mas in those with bmi greater than is an accurate method for assessment of ureteric lithiasis, resulting in a dose similar to a film ivu. mdct was used with × . mm collimation, mas, and kv (ctdi = . mgy). we compared reconstruction protocols (slicewidth/reconstruction interval: . / . mm, / . mm, / . mm). in addition, multiplanar reconstructions (mpr) in coronal plane were performed. experienced readers analyzed each scan. presence, number, size of calculi and additional findings not associated with urinary stone disease were evaluated. results: mdct was positive for calculi in cases independent of axial reconstruction protocols. coronal mpr's were helpful in evaluation of the precise stone location, although on mm mpr's significantly less calculi were depicted. there was also no significant difference between performed protocols in evaluation of additional findings. conclusion: axial reconstruction protocols ( . / . mm, / . mm, / . mm) are equally suited in the diagnosis of urinary stone disease. coronal mpr's are helpful in the evaluation of precise stone location, however very small calculi may be missed on mm coronal reconstructions. purpose: this study investigates the possibility of using combined blood oxygen level dependent (bold) imaging and diffusion weighted imaging to detect pathological changes in renal tissue induced by chronic renal hyper-filtration. the apparent diffusion coefficient (adc) and the t *value within the four inner compartments of the kidneys of rats with diabetes mellitus were compared with the results obtained from a control group of rats. furthermore, the influence of the hyper-filtration on the blood-oxygen saturation was evaluated by comparing the t *-values before and after the active tubular transport was reduced by injecting furosemide. results: all compartments of the diabetic kidney showed significantly (p < . ) lower t *-values compared to the control group. in particular, the very low values in the outer stripe of the outer medulla (t *-normal: . ± . ms; t *-diabetic: . ± . ms) indicated either hypoxia due to hyper-filtration or renal blood volume changes. diffusion imaging of the same area showed significantly lower adc values (adc-normal: . ± . ; adc-oedema: . ± . [ - m /s]) that correlated with pathological findings on biopsy. conclusions: bold-contrast imaging appears to be able to depict tissue that is at risk of suffering from ischemia by revealing information about the balance between tubular workload and delivery of oxygen and may thus reflect a measure of the reserve capacity. the diffusion measurements reveal complimentary information -adc imaging is not sensitive to the current energy metabolism but reflects the pathological changes within the tissue. therefore adc-measurement might be a sensitive indicator of the severity of the induced ischemic lesions. virtual endoscopy of moderate or non dilated renal pelvis and calices with unenhanced d t -weighted static fluid mr urography: a prospective study c. roy, c. vasilescu sr., l. solair sr., c. tuchmann sr., c. saussine sr., d. jacqmin sr.; strasbourg/fr purpose: to assess the accuracy and usefulness of virtual endoscopy (ve) by mr to study moderate dilated renal cavities. method/materials: patients, having excretory tumours (n = ), calculi (n = ), and extrinsic compressions (n = ) underwent mru ( t philips) using t d tse (tr/ete: / ms, etl: , slices, slice thickness: . mm, × , fov: , ta: min s. ve were reconstructed using volume rendering and were interpreted (mip reconstructions, sources images) by two radiologists. correlation was made with conventional endoscopy/pathological findings. results: mean operator time was min. endoluminal masses (up to mm) were depicted by source images and ve, but missed by mip in cases ( tumours, stones). morphologic assessment (smooth or irregular surface, position, number, surface extension) was more pertinent on ve than on sources images. blood clots ( cases) were misdiagnosed as tumoural polyps. a smooth surface with abrupt margins was present for all stones and in cases of tumoural process. an irregular surface was only present in tumoural processes. ve images did not allow evidence of intramural extension of the tumour. assessment of surface alone did not allow to differentiate between a calculus from a smooth polyp. conclusions: ve is easily feasible in moderate or non dilated renal cavities. it permits precise location and number of filling defects with delineation of the surface extension. it is not really time consuming and it seems to be a promising modality for optimal visualization of pelvo-caliceal pathology. in patients the process progressed to abscess formation. retracted cortical scars in patients reflected the healing phase. the ivu was normal in of patients with early lesions showing minimal delay of contrast excretion in the collecting system in patients. conclusions: early cortico-medullary and nephrographic phase spiral cts are highly sensitive in detection of compromised parenchyma in the pyramids indicating papillary necrosis and thereby allow treatment at a time when the disease process is still reversible. methods/materials: we minimize patient dose by adapting the tube current to anatomy in two ways: a local projection angle dependent tube current modulation that minimizes the current for projections of low attenuation is combined with a global tube current control that adapts the tube current ° mean level to the anatomic level. our method uses the projections currently scanned to "foresee" the behavior while scanning the next ° segment. based on user-defined image quality parameters (selected by choosing the desired reconstruction kernel and the image noise standard deviation in hu) the tube current curve is computed. the approach has been tested in simulations and phantom measurements on a somatom volume zoom scanner (siemens, forchheim, germany). to further reduce the projection noise we have implemented a raw data-based maf approach. it locally smoothes the projection values of highest attenuation. maf is utilized as a preprocessing step during image reconstruction; the algorithms are implemented on the syngo explorer workstation (vamp, moehrendorf, germany). results: maf reduces image noise by up to % and thereby allows for respective dose reduction. the combination of aec and maf allows to secure this reduction and to increase it further. conclusions/discussion: the combination of aec and maf allows to greatly reduce patient dose for a given image quality over complete anatomical ranges. the user simply specifies the desired image quality instead of setting the "mas-value" or other parameters. spiral imaging properties of a -slice ct-system t.g. flohr, k. stierstorfer, h. bruder, j. simon, s. schaller; forchheim/de purpose: the spiral imaging properties of a newly introduced -slice ct system (siemens, forchheim, germany) are evaluated. the -slice ct system provides a novel image reconstruction technique for multislice spiral ct (adaptive multiple plane reconstruction ampr) which takes into account the cone-angle of the measurement rays and allows for a free selection of the spiral pitch. for a given collimation (e.g. × . mm), a variety of different spiral slice widths is available. we measured spiral slice sensitivity profiles, image noise in a centered cm water phantom and dose (ctdi ) as a function of the spiral pitch in the range to . in our definition, the spiral pitch is the purpose: aim of our study was to establish a complete analytical description of noise and resolution in x-ray computed tomography (ct) and to predict trends for patient dose with respect to future developements in ct technology. we performed various simulations to validate the analytical predictions of pixel noise dependency on sampling distance in parallel beam geometry and the convolution filter. further, we measured image noise and high contrast resolution on a clinical ct scanner (siemens somatom volume zoom), thereby operating with all available scan modes. data sets were reconstructed with several convolution filters. results: noise variance at the center of a typical cm water phantom varies with the inverse third power of the sampling distance. the tests with measured data showed that the convolution filter influences noise and resolution directly with variance depending linearly on the total area under the squared modulation transfer function (mtf). based on the measurements we were able to derive noise equivalent quanta for the ct scanner under examination. conclusion: due to the interdependence of noise and resolution, which is an intrinsic property of tomographic reconstruction from projections, it can be predicted that the dose necessary for constant noise level and unchanged object size will increase by a factor of x / when the resolution element is reduced by /x. this has direct implications for future ct systems that employ flat panel detectors with sampling distances down to . mm, thereby yielding a tenfold improved resolution compared to today's high-end ct scanners. method and materials: patients with head and neck tumours were scanned using a multislice ct scanner (somatom volume zoom, siemens medical solutions, germany) with a high resolution protocol. reconstruction was performed using dedicated reconstruction software (impactir, vamp gmbh, germany) with the standard algorithm and the maf approach. we measured the noise for anatomical regions at the level of the humeral heads. image quality, image noise and the diagnostic value comparing the standard reconstructions to the multidimensional adaptively filtered images was rated. results: the use of maf significantly improves image quality by reducing noise levels and by removing noise structures in the images. noise is reduced by % on average, depending on the patient shape and the anatomical regions. the overall image quality is rated significantly better with maf in comparison to the standard reconstruction without any loss of image sharpness. especially the visualization of the cervicothoracic junction is drastically improved for all examinations, whereas the image quality of the upper neck is unchanged. the differentiation of anatomical and patholocical structures is enhanced in particular in the upper mediastinum and in the supraclavicular regions. the reduction of image noise, the improvement of image quality and the high diagnostic accuracy achieved with maf without any loss of image sharpness offers new perspectives to reduce patient dose. the reduction in patient exposure and image quality and noise were evaluated. to assess the noise, the standard deviation of the density of the trachea and the aorta were used. for the image quality a three point scale: worse -equivalentbetter. the mean dose reduction in the modulated scans was about % (p < . ). in the area of the shoulder it was about %, of the thorax and abdomen about % and of the pelvis about %. the noise of the images in the modulated scans was between % (p = . ) at the level of the trachea bifurcation and % (p = . ) at the level of the aorta bifurcation higher compared to the standard scans. with attenuation-based on-line modulation of tube current in cases the diagnostic image quality was assessed as equivalent to the images using the standard protocoll. in cases the image quality was worse. the use of attenuation-based online modulation of tube current allows a substantial dose reduction without a diagnostic relevant decrease in image quality. characterizing coronary artery motion using multi-slice ct m. vembar , d.j. heuscher , d.e. smith , d.d. matthews , s. chandra , m. garcia ; highland heights, oh/us, cleveland, oh/us purpose: d motion of proximal regions of the coronary arteries during the cardiac cycle were measured from image data obtained from multi-slice computed tomography to identify cardiac phases for optimal coronary imaging and to provide a realistic model for cardiac simulation. methods and materials: spiral ecg-gated contrast-enhanced mm retrospectively reconstructed scans were performed on patients with heart rates ranging from to bpm using four-slice ct (marconi mx ) at a temporal resolution of ms. using landmarks along the proximal regions of the coronary arteries (left main and anterior descending (lm and lad), right coronary artery (rca) and left circumflex (lcx)), we obtained estimates of d position and velocity of these arteries during a cardiac cycle. identifying phases with minimum velocity, we correlated the image quality in these regions with the estimates obtained. results: motion characteristics varied depending on the artery, with the highest degree of motion being observed for rca. the points at which the lowest velocities occurred correlated well with the images in which the arteries could be best viewed. though more than one minimum was observed within a heart cycle for all arteries, the most consistent image quality was observed at - % of the cardiac cycle. we were able to estimate the d motion of the three major coronary arteries. by identifying the phase in the cardiac cycle with lowest velocity, imaging of each coronary artery can be optimized. using these estimates in characterizing cardiac motion also provides realistic simulation models for future cardiac ct applications. and t -weighted (haste) sequences in coronal ( mm) and axial ( mm) plane, followed by a coronal gadolinium-enhanced-acquisition with fat saturation (flash d in accordance to the recist criteria for evaluation of tumor response, target lesions were analyzed. t weighted, native and dynamic enhanced t mri were acquired. shape and character were described. size was taken as the clinical gold-standard for response criteria progression, stable disease or regress. groups of patients were compared: response (n = ); stable (n = ); progression (n = ). signal-to-noise (snr) measurements in t and t were obtained and correlated with size. results: preliminary results show that sti- changes morphological characters of the target lesions dramatically. in the response group decreasing lesions correlate with snr in dynamic t mri (r = . ; p < . ) but not in t (r = − . ). in the progression group mri shows no significant correlation between size and dynamic t (r = . ) but in t images (r = . ; p < . ). these findings are concordant to the morphological change from solid to cystic or necrotic lesions. the information of mri in the early follow-up is helpful to individualise the management of patients in a timely way and to keep patients with increasing, but morphologic-changing tumor leasions in the study protocol. saturday material and methods: a prospective, randomized and double-blind trial was conducted in patients randomly distributed into groups: the control group (received only an oral solution) and a treated group (received the oral solution plus a subcutaneous injection of mg of butylscopolamine minutes before the mr examination). breath hold t w gre images were obtained. quantitative image analysis was performed of the signal intensity of the liver and in background air anterior and lateral to the patient. a qualitative analysis of the subjective image quality was also done, and the adverse reactions were registered. results: the groups were homogeneous regarding age, sex and weight distribution. no significant differences in the signal intensity of the liver and in the incoherent noise measurements were found between both groups. gastrointestinal noise was statistically lower for the butylscopolamine group compared to the control group. there was also a statistical difference in the image quality between groups: optimal studies were only found in the butylscopolamine group. regading adverse events, there was non-significant differences between groups. to define the spiral ct findings in patients with superior mesenteric vein (smv) thrombosis and to compare these with surgical findings. material and method: abdominal ct examination of patients with partial or total smv thrombosis were retrospectively reviewed by two radiologists. the level of the thrombus, patency of portal vein and intestinal findings were noted. these findings compared with the surgical findings in patients who were operated following smv thrombosis. results: in of the patients ( . %) there was complete thrombosis of smv and patients ( . %) thrombus was partial and non-occlusive. in one patient with complete smv thrombosis, air was observed within smv and portal vein. portal vein was totally thrombosed in patients ( . %), partially thrombosed in patients ( . %) and patent in patients ( . %). all patients with complete thrombosis smv were operated and smv thrombosis was confirmed in these patients. small bowel resection was performed in patients and sigmoid colon resection was performed in patient. ischemic changes in small bowel could be detected preoperatively in of the patients who had small bowel resection. colonic wall thickening was observed in patients including the patient with sigmoid resection. colonic ischemia was not confirmed by surgical findings in other patients. conclusion: spiral ct can reliably demonstrate the presence, level and extent of the smv thrombus. spiral ct can also detect ischemic changes in the intestine and especially small bowel findings correlate well with the surgical findings. to determine whether ultrasound-guided delineation of the tumour bed after breast conserving surgery can improve the accuracy of conventional electron boost planning. methods and materials: patients underwent post-operative radiotherapy plus electron boost following wide local excision for breast cancer, were selected at random. conventional boost planning was undertaken using clinical examination, surgical details and pre-operative imaging, and a standard boost field recorded. next ultrasound was used to delineate the tumour bed and an optimum boost field calculated using parameters including cavity size measured by ultrasound, mm margin and mm error margin. the standard and optimum fields were compared and potential areas of under and over-treatment of the standard field calculated. clinically acceptable values for these were set at % of optimum boost area for under-treatment and % of optimum area for over-treatment. the dmni visualisation and sampling management include galactography (ggr), mr and ultrasound ggr, fiber-ductendoscopy to investigate patients with intraductal abnormality. using ductal lavage (dl) and saline retrieval we tested material collected from breast ducts cells by methylationspecific pcr (msp) methylated alleles of cyclin d , rar-, and twist genes detected in fluid from mammary ducts or endoscopically visualized dcis. northern blot analysis was performed for expression in epithelial cells. results: we were successful in intraductal cannulation, endoscopies and molecular testing, resulting in % diagnostic accuracy. high-risk subjects were enrolled in two groups of a previous history of breast cancer and, a gail index score m . or brca /brca positive status. of eligible subjects suspicious/malignant cells were detected in % ( / ). a comprehensive database created from imaging, interventions and molecular study protocols explored current pathology management. mr, ultrasonography dgr, and ductoscopy revealed papillomas but no high-grade intraductal lesions correlated with the lavage cytology. immunohistochemistry, histology grading, and the relevance of diagnostic certainty were considered. the dmni is feasible for early breast cancer conservation and prevention. evaluation of cellular samples for tumour biology and molecular imaging are the strongest predictors of the outcome. diagnosis, risk assessment, and prognosis emphasise the indicators for breast dcis, dmni and for survival rates. preoperative assessment of axillary lymph node involvement in breast cancer by ultrasound r. wenke, l. sanders, a. grosse, i. schreer; kiel/de purpose: to assess the sensitivity of ultrasonographic axillary lymph node detection and accuracy of different sonographic signs of malignancy in correlation with histopathological examination. material and methods: we examined patients with preoperative histologically proven breast cancer. in patients conventional axillary dissection was performed, patients underwent excision of sentinel lymph node (s). clinical examination was performed independently. sonographic criteria included lymph node size, form, shape, presence or absence of hilar reflex, echogeneity, cortical rim thickening and vascularisation. results: ultrasonography detected - lymph nodes (mean . ) were detected in level and - (mean . ) in level . histologically - (mean . ) were detected in level and - (mean . ) in level . in patients ( . %) axillary lymph node metastasis was detected histopathologically. sonographically suspicious lymph nodes were inferred in / ( . %) patients. in cases ( %) lymph node metastasis was missed, including one case of micrometastasis. clinical examination revealed only / ( %) axillary metastases. sensitivity of ultrasonography was therefore %, specificity . %, positive predictive value . % and negative predictive value . %. a satisfying prediction of axillary lymph node involvement can be achieved by means of ultrasonography. the lack of detection of micrometastases and of lymph nodes smaller than mm is still a problem. the false positive rate ( ) could possibly be decreased by an optimised combination of morphologic aspects. with a negative predictive value of . % ultrasonography can be a powerful tool in pre-selection for sln biopsy and the necessary follow-up of these patients. . g needle with appendant coil was used. after the procedure the distance from the coil artefact to the lesion was measured in two planes (sagittal, transverse). all lesions have been histologically proven by excisional biopsy to hours after the mr-guided localisation. results: localisation and excision of the lesion was successful in all cases. each mr-guided procedure lasted - minutes (mean min). % ( / ) of the lesions were malignant. in most cases ( %, / ) the coil was placed immediately adjacent to the lesion. the coil was placed up to mm and - mm (mean distance . mm, range - , sd . ) away from the lesion in % ( / ) and % ( / ) of cases respectively. conclusion: mr-guided localisation of only mr-detectable breast lesions with an embolisation coil system is easy to perform and results in a high precision. the coils are hocked into the tissue and detectable by specimen x-ray. the aim of our study was to investigate the feasibility and potential of cryosurgery in the therapy of breast cancer. materials and methods: patients ( . ± . a) with histologically proven breast cancers underwent cryotherapy. after ultrasound-guided placement of the cryo probe in the tumour, two freeze/thaw cycles with a duration of and minutes respectively were carried out. the diameters of the occurring iceballs were measured sonographically. the patients were operated within to days later. the operation specimens were evaluated histologically. the maximum diameters of the iceballs were between and . mm. the surface of the iceballs was well definable in ultrasound. tumours with a diameter below mm and one tumour with a diameter of mm did not show rests of invasive cancer after treatment. of them had dcis in the surroundings. subtotal necrosis was observed in tumours which had a diameter of mm or greater. conclusion: after these first cases cryotherapy seems to be promising in the treatment of small breast cancers. the low detection rate of surrounding dciscomponents in pre-interventional mri of breast cancer results in remaining dcis after cryotherapy. in larger breast cancers two or more cryo probes should be used to achieve larger iceballs. purpose: to examine the effectiveness of a potential minimal-invasive method for the elimination of breast tumours by magnetic heating. methods: a human adenocarcinoma (mx- cells) was implanted into scid mice. after intratumoral application of iron oxides ( ± mg per mm tumour tissue; average particle diameter: nm), mice were exposed to an ac magnetic field ( min; amplitude: . ka/m, frequency: khz). controls did not receive an iron oxide application. temperatures at the tumour and rectum were monitored and quantified as total heat doses (thd = temperature × time). dna damages were investigated using the comet assay (percentage of dna in the tail). a calibration curve between temperature and dna damage was determined. results: intratumoural temperatures ranged from °c to °c (thd from to °c × min), the percentage of the total cellular dna in the tail was of ± %. in controls, no significant temperature elevation was observed and only ± % of the dna was found in the comets tail. in vivo and in vitro experiments showed a temperature threshold for cell destruction of °c. conclusions: reliable tumour cell destruction is possible by magnetic heating. methods and materials: mr images of the eurospin-to phantom were obtained using standard d se, d tse, d-spoiled gre and d mpr sequence types and evaluation of spatial and high contrast resolution was performed. all images were transferred to a standard pc workstation utilizing a dicom protocol. these images were then converted to the four most commonly used image file formats on the web: tiff, jpeg, gif and png. a total number of images using different file formats and compression ratios were evaluated. image quality a c d e f (iq) was evaluated by consensus by three reviewers utilizing a point grading scale ( : poor, : moderate, : good, : very good, : excellent). image size to image quality ratio's (is/iq) were also calculated for all images. results: minimal is/iq was obtained when working with low compression ( - %) jpeg images and moderate to high compression ( - %)png images. high compression jpeg images showed severe image distortion while maintaining acceptable spatial resolution. this problem was not encountered in png images. is/iq was quite satisfactory on gif images. tiff images were of excellent quality but with larger image sizes. the optimum compression levels were tested on routine brain and abdominal mr examinations with results comparable to phantom measurements. conclusion: the study determined the acceptable compression levels for jpeg and png mri images used for educational purposes on the web. the newly introduced png format offers high image quality with acceptable file sizes. • checking about homepages of international radiological institutes, • inquiries to eufora -a popular mailing list, • asking about medical students and residents in radiology. the favorite on-line teaching programs in radiology were evaluated by representatives of the target group - students and residents in radiologyaccording to user friendliness, didactic, interactivity, content and layout. results: we created an on-line list (radlist) of categorized and evaluated on-line teaching files in radiology, ranked according to user friendliness, didactic, interactivity, content and layout. conclusion: radlist (http://www.radlist.uni-erlangen.de/) is a useful on-line tool for students and residents in radiology to find their way within thousands of internet teaching files in radiology. radlist will be updated regularly. open connectivity and interoperability of web based medical teaching file servers using xml-based web services t. schaaf, j. hohmann, k.-j. wolf; berlin/de purpose: support of automated access to dynamic webbased medical teachingfile-servers. the connectivity and system interaction should be realized with the help of consistent methods based on common standardized concepts and protocols. methods and materials: by using soap (simple object access protocol) as the fundamental information exchange protocol in cross-language and cross-platform communication, the herewith provided webservices offers a consistent application interface to dynamic generated data of our medical teaching-file-server. soap is an standardized (http://www.w .org/tr/soap) and xml-based (extensible markup language; http://www.xml.org) protocol consisting a framework for describing the exchanged messages and their processing, rules for expressing instances of application-defined datatypes and definitions for representing remote procedure calls and remote responses. we have extend our multimedia teachingfile-server, built with no-cost common software components, with an php-based (php: hypertext preprocessor; http://www.php.net) soap-adaptor and could thereby offer the dynamic medical teaching-knowledge encapsulated in a medical webservice. since soap could be combined with existent common transport protocols such as http (hyper text transfer protocol), our webservice is seamless internet accessible. results: the php-based soap-adaptor handles the application-driven xml-defined messages addressing the server-stored procedures for accessing the medical teaching-file-data via the inter-/intranet. thus this application interface addresses the same database functions used by the beside existent human-computer-interface, our webservice provides the same programmed security issues. conclusion: the soap-ready extension of our multimedia dynamic webbased medical teaching-file-server supports the application layer interoperability through a consistent xml-based interface. thereby the provided medical knowledge could be easily accessed and integrated in decentralized, webbased knowledge-and workflow application frameworks in healthcare environments. building up a teaching system out of the radiological workflow a. schroeter , , k. annacker , , t. geisbe , m. kroll , , j. martin , j. holstein , d.h.w. groenemeyer , h.g. lipinski ; bochum/de, dortmund/de purpose: the aim is the development of a radiological teaching system, whose contents of the learning contexts are inferred directly from the radiological work routine. this system pulls dicom images, dicom presentation states and findings out of the ris and pacs to transfer them to an html learning text whitin an embedded dicom viewer. methods and materials: a radiologist will select a few images and send them to the teaching system together with the finding and presentation states. a learning text will then be extracted out of the finding. this text will be converted to an html page with an embedded java-based dicom viewer to visualize the medical images. within the html text, buttons will provide a context-referred view of the images via dicom presentation states. so all that radilogists will have to do, is to perhaps correct some text phrases or the layout. results: the result is a teaching system with its contents pulled out of the normal radiological workflow making it possible to transfer dicom images, presentation states and findings to interactive learning texts. dicom images can be freely manipulated and presentation states can be applied to achieve a context-referred view of medical images. conclusion: the efficiency of learning can be increased by being as close as possible to the real-life diagnostics and by making the images available for free manipulation. building up a learning case is quite easy because image data and views on these images already exist. webbased knowledge transfer in a radiology department for scientific and educational purposes j. hohmann, t. schaaf, k.-j. wolf; berlin/de purpose: to implement a basic system which allows: ( ) scientific chats and interactive lectures, ( ) live broadcast of scientific events, ( ) access to teaching-files and examples in a medical image database. materials and methods: ( ) the hyperchatsuite by fh software (www.fhsoftware.net) is freeware and allows common and private chat rooms as well. ( ) for evaluation purposes of the live broadcasting the no-cost realsystem server basic (www.realnetworks.com) was installed which allows up to concurrent users the access to the delivered data stream. realsytem servers supports up to media types and different operating systems. ( ) part of the teleteaching/-learning system is an access to teaching files and the medical database (introduced on ecr ). the medical database consists of open source components (mysql, www.mysql.com; apache, www.apache.org; php, www.php.net) and is in use since last year. results: ( ) we conceptualised a lecture together with scientific groups in the usa regarding the principles of digital imaging. after performing initial testlectures this lecture will be held next term at our radiology departement. ( ) the benjamin franklin contest was availaible as our first live broadcasted videostream of about hours. ( ) due to the flexible structure of the former medical image database the added functionalities with teaching files consisting of multi-media-data were easily achieved. conclusion: since the parts of the system fullfills our expectations in first trials we now have to get more experience during next term or year to find out about the advantages and disadvantages and to yield the necessary changes. current concepts in digital conference communication in radiology m.v. knopp, h. von tengg-kobligk, f.l. giesel, p.l. choyke; bethesda, md/us purpose: clinical conference of cases as well as group conference with clinician or research partners is one of the bases of radiological interaction in academia and hospitals. while pacs and all the advances in telecommunication have changed tremendously our work, these concepts have not been embraced sufficiently in conference communication. our group based in a major academic and research institution investigated the different capabilities available such as telephone (isdn) based systems picturetel, direct satellite links and web based approaches. the different systems were assessed using objective criteria such as speed, costs, image resolution etc. and subjective criteria using a questionnaire. results: many radiologists feel at unease using digital conferencing mostly due to lack of experience. after training, it was readily used and a code of conduct was helpful for training purposes. while image quality and speed is still superior with commercial systems, innovative uses of web based applications with concurrent b- : improving the workflow with central scheduling: introducing a "rad call center" p. gocke, a.p. bruckmann, j.f. debatin; essen/de purpose: to improve the workflow in a radiological department with central scheduling, by introducing a radiological call center (rcc) method/materials: with a separate module of our ris (radiological information system) we were able to introduce a central electronic scheduling. appointment schemes were created for all work places, time table-based or list-based. one central telephone number was assigned to the newly etablished radiological call center. rules were created for scheduling, and staff were trained by a telephone and marketing coach. results: with central electronic scheduling, the task of scheduling is removed from every workplace and focused on one center with specially trained staff. this center is an efficient tool offering flexible workload balancing. information about daily workload is available for every employee. especially helpful in workflow optimization was the introduction of 'virtual work places' were patients can be scheduled for urgent investigations and directed to the next available appointment. conclusions: central scheduling by a radiological call center improves workflow and enables a department to (re)direct patient flow and balance work load. inherent advantages were optimis ation of investigation strategies and avoidance of double/unnecessary investigations. acceptance of referrers is good (only one central telephone number!), especially when offering add-ons like a radiological advice service. work flow analysis using process simulation in a routine ultrasound division c. gillessen, u.k.m. teichgräber, j. ricke; berlin/de purpose: (i) to evaluate a routine ultrasound workflow by means of project graph technique (pgt) and process simulation (ps) and identify ways to redesign and improve it. (ii) to evaluate pgt and ps for significance and feasibility in workflow management. a workflow analysis of a routine ultrasound division was performed by: . observation and definition of work steps to perform an ultrasound examination. . time measurements of activities using a software tool for parallel work step measurement. . designing a project graph. . pgt: calculation of operational measures. ps: generating operational measures by applying process simulation on network plan. . identification of reasons for delay. . process redesign and re-evaluation. results: average realistic examination time for abdominal ultrasound was min s. average simulated examination cycle time with ultrasound devices, examiners and technicians was min s. by increasing personnel, average cycle time was reduced but average personnel slack time increased. major structural work flow deficits were not identified under given circumstances. replacing paper and film work associated activities with activities as expected with an electronic archive reduced total work effort by %. major advantages of simulation over npt were the ability to consider cycle overlap and to calculate cycle times. conclusions: (i) under given circumstances, the observed work flow showed high efficiency. major effort reduction by the introduction of an electronic report and image archive is predicted. (ii) process simulation is superior to pgt in evaluating workflows and anticipation of the effect of variations. is speech recognition the best reporting method for any case? p. gocke, c. hogh, e.r. gizewski, j.f. debatin; essen/de purpose: to decide in which cases speech recognition is the best method for reporting, and in which cases other existing methods should be preferred method/materials: in our department, 'instant reporting' is performed by residents typing preliminary reports into a ris (radiological information system) based reporting module using a special ms winword environment. additionally, we have reporting stations equipped with a state-of-the-art speech recognition system (latest dragon naturally speaking professional with radiological dictionary). to compare both methods, the residents hand-stopped the time needed for generating the first, preliminary report for three different types of investigations: ct, skeleton and chest x-ray. results were discussed and tips were delivered for developing efficient auto-texts and macros. results: for ct, speech recognition was faster ( min s ± min s) than typing ( min s ± min s). for chest x-rays, there was no significant difference (speech recognition: min s ± s, typing: min s ± min s). for skeleton x-rays, typing was faster ( min s ± s) than speech recognition ( min s ± s). conclusions: in many cases, speech recognition is an adequate technique for radiological reporting, but especially in cases of short and standardizable reports an autotext-and macro-based reporting technique is faster and more convenient. long-term experience with speech recognition of more than dictations t. ybinger, w. kumpan, f. karnel; vienna/at purpose: x-ray departments are increasingly under pressure to reduce costs and save time. this paper presents the experience of many years of using speech recognition to optime our services. the kaiser-franz-josef-spital in vienna is a -bed hospital which specializes in oncology and infectious diseases. a speech recognition system for producing reports was integrated into our ris early in . since then the system has proved itself by completing more then dictations. we also investigated the efficiency increase achieved by using the system and its influence on our work processes. results: speech recognition is used to transcribe more than % of our reports. we have been able to reduce the turnaround time for our reports by % to an average of hours. despite a high number of trainee doctors, % of all reports are signed within hours. our secretaries save approximately % transcription time, and we have become more flexible in the use of typists. the average recognition rate is around %, with some doctors clearly achieving even better results. however, of even greater importance to the workflow is an optimal integration into our ris. a c d e f conclusion: speech recognition has fully established itself in our hospital and is routinely used for practically all dictated reports. this has considerably increased the productivity of our typists and clearly reduced the turnaround time of reports. we are convinced that speech recognition will soon make its entry as state-of-theart technology in numerous other institutes. when the bladder was filled of contrast-material-enhanced urine, the patient in supine position was asked to urinate. during the micturition t -weighted spoiled d-gradient-echo acquisitions on sagittal plane were performed (acq.time: s). these acquisitions were post-processed with mip algorithm. patients performed retrograde and micturating conventional cystourethrography in the month preceding mri. one patient was unable to perform the exam because of the inability to urinate in the supine position. results: we always obtained perfect evaluation of the male urethra with voiding mr-cystourethrography. the visualization of the urethra with mip reconstructed images was considered comparable to that obtained with conventional cystourethrography. the analysis of d sagittal scans allowed a better evaluation of the urethral strictures in comparison with conventional cystourethrography. we detected cases of bladder neck obstruction, cases of urethral stricture and case of benign prostatic hypertrophy conclusions: voiding mr-cystourethrography demonstrates the morphology of the bladder neck and urethra during the micturition and can a substitute for standard retrograde and micturating cystourethrogram, avoiding radiation exposure to the gonads. patients underwent combined mri and d-mr spectroscopic imaging (mrsi) of the prostate after up to (n = ) or more than (n = ) weeks of ht. pretherapeutic psa levels ( . ± . vs. . ± . ng/ml) and gleason sums ( . ± . vs. . ± . ) did not differ significantly. posttherapeutic psa was dichotomised as being up to or more than . ng/ml. ht of more than weeks was significantly associated with psa up to . ng/ml ( / vs. / patients, p = . , chi square test) and loss of citrate from the peripheral zone of the prostate ( / vs. / patients, p = . ). psa exceeding . ng/ml was associated with prevalence of citrate ( / vs. / , p = . ). citrate was detected at mrsi in patients with psa under . ng/ml, including of patients on monotherapy with lhrh agonists for more than weeks. in conclusion, this study finds an association between psa decrease and loss of citrate from the peripheral zone of the prostate in patients on ht for locally confined pca. there is a hint of dissociation of psa loss and detectable citrate in patients on longer-term lhrh agonist monotherapy that warrants more extensive analysis. longitudinal follow-up with combined mri and d-mr spectroscopic imaging of patients on hormone therapy for locally confined prostate cancer u.g. functional assessment in non radicular low back pain patients with an ultrasound-based d-topometry-system (zebris®) and radiographic motion analysis of the lumbar spine correlated with the results of a self administered health status questionaire a. petrovitch, s.o.r. pfleiderer, t.u. schreiber, w.a. kaiser; jena/de purpose: non-radicular low back pain (lbp) is a leading cause for compensation in industrialised countries with high socioeconomic impact. in the past it was mostly described by structural deficiencies, but not by disturbance of functional spinal segments or the instantaneous axis of rotation. methods: out-patients (age - a; males, females) with suspected vertebral instability were included. general health and orthopedic status was evaluated at admittance. health status was evaluated using the self-administered sf- questionnaire, which includes eight scales of functional health. a self administered pain score was evaluated using the visual pain analogue scale (vas). the motion of the lumbar spine was analysed in lateral and ap projections using radiographs and in all three main axis of rotation with the topometric motion analysis system. results: compared to norm-based population scores for europe and north america, values are reduced below one standard deviation in almost all items using the sf- -questionaire. the items body pain and physical function are decreased by two standard deviations (sd) and role physical has a score reduced by more than three sd. where heavy pain was reported, the correlation between disturbed physical and mental scores was high (r = . ; p < . ), but no correlation to radiographic spondylolisthesis could be observed. conversely, a good correlation between reduced physical score (sf- ), pain and disturbed instantaneous axis of rotation was observed in d-topometry (r = . , p < . ). conclusions: this study supports a new concept in functional assessments of non-radicular lbp using ultrasound-based d-motion analysis. spinal pm msct-studies of consecutive patients, assessed for non-radicular, multisegmental cervical and/or lumbar pain syndromes by myelography and pm ms-ct were reviewed for additional information when compared to the myelographic findings alone by two neuroradiologists. all pm msct studies had been performed on a four-slice ct scanner using the following parameters: slice thickness of mm, reconstruction increment of . mm, field-of-view (cervical)/ (lumbar) cm. subsequently data postprocessing to multi-and curviplanar reconstructions was performed. in addition, the radiation exposure was assessed by calculating the effective dose values. results: msct yielded additional diagnostic information, termed as clinically significant in % of the studies. due to the resulting voxel size of about . × . × . mm multiplanar imaging of the spinal pathology in all planes with excellent image quality was possible. typical image artefacts at the cervico-thoracic junction as well as due to metallic implants were significantly reduced. the effective dose amounted to . msv (cervical spine) and . msv (lumbar spine). conclusion: pm spinal ms-ct is a useful tool in assessing multisegmental spinal pathology in patients in whom mr imaging is either contraindicated or not compatible with the clinical findings. in terms of radiation exposure, careful restriction of the scan area to the clinically relevant segments seems to be more important than the type of helical ct, i.e. single-vs. multi-slice. results: there were five women and one men, mean age of years. a diabetes mellitus was present in half cases. mean delay between vertebral collapse and the infectious syndrome was days. staphylococcus aureus, e coli, salmonella enteritidis, were the identified pathogens. bone biopsy isolated the pathogen in two third of cases, and was the sole positive sample in one third of cases. a thoracic vertebra was involved in three cases, a lumbar one in three cases. lysis of the spongious bone associated with a soft tissue mass thicker than mm was observed in five cases. two patients died from consequences of the disease. conclusion: we want to highligh a seemingly unusual entity to avoid a radiological diagnostic pitfall. calcified cervical intervertebral disc in children -radiological findings v. jevtic; ljubljana/si purpose: to describe radiographic, ct and mri features in a relatively rare entity of unknown etiology, calcified intervertebral disc in children (cidc). material & methods: patients ( males, females, mean age years) with clinical signs of limited movements, stiff neck, torticollis and pain were radiologically investigated. the patients were imaged using radiography, functional radiographic examination, ct and mri. plain films, ct and mri were analysed in a qualitative fashion. results: radiography demonstrated a calcified nucleus pulposus which was flattened, oval or round. in patients more than one disc space was calcified. additional radiographic findings included widening or narrowing of the disc space and moderate flattening of the vertebral bodies. in cases functional abnormalities were revealed at the level of disc calcifications. ct clearly demonstrated hyperdense disc calcifications with posterior disc protrusion in cases and extrusion into the epidural space in one patient. calcifications were shown as signal void areas by mri. there were also discrete signal intensity changes of bone marrow below the endplates. conclusion: cidc may be diagnosed using plain radiography, ct or mri. the advantage of ct examination is in exact demonstration of clinically important protrusion or extrusion of the calcified nucleus pulposus. sacroiliitis in children with spondylarthropathy: use of dynamic mr imaging to detect the therapeutic efficacy of intraarticular corticosteroid injection t. fischer, b. hamm, m. bollow; berlin/de purpose: our aim was to prospectively study the therapeutic efficacy of ct-guided intraarticular corticosteroid instillation of inflamed sacroiliac joints (sijs) in children with juvenile spondylarthropathy (spa) and to evaluate the role of mri as a procedure for establishing the indication and the therapeutic follow-up. method/materials: a total of ct-guided corticosteriod injections of the sijs were performed in children with inflammatory back pain (ibp): bilateral, unilateral. forty milligrams of a crystalline longacting corticoid was instilled in each inflamed joint. all patients underwent continuous clinical follow-up at week intervals after corticosteroid injection to a maximum of months. intensity of back pain before and after the intervention was graded on an visual analogue scale from (no pain) to (very severe pain). dynamic contrast-enhanced (gd-dtpa, . mmol/kg body weight) mri with quantitative determination of contrast enhancement was performed in all patients before the intervention and ± months after therapy. results: of the study patients ( . %) showed a statistically significant abatement of subjective back pain from . ± . to . ± . (p < . ) at . ± . weeks after therapy, and this improvement lasted for ± months. the percentage contrast enhancement at dynamic mri showed a reduction from . ± . % before to . ± . % after intervention (p < . ). conclusions: dynamic mri proved to be a reliable non-invasive tool for the assessment of inflammatory activity of sacroiliitis and the response to the therapy in patients with juvenile spa. congenital lesions of the lumbar spine: ct depiction and significance d. passomenos, g. mantzikopoulos, g. giannikouris, i. staikidou, c. pikoulas, s. ispanopoulou, c. dayiada; athens/gr purpose: congenital lesions of the bony skeleton are not uncommonly detected incidentally by plain films. moreover, posterior elements due to their complex anatomy and orientation are poorly visualized on plain films. in acute trauma setting, in order to exclude a fracture, further investigation without the problems of superimposition is needed. we retrospectively evaluated the files of patients examined to our diagnostic department over a period of months. patients ranged in age from to a. most of them presented with a history of minor recent trauma or had a vague intermittent back pain. cases of spinal cord lesions in association with bone dysplasias were excluded from the study. plain films were mostly suggestive of congenital lesions but further investigation with ct to ascertain the diagnosis was requested. scans consisted of consecutive mm cuts through the questioned area of the spine. obtained scans were imaged at softtissue and bone windows. sagittal and coronal reformatted images were also obtained. we could locate a total of cases of unilateral spondylolysis, butterfly vertebra, posterior limbus vertebra, hypoplastic or absent facets associated with hypoplastic arch, spina bifida and pseudo-arthrosis of transverse process. the lesions were mostly located at l -s level. purpose: to describe characteristics on mr imaging of radiation osteitis of the pelvis in patients who had received radiation therapy for gynaecological tumours. material and methods: women (mean age: . years) with gynaecological tumours who developed radiation osteitis where examined with radiography, computed tomography and magnetic resonance imaging (mri). on a . t system we used plain t -and t -weighted sequences and contrast enhanced t -weighted a c d e f sequences with and without fat saturation. mri was performed at different distances between the end of radiation therapy and developing pain. mr images where correlated with the results of clinical examinations. results: depending on the time from radiation therapy, radiation osteitis showed different signal intensities. the acquired images suggest that signal changes in t weighted images as well as the different enhancement behaviour of radiation osteitis might be dependent on the time from radiation therapy. best visualisation of regions with even low contrast enhancement was achieved with fat-saturated sequences. computed tomography showed increased density in the affected regions corresponding to osteosclerosis. in all cases at least one iliosacral joint was affected with different topographies in sacral and iliac bone. conclusion: mri is helpful in detecting and characterizing orn and eases the demarcation from secondary manifestations of the known malignancy. changes in signal intensity, based on histopatholocical tissue changes, might make a chronological classification possible. the purpose of this on going study is to evaluate the usefulness of whole body mri in the diagnosis of the inflammatory myopathy seen in polymyositis and to assess the disease extent in affected patients. materials and methods: eight patients with laboratory, muscle biopsy and electromyographic evidence of probable or definite polymyositis were referred for imaging. an additional patient was referred for mr to identify a potential site for muscle biopsy. coronal turbo stir images were taken in each of three or four body regions (tr/te/ti; / / ms). acquisition time per region was minutes seconds, with a total scan time of approximately minutes. results: mean patient age was . years ( to years). one patient with "probable" polymyositis by conventional criteria had a normal scan. one patient with polymyositis had inflammation in a myofascial distribution in the gluteal region. two patients had florid symmetrical myopathy involving proximal upper and lower limb girdle muscles, psoas, intercostal muscles and neck flexors and extensors. in addition, mild involvement of the calf muscles was also seen. three patients had more patchy asymmetrical muscle involvement, but also demonstrated involvement of psoas, intercostal and neck muscles. conclusion: whole body mri gives a much more extensive assessment of muscle involvement in polymyositis than the conventional mr protocols used to image these conditions. extensive muscle involvement of psoas, intercostal, neck and distal limb muscle groups were diagnosed. these muscle groups are not imaged on standard sequence protocols. the posterior half of the lateral tibial plateau and the lateral half of the medial femoral condyle were statistically more frequently involved than their corresponding halves (p < . for both parameters). the bare area of the medial, but not of the lateral tibial plateau is more frequently involved than the meniscus-covered area (p < . ). the meniscuscovered area of the lateral tibial plateau was more frequently involved than that of the medial tibial plateau (p < . ). results: mri allowed a good identification of the sites of osteochondral cylinder remotion ("donor" sites) and of the treated lesion sites at the month mri. small ferromagnetic particles artifacts due to surgical instruments were often present, with limitation of diagnostic value, in particular the "gap" regions between cylinders and health tissue were not individuated. only the oldest two patients showed mild inflammatory signs (intraarticular fluid collection, synovial hypertrophy) at the and month mri. no case of donor site degeneration was seen at the and month mri. in all cases, the sites of treated lesions showed regularity of subchondral bone and the fillling-repair of donor sites at the month mri. evaluation of the chondral portion was very difficult due to artifacts. conclusions: mri allows a good evaluation of knee chondral implant healing, especially of the subchondral bone repair and seems to be a good diagnostic tool, avoiding invasive examination. results: based on the statistical analysis of the ultrasonographic measurements, diagrams and tables were created. the study of these data concluded that: • articular cartilage thickness is the same in both knees. • articular cartilage of the knee is thicker in boys. • cartilage thickness reduces with age. • the rate of diminution is higher during the first six years of age and lower after the age of six years. • there is negative linear correlation between cartilage thickness and somatometric parameters. • body height is the somatometric parameter that has the strongest correlation with articular cartilage thickness. conclusion: equations, diagrams and tables of normal articular cartilage thickness of femoral condyles in children, measured with ultrasonography, represent a precise method for cartilage growth estimation. these equations, diagrams and tables afford an objective way to compare normal articular cartilage thickness with the thickness noted in various pathologic conditions affecting articular cartilage in children. opportunities for the use of high frequency ultrasound ( - mhz) in the diagnosis of degenerative-dystrophic changes of the knee joint n. lordkipanidze, d. tatishvili, m. lortkipanidze; tbilisi/ge the purpose of study was to define diagnostic criteria for degenerative-dystrophic damage to the knee joint according to the stage of disease using high frequency ultrasound. the investigations were performed on the "siemens sonoline elegra" ultrasound system using siescape panoramic imaging with a . - mhz frequency linear transducer. a group of patients, - years of age, with complaints of knee joint pain were included in this study. patients were diagnosed as having knee joint degenerative-dystrophic changes. the early stage is characterized by a normal or decreased hyaline cartilage thickness of the femoral condyle. ultrasound studies detected increased echogenity of the cartilage surface, existence of freely floating . - . mm crystals in the joint cavity and suprapatellar synovial bursa. the same type of crystals, in addition to insignificant synovitis, were found in sportsmen and dancers who exercised vigorously. in the case of difficulties in examining the lateral patellar and medial inferiorlongitudinal surface the existence of crystals was revealed during its maximum displacement from the condyles of the femur. in severe cases, examination revealed marginal joint osteophytes, margin skipping of cartilage surface, discontinuous contour of the femoral condylar bony surface, narrowing or complete disappearance of joint space and the existence of hypertrophic synovial membrane and villi and baker's cysts. as a result, pan zoom mode is used to detect joint crystals, to study in details the structure of hyaline cartilage, fluid and to identify their minimal changes, which helps to diagnose degenerative-dystrophic changes of the knee joint. multislice spiral ct (somatom plus volume zoom, siemens, germany) examination was performed after standard oral colonoscopy preparation and colonic distension with room air. images were obtained using . mm slice collimation; . mm slice thickness; . mm reconstruction interval; . mm/s table speed; kvp, ; and mas . supine and prone acquisitions were obtained in all patients. dose exposure was calculated. images were directly reviewed on a dedicated workstation by two experienced gastrointestinal radiologists using a software with volume-rendering capabilities (vitrea . , vital images, usa). conventional colonoscopy was performed on the same day in all patients and represented the standard of reference. results: all colorectal cancers were correctly identified at ct colonography ( / , sensitivity %). ct colonography also detected of polyps (sensitivity, . %). both false-negative findings were represented by lesions smaller than mm. dose exposure (ctdi) never exceeded . mgy for each scan. conclusion: although studies on larger series are certainly needed, our preliminary experience demonstrates that ultra-low-dose scanning is a feasible and accurate option for multislice ct colonography. this technique allows to scan the patient in both supine and prone positions with a radiation exposure lower than that of a double contrast barium enema, which is of paramount importance to introduce this imaging modality in screening programs. results: of cancers diagnosed in this cohort, were detected by ct colonography. were missed in our early experience with single slice spiral ct. were flat cancers < mm thick. was a polypoid tumour hidden by residue in a poorly prepared patient. this was obvious on a repeat study with adequate preparation. one recently missed cancer was in a co-existent acute diverticulitis and was described as suspicious for malignancy only. there were false positive diagnoses of cancer. all but were cases of diverticulitis or ibd. in only cases was no lesion found at laparotomy or repeated colonoscopy. . % of patients failed to complete their preparation or did not attend for scanning. this was no different to other complex ct examinations. % of studies were sub-optimal (poor preparation, no iv access, could not lie prone etc). only patient could not be scanned. conclusion: ct colonography is remarkably robust with a sensitivity of . % and a specificity of . % for the detection of colorectal cancer. is mm collimation (effective slice width . mm) essential for multislice ct colonography? a.r. gillams, v. munikrishnan, w.r. lees; london/gb purpose: whilst the finest collimation possible with adequate signal to noise may seem desirable, fine collimation results in increased radiation dose and generates very large data sets. this increases expense, slows down analysis and d reconstruction times. we studied the impact of . , . and mm slice width on polyp detection and cancer staging. methods and materials: symptomatic patients, male, referred for ct colography ± virtual colonoscopy underwent multislice ct following standard bowel prep, bowel paralysis and rectal air insufflation. scans were performed with mm collimation, effective slice width . mm, pitch , . s rotation time following iv contrast. retrospective reconstructions were performed at . mm, mm and mm. . and . mm overlap was used for the and mm data sets respectively. scans were analysed for the presence of lesions and any cancers detected staged. all patients had colonoscopic correlation and where cancer was detected the resected specimen was also included in the analysis. results: there were cancers and polyps. finer sections aided separate detection of small nodes but this did not impact staging. overall there was no difference in cancer staging between the three data sets. there was no difference in the number of polyps detected on the . and mm data sets. small polyps were smeared out on the mm data sets. conclusion: . mm slice width appears to be adequate for multislice colography. previous studies have shown no beneficial effect of using iv glucagons as a spasmolytic for ct colonography. studies of barium enema examinations, however, have shown that buscopan may be a more potent spasmolytic in the colon compared with glucagon. the use of buscopan in ct colonography has not been tested to date. the aim of this study was to assess the effect of iv buscopan on colonic distention and polyp detection when used as a muscle relaxant in ct colonography methods: patients undergoing ct colonography were randomized to receive iv buscopan or no muscle relaxant prior to air insufflation and scanning. patients were scanned in both supine and prone positions using a multislice helical ct acquisition. for the purposes of reporting, the colon was subdivided into different segments, yielding a total of colonic segments per patient. the degree of luminal distention of each segment was scored on a scale from to . the accuracy of ct colonography for polyp detection was based on findings at subsequent conventional colonoscopy. results: there was no significant difference in the degree of colonic distention achieved between the group receiving iv buscopan and those who did not. the addition of prone scanning was found to be the single most important factor in ensuring adequate visualization of the entire colon. there is no evidence to support the routine use of iv buscopan in ct colonography. mr was performed on a . t scanner by using gadolinium as a rectal enema. the d data set was post-processed on a workstation to obtain vdc and ssd images. radiologists with knowledge of the colonoscopic findings compared coronal and rotated views. they were compared by consensus in terms of the visualization of the mass lesions and normal colonic segments. technical visibility and interpretation accuracy of the colonic lesions were rated on a score. coronal vdc was regarded superior to ssd for assessment in of patients, equal to ssd in and worse than ssd in case. rotation of vdc and ssd improved the assessement of the colon. rotated vdc was regarded superior to ssd in , equal in and worse than ssd in in of cases. all mass lesions above mm were equally well depicted with the vdc mode compared to ssd conclusions: vdc and ssd are useful as a first step and possibly online analysis tools and could possibly allow for an earlier finishing of the mr exam in case of poitive findings. vdc appears to be superior to ssd in excluding colorectal mass lesions at the slice position with the visually largest lymph node extension in plain sequences, dynamic mri was performed using a turboflash starting withj a bolus injection of . mmol/kg b.w. gd-dtpa. results: in a retrospective evaluation, lymph node staging using the contrast enhanced endorectal and body-coil mri studies was based on the following criteria: stage n designated failure to identify nodal structures with a diameter larger than mm in the imaging volume including the perirectal space and the pelvic structures, and stage n designated visualization of four or less nodes larger than mm in diameter. in our series eleven patients (n = ) had histopathologically proven lymph node stage n ; all other patients (n = ) were stage n . we were able to depict the enlarged and involved lymph nodes in eight of eleven patients with stage n . we staged correctly nine of twelve patients with stage n (sensitivity of % and specificity of %). conclusions: high-resolution contrast endorectal mri was excellent for depicting perirectal nodes larger than mm in diameter. further studies are necessary to assess the architecture, geometry, and contrast-enhancement characteristics of lymph nodes to improve higher specificity. to investigate systemic and regional lv functional parameters including myocardial wall thickening in patients with symptomatic coronary artery disease and cabg. methods/materials: on a . t magnetom vision (siemens) patients with angiographically proven cad underwent prospective evaluation of ejection fraction (ef) and regional myocardial function in myocardial segments by cine mri (flash- d, tr = ms, te = . ms, flip °) at rest. consensus reading by two observers was used for the analysis of myocardial function. a phase-contrast flash- d sequence (pixel . × . , venc cm/s) was applied for flow measurements in the ascending aorta in order to derive functional parameters such as lv ejection time frame (Ät) and cardiac index. patients were re-examined months after surgery. results: clinical symptoms improved in of patients after cabg. in patients with significantly reduced ef (n = ) an improvement from . ± . % to . ± . % (p < . ) was found postoperatively. after cabg surgery functional improvement was observed in of myocardial segments (x of y patients) with severe hypokinesia (p < . ); mean increase of cardiac index was % (from . - . l/min/m to . - . l/min/m, p < . ), mean decrease of ∆t was % in patients with functional myocardial recovery (p < . ). in general, clinical improvement can be found months after cabg surgery and corresponds to improvement of systemic and regional lv function. patients with persistent symptoms still presented with pathological findings. therefore, mri can be used as a tool to follow-up symptomatic patients after cabg. the following effective doses (male/female) were calculated for the different calcium scoring modalities: sequential msct prospectively ecg-triggered ( msv/ . msv), spiral msct retrospectively triggered ( to . msv/ . to . msv), ebt ( . msv/ . msv). effective doses associated with ct coronary angiography were: spiral msct retrospectively triggered ( . to . msv/ . to msv), ebt ( . msv/ . msv). highest organ doses in all examinations were found for the female breast followed by the lungs and the oesophagus. conclusion: up to a -fold higher radiation dose is obtained in msct compared with ebct in coronary artery examinations. the high radiation exposure inherent in cardiac msct warrants careful analysis of the underlying clinical indication. bolus optimisation in multi-slice ct of the coronary arteries and assessment of diagnostic accuracy in comparison with cardiac catheter t.f. jakobs, c.r. becker, r. brüning, a. knez, c. thilo, m.f. reiser; munich/de objective: to determine optimal contrast concentrations and injection rates for detecting coronary stenoses with multi-slice ct (msct) angiography. materials and methods: patients, groups of patients, underwent msct (somatom volumezoom, siemens) with different contrast protocols: (a) mg iodine/ml at . ml/s; (b) mg/ml at . ml/s; (c) mg/ml at . ml/s; (d) mg/ml at . ml/s (byk gulden, konstanz, germany). assessment of location and degree of coronary stenoses was compared with cardiac catheter. results: the faster injection rates resulted in higher enhancement compared with the lower injection rates at both iodine concentrations ( . ± . hu (a) versus . ± . hu (d)). diagnoses of significant stenoses obtained by msct were confirmed by coronary angiography in out of patients ( %). among those with false negative results there were patients in whom msct failed to determine significant stenoses in the coronary arteries. the diagnostic findings as described in msct were not consistent with angiography with regard to localisation and degree of stenoses: in % of cases, the degree of the most severe stenosis was identical in msct and cardiac catheter. conclusion: superior coronary enhancement was achieved with higher iodine concentrations and flow rates. however, msct with any contrast protocol was unable to achieve the diagnostic level of coronary angiography in assessing location and degree of significant coronary stenoses. therefore further improvement of spatial and temporal resolution in msct-technique is required. coronary artery by-pass grafts: evaluation by retrospectively ecg-gated multislice spiral ct r. marano, m. zimarino, m.l. storto, r.l. patea, n. maddestra, l. bonomo; chieti/it purpose: to assess the potential value of multislice spiral ct (msct) using retrospective ecg-gating in patients who had undergone coronary artery by-pass grafting (cabg). retrospectively ecg-gated msct was performed in asymptomatic patients ( grafts) ± months after cardiac surgery. scanning parameters were: × . mm collimation, mm slice width, and . mm reconstruction increment. images were reconstructed during end diastole with an absolute or relative delay before the next r-wave and volume rendered images were obtained to display the grafts. visualization of the proximal, middle and distal segments of each graft was assessed. the presence of artifacts was recorded. results: left internal mammary artery (lima) to left anterior descending artery (lad) and non-lima grafts were studied. non-lima grafts were shown to be occluded. the entire lima to lad and non-lima grafts could be visualized free of artifacts in / ( . %) and / ( . %) cases, respectively (p < . ). the most frequent causes of incomplete visualization were the presence of surgical clips ( . %) and motion artifacts ( . %) impairing distal anastomosis evaluation. conclusion: ecg-gated msct is a promising imaging technique for non-invasive evaluation of cabg, allowing a complete assessment of lima to lad grafts. current limitations are artifacts from surgical clips and irregular heart rates. isotropic sub-millimeter volume scanning of the heart with ecg-gated multislice spiral ct: first experience t. we investigated the performance of a new multislice ct system with simultaneous acquisition of up to slices and sub-mm collimation (siemens, forchheim, germany) for ecg-gated cardiac imaging. ecg gated spiral data were acquired at pitch . - (pitch -feed/rot divided by one collimated slice width), providing continuous image data with up to ms temporal resolution. spatial resolution, image quality and artifacts were evaluated with a simulation study of an anthropomorphic heart phantom for . mm, . mm and . mm slice width. the results were confirmed by scans of coronary specimens. scan times and radiation exposure for coronary cta protocols were evaluated. first clinical results are presented. results: with the investigated ct system a mm heart volume can be covered in less then s with sub-mm slices. sub-mm slice width allows for improved assessment of non-calcified coronary wall changes, heavy calcifications and instent lumen. radiation exposure for coronary ctas with sub-mm slice width is about msv (male), which can be considerably reduced by ecg-gated dose modulation. a -slice platform can cover the heart with ecg-gated spiral acquisition with sub-mm slices within short breath-hold times. increased scan speed and isotropic resolution with voxel size >> . mm allow for substantially improved coronary imaging. a c d e f results: biexponential relaxation was more pronounced in "black hole" lesions and homogeneous enhancing plaques while dwm, nawm and hypointense lesions presented biexponential behavior with a lower frequency. non-enhancing isointense lesions and normal white matter didn't reveal any biexponentional behavior. linear regression between monoexponential t relaxation time and mtr measurements demonstrated excellent correlation for dwm, very good correlation for "black hole" lesions, good correlation for isointense lesions, moderate correlation for hypointense lesions and non-significant correlation for homogeneous enhancing plaques, nawm and nwm. conclusion: biexponential behavior is more evident on plaques with high degree of demyelination and homogeneous enhancing lesions when using conventional sequences with long first echo time. a strong correlation between mtr and t values in regions where either inflammation or demyelination is present was found while when both pathological conditions coexist this linear relation is destroyed. method and materials: mri of pediatric patients affected with definite ms ( male and female; mean age ) and with adem ( male and female; mean age ) were retrospectively evaluated to identify differences in the morphology, location and post-contrast behavior of the demyelinating lesions at the onset of the disease. clinical and laboratory data were not used. plain t and t weighted sequences were always available, flair in only % of more recent cases; i.v. contrast injection was done in adem and ms patients. results: lesions in adem patients were multiple in all but case and in / cases were more then ; / cases infratentorial region was involved; gray matter involvement was present in / and thalamus was the most common involved ( / ); corpus callosum was involved in / cases; contrast enhancement was present in / cases; a "lumpy-bumpy" effect was never remarkable. conclusion and discussion: differentiation of ms and adem has an high prognostic significance. clinical and laboratory data may often overlap between the two demyelinating disorders. even though single mri findings can be non specific, the global evaluation of each patient leads to a differential diagnosis in more then % of cases. results: mri of the brain revealed no abnormality in the patients who had lower plasma fa levels both in the last years and on the day of mri (mean . and . mmol/l respectively). however, the patients who had demyelination changes detected on mri had average plasma fa levels in the last years and on the day of mri of . and . mmol/l respectively. no difference of iq between both subgroups were observed. conclusion: the low number of patients within the study group precludes evaluation of the statistical significance of the detected differences, but a trend toward correlation between a degree of metabolic compensation of the disease and a presence of brain lesions can be observed; no correlation was detected between the lesions and a degree of mental development. intracranial tuberculosis: mri evaluation and year follow up i. tsitouridis, m. emmanouilidou, s. chondromatidou, f. goutsaridou, s. stratilati, p. papapostolou, a. morichovitou; thessaloniki/gr purpose: to present our experience in the mri diagnosis and follow up of patients with intracranial tuberculosis. materials and methods: patients with intracranial tuberculosis were evaluated by mri. the examinations were performed on a t, siemens expert plus scanner, using conventional se t wi and t wi. all the patients were conservatively treated and underwent clinical and mri examinations every two months for a year. results: patients revealed basal leptomeningeal dissemination and meningeal enhacement and of them also had a tuberculous abscess in this area. patients had disseminated parenchymal tuberculosis and of them had also and meningeal enhancement. one case had tuberculomas and aspergillomas closed together and this patient had a biopsy in the left parietal lobe. the other patients also revealed spinal subarachnoid dissemination. there was no correlation between the mri findings and the clinical status at the early stages of he disease. conclusion: we believe that mri alone or in combination with the other clinical data clearly can detect and characterize this group of patients. differentiation of tuberculous from non-tuberculous meningitis using magnetization transfer mr imaging: a prospective study p. kamra, r.k. gupta, s. pradhan, k.n. prasad, r. kumar, s. chawla, s. jha; lucknow/in purpose: infectious meningitis presents similar features on mr imaging regardless of etiology. the purpose of this study was to characterize meningitis of different etiology using mt imaging. methods and materials: one hundred patients with meningitis on post-contrast mt imaging - tuberculous, with viral, with fungal, and with pyogenic meningitis -were studied. the visibility of the meninges on pre-contrast mt imaging in different etiologic groups was studied and percentage difference between the mean signal intensity (si) of the meninges and the mean si of the surrounding t normal brain parenchyma was calculated. the mt ratio was also calculated from the thickened meninges in tuberculous meningitis. the mt ratio could not be calculated in other etiologic groups due to difficulty in the placement of pixel due to thin nature of the meninges and their location in the cerebral sulci. results: thickened meninges appeared hyperintense relative to surrounding brain parenchyma in the cisterns on pre-contrast mt-se images in all patients with tuberculous meningitis. meninges were not visible on pre-contrast mt images in the non-tuberculous group. the percentage difference in the mean si of the meninges and the surrounding brain parenchyma was significantly higher (p < . ) in the tuberculous group ( . % ± . ) compared to that in the non-tuberculous group ( . % ± . viral, . % ± . fungal, . % ± . pyogenic) and explains this difference in visibility. the visibility of meninges on pre-contrast mt-se imaging is specific for tuberculous meningitis, and helps in its differentiation from other non-tuberculous meningitis. purpose: septo-optic dysplasia is a variable condition, characterized by developmental anomalies of midline structures, the optical pathways, and the hypothalamus/pituitary system. while visual and hormonal disturbances are well known in these patients, neurological and mental development has not yet been related to the morphological findings. patients and methods: children, female, male, aged between - years at first presentation underwent mri ( . - . t superconducting systems, t w and t w sequences in section planes, slice thickness . - mm. in patients behavioural abnormalities and school performance could be analyzed with age appropriate tests. results: mri abnoralities consisted of a completely or partially missing septum pellucidum in cases, anomalies of other midline structures (corpus callosum, fornix, other commisures) in , / mr scans revealed hypoplastic optical structures. anomalies of the hypothalamius/pituitary system were seen in , hemisperic lesions (mainly schizencephalic clefts) or infratentorial abnormalities occured in , and pathological formation of the hippocampus in / scans. marked devel- the purpose of this presentation is to report on the prevalence of cerebrovascular complications in children with aids and investigate whether the mode of hiv infection plays a role in the development of this complication. children (ages, months to years) with aids were periodically evaluated with pre-contrast ct scans. further evaluation with mri was perfomed for patients with either focal neurologic deficits or ct findings other than diffuse atrophy. in five patients mr angiograms and in one conventional angiography were also performed. eleven children were found to have vascular lesions. only one had focal neurologic symptoms at the time of diagnosis. six children were found to have aneurysms. a seventh child had a surgical clip at the site a previously treated anerysm. eight patients were found to have infarctions. in four of the patients with infarctions, fysiform aneurysms of the cerebral arteries were also identified. nine of the patients in our study were infected by transplacental route or during blood transfusion in prematurely born infants. in this group of patients the diagnosis of cerebrovascular disease was made earlier (mean, . years) compared to the two patients that were infected later in life (mean, . years). there is increased prevalence of cerebrovascular disease in children infected by hiv. the risk is greater if the exposure to the virus took place prior to the th week of gestation. this finding suggests that the immature vessels of the fetuses or the prematurely born children are more vulnerable. a quantitative study of mr imaging in vascular dementia l. wang; beijing/cn purpose: to identify the neuroimaging determinants which could predict the occurrence of the vascular dementia (vad). the findings of cranial mri were compared in vad patients and stroke without dementia (swd) patients by means of quantitative measurement of some indexes. the indexes of measurement included the cerebral white matter lesion (wml) area, the cerebral infarct area, the ratio of ventricle-to-brain (vbr) and the ratio between the areas of the corpus callosum and supratentorial brain in the midsagittal plane. discriminant analysis was used to search for the indexes which could contribute significantly to distinguishing the two groups. results: small cerebral vessel disease and multi-infarct were two major basal diseases of vad in this series. the wml areas, the left cortical infarct and vbr were significantly higher and the corpus collsum areas was significantly lower in the vad group than the swd group. the indexes that could significantly discriminate the two groups was: callosal atrophy, ventricle-to-brain ratio, white matter lesions area, left cortical infarct area, left parietal infarct area, total cortical infarct area. conclusions: callosal atrophy, lateral ventricle enlargement and extensive wml are important predictors of incidence of dementia in the small vessel disease; however, left cortical infarct, especially left parietal infarct, is important predictor of incidence of dementia in the multi-infarct group. biological markers of alzheimer's disease: diagnostic imaging and oxidative stress d. lupoi, r. squitti, a. orlacchio; rome/it purpose: a bulk of evidence indicates that oxidative stress mediated by redox transition metals plays a central role in the neurodegeneration of alzheimer's disease (ad). iron and copper are strongly concentrated within neuritic plaques and represents the hallmark of the ad brain. recent studies indicate that peripheral markers of oxidative stress in ad patients could be informative about the pathophysiology of this brain condition and suggested that elevated copper in serum may represent a peripheral marker for ad. we report a pilot study examining the relation between copper and oxidative parameters in serum and the lesions present in the ad brain. we performed retrospective subjective qualitative and quantitative analysis of the mr brain images of subjects affected by ad and without ad (healthy control group). on imaging, we noted the degree of atrophy and amount vascular lesions in both patients and controls and correlated these with oxidative stress parameters. the preliminary results indicate that oxidative stress, with higher copper levels, are related to atrophy of temporal lobe. vascular lesions and global atrophy do not correlate with copper and peroxides in serum. our evidence sustains copper as peripheral marker in ad to help in the early diagnosis. to determine whether diffusion weighted mri (dwi) contributes to the differential diagnosis of patients with parkinson's disease (pd) and the parkinsonian variants of multiple system atrophy (msa-p) and progressive supranuclear palsy (psp) methods and materials: conventional dual-echo fast spin echo and dwi scans were obtained from msa-p, pd, and psp patients matched for age and disease duration. dwi was performed using echoplanar imaging with diffusionsensitizing gradients switched in slice direction and three different b-values ( , , ). regional apparent diffusion coefficients (radc) were determined in different brain regions including basal ganglia and pons. results: using the kruskal wallis test and post hoc testing with the mann whitney u test, significant differences in radcs of the putamen ( . vs. . s/mm ; p < . ) and the caudate nucleus ( . vs. . s/mm ; p = . ) were detected between patients with msa-p and pd. between psp and pd patients, significant differences in radcs were revealed in the putamen ( . vs . s/mm ; p = . ) and in the globus pallidus ( . vs . s/mm ; p = . ). no significant differences in radcs were obtained between patients with msa-p and psp. conclusion: the significant higher radcs in patients with msa-p (putamen, caudate nucleus) and psp (putamen, globus pallidus) compared to patients with pd may reflect a more advanced alteration of the cns tissue integrity due to neuronal loss and gliosis leading to increased random movement of water molecules. metabolic impairment of the brain in patients with apallic syndrome s. mirzaei, c. stepan, p. knoll, h. köhn, h. binder; vienna/at purpose: a reliable assessment of prognosis in acute/persistent vegetative state following cerebral anoxia is mandatory for clinical decisions concerning extended intensive care procedures. we evaluated five patients with apallic syndrome with [ f]- -deoxy-d-glucose (fdg) positron-emission-tomography (pet). pet images of the head were performed using a siemens ecat-art scanner (cti, knoxville). two cs point sources were applied for attenuation correction and osemalgorithm for iterative reconstruction. regional cerebral metabolism in cortical and subcortical regions was determined and compared to a normal control group. the global cerebral metabolism of glucose was markedly reduced in all patients. so far, a follow-up pet scan of the brain in one patient without clinical amelioration showed further decrease of cerebral glucose metabolism. in accordance with limited reports in the literature these results suggest that the extent of metabolic impairment may play an important role in order to assess the probability of clinical recovery from severe anoxic brain injury. methods and materials: a pioneer instance of a fully digital radiology department has been implemented at shanghai first hospital since aug. , which has been composed of a dicom compliance pacs and a chinese ris developed inhouse. two phases were implemented for whole setup procedures. results: in initial phase started in oct. , ct, mri, rf, dsa and a film digitizer connected to a central archiving system which involved a gbyte raid and a round about tbyte dvd jukebox, simultaneously a chinese ris was installed to implement the computerized management for routine workflow; full implementation of digital department was completed with three new modalities, a dr, a digital mammography and a digital radiofluoroscopy installed in aug. , which realized full electronically archiving of images and initiated a filmless procedure. central and distributed image store management and auto-routing procedure employed to reduce network traffic and improved processing response of the system. soft copy image diagnosis and the computerized management of imaging workflow elevate workflow efficiency and improve patients passthrough obviously. the chinese version ris, which was developed based on the workflow and routine manage model of typical radiology department of china, has successfully transferred traditional film-based management into a revolutionary efficient and reliable digital management. conclusion: phases approach is a perfect way to achieve the fully digital radiology department in china and a specifically ris would play an important bridge role in a complex medical information system environment. possible pitfalls in the digitalisation of the radiologic image archive p.m.a. van ooijen, m. oudkerk; groningen/nl purpose: with the increase in the amount of data produced at radiology departments, the importance of digitalisation of the radiologic image archive also increases. when planning a picture archiving and communiations system (pacs), an overview of the possible pitfalls is crucial to judge the quality of the implementation plan. we present such an overview based on our experience with the digitalisation of a radiology department in the netherlands. methods and materials: according to our experience, seven pitfalls are present when implementing a pacs: ( ) system acceptation by the radiologist; ( ) emphasis on storage instead of retrieval performance; ( ) reduction of data transfer capacity; ( ) undersized digital storage capacity; ( ) unpredictable radiologic workflow; ( ) functionality archive media; ( ) pseudo dicom . solutions. results: for a successful pacs, all pitfalls described above have to be eliminated. to achieve this, the everything on-line (eol) principle was developed based on the ground rule that all images have to be available to the radiologist fast at every workstation at all times (emphasis on retrieval). the eol pacs is a, windowsnt™ based, full dicom solution with a large (last months to years) raid- on-line archive (fast, standardized, scalable) and a large dvd-r on-line backup storage (non-erasable, standardize, scalable), eliminating dependency on workflow management, pre-fetching or auto-routing and increasing the ease of acceptation by radiologists. conclusion: a large number of pitfalls are present when digitising a radiologic image archive but with careful planning and by putting certain demands on the manufacturer, these pitfalls can be eliminated. this new technique is based on a regular ″ tft-flatscreen monitor equipped with a special filter system. this configuration allows the display of objects from different angles with a shift of one degree in between. of these perspectives only two reach the eyes of a viewer at one time. different viewers in front of the screen obtain different perspectives resulting in a stereoscopic view for all viewers in front of the monitor. to demonstrate d data sets, we use a ″ plasma display equipped with the "stereo viewing" panel. the stereoscopic view is used for still images and for movies, e.g. avi files. the described system was evaluated over a period of months. results: panel-based stereo viewing is possible. without the addition of cumbersome and costly glasses, the technique can be used to provide a d rendition of complex d mri-and ct-data sets for large audiences. the system proved easy to use and was widely accepted by referring physicians as a tool for rapid data assessment. a selection of cases will be presented in this presentation. conclusion: "stereo viewing" without glasses proved to be feasible and became widely accepted at our department, especially for demonstration purposes. accessing d purpose: accessing medical images everywhere and everytime on mobile hardware is very important for both routine diagnostic and research. therefore, we developed an application for mobile devices, which are increasingly present like pencils. methods and materials: java mobile-informations-device-profile (midp) was selected for development. for data-transfer the http network protocol is used. the image data is available in the dicom file standard. there is no need of special filepreparation before file access. stereoscopic images were generated with our previously developed medical interactive stereo- d visualisation tool. results: java was used because of the growing range of java-enabled hardware like mobile phones, personal-digital-assistants and tablet-pcs. the mid-profile was created especially for limited devices. our reference application is running on bit color palm-organizers. image files can be accessed through wireless or wired connections. once the data is retrieved from a server, the images can be viewed, edited and saved. it is also possible to list and edit the dicom tags and make additional comments. precalculated d-data (e.g. from ct-datasets) based on chromatek visualisation can be displayed stereoscopic on color devices. summary: the goals of a mobile implementation is not the replacement of medical desktop workstations, but enlargement. the implementation includes methods for intelligent interaction and reduction of drawbacks of limited devices. because of using distributed standards and the standalone implementation, the application can easily be integrated into medical systems. creating his-based quality mangement: the nottwil experience h. hawighorst, t. mayer; nottwil/ch the swiss paraplegic center was founded in and is a modern level i trauma center for patients with all type of spine injuries. in this presentation we will discuss our road to success and the difficulties lying ahead to fully integrate a knowledgebased quality management to our institution. pacs was installed in and is productive with his and ris as a knowledge based information system since the end of . radiological images and reports are distributed within the hospital by a webserver based intranet technology. for management purposes the model of efqm (european foundation for quality management) was choosen at the end of and aims at total quality management. although the pacs sytem is running quite well there are still problems to be solved. in the efqm model "processes" are the essential element. we adopted from the efqm matrix an audit matrix with quality steps. the result of the first quality selfassessment has shown that knowledge-based quality has to be transparent and understandable to employees and has to be "lived" and continuously "taught". to increase and assure widespread access and acceptance of quality management we bring intranet technology-based information together with continuous education of employee. however, trained people with skills in modern technology and quality mangement are warranted in this type of modern infrastructure. new approach to picture communication in an outpatient environment f.x.j. fruehwald, e. steiner, m. obermayer; st. pölten/at purpose: while pacs inside hospitals is a widely used technology nowadays, the situation is much different outside hospitals. a new approach offers picture communication to the medical community outside hospitals. while hospitals solutions are "islands" with little communication to the outside world, the new system supports communication between all providers of medical services materials and methods: application provided pacs allows storage of image data in a professionally organised server farm. patients are provided with a chipcard containing the name, a unique serial number and a pin. all doctors authorised by the patient can access the server and load down all images they want using secured lines. results: technological requirements and guaranty of privacy of medical data are described. the system has been implemented in a part of austria. some physicians up to now take part in this project. only normal amateur pc equipment is needed on the physician's side, adsl is recommended for download of dicom images; for use of jpeg images isdn standard would be sufficient. global access of the server is possible. conclusion: a combination of application provided pacs and a plastic card with a chip can transfer all advantages of hospital pacs into the extra hospital world. as storage costs and costs for telephone lines go down it is to be expected that this internet based system will replace traditional image communication per hardcopy and mail shortly. purpose: magnetic resonance imaging (mri) is limited by artifacts and image distortion in vessels after stenting. with a rigid active magnetic resonance imaging stent (amris) the stent lumen can be illuminated without causing artifacts, however, the use is limited due to the need for surgical placement. a new balloonexpandable stent design enables catheter implantation of the amris. the purpose of this study was to evaluate the imaging properties of this stent in a rabbit model using mr angiography (mra) and flow measurements. the amris was expanded with a balloon catheter in the abdominal aorta of five rabbits. flow measurements and mra before and after injection of an iron-oxide-based blood pool contrast agent were performed at . t. signal-to-noise ratios (snr) were calculated within and outside the stent lumen. results: placement of the expandable stent was feasible in all animals. snr outside as compared to within the stent increased significantly (p < . ) from . to . for plain, from . to . for contrast-enhanced mra, and from . to . for magnitude images of the flow measurements. flow volume curves within and distal to the stent were comparable. conclusion: mr imaging after interventional placement of the expandable amris is capable of illuminating the inner stent lumen. thus, follow-up after stent placement is feasible and it appears to be a useful tool for clinical follow-up and basic research on vessel alteration after stent placement. we retrospectively studied procedures of mechanical thrombectomy of ptfe dialysis access grafts with the at-ptd performed in our vascular department. dialysis accesses in patients were included (nine had a double procedure). the delay between thrombosis and percutaneous thrombectomy was less than hours. duration of the procedure, immediate technical results, primary patency and complication rates were analysed. the mean duration of the procedure was minutes. a venous stenosis was associated with thrombosis in % of cases. the technical success was . %. % of successfully declotted access grafts presented with early recurrent thrombosis less than months after the procedure: . % of them presented with residual stenosis at the end of the initial procedure and . % with residual clots. in this group, the mean primary patency was . days. three major and minor complications were observed. conclusion: thrombectomy of dialysis access graft with the at-ptd is a safe and effective technique. the mean patency rate is superior to pulse-spray and the complication rate is lower. moreover, the procedure seems to be faster to perform than other techniques. results: indications for pta were ulceration in limbs, rest pain in limbs, gangrene in limbs and bilateral intermittent claudication in a patient requiring total knee replacements. limbs underwent one procedure, underwent two and underwent three. technical success was achieved in / ( %), partial success in / ( . %) with failure to achieve any improvement ( . %). day mortality was / ( . %) from bronchopneumonia days post bkpta. mean/ median follow up was months (range - ). clinical improvement (ulcer healing, reduced or absent pain) was seen in patients ( %). expected major and minor amputations were ( %) and ( %). there were no major complications requiring further radiological/surgical interventions or increased hospital stay. there was minor groin haematoma. conclusion: bkpta is a safe, worthwhile procedure in carefully selected patients, although repeat procedures were required in almost half of the limbs treated. following appropriate inflow procedures we consider pta as a first line treatment for patients with distal critical ischaemia. ( ) after previous sfa angioplasty, underwent pta with adjuvant pdt using mg/kg of the photosensitiser -aminolaevulinic acid and nm light at j/cm to pta site. at months of follow up all patients were asymptomatic with no restenosis and no arterial complications. because of previous restenosis/re-occlusion these patients would be at a high risk of this complication again. results: these patients have now been followed up for ± months. patients were reviewed clinically and were offered duplex examination. six of the patients remained asymptomatic. one patient has had repeat angioplasty. a further patient had mild, unlimiting claudication. three of the patients who had duplex showed no restenosis. the th patient (the only currently symptomatic one) had a significant stenosis (psvr = . ). there were no arterial complications such as aneurysm formation or occlusion at the treated sites. conclusions: pdt as an adjunct to pta is a safe and feasible procedure and appears effective in the long term. we have now started a randomised control trial to assess its potential for the treatment of restenosis. purpose: to present statistical data from a registry including patients after angioplasty or stenting of atheromatous peripheral lesions (essentially renal and lower limb arteries). methods and materials: angioplasty with or without stenting of an atheromatous peripheral lesion was the criteria for inclusion: patients were included ( men, mean-age . years) between may and dec. , in centers. cardiovascular risk factors, symptoms and atheromatous localization were analyzed with a descriptive method; the population with renal disease was compared with the one with lower limb disease. results: smoking ( . %), hypertension ( . %), and hypercholesterolemia ( . %) were the most frequent risk-factors. men were more frequently smokers than women ( . % and . % respectively). lower limb arteriopathy was more frequent in men than in women ( . % and . % respectively). vasculo-renal disease was more frequent in women than in men ( % and . % respectively). smoking was much more frequent in the group with lower limb arteriopathy ( . %) than in the group with vasculo-renal disease ( . %). conclusion: this registry gives access to statistical data about a population of atheromatous patients treated for peripheral localization. long-term follow-up will allow us to evaluate the changes in the profiles of the patients and the morbidity and mortality in this population. results: all lesions with a maximum diameter of cm were treated with a safety margin of - mm around the lesion. lesions with a close relationship to the liver capsule, the gall bladder and major vessels were treated. in patients treated with litt for liver metastases from breast cancer the mean survival was . years ( % ci . - . years, median . years) after the first litt treatment and . years after the diagnosis of metastases, which was treated with litt ( % confidence interval . - . years, median survival . years , partial necrosis in the remaining lesions ( . %); two of these tumors were > cm. patients had no major complications except one hemorrage that required transfusion but resolved spontaneously. transient pain, nausea and fever were common minor symptoms that resolved within - days. the median follow-up was months. conclusion: rf ablation with the le veen probe is a safe, well tolerated and effective procedure for the treatment of unresectable liver tumors. enhanced gray scale ultrasonography with levovist and c -mode of hepatocellular carcinoma treated with interstitial laser photocoagulation l. tarantino , a. giorgio , g. de stefano , f. esposito ; torre del greco/it, naples/it purpose: to evaluate c -mode enhanced ultrasonography of hepatocellular carcinoma (hcc) treated with interstitial laser photocoagulation (ilp). method/materials: patients with a single hcc ( . - . cm) treated with ilp underwent helical ct and were also studied with c -mode™ (esaote biomedica, genoa, italy) and an i.v. microbubbles contrast agent (levovist, shering, berlin, germany). after injection of levovist ( g; mg/ml), c -mode™ scans were recorded at the times s, s, s, min, and min. the results of c -mode™ were compared with ct. results: after injection of levovist, c -mode™ showed homogeneous enhancement (hyperechogenicity) of liver parenchyma at s, s, s, min, and min. in patients, with complete necrosis of hcc at ct, the lesions did not show any intralesional enhancement during c -mode™ examination (complete agreement with ct). in one nodule, with enhancing intratumoral areas suggestive of viable tumor at ct, c -mode™ showed hyperechogenicity in the same corresponding areas (agreement with ct). in the remaining patient, ct showed complete necrosis of the nodule. howewer, enhanced spots along the inferomedial margin of the lesion suggested parenchymal infiltration left untreated by ilp. c -mode™ did not show enhancement in that area and a biopsy did not show malignancy. no relapse has been observed after months. follow-up of the patient is in progress. results: all patients tolerated the procedure well under local anesthesia. the total procedure time was minutes. all complications observed were minor and no further treatment was necessary. online mr thermometry allowed exact visualization of the extension of laser-induced changes and their relationship to the neighboring anatomy. lesions up to cm in diameter could be efficiently treated with a single laser application; larger lesions were treated with dual, triple and quadruple simultaneous applications. in . % we achieved complete necrosis of the tumor and a mm safety margin, resulting in complete destruction of the tumor without local recurrence. mean survival after the first laser treatment was . years ( % confidence interval (ci) . - . years) and . years ( % ci: . - . years) after the time of diagnoses of the hcc. conclusion: in hepatic involvement with oligonodular hepatocellular carcinoma, litt appears to be an effective therapeutic procedure. results: before treatment, intratumoral arterial-phase enhancement followed by a hypoechoic appearance in the portal venous and delayed phases was demonstrated by contrast us in ( %) of hccs. after rf, all the ( %) of the hccs that were found to be necrotic at spiral ct, failed to enhance using contrast us. by contrast, in the six hccs with residual viable tumor at spiral ct, intratumoral areas of persistent enhancement -corresponding to the enhancing areas at spiral ct -were identified using contrast us. these six nodules were retreated with rf, targeting residual tumor with contrast us guidance. conclusion: contrast-enhanced us, performed using c -mode imaging, shows promise in assessing the therapeutic effect of rf thermal ablation in hcc. purpose: cytokine-based gene therapy has been shown to be highly efficient in stimulating an immune response leading to tumor rejection in transplanted tumors. woodchucks infected with woodchuck-hepatitis virus (whv) develop orthotopic hepatocellular carcinomas (hcc). the purpose of this study was to evaluate the efficacy of mr-guided injection of a therapeutic adenovirus vector into hccs of woodchucks and to monitor the course of the tumor non-invasively using mri. for mr imaging five woodchucks with known hepatocellular carcinomas were anesthesized using ketamine and xylazine. the animals were examined using standardized sequences on a . t whole-body scanner. under mr-guidance either adil- /b . or a control adenovirus were injected into selected tumor nodules. the animals underwent axial mr examinations of the liver immediately as well as , , and weeks following application of the therapeutic agent. finally all animals were sacrificed and the liver was referred to histopathology. results: mri of all animals was feasible. injection of adil- /b . caused a reduction of the tumor nodule volume in all animals. in contrast, tumor areas injected with the control vector showed increased tumor size. histopathologic examination of liver sections revealed necrosis and inflammatory infiltration in tumor nodules injected with adil- /b . whereas typical features of neoplastic hepatic cells were found in areas injected with the control vector. conclusion: objective monitoring of gene therapy strategies in vivo by means of high resolution mr imaging in small animals is possible. purpose: paediatric diagnostic examinations in ireland are currently under investigation, such that recommendations may be made for greater optimisation of practice. methods and materials: a questionnaire survey established which irish hospitals perform paediatric examinations. dose measurement, using a combination of tld and dap monitoring, is being conducted in a sample of these. in line with european recommendations, diagnostic reference levels are being established for examinations with high effective dose. an evaluation panel is using image assessment criteria derived from those of the european commission to assign objective image quality scores. correlation of dose and image quality allows proposals for optimal techniques for paediatric examinations. results: there is a wide spectrum of paediatric practise nation-wide, in terms of caseload, equipment used, and technique applied. this has significant impact on the range of patient dose for similar investigations, and on the diagnostic quality of the images produced. comprehensive analysis of image quality is difficult, and in paediatrics, is complicated by the fact that essential image details depend heavily on the clinical situation. an absolute image quality measure such that the lowest achievable dose for an examination may be specified is being sought. the formulation of a non-biased, representative sample of hospitals is fundamental to the validity of any dosimetric survey, but particularly one concerned with the establishment of national reference doses. optimisation demands that image quality is evaluated in clinical radiographs -in paediatrics this requires consideration of the clinical context of the request. does an absolute image quality measure exist? purpose: to investigate in a controlled patient study the potential of online tube current modulation in subsecond multi-slice spiral ct (msct) examinations of children to reduce dose without loss in image quality. method/materials: dose can be reduced for non-circular patient cross-sections without an increase in noise if tube current is reduced at those angular positions where the patient diameter and, consequently, attenuation is small. we investigated a pre-release product version of an online control for the tube current integrated in a somatom vz with improved technical performance. we evaluated image quality, noise and dose reduction for examinations with online tube current modulation in msct of the thorax and the abdomen. we evaluated mas for tube current modulation and compared to the mas in standard protocols. image quality was rated as very good, good and poor in a consensus by three radiologists. noise was assessed in comparison to a control group and by phantom measurements. results: dose was reduced typically by to %, depending on the patient geometry and anatomical region (thorax to %, abdomen to %). in general, no loss of image quality was observed. measured noise did not change significantly. in some cases the noise pattern was improved. online tube current modulation is now used as a standard in multi-slice spiral ct at our institution. conclusions: dose in multi-slice spiral ct examinations of children can be reduced substantially in routine examinations by online tube current modulation without a loss of image quality. purpose: malformations of the corpus callosum (cc) may occur in many different syndromes. various forms have been observed with different degrees of structural abnormality. the purpose of this study is to review characteristic signs of callosal abnormality and try to find a correlation with the degree of clinical disability. material and methods: mri examinations were performed in patients with developmental delay. imaging included t and t -weighted sequences in all cases. all patients had a thorough neuropaediatric clinical examination. the mri images were evaluated regarding the degree of callosal hypoplasia, presence of a fornix and hippocampus, hydrocephalus and concomitant further abnormalities. results: seven different forms of malformation of the corpus callosum were encountered. in particular the development of the fornix and hippocampus differed significantly as did the amount of clinical disability. as a hippocampal commissure is a prerequisite of normal hippocampal development, the size of the temporal lobes depended on the degree of this midline abnormality. patients without hippocampi were all severely disabled. the clinical disability of the patients presented here differed significantly, which may in part be due to the different extent of the midline cerebral malformation. the relevance of the concomitant aplasia of the limbic system has not been addressed in detail before in the literature. purpose: to evaluate the role of ct and ct angiography in the diagnosis and treatment of pulmonary cystic and adenomatoid malformations in the newborn and young children. methods and materials: nine children aged between days and months with respiratory failure and cystic pulmonary malformations underwent conventional ct and ct angiography. lung abnormalities were present on all the chest radiographs prior to ct. the abnormalities had varying appearances; resembled pneumonia, appeared as a mass and as cysts. the ct acquisition protocol included sequential scanning with a mm scan thickness and scan interval, which was followed by high resolution ct in all cases and ct angiography in two. all ct studies were performed under general anaesthesia. the final diagnosis was based on the surgical data and morphologic examination of resected lung tissue in all patients. results: morphologic investigation revealed different types of cystic adenomatoid malformation in cases and persistent interstitial emphysema in association with other hallmarks of bronchopulmonary dysplasia in cases. the following types of congenital cystic adenomatoid malformation were found: type i ( ), type ii ( ), type iii ( ), and the ct data was in close relationship to the morphologic findings. in cases ct showed the presence solitary or multiply lung cysts. conclusion: ct is a useful diagnostic tool for precise estimation of the extent and differential diagnosis of cystic pulmonary malformations in the newborn and young child with respiratory failure. ct angiography can provide important diagnostic information in the preoperative investigation of pulmonary and mediastinal vessels in these cases. we analysed aubmt ( boys, age . a; girls, age . a), ( %) died and albmt ( girls, age a; boys, age a), ( . %) died. at least one plain radiograph and one ct were obtained before albmt and aubmt respectively. results: only ct examinations in clinically complicated cases were peformed after albmt. pathological findings were found in / ( . %). / ( %) later died because of infections. inflammatory pneumonia occured in cases, mycotic infection in cases and pneumonitis after chemotherapy was found in one case. graft versus host disease was the cause of death in / cases. ct examinations of patients were performed after aubmt, mostly to exclude lung metastases and to follow up mediastinal lymph nodes. in / patients with respiratory symptoms parenchymal changes were found. we diagnosed pneumonitis after chemotherapy, inflamatory pneumonia in cases and mycotic infection in cases. two patients had clinical symptoms with a negative ct. only / ( . %) died due to respiratory complications. conclusion: different imaging strategies for aubmt and albmt were used. the therapy of pulmonary complications is more complex with albmt, but there are frequently diagnosed with plain films. ct is used more frequently after aubmt in which pulmonary infections are rare and less serious. ct has a decisive role in bmt patients. chrispin-norman-score and bhalla-score of patients with cystic fibrosis: results: cn-scores varied between and in rx and mr. the mean cn-score was . ± . in rx and . ± . in mr. the cn-score was higher in rx in patients and higher in mr in patients. in . % the difference between the two scores was , in . % the difference was smaller than or equaled . high correlation was found between scoring with rx and mr with minor restrictions in differentiation of nodules and rings on mr. bhalla-scoring was possible in mr-imaging. conclusion: cn-scoring and bhalla-scoring of cf is possible with fast low-field mr. since scoring differences between rx and mr are not higher than interobserver differences in rx scoring, further research is strongly suggested to reduce radiation exposure in the long term follow-up of patients with cf, especially in children with minor pulmonary involvement. true-fisp lung mri at . t in pediatric oncology patients presenting with fuo g. schultz, c. laub, w. kenn, a. trusen, j. kühl, d. hahn; würzburg/de purpose: to compare conventional chest x-ray and mri in pediatric patients with a diagnosed cancer suffering from fever of unknown origin (fuo). materials and methods: patients (aged - years, mean age years) had chest x-rays and underwent mri in a . t mri unit (siemens magnetom open) using a phased array surface coil. the images were acquired in coronal and sagittal planes. for the mr investigation a trufi-sequence (tr = ms, te = ms, matrix , slice thickness - mm) was used with an acquisition time for slices of s. results: although breathhold-sequences were not possible in all cases, it was possible to evaluate all investigations. with regard to pulmonary infiltration coincident findings were achieved in / cases. out of infiltrations could only be detected on the mr images and the extent of infiltration was better evaluated in cases. additional mri-findings such as sinusitis, pericardial effusion and hepatosplenomegaly were detected. conclusions: true-fisp lung mri was found to be more sensitive than the conventional chest radiograph. additional important clinical information was also obtained with mri. underwent duplex ultrasound and digital subtraction angiography, followed by percutaneous treatment. duplex us was performed via trans-lumbar approach: ri derived from the interlobular arteries was obtained. pre-procedural mean ± sd values of ri and referral cut off values were calculated. patients were classified as cured/improved or not improved according to blood pressure values and changes in antihypertensive drugs before and after treatment. results: pre-procedure, mean ± sd ri values were different (p = . ) for atherosclerotic ( . ± . ) and fibrodysplastic ( . ± . ) stenoses, with no difference between cured/improved and not improved patients ( . ± . vs. . ± . ); no difference (anova p = . ) was found for medical therapy. in cured/ improved atherosclerotic patients ( / , %), ri was < . in ( % sonovue enhanced us measurement of altered renal haemodynamics in patients with liver metastases e. leen, j. macquarrie, w.g. angerson, p. horgan; glasgow/gb purpose: to assess sonovue enhanced ultrasound in the measurement of renal haemodynamics in patients with liver metastases. materials and methods: healthy volunteers and patients with proven liver metastases were studied; non-linear ultrasound imaging (m.i: . - . ) of each kidney was performed continuously in a sagittal plane before and after bolus intravenous injection of ml contrast medium (sonovue, bracco, milan). there was a minimum of minutes delay between the examinations of either kidney to allow for contrast clearance from the previous injection. digital data acquisition over a period of seconds was subsequently recorded for quantification analysis. timeintensity curves were derived from regions of interests placed over the kidneys. the contrast arrival times (at), peak amplitude (pa), time to peak (tp) & gradient (g) of the steepest portion of the curves for each kidney were measured. results: there was no significant difference in all the parameters between the contra-lateral kidneys for both controls and patients with liver metastases. there was no significant difference in the pa, at and tp indices between controls and metastases. in contrast the gradient values were significantly raised in those patients with liver metastases (metastases vs controls: . ± . vs . ± . , p < . ); there was clear separation of the gradient values between the two groups. to study diagnostic possibilities of d-vusa in evaluation of main renal vessels. materials and methods: consecutive patients were referred to d-vusa for assessment of major renal vessels: aortic aneurysm ( pts), renal tumors ( pts), suspicion of ras ( pts), suspicion of upj obstruction ( pts). d-vusa was performed on sonoline elegra (siemens) version . with power doppler and a special d program. postprocessing was performed using volume rendering data to obtain angiogramm-like virtual images. verification was made by conventional angiography ( pts) and surgery ( pts). sunday b results: d-vusa revealed / unilateral accessory ra, / bilateral accessory ra (sensitivity %, specificity %). upj obstruction was diagnosed by d vusa in cases and was confirmed by conventional angiography and operation in cases (sensitivity %, specificity %). ras was revealed in / patients referred to d-us study (sensitivity %, specificity %). d-vusa diagnosed infrarenal aortic aneurysms. in the cases of renal tumors d-vusa helped to delineate normal and abnormal renal vasculature, thus providing necessary information for nephron-sparing surgery. conclusion: d-vusa is a useful, noninvasive new promising method for evaluation of main renal vessels. we suggested it especially in children and young adults, in patients with renal failure, allergy to iodinated contrast agents, or fear of ionizing radiation or arterial catheterization. high resolution d mr-angiography in renal arteries using sense this was related by measurement to the umbilicus and asis. results: on ct, the median (interquartile range) of the distances between the umbilicus and the ab, from the asis to the ab and from the umbilicus to the iv were − . ( . ), ( ) and − . ( ) mm respectively. the mean angle of the umbilicus from the ab was . ° (range - °). on us, the mean distance from the iea to the midline was . mm ( - ) and from the iea to the asis was mm ( - ). the relationship between the level of the asis and ab/iv is more consistent than the position of the umbilicus. primary-port trocar insertion at an angle of ° and secondary-port insertion mm from the midline is recommended. renal cyst ablation using mixture of n-butyl cyanoacrylate and iodized oil in patients with autosomal dominant polycystic kidney disease: a preliminary report j. kim , s. kim , m. moon , h. lee , j. sim , s. kim , c. ahn ; seoul/kr, koyang/kr purpose: to assess the feasibility and effectiveness of renal cyst ablation using n-butyl cynoacrylate (nbca) in patients with autosomal dominant polycystic kidney disease (adpkd). materials and methods: during the past months, renal cysts in patients were treated with percutaneous needle aspiration and intracystic injection of : mixture of nbca and iodised oil. clinical follow-up was done in all patients for the period of - months. subjective symptoms, blood pressure, and serum creatinine level before and after the procedure were compared. ct follow-up was done in cysts in eight patients for the period of - months. the procedure was considered successful at follow-up ct when the diameter of the cyst decreased more than % after the procedure as compared to that before the procedure. results: after nbca therapy, symptom was improved in of patients ( %) and cyst was disappeared or decreased more than % in diameter after the procedure in of cysts ( %). there were no significant changes in blood pressure and serum creatinine level after the procedure. there was no significant complication related to the procedure in any of the patients. conclusion: percutaneous needle aspiration with intracystic injection of mixture of nbca and iodised oil appears to be feasible and may be an effective modality in ablating renal cysts in patients with adpkd. purpose: stimulated acoustic emission effect shows marked lesional difference in uptake of the microbubble levovist in its liver specific phase. benign lesions showed high uptake, malignancies appeared as defects. a multicenter trial using a novel non-linear mode (adi, acuson, mountain view) offering greater sensitivity and spatial resolution. methods and materials: patients with focal liver lesions characterised either by biopsy or serial/multimodality imaging have been studied. diagnoses were: metastases n = , hepatocellular carcinoma (hcc) n = ; haemangioma n = and benign non-haemangiomatous lesions (bnhl) n = , comprising focal nodular hyperplasia fnh; n = , focal fatty sparing n = , focal fat , adenoma n = , regenerating nodule: rgn n = . adi imaging of the lesion was performed without interval scanning after a delay of minutes from bolus injection of levovist ( . g). liver-lesional uptake differences (llud: as %) were compared using a visual analogue score. comparisons were made using non-parametric comparisons (kruskal-wallis anova; mann-whitney -column comparisons with bonferroni corrections). results: highly significant differences (p ≥ %), while fat/fatty sparing, rgn and fnh showed minimal differences (< %). hccs (mean liver-lesion difference %, range - %) and haemangiomas (average %, range - %) showed overlap features. intergroup comparisons showed significant differences between bnhl and all other lesion types and between metastases and haemangiomas. conclusion: this simple test shows marked differences between lesion types. it is a very useful test for fatty change, fnh and rgn. non-haemangiomatous lesions can be separated from metastases with particularly high accuracy. the present of high-uptake of levovist at minutes is strong evidence for benignity. b a c d e f contrast-enhancement patterns of hepatic lesions at c -mode intermittent us imaging d. cioni, r.a. lencioni, f. donati, l. crocetti, m. perri, c. franchini, c. bartolozzi; pisa/it purpose: to describe contrast enhancement patterns of focal hepatic lesions at c -mode intermittent us imaging. materials and methods: a series of hepatic lesions in patients were examined. us examination was performed by using c -mode intermittent imaging (technos, esaote biomedica) with . mechanical index after bolus injection of . g levovist (schering ag) at the concentration of mg/ml. us images were acquired in arterial ( - s), portal in-flow ( - s), full portal ( - s), and delayed ( - s) phases. findings at contrast us studies were correlated lesion-by-lesion with those at spiral ct or dynamic mri. results: four distinct enhancement patterns were observed: ( ) rapid enhancement in arterial phase, followed by either isoechoic ( / focal nodular hyperplasia, / hepatocellular adenoma, / haemangioma) or hypoechoic appearance ( / hepatocellular carcinomas) in portal-venous and delayed phases; ( ) peripheral globular enhancement in arterial phase, with centripetal fill-in in portal-venous and delayed phases ( / haemangiomas); ( ) rimlike enhancement in arterial phase, followed by hypoechoic appearance in portal-venous and delayed phases ( / metastases); and ( ) no enhancement in arterial phase followed by either isoechoic ( / macroregenerative nodules) or hypoechoic appeareance ( / metastases) in portal-venous and delayed phases. the enhancement patterns shown at contrast us correlated with spiral ct or dynamic mri findings in of lesions ( %). conclusion: c -mode intermittent us imaging is an accurate tool to evaluate the contrast enhancement patterns of focal hepatic lesions. findings correlate well with those at spiral ct or dynamic mri. clinical study of a d virtual sonographic system to be used for remote diagnosis d. jeanbourquin , t. le bivic , r. larrue , p. pineau , j.-c. provost ; clamart/fr, paris/fr objectives: virtualprobe system (iôdp, paris, france) allows to acquire sonographic images simultaneously with spatial position of the probe, in order to rebuilt exact d sonographic volumes. the system allows to rescan through the d volume in order to perform a complete but asynchronous sonographic examination. one possible application would be military medicine, because the expert is not present at the time and on the site where diagnosis has to be done. the objective was to evaluate the ability of the system to be used for remote medical diagnosis. the examinations from patients were done on non moving organs, mainly on cervical and abdominal areas. examinations using conventional method were performed and later on compared to those realized using virtualprobe. all examinations were done by qualified radiologists. the image quality of the methods were scored from to (poor to very good). moreover, the ability of the system to allow proper diagnosis was recorded. results: there was no difference between methods in image quality. for virtualprobe, diagnosis was adjudicated as "possible" in cases ( . %), "possible with some difficulties" in cases ( . %) and "not possible" in cases ( %) due to technical problems (electromagnetic interferences and patient with polypnea leading to the impossibility to do acquisition). conclusion: virtualprobe system is a powerful tool that would provide a significant improvement in remote medical diagnosis using ultrasonography. differentiation of neoplastic portal vein thrombus from vascular thrombus in cirrhotic patients using harmonic sonography and second generation contrast agents m. tonolini, v. osti, l. solbiati, p. marelli, v. kirn; busto arsizio/it purpose: assessment of neoplastic nature of intraportal thrombus is of crucial importance for staging and therapeutic choice in patients with hepatocellular carcinoma (hcc). we sought to assess the utility of grey-scale harmonic sonography using second generation contrast agents for differentiating between neoplastic and bland portal venous thrombus. materials and methods: cirrhotic patients with solitary or multifocal hcc were evaluated for potential rf ablation therapy with triphasic helical ct, b-mode and color doppler us. contrast enhanced ultrasonography (ceus) was performed using low mechanical index ( . - . ) and a second-generation contrast agent (sonovue, bracco). liver parenchyma and main portal branches were examined over arterial, portal, and delayed phases. results: in patients ( . %) conventional us and helical ct identified thrombus within the portal trunk or main branches. arterial enhancement was depicted by ct in / ( %) cases suggesting malignant nature. unenhanced color doppler detected arterial-type flow signals within the thrombus in of cases ( %). with ceus, / ( %) thrombus showed rapid and inhomogeneous enhancement in the arterial phase (p < . , compared to unenhanced us). in the portal phase, the enhancement of these thrombi decreased in proportion to the respective hccs, as contrast filled the patent portions of the vessel. in the remaining cases, no arterial enhancement was detected and no malignant cells were found by us-guided fine-needle aspiration biopsy. conclusions: our study suggests that continuous-mode, contrast-enhanced harmonic sonography may serve as an easy and highly reliable modality for the characterization of portal thrombus in cirrhotic patients. specificity of contrast-enhanced harmonic sonography for characterization of solid, incidentally detected focal liver lesions l. solbiati, m. tonolini, l. cova, d. della chiesa, v. kirn; busto arsizio/it purpose: to assess the use of contrast-enhanced harmonic sonography (ceus) in the differential diagnosis of incidentally detected focal liver abnormalities. methods and materials: patients underwent abdominal us for clinical questions unrelated to the liver. none of the patients had chronic hepatitis/cirrhosis nor history of malignancy. solid focal lesions were found in patients ( . %). lesions with characteristic features of hemangioma were excluded. low mechanical index, continuous-mode ceus was performed using a second-generation contrast agent (sonovue, bracco). final diagnosis was established by means of helical ct, dynamic mri and/or fnab. results: in / focal nodular hyperplasias (fnh) and / atypical hemangiomas the typical enhancement pattern was detected. in patients presenting multiple hyperechoic lesions, ceus showed enhancement analogous to that of the surrounding liver in all vascular phases, suggesting the diagnosis of focal fatty changes, subsequently confirmed with ct and fnab. in four patients with poorly enhancing lesions, ceus did not provide diagnostic findings and fnab was necessary to diagnose fibrotic hemangioma ( patient), multiple tubercolous granulomas ( ) and disseminated metastases form unknown origin ( ). conclusions: for the characterization of most incidentally detected and sonographically indeterminate benign lesions (fnh, atypical hemangioma, focal fatty change) ceus (through the assessment of the enhancement behaviour over the different vascular phases) showed specificity equal to that of helical ct. ceus will probably alleviate the need for further investigation with helical ct studies and aspiration biopsies. o. catalano , a. nunziata , f. sandomenico , a. siani ; pozzuoli/it, naples/it purpose: to evaluate if ce-pd is helpful in the differential diagnosis of focal hepatic lesions detected by grey-scale ultrasound. methods and materials: in a -year period consecutive patients where found to have previously unknown, non-cystic lesions on ultrasound examination ( subjects showed lesion, - lesions, and > lesions). these lesions were evaluated with levovist-enhanced pd and were fitted into categories (hepatocellular carcinoma, cholangiocellular carcinoma, adenoma, focal nodular hyperplasia, angioma, metastasis, dysplasic nodule, abscess, other). diagnostic confidence level was graded subjectively from (possible) to (certain). categorisation and diagnostic confidence scoring were repeated after ce-pd study. eight cases without confirmation were excluded. results: addiction of ce-pd study resulted in a change of category for patients ( . %), all with a single lesion; this modification proved correct in all of them. excluding subjects with a maximal scoring (level ), there were patients with increased confidence after ce-pd study, with decreased confidence, and with unmodified confidence after ce-pd; score change was never greater than level. in the two most commonly encountered issues, suspected nodule in chronic liver disease and angioma vs. hypovascular metastasis, ce-pd imaging was rarely useful. conclusion: ce-pd increased the characterisation accuracy of ultrasound only in selected cases while it is not cost-effective if employed routinely. these patients can usually be predicted on a clinical-sonographic basis allowing selective ce-pd imaging to be performed. purpose: to define and quantify acoustic parameters in order to characterize liver histopathologic findings in patients presenting with chronic hepatitis type c using a commercially available ultrasound system. materials and methods: patients with a chronic hepatitis type c were prospectively enrolled. cineloops from the liver and the spleen were acquired using an atl hdi unit (atl-philips, wa, usa). raw data were transferred to a pc for quantification with hdi lab, a software that eliminates the effects of the nonlinear b-mode map. two parameters were calculated using a linear time gain compensation: the liver and spleen attenuation coefficients (respectively lac and sac), and the signals of a region-of-interest (roi) located at cm depth (mean and sd, linear units). all results were correlated to the results of the liver biopsy (knodell and metavir score). results: lac was higher than the sac in all cases. lac and the normalized ac (lac − sac) was significantly higher in cases of cirrhosis (p < . ). the signal intensity from the roi was not correlated to the histological findings. the standard deviation increased in cases of cirrhosis due to the heterogeneity of the echostructure. conclusion: quantitative ultrasonography is feasible in routine practice and can improve the stadification of cirrhosis due to chronic hepatitis type c. evaluation of reformatted image quality using a new d imaging tool for ultrasound multiplanar reconstruction m.j. o'neill, s.i. lee, j.f. simeone, p. mattos, j. haase, p.r. mueller; boston, ma/us purpose: virtualprobe® (iôdp, paris) is ultrasound acquisition and post processing software that uses an electromagnetic field to acquire positional data, allowing retrospective multiplanar d rescanning through a volume of tissue. the aim of this study was to compare image quality of the d movie clips used for volume rendering and the d reformatted images to that of conventional d images. methods and materials: patients referred for exams of the kidney ( ) and abdomen ( ) were enrolled. each patient had a conventional ultrasound exam, followed by the virtualprobe. the static images, d movie clips, and d reformatted images were then graded by radiologists on a point scale ( = best quality and = worst). the difference between either the d clips or d reformats and the static images for right and left ( ) kidney ( ) liver ( ), pancreas ( ), cbd ( ), spleen ( ), gallbladder ( ), and bladder ( ) , for the static images, d clips, and d reformats. there was no significant difference in image quality for d movie clips or d reformats when compared to standard images. ratings when compared to the static images yielded p values ranging from . to . and . to . for d clips and d reformats. there is no significant difference in image quality between static ultrasound images, d movie clips, and reformatted multiplanar reconstructions when using the virtualprobe® post processing software. pim minutes after iv injection of levovist ( g, mg/ml). pim examinations were analysed in consensus by two radiologists who assessed the number of lesions, the conspicuity of lesions on a scale - , and the smallest lesion diameter in comparison with baseline us. ct studies were performed using a multidetector ct scanner with cm of a non ionic contrast agent ( mg i/ml) at a flow rate of ml/s. scans were acquired at scan delay for the hepatic arterial phase, s scan delay for the portal venous phase and s for the delayed phase, with a collimation of × . mm and a slice thickness of mm. all ct scans were evaluated in consensus by two experienced radiologists blinded to the results of us analysis. results: pim improved the conspicuity and the detection of lesions in comparison to baseline us ( % increase) and to msct ( % increase). in comparison with msct, the number of lesions detected with pim increased from to ; the improved detection rate was limited to lesions less than mm in diameter and to non-cirrhotic patients. conclusions: pulse inversion mode may depict more lesions than msct although patients with very inhomogeneous liver parenchyma can represent a limit. performance of a digital flat-panel detector system in the detection of subtle rib fractures: a comparison with a conventional screen-film system and a phosphor-storage system at different levels of exposure k. ludwig, c. schuelke, h. lenzen, t.m. bernhardt, s. diederich, d. wormanns, p. brinckmann, w.l. heindel; münster/de purpose: to compare a digital flat-panel detector in the detection of subtle rib fractures with conventional screen-film radiography and phosphor-storage radiography at different levels of exposure. method/materials: subtle fractures were created in of porcine rib specimens. specimens were mounted into a basin filled with water to obtain absorption and scatter radiation conditions comparable to a human chest. imaging was performed using a flat-panel detector system, screen-film system and phosphor-storage system. exposure settings comparable to clinical imaging were applied ( kvp, s = ). additional imaging was performed with both digital imaging modalities at lower exposure doses: with the flat-panel detector images were acquired at exposure doses corresponding to speed-class , and , with the phosphorstorage system to and . for each image the presence/absence of a rib fracture was assessed independently by three radiologists according to a five level confidence scale. roc-analysis was performed for a total of observations ( for each imaging modality/exposure level). multivariate analysis was used to compare aucs. introduction: new digital imaging techniques offer the ability to adjust the radiation dose required to answer the clinical question. irrespective of the type of imaging technique, the lowest dose compatible with the required image quality should be used. material and methods: a comparative study was performed with three units for storage phosphor and a flat detector unit. image quality was evaluated by a contrast detail radiography phantom (nuclear associates: digirad). this was completed by further studies using phantoms containing anatomical structures. clinical images and doses were also evaluated by european centres for radiology and medical physics that co-operate within the dimond- ec project. results: the images of the digirad phantom demonstrate differences in the image quality of storage phospor systems, but flat panel detector technology showed far the highest image quality. for the flat panel detector radiation dose can be decreased significantly in comparison to storage phosphor systems. using flat panel detectors all examinations can be performed with a maximum of halve the dose compared to storage phosphor systems, operated at a speed class. further dose reduction by a factor of is possible for specific examinations. conclusion: dose mangement with new digital imaging techniques can decrease radiation dose to the patient significantly. in a broad range dose and image quality can be optimized and adapted to the clinical question. performance of a digital flat-panel detector system in the detection of simulated rheumatoid erosions: a comparison with a conventional screenfilm system, a mammography-system and a phosphor-storage system at different levels of exposure k. ludwig, a. henschel, h. lenzen, t.m. bernhardt, d. wormanns, w.l. heindel; münster/de purpose: to compare a flat-panel detector system in the detection of simulated rheumatoid erosions with a screen-film system, mammography system and phosphor-storage system at different levels of exposure. method/materials: artificial lesions (diameter . - . mm, depth . mm) simulating erosions were created in predefined regions in the mcp-and pipjoints of monkey paw specimens. specimens were enclosed in containers with water for absorption/scatter conditions comparable to a human hand;imaging was performed at kvp using a digital flat-panel detector system with exposure-doses corresponding to speed-class (s) , , , , , , system, a phosphor-storage-system at (s) , , , , a speed-class screenfilm system and a mammography system. three radiologists independently evaluated each region for the presence/absence of a lesion according to a five level confidence scale. roc-analysis was performed for . observations ( for each imaging modality/exposure dose). multivariate analysis was used to compare aucs. in erosive lesions the flat-panel system is superior to conventional screen-film radiography and phosphor-storage radiography at clinical exposure settings. it offers the same diagnostic performance with a lower exposure. reference levels during interventional cardiology procedures: the european dimond experience v. neofotistou; athens/gr purpose: to present the european dimond approach in defining reference levels (rls) for radiation doses delivered to patients during interventional cardiology (ic) procedures, namely coronary angiography (ca) and percutaneous transluminal coronary angioplasty (ptca). rls have been suggested by the council directive of the european community / /euratom as a means of optimising diagnostic exposures. method: during the dimond (digital imaging: measures for optimising radiological information content and dose) european research program patients' doses during ic procedures were measured. this was done in terms of dose-area product (dap), fluoroscopy time and total number of radiographic exposures. values were obtained in three participating european hospitals, using previously checked x-ray equipment and according to a commonly agreed protocol. moreover, a dap trigger level has been defined in order to prevent skin injuries since ic techniques are known to be associated with high radiation doses and thus deterministic effects may be observed. results: rls for dap equals gycm and gycm , for fluoroscopy time . min and min and for number of frames and for ca and ptca respectively. dap trigger level for cardiac procedures, which should alert the fluoroscopist for probable skin injury, equals gycm . the proposed values, which should be considered only as interim rls, take no account of the complexity of particular case or patient's physical characteristics dimond rls are being updated with patient doses measurements taken in seven european countries and with degrees of tolerances assigned to complexity of procedure as well as the patient's size. optimized spectrum in direct digital mammography w.j.h. veldkamp, n. karssemeijer, r.e. van engen; nijmegen/nl purpose: the objective is to find the optimum target-filter and kilovoltage for varying simulated breast thicknesses when using a flat panel full field digital mammography detector (ge senograph d). we use the cdmam phantom that was developed at our institute. this phantom consists of a matrix of squared cells with dots of varying size and contrast. each cell contains two dots, one in the center and one in a scientific sessions sunday b a c d e f randomly selected corner. a computer program was used for automatic readout of the phantom recordings. the program uses the ideal observer model for detecting the dots. image quality is expressed by the contrast detail curve relating object size and contrast at some fixed detection threshold. to cover a range of exposure conditions and breast thicknesses a total of recordings were evaluated. the glandular dose was kept constant for each simulated breast thickness while spectrum parameters were varied. results: results showed that for cm perspex the rh-rh target-filter combination gave superior image quality compared to mo-rh and mo-mo. for and cm perspex the different target filter combinations gave comparable image quality. the results suggest that in full field digital mammography a rh-rh target-filter combination can be used for the whole range of breast thicknesses. an investigation of the observer variability in reading a contrast detail test object in digital mammography p. . images were printed on high resolution printers. a cdmam contrast detail phantom . (nijmegen, the netherlands) was placed on top of cm of polymethyl methacryllate. images were read by a group of experienced observers within the dimond iii ec project. optimal viewing conditions in respect of viewing box brightness and ambient light level were used. image scores were analysed using a computer program which incorporated the rules for interpreting images. results and discussion: contrast-detail curves and image quality factors could be calculated for the different observers and images. observer variability was compared with theoretical predictions and some readings from conventional mammography images. image quality factors were low, meaning that low contrast differences and small objects could be distinguished. the variability of the readings was large, but tolerances were similar in all observers. therefore, we propose to also acquire typical cdmam images from digital mammography systems as part of an acceptance testing programme. first clinical experience of a digital slot-scanning-area detector for mammography t. francke , j. egerström , m. eklund , l. ericsson , t. kristoffersson , v. peskov , j. rantanen , s. sokolov , p. svedenhag , s. thunberg , c. ullberg , n. weber ; stockholm/se, danderyd/se purpose: to compare image quality and dose for a novel digital slot-scanning area detector vs. conventional analogue film-screen images. the design of the detector, photon counting and small detector width of mm, results in a very high image quality (high resolution and high contrast) at a low dose. the avalanche gaseous photon counting technique, allows for virtually scatter free and noise free images, resulting in very high signalto-noise ratio. this new detector has been mounted on a commercially available mammographic unit (mammomat , siemens). the digital images taken with the instrument are compared to analogue film images, where the beam quality (kvp and anode/filter combination) as well as projections has been kept the same to allow a true comparison. results: a full field mammographic digital detector, × cm, based on a slotscanning-area technique with photon counting gaseous detectors has been evaluated. the performance of the detector has been studied and compared to analogue film-screen system by imaging phantoms, breast specimens and patients. the results are very promising, compared to conventional film-screen images, regarding image quality and a significant dose reduction. conclusions: noise-free photon counting is a promising method for digital x-ray imaging, improving image quality as well as significant reducing the glandular dose to the patient. first considerations regarding an acceptance protocol for full field digital mammography equipment: validation in a multicenter setting f. rogge , a.-k. carton , h. bosmans , e. vano , p. torbica , a. crevecoeur , y. palmers , k. faulkner , g. marchal ; leuven/be, madrid/es, innsbruck/at, liège/be, genk/be, newcastle upon tyne/gb purpose: the introduction of full field digital mammography equipment requires the development of acceptance testing protocols. we have reviewed the current european protocol for quality control in (conventional) mammography within the dimond- ec project and we propose a similar series of tests for digital systems. methods and materials: following tests had to be redefined: the assessment of the focal spot size, different tests of the automatic exposure control and tests of the detector including the grid. image quality was evaluated via phantom exposures and dqe measurements. the protocols were tested on digital senographe dmr systems (ge) and on digital fuji detector. results and conclusion: all the tests included in the revised acceptance protocol may be completed in under hours. the performance of the three systems was very stable. the doses for standard exposures were variable between the different sites. this has an impact on image quality. since the dose setting for a digital detector is a parameter of the x-ray system only (independent of any filmscreen combination) that can be freely adjusted in the different centers, we propose to use a quite strict guidance regarding the standard dose settings. a difficult practical problem is the transfer of data in order to perform some evaluations offline. further cooperation with the manufacturer may be needed to make this type of testing feasible for hospital medical physicists. interventional radiology purpose: percutaneous ct guided biopsy is an accurate and safe procedure to evaluate indeterminate adrenal masses in oncologic patients. we sought to assess the clinical outcome in patients with negative percutaneous needle biopsies of focal adrenal lesions materials and methods: retrospective analysis of oncologic patients (f:m, : ; age range - years, mean age years) who had undergone ct guided fna biopsies of an adrenal mass over a -year period were reviewed. the incidence of negative (for tumor) biopsy results were identified and assessed for subsequent evaluation of the biopsied lesion in these patients results: of the biopsies, ( %) were negative for neoplasm. the primary neoplasm in these patients included lung cancers, bladder, prostate, breast and renal malignancies with the size of the adrenal lesion ranging from . - cm. of these biopsies negative for tumor; were identified as adenomas and the rest showed benign adrenal cortical cells or hyperplasia on cytopathology and histopathology. an experienced pathologist interpreted all specimens as sufficient for diagnosis. repeat biopsies were obtained in / ( %) patients; whereas / ( %) had the adrenal glands analyzed on post mortem examination. none of these repeat evaluations yielded tumor conclusions: a negative or normal pathology result in a ct guided percutaneous adrenal biopsy can be regarded as a true negative evaluation in oncologic patients with no necessity to repeat the biopsy. a c d e f materials and methods: in patients ( liver tumors and different abdominal tumors) mr-guided biopsies or punctures were performed with a low field mri ( . t, magnetom open, siemens). for guidance of the needles, t -weighted flash sequences (tr/te / ; °) were performed in all patients and an additional fisp-rotated-keyhole-sequence (tr/te / ; °) was also used. after positioning of the needle tip in the tumor, biopsy specimens were acquired with - g cutting needles (somatex®) during the interventional procedures. the visibility of the needles, the tumors and the abdominal vessels were evaluated. results: all interventional treatments were performed without vascular or organ injury. adequate specimens for histological interpretation were obtained in cases ( . %). in patients ( . %) the biopsy result was non-specific and in patients ( . %) the lesion was missed. t -weighted flash images were useful for confirming needle-tip placement during the biopsies or punctures. the use of free slice orientation facilitated the interventional procedure. the organs, tumors and vessels were easily determined. the fisp sequence resulted in equal or inferior results. conclusion: mr-guided abdominal interventions can be performed with acceptable safety and accuracy with low field systems. lesion and needle visibility are significantly affected by user-defined parameters which must be considered during procedure planning. materials and methods: over . years, biopsies were carried out under ct-fluoroscopic control (philips aveu and toshiba aquilion) in the lung ( . %), mediastinum ( . %), abdomen ( . %), pelvis ( . %), retroperitoneum ( . %) and varia ( %). in cases, the obtained material was sent to pathology. % ( ) provided material for cytology, % ( ) for histology. a pathologist was on-site and decided, by means of a quick staining procedure, whether further tissue removal was necessary. the primary tumour was known in cases. the number of punctures, unsuccessful biopsies, positive and negative results (classified according to biopsying examiner and location), differences between histology and cytology and complications were analysed. results: on average, . punctures were performed to complete the procedure. tissue samples for cytology were obtained in cases ( %). the overall sensitivity for cytology and histology was % and %, respectively; % and % with known primary; % and % with unknown primary. in ( . %) and ( . %) of cases, no diagnostic material was obtained with cytology and histology, respectively, although the on-site pathologist assumed that sufficient material was present. benign lesions were found in cases ( . %), biopsies were unsuccessful ( . %). one less experienced examiner yielded only % sensitivity. overall, complications occurred in patients ( %). conclusions: ct-fluoroscopy-guided biopsy represents a safe and reliable technique with a high sensitivity for malignancy and minimal difference between cytology and histology. the examiners experience plays a decisive role in the diagnostic outcome. the device used (pin point*) is integrated into a multisclice ct (mx , *marconi medical systems). it uses a laser assisted proprietary articulated arm technology and displays corresponding multiplanar ct images as the computer assisted arm is manipulated along the patient's body. the system includes an intuitive virtual planning tool that allows simulation of the best instrument path from the entry point to the target area. biopsies of masses in patients were carried out. all biopsies were obtained using an or gauge high speed tru-cut biopsy gun. masses biopsied included lung ( ), lymph nodes ( ), bone ( ) and pelvis ( ). an average of . passes was performed. results: using this system interventions could be confidently planned and safely carried out even in difficult or risky areas in all cases. however, due to respiratory motion there are some limitations, particularly with lung lesions. mean proce-dure time was min ± min. in % of the cases biopsies were diagnostic. after central lung biopsy of patients with pneumothorax required a chest drainage. cases with haemoptysis resolved with conservative treatment. conclusion: the evaluated simulation and virtual planning system is safe, quick and convenient for ct-guided biopsies with some limitations due to respiratory motion. it may also become a useful tool for additional ct-guided therapeutic procedures. evaluation of age-related risk profiles for pneumothorax in ct-guided percutaneous thoracic biopsies b. rapprich , t. werba , r. tomczak , n. rilinger ; offenbach a. main/de, bad friedrichshall/de purpose: in studies of patients undergoing percutaneous thoracic biopsies, the risk for pneumothorax has varied from - %. our aim was to develop a risk profile for pneumothorax based on the severity of pneumothoraces and in correlation with age and the presence of emphysema. methods and materials: we retrospectively investigated outcomes of patients with ct-guided thoracic biopsies using an g coaxial cutting-needle with a high-speed-automatic system (biopty bard). pneumothorax was graded as: i minimal, local; ii < cm; iii > cm; iv chest tube required. emphysema was graded as: i discrete; ii moderate; iii extensive. results: . % of the biopsies in patients were successful. the diagnostic sensitivity was % and the incidence of pneumothorax was . % (grade i: . %; ii: . %; iii: . %; iv: . %). for younger patients the risk of severe pneumothorax (grade iii or iv) increased linearly. the degree of emphysema did not correlate with the incidence of pneumothorax. conclusion: the pneumothorax risk for elderly patients decreases in transthoracal ct guided automated high-speed cutting-needle biopsies. the incidence of severe, clinically relevant pneumothoraces increases linearly in younger patients. the linear correlation is caused by morphological and functional linear changes due to the regular aging of the lung. no correlation with pathological emphysema was found. purpose: the aim of this study was to examine the feasibility of percutaneous drainage of abdominal fluid collections using a mri-compatible drainage system. material and methods: in patients drainage procedures were performed with mri-compatible drainage systems (somatex®) for the interventional treatment of abdominal fluid collections). for all procedures a low field mr-system ( . t, siemens) was used. the punctures were controlled using t -weighted flash sequences (tr/te / ; °) and a fisp-rotated-keyhole-sequence (tr/te / ; °). after positioning of the catheter in the fluid collection, the topographic details were controlled with intracavitary injection of an aqueous gadolinium solution (dilution : ). results: all drainage catheters were successfully placed into the fluid collections under mr-guidance. the catheter position was easily visualized with the t weighted flash sequences. using the fisp sequences the visibility of the catheters was good or moderate and also useful for mr-guidance. no procedure-related complications occurred. the mean time needed for the drainage procedure was min ± min. the fluid collections were drained for a mean of days. the topic of the study presented here is the evaluation of the feasibility and acceptance of repeated ultrasound-guided lymph node puncture for vaccination. we performed ultrasound-guided punctures of inguinal lymph nodes in patients with proven malignant melanoma and biopsy confirmed metastases of the disease. we delivered a suspension containing antigen pulsed dentritic cells, under ultrasound view, directly into the lymph node's paracortical area. to visualize the procedure we used a high-resolution computed ultrasound system (sequoia ) with a mhz linear array probe. the tip of a g needle was placed into the paracortical area of the node, and application of the suspension was performed under ultrasound view. results: normal-sized, morphologically unsuspicious lymph nodes were found in every patient during every procedure. major side effects were not observed; we merely noticed fever in patient, painful swelling of the punctured lymph node in patients, and newly occurring vitiligo in patients. the immunological results of our therapy are still under evaluation. conclusion: ultrasound-guided intranodal vaccination is a reliable and reproducible technique to deliver antigen-pulsed dentritic cells into peripheral lymph nodes. the method is well accepted by patients. it could lead to changes in the therapeutical options of both malignant and infectious diseases. slowly-heparin-releasing drainage catheter: in vivo and in vitro assessment of clog-resistant effect j. han, k. lee, b.-i. choi, c. yoon, y. byun, h. moon; seoul/kr purpose: clogging of catheter is frequently encountered during various drainage procedures. we evaluated the effectiveness of a novel clog-resistant drainage catheter. we have recently developed slowly-heparin-releasing catheter by coating standard drainage catheter with the blend of amphiphilic heparin-derivative (heparin-deoxycholic acid) and polyurethane. in vitro fibrin formation test was performed by dipping heparin-coated catheter and non-coated catheter (as control) into fresh plasma for minutes, and the results were interpreted using scanning electron microscopy. for in vivo assessment, eight pairs of coated and control catheters ( french) were inserted into the peritoneal cavity in normal new zealand white rabbits (n = ). applying a basic principle in flow dynamics (resistance = pressure/flow rate), intra-catheter pressure was measured at the plateau (pmax) during saline infusion in constant rate ( . ml/s) and pmax was followed up for days to estimate the changes in effective caliber. results: on in vitro assessment, no fibrin formation was observed in heparincoated catheter compared to strong reaction in control catheter. on in vivo assessment, decrease in mean effective caliber was . % vs. . % (coated vs. control) at rd day (p = . , paired t test), . % vs. . % at th day (p = . ), . % vs. palermo/it purpose: hepatic artery stenosis and thrombosis are common complications in liver transplant patients. digital subtraction angiography (dsa) has served as the gold standard to make this diagnosis. more recently, three dimensional helical computed tomographic arteriography ( d cta) with maximum intensity projection and shaded surface display techniques has been compared with dsa. the purpose of this study is to determine if d cta with volume rendering technique is a useful and accurate tool in the detection of vascular complications after liver transplantation. methods: consecutive liver transplant patients underwent d cta with volume rendering technique. the standard of reference was dsa for patients and imaging and clinical follow-up for patients. two blinded reviewers evaluated the axial and d cta images in consensus. results: d cta with volume rendering technique detected hepatic artery stenoses, six hepatic artery thromboses, two hepatic artery pseudoaneurysms, two splenic artery aneurysms, two portal vein stenoses, and four redundant hepatic arteries. in one case ct detected a moderate hepatic artery stenosis, while conventional angiography showed a normal artery. the sensitivity of ct for detecting vascular lesions was %, specificity % ( of ), accuracy % ( of ), positive predictive value of % ( of ), and negative predictive value of % ( of ). conclusions: d cta is a useful and accurate noninvasive technique for detection of vascular complications in liver transplant patients. evaluation of an "all-in-one" multidetector-ct protocol for potential living liver donors t. schroeder, m. malagó, s. heistrüvers, s. nadalin, j. stattaus, j.f. debatin, s.g. rühm; essen/de purpose: to evaluate an "all-in-one" multidetector-ct-approach for evaluation of potential living related liver donors. materials & methods: consecutive potential living donors of the right lobe of the liver (mean age years) underwent three-phase, dual-enhancement multidetector-ct imaging to delineate biliary, vascular and parenchymal morphology. for display of the biliary system the first ct-image set was collected minutes following the infusion of ml of a biliary contrast agent (biliscopin). subsequently ct (slice thickness/collimation mm, pitch mm, table-speed mm/s) was performed for display of the arterial as well as the portal and hepatic venous systems, following automated injection of ml of an iodinated contrast agent (imeron ). analysis was based on source images and multiplanar reformats. the hepatic parenchyma was assessed for the presence of pathologies and volumetry was based on the venous data set. results: all potential donors tolerated the exam well. the 'in-room' time for the exam ranged between and minutes. one hemangioma and one adenoma were identified. total liver volumes ranged between and ml. the underlying biliary and vascular anatomy was displayed at least to the second intrahepatic branch in all cases. anatomic variations were observed involving the biliary system (n = ), the arterial system (n = ), the portal system (n = ) and the venous system (n = ). conclusion: the outlined approach proved efficient and robust. all relevant pre-op data for potential living related liver donation was collected in one single diagnostic step. ischemic-type biliary lesions following liver transplantation: evaluation with mr cholangiography p. boraschi, r. gigoni, l. urbani, e. neri, f. filipponi, c. bartolozzi, f. falaschi; pisa/it purpose: to assess the diagnostic value of mr cholangiography (mrc) when evaluating ischemic-type biliary lesions (itbl) in the follow-up of liver transplant patients. we retrospectively reviewed mr imaging and mrc of sixteen liver transplanted patients ( men, women) with ischemic changes of the biliary tree. the mr examinations were performed on a . t unit (signa, ge medical system) with high performance gradients. after the acquisition of axial t w and t w sequences, mrc involved a coronal, non breath-hold, respiratorytriggered, fat-suppressed, two-dimensional, thin-slab, heavily t w fast spin-echo sequence, and a coronal breath-hold, thick-slab, single-shot t w sequence. ten patients underwent either surgical reconstruction of the biliary system (n = ) or liver retransplantation (n = ); the pathologic specimens were employed as standard of reference. the final diagnosis was obtained through direct cholangiography in the remaining cases. without knowledge of the surgical, pathological and cholangiographic findings two experienced observers evaluated in conference the mr images to determine the presence of biliary tract abnormalities. results: mrc demonstrated strictures involving the hepatic bifurcation and extrahepatic pre-anastomotic bile duct with concomitant thickening of the biliary wall in patients; sludge or stones were present in out of these patients. in the other cases with circumscript extrahepatic lesion, mrc clearly showed intraductal sludge and/or biliary tract dilation above the non-anastomotic stricture, but direct cholangiography was more precise in determining the length of the stricture and grading the stenosis. we retrospectively reviewed doppler us images of the hv in consecutive patients who underwent lrlt. doppler us was performed between and times (mean, . times) during - days after lrlt. nineteen patients who were excluded for analysis of hv stenosis from various causes (early postoperative death, etc). patients who had more than mmhg of pressure gradient between the hv and the inferior vena cava during the procedure of hv stenting were considered to have significant hv stenosis. the control group included patients with no evidence of hv stenosis at least months after lrlt. spectral doppler us findings between the two groups were compared. results: five patients ( . %) had significant hv stenosis, and three of them showed persistent monophasic waves on doppler us whereas two patients showed monophasic waves on most of us examinations and a biphasic or a triphasic waves on -and -day follow-up. in control group (n = ), patients with persistent tri-or biphasic waves and with mixed monophasic wave with tri-or biphasic wave according to the follow-up period of us examinations, and showed persistent monophasic waves. conclusion: persistent monophasic waves on doppler us in the hepatic vein is a suggestive, but not a specific finding to be significant hv stenosis after lrlt. persistent triphasic waves on doppler us can confidently exclude significant stenosis. d ct angiography using multidetector row helical ct in the preoperative assessment of arterial supply to the liver g. brancatelli , , m.p. federle , v. kapoor , d.a. geller , j.j. fung ; pittsburgh, pa/us, palermo/it purpose: to evaluate the usefulness of ct angiography (cta) with d reconstruction to detect the arterial supply to the liver using a multidetector row helical ct. methods and materials: eighteen patients had cta. of these, had surgical correlation, including who also underwent conventional arteriography. the remaining patient had conventional arteriography only. images were reviewed in cine mode on a pacs station with d volume rendered images. axial ct sections and volume rendered images were prospectively reviewed by two blinded readers jointly. results: all studies were technically satisfactory. ct angiographic findings were confirmed at surgery in / ( %) patients (classical arterial anatomy, n = ; replaced left hepatic artery (lha) off the left gastric artery (lga), replaced right hepatic artery (rha) off the superior mesenteric artery (sma) and accessory lha to segment iv off the common hepatic artery (cha), n = ; replaced lha off the lga, n = ; replaced cha off the aorta, n = ; replaced lha off the lga and replaced rha off the sma, n = ; rha, lha and gastroduodenal artery off common hepatic as a trifurcation, n = ; rha off the coeliac trunk, accessory lha to segment iv off the cha, n = ). findings at cta and conventional arteriography were concordant in / patients. in the single discordant case cta depicted a rha off the celiac trunk and an accessory lha to segment iv off the cha, but did not identify a lha off the lga. conclusion: cta is valuable in detecting the arterial supply to the liver allowing for precise surgical plannning. there are a number of sonographic features of posterior tibial tendinosis (ptt). one of these is an increase in posterior tibial tendon calibre. the aim of this study is to compare the posterior tibial tendon calibre in patients with ptt against a group of normal subjects by ultrasound. methods: patients with ptt were referred by the orthopaedic department for assessment of the posterior tibial tendon. healthy asymtomatic volunteers were taken as normal subjects. the posterior tibial tendon was examined by high frequency ultrasound (at least . mhz, usually - mhz). the cross-sectional area was measured at three points along each tendon whilst keeping the probe at a right angle to the course of the tendon as it runs behind and under the medial malleolus and then forward on to its insertion at the navicular bone. the reference points were behind the medial malleolus, below the medial maleolus and just proximal to the tendon insertion. results: over a four year period, patients with uni-or bilateral ptt were examined. the tendon calibre was compared with measurements obtained from normal subjects from which the mean and standard deviation values were determined. it was shown that the vast majority of those with symptomatic ptt had values greater than standard deviations above the mean normal value at each reference level. conclusion: patients with posterior tibial tendinosis demonstrate an appreciably larger tendon calibre than normal subjects. this is a very helpful sign in the diagnosis of posterior tibial tendinosis. kinematic ankle mri with a low field mri system g. dazzi, e. silvestri, a. iozzelli, f. magnaguagno, g. garlaschi; genova/it purpose: to test the usefulness of kinematic ankle mri performed with low field mri equipment. methods/materials: from january until february we examined ankles using a . t mr system (artoscan, esaote). / patients (n = synovial anterior impingement, n = osseous posterior impingement, n = lateral ankle sprains) underwent kinematic evaluation. we obtained the adequate range of motion by moving the chair with the foot in a fixed position, so that the leg passes from a semiflexed to the fully extended position. in this way, the ankle moves from ° dorsiflexed to ° plantarflexed position. kinematic examinations were performed on sagittal and/or axial planes using hse t w sequences. results: we didn not identify significative findings in all cases of synovial anterior impingement. on the other hand, kinematic exams allowed a better evaluation of all patients with osseous posterior impingement. we directly visualized peroneal tendon instability in / cases of lateral ankle sprains. conclusions: kinematic ankle mri, performed with a low field unit, is a simple and quick technique in the study of some ankle pathologies. in particular, it seems to be very useful to evaluate the biomechanical alterations of osseous posterior impingement and to demonstrate the presence of peroneal tendon instability which is often unrecognized and misdiagnosed. purpose: the aim of this work was to assess mri diagnostic accuracy in detecting pathological conditions which lead to tibio-talar joint (ttj) impingement, using arthroscopy as the gold-standard. method and materials: patients (aged - years) clinically complaining of ankle unsteadiness and swelling entered this study; out of patients referred to a history of ankle sprain. mri examination was performed with both a . t whole-body (tse t -w and se t -w sequences) and a . t dedicated system (se t and t -w sequences). in cases i.v contrast material was administered followed by se t -w sequences with fat saturation pulse. all the patients underwent arthroscopy. results: mri examination revealed the presence of ttj synovial impingement in patients and in only of them the presence of contrast enhancement revealed acute inflammatory stage; arthroscopy always detected a thickened synovial lining. in patients mri examination showed the presence of tibio-peroneal tendon injury associated with synovial hypertrophy ("meniscoid syndrome"); in of these cases contrast enhancement was evident. in patients mri examination documented the presence of a bony impingement due to talus and tibial osteophyte; in these cases arthroscopy confirmed mri diagnosis. three patients had a completely negative mri examination, one of them showing a meniscoid syndrome on arthroscopy. conclusion: because of a good correspondence with arthroscopic findings we may consider mri very accurate in the diagnosis of different pathological conditions causing ttj impingement. mri is also able to detect extra-capsular causes of impingement. forty patients affected by tibio-talar pain and swelling were submitted to plain films and to mri using dedicated and whole body mri units. in of them history of a previous inversion ankle sprain was present. in five cases intra-articular injection of paramagnetic contrast media ( - ml of contrast medium obtained from the dilution of . ml of gd-dtpa in ml of saline) was performed. ct scanning was performed in nine cases. all patients underwent surgery. in of the cases arthroscopy confirmed the mri findings. examples of chondral disease were discovered by mri with differing degrees of severity ( low, mild, severe grade). in of low grade conditions, arthroscopy could not reveal the damage of the deepest aspect of the cartilage and subchondral drilling was performed on the basis of mri findings. in nine patients arthroscopy confirmed ct and mri evidence of osteochondritis dessicans. in the other cases mri and arthroscopy could not reveal any pathological condition. conclusion: on the basis of our experience, mr has to be considered the gold standard in the study of ttj cartilage allowing evaluation of its full thickness and of the subchondral bone. subjects and methods: patients with recurrent lateral derangement of the ankle were studied with ct and mri. ct was performed with coronal acquisitions using a conventional equipment. mri was performed with a superconductive scanner, and coronal and sagittal t and t *w images. in cases (selected group) no signs of alteration of both internal and external collateral ligaments were demonstrable. in these patient analysis of the angle between long axis of the tibia and major axis of subtalar joint (ts angle) was calculated and the appearance of the articular space of subtalar joint was also evaluated. analogous measurement was done in a control group of asymptomatic patients results: in cases ts angle appeared acute; in of them mri demonstrated partial synostosis/synchondrosis of the subtalar joint. in cases ts angle appeared highly obtuse and no signs of synchondrosis/synostosis were identifiable. in cases no signs of alteration of the subtalar joint were demonstrable both at ct and mri. to analyse the normal mr anatomy of the intermetatarsal space, with emphasis in the description of the intermetatarsal bursae and neurovascular bundles, using mr imaging, mr bursography, as well anatomic and histologic correlation in cadavers. high resolution mr imaging of intermetatarsal spaces derived from fresh human cadaveric feet was performed. the intermetatarsal bursae were injected, and mr imaging were performed. t -weighted and fat saturated t -weighted spin echo sequences were performed in the orthogonal planes. the intermetatarsal space anatomy was analysed. histologic examinations were performed. the intermetatarsal spaces were located in the forefoot, between two metatarsal heads, below and above the deep transverse metatarsal ligament (dtml) that divided them in two levels. the superior levels contained the synovial bursa, the interosseous muscles and tendons, and the collateral ligament complexes of the metatarsophalangeal joints, while the inferior levels contained lumbrical muscles and neurovascular bundles. one case presented a morton's neuroma. mr bursography improved the visualization of the structures of the superior level. the bursae extended distal to the dtml in the second and third spaces close to the neurovascular bundles and did not extend beyond the dtml in the first and fourth spaces. objective: plantar fibromatosis is an uncommon benign condition manifested by proliferation of fibrous tissue within the plantar fascia. as opposed to plantar fasciitis which affects the calcaneal insertion, plantar fibromatosis affects the mid-to forefoot region of the plantar fascia. methods: over a four year period, patients ( females; males, average age . years) with clinically suspected plantar fibromatosis were examined by ultrasound mhz (siemens sonoline) or - mhz (atl hdi ) linear array transducers. results: plantarfibromatosis was seen as a discrete fusiform-shaped nodular thickening of the plantar fascia removed from the calcaneal insertion. of the patients examined, ( %) had unilateral disease while ( %) had bilateral disease. of the affected feet, a single site of fibromatosis was present in ( %) feet with two or more sites in ( %) feet. of the discrete foci of fibromatosis, ( %) were hypoechoic to the plantar fascia and ( %) were isoechoic. the fascial margin was well-defined in ( %) and ill-defined in ( %). of the lesions ( %) showed mild internal vascularity. no correlation was found between the ultrasound appearances and the chronicity of patients symptoms. ( %) of lesions were located in the midfoot while ( %) were located at the forefoot. ( %) were located medially in the fascia while ( %) were located centrally. conclusion: this is the first reported series detailing the ultrasound appearances of plantar fibromatosis. while the ultrasound appearances are variable, they are still characteristic enough to allow a specific diagnosis in all cases. purpose: spontaneous involution of lumbar disc herniation in patients treated with conservative therapy is reported in up to % of cases. the aim of our study was to evaluate any eventually predictive signs on mr imaging of disc herniation involution. methods and material: patients, affected by lumbar disc herniations, entered a perspective study. mri examinations were performed on . t magnet, using sagittal and axial t w se sequences before and after contrast administration, and fse t w ones on the same scan planes. patient age, sex and level and size of disk herniation, clinical onset interval, type of herniation, t -w signal intensity and pattern of contrast enhancement had been registered. all the patients, conservatively treated, underwent clinical and mri follow-up after months: disc herniation size and contrast-enhancement variations were re-evaluated. results: mri follow-up showed herniation regression in % cases. extruded disk with high signal intensity on t w sequences regressed in % of cases. the same percentage of regression was registered in enhancing cases. free fragments disappeared in all cases. rest in bed for at least days resulted to be a significant factor for a favorable evolution of acute disk herniation. no relationship was found with side, size, level. conclusion: mri features seems to have a significant meaning in assessing spontaneous tendency on herniation involution, thus furnishing additional prognostic value. the role or mri and mra in diagnoses of cervical spondilotic myelopathy v.p. marchuk , a. chernenko ; vitebsk/by, minsk/by purpose: there are three important pathophysiologic factors in the development of cervical spondylotic myelopathy (csm): static and dynamic mechanical spinal cord compression, spinal cord ischemia. this study was performed to analyze the role of combination mri and mra in patients with csm. materials and methods: pts were examined on a . t picker vista unit - healthy subjects, pts had signs of discogenic radiculopathy and neuroreflected disorders (i), pts had signs of cervical spondylotic myelopathy (ii). mra was carried out in coronal projection, oriented perpendicular to the direction of blood flow of ra (tr/te / . , matrix, dft tof, mast, overlap . mm). mr investigation included standard protocol. the difference in groups were mainly obtained in the evaluation of the number of radicular arteries branches (ra) -more than branches were visualized (+) or were not visualized (-); and spine cord compression (c) -present (+) or absent (-). combination (ra+ c-) for healthy group displayed in %, for i group in . %, ii group in . %. combination (ra-c+) for i group . %, for ii group . %. the spinal cord damage and csm arising from inadequate blood passage in ra branches and spine compression were increased twofold in cases of combination (ra− c+). the mr technique allows these complications to be revealed simultaneously and serves as a basis for appropriate treatment. material & methods: patients who suffered from radiation myelopathy were examined by mr. patients underwent radiotherapy with total dose of - gy and irradiation was performed in two series, with one month time interval between them. radiotherapy was performed in patients with bronchial carcinoma ( patients) and malignant lymphoma ( patients). examinations were performed on . t mr imager using a surface coil. the protocol included t w and t w sagittal images, t w and t w axial images and images after application of gd dtpa. results: clinical signs of radiation myelopathy appeared - months after radiotherapy. symptoms included weakness of lower limbs and paresthesia. mr examination revealed abnormally decreased signal on t w images, increased signal on t w images, focal contrast enhancement and spinal cord enlargement. cord enlargement was detected in patients while in patient spinal cord atrophy was found. radiation-induced abnormal high signal intensity was presented in cervical and thoracal vertebral bodies due to fatty replacement of bone marrow with sharp boundary corresponding to the radiation field. conclusion: mr is easy, safe and valuable imaging method in diagnosis and differential diagnosis of radiation myelopathy. then we performed contrast-enhanced sagittal t -weighted scans after i.v. administration of gadolinium-dtpa (magnevist, schering, germany). when we recognized these features with mri, the exam was completed with axial scans using the same sequences. all the patients underwent lumbar puncture within days of the mr examination. results: in patients mri was positive. we detected diffuse sheet-like infiltration of the arachnoid membrane or neoplastic coating of the conus and cauda equina to nodular deposition throughout the subarachnoid space. the most sensitive acquisition was the contrast-enhanced se t -weighted sequence. only patients out of had a positive lumbar puncture. in the follow-up during therapy, mri was considered more accurate in the evaluation of the pathological evolution of leptomeningeal involvement by hematopoietic neoplasms. conclusions: in our limited experience, mri was more sensitive in the detection of spinal epidural and leptomeningeal involvement by hemopoietic tumors. in patients with strong clinical suspicion of this involvement and negative lumbar puncture, mri should be performed. purpose: knowledge of the exact site and localisation of a csf fistula is important for planning surgical procedures and to prevent further complications. the purpose of this prospective study was to establish and to evaluate gd-dtpa enhanced mr cisternography in the detection of rhinobasal csf fistulae in patients with suspected csf rhinorrhea. materials and methods: patients with suspected csf rhinorrhea were examined. clinical diagnoses were: severe head/brain trauma, meningocele, hydrocephalus and chronic sinusitis. mr cisternography included the following investigation steps: acquisition of non enhanced fat suppressed t -weighted se scans of the skull base and the paranasal sinuses, lumbar puncture with administration of ml gd-dtpa solute with ml nacl and performance of mr cisternography with the same fat suppressed t -weighted sequences as used initially. in patients gd-dtpa enhanced mr cisternography detected a csf fistulae ( sphenoidal and ethmoidal). while of these depicted leaks were confirmed surgically and sealed. in one case the csf fistula closed spontaneously. in another case, csf leakage after severe head injury was highly suspected clinically, but ceased prior to mr cisternography, which was unable to detect the temporary fistula. in the remaining patients with serous rhinorrhea mr cisternography did not provide any evidence for csf fistulae. intrathecal gd-dtpa injection was well tolerated. conclusions: mr cisternography after intrathecal administration of gd-dtpa is a safe, promising and minimally invasive method for detection of csf fistulae. this mr investigation provides excellent depiction of csf spaces and pinpoints csf fistulae. the description of the complex d shape of the ventricular system is an important aspect for the typisation of the ventriculomegaly. materials and methods: pd and t w d datasets were used for the segmentation of ventricular system. using the volume and surface data's a size independent shape descriptor number (edginess) was created. edginess number of atrophic, alzheimer and nph patient's was compared normal subjects database. results: upon statistical analysis the data for the control patient group showed a significant difference from those for the alzheimer's group (p < . ) and for the nph group (p < . ), but no significant difference from the atrophy group. with respect to the atrophy group a significant difference was ascertained both from the alzheimer's group (p < . ) and from the nph group (p < . ). significant difference was also ascertained between the alzheimer's group and the nph group (p < . ). discriminate analysis enables % reliability to be achieved in distinguishing the nph group. conclusion: size-independent shape description provides the opportunity for the objective monitoring of hydrocephalus cases, with particular respect to those occurring in developing children. it also enables ventricular shape changes developing in individual hydrocephalus cases to be differentiated. a substantial aspect the procedure creates a new possibility in differential diagnostics for the determination and type classification of every condition involving ventriculomegaly. aim of the study was to examine the effect of three different types of meal on the function of proximal stomach in alcoholic cirrhotic patients by ultrasound. the proximal stomach of normal volunteers and alcoholic cirrhotic patients were examined by ultrasound. each subject received on consecutive days ml meat soup, or ml of two different semisolid meals: yogurt with potato flakes or sour cream with potato flakes, the latter contained % fat. the proximal sagittal area and the frontal diameter were measured fasting and , , , , , and min. after a meal and my multiplication of these two parameters approximate volume (av) was calculated. relaxation of the proximal stomach was characterized by the ratio of fasting avf to the actual av at different time points. results: compared with healthy controls, av/avf was significantly decreased (p < . ) after liquid and semisolid meal in cirrhotic patients ( . ± . vs. . ± . after liquid and ± . ; . ± . after semisolid meal), while difference of this value was not observed after semisolid fatty meal between cirrhotic and healthy patients. the abdominal ct scans of patients were retrospectively reviewed by radiologists. eighteen patients had surgically proven internal hernias ( paraduodenal, transmesenteric, case group) while had no evidence of internal hernia at surgery (comparison group). images were reviewed in a random and blinded fashion. individual and group performance was evaluated by roc analysis, and inter-observer agreement was measured by cronbach's coefficient alpha. individual ct signs relevant as predictors of transmesenteric hernia were identified by logistic regression and ranked by their odds ratio and p-values. the paraduodenal hernias were diagnosed by all readers. ct signs of paradoudenal hernias include: a sac-like mass of small bowel, encapsulation of small bowel, mass effect on the posterior wall of the stomach, left displacement of the main mesenteric trunk and mesenteric vessel abnormalities. we found poor inter-observer agreement in diagnosing transmesenteric hernia in the case group, but good to excellent interobserver agreement for some of the ct findings predictors of transmesenteric hernia, with a cronbach's coefficient alpha value ³ . . logistic regression analysis suggests that clustering of small bowel loops, en-gorgement, stretching and crowding of the mesenteric vessels, right displacement of the main mesenteric trunk, and small bowel obstruction manifested as bowel dilatation with a transition point are associated with transmesenteric hernia. conclusion: ct may allow a diagnosis of internal hernia, although this diagnosis remains difficult, especially of transmesenteric hernia. provoked gastro-intestinal bleeding with tissue plasminogen activator -a useful diagnostic tool in patients with occult lower gi bleeding j.m. ryan, s. dumbleton, t. smith; durham, nc/us purpose: the purpose of this study was to assess the efficacy and safety of provocative mesenteric angiography with tpa, heparin and tolazoline in patients with occult lower gastrointestinal bleeding. materials: provocative bleeding studies were performed on patients for occult lgi bleeding including women and men, aged - years. all patients had previous negative endoscopic and negative angiographic studies. to provoke bleeding we used a combination of intravenous heparin (range - units), intra-arterial tolazoline (range - mg) and intra-arterial tpa (range - mg, mean . mg). results: studies were performed in patients leading to bleeding in patients ( . %). vascular abnormalities were diagnosed which did not bleed during provocation -an abnormality was identified in of patients ( %). there were no procedural complications encountered. of patients in whom bleeding was successfully provoked, bleeds occurred in the large bowel, and in the small bowel. patients had embolization at the time of provoked bleeding. of these patients required no further therapy for lower gastrointestinal bleeding. patients (including with vascular abnormality) did not bleed during the provoked study with tpa. of patients with normal study patients rebled during followup. conclusion: intraarterial provocative mesenteric angiography with heparin, vasodilator, and tpa identified the site of bleeding in . % of patients in our study group, and contributed to treatment in %. this small study indicates that the procedure appears to be safe. monday b methods and materials: ct films of cases with internal hernia including cases with paraduodenal hernia, cases with transmesenteric hernia, cases with transomental hernia and case with foramen of winslow hernia were retrospectively reviewed. surgical proof was obtained in all cases and strangulation was found in of the cases. results: prevalent ct findings found in internal hernia were cluster of small-bowel loops, crowding of mesenteric vessels, engorgement of the mesenteric vessels, evidence of small bowel obstruction, and closed loop. saclike mass was a helpful ct finding to diagnose internal hernia having hernia sac. mesenteric edema, bowel wall thickening, and ascites were frequently observed in cases with strangulation. in paraduodenal hernia, herniated bowel loops showed a sac like mass and were found posterior to either ascending or descending mesocolon. in a subtype of paraduodenal hernia and foramen of winslow hernia, herniated loops were found in the lessor sac. in transmesenteric and transomental hernias, herniated bowel loops were found lying adjacent to the abdominal wall displacing the colon centrally. conclusions: ct may allow the diagnosis of internal hernia based on the shape and anatomical location of the herniated bowel loops. the presence of strangulation can be assessed by the ct features of the bowel wall and mesentery. cross sectional imaging findings of juxtapapillary duodenal diverticulum c. balci, a. akinci, e. akun, c. duran; istanbul/tr objective: the purpose of this study was to evaluate the ct and mr imaging features of juxtapapillary diverticulum, correlating with ercp, duodenoscopy. we retrospectively evaluated ct (n = ) and/or mri (n = ) examinations of patients who were diagnosed juxtapapillary diverticulum on ercp (n = ) or endoscopy (n = ) examinations as correlative diagnostic examination. mri was performed in a . t scanner, ct was performed with helical technique using thin sections. ct (n = ) and/or mri (n = ) were primary imaging modalities in patients. size, location of the diverticula and imaging findings of associated biliopancreatic disease were assessed. results: diverticula were missed initially in three patients on ct (n = ) and/or on mri (n = ). size of the diverticula ranged between - cm. imaging findings of the juxtapapillary diverticulum was characterized as outpouching of the duodenal wall towards pancreatic head (n = ). on patients papillary relation to diverticular wall was evaluated on mri. on ct, layering of oral contrast with air level was characteristic imaging feature. on mri t -weighted true fisp and haste techniques demonstrated the air fluid level with hyperintense fluid and signal void air level above. associated imaging findings as dilated cbd (n = ), cholecystitis (n = ) cholecystolithiasis (n = ), chronic pancreatitis (n = ) and were visualized on both imaging modalities. conclusion: with a better recognition of juxtapapillary diverticulum on ct and mri, initial cause of biliopancreatic disease symptoms in patients with juxtapapillary diverticulum can be depicted by these modalities. results of screening ultrasound diagnosis of gastric and colonic cancer s. pimanov, a. sikora, c. vergasova, n. lud; vitebsk/by purpose: the problem of colonic cancer (cc) and gastric cancer (gc) diagnosis remains a difficult issue. a number of screening programs for cc diagnosis based on faecal occult blood tests and endoscopy are well-known. the objective of this study was to determine the possibilities of screening ultrasound examination for gastric cancer and colonic cancer. patients and methods: patients aged - with various diseases were examined for cc and gc diagnosis. screening ultrasound examination for cc and gc was performed in all the patients of the hospital and ambulance station who were examined by conventional abdominal sonography. cc and gc had not been suspected before the examination. revealing of concentric hypoechogenic thickening of the stomach and bowel wall with increased central reflection (i.e. non-specific "pseudokidney symptom") was defined as a pathological criterion. bowel and stomach sonography lasted for about minutes. results: the ultrasound examination resulted in revealing cases of cc and cases of gc. almost all patients with tumours were operated and in all cases the diagnosis was confirmed histologically. according tnm classification most of these patients had t -t stages of cancer. false negative results were analyzed using regional cancer register. conclusion: it seems quite possible to diagnose actively colonic and gastric cancer by means of screening ultrasound examinations. the aim of our study was to develop an examination protocol for esophagus virtual endoscopy, that in association to axial ct images allowed to evaluate malignant stenosis and diverticuli. methods and materials: virtual endoscopy of the esophagus was performed in patients with esophageal wall pathology. esophageal distention was obtained by oral administration of effervescent granules and intramuscolar injection of mg of scopolamine butylbromide. in all patients, spiral ct volume zoom examination ( / / mm/ mm/ mm/ . s kv/mas/slice coll./slice width/feed per rot/rot. time) of the thorax and upper abdomen was performed within a single breath-hold, before and after i.v. administration of contrast media. real time endoscopy images were reconstructed using volume-rendering techniques with a dedicated workstation and specific software (vitrea . , vital images). conventional esophageal endoscopy was performed in all cases and an additional bronchoscopy was executed. results: diverticuli and endoluminal stenotic lesions were founded. most of them were localized in the middle or lower thoracic esophagus and were displaied as a discontinuity of esophageal lumen. d ct imaging associated to axial images depicts esophageal tumoral extension, other mediastinal air filled structures, the gastroesophageal junction and shows the presence of diverticuli complications. conclusions: our protocol achieves excellent distention of the lumen both proximal and distal to the stenosis and allows a correct differentiation between malignant stenosis and tumor located into diverticular task. this technique allows to obtain additional informations in the stenosis that do not permitt the passage of an endoscope and comparing to barium studies excludes the risk of aspiration of contrast agent. in patients with positive egr, hp was negative, while both were negative in one patient. there was highly significant difference between the hp and egr findings (p < . ), meaning that statistically there was no dependence between hp and egr. in all patients, hp finding did not correlate with index values (r = . , p > . ). index of egr in patients with positive hp was c = . ± . %, while in those with negative hp were x = . ± . %. there were significant differences (p < . ) in the values of index in relation to the presence of hp, meaning that it was lower in the patients with positive hp finding. however, when only patients with pathologic values of egr were considered (egr > %), there were no significant differences (p > . ) in the values of index in relation to the presence (n = , x = . ± . %) or absence (n = , x = . ± . %) of hp. conclusion: there was no relationship between the presence of hp and egr. birmingham, al/us, rome/it introduction: cardiovascular mri (cmri)can accurately assess lv systolic function. diastolic function assessment involves complex methodologies such as phase contrast imaging or myocardial tagging. our purpose was to define diastolic dysfunction (dd) with a routine cmri approach. methods: using a . t system (ge signa cv/i; ge medical systems, milwaukee, wi), lv volumes and mass were calculated on cine short axis sequences in patients, with risk factors for dd (lvh, hypertension, coronary disease, etc) and (control group) without risk factors. post-processing was performed with mass analysis package (medis, leiden, the netherlands) studied variables were ventricular relaxation rate, lv mass index, ef, and end diastolic volume index. results: diastolic relaxation rate was calculated from a linear regression line fitted to the rate of lv volume change and was normalized using the body mass index. ef and lv mass index were calculated. using binary linear regression analysis, diastolic relaxation rate predicted patients with risk factors for dd with a of . (p < . ), whereas lv mass index predicted dd with a of . (p < . ). ef and end diastolic volumes were not significantly different between groups. normalized diastolic relaxation rate distinguished the two groups with % accuracy, cardiac mass index with %, and the combination of the two with %, with of (p < . ). conclusions: diastolic relaxation rate and lv mass index can be used to evaluate lv diastolic function as a component of every cmri study, using a simple cine sequence, without additional time or complex techniques not widely available. clinical usefulness of high dose dobutamine stress mri for the detection and cardiac tagging for the detection of myocardial ischemia d.y. kuijpers, k.y. ho; groningen/nl purpose: to evaluate the clinical value of high dose dobutamine stress mri (dsmri) for the detection of myocardial ischaemia by wall motion analysis using myocardial tagging. patients and methods: a consecutive group of patients with known or suspected coronary artery disease, who stopped their anti-anginal medication days before the examination, were examined with a cine breathhold using a standard segment short axis model. seven patients could not tolerate the examination. patients were examined at rest and during increasing doses of dobutamine stress at -minute intervals up to µg/kg/min. cine images were acquired during breathholds at short axis levels, including myocardial tagging. the data were evaluated for the presence of ischaemia, which was defined as a new wall motion abnormality (hypokinesia, akinesia, dyskinesia) in at least segments at different levels. mr images were interpreted during the examination by two experienced investigators. two datasets were not interpretable. results: average examination-time was minutes without major complications. patients who showed signs of ischemia, were examined with coronary angiography within weeks. patients showed significant coronary artery disease of whom needed revascularisation. three patients showed false-positive mri results, while sensitivity for % luminal narrowing was %. in the patients without ischaemia on mri, the cardiovascular occurence-free survival rate was % (average follow-up period was months). conclusion: high dose dsmri using myocardial tagging is a safe and clinically useful method for the detection of myocardial ischaemia. aim of this study was to investigate the capability of mr imaging as a noninvasive tool to follow up ventricular and valvular function, perivalvular flow and myocardial remodeling in patients after avr. methods: on a . t mr system patients with aortic stenosis and healthy volunteers were examined. cardiac output (co), ejection fraction (ef), enddiastolic volume (edv) and lv ejection time frame as a parameter of contractility (∆tlv) were determined using a velocity encoded d flash technique (tr ms, te ms) and cine sequence (tr ms, treff. ms, te . ms, flip °, temporal resolution ms). hemodynamic parameters and end-diastolic myocardial wall thickness (emwt) were determined ± . days pre/ ± days and ± months after implantation of a st. jude medical prostheses. invasive measurements (fick principle/thermodilution) and echocardiography served as reference standard. intra-and interobserver variability of two observers were calculated for mr measurements. results: for co a good correlation with invasive measurements was found using phase velocity mapping (r = . , p < . ). lv parameters normalized late postoperatively (∆t = ± ms/ ± ms, edmt = ± mm/ ± mm, pre/ ± months surgery, p < . ). differences between normal volunteers and patients were detected on a high level of significance (normal ∆t = ± ms, emwt = ± mm, p < . ). for mr flow measurements interobserver variability was . ± . %, intraobserver variability was . ± . %. in patients with suspected postoperative complications after avr cardiac mri should be applied prior to hospitalization and invasive diagnostic procedures. cardiac systolic rotation and contraction before and after valve replacement for aortic stenosis -a magnetic resonance myocardial tagging study j.j.w. sandstede , t. johnson , m. beer , k. harre , t. pabst , w. kenn , w. völker , s. neubauer , d. hahn ; würzburg/de, oxford/gb purpose: aortic stenosis leads to derangement of cardiac function and contraction mode due to chronic pressure overload that is relieved after surgical valve replacement (svr). this study aimed to determine the changes in left ventricular (lv) systolic wall function before and after svr using mr tagging, compared to age-matched healthy volunteers. monday b a c d e f materials and methods: patients with aortic stenosis were examined with an ecg-triggered d tagging sequence at . t before and months after svr. lv function and mass were determined by cine mri. cardiac rotation at the apical, mid-ventricular, and basal level and overall torsion were evaluated. healthy volunteers within the same age group served as a control. results: before surgery, all patients showed a significant increase of apical rotation and overall lv torsion, basal rotation was not significantly different compared to volunteers. apical rotation and torsion were negatively correlated with lv mass and end-diastolic volume. one year after surgery, basal rotation was reduced compared to controls. in comparison to pre-operative values, apical rotation also decreased but was still elevated, and this resulted in a normalization of lv torsion. conclusion: pressure overload before surgery is associated with an increase of systolic lv wringing motion, possibly serving as a compensatory mechanism. this mechanism declines with increasing lv hypertrophy and dilatation. svr for aortic stenosis leads to normalization of lv torsion one year after surgery. patients and methods: global and regional function was determined by cine mri in patients weeks after anterior mi. at the same time, p-spectra were obtained from infarcted as well as non-infarcted adjacent myocardium using a d-csi technique (voxel size ml each). pcr/atp ratios and signal to noise ratios (snr) were determined using amares. months after revascularization mri and mrs were repeated. gold standard for viability was recovery of regional function after revascularization. healthy volunteers served as control group. results: two groups of patients ( / ; wall motion recovery versus persisting wall motion abnormalities) were formed according to follow-up mri. at study entry patients with non-viable segments had significant reductions of pcr/atp-ratios in non-infarcted and infarcted myocardium due to a significant reduction of pcr snr, whereas patients with viable segments showed that only in the infarcted areas (p < . each). no significant differences were detected concerning morphologic or functional parameters between both groups. control examination months after revascularization revealed significant increases of energy metabolism and cardiac function for patients with viable myocardium (p < . ). conclusions: restoration of regional oxygen supply by revascularization therapy is connected with improvement of metabolism and function in patients with viable segments, whereas irreversible damage of infarcted tissue is connected with continuous depression of energy metabolism. time course of na signal intensity after myocardial infarction in humans j.j.w. sandstede , h. hillenbrand , m. beer , t. pabst , w. machann , w. völker , w.r. bauer , s. neubauer , d. hahn ; würzburg/de, oxford/gb purpose: elevated sodium (na) content in myocardial infarction (mi) can be imaged by increased na signal intensity ( na si). experimental studies described the temporal changes of myocardial na content post-myocardial infarction. aim of our study was to determine the time course of na si after mi in humans. materials and methods: patients were examined ± days and months after mi, patients underwent an additional examination ± days after mi. double angulated short axis na images of the heart were obtained in prone position using a na surface coil and an ecg-triggered d-flash-sequence with acquisitions. wall motion abnormalities were detected by cine mri. na si of mi was expressed as percentual increase compared with the entire circumference of noninfarcted myocardium. results: all patients showed an area of elevated na signal intensity correlating with wall motion abnormalities. na si remained elevated between day and day in the patients that were examined twice in the early stage after mi. all patients revealed a decrease of na si until months after mi. conclusion: na si is elevated in acute mi and throughout infarct healing but decreases until months after mi. this is in concordance with experimental studies, these studies showed the highest na content at day with a decrease until day . correlation of na si and myocardial viability in humans has to be determined in future studies. p-sloop-mrs. healthy volunteers were included in the study. results: compared to matched volunteers, a significant decrease of absolute pcr concentration was observed in patients with ms (p < . ), whereas atp concentrations showed no significant changes. functional analysis by mri depicted depressed left ventricular (lv) ef in patients. for ms patients with mitoxantrone treatment, an association between cumulative dose and ef could be detected (r = . ; p = . ). however, ef, lv esv and lv esv were not statistically significant between the two groups of patients. mrs detected no association for ratios or absolute values and cumulative mitoxantrone dosage. the reduction in cardiac high-energy phosphates as well as lv ef in some patients points to a subclinical involvement of the heart in ms. treatment with a putative cardiotoxic drug like mitoxantrone seems, however, not to aggravate a possible pre-existing heart disease within the examined cumulative dose range up to mg/m . absolute concentrations of cardiac high-energy metabolites -relation to clinical severity m. beer , h. köstler , j.j.w. sandstede , k. harre , s. neubauer , d. hahn ; würzburg/de, oxford/gb purpose: cardiac high-energy metabolism is impaired in failing human myocardium, and this may contribute to contractile dysfunction. current technical improvements of cardiac mr-spectroscopy (mrs) allow for absolute quantification. we tested the correlation between clinical severity and metabolite concentrations. patients and methods: patients with hypertrophic (aortic valve stenosis, avd) and dilated cardiomyopathy (dcm) were studied ( each). patients were graded according to nyha; lv volumes, mass and ef were determined by cine mri. pspectra were obtained using a d-csi technique. pcr/atp ratios and absolute values (mmol/kg) were determined using amares and sloop. healthy agematched volunteers served as control group. results: for nyha classes (vol), ii ( avd, dcm) and iii ( avd, dcm), pcr concentrations were . ± . , . ± . , and . ± . , atp levels . ± . , . ± . , and . ± . ; and pcr/atp ratios were . ± . , . ± . , and . ± . . pcr absolute concentrations showed the highest, atp intermediate and pcr/atp ratios lowest correlations with clinical and functional variables. conclusions: absolute concentrations seem to be more representative of the extent of energetic derangement in heart failure than established pcr/atp ratios. material and methods: high resolution mr imaging was performed on a . t unit (symphony quantum, siemens) using t -and stir t -weighted sequences via a dedicated wrist coil (total acquisition time min) a mean of . days after initial radiographs in patients with clinical suspicion of wrist fractures and normal plain or indistinct radiographs. initial radiographs were evaluated independently by two senior radiologists without knowledge of the mri findings. the resulting change in therapeutic strategy was clinically evaluated. results: in / wrists mri findings resulted in a change of diagnosis. there were false positive diagnoses on plain radiographs in cases ( %) and false negative diagnoses in cases. mri allowed to detect additional injuries of soft tissue in cases ( %). in / wrists the period of immobilization could be shortened or ended. in / it needed to be prolonged and in / a surgical intervention was necessary. in wrists mri had no therapeutic consequence. correspondingly, after mri examination the period of being unable to work was reduced in / , prolonged in / and was not changed in / patients. axial images were not helpful regarding diagnostic accuracy. conclusion: mri of the wrist is recommended on the day of trauma if there is clinical suspicion and normal plain radiographs. accurate diagnosis by mri examination on the day of trauma may reduce economic costs due to shortened immobilization time. mri evaluation of the wrist using dynamic studies m. mastantuono, e. bassetti, g. simonelli, l. di giorgio, r. passariello; rome/it purpose: in some painful syndromes of the wrist the conventional mri imaging is not satisfactorily for diagnosis. we describe a new dynamic mri method, that is accurate and easy to repeat, for the study of carpal instability and wrist pain. materials and methods: we performed a dynamic study of the carpus in healthy volunteers and on selected patients which we chose from a group of previously studied by static mri wrist examination. we used a dedicated magnet (artoscan, e-scan . t) that has revealed itself to be particularly useful for dynamic acquisitions. we standardized a technique of image acquisitions at different degrees of flexion both on the coronal plane in ulnar-radial deviation and in sagittal for palmar-dorsi-flexion. we used se and ge sequences obtaining sagittal and coronal scans with a slice thickness of - mm. results: the dynamic study is superior in the evaluation of carpal instability and in the assesment of capsular and ligamentous lesions if compared to standard mri examinations. the kinematic evaluation of the images acquired in the different positions of movement allowed to document the pathologic articular kinetics. conclusions: in our experience the mr kinematic study provided information that permitted differentiation of the possible mechanisms responsible for chronic wrist pain. kinematic mri is a simple and low time-consuming method of study that permits an accurate assessment of carpal instability, easily demonstrating articular biomechanical alterations that may be difficult to diagnose on static conventional mr examination. in patients we assessed direct mr-arthrography in comparison to multiportal wrist arthroscopy for the evaluation of extrinsic and intrinsic ligaments, the tfcc. we used a . t mr system (magnetom). after fluoroscopic-guided direct wrist arthrography into the mid-carpal and radiocarpal joint with a solution of ultravist and magnevist ( : ) we applied following sequences: ( ) t tse (tr ms, te ms) mm slice-thickness, coronal and sagittal plane, matrix , fov mm. ( ) d flash (tr ms, te ms, flip angle °) . mm slice-thickness, coronal and sagittal plane, matrix , fov mm. between and weeks after mr-arthrography, all patients underwent diagnostic multiportal arthroscopy. for the evaluation of the scapholunate ligament and the lunotriquetral ligament we subdivided lesions in partial defects and complete tears. the mr-sign of a partial-ligament defect was the passage of gadolinium-contrast agent between the mid-carpal joint and the radiocarpal joint, but with intact ligament structures palmar or volar to the defect visible. complete tfcc-defects, recognized by passage of contrast-agent into the distal ulnoradial joint, were classified according to palmer. results: for complete defects there was a high correlation between mr-arthrography and diagnostic multiportal arthroscopy (sen: . %, spez: . %, ppv: . %, npv: . %). for partial defects the correlation was moderate ( . %; . %; . %; . %). conclusion: for the evaluation of complete defects of the intrinsic and extrinsic ligaments, the tfcc mr-arthrography and multiportal arthrography have nearly the same diagnostic power. for evaluation of partial defects arthroscopy is superior to mr-arthrography. after undergoing arthrography with a mixture of : diluted contrast medium (gadolinium-dtpa: imeprol) injected radiocarpally and midcarpally under fluoroscopic control, patient suffering from ulnar-sided wrist pain were examined with a . t mr scanner. using computer-aided "navigator"technique, the d data sets were converted into a virtual arthroscopy. all these patiens underwent a conventional arthroscopy within hours. imaging results were compared with the virtual findings. results: in of the cases virtual arthroscopy could be performed adequately, whereas in / the procedure was not successful due to excessive narrowing of the ulnocarpal compartment or artefacts caused by patients movement. among to determine morphologic changes of the median nerve in median nerve entrapment syndrome after surgical decompression using high resolution ultrasonography and to correlate with the clinical outcome. materials and methods: carpal tunnels of patients ( women, men, mean age . years) with documented median nerve entrapment were examined with high resolution sonography before and at least months after surgical decompression. a subgroup of subjects was scanned before and after months following surgery. we evaluated nerve ap diameter, the flexor carpi retinaculum, postoperative scar tissue and correlation with clinical outcome. results: or more months after decompression the mean nerve diameter in the proximal canal is reduced from . mm to . (p = . ), in the distal canal from . to . (p = . ). there was no significant difference in the subgroup examined within months after decompression and in the relation proximal to distal nerve diameter pre-and postoperatively. the flexor retinaculum could be depicted clearly in all scans. the existence and extent of scar tissue and reduction of nerve diameter were found unreliable parameters regarding outcome. conclusion: analysed at least months after surgical decompression the ap diameter of the median nerve is significantly smaller compared to preoperative values. this diameter reduction, however, as well as existence and extent of scar tissue does not always correlate with clinical outcome. the relation between nerve diameter in the proximal and distal canal does not seem to be a helpful parameter in the diagnosis of median nerve entrapment. ultrasonography of hand joints in rheumatoid arthritis y. khodjibekova, t. zasteba; tashkent/uz purpose: the aim of this investigation was to study typical sonographic signs of hand joints lesion in rheumatoid arthritis. materials and methods: patients aged to years ( males, females) with rheumatoid arthritis affecting hand joints were investigated. the control group comprised healthy individuals. in all patients diagnosis was established by clinical, laboratory and radiographic examinations. results: soft tissues, bone contours, ligaments, joint-forming surfaces, joint space and synovium were visualized on hand joints sonograms. the first stage of the disease was characterized by soft tissue thickening, increase of ligaments echogenity, effusion and increase of joint space. at the second stage of the disease soft tissues thickness decrease, slight increase of their echogenity, periosteum thickening, joint-forming surfaces destruction, narrowing of joint space to a c d e f . - . cm were revealed on sonograms. at the third stage of the disease soft tissues were not visualized, bone contours were well-defined and deformed, periosteum was thickened, joint-forming surfaces were indistinguishable. conclusion: sonography is effective method for the diagnosis of hand joints lesion in rheumatoid arthritis, particularly in its early stages. preliminary experience with "extended field of view" (efv) ultrasonography in musculoskeletal disorders e. santacroce, c. avanzino, g. dazzi, l. raimondi, e. silvestri; genova/it purpose: to evaluate the usefulness of efv ultrasonography in the study of musculoskeletal system. materials and methods: forty subjects with musculoskeletal disorders were submitted to an efv ultrasound examination after a routine us evaluation. shoulders with anterior-superior impingement, wrists with carpal tunnel syndrome, wrists with de quervain's disease, ankles with achilles tendonitis and patients with post-traumatic muscle injuries were considered. an atl hdi system equipped with a broadband - mhz transducer with efv software was used. results: the efv evaluation improved the muscular and tendon anatomy demonstration and correctly showed the pathologic process extension in all cases. the larger field of view of this technique allowed more precise anatomic definition of muscles, tendons and peripheral nerves but did not provide further diagnostic information. not easy images acquisition, evaluation of small structures and convex bone surfaces are the main limits to this technique. purpose: this study was performed to establish the value of breathhold mr imaging in the diagnosis of acute appendicitis. materials and methods: over a -month period consecutive patients, clinically suspected of having appendicitis all underwent an us study and a subsequent mri. the mri images were obtained with breathhold coronal and axial fast spin-echo t , t , and t fat suppression sequences with mm thick slices. mri images were evaluated prospectively. appendiceal diameter, signs of periappendicitis, abscesses, fecaliths, free fluid, mesenteric lymphnodes, paralytic ileus, or the existence of an alternative diagnosis was noted. also the total duration of the mri study was noted. mri findings were correlated with surgical pathology in patients and clinical follow-up in patients. the mri findings of patients were interpreted as positive for appendicitis ( true positive, false positive). mri findings showed no signs of appendicitis in (true negative in all) and showed an alternative diagnosis in . sensitivity and specificity for detecting acute appendicitis were % and %. the median total duration of the mri study was min. conclusion: fast spin echo t , t and t -fat-suppression breathhold mri imaging for the evaluation of patients with suspected appendicitis achieved a high accuracy in the detection or exclusion of appendicitis or an alternative diagnosis. the use of short imaging sequences minimized the impact on the routine mri program. in selected cases mri is a reliable, safe and quick tool that can be implemented in a community hospital. helical ct diagnosis of closed-loop obstruction and strangulation: how and when m. scaglione, f. pinto, a. pinto, f. lassandro, n. renda, e. de lutio, s. romano, l. romano; naples/it purpose: definite confirmation or exclusion closed-loop obtruction (clo) is one of the most difficult tasks the radiologist has to face in the clinical practice. the aim of this presentation is to focus on the impact of helical ct in the diagnosis of clo and strangulation. materials and methods: cases of surgical proven clo diagnosed by helical ct were retrospectively reviewed. helical ct scans were performed after administration iv contrast material ( ml, s scan delay, . - ml/s rate), with initial × mm collimation and repeated × mm over the region of interest. the state-of-art ct signs were considered for the diagnosis. results: serrated beaks with poor or no contrast enhancement of the bowel walls, ascites or engorgement of the mesenteric vasculature are ct signs allowed the diagnosis of clo complicated by strangulation in / cases. u or c-sharped of dilated loops, radial distribution of the mesenteric vessels, beaks and whirls suggested clo in / cases, but did not help differentiate from strangulation in cases. conclusions: clo is a dynamic entity which may regress or need laparotomy depending on the time and degree of rotation of the incarcerated loops. ct is a reliable imaging modality able to differentiate clo from strangulation, which is rarely simple and obvious. detection of ischemic changes in the bowel walls and/or attached mesentery on ct scans imply strangulation highlighting the need for laparotomy; if only signs of clo are detected, the existence and/or development of strangulation cannot be predicted. results: a diagnosis of strangulation was made in patients at surgery. in the patients whose ct findings were mesenteric haziness and decreased conspicuousness of the mesenteric vessels with normal enhancement of the affected small bowel, diagnosis of viable ischemia was made at surgery. ct findings predicting strangulation were poor contrast enhancement of the bowel wall, haziness of mesentery, diffuse engorgement of mesenteric vessels and ascites. (p < . ). among these findings, poor contrast enhancement of bowel wall was the most significant one. in the patients with small bowel obstruction, poor contrast enhancement of the bowel wall, haziness of mesentery, diffuse engorgement of mesenteric vessels and ascites were useful ct findings for detecting and predicting strangulation. purpose: the aim of the study was to define the role of high resolution ultrasound in establishing the imaging diagnosis of the right iliac fossa pain syndrome (rifps). the retrospective study has included patients, which were admitted in the emergency room presenting the clinical picture of acute rifps. paraclinic investigations were: abdominal high resolution us, blood and urinary testes. we compared the diagnosis emitted ultrasonographically with the one established by the surgeons in the theatre following the intervention. results: ultrasound examination has showed: patients with inflammatory changes suggesting acute appendicitis (with a thickening of the appendic's wall greater than mm and free peri-cecal liquid collection; mild small bowel loops distension with reduced motility at the right iliac fossa in patients; patient with suggestive terminal ileitis and mesenteric adenitis; women with gynecological abnormalities ( with big right ovarian cyst and with ectopic right pregnancy) and douglas free of fluid collections; patient with ureteral impacted stone and dilatation of the right ureter. conclusions: ultrasound examination used in emergency rooms offers reliable differential diagnosis data between inflammatory ceco-appendicular disease and renal or gynecological disfunction. the high resolution us diagnosis has a high sensitivity and specificity concerning the gynecological abnormalities. the diagnosis of acute appendicitis requires a carreful and several "in dynamic" examination. the diagnosis of acute appendicitis is not in most of the cases exclusively done by us, it necessitates very often a correlation with the clinical examination and laboratory tests. helical computed tomography diagnosis of gastrointestinal perforation in the elderly patient a. pinto, f. pinto, m. scaglione, f. lassandro, e. de lutio di castelguidone, l. romano; naples/it purpose: to determine the diagnostic value of helical ct in a consecutive series of elderly patients referred with clinically suspected gastrointestinal perforation. methods and materials: our series includes consecutive elderly patients (mean age: years old) presenting with acute abdominal symptoms suggestive of gastrointestinal perforation. all the patients were prospectively submitted to abdominal ct evaluation. as revealed on helical ct, the presence of free air was considered diagnostic of gastrointestinal perforation. other ct findings considered indirect of perforation were: intraperitoneal free fluid, thickening of bowel wall, streaky density within the mesentery, the "dirty fat" sign, and focal collection of extraluminal fecal matter. results: at surgery, the following sites of perforation were found: duodenum ( . %); stomach ( . %); ileum ( . %); sigmoid colon ( . %); rectum ( . %); jejunum ( %); appendix ( %), and trasverse colon ( %). in our series, helical ct demonstrated the presence of free air in . % of cases, intraperitoneal free fluid in . %, and thickening of bowel wall in . %. streaky density within the mesentery was found in patient. conclusion: ct is a reliable and accurate imaging method for assessing gastrointestinal perforation by providing excellent contrast resolution to depict presence of even small amounts of free air in the abdomen. this is particularly helpful when elderly patients series are concerned. a c d e f materials and methods: female patients with disorders of defecation-and/or micturition were examined. video-fluoroscopy was performed in a sitting position. the urinary bladder was filled with water-soluble contrast media. rectum and vagina were contrasted with bariumsulfate. dynamic-mri was performed with a . t scanner (magnetom expert, siemens erlangen) using an t weighted gradient echo sequence ("true fisp"). patients were asked to present with full urinary bladder at the time of examination. rectum and vagina were filled with ultrasound-gel. results: in patients we found a anterior rectocele with a anterior extent between and cm in video-fluoroscopy. mri failed to visualise rectoceles in cases. in cases rectoceles lead to a displacement of the urethra thus causing a voiding deficiency of the urinary bladder. these findings could be depicted better in mri. patients presented a cystocele shown by both modalities. in another cases a enterocele could be detected. conclusions: mri is inferior to video-fluoroscopy for the detection and the estimation of the degree of anterior rectoceles. however mri is superior in assessment of the severity of displacement of the urinary bladder and the urethra. the extent of pelvic descent could more accurately be assessed by mri. due to the capability of mri of direct visualisation of the pelvic contents it is superior in demonstration of enteroceles. in , the gradual implementation of the nation-wide mammographic breast cancer screening in the netherlands was completed. since then, screening examinations are being performed annually in the agegroup - years, at an interval of two years. the medical performance of the various disciplines in the regional screening centres is assessed by means of regular site visits. at these site visits, first, the overall screening outcomes are evaluated. subsequently, screening and diagnostic mammograms of interval and screen-detected st. ii cancer cases are reviewed. results: despite the small size of the country, notable regional variations e.g. in the relative frequency of small tumours (t ) are observed, ranging from % to % at a national average of %. from a not blinded review of > interval cancers, we found that in about half of the previous screening mammograms in some way abnormal signs were notable. in one fourth of the cases, with a range from % to %, significant lesions were found, that should have been referred for further examination. conclusion: this large regional variation in outcomes prompted us to carry out the so-called national optimisation study. the objective is to learn in what aspects screening performance may improve as to the earlier detection of relevant lesions. these aspects include; ( ) double reading; ( ) contribution of additional craniocaudal views; and ( ) recall criteria for further assessment. the role of individual mcs shape and cluster shape in the interpretation of mammograms i. leichter , r. lederman , p. bamberger , b. novak , s. fields , s.s. buchbinder ; jerusalem/il, bronx, ny/us purpose: to evaluate the diagnostic role of computer extracted features reflecting the cluster shape compared to features reflecting the shape of individual microcalcifications, identified mammographically. material and methods: cases of clustered mc's with proven pathology were obtained from three university hospitals and reviewed by experienced mammographers. quantitative features characterizing the finding were extracted by a cad system following digitization at µm resolution. the shape factor and number of neighbors, according to delaunay and gabriel methods, were com-puted for each mc together with the eccentricity of the cluster. while shape is related to the individual mcs, the average number of neighbors and eccentricity reflect the cluster geometry. stepwise discriminant analysis (sda) determined the significance of the extracted features in predicting malignancy. the performance of a classifier based on these features was evaluated by roc analysis. results: sda assigned variability of shape the highest predictive power followed by average number of neighbors (delaunay) and average shape but excluded cluster eccentricity and number of neighbors (gabriel) from the model. a classification scheme assigned the variability of shape a weighting factor, about . times greater than that assigned to the number of neighbors and average shape. a scheme based on these three features yielded a roc curve with an az of . , indicating a ppv of % for % sensitivity. conclusion: the variability of shape of individual mcs was found to have a higher impact in differentiating benign from malignant clusters than the average shape or features characterizing the cluster geometry. the efficacy of the independent double reading of mammograms with consensus has been established, but the observer variability between the readers must be supervised to determine the homogeneity of radiological criteria. objective: the k index has been proposed as a method to calculate the interobserver agreement that was not due to hazard. we use the k index regarding the classification of mammographic findings in the assessment of mammographic categories (weighted k). status of nuclear medicine in breast cancer imaging, staging and therapy e. piperkova , a. grueva , s. sergieva ; sofia/bg, baltimore, md/us purpose: accurate staging in breast cancer depicting and averaging primary lesions, multifocal and spread of the disease and lymph nodes imaging by nuclear medicine (nm) effects surgery and treatment plans. current status, diagnostic importance, priorities and limitations of spet and pet modalities are analysed using different tumourtropic agents. materials and methods: evaluation of primary lesions, detection of regional and systematic metastatic disease and the assessment of treatment response are discussed through spet using tc-mibi or tc-anticea and pet using fes or fdg for two patients' groups in four trials targeted categories. in addition localisation of "hot spots" and tumour margins in radiodense breasts are introduced. mrm showed a significantly higher sensitivity, but its specificity was significantly lower than smm. in the subgroup of lesions equal or greater than mm (n = ) the figure of the sensitivity was higher ( . %), than the overall sensitivity of smm. using receiver operating characteristic (roc) analysis, between xmm and the combination of xmm and mrm we found no significant improvement, but the combination of xmm and smm yielded a significantly higher diagnostic accuracy than xmm alone. conclusion: both mrm and smm have adjunct value to xmm. mrm is to be preferred when high sensitivity and spatial resolution is essential, while smm is recommended as a complementary method in lesions larger than cm. tc-mibi. the one, measured in ipsilateral and/or contralateral area divided the count density, measured within a region of interest. this value represents coefficient of tracer uptake (in suv). differences between count densities in early and delayed images reflected the washout of the tracer from the tumour and thus sensitivity to chemotherapy. mr-mammography included assessment of t and t weighted images with the use of flash-mode and gd-enhancement. results: statistically significant correlation coefficients (t/nt) were observed for evaluated regions of increased uptake of radiopharmaceuticals in primary lesions: mibi > . ± . , fdg > . ± . . these data were concordant with mr findings of primary breast tumours. in all cases p < . . regional lymph nodes involvement in scintigraphy was assumed in cases of axillary region uptake > . ± . for pet and > . ± . . parasternal lymph nodes were only detected fdg-pet in pts. washout coefficients calculated using tc-mibi data stipulated for chemotherapy choice in consecutive pts. conclusion: mri-mammography, mammoscintigraphy and fdg-pet correlate in assessment of primary bc. the best tools for the staging and adequate planning of radiation and/or chemotherapy are mammoscintigraphy and fdg-pet. contrast enhanced digital mammography: phantom experiment and first clinical results c. marx , m. facius , s. muller , a. rick , k. benali , w.a. kaiser ; jena/de, buc/fr purpose: we evaluated on phantoms the capability of a full field digital mammography (ffdm) system to show lesion contrast enhancement after intravenous injection of iodine. acquisitions on patients have begun to validate the potential of this new application as an alternative to contrast enhanced mri of the breast. method/materials: using appropriate phantoms, we simulated the iodine diffusion in vessels and lesions to evaluate the threshold of detection of contrast uptake on ffdm images (senographe d, ge medical systems). the injections consisted of - cm of ml hexabrix diluted in ml of water, and were washed out using water. sequences of - images were acquired on ffdm ( - kv, mo/cu) and were analysed to quantify contrast uptakes. clinical use of contrast enhanced digital mammography (cedm) requires the uptake contrast to be visible for iodine concentration between . mg/cm and . mg/cm . results: detection thresholds, with and without structured noise, were . mg/cm and . mg/cm respectively. breast thickness has a low impact on uptake detection. spatial and temporal analysis showed delayed marginal contrast uptake and slow increase of contrast in the background. initial results on patients have demonstrated contrast uptake in malignant lesions. the shape of the uptake curves is influenced by the thickness of the breast under compression ( - dan). conclusions: given these initial results, contrast enhanced digital mammography may be a fast and less expensive alternative to mri for breast lesion characterisation. mri studies were performed at . t using a modified volumetric interpolated breathhold examination (vibe) sequence before and after administration of gadolinium. all images were evaluated prospectively regarding lesion detection and characterization. mri findings were correlated with final diagnoses. retrospective grading (scores - for "poor" -"excellent") was performed for: ( ) general image quality and presence of artifacts (rated "negligible" -"severe"); ( ) imaging quality of detected pulmonary lesions (conspicuity and contrast on pre-and postgadolinium images) results: solid pulmonary lesions, infiltrates and segmental atelectases, and cyst were detected and prospectively correctly diagnosed. sizes ranged from . - cm. the mean grading scores for overall image quality and presence of artifacts were . (sd . ) and . (sd . ), respectively. conspicuity and contrast of pulmonary lesions received mean scores between . and . (sd . we observed a lower peak intensity of emphysematous regions. in subjects with distractedly hypo-perfusion a hyper-perfused region was detected and this occurrence was interpreted as pulmonary circulation re-distribution. discussion: the low specificity was due to three positive cases observed in the control group. these perfusion defects were very well defined and there was total agreement between the three radiologists. in our experience, mr perfusion might be an effective alternative to perfusion scintigraphy in patients with pulmonary emphysema. after an informed consensus, non-smoker subjects, without any present or past pulmonary pathologies, were studied by means of an ultra-fast gradient echo sequence after a gd-dtpa intravenous administration. the acquisitions were performed in coronal and sagittal planes, in supine and prone position, in breath holding. an ulterior acquisition was performed in only five cases immediately after - minutes of physical exercise. results: all the examinations, reviewed according to a visual score by three independent observers, resulted fairly interpretable. the i/t curves, obtained in postprocessing evaluation, have the same trend in all cases and are correlated to the lung physiological criteria: the positional changes of the examined subjects confirm the gravity dependence of perfusion; the study performed immediately after physical exercise showed a reduction in the perfusion of the whole lung due to a transitory massive shift of blood mass from visceral to muscular compartment. the extremely short acquisition and post-processing time coupled with a simple feasibility, the ability to detect physiological perfusional changes, and the minimal invasiveness indicates a potential clinical use of mr in the evaluation of pulmonary perfusion defects. tl myocardial scintigraphy. results: echocardiography was normal in cases, including patients with cardiac-symptomatic sarcoidosis. mr images were normal only in cardiac-asymptomatic stage i or lofgren syndrome patients (n = ). multiple organ cardiac-asymptomatic sarcoidosis (n = ) displayed similar mr abnormalities to those observed in patients with cardiac symptoms (n = ). focal myocardial thickness and/or intramyocardial increased signal on t -weighted and/or intramyocardial increased signal on gadolinium-dtpa-enhanced t -weighted images, representing granulomatous inflammation, were correlated with segmental perfusion defects on the thallium scan. available mr follow-up in patients showed regression of gadolinium-dtpa uptake after corticosteroid therapy while progression was recorded in patients without treatment. conclusion: mr imaging enables valuable detection and localisation of cardiac sarcoidosis. the occurrence of subclinical lesions in multiple organ sarcoidosis may legitimise the use of mr as a screening method to identify early patients requiring careful review and treatment. detection of regional wall motion abnormalities: tissue doppler echocardiography in comparison with magnetic resonance imaging d.e. kivelitz, a.c. borges, g. baumann, b. hamm; berlin/de purpose: echocardiography when combined with spectral and color flow doppler is well established as a safe, non-invasive, and versatile diagnostic modality for evaluation of left ventricular global and regional function. tissue velocity imaging is a new technique that measures myocardial motion by tracking myocardial velocities with color doppler myocardial imaging principles. the purpose of this study was to compare this new tool with magnetic resonance imaging. methods and materials: patients with wall motion abnormalities underwent echocardiography (harmonic mode-octave) in comparison with tissue tracking (vivedfive, ge, vingmed ultrasound, horten norway, equiped with the echopac software package) which allows real-time acquisition of color doppler images and on-line as well as off-line analysis of time-velocities-integrals (tracking). magnetic resonance imaging (magnetom vision, siemens, erlangen, germany) was performed using stripe tagging. for regional wall motion analysis we used the segment model. results: in / patients we analysed quantitative data from tagging and tracking. the concordance was % and the best results were in septal, posterior and apical regions. conclusion: tissue tracking, compared with magnetic resonance imaging, is a reliable method for on-line quantification of global and regional systolic function of the left ventricle. fast assessment of abnormal valve function using mri a. meduri , , r.m. razmi , v.k. rathi , l. natale , g.m. pohost ; rome/it, birmingham, al/us background: valvular diseases can be rapidly assessed by fast cine (fc) mri. signal void is related to the te and determines the severity. a short te may impair assessment and detection of valvular lesions. we hypothesize that a lower receiver bandwidth, a longer te, increases sensitivity and accuracy. methods: a total of pts and valves were evaluated with the predefined bandwidth of . khz (te = . ± . ms) and with the narrower bandwidth of . khz (te of . ± . ms). length, area and maximum width of signal void associated with every diseased valve were calculated. each area was graded as mild, moderate or severe and compared with echocardiography. results: lowering the bandwidth significantly increases signal void area ( ± vs. ± pixel, p < . ), length ( ± vs. ± p < . ) and the width ( . ± . vs. . ± . , p < . ), graded as mild, moderate, or severe for each te. longer te increases the severity graded in / ( . %) valves with signal void and diagnosed one abnormal valve not detected with the shorter te. in the cases compared with echocardiography, the longer te showed a significantly better correlation (contingency coefficient . , r = . ). conclusion: lowering the bandwidth allows longer tes, giving better correlation with echocardiography. we conclude that a short te leads to underestimation of the severity of the valvular lesion. accordingly, a longer te should be used routinely in every comprehensive cardiac mri study. three-dimensional blood flow in the heart: evaluation with mri g. reiter, u. reiter, r. rienmüller; graz/at purpose: evaluate a method of -dimensional determination of the intercardiac flow for early recognition of flow based cardiac dysfunction using magnetic resonance imaging (mri). materials and methods: using flow quantification via phase contrast methods (tr = ms, te = . ms, flip angle °, slice thickness mm, pixel size . mm × . mm and matrix × ) of mri ( . t field strength, mt/m gradients) we measured and reconstructed discretized time-dependent -dimensional velocity fields of blood flow within the different intracardiac regions. at any time of the cardiac cycle calculated velocity fields were projected onto a corresponding cine-truefisp image (e.g. -chamber view). the protocol was designed on healthy volunteers. results: as result of reconstruction and projection we obtained a time series of truefisp images where in-plane velocities were displayed by vectors proportional to the in-plane velocity and through-plane velocities were color encoded. images can be displayed picture by picture as well as in cine mode. the presented method appears robust and sensitive in the -dimensional evaluation of the normal blood flow and promising to observe changes as possible causes of ventricle wall dysfunction. benchmarking non-rigid registration techniques for the quantitative analysis of myocardial function in tagged-mr imaging c. petitjean , n. rougon , p. cluzel , f. preteux , p.a. grenier ; evry/fr, paris/fr purpose: in the framework of quantitative analysis of myocardial function our purpose was to assess the relevance of non-rigid registration techniques for estimating dense displacement fields and functional parameters from tagged-mri sequences of the heart without performing tag extraction. the study was conducted on d tagged-mr sequences under short axis incidence using various gradient echo/tagging sequences including fisp/dante and bffe/spamm. pixel-based, non-rigid registration techniques which deliver dense displacement fields over the whole image domain by establishing pointwise correspondences without requiring preliminary segmentation of heart walls nor tagging pattern have been evaluated. state-of-the-art methods have been tested for major registration criteria: (i) "demon" algorithms using an optical flow constraint with prior elastic smoothing; (ii) fluid registration methods governed by deformation laws from fluid mechanics; (iii) informational techniques maximising entropic measurements between successive images. in each case deformation modelling has been addressed by comparing functional measurements derived from non-parametric and parametric motion estimates. using hierarchical solvers for handling large deformations has also been investigated. results: demon and mutual information maximisation techniques allow accurate derivation of dense maps of functional parameters including deformation tensor eigenelements, local contraction/dilation and circumferential/radial strains. moreover, informational approaches are insensitive to tag fade out. b-spline modelling offers a good trade-off between measurement accuracy and modelling compactness. multiresolution processing allows us to account for large deformations. conclusions: following this assessment stage, novel non-rigid registration techniques are have now been developed that incorporate local image geometry information to constrain and accelerate the matching process. evaluation of palliative procedures in functional singular ventricle with mri f. weiss, c.r. habermann, c. lilje, k. sasse, j. weil, g.b. adam; hamburg/de purpose: to determine the value of mri in the postoperative evaluation of singular ventricle compared to echocardiography and cardiac catheterisation. methods/material: patients (range: month to years) with functional singular ventricle who had undergone palliative corrective operations. patients were treated without separation of circulation to improve pulmonary perfusion with blalock-taussig-shunts. patients had cavopulmonary shunts, of them total cavopulmonary anastomosis, only partial separation with bidirectional glenn-anastomosis. patient was treated with a central shunt. the results were compared to percutaneous echocardiography, cardiac catheterisation and operation reports regarding postoperative morphologic changes. detectability of thombotic material in the low-flow-system was evaluated. conclusions: d-rotational angiography allows for a more exact depiction of anatomical details important in planning surgical and interventional therapy of intracranial aneurysms than dsa. ra also identified more aneurysms. b a c d e f incidence of old intracranial microbleeds in patients with acute intracranial hemorrhage m. alemany, r. raininko, a. stenborg, a. terent; uppsala/se purpose: previous publications have demonstrated, using blood sensitive t *weighted (w) sequences, the presence of incidental foci of signal loss which have been confirmed histopathologically to represent hemosiderin deposition from earlier bleeds. their clinical significance is still debated. our purpose was to evaluate the occurrence of old microbleeds in patients having acute intracranial hemorrhages and correlate these findings with clinical data. methods and material: we studied patients (mean age years) with acute intracranial hemorrhages. patients had spontaneous bleeds, appeared after subclavian dilatation and after coronary and lung thrombolysis, respectively. axial spin echo t -w and t -w, flair and gradient echo t *-w images were obtained using a . t system. results: besides the acute hemorrhages, evidence of prior bleeds were found in / patients ( %). / patients were hypertensive and / were normotensive. of the hypertensive patients ( %) and of the normotensive ones ( %) had evidence of old bleeds. other clinical data were also investigated (diabetes, abuse of alcohol or tobacco, anticoagulant treatment, etc) but no clear correlation with intracranial microbleeds was found. only the t *-w sequences were able to detect these lesions. our results support the hypothesis of a correlation between hypertension and old intracranial microbleeds. the microbleeds may be the sign of a microangiopathy that could give a increased tendency for intraparenchymal bleeding. the detection of old microbleeds is, thus, of diagnostic importance. they may also help to predict risk for spontaneous rebleeding or bleeding complications after anticoagulant therapy. multislice angio-ct in the evaluation of cerebral aneurysms m. wintermark, m. chalaron, p. maeder, a. uske, p. schnyder, r. meuli, s. binaghi; lausanne/ch purpose: evaluation of the accuracy of multislice angio-ct in the detection of cerebral aneurysms, by comparison with conventional cerebral angiography methods and material: consecutive patients, who successively underwent multislice cerebral angio-ct ( . mm-thick slice reconstructed every mm, pitch . , kvp, ma, timing determined with a bolus test) and conventional cerebral angiography, were prospectively identified in our department between july and august . both examinations were reviewed independantly by two neuroradiologists, who were blinded to their initial interpretation and who did not perform the cerebral angiography. angio-ct axial slices were reviewed, as well as d mip and d ssd reconstructions. angio-ct and angiography data analysis was performed separately, but according the same systematic interpretation strategy. results: cerebral aneurysms were diagnosed. sensitivity, specificity and accuracy of multislice angio-ct in the detection of cerebral aneurysms were %, % and %, respectively. the impact of aneurysm location was determined. the ability of multislice angio-ct in the characterization of cerebral aneurysms was evaluated: size (slope . , r = . , p < . ), orientation (accuracy . %), thrombosis, calcification, origin of arteries, apical teat. conclusion: multislice angio-ct of the willis circle is a worthy tool in the detection and characterization of cerebral aneurysms. its ability to detect aneurysm partial thrombosis is higher than that of conventional cerebral angiography. angio-ct allows for efficient planning of cerebral angiography and affords useful information in the determination of the therapeutical strategy. monday b a c d e f methods and materials: in a blinded, prospective study patients with acute subarachnoid haemorrhage underwent both cta and dsa. spiral ct with d reconstruction was performed. ml of intravenous contrast was administered at ml/s. collimation of mm. with a pitch of , and a reconstruction index of . was used. there were females and males entered into the study. the cta images were separately reviewed by two consultant neuroradiologists, who were blinded to the dsa findings. the ct angiograms were assessed for aneurysm size and location, in addition to adjacent vascular anatomy. the results were compared with dsa. results: from the initial group of patients with sah, no aneurysm was evident on either cta or dsa in eleven. of the remaining patients, aneurysms of varying types were diagnosed. cta accurately diagnosed of these (sensitivity %). of the intracranial aneurysms missed on cta all of these were under mm in size. specificity of cta is %. conclusion: cta would appear to be a safe and relatively reliable alternative to dsa in the management of acutely ruptured intra-cranial aneurysms. other advantages include speed, cost and its non-invasive nature. in addition it may be of benefit in the follow-up of known aneurysms. in view of these results we have since modified our protocol to improve sensitivity further. purpose: to evaluate the blood flow dynamics in patients with arterio-venous malformations (avms) before and after radio-therapy treatment. patients and methods: two different mr imaging techniques were used in a total of patients. a non enhanced dynamic mra based on a blood bolus tagging technique and a new contrast enhanced projection mra (fluoroscopic mra/ mrdsa) based on a fast flash sequence were used to assess the angioarchitecture of the malformation as well as the hemodynamics, mainly based on a calculated shunt-time between feeding arteries and draining veins. the conventional tof-mra and conventional dsa served as an internal standard. mrdsa was performed with a bolus injection of . mmol/kg bw of gadodiamide (omniscan®, nycomed-amersham) at an infusion rate of cm /s and a time resolution of ms per projection. images were assessed in regard to vessel detection and demarcation as well as the hemodynamic aspects of the malformation. results: both techniques were able to assess the angioarchitecture of the avm in all patients. the arterial feeder, the avm nidus and the venous drainage pattern could be clearly delineated. the time resolution of the non enhanced tagging technique was substantial better enabling a more precise assessment of the hemodynamics. discussion: mrdsa and dynamic non enhanced mra are able to assess both the avm angioarchitecture and the avm hemodynamics non invasively. the techniques are easy to implement and can be used for treatment planning. hemodynamic changes due to therapy (embolisation or radiosurgery) can be monitored. the role of transcranial doppler sonography (tcd), and somatosensory evoked potentials (sep), in the detection of vasospasm after subarachnoid hemorrhage a. fatourou, c. constantoyannis, e. solomou, p.a. dimopoulos; patras/gr purpose: to evaluate the correlation between blood flow velocity (bfv) and vasospasm in patients suffering from subarachnoid hemorrhage (sh). to detect any relationship between conduction time of somatosensory evoked potentials and vasospasm in the same group of patients. to assess the simultaneous use of tcd and sep in the detection of vasospasm. materials/methods: in our study, we included patients with subarachnoid hemmorhage (sh), diagnosed with ct. six of them also underwent a lumbar spine puncture (lsp). all of them had digital subtracted angiography (dsa), for aneurysm localisation. the follow-up was performed using tcd and sep. the diagnosis of sh, in patients was made with ct, and in the rest of them ( patients), was made with lsp. dsa revealed an aneurysm in patients, whilst there were no remarkable findings in patients. the latter were reviewed again and an aneurysm was detected in one more patient. vasospasm appeared in patients, whose bfv in the middle cerebral artery was . cm/s, and central conduction time (cct), was . ms. the remaining patients without vasospasm, had bfv . cm/s and cct . ms. conclusion: statistical analysis showed that the prediction of vasospasm, with the correlation of the two modalities tcd and sep, allowed a proper successful classification in . %. using two additional parameters, the fisher classification, and the classification hunt-hess, the percentage of proper successful classification did not change significantly. clinical and neuropsychological outcomes in patients presenting with a ruptured anterior communicating aneurysm: mid term follow-up b. jean, k. martin, m. gely-nargeot, a. bonafé; montpellier/fr purpose: rupture of an anterior communicating aneurysm (acoma) is associated with substantial cognitive and psychopathological dysfunction, disability in psychosocial activities and daily living. we report the clinical and neuropsychological outcome of patients treated by embolization of an acoma; subgroup of our base of acom aneurysm. material and method: from september to may we treated ruptured acoma by coil embolization. at admission age, aneurysm description, initial clinical wfns score, fisher grade were collected. at discharge occlusion rate, glasgow outcome scale (gos) and complications were reported. we followed patients at months, and year with clinical evaluation and an angiographic control. out of patients, we submitted patients to an extensive range of tests: comprehensive batteries of neuropsychological and psychopathological tests, daily living scales. cognitive outcome was evaluated using global rating scale (mattis), and assessment for attention, executive functions, explicit, implicit memory and psychiatric associated disorders. results: we treated patients using gdc coils. technical and clinical results are provided. we report our technical complications and complications due to sah evolution (symptomatic vasospasm, acute hydrocephalus). patients were submitted to the battery of neuropsychological tests. the patient's performances were characterized by neuropsychological deficits, especially impairments in learning and explicit long term memory, associated with functional frontal dysfunction. conclusion: aneurysm morphological characteristics and occlusion rate do not influence early clinical evolution in ruptured aneurysm. patients submitted to a battery of neuropsychological tests showed neuropsychological deficits and frontal dysfunction on mid term follow-up. purpose: although preoperative embolization of meningioma is a helpful procedure to minimize bleeding and to facilitate resection, some meningiomas showing lack of vascularity are not suitable for embolization. the dsa itself would therefore be an unnecessary procedure. the goal of our study was to predict poorly vascularized meningiomas using time resolved mra (tr-mra). materials and methods: tr-mras were performed on a . t whole-body unit (vision, siemens, erlangen, germany) in patients with meningioma using a snapshot flash optimized for d projection (tr/te . / . ms, slab thickness mm). a standard dose of gd-dtpa was injected with an automatic injector (volume ml at ml/s). coronally directed tr-mra was obtained using single slice, frames/s during seconds without time-interval. tr-mra, dsa and embolization were done at the same day when possible. signal intensity (si) of meningiomas in tr-mra was graded as if no si is detected. faint si was graded as +, good si as ++, and dense si as +++. grades of si on tr-mra of meningiomas and possibility of embolization were analyzed using x -test. results: in meningiomas, graded as +++, as ++, as +, and as in tr-mra. embolization was done in all graded as +++ and ++. however, embolization could not be performed on grade + and due to lack of vascularity from external carotid artery (p = . ). conclusion: tr-mra is an useful study to avoid unnecessary dsa in cases of meningiomas with lack of vascularity which would not be candidates for embolization. purpose: traditionally estimation of pancreatic exocrine function has been invasive e.g. duodenal intubation or non-specific. secretin mrcp can be used to calculate exocrine flow rates. we compared patients with normal pancreatic morphology and patients with chronic pancreatitis. materials and methods: following baseline ssfse, . ml/kg iv secretin was administered and the acquisition repeated every minutes for minutes. the receiver gain was held constant. flow rate = change in total signal intensity over time divided by the signal intensity of a voxel containing % water. breath-hold axial t w images and spiral ct were also performed as part of their work-up. patients had a normal pancreas on ct and ercp, had chronic pancreatitis of whom had had surgery, pancreatoduodenectomy in and a puestow procedure in . of the remainder, had severe, moderate and mild chronic pancreatitis. results: mean flow rates in the normal group were ml/min ± . and for patients with severe chronic pancreatitis . ± . . this difference was significant (student t test p < . ). within the chronic pancreatitis group there were patients with flow rates < ml/min all with longstanding chronic calcific pancreatitis. significantly different smrcp flow rates were seen in normals as compared to patients with severe chronic pancreatitis. very low flow rates were seen in patients with long standing chronic calcific pancreatitis. materials and methods: patients with suspected pancreatic lesion were studied in preoperative evaluation, including mri with vibe -a fast t w sequence tailored for dynamic d studies -with gadolinium dtpa dynamically, t w fse and t w haste. the mri findings (as described in the reports) were analysed, scored and compared to those from surgery and pad. results: mri detected / lesions (one papillary tumour was missed). / neoplastic tumours were correctly characterized as malignant (sensitivity %; specificity %). vascular encasement (of portal, superior mesenteric vein/artery, celiac trunk, hepatic artery and/or splenic vein/artery) was correctly described in / cases (sensitivity %; specificity %; ppv %; npv %). nodular metastases were correctly characterized in / (sensitivity %; specificity %; ppv %). lymph node enlargement (> mm) was metastatic in / . / liver metastases were found. the remaining non-tumoral lesions were histopathologically classified as inflammatory pseudotumours and papillary fibrosis. ( ) pancreatic lesions were accurately detected with mri/vibe. ( ) the method cannot differentiate benign from malignant lesion. enlargement of lymph nodes was not correlated to lymph node metastases. ( ) mri/vibe is an efficient tool to predict resectability in patients with pancreatic tumour. vascular encasement was well evaluated. small liver metastases (≤ mm) were not detected. methods and materials: all available ct and mr/mrcp studies of patients who underwent surgical resection were considered. the pathological exams revealed ipmt with hyperplasia/low-grade dysplasia, ipmt with moderate/ borderline dysplasia, ipmt with high grade dysplasia/carcinoma in situ, and ipmt with invasive carcinoma. observers retrospectively reviewed all the images, searching for signs indicative of either benignity or malignancy. results: considering the criteria reported in literature, after complete evaluation of the lesions the assessment of malignancy was made in / pts after consensus, being correct in / ( . %) cases. the false positive cases, regarding lesion histologically classified as low-grade dysplasia, the wrong diagnosis was related to their dimension (> cm). in false negative errors were made, concerning lesions lacking any sign indicative for malignancy (moderate/high grade dysplasia: ; carcinoma in situ: ). these results yielded a sensitivity, specificity, and accuracy of %, %, and %, respectively. conclusion: ( ) the assessment of malignancy is trustworthy, and warrants surgical resection. ( ) invasive carcinomas are always recognisable, thanks to the wall thickening, and parietal proliferations. . additionally, t -w contrast enhanced (ce), triphasic "volume interpolated breathheld examination" (vibe) was performed. in a control group of pts. vibe was replaced by ce d-gre. two observers analysed data with regard to image quality, tumor conspicuity (roc), diagnostic accuracy and interobserver variability. results: / pts in the study-and / in the control-group had pancreatic ca. vibe revealed the best image quality in the study-group ( . ± . ) outperforming d-gre ( . ± . ) (p < . ). haste, t -tse and mrcp also performed less well: . - . (p < . ). roc-analysis ( / . observer) showed that vibe ( . / . ) obtained higher values than haste ( . / . ), t -tse ( . / . ) or mrcp ( . / . ). d-gre performed signif. worse than vibe ( . ; p < . ). best diagnostic capability was obtained by combination of all sequences in the study-( . / . ) and the control-group ( . / . ). hence, sens. and specif. was higher in the study-( %/ %) than in the control-group ( %/ %) (p < . ). interobsever variability ranged from moderate . (haste), good . (vibe; d gre) to very good . (combination of all sequences). purpose: to evaluate the use of mr perfusion imaging to monitor organ function of pancreas and kidney grafts after combined transplantation. methods and materials: a coronal fgre sequence was used to monitor the signal intensity of transplanted pancreas and kidney grafts, of psoas muscle and aorta before and during the first min after bolus injection of . mmol gd/kg bw. a perfusion index as the percentage of maximum signal intensity in the organ relative to the maximum signal intensity in the aorta was calculated. in a prospective study patients underwent a total of examinations. mean follow-up after transplantation was days (range - ). perfusion index was used to judge function as good, fair or poor. results were correlated to clinical course and laboratory data. results: absolute values of perfusion index correlated with clinical course of organ function. in addition a strong correlation was found between the intraindividual course of the perfusion index and the clinical course during repeated measurements. the perfusion index can be used to monitor organ function after combined pancreas and kidney transplantation and is especially important in follow-up examinations to assess the intraindividual course of organ function. results: mean number of ct examinations per patient was . , maximum (in those with severe pancreatitis). mean number of series was . . mean effective dose was . mgy, maximum (performed with incremental ct and high exposition parameters) was calculated to result in . msv. mean dose lenght product was mgycm. risk for radiation-induced cancer could be estimated to be . % per average examination, cumulating to . % in a patient with ct examinations. as a worst case scenario, assuming that the dose per examination would have been the maximum found in this survey ( . msv), the radiation risk would be . %. conclusion: average number of examinations, cumulative dose and estimated radiation risk resulting from ct imaging in pancreatitis patients is moderate, especially in regard to the often severe course of the disease. however especially in young patients, examination parameters should be chosen with care, and mri should be taken into consideration. multidetector ct of isodense pancreatic adenocarcinoma: more there than meets the eye r.w. prokesch , l.c. chow , c.f. beaulieu , r. bammer , r.b. jeffrey jr. ; vienna/at, stanford, ca/us purpose: to assess the frequency of isodense pancreatic adenocarcinoma with multidetector ct (mdct) and determine the value of secondary signs which aid in their detection. materials and methods: patients with pancreatic adenocarcinoma underwent contrast-enhanced, biphasic mutidetector ct with curved planar reformations (cpr). tumors were initially deemed isodense or hypodense on the basis of visual inspection and then confirmed by calculation of mean attenuation differences between normal pancreatic parenchyma and tumor during the pancreatic phase. indirect signs of pancreatic tumor were tabulated in cases where an isodense tumor was identified. results: out of the patients, six ( . %) had isodense tumors with a mean tumor-pancreas contrast of . ± . hu during the pancreatic phase and . ± . hu during the portal venous phase. ancillary signs of a pancreatic tumor included an interrupted pancreatic duct (n = ), dilated biliary and pancreatic ducts (n = ), atrophic distal pancreatic parenchyma (n = ), and mass effect/convex contour abnormality (n = ). mean tumor-pancreas contrast for the remaining cases was . ± . hu during pancreatic phase. conclusion: isodense pancreatic tumors, even studied with high-resolution mdct, represent a significant percentage of pancreatic carcinomas. with no visible tumor-pancreas contrast, indirect signs such as mass effect, atrophic distal parenchyma and an interrupted duct sign are important indicators for presence of tumor. cpr of the pancreatic duct are particularly helpful in delineating the obstructed pancreatic ductal system. multislice helical ct with d and d multiplanar reconstructions using minimum intensity projection for assessment of the pancreatic ducts m. zins, n. bouzar, l. fontanelle, s. lenoir, c. strauss, r. palau; paris/fr to evaluate imaging quality of d and d multiplanar reconstructions with minimum intensity projection (minip) in assessment of the pancreatic ducts using multislice ct. methods and materials: consecutive patients with potential disorders of the pancreas were scanned using multislice ct. the ct parameters were: s scan delay for the pancreatic phase and s scan delay for the portal venous phase. pancreatic phase images were used for d and d reconstructions with the following parameters: . mm slice thickness; interval of reconstruction: . mm; the d and d data sets were evaluated in oblique axial and oblique coronal planes, using minip. qualitative assessment of the multiplanar reconstructions included: ( ) visibility and size of the main pancreatic duct (mpd), ( ) visibility of the major papilla, ( ) visibility and size of the duct of santorini, and ( ) visibility and size of the branch ducts. the mpd was entirely visualized in patients ( %) including with non dilated mpd. the major papilla was visualized in all patients. a non-dilated duct of santorini was visualized in patients; a dilated duct of santorini was visualized in three patients with intraductal papillary mucinous tumors of the pancreas (ipmtp). non dilated branch ducts were visualized in two patients and dilated branch ducts were visualized in patients. purpose: to assess main pulmonary artery dimensions in normal subjects and in patients with marfan's syndrome. materials and methods: marfan patients (mean age ( ) years, men, women) and matched control subjects (mean age ( ) years, men, women) underwent cardiac magnetic resonance imaging (mri). pulmonary artery dimensions were obtained on axial spin echo images at two different levels: ) the level of the pulmonary artery root and ) the level of the pulmonary artery bifurcation. results: upper limits of normal (mean + sd) at the pulmonary root and at the pulmonary artery bifurcation were . mm and . mm, respectively. pulmonary artery dilatation was demonstrated in ( %, root) and ( %, bifurcation) of the marfan patients. there was a good correlation between pulmonary and aortic root diameter in non-operated marfan patients (r = . ). dimensions of pulmonary root were larger ( . mm, range . - . mm) than dimensions at the pulmonary bifurcation ( . mm, range . - . mm, p < . ). marfan a c d e f patients with aortic root replacement (n = , root . mm, bifurcation . mm) had significantly larger pulmonary artery dimensions than non-operated marfan patients (n = , root . mm, bifurcation . mm, p < . ). conclusions: in the majority of marfan patients the main pulmonary artery, particularly the pulmonary root, was dilated. a good correlation between pulmonary and aortic root diameter was demonstrated. pulmonary artery dimensions were significantly larger in marfan patients with aortic root replacement than in nonoperated marfan patients. methods and materials: selective pulmonary dsa was performed in consecutive patients with ctph. six bolus injections of non-ionic contrast media were used (pa-, oblique and lateral projections of both pulmonary arteries, iomeprol, ml, ml/s). hemodynamics were obtained using swan-ganz catheters and classified in three groups depending on systolic pulmonary pressure (pasyst): group i: < mmhg, ii: to ≤ , and iii: > mmhg). results: pasyst was . ± . (group i, n = ), . ± . (ii, n = ), and . ± . mmhg (iii, n = ). pulmonary vascular resistance index (pvri) was ± (i), ± (ii), ± dyne⋅s⋅m ⋅cm − (iii), mean cardiac index (ci) was . (i), . (ii), and . l⋅min − ⋅m − (iii). pcw pressure was normal in all three groups indicating normal left heart function. contrast bolus injection caused only slightly increased pa pressure (dpasyst: . ± . (i), . ± . (ii), and . ± . mmhg (iii)). after completion of angiography right atrial pressure and pasyst were moderately increased (dra: . (i), . (ii), . mmhg (iii), dpasyst to determine the value of mri in the diagnosis of pulmonary embolism (pe) in patients unable to sustain apnoea, e.g. in acute pe. methods: a real time (rt) steady state free precession (ssfp, truefisp) sequence was adapted for the examination of the thoracic vasculature. consecutive patients with suspected pulmonary embolism were prospectively examined with mri using a rt-truefisp sequence and contrast enhanced mr-angiography (mra). the clinical stages of suspected pe were as follows: chronic , mild , severe , massive . results: % of the mra-sequences were diagnostic, excluding all patients with massive and some with severe pe. all rt-sequences were diagnostic. all lobar arteries and % of the segmental arteries could be evaluated, segments / being the most difficult. for the rt-sequences, no patient preparation, ecg or breathing commands were needed. pe was diagnosed in % of the patients by rt-mr. in patients with pe, mra detected additional thrombotic segments. two diseases mimicking pulmonary embolism could be diagnosed. in all remaining patients with clinically suspected severe and massive pulmonary embolism, thrombotic material could be visualized in the pulmonary arteries. chronic and acute pulmonary embolism could be differentiated, and the effect of thrombolytic therapy on thrombus size could be visualized. conclusion: rt-mri allowed the examination of any patient regardless of his clinical condition in min and required no preparation. therefore, the range of indications for mri in patients with suspected pulmonary embolism is extended. the well established mra technique has advantages in patients able to sustain apnoea. a differentiated approach to pulmonary embolism and deep venous thrombosis using multi-slice ct j.e. wildberger , a.h. mahnken , a.m. sinha , p. haage , s. schaller , r.w. günther ; aachen/de, forchheim/de purpose: to establish a protocol for multi-slice ct (msct) examinations for clinically suspected pulmonary embolism (pe) using pulmonary ct-angiography and indirect ct-phlebography (ctp). methods and materials: from february to july , patients ( male, female; age: m = . a ± . a) with suspected pe were examined on a msct (somatom volume zoom; siemens, germany). after intravenous injection of cm of contrast-medium, thin collimation chest ct was performed. ctp was added if pe was present or previous examinations and clinical signs suggested deep venous thrombosis (dvt). the latter was performed using a × mm protocol (slice thickness mm, reconstruction increment mm). venous phase scanning was completed at the level of the popliteal fossa minutes after contrastmedium injection. results: patients in our series suffered from pe. of these had additional deep venous thrombosis ( . %). the latter was ruled out in patients, one patient with pe did not receive this additional examination protocol due to their poor clinical condition, one subsegmental pe was initially not detected. of the patients without pe, also received indirect ctp. in cases dvt was proven, which was already known from previous examinations in patients. only in / patients ( . %) was a previously undiagnosed dvt found, despite exclusion of pe. the examination protocol presented is suitable for clinical use in patients with suspected pe and offers detailed examination of the venous system. if dvt is not likely, additional ctp is not recommended if pe has been ruled out by msct. methods: patients with severe chronic ctph were evaluated using multislice ct and selective pulmonary dsa for operative treatment planning. ct findings and angiographic findings were correlated at the level of major arteries, interlobar arteries, segmental and subsegmental arteries. diagnostic criteria included patency or occlusion, thromboembolic deposits, webs, bands, and anatomical allocation of the respective findings. results: in consecutive patients with severe ctph, ct and dsa findings of pulmonary vessel segments from major to subsegmental arteries were separately analysed. using multislice ct segments were insufficiently detected ( subsegments, segments) compared to segments in dsa ( subsegments, segments, and major arteries). predominantly segment iii and less often segment i arteries were insufficiently detected due to the position of the pigtail catheter. concerning inconspicuous vessles versus occlusion or any thromboembolic alterations, the diagnostic concordance of both methods overall was %, was . % for segmental arteries and . % for subsegmental arteries. concerning patency versus complete occlusion diagnostic concordance overall was . %, was . % for segmental arteries and . % for subsegmental arteries. dsa was superior for detection of peripheral thromboembolic alterations. ct was superior for anatomical allocation. conclusion: multislice ct is suitable for diagnosis of ctph on segmental and subsegmental level. however, for planning of pulmonary thrombendarterectomy both modalities, multislice ct and selective pulmonary dsa, are still necessary for exact anatomical allocation and precise visualisation of thromboembolic findings. epidemiologic, clinical and morphologic criteria as listed below. (advanced disease was defined as hepatic insufficiency leading to olt within the subsequent years). results: common and characteristic findings were as follows: % of patients were women with the onset of disease (diagnosis) in middle age (mean, . years, range, to years). the average time from diagnosis to liver transplantation was . years (range, . to years). ct findings in advanced pbc often resembled those seen in other forms of cirrhosis with a small heterogeneous liver, varices and splenomegaly. the liver in less advanced disease was usually enlarged or normal in size, with a smooth contour, little atrophy and lace-like fibrosis and regenerative nodules in nearly a third. even patients with less advanced disease frequently had varices ( %) and ascites ( %). prominent lymphadenopathy was seen in % of all cases. hepatocellular carcinoma was found in only patients, of whom also had chronic hepatitis c. only two patients had recurrence of pbc following olt conclusion: pbc is an important cause of liver failure with distinctive clinical and ct findings that may allow confident diagnosis and management. we reviewed retrospectively the imaging studies of five patients ( women; aged - years) with liver nodules associated with a spontaneous intrahepatic portosystemic venous shunt. color-doppler ultrasoud (us), helical-ct and arteriography were performed in all patients and mri in patients. nodules location, number, size, density or signal, homogeneity and pattern of vascularition were evaluated. hepatic vascularization, the morphologic type of the shunt and portal hypertension features were also analyzed. these findings were correlated to pathological results (transcutaneous biopsy of the nodules (n = ); transplantation (n = )). results: sonography and angiography demonstrated a portohepatic venous shunt (persistent arantius ductus (n = ), congenital absence of portal vein (n = ), left portohepatic venous shunt (n = ), left portoatrial shunt (n = )). hepatic arterialisation were observed in segment where no portal flow was seen and where hepatic nodules were present. the number of nodules in each patients was at least with a size ranging from to cm. most lesions were heterogeneous, hypoechoic on us, hypodense on ct, hyperintense on t , slightly hyperintense on t and enhanced slightly and heterogeneously on arterial phase after contrast injection. histological results showed nodular hyperplasia in the liver suggestive of focal nodular hyperplasia in all cases and adenoma in one case. conclusion: these findings emphasised the hypothesis that nodular transformation of the liver is probably due to the lack of portal blood flow and hepatic arterialisation and is usually of benign type. high resolution multislice spiral ct in liver metastasis: comparison of a high resolution vs a low resolution protocol f. fraioli, c. catalano, a. laghi, f. pediconi, a. napoli, r. brillo, m. danti, r. passariello; rome/it purpose: to evaluate the sensitivity and specificity of multislice spiral ct (msct) in the assessment of patients with suspected liver metastasis and to compare two different acquisition protocols. material and methods: patients referred for different neoplasms underwent msct. all patients underwent intraoperative ultrasound or, in case of diagnosis of unresectability in the first examination, a follow up ct at three months. pre ( × . mm collimation) and post-contrast ( × mm collimation, mm and mm reconstruction interval) acquisitions, during arterial and portal venous phases were performed after i.v. administration of ml of c.a. at ml/s. two observers blindly evaluated either mm axial images or mm axial and relative mprs, in terms of presence and number of lesions. results: ct correctly showed ( %) of the liver lesions shown at intraoperative ultrasound in patients. ct correctly evaluated all lesions greater than cm in size. regarding lesions smaller than cm in size ct evaluated as cyst lesions shown at intraoperative ultrasound as metastasys. real time interaction d data set with mm axial images, allowed to identify subcapsular lesions. sensitivity, specificity and accuracy in detection of smaller lesions smaller than cm was %, % and % using mm axial images and %, % and % using mm protocol. conclusion: high resolution msct with d data is a very accurate technique in the assessment of patients with liver metastases. the difference of images secretory and non-secretory carcinoid tumours using standard ct and functional techniques j.b. cwikla, j.r. buscombe, a.j. watkinson, m.e. caplin, a.j.w. hilson; london/gb functional and anatomical imaging modalities can underestimate presence or extent of disseminated carcinoid and should be used together. aim of study was to assess if there is any difference in imaging pictures between secretory and nonsecretory carcinoid and toconsider both techniques. overall patients, all with confirmed carcinoid. there were patients with primary disease. half of the patients had secreting tumours with carcinoid syndrome. ct and in octreotide study was performed in each case, using standard imaging protocol. in non-function tumours ct was able detect disease within liver in rate of . . in octreotide was positive in all patients. different sites within abdomen and chest in patients with non-secretory tumours ct and functional imaging detected with rate as follows: pancreas . / . , paraaortic nodes . / . , gut and/or mesentery . / . . other site of tumour spread: chest, pelvis, spleen or bone using ct was . and in octreotide . . those patients with secretory tumours had results as follows: liver deposits using ct in . , in octreotide . . in this group of patients other sites of tumour deposits within abdomen and chest ct and functional imaging detected with rate as follows: pancreas . / , paraaortic nodes . / . , gut and/or mesentery involvement both . . other site of tumour spread like chest, pelvis, spleen or bone involvement using ct was . and in octreotide . . these results suggest that any imaging modality is perfect to detect carcinoid deposits, additionally there is a difference with deposits distribution of carcinoid in patients with secretory and non-secretory tumours. lymphoma therapy monitoring by multislice perfusion-ct w. römer, l. muresan, r. repp, a. taubald, h. greess, w.a. kalender, w.a. bautz; erlangen/de purpose: the high frequent acquisition of multislice ct data after contrast medium bolus injection allows quantification of tumor perfusion. it was our goal to assess therapy induced changes of tumor perfusion early after initiation of lymphoma treatment using dedicated software to calculate parametric images. method: dynamic msct was performed in patients with lymphoma before and days after initiation of chemotherapy. after automatic bolus injection of ml contrast medium (flow ml/s), two mm-sections through the largest tumor region were scanned for s (siemens somatom volume zoom). the arterial input function was derived from the largest arterial vessel in the field of view. perfusion indices were calculated using graphical analysis and displayed as parametric color coded images. results: at baseline, all lymphoma lesions were visible in perfusion images by an enhanced perfusion index ( . ml/min/ml). seven days after initiation of chemotherapy, tumor perfusion decreased by % in high grade nhl and hodgkin's lymphoma, whereas in two patients with low grade nhl the perfusion index increased by %. in contrast, d-tumor size only decreased by % and %, resp. conclusion: these results indicate that chemotherapy-induced changes of tumor perfusion may be assessed by perfusion msct and documented in parametric images. in highly responsive tumors like high grade nhl and hodgkin's lymphoma, therapy induced perfusion changes occur within the first days after therapy and precede morphologic changes. we hypothesize that outcome of therapy may be predicted as early as days after treatment. the effect of intravenous secretin administration on hepatic enhancement during ct examinations of the abdomen s.m. lyon, t. fotheringham, p. o'sullivan, m.f. given, m.j. lee; dublin/ie purpose: intravenous secretin increases blood flow to the pancreas in animals. in an associated study we found that iv secretin caused significantly increased enhancement of the portal venous (pv) system. this study investigated the effect of secretin on hepatic enhancement. methods: patients (mean age ; range - ) were enrolled. triple phase helical ct of the abdomen was performed on successive days so that each patient acted as their own control. all patients had intra-abdominal malignancy and the study was approved by the hospital ethics committee. unenhanced and enhanced ct in the arterial phase and pv phase was performed without (day )and with (day ) secretin ( iu) given at t = s (n = ), t = s (n = ), t = s (n = ), t = s (n = ), t = s (n = ), t = s (n = ). percent enhancement of the liver was calculated using roi's obtained from studies with and without secretin. results: overall mean hepatic enhancement in the portal venous phase was % without secretin and % with secretin. the relative increase in hepatic enhancement after secretin when compared to hepatic enhancement without secretin was % at t = , . % at t = s, . % at t = s, . % at t = , . % at t = and . % at t = s. pv/smv enhancement was significantly increased in all secretin studies (p < . ) when compared with non-secretin studies. conclusion: secretin administration causes an increase in hepatic enhancement which may lead to better lesion conspicuity. the optimal timing for secretin administration and its effect on lesion-liver contrast differences will be determined as more patients are recruited. study completion is expected in november . imaging findings in extraosseous multiple myeloma m. patlas, i. hadas-halpern, c. reinus, e. libson; jerusalem/il purpose: extraosseous manifestations are rare and are found in less than % of patients with multiple myeloma. the purpose of this study is to illustrate the imaging features of extraosseous myeloma and to heighten the awareness of this phenomenon. we retrospectively reviewed the radiological files of myeloma patients. patients in whom the extraosseous masses were in contiguity with bony involvement were excluded from the study. results: seven of the ( . %)myeloma patients had extraosseous masses. there were men and women and the age range was - years old (mean age years). ct was available in five patients, mammography in three cases, and ultrasound in one case. biopsy revealed the diagnosis of plasmacytoma in all cases. the gamut of findings included breast masses (three patients), supraclavicular lymph nodes ( patient), pancreas and stomach ( patient), adrenal and pleura ( patient), thyroid cartilage ( patient). more than one site was present in of the patients (adrenal and pleura; pancreas and stomach). soft tissue plasmacytomas presented as relatively well-defined masses of various sizes, and could not be differentiated from other malignant or benign lesions on the basis of the imaging findings alone. conclusions: exraosseous myeloma is very uncommon in multiple myeloma. radiologists should be aware of this occurence so that extensive unnecessary interventions can be avoided when extraosseous sites of disease are encountered. quality indicators in radiology management: a methodology development study p.e. varga , e. belicza , e. sík , g. nagy ; budapest/hu, szekszárd/hu, zalaegerszeg/hu purpose: quality indicators are widely used in healthcare. though imaging is involved in almost all diagnostic procedure, few quality indicators are accepted in radiology. method: repeated x-ray examination data were collected in hospitals. the -month multicenter study aimed to develop an indicator as well as to test the indicator development method itself, using common data sheets. in the repeated examinations, the influence of different reasons of repetition was analysed. results: causes were identified. inappropriate exposition or positioning were leading causes, in . % of the cases in hospital , . % in hospital and . in hospital . failure of the equipment was the second cause: . %, . % and . %, respectively. low rates in hospital can be attributed to the newly equipped digital x-ray department. in other words: hospital and pay the price of the lack of investment with repeated examinations. day-section has a higher influence than workload: though the majority of the examinations were carried out during normal hours, . % of the repetitions occur on night duty. nearly half of the technicians involved found the data sheet too detailed and they proposed to modify his for automatic registration. as repeated examination means increased risk for the patient and the institution, economical consequences will be demonstrated. conclusion: repeated x-ray examination proved to be an appropriate quality indicator, as it is profession-specific, relevant and convenient for benchmarking. data collection is easy and economic data can be linked. quality management can be based on reason analysis. materials and methods: of patients who were referred for percutaneous drainage of hepatic abscess between and , cases with incorrect diagnosis or without pre-procedural contrast-enhanced ct were excluded, and abscesses in patients ( - years, m:f = : ) were included. patients had the predisposing factor such as hepatocholedocholithiasis (n = ), the history of biliary (n = ) or gastrointestinal (n = ) malignancy, or others. findings in dual-phase helical ct (n = ) or single-phase ct (n = ) were analyzed concerning the enhancement pattern of the abscess wall and adjacent parenchyma, and the presence of the thrombosis of intrahepatic vasculature. the abscess wall appeared as single layer of hyperdense ring in lesions ( %) or as double target (inner hyperdense ring and outer hypodense ring) in lesions ( %). there was thrombosis in the hepatic vein (n = ) and/or portal vein (n = ) noted in cases ( %). in cases with dual-phase ct, regional difference in parenchymal attenuation was noted in cases ( %), showing wedge-shaped hyperdense area surrounding the absecss in arterial phase (n = ) or hypodense area peripheral to the abscess in portal phase (n = ). of those cases with regional difference in parenchymal attenuation, cases ( %) had venous thrombosis (p = . , fisher's exact test). the abscess wall has characteristic enhancement pattern on dynamic ct. the enhancement pattern of adjacent parenchyma is more complex, and it may be associated with the venous thrombosis. the liver is the most commonly damaged organ in children following blunt abdominal trauma. a conservative non-operative approach is now the recognised standard of care. computerised tomography (ct) is the primary imaging modality of choice. this conservative approach can result in bile duct damage remaining undetected for several days. we have evaluated the pre-emptive use of tbida hepatoscintigraphy, to detect biliary leakage prior to the patient becoming symptomatic. at birmingham children's hospital, all patients who have a history of trauma and clinical suspicion of abdominal injury undergo an abdominal ct. in those cases where there was liver fracture greater than . cm or involving the portahepatitis, a tbida study was performed. patients underwent an abdominal ct abdomen. patients had a significant liver injury, all with fluid in the peritoneum and additionally had a tbida study. in patients the tbida demonstrated activity within the peritoneal cavity. intraoperative cholangiograms confirmed the biliary leaks that were surgically stented. both patients were asymptomatic with no evidence of a biliary peritonitis. the tbida in a third patient demonstrated a biloma that on follow-up ultrasound has shown to be shown to be the site of a portovenous fistula. all patients showed good recovery and returned to a normal lifestyle. tbida hepatoscintigraphy, when used pre-emptively, can detect biliary damage prior to the development of clinical symptoms. this early detection improves surgical outcome and reduces hospital stay. the investigation also allows the detection of other potential intrahepatic complications. b a c d e f acute pancreatitis in childhood l. laufer, o. kleiner, g. greenberg, z. cohen, y. hertzanu; beer sheva/il purpose: acute pancreatitis in children is rare. the aim of this study was to demonstrate the spectrum of imaging findings in relation to the aetiology. materials and methods: children aged - a between and the year were diagnosed at our hospital with acute pancreatitis. the diagnosis was established using clinical data, us and ct examinations. a history of trauma was present in children, cases were considered to be idiopathic. the other cases were secondary to biliary stones, thalassemia, steroid treatment and chemotherapy. results: there is a considerable difference between traumatic and nontraumatic pancreatitis. the imaging in most cases of idiopathic pancreatitis was normal or minimal changes were showed. the children with pancreatic injury demonstrated a large range of imaging findings. laceration or fracture ( cases), local or diffuse pancreatic enlargement ( ), nonhomogenous structure ( ), and pseudocyst formation ( ). the tail was involved twice as frequently as the head. the study showed a large difference between the groups. the contribution of imaging in diagnosis of idiopathic cases was minimal and follow-up was unnecessary. the imaging of posttraumatic pancreatitis demonstrates a large spectrum of pathology in the early examination and follow-up studies. when can balloon dilatation of esophageal strictures in children be considered successful? j. lisý jr., j. snajdauf, m. vyhnánek, s. tuma, j. neuwirth; prague/cz purpose: healing of a stricture by scar formation after balloon dilatation results in narrowing of the eosophageal lumen and reccurrence of dysphagia. consequently repeated dilatations are usually necessary. the authors tried to establish the delay after dilatation when the procedure could be considered successful and further dilatation or surgery was not indicated. methods and materials: eosophageal strictures in children were treated by balloon dilatations in total. children had an anastomotic stricture after surgery for eosophageal atresia, had a reflux stricture, a tight cuff after nissen fundoplication causing achalasia, a corrosive stricture, congenital stenosis and a stricture after radiation. dilatations were considered successful, when absence of dysphagia lasted for at least year after dilatation and the patient hadn't undergone surgery. results: one procedure completely treated the stricture in children ( %). none of them had surgery. repeated procedures were neccessary in patients ( %). the delay between dilatations in the case of repeated procedures ranged from week to years. dilatation avoided surgery in cases ( %). only of these patients had more than a month delay between procedures. the remaining children ( %) required surgery after repeated unsuccessful dilatations. however in none was there a need for repeat dilatation later than months following a previous procedure. conclusion: the authors conclude that a delay of months after dilatation is the key time for evaluation of success rate of eosophageal balloon dilatation. crohn's disease in paediatric patients: mr imaging of the small bowel using peg solution as an oral contrast medium a. laghi, i. carbone, i. baeli, r. iannaccone, p. paolantonio, f. iafrate, c. catalano, r. passariello; rome/it purpose: the aim of this study was to evaluate mr findings of the small bowel using peg solution as an oral contrast medium in paediatric patients with suspected crohn's disease. subjects and methods: twelve patients with clinical and laboratory findings indicating possible crohn's disease underwent mr study of the small bowel. after an overnight fast, immediately before mr examination, a fixed amount of ml/kg of weight of peg solution was orally administered. no antispasmodic drug or other drugs were given. mr study was performed using haste (tr/te/acq.t.: inf/ ms/ s) and trufisp (tr/te/acq.t.: . ms/ . ms/ s) sequences obtained sequentially for up to minutes, in axial and coronal planes. t weighted flash sequences (tr/te/acq.t.: ms/ . ms/ s) were acquired before and after dynamic contrast medium administration ( . mmol/kg of gd-dtpa). image were analysed by consensus by two experienced gastrointestinal radiologists. results: seven patients presented positive findings for crohn's disease. mr findings were represented by: wall thickening of the terminal ileal loop, with stricture in three cases. following contrast medium administration wall enhancement was observed in all the cases. conclusion: mr imaging of the small bowel after oral administration of peg solution is a reliable, reproducible, and safe imaging modality for the evaluation of crohn's disease. colonic duplication: clinical presentation and imaging features m.-j.g.j.g. grandsaerd, m.p. hartkamp, c. boetes, p. rieu, c. buonomo, c.e. van die, j.g. blickman; nijmegen/nl purpose: to make the imager and clinician aware that colonic duplication may present at birth, associated with other congenital anomalies or late, as an isolated finding. in the latter instance, the duplication almost always features connecting lumens. material and methods: we reviewed the clinical and radiological features of cases of colonic duplication over the last years. there were girls and boys. their age at presentation was either newborn ( , all girls) or between and years old ( boys, girl). all had contrast enemas, and underwent abdominal ct. results: those that presented at birth had multiple associated congenital anomalies, including partial and complete vater associations ( , all girls), duplication of the bladder in , uterus and vagina in , as well as situs inversus totalis in girl. the older presenting children all had long-standing symptoms of constipation and distended abdomens. all duplications had connecting lumens. conclusion: duplication of the colon is a rare congenital anomaly. this report illustrates that there are peaks of presentation: perinatally and later in childhood. furthermore, in the former group multiple associated congenital anomalies are present in all (or almost all) cases. as opposed to other gi duplications, these colonic duplications displayed connecting lumens. renal parenchymal volume assessment with d ultrasound in paediatric uroradiology g.a. fritz, m. riccabona, e. ring; graz/at purpose: to prospectively investigate the accuracy of renal volume assessment using three-dimensional ultrasound ( dus) compared to the results of dus, ct/ mri, or scintigraphy in neonates, infants and children. methods and materials: patients (mean age . ± . years) underwentadditional to conventional us and other conventional imaging as appropriate - dus of the kidney for anatomical and volumetrical assessment. dus was performed with a voluson (kretztechnik/ge, austria/usa) or an external d-system (echotech/ge, germany/usa). volume calculations were performed in dus applying the ellipsoid equation v = (p/ ) × l × w × ap, for dus using the system specific volumetric software; in ct/mri volume was calculated by planimetric analysis, and for scintigraphy the renal volume was quantified as relative renal volume. volume measurement focused on renal parenchyma, a dilated renal collecting system was subtracted. results: in / patients at least one dus acquisition/kidney was of diagnostic quality. dus volume measurements were accurate compared to ct/mri (± %). dus volume estimates showed a larger variation and difference (± %), particularly in kidneys with dilated collecting systems or scars, volumes differed significantly. there was a good correlation of relative renal volume in dus compared to scintigraphy in patients without acute pyelonephritis or other perfusion alterations. conclusion: dus is applicable to the paediatric genito-urinary tract. dus is a more accurate method than dus for assessment of (relative) renal parenchymal volume, particularly valuable in patients with hydronephrosis. dus improves sonographic potential and can be considered a useful adjunct to conventional imaging. pediatric excretory mr urography a. borthne, c. pierre-jerome, k. gjesdal, t. storaas; oslo/no purpose: normal-sized ureters are difficult to visualise in neonates and small children with the haste-technique (hydrography). an additional contrast-enhanced t -weighted fast gradient echo (fge)sequence was used for improvement of the image quality. methods and materials: an experimental study with pigs was first performed to validate the excretion-technique. we then studied patients ( neonates and children) with the same technique. after injection of gadolinium and mg of frusemide, contiguous coronal fge images were acquired with: matrix × , tr . ms, flip angle , fov mm, slice thickness . mm, gap . mm, nsa . -and -dimensional reconstructions of the entire genitourinary system were performed, followed by quantitative and qualitative image analysis. in all neonates the excretion technique proved better than hydrography; % of the ureters were completely visualised. in children patients with obstruction/reduced kidney function were better seen with hydrography. all the others were better or equally visualised with the excretion technique: complete assessment of the ureters were achieved in % of the children. the mean diameters of the ureters in neonates were: mm (proximal), mm (middle) and mm (distal segment); in children: mm, mm and mm respectively. conclusion: excretory mr urography is better than the non-enhanced hastetechnique (hydrography) for the assessment of the entire excretory system in neonates and children, except for those patients with marked obstruction or reduced kidney function. grade one vesicoureteral reflux -an undergrading? k. darge , g. roessling , j. , with the intravesical application of microbubbles containing the us contrast medium levovist, were performed successively during one examination session. any grade i reflux detected on vcug was compared to the reflux grade of the respective vus. furthermore, in an in-vitro set-up simulating the urinary tract the possibility of passive ascension of microbubbles in the ureter was examined using a uv-spectrometer. results: grade i reflux was identified on vcug in patients comprising of kidney-ureter-units [kuus] . in kuus the reflux was also grade i on vus. in the remaining kuus microbubbles were detected in the renal pelvises, the grades of vur being and in and kuus, respectively. prior to the administration of the us contrast medium dilated ureters were seen in kuus. the renal pelvis was dilated only in cases. in the in-vitro set-up using the same us contrast medium, despite the absence of counter-flow no microbubbles were detected at the site corresponding to the renal pelvis. conclusion: microbubbles detected in the renal pelvis can only have been actively propagated by the reflux pressure and do not ascend passively up the ureter. % of the grade i refluxes diagnosed in the vcug are actually grade ii or higher. review of imaging before and after surgery for posterior urethral valves n.p. power, k. mchugh, i. gordon, d. wilcox, p. duffy, p. ransley; london/gb purpose: to compare the imaging appearances on both micturating cystourethrography (mcug)and ultrasound (u/s)before and after surgery for posterior urethral valves (puv). to determine the clinical effectiveness of routine postsurgical mcug. materials and methods: the imaging findings of boys, of whom had two operations for puv were reviewed. mcug was performed before and after each operation making mcug in total. features evaluated included the appearances of the bladder, posterior and anterior urethra, the presence of vesico-ureteric reflux (vur) and the contemporaneous u/s results. age at surgery and creatinine results were also noted. results: age at surgery ranged from days to years months. % were less than a month at surgery. vur was detected in % of patients; most of these were unchanged post-operatively. the commonest bladder abnormality was trabeculation ( %); % were unchanged on follow-up. % of patients had a small volume bladder. when the posterior urethra was visualised it was invariably dilated. % of patients had an apparently narrow anterior urethra initially; most improved on follow-up. the commonest u/s findings were bilateral hydroureteronephrosis ( %)and bladder wall thickening ( %), although % of pre-operative u/s were normal. most patients had little change in u/s features. % had a fall in creatinine post-operatively. conclusion: a small number of boys with puv may have normal u/s appearances. imaging appearances on both mcug and u/s are frequently unchanged after puv resection. as patient management depends on several factors including renal function and cystoscopy findings, we question the clinical effectiveness of routine post-operative mcug. the transbrachial approach for sclerotherapy in paediatric varicoceles p. agresti, s. pieri, l. de medici, g. fiocca, a. calisti; rome/it introduction: percutaneous sclerotherapy has gained wide acceptance in the treatment of male and female varicocele. we introduced the percutaneous approach into the paediatric population, because it is minimally invasive, uses local anesthesia, is minimally traumatic and less expensive than a surgical option. we report our year experience with the transbrachial approach. materials and method: from to we have done procedures. inclusion criteria were positives at physical, doppler and ultrasound examination for varicocele type i, grade iii, and ii only if symptomatic. phlebography was done under local anesthesia, with a transbrachial approach. we first try to enter the right spermatic vein and then work on the left side. sclerotheraphy was done with tetra-decilsolfato (trombovar). follow up with clinical examination was done at - - months and - months with colour-doppler ultrasound. results: median age was . years. symptoms were present in only % of boys. there were / bilateral varicoceles, on the right and the remainder on the left. there were good clinical results with sclerosis in % of the treated boys. discussion: percutaneous sclerotherapy of varicoceles is a safe, effective and less expensive option than surgical therapy, especially in the bilateral form, with a low complication rate. methods: patients with fractures of the mandible underwent mri (gradient echo sequences before and after contrast administration). continuity of the nerve was evaluated by visual inspection, signal intensity was measured by region of interest in different locations. the nerve could be evaluated in all cases. the continuity or the disruption of the nerve detected on mri was confirmed by the surgical findings in all patients. there was no difference in the increase in signal intensity after contrast enhancement between patients with and without disruption of the nerve. some patients with neurological deficit without disruption of the nerve, showed a decrease of signal intensity distal the fracture. all the other patients without neurological deficit had an increase of signal intensity from proximal to distal. conclusion: it is possible to detect the disruption of the nerve by mri. the reason why the signal intensity in some patients decreases seems to be unclear. as we used gradient echo sequences, which in particular show blood flow effects, it might be possible to measure a reduced blood circulation in the perineurium distal the fracture by regions of interest. beside prevention of neurological deficits, this might be another argument for urgent surgical treatment. bmd measurements in the jaw from dental ct images. verification of the method and first applications in dental implantology a. beer, p. homolka, a. gahleitner, m. tschabitscher, r. nowotny, h. bergmann; vienna/at purpose: in implant dentistry, both bone quantity and quality, are of vital importance for preoperative planning. while bone quantity is well defined, different approaches on measuring bone quality exist. usually quite crude grading schemes are applied, that may not provide a quantitative measure for local bone quality exactly at the intended implantation site. a c d e f methods and materials: a calibration standard with known concentrations of hydroxyapatite is scanned simultaneously with the patient using an adapted dental-ct technique. conversion of hounsfield numbers to bmd values is accomplished using a linear relationship. bmd is evaluated locally using full ct image resolution on reformatted views to evaluate possible implant sites. results: in a cadaver mandible pilot study a strong correlation (r > . ) between bmd and the insertion torque of dental implants is demonstrated. therefore, bmd may serve as an estimate of achievable primary implant stability and thus, as a measure of bone quality. first clinical applications are going to be presented. conclusion: since a correlation with mechanical bone properties and accepted measures of primary implant anchorage has clearly been established, preoperatively determined bmd values of the jaw bone could help to assess possible implant sites to optimize primary stability and long term prognosis of the implants by guiding the surgeon through the choice of best suited implant site or implant type and preparation technique. periapical dental findings evaluated with coronal sinus ct c.r. krestan, p.l. peloschek, c. czerny, s. grampp, a. gahleitner; vienna/at purpose: to evaluate the frequency of chronic peripical periodontitis (cap) in teeth in the upper jaw using coronal sinus ct. methods: we reviewed coronal sinus ct examinations (ct-secura, philips medical systems, best, the netherlands) from non-selected clinical patients. sinus ct was performed with the patient in the prone position with a collimation of mm from the ventral border of the frontal sinus to the posterior edge of the sphenoid sinus. reconstruction was done using a high-resolution bone algorhythm. the frequency and size of hypodense periapical lesions was determined by two radiologists in a consensus reading. frequency and severity of artifacts from restoration dentistry and disease of the maxillary sinus was recorded. results: in out of patients ( . %) periapical disease (cap) could be dignosed. in of these patients metal artifacts reduced the image quality of the periapical region. the regions and were most affected by artifacts. there was no statistically significant difference between the site of periapical disease and concomitant sinus disease. conclusion: in up to percent of non-selected patients, referred for sinus imaging, we found periapical dental disease on coronal standard ct. although coronal sinus ct is not the method of choice for evaluating dental disease, it is worth to pay attention to periapical disease. atypical non-odontical chronic jaw pain: findings on panoramic radiographs and dental-ct-scans correlated with histology and microbiology p.l. peloschek, d. turhani, f. watzinger, m. püregger, i. sulzbacher, j. sailer, c. czerny; vienna/at purpose: the aim of this study was to compare radiographic, histological and microbiological findings of patients with atypical non-odontical pain of the jaw. patients and methods: from to out-patients with jaw pain of uncertain origin were prospectively analysed by panoramic radiographs and ct following open biopsy. the axial ct scans (philips ct secura; kv, ma, scan time seconds, slice thickness mm, table index mm, high resolution filter) were reformatted using dental-ct software (philips easyvision, dental reformatting package). usually no contrast enhancing media were given. inclusion criteria were long-term patient history with pain and/or swelling located in a tooth-free region and unclear conventional and panoramic radiographs. exclusion criteria were previous fractures, osteoradionecrosis and dental residuals. in this cohort, laboratory parameters were inconclusive. the bicortical bone-biopsies were classified following histological and microbiological findings. radiographic findings were correlated with the results of the histological and microbiological examinations. results: patients could be included. no significant correlation between radiological and microbiological or histological findings was found. histological diagnosis included unspecific post-inflammatory changes, active osteomyelitis and healthy specimen. conclusion: the use of conventional radiographs, panoramic radiographs and dental-ct in the diagnosis of chronical atypical non-odontical pain of the jaw should be re-thought. if panoramic radiographs give no appropriate information in finding a focus in chronic pain of a tooth-free region, dental-ct will not give further information. maybe dynamic mri will resolve this diagnostic dilemma. appropriate studies are in progress. does a dose reduction by a factor of affect the diagnostic value of multirow detector helical ct of the sinuses? d. tack, j. widelec, j.-m. bailly, c. delcour; charleroi/be purpose: to compare multiplanar reformations (mpr) and volume rendering technique (vrt) as well as virtual endoscopic views (ve) obtained from helical multirowdetector computed tomographic (mrdct) respectively with low-dose and standard-dose acquisitions in patients with sinusitis. method/materials: consecutive patients with headache referred for a standard dose brain ct and in whom a sinusitis was found or had to be excluded had a second acquisition with a low dose technique (volume zoom, siemens). following parameters were used for the standard dose acquisition: collimation × mm, rotation time: . s, kv, mas, pitch: . , ctdiw: . mgy, reconstruction width and increment . and . mm; low-dose acquisition: collimation × mm, rotation time: . s, kv, mas, pitch: , ctdiw: . mgy. coronal, axial and sagital mm thick mpr and selected vrt and ve views were obtained from both native image sets and analysed on workstations by radiologists who had to state the normal or abnormal appearence of different anatomic regions. the effective dose was computer simulated. results: in of of regions of interest, no difference was found by all readers. in the remaining regions, of readers stated that low-dose and standard dose images were equivalent. computer simulated effective dose were respectively for standard-dose and low-dose mrdct of . and . msv. purpose: due to the complex anatomy of the facial bones ct examinations of fractures in at least two planes are required for reliable diagnosis and operative planning. however, in some cases examination can be performed in the axial plane only. therefore high quality mprs from axial ct-datasets have to be obtained. aim of this study was to analyse the influence of collimation, reconstructed slice thickness/increment, reconstruction-kernel, tube current and ultra high resolution (uhr) and non-uhr acquisition on detectability of facial fractures. methods and materials: a cadaver head with artificial blunt facial trauma was examined using a siemens somatom volume zoom unit (siemens, erlangen, germany). acquisition parameters were: collimation × . vs × vs × . mm, tube current vs vs mas, uhr and non-uhr, reconstructed slice thickness/increment . / . vs . / . vs / . mm. out of these volume datasets coronar and sagittal mprs were obtained with the following reformation parameters: slice thickness . - mm, overlapping . - mm. fracture locations were scored blinded by experienced radiologists. inter-observer variability was determined with the Κ-test. differences in fracture detection of the respective algorithms were assessed with wilcoxon-and friedman-tests to p < . . results: detectability of fractures was higher in × . mm collimation (p = . to p < . ). uhr is superior to non-uhr (p = . ). mas exceeded and mas (p < . ) in uhr and non-uhr, respectively. thin mprs ( . / . mm, / . mm) are superior to thick mprs (p = . to p < . ), whereas there is no significant difference between . / . mm and / . mm (p = . ). conclusion: our data reliably prove that for subtle fractures thin mprs ( . / . mm, / . mm) should be obtained out of thin slices ( . mm) with mas in uhr. multi slice ct with d reconstruction in the maxillofacial diseases f.m. drudi, s. padula, a. righi, f. trippa, p. ricci, f. cascone, r. passariello; rome/it purpose: aim of our study was to demonstrate the utility of d-reconstruction and virtual endoscopy in the planning of surgical intervention and evaluation of treatment in maxillofacial diseases. materials and methods: thirteen patients (mean age ; range - years) underwent multi-slice ct examination (slice thickness mm; scan time . seconds; rotation time . seconds; feed rotation mm) using intravenous contrast agent, if necessary. volumetric data sets were post-processed with vitrea (vital images, milwakee) volume rendering software. results: in patients who presented keratocyst, d-reconstruction permitted an exact definition of volume and site of the cyst. also the trigeminal mandibular nerve branch pathway was clearly depicted. after surgery d-reconstruction showed a complete "restitutio ad integrum" of the bone. in patients, who presented floor-ofmouth carcinoma, d-reconstruction was performed before treatment to evaluate the dimensions of the mass and to exclude bone involvement. after treatment the examination was repeated to evaluate response to therapy. one patient who had undergone numerous operations for bilateral cleft leap, was studied to plan further surgery and to control the outcome. in patients who presented maxillary sinus osteoma, d-reconstruction evidenced tumor origin. virtual endoscopy showed the exact position of the neoplasia in relation to the maxillary sinus floor and permitted postsurgical evaluation of the maxillary sinus floor. conclusions: multi-slice ct with d-reconstruction and virtual endoscopy are useful tools in the evaluation of maxillofacial diseases before and after therapy. facial hemangiomas as anexternal manifestation of the segmental angiodysplasia: mri and mra diagnosis v. panov, a. ivanov, m. inaneishvily, a. nadtotchi; moscow/ru purpose: diagnosis of facial soft tissues angiodysplasia (fad) is not hard because of its well-known clinical symptoms. ultrasonography with color doppler mapping, invasive selective and super selective x-ray angiography are usually used for the evaluation of tumor volume, its syntopy, morphological structure variants and identification of main supplying vessels. the main task of this presentation is to the show possibilities of noninvasive mr-imaging (mri) and mr-angiography (mra) in fad diagnosis. methods & materials: patients with different forms of fad were examined. all mri and mra examinations were obtained on a t mri system harmony (siemens, germany) and were compared with noninvasive ultrasound and invasive x-ray angiographic data. results: in patients mri has found the following arterial abnormalities: different forms of unclosed willis ring ( cases); significant middle cerebral arteries asymmetry ( cases); lateral choroid artery displacement ( case). in patients vascular malformations were found: intracranial arterial malformations in patients, meningeal venous malformations in case. the disadvantages of mri were: the long time of examination, the necessity of sedation in young patients (younger than - years) and in patients with claustrophobia. conclusion: use of noninvasive mra made it possible to establish that in some cases fad was an external manifestation of a segmental angiodysplasia which could be diagnosed only by the combination of noninvasive ultrasound and invasive x-ray angiography. mri and mra allow to obtain the same information about fad as traditional methods but has additional advantages in diagnosis of such lesions due to opportunities for intracranial arterial and venous visualization. from ct through *.stl to rism: a few real steps in the future of craniofacial surgery a. nadtotchi, v. roginskij, o. topol'nitskij, a. evseev; moscow/ru purpose: the evaluation of ct-datasets allows the possibility of creation of realsize facial skeleton individual stereolitographic plastic models (rism). methods & materials: children with severe diseases and abnormalities of facial skeleton were examined by ct (conventional or spiral): patients had mandibular tumors, patients had mandibular congenital deformations and patients had postoperative defects, and children had complex craniofacial syndroms. after ct examination, the ct-dataset was transformed into the specially produced computerized stereolitographic files (*.stl). stl-files were send to the computer operated stereolitographic device that finaly created the facial skeleton rism. the rism was used not only for diagnosis but as an aid for operation planning in each individual case. using the rism it was easier for surgeons to define the access and operation techniques and to choose the optimal localisation of osteotomy lines. the rism was used as the base for preoperative manufacturing of exactly anatomical endoprotheses. this application of rism-technology is very progressive because: ( ) it allows an increase in both the quality of preparation of endoprothesis and in their organospecificity; ( ) it allows a decrease in the duration of operation of . - . hours. where it was necessary to enlarge the mandible with compression-distraction apparatus, rism allowed definition of construction and optimal position of compression-distraction devices. conclusion: rism will be used not only as diagnostic model, but as important and powerful aid in the different branches of cranio-facial surgery. that is why we are sure that the system "ct -*.stl -rism" is a real step in the future of surgery. purpose: investigate the utility of ct cystography in the study of bladder tumors. method and materials: patients with bladder tumours, ranging from solitary polypoid lesion to multiple endoluminal lesions with diffuse alterations of mucosal surface, were studied with ct cystography and the results compared with conventional cystoscopy. radiologists were blinded to the results of cystoscopy. ct cystography was performed with one helical acquisition of mm slices at pitch . , with images reconstructed each mm. in all patients, the bladder was inflated with room air via a foley catheter. the data were then downloaded to a workstation and reviewed, both on axial d and with d-intraluminal navigation. results: tumour lesions ( ) of the patients having localized lesions were recognized on the ct data. this included one small lesion less than mm. in the two patients having diffuse bladder involvement, ct cystography was able to detect the major polypoid lesions, but also identify a diffuse irregularity of the bladder inner surface corresponding to the spread of the lesions over the entire mucosal surface. ct axial data also predicted the extra-serosal spread of the disease by contiguity to the inner part of the anterior abdominal wall, which was confirmed by open surgery the day after ct cystography. urologists found the d images very similar to their own cystoscopy images. conclusions: recognition of bladder wall tumours is feasible by means of ct cystography. lesions equal or bigger than mm were shown. b a c d e f three-dimensional volume and surface rendered ultrasound of the urinary bladder: early experience g. helweg, a. klauser, l. pallwein, a.h. schuster, g. feuchtner, a. stenzl, d. zur nedden, f. frauscher; innsbruck/at purpose: we evaluated the feasibility of three-dimensional ( d) surface and volume rendered ultrasonography (us) for detection and differentiation of urinary bladder lesions. methods and materials: fourteen patients suspicious for bladder tumours on two-dimensional ( d) us underwent d imaging of the bladder prior to cystoscopy and transurethral bladder biopsy. the suspicious areas on d us were evaluated using the perspectivetm d us (acuson, moutainview, ca). tumour volume was calculated using the built-in software. documentation was done on video and printouts. the us findings of d and d us were compared with endoscopic findings and the biopsy results. results: eight of patients ( %) had biopsy proven bladder cancers. in addition to conventional d us, the mean time for the assessment of d data sets was . minutes (range: . - . min). d us allowed a better visualization of the inner contour, corresponding to the mucosal layer of the bladder. d surface and volume rendered us data sets, enabled the correct diagnose of a benign lesion in of patients, and of cancer in of patients. this revealed an overall accuracy of % for differentiating benign from malignant lesions. the tumour volume was overestimated ≥ % in of patients with cancer compared to cystoscopy measurements. conclusions: d volume and surface rendered us improves the differentiation between benign and malignant lesions of the urinary bladder, compared with conventional d us. this technique requires only a short additional examination time and does not put any burden on the patient. use of flair sequences for detection and local staging of bladder tumours with mri m. di girolamo , a. roncacci , g. brughitta , d. fini , s. cavalaglio , v. david ; rome/it, grottaferrata/it purpose: to increase the accuracy of mri in the detection and local staging of bladder tumours by using flair sequences. method and materials: patients with bladder tumours detected by us underwent mri using . and . t superconductive magnet. we performed se t weighted (tr: ms, te: ms), tse t -weighted (tr: ms, te: ms) and flair sequences (tr: ms, te: ms, ti: ms, n.ex.: ; acq.time: min s) on axial scans. the contrast to lesion ratio was evaluated in all sequences. all the patients underwent cystoscopy with transurethral biopsy and had subsequent cystectomy. results: in comparison with other sequences, flair sequence was more sensitive in the detection of bladder neoplasms. this sequence demonstrates the hyperintense signal of bladder neoplasms from the filled bladder lumen with no signal. the sensitivity in the identification of bladder neoplasms was % with flair sequences, . % with tse t -weighted sequences and . % with se t -weighted sequences. that was due to the higher signal to lesion ratio of the flair sequences in comparison with the others. in fact on flair sequences the mean value of contrast to lesion ratio of bladder neoplasm was . while on se t -weighted sequences and tse t -weighted sequences was respectively . and . . flair sequences allowed the detection of small papillomas (less than mm). tse t -weighted sequences were more sensitive in the study of bladder wall infiltration. conclusions: flair sequences were more sensitive in the detection of bladder neoplasms, due to their higher contrast to lesion ratio and can be very helpful in the visualization of small papillomas, especially when multifocal. purpose: evaluation of the diagnostic performance of virtual mr-cystoscopy for the assessment of bladder tumours. materials and methods: patients with bladder tumours were examined with a . t scanner, using a t -weighted d-tse-sequence (tr = ms, te = ms) with a voxel size of . × . × . mm . in patients the new "sensitivity-encoding"-technique (sense) was used, which allows a higher spatial resolution without increasing scanning time. the bladder-wall was divided into re-gions, which were analysed separately for the presence of tumours by radiologists without knowledge of the tumour location. findings of conventional cystoscopy and operation served as standard of reference. results: of tumours were detected by virtual cystoscopy with false positive results, resulting in an overall sensitivity of % and a specificity of %. all tumours larger than cm ( / , sensitivity %) and of tumours smaller than cm (sensitivity %) were detected. the tumours missed had a size of mm or smaller. on the average, the time needed for virtual-endoscopic reconstruction was minutes. with the new sense-technique, spatial resolution could be improved without increasing scan-time. limitations of virtual cystoscopy are the detection of flat lesions and the differentiation between neoplastic and inflammatory lesions. conclusion: virtual cystoscopy is a promising, completely non-invasive tool for the diagnosis and follow-up of bladder tumours. by using the new sense-technique, the spatial resolution can be further improved. mr virtual cystoscopy detection and staging of bladder lesions before performing conventional cystoscopy v. panebianco, r. iannaccone, i. sansoni, a. laghi, c. catalano, m. ciccariello, p. paolantonio, r. passariello; rome/it purpose: to identify and to stage bladder lesions with mr-cystoscopy combining axial and virtual images. methods and materials: patients with suspected or known diagnosis of bladder tumour underwent mr cystoscopy. we used natural contrast (urine) for bladder distention, monitoring bladder filling with dflash sequence with i.v. c.m. (optimal results after min). mri examinations were performed on a . t siemens vision plus mr imager. we obtained a d fse sequence on axial planes. for evaluation of bladder wall, we performed a t weighted gre sequence, with and without fat suppression, pre and post gd-dtpa ( . mmol/kg) i.v. injection. a dspgre sequence was obtained for monitoring bladder filling and for virtual endoscopy analysis, prior to furosemide ( cm ) administration. real time endoscopic views were reconstructed using volume-rendering reconstrution algorithm (vitrea . , vital images). results: image quality was considered optimal in all cases. a total of lesions were detected and confirmed at biopsy. in cases no lesions were evident at mri and at conventional cystoscopy. all lesions were evident on morphological t and t weighted images, with size ranging of - mm. mr virtual cystocopy allowed detection of the same lesions than conventional cystoscopy, providing comparable images. however, endoscopic images did not show intramural and extravescical extension of the tumour, whereas these findings were easily appreciated on morphological t and t weighted images. conclusions: mr virtual cystoscopy optimises detection and staging of the bladder pathology by combining axial t and t weighted and ve images. three-dimensional visualization of pelvic lymph nodes in staging and treatment of urinary bladder cancer using high-resolution mri a. welmers , b. schrier , h. huisman , j.r. fielding , l. o'donnell , w.m.l.l. deserno , r. kikinis , j.g. blickman , j.o. barentsz ; nijmegen/nl, boston, ma/us purpose: in this study we evaluated the possibilities of d modeling in lymph node visualization for surgical guidance during lymph node dissection (lnd) in bladder cancer using high resolution mr data. methods and materials: mri was performed on a . t mri using the d t -w mp-rage sequence (tr . , te . , . mm isometric voxel-size) with a pelvic phased-array coil. an iv uspio contrast agent was used to enhance the visibility of the lymph nodes. bladder, iliac vessels, ureters, obturatory nerves and lymph nodes were manually segmented from the mr data, using the software " d-slicer". from these segmentations d models were created. in total patients with histology proven urinary bladder cancer were evaluated. in all cases lnd was performed. five patients had enlarged metastatic lymph nodes, which were all segmented. during lnd the d models were used as a guiding tool for removing lymph nodes. results: in all patients a d model was created successfully, showing iliac vessels, ureters, obturatory nerves and lymph nodes. the d models allowed accurate localization of normal and metastatic nodes in relation to the surrounding structures, which enabled the surgeons to find and remove more lymph nodes than without this technique. conclusions: this technique simplifies visualization of lymph nodes. this increases urologist awareness of the exact location of lymph nodes, which results in a higher yield of nodes at node dissection. long fov whole body d mri using continuous table motion s.j. riederer, d.g. kruger, p.j. rossman, r.c. grimm; rochester, mn/us purpose: current methods for imaging an extended longitudinal field of view (fov) in mri either use multiple fixed stations or rapid d axial imaging similar to single slice, helical ct. the purpose of this work was to develop a method for d mr imaging of an arbitrarily long fov using continuous table motion. methods and materials: a method was developed in which data are collected as the table is moved continuously through the mr scanner gantry. after fourier transformation along the readout direction, every echo is assigned to hybrid (x, ky, kz) space, with longitudinal (x) location determined by table position at the time of the echo. as the table moves, all desired phase encodings are measured periodically. the method was tested in phantom, animal, and human studies. table velocity ranged from . to . cm/s. the longitudinal fov for readout ranged from to cm, and the total fov was as large as cm. results: complete d image sets were formed of objects up to ten times longer than the fov of the acquisition. correction for position at sub-pixel precision is critical to suppress ghosting artifacts. contrast-enhanced studies in pigs demonstrate the ability to follow the contrast bolus in peripheral runoff studies. results in humans suggest the feasibility of whole body imaging. conclusions: d mr acquisition during continuous table motion has been demonstrated. it offers potentially reduced acquisition time vs. fixed station d methods and improved snr vs. rapid serial d axial acquisition. spatial resolution in t -weighted conventional se and tse sequences: phantom measurements and in vivo results c. fellner, f.a. fellner, j.-c. georgi, w.a. kalender; erlangen/de purpose: assessment of spatial resolution in t -weighted tse sequences with different echo train lengths (etls) compared with an se sequence using phantom measurements and examination of healthy volunteers. materials and methods: t -weighted tse sequences with different etls ( , , ) and an se sequence with identical pixel size ( . mm) were evaluated with a custom-built resolution phantom offering resolution patterns from . mm to . mm in steps of . mm and in healthy volunteers focusing on the cranial nerves. the resolution in the phantom images was assessed visually, and the standard deviation in an roi containing the . mm stack was evaluated. image quality and delineation of cranial nerves (ii, iii, v) of the in vivo measurements were assessed by an experienced radiologist blinded to the sequence technique. statistical evaluation of the visual evaluation was done using wilcoxon's test (p < . ). results: the visual evaluation of phantom images yielded identical results for the se and the tse sequences with short etls ( , ); for an etl of the spatial resolution was deteriorated. the quantitative evaluation, however, showed a continuous decrease of the standard deviation with increasing etl. image quality of in vivo images and delineation of cranial nerves was significantly superior in se images compared with tse images -even if a very short etl was applied. conclusion: qualitative as well as quantitative evaluation of spatial resolution and anatomical details correspondingly revealed disadvantageous results for t weighted tse sequences with increasing etl. this result was even more pronounced in the in vivo examinations. deep brain stimulation during interventional mri: safety issues r. girnus, v. hesselmann, k. luyken, b. krug, g. nimtz, k. lackner; cologne/de purpose: to investigate safety aspects of linear conductive devices in interventional mri. materials and methods: the temperatures occuring in long wires placed in a . t mri (philips, gyroscan intera) were measured. the temperature increases (δt) at the tip of the electrode were determined using a mr-compatible opticalfiber-temperature system. the end of the wire was surrounded by cm of a . % nacl solution. the length and the position of the wire were tested as parameters influencing the hf-induced increases in temperature. furthermore the influence of the sequence was taken into account. result: the temperature increase of the wire aligned parallel to the z-direction and symmetric to the isocentrum showed a significant dependence on the length. a resonance length of about m could be observed, with a ät of °c at the tip located in the saline solution during a tse-sequence (sar = . w/kg). by moving the wire out of the isocentrum in x or y direction, the heating effect exceeded °c at the electrode tip. the ät fell below °c, if the wire length was different c d e f from m, the part of the wire inside the scanner bore was minimized and the wire was located in the center of the bore parallel to the z-direction. in general the ät can be reduced by applying gradient echo sequences with low flipangels. conclusion: under controlled conditions mentioned above it seems feasible to put a wire or stimulation electrode into an mr without risk of burning. liver iron overload: comparison of two methods in measuring liver r * values. correlation with serum ferritin concetration (sfc) and liver iron concentration (lic) t.g. maris , o. papakonstantinou , e. chryssou , v. ladis , s. kostaridou , n. papanikolaou , p.k. prassopoulos , n. gourtsoyiannis ; iraklion/gr, athens/gr purpose: to compare liver r * (r * = /t *) values obtained by means of quantitative mri (r *-qmri) using two regression analysis models and correlate them with lic and sfc. materials and methods: liver r * values were calculated in thalassaemic patients, and normal subjects on an . t mri system using a breathhold multislice-double-echo spoiled gre sequence with initial parameters: tr/te /te / . / . ms. the sequence was repeated four times, each time altering inter-echo time spacing. t * calculated image maps were post-proccessingly reconstructed using four different fitting methods (a, b, c, d) . methods (a) and (b) were based on a simple linear regression model applied to image pixel data. methods (c) and (d) were based on a weighted linear regression model on which pixel data were weighted according to background image random noise figures. results: differences of mean r * values between patients and normal subjects were considered extremely significant (t = . , p < . ). r * values correlated much closer with lic levels (r = . , p < . ) when using weighted linear regression models (c) and (d) than when using normal regression ones (a) and (b) (r = . , p < . ). r * were moderately correlated to sfc values regardless the use of the regression model (r = . , p < . ). r * values were linearly correlated with lic [r × (s − ) = . + . lic (mg/g) − , r = . , p < . ] conclusion: r * when calculated using weighted regression methods on . t systems seem to be a valuable means for the evaluation of liver iron overload when lic does not exceed mg/g (liver dry weight). improved mri-monitoring during rf-hyperthermia h. reinl , m. peller , m. hagmann , r. issels , m.f. reiser ; munich/de, salt lake city, ut/us purpose: in a mri-hyperthermia hybrid-system t relaxation-time changes are investigated for monitoring hyperthermia of deeply seated tumors. a water-bolus is needed for power transmission into the patient body. the signal of this bolus limits image quality by signal compression and artifacts. this can be avoided by using d o which would result in additional technical effort and high costs. the purpose of our study is to improve image quality, spatial and temporal resolution by using a paramagnetic suspension of magnetite instead. material and methods: all experiments were done on the hybrid-system which consists of a . t open mr-system and a hyperthermia system with a mr-compatible phased array applicator and an integrated mr receive-coil. the tested paramagnetic suspension was a commercially available ferrofluid (msg w , ferrofluidics corp.), normally used for material separation. a polyamidacryl gelphantom mimicking the human body was used for heating experiments. results: we found ferrofluid in a low concentration as a useful substitute. in the . t system a concentration of . % showed optimum results. below . % the bolus is still slightly visible and above . % the mr system is no longer tuneable. no artifacts are induced in this concentration-range. conclusion: by using the new bolus-filling an extinction of the bolus artifacts and a significant improvement in snr, spatial and temporal resolution are possible. this method of signal extinction in mri may be adapted to other experimental demands where mr-invisible fluids are necessary. stereological estimations of liver volume from mr images m. mazonakis, j. damilakis, t.g. maris, p.k. prassopoulos, n. gourtsoyiannis; iraklion/gr purpose: to investigate the possibility of generating stereological estimations of liver volume from magnetic resonance (mr) images. methods and materials: consecutive patients underwent . t abdominal mr imaging. two radiologists evaluated the mr images and found that the liver size appeared normal in and increased in cases. liver volume was estimated using the cavalieri method of modern design stereology in combination with point counting. the effect of the separation distance between test points of the grid in the efficiency of stereological estimations was examined. a systematic sampling of mr sections was performed to find the minimum number of sections needed to provide acceptable volume estimations. results: for both subgroups of patients with normal and increased liver size, it was found that - test points counted on - systematically sampled mr sections may provide reliable liver volume estimations with a coefficient of error (ce) of less than %. the mean time required for the stereological measurements was approximately min. the mean liver volume for the patients with normal and increased liver size was found to be . ± . and . ± . cm , respectively. the proposed volumetric technique may provide efficient liver volume estimations from mr images in patients presenting both normal and increased liver size. improvement of diagnostic accuracy of pet imaging using a high performance in-line pet-ct system: preliminary results t.f. hany, h.c. steinert, g.w. goerres, a. buck, g.k. von schulthess; zürich/ch purpose: we describe the first application and optimisation of a novel in-line system combining a high performance clinical positron emission tomograph (pet) scanner and a fast multi-slice helical computer tomograph (ct) scanner in a single machine (pet-ct) for tumour staging. methods: we examined patients with diagnosed or highly suspected malignancy. non-contrast-enhanced ct data with different tube currents ( , , and ma) were acquired, followed by pet acquisition. step-wise image analysis was performed using pet images alone compared to co-registered pet-ct with increasing ct energies (pet-ct , … pet-ct ). clinical or pathological staging was used as standard of reference for lesion-by-lesion as well as on patient based analysis. results: the following accuracy ratios for classifying tumour lesions were calculated: pet alone %, pet-ct %, pet-ct %, pet-ct %, pet-ct % and a significant difference was found between pet alone and co-registered images (chi square p < . ). conclusion: pet-ct fusion in a combined scanner using non-enhanced lowdose ct with ma is significantly increasing diagnostic accuracy regarding lesion classification, and by using the ct scan for transmission correction will reduce the acquisition time by % when compared to pet imaging alone. transmission scanning for attenuation correction in cardiac spect studies: patient effective dose and radiogenic risk k. perisinakis, j. damilakis, n. gourtsoyiannis; iraklion/gr purpose: to determine patient effective dose and associated radiogenic risk from the transmission scanning performed during cardiac spect myocardial perfusion studies to correct scintigraphic images for attenuation and scatter effects. materials and methods: transmission scans were obtained using an optima nx ge system, which involved an l-shaped dual headed gamma camera equipped with transmission scan hardware. two flat scan boxes each containing a collimated rod source of gadolinium were mounted on the gantry opposite each detector. a rando anthropomorphic phantom was used to determine radiation dose from transmission scanning in organs and tissues using thermoluminescent dosemeters. for each projection the resulting effective dose was calculated using the icrp tissue weighting factors. radiation risk was determined using age and sex related radiation induced fatal cancer risk factors. results: the effective dose corresponding to a typical s acquisition per transmission scan was psv. the organs receiving the highest amount of radiation dose is the lung and the oesophagus. the average lifetime risk for fatal malignancy is . × − for us and . × − for uk population. conclusion: present data allow the accurate estimation of patient effective dose and associated radiation detriment risk from myocardial perfusion spect studies. purpose: assessment of three different rectal agents (water, ultrasound gel and methylcellulose) for their suitability for colorectal imaging in multislice ct material and methods: patients with colorectal diseases underwent msct with varying rectal contrast agents in a prospective study. images were assessed by two independent ct-experienced radiologists. ct scans were analyzed for the following criteria: contrast of wall versus lumen (w/l), contrast of pathological wall versus lumen (p/l), distension of anal verge, distension of colon and artefacts (ar). a rating scale of (no) to (severe) was used. interobserver variability was assessed by kappa statistics. results: mean rating values of methylcellulose were higher in contrast of wall/ lumen ( . ± . ), pathological wall/lumen ( . ± . ) and least rate of artefacts ( . ± . ) than of water (w/l . ± . ; p/l . ± . ; ar . ± . ) and ultrasound gel (w/l . ± . ; p/l . ± . ; ar . ± . ). the distension of the anal verge was better in using ultrasound gel ( . ± . ) and methylcellulose ( . ± . ) than in water ( . ± . ). with water the best distension of colon ( . ± . ) could be obtained, it was nearly equal to methylcellulose ( . ± . ), but remarkable superior to ultrasound gel ( . ± . ). air artefacts only appeared in ultrasoundgel. an excellent interobserver correlation was found for the contrast of pathological wall versus lumen of methylcellulose (k = . ). a high rate of agreement between the criteria of both radilogists in final diagnosis could be achieved. conclusion: rectal filling with methylcellulose significantly improves diagnostic confidence in colorectal examinations. ease of application and lack of use suggest to use as a clinical routine. ct differentiation of colorectal mucinous and nonmucinous carcinoma e. ko, h. ha; seoul/kr purpose: to evaluate the ct findings which can help differentiate mucinous from nonmucinous colorectal carcinoma. ct scans of patients with pathologically proven mucinous colorectal carcinoma during a -year period, were analyzed. as a control group, consecutive patients with pathologically proven nonmucinous colorectal carcinoma in a -month period were included. retrospective review of ct was performed by two radiologists in consensus who were blind to the pathologic results. ct scans were analysed with regard to the site and length of involved segment and types of morphological features, bowel wall thickening and contrast enhancement patterns, degree of contrast enhancement in solid portion of the tumor. also evaluated were the presence of calcification, obstruction, lymphadenophathy, pericolic infiltration, local tumor extension, and distant metastasis. in heterogeneous masses, the extent of hypoattenuated areas within tumor was graded into three. statistical analyses were performed by using student t-test and pearson's ÷ -test. results: as compared with nonmucinous carcinoma, mucinous carcinoma showed more severe (p = . ) and more eccentric (p = . ) bowel wall thickening. heterogeneous contrast enhancement was more common in mucinous carcinoma (p < . ). significant difference was noted in the extent of hypoattenuated areas within tumor (p < . ). the solid portion of mucinous carcinoma showed hypoattenuation while nonmucinous carcinoma showed hyperattenuation (p = . ). although statistical values were not obtained, the presence of intratumoral calcification was more frequent in mucinous carcinoma ( % vs ). conclusion: ct is very useful in the differentiation of mucinous from nonmucinous colonic adenocarcinoma. usefulness of the hydrogen peroxide enhancement in the diagnosis of the anal and ano-vaginal fistulas i. sudol-szopinska, w. jakubowski, m. szczepkowski, d. sarti; warsaw/pl purpose of the study was to assess the usefulness of contrast-enhanced anal endosonography (aes) with hydrogen peroxide in the diagnosis of the anal fistulas. method and material: a bruel & kjaer scanner with a . mhz transducer was used. after visualization of the fistula tract in non-contrast aes, hydrogen peroxide was introduced into the fistula tract through the external opening in patients with different types of anal fistulas. results: both contrast-and non-contrast aes revealed transsphincteric, intersphincteric, suprasphincteric and ano-vaginal fistulas. simple tracts were found in cases and complex in cases in non-contrast aes. contrast-enhanced aes revealed simple and complex fistulas. internal openings visible in non-contrast aes were confirmed in contrast-enhanced aes in cases, which additionally found more internal openings. in all cases, surgery confirmed the diagnoses of the contrast-enhanced aes. conclusion: contrast-enhanced aes appears to be superior to non-contrast aes in preoperative assessment of the anal and ano-vaginal fistulas and in locating of the internal openings. contrast-enhanced multislice ct colonography in the diagnosis and staging of colorectal cancer i. carbone, a. laghi, r. iannaccone, i. baeli, r. ferrari, f. mangiapane, f. iafrate, c. catalano, r. passariello; rome/it purpose: to evaluate the role of ct colonography (ctc) in patients with suspected colorectal cancer. methods and materials: forty-eight patients ( females and males; age range - ) underwent conventional colonoscopy (cc) and ctc for suspected colorectal mass. multislice spiral ct (somatom plus volume zoom, siemens, germany) examination of the abdomen and pelvis was performed after routine bowel preparation and colonic distention with room air. patients were scanned in prone and supine positions using the following parameters: slice collimation, . mm; slice thickness, . mm; reconstruction interval, mm; mas, (prone) and (supine). ml of contrast medium were administered i.v. during the supine acquisition with a s delay time. images were subsequently downloaded and analysed on a dedicated workstation. surgical specimens were used as the standard of reference against which the findings of cc and ctc were compared. results: cc failed to visualize the entire colon in patients due to occlusive neoplasms. ctc allowed whole-colon evaluation in all the cases and correctly detected and staged out of colorectal cancers. ten synchronous colonic lesions ( adenomatous polyps, carcinomas) were identified in different patients at ctc. liver metastases were detected in patients. conclusion: contrast-enhanced multislice ctc is a valuable tool for the preoperative staging of crc. this imaging modality is very useful for presurgical planning due to whole-colon evaluation even in the presence of stenosing lesions, as well as optimal assessment of bowel wall invasion, lymphoadenopathies, and hepatic parenchyma. detection of colorectal lesions with ct colonography: comparison with conventional colonoscopy in patients i. carbone, a. laghi, r. iannaccone, i. baeli, r. ferrari, s. trenna, c. catalano, r. passariello; rome/it purpose: to compare the performance of ct colonography with that of conventional colonoscopy (cc) in a blinded, prospective study in patients with suspected colorectal lesions. methods: patients, all referred for cc, underwent preliminary ct colonography. after standard oral colonoscopy preparation and colonic distension with room air, ct colonography was performed either with a single-slice (somatom plus ; siemens, erlangen, germany) or multislice (somatom plus volume zoom, siemens, germany) scanner. imaging parameters for the single-slice scanner were: . mm slice collimation; . mm/s table speed; . s tube rotation; . mm reconstruction interval; × matrix; mas; kvp; and scan time - s. imaging parameters for the multislice scanner were: . mm slice collimation; . mm/s table speed; . s tube rotation; . mm reconstruction interval; mas; kvp; and scan time - s. ct images of all suspected lesions were analyzed on a workstation and subsequently compared to cc findings. results: there were colorectal cancers and polyps identified at cc. ct colonography correctly detected all cancers, as well as of polyps of mm in diameter or larger (sensitivity, %); of polyps between and mm (sensitivity, %); and of polyps of mm or smaller (sensitivity, %). the per-patient sensitivity and specificity were % and %, respectively. conclusion: ct colonography has a diagnostic sensitivity similar to that of cc for the detection of colorectal lesions larger than mm in diameter. colorectal polyps: improvement of detection with multi-slice ct colonoscopy j. wessling, r. fischbach, d. domagk, e. neumann, s. schierhorn, w.l. heindel; münster/de purpose: to compare the performance of virtual and conventional colonoscopy for the detection of colorectal polyps using a multi-slice spiral ct scanner (msct). material and methods: patients ( women, men, mean age . years) with clinical indication for conventional colonoscopy were prospectively studied using a msct (somatom volume zoom, siemens, forchheim). examination was performed after standard oral colonoscopy preparation and colonic distension with room air and i.v. buscopan. images were obtained in prone and supine position using a detector configuration of × mm, a feed of mm/rotation at mas and kv. slice thickness and reconstruction increment were and . mm, respectively. ct data were assessed by blinded radiologists on a vitrea workstation (vital images, usa) using a software with multiplanar and volume-rendering capabilities. results: patients had normal findings on conventional colonoscopy. a total of polyps and carcinoma were identified in patients. msct-colonoscopy detected all carcinomas and polyps ( %). of polyps were mm or more ( %), of polyps were to mm ( %) and of were smaller mm ( %). there were false positive findings for polyps ( were smaller mm) and no false positive finding of cancer. conclusions: compared to single-slice-ct, multi-slice ct colonoscopy increases the rate of detection of small colorectal polyps in particular. however, false positve results still remain a problem. does contrast enhancement contribute to ct colography? a.r. gillams, v. munikrishnan, w.r. lees; london/gb purpose: controversy persists over the usefulness of iv contrast in ct colography. enhancement in small lesions should facilitate detection particularly when there is adjacent fluid. we measured the attenuation values of polyps and cancers both before and after iv contrast. materials and methods: forty-nine patients, male, mean age ( - ) were studied. all patients had routine bowel preparation, iv smooth muscle relaxant and rectal air insufflation. supine and prone imaging was performed using a multi-slice ct, collimation mm, effective slice width . mm and pitch . . the second acquisition was performed s after pump injection of - ml of iv contrast injected at ml/s. all lesions were confirmed on colonoscopy. the attenuation values of polyps and cancers were measured both before and after iv contrast. results: eighteen cancers were detected and polyps. mean polyp size was mm ( - mm). both cancers and polyps demonstrated enhancement following iv contrast enhancement but was more marked in polyps. the mean attenuation value in the cancers prior to contrast was ± and following contrast ± . the mean attenuation value in the polyps prior to contrast was ± and following contrast was ± . the mean increase for cancers was and for polyps . conclusion: contrast enhancement is seen in both polyps and cancers but is more marked in polyps. enhancement could be used where there is diagnostic doubt on the pre-contrast imaging. colour doppler visualization of hemorrhoidary arteries during transrectal us a. sias, v. alvino, f. lecca, g. mallarini; cagliari/it purpose: the scope of this work is to evaluate the usefulness of color doppler transrectal us in the visualization of hemorrhoidal artery in patients undergoing non invasive surgery for hemorrhoids. material and methods: we have examined patients undergoing doppler-guided hemorrhoidal artery ligation for the treatment of hemorrhoids with modified morinaga technique. discussion: new surgical less-invasive techniques of treatment of hemorrhoids are being developed. one of this techniques involves the use of a modified proctoscope for artery ligation. colour doppler during transrectal us was used to evaluate the position of terminal arteries originating from the superior rectal artery. we were able to confirm the arrangement of these terminal arteries at , , , , , as seen in the lithotomy position. this was noted first by meintjes in . conclusion: colour doppler transrectal us allowed a clear visualization of hemorrhoidal arteries in the fixed position described by meintjes. our study was the first to show the reliability of this classification. although useful, well tolerated, quick and easy to perform, we do not recommend routine use of colour doppler transrectal us in all patients undergoing treatment for hemorrhoids with modified morinaha technique. this examination can be useful in those with recurrent secondary hemorrhage, as it can help avoiding further bleeding problems. results: volunteers: using the corrections the mean difference between the volume of the he-mri and the pft measured - ml (r = . ). patients: after the corrections the mean difference measured ml (r = . ). functioning lung grafts contributed ± %, their corresponding native ipf lungs ± % to total ventilated volume. conclusion: he-mri of the lung offers a new approach to regional determination of ventilated lung volume. the volunteers show good correlation and high consistence of the absolute values between he-mri and pft. the patients with sltx show good correlation and the possibility to measure the individual contribution of the graft in comparison to the native lung. he-mri ( ml hyperpolarized he gas; flash d, tr/te / . ms, fa < °, slice thickness mm, pixel size . × . mm, coronal) were performed. hrct was evaluated for main lesions: airway disease (bronchial wall thickening, air trapping), emphysema, and fibrosis. he mri was assessed for three main ventilation defects. functional compromise was scored on a -point scale independently for hrct and he-mri by two readers and compared to forced expiratory volume in s (fev ) and residual volume (rv). results: ventilation defects were depicted in total: % in both, % only on he-mri and % only on hrct. mean hrct score was . , mean he-mri score . , mean fev was %. there was no relevant correlation between hrct and fev (r = . ), but between he-mri and fev (r = . ), exhibiting significant differences between scores and (p < . ) as well as and (p < . ). there was no relevant correlation between hrct and rv (r = . ), but for he-mri (r = . ). conclusion: in comparison to paired in-and expiratory hrct, he-mri has a higher sensitivity in the detection of ventilation defects and correlates better with lft. thus, functional information is predicted better using he-mri. no single lung function test index correlates well with the severity of emphysema. the aim was to develop a composite pulmonary function score that best reflects the ct quantification of emphysema. material and methods: the hrct scans of cases of emphysema were scored objectively using a density mask. the following standard pulmonary function tests (pft): dlco, kco, fev , total lung capacity (tlc), residual volume (rv) were recorded. stepwise regression was used to identify the combination of pfts that best fitted the hrct score results: significant negative correlations were found between the hrct emphysema scores and dlco, kco and fev (r = . , r = . and r = . respectively) and positive correlations with tlc and rv (r = . and r = . respectively). a composite score representing the best fit combination of pfts against the ct emphysema score was: . purpose: this study evaluated the relationships between high resolution computed tomography (hrct) morphologic quantification of bronchiectasis and clinical and lung function parameters. materials and methods: chinese with steady state bronchiectasis underwent thoracic hrct scan and full lung function tests. exacerbation frequency/year and h sputum volume were determined. extent of bronchiectasis, bronchial wall thickening, and presence of small airway abnormalities and mosaic attenuation were evaluated in each lobe, including lingula. relationships between lung function, sputum volume, clinical exacerbation and hrct parameters were analysed. results: exacerbation frequency was associated with bronchial wall thickening (r = . , p = . ); h sputum volume with bronchial wall thickening, small airway abnormalities (r = . , . , p < . ), and fev , fev /fvc and fef - (r = - . , - . , - . ; p < . ). extent of bronchiectasis, bronchial wall thickening and mosaic attenuation were respectively related to fev (r = - . to - . p < . ), fef - (r = - . to - . ; p < . ), fvc (r = - . to - . , p < . ), and fev /fvc (r = - . to - . , p < . ). after multiple regression bronchial wall thickening remained a significant determinant of airflow obstruction, while small airway abnormalities remained associated with h sputum volume. women in general had milder disease than men, but showed more hrct-functional correlations. conclusion: this study has established a link between morphologic hcrt parameters and clinical activity, and emphasised the role of bwt in bronchiectasis. there are gender differences in bronchiectasis with respect to disease severity and sensitivity to hrct evaluation. morphology and lung function in healthy smoking and non-smoking men: a -year follow-up study j.d. vikgren, m. boijsen, b. bake, u. tylén; gothenburg/se purpose: there is demand for a reliable method for early detection of smoking induced disease. healthy smokers can present with or without normal lung function. having abnormal lung function, the smokers present with airway obstruction and/or emphysema. a possible way to elucidate early smoking induced changes, bronchiolitis, could be analysis of e/i quotient. material and methods: our study was a follow-up study. subjects were recruited from the randomised epidemiological study "men born in göteborg". hrct and lung function tests were performed with a five-year interval. smokers were subdivided according to presence of emphysema or not at the beginning of the study. computer calculation of e/i quotient was performed, i.e. quotient between cross-sectional area and mean attenuation values in inspiration and expiration. visual quantitation of emphysema and air trapping was evaluated by consensus. results: at follow-up there was a significant increase of the e/i quotient for mean attenuation for smokers with and without emphysema, but also for non-smokers. e/i quotient for cross-sectional area showed a significant decrease at follow-up c d e f only for smokers without emphysema. there was a significant progression in emphysema for smokers. analysis of the relation to lung function parameters as fev . , fvc, co-uptake and n -test are in progress. conclusion: there is a progress of emphysema with continued smoking. an increased e/i quotient has been interpreted as obstruction, but the fact that the e/i quotient increases in smokers as well as non-smokers requires further analysis. mediastinal lymphadenopathy in left heart failure: correlation of ct abnormalities with clinical and echocardiographic findings v. chabbert , g. canevet , g. philippe , p. otal , v. delannoy , f.g. joffre , m. rémy-jardin ; toulouse/fr, lille/fr purpose: to evaluate the frequency of mediastinal lymphadenopathy due to left heart failure on computed tomography (ct) scans in correlation with clinical and echocardiographic findings. materials and methods: consecutive patients (mean age, years) with left heart failure in a subacute phase were included in a prospective study between september and august . ct examinations (hrct and spiral ct scans) and transthoracic echocardiography were performed within hours after presentation. ct follow-up were obtained within days after initiation of medical treatment. results: at presentation, dyspnea was graded as type iv ( %), iii ( %), ii ( %) and i ( %). mean ejection fraction was %. enlarged mediastinal lymph nodes were seen in % of cases, heterogeneous in %, with a hazy perilymphadenopathy fat in . % of cases. all patients had pleuroparenchymal abnormalities due to left heart failure. peribronchovascular thickening, septal thickening, fissures thickening, ground-glass attenuation, condensations, micronodules and pleural effusions were present respectively in %, %, %, %, %, % and % of cases. after treatment, dyspnea was graded as type iii ( %), ii ( %) and i ( %). lymphadenopathy decreased in size in . %, was stable in . %, disappeared in %, and weas heterogeneous in %, fat abnormalities disappeared in all cases. pleuroparenchymal abnormalities decreased in %, disappeared in . % and were stable in . %. we examined consecutive patients ( lung lobes) referred for the assessment of possible airways disease using multislice ct. the thorax was scanned contiguously at mm slice thickness and this was reconstructed at mm slice thickness (lung windows utilising high spatial frequency algorithm) in the axial ( mm apart), sagittal ( per lung) and coronal ( ) plane. pedal wheel reconstructions were also performed. axial images were assessed by chest radiologists with and without the help of mpr at two separate occasions. the presence of bronchiectasis, emphysema and bronchiolitis in each lobe was documented on a confidence scale of - ( no disease, definite disease). result: there was no significant difference (p = . ) in the mean confidence in the diagnosis of airways disease with the help of mpr [observer a ( . axial, . mpr); observer b ( . axial, . mpr)]. in addition, weighted kappa showed no improvement in inter-observer agreement (kappa = . for axial; kappa = . for mpr). isolated cases wherein mpr was beneficial were noted, particularly in patients with bronchiectasis ( patients). due to the small number, this did not reach statistical significance. conclusion: our results did not demonstrate a significant increase in confidence in the diagnosis of airways disease. mpr was beneficial in a few selected cases of bronchiectasis. methods and materials: consecutive patients were randomized into groups of patients each. group underwent ssct with a standard protocol for the study of the airways and group underwent msct with the following protocol: × mm slice collimation, pitch ( . m), mm slice width, . mm reconstruction increment. two radiologists evaluated by consensus the axial images and vb reconstructions in order to assess the degree of visualization of the bronchial tree according to a three point scale (grade , and ). results: on axial images, msct yielded better results in the evaluation of the segmental bronchi of the middle lobe ( bronchi rated as grade by msct vs by ssct; p < . ), of the anterior segmental bronchus of the left upper lobe ( rated as grade by msct vs by ssct; p < . ) and of inferior segmental bronchus of the lingula ( rated as grade by msct vs by ssct; p < . ). evaluation of lobar and segmental bronchi was always possible when vb was obtained from msct data sets whereas / bronchi were scored when vb was obtained from ssct. subsegmental bronchi could be better evaluated with msct than ssct either on axial images or vb (p < . ). conclusion: msct with mm collimation significantly improves the visualization of segmental and subsegmental bronchi and is particularly useful for oblique oriented bronchi. methods: over a one year period patients had by pct. patients were directly examined by pct on admission day on icu. for this purpose a special interventional suite was prepared directly on icu. in this suite radiological modalities like radiography, sonography and portable angiography can be performed under intensive care monitoring and therapy. ct examinations are even possible by using pct in this special suite. on day of admission patients underwent extensive evaluation using modalities of this special interventional suite. results: in two cases a bedside ct procedure was performed the others were performed in the intervention suite on icu. in % of the cases a final diagnosis could be determined by ct examination. in % ct findings led to follow up evaluations by pct. even % of ct examinations led to direct therapeutic consequences such as surgical intervention. % of the ct indications were assessed as necessary or essential by an experienced icu physician. half of the follow up examinations had also direct therapeutic consequences. monday b results: using the sense technique the temporal resolution and spatial coverage could be increased from slices per . s up to slices per . s. as a consequence of the increase in k-space velocity using sense the typical susceptibility artifacts of epi sequences at the skull base were almost negligible. the s/n is strongly influenced by the specific coil arrangement and the actual number of profiles in k-space. for the applied double loop coil and a sense factor of two the s/n equals that of the standard scan (head coil) in superficial temporal regions and is reduced by a factor of . to . in central and occipital regions. however, the increased temporal resolution compensated for the decrease in s/n and the calculated parameter maps were always of good diagnostic quality. with a dedicated coil the sense technique allows substantial improvement in perfusion imaging. diffusion weighted mr imaging in the early diagnosis of periventricular leukomalacia a. bozzao, f. garaci, s. marziali, r. floris, g. simonetti; rome/it -presented by f. fasoli; rome/it purpose: the use of mr diffusion weighted imaging in detecting hypoxic-ischemic encephalopathy (hie) in neonates is still controversial. moreover few reports concern pre-term infants with possible periventricular leukomalacia (pvl). we examined the ability of this technique to detect cerebral changes of acute pvl. methods: fifteen mr examinations were performed in eleven preterm infants. imaging comprised conventional and diffusion-weighted (dw) sequences. conventional, dw sequences and apparent diffusion coefficient (adc) maps as well as us obtained in the acute phase were compared. all the neonates underwent us follow-up and months after delivery, those with suspect pvl also underwent mri follow-up at two months and one year. qualitative and quantitative evaluations were performed to assess the presence of dwi changes compatible with pvl. results: dwi showed signal hyperintensity associated with decreased adc values in subjects ( %); in these patients conventional mri sequences were interpreted as normal and us (performed at the same time) as doubtful in and compatible with pvl in one. mri and us follow-up confirmed severe damage in all these patients. in one neonate hemorrhages involving the germinative matrix were identified at mri and us without signs of pvl. follow-up mri and us confirmed the absence of pvl months later. in eight neonates mri was considered normal. in these subjects us follow-up confirmed no signs of pvl. apart from the well known image artefacts time consuming reconstruction periods often inhibit continuing data acquisition, particularly if sequences are used with more than one acquisition or with built-in postprocessing capabilities to automatically generate adc-maps. by using these sequences as the last sequence in the whole examination prior to the start of the subsequent examination of the next patient this time delay can be reduced. the aim of this prospective study was to find out if there is any diagnostically significant difference between acquisition of epi-dwi images before and after intravenous application of gd-dtpa. in patients a epi-dwi sequence was used (tr/te: / , slices, mm slice thickness, fov) both as the first (before i.v. cm) and the last sequence after cm. the mr indications were ischemic stroke, encephalitis, multiple sclerosis and brain tumor with and without disturbed blood brain barrier. the mri images were rated by two blinded, neuroradiologically experienced radiologists. results: intravenous cm had no influence on the diagnostic information of the images. there were no significant signal differences even in lesions with pronounced disturbances of the blood brain barrier. conclusion: it is possible to use epi-dwi after cm application without loss of clinical information. the proposed approach allows to reduce examination times. brain perfusion studies with trans cranial colour doppler using ultrasound contrast media g. salvaggio, g. caruso, t.v. bartolotta, a. scisca, g. caputo, r. lagalla, a.e. cardinale; palermo/it purpose: to evaluate the intracranial micro circulation using trans-cranial color doppler (tccd) with a contrast medium (levovist). material and methods: patients, (age range: - years; mean age years) affected by mellitus diabetes were selected. healty volunteers (mean age: years) acted as control. the examinations were performed using an atl hdi ultrasound unit provided with a phased array . mhz probe. mechanical index was calibrated to high value in order to obtain microbubbles rupture under ultrasound beam exposition. after positioning of an operator defined region of interest, intensity/time curves related to the parenchymal micro circulation were plotted, and the areas under the curves were calculated. results: in all controls, the areas under the curve showed a mean value greater than . that we considered as cut-off value of normal perfusion. on the other hand, the diabetic patients showed a lower mean value, to indicate a micro circulation disease. conclusion: thanks to software improvements and ever more effective algorithms, contrast-enhanced tccd is able to provide information on brain perfusion non invasively and at low cost. purpose: to present our initial clinical experience with a one-piece design -channel neuro-array coil for mri of the brain. methods and materials: mri examinations of the brain were performed in normal volunteers using an -channel parallel acquisition technique (pat) optimized neuro-array head coil (mri devices corporation, wisconsin, usa), and a standard circularly-polarized (cp) volume head coil. examinations were performed on a . t superconducting magnet (sonata, siemens ag, germany). signal-to-noise ratios were calculated and compared for the two coils in various anatomical locations including peripheral (cortex, subcortical white matter, etc.) and central (e.g. corpus callosum, sella, brainstem, etc.) parts of the brain. results: the -channel neuro-array coil provided excellent high-resolution imaging with anatomical coverage of the entire head. in the peripheral portions of the brain, snr was - % superior to that obtained with a standard cp volume head coil. in the deeper parts of the brain snr was at least equally good. the neuro-array coil is pat optimized and allows the use of sense/smash type sequences with flexible phase encoding. conclusion: the -channel neuro-array head coil provided excellent high-resolution mri of the entire brain. snr was markedly improved, especially in the peripheral parts of the brain. the pat optimized imaging capablities can be used to decrease imaging time, improve spatial resolution, or a combination of both. genetic approach to ct appearance of brain ischemic stroke l. cyrylowski, a. ciechanowicz, a. fabian, i. goracy; szczecin/pl purpose: there is evidence that an allelic variation in the angiotensin converting enzyme (ace) gene may confer an increased risk of cardiovascular disease. the aim of our study was to evaluate the relationship between the ace insertion/deletion (i/d) polymorphism and the prevalence of brain ischemic stroke as well as between the polymorphism and ct type of ischemic stroke. materials and methods: the ace i/d genotype was identified by polymerase chain reaction in patients ( males and females) with brain ischemic stroke, and in controls ( males and females). to assess the polymorphism frequencies, statistical analysis was performed. results: the d/d polymorphism frequency was significantly higher in the stroke group than in the controls ( . % vs. %; p < . ). the i/i and i/d polymorphism frequencies were similar in both groups ( . % vs. %, and . % vs. %, respectively; p > . ). conclusion: a positive association between the ace d/d allele and ischemic stroke was found in our study. the ace d/d allele may be an independent risk factor for the development of cerebrovascular disease. . the motorized c-arm provides fluoroscopic images during a ° orbital rotation computing a mm data cube. from these d data sets mpr reconstructions were obtained. all images were evaluated by four independent readers for the detection and extend of fracture lines. all fractures were classified according to the müller ao-classification. to confirm the results, the specimens were finally surgically dissected. results: % of the fractures were detected with cr, % with iso-c- d and % with ct. differences between cr and ct were significant (p = . ), not significant between iso-c- d and ct (p = . ). with cr % of the fractures were correctly classified, % with iso-c- d and % with ct. there was again no significant difference between ct and iso-c- d (p = . ), but between ct and cr (p < . ). the preliminary results suggest a remarkable efficient detection of tibial joint fractures with the iso-c- d. the evaluation of fractures with the iso-c- d is better than with cr alone and comparable to that of ct-scans. even if image quality is definitely inferior to ct, iso-c- d may be useful in planning operative reconstructions and evaluating surgical results in orthopaedic surgery of the limbs. dynamic ultrasonography in evaluation of muscular trauma a.k. nath, r. bouras; muscat/om purpose: role of dynamic ultrasonography in muscular trauma. methods and materials: male football players (aged to years) presenting with clinical muscular trauma in the thigh and calf region were evaluated in this study. dynamic ultrasonography of both the affected and contralateral normal region, with toshiba power vision ultrasound equipment using . mhz phased array linear transducer, in sagittal, coronal and angulated axis was performed, both without contraction and with contraction of the muscles. needle aspiration of suspected hematomas was performed for diagnosis and treatment. all muscles tears and hematomas were studied and followed up after hours, until complete healing. results: of the total patients had muscle tears and/or hematomos in thigh and calf region. pateints had no abnormality. patients had clear-cut muscle tears appearing as echogenic retracted portions surrounded by hematomas ranging from highly reflective mass to complete echo poor areas were observed on follow up. the remaining patients had partial tears. healed tears appeared as highly reflective scar tissue. ( ) ultrasonography is very useful in diagnosis, management, and followup of muscle tears and hematomas. ( ) dynamic ultrasonography is essential for diagnosis of partial tears. ultrasound and color doppler imaging of thrombosis of gemellary veins in patients with "tennis leg" lesion m. dahmane , c. martinoli , s. bianchi , f. zandrino , f. monetti , a. beghello , s. paltenghi , l.e. derchi ; genova/it, geneve/ch, alessandria/it purpose: to assess with ultrasonography (us) and color doppler imaging (cd) the association between rupture of distal myotendineous junction of the medial gastrocnemius ("tennis leg" lesion) and thrombosis of gemellary veins. materials and methods: consecutive patients with suspected "tennis leg" lesion were prospectively examined with - mhz us and cd to confirm the diagnosis and evaluate the possible association with thrombosis of gemellary veins. the us study had to be extended to the most proximal portion of the leg, to image the veins up to the popliteal; both compression evaluation and a cd exam were obtained to confirm patency. results: / patients had typical "tennis leg" lesions; had a ruptured baker cyst; had proximal rupture of gastrocnemius muscle. an associated thrombosis of the gemellary veins was detected in cases ( %); none had extension to the popliteal vein. conclusions: presence of associated thrombosis of the gemellary veins has to be considered in patients with "tennis leg" lesion, and the us examination technique has to be changed accordingly. in this study, we report our experience regarding the usefulness of mri in the evaluation of traumatic and microtraumatic bone pathology. we performed mri examinations in patients with knee pain and a negative plain film examination where a post traumatic or non traumatic pathology at the level of the joints (knee, ankle, wrist, elbow and hip) was suspected. mri examinations were performed with a low field dedicated unit for the study of limbs (e-scan and artoscan esaote) and in some cases with an high field mri unit (vision plus siemens). we used se t and turbo-t sequences, ge and stir. in some patients we administered i.v. contrast media. in cases we demonstrated the presence of post traumatic bone alterations or bone alterations not related to trauma that were not visible on conventional radiological examinations. in the bone alteration was the most important finding. in patients, a follow-up mri after month allowed correlation between the evolution of the clinical symptoms and the changes in the appearance of the bone injury. in patients, it was very useful to correlate the changes in the bone appearance with the clinical outcome. conclusions: in our experience mri has been very important in the evaluation of traumatic, post traumatic or non traumatic bone pathology and for a correct therapeutic assessment of the patient. purpose: to compare bone bruise patterns identified at mri incurred by impaction, distraction and shear injuries correlated with microtome sections and histopathology. methods: freshly harvested sheep cadaveric limbs were imaged on a . t philips mri intera scanner following exposure to impaction, distraction and shear forces. each limb was imaged using se t and stir sequences. following imaging, the cadaveric limb was sectioned using a microtome and pattern of trabecular damage correlated with identified bone bruise at mri. results: impaction forces produce poorly marginated globular bone bruises with extensive concertina type trabecular damage. distraction forces produce localised bone bruises in a linear pattern perpendicular to the axis of distraction with localised trabecular disruption, attenuation and stretching. shear injuries produce linear bone bruises obliquely oriented with localised linear disruption of trabeculae on microtome sections. conclusion: bone bruise patterns are dictated by mechanism. mri appearances reflect the underlying extent of trabecular damage at histopathology. to determine the diagnostic accuracy of contrast-enhanced, three-dimensional panoramic-table-mr angiography in the assessment of pelvic and peripheral arteries compared with conventional digital subtraction angiography as the standard of reference. in patients with suspected peripheral arterial vascular disease, both conventional digital subtraction angiography and three-dimensional mr angiography using an automatic tracking technique were performed. in a prospective blinded analysis, each vascular segment ( segments per patient) was evaluated for the presence of obstructive stenosis, graded as normal ( - %), mild ( - %), severe ( - %), or occlusion ( %). results: obstructive lesions were identified and graded correctly with mr angiography. overall sensitivity and specificity for the detection of hemodynamically significant disease (severe stenosis) on panoramic mr angiographic images were % and . %, and for the detection of occlusive disease were % and . %, respectively. the diagnostic accuracy of contrast-enhanced, three-dimensional panoramic- purpose: with d-mr-angiography gaining more acceptance for assessing the arterial system, the amount of data produced requires new tools for visualization of the datasets. recently, a new volume rendering method, "stereo viewing", has become available. the purpose of this study was to assess the potential diagnostic gain by "stereo viewing" in comparison to combined mip and mpr for various vascular territories. over an -month period d-mra was performed in patients. mras were obtained of the carotid, pulmonary, renal and pelvic arterial systems. imaging was performed on a . t mr scanner (sonata®, siemens). image sets were analyzed on a workstation (virtuoso®, siemens, germany), firstly based on a combination of mip and mprs, and a second time based on mip, mprs and "stereo viewing". the data sets were analyzed using a -point confidence scale ranging from 'stenosis/occlusion definitely present' to 'stenosis/occlusion definitely not present'. in addition to the level of confidence, the time required to reach the diagnosis was documented. results: the addition of "stereo viewing" led to a significant increase in diagnostic confidence regarding the presence/absence of stenosis/occlusion in all anatomic regions, evidenced by a greater area under the roc curve (p < . ). "stereo viewing" prolonged the analysis process by an average of %. conclusion: "stereo viewing" is an effective and accurate tool for assessing complex d-mra datasets as it provides more diagnostic confidence compared to the combination of common post-processing techniques (mip + mpr). the added time needed for "stereo viewing" results in enhanced diagnostic confidence. purpose: image quality of dsa of the hands is still superior to ce-mra due to the lower spatial resolution of ce-mra which is limited by the passage time of the contrast bolus through the arteries. the aim of this study was to demonstrate that temporary blood flow interruption with an inflated blood pressure cuff during the arterial first-pass can significantly increase imaging time and spatial resolution. materials and methods: volunteers and raynaud patients were examined with tac-cemra on a . t mr machine (philips intera). a blood pressure cuff was placed around the upper arm. after timing (bolustrac), ml iv. gadolinium-dota was administered and tac-cemra was performed. after cuff inflation at mmhg during the arterial phase, a d-gradient echo imaging sequence (tr . ms, te . , flip °, matrix × , fov , . mm-partitions) was acquired. slopes of histograms were measured perpendicular to the radial and one arch artery and cnr calculated. results were compared to a classic ce-mra study in all volunteers. results: compared to the classic first-pass mra with pixel dimensions of . × . mm, the use of tac-cemra allowed a significant increase in spatial resolution with voxels down to . × . mm. this gain did not impede the cnr which was not statistically significantly different ( a c d e f materials and methods: patients underwent pta of a single distal sfa stenosis. lesion length was < cm. hr-mri (magnetom vision, siemens) was performed within hours after the intervention using axial t -w, fat-saturated contrast enhanced t -w, t -w and d-tof sequences. maximum matrix size was × , minimum voxel size . × . × . mm. contrast enhanced mr angiography was employed for assignment of exact matching sites. ivus ( . f, mhz) images were recorded with a standardized motorized pullback system (pullback speed . mm/s). quantitative analysis for each segment included minimum and maximum luminal diameter and cross sectional lumen area. morphologic analysis included the absence or presence and extent of dissection. results: precise pre-and post-pta assignment of segments was successfully carried out according to our protocol. the lumen increase measured % to % with a remarkable agreement between ivus and hr-mri. post pta correlation for cross sectional lumen area (r = . ) was better compared to pre pta analysis (r = . ). hr-mri detected / ivus proven dissections while digital subtraction angiography failed to demonstrate / dissections. conclusion: our preliminary findings suggest that hr-mri has a high potential for non-invasive in-vivo assessment of quantitative and morphologic changes in atherosclerotic sfa lesions following angioplasty. the method for quantitatively determining contrast medium (cm) concentration by measuring the t *-effect (brady, ) was adapted to t w liver-mri. the cm used was an indium-doted spio. three groups of study animals (liver cirrhosis, hepatitis, fatty liver) and a control group were investigated ( rats/group). se and gre imaging was performed (n = /group, . µmol/kg bw); rats received no cm and animals each and µmol/kg. t -relaxation time of all livers were measured ex vivo by relaxometry, and cm concentrations were determined. q-values representing the phagocytosed cm were computed from the pre-and postcontrast si on both the se and gre images. spearman's correlation coefficient between cm concentrations and t -relaxation rates was significant in the control group at . (p < . ). in the study groups, pearson's correlation coefficient (pcc) between cm and t -relaxation rates was significant, ranging from . - . (p < . ) -a positive correlation between cm and t -relaxation rates in all groups. pcc between q-values and cm concentrations was significant at . (se) and . (gre) (p < . ) -positive correlation between the cm and q-values. the mann-whitney test yielded a significant difference in the qse values between the liver cirrhosis and fatty liver groups compared with controls (p < . ). regarding qgre values, a significant difference was identified only for the fatty liver group versus controls (p < . ). the animal experiments suggest that quantitative determination of phagocytic capacity as a functional parameter using contrast-enhanced mri has a potential for differentiating diffuse liver disease from healthy livers. results: in the detection of focal liver lesions, unenhanced plus dynamic plus late phase enhanced mri was more accurate than unenhanced plus dynamic and than unenhanced plus late phase enhanced examinations, which were more accurate than unenhanced imaging. the accuracy and observer confidence in the characterization of focal liver lesions were higher when dynamic examination was considered. methods and materials: patients were prospectively investigated using a . t magnetom (siemens symphony; philips acs nt). the sequence protocol included t w tse and t w se/gre scans using unenhanced and spio-enhanced studies (endorem: µmol/kg bw). diagnostic criteria unenhanced were: homogeneous isointensity/mild hyperintensity (t w); homogeneous iso-/mild hypointensity (t w); scar detection. the uptake of the spio-particels was calculated comparing contrast-enhanced with unenhanced scans. results: the standard of reference was histopathology providing surgery (liver resection) or needle biopsy. as a second option gadolinium-enhanced mri was accepted within a timeframe of month. in the resection group sensitivity was . % with a specificity of . %. signal intensity was homogeneous in t -and t w unenhanced sequences and similar to surrounding parenchyma in out of cases (group ). in eight cases the lesion was heterogeneous hyperintense in t w and hypointense in t w scans unenhanced (group ). group documented a significant signal intensity loss using spio-enhanced t w sequences compared with unenhanced prtocols. for group a statistical significant decreased uptake of spio-particles was documented. histopathology revealed high degree of fibrotic changes (group ). using spio-enhanced mri detection and delineation of central scar tissue was increased compared to unenhanced mri. conclusion: spio-enhanced mri is an effective imaging tool for the diagnosis of fnh nodules providing morphological and functional details sufficient for characterization. purpose: capillary and cavernous hemangiomas represent the most frequent benign lesions of the liver; atypical features due to complications may simulate different lesions; the rare occurrence of other vascular histotypes makes the differential diagnosis even harder. the aim of our study was to describe their imaging features and discuss their differential diagnosis. we reviewed ct, mr images in patients. ct protocol included: mm collimation, pitch . injection of iodinated contrast medium in the arterial, porto-venous and delayed phases. mr protocol included - mm slice thickness, t , t weighted sequences and post-gd evaluation. we evaluated the morpho-structural appearance and the contrast enhancement of the lesions. the comparison between different imaging modalities, the dynamic of contrast enhancement, the follow-up, the bioptic and surgical specimens allowed for the correct diagnosis in all the cases. results: we identified the typical patterns of capillary hemangioma ( ), cavernous hemangioma ( ), giant hemangioma ( ). in case we demonstrated intratumoral hemorrhage, in cases prevalent jaline and/or stromal components, in cases calcifications. we also found hemangioendotheliomas ( single, multiple), hemangiosarcomas ( showing extravisceral growth, multinodular, single), kaposi's sarcomas ( showing peri-portal infiltration, multinodular). conclusions: ct and mr demonstrate an elective role in the identification and often in the characterization of vascular tumors of the liver in adults. the presence of complications is also well depicted. mr gives important information regarding the structure of the lesions and in particular of the hemorrhagic components. methods: children ( m/ f, mean age . ± . a) suffering from marfan's syndrome were consecutively chosen from the department of pediatric genetics. bone ultrasound attenuation (bua) and speed of sound (sos) were calculated by sahara (hologic, usa). the standard-deviation-scores (sds) for both parameters were calculated using regional normative data ( children). and porosity index (pi) were estimated automatically from radiogrammetric measurements and bone texture analysis of the three middle metacarpal bones. for statistical analysis each case was pair-matched to a sex-and age-related healthy control. the mean bmd was . ± . g/cm in the marfan group versus . ± . g/cm in the control group. only pi showed a significant difference: . ± . versus . ± . (p < . ). conclusion: bmd was very similar in our patients with marfan syndrome compared to the reference population. statistically significant differences were only observed for the porosity index. data in the literature concerning osteoporosis in marfan patients is ambiguous. our findings may indicate a specific textural disturbance in the bones of marfan patients which does not result in overall altered bone density. there are potential limitations due to specific anatomic properties of the metacarpal bones in marfan syndrome. radiogrammetric based bone densitometry seems to be of promising clinical value in pediatric patients receiving x-rays of the wrist and hand routinely for determination of skeletal maturity. this new technology might be able to give additional information and reduce radiation exposure. gender-specific standard-deviation-scores (sds) were calculated using age, height and weight matched regional normative data ( healthy children). follow-up was performed in children during bisphosphonate-treatment over a period of years. results: patients had oi type i, had oi type iv. age-matched bua values were < − sd in / patients, < − sd in / patients and normal in the remaining children with type . / patients had sos values below − sd, / below − sd and were within the normal range. no bua and sos-values below − sd were observed in type ; and / patients had values below − sd. / patients had sos values < − sd, the others were within the normal range. mean bone values differences were significant: − . sd/− . sd (bua) and − . sd/ . sd (sos). there was a strong correlation of bua and sos (r = . , p < . ). / children showed a significant increase of bua and sos (more than sd), / a slight increase in values during follow-up treatment, had no change. in all treated cases fracture rates were significantly reduced. conclusion: ultrasound based bone densitometry may be of clinical value in children suffering from oi. oi type i causes severe disturbances of bone mineralization in contrast to type . ultrasound based bone densitometry of the os calcis measured on asthmatic children using regional normative data a. (sos)). bua/sos correlation was significant (r = . ; p < . ). conclusion: bone densitometry of the os calcis using ultrasound appears promising in detecting disturbances of bone mineralisation in children treated with low dose topical steroids. sos was more sensitive in detection of bone mineralisation in comparison to bua. girls seemed to be osteopenic more often. in contrast to steroid intake, asthma severity does not correlate significantly with bone mineralisation disturbances. the use of mri in the evaluation of paediatric wrist trauma k. johnson, a. page, f. haigh; birmingham/gb traumatic wrist injury in children is common but detection of fractures and other injuries can be difficult. we have evaluated the role of mr imaging in the assessment of paediatric wrist trauma. children with a history of wrist trauma in whom the there was either a discrepancy in the clinical assessment and the plain radiographic findings or normal radiographs and persisting symptoms underwent an mri examination of the wrist. all mri examinations were performed within weeks of the initial trauma, % within days. mri examinations were performed ( children has repeat examinations). ( %) patients with normal plain radiographs had fractures detected on mr imaging ( % in the carpus and % in the radius and ulna). in patients there was a discrepancy between the plain radiographic findings and the clinical assessment and in cases ( %) mri detected further occult fractures and soft tissue injuries. no patient with a negative mri examination has represented with a complication of the initial injury, indicating that mri has a % negative predictive value for wrist injuries. mr examination of the wrist in children significantly alters management. mr imaging detects radiographically and clinically occult fractures and soft tissue injuries. the technique is well tolerated by children. methods and materials: patients (age - years; m = , f = ) suffering from juvenile aseptic osteonecrosis (legg-calvé-perthes disease), underwent mri in a . t mr-scanner (gyroscan t nt, philips, eindhoven, the netherlands) using a fat-suppressed stir sequence, t -weighted turbo spin-echo and t -weighted spin-echo sequences. postcontrast t -weighted sequences were performed in each patient after administration of . mmol gadolinium/kg bodyweight (magnevist, schering, berlin, germany). all examinations were retrospectively assessed by two paediatric radiologists, evaluating the signal patterns of the femoral head and the metaphysis in each sequence in consensus. the mr features and the diagnostic accuracy were analyzed for the different sequences and compared to conventional x-ray. monday b results: based on the fat-suppressed and the contrast enhanced t -weighted images, six different signal patterns were differentiated within the femoral head as well as three different signal patterns being identified within the metaphysis. combinations of separate signal patterns within one thigh were a common finding, representing different stages of necrosis and reparation. for the differentiation of viable and necrotic osseous fragments, the administration of contrast material was mandatory. the combination of fat-suppressed and contrast enhanced t weighted images allows distinct staging of juvenile aseptic necrosis. a combination of these imaging modalities permits an efficient surveillance of the legg-calvé-perthes disease. the purpose: saethre-chotzen syndrome is an autosomal dominant syndrome with craniostenosis and syndactylies. the purpose was to evaluate the variability of anomalies on hand and feet radiographs of patients with genetically proven saethre-chotzen syndrome or muenke-type coronal synostosis. we evaluated radiographs of the hands in patients, with saethre-chotzen syndrome related to twist gene mutations and with muenke-type mutation. x-rays of the feet were available in cases. the age range was between month and years. radiographs were evaluated by radiologists in respect of morphological anomalies. results: we found a bone age delay in / patients, whose epiphyses were not fused. a brachyphalangy was noted in / patients, clinodactyly in / . partial syndactyly occured in cases, involving the soft tissues of the nd web space and additionally the rd in cases. / patients presented with partial carpal fusion, affecting the trapezoid and the trapezium in . coned epiphyses were present in / patients. other anomalies included a duplicated distal phalanx of the hallux (n = ), a triangular deformity of the epiphyses of the distal phalanx of the hallux (n = ), partial syndactyly (n = ) and brachyphalangy (n = ). conclusion: saethre-chotzen syndrome and muenke-type mutation have a variety of morphological anomalies of the hand and foot in which skeletal anomalies such as brachyphalangy and syndactyly are non-specific signs. different patterns of anomalies between both are a duplicated distal end and triangular shaped epiphysis of the hallux, which were only detected in patients with saethre-chotzen syndrome. purpose: saethre-chotzen syndrome (scs) and muenke-type mutation fgfr pro arg (mtm) are both complex syndromes with skeletal anomalies such as craniosynostosis, syndactylism and cervical spine abnormalities. in this study we analysed the variable cervical spine abnormalities identified on radiographs for specific features in patients with genetically proven scs and mtm. methods and materials: cervical spine radiographs of patients ( female, male; mean age a) were reviewed by to radiologists with experience of skeletal dysplasias. the patient population included patients with scs and patients with mtm. the appearance of the vertebral bodies, the posterior elements including the neural arch and the atlanto-axial joint were assessed. x-rays of the hands and feet were available in patients. results: fusion of vertebral bodies and posterior elements were noted in patients (level c / , c / and c / ). an isolated fusion of posterior elements occurred in patients (level c / (n = ), c / (n = ), c / (n = ), c / (n = )). / patients with cervical spine fusion additionally showed carpal and/or tarsal fusion. in / patients an enlarged vertebral space between c / was found. a hypoplastic neural arch was detected in patients and a long spinous process at c in a single case. the atlanto-axial joint space had a mean distance of . mm (range - mm). conclusion: scs and mtm display a great variety of cervical anomalies, however the radiological signs are morphologically non-specific. however, cervical vertebral fusion in these patients is often associated with carpal and/or tarsal fusions. ultrasound and mri in children with pyomyositis a. trusen, m. beissert, g. schutz, b. chittka, d. hahn; würzburg/de purpose: pyomyositis is an acute bacterial infection of the skeletal muscles, most often caused by staph. aureus. the purpose of our study was to evaluate the role of ultrasound and mri in the diagnosis of pyomyositis. material and methods: children with myositis were evaluated. the areas involved included the pelvic region (n = ), the shoulder (n = ), the thigh (n = ), the lower leg (n = ) and the elbow region (n = ). all patients were examined by ultrasound, of them had mri. symptoms and signs included swelling, pain and inflammation. results: in / the correct diagnosis was made by ultrasound. in cases, involving the pelvic region the ultrasound diagnosis was initially incorrect. in one child where the diagnosis of a tumour was made both on ultrasound and mri, the diagnosis of a proliferative myositis was subsequently made by histology after ultrasound guided biopsy. the extent of myositis was determined better with mri than ultrasound. in the extremities an abscess was detected by ultrasound, the accompaniing osteomyelitis could only be detected with mri. conclusion: in cases of suspected myositis ultrasound is the primary imaging modality, however, it has a lower sensitivity in the pelvic region. mri is necessary to exclude osteomyelitis and often to determine the exent of inflammation. a c d e f materials and methods: healthy volunteers and patients with tongue tumors underwent videofluoroscopy and real-time mri before and after tumor-resection, using a t -ffe sequence (tr = . , te = . , fa = , slice thickness . cm) with images per second. images were acquired in the midsagittal plane. swallowing of diluted magnevist-enteral solution, phonation of test words and defined testmovements of the tongue were evaluated. results were analysed by radiologists in comparison to videofluoroscopy as the standard of reference concerning overall quality of the depiction of tongue-movement and deglutition (mri better, equally good or worse), and depiction of the stages of swallowing (from = not recognisable to = very good depiction). results: in all cases, the important stages of swallowing could be successfully depicted with real-time mri. however, quality of videofluoroscopy was considered to be better in all subjects. discrete pathologies like laryngeal penetration could only be seen on videofluoroscopy. depiction of tongue-movement was better with real-time mri in / cases and equally good in / cases. this was due to the better soft tissue contrast of mri and the lacking of artefacts from teeth and metall implants. conclusion: real-time mri can successfully depict the normal physiology of swallowing. for the analysis of dysphagia, quality is inferior to videofluoroscopy, while for the analysis of tongue movement-disorders, real-time mri is superior to videofluoroscopy. examinations were performed on a . t scanner (philips nt intera), equipped with sensitivity-encoding mri (sense) imaging software. sense shortens acquisition time by reducing the number of phase encoding steps, using the coil sensitivity as an encoding effect. volunteers and patients suffering from post-operative dysphagia were examined using a sagittal dynamic t w d ffe sequence with frames/s (tr/te . / . ms, °, slice mm, matrix × , fov mm, ms/image, sense reduction factor ). water and yogurt (spiked with gadolinium : ) with a bolus size of - ml were used as oral contrast agents. oral and pharyngeal swallowing phases were assessed. results: oral and pharyngeal transit, laryngeal closure, epiglottic tilting and pe sphincter opening upon swallowing could be visualized in all volunteers. boluses of yogurt ≥ ml were found most useful. in patients, residue and intra-or postdeglutitive aspiration and in patient nasal regurgitation could be seen realtime. conclusion: mr fluoroscopic visualization of swallowing is possible using realtime d ffe imaging with sense. our initial experience indicates that functional swallowing abnormalities such as aspiration can be assessed with real-time mri. the leading symptoms were globus pharyngis or dysphagia, which could not be verified by means of endoscopy or ent-examination. in % of the patiens reflux disease was indentified as underlying disease be means of ph-monitoring. % showed reflux-associated motility disorders in videofluoroscopy. % of them showed a dysfunction of the upper esophageal sphincter, which could not be found by other diagnostic tool. due to the resultant pressure elevation they showed constant/inconstant zenker's diverticula of pharyngeal pouches of different degree. in % of those patients motility disorders of the oesophageal body were detected - % of them sufferd from a delayed cleaning function of the oesophageal tube. in the remaining collective hypermotile disturbances like segmental not propulsive contractions or reflux-associated non specific motility disorders could be verified. the results of the study will be demonstrated by digital and videofluoroscopic recordings. evaluation of patients with dysphagia by modified barium swallow examination u. coskun, m. cigiltepe; ankara/tr purpose: to determine the perceived radiologic abnormalities of dysphagia with modified barium swallow examination. materials and methods: patients with dysphagia were undergone modified barium swallow examination. utilization of a thickener abled us to determine the deglutition skill in different consistencies in anteroposterior, and lateral planes. results: the perceived radiologic pathologies are as follows. oral phase: % of the patiens with bolus formation whereas % with bolus transfer problems. pharyngeal phase: % of patients revealed pulling in pyriform sinuses, % had ventriculer residue . % problems with basal tongue retraction, . % had abnormal epiglottic tilt, % delayed elevation of the pharynx and hyoid elevation problems. premature spill is seen in % of them with stasis at the valleculae or pyriform sinuses, % had aspiration and % of them had backflow reflux. functional swallow refleks was delayed in %. oesphageal phase: % had upper oesophageal pathologies. % had lower esophageal pathologies and % had diffuse peristaltism disorder. conclusion: in our centre each study is tailored to the clinical history, the patients ability to undergo the examination, and the initial flouroscopic findings. according to the findings intervention techniques were establihed. those included positioning, alteration of the food texture, oral motor range of motion exercise. according to the results aspiration and aspiration related pneumonia free status was achieved. mealtime and videofluoroscopic fluids features affecting deglutitive events s. de giorgi, a. carniato; treviso/it a four years experience in dysphagic patients suggested that assessment of deglutition tested with videofluoroscopic fluids, doesn't closely enough reproduce deglutition with mealtime fluids. with this technique in fact only poor and approximate indications can be given to swallowing therapist concerning food to be used for rehabilitation. the aim is to give clinicians more precise and objective information about deglutition assessment. density and viscosity of videofluoroscopic fluids were measured and compared by means of a precision balance and a viscosimeter. videofluoroscopic fluids were more dense and viscous than mealtime food. different abilities to manage boluses in relation to their density and viscosity during each stage of swallowing were examined as well. the analysis of a recurrent aspiration pneumonia is difficult in newborns or children. besides the special requests of radioprotection the diminuished capacity of collaboration of small children is a considerable problem. therefore we use a dynamic recording unit with cine-fluoroscopy and with a videorecording system. the test-bolus consists of jotrolan (isovist r), which is a iso-osmolar, non ionic hydrosoluble preparation with a reduced pneumotoxicity. the taste is sugarlike. the analysis of the study should be done with the pediatrician or the paediatric ent-specialist in order to integrate the clinical findings with the radiologic pattern. the differentiation between an oral and a pharyngeal morphologic or functional swallowing disorder is of special therapeutic interest. in the analysis of the swallowing disorder the individual situation of the study has to be considered, since a rejection might be misinterpreted as a swallowing disorder of the first, the volontary phase. functional disorders as a complete or an incomplete paralysis of the velum or the pharynx, dysfunctions of the upper esophageal sphincter and alterations of the sensomotoric system can be differentiated with a high precision. the sensitive diagnostic tool allows to find an individual treatment plan in accordance to the therapy of castillo-morales, voita, pörnbacher or bobart for the single infant. patient examples will be shown and discussed. we studied up to now more than patients of which nearly had a neurologic disorder. only an adequate pretherapeutic work-up of the pathomechanism of an aspiration allows a correct therapeutic approach. the aim of the study is to assess the efficiency of the close cooperation of swallowing therapists and diagnostic radiologists, specially trained in the analysis of the pathomechanism of swallowing. the differentiation of the "pre-", "intra-" and "postdeglutitive" aspiration, which means aspiration before, during and after the triggering of swallowing reflex, turned out to have a great impact in the differential therapy of aspiration. moreover on the basis of dynamic imaging other important pathomechanisms of aspiration could be detected, which were the bases of the application of new therapeutic manoevers. by means of videofluoroscopy we examined patients before and after therapy. in % of them a sufficient swallowing rehabilitation without aspiration could be achieved. videoflouroscopy shortened the time of training-hospitalisation, because the therapist could immediately center on the relevant exercises for swallowing rehabilitation. conclusion: dynamic evaluation of the neurologic impaired patient makes rehabilitation more efficient and shortens hospitalisation-time and costs. flat panel x-ray detector radiography: comparison with storage phosphor radiographs and conventional radiographs p. boehm, p. homolka, s. grampp, c. czerny, a. ba-ssalamah, h. imhof; vienna/at purpose: to compare images obtained with a flat-panel x-ray detector based on amorphous silicon technology with conventional screen film radiographs and storage phosphor radiographs using different exposure parameters to evaluate dose reduction and image quality in skeletal radiology. a digital x-ray detector (trixell, siemens, erlangen, germany) based on cesium iodide and amorphous silicon technology was used. state of the art screen film radiographs and storage phosphor radiographs (adc system, agfa) were compared with digital detector images obtained at doses equivalent to those obtained with system speed of (hand: speed , femur and tibia: speed ). in vitro human cadaver specimen (femur, tibia, head, lumbar/thoracic spine, hand) were embedded in a pmma tube filled with water. a conventional and storage phosphor radiograph and digital detector radiograph were made of each specimen by varying the exposure parameters (kv, mas). the resulting images were evaluated independently by radiologists using a subjective ranking (grade - ) rating exposure, contrast resolution, spatial resolution and soft tissue presentation. from each group the best image was chosen and separately evaluated for comparison. results: radiation doses for digital detector images were equivalent or below the other methods giving the same or better diagnostic performance. the diagnostic performance of digital detector radiographs compared with conventional radiographs and storage phosphor radiographs suggests that this technology will be a useful tool in diagnostic imaging. comparison of a flat panel digital detector to screen-film by x-ray images of the hand t. pollack, h. pauls, k. köhler, r. friedberg, u. günl, f. stösslein; dresden/de purpose: to evaluate the image quality of hand images obtained with a new flat panel digital detector to those obtained with an extremity screen-film system. methods and materials: hand images were obtained on patients presenting for a rheumatologic baseline or follow-up exam. the patients were imaged such that one hand, selected randomly, was imaged with a digital flat panel table system (general electric, xr/d, milwaukee, wi) and the other with an extremity -speed screen-film (sf) system (agfa, curix ht . g plus). the dr images were printed using a laser printer. all images were obtained using the same x-ray tube and generator, without a grid, cm source-to-detector distance, kv, and . - . mas (dependent on the patient acquired with matched techniques). five radiologists scored pairs of images dr vs. sf using a -point scale (− clearly worse to + clearly better). observers were asked to score the image quality of eight anatomical criteria. results: all anatomical structures were scored equal or higher with the flat panel system compared to screen-film. comparing the digital flat panel to screen-film, dr was graded statistically superior: by of readers for cortical structures, by readers for trabecular structures and by readers for border structures, soft tissues and overall image quality. none of the observers rated the sf statistically superior to dr for any category. the results demonstrate that the digital flat panel system with a µm pixel size produced equal or superior hand images with respect to all anatomical criteria. cost-effective data recording device for mobile c-arm which has only analogue output: optimizing ordinary software of video-capturing and real time mpeg compression with limited funds a. sada, w. ikeda, e. nakagaki, k. hisazumi, i. imai, k. nakanishi; osaka/jp purpose: in our department, a mobile c-arm is used for routine digital subtraction angiography (dsa) because of limited funds. the purpose of our study is to find an adequate data saving device for this mobile c-arm which was equipped with only analogue output. materials and methods: a philips bv mobile c-arm was used as dsa. all dsa images were obtained at five images per second and imaging matrix was × . this machine has no facility for a data transport system. imaging data were generated by a video cassette recorder as an analogue output. a personal computer (macintosh powerbook g ) and mobile c-arm were connected through the analogue-digital converting and real time mpeg- compressing system (the pixela). from july to september , cases of dsa were performed (abdominal aortogram: , celiac arteriogram: , sma: , renal arteriogram: , common iliac arteriogram: , the others: ). the compressed image qualities were evaluated. the amount of data and cost were estimated. results: compression was about . %. average compressed data per one-series of dsa was . mb. average data per patient was . mb. therefore, about patients' data can be saved on mb mo disks and two mo disks will be required per year in our department. conclusion: with limited funds, our device (using ordinary computer and the real time mpeg compression software) was useful for saving the imaging data of dsa using a mobile c-arm system which has only analogue output. hodgkin's disease -radiological procedures for determination of clinical stage l. todoric; belgrade/yu purpose: to assess the value of us, ct and lymphography in determination of the clinical stage of the hodgkin's disease and to evaluate the reliability of the techniques in identifying the spread of disease into infradiaphragmatic lymph nodes. methods: patients with histologically confirmed diagnosis were examined using all three methods before the onset of treatment. the clinical stage of the disease was based on us and ct findings. lymphography was performed as the last diagnostic procedure. after this final staging took place. we compared and statistically analyzed us, ct, and lymphographic findings as well as the change of clinical stage after lymphography. results: lymphography did not show high aortic lymph nodes. us and ct did not show the changes in small or normal size nodes especially in pelvic region. statistically significant differences in alteration of the clinical stage, before and after lymphography, has been demonstrated in all stages. conclusion: lymphography enables a more accurate evaluation of lymph nodes in the pelvic and aortic region in comparison with us and ct and the assessment of the clinical stage resulting in an optimal therapeutic approach to hodgkin's disease. a c d e f methods and materials: five patients with chronic low back pain and two volunteers underwent routine magnetic resonance imaging (mri) protocol for the lumbar spine. a -plane localizer sequence was taken with and without a standard supportive cushion. the angle of lumbar lordosis was calculated by two 'blinded', experienced radiologists from consensus measurements of the angles at the l / s and l /l levels using a ruler line tool on a workstation. results: observations in the seven subjects who underwent lumbar spine imaging (mri) with and without the supportive cushion showed no change in the degree of lordosis; the mean angle with the supportive cushion was . ° (sd. . ) and . ° (sd. . ) without. the mean of the difference between the measurements for each subject was − . (sd. . ). conclusion: as the use of supportive cushions produces no practical change in the lumbar lordosis, the decision to employ them should be made entirely with respect to patient comfort. the military radiographer: a profession in constant evolution e. martinello, a. giardino, m. pari, c. turchetti, c. ottonello, s. panica; rome/it diagnostic imaging in military medicine can be divided into two branches: clinical (in homeland and in field hospitals) and forensic. the clinical branch is performed in all clinical hospitals, while the forensic branch is performed both in clinical hospitals and in dedicated medical forensic military centers. in the clinical branch, field hospital radiological activity (fhra)is very specific and interesting; it is performed in the homeland (great disasters or accidents) and abroad (military operations, as peace-keeping/enforcing). fhra is influenced by three important factors: mass (high spatial-temporal concentration of injured personnel), environment (e.g.: tropical countries: infectious or climatic changes or unusual diseases, and injurious agents, ballistical or thermal. a special modular rx unit ( parashutable packages) that can be easily and rapidly assembled and disassembled, and a us unit with . and . mhz probe are available in our field hospitals. the modular rx unit is composed of a "c" arm, tv unit with fluoroscopy, radiographic facilities and the ability to print on us type film. in the near future dedicated ct units, digital radiology devices and dry film processing units shall also be available. methods and material: over a two year period, patients ranging from to years with or without an intraspinal component of the lesion were subjected to fnac. all were performed with / to gauge needle. two or three passes were made. us guided biopsy was performed with - mhz linear probe with a free hand technique. ct was performed using a lead wire grid for accurate location. results: of these ( . %) were benign and ( . %) were malignant. patients underwent ct guided fnac as us guided was negative. the success rate of us guided fnac was / ( . %) and that of ct guided / ( . %). a conclusive diagnosis could not be reached in patients due to insufficient material caused by necrosis, clot or blood. conclusion: image guided fnac is an effective and safe procedure for evaluation of spinal and para spinal lesions for effective patient management. to evaluate the value of mri as an adjunct to clinical and sonographic findings for the prenatal diagnosis of fetal malformation as well as for the assessment of maternal disorders during pregnancy. methods: women with complicated pregnancies (fetal pathologies n = , maternal pathologies n = , mean age of gestation . ± . weeks) were referred for mri. imaging was performed in a . t system (gems) using t w ssfse sequences. images were analysed with regard to fetal and maternal abnormalities. findings were correlated with sonography, postnatal clinical and imaging findings and/or autopsy. results: most of the fetuses (n = ) had isolated pathologies of the cns. in cases complex malformation syndromes were present. the remaining pathologies included pulmonary (n = ), gastrointestinal (n = ) and other (n = ) pathologies. mri was equal or even superior to sonography for diagnosing cerebral malformation. due to the small size, the lack of real time examination and the missing flow information, the diagnostic confidence of mri was lower for pathologies of the heart, abdominal organs and extremities. maternal disorders included anomalies of the uterus (n = ), myoma (n = ), cervical carcinoma and borderline ovarian tumour. purpose: aim of this work was to compare the new d mr-histerosalpingography with the x-ray conventional one in the evaluation of female infertility. method and materials: infertile female patients (aging - years, mean ) were studied with a . t magnet unit (ge horizon . ) using a t weighted fse sequences on axial and coronal plane and a d fast spgr sequence ( d mra sequence) on coronal plane after injection of a diluted gadolinium solution into the uterine cavity via a balloon catheter. all the data were compared with conventional x-ray hysterosalpingography. the tomographic images provided a complete evaluation of the uterus and ovaries. the d mr technique provided the evidence of the uterine cavity and the patency of the fallopian tube with a complete concordance with x ray histerosalpingography. however the accuracy in detecting the fallopian tube calibre was considered inferior with mri than x-ray by two expert radiologists. two fallopian tube stenosis were missed at d mr-histerosalpingography. conclusion: d mr histerosalpingography may represent a real promising technique in the non-invasive evaluation of the infertile female. the main advantage is related to the lack of ionising radiation in these young females. up to date, in our experience, the mr technique does not have the same accuracy as x-ray in detecting the fallopian tube. improvement in spatial resolution probably have to be considered. the purpose of this study was to establish mr pelvimetric reference values in a large study taking into account the mode of delivery. intra-and interobserver errors and intra-individual variability of mr measurements were assessed in a complementary volunteer study. methods and materials: mr pelvimetric measurements of women ( . ± . a) were reviewed and correlated to obstetric history in order to establish normative values. subgroups were identified: ( ) spontaneous deliveries, and ( ) cases undergoing caesarean section or vacuum extraction due to fetalpelvic disproportion. in addition, mr pelvimetry was performed times in female volunteers ( . ± . a) on a . t system using t w fspgr sequences. all measurements were then performed twice by different observers to assess intra-and interobserver errors and intra-individual variability. results: mean obstetric conjugate measured . ± . mm, interspinous distance . ± . mm, intertuberous distance . ± . mm, transverse diameter ± . mm and sagittal outlet . ± . mm. there were significantly different measurements in the subgroups (p < . ), with wider measurements in the spontaneous delivery group. in the volunteer study intra-, interobserver and intra-individual reliabilities were accurate for obstetric conjugate ( . - . ), interspinous distance ( . - . ) and transverse diameter ( . - . ), however they were poorer for intertuberous distance ( . - . ) and sagittal outlet ( . - . ). the normative values established in this study stratified for mode of delivery are likely to influence obstetrical decision making in the future. intertuberous distance and sagittal outlet presented the largest variabilities. obstetric decisionmakers would be justified in approaching this parameter with caution. a single-shot echo-planar diffusion mr sequence with b-values ( - s/mm ) in the planes of space (x, y, z) was implemented on a . t magnet and systematically added to a routine liver protocol including t -, t -and gadolinium-enhanced t -weighted sequences in patients. fll were evaluated in patients separated in groups: metastases (n = ); hepatocellular carcinomas (hcc, n = ); benign hepatocellular lesions (bhl) including focal nodular hyperplasias and adenomas (n = ); hemangiomas (n = ); and biliary cysts (n = ). the adcs were measured on the normal and the cirrhotic liver and on the fll. the results were then compared between the groups of patients. the liver parenchyma and the fll were found to be isotropic. the adc (× − mm /s) of the cirrhotic liver ( . ± . ) was lower than that of the normal liver ( . ± . , p < . ). signal intensities of the focal lesions were rated by two radiologists as follows: hypointense, isointense, hyperintense, and markedly hyperintense. lesion-to-liver contrast-to-noise ratio (c/n) was measured for a quantitative assessment. results: on ferumoxides-enhanced fse images, % of cysts were 'markedly hyperintense' and most of the other lesions were 'hyperintense', and the mean c/n of cysts was significantly higher than that of other focal lesions. t *-weighted gre images showed most lesions with similar hyperintensities and the mean c/n was not significantly different each other. t -weighted in-phase images showed all fnhs and hemangiomas, ( %) hccs and ( %) metastases as 'hyperintense'. on t -weighted out-of-phase gre images, all hccs and metastasis except one were iso-or hypointense, while all of the fnhs and hemangiomas were hyperintense. ring enhancement was more commonly seen on the out-ofphase images than on the in-phase images. conclusions: addition of t -weighted in-phase and out-of-phase gre images is helpful for characterizing focal lesions in ferumoxides-enhanced mr imaging. was acquired before and immediately following i.v. injection of . mmol/kg of gadodiamide, during arterial and portal-venous phases. in-phase and opposedphase images were calculated at the end of the sequence; subtraction was performed for each series of images on the main console. results: images of diagnostic quality were obtained in all the cases. nine metastases, hemangiomas and cysts were detected, all showing low signal intensity on unsubtracted and subtracted images. increase in lesion/liver contrast was observed on subtracted images (p < . ). three hepato-cellular carcinomas previously treated with chemioembolization showed high signal on in-phase images and low signal in opposed-phase images; after subtraction bright signal was observed with increase in liver/lesion contrast (p < . ). focal fatty areas showed bright signal on subtracted images. in two patients with diffuse liver steatosis, three metastases were missed in both opposed-phase and subtracted images, but they were visible as low signal intensity nodules in in-phase images. in-phase and opposed-phase images with electronic subtraction may help in identifying focal liver steatosis and increase lesion/liver contrast in case of fat-containing lesions. which is the optimal phase for the detection of hypervascular liver lesions with multislice helical ct? comparison beetween early and late arterial phase r. basilico, m. ricciardi, a. di credico, e. cucci, l. bonomo; chieti/it purpose: to compare early and late arterial phase imaging with multislice ct in the detection and conspicuity evaluation of hypervascular liver lesions. materials and methods: patients with known hypervascular liver lesions ( hccs, metastases, haemangiomas, fnhs) were evaluated with double arterial phase ct. ct examinations were performed with multislice ct scanner using × . mm collimation and mm slice thickness during administration of cm of contrast agent ( mg i/ml) at cm /s. after a test bolus, early and late arterial phase images were obtained serially during a single breath hold in a cranio-caudal direction, with interscan delay of . seconds and mean scanning time of . seconds for each phase. each set of images were evaluated in consensus by two blinded, experienced radiologists. they determined lesion detection rates, recorded lesion size and scored the conspicuity of lesions on a scale - . the mean scanning delay for the early arterial phase was . seconds (range - seconds), whereas the mean delay for the late arterial phase was seconds (range . - . seconds). the number of lesions detected was with early phase and with late phase (p < . ). late arterial phase resulted in % increase in detection rate versus early arterial phase. lesion conspicuity and diameter significantly increased on late arterial phase. the detection of hypervascular liver lesions did not significantly improved with early and late arterial phase evaluated in combination. conclusions: late arterial phase imaging ( seconds after the peak enhancement in the aorta) significantly improves the detection of hypervascular liver lesions. a c d e f material and methods: consecutive patients underwent mri of the liver using a . t system with mt/m gradients with phased array bodycoil. imaging protocol includes t w tse with and without fatsaturation and breathhold t w flash. seven t w d flash datasets with parallel imaging (vibe with sense; tr/te/ matrix/slice thick./acq.t.: . ms/ . ms/ × / mm/ s) was performed as dynamic contrast study during infusion of gd-dtpa i.v. additional postcontrast breathhold t w flash was acquired. results: images of diagnostic quality were obtained in all cases. normal findings were observed in , ecchinococcus cyst in one, liver metastases in , hemangiomas in and hepatocellular carcinoma in cases. dynamic contrast studies gives important additional informations about the perfusion of focal hepatic lesions. with a slice thickness of mm in vibe sequence even in small hemangiomas typical contrast behaviours are seen. hepatocellular carcinomas are detected best in vibe sequence in early arterial phase compared with other sequences. conclusion: the vibe sequence with sense technique covers the whole liver within one breathhold. thus dynamic contrast studies in a slice thickness of mm are possible and important perfusion informations of liver lesions are available in a high spatial resolution. we think that this mr technique is a very promisable tool for liver diagnostic. the value of mri in the diagnosis of hepatic tuberculoma f.h. yan, m.s. zeng, k.r. zhou; shanghai/cn purpose: to analyse the mri findings of hepatic tuberculoma, to discuss the value of mri in the diagnosis and differencial diagnosis. methods and materials: ten cases with hepatic tuberculoma underwent mr se sequence and fmpspgr sequence dynamic contrast scanning. results: mri findings of total lesions in cases appeared as: ( )se sequence: all lesions were hypointense on t wi, lesions were inhomogeneous hypointense on t wi (central hypointense and peripheral hyperintense in lesions and punctual hyperintense in the center in lesions). the other lesions showed as hyperintense. ( ) fmpspgr dynamic contrast scanning: lesions had no enhancement and lesions had slight peripheral enhancement on the arterial phase, all lesions had various patterns of enhancement on the portal venous and delayed phase scanning, mainly peripheral enhancement and internal septal enhancement. conclusion: mri could reflect the pathological changing of hepatic tuberculoma and be of great value in the diagnosis and differencial diagnosis. comparative study of ctap and mndpdp enhanced mri of the liver in the pre-operative evaluation of colorectal metastases e.j. van der jagt, t. kok, m.j.h. slooff; groningen/nl purpose: to compare the sensitivity of ctap (computer tomography during arterial portography) with mndpdp enhanced mri in assessing the exact number of liver metastases before liver surgery. material and methods: in patients evaluated for surgical treatment of metastases of colorectal carcinoma, we performed ctap and mri with mndpdp contrast medium (teslascan). peroperative ultrasonography performed jointly by surgeon and radiologist served as the gold standard. ctap and mri were evaluated by two experienced radiologists blinded to the results of the operative findings and the result of the other technique. results: in patients at operation metastases were found, and focal nodular hyperplasia. ctap correctly showed ( . %) and mndpdp enhanced mri ( %)of these lesions. of the missed meastases in mri were smaller than mm and smaller than cm. two were missed because of technical failure, two of three by interpretative failure were found in retrospect. ctap showed lesions thought to be metastases not proven by surgery, whereas mri only scored false positive findings. in the non operated group patients underwent petscanning showing a total of metastases in the liver. of these were shown by ctap and by mri. when this group of patients is added to the operated group, sensitivity for ctap rises to % and for mri to %. conclusion: mndpdp-enhanced mri is less sensitive than ctap ( % versus % of proven lesions) but showes less false positive lesions. = ) , sle (n = ), idiopathic (n = )), cystic acinar transformation (n = ), oncocytic endocrine tumor (n = ) and isolated polycystic disease (n = ). we reviewed retrospectively the preoperative investigations (computed tomography, cholangio-mri, us-endoscopy, pancreatography) and correlated them to the histological results. results: ct and mri showed isolated abnormalities of the pancreatic ducts in patients involving the main pancreatic duct (mpd) (n = ) and the branch duct dilatation (n = ). the mpd was normal (n = ), dilated (n = ) or stenosed (n = ). the cystic lesions involved the head and/or uncinate process (n = ), the body and/or tail (n = ). the location was diffuse (n = ) or multifocal (n = ). the number of cystic lesions varied from to or more and the size was less than mm. a solid tumor was demonstrated in one patient. correlation with us-endoscopy was good. none of the patients were found to have mucous extrusion through the papilla. pancreatography was normal in case, showed a communication between the cystic lesions and mpd in cases or a stenosis in one case. ductal biopsies performed in cases (eus-guided n = ; transpapillary n = ) revealed epithelial proliferation in patients and were non-informative in . the pancreatic resection consisted with a pancreatico-duodenectomy in patients and total pancreatectomy in . to compare mr cholangiography to multislice ct cholangiography without biliary contrast agent in the assessment of patients with biliary obstruction. methods and materials: patients with clinical or biochemical signs of biliary obstruction were studied. mr cholangiography was performed with a . t unit, using respiratory-triggered three-dimensional fast-spin-echo and haste sequences; source images, maximum intensity projection, and multiplanar reformatted images were evaluated. ct cholangiography was performed using a multislice scanner, without biliary contrast agent, with intravenous injection of iodinated contrast material; axial, minimum intensity projection, and multiplanar reformatted images were evaluated. ct and mr findings were compared to ercp in patients, ptc in , intraoperative cholangiography in . six patients underwent surgery or fine needle aspiration. results: ercp, ptc, surgery, and pathology demonstrated: pancreatic, gallbladder, klatskin's, and ampullary carcinomas; bile duct obstruction due to enlarged hilar lymph nodes; patients with choledocholithiasis; chronic pancreatitis; patient with negative findings. regarding site of obstruction, agreement was observed among ct, mr cholangiography and conventional cholangiography in all cases. concerning the cause of obstruction, the correct diagnosis was made in patients by both mr and ct cholangiography. in two patients with choledocolithiasis, ct cholangiography was judged to be negative, but stones were correctly identified by mr cholangiography. conclusion: in the assessment of patients with biliary obstruction, multislice ct cholangiography can be considered a useful diagnostic tool alternative to mr cholangiography, which is still the non-invasive standard of reference in the evaluation of the biliary tract. mdct-ca was performed as part of a comprehensive preoperative assessment in potential living liver donors ( women, men; mean age years). for display of the biliary system, mdct of the liver (slice thickness/ collimation mm, pitch mm, table speed mm/s) was performed ± minutes following intravenous administration of meglumine iodipamide (biliscopin). subsequent mdct angiography was added to depict the topographic relationship between biliary and vascular structures. mdct findings were correlated with intraoperative findings (n = ). results: mdct-ca was diagnostic in all patients. of patients presented with variations in biliary anatomy. these include drainage of liver segment four into right hepatic duct (n = ), additional right/left segmental ducts draining into the common hepatic duct (n = ) or the left hepatic duct (n = ) and trifurcation at the upper confluence (n = ). biliary-vascular topography was well depicted in all cases. intraoperative assessment confirmed the preoperative mdct-ca findings in all cases. conclusion: variations in biliary anatomy appear to be the rule rather than the exception. mdct-ca represents a non-invasive means for accurately assessing biliary morphology. a continuous helical data set of the heart was acquired in patients (group ) using the standard protocol with constant tube current, and in patients (group ) using an alternative protocol with reduced radiation exposure during the systolic phase. the standard deviations (sd) of predefined regions of interest (rois) were determined as a measure of image noise and were tested for significant differences. results: there was no significant difference between group and group in respect of image noise. radiation exposure with and without tube current modulation was . msv and . msv, respectively (p < . ) for males and . msv and . msv, respectively (p < . ) for females. thus there was a mean dose reduction of % for males and % for females, respectively. conclusion: ecg-controlled tube current modulation allows significant dose reduction when performing retrospectively ecg gated msct of the heart. purpose: to analyse myocardial contrast dynamics and to calculate myocardial perfusion parameters using ecg-triggered multirow-detector computed tomography (mdct). methods and materials: patients with a suspicion of or known cad underwent retrospectively ecg-gated mdct angiography of the coronary arteries. prior to cta data acquisition a prospectively ecg-triggered transaxial dynamic scan ( × mm) over heart beats was applied to analyze myocardial enhancement patterns with subsequent assessment of perfusion parameters. contrast enhancement was provided by administration of ml of iopromid at a speed of ml/s followed by a ml saline flush. sequential image data was analyzed to calculate maximum left ventricular (lv) and myocardial signal intensity (si) increase and for maximum si upslope. all data were normalized to the lv input function. in addition quantitative measurements were performed using a fermi-function. coronary angiography was available in all patients. the lv si increase showed an amplitude of ± hu ( - hu) and an up-slope of . ± . ( . - . ). the range of si increase in myocardium was ± hu. within myocardial regions the normalized si increase and upslope were . ± . and . ± . , respectively. in regions of impaired blood supply si amplitudes and si upslopes tended to be lower. quantitative flow calculations revealed values close to those within normal myocardium ( . ± . ml/g/min). the use of mdct scanners the assessment of myocardial contrast dynamics is possible. however, ventricular coverage so far is insufficient. with optimized contrast enhancement protocols the reliability may be even better. so far, the relatively low myocardial enhancement leads to a low snr. a c d e f method/materials: in children ( male, female, mean age . years) with suspected aortic isthmus stenosis or re-stenosis mr imaging was obtained using a . t body scanner (magnetom vision, siemens). an optimized d ge sequence with double-slab excitation (tr . ms, te . ms, slab thickness . mm) was used in a sagittal plane. in children an additional ce mra was performed using a standard d ge sequence with short tr/te (~ ms/~ ms) after intravenous administration of gadolinium ( . mmol/kg). source images and maximum intensity projections (mip) were analyzed, evaluating blood-tissue contrast as well as size and focal stenoses of the aortic arch. results: in of an aortic coarctation could be found. using the double-slab technique, in % the image quality was high and there was a low sensitivity to flow and breathing motion. there was a good blood-tissue contrast without the use of contrast agent. using a combined analysis of source images and mip diagnostic accuracy could be improved. conclusion: mr imaging represents an excellent tool for non-invasive examination of the cardiovascular system of children. the double slab method allows recording of a large d data set in an adequate measurement time especially in small infants, which were not able to hold their breath, and it is well suited for d reconstruction. evaluation of the tais stent in short de novo coronary lesions i.v. pershukov , t.a. batyraliev , a.n. samko , z.a. niyazova-karben , y. pya , y.n. belenkov ; gaziantep/tr, moscow/ru purpose: the tais is a new balloon-expandable, stainless steel, tubular stent. this study was designed to assess the safety and efficacy of this novel coronary stent and by indirect comparison to indicate equivalence with other formal stent studies. methods and materials: patients with angina and a single short (< mm) de novo lesion in a native coronary artery of ≥ . mm diameter were included. a total of patients were allocated in centers. most patients ( %) had stable angina, and % of lesions were type b -c. clinical data was collected at sixand nine-month follow-up. in the first patients angiography was routinely performed at six months. the remaining patients were merely followed up clinically. results: no stent deployment failure occurred, as well as acute or subacute stent thrombosis. the primary end-point of the study, the six-month mace-rate was . %, which is similar to the calculated % mace-rate in comparable reference studies. secondary end-points included among others restenosis at six months in the first population. the target vessel diameter was . ± . mm. minimal lumen diameter pre/post procedure and at follow-up was . ± . , . ± . , . ± . mm, respectively. the binary restenosis rate was . %. conclusion: the coronary tais stent is safe and effective as a primary device for the treatment of native coronary artery lesions in patients with stable or unstable angina pectoris. clinical and angiographic results are in the statistical range of equivalence with comparable studies with other current stents. the aim of this study is to asses if the bmi affects the amount of pulmonary atelectasis developing after general anaesthesia, and its effect on atelectasis evolution. material and methods: two groups of volunteers aged from to years old were prospectively randomised. they all underwent surgical celioscopy. patients with a bmi over kg/m underwent a gastroplasty and patients representing the control group (bmi under kg/m ) underwent a cystectomy. before induction of general anaesthesia, three ct sections of mm, were acquired in expiration at the level of interventricular septum. immediately after surgery and hours later, three ct sections were acquired at the same level. with a threshold of − to + hounsfield units, the surface of pulmonary parenchyma was manually extracted from the ct sections. the amount of pulmonary atelectasis was determined with a − to + hu threshold. results: a statistically significant difference was observed in comparing the group with a bmi over kg/m and the control group in the development of pulmonary atelectasis (p = . ) and in its evolution ( h p = . ). the bmi affects the amount of pulmonary atelectasis developing after general anaesthesia and its evolution at hours. lymphomatoid granulomatosis: pulmonary abnormalities and correlation with pathology a. patsalides, g. atac, u. hegde, w. wilson, n. patronas; bethesda, md/us lymphomatoid granulomatosis (lyg) represents an angiodestructive lymphoproliferative disorder. immunosuppression is a major risk factor for the development of lyg and the lungs represent the most commonly affected organ. the purpose of our presentation is to report the pattern of respiratory tract involvement in lyg and assess evolution of these lesions after treatment. patients, six females and males, ranging in age from to years (mean, years) were enrolled on a study on the diagnosis and treatment of lyg. the diagnosis was confirmed by lung biopsy in all patients. ct imaging was performed in all patients upon entering the protocol and follow up scans were performed after the initial evaluation in order to assess the effect of treatment. pulmonary involvement was evident in all patients. masses were identified in , alveolar and/or interstitial infiltrates in , and lymphadenopathy in five patients. pleural effusion was present in six and pleural thickening in one patient. eight patients were found to have pulmonary cavities. pathology studies showed infiltration of the pulmonary parenchyma by lymphoid cells with prominent perivascular distribution. granulomas with various degrees of ischemia and necrosis were also present. on follow up studies, partial or complete resolution of the pulmonary lesions was noted after treatment. the pattern of pulmonary involvement in patients with lyg is consistent with the pathological findings. the imaging findings are not specific. pulmonary biopsy is therefore essential for the establishment of an accurate diagnosis. imaging studies however are useful for evaluating the response to treatment. method: patients with histologically diagnosed neoplasms underwent initial assessment with clinical examination, pulmonary function tests and high resolution ct. pulmonary clearance studies were carried out using using a proprietary nebulizer (amertec, uk) and baselines were obtained contemporaneously with pre-treatment hrct. investigations were repeated immediately after treatment and at one and four months. results were documented independently and compared to determine the presence, severity and timing of changes. results: eight patients were able to complete the study; one died and four were withdrawn on medical grounds. clearance was unaffected by treatment in only one patient, the rest showing a marked increase. in five patients clearance increased immediately post-treatment and occurred in both irradiated and contralateral lung. only of patients showed demonstrated late changes on hrct; there was no corresponding change in the contralateral lung on hrct. there was no correlation between radiation dose and alteration in lung clearance. the pilot study confirms that tc dtpa pulmonary clearance studies are a highly sensitive method of detecting radiation pneumonitis and presumed contralateral sympathetic pneumonitis, and confirms that pulmonary radiation has a systemic in addition to local effect. optimization of the acquisition protocol m. rémy-jardin, a. amara, p. campistron, i. mastora, v. delannoy, j. rémy; lille/fr purpose: to evaluate the accuracy of mm thick reconstructed sections in the diagnosis of bronchiectasis with msct. materials and methods: consecutive patients suspected of bronchiectasis underwent msct of the entire thorax with a × mm collimation. from each data set, two series of images were systematically reconstructed with a high-spatial frequency algorithm: mm (group ) and mm (group ) thick scans, at mm intervals. three observers independently analyzed the presence of bronchiectasis and associated abnormalities on group and group lung images. results: no significant difference between group and group was found in: (a) the detection of bronchiectasis [group : n = ( %); group : n = ( . %); (p = . )]; (b) the evaluation of the extent of bronchiectasis [focal: group ; n = ( %) and group ; n = ( . %); (p = . ) and diffuse: n = ( %) in both groups]; (c) the characterisation of bronchiectasis [cylindrical: group : n = ( %); group : n = ( %); p = . ; varicose: group : n = ( . %); group : n = ( %); p = . ; cystic (group : n = ( %); group : n = ( %)]. apart from the identification of abnormal bronchial wall thickening (group : n = ; . % vs group : n = ; . %; p < . ), recognition of associated abnormalities did not differ between the two groups. conclusion: a comparable accuracy of mm and mm thick reconstructed scans in the detection and characterization of bronchiectasis allows the recommendation of a × . mm collimation with reconstruction of mm thick scans in the screening of bronchiectasis, reducing the radiation dose of msct examinations by %. purpose: for the development, optimization and validation of inhalation therapies it is important to develop a model that covers individual anatomical data, application process, deposition and uptake of applied medication. using cfd, velocities and deposition within the individually segmented tracheo-bronchial tree were simulated. material and methods: multislice ct datasets (n = ) of the lung were segmented using a hybrid segmentation algorithm to detect the tracheo-bronchial-tree. this algorithm consists of: (a) d seeding process, (b) d bronchus finder (fuzzy-logicsystem), (c) d module to identify peripheral bronchi (template-matching). the influence of three reconstruction kernels on the segmentation process was inves-tigated. the hybrid system was compared to a merely threshold-based segmentation tool by visual assessment performed by two radiologists. the segmented images were used to reconstruct the d geometry of the tracheo-bronchial airways. this is meshed using an unstructured tetrahedral mesh. flow analysis and particle tracking model is carried out using cfd to simulate in-and expiratory breath velocities. results: due to the combination of the -step algorithm it is possible to segment down to the th generation of bronchi semiautomatically. depending on the kernel used the following sensitivity ranges were obtained: th generation - %, th - % and th - %. calculation of the velocity during in-and expiration revealed a ratio of up to . (peripheral bronchi/trachea). conclusion: combining individual anatomical data derived from radiological images and a comprehensive model of the respiratory tract enables the simulation of distribution and deposition of inhaled drugs. support: ec (ist- - : "cophit"), british council b- : ct bronchography: assessment and validation of two approaches for d reconstruction c.i. fetita , f. preteux , c. beigelman-aubry , p.a. grenier ; evry/fr, paris/fr purpose: to validate and compare two reconstruction techniques leading to the d ct bronchography, by means of a scoring system established with respect to a reference anatomical bronchial tree. the study was conducted on volumetric helical data sets obtained from patients with various chronic airway diseases. acquisitions were performed during breath holding following a full inspiration without any contrast agent. axial images were reconstructed with . mm thickness and . mm intervals. for each patient, the bronchial tree was reconstructed using different techniques. the first one consists in a slice-by-slice segmentation of airway lumens followed by a d reconstruction using a topological propagation and filtering. the second one is fully- d and relies on a diffusive-aggregative markovian modeling, which takes advantage of the structural and topological features of the airways. in both cases, the bronchial tree was visualized in a ct bronchogram mode, using a semi-transparent volume rendering technique. the images were assessed independently by radiologists using a scoring system established on the basis of a reference bronchial tree defined up to the subsegmental level. results: the bronchial tree was reconstructed up to the th order by both techniques without any significant difference ( % accuracy and % robustness). the fully d technique running twice faster, proved in addition the capability to reconstruct smaller bronchi distal to the th order. conclusion: d bronchography obtained from multislice ct is an accurate technique to reconstruct the airways up to the th - th order of division. . the results were compared to patients, which were examined with a standard protocol ( mas: g ). all other parameters were kept constant. subjective image quality was rated using a three point scale. objective criteria, based on signal-tonoise measurements, were assessed. results: image quality was sufficient in all cases. subjective gradings of image quality, based on soft tissue window settings, were . for the mas protocol, . (g+ ), . (g± ), . (g− ), and . (g− ), for the body weight adapted protocols. objective criteria showed mean standard deviation values of . hu for the mas protocol. for the dose reduced protocols, values were calculated as . hu (g+ ), . hu (g± ), . hu (g− ) and finally . hu (g− ). best correlation for the whole subgroup was achieved for the − protocol, with nearly constant noise related to the body weight in all patients. conclusions: by deriving mas values from body weight estimation, an individually adapted protocol for chest ct can be recommended. with an adaptation of the tube current time product (x mas = m − , m … body weight in kg), a well balanced examination, even in soft-tissue window settings, can be performed. therefore, for other types of ct scanners, analogous protocols may be adapted. highland heights, oh/us purpose: current ct liver perfusion methods typically involve limited ( cm or less) z-axis coverage with the results displayed in the form of axial cross-sectional perfusion maps. we implemented a full-organ liver perfusion technique and explored the usefulness of providing full-organ volume-rendered perfusion maps. methods: ten ct liver perfusion studies were acquired (technique) for patients with hepatic masses using a series of consecutive acquisitions of the liver during one breathold after the injection of a bolus of contrast ( - ml/s). images of each slice location were acquired every . seconds. liver perfusion maps were produced using previously published techniques and displayed in both axial and volume rendered modes. results: multislice-spiral acquisitions with a pitch of . and a . s rotation enabled full coverage of the liver, portal vein and spleen, which were used as inputs for the perfusion calculation. both the axial and volume-rendered perfusion maps depicted characteristic perfusion patterns of various types of hepatic tumors. small tumors were depicted as area of hyperperfusion, while advanced tumors exhibited a ring of hypervascular tissue surrounding a necrotic core. perfusion values of normal liver tissue corresponded to expected physiological ranges. further investigation is warranted to understand the sampling rate required for clinically relevant quantitative measurements. conclusion: multislice ct scanners may enable full organ assessments of liver perfusion. volume rendering of perfusion images allows potentially superior assessment of perfusion abnormalities and might be used to predict the effectiveness of chemo-and thermoablation therapy. (ratios) were determined using amares. additionally, absolute values of phosphorous metabolites were determined using sloop and an concentration of . mmol for atp as internal standard, including corrections for inhomogenous b -fields, t relaxation. healthy volunteers and patients with liver chirrosis were included. results: amares allowed relative quantification (metabolite ratios) in all volunteers, however, only in / patients, due to low signal to noise ratios. using, sloop as postprocessing method, all acquired p-spectra had sufficient signal to noise ratios for all analyzed metabolites. in healthy liver parenchyma, absolute concentrations for pme, pi and pme were . ± . , . ± . and ± . mmol respectively. for patients pme and pi increased to . ± . and . ± . , pde showed no significant changes ( . ± . ). conclusion: using sloop, significant changes of energy metabolism, which is a parameter for hepatic vitality, can be observed in patients with chronic liver disease. compared to conventional postprocessing packages, sloop allows for a robust and quantitative assessment. methods and materials: ct scans of patients with malignant ( primary and metastatic) and benign changes were retrospectively rewieved over a -year period. there were women and men. the study protocol consisted of and mm slices of the liver area. images were obtained before and after intravenous injection of non-ionic contrast agent (iopromidum . mg/ml) in a standard dosage cm /kg, as a bolus. original films were rewieved and sought in favour of capsular retraction by two independent radiologists. the number, location, size, density of the tumor and presence of capsular retraction were evaluated. the final diagnosis of focal changes was based on histopathological findings. results: twelve of patients (prevalence . %) revealed retraction of liver capsule, which was associated with adjacent hepatic tumor. all tumors were proven pathologically to be malignant ( hepatocellular carcinoma, colorectal metastases, stomach cancer metastasis, epithelioid hemangioendothelioma, prostate cancer metastasis, breast cancer metastasis and carcinoid). the occurrence of capsular retraction adjacent to the liver tumor in our study was a rarely observed but a specific sign (specificity %) of a malignant process. purpose: virtualprobe® (iôdp, paris, france) is ultrasound acquisition and post processing software that uses an electromagnetic field to acquire positional data, allowing retrospective multiplanar d rescanning through a volume of tissue. the aim of this study is to assess the accuracy of measurements made from the reformatted images of normal structures. methods and materials: patients referred for exams of the kidney ( ) and abdomen ( ) were enrolled. each patient had a conventional ultrasound exam, followed by the virtualprobe®. the average of measurements of sagittal right ( ) and left kidney ( ), sagittal bladder ( ), sagittal spleen ( ), cbd ( ), and gb wall ( ) were recorded. the correlation of the measurements between both methods was caclulated. analysis of variance for measurements of structures < cm (cbd, gb wall) was performed to assess for the intra-observer variability. the correlation coefficients between methods were . , . , . , and . for the right and left kidney, bladder, and spleen. the correlation coefficients were . and . for the cbd and the gb wall. the correlation coefficient for cbd and gb was . . the variance of measurements for the cbd and gb was . cm for conventional and . cm for virtualprobe®. although it exists a statistical difference between both methods for these two structures (p = . ), the absolute value of the measurement difference ( . cm) was less than the intraobserver variability of the conventional data alone (s.d. = . cm). to evaluate the possible role of multislice ct (msct) in the preoperative evaluation of patients candidate to laparoscopic splenectomy. material and methods: patients underwent msct with . seconds gantry rotation time. pre ( × . mm collimation) and post-contrast ( × mm collimation) acquisitions, during arterial and portal venous phases were performed after i.v. administration of ml of non ionic contrast agent at ml/s, with a delay time of respectively and seconds. real time interaction with the post-contrast d data set was performed on a dedicated workstation to determine total spleen volume, and to assess arterial and venous vascular anatomy. for volumetric determination an hand-trace editing was used to calculate spleen mass to select candidates for laparoscopic procedure. results: at surgery mean volume was cm . calculation based on ct provided a mean error of %. in none of the patients undergoing laparoscopic splenectomy, a conversion in laparotomy was needed. five patients underwent laparotomic splenectomy because of spleen volume greater than cm . in all cases optimal vascular detail was achieved. conclusion: high resolution msct afforded complete parenchymal, vascular, and volumetric preoperative evaluation of potential laparoscopic splenectomy. volumetric determination provided accurate and reproducible information. changing the imaging paradigm in ultrasound: can d technology improve productivity, decrease sonographer work-load and maintain study quality? m.j. o'neill, s.i. lee, j.f. simeone, g.j. harris, p.j. whelan, p.r. mueller; boston, ma/us purpose: virtualprobe® (iôdp, paris, france) is ultrasound acquisition and post processing software that uses an electromagnetic field to acquire positional data, allowing retrospective multiplanar d rescanning through a volume of tissue. the aim of this study was to assess the workflow impact for both sonographers and radiologists as well as overall image quality when conventional ultrasound examination was converted to an off-line interpretation model. methods and materials: patients referred for exams of the kidney ( ), thyroid ( ) and abdomen ( ) were enrolled. each patient had a conventional ultrasound exam, followed by the virtualprobe®. the d data were blindly reviewed. the time for conventional vs. d performance/review was compared for sonographer and radiologist. the diagnostic findings between both methods were compared. radiologist desire to rescan a patient was recorded on an ascending point scale. the average scanning and image review/rescanning time for the sonographer was . , . , and . min during the conventional and . , . , and . min during the d for renal, abdomen and thyroid. the average review/ interpretation time for the radiologist was . , . , . min for the conventional and . , . , . min for d for renal, abdomen and thyroid. the desire to rescan averaged . / and . / for conventional and virtualprobe. all findings on conventional scans were observed on d. findings were observed during the d only. conclusion: virtualprobe® allows for a fold increase in sonographer efficiency while minimally increasing radiologist time. overall study quality was not different between both methods. predictive ultrasound factors of an adequate biliary drainage through an endoprosthesis in proximal biliary obstructions z. spirchez, m. tantau, b. diaconu, o. anton; cluj-napoca/ro purpose: to study the ultrasound performance in the evaluation of an internal biliary drainage through an endoscopically inserted endoprosthesis in proximal biliary obstructions. materials and methods: patients ( males, females, mean age , range - ) with proximal biliary obstruction due to hilar tumors, treated by biliary stenting using plastic, - f, stents were studied. the efficacy of the drainage was assessed clinically and by biochemical parameters. ultrasonographically the size of the right and left hepatic ducts (rhd/lhd) and the intrahepatic bile ducts were noted before and after stenting. the presence and degree of aerobilia and the position of the stent (the proximal end above or below the stenosis) were noted after stenting. of pancreatic structures and abnormalities were evaluated using a three point grading scheme. furthermore the differentiation of cystic versus solid tumors was compared. results: in the detection of pancreatic lesions there was no statistically significant difference between both modalities (overall sensitivity % with thi and % with bm, specificity % with thi and % with bm). the differentiation between simple cystic, complicated cystic or solid tumors, is improved with thi. the visibility of the pancreas was not sufficient in % because of technical problems (eg. meteorism). in patients with adequate visualisation of the pancreas the pancreatic duct could not be sufficiently delineated in % with thi and % with bm. conclusions: image contrast and delineation of the pancreas as well as diagnostic accuracy are improved with thi in comparison to conventional sonography. characterization of focal liver lesions by pulse inversion harmonic imaging (pihi) with levovist in patients with cirrhosis b. forgács , e. quaia , m. bertolotto , l. crocè , l. dalla palma ; budapest/hu, trieste/it purpose: the aim of this study was to determine capabilities of pulse inversion harmonic imaging (pihi) with levovist in characterization of focal liver lesions in cirrhotic liver. methods and materials: liver focal lesions in consecutive cirrhotic patients identified by baseline ultrasound (us), were evaluated by color doppler (cd) and pihi. pihi was performed seconds (vascular phase) and - minutes (late phase) after levovist injection. helical ct (hct) (n = ) or surgical/bioptic histologic findings (n = ) were considered as reference procedures. results: lesions classified as hepatocellular carcinoma (hcc) by reference procedures appeared hypoechoic (n = ), isoechoic (n = ) or hyperechoic (n = ) on baseline us, with basket pattern (n = ), vessels within tumor (n = ), peripheral (n = ) or no vascular pattern (n = ) on cd. on pihi they appeared hyperechoic (n = ) or isoechoic (n = ) on vascular phase and prevalently hypoechoic (n = ) or isoechoic (n = ) and rarely hyperechoic (n = ) on late phase. four ( ) lesions classified as regenerative nodules by reference procedures appeared hypoechoic on baseline us, with peripheral (n = ) or no vascular pattern (n = ) on cd. on pihi they appeared hypoechoic (n = ) or isoechoic (n = ) on vascular phase, remaining prevalently hypoechoic (n = ) or isoechoic (n = ) on late phase. five ( ) lesions classified as hemangioma by reference procedures appeared hyperechoic (n = ) or hypoechoic (n = ) on baseline us with few flow signal on cd. on pihi they revealed progressive fill-in or dot-like enhancement during vascular and late phase. conclusions: pihi with levovist had identified some typical enhancement pattern in focal liver lesions in cirrhotic patients. conclusions: mri has low sensitivity to identify small lymph nodes. when visible, mri with sinerem has high sensitivity to identify metastatic lymph nodes; the overall low specificity was due to a learning curve in the first cases. when objective data are combined with subjective impression of the radiologist results are quite satisfactory. to assess the performance of ms- , a gd-based and albumin-bound contrast agent, for the differentiation of normal and tumor-bearing (vx ) lymph nodes of rabbits with interstitial mr lymphography. materials and methods: experiments were conducted on mature male white new zealand rabbits. fully anesthetized, the animals underwent mr examination twice: prior to and three weeks following implantation of vx -tumor cells to the left flank. for each session . ml of undiluted ms- was injected subcutaneously into both dorsal foot pads. d mr imaging was performed on a . t whole body scanner prior to as well as , , and minutes post injection of the compound. contrast medium uptake in the individual lymph nodes and the lymph node size were determined. finally all animals were euthanized and lymph nodes were analyzed by histopathology. results: interstitial mr lymphography with ms- visualized lymphatic structures as well as popliteal and inguinal lymph nodes in all animals. vx tumours were well differentiated from surrounding tissues in all rabbits. maximum enhancement values were present minutes following contrast medium injection in both normal and tumour-invaded lymph nodes. roi measurements in normal lymph nodes revealed statistically significant higher cnr values compared to tumourbearing lymph nodes. vastly reduced contrast medium uptake in tumour invaded lymph nodes permitted easy detection thereof. the size of normal and tumor-invaded nodes was not significantly different. in addition to providing a means for display of the normal lymphatic system, ms- -enhanced mr lymphography allows for depiction of direct tumour invasion in lymph nodes. interstitial mr lymphography in rabbits: assessment of inflammatory and normal lymph nodes by different gadolinium-based contrast agents (dota, p , p ) c.u. herborn, t.c. lauenstein, f.m. vogt, m. goyen, j.f. debatin, s.g. rühm; essen/de purpose: to assess three different gadolinium-based contrast medium compounds in order to distinguish normal from reactive inflammatory lymph nodes by interstitial mr lymphography in rabbits. materials and methods: experiments were conducted on , fully anesthetized mature white new zealand rabbits. in each set of three rabbits . ml of undiluted gd-dota, p , or p (guerbet, france) was injected subcutaneously into the dorsal foot pads. whereas gd-dota is an extracellular, commercially available contrast medium agent, the latter are new macromolecular compounds, undergoing pre-clinical testing. mr examinations were performed three times in each rabbit prior to as well as and days following induction of inflammatory lymph node reaction by the application of freund's complete adjuvant. imaging was performed on a . t mr system using conventional d sequences. contrast uptake in the individual lymph nodes as well as the lymph node sizes were determined. results: interstitial mr lymphography visualized popliteal and inguinal lymph nodes with all evaluated contrast agents. maximal enhancement occurred minutes after contrast medium injection for all three tested compounds. inflammatory lymph nodes revealed statistically significant higher cnr values compared to normal nodes (p < . ). average cnr values for the macromolecular contrast medium agents (p , p ) and the extracellular compound (gd-dota) were not statistically different. furthermore, the size of inflammatory and normal nodes was not significantly different. tuesday b a c d e f conclusion: all three contrast medium agents appear well suited for interstitial mr lymphography to visualize popliteal and inguinal lymph nodes in rabbits. determination of contrast medium uptake can aid in differentiating reactive inflammatory from normal lymph nodes. initial experience with mr-lymphography and employment of iron oxide contrast material for the detection of metastatic lymph node involvement in rectal cancer w. purpose: to evaluate mr-lymphography by employment of iron oxide contrast material (sinerem) in the preoperative evaluation of lymph node (ln) metastases of rectal cancer. method/materials: mr-lymphography of the pelvis was performed using plain and enhanced mr images after to hours after intravenous administration of superparamagnetic iron oxides at a dosage of . mg fe/kg b.w. conventional t and t -weighted spin-echo sequences as well as t -weighted gradient echo sequences were performed. a total of patients were examined. mri findings were correlated to histopathology in every case. results: a total of ln in patients were histopathologically evaluated and the findings correlated with mri. ln metastases were detected histopathologically. mri was able to detect of the metastatic ln. the size of the analysed ln was approx. mm in most of the cases. all malignant ln presented with a size between and mm. mri missed one ln metastasis with a size of mm. ln metastasis had a size between - mm, ln metastasis were - mm in size, and ln metastasis had a max. diameter of mm. conclusions: mr-lymphography with employment of the new iron oxide contrast material is a promissing imaging modality for the detection of ln metastasis. studies with a large study population need to further evaluate the potential of this imaging modality. optical imaging of lymph nodes -a new technique for lymphography p. wunderbaldinger , c. bremer , u. mahmood , l. josephson ; vienna/at, münster/de, charlestown, ma/us purpose: to validate the use of near infrared fluorescence imaging (nirf) using enzyme sensitive optical probes for lymph node detection. material and methods: an optical contrast probe that is activated by cystein proteases was used to visualize lymph nodes by nirf reflectance imaging. in order to quantitate the uptake of the optical probe in lymphatic tissue the biodistribution was assessed using the in labeled optical probe. sixteen balb-c mice were injected either intravenously (i.v., n = ) or subcutaneously (s.c., n = ) with the nirf-probe ( µmol gy/animal) and imaged hours after injection. signal intensities and target-to-background ratios of various lymph nodes were measured by manual regions of interest (rois). additional signal intensity measurements were performed of excised lymph nodes (n = ) from i.v. injected mice ( hours after injection) and compared to excised lymph nodes (n = ) of non-injected mice. the probe employed in this study was lymphotropic with about - % accumulation in lymph nodes ( . ± . %id/g). lymph nodes showed a high fluorescence signal throughout the body after i.v. injection ( ± . au) and/or regionally after s.c. injection ( ± . au). the signal intensities of lymph nodes was significantly higher after s.c. probe administration compared to iv administration (p < . ), as was the target-to-background ratio after s.c. administration ( . ± . vs . ± . ; p < . ). measurements of the excised lymph nodes (after i.v. injection) confirmed a significant increase in lymph node fluorescence signal ( ± . au vs. ± . au; p < . ). conclusion: detection and visualization of lymph nodes is feasible by nirf imaging using enzymatic activatable optical probes. ultrasmall superparamagnetic iron oxide particles (uspio) in magnetic resonance imaging (mri) of primary malignant lymphoma: are there changes in signal intensity of enlarged lymph nodes after contrast application? g. michna , j. kromeier , j. laubenberger , g. paul , m. langer ; freiburg/de, bonn/de purpose: the aim of this study was to assess the potential value of mri with uspio-particles (g - , sinerem®) for the nodal staging in primary malignant lymphoma. according to several studies normal tissue in liver, spleen, and lymph nodes shows an uptake of uspio particles due to phagocytic activity of res-cells. material and methods: ten patients with histologically proven untreated primary malignant lymphoma were studied. pre-and post contrast injections of sinerem® mr-scans were obtained from patients. the relative signal intensities of lymph nodes with a size of more than millimeters were measured. we compared (incl. sd) the delta of mean values of pre and post contrast signal intensities in t -w and t -w images. results: the diameter of lymph nodes ranges from mm to mm. in t -w images the delta of mean values of pre-and post contrast signal intensities varied between . and . . post contrast images showed no significant change in signal intensity. in t -w images the delta of mean values of pre-and post contrast signal intensities varied between . and . . there was no significant change in signal intensity in post contrast images. conclusion: there were no significant changes in signal intensity in post contrast t -w and t -w images in primary malignant lymphoma. this finding suggests that in these enlarged lymph nodes no active res-cells are present to phagocytise the uspio agent due to the malignant involvement. ionic and non-ionic iodinated contrast media induce neutrophil apoptosis through a caspase-dependent pathway n.f. fanning, b.j. manning, h.p. redmond, j.g. buckley; cork/ie purpose: iodinated contrast media (icm) can induce apoptosis (programmed cell death) in renal and myocardial cells. following intravascular injection, circulating immune cells are exposed to high concentrations of icm. as neutrophils constitutively undergo apoptosis, we hypothesised that icm may adversely affect neutrophil survival. our aim was, therefore, to investigate the effect of icm on neutrophil apoptosis. materials and methods: neutrophils were isolated from healthy subjects and cultured in vitro with ionic (diatrizoate and ioxaglate) and non-ionic (iohexol and iotrolan) icm. neutrophil apoptosis was quantified by annexin v flow cytometry, and caspase dependence determined using the caspase inhibitor zvad-fmk ( µmol). results: data presented as percentage apoptosis ± s.e.m. iso-iodine concentrations ( mg/ml) of ionic (diatrizoate . ± . ; ioxaglate . ± . ) and non-ionic (iohexol . ± . ; iotrolan . ± . ) icm significantly induced neutrophil apoptosis over control levels ( . ± . , n = ). ionic icm had a more significant (p < . ) apoptotic effect than non-ionic icm (p < . ). furthermore, icm reversed the anti-apoptotic effect of lipopolysaccharide ( ng/ml) treated neutrophils ( . ± . to . ± . ; n = ; p < . ). iohexol induction of apoptosis is caspase dependent as zvad-fmk reversed its pro-apoptotic effects to control levels ( . ± . to . ± . ; p < . ). these results clearly demonstrate that icm promote apoptosis in unactivated and activated neutrophils by a caspase-mediated mechanism. a recent report suggests that icm can increase the incidence of local and systemic septic complications in patients with mild acute pancreatitis (carmona-sanchez r.; arch surg, ; : - ) . icm, through induction of neutrophil apoptosis, could have significant deleterious effects on host immune defence and resolution of an inflammatory response. effect of intravenous injection of iopromide on regional renal blood flow and medullary oxygen tension in diabetic rats f. palm, p.-o. carlsson, p. hansell, a. fasching, o. hellberg, a. nygren, p. liss; uppsala/se purpose: hemodynamic disturbances with subsequent renal medullary ischemia have been suggested as key mechanism in the pathogenesis of contrast media (cm)-induced nephropathy. increased risk of cm-induced renal failure is seen during diabetes mellitus with nephropathy. the present study investigated the effect of an a c d e f injection of the cm iopromide ( mg i/kg) on regional renal blood flow (cortical and outer medulla) and oxygen tension (outer medulla) in streptozotozin induced four-or nine-week-diabetic wistar furth rats. material and methods: oxygen tension was measured with modified clark-type microelectrodes and blood flow with laser-doppler flow probes. results: administration of cm decreased the outer medullary oxygen tension in non-diabetic animals by ∼ %. this response was absent in diabetic animals. renal outer medullary blood flow of non-diabetic animals increased after cmadministration and remained elevated (∼ %). in contrast, no change in outer medullary blood flow occurred in the diabetic animals. glucose infused non-diabetic animals responded similarly in medullary oxygen tension to normoglycemic animals, but similarly to diabetic animals in medullary blood flow, following cminjection. conclusion: we conclude that diabetic animals have an altered response in renal outer medullary blood flow and oxygen tension to cm compared to normoglycemic animals. however, in contrast to corresponding control rats, outer medullary oxygen tension did not decrease in diabetic animals, which suggests other mechanisms than hemodynamic changes to explain the increased renal failure frequency in this risk group for cm-induced nephropathy. doppler intensitometry: quantitative comparison of two ultrasound contrast agents in humans j.-m. correas , v. dhalluin-venier , l. bridal , p. burns , o. hélénon ; paris/fr, toronto, on/ca purpose: to quantify the doppler signal enhancement following the injection of two different ultrasound contrast agents (uscas) in humans, levovist® (schering sa, germany) and optison® (fso , mallinckrodt, usa). materials: patients received bolus injection of optison® ( , , , and ml, randomized dose) and injection of levovist® ( . g, ml, mg/ml). the continuous doppler signals from the radial artery were digitized to calculate mean duration of the enhancement, peak enhancement and area under the time-intensity curve (auc). in patients, the doppler signals could not be analyzed due to wrist movement artifacts. results: the duration of the enhancement was respectively (mean ± standard deviation) ± s for the levovist® and ± , ± , ± and ± s for each dose of optison® ( , , , and ml). peak enhancement was respectively . ± . db for the levovist® and . ± . , . ± . , . ± . and . ± . db for each dose of optison®. auc was respectively (linear units) for the levovist® and , , and for each dose of optison®. a linear relationship was found between the dose of optison® and the enhancement (r > . ). levovist® enhancement exhibited a larger variability between patients. purpose: this study was designed to validate the reliability of the ao comprehensive classification using routine radiographs to predict the intra-operative findings. a second goal of this study was to assess interobserver variability of this classification. the radiographs or computed radiographs (cr) of the thoracic and lumbar spines of patients ( male, female) from jan to march , were reviewed retrospectively by four separate observers, two experienced staff and two residents without knowledge of the operative findings. each fracture was categorized according to the ao comprehensive spinal fracture classification into type a, type b or type c injuries based on agreed well defined radio-logic criteria. this was compared to the intra-operative findings which assessed the integrity of the posterior ligament complex and mobility of the injured segments. the concordance of the radiologic classification and the intra-operative findings was % ( / ) for orthopedic spine surgeon, % ( / ) for orthopedic resident, % ( / ) for skeletal radiology staff, and % ( / ) for radiology resident. the mean correct designation of the fracture classification was . %. there were % ( / ) of fractures categorized as type a injuries by % or more of the observers which proved to be type b injuries at surgery. conclusion: the use of plain films or cr to categorize fractures of the thoracolumbar spine according to the ao classification was associated with a designation of % of unstable b injuries as stable type a injuries. there is moderate interobserver variability. with suspected spine injury were evaluated using rx and spiral ct performed in admitting area. all patients received standard thoracic ct ( mm/pitch . ) and abdominal ct ( mm/pitch . ) according to an established trauma protocol including sagittal mpr reconstructions of suspicious vertebral bodies. rx and ct were independently evaluated by two blinded radiologists for detectability of fracture signs and classified in three groups (g -g ): definitely fractured (g ); non conclusive result (g ); definitely no fracture (g ). all suspected fractures were confirmed by an additional high resolution ct ( mm - mm/pitch . ) and clinical follow up. results: in patients ( %) of the patients a spine fracture could be depicted. fractures were missed in rx, none in ct. % of the ct reports and % of the rx reports were classified correctly true positive (g ) or true negative (g ). . % of rx-reports were non conclusive (g ), but only % in ct. in comparison ct versus rx sensitivity was / . , specificity . / . , positive predictive value . / . and negative predictive value / . conclusion: using an established standard ct protocol for chest and abdomen examination with slice thickness of mm and mm respectively all relevant spine fractures can be detected. these results suggest that rx of thoracic and lumbar spine is not mandatory in the admitting area, when thoracic and abdominal ct is performed. correlation between ct and clinical findings in patients with spine injuries -analysis of cases t. turek, m. sasiadek; wroclaw/pl purpose: to analyze the correlation between ct appearances of spine injuries and clinical findings and thus to establish the clinical significance of the finding at ct. methods and materials: ct studies have been performed in patients after spine injury. in most of them plain films of the spine were performed prior to ct. patients had also mr. head ct was performed in cases and chest ct in patients. ct findings (the presence of fractures and facet joints injuries, number of involved vertebrae and spinal columns, narrowing of spinal canal, instability features, intervertebral disc lesions, normal study, etc.) have been compared statistically with clinical symptoms (pain, spinal medulla injury, radicular symptoms, disturbance of consciousness, etc.). results: there was statistically significant correlation found between clinical signs of spinal medulla injury and several ct symptoms (instability, spinal canal narrowing, number of affected vertebrae and columns, facet joint lesions). in patients with pain and no severe neurological signs there was positive correlation with a normal ct study. radicular symptoms have been associated with intervertebral disc lesions and in chronic cases with degenerative changes of the spine. consciousness disturbances have been negatively correlated with spine fractures, while positively with normal ct appearance of the spine and traumatic changes on head ct. conclusion: ct symptoms of spine injury are highly correlated with severity of the clinical and neurological findings, except for consciousness disturbances which are associated with simultaneous head injury. thus, ct is very helpful in establishing prognosis and treatment planning. the purpose of this study is to evaluate the efficiency and safety of self-expandable stent insertion in patients with acute colonic malignant obstruction before elective surgical resection. between march and march , patients ( males and females, mean age , range - ) were included. all the patients were scored asa iii. colonic cancers were located between the rectosigmoid and the middle part of the descending colon. all patients had plain abdominal radiography and ct scan to demonstrate the complete obstruction of the colon and to localise the stenosis. immediate technical success was obtained in of patients ( %). the mean time between stent insertion and surgery was days ( to ). in cases ( %), stents were misplaced and did not covered the lesion which required the insertion of an other stent. in ( %)other cases, the stent was initially well positioned but migrated secondarily which required the insertion of a second stent in one and a surgery in a other one. colonic perforation occurred in ( %) patients. these patients underwent surgery, one of them developed an abscess which required percutaneous drainage under radiological guidance, other ( %) patients underwent ileostomia because of a missprepared colon by stent dysfunction (obstruction). there was no more morbidity ( %) and no death ( %) at the moment. self-expandable stent insertion is an efficient minimally invasive procedure that allows for single-stage surgery. however, this technique is quite difficult to perform and may be associated with some complications. sites of obstruction were antro-duodenum (n = ), postoperative anastomotic site (n = ; gastroenterostomy, six esophagojejunostomy, and one duodenojejunostomy). all stents were covered with polyurethane. the size of the stent ranged from - mm in diameter and - cm in length. with fluoroscopic guidance, covered self-expandable metallic stents were placed. results: stent placement was technically successful in all patients without or with the gastrostomy (n = ) and balloon dilatation (n = ). after stent placement, symptoms improved in all but one patient, who had another stenosis at the proximal jejunum. during the follow-up of - (mean ) weeks, stent migration occurred in four patients ( . %) - days after the procedure. those patients were treated successfully by means of placing a second covered metallic stent (n = ) or endoscopic reposition (n = ). recurred obstructive symptoms due to tumor overgrowth (n = ) and mechanical failure of stent (n = ) were noted. one of tumor overgrowth and both of the mechanical failure of stent were treated by means of coaxial placement of a second covered stent with good clinical result. conclusion: fluoroscopy-guided placement of covered self-expandable metallic stents can be considered as the primary choice for the palliation of malignant obstructions in those patients. the laparoscopically placed adjustable gastric band (lap-band™) has been popularised as a minimally invasive, adjustable and completely reversible surgical technique for the management of morbid obesity. we report our experience with particular emphasis on the radiological aspects of follow-up and patient results in terms of short-term weight loss and complications. methods: between may and december patients were treated ( male/ female) with a mean age of years (range - years). the technique of fluoroscopy guided band inflation is illustrated with particular emphasis on radiological lessons learned. a new method of measurement of pouch volume and the passage within the band is described. results: mean number of radiology-guided inflations per patient was . (range - ). the volume used for inflation was noted to be critical, with . ml making the difference between complete obstruction and optimal band inflation. the mean hospital stay was . days (range - days). % had gastric pouch formation and % had nonfatal pulmonary embolism. there was no mortality. the follow-up was up to months. the mean bmi decreased from the pre-operative level of kg/m (range - kg/m ) to . kg/m . the lap band is an effective procedure in the treatment of morbid obesity. initial weight loss is comparable with other open bariatric procedures but with the added benefit of a shorter hospital stay, less pain and a low frequency of complications. fluoroscopy guidance is useful in puncturing the subcutaneous valve and mandatory in assessing optimal band inflation. radiological percutaneous gastrostomy with ballon retained catheters in malignant upper digestive tract obstruction h.-p. dinkel, j. triller; berne/ch purpose: to assess success and feasibility of radiological percutaneous gastrostomy in malignant pharyngeal or esophageal obstruction where endoscopic passage was impossible. methods: we report a prospective series of consecutive patients with esophageal and/or head and neck tumors who required artificial enteral feeding by means of gastrostomy. in all patients endoscopic passage was not possible or extremely difficult. in order to avoid surgical gastrostomy we performed a radiological gastrostomy using the following technique. first, the stomach was punctured under fluoroscopic guidance and gastropexy using - cope-type t-fasteners was performed. then a balloon-type gastrostomy catheter was inserted using a peel-away sheath. results: pg was technically successful in all cases. the gastrostomy remained for to weeks. complications occurred in % ( minor, major). one patient developed a peristomal leakage due to bowel atony and incomplete voiding of the stomach managed by insertion of a jejunal nutrition catheter through the gastrostomy tract whereafter the leakage subsided an the gastrostomy tract healed. one patient had minor suture infection and delayed gastric voiding. in one patient the early catheter dislocation and peritonitis occurred due to erroneous food injection into the balloon port. conclusion: radiological gastrostomy by means of ballon-retained catheters is a feasible and relative safe procedure. most complications can be managed conservatively or interventionally. care should be taken to avoid erroneous injection into the balloon port, especially within the first week of pg in order to avoid tube dislocation. to compare the diagnostic accuracies of sonography, scintigraphy in diagnosing ileocecal crohn's disease (cd) and assessing its activity compared to enteroclysis and final diagnosis. method: a retrospective analysis of the studies of patients ( females, males, ages of - ) with verified cd (operation: , biopsy: cases). located to the ileocecal region was made. all patients had enteroclysis, sonography ( - mhz receiving frequency with native tissue harmonic imaging, and measurement of the flow in the superior mesenteric artery (sma)) and of them had tc agab immunoscintigraphy with spect. the results were compared. results: overall sensitivity of enteroclysis, sonography and immunoscintigraphy was %, % and %. in early crohn disease ( cases) the sensitivities were %, % and % respectively. in detecting active disease (determined by the presence of ulcerations or fistulas in enteroclysis) immunoscintigraphy had % sensitivity, % specificity. increased sma flow had % sensitivity; % specificity, while wall thickening (> mm) had % sensitivity; % specificity. using a combined sonographic criteria (presence of destroyed wall stratification or detection of fistulas or abscesses or increased sma flow) % sensitivity and % specificity is obtained. surgical indications (fistulas or abscesses) were detected in / cases by both enteroclysis and sonography. conclusion: although the sensitivity of sonography in early cd is not sufficient for detecting suspected cd, for follow up in advanced cases sonography could replace enteroclysis. new combined sonographic criteria gives excellent correlation with enteroclysis detected activity. sensitivity for detecting abscesses might compensate for missed fistulas. crohn disease: evaluation of small and large bowel with combined ct enteroclysis and ct colonography a. cieszanowski, k. wojciechowski, r. pacho, b. pruszynski; warsaw/pl purpose: to evaluate the new method -combined ct enteroclysis and ct colonography -for the assessment of whole bowel in patients with crohn's disease. method and materials: patients suspected of having crohn's disease underwent ct colonography after i.v contrast material injection. in of them ml of fluid was administered by nasoenteric tube positioned in the duodenojejunal region (ct enteroclysis) and in another patients water was given orally ( - ml), beginning - minutes before the examination. intestinal and extraintestinal abnormalities were evaluated. small bowel distention was assessed in grade scale (good = , poor = ). results were compared to enteroclysis, colonoscopy and intraoperative findings. results: in patients with confirmed crohn's disease ct correctly identified all involved small bowel (n = ) and colonic (n = ) segments, although underestimated their length in cases ( %). mesenteric involvement was seen in of patients with crohn's disease ( %), lymphadenopathy in ( %), perianal disease in ( %), abscess and fistula in patient ( %). the distention of small bowel was significantly better on ct enteroclysis (mean score . ) than on ct performed after oral fluid administration (mean score . ). conclusion: both techniques enabled simultaneous evaluation of small and large bowel during single examination and allowed identification of all involved bowel segments, although, visualization of small bowel was significantly better with the use of ct enteroclysis than after oral administration of fluid. material and methods: patients affected by cd were examinated at . t, using fat and non fat-suppressed t w haste sequences after administration of a negative superparamagnetic oral contrast agent and t w flash sequences, pre and post gd-dtpa injection. all patients underwent endoscopy, us, barium studies (gold standard), had surgery. all mri data were blindly evaluated by two radiologists. the degree of strictures, the presence of small bowel dilation, adhesions, sinus tracts, fistulas, abscesses, biliary, pancreatic and renal abnormalities were evaluated. results: mri correctly detected % of strictures ( / ), % of adhesions ( ), % of fistulas ( / ), % of abscesses ( ), hydronephrosis ( ), biliary, renal and pancreatic stones ( ). in / patients ( %) mri showed complications undetected by the gold-standard modalities. conclusions: mri is a promising method to assess main complications of cd. differentiation of inflammatory bowel diseases by hydro-mri k. schunk, s. reiter, a. kern, s. schadmand-fischer, t. orth; mainz/de purpose: to assess hydro-mri regarding the differentiation of inflammatory bowel diseases. after an oral bowel opacification using ml of a . % mannitol solution and a rectal bowel opacification using - ml of an . % saline solution, axial and coronal breath hold sequences ± gd-dtpa (haste ("half-fourier acquisition single-shot turbospinecho") and dynamic flash ("fast low angle shot")) were acquired in patients with inflammatory bowel disease. by mri findings, crohn's disease (cd; n = ) and ulcerative colitis (uc; n = ) should be differentiated. results: cd and uc showed significant differences regarding the number of affected bowel segments ( . ± . vs. . ± . ; p = . ), the incidence of nodular bowel wall thickening ( / vs. / ; p = . ), and the incidence of a blurred demarcation of the inflamed bowel wall against the surrounding mesenterial fat tissue ( / vs. / ); p = . ). there were no significant differences regarding the contrast enhancement of the inflamed bowel wall (+ . ± . % vs. results: before treatment unenhanced pd showed circumscribed hypervascularity of affected bowel loops, consistent with acute disease relapse, in / patients ( . %); in patients the typical acute stage hypervascularity was demonstrated only with ce-pd (p < . ). in seven patients with complete clinical recovery no residual enhancement of the affected loop was found at post-treatment follow-up by either unenhanced or ce-pd. of the patients with clinical persistence of acute disease, ( . %) showed typical hypervascularity on conventional unenhanced pd, ( . %) had hypervascularity documented only on ce-pd (p < . ) and ( . %)had no enhancement detected even after contrast administration. ce-pd had higher sensitivity ( . %) compared to conventional pd and % specificity. purpose: to assess feasibility, safety, and effectiveness of percutaneous imageguided radio-frequency (rf) thermal ablation of the lung. the research project includes an experimental animal study and two clinical phases. in the animal study, rabbits will undergo in vivo rf ablation of lung tissue. rabbits will be sacrificed and histologic analysis of the specimens will be performed to assess cell viability. the clinical part of the project includes two phases: ( ) patients with resectable cancerous nodules will undergo ct-guided rf ablation and subsequent pulmonary resection and pathology examination of surgical specimens; ( ) patients with unresectable lung tumors will undergo ct-guided rf treatment; in these cases the outcome of rf ablation will be assessed by follow-up ct studies performed month after the procedure a c d e f and at -month intervals thereafter. rf ablations are performed by using a w generator (rita medical systems) and a gauge, hook expandable electrodeneedle. results: to date, new zealand white rabbits underwent in vivo fluoroscopyguided rf of lung tissue. two rabbits were sacrificed immediately, one after hours, two after days, two after weeks, and one after month. on gross examination, round, sharply demarcated thermal lesions measuring . ± . mm in diameter were observed in all cases. histopatology analyses confirmed coagulation necrosis with no intervening viable cell. conclusion: findings of the animal study showed that rf ablation of pulmonary rabbit parenchima can be safely and effectively performed via a percutaneous, transthoracic approach, thus prompting the start of clinical studies. b- : -component fibrin clue injection for needle tract obliteration during ctguided percutaneous cutting biopsy of lung lesions m.c. freund , c. riedl-huter , k.m. unsinn , m. hackl , t. schmid , w.r. jaschke ; innsbruck/at, natters/at purpose: pneumothorax is the most common complication of percutaneous lung biopsy. in order to reduce the incidence for pneumothorax a commercially available -component fibrin glue (tissucol® duo quick) was injected in the puncture tract during the withdrawal of the coaxial sheath at the end of the examination. methods and materials: in total consecutive adult patients underwent ctguided percutaneous biopsy for histological evaluation of an intrapulmonary lesion utilizing a - g coaxial cutting biopsy system. all lesions were surrounded by aerated lung parenchyma and were located within . - . cm distance (mean, . cm) from the pleural surface. lesion size measured . - . cm (mean, . cm), in total - biopsy passes per lesion (mean, . ) were performed, and in / patients a perilesional hemorrhage . - . cm diameter (mean, . cm) was observed. patients were assigned to undergo biopsy either without (group i) or with (group ii) the use of a -component fibrin glue. all patients were observed after biopsy; after - hours a spiral-ct of the thorax and after approximately hours a chest radiography was performed for pneumothorax detection. the rate of ct-proven pneumothorax resp. for chest tube insertion in group i was % resp. % and in group ii % resp. %. conclusion: the injection of a -component fibrin glue in the puncture tract during withdrawal of the coaxial sheath significantly reduces the incidence for pneumothorax as well as the rate for chest tube insertion. parietal extrapleural saline for the reduction of pneumothorax in percutaneous lung biopsies (plb) t. petsas, i. tsota, c.p. kalogeropoulou, m. karamesini, n. samaras, d. dougenis, i. dimopoulos; patras/gr purpose: in this study we evaluate the efficacy of extrapleural injection of normal saline at the initial procedural phase of percutaneous lung biopsy in order to prevent pneumothorax. methods: patients underwent plb under ct guidance, for diagnosis of lung lesions. the patients were randomized in either group a or b. in patients (group a) normal saline was injected beneath the parietal pleura just before the procedure. in the remaining patients (group b) no saline was used. all biopsies were conducted under ct using a g - g coaxial needle system. in group a, after local anesthetic infusion, the needle was advanced in the subpleural fat and - ml of saline were injected extrapleurally, in order to create a bulge of pleura into the lung parenchyma, adjacent to the lesion. all patients had ct scan min after, and plain chest radiogram after hours after the procedure in order to evaluate the presence of pneumothorax. results: the procedure was well tolerated in group a. pneumothorax developed in patients ( . %) in group a. in group b, pneumothorax occured in patients ( . %) and in one instance drainage was required ( . %). the technique prolonged the duration of the procedure - min in group a. conclusion: our results suggest that extrapleural injection of saline reduces plb induced pneumothorax. it is a supplementary technique, which can be used in patients who are prone to develop pneumothorax. application of a new specially designed guide stylet set in chest biopsies t. petsas, c.p. kalogeropoulou, i. tsota, d. karnabatidis, p. angele, d. siablis, i. demitrios; patras/gr purpose: we evaluate the efficacy of a specially designed guide-stylet for percutaneous chest procedures. in patients, who underwent percutaneous procedures (lung biopsies n = , mediastinal n = , spinal and rib lesions n = ), a new specially designed guide stylet set was used. the set is composed of a guide stylet and a chiba needle. the guide stylet is made of stainless steel with a diameter of . mm (william cook europe a/s, bjaeverskov, denmark) the g chiba needle is initially introduced in the thoracic wall and the guide stylet is advanced through the needle towards the lesion. when the stylet has been correctly directed, the needle is also advanced towards the same direction. the stylet serves either as a guide for the biopsy needle, or as an exchange wire in cases where a larger (core or tru-cut) needle is required for adequate sampling. the stylet can be curved before its insertion inside the g needle in order to reach lesions which require redirection of the needle. for this purpose a torque device is used to point to the direction of the curved stylet results: the technique was easy to perform in all cases. five patients with lung biopsies developed pneumothorax ( . %). the stylet was advanced beyond the lesion in cases, without clinical consequences and without this affecting the biopsy outcome. conclusions: our results suggest that the guide-stylet is a useful tool for percutaneous procedures, especially biopsies, in cases were the lesions to be reached, are difficult in approach. new technique for ct guided lung biopsy k. ishii , y. wada , j. kanekawa , t. takahashi ; moriya/jp, ibaraki/jp purpose: we establish both new device and a biopsy method to localize lesions in term of three-dimensions by ct in order to perform the biopsy of small nodular lesions in the lung field confidently, safely, and rapidly. material and method: we carried out ct guided lung biopsy in cases of nodular lesions more than mm in diameter. none of them contained calcifications. we simulated a targeting line by using a new device for ct guidance, "targ" developed by us. we then confirmed the right track of the guiding needle. the biopsy needle that we used was "pro-mag". the average time needed to complete the procedure was fifteen minutes. results: ten lesions were primary lung cancer. one of them was ground glass opacity lesion measuring mm in diameter. this is what we call carcinoma of type a classified by noguchi. one case was lung metastasis from colon cancer ( mm in diameter). conclusion: this technique enables us to obtain enough material by pinpointing and shooting peripheral lung lesions approximately mm in diameter. we strongly believe that this technique contributes significantly to the progress of lung cancer treatment. ct guided percutaneous fine needle biopsy of small (≤ mm) lung lesions in outpatients: safety and efficacy of the procedure compared to inpatients m. romano, m. gentile, m. midulla, m. salvatore; naples/it objective: compare safety and efficacy of ct guided fine needle biopsy (fnab) of small (≤ mm) lung lesions in inpatients and outpatients. materials and methods: consecutive inpatients ( m, f, mean age ) and consecutive outpatients ( m, f, mean age ) who underwent ct guided fnab of small lung lesions at our institution from may to july were included. lesion size, thickness of aerated lung traversed, number of needle passes, presence of emphysema were recorded for the two patient groups. g chiba needles and the roll-over technique ( hour) were used for all patients; in the absence of significant pneumothorax at a subsequent expiratory chest roentgenogram, outpatients were allowed to go home and instructed to return in case of dyspnea or unusual symptoms. incidence of pneumothorax and other complications, need for tube insertion and percentage of diagnostic samples were noted for both groups. results: no statistical differences were observed in lesion size, thickness of aerated lung traversed, needle passes, presence of emphysema between the groups. we had pneumothoraces in inpatients, two requiring a small caliber chest tube, and in outpatients, all within hour from the procedure, none requiring a tube. citology diagnosed a malignant lung neoplasm in outpatients and inpatients, absence of malignant cells in and ; the sample was inadequate in and respectively. all differences are nonsignificant. conclusion: ct guided fnab of small lung lesions in outpatients is a safe and reliable procedure, allowing significant decrease in hospitalization costs. tuesday b a c d e f nant, % adh. the highest rate of malignancy was seen in indication c ( %) > a ( %) > b ( %) > e ( %) > d ( %). in the % benign cases mrvb was able to avoid diagnostic surgery. conclusion: mrvb is a reliable tool, which allows to solve problems of mr-detected lesions. good training is a prerequisite. radiological or surgical port device implantation: a -year institutional analysis of procedure performance, quality of life and cost for breast cancer iv chemotherapy p.y.r. marcy sr. , c. bailet , n. magne , j.c. machiavello , j.c. gallard ; nice/fr, caen/fr purpose: to evaluate the safety, efficacy, quality of life and cost of percutaneous radiologic arm port (pap) and surgical subclavian port (ssp) devices. this study involved a retrospective review of port device implantation procedures ( pap, ssp) performed over a -year period, in breast cancer patients. parameters analyzed included technical success, procedure duration, complications, analysis of the quality of life and cost evaluation for both techniques. the success rate for port implantation was higher for pap than for ssp ( % versus %). pap was subsequently performed in of ten patients in whom ssp procedure had failed; and ssp in of the three pap failure cases. ssp and pap were performed without conscious sedation (i.e., local anesthesia only). mean implant duration time was / days, the overall complication rate (r/s) was % versus % ( . - . / patient-days). mean implant duration time (r vs s), without any complication or death, was d vs d. median number of chemotherapy courses was (r = s). %, and % respectively of the devices had to be removed prematurely. complication rate was % and %. febrile neutropenia cases occurred in % of each file, without occurrence of any port infection. direct costs (r/s) were respectively . vs . • . conclusion: advantages of r over s include higher success rates, shorter procedure duration, higher cosmetic result despite a % relative overcost for r placement. to study functional recovery after surgical damage to the supplementary motor area (sma). patients and methods: patients were studied before and after resection of a medial frontal tumor, and compared to healthy subjects. all of the patient group presented with an sma syndrome. fmri examinations ( . t) included functional axial eg-epi and anatomical images. tasks consisted of flexion/extension of the fingers and a complex digital sequence of both hands. data analysis was performed using spm software. results: in control subjects and in patients during movements of the hand ipsilateral to the tumor, activation was present in the contralateral hemisphere in the primary sensorimotor cortex, postsma, and both secondary sensory cortex. during complex movements, additional activation was present in the contralateral presma, anterior cingulum, ipsilateral primary sensory cortex, lateral premotor area, and both parietal lobules. before surgery, activation patterns were similar. however, during simple movements contralateral to the tumor, additional activation was present in the ipsilateral postsma and lateral premotor area. during complex movements, activation was also present in the ipsilateral presma and anterior cingulum. after resection of the sma, the presma and the anterior cingulum of the healthy hemisphere were also activated during simple movements. during complex movements, activation in the ipsilateral presma and lateral premotor area was stronger. these results suggest that there is a dysfunction of the sma ipsilateral to the tumor before surgery, and that the sma, anterior cingulum, and lateral premotor area in the healthy hemisphere are involved in the functional recovery following surgery. purpose: first experiences in comparing different methods for localization of brain function in the setting of neuronavigated guided surgery. maximum accuracy by using the same mri- d-dataset for fmri and neuronavigation. material and methods: patients suffering from intracerebral tumours in the central region performed a finger-tapping task of the contralateral hand in fmri. activated areas were superimposed on a d-ge-mri dataset including the surface fiducials for neuronavigated surgery. the coordinates of the voxel with highest statistical threshold was determined and compared with the coordinates of maximal response using intraoperative monopolar cortical stimulation. results: in all patients central sulcus and postcentral gyrus were identified by fmri. in patients intraoperative stimulation was not possible. in patients coordinates of maximum activation differed by mm mean euclidean distance (stdev. mm, range to mm). the distance was mainly dependent on the different approach of cortical stimulation to the surface of the brain and fmri activation in the depths of central sulcus (hand motor area). larger distances were due to a distorted morphology of central area from invading tumour. there was no influence of tumour histology, had motion during the fmri experiment or hemiparesis. conclusion: in the setting of neuronavigated guided surgery and intraoperative monitoring, fmri may help to guide the placement of a cortical electrode on the surface of the brain. maximum stimulation or activation points differ due to the approach, especially if morphology of the central area is distorded by tumour. this has to be considered in preoperative planning. d mr reconstruccion for neurosurgical planning f. matute, a. saiz ayala, j. arrazola garcía, j. jimenez del rio, c. saldaña; madrid/es purpose: we used three-dimensional reconstructed magnetic resonance images for planning the operations of patients with intraxial brain tumors and vascular malformations. we studied the cases of these patients to determine the advantages and current limitations of our computer assisted surgical planning technique as it applies to the treatment of neurosurgical cases. we assessed the cortical surface-anatomy combining with vascular images using a single volumetric acquisition scanning technique from d spgr. in collaboration with neurosurgeons, we obtained tangential and oblique views, that simulates as properly as possible, the real surgical field. this technique, allow us not only to localize the lesion and define the tumor margins but to identify the superficial cortical veins related to the tumor. this multiplanar superficial venography will be used as a road map by the neurosurgeons at the moment of the craniotomy. in addition, a introperative electrical stimulation mapping was performed to assesses eloquent cortices. results: in each case neurosurgeons could easily reach the lesion with minimum risk because the combination of our multiplanar reconstruction model and intraoperative electrical mapping. conclusion: our technique is a easy and useful way of proper determining brain surface and venous anatomy over the tumor. this technique can be used to choose the best method of intervention, to minimize the surgical risk and to select the best surgical approach. intraoperative mri in a stereotactical operation unit: report on the first two cases v. hesselmann, r. girnus, u. von smekal, m. hoevels, b. krug, v. sturm, k. lackner; cologne/de purpose: to introduce practical issues for interventional procedures controlled by mri (gyroscan intera, philips, best, the netherlands) in a stereotactical operation unit. we report on a mri-controlled stereotactically guided catheter implantation for interstitial irradiation with iodine seeds (case ) in a patient with glioblastoma and the implantation of electrodes for deep brain stimulation (medtronics, minneapolis, usa) in a patient with parkinson's disease (case a c d e f ). patients were placed on a mri-compatible operation table and fixed in a mricompatible stereotactic head frame (mrc-systems, heidelberg, germany). trajectory and target planning had been done prior to the intervention with a computerized stereotactic treatment planning system (fischer leibinger freiburg, frg). anatomical (t -tse, t -se), real-time mri and functional imaging (fmri) using a fingertapping paradigm was performed in both cases. in case fmri was performed after placement of the head frame for localizing the motor hand area. in case fmri was performed during deep brain stimulation of the subthalamic nucleus. results: in case the trajectory for the catheter with i seed was remodeled after fmri. performance on fmri for monitoring the effect of deep brain stimulation was poor in case , as the localizer of the stereotactical system caused severe distortions of epi-images. monitoring the placement of deep brain electrodes could easily be controlled mri with t -weighted spin echo sequences. conclusion: intraoperative mri revealed decisive information during operation procedures such as brain shift, fmri and placement of catheters and electrodes. for fmri metallic materials are to be removed out of the scanner. neurovascular compression of the rostral medulla as a cause of essential hypertension? prospective mr study in hypertensive and normotensive subjects j. zizka , j. ceral , p. elias , l. klzo , m. solar , j. tintera ; hradec kralove/cz, prague/cz purpose: several experimental studies assigned vascular compression of the left rostral ventrolateral medulla (lrvm) as a possible cause of essential hypertension. published data concerning the mr imaging of the neurovascular compression of the medulla oblongata widely differ, particularly due to methodological incongruities. the aim of the study is to conduct a blinded prospective mr study of normotensive and hypertensive individuals. methods and materials: we examined patients with severe essential hypertension (mean age ± years) and normotensive subjects (mean age ± years). mr imaging protocol consisted of transverse and coronal t tse (slice thickness mm), transverse d tof mra ( . mm) and d ciss ( mm) sequences. the presence and degree of vascular compression at the lower brain stem and particularly at the lrvm were evaluated together with the conspicuity of the anatomical structures on different mr imaging sequences. results: among hypertensive patients, ( %) showed neurovascular contact of the medulla at any location and ( %) at the lrvm. in the control group of normotensive subjects, ( %) showed neurovascular contact of the medulla and ( %) of the lrvm. compared to t tse and d tof imaging sequences, d ciss offered better contrast resolution of neural and vascular structures and superior delineation of the outer vascular contours. conclusion: neurovascular compression of medulla oblongata is a frequent finding in both hypertensive and normotensive subjects. our results do not support the hypothesis of neurovascular compression at the lrvm as an etiological factor of essential hypertension. volume estimation of the fornix in patients with organic amnesias using co-axial mr images q.y. gong , d. montaldi , a.r. mayes , j. aggleton , j.r. hanley , d. scutt , n. roberts ; liverpool/gb, cardiff/gb, essex/gb purpose: the fornix is the principal tract that links the hippocampus with the midline diencephalon. the relative contribution of the fornix in human memory is debated and a reliable method is required for estimating the extent of fornix damage in patients with anterograde amnesias. this study aims to develop an efficient and unbiased approach for estimating the fornix volume on d mr images. subjects and methods: healthy subjects and four patients with organic amnesia (one or other of the fornices were severed) were recruited. mr examinations were performed using a . t signa (general electric, milwaukee), and t weighted images were obtained using a d spgr pulse sequence (tr/te / ms, flip angle °, slice thickness . mm). image analysis was performed using analyze tm (mayo foundation, rochester) and mri dx (http://www.liv.ac.uk/mariarc/mri dx). analysis algorithm using reformatted co-axial mr images was developed based on the pappus method of modern design stereology. results: the measurement reliability for fornix volume were obtained (cv = . %; r = . ). fornix volume in controls obtained was . ± . ml on the right and . ± . ml on the left. in three of four patients with radiological evidence of severance of either the left and/or right fornix, significant atrophy of the ipsilateral fornix was demonstrated, and ranged between . % and . %. the developed technique provides an efficient and mathematically unbiased approach for estimating the fornix volume on co-axial sections, and can be applied to assess the extent of fornix atrophy in patients with organic amnesia. voxel based morphometry in narcolepsy s.c.a. steens , s. overeem , c.d. good , g.j. lammers , m.a. van buchem ; leiden/nl, london/gb purpose: recently, a close association between narcolepsy and hla-dqb * was found and linked to loss of hypocretin production by hypothalamic neurons, as suggested by lack of csf-hypocretin- levels. the aim of this study was to assess potential (autoimmune-based) hypothalamic degeneration using voxel-based morphometry. methods/materials: narcoleptics and age-and sex-matched controls were included. all patients were hla-dqb * -positive, had typical findings during polysomnographic and multiple sleep latency testing, and had no csf-hypocretin- . to optimize gray-white matter contrast, we used a d-t gradient-echo sequence with tr/te / ms, flip-angle °, × matrix, slices of . mm and fov mm. vbm was used for brain extraction, spatial linear and non-linear normalization, segmentation and smoothing. univariate analyses for gray and white matter were performed with statistical parametric mapping, employing the general linear model. regionally specific increases or decreases in gray or white matter between groups were assessed, with age, sex and global mean voxel values as confounders (p < . , corrected for whole brain volume). because of our strong prior hypothesis for structural change in the hypothalamic region, we also assessed uncorrected data with a small volume correction for the hypothalamus (p < . ). results: no significant regional differences in gray and white matter could be detected between narcoleptics and controls, even with reduced thresholds and small volume corrections for the hypothalamus. conclusion: no evidence is found for structural changes in the hypothalamic region. either the hypothalamic changes are too subtle to be detected using vbm, or the hypocretin neurons remain intact but are not able to synthesize hypocretin. evaluation of requests for mri performed during weeks in stockholm, sweden b. isberg, o. flodmark, l. zachrisson, h. jorulf, y. palmquist; stockholm/se over the last years the use of mri as a diagnostic tool has increased as the method has been recognised as the most efficient way to investigate a variety of clinical conditions. in stockholm the use of mri has rapidly increased to a level of today mr examinations per inhabitants and year. a study was undertaken as an attempt to answer the question whether or not the indications for the mr study, were considered appropriate or not. method: all requests for mri studies performed during two weeks in the county of stockholm were collected and reviewed. material: the information on each request form was evaluated by one of four experts. two experts were clinicians two were radiologists. these experts were asked to evaluate whether the indications for study were considered appropriate or not. results: in the total material % of the studies were thought to be indicated, % probably indicated, % were thought probably not to be indicated, while % were clearly not indicated. in another %, the material was inadequate and the indication was not possible to evaluate. there were clear differences between different groups of referring physicians in their pattern of using mri as a diagnostic tool. as an example, specialists in hospital practice had the highest proportion of indicated requests. the results of this study strongly supports the need for ongoing education and precise guidelines in the proper utilisation of mri as a diagnostic tool. standardized virtual endoscopic approach to the intracisternal course of the cranial nerves v -viii r. klingebiel, c. heine, r. lehmann; berlin/de purpose: standardization of a virtual endoscopic (ve) approach to the intracisternal course of cranial nerves (cns) v -viii. methods and material: magnetic resonance imaging (mri) of the basal cisterns was performed in healthy volunteers on a . t unit, using a ciss sequence with an isotropic voxel size of . mm. data post processing (pp) was effected by means of direct volume rendering (vr), comprising the cn's complete intracisternal course as well as their root-entry-zone. subsequently, patients with clinical signs of intracisternal pathology were investigated by standardized ve approach. the pp time was recorded and image quality and diagnostic value were rated by consensus reading of two neuroradiologists, using a five-point score ( = insufficient, = excellent). results: - virtual endoscopic views were needed per cn for comprehensive intracisternal visualization (n. v = , n. vi = , n. vii/viii = ). the pp time per cn varied between - minutes. the average scores for image quality and diagnostic value amounted to . and . , respectively. in / patients comprehensive ve cn imaging was achieved. in / patients variations of the ve views were required. different intracisternal pathologies were assessed by the ve approach such as neurovascular conflicts between the aica and the cns v, vi and viii at the rez level. conclusion: comprehensive intracisternal d visualization of the cns v -viii is possible within a routine imaging setting, provided direct volume rendering and standardized pp protocols are used. the value of the sagittal median nerve diameter in the diagnosis of median nerve entrapment o.j. sommer , h. czembirek , h. gruber , p. kovacs , m. stiskal , f. kömürcü ; tuesday b a c d e f material and methods: patients with suspected carotid artery stenosis were examined with mscta after bolus administration of ml of nonionic contrast agent at ml/s. before the acquisition, a test bolus of ml of c.a. at ml/s was performed. real time interactive d evaluation was performed on a dedicated workstation. the degree of stenosis and the morphology of the plaque (qualitative and quantitative) were evaluated. in all patients dsa was also performed and considered the standard of reference. results: excellent image quality was obtained in all cases, without venous filling. good correlation with dsa was achieved using the interactive d assessment. a perfect correlation between mscta and dsa regarding the degree of stenosis was seen in carotids. in carotids, with moderate stenosis at dsa, mscta showed a severe stenosis, due to the presence of calcification. the values of sensitivity, specificity and accuracy were respectively %, % and %. regarding the morphology of the plaque, mscta correctly demonstrated all ulcerated plaques, also showing the presence, by means of quantitative assessment, of calcium, fibrous stroma and lipid. conclusion: mscta surpasses all the limitations of single slice spiral cta regarding venous overprojection and volume coverage. real time d interaction is necessary to correctly demonstrate the degree of stenosis. mscta appears to be particularly valid in the assessment of plaque morphology and therefore in treatment planning. carotid artery stenosis: accuracy of noninvasive imaging g. mansueto, m. d'onofrio, a. guarise, p. tamellini, c. procacci; verona/it purpose: this study prospectively compared contrast-enhanced magnetic resonance angiography (cemra) and doppler ultrasound (dopplerus) with digital substraction angiography (dsa) and endarterectomy findings to determinate the accuracy in assessing carotid artery stenosis. in this prospective study from january to may , patients underwent carotid endarterectomy, studied by cemra, dopplerus and dsa and with cemra and dopplerus. the degree of stenosis of carotid arteries ( patients) was analyzed with cemra and dopplerus and compared with dsa (reference standard) by using the spearman rank correlation coefficient (rs). in / patient eversion endarterectomy was performed; thus it was possible to compare cemra, dopplerus and dsa with the specimen measurement (reference standard). in / standard endarterectomies the presence of ulcers was documented to determinate the accuracy of noninvasive imaging. results: there was a significant correlation between cemra and dsa (rs = . ; p < . ) and between dopplerus and dsa (rs = . ; p < . ) for degree of stenosis. overestimation was the most frequent error, even in the specimen comparison. there was one false positive for cemra and dopplerus and one false negative for dsa, so the accuracy was the same at %. ulcers were most frequently seen at cemra. conclusion: there was a significant correlation between cemra, dopplerus and dsa for estimating the degree of stenosis with the same accuracy by comparing with specimen measurements. ce mra was shown to be the best imaging modality to detect plaque ulceration. multislice spiral ct angiography vs. time resolved contrast enhanced mr angiography in the assessment of carotid artery stenosis f. pediconi, c. catalano, a. laghi, f. fraioli, a. napoli, m. danti, r. ferrari, r. passariello; rome/it purpose: to compare multislice ct angiography (mscta) with contrast enhanced mr angiography (mra) in patients with suspected carotid artery stenosis. material and methods: patients with suspected carotid artery stenosis were examined with mscta and mra using a . t magnet. mscta was performed after bolus administration of ml of c.a. at ml/s. before the acquisition, a test bolus with ml of c.a. at ml/s was performed. ce-mra was performed using a multiphase sequence after bolus administration of ml of gd-dtpa at ml/s. a real time interactive d assessment of mscta images was performed in all cases, while mra images were assessed using a standard mip algorithm on the magnet console. the two techniques were compared for degree of stenosis and plaque morphology, using dsa as standard of reference. results: with both techniques images were diagnostic and free from artifact. no significant difference between the two techniques, regarding the degree of stenosis, was seen; the values of sensitivity, specificity and accuracy were respectively of , and % for both techniques. qualitative assessment allowed us to correctly demonstrate the morphology of the plaque in all cases with cta, while mra correctly demonstrated of ulcerated plaques. although multislice spiral ct encompasses most of the problems of spiral cta, contrast enhanced mra provides a simpler way to achieve comparable results, using well tolerated contrast agents and without ionizing radiation, regarding the degree of stenosis. nevertheless, mscta also appears accurate in the assessment of plaque morphology. power doppler screening for carotid artery stenosis in cardiac surgery patients v. beslagic, f. dalagija, z. merhemic; sarajevo/ba purpose: to assess the use of power doppler imaging as a screening tool for detecting carotid stenosis in the preoperative evaluation of cardiac surgery patients admitted at university clinical center sarajevo in an eighteen month period. material and methods: we surveyed patients admitted for cardiac surgery. imaging methods were power doppler, duplex doppler, mra, dsa. a two phase study was performed. in the first, a prospective preoperative evaluation of patients was performed using duplex doppler. during the second phase, prospective preoperative evaluation of patients was performed using power doppler imaging. in patients with % stenosis or more, duplex doppler was performed. imaging methods for further evaluation of % and above stenosis, in both groups, were mra and intravenous dsa. results: stenosis of % or more was found in ( %) patients in the first phase group and in ( %) of patients in the second phase group. stenosis of % and above was found in ( %) patients in the first phase group, and in ( %) patients in the second phase group. adequate images were achieved in % of the power doppler studies compared with % in the duplex doppler studies. conclusion: power doppler, as a screening tool for carotid stenosis, is a low risk, fast, cost effective method with accurate results. using power doppler to screen patients and duplex doppler to evaluate significant carotid stenosis with possible further diagnostic evaluation with mra and dsa, an optimal imaging approach is achieved. cerebral hemodynamics in patients with vertebral artery hypoplasia comparing those with and without atherosclerotic lesions of carotid arteries s.g. mazur, i.i. glazovska, v.v. kuznetsov; kiev/ua purpose: comparison of brain hemodynamics in patients with vertebral artery hypoplasia (vah) comparing those with and without atherosclerotic lesions of the carotid arteries. methods and materials: we examined patients, males and females, mean age ± years: ( ) patients without a history or signs of cerebrovascular diseases and without carotid stenosis: with vah ( a) and without vah ( b); ( ) patients with ischemic stroke caused by atherosclerotic lesions of the carotid arteries: with vah ( a) and without vah ( b). we used a sonography system "elegra" (siemens) to measure the vessel diameters, volume blood flow velocities (vf), total cerebral volume blood flow (tvf) -vf through both internal carotid arteries (vfica) + vf through both va (vfva). results: group a had lower vfva than b (p < . ), but there was no significant difference between tvf in these two groups. tvf in group a ( . ± . l/min) was lower compared with group b ( . ± . l/min, p < . ) resulting in a lower vfva in group a ( . ± . l/min and . ± . l/min respectively, p < . ). gropp b versus a patients had a higher severity of arterial narrowing. conclusions: patients with vah without stenotic lesions of the carotid arteries have brain hemodynamic compensation through the carotid arteries and contralateral vertebral artery. vah in patients with cerebral atherosclerosis evokes decompensation of cerebral hemodynamics and causes ischemic stroke with a lower grade of carotid stenosis than in patients without vah. purpose: the aim of this work was to retrospectively evaluate with mri, patients affected by anterior knee pain without clinical symptoms of meniscal or ligamentous injuries. materials and methods: patients with anterior knee pain entered this study. mr examination was performed using . t dedicated and . t whole body mr units. in cases dedicated mr unit was performed to have kinematic evaluation of the knee at three different degrees of flexion. in cases i.v. injection of contrast media was performed. all the patients underwent arthroscopy. results: in all the cases mri revealed a region of altered signal intensity in the superior aspect of the hoffa's body. arthroscopy revealed the presence of synovial thickening in cases and enlargement of the patello-femoral synovial recess in cases. in cases of synovial thickening infusion mri showed in cases contrast enhancement suggesting an acute stage of inflammation and in cases no enhancement was found due to the presence of synovial fibrous tissue. in cases of histologically proved villonodular synovitis se t w sequences showed a region of non homogeneous high signal intensity because of the presence of spots of low signal intensity. in all the patients showing synovial thickening of the hoffa's body apex, kinematic mr revealed impingement with the femoro-patellar joint. conclusion: our experience demonstrates that mri, eventually completed by kinematic study and/or infusion of contrast media, may be considered the method of choice in the evaluation of the synovial impingement of the knee. cystic degeneration of the lateral meniscus of the knee: mri evaluation before and after arthroscopic treatment using radiofrequency energy a. barile, a.v. giordano, m. caulo, m. sabatini, f. iannessi, g. bonanni, v. calvisi, c. masciocchi; l'aquila/it purpose: to assess by mri the potential benefit and efficacy of selective meniscectomy combined with radiofrequency ablation in cystic degeneration of the lateral meniscus treatment. materials and methods: forty-one patients entered this study. patients underwent arthroscopic selective meniscectomy and patients underwent arthroscopic selective meniscectomy and radiofrequency treatment (arthocare, sunnyvale, ca) of the meniscal remnant. all of them were submitted to mri and clinical evaluation three months later. in cases mri examination was performed before and after the surgical treatment. mri examination was performed using a dedicated . t (artoscan esaote italy) and a . t superconductive unit (ge signa horizon usa) employing se t -w, se t -w and ge t -w sequences in axial and longitudinal scan planes. in cases arthro-rm was also performed. clinical evaluation included physical examination and a questionnaire. results: clinical evaluation did not show statistically significant discordance between the two groups. mri follow-up after months demonstrated a very clear decrease of the degenerative spots inside the meniscal remnant in the group with combined treatment respect to the group treated only with selective meniscectomy. conclusion: in conclusion our experience considers mri the method of choice in the evaluation of post surgical treatment of degenerative cystic diseases of the lateral meniscus of the knee. bone-patellar tendon-bone (btpt) acl reconstruction of the knee: diagnostic imaging evaluation of failures compared to second-look arthroscopy a. barile, g. cerone, a.v. giordano, l. zugaro, a. catalucci, g. bonanni, v. calvisi, c. masciocchi; l'aquila/it purpose: to evaluate the capability of diagnostic imaging in cases of failed anterior cruciate ligament (acl) reconstruction. materials and methods: patients submitted to acl surgical reconstruction with patellar tendon entered this study. all the patients were clinically suspected of acl reconstruction failures and had diffuse pain and/or joint swelling or instability. all of them underwent mri from to months after surgery. all patients underwent plain film and / ct. in all cases mr study was performed using dedicated . t or whole-body superconductive . t units; in cases arthro-mri was also employed. results: in patients enlargement of the graft related to the presence of significant synovial reaction were found. in cases synovial reaction was exuberant (cyclops syndrome). in patients the bone tunnels were not perfectly aligned and standard examination revealed the presence of osteophytosis of the intercondylar fossa. in cases the bad positioning of the interference screws was found. in the last cases mri documented a tear of the graft. in all the cases arthroscopic second look confirmed the mri diagnosis. conclusion: mr manifested very accurate evaluation of the acl autograft because of its high contrast resolution and multiplanarity. in our experience mri eventually completed with arthro-mri may be considered the method of choice in the evaluation of acl reconstruction failures. dynamic mri in the evaluation of femoro-patellar disorders m. mastantuono, e. bassetti, m. francone, m. valeo, r. passariello; rome/it purpose: alterations of femoro-patellar biomechanics in the young and sports practicing subjects may determine the development of early involutive process and painful conditions. in our experience we verified the potential offered by kinematic studies of the extensor complex on sagittal and axial planes and we developed an innovative method of study that permits a correct clinical assessment of in this particular problem. we used a . t dedicated magnet, dedicated to the study of limbs with an adapting device holding the knee at different angles of flexion. we obtained images in different positions of flexion-extention acquired with a se t and t and g.e. sequences slice thickness - mm without gap. we studied healthy volunteers and patients with anterior pain or instability of knee joint of which was suspected of being femoro-patellar in origin. in patients the correlations between cartilage and subchondral bone sufference and the cinemotion findings were significant. conclusion: our method differs from the other dynamic studies described in the literature in that it allows volume study and permits a clear evaluation of the dynamic relationship between rotule and troclear articular surfaces. postoperative meniscus: assessment with dual-detector spiral ct arthrography of the knee c. mutschler, b. vande berg, f.e. lecouvet, p. poilvache, j.e. dubuc, b. maldague, j. malghem; brussels/be purpose: to evaluate dual-detector spiral computed tomography (ct) arthrography of the knee in the assessment of the postoperative meniscus. materials and methods: two observers retrospectively determined in consensus the meniscal changes observed in consecutive patients who have had partial meniscectomy (n = ) and who underwent dual-detector spiral ct arthrography of that knee for recurrent symptoms before second-look arthroscopy. at ct arthrography, postoperative menisci were considered to be either stable (no tear or small partial tear) or unstable (meniscal separation, complete tear, large partial tear, displaced meniscal fragment). the sensitivity, specificity, and positive and negative predictive values for the detection of unstable meniscal tears among all postoperative menisci at spiral ct arthrography was determined with second-look knee arthroscopy as the standard. the sensitivity and specificity for the detection of unstable postoperative meniscal tears among all postoperative menisci were % and %, respectively, with positive and negative predictive values of % and %, respectively. conclusion: dual-detector spiral ct arthrography of the knee is an accurate method for detecting unstable meniscal tears among postoperative menisci. purpose: to analyze mr-pathology of the knee joint at different stages of osteoarthritis and to find out whether pain, stiffness and limited function assessed clinically correlate with the degree of pathology assessed on mr images and radiographs. material and methods: the study population consisted of patients with varying degrees of osteoarthritis. osteoarthritis was graded clinically using the womac (western ontario and mcmaster university) score and on the basis of conventional radiographs using the standard kl (kellgren-lawrence) score. in addition mr imaging was performed at . t using a high-resolution fat-suppressed, spoiled gradient echo sequence, t -weighted fat suppressed fast spin echo sequences and t -weighted spin echo sequences. all images were analyzed by two readers concerning cartilage lesions, bone marrow edema and pathology of the ligaments and menisci. these findings were correlated with the clinical and the radiological score. results: / joints with a kl-score of showed full thickness cartilage lesions and bone marrow edema. meniscal tears were found in all joints with kl-score . cruciate ligament pathology was found in / kl-score and / kl-score joints. the kl-score correlated well with the extent of mr-pathology. correlations between the extent of cartilage damage, bone marrow edema and the kl-score versus the womac-score were non-significant (p > . ). conclusion: a high percentage of meniscal and ligamentous pathology, bone marrow edema and severe cartilage lesions could be shown in advanced osteoarthritis. however, a significant correlation between clinical findings and the extent of mr-and x-ray pathology could not be demonstrated. purpose: evaluation of real-time mri in the assessment of velopharyngeal closure in comparison to videofluoroscopy. materials and methods: healthy volunteer and patients with suspected velopharyngeal insufficiency (age from - years, mean years) underwent videofluoroscopy and real-time mri, using a tse "zoom" sequence (tr = ms, te = ms, slice thickness mm) with images per second. images were acquired in the midsagittal, the coronal and axial plane at the level of maximal velopharyngeal closure during phonation of test words. results were analysed by radiologists in comparison to videofluoroscopy as the standard of reference concerning overall quality of the depiction of the velopharyngeal isthmus and the pattern of velopharyngeal closure in all three image planes. results: in all cases, real-time mri could correctly depict the pattern of velopharyngeal closure in correspondence to videofluoroscopy: velopharyngeal insufficiency with wide open velopharyngeal portal (n = ), with moderate open velopharyngeal portal (n = ), close approximation of the velum (n = ) and velum touching the dorsal phayryngeal wall (n = ). in cases, the coronal plane was not of diagnostic quality in mri due to motion-artefacts. in one case, mri showed an asymmetric movement of the pharyngeal walls which could not be seen in videofluoroscopy. conclusion: real-time mri can successfully analyse the pattern of velopharyngeal closure even in small children. being a non-invasive method, it avoids the radiation exposure of videofluoroscopy and the discomfort of nasoendoscopy. evaluation of the movements of the oro-pharyngeal cavity during phonation with different voice intensity using mri m. di girolamo, g. ruoppolo, e. iannicelli, m. mattei, a. carriero, v. david; rome/it purpose: the aim of this study was to evaluate with mri the movements of the different anatomical structures of the oro-pharyngeal cavity during the utterance of the fundamental vowels with different voice intensity. we have evaluated volunteers using a . t mr superconductive unit (philips medical system). we performed turbo-field-echo sequence (tr: ms; te: ms; ti: ms; n.ex.: ; acq. time: s) with midsagittal scan (slice thickness: mm). the volunteers were asked to perform a prolonged emission of the fundamental vowels [a], [i], and [u] with normal voice intensity ( db) and with loud voice ( db). the voice intensity was measured with a phonometer before the mr acquisitions. on each midsagittal scan we measured the area of the mouth and pharyngeal lumen. results: in all the patients we accurately evaluated the movement and the activity of the lips, tongue, soft palate and the pharynx. comparing the utterance of loud voice to normal voice, we found an increase of the area of the mouth lumen for the vowels [a] and [u] and an increase of the area of pharyngeal lumen for the vowel [i]. the intensity of voice emission depends not only on subglottic air pressure and glottic rim dimension but also upon the oro-pharyngeal cavity volume. the three-dimensional ct study of the upper airway of obstructive sleep apnea syndrome: an oral appliance can change the volume of oro-and nasopharynx w. zhang; beijing/cn purpose: to evaluate the utility of the spiral ct and post processing with d remodelling to review the anatomical abnormalities and the changes of the upper airway of osas with or without an oral appliances in the mouth. method/materials: osas patients who had ideal oral appliance therapy have undergone spiral ct with or without the oral appliances in the mouth. scan was obtained with mm collimation at . : pitch from nasopharynx to the level of the hyoid bone at end expiration. d remodeling, raysum and mpr were performed at the workstation. luminal area at naso-, oro-and hypopharyngeal levels, the distance of the posterior airway space and distance between the hyoid bone and mandibular plan were measured. results: oro-and nasopharyngeal areas were significant larger in patients with oral appliances than in patients without oral appliances, p < . ( . mm ± . vs . mm ± . and . mm ± . vs . mm ± . ). no differences of hypopharyngeal areas were found between patients with or without oral appliances, p > . ( . mm ± . vs . mm ± . ). the three dimensional spiral ct scanning had many advantages in the evaluation and measurment the upper airway in patients with osas, these results show the main therapeutic mechanism of oral appliance use is the volume change of the oro-and nasopharynx. static and dynamic evaluation with mri of larynx and oro-pharingeal cavity in professional opera singers m. di girolamo, g. ruoppolo, f. assael, m. minnetti, e. iannicelli, v. david; rome/it purpose: to assess the anatomical configuration of phonetic organs by mri in singers with different vocal range. methods and materials: professional opera singers ( tenors, basses, sopranos, mezzosopranos) underwent mri, performing both static and dynamic studies. we performed tse t -weighted axial scans at the level of larynx in order to evaluate the area of superior surface of vocal cord. in the dynamic study, the singers were asked to perform a prolonged vocalization at a confortable tonality of the foundamental vowels a. we performed a midsagittal turbo-field-echo scan (acq.time: s) at the level of the oro-pharyngeal cavity measuring the area of the mouth and pharyngeal lumen. these data underwent statistical evaluation using the mann-whitney u-test. results: we determine the average size of the vocal cord (sopranos: . cm ; mezzosopranos: . cm ; tenors: . cm ; basses: . cm ) and of mouth and pharyngeal lumen (sopranos: . cm ; mezzosopranos: . cm ; tenors: . cm ; basses: . cm ). the differences in vocal cord size between sopranos and mezzosopranos (p: . ) and between tenors and basses (p: . ) are tendentially statistically significant. the variation in vocal tract size during the ut- tuesday b a c d e f terance of the vowel a between tenors and basses is considered tendentially statistically significant (p: . ) while the difference between sopranos and mezzosopranos is not statistically significant (p: . ). we demonstrate a correlation between the vocal cord's surface and the vocal tract configuration and the vocal tessitura of a singer. long vocal cord and wide vocal tract are characteristic of singers with low-pitched voice types (bass, baritone, contralto, mezzosoprano) while short vocal cord and narrow vocal tract are characteristic of singers with high-pitched voice types (tenor, soprano). correlation between arnold chiari malformation and sleep apnea syndrome (sas) i. thomassin , k. marsot-dupuch , v. stahl , f. bourquin , f. parker , p. lasjaunias ; le kremlin bicêtre/fr, bobigny/fr purpose: to identify morphologic abnormalities on cervical mri exams among patients suffering from sleep apnea syndrome and arnold chiari malformation. materials and methods: patients suffering from severe apnea syndrome ( / mn) were referred for surgery of arnold chiari malformation. pre-and post-contrast sagittal and axial t w and t w images of the brainstem and cervical cord were performed. were studied the cerebello-medullary cistern, the angle between posterior border of brainstem and cerebellum, location of cerebellar tonsilla, cervicooccipital junction and ventricular system. results: three brainstem abnormalities were detected (two isolated and one in a complex malformative syndrome). patients have filling of cerebello-medullary cistern and a diminution of the angle between the posterior border of the brainstem and the cerebellum. anterior translation of cerebellar tonsils was noticed. discussion: many authors have studied obstructive sas which was partially explicated by laryngo-pharyngeal abnormalities. associated transient ischemic attacks are well known. our study suggested that abnormalities of brainstem may alter the function of respiratory nuclei and tracks and that brainstem abnormalities may be linked with sleep apnea syndrome. conclusion: sleep apnea syndrome may be associated with lesions of brainstem. further larger study should be done to prove a statistical correlation. however radiologists should look for posterior fossa abnormalities when exploring patients referred for sleep apnea syndrome. comparison of differently viscous iodinated and barium-containing contrast agents in the detection of pharyngeal perforation m. keberle, g. wittenberg, a. trusen, w. baumgartner, d. hahn; würzburg/de purpose: unlike in the investigation of esophageal perforation, the more radiopaque barium-suspensions are not as important as iodinated aqueous contrast agents for the detection of pharyngeal perforations. this study was performed to find out whether the highly different viscosities (of iodinated and barium-containing contrast agents with comparable radiopacities) are a reason for this. methods: viscosity, subjective difference in contrast, and ct-density of an iodinated aqueous (telebrix) and a wt/vol% barium-containing contrast agent (micropaque) were determined. moreover, to exclude postoperative perforation, patients were prospectively examined by pharyngography using both contrast media. pharyngographies of patients with perforation were later compared by two independent readers. all patients with perforation were followed up clinically to exclude complications due to barium-application. results: in-vitro comparison showed comparable radiopacity but the wt/vol% barium-suspension was much more viscous than the iodinated contrast agent. in total, during pharyngography, perforations were clearly delineated with the iodinated aqueous contrast agent. however, two of them were not detected with the barium-suspension. all the other perforations presented equally. conclusions: given a sufficient radiopacity, a low viscosity appears to be essential for a contrast agent to detect pharyngeal perforation. thus, we recommend the sole use of an iodinated contrast agent (if suspicion of aspiration as isoosmolar variant) for this purpose. percutaneous tracheostomy (pt) in the intensive care unit (icu) using ultrasound guidance t. geroukis, d. voultsinou, a. papachillea, v. kalpakidis, p. palladas; thessaloniki/gr purpose: to present the ultrasonographic investigation of anterior neck structures conducted prior to the performance of pt in the icu patients. to determine whether the ultrasonographic contribution could reduce the complication rate and improve the outcome of these patients. we studied icu patients, with an average age of . the ultrasound investigation was performed with bedside portable equipment in the icu immediately prior to the tracheostomy, indicating the point of puncture and analyzing the relationships of the anatomic structures lying in the vicinity of the tracheostomy site. results: in patients the thyroid isthmus was extending over the tr -tr space and in patients a considerable isthmus thickness was calculated. goiter was found in patients whereas clinical examination indicated this in only in patients. the clinical examination was unable to evaluate by palpation the guiding points in patients. in all these cases the anatomical relations required were satisfactorily visualized ultrasonographically. complications included hemorrhage, pneumothorax and subcutaneous emphysema. the ultrasonographic results influenced the decision for surgical or transcutaneous tracheostomy or surgical management during the procedure in three cases but small complications were unavoidable. with increased practice and better evaluation of the ultrasound results, the radiologist can play a vital role in the management of the icu patient. possibilities of spiral ct in differential diagnosis of carotid chemodectomas g. results: chemodectomas were revealed in pts, neurinomas in pts and carotid arteries aneurysms in pts. among chemodectomas there were carotid and vagal tumours. the analysis of data revealed that chemodectomas were characterised with early (arterial phase) pronounced (up to hu) contrast enhancement. sometimes a low density area can be seen in center of the lesion. neurinomas are characterized with less pronounced enhancement (up to hu). "spots" and "stripes" of the contrasted vessels stand out against parenchyma in neurinomas. there was no significant difference (p < . ) of average density rates in arterial phase in chemodectomas ( . ± . hu) and in neurinomas ( ± hu). there was a simultaneous contrast enhancement both in aneurysm and in surrounding vessels. additional information valuable for differential diagnosis was not obtained in venous and delayed phases. simultaneous enhancement of tumor and carotid arteries gives the possibility of evaluat ing their relationship and the involvement of carotid arteries in pathological processes. conclusion: spiral ct with bolus contrast enhancement allows differentiation of tumors and other pathological masses of the carotid space and allows a d-image of the area of interest to be obtained for surgery planning. acute calcific retropharyngeal tendinitis m. tassart, c. le breton, f. bahlouli, n. szelei, j. bigot; paris/fr purpose: to improve early diagnosis of an under recognized cause of cervical pain and stiffness whose initial misdiagnosis can lead to parenteral administration of antibiotics or even open biopsy materials and methods: two patients ( male, a; female: a) were admitted to the hospital with dysphagia, severe neck discomfort and fever. lateral radiographs of the cervical spine were performed in patients, computed tomography in and mri in . using non-steroidal anti inflammatory medications (interruption of antibiotics), the two patients had complete resolution of the symptoms within one week results: the calcification of the prevertebral muscle was demonstrated by ct for patients and identified on lateral radiography in one case only. the soft tissue swelling was seen both on ct and mri. conclusion: acute calcific tendinitis is an under recognized disease which can be initially misdiagnosed as retropharyngeal or nasopharyngeal abscess, leading to unecessary parenteral injection of antibiotics or even biopsy. the radiologist has an important role to ensure the definitive diagnosis: in our cases, specific imaging led to the correct diagnosis. to test the hypothesis that the single testicular artery is low resistance, and two further arteries (cremasteric/differential) are high resistance, we examined the spermatic cord vessels in a cohort of healthy men. materials and methods: patients presenting for a scrotal us with normal testes and epididymis were recruited. the right and left spermatic cords were examined from the superior aspect of the testis to the external inguinal ring to locate the testicular, cremasteric and differential arteries. a l w multifrequency ( - mhz) linear array probe (acuson ca) identifed each artery as separate, allowing a spectral doppler waveform to be recorded. the resistive index (ri) from each artery was measured three times (right and left) and the mean calculated. the three arteries were labelled a (lowest ri) b and c (two higher ri). results: patients (median age a, range - a) were examined. the ri's on the right were: a: . ± . , b: . ± . , c: . ± . and the left a: . ± . , b: . ± . , c: . ± . . a paired t-test demonstrated a significant difference of the combined right and left measurements for avsb (p < . ) and avsc (p < . ) but not bvsc (p = . ). conclusion: although it is not possible to identify a named artery in the spermatic cord, consistently one artery has a significantly lower ri than the other two arteries. this finding may be useful as an adjuvant parameter in the assessment of scrotal pathology in particular with patients with spermatic cord torsion. age related changes in testicular perfusion and serum androgen levels o.j. sommer , k. kharom , t. zils , h. czembirek , h. pflüger , e. plas ; innsbruck/at, vienna/at purpose: to assess the peripheral vascular resistance of small testicular arteries in different age groups and to match these results with age and androgen levels. materials and methods: testicular units of healthy subjects were investigated. according to age, patients were divided into groups ( - , - , - , - , > a). using high resolution sonography ( - mhz, elegra, siemens, erlangen) including power mode we measured resistive indices (ri) and pulsatility indices (pi) of centripetal testicular arteries of the lobuli testes excluding mediastinal arteries. androgen (testosterone, free testosterone, fsh, lh, sexual hormone binding globulin) levels were evaluated between and a.m. and correlated with age, ri and pi values. results: there was a significant difference of . to . in ri (p = . ) and . to . in pi (p = . ) values between young and old men. with the exception of sexual hormone binding globulin (sbhg) ( . versus . ; p < . ) no significant correlation of androgens with age, ri or pi was shown. our study suggests a positive correlation of age with the peripheral resistance of small testicular arteries, i.e. an increase of peripheral resistance with increasing age. sbhg showed a positive correlation with age, ri and pi values. the other androgens do not seem to relate with ri and pi values of the aging male. consecutive patients referred for scrotal us were examined with a l w multifrequency ( - mhz) linear array probe (acuson, ca). if a focal testicular lesion was identified, the abnormality was re-examined with colour doppler mode ( - mhz). vascularity was classified into, (a) no intra lesional vessels, (b) surrounding but no intra lesional vessels, (c) intra lesional vessels present and subdivided into ( ) vessels crossing ( ) disordered vessels ( ) complete infilling. us findings were correlated with histology or findings confirmed on follow up. results: over a month period a total of patients were examined. focal abnormalities in patients were found. the distribution of vascular patterns was as follows: a: , b: , c : , c : , c : . primary testicular tumours (seminomas, teratomas) were detected, showing a c (criss cross pattern), a single well differentiated teratoma showing no intra lesional vessels (a). nine patients demonstrated a c vascular pattern; secondary tumours, acute myeloid leukaemia, chronic fibrosis and a single patient without histological diagnosis. the c pattern was present in % of primary testicular tumours. the presence of the 'criss cross' vascular pattern allows confident diagnosis of primary testicular tumours, although not differentiating seminomas from teratomas. with the improvement in probe technology, vascularity of testicular tumours proves to be an important differentiating feature. varicocele and venous insufficiency in left low extremity s. deftereos, g. alexiadis, g. kafetzis, s. touloupidis, j. manavis; alexandroupolis/gr the aim of our study is to compare the rate of incidence of varicocele and venous insufficiency in left low extremity. the flow pattern of left common iliac, external iliac, common femoral and great saphenous veins were evaluated with colour doppler sonography (cds) in patients ( - years old) with clinically suspected left varicocele. the same veins were also evaluated with cds in clinically healthy voluntaries (same age range). in patients of the first group ( patients with clinically suspected varicocele) when valsalva manouvre was performed with the patient in upright position, flow reversed for a period of one or more seconds in left common femoral vein. thus the diagnosis of venous insufficiency was made. in the second group ( clinically normal males) normal findings were found in thirteen persons. in the remaining two young men the diagnosis of venous insufficiency were made. the cds of scrotum revealed varicocele in both of them. on the basis of these findings and also because of the anastomotic branches between the veins of scrotum and low extremity we believe that a cds evaluation of the flow pattern in left common iliac, left common femoral and great saphenous veins must be performed before surgical treatment of varicocele in order to avoid the possibility of varicocele recurrence. quantitative evaluation of scrotal veins by colour doppler us in healthy population a. cina, t. pirronti, r. foschi, g. restaino, g. oliva, a. pignatelli, d. ribatti; rome/it scrotal varicocele (sv) is a very common disease of the male population. presently, colour doppler ultrasonography (cdus) represents the most frequently adopted technique for confirming the clinical diagnosis of sv and for a treatment indication. despite for several years cdus has been clinically used in cases of sv, discriminating quantitative values are not reported in medical literature. this is at least partly due to the lack of studies of cdus patterns obtained from large populations of healthy subjects. the aim of this paper is to investigate the role of ecd in instrumental diagnosis of male varicocele, the implications in selecting the patients who require treatment, and to investigate the risk of sv overdiagnosis by adopting the qualitative criteria currently used. we prospectively examined by cdus a population of healthy and symptomless subjects, with a negative clinical examination for varicocele, and a normal spermiogram. we found that the normal value range of the maximum diameter of scrotal veins ( . ± . mm) widely overlaps with the values currently accepted for a varicocele diagnosis ( . - . mm). furthermore, a venous reflux, a criteria adopted also for the diagnosis of subclinical varicocele, was present in % of the normal population. these data show that there is a risk of sv overdiagnosis by using cdus. the quantitative criteria for sv diagnosis should be re-examined. the patients group included uvjs with grade i -ii and uvjs with grade iii -iv of reflux. urethra-to-orifice distance (uod) and length of intravesical and submucosal parts of the ureter were measured. results: in normal cases ureteral orifices were situated on equal distances from urethra, the uod was . ± . mm (mean ± sd). the length of intravesical part of the ureter was . ± . mm and correlated with height (correlation coefficient . ), body surface area ( . ) and weight ( . ). the length of submucosal part of the ureter was . ± . mm and correlated with body surface area ( . ), weight ( . ) and height ( . ). the ratio between intravesical and submucosal parts of the ureter was . ± . . there was no significant difference between the normal values and values of all low-grade reflux uvjs. in from spontaneous resolution of the reflux during -year period was found. the grade iii -iv reflux orifices ( uvjs) were situated farther from urethra than opposite normal orifices, the uod was . ± . mm. the intravesical part of the ureter was short ( ± . mm) and submucosal part was absent in all cases. none high-grade reflux was resolved spontaneously. conclusion: ultrasonography is a valuable noninvasive method of examination of uvjs and may be useful in vesicoureteric reflux assessment. comparison of contrast-enhanced colour doppler targeted biopsy to conventional systematic biopsy: impact on prostate cancer detection f. frauscher, a. klauser, l. pallwein, a.h. schuster, h. volgger, g. helweg, d. zur nedden; innsbruck/at purpose: we investigated whether a limited biopsy approach with contrast-enhanced colour doppler ultrasound (cdus) targeted biopsy of the prostate could detect cancers as well as grey-scale us guided systematic biopsy with a larger number of biopsy cores. we examined men (psa ≥ . ng/ml). two independent examiners evaluated each subject. one investigator performed contrastenhanced targeted biopsies (≤ ) into hypervascular regions in the peripheral zone during intravenous infusion of levovist™. subsequently, a second examiner performed systematic biopsies of the prostate. cancer detection rates for the two techniques were compared. results: cancer was detected in / subjects ( %). cancer was detected in / subjects ( . %) by contrast-enhanced targeted biopsy, and in / patients ( . %) with systematic biopsy. cancer was detected with targeted biopsy alone in subjects, and with systematic biopsy alone in subjects. overall cancer detection rate was not significantly different for targeted and systematic biopsy (p = . ). the detection rate of targeted biopsy cores ( / ) was significantly better than that of systematic biopsy cores ( / ) (p < . ). targeted biopsy in a patient with cancer is . times more likely to detect prostate cancer than a systematic biopsy. conclusions: contrast-enhanced cdus targeted biopsy detected as many cancers as systematic biopsy with fewer than half the number of biopsy cores. although an increase in cancer detection rate is obtained by combining targeted and systematic techniques in this screening population, contrast-enhanced targeted biopsy alone is a reasonable approach to reduce the number of biopsy cores. intermittent contrast-enhanced ultrasonography for prostate cancer detection a. klauser, l. pallwein, w. horninger, f. frauscher, g. helweg, d. zur nedden; innsbruck/at purpose: we investigated the usefulness of intermittent contrast-enhanced ultrasonography (us) in the detection of prostate cancer. methods and materials: nineteen patients with an elevated prostate-specific antigen level (³ . ng/ml) or an abnormal digital rectal examination were enrolled in the study. we used an i.v. us contrast agent (levovist™). continuous greyscale, intermittent grey-scale, phase inversion grey-scale, and colour and power doppler us of the prostate were performed. sonographic findings were correlated with biopsy results. after us contrast agent administration we found significant enhancement on both grey-scale and doppler images (p < . ). in isoechoic tumours we only detected focal enhancement using intermittent imaging. focal areas of enhancement were identified in only patient ( %) without cancer. conclusions: intermittent contrast-enhanced us of the prostate seems to be useful for selective enhancement of malignant prostatic tissue. therefore, this technique may be useful for targeted biopsies. power doppler sonography was more sensitive in detection of tumoral vessels than pd sonography and increased ppv from % to %, npv from % to %, sensitivity from % to %, specificity from % to %. conclusion: d pd trus examination is more informative than pd trus examination in detection prostate cancer. d pd trus examination can be used as a diagnostic tool in addition to complex examination of patients with suspected prostate cancer. trus cd and mri with contrast agent in the evaluation of local recurrence after radical prostatectomy f.m. drudi, s. petta, a. carbone, a. righi, f. trippa, p. ricci, r. passariello; rome/it purpose: aim of our study was to evaluate sensitivity of us cd and mri, both with contrast medium enhanced, in the detection of local recurrence of prostate cancer after radical prostatectomy and to evaluate the specificity of these techniques in distinguishing recurrent cancer from fibrosis. materials and methods: twelve patients (mean age . ; range - ) presented with increasing psa values (> . ng/ml) in a variable period (mean time elapsed years; range months to years). all patients underwent bone scintigraphy before and after treatment, mri (gadolinium dtpa i.v. ml/s, ml total. flash t fat sat slice thickness mm), grey scale trus, trus cd (levovist shu ) and trus guided multiple biopsy. presence of colour signal and mr signal after c.a. was considered sign of recurrence, absence of recurrence or fibrosis. the results were compared to biopsy showing a sensitivity of % and a specificity of % for cd, while mr showed a sensitivity of % and a specificity of %. cd showed colour signal after c.a. in all positive patients. mr showed local recurrence in patients: cases had been evidenced already at cd examination and confirmed by biopsy, while one was a false positive. scintigraphy detected distant bone metastases in patients, one of which also presented local recurrence. conclusions: from this early experience we can say that trus cd with c.a. is a valid tool as compared to mr in the evaluation of local tumour recurrence in patients with rising serum levels of psa after radical prostatectomy. contrast media in mr, ct and dsa angiography mdct in emergency radiology: is a standardized chest and/or abdomen protocol sufficient for evaluation of thoracic and lumbar spine trauma? percutaneous image-guided radio-frequency thermal ablation of the lung bilateral inferior petrosal sinus sampling in cushing's syndrome; final solution? : multi detector ct in morphological assessment of pulmonary veins in patients with focal atrial fibrillation j. baqué, v. huart, a. azzarine, a. hakime, b. cauchemez, e. mousseaux; paris/fr purpose: to analyse the appearances of the pulmonary veins (pv) in patients with focal atrial fibrillation (faf) initiated by ectopic beats in the pv, compared to a control group. material and methods: the appearances of the pv were assessed in patients with faf originating from the pulmonary veins (confirmed by electrophysiological study) and in asymptomatic patients screened for coronary artery disease. the patients were paired by age and gender (age ± years). each patient underwent ecg-gated contrast-enhanced multi-detector ct (mdct) of the heart. the diameter of each of the four pv was calculated on mm thick slices on axial and coronal oblique images and was measured at the ostium and at , and mm. both the mean and the maximal diameters were calculated for each vein. any anomalies or abnormalities of the heart and vessels were also described. results: the maximal diameters of proximal portions of the right superior ( . ± vs . ± mm; p < . ) and the left inferior ( . ± vs . ± mm; p < . ) pv were significantly dilated in faf patients compared to controls. the right inferior ( . ± vs . ± mm) and left superior veins ( . ± vs . ± mm) were not significantly different between the two groups. conclusion: on mdct images, the proximal portion of right superior and left inferior pv was significantly dilated in patients with faf initiated by ectopic pulmonary beats. accurate evaluation of the appearances of the pv gives valuable and complementary information before selective cannulation of each vein and percutaneous radiofrequency ablation procedure. evaluation of left atrium and pulmonary veins with mri and mra before and after circumferential radiofrequency ablation of pulmonary vein ostia for atrial fibrillation f. de cobelli, f. gugliotta, r. mellone, m. venturini, c. pappone, a. del maschio; milan/it purpose: the pulmonary veins (pvs) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to genesis of atrial fibrillation (af). a new anatomic treatment aimed at isolating each pvs from the left atrium (la) by circumferential radiofrequency (rf) lesions around their ostia has been developed. we evaluated the role of mri and mra in assessment of pvs and la before and after rf ablation. method and materials: patients with resistant af underwent mri and mra before and the day after rf ablation. patients underwent mr after months. mr images were obtained with black-blood ecg-triggered breath-hold multishotfse sequences with double and triple inversion pulses (ir-msfse) (tr/te × rr/ , etl = ). mras were acquired with efgre d sequences (tr/te/ti/fa . / . / / °) with gadolinium injection and reconstructed with mip and volume rendering. results: at the pretreatment mra, all four pvs were visualized in all patients. in four patients, the following anatomic variants were found: a common ostium of the left superior (ls) and inferior (li) pvs; a single ostium of the ls and lipvs; a posterior ostium of lipv; separate right pvs ostia. at the post-treatment mri, high signal intensity was detected in the atrial wall around veins ostia due to oedema; in three patients a thin pericardial effusion was evident. at three months follow-up, the la volume was significantly decreased in patients who had sinus rhythm restoration; with mra, a left inferior pv stenosis was found. conclusion: mr is useful in evaluation of patients with af before and after rf ablation of pvs ostia. preoperative planning and intraoperative navigation with d-reconstructions and image guidance for robotically-assisted coronary artery bypass grafting t.c. mamisch , g. zuend , j. gruenenfelder , s.p. hoerstrup , f.a. jolesz , r.m.m. seibel , m. turina , r. kikinis ; mülheim a. d. ruhr/de, zürich/ch, boston, ma/us objective: closed chest coronary artery bypass grafting with the use of a telemanipulator is still performed in very few numbers worldwide. preoperative planning and intraoperative navigation might be a helpful tool for increasing success rates of this procedure. the most promising accomplishments of image guidance in surgery are three-dimensional image-processing algorithms.methods: creation of d-visualization involves segmentation from acquired crosssectional images. in patients cross-sectional images were obtained by ct and mr. images were digitally transferred via an internal high-speed to the surgical planning laboratory. we primarily used high-end computer workstations sparcand ultrasparc (sun microsystems, mountain view, ca), equipped with specially developed software, the d-slicer for registration, filtering of regions of interest, semi-automated segmentation and d-visualization. results: preoperative planning with identification of target vessels and assessment of wall quality, as well as the possibility of image-guided surgery can be obtained by the d-visualization of the acquired data-sets. together with the development of semi-automated segmentation, d rendering, integration of different image-modalities, intraoperative navigation and tracking can be provided for closed chest coronary artery bypass grafting. conclusion: d-image guidance in surgical procedures for preoperative planning in a non-invasive fashion, as well as intraoperative navigation and tracking of robotically-assisted instruments are very helpful in detecting complex coronary lesions and calcified vessels which facilitate closed chest coronary artery bypass procedures. patients with intramural vessels or severe calcification can be identified and the operative technique can be chosen adequately. subsecond spiral ct angiography for detection of small pulmonary thrombi: an experimental study k. li, y. li, x. du; beijing/cn purpose: to evaluate the diagnostic value of subsecond spiral ct pulmonary angiography (ctpa) to detect the small pulmonary thrombi (diameter . - . mm) in canine models. methods: ctpa was performed as a control study in dogs. pulmonary embolism was induced in the dogs by administation of autologous blood clots, after that ctpa and x-ray pulmonary angiography (xpa) were performed. the images were evaluated on a workstation by two radiologists and the image findings were compared with that of pathological dissections. results: pulmonary embolism models were successfully made in this study and thrombi were found during pulmonary artery dissection. the thrombi were same number as that injected and the all thrombi located in segment and subsegment of pulmonary arteries, of which thrombi were in field of the view (fov). thrombi were found with ctpa, whereas thrombi with xpa. the sensitivity of the ctpa and xpa was . %, . %, respectively, and the positive predictive values were . % and . % respectively for the diagnosis of small pulmonary thrombi. conclusion: subsecond spiral ct angiography has a high diagnostic value for detection of small experimental pulmonary thrombi in dogs, and the result is superior to routine x-ray pulmonary angiography. diagnosis of acute pulmonary embolism with contrast-enhanced mr angiography: an experimental study k. li, y. li, x. du; beijing/cn purpose: to assess the diagnostic value of three-dimentional gadolinium-dtpa contrast-enhanced magnetic resonance angiography ( d cemra) in acute pulmonary embolism (pe). methods: seventeen dogs with acute pulmonary embolism induced by autologous blood clots were examined with d cemra using a fast spoiled gradient echo technique and with x-ray pulmonary angiography (xpa). the findings were compared with pathological dissection. results: the d cemra signs of acute pe were: total vessel occlusion ( / ), pulmonary perfusion defect ( / ), partial filling defect ( / ) and central filling defect ( / ) in the pulmonary artery. the sensitivity of d cemra was . %, specificity . %, whereas the sensitivity and specificity of xpa was . %, . %, respectively. conclusion: d cemra for the detection of acute pe demonstrated high sensitivity and specificity, but the technique needs to be confirmed by further clinical trials. cardiac imaging in infants with aortic isthmus stenosis: a comparison of contrast enhanced mra and a high-resolution d double slab technique u. kramer, f. dammann, j. breuer, l. sieverding, c.d. claussen; tübingen/de purpose: comparison of a three-dimensional gradient-echo (ge) sequence with interleaved double-slab excitation versus a contrast enhanced (ce) mra for the assessment of the great thoracic vessels in children with congenital heart disease.purpose: to assess applicability and diagnostic performance of a standardized multidetector row spiral ct (mdct)-trauma imaging protocol for evaluation of the thoracic and lumbar spine in patients with blunt or spinal trauma. material and methods: mdct (siemens somatom volumezoom, germany) was performed in patients with a history of thoracoabdominal blunt or spinal trauma. all imaging was acquired using a collimation of × . mm and a pitch of . based on this raw data set, the spine was targeted reconstructed using the following parameters: slice width mm; reconstruction interval . mm. two readers separately assessed imaging quality of spinal structures for diagnostic purposes. in addition, both readers evaluated all patients for spinal fractures using five-point confidence scale ( = fracture definitely absent, = fracture probably absent, = equivocal, = fracture probably present, = fracture definitely present). the number and level of fractures were categorized and correlated to thin section mdct and/or surgical findings. results: visibility of spinal anatomic details for diagnostic purposes was rated as excellent by reader / in / levels and good in / levels of spinal levels using a standardized trauma protocol. scoring on the confidence scale was . (± . ) in case of fractures and . (± . ) in case of no fractures, respectively. of spinal fractures ( %) were correctly depicted by each reader. an anterior wedge fracture was missed by both readers. conclusion: evaluation of the thoracic and lumbar spine is possible with targeted image reconstruction based on standardized chest and/or abdomen mdct data sets. whole body spiral ct in trauma patients -part ii: spinal injuries j. von schlippenbach, t. albrecht, k.-j. wolf; berlin/de purpose: to assess the accuracy of a standardized "whole body" spiral-ct protocol in the initial work-up of spinal injuries in trauma patients and to compare spiral-ct with conventional radiography. methods: trauma patients with potentially life threatening injuries underwent a spiral-ct of the skull base and neck (collimation/table speed/reconstruction interval: / / mm), chest, abdomen and pelvis ( / . / ) immediately after resuscitation. additional dedicated axial and sagittal high-resolution reconstructions of the entire spine were performed from the data sets. patients also had conventional radiographs of the spine. ct findings were compared with conventional radiographs and final diagnoses at discharge or death. results: image quality was adequate in / cts and / conventional spine series. in the remaining cases at least one area of the spine was not adequately imaged, in ct this was most often the thoracic spine. the final diagnoses included cervical, thoracic and lumbar spine fractures; fractures were instable. on ct, all but thoracic and lumbar spine fractures were diagnosed. none of the undetected fractures were instable. on conventional radiography, cervical, thoracic and lumbar spine fractures were missed; again none of these were instable. conclusion: ct was superior to conventional radiography and allowed fast and accurate diagnoses of the vast majority of spinal fractures, and missed no instable fractures. in our experience, time consuming conventional spine radiography is dispensable with this approach in most cases. part i: b- (ss ) magnetic resonance imaging in traumatized intervertebral discs n.a. ghanem, p. uhrmeister, c.a. müller, c. altehoefer, m. markmiller, m. langer; freiburg/de purpose: evaluation of mri in trauma patients with traumatized adjacent discs of fractured vertebrae before dorsoventral stabilization material and methods: a prospective diagnostic study with trauma patients ( male, female, mean age: years, range: - ) was performed on a . t magnetom. the preoperative mri using sagittal t -w-se and t -w-tse was compared to the gold standard being intraoperative discography which was carried out on both intervertebral dics adjacent to the fractured vertebrae within a time frame of . days ( - ). beside signal alterations of adjoining intervertebral disc, morphological changes such as disc herniation and annular tears were evaluated in adjacent discs. in / ( %) patients and in / of the intervertebral adjacent discs, the results of both imaging findings were concordant. in patients the adjoining discs were normal. concerning the positive concordant imaging findings, mri and discography both revealed traumatized adjacent dics in cases. in cases the upper adjacent disc was injured. among these traumatized discs, intraosseous herniations into the fractured vertebrae and anuluar tears were depicted. in patients the findings were discordant. in one case mri was false positive whereas discography as the gold standard demonstrated no lesion. in cases mri failed to detect a disc injury. conclusion: mri as a noninvasive method may detect traumatized adjacent intervertebral dics, but mri is inferior compared with intraoperative discography although it does reveal additional preoperative information prior to dorsoventral stabilization. mri in traumatic lesions of cervical intervertebral disc b.w. raab, u. fischer, g. kernbach-wighton, k.s. saternus, e. grabbe; göttingen/de purpose: to demonstrate typical findings on mri in traumatic lesions of the intervertebral discs of the cervical spinal column. materials and methods: mri was evaluated in groups of patients with traumatic changes of the cervical spine column including an injury of intervertebral discs. the study included in-vivo examinations of patients and postmortem examinations (neck specimen, c -t including the skull base) of human corpses after an acceleration trauma. disc lesions were verified intraoperatively in all patients or macroscopically by sections of the specimen. results: the variability of traumatic lesions of the intervertebral disks ranged from small detachments of the disc from the vertebral body to large ruptures of the entire disc. extensive lesions of the disks were correlated with other injuries such as fractures or ligamental trauma. mri depicted all lesions with extension to the entire disk due to morphologic changes in hr-sequences and/or signal alteration in inversion recovery and t -wi sequences. most of the circumscribed disc detachments seen macroscopically were not detectable with mr imaging. conclusions: mri allows a reliable diagnosis of significant lesions of the cervical intervertebral discs after trauma. small detachments of the disc, however, will be missed. cervical spine injuries in elderly patients: does trauma mechanism and age influence the distribution, type and stability? f. lomoschitz , , c.c. blackmore , k.f. linnau , s.k. mirza , f.a. mann ; vienna/at, seattle, wa/us purpose: the purpose of our study was to describe types and distribution of cervical spine injuries in consecutive elderly patients in regard to causative trauma mechanism and to patient age. materials and methods: the distribution and type of cervical spine injuries in consecutive subjects older than years over a -year interval were retrospectively assessed. for each subject, initial imaging studies were reviewed and injuries were classified. the trauma mechanism (falls from standing or seated height vs. mechanisms consistent with higher energy) and initial clinical and neurological status were recorded. data were correlated according to patients' age ( - a and > a) and causative trauma mechanism. results: the majority of patients ( %) had injuries to the upper cervical spine. multilevel injuries were frequent ( %). the main causes for cervical spine injuries were motor vehicle crashes in "young elderly" ( - a) ( %) and falls from standing or seated height in "old elderly" (> a) ( %). fracture patterns at risk for neurologic deterioration were common (> %), even in absence of acute myelopathy or radiculopathy. subjects older than years, independent of causative mechanism, and patients who fell from standing height, independent of age, were more likely to have injuries of the upper cervical spine (p = . and p = . , respectively). conclusion: injuries of the cervical spine in elderly patients tend to involve more than one level with consistent clinical instability. "old elderly" patients (> years) and subjects who fall from standing height are more prone to injuries of the upper cervical spine. the fluid sign in acute vertebral compression fractures on mri a. baur, a. stäbler, r.h. dürr, m.f. reiser; munich/de purpose: to evaluate the occurrence of the linear fluid sign in acute osteoporotic and neoplastic vertebral compression fractures in magnetic resonance imaging (mri). methods and materials: the study group comprised consecutive patients with a total of acute vertebral compression fractures due to osteoporosis or neoplastic infiltration. the mri protocol included unenhanced t -weighted spin echo (se) and short-tau inversion recovery sequences (stir) on a . t system. confirmation of diagnosis was made by surgery, follow-up mri examinations, clinical follow-up or unequivocal imaging findings. results: all fractures showed hypointensity on t -weighted se images and hyperintensity on stir images, both in cases of osteoporosis (n = ) and tumor (n = ). in the fractured vertebral bodies the fluid sign appeared as a circumscribed lesion adjacent to the fractured end-plates, which exhibits signal intensities isointense to cerebrospinal fluid. the shape of the fluid sign was linear (n = ), triangular (n = ) or focal (n = ). it was associated statistically significant with the osteoporotic cause of a fracture (n = , %; chi square p < . ). the fluid sign occurred also in cases of neoplastic compression fractures ( %). at the site of the fluid sign histologic correlation demonstrated osteonecrosis, edema and fibrosis. the linear fluid sign represents areas of osteonecrosis with accumulation of fluid in acute vertebral compression fractures. it is highly indicative of osteoporosis, but may occur rarely in metastatic fractures. to compare the efficacy and stability of two different, "second generation", self-expandable, metallic, covered stents in patients with lower third malignant oesophageal strictures. material and methods: patients with inoperable disease were randomised to receive either an ultraflex (n = ) or flamingo (n = ) covered oesophageal stent. all procedures were performed in the interventional radiology suite using fluoroscopic guidance. dysphagia before and after stent placement was scored on a -point scale and the incidence of early and late complications was compared between the two groups. the initial technical success rate was % in both groups. improvement in the dysphagia score was demonstrated in both groups at both short and long-term follow-up (mean reduction of points). no significant difference was seen in the improvement of dysphagia between the two groups. the early (migration, severe reflux and perforation) and late (haematemesis, tumour ingrowth) complication rates were similar in both groups. purpose: mnd is characterized by bulbar symptoms resulting in reduced respiratory function, diaphragmatic paralysis and weakening of respiratory muscles. nutrition is a prognostic factor for survival but surgical or percutaneous endoscopic gastrostomy is not well tolerated. rig can be safely deployed with severe respiratory compromise. we describe our experience using a modified technique, which allows safe percutaneous puncture of a high subcostal stomach. mnd patients requiring nutritional support were selected for a rig as a consequence of a sub-normal vital capacity. the standard procedure for rig insertion was adhered to, with use of four t-fastners to secure a gastropexy. to take account of the high subcostal site of the stomach, the procedure was modified, performed with lateral screening, allowing for constant visualization of the puncture needles, to confidently puncture the anterior stomach wall.results: this modified technique has been employed in patients ( male and female, median age years, range - years) over a month period. standard radiological gastrostomy tubes were inserted, six were self retaining devices. the procedure was successful in patients ( %), tubes were reinserted ( %, all standard radiological tubes) over a variable period of time. the one failure was due to a high subcostal stomach in an obese patient. conclusion: diaphragmatic palsy presents a technical challenge for insertion of a rig in the conventional manner. using lateral screening a high success rate is achieved, and should be the method of choice for mnd patients with respiratory compromise. nineteen uncovered sems (diameters: - mm, length: - mm) were placed using fluoroscopic guidance in fifteen patients via a per-oral route using standard catheter and guidewire techniques. nine patients had pyloric obstruction. four had undergone gastric pull-up operations or partial oesophagogastrectomy for oesophageal or gastric carcinoma with pyloric dysfunction not responsive to balloon dilatation. five patients had inoperable oesophageal or gastric carcinoma involving the pylorus. six other patients had duodenal obstruction secondary to pancreatic carcinoma. in only three patients were two stents required to cover the obstruction. four patients with malignant obstructive jaundice required concurrent stenting of the common bile duct. results: all patients were able to consume an adequate diet after stent insertion. one stent migrated proximally into the fundus at day two in a patient with gastric carcinoma involving the pylorus. he presented five days later with perforation of the antrum at the tumour site which required emergency surgery. of the remaining patients (seven have died) none have experienced recurrent symptoms of gastric outflow obstruction over a mean follow-up period of fourteen weeks. conclusion: non-endoscopic placement of sems under fluoroscopic guidance is a safe and effective treatment for outflow obstruction secondary to pyloric and duodenal stenosis. it is particularly effective in the palliation of malignant disease, but also has a role on the treatment of pyloric dysfunction after gastric pull-up surgery. purpose: reference methods in diagnosis of crohn's disease are endoscopy and small bowel follow-through. involvement and activity of proximal segments of the small bowel is difficult to evaluate. our purpose was to develop a sensitive, easy to perform and minimal-invasive method for imaging small bowel without radiationexposure for mostly young patients. methods: patients ( female/ male) with suspected or established crohn's disease were included. the patients were administered orally . l of a mannitolsolution ( . %) within hour before imaging. a rectal mannitol-solution filling was also employed. butylscopolamin was administrated i.v. haste and fs-hastesequences and t -bh-sequences were acquired before and after (fs-t -bh) i.v. gd-dtpa administratio in transversal and coronal orientation. the images were analysed by three radiologist using a standardised protocol. in all cases a correlation with ultrasound-imaging was performed. results: alterations indicative of crohn's disease were noted in patients. in these cases we detected wall thickening with an average of . mm and with a mean length of . cm. the signal-intensity-increase after contrastmedium-application of thickened bowel wall was %. normal bowel-wall had an increase of signal-intensity after gd-dtpa of %. relevant stenoses ( %), abscesses ( %) and fistulas were visualized ( %). in ultrasound imaging we detected cases with a stenosis ( %), fistulous tracts ( %) and case ( %) with an abscess. conclusion: mannitol-mri of small bowel in patients with suspected or established regional enteritis is a promising method for the diagnosic work-up and renders results superior to ultrasound imaging. inflammatory bowel disease in children: helical ct with water enema administration g. tognini , f. ferrozzi , , g. zuccoli , a. patti , p. bini , p. pavone ; parma/it, cremona/it, reggio emilia/it purpose: the diagnosis of inflammatory bowel disease (ibd) in children, due to the non specificity of the clinical picture, is often difficult and delayed. the aim of our study was to assess the role of helical ct after water enema administration in the diagnosis and staging of ibd.materials and methods: consecutive patients with ibd ( ff, mm) age range: - years underwent spiral ct examination of the abdomen. the imaging protocol consisted of mm collimation, pitch: . , injection of iodinated contrast medium with high flow rates: - . ml/s. the lumen of the colon was filled with water ( - ml); oral administration of water was also performed in order to obtain gastric and duodenal distension. we evaluated: wall thickening, structure and enhancement of the involved segments, polypoid components, mesenteric fat involvement, adenopathies, extraparietal flogistic complications. / underwent endoscopic and bioptic confirmations: / were crohn's disease, ulcerative colitis, showed non specific features. results: wall thickening ( / ), increased contrast enhancement ( / ), endoluminal pseudopolyps ( / ), fibrofatty proliferation ( / ), edematous infiltration ( / ), mesenteric adenopathies ( / ), abscesses and flogistic complications ( / ). in / patients ct allowed for the correct differentiation between crohn's disease and ulcerative colitis. the morpho-structural evaluation which can be obtained by means of helical ct and water enema administration allow for an accurate study of the intra and extraluminal manifestations of the ibd. ct was found useful in the diagnosis but mainly in the follow-up of patients with ibd giving important differentiating criteria. ct signs of active crohn's disease and comparison with immunscintigraphy g. tóth, g. szentmártoni, t. györke, e.k. makó; budapest/hu purpose: this retrospective study compares the diagnostic yields of ct and immunscintigraphy in the assesment of activity in crohn's disease. we evaluated which ct signs are the best predictive signs of the activity in crohn's disease. we examined patients with clinically suspected crohn's disease. we studied patients first with bifasic dinamic helical ct and - days later with immunscintigraphy. ct studies were performed in a standard fashion: collimation mm, feed mm, reconstruction mm. i.v. contrast administration flow . ml/s, volume . ml/kg, delay s in a caudo-cranial direction. we were searching for bowel wall thickening, increased contrast enhancement of the bowel wall, mesenterial signs, fistulas and abscesses, and enlarged lymph nodes. ct results were correlated with immunscintigraphy. results: in cases where the affected loops showed thickened wall ( - mm) increased contrast enhancement and sourranded by a fibrofatty proliferation, with increased vascularisation the immunscintigraphy was positive in % of patients. when we saw fistulas, abscesses and a thickened bowel wall ( mm or more), with increased vascularisation in mesentery with prominent enlarged lymph nodes the immunscintigraphy was always positive. conclusion: contrast enhanced spiral ct study is a goog tool in the assesment of the activity in crohn's disease. results: in cases the embolization failed: no bronchial artery catheterized in the bleeding side (n = ), pulmonary artery bleeding due to central excavated lung tumors (n = ), right intercosto-bronchial trunk with a doubt about a spinal radicular artery (n = ), unstable catheter position (n = ) and technical problem (n = ). among the patients with at least one bronchial artery selectively catheterized (included non-embolized), bronchial hypervascularisation was visualized in associated with nonbronchial systemic hypervascularisation in cases. the immediate control of bleeding was obtained in %. long-term result was . %.complications were: acute but transient renal failure (n = ), cerebral ischemia (n = ) with one definitive deficit. conclusion: tumours are responsible of . % of massive hemoptysis and embolization is efficient. the bleeding is rarely due to nonbronchial arteries. stroke incidence is increased in comparison with other hemoptysis probably because of elderly patients. intraoperative transthoracic ultrasonography for the localization of hidden pulmonary nodules during thoracoscopy f. coppola, m. piolanti, f. gruppioni, s. papa, m.p. di simone, s. mattioli, g. gavelli; bologna/it purpose: the purpose of this study was the evaluation of intraoperative sonography in the detection of hidden pulmonary nodules during thoracoscopic resection. to perform intrathoracic ultrasonography an endosonographic linear probe with high-frequency transducer ( . - mhz) was employed. patients, entered the study; pulmonary nodules were preoperatively detected, by spiral ct and by pet. sonographic examinations were performed during thoracotomic surgery and examinations during thoracoscopy. the times needed to reach lung collapse and to localize the targets were recorded. complete lung collapse is essential to perform intraoperative sonography and can be accomplished by single controlateral lung intubation and ventilation for minutes at least. the sonographic examination is quick, unless the patient is affected by obstructive disease (such as centrilobular emphysema): retained air in the parenchyma reduces the explorability. all but one preoperatively detected lesions and two further unknown lesions were localized by intraoperative sonography. there were no complications related to the procedure. conclusions: intraoperative sonography proved itself to be a reliable and satisfactory localization technique of lung nodules during thoracoscopy. in comparison with the other localization techniques it shows several advantages, such as the capability of revealing preoperative occult lesions and determining the surgical borders. the aim of this study was to assess the accuracy of wire-versus carbon-localization in slobb. a total of slobbs were performed from / until to / in female patients (age range, - years) on a prone stereotactic unit (mammotest, fisher imaging, denver, co). in cases successful slobb was verified either by a malignant histopathological diagnosis or by immediate mammographic evaluation after surgery. in ( %) of these cases the lesion was localised with a wire, in cases ( %) carbon was used. both methods were used to localise the remaining cases ( . %). a lesion was considered as missed when it could be still seen on mammography performed after surgery. results: ten out of cases ( %) were missed at slobb. of these, lesions had been localised by wire ( / ; miss-rate . %) and lesions with carbon ( / ; miss-rate . %). there were no significant differences in miss-rates between wire-and carbon-localisation (p > . ). conclusion: both wire-and carbon-localisation are reliable and accurate in the localisation of non-palpable breast lesions undergoing slobb. considering the fact that wire-localisation is far more expensive than carbon-localisation the routine use of carbon should be considered. histological results of scnb and surgical biopsy were compared and scored for each needle size on a three point scale ( = no agreement, = partial agreement, = complete agreement) to determine the optimal needle size for such lesions. results: there were masses, asymmetric densities, and calcifications. a diagnosis of malignancy was found at surgery in / ( . %) [ ductal carcinoma in situ]. the remaining lesions revealed a benign histology. the g needle (score = ) scored better than both g needles (score = . ). conclusion: based on the relative low rate of carcinomas scnb should not be performed routinely in probably benign lesions (bi-rads ). mammographical short time follow-up seems to be more useful to confirm the benign nature of such lesions. if scnb will be performed g needles seem to be advantageous. does the preoperative core-cut biopsy influence the appearance of local recurrence of breast cancer? u.g. aichinger, j. ammon, r.w.s. schulz-wendtland, i. kuchar, w.a. bautz; erlangen/de objective: retrospective study to evaluate if preoperative core-cut biopsy influences the incidence of local recurrence of breast cancer and metastasis -a phenomenon described after puncture biopsies of the pancreas and the prostate. material and methods: core-cut biopsy was performed on patients with suspected breast cancer before undergoing surgery in the period - . the clinical outcome of patients was analysed retrospectively over a period of seven years. had undergone breast conservation therapy, had had a mastectomy. adjuvant therapy was also included in the evaluation. results: local recurrence after breast conserving therapy (bct) was seen in of patients ( %), and in of ( %) after mastectomy (mrm). the rate of local relapse after radiotherapy (rt) was of ( %) (bct) and of ( %) (mrm) respectively. in the group without rt of ( %) (bct) and of ( %) (mrm) relapsed respectively. in two cases the biopsy site was not removed. one of those, not having had a rt, had a local recurrence. conclusion: according to the literature, breast cancer local recurrence rate is - % per year. in our group recurrence rate reached . % totally per year and . % after bct being in agreement with international studies. no higher rate of local recurrence or metastasis was seen after core-cut biopsy. nevertheless the biopsy site should be removed in any case. multicenter evaluation of stereotactic vacuum biopsies of mammographically indeterminate or suspicious lesions the consensus was achieved based on the existing literature and on the experience of the participants using a consensus process as suggested by sackett. results: complete standard imaging work-up is the prerequisite before a decision for percutaneous breast biopsy is made. the following lesions are considered well-suited for vacuum biopsy: microcalcifications, small non-palpable masses with or without microcalcifications. the following indications may not be (as well) suited: architectural distortion (suspected radial scar) or lesions close to the skin. needle access (angulation of compression, stroke margin) must be exactly documented. acquisition of > cores ( g) shall be routinely attempted (goals: radiologic removal of lesions < mm to increase diagnostic reliability, decrease of underestimates). documentation of scout, pre-, post-fire and post-biopsy images and another orthogonal view after biopsy are required. final diagnosis must consider imaging-histopathologic correlation, and for certain histopathologic entities the result on an interdisciplinary conference. standard documentation of the examination and of months-follow-up is required. the closed architecture of . t whole body magnets makes it difficult to perform mr-guided biopsies at high-field strength. the aim of this study was to investigate the feasibility of mr-guided breast biopsy using a remote-controlled robotic system which assists the localisation of the target and runs inside the magnet. materials and methods: patients with suspicious lesions (diameter ± mm) in mr-mammography were biopsied using the robotic system. after localisation of the lesion the robotic system positioned the troacar at the correct position. the troacar was inserted into the breast in front of the lesion. the specimen was taken in coaxial technique using a g core needle biopsy gun. in case of malignant histology the patient underwent open surgery afterwards. the biopsy procedure inside the magnet was completely performed without interruption in all cases. operation proved the histological finding of breast cancer in cases. one patient was diagnosed as atypical ductal hyperplasia by biopsy and turned out to have an invasive ductal carcinoma. patients showed benign lesions and will be followed up. the current study demonstrated the feasibility of breast biopsies inside the magnet of a whole body scanner using a robotic system. one false negative case was due to tissue shift during the insertion of the troacar into the breast. first experiences with two patients show the procedure to be feasible. in future imaging, biopsy and therapy of breast lesions should be possible in one single patient session using this robotic system. to assess the feasibility of assessment of stent-graft patency by contrast-enhanced magnetic resonance angiography (ce-mra). materials and methods: bifurcated abdominal aortic aneurysm (aaa) stentgrafts made of nitinol, elgiloy or stainless steel were investigated regarding their appearance on mr imaging. the stent-grafts were positioned in a phantom filled with aqueous gadolinium solution. coronal and axial three-dimensional gradient echo sequences were performed (tr . ms/te . ms, fa °). relative signal intensity reduction within the stent-grafts and the difference of the real stent-graft lumen as compared to the lumen measured on the mr images were calculated. results: the graft lumen was depicted in prosthesis. the lumen of stainless steel stent-grafts showed a complete signal void. relative narrowing of the inner diameter on the mr images was less in the proximal part of the stent-grafts than in their legs. with a gadolinium dilution of : the artifical narrowing of the proximal lumen ranged from . % to . %, whereas in the stent-graft legs the visible lumen was diminished between . % to . %. only three stent-grafts presented with a lumen reduction on the mr images of less than % along the whole prothesis length. conclusion: to differentiate between artifacts and stenoses, a knowledge of the degree of signal intensity reduction and artificial lumen narrowing within aaa stentgrafts is essential. stent-graft composition and the design of the stent-graft influence the artifact behaviour and lumen visibility as displayed on ce-mra. only a minority of the investigated stent-grafts is suitable for imaging by ce-mra. patients with aaa undergoing endovascular stent grafting were included in the study. helical ct scanning was performed within one week following stent graft implantation with a scanning protocol of collimation mm, pitch . , and a mm reconstruction interval. contrast enhancement was given to all patients with a total volume of ml, flow rate of ml/s and scan delay of seconds. all patients received a zenith tm /aaa endovascular graft with uncovered supra renal struts of . cm length placed above the level of the renal arteries. vie images were created for each patient with analyze avw . . the follow-up period ranged from to months (mean . ± . months). results: of coeliac arteries, of superior mesenteric arteries, of right renal arteries and of left renal arteries were covered by the stent struts to different extents. vie demonstrated the number of metal wires crossing the arterial ostia and the configurations of these stent struts relative to the arterial ostia such as partial or complete encroachment. follow up ct scanning showed that all of these aortic arterial branches were patent. conclusion: vie is a novel imaging technique to visualise the d intraluminal relationship of the aortic stent struts to the arterial ostia in patients with aaa following suprarenal stent grafting. the current system consists of a see-through, headmounted display, a tracking system, computer system and tracked surgical instruments. interaction with the system is provided through voice and speech. the system produces a computer-generated image overlaid onto the real world, using virtual "hanging windows" for information display eg. ct/mr scans, real-time fluoroscopy, vital signs, live video (endoscopy), step-by-step instructions, dictation/ communication screens, d models of anatomy and other information to assist the radiologist during a procedure. in addition, different pre-and post-stent d models of the aortic aneurysm from recent procedures can be brought up within the environment for comparison or as a reference. the user can also bring up patient-specific d reconstructions. results: this system provides assistance during aaa stent placement. all previous imaging series (ct-, mr-, and conventional angiography), stent planning data, d models of the aneurysm and monitoring of vital signs are shown on one screen (head mounted display) in "hanging windows" on request. the software provides a real-time surgical simulation system with integrated monitoring and information retrieval and a voice input/output subsystem. the system provides all the important information on one screen (head mounted display) and can be used to assist various tasks such as stent implantation procedures in the interventional radiological theater. a.m. grozaj, t. pfammatter, m. lachat, u. wolfensberger, p.r. hilfiker; zürich/ch purpose: to report midterm results of endovascular stent-grafting in patients with ruptured abdominal aortic aneurysm (raaa). materials & methods: patients ( women, men; mean age years) with raaa were treated with bifurcated endoprostheses. preinterventional assessement was performed with ct (n = ), ultrasound (n = ) and angiography (n = ). all patients were a high operative risk. the procedure was performed under local (n = ) or general anesthesia (n = ). follow-up cta was performed after day, weeks, , , months and annually. results: immediate technical success was achieved in patients ( %). one needed conversion to open surgery due to progressive hemodynamic instability. mean intervention time was min (± ), mean icu stay . days (± . ) and mean hospitalization days (± ). the day mortality was %. within days one patient was treated with hemofiltration and three had reinterventions: replacement with homograft of an infected iliac-femoral extension sg; sg extension for retroperitoneal bleeding; embolization of the inferior mesenteric artery. in the mean follow-up period of months two endovascular reinterventions were performed: sg implantation for graft disconnection; thrombolysis of a stent leg. one patient needed elective late conversion to open surgery after months due to sg migration. aneurysmal diameter decreased in . %, increased in . % and remained unchanged in . % of patients. conclusion: endovascular treatment of raaa with sg implantation is feasible and safe. this technique seems to be a valuable alternative to emergency open surgery with its high mortality. emergency treatment of thoracic aorta diseases by endovascular stentgraft l. lovato, r. fattori, g. napoli, c. grazia, f. settepani, g. gavelli; bologna/it purpose: surgery of the thoracic aorta is characterized by high mortality and morbidity, especially if performed in an emergency. we report our experience in emergency endovascular treatment of the thoracic aorta. material and methods: from , patients underwent endovascular treatment of the thoracic aorta. seven ( type b acute aortic dissections, traumatic aortic ruptures, penetrating aortic ulcer and surgical prosthesis dehiscences) presented with clinical and/or imaging findings of impending aortic rupture and were treated as an emergency. before the procedure, spiral ct was used to define the lesion's anatomy. all procedures were performed in the operating theatre and monitored by a radiographic c-arm system and by echocardiography. results: stent-graft implant was successful in all patients. no death nor complication occured during the procedure. in cases, immediately after stent-graft implant, surgical drainage of a hemothorax was performed. the average time of intensive care unit stay was ± hours, while hospital stay was ± days. in patients a spiral ct follow-up showed complete aneurysmal exclusion; case showed persisting leakage over months and was converted to surgery. conclusion: endovascular stent treatment of thoracic aorta diseases could be a very effective option and an alternative to surgery, especially in an emergency. endovascular treatment of thoracic aortic aneurysms and dissections with the use of customized stent-grafts q. sénéchal, f. koskas, p. cluzel, j.-d. singland, e. kieffer, p.a. grenier; paris/fr purpose: to describe our experience with the use of a custom stent-grafts for the treatment of thoracic aortic aneurysms and dissection. patients and methods: from january to september , aneurysms and dissections were selected to be treated using custom stent-grafts of different designs. custom stent-grafts were constructed with gianturco z stents sutured together and covered with polyester (twillweave, vascutek, innachinnan, scotland). endovascular treatment of aortic arch aneurysms combined with extraanatomic bypasses were used in cases. elephant trunk in one step was used in three cases. endovascular bypasses were used as the second step of the elephant trunk technique in two cases. results: four patients ( %) were converted to standard open repair. no leakage of the thoracic aneurysms was observed at follow-up. sealing of the primary tear in thoracic aortic dissections was successful in all cases. three patients died of myocardial infarction in the perioperative period. conclusion: custom stent-grafts in the endovascular treatment of thoracic aortic pathology achieve good results. endovascular treatment of aortic arch aneurysms combined with extra-anatomic bypasses provides a less invasive method of treatment of these complex lesions. longer follow-up is needed for the device. percutaneous treatment of thoracic aortic dissections and thoracic aortic aneurysms using commercially available stent-grafts f. fanelli, f. salvatori, m. rossi, g. marcelli, f. venditti, p. rossi; rome/it purpose: to report our preliminary experience in the treatment of thoracic aortic dissections and thoracic aortic aneurysms (taa) using endovascular stent-grafts. methods and materials: from november , patients were treated using a commercially available stent-graft: thoracic excluder (w.l. gore). twelve cases were performed in the angio-suite and in the or under general or epidural anesthesia. taa: patients. in two patients ( . %), with a short proximal neck, the origin of the left subclavian artery was covered by the stent-graft. dissection: patients with type b dissection, acute and chronic. two cases were complicated by renal ischemia treated by renal stenting. the primary entry tear was located in patients less than cm from the origin of the left subclavian artery which was covered by the stent-graft. results: after a follow-up ranging from to months, all patients are in a good condition with no signs of paraplegia. taa: technical success with complete exclusion of the aneurysm was evident in all cases. dissection: technical complication ( . %) was observed during stent-graft deployment of antegrade extension of the dissection into the ascending aorta which was surgically managed. in all cases progressive thrombosis of the false lumen developed. in cases ( . %) an endoleak was detected: one, originating from the subclavian artery was treated by coil embolization; one sealed spontaneously after months; the last one is under control. conclusion: endovascular techniques represent a new frontier in the treatment of thoracic dissection and taa, but further evaluations are mandatory to clearly understand its efficacy. the probability of location of breast mass margin in digitised mammograms f. sendra-portero, e. ristori-bogajo, e. nava-baro, m. martínez-morillo; málaga/es purpose: most of the computational problems in segmentation are originated by tortuous contours which are difficult to be perceives by either a computer segmentation program or a human observer. a method based on successive interactive segmentations of breast masses in digitised mammograms to plot the probability of location of the mass contour is introduced. materials and methods: digitised mammograms including masses with different type of margins were studied. the border of each mass was outlined with a digitising tablet, encompassing all densities considered as part of the mass, including spicules and tracts. two observers repeated the same procedure three times. the segmentations of the same image were split off between them hours at least. a labelled image was obtained from the six binary images of each case, giving seven possible values per pixel, from to . thus, the lines that delimit each value are considered "isoprobability lines", encompassing a probability equal to . ; . ; . ; . ; . and . to find the mass margin. results: when the margin is well defined the isoprobability lines are closed one each other, with a sharp transition from to . in exchange, when the margin is illdefined obscured or speculated, the isoprobability lines spread out. in those combined type margins the uncertainly zones are clearly distinguished from well defined zones. conclusion: images obtained by this method can be used as a reference pattern to evaluate automatic or semi-automatic computer-aided segmentation systems of breast masses. results: mfe-vq employing , , and cvs identified clusters that could be attributed to known suspicious regions in each case. the lesions could clearly be differentiated from surrounding tissue. in patients, single clusters could be related to motion artifacts based on signal dynamics and cluster localization. in addition, a self-organized subclassification within the lesions could be achieved in up to clusters w.r.t. fine-grained local differences in mri signal amplitude and dynamics. conclusions: mfe-vq by deterministic annealing is a useful strategy for the analysis of contrast-enhanced mri mammography time-series without time-consuming interactive contour tracing of regions of interest by human observers, thus enabling segmentation of suspicious lesions. in addition, a subclassification w.r.t. local differences of perfusion patterns inside suspicious regions can be achieved. in three dimensional medical imaging like ct or mri, knowledge based approaches foster the robustness and reliability of segmentation processes. a robust fully automatic segmentation is a desirable task to acquire objective and accurate results. a d surface model for the segmentation of parenchymal organs in ct-and mri-datasets has been developed. the necessary training set for the surface model is computed from semiautomatically generated triangulated surface meshes of the objects. the generated surface model is capable of learning the characteristic shape and gravalue information stored in the training set. the optimization is performed by iteratively moving the surface points of the model towards fitting image structures under the constraints of its grayvalue and shape information. two different d surface models have been developed: a milt model consisting of training objects, and a kidney model generated from left kidneys. the two models have been tested on unknown milt-and also unknown kidney-datasets. the total cover between the model and the organs varied between % and %, which is a respectable result in the face of the small training set. further the computing time of the model optimization lies in contrast to other approaches within a few minutes on a standard pc. to overcome the problems segmenting organic structures in ddatasets using arbitrary methods, a knowledge-based d surface model has been successfully introduced. the segmentation accuracy of the model can be actually improved by using a larger training set in future. use of the dicom file format for quantitative analysis of brain images m. larobina , a. prinster , m. quarantelli , a. ciarmiello , j.p. hornak , b. alfano ; naples/it, rochester, ny/us purpose: to review our experience using dicom format files to perform quantitative analysis of mr brain images. we use an algorithm that performs segmentation and volumetric measurement of normal and abnormal brain tissue. the method is based on calculations of relaxation rates of brain tissues from spin-echo images. the algorithm reads dicom format images, and requires repetition time, magnetic field strength, slice location, fov, and matrix size information from the dicom file header. we have applied the algorithm to studies performed on ge signa . t, ge signa . t, philips gyroscan nt . t, picker eclipse . t, and siemens magnetom . t. results: images generated by these scanners reveal that the manufacturers interpret dicom standard differently. in some cases, the file header reports fields with structure or content not always in accordance with the dicom standards. deviations in the dicom header usually do not render the file unreadable, but do hinder the use of the header information and the dicom format. the dicom format has the potential to become the format of choice for all the post-processing of mr images. unfortunately, the standard is too complex to easily discover if violations of the standard are present. we emphasize the need to have a way to know if a set of dicom files is totally compliant with the dicom standard. the use of images that are labeled dicom-compliant except for information reported in one field represents a non-negligible problem. multi-slice ct for visualization of pulmonary embolism using perfusion weighted color maps j. purpose: to evaluate the feasibility of a new technique for perfusion weighted colour display of lung parenchyma density derived from multi-slice ct (msct) data sets for visualization of pulmonary embolism (pe). methods and materials: imaging of patients with suspected pe was performed on a msct (somatom volume zoom; siemens, forchheim, germany) after intravenous application of cm of contrast-medium. based on thin collimation axial slices (slice thickness . mm, reconstruction increment . mm), a new image processing technique was deployed. automated d-segmentation of the lungs was performed followed by threshold based extraction of major airways and vascular structures. the filtered volume data were color encoded and finally overlayed onto the original ct-images. this color encoded display was presented in axial, coronal and sagittal plane orientation. in ten patients with excluded pe as well as in ten patients with proven pe the new technique was performed. results: in ten patients, considered negative regarding pe on msct, lung densitometry showed a homogeneous distribution of color encoded densities without circumscribed decreased or increased areas. in the patient group with proven pe, low density values on perfusion weighted colour maps were found distally to the occluded pulmonary arteries. conclusion: our initial experience indicates that lung densitometry with an optimized colour encoded display of the density distribution within the lung parenchyma may provide additional information in patients with suspected or proven pe. the evaluation of first-pass myocardial perfusion imaging in patients with coronary artery disease (cad) represents a complex issue in the field of cardiac mri. commercially available software allows placement of regions of interests (rois) into the myocardium and calculation of mean signal-intensity over time. however, small perfusion defects may be missed using this method due to the large area of rois. purpose of our study was to develop a pixel-based evaluation software for mr myocardial perfusion images. we chose a matlab based approach (matlab version . ). our software enables the user to register the images using a least-square-algorithm. images can be filtered with a median filter. maximum upslope and area-under-the-curve for the signal intensity are calculated for each pixel and shown graphically. myocardial perfusion measurements were performed in patients with angiographically proven cad using a sr-truefisp- d-sequence (tr . ms/te . ms). mr perfusion data were analysed with our software and compared to spect and angiography. results: data of patients could be adequately analysed with the software developed. parameters upslope and area-under-the-curve in regions found to be malperfused by mri correlated well with angiographically detected coronary artery stenosis and hypoperfused areas detected by spect. main limitation of the method was incorrect registration of images, caused by cardiac arrhythmia and patient motion. conclusions: semi-automated pixel-based analysis of perfusion measurement is possible and the promising results of this analysis correlate with angiographic and spect findings. artefact free data acquisition and image registration are important and the limiting factor for pixel-based analysis. purpose: to evaluate clinical feasibility of spatial domain filtering as an alternative to additional image reconstruction using different kernels in chest ct. methods and materials: adult patients with clinical suspicion of pulmonary embolism were examined utilizing multi-slice ct (somatom volume zoom, siemens, germany). two sets of images were reconstructed using lung (b ) and soft tissue (b ) kernels, respectively. additionaly, b images were filtered in the spatial domain, producing images largely equivalent to b images. diagnostic images were compared to the initially reconstructed b images. subjective image quality was rated using a three point scale ( = excellent, = fair, = nondiagnostic). results: filtered images provided central emboli, segemental thrombi and emboli on the subsegmental level in the patients with proven pulmonary embolism. latter was excluded in the other subjects. subjective gradings of image quality, based on soft tissue settings were comparable for all data sets. therefore, these filtered images provided exactly the same diagnostic accuracy for central, segmental and subsegmental pulmonary embolism compared to conventional soft tissue reconstructions. the new method presented has proven to be clinically feasible and should therefore be implemented in the clinical enviroment. online modifications of image sharpness and pixel noise in real time will potentially replace the need for multiple reconstructions using different kernels. volume rendering of portal liver vessels: correlation between d recostruction parameters and image quality g. luccichenti, f. cademartiri, p. pavone; parma/it purpose: aim of this work is to determine the influence of the scan, density values and opacity curves in three-dimensional reconstruction with volume rendering technique of portal liver vessels. methods and material: patients with previous abdominal ct or us underwent spiral ct during the arterial and the portal phase with the following parameters: collimation mm, feed . mm, pitch . , increment mm. images were sent to a workstation running on a nt platform equipped with vitrea . (vital images, usa) allowing d reconstructions in order to generate volume rendering of the liver vascular supply. density values of portal vessel (p) and liver (l) parenchyma were measured and correlated with d image quality and the parameters of three different opacity curves (oc) utilized to obtained them. results: better visualisation of arterial supply was obtained with non linear opacity curves. it was possible to clearly demostrate them up to the fifth generation. significative correlations were observed between curve parameters (c), liver and portal vessels densities ratios (c vs p and c vs l r = . and r = . respectively for linear oc and r = . and r = . for non linear oc). correlation between c and d image quality was r = . and r = . for linear and non linear oc respectively. p/l density ratio poorly correlate with d image quality r = . . wilcoxon test was significant between the three opacity curves. conclusion: d image quality mainly depends on scan quality. density ratios are important to set the opacity curve parameters. direct volume rendering based interactive virtual colonoscopy d. jocha, j. koloszár; budapest/hu purpose: virtual colonoscopy is a non-invasive computerized medical examination method for examining the interior of the human colon, aiding the detection of polyps. nowadays systems for this purpose are slow and/or require special hardware and have many other problems making their usage difficult and limited. our purpose was to develop a system without these disadvantages. materials and methods: in our study we have examined the most popular approaches to the problems of high-speed rendering and navigation within the colon, and devised our own algorithms. our intent was to make them fast and reliable enough to be implementable on a consumer-end pc system, instead of state of the art high-end workstations, and to minimize off-line calculations. results: we present our idea of a real-time direct volume rendering based visualization technique combined with an on-line computer aided interactive navigation method for the examination of volume data constructed from ct scans. these algorithms have been implemented in our colon visualization program called colvis. the results are promising, the current implementation is close to the real-time requirements (∼ seconds/frame). conclusion: according to our results virtual colonoscopy can be an everyday diagnostic method in the near future. results: acl and pcl avulsion fractures occurred with equal frequency. acl avulsion fractures occurred more commonly in adults than previously believed. about one half of acl avulsion fractures are partial, involving the anteromedial bundle only, one quarter are comminuted and one-half are extended. pcl avulsion fractures occur in an older age group than acl avulsion fractures. the majority are complete, half are comminuted (between the individual pcl bundles) and half are extended. when compared to anteroposterior and lateral radiographs, ct is helpful at delineating the fracture margins (for type i and ii fractures) and at delineating comminution and extent in pcl injuries. three-dimensional ct allows good perception of the fracture type and tibial bony defect as a prelude to operative reduction. this study leads to a better understanding regarding the relative freqeuncy and variablity of cruciate avulsion fractures and indicates those areas where ct is particularly helpful. dual-detector spiral ct arthrography of the knee: assessment of anterior cruciate ligament and associated meniscal tears b. vande berg, f.e. lecouvet, p. poilvache, j.e. dubuc, b. maldague, j. malghem; brussels/be purpose: to assess dual-detector spiral computed tomography (ct) arthrography of the knee in the evaluation of anterior cruciate ligament (acl) and associated meniscal tears. the acl and meniscal abnormalities in consecutive patients who underwent dual-detector spiral ct arthrography of the knee were evaluated based on both initial interpretations and retrospective review of ct images and were compared with arthroscopic findings. the sensitivity and specificity of ct arthrography for the detection of acl tears and of meniscal lesions in aclabnormal knees were determined. results: the sensitivities and specificities for the detection of acl tears were % and %, respectively, at initial interpretation and % and %, respectively, at retrospective interpretation. the sensitivities and specificities for the detection of meniscal tears in acl-abnormal knees were % and %, respectively, at prospective initial interpretation and % and %, respectively, at retrospective interpretation. conclusion: dual-detector spiral ct arthrography of the knee is an accurate method for detecting acl and associated meniscal tears. d-tof unenhanced and d-spoiled-gre contrast-enhanced images were acquired. unmatched, randomized evaluation of images was performed on-site and by two off-site blinded reviewers. the change from unenhanced mra in total diagnostic quality (tdq) was evaluated for each patient using a five-point scale. evaluation was made also of the number of vascular lesions detected, confidence in lesion characterization and the ability to grade stenoses. a full safety assessment was performed. results: both off-site reviewers noted a significant improvement in tdq from preto post-contrast at all but the lowest dose. the increase appeared to plateau at . mmol/kg. the dose effect was significant for the on-site reviewers (p = . ) and off-site reviewer (p < . ) but not for off-site reviewer (p = . ). for all but the lowest dose group, gd-bopta increased (a) the number of patients with lesions detected and, for most patients, the number of lesions detected per patient; (b) confidence in lesion characterization; (c) the percentage of stenoses visualized clearly enough for grading (reviewers and graded - % and - % of stenoses, respectively). all doses were well tolerated. the overall incidence of adverse events was . %. conclusion: ce-mra of the pelvic arteries using gd-bopta is safe and significantly more effective than tof-mra. a dose of . mmol/kg appears the most suitable. purpose: the purpose of this study was to evaluate the feasibility of blood pool contrast-enhanced mra to visualize the arterial and venous vessel tree and to detect deep venous thrombosis (dvt) of the lower extremities. material and methods: nine consecutive patients with pulmonary embolism (mean age: ± ) were randomized to various doses of nc (between . and mg fe/kg b.w.). a t w d-gre sequence (te: . ms, tr: . ms) was used. two observers blinded to the dose of contrast agent assessed image quality, contrast attenuation and appearance of thrombi.results: qualitative assessment of overall mra image quality and semiquantitative vessel scoring revealed good to excellent delineation of venous and arterial vessel segments independent of the dose of nc . however, quantitative roi analysis revealed a significantly higher s/n ratio in the high dose group compared to the mid and low dose groups of nc (p < . ). between dose groups, s/n ratio was independent of vessel type (artery or vein) and vessel segment localization (proximal or distal). all seven venous thrombi (mean length . ± . cm) were characterized by a very low si, which was only . ± % of the si in adjacent venous segments (p < . ).conclusions: high quality mr angiograms of the lower extremities can be obtained using low concentrations of nc in combination with a strong t w d-gre sequence. the obvious delineation of venous thrombi suggest that this technique may be potentially used as a non-invasive "one-stop shopping" tool in the evaluation of thromboembolic disease. injection-associated pain in femoral arteriography: a european multicentre study comparing safety and efficacy of iodixanol and iomeprol c. manke , f. cognet , a. page , j. pueyo , n. batakis ; regensburg/de, dijon/fr, winchester/gb, mallorca/es, athens/gr purpose: to evaluate injection-associated pain, safety, and efficacy with the isoosmolar contrast medium iodixanol (visipaque mg i/ml) compared with iomeprol (iomeron mg i/ml) in femoral arteriography. materials and methods: a prospective, multicentre, double-blind, randomised, parallel-group clinical trial was performed in nine hospitals in europe. of the patients evaluated, received iodixanol and received iomeprol during peripheral arteriography (automated stepping intra arterial dsa). the first injection was standardised (volume ml, flow rate ml/s), additional injections were performed according to needs. the injection-associated pain, safety and efficacy were evaluated. adverse events were recorded during the procedure and up to hours after the examination. the iodixanol group reported statistically significant less injection-associated pain than the iomeprol group after first injection ( . % vs. . %; p = . ), and after all injections ( . % vs. . %; p = . ). no significant differences were found between the iodixanol group and the iomeprol group for frequency of contrast-related adverse events ( . % vs. . %). overall diagnostic utility was excellent/good for . % of the patients in the iodixanol group and . % in the iomeprol group (p = ns). in this trial iodixanol mg i/ml caused significantly less injectionassociated pain during femoral arteriography than iomeprol mg i/ml and was shown to be equally safe. despite lower iodine concentration, iodixanol provided similar diagnostic efficacy to iomeprol. optimizing vessel enhancement for cta of the pulmonary vasculature by contrast media dilution c.w. bader , j.m. froehlich , h.a. lohr , j. sousa , c.l. zollikofer , k. wentz ; winterthur/ch, wädenswil/ch purpose: to verify the hypothesis, that with a defined amount of g iodine a higher injection rate of diluted contrast media (iobitridol) results in higher vessel enhancement in pulmonary cta methods and materials: after bolus timing, ctas were performed in patients divided into groups: group a with patients (age ± a, ml cm, mg/ml concentration, flow ml/s) and group b with patients (age ± a, ml cm, mg/ml concentration, flow ml/s). each cm application was followed by a saline flush of ml. contrast enhancement of the pulmonary trunc, right and left main arteries and lower lobe arteries was measured. results: contrast enhancement of the pulmonary trunc was ± hu in group a and ± hu in group b, the right pulmonary artery ± and ± hu, the left pulmonary artery ± and ± hu. in the right lower lobe artery contrast enhancement was ± hu in group a and ± hu in group b, the left lower lobe artery ± and ± hu and the mean enlancement values of all measured pulmonary arteries was ± and ± hu. the effect on vascular enhancement was most significant (z-test, two sided p-values) in the pulmonary trunc (p = . ) followed by all measured pulmonary arteries (p = . ) and least remarkable in the lower lobe arteries. with an identical amount of g iodine, the higher injection rate of diluted cm leads to a significant increase of vessel enhancement in cta of the pulmonary vasculature. with exact bolus timing this can be used to reduce the applied dose of iodine per patient. purpose: to evaluate prospectively diagnostic accuracy of mol gadobutrol as a contrast agent for intraarterial x-ray digital subtraction angiography (dsa) in comparison to iodinated, non-ionic contrast media and . mol gadolinium-dtpa. methods: flush arteriograms (ascending, descending, abdominal aorta, iliac and femoral arteries) and selective angiograms (carotid, renal and visceral arteries) were obtained from bilateral femoral arterial access ( f sheaths) in ten domestic pigs ( kg body weight). digital subtracted angiograms were obtained during injecton of non-diluted mol gadobutrol, mg i/ml iopromide, or . mol gadopentetate. injection parameters (volume and velocity) were similar for all three contrast agents. in paired arteries, two different contrast media were used during the same angiographic run. diagnostic quality and accuracy of the angiograms were evaluated on a three-step scale by three independent blinded investigators. results: sufficient angiographic images were obtained in % of cases using iodinated contrast material. gadobutrol achieved sufficient non-selective angiograms in %. selective angiograms were sufficient in % using iodinated contrast material, % using mol gadobutrol and % using . mol gd-dtpa. adverse reactions to any of the used contrast agents were not noted. conclusion: mol gadobutrol solution allows x-ray digital subtraction angiography with an diagnostic accuracy equivalent to mg/ml iodinated contrast media, if selective injections are performed. flush aortograms are of inferior image quality to iodinated contrast material. m gadobutrol achieves significantly better image quality compared with . mol gadolimium solutions. high iodine concentration non ionic contrast agent. comparison with lower iodine concentration in peripheral multislice ct angiography c. catalano, a. laghi, r. brillo, f. fraioli, f. pediconi, a. napoli, i. reitano, r. passariello; rome/it purpose: multislice ct (msct) has already proved a very accurate technique in the assessment of different vascular pathologies. purpose of this study was to determine whether high iodine concentration non ionic contrast agent could improve vascular enhancement and vessel conspicuity. material and methods: patients referred for msct angiography (mscta) of the aorta and peripheral arteries were included in the study. all examinations were performed with a msct using a fixed delay time of seconds. in all patients a standard amount of g of iodine was administered at ml/s. all patients were randomly assigned to one of three following groups: group consisting of ml of mg i/ml; group consisting of ml of mg i/ml; group consisting of ml of mg i/ml. rois were obtained at different. a qualitative assessment was also made by two observers, regarding image quality and vessel conspicuity. results: no significant difference was detected between the and the mg i/ml contrast agents at the level of the aorta, pelvic and thigh arteries; a % difference was found between the and mg i/ml in the same districts. with the mg i/ml a significant increase in vascular enhancement of respectively and % was seen in the popliteal and infrapopliteal arteries. conclusion: a significant improvement in contrast enhancement and vessel conspicuity can be achieved in mscta by means of high iodine concentration contrast agents. key: cord- -hel h h authors: brown, julianne r.; bharucha, tehmina; breuer, judith title: encephalitis diagnosis using metagenomics: application of next generation sequencing for undiagnosed cases date: - - journal: j infect doi: . /j.jinf. . . sha: doc_id: cord_uid: hel h h background: current estimates suggest that even in the most resourced settings, the aetiology of encephalitis is identified in less than half of clinical cases. it is acknowledged that filling this gap needs a combination of rigorous sampling and improved diagnostic technologies. next generation sequencing (ngs) methods are powerful tools with the potential for comprehensive and unbiased detection of pathogens in clinical samples. we reviewed the use of this new technology for the diagnosis of suspected infectious encephalitis, and discuss the feasibility for introduction of ngs methods as a frontline diagnostic test. methods: a systematic literature review was performed, using mesh and text word searches for variants of “sequencing” and “encephalitis” in medline and embase, and searching bibliographies and citations using the web of science database. two authors independently reviewed, extracted and summarised data. findings: the review identified articles reporting case reports of patients with suspected encephalitis for whom ngs was used as a diagnostic tool. we present the data and highlight themes arising from these cases. there are no randomly controlled trials to assess the utility of ngs as a diagnostic tool. interpretation: there is increasing evidence of a role for ngs in the work-up of undiagnosed encephalitis. lower costs and increasing accessibility of these technologies will facilitate larger studies of these patients. we recommend ngs should be considered as a front-line diagnostic test in chronic and recurring presentations and, given current sample-to-result turn-around times, as second-line in acute cases of encephalitis. encephalitis is defined as inflammation of brain parenchyma associated with neurological dysfunction. , it is strictly a pathological diagnosis. recent epidemiological studies suggest that the global burden of encephalitis has been grossly underestimated, with current incidence suggested to be over annual cases in the uk, and , worldwide. , the syndrome encapsulates a myriad of diverse diseases, with distinct global distributions, presenting features and clinical courses. , infections represent the most frequently identified aetiology, with data suggesting this accounts for - % of cases. , , hundreds of pathogens have been associated with encephalitis, with the most frequently identified including herpes simplex virus (hsv), varicella zoster virus (vzv), enteroviruses, measles morbillivirus, mumps virus, japanese encephalitis virus (jev), influenza viruses, adenoviruses and mycoplasma pneumoniae. hsv, jev and rabies are the chief causes in europe, asia and africa respectively. the main alternative aetiology to infection is immune mediated, for which management includes immune suppression. it is critical to differentiate between autoimmune and infectious causes of encephalitis; immune suppression in cases where the cause is an undiscovered pathogen could be devastating. strikingly, more than one third of cases of encephalitis remain unidentified, even in the best-equipped medical centres. , , there are well-recognised challenges and inadequacies in current diagnostics and treatment, and these correspond with the poor reported outcomes. [ ] [ ] [ ] [ ] overall mortality is estimated at %, but is highly variable and dependent on the aetiology and access to supportive care. a high proportion is left with complex disability. the introduction of management guidelines for cases of acute encephalitis syndrome over the last decade has aimed to improve outcomes. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] notably, there are many differences between guidelines in the approach to diagnostic evaluation, such as standard and extended diagnostic testing, or whether to administer empirical aciclovir. these variations may reflect geographically contrasting aetiologies, timing of publication and the rapid acceleration of technologies, as well as available resources. further, there is a lack of a systematic approach to access to pathogen discovery methods, discussed below. it is only the newest french guidelines in which ngs is mentioned at all, and the authors reasonably state that the clinical role is still to be evaluated. current diagnostic techniques for suspected infectious cases rely on prior knowledge of the likely causative agent. informed by clinical presentation, epidemiological data, guidelines and local resources, a laboratory will perform targeted tests for a disease. these are largely confined to specific polymerase chain reaction (pcr) or serological assays. this approach has fundamental limitations, and contributes to the relatively high proportion of encephalitis cases that remain undiagnosed. aside from the difficulties of testing for the myriad of rare pathogens that might be expected to cause encephalitis, this approach does not permit the identification of new or unexpected pathogens. undeniably, methods for novel pathogen discovery such as electron microscopy and cell culture have existed for many years, however they are cumbersome, time-consuming, lack sensitivity and specificity and are often no longer routinely available. furthermore, there are groups of patients, such as immunosuppressed patients, who frequently present with subtle or non-specific symptoms and signs, are high-risk for encephalitis, infection with unexpected or unusual pathogens, and are seen to have more severe outcomes. there is a need for improved diagnostic methods for encephalitis. a method which has recently been applied to pathogen detection in cases of encephalitis is metagenomic analysis using next generation sequencing (ngs). proof of concept for its use in the diagnosis of encephalitis has been demonstrated in the literature, however its suitability for routine diagnosis has not been assessed and is the subject of this review. ngs, also known as deep sequencing, generates a single sequence from each fragment of dna, or cdna, present in a specimen. downstream analysis allows differentiation between the origin of sequence fragments, for instance human, a specific bacterial species or a particular virus. this means mixed specimens, that contain host and microbial sequences, can be resolved (fig. ). sequencing the total dna or rna (known as metagenomics) from a biopsy or body fluid allows the identification of genetic material from any microorganism present in the specimen, and thus potentially causing encephalitis. this approach overcomes the limitations of targeted diagnostic methods such as pcr as it requires no prior knowledge or assumptions about the type of pathogen causing infection therefore enabling detection of novel and unexpected pathogens. the majority of readily available sequencing methods to date are dna based, however sequencing only total dna would exclude detection of viruses with rna genomes. consequently, an alternative approach is to synthesise metagenomics for diagnosis of encephalitis complementary dna (cdna) from total rna, which will enable detection of viruses with rna genomes but also the rna transcripts of organisms with dna genomes. once sequences are generated, complex downstream bioinformatic analysis is required to identify the presence of any pathogen sequences. in brief, any reads mapping to the human genome are removed, after which all remaining nonhuman sequences are compared to a database of known sequences to identify the provenance of the unknown sequences (fig. ) . the possibility of incorporating unbiased pathogen discovery technology into routine diagnostics for encephalitis would represent a paradigm shift in diagnostic algorithms. we and others are validating the use of metagenomics for clinical use and prospective studies are already underway to examine whether application of ngs at the outset of management pathways improves patient outcome and costs, namely the precision diagnosis of acute infectious disease (pdaid) study. , nonetheless, there is a paucity of evidence in this field which is largely limited to case reports. we aim to perform a rigorous summary and critical review of existing evidence, to assess the utility of ngs in diagnosis of encephalitis. only articles reporting application of ngs in csf or brain biopsies in suspected encephalitis and published in english between january and april were included. the web of science database was also used to search bibliographies and citations of relevant article. two authors independently reviewed, extracted and summarised included literature. data was extracted in the first instance by the first reviewer into a custom data extraction excel sheet with pre-defined data headings (supplementary file ), designed for the purpose of this review; additional miscellaneous data or observations were also noted where relevant. the extracted data and each included study were independently reviewed by the second author, with a focus on technical and scientific aspects of each study. consensus extracted data was used in analyses; both review authors were in full agreement on the extracted consensus data. relevant manuscripts that were not identified through the initial search, but were identified in the reference list of included literature, were also included. the funding bodies had no role in the decision to write, the analysis, manuscript preparation or the decision to submit for publication. twenty-five articles were identified from the search (fig. ) . all the included articles were case reports, or case series of - patients. altogether cases were reported in which ngs provided a diagnosis in otherwise undiagnosed cases of encephalitis (table ). an exponential temporal increase in cases has been observed over the last decade (fig. ) . country of origin of cases included australia, china, france, germany, india, ireland, japan, poland, sri lanka, uk, usa, and vietnam. samples were analysed in laboratories largely in the usa and europe (uk, france, germany, poland), but also in china, japan and vietnam. among the cases for which age was documented, the median age was years (interquartile range - ). of the cases that reported immune status of the patient, % ( / ) were immunocompromised. there was uniformly poor reporting of encephalitis or meningoencephalitis case definitions, and limited explanation of diagnostic assays performed and algorithms used for testing. none of the studies reported adherence to published or unpublished clinical guidelines. in of the known cases, well-established causes of encephalitis were detected which could have been identified by rapid and specific primary screening methods such as pcr. these organisms included hsv, coxsackievirus a , measles virus, vzv, mumps virus, epstein-barr virus, jc virus and mycobacterium tuberculosis. however, in the remaining cases novel ( / ), rare ( / ) or unexpected ( / ) organisms were detected which could not (in the case of novel organisms) or are unlikely (in the cases of rare and unexpected pathogens) to have been detected using specific pcr assays. the five unexpected cases were known human pathogens but novel causes of encephalitis. although diagnostic pcr assays may exist for some of these viruses, they are unlikely to have been considered in the differential diagnosis and therefore would not be routinely tested. this included two cases of human parvovirus (parv ), first described in when it was associated with a viraemic patient in whom an acute viral infection was suspected ; one case of human coronavirus oc- , typically a human respiratory pathogen never previously described in a human case of encephalitis but known to cause encephalitis in mice ; one case of human astrovirus mlb , of mumps vaccine virus in a child who was vaccinated prior to a primary immunodeficiency diagnosis. the five cases in which rare causes of encephalitis were identified were brucella melitensis, candida tropicalis, leptospira santarosai and two cases of balamuthia mandrillaris. eighteen cases were considered to be novel pathogens. three ( / ) of the identified organisms were arenaviruses, three cases were a variegated squirrel bornavirus, four were a novel astrovirus (astrovirus va /hmo-c), three were cycloviruses, three were gemycircuarlviruses and one was a densovirus. the three arenavirus cases occurred in three solid organ transplant recipients who all received organs from the same donor, who was later shown to be antiarenavirus igm and igg seropositive. the three cases of variegated squirrel bornavirus occurred in three breeders of variegated squirrel and was retrospectively detected in one of the breeder's squirrels. the novel astrovirus va /hmo-c was initially detected in an adolescent with primary immunodeficiency; it has since been shown, through four further case reports identified by ngs, , , , as an emerging under recognised cause of encephalitis in immunosuppressed patients that should be included in the differential diagnosis of encephalitis in this patient group. the clinical significance of the densovirus, cyclovirus and gemycircularviruses is doubtful, and discussed in detail further on in this review. an additional advantage of using ngs for the diagnosis of encephalitis is that, aside from pathogen identification, in instances where virus titre and read depth is high enough it is possible to generate partial or full genome sequences for the pathogen. pathogen sequences can be used for phylogenetic analysis to elucidate the strain , or possible source of the organism, as was the case for morfopoulou et al., who demonstrated . % homology between the mumps virus found in the brain of an encephalitic child with primary immunodeficiency and the vaccine batch used to immunise the child. ngs is a powerful tool for pathogen detection, allowing us to detect organisms that may not previously have been described or associated with the disease in question. however, as with all molecular tools, detection of a microorganism does not prove causality. to provide further evidence for an aetiological role in encephalitis of the identified pathogen, a challenge reviewed in detail elsewhere, some reports make use of additional clinical and laboratory indicators to exclude the possibility that the detected organism is an incidental finding. seroconversion to the pathogen in question is highly suggestive of etiological significance of an organism however preinfection or follow-up serum samples are rarely available; of the cases identified in this review seroconversion was demonstrated in only two. , a further eight were able to demonstrate the presence of specific antibodies, but without knowledge of the sero-status prior to onset of symptoms. although detection of pathogen-specific intrathecal antibodies is also highly suggestive of a causal relationship and recommended by uk guidelines, none of the cases identified in this review reported intrathecal antibody testing. in cases where encephalitis is caused by reactivation of a dormant pathogen, rather than primary infection, or where the pathogen does not cause a strong systemic antibody response, serology may not be useful. in the case of a novel or emerging cause of encephalitis for which the clinical significance may be unclear, proving causality is particularly important. in this instance organismspecific immunostaining or in situ hybridisation in affected tissues will provide additional evidence of the cellular distribution of infection and exclude the possibility of reagent or tissue contamination; of the reviewed cases report confirmatory immunostaining or in situ hybridisation. in this context brain biopsies are a more useful specimen than cerebrospinal fluid (csf) since it allows immunostaining of the affected tissue. moreover, in encephalitis caused by mutated pathogens such as in subacute sclerosing panencephalitis (sspe) caused by chronic measles infection or cases of mumps vaccine encephalitis the pathogen may not be detected in csf but only in brain parenchyma. an alternative molecular method, such as pcr, can be used to confirm the presence of the detected organism and exclude the possibility that the identified organism is an artefact of the bioinformatics analysis. in this review / cases confirmed the presence of the organisms by pcr. pcr supports the identity of the organism sequenced by ngs, however does not contribute to proving causality. six cases identified novel small circular ssdna viruses in the csf of patients with encephalitis of unknown aetiology; three cycloviruses , and three gemycircularviruses. however, the clinical significance of these is doubtful. phan et al. confirmed, via repeat dna extraction using an alternative method, that the source of the cyclovirus is not reagent contamination. nevertheless, whilst screening csf samples for cyclovirus by pcr, tan et al. detected cyclovirus in the csf of patients in whom the aetiology of their central nervous system (cns) disease had already been confirmed as japanese encephalitis, dengue virus or bacterial meningitis. the only identified cellular host for gemycircularviruses is fungi. in the absence of other evidence of pathogenicity, such as seroconversion or demonstration of the pathogen within cells in the brain, the probability remains that detection of cyclovirus or gemycircularvirus in csf is an incidental finding. similarly the detection of densovirus, a small linear ssdna virus, in csf may be incidental since it was detected in a case with confirmed n-methyl d-aspartate (nmda)-receptor encephalitis. autoimmune antibodies have previously been co-detected with herpesvirus dna in csf from cases of encephalitis, however the host range of densoviruses is to date exclusively invertebrates; the authors suggest a possible explanation for detection in csf is the passive transfer of virus from an insect bite or csf contamination from skin flora or an environmental source. in these cases, further evidence is required before assigning a pathogenic role. as with other molecular tests, including pcr which has become the gold standard of virological diagnostics, results from metagenomics applied to cases of encephalitis should be interpreted in the context of other clinical and laboratory findings, particularly when a novel or unexpected organism is detected. the majority of reports concerning the use of metagenomics for diagnosis of encephalitis are comprised of single case reports, therefore it is difficult to assess the diagnostic yield (number of positive results/number of cases tested), and thus utility, of metagenomics for encephalitis. five reports included testing multiple cases of encephalitis; in these the diagnostic yield was % ( / ), . % ( / ), % ( / ), % ( / ) and % ( / ). the first three studies with low diagnostic yield of - % tested only csf supernatant which is cell-free, therefore only cell free viruses or cell-free microbial nucleic acid can be detected; moreover csf often contains a lower pathogen load then brain biopsies and so pathogen detection is more challenging. the aforementioned studies also included only samples for which primary routine diagnostic testing using standard methods was negative therefore the utility of ngs as a first-line test cannot be assessed. a higher diagnostic yield was reported where specimens were tested using metagenomics as a firstline screening tool; % using whole csf and % using brain biopsies. the use of brain tissue rather than csf may increase diagnostic yield. in three cases a pathogen was detected in brain biopsy but not in csf , , while the opposite was not observed, although in one instance the proportion of pathogen reads was greater in csf than brain biopsy. in our hands, the diagnostic yield for metagenomics in encephalitis is, to date, % ( / ) all of which were brain biopsies. the eight identified pathogens were coronavirus oc- , two cases of vaccine derived mumps virus, , toxoplasma gondii (unpublished) and four cases of astrovirus va /hmo-c , (two cases unpublished). all of our positive results were in immunocompromised patients and in the majority of cases there was a high index of suspicion of infection, suggesting metagenomics may be best applied to a targeted population in whom it will be most rewarding. quality assurance prior to providing a new diagnostic test, extensive validation must be undertaken to ensure the service is fit for purpose, such as determining the specificity and sensitivity of an assay, the purpose of which is to ensure a robust, accurate and reproducible result all of which is part of quality assurance. the regulatory requirements that should be fulfilled for the validation of metagenomics for pathogen detection is discussed in detail elsewhere, however one aspect that must continue beyond the validation stage is the use of positive and negative controls. in the context of metagenomics for pathogen detection a positive control is a specimen (real or constructed) that is known to be positive for one or multiple organisms; a negative control is one that is known to be negative for any pathogens. these should be included in every sequencing run; if the positive control fails (i.e. the known pathogen/s is not detected) this invalidates the results of all clinical specimens processed in parallel for which no pathogen was identified. conversely if the negative control fails (i.e. an unexpected organism is identified in the sequence data) this could indicate reagent contamination or a problem with the analysis pipeline and thus positive results from samples processed in parallel are invalidated and should be repeated. this having been said, of cases of encephalitis identified in this review (table ) , only included positive controls and included negative controls. the accuracy of a positive result is critical for patient management; however a negative result can also be useful to exclude infection, particularly where anti-inflammatory and immunosuppressive treatments are being considered. consequently prior to provision of a clinical service appropriate controls must be in place to ensure results are reliable and therefore clinically actionable. the use of controls is aptly demonstrated by mongkolrattanothai et al., who not only included positive and negative controls but also implemented defined criteria in their analysis pipeline that dictates any viruses detected in a clinical specimen should not be detected in the negative controls and, moreover, bacteria detected in a clinical specimen should only be reported as a significant finding if detected with a reads per million (rpm) ratio ≥ (rpm ratio = rpm sample / rpm negative control). this approach overcomes the common problem of reagent contamination with microbial nucleic acids; of cases in which the presence or absence of contaminating reads was reported, cases reported the presence of environmental bacteria, plant viruses, bacteriophages and/or avian retroviruses. , , , , , , [ ] [ ] [ ] [ ] , , , turn-around times only cases reported the time from specimen collection to pathogen identification; for these the turn-around time was - days, with a median time of days. due to limitations of currently available sequence library preparation methods and sequencing chemistries a sample-to-answer turn-around time as short as hours is only achievable with a fast downstream analysis pipeline; in the reported case analysis took only minutes compared to up to two days in other, computationally intensive, pipelines. nevertheless it serves as proof of principle that relatively short turn-around times are achievable, even though up to days is more common. the sample-to-answer turn-around time of specific realtime pcr, which is the current gold standard for diagnosis of viral infections, is often less than hours in a clinical laboratory and potentially less than hours without batch processing. consequently ngs cannot yet offer the same speed of result as pcr, which could delay the diagnosis in instances of encephalitis caused by well-known pathogens that are detectable by pcr. nonetheless with rapidly increasing library preparation and sequencing speeds, turn-around times are likely to significantly improve in coming years. metagenomics for pan-pathogen detection has the potential to revolutionise the diagnosis of encephalitis and other difficultto-diagnose infections; however, there are some limitations of the technique that should be considered. the sensitivity and limit of detection (lod) of metagenomics can be determined for model organisms that represent major pathogen groups, such as dna and rna viruses, gram positive and negative bacteria, fungi and parasites; however, the broad-range nature of the technique makes it impossible to determine the sensitivity or lod for every possible organism. this is also a recognised problem with pan-bacterial pcr detection which is used clinically, however can be confounded in metagenomics by differences between specimens and specimen types (for instance tissue biopsies versus csf) in the quantity of genomic material, the ratio of host:pathogen sequences and, depending on the sequencing chemistry and degree of specimen multiplexing, the sequencing yield. some of these limitations may be overcome by the careful use of processing and sequencing controls, as discussed elsewhere. whilst metagenomics will produce a sequence for every fragment of dna or rna in a specimen, only pathogens with homology to known organisms in the sequence database of choice will be identified. if an organism is missing from the database, or if the pathogen causing infection is novel with no homology to known organisms, it will not be identified. consequently, a negative result obtained by metagenomics, whilst reducing the likelihood of an infectious cause, cannot unequivocally exclude infection. sequencing total dna or rna will inevitably include sequencing host dna or rna transcripts which can result in > % of the sequence data generated mapping to the human genome. the consequence of this is wasted cost, as the sequencing reaction is dominated by host rather than pathogen sequences, and also has implications for the turn-around times and sensitivity of pathogen detection. in order to detect pathogen sequences, which can be as few as nine in million reads, vast sequencing read depths are required; very high throughput sequencing platforms with only a very limited number of samples sequenced in parallel are required to achieve this. to overcome this, depletion of host dna or rna prior to sequencing is required; however the options for this are currently limited and are not all suitable for detection of viral pathogens. improved methods for host dna and rna depletion would considerably reduce the cost and time to result and improve the sensitivity of metagenomics for diagnosis of encephalitis. finally it is important to remember that in some cases of encephalitis, the pathology is due to the immune response and the pathogen may be rarely detected if at all. for example in japanese encephalitis virus (jev) infection, the commonest cause of encephalitis in asia, the most sensitive rt-qpcr detects rna in less than % of cases, and the mainstay of diagnosis is serology. in these cases, ngs is unlikely to significantly improve the diagnostic yield. this systematic literature review and case series suggests there is preliminary evidence to support a role for ngs in the management of undiagnosed encephalitis. undeniably, the research is limited to case reports, with poor reporting of clinical case definitions of encephalitis, baseline tests performed, or adherence to clinical guidelines. nonetheless, current epidemiological data suggests that the cause of encephalitis remains unknown in - % of cases , ; and ngs has striking potential to identify undiagnosed pathogens and thus reduce the number of cases with unknown aetiology. ngs also has utility for pathogen detection in other clinical syndromes, such as respiratory infections, therefore the implementation of this technique in clinical laboratories would have wider implications for diagnosis of infection beyond encephalitis. notably, current turn-around-times prevent the replacement of routine methods, such as pcr, for the diagnosis of acute encephalitis. for these reasons, the role of ngs in clinical algorithms is still to be delineated. at this point in time, we suggest ngs is routinely applied for the diagnosis of acute cases of encephalitis for which no cause is found after targeted investigations using pcr. recommendations for firstline targeted testing are discussed in detail elsewhere but in the uk should include pcr for hsv, vzv and enteroviruses. however due to differing local epidemiology clinicians should consult the relevant national guidelines. , , , , in immunocompromised patients however, metagenomics ought to be considered earlier; % of case reports in this review involved immunocompromised patients. this is the population at most risk of infection with novel and unexpected organisms and, moreover, may present with a more chronic or insidious clinical history in which a one-week turn-aroundtime is more acceptable. given that the causative pathogen is not always detected in csf, in all cases of encephalitis in which diagnosis by ngs is being sought the preferred specimen type is brain biopsy. nevertheless csf samples are acceptable if it is the only specimen available. our recommendations for the use of ngs in diagnosis of microbial causes of encephalitis are summarised in fig. a , with the contrasting algorithm for targeted testing summarised in fig. b . this review was limited to pathogen detection by ngs in brain biopsies or csf. there may also be a role for testing other specimens, such as throat samples and urine. this was recently shown in an encephalitis case diagnosed by ngs of urine, identifying a case of japanese encephalitis virus. it is expected that over the next few years, the cost and time-to-result of metagenomics will reduce, and with this, it is foreseen that it will be possible to offer this as the first-line diagnostic test. this depends on the ability to deplete host dna and rna prior to sequencing, reduced read depth requirement and faster sequencing and bioinformatics technologies. the role of autoimmune encephalitis, in some instances triggered by an infection, is beyond the scope of this review. however, since up to % of cases of encephalitis are caused by autoimmune disorders, in which the immune system attacks specific host proteins, , a comprehensive diagnostic service should include antibody mediated, as well as infectious, causes of encephalitis. the clinical presentation of autoimmune (non-infectious) and infectious encephalitis are similar, however the treatment is often opposing. non-infectious causes may require immunosuppressive therapy ; however administering immunosuppressive therapy where the cause is infectious exacerbates the infection, with potentially fatal results. a conclusive diagnosis of the causative agent of encephalitis would improve differentiation between infectious and auto-immune causes thus appropriate management of immunosuppression. in addition to the direct impact on individual patients, improving the diagnosis of encephalitis will increase our understanding of the causes of encephalitis generally. this knowledge is critical for future development of fast point-of-care tests and to develop clinical algorithms that minimise the time to diagnosis and treatment, thus maximising the chances of recovery. tb and jrbrown conducted the systematic review and prepared the manuscript, figures and table. jbreuer contributed to manuscript preparation. case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium causality in acute encephalitis: defining aetiologies the epidemiology of acute encephalitis challenge of the unknown: a systematic review of acute encephalitis in non-outbreak situations approach to the patient with central nervous system infection beyond viruses: clinical profiles and etiologies associated with encephalitis diagnostic strategy used to establish etiologies of encephalitis in a prospective cohort of patients in england case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium neuroinfectious diseases: a crisis in neurology and a call for action suboptimal management of central nervous system infections in children: a multi-centre retrospective study long-term outcome of patients presenting with acute infectious encephalitis of various causes in france epidemiology and outcomes of acute encephalitis the management of encephalitis: clinical practice guidelines by the infectious diseases society of america management of suspected viral encephalitis in adults-association of british neurologists and british infection association national guidelines a cost-effective approach to the diagnosis and management of acute infectious encephalitis consensus guidelines for the investigation and management of encephalitis les encéphalites infectieuses aiguës : recommandations pour un diagnostic étiologique infectious encephalitis: management without etiological diagnosis hours after onset guidelines on the management of infectious encephalitis in adults should a hospitalized child receive empiric treatment with acyclovir? causes of encephalitis and differences in their clinical presentations in england: a multicentre, populationbased prospective study bayesian mixture analysis for metagenomic community profiling validation of metagenomic next-generation sequencing tests for universal pathogen detection actionable diagnosis of neuroleptospirosis by next-generation sequencing diagnosis of fatal human case of st. louis encephalitis virus infection by metagenomic sequencing a new arenavirus in a cluster of fatal transplant-associated diseases astrovirus encephalitis in boy with x-linked agammaglobulinemia human parvovirus as potential cause of encephalitis in children identification of a new cyclovirus in cerebrospinal fluid of patients with acute central nervous system infections deep sequencing to identify the causes of viral encephalitis astrovirus va /hmo-c: an increasingly recognized neurotropic pathogen in immunocompromised patients next-generation sequencing for diagnosis and tailored therapy: a case report of astrovirus-associated progressive encephalitis clinical metagenomic identification of balamuthia mandrillaris encephalitis and assembly of the draft genome: the continuing case for reference genome sequencing a variegated squirrel bornavirus associated with fatal human encephalitis diagnosis of neuroinvasive astrovirus infection in an immunocompromised adult with encephalitis by unbiased nextgeneration sequencing next-generation sequencing (ngs) in the identification of encephalitis-causing viruses: unexpected detection of human herpesvirus while searching for rna pathogens small circular single stranded dna viral genomes in unexplained cases of human encephalitis, diarrhea, and in untreated sewage diagnosing balamuthia mandrillaris encephalitis with metagenomic deep sequencing suspected encephalitis with candida tropicalis and fusarium detected by unbiased rna sequencing detection of virus in csf from the cases with meningoencephalitis by nextgeneration sequencing identification of viruses in cases of pediatric acute encephalitis and encephalopathy using next-generation sequencing an emerging opportunistic infection: fatal astrovirus (va / hmo-c) encephalitis in a pediatric stem cell transplant recipient human coronavirus oc associated with fatal encephalitis a new densovirus in cerebrospinal fluid from a case of anti-nmda-receptor encephalitis next-generation sequencing in neuropathologic diagnosis of infections of the nervous system acute encephalopathy in an immunocompromised boy with astrovirus-mlb infection detected by next generation sequencing neurobrucellosis: unexpected answer from metagenomic next-generation sequencing deep sequencing reveals persistence of cellassociated mumps vaccine virus in chronic encephalitis new dna viruses identified in patients with acute viral infection syndrome coronaviruses as encephalitis-inducing infectious agents viruses and koch's postulates subacute sclerosing panencephalitis and chronic viral encephalitis csf herpes virus and autoantibody profiles in the evaluation of encephalitis human ifnar deficiency: lessons for antiviral immunity development of broad-range s rdna pcr for use in the routine diagnostic clinical microbiology service japanese encephalitis surveillance standards. in: whorecommended standards for surveillance of selected vaccinepreventable diseases who/v&b metagenomic sequencing complements routine diagnostics in identifying viral pathogens in lung transplant recipients with unknown etiology of respiratory infection acute encephalitis in the immunocompromised individual central nervous system infection diagnosis by next-generation sequencing: a glimpse into the future? pediatric autoimmune encephalitis the spectrum of acute encephalitis: causes, management, and predictors of outcome encephalitis, myelitis, and acute disseminated encephalomyelitis (adem): case definitions and guidelines for collection, analysis, and presentation of immunization safety data a clinical approach to diagnosis of autoimmune encephalitis jr brown is supported by a paediatric research grant from the great ormond street hospital children's charity ("diagnosis of encephalitis by deep sequencing", v ). jbreuer receives funding from the ucl/uclh nihr biomedical research centre.all research at great ormond street hospital nhs foundation trust and ucl great ormond street institute of child health is made possible by the nihr great ormond street hospital biomedical research centre. the views expressed are those of the authors and not necessarily those of the nhs, the nihr or the department of health.the corresponding author (jbrown) had access to all the data and had final responsibility for the decision to submit for publication. the authors declare no conflicts of interest. supplementary data related to this article can be found at https://doi.org/ . /j.jinf. . . . key: cord- -ervaxqph authors: chang, luan-yin; hsiung, chao a; lu, chun-yi; lin, tzou-yien; huang, fu-yuan; lai, yu-han; chiang, yu-ping; chiang, bor-luen; lee, chin-yun; huang, li-min title: status of cellular rather than humoral immunity is correlated with clinical outcome of enterovirus date: journal: pediatr res doi: . / .pdr. . . sha: doc_id: cord_uid: ervaxqph we valuated specific cellular and humoral immune response of cases of enterovirus (ev ) infection and correlated immune response with clinical outcome. after obtaining informed consent, we enrolled ev cases including cases with brainstem encephalitis plus pulmonary edema, cases of cns (cns) involvement and uncomplicated cases. we measured antibodies specific to ev , lymphocyte proliferation response and ev -stimulated cellular response of th /th cytokines and chemokines. the ev cases involving brainstem encephalitis plus pulmonary edema had a significantly lower phytohemagglutinin stimulation index than other cases (p = . ). after ev stimulation of peripheral mononuclear cells, there was a significant increase in cellular th cytokine (γ-interferon) and proinflammatroy cytokines. however, cases with pulmonary edema had significantly lower cellular γ-interferon (p = . ), lower cellular il- β (p = . ), lower cellular il- (p = . ), lower cellular tumor necrosis factor-α response (p = . ), and lower cellular macrophage inflammatory protein- α (p = . ) response compared with other cases. their titers of ev neutralizing antibodies demonstrated no difference among cases. these results suggest lower ev -specific cellular response may be associated with immunopathogenesis of ev -related pulmonary edema. o utbreaks of enterovirus (ev ) encephalitis have been reported from the united states, europe, australia, japan, brazil and malaysia ( - ), since it was originally characterized from a california outbreak ( ) . before , there were three large outbreaks with dozens of fatal cases occurring in bulgaria, hungary, and malaysia (l , l , and , respectively) ( , , ) . the largest and most severe ev epidemic to date occurred in taiwan in ( ) ( ) ( ) ( ) ( ) ( ) . a total of , cases of hand-foot-and-mouth disease and herpangina (hfmd/ha) were reported ( ) . severe neurologic complications and/or pulmonary edema were reported in cases, and children died ( ) . most ev fatalities were cases of fulminant pulmonary edema ( ) . however, ev infection causes very diverse symptoms, ranging from none (about %) to fatality (about . %) ( , ) . it remains unknown why different hosts of the same ev infection have such a range of clinical outcomes ( , ) . perhaps this range is related to virulence or load of the virus, or particular host factors. to date no relationship has been found between ev genotypes and clinical outcome ( , ) , and ev virulence factors have not been clarified. it is possible that host factors, especially host immune response, may be of ultimate importance to clinical outcome. to clarify severe ev infection pathogenesis, we investigated factors of cellular versus humoral immune response and correlated this with clinical outcome. committee approved this study and informed parental consent was obtained, ev cases of different severity were enrolled. ev infection was confirmed by positive ev isolation and/or positive ev specific igm at the onset of their disease. the cns involvement was indicated in four types of cases. those with aseptic meningitis had headache and irritability along with cerebrospinal fluid (csf) pleocytosis (Ͼ leukocytes/l) and without an altered level of consciousness. the second type of cases involved encephalitis had altered level of consciousness plus cerebrospinal fluid (csf) pleocytosis. poliomyelitislike syndrome was defined as acute limb weakness and decreased reflex and muscle strength. finally, cases with encephalomyelitis had the occurrence of both encephalitis and poliomyelitis-like syndrome. laboratory studies. ev -specific humoral immunity: for ev -specific humoral immunity, ev neutralization antibody and igm were measured. ev igm was measured at the onset of disease and ev neutralization antibody was evaluated at the same time with the measurement of cellular immunity. the laboratory method for measuring ev neutralizing antibody followed the standard protocol of neutralization test in microtiter plates ( ) . serum samples were inactivated at °c for min and then serially diluted from -to , -fold. we mixed and incubated ( °c, h) l of each diluted serum with l containing one hundred % tissue culture infective dose (tcid ) of ev strain tw/ / (genbank accession number af ) in microtiter plates ( ) two replicate wells were used per serum dilution. then microtiter plates were seeded with l of rhabdomyosarcoma cells ( ϫ cells per ml) and incubated ( °c % co atmosphere, - d). each test was run with cell control, serum control and virus back titration with - . tcid . cytopathic effect was observed under an inverted microscope after incubation, and serotiter was determined when cytopathic effect was observed in tcid of the virus back titration. microtiter plates were fixed with % glutaraldehyde and stained with . % crystal violet. seropositivity was defined as serotiter Ն . for ev igm detection, ev isolate tw/ / was amplified and purified as an antigen for use in -capture elisa, whose sensitivity and specificity was . % and . %, respectively ( ) . cellular immunity: proliferation response, cellular th /th cytokine and chemokine response. to isolate peripheral blood mononuclear cells (pbmcs), blood samples were heparinized and subjected to ficoll-hypaque (pharmacia diagnostics ab, uppsala, sweden) gradient centrifugation. cells at the interface were removed carefully and washed twice with pbs. the isolated pbmcs were cultured in -well round-bottom microplates ( ϫ cells per well in . ml of culture medium) in rpmi medium supplemented with mm glutamine, mm sodium pyruvate, m -me, u/ml penicillin, . mg/ml streptomycin, and % human ab serum (biocell laboratories inc., rancho domingnez, ca). in addition, pbmcs were stimulated with phytohemagglutinin (pha) ( g/ml) or different concentrations of ev whole virus antigen ( , , and g/ml) tw/ / (genbank accession number af ) or in the absence of antigen (served as the control). ev whole virus antigen was purified by - % sucrose gradient centrifugation ( , rpm for h at °c) and the concentration of virus was measured by use of bio-rad protein assay reagents. after d of incubation, supernatant was collected and assayed for production of th /th (t helper /t helper ) cytokines (␥-interferon, il- ␤, il- , il- , il- , il- , il- , il- and tnf-␣) and chemokines (eotaxin, il- , ip- , mcp- , mcp- , mcp- , mcp- , mip- ␣ and rantes), which were measured with protein array kits (fast quant microspot assay, shleicher & schuell, dassel, germany). all the assays were triplicate. the detectable levels for il (interleukin)- ␤, il- , il- , il- , il- , il- , il- , ␥-interferon and tnf-␣ (tumor necrosis factor-␣) were - , , - , , - , , - , , - , , - , , - , , - , , and - , pg/ ml, respectively. the detectable level for ip- (interferon ␥-inducible protein- ) was . - , pg/ml and that for eotaxin, il- , mcp (monocyte chemoattractant protein)- , mcp- , mcp- , mcp- , mip (macrophage inflammatory protein)- ␣ and rantes (regulated on activation, normal t expressed and secreted) was . - , pg/ml respectively. proliferation response was measured at the end of the culture period. after d of culture, mci of h-thymidine (amersham, buckinghamshire, england) was added to each well for h, and the incorporated radioactivity was measured by ␤-counter (parkard instrument co., inc., meriden, ct). data are taken from triplicate wells as mean number of counts per minute (cpm). stimulation index was calculated by the formula of the cpm incorporated in response to antigen divided by the cpm incorporated in the absence of antigen. in each time of lymphocyte proliferation response, pbmcs of one healthy individual were stimulated with phytohemagglutinin (pha) ( g/ml) and used as the experimental control, and their pha stimulation index was ranged from - . statistics. data were analyzed with sas statistical package (version . , sas institute, cary, nc). because there was limited case number and values were not distributed normally, we used kruskal-wallis test and mann-whitney u-test for continuous variables. test was used for categorical data. wilcoxon signed rank test was used to compare cellular cytokine and chemokine response with or without ev antigen stimulation. to prevent the confounding effects of age and sex on the immune response, multiple logistic regression analysis was used to calculate the adjusted p values for cellular and humoral immunity after concomitant adjustment of age and sex. p Ͻ . was considered statistically significant. immune work-up was completed with ev cases. this included cases with brainstem encephalitis plus pulmonary edema, cases of cns (cns) involvement including of septic meningitis, of encephalitis, of poliomyelitis-like syndrome and of encephalomyelitis, and uncomplicated cases of hand-footand-mouth disease or herpangina. in cases, we isolated the virus itself, and detected positive igm of ev ; the remaining cases were negative for the virus but positive for ev igm at the onset of disease. their median (range) age at the onset of disease was . ( . - . ) year for the cases with brainstem encephalitis plus pulmonary edema, . ( . - . ) years for cases of cns involvement and . ( . - . ) years for uncomplicated cases; the age at the onset of disease was significantly younger for the group with brainstem encephalitis plus pulmonary edema than the other two groups (p ϭ . with kruskal-wallis test). the male-to-female ratio was : for the cases with brainstem encephalitis plus pulmonary edema, : for cases with cns involvement and : for the uncomplicated cases (p ϭ . with test). the median (range) interval between their disease onset and enrollment in this study was not significantly different among the three groups: . ( . - . ) years for the cases with brainstem encephalitis plus pulmonary edema, . ( . - . ) years for cases with cns involvement, and . ( . - . ) for uncomplicated cases (p ϭ . with kruskal-wallis test). the median (range) age at this immune study was . ( . - . ) years for the cases with brainstem encephalitis plus pulmonary edema, . ( . - . ) years for cases with cns involvement, and . ( . - . ) years for uncomplicated cases (p ϭ . with kruskal-wallis test). among the seven cases of brainstem encephalitis plus pulmonary edema, one recovered completely, one had sequelae of right upper-limb paralysis plus scoliosis, and five had polio-like sequelae and hypoventilation with ventilator support. all remaining cases of cns involvement as well as the uncomplicated cases recovered without neurologic sequelae. ev -specific neutralizing antibody titers. ev -specific humoral immunity is shown in fig. , and neutralizing antibody titers did not differ significantly among all the three groups of different severity (p ϭ . with kruskal-wallis test). age Ͻ y and gender did not affect the neutralizing antibody titers significantly, either (p ϭ . and p ϭ . with mann-whitney u-test, respectively). cell-mediated immunity. pha-stimulation index is shown in fig. . ev cases with pulmonary edema had significantly lower pha-stimulated lymphocyte proliferation (median only one ( %) of the pulmonary edema cases had a pha-stimulated index over (p ϭ . with test), whereas ( %) of non-pulmonary edema cases did. age Ͻ y and gender did affect the phastimulation index significantly (p ϭ . and p ϭ . with test, respectively). after adjusted with age and gender, cases of pulmonary edema was still significantly associated with lower rate of pha-stimulated index over (p ϭ . with multiple logistic regression analysis). ev stimulation index was dose-related. higher doses of ev antigen stimulation induce higher lymphocyte proliferation response. although ev -specific lymphocyte proliferation was higher in uncomplicated cases, no statistical difference in lymphocyte proliferation was found between pulmonary edema cases and other cases (p ϭ . , p ϭ . , p ϭ . for ev concentration , , or g/ml, respectively). the highest ev stimulation index levels are shown in fig. . the median ev -stimulated index of all cases was . . four ( %) of the pulmonary edema cases had an ev -stimulated index over . , whereas ( %) of non-pulmonary edema cases did (p ϭ . with test). overall only % ( / ) had peak ev siϾ ϭ , and included ( %) of pulmonary edema cases, ( %) of cns cases, and ( %) of uncomplicated cases (p ϭ . with test). age Ͻ y and gender did affect the ev -stimulation index significantly (p ϭ . and p ϭ . with test, respectively), either. cellular cytokine and chemokine response after ev stimulation. difference in the cytokine and chemokine response of peripheral mononuclear cells with and without ev antigen stimulation is shown in table . in comparison with condition of absence of ev antigen, ev antigen stimulation induced a significant increase in cellular th cytokine (␥-interferon) but a significant decrease in th cytokine (il- ). there were a ␥-interferon median increase of pg/ml and an il- median decrease of . pg/ml. as well, there was an increase of the pro-inflammatory cytokines il- (median increase, pg/ml), il- ␤ (median increase, pg/ml), and tnf-␣ (median increase, pg/ml). overall, ev stimulation had a positive effect on cellular th cytokine and pro-inflammatory cytokine response, but no effect or a mildly negative effect on th cytokines. pha stimulation index among ev cases with different severity (ev cases with pulmonary edema, ev cases with cns involvement, and uncomplicated ev cases). ev cases with pulmonary edema had a significantly lower pha stimulation index (p ϭ . , measured to compare the percentages of a response over the median level of increase of all the ev cases by using likelihood ratio test). peak enterovirus (ev ) stimulation index among ev cases with different severity (ev cases with pulmonary edema, ev cases with cns involvement, and uncomplicated ev cases). all peak ev stimulation index were statistically identical among the three groups (p ϭ . with kruskal-wallis test) the numbers in parenthesis are the ranges of the difference for peripheral mononuclear cellular cytokine and chemokine response with and without ev antigen stimulation. * the "-" denotes decreased response after ev stimulation. p-values were measured to compare the difference of cellular cytokine/chemokine response with or without ev antigen stimulation by using wilcoxon signed rank test. ns, not significant; tnf-␣, tumor necrosis factor-alpha; ip, interferon ␥-inducible protein; mcp, monocyte chemoattractant protein; mip, macrophage inflammatory protein; rantes, regulated on activation, normal t expressed and secreted. after ev stimulation, certain cellular chemokine responses significantly increased, including ip- (median increase, pg/ml), mcp- (median increase, , pg/ml), mcp- (median increase, pg/ml), mcp- (median increase, . pg/ml), mip- ␣ (median increase, , pg/ml), and rantes (median increase, pg/ml). after observing the significant increase in cellular response of ␥-interferon, il- ␤, il- , tnf-␣, ip- , mcp- , mcp- , mcp- , mip- ␣ and rantes, and the significant decrease in il- , we compared the cellular response of these cytokines/ chemokines with severity of cases. cases with pulmonary edema were found to have significantly lower cellular ␥-interferon ( fig. ; p ϭ . ) , lower cellular il- ␤, lower cellular il- , lower cellular tnf-␣ response and lower cellular mip- a response in comparison with other ev cases. in cases with pulmonary edema the percentage of increase over the median level of cellular ␥-interferon, il- ␤, il- , tnf-␣ and mip- ␣ was lowest ( table ). uncomplicated ev cases had highest percentages of increase over the median level of cellular ␥-interferon, il- ␤, il- , and tnf-␣ ( table ). age and gender did not affect their cellular cytokine response significantly. after age and gender adjustment, the percentage of increased cellular cytokines was still significantly different among the three groups with different clinical severity (p ϭ . for ␥-interferon, il- ␤, il- , and tnf-␣) (fig. ) . in contrast, % ( / ) cases with cns involvement and % ( / ) uncomplicated cases had decrease over the median level of cellular il- response after ev stimulation whereas none of the pulmonary edema cases had decrease of cellular il- response (p ϭ . ). in general, ev antigen enhanced cellular th cytokine, pro-inflammatory cytokine and chemokine response, and reduced cellular th cytokine (il- ) response in most cases of cns involvement and uncomplicated cases. however, ev antigen had little effect on cellular cytokine and chemokine response in most cases with brainstem encephalitis plus pulmonary edema. this study suggests that cellular immunity rather than humoral immunity may be associated with the clinical outcome of ev infections. age and gender may influence the immunity, however we demonstrate cellular immunity (pha stimulation index) and cellular cytokine (␥-interferon, il- ␤, il- , and tnf-␣) response were significantly weaker in ev cases with pulmonary edema than the other ev cases after age and gender adjustment. on the contrary, the humoral immunity (ev -specific neutralizing antibody) did not differ significantly among cases with different clinical severity. this study was an exploratory study with the small number of the cases and was not investigated prospectively, so the results * the "-" denotes decreased response after ev stimulation. p-value was measured to compare the percentages of cases with a response above the median level by using likelihood ratio test among the three groups. tnf-␣, tumor necrosis factor-alpha; ip, interferon ␥-inducible protein; mcp, monocyte chemoattractant protein; mip, macrophage inflammatory protein; rantes, regulated on activation, normal t expressed and secreted. . cellular interferon-␥ response after ev stimulation at the concentration of g/ml) among ev cases with different severity (ev cases with pulmonary edema, ev cases with cns involvement, and uncomplicated ev cases). ev cases with pulmonary edema had significantly lower interferon-␥ response than the other ev cases (p ϭ . , measured to compare the percentages of a response over the median level of increase of all the ev cases by using likelihood ratio test). immunopathogenesis of ev infection must be validated by further prospective immunologic studies in ev cases or host immune genetic studies. in the most severe ev cases with pulmonary edema there is lower cellular th cytokine coupled with a lower lymphocyte proliferation response. higher incidence of most severe ev diseases were found in children under y of age ( , ) , and this might be explained by their weaker cellular immunity. we hypothesize that lower cellular immunity may delay viral killing or clearance, thus resulting in viral dissemination, sustained systemic inflammatory response and subsequent pulmonary edema. host genetic factors may also play an important role and will require further investigation. yang kd et al. reported that patients with ev meningoencephalitis had a higher frequency of g/g genotype with a polymorphism of the cytotoxic t lymphocyte antigen- at position of exon than did control subjects without meningoencephalitis. in these cases there was no difference in specific ev neutralizing antibody titers in the groups ( ). in our study, humoral immunity did not affect the clinical outcome of ev infection, either. results from the two studies suggest that younger children with genetics involving decreased cellular rather than humoral response may be linked to severe ev infection. in this study control for differences in the ages of patients was tried in each of three presentations, but truly valid conclusions regarding differences in cell-mediated immune response in the brainstem encephalitis plus pulmonary edema group can only be established using age matched controls in the cns involvement and uncomplicated disease groups. another query is whether maternal ev could have been important in later cellular immune response antibody making the lower cellular ev immune response of the youngest subjects, as maternal antibody might be after administration of live viral vaccines. however, we had a seroepidemiology study, done in ( ) , which showed that % ( / ) of -to -month-old children and % ( / ) of -to month-old children did not have ev neutralizing antibody. the % of -to -month-old children might get their antibody through natural ev infection rather than maternal antibody. the results suggested that even the youngest group of ev cases seldom had maternal ev antibody, so their lower cellular immunity might be related to other causes rather than maternal antibody. our previous studies reported that patients with pulmonary edema had dramatically high blood values of il- ␤, il- , tumor necrosis factor-␣, white blood cell counts, and glucose levels ( , ) . these findings suggest that a combination of cns and systemic inflammatory response may trigger ev related cardiopulmonary collapse ( ) . another study of patients with pulmonary edema showed significant immunomodulator elevation as well as lower circulating cd ϩ t-cells, cd ϩ t-cells, and natural killer cells ( ) . they also suggested that the combination of an extensive systemic and cns inflammatory response and lymphocyte depletion appears to be responsible for the pathogenesis of ev associated pulmonary edema ( ) . suggested treatments have varied. since those cases with pulmonary edema had lower cellular immunity, a rational treatment may involve regimens to enhance cellular immunity. in the case of poliomyelitis, ifn-␥ treatment of age-dependent poliomyelitis-susceptible mice protected them from paralytic disease ( ) . recent studies have also shown that interferon-␥ synergizes with ifn-␣/␤ to inhibit the replication of both rna and dna viruses. scagnolari et al. investigated the effects of ifns on the replication of severe acute respiratory syndrome-associated coronavirus (sars-cov), finding that although sars-cov is only moderately sensitive to ifn-␤ and weakly sensitive to ifn-␣ and ifn-␥, in combination they have a strong synergistic effect on virus replication ( ) . these two studies imply treatments for severe ev infection, but further animal or clinical trial is mandatory to prove the efficacy of immunomodulators. in addition, use of an antiviral agent to decrease replication may also be beneficial ( ) . animal studies are ongoing on this topic. in the liu et al. study, an early administration of recombinant mouse interferon-␣ protected the mice against ev infection and in vitro analysis of virus-induced death showed that human type i interferons exerted a direct protective effect on ev , so interferons may play an important role in controlling ev infection and replication ( ) . currently there is no vaccine for ev . since the major cytokine response of mononuclear cells after ev challenge is th cytokines, induction of th cellular response may be critical to vaccine development for prevention of severe ev disease. therefore, an ideal vaccine should trigger adequate immunity in both cellular and humoral systems. in conclusion, we found that cellular immunity rather than humoral immunity may be related to the clinical outcome of ev infections. ev cases with decreased cellular immunity plus lower cellular ␥-interferon and other cytokine/ chemokine response may be prone to disseminated ev infection and subsequent pulmonary edema. an apparently new enterovirus isolated from patients with disease of the central nervous system new enterovirus type associated with epidemic of aseptic meningitis and/or hand, foot, and mouth disease epidemiological, clinical and pathomorphological characteristics of epidemic poliomyelitis-like disease caused by enterovirus outbreaks of hand, foot, and mouth disease by enterovirus : high incidence of complication disorders of central nervous system virological diagnosis of enterovirus type infections: experiences gained during an epidemic of acute cns diseases in hungary in enterovirus type infections: a varied clinical pattern sometimes mimicking paralytic poliomyelitis enterovirus infections and neurologic disease: united states, - role of enterovirus in acute flaccid paralysis after the eradication of poliovirus in brazil deaths of children during an outbreak of hand, foot, and mouth disease in sarawak, malaysia: clinical and pathological characteristics of the disease fulminant neurogenic pulmonary edema with hand, foot and mouth disease deaths among children during an outbreak of hand, foot and mouth disease-taiwan sentinel surveillance of enterovirus clinical features and risk factors of pulmonary edema after enterovirus -related hand, foot, and mouth disease an epidemic of enterovirus infection in taiwan neurological complications in children with enterovirus infection transmission and clinical features of enterovirus infections in household contacts in taiwan risk factors of enterovirus infection and associated hand-foot-mouth-disease/herpangina in children genetic analysis of enterovirus isolated from fatal and non-fatal cases of hand, foot and mouth disease during an epidemic in taiwan enterovirus from fatal and nonfatal cases of hand, foot and mouth disease epidemics in malaysia, japan and taiwan in - enterovirus responses of igm for enterovirus infection altered cellular but not humoral reactions in children with complicated enterovirus infections in taiwan pro-inflammatory cytokine reactions in enterovirus infections of the central nervous system different pro-inflammatory reactions in fatal and non-fatal enterovirus infections: implications for early recognition and therapy pathogenesis of enterovirus brainstem encephalitis in pediatric patients: roles of cytokines and cellular immune activation in patients with pulmonary edema inhibition of virus-induced age-dependent poliomyelitis by interferon-gamma increased sensitivity of sars-coronavirus to a combination of human type i and type ii interferons design, synthesis, and structure-activity relationships of pyrazolo[ , -d]pyrimidines: a novel class of potent enterovirus inhibitors type i interferons protect mice against enterovirus infection key: cord- -j tyjo j authors: rapkiewicz, amy v.; mai, xingchen; carsons, steven e.; pittaluga, stefania; kleiner, david e.; berger, jeffrey s.; thomas, sarun; adler, nicole m.; charytan, david m.; gasmi, billel; hochman, judith s.; reynolds, harmony r. title: megakaryocytes and platelet-fibrin thrombi characterize multi-organ thrombosis at autopsy in covid- : a case series date: - - journal: eclinicalmedicine doi: . /j.eclinm. . sha: doc_id: cord_uid: j tyjo j background: there is increasing recognition of a prothrombotic state in covid- . post-mortem examination can provide important mechanistic insights. methods: we present a covid- autopsy series including findings in lungs, heart, kidneys, liver, and bone, from a new york academic medical center. findings: in seven patients (four female), regardless of anticoagulation status, all autopsies demonstrated platelet-rich thrombi in the pulmonary, hepatic, renal, and cardiac microvasculature. megakaryocytes were seen in higher than usual numbers in the lungs and heart. two cases had thrombi in the large pulmonary arteries, where casts conformed to the anatomic location. thrombi in the ivc were not found, but the deep leg veins were not dissected. two cases had cardiac venous thrombosis with one case exhibiting septal myocardial infarction associated with intramyocardial venous thrombosis, without atherosclerosis. one case had focal acute lymphocyte-predominant inflammation in the myocardium with no virions found in cardiomyocytes. otherwise, cardiac histopathological changes were limited to minimal epicardial inflammation (n = ), early ischemic injury (n = ), and mural fibrin thrombi (n = ). platelet-rich peri‑tubular fibrin microthrombi were a prominent renal feature. acute tubular necrosis, and red blood cell and granular casts were seen in multiple cases. significant glomerular pathology was notably absent. numerous platelet-fibrin microthrombi were identified in hepatic sinusoids. all lungs exhibited diffuse alveolar damage (dad) with a spectrum of exudative and proliferative phases including hyaline membranes, and pneumocyte hyperplasia, with viral inclusions in epithelial cells and macrophages. three cases had superimposed acute bronchopneumonia, focally necrotizing. interpretation: in this series of seven covid- autopsies, thrombosis was a prominent feature in multiple organs, in some cases despite full anticoagulation and regardless of timing of the disease course, suggesting that thrombosis plays a role very early in the disease process. the finding of megakaryocytes and platelet-rich thrombi in the lungs, heart and kidneys suggests a role in thrombosis. funding: none. severe acute respiratory syndrome coronavirus (sars-cov- ) is responsible for the global pandemic of coronavirus disease . while the majority of patients with covid- experience mild symptoms, serious complications including ards, hemodynamic shock, acute kidney injury, cardiac injury, and arrhythmia contribute to the high mortality rate [ ] . elevation of cardiac troponin is common in covid- and has been associated with poorer outcomes [ À ] . st-segment elevation myocardial infarction in a small series of patients with covid- was associated with a relatively low likelihood of severe coronary artery disease (cad) [ ] . myocardial injury in covid- has been postulated to be due to viral myocarditis, but there has been a paucity of histologic evidence to determine the causes of troponin elevation. there is growing recognition of an increased rate of thrombotic complications in patients with covid- , higher than in respiratory failure due to influenza, and with the notable observation that pulmonary thrombosis in the absence of lower extremity deep venous thrombosis is frequently observed [ À ] . autopsy series have demonstrated a high prevalence of microthrombi in pulmonary capillaries as well as pulmonary arterial thrombosis [ À ] . in biopsy samples obtained from skin and kidney, there were frequent microthrombi in the microvasculature [ , ] . in addition, autopsy reports have shown thrombus formation in less common areas, including the hepatic portal vein, the prostatic venous plexus and in the heart [ À ] . observational studies suggest that anticoagulation therapy, including more intensive anticoagulation, may be associated with better outcomes in patients infected with covid- [ , ] . the mechanism for this prothrombotic milieu is yet to be determined. we present results of the first seven autopsies from an academic new york medical center, including findings from lungs, hearts, kidneys, liver, and bone. we hypothesized that post-mortem examination would improve our understanding of the reasons for multi-organ failure and thrombosis in covid- . hospital-based autopsies were performed by amy rapkiewicz using personal protective equipment in a negative pressure facility with limited staff participating to reduce risk. consecutive autopsies performed at nyu winthrop hospital among persons with laboratory-confirmed covid- or who were under investigation and tested positive on post-mortem pcr were included. the lungs, heart, kidneys, spleen, lymph nodes, liver, bone, and skeletal muscle were evaluated in detail in all cases. tissues were fixed in % buffered formalin for h and routinely processed. hematoxylin and eosin (h&e)-stained sections were prepared. immunohistochemistry (ihc) was performed via epitope retrieval using roche benchmark ultra with incubation time À min, depending on antibody. sections were incubated with cd (cell marque, clone f ), cd (predilute-roche, clone l ), cd (predilute-roche, clone gv ), cd (predilute-roche, clone sp ), cd (predilute-roche, clone sp ) and a rabbit polyclonal anti-sars nucleo-capsid protein antibody (novus biologicals) detection was carried out using optiview dab ihc kit. for electron microscopy, tissue samples were fixed in % glutaraldehyde buffered in ¢ m sodium cacodylate buffer, ph . , washed in sodium cacodylate buffer, post-fixed in buffered % osmium tetroxide, en-bloc stained with a saturated solution of uranyl acetate in % ethanol, dehydrated in a graded series of ethanol, infiltrated in propylene oxide with epon epoxy resin (lx , ladd industries, burlington, vt), and embedded. blocks were sectioned with a reichert ultracut microtome at nm. the resulting grids were post-stained with % aqueous uranyl acetate followed by ¢ % aqueous lead citrate and scoped on a zeiss em transmission electron microscope retro-fitted with an l c digital camera (sia, duluth, ga). electron microscopy was performed on limited samples based on resource availability, focusing on organs that were grossly abnormal, including lung (four cases), heart (four cases), kidney (five cases), liver (one case), fat (two cases), skeletal muscle (two cases), and bone marrow (one case). paraffin-embedded blocks of all tissues in all cases were sent to the laboratory of pathology of the national cancer institute for immunohistochemical consultation. we counted numbers of megakaryocytes in the lungs and the hearts of covid- cases and, for comparison, cases of patients who died with ards of other causes, selected as a convenience sample from autopsies previously performed at the national cancer institute between and . in the lungs ten consecutive highpower fields (hpf, x magnification) were scored three times for each case, while the whole section of the heart was used to count megakaryocytes. student's t-test was used to compare the number of megakaryocytes between covid- and other ards cases. p values < ¢ were considered statistically significant. chart review was performed to identify medical history, laboratory values (initial and peak, where available), and to review electrocardiography and imaging, when available. dr. rapkiewicz had access to all data. drs. rapkiewicz and reynolds had final responsibility for the decision to submit the manuscript. role of funding: there was no external funding for this analysis. this study was supported, in part, by the intramural research program of the nih, national cancer institute. ethics: reporting of this series of clinically indicated autopsies was exempted by the nyu grossman school of medicine institutional review board. consent was provided by the legal next of kin in each case. table summarizes the clinical presentation of the cases. the age range was À years, and four of seven cases were female. two presented with asystolic arrest at home after reporting symptoms for several days. two patients were known to be taking aspirin before they became ill. none were taking anticoagulation before illness, but the five patients who survived to hospitalization all received either therapeutic or prophylactic anticoagulation. each of the five hospitalized patients received at least one dose of azithromycin and hydroxychloroquine, and some received il- and il- inhibitors ( table ). all hospitalized patients were mechanically ventilated. all patients who died in hospital had pulseless electrical activity (pea). the two patients who died at home had asystole at first medical contact. evidence before this study covid- is associated with increased risk of thrombotic events. previous pathology studies, identified by searching pubmed on june , for the terms "covid- and "autopsy" or "histopathology", have reported findings in multiple organs, including thrombi on gross inspection, but did not use special stains to identify megakaryocytes and platelets in tissues of patients dying with covid- . the presence of circulating megakaryocytes on autopsy in various organs was also researched, for which we searched pubmed on june , for "pathology" or "autopsy" and "megakaryocytes". we present a covid- autopsy series including findings in lungs, heart, kidneys, liver, and bone, from a new york academic medical center. regardless of anticoagulation status, all autopsies demonstrated platelet-rich thrombi in the pulmonary, hepatic, renal, and cardiac microvasculature. megakaryocytes were seen in the vascular beds of multiple organs, and in higher than usual numbers in lungs and heart. megakaryocyte numbers were increased as compared with patients who died of acute respiratory distress syndrome (ards) unrelated to covid- . we report two cases with myocardial venous thrombosis and troponin elevation, one of which exhibited myocardial infarction on gross inspection, illustrating a previously unrecognized mechanism of mi. thrombosis is an important contributor to pathologic mechanisms underpinning multi-organ failure, severe hypoxia and death in patients with covid- . myocardial infarction may be caused by venous thrombosis in the absence of significant coronary artery atherosclerotic disease. platelets and circulating megakaryocytes are likely to play an important role in the increased thrombotic risk associated with covid- . all patients were positive for sars-cov- using the geneexpert (cepheid) test and negative for other respiratory viral pathogens on the cepheid analyzer, including common coronaviruses, before and/or after death. figure additional details of the laboratory findings, imaging findings, and hospital courses are in supplemental tables À . all cases, regardless of anticoagulation received, demonstrated platelet-rich thrombi in the pulmonary, hepatic, renal, and cardiac microvasculature (fig. ). in the lungs, thrombi involved large and small vessels, and platelets were noted within the alveolar capillaries. there were pulmonary arterial thrombi in four cases, three of which had received anticoagulation (two at therapeutic dose and one at prophylactic dose). this included obstructive, predominately white thrombus in the right main pulmonary artery, and multiple right ventricular mural thrombi, in case , and segmental pulmonary artery thrombi in cases , (bilateral) and (fig. ) . pulmonary artery casts conformed to the anatomic location in which they were found. the presence of lines of zahn in pulmonary, and cardiac intravascular thrombi strongly suggests antemortem thrombosis. thrombi were not found in the inferior vena cava. however, the deep leg veins were not dissected. megakaryocytes were seen in all cases in the microvasculature of the heart, in some glomeruli, and in higher than usual numbers in the lungs (fig. , supplemental fig. ). the median number of megakaryocytes/hpf in lung was (interquartile range [iqr], À ) in covid- and (iqr À ) in other ards, p = ¢ . the number of megakaryocytes in bone marrow was increased with focal clustering. bone marrow megakaryocyte morphology suggested active platelet production, with prominent pseudopodia. megakaryocyte numbers were increased in covid- hearts as compared with other ards (median . , iqr À , in covid- vs. median , iqr À , in ards, p = ¢ ). rare virions were identified on electron microscopy in bone marrow megakaryocytes (supplemental fig. ). in all cases, megakaryocytes associated with fibrin microthrombi were identified within the cardiac microvasculature. there were no viral inclusions on electron microscopy of the heart in any of four cases analyzed (cases , , and ). only one patient (case ) exhibited a focal inflammatory infiltrate composed of lymphocytes, mixture of b and t cells as per cd and cd , with cd in greater number than cd , with associated myocardial necrosis in the epimyocardial region (fig. ) . despite thorough sectioning, the infiltrate was localized, even though there was diffuse, transmural pallor of the left ventricle. immunohistochemical staining for cd (platelet glycoprotein iiia), a megakaryocytic and platelet marker, identified platelet microthrombi in the region of inflammation. there were no electrocardiographic abnormalities on admission or on the day of death in this patient, nor were there granulomas. staining for complement (c d) was performed to rule out complement-mediated myocyte damage and was negative in all cases tested. venous thrombosis was identified in two hearts (cases and ). in case , there was intramyocardial venous thrombosis with septal myocardial infarction (mi) despite only minimal coronary atherosclerosis (fig. ). this patient also had cirrhosis of the liver due to alcohol, and there were elevated levels of antiphospholipid igm antibodies detected post-mortem. the peak troponin was ¢ ng/ml, measured on the day of death (hospitalization day three). a limited cardiac ultrasound performed three hours after troponin showed right ventricular hypokinesis. left ventricular wall motion was normal on this limited study with only subcostal views. the electrocardiogram (ecg) at admission showed hyperacute t waves in v , and ecg on the day of death showed inferolateral st elevations with hyperacute t waves in leads v -v . in case , there was epicardial venous thrombosis, but mi was not noted on gross nor microscopic inspection fig. ) . troponin, measured four hours before death, was ¢ ng/dl, within the normal limits at our laboratory. otherwise, cardiac histopathological changes were limited to minimal epicardial inflammation (n = ), early ischemic injury (n = ), and mural fibrin thrombi (n = ). there was congestion on gross examination in all cases (representative images, supplemental fig. ). all cases exhibited diffuse alveolar damage (dad) with hyaline membrane formation, type ii pneumocyte desquamation, with a mixture of exudative, and proliferative phases of dad, corresponding to ards. rare virions were identified by immunohistochemical staining for nuclear capsid protein and by electron microscopy (supplemental fig. ). granulomas were not observed. immunostains with cd revealed platelet-rich thrombi in the pulmonary microvasculature. in case one there was a sparse septal and perivascular lymphocytic infiltrate, predominantly composed of cd positive t cells with a predominance of cd positive cells over cd positive cells. three cases had superimposed acute bronchopneumonia, focally necrotizing, one of which had an erosive bronchitis with fungal hyphae detected. platelet-rich fibrin microthrombi were seen in scattered peritubular capillaries and venules (fig. ) . despite some autolysis, acute tubular necrosis, cellular casts, and some pigmented red blood cell casts were seen in all cases (fig. ) . thrombotic microangiopathy within the glomeruli with large platelet-rich microthrombi, red cell fragmentation and mesangiolysis was seen in case , but not in other cases, where only rare small glomerular platelet aggregates were seen. several patients exhibited microhemorrhages within the interstitium, and rare schistocytes were observed. all of the cases exhibited mild to moderate arteriolosclerosis, and one demonstrated arteriolar hyalinosis, electron microscopy showed virions in proximal convoluted tubules, and rare podocyte virions (supplemental fig. ) . no changes to glomerular vessels, foot processes or glomerular basement membrane were observed on light or electron microscopy. stains for immunoglobulin, and complement were negative in cases and . bone marrow was hypercellular with increased megakaryocytes demonstrating focal clustering. there was progressive maturation of myeloid series with left shift and reduced erythropoiesis. hemophagocytosis was not identified. red blood cells with abnormal morphology resembling burr cells (echinocytes) were commonly seen. spleens were congested, partially autolyzed in one case. in most cases, there was white pulp depletion, congestion of the red pulp, and no evidence of extramedullary hematopoiesis. similar to what was observed in the lung, there was a predominance of t cells with slight cd excess. lymph nodes analyzed from cases showed dilated sinuses with marked sinus histiocytosis with focal erythrophagocytosis, numerous platelets, and megakaryocytes (best appreciated by cd stain). secondary follicles in the far cortex appeared hypocellular. lymph nodes were not readily located in the remaining cases or were grossly unremarkable. all of the cases showed mild, macrovesicular steatosis without significant inflammation or ballooning suggestive of steatohepatitis. case showed cirrhosis. numerous platelet-fibrin microthrombi were identified in hepatic sinusoids (supplemental fig. ) in six cases, but case showed only rare microthrombi. ischemic type hepatic necrosis was associated with the microthrombi in two of seven cases ( and ). larger platelet aggregates were also noted in the portal veins in these two cases. in case , this was associated with zone necrosis with a hepatic vein thrombus. epicardial, and mesenteric adipocytes were of variable size with evidence of lysis. a scattered lymphocytic infiltrate was present. in this series of seven autopsies in patients who succumbed to covid- , there are several unifying themes observed in the histopathology. thrombosis is a prominent feature in multiple organs, in some cases despite full anticoagulation. platelet-rich thrombi were present in the pulmonary, hepatic, renal, and cardiac microvasculature. based on the anatomic cast pattern of the thrombi, many of the thrombi appear to have formed in situ and ante-mortem, evidenced by lines of zahn. however, embolism with further local propagation cannot be excluded based on the lack of deep vein dissection. the extensive nature of platelet-fibrin thrombi in the alveolar capillaries in our patients may explain the observation that oxygenation is disrupted in an exaggerated fashion early in the disease course of patients with covid- , [ ] as this suggests evidence of ventilation-perfusion mismatch unrelated to hyaline membrane formation. our patients' lungs all had histopathologic findings of dad, which has been the most frequently reported finding in covid- autopsies thus far [ ] [ ] [ ] ] . our findings highlight a potential significant role of megakaryocytes and platelets in diffuse microvascular thrombosis in covid- . megakaryocytes were found in the microvasculature of the heart in all cases, in glomeruli, and in increased numbers in the lungs. bone marrow megakaryocytes were mildly increased in number with morphologic features indicating active platelet production, and contained virions as identified on electron microscopy (supplemental figure ) . these findings, in conjunction with extensive platelet-fibrin microthrombi detected on specific staining, suggest a profound platelet response in covid- that may be responsible at least in part for multi-organ failure. the conspicuous finding of megakaryocytes along with platelet-fibrin microthrombi within the heart microvasculature in this subset of gravely ill patients with covid- is provocative. there are rare reports of megakaryocytes within the heart; in the largest published series, there was an average of À . intravascular megakaryocytes in one cm of heart from autopsies, involving traumatic and in-hospital deaths [ , ] . notably, of cases were labeled as "infection and thrombosis." circulating megakaryocytes have been observed in mi, another thrombotic disorder [ ] . in our experience, and supported by these studies, it is rare to find megakaryocytes within the heart. our finding of platelet microthrombi in association with megakaryocytes in the microvasculature may provide a window into mechanisms of disease in patients with fatal covid- . thrombi were located in veins and in the pulmonary arteries and arterioles and in microvessels, but not in systemic arteries. despite elevated fibrin degradation products, in only one case of a patient with cirrhosis did we observe glomerular thrombotic microangiopathy, arguing against disseminated intravascular coagulation, hemolytic-uremic syndrome, or thrombotic thrombocytopenic purpura as a predominant pathophysiological pathway [ ] . schistocytes may suggest endothelial damage, but we found them only rarely. we found no endothelial abnormalities on microscopic review, in alignment with previous studies, but we cannot rule out increased exposure of tissue factor, erosion of the endothelial glycocalyx, or other mechanisms of endothelial dysfunction that could be pro-coagulant without showing histopathologic evidence of cell activation or erosion [ , , ] . a recent autopsy series of covid- cases incorporating endothelial electron microscopy demonstrated ultrastructural endothelial damage and increased angiogenesis as compared to cases of fatal influenza, with differential regulation of genes related to angiogenesis and inflammation [ ] . four of the seven patients in this series had pulmonary arterial thrombi. there are now multiple autopsy reports demonstrating a high prevalence of pulmonary arterial thrombi in the setting of covid- infection, including symptomatic thrombi and thrombi in the absence of coexisting deep venous thrombosis [ , , [ ] [ ] [ ] , ] . each of the thrombus casts in our patients conformed to the walls of pulmonary vasculature. this appearance suggests that the thrombi were formed in situ in pulmonary arteries rather than as the result of embolization, a conclusion also reached in prior reports [ , , ] . however, it remains possible that the large thrombi progressed rapidly, originating from smaller emboli without time for development of organization and adherence to the vessel wall. case had normal lower extremity venous duplex. however, our autopsies did not include dissection of the extremities to evaluate for deep vein thrombosis based on infection control restrictions. all patients tested had abnormal pt/inr and d-dimer. troponin elevation is common in covid- patients and is associated with increased risk of death [ ] [ ] [ ] . it may be surprising then that there was little myocardial inflammatory infiltrate in this case series, particularly considering that the heart expresses ace , a membrane protein used by sars-cov- as an attachment receptor. only one patient (case ) had a focal acute lymphocytic epimyocarditis, with no virions in cardiomyocytes. this mild epicardial inflammation did not cause any st-segment deviation on ecg. the patient had minimally elevated troponin on the day of death, but the point of care ultrasound noted reduced ejection fraction. the single focus of mild epicardial inflammation in this patient may be nonspecific. multiple additional sections of cardiac tissue were taken without further evidence of inflammation. one would expect more inflammation if cardiomyopathy were due to fulminant lymphocytic myocarditis. here, cardiomyopathy may be attributable to profound metabolic derangements, with severe metabolic and respiratory acidosis at the time of the cardiac ultrasound, immediately preceding cardiac arrest. though troponin elevation in patients with covid- has often been ascribed to myocarditis by clinicians, there have been very few reports of myocarditis with accompanying tissue samples showing lymphocytic infiltrate [ , À ] . one of the three previously published autopsy reports showing myocarditis described a covid- patient who was co-infected with influenza [ ] . when present, the infiltrate may be focal and epicardial, as seen in our one case with myocardial inflammation [ , ] . thus tissue-proven viral myocarditis appears to be relatively rare in covid- , and other mechanisms of myocardial injury must be considered. no evidence of complementmediated myocardial damage was present in our cohort, though we and others have demonstrated this previously in the setting of influenza [ , ] . another group reported a high degree of complement deposition in lung, and skin in covid- patients, but did not assess cardiac tissue [ ] . there are many potential causes of troponin elevation including ischemia, inflammation, metabolic derangement and trauma. right ventricular strain due to pulmonary thrombosis and hypertension is another potential mechanism [ ] . based on our data, thrombosis of the microvasculature and cardiac veins appears to be a common cause of elevated troponin in covid- . we demonstrate for the first time, to our knowledge, that thrombosis of a cardiac vein can cause acute mi in the absence of obstructive coronary atherosclerosis. st segment elevation on the ecg may prompt urgent coronary angiography in covid- patients. our group has reported that there is no obstructive coronary artery disease in approximately one-third of such cases [ ] . mi with non-obstructive coronary arteries is increasingly recognized [ ] . it remains to be learned whether myocardial venous thrombosis may in fact cause this entity in clinical situations other than covid- illness. case had thrombosis of an intramyocardial vein corresponding to the infarction zone. while case also had venous thrombosis, in the middle cardiac vein (epicardial), there was no gross or microscopic evidence of mi. a proposed explanation for this finding may be that thrombosis occurred just prior to cardiac arrest, since evidence of infarction on gross or histopathology appears hours after ischemia onset. renal findings in our patients shed light on the pathogenesis of acute kidney injury in covid- . virions were observed in proximal tubular cells. acute tubular necrosis and peritubular fibrin thrombi were apparent. a recently reported series of autopsies in covid- showed acute tubular injury of varying severity in all cases, with prominent microvascular obstruction by erythrocytes [ ] . renal tubular cells are known to present ace , the viral receptor, so it is logical that virions are most prominent in this location. the absence of virus in endothelial cells, rare infection of podocytes, and absence of visible glomerular pathology in most of our cases also argue against a glomerular cause of kidney injury, despite the proteinuria observed in many covid- cases [ , ] . obesity is a major risk factor for covid- morbidity, and mortality, though the mechanism for this relationship is not yet clear [ ] . adipose tissue expresses ace . adipocytes are a known contributor to the inflammatory cascade, upregulating cytokines such as tnf-a, il- , and il- [ ] . inflammatory dysregulation by infected adipocytes could exacerbate inflammation thus contributing to ards and the prothrombotic milieu. while adipocytes have been implicated as a reservoir for organisms like hiv, trypanosoma cruzi, and influenza a, there is currently no evidence to suggest that obesity is correlated with sars-cov- viral clearance [ , ] . dipeptidyl peptidase (dpp- ) is highly expressed on adipocytes and may play a role in covid- infection, as it was implicated as a functional receptor for the spike protein of the middle east respiratory syndrome-related coronavirus [ ] . in addition to its role in insulin metabolism, dpp- contributes to systemic inflammation and immune regulation via pathways including t cell activation [ ] . erythrophagocytosis was observed in lymph nodes. this nonspecific finding can be seen in multiple severe inflammatory conditions, including sepsis, macrophage activating syndrome and hemophagocytic lymphohistiocytosis [ ] . the significance of echinocytes in these cases is unclear, and here may be most related to abnormal ph. our study has several limitations. the sample size is limited and was based on referral for autopsy rather than pre-specified clinical parameters. laboratory testing was performed according to clinical routine and not done systematically; we do not have results for all laboratory parameters of interest in all cases. brain and deep leg veins were not evaluated based on autopsy restrictions for infection control. electron microscopy was performed on a limited basis due to limited availability of resources during the pandemic, and infection control concerns. in this series of seven covid- autopsies, macrovascular and microvascular thrombosis was a prominent feature, in some cases despite full anticoagulation. there were platelet-rich microthrombi and circulating megakaryocytes in multiple organs. one case demonstrated acute myocardial infarction due to thrombosis in intramural coronary veins, and one case had focal myocarditis. despite elevated fibrin degradation products, findings typical of renal thrombotic microangiopathy in glomeruli were absent in all but one case, arguing against classical disseminated intravascular coagulation as the underlying pathophysiologic mechanism. there was no external funding for this analysis. this study was supported, in part, by the intramural research program of the nih, national cancer institute. dr. carsons reports grants from novartis and grants from gsk, outside the submitted work. dr. berger reports grants from national heart, lung and blood institute, during the conduct of the study; grants from astrazeneca, other from jannsen, other from amgen, outside the submitted work. dr. charytan reports personal fees from plc medical, grants from bioporto, personal fees from merck, grants and personal fees from novonordisk, grants and personal fees from jannssen, grants and personal fees from gilead, personal fees from astrazeneca, grants and personal fees from medtronic, grants and personal fees from amgen, personal fees from fresenius, personal fees from gsk, outside the submitted work. dr. hochman was supported in part by the nyu ctsa grant ul tr , from the national center for advancing translational sciences (ncats) during the conduct of the study; grants from nhlbi, other from astrazeneca pharmaceuticals llc, other from arbor pharmaceuticals llc, non-financial support from abbott vascular, nonfinancial support from medtronic inc, non-financial support from st. jude medical inc, non-financial support from volcano corp, nonfinancial support from merck sharp & dohme corp, non-financial support from omron healthcare inc, non-financial support from amgen inc, outside the submitted work. dr. reynolds reports non-financial support from abbott vascular, non-financial support from siemens, non-financial support from biotelemetry inc outside the submitted work. clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical characteristics of deceased patients with coronavirus disease : retrospective study cardiovascular implications of fatal outcomes of patients with coronavirus disease (covid- ) association of cardiac injury with mortality in hospitalized patients with covid- in wuhan, china st-segment elevation in patients with covid- -a case series pulmonary embolism in covid- patients: awareness of an increased prevalence incidence of venous thromboembolism in hospitalized patients with covid- incidence of thrombotic complications in critically ill icu patients with covid- covid- and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up pulmonary arterial thrombosis in covid- with fatal outcome: results from a prospective, single-center, clinicopathologic case series post-mortem examination of covid patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings of lungs and other organs suggesting vascular dysfunction autopsy findings and venous thromboembolism in patients with covid- complement associated microvascular injury and thrombosis in the pathogenesis of severe covid- infection: a report of five cases association of treatment dose anticoagulation with in-hospital survival among hospitalized patients with covid- anticoagulant treatment is associated with decreased mortality in severe coronavirus disease patients with coagulopathy covid- does not lead to a "typical" acute respiratory distress syndrome covid- autopsies the frequency of megakaryocytes in autopsy sections the incidence, distribution and significance of megakaryocytes in normal and diseased human tissues circulating human megakaryocytes in cardiac diseases thrombotic microangiopathy and the kidney dying with sars-cov- infection-an autopsy study of the first consecutive endothelial cell infection and endotheliitis in covid- pulmonary vascular endothelialitis, thrombosis, and angiogenesis in covid- pulmonary and cardiac pathology in african american patients with covid- : an autopsy series from new orleans histopathology and ultrastructural findings of fatal covid- infections the emerging spectrum of cardiopulmonary pathology of the coronavirus disease (covid- ): report of autopsies from houston, texas, and review of autopsy findings from other united states cities acute myocarditis presenting as a reverse tako-tsubo syndrome in a patient with sars-cov- respiratory infection myocardial injury and bacterial pneumonia contribute to the pathogenesis of fatal influenza b virus infection a case of cardiogenic shock secondary to complement-mediated myopericarditis from influenza b infection the spectrum of cardiac manifestations in coronavirus disease (covid- ) -a systematic echocardiographic study contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the american heart association renal histopathological analysis of postmortem findings of patients with covid- in china kidney disease is associated with in-hospital death of patients with covid- caution on kidney dysfunctions of covid- patients clinical characteristics of covid- in new york city obesity-induced tnfalpha and il- signaling: the missing link between obesity and inflammation-driven liver and colorectal cancers adipocyte, adipose tissue, and infectious disease obesity increases the duration of influenza a virus shedding in adults dipeptidyl peptidase is a functional receptor for the emerging human coronavirus-emc the role of dipeptidyl peptidase iv (dp iv) enzymatic activity in t cell activation and autoimmunity practice point -infection-related hemophagocytic syndromes the authors thank nyu langone health dart microscopy lab alice liang, and kristen dancel-manning, nyu winthrop electron microscopist thomas palaia and julie alejo at the center for cancer research at nci for their assistance with electron microscopy. the nyu langone health dart microscopy laboratory is partially funded by nyu cancer center support grant nih/nci p ca . supplementary material associated with this article can be found in the online version at doi: . /j.eclinm. . . key: cord- - pjoz q authors: he, daihai; zhao, shi; lin, qianying; zhuang, zian; cao, peihua; wang, maggie h; yang, lin title: the relative transmissibility of asymptomatic cases among close contacts date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: pjoz q abstract asymptomatic transmission of the coronavirus disease is an important topic. a recent study in china showed that transmissibility of the asymptomatic cases is comparable to that of symptomatic cases. here we showed that the conclusion may depend on how we interpret the data. to the best of our knowledge, this is the first time the relative transmissibility of asymptomatic covid- cases is quantified. asymptomatic transmission of the coronavirus disease is an important topic. a recent study in china showed that transmissibility of the asymptomatic cases is comparable to that of symptomatic cases. here we showed that the conclusion may depend on how we interpret the data. to the best of our knowledge, this is the first time the relative transmissibility of asymptomatic covid- cases is quantified. keywords: covid- ; asymptomatic cases; relative transmissibility main text nishiura et al (nishiura et al, ) estimated the asymptomatic ratio of covid- was . % ( out of confirmed cases) among japanese individuals evacuated from wuhan, china. mao et al (mao et al, ) reported that out of confirmed cases are asymptomatic. one of the two cases showed rt-pct positivity th days after first diagnosis. mizumoto et al estimated that the . % of cases on the diamond princess cruise ship were asymptomatic case during the outbreak in february (mizumoto et al, ) . however, the transmissibility of asymptomatic case is unclear, and the positive rt-pct results only imply the potential infectivity. it is important to study the pattern of viral shedding and live virus isolation. wölfel et al studied hospitalized cases and found that live virus was isolated from throat and lung-derived samples between and days after symptom onset (wölfel et al, ) . when the rna concentration is above copies per ml (or equivalent ct-value lower than ), but not from stool samples, despite of high virus rna concentration. above the threshold, high rna concentration yields high probability of live virus isolation. this 'dose- response' association highlights a patient's rt-pcr level should be higher than a threshold to be effectively infectious. however, the mean infectious period (γ − ) of a symptomatic case may be longer than that of an asymptomatic case hypothetically. therefore, the combined effects of ρ and γ − probably lead to a higher reproduction number in the symptomatic group. additionally, chen et al (chen et al, ) showed that asymptomatic cases are more likely to produce asymptomatic cases relatively speaking, since the secondary cases from asymptomatic primary cases consist asymptomatic cases ( %). whereas, out of ( %) are asymptomatic from symptomatic primary cases. the odds ratio (or) is estimated in summary, we conclude that the relatively transmissibility of asymptomatic case could be significantly smaller than that of the symptomatic cases. the main contribution of (chen et al, ) is that they raise the alarm of the existence of the transmissibility of the asymptomatic cases. we remark that how efficient of the transmissibility of asymptomatic cases comparing to symptomatic cases warrants more study. here we showed that the conclusion may depend on how we interpret the data. we also reported the asymptomatic case ratio in hong kong over time due to a large number of young imported case. to the best of our knowledge, this is the first time the relative transmissibility of asymptomatic covid- cases is quantified. estimation of the asymptomatic ratio of novel coronavirus infections (covid- ) estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship the enlightenment from two cases of asymptomatic infection with sars-cov- : is it safe after days of isolation? sars-cov- viral load in upper respiratory specimens of infected patients virological assessment of hospitalized patients with covid- coronavirus disease in china. the new england journal of medicine serial interval of covid- among publicly reported confirmed cases. emerging infectious diseases covert coronavirus infections could be seeding new outbreaks the epidemiological characteristics of infection in close contacts of covid- in ningbo city modelling the coronavirus disease (covid- ) outbreak on the diamond princess ship using the public surveillance data from dh was supported by an alibaba (china)-hong kong polytechnic university collaborative research project. other authors declared no competing interests key: cord- -p ecpcll authors: fu, haiyan; li, hongjuan; tang, xiaoqing; li, xiang; shen, jie; zhou, yujun; xu, bing; luo, yu title: analysis on the clinical characteristics of cases of novel coronavirus pneumonia in kunming date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: p ecpcll objective: to analyze the clinical characteristics of patients with novel coronavirus pneumonia in kunming city, and to study the correlation between nutritional status and immune function. methods: clinical data of patients with novel coronavirus pneumonia in isolation area of kunming third people's hospital from january to february , were collected, and the basic situation, clinical characteristics, laboratory examination and ct imaging characteristics were analyzed. serum albumin (alb), prealbumin (pab), hypersensitive c-reactive protein (hs-crp), cd t cells, cd t cells, cd t cells and normal control group were analyzed. a simple linear regression analysis of the relationship between proalbumin and t cell subpopulation counts in the blood of patients. results: ( ) the patients with new coronavirus pneumonia in kunming were mainly of common type. ( ) % of the patients' first symptoms were fever and cough; ( ) the total number of white blood cells in peripheral blood was normal or decreased in cases ( %), and the lymphocyte count decreased in cases ( . %), without anemia. hypersensitive c-reactive protein increased in ( . %) cases, and procalcitonin increased in case. albumin decreased in cases ( . %), proalbumin decreased in cases ( . %), alanine transaminase increased slightly in cases ( . %), alanine transaminase increased slightly in cases ( . %), total bilirubin increased slightly in cases ( . %), and renal function and blood coagulation were normal. absolute value of cd +t cells is with a decrease in cases ( . %), cd +t in cases ( . %), cd +t in cases ( . %), and cd +/ cd + inverse in cases ( . %). ( ) the prealbumin, cd t cells, cd t cells and cd t cells in the new coronavirus pneumonia group were significantly lower than those in the normal control group, and the hypersensitive c-reactive protein was higher than that in the normal control group. ( ) the levels of pab in the serum of the patients were linearly correlated with hs-crp, cd t cells, cd t cells and cd t cells, and the correlation coefficients were - . , . , . and . , respectively, showing statistical differences. conclusion: the clinical characteristics of the novel coronavirus pneumonia in kunming are different from those in wuhan. the changes of serum proalbumin and t cell subsets are relatively obvious. changes in serum proalbumin may contribute to the early warning of novel coronavirus pneumonia. the nutritional status of patients with common and mild pneumonia should be considered. in december , a new outbreak of coronavirus pneumonia began in wuhan, hubei province, and it quickly spread to the whole country, even many overseas . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint countries. according to the outbreak dynamics released by china, most of the cases have come from hubei, but outbreaks have been detected throughout the country. as a place famous for tourism, yunnan has a large number of imported cases, and the incidence level is in the middle of the whole country. and light type, and a small number of patients with severe or critical type recovered relatively well. by : on february , , there were no death cases. in our clinical work, we found significant changes in patients' nutritional status, which may be related to inflammation and immunity. this paper will analyze the clinical characteristics of the new type of coronavirus pneumonia admitted to the third people's hospital of kunming city, and analyze the relationship between serum proalbumin and t cells and its clinical significance. this study was approved by the ethics committee of the third people's hospital of kunming, and all data were used for clinical studies only, with the written consent of patients and their guardians. according to the diagnosis and treatment scheme issued . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint by the national health commission of china , "the new coronavirus infection pneumonia diagnosis and treatment plan (trial edition ), the diagnostic criteria for new coronavirus pneumonia confirmed cases outside of hubei province [ ] : ( ) the history of epidemiology: ) within days before the onset, there was a history of traveling or living in the community of wuhan city, surrounding areas, or other pathological reported area [ ] ) within days before the onset, there was contact history with cases of the new coronavirus infection (positive nucleic acid detection); ) within days before the onset, there was contact with the patient with fever or respiratory symptoms from wuhan, surrounding areas or from communities where cases of the disease have been reported; ) aggregation of the disease. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. spss . software was used for data analysis. case or rate were used for data counting, and χ test was used for inter-group comparison; the measurement data of normal distribution were expressed as x±s, and the measurement data of non-normal distribution were expressed as median (quartile spacing). the measurement data of normal distribution was verified with t-test or analysis of variance, and the rank sum test was used for inter-group comparison of non-normal distribution. the relationship between pab and t cell subsets and hs-crp was analyzed by regression, and the scatter plot was made by simple linear regression and the regression equation was calculated. p < . was considered statistically significant. . clinical features: general data patients were diagnosed at the age of - years, with a median age of years, including children ( . %). there were males ( . %) and females . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint ( . %). there were cases with long-term exposure, cases with short-term exposure, and cases with unknown exposure time. there were previous smoking cases ( . %). there were patients with basic diseases ( . %), including patients with hypertension ( . %), patients with diabetes ( . %), patient with hypothyroidism ( . %), and patient with hyperlipidemia ( . %). there were cases of light type, cases of normal type and cases of critical type. there were ( %) cases in hubei and ( %) cases in yunnan. signs and symptoms (table ) . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint pulmonary ground glass shadow was found in ( . %) cases (fig. a) , pavement stone sign in ( . %) cases (fig. b) , strip shadow in ( . %) cases (fig. c) , consolidation shadow in ( . %) cases (fig. d) , aerated bronchi sign in ( . %) cases (fig. d) , and vascular thickening in ( . %) cases (fig. e) . typical performance is shown in figure : author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint decoction), patients were with treatment to enhance immunity, patients were with the using of immunoglobulin, patients were with hormone therapy, of whom the treatment for patients with hypertension were altered to calcium antagonist, and patients were treated with non-invasive ventilator assisted breathing. the results show that the pab, cd + , cd + and cd + t cells in the pneumonia group of the novel coronavirus are significantly lower than those in the normal control . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint group, and the hypersensitive c-reactive protein is higher than that in the normal control group, while there is no significant differences between the albumin and the normal control group. simple linear regression analysis of serum pab, hs-crp, cd + t cells, cd + t cells and cd + t cells in patients with novel coronavirus pneumonia: . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint this paper is the first reported clinical study in a non-hubei study in china. there are several differences, compared with the clinical analysis results reported by wuhan jinyintan hospital and tongji hospital affiliated to tongji medical college of huazhong university of science and technology (refer to as tongji hospital affiliated hereafter). only of the cases included in this study were assessed as critical on admission, while the rest of the cases were mainly of normal type and not severe. [ ] [ ] on admission, % of the patients had fever and cough as their first symptoms, mainly moderate and low fever, with few gastrointestinal symptoms. in this study, the lymphocyte absolute value reduction is only in cases ( . %), hypersensitive c-reactive protein increased in ( . %), significantly lower than the % and % reported by tongji hospital affiliated s, or less than % and % of the jinyintan hospital reports respectively. that may be involved with the fact that this study is mainly based on the common type and mild type. the changes of lymphocyte absolute value and hypersensitive c-reactive protein in patients with the common and mild cases of the new coronavirus pneumonia are not as evident as those in the severe and critical cases, which can be easily ignored during clinical observation. in this study, we found a decrease in prealbumin in cases ( . %), and no previous studies have reported prealbumin changes. prealbumin is usually used in clinical evaluation of the nutritional status of the body, and the half-life of serum prealbumin is short, so its changes may occur before albumin. in this study, there were only patients with decreased albumin, all of which were with a slight decrease, but patients ( . %)showed decreased prealbumin. the pulmonary ct findings of the patients were basically consistent with previous reports. twenty-two ( . %) of the patients showed abnormal findings, with ground glass density shadows. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint our study suggests that patients with novel coronavirus pneumonia experience a decrease in t-cell subsets on admission, and in combination with clinical typing, we speculate that immune function may be suppressed or impaired in the early stage of the disease. as a commonly used indicator to evaluate nutritional status in clinical practice, prealbumin is often utilized to evaluate tumor and postoperative recovery [ ] . domestic scholar cai chuanqi et al. [ ] found that hypoalbuminemia is an independent risk factor for the severity of disease in elderly pneumonia patients. this study found that the albumin in the disease group was basically normal, while the prealbumin was significantly lower than that in the normal control group. we analyzed the relationship between prealbumin and cd + t cells, cd + t cells and cd + t cells respectively. the regression model showed that there is a linear and positive correlation between the level of prealbumin in the serum of patients and cd + t cells, cd + t cells and cd + t cells, with the strongest correlation among cd + t cells. proalbumin is an acute reactive protein synthesized by liver cells with a half-life of days [ ] . in the early stage of the disease, proalbumin changes, which may be caused by the consumption of proalbumin by the body after infection with the virus, leading to the reduction of proalbumin in peripheral blood. recent studies have found that inflammation is an effective inhibitor of protein synthesis, and it may also inhibit the synthesis of visceral prealbumin during the occurrence and development of the disease, leading to a low level of prealbumin [ ] . due to fever and infection, the body is in a state of high decomposition and high energy demand. if at the same time with lack of energy and loss of appetite, the patient cannot ensure sufficient food intake through the mouth to meet the needs of the body. meanwhile if combined with basic diseases of other viscera, moderate or severe malnutrition can easily appear in pneumonia patients. clinical studies have found that malnutrition rates in patients with severe pneumonia are as high as %, with immune dysfunction. enteral nutrition or other forms of nutritional support are usually provided only to patients with severe pneumonia. good nutritional status not . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint only reflects the body's immune function to a certain extent, but also may play an irreplaceable role in fighting the emerging inflammatory storm. prealbumin can be used as an early warning indicator of immune function in patients with new coronavirus pneumonia. through the analysis of the relationship between prealbumin and t cell subsets, the decreased value of prealbumin indicates that the patient's cellular immune function is impaired, which plays a certain role in clinical condition monitoring. according to the current outbreak reports, most of the patients are mild and normal type. in this study, we concluded that lymphocyte changes are not significant in the early stage of the disease in both normal and mild patients, and that changes in t-cell subsets and prealbumin might be beneficial for evaluating the disease. national health committee of the people's republic of china. diagnosis and treatment plan for pneumonitis caused by new coronavirus (trial version clinical features of patients infected with novel coronavirus in wuhan analysis of clinical characteristics of cases of new coronavirus pneumonia in . chinese journal of tuberculosis and respiratory diseases effects of post-surgical parenteral nutrition on patients with gastric cancer predictive value of serum albumin and prealbumin on the status of senile pneumonia prealbumin is predictive for postoperative liver insufficiency in patients undergoing liver resection nutritional laboratory markers in malnutrition key: cord- -oee duz authors: gostic, katelyn; gomez, ana cr; mummah, riley o; kucharski, adam j; lloyd-smith, james o title: estimated effectiveness of symptom and risk screening to prevent the spread of covid- date: - - journal: elife doi: . /elife. sha: doc_id: cord_uid: oee duz traveller screening is being used to limit further spread of covid- following its recent emergence, and symptom screening has become a ubiquitous tool in the global response. previously, we developed a mathematical model to understand factors governing the effectiveness of traveller screening to prevent spread of emerging pathogens (gostic et al., ). here, we estimate the impact of different screening programs given current knowledge of key covid- life history and epidemiological parameters. even under best-case assumptions, we estimate that screening will miss more than half of infected people. breaking down the factors leading to screening successes and failures, we find that most cases missed by screening are fundamentally undetectable, because they have not yet developed symptoms and are unaware they were exposed. our work underscores the need for measures to limit transmission by individuals who become ill after being missed by a screening program. these findings can support evidence-based policy to combat the spread of covid- , and prospective planning to mitigate future emerging pathogens. as of february , , the novel coronavirus (now named sars-cov- , causing the disease covid- ) has caused over , confirmed cases inside of china and has spread to other countries (world health organization, b) . (hcov- has been proposed as an alternate name for the virus; jiang et al., ) . until now, local transmission remained limited outside of china, but as of this week, new epidemic hotspots have become apparent on multiple continents (world health organization, a; jankowicz, ; sang-hun, ; schnirring, a) . many jurisdictions have imposed traveller screening in an effort to prevent importation of covid- cases to unaffected areas. some high-income countries have escalated control measures beyond screening-based containment policies, and now restrict or quarantine inbound travellers from countries known to be experiencing substantial community transmission. meanwhile, in many other countries, screening remains the primary barrier to case importation (guardian reporting team, ; schengen visa info, ) . even in countries with the resources to enforce quarantine measures, expanded arrival screening may be the first logical response as the source epidemic expands to regions outside china. furthermore, symptom screening has become a ubiquitous tool in the effort to contain local spread of covid- , in settings from affected cities to cruise ships to quarantines. our analysis is pertinent to all of these contexts. it is widely recognized that screening is an imperfect barrier to spread (bitar et al., ; cowling et al., ; gostic et al., ; mabey et al., ; quilty et al., ) , due to: the absence of detectable symptoms during the incubation period; variation in the severity and detectability of symptoms once the disease begins to progress; imperfect performance of screening equipment or personnel; or active evasion of screening by travellers. previously we estimated the effectiveness of traveller screening for a range of pathogens that have emerged in the past, and found that arrival screening would miss - % of infected cases even under optimistic assumptions (gostic et al., ) . yet the quantitative performance of different policies matters for planning interventions and will influence how public health authorities prioritize different measures as the international and domestic context changes. here we use a mathematical model to analyse the expected performance of different screening measures for , based on what is currently known about its natural history and epidemiology and on different possible combinations of departure and arrival screening policies. first we assess the probability that any single individual infected with sars-cov- would be detected by screening, as a function of time since exposure. this individual-level analysis is not a comprehensive measure of program success, but serves to illustrate the various ways in which screening can succeed or fail (and in turn the ways it can or cannot be improved). further, these analyses emphasize the importance of the incubation period, and the fraction of subclinical cases, as determinants of individual screening outcomes. we define subclinical cases as those too mild to show symptoms detectable in screening (fever or cough) after passing through the incubation period (i.e. once any symptoms have manifested). the true fraction of subclinical covid- cases remains unknown, but anecdotally, many lab-confirmed covid- cases have not shown detectable symptoms on diagnosis (hoehl et al., ; nishiura et al., ; . about % of clinically attended cases have been mild (the novel coronavirus pneumonia emergency response epidemiology team, ), and clinically attended cases have been conspicuously rare in children and teens the novel coronavirus pneumonia emergency response epidemiology team, ; huang et al., ; , raising the possibility that subclinical cases may be common. next, we assess the overall effectiveness of a screening program by modeling screening outcomes in a hypothetical population of infected travellers, each with a different time since exposure (and hence a different probability of having progressed through incubation to show detectable symptoms). crucially, the distribution of times since exposure will depend on the epidemiology of the source population, so this overall measure is not a simple average of the individual-level outcomes. we estimate the fraction of infected travellers detected, breaking down the ways in which screening can succeed or fail. an alternate measure of program success is the extent to which screening delays the first importation of cases into the community, possibly providing additional time to train medical staff, deploy public health responders or refine travel policies (cowling et al., ) . to quantify the potential for screening to delay case importation, we estimate the probability that a given screening program would detect the first n or more imported cases before missing an infected person. screening will be less effective in a growing epidemic, due to an excess of recently-exposed and not-yet-symptomatic travellers (gostic et al., ) . in the context of covid- , we consider both growing and stable epidemic scenarios, but place greater emphasis on the realistic assumption that the covid- epidemic is still growing. since late january , the chinese government has imposed strict travel restrictions and surveillance on population centers heavily affected by covid- (bbc news, ; cellan-jones, ) , and numerous other countries have imposed travel and quarantine restrictions on travellers inbound from china. until about feb. , , these measures had appeared to successfully limit community transmission outside of china, but all the while multiple factors pointed to on-going risk, including evidence that transmission is possible prior to the onset of symptoms , and reports of citizens seeking to elude travel restrictions or leaving before restrictions were in place (ma and pinghui, ; mahbubani, ) . now, in the week following feb. , , new source epidemics have appeared on multiple continents (world health organization, a) , and the the risk of exportation of cases from beyond the initial travel-restricted area is growing. as the epidemic continues to expand geographically, arrival screening will likely be continued or expanded to prevent importation of cases to areas without established spread. at the same time, there is great concern about potential public health consequences if covid- spreads to developing countries that lack health infrastructure and resources to combat it effectively (de salazar et al., ) . limited resources also could mean that some countries cannot implement large-scale arrival screening. in this scenario, departure screening implemented elsewhere would be the sole barrierhowever leaky -to new waves of case importation. it is also important to recognize that, owing to the lag time in appearance of symptoms in imported cases, any weaknesses in screening would continue to have an effect on known case importations for up to two weeks, officially considered the maximum incubation period (world health organization, c) . accordingly, we consider scenarios with departure screening only, arrival screening only, or both departure and arrival screening. the model can also consider the consequences when only a fraction of the traveller population is screened, due either to travel from a location not subject to screening, or due to deliberate evasion of screening. our analysis also has direct bearing on other contexts where symptom screening is being used, beyond international air travel. this includes screening of travelers at rail stations and roadside spot checks, and screening of other at-risk people including people living in affected areas, health-care workers, cruise ship passengers, evacuees and people undergoing quarantine (hoehl et al., ; japan ministry of health, labor and welfare, ; nishiura et al., ; schnirring, c) . below, we chiefly frame our findings in terms of travel screening, but these other screening contexts are also in the scope of our analysis. any one-off screening effort is equivalent to a departure screen (i.e. a single test with no delay), and our findings on symptom screening effectiveness over the course of infection are directly applicable to longitudinal screening in quarantine or occupational settings. the central aim of our analysis is to assess the expected effectiveness of screening for covid- , taking account of current knowledge and uncertainties about the natural history and epidemiology of the virus. we therefore show results using the best estimates currently available, in the hope of informing policy decisions in this fast-changing environment. we also make our model available for public use as a user-friendly online app, so that stakeholders can explore scenarios of particular interest, and results can be updated rapidly as our knowledge of this new viral threat continues to expand. the core model has been described previously (gostic et al., ) , but to summarize briefly, it assumes infected travellers can be detained due to the presence of detectable symptoms (fever or cough), or due to self-reporting of exposure risk via questionnaires or interviews. these assumptions are consistent with who traveller screening guidelines (world health organization, b; world health organization, c). upon screening, travellers fall into one of four categories: ( ) symptomatic but not aware of exposure risk, ( ) aware of exposure risk but without detectable symptoms, ( ) symptomatic and aware that exposure may have occurred, and ( ) neither symptomatic nor aware of exposure risk ( figure ) . travellers in the final category are fundamentally undetectable, and travellers in the second category are only detectable if aware that they have been exposed and willing to self report. in the model, screening for symptoms occurs prior to questionnaire-based screening for exposure risk, and detected cases do not progress to the next stage. this allows us to track the fraction of cases detected using symptom screening or risk screening at arrival or departure. additionally, building on the four detectability classes explained above, the model keeps track of four ways in which screening can miss infected travellers: ( ) due to imperfect sensitivity, symptom screening may fail to detect symptoms in travellers that display symptoms; ( ) questionnaires may fail to detect exposure risk in travellers aware they have been exposed, owing to deliberate obfuscation or misunderstanding; ( ) screening may fail to detect both symptoms and known exposure risk in travellers who have both and ( ) travellers not exhibiting symptoms and with no knowledge of their exposure are fundamentally undetectable. here, we only consider infected travellers who submit to screening. however, the supplementary app allows users to consider scenarios in which some fraction of infected travellers intentionally evade screening ( figure e ). the probability that an infected person is detectable in a screening program depends on: the incubation period (the time from exposure to onset of detectable symptoms); the proportion of subclinical cases (mild cases that lack fever or cough); the sensitivity of thermal scanners used to detect fever; the fraction of cases aware they have high exposure risk; and the fraction of those cases who would self-report truthfully on a screening questionnaire. further, the distribution of individual times since exposure affects the probability that any single infected traveller has progressed to the symptomatic stage. if the source epidemic is still growing, the majority of infected cases will have been recently exposed, and will not yet show symptoms. if the source epidemic is no longer growing (stable), times since exposure will be more evenly distributed, meaning that more infected travellers will have progressed through incubation and will show detectable symptoms. we used methods described previously to estimate the distribution of individual times since exposure in a growing or stable epidemic, given various values of the reproductive number r (gostic et al., ) . briefly, early in the epidemic when the number of cases is still growing, the model draws on epidemiological theory to assume that the fraction of cases who are recently exposed increases with r . the distribution of times since exposure is truncated at a maximum value, which corresponds epidemiologically to the maximum time from exposure to patient isolation, after which point we assume cases will not attempt to travel. (isolation may occur due to hospitalization, or due to confinement at home in response to escalating symptoms or covid- diagnosis. in the non-travel context, this would correspond to cases that have been hospitalized or otherwise diagnosed and isolated.) here, we approximate the maximum time from exposure to isolation as the sum of the mean incubation time, and mean time from onset to isolation. to consider the epidemiological context of a stable epidemic in the source population we assume times since exposure follow a uniform distribution across the time period between exposure and isolation. as of february , , covid- -specific estimates are available for most parameters, but many have been derived from limited or preliminary data and remain subject to considerable uncertainty. table and the methods summarize the current state of knowledge. here, we used two distinct approaches to incorporate parameter uncertainty into our analysis. first, to estimate the probability that an infected individual would be detected or missed we considered a range of plausible values for the mean incubation time, and the fraction of subclinical table . parameter values estimated in currently available studies, along with accompanying uncertainties and assumptions. ranges in the final column reflect confidence interval, credible interval, standard error or range reported by each study referenced. best estimate (used in figure ) plausible range (used in figure ) mean incubation period . days sensitivity: . or . clinical data: % fever, % cough, n = (chan et al., ) % fever, % cough, n = % fever, % cough, n = . % fever at hospital admission, . % fever during hospitalization, n = active monitoring after repatriation flights or on cruise ships: % asymptomatic at diagnosis . % ( / ) (japan ministry of health, labor and welfare, ) . % ( of ) (nishiura et al., ) . % ( of ) we assume a low percentage, as no specific risk factors have been identified, and known times or sources of exposure are rarely reported in existing line lists. sensitivity of infrared thermal scanners for fever % - % most studies estimated sensitivity between - % (bitar et al., ; priest et al., ; tay et al., ) . but a handful of studies estimated very low sensitivity ( - %). in general, sensitivity depended on the device used, body area targeted and ambient temperature. probability that travellers self-report exposure risk % - % % is an upper-bound estimate based on outcomes of past screening initiatives. (gostic et al., ) time from symptom onset to patient isolation (after which we assume travel is not possible) no effect in individual-level analysis. median days from onset to hospitalization (n = ) (chan et al., ) mean . days onset to patient isolation (n = ) median days from onset to hospitalization (n = ) as awareness increases, times to isolation may decline. * from family cluster. † parametric distributions fit to cases with known dates of exposure or travel to and from wuhan. cases. we focus on the incubation period and subclinical fraction of cases because screening outcomes are particularly sensitive to their values. all other parameters were fixed to the best available estimates listed in table . second, we considered a population of infected travellers, each with a unique time of exposure, and in turn a unique probability of having progressed to the symptomatic stage. here, the model used a resampling-based approach to simultaneously consider uncertainty from both stochasticity in any single individual's screening outcome, and uncertainty as to the true underlying natural history parameters driving the epidemic. details are provided in the methods, but briefly, we constructed candidate parameter sets, drawn using latin hypercube sampling from plausible ranges for each parameter (table ) . using each parameter set, we simulated one set of screening outcomes for a population of infected individuals. as of february , , approximates the maximum known number of cases imported to any single country (world health organization, b), and thus our analysis incorporates a reasonable degree of binomial uncertainty. the actual number of infected travellers passing through screening in any given location may be higher or lower than , and will depend on patterns of global connectivity, and on the duration of the source epidemic (chinazzi et al., ; de salazar et al., ) . finally, we analysed the sensitivity of screening effectiveness (fraction of travellers detected) to each parameter, as measured by the partial rank correlation coefficient (prcc) (marino et al., ) . the black dashed lines separate detected cases (below) from missed cases (above). here, we assume flight duration = hr, the probability that an individual is aware of exposure risk is . , the sensitivity of fever scanners is . , and the probability that an individual will truthfully self-report on risk questionnaires is . . table table . dots and vertical line segments show the median and central %, respectively. text above each violin shows the median and central % fraction detected. (b) mean fraction of travellers with each screening outcome. the black dashed lines separate detected cases (below) from missed cases (above). (c) fraction of simulations in which screening successfully detects at least n cases before the first infected traveller is missed. figure continued on next page individual probabilities of detection first, the model estimated the probability that any single infected individual would be detected by screening as a function of the time between exposure and the initiation of travel (figure ) . incubation time is a crucial driver of traveller screening effectiveness; infected people are most likely to travel before the onset of symptoms. here we considered three mean incubation times, which together span the range of most existing mean estimates: . , . and . days ( table ) . additionally, we considered three possible fractions of subclinical cases: % represents a worst-case upper bound, % represents a best-case lower bound, and % represents a plausible middle case. (table , materials and methods). since resubmission, a new delay-adjusted estimate indicates that . % of infections are asymptomatic (mizumoto et al., ) , intermediate between our middle and worst-case scenarios. even within the narrow range tested, screening outcomes were sensitive to the incubation period mean. for longer incubation periods, we found that larger proportions of departing travellers would not yet be exhibiting symptoms -either at departure or arrival -which in turn reduced the probability that screening would detect these cases, especially since we assume few infected travellers will realize they have been exposed to covid- . a second crucial uncertainty is the proportion of subclinical cases, which lack detectable fever or cough even after the onset of symptoms. we considered scenarios in which %, % and % of cases are subclinical, representing a best, middle and worst-case scenario, respectively. the middle and worst-case scenarios have predictable and discouraging consequences for the effectiveness of traveller screening, since they render large fractions of the population undetectable by fever screening ( figure ) . furthermore, subclinical cases who are unaware of their exposure risk are never detectable, by any means. this is manifested as the bright red 'undetectable' region which persists well beyond the mean incubation period. for a screening program combining departure and arrival screening, as shown in figure , the greatest contributor to case detection is the departure fever screen. the arrival fever screen is the next greatest contributor, with its value arising from two factors: the potential to detect cases whose symptom onset occurred during travel, and the potential to catch cases missed due to imperfect instrument sensitivity in non-contact infrared thermal scanners used in traveller screening (table ) . considering the effectiveness of departure or arrival screening only (figure -figures supplement , ) , we see that fever screening is the dominant contributor in each case, but that the risk of missing infected travellers due to undetected fever is substantially higher when there is no redundancy from two successive screenings. overall screening effectiveness in a population of infected travellers during a growing or stable epidemic next we estimated the overall effectiveness of different screening programs, as well as the uncertainties arising from the current partial state of knowledge about this recently-emerged virus. we modeled plausible population-level outcomes by tracking the fraction of infected travellers detained, given a growing or stable epidemic and current uncertainty around parameter values. we separately consider the best, middle and worst-case scenarios for the proportion of infections that are subclinical, and for each scenario we compare the impact of departure screening only (or equivalently, any on-the-spot screening), arrival screening only, or programs that include both. the striking finding is that in a growing epidemic, even under the best-case assumptions, with just one infection in twenty being subclinical and all travellers passing through departure and arrival screening, the median fraction of infected travellers detected is only . , with % interval extending from . up to . ( figure a) . the total fraction detected is lower for programs with only source data . source data for figure a . source data . source data for figure b . source data . source data for figure c . one layer of screening, with arrival screening preferable to departure screening owing to the possibility of symptom onset during travel. considering higher proportions of subclinical cases, the overall effectiveness of screening programs is further degraded, with a median of just one in ten infected travellers detected by departure screening in the worst-case scenario. the key driver of these poor outcomes is that even in the best-case scenario, nearly two thirds of infected travellers will not be detectable (as shown by the red regions in figure b ). there are three drivers of this outcome: ( ) in a growing epidemic, the majority of travellers will have been recently infected and hence will not yet have progressed to exhibit any symptoms; ( ) we assume that a fraction of cases never develop detectable symptoms; and ( ) we assume that few people are aware of their exposure risk. as above, the dominant contributor to successful detections is fever screening. in an epidemic that is no longer growing (figure -figures supplement ) , screening effectiveness is considerably higher, as a lower proportion of travellers will be recently exposed. this is shown by the smaller, red 'undetectable' region in figure -figures supplement b. in a stable epidemic, under the middle-case assumption that % of cases are subclinical, we estimate that arrival screening alone would detect roughly one third ( - %) of infected travelers, and that a combination of arrival and departure screening would detect nearly half ( - %) of infected travellers. in short, holding all other things equal, screening effectiveness will increase as the source epidemic transitions from growing to stable, owing simply to changes in the distribution of 'infection ages,' or times since exposure. to assess the potential for screening to delay introduction of undiagnosed cases, we evaluated the fraction of simulations in which screening during a growing epidemic would detect the first n or more infected travellers ( figure c ). depending on the screening strategy (arrival, departure or both) and assumed subclinical fraction ( %, %, or %), the probability of detecting at least the first two cases ranged from . to . , and the probability of detecting three or more cases was never better than . ( figure c ). in all tested scenarios, more than half of simulations failed to detect the first imported case, consistent with probabilities of case detection in figure a . probabilities of detecting the first n consecutive cases were marginally higher in the stable epidemic context (figure -figures supplement ) , but still the probability of detecting at least the first three cases was never better than . , and the probability of detecting the first four cases was never better than . in any tested scenario. taken together, these results indicate that screening in any context is very unlikely to delay case importation beyond the first - cases, and often will not delay the first importation at all. what duration of delay this yields will depend on the frequency of infected travellers. in the context of a growing epidemic, sensitivity analysis using the method of latin hypercube sampling and partial rank correlation (marino et al., ) showed that the fraction of travellers detected was moderately sensitive to all parameters considered -most coefficient estimates fell between . and . in absolute value ( figure ). sensitivity to r was somewhat higher than sensitivity to other parameters, but the difference was not statistically remarkable. r and the mean incubation period were negatively associated with the fraction of cases detected. an increase in either of these parameters implies an increase in the probability an infected traveller will be undetectable, either because they have been recently exposed (r ), or have not yet progressed to the symptomatic stage (mean incubation time). the positive association between the fraction of cases detected and the sensitivity of thermal scanners, sensitivity of risk questionnaires, or the fraction of travellers aware of exposure risk is intuitive. finally, the duration from onset to isolation effectively describes the window of time in which we assume a symptomatic individual could initiate travel. here, a wider window is associated with increased screening effectiveness, because it will lead to a higher proportion of infected travellers who are symptomatic. figure shows results from the middle case scenario, in which % of cases are subclinical. considering scenarios where more or fewer cases are subclinical, we see increased influence of the factors based on exposure risk (questionnaire sensitivity and the fraction of cases aware of their exposure) as the proportion of cases with detectable symptoms declines (figure -figures supplement ) . in the context of a stable epidemic, a greater proportion of infected travellers will have progressed to show detectable symptoms, and so screening effectiveness was more sensitive to parameters that impact symptom screening efficacy (thermal scanner sensitivity, and to the time from symptom onset to isolation). note that by construction, model outcomes are insensitive to parameter r in the stable epidemic context. as a result, r coefficient estimates are very small (non-zero due to stochasticity in simulation outcomes), and never significant. (figure -figures supplement ). we have developed an interactive web application using the r package shiny (chang et al., ) in which users can replicate our analyses using parameter inputs that reflect the most up-do-date information. the supplementary user interface can be accessed at https://faculty.eeb.ucla.edu/lloydsmith/screeningmodel. please note that while the results in figures and consider a range of plausible values for each parameter, the outputs of the shiny app are calculated using fixed, userspecified values only. the international expansion of covid- cases has led to widespread adoption of symptom and risk screening measures, in travel-associated and other contexts, and programs may still be adopted or expanded as source epidemics of covid- emerge in new geographic areas. using a mathematical model of screening effectiveness, with preliminary estimates of covid- epidemiology and natural history, we estimate that screening will detect less than half of infected travellers in a growing epidemic, and that screening effectiveness will increase marginally as growth of the source epidemic decelerates. we found that two main factors influenced the effectiveness of screening. first, symptom screening depends on the natural history of an infection: individuals are increasingly likely to show detectable symptoms with increasing time since exposure. a fundamental shortcoming of screening is the difficulty of detecting infected individuals during their incubation period, or early after the onset of symptoms, at which point they still feel healthy enough to undertake normal activities or travel. this difficulty is amplified when the incubation period is longer; infected individuals have a longer window in which they may mix socially or travel with low probability of detection. second, screening depends on whether exposure risk factors exist that would facilitate specific and reasonably sensitive case detection by questionnaire. for covid- , there is so far limited evidence for specific risk factors; we therefore assumed that at most % of travellers would be aware of a potential exposure. it is plausible that many individuals aware of a potential exposure would voluntarily avoid travel and practice social distancing-if so, the population of infected travellers will be skewed toward those unaware they have been exposed. furthermore, based on screening outcomes during the influenza pandemic, we assumed that a minority of infected travellers would selfreport their exposure honestly, which led to limited effectiveness in questionnaire-based screening. the confluence of these two factors led to many infected people being fundamentally undetectable in our model. even under our most generous assumptions about the natural history of covid- , the presence of undetectable cases made the greatest contribution to screening failure. correctable failures, such as missing an infected person with fever or awareness of their exposure risk, played a more minor role. our conclusion that screening would detect no more than half of infected travellers in a growing epidemic is consistent with recent studies that have compared country-specific air travel volumes with detected case counts to estimate that roughly two thirds of imported cases remain undetected bhatia et al., ) . furthermore, the finding that the majority of cases missed by screening are fundamentally undetectable is consistent with observed outcomes so far. analyzing a line list of cases imported into various countries , we found that symptom onset occurred after the date of inbound travel for % ( / ) of cases for whom both dates were available, and a further % ( / ) had symptom onset on the date of travel. even among passengers of repatriation flights, or quarantined on a cruise ship off the coast of japan (who are all demonstrably at high risk), numerous cases have been undetectable in symptom screening, but have still tested positive for sars-cov- by pcr hoehl et al., ; japan ministry of health, labor and welfare, ; nishiura et al., ; . the onset of viral shedding prior to the onset of symptoms, or in cases that remain asymptomatic, is a classic factor that makes infectious disease outbreaks difficult to control (fraser et al., ) . our results emphasize that the true fraction of subclinical cases (those who lack fever or cough at symptom onset) remains a crucial unknown, and strongly impacts screening effectiveness. reviewing data from active surveillance of passengers on cruise ships or repatriation flights, we estimate that up to half of cases show no detectable symptoms at the time of diagnosis. to complicate matters further, the fraction of subclinical cases may vary across age groups. children and young adults have been conspicuously underrepresented, even in very large clinical data sets the novel coronavirus pneumonia emergency response epidemiology team, ; huang et al., ; . only . % of the first , confirmed cases were observed in children under years of age (the novel coronavirus pneumonia emergency response epidemiology team, ). the possibility cannot be ruled out that large numbers of subclinical cases are occurring in young people. if an age-by-severity interaction does indeed exist, then the mean age of travellers should be taken into account when estimating screening effectiveness. there are some limitations to our analysis. parameter values for covid- may be affected by bias or censoring, particularly in the early stages of an outbreak when most cases have been recently infected, and when severe or hospitalized cases are overrepresented in the available data. in particular, the tail of the incubation period distribution is difficult to characterize with precision using limited or biased data. as country-specific screening policies can change rapidly in real-time, we focused on a general screening framework rather than specific case studies. we also assumed traveller adherence and no active evasion of screening. however, there are informal reports of people taking antipyretics to beat fever screening (mahbubani, ) , which would further reduce the effectiveness of these methods. with travel restrictions in place, individuals may also take alternative routes (e.g. road rather than air), which would in effect circumvent departure and/or arrival screening as a control measure. our quantitative findings may overestimate screening effectiveness if many travellers evade screening. our results have several implications for the design and implementation of traveller screening policies. if the infection is not yet present in a region, then arrival screening could delay the introduction of cases, but consistent with previous analyses, (cowling et al., ) , our results indicate such delays would be minimal. our findings indicate that for every case detected by travel screening, one or more infected travellers were not caught, and must be found and isolated by other means. we note that even with high r and no control measures in place, a single case importation is not guaranteed to start a sustained chain of transmission (kucharski et al., ; lloyd-smith et al., ) . this is particularly true for infections that exhibit a tendency toward superspreading events, as increasingly reported for covid- , but the flipside is that outbreaks triggered by superspreading are explosive when they do occur (lloyd-smith et al., ) . we did not analyze second-order benefits from screening, such as potential to raise awareness. official recommendations emphasize that screening is an opportunity for 'risk communication' in which travellers can be instructed how to proceed responsibly if symptoms develop at the destination (world health organization, d). alongside increased general surveillance/alertness in healthcare settings, such measures could help reduce the risk of local transmission and superspreading, but their quantitative effectiveness is unknown. once limited local transmission has begun, arrival screening could still have merit as a means to restrict the number of parallel chains of transmission present in a country. once there is generalized spread which has outpaced contact tracing, departure screening to prevent export of cases to new areas will be more valuable than arrival screening to identify additional incoming cases. altogether, screening should not be viewed as a definitive barrier to case importation, but used alongside on-the-ground response strategies that help reduce the probability that any single imported case spreads to cause a self-sustaining local epidemic. the cost-benefit tradeoff for any screening policy should be assessed in light of past experiences, where few or no infected travellers have been detected by such programs (gostic et al., ) . while our findings indicate that the majority of screening failures arise from undetectable cases (i.e. those without symptoms or knowledge of their exposure), several factors could potentially strengthen the screening measures described here. with improved efficiency of thermal scanners or other symptom detection technology, we would expect a smaller difference between the effectiveness of arrival-only screening and combined departure and arrival screening in our analysis. alternatively, the benefits of redundant screening (noted above for programs with departure and arrival screens) could be gained in a single-site screening program by simply having two successive feverscreening stations that travellers pass through (or taking multiple measurements of each traveller at a single station). as risk factors become better known, questionnaires could be refined to identify more potential cases. alternatively, less stringent definition of high exposure risk (e.g. contact with anyone with respiratory symptoms) would be more sensitive, but at the expense of large numbers of false positives detained, especially during influenza season. the availability of rapid pcr tests would also be beneficial for case identification at arrival, and would help address concerns with false-positive detections by screening. if such tests were fast, there may be potential to test suspected cases in real time based on questionnaire responses, travel origin, or borderline symptoms; at least one pcr test for sars-cov- claimed to take less than an hour has already been announced (biomeme, ) . however, such measures could prove highly expensive if implemented at scale. there is also scope for new tools to improve the ongoing tracking of travellers who pass through screening, such as smartphone-based self-reporting of temperature or symptoms in incoming cases . smartphone or diary-based surveillance would be cheaper and more scalable than intense, on-the-ground follow-up, but is likely to be limited by user adherence. our analysis underscores the reality that respiratory viruses are difficult to detect by symptom and risk screening programs, particularly if a substantial fraction of infected people show mild or indistinct symptoms, if incubation periods are long, and if transmission is possible before the onset of symptoms. quantitative estimates of screening effectiveness for covid- will improve as more is learned about this recently-emerged virus, and will vary with the precise design of screening programs. however, we present a robust qualitative finding: in any situation where there is widespread epidemic transmission in source populations from which travellers are drawn, travel screening programs can slow (marginally) but not stop the importation of infected cases. screening programs implemented in other settings will face the same challenges. by decomposing the factors leading to success or failure of screening efforts, our work supports decision-making about program design, and highlights key questions for further research. we hope that these insights may help to mitigate the global impacts of covid- by guiding effective decision-making in both high-and low-resource countries, and may contribute to prospective improvements in screening policy for future emerging infections. the model's structure is summarized above (figure ) , and detailed methods have been described previously (gostic et al., ) . here, we summarize relevant extensions, assumptions and parameter inputs. our previous model tracked all the ways in which infected travellers can be detected by screening (fever screen, or risk factor screen at arrival or departure). here, we additionally keep track of the many ways in which infected travellers can be missed (i.e. missed given fever present, missed given exposure risk present, missed given both present, or missed given undetectable). cases who have not yet passed the incubation period are considered undetectable by fever screening, even if they will eventually develop symptoms in the future. in other words, no traveller is considered 'missed given fever present' until they have passed the incubation period and show detectable symptoms. infected travellers who progress to symptoms during their journey are considered undetectable by departure screening, but detectable by arrival screening. additionally, we now provide a supplementary user interface, which allows stakeholders to test input parameters of interest using up-to-date information. here, in addition to the analyses presented in this study, we implemented the possibility that some fraction of infected travellers deliberately evade screening. existing point estimates for r span a wide range ( . - . ), but most fall between . and . ( table ) . the vast majority of these estimates are informed by data collected very early in the outbreak, before any control measures were in place. however, several studies already demostrate decreases in the reproductive number over time, as a consequence of social distancing behaviors, and containment measures (kucharski et al., ; liu et al., ) . realistically, r will vary considerably over time, and across locations, depending on the social context, resource availability, and containment policies. our analysis considers a plausible range of r values spanning . - . , with . representing a plausible maximum in the absence of any behavioral changes or containment efforts, and . reflecting a plausible lower bound, given containment measures may already be in place at the time of introduction. to estimate the upper-bound fraction of subclinical cases, we draw on data from active surveillance of passengers quarantined on a cruise ship off the coast of japan, or passengers of repatriation flights. these data show that - % of cases are asymptomatic at the time of diagnosis nishiura et al., ; schnirring, c; schnirring, b) . we estimate that % subclinical cases is a reasonable upper bound: due to intensive monitoring, cases in repatriated individuals or in cruise ship passengers will be detected earlier than usual in the course of infection-and possibly before the onset of symptoms. from clinical data (where severe cases are likely overrepresented), we estimate a lower bound of %: even among clinically attended cases, - % lack fever or cough, and would be undetectable in symptom screening (chan et al., ; chen et al., ; the novel coronavirus pneumonia emergency response epidemiology team, ; huang et al., ) . in addition to the upper and lower bound scenarios, we consider a plausible middle-case scenario in which % of cases are subclinical. a very recent delay-adjusted estimate indicates - % of infections on the cruise ship quarantined off the coast of japan are asymptomatic, so the truth may fall somewhere between our middle and worst-case scenarios (mizumoto et al., ) . we use a gamma distribution to model individual incubation times. we choose this form over the weibull and lognormal distribution for ease of interpretation (gamma shape and scale parameters can be transformed easily to mean and standard deviation). so far, best-fit gamma distributions to covid- data have had mean . and standard deviation . (backer et al., ) , or mean . and standard deviation . (lauer et al., ) . here, to model uncertainty around the true mean incubation time, we fix the standard deviation to . (intermediate between the two existing estimates), and allow the mean to vary between . and . days (figure -figure supplement ) . the th percentile of the distributions we consider fall between . and . days, slightly below the officially accepted maximum incubation time of days, and consistent with existing estimates ( table ; backer et al., ; lauer et al., ) . the probability that an infected traveller is detectable using questionnaire-based screening for exposure risk will be highest if risk factors with high sensitivity and specificity are known. currently, official guidance recommends asking whether travellers have visited a country with epidemic transmission, a healthcare facility with confirmed cases, or had close contact with a confirmed or suspected case (world health organization, c). given the relative anonymity of respiratory transmission, we assume that a minority of infected travellers would realize that they have been exposed before symptoms develop ( % in figure , range - % in figure ). further, relying on a previous upper-bound estimate (gostic et al., ) we assume that only % of travellers would self-report truthfully if aware of elevated exposure risk. table summarizes the state of knowledge about additional parameters, as of february , . all code and source data used to perform analyses and generate figures is archived at https:// github.com/kgostic/traveller_screening/releases/tag/v . . (gostic, ; copy archived at https:// github.com/elifesciences-publications/traveller_screening). the funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication. there are no data inputs into our model. all parameter input values are specified in table , or in the manuscript text. we provide a link to the github repository containing all code necessary to run the analyses and generate figures (https://github.com/kgostic/traveller_screening/releases/tag/v . , copy archived at https://github.com/elifesciences-publications/traveller_screening). incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china china restricts movement to fight coronavirus relativesensitivity of international surveillance: imperial college fast detection is critical to contain deadly wuhan coronavirus international travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers estimating the effective reproduction number of the -ncov in china china launches coronavirus "close contact a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster shiny: web application framework for r epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study the effect of travel restrictions on the spread of the novel coronavirus ( -ncov) outbreak. medrxiv entry screening to delay local transmission of pandemic influenza a (h n ) using predicted imports of -ncov cases to determine locations that may not be identifying all imported cases severity of -novel coronavirus (ncov): imperial college factors that make an infectious disease outbreak controllable effectiveness of traveller screening for emerging pathogens is shaped by epidemiology and natural history of infection code for analyses in ncov preprint clinical characteristics of coronavirus disease in china coronavirus quarantine precautions around the world. the guardian evidence of sars-cov- infection in returning travelers from wuhan, china clinical characteristics of asymptomatic infections with covid- screenedamong close contacts in nanjing clinical features of patients infected with novel coronavirus in wuhan south korea and vietnam are asking millions to stay home to avoid coronavirus as more people get infected and die outside of china japan ministry of health, labor and welfare a distinct name is needed for the new coronavirus. the lancet group c ncov working. . early dynamics of transmission and control of -ncov: a mathematical modelling study. medrxiv the incubation period of -ncov from publicly reported confirmed cases: estimation and application early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia time-varying transmission dynamics of novel coronavirus pneumonia in china superspreading and the effect of individual variation on disease emergence . million left wuhan before lockdown, , new coronavirus cases expected in city. south china morning post airport screening for ebola: will it make a difference? a chinese embassy in paris tracked down a woman who gloated on social media about cheating airport detection with a medicine that lowered her fever a methodology for performing global uncertainty and sensitivity analysis in systems biology estimating the asymptomatic ratio of novel coronavirus onboard the princess cruises ship quantifying bias of covid- prevalence and severity estimates in wuhan, china that depend on reported cases in international travelers the rate of underascertainment of novel coronavirus ( -ncov) infection: estimation using japanese passengers data on evacuation flights thermal image scanning for influenza border screening: results of an airport screening study effectiveness of airport screening at detecting travellers infected with novel coronavirus ( -ncov) novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions pattern of early human-to-human transmission of wuhan novel coronavirus ( -ncov) the novel coronavirus, -ncov, is highly contagious and more infectious than initially estimated shadowy church is at center of coronavirus outbreak in south korea. the new york times some schengen visa centers in china reopen, others remain closed indefinitely china's covid- death toll tops , ; iran reports first cases as cruise ship covid- numbers climb, nations evacuate passengers china covid- cases rise, as do worries over diamond princess risk estimation of the transmission risk of the -ncov and its implication for public health interventions comparison of infrared thermal detection systems for mass fever screening in a tropical healthcare setting the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) world health organization. a. coronavirus disease (covid- ) situation report coronavirus disease (covid- ) situation report - management of ill travellers at points of entry -international airports, seaports and ground crossings -in the context of covid - outbreak updated who advice for international traffic in relation to the outbreak of the novel coronavirus nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study a familial cluster of infection associated with the novel coronavirus indicating potential person-to-person transmission during the incubation period we are grateful to miaka mcclenahan and pieter de ganon for translation assistance. we thank the cobey lab for helpful comments. grant reference number author key: cord- -ywgoqlxj authors: ribeiro, haroldo v.; sunahara, andre s.; sutton, jack; perc, matjaž; hanley, quentin s. title: city size and the spreading of covid- in brazil date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: ywgoqlxj the current outbreak of the coronavirus disease (covid- ) is an unprecedented example of how fast an infectious disease can spread around the globe (especially in urban areas) and the enormous impact it causes on public health and socio-economic activities. despite the recent surge of investigations about different aspects of the covid- pandemic, we still know little about the effects of city size on the propagation of this disease in urban areas. here we investigate how the number of cases and deaths by covid- scale with the population of brazilian cities. our results indicate small towns are proportionally more affected by covid- during the initial spread of the disease, such that the cumulative numbers of cases and deaths per capita initially decrease with population size. however, during the long-term course of the pandemic, this urban advantage vanishes and large cities start to exhibit higher incidence of cases and deaths, such that every % rise in population is associated with a . % increase in the number of fatalities per capita after about four months since the first two daily deaths. we argue that these patterns may be related to the existence of proportionally more health infrastructure in the largest cities and a lower proportion of older adults in large urban areas. we also find the initial growth rate of cases and deaths to be higher in large cities; however, these growth rates tend to decrease in large cities and to increase in small ones over time. human activities have become increasingly concentrated in urban areas. a direct consequence of this worldwide urbanization process is that more people are living in cities than in rural regions since [ ] , and projections indicate that the world urban population could reach more than % by the end of this century [ ] . besides being increasingly urbanized, we live in an unprecedentedly connected, and highly mobile world with air passengers exceeding billion in [ ] . on the one hand, a highly connected and highly urbanized society brought us innovation, economic growth, more access to education and healthcare; on the other, it has also lead to pollution, environmental degradation, privacy concerns, more people living in substandard conditions, and suitable conditions for dissemination of infectious diseases over the globe. in particular, the emergence of infectious disease outbreaks has significantly increased over time, and the majority of these events are caused by pathogens originating in wildlife [ ] , which in turn has been associated with changes in environmental conditions and land use, agricultural practices, and the rise of large human population settlements [ ] . the ongoing outbreak of the novel coronavirus (sars-cov- ) seems to fit well the previous context as it was first identified in wuhan in december , an influential chinese city exceeding million inhabitants, and apparently originated from the recombination of bat and malayan pangolin coronaviruses [ ] . the coronavirus disease (covid- ) initially spread in mainland china but rapidly caused outbreaks in other countries, making the world health organization first declare a "public health emergency of international concern" in january , and in mid-march, the outbreak was reclassified as a pandemic. as of august , over . million cases of covid- have been confirmed in almost all countries, and the worldwide death toll exceeds thousand people [ ] . the covid- pandemic poses unprecedented health and economic threats to our society, and understanding its spreading patterns may find important factors for mitigating or controlling the outbreak. recent works have focused on modeling the initial spreading of covid- [ ] or the fatality curves [ ], projecting the outbreak peak and hospital utilization [ ] , understanding the effects of mobility [ ] , demography [ ] , travel restrictions [ ] , behavior change on the virus transmission [ ] , mitigation strategies [ ] , non-pharmaceutical interventions [ ] , networkbased strategies for social distancing [ ] , among many others. despite the increasing surge of scientific investigations on the subject, little attention has been paid to understanding the effects of city size on spreading patterns of cases and deaths by covid- in urban areas. the idea that size (as measured by population) affects different city indicators has been extensively studied and can be summarized by the urban scaling hypothesis [ ] [ ] [ ] [ ] . this theory states that urban indicators are non-linearly associated with city population such that socio-economic indicators tend to present increasing returns to scale [ , , ] , infrastructure indicators often display economy of scale [ , ] , and quantities related to individual needs usually scale linearly with city population [ , ] . urban scaling studies of health-related quantities have shown that the incidence and mortality of diseases are non-linearly related to the city population [ ] [ ] [ ] [ ] . despite the existence of several exceptions [ ] , noninfectious diseases (such as diabetes) are usually less prevalent in large cities, while infectious diseases (such as aids) are relatively more common in large urban areas. this different behavior is likely to reflect the fact that people living in large cities tend to have proportionally more contacts and a higher degree of social interactions than those living in small towns [ , ] . within this context, the recent work of stier, berman, and bettencourt [ ] has indicated that large cities in the united states experienced more pronounced growth rates of covid- cases during the first weeks after the introduction of the disease. similarly, cardoso and gonçalves [ ] found that the per capita contact rate of covid- increases with the size and density of cities in united states, brazil and germany. these findings have serious consequences for the evolution of covid- and suggest that large metropolises may become infection hubs with potentially higher and earlier peaks of infected people. investigating whether this behavior generalizes to other places and how different quantities such as the number of cases and deaths scale with city size are thus important elements for a better understanding of the spreading of covid- in urban areas. here we investigate how population size is associated with cases and deaths by covid- in brazilian cities. brazil is the sixth most populous country in the world, with over million people, of which more than % live in urban areas. while it is likely that the novel coronavirus was already circulating in brazil in early february [ ] , the first confirmed case in the country dates back to february , in the city of são paulo. between the first case and august , brazil has confirmed , , cases of covid- (second-largest number) spread out over . % of the , brazilian cities. this disease caused , deaths (second-largest number) with , cities reporting at least one casualty as of august . we start by briefly presenting our data set (see methods for details). our investigations rely on the daily reports published by the health offices of each of the brazilian federative units. these daily reports update the number of confirmed cases (y c ) and the number of deaths (y d ) caused by covid- in every brazilian city from february (date of the first case in brazil) to august (date of our last update). from these data, we create time series of the number of cases y c (t c ) for each city, where t c refers to the number of days since the first two daily cases reported in each city. similarly, we create time series of the number of deaths y d (t d ), where t d refers to the number of days since the first two daily deaths reported in each city. by doing so, we group all cities according to their stage of disease propagation (as measured by t c or t d ) to investigate the evolution of allometric relationships between total cases or deaths and city population. we have also considered different number of daily cases or deaths as the reference point, and our results are robust against different choices (from one to seven daily cases or daily deaths, see the number of cases is well described by a power-law function of the city population where β c is the so-called urban scaling exponent [ ] . similarly, fig b shows the association between the number of casualties and the city population on logarithmic scale (logy d versus logp) for different numbers of days since two daily deaths first reported (t d = , , and days). again, the results indicate that the number of deaths is approximated by a powerfunction of the city population where β d represents the urban scaling exponent for the number of deaths. the results of fig also show the adjusted allometric relationships (dashed lines) and the best fitting scaling exponents β c and β d (see methods for datails). these exponents exhibit an increasing trend with time so that β c and β d exceed one after some number of days after the first two daily cases or deaths. this dynamic behavior is better visualized in fig , where we depict β c and β d as a function of the number of days since the first two daily cases (t c ) or deaths (t d ). the scaling exponent for the number of cases β c is sub-linear (β c < ) during the first four months and appears to approach a super-linear plateau (β c > ) as the number of days t c further increases. the dynamic behavior of the scaling exponent for deaths β d is similar to β c ; however, β d appears to be approaching a plateau larger than the one observed for β c . the evolution of the scaling exponents for cases and deaths indicates that small cities are proportionally more affected by covid- during the first four months. however, this initial apparent advantage of living in large cities vanishes with time, and become a disadvantage after about four months. this is more evident by estimating the number of cases per capita from eq ( ), that is, y c /p � p β c − . similarly, we can estimate the number of deaths per capita from eq ( ), yielding y d /p � p β d − . thus, we expect the number of covid- cases or deaths per capita to decrease with the city population if β c < and β d < ; conversely, these per capita numbers are expected to increase with the city population if β c > and β d > . for instance, because β c � . and β d � . after days since the first two daily cases or deaths, the number of cases and deaths per capita decreases with population as y c /p � p − . and y c /p � p − . . at those particular values of t c and t d , an % rise in the population is associated with a � . % decrease in the incidence of covid- cases and � . % reduction in the incidence of deaths. in a concrete example for t c = t d = days, we expect a metropolis such as são paulo (with � million people) to have � % less cases and � % less deaths per capita than a medium-sized city such as maringá/pr (with � thousand people, � / of são paulo), which in turn is expected to have � % less cases and � % less deaths per capita than a small-sized city such as paranaíba/ms (with � thousand people, � / of maringá). however, both scaling exponents increase with time, such that this urban advantage vanishes and become a disadvantage during the long course of the pandemic. by considering our latest estimates for the scaling exponents, we find β c � . (t c = days) and β d � . (t d = days). thus, at these particular values of t c and t d , we expect the number of cases per capita to slightly increase with population (y c /p � p . ) and the number of fatalities per capita to increase with population as y d /p � p . . thus, for β d � . at t d = days, we expect a metropolis such as são paulo (� million people) to have � % more deaths per capita than maringá/pr (� thousand people), which in turn is expected to have � % more deaths per capita than paranaíba/ms (� thousand people). figs - in s appendix show that the scaling relations for number of cases and deaths per capita support the previous discussions. the latest estimates of β c found for cases of covid- are smaller than those reported for the h n pandemic in brazil (β c � . ) and hiv in brazil and united states (β c � . ) [ ] . similarly to what we observe for the cases of covid- , the allometric exponent for hiv cases in brazil was initially sub-linear during the s, became super-linear after the s, and started to approach a super-linear plateau after the s [ ] . however, the evolution of the allometry for hiv has been much slower than what we have observed for the covid- . another interesting point reported by rocha, thorson, and lambiotte [ ] is that the number of h n cases in brazil started to scale linearly with city population in (one year after the first outbreak). these authors also argue that this reduction in the scaling exponent possibly reflects a better response for the spread of h n after the pandemic outbreak. if the behavior observed in the h n pandemic generalizes (at least in part) for the current covid- pandemic, we would expect a decrease in values of β c in the future. the lastest estimates of β d for covid- deaths are larger than those reported for diabetes (β d � . ), heart attack (β d � ) and cerebrovascular accident (β d � ) in brazil after the s [ ] . conversely, scaling exponents related to disease mortality in brazil displayed a decreasing trend with time, and values as high as . were observed for diabetes in (β d � . ) and heart attack in (β d � . ) [ ] . the convergence of these exponents to linear or sub-linear regimes may reflect the increasing access to medical facilities in urban areas [ ] . based on currently available data (fig ) , it is hard to confidently assert whether the values of β c and β d will remain larger than one during the long-term course of the pandemic. however, the persistence of this behavior indicates large cities are likely to be more affected at the end of the covid- outbreak. part of this behavior may be due to large cities testing for covid- proportionally more than small ones. results for the united states indicate that more rural states have lower testing rates and detect disproportionately fewer cases of covid- [ ] . as brazilian cities are likely to suffer from this bias, we would expect a decrease in the scaling exponent β c after the observed increasing trend depending on the magnitude of this effect (that is, as small cities increase their testing capabilities, their number of cases tend to increase and bend the scaling law downwards). on the other hand, it is clearer that large cities were proportionately less affected during the initial months (since the first two daily cases or deaths) of the pandemic. we believe there are at least two possible explanations for this behavior. first, it may reflect an "increasing urban advantage" where the larger the city, the more access to medical facilities and so the chance of receiving more appropriate treatment against the coronavirus disease. a second cause can be associated with age demographic changes with the city population; specifically, a smaller proportion of older adults at high risk for severe illness and death from covid- leads to a reduced number of deaths per capita. another possibility is that the strategies and policy responses of large and small cities to covid- are different, which in turn may lead to different efficiency in containing the pandemic. these responses are highly heterogeneous at the national level [ , ] as well as among counties in the united states [ ] . among these three possibilities, we did not explore the possible effects of different city strategies against the covid- , but in light of the findings for the united states [ ] , this effect is likely to play an important role in the brazilian case and may deserve further investigation. to test for an increasing urban advantage for the treatment of covid- during the initial spread of the disease, we investigate the scaling relation between the number of hospital intensive care unit (icu) beds and city population. because critically ill patients frequently require mechanical ventilation [ , ] , the number of icu beds has proved to be crucial for the treatment of covid- . fig a shows the allometric relationship between the number of icu beds from private and public health systems (y icu , as of april ) and the population, where a super-linear relationship emerges with scaling exponent β icu � . . the super-linear scaling of icu beds indicates that large brazilian cities are better structured to deal with critically ill patients, which in turn may partially explain the reduction of deaths per capita with the city size during the initial three-four months since the first two daily deaths. it is worth noting that the brazilian public unified health system (sistema Ú nico de saúde-sus) is decentralized and composed of "health regions", contiguous groups of cities usually formed by a large city and its neighboring cities [ ] . cities within the same health region may share medical services, which may in turn partially explain the reduction of the structural advantages of large urban areas during the long-term course of the pandemic. we have also investigated how age demographic distribution changes with city population. estimates have shown that the case fatality rate of covid- is substantially higher in people aged more than years ( . % for those younger than years versus . % for those older than years [ ] ). thus, the age demographic of cities represents an important factor for the number of deaths caused by covid- . fig b and c show how the number of people older (p hr , the high-risk population) and younger (p lr , the low-risk population) than years change with the total population (p). we note that the high-risk population increases sub-linearly with city size with an exponent β hr � . , while the low-risk population scales linearly (β lr � ) with city size. this result shows that large cities have a lower prevalence of adults older than years, such that a % increase in city population is associated with a . % rise in the high-risk population. in a more concrete example, we expect a city with one million people to have proportionally � % fewer adults older than years when compared with a city of thousand inhabitants. thus, a low prevalence of elderly in large urban areas may also partially explain the initial reduction of the number of deaths per capita with the increase of city population. in addition to addressing the urban scaling of cases and deaths of covid- , we have investigated associations between the growth rates of cases and deaths and the city population (figs - in s appendix). as mentioned, the work of stier, berman, and bettencourt [ ] shows that the initial growth rates of covid- cases in metropolitan areas of the united states scale as a power-law function of the population with an exponent between . and . . by using our data and as detailed in methods, we have estimated the growth rates of cases (r c ) and deaths (r d ) for brazilian cities. in agreement with the united states case, our results also indicate that covid- cases initially grow faster in large cities (fig in s appendix) , such that r c � p b r c with b r c between � . and � . during the first three months (t c ≲ , fig in s appendix). we also found similar behavior for the growth rate in the number of deaths r d , where a power-law relation r d � p b r d is a reasonable description for the empirical data with a scaling exponent b r d between � . and � . during the first three months (t d ≲ , fig in s appendix). the growth rate depicts a more instantaneous picture of the covid- spreading process, and its association with size may change during the long-term evolution of the pandemic. these changes may reflect the different actions taken by each city to face the covid- pandemic and other particularities affecting the covid- spreading. for the spreading of covid- in the united states, heroy [ ] has reported that large cities appear to enter in an exponential spreading regime earlier than small ones. to better investigate these possibilities in our data, we have estimated the average relationship between the growth rate of cases (r c ) and deaths (r d ) and the city rank s (s = represents the largest city in data, s = the second-largest, and so on) at different periods. fig a shows the results for the growth rates in the number of cases (r c ). in agreement with the power-law association between r c and the city population (figs - in s appendix), we note that lower values of the city rank s are associated with higher growth rates r c in the initial days since the first two daily cases. however, as time goes by, the growth rate of cases starts to decrease in large cities (low-rank values) and to increase in small ones (high-rank values). this result appears to agree with the findings of heroy [ ] in the sense that there is a delay in the emergence of high growth rates of cases between large and small cities. fig b shows the same analysis for growth rate in the number of deaths r d . while we also observe a decrease in r d for large cities and increase for small ones, the differences in r d are less pronounced than in r c . these findings also emerge when investigating the scaling exponents associated with the growth rates of cases (b r c ) and deaths (b r d ). the results of fig in s appendix show that these exponents start to decrease around t c � t d � days and become negative in our latest estimates. it is worth remembering that the time t c (or t d ) is measured in days since the first two daily cases (or first two daily deaths) for each city; thus, the results of fig do not reflect delays in the emergence of the first case in each city. we have studied scaling relations for the number of covid- cases and deaths in brazilian cities. similarly to what happens for other diseases, we found the number of cases and deaths to be power-law related to the city population. during the initial three-four months since the first two daily cases or deaths, we found a sub-linear association between cases and deaths by covid- , meaning that the per capita numbers of cases and deaths tend to decrease with population in this initial stage of the pandemic. we believe this behavior can be partially explained by an "increasing urban advantage" where large cities have proportionally more icu beds than small ones. in addition, changes in age demography with city size show that large cities have proportionally less elderly people who are at high risk of developing severe illness and dying from covid- . this may also partially explain the initial reduction of fatalities per capita with the city population. in addition, we have argued that the strategies and policy responses of large and small cities to covid- may also be different and lead to different efficiency in containing the pandemic. however, we found that this "urban advantage" vanishes in the long-term course of the pandemic, such that the association between cases and deaths by covid- with population becomes super-linear in our latest estimates since the first two daily cases or deaths. thus, the persistence of this pattern indicates that large cities are expected to be proportionally more affected at the end of the covid- pandemic. this result is in line with the findings for other infectious diseases [ , ] and probably reflects the existence of a higher degree of interaction between people in large cities [ , ] . because social distancing is currently the only available measure to mitigate the impact of covid- , our results suggest that large cities may require more severe degrees of social distancing policies. in agreement with the results for metropolitan areas in the united states [ ] , we have found that large cities usually display higher growth rates in the number of cases during the initial spread of the covid- . however, our results also show that these growth rates tend to decrease in large cities and to increase in small ones in the long-term course of the pandemic. this behavior suggests the existence of a delay in the emergence of high growth rates between large and small cities. similar behavior was also found in the united states [ ] , where large cities appear to enter an exponential growth regime earlier than small towns. the existence of this delay suggests that the initial slow-spreading pace of the covid- in small cities is likely to be a transient behavior. together with the recent findings of stier-berman-bettencourt [ ] and heroy [ ] for the united states, as well as those of cardoso and gonçalves [ ] for united states, brazil and germany, our results suggest that social distancing policies and other actions against the pandemic should take into account the non-linear effects of city size on the spreading of the covid- . the primary data set used in this work was collected from the brasil.io api [ ] . this api retrieves information from covid- daily reports published by the health offices of each of the brazilian federations ( states and one federation district) and makes it freely available. this data set comprises information about the cumulative number of cases and deaths of covid- from february (date of the first case in brazil) until august (date of our last update) for all brazilian cities reporting at least one case of covid- . the brasil.io api also provides population data of brazilian cities, which in turn relies on population estimates for the year released by the brazilian institute of geography and statistics (ibge). there is a total of , brazilian cities with at least one reported case of covid- on august , corresponding to . % of the country's total number of cities. in addition, , cities suffered casualties from this disease, representing . % of the total. to ensure that our estimates rely on at least cities, we consider a suitable upper threshold for the time series length (fig in s appendix) . the data about age demographics refer to the latest brazilian census that took place in , while the data about the number of icu beds are from april . these two data sets are maintained and made freely available by the department of informatics of the brazilian public health system (datasus) [ ] . urban scaling [ ] usually refers to a power-law association between a city property y and the city population p, and it is expressed by where y is a constant and β is the urban scaling exponent. eq ( ) can be linearized by taking the logarithmic on both sides, that is, where log y and log p are the dependent and independent variables of the corresponding linear relationship between log y and log p. we have estimated the power-law exponents in eq ( ) by using the probabilistic approach of leitão et al. [ ] . specifically, we have found the probabilistic model with lognormal fluctuations and where the fluctuations in log y are independent of p to be the best description of our data in the majority of scaling laws. thus, we assume these lognomal fluctuations in all adjusting procedures in order to estimate the values of β. it is worth mentioning that this maximum-likelihood estimate for scaling exponents is analogous to the one obtained via usual least-squares with the log-transformed variables (log y versus log p). let us consider that x t (t = , . . ., n) represents the cumulative number of cases (y c ) or the cumulative number of deaths (y d ) for covid- in a given city at time t (number of days since first case t c or death t d ). the logarithmic growth rate r t at time t is defined as where τ is a time delay. if we assume the numbers of cases or deaths to initially increase exponentially (x t � e rt , where r is the exponential growth rate), r t represents an estimate for the growth rate of this initial exponential behavior (r). we have estimated r t for the number of cases (r c ) and deaths (r d ) up to values of t c and t d ensuring a sample size of at least cities for the allometric relations between these growth rates and the city population (fig in s appendix). all results in the main text were obtained for τ = but our discussion is robust for τ between and days (figs - in s appendix). supporting information s appendix. supplementary figs ( - ) world urbanization prospects: urban population (% of total) global urbanization projections for the shared socioeconomic pathways international civil aviation organization, civil aviation statistics of the world and icao staff estimates global trends in emerging infectious diseases origins of major human infectious diseases isolation of sars-cov- -related coronavirus from malayan pangolins projecting hospital utilization during the covid- outbreaks in the united states spread and dynamics of the covid- epidemic in italy: effects of emergency containment measures demographic science aids in understanding the spread and fatality rates of covid- the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak applying principles of behaviour change to reduce sars-cov- transmission the impact of covid- and strategies for mitigation and suppression in low-and middle-income countries estimating the effects of non-pharmaceutical interventions on covid- in europe social network-based distancing strategies to flatten the covid- curve in a post-lockdown world growth, innovation, scaling, and the pace of life in cities the origins of scaling in cities the new science of cities scale: the universal laws of growth, innovation, sustainability, and the pace of life in organisms, cities, economies, and companies scaling and universality in urban economic diversification computational socioeconomics influenza and pneumonia mortality in large cities in the united states in years surrounding the pandemic growth patterns and scaling laws governing aids epidemic in brazilian cities statistical signs of social influence on suicides the non-linear health consequences of living in larger cities the scaling of human interactions with city size covid- attack rate increases with city size urban scaling of covid- epidemics tracking the onset date of the community spread of sars-cov- in western countries a commentary on rural-urban disparities in covid- testing rates per , and risk factors. the journal of rural health the effect of large-scale anti-contagion policies on the covid- pandemic quantifying policy responses to a global emergency: insights from the covid- pandemic creatures of the state? metropolitan counties compensated for state inaction in initial us response to covid- pandemic. mansueto institute for urban innovation research paper critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response covid- : a novel coronavirus and a novel challenge for critical care brazil's unified health system: the first years and prospects for the future estimates of the severity of coronavirus disease : a model-based analysis. the lancet infectious diseases metropolitan-scale covid- outbreaks: how similar are they? boletins informativos e casos do coronavírus por município por dia public healthcare system (sus), department of data processing (datasus) is this scaling nonlinear the authors have declared that no competing interests exist. key: cord- -zpiaka authors: biscayart, cristian; angeleri, patricia; lloveras, susana; chaves, tânia do socorro souza; schlagenhauf, patricia; rodríguez-morales, alfonso j. title: the next big threat to global health? novel coronavirus ( -ncov): what advice can we give to travellers? – interim recommendations january , from the latin-american society for travel medicine (slamvi) date: - - journal: travel medicine and infectious disease doi: . /j.tmaid. . sha: doc_id: cord_uid: zpiaka nan on december th, , the wuhan municipal health commission (wmhc) in the people's republic of china reported human cases of viral pneumonia, of them seriously ill. all had a shared exposure in the huanan seafood wholesale market, where farm animals, bats, and snakes were also sold [ , ] . the city of wuhan, in the province of hubei, has almost million inhabitants. its airport, tianhe international, located km from its center, is a hub for major chinese airlines [ ] . in alone, , , passengers arrived and departed. although it is mostly a domestic airport, code sharing with several european and north american airlines allows with a single stop, to fly in a few hours to the major capitals and main cities around the world. in latin america only ciudad de mexico international airport [ ] , são paulo guarulhos international in brazil [ ] , and el dorado international airport in bogotá, colombia [ ] , outdo that level of passenger traffic. this fact alone accounts for a realistic possibility of the global dispersal of the causative agent from china since human to human transmission has already been demonstrated [ ] . the culprit has been identified as a new coronavirus -known provisionally as -ncov-from the findings of ongoing investigations and by genomic sequencing carried out in local laboratories [ ] . coronaviruses (covs) belong to the coronavirinae subfamily in the family coronaviridae of the order nidovirales, and this subfamily includes four genera: alphacoronavirus, betacoronavirus, gammacoronavirus, and deltacoronavirus [ ] . the cov genome is a singlestranded rna. these are important pathogens of humans and other vertebrates. they can infect the respiratory, gastrointestinal, hepatic and central nervous system tracts of man, cattle, birds, bats [ ] , rodents and various wild animals [ ] . coronaviruses, like influenza viruses, circulate in nature in various animal species. alphacoronaviruses and betacoronaviruses can infect mammals and gammacoronaviruses and deltacoronaviruses infect birds, but some of them can also be transmitted to mammals [ ] . to date, seven coronaviruses that can infect humans have been described. common human coronaviruses betacoronavirus hcov-oc and hcov-hku , as well as alphacoronavirus hcov- e cause common cold and also severe lower respiratory tract infections in children and the elderly, while alphacoronavirus hcov-nl is considered to be an essential cause of (pseudo)croup and bronchiolitis in children [ ] . the emergence of coronaviruses infections with high impact in public health began in - with the sars outbreak [ , ] and in , mers-cov, another highly-pathogenic coronavirus which still circulates in the middle east and causes severe respiratory disease [ , ] was reported. regarding -ncov investigations, to date, could already reveal that its genome (genbank accession mn ) has the highest similarity ( %) to a sars-related member of the sarbecoviruses (genbank accession mg ), a subgenus within the betacoronavirus genus [ ] . this fact could perhaps be part of the explanation about the behavior of this novel coronavirus concerning human infection. preliminary genome sequencing suggested the snake as a likely wildlife reservoir responsible for the current outbreak of -ncov infection and origin-unknown homologous recombination identified within the spike glycoprotein of the -ncov may explain snake-to-human cross-species transmission [ ] . however, this theory has now been largely discounted and some researchers point towards bats as a reservoir and doubt that the coronavirus could have originated in animals other than birds or mammals [ ] ; they are skeptical that the animal host or hosts of -ncov can be identified without further field and laboratory research. many hope that genetic tests of animals or environmental sources, such as cages and containers, from the wuhan market will reveal clues [ ] regarding the definite origin of the virus. the outbreak of viral pneumonia in wuhan is associated with exposures at the huanan seafood wholesale market, suggesting a possible zoonosis. the incubation period is estimated between and days. symptoms are similar to those from other respiratory viruses, including https://doi.org/ . /j.tmaid. . received january ; accepted january travel medicine and infectious disease ( ) available online january - / © elsevier ltd. all rights reserved. t fever, cough, and shortness of breath with radiographs showing invasive lesions in the lungs. some cases need hospitalization due to the worsening of the clinical status and in several cases, the complications could lead to death [ ] [ ] [ ] . who has constantly updating information on the outbreak and definitions under (https://www.who.int/healthtopics/coronavirus). as of january , , a total of about confirmed cases have been reported for novel coronavirus ( -ncov) globally (> from china) (https://gisanddata.maps.arcgis.com/apps/opsdashboard/ index.html#/bda fd b e ecf ), with imported cases in countries outside china [ , ] including seven confirmed cases in australia, five cases in the us, five cases in france, a cluster of four cases in germany, three in canada, one in finland, one in ivory coast (africa), and cases in several other asian countries. who reported an increase in the number of confirmed and suspected cases and affected provinces. the case fatality rate of the currently reported cases is less than % ( deaths, including one case in a healthcare professional), which implies that so far, this novel coronavirus does not seem to cause the high fatality rates previously observed for sars and mers-cov, % and %, respectively [ ] . of the confirmed cases, % are reported to be severe and underlying comorbidities were detected in many of them and elderly. the chinese government declared the death of the first health professional who provided assistance at wuhan hospital. remarkably, who has reported that in the last one week, less than % of new cases reported had visited the huanan market. health care workers have also been infected. fourth-generation cases in wuhan and second-generation cases outside wuhan, as well as some clusters outside hubei province, could be traced back [ ] . these findings underscore the role of human-to-human transmission of -ncov [ ] . all these facts together have led chinese authorities to enforce drastic containment measures such as the closure of public-transportation systems in wuhan as well as in other cities in the country including wuhan international airport [ ] . the who emergency committee met on january rd and although the situation at that time is not considered to be a public health emergency of international concern (pheic), who monitors the situation closely and can, under the global legal framework, the revised international health regulations (ihr), recommend travel and trade restrictions when these are deemed necessary. at the moment of proofs correction of this editorial, the committee was about to be convened again (jan. , ) in order to reassess the situation and if declare the pheic. an estimate of r of . - . was presented [ ] . other estimates, however, yield higher r figures. as researchers are saying, sustained human-to-human transmission of -ncov is one of the most important topics issues that could explain the scale of the wuhan outbreak. considering this, it is not only important to follow the progression of the epidemic closely but to also coordinate the countries' mechanisms to mitigate the impact in health care services and the community [ ] . there are no known useful treatments for the disease caused by this new coronavirus; therefore, contact and respiratory precautions are the only effective measures to prevent this emerging coronavirus [ ] . given this situation, there are some key considerations and recommendations for travelers to southeast asia, especially china (table ) , and other affected areas that should be considered. similar to the sars outbreak in guangzhou, wuhan is also a rapidly flourishing capital city of the hubei province and the traffic hub of central china. moreover, both outbreaks were initially connected to "wet markets" where game animals and meat were sold [ ] . in the case of sars, the person-to-person transmission was efficient and super-spreading events led to significant outbreaks in hotels and hospitals. learning from the sars outbreak, which started as animal-tohuman transmission during the first phase of the epidemic, all game meat trades should be optimally regulated to terminate this portal of transmission [ ] . emerging and reemerging pathogens are global challenges for public health and a matter for concerns in travelers from all over the world. as in previous scenarios [ , ] , the latin american society for travel medicine (slamvi), is concerned for travelers arriving from china and other affected locations that would bring the -ncov but also given the potential exposure for travelers from this table key considerations and recommendations for travelers in the context of the ongoing outbreak of -ncov (as of jan. , ). • the outbreak is ongoing so that the control measures may vary according to the evolution in the different countries. • according to preliminary reports, the confirmed cases have a direct or indirect epidemiological relationship with china, and in particular, the city of wuhan. • the tourism industry in latin america is expanding and contribute in the fourth place to the world gdp after northeast asia, north america, and the european union. in that context, globalization implies that travelers to southeast asia could move in a few hours to countries where there are currently no suspicious cases. • since the clinical respiratory symptoms of -ncov are similar to influenza, it is essential not to underestimate the symptomatology in order to identify eventual suspected cases in travelers. make sure to be up to date with your influenza vaccine to rule out this differential diagnosis • underlying comorbidities are present in many cases. however, to date, the mortality rate is under %. • human-to-human transmission is already confirmed, and it would be highly feasible that would lead to the progress of the current epidemiological situation. consult public health information websites such as https://www.who.int/health-topics/coronavirus. • avoid travel to the cities and areas mainly affected by the -ncov. • an innovative, and useful real-time online map is available at https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda fd b e ecf . this was developed by john hopkins researchers to track the spread of the ongoing outbreak (fig. ). • avoid visiting wet markets, especially those in which live animals are traded. • the consumption of raw or undercooked animal products should be avoided. raw meat, milk or animal organs should be handled with care, to avoid cross-contamination with uncooked foods, as per good food safety practices. • avoid large concentrations of people in public spaces (public transport, theaters, cinemas, shopping centers, offices, educational establishments, restaurants). • in the event these other activities are unavoidable, refrain from touching objects such as handrails, doorknobs and bringing hands to nose or mouth. • avoid close contact with anyone who has fever and cough. • avoid contact with sick people. • avoid contact with animals (alive or dead), animal markets, and products that come from animals (i.e., raw or undercooked meat). • when coughing and sneezing cover mouth and nose with flexed elbow or tissue -dispose tissues immediately and wash hands • wash hands frequently with soap and water for at least seconds. use an alcohol-based hand sanitizer if soap and water are not available. • seek prompt consultation in case of fever and respiratory symptoms during or after the trip (up to days). use your local emergency numbers to find out how to seek care and use a face mask if you go to health care facilities. region to china and other attractive countries, that may hold mass gathering events in the upcoming weeks, such as the upcoming olympic games in tokyo, japan to be celebrated on july -august , [ ] , even more, when up to date, this country has also confirmed china-imported cases ( ). none. outbreak of pneumonia of unknown etiology in wuhan china: the mystery and the miracle discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin wuhan airport aeronautica civil de colombia global health concern stirred by emerging viral infections recent advances in the detection of respiratory virus infection in humans the structure and functions of coronavirus genomic ' and ' ends emerging coronaviruses: genome structure, replication, and pathogenesis sars and other coronaviruses as causes of pneumonia travel implications of emerging coronaviruses: sars and mers-cov the severe acute respiratory syndrome: impact on travel and tourism asymptomatic middle east respiratory syndrome coronavirus (mers-cov) infection: extent and implications for infection control: a systematic review mers-cov as an emerging respiratory illness: a review of prevention methods preparedness and proactive infection control measures against the emerging wuhan coronavirus pneumonia in china why snakes probably aren't spreading the new china virus a novel coronavirus from patients with pneumonia in china a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster clinical features of patients infected with novel coronavirus in wuhan novel coronavirus ( -ncov) -situation report - - world health organization. novel coronavirus ( -ncov) -situation report - - statement on the meeting of the international health regulations ( ) emergency committee regarding the outbreak of novel coronavirus fifa world cup: communicable disease risks and advice for visitors to brazila review from the latin american society for travel medicine (slamvi) pan american games: communicable disease risks and travel medicine advice for visitors to peru -recommendations from the latin american society for travel medicine (slamvi) risk assessment of dengue autochthonous infections in tokyo during summer, especially in the period of the olympic games panel of scientific publications and teaching, latin american society for travel medicine (slamvi) key: cord- -z n ys authors: murray, jillian; cohen, adam l. title: infectious disease surveillance date: - - journal: international encyclopedia of public health doi: . /b - - - - . - sha: doc_id: cord_uid: z n ys world health organization retains copyright in the manuscript and provides elsevier the permission to publish the manuscript as a chapter in this book. infectious disease surveillance is an important epidemiological tool to monitor the health of a population. the goals of infectious disease surveillance are threefold: ( ) to describe the current burden and epidemiology of disease, ( ) to monitor trends, and ( ) to identify outbreaks and new pathogens. first, describing the burden and epidemiology (including seasonality, age distribution, age groups, etc.) of disease is critical for demonstrating the need and advocating for interventions, such as vaccination and mass drug administration. surveillance is also used to detect antimicrobial resistance in certain pathogens (for example, fluoroquinolone resistance in gonorrhea) and the circulating strains of disease, which helps target vaccine interventions (for example, annual influenza vaccine composition). second, infectious disease surveillance is used to monitor disease trends, such as the impact of interventions like vaccination. disease trends do not only mean the number of cases, but also the etiology of cases. for example, after pneumococcal conjugate vaccine introduction, the distribution of serotypes causing disease should be surveyed for serotype replacement, when the incidence of disease caused by serotypes not covered in the vaccine may increase following the decline in disease due to vaccine serotypes from vaccination. information garnered from vaccine effectiveness studies can be coupled with burden and cost information to describe the cost-effectiveness of interventions. surveillance also monitors the control, elimination, and eradication of diseases. disease control refers to reducing the incidence of disease to a desired level (which will vary depending on the disease) and includes diseases such as malaria (dowdle, ) . disease elimination is defined as zero disease in a defined geographic area as a result of control measures. progress toward disease elimination requires control measures to stay in effect. disease eradication is defined as zero disease globally as a result of control measures, which are no longer required. smallpox is the only human disease and rinderpest is the only animal disease that have been eradicated from the world, but efforts are underway to eradicate polio and dracunculiasis. finally, a key aspect of infectious disease surveillance is the cycle of detecting, responding to, and preventing outbreaks. ongoing surveillance for an outbreak-and epidemic-prone disease can facilitate early detection of an outbreak, allowing a more rapid response and therefore mitigation of the outbreak. epidemic meningococcal disease in the meningitis belt in africa requires ongoing surveillance to identify outbreaks in the region. cholera surveillance is maintained globally to detect outbreaks and requires mandatory reporting to the world health organization (who). emerging and reemerging diseases also pose a big risk to public health. these diseases include both unknown pathogens that appear for the first time in a population as well as known pathogens that increase in geographic spread or severity or are reintroduced into the population. the zika outbreak in south america in - demonstrates how rapidly a known pathogen in a naïve population can spread. infectious disease surveillance can have different approaches based on the epidemiology and clinical presentation of the disease and the goals of surveillance. we will discuss some distinctions between infectious disease surveillance methods and give examples below. in passive surveillance systems, medical professionals in the community and at health facilities report cases to the public health agency, which conducts data management and analysis once the data are received. public health staff do not engage in identifying cases but rather assess data completeness and reliability of the reported cases. in contrast, active surveillance requires public health staff to engage actively in the system and take action in order to receive reports of disease cases. this may involve calling or visiting health facilities to encourage follow-up or having staff review medical records to identify cases meeting prescribed case definitions. active surveillance aims to detect every case, and passive surveillance likely misses cases due to the reporting structure. although active surveillance is more comprehensive, it requires significant human and financial resources, so passive surveillance is often implemented. notifiable disease surveillance is an example of passive surveillance. notifiable diseases are classified as such because they are of public health importance: they can be a severe risk to human health, outbreak prone, considered to be an emerging or reemerging disease, or have a timely intervention available for control of the disease. countries mandate which diseases are notifiable, many of which are infectious diseases. globally, the who, as described in the international health regulations, defines what is notifiable by every country to who, such as mers-cov (middle east respiratory syndrome coronavirus) and ebola. nationally notifiable diseases depend on the country. in the united states, the centers for disease control and prevention (cdc) and the council of state and territorial epidemiologists compile a list of diseases that have mandated reporting to the cdc. these include foodborne and sexually transmitted infections, other infectious diseases such as dengue, malaria, and hiv, and noncommunicable diseases such as cancer. the list is updated every year. on january , the list was amended to include zika virus disease after an outbreak in south america resulted in cases being imported into the united states. although not commonly used for surveillance purposes, administrative data or vital statistics are another example of routinely gathered data that can be used as passive surveillance. the international classification of diseases (icd- ) is used globally for the standard naming of diseases in hospitalized patients. administrative data such as hospital billing data using icd codes can be used for syndromic surveillance, such as for pneumonia, if it is available for ongoing monitoring of disease. these data may provide information on the clinical characteristics of patients across different regions and hospitals. active surveillance can have many approaches, including country-wide (e.g., for polio, measles, and rubella) or restricted to sentinel sites that capture cases within a demined catchment population. for example, as of , the whocoordinated global invasive bacterial vaccine-preventable disease (ibvpd) sentinel site surveillance network is a system of more than hospitals in more than countries that conducts active surveillance for meningitis, pneumonia, and sepsis ( figure ). within this network, staff are engaged to work specifically on finding all cases meeting the case definition at the sites. cases are enrolled into surveillance after they have been admitted to the medical facility. a case report form, filled out by the dedicated staff member, details their clinical symptoms. laboratory testing is done at the hospital for initial diagnosis or at a national or regional reference laboratory to monitor for trends in culture positivity and serotype/serogroup incidence. these data are reported to the ministry of health and who. data are analyzed to look at trends of disease, including pre-and postintroduction of vaccine. other diseases that have globally coordinated sentinel surveillance networks include rotavirus, influenza, and congenital rubella syndrome. surveillance for some diseases can be a mixture of passive and active surveillance wherein passive surveillance is complemented by active surveillance to investigate outbreak signals detected through passive surveillance. for example, surveillance for ebola virus disease is ongoing throughout the year as it is a notifiable disease for many countries and globally. during an outbreak, active case finding in the community is enacted to find symptomatic patients as well as contact tracing to find those at risk for developing the disease. choosing where to conduct surveillance is based on a number of considerations: how severe is the disease and how does it present? how important is it to find every single case? how outbreak prone is the disease? cases of infectious disease can be identified at medical facilities (hospitals and outpatient clinics) or in the community. the location of individuals enrolled into surveillance can vary based on clinical presentation of disease and access to health care. more severe cases of disease can often be identified at hospitals. hospitalized cases are those that are severe enough to be admitted to the hospital for treatment and have the resources to seek care. hospitalized cases can be enrolled prospectively or retrospectively when a case report form is filled out based on their medical chart. identifying cases in hospitals can be easier than identifying cases in the community, but the cases may only represent a small proportion of cases and miss cases that do not seek health care. an example of hospital-based surveillance is severe acute respiratory illness (sari) surveillance for influenza. for diseases like ebola, where fear in the community might prevent cases from going to seek health care, hospital surveillance would be insufficient alone. individuals with milder cases of disease may also seek medical care, such as at outpatient clinics, so surveillance may be conducted at medical facilities outside of hospitals, such as with influenza-like illness (ili) surveillance. some cases of disease are so mild or the patient's situation is such that they will not be able to seek care at medical facilities. in that case, community-based surveillance can monitor disease outside of health facilities, such as at schools, homes, traditional medicine practitioners, and other community facilities. this type of surveillance aims to capture cases beyond those that are admitted to a health facility, therefore enrolling a wide range of disease severity and access to medical care. community-based surveillance is useful for surveying diseases targeted for eradication because all cases must be traced and is not limited to those severe enough to be admitted to a hospital or those that have access to a health-care facility. acute flaccid paralysis (afp) surveillance is an active surveillance network that aims to identify every case of polio, which is currently targeted for eradication. suspect cases are sought in the community and at health facilities to identify any unreported cases. this type of surveillance was also a method used in the ebola virus disease epidemic of - . community members and volunteers would report individuals with symptoms meeting the case definition for ebola, who would then be visited by health personnel for testing. community-based surveillance was supplemented by contact tracing, where individuals who had been in contact with confirmed ebola patients were sought out in the community and monitored for symptoms. a sentinel surveillance site is a single or small number of health facilities that are responsible for collecting data on cases enrolled with the case definition under surveillance including global networks surveying for diarrhea or pneumonia. most sentinel sites do not have a predefined catchment population (or denominator to calculate incidence), and therefore data at these sites are simply numbers of cases (numerators). sentinel site surveillance provides useful epidemiological information on proportions caused by different pathogens, age distribution, and risk factors and could also be used for monitoring trends of hospitalized cases within a health facility if health-care patterns and population have been stable. furthermore, these data may be used in case-control studies to assess effectiveness of a vaccine or other preventive measures. surveillance focused on one or a small number of surveillance sites often allows for gathering more data of higher quality. in contrast, with population-based surveillance, every appropriate health facility reports on the predefined diseases with the goal of identifying all cases in a specific geographic area. population-based surveillance can either represent the whole country (national) or a defined subnational population area. since the population is defined, these surveillance sites can produce rates of disease (for example, incidence and mortality rates), which allows for comparison of rates of disease between other population-based surveillance sites. population-based surveillance is more costly than sentinel site surveillance, but produces more generalizable data on incidence of disease. aggregate surveillance data can exist in a variety of forms, but the main feature is that it lacks detailed information on specific cases. aggregate data typically include the number of cases (for example, number of suspect and confirmed neonatal tetanus cases, or by age group) for a specific region and time period. this information can monitor the number of cases but lacks the individual-level data required for specific analyses. an example of this is the integrated disease surveillance and response (idsr) system which asks clinicians to report the number of cases of specific diseases. case-based surveillance refers to surveillance systems that collect information about each case at the individual level. this type of surveillance system has a case investigation form where information can be gathered from the patient or their family members, their medical records, and their laboratory records. at a minimum, more detailed information on person (who is infected), place (where they live, where they might have been infected), and time (when they became ill) is collected. a line list from this investigation form is created and reported up their normal reporting channels. in some scenarios, a case-based surveillance system might transition to aggregate as the number of cases becomes large as it overwhelms the system, like what happened during the h n outbreak. in contrast, an aggregate surveillance system might become case-based temporarily in an outbreak to understand more of the epidemiology of the disease. certain diseases, such as polio and measles, are recommended to be case-based. measles surveillance has seen a movement away from aggregate and toward case-based surveillance (who, ) . initially, when the united nations (un) development goals were established in , measles was endemic in many countries, and mortality reduction was the primary goal. given this, aggregate data were the most feasible approach and were conducted in most countries. by , all six who regions have measles elimination goals. as measles has moved away from control and toward elimination, case-based surveillance is needed to ensure every case is reported and investigated. when disease was endemic, case-based surveillance would quickly be overwhelmed given the time and resources, but as countries have fewer and fewer cases, it is relatively easier to conduct an investigation on every single case. who recommends the type of data to be collected in an investigation. one key advantage of case-based surveillance is that it allows one to analyze which age cohorts are being infected and their individual vaccination status to help to target vaccination efforts and close existing immunity gaps. surveillance networks identify and enroll cases that meet a specific case definition. case definitions have three essential components: person, place, and time. case definitions vary in sensitivity and specificity. sensitive case definitions are more inclusive, are less likely to miss cases, but will include patients that do not have the disease. specific case definitions have stricter criteria and exclude more patients that do not have the disease but can also miss patients with milder or atypical disease presentations. both sensitive and specific case definitions can be used in infectious disease surveillance depending on the goals of surveillance. for example, sensitive case definitions may be preferred if it is important not to miss cases. in general, case definitions should be as sensitive and specific as possible. however, since a highly sensitive and specific case definition is not always possible, it is important that the case definition is at least applied systematically and consistently over the surveillance period. syndromic surveillance involves monitoring cases that meet a clinical case definition for the disease under surveillance, typically without laboratory confirmation (henning, ) . this allows for rapid identification of a cluster of cases that might warrant further investigation. an example of syndromic surveillance includes acute fever/rash surveillance in many countries, which is used to monitor measles and rubella. the fever and rash could be due to a multitude of causes, and if there is an increase in the number of fever/rash cases reported, this could indicate an outbreak. as field investigations are ongoing, laboratory testing can be performed on some or all of the cases identified by syndromic surveillance to determine the etiology. in the acute fever/rash surveillance system, laboratory specimens might be collected to undergo testing for measles and rubella. a wellestablished global who-coordinated measles laboratory network provides support to monitoring measles cases and provide genotype information globally. syndromic surveillance case definitions can be used in emergency or outbreak situations as an alert system to identify suspect cases that meet a broad case definition to then be further investigated. during the ebola outbreak in - , airport security was increased to identify people with a fever and a history of travel to an ebola-affected country in order to stop the disease from traveling between countries. in contrast, some surveillance case definitions are based on confirmed cases in a laboratory where the etiologic agent can be identified through a variety of laboratory tests (e.g., serology testing, bacterial culture, or molecular diagnostics) or at the bedside with well-validated commercial rapid diagnostic tests (e.g., malaria and streptococcus pneumoniae). as an example, virologic influenza surveillance networks use laboratoryconfirmed influenza to determine the circulating strains to provide information for vaccine composition. a critical objective of laboratory-based surveillance is to monitor for emerging drug resistance in pathogens or shifts in serotype distribution. cases meeting a suspect case definition (a sensitive case definition) may undergo laboratory testing leading to a more specific case definition. for example, the case definition for suspect meningitis as part of the who invasive bacterial vaccine-preventable disease network is very sensitive: a hospitalized patient at a surveillance hospital with sudden onset of fever and at least one meningeal sign during the surveillance period. after being enrolled into surveillance, additional clinical and laboratory information can reclassify a patient as having probable bacterial meningitis (namely having abnormal white cell count, protein or glucose levels in cerebrospinal fluid). this definition has a greater specificity but lower sensitivity. the most specific meningitis definition is confirmed meningitis by polymerase chain reaction assay or other laboratory test. this definition may lose some sensitivity because confirmatory tests can have false negatives, especially in areas with high antibiotic usage. zoonotic diseases cause disease in humans and can be challenging to control since both animals and humans can be hosts. many zoonotic diseases of public health importance are covered in other articles of this encyclopedia, including west nile virus, avian influenza, ebola (and other hemorrhagic fevers), lyme disease, sars, nipah virus, and rabies. historically, zoonotic and human disease surveillance existed separately, but there is a push to harmonize these systems to improve surveillance for diseases affecting both populations. illness in one species might be a harbinger of illness in humans, and an integrated comprehensive surveillance system can help identify potential disease transmission that might be ongoing. for example, surveillance for borrelia burgdorferi, the causative agent of lyme disease, in the tick population can help public health authorities determine proper interventions to decrease the transmission from ticks to humans. one health emphasizes the link of human health to the surrounding environment and animals. one of the mission statements of one health is to improve the lives of all species by harmonizing both animal and human disease surveillance and control efforts. international organizations participating in one health include who, the un food and agricultural organization, and the world organization for animal health. serosurveillance involves the use of blood specimens to determine the burden of disease or immunity gaps in a population. serosurveillance is frequently done as a periodic survey for multiple diseases of interest simultaneously. however, serosurveillance cannot provide information in a timely manner; thus an outbreak might have occurred that is discovered by serosurveillance, but it might be potentially too late for an intervention to decrease disease transmission. serosurveillance is sometimes the only type of surveillance conducted for an infectious disease. for example, hepatitis b is frequently asymptomatic in children, making evaluating the impact of vaccination efforts extremely challenging (who, ) . the standard has become to perform serosurveillance among cohorts of vaccinated children to identify the burden of disease and determine the impact of vaccination efforts. in some countries, national health surveys, such as the national health and nutrition examination survey (nhanes) and malaria indicator surveys, are conducted periodically and include a serologic component, allowing one to monitor trends in diseases and immunity over time. for example, nhanes includes data on hepatitis b, c, and d antibodies. adverse events following immunization (aefi) surveillance is a critical component of ensuring vaccine safety in the populations where the vaccines are being used. surveillance often begins at the health facility level, where health workers are trained to recognize adverse events from immunizations, and is reported to national regulatory agencies and who. this surveillance is critical for investigating problems that could occur with bad lots of vaccines and mishandling of vaccines in the cold chain (improper storage) which can contribute to the public perception of the vaccine program. technology is increasing the availability of data on health that can be used for infectious disease surveillance, including sources that go beyond that of traditional passive or active surveillance systems. new sources of data include mobile data, electronic health records, and social media. these aggregate sources and the speed at which they can be compiled are referred to as 'big data' (wyber et al., ) . these sources of data can provide more real-time information to help mitigate outbreaks or improve the health of a population. in , google started a venture called 'google flu' which was an algorithm tracking global search habits (such as search engine queries for 'influenza') with the hope that it could act as a real-time syndromic surveillance system. it was one of the first 'nowcasting' surveillance technologies and was able to predict influenza disease with some accuracy, close to the us cdc influenza reports based on laboratory-confirmed influenza surveillance. however, after a couple of years, it was found to overpredict the number of influenza cases given the generic case definition used. the system is no longer active, but is used to help groups develop newer public health analytics. the use of mobile technology to improve systems is an important area for public health (also referred to as mhealth) and has a growing use for surveillance. mobile data can monitor the movement of people during an outbreak, and this information can allow health officials to better predict where a given disease will spread. the un pulse project supports infectious disease mapping in kampala, uganda, using m-health (un global pulse, ) . in , there was a typhoid outbreak in uganda. the pulse lab in kampala provided mobile data to complement data which the ministry of health collected on cases. these data sources combined allowed better visualization of the outbreak and where clusters of infections were happening and therefore permitted improved mobilization of resources to respond to the outbreak. flowminder is another organization developing the use of mobile technology in outbreak situations. it currently has projects supporting monitoring the spatial patterns of individuals during outbreaks using data from mobile phones. during a cholera outbreak in haiti in , researchers from flowminder mapped the movement of people using anonymous data from mobile usage from the affected areas (bengtsson et al., ) . following the outbreak, the data were analyzed, and it was shown that this was an effective way of mapping the spread of the outbreak. many partnerships between academic, programmatic, and global organizations exist to facilitate ongoing infectious disease surveillance and promote global health security. partnerships can take different forms and often include providing technical and operational support and resources to facilitate ongoing surveillance. some examples are as follows. in , the idsr strategy was first drafted by the who regional office for africa in order to harmonize existing surveillance networks (including afp and neonatal tetanus) in the african region (who, ) . the strategy aims to integrate surveillance being done at the community, health facility, district, and national level to improve the data collected and to conserve resources. idsr includes standard case definitions and protocols and involves collecting only data necessary for disease control, often aggregated data. this helps to decrease the work burden at all levels on health staff, is more efficient, and costs less than nonintegrated surveillance. however, the challenge of integrated disease surveillance is that sometimes more information is needed than is readily available to target intervention activities. the global outbreak and response network (goarn) is a who-coordinated network comprised of over partners worldwide, including government, technical, and academic institutions involved in epidemic surveillance. the purpose of goarn is to coordinate a rapid response to international disease emergencies through deployment of resources to the affected countries. goarn coordinates a multidisciplinary team comprising clinicians, epidemiologists, social mobilization, and communications experts. the increase in international travel is an important risk factor in the spread of infectious diseases. travelers can contract many infectious diseases, from common travelers' diarrhea to more serious conditions such as ebola. this can pose a serious public health risk if conditions are right for an outbreak or when novel pathogens are introduced into a naïve (not vaccinated or without protective antibodies) community. geosentinel is a global network of clinics assessing travelers' and migrants' health for illnesses acquired while abroad (leder et al., ) . this network of clinics confirms and registers cases of infectious diseases acquired while traveling. this surveillance information is critical for tracking the movement of diseases and informing guidelines for travel medicine. surveillance is an action-oriented public health tool. time lags in surveillance can affect outcomes if there is not a rapid response with interventions. surveillance information can be used at the global, regional, national, local, and individual levels. new technologies are being developed to assist with more real-time data dissemination. surveillance bulletins and reports are a frequently used method for disseminating surveillance information. many surveillance networks use them to send information to stakeholders and partners involved with the surveillance. these can be frequent (weekly or monthly reports) or more infrequent such as annual or biannual surveillance bulletins. these normally include case counts for the disease under surveillance or detection of new outbreaks. the scientific literature (peer-and non-peer-reviewed publications) and scientific conferences are also important venues for disseminating surveillance data. the audience for publications can be much wider than bulletins since they are accessible by a wide range of individuals. there can be a long lag-time between data generation and publication. these modes of communication are critical for improving the wealth of available knowledge and advancing research, but are not timely enough to mobilize a response to an outbreak. the morbidity and mortality weekly report (mmwr) from cdc and the weekly epidemiological record (wer) from who are two examples of periodic, non-peer-reviewed dissemination tools. the mmwr publishes an annual list of notifiable diseases using weekly data on the cdc surveillance systems. the mmwr publishes weekly reports for outbreaks and case reports for diseases under the international health regulations. with the advance of social media and the internet, there have been innovative strategies for more quickly disseminating surveillance information for rapid public health intervention. for example, the program for monitoring emerging diseases (promed) is a popular tool run by the international society for infectious diseases. it consolidates and verifies reports from media, observers, and news and disseminates via email and their website. they have a large audience since their information is free and easily available on the internet. they act as an important early warning of outbreaks to facilitate public health preparedness. online platforms are creating innovative ways of displaying the surveillance data that are collected. an online platform called healthmap run by boston children's hospital is one example (figure ) . reports of disease cases come from a series of vetted online sources (including promed, who, and online news outlets) and are mapped on an interactive interface allowing users to view the geographic distribution of multiple diseases. physicians and individuals can use healthmap to identify diseases occurring close to them or their travel destination. other tools include the health alert network (han) at cdc, which is used for quickly disseminating confirmed disease reports and information to medical and public health professionals at a national level. han disseminates four types of information: ( ) health alerts (where an action required); ( ) health advisories (information on health events where no action required), ( ) health updates (information on given events); and ( ) general public health information. in february , han released an official cdc health advisory on preventing sexual transmission of zika virus after a confirmed sexually transmitted case in texas. event-based surveillance entails monitoring cases and outbreaks of disease through formal and informal news and online reporting platforms. traditional surveillance can miss many outbreaks or delay the opportunity to intervene. eventbased surveillance includes reports from the community, health facilities, universities as well as media and online sources in order to develop alerts of health situations that are developing. the data and reporting methods are much less structured than other surveillance, but allow for quick detection of events that need to be investigated. surveillance is in and of itself a critical tool for public health. using an existing surveillance network as a platform for surveillance of additional diseases allows streamlining resources and can be a cost-effective measure to improve public health. for example, influenza surveillance is being leveraged to conduct surveillance for other respiratory viral diseases, such as respiratory syncytial virus. additionally, the laboratory, clinical, and epidemiological capacity built to run a surveillance network can be utilized for other public health studies. surveillance sites can be used as platforms for research and special studies. since infectious disease surveillance sites often conduct surveillance for vaccine-preventable diseases, studies on vaccine effectiveness and vaccine impact can be built on the platform of surveillance. vaccine impact studies can use surveillance to demonstrate reduction of disease after introducing an intervention such as a vaccine. these impact studies require baseline data before the vaccine was introduced in order to compare the postvaccine era to the prevaccine introduction disease incidence. special studies that gather additional information may complement surveillance disease trends. vaccine effectiveness studies evaluate the ability of a vaccine to control the disease in a real-world setting, which differs from vaccine efficacy studies where the vaccine impact is estimated in a controlled clinical situation. a good example of this is rotavirus diarrheal sentinel site surveillance, which has been used both to show the decline in rotavirus disease among age groups vaccinated as part of routine immunization and has also been used as a platform to conduct vaccine effectiveness studies. estimating the burden of disease at the country or global level with epidemiological models can be a critical part of using surveillance data and advocacy for disease interventions. in many countries, surveillance data alone may not be sufficient to provide informative data for a specific disease for a number of reasons: surveillance data may not be available, there might not be laboratory confirmation, or the data necessary to answer a certain question may not have been collected. in these situations, models using local and nonlocal data can be very useful. in addition to data from one region being extrapolated to inform on the disease within that region, data from similar regions can also be used to fill in gaps where surveillance is missing. there are many global burden estimation projects updated regularly to give global prevalence and mortality estimates by different government, research, and academic groups for a number of diseases (for example, influenza, s. pneumoniae, and rotavirus). burden estimation modeling can also be done on the national level using surveillance data collected locally. surveillance data have been used in a model to extrapolate the burden of influenza-associated hospitalizations in south africa, guatemala, and kenya using local surveillance data from the country (murray et al., ) . using mobile phone data to predict spatial spread of cholera the principles of disease elimination and eradication overview of syndromic surveillance: what is syndromic surveillance? geosentinel surveillance of illness in returned travelers figure healthmap displaying reported measles cases for the past month determining the provincial and national burden of influenza-associated severe acute respiratory illness in south africa using a rapid assessment methodology data visualisation and interactive mapping to support response to disease outbreak who-recommended standards for surveillance of selected vaccine-preventable diseases [online]. who document production services technical guidelines for integrated disease surveillance and response in the african region documenting the impact of hepatitis b immunization: best practices for conducting a serosurvey big data in global health: improving health in low-and middle-income countries united nations global pulse the views expressed in this article are those of the authors and do not necessarily reflect the views of who.see also: childhood infectious diseases: overview; ebola and other viral hemorrhagic fevers; geographic information systems (gis) in public health; health-care delivery systems; influenza; measles; poliomyelitis; surveillance of disease: overview. key: cord- - tmtvw r authors: singh saraj, k.; mishra vishal, a.; jha vikas, c. title: modification of neurosurgical practice during corona pandemic: our experience at aiims patna and long term guidelines date: - - journal: interdiscip neurosurg doi: . /j.inat. . sha: doc_id: cord_uid: tmtvw r background: first case of covid- was confirmed on (th) january, in india. our state, bihar reported its first confirmed case of covid on (nd) march at aiims patna. for safety, electives surgeries and outpatient department was suspended temporary since (th) march. standard operating procedure (sop) was framed for covid suspected, covid positive and negative patients. neurosurgery department formulated their own strategy for successful and covid free management of neurosurgical patients along with zero transmission rate among doctors and staff. methods: all neurosurgical patients who got attended, admitted and operated from (th) march to (th) june (period of lockdown) were taken in this study. categorizations of the patients were done according to the urgency and elective nature of pathology after corona screening and rt-pcr testing of covid- . a proper training to all neurosurgical staff and residents were given for management of patients (admission to operation to discharge). results: total patients were attended and were admitted. we operated cases (major - , minor – ) during the lockdown period. out of this were corona positive (both eventually succumbed) and rest was corona negative. one patient who was operated with corona negative report became positive after days of surgery inward. all the residents, faculty and nursing staff remain asymptomatic throughout the lockdown period with zero infection rate and zero transmission rate. conclusion: following a properly made standard operating procedure and strictly implementing it can avoid any type of misadventure in neurosurgery during corona pandemic. key message: adequate planning and sufficient training is necessary to avoid any untoward incident of infection. proper utilization of limited human resources and infectious kit is needed at this time. the first case of covid- was reported in india on january . as of th may , the ministry of health and family welfare have confirmed a total of , cases, , recoveries (including migration) and , deaths in the country. [ ] india currently has the largest number of confirmed cases in asia with number of cases breaching the , mark on th may and million in august. [ ] after successful trial of brief curfew on nd march, indian prime minister narendra modi followed it with complete nationwide lockdown from th march for days. the period of lockdown was subsequently increased three times in two months. [ , ] first proven case of covid in bihar was reported on nd march at our institute, all india institute of medical sciences, patna. he was -yearold male with a travel history to qatar. [ ] the virus has spread in districts of the state, of which patna has the highest number of cases. [ ] the state with a population of more than million people was under complete lockdown from th march to st may. it remained in partial lockdown status till st july . approximately , people got infected with covid till th june . after th june our hospital got converted into covid dedicated hospital. the state government has responded to the outbreak by following a contact-tracing, testing and home to home surveillance model. all outpatient services were shut down in our hospital since th march . however emergency services were continued and standard operating procedure (sop) was made both for the institute and our department. as our department is the only neurosurgical unit dealing vascular neurosurgery in the whole region of million, our responsibility was more as compared to other hospitals. to avert crisis during such pandemic, hospital and department both need a strategy to meticulously manage their staff, emergency, operation theatre complex (otc), intensive care unit (icu) and wards. here we are discussing our department response, guidelines, drawbacks and analysis of one of the most important emergency services at aiims patna with safe execution and management of neurosurgical patients. we also finalized a roadmap for future management of neurosurgical patients for next few months till this pandemic gets over. consecutive patients of neurosurgery (both traumatic and non-traumatic) at our institution were considered for the study. all patients who attended, admitted and operated from th march to th june (period of lockdown) were taken in this study. all all admitted patients were categorized on the basis of emergency for intervention data collection methods: data was collected prospectively when the patient was in emergency and trauma in the form of demographic profile at the time of admission and operation, comorbidity, gcs at the time of surgery. all patients were assessed on the basis of severity and admission was done. all admitted patients were categorized on the basis of protocol we made for department. (table no ) management was done on the basis of this protocol. along with urgency of the cases. in category i, patients were operated in emergency within hours with only corona screening. in these patients, nasopharyngeal swab were sent before taking up for surgery. external ventricular drain insertion, vp shunting (ventricularperitoneal shunting), edh (extradural hematoma) evacuation and decompressive craniotomy were included in this category. in category ii, patients were operated on urgent basis within - days after admission. results of rt-pcr were assessed before taking up for surgery. category ii was formalized by keeping incubation period of covid - in minds ( - days the surgeries needing more than - hours of exposures were categorized in major group and less than hour were categorized in minor group. in emergency, total patients were attended during lockdown period. out of this, were admitted in which were female and were male. mean age was . years. total patients underwent procedures/operations. (table no (table no )out of patients that got admitted, two came out as positive and rest were negative. one was having hypertensive bleed with intraventricular extension. in this patient evd was inserted after wearing full ppe kit. other was chronic sdh with severe mass effect which came with poor gcs (gcs- ). here twist drill was done and hematoma evacuated. but both the patients eventually succumbed. one covid negative patient became covid positive at th postoperative day on routine testing. however she was asymptomatic. she was transferred to covid positive ward and discharged from there after testing negative on rt-pcr. after lockdown from th march, the whole outpatient department (opd) was closed. all patients with minor ailments were advised to stay at home and only emergency patients were getting attended at trauma and emergency. from the beginning, contact details of the department were getting circulated in local newspapers for benefit of the patients. for initial to days, patients having traumatic head injury and spinal injury were getting admitted. than later on stroke, aneurysm rupture and large intracranial space occupying lesions also started arriving in emergency. after triage from institute, our department was also categorizing the patient on the basis of severity. it was observed that just by differentiating the cases into emergency and elective procedure, we are just avoiding the bay and not the storms. most of patients with benign intracranial or spinal pathologies will land up in emergency within days or months. so by doing triage we are just segregating emergency and urgent cases at that particular point of time. even after development of vaccine, covid- is going to stay for a longer period of our life. so we needed a triage system where we can deal with all types of cases with avoidance of covid exposure. the study from italy has provided a framework for creating an emergency task force, streamlining a stringent protocol and adequate training to achieve zero infection and transmission rate. [ , ] they have created treatment hubs with interchanging of neurosurgeons along with transport of patients from one hospital to other hospitals. they also created a task force which helped in reducing non-urgent cases. most of the urgent neurosurgical procedures were performed by a strict number of operators. [ ] it was not possible for us, because our institution is the only institution where active and specialized neurosurgical procedures is happening presently in the whole state of bihar having a population of more than million. . our team was composing of seven junior residents, four senior residents and two actively working faculties. we made a team of seven residents who were attending and admitting the patients from emergency. all emergencies were first attended by our junior residents. one resident was given an emergency duty of hours followed by days off. they were exempted from duties of ward and icu. each resident was covered by senior resident and one faculty on alternate days. . all senior residents were rotated weekly. one resident was fixed for taking rounds of covid negative patients in the ward and icu for week. in second week he got shifted to total junior residents everyone attending emergency one day/week duty off for next days operation theatre. his assistance was utilized for week. during third week he got shifted to covid ward and he was taking rounds of covid positive/ covid suspected patients followed by week of quarantine. above mentioned cycle was followed by each resident and it got repeated every month. . two faculties were actively working in the department. both of them took alternate turns for operation theatre/ ward rounds. faculty a was posted on st and rd week, faculty b on nd and th week. both the faculties were getting week of quarantine. following this protocol we maintained minimal interaction between faculties, senior residents and junior residents. it was followed till th june, . after that our hospital got converted from covid care center into covid dedicated hospital and all emergency services were closed. week - week - week - week - mask, head and shoe cover, goggles). (figure ) lifesaving procedures were done in corona suspected ward, bed side only like evd (external ventricular drain) insertion, twist drills. if rt-pcr comes positive, then patient is shifted in corona ward/ corona icu for further management. category i patients were planned for urgent surgeries and category ii patients were planned for surgery within - days. these patients were operated under strict covid protocol and again shifted back to covid icu. a dedicated transportation route is recommended during this covid pandemic. [ , ] and our department complied with it and neurosurgical patients were carried to operation theatre complex (otc) from different route. the whole route was sanitized once the transportation was completed. it is advised to do ct chest for all the patients. [ , , , ] nasopharyngeal swab for all the patients were sent. in trauma ward / icu total admissions took place. on rt-pcr all came out as negative. negative patients were shifted to neurosurgical ward/ neurosurgical icu. sensitivity of rt-pcr of different body fluids had been analyzed and published in jama. in this bronchoalveolar lavage fluid is the most sensitive specimen ( %), followed by sputum ( %), nasal swab ( %), fibrobronchoscope brush biopsy ( %), pharyngeal swabs ( %), feces ( %), and blood ( %). [ ] but we don't recommend multiple testing from different sites even if it can improve sensitivity and reduces false-negative results. however we recommend multiple modalities of investigations like chest x ray, rt-pcr from swab along with thermal screening and most important clinical assessment. at our institution only corona screening, chest x ray and rt-pcr for nasopharyngeal swab was done for all the patients. recent guidelines at present recommend a single upper respiratory nasopharyngeal swab for suspect cases. [ ] also a recent survey has indicated that, nasopharyngeal swab was the preferred method for screening ( %), followed by ct scan ( %), and chest radiograph ( %). some respondents indicated more than one screening method, especially those from italy ( %) and india ( %), where the most common combination was the nasopharyngeal swab with chest radiograph. [ ] the most important thing during preoperative period is mobilization of patients. it is the most important factor as patient can acquire these infections from hospital surroundings. we suggest that mobilization should be grossly restricted. radiological investigations like chest x ray, ct, mri and dsa should be done after keeping in mind the usefulness of these in planning surgery. if possible, all should be done in single transportation and sittings. [ , ] all patients were operated under strict covid operating room protocol. training -it has been shown by hoz et al that without sufficient quantity of ppe kit and also without adequate training, the whole system will collapse and staff will suffer along with the patients. [ ] so a proper training is mandatory for the whole surgical team before going for any surgery. a rigid training was given to all dedicated neurosurgical staff, technicians, residents and faculties to prepare for emergency cases. all steps (in sequence) were revised for many days in a dummy class by neurosurgical residents and faculties. multiple classes were taken for proper donning and doffing sequence of ppe kit for all the staff. already neurosurgical procedure needs a very smooth coordination of staff and operating surgeon which was stressed during this pandemic. movement of technicians and staff were kept very minimal. and neurosurgical nursing staff was allowed to assist only on the allotted specific days for surgery for a week followed by quarantine on next week. for initial month preferably accidental cases were taken for surgery, as this surgery needs less expertise from neurosurgical point of view. it will also give neurosurgical team and staff to acclimatize to work in pandemic atmosphere. avoiding surgeries is neither beneficial for the surgeons and nor for the patient. so battling the fear and rigorous training can only help us achieving zero infection rates with good post-operative results. needed during such pandemic to avoid transmission of infection. [ , , ] it was advised to have dedicated operation theatre for neurosurgery during this pandemic. [ , ] but survey has indicated that majority of institutions and centers had not done it. [ ] however as it was getting not possible in our institute, we opted for high air flow otc to reduce viral load. after each operation the otc was fumigated twice with sodium hypochlorite ( %) before taking up another case. in otc, all major neurosurgical equipment was covered with sterile covers. operating microscope was covered with drape and vision guard. c-arm was draped with sterile covers. equipment (ppe). patient face was covered with square transparent box during intubation. as anesthetist are in direct contact, risk of aerosol dispersion is maximum during intubation, hence it has been suggested that the whole face area may be covered by a transparent sheet and the hands may be inserted under the sheet to intubate the patients, while the edges should be stuck to the surface. a preferred protocol is the use of a separate room for intubation and then bringing the patient to the or, so the risk is minimized to the surrounding health personnel. [ , ] however as it was not possible at our center, our anesthetist opted for intubation after wearing ppe kit and head shield. during anesthetic procedure (intubation, arterial line insertion, central line insertion), all neurosurgical team was advised to stay outside. operative procedure -patient positioning was done after wearing n mask and head shield. during initial phase while we were not having any ppe kit for otc, we utilized "universal precaution kit" for performing surgeries. later on we switched over to ppe kit. it has been advised that surgical procedure should be performed after wearing level - protections kit. [ , , , ] only disposable items were utilized in surgeries like coverings, draping and gowns at our center. it is mandatory to wear two layers of surgical gloves to avoid infection from breakage of gloves. all surgeries should be performed after proper distribution of various stages to different surgeons. aerosol dispersal and blood spillage should be minimal. [ , ] at our center, only one surgeon at a time was involved in operative procedure. opening and closure was done by senior residents. middle portion of surgery was performed by the faculty. for complicated and long procedure, other faculty was kept on standby. during macroscopic phase (craniotomy, laminectomy) of surgery, head shield and eye goggles were utilized. (figure ) throughout the drilling process, copious irrigation was continued to allow minimal dispersal of aerosols. drilling was kept at minimal level to avoid dispersal of aerosol. operative procedure was done slowly and meticulously, especially the opening phase to avoid blood loss and spillage. (figure a and b) craniotomy utilizing hudson burr and gigli wire/saw should be avoided. it causes inappropriate dispersal of bone dust and blood. also it is very cumbersome to use and injury prone. transnasal vs transcranial approach -throughout the pandemic and even after opening of lockdown, we are continuously giving transnasal approach (both microscopic and endoscopic) a back seat. transcranial and spinal procedures are considered as safe. csf dissemination of virus has been rarely reported. only one case from china and one from japan has been reported with covid meningitis. [ ] however during pandemic, we should treat all cases of neurosurgery as covid positive case. by avoiding transnasal route we are also nullifying the chances of invasive covid meningitis. operative time -many of the neurosurgical procedures needing longer stay in otc can be deferred. however some of them needing urgent intervention like giant craniopharyngiomas, skull base tumors (giant vestibular schwannonas, glomus jugulare), bypass for giant aneurysms, multiple intracranial tumors (neurofibromatosis) and multiple aneurysms can be staged. longer contact period with the patient on ot table is one of the factors for surgeons getting infected with covid. [ , ] young neurosurgeons with good experience, precision and adequate speed should perform major surgeries, as they can sustain longer time and contact period in otc. neurosurgeons with comorbidities (like copd, hypertension, and diabetes mellitus) and age more than years should not opt for performing major surgeries at this time of pandemic. however trainees should be given a back seat at this moment of epidemic. postoperative period -ideally all post-operative patients should be categorized as covid suspected. they should be quarantined in ward. it has been recommended to take throat swab and do a ct chest at least thrice weekly. [ , , ] majority of the patient in neurosurgery get shifted in icu. so ventilators and monitors are necessary equipment. also nutritional support is very important to regain natural immunity in post-operative period. [ , , ] at our center, all patients were shifted to neurosurgical icu in post-operative period. air duct of ventilators were getting replaced daily. nasopharyngeal swab was sent and chest x ray also done but only once in two weeks. we avoided unnecessary mobilization of patient postoperatively for multiple investigations. all the patients were started with early feeding, either orally or ryle's tube feeding. immunosuppressive drugs like steroids were avoided in majority of the patients in post-operative period. mobile ct machine and mobile x ray machines should be used aggressively during this pandemic and cover should be destroyed after each round of utilization. [ , , ] we kept a separate x ray machine and technician for neurosurgical icu. as mobile ct was not available, timing slots were given to respective departments. our patients were mobilized for postoperative or preoperative ncct head or mri / dsa at allotted time slots. none of the patients came positive on immediate postoperative swab. however one patient of ica cavernous segment aneurysm (ica trapping was done) came positive in the ward after days. on repeating pcr of rest of the patients in adjacent bed, it came negative. we fumigated that section of ward covered with glass shield. multiple articles have suggested that patients with stable condition should be postponed. [ , , , , , , , , ] the covid- outbreak had a relevant impact on surgical planning. in survey by fontanella et al most have responded with a significant change in surgical activity in their institutions ( %). [ ] the majority ( %) performed only urgent and emergency procedures; with few had ( %) completely closed the entire neurosurgical department. there is % reduction of surgical interventions. delaying elective procedures will contain the spread of sars-cov- by reducing no of visits and it will also reduce possibility of treating asymptomatic carriers. [ , , ] by following this zero infection and transmission rate can be achieved. however, as ours is an apex center catering around million population, we developed our own triage system. we categorized the patients according to the condition of the patient. stable patients were postponed but not cancelled indefinitely. they were taken up at later date after doing an rt-pcr of nasopharyngeal swab just before the operative procedure. at our department, the number of cases dipped minimally. however, number of elective cases went down but emergency cases went up significantly. as most of the private hospitals in our state got closed, our load remained fairly constant. academic activities -intra-hospital and intradepartmental movements were restricted and minimum residents were kept for functioning of the department. it is suggested that all the academic activities like mortality meetings, journal club, and case discussions should be done through video conferencing and webinars. it is also recommended that physical distancing should be maintained during rounds and departmental meetings also. [ ] we strictly adhered to it. however from st july, all rounds, operative teachings and classes were suspended. all the residents came into common pool and got involved in covid patient care only. but we are still continuing with webinars and online classes. future plan-it has been outlined that telemedicine and telephonic communication is the future. [ , ] our department is planning to initiate telemedicine for patients both telephonically and on video calls. it will help us to follow our post-operative cases. through this assessment of preoperative cases can be also be done and they can be given appointment for surgeries especially elective cases. semi urgent cases can be followed weekly and in case of deterioration they can be called up to emergency directly. our department is already having policy of giving contact details of our common duty mobile number to all our preoperative and post-operative patients and their relatives. during this pandemic we encouraged these types of communications significantly. this cell phone is carried by neurosurgical resident and covered by one of the faculty daily. it was planned to give dates to all elective cases, so that they can plan their transportation and safety before arriving in opd. they will come one day before opd and get themselves tested for covid- . maximum new cases and old cases will be entertained per day. we have planned to erect glass shield along with microphones so that clinical history can be taken maintaining physical distancing. clinical examination will be done after wearing protection kit. mri, ct scan, dsa will be done at our center. it will minimize our contact with fomites. if already done outside, every patient will be advised to carry dvd / cd of their imaging. majority of these things we had already started and practicing in our institute and department. however due to conversion of hospital into covid dedicated center, it took back seat. as patients are piling up, sooner we will restart our department and center with same protocol. however as more cases of covid related encephalitis are getting reported, it may get delayed. [ ] during corona pandemic, it is advised to do meticulous triage of neurosurgical patients. home | ministry of health and family welfare | goi hindustan times india to go into nationwide lockdown india's coronavirus lockdown: what it looks like when india's . billion people stay home india reports seven coronavirus deaths as die in mumbai what are red, orange, green zones". the times of india neurosurgery during the covid- pandemic: update from lombardy, northern italy neurosurgical practice at the time of covid- neurosurgical practice during the severe acute respiratory syndrome coronavirus (sars-cov- ) pandemic: a worldwide survey preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of coronavirus infection preparing for a covid- pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore neurosurgery and neurology practices during the novel covid- pandemic: a consensus statement from india detection of sarscov- in different types of clinical specimens covid- ) neurosurgery in iraq at the time of corona roadmap for restarting elective surgery during / after covid- pandemic letter: safety instructions for neurosurgeons during covid- pandemic based on recent knowledge and experience letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm covid- in neurosurgery news, guidelines and discussion forum american college of surgeons. covid- : recommendations for management of elective sources of support (if applicable): none conflict(s) of interest: none key: cord- - tb b z authors: freitas, a. s.; silva, l. s.; sandes, s. s. l. title: new s.i.r. model used in the projection of covid cases in brazil date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: tb b z in this work, we proposed a variant of the sir model, taking as based on models used to describe the epidemic outbreak in south korea and portugal, to study the sars-cov- epidemic curve in brazil. the model presented here describes with reasonable agreement the number of covid- cases registered in brazil between february and april , based on the hypothesis that there a large number no notified cases ( to ) and variation in contagion rate according to social isolation measures and greater or lesser exposure to the virus (highest rate in beginning from epidemic). to this end, we introduced an exposure factor, called {beta} /{beta} , which allows us to describe the influence of factors such as social isolation on dispersal from disease. the results also corroborate a phenomenon observed in countries that registered a high growth in cases in short period of time, to example of italy, spain and usa: if isolation measures are imposed late, the total number of cases explodes when the epidemic is approaching from peak, which implies a higher exposure rate in the first days of case registration. the model also predicts that the peak epidemic outbreak in brazil, based on the number of cases, will occur around may , . since the outbreak of the disease covid- in the city of wu han, china, in just over two months the epidemic spread rapidly around the world, until that on march , , the world health organization (who) declared the covid- pandemic (zhang et al., ) . until april , the number of cases in the world had already exceeded million, with approximately . confirmed confirmed deaths. with the explosion in number of cases from covid- in brazil and worldwide, to understand how it happens the evolution of the number of cases is important to evaluate the measures taken until the moment were effective, as well to determine the next actions to be executed in order to prevent the collapse of the country's health system. in , w. o. kermack and a. g. mckendrick ( ) created a model that considers a fixed population with only three compartments: sensitive, s (t); infected, i (t), and removed, r (t) -sir (susceptible-infected-recovered) -for the first time, in order to study the evolution of epidemic processes and how the spread of infectious diseases over time . other models were created along the history, for example one developed by daniel bernoulli in to study the variola epidemic (herben, ) . the s.i.r model allows to project the evolution of an infectious disease in a population in agreement with their state transition rates and their initial conditions s( ), i( ) and r( ) and it gets, with reasonable precision, to describe quantitatively, for instance, the time interval from the first contagion until the number of infected people reaches the epidemic peak, important information that allows governments to develop actions to reduce the number of having infected or, at least, extend the time in that peak of infections will be reached (schimit, ; jo, ) . however, there are variants of the sir model that can be applied in situations in which another variables are important for description how the infection spreads in a population of s susceptible individuals, to example as was done in teles' work ( ) adapting the sir model to describe the behavior of the coronavirus infected curve in portugal. in this work, we propose a variation of the sir model, taking initially described by jo et al. work ( ) , to describe the projection of cases of covid- in a qualitative and quantitative way in brazil since the first day in wich cases were confirmed, february , , until april , . for this, we will use what here we will call sier model, susceptible-infect-exposed-recovered, that is, a model that also considers that there exposed individuals, represented by the e(t) function, which have a higher probability of infection than average populational. in the following sections, we will present the model and the method used to solve the differential equations originating from it; then we will present the results obtained, following by the final considerations. in this work a variant of the s. i. r. model -susceptible, infected and removed (recovered and/or died), with fixed number for the population (normalized, n= ), without taking into account the amount of births/deaths, but taken into account that, in the universe from susceptible individuals, s(t), there is a smaller number of individuals e(t), that are those susceptible, however more exposed to infection, to example of people that be not able to adhere the complete social isolation or professionals of health, that are in frontline from caring of those infected. the model takes into account that a s(t) -e(t) number of individuals can be infected at rate β and a e(t) number of individual can be infected a rate β >β , once the exposed individuals have larger probability to contract the virus and infect other individuals. the functions that represent the susceptible individuals, s(t), infected, i(t), exposed, e(t), and removed/recovered, r(t), are link with their respective rates of temporal variation from the system of differential equations (to a time t > ): . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . where γ is the average recovery rate ( /γ is the period during which the infection continues), and the functions s(t), i(t), e(t) and r(t) obeying the following conditions: is the effective contagion rate (with n = ). this model is appropriate for diseases that spread quickly and give immunity to survivors, to example as the flu (schimit, ), but can, without loss of generality, be used to describe the installation of agricultural pests or spread of computer virus. in most varied lattices topologies, for instance, since the propagation processes, of the disease or information, are very similar (hastings, ; pachi, ) . there are other models that take into account differences between the propagation mechanisms or even larger complexity in the individuals interaction, but they will not be treated in this work. the eqs. ( ) are of difficult analytical resolution, what takes to approaches or it looks for numeric treatment to arrive to the curves that represent s(t), i(t), e(t) and r(t). to this, a computational routine was developed for language octave with the intention of obtain the numeric solutions for that model and to apply it to study spread of covid- in brazil, without considering the differences of each place. octave is a software of free distribution, following the patterns of distribution of the general public license (gnu), with several functions for resolution systems of differential equations for instance (scherer, ) . here, we suppose that all individuals belonging to population have equal contracting / transmitting probability the disease in certain time interval (keeling, rohani, ; newmann, ) . the presented results will be analyzed according with the following premises: i) the number of cases is, at least, eleven times greater than that officially registered (walker et al., ) ; ii) the rate of contagion doesn't vary with time and is the same for all individuals; iii) the relationship among β and β parameters, specifically the ratio β / β , is the important coefficient for analysis from impacts of high exposure to virus and its consequences in which concerns the spread of infection by population; iv) the absence of politics of social isolation (high exposure from relatively large portion of population) implies more, in our analysis, a greater number of cases than a significant change at time when the epidemic curve reaches the peak maximum. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . fig. shows the behavior of the curves of infected and exposed individuals (that still didn't contract the disease) in function time, in agreement with the model proposed in this wo qualitative way, however there is slight dependence between the date which the peak of infection occurs and total percentage of infected (number of accumulated cases) at the peak of infection: the larger infected and if the total number of infected is greater (especially in the epidemic peak), the impact on health system is considerably greater (taking into account the same rate of contagion in two cases) . it`s observed that there is no significant difference in the number of cases at beginning from epidemic, independent of greater number or not from highly exposed susceptible individuals. this characteristic has been observed in several countries, especially in those where politics of social isolation were not initially imposed. in the beginning of the outbreak, governments that did not adopt isolation politics because, apparently, the epidemic outbreak had lost force, were eventually forced to adop once the cases number exploded after a short period of time, and this is exactly the behavior visualized in the epidemic curves shown in fig. . the graphs from figures and shows the epidemic curve for different scenarios, with slightly different β we have the variation in number of infected individuals (percentage of infected in the graph in fig. shows the behavior of the curves of infected and exposed individuals (that still didn't contract the disease) in function time, in agreement with the model proposed in this work. the curves show a typical epidemic pattern, in a qualitative way, however there is slight dependence between the date which the peak of infection occurs and total percentage of infected (number of accumulated cases) at the peak of infection: the larger contagion factor β /β , the larger the total number from infected and if the total number of infected is greater (especially in the epidemic peak), the impact on health system is considerably greater (taking into account the same rate of it`s observed that there is no significant difference in the number of cases at beginning from epidemic, independent of greater number or not from highly exposed susceptible individuals. this characteristic has been observed in several countries, especially in those where politics of social isolation were not initially imposed. in the beginning of the outbreak, governments that did not adopt isolation politics because, apparently, the epidemic outbreak had lost force, were eventually forced to adop once the cases number exploded after a short period of time, and this is exactly the behavior visualized in the epidemic curves shown in fig. . . curve showing the number (percentage) of infected and exposed individuals in time function to different values from exposure factor, β /β . the graphs from figures and shows the epidemic curve for different scenarios, with slightly different β /β ratios, as well as different contagions. in figure we have the variation in number of infected individuals (percentage of infected in the graph in fig. shows the behavior of the curves of infected and exposed individuals (that still didn't contract the disease) in function time, in agreement with the rk. the curves show a typical epidemic pattern, in a qualitative way, however there is slight dependence between the date which the peak of infection occurs and total percentage of infected (number of accumulated cases) at the , the larger the total number from infected and if the total number of infected is greater (especially in the epidemic peak), the impact on health system is considerably greater (taking into account the same rate of it`s observed that there is no significant difference in the number of cases at beginning from epidemic, independent of greater number or not from highly exposed susceptible individuals. this characteristic has been observed in several countries, especially in those where politics of social isolation were not initially imposed. in the beginning of the outbreak, governments that did not adopt isolation politics because, apparently, the epidemic outbreak had lost force, were eventually forced to adopt them, once the cases number exploded after a short period of time, and this is exactly the . curve showing the number (percentage) of infected and exposed individuals in time the graphs from figures and shows the epidemic curve for different ratios, as well as different contagions. in figure we have the variation in number of infected individuals (percentage of infected in . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . relation to the whole brazil population ( . . people more than sixty days as time fun figure . epidemic curves for several scenarios, with different contagion rates and exposure factors. using the hypothesis that there are eleven cases for each case officially notified in brazil (walker et al., ) . the curve that best fits the case number registered in the country between february and april , is to contagion factor equal to . . the graph shows, taking into account the contagion rate curve . , that the epidemic peak will be reached around may , . data available at: coronavírus brasil, https://covid.saude.gov.br/ the epidemic curve in fig. present a compatible pattern with infection models with exponential growth during the initial period, change in the concavity of curve that describes the number of infected, i(t), until reaching the peak, for a given percentage cases, and the decrease from accumulated amount from registered cases. interesting to observe that, using the hypothesis that there are eleven cases for each officially notified case in brazil (walker registered in the country between february and april , is that to contagion factor is equal to . . it`s also observed that one that more influences in the fast initial virus spread is the contagion rate, serving the exposure factor β differentiate the speed with which the epidemic will spread taking into account a same contagion rate. for instance, if the contagion rate is high, even with a low β exposure factor, the epidemic spreads quickly. the graph in fig. displ account the contagion rate curve . , that the epidemic peak will be reached around may , , but is important have caution about this data, once brazil is a country relation to the whole brazil population ( . . people -ibge, ) along little more than sixty days as time function. epidemic curves for several scenarios, with different contagion rates and exposure factors. using the hypothesis that there are eleven cases for each case officially notified in brazil (walker et al., ) . the curve that best fits the case ered in the country between february and april , is to contagion factor equal to . . the graph shows, taking into account the contagion rate curve . , that the epidemic peak will be reached around may , . data available https://covid.saude.gov.br/. the epidemic curve in fig. present a compatible pattern with infection models with exponential growth during the initial period, change in the concavity of curve that describes the number of infected, i(t), until reaching the peak, for a given percentage cases, and the decrease from accumulated amount from registered cases. interesting to observe that, using the hypothesis that there are eleven cases for each officially notified case in brazil (walker et al., ) , the curve that best fits the number registered in the country between february and april , is that to contagion factor is equal to . . it`s also observed that one that more influences in the fast initial virus spread is the contagion rate, serving the exposure factor β /β differentiate the speed with which the epidemic will spread taking into account a same contagion rate. for instance, if the contagion rate is high, even with a low β exposure factor, the epidemic spreads quickly. the graph in fig. displ account the contagion rate curve . , that the epidemic peak will be reached around may , , but is important have caution about this data, once brazil is a country ibge, ) along little epidemic curves for several scenarios, with different contagion rates and exposure factors. using the hypothesis that there are eleven cases for each case officially notified in brazil (walker et al., ) . the curve that best fits the case ered in the country between february and april , is to contagion factor equal to . . the graph shows, taking into account the contagion rate curve . , that the epidemic peak will be reached around may , . data available the epidemic curve in fig. present a compatible pattern with infection models with exponential growth during the initial period, change in the concavity of curve that describes the number of infected, i(t), until reaching the peak, for a given percentage of cases, and the decrease from accumulated amount from registered cases. interesting to observe that, using the hypothesis that there are eleven cases for each officially notified , ), the curve that best fits the number of cases registered in the country between february and april , is that to contagion factor is equal to . . it`s also observed that one that more influences in the fast initial /β as a way to differentiate the speed with which the epidemic will spread taking into account a same contagion rate. for instance, if the contagion rate is high, even with a low β /β exposure factor, the epidemic spreads quickly. the graph in fig. display, taking into account the contagion rate curve . , that the epidemic peak will be reached around may , , but is important have caution about this data, once brazil is a country . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . from continental dimensions, with important regional differences that each state will reach the peak in different dates. in fig. have the percentage data of infected people over thirty days, considering the first thirty days starting from the first case registered in brazil (february , , day ) until april , . can be observed in this graph that the number of cases (hypothesis of eleven for each registered case) in brazil increase with a contagion rate close in . in the first thirty days from epidemic outbreak, dropping to . after thirty days, indicating that measures of social isolation adopted in the country, even if partially, served to reduce the speed of spread from virus, even with different rates of beta exposure, which indicates that the ideal is to combine the rates of contagion and exposure this way we have a real picture how the epidemic is spreading. it`s evident that contagion isn`t fixed in time and depends strongly on isolation measures: in the beginning from pandemic, with many exposed individuals, the contagion is high and can remain so (or even increase) if no measure of social isolation is adopted , falling continuously with time, because a combination of isolation measures with factors such as climate and seasonal diseases. for instance, in winter, flu syndromes are more common, which ends up taking more people to hospitals (increased exposure rate). going to hospitals, these people are subject to contact with other individuals infected by coronavirus, fact that increases the contagion chance both for those have another type of comorbidity and for their companions from continental dimensions, with important regional differences that may indicate that each state will reach the peak in different dates. in fig. have the percentage data of infected people over thirty days, considering the first thirty days starting from the first case registered in brazil (february l april , . can be observed in this graph that the number of cases (hypothesis of eleven for each registered case) in brazil increase with a contagion rate close in . in the first thirty days from epidemic outbreak, dropping to . after s, indicating that measures of social isolation adopted in the country, even if partially, served to reduce the speed of spread from virus, even with different rates of beta exposure, which indicates that the ideal is to combine the rates of contagion and exposure this way we have a real picture how the epidemic is spreading. it`s evident that contagion isn`t fixed in time and depends strongly on isolation measures: in the beginning from pandemic, with many exposed individuals, the remain so (or even increase) if no measure of social isolation is adopted , falling continuously with time, because a combination of isolation measures with factors such as climate and seasonal diseases. for instance, in winter, flu e common, which ends up taking more people to hospitals (increased exposure rate). going to hospitals, these people are subject to contact with other individuals infected by coronavirus, fact that increases the contagion chance both for type of comorbidity and for their companions . curves with the percentage of infected (in relation to the total brazilian population) in an interval of days. may indicate that in fig. have the percentage data of infected people over thirty days, considering the first thirty days starting from the first case registered in brazil (february l april , . can be observed in this graph that the number of cases (hypothesis of eleven for each registered case) in brazil increase with a contagion rate close in . in the first thirty days from epidemic outbreak, dropping to . after s, indicating that measures of social isolation adopted in the country, even if partially, served to reduce the speed of spread from virus, even with different rates of beta exposure, which indicates that the ideal is to combine the rates of contagion and exposure this way we have a real picture how the epidemic is spreading. it`s evident that contagion isn`t fixed in time and depends strongly on isolation measures: in the beginning from pandemic, with many exposed individuals, the remain so (or even increase) if no measure of social isolation is adopted , falling continuously with time, because a combination of isolation measures with factors such as climate and seasonal diseases. for instance, in winter, flu-like e common, which ends up taking more people to hospitals (increased exposure rate). going to hospitals, these people are subject to contact with other individuals infected by coronavirus, fact that increases the contagion chance both for . curves with the percentage of infected (in relation to the total brazilian the real data from pandemic is very underreported, a rising carried out by open knowledge brasil ( ) , organization that act in the area of transparency and openness from public data, in evaluation that considered the content, format and level of detail from information published on the portals from state governments and federal government; brazilian states do not publish minimum data, in which % of the evaluated states, until april , , still did not publish enough data to accompany the spread from covid- pandemic across country, including the federal government. like this, any scenario drawn by mathematical systems based on government data can`t represent the real situation of the pandemic in brazil. in addition, until april , , more than thousand tests for covid- were still waiting for results, a number three times higher than the number of confirmed cases until that date. considering that the ministry of health from brazil recommends testing only severe cases, considering that tests are still lacking even for severe cases, added to fact that large part from population is asymptomatic for covid- , we noticed that the number of underreported cases in brazil it is extremely underestimated, which reinforces the hypothesis adopted here, based on the study by walker et al. ( ) eleven cases for each made registration. the analysis of the behavior from epidemic curves shown in the graph in fig. ensures the validity of one of our hypotheses, that the contagion rate in brazil is between . and . . if no measure of social distancing or decrease in exposure the contaminated was adopted, the contagion rate could be higher than . . is important to express that the curves modeled by the s.i.r. model not consider crucial factors that can lead to even worse panoramas, such as, for instance, the virus is already present in slums in brazil, where more than million people live, according to the locomotiva institute ( ). in these places, families live in just one room, being impossible to separate risk groups, such as senior, from people who need to go out to work and return home, increasing the risk of contamination. in many of these communities, there no are basic sanitation conditions are, impending simple processes such as hand hygiene frequently, as recommended by authorities. in summary, the model presented here describes with reasonable agreement the number of cases from covid- registered in brazil between february and april , with based on hypothesis that there a large number of underreported cases ( to ) and variation in the contagion rate of according to measures of social isolation and greater or lesser exposure to the virus (higher rate at the beginning of the epidemic). the results also corroborate with a phenomenon observed in countries that registered a high growth in cases in a short period of time, such as italy, spain and the usa: if isolation measures are imposed late, the total number of cases explodes in way epidemic is approaching from maximum peak, which implies a higher exposure rate in the first days of case registration. the model also predicts that the peak epidemic outbreak in brazil, based on the number of cases, will occur around may , . science . v . p. - . . . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . the mathematics of infectious diseases analysis of covid- spread in south korea using the sir model with time-dependent parameters and deep learning contributionstothemathematicaltheoryof epidemics spread of epidemic disease on networks modelo matemático para o estudo da propagação de informações por campanhas educativas e rumores modelagem e controle de propagação de epidemias usando autômatos celulares e teoria dos jogos métodos computacionais da física. ª ed. editora livraria da física predicting the evolution of sars-covid- in portugal using an adapted sir model previously used in south korea for the mers outbreak the global impact of covid- and strategies for mitigation and suppression the use ofanti-inflammatory drugs in the treatment of people with severe coronavirus disease (covid- ): the experience of clinical immunologists from china key: cord- -u m t authors: morrison, daniel r.; gentile, christopher; mccammon, susan; buczek, erin title: head and neck oncologic surgery in the covid‐ pandemic: our experience in a deep south tertiary care center date: - - journal: head neck doi: . /hed. sha: doc_id: cord_uid: u m t introduction: the ongoing worldwide pandemic due to covid‐ has forced drastic changes on the daily lives of the global population. this is most notable within the health care sector. the current paper outlines the response of the head and neck oncologic surgery (hns) division within our academic otolaryngology department in the state of alabama. methods: data with regard to case numbers and types were obtained during the pandemic and compared with time matched data. our overall approach to managing previously scheduled and new cases, personal protective equipment (ppe) utilization, outpatient clinic, and resident involvement is summarized. discussion: our hns division saw a % reduction in surgical volume during the peak of the covid‐ pandemic. we feel that an early and cohesive strategy to triaging surgical cases, ppe usage, and minimizing exposure of personnel is essential to providing care for hns patients during this pandemic. severe acute respiratory syndrome coronavirus (sars-cov- ), known colloquially as covid- , is a novel zoonotic infection that has caused a worldwide pandemic. in many parts of the world, the medical system has been severely stressed by the burden of this novel illness as the demand for medical care exceeds capacity. the illness is highly contagious and is spread through respiratory droplets. the highly contagious nature and relatively high mortality compared to other viral respiratory illnesses has made covid- a "perfect storm" for a pandemic. otolaryngologists are at high risk for transmission of covid- due to the high risk of contact with aerosolized nasal, pharyngeal, or tracheal secretions during many of our routine procedures. , the first reported physician death in wuhan was an otolaryngologist. as of april , there were confirmed covid- cases in the state of alabama ( overall tested) with reported deaths. of all patients tested, . % were positive. for comparison, the state of new york, the hardest hit state in the united states thus far, had total cases and deaths ( overall tested). . % of tests given in ny state have been positive. our institution is a large, tertiary care center situated in birmingham, al and receives patients from our entire state as well as portions of neighboring daniel r. morrison and christopher gentile are co-first authors. states (tn, ms, ga, fl). this is in contrast with ny, which has a much larger health care system, with multiple large hospital systems in the city of new york alone. our relatively low overall case numbers compared with other regions are due to a multitude of reasons, including our relatively low population density, low amount of travel in and out of the state, and testing limitations. at our institution (university of alabama-birmingham), the number of covid- + inpatients has not exceeded . we have had no documented positive covid- tests among faculty, residents, advanced practice providers (apps), or ancillary staff in our otolaryngology department. a focused timeline of events is shown in figure . there have been several recent publications focused on the response to covid- within the otolaryngology community. currently, the american academy of otolaryngology-head and neck surgery (aao-hns) has recommended delaying all nonemergent operations and postponing all nonessential face-to-face clinic encounters. consistent with this is the recommendation that all tier and procedures as defined by the centers for medicaid and medicare services (cms) should be deferred during the pandemic. , early data from the pandemic also showed that patients with cancer have significantly worse outcomes when infected with covid- . these data are to be interpreted with caution given possible regional differences in practice patterns with regard to resource utilization. with this context in mind, the current paper will retrospectively discuss the approach of the head and neck surgery (hns) division of our tertiary care center in birmingham, al with regard to surgical care, outpatient care, and academics. current covid- case numbers were reviewed nationally, statewide, and institutionally. surgical volume was analyzed within the affected timeframe and compared with the year prior. as noted in figure , hospital administration made the decision on march to move to a limited or model. therefore, we selected march as the starting point for our analysis and have analyzed up to april , . our approach to managing clinic outpatients is also reviewed as well as a brief overview of changes to resident involvement and inpatient management. throughout february and early march, our department and hospital administration were closely monitoring the covid- outbreak, however there were no changes to clinical operations. on march , one hns case was canceled due to blood shortages. uab administration decided on march to move to a limited operating room (or) model, where only six ors were to be opened daily, with two additional rooms open as needed for emergencies. our freestanding outpatient surgical center was reduced to three working ors with one available as needed for emergencies. at this point all elective cases were postponed indefinitely. for reference, our institution has total ors in our main hospital and ors at our outpatient center. the hns division began meeting virtually at this point to collectively triage cases. remote conferences with this goal were held twice weekly during the limited or model period. cases were organized first into elective vs nonelective cases. patients requiring nonelective surgery were defined as having a surgical disease process that will irreversibly worsen in a way that affects survival or extent of surgical intervention if surgical intervention were delayed. elective cases were postponed indefinitely to be reassessed by each individual surgeon when conditions allow. among the nonelective cases, three categories were described and are as follows: cases which should be done within weeks, cases that should be done within to weeks, and cases that are nonelective but can wait > weeks. these definitions were based on the likelihood of significant morbidity or mortality occurring within the defined time periods. for example, patients with significant airway concerns such as advanced laryngeal cancers and airway stenosis were placed in the week category, while most thyroid malignancies were placed in the > week category ( figure ). perioperative leadership including chairs of the surgical departments met to outline an appropriate triage strategy for operative cases. per these institutional guidelines, each case scheduled required department chairman approval and was subject to review by the chief of surgical services. this model remains in place. our division now has a secure online calendar showing all hns cases which is accessible by all faculty. this was used to streamline the chairman approval process. figure represents our case numbers during the time period under investigation. of the utmost importance in triaging and completing these cases was a collective willingness in our division to cover cases for other surgeons in the case of mandated quarantines. particularly early in uab's response to the pandemic, pre-op testing was not available. during this time, we recognized there were approximately to patients that we considered urgent but also very high risk (endoscopic airway for stenosis, laryngeal carcinomas with airway compromise, etc). we decided collectively that we would not perform these urgent but high risk cases without pre-opcovid testing or if not made available we would utilize all necessary ppe (see below) to perform these cases. we met with anesthesia and operating room leadership to discuss the specific logistics of doing these cases. this decisive action led to early pre-op testing for our high risk patient population and likely saved the use of needed ppe. availability of covid- testing nationwide has been a major issue during this pandemic. initially, we were not able to preoperatively test our surgical patients. during this time, we were avoiding any procedure that risked exposure to aerosolized procedures such as tracheotomy and oral cavity cases. on march , our first preoperative covid- tests were performed for planned operations on outpatients. initially, we had only the capacity for covid- tests per day. therefore, anesthesia staff selected the cases with highest risk exposures for preoperative testing. these patients were tested within hours of their planned surgery. by april , we had increased our testing capacity and all surgical patients were tested once preoperatively within hours of their surgery. all testing was rt-pcr via nasopharyngeal swab. at the current time, our institution is not using serologic testing to direct management. personal protective equipment (ppe) is paramount in protecting the surgeon as well as the patients and limiting disease spread. as the crisis progressed, we began concerted efforts to conserve essential ppe, most notably n respirators, gowns, gloves, and face shields. although the data are conflicting regarding efficacy, n respirators are recommended for health care providers dealing with patients with unknown covid- status during aerosol generating procedures. , per recommendations from the stanford group, we used tiered ppe depending on the case type. extreme airborne precautions (papr in addition to surgical gowns/gloves) were used for covid positive cases and were considered high risk of transmission (upper aerodigestive tract, sinonasal cases, mastoidectomy). enhanced airborne precautions (n respirator, eye protection, surgical gown/gloves) were used in covid negative cases with high risk of transmission, any emergent case with unknown covid status, urgent cases with covid status unknown, positive symptoms or high risk cases. standard ppe was used in low risk of transmission covid negative cases and covid unknown, asymptomatic patients undergoing urgent but low risk of transmission procedures. these guidelines are comparable to precautions outlined by other institutions. - additionally, we have been extending the use of n respirators in accordance with the cdc's recommendations and prior data. , our institution has been reprocessing n respirators for repeated use using a combination of uv light radiation and vaporized hydrogen peroxide. [ ] [ ] [ ] notably, once the decision was made to operate we did not alter our surgical approach for cases. some data f i g u r e stratification of surgical case urgency with representative examples have shown a reduction or complete cessation in free flap surgeries during the pandemic at other institutions. free tissue transfer and tracheostomies were still performed when indicated. we continued holding weekly multidisciplinary tumor board (mdtb), albeit this was done remotely via videoconferencing. the multidisciplinary hns clinic includes eight specialists and five apps and typically sees approximately new cancer cases every year. beginning march th, a widespread clinic freeze was instituted by the department. clinicians were asked to review their schedules for the next several weeks in order to identify patients on a case-by-case basis that could not be postponed. patients were contacted individually by phone to reschedule although clinics were still open from an institutional standpoint. until march th, clinics were continued on a limited basis to head and neck patients with an urgent need; new confirmed cancer diagnoses, post-op care, or patients with worsening symptoms due to their disease process/malignancy. beginning march th, all hns clinics were consolidated to initially one clinic, day per week. due to volume, a second clinic day was added beginning april sixth. with the removal of dedicated clinic and or block time, clinicians were able to remain flexible when covering the clinic days to allow for back up in the event of clinician exposure. our department was fortunate to not have any confirmed cases of covid- among the health care team, however one attending was symptomatic and subsequentially self-quarantined although ultimately tested negative. this clinician was able to continue to participate in telemedicine from quarantine. additionally, our department instituted a proactive and aggressive plan to pursue telemedicine for suitable patients to maintain continuity of care. it was left to the discretion of providers to determine patient's that would require in-person visits. as mentioned earlier, patients with a new cancer diagnosis, with recent surgery requiring wound checks or drain removals, or patients symptomatic with malignancy related symptoms were prioritized for in-person clinic visits. when clinically appropriate, imaging was substituted for a physical exam to limit physical contact. while telemedicine certainly has its limitations, it also has notable advantages that merit discussion. immunocompromised and medically infirm patients are able to stay at home and not risk exposure. there is more time for discussions regarding diagnoses, goals of care, and so forth as well as a possibility of more frequent follow-up. we anticipate that our practice patterns in the future will be adjusted to include more telemedicine as a result of this pandemic. there continue to be limitations to this model. telemedicine visits require patient access to an internet network or a "smartphone," limiting its use in some more isolated patient populations. limiting the use of flexible scope exams in clinic and relying more heavily on imaging will likely have unforeseen consequences with regard to cancer surveillance, although this has yet to be seen and more data necessary to draw conclusions. outside of the clinic and or setting, our department made several changes in the residency structure that will be detailed briefly. institutionally, residents were not allowed to take care of covid- positive patients or patients under investigation (puis). from a surgical standpoint, only one resident was allowed in a case at a time to conserve ppe. beginning on march , the residency program was platooned into two groups, which alternated weekly shifts. the team that was not actively deployed at the hospital was responsible for continuing didactics and to remain on reserve in the event residents needed to be quarantined or became ill. during this time, the head and neck service accounted for two fellows, a senior level resident, and three junior level residents. operative cases were performed with the least amount of personnel in the room, with the most experienced members performing the cases. junior level residents (pgy - ) were generally not involved in operative cases during this time period unless needed. many cases were done only by attending surgeons or by fellows. when junior residents were involved it was for assistant purposes only in order to maximize efficiency. in attempts to minimize exposures, inpatient rounds were still performed by the resident teams with fellow assistance. only senior residents examined inpatients and wore appropriate ppe depending on covid status. if a patient had unknown status, a gown, gloves, and n respirator were worn. covid+ patients were only seen in person by attending physicians wearing appropriate ppe (n , gown, gloves, face shield). by order of the alabama governor, inpatient guest visitation was extremely limited. this hindered family education of trach care, wound care, use of nasogastric or gastrostomy tube, among other routine postoperative care. residents were tasked with telephone updates following rounds. we anecdotally suspect this led to slightly longer inpatient stays due to the decreased hands-on training of family members. hns patients are particularly reliant on family assistance after discharge. we did have some patients cancel their surgeries initially due to these restrictions. we ultimately were able to have family members receive in-person teaching toward the end of the hospital stay. a "compassionate" exception was made for patient with dementia or other factors requiring close caregiver participation (this was allowed with two patients). another unforeseen circumstance of the visitation restrictions was the occasional cancelation of urgent cases by patients. in addition, patients were not routinely screened postoperatively for covid- unless they began to develop symptoms. while there are many factors involved, the overall low population density, early mitigation in alabama's largest urban area (birmingham), and limitations in testing have contributed to lower covid- case numbers. due to the trajectory and distribution of new covid- cases, our department has been able to implement strategies used in other states and countries. , , , [ ] [ ] [ ] [ ] the authors would direct you to patel et al for a recent description of hns practice patterns nationwide during the pandemic. since the beginning of the pandemic, the maximum number of covid- patients at our institution has not exceeded and therefore, our institution has not yet experienced ventilator or ppe shortages suffered by other health care centers. we feel that thus far our division has been able to effectively triage hns patients and complete their oncologic surgeries safely, while simultaneously reducing nonurgent surgeries. we reduced our surgical volume by % during the critical time period and this was predominantly by postponing elective, outpatient surgeries. of note, we feel strongly that a team-based approach toward completing surgical cases is of the utmost importance in this situation. this requires interprovider consistency with regard to management strategies, a high level of communication, and an understanding between the patient and provider that another surgeon may be involved or primarily responsible for their care. a foundation of trust between the patient and provider is elemental in the success of this model. we would advocate a high level of detail with regard to documentation and completion of the surgical consent with these principles in mind. an early and constantly evolving response to the covid- crisis remains critical to avoid an overwhelming surge on our medical system. at this time, ors both at our institution and around the country are beginning to reopen to clear the logjam of semiurgent and elective cases. we feel the keys to safely moving forward with increased head and neck surgical volume is with widespread, reliable preoperative covid testing, adequate ppe and a clear mechanism to triage cases according to urgency and safety via a teambased approach. while our experience may not be reproducible for smaller community hospitals or tertiary centers located in more urban settings, they do serve to highlight the response and experience of a high-volume head and neck cancer tertiary center situated in the deep south. the authors declare no potential conflict of interests. clinical features of patients infected with novel coronavirus in wuhan medicine jhuo. covid- dashboard by the center for systems science and engineering coronavirus disease (covid- ): emerging and future challenges for dental and oral medicine sars-cov- viral load in upper respiratory specimens of infected patients practical aspects of otolaryngologic clinical services during the novel coronavirus epidemic: an experience in hong kong alabama's covid- data and surveillance dashboard nysdoh covid- tracker; . https:// covid tracker.health.ny.gov/views/nys-covid -tracker/ nysdohcovid- tracker-map?% aembed=yes&% atoolbar=no&% atabs=n new recommendations regarding urgent and nonurgent patient care impact of coronavirus (covid- ) on otolaryngologic surgery: brief commentary non-emergent, elective medical services, and treatment recommendations cancer patients in sars-cov- infection: a nationwide analysis in china effectiveness of n respirators vs surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis effectiveness of n respirators vs surgical masks against influenza: a systematic review and meta-analysis covid- and the otolaryngologist: preliminary evidence-based review head and neck oncology during the covid- pandemic: reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks corona-steps for tracheotomy in covid- patients: a staff-safe method for airway management approaches to the management of patients in oral and maxillofacial surgery during covid- pandemic impact of multiple consecutive donnings on filtering facepiece respirator fit strategies for optimizing the supply of n respirators ultraviolet germicidal irradiation of influenzacontaminated n filtering facepiece respirators reuse of n masks. engineering (beijing) decontamination and reuse of n respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sars-cov- (covid- ) pandemic early institutional head and neck oncologic and microvascular surgery practice patterns across the united states during the sars-cov- (covid ) pandemic. head neck cases of coronavirus disease (covid- ) in the u.s; census: population density data safety recommendations for evaluation and surgery of the head and neck during the covid- pandemic cancer surgery and covid surgical management of head and neck tumours during the sars-cov (covid- ) pandemic brief guideline for the prevention of covid- infection in head and neck and otolaryngology surgeons key: cord- -ubm j xe authors: wang, pengfei; chen, kaiyu; zhu, shengqiang; wang, peng; zhang, hongliang title: severe air pollution events not avoided by reduced anthropogenic activities during covid- outbreak date: - - journal: resources, conservation and recycling doi: . /j.resconrec. . sha: doc_id: cord_uid: ubm j xe abstract due to the pandemic of coronavirus disease in china, almost all avoidable activities in china are prohibited since wuhan announced lockdown on january , . with reduced activities, severe air pollution events still occurred in the north china plain, causing discussions regarding why severe air pollution was not avoided. the community multi-scale air quality model was applied during january to february , to study pm . changes under emission reduction scenarios. the estimated emission reduction case (case ) better reproduced pm . . compared with the case without emission change (case ), case predicted that pm . concentrations decreased by up to % with absolute decreases of . , . , . , . , . , . , . , . , . and . μg/m in guangzhou, shanghai, beijing, shijiazhuang, tianjin, jinan, taiyuan, xi'an, zhengzhou, wuhan, respectively. in high-pollution days with pm . greater than μg/m , the reductions of pm . in case were . , . , . , . , . , . , . , . and . μg/m in shanghai, jinan, shijiazhuang, beijing, taiyuan, xi'an, tianjin, zhengzhou and wuhan, respectively. the reductions in emissions of pm . precursors were ~ times of that in concentrations, indicating that meteorology was unfavorable during simulation episode. a further analysis shows that benefits of emission reductions were overwhelmed by adverse meteorology and severe air pollution events were not avoided. this study highlights that large emissions reduction in transportation and slight reduction in industrial would not help avoid severe air pollution in china, especially when meteorology is unfavorable. more efforts should be made to completely avoid severe air pollution. along with the substantial development in the past decades, china is suffering severe air pollution, causing significant economic loss and health outcomes (han et al., a; huang et al., ; cheng et al., ; chai et al., ; zhao et al., ; chen et al., ; cao et al., ; richter et al., ; zhang et al., b) . with the expectation of controlling air pollution problem, the chinese government released and implemented the air pollution prevention and control action plan (the "action plan") in september (china, b) . from the plan, the concentrations of fine particulate matter (pm . ) in beijing-tianjin-hebei (bth), yangtze river delta (yrd) and pearl river delta (prd) area shall decrease by %, % and % by the end of compared with , respectively. to fulfill this goal, tremendous effects have been made such as strengthen industrial and vehicle emission standards, closing small and polluting factories, and upgrades on industrial boilers, and air quality has been largely improved ma et al., ; china a) . the severe particulate pollution days were decreased from and in to and in within bth and yrd areas . meteorology plays significant roles in air pollution formation, transport, deposition and transformation and unfavorable meteorological condition could bring severe pollution days even the total emission is reduced (shi et al., ; xu et al., ; li et al., c; cai et al., ; gui et al., ; wang et al., b) . in the pollution period of december - , in bth region, about % increasing of pm . are believed due to adverse meteorological condition (ma et al., ) . wu et al. ( ) found a high relative humidity (rh) decreased planetary boundary layer (pbl) height restrained the air pollutant dispersion and increased rh accelerated the transformation of secondary pollutants. meteorological condition in winter are more unfavorable to pollutant dilution and dispersion than other three seasons . compared with december , the pm . concentration increased by % in bth region. liu et al. ( ) attributed the increase to unfavorable meteorology of pbl, rh and wind. can severe air pollution events be avoided by controlling anthropogenic emissions? the answer is true. china has succeeded in various emission reduction campaigns such as during the asia-pacific economic cooperation (apec) meeting and the china victory day parade wang et al., ; xue et al., ; li et al., ) . in order to reduce anthropogenic emission, factories, industrial plants, construction sites, and gas stations was temporarily closed in and around beijing, vehicles were kept off the roads, and -days mandatory holidays were brought to state-owned enterprises, local government offices and educational institutions (sun et al., ; wang et al., ; li et al., d; huang et al., ) . "apec blue" and "parade blue" are referred to the good air quality during the time afterward. the daily pm . concentrations in beijing were . µg/m during "apec blue" and . µg/m during "parade blue" (lin et al., ) . coronavirus disease (covid- ) is an infectious disease initially identified in wuhan, china in december . covid- has led to deaths by february , worldwide (who, ). due to the contagion of covid- , the unofficial transit going in and out of wuhan was shut down on january , and in the whole hubei province a couple of days after. the spring festival holiday started on january , and was extended to after february nationwide because of the disease. most transportation was prohibited and almost all avoidable outdoor human activities stopped all around the country. however, severe air pollution episodes still occurred in the north china plain (ncp). it is of great concern for people who are limited to use mobile vehicles on heavy pollution days why severe air pollution events were not avoided when no one was on road. thus, this study used the community multi-scale air quality (cmaq) model to assess emission and meteorology conditions for air pollution during the outbreak of covid- . different emission cases were simulated to see why the severe air pollution was not avoided. the cmaq v . . model was applied to simulate air pollution in china with a horizontal resolution of km × km during january to february , (fig. ) . the model has been updated to better predict air pollutants in china and details can be found in hu et al. ( ) . the meteorological inputs were generated using wrf v . . with initial and boundary conditions from the national center for environmental prediction (ncep) fnl operational model global tropospheric analyses dataset (zhang et al., a; ncep, ) . multi-resolution emission inventory for china of (meic) (http:// www.meicmodel.org) was used for the monthly anthropogenic emissions from china. emissions from other countries were obtained from mix asian emission inventory (li et al., b) . the model of emissions of gases and aerosols from nature (megan) v . was used for generating biogenic emissions (guenther et al., ) . the emissions from biomass burning were based on the fire inventory from the national center for atmospheric research (ncar) (finn) (wiedinmyer et al., ) . in order to investigate the effect of reduced anthropogenic activities on air pollution, three simulation scenarios were performed and compared (table ) the case , case had a decrease of % and % in transportation and industry emission, respectively. emission from residential was lifted by % and emissions from agriculture and power remain unchanged. in case , transportation, industry and agriculture emission in hubei province are decreased by % while residential and power emission is kept the same with the case . for areas out of hubei province, % of transportation emission and % of industry emission are cut while all the rest are kept still. since there is no official emission inventory released, emission changes suggested by the chinese research academy of environmental sciences are being used to set emission reduction scenarios (craes ). an interview of professor kebin he from tsinghua university refers to the high-pollution in bth regions in february by china central television (cctv) was also considered (cctv, ). many people came back for the spring festival and were trapped due to covid- epidemic, the residential emission from cooking and heating was asummed to increase in rural areas including hebei, henan and shandong. the notices released from goverment were the basis for emission reduction in hubei province (hubei, f, e, d (hubei, f, e, , c (hubei, f, e, , b . the governme announced that from am in january , , buses, subways, ferries, and long-distance passenger transportation in wuhan were temporarily suspended, and outbound of railway and air planes were closed (hubei, p. s. g. o. g) . all the enterprises are remaining closed no earlier than february except required for public service operation, epidemic prevention and control, and residential life needs (hubei, p. s. g. o. a). the agriculture production was highly affected because there was nowhere to buy seeds and fertilizer (daily, ) . hourly pm . observations at monitoring sites nationwide were downloaded from the publishing website of the china national environmental monitoring center (http://www.mee.gov.cn/hjzl/dqhj/ ). the data were validated, and sanity check was conducted as previous studies (hu et al., ; wang et al., ) . meteorological observations were obtained from national climate data center (ncdc), including precipitation, ws and wind direction (wd) at m, as well as air temperature (t ) and rh at m above the ground level. to better understand the role of emissions changes and meteorological conditions, a rough method is proposed with similar idea of a previous study (wang et al., b; liu et al., ; wei et al. ; li et al., ) . the changes due to emission changes are calculated by subtracting the concentrations in case from that in case , while the changes due to meteorology are calculated using concentrations in high-pollution days minus concentrations in low-pollution days, assuming that meteorology is the reason for severe pollution as the emissions are not changing day by day. it should be note that this is a rough estimate without considering the feedbacks of aerosols on meteorology. the performance of meteorology simulation by wrf for the simulation period is validated including t , ws, and wd at m and rh, as statistic results are shown in table s . the benchmarks are suggested by emery et al. ( ) . wrf has slightly underpredicted t with mb of − . . both t and wd went beyond the ge benchmark by % to %. the ge of ws is within the benchmark, and high rmse of . indicated oscillations among prediction results. wd prediction results were acceptable with mb of . while rh was slightly under-predicted. it should be declared that out of the benchmark does not mean failure of the prediction as the benchmark value is constructed on the mm simulations for the eastern united states with finer grid resolutions ( km and km). the wrf model predictions are normally reliable since the model performance statistics are like other wrf studies applied over china (zhang et tables s and s show the model performance statistics of pm . from the two emission reduction cases. mean observations, mean predictions, mean fractional bias (mfb), mean fractional error (mfe), mean normalized bias (mnb) and mean normalized error (mne) were calculated for each city from january to february , . pm . is well predicted in all cities in both cases except wuhan in case with mfb exceeding the criteria suggested by epa (epa ). as activities in hubei were much more strictly limited, case is a better estimation and is used in following discussion. fig. shows the predicted and observed daily pm . and its components in major cities based in case . compared with observation results, the model presented great performance. in wuhan, the model captured the changes of pm . except for few overpredicted days. in all the other cities, the model successfully predicted peak and valley values not only in the most polluted cities like xi'an, zhengzhou but in relatively less polluted cities such as shanghai and guangzhou. the model also succeeded in reproducing the significant decrease of pm . that occurred from january to february in all cities. the changes of predicted pm . and its major components between two emission reduction cases (case and case ) and case are shown in fig. . the total pm . is decreasing mainly in south china in both cases (case and case ), while an increasing (up to µg/m ) is observed in northeast china in case as residential activities were increased possible due to more people were staying at home. more significant pm . decrease (averaged - %) is observed in case in central china, while for case the averaged decreased rate is less than %. among all the components, no shares the largest reduction since transportation is the key factor in both emission reduction cases. except ec and poa, all the species were decreasing in case . a % increase in ec is shown in northeast and southwest china (fig. s ) . poa increases by % on average in large areas of china with peak values in northeast, henan, hebei and the sichuan basin as residential emissions were increased. all the country experiences reduction of pm . by ~ % due to the significant emission reductions in case . most significant decreases of pm . and its components ( - %) of so , no , nh , and soa are observed in hubei (fig. s ). based on the emission scenario, the falling of so concentration mostly results from the emission reduction of industry release. the decrease of no is likely due to the reduction of transportation and the drop of agriculture emission explains the nh decrease. the amount of soa was fell because of the lack of precursors due to the emissions reduction of all three. overall, the emission reductions due to covid- did result in reductions of pm . by - % nationwide. fig. shows the averaged predicted and observed pm . concentrations with components in major cities of these three wang, et al. resources, conservation & recycling ( ) scenarios from january to february , . the positive effect of emission reduction on decreasing pm . concentrations can be clearly observed. at least μg/m (guangzhou) decrease was found in each city while wuhan had the largest decrease up to . μg/m . compared with the case , the decreases of pm . in case in beijing, tianjin, shijiazhuang, jinan, taiyuan, zhengzhou, xi'an, and shanghai were . , . , . , . , . , . , . , and . μg/m , respectively. fig. shows the predicted and observed pm . during the high-pollution days and low-pollution days in theses cities (separated based on the standard of the second level of chinese naaqs, μg/m of observation values). the pm . reductions in high-pollution days in case were . , . , . , . , . , . , . , . , and . μg/m in beijing, wuhan, tianjin, shijiazhuang, shanghai, taiyuan, zhengzhou, xi'an, and jinan. all the changes were larger than % compared with pm . concentrations in case and the largest decrease of . % was found in wuhan. during low-pollution days, the reductions were . , . , . , . , . , . , . , . , fig. . predicted daily pm . and its components with observed daily pm . in major cities in case . units are µg/m³. p. wang, et al. resources, conservation & recycling ( ) and . μg/m in above cities with the same consequence, separately. with a . % decrease in low-pollution days, wuhan ranked first. tianjin and shijiazhuang had the decreases of . % and . %, separately. the reduction percentage in all other cities were larger than %. basically, secondary components of soa, so and no contributed the most both in high and low-pollution days. this indicates that the role of chemistry and meteorological condition in secondary pollutants formation should not be neglected. fig. . predicted pm . and its major components and the changes between cases in unit of µg/m³ during january to february , . so is sulfate, no is a nitrate, nh is ammonium, ec is elemental carbon, poa is primary organic aerosol, soa is secondary organic aerosol and other is the sum of inexplicit components. p. wang, et al. resources, conservation & recycling ( ) as we can see from above results that the concentrations of pm . did reduce within the emission reductions cases. but it is important to know how efficient it was. fig. shows decreasing ratios of predicted pm . , ec, oc, so , no , and soa concentrations by case and the emission rates of related precursors in beijing, wuhan, guangzhou and shanghai during the simulation period. all species decreased as the emissions were reduced in a monotonic but non-linear way. this is consistent with the nonlinearity of atmospheric processes as confirmed by previous studies (cai et al., ; zhao et al., ; han et al., b; wang et al., ) . in beijing, emissions of primary pm . , ec and oc were decreased by %, % and %, while the concentrations of them were decreased by %, % and %. so , nox, and vocs emissions were decreased by %, %, and % while concentrations of so , no , and soa were decreased all by less than %. similar cases are observed in other cities. for wuhan and guangzhou, the reductions in concentrations were about half of the decreases in emissions. while for shanghai, the emission reduction ratios were only slightly higher than the concentration reduction ratios. although nonlinear chemical processes are noneligible in this situation, effects of meteorology should not be neglected. through the emission reduction process, the decreases in pollutant concentrations were observed. the ratios of pm . and precursors reductions in emission are larger than the reductions in pm . and its components in four selected cities. this indicates that meteorological conditions were favorable for pollution formation. fig. s showed the time series of meteorological parameters in beijing and guangzhou from january to february , . there was seldom wet deposition of pm in guangzhou and beijing due to the rare of rains during the simulation period. the low pbl increased atmospheric stability, the low wind speed made it worse for difficult dispersion of air pollutants liu et al., ) . high rh and temperature usually accelerate secondary pm formation by speeding up chemical reactions wang et al., a; rahman et al., ) . thus, it is very important to quantify the contribution of meteorological conditions when deciding controlling efficiency. the contributions of emission reduction and meteorological conditions are estimated and shown in fig. . emission reductions led to the reductions of pollutants in all cities with the largest in wuhan (− . μg/m ) and the lowest in shanghai (− . μg/m ) and jinan (− . μg/m ). all other cities experienced a > μg/m contributions, with the exactly values of − . , − . , − . , − . , − . , and − . μg/m in beijing, tianjin, shijiazhuang, taiyuan, zhengzhou, and xi'an, separately. in contrary, unfavorable meteorology resulted in increases of pm . , with the largest value of . μg/m in tianjin. for wuhan and jinan, unfavorable meteorology had less effect compared with emission changes. in xi'an, the unfavorable meteorology brought . μg/m increase of pm . , which almost fully counteracts the contribution of emission reductions. in all other cities, the increases caused by meteorological conditions timely overstepped the positive influences from emission reductions. fig. . predicted daily pm . with components and observed pm . in major cities of three scenarios during january to february , . units are µg/m³. p. wang, et al. resources, conservation & recycling ( ) fig. . averaged predicted daily pm . with components and observed pm . in major cities of three scenarios on high-pollution days (> µg/m³, left column) and low-pollution days (right column). the number of days in high (h) and low (l) pollution days are marked after the city names. units are µg/m³. fig. . relative changes in concentrations of primary pm . (ppm) and secondary components, and in emissions of related precursors in case to case in four cities. p. wang, et al. resources, conservation & recycling ( ) in this study, the influences of emission reductions due to reduced anthropogenic activities during the covid- outbreak in china on air pollution were investigated. it is concluded that anthropogenic emission decreases, mainly on transportation and industry, contributed to the decreases of pm . concentrations. the decreases of pm . in beijing, shanghai, guangzhou, and wuhan were . , . , . , and . μg/m , respectively. however, this is not enough to avoid severe air pollution events in most areas. the reduction ratios of pm . concentrations were smaller than the reduction ratios of precursor emissions, partially due to the unfavorable meteorological conditions. this study highlights the importance of understanding the role of chemistry and meteorology in designing emission control strategies. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. fig. . estimated contributions of meteorology and anthropogenic emissions changes to averaged pm . concentrations in selected cities during january to february , . units are µg/ m³. guangzhou is not included as it had no high-pollution days during the episode. p. wang, et al. resources, conservation & recycling ( ) the impact of the "air pollution prevention and control action plan" on pm . concentrations in jing-jin-ji region during - weather condition dominates regional pm . pollutions in the eastern coastal provinces of china during winter association between long-term exposure to outdoor air pollution and mortality in china: a cohort study experts interpretation: the recent heavy pollution in beijing-tianjin-hebei and surrounding areas are due to emissions and low environmental capacity spatial and temporal variation of particulate matter and gaseous pollutants in cities in china unit-based emission inventory and uncertainty assessment of coal-fired power plants long-term exposure to urban air pollution and lung cancer mortality: a -year cohort study in northern china longterm trend of haze pollution and impact of particulate matter in the yangtze river delta notice of the general office of the state council on issuing the air pollution prevention and control action plan this is a tough battle and a protracted battle-understanding the causes of pollution during the spring festival spring farming is busy at villages without epidemic guidance on the use of models and other analyses for demonstrating attainment of air quality goals for ozone, pm . , and regional haze emission inventory of primary pollutants and chemical speciation in for the yangtze river delta region, china the model of emissions of gases and aerosols from nature version . (megan . ): an extended and updated framework for modeling biogenic emissions satellite-derived pm . concentration trends over eastern china from to : relationships to emissions and meteorological parameters spatial and temporal variation of haze in china from to assessment of the impact of emissions reductions on air quality over north china plain one-year simulation of ozone and particulate matter in china using wrf/cmaq modeling system characterizing multi-pollutant air pollution in china: comparison of three air quality indices the "apec blue" phenomenon: regional emission control effects observed from space typical types and formation mechanisms of haze in an eastern asia megacity notices of wuhan coronavirus prevention and control headquarters notices of wuhan coronavirus prevention and control headquarters notices of wuhan coronavirus prevention and control headquarters notices of wuhan coronavirus prevention and control headquarters notices of wuhan coronavirus prevention and control headquarters notices of wuhan coronavirus prevention and control headquarters notices of wuhan traffic emergency control the "parade blue": effects of shortterm emission control on aerosol chemistry severe particulate pollution days in china during - and the associated typical weather patterns in beijing-tianjin-hebei and the yangtze river delta regions characteristics and source apportionment of pm . during persistent extreme haze events in chengdu, southwest china mix: a mosaic asian anthropogenic emission inventory under the international collaboration framework of the mics-asia and htap characteristics and formation mechanism of regional haze episodes in the pearl river delta of china temporal and spatial analyses of particulate matter (pm and pm . ) and its relationship with meteorological parameters over an urban city in northeast china the "apec blue" endeavor: causal effects of air pollution regulation on air quality in china source contributions of urban pm . in the beijing-tianjin-hebei region: changes between and and relative impacts of emissions and meteorology mortality benefits of vigorous air quality improvement interventions during the periods of apec blue and parade blue in beijing attributions of meteorological and emission factors to the winter severe haze pollution episodes in china's jing-jin-ji area assessment of meteorological impact and emergency plan for a heavy haze pollution episode in a core city of the north china plain air pollution characteristics and their relationship with emissions and meteorology in the yangtze river delta region during - national centers for environmental prediction/national weather service/ noaa/us department of commerce. , updated daily. ncep fnl operational model global tropospheric analyses, continuing from local and regional contributions to fine particulate matter in the cities of sichuan basin, southwestern china influence of atmospheric pm . , pm , o , co, no , so , and meteorological factors on the concentration of airborne pollen in guangzhou, china increase in tropospheric nitrogen dioxide over china observed from space meteorological conditions conducive to pm . pollution in winter / in the western yangtze river delta apec blue": secondary aerosol reductions from emission controls in beijing characteristics and emission-reduction measures evaluation of pm . during the two major events: apec and parade the impacts of the meteorology features on pm . levels during a severe haze episode in central-east china apec blue"-the effects and implications of joint pollution prevention and control program analysis of a severe prolonged regional haze episode in the yangtze river delta responses of pm . and o concentrations to changes of meteorology and emissions in china impact assessment of ammonia emissions on inorganic aerosols in east china using response surface modeling technique spatial and temporal variations of six criteria air pollutants in provincial capital cities in china during trends of surface pm . over beijing-tianjin-hebei in - and their causes: emission controls vs. meteorological conditions who. . coronavirus disease (covid- ): situation report the fire inventory from ncar (finn): a high resolution global model to estimate the emissions from open burning aqueous-phase reactions occurred in the pm . cumulative explosive growth during the heavy pollution episode (hpe) in beijing wintertime the meteorological modulation on pm . interannual oscillation during air quality improvement in a megacity beijing parade blue pollution control actions aerosol composition, oxidation properties, and sources in beijing: results from the asia-pacific economic cooperation summit study multi-dimension apportionment of clean air "parade blue" phenomenon in beijing spatiotemporal variations of air pollutants in western china and their relationship to meteorological factors and emission sources source apportionment of pm . nitrate and sulfate in china using a source-oriented chemical transport model cleaning china's air drivers of improved pm . air quality in china from a modeling study of the nonlinear response of fine particles to air pollutant emissions in the beijing-tianjin-hebei region analysis of a winter regional haze event and its formation mechanism in the north china plain quantifying the uncertainties of a bottom-up emission inventory of anthropogenic atmospheric pollutants in china a highly resolved temporal and spatial air pollutant emission inventory for the pearl river delta region, china and its uncertainty assessment portions of this research were conducted with high performance computing resources provided by louisiana state university (http:// www.hpc.lsu.edu). supplementary material associated with this article can be found, in the online version, at doi: . /j.resconrec. . . key: cord- -rw vmlno authors: wiwanitkit, viroj title: the usefulness of case reports in managing emerging infectious disease date: - - journal: j med case reports doi: . / - - - sha: doc_id: cord_uid: rw vmlno emerging infectious diseases are an important problem in medicine. case reports usually document episodes in the early emerging phase or in a small outbreak. although the case report is considered weak evidence in medical literature, it is usually the first report when there is a new emerging infectious disease. there is no doubt that case reports can provide useful information for further case series, reviews and studies. this editorial focuses on the usefulness of the case report on emerging infectious disease to the medical society. publication in this area is highly welcomed by the journal and can serve as a future point of reference. the case report is a specific kind of publication in the medical literature. this specific kind of article is seldom seen in other non-medical literature. the case report is usually a short article describing "an interesting case" in medicine [ ] . this might be a new medical condition, a new diagnostic approach, a new treatment or a new disease. in general, case reports usually describe a specific group of medical disorders including metabolic diseases, malignancies, infections and genetic disorders. case reports on infection have a long history. some case reports can be found in the ancient literature. a good example is the description of a condition that is believed to be "malaria" in the papyrus [ ] . in ancient chinese and egyptian papers, a condition that is believed to be "syphilis" is also recorded [ ] . hence, there is no doubt that infection has been focused on by physicians and medical scientists for many centuries. concerning the nature of case reports on infection, a variety of reports can be seen. for example, reports can be on new disease, a rare disease, a new diagnostic tool or a new treatment. an interesting type of case report is that of an emerging infectious disease. by definition, an emerging infectious disease is a condition of outbreak or epidemic of an infection [ ] . this can be a newly detected disease or the reemergence of an old disease. emerging infectious disease is a condition that needs urgent management, and it is a public health focus. in the early emerging phase or in a small outbreak, the case reports are usually the first documents on those problems. a good example is the first case report from mexico on the influenza of or swine flu before the present pandemic [ ] . this outbreak report brought global attention to the possible emergence of this new serious infection [ ] . later, the infection became a pandemic around the world. hundreds of publications on swine flu were published following this first case report. of interest, the first case report in each country is usually the starting point to draw attention from local physicians and medical scientists. for example, the first case report on swine flu by grasselli et al. [ ] promoted generalized awareness of swine flu in italy. another similar scenario is the report on the outbreak of bird flu, another problematic atypical infection [ ] . this report was also published before the existence of the outbreak of bird flu in many asian countries. case reports cannot have as high scientific merit as well-designed, randomized clinical trials or meta-analyses. however, if the case report is well reviewed and screened before publication, it can be reliable [ ] . nevertheless, although the case report is considered weak evidence in the medical literature, it is usually the first report when there is a new emerging infectious disease. a case report on an emerging infectious disease is a signal emerging from the background noise. it is not possible to perform good research on the new emerging infection at its first appearance, since no one completely knows the details of that infection. during the early period, the focus is usually on controlling the new disease. in addition, good research on the emerging infectious disease usually takes a long time to perform and a longer time for publication of the results to occur. hence, the data in case reports are useful information for planning corresponding to the emerging infection. the recommendation for treatment is usually set on the basis of the clinical information that can be derived from published case reports. a good example is the setting of the new severe acute respiratory syndrome (sars) preparedness program based on the analysis of case reports on sars [ ] . however, having a case report peer-reviewed and published in a journal in the classical way might still take a long time. the present rapid online publication policy of the journal of medical case reports (jmcr) can help reduce delays in publication of interesting emerging infectious diseases. for example, jmcr has published an interesting first case report on an infection associated with the panola mountain ehrlichia species [ ] . in medicine, analysis of case reports can provide useful information for the general practitioner on the way an outbreak has emerged. new lessons might be learned. in terms of research, the case report can contribute to better understanding of a new and emerging infectious disease through a case series review. publication in this area is highly welcomed by the journal and can serve as a future point of reference. comments on: effective medical writing: writing a case report infectious diseases in ancient egypt mercury: a major agent in the history of medicine and alchemy emerging infectious diseases and the emergence of diseases: a conceptual revision and new issues emergence of a novel swineorigin influenza a (h n ) virus in humans a case of ards associated with influenza a-h n infection treated with extracorporeal respiratory support cases of influenza a (h n ): thailand development of a case report review instrument lessons learned from sars: the experience of the health protection agency the first report of human illness associated with the panola mountain ehrlichia species: a case report submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution key: cord- - kxj s authors: imdad, kashif; sahana, mehebub; rana, md juel; haque, ismail; patel, priyank pravin; pramanik, malay title: a district-level susceptibility and vulnerability assessment of the covid- pandemic's footprint in india date: - - journal: spat spatiotemporal epidemiol doi: . /j.sste. . sha: doc_id: cord_uid: kxj s in this study, we trace the covid- pandemic's footprint across india's districts. we identify its primary epicentres and the outbreak's imprint in india's hinterlands in four separate time-steps, signifying the different lockdown stages. we also identify hotspots and predict areas where the pandemic may spread next. significant clusters in the country's western and northern parts pose risk, along with the threat of rising numbers in the east. we also perform epidemiological and socioeconomic susceptibility and vulnerability analyses, identifying resident populations that may be physiologically weaker, leading to a high incidence of cases and pinpoint regions that may report high fatalities due to ambient poor demographic and health-related factors. districts with a high share of urban population and high population density face elevated covid- risks. aspirational districts have a higher magnitude of transmission and fatality. discerning such locations can allow targeted resource allocation to combat the pandemic's next phase in india. the emergence of the covid- pandemic from wuhan, china (columbus et al. ; lupia et al. ; torales et al. ) , in december and its rapid dispersion across the globe (bonilla-aldana et al. ; cruz et al. ) , caught most countries and healthcare systems off-guard. ameliorative measures ranged from initially quarantining patients to progressively containing entire provinces (harapan et al. ) , as the virus' ambit grew beyond political and geographic boundaries. however, with the virus' spread continuing unabated and being supplanted by transmissions from pre-symptomatic and asymptomatic individuals (who b), partial and complete lockdown of regions and entire countries were quickly adopted. nations like india, where the outbreak became potentially threatening after its initial rampage in east asia and western europe, were somewhat quicker to impose such lockdown measures (the lancet ). yet, despite such restrictions being imposed, many countries, india included, have experience sharp jumps in cases due to existing gaps in their healthcare systems and vulnerabilities in their socioeconomic and politicaladministrative setups (mcaleer ), which exacerbate contamination risk and dampen recovery rates. furthermore, the closure of offices and factories has already cast a lasting effect on the global economic landscape (ajami ; gong et al. ; mckibbin and fernando ) . large numbers of low-income migrant workers, who mostly live on-site at their workplaces or are heavily dependent on daily incomes/wages for sustenance, have perforce been uprooted. this has, in all probability, further reduced their ability to withstand a viral outbreak due to impaired health from malnutrition/hunger and the need to travel long distances to return to their original homes. such a situation has especially emerged in india, where thousands of migrant workers mostly from the southern and western zones of the country, have thronged bus terminals and railway stations or have even attempted to travel across states on foot (lal ; singh ) , raising the spectre of further widespread community transmission and the incursion of the virus into especially socioeconomically vulnerable areas (and more importantly into rural hinterlands) that are ill-equipped in terms of healthcare (both at the individual and community level for resident populations and returning migrants- nacoti et al. ) and economic resources to deal with a surge in infections. we therefore seek to examine a number of aspects in this paper. firstly, we delve into the pattern of covid- outbreak in india, relating this with air-travel from abroad (as the covid- is essentially an 'imported' virus-who b) and those availing the same within the country. secondly, we track the contagion's spread through the nation during the successive lockdown phases by mapping its geographic trajectories and its potential outreach zones, i.e. the areas where the virus is most likely to spread into. for doing this, we have had to perforce use slightly older data than that which reflects the current situation, due to the intervening lag time for computation, analysis and writing up of the results. some research accounts have noted that the contagion's virulent nature is dampened and hindered by higher temperatures (briz-redon and serrano-aroca ; prata et al. ; xie and zhu ) and that it reacts to raised humidity levels (ahmadi et al. ; luo et al. ; qi et al. ), conditions which mostly persist across india. along with this, some studies have reported that hydroxychloroquine or chloroquine-based drugs may be useful in combating this virus (colson et al. ; gao et al. ; , though this finding is disputed as well (boulware et al. ; hernandez et al. ) . india has had a history of chloroquine use and vaccination due to its historical struggles with malaria (das et al. ; anvikar et al. ) , and it may thus be seemingly possible that her citizens are likely more resistant to the covid- threat. based on the above two aspects, we first estimate the epidemiological susceptibility of a particular location (since this is a medical/health issue foremost), identifying those areas where the disease is most likely to affect people. subsequent to this, we examine the overall susceptibility of a region to a covid- outbreak, factoring in the socioeconomic and health conditions of its residents, which makes them more prone to succumbing to the virus. finally, we look at the overall socioeconomic vulnerability of the districts (i.e. where deaths are most likely to occur) and its variation across the country. susceptibility analyses are important to ascertain the likely incidence of a disease and the populations it can affect (lohmueller et al. ) . this also helps health-care providers perceive the risks involved for certain groups in order to better influence their health-related behaviour (bmj ; brewer et al. ) . in relation to the virus, a range of susceptibility studies have been performed to understand how the physiological attributes of patients condition their response to the virus (rothan and byrareddy ; shi et al. ; zhao et al. ) , and its links with the disease's spread in different areas (fanelli and piazza ; karako et al. ) . other studies have compared habits like smoking or ambient environmental conditions (coccia ; with the virus' threat and examined how co-morbidities can occur due to underlying health issues yang et al. ). attempts to estimate this coronavirus' spread have however been comparatively less in the overall indian context (e.g. biswas and sen ; dhanwant and ramanathan ; pandey et al. ) , with some regression models being employed to predict virus outbreaks across the country (tomar and gupta ; singh and adhikari ) . others have tried to estimate the covid- 's prevalence within smaller regions (e.g. simha et al. ( ) for the southern indian state of karnataka and kumar ( ) for the western state of maharashtra), measures of controlling its rampage across the country (mandal et al. ) and the debilitating effects it can engender on the nation's overall healthcare system/setup (chatterjee et al. ) . the other aspect examined in the indian context has been the efficacy of the implemented lockdown measures (e.g. paital et al. ) , following similar studies that were undertaken elsewhere (e.g. ibarra-vega ; tobias ). sardar et al. ( ) in examining the effects of the initial lockdown measures have opined that it would have little effect in the western indian states that are the most affected by the virus but can prove to be somewhat beneficial in other areas, while das et al. ( ) have provided guidelines on the critical community size required to make lockdowns effective. however, it has been demonstrated that there exists a great deal of heterogeneity in how people and regions respond to and are affected by this pandemic (sominsky et al. ) , with an urgent need for further science-based assessments of the virus' spread (bedford et al. ) . with india being an extremely diverse country, in geographic as well as socio-demographic aspects, it is very much feasible that the virus' impact and spread will vary markedly across regions. furthermore, due to the large variations in economic and healthcare attributes across the nation, the physiological response and case-fatalities will also differ significantly across areas. therefore, we seek to examine the covid- 's footprint across the nation and link it intricately with the situational realities in different locales, something which is sorely required but has received scarce attention in the current context. the entire analysis has been based on the district-level administrative zones ( figure ) denoted in the indian population census of , which lists districts nationwide, in order to keep parity with the census datasets used. the number of district-level covid- cases as reported by the ministry of health and family welfare (mohfw), government of india (goi) was the principal secondary dataset utilized. this data was also used for the identification of covid- hotspots and analysis of its possible outreach. on th march , the government of india (goi) ordered a nationwide lockdown for days (phase-i), from march - april , further extending this in phase-ii ( april - may) and then to phase-iii (may to may ). therefore, when this study was commenced in april, , the district-wise numbers of covid- cases were collected on four dates from the mohfw, goi, database to understand the patterns of the virus' spread in each timeslot and feasibly represent each of the lockdown phases. these dates were-a) pre-lockdown phase (on rd march); b) early lockdown phase ( th march); c) mid-lockdown phase ( th april) and d) late lockdown phase ( th april). subsequently, the lockdown was extended till may (phase-iv, though with significant allowances for transport and industries/commercial establishments). to show this evolving situation, we have subsequently also mapped the nationwide situation on june and again on july (see section . ). two sets of indicators were used for the ensuing susceptibility and vulnerability analyses. for selecting these, we considered all the relevant information at the district level that could feasibly be associated with the covid- outbreak (these datasets were collated from information made available by office of the registrar general of india ( ), mohfw ( ), iips and icf ( ) and similar other sources-see table and table ) . the district-level susceptibility is related to the viral transmission, while the vulnerability denotes the risk of fatality after infection. we identified the various potential indicators based on an extensive literature review (e.g. coudhry and avindandan ; dowd et al. ; frança et al. ; rocklov and sjodin ; sajadi et al. ; who a; zhong et al. ) and the parameters finally selected for both the susceptibility and vulnerability analyses basically encapsulate the district-wise overall socioeconomic, demographic, climatic, health and hygiene conditions. their descriptions and references are listed in table and table , respectively, while the conceptual framework devised for the entire workflow is depicted in figure . since the dispersion of the covid- virus from its source region and its subsequent entry into other locales was mostly via returning air-travellers, the initial spreading centres were most likely to develop around cities that handled large volumes of air traffic. the annual air passenger data for - was collected from the airports authority of india (https://www.aai.aero/en) for international airports across the country. the number of covid- cases within a district was used as an attribute of its centroid, and a spatial buffer analysis was done to understand the relation between the distance from the airport and the number of covid- cases. the inverse distance weighting interpolation method was used to represent the ratio between the number of covid- cases and the number of air passengers for each international airport, with higher ratios obviously indicating the greater likelihood of a large number of covid- cases emanating from or being transmitted by passengers who have passed through that particular airport. the district-level numbers of coivd- cases in the different time periods were visualised through a series of maps. similarly, changes in the virus hotspots and its potential outreach were identified for each time step using the getis-ord gi* statistic (getis and ord ; ord and getis ) . in contrast, the moran's i values (moran ) were used to distinguish between statistically significant covid- clusters and their relations with other such proximate clusters (cf. ). the covid- 's potential outreach was assessed using the vector-based double and vector-based integer assessment through python coding. the euclidean distance was computed from each district's centroid and the number of covid- cases for that district was used as its mass (cf. dong et al. ; klobucnik and malikova ) . as such, the higher the number of covid- cases in a district, the higher would be its outreach potentiality towards the surrounding districts -with this following a distance-decay function (e.g. frolov ; pueyo et al. ). the estimated covid- potential value was normalized (cf. choi et al. ) in the range of - for weighting each conditioning parameter. subsequently, the derived normalized district potential outreach values were also scaled between to and the natural breaks classification scheme was used to group the districts on the basis of their respective values. the term susceptibility and vulnerability are often used interchangeably for individuals and communities with excessive health burdens or issues. more specifically, the vulnerability component indicates the external factors (i.e. exposure to a disease), while the susceptibility aspect refers to the inherent (mostly physiological) characteristics/capabilities of individuals and communities of coping with the diseases (kovats et al. ) . in this study, the covid- susceptibility indicates the efficiency of the disease's spread into regions/communities, whereas the vulnerability implies the degree to which these regions/communities may be unable to cope with the adverse effects of covid- infection and thereby suffer grave health consequences and possible death (kovats et al. ) . so, higher values of susceptibility indicate an enhanced risk of the spread of this infection, while higher values of the vulnerability index imply a greater threat of death from the covid- infection. the epidemiological susceptibility analysis dataset, therefore, includes the actual number of covid- cases in the country along with other relevant socioeconomic, demographic and climatic factors. the socioeconomic susceptibility analysis dataset, on the other hand, excludes the variable denoting the number of covid- cases in a district. we sought to undertake such a dual analysis in order to represent both, the actual situation which has emerged (keeping in mind data limitations and lags) as well as the situation that can arise (i.e. if all areas are eventually targeted or intruded into by the virus, which ones may succumb more easily). while constructing the epidemiological susceptibility index, the maximum weightage was given to the variable denoting the district-wise number of covid- cases, as the virus' mere presence in a district endangers that area the most and makes it more liable to become a spreading centre than any other ambient socioeconomic, demographic or climatic factor. for the socioeconomic susceptibility index, all variables were given almost equal weights (see table ). with the widespread transmission of covid- already underway, it is tricky to conduct any susceptibility analysis using real-time information due to the obvious time-lag between information gathering and analysis. in this paper, we have used the then most recent available data for the districts as released by the mohfw, goi, when we commenced our analysis in the latter half of april . similar to the weightage pattern accorded for the socioeconomic susceptibility computation, the index for ascertaining the socioeconomic vulnerability was also developed by assigning equal weightage to all variables ( table ) . the above computed socio-economic susceptibility and vulnerability indices have some indicators that are common to both and some that are exclusive to each. the justification for each indicator has been mentioned in the relevant tables. for example, some of the indicators which are not related to the spread of infection (and thereby the computation of the susceptibility index) but are associated with fatality (such as old age population and health infrastructure) were considered only while computing the vulnerability index (see table ). the susceptibility or vulnerability index is the normalised value of the un-normalised index. for computing the susceptibility and vulnerability indices, an un-normalised index (i.e. the summation of all the weighted indicators) was first computed (eq. ). after this, a normalised index was prepared, which ranged between to (eq. ). before beginning the statistical enumeration, all the variables were converted to positive directions (i.e. a higher value would show a greater risk of susceptibility or vulnerability). the index construction procedure can be specified as follows: where, w stands for the weight assigned to each ith indicator. the expresses the scale free indicator obtained by dividing the original value (x) by the mean value ( ̅ ) for the variables (eq. ). the rationale of this scale free indicators has been previously analysed in the literature (kundu , c.f. haque . (eq. ) eventually, the normalised index was computed as follows: the final output value obtained ranged between and (normalised index), with a higher value representing a greater risk of susceptibility or vulnerability to covid- . the assessment of spatial heterogeneity in the relationship between two variables may be useful if the presence/numbers of covid- cases is available for all districts. due to the unavailability of this data, we have only focussed on eliciting linear and non-linear relationships of the district-wise number of covid- cases with the ambient socioeconomic, demographic and climatic variables. in computing the linear relationship, we obtained the pearson's correlation plot using the 'corrplot' package in r (wei and simko ) . for the multivariate analysis, the non-linear relationship of covid- cases and its correlates were computed using the generalized additive model (gam), via the 'gam' package in r (hastie ). covid- cases were first diagnosed in india in late january, and crossed , cases by the end of the second week of may (with present numbers in early-august, being more than lakhs). with this highly contagious disease transmitting primarily through international tourists and returning travellers from aboard, the initially affected sites in india were mostly cities that have international airports (or regions adjoining such places) or are major tourist destinations. this is made apparent by the district-wise spread pattern of the covid- virus ( figure ). in the first phase ( figure a ), cases were reported from western india (around mumbai and ahmedabadtwo of the main commercial hubs of the country), from around new delhi (the national capital) and ladakh (popular tourist destination and a prominent indian army base) and from the southern states of kerala (from where many residents migrate/travel for work to the gulf region), tamil nadu, andhra pradesh and karnataka (all of which have major metropolitan centres and commercial hubs-chennai, hyderabad and bengaluru). further intensification of the above pattern in the next time step of th march was apparent, with the adjoining regions reporting substantial case numbers ( figure b ). broad swathes of the eastern part of the country still remained mostly unaffected, except for kolkata (the major regional metropolitan centre) and its surroundings. in the next time step ( th april ), two large contiguous zones in northern india and western-central-south india april ( figure d ), showed the merging of the two entities described above, with infilling of their intervening districts (i.e. reporting of cases from previously unaffected areas) and a rise in cases in districts already afflicted. this resulted in a near-continuous stretch, from kashmir to kanyakumari, along the central and western corridors and down the eastern and western coastal belts, reporting covid- cases. by now the eastern zone had noted a rise in cases (with its epicentre at kolkata). this manifested as a narrow line of districts along the densely populated ganga plains in uttar pradesh and bihar, which merged into the larger/more contiguous zone further west. the above trends highlighted that, as expected, the distance from an international airport and the numbers of covid- cases were characterised by distance-decay [i.e. were inversely correlated and with increasing distance from the airport, case numbers decreased (figure ) ]. during the successive lockdown phases, the percentage of cases within km of an airport had decreased slightly, but numbers rose gradually for locations within - km of an airport. thus, districts situated within this distance buffer ( - km) seemingly had a higher probability of being affected by covid- and thereby swelling the overall case numbers. this indicated that the virus had spread out from its initial centres during the latter part of the lockdown and that its footprint was becoming much more apparent across the hinterland. of the international airports examined, the ratio of air passengers to covid- cases were far higher for the mumbai, delhi, bengaluru and hyderabad airports ( similarly, hyderabad and bengaluru (the main information technology hubs of india) are also entwined with global markets while new delhi (the national capital) is connected by flights worldwide for diplomatic, administrative and tourism purposes. thus, the initial outbreaks occurred mostly through these four airports. as mentioned before, many residents of kerala work in the gulf countries and this state is also a major tourist destination, with numerous flights routed to it through the mumbai and bengaluru airports. therefore, it was also an initial hub of covid- cases. the getis-ord gi* method was used to identify the spatial distribution of potential hot spots (statistically the location of the cold spots remained almost similar to that discerned from the pre-lockdown phase data of rd march , with clustering mainly around west bengal. the mid-lockdown phase data of th april ( figure c ) indicated intense clustering of high values around maharashtra and gujarat. however, the initial high values clustering around kerala started diminishing in this mid-lockdown phase, possibly due to the pre-emptive actions regarding testing and quarantine taken by the kerala state government and the union government's policies. in fact, kerala was initially considered as the first indian state likely to 'beat the curve' when it showed a continuous downtrend/decrease in its number of active covid- cases from th april till th may (this situation has subsequently changed markedly for the worse and the patterns/trends as of st june and th july for the whole country have also been discussed in section . ). the cold spot intensity had declined in the eastern part, almost throughout west bengal. the th april dataset ( figure d ) revealed a much more concentrated hot spot with a z-score of . in maharashtra and gujarat. by then, the entirety of kerala and andhra pradesh had ceased to be part of any hot spot region. however, the area and intensity of the cold spot region located in the eastern part of the country had also declined significantly, indicating that the next phase of the virus' spread could target this zone. again, subsequent events and updated news reports about the covid- spread has validated just this, with the eastern region around kolkata presently emerging as one of the most affected by the pandemic. while the getis-ord gi* analysis of the district-level covid- cases identified the clustering of low and high index values, it only delineated large clusters through neighbourhood analysis and ignored those districts that had high numbers of cases but were surrounded by low-value neighbours or vice versa. thus, the mo n's i (jackson et al. ) was computed to obtain additional insights into the statistically significant high-high, high-low, low-high and low-low clusters derived previously for each of the four datasets (figure ) . orissa are easily visually correlated as districts with high epidemic susceptibility. the potential gravity of the covid- spread was assessed for the four different time steps to ascertain its likely outreach areas (figure ). the possible potential outreach on rd march ( figure a ) was mostly around the delhi ncr (national capital region). some small outreach pockets were seen in kerala and maharashtra (e.g. mumbai and pune). from the th march dataset ( figure b ), potential outreach epicentres were found in three significant locations-delhi-centric, mumbai-centric and kerala-centric (due to reasons outlined in section . ). in the th april dataset, kerala displayed a marked improvement in controlling the outbreak, as discussed previously ( figure c ). however, rapid growth was observed for mumbai and its surrounding areas and this scenario continued into the next phase as well ( figure d ). we thus predicted that based on the potential outreach analysis, the gravity of the covid- outbreak was likely to be very high in western india, especially in maharashtra. the current situation reflects this, as this state ranks highest within india in covid- incidence with over . million reported cases, numbers of active cases as well as deaths (india covid- tracker at https://www.covid india.org/ as on st october ). maharashtra is overwhelmingly afflicted in mumbai and its nearby areas of thane and pune. neighbouring gujarat has also been hardest hit in ahmedabad, surat and vadodara. as per the performed potential outreach analysis, the north-eastern states (except assam) and the himalayan states are relatively less affected by the covid- outbreak. however, the eastern districts of bihar, jharkhand and west bengal are seen to gradually come under the pandemic's grasp, over the different times-steps, pointing towards this zone possibly carrying forward the rising patient numbers in the near future, as the spread in western/northern india may start to peak or gradually decline. most of the covid- afflicted residents in eastern india have a travel history from either mumbai, kerala or delhi. initially, only a few cases were observed in this region due to its lower volume of international air traffic (as denoted by the lower air passenger to covid- case ratio) but case numbers have risen during the latter lockdown phases and beyond it due to inter-state in-migration from the western and southern parts of the country, particularly as a result of large numbers of returning migrant workers (mullick ) . overall, the potential outreach analyses denoted that the virus' epicentres have been mostly concentrated in and around mumbai in maharashtra. as kerala and also karnataka initially recovered quite quickly, the earlier epicentre in southern india was reduced during the subsequent lockdown phases (however, infections have again risen sharply in karnataka and tamil nadu towards the end of the final lockdown phases in may as restrictions have relaxed and presently, these two states along with andhra pradesh occupy the second to fourth positions in the country in terms of covid- incidence). the eastern part of the country now faces the imminent threat of becoming an epicentre if further transmissions into the region occurs from the ongoing return of many currently unemployed migrant labourers from other parts of the country and consequent community transmissions. the comparative outlooks of the undertaken hotspot and the potential outreach analyses differed slightly in perspective. while the hot spot enumeration discerned covid- affected zones based on the actual ground situation/data as ascertained for that point in time, the potential outreach maps denoted the gravity factors for the four different time periods and depicted how conditions may worsen in the major epicentres or have eased off in other areas (based on the then available data). the outreach analysis thus gauges the outbreak's potential across india and denotes zones likely to be affected next. using the indicators listed in table and table , we had developed the area-based composite covid- susceptibility and vulnerability indices at the district level-for india, with a view towards providing policy makers with some indication on which districts are likely to be most susceptible or vulnerable to a covid- outbreak and specifically where should the government target its resources and accordingly plan a data-driven intervention strategy. the elicited results from these indices are presented below. a five-pronged classification scheme (ranging from very high to very low) was used to visualise the enumerated district-level epidemic susceptibility values (derived using quintile class- table ). there are significant regional clusters in the northern, eastern, southern and parts of the north-eastern states of india (figure ). large swathes of south-western and northern india, covering most districts of kerala, tamil nadu, telangana, andhra pradesh, karnataka, maharashtra, gujarat, rajasthan, delhi, haryana and punjab are highly susceptible to this pandemic. primarily, these were the areas where the initial outbreak occurred and the subsequent transmission of has been phenomenal, with people therein being seemingly less able to cope with the covid- virus (i.e. their physiology is more easily affected by it). possibly, the prevalence of urbanization (which creates congestion), an existing burden of non-communicable diseases (hyper tension, diabetes and obesity) and a greater proportion of the elderly population in these regions may have heightened the overall epidemic susceptibility. ironically, most of the highly urbanized and economically well-off states seem to have reported higher covid- susceptibility, since the initial epicentres of the virus outbreak were in their large cities. contrarily, almost all districts in the seven north- susceptible to the pandemic. it is interesting that despite being economically poorer and having low indicators with respect to almost every socioeconomic and health related parameter than the rest of india, these areas are less susceptible to the pandemic, suggesting that the covid- outbreak might be an erratic phenomenon that cannot be explained solely by traditional socioeconomic theories and which might require further investigation. as many districts in the moderate susceptibility to covid- class lie in economically poorer zones, this can have important connotations in terms of impaired health-care services and facilities, thereby deteriorating immune response and patient recovery. furthermore, as discerned in previous sections, india's eastern region is likely to become a secondary virus epicentre. thus, even though this zone is denoted in the moderate susceptibility category, its lower socioeconomic standing and existing poorer healthcare assets and availability/accessibility accord it high priority for pre-emptive future resource allocation in order that the likely forthcoming challenges can be met adequately. figure visualizes the socio-economic susceptibility index for india's districts, following a similar classification to that adopted for figure (see table ). the underlying assumption of this particular index is that if all districts are evenly infected by the covid- outbreak, then what would be the magnitude or susceptibility of further transmission in a certain area, with this being dependant on its socioeconomic status. results reveal that large portions of eastern, north and north-western india are high to very highly socioeconomically susceptible to this pandemic. these areas are particularly characterized by high population densities, chronic malnutrition, poor health infrastructure, larger family sizes, poor hygiene practices, poverty concentration and marginalization including lower health-related knowledge and awareness, thereby precipitating such outcomes. on the contrary, most districts in the north-eastern, southern and extreme northern regions (e.g. in the northern part of rajasthan and in punjab, himachal pradesh, jammu and kashmir and uttarakhand), and are found to be socioeconomically less susceptible in terms of covid- transmission. interestingly, some areas that initially had higher numbers of covid- cases have emerged in the low susceptible category (e.g. kerala) and this merits further explanation. in kerala, after the initial outbreak was reported, effective state government measures temporarily lowered further transmissions by facilitating mass testing, awareness creation at the community level and though stringent physical distancing and lockdown norms. alongside this, most importantly, there has been efficient management of both international and inter-state migrants in the state. however, conditions have progressively worsened as restrictions have eased, and large numbers of expats have returned from the gulf region and from other parts of the country (nidheesh ) . the state has also seen a very high jump in the number of reported cases in the aftermath of the annual onam festival (held from august to september) (the hindu ), with numbers rising from about , before it to above , presently by the end of september (india covid- tracker at https://www.covid india.org/ as on st october ). with the autumn festival season approaching fast, there are thus grave fears that there could be a significant rise in case numbers across the country (cna ), while fears over such a rise have also affected local economies further (sharma ) . aspirational districts (ads) are more susceptible to covid- outbreaks due to their already limited coping-up capacities, as they are some of the socio-economically poorest/most backward regions of india. the overall health infrastructure and particularly the numbers of primary and community health centres in such locales are also less, with limited staff and bare minimum facilities further compounding the issue. however, the incidence of covid- cases in these areas was initially fairly low, being less than % (a total of cases as of th may ) of the total cases nationwide. of the ads affected by the virus on the above date, the worst-hit have been ranchi ( cases), baramulla ( ), ysr ( ), nuh ( ), jaisalmer ( ) and kupwara ( ), which are all located in the red zone (the locales that faced the most stringent lockdown norms) as per the indian government's classification. considering their susceptibilities, the goi (through the niti aayog) has taken steps to ensure appropriate and timely action for resolving supply shortages in test kits, personal protective equipment (ppe) and in providing masks to the respective empowered populations/groups in these districts. we were also able to identify these districts based on their respective susceptibility indicators, e.g. percentage of poor population, household size, impaired child health (i.e. suffering from anaemia, underweight or stunted development), and poor female health (anaemia and underweight). apart from these ads, we further identified some other districts that are also quite susceptible due to their socioeconomic background and these areas (most districts of madhya pradesh, orissa, andhra pradesh, bihar, jharkhand, west bengal and uttar pradesh) need support similar to that being provided to the ads (i.e. urgent supply of testing kits, ppe and masks). based on the selected set of indicators, the discerned socioeconomic vulnerability to the covid- 's impact ( figure ) is likely to be higher in many districts of madhya pradesh, orissa, telangana, andhra pradesh, bihar, jharkhand, west bengal and uttar pradesh and these areas are likely to report higher fatalities. there is a % overlap of the places most at risk in these states with those demarcated under the union government's aspirational districts programme, i.e. of the discerned highly to very highly vulnerable districts are also ads. the scarcity of healthcare facilities and personnel in these districts remains a major issue and such areas also have a large number of inter and intra state migrants, who have steadily returned home during the lockdown. therefore, it is quite possible that cases of covid- infection shall sharply rise in these locations and that the poorer medical infrastructure shall increase the infection rate and incidence of deaths, if adequate measures are not taken. contrastingly, this impact shall be markedly lower in the states of kerala, punjab, haryana, himachal pradesh and in most of the north-eastern states and the rann of kachch (in gujarat). some districts of tamil nadu, gujarat, rajasthan and maharashtra are moderately vulnerable. the enumerated index values are higher in some districts due to these housing a greater proportion of those that are more vulnerable to this contagion (i.e. more number of children and women who are anaemic and/or underweight, lower female education levels and a higher prevalence of diabetic patients). therefore, these districts are likely to find it difficult to cope with the covid- threat and its related morbidity aspect. on the other hand, the lesser vulnerable districts seemingly do have sufficient capability to deal with the threat, as observed in the districts of kerala, from where very few morbidity cases were initially reported, compared to the other parts of india, despite this state being an early epicentre of covid- . figure shows the correlations derived between the covid- cases (i.e. the number of cases per district) and its socioeconomic, demographic and climatic factors. this pandemic is positively associated with the percentage of urban population and the population density of a district. it is also positively associated with the percentage of women having attained th or lower standard of schooling. furthermore, districts with a higher share of poorer households ( %) had lower viral transmissions. in the second half of april , although the virus had spread across districts, the gravity of the outbreak was mostly concentrated in districts that were major urban agglomerations, such as mumbai, delhi and hyderabad. people in urban areas are relatively more mobile (with the resultant greater public transport congestion and crowds) than ruralites. they may also be forced to maintain lower residential and social distances due to the higher densities of built-up zones as well as population, especially within slums areas where housing shortages are quite severe (haque et al. ) . these factors together with the inherent economic deprivation faced by slum residents would likely enable a more widespread outbreak in such congested locales (ahmed et al. ) , as has been evidenced by the large numbers of cases reported from the dharavi slum area of mumbai, which is one of the largest such entities in asia. this is also the likely cause for the extremely high number of infections being subsequently reported from delhi and its surrounding urban agglomeration and from chennai and its neighbourhoods. as urbanites generally attain a higher level of education, the pandemic's outbreak is also positively associated with the educational status, more so because this 'imported' virus mainly came into the country via air-travel (i.e. from the movement of economically well-off sections of the population, who can be expected to have also attained higher education levels). the above bivariate linear relationships do not provide the non-linear associations between variables. for this, the multivariate non-linear association was evaluated via the gam. the outcome variable for this model was the cumulative number of covid- cases in the district, i.e. the total tested/confirmed positive cases. the obtained findings predict a flexible relationship between the enumerated variables ( figure ). districts with a population density between - people/km specifically have a higher risk of this virus spreading amidst them. of the districts affected by the virus (as per the last date on which the data for this paper was collected), apart from a few situated in urban metropolitan cities, all others contain medium to large towns which have a moderate level of population density. the highly urban districts face a greater threat of a covid- outbreak, particularly when the urban population share crosses %. in the urban agglomerations of india, a significant proportion ( . %) of residents live in slums (e.g. about half the population of greater mumbai lives in such locales). while they play a vital role in the city's functioning, these slum areas are poorly planned and obviously very densely populated, as a result of the ever-accelerating urbanization trend in india. such sites thus become potential hotspots for infectious diseases like covid- . this unplanned urban growth also poses considerable risk in terms of impaired preparedness and ready response to any infectious disease outbreak, with mass quarantining at such close quarters, while maintaining social distancing, being almost impossible. hence, the responses of healthcare officials, governments and communities to this ongoing pandemic can be devised towards generating a paradigm shift in how urban spaces and residences are planned and designed, with possible ramifications for future peri-urban transformations, inner-city renewal and slum rehabilitation (jha ; regmi ; van den berg ). the findings also suggest that although districts with a higher prevalence of children suffering from anaemia and/or being underweight face an elevated risk of this viral transmission, the relationship slope is not very significant. thus, these health indicators are not strongly correlated with covid- cases in the indian context. a possible reason for this seemingly discordant finding is that may be the goi and/or state governments had till the last date of the initial data collection for this paper (i.e. th april ) not conducted an adequate number/proportion of population-level tests, rather testing only those who had already developed covid- related symptoms. therefore, a similar analysis performed on a bigger and possibly more representative sample obtained via large-scale population-level testing may yield better explanations. several studies have found that climatic parameters such as mean annual temperature and relative humidity have a crucial role in spreading the covid- virus (sajadi et al. ; , with evidence suggesting that a mean temperature of °c and a medium to high ( % to %) relative humidity range is most suitable for its transmission. the greater majority of india's districts have a higher daily mean temperature than °c in april and except for a few districts in the himalayan and coastal belts, all districts have an average relative humidity less than the suitable level. therefore, unlike as discerned in other studies, we could not find any significant relationship between the currently prevalent climatic parameters and this viral outbreak. the lockdown measures in india were extended to may (phase-iv, though there were significant allowances in terms of movement and industries/commercial establishments gradually during this period), with the period from june till june being denoted as unlock- and again as unlock- (from july to july), as the nation reopened and eased off restrictions further. each of the three attributes-the spread of covid- cases, the clustering of cases and the hot/cold spots have thus evolved further since this study was commenced with the initial database of the first few lockdown phases in mid-april, . this section has thus been prepared to show the changed conditions as on st june , and on th july , in the above aspects, thereby denoting the complete scenario at the end of all the lockdown phases, that effectively ended on st may , and the continued evolution of the disease in india during the unlock- ( - june) and unlock- ( - july) phases. it was apparent that the spread of covid- in india could not be wholly attained simply by the various lockdown measures. this was evidenced by the overall continued rise in case numbers throughout the country [ figure in the central portion of the country overall cases were still relatively on the lower side. hotspots were clustered mostly in a broad swathe along the western and southern region [ figure (b)]. cases in the western part of the country were more intensely concentrated in certain districts, as was evident from the low-low and low-high clustering patterns [ figure (c)]. the covid- crisis' impact on society and the global economy has been profound and likely to be long-lasting. possibly, governments either underestimated its threat or did not have robust enough socio-political systems and healthcare infrastructure to combat transmissions. instead, while helpful, the lockdown measures have engendered economic instability and developing nations have been the worst affected, trying to contain the pandemic while addressing rising unemployment and at-stake livelihoods of a vulnerable population. thus, it is paramount that correct and sustainable economic/socio-political decisions are taken. for this, proper predictions of the pandemic's path, with pinpointing of areas that it can affect the most, are pertinent, for prudent and targeted resource allocation. our analysis has highlighted the initial centres of the covid- pandemic in india and its spread. by identifying its hotspots and significant clusters, we pinpointed locales where possible community transmissions have occurred. our computations were based on the data garnered during the initial lockdown phases implemented in india. however, subsequent reports of the pandemic's spread have largely validated our earlier estimates of the areas that were most likely to be affected (i.e. the virus gaining a foothold and then spreading in various clusters of eastern india, around kolkata). our analysis thus lays the groundwork for identifying future hot spot zones so that communities and local governments can anticipate and allocate critical resources accordingly. mass testing of covid- in such hotspots can curb the disease's spread into adjoining areas. by also designating locales that are relatively safer and less susceptible/vulnerable to the pandemic (i.e. cold spots), we also provide a framework for earmarking places where economic activities can be carried out more safely, to boost flagging economies. we have also identified districts that are more vulnerable to the virus. these locations can, if possible, strive to build food stocks to avoid any food-security related issue in case sudden lockdowns are again required if a second wave of the virus arises. in the most vulnerable cities and the suburban areas located within - km around them, crowds in market places must be stringently restricted, with continued social distancing norms and masks being mandatory. districts that have high epidemiological susceptibility need enhanced vigilance (possibly through specially constituted rapid-action teams and through detailed co-morbidity surveys) to avoid transmissions and a higher incidence of death. areas that are socioeconomically susceptible face the greatest threat as they house substantial numbers of people who may not be physiologically capable of coping with the covid- virus. overall, our demarcated hot and cold spot areas and those that are epidemiologically susceptible or socioeconomically vulnerable tallies quite well with the red-orange-green containment zones delineated by the goi (ndma ), providing further validation of the performed analyses. there are still some parts of india where the covid- has not been able to intrude significantly, especially in physiographically rugged and isolated tracts and in some rural hinterlands. it is paramount that these locations be guarded against community transmissions while more afflicted areas are dealt with adequately. though the quickly enforced lockdown no doubt caused much misery, especially for migrant workers far from home, it may have also given the country some time to build up its medical responses and anticipate where the contagion can spread next. we hope that our study has created a framework that enables this to be accomplished fruitfully. densely populated areas raise the risk of greater physical contact among people. as the sars-cov- is a highly contagious virus, population density is an unavoidable measure (rocklöv and sjödin ) investigation of effective climatology parameters on covid- outbreak in iran why inequality could spread covid- globalization, the challenge of covid- and oil price uncertainty antimalarial drug policy in india: past, present and future global database of plasmodium falciparum and p. vivax incidence records from - . sci. data a new twenty-first century science for effective epidemic response space-time dependence of corona virus (covid- ) outbreak covid- : risk factors for severe disease and death coronavirus infections reported by promed a randomized trial of hydroxychloroquine as postexposure prophylaxis for covid- meta-analysis of the relationship between risk perception and health behavior: the example of vaccination a spatio-temporal analysis for exploring the effect of temperature on covid- early evolution in spain estimation of covid- prevalence in italy healthcare impact of covid- epidemic in india: a stochastic mathematical model application of a fuzzy operator to susceptibility estimations of coal mine subsidence in taebaek city covid- sows dread in india's festival season as infections cross million factors determining the diffusion of covid- and suggested strategy to prevent future accelerated viral infectivity similar to covid chloroquine for the novel coronavirus sars-cov- novel coronavirus: an emerging global threat why covid- outbreak in india's slums will be disastrous for the urban poor covid- , a worldwide public health emergency. spanish clinical magazine malaria in india: the centre for the study of complex malaria in india critical community size for covid- -a model based approach covid- associated pneumonia in clinical studies the analysis of spatial association by use of distance statistics a balance act: minimizing economic loss while controlling novel coronavirus pneumonia infrastructure development and access to basic amenities in class-i cities of west bengal, india: insights from census data location matters: unravelling the spatial dimensions of neighbourhood level housing quality in kolkata coronavirus disease (covid- ): a literature review generalized additive models hydroxychloroquine or chloroquine for treatment or prophylaxis of covid- : a living systematic review modeling containing covid- infection. a conceptual model national family health survey (nfhs- ) a modified version of moran's i observer research foundation analysis of covid- infection spread in japan based on stochastic transition model the impact of population potential on population redistribution in the long-term historical context: case study of region stredne povazie methods of assessing human health vulnerability and public health adaptation to climate change. world health organization, health canada, world meteorological association, united nations environment programme predication of pandemic covid- situation in maharashtra measurement of urban processes: a study in regionalization towards building a composite index for asia: realising the millennium development goals, vi- . united nations development programme (undp) covid- and india's nowhere people. the diplomat prevalence and impact of cardiovascular metabolic diseases on covid- in china meta-analysis of genetic association studies supports a contribution of common variants to susceptibility to common disease the role of absolute humidity on transmission rates of the covid- outbreak novel coronavirus ( -ncov) outbreak-a new challenge prudent public health intervention strategies to control the coronavirus disease transmission in india: a mathematical model-based approach prevention is better than the cure: risk management of covid- the global macroeconomic impacts of covid- : seven scenarios district wise health care infrastructure notes on continuous stochastic phenomena covid- cases spike in states as migrants return. hindustan times, th june at the epicenter of the covid- pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation. innovations in care delivery ndma (national disaster management authority) ( ) hotspot' (red zone) classification kerala reopens without communal transmission despite covid rise. livemint, th june census of india . ministry of home affairs, government of india local spatial autocorrelation statistics: distributional issues and an application inter nation social lockdown versus medical care against covid- , a mild environmental insight with special reference to india seir and regression model based covid- outbreak predictions in india climatic factors influence the spread of covid- in russia climatic influence on the magnitude of covid- outbreak: a stochastic model-based global analysis temperature significantly changes covid- transmission in (sub) tropical cities of brazil assessment of days lockdown effect in some states and overall india: a predictive mathematical study on covid- outbreak covid- cuts into business of religion in india host susceptibility to severe covid- and establishment of a host risk score: findings of cases outside wuhan a simple stochastic sir model for covid infection dynamics for karnataka: learning from europe. populations and evolution (preprint) chloroquine and hydroxychloroquine in the treatment of covid- with or without diabetes: a systematic search and a narrative review with a special reference to india and other developing countries age-structured impact of social distancing on the covid- epidemic in india explained: indian migrants, across india. the indian express one size does not fit all -patterns of vulnerability and resilience in the covid- pandemic and why heterogeneity of disease matters the hindu ( ) coronavirus | kerala cases rise to new high after onam drop. the hindu the lancet ( ) indian under covid- lockdown evaluation of the lockdowns of the sars-cov- epidemic in italy and spain after one month follow up prediction for the spread of covid- in india and effectiveness of preventive measures the outbreak of covid- coronavirus and its impact on global mental health how will covid- affect urban planning? the cityfix susceptibility analysis of covid- in smokers based on ace high temperature and high humidity reduce the transmission of covid- a review of the novel coronavirus (sars-cov- ) based on current evidence r package "corrplot": visualization of a correlation matrix (version . ) who (world health organisation) ( a) (world health organisation) ( ) newsroom/coronavirus (covid- who (world health organisation) ( b) coronavirus disease (covid- ) situation report- . world health organisation exposure to air pollution and covid- mortality in the united states. medrixv (preprint) effects of temperate and humidity on the daily new cases and new deaths of covid- in countries association between ambient temperature and covid- infection in cities from china prevalence of comorbidities and its effects in patients infected with sars-cov- : a systematic review and meta-analysis relationship between the abo blood group and the covid- susceptibility. medrxiv preprint knowledge, attitudes, and practices towards covid- among chinese residents during the rapid rise period of the covid- outbreak: a quick online cross-sectional survey the authors are grateful to their respective institutions for providing the infrastructure required to conduct this research. the assistance of ms. sayoni mondal, research scholar at the department of geography, presidency university, kolkata, india in arranging the article references is gratefully acknowledged. none percentage of the total population living in urban areas urban areas are particularly most vulnerable as they are the initial centres of the outbreak. the prevalence of slums within cities especially raises the risk of this viral transmission (coudhry and avindandan ) .office of the registrar general of india ( ) percentage of women having th standard education and aboveproxy parameter for the awareness about the covid- spreading. it is assumed that if an area has a higher proportion of women or more years of schooling, then overall household awareness will be higher and this can lower transmission (zhong et al. ). ( ) percentage of households exposed to smokingsmoking or being exposed to smoking in any form can elevate the risk of infection from covid- (who ). wealth status the economically wealthier section can make better arrangements for rigid interventions such as lockdown while poor people may be forced to go out to arrange food supplies. accessing meals from community kitchens, receiving food items from donations, buying essentials items from the government fair shops, may elevate the probability of the less economically well-off sections to catch the infection. percentage of households exposed to smokingsmoking may not only increase the risk of viral transmission but also raise the probability of dying, as the covid- primarily afflicts the pulmonary system. key: cord- -q de r p authors: griette, p.; magal, p. title: clarifying predictions for covid- from testing data: the example of new-york state date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: q de r p in this article, we use testing data as an input of a new epidemic model. we get nice a concordance between the best fit the model to the reported cases data for new-york state. we also get a good concordance of the testing dynamic and the epidemic's dynamic in the cumulative cases. finally, we can investigate the effect of multiplying the number of tests by , , , and to investigate the consequences on the reduction of the number of reported cases. the epidemic of novel coronavirus infections began in china in december and rapidly spread worldwide in . since the early beginning of the epidemic, mathematicians and epidemiologists have developed models to analyze the data and characterize the spread of the virus, and attempt to project the future evolution of the epidemic. many of those models are based on the sir or seir model which is classical in the context of epidemics. we refer to [ , ] for the earliest article devoted to such a question and we refer to [ , - , , , , , ] for a rather complete overview on sir and seir models in general. in the course of the covid- outbreak, it became clear for the scientific community that covert cases (asymptomatic or unreported infectious case) play an important role. an early description of an asymptomatic transmission in germany was reported by rothe et al. [ ] . it was also observed on the diamond princess cruise ship in yokohama in japan by mizumoto et al. [ ] that many of the passengers were tested positive to the virus, but never presented any symptoms. we also refer to qiu [ ] for more information about this problem. at the early stage of the covid- outbreak, a new class of epidemic models was proposed in liu et al. [ ] to take into account the contamination of susceptible individuals by contact with unreported infectious. actually, this class of model was presented earlier in arino et al. [ ] . in [ ] a new method to use the number of reported in sir models was also proposed. this method and model was extended in several directions by the same group in [ ] [ ] [ ] to include non-constant transmission rates and a period of exposure. more recently the method was extended and successfully applied to a japanese age-structured dataset in [ ] . the method was also extended to investigate the predictability of the outbreak in several countries china, south korea, italy, france, germany and the united kingdom in [ ] . the application of the bayesian method was also considered in [ ] . in parallel with these modeling ideas, bayesian methods have been widely used to identify the parameters in the models used for the covid- pandemic (see e.g. roques et al. [ , ] where an estimate of the fatality ratio has been developed). a remarkable feature of those methods is to provide mechanisms to correct some of the known biases in the observation of cases, such as the daily number of tests. here we will embed the data for the daily number of tests into an epidemic model, and we will compare the number of reported cases produced by the model and the data. our goal is to understand the relationship between the data for the daily number of tests (which will be an input our model) and the data for the daily number of reported cases (which will be an output for our model). the plan of the paper is the following. in section , we will present a model involving the daily number of tests. in section , we apply the method presented in [ ] to our new model. in section , we present some numerical simulations, and we compare the model with the data. the last section is devoted to the discussion. let n(t) be the number of tests per unit of time. throughout this paper, we use one day as the unit of time. therefore n(t) can be regarded as the daily number of tests at time t. the function n(t) is actually coming from a database for the new-york state [ ] . let n (t) be the cumulative number of tests from the beginning of the epidemic then n (t) = n(t), for t ≥ t and n (t ) = n . ( . ) remark . section is devoted numerical simulations. we will use n(t) as a piecewise constant function that varies day by day. each day, n(t) will be equal to the number of tests that were performed that day. so n(t) should be understood as the black curve in figure . the model consists of the following system of ordinary differential equations this system is supplemented by initial data (which are all non negative) thereby assuming that the disease was introduced by an individual incubating the disease at some time before t . the time t corresponds to the time where the tests started to be used constantly. therefore the epidemic started before t . here t ≥ t is the time in days. s(t) is the number of individuals susceptible to infection. e(t) is the number of exposed individuals (i.e. who are incubating the disease but not infectious). i(t) is the number of individuals incubating the disease, but already infectious. u (t) is the number of undetected infectious individuals (i.e. who are expressing mild or no symptoms), and the infectious that have been tested with a false negative result, are therefore not candidates for testing. d(t) is the number of individuals who express severe symptoms and are candidates for testing. r(t) is the number of individuals who have been tested positive to the disease. the flux diagram of our model is presented in figure . susceptible individuals s(t) become infected by contact with an infectious individual i(t), u (t) or d(t). when they get infected, susceptible are first classified as exposed individuals e(t), that is to say that they are incubating the disease but not yet infectious. the average length of this exposed period (or noninfectious incubation period) is /α days. after the exposure period, individuals are becoming asymptomatic infectious i(t). the average length of the asymptomatic infectious period is /ν days. after this period, individuals are becoming either mildly symptomatic individuals u (t) or individuals with severe symptoms d(t). the average length of this infectious period is /η days. some of the u -individuals may show no symptoms at all. in our model, the transmission can occur between a s-individual and an i-, u -or r-individual. transmissions of sars-cov- are described in the model by the term τ s(t)[i(t) + u (t) + d(t)] where τ is the transmission rate. here, even though a transmission from r-individuals to a s-individuals is possible in theory (e.g. if a tested patient infects its medical doctor), we consider that such a case is rare and we neglect it. : key time periods of covid- infection: the latent or exposed period before the onset of symptoms and transmissibility, the incubation period before symptoms appear, the symptomatic period, and the transmissibility period, which may overlap the asymptomatic period. the last part of the model is devoted to the testing. the parameter σ is the fraction of true positive tests and ( − σ) is the fraction of false negative tests. the quantity σ has been estimated at σ = . in the case of nasal or pharyngeal swabs for sars-cov- [ ] . among the detectable infectious, we assume that only a fraction g are tested per unit of time. this fraction corresponds to individuals with symptoms suggesting a potential infection to sars-cov- . the fraction g is the frequency of testable individuals in the population of new-york state. we can rewrite g as where p is the total number of individuals in the population of the state of new-york and ≤ κ ≤ is the fraction total population with mild or sever symptoms that may induce a test. individuals who were tested positive r(t) are infectious on average during a period of /η days. but we assume that they become immediately isolated and they do not contribute to the epidemic anymore. in this model we focus on the testing of the d-individuals. the quantity n(t) σ g d is flux of successfully tested dindividuals which become r-individuals. the flux of tested d-individuals which are false negatives is n(t) ( − σ) g d which go from the class of d-individuals to the u -individuals. the parameters of the model and the initial conditions of the model are listed in table . before describing our method we need to introduce a few useful identities. the cumulative number of reported cases is obtained by using the following equation ( . ) all rights reserved. no reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in the copyright holder for this this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint the daily number of reported cases dr (t) is given by ( . ) the cumulative number of detectable cases is given by and the cumulative number of undetectable cases is given by time (in days) number of reported (tested infectious) cases at time t cumulative number of reported (tested infectious) cases at time t daily number of reported (tested infectious) cases at time t cumulative number of undetectable infectious at time t ( . ) in order to deal with data, we need to understand how to set the parameters as well as some components of the initial conditions. in order to do so, we extend the method presented first in [ ] . the main novelty here will concern the cumulative number of tests which is assumed to grow linearly at the beginning. this property is satisfied for the new-york state data as we can see in perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in the copyright holder for this this version posted october , . . this means that we can find a pair of numbers a and b such that where a the daily number of tests and n is the cumulative number of tests on day t . by using the fact that n (t) = n(t) we deduce that april. figure shows that the linear growth assumption is reasonable for the new-york state cumulative testing data. phenomenological models for the reported cases: at the early stage of the epidemic, we assume that all the infected components of the system grow exponentially while the number of susceptible remains unchanged during a relatively short period of time t ∈ [t , t ]. therefore, we will assume that we deduce that the cumulative number of reported satisfies hence by replacing d(t) by the exponential formula ( . ) and it is makes sense to assume that cr(t) − cr(t ) has the following form by identifying ( . ) and ( . ) we deduce that all rights reserved. no reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in the copyright holder for this this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint by using ( . ) we obtain ( . ) finally by using ( . ) d = χ χ σ a g . ( . ) and by using ( . ) we obtain ( . ) we assume that the transmission coefficient takes the form where τ > is the initial transmission coefficient, t m > is the time at which the social distancing starts in the population, µ > is serving to modulate the speed at which this social distancing is taking place. to take into account the effect of social distancing and public measures, we assume that the transmission coefficient τ (t) can be modulated by γ. indeed by the closing of schools and non-essential shops and by imposing social distancing the population of the new-york state, the number of contacts per day is reduced. this effect was visible on the news during the first wave of the covid- epidemic in new-york city since the streets were almost empty at some point. the parameter γ > is the percentage of the number of transmissions that remain after a transition period (depending on µ), compared to a normal situation. a similar non-constant transmission rate was considered by chowell et al. [ ] . in figure we consider a constant transmission rate τ (t) ≡ τ which corresponds to γ = in ( . ). in order to evaluate the distance between the model and the data, we compare the distance between the cumulative number of cases cr produced by the model and the data (see the orange dots and orange curve in figure -(a) ). in figure -(c) we can observe that the cumulative number of cases increases up more than millions of people, which indeed is not realistic. nevertheless by choosing the parameter g = . × − = / s in figure -(d) we can see that the orange dots and the blue curve match very well. all rights reserved. no reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in the copyright holder for this this version posted october , . we plot the number of cases obtained from the model. we can observe that most of the cases are unreported. in figure (d) we plot the daily number of tests (black dots), the daily number of positive cases (red dots) for the state of new-york and the daily number of cases dd(t) obtained from the data. in the rest of this section, we focus on the model with confinement (or social distancing) measures. we assume that such social distancing measures have a strong impact on the transmission rate by assuming that γ = . < . it means that only % of the transmissions will remain after a transition period. in figure -(c) we can observe that the cumulative number of cases increases up to (blue curve) while the cumulative number reported cases goes up to . in figure -(d) we can see that the orange dots and the blue curve match very well again. in order to get this fit we fix the parameter g = − . in figure (a) and (b), we aim at understanding the connection between the daily fluctuations of the number of reported cases (epidemic dynamic) and the daily number of tests (testing dynamics). the combination of both the testing dynamics and the infection dynamics gives indeed a very complex curve parametrized by the time. it seems that the only reasonable comparison that we can make is between the cumulative number of reported cases and the cumulative number of tests. in figure in figure , all the curves are time dependent parametrized curves. the abscissa is the number of tests (horizontal axis) and the ordinate is the number of reported cases (vertical axis). it corresponds (with our notations) to the parametric functions t → (n data (t), dr(t)) in figures (a) and (b) and their cumulative equivalent t → (n data (t), cr(t)) in figure (c) and (d). in figures (a) and (c) we use only the data, that is to say that we plot t → (n data (t), dr data (t)) and t → (n data (t), cr data (t)). in figures (b) and (d) we use only the model for the number of reported cases, that is to say that we plot t → (n data (t), dr model (t)) and t → (n data (t), cr model (t)). all rights reserved. no reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in the copyright holder for this this version posted october , . figure . in figure (a) we plot the daily number of cases coming from the data as a function of the daily number of tests. in figure (b) we plot the daily number of cases given by the model as a function of the cumulative number of cases coming from the data. in figure (c) we plot the cumulative number of cases coming from the data as a function of the cumulative number of tests. in figure (d) we plot the cumulative number of cases coming from the model as a function of the cumulative number of tests from the data. in figure , our goal is to investigate the effect of a change in the testing policy in the new-york state. we are particularly interested in estimating the effect of an increase of the number of tests on the epidemic. indeed people commonly say that increasing the number of tests will be beneficial to reduce the number of cases. so here, we try to quantify this idea by using our model. in figure , we replace the daily number of tests n data (t) (coming from the data for new-york's state) in the model by either × n data (t), × n data (t), × n data (t) or × n data (t). as expected, an increase of the number of tests is helping to reduce the number of cases. however, after increasing times the number of tests, there is no significant difference (in the number of reported) between times and times more tests. therefore there must be an optimum between increasing the number of tests (which costs money and other limited resources) and being efficient to slow down the epidemic. all rights reserved. no reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in parameter values: are the same as in figure . in figure (a) we plot the cumulated number of cases cr(t) as a function of time. in figure (b) we plot the cumulative number of undetectable cases cu (t) as a function of time. in figure (c) we plot the cumulative number of cases (including covert cases) cd(t) as a function of time. note that the total number of cases (including covert cases) is reduced by % when the number of tests is multiplied by . in this article, we propose a new epidemic model involving the daily number of tests as an input of the model. the model itself is extending our previous models presented in [ , [ ] [ ] [ ] [ ] [ ] . we propose a new method to use the data in such a context based on the fact that the cumulative number of tests grows linearly at the early stage of the epidemic. figure shows that this is a reasonable assumption for the new-york state data from mid-march to mid-april. our numerical simulations show a very good concordance between the number of reported cases produced by the model and the data in two very different situations. indeed, figures and correspond respectively to an epidemic without and with public intervention to limit the number of transmissions. this is an important observation since this shows that testing data and reported cases are not sufficient to evaluate the real amplitude of the epidemic. to solve this problem, the only solution seems to include a different kind of data to the models. this could be done by studying statistically representative samples in the population. otherwise, biases can always be suspected. such a question is of particular interest in order to evaluate the fraction of the population that has been infected by the virus and their possible immunity. in figure , we compare the testing dynamic (day by day variation in the number of tests) and the reported cases dynamic (day by day variation in the number of reported). indeed, the daily case is extremely complex, but we also obtain some relatively robust curve for the cumulative numbers. our model give a good fit for this cumulative cases. in figure , we compare multiple testing strategies. by increasing , , and times the number of tests, we can observe that this efficient up to some point and but increasing times is not making a big difference. therefore, it is useless to test to many peoples and there must an optimum (between the cost of the tests) and the efficiency in the evaluation of the number of cases. infective diseases of humans: dynamics and control simple models for containment of a pandemic the mathematical theory of epidemics mathematical epidemiology mathematical models in epidemiology vertically transmitted diseases: models and dynamics the basic reproductive number of ebola and the effects of public health measures: the cases of congo and uganda modelling the covid- epidemics in brasil: parametric identification and public health measures influence mathematical tools for understanding infectious disease dynamics unreported cases for age dependent covid- outbreak in japan the mathematics of infectious diseases modeling infectious diseases in humans and animals understanding unreported cases in the -ncov epidemic outbreak in wuhan, china, and the importance of major public health interventions predicting the cumulative number of cases for the covid- epidemic in china from early data a covid- epidemic model with latency period a model to predict covid- epidemics with applications to south korea predicting the number of reported and unreported cases for the covid- epidemics in china estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship covert coronavirus infections could be seeding new outbreaks using early data to estimate the actual infection fatality ratio from covid- in france effect of a one-month lockdown on the epidemic dynamics of covid- in france transmission of -ncov infection from an asymptomatic contact in germany mathematics in population biology estimation of the transmissionrisk of the -ncov and its implication for public health interventions evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease nowcasting and forecasting the potential domestic and inter-national spread of the -ncov outbreak originating in wuhan, china: a modelling study key: cord- -t mykk authors: kong, dechuan; wang, yuanping; lu, lu; wu, huanyu; ye, chuchu; wagner, abram l.; yang, jixing; zheng, yaxu; gong, xiaohuan; zhu, yiyi; jin, bihong; xiao, wenjia; mao, shenghua; jiang, chenyan; lin, sheng; han, ruobing; yu, xiao; cui, peng; fang, qiwen; lu, yihan; pan, hao title: clusters of coronavirus disease (covid‐ ) cases in chinese tour groups date: - - journal: transbound emerg dis doi: . /tbed. sha: doc_id: cord_uid: t mykk international travel may facilitate the spread of the novel coronavirus disease (covid‐ ). the study describes clusters of covid‐ cases within chinese tour groups travelling in europe january – . we compared characteristics of cases and non‐cases to determine transmission dynamics. the index case travelled from wuhan, china, to europe on january , and to shanghai, china, on january , within a tour group (group a). tour groups with the same outbound flight (group b) or the same tourism venue (group d) and all chinese passengers on the inbound flight (group c) were investigated. the outbreak involved confirmed cases, suspected cases and six tourists who remained healthy. group a, involving seven confirmed cases and six suspected cases, consisted of familial transmission followed by propagative transmission. there was less pathogenicity with propagative transmission than with familial transmission. disease was transmitted in shared outbound flights, shopping venues within europe and inbound flight back to china. the novel coronavirus caused clustered cases of covid‐ in tour groups. when tourism and travel opens up, governments will need to improve screening at airports and consider increased surveillance of tour groups—particularly those with older tour members. a novel coronavirus (sars-cov- ) was discovered in mainland china in december (harapan et al., ; wu et al., ) . the world health organization (who) declared coronavirus disease a pandemic on march (world health organization, d . in many countries outside of china, the first cases were identified as tourists and students from the city of wuhan travelling abroad. similarly, the spread of sars-cov- throughout southwestern and central asia has been facilitated by iranian citizens and residents who were travelling outside of iran (tuite et al., ) . shown that there is person-to-person transmission among close contacts since the middle of december . in recent studies, clusters of covid- cases have been principally identified in family settings (bai et al., ; chan et al., ) . these patterns suggest that familial transmission-through living and eating together-is a key contributor to the spread of covid- . how disease is spread outside of close contacts is less clear. other infectious diseases with airborne transmission have reported clusters of cases outside of family settings. in , a cluster of influenza a/h n cases occurred in a tour group in tour bus in sichuan province, china (han et al., ). in the current covid- pandemic, two cases were reported at a conference in germany (rothe et al., ) . another notable example has been the diamond princess cruise ship, which initially carried approximately , passengers and crew from more than countries and regions. there have been more than confirmed cases of covid- in the ship. the spread of disease thought to be attributable to inappropriate containment measures in the ship (world health organization, a). year, or the spring festival, the most important holiday in china. during this time, chinese people often travel domestically and abroad. before wuhan was closed off, it is believed that a couple of million local people left the city for travel, which could have facilitated the spread of covid- to foreign countries. it is not as clear how well the infection is transmitted in tour groups outside of the familial setting. our study describes clusters of covid- cases within tour groups travelling in european countries from january through . this study conducted a retrospective look at four cohorts of individuals. the index case was a -year-old chinese man who had travelled from the city of wuhan, china, to paris, france, on january and back to shanghai, china, on january , within a tour group of totally members (group a). during the travel, a total of seven confirmed cases and six suspected cases were documented within the tour group. group a were on three flights, af (wuhan-paris), af (paris-rome) and af (paris-shanghai). we examined two other groups have epidemiological evidence, that is travelling or living in hubei province or communities with a confirmed case of covid- , or having contact with a confirmed case of covid- or having contact with patients with fever and/or respiratory symptoms from hubei province or communities with confirmed case of covid- within days. cases' clinical evidence could include fever and/or respiratory symptoms, pneumonia-related radiological finding, normal or reduced white blood cell count or reduced lymphocyte count. a suspected case was defined by at least one of epidemiological criterion combined with at least two clinical criteria or clinical evidence combined with zero epidemiological evidence. a confirmed case was defined by a positive rt-pcr test. based on their exposure history, we categorized cases as having familial or propagative (i.e. within tour group) transmission. we calculated the proportion of pathogenicity by group by counting the number of individuals with a sign or symptom of disease. the data that support the findings of this study are available on request from the corresponding author. the data are not publicly available due to privacy or ethical restrictions. the index case and his wife and parents-in-law lived in two separate apartments in a city km away from wuhan, in hubei province. on january , they went to wuhan for a schengen visa application and then had a dinner taking wild eel (monopterus albus) at the aquatic food corner of huanan seafood wholesale market where initial cases were reported in the beginning of the covid- epidemic . it is likely that some of the family members were exposed to sars-cov- . on january , the family joined the tour group a and boarded the flight af . the index case's father-in-law (zero case), the index case, the index case's wife (case ) and mother-in-law (case ) successively had symptoms on january , , and . the zero case developed severe symptoms and was hospitalized in paris on january , and was taken care of by his daughter (case ). these two were labelled as the th and th cases in france. the index case and case went back to china on january and were immediately diagnosed as covid- confirmed cases. the timeline was listed in figure . group a was placed under quarantine once they arrived back in shanghai, china. among the rest (n = ) of the group, a total of nine members successively developed symptoms from january through february in quarantine, including three confirmed cases and six suspected cases. the cases and their family members/ accompanying friends are described in figure . clinical examinations and virological testing results are presented in table . pathogenicity in the group transmission ( / ) was lower compared with the familial transmission ( / ). similarly, pathogenicity seemed to be weakened as all of the family were confirmed cases ( / ), whereas the following cases in the group transmission included both confirmed ( / ) and suspected ( / ) cases. tour group transmission may have occurred in the following sce- paris-shanghai, all of the confirmed and suspected cases had seats within two rows ( figure ). furthermore, suspected cases had nearer seat proximity to the family cases, compared with the other three confirmed cases (case , , ) which may be attributable to the suspected cases being less contagious. considering time sequence of onset and exposure/ contact history, we inferred that there was initially a familial transmission, followed by a propagative transmission within the group, which possibly occurred during the tour and on the inbound flight. in addition, we identified that five members had close contact with the cases, who remained healthy during the -day tour in europe and in -day quarantine in shanghai ( figure ) . similarly, some members who had seats close to the confirmed cases remained healthy (figure ). on af , there was a cluster consisting of two covid- confirmed cases and one suspected case, which all belonged to tour group b (table ) . they shared the same outbound flight from wuhan with group a and then had different itineraries in europe (figure ). on board, the cases in group b had a seat proximity of > rows to the family in group a. at this point, the zero case did not have any symptoms. the onset of disease in the first case (case ) in group b occurred on january , which was days later than the zero case in group a. thus, we could not completely exclude the connection to group a. on af , there were approximately chinese passengers (group c; they shared the same flight but not belonged to a same tour group), in which two were diagnosed as suspected case in quarantine after arrival in shanghai (figure ; table ). case was an independent traveller, and case was a guide of a tour group of members (the rest of the tour group have not developed symptoms). their seats were < rows away from the cases in group a. neither of them reported travel or living history in hubei province/ communities with confirmed case of covid- ; contact with confirmed case of covid- ; or contact with patients with fever and/ or respiratory symptoms from hubei province/ communities with confirmed case of covid- , within days before the onset. they might have a connection to group a. we identified another group of tourists (group d), which had been visiting interlaken, switzerland, in the afternoon of january , sharing the same shopping venue with the group a. the group d was not placed under quarantine after they arrived in shanghai. later, two confirmed cases and one suspected case were successively diagnosed, which composed a cluster (figure ; table a large concern is if sars-cov- is able to efficiently spread in settings beyond the family or other sustained close contact. we reported three clusters of covid- confirmed cases in three tour groups travelling in european countries and one cluster of suspected cases on one flight in late january . the outbreak in total involved confirmed cases, suspected cases and more than two hundred persons placed in quarantine. in group a, the cluster was initiated by a familial transmission, followed by spread of disease to out of members in the -day tour. group a was characterized by lower pathogenicity in the following group transmission, compared with the familial transmission which might be attributable to exposure to the huanan seafood wholesale market. in our study, the first case in group d might have been infected through a casual meeting with the zero case in group a at a shopping venue. a similar finding had been reported in a previous study that reports that chinese tourists wearing facial masks may have infected a thai taxi driver (pongpirul, pongpirul, ratnarathon, & prasithsirikul, ) . thus, there may be two conditions facilitating efficient transmission, ( ) confined space and ( ) consistent close contact. however, we found five tour group members who remained healthy even after sustained contact with the cases, such as sharing same hotel rooms, taking dinner together and having neighbouring seats. one explanation is that children are less susceptible to the virus (del rio & malani, ) . further studies on how the virus transmits across different age groups are urgently warranted. this is especially important considering the possible role of pre-symptomatic transmission . furthermore, we supposed that group c had a connection to group a and could not exclude a connection between groups b and a. these connections suggest potential transmission on the plane. recent studies have documented conflicting findings, including possible transmission on planes (liu, liao, chang, chou, & lin, ) or in cars (pongpirul et al., ) , but also no observed transmission in vehicles (phan et al., ) . previous studies have shown that planes have high-efficiency particulate air filters that may avoid airborne transmission of pathogens, whereas buses have about % recirculated inside air (han et al., ). we did not precisely examine the seats in tour bus. the confirmed and suspected cases had an obvious cluster of seats on the inbound flight, suggesting the infection was very likely to occur on plane, which may be associated with high affinity of sars-cov- spike glycoprotein binding ace (wrapp et al., ) . however, we also identified healthy members after taking seats close to the family cases on board. thus, we hypothesized that the zero case and case were hospitalized in paris; thus, we did not obtain detailed clinical examination and virological testing results. b case was kept in quarantine for days after her arrival in china and then diagnosed another days later, due to a stay-home notice sent by shanghai municipal center for disease control and prevention; thus, we did not obtain detailed clinical examination and virological testing results. disabling the efficient transmission of sars-cov- may depend on social distance and personal protection, in addition to air conditioning system and air filters. the tour groups included in our study had visited france, italy, switzerland, spain, portugal, germany and morocco, which has raised a public health concern of spreading the virus internationally. currently, china is the number sender of tourists globally and is estimated to be by (arcibal, ) . however, the entry-exit quarantine in airports has limited capability in detecting cases whose course of infection is in the incubation period. this problem of detection has been documented in the influenza a/h n (priest, duncan, jennings, & baker, ) and current covid- pandemic (gostic, gomez, mummah, kucharski, & lloyd-smith, ) . the spread of sars-cov- into south korea, italy and iran has increased attention towards those tourists (gostic et al., ; pongpirul et al., ; tuite et al., ) . however, it is possible that the typical activities undertaken by tourists make them less likely to infect compared with other members of the tour group. the zero case in group a was diagnosed in france. however, we did not identify any local cases epidemiologically linked to the tour group members in the above-mentioned countries. this lack of transmission may be attributed to the absence of sustained contact in a confined space between local people and chinese tourists. there of course could be existing cases with mild or no obvious symptoms. since february , covid- cases have increased dramatically in italy, iran and south korea, which have been retrospectively traced to some locals who reported no known exposure history (world health organization, b, c). they might have been exposed to asymptomatic carriers of sars-cov- . thus, improvement in the continuous surveillance on international tourists remains crucial. the study has several limitations. the sensitivity of the pcr assays could be low and result in a large number of false-negative results in the diagnosis of covid- (sheridan, ; wang et al., ) . all of the suspected cases reported in this study were finally excluded from the diagnosis of covid- due to a negative rt-pcr test, though some of them had pulmonary inflammation according to chest ct examination. because our diagnostic methods may have underestimated the incidence of disease in the study population, we combined suspected cases with confirmed cases to explore potential transmission dynamics. another limitation was recall bias and concealment in the investigation. we checked the activities with each case, cross-checked activities between cases, illustrated the transmission chains and then determined the potential connections between cases and groups. we also may have missed asymptomatic carriers on the passenger flights. in conclusion, we reported a cluster of covid- cases, which was initiated by within-family transmission followed by propagative transmission into tour groups travelling in european countries. the study findings show that clustered cases in tour groups may be more propagative than simple familial transmission. currently, the covid- pandemic is spreading to increased numbers of countries and regions worldwide. if we consider each country as a group, such as china, south korea, iran and italy, we could understand the pandemic of the covid- as a propagative transmission within a 'group' and then between 'groups'. thus, the government should improve screening at airports and consider increased surveillance of tour groups-particularly those with older tour members. we thank all the investigators in the pudong new area, huangpu tion, analysis and interpretation of data; the writing of the manuscript; the decision to submit the manuscript for publication. all authors declare no competing interests. this study involved the use of existing, routinely collected data from a public health outbreak investigation, under the national health commission of the people's republic of china. all data included in the study were kept confidential without person identifiers. no additional interviews were conducted, and no data were collected independently for this study. thus, this study is exempt from ethical review and there was no need of obtaining informed consent. the data that support the findings of this study are available on request from the corresponding author. the data are not publicly available due to privacy or ethical restrictions. yihan lu https://orcid.org/ - - - hao pan https://orcid.org/ - - - mainland chinese will overtake americans to become largest group of international tourists by , says euromonitor a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster novel coronavirus-important information for clinicians diagnostic and treatment protocol for novel coronavirus pneumonia (trial version estimated effectiveness of symptom and risk screening to prevent the spread of covid- lack of airborne transmission during outbreak of pandemic (h n ) among tour group members, china coronavirus disease (covid- ): a literature review pre-symptomatic transmission of novel coronavirus in community settings. influenza and other respiratory viruses early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a locally transmitted case of sars-cov- infection in taiwan importation and human-to-human transmission of a novel coronavirus in vietnam journey of a thai taxi driver and novel coronavirus thermal image scanning for influenza border screening: results of an airport screening study transmission of -ncov infection from an asymptomatic contact in germany coronavirus and the race to distribute reliable diagnostics estimation of covid- burden and potential for international dissemination of infection from iran clinical diagnosis of samples with -novel coronavirus in coronavirus disease (covid- ): situation report - missi on-in-italy -to-suppo rt-covid - -contr ol-and-preve ntion -efforts. world health organization ( c). who director-general's opening remarks at the mission briefing on covid- who director-general's opening remarks at the mission briefing on covid- - who director-general's remarks at the media briefing on -ncov on cryo-em structure of the -ncov spike in the prefusion conformation a new coronavirus associated with human respiratory disease in china clusters of coronavirus disease (covid- ) cases in chinese tour groups key: cord- -nqq d m authors: zou, d.; wang, l.; xu, p.; chen, j.; zhang, w.; gu, q. title: epidemic model guided machine learning for covid- forecasts in the united states date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: nqq d m we propose a new epidemic model (sueir) for forecasting the spread of covid- , including numbers of confirmed and fatality cases at national and state levels in the united states. specifically, the sueir model is a variant of the seir model by taking into account the untested/unreported cases of covid- , and trained by machine learning algorithms based on the reported historical data. besides providing basic projections for confirmed and fatality cases, the proposed sueir model is also able to predict the peak date of active cases, and estimate the basic reproduction number (r ). in particular, the forecasts based on our model suggest that the peak date of the us, new york state, and california state are / / , / / , and / / respectively. in addition, the estimated r of the us, new york state, and california state are . , . and . respectively. the prediction results for all states in the us can be found on our project website: https://covid .uclaml.org, which are updated on a weekly basis, and have been adopted by the centers for disease control and prevention (cdc) for covid- death forecasts (https://www.cdc.gov/coronavirus/ -ncov/covid-data/forecasting-us.html). one of the best ways to prevent the spread of covid- in the short term is to follow the mitigation strategies such as social distancing, quarantine, and isolation. for example, the state of california in the us has issued mandatory stay-at-home order on march , shutting down all non-essential businesses. only essential services, such as grocery stores, pharmacies, delivery restaurants, have remained open, and residents who need to leave home to take part in essential activities are advised to practice social distancing. with the increasing availability of public data on covid- , more and more researches (flaxman et al., ; bendavid et al., ; sutton et al., ; altieri et al., ; bertozzi et al., ; murray et al., ) have been carried out to understand and prevent the spread of covid- from different aspects. among them, one important research direction is to model and forecast the spread of covid- , such as predicting the peak of the active cases on the virus and the size of the coronavirus outbreak. such results can help government agencies better understand the overall impact of the disease and also facilitate policy makers in terms of pandemic preparedness and response such as allocating the medical resources. one widely used method for modeling the spread of infectious disease is to use epidemic models such as susceptible-infected-resistant (sir) (kermack and mckendrick, ) and susceptible-exposed-infected-removed (seir) (hethcote, ) . such epidemic models are quite useful in describing the dynamics of transmission and are well-suited for predicting the peak of active cases on the virus. from the decision-making perspective, the peak prediction is able to forewarn the health system when to expect a surge in cases. furthermore, the reproduction number (fraser et al., ) estimated by the epidemic model can be directly used to measure the effectiveness of the intervention strategies such as social distancing and quarantine. several recent work used epidemic models such as the sir and seir models li et al., a; wu et al., ; kucharski et al., ; read et al., ; tang et al., ; ferguson et al., ) to simulate the spread of covid- in different regions and were able to forecast the size and severity of such epidemic outbreak. some other work (chinazzi et al., ; kraemer et al., ; dandekar and barbastathis, ) also applied these epidemic models to study the role of quarantine controls such as travel restrictions in the spread of covid- . most of the aforementioned studies consider classical epidemic models, e.g., the sir and seir models, and base their analyses on the public reported data. however, it is often the case that the number of publicly reported cases (including confirmed cases and recovered cases) are much less than their real numbers as many infectious cases have not been tested due to test capability and asymptomatic patients, or even possibly under-reporting (li et al., b) . as a result, classical epidemic models such as sir and seir cannot accurately characterize the epidemic evolution of covid- without taking such unreported cases into consideration. in addition, most existing work is focused on the nation-wide prediction. nevertheless, it is also very important and beneficial to provide state and county level forecasts to assist local public health departments and governments to prevent the spread of covid- . the goal of this paper is to make good use of the current public data on covid- to better understand the spread of the coronavirus and to facilitate informed decisions by policy makers. in order to achieve this goal, we develop a new epidemic model, called the sueir model, to forecast the active cases and deaths of covid- by taking the untested/unreported cases into consideration. in addition, we use machine learning based methods to train our model, which enables us to train the model efficiently. based on the proposed model, we are able to make accurate predictions on the numbers of confirmed cases and fatality cases for nation, states and and counties. moreover, our model can also predict the peak dates of active cases and estimate the basic reproduction number (r ) of different states in the us. in this subsection, we briefly introduce two classical epidemic models, i.e., the sir (kermack and mckendrick, ) and seir models (hethcote, ) , which have been adopted in many previous work to study the epidemic outbreaks such as sars (fang et al., ; saito et al., ; smirnova et al., ) and the ongoing covid- (read et al., ; tang et al., ; wu et al., ) . the sir model. the sir model is an epidemic model that shows the change of infection rate over time. more specifically, it characterizes the dynamic interplay among the susceptible individuals (s), infectious individuals (i) and removed individuals (r) (including recovered and deceased) in a certain place. in the sir model, the susceptible individuals may become infectious individuals over time, which depends on the spread rate of the virus, often called the contact rate. recovered individuals are assumed to be immune to the virus and thus cannot become susceptible again. to characterize this dynamics, we use s t , i t , r t to represent the number of susceptible, infectious, and removed individuals at time t, respectively. suppose that the total population in a certain area is fixed as n , then the evolving equations of the above variables over time are defined as follows: where β is the contact rate between the susceptible and infectious groups, and γ is the transition rate between the infectious and removed groups. the above ordinary differential equations indicate that at every time unit the total number of susceptible individuals will decrease by a quantity −βi t s t /n , which will transit into the infectious group. apart from the increase from the transition of susceptible individuals, the size of the infectious group will also decrease by a factor of γ. the seir model. for many diseases, there is often an incubation period during which individuals who have been exposed to the virus may not be as contagious as the infectious individuals. therefore, it is necessary to separately model these cases as the "exposed" group, and this gives rise to the seir model. the dynamics of the seir model introduces a new compartment e t , which models the number of individuals that are exposed to the disease but have not developed obvious symptoms. among all the exposed cases, there are only a σ fraction of people who will develop observable symptoms in a time unit. therefore, the dynamic of this model can be defined by the following ordinary differential equations: compared with the sir model, the seir model has more elaborated model parameters. the parameters σ, β and γ can be learned from the reported data. reproduction number. an important quantity to characterize the dynamic of a pandemic is the basic reproduction number r , which is the expected number of cases directly generated by one case in a population where all individuals are susceptible to infection (fraser et al., ) . the . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . basic reproduction number in the sir and seir models can be computed as r = β/γ. in this section, we propose a new epidemic model and a machine learning method to train this model. it is observed that covid- has an incubation period ranging from to days (lauer et al., ) . it has also been observed that individuals who have been exposed to the coronavirus can also infect the susceptible group during this period. in addition, it is often the case that the number of reported cases (including confirmed cases and recovered cases) are less than their real numbers as many exposed cases have not been tested, which will not pass to the next compartment. however, such important factors cannot be characterized by the classical epidemic models such as the sir and seir models. we also observe that directly applying sir or seir model to fit the reported data will lead to unreasonable predictions. therefore, we proposed a new epidemic model that takes the untested/unreported cases as well as the "silent spreaders" into consideration. we call our model the sueir model and it is illustrated in figure . in particular, the compartment exposed in our model is considered as the individuals that have already been infected and have not been tested. therefore, they also have the capability to infect the susceptible individuals. moreover, some of such individuals can receive a test and be further passed to the infectious compartment (as well as reported to the public), while the others will recover but not appear in the publicly reported cases. therefore, we introduce a new parameter < µ < in the evolution dynamics of i t to characterize the ratio of the exposed cases that are confirmed and reported to the public, which we call it the discovery rate. this discovery rate reflects the unreported/undiscovered cases, which is an important latent factor in the dynamics of the epidemic model. as a result, we propose to use the following ordinary differential equations to describe our . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint proposed sueir model: where β denotes the contact rate between the susceptible and "infected" groups (including both exposed and infectious compartments in figure ), σ denotes the ratio of cases in the exposed compartments that are either confirmed as infectious or dead/recovered without confirmation, µ is the discovery rate of the infected cases, and γ denotes the transition rate between the compartments i and r. in this subsection, we will introduce our proposed machine learning method for training the sueir model. in addition, we will also present the detailed configurations used in our experiments. model training. as aforementioned in this paper, our model can be described by the ode ( ), which is determined by the parameters θ = (β, σ, γ, µ). in particular, given the model parameters θ and initial quantities s , e , i , and r , we can compute the number of individuals in each group (i.e., s, e, i, and r) at time t, denoted by s t , e t , i t and r t , via applying standard numerical ode solvers onto the ode ( ). then we propose to learn the model parameter θ = ( β, σ, γ, µ) by minimizing the following logarithmic-type mean square error (mse): where with i t and r t denote the reported numbers of infected cases and removed cases (including both recovered cases and fatality cases) at time t (i.e., date), and p is the smoothing parameter used to ensure numerical stability. note that given s , e , i and r , i t and r t can be described as differentiable functions of the parameter θ. then the model parameter θ = argmin θ l(θ; i, r) can be learnt by applying standard gradient based optimizer (e.g., bfgs) onto the loss function ( ) under the constraint that β, σ, γ, µ ∈ [ , ]. estimation of the number of removed cases r t . note that i t and r t in our model determine the number of "current" infectious cases (a.k.a., active cases) and the removed cases, i.e., the sum of recovered and fatality cases, respectively. however, most of the reported data only include the number of confirmed cases, i.e., sum of infected cases and removed cases i t + r t . in order to train the model, we need to get i t and r t separately. in addition, the sueir model can only predict the number of removed cases, while in many cases people are more interested in the number of fatality cases. therefore, in order to enable the training of the sueir model, as well as provide the . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . predictions for the number of fatality cases, we have to: ( ) estimate the number of removed cases; ( ) determine the number of active cases in the reported data by subtracting the estimated number of removed cases. in order to do so, we propose to use the following exponential function to model the ratio between the daily increased fatality cases and the removed cases, where a, b > are parameters controlling the shape of the exponential function and t denotes the number of days since the starting date. in order to demonstrate its effectiveness, we evaluate the approximation error based on the reported data in four countries: us, china, france, and italy, which have separately reported fatality and recovered cases. more specifically, given parameters a, b and the number of fatality cases, we are able to estimate the corresponding number of removed cases. then the optimal parameters a and b are obtained by minimizing the mse between the reported number of removed cases and the estimated one on different dates. the results are displayed in figure , which clearly shows that the exponential functions can well describe the ratio between the daily increased numbers of fatality and removed cases. for each state and county in the us, we try several different choices of a and b around the optimal ones we obtained for the us, and pick the one with the smallest validation error. initialization. in terms of the initialization, we directly set i = i and r = r . additionally, one can typically set s + e + i + r = n , where n is the total population of the region (which can be either a country or a state/county). however, since most of the states/counties in the us have already issued the stay-at-home offer, the actual total number of cases in the sueir model will be strictly less than n . thus we set s + e + i + r = n for some n < n . moreover, it is worth noting that the initialization of e, i.e., e , is a bit tricky since we do not know the number of infected cases before testing them. it is not reasonable to set e = since generally there has already existed a large number of infected cases when the local governments began to test. therefore, we propose to use a validation set to choose the optimal initial estimates n and e when training our model. to determine the initial values of n and e , we first divide our data into the training data set and the validation data set. in detail, we choose the data in the most recent here we omit the numbers of removed cases and recovered cases at the initialization by setting i and r to be the reported numbers of confirmed cases and fatality cases. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . days as the validation set, while treating the remaining as the training set. for example, suppose we have the data up to may , , the data after may , will be used as the validation set, and the data up to may , will be used as the training set. we then do a grid search on different combinations of n and e and train different models on the training set accordingly. finally, we choose the combination of n and e with the smallest validation loss (evaluated using the loss function ( )) along with the best model parameters (i.e., β, γ, σ, µ) to build the sueir model for prediction. given the initial quantities s , e , i , r , we can solve the optimization problem in ( ) to obtain the model parameter θ = ( β, σ, γ, µ). to assess the confidence of our estimator, we construct the confidence interval of θ following the previous work (ma, ) . more specifically, for a valid model parameter θ, we can compute the loss l θ in ( ), and construct the test statistic as t θ = t l θ − l( θ) , which represents the loglikelihood ratio between the point estimator θ and θ. note that θ contains four free parameters (i.e., β, σ, γ and µ) while θ is fixed. by wilks's theorem (wilks, ) , we know that t θ follows χ distribution asymptotically. as a result, we can compare t θ with the ( − α) quantile of the χ distribution and determine whether θ is in the confidence interval or not. in our experiment, we apply grid search on both sides of the point estimator θ to find the boundary of the confidence interval. we can also compute the basic reproduction number based on our proposed sueir model. note that our model has a different dynamics from that of sir and seir models. thus we cannot directly apply the standard computation method of r for the sir or seir model to compute such number. instead, we use the method proposed in heffernan et al. ( ) to calculate r based on the nextgeneration matrix. in specific, let x = (x , . . . , x ) with x i being the number of infected individuals in the compartment i. then we denote by function f i (x) the rate of new infections in compartment i, and denote by v − i (x) and v + i (x) the rate of individuals transferred out of the compartment i and the rate of individuals transferred into the compartment i by all other means respectively. let . . , f (x)) and v (x) = (v (x), . . . , v (x)) . the ode ( ) can be rewritten as note that the disease-free equilibrium of our model is x * = (n, , , ) . let f and v be the partial jacobian matrices of functions f (x) and v (x) with respect to the number of individuals in the . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https: //doi.org/ . //doi.org/ . / "infective" compartments (both e and i compartments in the sueir model), i.e., x and x , i.e., then the next-generation matrix g = fv − can be computed as follows: note that r is given by the largest eigenvalue of next generation matrix g (heffernan et al., ) . therefore, it is easy to show that the basic reproduction number of our proposed sueir model is in contrast, the basic reproduction number for sir and seir is r = β/γ. in this section, we present the forecast results, including confirmed cases and deaths, peak date and reproduction number, by our method. data collection. we use the data from the johns hopkins university center for systems science and engineering (dong et al., ) to train our model for national-level forecasts. to train the state-level models, we use the data from the new york times . in addition, we use the data from / / (most states have already issued the stay-at-home order by this date) to / / to train our models. more specifically, we use the reported data from / / to / / to train the sueir model while using the data from / / to / / for validation. prediction results. for the interest of space, we present the forecast results of our models for the us and states with more than , total cases, including new york, new jersey, illinois, massachusetts, california, pennsylvania, michigan, florida and maryland. for more forecast results, please refer to our forecast website https://covid .uclaml.org table summarizes the projected death and its corresponding % confidence interval in the aforementioned regions from / / to / / . the results show that our predictions are very close to the reported data, which suggests that our method performs very well in terms of the death forecasts. we also show the long term death forecasts by our method in table . our results suggest that by june , the projected death for the us is . × ( % ci . × - . × ). we demonstrate the projected number of confirmed cases by our approach along with its % confidence interval in table . the results suggest that our predictions in terms of the number https://github.com/cssegisanddata/covid- https://github.com/nytimes/covid- -data . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . table : short-term (daily ahead) prediction (× ) of total deaths in the us and states with more than , total cases. for each region, we present the predicted cumulative fatality cases with a % confidence interval. the reported number of deaths (groundtruth) from the jhu csse (for the us) and the new york times (for different states) is presented right below the predictions. of confirmed cases are also reasonably accurate. for example, the reported number of confirmed cases in the us on / / is × , and our projected number is × ( % ci × - × ), which underestimates × cases. in addition, the projected number of long term confirmed case is presented in table . it shows that by / / , the projected number of confirmed cases for the us is × ( % ci × - × ). our method can also forecast the peak date in different regions, i.e., the date with the largest number of active cases, as shown in table . it can be seen that the projected peak date of the us is / / , new york state is / / , new jersey is / / , illinois is / / , [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] nj . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] il . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] ma . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . [ . , . ] . massachusetts is / / , california is / / , pennsylvania is / / , michigan is / / , florida is / / , maryland is / / . table summarizes the basic reproduction number r estimated by ( ) in different regions, which characterizes the spread of the virus at the beginning of the epidemic. the results vary for different states, which are consistent with the severity of the coronavirus outbreak in these regions since mid march. for example the r values of the states in the northeastern us (e.g., ny: . , nj: . , ma: . ) are significantly higher than those of other states (e.g. ca: . , mi: . , fl: . ). we developed a novel epidemic model called sueir to infer the unreported cases of individuals contacting covid- . based on this new model, we further develop a machine learning approach to forecast the numbers of confirmed and fatality cases in the us. our model can provide accurate short-term (daily ahead) projections for both confirmed cases and fatality cases at national and state levels, which demonstrates its effectiveness. in the long term, the prediction results by our model suggest that the numbers of confirmed cases and death will keep increasing rapidly within one month. in particular, at the end of june, our model forewarns that there will be approximately millions confirmed infectious cases and k reported deaths in table : short-term (daily ahead) prediction (× ) of total confirmed cases in the us and states with more than , total cases. for each region, we present the predicted cumulative confirmed cases with a % confidence interval. the groundtruth number from the jhu csse (for the us) and the new york times (for different states) is presented under the row of predictions. the united states. our model uses training data since / / at which most states have already issued stay-athome order, and assumes that the contact rate maintains the same level during the training and prediction period. however, starting in may, many states have already lifted the restrictions of businesses and public spaces and considered reopening that allows people to go back to restaurants and offices and places of worship. it remains unclear how these reopening orders affect the contact rate as well as the spread of the virus and therefore our current model does not take this into consideration. table : long-term (weakly ahead) prediction (× ) of total confirmed cases in the us and states with more than , total cases. for each region, we present the predicted cumulative confirmed cases with a % confidence interval. moreover, we found that for most states, the learned discover rate (i.e., µ) is less than . , which implies that a large fraction of "exposed" individuals will finally recover/die without being tested and reported. this further suggests that the actual number of infected cases in the us may be more than millions, while most of them are not counted. this result is consistent with the recent findings by the researchers from the university of southern california , which show that . % (ci: [ . %, . %]) of los angeles residents have already contracted the covid- virus, which is approximately times more than the official reported numbers. curating a covid- data repository and forecasting county-level covid- antibody seroprevalence in santa clara county the challenges of modeling and forecasting the spread of covid- a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster the effect of travel restrictions on the spread of the novel coronavirus quantifying the effect of quarantine control in covid- infectious spread using machine learning. medrxiv an interactive web-based dashboard to track covid- in real time. the lancet infectious diseases modelling the sars epidemic by a lattice-based monte-carlo simulation estimating the number of infections and the impact of non-pharmaceutical interventions on covid- in european countries: technical description update pandemic potential of a strain of influenza a (h n ): early findings. science perspectives on the basic reproductive ratio the mathematics of infectious diseases report : transmissibility of -ncov a contribution to the mathematical theory of epidemics the effect of human mobility and control measures on the covid- epidemic in china early dynamics of transmission and control of covid- : a mathematical modelling study. the lancet infectious diseases the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) estimating epidemic exponential growth rate and basic reproduction number forecasting covid- impact on hospital bed-days, icu-days, ventilator-days and deaths by us state in the next months novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions extension and verification of the seir model on the influenza a (h n ) pandemic in japan forecasting epidemics through nonparametric estimation of time-dependent transmission rates using the seir model seroprevalence of sars-cov- -specific antibodies among adults universal screening for sars-cov- in women admitted for delivery estimation of the transmission risk of the -ncov and its implication for public health interventions coronavirus disease (covid- ) situation report naming the coronavirus disease (covid- ) and the virus that causes it the large-sample distribution of the likelihood ratio for testing composite hypotheses. the annals of mathematical statistics nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study key: cord- -iua c hy authors: zia, kashif; farooq, umar title: covid- outbreak in oman: model-driven impact analysis and challenges date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: iua c hy motivated by the rapid spread of covid- all across the globe, we have performed simulations of a system dynamic epidemic spread model in different possible situations. the simulation, not only captures the model dynamic of the spread of the virus, but also, takes care of population and mobility data. the model is calibrated based on epidemic data and events specifically of sultanate of oman, which can easily be generalized. the simulation results are quite disturbing, indicating that, during a process of stringent social distancing and testing strategies, a small perturbation can lead to quite undesirable outcomes. the simulation results, although consistent in expected outcomes across changing parameters' values, also indicate a substantial mismatch with real numbers. an analysis of what can be the reason of this mismatch is also performed. within these contradictions, for oman, regarding the eradication of epidemic, the future is not extremely alarming. covid- is the latest evidence of epidemic disease capable of producing an extraordinarily large number of infections starting from a few [ ] . according to lippi and plebani, coronavirus disease (covid- ), which originated in the city of wuhan china on december , , is a respirational and zoonotic disease, caused by a virus of the coronaviridae family [ ] . the virus strain is severe acute respiratory syndrome coronavirus (sars-cov- ), resulting in fever, coughing, breathing difficulties, fatigue, and myalgia. it may transform into pneumonia of high intensity. towards successful diagnostic and cure of covid- , scientists in the field of molecular biology [ ] are working hard to find answers about its spreading and infecting by examining virus samples. although, the disease strain is known, but, the vaccine is no where near. and it is essential to ensure strict mitigation actions so that virus can be contained. already, most of the countries are taking different kinds of precautionary measures to cope with it so that the losses can be reduced. from the experiences of china and south korea, the countries able to contain the spread of the disease so far, it is learnt that social distancing and testing are the key factors. another factor responsible of spreading of the disease worldwide was regional and global travellers. although, air travel is almost suspended now, but, this initial shock and countries (and people) not taking it too seriously has taken many countries in europe and north america to a real bad situation. in this overall scenario, after widespread suspension of air travels, oman has taken various other measures to avoid spreading the infection. schools and colleges/universities were closed from mid of march, followed by other nonessential offices and services. the situation is been monitored on daily basis by the government. however, there are many suspected cases which are not been tested so far. by the time of this writing, most of the country is partially locked downed. although, the spread of the disease is not that much as of today (march , ). but, the new cases are appearing continuously. and the next few week are very important. to know what may happen, we need to model and simulate. towards this, we model the dynamics of spread of the disease (the epidemic model), population data and mobility of people. we have used a system that is designed to to it. the epidemic model presented in this paper is not novel. in fact, similar (or even same) models are already proposed in different fields of study. however, contextualization and implementation of the model in the current global and regional situation is significantly important. already such studies are been taken up by the research groups working in this area [ ] . through this paper, we have provided a focused analysis of the situation and asked important what-if questions, particularly in the context of oman. however, the suggested method can be applied to any other country of the world, or even at the global level. also, we have tried to argue why there is a big mismatch between real cases and cases predicted by the simulation. the model is based on well-established state-transition systems that are being used to study epidemics for a long time. the simplest one are si (susceptibleinfectious) and sir (susceptible-infectious-recovered) models [ ] . in both, an infectious individual infects a susceptible individual at a rate β. in sir model, we also have a recovery rate (µ) after which an infectious individual is recovered permanently. it can easily been seen that simple sir model does not fully grasp covid- . for epidemics like corona-virus, sir model was extended to seir [ ] , introducing a new state exposed between susceptible and infectious. this state is also known as latent, representing the period during which the individual has been infected but is not yet infectious himself. therefore, we also have an exposed rate denoted by . still, the model needs further extension. the closet model representing the covid- specifications is the one proposed for h n epidemic [ ] . like in h n , in covid- , we have two types of infectious individuals; one that show symptoms (symp) and the other who do not show symptoms (asymp). and, an exposed individual can transit to state infectious symp with rate or to a state infectious asymp with rate − . the base model adapted from [ ] is further extended to incorporate a new state isolated or quarantine. the isolated state represents the possibility of transferring an infectious individual with symptoms to isolation with a rate α. the value of α is then used to represent preparedness of health system of a country (or globe). all three states infectious symp, infectious asymp, and isolated, transits to recovered state with same rate µ. also a transition from infectious asymp to infectious symp is made possible with a rate ρ. the final model is shown in figure. . the model is implemented in gleamviz [ ] , the global epidemic and mobility model. gleamviz is a simulator which uses real-world data of population and mobility networks (both airways and commuting) on the server side. it integrates this data with the model developed by a user on the client side (similar to what we have presented in figure. ). hence, the simulation generated in data driven, in which a user is responsible of describing system dynamics model of the epidemic, whereas, all the relevant population and mobility global data in integrated at the server side. as a result, the time-series data of spread of epidemics is generated by the server system. in gleamviz client, the model is developed by showing transitions between different compartments (states). the model, conceptualized in the previous section, built on compartments and transitions is shown in figure . one aspect not explained yet is that there are two type of transitions. the infectious transition is represented by "+" sign, depicting an addition of infectious cases. there is only one instance -from susceptible to exposed/latent -like that. the other transitions are spontaneous (represented by dot sign). the initial seed to the model is provided at compartment infectious asymp, that is, few initial effectees as starting seed that do not possess any symptoms. . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the are two functional modes of the model. an individual who is exposed to the virus (whether with symptoms or without) is the carrier of the virus. therefore, a susceptible and recovered individual is not a carrier, while others are. although, technically, an isolated/quarantined individual is a carrier, but, we have assumed that she/he is quarantined and is no longer able to transmit. next are mobility possibilities. we have mimicked very recent situations to restrict or allow mobility. for example, considering all air traffic suspended, no compartment allows air travel. whereas, all individuals who are not quarantined are allowed to commute locally. the commuting restrictions are further modified by using different transition variables. the following are the transition rates from one compartment to another. note, that there are quite a few refinement in the base model. also, for a greek alphabet, it's symbol and text is used interchangeably. all rates vary between and , inclusive. • beta: infectious rate that transforms susceptible to exposed. this happens under the influence of both individuals with or without symptoms. to differentiate, we have taken bbeta as the β value for individual with no symptoms, and abeta × β as the value for individual with symptoms. in this way, we are able to relate the infections incurred in different situations. • epsilon: rate of transiting from exposed to infectious state. an exposed individual can transit to state infectious symp with rate or to a state infectious asymp with rate − . the value of is reciprocal of exposed period, which is equal to . days in our model [ ] . • rho: rate of transiting from infectious asymp to infectious symp state. the value of ρ is reciprocal of symptoms appearing period, which is equal to . days in our model [ ] . • mu: rate of transiting from being infectious or isolated to recovered. the value of µ is reciprocal of infectious period. it is taken days in case of covid- . • alpha: rate of transiting from infectious symp to isolated state. . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. what can be worse than a complete inaction by the authorities? the default values assigned to the variables: beta = bbeta = . , abeta = , and alpha = . , were able to generate such a situation. in this case, abeta×beta = . × . (infectious rate incurred by infected individuals with symptoms) and bbeta = . (infectious rate incurred by infected individuals with no symptoms) both are . , depicting the basic setting with no differentiation. the fact that the rate of getting isolated in really low (alpha = . ), depicts that there is no effort yet put by the authorities to contain the epidemic. in the context of oman, we have put a few cases in muscat, khasab, and salalah as the starting cases which got symptoms, and ran the simulation for a year, starting from february, , (when a few such cases were reported). even though the infection rate this is case shown in figure . it suggests that the outbreak would be rapid and extreme, reaching . million cases per day after days of the outbreak, . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure. . there is a clear mismatch. one reason can be the lack of testing. as of today (march , ), oman still have several thousands suspected cases (the cases without testing). but, the gap is till very high, indicating that there may be lack of data about oman in the simulator database itself. nevertheless, we are not going to see this case as reality after the actions been/being taken. in this case, we try to mimic a forced isolation and a limited lock-down (enforced social distancing). this happens one week after the identification of the first cases in oman. many countries tried to put such restrictions for two weeks only, which were extended later on. we reproduced that by imposing if from march , , but for days. gleamviz provides an option to put exceptions in the form of rules to be applied for certain time period and for certain locations. the rules relate to setting the values based on mathematical expressions. for the above stated days, we created exceptions, which are: abeta = . , bbeta = . , and alpha = . . what these values mean? the alpha = . means that infectious symp to isolated rate is % leaving only % patients to infect others. however, there is . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint less probability of that happening due to lock down. hence, we multiple abeta with beta to reduce it. bbeta is also reduced due to this reason. however, these reductions are quite strict and would be relaxed a bit in case . these exceptions were applied all across oman. the curve shown in figure of case simply shows that quite a few cases appeared in first week or so and then epidemic was eradicated. case and , both are unrealistic, however, they educate us about extreme situations. the real problem with this virus is that it may infect others from patients who do not have any symptoms. the authorities always report confirmed case. they are usually quarantined. but the threat is always there from people who are infected and in the society undetected. to represent this situation, we created the following exceptions: • at the start of the simulation, introduced a few patients with symptoms and same number of patients without symptoms, at the three cities mentioned before. • the following exceptions were applied (based on real events): after the first three weeks, real isolation activity was realized, first in small cities and after further three weeks all across oman, by setting alpha = . , and abeta = . . • a complete lock down was implemented after one month by setting bbeta = . . . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . the above constituted an optimistic case named as case (a). further, we introduced bulk cases (patients travelling and entering into oman) into the three omani cities. initially many of these cases were gone undetected. avoiding any presumed extreme values, we opted to create two situations: many countries in the world are now aware that a lock-down of a few weeks would not be sufficient. therefore, in this case, we also extended the lock-down indefinitely after first month. hence, the results of this case can be considered as nearest to reality according to current actions of the authorities. unfortunately, the results of the simulation were not good. starting with the optimistic case (case (a)), we can see that the daily confirmed cases with symptoms reached to its peak of cases at day . then they started to drop and reached to at day . according to the timeline, day is on april , . in the context of the timeline, almost same pattern emerges for other two case (with bulk inclusions), but the numbers are much higher. irrespective of the discrepancy between the reported cases and simulated ones, its a good news for oman. we are close to peak and bracing for a downhill trajectory. definitely, the containment policies should continue for at least one more month, hoping that epidemic does not start its second cycle. why case (a) is closet to real data. according to the [ ] , on may , , oman had around suspected cases. if we just distribute this number equally after the first days, and add them with the reported cases, we get a new curve (shown in figure ). this curve is very close to case (a) curve, actually it crosses it at day . there can be two reasons of this discrepancy. first is exactly the one we did the remedy for, that is, taking care of suspected cases. second can be the lack of data in the simulator's database itself. simulator only has three cities of oman. we did not notice much mobility across the populated coastal area. that can be one reason that the epidemic did prolong for only days. with a system dynamic model of epidemic spread, incorporated with population and mobility data, we performed simulation of many different cases of covid- impact, representing different real situations. the data used was only about oman, but following the method adopted, the simulation can be performed for any country or region. like most countries around the world, omani authorities took strict action against the spread of dangerous covid- epidemic. hence the first case . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . (case ) of unbounded spread, affecting almost % of population can easily be ignored. the epidemic is becoming more and more dangerous, partially due to absence of strict actions early on. the actions required are social distancing and healthcare management (including testing and isolation of patients). a really strict action towards this is not possible as evidenced around the world. hence the case was also ignored. in case , we implemented some real scenarios. we have seen that in case (a), the epidemic's peak is near, followed by a decline towards its eradication. however, we should be careful about it due to two reasons. there is a substantial number of suspected cases, which have not neither been tested positive or negative. how many of these people are truly quarantined would be a deciding factor. the second aspect of it is inward traveling. as observed in china, a new wave of spread of epidemic may start due to people traveling into the country. representing both these situations, as we can see in case (b and c), just a dozen of these cases may have a big impact. the simulator that was used has apparent limitations. there are only three cities for which the simulator has data. also, during the running of the simulation, it was observed that mobility between the cities is almost non-existent. it is understandable, considering that cities of muscat, khasab, and salalah are at the three corners of the country. with a more representative population and mobility data about different regions of the country, we may see more cases and a longer impact. in fact, it was surprising to see that oman has an epidemic timeline of only two months, which cannot even be imagined in current unfolding of the events. we performed a simulation with similar kind of settings for pakistan and found out that the impact may extend to to months [ ] . nevertheless, the cases and results provide an educated guideline to the authorities about worst and best case scenarios and important factor leading to corresponding outcomes. the paper also guide other researchers towards modeling such systems and why they should be careful about putting forward predictions. . cc-by . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint closed environments facilitate secondary transmission of coronavirus disease (covid- ). medrxiv laboratory abnormalities in patients with covid- infection china coronavirus: labs worldwide scramble to analyse live samples mathematical models in population biology and epidemiology an agent-based approach for modeling dynamics of contagious disease spread wouter van den broeck, et al. seasonal transmission potential and activity peaks of the new influenza a (h n ): a monte carlo likelihood analysis based on human mobility the gleamviz computational tool, a publicly available software to explore realistic epidemic spreading scenarios at the global scale expected impact of school closure and telework to mitigate covid- epidemic in france coronavirus pandemic in oman covid- outbreak in pakistan: model-driven impact analysis and guidelines key: cord- -nr fu qb authors: wang, yu; tian, huaiyu; zhang, li; zhang, man; guo, dandan; wu, wenting; zhang, xingxing; kan, ge lin; jia, lei; huo, da; liu, baiwei; wang, xiaoli; sun, ying; wang, quanyi; yang, peng; macintyre, c. raina title: reduction of secondary transmission of sars-cov- in households by face mask use, disinfection and social distancing: a cohort study in beijing, china date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: nr fu qb introduction: transmission of covid- within families and close contacts accounts for the majority of epidemic growth. community mask wearing, hand washing and social distancing are thought to be effective but there is little evidence to inform or support community members on covid- risk reduction within families. methods: a retrospective cohort study of people in families and with at least one laboratory confirmed covid- case was conducted from february to march , in beijing, china. the outcome of interest was secondary transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) within the family. characteristics and practices of primary cases, of well family contacts and household hygiene practices were analysed as predictors of secondary transmission. results: the secondary attack rate in families was . % ( / ). face mask use by the primary case and family contacts before the primary case developed symptoms was % effective in reducing transmission (or= . , % ci . to . ). daily use of chlorine or ethanol based disinfectant in households was % effective (or= . , % ci . to . ). wearing a mask after illness onset of the primary case was not significantly protective. the risk of household transmission was times higher with frequent daily close contact with the primary case (or= . , % ci . to . ), and four times higher if the primary case had diarrhoea (or= . , % ci . to . ). household crowding was not significant. conclusion: the study confirms the highest risk of transmission prior to symptom onset, and provides the first evidence of the effectiveness of mask use, disinfection and social distancing in preventing covid- . we also found evidence of faecal transmission. this can inform guidelines for community prevention in settings of intense covid- epidemics. introduction transmission of covid- within families and close contacts accounts for the majority of epidemic growth. community mask wearing, hand washing and social distancing are thought to be effective but there is little evidence to inform or support community members on covid- risk reduction within families. methods a retrospective cohort study of people in families and with at least one laboratory confirmed covid- case was conducted from february to march , in beijing, china. the outcome of interest was secondary transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) within the family. characteristics and practices of primary cases, of well family contacts and household hygiene practices were analysed as predictors of secondary transmission. results the secondary attack rate in families was . % ( / ). face mask use by the primary case and family contacts before the primary case developed symptoms was % effective in reducing transmission (or= . , % ci . to . ). daily use of chlorine or ethanol based disinfectant in households was % effective (or= . , % ci . to . ). wearing a mask after illness onset of the primary case was not significantly protective. the risk of household transmission was times higher with frequent daily close contact with the primary case (or= . , % ci . to . ), and four times higher if the primary case had diarrhoea (or= . , % ci . to . ). household crowding was not significant. conclusion the study confirms the highest risk of transmission prior to symptom onset, and provides the first evidence of the effectiveness of mask use, disinfection and social distancing in preventing covid- . we also found evidence of faecal transmission. this can inform guidelines for community prevention in settings of intense covid- epidemics. in the absence of a vaccine for covid- , non-pharmaceutical interventions (npis) are the only available disease control measures. we have shown that population level npis, including travel bans and the national emergency response, were effective in flattening summary box what is already known? ► mitigation of the covid- pandemic depends solely on non-pharmaceutical interventions until drugs or vaccines are available. transmission of covid- within families and close contacts accounts for the majority of epidemic growth. community mask wearing, hand washing and social distancing are thought to be effective but the evidence is not clear. what are the new findings? ► the overall secondary attack rate in households was . %. face masks were % effective and disinfection was % effective in preventing transmission, while close frequent contact in the household increased the risk of transmission times, and diarrhoea in the index patient increased the risk by four times. the results demonstrate the importance of the pre-symptomatic infectiousness of covid- patients and shows that wearing masks after illness onset does not protect. what do the new findings imply? ► the findings inform universal face mask use and social distancing, not just in public spaces, but inside the household with members at risk of getting infected. this further supports universal face mask use, and also provides guidance on risk reduction for families living with someone in quarantine or isolation, and families of health workers, who may face ongoing risk. the covid- epidemic curve in china. however, the effect of other npis, such as mask use and hygiene practices, have not been well studied in the covid- pandemic. in the usa, the use of face masks in the community has been recommended. it is thought that universal face mask use (ufmu) may reduce outward transmission from asymptomatically infected people and protect well people from becoming infected. however, the world health organization and public health england recommend against ufmu on the grounds that there is little evidence from randomised controlled trials to support this. some experts suggest that in a pandemic, the precautionary principle should be used and ufmu encouraged as it is unlikely to cause harm and may result in public health gain. in countries where personal protective equipment is scarce, people are making their own masks. in china, over % of human-to-human transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) occurred in families. however, data to inform covid- risk reduction in households are unavailable. given epidemic growth is dominated by household transmission, studying the use of npis, such as face masks, social distancing and disinfection in the household setting, may inform community epidemic control and prevent transmission of covid- in households. we conducted a retrospective cohort study involving families of laboratory confirmed covid- cases in beijing, china. we defined family members as those who had lived with primary cases in a house for days before and for more than hours after the primary cases developed illness related to covid- . as of february , all laboratory confirmed covid- cases reported in beijing were enrolled in our study and followed-up. the outcome of interest was secondary transmission in the household. families with secondary transmission were defined as those where some or all of the family members become infected within one incubation period ( weeks) of symptom onset of the primary case. to analyse the predictors of household transmission, we compared families with and without secondary transmission for various measured risk factors, preventive interventions and exposures. definition of confirmed case according to national prevention and control guideline (fifth edition), confirmed cases were those who met the clinical, epidemiological and laboratory testing criteria for covid- simultaneously. . clinical criteria included: (a) fever and/or one or more respiratory symptoms; (b) radiological evidence of pneumonia; (c) white blood cell count normal or decreased, and lymphocyte count decreased at the early stage of illness. . epidemiological criteria included: (a) visits to/living in wuhan or cities around wuhan or other communities which had already reported covid- cases in the days prior to the onset of symptoms; (b) having contact with a person known to have infection with sars-cov- in the days prior to onset of symptoms; (c) having contact with a person who had fever or respiratory symptoms and came from wuhan or adjacent cities or other communities which had already reported covid- cases in the days prior to onset of symptoms; (d) being one of the cluster cases. suspected cases met one of the epidemiological criteria and any two of the clinical criteria, or met all of the clinical criteria. confirmed cases were those suspected cases who met one of the following criteria: (a) respiratory or blood specimen tested positive for sars-cov- by real time reverse transcriptase-polymerase chain reaction; (b) virus in respiratory or blood specimen was highly homologous with known sars-cov- through gene sequencing. data collection a three part structured questionnaire was developed. the first part included demographic and clinical information of the primary case. the second part was mainly focused on the primary case's knowledge about and attitudes toward covid- , and their self-reported practices (mask wearing, social distancing, living arrangements) and activities in the home. the third part was about self-reported behaviours of all family members, as well as the family's accommodation and household hygiene practices from days before the illness onset to the day the primary case was isolated, including room ventilation, room cleaning and disinfection. close contact was defined as being within m or feet of the primary case, such as eating around a table or sitting together watching tv. the frequency of contact, disinfection and ventilation was measured. after diagnosis, the primary case was hospitalised as per standard practice in beijing. eligible primary cases and their family members were interviewed between february and march. data on the primary case were extracted from epidemiological investigating reports from beijing centre for disease prevention and control and supplemented by interview. the clinical severity of the covid- case was categorised as mild, severe or critical. mild disease included nonpneumonia and mild pneumonia cases. severe disease was characterised by dyspnoea, respiratory frequency ≥ /min, blood oxygen saturation ≤ %, pao /fio ratio < and/or lung infiltrates > % within - hours. critical cases were those who exhibited respiratory failure, septic shock and/or multiple organ dysfunction/ failure. statistical analysis risk factors for secondary transmission were analysed by characteristics of the primary case, characteristics of well family members and household hygiene practices. categorical variables are presented as counts and percentages, and continuous variables as medians (iqr). the χ test and fisher exact test were applied to compare difference between groups when necessary. a composite covid- knowledge score and hand hygiene score were created with multiple sub-questions. a multivariable logistic regression model was used to identify risk factors associated with sars-cov- household transmission. univariable analysis was first performed with all measures and only those variables significant at p< . could be selected in the following multivariable logistic regression analysis. backward elimination was performed to establish a final model retaining those with p< . in the model. statistical analyses were performed using sas software (v. . ). as our study was embedded within the covid- prevention and control practice within public health units, and the telephone interview was a supplementary survey of the epidemiological field investigation, ethics approval was not required. we obtained subjects' verbal informed consent before the start of the interviews. no patients or the public were involved in the study design, setting the research questions, interpretation or writing up of results, or reporting of the research. as of february , confirmed covid- cases in families were reported in beijing. four family clusters were excluded because we were unable to determine whether there was secondary transmission or co-exposure, leaving families. after reviewing information in the epidemiological investigation reports and survey calls, families were excluded as they did not meet the study inclusion criteria. a further families declined to be interviewed and were also excluded, leaving families for study (figure ). over the weeks of follow-up from onset of the primary case, secondary transmission occurred in / families ( secondary cases), and / families had no secondary transmission. the overall secondary attack rate in families was . % ( / ). in the secondary transmission group, primary cases caused secondary cases, with a median secondary case number in families of (iqr - ). in the secondary transmission group, the secondary attack rate in children < years of age was . % ( / ), compared with . % ( / ) in adults, and the difference between these two age groups was significant (χ²= . , p< . ). the median age of the secondary child cases was years (iqr - ), / were bmj global health in multivariable logistic regression model, four factors remained significantly associated with secondary transmission. the primary case having diarrhoea in the home and daily close contact with the primary case in the home increased the risk. transmission was significantly reduced bmj global health by frequent use of chlorine or ethanol based disinfectant in households and family members (including the primary case) wearing a mask at home before the primary case developed the illness (table ) . this study confirms that the highest risk of household transmission is prior to symptom onset, but that precautionary npis, such as mask use, disinfection and social distancing in households can prevent covid- transmission during the pandemic. this study is the first to confirm the effectiveness of mask use prior to symptom onset by family members, daily household disinfection and social distancing in the home. this could inform precautionary guidelines for families to reduce intrafamilial transmission in areas where there is high community transmission or other risk factors for covid- . household transmission is a major driver of epidemic growth. further, in countries where health system capacity is exhausted, many people with infection are required to self-isolate at home, where their household contacts will be at risk of infection. in our study, the median family size of the families was (range - ), usually with children, parents and grandparents, which is similar to the social structure of most chinese families. therefore, the risk of sars-cov- household transmission is high if a primary case was introduced and no measure was adopted. we showed that npis are effective at preventing transmission, even in homes that are crowded and small. ufmu is a low risk intervention with potential public health benefits. the results suggest that community face mask use is likely to be the most effective inside the household during severe epidemics. almost a quarter of family members became infected, and the findings suggest that the risk was highest either before symptom onset or early in the clinical illness, as most primary cases were hospitalised after diagnosis, and interventions were not effective if applied after symptom onset. in the univariate analysis, wearing a mask after illness onset was significant, but in multivariate analysis, only wearing it before symptom onset was effective. viral load is highest in the days before symptom onset and on the first day of symptoms, and up to % of transmission is during the pre-symptomatic period in settings with substantial household clustering. this supports ufmu, probably by reducing onward transmission from people in the pre-symptomatic phase of the illness as well as protecting well mask users. randomised clinical trials of face masks in the household have confirmed protection against other respiratory viruses if compliant, if used within hours of the primary case symptom onset, and alone or in combination with hand hygiene. this study now provides specific evidence for ufmu in settings of high epidemic growth to protect against covid- . in our study, . % ( / ) of primary cases had a high score on hand hygiene, but it was not effective, confirming the results of previous randomised clinical trials which showed hand bmj global health hygiene alone did not protect against respiratory transmissible viruses, but masks combined with hand hygiene did have effect. as the compliance of ufmu would be poor in the home, there was difficulty and also no necessity for everyone to wear masks at home. we recommended that those families with members who were at risk of getting infected with sars-cov- (such as ever having contact with a covid- patient, medical workers caring for a covid- patient or having a history of travelling to high risk areas) should apply ufmu to reduce the risk of household transmission. this study showed that social distancing within the home is effective and having close contact (within m or feet, such as eating around a table or sitting together watching tv) is a risk factor for transmission. the study also provides evidence of effectiveness of chlorine or ethanol based household disinfection in areas with high community transmission, or where one family member is a health worker, or where there is a risk of covid- , such as during home quarantine, consistent with advice provided by local health authorities or organisations. diarrhoea as a symptom in the primary case is also a risk factor for sars-cov- transmission within families, which highlights the importance of disinfection of the bathroom and toilet, as well as closing the toilet lid when flushing to prevent aerosolisation of the virus. our study has limitations. telephone interview has inherent limitations, including recall bias. it would take about min to complete an interview, and % ( / ) of interviews were rated as informative by the interviewers. the evaluation results of mask wearing were reliable, but we did not collect data on the concentration of disinfectant used by families. the strengths of the study were that we had complete follow-up data and were able to accurately ascertain the incidence of secondary transmission in the cohort. household transmission in the pre-symptomatic or early symptomatic period of covid- is a driver of epidemic growth and any measure aimed at reducing this can flatten the curve. this study reinforces the high risk of transmission in households but importantly shows that ufmu and hygiene measures can significantly reduce the risk of household transmission of covid- , independent of household size or crowding. this is the first study to show the effectiveness of precautionary mask use, social distancing and regular disinfection in the household, and can inform guidelines for prevention of household transmission. the results may also be informative for families of high risk groups, such as health workers, quarantined individuals or situations where cases of covid- have to be managed at home. an investigation of transmission control measures during the first days of the covid- epidemic in china recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission face masks for the public during the covid- crisis covid- : should the public wear face masks? yes-population benefits are plausible and harms unlikely report of the who-china joint mission on coronavirus disease (covid- ) new coronavirus pneumonia prevention and control program the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) -china china statistical yearbook- virological assessment of hospitalized patients with covid- temporal dynamics in viral shedding and transmissibility of covid- potential presymptomatic transmission of sars-cov- presumed asymptomatic carrier transmission of covid- face mask use and control of respiratory virus transmission in households facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial hand hygiene and risk of influenza virus infections in the community: a systematic review and meta-analysis centers for disease control and prevention. cleaning and disinfection for households: interim recommendations for u.s. households with suspected or confirmed coronavirus disease (covid- acknowledgements we thank the staff members in the district and municipal centres for disease prevention and control, and medical settings in beijing for conducting field investigation, specimen collection, laboratory detection and case reporting. we also thank all patients and families involved in the study.contributors all authors approved the final draft of the manuscript. the corresponding authors attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.funding this work was supported by beijing science and technology planning project (z ). competing interests none declared.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. key: cord- -gv q sf authors: fukada, ai; kitagawa, yutaro; matsuoka, masaru; sakai, jun; imai, kazuo; norihito, tarumoto; orihara, yuta; kawamura, rieko; takeuchi, shinichi; maesaki, shigefumi; maeda, takuya title: presepsin as a predictive biomarker of severity in covid‐ : a case series date: - - journal: j med virol doi: . /jmv. sha: doc_id: cord_uid: gv q sf guidelines for the diagnosis and treatment of the novel coronavirus disease (covid‐ ) present clear criteria, including respiratory rate, hemoglobin oxygen saturation (sao( )), and oxygenation indicator (pao( )/fio( ))( ). this article is protected by copyright. all rights reserved. university hospital from february to march . disease severity was classified according to the chinese clinical guidance for covid- pneumonia diagnosis and treatment ( th edition) . the patients were at different stages and had different severity of infection. three had moderate disease on admission that was later determined to be severe covid- (the moderate-to-severe group), in whom secondary worsening resulted in invasive mechanical ventilation (cases - ); of these intubated patients ultimately died of covid- pneumonia (case ). the other patients (cases - ) were diagnosed as having mild covid- (mild group). the supplementary table shows the baseline clinical laboratory findings. the initial clinical laboratory workup included a complete blood count and the inflammatory biomarker profiles for c-reactive protein (crp), p-sep, procalcitonin (pct), and krebs von den lungen- (kl- ). the figure shows clinical course of each patient in terms of changes in laboratory findings and in treatment outcome until discharge alive, transfer from infectious disease ward, or death. p-sep levels were measured using the stacia  clinical assay system (lsi medience corporation, tokyo, japan) based on a chemiluminescent enzyme immunoassay, which has a normal reference range of - pg/ml. the majority of serum biochemical markers, including white blood cell, lymphocyte, and platelet counts, showed no differences between the mild and severe covid- groups. p-sep and crp were higher on admission in the moderate-to-severe group than in those in the mild group, although pct was slightly higher in the moderate-to-severe group. baseline kl- levels for both groups were within normal limits (supplementary table ). the figure shows the this article is protected by copyright. all rights reserved. the notice of launching guideline on diagnosis and treatment of the novel coronavirus pneumonia (ncp) key: cord- -xs v uc authors: kessler, remi a.; zimering, jeffrey; gilligan, jeffrey; rothrock, robert; mcneill, ian; shrivastava, raj k.; caridi, john; bederson, joshua; hadjipanayis, constantinos g. title: neurosurgical management of brain and spine tumors in the covid- era: an institutional experience from the epicenter of the pandemic date: - - journal: j neurooncol doi: . /s - - - sha: doc_id: cord_uid: xs v uc the challenges of neurosurgical patient management and surgical decision-making during the – covid- worldwide pandemic are immense and never-before-seen in our generation of neurosurgeons. in this case-based formatted report, we present the mount sinai hospital (new york, ny) department of neurosurgery institutional experience in the epicenter of the pandemic and the guiding principles for our current management of intracranial, skull base, and spine tumors. the detailed explanations of our surgical reasoning for each tumor case is tailored to assist neurosurgeons across the united states as they face these complex operative decisions put forth by the realities of the pandemic. the severe acute respiratory syndrome coronavirus (sars-cov- ) and its associated coronavirus disease , is a new disease that manifested in late that was declared a global pandemic by the world health organization (who) on march , [ ] . this virus originated in the city of wuhan, china and then disseminated rapidly to over countries. according to the centers for disease control (cdc) surveillance system, as of april , , there were , cases and , deaths in the united states [ ] . the cases are now most highly centralized in the states of new york and new jersey, with other significant clusters in washington, louisiana, california, and michigan. at this present juncture, all states have confirmed covid- cases. new york city (nyc) specifically provides some unique challenges to combatting covid- due to the high-density population of the city and its outer boroughs. there are currently almost , covid- cases in new york and more than , patients have died due to the coronavirus at present time [ ] . there are seven hospitals within the mount sinai health system in various locations across the neighborhoods of manhattan, brooklyn, and queens. the main teaching hospital is a -bed, tertiary care academic center located on the upper east side of manhattan. in addition to the aforementioned hospitals, the department of neurosurgery also provides coverage for the elmhurst hospital, a -bed level i trauma county facility in queens, ny. this region of nyc has been particularly hit hard by covid- due to the nature of the public hospital system and the dense patient population it serves. covid- has created unprecedented changes to healthcare delivery in nyc. due to the staggering number of covid- patients, the mount sinai health system has reallocated resources and space for patients who become oxygen dependent and may ultimately require mechanical ventilation. redeployment of attending neurosurgeons and residents to assist in covering a covid- intensive care unit (icu) has become essential in the fight against the coronavirus. all outpatient clinic visits have been transformed to telehealth visits and all resident teaching conferences are virtual. the cancellation of all elective neurosurgeries was decided early in the nyc pandemic due to the diversion of regular post-operative beds into covid- units, the re-direction of anesthesia and operating room (or) staff to other units, the repurposing of or anesthesia equipment for mechanical ventilation, the need for preservation of personal protective equipment (ppe), the closing of neurorehabilitation, and most importantly the protection of fresh postoperative patients from covid- . the regular or capabilities have essentially ceased with the exception of emergency cases that require special approval by hospital leadership to proceed. as the pandemic marches forward into an unclear future, the definitions of "emergent" and "elective" procedures are not always so straightforward and as neurosurgeons, when to operate and when to delay becomes a complex decision-making process. with that said, a small subset of neurosurgical procedures is still taking place, specifically those that our surgeons have deemed necessary to operate on without delay to avoid impending death or irreversible harm to the patient. this is especially true with respect to brain and spine tumor cases in our neurosurgical oncology practice. operative intervention is often required to relieve tumor mass effect on the brain and spinal cord in order to preserve and/or improve neurologic function. these procedures also permit proper diagnosis of malignancies that require urgent adjuvant therapies for ultimate improved survival of patients. however, a balance of when to use precious or resources as well as the serious exposure risk to anesthesiologists, neurosurgeons, and or staff during the intubation process, must be taken into consideration since all patients are presumed to be infected by the coronavirus. certain patients who normally would undergo a resection may indeed require a biopsy since the disposition of the patients to rehabilitation is lacking. other elderly patients with multiple comorbidities who are at increased risk for covid- may not be proper candidates for any surgery. furthermore, how to manage the surge in the backlog of cases that will require more urgent intervention at the conclusion of the pandemic is an unanswered question at this time. despite all of the above circumstances, it is important that neurosurgical patients, who often have serious life-threatening conditions, are not neglected by our specialty even during a time of exceptional stress. in this paper, we present our institutional neurosurgical oncology patient management approach for the treatment of brain and spine tumors during the covid- pandemic in nyc. for each tumor type (cranial, skull base, and spine), we provide one case example that was managed differently from the perceived standard of care due to the covid- crisis. the following example cases are solely to provide our guiding principles and experience at this unprecedented time in neurosurgical practice at a large tertiary care academic medical center in nyc, the heart of the coronavirus pandemic in the united states. individual patient management should always remain at the discretion of the treating neurosurgeon's clinical judgement and expertise. the patient is a year-old female who presented with fever, chills, and shortness of breath. the patient had a past medical history significant for multiple comorbidities, including hypertension, diabetes mellitus, chronic kidney disease, peripheral vascular disease, and parathyroid carcinoma status post parathyroidectomy. a chest x-ray (cxr) revealed possible atypical bilateral pneumonia consistent with covid- . the patient underwent coronavirus nasopharyngeal swab testing which was negative. however, due to the possible pneumonia and close to a % false negative coronavirus testing by nasopharyngeal swab, the patient was admitted for further observation. after admission to the covid- hospital ward, evaluation of the patient revealed she was having word finding speech difficulties and right sided weakness. mr imaging revealed a large ( . × . × . cm), heterogenous contrast-enhancing left frontoparietal mass causing cerebral compression, edema, and midline shift of mm (fig. ) . the patient was started on high-dose steroids and given antiepileptics. the family was counseled on the need for a tissue diagnosis and possible surgical decompression of the tumor since the patient had evidence of right sided weakness from the tumor mass effect. however, after discussion with the family and the medical team, the decision was made to just perform a stereotactic biopsy of the mass for diagnostic purposes. since there was no possibility for any postoperative rehabilitation due to closing of the rehabilitation unit, and the high likelihood the patient had a high-grade glioma in the setting of advanced age and comorbidities, a craniotomy was not offered to the patient. the stereotactic biopsy was performed and revealed a glioblastoma tumor. she also also had a ct scan of the chest which showed improvement of the findings on her initial cxr. the patient is starting radiation therapy and temozolomide at the end of month of april and will require high dose steroids due to edema and mass effect of the tumor. the patient is a year-old female with a past medical history of hypertension and blindness secondary to glaucoma who presented to an outside hospital with right-sided facial palsy, altered mental status, and a fall eight days prior with no loss of consciousness or trauma. a head ct scan showed a large ( . × . × . cm) mass within the sella and suprasellar cistern with sellar expansion, moderate mass effect, and some obstructive hydrocephalus. the patient was then emergently transferred to our hospital for surgical evaluation and possible csf diversion. she then underwent mri, which suggested a pituitary adenoma with significant displacement of the optic apparatus, cavernous sinus, third ventricle and midbrain, along with hydrocephalus (fig. ) . she also underwent standard pituitary tumor lab work-up, with results showing normal levels of prolactin ( . ), am cortisol ( . ), and tsh ( . ) and low levels of igf- ( ), free t ( . ), and acth ( . ). given that the prolactin level was within normal limits, we did not elect to manage the tumor medically, since it was not a prolactinoma. the hydrocephalus was from the obstruction of the rd ventricle due to mass effect from the large pituitary tumor. the patient was brought to the or and underwent a right frontal ventriculoperitoneal shunt (vp) shunt and endoscopic septal fenestration with a certas programmable valve. the standard of care, an endoscopic transnasal transsphenoidal approach for maximal resection of tumor, was not offered at this time to the patient due to the covid- crisis and the need to mitigate surgical exploration involving the nasopharynx as a nidus of infection. instead, the patient was offered and underwent vp shunt placement to alleviate the emergent hydrocephalus. the patient did well postoperatively and was discharged to home on postoperative day two. the patient is a year-old male with multiple myeloma who presented initially with neck pain and was found to have a pathologic fracture at c . the overall alignment of the spine was maintained and there was no evidence of spinal cord compression. given the lack of neurologic compromise and overall preserved alignment of the spine, it was decided that a minimally invasive approach could be attempted by neuro-interventional radiology. the patient underwent a c cement augmentation. post procedurally, the patient did very well. however, he re-presented to the emergency department (ed) with worsening neck pain, bilateral hand numbness, and pneumonia. a cervical spine ct scan showed new dissociation between the odontoid and the cemented c vertebral body with resulting severe stenosis and spinal cord compression (fig. ) . given the underlying pneumonia and stable neurologic condition, the decision was made to keep the patient on bed rest in a rigid orthosis while he underwent treatment for the pneumonia and covid- testing. once the pulmonary issues resolved and the patient had multiple negative covid tests, he was taken to the or for a posterior decompression and fusion from c - . after surgery, his pain was significantly improved and his upper extremity numbness resolved. the initial recommendation was for inpatient rehab, however after prolonged discussion with the patient and his family, it was felt that he would be safer to be discharged home with home services and family education. the severity of the covid- pandemic in the state of new york, and in particular new york city, has required neurosurgeons to dramatically alter their practice in a very short period of time. the diversion of essentially all hospital facilities and resources to combatting this highly contagious disease and the cancellation of all elective procedures has this is due to several reasons, one of which is that many tumor patients tend to be of middle or older age, and the death rate for covid- is significantly higher in older adults and for those with various cardiopulmonary comorbidities [ , ] . patients with diabetes mellitus are also at much higher risk for severe complications [ , ] . second, patients with malignant brain or spine tumors may have undergone chemotherapy prior to surgical resection or in between subsequent resections, thus placing them in an immunocompromised state and further increasing their risk of acquiring covid- [ ] . patients who have metastatic disease are also often immunosuppressed on systemic chemotherapeutic agents. due to the highly contagious nature of covid- , it has even been recommended that cancer patients avoid treatment regimens that cause immunosuppression or have their dosages reduced should they become infected [ ] . these are clearly dramatic changes from normal clinical practice, which reflect the severity of the covid- virus. risks of acquisition are only further exacerbated when a significant surgical procedure occurs that then necessitates a prolonged hospital stay. taking the aforementioned aspects into consideration changes the calculus of the preoperative risk assessment but represents only one component of the surgical decision-making thought process needed in light of covid- . for the cranial tumor surgeon, several factors come into play in deciding if and when to operate. in case # , the patient was originally admitted to the hospital for pneumonia-like symptoms, suspicious for covid- . she later experienced a variety of neurological symptoms, including focal deficits, completely unrelated to any prior medical history or her infectious workup. she was incidentally found to have a very large mass lesion with compression of surrounding structures, the likely cause of her new symptoms, and started on high-dose steroids. at mount sinai in the covid- era, there have been no changes to the use or dosing of steroids to treat edema from brain tumors. of note, steroids are even being used for patients with covid- who experience acute respiratory distress syndrome (ards) [ ] . under non-covid- circumstances, the routine care at our institution would have been maximal surgical resection with preservation of neurological function given that her lesion was in a surgically-amenable location. however, neurorehabilitation services are presently not available due to the closing of the normal rehabilitation unit and the rerouting of all its staff to covid- units. as such, the decision to solely conduct a stereotactic biopsy for histopathologic analysis represents a deviation from our typical standard of care. while entirely out of the neurosurgeon's control, this is a serious issue for patients with malignant lesions, which are obviously time-sensitive for growth, in that these lesions can no longer be resected in a timely manner as there is now no postoperative care for them. the reasoning for the stereotactic biopsy in this case was that at the very minimum, there would be a definite diagnosis for this severely symptomatic patient, which could elucidate whether the tumor had malignant features. additionally, a clear tissue diagnosis, despite the present incapability for maximal resection, would guide further treatment, including possible radiation therapy and chemotherapy, and patient expectations about next steps. this change from not offering maximal surgical resection for a tumor with clear effects of edema and compression is a remarkable departure from our traditional practice. our decision-making shares similarities with the neuro-oncologic community consensus at this time for the treatment of gliomas, in that diagnostic surgery and adjuvant therapy can be delayed if the patient is stable and if further tumor expansion will not hinder complete resection later on [ ] . in case # , the patient presented with a pituitary macroadenoma with altered mental status and falls due to mass effect from the large sellar lesion and associated obstructive hydrocephalus. the decision to solely place a vp shunt and withhold surgical resection represents a striking departure from our institutional neurosurgical standard of care for a symptomatic pituitary tumor. treating the hydrocephalus expeditiously is in keeping with the general guidance recently put forth by the american association of neurological surgeons/congress of neurological surgeons (aans/ cns) tumor section and society for neuro-oncology [ ] . the endoscopic transnasal transsphenoidal approach for anterior skull base resection is cause for concern for the operating skull base neurosurgeon due to additional risk of the nasopharynx harboring the covid- virus. specifically, this is due to the high nasal viral titers and the potential for aerosol production during endonasal instrumentation. one particular study simulated surgical aerosolization during non-powered instrumentation, suction microdebrider, and high-speed drilling in cadavers after nasal fluorescein application [ ] . they found that an intact surgical mask and vent mask for endoscopy removed all detectable spread of aerosol particles. in addition, microdebrider and cold instrumentation use did not produce detectable aerosols, however high-speed drill generated remarkable aerosol spread, with significant risk to the endoscopic skull base surgeon. preliminary safety recommendations for otolaryngologic surgery based on anecdotal experience include the complete postponement of endoscopic nasal procedures in patients with covid- or those who cannot be tested [ ] . one other group recently described precautions to be taken in endoscopic endonasal surgery, but noted that they are based only on personal communication with international colleagues in china, italy, iran, the united kingdom, and greece reporting on their individual experiences. in summary, they describe a number of physicians becoming infected with covid- as a result of endoscopic procedures, with some resulting in deaths, and emphasize to only perform urgent/emergent surgery [ ] . in the case when surgery is critical, a number of specific precautions with respect to intubation and extubation procedures have also been recommended [ ] . in case # , the patient's re-presentation to the ed with severe cervical stenosis and spinal cord compression after a neuro-interventional radiology procedure for a vertebral compression fracture was complicated by additional newonset pneumonia. given the high likelihood of a covid- etiology of the pneumonia and the fact that the patient was mostly neurologically intact, the decision was made for the patient to be treated for the infection first, while being maintained in rigid orthosis in bed, and await surgery until the pneumonia had cleared. in non-covid- times, patients with pneumonia are generally not operated on unless it is a surgical emergency. that is consistent with the management plan here. however, given the highly contagious nature of covid- and its potential complications, extra precautions were taken to ensure the pneumonia was entirely cleared prior to bringing the patient to the or. in other words, the preference was for the patient to be maintained in rigid orthosis as long as necessary, which is a change from standard of care. one other institution, the university of california at san francisco, has described their own protocols for the scheduling of neurosurgical cases and for neurosurgical coverage throughout the covid- pandemic [ ] . of particular interest to the topic of this paper is the checklist they developed to determine what constitutes an emergent versus urgent versus elective neurosurgical procedure (fig. ) . our surgical decision-making process for tumor cases in light of covid- is overall consistent with their global approach. nevertheless, our institutional experience and subsequent changes to patient management will inevitably differ given that our hospital is located in the epicenter of the pandemic across the us, and faces distinct challenges, including an intensive care unit that is currently at triple its normal full capacity due to covid- patients. to address these concerns, we have developed our own institutional algorithm for the management of brain and spinal tumors (fig. ) , which is put to use in all three cases outlined above. despite all the above tumor-specific considerations, protecting our surgeons, residents, nurses and all other medical staff must be of highest priority. transmission of the virus necessarily increases in the close proximity of the hospital, placing both medical staff and patients at risk. specifically, the intubation process is considered one of the highest risk procedures for viral droplet spread [ , ] . as the vast majority of neurosurgical procedures are conducted under general anesthesia, minimizing cases to those that are only truly emergent also protects our anesthesiologists, neurosurgeons, residents, and or staff from acquiring the virus. as was done in our institution's tumor the mount sinai department of neurosurgery tumor management algorithm cases described above, maximal or precautions were taken at all times throughout the intubation process and in the post-operative setting. patients were generally considered to be covid- positive until proven otherwise, and multiple rounds of testing were sent as soon as possible, when available. furthermore, not taking away from other needed hospital resources, including icu beds with ventilators, nursing capabilities, and personal protective equipment (ppe), should be considered in circumstances in which delaying surgery causes no harm to the patient. it is important to note that different hospitals have varying levels of available resources, and given that our institution is a large tertiary-care academic hospital at the epicenter of the pandemic, our facilities may differ widely from those at community hospitals. such differences necessarily impact patient management in a time of crisis. the covid- global pandemic and its colossal impact on all hospitals around the world has necessitated a vast change in standard neurosurgical oncology practice to accommodate for shifting resources. in this report, we provide examples of the mount sinai hospital (new york, ny) neurosurgical experience and clinical reasoning for the changes in management of brain and spine tumors. we continue to operate on neurosurgical emergencies, evaluate tumors on a case-by-case basis, and make alterations or delay procedures when clinically feasible without causing any harm to the patient. while we would operate on all the cases above in a timely fashion under normal circumstances, the reality of the covid- pandemic necessitates that neurosurgeons balance providing the best care for their patients while minimizing the spread of the virus. funding this study did not receive any funding. conflicts of interest remi a. kessler, jeffrey zimering, jeffrey gilligan, robert rothrock, ian mcneill, john caridi, joshua bederson has no conflict of interest. constantinos g. hadjipanayis is a medical advisor to nx development corp, is entitled to royalties from nx development corp, and is a consultant to synaptive medical (not related to the content of this study). ethical approval this article is a general institutional overview of department regulations that include three retrospective case reports. these patients' medical records were reviewed under a mount sinai irb-approved protocol. informed consent informed consent was not required in this study as they were solely case reports with all patient information completely de-identified. research involving human and animal rights all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the helsinki declaration and its later amendments or comparable ethical standards. who director-general's opening remarks at the media briefing on covid- - cases in u.s. centers for disease control new york region explores reopening as cases 'plateau.' bbc news comorbidity and its impact on patients with covid- in china: a nationwide analysis prevalence of comorbidities in the novel wuhan coronavirus (covid- ) infection: a systematic review and meta-analysis covid- in patients with diabetes: risk factors that increase morbidity clinical considerations for patients with diabetes in times of covid- epidemic a practical approach to the management of cancer patients during the novel coronavirus disease, (covid- ) pandemic: an international collaborative group clinical characteristics of covid- -infected cancer patients: a retrospective case study in three hospitals within wuhan management of critically ill adults with covid- urgent considerations for the neuro-oncologic treatment of patients with gliomas during the covid- pandemic inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the covid- pandemic: general guidance for neuro-oncology practitioners from the aans/cns tumor section and society for neuro-oncology endonasal instrumentation and aerosolization risk in the era of covid- : simulation, literature review, and proposed mitigation strategies safety recommendations for evaluation and surgery of the head and neck during the covid- pandemic precautions for endoscopic transnasal skull base surgery during the covid- pan-demic report from wuhan: hard-won insights from china letter: the coronavirus disease, global pandemic: a neurosurgical treatment algorithm staff safety during emergency airway management for covid- in hong kong coronavirus disease (covid- ): critical care issues publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- - qt vf authors: chakraborty, amartya; bose, sunanda title: around the world in days: an exploratory study of impact of covid- on online global news sentiment date: - - journal: j comput soc sci doi: . /s - - - sha: doc_id: cord_uid: qt vf the world is going through an unprecedented crisis due to covid- breakout, and people all over the world are forced to stay indoors for safety. in such a situation, the rise and fall of the number of affected cases or deaths has turned into a constant headline in most news channels. consequently, there is a lack of positivity in the world-wide news published in different forms of media. texts based on news articles, movie reviews, tweets, etc. are often analyzed by researchers, and mined for determining opinion or sentiment, using supervised and unsupervised methods. the proposed work takes up the challenge of mining a comprehensive set of online news texts, for determining the prevailing sentiment in the context of the ongoing pandemic, along with a statistical analysis of the relation between actual effect of covid- and online news sentiment. the amount and observed delay of impact of the ground truth situation on online news is determined on a global scale, as well as at country level. the authors conclude that at a global level, the news sentiment has a good amount of dependence on the number of new cases or deaths, while the effect varies for different countries, and is also dependent on regional socio-political factors. we are in the midst of a global crisis, owing to the outbreak and spread of the covid- virus, and the substantially damaging influence of this viral infection has forced the world health organization (who) to declare the ongoing situation as a pandemic. as per the official statement of who, "covid- is the infectious disease caused by the most recently discovered coronavirus. this new virus and disease were unknown before the outbreak began in wuhan, china, in december . covid- is now a pandemic affecting many countries globally" [ ] . as a precautionary or preventive response to this declared pandemic, countries all over the world have introduced restrictions on mobility and transportation, referred to as lockdowns. consequently, citizens are being asked to stay indoors as a measure of safety from the infection. in this age of a multitude of news channels and popular virtual social frameworks aimed at better connectivity, a massive share of the time spent indoors is undoubtedly invested in engaging with such media. this is corroborated by the recent study [ ] which has revealed that there has been about % increase in news consumption by watching television or on smartphones, due to constant indoor presence. a primary obsession of people during this pandemic is about the changing statistics of affected or deceased people world-wide, and needless to say, such articles form the crux of news that the different media channels publish. this virus outbreak has also raised a plethora of other controversial issues, leading to continuing debates and discussions with consequences at both local and global levels. as a whole, it is apparent that there is only a limited number of news delivered with a positive note. the impact of negativity in the news is a long-standing concern, and has been addressed from time to time [ , ] , but the prevailing situation is predicted to leave a long-lasting and damaging impact on mental health and human psychology as a whole [ ] . meanwhile, the day-to-day statistics of deaths or count of affected patients due to the pandemic is expected to influence the news sentiment too. the authors have taken up this challenge of determining the news sentiment during a fixed period of study, as well as analyzing the influence of world-wide and countrywide statistics on the news sentiment during the selected duration. the organization of the paper is as follows: "literature review" section gives a brief description of the studied related works and motivations drawn for the current work; the details of each data corpus used in the work are provided in "data description" section; "data processing" section lists the techniques used for processing the comprehensive data corpora; the experiments and observations are discussed in "experiment : sentiment analysis" section, "experiment : statistical analysis" section, "experiment : n-gram analysis" section, "experiment : case studies" section; finally, the concluding remarks are offered in "conclusion" section. the challenge of opinion mining as an application field of data mining is well addressed, and there have been multiple works in this domain with a variety of solutions based on the increasing availability of growing datasets. a vast majority of these works are dedicated to the challenge of sentiment analysis in text collections of different types. similar to challenges in other domains, the task of sentiment analysis can also be approached as either as a supervised classification problem, or an unsupervised approach for sentiment identification [ ] . the number of works that have addressed the problem of sentiment analysis with a supervised approach is more than the ones that have used unsupervised, exploratory techniques. for a supervised sentiment classification problem, the primary requirement is that the text corpus needs to be labeled, i.e., each text string in the whole data set needs to be annotated as belonging to a particular class-positive, negative, or neutral in this case. a study of the state-of-the-art works reveals that for previously annotated texts mostly based on twitter data, blog posts, web logs, movie reviews etc., the researchers have used some common machine learning techniques, namely support vector machine, naive bayes [ ] [ ] [ ] [ ] [ ] [ ] , or even deep convolutional neural networks [ , ] , etc. it is a general observation that such techniques are more efficient in sentiment analysis tasks than the other unsupervised approaches. also, the overall performance of supervised algorithms in challenges of opinion mining is generally lower than that in other domains [ ] . on the other hand, the task of analyzing sentiments is more challenging with the use of unsupervised learning techniques. also, such techniques are often more suited for mining the sentiment from bulky sources of data. identification of semantic orientation [ ] , comparative study and low performance of the sentiwordnet lexicon in sentiment analysis [ ] , development of novel emoji and linguistic contentbased lexicons using unsupervised approach [ , ] , sentiment polarity detection system using unsupervised approach on turkish movie reviews [ ] , etc. are all different interesting research works that use unsupervised approach. the application of standard lexicons such as sentiwordnet [ ] , afinn [ ] , etc. in unsupervised sentiment classification is widely studied and evaluated in different works [ ] [ ] [ ] . these lexicon based techniques are employed in solving interesting problems, such as analyzing the sentiment of the characters in shakespeare's plays [ ] , opinion mining from clinical discharge summaries [ ] , development of bias-aware systems [ ] , etc. other popular methods for sentiment identification include k-means [ , , ] , latent dirichlet allocation (lda) [ , ] , etc. in all such cases, it is seen that the inherent simplicity, lack of training, and lower computation requirement involved in unsupervised approaches make it easier to use on and learn from data corpus of substantially large size [ ] . during a survey of state-of-the-art research using unsupervised lexicon based approach on text data, it is seen that most of these works are based on exploratory sentiment analysis and evaluation of classification techniques, used on different types of data. however, there is a relatively small amount of research that has worked with news data, and almost all such works are based on financial news and stock price prediction [ ] [ ] [ ] [ ] [ ] , etc. similarly, there are only a few works regarding the statistical effect of real-world events on the overall sentiment of global news, mostly related to the financial sector [ ] [ ] [ ] , etc. in this technologically developed era, people are engrossed in the news media, and agenda setting [ ] has a crucial role to play in times of a crisis. researchers have often determined the role played by mass media in determining or setting the agenda in response to a particular incident or event, and this is rapidly propagated among the audience [ ] . obviously, it entails a number of problems as well as ludicrous opportunities for the media agencies, as explored in [ ] . in a related context, the work by kirk et al. [ ] analyzes the agenda setting and media policies in response to a disaster. while the proposed work does not focus on these issues, the authors wish to highlight the underlying role of media in maintaining global public sentiment and mental health given the ongoing covid- -related crisis. the news media need to be responsible as well as alert to ensure the proper propagation of awareness and shaping of public sentiment particularly involving second-level agenda setting [ , ] . given these observations and the ongoing pandemic, the authors were motivated to make the following research contributions: -the current work determines the general sentiment of news articles during the ongoing pandemic with unsupervised and transfer learning-based approaches, -this is the only work, as per the authors' knowledge, that determines the implications of temporal statistics in a pandemic situation, on news sentiment throughout the world during a fixed period of study. the current work statistically determines how and after what amount of delay, the number of affected patients, and number of deaths due to covid- , impacts the news sentiment in regional and world-wide news, -the authors also analyze other relevant factors that contribute to rise or fall of global news sentiment related to particular countries. the proposed work uses data regarding the daily news articles published online globally, as well as the statistical details of day-to-day cases and deaths due to covid- throughout the world. accordingly, two comprehensive data sets have been used in this work, as described below: - the unlabeled news data described in the previous section have been processed in this part of the work. all of the steps discussed below are performed for each day's data, to generate usable corpora for the experiments. -data merging: there are files containing news snippets from each day, and these are initially merged to generate a single data repository per day. thereafter, some steps are followed for processing, as described below. -removing numbers: initially, the news text contained in the merged corpus for each day of the study is processed using regular expression-based operations. -removing stop words: a common approach is followed to remove the words that are not useful in sentiment analysis process, but which make up a significant part of any text. examples of such words are: and, for, is, the, to, at, in, etc. -stemming: as a last step of processing the news articles, stemming is applied to derive the root form of the inflected or derived words in each cleaned string. such derived words are used to propagate different grammatical concepts such as mood, tense, voice, etc. as a simple example, the words working, works, and worked all have the same stemmed form work. once all the above steps have been performed, the processed texts for the total duration of the current study in processed files are merged as a single file containing over . million distinct news articles. the merged news data corpus consisting of comprehensive, cleaned strings from the previous step is unlabeled in nature, i.e., the news articles are not originally assigned any particular sentiment label. for this purpose, any machine learning and classification-based sentiment analysis are not directly possible on this data set. for sentiment prediction, the cleaned text articles for each day are now scored using two different approaches, namely the afinn lexicon [ ] in an unsupervised learning approach, and by the naive bayes [ ] -based transfer learning approach which has been trained on a popular movie reviews dataset [ ] . a lexicon is a comprehensive collection of words, and afinn is one such widely used lexicon consisting of over words where each word contains a corresponding sentiment score value. this polarity score lies between + to − , and every string in our cleaned news text is now analyzed by applying the afinn lexicon, to generate corresponding sentiment scores. as an example, the string it was a good memory is analyzed and scored word by word using afinn, where the scores are , , , , and , respectively, to give a total score of + . evidently, the stop words have no role to play in such analysis, and thus, they have been removed during text processing in the previous section. the determined scores (using afinn lexicon), are now converted to sentiment category. for this purpose, all texts with score less than are labeled negative, those with score equal to are neutral, and all remaining texts are annotated as positive. a notable observation is that such approaches consider only single-word construct or unigrams for sentiment scoring. this is a prime weakness of such approach, as it fails to capture the inherent essence of different multi-word constructs in english, and fails to recognize emotions and complexities of the language. in contrast, the trained naive bayes classifier uses its knowledge about sentiment polarity from the aforementioned movie reviews corpus, and correspondingly applies it to assign a sentiment category to each news article per day. unlike afinn, this supervised classification approach considers the complete text at a time and is more sensitive to emotions, inherent figures of speech and multi-word constructs in the language used. also, this approach gives a different view of the studied corpus of news texts, and returns the sentiment category for each news article. in this manner, for every piece of cleaned news text, we now have an overall sentiment score (for afinn) and sentiment category (for naive bayes classifier) which is either positive, or negative, for that string. the news data corpus for different days do not consist of the same number of text articles, and also each news article has a different sentiment category predicted by afinn and the trained naive bayes classifier. therefore, there is a need for normalization, before any comparative study of news sentiment on different days is conducted. for this purpose, a negativity index for each day is calculated and is used as an indicator of the overall negative sentiment in news on that day. the index for the ith day is calculated as: ( ) neg i = number of articles of negative category total number of news articles similarly, indices for positive sentiment and neutral type of news articles are determined using equations: these index values are calculated for the comprehensive data on news articles for the duration of study. the overall spread of these sentiment indices, as determined by the analysis using unigram-based afinn, are shown in fig. , while fig. illustrates the same as analyzed by naive bayes-based classifier. notably, with the use of the latter, substantially large negativity (about %) and low positivity (about illustration of the significance of the three sentiments in global news during the period of study, determined using afinn lexicon. news with neutral sentiment has minimum presence, and positive news sentiment seems to be slowly catching up with the negativity fig. illustration of the significance of the three sentiments on global news during the period of study, determined using naive bayes. news with neutral sentiment has minimum presence, and there is a substantial gap between the positivity and negativity in news sentiment %) values are detected, whereas the neutrality decreases by more than % and is deemed almost irrelevant to the study at hand. also, in both cases, it is obvious that any fall in negativity, results in an increase in positive sentiment, and vice versa. therefore, news of neutral sentiment plays a negligible role. consequently, a statistical study of the sentiment indices determined in both approaches reveals that negative sentiment has the highest mean, followed by the mean number of positive news articles. also, these two sentiments show almost similar deviation during the studied duration, using both the scoring techniques. finally, it is evident from both pairs of figs. , and and that the overall variation in sentiment patterns is more profound in the detection by afinn lexicon, in spite of its poor sentiment detection performance, and is selected for the experiments in the next section. the most commonly occurring words in the news articles with negative sentiment, for the complete duration of study, are illustrated in fig. . this is the next set of experiments where two separate sets of data are utilized, namely: -the world-wide news-based negativity index values from the previous experiment determined using afinn lexicon based approach, as the variation of sentiment polarity is found to be more in that case, and, -the number of new cases and number of deaths per million of the population, these corpora are analyzed to determine the underlying relation between the variation of news sentiment and ground reality of cases and deaths due to covid- pandemic. to statistically determine the link between the news negativity and number of cases or number of deaths due to the pandemic, it is essential to determine the distribution of each of these variables. figure shows the respective distributions. from the figures, it is noticed that all the three variables used in this work follow a near-normal or near-gaussian [ ] distribution. therefore, it is feasible to directly determine the statistical relation between these variables. initially, an attempt has been made to visually determine the relation between distribution of features from two different data corpora. in fig. , the number of confirmed covid- cases during the span of the study has been represented as bar plots. the negativity index values in global news have been plotted for the same this word-cloud highlights the specific words which are present in each day's most negative news articles. the relatively large size of words, such as death, fatality, case, coronavirus, died, infection, and hospitalized are representative of their frequencies of occurrence during the -day period of study duration as a line plot. it is seen that peaks in news negativity are quite often related to the rise in number of cases, as seen in the variations of both variables for different set of days. also, the decreasing step pattern in number of cases during days - and - is distinctively reflected in the news negativity plot too. similar to the previous case, fig. gives the number of daily deaths in bar stacks, while the line plot is the same as the previous figure. it is seen that there is not much similarity in trends between the two data during the first days. in contrast, some similarity in the data patterns is evident in the duration of days - , after which there is no visible similarity. however, in both the above cases, it is observed that similar patterns in news occur at a delay of a few days. this can be attributed to the fact that day-to-day statistics do not get immediately reported on the same day, and generally takes at least a day or two, to appear and make impact on the global news sentiment. this observation leads to the need for determining the optimal time window, at which the trends in the corpora are most similar. from the previous section, it is observed that the trends in news negativity are more or less affected by the variations in the number of cases and the number of deaths. also, the impact of the trends in number of cases or deaths is visible at a delay of a few days. therefore, it is necessary to statistically determine the exact delay at which the news sentiment reflects the reality of the situation. the statistical measure of similarity in data for two variables can be determined by calculating their correlation coefficient. in this part of the experiment, the authors have experimentally determined the correlation coefficient r n , between the news sentiment and number of cases or number of deaths, using a set of sliding windows on the news sentiment index values, where each such window is shifted n days ahead of the actual duration of the conducted study, for values of n = ( , , , , ). this means, to re-create the most visibly aligned variations, a statistical study is done using a same set of values for the number of cases or deaths, along with values of news negativity index considered during temporally shifted sets of days each. in all cases, the correlation is calculated using the pearson correlation coefficient [ ] between two variables x and y, given by the formula: this coefficient value for any two variables remains between − and + , where a positive value close to indicates that both variables change simultaneously in same direction, a negative correlation stands for two variables changing in opposite direction, and zero correlation denotes no similarity in the variables. in practice, any correlation value above . is treated as a moderately strong positive correlation. using these concepts, along with the previous observations about delay in impact of actual change in parameters on the news sentiments, the optimal maximum positive correlation value is determined to derive the actual delay. a similar use of correlation is seen in the works by fu et al. and zhang et al. [ , ] . from table , it is obvious that in general, there exists more correlation between the daily negative sentiment in news and number of covid- -related deaths, considering data world-wide, and that the positive correlation is maximum between these variables when the news negativity indices are considered using a -day shifted sliding window, i.e., it takes days for the trends in the number of deaths, to have impact on the global news sentiment. similarly, this shift is confirmed for the global number of cases at a delay of days. this experiment validates the observation about a delay in the impact of number of confirmed patients and number of deaths, on the news sentiment, and also determines the delay in said impact on a global scale. in the final part of this experiment, the correlation values and optimal time-windows determined in the previous section are used for plotting time-shifted news sentiment curves along with the daily number of cases and number of deaths. accordingly, the news sentiment about daily number of cases is considered at a shift of days, while that concerned with daily death count is plotted at a shift of days to get the ideally aligned plots. these are shown in figs. and , respectively. it can be seen from fig. that there are almost perfect matches in pattern in the duration of days , - , - , and onwards, though due to differences in scale, the variations are not equally spaced. the visible resemblance in variations is also noted in fig. , especially in days - , - , the abrupt spikes in - , - . however, it is a general observation that the negativity in news prevails even when the global statistics in both cases and deaths are declining which can be attributed to other factors as determined in succeeding experiments. therefore, it can be said that the negativity index, considering global news, is quite indicative of the changes in the number of new cases and deaths during the ongoing pandemic, while the declining statistics do not seem to have much effect on the overall negativity. a n-gram can be defined as a continuous sequence of n words from a given sentence or text. in this part of the experiments, the authors have determined the most common tri-grams that occur in the news during the period of study. this analysis highlights the several events, topics, or persons that have been most widely publicized by the online global news in relation with the pandemic scenario. the trigrams have been listed along with their corresponding weighted frequency (calculated using tri-gram frequency and total occurrence of most common tri-grams), as shown in table . it is obvious from the table that most of the tri-grams are regarding the pandemic, with massive usage of phrases such as tested positive coronavirus, tested positive covid, confirmed case covid, etc. in the global news. the news agenda during the studied period of time revolves around this central theme, and involves daily covid- -related updates and awareness programs being broadcast as deduced from the usage of phrases like personal protective equipment, confirmed case covid, people tested positive, number covid case/number coronavirus case, social distancing guideline, practice social distancing, etc. the crucial and commendable role played by world health organization, centers for disease control and prevention (cdc), john hopkins university, and health care workers all over the globe in shaping the different challenges and aspects of this pandemic is also prominently noted from the table. a remarkable observation is that only three state leaders have made it to this list, namely the president of the united states of america (whose name is incidentally in the third most common tri-gram), and the prime ministers of united kingdom and india, which emphasizes the prominence they enjoy as world leaders in global news, even in these times of distress. in this last part of the experiments, the observations about the delayed impact of globally changing count of affected patients and deaths on the news sentiment as seen in the previous section have been used to identify similar trends for some specific countries using the respective correlation values. the study is conducted for four countries ordered chronologically, based on when the first virus outbreak occurred in that area, and all articles mentioning country x have been extracted from online global news to perform the corresponding case study on country x. for this purpose, the authors have extracted all news articles corresponding to the countries in question, from the comprehensive global news corpus, for the whole period of the study. also, in this experiment, z-score [ ] technique has been used on both the variables, to normalize the values prior to visualization. the z-score is used to bring values of different variables on the same scale, and is calculated as: where, x i denotes the current data element, denotes the mean of the variables, and is standard deviation. using this method, the data for each variable are converted to have a mean of , so in the following graphical representations, all values below the mean will denote a decreasing trend and vice versa. a visual analysis of these images reveals how the observations are generally applicable throughout the data from different countries; that is, whether the global news sentiment about a country is actually affected by the daily trends in number of new cases or deaths. this is determined by the individual correlation of countrywise statistics with appropriately time-shifted global online news about that country. the scatter plots are generated for the four countries in question. in every set of two plots for each country, perfect or partial overlaps signify only discrete, temporal alignment of the variables, and cannot be treated as a measure of continued similarity in trend, which can be better determined from a set of parallelly distributed data values. the current virus outbreak is believed to have originated in china much early, in the month of december , and so, the current duration of study has witnessed a sharply flattening curve in the number of cases, and complete prevention of deaths successfully. among the . million news texts, only those that feature 'china' have been extracted along with the corresponding sentiment index values per day. the correlation coefficients determined by sliding window approach are quite low and insignificant from a statistical point of view, as calculated and shown in table . however, in the current context, such values are indicative of loosely positive similarity in trends. remarkably, there seems to be an immediate impact of the number of daily deaths per million in china on the global news, whereas the number of cases per million takes quite some time. along with this, the highly minimized and flattened death or infection rate is evident from figs. and . also, it is seen that in spite of the flattened curves for cases and deaths, the negativity index values are distinctly high, and show a decreasing trend only after the th day of our study. the corresponding correlation coefficient values indicate more parallelly aligned set of points as seen in the first figure for the number of cases, while the points are more dispersed around the flattened death curve in the second figure, in spite of multiple overlaps, shown as deep red. observations: the observed negativity, though generally aligned, could be due to different other issues as evident from the global news related to china (shown in table ). for instance, the rise in negativity during days - of the study relate with news articles and , while articles , , and attest to the decline in negativity that follows. on a similar note, the high negativity around days - of the study can be attributed to articles to , while the succeeding positivity is enforced by articles like - . therefore, it is evident that the global news agenda related to china is mostly motivated in driving an overall negative image of the country and its actions during the ongoing pandemic. the outbreak spread to usa in late january, and a substantial part of the pandemic's effect on news is observable in this case. similar to the previous case, the news table shows that the number of confirmed cases has more impact on negative sentiment in the news based on usa, at a delay of days, and a lower impact of the number of deaths at an overall delay of days. the overall correlation is weakly positive for both the pair of variables. the spread of both the number of cases and deaths, in the case of the usa, resembles bell curve for the current duration of study, with gradually increasing values up to day , and an opposite trend thereafter. figures and show that towards the later half of the studied duration, the overall number of confirmed cases and deaths follows a decreasing trend (more data points below mean), whereas negative sentiment thrives and even increases. observations: apart from the effect of covid- -related statistics, different media reports citing the anti-china sentiment of the president of the country and governmental decisions appear to have influenced the news sentiment, as well. a set of such news articles has been provided in table , while the prominence of the us president in global news is already established in table . the high amount of negativity during the initial days of the study, may be an effect of the articles - , while the decreasing negativity since day may be due to the event that article and correspond to. similarly, the positive sentiment at about day is aligned with the article , whereas the succeeding rapid rise in negativity (in spite of a drop in covid- cases and deaths) could be attributed to events highlighted by articles - . similar to the observations regarding china, the agenda of global online news is driven more by different socio-political activities concerning the country. italy is one of the most badly affected countries due to the covid- virus outbreak. during our period of study, both the death count as well as number of more than , physicians across the country signed a letter urging president donald trump to keep social distancing practices in place after he said he wants to reopen businesses by easter. "significant covid- transmission continues across the united states, and we need your leadership in supporting science-based recommendations on social distancing that can slow the virus," the letter, released by the council of medical specialty societies, said. "our societies have closely adhered to these measures by moving our staff to fulltime telework and canceling in-person meetings (including annual meetings). these actions have helped to keep physicians and other health professionals in health care facilities, including hospitals, and reduce the risk of spreading covid- " health care workers say that they are being asked to reuse and ration disposable masks and gloves. a shortage of ventilators, crucial for treating serious covid- cases, has also become critical, as has a lack of test kits to comply with the world health organization's exhortations to test as many people as possible. in the united states, a fierce political battle over ventilators has emerged, especially after president donald trump told state governors that they should find their own medical equipment if they think they can get it faster than the u.s. government president donald trump signed into law the unprecedented $ trillion economic stimulus package friday, capping a week that saw markets yo-yo as recession concerns grew worldwide. now that the package has been signed into action, attention turns to how quickly the u.s. treasury and other departments can distribute checks to individual americans and businesses grappling with the ongoing effects of covid- . it could prove to be a herculean effort to flood the money into the economy quick enough to prevent more job losses and businesses going under president donald trump signed an unprecedented $ . trillion economic rescue package into law after swift and near-unanimous action by congress to support businesses, rush resources to overburdened health care providers, and help struggling families during the deepening coronavirus epidemic. acting with unity and resolve unseen since the / attacks, washington moved urgently to stem an economic free fall caused by widespread restrictions meant to slow the spread of the virus that have shuttered schools, closed businesses and brought american life in many places to a virtual standstill. "this will deliver urgently needed relief," trump said as he signed the bill friday in the oval office, flanked only by republican lawmakers confirmed cases are seen to be gradually declining. the global news articles which feature 'italy' have been extracted along with the corresponding sentiment category of each article for this experiment. similar to the previous experiments, for assessing the impact of death or infection-based statistics on news sentiment, a study of correlation has been undertaken. this helps to determine the measure by which the news sentiment reflects the ground reality, by considering days shifted one at a time upto days. the results of the study for italy, as shown in table . it is seen that there is maximum impact of the covid- situation in italy, on global news, on the th day, though there is a high continuing correlation. accordingly, the aligned scatter plots are generated using the z-scored, normalized values, as shown in figs. and . evidently from the table and figures, there exists a higher correlation between the deaths in italy and negativity index in global news, than that due to number of infected cases, although both these variables show a comparatively strong correlation with the negative news sentiment. this can also president donald trump attacked the united nations health body as a chinese "puppet" on monday and confirmed he is considering slashing or cancelling us support. "they're a puppet of china, they're china-centric to put it nicer," he said at the white house. trump said the united states pays around $ million annually to the world health organization, the largest contribution of any country. plans are being crafted to slash this because "we're not treated right. they gave us a lot of bad advice," he said of the who be observed by the higher number of complete and partial overlaps, as well as the gradually decreasing dispersion of the negativity proportional to the parametric values of confirmed cases or deaths in and . observations: due to the determined strong correlation, it can be determined that covid- statistics are most effective on global news sentiment regarding italy. however, a small set of relevant news articles has been put up in table . though the first confirmed covid- case in india was noted at almost the same time as italy, the rising effect of outbreak is quite clear in our studied time period. the study reveals interesting results, where both the number of affected cases, and number of deaths, is steadily increasing during the time period considered. the correlation coefficients determined by shifted negativity index table . surprisingly, the correlations are all negative in nature, indicating that the overall impact of rising deaths and spread of covid- in india has a very weak effect on global news sentiment about india. given that the study intends to determine the similarity in trends of news sentiment and death or infection statistics, the least negative correlation coefficient values are selected for visualizing the trends, which are noted at a delay of days in each case. a notable fact is that, statistically, this minimum negativity indicates almost no correlation. the same is depicted in the scatter plots in figs. and , where the negativity index values are highly dispersed, and even show a decreasing trend in the later half of the study in spite of the steep climb of actual statistics. as noted in "experiment : sentiment analysis" section, the neutral news has minimal role in the global scenario, and that should be significantly minimized at a country-wide level. a possible inference may be that the negative sentiment in global news based on 'india' is minimized so as to prevent panic among the huge population, or that the global news is not really representative of only the covid- statistics in indian context. observations: the lack of proper correlation suggests that the news agenda is influenced by many factors other that covid- , during our period of study. table highlights some of the problems that were initially a cause of the massive negativity in news sentiment in spite of the minimum rate of covid- affection. this covers several socio-economic aspects of indian life during this crisis, and the analysis and discussion of such observations in itself, can be articulated as a full-fledged study of the agenda setting policies of online news media. the proposed work addresses the challenge of identifying the general sentiment in globally published news articles as an effect of the ongoing pandemic, in both unsupervised and transfer learning-based approaches, on comprehensive data gathered for a fixed period of time. a statistical study is also undertaken to determine the impact of variations in the number of affected patients and deaths due to the covid- virus, on the news sentiment at a global scale. the same study is also repeated for some countries and the sentiment of global news which pertain to the effect of covid- in those countries, by considering normalized values of all variables. the observations are substantiated by n-gram analysis that highlights the most prominent tri-grams or three-word phrases that have been used in online news globally. the strongest correlation between news sentiment and covid- statistics exists for italy, which is almost similar to the observation considering news and mumbai police friday arrested three men for allegedly storing bottles of hand sanitiser, worth an estimated rs . lakh, at a flat in mahim and illegally selling them above their maximum retail prices. the crime branch raided the flat after it received information that ml bottles of hand sanitiser were being sold for rs , which was rs more than the mrp the national commission of women ncw has received over complaints, since the country-wide lockdown was imposed to control the spread of coronavirus out of which were cases of domestic violence which it said has been increasing since then. since the lockdown was imposed, a total of complaints related to various offences against women were received out of which complaints are related to domestic violence the data released by the ncw showed. ncw chairperson rekha sharma said the number of cases of domestic violence must be much higher, but the women are scared to complain due to constant presence of their abuser at home kumar said, his union is in touch with nearly families who need the rations urgently, having lost incomes for over a week now. for lakhs of migrant workers in maharashtra, lack of clear information has continued to cause anxiety, especially after the centre and state governments issued instructions sunday to prevent them from attempting to return to their native places. their biggest concern being accessible accommodation and food for the remainder of the -day lockdown period. "what's going to happen will be reminiscent of the bengal famine" "while no definite conclusion can be drawn, this is probably due to the circumspection on the part of victims in reporting such incidents due to the presence of the perpetrators in the house and the fear of further violence if such attempt to report were made known to the perpetrator", the commission had said. it had also said that the cases of molestation, sexual assault, rape, kidnapping, and stalking have decreased manifold presumably, since a large number of these incidents take place outside the domestic setting and by third parties. aichls in its plea has contended that incidents of domestic violence and child abuse have gripped not only india, but countries such as australia uk and usa, and the reports suggest that countries are witnessing a horrific surge in domestic violence cases the video showed around migrant workers sitting on the roadside in full clothes, including women, while water jets were showered on them through fire tenders by men in white protective kit. in the video, one of the officials is heard asking the migrants to keep their eyes shut after the lockdown announcement, the badli workers in west bengal's jute mills are the worst affected out of the lot "we may survive from corona but not hunger": bengal's daily wage workers struggle for survival. in india, thousands of workers are lining up twice a day for bread and fried vegetables to keep hunger at bay job loss pay cuts worry indians the most during lockdown: survey. every in indians is now worried about losing his or her job as the coronavirus pandemic has shut industries and businesses in india, a new survey warned on wednesday. according to the survey conducted by yougov, an internet-based market research and data analytics firm, some indians worry about the economic impact of the virus such as losing their jobs ( %), getting a pay cut ( %), or not getting a bonus or increment this year ( %) statistics on a global scale. the authors have also utilized a set of relevant news articles to substantiate the observations during the case studies. the authors have determined that negativity is a pre-dominant sentiment in global news, and that the covid- -related real-world statistics, agenda setting by news agencies as well as different social (such as job loss, migrant worker problems) and political factors (such as the continued tussle between the presidents of the usa and china), drive the negativity in online news quite strongly, which could lead to long-standing effects on mental heath of the news audience. the results lead to relevant questions and consequently a plethora of computational and social study-based research challenges. such studies will be useful in determining the long-standing, psychological effects of news sentiment on mental health in a pandemic situation, representation of regional challenges in online global news, news media agenda setting, etc. in future, the authors wish to extend this work by utilizing country-specific news data in their respective national official languages, which will aid in further fine-grained analysis. q and a on coronaviruses (covid- ). accessed time spent on watching tv, with smartphone rises as people stay indoors: barc data the psychological effects of tv news what constant exposure to negative news is doing to our mental health health experts on the psychological cost of covid- sentiment analysis of english tweets: a comparative study of supervised and unsupervised approaches mining sentiment classification from political web logs mastering machine learning with scikit-learn sentiment analysis of textual reviews; evaluating machine learning, unsupervised and sentiwordnet approaches thumbs up?: sentiment classification using machine learning techniques sentiment analysis of movie review comments deep convolution neural networks for twitter sentiment analysis unitn: training deep convolutional neural network for twitter sentiment classification unsupervised learning of semantic orientation from a hundredbillion-word corpus unsupervised method for sentiment analysis in online texts creating emoji lexica from unsupervised sentiment analysis of their descriptions a framework for sentiment analysis in turkish: application to polarity detection of movie reviews in turkish sentiwordnet . : an enhanced lexical resource for sentiment analysis and opinion mining afinn. richard petersens plads, building twitter, myspace, digg: unsupervised sentiment analysis in social media a comparative study on twitter sentiment analysis: which features are good valento: sentiment analysis of figurative language tweets with irony and sarcasm character-to-character sentiment analysis in shakespeare's plays word vec and doc vec in unsupervised sentiment analysis of clinical discharge summaries bias-aware lexicon-based sentiment analysis using text mining and sentiment analysis for online forums hotspot detection and forecast opinion mining on large scale data using sentiment analysis and k-means clustering sentiment analysis with global topics and local dependency network text sentiment analysis method combining lda text representation and grucnn. personal and ubiquitous computing sentiment analysis and the complex natural language stock price prediction using news sentiment analysis sentiment analysis on english financial news finenews fine-grained semantic sentiment analysis on financial microblogs and news market trend prediction using sentiment analysis: lessons learned and paths forward enhanced news sentiment analysis using deep learning methods discovering the correlation between stock time series and financial news time series analysis on stock market for text mining correlation of economy news trading strategies to exploit blog and news sentiment agenda-setting the agenda-setting function of mass media problems and opportunities in agenda-setting research after disaster: agenda setting, public policy, and focusing events the dynamics of public attention: agenda-setting theory meets big data agenda-setting effects of business news on the public's images and opinions about major corporations coronavirus source data now live updating & expanded: a new dataset for exploring the coronavirus narrative in global online news idiot's bayes-not so stupid after all? learning word vectors for sentiment analysis gaussian distribution proceedings of the royal society of london. number v. advanced engineering mathematics, th edn publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations on behalf of all authors, the corresponding author states that there is no conflict of interest. key: cord- -ulvnn we authors: perdana, tomy; chaerani, diah; achmad, audi luqmanul hakim; hermiatin, fernianda rahayu title: scenarios for handling the impact of covid- based on food supply network through regional food hubs under uncertainty date: - - journal: heliyon doi: . /j.heliyon. .e sha: doc_id: cord_uid: ulvnn we this paper discusses an optimization model for handling the impact of the covid- pandemic based on food supply network through regional food hubs (rfhs) under uncertainty. to this end, uncertainty is assumed in the demand and production data. during the pandemic covid- period, uncertainty has increased and the food supply chain system has changed. thus, a new configuration of the food supply network requires analysis. in this paper, the concept of rfh is introduced to connect producers in rural areas and customers in urban areas. this paper determines the location and capacity of rfhs, the food supply network, the sum of maximum food supplies, and minimum logistics cost. this is done via a multi-objective many-to-many location-routing problem model. furthermore, since the conditions of the covid- pandemic is uncertain, robust optimization is employed to handle uncertainties. during the current pandemic, red zones are defined to indicate the severity of the pandemic in a region. in this paper, the numerical experiment is considered for three scenarios: when a region is in large-scale social distancing, partial social distancing, or normal conditions. this social distancing situation is based on the defined red zones. the optimal food supply network is obtained for the three scenarios and the best scenario among the three is identified. the indonesian government's initial attempt to minimize the covid- pandemic's seriousness by taking early preventative measures has resulted in it forfeiting the opportunity to keep the covid- pandemic under control in the short phase of the outbreak. according to statistics indonesia ( ), approximately . % of indonesia's population is in urban areas, and most covid- cases in the country have been concentrated in these areas. furthermore, the pandemic is having several effects on environmental, social, and economic aspects, as well as on food security. one result of the covid- pandemic is the bullwhip effect of food supply, which has caused uncertainty in demand and supply and increased the complexity of the food supply chain (mitchell et al., ; chen et al., ) . as a result, the consumption of food in urban areas will be more volatile, which the distribution system will need to accommodate. during the pandemic, the emerging stockpile of staple food must gain significant attention as a government concern, specifically for areas designated as red zones . thus, in the red zone, large-scale social distancing and restrictions are imposed, which impacts the distribution of some food products from the production areas. large-scale social distancing also affects economic growth, changes consumer behavior, and results in the decrease in purchasing power parity for food products (hobbs, ; mukhamedjanova, ; gregorioa and ancog, ) . this situation is also exacerbated by the closure of several public facilities, such as restaurants, caf es, schools, offices, and shopping centers. public discourse in indonesia is predictable focused on how the community can survive in the middle of large-scale social distancing and how people can get food supply (rizou et al., ; hobbs, ; pulighe and lupia, ) . these conditions have implications for the availability of food, hampered access to food for the community, restrictions on interaction between red zones and other areas, and the affordability of supplies (pulighe and lupia, ) . the food distribution system is the foundation to decrease hunger, malnutrition, and food insecurity (galanakis, ; devereux et al., ) . in recent times, food access has impacts on social, economic, and sustainability factors (black et al., ; hilmers et al., ; walker et al., ) . therefore, understanding the complex system of food security is essential for social development (b en e, ; devereux et al., ) . several actions and policies have been implemented to address food security (ge et al., ; blay-palmer et al., ; johnson et al., ) . affordability, availability, and food accessibility for the communities has been the focus for the government, the private sector, and other stakeholders. food security during the pandemic should be ensured by using technology such as e-commerce and the internet of things (iot), not only to improve food security but to also help enhance food safety (deng et al., ) . recovering downstream processing could help with adopting the latest technology (galanakis, ) , which can assist in providing food for the community and improving the value of the products (galanakis, ; hobbs, ; barba et al., ) . however, innovation, technology, and regulations are not keeping pace with the food consumption needs. various problem in this regard have been apparent in recent time, such as uncertainty of food demand and supply, the high cost and inefficiency of logistics and delivery services, the high volume of losses and waste, the powerless of the upstream actors, and food safety (mitchell et al., ; chen et al., ; rizou et al., ) . the covid- pandemic has led to the emergence of a new era of the food supply network (rizou et al., ) where food safety has become one of the focus components (galanakis, ) . to minimize the transmission of the coronavirus, the main concern must be product and worker hygiene to achieve food safety (who, ; galanakis, ; rizou et al., ) . during the distribution process, the transportation system becomes an essential element to protect customers and food supply services providers (gray, ) . attention to macromolecules and micromolecules could be given for the application of food safety and food hygiene protocols (galanakis, ) . the pandemic has also changed consumer behavior in choosing food. consumers seek to protect themselves and improve their immune system, and are concerned about changing their food consumption habits, bioactive ingredients, and nutritional content (galanakis, ; rizou et al., ; zinoviadou et al., ) . therefore, the food system should develop structured managerial systems, adequate infrastructure, facilities, and sustainable food supply (galanakis, (galanakis, , rizou et al., ; gray, ; mitchell et al., ) . an effective strategy to ensure food supply is to develop food hubs. a food hub is a business organization that supports local and regional producers, principally as an aggregator, distributor, manager of food security, and marketing operator for smallholder distributors, as well as to satisfy the wholesaler, supermarket, horeca (hotel, restaurant, and catering) , and other marketplaces (levkoe et al., ; fischer et al., ) . the conceptual model of food hubs is evolving, and hubs have widely adopted innovation to support locales and their goals (ballantyne-brodie and telalbasic, ) . in recent decades, regional food supply chains have become an essential issue, and food hubs are emerging as principal factors for developing viable local and regional food systems (sharpe et al., ; blay-palmer et al., ) . besides being a principal factor of the food system, regional food hubs (rfhs) have a role in regulating and guaranteeing food supply, in ensuring food security and access in some regions, and will likely have a positive impact in the development of the regional economy (sharpe et al., ; etemadnia et al., ; farmer and betz, ; kotani et al., ) . for food security issues, the rfh becomes a critical facility to optimize food supply to consumers, as well as pay attention to sustainability aspect as a part of food security (sharpe et al., ; sonnino et al., ; etemadnia et al., ; farmer and betz, ) . rfh is a centralized facility with a business process management that aims to ensure food supplies and connect the various actors to strengthen food security and food safety through coverage of specific areas. rfh plays an essential role in developing local food systems and promotes entrepreneurship, develops local jobs, and fights food insecurity (o'hara, ; silver et al., ; rose, ) . the rfh has become a network to collaborate with local producers and customers, forming local food networks by adopting socio-technical processes to address socio-economic and political tensions and support a fairer, more sustainable, and socially just food system (prost et al., ) . rfhs should develop through a mutually beneficial collaboration network by involving the local food hub (lfh) to provide a source of the food supply. the lfh acts as a local aggregator hub for some local sources and specialty food distributors. it serves high-quality and locally grown products from small and mid-sized farms, and aims to meet the demands of its customer base (barham et al., ) . meanwhile, supermarkets, restaurants, caf es, and catering services partner with the rfh to sell products to the customers and other food service providers. rfh uses design-driven innovations to approach daily challenges, such as maintaining the constant balance of food availability in a region. rfh used as a continuous cycle of a strategy to change the sustainable local food supply networks system (ballantyne-brodie and telalbasic, ). the food supply network system is a strategically interconnected network that improves the optimization, efficiency, and effectiveness of the food production and delivery process (robinson et al., ). in the system, transparent edges between producers and consumers are a critical aspect to meet the sustainability goals (brinkley, ; le velly and dufeu, ) . the food supply network system must be prepared for various conditions, and must function not only under regular conditions but also during the pandemic. the rfh makes an essential contribution to the disaster relief supply by providing essential food for the communities during disasters and post disasters. in the time of pandemics, such as today, rfh could also function as a food resilience network (frn) to make food available, affordable, accessible, and hygienic for communities affected by the pandemic (brand et al., ; berno, ; dasaklis et al., ) . the pandemic might raise food deficiency due to the obstruction of the food supply chain. the locations for the development of rfhs and optimal logistics for the food network must be determined based on various general conditions and, at the time of a pandemic, by considering the entire community as victims affected by it. the covid- pandemic will have a longlasting effect on the food supply network, including the development of e-commerce and customer preference toward local food (hobbs, ; galanakis, ) . research on rfh logistics optimization is largely underway in europe, the united states, canada, and mexico (mittal et al., ). the conceptual model of rfh is still emerging and is increasingly applied to the development of logistics systems for agriculture (mittal and krejci, ; fischer et al., ) . the rfh movement embraces a bank of locally adapted food networks, food traceability, inventory, and warehouse operation management (mittal and krejci, ; prost et al., ) . further, rfh has been developed for the sustainability of the local food system (cleveland et al., ) . sharpe et al. ( ) notes the importance of providing access to healthy food for all levels of society by optimizing the role of food hubs. other research has developed conceptual models for optimizing food supply networks during the pandemic (liu et al., ; tang and lau, ; dasaklis et al., ) . however, studies have not considered the location for the development of rfh and the food network in all conditions, especially during the pandemic. this paper aims to determine the optimal location of rfh and food supply networks connecting producers in rural areas and customers in urban areas. it focuses on food security to ensure that food is available, affordable, accessible, and safe at all times, including in the new era food supply network. the many-to-many location-routing problem (mmlrp) is used in this paper to examine the location and capacity of rfh, the food supply network, the sum of maximum food supplies, and minimum logistics costs. several pervious works have attempted to solve the food supply network problem using mmlrp. wang et al. ( ) discuss mmlrp for cold chain logistics. the scheme proposed in their model consists of supply point, distribution center (dc), and demand point. in their model, mmlrp is used to determine dc location and the network distribution. another work of mmlrp in the food supply network problem is hiassat et al. ( ) , who use the mmlrp model for perishable products and propose a scheme that consists of warehouse and customer. mmlrp is used in their model to determine the warehouse location and food distribution network. however, neither model considers uncertainties, such as demand or production capacity uncertainties. they also do not consider multi-item products in their mmlrp model. therefore, an mmlrp model that considers multi-item (multi-commodity) products is developed in this paper. this model also addressed several uncertainties, such as food demand, food production, and distribution cost uncertainties using robust optimization (ro) that assumes that the uncertain parameters lie in an uncertainty set (ben-tal et al., ; gorissen et al., ; yanıko glu et al., ) . ro aims to remove all the uncertain parameters from the uncertain problem and obtain a robust reformulation of the uncertain problem called a robust counterpart (rc). furthermore, a two-objective mmlrp is proposed in this paper: ( ) maximize food supply, and ( ) minimize logistics cost. the latter includes food handling costs under several health protocols to guarantee food safety. to solve this multi-objective mmlrp (mommlrp), the lexicographic method is applied. the lexicographic method is a way to handle multi-objective optimization problems, by priority-ordering the objectives and solving them iteratively (stanimirovic, ) . the rest of this paper is organized as follows: section paper discusses the problem statement related to this paper, followed by the methodology employed in this research. it is followed by a case study that explains the research location. the results and discussion sections describe three alternative simulation scenarios in the covid- situation. the conclusion focuses on the result of the paper that answer the problems discussed in the next section. this paper addresses the problem of determining the optimal location of rfh by considering aspects of sustainability and food security for all conditions, including during pandemics. by connecting the local producer and customers through rfh, the food supply network could be developed to maintain food security. this paper discusses three alternative scenarios to tackle rfh during the pandemic. it aims to identify the best alternative rfh location and capacity and food distribution network; the maximum product fulfillment of each region; and the minimum logistic costs in red zones, defined as an area at the epicenter covid- infection. scenario represents the large-scale social distancing condition in red zone areas. food supply from the green zone is not allowed in the red zone. the red zone must survive by relying on the food products of its region. this condition is intended to minimize the spread of the covid- pandemic and to determine if the red zone can fulfill food demand. further, this condition is designed to determine if the green areas can meet food demand without any supplies from the red zones. the food distribution problem in scenario is illustrated in figure . in scenario , the partial social distancing condition was applied in the red zone. these areas are forbidden from delivering food products to other regions. however, other regions can supply food to red zones. these conditions are meant to decrease the spreading of covid- from the red zone to other areas, and other regions can support the red zones. this scenario problem is illustrated in figure . alternative scenario is used in the new era condition in which a food supply network is allowed to function as usual. however, security protocols are applied following health standards for the prevention of covid- due to the transformations in the food supply chain during this covid- pandemic (rizou et al., ) . this scenario considers the function of rfh after the covid- pandemic condition. this condition is intended to compare the results of the two preceding alternative scenarios. figure illustrates the problem in scenario . an optimization model with mommlrp can describe the best alternative solution for complex problems. variables, objective functions, constraints, and coefficients are used as the central concept of optimization models. the assumptions for the three alternative scenarios are determined using several parameters: food demand, production capacity, and operational costs. in this paper, the food in question is the commodity of rice as the staple food of indonesians, chicken eggs as an alternative source of animal protein consumed, and vegetables as a source of fiber. in this study, vegetable commodities are limited to the most common vegetables consumed by indonesians, shallots, red chilies, beans, potatoes, carrots, tomatoes, spinach, and water spinach. furthermore, each scenario's mommlrp model involves several uncertain parameters, that is, food demand, food production, and distribution cost, which makes the mommlrp model uncertain. ro is applied to solve the uncertain mommlrp by removing all uncertain parameters from the uncertain problem and to obtain a robust reformulation of the uncertain problem called the rc, which is used to give a robust alternative scenario. the rc of each scenario is solved by numerical simulation to find a robust solution that is feasible under all possible disruptions. general optimization problems often involve uncertain parameters. the uncertain parameters are likely caused by measurement error, such as temperature or size measurements. the uncertain parameters could also be caused by mistakes in estimating the data, for instance in estimating demand, profit, selling price, or travel time. in this paper, ro is used to handle the uncertain parameters, that is, food demand, production capacity, and distribution cost. ro is a method to handle uncertain parameters that are assumed to be part of an uncertainty set (ben-tal and nemirovski, ) . the method's primary purpose is to achieve an optimal solution that is robust to uncertain data. the mathematical formulation for the general uncertain linear programming as proposed by ben-tal et al. ( ) and discussed by gorissen et al. ( ) is given by ( ). where c;x r n ;a m mÂn ðrÞ, b r m , and u is primitive uncertainty set (an uncertainty set that has not yet been determined). the aim of ro is to remove all the uncertain parameters in uncertain problem ( ) and obtain a robust reformulation of it, called the rc. to solve the uncertain problem ( ), several assumptions are necessary, as discussed by ben-tal et al. ( ), gorissen et al. ( , and yanıko glu et al. ( ): (a ) the objective function is certain, (a ) the right-hand side vector is certain, and (a ) the uncertainty is constraint wise. under assumptions (a ) and (a )-that is, assume that c r n and b r m are certain-the uncertain problem ( ) can be rewritten as ( ). now, since c r n and b r m are certain, the robust reformulation of ( ), which is generally referred to as the rc problem, is given by ( ): where z ⊂r l . the constraint in ( ) can be rewritten constraint wise. denoting a i as the i-th column in matrix a, ( ) becomes ( ): where a i r n ; d i m nÂl ðrÞ, and b i r; i f ; ; ⋯; mg. in this paper, a box uncertainty set is used, with uncertainty parameters as discussed by ben-tal et al. ( ) and gorissen et al. ( ) . the box uncertainty set is defined by z box ¼ fζ : ζ j ∞ g (gorissen et al., ) . thus, ( ) can be written as ( ): ða i þ d i ζÞ t x b i ; i f ; ; ⋯; mg; ζ z box : by using the concept of the best worst-case reformulation as discussed by gorissen et al. ( ) thus: take ζ as the unit vector: thus, ( ) can be rewritten as follows: in the case of box uncertainty, the rc of ( ) is given by ( ): by repeating this step for all other uncertain constraints, rc for the uncertain problem ( ), where ζ z box , is given by ( ): i f ; ; :::; mg É : ( ) this section describes the experimental mommlrp model for optimal rfh locations and food networks based on the three scenarios described in the problem statement section. it also discusses the robust mommlrp model to handle food demand, production capacity, and distribution cost uncertainties. the mommlrp models are designed based on the three scenarios to describe the development of an rfh location and network in west java province. this subsection discussed the mommlrp model developed in this study for the three scenarios. first, the mommlrp model for large-scale social distancing is discussed. then, the mommlrp model for partial social distancing and for normal conditions are discussed based on the differences from the large-scale social distancing model. the mommlrp model of the three scenarios is then summarized. to solve the problems in scenario , a mommlrp model seeks the maximum demand fulfillment and minimum total cost of logistics. the sets that are used in this model are i, which represents the demand zone, j, which represents rfh, k, which represents the production zone, c, which represents commodity, and r, which represents the red zone or the epicenter of covid- infection. the parameters used in scenario are d ci , which represents the demand for food c from district i (kilotonne/day); v ci , which represents the selling price of commodity c in district i (rp/kilotonne); f ck , which represents the production capacity of commodity c on central production district k (kilotonne/day); b ji , which represents distribution cost between district j and district i for transporting the food (rp/kilotonne); q which represents food handling cost under several health protocols (rp/kilotonne); and h which represents the rfh-building cost (rp/hub). the decision variables used in this model are x j , which decides if the rfh will be built on district j, which takes if the rfh will not be built on district j, and otherwise; p cj , which decides the rfh capacity for commodity c in district j (kilotonne/day); y ckj , which decides how much of the commodity c produced on district k is sent to the rfh in district j in proportion to production capacity f ck ; and w cji which decides how much commodity demand c on district i is fulfilled by the rfh in district j, in proportion to demand d ci . the decision variables x j are binary (x j ; ; j j). the decision variables p cj are real numbers (p cj r; c c;j j). the decision variables y ckj are real numbers between and (y ckj ½ ; ; c c; k k; j j). decision variables w cji are real numbers between and (w cji ½ ; ; c c; j j; i i). this model has two objectives, maximizing demand fulfillment and minimizing logistics cost. the source of the logistics cost is the operational costs for distributing the food between segments (production area-rfh-customer). the logistics cost also includes the operational costs of the rfh building and food handling under the pandemic with several precautions to maintain food safety. the objective function to maximize the demand fulfillment is given by ( ): the objective function to minimize the logistics costs as explained above is given by ( ): the constraints that guarantee the determined rfh capacity of all commodities are determined based on the demand and the production capacity are given by ( ): the constraint that guarantees that the commodities delivered from the production area to the rfh will not exceed the production capacity for those commodities is given by ( ): x j j y ckj ; c c; k k the constraint that guarantees that the demand fulfilled by the rfh will not exceed the demand is given by ( ): x j j w cji ; c c; i i the following constraint guarantees that no commodities will be delivered to the red zone if the rfh is not built in that zone: the constraint that guarantees that no zone's demand will be fulfilled if the rfh will not be built in that zone is given by ( ): the constraint given below guarantees that there will be no food distribution to an rfh in the red zone from the production area in other zones: the following constraint guarantees that there will be no food distribution to the customer in the red zone from an rfh outside the red zone: the constraint that guarantees that there will be no food distribution from a production area in the red zone to an rfh in other zones is given by ( ): the following constraint guarantees that there will be no food distribution from an rfh in the red zone to customers in other zones: the difference between the first and second scenarios is that in the second, the production areas would distribute food to the rfhs in red zones. this is considered so that the food demand in the red zones can be fulfilled, aiming to decrease food insecurity. however, the quantity of food distributed to the red zone is limited by the maximum transportation capacity for food per delivery period. accordingly, parameter n c has been added, which represents the maximum amount of commodity c that could be distributed in one-way distribution (tonne/ distribution). also, two new decision variables are introduced, m r and m r . decision variable m r decides how many times the distribution should be done to the rfh in red zone r. decision variable m r decides how many times the distribution should be done to the consumer in red zone r. constraint ( ) in scenario is changed to constraint ( ) below, which guarantees that the food distribution to the rfh in red zone is allowed. constraint ( ) also calculates how many times the distribution should be done, as follows: x k kÀfrg y ckr f ck m r n c ; c c; r r constraint ( ) in scenario is modified into constraint ( ) below, which ensures that the food distribution to consumers in the red zone is allowed. constraint ( ) also calculate how many times the distribution should be done, as follows: x j jÀfrg w cjr d cr m r n c ; c c; r r ( ) scenario adopts a typical food supply network, in which there are no constraints on the distribution process of each zone aiming to fulfill the food demand. the limit on scenario is the maximum capacity of food supply delivery in one distribution period, noted by n c (tonne/ distribution). corresponding to the statement above, two new decision variables are added, m r and m r . decision variable m r decides how many times the distribution should be done from the red zone r. decision variable m r decides how many times the distribution should be done from the rfh in red zone r. constraint ( ) in scenario was modified into constraint ( ). constraint ( ) guarantees that the food distribution from the red zone is allowed. constraint ( ) also calculates how many times the distribution should be done as follows: x j jÀfrg y crj f cr m r n c ; c c; r r constraint ( ) in scenario was modified into constraint ( ), which guarantees that the food distribution from rfhs in red zones is allowed. constraint ( ) also calculate how many times the distribution should be done as follows: x i iÀfrg w cri d ci m r n c ; c c; r r the differences between the models in the three scenarios are measured based on the maximum, minimum, and constraints used in each scenario. the differences between the mommlrp model of the three scenarios are summarized in table . in this study, we assume that the uncertain parameters are demand for the commodities d ci , production capacity for commodity f ck , and transportation costs between locations b kj and b ji .the multiplication of the uncertain parameters b ji d ci in objective function ( ) is considered as a single uncertain parameter m cji , which represents the maximum travelling cost to fulfill the demand for commodity c in district i from the rfh in district j. besides, the multiplication of the uncertain parameters b kj f ck in objective function ( ) is considered as a single uncertain parameter n ckj , which represents the maximum travelling cost to deliver all the commodity c that was produced in district k to the rfh in district j. the transformation is given as follows: thus, the uncertain parameters considered in this model are d ci ; f ck ; m cji ; n ckj , as in ( ): by substituting ( ) into objective function ( ), the objective function ( ) a new objective function ( ) is obtained: constraints ( ), ( ), ( ), ( ), ( ), ( ) constraints ( ), ( ), ( ), ( ), ( ), ( ), the objective function ( ) is replaced with ( ). the uncertain mommlrp model for each scenario is presented in table . ro is employed to handle the uncertain problem. this can be done by removing all uncertain parameters from the uncertain problem to obtain a robust reformulation of the uncertain problem called the rc, as discussed in the methodology section. by using the assumption (a ), the uncertain objective function ( ) becomes ( ): with a new decision variable z added and defined in a new constraint: all the uncertain parameters are on the left-hand side of constraints. the uncertain constraints in the uncertain mommlrp model for all scenarios are ( ) and ( ). by using assumption (a ), the uncertain mommlrp can be used for every single uncertain constraint ( ) and ( ). the single uncertain constraint ( ) and ( ) can be written in vector as given in ( ) and ( ): where f r jkj ; d r jij ; m r jcjþjjjþjij ; n r jcjþjkjþjjj and p; z r. as it is assumed that the parameter f; d; m and n are contained in a box uncertainty set, the constraints ( ) and ( ) can be rewritten as ( ) and ( ): then, the rc of ( ) and ( ) are given by ( ) and ( ): in this case, d ;d ;d , and d are diagonal matrices. thus, the terms of d t y;d t w;d t w, and d t y are vectors as presented in ( ) and ( ): since the ℓ -norm of those vectors are the summation of its elements, constraint ( ) and ( ) can be rewritten in the form of a summation as given in ( ) and ( ): where f ck is the average production capacity for commodity c in production area k; d ci is the average demand for commodity c in district i; m cji is the average distribution cost to fulfill the demand for commodity c in district i from the rfh in district j; n ckj is the average distribution cost to deliver all the commodity c that was produced in district i to the rfh in district j; and s ck ; t ci ; u cji ; v ckj is the uncertain part of f ck ;d ci ;m cji ;n ckj . in this paper, all the uncertain parts are set based on the average. by repeating the same step for all other uncertain constraints, the rc of uncertain constraint ( ) and ( ) is given in ( ) and ( ): the rc of the uncertain mommlrp for each scenario is presented in table . the rc model of all scenarios in table is then called the robust mommlrp model (rmommlrp), which is robust against the uncertain food demand, production capacity, and distribution cost. the rmommlrp models have two objectives as seen in table , which maximizing demand fulfillment and minimizing logistics cost. therefore, the lexicographic method is used to solve the problem. the lexicographic method is a way to handle multi-objective optimization problem (stanimirovic, ) . it orders the objectives based on priority (rao, ) . the multi-objective problem is then solved iteratively from the first objective and substituted back to the problem as a new constraint with the following objective. case studies are carried out in west java, the most populous province in indonesia. according to statistics indonesia ( ), west java is the third leading agricultural producer in indonesia after east java and central java, as well as a strategic marketing area because . % of indonesia's population is in west java province. in this study, the commodities analyzed are the strategic commodities of the people of west java, that is, rice, chicken eggs (particular chicken eggs), and vegetables. rice as a staple food for indonesia as a complex carbohydrate source. chicken eggs (layer) are the most consumed protein due to the low price and availability. moreover, vegetables are considered a high-value commodity, that is, shallots, red chilies, beans, potatoes, carrots, tomatoes, spinach, and water spinach. the demand and production capacity of each commodity are assumed to be uncertain. accordingly, ten-year consumption and production capacity data from west java were analyzed for each commodity over the period - (statistics of jawa barat, barat, , barat, , barat, , barat, , barat, , barat, , barat, , barat, , barat, , . the logistics costs for each region are assumed to be uncertain and calculated based on the price of commodities and diesel fuel price. in this model, diesel fuel prices are the benchmark for calculating logistics cost because these types of fuel are widely used by mini trucks, which distribute food commodities (pertamina, b,c,a) . other logistics costs that are calculated in this model are operational cost and cost of investment. data on the selling price of each commodity was obtained the rfh location is also determined for the red zones, as presented in figure . as claimed by pikobar, as of may , . % of patients exposed to covid- were in west java, placing west java in the third position for the highest number of covid- cases in indonesia after dki jakarta and east java. some red zones in west java are urban areas with high population density and are far from food supply sources. moreover, west java province does not yet have an rfh to manage food supply sources for the community, and thus faces a severe food security problem. according to pikobar, districts or cities in west java province have patients who tested positive for covid- . in the scenarios constructed, eight districts are considered red zones in case (based on data from march , ) and thirteen red zones are identified in case (based on data on may , ). all red zones are in urban areas and are the focus of the central and regional governments' monitoring activities. none of the districts in the red zone have a robust food supply network yet, and the government thus gives high priority to the issue of food security. in this paper, the rfh model was also designed based on the governor of west java's flagship program, "jabar juara" (west java champion). rfh development in west java province emphasizes the concept of the smart supply chain for agricultural development. it aims to provide a stable food supply network and focus on the optimization of local production levels. the west java provincial government also aimed to meet the nutritional needs of the community, reduce food loss and waste, and adopt sustainable agriculture by developing rfhs. therefore, presidential directives have a significant point of working related to food security (djalante et al., ) . this subsection discusses the results of the numerical simulation for the three scenarios. first, the result for each scenario is discussed, which are then compared at the end of the subsection. the optimal location for the rfh in scenario is developed based on case (eight red zones) presented in table , and case (thirteen red zones), as shown in table . there are eleven alternative rfh locations in case , eight in red zones and three outside. in this scenario, large-scale social distancing is applied as protection aimed to limit space in the red zone. the rfh development area in scenario is at high risk for deficiency of food supply. further, hunger will continue to increase in the red zone as it cannot depend on the other production areas. the total logistics cost for scenario in case is rp , . /kg production. in case , seventeen optimal rfhs must be built, thirteen in the red zone and the rest from other zones. the implementation of large-scale social distancing reduces food distribution from other districts. in scenario , there is a change in the amount of rfhs that must be built. as more red zones and locations change, the need for rfh development will continue to increase. it can affect the availability of food in areas affected by large-scale social distancing. the total logistics cost for scenario in case is rp , . /kg. as discussed before, the greater the number of red zones, the higher is the need for rfh development. this is due to the restriction of the food supply network in the red zones. rfhs should be built in every red zone to maximize demand fulfillment in those areas to avoid an increase in hunger. in terms of the complexity of the problems, case in scenario has , decision variables and parameters, which are involved in , constraint functions. meanwhile, case in scenario has the same decision variables and parameters, which are involved in , constraint functions. the greater the number of red zones involved in the case, the more complex the model will be. in this scenario, the rice demand of urban areas that become the epicenter of covid- could not be fulfilled, as presented in table . the area's capacity to produce rice cannot match its total rice needs. the rfhs in four red zones could not import rice from the production areas outside the red zones, due to the policies that forbid distribution from or to the red zones. thus, more than million citizens in four red zone are in food insecurity. changes in the classification of red zones affect rice demand fulfillment. depok and bandung city, whose production capacity cannot fulfill their demand, were classified as red zones in case . however, in case , they are no longer classified as red zones, and so their demand could be fulfilled by other districts, resulting in an increase in the rice fulfillment in those districts. in contrast, cimahi city was classified as a green zone in case , and other districts could fulfill its demand. however, in case , cimahi city became a red zone that could not fulfill its demand, resulting in a decrease in rice fulfillment in cimahi city. although there are other red-zone status changes in several districts, their demand fulfillment was figure . food supply network from production zone to rfh for case in scenario . t. perdana et al. heliyon ( ) e not affected, e.g., tasikmalaya, indramayu, sukabumi, bogor, cianjur, purwakarta, and karawang. their capacity to produce rice can meet their demand, so the demand fulfillment in those districts will not change if they become red zones. overall, the rice fulfillment increase in depok and bandung is higher than the rice fulfillment decrease in cimahi. at the same time, other changes in red zones did not affect rice demand fulfillment. this makes rice fulfillment in case is higher than in case . unlike rice commodities, demand for chicken eggs can be met by all areas, as presented in table . the districts/cities in west java can produce chicken eggs without depending on other production areas. the classification of the red zone thus does not affect the fulfillment of chicken egg needs. however, chicken eggs are insufficient to reduce the risk of hunger and the issue of immunity during the covid- pandemic. changes in the classification of red zones did not affect the fulfillment of the egg demand. when green zones in case become red zones in case , their egg demand could not be supported by other districts. however, their own capacity to produce eggs could fulfill their demand, and so the demand fulfillment in those districts could be maintained. when a green zone in case became a red zone in case , the eggs produced there could no longer be distributed to other districts. however, other districts produced sufficient eggs, and so the egg demand in green zones was still fulfilled, thus maintaining the overall fulfillment of egg demand. when the red zone in case became a green zone in case , the egg produced could be distributed to another green zone. further, their demand could be fulfilled by another green zone, which makes for a better and more productive food supply network. about eight districts/cities in case and nine red zones in case could not meet vegetable demand, as presented in table . this was because these zones are not the main vegetable-producing area. the main production areas were restricted from distributing the vegetable yields to the red zones, which makes the vegetable fulfillment in this scenario even worse. based on the rate of vegetable consumption in each district, it is estimated that more than million people in west java could not fulfill their vegetable needs. changes in the classification of red zone affect vegetable fulfillment. the fulfillment ratio of a red zone in case that changed into a green zone in case will remain the same or increase. whenever a red zone becomes a green zone, its demand can be fulfilled by other districts, and so its demand fulfillment increased or at least remains the same. in contrast, the fulfillment ratio of a green zone in case that changed in a red zone in case will remain the same or decrease. whenever a green zone becomes a red zone, its demand cannot be fulfilled by other districts anymore, and so their demand fulfillment decreases or at least remains the same. the green zones in case that changed into red zones in case figure . food supply network from rfh to consumer for case in scenario . are predominantly in suburban areas, with sufficient production capacity to fulfill their own demand. the red zones in case that changed into the green zone in case are predominantly urban, with a high population density, resulting in more people requiring vegetable supply. this makes the vegetable fulfillment in case higher than in case . scenario restricted the food supply network from the production area to the rfhs in the red zones, who are then forced to produce food. the scenario creates a significant rfh development cost because every time an additional red zone comes up, the government must build an rfh. limited movement causes shortage of some food commodities. this scenario cannot optimize the rfh function as an aggregator between food production and consumer areas. these conditions result in food insecurity and malnutrition. scenario is not compatible when applied in the long term. it would cause certain areas to be isolated from production areas and reduce the fulfillment of food demand. although rfhs are required to serve all consumers, the supply does not match the consumption needs. in figures and , the rfh is not optimistic about providing food for the community. the optimal location for the rfh in scenario is developed based on case (eight red zones) in table , and case (thirteen red zones) in table . scenario was built, in which partial social distancing conditions were applied in the red zone areas. although the production center can supply food to the rfhs in the red zone, the addition of the red zone still affects the number of rfhs that must be built. the total rfhs built is eleven in case , eight in the red zones, and the rest outside. the total logistics cost for scenario in case is rp , . /kg, and the fulfillment ratio of rice and chicken egg reaches %; only the demand for vegetables could not be fulfilled. if the vegetables produced in west java is sufficient to fulfill the overall demand, rfh development will not be affected by the changes in the classification of red zones. however, since this is not the case, rfhs should be built in the red zones so that the vegetables produced in the red zones could be distributed to fulfill their demand. this condition makes the number of rfhs increase in case , in which sixteen rfhs are built. the total logistic cost for scenario in case is rp , . /kg. in terms of the complexity of the problems, case in scenario has , decision variables and parameters, which are involved in , constraint functions. meanwhile, case in scenario has , decision variables and parameters involved in , constraint functions. the greater the number of red zones involved in the case, the more complex the model will be. in this scenario, rfhs become crucial to maximize the supply of products. according to table , all areas in cases and could fulfill rice demand, as rice production in every area in west java is sufficient to satisfy their demand. the application of partial social distancing helps rfhs to provide for the rice needs in each rfh. further, hygiene and food safety standards must be implemented in the case of partial social distancing in food distribution. the changes in the classification of red zones did not affect the rice demand fulfillment in scenario . this is because when a green zone in case became red zone in case , their produced rice could no longer be distributed to other districts but there other districts produced sufficient rice, which maintains the fulfillment of rice demand. when a red zone in case became a green zone in case , fulfillment of rice demand improved because the rice produced in those districts is no longer restricted, which provides additional rice supplies from those districts, resulting in a the better and more effective food supply network. the chicken egg requirement in scenario can be fulfilled % in each district of west java province, as presented in table . the partial social distancing for some commodities could build customer confidence to reduce risk exposure and guarantee universal health coverage. these results carry obvious implications for household food security and nutrition, particularly for those in the red zone. the changes in the classification of red zones did not affect the egg demand fulfillment in scenario . this is because when the green zone in case becomes a red zone in case , the egg produced there could no longer be distributed to other districts. however, other districts could produce sufficient eggs, which helps maintain the fulfillment of egg demand. when the red zone in case became a green zone in case , the egg demand fulfillment improved because the eggs produced in those districts is no longer restricted, which increases egg supply from those districts. in this scenario, partial social distancing cannot meet the needs of vegetable consumption, as presented in table . therefore, vegetable needs can be substituted with other vegetable commodities to meet daily food fiber needs. there are about . million people in west java whose figure . food supply network from production zone to rfh for case in scenario . changes in the classification of red zones affect vegetable demand fulfillment. this is because the vegetables produced in west java are less than the demand for them. when the red zones in case become green zones in case , the vegetable produced there could be distributed to other districts, which strengthens the food supply network. however, when a green zone in case becomes a red zone in case , the produced vegetable could no longer be distributed to other districts anymore. meanwhile, the vegetable produced in other districts is insufficient to fulfill the overall demand. thus, the greater the number of red zones, the lower the vegetable supply, which results in a decrease in vegetable fulfillment. this condition could worsen if the green zones that change into red zones are predominantly in suburban areas with high vegetable production capacity. in case , the vegetable fulfillment reached maximum with all the vegetable produced. all vegetable produced are distributed in case . however, as the number of red zones increased in case , vegetable fulfillment decreased. cianjur is one of the suburban areas with high vegetable production capacity. when cianjur becomes a red zone in case , west java loses one of its main vegetable production sources, which makes the vegetable fulfillment in case lower than case in . although rfhs can receive supplies from several nearby production areas, the red zones are restricted from supplying food to other districts, as shown in figures and . this distribution model is still safe if the area affected by the pandemic is an urban area. however, if the pandemic extends to areas of food production centers in west java, food shortages is likely to occur in various districts. the food supply network of rfhs can only serve consumers who are in the red zone. this scenario is safe if the red zones are confined to urban areas-this model is designed to ensure that customers in the red zone have food security. however, the large number of rfhs has caused high rfh development costs. the optimal location for the rfh in scenario is developed based on case (eight red zones) in table , and case (thirteen red zones) is shown in table . unlike scenarios and , in scenario , rfh development is not affected by the change in the classification and increase of red zones. the number of rfh that must be built does not change in scenario , which has implications for the cheaper rfh development. the rfh is built near central production areas, and can optimized to supply food to a broad range of consumers. the total logistics cost in model is thus lower than in scenario and , at rp , . /kg. the demand fulfillment of all food commodities reaches its maximum in this scenario. the number of rfhs built in this scenario is less than in scenarios and , whereas, the total capacity of all rfhs is higher. the food supply network in this scenario is more effective than in scenarios and . in terms of the complexity of the problem, case in scenario has , decision variables and parameters, which are involved in , constraint functions. meanwhile, case in scenario has , decision variables and parameters, which are involved in , constraint functions. the greater the number of red zones involved in the case, the more complex the model will be. in scenario , the rfh development can optimize food security for the whole community. the food supply network that carries out normal conditions could impact the economic circulation. food security in the covid- pandemic is vital for the survival and health of society. for the people of west java, rice supplies are crucial, especially when there is social distancing. the needs of rice in west java can be fulfilled, as presented in table . the needs of the chicken egg in west java province can also be fulfilled, as presented in table . six districts control up to . % of the total production of chicken eggs in west java province. this scenario can guarantee the sustainability and availability of egg supply in each customer area in west java province. two cities could not meet vegetable demand, and one district cannot fulfill % of the vegetable needs in the area, as presented in table . around . million people are threatened with a shortage of vegetable supplies. as stated earlier, the lack of fulfillment of vegetables can be substituted with other commodities that are not considered in this model. therefore, vegetable consumption fulfillment can be reconsidered by adding consumption and production components of other vegetable commodities produced locally. each production area can supply crops to the nearest rfh with due consideration to hygiene protocols as a preventive measure for covid- transmission. the food supply network with a system based on normal conditions ensures the availability of food for the communities, as presented in figure . this condition can have implications for social and economic factors of the communities in urban and rural areas. in distributing food from rfhs to consumers, rfh services cover all areas within a certain distance, as presented in figure . food distribution from rfhs is done through traditional markets, modern markets, caf es, restaurants, catering services, hospitals, hotels, and online market places. the distribution system guarantees the availability and traceability of food, making it easy to control food security in each consumer area. as a result of the covid- pandemic, the issue of the food system has emerged. the food system includes all aspects of providing food. the implementation of the large-scale social distancing impacted the uncertainty of food demand and supply. therefore, it is essential to develop a food system to tackle the uncertainty of food supply. in this paper, a model was developed that focuses on the rfh location and network. it determined the improvement of food security for society by considering aspects of sustainability, food safety, and effectiveness of the food supply network. a set of rules were applied to each situation to arrive at the best scenario for food supply during the pandemic. the three scenarios are compared and summarized in table . scenario implements large-scale social distancing so that areas designated as red zones cannot deliver or receive food supplies from other regions and vice versa. the limitation in this scenario aims to minimize the spread of the disease. this scenario becomes a problem if the red zone only falls in urban areas that do not have sufficient capacity for food production. the number of rfhs in scenario is higher than in both scenarios and . the results for this scenario will also worsen when the number of areas classified as red zones increases, as each location will need to build rfhs and fulfill food needs independently. a change in the number of red zones also affects the total cost of rfh development. the application of large-scale social distancing on the food supply network inhibits economic circulation and social activities. this condition is not in line with the principle of food security and sustainability (sharpe et al., ) . scenario applies partial social distancing; other zones support the food needs of the red zone and are predicted to decrease hunger. food distribution activities from the other areas are also carried out by implementing food and health safety protocols recommended by the government as a way to minimize the spread of the disease. food security should consider the spreading of the virus between producers, retailers, and customers and avoid massive food insecurity. scenario aims at keeping the food supply network functioning to be able fulfill food needs. however, this scenario will only work well if all red zones are in urban areas. the situation would be different if the red zone extends into the production center, causing a shortage of food supply in several areas. it is feared that this situation will worsen the community's physical and mental health (highlander and singley, ) . moreover, the costs required for rfh development are not much different from scenario . in scenario , food delivery is carried out under the new era in the food supply chain, which involves the implementation of health and food safety protocols. each production area can supply the crops to the nearest rfh, and rfhs can serve the entire area based on their range and capacity. the vegetable needs can be fulfilled by substituting other vegetable commodities not included in this model's calculation. rfh development in scenario is not affected by the increase in the number of red zones and location changes. therefore, the costs required for rfh development is lower than in scenarios and . the rfh could be the optimal form of food supply network as it can ensure the supply of food for the entire region, and also has implications for reducing carbon emissions (galanakis, ; hobbs, ; sharpe et al., ) . the determination of the scenario takes into account aspects of the food system, sustainability, and health regulations (hobbs, ; sharpe et al., ; djalante et al., ; brand et al., ; mittal et al., ; brinkley, ; ge et al., ; levkoe et al., ; dasaklis et al., ). the food system should be developed with consideration of food security and food safety (galanakis, ; rizou et al., ) . in scenario , rfh is designed to benefit all levels of society from the availability of sufficient food. upstream actors can minimize overproduction to increase production efficiency and value addition (kharisma and perdana, ; barba et al., ) . downstream actors are becoming interested in local foods, including perceptions about sustainability, hygiene, and health benefits (hobbs, ; galanakis, ; rizou et al., ) . food security during the pandemic must be ensured. maintaining hygiene during production and logistics, as well as the hygiene of food and workers are important considerations while ensuring food security to the whole community during a pandemic (who, ; rizou et al., ; galanakis, ) . therefore, rfhs could be used as a resilient food network to ensure the availability and safety of food (b en e, ; galanakis, ; rizou et al., ) . from the perspective of sustainability, food delivery can reduce carbon emissions from efficient use of vehicle fuel, decreased food loss during distribution and post-harvest, and reduction of food waste during the selling process (hakovirta and denuwara, ; nagarajan et al., ; galanakis et al., ) . rfhs are designed based on the locality of agricultural products and aim to improve the social and economic condition of communities affected by the pandemic (nicola et al., ; phillipson et al., ) . therefore, the development of rfhs needs to be strengthened by the development of efficient and interconnected food chain networks (galanakis, ; handayati et al., ) . to reduce the spread of covid- and support physical distancing, digital food services could be adopted to optimize the rfh services. such services will have a longer-term effect on the food supply chain, including the increase of e-commerce and customer preference on the local food supply network (hobbs, ; keesara et al., ) . digital food services could also reduce food loss and waste, make a traceability system possible, fulfill the nutrition requirements of the customer, as well as provide a fast response to imminent economic crises in the era of the covid- pandemic (sarfarazi et al., ) . functional local food can fortify health and improve the consumer's immunity system (galanakis, ) . the conception of the model also considers the policies that apply both in west java province and the central government (manganelli et al., ). an alternative model of rfh development in west java province can be a reference for the government to build a food supply network that emphasizes aspects of food safety and health based on the specific conditions in west java province. the best scenario is scenario , as it illustrates ideal conditions during typical situations. this scenario is chosen because none of the rfhs have territorial boundaries (red and green zones) during the procurement. the food supply network's delivery should conform to health and safety protocols to minimize the spread of disease. the number of rfh that should build is fixed, that is, six rfhs, and so the investment cost of rfh development is lower than in scenarios and . the rfhs and food supply network are in a strategic location, food is supplied from the nearest rfh region, and rfh serves the closest coverage area. this scenario has an impact on the efficiency of distance and the use of diesel fuel, which leads to an increase in farmers' income and customers' access to local food. a possible topic for future research is minimizing the spread of disease by developing digital services. digital food services could be an alternative technology to decrease human interaction, reduce the time spent in product purchase, decrease carbon emissions, reduce food loss and waste, and maximize warehouse capacity. some food processing technologies to process food waste from the supply chain could also be considered. digitalization is useful in obtaining bioactive ingredients to strengthen the consumer's immune system and minimize food waste for a more sustainable food supply chain. the model scenario presented here could be used as a reference for the provincial government to build rfh during the covid- pandemic and as a recommended strategy to develop food security in the new era. author contribution statement t. perdana: conceived and designed the experiments; performed the experiments; analyzed and interpreted the data; wrote the paper d. chaerani and a. l. h. achmad: performed the experiments; analyzed and interpreted the data; contributed reagent, materials, analysis tools or data; wrote the paper f. r. hermiatin: performed the experiments; analyzed and interpreted the data; and wrote the paper. designing local food systems in everyday life through service design strategies potential use of pulsed electric technologies and ultrasounds to improve the recovery of high-added value compounds from blackberries regional food hub resource guide robust optimization, robust optimization-methodology and applications resilience of local food systems and links to food security-a review of some important concepts in the context of covid- and other shocks social enterprise, sustainability and community in post-earthquake christchurch dietary inequalities: what is the evidence for the effect of the neighborhood food environment? constructing resilient, transformative communities through sustainable "food hubs the role of placemaking as a tool for resilience: case studies from post-earthquake the small world of the alternative food network subsidies under uncertainty: modeling of input and output-oriented policies local food hubs for alternative food systems: a case study from epidemics control and logistics operations: a review the effects of conventional and non-conventional processing on glucosinolates and its derived forms, isothiocyanates: extraction, degradation, and applications conceptualizing covid- 's impacts on household food security review and analysis of current responses to covid- in indonesia: period of optimal wholesale facilities location within the fruit and vegetables supply chain with bimodal transportation options: an lp-mip heuristic approach rebuilding local foods in appalachia: variables affecting distribution methods of west virginia farms food hubs: definitions, expectations, and realities recovery of high added-value components from food wastes: conventional, emerging technologies and commercialized applications emerging technologies for the production of nutraceuticals from agricultural by-products: a viewpoint of opportunities and challenges separation of functional macromolecules and micromolecules: from ultrafiltration to the border of nanofiltration phenols recovered from olive mill wastewater as additives in meat products the food systems in the era of the coronavirus (covid- ) pandemic crisis implementation of phenols recovered from olive mill wastewater as uv booster in cosmetics optimal locations of fresh produce aggregation facilities in the united states with scale economies a practical guide to robust optimization agriculture, transportation, and the covid- crisis assessing the impact of the covid- pandemic on agricultural production in southeast asia: toward transformative change in agricultural food systems how covid- redefines the concept of sustainability value co-creation in agri-chains network: an agent-based simulation a genetic algorithm approach for locationinventory-routing problem with perishable products covid- : a mathematical model for the effect of social distancing on the spread of covid- neighborhood disparities in access to healthy foods and their effects on environmental justice food supply chains during the covid- pandemic the role of local food systems in us farm policy covid- and health care's digital revolution linear programming model for vegetable crop rotation planning: a case study potential of a shopping street to serve as a food distribution center and an evacuation shelter during disasters: case study of kobe alternative food networks as "market agencementse": exploring their multiple hybridities building sustainable communities through food hubs epidemic-logistics modeling: a new perspective on operations research socio-political dynamics of alternative food networks: a hybrid governance approach the impact of covid- on the uk fresh food supply chain arxiv preprint a hybrid simulation modeling framework for regional food hubs logistics best practices for regional food systems: a review the impact of the covid- pandemic on the supply chain of agricultural products a facile water-induced complexation of lycopene and pectin from pink guava byproduct: extraction, characterization and kinetic studies the socio-economic implications of the coronavirus and covid- pandemic: a review food security: the urban food hub solution daftar harga bbk tmt oktober -pt pertamina persero daftar harga bbk tmt februari -pt pertamina persero daftar harga bbk tmt maret -pt pertamina persero the covid- pandemic and its implications for rural economies food democracy in the making: designing with local food networks food first: covid- outbreak and cities lockdown a booster for a wider vision on urban agriculture engineering optimization: theory and practice safety of foods, food supply chain and environment within the covid- pandemic network optimization of food flows in the us community food hubs: an economic and social justice model for regional australia? evaluation of microwave-assisted extraction technology for separation of bioactive components of saffron (crocus sativus l.) covid- : pandemic contingency planning for the allergy and immunology clinic effects of a food hub initiative in a disadvantaged community: a quasi-experimental evaluation creating integrated strategies for increasing access to healthy affordable food in urban communities: a case study of intersecting food initiatives reflexive governance for food security: the example of school feeding in brazil compendious lexicographic method for multi-objective optimization jawa barat province in figures logistics aspects of avian influenza pandemic in hong kong disparities and access to healthy food in the united states: a review of food deserts literature optimization of location-routing problem for cold chain logistics considering carbon footprint fruit juice sonication: implications on food safety and physicochemical and nutritional properties the authors thank the west java development planning agency and universitas padjadjaran, which supported this study by providing research data. red zone ( figure . food supply network from production zone to rfh for case in scenario . this research was funded by indonesian the ministry of research and technology/national research and innovation agency ( /un . . / lt/ ). the authors declare no conflict of interest. no additional information is available for this paper. key: cord- -kof tcoe authors: p, r.; g r, d. l. title: covid pandemic analysis using regression date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: kof tcoe covid- is a pandemic which has affected all parts of the world. covid- is a pandemic which can be controlled only by maintaining social distancing, proper hygiene, wearing mask, hand sanitation and to a extend by wearing face shield. even though each state has followed their own ways of controlling the infection, awareness among citizens and behaving as responsible citizens is very important in controlling this disease. contact tracing plays an important role in controlling this pandemic. this paper deals with the effect of covid- in various states of india and also forecasts its effect using machine learning techniques. regression analysis like linear and polynomial have been used for analysis of covid- , where kaggle dataset has been used. this helps in understanding the much-affected states in india and helps to understand the infrastructure requirements to handle this pandemic efficiently. sore throat, tiredness, chills and fever. there are some cases where people don't show any symptoms and are called asymptomatic. very specific symptom of covid- is the loss of ability to taste or smell which is very rare in other infections. patients should immediately seek medical care if there are warning signs or symptoms like i) blue lips or face, which could mean they are not getting enough oxygen. ii) chest pain when breathing iii) shortness of breath. iv) new confusion or difficulty waking up. people who are more affected by covid- are older adults greater than years of age, obese and who have diabetes, hypertension or other ailments. so it's better that these category people quarantine from other members in the family. % of people infected with sars-covid- will become ill within days after they get infected. people who are asymptomatic can also be infectious. it's more difficult to define infectious period for such people. reproductive number gives a measure of how fast the disease can spread. the higher the reproductive number, the more people will be infected. the r of sars-covid- is to . if each infected person infects just two people, the size of outbreak doubles quickly. so contact tracing is also very important to reduce the transmission of covid . different countries are following different methods of electronic media to trace contacts. india is a country where citizen privacy is given utmost importance. there also many apps which are used to identify whether a person was exposed to covid positive patient. but efficiency of this depends on the number of people using the app and also the data should be updated by all who are using it. if the contacts can be traced efficiently and depending on the situation, if they can be isolated or quarantined, the spread of the disease can be controlled to a great extent. regression analysis has been used to understand the effect of covid- on various indian states. india is a country where initially covid- infection was controlled through lockdown of entire country and later by restricted lockdown. as the number of cases increased, depending on clusters lockdown is imposed. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october , . . cases in various states of india has been analysed in terms of confirmed cases, death cases and recovered cases. dataset has been taken from kaggle website from nd march to th july . the number of cases in tamil nadu is much more compared to other four states and kerala have been the least for the considered time period. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint kerala has been a state which received much appreciation world wide for initially flattening the curve.but later kerala also lost his control over infection rate.the recovery rate of delhi is much better compared to other states.there has been a steep increase in cases in all the states after the month of june. linear regression analysis and polynomial regression analysis has been modelled using matlab software and effect of covid- has been analysed.a relationship between variables are modelled using regression analysis.the variables considered are confirmed cases and mortality rates. the results of linear regression are shown in below figures.the results for karnataka almost matched with training set,but in case of other states there is slight deviations.initially all the states tried to control the disease by quarantining the prople who got infected.but in case of all the states the number of cases are increasing.the mortality rate of kerala is much less compared to other states. kerala had initiallycontrolled by very efficiently tracing the contacts. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october , . . in case of karnataka,for above , cases there are chances of nearly deaths.the number of cases of tamil nadu is much more compared to other states.the mortality rate of tamil nadu and delhi is almost same even though the number of cases in tamil nadu is much more than delhi. as on rd august the number of confirmed cases in karnataka is and deaths are .in delhi the number of confirmed is and deaths are .in tamil nadu, has lost their lives and are confirmed cases .in kerala, number of confirmed cases is and number of death is which is much less compared to other states. maharashtra has the highest number of cases and mortality rate. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint polynomial regression is also done using kaggle dataset till th july .the predicted and actual results almost matches as shown in the graphs. regression analysis like linear and polynomial is used to analyse the effect of covid on different states of india.the results can vary depending upon the data set considered.in this paper,some of the states has been considered.this analysis can be extended to other states also.also analysis can be done considering confirmed cases and recovered cases. analysis shows that the number of confirmed cases and mortality rate is going to increase in the coming months as community spread has started. maharashtra has the highest with confirmed cases and deaths.andhra pradesh has cases with deaths.madhya pradesh has confirmed cases and deaths.uttar pradesh has confirmed cases and deaths.west bengal has recorded confirmed cases and deaths.rajasthan has cases and deaths as on rd august .mizoram and lakshadweep has zero mortality has on rd august.almost all states are affected by covid and all measurements has to be taken to reduce the spread and to give accessibility to health care irrespective of whether rich or poor. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october , . . in this paper,covid cases has been analysed using dataset from kaggle website.linear regression and polynomial regression has been done using the available dataset.this analysis shows that the number of cases are going to increase in the coming days.with respect to mortality rate,maharashtra is the worst affected.delhi and tamil nadu are aslo badly affected with respect to confirmed cases and mortality rate.kerala has less mortality rate as compared to its confirmed cases. this study can be further extended by considering recovery rate and confirmed cases.also other than regression, other models can also be used for analysis. linear regression analysis to predict the number of deaths in india due to sars-cov- at weeks from day ( cases preliminary estimate of excess mortality during the covid- outbreak saibal pal, seir and regression model based covid- outbreak predictions in india trend analysis and forecasting of covid- outbreak in india data analysis of covid- epidemic using machine learning methods: a case study of india short-term forecasts of covid- spread across indian states until basic reproduction rate and case fatality rate of covid- : application of meta-analysis data-based analysis, modelling and forecasting of the novel coronavirus ( -ncov) outbreak," medrxiv covid- in india: state-wise analysis and prediction data analytics for novel coronavirus disease digital technology and covid- machine learning approach for confirmation of covid- cases: positive, negative, death and release key: cord- - m cur authors: plank, m. j.; james, a.; lustig, a.; steyn, n.; binny, r. n.; hendy, s. c. title: potential reduction in transmission of covid- by digital contact tracing systems date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: m cur digital tools are being developed to support contact tracing as part of the global effort to control the spread of covid- . these include smartphone apps, bluetooth-based proximity detection, location tracking, and automatic exposure notification features. evidence on the effectiveness of alternative approaches to digital contact tracing is so far limited. we use an age-structured branching process model of the transmission of covid- in different settings to estimate the potential of manual contact tracing and digital tracing systems to help control the epidemic. we investigate the effect of the uptake rate and proportion of contacts recorded by the digital system on key model outputs: the effective reproduction number, the mean outbreak size after days, and the probability of elimination. we show that effective manual contact tracing can reduce the effective reproduction number from . to around . . the addition of a digital tracing system with a high uptake rate over % could further reduce the effective reproduction number to around . . fully automated digital tracing without manual contact tracing is predicted to be much less effective. we conclude that, for digital tracing systems to make a significant contribution to the control of covid- , they need be designed in close conjunction with public health agencies to support and complement manual contact tracing by trained professionals. contact tracing has become a key tool in the global effort to control the spread of covid- . contact tracing has been crucial in controlling several disease outbreaks, notably sars, mers and ebola (who & cdc, ; kang et al., ) . while contact tracing alone is unlikely to contain the spread of covid- kucharski et al., ) , in countries like new zealand where cases have been reduced to very low numbers (cousins, ; binny et al., ) , it may allow population-wide social distancing measures to be relaxed. in countries with more widespread epidemics, it can allow safe reopening. manual contact tracing typically involves interviewing confirmed cases about their recent contacts, getting in touch with those contacts and asking them to take measures to prevent onward transmission of the disease in case they are infected. such measures may include limiting their interactions with others, formal quarantine, getting tested, or remaining vigilant for symptoms. manual contact tracing is intensive work and requires highly trained public health professionals to be implemented effectively (verrall, ) . it is also difficult to scale manual contact tracing up to deal with very large outbreaks. in response, many countries have attempted to develop digital contact tracing systems using smartphone apps. there are multiple different approaches to this problem, for example qr code-based systems, bluetooth-proximity based apps, automated exposure notification features, and systems that do not rely on smartphones such as card-based proximity detection. these systems can offer, to varying extents, three main benefits to controlling covid- : (i) an increase in the proportion of contacts who are traced (e.g. contacts that would not be traced by case recall but are recorded by the digital system); (ii) a reduction in the time taken to identify and notify traced contacts (e.g. via an exposure notification feature); (iii) improved scalability over manual contact tracing. the effectiveness of digital contact tracing is still unproven, with limited real-world data (anglemyer et al., ) . here, we use a model of covid- transmission and contact tracing to evaluate the potential of digital contact tracing systems to reduce the spread of covid- . we evaluate the benefits of digital contact tracing both alone and in combination with manual tracing, over a range of uptake rates, tracing probabilities, and the effectiveness of quarantine. transmission and contact tracing model. we use an age-structured branching process model for covid- transmission and contact tracing that is an extension of the age-structured model of james et al. ( ) to include different contact types (see below). we assume that the outbreak is sufficiently small that the effect of infection-induced population immunity can be ignored. the time from infection to symptom onset is gamma distributed with mean . days and standard deviation . days (lauer et al., ) . infectiousness is a weibull function, timeshifted such that % of transmission occurs prior to symptom onset (ferretti et al., ; ganyani et al., ) . infections have an age-dependent probability of being subclinical (davies et al., ) that decreases linearly from % in the - year age group to % in the over years age group. subclinical infections are assumed to be % as infectious as clinical cases. contacts are categorised into one of four different types: home, work, school and casual. each contact has a probability, called the secondary attack rate (sar), of resulting in transmission. the sar is assumed to be % for home contacts and % for work, school and casual contacts . age-specific contact rates in each of these four settings are based on the contact rates estimated by prem at al. ( ) for the new zealand population. the average number of age-specific home contacts was taken directly from the results of prem et al. ( ) and assumes that household contacts do not vary from day to day. the average number of work, school and casual contacts made during the infectious period was chosen to be a fixed multiple of the number of daily work, school and casual contacts in prem et al. ( ) , chosen to give a basic reproduction number (in the absence of any control measures, case isolation, or contact tracing) of = . . we model heterogeneity in number of contacts via gamma distributed individual multipliers for each of the four settings (lloyd-smith et al., ) . heterogeneity is assumed to be higher in work, school and casual contacts than in home contacts, reflecting a greater occurrence of superspreading events in these settings. we model homophily by assuming that the number of contacts of a secondary case is correlated to the number of contacts of the index case in the setting in which transmission occurred. we assume that each transmission via a non-home contact results in infection of a new household, which is assigned a household size according to the age-specific distribution of home contacts. each household is assumed to consist of a fixed group of individuals, so that subsequent infections within the same household deplete the pool of susceptible home contacts (see appendix for details). in the absence of any contact tracing, clinical cases are assumed to be eventually tested with probability = (i.e. all clinical cases are eventually detected). the delay from onset of symptoms to testing is assumed to be gamma distributed with mean . days and standard deviation . days (estimated from new zealand data for the march-april outbreak). cases are isolated at the same time as getting tested and this prevents any further transmission. there is a further delay between getting tested and the test result being returned that is a minimum of . days, plus an exponentially distributed random variable with a mean of . days. subclinical cases do not get tested are do not isolate. the contact tracing model is illustrated in figure . when a new positive test result is returned and contact tracing for that case begins, we refer to the individual testing positive as the index case and to contacts of the index case as secondary cases. contacts who do not end up getting infected are not modelled explicitly (but see discussion about effects of quarantining false positives). tracing of the index case's contacts begins when the index case returns a positive test result. under manual tracing, each contact has a probability of being traced, and a time taken to trace, both of which may differ across the four settings. traced contacts who are not currently symptomatic (i.e. either subclinical or presymptomatic) go into quarantine, which is assumed to reduce onward transmission to a level < relative to no quarantine. traced contacts who are symptomatic go into isolation immediately on symptom onset, which is assumed to completely prevent any further onward transmission. untraced contacts do not go into quarantine, and experience a delay between symptom onset and isolation and testing (see above). effective contact tracing therefore reduces transmission in two ways: (i) quarantining of contacts who are not currently symptomatic; and (ii) prompt isolation of contacts immediately on symptom onset. home contacts are always assumed to be traced instantly (i.e. immediately after the index case returns a positive test result) with probability , and this happens independently of any digital contact tracing system. under manual contact tracing, work contacts are traced with probability . , school contacts with probability . , and casual contacts with probability . . work and casual contacts are assumed to have a tracing time that is gamma distributed with mean days and standard deviation . days. school contacts are assumed to be traced more rapidly but not instantly ( . days after the index case returns a positive test result). . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure . schematic diagram of the contact tracing model. infectious individuals are initially asymptomatic (yellow). for the index case who was not traced ( ), there is a delay between onset of symptoms (red) and getting tested. isolation occurs at the same time as getting tested. there is a subsequent delay to the test result being returned (+) and tracing of contacts. traced contacts ( - ) are quarantined when contacted by public health officials (phone icons) and are isolated and tested immediately on symptom onset. traced contacts ( ) who are already symptomatic prior to being traced are isolated immediately when contacted. traced contacts ( ) that have already isolated prior to being traced are not affected. contacts that cannot be traced ( ) may still get tested and isolated, but this is likely to take longer. subclinical individuals ( ) do not get tested or isolated, but will be quarantined if they are a traced contact. we model alternative digital contact tracing systems by varying key parameters of the contact tracing model. home contacts are assumed to be always traced rapidly by the manual system, so digital contact tracing applies to school, work and casual contacts. for each scenario, we assume there is an uptake rate and that each individual in the population is a user of the digital tracing system (e.g. has installed the app) with probability , independently of all other individuals. this ignores any correlation in the usage probabilities of close contacts. provided the index case and secondary case are both users of the system, the contact is digitally logged with probability , which we assume is the same for school, work and casual contacts (see table ). we set a default value of = %, but also investigate values of smaller than this. a tracing probability of % is likely to be unachievable, for example because there will be situations where one or both individuals failed to carry the smartphone or card with them. contacts that are digitally logged are assumed to be quarantined immediately after the index case returns a positive test result, the same as for home contacts. if neither or one of the index case and the secondary case is a user of the system, or both are users but the contact was not logged by the digital system, the contact is not traced digitally, but may still be later traced manually. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . in addition to the benefits of instant tracing described above, some digital tracing systems may also help improve coverage of manual tracing. for example, location-based tracking or a digital diary feature may enable contact tracers to identify and follow up contacts who would otherwise be missed. we do not explicitly investigate these scenarios, though they could be modelled via an increase in the manual tracing probabilities of relevant settings in table . rather than making estimates of tracing probabilities for alternative digital systems, we investigate how the performance of the contact tracing system varies with the uptake rate and the probability of digital tracing (see table ). we assume that isolation of symptomatic traced contacts is % effective in preventing onward transmission, but quarantine of pre-symptomatic and subclinical traced contacts is only partially effective. we investigate two scenarios: ( ) quarantine reduces transmission by % ( = . ); ( ) quarantine reduces transmission by % ( = . ). we assume the effectiveness of quarantine/isolation is the same for contacts that are traced digitally and contacts that are traced manually. this is likely to require effective manual follow up of digitally traced contacts as opposed to relying solely on automatic exposure notifications. we also investigate the additional benefit from including recursive tracing of second-order contacts (i.e. quarantining the contacts of contacts of a confirmed case) in the model. recursive tracing and effective quarantine of second-order contacts is more difficult to achieve in practice because of the much larger number of second-order contacts and the lower risk of them being infected. in the case on an ongoing outbreak with a large number of cases, the number of uninfected individuals being quarantined under recursive tracing is likely to be prohibitively large (firth et al., ) . however, recursive tracing could potentially be useful in suppressing a small outbreak in its very early stages. we assume that tracing of second-order contacts begins days after tracing of the first-order contact and can occur digitally or manually following the same rules described above ( figure ). this means that second-order contacts who are traced digitally are quarantined days after quarantining the first-order contact; second-order contacts traced manually are quarantined later. any second-order contacts made subsequent to quarantine of the first-order contact cannot be traced recursively (but may still be traced on or after the positive test result of the first-order contact). third-order contacts were not traced recursively. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . manual contact tracing has different tracing probabilities and times for home, school, work and casual contacts. home contacts are always traced and this is assumed to happen with no delay. school contacts are traced with probability % and this takes half a day. work and casual contacts have lower tracing probabilities and a delay of days on average. we investigate manual contact tracing supported by a digital contact tracing system that has probability (default value %) of instantly tracing school, work and casual contacts, provided both the index case and the contact are users of the digital system. contacts that are not traced by the digital system may still later be traced manually. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint we measured the reduction in spread of covid- by looking at three model outputs: (a) the effective reproduction number (average number of secondary infections per case); (b) the mean outbreak size (total number of cases per seed case) after days; (c) the probability of extinction of an outbreak starting from a single seed case. together these outputs measure the relative effectiveness of the contact tracing system in containing the virus. these results are robust to the initial number of seed cases: if there are multiple initial seed cases, the reproduction number is not affected; the mean outbreak size is simply multiplied by the initial number of cases, and the probability of elimination is raised to the power of the initial number of cases. for each combination of contact tracing parameters, we ran multiple simulations each of which was initialised with a single infected seed case. results are shown for uptake rates ranging from to % and were calculated by averaging over a sufficient number of simulations to provide an aggregate total of at least , cases. with case isolation in the absence of any contact tracing, the effective reproduction number was = . , the mean outbreak size after days was , and the probability of extinction was approximately %. manual-only contact tracing (which corresponds to a digital uptake rate of = in fig. ) with moderately ( %) effective quarantine of pre-symptomatic or subclinical individuals reduced to . , the mean outbreak size to approximately and increased the probability of extinction to %. when quarantine is moderately effective (reduces transmission by %, blue curves in fig. ), the addition of digital tracing with high uptake rate (> %) and high probability of logging contacts ( = %) reduced to around . , mean outbreak size to , and increased the probability of extinction to %. if quarantine is more effective (reduces transmission by %, red curves in fig. ) , digital tracing can reduce to approximately . and increase probability of elimination to %. adding recursive tracing of second-order contacts (orange curves in fig. ) provides a relatively small reduction in to . , although this does increase the probability of elimination from % to %. lower uptake rates (< %) result in poorer performance although there is still some noticeable benefit of digital tracing at an uptake rate of around %, provided the probability of a close contact being logged is high ( = % in fig. ). if is much lower than this, performance will deteriorate. however, the results are not as sensitive to as they are to uptake rate , because the requirement for both the index and the secondary case to be users of the system means there is a quadratic dependence on uptake rate. this means that a % reduction in is approximately equivalent to a % reduction in uptake rate. we also considered a scenario in which there is no manual contact tracing, except for home contacts which are still assumed to be traced instantly (figure ) . this could represent a situation where a larger outbreak has exceeded the capacity of the manual contact tracing system, so non-household contacts can only be traced digitally. in this scenario, we assume that quarantine of pre-symptomatic individuals is only moderately ( %) effective and there is no recursive tracing, representing a digital-only contact tracing system without consistent follow-up from trained public health professionals. we measure the effectiveness of contact tracing by , as the other two measures (mean outbreaks size per seed case and probability of elimination) are less relevant in the case of a large outbreak. in this scenario, digital contact tracing makes a larger relative contribution to controlling the spread of covid- . however, it also means that digital tracing alone is unlikely to be able to contain an outbreak: even with a very high uptake rates ( %) of an effective digital tracing system ( = %), is around . . this is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . implies that digital contact tracing would need to be combined with significant population-wide control measures in order to avoid a major epidemic. ; (b) mean number of cases per seed case after days; (c) probability of elimination of an outbreak starting from a single seed case. proportion of contacts logged by digital tracing system when both individuals are users of the system is = %. quarantine reduces onward transmission by % (blue), by % (red), by % and with recursive tracing (orange). isolation of symptomatic cases completely prevents onwards transmission. results are averaged over sufficient simulations of the branching process to give a total , cases. . home contacts are still traced manually, but other contacts can only be traced digitally. proportion of contacts logged by digital tracing system when both individuals are users of the system is = %. quarantine reduces onward transmission by %. isolation of symptomatic cases completely prevents onwards transmission. results are averaged over sufficient simulations of the branching process to give a total , cases. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint table shows a comparison of the effectiveness of alternative technological approaches to digital contact tracing, modelled as having different probabilities of recording contacts. table shows the effective reproduction number for manual contact tracing plus digital tracing systems at different levels of uptake, with highly effective ( %) quarantine and without recursive tracing of second-order contacts. systems based on qr codes alone without proximity detection are likely to perform less well because of the additional steps required for a contact to be recorded: the location needs to have a qr code displayed and both the index case and secondary case need to scan it. this does not diminish the benefit to manual tracing of users scanning qr codes to maintain a record of their movements, but we do not explicitly model this here. fully decentralised bluetooth apps are estimated to be less effective than centralised apps at the same level of uptake, because of a reduced likelihood of users reacting to automatic exposure notifications from a decentralised system without follow up from manual contact tracers. a card-based proximity system is estimated to perform similarly to a centralised bluetooth app, though with a slightly reduced effectiveness because notifications cannot be sent natively and need to be made via a separate system which requires current contact details. effective reproduction number of manual contact tracing plus different types of digital tracing system at % uptake, % uptake and % uptake, with highly effective ( %) quarantine and without recursive tracing. a system based on qr codes with no proximity-detection is modelled as logging a low proportion ( %) of contacts, because the location needs to have a qr code displayed, as well as both contacts taking the additional step of scanning the code. bluetooth apps are modelled as logging a high proportion ( %) of contacts, but in decentralised systems only % of users are assumed to quarantine following a notification. a card-based proximity detection system is assumed to have similar detection probability as a bluetooth app, but only % of contacts lead to an instant notification because the card is separate from user's phones. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https: //doi.org/ . //doi.org/ . / successful control of covid- is likely to require a range of intervention strategies, including some or all of: moderate population-wide social distancing; widespread use of face coverings; restrictions on large gatherings or other interventions targeting superspreading events; case isolation and household quarantine; manual and digital contact tracing (ferreti et al. ; hellewell et al., ; . establishing trusted relationships with cases and contacts is crucial both to increasing contact tracing coverage and to supporting effective quarantine and isolation. there is still limited evidence on the effectiveness of digital tracing systems (anglemyer et al., ) and reliance on digital tracing alone is unlikely to be sufficient. however, there is potential for digital tracing to enhance the coverage and/or speed of contact tracing systems run by trained public health professionals . digital systems should therefore be seen as an opportunity to improve coverage and/or speed by acting in a complementary role to manual contact tracing. emphasis should be on how these systems can provide additional useful information to contact tracers in a timely way or fill potential gaps in the manual system. this implies that thorough consultation with public health agencies undertaking contact tracing should be a pre-requisite for an effective digital support system. in this paper, we modelled the effect of manual contact tracing supported by a digital tracing system with varying levels of uptake and effectiveness. our results show that manual contact tracing can significantly reduce the spread of covid- , but on its own is not sufficient to make the effective reproduction number less than . manual contact tracing supported by a digital tracing system can further reduce spread, depending on the effectiveness of quarantine of unconfirmed (pre-symptomatic and subclinical) cases. if quarantine is moderately effective (reduces transmission by %), a manual plus digital tracing system with very high uptake (> %) could reduce to around . . if quarantine is highly effective (reduces transmission by %), can be reduced to approximately . , which could be sufficient to contain the majority of small outbreaks. however, if the uptake rate is less than around %, the reduction in is not sufficient to contain an outbreak without additional measures. our results suggest that the additional benefit from recursive tracing of second-order contacts is relatively small. in the case of a small outbreak, this may be worthwhile as it could increase the probability of elimination from % to % provided uptake is high and quarantine is effective. however, given that it is likely more difficult to effectively quarantine second-order contacts, and the number of uninfected people being quarantined would be much higher, it may be more beneficial to focus on effective quarantine of first-order contacts than attempting to locate second-order contacts. in our model, untraced clinical cases take . days on average to get tested after onset of symptoms. this assumption was based on the onset to reporting times in data from the march-april outbreak in new zealand. the aim of contact tracing is to find close contacts of confirmed cases and therefore enable early quarantine or isolation. however, it is important to recognise that reducing the time between symptom onset and isolation can bring significant benefits, even in the absence of contact tracing. this implies that enhancing public awareness of covid- symptoms and the need to get tested quickly, ensuring equitable access to healthcare, and maintaining rapid testing capacity are equally important as investment in contract tracing. we have not considered the consequences of false positives from digital contact tracing systems, i.e. people who are recorded as potential contacts by the digital system but have not in fact been at risk of exposure to covid- . for countries such as new zealand that have reduced cases to very low numbers and where the primary goal is to achieve or maintain elimination of community transmission, we assume that the number of false positives is not a primary consideration. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . if case numbers exceed the capacity of the manual contact tracing system, its performance will rapidly deteriorate. under this scenario, digital tracing can make a significant contribution to slowing the growth of the outbreak, but if it became the dominant form of tracing it is likely to be insufficient to reduce under . this implies that population-wide control measures would likely be needed to prevent a major epidemic. a low false positive rate is a more important consideration in this situation. our model allowed for age-specific mixing patterns in home, work, school, and casual contacts, and for heterogeneity and homophily in individual contact rates. however, the model ignores other sources of heterogeneity, for example in types of workplace. some workplaces will be much more amenable to rapid contact tracing than others, for example where employees tend to work in a consistent physical location each day. this could be modelled via individual heterogeneity and homophily in contact tracing probabilities as well as contact rates, however the mean tracing probability is likely to remain the most important parameter. we have taken a technology-agnostic approach to modelling digital contact tracing. among the most important parameters for any digital tracing system are the uptake rate (number of people using the system) and the probability of close contacts being logged. our results show that to contain an outbreak, a well-functioning manual contact tracing system needs to be combined with a digital tracing system that should ideally have at least % uptake and record and record % of close contacts. different systems may have different uptake rates, for example due to usability and privacy issues, so a careful study of expected uptake rates is critical to choosing the best system. the proportion of contacts logged will be affected by the usability of the system and by individual behaviour. for example, contacts will be missed in situations where a user forgets or loses their phone or card, has the phone switched off or a flat battery, or has bluetooth deactivated. systems that rely solely on qr code scanning for exposure notification are likely to perform less well than systems with proximity-based detection at the same level of uptake. this is because successful tracing requires the location to have a compatible qr code displayed, both individuals to have the app installed and to take the additional step of scanning the code. there may be benefits to a qr code app in keeping a record of movements or digital diary, but we did not explicitly consider these here. prem k, cook ar, jit m ( ) . projecting social contact matrices in countries using contact surveys and demographic data. plos computational biology. ( ): e . tindale l, coombe m, stockdale je, garlock e, lau wyv, saraswat m, lee y-hb, zhang l, chen d, walinga j, colijn c ( ). transmission interval estimates suggest pre-symptomatic spread of covid- . medrxiv preprint. doi: https://doi.org/ . . . . . verrall, a ( . rapid audit of contact tracing for covid- in new zealand. ministry of health. who & cdc ( ) . implementation and management of contact tracing for ebola virus disease: emergency guideline. retrieved from: http://www.who.int/csr/resources/publications/ebola/contacttracing/en/ . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . when case infects a new case, the new case occurs in age group and setting with probability each new secondary case needs to be assigned individual multipliers ( ) for each of the setting types. the multiplier for the setting ( = * ) in which case was infected is correlated with the multiplier for the index case . this models assortative mixing, meaning people with high contact rates in setting tend to be linked to other people with high contact rates and vice versa). multipliers for different settings ( ≠ * ) are assumed to be uncorrelated with the multipliers for the index case. for simplicity, we assume that for work, school and casual transmission, the secondary case's multiplier for that setting is equal to the index case's multiplier for that setting with probability , and is independent from the index case's multiplier with probability − : ).when a secondary case occurs via household transmission it shares the same household id as the index case . the expected number of home contacts decreases by one with each new case in that household. this means that, eventually, transmission chains within a given household will always go extinct as the pool of susceptible household members is depleted. for simplicity, network effects and infection-induced immunity for work, school and casual contacts are ignored, i.e. all non-household contacts of the secondary case are assumed to be mutually exclusive of the non-household contacts of the primary case. the parameter ( ) , the standard deviation of the distribution of , represents the degree of heterogeneity in individual contact rates in setting s. higher values of ( ) correspond to a greater degree of superspreading in the transmission dynamics (lloyd-smith et al., ) . we set ( ) = for home contacts and ( ) = √ for work, school and casual contacts. this represents greater heterogeneity in contact rates outside the home and more potential for superspreading events in nonhousehold settings, and corresponds to a negative binomial over-dispersion parameter of = . for infections outside the home. supplementary figure s shows an example simulation of the branching process and contact tracing model. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . supplementary figure s . contact matrices in -year age bands derived from results of prem et al. ( ) . each matrix shows the average number of home, work, school or casual contacts that an individual in age group has with an individual in age group over the course of their infectious period. the number of home contacts are taken directly from the results of prem et al. ( ) for new zealand. the number of work, school and casual matrices are scaled up by a factor of from the number of daily work, school, and other contacts in prem et al. ( ) to allow for an infectious period longer than day. the factor of was chosen to make = . in the absence of any control measures. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . supplementary figure s . example branching process simulation starting from a single infected seed case. cases are represented as nodes with the vertical coordinate corresponding to time of symptom onset. transmission routes are blue lines. node labels indicate age group ( = - years, = - years, etc.), red indicates traced contacts, black indicates untraced, grey/pink indicates subclinical infections. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . digital contact tracing technologies in epidemics: a rapid review epidemiology and transmission of covid- in cases and of their close contacts in shenzhen, china: a retrospective cohort study probability of elimination for covid- in aotearoa new zealand new zealand eliminates covid- cmmid covid- working group age-dependent effects in the transmission and control of covid- epidemics quantifying sars-cov- transmission suggests epidemic control with digital contact tracing using a real-world network to model localized covid- control strategies estimating the generation interval for coronavirus disease (covid- ) based on symptom onset data centre for the mathematical modelling of infectious diseases covid- working group successful contact tracing systems for covid- rely on effective quarantine and isolation quantifying the impact of physical distance measures on the transmission of covid- in the uk contact tracing for imported case of middle east respiratory syndrome effectiveness of isolation, testing, contact tracing and physical distancing on reducing transmission of sars-cov- in different settings the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application superspreading and the effect of individual variation on disease emergence the authors acknowledge the support of statsnz, esr, and the ministry of health in supplying data in support of this work. the authors are grateful to andrew chen, matt parry and philippa yasbek for discussions about digital contact tracing systems and feedback on an earlier version of this paper. this work was funded by the ministry of business, innovation and employment and te pūnaha matatini, new zealand's centre of research excellence in complex systems. ,individual cases ( for index case, for secondary case),age groups ( )age group of case setting (home/work/school/casual) contact structure ( )contact matrix representing the average number of contacts that an individual in age group has in age group and setting (home/work/school/casual). these were obtained from the results of prem et al. ( ) using the number of daily contacts for new zealand combined into year age bands. the total numbers of work, school and casual contacts were scaled up by a common factor from the number of daily work, school and casual contacts to model an infectious period longer than day. the total number of household contacts was set equal to the number of daily household contacts, to reflect the fact that household contacts do not usually change from one day to the next. the common scaling factor for work, school and casual contacts was set to be . to give a basic reproduction number of = . in the absence of any control measures. this corresponds to a reproduction number of approximately . with case isolation and no contact tracing. contact matrices are shown in supplementary figure s . has a greater than average number of contacts in setting and is more likely to be a superspreader. this parameter may be correlated between index case and secondary cases transmitted in setting (see below).( )attack rate for contacts in setting , assumed to be % for household contacts and % for nonhousehold contacts , independent of age . = . if case is subclinical and = otherwise. a case in age group is subclinical with probability ( ) the total expected number of new cases infected by case between time and time + is:, is the symptom onset time for case , ( ) is equal to if case is in quarantine at time , if case is in isolation at time , or otherwise. the function is the probability density function of a weibull distribution (see supplementary table s ). key: cord- -nqy m f authors: peng, philip w. h.; wong, david t.; bevan, david; gardam, michael title: infection control and anesthesia: lessons learned from the toronto sars outbreak date: journal: can j anaesth doi: . /bf sha: doc_id: cord_uid: nqy m f purpose: to describe the outbreak of severe acute respiratory syndrome (sars) in toronto, its impact on anesthesia practice and the infection control guidelines adopted to manage patients in the operating room (or) and to provide emergency intubation outside the or. clinical features: the sars outbreak in toronto was the result of a single index patient. the causative virus, sars-cov, is moderately contagious, and is spread by droplets and contact. the virus gains access to host through the mucosa of the respiratory tract and the eyes. it can affect both healthy and compromised patients. the use of several precautionary measures such as goggles, gloves, gowns and facemasks and the application of various infection control strategies designed to minimize the spread of the virus are discussed. conclusion: in containing the spread of sars, vigilance and strict infection control are important. this results in the rediscovery of standards of infection control measures in daily anesthesia practice. s of july , , cases ( probable, suspect) of severe acute respiratory syndrome (sars) were reported in canada, ( . %) of which occurred in ontario. the majority of cases in ontario occurred in the greater toronto area (gta). sars has resulted in unprecedented apprehension in the local community and severe economic harm to local business and tourism. more importantly, it has challenged health care workers to use effective infection control measures. in the present article, we will discuss the infection control guidelines for the anesthesiologist that were adopted by our institution, the rationale behind them and the impact of the sars outbreak on anesthesiologists in toronto. illness was called severe acute respiratory syndrome (sars) with a case definition (table i) from the world health organization (who). on march , , who issued a global alert in relation to clusters of sars. in toronto, the first documented case was a -yr-old woman who had travelled to hong kong on february with her husband. in hong kong, she and her husband stayed at a hotel at the same time and on the same floor as the guangdong physician from whom the outbreak in hong kong originated. on returning to toronto on february , she stayed in her apartment, which she shared with family members. two days later, she became ill and died at home on march , . several of the family subsequently developed respiratory symptoms. the -yr-old son was admitted to the emergency department of a community hospital in scarborough that became the epicentre of the toronto outbreak. by the end of april, sars cases ( probable, suspected) and deaths had been reported in ontario, the majority in the gta. all these cases could be traced back to the original index patient. on april , who issued a travel advisory warning for toronto, which was removed one week later. on may , toronto was removed from the list of areas affected by sars as no new probable case had been reported since april . however, another cluster of sars patients was discovered on may , . the second cluster was traced to a -yr-old man who underwent surgery for a fractured pelvis in a hospital in north york on april . while in hospital he developed sars but it was managed as postoperative pneumonia. he infected several other patients in his ward, including a woman who was later transferred to a rehabilitation hospital. this resulted in a further cases in the gta as of july , . eventually, on july , who removed toronto from the list of areas with recent local transmissions. r re e--e ex xa am mi in na at ti io on n o of f i in nf fe ec ct ti io on n c co on nt tr ro ol l m me ea as su ur re es s the sars outbreak is unique in recent history of public health because of its rapidity of transmission, its concentration in health care settings and the large number of health care workers who were infected. in an analysis of a cohort of patients with sars in the gta, ( %) were health care workers, including ( %) physicians and ( %) nurses. anesthesiologists, as specialists in airway management, are at high risk because of frequent exposure to patients' respiratory secretions. three anesthesiologists in our area were infected. they contracted the disease after tracheal intubation of patients with respi- -high fever (> °c) and -cough or breathing difficulty and one or more of the following exposures during the ten days prior to onset of symptoms: -close contact b with a person who is a suspect or probable case of severe acute respiratory syndrome (sars); -history of travel to an area with recent local transmission of sars -residing in an area with recent local transmission of sars a person with an unexplained acute respiratory illness resulting in death after november , a but on whom no autopsy has been performed and one or more of the following exposures during to ten days prior to onset of symptoms: -close contact, b with a person who is a suspect or probable case of sars; -history of travel to an area with recent local transmission of sars -residing in an area with recent local transmission of sars probable case a suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (rds) on chest x-ray (cxr). a suspect case of sars that is positive for sars coronavirus by one or more assays. a suspect case with autopsy findings consistent with the pathology of rds without an identifiable cause. ratory failure of unknown cause. these cases occurred in the early stage of the outbreak before sars was suspected. the anesthesiologists wore surgical facemasks, gowns and gloves but no goggles/visors. international investigations have revealed important information that prompted health care workers to reexamine the precautionary measures for infection control. the agent that causes sars is a new coronavirus (sars-cov), unlike any other human or animal virus in the coronavirus family. , the virus can survive for up to hr after drying on plastic surfaces. in hong kong the virus survived in urine and feces for at least and hr respectively. in patients with diarrhea, the virus can survive up to four days in the stool sample which has a lower acidity than normal stools. thus, once the body is exposed to this viral agent, the body surface can be contaminated for an extended time. similarly, exposed inanimate objects may act as carriers for up to hr. the virus is spread predominately by infectious droplets and contact. because of early reports of clusters of cases in community settings such as apartment buildings and the high infection rates among health care workers in hong kong, taiwan, hanoi and toronto, the etiological agent of sars was thought to be highly contagious. , however, with the exception of 'superspreaders', there is growing evidence that sars-cov is only moderately transmissible. , the average number of secondary infections generated per case at the start of the epidemic was estimated as . , which is much lower than that for influenza. in some instances, however, a single individual ("superspreader") has directly infected a large number of other people. this is exemplified by the singapore outbreak in which half of the first reported probable cases were infected by five source cases. despite the discovery of the virus and its genome, it is still uncertain when patients are most infectious and how to identify 'superspreaders'. in hong kong and toronto, most of the patients infected with sars had no co-morbid illnesses and half of them ( - %) were fit health care workers. , approximately one in five ( - %) patients with sars required admission to intensive care units (icu) with or without ventilatory support. in a detailed analysis of cases identified in the initial outbreak associated with the nosocomial transmission of sars in the index hospital in toronto, the case fatality rates were . % and . % for those aged less than or over yr respectively. the case-fatality rate was calculated by dividing the cumulative number of deaths within days after symptom onset by the total number of probable and suspect cases. data from the who revealed that the overall case fatality ratio was to % and was influenced by age (table ii) . this ratio was estimated by survival analysis based on the individual data from the onset of the illness until death or full recovery. early in the toronto sars outbreak, full protective gear (goggles, gowns, n masks and gloves) was considered to be sufficient to protect health care workers from sars. in april, a number of health care workers contracted the infection during their care of sars patients despite increased protective precautions. , experience from hong kong suggested that the infection among 'protected' health care worker was related to how well the precautionary measures were used. in a case-control survey, they found no infection in staff using complete precautionary measures, whereas infected staff had omitted at least one of the precautionary measures. this demonstrates how difficult it is to practice and perfect full infection control in view of the long survival ability of the virus outside the body. additional measures have been suggested. however, most important of all is the 'hypervigilance' of health care workers in practicing infection control measure. i in nf fe ec ct ti io on n c co on nt tr ro ol l g gu ui id de el li in ne es s f fo or r a an ne es st th he es si ia a exposure to oral and respiratory secretions at the time of tracheal intubation subjects the anesthesiologist to a serious risk of acquiring the infection. health organizations and agencies such as who, this guideline applies to all surgical patients and is based on long-standing recommendations by health canada that masks and eye protection or face shields should be worn where appropriate to protect the mucous membranes of the eyes, nose and mouth during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions. for practical purposes, the anesthetic machine is considered 'dirty' and the anesthetic drug cart as 'clean'. the machine is usually the first area anesthesiologists touch after contact with the patient. a large container is positioned on the anesthesia machine in which all airway equipment (laryngoscope blade and handle, mask, suction catheter, etc.) is placed after use. the container and its contents are removed from the or as soon as possible following intubation. the contents are separated for cleaning, sterilization or disposal before they are returned to the or. a second set of equipment including clean masks, laryngoscope handles and blades is immediately available. all steps are taken to keep the anesthesia drug cart 'clean'. the cart is used only after hand-washing or removal of the outer pair of gloves. thus, the infection control team should be informed about the transfer route. the spread of respiratory droplets from the infected patient should be minimized by the patient wearing a n mask without an expiratory valve. staff involved in the transfer and the care of patients in the or should take full droplet/contact precautions. clean surgical scrub suits laundered by the hospital should be worn and personalized hats or hair covers are avoided. the rationale for using alcohol-based hand rub, n masks, gowns, gloves and powered respirators in the or has been reviewed recently. because the sars-cov virus is spread by droplets and can survive on inanimate objects for hr, extra precautions and vigilance are important to avoid contaminating anesthesia equipment or surfaces such as the telephone in the or. double gloves are recommended when handling sars patients. the outer pair is removed after direct patient contact and before touching equipment or furniture in other areas of the room. of the precautions recommended above, the use of personal protection systems (pps) may be the most unfamiliar for anesthesiologists. although it is not currently recommended by health canada, hospitals in ontario are using pps according to the directive from the ministry of health and long-term care of ontario to all ontario acute care hospitals for high-risk procedures. the pps adopted in our institution is the powered air-purifying respirator (papr m, berkshire, uk) system while other hospitals have purchased the stryker® t (stryker, kalamazoo, mi, usa) pps. no consensus has been reached regarding which has the better air filtration system. nonetheless, these systems are considered to be important barriers to protect health care workers during high-risk procedures such as intubation and extubation. the papr consists of a beltmounted powered air purifier with a high efficiency particulate air (hepa) filter, connected via a tube to a lightweight headpiece (figures and ) . the hepa filter removes particles of . to µ with an efficiency of to %. the lightweight hood or headpiece provides excellent coverage of the head, face and neck. we have several years experience in using the papr system in the bronchoscopy suite without disease transmission to health-care workers. there are several important clinical points to remember. first, it takes time, training and assistance to put on the personal protective equipment and the papr system properly. advance warning of a patient in need of tracheal intubation is required in order to prepare properly. second, the personal protective equipment must be removed in proper sequence to avoid contamination of the users. third, it is difficult to communicate with each other due to the noise generat-ed by the high flow through the papr system. this noisy environment may cause errors due to its potential for miscommunication. contaminated protective gear must be removed before transferring the patient to the recovery room. time should be allowed for the anesthesiologist and assistant to remove contaminated gloves, gowns, face shields or masks and head cover and renew protective precautions at the end of the case. the anesthesia machine is protected with high efficiency, low volume filters placed in both the inspiratory and expiratory limbs of the circuit. hydrophobic filters are used in our institution as the filtering process is based on pore size and not on hydrostatic charge. the hygroscopic filter based on hydrostatic charge may become overwhelmed when wet and will allow passage of virus. with the filter placed in both limbs of the circuit, the soda lime does not need to be changed but the end-tidal co sample line and trap must be changed after the case. most ors currently use positive pressure with up to room air exchanges per hour. because of the high air exchanges in the or, aerosolized infectious particles will be cleared rapidly. however, those in close contact during a high-risk procedure such as tracheal intubation/extubation may still have a high exposure, and those outside the room may be exposed to infectious aerosols if the door to the or is left open. therefore, movement in and out of the or must be kept to a minimum during the procedure. local experience from personnel who contracted sars during airway instrumentation suggested that patient coughing should be kept at a minimum before, during and after intubation and/or induction of anesthesia. instrumentation of the airway with either a cuffed endotracheal tube or laryngeal mask airway is acceptable and should be performed by the most experienced staff available. despite the long list of precautions suggested by our institutional guidelines, it is difficult to list details of all the modifications to practice that have occurred. questions concerning best practice remain. for example: should the pager be clipped on the or uniform inside the or? should we use tape from the roll to secure the endotracheal tube or should the tape be precut? anesthesiologists are familiar with the importance of vigilance in maintaining patient safety. a similar high level of vigilance is necessary to prevent the spread of this serious infection. in the second month of the outbreak, a cluster of six health care workers contracted sars after participating in a difficult and prolonged tracheal intubation. since then, most hospitals have included anesthesiologists, the specialists in airway management, to assist in the tracheal intubation of sars patients. to minimize aerosol spread by coughing, intubation is performed in sedated and paralyzed patients. personnel performing intubation, anesthesiologists and respiratory technicians, must take full precautions including the papr figure the powered air-purifying respirator (papr) system consists of a belt-mounted powered air purifier with a high efficiency particulate air (hepa) filter. figure a lightweight headpiece is connected to the powered air purifying respirator (papr) system via a tube hood, gown, gloves etc., as outlined in the previous section. there must be a well-rehearsed plan and protective clothing, intubating equipment and essential drugs must be provided. particular care is necessary for the removal of potentially contaminated clothing. in summary, it is extraordinary that the spread of the infection in the gta outbreak can be traced to one person with unrecognized sars. the outbreak disrupted the health care and living in a city the size of toronto. one hopes for greater vigilance in the future. anesthesiologists are unique in their frequent exposure to respiratory secretions and blood. we must pay greater heed of our environment to protect ourselves, our patients and our families from infectious disease. a ap pp pe en nd di ix x i i routine precautions for non-severe acute respiratory syndrome patients in the operating room (or) . . d dr re es ss s --r ro ou ut ti in ne e p pr re ec ca au ut ti io on ns s -for all patient contact in the or and postanesthesia care unit, anesthesia staff should wear gloves, and surgical facemasks. -for tracheal intubation, extubation and all other maneuvers involving the airway, goggles or a face shield should be worn. gloves should be removed after intubation and before touching anesthesia machines, charts, pens etc. . . d di is sp po os sa al l o of f e eq qu ui ip pm me en nt t -immediately after intubation has been completed all equipment used during intubation (laryngoscope -blade and handle; airway, lighted stylet, suction catheter, facemask, etc.) should be placed in a container or box. -in the or a large container will be placed on the anesthesia machine. the circulating nurse will remove the box and contents, for appropriate cleaning and/or sterilization after intubation is complete. a spare laryngoscope and mask are available in the anesthesia machine drawer. -the anesthesia machine (surface, adjustments knobs etc) will be cleaned between cases but it should be considered dirty. all equipment must be removed from the surfaces of the machine between cases. -do not place the anesthesia record, pens, patient charts on the anesthesia machine. if the anesthesia machine or the monitors become visibly contaminated, they should be wiped with a damp virucidal cloth. in our hospital, we use an accelerated hydrogen peroxide cleaner/disinfectant (virox- , virox technology inc., mississauga, on, canada). . . t th he e a an ne es st th he es si ia a c ca ar rt t i is s " "c cl le ea an n" " -all steps should be taken to ensure that the anesthesia cart remains clean. (remove contaminated gloves before handling drugs etc., remove drugs required for the patient with clean hands and keep them on the anesthesia machine until the end of the case). -the transfer route should be discussed with 'infection control' team member. -patients should wear a facemask (n mask). -transporters should adopt full droplet /contact precautions (see below). -assistance (respiratory therapist) should be provided for the anesthesiologist. -staff should wear clean surgical scrub suits laundered by the hospital. -minimize the number of individual staff members present. there should be no exchange of staff for the duration of the case. -communicate with all level of staff involved in the care of the patient regarding the patient's sars status. -clear the room of unnecessary or over stocked equipment. -post "sars patient" signs on the or doors to minimize traffic. keep doors closed. -wash hands (before and after patient care). full droplet/contact precaution should be practiced and movement in and out of the or must be kept to a minimum during the procedure. -gown (double gown for high risk procedure). -double glove. remove and dispose of outer pair after direct patient contact and before touching other areas of the room/ anesthesia machine. subsequent intervention must be performed with double gloves. -use n mask or equivalent. -use a full-face disposable plastic shield for eye protection. -powered air purifying respirator (papr). required for staff member performing laryngoscopy or any other airway intervention (including extubation). -it is recommended that, where possible, staff stay a minimum of metres from the patient to avoid droplet contamination. -remove gloves / gown and decontaminate hands with alcohol hand wash. -remove face shield / n mask / hair cover and wash hands again -re-gown, glove, hair cover and mask. -transfer directly to the postanesthesia care unit isolation room. -remove gown/gloves and mask prior to exiting the isolation room. -change surgical scrub suit immediately or as soon as practically possible. . . a an ne es st th he es si ia a m ma ac ch hi in ne e a. filters -correct use of a high efficiency, low volume hydrophobic filter provides bacterial/ viral removal greater than . %. -use disposable circle circuit. -a high efficiency viral filter should be placed on the inspiratory and expiratory limbs of the circuit. -the soda lime does not need to be changed. the end-tidal co sample line and trap must be changed after the case. -place the anesthesia machine as far from the patient as practically possible. -place contaminated airway equipment in the plastic box for removal from the or after intubation. discard needles and syringes immediately after use. . . a an ne es st th he et ti ic c t te ec ch hn ni iq qu ue e the general aim is to minimize patient coughing before, during and after anesthesia. a. choice of airway -endotracheal tube. proper sedation and paralysis prior to tracheal intubation -laryngeal mask airways are permitted (and preferred, to reduce airway irritation) if appropriate -discard after use, along with oral and nasal airways. tailor to the patient's needs. no special directives. -use axillary temperature probe. avoid nasal or esophageal probe. . . c cl le ea an ni in ng g a an ne es st th he es si ia a e eq qu ui ip pm me en nt t -touched parts of the anesthesia machine/monitors will be wiped from time to time with a damp virucidal wipe. -an attendant, at the conclusion of the proce-dure, will wipe down the anesthesia machine, other than the lcd screen. -the anesthesiologist, or respiratory technician, is asked to wipe the monitor screen surface if visibly or knowingly contaminated, with a damp virucidal wipe, taking care that the cleaning solution does not drip on the screen. . . l la ab bo or ra at to or ry y s sp pe ec ci im me en ns s -indicate the following on the laboratory requisition form: "sars special investigation", date of onset of illness, 'travel history' and/or 'contact of known case'. -communicate with laboratories first before sending samples. -do not send specimens in the pneumatic tube. send in biohazard bags, in biohazard screw top bottles and have hand delivered to the laboratory. a ap pp pe en nd di ix x i ii ii i emergency tracheal intubation of severe acute respiratory syndrome (sars) patients outside the operating room (or) when patients with suspected sars require tracheal intubation, staff physicians in the intensive care unit (icu), emergency room (er) sars unit may request the assistance of the on-call staff anesthesiologist. battery belt pack is charging on the unit -intubation equipment: laryngoscope, endotracheal tube . , . mm, oral airway, yankauer sucker, stylette, ties/tape, co detection device -anesthesia and resuscitation drugs: midazolam mg, succinylcholine mg, rocuronium mg, ephedrine mg, atropine . mg -syringes and needles: x ml, x ml, and x ml . . p pr ro oc ce ed du ur re e a. after hand-washing, both laryngoscopist and respiratory technician will put on double gloves, gowns, goggles, n masks and papr hoods in the anteroom, or outside the patient's room. b. intubation will be performed in patients who are sedated (midazolam) and paralyzed (succinylcholine or rocuronium). after intubation intermittent positive pressure ventilation will be facilitated with rocuronium. c. after intubation, the gowns, hoods, and outer gloves will be removed in the anteroom or inside the patient's room. first, the laryngoscopist will be assisted by the respiratory technician whose equipment will then be removed. d. the patient is returned to the on-going care of the referring physician. investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada acute respiratory syndrome, china severe acute respiratory syndrome (sars) world health organization. who issues a global alert about cases of atypical pneumonia identification of severe acute respiratory syndrome in canada ministry of health and long term care, government of ontario. fact sheet. severe acute respiratory syndrome (sars) update. available from url toronto succumbs to sars a second time clinical features and short-term outcomes of patients with sars in the greater toronto area anaesthesia and sars (editorial) a novel coronavirus associated with severe acute respiratory syndrome characterization of a novel coronovirus associated with severe acute respiratory syndrome updated -studies of sars virus survival, situation in china but fast enough? responding to the epidemic of severe acute respiratory syndrome (editorial) center for disease control and prevention. severe acute respiratory syndrome -taiwan transmission dynamics of the etiological agent of sars in hong kong: impact of public health intervention transmission dynamics and control of severe acute respiratory syndrome a population-dynamic model for evaluating the potential spread of drug-resistant influenza virus infections during community-based use of antivirals center for disease control and prevention. severe acute respiratory syndrome -singapore sars virus identified, but the disease is still spreading a major outbreak of severe acute respiratory syndrome in hong kong update -sars case fatality ratio, incubation period sars among ontario health care workers clinical course and management of sars in health care workers in toronto: a case series effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) world health organization. hospital infection control guidance for severe acute respiratory syndrome (sars) a ac ck kn no ow wl le ed dg ge em me en nt t the authors would like to thank dr. damon kamming for reviewing this manuscript. key: cord- -hptjqmrl authors: xiang, nijuan; song, ying; wang, yu; wu, jiabing; millman, alexander j.; greene, carolyn m.; ding, zhentao; sun, jie; yang, wei; guo, guoxia; wang, ruirui; guo, ping; ren, zhixing; gong, lei; xu, pengpeng; zhou, suizan; lin, dan; ni, daxin; feng, zijian; li, qun title: lessons from an active surveillance pilot to assess the pneumonia of unknown etiology surveillance system in china, : the need to increase clinician participation in the detection and reporting of emerging respiratory infectious diseases date: - - journal: bmc infect dis doi: . /s - - - sha: doc_id: cord_uid: hptjqmrl background: we sought to assess reporting in china’s pneumonia of unknown etiology (pue) passive surveillance system for emerging respiratory infections and to identify ways to improve the pue surveillance system’s detection of respiratory infections of public health significance. methods: from february –may , , we actively identified and enrolled patients in two hospitals with acute respiratory infections (ari) that met all pue case criteria. we reviewed medical records for documented exposure history associated with respiratory infectious diseases, collected throat samples that were tested for seasonal and avian influenza, and interviewed clinicians regarding reasons for reporting or not reporting pue cases. we described and analyzed the proportion of pue cases reported and clinician awareness of and practices related to the pue system. results: of ari admissions in two hospitals, ( %) met the pue case definition; none were reported. of specimens tested, ( %) were seasonal influenza virus-positive; none were avian influenza-positive. < % pue case medical records documented whether or not there were exposures to animals or others with respiratory illness. most commonly cited reasons for not reporting cases were no awareness of the pue system ( %) and not understanding the case definition ( %). conclusions: most clinicians have limited awareness of and are not reporting to the pue system. exposures related to respiratory infections are rarely documented in medical records. increasing clinicians’ awareness of the pue system and including relevant exposure items in standard medical records may increase reporting. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. china established the pneumonia of unknown etiology (pue) surveillance system in for timely detection of emerging respiratory infectious diseases [ ] , and the system has played an important role in detecting human infections with novel avian influenza viruses including a(h n ), a(h n ), a(h n ), and a(h n ) [ ] [ ] [ ] . nevertheless, a evaluation identified persistent underutilization of the pue surveillance system [ ] . more recently, inconsistent reporting occurred during the initial outbreak of low pathogenic avian influenza (lpai) a(h n ) [henceforth a(h n )], prompting public health authorities to allow clinicians to report cases directly without expert consultation committee approval. this change resulted in the reporting of cases in weeks compared with cases in the previous years [ ] . laboratory and case investigation resources were quickly strained and reporting procedures reverted to those used prior to the outbreak [ ] . as a result, case reporting subsequently decreased. a assessment of clinician and health administrator knowledge, attitude and practices related to pue surveillance conducted within healthcare facilities revealed a willingness to report pue cases, but identified limited awareness of the pue system, lack of understanding of the reporting process, and failure to follow the case definition [ ] . to evaluate these gaps, we piloted a -month active surveillance program in two hospitals to ) quantify the number of cases meeting the pue case definition and the number reported and ) to identify ways to improve the pue surveillance system's detection of respiratory infections of public health significance. national guidelines [ ] require all inpatient and outpatient healthcare facilities to report cases meeting the pue case definition. clinicians should report cases to an expert consultation committee, which after review of clinical and laboratory data determines whether to report the case to the pue surveillance system [ ] . if a case is reported to the pue system, the local center for disease control and prevention (cdc) will conduct a field investigation, collect respiratory specimens and send them to a national influenza surveillance network laboratory for testing of avian influenza viruses and, if associated with clusters of respiratory disease or relevant travel history, testing of severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov). a pue case is defined as an illness of unknown etiology with ) axillary temperature > °c, ) radiographic pneumonia, ) low or normal leukocyte count or low lymphocyte count during the early stages of disease, and ) no improvement or worsening symptoms after - days of antimicrobial treatment per clinical guidelines [ ] . participating hospitals were selected based on four criteria: if the facility ) admitted at least patients per month with a discharge diagnosis of pneumonia during february through may - ; ) used an electronic hospital information system; ) demonstrated willingness and capacity to collaborate with both national and local cdcs and ) was located within one of china's of provinces with previously identified h n and/or h n human cases. we selected two tertiary hospitals in anhui province: the second people's hospital of fuyang city, a -bed facility, which from february through may - , admitted an average of pneumonia patients per month, and lu'an city people's hospital, a -bed facility, which over the same time period admitted an average of pneumonia patients per month. fuyang hospital, an infectious disease hospital, had experience treating human infections with avian influenza, while lu'an hospital, a general hospital, did not. after reviewing the hospital information systems, the evaluation team developed a list of admission diagnoses that captured the majority of acute respiratory infections (ari) (additional file ). every day (including weekends) from february through may , , a designated, trained surveillance officer in each hospital ) reviewed the hospital admission registry database to screen all admission diagnoses from the prior days for diagnoses from the screening list (additional file ); ) reviewed admission medical records with a matching diagnosis to identify and enroll patients with illnesses meeting the pue case definition; ) days later, conducted a second medical record review for patients not enrolled during the first review to identify and enroll patients with illnesses newly meeting the case definition (for example, patients with no improvement or worsening symptoms after - days of antimicrobial treatment per clinical guidelines); and ) days later, conducted a third review of records for patients not enrolled during the first two reviews to enroll any remaining patients meeting the case definition. [fig. ]. for patients with illnesses meeting the pue case definition, the surveillance officer used a standard questionnaire to collect information from the hospital information system related to demographics and, if available, epidemiological risk factors, including exposures to poultry, patients with similar symptoms, and travel history. surveillance officers followed the pue surveillance protocol [ ] to investigate enrolled pue case-patients. surveillance officers conducted face-to-face patient interviews using a standard questionnaire to collect the same information described in the medical records review section above to determine both accuracy and completeness of medical records. surveillance officers collected throat swabs from all identified pue case-patients per the surveillance protocol [ ] . specimens were transported to the local cdc laboratory per standard procedures and tested for influenza viruses using real time reverse transcription polymerase chain reaction (rrt-pcr). if identified pue case-patients were part of a cluster of epidemiologicallylinked respiratory illnesses, specimens would also be tested for sars-cov and mers-cov. if a case-patient reported travel history to the middle east, specimens would be tested for mers-cov. the pue surveillance protocol describes a three-step procedure for reporting cases to the pue system: ) clinicians report identified pue cases to their supervisor; if the supervisor concurs, the case is reported to the director; ) the director determines whether to report the case to an expert consultation committee which usually includes specialists from the respiratory medicine department, the radiology department, and infection control; and ) the expert committee determines whether to report the case to the pue system. [ fig. ]. in our evaluation, after patients with illnesses meeting the pue case definition were enrolled, surveillance officers interviewed all clinicians who had primary medical responsibility for these patients. if the case were reported to the clinician's supervisor, the surveillance officer also interviewed the supervisor and a representative member of the expert committee. [ fig. ] surveillance officers used a standard questionnaire to collect ) demographic and occupational information about the clinician being interviewed and, when applicable, ) demographic and occupational information about the senior clinicians who received the case report, and ) reasons for reporting or not reporting pue cases. first, we described the number, proportion, ward distribution, and testing results of pue cases identified by surveillance officers. wilson score was used to calculate % confidence intervals (ci) for proportions. second, we described and compared epidemiologically-linked exposures documented by clinicians in the medical records and used chi-square tests to compare differences in the frequency of exposure histories collected by surveillance officer interviews. third, we described the number of pue cases reported at each of the tiers of the three-step reporting process. finally, we described factors associated with clinicians' reporting or not reporting pue cases. during the evaluation period, surveillance officers reviewed , hospitalization registrations, and screened patients with ari admission diagnoses. of those were from lu'an hospital and were from fuyang hospital. among all ari patients, ( %) had illnesses that met the pue case definition. the proportions of ari cases meeting the pue case definition in each of the two hospitals were similar [ % ( / ) vs. % ( / ), p = . ]. among the pue case-patients identified, % were male, and % were aged - years; most were from the pediatrics ( %) and pulmonary ( %) departments. [ table ]. the proportion of ari admissions meeting the pue case definition was highest in the icu ( %), followed by the infectious disease ( %), tuberculosis ( %), pediatrics ( %) and pulmonary ( %) departments. oral throat swabs, collected within hrs of pue case enrollment, were tested from ( %) of the identified pue case-patients. of the specimens, ( %) were positive for seasonal influenza viruses and none were positive for avian influenza viruses. none met sars-cov or mers-cov testing criteria. of pue case-patients with laboratory results, % ( / ) had documented exposures; % had documented histories related to contact with water potentially infected with parasites which is recorded as standard practice within the "personal history" section of the medical record in china. other exposures which were intermittently documented in the medical records included ( ) ( ) internal medicine emergency room ( ) ( ) internal medicine ( ) ( ) other departments ( ) ( ) animal exposure ( %), contact with persons with respiratory illnesses ( %), exposure to healthcare facilities caring for patients with respiratory illnesses ( %), and any travel history ( %). in addition, ( %) records documented occupation, a required item in the demographic section of the medical history, and identified two pue case-patients as healthcare workers [ table ]. among the enrolled pue case-patients interviewed by surveillance officers, ( %) had at least one exposure relevant to respiratory infections of public health significance, including animal exposure, contact with similar cases of respiratory disease, travel to/living in areas of novel respiratory epidemics, and occupational exposures. in the days before illness onset, ( %) had occupational exposure to poultry/livestock, ( %) were medical staff, ( %) had animal exposure ("exposure to poultry, pigs, etc."), ( %) had close contact with persons with similar respiratory disease symptoms, and ( %) had exposure to a healthcare facility caring for patients with respiratory illnesses [ table ]. although the relevant respiratory infectious disease exposures identified in the medical record and the surveillance officer interview were the same in > % for all exposures analyzed, there were discrepancies. occupational exposures, exposures to persons with similar respiratory symptoms, and animal exposures were identified less frequently through medical records compared to surveillance officer interviews [ table ]. none of the clinicians interviewed from lu'an hospital reported knowledge of the pue surveillance system compared with ( %) of the clinicians from fuyang hospital. at fuyang hospital, knowledge was highest among clinicians with > years ( %) and - years of work experience ( %) and lowest among those with < years of work experience ( %). none of the patients meeting the pue case definition were reported to the surveillance system. during the interviews with clinicians, the most common reasons clinicians cited for not reporting included: being unaware of the pue surveillance system ( %), not understanding the pue case definition ( %), and not accepting the pue case definition ( %) [ table ]. although none were reported to the national system, a clinician reported one pue case with acute respiratory distress syndrome (ards) and possible viral pneumonia to his supervisor. due to disease severity, the lack of a diagnosed pathogen, and no improvement on treatment, the supervisor reported the case to the director, and experts within the ward concluded that the illness met the pue case definition. they reported the case to the hospital's expert committee, which reported to the hospital's department of disease control, which reported the case to the local cdc and sent specimens for laboratory from february through may , , we conducted active surveillance in two hospitals and found that % of all patients admitted with ari met the pue case definition. none of the respiratory specimens tested were positive for avian influenza. only one pue case was reported to the local cdc; however, it was not reported to the national system because the specimen tested negative for avian influenza virus. our findings raise questions about the feasibility of using the existing pue case definition to identify respiratory infections of public health significance. extrapolating our results, if clinicians reported all illnesses meeting the pue case definition from china's more than , hospitals, the number of pue cases identified would be in the hundreds of thousands per year. such numbers would overwhelm the public health system's capacity for laboratory testing and epidemiologic investigations. the impracticality of the existing pue case definition is supported by both a prior study which found that % ( / ) of community-acquired pneumonia diagnoses met the pue case definition [ ] and by the pue surveillance experience in when streamlined reporting procedures led to a surge in cases that quickly strained response efforts [ ] . modifying the system to decrease the number of cases that meet the pue case definition but are not emerging respiratory infections of public health significance would increase the system's feasibility, acceptability, and usefulness. the extent of under-reporting in this pue assessment far exceeds the estimated - % under-reporting of cases of notifiable diseases identified during - in evaluations of the china national notifiable disease reporting system for notifiable diseases, for which reporting is required by law [ ] [ ] [ ] . during our evaluation, none of the identified pue cases was reported to the national system. one clinician reported one pue case appropriately, but the expert committee did not appropriately follow final reporting procedures by reporting the case to the pue system. the two most common reasons clinicians cited for not reporting pue cases to the system were not having knowledge of the pue system and not understanding the pue case definition. knowledge varied by hospital, with > % of clinicians from fuyang hospital reporting knowledge of the pue system compared with none from lu'an hospital. this difference may be explained by fuyang hospital's specialization in infectious disease and its recent experience treating one avian influenza a(h n ) virus infection and one avian influenza a(h n ) virus infection in and respectively. lu'an hospital, a general hospital, had no recent experience treating infections with avian influenza virus. pue surveillance system knowledge also varied significantly by clinicians' years in practice. china cdc conducted intensive, national clinician training on the pue system when the system was established and on-going trainings during the h n outbreaks through . in , the ministry of health required training on the new protocol of surveillance, investigation and management for pue for clinicians at all medical wanted to treat the patient longer prior to reporting ( , ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( , - . ) ( , - ) the patient was transferred to another hospital or ward ( , - ) ( , - . ) ( , - ) when a case is reported, the laboratory results are returned too late such that the testing is not helpful for diagnosis and treatment *ci refers to confidence interval institutions [ ] , however, national pue-related training has not occurred since . therefore, clinicians with < years work experience have not received systematic, indepth training on pue surveillance. another recent study among hospital clinicians in beijing found that new clinicians knew little about key public health concerns, such as infection control within healthcare facilities, without having received formal training [ ] . these findings highlight the importance of training clinicians on public health surveillance systems, reporting requirements and other key public health topics both as they enter the workforce and as refresher courses to improve their capacity to identify and report emerging and re-emerging infectious diseases. this evaluation found that clinicians did not document respiratory infection-related exposures. during the interviews, % identified pue case-patients reported recent exposures to animals and % reported exposures to patients with similar illnesses, yet these exposures were rarely documented in the medical record. these findings suggest that clinicians may not routinely assess respiratory infection-related exposures. about half of the medical records from identified pue cases documented any contact with parasites-infected water, because asking about "any potential exposure to parasite infected water" is a routine practice when completing the "personal history" section of the medical record [ ] . this finding suggests that clinicians are more likely to ask about specific exposures when they are part of routine practice as opposed to exposures that may only be asked intermittently if not part of routine practice. the widespread use of electronic medical records in china provides an opportunity for prompting clinicians to ask about certain exposures relevant to infectious diseases that can be documented in a standardized way in patient's medical record. by developing a checklist within the electronic medical record with questions related to exposures relevant to emerging respiratory diseases such as live poultry and swine for priority use in inpatient wards in china, clinicians would be prompted to routinely ask about these exposures. this may in turn improve detection and reporting of emerging respiratory infections. first, increasing documentation of relevant exposures may facilitate the addition of more specific epidemiologic criteria to the pue case definition to reduce the number of cases meeting the case definition that are not infections of public health concern. second, clinicians who identify concerning exposures in patients with respiratory diseases may be more likely to report these cases to the pue system. finally, since the majority of hospitals in china now use electronic medical records system, if exposure data were collected systematically as part of these systems, it is possible that cases with relevant epidemiological data could be automatically flagged for reporting. further investigations would be needed to assess these modifications to see if they have a positive impact on case reporting without overwhelming the pue system. this evaluation is subject to several limitations. first, the assessment occurred when there were no local reports of human infection with avian influenza virus. pue case identification and reporting may increase during outbreak periods. however, in , during the th epidemic of influenza a(h n ) which had the largest number of human infections to date, fuyang hospital did not report any cases to the national system despite sending potential pue case specimens to local cdc for testing, of which two were positive for influenza a(h ). during this same period, lu'an hospital did not send any potential pue case specimens to local cdc for testing, nor did it report any cases to the national pue system. lu'an hospital did, however, report one confirmed h n case to china cdc directly. second, the reporting practices within these two hospitals may not represent reporting practices throughout china. finally, the screening admission diagnosis list may not have captured all pue cases [additional file ]. our findings suggest that most clinicians are not reporting cases to the pue surveillance system. if clinicians were to report all cases meeting the pue case definition, the large number reported would likely overwhelm the public health system's capacity for laboratory testing and case investigation. of those reported, the vast majority of cases would not be emerging infections of public health concern. our findings lead to several recommendations that may increase the specificity of the pue case definition, increase clinician participation in the pue system, and contribute to the early detection of emerging respiratory infections in china. ) modifying the existing pue case definition by adding relevant exposure history may improve the specificity, feasibility and utility of case reporting. ) including exposure items related to emerging respiratory infectious diseases in the standard infectious disease history documented in medical records may increase the likelihood that clinicians will assess exposure histories relevant for emerging respiratory infections. including these items in the respiratory diseases department, the pediatric department and the intensive care unit, where pue cases are more common, may be most useful. ) providing clinicians with frequent publichealth related training and communications will ensure that clinicians are aware of public health reporting requirements. a multi-pronged approach to incorporating public health practice into clinical settings may include: offering training to clinicians as they enter the workforce followed by annual refresher courses, posting publichealth related updates and notices in clinical areas, incorporating public health guidance into hospital policies, engaging clinicians in the development of clinically-appropriate and easy-to-apply case definitions, and regularly sharing local and national public health data of interest with clinicians to highlight the public health importance of their work. ministry of health protocol of surveillance, investigation and management for pneumonia of unknown etiology investigation and analysis on the first case of human infected with avian influenza (h n ) in yunnan province epidemiological on the first human case with avian influenza a (h n ) virus in hubei province analysis on reporting of unknown etiology pneumonia cases in china the evaluation of surveillance system of highly pathogenic avian influenza virus infection in china. beijing: chinese center for disease control and prevention use of national pneumonia surveillance to describe influenza a(h n ) virus epidemiology, china assessing clinicians' acceptance of the pneumonia of unknown etiology surveillance system current status and clinical study of suspected pneumonia cases of unknown origin in china an investigational analysis of missing reports of notifiable diseases in medical facilities all over china in evaluation on management and quality of communicable diseases network direct reporting in china reporting quality of notifiable communicable diseases in hospitals in china the notice for the intensive training of local clinicians in different level of medical institutions for detection and reporting of avian influenza an analysis on knowledge survey of hiv occupational exposure and the influencing factors in medical workers at two tertiary general hospitals in beijing the notice of the ministry of health on the issuance of basic rules of medical records publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank the colleagues from china cdc, anhui province cdc, lu'an prefecture cdc, fuyang prefecture cdc, lu'an city people's hospital and the second people's hospital of fuyang city who supported project implementation for this assessment, including case screening and investigation, clinician interviews, specimen collection, laboratory testing, and logistical administration. authors' contributions nx, ys, yw, jw, cm. g, zf and ql contributed to the design of this study; nx, yw, jw, zd, js, wy, gg, rw, pg, zr, lg, px and dl contributed to the implementation and data collection of this study; nx, ys, yw, aj. m, cm. g, sz, dn, and ql contributed to data analysis, manuscript writing and manuscript revision. all authors have read and approved the final version of the manuscript. dr. nijuan xiang is an epidemiologist and chief of the surveillance, alert and risk assessment (sara) branch, public health emergency center, chinese center for disease control and prevention. her research interests include surveillance for emerging infectious diseases, prevention and control strategies for emerging infectious diseases, and surveillance and risk assessment for public health emergencies. this work was funded by a us cdc cooperative agreement ( u gh - ) and supported by the china-us collaborative program on emerging and re-emerging infectious disease. the fund body did not participate in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. all data generated or analysed during this study are included in this published article [and its supplementary information files]. the datasets generated and/or analysed during the current study are not publicly available due to the datasets containing personally identifiable information used for public health surveillance purposes. requests for data can be directed to the corresponding author.ethics approval and consent to participate this evaluation was approved by the chinese center for disease control and prevention institutional review board (number: ) and was determined to be non-research public health practice by us cdc. all patients participating in this evaluation, or their parent or guardian for patients < years of age, provided oral informed consent prior to interview and written informed consent prior to throat swab collection. not applicable. the authors declare that they have no competing interests. key: cord- - st mvh authors: overton, christophere.; stage, helenab.; ahmad, shazaad; curran-sebastian, jacob; dark, paul; das, rajenki; fearon, elizabeth; felton, timothy; fyles, martyn; gent, nick; hall, ian; house, thomas; lewkowicz, hugo; pang, xiaoxi; pellis, lorenzo; sawko, robert; ustianowski, andrew; vekaria, bindu; webb, luke title: using statistics and mathematical modelling to understand infectious disease outbreaks: covid- as an example date: - - journal: infect dis model doi: . /j.idm. . . sha: doc_id: cord_uid: st mvh during an infectious disease outbreak, biases in the data and complexities of the underlying dynamics pose significant challenges in mathematically modelling the outbreak and designing policy. motivated by the ongoing response to covid- , we provide a toolkit of statistical and mathematical models beyond the simple sir-type differential equation models for analysing the early stages of an outbreak and assessing interventions. in particular, we focus on parameter estimation in the presence of known biases in the data, and the effect of non-pharmaceutical interventions in enclosed subpopulations, such as households and care homes. we illustrate these methods by applying them to the covid- pandemic. mathematical epidemiology is a well-developed field. since the pioneering work of ross in malaria modelling [ ] and kermack and mckendrick's general epidemic models [ ] , there has been gathering interest in using mathematical tools to investigate infectious diseases. the allure is clear, since mathematical models can provide powerful insight into how these complex systems behave, which in turn can enable these problems to be better controlled/prevented. not only is the power of the mathematical tools increasing, but the availability of data on infectious diseases, whether this be a rapid release of data during an outbreak or detailed collection of data for endemic pathogens, is increasing. rapid interpretation of epidemiological data is critical for the development of effective containment, suppression and mitigation interventions, but there are many difficulties to interpreting case data in real-time. these include interpreting symptom progression and fatality ratios with delay distributions and right-censoring, exacerbated by exponential growth in cases leading to the majority of case data being on recently infected individuals; lack of clarity and consistency in denominators; inconsistency of case definitions over time and the eventual impact of interventions and changes to behaviour on transmission dynamics. mathematical and statistical techniques can help overcome some of these challenges to interpretation, aiding in the development of intervention strategies and management of care. examining key epidemiological quantities alongside each other in a transmission model can provide quantitative insights into the outbreak, testing the potential impact of intervention strategies and predicting the risk posed to the human (or animal) host population and healthcare preparedness. mathematical modelling has been used as part of the planning process during outbreak response by governments worldwide for many recent outbreaks. for example the uk department of health has a long established committee scientific pandemic influenza group on modelling, or spi-m to advise on new and emerging respiratory infections [ ] . one of the largest instances of such an outbreak in recent history was the h n pandemic. the world health organisation developed a network of modelling groups and public health experts to work on exploring various characteristic of the outbreak [ , ] . these ranged from characterising the dynamics of the outbreak to investigating the effectiveness of different intervention strategies. this integration of mathematics into policy design indicates the important insights that modelling and statistics can provide. this paper is a collection of work-streams addressing various technical questions faced by the group as part of the ongoing response to covid- , and as such is written to be reflective of the experience we have gone and are currently going through. therefore, to aid the reader each section includes results and a short discussion. many of the questions and techniques presented here can be further developed as the availability of data and research interests evolves, but are compiled into this manuscript as an overview of methodology and scientific approaches beyond the standard sir textbook model that benefit the ongoing efforts in tackling this and other outbreaks. first documented in december , an outbreak of community-acquired pneumonia began in wuhan, hubei province, china. in january, this outbreak was attributed to a novel coronavirus, sars-cov- . the initial spread of the pathogen in wuhan was fast, and after a period of case-finding and contact tracing, china moved to implement a 'shutdown' of wuhan on january , and other cities in china the following days, to try to suppress the growth of the epidemic. these measures may have succeeded at slowing down the rate at which cases have been seeded elsewhere, but in many countries initial importation of cases and transmission has not been contained. countries around the world are now seeing outbreaks that are overwhelming, or have the potential to overwhelm, healthcare systems and cause a high number of deaths even in high-income countries [ ] . while the majority of documented symptomatic cases are mild, characterised in many reports by a persistent cough and fever, a significant proportion of these individuals go on to develop pneumonia, with some then developing acute respiratory failure and a small proportion of overall cases becoming fatal. severity of symptoms has been observed to increase with age and with the presence of underlying health conditions such as diabetes [ ] and cardiac conditions, with some evidence that severity of symptoms might depend on gender and ethnicity [ , , , , ] . sars-cov- has a fast doubling time (the time it takes for the number of cases in the region to double, estimated at approximately days [ ] ) and, potentially, a very large r (the average number of infections caused by each infected individual, with estimates ranging from . to . [ , , , ] ). it is possible that there is a significant degree of asymptomatic and/or pre-symptomatic transmission [ , , ] , though without robust serosurveys, this is difficult to quantify with certainty. these characteristics result in the pathogen being able to spread widely, rapidly and undetected, presenting a significant risk to public health. typically, the aim of an intervention strategy would be to push and keep the reproduction number t r , defined as the average number of cases generated by a typical infective at time t, below . at this point each infected individual subsequently infects, on average, less than one individual, such that the number of cases should decline. the basic reproduction number, r , represents the initial value of t r , before any intervention is put in place and the population can be assumed to be fully susceptible. high r , fast growth, and possible pre-or asymptomatic infection make the design of potential interventions, and the modelling that would inform them, particularly challenging. large values of r mean a substantial amount of transmission needs to be halted; fast growth causes the number of cases in the absence of interventions to rise rapidly, so that the time scale of interventions to reduce r must also be fast in order to effect substantive early changes on a population level; finally, the resulting interventions must encompass possible pre-and asymptomatic cases, a challenging prospect when in many instances these individuals are indistinguishable from healthy individuals. consequently, we must consider the possibility of interventions that are massively disruptive to society and may have to be sustained for a long period of time in order to cause the number of infections to decline towards zero [ ] . if infections remain, and the susceptible proportion of the population remains above the herd immunity threshold, these interventions must be upheld to prevent a second wave of the epidemic. there is not yet conclusive evidence as to the degree and duration of immunity conferred by infection with sars-cov- nor the feasibility of a vaccine, the timeline for which is unlikely to be any time shorter than months away at the time of writing [ ] . therefore, short term extreme interventions are not as effective as they might be in other circumstances, since after their removal there remains a long period of time in which cases can rise again. the longer these significantly suppressive and disruptive interventions are in effect, the more severe the effect on the economy, and broader societal health and well-being. furthermore, adherence to interventions will likely vary with their duration and severity. we are further challenged by the lack of transferable intuition. early work looked at intuition gained from sars and mers outbreaks, also caused by coronaviruses. some parameters do appear to be similar to these pathogens, such as the average length of the incubation period [ , , ] . however, there are also clear differences, with both sars and mers being more fatal, but seemingly less efficient at spreading since they did not seed major global pandemics. another complication is the spread of the infection during the chinese spring festival, a time period during which movement, social, and contact patterns vary significantly. this presents significant challenges as experience and intuition from other studies regarding population mixing and spatial patterns must either be modified or are invalid. furthermore, the pandemic has received a proportionately larger level of public attention than e.g. the h n pandemic [ , ] , largely boosted by social media. this greater level of public awareness, and the successive, staggered interventions placed to prevent disease spread are responsible for significant variations in behaviour [ , ] and adherence to public guidance both in china and abroad. the structure of this paper follows two main themes. in section , we discuss various biases that are present in outbreak data and techniques for estimating epidemiological parameters. accounting for biases and producing robust parameter estimates is important throughout the duration of an epidemic, both for increasing our understanding of the underlying dynamics, and for feeding into models. firstly, we discuss a bias-corrected method for estimating the incubation period, which can also be applied to serial intervals, onset-to-death time, and other delay distributions. we then present a method for estimating the true growth rate of the epidemic, accounting for the bias encountered since infected individuals may be exported from the region. our next method is a tool for estimating the expected size of the next generation of infectives based on the rate of observed cases. this tool provides insight into the size of small outbreaks, which can inform decision making when trying to prevent a major outbreak taking off. in section , we propose a variety of mathematical models looking at disease impact and intervention strategies, with particular focus on non-pharmaceutical interventions due to the current lack of widely deployable, targeted pharmaceutical treatments. these models focus on enclosed populations, since this is the level at which most interventions are implemented. since the disease is particularly fatal in the elderly and other at-risk groups, we develop a care home model to investigate how the pathogen may spread through care homes. we also develop household models to investigate the impact of different intervention/control strategies. these models can inform policy design for mitigating or controlling epidemic spread. finally, in the context of relaxing strong social distancing policies, we investigate the extinction probability of the pathogen. we first consider the extinction probability after lifting restrictions. we then develop a household-based contact tracing model, with which we investigate the extinction probability under weaker isolation policies paired with contact tracing, thus shedding light on possible combinations of interventions that allow us to feasibly manage the infection while minimising the social impact of control policies. . biases and estimation during outbreaks . . potential biases in the outbreak data techniques are constantly developing that enable higher volumes of more accurate data to be collected real-time during an epidemic. these data present a large opportunity for analysis to gain insight into the pathogen and the dynamics of the outbreak. however, although the quality of the data is constantly increasing, there are still many biases present. some of these are due to the data collection methods, and in an ideal world we would be able to eliminate them, and some are simply due to the nature of the outbreak, and will be present regardless of data collection methods. during an outbreak, many parameters depend on delay distributions (the length of time between two events), such as the time from infection to symptom onset (the incubation period). if an individual can be followed indefinitely, it is easy to determine the length of these events. however, in reality only events that occur before a given date are observed. therefore, the data is subject to censoring and truncation issues. in the incubation period, for example, censoring comes into play since, if we have observed an infection but the individual has not yet developed symptoms, we only have a lower bound on how long it will take them to develop symptoms. to account for this, we can instead condition on observing symptom onset before the cut-off date. however, this leads to a truncation issue, since individuals who were infected close to the cut-off date will only be observed if they have a short incubation period, which leads to an overexpression of short delays. the number of cases tends to grow exponentially during the early stages of an outbreak, causing the force of infection and the number of reported cases to increase with time. this further complicates the truncation issue since not only are recent cases truncated but they also account for the majority of cases. the growing force of infection also needs to be accounted for, since if the potential time of infection is interval-censored rather than observed directly, the probability that the case was infected in each day of that interval is not constant. in theory, both of these biases are relatively straightforward to account for. in practice however, there are other biases in the data. one of the major biases is the reporting rate. although the total number of cases may be reasonably described as growing exponentially with a constant rate in the early stages of an outbreak, high-resolution data may exhibit more complex behaviour. this can be due to a variety of reasons, such as the workload becoming overwhelming, the availability of individual-level data decreasing, the laboratories or offices slowing down activity over the weekend, the case definition changing, the testing capabilities increasing, and so on. another uncertainty arises since generally only the date of each event is recorded rather than the time. this presents a large window of uncertainty in the length of the delay, since the time of each event can vary up to hours, and for a delay distribution, which depend on two events, it could vary by up to hours. travel rate is another bias present in the data. for example, this changes the density of observed cases in a region, which can change the apparent growth rate. intervention strategies present a further bias because this can change the growth rate of the epidemic and the reporting rate. additionally, estimates of certain parameters may vary depending on the interventions that are implemented, so these need to be considered carefully. to model the incubation period, we require information regarding when an individual was infected and when they expressed symptoms. observing exact time of infection is unlikely, but it can be possible to find potential exposure windows. we consider three different data sets. the first two consist of individuals who travelled from wuhan before expressing symptoms. we can assume these individuals were infected in wuhan, since at the time of this data, the force of infection was significantly higher in wuhan than elsewhere. the length of time spent in wuhan therefore provides a window during which each individual became infected, and for many of these individuals we also have the date of symptom onset. in the early stages, the growth rate in reported cases was constant, and dependent on the epidemic growth rate in wuhan and the rate at which people left wuhan. by using travel to estimate the true number of cases, we estimate the exponential growth rate in wuhan as . r = (see section . ). therefore, the force of infection on day i, ( ) g i , is proportional to . e i . after january when significant travel bans were introduced, the rate at which individuals left wuhan diminished significantly, causing the reporting rate for our sample dataset to suddenly drop. this occurs since cases are only included if we have a fixed window of time spent in wuhan prior to developing symptoms. therefore, if the data is truncated after january, the reporting rate must be appropriately adjusted. this is illustrated in figure a . the difference between these two datasets is the truncation date, with the first truncated at january and the second at february. the third dataset contains cases that were infected through a discrete infection event, such as spending time with a known infected case. in this ''non-wuhan" dataset, the reporting rate is constant and the force of infection can be assumed constant over each exposure window. the source we use for these three data sets is a publicly available line-list [ ] . incubation periods, and many other delay distributions, are generally observed to have right skewed distributions. we therefore choose to use a gamma distribution, though other distributions can also be applied using the proposed methods, such as weibull and log-normal. to fit the data, we use maximum likelihood estimation. to adjust for the biases we use a ''forwards'' approach [ , , , ] , where we condition on the time of the first event, time of exposure, and find the distribution looking forward to the second event, time of symptom onset. for a data point { } , , infection occurs between i a and i b , and i y is the symptom onset date, the likelihood function is given by where ( ) g ⋅ is the density function of the infection date and ( ) f θ ⋅ is the density function of the incubation period parameterised by θ. from this, the likelihood function for our dataset x is given by this approach is independent of the reporting rate bias, since the reporting rate depends on the date an individual leaves wuhan ( i b ), which is conditioned against (see appendix ) . we use the mean and standard deviation to characterise the mle. since the tail of the incubation period is important when designing quarantine strategies, we then calculate the probability that the incubation period is longer than days and find the minimum day by which % of cases will have expressed symptoms (excluding true asymptomatic cases). we also investigate the reporting date uncertainty mentioned in section . by considering the different extremes that the data could represent. this is achieved through adding or subtracting a day to all recorded data. methods accounting for truncation and growth biases in epidemic data have been discussed widely in the literature [ , , , ] , however there are fewer applications to outbreaks [ ] . in the context of covid- , estimates have considered growing force of infection, for example [ ] , and some approaches have considered truncation, for example [ ] . however, these attempts do not adjust for the reporting rate in the data or use the correct force of infection, causing the incubation period to be overestimated. although the method presented here is independent of the reporting rate, other approaches for estimating the incubation period are not. here we demonstrate the importance of truncation (table ) . we use the data truncated at january, which has exposure windows between december and january. this data set is chosen since it is most sensitive to truncation due to the exponentially growing force of infection and high reporting rate. without accounting for truncation, the length of the incubation period is significantly underestimated, which could have a large impact on the success of intervention strategies. to demonstrate the effectiveness of the bias correction method, we compare three different data sets ( table ) . the similar distributions predicted across these datasets suggests a robust method. figure b compares the full distributions for these three estimates. here we investigate the effect that uncertainty in the reporting date can have on the results, using the data truncated at february (table ) . the standard interval is the recorded data, wide intervals are obtained by removing a day from the exposure window lower bound and adding a day to the upper bound, and the narrow interval vice versa. the uncertainty in the reporting date can impact the estimated incubation period, showing that it is important to consider this risk when designing interventions. when constructing intervention strategies for an epidemic, the incubation period is an important parameter. for example, consider the quarantine strategy deployed in many countries during the early stages of the epidemic, aimed at preventing cases being imported from wuhan. this strategy quarantined individuals upon their return from wuhan for days. for such a strategy to be effective, we require most incubation periods to be less than days, so that the majority of infected people would develop symptoms before quarantine ended, enabling them to be further isolated. in this analysis, we show that in the worst-case scenario we would expect in cases to slip through this quarantine, with the best fit predicting in cases. therefore, the day quarantine period would capture the majority of cases. throughout the epidemic, this seems to have been reasonably successful and prevented early seeding of cases in many countries. however, potentially due to complicated travel patterns or asymptomatic transmission, cases have slipped through detection and not been quarantined, which unfortunately has led to the situation observed today. in addition to the incubation period, there are many other delay distributions that must be estimated while an epidemic is growing, which can be estimated using the same technique. these include the generation time, the time between two infection events in a transmission chain; the serial interval, the time between symptom onset of an infector to their infectee; and the onset-to-death delay, the time from symptom onset to death. transportation modelling plays a crucial role in the early stages of an outbreak; an infected individual may travel outside of the region in which they were originally infected and seed further infections across geographical scales which are impossible to contain. furthermore, as the rate of travelling increases, the number of observed cases within the known ''origin" region decreases, and if exportation is not taken into account this results in an underestimation of the number of cases. these underestimates can be improved by looking at the total number of cases across all known affected regions, but doing so introduces further complications. for example, if an individual has less severe symptoms they may not seek medical assistance, thereby not being recorded as a case at their destination. this underestimation of cases can have significant effects if the traveller is able to infect more people. a new transmission chain can thus be started which remains undetected for some time due to a lacking known connection to the ''origin" region. in the ''origin" region an individual with mild symptoms may still be tested for an infection due to a higher level of alertness in the local health care system. however, this level of active case-finding may not be present elsewhere, or may not have been allocated a comparable level of resources. further complications to this model arise from the incubation period of individuals wherein detection is unlikely, and the variations in movement and mixing between people when preventative measures are put in place. we consider a metapopulation model seeded with an infection in one of the regions, o, and investigate how exportation from this region combined with variability in case-finding can alter estimates for the doubling time and the expected portion of the population we expect to identify. this accordingly bounds the proportion of the infected population one would be able to target for personal intervention (e.g. quarantine or treatment). note that the proportion of identified cases need not necessarily correlate with the proportion of the infected population who exhibit symptoms. let us assume that movement from o begins at time where ω is the mean case-finding ability across all destinations. in the presence of real-time transition probabilities ij p of moving between two regions, these estimates can be further elaborated. we assume that detection occurs immediately following the end of the incubation period, i.e. . similarly, we assume a gamma-distributed incubation period with shape and scale parameters k and θ, respectively. we can parametrise this distribution using the ''non-wuhan" estimate of the incubation period in table , which yields a gamma-distribution with mean . and standard deviation . . in contrast to other values in the table, this estimate is obtained from discrete infection events, e.g. contact with a known infected case, and therefore has a constant reporting rate, and a constant force of infection over each exposure window. therefore, this estimate of the incubation period does not rely on the exponential growth rate unlike other estimates from section . when accounting for ρ. this difference may seem small, but it reduces the doubling time by approximately hours. the expected value of r grows linearly with the exportation rate, which has also been observed with real-time travel models [ ] . further models have also been developed which consider travel and exportation of cases in greater detail [ , ] . the relationship between the observed cases in our origin and destinations can be used to determine the case-finding ability, though it should be noted that ω likely varies with time as burdens are increased on public services and the number of cases grow. early estimates using data from [ ] indicate at most an % case-finding ability, suggesting thousands of undetected cases exported to other regions of china, a sufficient quantity to sustain further transmission post-exportation independently of the number of asymptomatic cases present. the intention of these estimates is not to provide specific values for the doubling time of the spread of covid- in china (as the estimates above use historic travel data and are limited by the availability of data), but to bring attention to the unusual circumstances surrounding changes in contact patterns, and mobility during the chinese spring festival, the largest human migration on earth [ ] . failing to account for the significant level of dispersion or exportation of cases during these circumstances will significantly skew our estimates. in a scenario where a single individual exposes a group to infection, it can be unclear how many people have been infected since they do not immediately develop symptoms. however, knowing the true prevalence in the population is essential to determine the most effective interventions to put in place, and to estimate future burdens on public services. using the probability density function of the incubation period, we consider the efficacy of using the time it takes for people to present with symptoms as a predictor for the size of the infected group. this analysis is an effective ready reckoner at early stages of a novel infection, or in close contact environments, and is useful for predicting generation size when a complete data set is not yet available. in this analysis we focus on a scenario where infection time is known. in reality, we may only know an exposure window. for short exposure windows this method can still be valid, but for longer exposure windows it will need extending to account for this added uncertainty. we assume that the number of individuals who have been exposed to potential infection is known, in which case the number of people who are infected can be assumed to be binomially distributed with an unknown probability p that each individual has been infected. to determine the distribution of infected individuals, we use the available information regarding the number of individuals who have expressed symptoms. this yields two cases. in the first case, we assume that the true number of symptomatic individuals are observed. in the second case, we take the number of observed symptomatic individuals as a lower bound on the true value. we wish to determine the probability that the first generation has e individuals, e e = , given that i τ symptomatic individuals are observed on day τ, i i τ τ = . this is given by (see appendix ) this gives a distribution of the generation-size based on the number of observed symptomatic individuals by time τ. we can extend it to investigate a scenario where no symptomatic individuals have been observed by time τ by using a value of for i τ : this can be used to illustrate worst and best case scenarios given τ time has passed without symptomatic individuals. additionally, if we consider the probability that e = , we can find the value of τ where we can have a % confidence that there will not be a second generation: this analysis considers the case when the number of observed symptomatic individuals to date is the true number. in practice however, we do not generally observe every symptomatic individual, so the number of observations is only a lower bound on the true number. to address this, rather than considering i τ as the total number of people who have developed symptoms by time τ, we can define i τ as the minimum number of people who have developed symptoms by time τ. we assume that the probability that i τ is equal to i τ for a given value of i τ is uniform at i τ + . we can then use the same methods as above to infer a distribution for p. details are provided in appendix . e , in an infection event in which people were exposed. a, b and c show the density when the number of observed symptomatics is taken to be the true number of symptomatics, d, e and f consider the case where the observed symptomatics is a lower bound on the true symptomatics. a and d consider the case when zero symptomatics are observed after days, b and e when are observed after days, and c and f when are observed after days. the incubation period for the disease has been modelled as a gamma distribution with a mean of . and standard deviation of . ( table ) . as we can see from figure , this method can be used to predict the number of infected individuals in the original exposed group. however, we have also demonstrated the importance of caution when interpreting this data. if there is uncertainty surrounding the presentation of symptomatic patients, using i τ as a lower bound is a robust method to ensure the size of the generation is not underestimated. . modelling intervention strategies when designing intervention strategies, we need to consider how adherence may alter their effectiveness. this is important, since highly effective interventions may not be adhered to if they present great individual cost to a population. in this case, a theoretically less effective intervention may perform better, if it has sufficient reduction in individual-level cost. in this section, we illustrate the potential impacts of adherence on the effectiveness of interventions using a toy model. consider a standard sir model, and denote by ( ) s t and ( ) r t , respectively, the susceptible and recovered/immune fractions of the population at time t. we can write s in terms of r such that if an intervention is put in place that reduces (with full adherence) r < then the outbreak will be controlled. indeed, let us assume that r is reduced to zero by the intervention: for example, assume that social distancing is perfect and the number of contacts of a fully-adherent individual is zero. if only % of people adhere to the intervention then the average number of contacts is effectively reduced by a half and logically † / . r r = = (the † representing quantities post intervention) and ( ) † . r ∞ = in this case. however, this assumes that adherence is an independent random process at each contact. this suggests that for each contact an individual would ordinarily make, they ''toss a coin" to decide whether to isolate or not. in reality, individuals are more likely to show polarity, where some individuals reduce all their contacts and follow the measures and a proportion of individuals choose to not adhere to the intervention. if there was distinct polarity in the population such that % adhered perfectly and % ignored policy, then a toy model can be created with two infectious groups, a i and b i , that behave differently. in this case where a dot over a variable represents its time derivative. such an epidemic model, where the two groups have the same susceptibility but different infectivity, has the same final size as an epidemic in a single-type model with the same r (e.g. see [ ] ). however, they have different durations as can be seen in figure , where this shows that the assumptions about the nature of adherence predict the same growth rate and final size, but that the more polarised adherence has faster early growth and therefore an earlier peak. more complicated model structures could be constructed by incorporating adherence with intervention by susceptible states, which would lead to core group dynamics (see for example [ ] ). this issue of independent versus polarised adherence is related to the idea of all-or-nothing versus leaky vaccination [ , ] , where you either vaccinate a fraction of the population with % efficacy or vaccinate % of the population with reduced efficacy [ ] . note however that vaccination reduces your susceptibility (whether only or also), rather than only your infectivity as in the model discussed above, and variation in susceptibility does reduce the final size, with imperfect coverage with a perfect vaccine (all-or-nothing) leading to a lower final size than full coverage with a leaky vaccine (all individuals having the same mean susceptibility). the ongoing covid- outbreak is known to have higher mortality rates amongst the elderly, the immunocompromised and those with respiratory and health complications [ , , , , ] . in this section, we model the introduction of an infectious disease into care homes, in order to obtain estimates of the final size of the epidemic in the vulnerable population as well as predictions for the number of hospitalisations and fatalities. modelling of care homes in the uk is conducted against the backdrop of a wider epidemic in the general population, which we here assume to be following seir dynamics with a basic reproduction number r that might be different from the within-care home reproduction number c r . care homes are assumed to be closed populations, with the infection entering each of them independently with a certain probability. infection is seeded only once, and within-care home outbreaks then evolve independently from, and do not contribute to, other care home outbreaks and the epidemic in the background population. to keep track of hospitalisations, we model the withincare home infection dynamics using a compartmental model that, in addition to seir model, has compartments for mildly symptomatic prodromal cases (p), who show no symptoms but are capable of transmitting the virus, those who recover from the disease after mild symptoms that did not require hospitalisation (m), those who have severe symptoms and are admitted to hospital (h), those who recover after hospitalisation (r), and those that die (d). this is illustrated in figure . the infection pressure up to time t for a median sized care home is the integral from to t of the force-of-infection (foi) applied to the care home coming from all infectious sources, multiplied by a probability p. this probability represents the probability of the infection being introduced to a median-sized care home. for other care homes, we allow this probability to be proportional to its size, under the assumption that larger care homes employ more staff and are therefore at higher risk of introduction. when the infection pressure becomes higher than an individual care home's resilience threshold, that care home begins its own deterministic infection dynamics with a single initial infected case. the equations describing the background epidemic and the within-care home epidemic are given in appendix . figure : compartmental model for disease dynamics within a care-home. we extend a deterministic seir model to include compartments for prodromal (infectious) cases (p), mildly symptomatic cases that recover without requiring hospitalisation (m), cases that do require hospitalisation and are removed from the care home (h), cases that die in hospital (d) and cases that recover in hospital (r). we run this model on data for the entire care home population in the uk, so that there are approximately , care homes with a total population of approximately , residents [ ] . care home sizes range from to , with a mean size of . . in this model we only consider the vulnerable population within care homes. we assume . r = in the background epidemic, a relatively low value that somehow accounts for a certain degree of control, and an c r = to allow relatively explosive epidemics in care homes due to potentially more frail individuals, difficulty in isolation and staff inadvertently passing the infection from one case to the next. the other parameters in the baseline scenario are reported in table . apart from the reproductive number, the background epidemic uses the same parameters as the care home epidemic. however, in the background model there are only rates from e to i and i to r, which are taken to be the rates from e to p and i to m, respectively. there are a variety of assumptions underpinning this model. firstly, the background epidemic ignores structure and assumes homogeneous mixing. this is likely to make the peak more pronounced, so presents a worst case scenario for the demand on hospital beds. the assumption of r for the background epidemic only affects the shape and duration of the background epidemic, since the tuneable parameter p controls the risk of introduction to the care home. that is, if r is small, a large p still presents a high force of infection into the care homes. therefore, for a fixed p, we expect that changing r does not affect the total number of deaths, but it changes the peak hospitalisation incidence because a faster and more explosive background epidemic makes epidemics in care homes more synchronised. in fact, when testing the impact of a longer, flatter background epidemic, for example obtained by simulating three slightly desynchronised background seir epidemics, results have lower peaks and a much more variable timing (not shown). assuming each care home is independent might not be realistic, since it is likely that staff are shared between multiple homes, in which case they can act as vectors of transmission between homes. however, in the model current outbreaks are already quite synchronised (the within care home outbreaks occur at similar times), so the effect of this assumption is likely to be minimal. the final major assumption is that the epidemic within the care homes is deterministic. this removes the probability of random extinction and random delays, and should obviously be relaxed with a stochastic model, given half of care homes have size smaller than . however, the extinction probability is very low with c r = , so this stochastic effect is unlikely to have a large impact. random delays, instead, may change the shape and timing of the epidemic, which could potentially reduce the peak burden. therefore, this model represents a worst case scenario. in the absence of cure or vaccine for covid- , governments worldwide must rely on nonpharmaceutical interventions (npis) to control the outbreak [ ] . a natural such intervention is to ask individuals who express symptoms similar to covid- to isolate themselves, but variants to such individual isolation might include policies sometimes referred to as household isolation, household quarantine and mixed isolation. in this section, we investigate how such strategies affect the spread of the epidemic when bearing in mind that adherence to each intervention may differ. individual isolation relies on individuals staying in isolation when they express symptoms, thereby stopping transmission. however, there is potential asymptomatic or prodromal transmission before they go into isolation. additionally, isolation strategies generally ask infected individuals to remain at home, which presents an infection risk to the other members of their household, who may go on to spread the infection. the term 'household isolation' refers to a policy where, upon first detection of symptoms within a household, all individuals within the household go into isolation for a fixed duration of time. this strategy reduces the risk that other household members, if they are infected within the household, transmit in the community when pre-symptomatic (and hence before they self-isolate themselves) or if asymptomatic but still infectious. a blanket policy invoking a fixed duration of household isolation might cover the full epidemic in a small household. however, a larger household might present multiple generations of infection, potentially extending the within-household outbreak beyond the fixed duration of the household isolation policy. to address this issue, 'household quarantine' is another potential strategy. upon detection of symptoms, the entire household is isolated until a fixed duration of time after the last symptomatic case within the household expresses symptoms. this ensures that there are no symptomatic cases evading intervention but applies quite drastic measures to the household. a fourth strategy, that reduces the cost relative to household quarantine, is mixed isolation. here, upon detection of symptoms the entire household is isolated for a fixed length of time. any subsequent cases within the household then undergo individual isolation as described above. this reduces the risk of cases not being isolated whilst allowing recovered individuals to return to work. there is however still some remaining risk that infected individuals may not yet express symptoms after the end of the isolation period, but this risk can be controlled through the duration of each isolation. although there is now a rich theoretical literature on households models [ , , ] , the mainstream methodological tools in this research area present important limitations that make them not directly applicable to studying these control policies. first, exact theoretical or asymptotic results in these models are mostly restricted to time-integrated quantities, i.e. those quantities that do not depend on the detailed temporal shape at which the infectivity is spread by an individual: these are r (or any other reproduction number [ , ] , e.g. the household reproduction number * r ), the probability of a large epidemic, and the epidemic final size [ ] . for this reason, the vast majority of the literature relies on the standard stochastic sir model [ ] , despite its unrealistic infectivity profile. even if more recent work has expanded beyond time integrated quantities, for example considering the real-time growth rate [ , ] , if the interest is on tracking the dynamics of infection spread, a model based on full temporal representation of between-and within-household dynamics [ ] appears necessary. a second limitation of standard household models is the key assumption of constant parameter values. this appears essential for any form of analytical progress. however, in the context of the interventions discussed above, a reduction in transmission between households, as well as a potential increase in within the household, require parameters to change over time. to overcome these limitations, we consider two approaches. the first approach fully captures both within and between-household dynamics with a master-equation formalism, i.e. by relying on a markovian within-household dynamics and keeping track of the expected number of households in each possible state of their internal dynamics. the second approach has a greater emphasis on withinhousehold dynamics, and is fundamentally an independent-households, individual-based, stochastic simulation. the more limited mathematical tractability is the price to pay for an increased flexibility, as the within-household markov assumption is relaxed and exact distributions for delays between events, typically informed by the data, can be explicitly inputted. although both approaches can account for increased within-household transmission as isolation and quarantine are imposed, we only consider this for the second method here. this aspect allows us to study the increased risk of infection a vulnerable individual in the household would experience following the implementation of a control policy. to model the households in the uk, we construct a realistic distribution of household sizes (which is given in the supplied code). we take this demographic data from the census [ ] . more recent information, though less specific on large household sizes, shows that sizes of smaller households are largely unchanged over time [ ] . . in this section, we investigate the above intervention strategies under the assumption that a fraction of households adhere % with an intervention and the remaining households ignore the intervention. to model the interventions, we implement a dynamical household model that explicitly represents the small sizes of households. the dynamics of the outbreak are simulated using an sepir model. this model assumes that there are five possible states in which an individual can be. these are, susceptible, latent, mildly symptomatic prodrome, symptomatic infectious and removed. individuals are infectious during the mildly symptomatic prodrome state and the symptomatic infectious state. following [ ] , we assume that within-household transmission scales with the inverse of the household size to a specified power η. such a model can be used to investigate how the pathogen spreads through and between households. the methodology involved is the use of self-consistent differential equations, first written down by ball [ ] . more recent developments, including numerical methods for these equations, include [ , , , ] . important features of this approach include allowing for a small, finite size of each household in which random effects are important and each pair can only participate in one infection event. here Λ represents infections imported from outside the population of households, and the other terms represent between-household transmissions. in our code, we assume Λ is a step function. results are largely insensitive to the precise choice of Λ , but compared to, for example, random seeding of infections in households, starting the whole population susceptible and exposing to a small amount of external infection for a fixed time period has less room for the precise initial condition chosen to influence results, and is more realistic for the situation observed in countries apart from china. we take a 'global' intervention as part of the baseline, in particular, we can model phenomena such a school closures that hold during a set of times t as we call ε the global reduction. we will generally drop this t-indexing for simplicity, and will also consider only a household isolation strategy (though the other strategies can be considered similarly, with an example of how other strategies could be captured in this model framework given in appendix ). instead of isolating for a fixed duration, we assume that a fraction w α of households isolates when there is at least one symptomatic case in the household, and isolating households leave isolation when no symptomatic cases remain. we make this assumption since it may potentially capture the behaviour of real households, who are more likely to remain isolated based on presence of symptoms rather than for a fixed duration. in the non-markovian household model in section . using the methods in [ , ] , it is possible to fit household models of this kind to the overall growth rate, r, which we take to correspond to a doubling time of three days. natural history parameters can then be set directly based on reasonable estimates: e p r → to the inverse of the latent period; p i r → to the inverse of the prodromal period; i r ∅ → to the inverse of the symptomatic period. shaw [ ] analyses various household datasets for respiratory pathogens and estimates values for η close to , so this is taken to be . . the remaining degrees of freedom are relative infectiousness of the prodrome (taken as a third) and the probability of transmitting within a pair, which we can take as a typical value given by shaw [ ] . for the numerical results in figures and using the given parameter values for our baseline scenario (table ) , we consider a combination of household isolation (which follows all-or-nothing adherence) with global reduction in transmission (which follows leaky adherence) for three weeks and show the results in figure . the distribution of infectious individuals varies with household size, which is shown in figure for different durations of global intervention. applying household isolation at % adherence ( . w α = ) manages to reduce the spread of infection, but appears insufficient in this model and with baseline parameters for controlling the outbreak in the long-term, unless other intervention strategies that reduce the global transmission (increasing ε) are adopted at the same time. alternatively, different levels of adherence can be considered to determine if and when control may be achieved purely through household-based interventions. for the model proposed in the next section, we look into the effectiveness of increasing adherence. parameters are in the main text. the model described above has the advantage of being able to track the dynamics within the household as well as the overall epidemic in the population in a relatively efficient manner. we now discuss a different framework that loses part of the capability in keeping track of the overall epidemic, but offers further flexibility both in the impact of policies on the within-household dynamics and in the distributions between events in the infectious life of an individual. we use this model to investigate the relative effectiveness of the different control policies. we also consider allowing recovered individuals to leave the household, even in the context of household isolation or household quarantine. this has no impact on the transmission dynamics, but reduces the individuals' life disruption and potential economic cost of any policy implemented. this model assumes that there is no reintroduction within households so each household can only be isolated or quarantined once. the assumption that only one household member is infected from outside is approximately satisfied if we assume homogeneous mixing between households and a large number of households, which are all fully susceptible at the start of the epidemic. however, the reality of heterogeneous mixing makes reintroduction a likely possibility even early on in the epidemic. this model, therefore, lacks an explicit description of the social network structure beyond the household. for simplicity, we assume that within households all individuals are identical in terms of their disease dynamics, although the method might be extended to allow for different age/risk groups with different disease dynamics. we assume that the level of within-household transmission in a household of size n scales proportionally to ( ) / n − , though we acknowledge that true transmission is slightly more complex [ ] . we consider independent households of size each individual is given an indicator function of whether they are symptomatic or not (individuals show symptoms independently of each other with probability s p ) and a resilience threshold. this last quantity is drawn from an exponential distribution with mean , and represents the overall infection pressure this individual is able to withstand before they get infected. the infection pressure up to time τ is the integral from to τ of the force-of-infection (foi) applied to this individual coming from all infectious sources. at the beginning of the within-household epidemic, a single initial case is assumed. time is discretised with a predefined time step d . t = days. at any time step, the current infectivity of all infectives in that time step is summed over, keeping track differently of the infectivity spread outside and inside the household. an overall measure of the accumulated infectivity within the household is updated at each time step and when this crosses the resilience threshold of a susceptible individual, they acquire the infection. we assume an individual spends half of their time outside and half inside the household. when selfisolation starts, the assumed adherence i a represents the fraction of the time spent outside that is shifted from outside to within the household. therefore, for perfect adherence, from the moment symptoms occur, the individual stops transmitting outside but their infectivity within the household grows by %. we also explore variations in this compensatory behaviour, so that the time of an individual is split in a more flexible proportion than : . the same argument applies to other control policies, with adherence levels h a for household isolation and q a for household quarantine. when multiple control policies are in place at the same time, their effect is assumed to be multiplicative: if an individual has symptoms and the household isolates, the outside transmission rate from that individual is reduced from baseline by a multiplicative factor ( ) ( ) ( ) and the area under this curve is known in the literature as the household reproduction number, and is typically denoted by * r . if enough transmission is prevented, so that * r < , the epidemic is controlled. the basic reproduction number r and * r share the same threshold at one, so they are simultaneously larger, equal or smaller than unity. however, in a growing epidemic * r r < [ , ] . the real-time growth rate r is related to * r by the lotka-euler equation asymptomatic cases, which are assumed to be half as infectious as symptomatic ones. the total number of cases under isolation (possibly compounded, e.g. both household and individual isolation) is shown in red (right axis). all random numbers involved in the realisation of the stochastic epidemic are drawn at the start, before the impact of each control policy is implemented. row shows no isolation and individual and isolation. rows , and show, respectively, household isolation, mixed isolation and household quarantine. the difference between the columns is that the basic policy on the left is ''upgraded'' to the more cost-effective version on the right that allows recovered individuals to leave the house as they cannot transmit outside anymore. when no control is implemented, the primary case (individual a, infected at time ) infects another individual (b) around time . after a long latent period (i.e. incubation minus prodromal), b becomes infectious and infects a further individual (c). the last individual (d) escapes infection. when different intervention strategies are in place, within-household infectivity is increased. this can result in individual c becoming infected earlier in the outbreak and individual d no longer escaping infection, both due to the increased force of infection. in this simulation, the dynamics for individual b do not change since they are infected before a becomes symptomatic. individual d is infected earliest under mixed isolation, because within-household transmission is higher than household isolation alone, due to increased adherence from individual isolation also being in place. adherence levels to household quarantine are lower than those of household isolation, due to the higher demand of full quarantine, thus leading to less enhanced within-household transmission. we assume that adherence to individual isolation is %, household isolation is % and household quarantine is %. the more severe the intervention, the better it captures the infectious periods of infected individuals within the household. the lower x-axis gives the adherence to household quarantine, and the upper x-axis adherence to household isolation. we assume that household isolation is less demanding, and therefore adherence is assumed to be ''twice as high'', meaning it is at the midpoint between that of household quarantine and (e.g. . for an x value of . , . for an x value of . , etc.). the black dash-dotted line in (a) gives the amount needed to control the spread by achieving * r = . notice how: the effect of individual isolation is independent of adherence to household quarantine (dotted lines); the effect of household isolation is independent of adherence to individual isolation (overlapping dash-dotted lines); mixed isolation is always superior to household isolation; household quarantine is only optimal at really high levels of adherence (for these baseline parameters, generally, beyond the level needed to achieve control), but quickly becomes suboptimal to mixed isolation as adherence is reduced. when a sufficiently large reduction in * ); similarly, in all households, individual isolation would total exactly days if all cases were symptomatic and all individuals in the household were ultimately infected. in (d), we assume that adherence is % to each intervention. under the baseline parameter values (table ) , control can in principle be achieved via certain interventions, but only for high levels of adherence, which might be difficult to enforce for a prolonged length of time (figure a ). more importantly, the model's conclusions are highly sensitive to variations in parameter choices, which are uncertain. parameters that present problems here are the delay from symptom onset to isolation (with control failing for day detection delay unless adherence is essentially perfect), proportion of asymptomatic infections (any chance of control lost at %) and the strength of asymptomatic transmission. the short delay before symptomatic individuals isolate may be unrealistic unless the susceptible population is very well-informed about symptoms that call for isolation, and so likely does not apply in very early stages of an outbreak. overall, in the face of the many uncertainties, household-based interventions triggered purely by symptoms appear useful to slow the spread but need to be complemented by other policies. comparing the different strategies (figure b , household quarantine can be optimal (as one might expect), but this requires high adherence levels. as adherence drops, this strategy becomes suboptimal to mixed isolation. mixed isolation is significantly better than household isolation on its own and requires little extra social cost, so should not cause adherence to drop (relative to household isolation adherence levels). the difference between the two strategies comes down to the transmission slipping through after the day household isolation. the cheapest strategy, when considering working age adults, is individual isolation (figure d ), but the effect is limited compared to the other models and cannot achieve control in the baseline scenario even with % adherence. overall, the mixed isolation strategy appears to be most cost-effective. however, this is dependent on the assumption that adherence is better for day isolation rather than a very long quarantine. it can be observed that household-based interventions are more effective than individual isolations, demonstrating the importance of these strategies in designing intervention policy. figure shows how the different isolation strategies contain the infectious periods of individuals within the household and also indicates the number of individuals being isolated within the household. to study the impact such an increased within-household transmission has on the chance that a vulnerable individual is infected in the household, we randomly choose one non-primary case in the household as the vulnerable one and count how many of the e n epidemics result in this individual being infected under the different control policies (figure c ). under these interventions, the risk of a vulnerable individual getting infected within-household, conditional on the infection entering it in the first place, is in the range % − . since this model relies on the sellke construction, we calculate the infection pressure that accumulates (within a household) during the outbreak. in relation to figure , we report in figure the infection pressure that accumulates for the different control policies, showing the different impact each intervention can have on the within household dynamics. figure : accumulated infection pressure in the simulation presented in figure for different control policies. horizontal dotted lines represent individuals' resilience thresholds. as time progresses, the accumulated infection pressures (coloured lines) increase and when they cross the resilience thresholds, the corresponding individual acquires infection. notice that: in the absence of control, one individual escapes infection; with household isolation only, the infection pressure reaches a relatively low endpoint because of the last symptomatic individual slipping through and not transmitting much in the household; with mixed isolation, infection pressure is higher due to combined adherence; and with household quarantine, the infection pressure builds up more slowly at the beginning due to lower adherence. we assume that adherence to individual isolation is %, household isolation is % and household quarantine is %. social distancing, isolation and lockdowns act to mitigate the spread of an infectious disease and reduce the number of cases. however, such interventions, particularly widespread lockdowns, cannot be maintained indefinitely and must be lifted at some point. for the disease to be controlled, these interventions can be implemented until pharmaceutical interventions are developed, such as a vaccine, or until the case numbers are low enough that the disease may go extinct. here, we consider the situation where interventions are lifted just before extinction, when the number of cases has reached a low but non-zero initial value n : at this point, the number of cases might rebound or might go extinct by random chance despite an r > . we use a time-inhomogeneous birth-death chain model [ ] to , q t s satisfies the differential equation subject to the initial condition ( ) , . q s s = solving for q and setting s = gives the probability that, at time t, the number of cases has reached zero and the disease has become extinct. we denote this probability by ( ) q t [ ] , which is given by the corresponding generating function, ( ) , r t s , for this random variable satisfies again, solving for ( ) we simulate data based on one initial case n = , though this may easily be extended to any number of initial cases. we run simulations both with and without immigration, choosing w is the initial (constant) rate of importation of cases before any controls on immigration are put into effect. we set w = imported cases per day. with these choices of parameters, the resulting extinction probabilities are given in figure . note that we are assuming the immigration rate is decreasing to , so if the infection is controlled internally for long enough, an overall ultimate extinction is possible in this model. for these parameter choices, the final probability of extinction, defined as n q t . these probabilities suggest that, without widespread immunity, stochastic extinction might be aided by social distancing but is heavily compromised by immigration. border controls, therefore, if of limited use when transmission is self-sustaining, become key when the number of cases is low. note that we have assumed an importation function ( ) t η that goes to for large t, in line with a pandemic that goes extinct in other geographical regions. however, the presence of an animal reservoir might lead to an importation function that is non-zero over longer time scales, thus effectively making ultimate extinction impossible unless the effective reproduction number is kept below one by a systematic and permanent intervention (e.g. technology-based change in behaviour) or herd immunity. contact tracing is a complementary control policy to isolation or quarantine. when a case is discovered, attempts are made to identify and isolate individuals who may have been infected. in doing so, some of the secondary cases will be discovered and isolated early in their infection, decreasing their effective infectious period. if contact tracing is successful, it can greatly reduce the effective reproduction number of the infection, and in combination with other interventions may drive an epidemic extinct, as was seen in the case of sars [ ] . contact tracing in itself presents numerous challenges, which are exacerbated by its success relying not only on the effectiveness of the tracing process but also the underlying transmission characteristics. for covid- , some of these challenges include mild symptoms which cause infections not to be reported, pre-symptomatic transmission which occurs before a case is reported, and short generation times [ ] which can cause the epidemic to outrun contact tracing. additionally, contact tracing is only feasible for smaller case numbers, because each case generates multiple contacts to follow up, so the tracing workload expands dramatically, and an increasing number of chains remain unobserved. this makes it a viable strategy in the early days of an outbreak, or, if containment has failed, following a period of severe interventions, such as a lockdown. combining contact tracing with isolation is being considered by many countries as part of a test, trace and isolate strategy to be implemented once lockdowns or comparable measures are lifted, provided these lockdowns succeed at driving case numbers sufficiently low. in this section, we develop a householdlevel contact tracing model for an emerging outbreak, since we do not wish to make assumptions about immunity or depletion of susceptibles. these assumptions can be added to the model as the availability of data into immunity improves. we are interested in the likelihood that the contact tracing process is overwhelmed by large case numbers and the likelihood that, combined with isolation, it can drive the disease to extinction. the early days of an outbreak can be modelled using a branching process, where generations of infections produce infectious offspring. contact tracing processes can be incorporated as a superinfection along the tree generated by the branching process [ ] . when a node is 'superinfected' by the contact tracing process, it is isolated. we model the infection spreading through a fully susceptible population of individuals, segmented into households of different sizes according to the ons survey [ ] , and progress through discrete time steps of day. as such, our branching process is at the household level, coupled with localised within-household epidemics. this allows us to model contact tracing strategies that isolate whole households, which may contain several undetected infections. it also enables a wider range of contact tracing strategies to be modelled, each with different intervention scope and costs. each day, individuals (or nodes) make contacts to a random set of individuals; divided into local contacts to members of the same household, and global contacts to members of other households. the number of individuals contacted in a day is distributed using an overdispersed negative binomial distribution and parameterised using estimates from the polymod social contact survey [ ] , stratified by household size. since the probability that a contact causes infection cannot be directly observed, we use improper hazard rates that give rise to the day covid- generation time [ ] and r = . for contact tracing to begin, an infection must be diagnosed, which we assume occurs % of the time among infected individuals due to flaws in reporting or very mild symptoms in those infected. we assume a gamma distributed incubation period with mean . (table ) and a geometric reporting delay from symptom onset with mean . days [ ] . intuition suggests that if r = then tracing two thirds of contacts will control the epidemic. however, in practice transmission may occur before tracing, so this will not reduce the number of infectious contacts by two thirds. to demonstrate this, we assume that contact tracing successfully traces two thirds of contacts. trained professionals have to trace all reported contacts from the last days, so we assume that the contact tracing delay follows a geometric distribution with a mean of days. individuals are considered recovered days after infection, as the chances that they are still transmitting then are negligible. though our general framework can be modified extensively, we assume the following contact tracing strategy. when an individual reports infection, their household is immediately isolated. contact tracing attempts are then made for all households connected to one of the individuals in this household, whether symptomatic or not. when a connected household is identified (after the contact tracing delay), all individuals within the household are immediately placed under observation. if any of the individuals in the observed households develop symptoms, then the household becomes isolated and the contact tracing process continues to connected households. when a household is isolated, we assume all individuals are isolated with % adherence, and cannot transmit the virus within or outside the household. the assumption that isolation prevents local infections is unrealistic, but does not change the overall behaviour of the process as there are no more global infections. this strategy imposes high individual-level cost, since by isolating all individuals within a household, it isolates individuals who have not had direct contact with an infected individual. in practice, such a strategy may have poor adherence. figure a shows an example contact tracing network. . when choosing contact tracing strategies, a balance must be struck between the effectiveness of a strategy and the resources that it requires. some strategies are only feasible when there are few infections, since the resources required can grow rapidly depending on the dynamics of the outbreak and the contact tracing process. to define the capacity of the contact tracing process, we consider the ability of a public health agency to observe the condition of those asked to self-isolate, due to their recent exposure to an infected individual. the health agency must remain in contact for the duration of the day self-isolation period, so that if any individual under isolation develops symptoms and then tests positive, the contact tracing process can be initiated on this node. we will define the capacity of the contact tracing process to be the number of people that can be placed under observation and assume two possible capacities: and . we assume that when a node is contact traced, they are asked to report their global contacts for the last days. all global contacts are assumed to be to a new person since we are in the early stages of an outbreak. parameters are given in table . hitting probability ( ) . % we carried out simulations of the contact tracing process for days. contact tracing capacity was reached in simulations, and in the epidemic neither went extinct nor was the capacity reached. in the remaining simulations, the epidemic went extinct. figure a and table show that increasing the contact tracing capacity tenfold less than doubles the time until that capacity is reached. however, it does increase the odds of driving the epidemic to extinction without hitting the capacity by about % (table ) . different contact tracing strategies will strain different aspects of the health agency. a strategy that generates large amounts of work is only feasible if there are few active infections. the optimal strategy will need to compromise and may need to change depending on the number of active infections, which cannot be directly observed. figure : capacity hitting times for the contact tracing model. when there is a small number of cases in a single country, it may be possible to drive the pathogen to extinction. this small case number could correspond to the start of an outbreak or removing of severe interventions. we consider the latter case, but conservatively assume a fully susceptible population. we assume that social distancing is enforced on day and reduces global contacts by %. full parameters are given in table . since we are interested in extinction, we will no longer consider the contact tracing capacity. under these baseline parameter assumptions and simulations, the combined force of this contact tracing strategy and isolation is enough to drive the epidemic extinct ( figure b ), but measures will need to be in place for months in some cases. if the infection is ever re-imported, then the process would begin again, since herd immunity is not achieved. note that the minimum extinction time is days due to this being the time after which an infected individual is labelled recovered. additionally, this model only considers extinction under the assumption that no cases are imported. in section . , we have shown that importation of cases significantly reduces the extinction probability. this suggests that extinction may no longer be guaranteed, and the time to extinction will be significantly increased. this analysis has focused on a single contact tracing strategy using indicative parameters for covid- . the proposed model can be extended to more strategies and region specific parameters to inform the design of control policies. also, as is shown in table , contact tracing capacity is likely to be reached, which may prevent extinction from being achieved. this complication is compounded by the issues of loss of immunity or the presence of an animal reservoir discussed in section . . figure : example of the contact tracing process (a) and the extinction times distribution (b) for the contact tracing model. . discussion in this manuscript we have presented a range of mathematical tools to tackle infectious disease outbreaks. in particular, these tools address various technical questions posed by the authors to support the ongoing public health response to covid- . this toolkit considers both estimation efforts for key parameters, and investigative efforts (often numerical simulations) in gauging the effectiveness of various intervention or control measures. joint consideration of estimation and simulation efforts is critical. parameter estimates are obtained using a certain set of assumptions regarding the data, and investigations or simulations utilising these estimates should ensure that their underlying assumptions are consistent. these challenges in model construction and applicability of statistical methods are compounded by the limitations of the data with which decisions must be made. some of the biases present in the data can be addressed with an improved data collection methodology -often challenging in the context of a fast-moving outbreak -but many are also inherent to the nature of early outbreak data [ , ] . the consequent lack of intuitive insight from this data underscores the need for careful parametric estimates, especially considering the large variability in predicted outcomes resulting from small differences in parameters. even with robust estimates for some parameters, many other parameters are challenging to estimate using the available data. therefore, models need to address this variability and uncertainty in order to inform public health policy. we have presented methods to address biases arising from a growing force of infection, changes in the reporting rate, truncated data samples and a varying travel rate. we use these methods to account for these biases when estimating delay distributions, such as the incubation period, and the growth rate/doubling time. these biases can have significant impact when estimating key parameters: the mean incubation period estimates for covid- range from . days without correcting for truncation to . days with the correction, and the doubling time in hubei province decreases from . days without correcting for travel to . days. these differences can significantly alter our understanding of the outbreak, and could have a large impact on policy and public health. for instance, underestimating the incubation period may lead to quarantine strategies failing to identify infected individuals if the quarantine length is too short. overestimating the doubling time (or underestimating the growth rate) will underestimate the risk posed to the host population -both in terms of final size of the epidemic and the rate at which it spreads, which can have significant public health impacts as discussed in [ ] . it is important to note that the above-mentioned biases, and consequent impact of implementing the methods correcting for their presence, may vary across different settings. as an example, the potential underestimation of the covid- growth rate is exacerbated by an overlap in early outbreaks with a period of significant travel and movement in china, and would be less detrimental if first observed in other populations such as italy. also, for the incubation period, we have shown two different types of data; one from wuhan and one from discrete infection events. in the wuhan data set, truncation and force of infection biases are very important, whereas in the other data set, there is no force of infection bias since the infection events are observed. when an outbreak occurs in an enclosed group, such as a large gathering, we may wish to know how many individuals are likely to be infected. we developed a statistical method to estimate the first generation size based on the number of symptomatic individuals, taking care to account for the uncertainty in this quantity. this ready reckoner can inform testing of large groups to help control the disease spread, but does not apply to later generations or the possible interventions enacted on the population. building on these enclosed population scenarios, we have developed a set of models that investigate public control measures or interventions on enclosed populations, such as households and care homes. these structured descriptions improve the population risk profiles relative to assumptions of homogeneous mixing. a complementary aspect to a structured population when modelling interventions is adherence. motivated by vaccination modelling, we consider leaky adherence, where every household chooses to adhere or not whenever an event occurs, and all-or-nothing adherence, where some households adhere every time and some never adhere. we observed that in a homogeneous population, although the two types of adherence predict the same growth rate and final size, the timing of the peak and the early growth can be faster under all-or-nothing adherence. this insight, combined with lessons from the vaccination literature, suggests that efforts should focus on ensuring complete adherence in individuals or households with some level of pre-existing adherence, rather than pushing non-adherent individuals or households to change behaviour. dedicated modelling of disease spread in care homes is essential due to the documented history of comorbidity of their residents during pandemics [ , , , , ] . we do so by regarding care homes as closed populations that are subjected to a force of infection from an external epidemic. we develop a tool for analysing the risk posed to this population by determining the peak size of the epidemic within the care homes and the number of deaths. applying this model to covid- , we find that by ''cocooning" the care homes, i.e. shielding them to reduce the chance of introduction from the external outbreak, we can significantly reduce the size of the peak and therefore reduce the number of deaths. however, assessing the necessary level of shielding requires accurate characterisation of the external force of infection, and underestimating this may invalidate shielding efforts. a limitation to the proposed model is the deterministic within care home epidemic. however, since the average size of care homes is relatively large and we assume a high r within care homes, the deterministic assumption is unlikely to significantly alter the conclusions. when modelling households however, we are concerned with much smaller population sizes. therefore, it is important to consider stochastic effects within each household, combined with between-household dynamics. we consider two different household models: one which contains features of both within-and between-household transmission, where small-scale transmission can be linked to the epidemic on a population level, and another which facilitates more detail in the withinhousehold transmission and delay distributions, but with reduced correspondence to the populationwide transmission. with the first model, a % adherence to household isolation appears insufficient to control the epidemic without severe global reductions in transmission. coupled with a short term global reduction, the epidemic can be controlled, but upon lifting the global intervention, which could take the form of a lockdown, household isolation is insufficient to maintain control. for the second model, we look into changing the strength of adherence, and the impact this can have on achieving control. indicative but reasonable parameter values suggest that the covid- outbreak can potentially be controlled using household isolation strategies, provided the level of adherence is sufficiently high. however, such a high level of adherence may be difficult to maintain in the long-term and this modicum of control is anyway highly sensitive to the chosen parameters. we further investigated the efficacy of various isolation or quarantine measures. a policy of individual isolation struggles to curtail the epidemic for any adherence. instead, mixed isolation, whereby first the whole household isolates and any individual infected during isolation goes on to self isolate after household isolation is lifted, appears to be the most cost-effective strategy. countries have put into place strict social distancing and lockdown intervention to suppress or regain control of epidemics that threaten to overwhelm the health system and cause massive mortality, but they cannot be sustained in the long term without growing social and economic costs. we have shown however, that the probability of the epidemic becoming extinct once these policies are lifted, even when very few cases remain, is very small. we therefore consider a contact tracing intervention as a potential strategy for managing the covid- outbreak, once severe lockdown interventions are lifted. we developed a household-level contact tracing model to explore the feasibility of combining these strategies to control the epidemic. firstly, we noted that by using knowledge of household structure, we can reduce the burden on the contact tracing process by isolating household and removing them from the contact tracing process once an infected member has been identified. secondly, we investigated how contact tracing combined with household isolation may drive the disease to extinction, finding that aggressive contact tracing coupled with household isolation can drive the epidemic to extinction under the indicative parameters assumed, when starting with a single infection. however, the time until extinction can be impractically long, which risks the contact tracing capacity being overwhelmed, suggesting such a strategy may be infeasible in practice. a less aggressive strategy could be implemented that would be less likely to overwhelm local health agencies. whilst it may not lead to extinction, this can still be beneficial at mitigating and controlling the spread of an outbreak as part of a test, trace and isolate strategy. there are many complexities when modelling an outbreak of a novel infectious disease. to address some of these, we have described a variety of techniques to serve as part of a generally applicable toolkit. however, our proposed models, and many other models, are subject to important limitations which must be considered prior to their application. key among these is the lack of heterogeneous population mixing, such as through age-stratification [ ] and different risk-groups [ ] , and spatiotemporal variations [ ] , all of which influence modelling estimates and predictions. nevertheless, the relative simplicity of the presented models allows for the development of qualitative intuition regarding the efficacy of various intervention methods, whilst providing tractable theoretical frameworks which can be further developed and better inform policy-makers. . independence of the incubation period likelihood function and the reporting rate to estimate the incubation period distribution, we need to find the distribution that maximises the probability of observing the sampled data. however, the sampled data does not directly record incubation period, and instead contains infection exposure window and the symptom onset date. additionally, the sample does not contain all individuals, and therefore there is a reporting rate that must be incorporated into the likelihood function. if the reporting rate is constant, it can be ignored. however, in the data coming out the wuhan, the reporting rate varies significantly, since individuals are no longer exported from wuhan after travel restrictions. since the reporting rate depends on individuals leaving wuhan, the main factor effecting the probability that a case is included in the data set is the date an individual leaves wuhan. therefore, the reporting rate depends on the days an individual spends in wuhan and is independent of their symptom onset date. we need the likelihood function that an individual was infected between days a and b, had symptom onset on day y, and was included in the data set. we will condition against the infection window, a i b < < , the case being included in the data set, x d ∈ , and symptom onset occurring before the truncation date, y t < , and determine the probability that for such an individual we observe the given symptom onset date, y y = . where f θ is the probability density function of the incubation period distribution. therefore, the likelihood function ( | , ) p y y a i b y t = < < ≤ is independent of the reporting rate for the data coming out of wuhan in the early days of the outbreak. . generation-size derivation to solve this, we need to determine the distribution of the infection probability p given the number of observed symptomatics. assuming that p is uniformly distributed, we have f represents the hypergeometric function [ ] . substituting this into equation ( ) gives ( ) ( . estimating the generation size using a lower bound on the number of symptomatic individuals in the analysis in section . , it is assumed that every person who has developed symptoms by time τ is known to the observer. however, depending on the disease, symptoms can be subjective. one person may not notice something another person may visit hospital for. additionally, one person may not want to come forward with symptoms if they are worried about the repercussions of coming forward (for example being isolated against their own will). to address this, rather than considering i τ as the total number of people who have developed symptoms by time τ, we can consider i τ as the number of people who have presented with symptoms by time τ. we do no know the true value of i τ , but we know that it cannot be below i τ . we assume that the probability of i τ being i τ for a given value of i τ is uniform at i τ + , di e i dt ρ γ = − ( ) . dr i dt γ = ( ) this provides a force of infection that is used to model seeding within each care home via the sellke construction, with the details provided in the main text. once infection has been seeded within a care home, the epidemic progresses using the following ordinary differential equations handbook of mathematical functions with formulas, graphs, and mathematical tables pre-existence and emergence of drug resistance in a generalized model of intra-host viral dynamics stochastic epidemics in dynamic populations: quasi-stationarity and extinction the final size of an epidemic and its relation to the basic reproduction number stochastic and deterministic models for sis epidemics among a population partitioned into households seven challenges for metapopulation models of epidemics, including households models household epidemic models with varying infection response epidemics with two levels of mixing reproduction numbers for epidemic models with households and other social structures ii: comparisons and implications for vaccination stochastic epidemic models featuring contact tracing with delays coordinating the real-time use of global influenza activity data for better public health planning characterising pandemic severity and transmissibility from data collected during first few hundred studies the final size of a serious epidemic estimation in emerging epidemics: biases and remedies models overestimate ebola cases a bayesian mcmc approach to study transmission of influenza: application to household longitudinal data pandemics in the age of twitter: content analysis of tweets during the h n outbreak the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak. science care quality commission. cqc care directory -with ratings department of health and social care. spi-m modelling summary for pandemic influenza are patients with hypertension and diabetes mellitus at increased risk for covid- infection? sars incubation and quarantine times: when is an exposed individual known to be disease free? impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand quantifying sars-cov- transmission suggests epidemic control with digital contact tracing the spread of awareness and its impact on epidemic outbreaks estimating the generation interval for covid- based on symptom onset data. medrxiv reproductive numbers, epidemic spread and control in a community of households estimated effectiveness of symptom and risk screening to prevent the spread of covid- . elife clinical characteristics of coronavirus disease in china oxford covid- government response tracker (oxcgrt deterministic epidemic models with explicit household structure epidemic prediction and control in clustered populations coronavirus: gsk and sanofi join forces to create vaccine regression models for right truncated data with applications to aids incubation times and reporting lags modeling infectious diseases in humans and animals china braces for world's biggest travel rush around spring festival on the generalized ''birth-and-death" process containing papers of a mathematical and physical character scabies in residential care homes: modelling, inference and interventions for well-connected population sub-units the effect of human mobility and control measures on the covid- epidemic in china spatial and temporal dynamics of superspreading events in the - west africa ebola epidemic the incubation period of -ncov from publicly reported confirmed cases: estimation and application the epidemiologic toolbox: identifying, honing, and using the right tools for the job substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data the reproductive number of covid- is higher compared to sars coronavirus china coronavirus: what do we know so far? early in the epidemic: impact of preprints on global discourse about covid- transmissibility. the lancet global health estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship the largest human migration on the planet: what happens in china when . bn go on holiday at the same time social contacts and mixing patterns relevant to the spread of infectious diseases time variations in the generation time of an infectious disease: implications for sampling to appropriately quantify transmission potential world health organisation. coronavirus disease (covid- ). situation report - reproduction numbers for epidemic models with households and other social structures. i. definition and calculation of systematic selection between age and household structure for models aimed at emerging epidemic predictions epidemic growth rate and household reproduction number in communities of households, schools and workplaces challenges in control of covid- : short doubling time and long delay to effect of interventions. arxiv covid- and italy: what next? the lancet covid- : disproportionate impact on ethnic minority healthcare workers will be explored by government calculation of disease dynamics in a population of households the prevention of malaria public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey some model based considerations on observing generation times for communicable diseases on the asymptotic distribution of the size of a stochastic epidemic sir epidemics in a population of households modeling left-truncated and right-censored survival data with longitudinal covariates empirical estimation of a distribution function with truncated and doubly intervalcensored data and its application to aids studies early epidemiological analysis of the coronavirus disease outbreak based on crowdsourced data: a population-level observational study. the lancet digital health a note on generation times in epidemic models evaluating factors associated with std infection in a study with interval-censored event times and an unknown proportion of participants not at risk for disease reorganization of nurse scheduling reduces the risk of healthcare associated infections. medrxiv epidemic and intervention modelling: a scientific rationale for policy decisions? lessons from the influenza pandemic investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada comparison of incubation period distribution of human infections with mers-cov in south korea and saudi arabia can we contain the covid- outbreak with the same measures as for sars? estimating clinical severity of covid- from the transmission dynamics in wuhan, china characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention prevalence of comorbidities in the novel wuhan coronavirus (covid- ) infection: a systematic review and meta-analysis clinical course and risk factors for mortality of adult inpatients with covid- in wuhan author contributions co and hs compiled the manuscript. all authors were involved in the research and revising of the manuscript. the authors declare no competing interests. all data and code used in this analysis is provided in the github repository https://github.com/thomasallanh ouse/covid -stochastics and https://github.com/thomasallanhouse/covid -growth, with the exception of uk specific data. this data is provided by public health england under a data sharing agreement and we are unable to share this data. where c is a normalising constant such that we add further compartments to the within care home model since we are interested in the different pathways that these individuals may take. for the background epidemic this is not important, since all we need is a force of infection provided by individuals in the infectious class. . population and household transmission: individual isolation and household quarantine individual isolation does not intimately involve the household and so we assume that a fraction i α of symptomatic cases self-isolates and ceases transmission outside the household, meaning that we take the baseline but with to capture the essential features of household quarantine, we need to add states to the dynamical variables. let we now suppose that a fraction s in this model, we assume that the duration of isolation after the absence of symptoms is exponentially distributed with mean equal to the fixed isolation period, given by / σ . this assumption aids the modelling and is justifiable because, in reality, although a household may choose to isolate, they may not strictly follow the fixed period. it is likely that within-household isolation will increase transmission to other members of the household. we do not incorporate this property into the model, but this limitation is worth bearing in mind when drawing conclusions about the effectiveness of different strategies. key: cord- -de kyjup authors: chen, peng; zhang, ying; wen, yongsheng; guo, jinjun; jia, jinwei; ma, yu; xu, yi title: epidemiological and clinical characteristics of cases of covid- in main district of chongqing date: - - journal: j formos med assoc doi: . /j.jfma. . . sha: doc_id: cord_uid: de kyjup background: we did a comprehensive exploration of the epidemiological and clinical characteristics of patients with confirmed covid- in main district of chongqing which was adjacent to the west of hubei province. methods: this study was conducted on patients with covid- in main district of chongqing from jan to feb , . data of patients included demographic, epidemiological, clinical features, chest radiographs of imported cases, local cases, second-generation cases and third-generation cases. student's t-test was adopted for quantitative variables while pearson chi-squared test or fisher's exact test for categorical variables. results: the median age was years and common symptoms of illness were cough ( . %), fever ( . %) and fatigue ( . %). the time from contact symptomatic case to illness was . days, and patients ( . %) were cluster cases, radiological evidence found bilateral lung involvement was common ( . %).compared with the imported cases, the local cases were significantly older, the proportion of men is lower. there was higher proportion of cluster cases in local cases. unlike imported cases, which fever was the dominant symptom, the local cases have more cough patients, with a significant higher proportion of asymptomatic patients. the third-generation cases have a significant higher proportion of asymptomatic patients. conclusions: we concluded the epidemiological and clinical characteristics of the cases andsuggested to take more comprehensive measures for screening patients, especially for elderly person, avoid family gatherings, and implement more closely surveillance of suspect patients and their close contacts. this study was conducted in accordance with the declaration of helsinki. this case series was approved by the institutional ethics board of chongqing emergency medical center (no. ). this research was a retrospective and analyzed using anonymous clinical data. data were analyzed from patients of covid- who were transferred to the designated hospitals in main district of chongqing from jan to feb , .the definition of cases was as follows. the data of patients included demographic (age, gender), epidemiological (days from contact to illness onset, days from illness to admitted, clustering), clinical features (fever, cough, fatigue, dyspnoea, headache), chest radiographs for the patients. we described and compared epidemiological and clinical data between imported cases and local cases, secondgeneration cases and third-generation cases. two independent reviewers extract data and evaluate the eligibility of the original data was applied. all data were analyzed by another two researchers. a confirmed case was defined as a suspected case with the laboratory test for the covid- from the respiratory specimens show positive result by the real-time reversetranscription-polymerase-chain-reaction (rt-pcr) assay, while a suspected case was defined according to the diagnosis and treatment protocol for covid- . the imported cases were defined as cases those patients from wuhan or surrounding areas in hubei province before illness onset. the local cases were defined as cases those patients have not left chongqing, and the infection site belongs to main district chongqing. the second-generation cases were defined as the local cases those patients direct contacted with confirmed patients who from wuhan or surrounding areas before illness onset. the third-generation cases were defined as the local cases those patients direct contacted with confirmed patients who has not left chongqing before illness onset. the study included patients who were identified as a confirmed covid- infection in main district of chongqing. comparison of epidemiological and clinical characteristics between the imported cases and local cases were further conducted in admitted. there was higher proportion of cluster cases in imported cases ( / , . %), which was statistically significant with imported cases ( / , . %). in imported cases, cluster cases were most common in families ( / , . %). clinical data revealed that the most common symptoms of imported cases was fever ( . %), followed by cough ( . %). however, in local cases, the most common symptoms were cough ( . %), followed by fever ( . %). the proportion of patients with fever reached statistical significance between two cases, as patients in imported cases were more likely to fever. the incidence of asymptomatic sign was only . % in imported cases ( / patients), which was lower than that in local cases ( / , . %). while the incidence of bilateral lung involvement showed no significant difference between imported cases and local cases. comparison of epidemiological and clinical characteristics between the second-generation cases and third-generation were conducted in table . in all the local cases, patients were local second-generation cases, while patients were local third-generation cases. there were no significant difference regarding age, gender, days from contact to illness, days from illness to admit between secondgeneration cases and third-generation cases. the most common symptoms of illness were fever ( . %) in secondgeneration cases, which were cough ( . %) in thirdgeneration cases. the proportion of patients with fever reached statistical significance between two cases, as patients in second-generation cases were more likely to fever. the incidence of asymptomatic sign was . % in second-generation cases ( / patients), which was lower than that in third-generation cases ( / , . %). there was also no significant difference regarding the incidence of bilateral lung involvement between second-generation cases and third-generation cases. the covid- outbreak in china was the third outbreak caused by a coronavirus since the st century, and the number of infected people has exceeded the previous sars and mers. e with the strengthening of diagnosis, treatment, prevention and control of disease, patients diagnosed with covid- in wuhan and surrounding areas in hubei province have achieved good effects; however, how to prevent the spread of covid- in other regions was another important issue. although there have been a large number of researches on the epidemiology and clinical characteristics of the covid- , the researchers were mainly from wuhan, e and the local epidemiology of the covid- in imported cities was extremely scarce. the epidemiological and clinical characteristics of local cases and imported cases were still unclear, which hindered the assessment of the potential of the covid- to spread outside wuhan and made the epidemic prevention and control in imported cities more complicated. we conducted a statistical comparison of the epidemiological and clinical characteristics of imported cases and local cases in main district of chongqing, hoping to provide guidance in preventing local epidemics, and to provide a reference for the development of prevention and control measures in other provinces and regions. this research provided epidemiological and clinical characteristics of confirmed covid- patients in main district of chongqing. among the confirmed patients, the age was mainly concentrated in the age of e . there was no difference in the incidence between male and female. the clinical characteristics were still mainly cough, fever, and fatigue. the above characteristics were not significantly different from those in wuhan and hubei province. , , in patients, were imported cases ( . %) and were local cases ( . %). we found that with the spread of covid- in main district of chongqing, the number of confirmed local cases has exceeded the number of imported cases. compared with imported cases, local cases were characterized by older age, more females, cluster transmission, and family gathering cross-infection was more common. e the clinical symptoms of local cases are mainly cough rather than fever. the proportion of asymptomatic patients was higher. there are no differences in indicators such as incubation period, days from illness to admitted and bilateral lung injury. as per published article, the major symptoms of covid- infection remain same and mainly cough, fever and dyspnea. in mild to severe stage, patients have mild fever, dyspnea and mild hypoxemia on day of initial illness with bilateral infiltrating pneumonia in chest x-ray. this characteristic features coincided with the first confirmed covid- case in the china and u.s. as well. covid- can spread from human to human, , , , but there were no comparison of characteristics in different generation. we divided local patients into secondgeneration cases and third-generation cases according to the previous definition. we found that the third-generation cases had a lower rate of fever and a higher proportion of asymptomatic symptoms. we consider that it may be related to the more serial passage of covid- , the less pathogenic it became. , alternatively, some of the asymptomatic third-generation cases might be still in the pre-symptomatic stage because of their shorter follow-up time compared with the second-generation cases. further clinical follow-up and laboratory studies would be required to provide more data for answering this important questions. moreover, this phenomenon suggested that with the spread of covid- in main district of chongqing, the symptoms of patients before illness become more and more insidious, and clinical symptoms such as fever cannot be used as the exclusive early identification factor of the covid- . for suspected patients and their close contacts, surveillance is an important measure for local prevention. , as a municipality directly under the central government, chongqing was adjacent to the west of hubei province and km away from wuhan. it has a population of about million, of which the main district has a population of about . million. there were frequent personnel flow between chongqing and wuhan, and the situation of epidemic prevention and control was severe. by comparing imported cases with local cases, secondgeneration cases and third-generation cases, we can better detect the typical and evolutionary characteristics of the disease, and formulate effective and targeted measures. for example: take more comprehensive measures for screening patients, especially for elderly person, avoid family gatherings, and implement more closely surveillance of suspect patients and their close contacts. , e compared with the imported cases of the covid- infection, the local cases were significantly older; the proportion of men is lower. there was higher proportion of cluster cases in local cases. unlike imported cases, which fever was the dominant symptom, the local cases have more cough patients, with a significant higher proportion of asymptomatic patients. compared with second-generation cases, the third-generation cases have a higher proportion of patients with cough rather than fever. the third-generation cases have a significant higher proportion of asymptomatic patients. it implied illness may not be accompanied by any of the acute signs but may appear insidiously in thirdgeneration. in summary, the characteristics of imported and local cases of covid- in main district of chongqing were different. local cases were older and were mainly females. the family gathering cross-infection was more common in local cases. in addition, the cough was dominant symptoms than fever. with the increase generation in population spread and more concealed symptoms.as covid- spread from generation to generation, it implied illness may p. chen et al. not be accompanied by any of the acute signs but may appear insidiously. it was suggested to take more comprehensive measures for screening patients, especially for elderly person, avoid family gatherings, and implement more closely surveillance of suspect patients and their close contacts. it is hoped that characteristics of cases and prevention protocol in main district of chongqing could provide a reference for other provinces and regions. this research represented the characteristics of early cases of covid- in main district of chongqing, which has certain limitations. firstly, we only collected the data that were transferred to the designated hospitals in main district of chongqing. in order to obtain more accurate results, it was better to extend the collection of more patient data. secondly, the observation period of this research was only days, which was relatively short. the clinical laboratory examination results, cure rate, mortality and other indicators need further observation. none. the authors have no conflicts of interest relevant to this article. epidemiological and clinical characteristics of covid- in chongqing, china + model q . special expert group for control of the epidemic of novel coronavirus pneumonia of the chinese preventive medicine a epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province clinical features of patients infected with novel coronavirus in wuhan, china clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a rapid advice guideline for the diagnosis and treatment of novel coronavirus ( -ncov) infected pneumonia (standard version) the sars, mers and novel coronavirus (covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned? receptor recognition by novel coronavirus from wuhan: an analysis based on decade-long structural studies of sars sars to novel coronavirus -old lessons and new lessons novel coronavirus of pneumonia in wuhan, china: emerging attack and management strategies a familial cluster of pneumonia associated with the novel coronavirus indicating personto-person transmission: a study of a family cluster epidemiologic characteristics of early cases with novel coronavirus ( -ncov) disease in republic of korea first case of coronavirus disease (covid- ) pneumonia in taiwan importation and humanto-human transmission of a novel coronavirus in vietnam euro surveill : . bulletin europeen sur les maladies transmissibles z european communicable disease bulletin identification of the mechanisms causing reversion to virulence in an attenuated sars-cov for the design of a genetically stable vaccine a live, impaired-fidelity coronavirus vaccine protects in an aged, immunocompromised mouse model of lethal disease initial rapid and proactive response for the covid- outbreak-taiwan's experience putting resiliency of a health system to the test: covid- in taiwan early containment strategies and core measures for prevention and control of novel coronavirus pneumonia in china zhonghua yu fang yi xue za zhi efficient management of novel coronavirus pneumonia by efficient prevention and control in scientific manner the first case of novel coronavirus pneumonia imported into korea from wuhan, china: implication for infection prevention and control measures none. key: cord- -myiuhxdb authors: peña, laura; garcia, pilar; jiménez, ma. Ángeles; benito, alberto; alenza, ma. dolores pérez; sánchez, belén title: histopathological and immunohistochemical findings in lymphoid tissues of the endangered iberian lynx (lynx pardinus) date: - - journal: comp immunol microbiol infect dis doi: . /j.cimid. . . sha: doc_id: cord_uid: myiuhxdb the iberian lynx (lynx pardinus) is the most threatened wild feline in the world. little is known about the diseases and pathology that affect this animal. the aim of this study was to evaluate the histopathological status of the peripheral lymphoid tissues and thymus of iberian lynxes necropsied between and . seventeen animals including females (n= ) and males (n= ), age range of months to years, with different causes of death were histopathologically and immunohistochemically (anti-cd , cd , mac , cd ) studied. feline immunosuppressive virus laboratorial tests were negative. five individuals presented neoplasia and/or tuberculosis. all animals presented some degree of both b and t cells depletion in peripheral lymphoid tissues and follicular hyalinosis in the center of depleted follicles. a viral origin of the lymphoid depletion is postulated although other causes (inbreeding, stress, toxic) are not ruled out. the loss of the effectiveness of the immune system increases the vulnerability of the critically endangered iberian lynx to pathogens. the iberian lynx (lynx pardinus) is the most threatened wild feline in the world [ ] . it is considered 'critically endangered' [ ] and it is located only in two small isolated metapopulations in southern spain, the doñana area and sierra morena [ ] . the progressive disappearance of these animals in the past decades has been attributed to decreases in the populations of their main prey, the rabbit (oryctolagus cuniculus), due to myxomatosis, traps and hunting [ ] [ ] [ ] . nowadays, the iberian lynx is threatened by the fragmentation and loss of its habitat [ ] , estimating a total population under individuals [ ] . the conservation of this european large wild cat is of great concern to the european union authorities who are given large amounts of funds for its conservation. the causes of 'non-natural' mortality (prompted by human intervention) of the iberian lynx have been thoroughly studied during the past decades [ ] , but there are no references of mortality by diseases or necropsy findings. little is known about diseases and pathology that affect the iberian lynx; there are only a few publications about tuberculosis [ ] [ ] [ ] and parasites [ ] [ ] [ ] in the iberian lynx, and there are no previous reports concerning histopathological findings. the aim of this study was to evaluate the histopathological status of the peripheral lymphoid tissues and thymus of iberian lynxes necropsied between and in relation to other pathologies found in the animals. tissue samples fixed in neutral % formalin of multiple organs from iberian lynxes necropsied, found dead or that died in captivity between and , were sent for infectious agents in the dead animals was investigated from tissue samples or carcass fluids, whenever possible, by pcr or serology depending on the availability of the samples. the positive results and the corresponding method of detection are displayed on table . formalin tissue samples were paraffin embedded, cut in mm sections, deparaffined and h&e stained. a complete histopathological study was performed in each case. ziehl-neelsen technique for acid-fast bacilli and streptavidin-biotin-peroxidase complex anti-mycobacterium tuberculosis (mouse monoclonal primary antibody, reacts with other members of m. tuberculosis complex, i.e. mycobacterium bovis, novocastra ncl-mt, : , incubation overnight c; secondary antibody) were performed in the tuberculosis granulomas to locate the bacilli 'in situ'. the lymphoid tissues histologically evaluated included spleen, lymph nodes (at least three per animal; lymph nodes without granulomas were studied to establish cellular depletion in the cases with tuberculosis), malt (respiratory and intestinal mucosa-associated lymphoid tissue) and thymus (three samples of animals aged , months and years old). thymus involution was evaluated according to histological criteria published for the domestic cat [ ] . the severity of lymphoid depletion/animal (ld) was categorized in none, mild, moderate and severe considering two variables: (a) number and type of lymphoid tissues affected and (b) grade of lymphoid depletion/tissue: normal, mild, moderate and severe ( table ) . immunohistochemistry (streptavidin-biotin complex peroxidase method) was carried out on deparaffined sections after a high temperature antigen unmasking protocol (in a pressure cooker, sections were immersed in citrate buffer ph . and boiled for min). the primary antibodies used were: rabbit polyclonal antibody anti-cd , pan-t cell marker (dako a , dilution / , incubation overnight c); mouse monoclonal antibody anti-cd , mature b cells marker (clone hm , dako m , dilution / , incubation overnight c); mouse monoclonal antibody clone mac myeloid/histiocyte antigen (dako m , dilution / , incubation overnight c); and mouse monoclonal antibody anti-cd macrophage tissue depletion was categorized in: znone, zmild, zmoderate and zsevere. a grade of lymphoid depletion/animal was based mainly on the splenic depletion. b ln, lymph nodes; the median of the tissue depletion scores of the three lymph nodes studied (a, b, c) was considered. c malt(r), respiratory mucosa-associated lymphoid tissues; malt(i), intestinal mucosa-associated lymphoid tissues; when depletion was different in both tissues, the less altered one was chosen for the total scoring. lymph nodes and malt tissues were considered only if regional pathologies were ruled out. (clone pg-m ) (dako m , dilution / , incubation overnight c). m. tuberculosis, cd , mac and cd sections were subsequently incubated with anti-mouse biotinylated secondary antibody (dako e , dilution : , min at room temperature). cd sections were subsequently incubated with with anti-rabbit biotinylated secondary antibody (vector laboratories ba , : , min at room temperature). next, all the slides were incubated with streptavidin conjugated with peroxidase (zymed p , : , min, at room temperature). all washes and dilutions were made with tris-buffered-saline (tbs) (ph . ). the slides were developed with a chromogen solution containing - diaminobenzidine tetrachloride (sigma chemical co. d ) and h o in distilled water and counterstained in hematoxylin (sigma gh - - ). negative control slides were used by substituting the primary antibody by tbs. evaluation of the leucocyte populations labeled with each antibody was made by two observers simultaneously and scored as increased, normal, mild decreased, moderately decreased and severely decreased. for immunohistochemical validation of the antibodies to the iberian lynx tissues, healthy domestic cat tissues, with known reactivity for the antibodies employed, were used as positive controls. the grade of lymphoid depletion/tissue (normal, mild, moderate and severe) and the severity of lymphoid depletion/animal (ld) (none, mild, moderate and severe) on h&e slides are depicted in tables and . the spleen was the lymphoid organ in which the cellular depletion (number of follicles and cellular density) was more evident and frequent (table ) . it was not possible to carry out the histological evaluation due to autolysis in two cases. one case did not show immune depletion with h&e and the rest of the animals studied presented some degree of lymphoid depletion ( mild, moderate and severe). the grade of ld per animal did not depend on the origin of the animal, whether it was free or captive, or the cause of death, and it increased with age: mild ld was found mainly in young or young-adult animals while moderate and severe ld was more frequent in aged animals. ld was also severe in two iberian lynxes suffering tuberculosis (cases and ). hyaline substance deposition was commonly observed in lymphoid follicles with evident lymphoid depletion (fig. ) . besides traumatic lesions, the most interesting histopathological findings were pneumonia, epithelial neoplasms and tuberculosis (table ) . five individuals (cases , , , and ) presented neoplasia (squamous cell carcinoma of the skin and urinary bladder 'in situ' carcinoma) and/or tuberculosis (m. bovis, pcr). in one of the cases with tuberculosis (case ), the granulomas were only found in the lung (tuberculous primary complex); in another case with disseminated tuberculosis (case ) the main tuberculosis lesions were found in liver and lymph nodes, although small granulomas were also observed in the lung; another animal with a history of blindness (since months of age) with generalized tuberculosis (case ), granulomas of tuberculosis were found in lung, liver, lymph nodes, both adrenal glands, and in both ocular globes (bilateral tuberculos granulomatous uveitis). in all granulomas acid-fast bacilli were histologically identified by the ziehl-neelsen technique and immunohistochemistry. multinucleated cells ( - nuclei) were observed in the granulomas. no evidence of feline immunosuppressive virus infection (feline immunodeficiency virus, feline leukaemia virus, feline coronavirus and feline panleukopenia virus) was found in any of the individuals. cd , cd , mac and cd immunohistochemistry is represented in fig. . cd immunostaining was seen labeling cells in t areas (periarteriolar lymphoid sheets and marginal zones in splenic white pulp and parafollicular areas in lymph nodes and malt) (fig. ) ; cd positive cells were found in b areas (lymphoid follicles) ( fig. a and b) . mac stained large macrophages mainly located in splenic red pulp, medular lymph node and malt (fig. c) ; cd labeled scarce macrophages, dendritic cells and follicular dendritic cells (fig. d) . the spleen was the organ with less immunostaining of the cellular subpopulations analyzed. comparing the results among the leukocyte subpopulations studied (fig. ) , t cells (cd -positive cells) were seriously decreased in most of the tissues analyzed, being the spleen the tissue with the most striking reduction; b cells were decreased in many cases in the spleen and lymph nodes but normal or increased in malt; in many animals, coexisting reductions in both b (cd ) and t (cd ) cell subpopulations was observed in the spleen ( / , . %) and lymph nodes ( / , . %). levels of macrophages and dendritic cells (positive cells to mac and cd , respectively) were normal in malt samples; mac -positive cells were mildly reduced in some lymph nodes ( / , . % of the cases); splenic mac and cd positive subpopulations were normal (mac / , . %; cd / , . %) or increased (mac / , . %; cd / , . %). histologically, the -year-old iberian lynx thymus sample was involutioned with abundant interlobular adipose tissue and low cellularity of lymphoid tissue, therefore, it was not included in the immunohistochemical study. the other two samples of thymus (from iberian lynxes aged and months) were mildly involutioned with defined thymic lobules and medium cellularity. in these two cases, there were mild and severe reductions of cd positive subpopulations. this is a descriptive study in which reductions of immune cells were found by histopathology (h&e) and immunohistochemistry in peripheral lymphoid tissues of iberian lynxes. this is a very representative population considering that the total estimated population of this species left is of animals. the leukocyte subpopulations detected by immunohistochemical methods was restricted to t lymphocytes, b lymphocytes and macrophages, since all the samples available for the study were formalin-fixed and paraffin embedded. antibodies anti-human cd , human mac , human cd and human cd (clone pg-m , clone ebm ) have been tested in formalin-fixed tissues of domestic species, including the domestic cat [ ] [ ] [ ] [ ] . according to our results, the antibodies used also show cross-reaction with lynx tissues. to our knowledge, this is the first report of immune detection of leukocyte subpopulations in wild felids. in most animals, the lymphoid depletion observed with h&e had parallel decreases in cd and cd positive cells which indicate a partial combined immunodeficiency affecting t and b cells subpopulations. spleen was the lymphoid organ with more evident hypocellularity and decreases of cd and cd populations (t and b lymphocytes). b cells were decreased in many cases in the spleen and lymph nodes but normal or increased in malt. minor reduction in t and b subpopulations, together with increases of macrophages (mac and cd positive-cells) in lymph nodes and malt samples could have been influenced by local pathologies (i.e. intestinal parasitic infestations in mesenteric lymph nodes and intestinal malt). the increased number of macrophages and dendritic cells (mac and cd positive cells) found in the splenic red pulp and lymph node medulla of tissues with t and b cell reductions indicates a proliferation of these cell types that remains unexplained although it could represent a compensating situation. t and b cell depletion and increase macrophage proliferation has been indicated in lymphoid tissues of domestic cats with experimental feline infectious peritonitis (feline coronavirus) [ ] . follicular hyalinosis in the center of depleted follicles is a common histopathological finding in domestic cats with panleukopenia (feline parvovirus, fpv) [ ] . in our opinion, the histopathology and immunohistochemistry of the three samples of thymus analyzed in this study are not representative. to evaluate properly the cellularity of the thymus, it is necessary to know the normal thymic involution in the lynx, and there are no studies on this species. in our cases, times and histological characteristics of thymic involution had to be compared with data published in the domestic cat [ ] . nevertheless, the two animals with similar ages ( and months) were both categorized as mild involution but one showed mild and the other severe t-cell reduction indicating that, at least in the latter case, it was a true depletion of t-lymphocytes and not a normal thymic involution. iberian lynxes included in the study presented generalized immune depletion, which coexisted with high prevalence of neoplasms and tuberculosis (m. bovis). it is known that devastating diseases (late generalization of tuberculosis) and metastasic tumors can cause depression of the immune system [ ] . in our opinion, the presentation of these neoplastic and infectious diseases were promoted by the defects in the immune system although the alternative hypothesis is equally valid. the coexistence in the same animal of pulmonary tuberculosis and squamous cells carcinoma of the skin and, in another case, the coexistence of two different epithelial carcinomas (skin and urinary transitional epithelium), could be coincidental, but also could be the result of a immunodeficiency status. to our knowledge this is the first report of any kind of tumor in the iberian lynx. there are several publications describing tuberculosis in the iberian lynx [ ] [ ] [ ] . in two of our three cases, the primary pulmonary lesions indicate that the contamination was probably by inhalation from contaminated food as it has been indicated in a previous case of tuberculosis in the iberian lynx and in other wild felids [ , ] . in the remaining case, the distribution and size of the lesions do not confirm an inhalation route of contamination and suggest a digestive origin of the tuberculosis. multinucleated cells ( - nuclei) observed in the granulomas did not display the typical aspect of langhans' cells as in other species infected with m. bovis [ ] . the presence of multinucleated cells in tuberculosis of iberian lynx have not been previously indicated. it is interesting to note that one animal with disseminated tuberculosis (case ) presented granulomas in both adrenal glands and in both ocular globes. in the previous report about the pathology of one iberian lynx with tuberculosis [ ] , both adrenal glands were also affected. this fact could indicate a special predisposition of these animals to have adrenal tuberculosis, since adrenal glands are not a common site for tuberculosis lesions in other animal species [ ] . ocular tuberculosis is an uncommon but documented finding in the domestic cat [ ] that has never been referred to in wild felids and could be also a consequence of an immune deficiency status. in our case, the early appearance of blindness ( -month-old) seems to indicate an ocular primoinfection rather than a dissemination, possibly due to contact with contaminated food. nevertheless, the high prevalence of tuberculosis in our series of cases can be also influenced by the high prevalence of the disease in wild and domestic ungulates living in the same areas [ ] . by far, the information available does not allow to establish the most likely cause of the immune depletion. all the animals were negative to feline immunosuppressive viruses (felv, fiv, fcov, fpv) using conventional techniques for the domestic cat, which do not exclude the possibility of infection with lynx-specific viral strains or unknown viruses. in fact, the histopathological findings of the present study are coincident with those found in cats infected with immunosupppressive viruses, specially in non-acute diseases or carrier stages [ , ] . stress should also be taken into account as a possible origin of the immune depletion but only in the captive animals (nz ). finally, there are several reasons to consider a primary immune system defect due to the inbreeding of the iberian lynx. evidences for reduced genetic variability in the iberian lynx, due to the low number of individuals separated in two small subpopulations, have been recently published [ ] . the results of our study indicate that all animals presented some degree of immune depletion, affecting both b and t cells, which could only be explained in a few cases by old age and/or concomitant diseases (tuberculosis, tumors). prospective investigations are necessary to assess the clinical immune system parameters (serum concentrations of iga, igg, igm; in vitro lymphocyte blastogenesis with mitogens; flow cytometric quantification of blood subpopulations of leukocytes) in appropriate samples of living iberian lynxes to know (a) if the histological cellular depletion found in this series of cases is present in the left population of iberian lynxes; (b) if there are important clinical consequences and (c) the possible existence of a viral infection non-detected by conventional laboratorial techniques. the free status of the animals and therefore delicate management of this species makes it difficult to carry out such studies; in any case, sampling of living animals requires capture and anesthesia. our preliminary results of an ongoing prospective study indicate the presence of leukopenia and lymphopenia in some of the animals. the reduction of the effectiveness of the immune system could increase the state of vulnerability in the critically endangered iberian lynx to pathogens. according to our results, the iberian lynx could be in serious risk of extinction not only due to known causes (habitat destruction, road accidents, traps.) but also to its immune vulnerability. wild cats: status survey and conservation action plan updated iucn red list of threatened species iberian lynx (lynx pardinus) distribution and current conservation status in spain survival of injured iberian lynx (lynx pardinus) and non-natural mortality in centralsouthern spain the iberian lynx (lynx pardina) in spain: distribution and conservation problems internal structure and patterns of contraction in the geographic range of the iberian lynx phylogenetic and phylogeographic analysis of iberian lynx populations patterns and causes of non-natural mortality in the iberian lynx during a -year period of range contraction bovine tuberculosis and the endangered iberian lynx tuberculosis in an iberian lynx (lynx pardina) bovine tuberculosis (mycobacterium bovis) in wildlife in spain gastrointestinal parasites of the iberian lynx and other wild carnivores from central spain helminth fauna of the iberian lynx, lynx pardinus epidemiology of ancylostoma spp. in the endangered iberian lynx (lynx pardinus) in the donana national park, south-west spain a comparison of lymphatic tissues from cats with spontaneous feline infectious peritonitis (fip), cats with fip virus infection but no fip, and cats with no infection distribution of anti-cd (ebm ) immunoreactivity in formalin-fixed, paraffin-embedded bovine tissues characterization of immunocompetent cells in the diseased canine periodontium characterization of immune cell populations in oral mucosal tissue of healthy adult cats pathology of domestic animals tuberculosis in buffaloes (syncerus caffer) in the kruger national park: spread of the disease to other species retinal detachment and bovine tuberculosis in cats the cat diseases and clinical management we thank celia sánchez, margarita galka and pilar fernández for submitting the samples and doñana national park authorities for making this work possible. we also thank our colleagues astrid vargas, fernando martínez and javier millán for the ongoing study. we are grateful to pedro aranda and mario hernando for their technical assistance. this work was supported by the spanish ministry of enviroment, research project / . key: cord- -ad tct b authors: pinotti, francesco; di domenico, laura; ortega, ernesto; mancastroppa, marco; pullano, giulia; valdano, eugenio; boelle, pierre-yves; poletto, chiara; colizza, vittoria title: lessons learnt from covid- international cases: importations over time, effect of interventions, underdetection of imported cases date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ad tct b cases have been confirmed out of china from january to february , . we collected and synthesized all available information on these cases from official sources and media. we analyzed importations that were successfully isolated and those leading to onward transmission. we modeled their number over time, in relation to the origin of travel (hubei province, other chinese provinces, other countries) and interventions. we characterized importations timeline to assess the rapidity of isolation, and epidemiologically linked clusters to estimate the rate of detection. we found a rapid exponential growth of importations from hubei, combined with a slower growth from the other areas. we predicted a rebound of importations from south east asia in the upcoming weeks. time from travel to detection has considerably decreased since the first importation, however cases out of were estimated to go undetected. countries outside china should be prepared for the possible emergence of several undetected clusters of chains of local transmissions. twenty-six countries worldwide have declared cases of the novel coronavirus, covid- , as of february , . only china so far registered a widespread epidemic , and authorities have implemented massive intervention measures to curtail it . outside china, affected countries are facing importations of cases and clusters of local transmission , , border controls have been reinforced in many countries, and active surveillance has been intensified to rapidly detect and isolate importations, trace contacts and isolate suspect cases , . the effectiveness of such measures, however, critically depends on covid- epidemiology and natural history , , as well as the volume of importations . the presence of an incubation period, during which infected individuals carry on their usual activities (including travel), is a major challenge for screening controls at airports . moreover, mild non-specific symptoms and transmission before the onset of clinical symptoms , may compromise infection control measures for importations and onward transmissions . there is concern that imported cases may have gone undetected and contribute unknowingly to the global spread of the disease - . here we systematically collected and analyzed data on covid- confirmed cases outside china. we analyzed importations that were successfully isolated and those leading to onward transmission, characterizing their case timeline. we developed a statistical model to nowcast trends in importations and quantify the proportion of undetected imported cases. we collected all international cases confirmed by official public health sources in the period from january to february , . case history was reconstructed by searching the scientific literature, official public health sources, and news. case history included: dates of travel and symptoms onset, date of covid- confirmation, date of hospital admission, date of case isolation, travel history, epidemiological link with other cases, hospitalization history. international cases included imported cases, secondary cases out of china, and repatriations. cases from cruises were not considered here. information was extracted by ldd and eo and checked by mm. the full database, along with the database describing clusters, were made publicly available . for imported cases with full information on the timeline of events, we computed the average duration from travel to onset, from travel to hospitalization, and from hospitalization to reporting. we used analysis of variance to compare groups of imported cases that generated or did not generate local transmissions. we extended the analysis to all imported cases combining cases with full and partial information on the timeline. we used the analysis of variance and multiple imputation for the missing data. results were combined using rubin's approach . we modeled the total number of imported cases out of china over time accounting for date of travel, delay in reporting, and source areas. we distinguished between three different sources: hubei province (h), the rest of china (c), other countries (o). we modeled imported cases over time as a piecewise exponential function depending on the source and on travel restrictions in place. we assumed a different situation in hubei province and the rest of the world due to the level of awareness in the different phases of the outbreak. the exponential functions are defined as follows: where @ '() is the growth rate of cases coming from hubei, and a '() , = '() , with a '() = = , the growth rates of cases coming from the rest of china and other countries, respectively. travel restrictions were modelled by assuming a discontinuity in the growth rate. for hubei, we assumed the growth rate to change from @ '() to @ ' $ after the travel ban of january , (indicated with @ ); for the rest of china, we assumed an analogous change from a '() to a ' $ after january , ( a ), date of first flight cancellations . no change was considered for the other countries ( = constant over time), as no restrictions of travel were established towards these countries. the scale parameters of the exponential functions ( @ '() , @ ' $ , a '() , a ' $ , = ) were assumed to be different among the three sources, to account for different traveling volumes and dates of beginning of importations. we modelled the time from importation to detection of a case with a gamma distribution, $ ( ), conditioned to the date of case importation, . $ ( ) was assumed to have constant coefficient of variation (sd/mean) achieved by a constant shape parameter and a rate parameter varying smoothly in time to capture change in surveillance efficiency. we used a bayesian framework to fit the model to imported cases by origin, travel date, and confirmation date. cases with partial information (e.g. missing date and/or origin of travel) were included by defining latent variables marginalized out during inference. the model was then used to nowcast imported cases two weeks in the future. all details of the analysis are reported in the appendix. we analyzed clusters of transmission generated by imported cases (index case(s) in each cluster) to estimate undetected importations. a cluster can be seeded by more than one index case when local transmissions are epidemiologically linked to more cases traveling together (e.g. infected family members traveling together). we modelled the number of such 'cluster seeds', i.e. groups of index cases, with a multinomial distribution depending on the portion of cluster seeds of size or greater than (for simplicity, this was taken as ), on the probability of detection of a seed, and on occurrence of secondary transmission. the likelihood function was a function of: the number g of observed clusters with one index case; the number h of observed clusters with more than index cases; the number j of detected index cases not leading to onward transmission; the number of clusters whose index cases have not been identified; and the number of undetected imported cases that did not generate any cluster. can be estimated through likelihood maximization from the records of g , h , j, . we collected cases, including imported cases, local transmissions, repatriations, and case of unknown origin. fifteen cases were classified as both imported and local transmissions, since they contracted the infection outside china and traveled to a different country once infected (es , es , gb , gb , gb , gb , gb , gb , kr , kr , kr , kr , my , th , th in our database ). figure summarizes the timeline of imported cases. symptoms onset occurred after the travel to the destination country for almost all cases for which date of travel and of onset are available ( out of , %). complete information was available for ( %) imported cases, with quality of information decreasing over time ( figure s of the appendix). . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . among imported cases with full information, the delay from travel to hospitalization was longer in cases that generated secondary transmissions (mean of ± . days compared to . ± . days, p= . ). overall, the duration from travel to first event (whether symptom onset, or hospitalization for asymptomatic) was also longer, although the difference was not statistically significant ( . ± . days vs. . ± . days p= . ). durations of hospitalization were instead comparable among the two groups of cases ( . ± . days vs. . ± . days for cases that generated or did not generate secondary transmissions, respectively). including imported cases with missing information through imputation, we found the same trend though smaller in magnitude and not statistically significant (delay from travel to hospitalization . ± . vs. . ± . days p= . ; delay from travel to onset . ± . vs. . ± . p= . , for cases that generated or did not generate secondary transmissions, respectively). this suggests that importations with missing information may be closer in characteristics to index cases leading to onward transmission. the statistical model predicted a decrease in the average time from travel to detection from . ± . days on january , to ± . days on february , ( figure ). the model predicted a rapid exponential growth of importations from hubei, with a growth rate the predicted trend of all imported cases over time is shown in figure , compared with the observed data. reported importations are predicted to remain stationary in the second and third week of february and to rise again due to the effect of transmission clusters outside china. imported cases after february , are in agreement with model predictions (fig. ) . forty-two transmission clusters were identified out of china in the timeframe under study. table summarizes the size and country of each cluster. clusters were grouped according to whether the index case: (i) was a traveling case identified prior to cluster detection; (ii) a traveling case not identified or identified retrospectively once the cluster was observed; (iii) completely unknown. assuming that clusters of unknown origin were linked to one of the already observed imported casesor, in other words, not linked to an undetected imported case -led to an estimate of [ , ] undetected imported cases. in this scenario, detected cases would amount to % of all imported cases. assuming instead that all clusters of unknown origin were due to undetected imported cases . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . increased the number of undetected cases to [ , ], i.e. detected cases would correspond to only % of the total. ( ), cjp ( ), cjp ( ), csg ( ), csg ( ), csg ( ), csg ( ), csg ( ), csg ( ), csg ( ), cth ( ), cth ( ), cth ( ), cae (****) § cluster associated to two traveling cases *the index case was identified independently from secondary transmissions **the index case was either: identified retrospectively following case investigation prompted by the detection of secondary cases - the identity was not identified; however, the cluster was linked to a specific location/circumstance visited by chinese travellers (shop, conference, bus tour) ***no connection with other case or source of infection has been identified yet ****insufficient information as the covid- epidemic in china shows effects of mitigation , increasingly larger clusters of infections reported outside china are raising concern that other territories may start sustaining the outbreak , . to contain it globally, identification, rapid management of cases, and contact tracing are key. the success of these response measures depends critically on the volume of importations and the sensitivity of active surveillance , . we reviewed here all confirmed cases out of china from january to february , and gathered detailed information on case history and epidemiological links. we identified salient epidemiological features, and modeled the number of importations over time. international exportations from hubei grew rapidly, fueled by the local epidemic, up to the closure of wuhan airport preventing further travel of cases. exportations from other chinese provinces and other countries grew at a considerably slower pace. this is related to the difference in the increase of cases between hubei province, origin of the outbreak, and the rest of the affected areas . such difference is likely an outcome of the implementation of containment measures in china , , , and of the increased awareness at different phases of the outbreak - (i.e. before and after containment measures) leading to self-isolation and quarantine. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the reduced volume of exported cases worldwide following the travel ban may have given countries the time to prepare and strengthen their surveillance systems, as signaled by a reduction of the interval from travel date to detection over time. our model predicts that exportations will likely rise from areas outside china. the number of local transmissions is rapidly increasing in the republic of korea, japan, and singapore , and few importations in asia and europe were registered already from travelers from japan and singapore. for this reason, certain countries have updated the history of travel for the case definition of a suspect imported case to include additional countries in south asia besides china or banned travelers from east asian countries . ecdc and who currently base their case definition on travel from china only , , but this may rapidly change in the next days. before the likely rebound of exportations, identification and isolation of possible clusters outside china remain essential to contain local transmission. the increasing reporting of clusters outside china with no known epidemiological link , raises important concerns on the possibility to contain covid- epidemic worldwide. our estimates indicate an ability of % to detect imported cases in countries outside china. this means that approximately imported cases out of have gone undetected. previous estimates range from % to % , detection rates, with variations across countries , . ascertainment was estimated to be even lower (approximately %) when assessed on repatriations . here, we excluded from this analysis all repatriation events and cruises with outbreaks, as conditions for detection and identification may be different. underdetection may be due to several different factors including asymptomatic infections, infections with mild clinical symptoms, health-seeking behavior and declaration of travel history, case definition, and underdiagnosis. underdetection of imported cases is likely to be higher than what we estimate here, as our analysis is conditional to the identification of clusters of cases. the current situation in italy, with different clusters emerging in the timeframe of few hours in different areas in the north of the country , shows that clusters have gone undetected and epidemiological links with the index case are still missing. countries outside china should be prepared for the possible emergence of several undetected clusters of chains of local transmissions. surveillance efforts to track all suspect cases may become impractical if the number of cases increases too rapidly . if that situation occurs, countries should be ready to step-up their response and take preparatory steps for community interventions. mrc centre for global infectious disease analysis. report : relative sensitivity of international surveillance. https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/news-wuhan-coronavirus/. . salute, m. della. covid- -situazione in italia e nel mondo. http://www.salute.gov.it/portale/nuovocoronavirus/dettagliocontenutinuovocoronavirus.jsp?lingua =italiano&id= &area=nuovocoronavirus&menu=vuoto. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint . the times of israel. israel bans foreigners coming from east asian countries over virus fears. https://www.timesofisrael.com/israel-bans-foreigners-coming-from-east-asian-countries-over-virusfears/. case definition and european surveillance for human infection with novel coronavirus (sars-cov- ). european centre for disease prevention and control https://www.ecdc.europa.eu/en/casedefinition-and-european-surveillance-human-infection-novel-coronavirus- -ncov. world health organization (who). global surveillance for human infection with coronavirus disease (covid- ). https://www.who.int/publications-detail/global-surveillance-for-humaninfection-with-novel-coronavirus-( -ncov). nishiura . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . dataset: the individual data consists of t-uples ( , , ), where: • indicates place of departure as hubei province ( ), china other than hubei ( ), outside china ( ); • ∈ { , … , } is the day the case arrived at destination, counted from january th up to current date ; • ∈ { , … , } is the day the case was confirmed, counted from january th . modelling the detection delay: the difference = − corresponds to the time from arrival to confirmation. to account for changes in detection efficiency, we modelled as a (discretized) gamma distribution with parameters changing with time. more precisely, the rate parameter of the distribution was x = * zx . the shape parameter was constant, leading to a constant coefficient of variation we truncated the distribution at ^= days and computed probabilities that was τ days as : where is a normalization constant accounting for the truncation at ^. we denote the corresponding cumulative distribution function of d by x ( ) = ( ≤ + . | x , ). modelling cases arrival: we computed " = n ",$ o $pg,…,q the daily number of cases arriving from location on date t that had been detected before time t, and " = ∑ ",$ $ the total number of such cases arriving from location . due to the time lag between arrival and confirmation, some cases arriving on time t from location s can be undetected as of time t. we denote ",$ the number of such cases. then, the total count of cases arriving on day t is given by ",$ + ",$ . we assumed a poisson distribution for this count, ",$ + ",$~ ( ",$ ), where ",$ represents the expected number of imported cases from location on day . we modelled ",$ as a piecewise exponential function in each location of origin s, the exponential growth parameter changing in hubei after the ban instated on january rd and in the rest of china after flight cancellation by major airline companies on january th . ",$ was therefore: . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . outside china we assumed a single exponential function with the same growth rate as in china outside hubei before travel restrictions were put in place ( = = a '() ) and a different scale : =,$ = = * ( > $ confirmed cases had no information on date of arrival and/or origin of travel. these cases were described with latent variables as follows: , the time series that accounts for case counts with unknown date of arrival; • " = n ",$ o $pg,…,q , i.e. case counts with unknown travel origin; , i.e. cases with both information missing. the framework described above was extended to account for these cases, i.e. we considered ",$ + ",$ (z) + ",$ + ",$ + ",$ (z)~ ( ",$ ) to be the number of cases arriving from destination s on time t. likelihood function: the components of the estimated parameters θ and prior distributions are listed in table s . the likelihood of the observations is given by: ( ) = ( | , , , ) ( , , | ) ( ) . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . confirmed on day , e.g. the average value as well as upper and lower quantiles, using poisson distribution with mean ( ) = ∑ " ( ) "p@,a,= . dataset: we define as seed an imported case or a group of cases that could have started a cluster of local transmission outside china. we computed the number g of transmission clusters where a seed of size was among the cases identified in the cluster and likewise h with seeds of size > . we also computed the number j of imported cases that did not start a transmission cluster and the number of clusters for which a seed was not observed among the tested cases, i.e. clusters without a direct link to an imported case. modeling index case detection: we assumed that seeds could be of size with probability or of size with probability − . a seed could be observed with probability and started a cluster with probability . the number j of imported cases that did not start a cluster consist of y and y seeds of size and such that y + y = j and y + y = ; however the grouping of these cases is unknown. we computed y out of j using a plug-in estimate where the mean of the fraction y /y was /( − ), i.e. denote the number of seeds of any size that went undetected and did not give start to a cluster, with probability: ( − )( − ). is latent and estimated together with , and . likelihood function: the likelihood is based on a multinomial distribution for g , h , , and : ). we then find: by replacing » and » in the previous equation we find that the maximum likelihood estimator for is given by: . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint confidence intervals are computed using profile likelihood methods. finally, we estimate the number of unobserved cases that did not give start to a cluster as ¼( − º ). the confidence interval on this last quantity is computed by multiplying the confidence intervals of both factors. we analyze in figure s the proportion of traveling cases for which we have complete information regarding the timeline of events. detailed information of the clusters of transmission is reported in table s . figure s . fraction of imported cases for which we have a complete information on the timeline of importation. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint we provide in table s all parameter estimates and their confidence intervals. the convergence of the mcmc and the posterior distribution of key parameters are shown in figure s . . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure s . convergence of mcmc fitting procedure. on the left we show the evolution of each chain for every individual parameter. on the right we plot the corresponding posterior distribution (shaded histogram) as well as the posterior distribution (black line). . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint on / / all trains, flights and public transports connecting wuhan with the outside were suspended. we accounted for the possibility that this ban was initially not completely effective, e.g. people at the point of departing were still able to get out of the area with private transports. we consider a sensitivity scenario in which the effects of the travel ban in wuhan took place on the / / , one day later. we found that growth rates changed slightly with respect to the baseline case; in particular: @ '() = . here we report maximum likelihood estimates of parameters in the analysis of imported clusters. we estimate the number of unobserved cases that did not give start to a cluster as ¼( − º . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint coronavirus disease (covid- ) situation reports - quantifying bias of covid- prevalence and severity estimates in wuhan, china that depend on reported cases in international travelers multiple imputation for nonresponse in surveys airlines around the world are suspending flights to china as the coronavirus spreads feasibility of controlling -ncov outbreaks by isolation of cases and contacts the effect of travel restrictions on the spread of the novel coronavirus ( -ncov) outbreak. medrxiv assessing spread risk of wuhan novel coronavirus within and beyond china early epidemiological analysis of the -ncov outbreak based on a crowdsourced data risk of mers importation and onward transmission: a systematic review and analysis of cases reported to who public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey survey on the likely behavioural changes of the general public in four european countries during the / pandemic. in modeling the interplay between human behavior and the spread of infectious diseases ebola outbreak: media events track changes in observed reproductive number this study is partially funded by: the anr project dataredux (anr- -ce - - ); the eu grant mood (h - ); the municipality of paris through the programme emergence(s). we thank reacting (https://reacting.inserm.fr/) for useful discussions. where:-( , , | ) is the term describing observed incidence according to the model as:( , , | ) = • • b ",$ , ",$ (z) , ",$ , ",$ (z) , ",$ Ž j q $pg "p@,a,=where ",$ is the expected incidence in location s at day t described above;-( | ) is the term describing observed and unobserved duration between arrival and detection:where ds,t,i are the individual times to detection of those travelling from location s on day t,-( ) is the prior model for all parametersfor ease of computation, the likelihood is marginalized over latent variables " , " (z) and " the final likelihood is: here we have defined for convenience the following variables: $ = ∑ ",$ and introduced " the number of cases travelling from source and with unknown date of arrival, $ is the number of cases that arrived on day from an unknown source, and ' is the number of cases with unknown travel source and date of arrival.inference was performed by mcmc sampling using stan. we used chains with iterations and discarded the first % as burn-in.we computed the median of the posterior distributions as well as credible intervals for each parameter in θ. additionally, we computed predictive distribution statistics about the number of cases key: cord- -xi zy ow authors: allam, zaheer title: the third days: a detailed chronological timeline and extensive review of literature documenting the covid- pandemic from day to day date: - - journal: surveying the covid- pandemic and its implications doi: . /b - - - - . - sha: doc_id: cord_uid: xi zy ow this chapter surveys the global unfolding of events during the third days of the covid- pandemic that originated from china. the third days of the unfolding of the events showcased how city-wide lockdowns were started to be considered globally, the moving of the epicenter from china to europe, and major industries being impacted worldwide. to document this, an extensive review of the literature provides a daily overview of the situation covering health, economic, political, and social perspectives and outlines key events during the unfolding of the pandemic. this chapter surveys, and establishes a chronological timeline of the outbreak from day to day , covering issues appertaining to health policy and dwells into socioeconomic measures and impacts during the unfolding of the pandemic. the past days of the covid- pandemic had been eventful, as the reality of the disease was clear globally, where no single continent had been spared. the next days (day to day ) were marked with major milestones, challenging and most trying in different spheres of life as is demonstrated in succeeding sections. to start with, during this period, the number of confirmed cases increased from slightly above , to a high of million and counting (spotlight, ) , with the number of casualties increasing from deaths to over , deaths across the globe by the end of the days. in addition, the number of affected countries increased from countries to countries and territories (worldometer, ) . another change that was witnessed within the third days is the shifting of the covid- pandemic epicenter from europe to the united states, where the numbers of confirmed cases in the country, beingdby that timedmore than a quarter of the confirmed cases in the rest of the world (kirby and stewart, ). as the impacts of the coronavirus continued to be felt, there was evidence of an economic downturn in different countries, including in developed economies, where the number of people filing for unemployment claims increased. due to the economic hardships, it became apparent that many countries were trying to ease the lockdown restrictions to allow for reopening of economies, but in a gradual and cautious manner to avoid the reemergence of cases. it is within these days that governments were seen to propose economic stimulus packages to bail out their citizens and economies, including companies that were already struggling due to reduced activities. at the same time, due to the economic and social strives, there was evidence of political tension between countries as they trade blame on responsibilities toward containing the coronavirus before it spread, and become global pandemic (business davidson, a; smith, ) . during these days, it also became clear that the world was a long way before a vaccine could be developed and thus, the demand for personal protective equipment (ppes) would continue, and we see countries and regions formulating policies to control the exportation of ppes and medical supplies to other countries. with the increasing scarcity of ppes and other basic, medical essentials, these were seen to rely on the world health organization (who) and well-wishers for the supplies. within these days, there is also evidence of there was no safe-haven against coronavirus, as even those in cruise ships and aircraft carriers were infected and with cases in such places spreading faster (cna, c; gajanan and mansoor, ; kaneko and kim, ; willsher and sabbagh, ) . it also dawned that even those in positions of power and authority are not immune to the virus, where some even succumbed to their injuries. within these days, it also became apparent that every single sector is highly dependent on the health sector, as those like sports and entertainment, religious sectors and others remained "grounded" with some high profile events such as professional football leagues, olympics, and wrestling being canceled, postponed, or suspended indefinitely (bbc sport, ; cacciola and deb, ; schad, ) . during this period also, it becomes apparent that it is possible for technology companies to set aside their competition and come together for the common goal of humanity (apple, ) . therefore, even as events of these third days had been devastating and heartbreaking, there is much that humanity can learn, and have learned, and going forward, even after the covid- is finally phased out, as people, governments, regions, and economies embark on rebuilding, some of the positives that have been learned will need to be kept alive. the following sections document the unfolding of the pandemic. during this month, every effort counted in the fight against the spread of covid- , and this was emphasized by the events of march . on this day, finally, the who conceded that without a doubt, coronavirus amounted to a global pandemic (who, ad) . the build-up to this global pandemic announcement saw a national wide lockdown declared in italy on th following an uncontrollable and astronomic increase in the number of new cases and deaths in the country (bbc, c) . following this, the country was beginning to experience unprecedented abandonment by its neighbors and country members of the eu who had continued to issue a travel advisory to their citizens against traveling into or from italy (gov.uk, a) . unsurprisingly, by th, all eu member states had experienced the outbreak of the covid- disease, and most of the first cases were related to travelers fleeing italy after the situation therein started to worsen (who, ad) . in north america, the situation in the united states was also getting out of hand, with over states including arizona, washington d.c., michigan, colorado, vermont and rhode island, and others declaring states of emergency (razek, ) . here, on march , the united nations headquarters in new york closed its doors to the public for fear of spreading the virus (krisel, ). as the situation escalated, with over confirmed cases in the country, and over deaths from the virus, the national basketball association (nba), one of the most popular and fancied sporting activity in north america abruptly suspended its season, as of march , when a player of the utah jazz tested positive for coronavirus, just before their game with oklahoma city began (cacciola and deb, ) . these unfolding attracted a host of intervention measures in the country to ensure people would observe the health guidelines, especially by staying at home and keeping social distancing. first, on march , vice president pence announced that medical insurance companies had agreed to waive all copayments on covid- testing and also extended their coverage for the treatment of the disease (office of the president, b). similarly, the country, through homeland security, announced a level travel advisory and subsequently temporarily restricting entry to all foreign travelers from china, iran, and certain countries of europe. the restrictions also demanded that all american citizens and legal permanent residents and their immediate families returning from countries already affected by the virus must undergo a self-quarantine for a minimum of days upon arrival (homeland security, ) . this announcement was affirmed by the oval office address by president trump stating that travel advisory applied to all the countries in the schengen area (collinson, ) . the decision by trump was disapproved by the eu leaders (gaouette et al., ) . elsewhere, to control and reduce the spread of the virus, the schooling system in different countries was seen to be disrupted. as of march , a un report indicated that about % of students across the globe were out of school and this included countries like italy, czech republic, part of spain (madrid region), greece, and austria among many others that took the decision of closing the school to protect students and their families, as a mean to comply with who's health guidelines (who, p) . surprisingly, as countries hastened to close down schoolsdhighlighting the worsening of this situation, reports from china indicated that normalcy was returning to a point that some schools were reopening especially in qinghai province (cgtn, ) . in regard to financing efforts against this disease and supporting technological advancement in the development of test kits and vaccine development, on march , the bill & melinda gates foundation, mastercard, and wellcome together committed approximately $ million (bill and melinda gates foundation, ). on the same date, the coalition for epidemic preparedness innovations on its part committed an extra $ . million to render the organization's total investment in vaccine development to $ . million, with the funds expected to help both the company novavax and the university of oxford to research and develop a vaccine for this disease (kff, ). furthermore, on march , the united kingdom announced more funding ($ . million) , this time from its national budget to aid vulnerable countries in their efforts against covid- (gov.uk, b) . two days after declaring the coronavirus a global pandemic, circumstances in the western part of the globe have led the who to make another declaration; this time, the new epicenter of the outbreak of coronavirus was europe (who, ae). this announcement was not surprising as of then, italy was already overwhelmed ( , cases and deaths already) (snuggs, ) , and spain had in the day declared a state of emergency (cnbc, ) . things in other member countries of the union were also worsening, with the region recording over deaths in a span of h from the disease, and over new cases in the same period (who, c) . and surprisingly, from the situation report by the who (who, c), all the cases in each of these countries were of local transmission; thus, warranting the decision different countries were making to restrict movements, and where possible, instituting total lockdowns like the case of italy. on the western side of the globe, more states in the united states were declaring a state of emergencies, restricting the number of people in gatherings, closing all learning institutions, and restricting movements among other things. these happenings were more pronounced on march , and when the worse came to worst, present donald trump, under the robert t. stafford disaster relief and emergency assistance act (stanford act), declared a state of national emergency (office of the president, a). by then, the number of cases in the united states had increased to and those who died from the disease reached deaths, with transmission happening locally (who, j) . in total, the global number of confirmed cases had reached a high of , cases, with of those reported in the past h. of the sum, , had been confirmed from countries, of which were reporting their first cases. the remaining cases were reported in china, where situations were coming back to normal, with only new cases reported in the populous country, and deaths were reported in the -h period. wuhan, the former epicenter only recorded five confirmed cases (reuters, c) . outside china, the deaths increased by , raising the total tally to cases (who, c). following these unprecedented unfolding globally, economies were facing numerous challenges, as most economic activities had stalled or were nonexistent. for instance, in the united states, the stock exchange recorded the lowest point, only reminiscence with situations of (mccabe and ostroff, ). for this reason, different agencies introduced financial packages to offer some support. for instance, the adb announced a $ million package that could be accessed by companies to supply critical essentials for combating covid- (adb, ) . in europe, the european bank for reconstruction and development is reported to have approved a $ . billion financial package to help companies in the region to remain afloat during this period the region was experiencing the most trying moment in the recent history (williams, ) . amid the challenges of covid- and its impacts, some countries like taiwan found some solace in the use of technology to track and instill the mandatory quarantine, especially for those coming from certain areas. with technology, enforcement officers were able to know those who were flaunting rules and their whereabouts, and this helped reduce the spread of the virus, despite it being just kilometers from china where things were worse some days ago (yun, ) . in europe, there was some use of technology, especially mobile apps, that helped in mapping and tracking cases, and to bolster this even further, the european commission (ec) was offering funding to a tune of v m ($ . ) for start-ups or small medium enterprises (smes) developing technologies with capacities to treat, test, monitor, or offer other aspects that could help in the fight against covid- (euroean commission, a). in the past month since the first case was confirmed in africa, the number of countries affected in the continent increased to by march , with seven reporting their first case in a span of h. also, a week prior, the number of cases in the continent was only , but they increased to with six deaths reported to have been imported, except for south africa, algeria, senegal, and cameroon (who, k) . in europe, most countries were receiving unprecedented numbers of new cases, especially in italy, spain, france, and germany, which recorded , , , , and new cases, respectively, and almost all cases in most of these eu countries were locally transmitted (who, k). the number of deaths in the region was also rising with italy losing people in a single day (snuggs, ) , while spain lost , france , and the united kingdom lost lives. in germany, which was reported to have embarked on mass testing as early as the situation warranted so, the number of deaths was relatively low (only two reported by th) (who, k) . following the dire state in the region, the european commission published guidelines (euroean commission, b) on the exportation of ppes out of the region. among such guidelines were the restriction of exportation of the said equipment unless with express green light from the eu member states. however, the eu was categorical that the measures taken were only within a specified period, especially during that period when those ppes were greatly needed locally; and thus, it was not a total ban on export, which would contravene the region's international obligations in matters of trade (euroean commission, b) . in the middle east, the severity of the disease was still present in iran, which until th had a total of , confirmed cases and deaths, with a high of deaths having been reported in a period of h. the situation in other countries within the region was controlled with only deaths reported ( in iraq, in lebanon, and in bahrain). in the american region, only a few confirmed cases were reported, and only deaths were reported in ecuador. however, the government there continued to institute proactive response measures to ensure the spread would be contained. for instance, the cdc announced that no gathering would be allowed in the united states that have more than people, thus putting into disarray functions such as weddings, concerts, and sporting events among others that are known to attract a large crowd (the new york times, a). more states declared a state of emergencies, while more schools in different states (more than states), including new york city with over . students (shapiro, ) calling for the closure of schools. one major news in the united states on that day was the negative test results for the country's president, who a few days ago had some contact with a brazilian official who turns positive after the testdprompting president trump to undergo testing (education week, ) . in other places, country borders were being closed. for instance, after confirming their first covid- cases, kazakhstan and uzbekistan closed their borders (reuters, j) . colombia also closed its border with venezuela, while turkey, with one of the leading airline services globally, suspended flights to nine european countries (liptak, ) . lebanon reported to have called for a -day lockdown in the entire country to curb the spread of the virus, which for the past week had claimed the lives of three people (france , b). the other goods news of the day came from south korea, which had shown a great resolve in bringing down the number of new cases, and this was bearing fruits after it implemented a number of strategies that involved the use of advanced technologies. first, it adopted the use of drive-thru clinics where people could be tested within min and receive their results the following day. this allowed them to test over people per hour, as there were such clinics countrywide, where six people were being tested in an hour per clinic (choon, ) . the strategy also reduced local transmissions as contacts were greatly reduced. the country also implemented the use of mobile apps to enforce quarantines and track the spread of the virus (park, ) . the success of the drive-thru clinics and apps were later adopted by the united states and germany (yamey, on th, the health landscape in different regions changed even further, with the western pacific region having the highest number of confirmed cases, mostly because of china. the european region was on its knees, health-wise, with , confirmed cases, with of these being reported in a single day. the number of deaths in this region had also increased by to take the region's tally to deaths. both north and south american regions had cases, and a total of deaths ( deaths reported in a day). the african and the south-east asia regions were relatively saved until then, with only and confirmed cases, respectively, and total deaths for both regions being (who, l). following the dire need in the european region, the eu closed its borders except for essential travels. russia also closed its borders, only allowing its citizens and legal permanent residents to travel back. spain was also reported to have instituted border restrictions for all noncitizens and residents. in france, besides instituting border restrictions like a majority of its eu counterparts, it also announced a countrywide lockdown, which meant that no gathering of any size would be allowed, with people expected to remain at home with some exceptions (onishi and méheut, ) . similar events of widespread lockdowns and border restrictions were also observed in latin america, with countries such as venezuela and peru leading the cue in countrywide lockdowns. colombia and costa rica also instituted border restrictions and control. however, brazil, which by then (march ) had the most confirmed cases in the region, overlooked all the measures that the rest of the world were implementing, and had a section of its population (supporters of their president; jair bolsonaro) demonstrate against his opponents (harris and schipani, ) . in iran, the government was forced to release over , prisoners as a way of curbing the spread of the virus in the country, which was already at alarming levels (hawkins, ) . as the global social fabric was being dismantled by the disease, its impacts were being felt in the economic sphere. for instance, on th, the airline industry in the united states was seeking government financial assistance of up to $ billion to help them remain afloat (sider and mann, ) . the dow jones industry also recorded its historical low after dropping . points; the worst day crash since the "black monday" crash (millhiser, ) . following those uncertainties and the threat covid- posed to the global fabric, a number of well-wishers and philanthropists were seen to be in the frontline of helping countries win this war. on th, the jack ma foundation donated assorted ppes and testing kits to the united states , which greatly needed these following the increasing demand, and the disruption of supply chain following the slow activities in china. on th, the world bank group committed another $ billion to help in the fight against the diseases (the world bank, b), while on the same day, bloomberg philanthropies gave a financial package of $ million, especially to help low-x and middleincome economies (bloomberg philanthropies, ). as the dark crowd of coronavirus continued to spread in italy, its impacts were becoming evident, as in a month, the number of deaths ( ) in the country surpassed those in china ( ) since the onset of the outbreak to march (quinn, b) . its health sector was completely overwhelmed with images of dejected nurses trending on social media, and while that was happening, china reported no new confirmed cases attributable to local infection, as the new cases that it confirmed were suspected to have been imported from other countries (siobhán o'grady et al., b) , as it had started to ease its border restrictions. the number of new cases in italy also increased by cases, bringing their country total to , , becoming the second most affected country after china. as for the european regions, italy recorded a total of over , cases on both th . the number of deaths for both days totaled , far much more than the rest of the regions combined. in the americas, new cases on th were : almost double of what was recorded the previous day ( new cases on th). the eastern mediterranean region recorded new cases to push their region total to , , and the number of deaths in the region reached after ( died on th), with most of these coming from iran. in total, the global confirmed cases had increased to , cases on th after , more cases were reported. the number of total deaths globally increased by a total of to reach a global tally of cases (who, m). on local scenes, the disease affected some prominent people, celebrities, and sports personalities. for instance, in the us nba teams, denver nuggets (wimbish, ), los angele lakers (whitcomb, b) , philadelphia ers (zagoria, ) , and boston celtics (ward-henninger, ) reported that each had some of their players confirmed positive, but they decline to give the names of those players. on the same land, congress representatives, ben mcadams (d-utah) and mario diaz balart of florida, confirmed that they had also contracted the disease (helsel, ) . in washington, two employees of the world bank group tested positive on the th with fears that more could have been affected. on the th, there were reports that prince albert of monaco also tested positive for covid- (romo, ) . another person is the executive director of the world food program, david beasley, who also tested positive after returning from canada (world food program, ) . to respond to the numerous cases and scenarios prompted by the covid- case, different regions, individual countries, and agencies adopted different and diverse measures. for instance, in india, the government was reported to have banned any export of ppes, ventilators, and certain medications and supplements as such were not enough locally (suneja, ) . in addition to this, to reduce further spread, especially from imported cases, it closed its borders for incoming flights (business today, b). in the united states, the number of interventions was observed, for instance, the two june scheduled party primaries in connecticut were postponed (pramuk and dzhanova, ) . president trump also signed into law the family first coronavirus response act that would see most americans receive a family relief of $ . the act also gave $ billion to be accessed by smes (erica werner et al., ) . the university of hong kong received $ , from the coalition for epidemic preparedness innovations to continue with vaccine testing for covid- (galford, ) . on the th, the rockefeller foundation committed a $ million to assist in response to covid- , especially in cities such as nairobi, new york, washington, bangkok, and bellagio (rockefeller foundation, ). since the onset of the coronavirus, there had been a theory that it was mostly affecting older people, but the who debunked this, by indicating that data on those affected in different countries and regions have shown that a significant proportion of those in hospitals are aged below years; hence, calling the younger generation to be also extra cautious. the organization also launched a health alert messaging services through whatsapp and facebook, demystifying the importance of technology in the fight against covid- , especially in sharing data and information (who, d). the organization also reported that it had reached an agreement with different producers in china who were ready to supply the organization with ppes, so that it could continue supporting countries in need of such across the world (schnirring, ) . while that was going on, they delivered an extra . million laboratory test kits for covid- to different parts of the world (watts and simon, ) . there was also news that first vaccine trials had begun, and the who together with its partners was to organize an international study dubbed solidarity trial in different countries aimed at trying different treatments that could be adopted to win over covid- (who, d) . regarding the reports on the spread and impacts of the coronavirus on this day (march ), the situation reported by world health organization indicated that the world was still in great danger of recording even more cases. for instance, italy reported the single largest number of deaths, where people died, and those confirmed increasing to , cases. in the united states, the cdc indicated that it had confirmed a total of , cases (cdc, ). as that was happening, president trump invoked the defense production act, to force general motors (gm) to produce ventilators to fill the gap after the situation in the hospital become dire (haynes, ) . on this, earlier on the day, gm rejected the move, prompting the president to apply his executive authority on them, and the new york governor equated the ventilators to missiles during world war ii (klein and raju, ) . the controversies in the united states were not over as it was reported that canada, through its prime minister, justin trudeau, would return all asylum seekers to the united states (austen, ). elsewhere, cuba invoked border restrictions for all noncitizens and nonresidents. it had delayed this decision to "keep its key tourism industry alive," but the threat of the coronavirus forced the president to take that crucial and bold decision (france , a). as time passes, the spread of the coronavirus virus took hold across the globe. on march , the who declared the virus outbreak as a global pandemic, and days later (on th), the director-general declared that the "pandemic is accelerating" (chappell, ) . and true to his word, in the past days, the number of new confirmed cases each day were averaging , new cases, to push the global total to , confirmed cases. the number of new deaths in those days was also increasing at an average of almost each day, and by rd, the total number of deaths had reached , globally (who, n). of great concern on those numbers is that most of them were coming from the european region, which by rd had reached a high of , confirmed cases and total deaths. the only regions that had shown a lot of resilience were the african region with only total confirmed cases and total reported deaths. the south-east asia region was also relatively spared having confirmed only cases and total deaths. the region of americas was showing worrisome trends, having reported a high of , new cases in a single day (march ) to push its total tally of confirmed cases to , cases and a total tally of deaths ( deaths) reported in a single day (who, n). while a majority of countries, especially in europe writhed in desperation from the impacts of covid- , china reported a third consecutive day with no local new case of coronavirus (the straits times, c). this meant that they could slowly transition back to their previous economic routine, and it also gave hope to those whose situation was worsening. in the other regions, including africa where confirmed cases were low, they were responding to the spread by escalating lockdowns and border restrictions (aljazeera, b) . other countries followed this trend. for instance, on march e , bolivia (reuters, b) , greece (stamouli, ), cuba (oppmann, ) , and the united kingdom (sparrow et al., ) imposed total lockdown in their countries (aljazeera, b) . egypt on the other hand called off all religious activities in mosques and churches for days (mourad, ) . during this period still, other countries including pakistan (reuters, n), vietnam, singapore (benner, ), uae, panama (aljazeera, b) , india, nigeria (reuters, m), and zimbabwe (the citizen, ) closed their borders to all foreign travels and nonresidents and banned international flights to or from their soils for a minimum of days. germany, on the other hand, banned gatherings of more than two persons, as cases in the country started to soar, while on the same day, spain extended the state of emergency for more days, as the situation internally was getting out of hand, with thousands hospitalized, and cases soaring each day (picheta, ) . the decision taken by each individual country was meant for the good of the citizens, but such also had a far-reaching impact on the economy. for instance, the banning of the international flights in these days, and others that had been instituted earlier mean that sectors such as tourism, hospitality industry, and others are grounded, with millions of workers employed in those sectors uncertain of what the future holds. in such circumstances, governments were forced to rely on external organizationsdlike the jack ma foundation, which on nd delivered a consignment of assorted ppes, and test kits to african countries to fight the covid- (meseret and meldrum, ). on rd, the world bank group's president was also pleading with bilateral creditors to extend debt relief to low-income economies to help them build some capacity that could allow them to fight the disease (bank, ) . while this was going on, african finance ministers were pleading for a $ billion economic stimulus in addition to the suspension of external debt to allow their individual countries to fight the coronavirus pandemic (uneca, ). china's progression toward containing the virus received a boost after the province of hubei was freed from the lockdown after almost months since the lockdown was instituted (associated press, ). it was a relief to the residents who, for such a long period, lived in fear and uncertainty of when they would return to their previous routines. the good news was that wuhan, the first epicenter of coronavirus was to open a month later, as the number of new cases had reduced significantly. in the last h, the entire country of china reported on new cases, of which, cases were reported to have been imported (cna, a). the number of deaths had also increased, with seven reported in the city of wuhan (the star, ) . the other good news came from germany where the chancellor's, angela merkel, the first test came back negative for coronavirus, but would undergo the same process a few days later to confidently confirm this result (mischke, ) . the fear that she would have contracted the disease came after a doctor who had attended her turned positive, forcing the chancellor into a safety procedure of self-isolation (mischke, ) . the day however did not present the good news to everyone, especially to governments, health workers, and security forces implementing lockdowns and other measures in different countries and to the general global population. on this, in the past h alone, the number of newly laboratory-confirmed cases neared , and the deaths on a single day accumulated to globally (cna, a). the most unfortunate report on this is that half of the new cases and deaths reported came from european countries ( , cases and deaths), with the american regions also experiencing a high of , new cases and deaths (who, e). regarding the accumulation of confirmed cases, it took at least months for cases to climb to , confirmed, and only days to reach , cases. from here, it only took days for the global total to surpass , confirmed cases, and even more startling, only days for the total to reach almost , confirmed cases. such trends prompted the international olympics committee and japan's olympic authority, led by prime minister shinzo abe, to postpone the olympics scheduled for summer to as more countries had expressed their fears of the virus (ramsay, ) , while others cited lack of preparation and other technicalities (aarons, ) . they also prompted the prime minister of india, narendra modi, to lock down the country for days, only a day after the later declared an immediate grounding of all flights in or out of india (shroff, ) . new zealand also went into lockdown (bbc, e), as australia announced a ban on all overseas travel (whiteman and sharma, ) . while in the united states, a troop of , us national guards was mobilized in states to help in response to the disease (gresik and altman, ), as it had already infected more than , people countrywide. while those were being mobilized, three of their colleagues in the navy (sailors) contracted the virus, when an aircraft carrier they were boardingdtogether with approximately other peopledset sail from vietnam. by now, the situation of covid- globally reached fever-pitch where the u.n. secretary-general antónio guterres argued that the disease was ravaging the whole of humanity, with approximately one-third of the population experiencing one or more covid- -related restriction (unicef, ). following this, there was shortages in all sectors, with the who warning that already, the world was facing a "significant shortage" of assorted medical supplies. on the social sphere, there was a shortage in the health sector prompting the un to launch a $ billion financial package on march targeting global humanitarian responses, especially to be advanced to vulnerable countries (un secretary-general, ). with the funds, those countries would manage to bolster their laboratory equipment, build and increase available sanitation (handwashing) stations, and increase medical supplies among other things. besides the financial package, the who was calling on developed economies to assist african countries with health machines such as ventilators and respirators as the continent cannot satisfy the demand for such, especially if cases of covid- were to increase (ighobor, ). those calls and interventions come at a time when most countries, especially in europe and america, were experiencing one of the darkest moments of their history. for instance, in spain, as of th, the number of reported deaths ( deaths) surpassed those reported in china ( ). but still, italy was leading in the number of people who had died with a total of , with having died in a span of only h. france had also started to lose a significant number of people as a result of the covid- , with already having succumbed in the past h. the islamic state of iran and the united states were also affected with (total deaths ) and (total deaths ) deaths having died in the past h. in regard to the number of confirmed cases, which were averaging , cases per day in the past days, the global total had increased to , by th according to the who data. africa was still showing some resilience despite reports of weak health system, with only deaths reported coming from confirmed cases across the globe (who, o). the economic situation globally was worsening, but even more in the united states where it was reported that by march , over . million american had filed for their employment benefit (casselman et al., ) ; a figure that is thought to be the highest in the history of the country. this could be attributed to the increasing number of people who were contracting the coronavirus especially in new york, which had become the epicenter of the outbreak in the northern american region, with the united states having more cases than any other country (kirby and stewart, ; the new york times, b). but, fortunately, the trump administration's stimulus plandworth $ trilliondwas unanimously passed the senate (carney, ) , thus allowing the government to offer some financial support, especially to those who continued to lose their livelihoods. elsewhere, more countries were responding to the pandemic by instituting lockdowns or other strict measures that would somehow suppress the local transmission. on this, on march , panama was reported to have suspended any form of domestic flights , days after, it had suspended international flights (aljazeera, b) . in thailand, the government declared a state of emergency forcing more areas within the country to shut down (techakitteranun, ) , while iraq and lebanon extended their curfews by days in each country. in russia, moscow shut down all forms of businesses and activities for a week (march to april ), except for essential businesses such as pharmacies and grocery stores (astapkovich, ) . the highlight of the day was the testing positive for coronavirus of uk prime minister boris johnson, which he announced to the world via a video on twitter (bbc, g). he reported that, henceforth, he would be in self-isolation and will continue working from. but, while this was breaking news, the greatest and most unfortunate news came from italy and spain. in spain, it had earlier been reported that it had recorded the highest number of deaths in a single day ( ) (rtve, ), but later only italy released its official report of the day where it indicated that approximately (who later reported (who, f)) people had died within a span of only h. italy had also confirmed new cases while spain reported new cases bringing the total confirmed cases to , and , cases, respectively. however, the united states reported the highest number of new confirmed cases ( , ), taking its total tally to , according to the data by who (who, f) but according to the us cdc data (cdc, ), the total number of cases reported in the country by th had reached , , thus leading globally. in the middle east, iran was reporting the highest numbers of new cases, with cases reported within h and new deaths during the same period (who, f). other countries in the region were relatively calm with no other reporting more than a cases a day. in africa, algeria reported the highest number of deaths ( ) (who, f) while south africa reported the first death from the virus. this death and the increasing number of confirmed cases in the country prompted the government to announce a -week nationwide lockdown (neuman, b) . elsewhere, china reported new cases and new deaths, in what seemed like a signal to a second wave of infection. following this, the government announced a ban on all foreigners, suspecting that they were the cause of this new trend in rise of cases, as out of those new cases, none were from local transmission (bbc, a; mai, ) . on the same date, the african development bank (afdb) provided aid to the continent with a $ billion social bond targeted to economic and social sectors facing stiff challenges from the impacts of covid- (afdb, ). at the same time, the who announced that the vaccine trial dubbed solidarity trialdthat it had announced about on march dwas to begin shortly, with the first trials administered to patients drawn from norway and spain, but overall, the trials would be extended to more than countries that had agreed to be part of the program (who, af). in the united states, the food and drug administration authorized the use of a -min diagnostic kit for coronavirus intended to speed-up the testing process, but a shortage of necessary equipment for collecting specimens was feared to derail the use of this kit (azad, ) . on the same land, donald trump, president of america, signed the $ trillion stimulus that was passed the previous day by the senate (foran et al., ) . even as the month of march came to an end, the incidences related to covid- continued almost unthwarted. for instance, the number of new confirmed cases for the past days has been increasing at an average of above , each day, and the number of deaths occurring each day likewise increased at an average of deaths. within the days, the total number of confirmed cases globally increased from , das captured by the who on march (who, f)dto , by march . another astonishing occurrencedespecially on march dwas the number of people that died in a single day in both spain and italy, which recorded and new deaths, respectively (who, p) . this happened while the number of patients being admitted to different hospitals in both countries exceeded their bed capacity and human resources allocation (cheng, ) . the united states was also going through thick and thin, as the number of new cases in the country continued to soar at alarming rates. even in africad which had shown some levels of resilience against the spread of this pandemicdthe numbers for the past days seemed to increase at an average of almost daily, with egypt, algeria, and south africa being the most affected (who, q) . in fact, the who's director-general highlighted the plight of the global health system and argued that there was a chronic global shortage of medical supplies such as ppes, ventilators, and other basic amenities required to saving lives (who, af). these unfolding events were happening amidst numerous responses and interventions both at local, regional, and international levels by government, international organizations like the who, the world bank, and others. among the new interventions that countries were implementing include the extension of the social distancing guidelines in the united states by president donald trump until the end of the following month (april ), and perhaps with a possible extension to june (shear, ) . the country had also accelerated the testing of individuals, and by th, the president announced that over one million people had been tested despite earlier hiccups in regard to faulty testing kits (tirrell et al., ) . in africa, on th, nigeria was reported to have directed the cessation of movement in two of its most populous cities, lagos and abuja, to reduce the chances of importation of the coronavirus to rural areas (akwagyiram, a) . in mexico, in a bid to reduce the soaring confirmed cases and growing number of deaths as a result of covid- , the government declared a health emergency (reuters, l) . in portugal, the government had resulted in treating everyone including foreigners with pending applications as permanent residents of the country so they could access public health facilities without encountering hitches (reuters, o) . but despite all those negatives, there was good news from the city of wuhan, which after undergoing a "dark moment" in the past months, saw authorities relaxing some quarantine measures, including rail services in and out of the city, meaning that people could eventually access the rest of the country (beaumont, ) . authorities in the province of hubei also announced that they would allow domestic flights to resume in all airports, except tianhe international airport in wuhan (xinhua, c) . the other goods news is that on , the bill & melinda gates foundation, wellcome, and mastercard together granted three institutions (the university of washington, university of oxford, and la jolla institute for immunology) financial support worth $ million to facilitate clinical trials for immunotherapies they were developing (mastercard, ) . in the wake of the new months, the reality of devastation of the covid- in different countries, regions, and globally was becoming clear. for instance, in spain, by april , the number of those affected reached , . but, by then, italy had more than these cases with , confirmed cases, while the united states, which had become the new epicenter, had , confirmed cases, as per the cdc data (cdc, ), while the who reported , (who, r). regionally, cases in europe reached more than half a million people ( , ), where , of those had succumbed to the virus. the region of the americas was the second most affected with a total of , confirmed cases and deaths. the western pacific region was the third hardest hit, with , infected and deaths. the eastern mediterranean regions had , confirmed cases and recorded deaths, while the african region had confirmed cases and reported deaths from the virus. overall, the global total number of confirmed cases had reached , , and an addition of , from the previous reported numbers. the number of deaths had also reached , , with a high of dying in the past h (who, r). by april , the global total exceeded the , , mark as per the john hopkins data, ncov .live, and other websites, but who reported the total numbers at , confirmed cases (who, g). the reality was reflected in the economic sector with the world bank reporting that the impacts of covid- pandemic would force more than million people into poverty (the world bank, a) . the reality of this statement was affirmed in the happenings in the united states, where it was reported that in a period of just week, . million more people filed for unemployment benefits, taking the number of those who had filed for the benefits to over million people (long and dam, a) . the same trends of unemployment were also being experienced in austria where the unemployment levels jumped to % in the country within the months since the onset of the pandemic (reuters, a) . the said reality prompted several unprecedented actions in different countries and organizations. for instance, on april , the un announced the postponement of the climate conference (cop ) scheduled for november due to covid- (un, ) . in the sporting world, the all england club announced that the wimbledon tennis tournament was canceled due to covid- , and this was the first time since world war ii that the championship was called off. on the same day, the health minister in italy announced that the countrywide lockdown would continue to be in force until the th of the month as the number of confirmed cases, and deaths continued to increase (reuters, i). the announcement was also confirmed by the country's prime minister giuseppe conte said that the situation in the country forced him to sign the decree to extend the measures (orihuela et al., ) . the same measures were taken by germany. on april , more actions continued, with saudi arabia extended its curfew to h on its most visited and the holiest cities in islam: mecca and medina (aljazeera, c) . a similar action was taken in thailand involving the entire country, with exception of medical personnel, and those transporting essential products, and for people moving to quarantine or health facilities (the nation, ). peru and panama establish a different strategy for reducing the number of people outside by imposing a gender divide, where certain days were set aside for only men and the others for men. this way, it would be impossible for those living together leaving their homes together (aquino and moreno, ). in the united states, the white house was encouraging people going out to wear masks (sun and dawsey, ) , and this came while most of the citizens were trying to come to terms with stay-at-home orders that had been declared in almost states in the country (nottingham, ) . the highlight of the day is the worsening health status of the uk prime minister boris johnson, prompting him to be moved into intensive care. he was taken to hospital in london the previous day (april ), after the covid- symptoms persisted, days after he tested positive (bbc, g). on the same day, in the same country, new deaths were reported, taking the country's total death toll to while the total number of confirmed cases increased to , after new cases were reported in a period of h. within the european region, the total number of confirmed cases had increased to , after , more cases were reported in a span of h. the number of deaths also had increased by a total of deaths to take the total tally for the region to , , and these were far much more than the total deaths of all other regions combined. on the same day, the united states reported , new cases to take their country's total to , (who, s) and also reported a high of deaths increasing the total deaths recorded in the country to , while other data showed that deaths had reached , (siobhán o'grady et al., a) . in the previous day (april ), it had reported cases and , new cases; the highest reported data in the region since the onset of the pandemic (who, a). as these occurred, president trump reported that hydroxychloroquine, an antimalaria drug, could be used against covid- (crowley et al., ) . in the middle east, the total number of confirmed cases in iran increased to , after more people tested positive. globally, the total confirmed cases stood at , , and the total deaths reported were , (who, s). in africa, where cases had started to increase significantlydreaching and deaths, it was reported that the former libya prime minister mahmoud jibril died of coronavirus the previous day after fighting the covid- disease for approximately weeks (aljazeera, d). in china, which reported new cases and only deaths, fears were that the country would be experiencing asymptomatic transmissions of the virus; hence, the increase in newly reported cases. these were experienced though the country had already introduced border restrictions with other countries, and following the fear of asymptomatic cases, the government vowed to tighten border control measures even further (zhang and munroe, ) . the most astonishing news reported on april was that of the positive testing for coronavirus of four tigers and three lions in the bronx zoo, bringing the total number of cats reported to have contracted the virus to (daly, ) . this raised alarms as no known research had shown that the virus could be passed from humans to animals. this far, a report by the who indicated that more than % (approximately . billion) of students globally have had to remain at home following the closure of school. to offer some intervention on this, the organization, together with unicef and the international publishers association, launched the "read the world" initiative to allow student access learning materials even during the difficult times (who, a). in the sporting sector, to safeguard the lives of participants and to comply with the health guidelines of social distancing and others, the open golf championship was called off; being the second time, it was canceled since during the ww (the open, ). after days of uncertainties, the chinese authorities finally lifted the lockdown on wuhan as promised, after the city successfully saw a reduction in the number of new confirmed cases for the coronavirus (aljazeera, a) . in fact, the report from the entire country was that the new cases that were being reported were all imported ones, and the government had vowed to take extra measures to control its borders (zhang and munroe, ) . the good news on the country is that on the previous day (april ), despite reporting new confirmed casesdwhich were all imported, the country reported zero death for the first time since it started publishing figures of the death related to covid- (who, b) . even on th, the number of new cases was only : all imported and only two deaths. the situation was, however, totally different in other regions, especially in europe where france, on a single day, reported new deaths to push its total death toll to , , while those whose tests turned positive in the past h increased by to take the country's total to , (who, t) . this total was however smaller compared to germany, italy, and spain whose totals had increased to , , , , and , cases, respectively. belgium and the netherlands also witnessed an increase in the number of deaths with and new recorded deaths, respectively (who, b). on this, despite germany having more confirmed cases, it had managed to keep the death toll relatively low, with reports showing that it is due to the mass testing initiative it had embarked on; thus, cases were getting identified before becoming critical (perrigo, ) . until eighth, it had only lost people, while its european counterparts were worse off (who, t) . the other nation that saw the number of casualty increase was the u.s, which, since a few days ago had started to witness numerous deaths, and confirmed cases. on this day, the country lost lives to the disease, and , were the newly confirmed cases taking the country's total to , , according to who data (who, t), but the uscdc reported the total number as , cases (cdc, ), where the difference could be due to difference in reporting time between who on central european time (cet) and us edt time zones. while this was happening, the country's president, donald trump who had frequently attacked the who for failing in its mandate in detecting the virus earlier threatened to withdraw funding to the agency (sevastopulo and manson, ) . he categorically said that the organization had withheld information about the virus and was wrong about the outbreak in china (davidson, a) . but, in a quick rejoinder, the who's director-general warned that it would be disastrous to politicize the fight against the pandemic (wise, ) . following the health situation in france, authorities announced that they were imposing a ban on daytime outdoor exercise in paris, which had allowed its citizens to enjoy despite the country being on lockdown (bbc, f). on the same day (april ), the egyptian authorities announced that the ban on mosques and churches would still continue even during the ramadan period as the country was still facing the challenge of coronavirus, with new cases increasing and more deaths being witnessed (egypt independent, ) . in the asian region, japan joined the list of many other countries who had declared a state of emergency as the number of cases in the country had started to rise in the month (rich et al., ) . in singapore, to contain the spread of the covid- , the health minister gan kim yong announced that the government was banning any form of social gathering whether at home or in public (zhang, ) . the ban came just a day after a motion to outlaw social gathering in the country was rushed and passed to the law in parliament the previous day. elsewhere, as the impacts of the virus continued to be felt, the wellness trust, on april , started an initiative aimed to raise a minimum of $ billion from the private sector by the end of april to fill the financial gap being experienced in search vaccines, drugs, and tests for covid- (wellcome, ) . a similar initiative dubbed "afrochampions initiative" was launched by african union and africa centres for disease control and prevention to raise over $ million for medical responses, with $ million required urgently for the same purpose (africanews, ) . after spending three nights in the intensive care unit, the uk prime minister boris johnson was finally discharged from the unit and transferred to a normal ward where he recovered. in fact, it was reported that he could manage short walks, though he needed some time to feel better (the sun, ) . while the report of his improvement was encouraging, it was not the case for over families in the country, from england who had lost their loved ones as a result of the disease on that particular day. in italy, a total of people lost their lives on th (who, h), while had died the previous day (who, u) . in total, the number of deaths in italy had reached a high of , by th with of these being doctors who had contracted the virus while in line of duty (aljazeera, g) . in spain, hopes of flattening the curve were high after the country saw a decline in the number of deaths for the third consecutive day (landauro and keeley, ) . however, the number of new cases in the country was increasing and had climbed to , cases after more cases were confirmed on th. the renewed hope was also being experienced in china after it continued to witness a reduced number of deaths in the country, as well as more recoveries, which had reached , (regencia et al., ) . while that was happening, the spread of the virus has gone as far as in deep rural areas where a -yearold boy from the indigenous tribe of yanomami found in brazil, amazon forest was confirmed with the coronavirus on t th, and on th, unfortunately, he passed away (phillips, ) . another rare place where the virus was reported was in the cook county jail in chicago where new cases involving inmates and staff were reported (whitcomb, a) . in america still, the number of death from covid- were increasing at an alarming rate, where new deaths were reported on th (who, h) and more had died the previous day (who, u). following these increases, with most of them coming from new york cities, the state had resulted in burials in mass graves as the numbers kept on increasing (anderson, ) , with its confirmed cases being more than any other country globally (bbc, d) . the situation in the united states prompted the german foreign minister to criticize the us handling of the virus (connor, ) . another rare place that was affected by coronavirus is a french navy airplane carrier, where servicemen tested positive to covid- (aljazeera, e) . as the cases globally increased to over . million people, the economic impact of the virus continued to bite. for instance, in the united states, another . million people filed for unemployment claims bringing the total number of those in the same predicaments into almost million in only weeks (long and dam, b) . in vietnam, it was reported that the country was in dire need of almost $ billion to caution its economy against the budget deficit that continued to widen (reuters, r) . albania was also trending on a tight economic path, prompting it to seek financial support from the imf, which extended a loan of $ . million (imf, ) . in zimbabwe, following the ban on all international flights in or out of the country, air zimbabwe sent its employees on leave, which was, unfortunately, unpaid (the herald, ). on the same continent, senegal adopted a directly opposite approach of protecting its workers against being laid off by companies in excuse of the covid- crisis (france-presse, ). on other news, there were reports that google and apple would cooperate to develop a mobile app that would help in tracking coronavirus spread (apple, ) . although that was good news especially coming from the tech world, in singapore, the use of technology faced concerns when online learning platforms that the government had initiated were suspended after the video conferencing zoom platform was hacked during a learning session, and the hackers displayed explicit images to the students (lee, ) . although the death tolls in at least four countries crossed the , mark, others have witnessed significant declines in the number of new cases being reported daily, and thus planning to ease lockdown stances and other strict measures that had been put in place. until april , countries like the united states ( , deaths), spain ( , deaths), italy ( , deaths), and france ( , deaths) were most affected, with the situation in the united kingdom worsening ( , ) (who, w). indeed, a report by the office for national statistics highlighted that uk numbers were underreported by %, the number in the country would be reading over , cases (bruce, ) . on this, it was highlighted that the number of deaths reported did not reflect the actual number represented in over care homes, where most of the elderly population were (mcintyre and duncan). although those numbers are many, there was hope in spain and italy as the number of deaths kept on decreasing each day, and from the report, these were optimistic that they would ease their stand on lockdowndspain by end of june (bbc, h). on this, other more countries including greece (by may ) (tugwell, ) , portugal (by may ), australia (had already started by then), pakistan, and austria (with already thousands of shops reopened (niesner and murphy, )) were considering this move (dw, ). although those countries were eager to lift lockdown measures, germany was considering reintroducing it after community infection cases over the past few days started to rise after the country had cautiously tried to ease the lockdown (mayberry et al., ) . in moscow, president putin strengthened the lockdown measures until may to counter the rising cases of infections (davidson, b) . similar measures were also being taken in china, in the heilongjiang province bordering russia, where cases were reported on april , where chinese nationals who had fled to russia tried to return home (wu, ) . following this, the cases in the province increased to , and chinese authorities in the province promised to reward locals who would report the "illegal migrants" (the straits times, b). georgia, on its part, was planning to lock down four of its largest cities, including its capital tbilisi for days as local transmission started to increase with the county's total cases reaching (who, w), an addition of more confirmed cases (who, v) . on the economic front, the imf warned that the global economy would shrink by approximately % following unprecedented measures like lockdowns, and ban on transportations, and closing down of manufacturing and other industries (rapperport and smialek, ) . in a way to ease the economic pressure, president donald trump started issuing stimulus checks to americans, amid some delays after he realized that his name did not appear on the checks (rein, ) . the situation of the economy is also pointed by activities in heathrow airports where passenger demands were expected to reduce by almost % this month (april), after having plummeted by % last month and cargo volume reduced by . % (rojas, ) . the economy was worsening also for the who after president trump retaliated that he was halting funds to the agency following its mismanagement of the coronavirus (mayberry et al., ) . on the societal fronts, the racial discrimination of blacks in china continued, with the mcdonald outlets in china forced to apologize after the store displayed posters banning black people from accessing the china store (folley, ) . elsewhere, turkey was planning to temporarily release over , inmates, after getting approval from parliament to ease overcrowding; thus, void the risk of coronavirus infection in the facilities (wilks, ) . as of th, covid- had spread to countries and territories across the globe with over , , confirmed cases and , deaths reported. of those cases and deaths, % were reported in europe, while more than % of the remaining cases ( , confirmed cases and , deaths) reported in regions of the americas. the eastern mediterranean region had , confirmed cases and deaths while the south-east asia region had a count of , confirmed cases and deaths. africa, which had started to experience some significant increase in infections, had , confirmed cases with of those newly reported and deaths of which of those occurred in a span of h (who, aa). still in africa, it was noted that out of the countries that had reported cases of covid- were drawn from the western and central part of the continent, and who officials reported that they had teams on the ground to establish the real reason why this was happening (who, ac) . of the total reported deaths, the highest number occurred in the united states with a high of deaths, while the united kingdom had the second tally of the day with cases. france had cases while italy and spain, two countries that had for past days shown remarkable improvement, had and cases, respectively (who, aa). on th, the french navy reported that an airplane carrier had soldiers affected, and in less than a week, on th, the number of those had increased to a total of (willsher and sabbagh, ). although reports in the health sector showed that the world was still unsafe, as had also been warned by the who, other issues were coming up in other sectors. for instance, in japan, whose total confirmed cases tallied to dwhich included three cabinet officialsd and the number of deaths increasing to , the prime minister shinzo abe declared a nationwide state of emergency (mccurry, ) . he also advanced a handout worth u , to every resident of the country regardless of their economic status to caution them during the period of this emergency (the japan times, a). in the united states, on the same day, . million people filed unemployment claims bringing the total number of those in this situation to more than million people in a period of only weeks (long, ) . following this, president donald trump unveiled guidelines aimed to help some economic activities in the country to resume, but he left the final decision of opening the economy, by easing the restrictions on each individual state, to the individual state governors (white house, ). in germany, after experiencing prior issues after easing lockdown measures resulted to increased number of confirmed cases, the government was planning to reopen the economy as from april by allowing some nonessential stores to open and also allowing schools to resume as from may (morris and beck, ). in brazil, president jair bolsonaro fired the minister for health after the minister insisted on strict social isolation guidelines, a move that the president was against. unfortunately, the president had been seen to have regularly downplayed the outbreak of the virus in his country despite the country having , confirmed cases and deaths by april (quinn, a) . in sports, following the situation in france, the tour de france scheduled for june and july was postponed to a tentative date between th august and th september, as the government banned public gatherings to reduce the spread of the coronavirus (tour de france, ). for world wrestling entertainment, the company was planning to lay off some employees including wrestlers and producers such as kurt angle (russell, ) . the move was to caution the company against the financial decline it was facing following the impacts of the pandemic. after months of extreme pressure, anxiety, and uncertainties, wuhan settled and revised its official data relating to the coronavirus. after the review, the death toll from the covid- pandemics increased by % meaning that its number increased from deaths to deaths, pushing the country total by april to deaths. the errors in reporting were attributed to delays, omissions, and incorrect reporting that are understandable following all the many things that are happening during that period (neuman, a) . the number of reported deaths also increased in the african continent after more deaths were reported, taking the total tally to , while new confirmed cases increased by , pushing the continent's total to , , according to africa centres for disease control and prevention (africa cdc) (xinhua, a) , but data by the who for the same period show a total of , cases and deaths (who, x) . death tolls were rising by higher margins in the european regions and had exceeded , deaths, from , , cases reported in the region. this increase, observed throughout spain and italy, however, continued to experience improvements with death rates reducing each day. the united kingdom, france, and belgium still reported increasing numbers of deaths ( , , and , respectively) . however, the united states still leads in the number of confirmed cases ( , on april ) and death tolls ( on the same day) per day for more than two consecutive weeks (who, x) . globally, the total number of cases had increased to a high of over . million, with the number of deaths exceeding , by april (who, x) . despite the risk of the disease being live, the orthodox churches in georgia were observed to flaunt the state of emergency declaration to hold easter masses, where hundreds of congregants attended (antidze, ) . in the united states, a day after the president had outlined a set of rules for reopening the economy, but left the final say on the hands of the governor, some protesters were observed in states of michigan, minnesota, and ohio and others, calling their governors to lift the restrictions in their states (gabbatt, ) . at the same time, texas governor is said to have signed an executive order to allow a reopening as from may (office of the texas governor, ). this was happening, even as the us secretary of defense extended the travel ban for one more month to void the earlier expiry scheduled for may ; thus, showing that the country was still not ready to ease the restrictions it had set. further south, in chile, the government started issuing "immunity cards" for all those who had infected and recovered from the virus. with the card, these could comfortably return to their work stations (thomson, ) . as this was happening, the number of cases in the country rose to , , taking the country as the third most affected in latin america (who, x) . however, the who, through dr. michael ryan, one of the executive directors, warned that there was no evidence that those who were recovering from covid- were developing any immunity that could prevent them from being reinfected (who, ab) . during the same press conference, the director-general emphasized that as chinese authorities allowed the wet market to reopen, they would ensure conformity to food safety and highest levels of hygiene and that the law banning any trade in wildlife for food was to be implemented strictly to save the world from future pandemics like the coronavirus (who, ab). elsewhere, more countries were slowly and cautious easing restrictions, with france allowing visitors to care homes, albeit some conditions (dodman, ). croatia also eased some restrictions allowing people to travel within their districts. in other countries such as the united kingdom and zimbabwe, the lockdown measures were to remain intact until when the government is confident the situations are controlled (today, b) . in saudi arabia, despite the start of ramadan, the top religious authorities of the country were recommending people to pray at home to reduce the spread of the virus among the faithful (reuters, p) . this was necessary, as already, deaths were not sparing countries' leadership. for instance, in nigeria, president buhari's chief of staff, abba kyari became the latest topranking official to die from covid- (akwagyiram, b) . a similar case was reported in guinea where a top official and ally of the president alpha condé also died (afp, a). within a period of h (april e ), the number of infections globally increased from . million cases to over . million, while the number of deaths increased to above , globally (reuters, g) . in europe, the number of those infected increased over this period to over . million, with a daily average increase of approximately , new cases, while the number of new deaths in the areas also increased by an average of above each daydtaking the total deaths in the region to , according to data by the who (who, y). in the american regions, cases increased by an average of , confirmations pushing the total confirmed cases to , cases (who, y). the number of deaths increased to approximately , by april , with a majority of these reported in the united states, which was the new epicenter for the coronavirus. the eastern mediterranean region had its total confirmed cases increase to , cases with people dying from covid- . the western pacific region had a total of , cases after new cases were confirmed while the number of deaths increased to . the south-east asia region and african regions, though have had their cases increase, have shown remarkable levels of resilience despite having some of the weakest health systems. their total confirmed cases increased to , and , cases, respectively, while the number of people who succumbed to the covid- in the regions increased to and deaths, respectively, (who, y) . following the unprecedented increase of infections in the united states, president donald trump had reported on april that he would be signing an executive order to suspend immigration to the united states for the next days. and, true to his word, on st, he signed the order meaning that green card recipients would be blocked from moving into the country, with only workers holding nonimmigrant visas allowed (nick miroff et al., ) . he supported his decision by arguing that the unprecedented effects on covid- had pushed many americans out of jobs, and he would wish to see them access the available job opportunities without having to compete with migrants (nick miroff et al., ) . and to ensure that job opportunities would be available, on the same day, his office and congressional leaders agreed on a $ billion small business and hospitals stimulus package, that now only awaited approval from the house of representatives (roberts, ) . in africa, south africa took a similar approach of bailing out the economy by unveiling a $ billion relief plan that would also aid the most vulnerable in the society during the period that the country was struggling with increasing cases of coronavirus and the lockdown measures (channelstv, ) . the economic struggles saw iran start to reopen its economy with major shopping centers in the capital tehran being the first (press, ) . similar actions were observed in israel, which eased lockdown restrictions to allow small shops and stores to open and allow people to move around, but on condition mask-wearing in public (haaretz, ) . this came as the number of recoveries in those countries started to increase, while the death toll contained (efrati and rabinowitz, ). in the poorest countries in the world, the world bank supported the pandemic bond, launched in , with an amount of $ . million to assist nations from the impacts of covid- (baker, ) . this came as the un world food programme warned that the impacts of covid- would result in the doubling of world hunger, representing a total of million people (anthem, ) . the economy was however not worsening for individuals only, but on this day, it was seen to have particularly worsened for us oil-producing economies and companies, with the prices per barrel going down to $ , a historical event that has never happened (suleymanova, ). the only sector that was seen to be doing well, especially in the united states is the gaming industry, probably due to the "stay-at-home" orders and also due to the closure of schools. but, while the market increased, there were fewer games produced due to the impacts sparked by the coronavirus (schreier, ) . the other sector that was seen to benefit from the impacts of covid- was the environment, where it was reported that following the reduced activities in the manufacturing and transport sector, less emissions ( % drop) are expected during the year (marchand and faigle, ). as over countries continued to fight the spread, and the impacts of covid- in their countries, the united states was the most hit with over , cases and over , reported deaths as up to april . the new cases in the country had increased at an average number of approximately , (cdc, ). as the number of cases continued to increase, and other more "staying-at-home" measures following the lockdowns in different states, the number of those filing for unemployment claims continued to increase with over . million additional claims reported over the past week, which was the fifth consecutive week since this trend started (lambert, ) . these new numbers raised the total of those who had filed for their employment benefits to over million people (chaney and guilford, ) . outside the united states, there were mixed responses to the virus. some were seen to ease and lift the lockdown and subsequent measures they had implemented, while others were seen to be in haste to institute those measures. for instance, in the netherlands, after experiencing some "relative calm" over the past weeks in respect to infections in the country, its number had started to rise with new deaths averaging over each day and reaching a high of deaths and , confirmed cases by april (who, z). to minimize further infection, a stern decision was taken to ban any form of public gather until september ( months extension) the first of such a ban globally. that means that events such as sports, music festivals, and religious grouping would not be resuming anytime soon (reuters, e) . but, it was not the only one extending such measure as in pakistan, the lockdown was extended by two more weeks until may , as the country was still experiencing increasing numbers of local transmission of the virus, and the lockdown extension would somehow reverse these trends (cherian, ) . indonesia also joined the list of those that were strengthening their measures after the government announced that it would be temporarily suspending nonessential domestic and international air and sea travel until the end of may to curtail the spread of the coronavirus in the country (bangkok post, ) . others that extended their lockdown include liberia (garda, ) , lebanon (reuters, k) , and czech, which sought parliamentary intervention to allow the extension of the state of emergency until may (xinhua, b) . on the same breath, some countries and states in the united states started easing restrictions to allow the reopening of their economy. these include states such as georgia, oklahoma, and others in the united states, which took these decisions despite the disapproval of president trump (smith, ) . belgium was ready to start reopening some businesses and schools as from may, but gradually and cautiously (martens, ) . although countries were reacting to covid- situations in different ways, some unfortunate news besides new cases and deaths were also reported. for instance, in the united kingdom, which had seen the confirmed cases increase significantly and the number of deaths rising to beyond , there were reports that among the dead were national health service personnel who had paid the ultimate price in a bid to save their country from the pandemic (express and star, ) . in bangladesh, it was reported that frontline doctors had tested positive for the coronavirus due to strains that the covid-i had put on the healthcare system, with most of those in the frontline experiencing a shortage of ppes, test kits, and hospital beds, among other basic essentials (mahmud, ) . elsewhere in japan, after a dreadful experience with the diamond princess cruise ship, on st, another fateful incidence involving an italian cruise ship (costa atlantica) happened in nagasaki shipyard (the japan times, b). it started when one of the crew members tested positive for coronavirus, while of his colleagues were also showing signs, especially high fever. the following day, after contact tracing from the first confirmed cases, another cases tested positive (the straits times, a). h later, another people tested positive (kaneko and kim, ) and by th, a total of people; all crew members were confirmed as testing positive (cna, b) . following this, the japanese government stated that it would test people, out of the who were on board the cruise ship and those who turned negative would be repatriated back to their home countries. as the fifth month, since the onset of the coronavirus, is almost over, the number of those confirmed to have contracted the virus increased to over million people globally, and at least , were reported to have succumbed to the disease. over the same period, of the million, over , patients had recovered (spotlight, ). one country where success against covid- have, and continued to be celebrated, was in wuhan, hubei province, china, where healthy officials reported that they had treated all cases and those who recovered were discharged from hospital (o'donnell, ) . in fact, as previously reported, the restrictions and lockdown in the provinces were lifted including in wuhan, on april (aljazeera, a) . following this, on rd, china pledged additional funding, amounting to $ million, to the who (shih, ) , as already, it could manage the few cases emerging, and the funds could help other areas that were experiencing high pressure from the pandemic. in the new cases, between th and th, china was reported to have only recorded a total of new cases and asymptomatic cases, but no death was reported in the days (who, i). as cases in china reduced, those in the european region seemed to have continued increasing reaching a high of , , cases after the addition of , new cases on th, and the number of deaths increased to , . in the american region, the number of cases was , , and , deaths reported, according to data by the who (who, i). the eastern mediterranean, western pacific, and south-east asia regions had , , , , and , confirmed cases, respectively. the african region continued to show high levels of resilience with only , confirmed cases and deaths reported (who, i). but as the number of cases continued to increase, reports of more countries planning to ease up the lockdown also increased. as of th, italy and spain, two of the most affected countries by the covid- pandemic, with cases of death in each exceeding , (italy , deaths, spain , ) unveiled plans of how they would open up their country as from may . in italy, according to prime minister giuseppe conte, the manufacturing industry would gradually open as from may , but schools would remain closed for three more months until september (kayali, ) . in spain, people would be allowed to walk out for physical activities, but social distancing will have to be observed, as infections in the country were still real (reuters, q) . saudi arabia is another country that considered lifting the nationwide curfew, except for mecca, which remained under -h curfew (aljazeera, h). in germany, after easing the restrictions a few days ago, it is reported that volkswagen was gearing to resume production in their wolfsburg factory on april (allan, ) , the same decision was also taken by bmw company and other companies such as mercedes, jaguar land rover, and others reopening in a few days (reuters, f) . this came as some protests were witnessed in berlin as people demanded the easing of lockdown measures to allow them to return to work (reuters, d) . in the united states, as some states started reopening businesses, the airline industry, which was yet to resume, received support funds amounting to $ . billion -taking their bailout total from the us treasury to $ . billion, with the first disbursement received on april (landay and shephardson, ) . although those countries were gearing to resume business, others insisted on strict measures as cases continued to rise. for instance, the united kingdom maintained the lockdown as it was still not safe from the virus infections (bbc, i). sri lanka also extended the lockdown in the country to counter the increasing number of cases (afp, b). honduras was even considering extending the lockdown by at least one more week until may (reuters, h) . in india, prime minister modi urged his citizens to piously adhere to the nationwide lockdown to contain the rising cases that came amid the month-long curfew (the straits times, d). by april , it became official that the number of covid- infection cases had exceeded the million (the who reported . million cases and , deaths) people and caused the death of over , people globally. of the confirmed cases, over million were reported in the united states while a quarter of reported deaths from the virus coming from the united states. the number of deaths in the country ( , ) even surpassed the total of those who died during the vietnam war between and , where nearly , people died (woodward, ) . in new york, it was reported that for every four people, one of them had contracted the coronavirus. this is after almost , cases had been confirmed, and more than , deaths were reported in the city alone. these numbers in the united states eclipse those of other reported regions. for instance, as of th, the total number of reported cases in africa ( , ) was far much less than the total number of deaths ( , ) reported in the united states on the same day. in addition, they were more than the total number of deaths ( , ) in italy and the united kingdom, which were leading in terms of reported deaths in europe (worldometer, ) . to reduce these unprecedented trends, some states in the united states started testing for asymptomatic residents such as delivery drivers, rideshare drivers, and others. this came as most of the states were planning to reopen by easing the lockdown restrictions, amidst opposition from president trump, and the latest, judge clay jenkins of dallas county, who mentioned the solution, for now, was to follow science and people to stay at home (holcombe, ) . besides the united states, other countries that are yet to experience some reductions in a number of cases include russia, where president vladimir putin stated that the country was bracing for a new and grueling phase of the pandemic (llyushina, ) . his statement came at a time when the number of confirmed cases had continued to stabilize, and the country performed significantly well to reduce casualties. italy, though determined to ease its lockdown restrictions, was experiencing some new cases, with its numbers reaching beyond the , mark. according to the who, africa, eastern europe, latin america, and parts of asia were still not yet out of risk; hence, caution was required even as some actions such as easing the restriction were being taken. this came as eu experts warned that the world would have to wait longer for the vaccine, which would not be ready until the end of , especially considering the cost implications, and other processes that have to be accomplished (cullen, ) . in relation to this, in new york city, it was reported that medical personnel had started testing famotidine; an over-thecounter heartburn medication could cure covid- (lentile, ) . this came as human trials had also started in germany where biontech, a pharmaceutical company was testing its vaccine on volunteers, with participants already having received the dose as from april (aljazeera, f) . as solutions for the covid- continued to be sought, some diplomatic disharmony was witnessed when india canceled orders for , rapid test kits from china after claiming that they were "faulty," and also went forth to withdraw some of the kits that were already in use in several states (bbc, b) . china responded harshly and claimed that it was unfair and irresponsible for india to label chinese products as "faulty" (business today, a). in sports, following the unseen end for the pandemic, french authorities stated that there was no hope for "big sporting affairs" to come back until september in the years, thus, throwing the french football season in disarray, thus, causing them to be canceled (aarons and lowe, ) . the cancellation came as other countries like germany had already announced that the football season (bundesliga) would return in a date to be confirmed albeit under closed doors (bassell, ) . regarding the olympics, the olympics international committee stated that it would cancel the event coming in the next year if the pandemic would not have ended (schad, ) . olympics must be delayed to ensure french football season will not resume but la liga has new hope of restart adb to provide $ million to support strained supply chains in fight against covid- african development bank launches record breaking $ billion "fight covid- leading member of guinea government dies from coronavirus sri lanka extends virus lockdown coronavirus e africa: african union and african private sector launch covid- response fund nigeria orders -day cessation of movement in lagos, abuja to fight coronavirus nigerian president's chief of staff dies from coronavirus china's wuhan ends coronavirus lockdown but concerns remain coronavirus: travel restrictions, border shutdowns by country curfew in mecca, medina extended to hours over coronavirus former libya prime minister mahmoud jibril dies from coronavirus france reports covid- cases on board aircraft carrier germany company begins human trials of coronavirus vaccine one hundered italian doctors have died of coronavirus saudi arabia partially lifts curfew except in mecca volkswagen restart production as european car factories reopen burials on new york island are not new, but are increasing during pandemic risk of hunger pandemic as covid- set to almost double acute hunger by end of hundreds of parishioners attend orthodox easter vigil in georgia apple and google partner on covid- contact tracing technology ( ) china to end lockdown of coronavirus-hit hubei province; wuhan to open next month moscow shuts down all non-essential shops & restaurants to stop spread of covid- trudeau says canada will return asylum seekers to fda authorizes -minute coronavirus test poorest countries finally set to get world bank pandemic bond funds indonesia bans air, sea travel until june over virus fears world bank group president malpass: remarks to the development committee bundesliga return in may now looks inveitable but fans far from happy coronavirus travel: china bars foreign visitors as imported cases rise coronavirus: india cancels order for "faulty coronavirus: italy extends emergency measures nationwide coronavirus: new york has more cases than any country bbc. ( e) coronavirus: new zealand announces lockdown coronavirus: paris bans daytime outdoor exercise coronavirus: prime minister boris johnson tests positive coronavirus: spain plans return to 'new normal' by end of coronavirus: uk must find 'new normal' to ease lockdown e raab formula e: china race called off amid coronavirus outbreak wuhan eases quarantine as coronavirus cases in us pass , singapore closes borders to keep virus at bay, but no shutdown bill & melinda gates foundation, wellcome, and mastercard launch initiative to speed development and access to therapies for covid- uk coronavirus death toll could be far higher than previously shown coronavirus crisis: china fumes over icmr clampdown on 'faulty' rapid testing kits, calls it 'unfair business today. ( b) coronavirus outbreak: india bans international flights till suspends season after player tests positive for coronavirus senate unanimously passes $ t coronavirus stimulus package it's a wreck': . million file unemployment claims as economy comes apart coronavirus disease : cases in the us china's first batch of schools reopens in qinghai province available at south africa president ramaphosa unveils $ bn covid- relief plan coronavirus: who head says nations must attack as 'pandemic is accelerating europe's hospitals among the best but can't handle pandemic pakistan extends lockdown for days, until may south korea throws up innovative tech solutions in coronavirus fight. available at: straitstimes. com/asia/east-asia/south-korea-throws-up-innovativetech-solutions china's imported covid- cases spike as fears grow of second wave covid- tally rises to on italian cruise ship in japan cruise ship stranded by covid- fears to dock in cambodia spain impose nationwide lockdown due to virus, closes all stores except groceries and pharmacies trump address sparks chaos as coronavirus crisis deepens germany's maas: trump coronavirus response took 'too long ignoring expert opinion, trump again promotes use of hydroxychloroquine coronavirus vaccine won't be ready until end of under "most optimistic seven more big cats test positive for coronavirus at bronx zoo donald trump stokes fresh coronavirus row as wuhan reopens global covid- cases near million as putin warns russia faces 'extraordinary' crisis devil's dilemma': france lifts ban on nursing home visits as some warn against relaxing rules coronavirus: what are the lockdown measures across europe? available at map: coronavirus and school closures israel reverses the trend: more coronavirus recoveries than new cases mosques to remain closed, charity iftar tables banned in ramadan negotiations intensify on capitol hill over massive stimulus legislation as coronavirus fallout worsens applications welcome from startups and smes with innovative solutions to tackle coronavirus outbreak commission publishes guidance on export requirements for personal protective equipment the nhs workers who have died during the coronavirus pandemic mcdonald's apologizes after store in china displayed sign banning black people trump signs historic $ trillion stimulus after congress passes it friday senegal bans layoffs during coronavirus crisis cuba closes borders to non-residents over virus: president lebanon announces two-week lockdown over coronavirus us anti-lockdown rallies could cause surge in covid- cases, experts warn cruise ship docks in mexico, passengers allowed to disembark after being denied entry in jamaica, cayman islands amied coronavirus fears cepi invests $ , into potential covid- vaccine from university of hong kong european union leaders denounce trumps coronavirus travel restrictions liberia: president extends lockdown measures for two weeks from april /update foreign travel advice: italy uk helps world's poorest countries withstand the economic disruption of coronavirus latest guard update: more than , troops mobilised for covid- response a fine for not wearing a mask: these are israel's new coronavirus regulations bolsonaro defies coronavirus to rally against congress coronavirus: iran release , prisoners in bid to tackle spread of virus trump invokes defense production act to force gm to make ventilators dallas county judge opposes governor's plan to reopen and calls for residents to follow science and stay home fact sheet: dhs notice of arrival restrictions on china, iran and certain countries of europe together we can with the war against covid- ) imf executive board approves us$ . million in emergency support to albania to combat italian cruise ship in japan has coronavirus cases italy and spain announce plans to ease coronavirus lockdowns further cepi approves $ . m in additional funding for coronavirus vaccine research, bringing total to $ how new york became the epicenter of america's coronavirus crisis ventilators are to this war what missiles were to world war ii un headquarters closes to public as coronavirus precaution real unemployment rate soars past %dand the u.s. has now lost . million jobs spain sees slowing coronavirus toll, holds virtual easter parades airlines receive extra $ . billion in payroll support singapore stops zoom for home-schooling after hacking report famotidine trial underway in nyc for covid- treatment trump declares national emergency e and denies responsibility for coronavirus testing failures russia will "face a new and grueling phase of the pandemic now has million unemployed, wiping out a decade of job gains america is in a depression. the challenge now is to make it short-lived america is in a depression. the challenge now is to make it short-lived hundreds of doctors in bangladesh infected with coronavirus coronavirus: beijing's ban on foreign travellers comes into force months after it criticised other countries for 'isolating china will coronavirus reduce emissions long term? available at belgium to gradually ease virus lockdown in first half of may covid- therapeutics accelerator awards $ million in initial grants to fund clinical trials coronavirus crisis 'like no other' as cases near m: live updates stocks plunge % in dow's worst day since japan declares state of emergency over coronavirus care homes and coronavirus: why we don't know the true uk death toll as virus spreads, africa gets medical supplies from chinese billionaire the dow jones had its biggest point drop in history monday angela merkel's first coronavirus test result is negative panama suspends domestic flights to curb the spread of coronavirus: civil aviation authority germany to reopen schools, shops after 'fragile' success egypt shuts mosques and churches over coronavirus fears china raises wuhan death stats by half to account for reporting delays and omissions goes into -week lockdown trump to suspend immigration to u.s. for days, citing coronavirus crisis and jobs shortage austria reopens thousands of shops in first loosening of coronavirus lockdown nearly % of americans have been ordered to stay at home office of the president. ( a) letter from president donald remarks by president trump and vice president pence at a coronavirus briefing with health insurers governor abbott issues executive order establishing strike force to open texas coronavirus-press-conference- apr .pdf?sfvrsn¼ bd c cd_ cuba is going under lockdown over coronavirus concerns italy joins germany in prolonging lockdown to quell outbreak covid- : how a phone app is assisting south korea enforce self-quarantine measures why is germany's coronavirus death rate so low? available at first yanomami covid- death raises fears for brazil's indigenous peoples spain to extend coronavirus state of emergency as deaths soar connecticut becomes latest state to postpone primary as coronavirus spreads iran begins to open its economy despite fears of second wave of infection brazil's populist president ousted his respected health minister while continuing to downplay the coronavirus pandemic italy's coronavirus death toll surpasses china's japanese pm and ioc chief agree to postpone olympics until ) i.m.f. predicts worst downturn since the great depression states have declared a state of emergency due to coronavirus global coronavirus death toll exceeds , : live updates unprecedented move, treasury orders trump's name printed on stimulus checks austrian joblessness hits record despite government bit to avoid layoffs bolivia postpones elections, announces nationwide -day quarantine to stem spread of coronavirus china's coronavirus epicenter reports just five cases, beijing tomb-sweepers urged to stay back dozens of protesters were arrested in berlin on saturday for flouting lockdown rules and staging a demonstration against lockdown measures dutch extend ban on major public events until sept europe restarts car factories amid uncertain demand global coronavirus cases pass . million as u.s. tally surpasses , honduras extends coronavirus curfew by one week to may italy's coronavirus lockdown measures to be extended to april : minister kazakhstan, uzbekistan close borders after first coronavirus cases kazakhstan-uzbekistan-close-borders-after-first-coronaviruscases-iduskbn ex lebanon advised to extend coronavirus lockdown to may mexico declares health emergency as coronavirus death toll rises nigeria closes land borders to fight coronavirus spread pakistan suspends internationa flights for two weeks portugal to treat migrants as residents during coronavirus crisis saudi top religious authority recommends home prayers in ramadan amid coronavirus spain to allow outdoor exercise if coronavirus cases contine to fall vietnam in talks to borrow $ billion as budget deficit seen widening japan declared a coronavirus emergency. is it too late? available at us senate approves $ bn funding for small businesses rockefeller foundation. ( ) the rockefeller foundation commits $ million in covid- assistance coronavirus: heathrow passenger demand to fall by more than % in april prince albert ii of monaco test positive for coronavirus the coronavirus map in spain: , dead and more than , infected wwe announces layoffs two days after florida deems company an 'essential business tokyo olympics will be canceled, not delayed, if coronavirus pandemic still poses threat in as italy covid- cases soar, who tackles ppe, test shortages gaming sales are up, but production is down donald trump threatens to freeze funding for who new york city public schools to close to slow spread of coronavirus trump extends social distancing guidelines through end of april china pledges additional $ million funding for world health organization india extends ban on international flights until airlines seek $ billion coronavirus aid package coronavirus deaths surpass , , hhs watchdog says american hospitals face 'severe' shortages of equipment, staff and tests china reports zero new local coronavirus infections; trump signs bill to ensure paid leave, other financial benefits too soon': trump disagrees with georgia governor's decision to reopen businesses coronavirus deaths in italy up by in a day to , global death toll from coronavirus tops greece to go into coronavirus-induced lockdown crash! us crude futures turn negative for first time in history white house expected to urge americans to wear face coverings in public to slow spread of coronavirus government bans exports of certain masks, ventilators, raw material for masks zimbabwe shuts borders after first coronavirus the herald. ( ) breaking: air zim sends workers on unpaid leave japan to declare nationwide state of emergency as virus spreads the japan times. ( b) one crew member tests positive, feverish on cruise ship in japan. available at the nation. ( ) pm announces pm to am nationwide curfew gives new guidelines, new york to close restaurants and schools and italian deaths rise the new york times. ( b) u.s. now leads the world in confirmed cases. available at statement from the r&a/the open in to be cancelled china reports newly imported covid- cases and one in wuhan cases-on-cruise-ship-docked-fo r-repairs. the straits times. ( b) china tightens russian border checks, approves experimental coronavirus vaccine china's imported coronavirus cases soar, no local transmission for third straight day the straits times. ( d) indian pm modi urges citizens to follow lockdown as coronavirus cases rise boris johnson's move from intensive care to a general ward is the lift britain needed world bank group increases covid- response to $ billion to help sustain economies world's first covid- immunity cards are coming to chile more than million people tested for coronavirus in us, but access varies from state to state georgia proposes -day lockdown of four cities including capital uk not thinking of easing virus lockdown measures yet: minister the tour de france greece to gradually start lifting lockdown measures on may . available at: greece to gradually start lifting lockdown measures on key cop climate summit postponed to 'safeguard lives secretary-general's remarks at launch of global humanitarian response plan for covid- african finance ministers call for coordinated covid- response to mitigate adverse impact on economies and society a global approach is the only way to fight covid- , the un says as it launches humanitarian response plan coronavirus: boston celtics guard marcus smart tests positive for covid- chinese businessman to donate , test kits and million masks to the world health organization has distributed . million coronavirus lab tests around the world global covid-zero initiative launched to fill $ bn shortfall for coronavirus response chicago's largest jail reports inmates, staff positive for coronavirus two los angeles lakers players have tested positive for covid- , team says president donald j. trump is beginning the next phase in our fight against coronavirus: guidelines for opening up america again australia bans overseas travel and extends social restrictions situation report - . available at who. ( b) coronavirus disease (covid- ): situation report - . available at who. ( c) coronavirus disease (covid- ): situation report - . available at who. ( d) coronavirus disease (covid- ): situation report - . available at who. ( e) coronavirus disease (covid- ): situation report - . available at who. ( f) coronavirus disease (covid- ): situation report - . available at who. ( g) coronavirus disease (covid- ): situation report - . available at who. ( h) coronavirus disease (covid- ): situation report - . available at who. ( i) coronavirus disease (covid- ): situation report - . available at who. ( j) coronavirus disease (covid- ): situation report - . available at who. ( k) coronavirus disease (covid- ): situation report - . available at who. ( l) coronavirus disease (covid- ): situation report - . available at who. ( m) coronavirus disease (covid- ): situation report - . available at who. ( n) coronavirus disease (covid- ): situation report - . available at who. 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( ac) opening statement who director-general's opening remarks at the media briefing on covid- e who director-general's opening remarks at the media briefing on covid- e who director-general's opening remarks at the media briefing on covid turkey to free one-third of its prisoners to curb coronavirus ebrd unveils v billion emergency coronavirus financing package inquiry after of french aircraft carrier's crew catch coronavirus coronavirus: nuggets report member of organization tested positive for covid- who chief warns against 'politicizing' coronavirus unless 'you want to have more body bags world food programme. ( ) statement from wfp executive director david beasley report coronavirus cases remote chinese city hit by coronavirus after weeks of feeling safe africa's covid- death toll hits , , as confirmed cases rise to czech parliament oks extending state of emergency until except wuhan, china's hubei reopens domestic flights what the u.s. needs to do today to follow south korea's model for fighting coronavirus how taiwan is containing coronavirus despite diplomatic isolation by china three members of the philadelphia ers organization test positive for coronavirus china sees rise in asymptomatic coronavirus cases, to tighten controls at land borders key: cord- -bg y nsp authors: cantais, aymeric; mory, olivier; pillet, sylvie; verhoeven, paul o.; bonneau, julie; patural, hugues; pozzetto, bruno title: epidemiology and microbiological investigations of community-acquired pneumonia in children admitted at the emergency department of a university hospital date: - - journal: j clin virol doi: . /j.jcv. . . sha: doc_id: cord_uid: bg y nsp background: the management of children with community-acquired pneumonia (cap) is largely influenced by the development of new molecular diagnostic tests that allow the simultaneous detection of a wide range of pathogens. objectives: evaluation of a diagnostic approach including multiplex pcr assays for revisiting the epidemiology and etiology of cap in children at hospital. study design: children of all ages consulting at the emergency department of the university hospital of saint-etienne, france, during the – winter period were included. in addition to bacterial cultures, the following pathogens were detected using biplex commercially-available rt-pcr tests: adenovirus, respiratory syncytial virus, human metapneumovirus, bocavirus, rhinovirus/enterovirus, coronavirus, influenza viruses a and b, parainfluenza viruses, mycoplasma pneumoniae and chlamydophila pneumonia. results: from patients with cap, at least one pathogen was identified in cases ( . %), including bacterial exclusive infections ( . %), viral exclusive infections ( . %) and mixed infections ( . %). coinfection by at least two viruses was observed in cases ( . %). mean age was higher in the case of documented bacterial infection (p < . ). in the subgroup of viral exclusive infection, the mean age of severe cases was . years vs . years in mild and moderate cases (p < . ). conclusions: these findings highlight the huge proportion of cap of viral origin, the high number of co-infection by multiple viruses and the low number of bacterial cap, notably in children under years, and address the need to re-evaluate the indications of empiric antimicrobial treatment in this age group. community-acquired pneumonia (cap) is the leading cause of death in children under five years of age in the world [ ] . in developed countries, the systematic prescription of antimicrobial drugs to patients with cap has led to a dramatic reduction in mortality linked to this pathology [ , ] . however, a bacterial origin of cap has not been documented in a large proportion of cases despite extensive aetiological investigations. the current recommendations [ ] [ ] [ ] encourage pediatricians to prescribe a probabilistic antimicrobial treatment, even when no bacterial infection is documented, which results in prolonged use of antibiotics and in the possible selection of resistant strains within the endogenous flora [ ] . until the beginning of the current century, the absence of documented bacterial infection was attributed to the difficulty in obtaining deep respiratory specimens that are not contaminated by bacteria from the local flora [ ] together with the lower sensitivity of blood cultures in proving bacterial sepsis [ ] . at this time, most of the epidemiological data from pediatric cap relied on traditional bacteriological cultures. with the occurrence of new diagnostic tools and notably of multiplex pcr assays able to simultaneously detect a large panel of viruses and atypical bacteria, it now appears that a large proportion of cap could be related to viral infection [ ] [ ] [ ] . many studies have evaluated these new tools but most of them were limited to subgroups of children notably to the young [ , ] , to hospitalized children [ , [ ] [ ] [ ] [ ] [ ] , or for selected pathogens [ , , , ]. the aim of the present study was to document the presence of a large variety of pathogens in respiratory specimens from children attending the pediatric emergency department of the university hospital of saint-etienne, france, during a six-month period and presenting a cap based on clinical and radiological evidence. the microbiological diagnostic approach combined bacterial cultures and biplex commercially available rt-pcr tests detecting a wide range of respiratory pathogens. a single center epidemiological observational study was conducted over a six-month period (november to april ) on children aging from one month to . years and presenting with cap at the pediatric emergency department of the university hospital of saint-etienne, france. the study was submitted for approval to the local ethics committee. after oral information was given together with a form explaining the content of the research, a consent form was signed by a parent or legal tutor before inclusion of each patient. a cap case was defined [ ] as a subject with fever of at least . • c, an age-corrected polypnea [ ] and a chest radiograph showing images of acute pneumonia confirmed by a second examiner (a pediatric radiologist for ambulatory children or a pediatrician for hospitalized patients). a few subjects were excluded after this second reading, notably in the case of associated bronchiolitis. the data collected at inclusion comprised the demographic characteristics of the child, their vaccine status, the smoking habits of parents, the date of the beginning of the current respiratory episode and the drugs, including antimicrobials, that they received during this period. according to the current guidelines [ ] [ ] [ ] , a pneumonia was defined as severe for this study if the patient presented at least one of the following criteria: respiratory rate above per minute in infants less than year of age and above per minute for older children, a tachycardia adjusted to age, a capillary refill time > s and an oxygen saturation < %. a control visit was systematically carried out at days and either by phone call for ambulatory-treated children or after a physical examination in the service of hospitalization for children admitted to hospital. a number of biological parameters were recorded systematically, including c reactive protein (crp), procalcitonin (pct), white blood cell count and natremia. nasopharyngeal secretions obtained by sputum induction [ , ] were sampled at entry for all the participants. the following tests were performed at inclusion: standard detection of conventional bacteria by culture, detection of five different viruses (respiratory syncytial virus (rsv), influenza viruses a and b, parainfluenza viruses, metapneumovirus and adenovirus) by indirect immunofluorescence (ifi) assay and detection of atypical bacteria by pcr as previously described [ ] . in parallel, blood cultures and pneumococcal antigenuria were tested if prescribed by the clinician, notably in the case of hospitalization. in addition to the test listed above that were performed at the time of hospital attendance, a rtpcr assay was performed at the end of the study on an aliquot fraction kept frozen at − • c for the whole panel of nasopharyngeal aspirates, as previously described [ ] . briefly, l of aspirate was extracted on nuclisens ® easymag tm (biomérieux, marcy l'etoile, france). the respiratory multi well system (mws) r-gene tm (chla/myco pneumo, influenza a/b, rsv/hmpv, ad/hbov, hcov/hpiv, and rhino&ev/cc) from biomérieux was used for molecular testing. it consists of a series of biplex assays detecting either a couple of pathogens or a single pathogen and a cell control (cc) attesting for the presence of cellular nucleic acids within the specimen. the following pathogens were tested: mycoplasma pneumoniae and chlamydophila pneumoniae, influenza viruses a and b, rsv and human metapneumovirus (hmpv), adenovirus (adv) and bocavirus (bov), parainfluenza viruses and coronaviruses, rhinovirus/enterovirus (hrev) and a cell control. an univaried analysis was performed to compare the cases documented as probably related to a bacterial infection (threshold of cfu/ml for conventional cultures [ , ] or the presence of atypical bacterium by pcr in nasopharyngeal aspirates), and the others. comparisons adjusted for age, severity of pneumonia and mono/multiple infection were also performed. the chi-square test or the fisher exact test was used to compare qualitative variables whereas the student t test was used for quantitative variables. a p value of . was considered as statistically significant. a multivariate analysis of factors independently associated with detection of bacterial was secondarily performed; the parameters included in the logistic regression model were those with p < . by univaried analysis. over the six-month period of the study, children thought to have cap were included; of them were excluded secondarily, comprising cases with non-cap infection, cases without nasopharyngeal aspirate and one case of cap whose inclusion was not consented by the child's family. with reference to the total number of cases of cap recorded over the same period in the pediatric emergency department (n = ), the representation rate was of . % ( / ). the demographic and clinical characteristics of the included cases together with the mode of management (ambulatory or hospital) and the probabilistic antimicrobial treatment are listed in table . apyrexia was observed in . and . % of cases at day and , respectively. from the children hospitalized at entry, ( . %) and ( . %) were still hospitalized at day and , respectively. only one child needed intensive care within the pediatric intensive care unit. the antimicrobial treatment was modified in only three cases. neither fatal cases nor immediate sequelae were observed during the study. twenty-six cases ( . %) were classified as severe cap. the general biological characteristics of the included cases were as follows: the median count of leukocytes was . per liter (interquartile range . - . ), with . % of neutrophils; the crp median rate was of . mg/l (interquartile range: - ), the pct median rate was of . g/l (interquartile range: . - . ); an hyponatremia (< meq/l) was observed in cases ( %). by using ifi prospectively, only of the nasopharyngeal aspirates ( . %) were found positive, including rsv, adv and influenzavirus b; all of these infections were confirmed by the retrospective rt-pcr assay. the pneumococcal antigenuria, available in cases, was positive in patients, of them exhibiting a threshold of cfu/ml by conventional culture. in the three other pneumococcal infections, no antigenuria was available. blood culture, performed in cases ( %), was found positive for streptococcus pneumoniae in only one case. by combining bacterial culture and retrospective rt-pcr assays, at least one pathogen was identified in cases ( . %). the number of detected pathogens was of , , , , and in ( . %), table ) . from the cases of cap, bacterial exclusive infections were observed ( . %), infections with at least one bacterium and one virus ( . %) and viral exclusive infections ( . %). coinfection by at least two viruses was observed in cases ( . %). table displays the distribution of the identified pathogens and specifies the various associations, the most common being adv/rsv ( cases), haemophilus influenzae/adv( cases) and hrev/bov ( cases). the monthly distribution of microbiological infections is depicted in fig. . as shown in table , none of the variables tested was statistically correlated to the presence of a bacterial pathogen by univaried analysis, with the exception of age that was higher in the case of documented bacterial infection (mean age of . vs . years; p < . by student t test) and the presence of abdominal pain at clinical examination at entry (p = . ). concerning biological parameters, no correlation was observed between bacterial and non-bacterial cases for the most of them, notably for crp and pct, with the exception of the white blood cell count that was higher in case of viral infection. severity was statistically associated neither to the bacterial or non bacterial etiology of cap, nor to a younger age, except in the subgroup of viral exclusive infection (n = ), in which the mean age of severe cases was . years vs . years in mild and moderate cases (p < . by student t test). coinfection was not associated to a younger age or a more severe disease, even if the number of detected pathogens tended to be related to the severity of cap ( . infected agents in severe cases vs . in non-severe cases, p = . by student t test). by multivariate analysis, none of the tested variables was independently associated with bacterial infection. the demographic characteristics of the included patients were coherent with those of the literature [ ] in terms of age (median age of . years; interquartile range: . - . years) and sex ratio ( . to the benefit of males). those patients with cap were shown to exhibit different risk factors as illustrated by a lower vaccination coverage as compared to that of the french population, an elevated rate of previous hospitalization ( / , . %), a history of frequent respiratory disease ( / ; . %) and a high level of smoking habits in parents (table ) . approximately children out of reached hospital without having consulted another physician; most of them had already received an antipyretic treatment, mainly acetaminophen but also non-steroidal anti-inflammatory drugs (nsaid), despite the fact that the use of nsaid may be harmful [ ] . at entry, . % ( / ) of children had received an antimicrobial treatment. in most cases, the first choice for antimicrobial drug was amoxicillin, as currently recommended [ ] [ ] [ ] . despite the limited size of the present study and its restriction to a single center, its originality lies in the diversity of the included table detailed presentation of cases of community-acquired pneumonia exhibiting an infection with at least pathogens. gray boxes indicate the total number of positive cases for each pathogen. white boxes corresponds to the cases with co-infection. from a microbiological point of view, it is first useful to justify the definition of what level of detection constitutes a causative agent in children with cap included in this study. concerning bacterial loads, the threshold of cfu/ml was retained as recommended by european experts when induced sputum specimen are used [ ] . it helps the discarding of pneumococcal colonization with prevalence of up to - % in children of less than years old [ , ] from true infection. by contrast, "the asymptomatic carrier state of viruses is rather uncommon for most respiratory viruses [ , ] , apart from the post active phase of respiratory virosis" [ ] , which justifies to consider the detection of viral genome in respiratory specimens as a marker of probable viral infection. in the more exhaustive studies performed earlier, the percentage of elucidated cases from a microbiological point of view ranged from % to % [ , , ] whereas it was of . % in the present study detecting a wide spectrum of infectious agents with respiratory tropism. as reported earlier [ ] , viral infections were shown to be predominant in children under years of age and only % of all cap were found to be of bacterial origin. eighteen children received antimicrobial therapy before emergency consultation, which could be considered as a source of false-negative culture. however, all of them were always symptomatic at entry, which implies that a bacterium, if present, had a significant opportunity to be recovered by culture. an interesting finding of this study is the large proportion of viral coinfection ( . %), much higher than that previously reported [ , , ] , notably for bocavirus, metapneumovirus and adenovirus that were detected in association with at least one other virus in more than % of the cap cases involving these agents ( table ). it has been suggested that infection by several viruses could enhance the severity of cap [ , [ ] [ ] [ ] . in the present study, a trend was observed in the association between the mean number of infectious agents and the severity of cap as defined above (p = . ); a larger effective size would have been needed to determine a statistically significant difference. in terms of clinical evolution, neither death nor major complications were reported in this study, despite rates of . % for severe pneumonia and . % for hospitalization. there was no statistical difference in the severity of cap between viral and bacterial infections. almost all of the children received antibiotics, which was unnecessary in a large proportion of cases ( . %) for which only viruses were detected. this finding raises the question of the systematic use of antimicrobials to treat childhood cap, which is still recommended in different guidelines [ ] [ ] [ ] . the present findings, together with those of others, allowed the identification of a subpopulation of children less than years of age with mild or moderate symptoms for which a viral etiology of cap is highly probable. this situation represents half of the cases recorded in this study: children ( . %) were less than five-years old, and of them presented a mild or moderate cap, which corresponds to . % of all cases. the use of a rapid molecular test detecting a large set of viral and bacterial pathogens within or hours, such as that described in [ ] , would allow an improvement in the management of the antimicrobial treatment. in the case of positive result, it would be recommended to avoid the use of amoxicillin as a first-intent therapy (or to prescribe erythromycin in the case of detection of an agent of atypical pneumonia) and to reconsider the use of antimicrobial treatment - h later according to the clinical evolution and to the results of bacterial cultures. conversely, the negativity of the rapid test would lead to the empiric prescription of amoxicillin, as currently recommended [ ] [ ] [ ] . it is obvious that this attitude would be dedicated to cap with mild or moderate symptoms and that cap with severe presentation at entry should include a systematic probabilistic antimicrobial therapy, whatever the results of pcr assay. the present results are indicative that this strategy could dramatically reduce the proportion of unnecessary antimicrobial treatments in mild or moderate child cap. wider studies are needed to prospectively evaluate the benefits of this approach in terms of patient recovery, prevention of antibiotic resistance and medical economy. the reagents used for the retrospective analysis were funded by a grant from the medical association of pediatricians of the university hospital of saint-etienne for research and studies (aderps), france. from the medical association of paediatrician of the university-hospital of saint-etienne for research and studies (aderps). who estimates of the causes of death in children global, regional, and national causes of child mortality in : a systematic analysis epidemiology and etiology of childhood pneumonia the management of community-acquired pneumonia in infants and children older than months of age: clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of america japanese guidelines for the management of respiratory infectious diseases in children with focus on pneumonia british thoracic society guidelines for the management of community acquired pneumonia in children: update antibiotic therapy for pediatric community-acquired pneumonia: do we know when, what and for how long to treat? breathing new life into pneumonia diagnostics blood culture is poor method of confirming pneumococcus as cause of childhood pneumonia association of human metapneumovirus with radiologically diagnosed community-acquired alveolar pneumonia in young children comprehensive detection of causative pathogens using real-time pcr to diagnose pediatric community-acquired pneumonia viruses in community-acquired pneumonia in children aged less than years old: high rate of viral coinfection etiology of community-acquired pneumonia in hospitalized school-age children: evidence for high prevalence of viral infections etiology of community-acquired pneumonia in hospitalized children based on who clinical guidelines community acquired pneumonia -a prospective uk study epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children human metapneumovirus and community-acquired pneumonia in children development of three multiplex rt-pcr assays for the detection of respiratory rna viruses role of mycoplasma pneumoniae and chlamydia pneumoniae in children with community-acquired lower respiratory tract infections diagnostic value of tachypnoea in pneumonia defined radiologically comparing nose-throat swabs and nasopharyngeal aspirates collected from children with symptoms for respiratory virus identification using real-time polymerase chain reaction induced sputum in the diagnosis of childhood community-acquired pneumonia development and evaluation of chlamylege, a new commercial test allowing simultaneous detection and identification of legionella, chlamydophila pneumoniae, and mycoplasma pneumoniae in clinical respiratory specimens by multiplex pcr comparative evaluation of six commercialized multiplex pcr kits for the diagnosis of respiratory infections european manual of clinical microbiology pneumonia methods working group, et al. laboratory methods for determining pneumonia etiology in children prevalence and risk factors of suppurative complications in children with pneumonia indirect effect of -valent pneumococcal conjugate vaccine on pneumococcal colonization among unvaccinated household members the descriptive epidemiology of streptococcus pneumoniae and haemophilus influenzae nasopharyngeal carriage in children and adults in kilifi district impact of viral infections in children with community-acquired pneumonia: results of a study of respiratory viruses human bocavirus: a novel parvovirus epidemiologically associated with pneumonia requiring hospitalization in thailand unsolved problems in the approach to pediatric community-acquired pneumonia comparison of the idaho technology filmarray system to real-time pcr for detection of respiratory pathogens in children the authors are indebted to the patients' families who gave their consent for participating to this study. philip lawrence is warmly acknowledged for his careful checking of english language. the reagents used for the retrospective analysis were funded by a grant the authors declare that they have no conflict of interest regarding the object of this study. the study was submitted for approval to the local ethics committee. key: cord- - rk ef authors: etchenique, r.; quiroga, r. title: estimate of the actual number of covid- cases from the analysis of deaths. date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: rk ef using the calculated values for the infection fatality rate (ifr) of covid- it is possible to estimate the prevalence of cases of infection in the city of buenos aires, argentina, throughout the pandemic. the use of confirmed cases as a metric and their replacement by more reliable parameters such as death figures are discussed. the results are analyzed according to age ranges and possible sources of error in the estimates are established. the number of confirmed cases of covid is usually established in all countries through testing (usually rt-qpcr) which is done under passive (person using the health system) or active surveillance plans (search and tracing of cases through street or home operations). there are enormous differences between the various testing systems, which leads to very different figures of positivity: from more than tests/case confirmed (new zealand) to . test/case confirmed (mexico). argentina is close to the lower limit, with only . tests/cc, which corresponds to a positivity in the order of %. [ ] . these differences make virtually useless the comparisons of case numbers between countries, between districts within a country, or even between different times within the same district or country, as the number of confirmed cases is strongly influenced by the testing strategy. while with low positive rates and efficient tracking a high percentage of actual cases can be detected, in a test saturation situation the proportion of detected cases to real cases can be very low. for this reason it is convenient to use other methods for prevalence estimation, which do not imply the use of the number of confirmed cases, which is of little value. in countries in advanced stages of the epidemic it is useful to use the number of deaths. statistically, the relationship between infected and deaths has been estimated through large serology studies [ ] . one of the most advanced studies was done in spain, using seroprevalence studies, distributed by age and district [ ] . by having the fraction of igg positive in each age range, and the data on deaths due to covid- , which are more reliable than confirmed cases (despite possible undercounts, vide infra) it is possible to determine the infection-fatality ratio (ifr) for each age range. through these rates it is possible to determine the probable number of actual cases of infection that generated a certain number of deaths. this can be done in multiple ways. a rule-of-thumb rule known as garber's theorem was used, estimating the infections as times the deaths figures. guillermo durán and rodrigo maidana calculated the proportion of cases detected in each province of the country, [ ] as shown in table . this estimate uses the age pyramid of each district to calculate the expected ifr if the prevalence of infections was homogeneous in all age groups. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . this calculation considers that the infections are reflected in deaths days after they occurred, which is a reasonable approximation, compatible with the data obtained from the argentinean centralized data system (sisa). with this estimate it is possible to reconstruct the current value of prevalence by extrapolating the values according to the rate of increase of deaths in recent weeks. however, there are strong reasons to expect that the prevalence will be higher in some particular age groups. therefore, these estimates may be closer to reality if we take into account the true age pyramid of deaths, which will have in its composition not only the population age pyramid and the ifr of each range, but also the proportion in which, due to behavioral differences, each age range is susceptible to infection. this preliminary work addresses the case of the autonomous city of buenos aires (caba) as an example for the determination of infections by the ifr method of cases of death. the basis of the proposed calculation is to use the reciprocal function of the ifr, which indicates the number of infections corresponding to each death. although this can be done directly with the data of each range, we chose to fit a smooth log-polynomial curve (to reduce the noise of the determination) to the ifr values obtained from the spanish study. to do this, equation ( ) was fitted to the centers of the ranges referred to in table . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . figure shows the result of the transformation of each death in a number of cases according to the curve in figure for caba. the high peaks that are seen are the product of the few deaths that occurred in individuals of low age, which are interpreted as the product of a large number of point infections with a delay of days in their death with respect to the date of infection. while these curves can be smoothed out, they do not reflect the likely dynamics of the deaths. it is important to note that the final drop does not correspond to a real trend but rather to the undercounting of deaths by two factors: ) the infection-death time is very variable and ) many districts are slow to register a large proportion of deaths in the system. thus, each death registered in the argentinean integrated health information system will have a previous number of cases /ifr. although this number of estimated actual infections can be entered in a single day, in that case the temporary values obtained will be noisy, especially for the age ranges of lower ifr. to eliminate these problems, an infection-to-death function obtained from the experimental data was used. figure shows the histogram from the recorded date of symptom onset to the date of death. the data were fitted with the following empirical expression: once this statistical dependency is established, each death will be counted as /ifr number of cases distributed in the previous days according to the previous curve. a typical result of this procedure is shown in figure . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint the local maxima observed in mid-may and june correspond to events of death of young people with very low ifr. if restricted to those over years of age, the dependency takes on the appearance of figure . the decrease observed at dates at the end of the graph, close to that of the used dataset is again the result of data censoring. many cases of infection that will end in death are not yet counted, and a proportion of cases that have already died have not been loaded into the system. to solve this problem, a normalizing function was built by using the data recorded on / / and comparing it with the data from / / , the date on which all the july data are supposed to be stable. this function is defined by the following empirical expression equation ( ) in which t is the temporal distance in days between the last date of the dataset and the date of estimated cases of infection, a = . and b= . , values obtained by fitting the old data to the new one using the transformation d old •y = d new the result of applying this transformation is shown in figure . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. since the data have been obtained with ifr as a function of age, it is possible to determine the dynamics of each age range individually. the result, once normalized, is shown in figure . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the time integration of the curves in figure corresponds to the cumulative prevalence for the city of buenos aires and can be seen in figure . the estimated prevalence as of august , is shown in figure . the use of "confirmed cases" as a widespread metric throughout the world, especially in the media and social networks has many implications not usually considered. one of them is the factual impossibility of comparing situations in different regions, countries, districts, and even within the same area at two different times. this is because the relationship between "confirmed cases" and actual cases of sars-cov- infection is extremely uncertain, and depends heavily on the testing policy and strategy and the capacity of the system to manage large numbers of infections in a timely manner. only a tiny minority of countries have achieved a testing system that roughly reflects the actual number of infections, which is particularly difficult since many of them are asymptomatic, with estimates varied from % to % of those infected. [ , ] the terminology frequently used in the media, calling confirmed cases "contagions", suggests that this number of reported cases actually corresponds to those infected. however, it is common to find whole countries where the number of confirmed cases can be estimated to be - times lower than the actual number (e.g., belgium) or cities where the ratio was to (london). this effect is exacerbated when in a situation of mass transmission and system saturation. the mandatory social preventive isolation (aspo, from its initials in spanish) was nationwide in argentine at march th, and was effectively complied with in all districts for approximately to weeks. from that moment on, different districts carried out different policies in the management of the pandemic. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . in particular, the autonomous city of buenos aires had an openness policy from the beginning, taking to the extreme the original idea of "flattening the curve" of infections (aka mitigation, as contrary to suppression) so that the population would be infected at a low rate in order to prevent the collapse of the health system, but not adopting active policies that would try to eliminate or reduce the number of daily infections. additionally, the policy of control and sanitary isolation of those who arrived in argentina in repatriation flights from countries with very high viral circulation was not very effective. they were isolated in hotels, with subsequent swabbing and return home in case of negative results. the high rate of false negatives in pcr during the first days after infection [ ] , and the possible subsequent failure to comply with the mandatory isolation in homes, may have produced a continuous influx of infected during the months of march to june, which may explain the inability to reduce cases to very low levels as happened in the rest of the argentine provinces. after months of rising daily confirmed cases, the dynamics of cases in caba began a series of rises, stabilizations and gentle declines that remained around the confirmed cases per day on average. this trend is shown in figure . however, the positivity of the tests in the order of to % on most days indicates that the actual number of cases per day should be much higher than those reported. for this purpose, the number of deaths through the ifr can be used, obtaining the dynamics shown in figure and following. through this analysis, it can be seen that the curve of cases estimated from the ifr is approximately times higher than the curve of confirmed cases, indicating that % of cases go undetected. on the other hand, the shape of the curve of confirmed cases shows a saturation effect that is not observed in the curve of infections estimated from the ifr, suggesting that the limit imposed by the testing system is . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint responsible for the high positivity and the subsequent loss of cases. this behavior can be seen in figure . this ratio of approximately to has important consequences when analyzing the situation of the city. the most important is that the number of confirmed cases accumulated at the end of august corresponds to approximately . % of the total population. this number sets a lower limit for cumulative prevalence. in contrast, the integration of the cases estimated by ifr corresponds to % of the total population of caba, which would indicate a completely different situation. the analysis by age range of this % indicates that while in the range of to years the contagion would reach about % of the population, the prevalence in senior citizens is much lower. this may be due to fewer daily social contacts by seniors [ ] , the greater caution they have taken to protect themselves from the virus (fright immunity, "inmunidad de cagazo" in original argentinean slang) and/or the fact that people in their s and s make up the majority of active workers. there were no specific health measures to reduce the exposure of the older population, except for some preventive and early detection measures in geriatric hospitals. on the other hand, despite the noise inherent in the low ifrs of these age ranges, the curves corresponding to individuals aged - years suggest stagnation, perhaps due to the higher rate of previous infection. this trend is not clearly seen in the other ranges. if this is indeed the case, this situation poses an imminent danger. by lowering the number of daily cases due to the reduction of the susceptible population through infection in conjunction with reduced mobility and social connectivity through current health regulations, the recovery of confidence and "back to normality" of the elderly in an environment of high viral circulation could lead to a significant increase in the death rate without a large prior increase in the number of cases, given the high ifr in adults over . however, the case growth curves shown in figure suggest that an overall prevalence of %, with peaks of % in the most mobile sector of society may be the result of an underestimation of the ifr. assuming that individuals are immune to reinfection (at least in short time), for the values of the expected and estimated r reproduction number in conditions of social distancing, and confirmed by the low slope of the infection curve, a cumulative prevalence of % should be accompanied by a clear lowering of cases, beyond the sanitary measures provided, which is not observed, although it is glimpsed in the last week analyzed. a possible source of error is the undercounting of deaths in spain, which is known given the figures of excess death over previous years. while the confirmed covid deaths as of june are , , the excess deaths for that date total , . some of these deaths may be due to the collapse of the health system, but many others probably correspond to unrecorded cases of covid- . this could raise the ifr values to twice their reported value. if this were the case, the cumulative prevalence values in caba could be around %. the only prevalence study made public in caba was conducted between may and july , and indicated about % for the estimated dates [ ]. however, this low prevalence would indicate that the ifr values in argentina would be much higher than the values reported in europe. on the other hand, the unreported deaths in spain are considered to have occurred primarily among older people, many of whom lived in nursing homes. this would imply that only the ifrs in these ranges would be higher, further lowering the calculated prevalence. another possible cause of error due to excess prevalence could be the socioeconomic conditions of caba, which on average could be worse than the spanish average weighted by the regions where there were more infections. this situation could be aggravated by factors related to the health system. however, although this could be the reality in other regions of argentina, the city of buenos aires has a gdp/capita of values close to those of europe, although much more unevenly distributed. this situation could distort the age distribution of the ifr. of these possible causes of error, the underestimation of the ifrs in spain due to the undercounting of deaths by covid is more plausible. more recent estimates of ifr values [ ] using the figures for excess deaths during the initial period of the pandemic in spain tend to confirm this possibility. although these new values are erratic in the lower age ranges, due to a significant amount of excess deaths which do not necessarily have to be attributed to covid- , a log-linear extrapolation to these low ranges allows estimating these ifr values. on the other hand, this new work does not differentiate between the - and + age ranges, an aspect that is particularly important due to the large difference in ifr observed between the - and + age groups. figure shows the ifr values corresponding to both estimates. using the loglinear expression for the corrected ifr, the prevalence values of figure b are obtained, more in accordance with the observed slope in cases and death curves. other considerations will be . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint included in future versions of this work and it will be extended to other districts where death analysis is possible. figure . a) ifr originally calculated from confirmed covid- data deaths from spain. diamonds: raw ifr by age range. blue line: log-polynomial interpolation. squares: new ifr using excess of deaths as estimator. red line: loglinear interpolation, without taking into account the lowest age ranges. b) accumulated prevalence at / / in the autonomous city of buenos aires according to age range, estimated from ifr values using excess deaths values. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint prevalence of sars-cov- in spain (ene-covid): a nationwide, population-based seroepidemiological study sars-cov- infection fatality risk in a nationwide seroepidemiological study estimating the extent of asymptomatic covid- and its potential for community transmission: systematic review and metaanalysis covid- : four fifths of cases are asymptomatic, china figures indicate recommendations for sars-cov- /covid- testing: a systematic review to consolidate guidance for policy and practice social contacts and mixing patterns relevant to the spread of infectious diseases re and rq are members of conicet. fruitful discussions with g.duran, r.castro, j.aliaga and j.tiffenberg are kindly acknowledged. key: cord- - r lsq authors: martinez, edson zangiacomi; aragon, davi casale; nunes, altacílio aparecido title: long-term forecasts of the covid- epidemic: a dangerous idea date: - - journal: revista da sociedade brasileira de medicina tropical doi: . / - - - sha: doc_id: cord_uid: r lsq introduction: mathematical models have been used to obtain long-term forecasts of the covid- epidemic. methods: the daily covid- case count in two brazilian states was used to show the potential limitations of long-term forecasting through the application of a mathematical model to the data. results: the predicted number of cases at the end of the epidemic and at the moment that the peak occurs, is highly dependent on the length of the time series used in the predictive model. conclusions: predictions obtained during the course of the covid- pandemic need to be viewed with caution. in december , in wuhan, china, a new beta coronavirus was discovered. in january , the world health organization declared this outbreak to be a global health emergency and named the correspondent disease as coronavirus disease (covid- ). since then, global efforts are being made to find solutions for the management of covid- . among other important contributions, mathematical and statistical models are being used to forecast the short and long term course of the covid- epidemic in a given population; these results are useful for estimating medical capacity requirements and to keep the public and decision-makers informed. however, it is well-known that these forecasts are very difficult, as they hinge critically on the change of epidemiological parameters in response to interventions . forecast models are based on the premise that, "the most reliable way to predict the future is understand the present" and, for this reason, these models do not say what will actually happen in the future, but say what can happen if the conditions observed in the present do not change. based on this idea, in mid-march , prof. neil ferguson and his colleagues at imperial college's mrc centre for global infectious disease analysis presented the results from a mathematical model that indicated that the united kingdom's health service would soon be overwhelmed with severe cases of covid- and more than , deaths, if the government did not take action , . this model also suggested that, in the absence of action, . million people would die from the disease in the united states . these predictions were based on some assumptions regarding the natural history and clinical management of the covid- epidemic, including incubation period, infectiousness before symptom onset, mean generation time, and the basic reproduction number . however, during a pandemic it is very difficult to get reliable data, especially in cases where knowledge about the disease and the biopathogenic characteristics of its etiological agent, is limited. the imperial college model was criticized for not utilizing actual data, but ferguson defended the results by arguing that "models are not crystal balls", but tools to provide simplified representations of reality , . during the course of the covid- pandemic, a number of authors used simpler models than the one proposed by the imperial college to attempt long-term forecasts of the number of cases , . however, many of these models are based only on mathematical premises, while there are many unquantifiable factors like changes in public health policies, dynamics of the disease, and the biological and sociodemographic characteristics of the population, that can substantially affect long-term forecasts. a common strategy is to model the cumulative number of cases of covid- on an s-shape (sigmoid) growth curve and thus graphically observe the behavior of the curve in the following days. these curves are usually based richards growth curve richards growth curve days after of st recorded case cumulative number of cases (x , ) days after of st recorded case cumulative number of cases (x , ) on well-known cumulative distribution functions, such as those corresponding to the gompertz, logistic, log-normal and gumbel distributions . as a special case, the richards growth curve assumes that the cumulative number of cases of the disease at time t is indicated by the expression: the structure of this equation is amenable to infectious disease modeling, since its parameters have direct interpretations. k is the cumulative number of cases at the end of the epidemic, r is the per capita growth rate of the cumulative number of cases, a is the exponent of deviation of the cumulative case curve, and b is the turning point, or the moment at which the peak occurs . to illustrate our point, we take the official number of daily reported cases in the brazilian states of são paulo (sp) and ceará (ce) from the date of notification of the first case in each state, up to july , . these data were obtained from the brazilian health ministry . the first cases of covid- in sp and ce were reported on february and march , respectively. panels (a) and (b) of figure compare the actual cumulative number of daily reported cases with the curves fitted by a richards model considering normal errors. for applying this model, we used the nls function (nonlinear least squares) of the r language (version . . ). for both states, we observe a good fit of the model to the data, given that the estimated growth curves are close to the actual values. however, the fact that a model is capable of providing a curve very close to the actual data, does not mean that it is useful for making predictions. considering the model based on the richards curve, it is estimated that in sp there will be k = , , cases of covid- by the end of the epidemic, and the peak of cases will occur on day b = . (tentatively, august , ). in addition, it is estimated that in ce there will be k = , cases of the disease by the end of the epidemic, and that the peak of cases occurred on b = (june , ). presented in the lower panels of figure are the projections of the growth curves during a period of days. although the actual values and those obtained from the fit of the richards model are quite close (as shown in figure ), there is no guarantee that the epidemic curve will continue to grow according to this mathematical model after the period used to adjust the curve. therefore, these estimates for k and b obtained from the richards model, although correct from a mathematical perspective, are highly unrealistic. in order to demonstrate this statement, we fit the richard model to data from sp and ce, considering the daily reported cases from the date of notification of the first case in each state, up to three different dates: may , june and june , . figure compares the projections of the obtained growth curves over a period of days for sp and days for ce. we can observe in panels (a) and (b) of figure that the estimates of the cumulative number of cases at the end of the epidemic k, and at the moment of occurrence of the peak b, vary widely according to the period considered. in both states, though more pronounced in ce, a decrease in the daily covid- reports was observed close to may , followed by a sudden increase in the records. this was probably due to delays in diagnosis or in notification, but was enough to produce a false impression that the peak would occur soon, as shown in figure . in ce, the daily covid- reports increased significantly close to june , but a deceleration in diagnosis (or notifications) was observed in the following days, which may be a consequence of social isolation measures, and/or reduced testing. thus, figure shows that the forecasts on june in ce produce a more pessimistic scenario for the disease than the forecasts on a posterior date (say, june ). figure shows estimates of parameters k and b obtained from the fit of richards models to the daily covid- reports in sp and ce, considering a time series beginning on the date of notification of the first case in each state and ending on different dates, in a range from april to july , . considering the high variation of the estimates shown in these graphs, these findings reinforce the conclusion that, during an epidemic (at least mathematically), the prediction of the number of cases at the end of the epidemic and at the moment of occurrence of the peak is highly dependent on the number of days used in the predictive model. that is, all other important variables, such as the natural history of the disease, population biological and sociodemographic characteristics, as well as public policies for mitigating the epidemic, are completely unforeseen by the model. therefore, models based on s-shape curves are more appropriate to describe the dynamics of an epidemic after its abatement. if they are used at the beginning of the epidemic, just to obtain a smoothened curve of the cumulative number of cases, care must be taken with the interpretation of their parameters. short-term forecasts can be obtained from the immediate trajectories of the curves obtained from these models, which are likely to be more accurate than long-term forecasts, but are also sensitive to the high volatility observed at the end of the time series of reported cases . these variations occur due to extrinsic factors, such as the availability of tests for essential screening, the natural history of the disease and changes in mitigation measures. using an s-shape curve model, faranda et al. demonstrated the high sensitivity of the estimates to the last point of covid- datasets. these authors provide a simulation study, replacing the last data point of the epidemic curves in the uk, france and italy with a random number drawn from a uniform distribution, showing that the trajectory of the curves obtained under this process have a very high variability. faranda et al. also showed that long-term forecasts and predictions based on more sophisticated models, such as the susceptible-exposed-infected-recovered (seir) compartmental model, are also extremely sensitive to biases in data collection and crucially depend on the last available data point. thus, during its course, the future of an epidemic in a real population is unpredictable due its natural dependence on a broad number of variables. the use of more sophisticated mathematical tools require a minimal number of premises to obtain less biased estimates. these premises include the necessity of accurate information on the number of susceptible, infected, exposed and recovered people, which is extremely difficult to obtain in any country . among the sources of uncertainty, we have underreporting and delays in reporting cases; inaccuracies in the estimates of the percentage of people that comply with measures of social distancing and wearing masks; unavailability of tests and lack of accuracy of test methods; limited knowledge about herd immunity and the mechanism that enables oligosymptomatic or asymptomatic individuals to transmit the disease; the incubation period of the virus; and other factors , . declaring all the mathematical assumptions of a model is essential but is not sufficient for an adequate interpretation of the results. an extensive discussion of these premises is essential in any scientific work aimed at forecasting cases of covid- . at the same time, it is necessary to develop scientific literacy for all citizens, since the constant appearance of epidemic curves and predictions in newspapers and electronic media has made these tools popular with the general population. in a quote attributed to the american business tycoon warren edward buffett, one of the most successful investors worldwide, it is stated that "forecasts may tell you a great deal about the forecaster; they tell you nothing about the future" . if in the business world, predictions need to be viewed with caution as they essentially express an investor's point of view, in an epidemic the prediction of peak cases, the possible flattening of the epidemic curve or the date of the end of the epidemic can also just be someone's guess, and may not necessarily be a scientific prediction of the future, obtained from mathematical modeling. in conclusion, remembering the premise that "all models are wrong, but some are useful", a quote attributed to the british statistician george box, adequate covid- epidemic forecasts require a deep understanding of mathematical, statistical and epidemiological methods, and their assumptions and premises must be adequately verified and validated by experts. this study was supported by the conselho nacional de desenvolvimento científico e tecnológico (cnpq, process / - ). inferring change points in the spread of covid- reveals the effectiveness of interventions impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand. london: imperial college covid- response team special report: the simulations driving the world's response to covid- predictive mathematical models of the covid- pandemic: underlying principles and value of projections estimation and prediction of covid- cases in brazilian metropolises forecasting the rate of cumulative cases of covid- infection in northeast brazil: a boltzmann function-based modeling study mathematical models in epidemiology middle east respiratory syndrome coronavirus (mers-cov) nosocomial outbreak in south korea: insights from modeling painel de casos de doença pelo coronavírus (covid- ) no brasil. brasília: ministério da saúde short-term forecasting of daily covid- cases in brazil by using the holt's model asymptotic estimates of sars-cov- infection counts and their sensitivity to stochastic perturbation contact tracing assessment of covid- transmission dynamics in taiwan and risk at different exposure periods before and after symptom onset risk factors associated with covid- infection: a retrospective cohort study based on contacts tracing transmission of -ncov infection from an asymptomatic contact in germany value investing: from graham to buffett and beyond the authors declare no conflicts of interest. all authors participated equally in the study conceptualization, data collection, information analysis, manuscript writing, and approval of the final version of the manuscript processes. key: cord- -opf qwgl authors: hiremath, channabasavaraj shivalingaiah; yadava, om prakash; meharwal, zile singh; iyer, krishna subramony; velayudhan, bashi title: iacts guidelines: practice of cardiovascular and thoracic surgery in the covid- era date: - - journal: indian j thorac cardiovasc surg doi: . /s - - -w sha: doc_id: cord_uid: opf qwgl patients undergoing cardiovascular and thoracic procedures are at an accentuated risk of higher morbidity and mortality, which are a consequence of the proliferative nature of the severe acute respiratory syndrome-corona virus (sars-cov- ) on the lung vasculature, which in turn reflects as a cascading effect on the interdependent physiology of the cardiovascular and pulmonary organ systems. these are secondary to systemic inflammatory response syndrome and immunosuppressive responses to surgery and mechanical ventilation. thus, the need to establish guidelines for the practice of cardiothoracic surgery which is safe for both the patient and the healthcare team presents as a priority, which is the mainstay of this article. the corona virus disease- (covid- ) pandemic has caused a profound global impact. the medical infrastructure across the world continues to be the first response in tackling the challenges. needless to say, the medical workforce has been pressed into action, beyond capabilities to cater to the affected, making it the largest workforce the world over, working beyond its functional capacity. albeit there have been significant restrictions on routine medical practice and cardiothoracic disease, coronavirus by virtue of its behaviour presents without attenuation of intensity and time. with most testing and diagnostics at an all-time high of deferrals, patients with underlying cardiovascular lesions are at an unprecedented risk of adverse complications. deferring care to such patients can aggravate risk and potentially turn fatal. noting the pressure and presentation across subspecialties of medicine, cardiovascular care, if optimized and prioritized based on diagnosis, can help ease the caseload on the infrastructure with appropriate referral and recall. covid- trends have been inconsistent and unpredictable. thus, all stakes boil down to how well our practice can be optimized to unload the burden on our health infrastructure. a number of guidelines have been laid out in the public forum, by counterpart organizations to resume the practice of cardiovascular interventions through the peak of the pandemic. this advisory shall systematize resumption and caution in cardiothoracic surgical practice, as india continues to battle the pandemic at its peak. the indian association of cardiovascular-thoracic surgeons supports this document. as per ministry of health and family welfare, the covid- case definitions are as follows [ ] . a. a patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath) and a history of travel to or residence in a location reporting community transmission of covid- disease during the days prior to symptom onset or b. a patient with any acute respiratory illness and having been in contact with a confirmed or probable covid- case in the last days prior to symptom onset or c. a patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough and shortness of breath, and requiring hospitalization) and in the absence of an alternative diagnosis that fully explains the clinical presentation a. a suspect case for whom testing for the covid- virus is inconclusive or b. a suspect case for whom testing could not be performed for any reason a person with laboratory confirmation of covid- infection, irrespective of clinical signs and symptoms. suspected and probable cases are put together for ease of management as shown in fig. . a -day quarantine mandate for all patients is ideal for optimal detection of covid- symptoms [ ] . however, surgical emergencies may be taken up with universal precautions and level iii personal protective equipment (ppe). in all such cases, a baseline nasopharyngeal swab for reverse transcription polymerase chain reaction (rt pcr) should be sent. all patients who are symptomatic, rt pcr positive or with positive findings on high-resolution computed tomography (hrct) should be referred for covid- treatment. figure outlines the management of a suspected covid- case. an asymptomatic patient with negative rt pcr and hrct can become positive during the course of hospital stay in view of longer incubation periods. hence, repeat of rt pcr tests every days for a period of weeks during the course of hospital stay is recommended. [ ] . however, repeat rt pcr testing can be avoided in patients with a positive baseline rapid antibody test [ ] . hrct is currently not recommended by the centers for disease control and prevention (cdc, usa) or by the american college of radiology guidelines to establish diagnosis of covid- . nevertheless, in situations of equivocality or when there is no facility for rt-pcr testing, the team may use their discretion to perform a hrct chest as an adjunct investigation to add to the positive predictive value of preoperative workup [ , ] . as an exemption to this rule, given the lack of evidence as well as requirements of sedation and radiation exposure, hrct chest may be used sparingly and with caution in children undergoing surgery [ ] . newborns needing cardiac surgery should be isolated from covid- -positive mothers in order to avoid post-natal infection. it is recommended that they be tested at , and days of life [ ] . vertical transmissions are not known to occur, so if the baby has been separated from the mother at birth, then testing may not be necessary [ , ] . the accompanying person/parents entering the hospital or outpatient department (opd) should also be screened for history and symptoms of covid- . microbiological testing of the attenders/parents should be done when the patient is planned for admission. respiratory specimen collection methods [ ] lower respiratory tract • bronchoalveolar lavage, tracheal aspirate and sputum • collect - ml into a sterile, leakproof, screw-cap sputum collection cup or sterile dry container. & oropharyngeal swab (e.g. throat swab): tilt patient's head back °. rub swab over both tonsillar pillars and posterior oropharynx and avoid touching the tongue, teeth and gums. use only synthetic fibre swabs with plastic shafts. do not use calcium alginate swabs or swabs with wooden tilt patient's head back °. while gently rotating the swab, insert swab less than one inch into nostril (until resistance is met at turbinates). rotate the swab several times against nasal wall and repeat in other nostril using the same swab. place tip of the swab into sterile viral transport media tube and cut off the applicator stick. for throat swab, take a second dry polyester swab, insert into mouth and swab the posterior pharynx and tonsillar areas (avoid the tongue). place tip of swab into the same tube and cut off the applicator tip. tilt patient's head back °. insert flexible swab through the nares parallel to the palate (not upwards) until resistance is encountered or the distance is equivalent to that from the ear to the nostril of the patient. gently, rub and roll the swab. leave the swab in place for several seconds to absorb secretions before removing. clinicians may also collect lower respiratory tract samples when these are readily available (for example, in mechanically ventilated patients). in hospitalized patients in dedicated covid- hospitals (severe cases with confirmed covid- infection), repeat upper respiratory tract samples should be collected to demonstrate viral clearance. in the setting of substantially limited resources, proper prioritization of patients requiring surgery is of paramount importance. hence, it is important to triage patients into elective and emergency patients (fig. ). all adult cardiac, congenital cardiac [ ] , thoracic [ ] and vascular cases [ , ] may be categorized into 'emergent cases' requiring intervention within to h, 'urgent cases' requiring surgery within weeks and 'high-priority' cases which have to be prioritized over the rest of the cases. all elective/deferred patients should be periodically re-evaluated and re-triaged based on signs and symptoms (table ) . (table ) orthotropic heart transplantation is excluded from table . the decision to accept a donor heart during this pandemic depends on the clinical status of the recipient, the estimated risk of the donor's potential exposure to covid- in their community and hospital, and the prevalence of covid- in the hospital and community of the recipient in light of the immunosuppression the recipient will receive. thoracic surgery (table ) vascular surgery (table ) it is the responsibility of the lead surgeon to explain the risks associated with surgery and postoperative care during these extraordinary circumstances. in addition to regular surgical consent, the following points need to be impressed on the patient/attenders as part of informed consent. not much is known about the pathophysiology and course of covid- , and most treatments available are experimental. there is a proven increased risk in morbidity and mortality in covid- patients undergoing cardiac surgery [ ] . a sample consent form can be downloaded from www. iacts.org. the ppes are to be used based on the risk profile of the health care worker. table describes the level of ppe to be used in different settings [ ] . intra-operative guidelines [ ] [ ] [ ] [ ] operating room management operating rooms should be sanitized after each case or dedicated operating rooms if feasible should be set up for all confirmed or suspected covid- patients. "covid- precautions" signs to be posted on all doors to the operating rooms (or) suite to inform staff of the potential risks and minimize exposure. majority of operation rooms in india are not negatively pressurized; the positive-pressure system and central air conditioning must be turned off. to convert an existing or into a covid- or, it is first necessary to convert the or into a non-recirculatory system ( % oncethrough system) the exhaust air quantity shall be greater than the supply air quantity such that a negative pressure of minimum . pa (preferably > pa) is achieved in the room. the supply air quantity shall be such that it will provide a minimum of air changes per hour. the position of the exhaust in the or should ideally be above the head of the patient [ ] . maintain relative humidity between and % [ ] . there should be dedicated rooms for donning and doffing of ppe with separate entry and exit points. the donning area should have adequate number of presterilized ppe kits and hand scrubbing facility. all or staff to be kept at the minimum with minimum movement in and out of the or complex. or doors should always be kept close. the staffs are required to practise enhanced droplet and contact precautions in the or at all times with ffp- masks, disposable fluid-proof gown, gloves, cap, face shield or goggles and shoe covers. the ministry of health and family welfare (mohfw) recommends the use of various levels of ppe as per risk as given in table . a team meeting albeit with physical distancing should take place before surgery to ensure everyone understands the plan for anaesthesia, perfusion and surgery. this enables seamless teamwork and ensures that all necessary drugs and equipment have been prepared. it also minimizes the need to leave and re-enter the or to bring in missing equipment. extubation requires similar precautions. antitussives and antihistaminics to be considered as premedication. [ ] . induction of anaesthesia and securing of the airway should be performed by the most skilled operator using adjuncts like video-laryngoscopy. in case the patient has increased secretions, layers of wet gauze can be used to cover the patient's nose and mouth. endotracheal tube (ett) cuff to be inflated immediately after intubation to prevent aerosolization. intubating personnel should be double gloved and be distant from the airway. minimize the period of mask ventilation as far as possible as this is considered an agp. induction can be performed using waters or circle systems, with heat and moisture exchange filters (hmef) as close to the patient as possible. once circuit has been secured, vigilance should be exercised as disconnection will cause aerosolization. anti-emetics should be administered to reduce postoperative retching. a rigid suction catheter may be used to reduce the chance of contaminating the surroundings with the soft flexible suction catheter. all lines should be inserted after intubation. staff to be kept at a minimum until intubation is done. equipment around the patient's head should be immediately cleaned with disinfectant to reduce the risk of fomite spread. trans-oesophageal echocardiography (tee) in an intubated patient has not demonstrated aerosol production. after removal, it should be decontaminated using . % alkaline glutaraldehyde solution for min or as per local institutional protocols of tee disinfection. the hightouch surfaces of the machine and probe should be covered by disposable plastic sheets [ ] . technician or helping staff should maintain -m distance or as much as possible at the time of induction. routine antibiotic prophylaxis is to be followed. there is no evidence or recommendation for the use of hydroxychloroquine or azithromycin prior to surgery. however, as per ministry of health and family welfare, all hospital personnel handling covid- cases are advised hydroxychloroquine prophylaxis. the surgical and perfusion teams to enter or min after intubation if haemodynamic status of the patient permits. however, they should be available in close vicinity of the patient for any emergency. this may be avoided if the patient has tested covid- negative. a smoke evacuator may be used when electrocautery is being used [ ] . the mister blower should be used with caution. use of video-assisted thoracoscopic surgery (vats) and minimally invasive cardiac surgery (mics) should be decided on case-to-case basis due to risk of aerosolization from co insufflation systems with inadvertent lung injury. use of a non-sealed endoscopic vessel harvesting (evh) approach during coronary surgery using an endoscopic retractor (bisleri model, karl storz, tuttlingen, germany) to spread the tissue instead of co insufflation [ ] . there are no contraindications for the use of blood and blood products as sars-cov- is not known to produce viraemia. emphasis should be laid on meticulous haemostasis. it is better to wait in or for a while before chest closure than to wheel the patient back to or for re-exploration. extubation/transfer of patient as most cardiac patients being operated on during the pandemic are of a sicker subset, patients should be transferred directly to the designated intensive care unit (icu) for delayed extubation. the total period of mechanical ventilation should be reduced as far as possible with early weaning and extubation. helping staff/technician should assist extubation from head end, instead of coming in line of patient's aerosol direction [ ] . ett cuff to be deflated at the very last, just before removal of ett. post extubation, protective masks to be applied at the earliest on the patient. supplementary oxygen mask can be put over the protective face mask if needed. all the soiled and disposable items should be discarded as per protocol for biomedical waste disposal. staff to doff the gowns into appropriate biohazard bags, keeping ffp mask and hoods on. while leaving the or complex, ffp masks and hoods can be removed. if facilities exist, all staff are advised to shower, preferably before leaving the or complex. the or ventilation system is to be kept at positive pressure during decontamination. after the patient has been wheeled out, the theatre is left empty for at least min before cleaning is commenced. positive-pressure airflow is maintained for more minutes to allow air exchange [ ]. after surgery for emergency cases/unknown covid- status, the anaesthetic breathing circuit and canister of soda lime should be discarded to eliminate the negligible risk of circuit contamination [ ] . all airway equipment should be sealed in double ziplock plastic bags before being sent for decontamination and disinfection [ ] . unused items on the drug tray are assumed to be contaminated and hence discarded. metallic equipment to be kept in % sodium hypochlorite solution for at least min. routine cleaning of all surfaces and ot equipment using a chlorine or chlorine dioxide-based disinfectant should be done. high-touch areas such as that of the anaesthetic and echocardiography machines may be wrapped with plastic sheets to facilitate decontamination [ ] . the cardiopulmonary machines have varying surfaces which must be cleaned with the appropriate agents. the corridor areas outside of the theatre within m should also be cleaned. fumigation of or with sodium hypochlorite ppm and ammonium chloride-based solution or % alcohol wiping of surfaces should suffice. additional protocols with hydrogen peroxide vaporization or ultraviolet (uv)-c irradiation may be deployed if available [ , ] . there is no requirement of a quarantine zone around or [ ]. modifications to be adopted to routine cardiac critical care management during the covid- era [ , ] . & personnel performing endotracheal suctioning should wear level ii ppe [ ] . & intercostal drain care in case of an air leak, there is aerosolization via chest drain circuit. in a patient without covid- symptoms and negative rt pcr, routine intercostal drain (icd) care is to be followed [ ] . in a suspect patient, a subsequent covid- positive patient, the following measures could be taken. -it can be directly connected to the wall suction to minimize exposure. -a viral filter can be attached at the suction port [ ] . -a cut ett attached to a hmef filter can be fixed to the suction port [ ] . & tracheostomy care level ii ppe for personnel performing suctioning and tube change. level iii ppe in covid- -positive cases. closed suction system is to be used and usage be guarded. a double lumen-cuffed tube may be used to avoid frequent tube change due to tube blockage postoperatively. hmef is to be attached to tracheostomy tube when patient is shifted to icu. a suspected covid- patient with a tracheostomy, who has been weaned off mechanical ventilation and oxygen, the tracheostomy tube may be further covered with a ffp- mask to prevent aerosolization [ ] . & anticoagulation and antiplatelet therapy recommendation [ ]. a patients who are on anticoagulation or antiplatelet therapy for other underlying conditions should continue these medications even if they are diagnosed covid- positive. b anticoagulation and antiplatelet therapy to be followed as per routine protocol in hospitalized patients irrespective of covid- all patients and their accompanying persons entering the hospital should be masked at the triage area. a screening and temperature check is to be performed on all patients before sending to designated opds. in the waiting area, a distance of m is to be maintained between the patients. all the health personnel in the opd not indulging in agps should protect themselves with n masks and gloves. this document is an advisory-based position statement based on current practice, literature, resources and expert opinion as on date. it is pertinent to state that new evidence is continuously emerging and guidelines are being issued regularly. this is formulated with a hope to guide surgeons to resume cardiac surgery keeping in view the safety of the patient and hospital personnel. all guidelines for routine surgical practice still hold true, and the above document should not be read in exclusion. these guidelines are not binding and the user may modify them based on local circumstances. it is reemphasized and worth noting that regular handwashing, utility of face masks and maintaining social distancing will help keep the virus as far away as possible and help win this arduous battle of these times. ment and treatment of covid- and asymptomatic healthcare workers working in non-covid hospitals/ non-covid areas of covid hospitals/blocks asymptomatic frontline workers, such as surveillance workers deployed in containment zones and paramilitary/ police personnel involved in covid- -related activities. asymptomatic household contacts of laboratory confirmed cases. the drug is contraindicated in persons with known case of: retinopathy hypersensitivity to hydroxychloroquine (hcq) or aminoquinoline compounds glucose phosphate dehydrogenase (g pd) deficiency. pre-existing cardiomyopathy and cardiac rhythm disorders. the drug is not recommended for prophylaxis in children under years of age, pregnancy and lactation. rarely, the drug causes cardiovascular side effects such as cardiomyopathy and rhythm (heart rate) disorders. in that situation, the drug should be discontinued. it can rarely cause visual disturbance including blurring of vision which is usually self-limiting and improves on discontinuation of the drug. for the above-cited reasons, the drug has to be given under strict medical supervision with an informed consent. kindly refer to the indian council for medical research (icmr) guidelines for further information. directorate general of health services, ministry of health and family welfare, government of india. clinical management protocol covid- (version the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application testing recommendation for covid- (sars-cov- ) in patients planned for surgery -continuing the service and 'suppressing' the pandemic american college of radiology recommendations for the use of chest radiography and computed tomography (ct) for suspected covid- infection correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases covid- faq's in pediatric cardiac surgery an analysis of pregnant women with covid- , their newborn infants, and maternal-fetal transmission of sars-cov- : maternal coronavirus infections and pregnancy outcomes vertical transmission of coronavirus disease (covid- ) from infected pregnant mothers to neonates: a review covid- : crisis management in congenital heart surgery covid- : elective case triage guidelines for surgical care (thoracic surgery vascular surgery in the covid- pandemic covid- : elective cases triage guidelines for surgical care (vascular surgery mortality and pulmonary complications in patients undergoing surgery with perioperative sars-cov- infection: an international cohort study. the lancet directorate general of health services, ministry of health and family welfare, government of india. novel coronavirus disease (covid- ): guidelines on rational use of personal protective equipment category of personnel and treatment of covid- and asymptomatic healthcare workers working in non-covid hospitals/non-covid areas of covid preparing for a covid- pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore cardiac surgery and the covid- outbreak: what does it mean? available from guidance document to uk cardiac and thoracic teams for procedures on patients with covid- adult cardiac surgery and the covid- pandemic: aggressive infection mitigation strategies are necessary in the operating room and surgical recovery covid operation theatre-advisory and position statement of indian society of anaesthesiologists (isa national) specific considerations for the protection of patients and echocardiography service providers when performing perioperative or periprocedural transesophageal echocardiography during the novel coronavirus outbreak: council on perioperative echocardiography supplement to the statement of the american society of echocardiography: endorsed by the society of cardiovascular anesthesiologists covid- : considerations for optimum surgeon protection before, during, and after operation improved safety of endoscopic vessel harvesting during the covid- pandemic intensive care management of coronavirus disease (covid- ): challenges and recommendations ministry of health & family welfare, government. guidelines for safe ent practise in covid pleural services during the covid- pandemic coronavirus disease- : modified underwater seal chest drain system covid- rapid evidence summary: angiotensin-converting enzyme inhibitors (aceis) or angiotensin receptor blockers (arbs) in people with or at risk of covid. available from: www.nice.org.uk/guidance/ es ministry of health & family welfare, government of india. revised advisory on the use of hydroxychloroquine as prophylaxis for sars-cov- infection publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -kx u authors: karaye, ibraheem m.; horney, jennifer a. title: the impact of social vulnerability on covid- in the u.s.: an analysis of spatially varying relationships date: - - journal: am j prev med doi: . /j.amepre. . . sha: doc_id: cord_uid: kx u introduction because of their inability to access adequate medical care, transportation, and nutrition, socially vulnerable populations are at increased risk of health challenges during disasters. this study estimates the association between case counts of coronavirus disease (covid- ) infection and social vulnerability in the u.s., identifying counties at increased vulnerability to the pandemic. methods using social vulnerability index and covid- case count data, an ordinary least squares regression model was fitted to assess the “global” relationship between covid- case counts and social vulnerability. local relationships were assessed using a geographically weighted regression model, which is effective in exploring spatial non-stationarity. results as of may , , a total of , , people had been diagnosed with covid- in the u.s. of the counties included in this study ( . %, , / , ), the highest case count was recorded in trousdale, tennessee ( , . per , ) and the lowest in tehama, california ( . per , ). at the “global” level, overall social vulnerability index (e β= . , p= . ) and minority status and language (e β= . , p< . ) were associated with increased covid- case counts. however, based on the “local” geographically weighted model, the association between social vulnerability and covid- varied among counties. overall, minority status and language, household composition and transportation, and housing and disability predicted covid- infection. conclusions large-scale disasters differentially affect the health of marginalized communities. in this study, minority status and language, household composition and transportation, and housing and disability predicted covid- case counts in the u.s. addressing the social factors that create poor health is essential to reducing inequities in the health impacts of disasters. when disasters of any type occur, the socially vulnerable are at the greatest risk. [ ] [ ] [ ] recent reports on morbidity and mortality of coronavirus disease (covid- ) have indicated a higher burden among racial/ethnic minorities, the elderly, the poor, and people with the lowest educational attainment. [ ] [ ] [ ] [ ] [ ] [ ] [ ] the disproportionate burden of the pandemic among socially vulnerable communities has been explained, in part, by the endemic inequities in these populations, including income, education, nutrition, transportation, housing, jobs, environment, psychosocial stresses, and health care, which contribute to poor health. [ ] [ ] [ ] [ ] [ ] [ ] for example, african americans are more likely to live in environmentally polluted neighborhoods than whites, [ ] [ ] [ ] which increases their propensity to developing environmental health problems like asthma [ ] [ ] [ ] as well as their subsequent risk of covid- morbidity. , according to a report published by the national association for the advancement of colored people and clean air task force, african americans are % more likely to reside in proximity to a polluting facility like a factory or refinery than other americans and are exposed to air that is % more polluted compared with whites. poor housing and crowded neighborhoods, where minorities are overrepresented, make the type of physical distancing that can be protective against covid- infection less feasible, increasing the risk of becoming infected. , minorities are also more likely to work in the service industry that requires physical presence, making physical distancing less feasible. other chronic diseases associated with worsening prognosis of covid- include hypertension and diabetes. unfortunately, opportunity to improve diet and increase physical exercise are substantially associated with material factors-household income, financial assets, and the local built environment. , lower median household incomes among african americans, along with lower rates of medical insurance and institutional racism, diminish access to health care. , , , according to the institute of medicine (now known as the national academy of medicine), regardless of income, insurance status, age, or severity of medical condition, racial and ethnic minorities are more likely to be provided inferior medical care than is provided to whites. a review of billing information on covid- by rubix life sciences also revealed that physicians are less likely to refer african americans for screening when they present with symptoms. despite increasing concerns about the disproportionate burden of the pandemic on minority communities, race-stratified data are yet to be released for most u.s. states; only seven states, california, illinois, louisiana, michigan, minnesota, new york, north carolina, had released race-disaggregated data by april , . , , through april , , a total of , deaths have occurred, but only % of the mortality records included information on race and ethnicity. owing to the insufficiency of race-stratified data, , , few primary studies on social vulnerability to covid- have been undertaken. using publicly available secondary spatial data on social vulnerability and covid- case counts, this study assesses the association between social vulnerability and the pandemic's case counts in the u.s., and identifies "hot spots" where social vulnerability was positively associated with case counts. county-level publicly available data on social vulnerability for the lower u.s. states were obtained from the center for disease control and prevention's (cdc's) agency for toxic substances and disease registry (atsdr, ). data on the number of people tested for covid- were derived from the covid tracking project. finally, regional boundary data on states and counties were downloaded from data.gov. in the event of disasters of all types, including pandemics like covid- , social factors like the percentage of people living in poverty or without access to transportation can contribute to the degree to which communities withstand disaster impacts and minimize human suffering and financial loss. factors that describe a community's social vulnerability were compiled by cdc into a social vulnerability index (svi) to enable the identification of populations most likely to need support before, during, and after a disaster. cdc's svi estimates the relative vulnerability of each census tract or county in the u.s. by ranking variables in four major themes: ses, household composition and disability, minority status and language, and housing and transportation. the socioeconomic theme comprises four variables: percentage below poverty, percentage unemployed, per capita income, and percentage with no high school diploma. the household composition and disability theme comprises the percentage aged ≥ years, percentage aged ≤ years, percentage civilian with a disability, and percentage single-parent households. the minority status and language theme comprises two variables: percentage minority and percentage who speak english "less than well." finally, the housing and transportation theme constitutes five social variables: percentage multi-unit structures, percentage mobile homes, percentage crowding, percentage no vehicle, and percentage group quarters. the overall index is scored from to with higher values denoting higher vulnerability. additional detail on cdc's svi variable selection and methods is available elsewhere. , for each county, the authors derived the outcome variable by dividing the cumulative counts (between january , and may , ) of confirmed covid- cases by county total population multiplied by , . to satisfy the parametric requirement for normality, the authors log-transformed the outcome variable and exponentiated the model coefficients for ease of interpretation. overall, . % of u.s. counties ( / , ; . % of the national population) were excluded from the study because of missing data. the global association between covid- case counts and social vulnerability was assessed by fitting a multiple linear regression model using ordinary least squares (ols) regression. the relationship of the outcome variable was assessed with svi and its four themes, including ses, household composition and disability, minority status and language, and housing and transportation. covariates were included to adjust for the potential confounding effect of population size, population density, number of people tested, average daily sunlight, precipitation, air temperature, heat index, and fine particulate matter (pm . ). ols regression is considered "global" as it estimates a single parameter for each variable and assumes that the relationship between outcome and predictor variables holds the same everywhere in the study area. however, because vulnerability to covid- may actually be non-stationary and vary between u.s. counties, the authors also fitted a geographically weighted regression model (gwr) using the variables previously included in the ols model. unlike the global ols regression, gwr estimates a "local" model and computes parameters for all sample points taking into account the spatial variation in relationships. the model was configured with a fixed (gaussian) kernel type, corrected akaike information criterion's bandwidth, and a cross-validated optimal number of neighbors. to identify which svi themes predict covid- case counts across the spatially varying regions of the u.s., coefficient raster maps were generated for the predictor variables using hot/cold rendering color schemes. as of may , , a total of , , people had been diagnosed with covid- in the u.s. of the , counties included in the study ( . %; , / , ), the highest case count was recorded in trousdale county, tennessee ( , table ). sensitivity analysis of six states (and dc) with the highest rate of testing affirmed the strong association between minority status and language and covid- case counts (e β = . , p< . ). the results did not differ significantly when missing data from counties were imputed using spatial prediction methods ( table ) . the negative relationships between household composition and disability, and housing and transportation, with case counts, were counterintuitive. however, these associations were better described by local spatial variations between counties, as captured by the gwr model. although social vulnerability was associated with increased case counts at the global level (as demonstrated by the ols), the direction and magnitude of this association varied among u.s. states. the authors explored this spatial non-stationarity with a geographically weighted regression model (figures - ) . in the states of washington and oregon, minority status and language and household composition and disability were more predictive of covid- case counts than housing and transportation. in the u.s. gulf coast states (especially eastern texas, louisiana, mississippi, alabama, florida), southern arkansas, and western tennessee, vulnerability to covid- was better explained by housing and transportation than minority status and language. consistent with the ols regression results, the gwr model confirmed a strong association with minority status and language than with other svi themes (figures - ) . counties ("hot spots") identified as demonstrating both high svi and high covid- case counts are summarized in appendix table . disasters and emergencies, be they natural or anthropogenic, profoundly and inequitably affect the health of socially vulnerable populations. , such events expose inequities in areas including access to quality housing and education, as well as issues of economic and environmental justice that create conditions that make it difficult to maintain health. after all types of disasters, minority communities have been documented in the literature to be faced with a disproportionate share of detrimental physical and mental health outcomes. [ ] [ ] [ ] these disparate health impacts may be due to an inability to fully understand warning advisories related to an impending hazard event or further, caused by living in areas of high hazard vulnerability and poor access to health care. , the principal finding from this study, increased covid- cases in some of the most socially vulnerable counties in the u.s., underscores the importance of continuing to work to address inequities related to the social determinants of health. at the "global" level, the finding that overall svi and minority status and language were associated with increased covid- case counts, highlights the impact of social vulnerability on the pandemic. notably, this study found that the relationship between social vulnerability and covid- was not stationary but varied between u.s. counties. for example, the variables associated with increased case counts were not the same for southwest georgia household composition and disability, as they were for new york city minority status and language. these spatially variable findings contribute to previous studies that demonstrated non-uniform distribution of social vulnerability to u.s. disasters. [ ] [ ] [ ] [ ] [ ] in the context of the covid- pandemic, further research is needed to substantiate the current findings and elucidate possible mechanisms for these associations. in the u.s., million adults are underinsured, including % of adults aged - years who face high copays and out-of-pocket costs. nearly million americans lack running water in their homes, with native americans times more likely and african americans and hispanics twice as likely to lack indoor plumbing than whites. this makes basic infection prevention practices, like hand washing, less attainable for mitigating the spread of the disease. the lack of paid sick leave among low-wage earners, whose work often involves face-to-face interaction, also makes self-quarantining a less feasible option. in addition, because of low wages, many workers hold multiple jobs to support their families, which may further increase their risk of contracting or spreading covid- . for fear of retaliation and deportation, undocumented migrants are less likely to report covid- symptoms or to present themselves for medical screening, which could potentially heighten their risk of contracting or transmitting the disease. [ ] [ ] [ ] [ ] the families first coronavirus response act enacted on march , addresses some disparities related to covid- , making provisions for paid sick leave to some employees, as well as providing free testing, nutrition assistance, and expanded unemployment benefits. however, as the u.s. nears the peak of the pandemic, more could be done to mitigate the disproportionate burden of the pandemic among marginalized communities. for example, massachusetts convened an emergency task force on coronavirus and equity to develop policy recommendations for communities particularly vulnerable to covid- and many of these recommendations could be applied to other states: prohibiting u.s. immigration and customs enforcement from entering healthcare facilities and shelters, and assuring residents of universal healthcare provision without question of immigration status; financially assisting communitybased organizations to support immigrant populations; expanding unemployment benefits, paid time off, paid family leave, and parental leave to cover the vulnerable for as long as the pandemic lasts; providing safety training to public-facing employees (e.g., first responders); improving sanitation and access to testing and treatment for nursing home residents, the prison population, residents of detention centers, and the homeless; reinforcing nutrition assistance programs for adults and children; improving access to care for the disabled, especially those with disrupted support systems; improving access to quality internet connection for rural communities to support remote work; and financially covering unexpected costs that may be incurred by government agencies and health departments. in the face of limited resources, support can be prioritized to the more socially vulnerable counties, such as those identified in this study, as their populations may have stronger social vulnerability to covid- . there are several limitations to this study. social vulnerability was assessed using cdc's svi, a hierarchical index that has been shown to be associated with lower precision and weaker internal validity. the svi's precision was also reported to be sensitive to the weighting scheme chosen. despite these inherent limitations, the authors used the svi because it has demonstrated higher accuracy than other models and compares well to other indices of social vulnerability. , the data are also publicly available and widely cited in the literature. although the authors adjusted for demographic and environmental factors-population size, population density, number of people tested, average daily sunlight, precipitation, air temperature, heat index, and fine particulate matter (pm . )-svi variables explained only . % (r = . ) of the variability in covid- case counts. further studies are warranted to explore additional factors, which explain the burden of the pandemic. given the potential heterogeneity of vulnerable regions within a county, census tract level might be more suitable for analysis. as the authors do not have publicly available data disaggregated on census tract level, this could be examined in future research. in addition, because disparities in exposure and susceptibility to pandemics may vary across time, it may be suitable to analyze the rate of increase in case counts at multiple time points for each county. the authors do not have longitudinal data to permit trend analysis, and this could be investigated in future studies. this study was further limited by covid- case counts. in particular, potential substantial undocumented cases of covid- infection in the u.s. may have limited the use of "confirmed case counts" as outcome in the study. finally, the exclusion of . % of u.s. counties ( / , ) owing to missing data is a limitation. however, the sensitivity analysis with imputed data yielded results similar to the original model (table and appendix figures - ) , thus suggesting that comparable findings would be obtained if data were not missing. nonetheless, given the continuing spread of the disease, periodic updated spatial statistical analyses may be warranted. large-scale disasters, whether natural (e.g., , traumatic (e.g., the world trade center attack or mass shootings), or environmental (e.g., the deepwater horizon spill), profoundly affect the health of socially vulnerable communities. in this study, minority status and language, household composition and disability, and housing and transportation were found to predict covid- case counts in u.s. counties. addressing the social determinants of health, such as housing, education, and environmental and economic justice, is essential to reducing inequities in the health impacts of disasters. no funding was received for this work. the authors have no financial or other conflicts of interest. all the authors made substantial contributions to this paper and take responsibility for it. ik and jh conceived of the presented idea; ik collected and analyzed the data; ik wrote the manuscript; jh verified the analytic methods, reviewed, and provided substantial edits to the manuscript; and both authors approved the final version of the manuscript. social vulnerability to large wildfires in the western usa social vulnerability to floods: review of case studies and implications for measurement self-rated mental and physical health of u.s. gulf coast residents variation in covid- hospitalizations and deaths across new york city boroughs covid- and african americans black americans face alarming rates of coronavirus infection in some states. the new york times percent of the people in chicago killed by the coronavirus are black why are blacks dying at higher rates from covid- ? brookings why misinformation and distrust are making covid- more dangerous for black america. npr african americans may be dying from covid- at a higher rate visible and invisible trends in black men's health: pitfalls and promises for addressing racial, ethnic, and gender inequities in health patterns and causes of health inequities during a pivotal period in the life course health haves, health have nots, and heterogeneity in population health health insurance coverage eight years after the aca: fewer uninsured americans and shorter coverage gaps, but more underinsured. commonwealth fund paid sick days work for u.s. employees and employers health inequalities and infectious disease epidemics: a challenge for global health security air pollution could make the covid- pandemic worse for some people: pollution piles on top of other risk factors. the verge low-income, black neighborhoods still hit hard by air pollution. science daily hud's fair housing policies could promote further racial discrimination, experts say. nbc news the trump administration blames covid- black mortality rates on poor health. it should blame its policies african americans with asthma: genetic insights office for minority health case-fatality rate and characteristics of patients dying in relation to covid- in italy exposure to air pollution and covid- mortality in the united states fumes across the fence-line: the health impacts of air pollution from oil and gas facilities on african american communities the devaluation of assets in black neighborhoods are patients with hypertension and diabetes mellitus at increased risk for covid- infection? office for minority health. black/african americans closing the health gap to fight coronavirus unequal treatment: confronting racial and ethnic disparities in health care covid- and minority health access: illustrating symptomatic cases from reported minority communities and healthcare gaps due to covid- the color of corona virus: covid- deaths by race and ethnicity in the democratic law makers call for racial data in virus testing wonder online databases what predicts psychological resilience after disaster? the role of demographics, resources, and life stress lewis ba social vulnerability index for disaster management charting the coronavirus pandemic state by state disaster mental health services review of care for older persons after disasters healthcare challenges after disasters in lesser developed countries cumulative disaster exposure and mental and physical health symptoms among a large sample of gulf coast residents seafood contamination after the bp gulf oil spill and risks to vulnerable populations: a critique of the fda risk assessment oil spill modeling: risk, spatial vulnerability, and impact assessment public health and marginalized populations: a public health of consequence handbook of disaster research the geography of despair: environmental racism and the making of south phoenix double exposure in the sunbelt: the sociospatial distribution of vulnerability in phoenix, arizona race, place, and environmental justice after hurricane katrina: struggles to reclaim, rebuild, and revitalize new orleans and the gulf coast the production of unequal risk in hazard scapes: an explanatory frame applied to disaster at the us-mexico border closing the water access gap in the united states: a national action plan not everybody can work from home: black and hispanic workers are less likely to be able to telework. economic policy institute the effect of fear on access to care among undocumented latino immigrants undocumented us immigrants and covid- covid- : the painful price of ignoring health inequities. the bmj opinion venezuelan migrants "struggling to survive" amid covid- the families first coronavirus response act: summary of key provisions. kff global health policy. march , . www.kff.org/global-health-policy/issue-brief/the-families-first-coronavirus-response-actsummary-of-key-provisions slowing the spread of covid- the right way. common wealth how valid are social vulnerability models? social vulnerability indices: a comparative assessment using uncertainty and sensitivity analysis. nat hazards (dordr) validating resilience and vulnerability indices in the context of natural disasters substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) key: cord- -fwm rfps authors: ng, boon hau; mat, wan rahiza wan; abeed, nik nuratiqah nik; hamid, mohamed faisal abdul; yu‐lin, andrea ban; soo, chun ian title: silicone pneumonitis after gluteal filler: a case report and literature review date: - - journal: respirol case rep doi: . /rcr . sha: doc_id: cord_uid: fwm rfps liquid silicone (polydimethylsiloxane) is an inert material that is commonly used for cosmetic purpose. silicone embolization syndrome (ses) can rapidly progress to pneumonitis as a consequence of the injection of nonmedical‐grade liquid silicone. we describe a case of severe silicone pneumonitis complicated with acute respiratory distress syndrome and bilateral pneumothorax secondary to silicone gluteal augmentation. in this case report, we aim to discuss our experience and approach in managing an uncommon case of ses. for decades, liquid injectable silicone has been used for correction of contour defect or soft-tissue augmentation. medical-grade liquid silicone (polydimethylsiloxane) becomes the preferred inert material for cosmetic purpose due to its durability, a lack of immunogenicity, and thermal stability; but later found to be associated with silicone embolism syndrome (ses). liquid injectable silicone induced embolism has been reported by several studies as a cause of acute pneumonitis with alveolar haemorrhage [ ] [ ] [ ] . a previously healthy -year-old woman presented with three days history of cough with dyspnoea and fever. she had a history of breast augmentation with silicone implant two years ago and had received bilateral gluteal silicone injections from an unlicensed provider one week before the current presentation. the injected volume was approximately ml for each gluteal. the physical examination was tachycardia, tachypnoea with the respiratory rate of breaths per minute and a temperature of c. results of the arterial blood gas performed while the patient was breathing room air were as follows: ph, . ; paco , mmhg; pao , mmhg; and peripheral oxygen saturation, %. lungs examination revealed bilateral lower zone crepitations. other blood investigations which included a complete blood count, comprehensive metabolic panel, and lactate were unremarkable. she was initiated on broadspectrum antibiotics, oseltamivir, intravenous hydrocortisone mg every h, and l/min (fio : %) of high-flow oxygen supplement. however, she developed right-sided pneumothorax and worsened respiratory failure h later. on chest radiograph, diffuse alveolar opacities in both lung fields were observed. a computed tomographic scan of her thorax demonstrated diffuse bilateral ground-glass infiltrates (fig. ) . fiberoptic bronchoscopy was performed, which revealed normal lung segments. transbronchial lung biopsy showed non-refractile lipoid vacuoles, consistent with silicone pneumonitis (fig. ) . magnetic resonance imaging of the breast confirmed no intracapsular and extracapsular rupture of the bilateral breast prosthesis. her bronchial wash was positive for coronavirus nl rna pcr. she received lung protective ventilation for acute respiratory distress syndrome (i.e. low tidal volumes and high positive end-expiratory pressure (peep)) for continued hypoxia. unfortunately, two weeks later, she again developed another spontaneous pneumothorax on the left lung and required chest tube drainage. over four weeks in the intensive care unit, we manage to wean down the ventilatory support. she had an excellent clinical response and discharged with tapering prednisolone over two weeks. at six weeks of outpatient follow up, she was symptom-free, and her chest x-ray revealed residual bilateral reticulations. the respiratory consequences that associated with silicone injection include acute pneumonitis [ ] , acute respiratory distress syndrome, alveolar haemorrhages, and pulmonary embolism [ ] . the respiratory symptoms generally present within h after injection of higher dose silicone, and a delayed reaction can be seen up to a year and a half after injection [ ] . pulmonary ses results from silicone embolizing to the lungs from an inadvertent intravenous injection or local tissue destruction. the neutrophils ingested the embolization of the silicone material into the lung via the haematogenous or lymphatic and alveolar macrophages induces pneumonitis by local cell-mediated inflammation and release of free radicals and proteolytic enzymes [ ] . the release of silicone emboli also leads to occlusion of the microvasculature and trigger the inflammatory response, resulting in pulmonary oedema and haemorrhage. diagnosis of the silicone pneumonitis is based on the clinical history of silicone implant or injection, the radiological pattern of subpleural infiltrates and peripherally distributed ground-glass opacities (ggo) [ , ] , and tissues biopsy with histopathological features of alveolar haemorrhage [ ] and non-refractile vacuole-like structure within the alveoli [ ] . presence of alveolar macrophages with intracytoplasmic silicone inclusions in bronchoalveolar lavage sample is useful in facilitating a diagnosis [ ] . survival is likely, and treatment involves ventilation if necessary and steroids with uncertain utility. the rate of mortality is directly associated with the large volumes of silicone and high-pressure injection [ ] . there is no consensus on the treatment of the silicone induced pneumonitis, but case report series show a favourable response with the use of the steroid (table ) to reduce the airways inflammation [ , , ] . general measures include nutrition and ventilation support. extracorporeal membrane oxygenation (ecmo) may be considered in cases of severe acute respiratory distress syndrome (ards) deteriorating on mechanical ventilation. surgical extraction of the silicone from subcutaneous tissues have had poor outcome due to risk of adverse systemic effects and technically complicated surgery [ ] . carolyn et al. reported a case of acute pneumonitis after silicone injection for gluteal augmentation. the patients presented with haemoptysis, shortness of breath, and acute respiratory failure two days after the silicone injections [ ] . her computed tomography (ct) thorax showed predominantly basilar and peripheral ggo and pulmonary nodules bilaterally. she required ecmo and her condition improved with intravenous methylprednisolone mg every h. srilekha sridhara et al. reported a rare case of silicone pneumonitis with pneumothorax occurred even after - years of silicone injection [ ] . bronchoscopic lung biopsy demonstrated alveolar interstitium with numerous lipoid vacuoles, compatible with silicone deposition. the patient succumbed despite treated with intravenous corticosteroids, broad-spectrum antibiotics, and mechanical ventilation. elizabeth et al. reported three cases of breast implants with the onset of symptoms ranges - years [ ] . the ct features of these patients demonstrated diffuse ggo. all three patients responded to prednisolone mg/day. our case demonstrates the features of ses after the gluteal silicone filler. no specific site for vascular infiltration was identified in our case; however, many injection marks were observed on the buttocks. mri breast confirmed that there is no leak from the silicone breast implants and no residual collection in the gluteal region. thus, the decision not to remove the breast implant and not for surgical exploration of the possibilities of remaining gluteal silicone collection was made after a multidisciplinary meeting comprises of pulmonologist, plastic and reconstructive surgeon, and anaesthetic team. a trans-bronchial lung biopsy was deemed to be a less invasive approach to obtain lung biopsies in order to avoid the risk of general anaesthesia due to poor pulmonary reserve. the detection of hcov-nl in our patient is incidental. this is consistent with the literature that hcov-nl can be frequently found in asymptomatic individuals [ ] . although, hcov-nl can infects both the upper and lower respiratory tract, it generally associated with mild symptoms, such as fever, cough, pharyngitis, and rhinitis [ ] . in rare cases, pneumonia can occur. in total contrast to silicon pneumonitis, lung biopsy histopathological features of hcov-nl pneumonia are chronic pulmonary inflammation, severe alveolar damage, intra-alveolar hyaline membranes, and interstitial oedema [ ] . the result of the lung biopsy of our patient was consistent with the diagnosis of silicone pneumonitis. learning points for our case includes: . corticosteroids are potentially beneficial in reduces the inflammation of the airways that leading pneumonitis with acute respiratory distress syndrome but does not have any mortality benefits [ , ] . . lung-protective ventilation strategies improve survival. . vigilance in the occurrence of pneumothorax in cases of ses especially if complicated with ards and requiring mechanical ventilation. risk of pneumothorax in ses and will usually resolve after chest drain intervention. . trans-bronchial lung biopsy is useful in assisting the diagnosis. . patients should be advised that there is a risk that silicone injections can be associated with serious pulmonary complications. the injection of silicone for cosmetic purpose is debatable due to the sequelae of the pneumonitis and the potential for pulmonary toxicity in asymptomatic patients who receive silicone injections. bronchoalveolar lavage and trans-bronchial lung biopsy can help to confirm the diagnosis. this case report serves to highlight an emergent danger associated with illicit silicone use for cosmetic purposes and clinicians should be aware of the potential complications. appropriate written informed consent was obtained for publication of this case report and accompanying images. clinicopathologic review of pulmonary silicone embolism with special emphasis on the resultant histologic diversity in the lunga review of five cases silicone embolism syndrome: a case report, review of the literature, and comparison with fat embolism syndrome acute pneumonitis after subcutaneous injections of silicone in transsexual men case report and literature review: acute pneumonitis and alveolar hemorrhage after subcutaneous injection of liquid silicone forensic examination of toxicological specimens for dimethylpolysiloxane (silicone oil) silicone pulmonary embolism: report of cases and review of the literature massive systemic silicone embolism: a case report and review of literature silicone injection causing acute pneumonitis: a case series subcutaneous silicone injection leading to multi-system organ failure acute pneumonitis after subcutaneous injection of liquid silicone as a breast implant in a male-tofemale transsexual pulmonary embolism secondary to silicone injection a rare case of delayed chronic pneumonitis following nonmedical grade silicone injections in a transgender woman interstitial lung diseases associated with metal content in silicone breast implants: a case series respiratory pathogens in children with and without respiratory symptoms human coronavirus nl infection in canada fatal lower respiratory tract disease with human corona virus nl in an adult haematopoietic cell transplant recipient pulmonary fibrosis and embolism secondary to silicone implant leak vv ecmo rescue of silicone syndrome silicone migration after buttock augmentation subacute silicone pneumonitis after silent rupture of breast implant pulmonary empty spaces: silicone embolism-a decade of increased incidence and its histological diagnosis chronic pulmonary silicone embolism relatedto saline breast implants a serious complication of illicit silicone injections: latent silicone embolization syndrome after incision and drainage of local injection site respiratory disease following illicit injection of silicone: a case report an unusual case of pulmonary embolism subcutaneous silicone injection and the silicone embolism syndrome: a clinicopathologic correlation of two cases acute pneumonitis secondary to subcutaneous silicone injection silicon emboli syndrome: a sequela of clandestine liquid silicone injections. a case report and review of the literature acute pneumonitis and alveolar hemorrhage after subcutaneous injection of liquid silicone subcutaneous silicone injection leading to multisystem organ failure pulmonary embolism due to liquid silicone: case report silicone pneumonitis after a cosmetic augmentation procedure the silicone syndrome ct visualization of silicone-related pneumonitis in a transsexual man a case of acute pneumonitis induced by injection of silicone for colpoplasty key: cord- -ytix l o authors: samillan, v. j.; flores-leon, d.; zutta, b. r.; rojas, e. title: environmental and climatic impact on the infection and mortality of sars-cov- in peru date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ytix l o the role of the environment and climate in the transmission and case-fatality rates of sars-cov- is still being investigated. elevation and air quality are believed to be significant factors in the current development of the pandemic, but the influence of additional environmental factors remain unclear. in this study, we explored the relationship between the cumulative number of infections and mortality cases with climate (temperature, precipitation, solar radiation, water vapor pressure, wind), environmental data (elevation, ndvi, pm . and no concentration), and population density in peru. using the data from confirmed cases of infection from districts and confirmed cases of mortality in districts, we used spearman's correlations to assess the correlation between environmental and climatic factors with cumulative infection cases, cumulative mortality and case-fatality rate. we also explored district cases by the ecozones of coast, sierra, high montane forest and lowland rainforest. multiple linear regression models indicate elevation, mean solar radiation, air quality, population density and green cover are influential factors in the distribution of infection and mortality of sars-cov- in peru. the case-fatality rate was weakly associated with elevation. our results also strongly suggest that exposure to poor air quality is a significant factor in the mortality of individuals with sars-cov- below the age of . we conclude that environmental and climatic factors do play a significant role in the transmission and case-fatality rates in peru, however further study is required to see if these relationships are maintained over time. as sars-cov- has spread around the world in a few months, several groups of investigators have started to look into the different factors that could be related to the distribution of the infection and the severity of the disease. the incidence of infection in different countries and cities suggests that several factors influence the rate of infection, which are not only related to the virus and the immune system. in the case of peru, the cities that have the most cases are generally located near the coast and have poor air quality throughout the year (https://www.datosabiertos.gob.pe/). in addition, population density seems to be a key factor in the spread of the virus, where overcrowded cities increase the probability of contact with infected individuals, increasing the number of infection and mortality cases in a short amount of time. therefore, population density should be taken into account when analyzing different cofactors sars-cov- distribution. although more studies are necessary, the rate of infection and the severity of the diseases seems different for people living in cities at high altitudes, where not only hipoxia is a major factor, but other factors such as air quality, solar radiation, and population density, could play a role in sars-cov- person-to-person transmission. arias-reyes et al. ( ) suggested that there exists less rate of infection at high altitude possibly due to a lower level of expression of ace compared to sea level. this observation is important, particularly since sars-cov- uses ace as a point of infection for the cells (ren et al., ) . yao et al. ( ) explored the rate of sars-cov- infection across china, and concluded that there was no correlation between temperature, uv and the rate of infection. however, they recommended future studies using more complex models and environmental factors. finch et al., ( ) explored the role of pollution exposure in the development of different diseases, where heart and respiratory diseases indicated a detrimental role of pollution on the endothelial integrity, and the changes in the levels of endothelin i could be observed in people that were exposed to air pollution. (briet et al. ) environmentals factors related to mechanics of different virus spread have been studied by several groups, before the pandemic. pica et al. ( ) studied the environmental factors related to the spread of seasonal influenza and concluded that some meteorological factors play a central role in the person-to-person transmission of the virus, besides the sociodemographic factors. it is well known that uv radiation can decontaminate surfaces and air, and uv incidence increases at higher elevations and cities will have different exposures depending on their location. kowalsky et al. ( ) demonstrated that the uv light can destroy a bacteries, many viruses and fungi, but additional studies are necessary to understand the impact of uv on sars-cov- in the natural environment. understanding all the factors that are related to the spread of sars-cov- will be an important part of public policy, particularly towards the implementation of focalized quarantines in cities and districts where the cases of infection are high. therefore, this study aims to explore the different cofactors that could increase or decrease the possibility of person-to-person transmission of sars-cov- . the main objectives of this study was to explore the relationship between sars-cov- infection and mortality cases, case-fatality rates with a set of climate (temperature, precipitation, solar radiation, water vapor pressure, and wind), environmental data (elevation, ndvi, pm . and no concentration), and population density in peru. we also divide the distribution of infection, mortality and case-fatality rates by four ecozones (coast, sierra, high montane forest and lowland rainforest) and subset mortality cases by age groups and gender. we obtained sars cov confirmed cases by district, of the districts in peru, from official reports provided by the peruvian ministry of health (minsa), through an official government open data portal (https://www.datosabiertos.gob.pe/). we used the cumulative number of confirmed cases of infection from districts and confirmed cases of mortality in districts, where at least confirmed case was registered as of june , ( figure ). the first case of sars cov was registered on march , . under this criteria, the number of positive sars cov cases analyzed were , and , deaths by june , . available data of infection included date of confirmation, while data on mortality included age, sex, and date registered. the first confirmed case of sars cov in peru was on march , . infection and mortality values were log-transformed to meet statistical assumptions in relation to residuals and added to avoid taking the logarithm of xie and zhu, ; zhu et al., ) . we also assessed case-fatality rates, which implies the severity of the condition by estimating the proportion of cases that die of a given condition (segovia-juarez et al., ) . the casefatality rate was estimated by dividing the number of cause-specific deaths among the incidence cases by the total number of incident cases* (cdc, ) we labeled districts based on four ecozones, including coast, sierra, high montane forest and lowland rainforest, which was originally developed based on elevation and biogeography and used in national and international reporting, and have a significant effect on agricultural activity, population density, population connectivity and other socioeconomic activities (minam, ) . a set of climate metrics were obtained from worldclim version . (fick & hijmans, ) , which presents a historical baseline from the years to and includes monthly temperature, rainfall, wind speed, and solar radiation. satellite-based environmental data was obtained from a variety of satellite sensors that detect environmental variables, including elevation, vegetation cover, and air quality. vegetation cover was estimated through ndvi (normalized difference vegetation index), a commonly used spectral index used to quantify green cover, including agricultural extent, forest cover, and green cover in urban settings. we infer air quality through the metrics of two health-relevant air pollutants, which include particulate matter at . μ m (pm . ) and nitrogen dioxide (no ). population density was obtained from the worldpop model of population density (people km − ) for peru adjusted to match official united nations population estimates for the year (www.worldpop.org). further details on climate data and satellite-based environmental data are provided in the online supplementary material. we extracted the zonal statistics by district (i.e. average value per district polygon) of each of the climate, remotely sensed and population density layers using arcpro (verison . ). we used spss . (ibm, usa) for all statistical analysis of the extracted values. we used the onesample kolmogorov-smirnov parametric test to evaluate the distribution of residuals obtained for each district from each of the original data layers used. covariance within the subsets of climate and environmental variables were estimated with spearman's rho correlation, where correlation of the order of . or larger were determined to have a high covariance. as a result, the final reduced data set used in this study were data layers, including climatic layers, environmental layers and the population density model (table ). the climatic layers included temperature, rainfall, solar radiation, wind speed and water vapor metrics. all environmental layers and the population density model had a relatively low level of covariance and were kept for further analysis. the climate and environmental data were also normalized (following zhu et al., ), due to the different units used in each variable, through the following method: where x is the normalized data, x n is the raw data for the variable, x an is the mean value of the raw data, and s n is the standard deviation of x n . we used stepwise linear regression to explore the association of climatic and environmental variables with the log-transformed data of cumulative number of confirmed cases of infection all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . and confirmed cases of mortality, across peru and within ecozones. the number of cases were used as dependent variables, and the environmental and climatic were selected as independent variables. the resulting statistically significant predictive models use one or multiple variables that best explain the dependent variable. the adjusted r from model fitting indicates the percentage of all factors that explain the distribution of cases and the magnitude of the standardized β reflects the influence of the corresponding variable in the predictive model. collinearity diagnostics, resulting from the regression, were also used to identify model variables that were highly correlated. significant differences between means were evaluated using one-way anova followed by a tukey test. the district of san juan de lurigancho, of the department of lima and in the coastal ecozone, had the most number of confirmed infected cases and case fatalities of sars-cov- , with , total infections and fatalities, up until the date of the data obtained for this study. the average number of confirmed cases of infection and fatalities was (sd ± ) and . (sd ± . ) per district, respectively. across ecozones, the number of registered male fatalities was , ( . %) and females was , ( . %). the average age of total male fatalities was . (sd ± . ) and females was . (sd ± . ). there was also a significant difference between ecozones for mean age of fatalities (f = . , p< . ) and female only cases (f = . , p< . ), but not in male only cases (f = . , p= . ). we found no significant difference between the mean case-fatality rates by ecozones (f = . , p= . ; table ). correlation analysis indicated a positive correlation of total infections with pm . ( = . ) and a negative correlation with elevation ( = - . ), where the number of infections correlates with increased air pollution, while there are less number of infections with elevation figure ). similarly, correlation analysis indicated a high positive correlation coefficient between mean tropospheric no ( = . , p< . ), pm . ( = . ; p< . ) and registered mortality across sexes and in the male population with = . and = . , respectively. in stepwise linear regression model fitting, the three most important parameters that explain the distribution of cumulative number of infections across the country (r = . ; p-value = . ) were ndvi (β = - . ), elevation (β = - . ), and mean solar radiation (β = - . )( table ). the negative correlation indicates a decrease in the cumulative number of infections, with an increase in surrounding green cover (ndvi). in addition, the cumulative number of infections decreases with increasing elevation and increasing mean solar radiation. within each ecozone, parameters importance change indicating the importance of population density (β = . ) in the coast, ndvi (β = - . ) in the sierra, maximum no (β = . ) in high montane forest, and elevation (β = - . ) in lowland rainforest. model fitting for cumulative mortality cases across the peru indicated the negative correlation of ndvi (β = - . ), elevation (β = - . ), and mean solar radiation (β = - . ), and the positive correlation with mean no (β = . ) and population density (β = . ) ( table ) . population density was the most influential factor for mortality in the coastal ecozone, lowland rainforest, and male and female mortality across the country. it is worth noting that adjusted r indicated that the models included at least % of the factors that affect the difference in mortality. regarding age groups, mean no was the most influential factor of difference of mortality for individuals with an age range of to (β = . ) and to (β = . ) ( table ) . population density was the most influential factor for the remaining age ranges of to (β = . ), to (β = . ), and above (β = . ). however, it is worth noting that mean no was indicated as an influential factor for mortality for the age ranges of to (β = . ) and above (β = . ). a positive correlation from model fitting was found between case fatality rates and elevation (β = . ), although a relatively low explanatory factor (r = . ; p-value = . ) compared to most predictive models performed in this study (table ). indeed, case fatality rate models had the lowest r , although statistically significant (p < . ), compared to models for infection and mortality. elevation was the most influential factor for the coast (β = . ), sierra (β = . ), and high montane forest (β = . ). mean diurnal range was the main factor for case fatality rates in high montane forests (β = . ) and the only climate variable to appear as a factor for model fitting in this study. our study found that several environmental factors are influential in the cumulative number of sars-cov- infection and mortality, with particular factors having apparently significant roles in specific scenarios. generally, the cumulative number of infections is reduced with increased elevation and solar radiation, but other factors such as poor air quality and population density have significant roles. surprisingly, ndvi, as a measure of green cover and socioeconomic level in urban settings, was a strong predictive factor of sars-cov- infection (table ) . previous studies have found that more affluent suburbs in peru tend to be less populated, have more green space that reflects higher property values (duarte-garcia et al., ) , and therefore, residents may be more likely to have access to private health measures that could decrease rates of infection in the longer term. once we separate infection and mortality by ecozones, the influence of environmental factors is similar to looking at peru as a whole, with a few notable exceptions. solar radiation is a much more influential factor in the sierra, where there are strong geographic patterns particularly in the south, and uv radiation is known to be strong in these drier environments (figure ). if we take into account the uv radiation as a possible factor that could decrease the survival of the virus in the air, this could account for the decrease of infected people in the sierra and in the south of the country. mean no concentration is an overriding factor for the cumulative number of mortality for ages below . higher mean no concentration is indicative of anthropogenic activity, such as fossil fuel consumption and biomass burning, which occur in more population dense districts, but it is only moderately correlated with population density in peru. mean no concentration in was highest in the metropolitan cities of lima, arequipa and the small southern city of moquegua, where no density of above µmol m − were found year round. seasonal high concentrations, due to agricultural and other biomass burning, are found in cities in the amazon basin during the dry season. the overall detrimental effects of air pollution on the health and mortality within populations, in accordance to type and length of exposure is known (carey et al, ) , along with other studies exploring its effects on the current pandemic (fattorini and regoli, ) . unlike male mortality, we found a significant difference in the mean age of women who died across ecozones in peru, with a higher average age for women in the sierra. to our knowledge, this is the first study to indicate the multiple factors that seem to influence female mortality, including a negative correlation with elevation and mean solar radiation, but a larger positive correlation with population density, ndvi and mean no density. female mortality from sars-cov- is lower than males in all the countries possibly due to the expression of the ace (angiotensin converting enzyme ) receptor regulated by female hormones. however, protection is lost in older women, as the levels of hormones decrease. the probability of infection in older women becomes similar to their male counterpart, but there is still a higher rate of fatalities in men than women independent of age (jin jiam-min et al, ). our study also found elevation to be an influential factor in case fatality rate for the coast, sierra, high montane forest, lowland rainforest, and the country as a whole when looking at the data at the district level. this is contrary to the findings segovvia-juarez et al. ( ), which studied cases at the provincial level, instead of the district level, and found that the case fatality rate was not modified by elevation. our analysis indicates a rather weak but statistically significant correlation. however, we acknowledge that further studies still need to be conducted to see if this relationship continues throughout the course of the pandemic. the limitations of this study are indicative of the asymptomatic nature of sars-cov- for many patients. it is currently unclear the magnitude of underestimation occurring at the present time and accurate numbers may not become available until widespread molecular testing is performed. also, news reports indicate that the cumulative number of mortality may also be significantly underestimated due to the lack of testing and patient care in overwhelmed urban and rural hospitals, particularly during the peaks of sars-cov- infection. in conclusion, elevation is one of several factors that has determined the number of infections and mortality. other significant factors include population density, air quality, solar radiation and ndvi, as a measure of both green cover and socioeconomic level. poor air quality was the single most important factor to determine mortality below the age of . we also found that case fatality rate is modified, albeit weakly, by elevation, which is contrary to previously published findings. as more data becomes available, this study can be replicated to see if the relationship between sars-cov- and climatic and environmental factors are maintained over time. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . table predictive models of the relationship of case fatality rates and environmental and climatic variables. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . figure a) cumulative number of confirmed infected cases per district, b) modeled population density (people km − ) for the year , c) maximum tropospheric no density (µmol m − ) for , and d) mean solar radiation (kj m − day − ). outlines in a) and b) are district boundaries, while outlines in c) indicate departmental boundaries and d) (left to right) the coast, sierra, high montane forest and lowland rainforest ecozones. figure spearman's correlation between climatic and environmental factors and the cumulative cases of infection, case-fatality rate (cfr) and mortality. the color gradient indicates correlation coefficients, where darker red indicates a correlation approaching and a darker blue indicates a correlation approaching - . statistical significance were * p< . , ** p < . , and ***p< . . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. for the purposes of our study, the ecozones originally categories as "selva alta accessible" (accessible high jungle) and "selva alta dificil" (difficult high jungle) were merged to high montane forest ecozone. similarly, the hydromorphic zone was merged with the lowland rainforest ecozone. a set of climate metrics were obtained from worldclim version . (fick & hijmans, ) . these metrics are derived from monthly climatologies, which include monthly temperature, rainfall, wind speed, and solar radiation. these monthly climatologies were developed using a series of global and country networks of weather stations and represent a historical baseline from the years to . the data is interpolated into monthly climate metrics at a km spatial resolution and at the global scale. eleven temperature and eight precipitation metrics were used, which represent measures of annual means and seasonality. three wind speed and three solar radiation metrics were also used, which include annual mean, annual standard deviation and annual maximum. the total number of climate layers initially available for this study was before they were reduced to avoid collinearity environmental data was obtained from a variety of satellite sensors that detect environmental variables, including elevation, vegetation cover, and air quality. we used the shuttle radar topography mission (srtm) digital elevation data at the native m spatial resolution. to quantify vegetation cover, we used the modis (moderate resolution imaging spectroradiometer) terra -day ndvi (normalized difference vegetation index) product to calculate the mean ndvi value over peru for the year . ndvi is a widely used spectral index that is highly correlated with vegetation and has a range of value from + to - , where values close to + , indicate dense green vegetation, and values close to indicate barren ground or artificial surfaces. ndvi values of peruvian rainforests or well irrigated agricultural plants would approach a value of , while cities with mostly artificial surfaces and very few urban trees or gardens would have an average value closer to zero. we infer long term exposure to air pollution through the metrics of two health-relevant pollutants, which include particulate matter at . μ m (pm . ) and nitrogen dioxide (no ). mean pm . (dust column mass density in kg m - ) was obtained from the merra- (modern-era retrospective analysis for research and applications version ) using the the goddard earth observing system model, version (geos- ) with its atmospheric data assimilation system (adas), version . . , which was available through nasa´s giovanni application (v. density (µmol m − ) for was obtained from the copernicus sentinel- p satellite, which holds the tropospheric monitoring instrument (tropomi). we used the native spatial resolution of km and metrics of annual mean and maximum value for the year , which was obtained through google earth engine. the total number of environmental data layers assessed for this study was , which were assessed for collinearity through superman´s rho correlation and stepwise linear regression collinearity diagnostics. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . jorgesolizab does the pathogenesis of sars-cov- virus decrease at high-altitude? endothelial function and chronic exposure to air pollution in normal male subjects mortality associations with long-term exposure to outdoor air pollution in a national english cohort air pollution-induced vascular dysfunction: potential role of endothelin- (et- ) system role of the chronic air pollution levels in the covid- outbreak risk in italy worldclim : new km spatial resolution climate surfaces for global land areas plataforma nacional de datos abiertos yang jin-kui gender differences in patients with covid- : focus on severity and mortality ultraviolet germicidal irradiation handbook: uvgi for air and surface disinfection on the use of hedonic price indices to understand ecosystem service provision from urban green space in five latin american megacities identification of a novel coronavirus causing severe pneumonia in human: a descriptive study environmental factors affecting the transmission of respiratory viruses high altitude reduces infection rate of covid- but not case-fatality rate no association of covid- transmission with temperature or uv radiation in chinese cities the authors wish to thank professor dr. michal horowitz for her critical reading and discussion of the manuscript. key: cord- -naqo m r authors: prayuenyong, pattarawadee; kasbekar, anand v.; baguley, david m. title: clinical implications of chloroquine and hydroxychloroquine ototoxicity for covid- treatment: a mini-review date: - - journal: front public health doi: . /fpubh. . sha: doc_id: cord_uid: naqo m r at this time of the covid- pandemic, potentially effective treatments are currently under urgent investigation. benefits of chloroquine and hydroxychloroquine for the treatment of covid- infection have been proposed and clinical trials are underway. chloroquine and hydroxychloroquine, typically used for the treatment of malaria and autoimmune diseases, have been considered for off-label use in several countries. in the literature, there are reports of ototoxic effects of the drugs causing damage to the inner ear structures, which then result in hearing loss, tinnitus, and/or imbalance. this mini-review represents a summary of the findings from a systematic search regarding ototoxicity of chloroquine and hydroxychloroquine in the published literature. the characteristics of sensorineural hearing loss and/or tinnitus after chloroquine or hydroxychloroquine treatment can be temporary but reports of persistent auditory and vestibular dysfunction exist. these are not frequent, but the impact can be substantial. additionally, abnormal cochleovestibular development in the newborn was also reported after chloroquine treatment in pregnant women. the suggested dose of chloroquine for covid- infection is considerably higher than the usual dosage for malaria treatment; therefore, it is plausible that the ototoxic effects will be greater. there are potential implications from this review for survivors of covid- treated with chloroquine or hydroxychloroquine. patient reports of hearing loss, tinnitus, or imbalance should be noted. those with troublesome hearing loss, tinnitus and/or imbalance are encouraged to be referred for hearing evaluation and interventions once they are stable. clinical trials of chloroquine or hydroxychloroquine should also consider including audiological monitoring in the protocol. at this time of the covid- global pandemic, potentially effective treatments are currently under urgent investigation. currently, there is no evidence from randomized clinical trials that any specific therapy improves outcomes in patients with covid- ( ). chloroquine and hydroxychloroquine are considered to be promising repurposed drugs against covid- , based on pathophysiological considerations and in vitro results ( , ). these drugs have received particular attention as they are widely available and inexpensive. chloroquine and hydroxychloroquine, quinine-related compounds, have been used for the treatment of malaria and chronic inflammatory diseases such as systemic lupus erythematosus and rheumatoid arthritis. the anti-viral and anti-inflammatory properties may account for the efficacy in treating patients with covid- infection ( ). there have been reports that patients who received chloroquine or hydroxychloroquine had faster virological clearance ( , ) , however there are some limitations of the studies such as small sample size and questionable methodology. there is no high-quality evidence of potential benefit of these drugs at the moment. presently, there are over registered ongoing trials worldwide examining the role of chloroquine and hydroxychloroquine in covid- treatment ( ) . clinical practice guidelines have considered chloroquine and hydroxychloroquine for off-label and compassionate therapies against moderate to severe cases of covid- in several countries including china, korea, usa, france, italy, and belgium ( ) . there is currently also a massive global demand for chloroquine and hydroxychloroquine as people around the world are self-medicating after health professionals and politicians have endorsed the drugs. chloroquine and hydroxychloroquine are also freely available in the uk and other countries without prescription. some potential side effects of chloroquine and hydroxychloroquine are cardiac arrhythmias, retinopathy, and muscle weakness ( ). the clinical and research literature also contains reports of ototoxic effects after chloroquine and hydroxychloroquine treatment. ototoxicity refers to drug-related injury causing damage to the inner ear structures, which then result in hearing loss and/or tinnitus (the subjective perception of sound such as ringing, hissing, or buzzing, without an external source), and/or imbalance ( ) . permanent hearing loss can adversely affect cognitive health ( ) and mental well-being ( ) . troublesome tinnitus is associated with insomnia, poor concentration, anxiety and depression ( ) . the mechanisms of chloroquine associated hearing loss include cochlear outer hair cell dysfunction, and inhibition of post synaptic sodium channel function in cochlear spiral ganglion cells ( ) . additionally, some alterations in central auditory function, which may trigger tinnitus, have been observed after quinine administration ( ) . this mini-review represents a summary of the findings from a literature search regarding ototoxicity of the drugs in the published literature as well as the discussion of potential implications for survivors of covid- so treated. a systematic literature search on medline and embase platforms was undertaken on th march , updated on rd april . the search strategy combined mesh terms and keywords of chloroquine or hydroxychloroquine, ototoxicity, hearing loss, hearing, tinnitus. english language publications containing relevant data to this review were included. data extraction items included year, study design, sample size, and audiological outcomes. data were collated in the table and then summarized by narrative synthesis. recommendations from audiological professional perspectives were then made. eleven publications, reporting topics associated with ototoxic effects of chloroquine, were identified and are summarized in table . the year of publication ranged from to . there were case reports, observational studies, case control study, and review article. the sample size of the study participants varied from to . ten patients ( adults and children) in publications had either abnormal audiogram or reported hearing loss after chloroquine treatment. three out of ten cases had temporary sensorineural hearing loss after chloroquine treatment that improved after cessation of the medication ( , ) . a prospective observational study in concluded that ototoxic effects of chloroquine at regular doses for malaria treatment ( . g daily for days) were fully reversible ( ) . sensorineural hearing loss after chloroquine in a -year old girl was partially reversible after prednisolone administration ( ) . however, permanent severe sensorineural hearing loss has also been reported in cases ( , ) . additionally, reversible chloroquine-induced cochlear injury was detectable by brainstem audiometry in out of patients despite normal pure tone audiogram results ( ) . tinnitus has also been reported concurrently with persistent hearing loss in case ( ) . imbalance was reported in cases ( , , ) . while there was no difference in hearing thresholds between children who were and were not exposed to chloroquine during gestation ( ) , there were case reports of intrauterine effects of chloroquine associated with abnormal cochleovestibular development in newborns ( , ) . six case reports, describing ototoxic effects associated with hydroxychloroquine, were identified and are displayed in table . publication year ranged from to . sensorineural hearing loss was identified after hydroxychloroquine treatment in five adults and two children. the sensorineural hearing loss was found to be either reversible ( , ) or irreversible ( , ) . the onset of hearing loss after hydroxychloroquine treatment varied from month ( ) to several years ( ) . tinnitus was also reported concomitantly with hearing loss in cases ( , ) . the manifestation of sensorineural hearing loss and/or tinnitus and/or imbalance after chloroquine and hydroxychloroquine can be either temporary or permanent. most of the studies on this topic were case series or case reports with only a few observational studies. information from a definitive large study with good methodology is still lacking. ototoxicity after chloroquine use tends to be more sudden, while assessment of short term chloroquine-induced ototoxicity in malaria patients ( ) subramaniam and vaswani ( ) prospective observational study (aged - years old) mg loading load then mg oral every hours for days - subjects showed a change in hearing thresholds on high frequency audiometry ( ) ( ) ( ) ( ) ( ) . pure tone audiometry showed bilateral mild sensorineural hearing loss at khz in subject, and bilateral mild to moderate sensorineural hearing loss at khz in another. the otoacoustic emission (oae) and auditory brainstem response (abr) findings were also abnormal in these subjects. a month follow-up pure tone audiogram was normal. - subject showed vestibular side effects in the form of 'giddiness' and nystagmus which spontaneously resolved on completion of therapy. chloroquine ototoxicity ( ) bortoli and santiago m ( ) review ---some reports have described sensorineural hearing loss, tinnitus, sense of imbalance after prolonged high dose of chloroquine. -the reversibility of chloroquine ototoxicity has been debatable. chloroquine gestational use in systemic lupus erythematosus: assessing the risk of child ototoxicity by pure tone audiometry ( ) borba et al. ( ) case-control study (mean age of mothers was years old) mg daily -there was no difference in hearing thresholds by pure tone audiometry of children between chloroquine exposure and non-exposure groups during the gestation. the mean hearing thresholds (pure tone audiometry) at low frequencies of exposure and non-exposure groups were similar ( . ± . vs. . ± . db; p = . ). the mean hearing threshold at high frequencies of exposure and non-exposure groups were not significantly different ( . ± . vs. . ± . db; p = . ). chloroquine ototoxicity: an idiosyncratic phenomenon ( ) hadi et al. ( ) case report of a . -year-old boy no information -abnormal gait a few hours after single chloroquine intramuscular injection. severe hearing loss on the nd day. days later, he was treated with steroid and plasma expander. he still had permanent severe hearing loss at - years follow up. no testing technique information given. alterations of auditory evoked potentials during the course of chloroquine treatment ( ) bernard ( ) observational study no information -there was no hearing change by pure tone audiogram. -there were abnormal results of brainstem audiometry (auditory brainstem audiometry) in patients which resolved after chloroquine discontinuation. chloroquine ototoxicity-a reversible phenomenon? ( ) mukherjee ( ) case report of a -year-old girl mg intramuscular injection daily for days -she complained of hearing loss, and had abnormal gait after chloroquine injection for malaria. pure tone audiometry indicated severe unilateral sensorineural hearing loss, which was worse at mid frequencies (mean hearing threshold at mid frequencies = db) -patient hearing improved after prednisolone administration, and pure tone audiometry indicated the mean hearing threshold at mid frequencies was db bilaterally. ototoxicity of chloroquine phosphate: a case report ( ) dwivedi and mehra ( ) case report of a -year-old man , mg loading load -the patient had bilateral permanent deafness, severe vomiting, vertigo, blurring of vision and tinnitus at . hour after taking a single dose of g of chloroquine. pure tone audiometry indicated hearing thresholds of more than db in both ears. obiako (personal communication) case report no information -there were cases of sensorineural deafness following chloroquine phosphate injections. no testing technique information given. ototoxicity of chloroquine ( ) matz and naunton ( ) case report no information -there was a complete absence of inner and outer hair cells throughout the length of the cochlea in a deaf child whose mother took chloroquine during pregnancy. no testing technique information given. the ototoxicity of chloroquine phosphate ( ) hart and naunton ( ) case report no information -there were cases of severe bilateral cochleovestibular paresis whose mothers were treated with chloroquine during her pregnancy.no testing technique information given. dewar and mann ( ) case report no information -the patient had irreversible sensorineural deafness, after being treated with chloroquine for months. no testing technique information given. frontiers in public health | www.frontiersin.org ( ) coutinho and duarte ( ) case report of a -year-old girl mg daily -patient had unilateral slowly progressive hearing loss after years of hydroxychloroquine use. pure tone audiometry indicated moderate to severe sensorineural hearing loss (mean hearing threshold db). the auditory brainstem response (abr) test showed absence of response at db in the right ear. hydroxychloroquine ototoxicity in a patient with rheumatoid arthritis ( ) seckin et al. ( ) case report of a -year-old woman mg daily -patient complained of hearing loss and tinnitus after months of hydroxychloroquine use. pure tone audiometry indicated bilateral mild sensorineural hearing loss. after discontinuation of hydroxychloroquine, patient symptoms improved and the follow-up audiogram was normal. otoxicity due to hydroxychloroquine: report of two cases ( ) johansen and gran ( ) case report of a -year-old woman and a -year-old man no information -patients had irreversible sensorineural hearing loss after several years of hydroxychloroquine use. no testing technique information given. frontiers in public health | www.frontiersin.org hydroxychloroquine is more likely to cause ototoxicity after prolonged use. this could be due to different drug efficacy and equivalent dosage. furthermore, hearing loss in these patients could be associated with other possible causes rather than chloroquine and hydroxychloroquine including autoimmune disease e.g., systemic lupus erythematosus ( ) , sudden sensorineural hearing loss or presbycusis. the suggested dose of chloroquine for patients diagnosed with covid- infection ( g daily for days) is substantially higher compared with the usual dosage of chloroquine for malaria treatment ( g daily for days) ( ). there is no information regarding the ototoxic effect of chloroquine at this higher dose. patients with chronic inflammatory diseases were treated with a usual dose of hydroxychloroquine mg daily for long durations (months or years). a suggested dose of hydroxychloroquine for covid- infection is an initial loading dose of mg followed by mg daily for days based on the in vitro model ( ), and mg daily for days from a french study ( ) . in general, the recommended dosage of hydroxychloroquine in covid- patients is slightly higher but in a shorter duration compared to that in autoimmune disease. the ototoxic effects of these regimens are unknown. due to the potentially substantial number of the world's population who may take chloroquine or hydroxychloroquine, there is the prospect of a significant number of people being affected with ototoxic side effects. it is therefore vital to build awareness about the presentation and impact of the symptoms of drug-induced ototoxicity. patient reports of hearing loss, tinnitus, or imbalance should be noted. those with troublesome hearing loss or tinnitus are encouraged to be referred for hearing evaluation, including extended high frequencies audiometry at - khz where possible, once they are stable. available options of audiological interventions for those with bothersome hearing impairment or tinnitus are counseling, hearing aids, and tinnitus therapy. the possibility of exacerbation of pre-existing hearing loss and/or tinnitus should be considered. synergistic adverse auditory effects when other ototoxic medication is administered with chloroquine or hydroxychloroquine, such as aminoglycoside antibiotics and azithromycin, is a further risk ( ) . severe cases of covid- can also progress to respiratory distress and hypoxia ( ) . hypoxia is known to have deleterious effects on the stria vascularis of the cochlea organ including alterations to cochlear potentials and histologic changes ( ) . therefore, it is certainly possible that the combined effects of hypoxia and administration of chloroquine or hydroxychloroquine on hearing could be worse than either one alone. clinical trials of chloroquine or hydroxychloroquine should also consider including audiological monitoring in the protocol. ideally, a hearing test should be conducted both before and after drug administration to examine drug-induced hearing change. common methods for audiological evaluation include pure tone audiometry, otoacoustic emission (oae), and tinnitus questionnaire. however, conventional methods and setting of hearing evaluation is impractical based on the infectious nature of covid- and the urgency of drug administration. selfmonitoring by validated smartphone-based apps for hearing assessments in addition to self-report of symptoms is an approach of interest in this situation. although chloroquine and hydroxychloroquine are generally considered safe in pregnant women, the use of chloroquine during pregnancy in the first trimester should be contemplated with particular caution since there are reports of abnormal cochleovestibular development in newborns. hydroxychloroquine has a safer clinical profile in pregnancy, thus is a more suitable option than chloroquine ( ) . recent publications have brought attention to the possible benefit of chloroquine and hydroxychloroquine in covid- treatment. it is important to build awareness about the possibility of ototoxicity in survivors of covid- treated with these drugs. patient reports of hearing loss, tinnitus, or imbalance should be noted. those with troublesome hearing loss or tinnitus are encouraged to be referred for hearing evaluation and interventions once they are stable. clinical trials of chloroquine or hydroxychloroquine should also consider including audiological monitoring in the protocol. hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial chloroquine and hydroxychloroquine in covid- expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia. zhonghua jie he he hu xi za zh pharmacological drugs inducing ototoxicity, vestibular symptoms and tinnitus: a reasoned and updated guide hearing loss as a risk factor for dementia: a systematic review hearing loss and depression in older adults: a systematic review and meta-analysis problems and life effects experienced by tinnitus research study volunteers: an exploratory study using the icf classification clinical and research perspectives assessment of short term chloroquine-induced ototoxicity in malaria patients chloroquine ototoxicity chloroquine gestational use in systemic lupus erythematosus: assessing the risk of child ototoxicity by pure tone audiometry chloroquine ototoxicity: an idiosyncratic phenomenon alterations of auditory evoked potentials during the course of chloroquine treatment chloroquine ototoxicity-a reversible phenomenon? ototoxicity of chloroquine phosphate. a case report ototoxicity of chloroquine the ototoxicity of chloroquine phosphate chloroquine in lupus erythematosus hydroxychloroquine ototoxicity in a patient with systemic lupus erythematosus a case report of hearing loss post use of hydroxychloroquine in a hiv-infected patient hydroxychloroquine-induced ototoxicity in a child with systemic lupus erythematosus hydroxychloroquine ototoxicity in a child with idiopathic pulmonary haemosiderosis hydroxychloroquine ototoxicity in a patient with rheumatoid arthritis ototoxicity due to hydroxychloroquine: report of two cases hearing loss in patients with systemic lupus erythematosus an overview of coronaviruses including the sars- coronavirus -molecular biology, epidemiology and clinical implications effects of hypoxia on cochlear blood flow in mice evaluated using doppler optical microangiography covid- : a recommendation to examine the effect of hydroxychloroquine in preventing infection and progression all authors planned and structured the paper. pp undertook the review and wrote the first draft. db, pp, and ak jointly revised the manuscript. pp and db receive support from the uk national institute for health research (nihr), but their views are their own and do not reflect those of nihr nor the uk department of health and social care. key: cord- -s vvfejn authors: bellido-blasco, j.b.; arnedo-pena, a. title: epidemiology of infectious diarrhea date: - - journal: encyclopedia of environmental health doi: . /b - - - - . - sha: doc_id: cord_uid: s vvfejn diarrhea is a very frequent symptom. a great variety of chemical agents, microorganisms, and biotoxins can cause diarrhea, acute or persistent, slight or serious. from the epidemiological point of view, the cases can be sporadic or epidemic, and identification of the infection source and transmission mechanism is important for prevention and control. knowledge of the etiology is a great help. the entrance route to the human body is usually through the digestive system. from some source in an individual's surroundings, the causal agent somehow reaches the mouth of the susceptible person. the hands play a fundamental role in many situations. this article revises the most important epidemiological characteristics of the agents that produce diarrhea as a main symptom, placing an emphasis on epidemiological point of view and environmental transmission mechanisms. some aspects regarding individual susceptibility (genetic or other types) are also mentioned. because the long-term consequences of infectious gastroenteritis are less well known, a small section dedicated to the long-term consequences of infectious gastroenteritis has been included. with suitable prevention, not only the acute consequences but also the aftereffects of these diseases can be avoided. diarrhea is a symptom of very diverse causes, and it is characterized by three circumstances: consistency, number, and volume of waste excretions. the consistency of the feces is liquid, or pastelike, adapting to the form of its receptacle. the frequency and volume of the excretions can be seen to increase within a highly variable range, starting with very slight diarrhea up to that which can put the patient's life at risk. the volume of feces in a healthy adult is almost ml. diarrhea's pathogenic mechanism is responsible for an acceleration of intestinal transit. the world health organization (who) defines diarrhea as ''the passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual. it is usually a symptom of gastrointestinal infection, which can be caused by a variety of bacterial, viral and parasitic organisms. infection is spread through contaminated food or drinking-water, or from person to person as a result of poor hygiene.'' dr. sherwood l. gorbach states: ''acute diarrhea is often defined as the occurrence of three or more unformed bowel movements a day or any number of such movements when accompanied by fever, abdominal cramps, or vomiting.'' while carrying out studies epidemiologists can use other operative definitions adapted to the objectives of each study, taking into account the sensitivity and specificity of the definitions in each case. from this three clinical syndromes can be described: a. acute watery diarrhea: beginning abruptly, it consists of the passing of a great amount of liquid feces without blood. main symptoms usually remain for less than days (but can persist up to weeks at most); it can be accompanied by vomiting and fever, but it also presents a greater problem, the possibility of dehydration. it is a result of the alteration of absorption and secretion balance. causal agents include rotavirus, campylobacter, nontyphoidal salmonella, enterotoxigenic escherichia coli, vibrio cholerae, and so on. b. dysentery: when diarrhea is accompanied by visible traces of blood in the feces, it is called dysentery. it is a result of damage suffered by intestinal mucus in the colon ravaged by an external agent, such as shigella dysenteriae, nontyphoidal salmonella, entamoeba histolytica, and campylobacter. rapid weight loss is the most frequent consequence. c. persistent diarrhea: with a duration of more than days, it can start as acute diarrhea or dysentery. it should not be confused with chronic diarrhea due to noninfectious causes. it can produce noticeable weight loss and a risk of dehydration. causal agents include shigella, enteroaggregative e. coli, cryptosporidium, and giardia. the consequent effects of diarrhea can be highly variable: from a slight and transitory condition that spontaneously resolves itself to its more severe incarnations where loss of water and electrolytes can be an important factor. the resulting hypovolemic shock can cause renal failure, disorders in other organs, and in the most vulnerable patients it can prove to be fatal. the appearance of diarrhea results from confrontation between aggressive external elements (a causal agent's toxicity or virulence, the quantity of the inoculant dose) and the body's own defense mechanisms. among the defense mechanisms combating infectious agents, the following can be highlighted: gastric acid, gastrointestinal mucus, intestinal motility, bile salts, regular intestinal bacteria, macrophage cells, lymphocyte cells, and type iga immunoglobulin in the mucus. additionally, there are genetic factors that can affect resistance to particular infections; for example, blood group 'o' individuals are at greater risk of suffering from cholera, whereas the socalled nonsecretory individuals, with certain fut gene mutations, are partially resistant to norovirus infection. other specific external circumstances such as the ingestion of alcohol or (nonvolatile) red wine could act as protective factors against infection by salmonella when the ingestion of the microorganism and those kind of drinks is almost simultaneous. there are few vaccines effective against diarrheal diseases. recently, a vaccine against rotavirus has been authorized, which is expected to show positive results. occasionally, diarrhea presents itself as an accompanying symptom of chronic conditions, such as the collateral effect of some medicines or a sign of malnutrition. however, this article discusses diarrhea as the principal effect of infections and poisoning by microorganisms, ingestion of animals, plants, or compound chemical toxins. in this context, it is very common to associate diarrhea with the ingestion of food that is either contaminated or well past its best. but infections and food poisonings do not always present themselves as the clinical profile in which diarrhea is predominant. for example, in botulism or some marine biotoxins the essential factors are the neurological signs -diarrhea may or may not be present. infant mortality from acute diarrhea has reduced throughout the last years of the twentieth century, essentially due to improvements in sanitation and the implementation of oral rehydration therapy programs by the who. even so, in the year , it caused approximately million deaths. the vast majority was related to avoidable causes. in the distribution of diarrhea cases there are geographic and age-related differences. with as much respect to etiology as to the seriousness of the cases, somewhat different patterns have been found, according to whether the countries are industrialized or not. certain parasites and cholera, for example (of whom the who is continuously in international pursuit), are still frequent in some underdeveloped regions where favorable conditions for their propagation exist. bad conditions of individual hygiene, nutrition, and existing public sanitation in many poor countries favor the presence of diarrhea. even when incidences of the infection do not display such great geographic differences, in the case of some viruses, the indicators in terms of its lethality are noticeably different; for example, rotavirus is very frequent in all types of countries, but its severity (mortality rate) is greater in poor countries. in england and wales, the microorganisms that most frequently cause diarrhea are campylobacter, rotavirus, norovirus, salmonella, giardia, and cryptosporidium. since means have been available for the virological diagnosis of gastroenteritis, it has been seen that viruses are the most common cause of diarrhea in western countries. generally they do not cause very serious illnesses at the individual level, but they are responsible for a considerable social burden in the form of hospital admissions and scholastic and employee absenteeism. the age of patients, the seriousness of the illness, and the capabilities of laboratories are factors that determine the scope of the etiological diagnosis. age also relates to the etiology of diarrhea ( figure ) and to the probability of fecal analyses. faced with a similar clinical profile, a child does not have the same probability as an adult of receiving an etiological diagnosis: in the child's case it is more likely. the same happens with serious conditions in comparison to slight ones. the slight diarrheas often go without etiological diagnosis. this is also the case with conditions caused by agents that are not detected by the laboratory participating in the analysis. age bias, age, and technical ability need to be considered when analyzing epidemiological statistics. however, epidemiological studies were performed in england and holland at the end of s and in the united states in and , in which a thorough fecal examination of all patients was undertaken, independent of their age and the seriousness of their condition, including those patients who no longer showed symptoms of diarrhea. in these studies, fecal examination was also carried out in healthy control subjects, so that the frequency in which specific microorganisms appeared could be compared with asymptomatic subjects. usually the etiological diagnosis of acute infectious (or toxic) diarrhea is obtained by fecal analysis: wet mount, coproculture, antigen detection, toxin detection, or other analyses. specialized laboratories can use more complex techniques that, generally, prove to be more sensitive and specific, but are also more expensive and difficult. nevertheless, many of the coprocultures a standard laboratory requests and examines are negative. a negative result can be the consequence of the following reasons: diarrhea is not actually infectious, it is caused by an agent for which the laboratory has no data, there is a failure in the test sensitivity, the patient may have taken antibiotics, or there may have been problems in fecal transport. cases that have returned negative results are a mixture of etiologies, and for that reason further investigation makes little sense. in the edics study (study of infectious diarrhea in castellón) of risk factors in infantile diarrhea, no risk factors were found associated to the cases with a negative fecal analysis result. on the contrary, risk factors were found in cases of campylobacteriosis, salmonelosis, or rotavirus. this indeed suggests that the group of negatives is a mixture of different etiological cases without common origin and with few shared risk factors. the appearance of vomit as an initial symptom, the absence of fecal blood (macro-or microscopic,) and low pcr (reactive c protein) are signs suggestive of viral etiology, especially in children. faced with an epidemiological case of diarrhea two questions arise: one, if the etiology is already known; two, if there are more cases related to the original. these two elements are represented in table , where each cell signifies a distinct epidemic concern. there are noticeable differences in modes of approaching the epidemiological study of diarrhea cases according to their sporadicity or pertinence to an outbreak. certain microorganisms have a preference to appear fundamentally as one of these forms. as such, campylobacter or rotavirus constitutes the majority of sporadic cases, not excluding the possibility of producing outbreaks. on the contrary, salmonella and, especially, norovirus more characteristically present themselves in the form of outbreaks. from the epidemiological point of view, it could be said that epidemic cases 'come' to the investigator as one, whereas the investigator 'goes' in search of the sporadic cases and reunites them for their studies. among the sporadic cases there is a group, which in fact belongs to small clusters, that escapes common systems of epidemiological monitoring and needs special investigations. this group of apparently sporadic cases (but which, in fact, are not sporadic) can only be detected by the existence of an exceptionally good monitoring system or by performing specific studies. steen ettenberg and other collaborators performed a specific study on cases registered throughout denmark in the s and found that . % of salmonella enteritidis, . % of shigella sonnei, . % of salmonella serotype typhimurium, . % of campylobacter, and . % of yersinia enterocolitica cases belonged to this type of clusters, which is a large majority unknown to epidemiological monitoring systems. in absolute terms, the cases of campylobacteriosis were the most numerous due to the large amount of patients diagnosed with the infection in the last years of the study. in a much smaller study in castellón (spain), clusters of this type were identified after systematic investigation of coprocultures in an area of inhabitants. small family clusters of campylobacter, s. enteritidis, rotavirus, and intestinal adenovirus were found. in addition to the etiology and level of aggregation, a third question arises: the source of infection and its mechanism of transmission. when the etiology is well known, the epidemiology of the agent involved is generally known. table summarizes some epidemiological characteristics of five infection sources and significant mechanisms of transmission. figures and represent two outbreaks of diarrhea by norovirus in residential homes for the elderly; these charts clearly demonstrate two mechanisms of transmission. figure shows a specific outbreak transmitted by foods (foodborne point source outbreak), and figure shows an outbreak, beginning gradually and progressively exacerbating, in which the transmission mechanism was predominantly 'person to person' and environmental (surfaces, fomites). figure represents a simple theoretical diagram for the investigation of transmissible disease cases by using the armigo system (agent, reservoir, mechanism of transmission, individual, groups, other people). following an outline inspired by the epidemic cases of table , three situations can be distinguished according to the characteristics of the affected population. first, a defined, open population with a specific exposure, which refers to people who only momentarily shared an exposure factor, for example, attending a shared dinner or banquet. second, a defined, closed population with lasting exposure factors, for example, permanent residents within a closed institution, who continually share meals, places, and activities. and third, an indefinite population, with or without specific exposure, which occurs when there is no obvious relationship between people and they are implicated in an outbreak, solely by sharing an exposure factor distributed throughout the population. in the case of laboratory analysis, an epidemic is identified where some rare microorganism in unusually large numbers of people is detected in a fairly prolonged time frame. for example, an outbreak that occurred in the united states in the first half of was produced by salmonella saintpaul with the same genetic fingerprint that affected more than people in states. the epidemic was related to the consumption of tomatoes distributed throughout the country. table shows the agents that most frequently cause diarrhea, and table summarizes the more relevant epidemiological features of the diarrhea caused by these agents. some of these microorganisms are discussed below. this was identified by ruth bishop in and was named as such because of its 'wheel-like' form. there are various groups of rotavirus capable of producing infections in humans. the vast majority of cases are children infected by group a rotavirus. group b is related to diarrheas in adults and group c to slight diarrheas at any age. other serogroups are zoonotic and are possibly transmitted by some animals. rotavirus is the main etiological agent for serious diarrheas in children all over the world. at a very young age, a large number of children have already been infected or reinfected. rotavirus has limited capabilities for producing outbreaks. the most important problems it constitutes are sporadic and hospital cases. many cases are relatively serious infections that require hospitalization. according to a study of common rotaviral diarrhea in children under years of age, carried out in and again in in castellón, almost half of the patients were hospitalized. in nonindustrialized countries, hospitalizations are fewer because welfare services are less accessible; mortality rates, however, are greater. year saw the august september notification and control authorization of two new oral vaccines that promise to be effective: rotateq s and rotarix s . previously known as 'agent norwalk,' this virus was identified by albert kapikian in . it is related to the caliciviridae family, of which only norovirus and sapovirus cause diarrhea in humans -the former preferentially causing epidemic cases (outbreaks) and the latter causing sporadic ones. norovirus, especially genogroups i and ii, actually constitutes the most frequent cause of viral diarrhea epidemics in industrialized countries. if rotavirus is characterized by producing sporadic cases, norovirus characteristically produces outbreaks; especially in semi-enclosed spaces such as residential homes for the elderly. the infection originates from diverse sources: foods, water, patients, and environment. the fingers are easily contaminated. a small dose of inoculant is sufficient to produce symptoms in susceptible people. on wood, metal, or plastic surfaces, the virus can survive for hours or even days. it has been proven that transmission is possible through typical hand-to-surface contact, such as door handles, telephone receivers, or taps. an experimental study found that contaminated fingers could transfer the virus to the clean surfaces they touch by up to seven times, and at least people could be contaminated by touching the same surface. alternatively, it is known that certain subjects are genetically resistant to infection by norovirus. the polymorphism of gene fut divides into secretory and nonsecretory individuals, who are susceptible and resistant, respectively. approximately % of caucasian subjects are nonsecretory. however, recently it has been seen that nonsecretory subjects are not totally resistant, suggesting some norovirus strains use alternative routes of infection. the characteristics of norovirus make it difficult to produce a vaccine against it. these serotypes generally cause cases of infantile diarrhea throughout the year. the only demonstrated mechanism of infectious transmission is direct contact between people. perhaps they have a limited epidemic potential. the infectious capacity of this virus is not accurately known. this was first identified in in a fecal examination among children with diarrhea. the astroviridae family, to which it belongs, was established in , and was named after its star-shaped appearance. it causes diarrhea in children and adults, with a slight seasonal pattern of predominance in cold months in regions with a temperate climate. the infectious capacity is high, perhaps very few viral particles can produce disease. epidemiological data suggest that immunity does not last and is serotype specific. few laboratories can diagnose the routine of this infection. it is believed that the virus can be an important factor in hospital diarrheas as much as in external cases. these belong to the coronaviridae family. among the viruses that cause diarrhea in humans, they are the only ones that possess envelopes. it is believed that the torovirus produces acute diarrhea in children and can also be an important factor in nosocomial diarrhea. coronavirus occasionally produces diarrhea, but it gained importance as a result of severe acute respiratory syndrome (sars) outbreaks, originated by coronavirus with a great capacity for environmental and person-to-person dissemination. the elimination of the virus in feces is less at the beginning of the illness. however, viral particles have been found several months after the symptoms first started. campylobacter, especially campylobacter jejuni, is responsible for the majority of bacterial gastroenteritis cases in the industrialized countries. it is a germ that grows little or nothing in foods. this is the probable cause of its limited epidemic potential and the scarcity of known outbreaks. some relationships to the ingestion of milk or public drinking water have been described. however, the majority of diagnosed cases are sporadic, essentially occurring in very small children and with little evidence of any seasonal pattern. it is possible -as happens with other microorganisms -that this predominance of diagnosed cases in children may be the consequence of a diagnostical age bias. studies on intestinal infection where adult participants were asked to provide fecal cultures revealed that campylobacter is also frequent in adolescents, adults, and the elderly. the majority of diagnosed intestinal infections do not require hospital admission. according to the authors of this article, only % of cases resulted in patients being hospitalized. reservoirs of campylobacter are not only found in farm animals, essentially avian, but also found in bovine livestock. companion animals, if they have diarrhea when very young, can pose an infection risk to their owners. the study of risk factors in campylobacter infection presents difficulties given that the majority of cases are sporadic and in children under the age of years. exposure to avian or bovine meat products has been related to infection. exposure is not necessarily by direct consumption; the presence of these products in home kitchens presents a risk factor, probably by cross-contamination due to poor hygienic practices. the existence of other diarrhea cases in the patient's nearby surroundings implies that there are small groupings, small outbreaks not identified by conventional systems of epidemiological monitoring. salmonella owes its name to the north american veterinarian daniel elmer salmon, who was one of the pioneers of microbiology toward the end of the nineteenth century. diarrhea by salmonella is a very common zoonosis all over the world. the clinical profile in many patients consists of diarrhea with fever and an exaggerated variable state of health. in the nontyphoidal salmonella group, there are more than serotypes that can cause gastroenteritis in humans, most common are s. enteritidis and s. typhimurium, although many others have been identified on numerous occasions. when available, the serotype and fagotype are laboratory data that aid in the investigation of epidemiological factors and the infection source (eggs, birds, and other animals). some serotypes have a preference to form reservoirs in specific animals. chickens and hens are principal reservoirs of s. enteritidis; however, pigs and cattle transmit s. typhimurium. other serotypes such as s. hadar, s. virchow, and s. heidelberg are also present in chickens and hens. reptiles are transmitters of some less frequent serotypes. hen eggshells can also be contaminated. but a remarkable fact is the vertical transmission of salmonella in hens, laying eggs that are internally contaminated. adequate data about the prevalence of contaminated eggs do not exist. at the beginning of the s, random sampling was carried out for a study in castellón, the estimation was little more than in a . also, common vegetables (tomatoes, watermelon) and foods with little water activity such as chocolate or powdered milk have been implicated in outbreaks. an outbreak was even transmitted by marijuana consumption. in , an outbreak in the united states transmitted by tomatoes affected more than people in some states. when investigating outbreaks, the possibility of secondary cases has to be taken into account. it is not believed that there are chronic carriers as with s. typhi, but the feces of some patients can remain contagious for months, especially in children. these situations and the cases with few symptoms are particularly important when they occur in food handlers. the infectious dose, the conditions surrounding its ingestion (accompanying food, antacid medication, etc.) and some characteristics of the host can act as factors that greatly modify the incubation period and the severity of the clinical profile. symptoms can start from h up to days after the ingestion of contaminated produce. some greasy foods facilitate salmonella's crossing the stomach without being eliminated by the extreme acidity of the gastric juices. it has been suggested, when faced with infection by s. ohio, that the simultaneous ingestion of alcohol (or red wine) has a protective effect. several serotypes of shigella exist. of them, s. dysenteriae type is responsible for the most serious cases, bacillary dysentery, due to the shiga toxin. other serotypes are s. sonnei, s. flexneri, and s. boydii, which in general produce less severe profiles, accompanied by watery diarrhea. the geographic distribution of each serotype is different. in industrialized countries the impact is diminished. in asia, it seems that incidents of shigellosis maintain a presence but tend to be less serious. little is known about incidents in africa. the infectious dose is very low (from to bacilli); therefore, secondary cases are very frequent due to easily contaminated hands. shigella produces outbreaks and sporadic cases. the incubation period of s. dysenteriae is longer, up to a week. carriers can be asymptomatic for weeks, and with antibiotic treatment they could reduce the time needed for elimination of shigella in the feces. however, the appearance of antibiotic resistance has been observed. the protection from natural infection it offers is type specific. within the yersinia genus there are numerous nonvirulent environmental strains. those that most frequently cause intestinal infection are y. enterocolitica and y. pseudotuberculosis. the former (whose taxonomic classification has undergone important changes from its initial description in as flavobacterium pseudomallei to the denomination yersinia at the beginning of the s) produces a diarrhea profile that includes abdominal pain and, sometimes, fever; the latter (whose first identification dates from many years earlier, in ) produces a clinical profile in which it is worth mentioning the symptoms of mesenteric adenitis, which can sometimes simulate an appendicitis. not all strains of y. enterocolitica are pathogenic in humans; furthermore, different pathogenic serotypes and biotypes are unequally distributed among the population. specific culture media are required for the identification of yersinia from human fecal samples; standard culture mediums are not usually sufficient. changes in laboratory practice have been considered an explanation for observed increases in the s and some geographical differences. the large majority of y. enterocolitica cases are sporadic. in many countries with temperate climates, the patients are usually small children diagnosed in winter months. the percentage of total diagnosed cases of diarrhea is small. the y. pseudotuberculosis species is less frequent and little knowledge exists regarding its mechanisms of transmission. there have been cases grouped in spatiotemporal clusters without a commonly identified nexus. in these clusters no secondary cases were observed, suggesting the source was most probably environmental. y. enterocolitica is frequently found in pig's tonsils. in the case of y. pseudotuberculosis, the reservoirs are wild rodents and birds. there is a possibility that some humans may be carriers of y. enterocolitica. also, yersinia, from these reservoirs, may contaminate foods or water, which will then infect those who consume them. in the case of y. pseudotuberculosis, there are recorded outbreaks transmitted by 'iceberg' lettuce and radishes. it is postulated that initially the infection is caused by waters contaminated by animal reservoirs, which indicates that the washing of fresh vegetables is a method to prevent infection. but an outbreak that occurred in finland in experimentally demonstrated the possibility of internal contamination of the lettuces, with the result that in such an eventuality external washing would have little effect. escherichia coli is a bacterium that forms part of the normal intestinal flora in humans and other warm-blooded animals. nevertheless, in the s, it was discovered that certain strains of e. coli had a pathogenic capacity in humans. there are many serotypes. their capacity to produce different clinical syndromes and affect different age groups is a factor unique to each serotype, ranging from 'traveler's diarrhea' to a serious profile of hemorrhagic colitis. the serotypes able to cause diarrhea are enterotoxigenic e. coli (etec), enteropathogenic e. coli (epec), enteroinvasive e. coli (eiec), enteroaggregative e. coli (eaec), and most virulent of all enterohemorrhagic e. coli, also named verocytotoxic e. coli (ehec or vcec) of the serotype o :h . the geographic distribution and transmission channels vary between serotypes. among the clinical characteristics of these infections, it is worth mentioning a serious complication of serotype o :h , hemolytic-uremic syndrome (hus), which appears mainly in children, and can be exacerbated by taking antidiarrheal or antibiotic medicines. this virulent stock of e. coli is transmitted mainly through ingestion of contaminated meat from bovine livestock, but it is also possible that there are other environmental routes of contagion by contact with surfaces or dust and sawdust in farms and zoological parks. recent studies suggest that eaec can cause both traveler and chronic diarrhea. furthermore, the inflammatory response to this infection depends on human genetic factors linked to interleukin- . this is a microorganism that can cause serious diarrhea, occasionally as pseudomembranous colitis, especially in hospitalized and debilitated patients. usually, it is triggered by taking antibiotics for therapeutic or preventive purposes. nevertheless, slight cases exist that are not diagnosed and are only detected in specific studies. the asymptomatic carrying and elimination of bacterial spores is relatively frequent in small children, but it is only patients with established diarrhea who are contagious. the origin of diarrhea from microorganisms previously present in the same individual can be endogenous. these microorganisms are stimulated when intestinal flora is altered as a result of taking antibiotics; this can happen for - days at the beginning of an antibiotic course and even later, up to or weeks after starting. in these cases, it is difficult to speak of an incubation period in the classic sense. there may also be exogenous contagion from environmental spores or c. difficile excreted by another patient. in some countries improvement in diagnostical methods has contributed to the increased number of diagnoses, especially in hospitalized patients. it is rare that it produces communal outbreaks. when it appears in an epidemic form it usually does so in hospitals. according to what is known of its clinical and epidemiological characteristics, cholera only produces the v. cholerae serogroups o and o , the latter confined to southeast asia. other serogroups, denominated 'non-o ' and 'non-o ,' usually present themselves as sporadic cases or small outbreaks with an incubation period of - h. as per epidemiological characteristics of cholera, it is easily spread through water or foods but not from person to person. in countries where there is overcrowding, poor nutrition, and poor environmental hygiene, cholera remains a very serious problem. people with blood group o are generally more susceptible to severe diseases. clostridium perfringens, bacillus cereus, and vibrio parahaemolyticus all these cause diarrhea through the consumption of contaminated food. the first two have the capacity to form spores and are found in terrestrial environments (the ground, for example). v. parahaemolyticus is halophilic and is found in marine environments and seafood products. person-to-person transmission, if it exists, would be rare. diarrheas caused by parasites usually have a more prolonged and insidious course. relapses and chronic forms are frequent and cause weight loss. they are usually resistant to the levels of chlorination in drinking water. entamoeba histolytica is frequent in tropical and subtropical countries. patients with diarrhea dispose of the parasite in trophozoit form, a form with little infectious potential due to its environmental fragility. in contrast, a significant number of infected people remain asymptomatic for months or years, eliminating cysts that have a greater infectious capacity than trophozoit. giardia lamblia is distributed by people all over the world. outbreaks caused by giardia are relatively common in day-care centers, especially when there are poor hygienic conditions that facilitate person-to-person transmission. foods and water can also provide vehicles of transmission. the reservoir is human and, perhaps, some animals such as beavers. people can remain carriers for months. cryptosporidium parvum produces diarrhea in humans and can also affect systems other than the digestive system. they are parasites resistive to the levels of chlorination used to disinfect drinking water; therefore, hydric transmission outbreaks occur without requiring failures in chlorination. water filtration is a preventive method to avoid propagation. it has a good survival capacity in the aquatic environment of continental waters. it is responsible for % of gastroenteritis outbreaks related to swimming venues in the eu, although hyperchlorination can inactivate cysts present in the water. it has been diagnosed with relative frequency throughout and in ireland, england, and belgium, and with less frequency in germany. there have been outbreaks from tap water contamination. parasites such as cyclospora cayetanensis, balantidium coli, and isospora belli have less importance than the ones mentioned earlier. there are even doubts about their capacity to produce symptomatic infection in humans. there is a very diverse range of agents that cause, or can cause, diarrhea (table ) . they are characterized by short incubation periods following ingestion (minutes or hours). they have a very broad clinical spectrum. notable among the biotoxins is scombroid fish poisoning, which can take place after ingestion of certain scombroid fish (such as tuna and herring) in certain circumstances. the symptomology simulates an allergic reaction that presents itself in an epidemic form. ciguatoxin, tetrodotoxin, and gempilotoxin are marine biotoxins that can produce very serious digestive and neurological symptoms. especially striking is gempilotoxin poisoning, in which diarrhea with orange colored feces has been observed. among vegetables, mushroom poisoning can cause serious consequences. less well known is the diarrhea from robinia pseudoacacia poisoning, which can be observed after chewing the bark of common trees. as consequences of the intestinal infections, complications and long-term aftereffects are distinguishable. the former occurs in the acute phase and the latter appears weeks or year after resolving the clinical profile, sometimes even later. studies used by epidemiologists to investigate aftereffects are: • point source outbreaks studies • prospective cohort studies of sporadic cases • retrospective cohort studies. the etiology of inflammatory bowel disease (ibd) is not known, but cohort studies carried out in the united kingdom and sweden indicate that previous bacterial intestinal infections by salmonella, campylobacter, or diarrheagenic e. coli and other agents of acute gastroenteritis double or triple the risk of suffering from some ibd variants, with incidences reaching almost per person-years. irritable bowel syndrome (ibs) can develop after infectious gastroenteritis by campylobacter, shigella, salmonella, or e. coli o :h . by case-control studies, a statistically significant odds ratio of . has been estimated. it is believed that age (young), sex (feminine), psychological profile, severity, and duration of gastroenteritis are all risk factors in contracting ibs. the leirisalo-repo definition of reactive arthritis (rea) is ''joint inflammation that develops soon after or during infection elsewhere in the body but in which the microorganism cannot be recovered from the joint.'' it usually occurs in the first weeks after infection, is selflimiting, and affects a single joint. incidence varies according to the germ and its serotype, as well as the patient characteristics and case definition in each different study. although the frequency of bacterial musculoskeletal symptoms after foodborne infection can reach up to % of affected patients, the incidences of rea are positioned between % and %. microorganisms related to rea are enteric salmonella, shigella, campylobacter, yersinia, e. coli o :h , and c. difficile. perhaps there may be more. apparently women, adults (above years), and those who have suffered more serious illnesses are at greater risk. the genetic marker hla b would be associated more with severity than incidence. the effect of taking antibiotics during the acute phase of intestinal infection is an object of discussion relating to the appearance of rea. guillain-barré syndrome (gbs) is an acute neuropathy of immune origin, which is associated with infections from campylobacter and cytomegalovirus. studies from the united kingdom give an incidence of gbs, which takes place - weeks after infection, in out of every inhabitants, especially for some serotypes of campylobacter such as o and o . males are at greater risk of suffering from gbs. after years of monitoring, a greater risk of hypertension and problematic kidney function after exposure to c. jejuni and e. coli o :h has been observed in hydric outbreaks of gastroenteritis. autoimmune diseases (graves' disease, autoimmune tiroiditis, kawasiki disease, sjogren syndrome, and psoriasis) have been related to previous intestinal infections by staphylococcus and yersinia. the aftereffects of viral intestinal processes are less well known due to limitations of diagnosis in conventional laboratories. some of them are fibromyalgia or chronic fatigue syndrome (cfs), and chronic inflammatory muscle disease (cimd). studies of stomach biopsies and the presence of enterovirus in skeletal muscles suggest the persistence of infection with viral replication in these patients. some cohort studies carried out in the united states suggest that children between and months of age infected by norovirus, sapovirus, or rotavirus are at greater risk of displaying persistent diarrhea in the months following viral infection. cross-sectional epidemiological studies and prospective studies in children have suggested the importance of enteric viral infections in the development of autoimmune celiac disease (acd). also we thank you for the review dr neighborhoods and environmental determinants of infectious diseases effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces the protective effect of alcoholic beverages on the occurrence of a salmonella food-borne outbreak outbreaks of acute viral gastroenteritis in geriatric homes: threshold detection system for prevalence (sidup) incidencia de artritis reactiva y otras secuelas osteoarticulares despué s de un brote de salmonella enteritidis fagotipo fecal-oral transmisió n an outbreak of escherichia coli o :h among visitors to a dairy farm direct exposure to animal enteric pathogens household outbreaks among culture-confirmed cases of bacterial gastrointestinal disease risk factors for acquiring sporadic campylobacter infection in france: results from a national case-control study infectious diarrhea short and long term mortality with foodborne bacterial gastrointestinal infection: registry based study chronic sequelae of foodborne disease a widespread outbreak of yersinia pseudotuberculosis o: infection from iceberg lettuce microbicides and the environmental control of nosocomial viral infections salad and pseudoappendicitis: yersinia pseudotuberculosis as a foodborne pathogen short and long-term effects of bacterial gastrointestinal infections mr. richard nightingale translated the text from spanish according to a cohort study carried out in finland in , enteric viruses (rotavirus, adenovirus, and others) could increase the risk of type diabetes in children with a genetic predisposition to that disorder.it will be necessary to incorporate knowledge of medium and long-term effects to what is already known about the acute effects of intestinal infections. epidemiological investigation has a prominence in this investigation. possibly intestinal infections will gain even greater importance in public health. key: cord- -lqyo px authors: chaw, liling; koh, wee chian; jamaludin, sirajul adli; naing, lin; alikhan, mohammad fathi; wong, justin title: analysis of sars-cov- transmission in different settings, brunei date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: lqyo px we report the transmission dynamics of severe acute respiratory syndrome coronavirus (sars-cov- ) across different settings in brunei. an initial cluster of sars-cov- cases arose from persons who had attended the tablighi jama’at gathering in malaysia, resulting in locally transmitted cases. the highest nonprimary attack rates ( . %) were observed from a subsequent religious gathering in brunei and in households of attendees ( . %). household attack rates from symptomatic case-patients were higher ( . %) than from asymptomatic ( . %) or presymptomatic ( . %) case-patients. workplace and social settings had attack rates of < %. our analyses highlight that transmission of sars-cov- varies depending on environmental, behavioral, and host factors. we identify red flags for potential superspreading events, specifically densely populated gatherings with prolonged exposure in enclosed settings, persons with recent travel history to areas with active sars-cov- infections, and group behaviors. we propose differentiated testing strategies to account for differing transmission risk. calated since the disease was initially reported on december , . a rapid response by the global scientific community has described many aspects of the causative agent, severe acute respiratory syndrome coronavirus (sars-cov- ). estimates suggest a basic reproduction number of - in the early stages of the outbreak ( ), which can be valuable in assessing the spread of the virus but obscures individual heterogeneity in the level of infectivity among persons and in different settings ( , ) . early reports suggest that superspreading events (sses) might play a role in the explosive propagation of sars-cov- ( ) . targeted approaches that reduce the likelihood of sses are contingent on the environmental, behavioral, and host factors that drive transmission and the most effective interventions to control those factors. to address these factors, we report an analysis of a transmission chain in brunei that resulted from an international sse. brunei is a small, well-connected country in southeast asia with a population of , ( ) . brunei has multiple land borders and limited state capacity to manage large-scale outbreaks ( ) . multigeneration households are common and social interactions center on strong family and religious relationships ( , ) . these characteristics make brunei particularly vulnerable to outbreaks and the rapid progression of clusters to widespread community transmission ( ) . a covid- case was detected in brunei on march , after a -day religious gathering, tablighi jama'at, in neighboring kuala lumpur, malaysia. the tablighi jama'at gathering in malaysia has been recognized as an sse and had > , attendees, including international participants ( ) . tablighi is an apolitical islamic movement with adherents from > countries. tablighi adherents usually gather at annual international events lasting several days where they participate in communal prayers, meals, and speeches. in malaysia, the participants stayed and slept at the mosque, and several of them were deputized to cook and clean. seventy-five persons from brunei attended this event. of the confirmed cases in brunei reported by the first week of april, ( . %) cases had an epidemiologic link to this event ( figure ). because sars-cov- is a novel infection in a naive population, an outbreak investigation of this event can provide insights into its transmission dynamics and the effectiveness of outbreak control measures. brunei's thorough contact tracing provides a rare opportunity to study the epidemiologic and transmission characteristics of sars-cov- in different community settings. brunei's ministry of health (moh) is responsible for communicable disease surveillance and implemented testing criteria for suspected covid- cases on january , . initially, only persons with acute respiratory symptoms and history of travel to a high-risk area were tested for sars-cov- . over the next several weeks, the program expanded to include contacts of a confirmed case, regardless of symptoms; persons with pneumonia admitted to an inpatient healthcare facility; and persons with acute respiratory illness treated at a health facility for the second time within days. on march , moh started testing and isolating all travelers and returning residents. on march , moh introduced sars-cov- sampling at selected sentinel health centers to test persons with influenza-like symptoms, and on april , moh implemented mandatory random screening for selected groups of foreign workers. moh defined a confirmed covid- case as a person who tested positive for sars-cov- through real-time reverse transcription pcr (rt-pcr) testing on a nasopharyngeal (np) swab specimen ( ) . the first positive case in brunei was detected on march in a person who met the testing criteria by having a fever and cough and having recently traveled to kuala lumpur. under the infectious disease act, moh conducted epidemiologic investigations and collected data for each case and close contact by using the world health organization's first few cases protocol ( ) . the first identified case-patient was interviewed for demographic characteristics, clinical symptoms, travel history, activity mapping, and contact history. once moh identified the case-patient's participation at the tablighi event in malaysia, they identified several other persons from brunei who also had participated at the event. we subsequently obtained the details of all participants from brunei. np swabs were collected from all identified participants and tested with rt-pcr. persons who tested positive were admitted to the national isolation centre (nic). persons who tested negative were quarantined for days after their return to brunei at a designated community quarantine facility, where they were screened for symptoms and body temperature daily. persons who had symptoms develop at the nic were retested. activity mapping of confirmed cases was conducted, and contact tracing was initiated. we defined a close contact as any person living in the same household as a confirmed case-patient or someone who had been within m of a confirmed case-patient in an enclosed space for > minutes ( ) . we identified secondary cases through interviews and checked cellular phone data when information on contacts was uncertain. np swabs from all close contacts of confirmed case-patients were tested by using rt-pcr. persons who tested positive were admitted to the nic and persons who tested negative were placed under home quarantine for days from their last exposure to the confirmed case-patient. public health workers monitored the compliance and health status of persons under home quarantine daily through video calls or face-to-face assessments. persons who had symptoms develop during home quarantine were retested. all confirmed case-patients were treated and isolated at the nic and monitored until recovery. we obtained clinical information on case histories, including any prior treatment by health services, clinical examination, and laboratory and radiological results, from digital inpatient records on the national health information system database. in addition, we collected information on each case-patient's oral history to ascertain whether they had symptoms ≤ days before diagnosis. case-patients were discharged from the nic after consecutive negative specimens collected ≥ hours apart. we categorized cases into groups: primary cases were in persons presumably infected at the tablighi event in malaysia and nonprimary cases were in persons who had an epidemiologic link to a primary case but did not attend the tablighi event in malaysia. for each casepatient, we recorded symptom status and classified them as follows: symptomatic patients reported having symptoms during or before np swab collection; presymptomatic patients reported having symptoms after np sampling but during admission to the nic; and asymptomatic patients reported no symptoms during np swab collection or admission to the nic. we classified close contacts into groups or settings: household, relatives, workplace, social, and a local religious gathering. we defined household contacts as persons living in the same household and further classified them by their relationship to a case-patient (spouse, child, or other, which included other familial relationships or housekeepers living in the household). we defined relatives as persons related to a case-patient who lived outside the household, workplace contacts as persons encountered at a workplace or school, and social contacts as those encountered during travel or at social events. we defined contacts from a local religious gathering as persons who attended a local tablighi event in brunei on march ; the event ran throughout the night, and participants stayed all night. such small local weekly gatherings usually take place among tablighi adherents in their home countries. we used χ , fisher exact, or mann-whitney tests to compare groups of primary and nonprimary cases, as appropriate. we calculated the incubation period from dates of exposure and symptom onset, when these were clear. we calculated serial interval by subtracting the date of symptom onset of an infectee (secondary case) from the date of symptom onset of the infector (primary case); we only included symptomatic and presymptomatic infector-infectee pairs for which epidemiologic links were clear. we calculated the attack rate for each setting by dividing the number of positive contacts by the total number of close contacts. to identify risk factors for infection, we applied a log-binomial regression analysis to estimate the risk ratio for gender, age, and setting. we performed further stratification to assess differences in the symptom status of infectors across settings. we estimated the % ci by using the normal-approximation method, or the binomial method if the count was < . we calculated the mean observed reproductive number (r) and distribution of personal reproductive numbers in each setting by using the number of close contacts infected by each primary case-patient. we estimated the % ci by using a poisson distribution ( ) . we conducted all analyses by using excel (microsoft, https://www.microsoft.com) and r version . . ( ) . we considered p< . statistically significant. we obtained ethical approval from the university research ethics committee, universiti brunei darussalam (approval no. ubd/oavcr/urec/ apr - ). among persons from brunei who attended the tablighi event in malaysia, tested positive for sars-cov- ; local close contacts also tested positive, bringing the total cluster size to . we analyzed the epidemiologic links in this cluster by generation in the transmission chain and case-patient symptom status. we noted ( . %) cases in generation , ( . %) in generation , and ( . %) in generation ( figure ). we also analyzed the demographic and clinical characteristics of case-patients in the cluster ( table ). the median age was . years (interquartile range [iqr] - years), ( . %) case-patients were male and ( . %) female, and ( . %) had preexisting chronic conditions. compared with nonprimary casepatients, primary case-patients were much older, and most were men. most ( / ; . %) persons with diagnosed covid- were immediately admitted to the nic within days of symptom onset or np swab collection (data not shown). many case-patients were presymptomatic ( / ; . %) or asymptomatic ( / ; . %) and ( . %) case-patients reported symptoms during contact tracing investigation. the most reported symptoms were fever, cough, and sore throat. only ( . %) case was critical and ( . %) were severe. we calculated the incubation period from casepatients who had confirmed epidemiologic links and had attended the march religious gathering in brunei. by using march as the exposure date, the median incubation period was . days (range - days; iqr . - . days). based on symptomatic infector-infectee pairs, the serial interval was . days (sd ± . days; range - to days). among the symptomatic infector-infectee pairs, ( . %) had negative serial interval values. we noted that the serial interval distribution resembled a normal distribution (appendix figure , https://wwwnc.cdc.gov/ eid/article/ / / - -app .pdf). among , close contacts of the covid- cluster among tablighi members in brunei, local transmissions were detected, giving an overall nonprimary attack rate of . % ( % ci . %- . %). we excluded case ( figure ) from the analysis because the case-patient was not detected during contact tracing. the highest attack rates were among spouses ( . % attack rates also differed by symptom status of the infector (table ; appendix table) . in households where the infectors were symptomatic, attack rates were higher ( . %) than in households in which the infectors were asymptomatic ( . %) or presymptomatic ( . %). we could not calculate the attack rate for attendees of the local religious gathering because the primary cases at the event had different symptom statuses and we could not ascertain how transmission occurred. in the household setting, symptomatic casepatients had . times the risk of transmitting sars-cov- to their close contacts, compared with asymptomatic and presymptomatic case-patients (crude risk ratio . [ % ci . - . ]; table ). the mean observed r was highest ( . ) among attendees of the local religious gathering. observed r was . ( % ci . - . ) for household members ( table ). the observed r distribution for the household setting was skewed toward (appendix figure ) , and . % ( / positive contacts) of household infections were from . % ( / ) of possible links to primary cases. we characterized a cluster of covid- cases in brunei among attendees of the tablighi jama'at in malaysia, an sse that led to an epidemic in brunei. our analysis revealed several key findings. first, sses play a major role in sars-cov- transmission. second, transmission variability is high across different settings. third, transmission varies between symptomatic, asymptomatic, and presymptomatic persons. our findings highlight the potential for silent chains of transmission. within this cluster, % of all cases were among participants at an sse: ( . %) from the tablighi event in malaysia and ( . %) from a local religious gathering. of note, / persons from brunei who attended the tablighi event in malaysia tested positive for sars-cov- . assuming a representative sample, this suggests an attack rate of % and implies that > , of the ≈ , participants at the event in malaysia might have been infected. moreover, we found that the highest overall nonprimary attack rate ( . %) and mean observed r ( . ) were from a local religious gathering, which were higher than the attack rate ( . %) and mean observed r ( . ) for the household setting. these observations suggest that mass gatherings facilitate sars-cov- transmission. during this investigation, we identified several common characteristics at both the local religious gathering and the event in malaysia ( ) . first, large numbers of attendees gathered in an enclosed area for a prolonged time. second, some attendees had a history of recent travel; the tablighi event in malaysia drew participants from across the world and ≥ attendees of the local religious gathering had recently returned from malaysia. third, the gatherings included communal sleeping areas, sharing of toilet facilities, and shared dining. we propose that these characteristics are hallmarks for an sse for sars-cov- transmission. health authorities can use these characteristics as red flags in their risk assessment and mitigation strategies for preventing and detecting high-risk activities, including mass gatherings, and in other institutional settings, such as care homes, prisons, and dormitories. to a lesser degree, our observations on the within-household transmission are similar to those observed for the religious gatherings. among household contacts who subsequently became first generation cases, ( . %) were from just primary cases. however, even within similar settings, we can expect wide variability in transmission patterns. this observation supports our finding of a moderately high household attack rate but an observed r of < , suggesting that transmission is driven by a relatively small number of cases ( ) . high attack rates in spouses and children reflect intimate relationships with a high degree of interaction, close proximity, and in the case of the spouse, sleeping in the same room. concordant with our sse findings, we suggest that encounters among groups that involve close proximity in enclosed settings for prolonged times (≥ night) are a main driver of sars-cov- transmission. our overall nonprimary attack rate result of . % in the household setting is comparable to other studies that used contract tracing datasets ( ( ) , reported a higher attack rate of . %, but they detected . % of cases > days after persons began having symptoms. by contrast, . % of cases in our study were detected and patients were isolated ≤ days of symptom onset, suggesting that early case isolation can reduce the attack rate. the brunei moh's strategy of aggressive testing of contacts might have contributed to reduced attack rates among household members. we noted a low nonprimary attack rate (< %) and mean observed r (< . ) for workplace and social settings. moderate physical distancing was implemented in brunei following the identification of this cluster, but community quarantine and lockdown were not implemented. public services and businesses remained open and no internal movement restrictions were imposed in the country. combined with our observations on the role of sses in driving sars-cov- transmission, we suggest that areas with limited community transmission can avoid full lockdown measures that adopt a blunt approach of restricting all movement. instead, such areas can use a more targeted approach that combines case isolation, contact tracing, and moderate levels of physical distancing and takes into account the red flags for mass gatherings we identified. however, this approach is resource intensive and only feasible in communities with sufficient public health capacity. the high proportion of asymptomatic persons suggests that even with best efforts at contact tracing, the potential for widespread community transmission is clear. once sars-cov- is established in a location, its suppression requires implementation of broader physical distancing measures ( , ) . nonetheless, effective contact tracing and case isolation approaches have been shown to control covid- during the early stage of outbreaks ( ) . in addition, modeling studies using data from south korea showed that less extreme physical distancing measures can help suppress an outbreak ( ) . we identified several environmental settings and behavioral factors that potentially account for higher attack rates observed in mass gatherings and households. to assess the effect of host factors in driving transmission, we compared the nonprimary attack rate in symptomatic, asymptomatic, and presymptomatic persons, considering the high proportion of asymptomatic ( . %) and presymptomatic ( . %) case-patients. case reports of presumptive asymptomatic and presymptomatic sars-cov- transmission have been published ( , ) , but few observational studies quantify such transmissions. a study from ningbo, china, analyzed the overall attack rates between symptomatic and asymptomatic covid- case-patients and did not find major differences between the groups ( ) . another study reinterpreted the same data and theorized that sars-cov- could be more transmissible from symptomatic than asymptomatic persons under certain conditions ( ) . in fact, our overall crude risk ratio for symptomatic case-patients showed no statistically significant difference compared with asymptomatic or presymptomatic case-patients ( table ; appendix table) . however, we suggest this finding masks the true picture in transmissibility when different settings are taken into account. we did not find statistically significant differences in the attack rate for nonhousehold settings, which usually practice some form of nonpharmaceutical interventions (npi), such as taking medical leave for persons with moderate or severe symptoms. in addition, some physical distancing likely would be practiced by contacts of persons with visible symptoms. however, our findings suggest that transmission occurs more frequently at the household level where such physical distancing and control measures are less practical. we observed that the household attack rate for symptomatic persons ( . %) is higher than that of asymptomatic ( . %) or presymptomatic ( . %) persons, suggesting that presence of symptoms is a host factor in driving transmission. the higher household attack rate observed among symptomatic case-patients suggests that testing for contacts of symptomatic persons should be prioritized, especially in low resource areas. nonetheless, the attack rates we observed for asymptomatic ( . %) and presymptomatic ( . %) case-patients were not negligible and our findings have several implications for high resource areas with greater testing capacity. first, it strengthens the argument for testing household contacts in the absence of symptoms. second, some flexibility should be permitted in the surveillance system because the high proportion of asymptomatic casepatients poses challenges for rapid detection and isolation. thus, we recommend that moderate levels of physical distancing should be implemented even in countries with highly developed testing and tracing capacities. third, proactive testing of travelers, attendees of red flag events, and persons housed in institutional settings might be necessary to contain covid- spread. this study has several limitations. first, because we conducted a retrospective study based on a contact tracing dataset, determination of the index case and direction of transmission could be uncertain, particularly because a substantial proportion of case-patients were asymptomatic. moreover, we did not account for outside sources of infection, so setting-specific attack rates could have been overestimated even though no community transmission has been detected in brunei. viral sequencing can confirm homology between the strains infecting index and secondary cases across the various settings but was not conducted for all cases. second, we have not accounted for other potential environmental factors, such as the relative household size, time spent at home with others, air ventilation, and transmission from fomites. third, we do not have information on npis practiced by close contacts; presumably, persons would take precautions during an outbreak. fourth, case-patients reported their symptom status during np swab collection, which we assumed to be reflective of their condition when their close contacts were exposed; however, this might not be true for all cases. finally, the generalizability of our results is limited because there was no community transmission, the small number of cases, and the lack of cases in communal settings, such as residential care facilities and dormitories. the main strength of our study is the availability of a complete contact tracing dataset at the national level. because all case-contacts were tested, we believe our study more accurately describes sars-cov- transmission than studies in which only symptomatic case-contacts were tested. in conclusion, our analysis highlights the variability of sars-cov- transmission across different settings and the particular role of sses. we identify red flags for potential sses and describe environmental, behavioral, and host factors that drive transmission. overall, we provide evidence that a combination of case isolation, contact tracing, and moderate physical distancing measures can be an effective approach for sars-cov- containment. centre for mathematical modelling of infectious diseases covid- working group. early dynamics of transmission and control of covid- : a mathematical modelling study secondary attack rate and superspreading events for sars-cov- tracking social contact networks with online respondentdriven detection: who recruits whom? identifying and interrupting superspreading events-implications for control of severe acute respiratory syndrome coronavirus department of economic planning and development. mid-year population estimates for brunei darussalam responding to covid- in brunei darussalam: lessons for small countries attitudes towards family formation among young adults in brunei darussalam diaspora community in brunei: culture, ethnicity and integration the potential effects of widespread community transmission of sars-cov- infection in the world health organization african region: a predictive model a single mass gathering resulted in massive transmission of covid- infections in malaysia with further international spread probable causes and risk factors for positive sars-cov- test in recovered patients: evidence from brunei darussalam the first few x (ffx) cases and contact investigation protocol for -novel coronavirus ( -ncov) infection, version . geneva: the organization global surveillance for co-vid- caused by human infection with covid- virus: interim guidance the reproductive number of covid- is higher compared to sars coronavirus r: a language and environment for statistical computing. vienna: r foundation for statistical computing household secondary attack rate of covid- and associated determinants in guangzhou, china: a retrospective cohort study the characteristics of household transmission of covid- only strict quarantine measures can curb the coronavirus disease (covid- ) outbreak in italy the positive impact of lockdown in wuhan on containing the covid- outbreak in china centre for the mathematical modelling of infectious diseases covid- working group. feasibility of controlling covid- outbreaks by isolation of cases and contacts potential role of social distancing in mitigating spread of coronavirus disease, south korea. emerg infect dis presymptomatic transmission of sars-cov- -singapore covid- transmission within a family cluster by presymptomatic carriers in china epidemiological characteristics of infection in covid- close contacts in ningbo city the relative transmissibility of asymptomatic covid- infections among close contacts the authors thank haji mohamad ruzaimi haji rosli from corporate communications, ministry of health brunei, for his assistance in designing the figure for this manuscript.l.c. and j.w. conceptualized and designed the study. j.w., s.j., and f.a. acquired data. l.c., w.c.k., and l.n. analyzed data. l.c., w.c.k., l.n., and j.w. interpreted data. l.c., j.w., and w.c.k. provided critical revisions of the manuscript for important intellectual content. all authors contributed to the writing of the first and final draft. dr. chaw is a lecturer at the pengiran anak puteri rashidah sa'adatul bolkiah institute of health sciences, universiti brunei darussalam, bandar seri begawan. her primary research interests include the burden and transmission dynamics of infectious diseases, particularly for acute respiratory diseases. key: cord- -n rec i authors: varatharaj, aravinthan; thomas, naomi; ellul, mark a; davies, nicholas w s; pollak, thomas a; tenorio, elizabeth l; sultan, mustafa; easton, ava; breen, gerome; zandi, michael; coles, jonathan p; manji, hadi; al-shahi salman, rustam; menon, david k; nicholson, timothy r; benjamin, laura a; carson, alan; smith, craig; turner, martin r; solomon, tom; kneen, rachel; pett, sarah l; galea, ian; thomas, rhys h; michael, benedict d title: neurological and neuropsychiatric complications of covid- in patients: a uk-wide surveillance study date: - - journal: lancet psychiatry doi: . /s - ( ) -x sha: doc_id: cord_uid: n rec i background: concerns regarding potential neurological complications of covid- are being increasingly reported, primarily in small series. larger studies have been limited by both geography and specialty. comprehensive characterisation of clinical syndromes is crucial to allow rational selection and evaluation of potential therapies. the aim of this study was to investigate the breadth of complications of covid- across the uk that affected the brain. methods: during the exponential phase of the pandemic, we developed an online network of secure rapid-response case report notification portals across the spectrum of major uk neuroscience bodies, comprising the association of british neurologists (abn), the british association of stroke physicians (basp), and the royal college of psychiatrists (rcpsych), and representing neurology, stroke, psychiatry, and intensive care. broad clinical syndromes associated with covid- were classified as a cerebrovascular event (defined as an acute ischaemic, haemorrhagic, or thrombotic vascular event involving the brain parenchyma or subarachnoid space), altered mental status (defined as an acute alteration in personality, behaviour, cognition, or consciousness), peripheral neurology (defined as involving nerve roots, peripheral nerves, neuromuscular junction, or muscle), or other (with free text boxes for those not meeting these syndromic presentations). physicians were encouraged to report cases prospectively and we permitted recent cases to be notified retrospectively when assigned a confirmed date of admission or initial clinical assessment, allowing identification of cases that occurred before notification portals were available. data collected were compared with the geographical, demographic, and temporal presentation of overall cases of covid- as reported by uk government public health bodies. findings: the abn portal was launched on april , , the basp portal on april , , and the rcpsych portal on april , . data lock for this report was on april , . during this period, the platforms received notification of unique cases that met the clinical case definitions by clinicians in the uk, with an exponential growth in reported cases that was similar to overall covid- data from uk government public health bodies. median patient age was years (range – ; iqr – ). complete clinical datasets were available for ( %) of patients. ( %) of patients presented with a cerebrovascular event, of whom ( %) had an ischaemic stroke, nine ( %) an intracerebral haemorrhage, and one ( %) cns vasculitis. ( %) of patients presented with altered mental status, comprising nine ( %) patients with unspecified encephalopathy and seven ( %) patients with encephalitis. the remaining ( %) patients with altered mental status fulfilled the clinical case definitions for psychiatric diagnoses as classified by the notifying psychiatrist or neuropsychiatrist, and ( %) of these were new diagnoses. ten ( %) of patients with neuropsychiatric disorders had new-onset psychosis, six ( %) had a neurocognitive (dementia-like) syndrome, and four ( %) had an affective disorder. ( %) of patients with altered mental status were younger than years and ( %) were older than years, whereas ( %) of patients with cerebrovascular events were younger than years versus ( %) patients older than years. interpretation: to our knowledge, this is the first nationwide, cross-specialty surveillance study of acute neurological and psychiatric complications of covid- . altered mental status was the second most common presentation, comprising encephalopathy or encephalitis and primary psychiatric diagnoses, often occurring in younger patients. this study provides valuable and timely data that are urgently needed by clinicians, researchers, and funders to inform immediate steps in covid- neuroscience research and health policy. funding: none. in december, , who was notified by clinicians in wuhan, china, of a novel and severe respiratory virus, later called severe acute respiratory syndrome corona virus (sarscov ). covid , the disease caused by sarscov , was recognised as a substantial global public health emergency and sarscov was declared a pandemic on march , . the neurological com munity were alerted to the high prevalence of anosmia and dysgeusia in early reports. , , some of these early cohorts also featured nonspecific neurological symp toms, such as dizziness and headache. however, severe neurological and neuro psychiatric presentations asso ciated with covid have become increasingly apparent, including a patient with encephalitis in china in whom sarscov was identified in cerebrospinal fluid (csf), a patient with acute necrotising ence phalopathy in japan, and cases of cerebrovascular disease. , during other pandemics of respiratory pathogens, including severe acute respiratory syndrome, middle east respiratory syndrome, and h n influenza, there were similar reports of patients with neurological compli cations, , either during the acute phase, thought to reflect direct viral cytopathy or a parainfectious cytokine storm, or later as a postinfectious, probably cellular immune or antibodymediated phenomenon, classically manifested as guillainbarré syndrome. additionally, occasional neuro psychiatric and psychiatric presentations have been reported in severe coronavirus infections, although such presentations could reflect broader socioeconomic implications of the pandemic on mental health. these complications are relatively uncommon, but such patients are often the most severely affected, neces sitating protracted intensive care admis sion and often resulting in poor outcomes. most published reports on the neurological compli cations of covid are limited to individual cases or small case series. , , a few studies showed the benefits of identifying patients with neurological complications across centres. , however, these studies have largely been limited to two or three hospitals and are restricted by both geography and specialty, therefore not assessing the neurological and neuropsychiatric complications of covid across the clinical spectrum of neurology, stroke or acute medicine, psychiatry, and intensive care. consequently, many important questions remain for neurologists and psychiatrists. how common are neurological and psychiatric complications in patients with covid ? what proportion of neurological and psychiatric complications affect the cns versus the peripheral nervous system, and are novel syndromes emerging? and who is most at risk? the breadth of early clinical presentations has not been represented in the literature, at least in part because evidence before this study we searched pubmed on jan , , and may , , with no language restrictions, using the search terms "covid- or sars-cov " with "neurological or psychiatric" and identified publications and publications, respectively. a focus on publications that reported data for the onset of new neurological or psychiatric diagnoses in hospitalised patients with confirmed or probable covid- identified a more restricted subset of baseline data. from a neurological perspective, these publications included case reports or series (with less than ten patients) of stroke (six publications), encephalitis (five publications), seizures (one publication), cranial neuropathies (two publications), and posterior reversible encephalopathy syndrome (one publication). a larger series of patients from wuhan reported neurological symptoms in patients. however, many of these symptoms were vague-for example, dizziness or headache-although a subset of patients had a cerebrovascular diagnosis. a study from france reported patients with covid- -related acute respiratory distress syndrome, of whom eight had neurological manifestations, including two with strokes. we identified many publications that addressed the mental health effects of covid- on the general population, health-care workers, and those with pre-existing psychiatric diagnoses. however, cases of new-onset psychiatric diagnoses in hospitalised patients with confirmed or probable covid- were limited to a few case reports. in the large wuhan study, acute psychiatric diagnoses were not described. in the french study, although a dysexecutive syndrome was reported in patients and were described as confused, little information was available with regard to what the psychiatric diagnoses were, and this cohort represented only the severe end of the respiratory spectrum. by working across the clinical neuroscience communities of neurology, psychiatry, stroke, and neurointensive care, we identified acute presentations of new-onset complications of covid- , reflecting the spectrum of the burden of disease. ischaemic stroke was common in our cohort of patients (most of whom were confirmed to have covid- ). we identified a large group of patients with altered mental status, reflecting both neurological and psychiatric diagnoses, such as encephalitis and psychosis. altered mental status was identified across all age groups, and many younger patients had this presentation. our work highlights the importance of interdisciplinary work in the clinical neurosciences field in the covid- era. clinicians should be alert to the possibility of patients with covid- developing these complications and, conversely, of the possibility of covid- in patients presenting with acute neurological and psychiatric syndromes. these findings should direct future research to establish the role of viral neurotropism, host immune responses, and genetic factors in the development of such complications so that clinical management strategies can be developed. patients could be primarily managed by physicians with various clin ical specialties, including neurologists, stroke or acute medical physicians, psychiatrists, or intensive care physicians. more comprehensive and integrated epidemi o logical characterisation is crucial to under standing the mechanisms that underlie these presen tations, without which it will be impossible to rationally select, evaluate, and use appropriate therapies. we aimed to collate data through a largescale, national, dynamic, crossspecialty collaborative structure, to both inform best practice management guidelines and to direct research priorities. during the exponential phase of the pandemic, we developed an online network of secure rapidresponse case report notification portals (coronerve platforms) comprising the association of british neurologists (abn) rare diseases ascertainment and recruitment (radar), the british association of stroke physicians (basp), and the royal college of psychiatrists (rcpsych), in collabo ration with the british paediatric neurology association (bpna), the neuro anaesthesia and critical care society (who used the abn portal), the intensive care society, and key stakeholders. reporting portals for fully anonymised details were hosted on the web platforms of these collaborating professional bodies and via a novel web portal. members of these professional organisations were emailed weekly to remind them of the surveillance programmes and were invited to notify the central coronerve group at coronerve.com of any cases of covid associated with any of the clinical case definitions that they had seen through these portals. because of the clinical demands of the pandemic, we identified minimum clinical datasets that could be completed in under min to reflect the crucial data required to determine the confidence in the diagnosis of covid , demography, geography, and the nature of the clinical syndrome. physicians were encouraged to report cases prospectively and we also permitted recent cases to be notified retrospectively when assig ned a confirmed date of admission or initial clinical assess ment, allowing identification of cases that occur red before notification portals were available. patients were not randomly assigned. awareness of the study and notification portals was increased through social platforms during the peak of the pandemic, including professional webinars, recorded online presentations, and social media. the abn portal was launched on april , , the basp portal on april , , and the rcpsych portal on april , . data lock for this report was on april , . given the propensity for hospitalisation with covid for older demographic groups, older patients were defined as those aged years or older and younger patients as those less than years old. for a full list of participating hospitals and the number of cases they notified see the appendix (pp - ). evidence of sarscov infection was defined as confirmed covid if pcr of respiratory samples (eg, nasal or throat swab) or csf was positive for viral rna or if serology was positive for antisarscov igm or igg. cases were defined as probable covid if a chest radiograph or chest ct was consistent with covid but pcr and serology were negative or not done. cases were defined as possible covid if the disease was suspected on clinical grounds by the notifying clinician but pcr, serology, and chest imaging were negative or not done. broad clinical syndromes associated with covid were classified as a cerebrovascular event (defined as an acute ischaemic, haemorrhagic, or thrombotic vascular event involving the brain parenchyma or subarach noid space), altered mental status (defined as an acute alteration in personality, behaviour, cognition, or consciousness), peri pheral neurology (defined as involving nerve roots, peripheral nerves, neuromuscular junction, or muscle), or other (with free text boxes for those not meeting these syndromic presentations). data were collected on the specific clinical case definitions within these broad pre sentations, as follows: a cerebrovascular event (ischaemic stroke, intracerebral or subarachnoid haemorrhage, cerebral venous sinus thrombosis, or cerebral vasculitis); altered mental status (encephalopathy, encephalitisdefined as ence phalo pathy with evidence of inflammation in the cns [csf white cell count > cells per µl, protein > · g/dl, or mri consistent with inflammation], seizures [clinical or elec tro enceph alo graphic evidence], and neuropsychi atric syn dromes notified through psychi atrists or neuro psychiatrists [psychosis, neuro cognitive dementialike syndrome, personality change, catatonia, mania, anxiety or depres sion, chronic fatigue synd rome, and posttraumatic stress disorder]); and peri pheral neurology (guillainbarré syndrome, miller fisher synd rome, brachial neuritis, myasthenia gravis, peripheral neuro pathy, myopathy, myositis-defined as myopathy with evidence of inflammation [eg, by mri or biopsy of muscle with elevated creatine kinase], and critical illness neuro myopathy). when patients met more than one specific clinical case definition (eg, seizures and encephalitis), the underlying causal diagnosis was considered primary and compli cations of that diagnosis considered secon dary features (eg, encephalitis would be con sidered primary and seizures secondary). where there were discrepancies in classification, these were resolved through discussion with senior authors (bdm, ig, and rht). by asking reporting physicians to submit their contact details at the time of notification (including a national health service email address), we established confir mation of the veracity of the data and created a log for subsequent sample collection and longitudinal followup studies, through linkage with existing plat forms including corecruitment into the international severe acute respiratory and emerging infection consor tium (isaric) clinical characterisation protocol, which was also recorded. data collected were compared with the geographical, demographic, and temporal presentation of overall cases of covid as reported by national government public health bodies representing each of the regions of the uk (public health england, health protection scotland, public health wales, and the public health agency [northern ireland]). the uk health research authority formally confirmed this approach was compliant with regulations regarding anonymised surveillance of routine clinical practice in pandemic conditions, as initiated by the local attending clinician. there was no funding source for this study. the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. in the first weeks of the submission portals accepting notifications (april - , ), the coronerve study platforms received notification of unique cases that met the clinical case definitions by clinicians in the uk. patients were geographically dispersed across the uk, as were overall laboratoryconfirmed cases of patients with covid reported by government public health bodies during the same time period (appendix p ). data from the admitting medical units were available for ( %) of patients. ( %) of patients were from tertiary care hospitals, ( %) were from secondary care hospitals, and one ( %) was from primary care. overall, ( %) of cases were notified through the basp portal, ( %) through abn or coronerve.com, and ( %) through the rcpsych portal. cases were reported retrospectively for ( %) of patients and the remainder were reported prospectively. the bpna surveillance network was not available for notifications, as the portal was not live during the study period. data on reporting physician specialty were available for patients: ( %) were stroke physicians, ( %) were neurologists, ( %) were psychiatrists or neuro psychiatrists, ( %) were acute medicine or other physicians, and one ( %) was a general practitioner. complete clinical datasets were available for ( %) of patients. dates of admission or initial clinical assessment were available for ( %) of patients and correlated with the national case identification data of all laboratoryconfirmed patients with covid reported by government public health bodies over the same time period, reflecting the exponential phase of infection ( figure ) . data on the sex and age of notified patients are reported in the table. overall, the median age of years (range - ; iqr - ) was similar to national data collected through uk government public health bodies over the same time period, although for some centiles an older population could be overrepresented within the study cohort (figure ). data were available for sex for ( %) of patients as this question was not included in the original abn radar web portal, representing ( %) cases, and this question was not answered in the other portals in eight ( %) cases. therefore, data regarding sex were available for ( %) of patients for whom these data were requested. ( %) of patients with complete notification data met the criteria for confirmed sarscov infection, five ( %) met the criteria for probable sarscov infection, and five ( %) met the criteria for possible sarscov infection. ( %) of patients presented with the broad clinical syndrome of a cerebro vascular event, of whom ( %) had an ischaemic stroke and nine ( %) an intracerebral haemorrhage. a clinical diagnosis of cns vasculitis was reported in one ( %) patient with an unusual and otherwise unexplained infarct of the corpus callosum and imaging appearances sug gestive of vasculitis; however, the full angiographic report and pathological confirmation were not provided ( figure ) . beyond cerebrovascular events, ( %) of patients presented with altered mental status, figure : number of broad and specific clinical case definitions notified in the dataset, including evidence for severe acute respiratory syndrome coronavirus within each grouping, according to the clinical case definition *one patient with opsoclonus-myoclonus syndrome, one patient with sixth nerve palsy, and one patient with seizures. †two patients with cerebral venous thrombosis, two patients with transient ischaemic attack, one patient with subarachnoid haemorrhage, and five unspecified. ‡ case with missing sars-cov data. §one patient with brachial neuritis and one patient with myasthenic crisis. ¶three patients with depression, two patients with personality change, one patient with catatonia, and one patient with mania. age data were available for ( %) of patients with cerebrovascular events and ( %) of patients with altered mental status. ( %) of patients with altered mental status were younger than years and ( %) were older than years, whereas ( %) of patients with cerebrovascular events were younger than years versus ( %) patients older than years (figure ). to our knowledge, this is the first systematic, nationwide uk surveillance study of the breadth of acute compli cations of covid in the nervous system, undertaken through rapid mobilisation of uk professional bodies representing neurology, stroke or acute medicine, psychi atry, and intensive care. cases notified by the professional membership of these bodies were obtained from across the uk, and an exponential rise in cases of neurological and psychiatric complications of covid occurred during the exponential rise in overall covid cases reported by uk government public health bodies. future studies on neurological complications of covid , particularly those assessing genetic and associated risk factors, would benefit from obtaining notification of all cases of infection admitted to every hospital as a denominator, or a cohort of covid patients without neurological or psychiatric compli cations as a control group. however, given the time pressure on busy clinical teams during the pandemic, we focused our notification structure on patients with neurological or psychiatric complications of infection. cases were reported from physicians who spanned various specialties, and almost all cases met the case definition of confirmed sarscov infection. cerebrovascular events in patients with covid , which have been well described elsewhere, , were also identified as a major group within our cohort. however, we identified a large proportion of cases of acute alteration in mental status, comprising neuro logical syndromic diagnoses such as ence phalo pathy and encephalitis and primary psychiatric synd romic diagnoses, such as psychosis. although cerebro vascular events and altered mental status were identified across all age groups, our cohort confirms that cerebrovascular events pre dominate in older patients; however, these early data identify that acute alterations in mental status were disproportionately overrepresented in younger patients in our cohort. our rates of neurological and psychiatric complications of covid cannot be extrapolated to mildly affected patients or patients with asymptomatic infection, espe cially those in the com munity, but give a broad national perspective on complications severe enough to require hospitalisation. our approach to case ascertainment has the potential for reporting bias and requires validation through detailed prospective clinicoepidemiological data collec tion. plans for such studies should be developed in advance of future pandemics, so that they can be mobilised early during disease spread. a more engaged professional membership or those more used to sub mitting data to surveillance studies through this approach could potentially be over represented in our results. however, this study was the first major national investigation to use a data surveillance approach for clinicians, who notified a large proportion of our cohort (ie, basp and rcpsych). additionally, the present study included a priori consider ations to deter mine the strength of the evidence for sarscov infection, and data collection was informed by clear clinical case definitions. moreover, in this cohort, we conclude that this study is unlikely to have had systematic over ascertainment bias for psychiatric or neuropsychiatric presentations. % of cases were reported by stroke physicians, and the rcpsych web portal was launched days later than the other neurological, stroke, and intensive care unit or more general portals, yet we observed a large number of psychiatric or neuro psychiatric notifications. indeed, as many patients with covid are managed in intensive care units with sedative and paralytic medications, which can both mask and contribute to iatrogenic complications, our cohort might under represent the rate of neurological or psychiatric symptoms. since we specifically identified moderate to severe complications of covid as they were reported for inpatient cases by neurologists and psy chiatrists, our cohort might underrepresent patients with milder outpatient symptoms, such as reduced taste or smell. future hypothesis testing studies building on our findings to infer causal relationships between infection and neurological or neuropsychiatric presen tations should adhere to basic principles, such as the criteria for causation outlined by bradford hill as they pertain to pandemic respiratory infection and effects on the brain. many cerebrovascular events were identified in our study, as reported in previous cohorts and case reports of acute covid complications. , , the pathophysio logical mechanisms that underlie cerebrovascular events in covid require further study, but there is a potential biological rationale for a vasculopathy, with a report of sarscov endothelitis in organs outside the cerebral vasculature and cerebrovascular events, in addition to coagulopathy, along with conventional stroke risk during sepsis. , , comprehensive studies with clear control groups, including patients hospi talised with covid but without cerebrovascular events and patients with cerebrovascular events but who do not have covid , are required to address this issue. confirmation of the link between covid and new acute psychiatric or neuropsychiatric complications in younger patients will require detailed prospective longi tudinal studies. understanding this association will require systematic participant evaluation, characterisation of immune host responses, exploration of genetic asso ciations, and comparison with appropriate controls (including patients hospitalised with covid who do not have acute neuropsychiatric features). altered mental status is common in patients admitted to hospital with severe infection, especially in those requiring intensive care management. however, this symptom typically predominates in older groups, and might reflect an unmasking of latent neurocognitive degenerative disease or multiple medical comorbidities, often in association with sepsis, hypoxia, and the requirement for polypharmacy and sedative medications. in this study, we observed a dis proportionate number of neuropsychiatric presentations in younger patients and a predominance of cerebrovascular complications in older patients, which might reflect the state of health of the cerebral vasculature and associated risk factors, exacerbated by critical illness in older patients. the large number of patients with altered mental status might reflect increased access to neuropsychiatry or psychiatry review for younger patients, and increased attribution of altered mental status to delirium in older patients. nevertheless, the increased recognition of acute altered mental status in patients hospitalised with covid warrants study. the exclusion of iatrogenic factors, such as sedatives and antipsychotics, should be quantified in future modelling studies. in our study, although most psychiatric diagnoses were determined as new by the notifying psychiatrist or neuropsychiatrist, we cannot exclude the possibility that these were undia gnosed before the patient developed covid . our study population represents a snapshot of hospi talised patients with acute neurological or psychiatric complications associated with covid . larger, ideally prospective, studies should identify the broader cohort of covid patients both in and outside hospitals, with capture-recapture analysis and health record linkage to determine clearer estimates of the prevalence of these complications and individuals at risk. additionally, community studies are required to identify those at risk of both covid and neurological or psychiatric complications, although this strategy will require widespread serological testing. the importance of data sharing is increasingly recog nised as fundamental to facilitate rapidly responsive clinical research and is particularly crucial during an international emergency, such as the sarscov pandemic. the coronerve study group has been made possible by open collaboration between several uk institutions. we anticipate added value of sharing data more widely, across european and global partners, particularly in lowincome and middleincome countries. the brain infections global covidneuro network is supporting data collection in such countries through freely available case record forms. wide collaboration is likely to be even more important for characterising rarer or novel covid associated neurological syndromes. these enriched populations that reflect less common, but nevertheless severe, disease must be studied in close collaboration with larger surveillance efforts, such as the isaric clinical characterisation protocol, to identify at risk groups, determine the strength of relative risk factors, and have adequate controls for mechanistic studies. our nationwide, clinicianreported cohort approach provides valuable and timely information that is urgently needed by clinicians, researchers, and funders to inform the immediate next steps in covid neuroscience related research and health policy planning. these national data begin to characterise the spectrum of neurological and neuropsychiatric complications that need to be addressed. this multidisciplinary, coordinated approach should be emulated in detailed national mechanistic studies of covid and the brain, to distinguish the role of the virus and the host inflammatory response versus the broader socioeconomic effects of the pandemic. contributors av and bdm drafted the initial manuscript and the document was edited and approved by all coauthors. av is a medical research council (mrc) phd fellow. mae is an association of british neurologists phd fellow. mz reports personal fees from ucb pharma outside the submitted work. jpc received funding from the national institute for health research (nihr) cambridge biomedical research centre during the conduct of the study. lab reports funding from glaxosmithkline and research england, outside the submitted work. ac reports personal fees from independent testimony in court on a range of neuropsychiatric topics and as a paid editor of the journal of neurology, neurosurgery and psychiatry, outside the submitted work. additionally, ac is planning a rehabilitation trial after covid , which could produce an application that might be associated with intellectual property. cs has received funding from the mrc, nihr, the leducq foundation, and the stroke association. mrt reports grants from motor neurone disease association and my name' doddie foundation, and personal fees from oxford university press, oneworld, karger publishing, orphazyme, bmj publishing, and glg consulting, outside the submitted work. ts reports consultancy for glaxosmithkline ebola vaccine programme, siemens diagnostics clinical advisory board, siemens healthineers clinical advisory board, and the data safety monitoring committee of the glaxosmithkline study to evaluate the safety and immunogenicity of a candidate ebola vaccine in children gsk a (chad eboz) vaccine, during the conduct of the study. additionally, ts has a patent filed for a blood test for bacterial meningitis (gb . ; april , ). ts is supported by the european union's horizon research and innovation program zikaplan (preparedness latin america network; ). slp has received funding from the mrc. ig has received funding from the nihr. rht reports personal fees from eisai, gw pharma, sanofi, ucb pharma, zogenix, bial, and arvelle, outside the submitted work. rht has received funding from the academy of medical sciences (ams) and wellcome. bdm has received funding from the mrc, ams, wellcome, and the nihr. bdm and ts are supported by the nihr health protection research unit in emerging and zoonotic infections (ishpu ) and the nihr global health research group on brain infections ( / / ). all other authors declare no competing interests. the authors are committed to open science. the broader data from these studies will be made available at the end of the studies wherever possible, within the terms of participant consent and when not otherwise restricted by intellectual property rights or ongoing collaborative research. to avoid the possibility of identifying individual cases, detailed data are not given in the paper or appendix but are available on appropriate request to the corresponding author. neurologic manifestations of hospitalized patients with coronavirus disease olfactory and gustatory dysfunctions as a clinical presentation of mildto moderate forms of the coronavirus disease (covid ): a multicenter european study selfreported olfactory and taste disorders in sarscov patients: a crosssectional study a first case of meningitis/ encephalitis associated with sarscoronavirus covid associated acute hemorrhagic necrotizing encephalopathy: ct and mri features neurological associations of covid neurological manifestations of influenza infection in children and adults: results of a national british surveillance study neurological complications during treatment of middle east respiratory syndrome coagulation disorders in coronavirus infected patients: covid , sarscov , merscov and lessons from the past psychiatric and neuropsychiatric presentations associated with severe coronavirus infection: a systematic review and metaanalysis with comparison to the covid pandemic neurologic features in severe sarscov infection the association of british neurologists the british association of stroke physicians. basp surveillance for stroke associated with suspected or confirmed covid infection the royal college of psychiatrists. coronerve surveillance survey the british paediatric neurology association. neurological complications of covid management of suspected viral encephalitis in adults-association of british neurologists and british infection association national guidelines the global health network. the isaric clinical characterisation protocol neurological manifestations of the coronavirus (sarscov ) pandemic defining causality in covid and neurological disorders largevessel stroke as a presenting feature of covid in the young characteristics of ischaemic stroke associated with covid endothelial cell infection and endotheliitis in covid coagulopathy and antiphospholipid antibodies in patients with covid emergency room neurology in times of covid : malignant ischaemic stroke and sarscov infection risk of acute stroke after hospitalization for sepsis: a casecrossover study the global health network. brain infections global covidneuro network multidisciplinary research priorities for the covid pandemic: a call for action for mental health science key: cord- -s jfadyp authors: gökçe, Şule; kurugol, zafer; aslan, aslı; Çiçek, candan title: corrigendum to “a rare cause of childhood cerebellitis-influenza infection: a case report and systematic review of literature” date: - - journal: case rep pediatr doi: . / / sha: doc_id: cord_uid: s jfadyp [this corrects the article doi: . / / .]. in the article titled "a rare cause of childhood cerebellitis-in uenza infection: a case report and systematic review of literature" [ ] , dr. candan Çiçek was missing from the authors' list. e corrected authors' list is shown above. additionally, there were errors in the case representation section which should be corrected as follows: a rare cause of childhood cerebellitis-in uenza infection: a case report and systematic review of literature key: cord- -mvtux x authors: pullano, g.; di domenico, l.; sabbatini, c. e.; valdano, e.; turbelin, c.; debin, m.; guerrisi, c.; kengne-kuetche, c.; souty, c.; hanslik, t.; blanchon, t.; boëlle, p.-y.; figoni, j.; vaux, s.; campese, c.; bernard-stoecklin, s.; colizza, v. title: underdetection of covid- cases in france in the exit phase following lockdown date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: mvtux x a novel testing policy was implemented in may in france to systematically screen potential covid- infections and suppress local outbreaks while lifting lockdown restrictions. , virologically-confirmed cases were reported in mainland france from may , (week , end of lockdown) to june (week ). accounting for missing data and the delay from symptom onset to confirmation test, this corresponds to , [ % ci , - , ] cases with symptom onset during this period, a likely underestimation of the real number. using age-stratified transmission models parameterized to behavioral data and calibrated to regional hospital admissions, we estimated that , [ , - , ] covid- symptomatic cases occurred, suggesting that out of cases with symptoms were not ascertained. median detection rate increased from % [ - ]% to % [ - ]% over time, with regional estimates varying from % (grand est) to % (normandy) by the end of june. healthcare-seeking behavior in covid- suspect cases remained low ( %) throughout the period. model projections for the incidence of symptomatic cases ( . [ . - . ] per , ) were compatible with estimates integrating participatory and virological surveillance data, assuming all suspect cases consulted. encouraging healthcare-seeking behavior and awareness in suspect cases is critical to improve detection. substantially more aggressive and efficient testing with easier access is required to act as a pandemic-fighting tool. these elements should be considered in light of the currently observed resurgence of cases in france and other european countries. as countries in western europe gradually relaxed lockdown restrictions, robust surveillance and detection systems became critical to monitor the epidemic situation and maintain activity at low levels . the need is to rapidly identify and isolate cases to prevent onward transmission in the community and avoid substantial resurgence of cases. in france, the surveillance strategy implemented by authorities to exit lockdown on may , was multifold , and based on an expanded case definition for covid- suspect cases to guide clinical diagnosis ; recommendations to the general population to seek healthcare even in presence of mild symptoms; prescription of diagnostic tests to suspect cases by general practitioners for systematic and comprehensive testing; isolation of confirmed cases and tracing of their contacts. the specific characteristics of covid- epidemic, however, hinder the identification of cases . large proportions of asymptomatic infectious individuals , and presence of mild or paucisymptomatic infections that easily go unobserved , present serious challenges to detection and control [ ] [ ] [ ] . this may potentially result in substantial underestimates of the real number of covid- cases in the country. here we estimated the rate of detection of covid- symptomatic cases in france in may-june after lockdown, through the use of virological and participatory syndromic surveillance data coupled with mathematical transmission models calibrated to regional hospitalizations. the study focused on mainland france where the epidemic situation was comparable across regions, and excluded corsica reporting a very limited epidemic activity and overseas territories characterized by increasing transmission . covid- epidemic management in france in the post-lockdown phase involved the creation of a centralized database collecting data on virological testing (si-dep, information system for testing) to provide indicators to monitor the epidemic over time , . , virologically-confirmed cases were reported from may (week ) to june (week ) in mainland france. after imputation of missing data (see methods), an estimated , [ %ci , - , ] cases with symptoms resulted in the study period (figure ) . the average delay from symptom onset to testing decreased from . days in week (w ) to . days in w . accounting for this delay (see methods), we estimated that , [ % ci , - , ] confirmed symptomatic cases had onset in the study period, showing a decreasing trend over time ( , in w , in w ). the test positivity rate decreased in the first weeks and stabilized around . % (average over w -w ). a digital participatory system was additionally considered for covid- syndromic surveillance in the general population , including those who do not consult a doctor. called covidnet.fr, it was adapted from the platform grippenet.fr (dedicated to influenza-like-illness surveillance since , ) to respond to the covid- health crisis in early . it is based on a set of volunteers who weekly self-declare their symptoms, along with socio-demographic information. based on symptoms declared by approximately , participants each week, the estimated incidence of covid- suspect cases decreased from about % to . % over time (figure ) , according to the expanded suspect case definition recommended by the high council of public health for testing (methods). out of suspect cases ( %) consulted a doctor in the study period. among them, ( %) received a prescription for a test, resulting in screening for individuals ( % of those given the prescription). week of symptom onset for symptomatic confirmed cases was estimated based on patients' declarations (see panel b) through a gamma distribution fitted to the data with a maximum likelihood approach. missing data about presence/absence of symptoms and declaration of onset were imputed by region and by week, by sampling from a multinomial distribution according to the observed breakdown among cases with complete information (see methods). test positivity rate was computed on cases with complete information. data for weeks - were consolidated in w . (b) breakdown of virologically-confirmed symptomatic cases by week of testing according to declared onset of symptoms, along with estimated mean time from onset to testing. (c) incidence of covid- suspect cases (estimates by week and -week moving average (thick line)), along with percentage of those seeking healthcare, estimated from participatory surveillance system covidnet.fr. (d) number of covid- suspect cases of the participatory cohort seeking healthcare, and among them those receiving a prescription, and performing a virological test given the prescription. covidnet.fr estimates were adjusted on age and sex of participants. (e) estimated change in individuals attending their workplace locations over time and by region based on google location history data we used stochastic discrete age-stratified epidemic models , based on demography, age profile , and social contact data of the regions of mainland france, to account for age-specific contact activity and role in covid- transmission. disease progression is specific to covid- , and parameterized with current knowledge to include presymptomatic transmission , asymptomatic and symptomatic infections with different degrees of severity (paucisymptomatic, with mild symptoms, with severe symptoms requiring hospitalization) , . the model was shown to capture the transmission dynamics of the epidemic in Île-de-france and was used to assess the impact of lockdown and exit strategies , . full details are reported in the methods section. intervention measures were modeled as modifications of the contact matrices, accounting for a reduction of the number of contacts engaged in specific settings, and were informed from empirical data. lockdown data came from refs. , . the exit phase was modeled considering region-specific attendance at school based on . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint ministry of education's data , partial maintenance of telework according to estimated presence in workplaces from mobile phones location history data (figure ) , reduction in adoption of physical distancing over time based on survey data (figure ) , partial reopening of activities, senior protection . a sensitivity analysis was performed on the reopening of activities and senior protection, as data were missing for an accurate parameterization. testing and isolation of detected cases were implemented by considering a % reduction of contacts for the number of virologically-confirmed covid- cases , . region-specific models were calibrated to regional hospital admission data (figure ) through a maximum likelihood approach in the phase before lockdown, during lockdown, and in the exit phase. further details are reported in the methods section. (a-c) hospital admissions over time, data (points) and simulations (median and % probability range), for Île-de-france (a), pays de la loire (b), normandie (c). hospital admission data up to w (consolidated in w ) were used to calibrate the models. (d-f) projected number of new symptomatic cases over time (median and % probability range) and estimated number of virologically-confirmed symptomatic cases by week of onset (points), for the same regions above. the estimated detection probability of symptomatic cases (%) is also shown (red points, median and % probability ranges, right y axis). projected number of cases decreased over time in all regions, in agreement with the decreasing tendency reported in hospital admissions in the study period (figure ) . overall, , [ , - , , % probability range] new infections were predicted in mainland france in weeks - (from , [ , ] in w to , [ , - , ] in w ). Île-de-france was the region with the largest predicted number of cases ( , [ , - , ] to [ - , ] from w to w ), followed by grand est and hauts-de-france (table ) . projections were substantially higher than virologically-confirmed cases (figures and ) . the estimated detection rate for symptomatic infections in mainland france in the period w -w was % [ - %], suggesting that out of new cases with symptoms were not identified by the surveillance system. estimated detection rate increased over time ( % [ ] [ ] [ ] [ ] % in w , % [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] % in w ). by the end of june, . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint regions had a median detection above or equal % (figure ) , and regions detected a number of cases within the probability ranges of model projections ( table ) . all regions except pays de la loire displayed increasing trends in the estimated detection rate. we compared the projected incidence of covid- symptomatic cases in w ( . [ . - . ] per , ) with the value obtained from confirmed cases ( . per , ) and two estimates based on covidnet.fr data (figure ). the first estimate applies the measured test positivity rate to the number of self-reported covid- suspect cases (estimate # , yielding . [ . - . ] per , ); the second additionally assumes that only % would be confirmed as suspect case by a physician and prescribed a test (according to covidnet.fr data on consulting participants, estimate # , yielding . [ . - . ] per , ). our projections are in line with plausible estimates from covidnet.fr. sensitivity analysis showed that findings were robust against elements of the contact matrices that could not be informed by empirical data, and against current epidemiological uncertainties. including in the analysis also asymptomatic cases led to higher detection rates, % [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] % in w compared to % [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] % for symptomatic cases only. this however assumes that asymptomatic cases were detected by the virological surveillance system in the week of infection, as no additional information was available to adjust for the possible delay. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint table . number of virologically-confirmed symptomatic cases, number of projected symptomatic cases, estimated detection rate, estimated trend in detection rate, population per region. regions are ranked by decreasing number of confirmed cases in w . the trend is estimated comparing the average of the estimated detection rate in the weeks of june (w - ) with the average in the weeks of may (w -w ). despite a test positivity rate in mainland france well below who recommendations ( %) , a substantial proportion of symptomatic cases ( out of ) remained undetected in the first weeks following the end of lockdown. more than , symptomatic infections were not ascertained by the surveillance system from may to june , , according to our estimates. surveillance improved substantially over time. detection rate was estimated to be % [ ] [ ] [ ] [ ] % at the national level in mid-may, in line with estimates for the same period from a seroprevalence study in geneva, switzerland . by the end of june, it increased to % [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] %, leaving about / of cases with symptoms undetected. two regions (occitanie, normandy) reported cases compatible with model projections. these figures suggest that the new surveillance framework was progressively strengthened with increasing resources and capacity over time. detection became also faster, with a % reduction of the delay from symptom onset to testing. at the same time, increasing performance benefited from a concurrent decrease of the epidemic activity in all regions. despite this positive trend, our findings highlight a critical need for improvement. some regions remained with limited diagnostic exhaustiveness by the end of june. this is particularly concerning in those regions predicted to have a large number of weekly infections, such as Île-de-france where approximately only out of cases with symptoms were detected by the end of june, and grand est ( out of ). novel recommendations since the end of lockdown require that all patients with symptoms suggestive of covid- (as well as contacts of a confirmed case) be screened for sars-cov- . almost all cases ( % since may ) clinically diagnosed by sentinel general practitioners as possible covid- cases were prescribed a test . however, only % of individuals with covid- -like symptoms consulted a doctor in the study period according to participatory surveillance data. overall, these figures suggest that a large number of symptomatic covid- cases were not screened because they did not seek medical care despite recommendations. a similar evidence emerged from a large-scale serological study in spain where only . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint between % and % of symptomatic participants with antibodies against sars-cov- reported a previous virological screening . by combining estimates from virological and participatory surveillance, together with measured rates for test recommendations by general practitioners (e.g., due to misclassification of selfreported symptoms), we extrapolated an incidence of symptomatic cases from crowdsourced data that is compatible with model projections. this finding further supports consultation for all covid- suspect cases. large-scale communication campaigns should reinforce recommendations to raise awareness in the population and strongly encourage healthcare-seeking behavior especially in patients with mild symptoms. at the same time, investigations to identify reasons for not consulting could be quickly performed through the participatory surveillance system. red tape might have contributed to low testing rates. prescription for a test was deemed compulsory in the new testing policy to prevent misuse of diagnostic resources , however the path involving consultation, prescription, and lab appointment may have discouraged mildly affected individuals not requiring medical assistance. to facilitate access, some local initiatives emerged recently that increase the number of drivethrough testing facilities, mail test vouchers to promote massive screening in certain regions (e.g. in Île-de-france ), offer temporary mobile testing facilities (buses, pavilions) to increase proximity with the population . these initiatives are particularly relevant for counteracting socio-economic inequalities in access to information and care in populations vulnerable to covid- and may be established in the longterm. given the non-uniform detection rate estimated within the country, learning from specific regional realities may aid to improve detection. the recent change in screening policy no longer requiring a prescription for testing could further improve access. screening rates remained overall well below the objective fixed by authorities for the post-lockdown phase (average weekly number of tests in may-june was , vs. target of , ), and the delay from onset to screening was still very long ( days) by the end of june, despite substantial reduction over time. the large demand for testing currently observed in certain regions, mainly as a result of imminent travels and protocols imposed by certain countries and air companies, is reportedly causing long waiting lists at overwhelmed testing sites . given pre-symptomatic transmission, notification to contacts should be almost immediate to allow the effective interruption of transmission chains . for testing to be an actionable tool for surveillance and, most importantly, for control of covid- transmission, screening rates should be radically increased and delays suppressed. the risk would otherwise be a rapid and uncontrolled resurgence of cases with potential transmission in the community , as currently reported in some french areas (e.g. mayenne district in pays de la loire region) and countries in europe . such risk is expected to increase if the reported relaxation in preventive behaviors persists, due to adhesion fatigue . aggressive and efficient testing will become increasingly more important in the fall months, as other respiratory viruses, such as influenza, rsv, rhinoviruses, will start to circulate and influenza-like-illness incidence levels will become comparable with those of covid- . reviewing the testing strategy over summer, while at low covid- epidemic activity, is an important opportunity to strengthen french response system for next season. models were region-based and did not consider a possible coupling between regional epidemics caused by mobility. this choice was supported by stringent movement restrictions during lockdown , and by the limited mobility increase in may-june , before important inter-regional displacements took place at the start of summer holidays in july. foreign importations were neglected , as france reopened its borders with eu member states on june , and the schengen area remained closed till july. covidnet.fr cohort is not representative of the general population , however the agreement found with sentinel incidence trends for influenza-like-illness suggests that these limitations have little effect once results are adjusted for lack of representativeness . underdetection may also proceed from the imperfect characteristics of rt-pcr (reverse transcription-polymerase chain reaction) tests used to identify infected cases . some cases tested for sars-. cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint cov- could have been falsely negative. this would affect the analysis presented in the manuscript and would be in line with our conclusion that a large part of cases may have been undetected. asymptomatic infections were not considered in the main analysis, as we lacked information on the likely time of infection. the median duration from first to last positive nasopharyngeal swab was estimated to be days in asymptomatic patients in china, with the longest duration at days . no such analysis has been performed in france yet. assuming that asymptomatic infections were rapidly identified through contact tracing yielded higher detection rates than estimated for symptomatic cases only. this is due to a proportionally higher fraction of asymptomatic cases among the confirmed ones. though limited by the underlying assumption, this result further strengthens the main conclusion that detection of symptomatic index cases is the key aspect that requires fundamental improvement. our findings identify critical needs of improvement to increase case ascertainment in france and the performance of the response system to monitor and control covid- epidemic. substantially more aggressive and efficient testing needs to be achieved to act as a pandemic-fighting tool. these elements should be considered in light of the resurgence of cases currently observed in some regions in france and in other countries with similar response systems. virological surveillance data and analysis. the centralized database si-dep for virological surveillance collects detailed information on patients tested in france, including (i) date of test, (ii) result of test (positive or negative), (iii) location (region), (iv) absence or presence of symptoms, (v) self-declared delay between onset to test in presence of symptoms. the delay is provided with the following breakdown: onset date occurring - day before date of test, - days before, - days before, - days before, or > days before. the si-dep database provided complete information for , ( %) out of , laboratory-confirmed covid- cases tested between week (may -may ) and week (june -july ), with an increasing trend of complete information over time. the study referred to the period from w to w ; data of w were used to account for the delays. data were consolidated in w . for cases with complete information, we estimated the number of symptomatic laboratory-confirmed covid- cases by date of onset, using the information on the date of test and the time-interval of onset-to-test delay declared by the patient. we fitted a gamma distribution to these data with a maximum likelihood approach, obtaining a shape parameter equal to . , and expected value of delay equal to days. given a symptomatic confirmed case tested on a specific date, we assigned the onset date by sampling the onset-to-testing delay from the fitted distribution, conditional to the fact that the delay lies in the corresponding time-interval declared by the patient. to account for the changes in the distribution of self-declared delays over time, we also fitted the distribution to three periods of time, obtaining no significant difference. cases with missing data were imputed by sampling from a multinomial distribution with probabilities equal to the rate of occurrence of the labels reported for cases with complete information. imputation was performed by region and by week. onset date was then estimated for the imputed symptomatic cases. participatory surveillance data and analysis. covidnet.fr is a participatory online system for the surveillance of covid- , available at www.covidnet.fr. it was adapted from grippenet.fr to respond to the covid- health crisis in march . grippenet.fr is a participatory system for the surveillance of influenzalike-illness available in france since through a collaboration between inserm, sorbonne universite and sante publique france , , , supplementing sentinel surveillance. the system is based on a dedicated website to conduct syndromic surveillance through self-reported symptoms volunteered by participants resident in france. data are collected on a weekly basis; participants also provide detailed profile information at enrollment. in addition to tracking influenza-like-illness incidence , , grippenet.fr was used to estimate . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint vaccine coverage in specific subgroups individual perceptions toward vaccination and health-seeking behavior . it was also used to assess behaviors and perceptions related to other diseases beyond influenza . participants are on average older and include a larger proportion of women compared to the general population , . participating population is however representative in terms of health indicators such as diabetes and asthma conditions. despite these discrepancies, trends of estimated influenza-like-illness incidence from grippenet.fr reports compared well with those of the national sentinel system , . all analyses were adjusted by age and sex of participants. to monitor covid- suspect cases in the general population, we used the expanded case definition recommended by the high council of public health for systematic testing and described in their april notice : • (sudden onset of symptoms or sudden onset of fever) and (fever or chills) and (cough or shortness of breath or (chest pain and age > years old)) • or (sudden onset of symptoms or (sudden onset of fever and fever)) and o (age > years old and (feeling tired or exhausted or muscle/joint pain or headache or (loss of smell without runny/blocked nose) or loss of taste) o or ((age ≥ years old or age < years old) and diarrhea) o or (age < months old and (fever without other symptoms))). figure reports two estimates obtained from covidnet.fr cohort data for the incidence of symptomatic cases in w . they are computed as follows: • estimate # = (covidnet.fr estimated incidence in w ) * (test positivity rate from si-dep in w ) • estimate # = (covidnet.fr estimated incidence in w ) * (estimated proportion screened and confirmed as covid- suspect case by a physician, and prescribed a test; estimates from covidnet.fr) * (test positivity rate from si-dep in w ) ethics statement. grippenet.fr/covidnet.fr was reviewed and approved by the french advisory committee for research on information treatment in the health sector (i.e. cctirs, authorization . ), and by the french national commission on informatics and liberty (i.e. cnil, authorization dr- - ) -the authorities ruling on all matters related to ethics, data, and privacy in the country. transmission models summary. we used a stochastic discrete age-structured epidemic model for each region based on demographic, contact , and age profile data of french regions . four age classes were considered: [ - ), [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , , and + years old. transmission dynamics follows a compartmental scheme specific for covid- , where individuals were divided into susceptible, exposed, infectious, and hospitalized. we did not consider further progression from hospitalization (e.g. admission to icu, recovery, death ) as it was not needed for the objective of the study. the infectious phase is divided into two steps: a prodromic phase ( ) and a phase where individuals may remain either asymptomatic ( , with probability = % ) or develop symptoms. in the latter case, we distinguished between different degrees of severity of symptoms, ranging from paucisymptomatic ( ), to infectious individuals with mild ( ) or severe ( ) symptoms. prodromic, asymptomatic and paucisymptomatic individuals have a reduced transmissibility = . , as estimated in ref. . a reduced susceptibility was considered for younger children and adolescents, along with a reduced relative transmissibility of younger children, following available evidence from household studies, contact tracing investigations, and modeling works [ ] [ ] [ ] [ ] [ ] [ ] . a sensitivity analysis was performed on relative susceptibility and transmissibility of younger children, and on the proportion of asymptomatic infections. models calibration. models were calibrated regionally to daily hospital admission data through a maximum likelihood approach. the likelihood function is of the form . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . is the time window considered for the fit. calibration involved three steps, each one corresponding to a different epidemic situation: pre-lockdown , during lockdown , post-lockdown. covid- ) in the eu/eea and the uk -tenth update prise en charge par les médicins de ville des patients atteints de covid- en phase de déconfinement testing for covid- : a way to lift confinement restrictions signes cliniques d'orientation diagnostique du covid- factors that make an infectious disease outbreak controllable suppression of a sars-cov- outbreak in the italian municipality of vo' substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) estimates of the severity of coronavirus disease : a model-based analysis tracing and analysis of early sars-cov- infections outside china: a modeling study reconstruction of the full transmission dynamics of covid- in wuhan données relatives aux résultats des tests virologiques covid- the potential value of crowdsourced surveillance systems in supplementing sentinel influenza networks: the case of france evaluating the feasibility and participants' representativeness of an online nationwide surveillance system for influenza in france covid- community mobil covid- : une enquête pour suivre l'évolution des comportements et de la santé mentale pendant l'épidémie. /etudes-et-enquetes/covid- -une-enquête-pour-suivre-l'évolution-des-comportements-etde-la-sante-mentale-pendant-l-epidemie impact of lockdown on covid- epidemic in Île-de-france and possible exit strategies expected impact of reopening schools after lockdown on covid- epidemic in Île-de-france pyramide des âges -france et france métropolitaine the french connection: the first large population-based contact survey in france relevant for the spread of infectious diseases quantifying sars-cov- transmission suggests epidemic control with digital contact tracing déconfinement phase : point de situation au mai. ministère educ. natl public health criteria to adjust public health and social measures in the context of covid- seroprevalence of anti-sars-cov- igg antibodies in geneva, switzerland (serocov-pop): a population-based study prevalence of sars-cov- in spain (ene-covid): a nationwide, population-based seroepidemiological study covid- : une campagne de tests à grande échelle débute dans communes d'ile-de-france covid- : dépistage gratuit dans un labo itinérant coronavirus highlights inequality in france's poorest department covid- : les tests de dépistages sont possibles sans prescription médicale tests covid- : les délais d'attente s'allongent dans les labos surchargés. lci covid- country overviews-week population mobility reductions during covid- epidemic in france under lockdown mobility patterns in paris before, during, and after lockdown assessing the impact of coordinated covid- exit strategies across europe pitfalls in sars-cov- pcr diagnostics clinical and immunological assessment of asymptomatic sars-cov- infections participatory syndromic surveillance of influenza in europe influenza during pregnancy: incidence, vaccination coverage and attitudes toward vaccination in the french web-based cohort g-grippenet opinion about seasonal influenza vaccination among the general population years after the a(h n )pdm influenza pandemic healthcare-seeking behaviour in case of influenza-like illness in the french general population and factors associated with a gp consultation: an observational prospective study population perception of mandatory childhood vaccination programme before its implementation the representativeness of a european multi-center network for influenza-like-illness participatory surveillance changes in contact patterns shape the dynamics of the covid- outbreak in china age-dependent effects in the transmission and control of covid- epidemics coronavirus infections in children including covid- : an overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children a case series of children with novel coronavirus infection: clinical and epidemiological features sars-cov- infection in primary schools in northern france: a retrospective cohort study in an area of high transmission cluster of covid- in northern france: a retrospective closed cohort study. medrxiv this study was partially supported by anr project dataredux (anr- -ce - - ) and evalcovid- (anr- - covi- ); eu h grants mood (h - ) and recover (h - ); reacting covid- modeling and surveillance grants. we thank pascal crepey, camille pelat, edouard chatignoux, juliette paireau, daniel levy-bruhl for useful discussions. we also thank all participants of covidnet.fr system. key: cord- -cmqj get authors: walach, h.; hockertz, s. title: what association do political interventions, environmental and health variables have with the number of covid- cases and deaths? a linear modeling approach date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: cmqj get background: it is unclear which variables contribute to the variance in covid- related deaths and covid- cases. method: we modelled the relationship of various predictors (health systems variables, population and population health indicators) together with variables indicating public health measures (school closures, border closures, country lockdown) in european and other countries, using generalized linear models and minimized information criteria to select the best fitting and most parsimonious models. results: we fitted two models with log-linearly linked variables on gamma-distributed outome variables (cov cases and covid- related deaths, standardized on population). population standardized cases were best predicted by number of tests, life-expectancy in a country, and border closure (negative predictor, i.e. preventive). population standardized deaths were best predicted by time, the virus had been in the country, life expectancy, smoking (negative predictor, i.e. preventive), and school closures (positive predictor, i.e. accelerating). model fit statistics and model adequacy were good. discussion and interpretation: interestingly, none of the variables that code for the preparedness of the medical system, for health status or other population parameters were predictive. of the public health variables only border closure had the potential of preventing cases and none were predictors for preventing deaths. school closures, likely as a proxy for social distancing, was associated with increased deaths. conclusion: the pandemic seems to run its autonomous course and only border closure has the potential to prevent cases. none of the contributes to preventing deaths. the novel coronavirus sars-cov (cov ) which surfaced in china in december for the first time created a world-wide pandemic , and an associated disease, named , with respiratory stress, heart problems, kidney failures and immunological problems associated with it [ ] [ ] [ ] [ ] [ ] . countries closed down their borders, their schools, universities and cultural facilities and sometimes even their whole activities. this was due partially to its novelty and its largely unknown properties, but also, because it was soon clear that those infected by the virus could be asymptomatic for up to a week or longer, while still being infectious to others, and because high infectivity, virulence and mortality was assumed. the spread of the virus was initially very quick following a seemingly exponential growth curve, but abated and the replication numbers went into decline. currently it is highly debated what contributes to the variance that can be seen both in cov cases, as well as in deaths attributed to . while most people assume that political measures have mitigated the spread of the virus , others hold that the process is rather autonomous, that the virus recedes after having infected all those in a population susceptible to it and then the infection abates , . moreover, most modeling approaches that were used in early stages of the disease to inform political decision making did not take into account potential inhomogeneity of a population due to natural or specific immunity of a large part of the population , . more recent models that take such inhomogeneity parameters into account, informed by novel data, estimated that after about to % of a population have been infected herd immunity is reached, because the rest of the population might not be susceptible to the virus , . since it is largely unclear what variables contribute to the variance in cases and deaths attributable to cov , we wanted to study this question by building linear models using various predictor variables to study their influence on the outcomes covid- cases and deaths in various countries. we collected data on covid- cases and deaths as presented by the database of the european center for disease prevention and control on their website by th may . we used european and oecd countries, because those data are most relevant to our question and are more validly accessible. we included the following countries covid- cases and deaths were summed for the total period covered by the ecdpdatabase and used as dependent variables (criterion). we standardized cases and deaths on . inhabitants, taken from the population size in the same data-base. as predictors we collated data from publicly available sources (see supplementary material for a list and for sources) for population, health, health systems, and environmental indicators between may th and th . the variables used as predictors are described in a protocol that was published on the server of the open science framework (https://osf.io/x np/). briefly, we used population indicators (life-expectancy, percent single households, city dwelling, age groups, population density), health systems indicators (number of doctors, hospital beds, icu beds, pcr tests), health indicators (percentage of obese, diabetes, smoking and physically inactive persons), air pollution, and finally variables coding for political . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / actions: closure of borders, closure of schools, country lockdown, including the rapidity of implementation since the first case was noted (see table ). we built two separate linear models to predict the influence of variables on populationstandardized cov -cases and covid- associated deaths. in order to investigate which variables might be potential predictors first order correlations of all relevant variables with the outcome variables were calculated, using nonparametric correlations, and their inter-correlation structure was studied. only variables that contributed with an effect size r > . or with significant correlations were further considered for modeling. as cases offer enough stability to estimate about parameters reliably , we opted for small models to start with and included a further predictor only if it was theoretically meaningful, empirically supported (i.e. a significant predictor) and improved model fit. we included first all those relevant predictors from population, health systems, and environmental sets in separate steps that correlate significantly with the outcome and are not collinearly related with each other. we explored model fit to find the best subset for each small group of indicators with forced entry of not more than four variables at a time, retaining only significant predictors for the next step. in a final step we included potential predictors from the set of public health indicators to investigate whether there is any improvement in model fit and whether these variables were significant predictors. the rationale of this procedure is: if the public health measures contribute to preventing cases and deaths, then they would have to emerge as potential significant predictors with negative sign (as they were dummy coded with coding for present and coding for absend). in addition, the model fit of the enlarged model would have to improve. as an indicator of improved model fit we used the difference of akaike information criterion (aic in its original and corrected version), the difference of bayes information criterion (bic) and the chi -goodness of fit test statistic divided by degrees of freedom conjointly to avoid over and underfitting. we always used the model that minimized all of them conjointly. to assess model adequacy, plots of predicted versus observed cases, residual distribution plots, and residuals vs. cases were visually analyzed and residual plots were screened for outliers (residuals vs. chi statistic). in a sensitivity analysis the model was recalculated without outliers to see whether the model structure, i.e. the variables used as significant predictors would be the same and goodness of fit improved. for those sensitivity analyses, aic and bic were only used as a further criterion if the difference was large, as the efficiency of these information criteria change with number of cases/degrees of freedom and number of variables , . we used statistica version . for all analyses. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / the nonparametric correlations (spearman's rho) between the two predefined outcome variables, cases and deaths per . inhabitants, as well as the case-fatality rate (cfr), for illustration, are reported in table . insert table here of the structural variables describing the health systems only the number of tests conducted correlated significantly with number of standardized cases (r = . ) and deaths (r = . ), as well as with case-fatality rate (r = . ) and with number of icu beds (r = . ). of the variables describing political actions only border closure was negatively and significantly related with standardized cases (r = -. ), but only weakly and non-significantly with number of deaths (r = -. ): cases tended to be higher in countries that did not close the border. but neither lockdown nor school closures were significantly and sizably related with number of cases or number of deaths. only full closure of schools was slightly, but nonsignificantly related with number of cases (r = -. ) but not with number of deaths, indicating that cases were higher in countries that had not closed schools. however, as school closure was correlated positively, but non-significantly (r = . ) with cfr, it is necessary to clarify by modeling, which covariation might be influential. the duration or length of border-or school closures was only marginally and nonsignificantly negatively correlated with number of deaths and cases. the rapidity with which countries reacted, i.e. the time difference between the registration of the first case and the initiation of political reactions was only slightly correlated with number of cases, and significantly correlated only with the case-fatality rate (r = . ), i.e. countries that were slower in initiating political actions had a higher case-fatality rate. higher and significant correlations were visible with descriptors of populations and health status. there were more cases in countries that had a higher life-expectancy at birth (r = . ), and there were more deaths (r = . ) in such countries. there were more cases (r = . ), as well as more deaths (r = . ) in countries with a higher percentage living in cities. however, neither population density of a country, nor percentage living in single households emerged as a potential predictor. potentially interesting correlations emerged between case-rate and death rate with percentage of population taking lipid lowering drugs (r = . ) and with amount of mercury used in the alkaline-chlorine industry (cases: r = . , deaths: r = . ). but since we were unable to find enough data for all countries of interest, these variables could not be used for modeling. none of the other variables describing the health status of a population (obesity rate, insufficient physical activity, sleep problems, vaccination rate, percent of diabetes patients in a population) emerged as potential predictors. paradoxically, there were more cases (r = -. ), as well as deaths (r = -. ) in countries that had a lower percentage of smokers in the population. as this correlation was even higher for male smokers, likely because smoking is predominantly a male phenomenon, the percentage of male smokers was used for further modeling. the same paradoxical relationship can be seen with variables that code for air-pollution, especially with very small particles (pm -particulate matter of micron size per m air), where we see significant negative correlations of r = -. with cases and r = -. with deaths. although the correlation with pm was somewhat higher, we used pm for modeling, because pm and pm are highly intercorrelated (r = . ) and because we had more cases with data for pm , most notably usa. following our protocol, we constructed a model to account for the covariance structure of the variables. since the outcome variables, cases and deaths standardized on . inhabitants per country, showed adequate fit to a gamma-distribution (see e- figure ), we calculated a generalized linear model with a log-link-function on gamma-distributed outcomevariables: where Γ refers to the gamma distribution with shape ki and shape si, i , … , . we used the gamma distribution as it maximizes entropy. although the (overdispersed) poisson distribution may have been a choice, we opted for the gamma distribution because by modelling standardized cases, we are effectively modelling a continuous variable, thereby excluding the poisson distribution (which models discrete events). we also considered logtransforming the outcome variables to approximate a normal distribution, but the fit was not adequate and sensitivity analyses using linear regression on a log-transformed outcome variable yielded essentially the same results, but with inadequate fit. the models that best predicted standardized cases are presented in table . the first model describes the best fitting model for all countries predicting cases. the variables entering the model are life-expectancy, number of tests and smoking. parameter estimates are positive for life expectancy and number of tests, and negative for smoking. in a second step variables coding for political decisions (country lockdown, border closure, school closures) were entered. the best fitting model emerged with border closure as a negative predictor, with smoking removed. the model fit statistics show improved model fit over the first model (akaike information criterion -aic , vs. , ; bayes information criterion , vs. ; chi /degrees of freedom , vs. , ). we inspected the chi vs. prognosis plot to spot outliers. there was only one clear outlier, belgium (efigure ). removing this outlier improved model fit considerably (aic , ; bic , ; chi /degrees of freedom , ), with air-pollution pm added to the model as a negative predictor. table here the model predicting covid- related deaths is presented in table : here the duration the infection had been in the country is a significant positive predictor, and so is life expectancy. smoking is a negative predictor. when entering the public health variables only school closures emerged as a significant positive predictor that improved model fit. excluding . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / belgium, the only serious outlier, improved model fit. the same variables remain in the model as significant predictors with nearly the same regression coefficients including their sign. table here inspection of residuals show that the linearity assumption is warranted. the model can predict the cases reasonably well. a plot of countries vs. residuals is presented in e- figure . the major findings of this modeling study using population data for countries are clear, if surprising: life-expectancy emerges as a stable positive predictor both for standardized cases of cov infections, as well as for covid- related deaths. surprisingly, smoking emerges as a stable negative predictor, i.e. protective factor. of the public health or political variables only border closure emerges as a strong negative predictor for cases. but school closures is a strong positive predictor for deaths, i.e. is associated with more deaths. the parameter for number of tests conducted in a country emerges as a strongly significant positive predictor. the fact that life expectancy is the most consistent positive predictor -the longer the life expectancy in a country the more cases and deaths -is easy to understand. the disease affects most aggressively elderly and multimorbid patients. life expectancy is a complex variable, incorporating social and medical progress in a country as well as economic indicators, and hence it denotes the number of the elderly in a population, as well as the intensity of medical care. only the number of cov -pcr-tests, out of all health systems variables, enters the model as a significant positive predictor. other quality indicators of the medical system (number of doctors per . inhabitants, number of icu or hospital beds) do not enter the model. that number of tests should be related to the number of cases is evident: the more tests are conducted in a country the more cases can be potentially registered. the absence of other indicators from the set of medical system variables shows that the development both of infections and deaths is rather independent of the preparedness of the medical system. although some interesting first order correlations indicated that health status variables might be interesting to explore, none of them emerged as a predictor, except smoking as a somewhat protective variable. this might have to do with the fact that smokers may have a hyperactive system to combat airborne noxes and hence might have a small advantage against this particular disease , . a large cohort study has documented a similar counterintuitive effect , and an argument could be made that this might have to do with the fact that smokers express fewer ace receptors , which are the main entry gate of cov into the lungs. however, the correlation of smoking with life expectancy is negative (r = -. for men), and hence smoking might confer other risks that shorten lives. only in one model, excluding the outlier belgium, does air pollution play a role as a potential negative predictor, i.e. as a potential preventive factor. this is rather counterintuitive. either it could be understood along the same lines: lungs prepared to deal with small noxes might be better prepared to fight a virus. or else, airborne viruses might be captured by small airborne particles and might fall to the ground earlier. again, this could be an accidental effect that should not encourage air pollution, as this has detrimental effects elsewhere. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / the closing of borders is a significant negative predictor, denoting a protective effect, in the model including all countries and predicting number of cases, but not for predicting number of deaths. in all models predicting death the duration of the infection is a positive predictor. as deaths develop with a delay of perhaps - weeks after the first contact with the virus - , this relationship reflects a quite independent temporal dynamic of the infection. it is interesting to observe that closure of schools emerges as a strong positive predictor for the number of deaths, i.e. school closures are associated with more deaths. this could be an indicator for strong social distancing rules in a country which might be counterproductive in preventing deaths, as social distance for very ill, and presumably also very old patients, might enhance anxiety and stress and could then become a nocebo , . it could also reflect the fact that countries which saw a rising tendency of deaths closed schools as an emergency measure, and hence school closure is an indicator of fear in a country. but considering the prevention of deaths, none of the public health measures studied are associated with the prevention of deaths. border closure might be an exception in that it is associated with reduction in the number of cases and hence, indirectly, the number of deaths. but in the full model predicting deaths it is not a significant predictor. this seems to contradict new modeling data using time series models , that report clear evidence for the effectiveness of non-pharmaceutical interventions. we actually doubt the validity of these findings. the major shortfall of these models is that they ignore the most likely reason why we find the data we find: immunity in the population and neglecting the strength of natural immunity (see below). thus, a new reliability study of such models shows that they are crucially dependent on assumptions, parameters assumed and the time point at which they capture data . if the wrong assumption about a potential resistance against an infection in a population is made, the results are far off from true values. rapidity of reaction can be a positive predictor in some models, but reliably leaves the equation, as soon as the duration of infection is taken into account. this signals in our view, the fact that the dynamics of the infection develops quite independent of political actions, or rather that political actions are mostly too late. the duration of an infection in a country was only a significant predictor for standardized deaths. a model including this variable to predict standardized cases is not significant and does not improve model fit. one might argue that a perhaps more conventional way of modelling would have been to log-transform the outcome variables and use standard linear regression approaches. we tried this as a sensitivity analysis but did see essentially similar results with a residual distribution that signaled model inadequacy, and hence we doubt that such a model would have helped with understanding the data. as data on number of tests were not available for china one might argue that our model is inadequate, as it excludes an important country. while this is true, we fitted models without the number of tests as a predictor which did not lead to better fitting or more meaningful models. we also used population standardized tests as an alternative to raw number of tests, but found that the model fit was much worse. thus, the image that emerges from the data and the attempt to understand their relationship through modeling is that of a largely autonomous development. it affects mainly the elderly. smoking is somewhat protective and border closures is associated with a lower number of cases. but other measures -closing of schools and lockdown of whole countries -. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / do not contribute to a reduced number of cases or deaths. this may have to do with the fact that the virus travels extremely quickly. even the shutdown of wuhan airport delayed the spread across china only by , days , , and as chinese airports remained open the spread of the virus across the world was guaranteed and could not be stopped by gross measures such as border closures, as these came too late. an italian seroprevalence study estimated that even at the very beginning of the pandemic in italy there were . % of the population in milan that had had contact with the virus. the examples of taiwan and hongkong show that containment is possible, if reactions come very quickly and if cases can be traced close to %. but already the presence of cases in a population increases the likelihood of a pandemic by %. , once infections are in the vulnerable segments of a populations, like in hospitals or homes for the elderly, political actions like school closures or country lockdowns do not prevent deaths. if anything, social distancing seems to be harmful. what might be useful but cannot be seen in our coarsegrained data are special protective measures geared to protect these vulnerable populations, such as protective masks for personnel and visitors in hospitals and old people's homes, or the wearing of face masks in places with bad ventilation and close proximity of people. why, then, have infections subsided and deaths receded since we gathered our data on may th ? most people would say this was due to the public health measures , and recent modelling studies seem to support this , , . however, we have pointed out that the peak of the cases had been reached in wuhan already on january th , only days after the city lockdown. this was surely too short to be an effect of public health measures, as cases manifest with a delay of at least , rather more days. and a careful analysis shows that, if one uses realistic retrodiction of cases, then effects of public health measures cannot be seen . thus, our modelling supports the view that the public health measures of school closures and country lockdown, with the exception of the closure of borders to reduce cases, were likely ineffective in influencing cases and deaths. if anything, social distancing might even be harmful for seriously ill patients. very likely, scientists and governments overestimated the danger this virus presented and underestimated the immunological resistance in the population. while there is no doubt that those really falling seriously ill from this infection suffered a lot more and were in much greater danger than comparable patients suffering from flu or other respiratory infections , there can also be little doubt that basic immunological insights were neglected from the outset. both specific [ ] [ ] [ ] and non-specific immunity [ ] [ ] [ ] seems to have been much greater in the population than initially assumed. this is likely the case because the difference of cov from other corona-viruses is not as great as initially thought. thus, a considerable percentage of any population would have been immune through specific cross-immunity against other coronaviruses, apart from the fact that non-specific immunity has been neglected in the discussion nearly completely. this is the reason why more recent models that account for this fact and introduce inhomogeneity parameters reach the conclusion that it is sufficient if %- % of a population have had contact with cov to reach herd immunity , and that further waves are unlikely given immunity . our data are not foolproof but first important hints. we were unable to code more countries, due to restrictions in time, resources and availability of data. this reduces the stability of estimates and to some degree also variance, although for those variables of interest variance was large enough to estimate stable models. for the chosen models the goodness of fits test signals good fit, and the relative improvement of aic and bic values is obvious and . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / well below conventional thresholds of differences between source model and improved model. [ ] [ ] [ ] we opted for completeness of data as much as possible rather than for a large number of countries, as modeling depends on the completeness of case-wise data. some interesting and potentially useful predictors we were unable to gather: a more fine-grained resolution of different social distancing rules in different countries, availability and wearing of face masks for medical personnel and the public, for instance. every model is wrong , but given the data our models have a comparatively good fit. this can also be seen indirectly, as excluding outliers improved model fit, but did not change the predictors and their overall structure. obviously, in a population-based study we have to rely on the validity of the data provided by other sources, which may be of variable, even doubtful quality. this limitation has to be borne in mind. an exploratory modeling approach like ours is always open to critique. we decided to build parsimonious models that are theoretically guided and conceptually informed , starting with health systems, structural and population indicator variables and entering political public health variables in a last step, then adapt the model to find the best model fit. we followed a predefined, published protocol which guarded us against aimless fishing, and strove for parsimonious models that could explain the data with a minimum of predictors and good model fit. we avoided computer guided step-down and step-up procedures as they are inefficient or prone to overfitting. thus, we are quite confident that we did not overlook an important contribution of political actions to an explanatory model: they are not visible in our data except for those we report. in conclusion: in our data-set of countries, only border closure had the potential to prevent cases. other public health measures were not associated with reduced cov -cases or covid- associated deaths. rather, the pandemic seems to take its own course. since being elderly is a risk factor for many diseases, and eventually death, and cannot be changed, political actions in future pandemics would likely need to focus on protecting these members of society first. apparently, closing schools and locking down countries is not the right method to prevent deaths. perhaps the most sensible measures against pandemics are high alertness and an early warning system that initiates rapid actions that can prevent pandemics from developing. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / we are grateful to sebastian sauer for advice on modeling and for counter-checking the validity of our modelling with r-routines and for critically commenting on an earlier draft. we thank the students of the master class "quantitative research methods" of the msc course "health promotion" who gathered the data for this study and participated in discussing and initiating this project. not applicable for secondary data-analysis. no external funding and no external influence. none of the authors has a conflict of interest. data will be made publicly available after publication and for peer review and qualified requests beforehand. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . residuals for full models per country; the last country is usa; china is missing, because there were no data for tests conducted in china . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . figure e -model diagnostic: histogram of raw residuals -predicting cases . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . data were extracted from the the database of the european center for disease prevention and control, as of th may . this yields day-wise cases, deaths and population numbers for each country. the data were parsed (cases and deaths summed, date of first case registration and populations numbers extracted) using the statistica data reporting tool and the countries of interest included. these were all european countries including switzerland, as well as other countries of the oecd, including china, iran, russia, india, japan and brazil to represent all countries that were at the beginning of the crisis, as well as other large countries in the world. we excluded africa, other south and middle american and asian countries because of a lack of resources, time and because we were not sure we would be able to find sufficient data. this yielded the countries described in our protocol. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / data for border closure of iran suggested that other countries closed their borders against iran, but not iran against other countries. hence this was marked as open. we wanted to include the availability of face masks and their number, but those data were unavailable for most countries, so we excluded this variable. were taken from the unesco data base which updated them on a daily basis; we extracted the data on the th of may: unesco. covid- educational disruption and response. access on . . . https://en.unesco.org/covid /educationresponse we extracted data for vaccination rates from https://de.statista.com/statistik/daten/studie/ /umfrage/laender-mit-d,er-hoechstenimpfquote/ this is a representative survey and covers all different vaccinations. as this covers only europe, we searched other sources. for china, india, iran, japan data came from https://ourworldindata.org/grapher/immunization-coverage-against-diphtheria-tetanus-andpertussis-dtp -vs-gdp-per-capita for brazil from https://academic.oup.com/jtm/article/ / /tay / for canada from https://www.canada.ca/en/services/health/publications/vaccinesimmunization/vaccine-uptake-canadian-children-preliminary-results- -childhood-nationalimmunization-coverage-survey.html usa from https://www.epa.gov/outdoor-air-quality-data/air-quality-statistics-report csv formatted for all counties for ; imported into new spreadsheet and calculated median across pm . weighted h average, because there were a few counties with very high . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / doi:https://doi.org/ . /j.atmosenv. . . ) did not contain data. prof. kümmerer, an expert in environmental toxicology did not have any information, neither did other experts asked. hence we dropped this variable in the final analysis, as the data from the un-en report on mercury in the alkaline industry was too patchy. at each step new partial data-sets were created and added to the master database with the statistica-data "merge" command with variable merging according to country names and each set was saved under a new name. since some variables were created as functions of others and indexed by the original variable number, the final database contained all variables, even those that were never further used except for orienting correlations. outcome variables were log-transformed to check whether they would then be normally distributed to allow for a normal linear regression. as the result was less than satisfactory we decided to go for a generalized model and regress on a gamma-distributed variable, as the variables were clearly gamma-distributed. date variables were calculated from starting date to the th may for border closure, school closure, and finally for the rapidity of reaction as the difference. this was defined as the date when the first measure, either border closure or school closure was registered and the days to first case registration was calculated. distribution analyses of the dependent variable showed that it was gamma distributed and that a log transformation cannot rectify this. hence it was decided that a regression on gamma-distributed variables should be calculated. first non-parametric correlations were correlated to see which variables correlate at all with the outcome, and as defined in the protocol, only variables with r > . and/or significantly correlating variables were considered further in regression models. the regression models used the functionality generalized linear models, stipulating a gamma distributed outcome variable with a log-link function. the parametrization method was overparametrized, as there was no sigma restricted coding in our data. all potentially included variables were inspected for their descriptive parameters and to see, whether they contribute any variance. if several similar variables (.e.g. air pollution variables) were available we used those that had the least missing data in order to not lose power. all modeling approaches included first health serviced, population and health parameters in a model, trying to fit the most parsimonious model with only significant predictors in the equation. this was done by calculating forced entry models, excluding non-. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / significant predictors and recalculating the model. highly intercorrelated variables were never used together, but separate models were calculated and the model with the best model fit was selected. after that variables representing political actions (country lockdown, school closure) were entered in an additional model and used if significant as predictors. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org / . / . / association of public health interventions with the epidemiology of the covid- outbreak in wuhan on the origin and continuing evolution of sars-cov- . national science review sars-cov- infects t lymphocytes through its spike protein-mediated membrane fusion sars-cov- invades host cells via a novel route: cd -spike protein functional exhaustion of antiviral lymphocytes in covid- patients baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region epidemiology and transmission of covid- in cases and of their close contacts in shenzhen, china: a retrospective cohort study. the lancet infectious diseases inferring change points in the spread of covid- reveals the effectiveness of interventions the end of exponential growth: the decline in the spread of the coronavirus von der fehlenden wissenschaftlichen begründung der corona-maßnahmen impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand. london: imperial college individual variation in susceptibility or exposure to sars-cov- lowers the herd immunity threshold why herd immunity to covid- is reached much earlier than thought model selection and inference: a practical information-theoretic approach regression and time-series model selection feasibility of controlling covid- outbreaks by isolation of cases and contacts. the lancet global health early dynamics of transmission and control of covid- : a mathematical modelling study. the lancet infectious diseases wuhan covid data -more questions than answers inferring change points in the spread of covid- reveals the effectiveness of interventions). advance social sciences and humanities preprint asymptomatic seroconversion of immunoglobulins to sars-cov- in a pediatric dialysis unit human coronavirus reinfection dynamics: lessons for sars-cov- . medrxiv the infection fatality rate of covid- inferred from seroprevalence data. medrxiv epigenetic landscape during coronavirus infection sars coronavirus pathogenesis: host innate immune responses and viral antagonism of interferon. current opinion in virology recognition of virus infection and innate host responses to viral gene therapy vectors second waves, social distancing, and the spread of covid- across america interpreting and understanding logits, probits, and other nonlinear probability models model selection and model averaging in behavioural ecology: the utility of the it-aic framework aic and bic: comparisons of assumptions and performance aic model selection using akaike weights model selection and model averaging values, median was taken, else it would have been instead of . only pm and pm data including us air-pollution data covid -mastertabelle .sta some countries missing on that variable worldwide trends in insufficient physical activity from to : a pooled analysis of population-based surveys with · million participants world health statistics : monitoring health for the sdgs, sustainable development goals. geneva: world health organization; . licence: cc by-nc-sa . igo. other sources on health and population data japan und deutschland im zahlenvergleich ( ): bevölkerung. accessed türkei: mehr einpersonenhaushalte und kleinere haushaltsgrößen. accessed idf mena members. accessed south-and-central-america/members.html international diabetes federation. ( ). idf sea members. accessed idf western pacific members. accessed bevölkerungsdichte nach ländern. accessed do more people live in urban or rural areas? accessed anteil der einpersonenhaushalte an allen privathaushalten in den ländern der eu im jahr china: altersstruktur von großbritannien: altersstruktur von japan: altersstruktur von norwegen: altersstruktur von prävalenz von diabetes bei zwischen -und -jährigen in ausgewählten ländern weltweit im jahr russland: altersstruktur von türkei: altersstruktur von usa: altersstruktur von altersstruktur der ständigen wohnbevölkerung in der schweiz von bis . accessed brasilien: altersstruktur von europäische union: altersstruktur in den mitgliedsstaaten im jahr . accessed europäische union: bevölkerungsdichte in den mitgliedsstaaten im indien: altersstruktur von iran: altersstruktur von kanada: altersstruktur von substantial-investment-needed-to-avert-mental-health-crisis prevalence of insomnia from various review sources: canada ohayon & sagales ( ) incidende of insomnia european guideline for the diagnosis and treatment of insomnia sleep dissatisfaction from canada switzerland: statista "leiden sie unter schlafstörungen and prevalence of sleep problems from van de straat & bracke then a new hyper-variable was constructed in which the mean rank of those variables that were available per country was deposited. finally, this new mean rank-variable was again ranked to yield the rank order of countries with sleep problems. this was used for further analysis. health services data: we exctracted number of doctors, standardized per . inhabitants, number of hospital beds and number of icu beds, standardized. hospital beds (per . inhabitants) who: global health observatory data repository beyond-containment-health-systems-responses-to-covid- -in-the-oecd- ab c / the following countries are not contained in this list and data for these countries come from the according sources: china: phua drugs we attempted to get data for lipid-lowering drug consumption, but as these data were sparse and not systematically comparable, we desisted from further attempts. mercury country wide mercury consumption is not easily available. un-en reports give tons of consumption for those countries that use mercury in the chlorine-alkaline industry but this is only about half of the countries. for the rest only regional data were available. we contacted dr. steenhuisen and prof. kümmerer in the hope to get help. dr. steenhuisen did not provide data and the publication key: cord- - bt zv authors: gorges, rebecca j.; konetzka, r. tamara title: staffing levels and covid‐ cases and outbreaks in us nursing homes date: - - journal: j am geriatr soc doi: . /jgs. sha: doc_id: cord_uid: bt zv background / objectives: nursing homes have experienced a disproportionate share of covid‐ cases and deaths. early analyses indicated that baseline quality was not predictive of nursing home cases, but a more nuanced study of the role of nurse staffing is needed to target resources and better respond to future outbreaks. we seek to understand whether baseline nurse staffing is associated with the presence of covid‐ in nursing homes and whether staffing impacts outbreak severity. design / setting: we analyze cms facility‐level data on covid‐ cases and deaths merged with nursing home and county characteristics. we use logistic regressions to examine the associations of staffing levels from nursing home compare with the outcomes of any covid‐ cases and, conditional on at least one case, an outbreak (defined as confirmed cases / certified beds greater than % or total confirmed and suspected cases / beds greater than % or greater than deaths). among facilities with at least one case, we model count of deaths using hurdle negative‐binomial‐ regressions. results: % of the , nursing homes that reported covid‐ data as of june had at least one case among residents and/or staff. of those, % experienced an outbreak. higher rn hours are associated with a higher probability of experiencing any cases. however, among facilities with at least one case, higher nurse aide and total nursing hours are associated with a lower probability of experiencing an outbreak and with fewer deaths. the strongest predictor of cases and outbreaks in nursing homes is per capita cases in the county. conclusions: prevalence of covid‐ in the community remains the strongest predictor of covid‐ cases and deaths in nursing homes, but higher nurse aide and total nursing hours may help to contain the number of cases and deaths. residents and staff at nursing homes account for over , cases and , deaths, or % of cases and % of deaths from covid- in the united states. in some ways, the high rates are not surprising. nursing homes house, in close quarters, large numbers of individuals with multiple comorbidities who need hours of hands-on care on a daily basis. these facilities are often understaffed and depend on medicaid reimbursement for the majority of their residents. during the pandemic, they have had to compete with hospitals for personal protective equipment, still in short supply in many areas, putting both staff and residents at risk. these circumstances lend an aura of inevitability to cases of covid- appearing in nursing homes. a natural question is whether the risk can be identified and mitigated. recent examinations of selected states found that the percent of nonwhite residents was a strong predictor of cases ; and that in addition to race, larger facility size, urban location, non-chain status, state and county-level virus prevalence were associated with more cases. none of these studies found an association between cases and nursing home compare star ratings, implying that location of the nursing home, rather than quality level, determined vulnerability to covid- . however, it seems counterintuitive that nursing home staffing, a primary driver of quality, plays no role. single-state studies of nursing homes in california and connecticut have found that facilities with lower rn staffing have more cases. our objective is to take a nuanced look at the role of nursing home staffing in covid- cases and deaths using national data. first, are staffing levels associated with the probability of any covid- cases in a facility? second, among facilities experiencing at least one case, is staffing associated with severity of the outbreak that develops? this article is protected by copyright. all rights reserved. we merged nursing home covid- case and death counts with facility and county characteristics. covid- cases and deaths are from the covid- nursing home dataset released by cms on june , . this file contains weekly case and death counts among residents and staff reported by facilities to cms. we then linked nursing homes by provider id to two sources of facility-level data: nursing home compare archives (nhc) and ltcfocus . nhc provides the nursing home location, ownership, number of beds, nhc star ratings, and staffing levels as of the first quarter . using staffing levels from early reflects the extent to which nursing homes were sufficiently staffed directly prior to the pandemic, which could enable better infection control once the pandemic started. ltcfocus contains information on resident characteristics (percent medicaid, percent white) as of . finally, we include two countylevel characteristics: covid- cases per , residents as of june , and metropolitan status (usda rural urban continuum codes). the study sample consists of , nursing facilities: the % of facilities in nhc that report covid- data for at least one of the first four weeks of cms reporting and that have staffing hours in nhc. we examined two main outcomes: ( ) whether facilities had any covid- cases and ( ) among facilities with at least one case, the size of the outbreak. we defined any cases as a binary outcome indicating whether the facility reported at least one confirmed or suspected covid- case among residents or staff. we measured outbreak size in two ways. first, we determined whether the facility met the cms threshold of an outbreak: greater than confirmed case per certified beds or greater than total confirmed and suspected cases per certified beds or greater than deaths . second, we examined this article is protected by copyright. all rights reserved. the number of covid- deaths as a count variable, including suspected and confirmed deaths among residents and staff. staffing levels are from nhc and are derived from the payroll-based journal. we used the case-mix adjusted hours per resident per day for nursing aides (nas), licensed practical nurses (lpns), and registered nurses (rns). we also created a measure to characterize the intensity of rn staffing: share of total nursing hours provided by rns. we began by examining unadjusted associations between facility characteristics and county characteristics with the two outcomes of any cases and, among facilities with at least one case, presence of an outbreak. next, we used multivariable regressions to determine the adjusted association between staffing levels and covid- cases/outbreaks. we conducted two sets of regressions for each outcome, one examining the individual effects of na, lpn, and rn hours and one examining the effect of total nursing hours and rn hours/total nursing hours. staffing measures were converted from continuous measures of hours to categorical variables by dividing the hours into three quantiles, using the middle third of the distribution as the reference category. for the binary outcomes of any cases and outbreak, we used logistic regressions. for the count outcome of number of deaths, after comparing fit of several possible count data options, we used hurdle negative binomial- regressions . in addition to the staffing variables of primary interest, we controlled for facility size, ownership type, chain status, % medicaid residents, % white residents, metropolitan status, and county cases per capita. standard errors are clustered by state. this article is protected by copyright. all rights reserved. unadjusted associations , nursing facilities, or . % of the sample, reported at least one covid- case. among facilities with cases, . % experienced an outbreak, and the mean (median) number of deaths was . ( ). we report the unadjusted associations between facility and county characteristics and covid- cases/outbreaks in table . larger facilities, non-profit ownership, fewer white residents, metropolitan county, and more county-level cases are associated with higher probability of having any cases. the associations are of the same direction for probability of an outbreak for all characteristics except ownership: for-profit ownership is associated with higher probability of an outbreak among facilities with at least one case. not being part of a chain and higher share of medicaid residents are associated with higher probability of an outbreak. facilities report whether there is access to covid- testing for residents, and personal protective equipment (ppe) and staffing shortages. access to testing is higher and shortages are more prevalent among facilities with cases and outbreaks. overall nhc star ratings are similar between facilities with cases and outbreaks and those without. facilities without cases / outbreaks have marginally higher health inspection ratings and lower quality measure ratings. interestingly, staffing ratings are higher among facilities with cases than without but among facilities with cases, staffing ratings and na, total nurse and rn/total nurse hours are higher among facilities without outbreaks than facilities with outbreaks. we explore this unadjusted relationship between staffing and cases / outbreaks graphically in figure . this article is protected by copyright. all rights reserved. pattern in which more staffing is not associated with the probability of any case but is associated with fewer outbreaks is also evident for total nursing hours. we replicate this figure for the other measures of staffing in supplemental figures s -s . lpn, rn, and rn/total nursing hours do not exhibit these same associations with cases and outbreaks. regression-adjusted results are presented in table . high rn hours are associated with higher probability of a facility experiencing any cases. among facilities with at least one case, high na hours and high total nursing hours are associated with a lower probability of outbreak and fewer deaths. low lpn hours is associated with fewer deaths but not the probability of an outbreak. rn hours and rn/total nursing hours are not associated with outbreak severity. we report the odds ratios/marginal effects for the facility and county characteristics in supplemental table s . by far, the largest association with covid- outcomes is the county-level number of cases in the community, i.e. where the virus is circulating. we report the results of several robustness checks in the supplemental appendix. first, we control for concurrent staffing and ppe shortages and resident access to testing, and associations between the outcomes and baseline staffing remain unchanged (supplemental table s ). second, we repeat the analyses controlling for state. we find that both between-state and within-state variation in staffing contribute to the overall findings (supplemental table s ). finally, the main analyses examine relationships between baseline staffing and cumulative cases and deaths. we use weekly cases and deaths for the week ending june to explore if these relationships change over time; they do not (supplemental table s ). this article is protected by copyright. all rights reserved. we conducted the first national examination of the association of nursing home staffing levels and covid- cases and outbreak severity using the newly available cms nursing home covid- data. we find a nuanced story: staffing levels may play one role (or no role) in the probability that covid- gets into a nursing home, and another role in trying to stem transmission and deaths once it is in. for example, whereas staffing levels are unrelated to the probability of having at least one case or even increase that probability, perhaps by increasing traffic in and out of the facility, higher na and total nursing hours are associated with lower probability of a larger outbreak and fewer deaths. the effect sizes of staffing are relatively small. for example, being in the top third of the distribution of na hours is associated with fewer death; similarly, being in the top third of total nursing hours is associated with . fewer deaths. while potentially meaningful, these effects are dwarfed by the effect of where the virus is circulating. the largest magnitude effects we find are for county metropolitan status and county-level number of covid- cases per capita that occur among the general population. compared to counties in the lowest th percentile of per capita cases, counties in the highest th percentile experience . times the odds of detecting any cases, and among facilities with one or more cases, . times the odds of an outbreak or additional deaths. it is important to acknowledge the limitations of the covid- nursing home data. cms required reporting beginning may , and facilities have the option to report cases/deaths going back to january . as a result, the cms data on total cases/deaths represents an undercount, especially in states that experienced early outbreaks. these limitations aside, using the newer, national cms covid- data, we confirm the conclusions of earlier, more geographically limited studies - that found that higher nhc ratings are not associated with better covid- outcomes (supplemental table s ). the prevalence of the virus in the community this article is protected by copyright. all rights reserved. remains the strongest predictor of how nursing homes fare under the pandemic, and this fact should guide policies about assistance and resource distribution. at the same time, although staffing ratios are part of the star ratings, our detailed examination found a nuanced story of the role of nursing home staff. as the pandemic continues and best practices emerge, the role of staffing is likely to take on increased importance. implementing efforts to stem transmission, such as regular testing and cohorting of both residents and staff, is difficult without sufficient staffing levels. with states relaxing visitor restrictions, the daily traffic of staff in and out of the facility, and asymptomatic spread, keeping covid- out of nursing homes may be close to impossible. however, along with sufficient ppe and regular testing, having enough nurse aides to implement virus containment will be crucial if deaths are to be averted. while nursing homes in neighborhoods with the highest virus prevalence will continue to be the most vulnerable and in need of assistance in the short run, a critical and longer-run focus must be to improve nursing home staffing. this is a longstanding challenge that is likely to become even more important as the pandemic continues. accepted article this article is protected by copyright. all rights reserved. coronavirus deaths are linked to nursing homes -the new york times characteristics of u.s. nursing homes with covid- cases variation in sars-cov- prevalence in us skilled nursing facilities nurse staffing and coronavirus infections in california nursing homes covid- infections and deaths among connecticut nursing home residents: facility correlates covid- nursing home data. accessed long-term care: facts on care in the us -ltcfocus.org. accessed coronavirus locations: covid- map by county and state. usafacts.org covid- survey activities, cares act funding, enhanced enforcement for infection control deficiencies, and quality improvement activities in nursing homes outbreak = > %confirmed cases/beds or > % confirmed + suspected cases/beds or + deaths. standard errors clustered by state regression also controls for nursing facility and county characteristics (omitted here for brevity) columns - include all nhc facilities with covid- reporting and complete staffing rating information. columns - limited to facilities with at least case th] percentile of case-mix adjusted hours. figures title: figure : unadjusted percent of nursing homes with any cases and outbreak by quintile of nurse aide and total nursing hours accepted article this article is protected by copyright the authors have no conflicts. all authors contributed to develop the study concept and design. rebecca gorges performed the data analysis. all authors contributed to the interpretation of the data and preparation of the manuscript. accepted article key: cord- -u bs sj authors: garcia, l. p.; goncalves, a. v.; de andrade, m. p.; pedebos, l. a.; vidor, a. c.; zaina, r.; canto, g. d. l.; de araujo, g. m.; amaral, f. v. title: estimating underdiagnosis of covid- with nowcasting and machine learning: experience from brazil date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: u bs sj background: brazil has the second largest covid- number of cases, worldly. even so, underdiagnosis in the country is massive. nowcasting techniques have helped to overcome the underdiagnosis. recent advances in machine learning techniques offer opportunities to refine the nowcasting. this study aimed to analyze the underdiagnosis of covid- , through nowcasting with machine learning, in a south of brazil capital. methods: the study has an observational ecological design. it used data from notified cases of covid- , from april th to june nd, , in florianopolis, santa catarina, brazil. we used machine-learning algorithm to classify cases which had no diagnosis yet, producing the nowcast. to analyze the underdiagnosis, we compared the difference between the data without nowcasting and the median of the nowcasted projections for the entire period and for the six days from the date of onset of symptoms to diagnosis at the moment of data extraction. results: the number of new cases throughout the entire period, without nowcasting, was . with nowcasting, it was (ui - , ). at the six days period, the number without nowcasting was and ( % ui - ) with. the underdiagnosis was . % in the entire period and . % at the six days period. conclusions: the underdiagnosis was more critical in six days from the date of onset of symptoms to diagnosis before the data collection than in the entire period. the use of nowcasting with machine learning techniques can help to estimate the number of new cases of the disease. the world health organization has reported more than million cases of sars-cov- infection and , deaths, a significant part of which had occurred in brazil. according to the brazilian ministry of health, the country overcame , million cases and thousand deaths, what meets the imperial college london prediction of growing in deaths caused by the covid . brazil has the biggest number of deaths among the latino-american countries. the lancet has dedicated, recently, an editorial to the political-sanitary disaster that desolate the country. despite the already alarming numbers, the editorial and other studies had drawn attention to the possibility of a large number of underdiagnosed cases. one of the causes of underdiagnosis is the low testing rate of suspected individuals: . tests for a thousand habitants. this rate is much lower than countries like iceland ( . ), united states ( . ), chile ( . ), south africa ( . ). dealing with the underdiagnosis is essential so that appropriate actions can be taken to reverse the progression of deaths in the country. many countries are using a combination of containment and mitigation activities to stem the progression of sars-cov- and thus, manage the demand for hospital beds. nonpharmacological measures have been shown to be effective in controlling the transmission of covid- . [ ] [ ] [ ] [ ] [ ] they can reduce the impact in the health system, given managers time to organize properly the system. these measures also reduce the need for hospitalization by other conditions that could compete for beds with sars-cov- patients. in addition, they increase the chance that a substantial number of people not be infected until a treatment and vaccine be developed. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint in outbreak situations, in which rapid changes are common, the actual number of infected cases must be closely monitored. artefacts variations produced during the monitoring process should be distinguished of the real cases variation. among the artefacts are less testing capacity than suspected cases notification, for example. if the number of individuals notified as suspects is much higher than the testing capacity at the present time, this difference can cause an underdiagnosis of the current cases. data about pathogens transmissibility and exposed population susceptibility, population density and demographic characteristics of the affected population, besides the temporal spatialdistribution of cases and population mobility, can contribute to the correction of such artefacts. the natural history of the disease, on the other hand, is an important factor in determining the optimal case count update in the frequency monitoring. rapidly progressing diseases like covid- require daily updates, while monthly updates may be sufficient to others with slower progression, such as hiv / aids. a frequent analysis may also be necessary in times when transmissibility is expected to be changing, for example when control actions are initiated, enhanced, or stopped. nowcasting approaches try to estimate the number of a given event in the present. , , this strategy has been used to improve surveillance of infectious diseases like aids , cholera, influenza infections , and, recently, covid- . , , , , nowcasting techniques, in general, uses time-series predictions. - recent advances in machine learning techniques offer opportunities to refine the nowcasting of an epidemic behavior. the main objective of machine learning techniques is to produce a model that can be . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint used to classify, predict, or estimate a phenomenon. this approach is useful in several applications in biomedical research, [ ] [ ] [ ] [ ] [ ] [ ] [ ] including concerning monitoring the impact of non-pharmacological actions is essential to optimize the allocation of scarce resources in non-high-income-countries, like brazil. in these, the maintenance of long quarantine periods is even more challenging due to the deficiencies on the social protection system, the economic vulnerability of the population and the large portion of people acting as informal workers. no single set of interventions is appropriate to all contexts owing to the combination of these factors with climatic, demographic and organization issues of each country. thus, monitoring on near real time should be a key part of the strategy to couple with sars-cov . among the challenges for timely monitoring are delays in providing medical care after onset of the symptoms and delays in diagnosis. it is plausible to assume that these challenges are even greater in nonhigh-income-countries, with less comprehensive health systems. to help overcome this challenge, the present study aimed to analyze the underdiagnosis of covid- cases, through nowcasting with machine learning, in a south of brazil capital city. this project was submitted to the ethics in research with human-beings council at the cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint under cae nº . . . / . we used exclusively secondary and anonymized databases. the present study has an observational ecological design, using data from notified cases we used the random forest machine learning algorithm to classify the notified cases which had no diagnosis yet, producing the nowcast. to analyze the underdiagnosis, we compared the difference between data without nowcasting and the median of the nowcasted projections for the entire period of analysis and for the period from may th to june nd , . the latter corresponds to the six days from the date of onset of symptoms to diagnosis at the moment of data extraction. notification of suspected cases of covid- within hours is mandatory in brazil. from april th , , florianópolis adopted the same criterion of notification used by covid- as the criteria used by the brazilian ministry of health: fever accompanied by cough, dyspnea, runny nose or sore throat. the cases have been confirmed by real . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint time reverse-transcriptase-polymerase-chain-reaction (rt-pcr), serological tests or clinical-epidemiological criteria. we used three data sources for the nowcasting, all from the public health department of florianópolis: ) anonymized database of suspected and confirmed cases of florianópolis' residents; ) demographic data for the health regions; and ) traffic data, as a proxy for the movement of people in the municipality. the following variables were extracted from anonymized database of suspected and confirmed cases: i) diagnostic (confirmed, discarded or missing), ii) sex, iii) age (in years), the number of infected people (with a positive diagnosis and less than days of symptom onset) and the rate of infected people per , inhabitants were calculated for the health regions where each notified person resides. in addition, the following demographic data from these regions were included in the analysis: i) the total number of inhabitants and by sex, ii) the number of persons aged year old, years old and so on up to years old or more, iii) the number of people by race (white, black, yellow, brown, indigenous and ignored), iv) the number of people by years of schooling (from to years completed or more, in addition to literate, non-literate, literate through youth and adult literacy programs and with uninformed schooling), v) total income per household, average income of households, total income of heads of households, average income of . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint heads of households, total income per person and average income per person. the proportion of male people, people aged years old or over, people with non-white race and people with or less schooling time, was calculated as possible indicators of vulnerability. the average daily traffic in four important avenues in the city was used as a proxy of people's mobility in the city. we hypothesize that there is a lag between the increase in mobility and the identification of the increase in cases, so we used the average traffic of the day and the average lagged daily until the thirteenth day of the onset of the symptoms of the notified cases. there was no imputation for missing data. to compare the characteristics of people with a confirmed and discarded diagnosis of covid- , t test was used for continuous variables and chi-square for categorical, adopting the p-value < . as a threshold of statistical significance. we used the random forest to carry out the nowcasting. the database was initially splitted in the training-validation-test database, formed by cases whose diagnosis (confirmed or discarded) was known; and the prediction database, which had no diagnosis. the training-validation-test database was divided, next, in training-validation database and test database, using % and % of the data, respectively. the training-validation basis was subjected to undersampling to improve the sample's balance as the number of discarded cases was much higher than confirmed. the balanced training-validation database was used to perform the feature selection and . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint hyperparameter tuning. nested cross validation was performed with folds, both in the inner and outer loop. the feature selection and hyperparametrization were performed simultaneously in the inner loop using a random search to maximize the accuracy. folds were balanced with respect to the outcome. table shows the range for feature selection and hyperparameters used. we analyzed the training and validation results. the model with the best fit was used for classification in the test database. the test database was not submitted to undersampling reflecting the prediction database as close as possible. finally, the cases were classified as confirmed or discarded, based on the predictions. we repeated the resampling of the databases, the training and the testing of the algorithms times to determine the % uncertainty intervals (ui), the median of accuracy, sensitivity and specificity, in addition to the final classification of cases. the underdiagnosis was analyzed by the difference between the median of the number of cases predicted by the model (incidence with nowcasting) and the number of the cases diagnosed by the public health department of florianópolis (incidences without nowcasting). this analysis was carried comparing the entire period and the period from may th to june nd , . the number of cases was also smoothed by a loess regression and the cumulative number, without and with nowcasting, were presented graphically by day of symptom onset. all analyzes were performed using the software r v. . . . anonymous scripts and databases are available at: https://github.com/lpgarcia /underdiagnosis_of_covid_ _cases_in_brazil . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint during the analysis period, individuals residing in florianópolis were reported as suspects for covid- . among all notified individuals, had a positive diagnosis, discarded diagnosis and had no diagnosis yet. the association of individual characteristics, health regions and displacement of people with confirmed or discarded cases can be seen at the table and at the supplement. the group of individuals with a positive result for sars-cov- had an earlier symptom onset date and later notification dates than individuals with negative results. there was also a difference regarding the distribution according to sex and race between the two groups. the average age among confirmed cases was higher than among discarded cases. there was a heterogeneous distribution of confirmed and discarded cases among table . the incidence without nowcasting throughout the entire period was new cases. with the nowcasting it was (ui % - ). at the period from may th and june nd , , the incidence without nowcasting was new cases and (ui % - ) with nowcasting (table ) . thus, the underdiagnosis was . % in the entire period and . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint . % in six days from the date of onset of symptoms to diagnosis at the moment of data extraction. the difference in the progression of new cases with and without nowcasting can be seen in figure . non-high-income-countries due to the magnitude of underreporting even so, the number of covid- cases has grown rapidly in brazil, and the country has the second largest number of cases in the world nowadays. the city of florianópolis has, so far, maintaining strong measures of social distance for long periods, however, may not be sustainable. these restrictions have already caused a slowdown in the world economy. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint research in non-high-income-countries shows an average % fall in income and % less in consumption expenses. strategies that combine more restrictive periods with moments of relaxation of these restrictions have been identified as ideal for countries with few resources. interleaving periods with greater restriction of social contact with periods of relaxation of the restrictions, but with an intensification of testing, case isolation, contact tracking and protection of vulnerable people, can allow a return to the minimum coexistence between people, and the resumption of economic production. florianópolis has carried out more than , tests so far, that is, more than tests per thousand inhabitants, more than times the national average. even with this greater number of tests, which should reduce the impact of underdiagnosis in the municipality, it is possible to observe a great disparity between the number of new cases confirmed by the municipality and the one predicted by the nowcasting. the underdiagnosis was more important in the proximal period of analysis. it shows the significance of underdiagnosis in the six days between the date of onset of symptoms and the date of diagnosis prior to the data collection. the underdiagnosis, probably produced by the mismatch between the onset of symptoms and the time of testing, may interfere with the current estimate and future projections of the disease incidence. in this context, the use of machine learning techniques can assist to enable adequate monitoring of the number of new cases and better decision making. the algorithm performance was better in detecting negative cases (specificity) than positive cases (sensitivity). in this sense, a greater number of false positives are expected compared to false negatives, and the interpretation of nowcasting should take this into account. a greater amount of individual data, such as data related to symptomatology, . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint can improve model sensitivity. besides, the association of sars-cov- infection rates with climate issues has been described. , the introduction of these data may also assist and should be considered in future studies. the present study demonstrated the underdiagnosis of cases of covid- in florianópolis. the underdiagnosis was more important in the period of six days before the data collection than in the entire period, corresponding to an artifact in the monitoring caused, probably, by the greater capacity in notifying than in the testing processes. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint funding this work has not received any financial support. thus, there is no funding interest in the study design, data collection, data analysis, data interpretation, writing of the manuscript, or in the decision to submit the manuscript for publication. the content is solely the responsibility of the authors and does not necessarily represent the official views of the funding sources. the authors have no competing interests. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint legend: the shaded area corresponds to the % uncertainty interval. who. coronavirus disease short-term forecasts of covid- deaths in multiple countries interim analysis of pandemic coronavirus disease (covid- ) and the sars-cov- virus in latin america and the caribbean: morbidity, mortality and molecular testing trends in the region. medrxiv characterization of the covid- pandemic and the impact of uncertainties, mitigation strategies, and underreporting of cases in south korea, italy, and brazil covid- coronavirus pandemic nowcasting by bayesian smoothing: a flexible, generalizable model for real-time epidemic tracking covid- : towards controlling of a pandemic nowcasting and forecasting the spread of covid- and healthcare demand in turkey, a modelling study. medrxiv impact of nonpharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand impact assessment of nonpharmaceutical interventions against coronavirus disease and influenza in hong kong: an observational study effect of non-pharmaceutical interventions to contain covid- in china implementation of mitigation strategies for communities with local covid- transmission. . . ihme covid- health service utilization forecasting t. forecasting covid- impact on hospital bed-days, icu-days, ventilator-days and deaths by us state in the next months. medrxiv real-time epidemic forecasting: challenges and opportunities. heal secur nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study regression analysis of censored and truncated data: estimating reporting-delay distributions and aids incidence from surveillance data real-time estimation of the risk of death from novel coronavirus (covid- ) infection: inference using exported cases nowcasting the number of new symptomatic cases during infectious disease outbreaks using constrained p-spline smoothing. epidemiology. . . review of "nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study the whole is greater than the sum of its parts: combining classical statistical and machine intelligence methods in medicine machine learning classifies cancer probabilistic machine learning and artificial intelligence machine learning: trends, perspectives, and prospects. science ( -) short-term forecasting covid- cumulative confirmed cases: perspectives for brazil. chaos, solitons & fractals; . . chimmula vkr, zhang l. time series forecasting of covid- transmission in canada using lstm networks random forests emergência de saúde pública de importância nacional pela doença pelo coronavírus . vigilância integrada de síndromes respiratórias agudas doença pelo coronavírus available from: ourworldindata.org. . . brasil. painel de casos de doença pelo coronavirus (covid- ) no brasil pelo ministério da saúde mathematical modelling of covid- transmission and mitigation strategies in the population of ontario, canada. cmaj; . . baldé mamt. fitting sir model to covid- pandemic data and comparative forecasting with machine learning the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study remuzzi a, remuzzi g. covid- and italy: what next? lancet temperature and latitude analysis to predict potential spread and seasonality for covid- incidence -entire period(ui %) incidence may th key: cord- - avoulan authors: raman, eshwara v.; shivnani, deepa title: pediatric airway surgeries in covid era date: - - journal: indian j otolaryngol head neck surg doi: . /s - - - sha: doc_id: cord_uid: avoulan to outline a set of recommendations on the management of pediatric cases who requiring airway surgery in the context of covid pandemic. a set of recommendations have been prepared based on national and international published scientific literature and recent updates on covid . these has been implemented in our tertiary care centre. due to the evolving nature of covid and existing knowledge gaps, these recommendations may have to be revised periodically. the incidence of covid is very low ( – %) in the pediatric age group with relatively good prognosis. pediatric airway surgeries should be restricted to emergency cases only. the decision of postponement of the surgical cases should be taken by the team of senior pediatric airway surgeons. flexible laryngoscopy should be avoided. foreign body cases should undergo a computed tomography scan to avoid diagnostic bronchoscopies. all the measures should be taken to prevent direct contact of aerosol so powered instruments should not be used unless mandatory. protective draping method should be adopted to prevent aerosol exposure. as paediatric airway surgeries are aerosol generating procedure where the risk of contracting covid by the surgeons and support staff is very high, we suggest recommendations to prevent the contact with infected aerosol. we assure these recommendations are easy to follow and can impact good quality outcome during this pandemic crisis. the number of positive or confirmed cases of covid are much lesser in paediatric age group as compared to adults [ ] . only % of patients were under years of age and . % under years of age out of , confirmed cases in a chinese series [ ] . in a korean series, . % of patients were under years of age [ ] . . % of patients were younger than out of , confirmed cases in italy [ ] . and, in the united states, only % are children out of confirmed cases were found [ ] . the prognosis of covid is good in paediatric population as no death has been reported so far in italy or china [ , [ ] [ ] [ ] . various publications and articles were reviewed to know about current clinical practice guidelines for covid . a set of recommendations has been prepared based on national and international published scientific literature and recent updates on covid . these have been implemented in our tertiary care center. due to the evolving nature of covid and existing knowledge gaps, these recommendations may have to be revised periodically. these recommendations have been made to help other pediatric airway surgeons to manage airway cases, however, this can be changed during this pandemic crisis though this can be changed later due to the evolving nature of covid and available evidence. as we know that airway surgeons are at high risk of contracting covid due to the high concentration of the virus in nasal cavity, nasopharynx and oropharynx. a precise set of recommendations has been documented here which is based on the available evidences and literature [ , [ ] [ ] [ ] [ ] [ ] on covid at present. there should be a designated team which is thorough with all safety precautions and must be able to perform these procedures with maximum efficiency and safety. pediatric airway surgeries should be restricted to emergency cases only. the decision of postponement of the surgical cases should be taken by the team of senior pediatric airway surgeons. flexible laryngoscopy should be avoided. foreign body cases should undergo ct scan to avoid diagnostic bronchoscopies. all the measures should be taken to prevent direct contact of aerosol so powered instruments should not be used unless mandatory. protective draping method should be adopted to prevent aerosol exposure. covid testing should be done prior to all the surgical cases. all cases irrespective of age with unknown covid status should be considered as positive. cases should be postponed if it is not urgent or can be manage conservatively. surgical mask should be provided to all children presenting with symptoms of upper airway infections. during examination of oral/nasal cavity in opd: ppe (personal protective equipment-n mask, water impermeable gown, disposable gloves, disposable cap, face shield and shoe covers) is highly recommended to prevent any aerosol contact while examining oral or nasal cavity of a child with unknown covid status. cases should be categorized as follow: elective, semi elective, semi urgent, urgent/emergency. only urgent or emergency cases should be taken on priority to prevent morbidity or mortality. all children and parents should undergo covid testing prior to the procedure and should be quarantined till discharged. designated core covid airway team of limited members who can perform airway procedures efficiently and quickly should be involved. experienced senior surgeons, anesthetist and senior staff should be involved in the procedure. complete case discussion should be done among the team prior to patient mobilization into the theatre and before donning to prevent communication problem while using ppe. precaution should be taken to prevent aerosol generation in all surgical cases. continuous suction system should be kept near the operative field. use of electro cautery, powered instrument, drills, coblation device, monopolar tip, microdebrider and laser should be avoided as much as possible. if those are required to be used then papr (powered air purifying respirator) mask should be used. specific surgical draping (see through plastic drape- fig. ) should be opted to cover the child in all aerosol generating procedures. fig. see-through plastic drape covering the endoscope to prevent aerosol generation while insertion or removal of the instruments extubation should be done under the plastic drape to prevent droplet contamination. flexible laryngoscopy should be avoided if child is stable. if performed, complete ppe should be worn. diagnostic flexible laryngoscopy for foreign body should be avoided. a ct scan can be taken for the same to confirm foreign body. flexible laryngoscopy can be performed with full ppe in case of repeated extubation failures. nasal cavity should be irrigated with betadine solution ( % betadine solution, dilute to . % in : ratio) prior to the procedure. care must be taken to sterilize the equipment properly after the use. direct laryngoscopy/bronchoscopy is considered as a highrisk procedure as it is an aerosol generator as well as prolonged open ventilation procedure. video laryngoscope should be preferred. sterile transparent/plastic drape/see through protective box with surgeon's arm holes (fig. ) should be covered over child's head to prevent aerosol/droplet contact. instrument handling should be done under the drape to prevent contact with droplets. continuous close suction should be kept in hypopharynx for continuous suctioning if required. avoid direct visualization of the surgical field. direct endoscopic evaluation should be done while performing bronchoscopy. optical instruments with endoscope and camera should be used in case of foreign body removal. removal of the instruments from larynx/bronchus should be done slowly to prevent droplets shedding in the surroundings. care must be taken to keep all the instrumentation under the plastic drape. drape should be removed with utmost care and with inward folding from all the margins to keep dirty/infected side in. preferable site should be or (operating room) rather than icu (intensive care unit). elective tracheostomy should be avoided as long as days * post intubation. once procedure is started the door of the theater should remain closed till the procedure gets over. * tracheostomy may be performed between and days in high prevalence areas to reduce the burden on ventilators and as early as days in patients with neuromuscular disease. only cuffed, non-fenestrated tracheostomy tubes should be used. one circulating sister should arrange heat moisture exchanger (hme) with viral filters beforehand. patient should be completely paralyzed to reduce risk of coughing. try to use surgical ties (if needed bipolar) rather than diathermy to prevent virus containing plumes. every effort should be made not to pierce the cuff of endotracheal tube while giving the tracheal incision. pause and inform anesthetist of readiness to open trachea. pre oxygenate with peep then stop ventilation and turn off flows before giving incision over trachea. clearly communicate to cease the ventilation before opening the trachea. attach syringe to tracheostomy cuff tube for instant inflation of cuff. immediately inflate tracheostomy tube cuff once tube is in place. insert inner tube with attached hme with prompt attachment of circuit. resume ventilation once circuit is connected. confirm positioning of tube with et co (avoid auscultation to prevent contamination of stethoscope). secure tube with ties and sutures. use appropriate dressing. immediately doffing at designated zone of disposal is mandatory. use only in line closed suction circuits all time. cuff should not be deflated. do not change the dressing unless frank signs of infection are noticed. delay first tube change to - days. wear full ppe (personal protective equipment). perform same sequence of pause ventilation before deflating the cuff. immediately insert the tube, inflate the cuff and connect the circuit. always use cuffed non-fenestrated tube unless patient is negative for covid . further tube change can be planned according to the patient's condition. cuff can be deflated if patient is found negative for covid . emergency and critical (button battery) foreign body should be removed to prevent complications. nose should be decongested with cotton pledgets rather than nasal anesthetic sprays. endoscopic assisted removal should be done. foreign body should be removed under the plastic see through cover to prevent droplets contact. open airway surgeries can be avoided if patient is tracheostomized. endoscopic procedures should be preferred in acute airway compromised cases over tracheostomy or open reconstruction surgeries. covid testing should be performed prior to open airway procedures. single stage procedure should be preferred over double stage to avoid tracheostomy and post tracheostomy care for longer duration. as paediatric airway surgeries are aerosol generated procedure where the risk of contracting covid by the surgeons and support staff is very high, we suggest recommendations to prevent the contact with infected aerosol. we assure those recommendations are easy to follow and can impact good quality outcome during this pandemic crisis. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) korean society for antimicrobial therapy, korean society for healthcare-associated infection control and prevention coronavirus disease (covid- ) in italy severe outcomes among patients with coronavirus disease (covid- )-united states epidemiological characteristics of pediatric patients with coronavirus disease in china chinese pediatric novel coronavirus study team et al ( ) sars-cov- infection in children novel coronavirus infection in hospitalized infants under year of age in china consensus statement: safe airway society principles of airway management and tracheal intubation specific to the covid- adult patient group covid- airway management principles tracheostomy guidance during the covid- pandemic asohns-asohns guidelines addressing the covid- pandemic. nd march publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgement we sincerely thank dr.bathi reddy for permitting us to take images of operative field while performing surgery. conflict of interest the authors declare that they have no conflict of interest.ethical approval institutional review board approval was obtained. key: cord- - a cbuh authors: boshoff, willem h. title: south african competition policy on excessive pricing and its relation to price gouging during the covid‐ disaster period date: - - journal: s afr j econ doi: . /saje. sha: doc_id: cord_uid: a cbuh the declaration of a state of national disaster in south africa, due to the covid‐ pandemic, was followed by excessive‐pricing regulations pertaining to certain consumer and medical products and services. the regulations and their application suggest an intertemporal benchmark to judge excessive pricing, deviating from previous practice. intertemporal comparisons assume a structural shift during covid‐ that changes competitive conditions, related to changes in consumer behaviour. such comparisons must also account for demand and cost changes. while the covid‐ regulations allow for cost‐based price increases, demand‐based increases are not explicitly accounted for, suggesting that the regulations are framed more generally as price‐gouging regulations. the differences between price‐gouging and excessive‐pricing benchmarks depends on the type of disaster‐period demand shock. they are similar following a transitory demand spike, provided sufficient time is allowed for dynamic price behaviour, but differ markedly when demand is elevated for the duration of the disaster period. applying simple cost‐based comparisons in recently concluded cases against smaller retailers are consistent with excessive pricing, given the presence of a demand spike. to the extent that these involve persistently higher demand, cases against wholesalers and larger retailers will be more complicated, as such demand must be reflected in competitive prices. extreme exogenous shocks to the economic system (due to war or natural disaster) may bring surges in demand for various goods and services and disruption to supply, often producing sharp acceleration in prices. during such times, regulations against price gouging -especially in relation to basic food and other consumer items -may form part of the policy response. accordingly, following declaration of a state of national disaster due to the covid- pandemic, the south african minister of trade, industry and competition published regulations pertaining to the pricing and supply of certain consumer and medical products and services during the disaster period. this market, competition practitioners seek to understand the relative size of the firm and the extent of competition (and potential competition). consequently, the definition of the relevant market (from both a product and geographic perspective) is a critical first step in the assessment of market power. it is therefore vital to assess how the covid- disaster may affect market definition, in order to assess the extent of its expected impact on market power. the thought experiment that underlies market definition in most competition jurisdictions, including in south africa, is the hypothetical monopolist (hm) test. the hm test focuses on demand-side substitutability, i.e. the substitutes available to buyers of the product or service offered by the firm under investigation. the analyst applying the test must consider when it would be profitable for the firm to impose a "small but significant non-transitory increase in price" (ssnip), assuming that the firm acts as a hypothetical monopolist (i.e. controls an ever-growing set of substitutes for its own product). the smallest possible set of substitutes for which a ssnip is profitable is considered the relevant market (together with the firm's own product): this set of substitutes significantly constrains the market power of the firm under investigation, as they are the key alternatives available to the customers of this firm. the covid- disaster can affect how analysts define markets, because of its impact on demand-side substitutability. as discussed later, changes in consumer behaviour during the disaster period -including increased search costs and/or higher valuation of particular product characteristics -may reduce demand-side substitutes and increase the unilateral pricing power of firms -at least in certain types of market (frank, ) . this would imply narrower product and/or geographical markets and, hence, increased market power. from the supply side, limitations on business operations may also delay or prevent entry of new competitors during the disaster period, which would further support arguments that market power may rise during the disaster period. indeed, competition authorities often view a lack of entry as an important condition for prosecuting excessive pricing (jenny, ) : entry may temper excessive pricing in the medium run, limiting enforcement costs (see ezrachi and gilo, ; mncube and ngobese, ; das nair and mondliwa, on how entry and investment considerations played out in seminal excessive-pricing cases in south africa). the covid- disaster may give rise to significant, though transitory, market power with no prospect of an immediate increase in competition: the short duration of the disaster period may limit the probability of entry. changes in the behaviour of consumers and competitors during the covid- disaster period may give rise to a temporary increase in market power. conventional competition policy, both in south africa and abroad, deals with market power as a long-run structural feature: economists view market power as the ability to influence the long-run level of mark-ups, i.e. the extent to which prices exceed cost in the long run. market changes resulting in higher long-run mark-ups, rather than transitory price increases, are usually the subject of interest. a substantial and sudden increase in price does not offer sufficient evidence of market power or its abuse. even under perfectly competitive conditions, a firm can always increase its price. however, within a short period of time, such a price increase will be met with consumer substitution to other firms, forcing the firm to reduce its price or exit the market. in the case of a positive, but firm-specific, demand shift, the resultant increase in price will draw heightened competition for customers, ultimately resulting in a demand shift away from the firm to its competitors. intense competition therefore ensures that firm-specific price increases, and hence margin increases, are transitory. the question, therefore, is whether a substantial or sudden increase in price can be sustained. substantial welfare losses obtain when competitive responses to such a firm-specific price increase are muted or slow. under these circumstances, a firm may be able to implement and maintain an increased price and, hence, margin. such ability, or market power, is evident from long-run equilibrium behaviour. the typical horizon over which competition economists study price behaviour is months and beyond, as this allows an assessment of the equilibrium relationship between price and its underlying determinants, including rivalry. the hypothetical monopolist test for market definition, in which the analyst considers whether a firm can maintain a small non-transitory price increase, therefore typically relies on a period of months or longer (see bishop and walker ( ) for an overview). a -month or longer horizon is also broadly consistent with the empirical evidence on the speed with which equilibrium between price, demand and cost is established in most markets. for example, south african evidence suggests that the median frequency of price changes for consumer prices is approximately months (ruch et al., ) . the duration of the disaster period may well exceed months. given the above, under normal circumstances, persistent pricing behaviour -including excessive pricingwould attract policy interest if it was maintained over this period. yet the covid- regulations seek to do more. the recently completed cases confirm that south african competition authorities focus on particularly short time horizons in assessing pricing conduct during the disaster period. the cases completed so far, discussed later in this paper, indicate a policy concern with price changes in the immediate weeks prior to, or following, the start of the disaster period. this short horizon may partly reflect, as mentioned, a concern that a firm under investigation may enjoy significantly enhanced market power due to changes in customer behaviour and limits on new entry during the covid- disaster. yet, as argued further in this paper, policymakers must still distinguish between anti-competitive conduct due to such market power and normal market behaviour -which involves price responding to demand and supply shifts. the assessment of price responses to demand and cost changes is not necessarily quicker or easier during disasters than in other cases. as discussed later, dynamic price adjustment involves partial and lagged responses to demand and cost changes. particular care may be required when assessing price behaviour during a disaster period. a sharp increase in price immediately following a disaster is often a response to significant uncertainty about demand and cost conditions. studies of price gouging following natural disasters suggest that short-run price spikes typically occur in the days immediately following a disaster, after which price returns to levels consistent with cost increases (wilson, ) . the uncertainty associated with the disaster period suggests that a short-term horizon must at least account for those initial weeks. a policy concern with short-term pricing power and conduct bears resemblance to price-gouging laws, which do not necessarily rely on market power considerations. the enforcement of the new excessive-pricing regulations have often been aimed at smaller firms, which would not traditionally be considered dominant (see the final section for a discussion of these cases). the focus on shorter horizons to assess market power has therefore facilitated an expanded scope of south african competition policy during the covid- disaster, especially in relation to excessive pricing. historically, excessive-pricing enforcement have been limited to highly selective enforcement against large corporates, including sasol and mittal, in markets with a particular policy history. this expanded scope, while capitalising on the institutional strengths of our competition authorities, also pushes the excessive-pricing provisions towards a more general price-gouging tool. as discussed in section , by august , two contested cases, involving excessive pricing during the disaster period, had been concluded in south africa -in addition to several non-contested cases. one case involved a small wholesaler of facemasks (babelegi) and another a large pharmacy group (dischem) for the pricing of its retail mask products. it is useful to briefly note the approach taken by the competition authorities in evaluating temporary market power in these cases, given the arguments presented here. in both cases, the competition commission, as plaintiff, did not engage in a rigorous market definition exercise, but instead argued that market power can be inferred from the conduct itself -effectively, this entails an argument that it is not possible to impose a large price increase if the relevant firm does not enjoy substantial market power. while the competition tribunal appears to have accepted this approach in their judgement in the babelegi case, the tribunal did engage in a market definition exercise in the later dischem judgement. arguably, the latter approach accords with the position advocated in this paper, as it recognises both that the disaster period may affect substitutability and that fact-based analysis is required. as argued earlier, merely observing a firm-specific price increase of a substantial size order does not offer conclusive proof of market power. furthermore, as explained subsequently, the nature of demand changes during the disaster period (whether they are sustained or involve transitory spikes) are critical to determining the appropriate standard for excessive pricing. in this regard, a rigorous market definition exercise, shedding light on the features of demand, can be useful. as argued in the introduction, in addition to changes in the assessment of market power, the covid- excessive-pricing regulations raises questions about the relevant standard for excessive pricing. the emphasis on cost-based increases in the new excessive-pricing regulations affects how competition authorities evaluate demand-based price increases. the simulations presented later in this paper show that price-gouging and excessive-pricing benchmarks may differ substantially if demand remains elevated over the disaster period, but may be similar when demand experiences only an initial disaster-period spike. in terms of section ( ) of the south african competition act (act of , as amended), a dominant firm is prohibited from charging its customers a price that is excessive. in the original formulation of the act, an excessive price was to be determined by reference to "economic value," a concept which was given content in subsequent case law. the amended act removes this concept, setting out the factors that should be considered in determining a benchmark competitive price and whether a price is deemed excessive relative to such competitive price. the factors identified in the act are: (i) price-cost margins and other profitability measures; (ii) prices charged by the respondent in other markets and over time; (iii) prices and profits of comparator firms in competitive markets; (iv) duration of pricing at that level; (v) structural characteristics of the relevant market, including market share, contestability, barriers to entry and past or current advantage that is not due to the respondent's own commercial efficiency or investment; and (vi) any regulations made by the minister of trade, industry and competition, "regarding the calculation and determination of an excessive price." following the declaration of a national disaster due to covid- , the minister relied on section ( )(f ) to introduce new regulations on determining excessive pricing, in selected industries, during the period of national disaster. these regulations define an excessive price increase as a price increase that (i) does not correspond to increases in costs or (ii) results in an increased markup relative to the average markup achieved over the threemonth period from december to february . the regulations apply to four broad groups of goods and services: (i) basic food and consumer items; (ii) emergency products and services; (iii) medical and hygiene supplies; and (iv) emergency clean-up products and services. these regulations, which pertain to competition policy, are the focus of this paper. even so, the regulations were accompanied by regulations, similar in form, pertaining to the south african consumer protection act (act of , amended). this act contains provisions against "unconscionable, unfair, unreasonable and unjust" prices. the regulations rely on section ( )(d) to define, for the period of national disaster, price increases as unfair if the price increase meets the same conditions as those for excessive pricing: it does not correspond to increase in cost or results in an increased markup when compared to the -month period prior to the disaster period. in contrast to the broad groups defined for excessive pricing, these regulations apply to a specified set of household products and medical services. subsequently, the minister tasked the south african competition authorities to implement both the competition-law and the consumer-law regulations. this is arguably a pragmatic decision to capitalise on the institutional strengths of the competition authorities. even so, the benchmark triggering competition-law investigations of excessive pricing differs from the benchmark triggering investigations of price gouging, which is the focus of the consumer-law-based regulations mentioned above. this distinction receives further attention in the subsequent sections. the principal economics concern in excessive-pricing cases is the determination of the competitive benchmark price. competition policy allows for imperfect competition, implying that a perfectly competitive price does not offer an appropriate benchmark. while allowing imperfect competition to affect pricing, competition policy against excessive pricing does not permit monopoly pricing. excessive-pricing provisions are specifically aimed at preventing firms from fully exploiting consumers' willingness to pay prices that would not prevail in a more competitive market. indeed, the challenge of determining an appropriate competitive benchmark is a key reason for the circumscribed application of excessive-pricing provisions (drexl, : ) . international competition policy practice features two approaches to obtaining competitive benchmark prices in excessive-pricing cases (gilo, ) . comparative benchmarking involves comparison of the market price under investigation with prices set by the firm under investigation, or similar firms, in other markets (gilo and spiegel, ) . to the extent that demand and supply conditions are similar to the market under investigation, so that the markets are broadly comparable but for the difference in competitive conditions, the latter would offer competitive benchmarks for the market under investigation. if this condition is met, significant price differences can be attributed to differences in competition. specifically, if prices are significantly higher in the market under investigation, it may be considered evidence of excessive pricing. an alternative approach entails cost-based benchmarking, which involves assessing a firm's cost structure -to determine average cost for the product under investigation -and identifying an appropriate profit margin. as discussed below, south africa has been a front-runner in developing this approach, with several well-known cases featuring sophisticated cost-benchmarking exercises. while comparative and cost-based benchmarks offer complementary approaches to obtaining competitive reference prices, a cost-based approach faces significant practical challenge. first, the determination of a firm's cost structure requires a bottom-up approach, including translating accounting costs into economic costs and allocating such costs to the product under investigation. misallocation, including of common costs, may upwardly bias the estimated competitive price. second, a cost-based approach faces the task of determining the profit margin that would apply if the market was "competitive." there are conditions under which a cost-based approach may be preferable, notably in the absence of comparator markets or firms. apart from these select cases, comparator approaches may well be preferable. comparator approaches can provide a range of price estimates, allowing practitioners to infer an upper bound for the competitive price (gilo, ) . besides, realised price exceeding this upper bound is a sufficient condition for its also exceeding a cost-based benchmark. it is useful to distinguish between comparator benchmarks based on spatial or rival comparisons and those based on intertemporal comparisons. spatial comparisons involve as reference prices those charged by the same or other firms in more competitive markets or to other classes of consumer in the market. similarly, rival comparisons rely on prices charged by direct rivals of the firm in the market under investigation. intertemporal comparisons -the focus of this paper and of the new regulations -involve a comparison of price in the period under investigation against prices charged in a different period. intertemporal approaches can involve either before-and-during analysis, in which a preceding period is used as the reference competitive period, or a during-and-after analysis, which relies on a subsequent period. intertemporal comparisons are preferable to spatial comparisons when seeking to identify benchmark competitive prices. it is often challenging to account for idiosyncratic features of demand, supply or structure in other markets and many of these features may be unobservable. this undermines the general utility of spatial comparisons in excessive-pricing investigations. price comparisons based on the same, rather than a different, market may largely avoid this problem (akman and garrod, ) . where the same market can be observed, under periods with different competitive dynamics, price differences between the periods can be related to competitive differences with relatively high confidence. consequently, where data availability permits, the preferred benchmark in excessive-pricing investigations should be the market under investigation over an earlier or subsequent time period. during the disaster period, rival price comparisons may be even less useful, especially if rivals have also increased prices during this time (when prices are strategic complements). similarly, spatial price comparisons may ignore that prices may have increased in other geographic locations because of similar increases in market power. preliminary indications from other jurisdictions suggest cases clustering in the same type of product market (e.g. face masks). therefore, for cases involving markets of a considerable geographic scope, international price comparisons, for examples, may be problematic. where the disaster period does not raise such additional concerns (perhaps in cases featuring local geographic markets, which allow price comparisons with, for example, nearby markets), intertemporal comparisons continue to offer more appropriate benchmarks for covid- -related investigations, for the reason discussed above. the utility of an intertemporal benchmark vitally depends on the presence of an exogenous structural shift that results in significantly different competitive conditions in the period under investigation compared to the benchmark period. gilo ( ) identifies three such structural shifts for excessive pricing benchmarking. first, the entry of new competitors can materially affect ex post competitive conditions. competition authorities can prove ex ante excessive pricing by comparing pre-and post-entry prices in the market. second, changes in regulation (specifically, deregulation) or related marketing strategies can affect competitive behaviour. especially in markets with some form of price regulation, which can be taken as attempts to establish more competitive prices, the regulated period may be an appropriate benchmark period. for example, recent excessive pricing cases in pharmaceutical markets relate to price increases following changes in branding in order to avoid regulation (see the recent flynn pharma limited and pfizer limited v the competition and markets authority ( ) case in the uk court of appeal). third, changes in consumer behaviour can affect competition and pricing. gilo ( ) notes an example related to consumer boycotts of cottage cheese in israel, where higher price elasticity during the boycott period resulted in significantly lower prices. © economic society of south africa anti-cartel policy also relies on structural shifts related to competition when identifying the price overcharge of cartels. cartel overcharge models compare prices during collusion with prices prior to or following collusion and depend critically on the presence of structural changes associated with the end (or onset) of cartels. such changes may include cartel enforcement or the entry of new competitors. the structural shifts on which intertemporal benchmarking relies must be clearly linked to changes in competitive conditions. the covid- regulations suggest that the national disaster is considered a structural shift that delineates a more competitive pre-disaster and less competitive disaster period, allowing identification of price changes with changes in competition. however, we note below that this shift is difficult to disentangle from demand and cost changes during this period. a further condition for intertemporal benchmarking, to provide comparable reference prices, is that the benchmark period must involve transactions under similar demand and cost conditions to those of transactions in the period under investigation (akman and garrod, : ) . consequently, one should distinguish between unconditional (which do not correct for the impact of demand or cost changes on price) and conditional comparisons. to the extent that demand and cost conditions are broadly similar, the former may be sufficient. in most cases, however, conditional comparisons are required. a conditional intertemporal benchmark price is a constructed, or counterfactual, price. it refers to the price that would have been charged if the benchmark period was characterised by the same demand or cost conditions prevalent in the period under investigation. the competition-economics literature has built up a significant body of work around the estimation of conditional intertemporal benchmarks relying on statistical analysis, to which we return later in this paper. the conditionality requirement represent a significant challenge when relying on intertemporal benchmarking in a market that is subject to significant demand or cost shocks. if the benchmark period does not contain periods during which prices have had to respond to large demand shocks or to significant increases in cost or cost uncertainty, it may be challenging to obtain comparable conditional prices. as discussed below, this should be considered at the core of the challenge facing economic analysis in covid- excessive-pricing investigations. south african competition policy has been a leader in the prosecution of excessive pricing. a number of high-profile cases -including cases involving mittal-harmony and sasol -raised important questions about the appropriate competitive benchmark. das nair and mondliwa ( ) in the seminal excessive-pricing cases in south africa, preferring cost-based benchmarks. roberts ( ) , das nair ( ) and calcagno and walker ( ) provide in-depth analyses of cost-based benchmarks in the seminal mittal-harmony case, highlighting the variety of challenges associated with cost and profit measurement. in the earlier cases, intertemporal comparisons would have been less useful, due to the unique competition problems associated with these cases, which involved the exploitation of market power over many years, with no discernible competitive period (e.g. see mondliwa and roberts ( ) on the sasol case and the role of state support). indeed, most comparator-based methods would have faced challenges in these cases, given that underlying demand conditions may not be similar in different markets (see murgatroyd and baker ( ) ). the covid- regulations require the assessment of excessive pricing during the national disaster period to rely on an intertemporal comparison of prices. as noted earlier, the regulations consist of two parts and breaching either part is sufficient to trigger prosecution. the first part of the regulations emphasise that price increases that do not correspond to cost increases will be considered excessive. an economics interpretation of this provision is that the correlation between price and cost during the disaster period must be unchanged relative to that of a prior benchmark period. retrospective analysis is essential, especially given that price may respond differently to different cost items and given the dynamic nature of price adjustment. the second part of the regulations emphasise that profit margins must be constant between the disaster period and a -month period preceding the disaster period, which would also imply an intertemporal benchmark approach. as discussed previously, an intertemporal benchmark for excessive pricing during the disaster period must meet two conditions. first, the disaster period must be associated with a structural shift that can be linked to changes in competitive conditions. second, the comparison must control sufficiently for demand and supply conditions to ensure that transactions between the two periods are comparable. crisis conditions can imbue smaller firms with market power (as is evident in the prosecution of smaller retailers during the disaster period) and enhance the market power enjoyed by larger firm or provide incentives for currently powerful firms to raise prices. one may advance two hypotheses concerning the impact of the covid- disaster on consumer behaviour. the first hypothesis is that the disaster period may significantly raise transaction costs, including search costs, for buyers of retail goods and services, which will reduce the set of substitutes that constrain the market power of firms. in particular, transaction costs may be higher (relative to the pre-disaster period) for at least two reasons. first, lockdown and other restrictions on movement during the disaster period may reduce the mobility of customers and their associated ability and willingness to respond to price increases. second, and related, health concerns may reduce willingness to enter alternative outlets in search of substitute products. consequently, market definitions are likely to be narrower. the second hypothesis is that the disaster period may significantly alter consumers' valuation of product characteristics for selected products, reducing or otherwise limiting the set of substitutes that would constrain the market power of firms selling those © economic society of south africa products. for example, whereas hand sanitisers with lower alcohol content may have been substitutable with other soaps or sanitisers, they may now be significant less substitutable. consequently, market definitions are likely to be narrower. these hypotheses are likely of greater import in retail markets, which would that the retrospective benchmark implied by the regulations may well be easier to sustain in the context of cases against retailers. even so, the empirical support for these hypotheses will have to be considered on a case-by-case basis, as part of the market definition exercise. for example, the increase in transaction costs may be weaker in high-income retail settings. firms offering online substitutes for the products of bricks-and-mortar retailers have rapidly expanded in a few weeks during the lockdown period, which undermines the argument that retailers of food and other essentials would gain much local power. the hypothesis may enjoy stronger support in low-income settings where consumers do not have online alternatives. in upstream wholesale and input markets, the first hypothesis may enjoy less support. search costs may be less significant in markets involving business-to-business transactions, where a significant portion of which may be governed by long-term contracts and involve negotiation with powerful buyers. in any event, many south african wholesale markets for food products do include a large number of smaller buyers, which already suggest market power for sellers. in contrast, the second hypothesis would imply changes in the inputs purchased by retailers, and may be supported in markets where upstream suppliers and manufacturers face weaker competition from competing suppliers due to supply disruption during the disaster period, especially in those markets where international suppliers compete. apart from changes in consumer behaviour, competition authorities may also rely on the impact on the impact of the regulations on the extent to and speed with which firms not currently active in the defined market may enter. in this regard, one hypothesis concerning the impact of the covid- disaster would involve that, in those industries facing fixed costs, the relatively short duration of the disaster period would limit entry and, hence, supply side substitutability. a lack of entry is a core consideration in excessive pricing investigations: competition practitioners are often willing to limit enforcement to high profile cases if, in the long run, entry is considered unlikely or ineffective. the very nature of the covid- disaster may limit the potential of new competitors to enter. even so, it would appear that there is no necessary link between the regulations and changes in competitive conditions. such a link may well be likely in particular retail settings, which would support the focus of the initial enforcement efforts on retailers. apart from relying on a structural shift impacting competitive conditions, intertemporal benchmarking requires similar demand and cost conditions to hold during the two periods, i.e. before and after the structural shift. as argued, markets may well be characterised by changes in demand and supply, making conditional comparisons essential. the first part of the new regulations require price comparisons between the periods to be conditional on cost changes. the second part of the regulations (which require profit margins to remain constant) also imply this conditionality: formally, the second part may be interpreted as defining a price increase as excessive if: with t the profit margin at time t. ε is a parameter to reflect the burden of proof, which eliminates the prosecution of profit differences of an appropriately small degree. frank ( ) argues for a safe harbour if the gap between price and cost does not exceed %, consistent with south african competition authorities' reliance on a % harbour on the basis of "economic value" in previous cases. as noted earlier, the amended act has removed reference to economic value. the above profit condition can be decomposed in its price and cost components as follows: re-arranged, the condition can be stated as: consequently, the second part of the regulations permits increases in price, relative to the price prevailing during the pre-disaster period, if the price increase is consistent with an increase in cost. intertemporal price comparisons that are conditional on cost must be sensitive to changes in the cost structure of firms during the disaster period. the disaster period may bring novel cost pressures from various sources. first, interruptions to supply chains can constrain production or sales and increase costs. for example, disruptions may arise in the distribution network (due to constraints at maritime ports and airports), upstream production or a reduction in available labour (including due to constraint in operating hours and new health regulations). second, search costs may increase significantly, if supply disruptions require firms to identify new suppliers and negotiate prices. for example, in the absence of favourable contract-based terms with existing suppliers, a firm may need to pay spot prices. suppliers may also invoke force majeure clauses, allowing the pass-on of higher costs to buyers. third, surges in demand may create capacity constraints, which may cause firms to incur additional costs. finally, firms may be required to incur additional costs related to hygiene and sanitisation. while a sensitivity to higher or additional costs may appear consistent with the new regulations, it is not immediately clear how demand-based price increases are to be treated. the regulations make no explicit reference to demand conditions. by focusing exclusively on cost-based price increases, the regulations identify as anti-competitive any price response to a demand-side factor during the disaster period. this approach effectively transforms excessive-pricing regulations into price-gouging regulations, which typically treat any demand-based price increase as "unfair." indeed, the consumer protection sections in the disaster-period regulations rely, similarly, on exclusive cost-based criteria to determine "unconscionable, unfair, unreasonable and unjust" prices: the excessive-pricing provisions are therefore similar to consumer-protection provisions (with the latter focused on a somewhat broader set of products and not requiring a finding of dominance). an exclusive cost-based focus is contrary to the objective of relying on retrospective prices to provide reference prices that can be considered competitive. indeed, motta and de streel ( ) note explicitly that a competitive price "is not only determined by supply-side factors (in particular the cost of production), but also by demand side factors (demand elasticity, willingness and ability to pay)." demand shifts in consumer income, © economic society of south africa prices of substitute products and demand seasonality may affect prices, even in competitive settings. expected normal demand features as a statistically significant factor in empirical models of price (see seminal work on manufacturing industries by maccini ( ) ). competition policy practice recognises that obtaining a comparable competitive price from the benchmark period requires accounting for both cost and demand differences between the periods (gilo, ) . international practice suggest that even cost-based benchmarks for excessive pricing must at least account for demand factors. for example, in its port of helsingborg decision, the european commission explicitly considered aspects of port customers' willingness to pay in applying cost-based tests. in a prominent attheraces appeals case in the united kingdom, excessive-pricing findings were overturned based on failure on the part of the authorities to account for customer valuation when assessing excessive pricing. indeed, motta and de streel ( ) use the requirement to at least account for demand as one reason for relying on multiple excessive-pricing tests. to the extent that south african policymakers have chosen to rely on competition policy to address pricing behaviour during the national disaster period, it follows that such policy must be sensitive to demand-based price increases as indicative of normal competitive behaviour. previous excessive pricing cases in south africa have attempted to grapple with the impact of demand: in the mittal case, cost and profit comparisons accounted for global steel demand conditions. however, these cases did not involve controlling for demand in the context of intertemporal benchmarking. an intertemporal benchmarking approach sensitive to demand would be consistent with south african policy approaches to damage determination in cartel cases -indeed, the proposed econometric approach in section draws heavily on damages models which typically control for both demand and supply factors when estimating the price overcharge of a cartel. for example, boshoff and van jaarsveld ( ), when estimating overcharges by the cement cartel, control for the impact of construction demand, including the world cup construction boom. therefore, an alternative interpretation of the new regulations would be that they may be concerned with prohibiting price changes due to exogenous changes in demand or supply, rather than adopting a narrow focus on the effects of market power and its abuse during the disaster period. a narrow focus does not imply that competition policy allows rational monopolists, or firms otherwise enjoying market power, to set prices at levels that fully exploit their customers' willingness to pay. the case law recognises that such a benchmark would impair the enforcement of excessive-pricing policy, as monopoly pricing is its primary concern (gilo, ). even so, international legal practice affirms the need to account for demand-side factors when evaluating excessive pricing: even after the competition authority has decided to enforce an excessive-pricing prohibition on a dominant firm, the recent flynn pharma/pfizer case in the united kingdom confirms that a respondent must be given an opportunity to show that the price it charges is justified, at least partly in relation to the consumer benefit of the product. an intertemporal benchmark overcomes the difficult problem of accounting for demand shifts and consumer benefit, while disallowing full exploitation of willingness-to-pay. intertemporal comparisons allow for price changes due to changes in demand-shift variables between the period under investigation and the benchmark period, but not for price changes due to structural changes in demand (which are the sources of market power, as discussed earlier). this advantage of the intertemporal benchmark is even more important in the context of covid- cases, where changes in the willingness-to-pay is at the heart of excessive-pricing investigations: as argued earlier, changes in the willingness-to-pay underlies increased market power and its potential abuse during the disaster period. a consideration of the influence of demand shifts on price may also be important to an assessment of cost. "demand"-related variables, such as measures of unfilled orders and of finished-goods inventories, may be significant drivers of price, either because they shift demand or, importantly, affect the cost function of firms. the effects differ depending on the type of production in which the firm is involved. firms that produce to stock are primarily concerned with goods inventories, maintaining a particular level of stock (say, at retail outlets) depending on anticipated demand. firms involved in production to order are concerned with responding to demand, keeping delivery lags minimal. in production-to-order, a large order backlog -due to a surge in demand -may permit production smoothing (and lower costs), while larger inventories increase holding costs (including storage and insurance costs) in production-to-stock markets. case-by-case assessment of the mode of production is therefore required. treating demand-based price increases during the disaster period as necessarily anticompetitive undermines the consistency introduced by retrospective benchmarking: it is not clear why price-cost relationships in the past should be considered an appropriate guide for the present, while price-demand relationships are not. subsequent sections in this paper explore and contrast such a price-gouging view against the standard excessive-pricing view. we show that there are conditions where economists may discount demand-based price spikes, as long as average prices over a sufficient period is considered. the excessive-pricing regulations in south africa also specify the period (december to february ) applicable in determining the intertemporal benchmark. the literature on intertemporal benchmarks refrains from linking such benchmarks to particular time frames. a benchmark price is the average price over a competitive period of suitable duration, where such duration should reflect a balance between obtaining a thorough assessment of price setting and minimising the risk of structural or other factors contaminating the assessment. as far as the former requirement is concerned, an interval of sufficient duration is required in order to assess the dynamic nature of price, cost and demand as well as their respective relationships. from the perspective of the latter requirement for structural stability, an interval of sufficiently short duration is required to ensure that market conditions approximate those prevailing during the period under investigation. the trade-off between a choice © economic society of south africa of duration that enables a complete assessment and one that limits structural changes is heavily dependent on the frequency of price changes and the availability of data. lowfrequency price changes (quarterly and lower) would imply that an interval of a longer duration is required, while the availability of data may also result in a duration less than the ideal. even where price changes are of a higher frequency, it may be necessary to look further back before the december-february period, when historically subdued demand and cost increases, seasonal fluctuations or other idiosyncratic price behaviour (including special discounts) characterise the market. a short reference period may be particularly problematic in retail setting relying on promotional pricing, where a return to normal pricing coinciding with the disaster period may lead to incorrect inferences of unjustifiable price increases. furthermore, in relation to demand spikes, it may be particularly important to consider past responses to periods of unexpected and large demand (or cost) shocks. consequently, a three-month period is not necessarily appropriate for the estimation of underlying elasticities, even for prices set at a relatively high frequency. this is true whether or not actual econometric analysis is employed: even in those instances where authorities rely on a qualitative analysis of price elasticity, it is preferable to draw on the experience over a longer period to infer average behaviour. as shown in the case overview presented later in this paper, it is not clear to what extent competition authorities have limited their analysis to the three-month horizon. the covid- regulations require a conditional intertemporal benchmark, which involves a comparison of prices during the period under investigation (disaster period) with those of a benchmark period (pre-disaster period), after controlling for both demand and cost differences between the periods. the literature on cartel damages offers an econometric methodology for obtaining benchmark prices, using reduced-form regression. the following sections discuss this econometric methodology, as applied to conventional excessive-pricing and (for a comparative view) price-gouging investigations. as shown, the distinction between conventional excessive-pricing and price-gouging benchmarks matters for covid- excessive-pricing investigations. intertemporal benchmarking requires conditional comparison of prices in the benchmark period (which we have argued is considered more competitive) relative to those in the period under investigation (which, due to a structural shift, is now less competitive). in the context of covid- , conditional comparisons would be between the disaster period (the period under investigation) and the ex ante period (the competitive benchmark period). conditional comparisons discount price differences that are due to cost and demand differences. econometric modelling can assist in discounting demand and cost differences. benchmarking requires a study of reduced-form price elasticities, with respect to both demand and cost, during the benchmark period (nieberding, ; rubinfeld, ) . these elasticities, applied to demand and cost factors during the period under investigation, allows a forecast of the price that the firm would have charged if it had still faced the pre-disaster competitive conditions. the cartel damages literature has long relied on such econometric modelling to achieve benchmarking (rubinfeld, ) . price overcharge during collusion is the basis of cartel damages and is typically determined by comparing prices during the cartel period with prices during a more competitive period, preceding or following the cartel period. intertemporal benchmarking in excessive pricing investigations face a similar problem to determine the 'overcharge' relative to the price in a competitive period. as explained below, the cartel-damages literature offers a reduced-form econometric methodology for estimating competitive benchmark prices in excessive-pricing investigations. practical considerations may prevent the explicit use of econometric analysis, especially in the context of excessive pricing investigations under the new regulations (with their truncated adjudication periods). but even where econometric modelling is not possible, the exposition in this section elucidates key empirical issues in the assessment of excessive pricing. the econometric methodology provides a guide for an empirical strategy based on qualitative analysis or more rudimentary quantitative techniques. even if econometric analysis is feasible, it may be preferable to rely on multiple approaches in order to triangulate estimates. econometric analysis allows an assessment of the dynamic relationships between cost, demand and price. menu costs (including the cost of re-negotiating prices or changing list prices) may lead firms to limit the response of price to small cost changes and gradually increase prices over time. prices may also increase at different time points for different customers, depending on contractual arrangements. similarly, prices may not respond to short-term demand or cost fluctuations immediately, as firms seek to smooth production over time to avoid costs related to varying production. dynamic econometric models capture these effects. furthermore, incorporating lagged price terms in dynamic models also allows controlling for the influence of non-observable information. for these reasons, the cartel-damages literature relies on dynamic price regressions (for a recent summary, see boswijk et al. ( ) , for south african applications see govinda et al. ( ) , mncube ( ) and boshoff ( ) ). consider a reduced-form model of price during the pre-disaster period (t = , … , t , with t the end of the period): where p is the price of the product, d is a demand shifter and c is a cost shifter, with t ∼  ( , ). the autoregressive distributed lag (ardl) specification reflects the dynamic adjustment of price, cost and demand, allowing for both contemporaneous and lagged price adjustment. intertemporal benchmarking relies on the parameter estimates from ( ) to obtain dynamic price forecasts p t during the disaster period (t = t + , … , t ): see boshoff ( ) for a defence of limited-information quantitative tools in competition analysis, with applications to south african competition policy. ( ) these forecasts constitute the competitive benchmark prices, applicable to the disaster period. under this approach, price is excessive to the extent that it deviates from the benchmark level suggested by demand and cost factors. applied to the covid- disaster, the assumption is that the deviation of the actual and benchmark price during the disaster period is a reflection of a change in competitive conditions due to the crisis, the sources of which must be verified (and relate to changes in consumer behaviour and lower likelihood of new entry). conventional excessive-pricing investigations focus on pricing due to a lack of competition after controlling for non-competition factors -specifically, demand and cost factors. in contrast, price-gouging cases emphasise price responses to demand as undesirable. as noted earlier, price gouging laws differ across a variety of jurisdictions (including within the united states), but the overarching aim is to keep prices as close to their pre-disaster behaviour as possible. at the same time, it is often accepted that prices may vary for cost-related reasons. research following hurricane katrina in the united states reject a hypothesis of price gouging, with the evidence indicating that cost explains most of the price increases following the disaster, at least if one excludes the first days immediately following the disaster (see montgomery et al., ; wilson, ) . a version tolerant of market forces would also allow for a price response to "normal" demand. therefore, a generous benchmark price for the purposes of assessing price gouging would reflect cost as well as "normal" demand, i.e. demand neutral to a disaster-period surge. price-gouging counterfactual prices (p * ), neutral to a demand surge during the disaster period (t = t + , … , t ), would be: where d t is a forecast of the demand-shift variable, based on pre-disaster behaviour. as demonstrated by the following simulation example, the nature of the disaster-period demand surge will determine the extent to which a price-gouging benchmark in ( ) differs from an excessive-pricing benchmark in ( ). price-gouging laws are primarily aimed at muting price responses in the immediate runup to and aftermath of a natural disaster. demand spikes, due to panic buying, often put extreme pressure on prices. some of the initial cases investigated under the new regulations in south africa reflect such a spike in demand. these include retail cases involving an alternative approach involves estimating equation ( ) over both the pre-disaster and disaster period, but adding a disaster-period dummy variable as well as a set of variables capturing interactions between the dummy variable and the various demand and supply terms. the sum of the coefficients on these additional variables then measure the extent to which price deviates from the predicted pre-disaster level. there is an extensive literature on the conditions for equivalence between forecasting and dummy-variable approaches, with the latter potentially improving forecast accuracy by increasing sample size, but the former allowing a more flexible treatment of parameter constancy (see, for example, mccrary and rubinfeld, ) . boshoff and van jaarsveld ( ) discuss the impact of time-series properties on the equivalence of the two approaches. ( ) panic purchases of hand sanitiser and, for the smaller retailer cases, masks at the start of the lockdown period. yet not all disaster-period demand changes take this particular form. a number of cases involve consistently elevated demand, including demand for masks from manufacturers and larger retailers. a distinction between cases involving demand spikes and cases involving persistently elevated demand matter for the determination of average benchmark prices. the primary aim of the forecasts in ( ) and ( ) is to estimate an average price. average prices, calculated over a sufficiently long period, reflect long-run equilibrium prices. as argued earlier in this paper, long-run equilibrium prices are the traditional focus of competition policy. short-run fluctuations are important in relation to how they contribute to the maintenance of long-run equilibrium. for example, nieberding ( ) studies how a short-run model, specifically a reduced-form error-correction model of price, can yield insight into the long-run effect of anti-competitive behaviour. in the absence of trending behaviour in prices, as exhibited in the example below, dummy-variable methods are often used as a substitute for forecasting methods. these dummy-variable methods yield an estimate of the average price increase for the period under investigation, rather than price forecasts for each date in the period. in the presence of trending behaviour, where dummy-variable methods are less useful, one can infer an average price increase based on the individual date forecasts. a disaster-period demand spike may produce a short-term price increase that does not change the excessive-pricing benchmark significantly, resulting in a benchmark quite similar to that of price-gouging. in contrast, elevated demand may well raise the average benchmark prices obtained from ( ), resulting in a significant difference between the price-gouging and excessive-pricing benchmarks. consider a model based on ( ), with the following parameterisation for the pre-disaster period t = , …, : where cost evolves as follows: and demand as follows: the chosen parameterisation ensures trending behaviour in both costs and demand, with ( ) ensuring that demand shocks are not permanent -an important feature for the subsequent simulation exercise. suppose that cost remains unchanged. consider two possible demand processes for the disaster period. first, suppose that the disaster period, t = , …, , is characterised by a demand shock of size at the start and demand subsequently returns to its pre-disaster trajectory: ( ) this is not key to the result, but ensures that disaster-period price behaviour can be linked to demand in the particular simulation exercise presented in this paper. second, suppose that demand is elevated, by size , for the duration of the disaster period: with t = for t = , …, fig. shows prices during the pre-disaster period together with a set of benchmark prices for the disaster period. this figure does not include any realised price for the disaster period, in order to focus attention on the various benchmarks. in particular, fig. shows the benchmark price under a price-gouging law (p * , based on equation ( )). as discussed earlier, while this particular price-gouging benchmark makes no allowance for abnormal demand during the disaster period, it does reflect price-responses to the normal trajectory of demand. given that we have not allowed for cost increases in this simulation, this benchmark behaves similar to the pre-disaster price. furthermore, fig. shows two excessive-pricing benchmarks (p, based on equation ( )), when disaster-period demand follows the spike defined by ( ) and when it is elevated for the entire period, as defined by ( ). the excessive-pricing and price-gouging benchmarks are similar in the case of a disaster-period demand spike: given a period of sufficient duration, average price increases predicted by the two benchmarks are similar. the benchmarks differ substantially when demand is persistently elevated over the disaster period. in these cases, excessive pricing sets a more lenient benchmark, to allow the demand shift to be reflected in prices. without a sufficient period to account for the dynamic behaviour of price, a transitory price response to a demand spike would be easily confused with a price response to elevated demand. even for a transitory shock limited to period , the lagged response of price generates increases until period and elevated levels (relative to the price-gouging benchmark) for several periods afterwards. because of this dynamic behaviour, and the impact of idiosyncratic demand and supply shocks in any one period, interval forecastswhich involves average forecasts over a particular horizon -are superior to point forecasts. the duration of such an interval is an empirical matter based on an understanding of price-demand dynamics in the case at hand. fig. elucidates this point, focusing exclusively on a demand spike at the start of the disaster period. the graph shows two realised price series over the disaster period (denoted case and case ), together with the relevant excessive-pricing and price-gouging benchmarks. as shown , only when considering the average of the price forecasts, can case (competitively neutral) be distinguished from case (anti-competitive). to the extent that the spike in prices does not persist in case , the average price will not be in excess of the price-gouging or excessive pricing benchmarks. only in case , where it can be shown that the price was persistently higher than the benchmarks, despite the demand spike having subsided, can it be argued that excessive pricing has taken place. while a failure to rely on a longer interval in assessing excessive pricing may raise the risk of over-enforcement in some cases, it may raise the risk of under-enforcement in other cases. consider a variant of case , where the realised price increase is muted, such that it falls below the excessive pricing benchmark, but does not return to its original level. a hasty investigation, with a limited interval following the demand spike, will not flag this problematic case, implying under-enforcement. figs and suggest that an excessive-pricing and a comparatively generous price-gouging benchmark will deliver similar price forecasts in the presence of demand spikes, provided a sufficient interval of assessment. however, if demand is persistently elevated during the disaster period, fig. suggests that the benchmarks produce markedly different price forecasts. as shown below, reliance on a price-gouging benchmark would flag a further set of potentially anti-competitive cases, which would not ordinarily attract scrutiny under an excessive-pricing benchmark. similar to figs and shows two realised prices, together with the relevant excessive-pricing and price-gouging benchmarks. the first realised price (denoted the "simple case") exceeds the higher excessive-pricing benchmark and would attract an investigation under the standard approach. the second realised price (denoted the "harder case") falls between the two benchmarks. judging this price as excessive requires price responses to elevated demand during the crisis period to be judged differently to price responses to "normal" demand during the pre-disaster period. as argued, competition authorities would find it hard to justify that the elasticity of competitive prices with respect to demand must necessarily be lower during disaster periods. the simulation exercise offers two insights for enforcement against excessive pricing during the covid- disaster period. first, it is not necessarily inappropriate for excessive-pricing policy to be pursued as a price-gouging tool in the presence of cases involving demand spikes. price-gouging and excessive-pricing benchmarks produce similar price forecasts, provided that a sufficient forecast interval is allowed. competition practitioners must however (i) reach a sufficient understanding of the nature of the demand response in any particular case and (ii) ensure that an interval of appropriate duration is allowed, again based on a case-specific understanding of the dynamics of price behaviour. such an approach would be consistent with the general approach to price gouging elsewhere. wilson ( ) documents various instances over the past four hundred years where natural disasters gave rise to claims of significant price increases. older examples include increases in fish prices following the great fire in london (+ %) and increases in transport wagon prices following the san francisco earthquake in (+ %). contemporary examples include claims of gasoline price gouging following hurricane katrina (+ % on average) and several other hurricanes as well as claims of exorbitant price increases in building supplies and services following the christchurch earthquakes in new zealand. wilson ( ) documents the empirical record on these price increases, which suggests that price spikes -where confirmed -are often limited to shorter intervals. in many of these modern examples, there has been strong political support for policy action, although wilson has noted that the short time horizons have usually limited concrete interventions. second, if the demand evaluation suggests elevated demand -rather than a mere demand spike -and if price falls between the excessive-pricing and price-gouging benchmarks, it is critical to justify why price responses to abnormally high demand over a sustained period -i.e. to elevated demand beyond that predicted by its pre-disaster trajectory -must be treated differently. this justification ensures that the focus of excessive-pricing policy -even when applied in disaster periods -remains on market-powerrelated abuses and harm to competition. it is also consistent with the earlier arguments concerning changes in market power as the basis for an intertemporal benchmark. while our simulation exercise also emphasises the importance of an interval of sufficient duration, the requirement for a longer interval need not be incompatible with the covid- policy aim of rapidly prosecuting abuses of temporary market power. all that is required is a sufficient period for equilibrium adjustment, as is evident from the brief discussion of completed cases that follows. since march , south african competition authorities have been active in pursuing excessive-pricing cases based on the new regulations. to consider the extent to which enforcement has been sensitive to the distinction between demand spikes and elevated demand -and the associated need for a sufficient interval -we distinguish between cases against smaller firms in narrow geographic markets (the majority of cases) and cases against larger firms that meet the traditional requirements for dominance. settlement agreements were concluded with several small respondents in the first months of the disaster period. table shows agreements concluded until may , with subsequent settlements following similar patterns. the cases involve small retailers (mostly individual pharmacies) facing a demand spike for, or panic buying of, either hand sanitiser or face masks at the start of the national disaster period. even though market-wide demand for hand sanitiser or face masks may remain elevated for the duration cedar pharmaceuticals t/a bel-kem co may hand sanitisers mark-up not reported but found in contravention of the disaster period, the initial spike in demand at these individual retailers is likely to have subsided significantly and rapidly, as new supply became quickly available during the course of march and april. the benchmark relied upon was not always an intertemporal benchmark. a selection of the cases involve firms selling hand sanitiser or face masks for the first time. it is not clear from the limited information available in the published tribunal orders on which benchmark the competition commission had relied in these cases, given the absence of retrospective prices or margins. the remainder of the cases appear to apply an intertemporal comparison. furthermore, in these cases, the requirements set down by the simulation exercises appear to have been broadly met. based on the limited information available from the tribunal orders, it appears that price responses to demand and cost were relatively quick in these cases, implying a shorter interval for dynamic price adjustment. in addition, it would have been relatively clear in these cases that the demand spike had subsided after a few weeks. consequently, these cases involve a reasonably straightforward judgement of whether price continued to exceed the higher level justified by the initial demand spike and, hence, whether the price is excessive. in this sense, these cases appear to meet the requirements set down by the simulation exercise. in addition to the cases settled by consent agreement, the authorities have also completed a contested case, involving babelegi workwear overall manufacturers & industrial supplies cc (babelegi), a small wholesaler, for excessive pricing of its face masks (case number cr apr ). in this case, the tribunal noted price increases from january to march in comparison to prices in december (see also frank, ) , confirming its reliance on an intertemporal benchmark. in relation to the earlier arguments (see section . ) concerning the appropriate length of the benchmark period, it is noteworthy that the competition authorities and the tribunal did not consider themselves bound to rely on prices from the three months preceding the disaster period for benchmarking purposes: the babelegi complaint focused on pricing behaviour prior to the start of the disaster period. indeed, in its judgement against babelegi, the tribunal emphasised the substantial differences in calculated profit and price increases for alternative benchmark periods. the tribunal found that babelegi's price increases were not consistent with cost increases. furthermore, the tribunal noted that the price increases occurred prior to the cost increases, which suggests that it did not consider demand fluctuations as a driver of competitive pricing. given that this case involves a wholesaler supplying to various clients, demand may well have remained elevated (compared to pre-disaster levels) after the initial spike in demand, which would require further analysis, similar to the final case against dis-chem, noted below. at the time of writing, babelegi's appeal against the decision was yet to be heard by the competition appeals court. in keeping with its standard practice of prosecuting large firms, the commission also brought a case against dis-chem, a large pharmacy group in south africa, for price increases between % and % on some of its surgical face mask products (case number cr apr ). again, the implications of our earlier simulation evidence suggest that the commission should have considered whether dis-chem faced sustained higher demand for its face masks, rather than a mere spike. it is plausible that dis-chem, as a more sophisticated buyer than the individual pharmacies involved in the consent agreements, would not have acquired substantially more face masks, without judging demand to be elevated over this period. however, in its judgement, the tribunal did not consider whether demand was permanently elevated. there was significant debate during the trial about the appropriate horizon for the long run, especially in light of societal pressure for swift policy action. yet a requirement to ascertain whether increased demand is persistent does not necessarily, or always, imply a long lag for policy action. sales and sales orders, for example, may be used to determine the persistence of increased demand in a matter of weeks. if the demand increase is confirmed to be transitory, it will be comparatively easy to assess whether price increases have also been transitory, so that it would be possible to prosecute short-term price increases. eon the other hand, to the extent that the babelegi and dis-chem cases are characterised by elevated demand, rather than transitory demand spikes, the benchmark for excessive pricing in such cases cannot be a price-gouging benchmark (i.e. one predominantly based on cost). the brief overview of completed excessive-pricing cases during the disaster period suggests that the policy decision to implement a reverse legal onus (on respondents), and to accelerate adjudication of excessive pricing cases, may be merited in those cases dealing with spikes in demand. these circumstances are also closer to the ones contemplated in traditional price-gouging policy. cases involving sustained higher demand during the disaster period, however, requires an approach closer to that employed in conventional cases. in such cases, the elasticity of price, with respect to abnormal demand, must be better understood, including to what extent a different competitive reaction is to be expected. the subsequent judgements may clarify matters. during times of extreme economic disruption, prices of food and other essential goods and services may rise significantly. such price increases, and their accompanying consumer welfare effects, have often attracted policy intervention. periods of war and natural disasters are often associated with various forms of price control, as the introduction and enforcement of price-gouging laws and regulations in various jurisdictions have shown. as part of their response to the covid- disaster, south african policymakers have elected to rely -predominantly -on competition policy to deal with price increases. south african policymakers introduced excessive-pricing regulations applicable during the period of national disaster, which prohibit price increases that do not correspond to cost increases or which result in changes in profit margins compared to the pre-disaster period. a focus on competition policy, as an expansive tool to address price gouging and other pricing concerns, is novel in the international context. historically, the prosecution of excessive pricing -both in south africa and abroad -is limited to select high-profile cases, partly because of the complexity of analysis required. in contrast, the re-allocation of resources within the south african competition authorities have allowed expansive screening of complaints and prosecution during the disaster period. an expanded enforcement effort raises the question of whether covid- -related excessive-pricing investigations involve less complex analysis. the complexity of analysis in excessive-pricing investigations is, too a significant extent, determined by the relevant benchmark used in judging whether prices are excessive. in this regard, this paper delivers five key insights. first, the paper argues that the covid- excessive-pricing regulations introduce an intertemporal benchmark for the evaluation of excessive pricing. the regulations require a comparison of prices during the period under investigation (the disaster period) with prices during the pre-disaster period, which are considered to represent a more competitive period. international experience, and the associated economics literature, support intemporal benchmarks as preferable to other benchmarks, including cost-based benchmarks or comparisons against prices in other geographic markets: the data for intertemporal comparisons are easier to obtain and avoid difficult accounting cost and profit calculation exercises. second, the paper argues that the basis of an intertemporal assessment is the presence of a structural shift that causes a change in competitive conditions. in covid- cases, this structural shift must be shown to be related to either or both changes in consumer behaviour and weakened entry during the disaster period. this underlines the importance of the market power assessment, which should precede the pricing analysis. while the consent agreements listed earlier often contain references to "temporal market power" during the disaster, the extent of case-specific analysis is unclear: the consent agreements rely heavily on an approach that views the ability to implement excessive price increases a sufficient condition for possessing market power. this behavioural view of market power requires further academic scrutiny. third, and importantly, the paper highlights that the structural shift associated with the covid- crisis is also associated with a surge in demand and/or cost. the paper emphasises that price responses to demand or cost surges are not incompatible with competitive behaviour, as such surges may cause prices to rise significantly even in competitive markets. consequently, intertemporal comparisons must always be conditional on demand and cost drivers. the covid- regulations do not appear to reflect this position: while allowance is made for cost-based price increases during the disaster period, demand-based increases receive no explicit attention. in this sense, covid- excessive-pricing regulations may be interpreted as price-gouging regulations: price-gouging policy does not typically allow for demand-based price increases following a natural disaster, though it often allows for cost-based increases. fourth, the paper relies on an econometric methodology, drawn from the empirical cartel literature, to study the differences and similarities of a price-gouging and a standard excessive-pricing benchmark. using simulations, the paper shows that the nature of the disaster-period demand surge determines the extent to which a price-gouging benchmark differs from a standard excessive-pricing benchmark. provided that a sufficient period is allowed for calculating benchmark prices, the two benchmarks deliver similar average prices following a transitory demand spike: if competition authorities allow a sufficient time period for price responses to demand and cost changes, the distinction between price gouging and excessive pricing becomes less relevant. a sufficient time period allows clear distinction between cases involving a temporary upshot in price, which subsequently returns to the benchmark level, and cases involving sustained price increases over a longer period. the former are likely "normal" market reactions to uncertainty, whereas the latter should potential attract antitrust scrutiny. the two benchmarks differ substantially if demand is permanently elevated over the disaster period. again, for those cases involving sustained price increases beyond the standard benchmark, excessive pricing will be easy to identify. but, in the case of elevated demand, price increases below the standard excessive-pricing benchmark, but above the price-gouging benchmark, will present particular difficulties. viewing such prices as excessive implies that price responses to demand during the disaster period are viewed different to those in the pre-disaster period. while one portion of the literature supports an assumption that price competition may be heavier during periods of high demand, other evidence points to the contrary. this requires case-by-case evaluation. in practice, such evaluation need not involve econometric analysis, and it is preferable to employ multiple analytical approaches. but even qualitative analysis will have to pay careful attention to the impact of demand and cost drivers on price. fifth, the paper studies the extent to which the completed covid- cases in south africa (finalised in april and may ) have followed the principles elucidated by the simulation exercise. these cases all involve smaller retailers (often pharmacies) selling hand sanitiser and face masks, which would not ordinarily attract antitrust scrutiny. for those retailers that have been selling these items pre-disaster, the approach adopted (as described in the consent agreements) appears largely consistent with the guidance from the simulation results, to the extent that these cases involve retailers dealing with a demand spike. even so, the intertemporal benchmark has not been consistently applied in those cases where firms introduced a new product. furthermore, for the on-going cases involving especially larger retailers (dis-chem), ignoring elevated demand over the disaster period raises significant challenges for the economic analysis. if competition authorities treat pricing behaviour without acknowledging structurally higher demand for the duration of the disaster period they may significantly impair the functioning of markets, especially if they lead to shortages. in sum, a greater policy emphasis on intertemporal benchmarking in excessive-pricing cases is a welcome development. it is particularly useful in the context of the covid- disaster, where the disaster may provide a structural shift directly linked to market power. the challenge, however, lies with obtaining case-specific evidence of such market power and with understanding the nature of the demand shock associated with the disaster. especially the latter will be important in justifying using excessive-pricing cases as price gouging tools against smaller players. the role of a sufficient time period, even if much shorter than the traditional horizon, will be critical in this regard, to avoid both over-and under-enforcement errors. one of the critical remaining issues concerns the impact of demand spikes on vulnerable households, especially in those cases where the horizon of the price spike is too short to support competition policy intervention. the older literature on price gouging suggests that policymakers can support households (and, simultaneously, maintain functioning markets) by ensuring that supply chains remain operative. functioning supply chains ensures quicker supply responses to any demand increase. in this regard, the relatively limited price increases in food during the first months of the disaster period can be linked to pro-active management of supply chains, in part due to coordination facilitated by government. in some instances, however, supply coordination may not be sufficient and other forms of government support -such as the increased income support provided to poorer households -may be required. when are excessive prices unfair economics of e.c. competition law: concepts, application and measurement conceptual and empirical advances in antitrust market definition with application to south african competition policy recurrent collusion: cartel episodes and overcharges in the south african cement market cartel dating excessive pricing: towards clarity and economic coherence measuring excessive pricing as an abuse of dominance -an assessment of the criteria used in the harmony gold/mittal steel complaint excessive pricing under the spotlight: what is a competitive price competition law and economic regulation in southern africa on the (a)political character of the economic approach to competition law excessive pricing, entry, assessment and investment: lessons from the mittal litigation case c / / & . available at prohibiting monopolistic excessive pricing during the time of covid- a coherent approach to the antitrust prohibition of excessive pricing by dominant firms the antitrust prohibition of excessive pricing estimating the benefits of anti-cartel interventions: the case of the south african cement cartel abuse of dominance by firms charging excessive or unfair prices: an assessment the impact of demand and price expectations on the behavior of prices measuring benchmark damages in antitrust litigation the south african wheat flour cartel: overcharges at the mill working out the standards for excessive pricing in south africa from a developmental to a regulatory state? sasol and the conundrum of continued state support potential effects of proposed price gouging legislation on the cost and severity of gasoline supply interruptions competition policy: theory and practice excessing pricing in competition law: never say never? the pros and cons of high prices does import parity pricing constitute evidence of excessive pricing and what are the consequences of attempting to remedy it? excessive pricing regulation in china, south africa, and other brics member states estimating overcharges in antitrust cases using a reduced-form approach: methods and issues assessing excessive pricing: the case of flat steel in south africa chicago: american bar association section of antitrust law quantitative methods in antitrust litigation decomposing inflation using micro-price-level data: south africa's pricing dynamics price gouging, construction cartels or repair monopolies? competition law issues following natural disasters key: cord- -le t l g authors: nan title: pathological society of great britain and ireland. rd meeting, – july date: - - journal: j pathol doi: . /path. sha: doc_id: cord_uid: le t l g nan claire m allen, d m hansell. mary n sheppard depanmenls of diagnosbc radrology and lung palhalogy royal bromplon nahonal hean and lung hosprlal, sydney slree:. london sw np percutaneous fine needle biopsy s an established diagnostic technique for lung lesion^ afirm diagnosisofbenign versus malignant is often achieved but histological interpretation of small fragments or groups of cells is difficult manual cutting (twcut) needles provide asuperior histological specimen but are associated with a high complication rate and have been mainly used for pleural lesions this s the first prospective study to assess the feasibility of obtaining histological samplesfrom lung lesionswing apoweredcuning needle (biopty gun) we have biopsied patients using biopty gun there were no major complications histological diagnoses were obtained in patients ( malignant, benign) the malignant lesions identified included nan-small cell carcinomas. adenocarcmamas. squamous cell carcinomas, bronchiolaalveolar cell carcinomas, -cell lymphomas, small cell carcinoma. atypical camnoid and metastatic breast carcmoma. the benign es ons included sarcoidosis. clyptogenic organising pneumonia. wegener's, resolving pneumonias with chronic inflammation the rad~ologistls assessmentaftheamauntoftissueobtainedconelated withgood histology. thethreefalsenegativespecimens obtained the radtdogist noted the inadequacy of the samples ~n two cases and the third was a geographic miss percutaneous biopsy using the biopty gun is a simple and effective means of obtaining good quality histological material from lung parenchyma with a high degree of diagnostic accuracy for bath benign and malignant lesions inorganic particulate matter in "normal" lung: a study using light microscopy (lm), scanning electron microscopy (sem), and energy dispersive x-ray analysis (edxa) london, onlano. l partmeni of palhology soulh sireel london onlano n a g canada h e possible association between inhaled inorganic matter and some cases of usual inter tltial flbrosis (uipi has been of longstanding interest to pathologists and cllnoians. unfortunately. most analytical techniques are impracticable ~n the context of a pathology sewice laboratory in an anempt to find a practicable s utm to this problem and to establish a baseline for inorganic particle load in a "normal" population, a study was undertaken using techniqueswhichwauld beavailable ~nmostlargepathologylaboratories ninecaseswereselectedfram the case(centra andperipheralparliansaf lower. middleand upperlobesjandexamined with thesemand edxaand compared with the lm appearance to determine the panicle type and distrlbutm m a "normal" population. a wide range of inorganic matter was ldentlfied canespanding to siiicb. aluminium and magnesium s cate , rutile and alumina "like" particles varying from < p to p in size in addition. trace elements including zinc. cadmium and increase in number of particles wasalso noted in areas of fibrosis which were present in two cases (old mflammatory disease) preseumably related to problems in particle clearance the findings of this pilot study suggest that although the sem and edxa will likely prove useful tools in the evaluation of lung biopsy soeclmens. the findinq of lnorqanic material in cases of uip must be interpreted with caution autopsy senicb whlch had no known expcsure to lnorganlc dust sectlons were taken from the nght lung each pulmonary adenomatosis has been described as adl~tinctive pathologlcal change seen in the lungsolexperimental area of replacement of normal alveolar lining cells by a taller more glandular type of eplthelwm. usually wlthwt significant cytological atypia. we describe cases i" whlch a smtlar change was seen as an mdental fcndlng ~n resection specimensfor primary pulmonary adenocaranoma. the lesions (usually multlpleand each mm orless m diameter) were identified in lung parenchymaat a distance from the tumour and consisted of thickened alveolar walls lined by prominent, distinctly atypical cells morphologically slmllar to type i pneumacytes and cytologically different to the associated turnour reactive changes " lung involved by obstrmtive pneumonitis were not included !n thts sews all of the associated tumwra were peripheral adenocarcinamas and all showed a pattern of alveolar wall spread at the tumour periphery clinically of the patients were female and all were smokers or ex-smokers the slgnlflcance of this lesion in the histogenesis of primary pulmonary ademcarcinoma is. as yet, unclear animals often i" assoclatlon wlth exposure to inhaled camnogens morphologically the lesion is a clrcumscrlbed departmen ofli~slopafhology sf richard's hosprlal. chrcheslei wesf sussex. po se a series of consecutive personally conducted autopsies in patlenfsdying suddenly outside hospnal and where the death was reported to h m coroner presented cot deaths were excluded. in cases the death had been reported because theattendingdoctarwas unwillingtoissueadeathcertlficate. in theother cases. deathwasnot duetonaturalcausesandfallowedsuicidearan accident oftheformetgroup, therewere t unsuspected malor findings cn patients ( . %). that s to say findings which were either the cause of death or would have led to admission to hospital far assessment and possible treatment they had been discovered in life the largest group were cardiovascular ( ) but there were cases of unsuspected malignant disease there were only five malor unsuspected findings in the group of unnatural deaths years). these results highlight the loss of teaching material in the coroner's system, at a time when hospnal postmortem rates are in universal decline. this matenal would be of value to medical students and to pathologists in traming. and largely comes from cases of lmle or no medico-legal significance. %) and these were in older sublects (mean age . a total of postwnortem specimens refened to the royal victoria ho~pdal electron microscopy unit dunng the years - havebeen reviewed thkscompnsed . vo of thetotalnumber of sewre-relatedcaaesreferred to theunit.oulof ocasesreferred. wereexaminedandrecorded indetail theremainderdidnotundergoelectron microscopic examination for various reasons, such as a concius~ve diagnosis being reached by light microscopy alone. and semi-thin sections showing severe tissue mtoiysis. the most common tssues referred for examination were lung, kidney. liver, brain and head the range of e m. studies carried out included transmission electron microscopy item). scanning electron microscopy (semi and x-ray microanalysis on sem. theelectron micrographs wererevlewedwlth respect totlssuepresewatlanand th wa correlatedwlth the timeintervalbetweendeathand autopsy. electron microscopy was considered, an review. to have been diagnostically useful in % of cases an which it was deployed c s herringtan, a k graham, k cooper, j mcgee it was shown prev usiy that the discrimination of human papillamavirus (hpv) types and by nlsh in archival biopsy matenal requires dlfferent conditions from those predicted by conventional solufion kinetic analysis the parameter tm' (tissue tm) was defined in order to describe these differences in this study. these pnnciples were extended to the discrimination of hpv . and in casesol cln the results of nlsh analysis werecompared with both immunohistochemistry for viral capsid protein and pcr typing these data demonstrate that crosshybndisatm of high nsk viral types occurs ~n clinical lesions under conventional hybridisation and stnngency washmgcondit ns thiscross hybridisation isnot due to thepresenceofviralcapsidproteinand sm relikelyto be areflectionoftheendpoint usedinn sh.i e thepresenceofvisiblesignal.practcally.multiplenlshsignalsduet closelyrelatedprobesinarchival materialarenot indicativeofmultiplehpvinfectionunlesstheyarepresent either ~n morphologically discrete areas of the biopsy or their presence has been confirmed by another molecular technique. motegenerally, thepresenceof asignal in nlsh usingaparticularprobedoes not implythattheidentity of the target nucleic acid is that of the probe medical students in the autopsy room shows that % thought faces should be covered during autopsy, and % thought that genitals should be covered. about half the group were indifferent to both proposals % thought the patient's identrty should be concealed from observers three students thought there should be no conversation at all. % thought that conversation should be limned to procedures and findings and % thought it should be limited to professional maners;conversely. % thought thereshwldbenolimitson thetopicsdiscwaed nearlyso% thoughtstudents should beencouragedtoassistbutnotpressuredintadoingsa. . % thoughtthatallshould becompelledtoassist, but % thought that students should onlv obsewe. and not be allowed to ass s.t. % of students thought that they should oni!iobsene autopsies on patients they had clerked. whereas % thought they should onlfbe on autopsies on patients they had not clerked. fmally. % thought that relations should give spmfic perm on before students observed autopsies. whereas . % thought not a quantitative study of the effects of fibroblast growth factor on wound strength and cellularity fibroblast growih factor (fgf) has potent angiogenic and fibrogenlc effects and is lmpllcated in the formatlon of granulation tissueand healing few attempts have been made toquantity theseeffectsmnvo. we havestudled arat skinwound modelusing red cellghostsasan fgfvehicle tensiometv ofthewoundsshowed amaxlmaleffectof the fgf after seven days when the wound strength was % above that m controls (p < ) this effect had disappeared by fourteen days. computerized image analys~ using a joyce lo& mini magiscan measured total nuclear content of areas i" the wounds. permitting a topographic analysis of cellulanty versus distance from the wound centre cellularlty effects showed adifferent time course from wound strength. a % increase at fouldays anda % decreaseat sevendays. relative tocontrols(bothp < . ) attwelvedaysthecellularityeffectwasstill sqnlflcant at a vo decrease but by twenw-one days it had dwappeared the results suggest that fgf causes an early transient increase in cellulardy and more rapid increase in wound strength: most of these cells are macrophages and fibroblasts suggesting a connection between thesetwo obsenat ns. the adhesion molecule$ integrin (cd ). integrin (cdl ). and intercellular adhesion molecule- (icam- , cd ) are essential to the intimate co-operation of antigen presenting cells (apcs), t cells and keratinocytes cyclosponn. which is an effective treatment for psonas~s, may cause immunosuppression by altering antigen presentation we have pertormed a quantitative immunohistochemical assessment of the effect of low dose ~yclosporin on the expression of p -integnn. p -integnn and icam-f m the epidermis in chronic plaque psonas s. staininglevels werecompared withclinicalresponseasassessed bythepsoriasisareaseverihllndex(pas score) pt-lntegnnand cam expressionon keratioocyteswerenotaltered bytherapy buttherewasasignificantdecrease inthemeanlevelsof p positivelargedendriticcells(apc )within theepidermis.bz-integnn wasnot expressed by keratinacytes there was a strong correlation between p expression and pas score after three months on cyclosporln and one month off therapy these results lndlcate that p stalnlng on large dendrltlc epidermal cells previous studies enumerating silver stained n~c l~l a r organiser regions in problematic cutaneous melanocytic lesions have yielded inconsistent. but generally favourable, resulis. it seems probable that such inconsistencies. arise largely from differences ~n fixation. staining and counting strategies. our group, having devised improved methods of agnor staining and counting. is now able to re-examine the potential role agnors in borderline lesions pilot work demonstrated potentially significant differences in agnor dispersal between benign and malignant lesions and i" this study bath agnor numbers and dispersal patiems have been evaluated a range of melanocytic lesions including banal naev~. dysplastic naevi. typical melanomas, spiu naevi, atypical spih le~ions and minimal deviation melanomas were collected virtualty all of the unusual lesions had been diagnosed by specialists in dermatopathology. using a combined assessment of agnor numbers and dispersal, it proved possible to discriminate borderlip lesions from banal naevl and typical melanomas. benign borderline lesions -such as spit naevi ~ possess numerous nor$ but display tight clustenng in contrast to malignant melanomas wherenordispersa isaprominentfeature discriminatinganetypeaf borderlinelesionfromanathercauld not be achieved however, in practice this distinction is probably less important than assigning a aoirary specimen to a benign or malignant group a larger prospective trial of agnors in melanocytic lesions currently in progress with a mean total exposure of pack-years. alihough p was expressed more commonly in adenocarcinoma ( rof lo)andsquamouscarc~noma( ~~of )than~nsmallcelltumours(l %of o),thiscouldbeaccountedfor by the smoking history. since patients with non-small cell carcinoma smoked more (a mean af pack-yeas) than those with small cell lesions (mean of pack-years). there was no relationship between p expression and sunlyal. s. a. sun. j. r. ~a s n e y depaitmenl ofpathology university of liverpol, p box , l!vemooi. l bx activation of thec-myconcqene with overexpression of itsancopratein product ocurs in bronchlal malignancles ofalltypes, but has beenmost extensivelystudied insmall celicarcmoma, wherensaverexpression~n culturedllnes has beenassociatedwithdevelopmentoffast-growingvanants whlchlosemuchofthelrendocrlnephenohlpeand aner their morphology. it has been suggested that these vanant lines might be the equlvalent of the large cell bronchial endocrine carcinomas sometimes seen i " yiyo, but this is not proven. we have used th myc - e monoclonal antibody and the avidin-biotin technique to study the panem of expression of the p oncoprotein product of the c-myc gene in turnour deposits of twelve subjects coming to necropsy with disseminated small cell carcinoma in an attempt to relate l o morphological vanablity and metastatic site. anhough expression bore no relationship to morphological vanation. it ohen differed markedly horn site to slte. whereas parts of the primary t m w r strongly overexpressed the protein ~n all but one wbfect, there was considerable vanability between secondary deposits. oossiblv mdicatina arelation~hi~ between c-mycex~resslon and propensltvfor metastasls to certain iocations. tumour growth rate is a key parameter of neoplastic aggression. and is determined by the balance of cell gain and loss.apoptos~sisama]ormadeoftumourcellloss, but linleis knownof itsregulation. dieremesin turnourgrowth conferred by hpvtypes and werestudied in aratfibroblast modelsystem. immortaiisedcells weretransfected with hpv and expression vectors. either alone or with activated c-ha-rasl. monoclonal cell lines were established. and their vector dna content was confirmed by pcr tumour cell ddfered in their growth properties m wvo and m vilro. hpv containing turnours were larger and showed less apoptosis than those containing hpv , although bothshowed moreapoptasls than thenodulestormed bytheparentfibroblastsalone. in all turnours the presence of ras greatly reduced apoplosis and increased the growth rate. very similar propetlies wereobswvedin culture, and apoptoticratesshowed astranglnveneconelatlonwlthratesofnet cellgrowth. hpvs appeared iostim"latetumourcei apoptasis, butthiswas suppressed byras. melowerapaploslsassoclatedwilh hpv compared with hpv may partly explain the more aggressive phenotype of cervical c a n m containing hpv . it hasbecomeapparent thatanumberof maleculesmaybeexpressed byrestingorqu~escentcellsandarelostwith transition into the cell cycle. in addition to being of biological interest, such molecules may prove useful as operatcanal mahers of quiescent cell populations in histological material and allow the further characterisation of cellular subpopulations. one such molecule is statin. a kd protein previously reported to be expressed only by cells ~n go. we have shown bylaserconfocalfluarescence microscopythat thestatin antigen is associated with the nuclear envelope with a dstnbution m l ar to that of nuclear lamins. using a monoclonal antibody ( - ) that recognises slatin we have defined the tissue distribution of statin immunoreactivlty in a range of continuously renewing, conditionaily renewing and non-renewing tissues. the distribution of immunoreactivlty s essentially as would be expected of a maher of quiescent ceils. in contrast. in established pancreatic carcinoma and other epithelial ceil lines. we have found $latin immunoreactivity ~n cycling cells using biotinylated k slatin double labelling techniques. in conciusion. statin lmmunoreactivitv in normal tissues correlates with auiescence but this realtionship is lost, at least in vifro. loss of cell-cell and cell-substratum adhesion are imponantfactors during turnourprogression. tumour promoten are compounds which although not carcinogenic themsews increase the frequency of turnour development in animals previously exposed to carcinogens. we have used the turnour promoter tpa on cultured human renal epithelia ~ells mimic nwplastlc transformation. following tpa treatment we haveexamined thedistribution of vlnculin, b integrin and actin within thetreatedcells byfluorescencemicroscopy.treatment of therenal epithelium by tpacauses arounding up of the cells and a loss of adhesion toeither laminin or fibronecttn substrata fiuorescent microscopic examination reveals a progressive loss of reactivity for vinculin and b inlegrin within local conlacts. these changes are accompanied by a redistribution of the actin microfilaments from orientated bundles of stress fibres to a circumferential arrangement these changesofareduction in focal contact componentsand disarganised actin cytoskeietan mimic the changes we have previously described in renal carcinoma. glutathione s-transferases are a diverse group of enzymes with an important role !n the metabolism faelgn compounds including some carcinogens and cancer chemotherapeutic agents. increased expression of gst pi is seen in manyanimal and humancancersandisassociated with resistancetocalboplatinandcisplatin in humanlung cancet cell iines. gsts are involved m steroid hormone transport and metabolism and have a role in the complex metabolic relationships between settoli ceils and germ cells. we have studied gst isoenzymne expression by an immunohistochemical method in stage i teratomata. stage i tetatomata, stage i seminoma, cases of intratubulargerm cell neaplasia( tgcn) and a groupof cryptorchid and normal testes. the stage i teratomata had beentreated with cisplatin based therapyand bothprimmaryandpost-therapymetaftatictumourtissuewerestudied. gstalphaexpression correlated with morphological evidence of epithelial differentiation in teratomata.therewas no difference in gst expression between stage i and stage i pnmary testicular iumours nor between primary testicularand post-therapy metastatic tumours. gstexpression did not correlate with survwal. gst pi was strongly expressed in the neoplastic germ cells of itgcn but was weak or negative in normal germ cells. this may be significant in view the potential for later contralateral turnour development tn patients treated by cisplatin based therapy. in summary, gstexpression in testicular germ cell turnours reflectedlheirdifferentiationandappsared to be unrelated l o therapy and subsequent survival. a case illustrating the usefulness of electron-microscopic examination of fine needle aspirates s described fine needleaspiration wasperlormedon asubcutanwusnoduleinthechsstwall ofaneldedyman whowassuspmted tobesuffering from bronchogeniccaronomaanclinicaland radiologicalfindings.mesmears werenotdiagnan~c. but ~n view of the history af asbestos exposure, the needle washings were submined for eiectron-microscopic examination, which showed mesathelial differentiation and a diagnosis of metastatic malignant mesotheiioma was suggested. an autopsy perlormed eight months later confirmed the diagnosis of malignant mesotheboma. t. dorman, a ti ismail, b cunan, m. leader pathology department hoyal college of surgeons m ireland, dublln many histologi~allymalignantfeaturessuch as hypercellularltyand high mitoticcounts, but clinically followa benign course. demoid tumours and fibromafoses can be densely cellular but usually quite bland histologically and are associated wdh infiltrative marginsand repeated local recurrences. in addtion irradiated tissue often contains many cellswithcytologicalfeaturesol malignancy thisstudyexaminesthepioidyofsuch lesionsbyboth olthecunently availabletechniques using dlsaggregated formalin fixed paraffin embedded tissue sixteen cases nf, dfsts. dts. fibromatoses( nci~ding palmar, plantar. retrcpentonealand soh tissue) and miscellaneouscases including leiomyoblastoma, inflammatory pseudosarcoma and plexiform histlocytama. one malignant fibrous histimytoma and t paragangliama were included as possible poslive controls. cases containing numerous irradiation fibroblasts were alm analysed all 'pseudosarcwnas' were euploid by both image analysis and flow cytometry the malignant fibrous histiocytoma was aneuploid by image analysis and flow cytometry and the paragangliomawasaneuplaid by imageanalysis and tetraploid by flow cytometv themndwonsof thisstudv are that pseudosarcomas are euploid and aneuploidy would appear to be confined to malignant tumours of mesenchymal ongm. other sites we collected cases to study their morphology and antigenic profile after staining for the epithelial markefficam . flow molecularweight keratins)andlp (high molecular wefghtkeratins), thegeneralmelanoma and neural markers s w. neurone specific enoias (nse). protein gene product . (pgp) and the melanoma s w i f l c marker hmb , the neuroepithelia markers leu and glial fibnllary acidic protein (gfap), and the intermediate ftlaments vimentln vim) and nsurofilament (nr the following turnour types emerged: i pure spindle celltype(n = ), ,purepolyganalcelltumaun(n = )comp sedofpleomorphiccells(n = ).undwmcellswith an alveolar in = ) or sheet arrangement (n = ). and mixed pleomorphic spindle and polygonal cell tumouffi (n = ). two tumouffi proved to be lymphomas an intraepithelial melanocytic component could be established in cases within adjacent respiratory or squamous melaplastic epithelium. in cases n e w trunks a~mclated with tumour contained increased numbers of atypical schwann cells. consistently expressed were s w ( and colon ovanan tumour antigen (cota). csais a heat stablemucin associated antigen present m normal colonic epithelial cells and is expressed m greater quantitites tn colon c adenmarcinomas cota is a heat stable antigen present n colanicneoplasiaand mumowwananturnours but not ~nnormalcalonicepithelium psmionsfrom to primary adenocarcinomas ( ovanan, colo-rectal, gastric. breast. oesophageal. prostatlc. pancreattc, endometnal and t gallb adder)and two adenmarcinomas metastatic tothe liverwere incubated with anti csa and anti cota antibodies using the p.a.p technique with positive and negative controls. while anti csa positivitywasseenin d ~ loni~aden carcin ma~( wsakand lo~tr~"g).~twasalsaseen n af ovanan ( weekand strong). of gastric ( weakand strong), of breast( weak and strong). of oesophageal ( weak and strong). of prostatic (all weak). of pancreatic ( weak and strong). of endometnal (all weak) and the gallbladder ademcarcinoma. both liver metastatic adenocarcinomas were negative in additim while anti cota staining was positive m of colonic adenocarcinomas ( weak and strong) and of ovarian adenocarcinomas.~twasalsapositive~n af gastnc( weakandzstrong). al lobreast( weakand stlmg), all esophageal(allweak) of pr ~tati~(allweak), pa"creatic(low akand t strong),all endometnal(all weak) and the case of gallbladder endocarcinoma (strons) both liver metastatic adenocarcinomas were negative. m e c o~c~u s~o~ of this study s that anti csa and anti cota are not adequately specific in the identification of a ~olonlc or ovarian origin af an adenocarcinoma and cannot reliably be applied to the identification of a metastatic adenocarcinoma of unknown primary site the early intfa-epithelial changes of adenocarcinoma of the nose and paranasal sinuses were sought in the histological sections from high grade adenocarcinomas and cyclindric cell carcinomas from this region none of which had had previous radiotherapy treatment. of the cases came from wwd-workers. i r m a polishw and from a plasterer attention was directed to the non-neoplastic epithellm of the surface and of the sera-muclnous glands. in casesofadenocarcinomaand t of cylindriccell carcinoma surfacechaogeswere detected these took the form of hyperplasm of goblet cells of the rsspiratq epithelwm accompanied by dysplastic changes of other epithelial cdls: m the latter these became enlarged and irregular m shape with large hyperchromatic nude and prominent nucleoli. lnthsmajorityof iesionsthesechangeswereisolatedin theepithelium. changesof thesetypes were never seen in sefomucinous gland epithelium. in addition similar changes were not noted m the coverlng respiratoryepithelium in casesofnasal polyps evenwhen severely inflamed thesemsmchangesso described haematoporphynn derivative sensitised tumwr tissue. s underwing evaluaton " widesptead and m i s t a n t papillary tumoursand ,n casesof rvldespreadseveredysplasra/carnnoma,nufu". arewewof spallents ( , m, ages years. pre-and post therapy) has revealed no change ~n histological grade and stage ~n patients, progression to invasion in t case and a redunion to mild urothellal atypla alone in case. local tissue changes following treatment were limnedto oedema and an acute lntlammatoryreactlon. no metaplastlc. stromalfibroblast or nene changes were seen variations ~n bladdw size. both increased and dlmtnlshed, wwe encountered the histological grading of tcc following pot shows little improvement. but studies are in progress to improve lhght delivery in the bladder, and hence improve treatment outcome. a armour. a. s. jack bpartment of pathology, umverslty of i d s . leeds. lsz jt follicular lymphoma is a disease characterised by widespread lymph node involvement usually at the time of presentation proper tie^ of lymphocyte homing and circulation appear to be mediated by a variety of cell adhesion molecules. the a m of this study was to compare mrmal nodal lymphocytes with the neoplastic populatlm m folllcularlymphoma. hall casesalloftheneaplasticfolliclesexpressed lcaml but thisyanedfromonlyafewcellsto % of cells within a follicle this dosltlvlty included dendmic retic~l~rn cells. germinal centre cells and neoplastic lymphocytes. leu (lymphocyte homing receptor) showed an inverse pattern of expression in all but cases the phenotype (icaml + l a is a feature of germinal centres and scanwed paracontcal blasts in reaclive nodes anhough there is uniformity of expression of lcaml in germinal centres which is not apparent in any folllcular lyumphoma case. this study showed a loss of lcamt and increased leu expression by neoplastic lymphocytes within follicles this may relate to the propensity of this disease to spread widely throughout the lymphatic system activation leads to an alteredfunction and aconcomitant aneration in the chemistry ofthe cell surface, which ~s a site nchincalbohydrate. rat lymph nodelymphacytes.eitherunactivatedoraclivatedfot days namixedlymphocyte reanlon. were treated with biotinylated iectins from a large panel. chosen to probe surface glycans lmlns were revealed with awdln-phycoerythnn and cell populations were analysed in a fluorescence activated cell-sorter double-stalnlng with fitc-monoclonal antlbodles defined the functional lymphocyte subsets. uea- and lta boundtonoce sof anytype. unactivatedb-cells boundall theremaininglectins.savempa. toagreaterextentthan did unactlvatedt-cellsand b-cell actlvatlon produced no change i" glycan sxpresslon. unactlvated and actlvatedtcells all expressed a . -linked sialyl residues, but o- . -linked sialyl expression was hetrogeneous, did not conespond toanysubsets,and wa~unchangedonanlvatian.alargegroupof lectinsshowedlow wno binding to unactlvatedt-cells, but boundonactivatianexactly in parallel to l- receptorexpressionctacantigen) thes~ngle structure gawgalnacal, galpl, glcnac-) galigalnacat , gal~ , glcnac-) r could account for their binding the presence of neoplastic (light chain restricted) b cell follicles in low grade b c d gastrolntestlnal (gi) mmphomaof although malt s not present in normal human gastric mucosa, lymphold t,ssue ,* acqulr& ,n response lo colonisationof themucosa by helrcob~cleipyioii. we have investigated the possibility that thisacquiied lymphoid t ssue is malt type whlch may povovlde the background i" which lymphoma can arl~e w e examined gast,,c b~ p ~e fr m casesafh~l~~~bacrerassaciatedgastntis.and biopsyandresectionspecimensfram casesaf t"mours has contr'buted to a peklstence of ihe more "iew arefofl'cle (fee) gastrlc cell lymphomaof malt in cases of hebcobaciergastritis prominent lymphoid follicles were idenfilled in aftheee b cell clusters were identified within the gastric epithelium. reminiscent oltheteatures seen the dome epithelium of sm intestinal peyer'z patch. thls b cell-eplthelh assoclatlon was not assaclated with the eplthelm cell changes or the glandular destructm seen ~n lymphoeplthellal i~s i o~s malt lymphomas. in / cases of gastric maltlymphoma helicobaclercould be identified oltheremaining cases. weiegastrecfamy specimens n which specimen washing may have contributed to the negativefindings. we suggest that gastrlc malt s acqulred in response to local immunological stimulation as a result of mucosal colonisation by hel~cobaclerpylon, and that the development of malt lymphoma is a subsequent event mucosa associated hmphold tlssue (malti has been explained on the bas of speclftc colonization at reactlve b lymphomasbe included in lhecatqoryof malt lymphoma but the frequent presenceotafoll~culapanem in these foltic es by ihe neaplastlc cantrocyte-like(ccl) it has been low grade cellthyro d we have ihe and 'nvesflgated the and genotype of' of primary low gradebcelllymphomasofthethyro'd alsodemonstratedfeatures ofmalt ymphama'ncludtng cclce and l y m p h~' t h~' a l l~' o n s . m e appearances and immunoh'sto'og~ofthefo'l'c'es werethoseofto'l'cularcalon'rat'on described 'ngimaltmmphomarather thanfccfoll'cular'~mphoma thepredomlnant iwg ~ane'naffoll~cularcolon~rat~~nconformed tothatdeslgnated cclcells show'ng astnk'ngly h'gh prol'feratton late no evidence of the '( ' ' transiocat'an was found in any on dna extracted from fresh (n = ) or paraffln embedded (n = ) t sue mese ilndlngs argue against a fcc lineage lor primary thyroid lymphomas and support their ncius on " the maltcategory we have used a panel of antibode$ to demonstrate stages of granulocyte maturation by immunoh~st chemistry i" decalcified. wax-embedded bane marrow trephine biopsies antibodies reactive with muramidase. u- -ant~tryps,n. neutraphil elaslase and cd react with early granulocyte precursors. cd and calgranulin identity later granulocytes. ihdiylduai antibodies dlfier rn the populations cells ldentlfled theantlbcdtes also react with cells of mwlocyte llneageand provide information concerning theorganlsatlon afmonopolesls about whlch liffle is known in normal marrow granulopoiesis is zonal wlth maturation occurring radially around trabeculae and blood vessels this pattern is exaggerate in reactive hyperplasia and chronic granulocytic leukaemia (cgl) there is marked disruption of this zonal organisation in myeloproliferative and myelodysplastic states, with considerable overlap patterns between these conditions in chronic mvelomonacvtic leukaemia (cmml) there is comdlete absence of zonal arrangement of granulopaiesis possibly due to monocytic proliferation obscuring the underlying marrow spaces and that by analogy with cgl cmml represents an exaggeration of this normal panern granulopoletlc panern we hypotheslse that monopoles normally occurs " a randomly dispersed fashion within as previously shown by us in animals untreated with cyclosparin a. the cell birth rate fell from an initial prelmmunisation valueof cellsit cellsihour to cells celldhouran day followed by a rise cellsit cellslhour on day however, in cyclosporin a treated animals the cell birth rate ( ce s/looo cells/hour) was signiticantlydepressed belowthecontrol pre-immunisation levelandremained suppressedupfaday fallowed by an abrupt rise these results are consisten with the hypothesis that t lymphocytes or their pmducts not only drwe the morphological appearancescompnsed lymphoepithelia lesions (in onecase). numerous lymphoid follicles and a diffuse infiltrate of monocytoid cells (centrocyte like cells) there was striking plasma cell differentiation and colonisation of lymphad folllcks by monacytoid cell?. and neoplastic plasma cells. lmmunahistochemistry convincingly demonstrated heavy and light chain restriction ~n all the biopsies from both the cases the bladder s developmentally related to the hind gut and this manifests " the variety of metaplastic epithelium seen at this site circulating cells. encauntenng the endothelial surface. make contacts an environment rich n glycan. a large panel of biotinylated lectins was used to probe far variations in the glycans expressed on endathelia of artenes. veins, arterioles, venules. capillanes, high endothelia vessels and lymphatics m a range of normal and pathological human tissues formalin-fixed, paraffln embedded specimens from the files of manchester royal infirmary and manchester royal eye hospital were used lectins were revealed with an avidin-peraxidasesystem no differences werefound between arterial. arteriolar, venular, veinous or lymphatic endothelia all expressed abundant complex-type n-linked glycans. of several subtypes. capillaries were highly variable and showed heterogeneity ~n their expression of ) outer chain sequences fn n-linked glycansand ) mucin-type sequences. both between different. normal organs and within an organ. implying that the surrounding tissue probably had a regulatory effect where endothelium was reactive, additional aneratiom wete seen and actively growmg endothelium in granulation tissue expressed hqhmannose siwctwes. high endolhelial ybss~is showed a much lower density and narrower range of glycan expression thandidad~acenlnormalcapillanes,despite theirknownvery highrateofglycansynthesisand secretion the iymphocyteiln-homing receplor(s) would be a component of this restricted porlfolio of glycan monocyte margination in atherosclerosis associated with immunological injury n. j. combs, p j gallagher. p. s bass clinical and experimental evidence indicates that immunological injury is associated with accelerated atherosclerosis. allograft recipients may develop accelerated atheroscleross and anlmalsgwen serum sickness and a high fat diet develop more extensive atherosclerosis than controls fed the diet alone we have tested the hypothesis that atherosclerosis ~n these animals is associated with increased adhesion of monocytes to the aortic endothelium. chronicswum sickness was induced in genetically hyperlipidaemic rabbits with nativeanionic bovine serum albumin (nbsa) or highly cationised protein (cbsa) rabbits given nbsa showed a spectrum of glomerular endocapillary prollferativechange thasegiven cbsa developed early membranous glomerulopathy in controls the numberofmanocytesadherent to theendothelium ranged from y isq mm and m animals given senm sickness - isq mm (nbsa)or ~ isqmm(cbsa) as therewerenosignificant intergroupdifferences theseiesultsdo not support the hypothesis that immunological injury increases monocyte adhesion to the aortic endothelium departmen! oipatholcgy, souihampfon universily hospdals soufhamplon. so xy amyloidcan beidentified nupta % of elderty hearts,especiallyin themyocardium oftheatrialappendages in a small prapanionofth%lecasesamylaid~salsapresent inthecardiacvalve~ butisolatedvalvulardepos,tsarerare. a year old male presented with bilateral leg weakness and an intradural turnour. he died days after spinal surgeryanddeposltsofaglloblaslomamunlforme wereldentlfledm both thecerebrumand thecord therewasno hlstory of cardiac disease but all four valves showed translucent verrucous thrkenlngs. these had a uniform eosnophilc hi~lologicalappearance. stainedwithcongo red and had ultrastnucturalfeatures of amyloid amyloid p proteinwas identified immunohistochemically ~n thesedeposits but negative multswere obtained withantibodies t o m . aland a proteins. mwewas no evidenceof cerebrovascular ormyocardial amyloidosis the involvementof all four cardiac valves. the stnking absence of amyloid i" other organs and the a~~o~l a t i o n with a widespread glioblastoma are unusuai but unexplained features of this case the ima s used as a bypass of narrowed coronary arteries it is said to be less prone than vein gratk to develop subsequent occlusivedisease. thisstudy of pairs of imasfrom subjects of vario~s ageswas to see if the histological structure ofthevessel might explain immunityto graft disease sixteen imas were fixed in distension byformalln at cm of water pressure and secllon~ taken at the level of each nb (first to stxth). all arteries undelwent similar changes along thelr length. wlth no slgniflcant difference between left and rlght lntimal changes were minor conssting of lbro-elastic muscular thickening in all age groups and in those who had died from vascular disease theinternalelastic lamellawaswelldefinedat all levels. buttheexternallamellawasclearlydefinedonlyatthelevel ofthefmhandslxthnbs(i.e. mthedetalartwyj. medral thrckne~~decreasedalongthelengthofthearter~esandinall cases changes from an elastic to a muscular structure, generally at the level of the fourth or fiflh rib the ratio of medial thickness to numbw of lmdlae in~reases along the artery. notably at its point of change muscle fibre orientation changes from inter-mixed cir~ular and longitudinal in the elastic part to predominantly circumferential in the muscular pan. the pronounced stnctural differences of the ima compared to the similar sired epicardia coronary arteries. which are muscular. may be of relevance in explaining their markedly different incidence of atheroma. naomi carter, s variend fatty change of the heart is a pwrly defined pathological entity which in the adult hean can be caused by severe hypoxia nutritional disorders. poisoning by selected drugs and catecholaminerelease it is most commonly seen ~n association with coronary artery disease little data exists with regard to the paediatric hean in pediatric deaths coming to post mortem over a year period. there were cases of myocardial fatty change of varying seventy and distribution detected ~n red -stained sections infection and congenital disordenwereimplicated n deaths infectionand cangenitaldisordenwereimplicated n deaths. fallcasesoffarmchangeand % of all deaths seven ofthe e~ases had acombined ~nfecti~u~andcangennalaetiology othercausesofdeath included turnour, traumaandcomplicationsofbinh % of casesofsudden infant dealhsyndrome(s ds) hada fatty heart only one case of the total cases showed deflnlte hlstaloglcal evldence of ischaemic myocardial damage. insome instances, thedegreeaffattychangemayberelatedtathedurationand seventyoftheundertyng condition someofthesechildren may havean occunnutritional orenlymedisarderwhich ~sexpressedatacellular level ~n the form o! fatty change and that contibutes to their early death. we havecampared thereparting oftemporalarterybiopsiesbetween - ( cases)and ( cases). the overall incidence of positive biopsies was . % and . % in each period the number of patients with clear clinical evidence of cranial arteritis was % but in - , % and in , % of these had positive temporal artery biopsies when the histology was reviewed approximately % of biopsies in each period had been erroneou~ly reported as healed or atypical artentis. in contrast. a true histological diagnosis of artetitis was missed in~nlya~inglepatient approximately % ofall patientswithaclinicaldiagnosisof giant cellarteritisdevelopedan additional symptom or pathological change associated with steroid treatment frequent final clinical diagnoses in patients with negative temporal artery biopsies were transient ischaemic attacks, cerebrovascular accidents. unexplained headache or migraine. polyarteritis or polymyalgia hwmatica these resuns confirm that one third of patients with deflnite clinical evidence of cranial arteritis will have negative biopsies pathologists continue to misinterpret normal arterial ageing changes as evidence of healed or atypical arteritis depanmenf hslopafhology and depanmen! resp raioiy medicne. sl banholomew s hospifal london ecla /be adhesion ~fepithelium to extracellularmatrices is mediated partly byafamily of heterodimeric molecules known as megrins we haveexamined theexpressionofthealpha- toalpha- integnn subunits in~unured human branchia epithelial cells. and in bronchial biops es from normal subjects and atopic asthamtics. we have also studied the expression of intercellular adhesion molecule-t (icam- , cd , rhinovirus receptor) br~nchialepithelia cells from surgical specimens were grown as explant cultures on glass covenlips. bronchial biopsies were taken from right upper and middle lobe carinas lmmunastaining was performed on acetone fixed cells and frozen tissue sections using alkaline phosphatase and immunoperoxidase techniques all biopsies showed strong positive staining of epithelium for alphe?, alpha~ and alpha- integnns. stainingforalpha- was weak or negativeand epithelium was negative foralpha- and alpha- except in twoasthmaticswhere itwas weakhi alpha- posittve. in contrast. cultured bronchial epithelial cellswere positive for all these mtegrinsexcept alpha- . epithelium was positive for cam- in asthmatics but negative all other biopsies. cultured cells were ~trongly positive for this molecule it concluded that expression of some adhesion molecules bv bronchial emhelium may vaw ~n relation to the cellular environment and that ths may be imponant tn disease l%panmen! of pafhology univeisrty of birmingham and departmenrs o! 'immunology and his!opalho!ogy eas! blood eosinophils are in a relatively inactive state with migration into tissues eosinophils became more activated these activated cells are hypodense compared to most blood eosnoph s low affinity receptors for both ige (fcerii. cd and igg (fcgriii. cd ) have been documented on activated. hypodense eosinophils this study assessed the expression of these proteins on ttssue eosmophk derived from nasal wlyps the blood and nasal polyps of seven patients undergoing nasal polypectomy were studied nornodense and hypodense eosinophils were isolated from venous blood by centrifugation an a discontinuous percoll gradient percoll wassimilarly used to obtainaneosinophilrichpreparationfromcellsearactedoutafthenasalpolyps cytospin preparationswetem?.de of these samples frozen sections of each polyp were also prepared lmmunostaining using an alkaline phosphataseianti-alkalln phosphatase detection system demonstrated that neither blood nor nasal polyp eosinophilsexpressed detectablecd orcdt l t i~p~~~i b l e t h a t e~~i n~p h l l s o f na~alp~lyp~aresimilarto blood eosinophils and are in a relatively inactive state lavage and biopsy studies. the relationships between mucosal inflammation. bronchospasm and bronchial hyperreactivity are unclear since bronchial smwth muscle has an essential rolein the pathophydogyof asthma. we haveexamined theextentto which it ~sin~ol~ed~nallergicinflammation bi p~ie~in~l~ding~moothmu clefr m asthmatics (age range who did not use steroids and controls (age range ) were embedded i" araldite and stainedformast cells ~monocional ant bodyaat)and eosinophils(monoclona antibody eg ). mast cell numben in the lamina propria and smooth muscle were similar for both asthmatic and control sub e m (mean values. astham lamina propna mm . smooth muscle timm , controls /mm and blmm'respectively) eosinophil numbers in the lamina propria were increased -fold in the asthmatics (p = ) but there was no significant increase in the number of eosinaphils rn the bronchial smooth muscle eosinophil numbers in the asthmatics correlated positively with fev, we conclude that the role of muco~al inflammation in the pathophysiology of asthma has yet to be determined we present cases ofextra-pulmonary pneumocystosis diagnosed on routinesurgical specimens (two biopsiesof liver. and one each of gastric mucosa. small intestine and a pen-anal mass). in each case. the histological features were similar to those seen in the lung. and as in other material from cases of aids, munlple pathology was often found extra-pulmonaly pneumocystasis s now being reported from a widerangeof clinical specialties. one reason forthismcreasemaybe that impraved patient suiyiy~i with"topicay inhalatiooalpentamidinetherapyallowsvisceral foci of infection to become clinically apparent this hypothesis is supported by the finding that ofour cases were taking nebulised pentamidme inthesehypersensltivitystatestothatobselved mbronchiectasis (a chronic suppurative lung condition not thought to in~olve a hypersensitivity aetiology) and in smokers and non-smokers with no evidence of active pulmonary inflammation ourresuns havesh wnthattheb:tlymphocyteratioisnodifferent ineaaandsarcoidfromthat seen ~n bronchiectasis and in normal lungs. we believe that thns is further evidence to suggest that bal is an unrepiesentativetechnlquetorlhestudyof interstitial lung diseasesand that morecansiderationshould begivento the possibility of humoral immune components in the pathogenesis of ea determine its effects upon the number of pulmonary neuroendocrine cells and their peptides. in one experiment. the concentration of noradrenaline in the lung was estimated by chromatography, and that of the peptides bombesm. neurotensin and caknonin gene-related peptide (cgrp) by radiaimmunoassay. there was significantly ies noradrenaline and bornbesin in the lungs of test rats than in controls but the levels of neurotensin and cgrp were unchanged. in a second experiment, pulmonary neuroendocrlne cells in histological sections were labelled with antiserato bombesin,calc,t~tonin,cgrp andproteingenepmduct [pgp s ) a~d =~" " t~d . t h~, e w =~ nochange in the number of labelled neuroendocrine cells expressed per unit area of lung or per unit length of airway between test and control rats for calcitonln. cgrp or pgp . . bornbesin-containing cells could not be identified in either group. an increase ~n pulmonary neuroendocrine cells could not be identified ~n either group. an increase in pulmonary neuroendacrine cells immunoreactive for bomtesin and calcitonin occu~s in the early stages of plexogenicpulmonaryartertopathy in man. theabsence ofsucha change in monocrotallnedulmonanhydertenslon in the rat suggests that this is a poor model for the human disease. this preliminary study was carried out to assess the quantitative expression of neuroendocrine and mast cells in adun humanlungsofcasesofasbestos-relateddisease.tencaseseachofasbestasis, pleuralplaques,carcinoma and mesothelioma were studied m comparison with ten normals wnh no history exposure to asbestos the lung sections were stained lor neuroendocrine markers neurone specific enolase (nso and chromagranln. and, chloroacstate esterase and toluidine blue for mast cells. there was a notable variation in the number of neuroendocrine and mast cells between the control and asbestos-related disease group the variation was also seen between the various asbestos-related diseases. though not statistically sbgnificant. the trend of the vanatton indicated that the individual diseases follow a particular pattern a n lhe expresston of these two cell popuipioiis. we have studied fibrous turnours of the pleura using morphology. immunohistwhemislry and eleclronmaroscopy. the findings were compared and contrasted with reactive pleural fibrosis and desmoplastlc mesothelioma. the fibroustumwn hadarangeof histologicalappearancesand % weremalignant ~nnature.theimmunophemtype was uniform and consistent with positive staining for vimentin and alpha m w t h muscle actin. this was ~n sharp contrast to findings ~n reactive pleural fibrosis and desmoplastic mesothelioma. uttrastructural appearances of the fibrous tumours of the pleura were supportive of a myofibroblastic ongin. we propose that fibrous tumours of the pleura arise from the submesothelial myofibroblast. the malignant fibrous turnours have a distinct immunohistochemical profile and electron microscopic features to differentiate l from themalignant mesenchymai mesothelioma. a study was undenaken to evaluate the use of immunaperoxidase stains on paraffin embedded tissue lo define the cell type in routine lung cancer preparations. and in particular to identdy a subgroup of turnours showing neuroendocrinedifferentiation. forty lour consecutivethoracotamycaseswere selected. following apilot study of cases. to assess digestion times and potentiaily useful antibodies, the remaining cases were processed using a battery of monoclonal antibodies: cytokeratr iaelfae , e ). neuron specitic enolase (nse), chromogranin. and beta microglobulm. in addition to the carcinoid turnours and oat cell carcinoma in the study large cell carcinomas and adenmarcinomas demonstrated positive neuroendocrine markers. uiirastnrcturally, dense core granules could be demonstrated in only / of the large cell carcinomas and in / adenocarcmomas. the discrepancy between the lmmunoperoxldase staining and electron microscopic features likely reflects the heterogeneityafthese turnours. in thisstudy noneof the turnours co-expressed neuroendocrine markersand beta microglabulm. however, the staining panern was inconsistent m the remaining cases high molecular weight cytokeratin ( pe ) was stronglyposltlve m all casesot squamouscell carcinoma and negativein everyihing else. in summary. monoclonal nse and chromogranin appeared to provide sufficient information to identity neuroendocrinedifterentiatian in thecasesexamined m this study. high molecularweight cytokeratinwasfound to bea usefuldiscriminaforforsquamouscelicarcinoma. beta microglobulin was negativemall the turnoursshowing neuroendocrine differentiation. butthe inconsistency of staining m non neuroendocrinetumaurs. made it less helpful for routine laboratory use although endocrine differentiation is the essence of small cell carcinoma of the bronchus, its occurrence m other morphological ("on-small cell) types of bronchial umour (large cell, squamous and adenmarcdnoma) is welldescribed however, its prevalence m such tumours is uncertam, estimates differing from study to rudy and accordingto how it is sought. we have examined, byimmunalabellmg, expression offiveendocrine markerproteins (neuron-specific enolase (nso, protein gene product [pgp) . , the bb isoenzyme of creatine kinase [ck-bb), synaptophysinands-t protein)m bronchoscopictissue biopsiesof "on-smallcellcarcinomaandasse~ns varlabiltty within and between tumour deposits in subjects coming to necropsy with disseminated disease exactly half of the tissue biopsy specimens immunolabelled for one or more marken; one for four, four for three, twenty lor two and five for one. possibly indicating an element of endocrine dtflerentiation inapparent from their morphology. expression was even more prevalent amongst the extensively-sampled turnours at necropsy, but since theinlraductionofthenewgeneralpractnianercontractmapril ,lhere hasbeenasignlicant increasein thenurnbeisof skin biopsiesreceivedmhistopathologydepa~ments in ourdepartment there has beenalhreefold increase in numbers of general practiioner skin biopsies. the aims of this study were to crnlcally appraise these biopsiesand comparethem tosimilarlysized skin biapsiesreceivedfrom hospital in-patientsviageneraland plastic surgeons for the six months prior to and aner st april . data collected included numbers received, ranae of pathological diagnoses, quality information supplied on the request card, accuracy clinical diagnoses. adequacy of excision, age. sex and sites of lesions the resuns showed a similar range of pathological diagnoses. the quality of clinical information supplied was comparable in the two groups as was the age and sex of patients. general practitioner biopsies were less common from the face. clinical recognition of lesions was somewhat less accurate amongst general practitioners than amongst hospital surgeons inadequate excision was more common m general practnioner cases. . % of general practitioner lesions were found unexpectedly to be premalignant or malignant (eight cases) and all ofthesewere inadequatelyexclsed. important implicationsemergingfromthisstudy are dlscussed an audit of skin biopsy specimens from general practitioners in grampian region: changes in requesting practice and specimen type assessmen ofresaction marginsofsurgicalspecimens~s becming more important m manyfieldsofpathology. we wwe interested in developing a means of assessing surgical margins dermatopatholqy in both conventionally removed skin ellipses and m skin ellipses removed during m o~s chemasurgery technique many of the conventionally used markers, such as indian ink, alcian blue and tipp-ex correction fluid are difficult to use i" that they are messytoapply. slow todry and show insufficient contrast wiih oneanother both lnthegrass specimen and microscopically weused"superman'paint,apaintusedforresinandplastermodels,wh,chcomesin awlderange of colours. the paint was easyto apply. did not run and dried qwckiy becauseof the variety of colours avaciablewe were able to apply contrasting c~l o u n to the vertical and horizontal axes of b x c~s i o~ af skm elhpses removed by mohschemosurgery.thepaint proyidedagaodmarkergrasslyand wasnot affected byfreezinqthetissue model paint provides another marker lor surgical bxcij~ii margins and s particularly useful for moh's chemasurgery where horizontal and vertical axes aremarked inorderto assess theadequacyoftheexcision.the model paint may also be usetul in other branches of surgical pathology where resection margins are important. in psoriasis there is altered bpidermal dmwentiattan and increased epidermal turnover both which involve changesin intercellularadhesion aquantnative imm~noh~st chernicaicompa~~sonof the expression of the integrin staining of integrin p subunlts - and e subunlts were disclosed usmg an andin-blatln peraxidase techn!que. large epidermal dendritic cells (antigen presenting cells) expressed p- the psoriatic skm.showed increased - a- . - . and p- expression. buta- and~- showednosignificantdifferencefromnormal thelncreasedlntegrin expression by keratinocytes seems to be a reflection of awered epidermal differentiation rather than increased keratinoc ?turnover themcrease in ~- pasitivedendriticceilscauidbeareflectianofalteredanfigen handkngin psonatic gin. interleukm- (il- ). used m the treatment of patients with metastabc disease fallmg to respond to conventional treatment, can induce regression oftumwrbuik in certain patients however, the systemlc administration ofil- is associated wlth a number of toxic effects, including dermatological compl#catlons. these have been poorly documented we have prospectivehl studied the dermatological reactions patlents treated wiih il- for metastats cdorectal ~arconoma. pre-and past-treatment biopsies were obtwied where possible, arid sect~ons stained with h e. giemsaand pas: hesh tissues weresubjected to immunophenotyplng.there were femaleand malepatients.with treatmentrour~sranginginnumbwfrom - onlyonepatlenthadapastmedlcal hlstoryof any skm complaint (eczema]. four patlenk suffered a dlffilse eryihematous reaction with mild desquamatm and dryness the other patient developed genwalised erythroderma and an additlonal photosensitivity type reaction. histology, anerthe initialcourse. revealed patchyspmgios s. exocylosis and basal layer epidermaldamagewnh a mild perivascular chronic inflammatory cell mfinrate. with suhsequent treatment there wasthlckenmg ofthe epiderrnls, plgrnent incontinence. dermal oedema and more marked chronic perivascular cell tnfiltrate. immunohistcchemistry revealed markedchanges inthe expression of cdt , hladr, cam- and cd m the derm . these changes were greatly heightsnedwith subsequent liealmsnts. with addnional changes tn other t cetl markers. clearly il- enhances the parenchymal expression of antibody-dependent and antigen-mdependent accessory molecules which are important in focusing the immune response. claire m. thornton. maureen y. waish weexaminedalfprimarycutaneaus malignant melanomas seen rn thmdepartmmtover a fweyear permd from to . the total number of tumoum was the number of cases of malignant melanoma both invasive and m m u , increased from cases ~n to cases in . superfmal spreading melanoma was the most common type of melanoma, accounting for % of the total cases this was followed by the nodular melanoma whch accountedfor %. wlthlentigamallgnamelanomaandacral lent~g~nousmelanomabe~ngtheleast commontypes. therewasanincreasmg numberoftumourspresentlngwlth abreslow'sdepthoflessthan t mm. thefigurermng from % of cases in lo % of cases m most cases were stdl of ciar*e kud ivanhough mcreasing numbersaftumour presented at clarke levels i and i wlth a corresponding reduction ~n cases presenting at clarke level v more lesions presented with a flat cross sectlonal profile ~n the later years the figures lncreaslng from % in % in i w o he numbor of i c s~s showlng surface ulceratan at predentatlon d-reased from % in t to % in themltotlcact~vlty. thedegreeofp~gmentalion. theintensiiyofthe~nnammatorycell infiltrate. the predominant cell type and the mcldence of vascular lnvaslon showed no change over the study penod classification of benign vascular tumours is notoriousiy difliwlt and ciinicopathological correlation is often imprecise. this almost certainly reflects the tendency of pathologists to lump together different lesions under the broad heading 'haemangioma', sometimes with capillarylcavernous subtyping. twelve cases of a distinctive subset of cavernous haemangiomas, to be known as sinusoidai haemangioma, are presented. these presented in adws ( female. male. mean age years. range & ). five arose in the upper limb and five an the trunk (of which two developed in mammary subcutis). all were solitary and presented as a bluish cutanmus swelling up to . cm in diameter of variable duration. one case was associated with ipsilateral gynaecomastia. average foiiow-up of . years has revealed no tendency far local recurrence or metastasis. histologically these were subcutaneous/deep dermal lesions with a lobular, sieve-like appearance and focally ill-defined margins. they were composed of dilated. thin-walled interwmmunicating vascular channels with a pseudopapillary architecture. thrombi were common and two cases showed central infarction. vascular spaces were lined by monolayered endothelium which was often plump and hyperchromatic but n d mitotic. distinction from wnventional cavernous haemangioma and angiosarcoma (particularly in breast lesions) is discussed. current methods forthe identification of herpes simplex virus (hsvj may fail to identity the presence ofthe virus in biopsy or autopsy material. we have investigated autopsy cases and neurosurgical biopsy cases of clinically suspected herpes simplex encephalitis by a nested polymerase chain reaction (pcr). dna was extracted from routineiyprocessedand paraffin embedded material byproteinase k incubation, phenol chloroform extractionand ethanol precipitation. nested pcr was performed using known oligonmlaotide primers designed from the hsvtype giywprotein d gene from an area with the lowest homology with hsv type . two of autopsy c a w and of neurosurgical biopsy cases ware pcr positive for hsv. the third neurosurgical biopsy case was not confirmed by pcr as being due to hsv. such primers lo hsv allow the rapid retraspeaive diagnosis of herpes simplex encephaliis and should be of value to neurapathologists. tissueembedded at lowtemperaturein lowicryl-k m resin hasbeenshownto besuitableforimmunogoldlabellng of cellular antigens, and to be capable of withstanding the processing required for hybridization of nucleic acid probas.theaimofthisstudywastoestablish basic wnditionssuitabieforhybridirationof digoxigenin labelled dna probes to lowicryl embedded material, both at the light and electron microscope levels. cultured haemopoietii cells wereembedded afler brief aldehyde fixation. digaxigenin labelled whole human dna or plasmid per (negative control) probeswereappliedtothinandsem-thinsectionsafterproteolytictilgestion and/or denaturation by heat or alkali. hybrids were detected in semi-thin sections by standard wlourimetric methods. and in thin sections by immunogold techniques. elaborate blocking procedures and prolonged washes were found to be unnecessary. specificnu~l~earsignaiwasseenatbdhthelightandemisv~iwiththewhalednaprobe,revealingdetailsof nuclear dna distribution not evident in paraffin sections or cytospun preparations. non-specific binding and background were minimal. signal was greatly reduced if the denaturing step was mined, and was slightly increased by protwlytic digestion, though at the expense of cytoplasmic morphological integrity. while the sensitivity of this system is limited by the fact that hybridization occurs only at the suriace of the section, it is a rapid and specific means of nudaic acid detection, and offers the dossibilitv of accurate iocalization of intracellular human and viral nucleic acid sequences at a fundamental level. of prostatic carcinoma, mouse liver, kidney and gut were used. acp was demonstrated using an kc-dye cwpling method. the acp was unaffected by the addition of mm tartrate. although the acp was known to be 'tartrate sensitive'. the addition of mm tartrate or mm sodium fluoride weakened but did not eliminate the reaction. mouse tissues, prostatic carcinoma and leiomyosarcoma tissues were processed using variausfixatives and embedding procedures. these were tested for acp and trap. the acp in the muilinucleated giant calk of the leiomyosarcoma survived standard formalin fixation and paraffin wax processing and was tartrate resistant. as expected mouse liver, kidney and gut acp and prostatic acp did nd survive most fixatives and embedding procedures. however acp could be demonstrated in those tissues processed bythe 'amex' method. i.e. fixed in acetoneat - o' c. processed throughmethyi benzoateand xyianeto paraffin wax. theacp.thus imalised in paraffin blocks was eliminated by the addition of mm tartrate to the incubating medium. if needed the amex pracedure prrsenes some tartrate sensitive acp in paraffin blocks. acp that survives standard fixation and embedding procedures is iikeiy to be tarfrate resistant. showed acp only in osteoclasts. various elements ot tissue processing procedures were examined to find the wnditionsnecessarytoachievemaximum acp localisation. tissue blockswere pr-ssbdintowaxusingstandard embeddingprocedures. threefixativeswereused. % neutral bufferedfmalin, formalcalcium and ethanol allat + 'cfor hours.twodecalcifyingfluids wereemployed, %ethylenediamine-tetraaceticacid(edta)ph . at + %, zo' c and 'c.andformicacidisodium citrateat+ %forw hats. formalinfixed edtatreatedtissuaat + % produced maximum acp activity. acp was shown in osteociasts, some ostwcytes, chandrocytes. cement lines., tide mark, periosteaicellsand large macrophage likecells inbona matraw. formalinfixed tissues decalcified in edtaatzo'cand 'c werenegativeforacpaswerealltissuesfixedinethana . lnformalcalciumfixedtissueand formic acidlsodium citrate decalcified tissue the acp reaction was weaker. with some elements, e.g. chondrocvtic acp missing. all the acp preserved through paraffin processing was tartrate resistant. it is well recognised that morphology and optical resoiution are vastly improved with resin as opposed to paraffin embedding of tissue. however, difficulties in producing consistent immunopetoxidase reactions on resin sections have caused many departments to abandon thetechnique. although antigenicity is preserved the low optical density of diaminobenzidine (dae) means that the reaction product is barely visible in thin resin sections. the aim of this study was to develop a method whereby antibodies wmmonly used on paraffin sections wuld be successfully applied to pm resin sections. tissues fixed for - hrs in % formol saline were partially dehydrated and infinratedwithlr whiteresinat °cfollowed bypolymerisationat cusingacatalyticmethod. pmsectionswere reacted with polyclonai and monocionai antibodms using a standard indirect immunoparoxidase technique. visualisationwas with a silveramplification systemfordae (amenham) appiiedasthetinalstage. excellent resuns have been obtained with a rangeof antibodies including s , von wiilibrand factor. immunoglobulins, uchll and l (dakoltd.). usingthistechniqueitisnowpossibletocombinehighresoiutioniightmicroscopywithaprecise immunocytochemicai reaction. the advantages are obvious and are particularly relevant in the field of lymph node pathology. however, at and gythe number in muscle dropped significantly . and hoursfoilowing treatment, but hadrecoverad to w n t m levels byfivedays. in the lamina propria, agnor numbersincreasedinitiailyaflerthe . and gy treatments but returned to control values by five days. with gy the agnor numbers showed a significant fall hours after irradiation: this decline continued up to five days. it is evident that &nor numbers within the small intestine are affected following irradiation. the variation in counts is dependent on dose, cell type and time since irradiation. karen m. britten, w. r. roche oepartment of pathology, southampton unwewty general hosp~lai, southampton, so xy in response to ever-increasing demands for immunophendyping in inflammatory disorders, we have developed anernatwefixation and embeddingtechniquesforsmall biopsy specimens. bronchial biopsieswerefixed in buttered formaiin and processed lor embedding in araidite or were fixed in acetone containing protease inhibitors and embedded in the water-soiubk resin glycol methacrylate (gma). gma allowed for the investigation of a full phenotypic profile akin to that which may be wfwmed in frozen section while yielding far superior morphology and greater numbers of d a n s from small biopsies. the phenotypic markers included those for t-ceiis (cd . cd , cd ,cd andlfal),macrophages(cdllc, cd ),mastcelis~b b andaat)andeosinophils(mbp, egl and eg ). wehaveaisodemonstratednautrophiieiastase,cytokinesandtheceiiadhesionmolecuiesicaml .elamand vcam. similar high qualty sections were obtained with araidne but the repertoire of antibodies was restricted to thoseantibodieswhichcannarmailybeappiiedin paraffin. wesuggestthatforsmaii biopsies whichrequiredetailed immunohistochemistry, such as in the areas of transplantation and mucosa immunology, fixation in acetone at - % with the inclusion of protease inhibrors and processing into glvcolmethacwiate with careful temderature control gives optimum results. these included % formaiin at vanous temperatures, microwave treatments. bouin's fluid and a wmmercialiy avaiiabieproduct "rapid fix".thetissueswereroutinelyprocessed. embedded in paranin wax andstained wilhthe haematoxylinandeosin method. an eval"ation~fthefi~alion methodswasaisocarriedoutforimmunocytachemicai stains. from microscopic examination of the results t was evident that for the haematoxyiin an+eosm stains. % formaiinat o'cwa~ wnsistentiytheoplimum methodof choice. farimmunocytochamistryali methodsrasuited in a poor performance using a standard trypsinisetion time. however, an acceptable result was achieved from % formalinat °canda microwave fixative method. byreducingthetrypsinisation time. this. however, required strict wntroi. thus it is possible to fix tissue within one hour. by a method which is cost effective and which can be used within limitations for immunacytochemistry. we set out to study the extent and time dependency of storage related artefacts in cytospin fluid (shandon). we assessedtheeffectof stwage in cytospin fluidon the nuciearmarphoiqlyof breast fnac. fnaspecimsns were coiiected on day and slides were made from each specimen on day . day and day . these were fixed with a spray fixative. between each sampk preparation, the cytospin colleaion fluid was kept at %. the slides were fauigen stained and nuclear morphological parameters (area, perimeter, form ar. farm pe. and convexity-concavity) weremeasured using aseescansoiitaire plus imageanalysis system. there wasasignlticantchange in ail the parametem betwwn day and day , and between day and day (p < . ). the measurements were repeatableon differentoccasionswithoutsignificant difference in theresuns. these results indicate thatstorage in cytospin fluid significantly aners nuclear morphology. the nuclei become progressively larger and more irregular in shape. il is therefore important to standardize the storage conditions of fna specimens. if accurate objective comparisons are required. the identification of macromolecular components of hydrated patholqlicai tissues revealed by low temperature scanningeiectron microscopy (ltsem) isan emergingfieldof enquiry. in orderthatthetechnicaidetaiisforltsem labeilingmaybeestablishedanexperimentaiprotocoi has beendrawninwhichiabeiparticiesofhighatomicnumber are visualized. the experiment comprises a mcdei system in which bovine serum albumen as a known amigen is dissolved in phosphatebutteredsalineand adsorbedontonitroceiiuiosemembtane. theantigen onthemembrane is subsequently reacted mth rabbt anti-cow antibody and then elther protein a-goid or goat anti-rabbn-gold. aner treatmentwithadeveiopertoaddaiayerofsiivertothegoidparticies,thepreparationsareanachedtostubs,rapidiy frozen in nitrogen slush at - ooc, coated with aluminium and observed on the ltsem stage at approximately - °c. backscaneredeiectronimagingathighacceleratingvoltages( kv)isusbdtodetectsilver-enhancedgoid partic es.these areciearlyvisuaiized. thefrozen hydrated preparationsarestabieunderthe described wndtions of ltsem operation. in contrast dry, wnventionai. sem preparations are beam sensitive; their initially observed delicate uitrastncture quickly dearades an exeosure to even the moderate i kw electron beams emdioved in secondary electron imaging. a new approach to systematic storage of pathological specimens for low temperature scanning electron microscopy as greater numbers of pathological specimens are stored for wnvenient future imaging by iow temperature scanning electron microscopy (ltsem). it is increasingly important to maximise expensive cryostare capacity. a cassenesystem hasthereforebeendeveiopedwhichincreasesthe hoidingcapacityof cryostoresbyafactord . over conventional bee storage. each c-he consists of an aluminium disc . mm in diameter wilh cylindrical wells mmindiametereveniyspacedand . mmapart. specimens. mountedan jeolstubs,areretainedinthe wells by set screws. five cassettes fit into each x mm glass storage jar, gwmg a capacny for a canister cryastore(w th @rs percanister)of oostub-mounted specimens an addtionai benefit ofthecassettesystem is that each specimen is afforded a mechanically and thermally protected environment. specimen collection for ltsem may take place in a distant operating theatre or laboratory. lmmobiiiration of specimens whilst they are in transit excludes any possibility of their being damaged during normal handling and improves the prospects for survivalof accidents.afurther benefitisthataparticuiar mountedspecimencannow bemorespeedily identlledand removed for ltsem from rs well. many pathological condtions are charactensed by the presence of cellular degeneration accompanied by cytoskeietai abnormalities. in many such diswders it is not clear whether cytoskeietai abnormalities are pftmary process or are part of a secondary response to cellular insun by other agents or mechanisms. we have used a fibroblast ceii culture mcdei to study the effects of physical distension on the cellular cyioskeielon. inert beads of and pm were introduced intoceils byallowingendocytosisor bymicroinjection.thecytoskeietai response tothese beads was studied using immunofiuorescence microscopy. beads introduced by endocytosis migrated to the prinuciear region and over hours became enmeshed in intermediate filament and mlcrotubuiar aggregates. actln microfilament organiselionwas not alfected. incontrast. microinjectionof beadsproduced an immediatecollapseof morofilaments,wiulvimenbnandtubuiin distribution being presened.the immediateresponseto microlnlectlon is similar to the collapse of actin filaments s w n upon thermal stress. this experimental model has shown !hat aggregates of cytoskeietai proteins may be produced within cells as a secondary responseto intraceiiuiar debris, and that microinjection may induce cytoskeietal abnormalnies similar to those seen in thermal stress. thedetection of numerical chromosome aberrations m interphasetumourceiis bynonisotopic insitu hybridisation has been previously described but the application d t h s technique to paraffin embedded material has been wmpiicatsd bythe requirementfottissuesectioning with the production of partial nuciei. inthisstudy, the analysis - pm thickparaffin sectionsolconventionally processed caski ceilsusing both human papliiomavlrus(hpv type l e a d achromosome specificalphoid probe wascompared with resunsomained usingintactceils.the use of sectioned material did not give signal distributions comparable to those obtained using whale cells. this is consistent wnh a mathematical model derived for the relationship between section thickness. nuclear size and nuclear retention in paranln sections. a method was therefore developed for the extraction and analysis of nuclei fromthick( pm)paraltinsectionsandappiiedtotheanaiysisof squamouscelicarcinomasofthecervix(n = ). the number of copies of chromosome varied from to and this variation was apparent both between lesions and between tumour ceiis within the same ieaon. this is comparable to resuns obtained wth cervical carcinoma derived csll lines. there was. however, no clear relationship between the presence of hpv sequences and chromosome number. these preliminary results suggest that the postulated loss of host suppression of hpv gene function by deletion of genes on chromosome does not occur through gross chromosomal abnormalities. membranous giomeruionephritls (mgn). an immune-mediated disease, is a frequent caused renal morbidity in man. cationic bovine serum albumin (cbsa), given to nzw rabbits in a chronic serum sickness-type protocol. is knowntoinduceglomerularchangessimilartothe humandisease. we~ssedtheenectofashortcourseofthe immunosuppressivedrug cyaon thedevelopmentof early stage.cbsa-induced mgn. fourteen male nzwrabbts received an iv immunismg dose of mg cbsa and p g e. coliendotoxin. one week later they commenced daily iy inlectionsaf mgcbsafor ~onsec~t~vedays. three rabbtsweresacftficed atthistime. sixofthe remaining rabbits were commenced on a short cou~sb of o m cya. whilst continuing to recewe daily doses of cbsa. the remainingrabbitswsregivencbsaonly.after consecutivedosesofcbsathesell anlmaisweresacnficed.ali rabbns given doses cbsa showed early stage mgn and those given doses of the cationic protein showed a more mature, established disease (thickened glomerular capillary wails wth diffuse. global. granular deposition of igg/c and subepithelial electmn dense deposits). four of the cya-treated cbsa rabbns showed a marked reduction in giomerular capillary wail c deposition. three of these rabbns had considerably less severe disease ultrastructuraiiy. these results suggest that cya may aker the course of cbsa-lnduced mgn. 'oroartment of pathology university of edmburgh m&~aischooi: late renal aliogran loss s due to arterial intimai proliferation and iumenai narrowing. there are few studies ofthe phenotypes of the intimai cells. we analysed these lesions by light microscopy and immunmyiochemistry using antisera against t-lymphocytes. b-iymphocytes. macmphages, smooth muscle cells, class ii hla or molecules and the proideration antigen pclo vessels were studied from gran nephrectomies resected between and months post-transplantation. we identified an arterial endolheliaiilis, r-rted in cardiac aliografts, but not emphaszed in renal graftrejection. panernsolarterial pathoiogywwerewgnisd: ( ) endotheiialitis in nnteriobuiar arteries without intimal proliferation, ( ) endothelialiis in larger arteries accompanied by intimal prdtferat!on of smooth muscle. ( ) '"inactive" lesions with thickened intima (i foam cells) but no endotheliaiitis, and ( ) 'natural" atherosclerosis of larger arteries. the endothellaidis tended to m u r in shmw sumving grafts. the pedominant cell was the macrophage. with fewer t-lymphocytes. pclo was expressed in mononuclear ceiis, smwth muscle cells and endothalid ceiis. pmicuiariy. but not exclusively in younger grafls. we proposb these ledonsevolve, variably. from an early endotheiiaiitis to late chronic vascular rejmlon or gralt athwmierosis. the predomlnance of the macrophage at ail stages, suggests it plays a significant roia in the evolution of these lesions. the rat is used to study the response of the renin-angiotensm system m diseases such as hypertension there are structural differences in the jga butthere are few comparisons of its response to stimulalion between species we used renin antisera and an lmmunoperoxidase technique to stain renin-containing cells (rcc) ~n rat (n = i t ) and human kldneys(l nephrectomy and autopsycases). westmulated therenin-angintensin system experimentally by clipping one renal artery ( rats) and inducing sodium depletion ( rats) and studied the analogous human diseases-renal artery stenosts ( cases) andaddison'sdissase( untreated and treated eases). wecounted the rcc and plotted their distribution on scatter diagrams. there were some dinerences in distribution between the species but in boththerewasagradient in distributionof rcc which predominated m the superficial renal cortex. in sodium depleted rats. recruitment of rcc in the iuxtamedullary jgas abolished this gradient. while in some of the animals with renal artery clip hypeitension the normal gradient was reversed, with most rcc in the deep cortex. in bdhu~nreatedaddison' diseaseand~nrenalanerystanosistherewasanoveralincrease(xs)m rcc butthenormal gradientoftheirdistnbution withintherenalcortexwasmainlained.theseresults haveimpl,cationsfortheroleolthe intrarenal renin-anglotensln system in the control of renal haemodynamcs. we have developed a model of adult human prostatic epdhelium that allows arch$tectuml and cytologioai features to be maintained. epithelial organolds produced by enzymic digestion of human benlgh prostatic hyperplasla tissue weresuspendedm type collagengelandsubcutaneouslyxenogranedintointact malenudemice.thexenogranis progressively invaded by mouse stromal cells thesesurround theepithelial organoids and supportthe reformation of epithelial structures with a lumen, lined by a mixed epithelial layer. as the lumen forms tall columnar epithelial cells begin to be seen, these progressively express the prostate specific epithelial markers. psa and psap further the xenograflsexpress appropriatecyiokeratin markers in boththeluminaland basaleplthellal cells. gelsplaced within a . pm millipore chamber, which do not undergo stromal invaston. lose all epithelial organisation with disorganised sheetsand ballsofcellsbeingfound.these cellsdonot express thesecretory markers. in the absence lanandr genic~tim~i~sep,th~l~~l structures wsth a lumen are formed but there are no tall columnar secretory cells and noexpression ofthesecretory markers. thismodel hasfurther been investigated todetermine theresponseof human prostatic cells growing in vivo to the antiandrogen flutamide and to a -aza-steroid e-reductase inhibitor these observations indicate the essential role of both stromal cells and androgens m dictating functional dlfferentlatnon this model will allow the dissection of the regulatory processes involved in prostatic differentiation. hepatocyte growth factor (hgf) is the most potent known mitogen for adult rat hepatocytes in pimary cuiture and isthoughtto haveanimportant rolelnlivergrowihandrepalr linle~sknownaboutthemechanismofactionof hgf on hepatocytes. since the adenylate cyclase system has been implicated in hepalocyie growth control. we examined the role of adenylate cyclase and cyclic amp wmp) in hgf-stimulated dna synthesis. human recombinant hgf (hrhgf. numl) had no elfect on baa or stimulated adenylate cyclase activity in membranes prepared from freshly isolated rat hepatocytes. similarly, hrhgf had noeffect on intracellular camplevels in cultured hepatocytes. furthermore, agents which increase camp inhibited hrhgf-stimulated dna synthesis m primary hepatocyte cui ures glucagon had an i . c. , of lo-'; fotskolin ( . ibmx ( "m). -broma camp ( pm) and dibutyryl camp ( pm) completely inhiblfed hrhgf-stimulated dna synthesvs. from thts. we conciude that adenylate cyclase and camp do not have a role m hgf-stimulated dna synthesis m pnmarycultures oladult rat hepatocytes. the receptor for hgf has recently been identified in tissues other than the liver, as c-met a protooncogenewith intrinsictyrosinekinaseactivitv. whether or notc-metactsasthsrecedtorfor hgf ~n heoatocvtes s currently under investigation a novel in wvomodel of intestinal differentiation is descnbed. fourteen-day, undifferentiatedfetal rat small intestine. stripped of the major part of s mesenchyme. then suspended in a type i collagen gel and renografted ~n a nude mouse. undergoessmall mntestbnal morphogenesis and cytod$ffeienbat$on. all tourmapr epithelial imeages. namely paneth. goblet. columnar and endocrine. are present. double labelling m sit" hybndlzatlon, employing biotinylated and digoxigenin labelled dna probes to whole rat dna and whole mouse dna, reveals an unusual ]uxtaposition of species specific stroma. the outer longitudinal smooth muscle layer, and the major part of the lamina propria. p isthemost commdnlyalteredgene~n humanturnours. mutati~nleadstothep~oducfionolanabnormalprotein which can be detected by immunohistology. such abnormalales are seen in a wide variety of turnours, including colon cancer. abnormal p protein levelshavebeen detewed in & % of sporadiccolorectaltumours. in order to determine i p mutations occur in carcinomas arising from dyspiasla. we have investigated the prevalence of such mutations m colorectal carcinomas from patients wr)h long-standing ulceratwe colitis %). lmmunocytochemicalstalnlng waspwformedon freshand paralflnembeddeduccarclnomasand sporadlc carcinomacontrols matched forsite, stageand grade six areas ofdysplasla, (fourassoclatedwlth uccancers)and sporadic adenomas were also stained. p protein was detected by immunohistochem~stry m the fresh uc cancers and / ( %) ofthe paraffin embedded uc cancers usmg the antibodies cmi, pab , pab and pab . slmllarresuitswere obtained in thesporadic carcinomasw,th fresh cancers positlvefor p and / ( %) of the paraffin embedded cancers. two areas of dysplasla which were associated with p postlve uc cancer~also showed positive p staining, alongwith an adenoma. our results indicatethatunlike k-ras mutations, p proteinabnormalities occurat a similarfrequencyln sporadic colorectal carcmomas, carcinomasar sing !n uc as well as being present in uc dysptasasla. this work suggests that p mutations play a mle m the dysplastacarcinoma sequence. threepanernsofstainingareloundin humancolonusingatechniquetodemonstrateo-acetylationofsialomucins (mpasj. % afindivdualsshowunifwmmpas-positivity. theremaindwareeitherent~~ympas-negativewmpasnegativewith occasional positive crypts. we suggestthatthisrepresentspalymorphismof an autosomal gene ( sa) controlling -acetylation of sballc acid. isolated crypt-restricted mpas-posltivky in otherwise negative indivtduais representing somatic mutation of the ma* gene in crypt stem cells of osa'/osa-individuals. to test this we have studied colons from patients with rectal carcinoma, half of whom had received cgy radiation days preoperataely. radialiond~dnotaffecttheprevalenceofthethreepnenotypesbutincreasedthefrequencyofmpasposltlvecryptsinanegativebackground(t ~ ~~~ . ~ to*, p < . ), largelyduetocryptsshowingseclorial mpas-positivlty ( . x lo* ys . x to , p < o.c€ql). consistent with incomplete crypt colonisation by a recently mutated phenotype. the prevalenceofthisosa*/osa~phenot~e(radiated %, non-radiated %) isveqcloseto the predicted heterorygosily rate ( . %. hardy-welnberg law). thew resuns suggest that human colonic crypts are monoclonal with a longer stem cell cycle than the mouse and that mpas staining provides a method for measuring human stem cell mutattonal load. pouchrris m leo-anal resarvoirs is a frequent complication of restorative practocolectamy which is associated wtih constderable morbidity. long term complications of pouchitis are unknown, however patient follow-up wlth sigmoidoscopic surveillanceis mandatory to assessdysplamc or neoplastic changes in resldual rectal mucosa. we examined epithelial cell proliferative activdy in the ileal mucosa of pouch biopsies using the antibody pclo which detects nuclear expression of the kd nuclear protein proliferating cell nuclear antigen (pcna). ten patienls with functtoning ,lea-anal pouch reservoirs of at least one year duration were biopsied and assessed histologically for evldence of pouchitis formalin fixed paraffin embedded biopsies from anterior and posterior pouch wall were examlned with pclo using the pap technique. ten terminal ileum sctions from right hemicokctomy specimens werenormalcontrols. cryptsin pouch biopsiesand normalcantralshadasimilarpciolabelling indexmeanof k and % (mean values - and w ) respectiveiy the sides and tips of villi had a significantly greater pclo labellmg indexinthepouch biopstes( mean. range - ). compared withnormaicontrols(t % mean, range - ) these resulk demmstiate an expanded proliferatwe epnhelial compartment in ileal pouch mucwhich in contrast to normal terminal ileum involves villous surfaces. considering the frequency and long term natllrs pouchitis. thesefindingssupportthe need for continued pathalogical and clinical assessmentof the ileal mucosa in the neo-rectum of these patients. we, cui, i c talbot, j. m. a. northover signiticant alterations in structure. function and gene expression of mltochondna have been reported in cobrectal turnours. but it $ not known rf these abnormalities are due to mitochondria genetic alteration. in this study, total cellular dna was isolated from l lo rectal carcinomas, adenomas and their adlacent histologically normal mucosa. these dna samples were digested separately with different restriction endonucleases. and then analysed by southern blotting using apurified mtdnaprobe. the restriction fragment pattern oftumourmtdnawas comparedta thatofeorrespondingnormalmucosalmtdna.theseresultsshowedthattherearenalargedeletions. insert~ons, or rearrangements $n turnour mtdna. and no single base changes m the delectable regions in spite of some polymorphic vanations. our results suggest that mtdna changes are unlikely to have a malor role in human colorectal tumoungenesis. hence, alterations in colorectal turnour mitochondria must be dependent upon other mechanisms crescentic colitis: the clinicopathological spectrum of a distinctive endoscopic feature in the sigmoid colon n. a. shepherd, s. gore, s. p. wilkmson oepariments ofnsfopafholcgyand gastreoterol~y, gloucestershre royal hospml, great western road, gloucesfw, crescentic coibs describes an endoscopic appearanc of the sigmoid colon charactwised by mucosal swellmg, eqhema and haemorrhagestrictly localised tothecrescentic mucosal folds. in alive yearpericd thisdiagnosiswas made m patrents, representvlg .a% of ail fbeopta endoscopies. there was a male predominance and most plients were middle-aged or elderly. dwerticulosis waspresent m most ( %) but theabnomallf~es wareconfined to the crescentic mucosal folds with sparing of the divenicular onfices. the malorlty of patients presented with a history of bleeding perano. histologically there wasaspectrum of changesvaryingfrommlnorvascularcongestian to florid active inflammatory disease with crypt architectural abnormalities mimicking ulcerative colitis. three patients presenting with crescentc colitis later developed the clinical, endoscopic and histopathological features of distal ulcerative coliitls: two other patients with a history of distal ulcerative colitis were found to have the charaderlstlc changes crescentic colitis only at endoscopy. three cases showed the histological features of mucosai prolapse the findings in thisstudy demonstratethat arelativelyspecificendoscopicfeaturemayexhibit a wide spectrum of pathological changes whilst luminal mucosal inflammation of the sigmoid colon, usually in a sociat on wiih diverticuioss. may mimic the pathology of chronic inflammatory bowel disease. asmall propartion of these cases may represenl a strictly locallsed form of chronic ulcerative colitis. of genome and antigen a n various anatomtcal sees the resuns have imolications lor the mechanism of e n t~ of mv into neurons and for mechanisms of transynaptic viral spread neuiopathology, fnstitute of pathology j chow, j tobias.' k co ston. t j chambers estrogen is generally considered to maintain bone mass through suppression of bone resorption we have previously demonstrated that administration of pharmacologic doses of estrogen increased bone formation in ovary-intact rats to assess theeffectsof physiological concentrationsol estrogen on boneformatian. estrogen was administered to ovariectamised rats fi n which bone resorption was suppressed by ahprbp. animals receiving exogenous p-estradtal (ed ( wglkg. t o wgikg and w pgkg daily for days) showed a dose-dependent increasemtrabecularbonevolumeaft %. . % and . % respectively, compared wnhthoseratstreated with ahprbp alone. the increase in bone volume was due to bane formation in e,-treated animals, in which bone resorption had been almost completely suppressed by ahprbp neither ovanectomy. ahprbp nor e,-treatment had asignificanteffecton thevolumeorrateoflormationofcortical bone thus. theiocreasedbonerasorptionwhichis aconsequence estrogen-dellclency entralns lncreased bone formation, whlch masks a slmunaneous reduction in estrogen-dependent bone formation. it thus appears that estrogen maintains bone volume not only through inhibition of bone resorption. but also through stimulation of bone formation. pgs m bone formation m vmo. which may represent a pathway common to bone anabolism that s observed !n response to many e""lio"mental t m"ll pgf , was wlthoul effect we found that nodule mductton by pgs occutred early the cunures, belore nodules lntegrln expression e n human bone was examkned by immunohistolqlical stalnmg of edta-decalcrfec and undecalcllned cryostat sections of fracture-and tumour-associated callus dbtalned at surgery and neonatal costochondral )unctions obtained at autopsy. cases were stained wlth a panel of well-charactsnsed monwlonai antibodies against p - . el- and uvp integrios using abc peraxidase and indirect immunofluorescence techniques. osteoclasts stained lor pl , p . u and ovp mtegnns. indicating that they express u p nlp- ) and uvp (classm vttranectin receptor) ostmblasts stained lor pl, and u , and osteocytes stained for p l and . indicating that ostmblasts express n pl nlp- ) and m gl nlp- . classical fibronectin receotorl and that vlp- expression s reduced or lost during differentiation to astwcytes j qulnn. n a. athanasau nufield depanment of paihology and bactenotogy, level , john radcoffe hospital, oxford, ox du osteoclasts are known to effect bone resorption in inflammation and malignancy but whether other cells of the mononuclear phagocyte system. particularly macrophages and macrophage palykaryons, are similarly capable of pathological bone destruction is uncertain macrophages derived from tumours (human lung camnomas. murine mmw-assmated mammary carcinomas) and inflammatory lesions (munne foreign body granubmas) were cuituredonboneslicesbothin thepresenceandabsenceaf stz slromalcells.theseneoplasticand inflammatory iesions contained a heavy macrophage infiltrate but no giant cells and no calcified tissue. there was superficial roughening ofthebonesurfacebymacrophagesboth inthepresenceandabsenceofst cellsand.aher t days. scattered areas of lacunar resorption n co-cultures of macrophages and st cells. normal pulmonary tissue macrophagesdid not produce resorption lacunaeunder these conditions. the results show that macrophages alone are capable of atype of low-grade boneresorption and that a subpopuwion of turnour inflammation-assaoated macrophages following specific interaction with slromal cells, can differentiate intocellscapable of the special sed function of high-grade lacunar bone resorpt on macrophages may thus directly contribute to the mteolysis associated with metastatic turnours and inflammatory lesms in bone differences in the grade of osteolysis may also account for clinical differences tn the degrees and rate at which pathological bane resorption occurs the george washmgton university medtcal center, washnqton, c , u s a for decades, new technological advances have been hailedor condemnedas representing the extinclion cla~s~cal diagnostic surgical pathology, but so far the reports of the death of our specialty have been grossly exaggerated. indeed, the newtechnologies of the sare seenas aids torathet than replacementsfor careful and intelligent gross and micmscopic examination and interpretation, which havealways remained the 'gold standard" against wnichnewtechniquesaremeasuted thedecade will bemarked by anexplosionof pos ibilitiesfort ueas well a non-tmue diagnosis, balanced by a shrinkage in both specimen sizes (already evident in breast pathology) and healthcare budgets.thus. thesurgical pathalogist will haveto becometoanevengreaterextentthecomplete physician. in order to beable to choose wiselyand economically from thediagnostic"menu"availab e. thesurgical pathologist w d also have a greater need than heretofore to be a competent cytopathologist as well, as many of his or her cases will also have fine needle aspiration material and a nuclear grading will assume greater significance o n tumor pathology. finally, the roles of the surgical pathologist ~n both research and patient care (including direct patteoi contact) will require emphasis m order to attract more medical students into our specialhl. womenorthosewithlowgradedisease.this hasledto theviewthathpv s~nielatedtocer~ c~l cancer asimple pcr protocol was developed using standards containing . - fg of hpv dna in ng of normal human placental ona toestimate levelsaf hpv dnain smearsor biopsies. the quantltativedistribution of hpv dna tn normal and abnormal ~ervlcal epithelium was mapped thmughout loop biopsy and hysterectomy specimens using micro-dissectionand histologyof alternate millimeter slices levels were measured in parallel c~n~c~i smears. preliminaryresuits show a low lwel of hpv dna(equiva ent to one copy per cells) was usual in women with normal smears or low grade abnormalities replication of hpv dna to a level of one copy or more per cell was limited to areas of cin ~ which may be very small and to atypical immature metaplasia. the level was reflected ~n the smear aswitch to a high level of hpv dna s a biological and potential diagnostic maherfor high grade precancer. cerv cal biopsies were stained by the cracker technique to demonstrate agnors. for the purposes of the study, b~opsiesweredividedlntaflvegroups-normal, kallocytosis.cini.cin iiandciniii.usinganiemps/ hastingan a m s photon framestore a customised image analysls system was created. the image s dllated and eroded to close any cavities an outlining procedure locates the agnors and records their mid-pants. from this st of midpants themeandistanceofeach agnor'slhreenearest neighboursiscalculated.thlsprocedurescanledoutfor several lelds of view. this study attempts to relate the shape of the associated "mean distance" histograms to the histologlca diagnoses in flry cases. primary adenocarcinoma of the cervix: a retrospective clinicopathological study of cases r ananoos, kamta nahar.' alison b,grigg.'s. roberts? sergin m. sma the patientfen healthy with a tendency togain weight being heronlycomplaint. gynaecological referral revealeda week gestation abdominal mass and bilateral varicose veins. laparotomy, lee oapharedomy, total abdominal hysterectomy and right salpingo-oophorectomy were carried out the len ovarian turnour was cyst~c, smoath surfaced. unilocular,cantainedturbid brownnon-greasycontentsand was cmln diameter.al cmsquarearea of lhe lining showed papillary tutmg. and the remainder was smooth. hiatology of these papillary areas revealed a papillomatow proliferative squamous neoplasm with keratinization and mild acute inflammatm. wthout evidence of cytologicalatypia.stromal invasionora benigncysticteratoma.theremainderofthecystshowednat swamous. cuboidal, or low-coiumnar type epithelium with an underlying vaguely endometrial type stroma in minute focl, with occasional small secondary cysts thls unusual squamous neoplasm was diagnosed as a proliferative epbdermoid meglomerularperipolarcell isan epithelial cell snuted atthe vascularpole ofthe glomerulus recently, theexistence of the penpolar cell has been doubted the aims of this study were first, to establish whether the peripolar cell is a m q v e cell type ~n the mammalian kidney. and second, to compare their numbers and morphology in different speces we used scanning electron microscopy to study - kidneys from each of mammalian species including man. we removed the glomeruli by microdissection and examined a minimum of vascular poles from each kidney penpolar cells were largest and most numerous m goat and sheep kidneys ( w% and % of glomerul~) meywerescant~estandsmallest humanand bovinekidneys( % and %).whileaspectsotsome per~polarcells resembled podocytesand otherperipolar cells had features reminiscent of parietal epithelialcells. in each ~pe~ie~wewereabletadistinguishperipolarcellsasaspeciflccellhlpe. weconcludefirst. that theglomerular peripolar cell s a unique cell type ~n the mammalian glomerulus, and second. that their morphology and number cystlc renal disease occurs in various forms characterised by dilatation of different pans of the nephron. the morphologoal, clinical and genetic features of these diseases is variable but some animal models have been developed m an attempt to understand the mechanism of cyst formation within the nephron. we describe a polycybtic . .ofthe kidneyinthscea-n mousew~hanx-linkedrecessive~mmunodetic,entsyndrome there is progressive cystlc dilatation affecting all parts of the nephron. the cyst lining is composed of a single l a y m c epithelium with focal nuclear crowding and the formation of micropapillary structures. the cystlc epithelial cells show subnuclear vacuolation focal basement membrane thickening is also a feature. there is no signdicant inflammatory infiltrate present within these ktdneys. election rni~roscoptc examination w e a l s that the subnuclear vacdation s due to loss of the membrane infoldings at the basal pole of the eplthelial cell wlth flud accumulatlon within the extracellular space. the basement membrane thickening is due to expansion of the lamina dense. the finding of a plycystic kidney lesion on these mice offers an opportunity to investigate the relationship beween the immune system and renal cyst formation. eqthropomtin. a circulating glywprotem, is the principal humoral regulator of elythropoiesis. it s produced in the kidney butthe precisecell oforigin iscontroversial. erythropoietin participates in a~ ~ssicaif dbackcontroi system whch attemots to restore oxvaen deiivew lo the tissues. normallv erdhrowiatin is resent in the sbnm at picomolar c mntrations bui revels may h e up to oid durilg ?&erehkpoxic ;tress. the mechanism linking renal oxygen sensing with erythropoietin synthesis is p o~l y understood but there s evidencethat cells of the innsr cortex respond to tissue hypoxia by producing elythropoietln. eryihropoietin geneexpression in the kidney can be detected by northern blot anaiysis within one hour of exposure to hypoxie stimulation. the cellular location of erythropaietin m-nger rnawasdetected inamurine model byinsdu hybridizationemploying radioiabeiled dna probes and autoradiography techniques. tubular cells of the inner renal cortex wbi b identifled as the main site of ervfhropoietin gene transcription. the location oterythropaetm production was confirmed by immunohistochemistry with anti-sera ra sed to pure recombinam dna-denvea human elythropoetin. the specific antibodies bound oniy lo tubular cell cytoplasm, confirming the tubular location of erythropoiet,n-producing cells. severe reversible acute renal failure and iga nephropathy r jackson, k l. c. mclay unrvemty diws~lon of pathology, giasgow ropl infirmary, castle sireel. glasgow, g osf whilst progressive, irreverable renel failure is well known in the evolution of a stgnificant proportion of cases of iga nephropathy, disease-related. reuerstbie, severe deteiioretion in renei function s a less well recognized phenomenon. relatively few cases aredocumented in the literatureand these have invariably been associated with m-iw haematuna. renal failure has been largely attributed to a combination of tubular obstruction by red - cast~andacutetubularn%crosisthaughttabetheresunof adirecttubulo-toxiceffectof released haemoglobin. in a review of cases of i@ nephropathy we have encountered two cases of this type. the clinical. histological. immunohistochemical and ultrastructural data relating to these cases are presented. on the basis of this evidence and an analysisof the relevant literature. isconcludedthat the accepted pathogenetic hypothesisdnot provide an entirelysatisfactaryexpianationof the phenomenon. itisfurlhersuggested that immunologically mediated injury dfrected at the glameruiar vascular pole and possibly the extraglamerular mesangium could compromise thetubular blood supply and might also lead to haemorrhage into the distal tubule at the macuia densa. scanning electron microscopy (semi when combined with electron microprobe analysis (mpa) s an expeditious and accurate method of identitying substances deposited in tissues. we report a case in which these techniques were used to study crystals in a transplanted kidney. the patient presented at age three with vitamin d resistant rickets and fanconi syndrome on the basis of cystlnosis. he gradually went into renal failure and received a kidney transplantfrom hismother. itfunctionedwsiifarafewmonths butthen deterioratedandwas removedone year after transpiantation.afewcrystalswereob~ed by light microscopy ma biopsytakenattwomonths. arepeat biopsy at four months was examined by sem and contained the typical hexagonal cryystais of cystine. the s o i i i sulphur peak obtained with mpa confirmed their elemental compojltion. the hydrophilic nature of the cystlne prevented their identificetion within routine sectionsfor transmission electron microscopy (tem). the hexagonal o~tline of aystaiswas confined to interstiitat macrophages rather than tubular arglomeruiar ceiis. pm frozen sections mounted on carbn pianchets diowed vlsualisation and analysis of the crystal deposits by sem. the use of appropriate processing methods may be crucial m identifying crystal dspasition within pathological specimens. during the year period - . new cases of dense deposit disease (m~~b,a"op,olif~=ti"~ giomerulonephritis type ill were diagnow in nonhern ireland. two further known patients developed recurrent disease in renal transplants. the mean age of onset was years (range eight- years) with five males and eight females affected. renal function was impaired in % patients at presentation which ranged from nephrotic syndrome ( %). nephrilidnephrotc syndrome ( %) and macroscopic haematura with mild protelnuria ( %) lo mild protemuria f microsopic haematuna ( %). serum c was universally low. haw of initial biopsies showed cr-entsusuailyaiatedwith rapidansefrenaifailure. % ofpatientsrequired diaiysisatorwithin twomonths of presentation. a further % d patmnts developed renal failure within three pars of disease onset of the six patientstranaplanted haw havedaveioped rmrrent diseasin their grafts six patients havenot required dialysisat ameanfoilaw upoffour yearr(ranse neloeightyears). mhaugh reialweiyuncommon, dense deposit disease isan important causeof renal failure in children and adolescents. we have confirmed that this disease has a poor outlook in terms of renal function with a tendency towards recurrence in grafts a review of renal biopsies from patients with diabetes mellitus. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . showed with diabetic giomeruionephropathyalone, with other renal diseaseand with both diabetic giomerulonephropathyand other renal disease. eight with the histologiwl appearances of diabetic nephropathy without known diabetes were alsn identified. clinical details were available on ofthe patients. these showed that in type (insuiin dependent) diabetes ( ). most ( ) showed diabetic giomeruionephropathy, showed both diabetic glome~lon~phropathy and another diagoaas, and showed aniy another diagnosis in type (non insuiin dependent) diabetes ( ). showed diabetic glomerulonephropathy with showing another renal diagnosis without diabetic giombrulonephropathy, and with both diabetic glomeruionephropathy and another diagnosis. patients investigated with nodular glomerulosclerosis resembling that seen in diabetes but not known to be diabetic at the time of biopsy, showed abnormal glucose metabolism on investigation and t showed a paraprotein. this review showsthatinpatientswithciinicairenaldiseaseanddiabetesmeliitus,therenaldiseasecannotalways beassumed to be diabetic nephropathy especially ~n type diabetes where a wide range of other renal disease can occur histological findings of diabetic nephropathy may occur in patients before diabetes is diagnosed cllnlwiiy. a j. hawie, r. l. bryan in a biopsyof arenaltransplant. we notedan artmalabnormalitythat wasunrecorded in standard texts. in an arcuate artery. theiewastheappearanceafformation ofanewartery inside theoid, with layersof muscleandelastic fibres that in places resembled an internal elastic lamina. separated from the original internal elastic lamina by loose connective tissue. in a systematic study of consecutive transpiant biopsies and consecut~ve transplant nephrectomies. another six examples of this abnormality were found. these six and the index specimen showed changes cons~stent with chronic vascular rejection. in a systematic study of consecutive nan-transplant renal biopsies showing interstitial nephritis. another example ofthis lesion was found, in a kidney showing chronic interstitial nephntis. thischange isprobablyavmantfom of muscularisation ofthsarteriai intima, isseen in chronlc renal damage, and occurs in transplanted and native kidneys. localised myloidasis ofthe lower genito-unnarytractisararedisease. few studleshaveanempted tocharacterise theamyloidtypeusing immunohistochemicalstains. wereportaseriesofnin~casssinvoivingthebladder( ), lower ureter ( )and penile urethra( ). thesecomprised malesand pfemaies with an age ranged & years. nonsof the patients had evidence of systemic amyioidoss. three patients had a past history of lower genito-urinq tract infection and of these, one had repeated instrumentation. one patient had prostatic carcmma the cmmonast presenting wmpiaint washaematuriaand the mostfavouredsurgicaldiagnosiswasa neoplasm. fowpat#ents had repeat biapsiesfor persistent orrecurtentamyloidosiswith atimeintmal ofupto t yearsfram initial presentation. bght microscopy showed amyloid deposmon throughoutthebiopsies, in lamina propria. muscle. adiposetissueand vessel wails. with a variable giant cell reaction and lymphoplasmacytic infillrate. an abc-immunaperoxidase techniquewas usedwith antibodmsto pcamponent, serum amyioidaprote n prealbummandkappaand lambda light cham in an attempt to classify the amyloid type. this was found to b e d non-pa. non-prealbumm type. a negative or equivocal reaction was seen for kappa and lambda light chains however, such antibodies may not necessarily be immunoreactive with light chains or fragments of light chains m amyloid deposits. features of bile reflux type gastntis: glandular distmion (branching, "carkscrewmg"). nuclear regeneratwn, intramucosal smooth musclefibresandpaucityof inflammation. helicobacterpylanarganiams werenoted bileacid concentration #n gastrc aspirates collected by endoscopy at the time of biopsy was estimated using an optical densitymethod.gi casesshowingglandulardistorti~ hadraisedgasttic bileacidconcentration.m cases with mahednuclearregeneration hadraised bileacidsandof case~withinbamucosalsmoothmuxlefibres had raised bile acids nine of cases with raised bile acids showed a chronic inflammatory response the histological features of bile reflux type gastritis which correlate best with estimation of bile m gastric juice are glandular branching, "corkscrewing" and intramucosal smooth muscle fibres whereas pauclty of chronlc inflammation does not h pylon was identified in of cases with raised bile acid. aims to compare the bacterial flora of normal and inflamed appendices. and to conelate this with various histological features. to establish the incidence of yeninla infection ~n acute appendicihs !n southampton. methods resectedappendicesweresentheshta histopathologyandal cm portionwasremovedandcultured for aerobic and anaerobic organisma. the remainder was fixed ~n % buffered formalin and pocessed for rwtine histology results: appendices showed acute ap+endicitis, and were normal. histology there were statistically significant differences between the two groups for the p s e n c e o f faecollfhs (p < . ). fibrosis (p < . ) and prominent follicles (p < ) -all were more common ~n the normal appendices. microbiology no yer~inia was cultured in enher group. there were statistically significant differences in the number in each group which grew anaerobes and streptococci. anaerobes were more common in the normal group (p < . ). and streptococci morecommon in inflamedappendaes(p< ) conclusions. .thereisanaiiwed bactenalflora in acute appendicitis. yersinia does not contnbute to acute appendicitis in southampton. faecoliths. fibrosis and prominent follicles are significantly more common in normal appendces le antigen (using cat - ) a i d type h antigen using a specific moncbnal antiserum. we f w n d a widespread distribution oftype structures in both benign and malignant epnhelium oftheextrahepatic biliarytract and ampulla of vater. type h antigen expression was seen in benign epnhelium and in non-papillary tumoun and ampullary carinomas. lmmunohistochemical detection of tyw blood qrou antlqens does not adpear to be ofprwnostlc the majority of cases bearclose relationship to human ulcerativecolitisclinically, endoscopcallyarid i" re-nseto treatment one hundred postmortem iiyerswerestudiedfromconontoptamanns with totalseversul~ataecolitis who were pathogen free and had a histological picture resembling human uicerallve cdhs only iivwere normal in there was a mild penportal chronic inflammation. had extens~ve steatosts, had an appearance resembling chronic active hepatitis and ~n the histology resembled that of sclerosng cholangitja. other hepatic pathologies were s e n in smaller numbers. these changes parallel the itver disease seen in association wlfh "icbrativbcolitisinman. webelievetheconon toptamannprovidesthefirst modelof l i~e r d i~~~~e m u l~e r a t i v e~~l n to allow sturty of the pathogenesis of the enralntestinal manifestations of ulcerative colitis. r-rvolr and ilm-anal anastomosis. pre-and pan-surgical specimens were studied and compared using routine histological and histochemicaltechniqm themalontyofcasssexhibitedan lncreasem chronc lnflammatlon wlth n or noacute inflammation.the levelsof chronic innammation were found to bemost severe i" those cases which ~~fferedhompouchiti~. morphomstncalanalysisrevealedan~ncreaseincrypt depthtovillousheightration(cdvh) ~n % of cases. the cdvh in the pouchitis cases was greater than n the other specimens studied the resuns of m u m histochemical analysis did not show any charactenstic changes occumng. in the cases studied. lectm histochemistry demonstrated an increase an supranuclear staining of the pouches with dba. sea, wfa and wa. which is similar to that fwnd in poximal colon. staining with psa, lca. u f and lta revealed charactenstic changes in binding panem th-may mdjcale changes m tucosylation of certain cellular canponents. certain changes in lectin binding were found to be more sjgnificant in the pouchitis group of cases. the changes in the ra~ewoir mucosa are most irkely to be an adaptive response to the new mtra-lummal environment wlth the acqmdfon of cmain mime chaiacteristics. thereare alsosp~ciftc changes which occur to a greatsrdegree m the cases with wuchits, these may occur as a result of or lead to the occunence of puchms. these resuns may be cryostat sctionshomten patientswith ileal pouches lor extensive colitis, ten distal ulcerative ~olitics and five normal mall intestines were assessed immunohistochemically for macrophages (leu m antibody). rfdl gnterdigitating antigen presenting cells). and rfdt (resting macrophages)antigencantainingcellsin lminapropna. result~areexpressbdasape~=~~t=g~~f thetotal. normal small intestine contained a mean ? % and % (ranges - . - , and - ) leu m . rfdl and rfdt positive ~ell~re~pecl~~elywh~chcontrastswiththoseh~ghervaluesinpouchbiapsies- %, %and %(ranges - , - and )respectively. distal ulcerative coilticscontalned increased macrophagenumbers( . and % for the three antibodies) but have a predominance of the rfdi positive population in contrast to pouchitis patients in whomthe rfd positive cells predominate thesefindings demonswate remarkably high macrophagenumbersin pouchitis, howeverthe rfd positive sub-populations predominance suggests an aetiologv other than ulcerative colitis for muchitis. margaret balsltis. yah mahida the wide family of cell adhesion molecules (including the subgroups of the immunoglobulin supergene family. the integnn receptors andtheselectins) are involved in controlling interactions between endothella cells and leucacytes !n inflammatory states. this is partly by their influence on adhesion and migration of leucacytes to and through endothellurn. using monoclonal antibodies, we have compared expr~ss~on of the three cell adhesion molecules icam-t (interceiiular adhesion molecule- ). elam-t lendothelial leucocyte adhesion molecule-t and vcam- (vascular cell adhesion molecule-t) ~n normal colonic mucosa with muwsa from cases of inflammatory bowel disease. wehavefoundexpressianafthese threemoleculesto beincreased~ninflammatarybaweldiseaseandthis change involvesendothelial cells as well asleucocytes we will dixussthbrelationship between adhesion molecule expression and dlsease actlvlty and posslble therapeutic implications granulomatous enterocolitis associated with therapeutic irradiation . . mangham. k m newbold, s dover the universty of bmmgham department of palhology, sci ool of m&mi science the medrcal schwl, edggbaslon. chronic radiation-induced entero~olitis s a weli recognised complication of radiotherapy for mtra-abdominal or pelvbcmalignancy. the pathological features includepwforatlon. fistula formation. segmental necros~s. and stncture formation. the histologicalfeaturesareessentially lxhaamic in nature. consequent upon the characteristic vascular damage. two case of inadtation-induced granulomatous enterocolltis are described ~n which non-caseating epithelcoid granulomas were present ~n the bowel well. to our knowledge. granulomas have not been previously &="bed in radiation coldisor any other formof ixhaemic bowel disease thsgranulomaswere largely confined to the mmosz-associated lymphoid tissue and the draining lymph nodes. naked submucosal granulomas were, however atso present. this distribution is similar to that seen m crohn's disease and tuberculosis. no evidence of these, or any othersystem!c ~r a n " l~r n a t~~~~~n d i t l~n~ was present these cases suppon theview that granulomas in bowel disease are secondary to an tmpaired muwsal bamer to antigens and highlight the non-specifiaty of granulomas m the diaynoscs of inflammatozy bowel diseases between and % of crohn's disease patients have involvement of the upper gastrointestlna tract the identification of granulomata is normally required to make a specific diagnosts but this may be dinicult in small endoscopic biopsies. we present t o cases where there was a strong suggestion of upper gastrolntestinal crohn's disease with a definitive diagnosis established on more distal invoivbment. four of the biopsies contained granulomata. the remaindershowedeitherpatchy inflammation, local ulceration orvillo~s dtjtmtlon only in aneffort to establish whether crohn's disease biopsies contained specific macrophage or lymphoid populations we applied the~onoclonal antibodies. mt (cd ). uchll (cd ro)). muramidass. mac , alpha- antltwsin and kpt (cdg ) using immunohistochemistry. theresuns were compared with casesot "on-specific duodenitis orlelunltis crypt-restricted loss of g pd activity has been used to quantify carcinogen-induced somatic mutation of the x- samples of peripheral nerve (sciatic nerve) of mice from varylng age groups were examlned over the past years. development olage~related penpheral neivefibredegeneraflon was observed among mlce over months age. the spontaneous peripheral nauropathy was characterized by walierlan type degeneratlon. teased nerve flbres from mice of years old showed evidence of swelling of the myelin sheath. fragmentation d myelin into myelin balls or ovoids, with areas of segmental demyellnatlon. light microscopic examination of h e stained sections revealed axonal degeneration, and myelin fragmentation. with vawolation of nerve fibres. on ultrastructural studies. there was evidence of axa-myelin degeneration. axxoplasm showing dark stained bodles suggemng of degenerate mitochondria the myelin sheath a l~o showed disorganization and fragmentation myelin, sometimes with whorl lormatron rithcm the cyroplasm of schwann cetk, wtth evidence of autophagocytosis by schwann ceiis. in some inslancestherawere sgnsofproliferation at schwann cells. nervefibredegeneration affected both non-myelinated and myelmated fibres generally, therewereapparentlygreaternumbers fdegeneratenan-myelinated nerrefibres than myelmated nerve fibres. furthermore the numben of degenerate myelinat& nerve fibres were less than in seontaneous peripheral neuopathy in ageing rats (personal obsenat on) swntaneous peripheral neuropathy of sciat,cnenesmainlyappearedin miceaged manlhsormore, s eenonlvvelyr rely in mlceof months. younger mice did not show any evidence of this change age-related penpheral nelimpathy is not usually accornpan~~d by any clln,cal ,gns neur~. fhology. uhversrty ofiowa, iowa. u s a v~scuiarendothellalcclls(rn)conslitufet~elntertace betweenthe bloodstreamand thetcsske and pertoormsevetal key roles ~n the development immune and inflammatory responses endothellal cell from the braln display slgnlflcantly different momhoiogy from other en. having ilght ]unctlons between them and pauclty at micropinacytolic ves~cles dunng inflammatory conditions of the cns interaction between mlammataly cells and rbb en s an initial important event. it s known that expression of several adhesion molecules on b r m en is upregulated !n intlammatorycondtti~ns and cytokine-induction ofthese molecules has been investigated however an ~mparlanl mechanism of adheson molecule induction and hence modulation of tmflammatq cell/en binding might beviral infect onofbrainen wehaveexamined theabilityofmeaslesvirus(human )andherpes simplex virus to infect cerebral endothelial cells. adhesion of syngenelc splenocytes to both vlrally-infected and mock infected cells was determined using a chromiums assay. by h of infection with measles yins, cytopathic effect was eadent. and splenocyte adherence was increased to a mean of % of the control mock-infected aner h mock-infecled expression of the adhesion molecules meca- and mala-lon virally-infected cells was determined possible mechanisms for enhancement of adhesion will be discussed and subsequent implications of virus inlectiun of cerebral en ~n relation to homing of inflammatory cells into the brain. ultrastructulal dbsenamns were made on the mechanism and route of innanmatory cell diapedesis through cerebral vessel walls in an experimental model of can~ned~stempervlrusencephalamyel~t~s ~n the hamster migrating monocyies and lymphacyiesextended pseudopodiawhich contacted, indented and adhwedtoendothelwm. they lhen invaded the endnthel l cells. becoming enveloped by endothelial cytoplasmic processes which re-establishec the continuity of the vascular lining as the migrating cell passed through although mlgratlng cells were frequently seen close to intei endotreiml junctions. they were ever seen wlthln iprctlons. or between adlacent endothelial cellsand therewas noev!denceof opening of mterendothelial tlghtpnmons aherpasslng through the endothel~al layer. cells squeezed through small pores (migration porest in the t h r sub-endothellal basal lamina me present study confirms and extends previous observations on the operation u;#thr the cns of a trans-endothel~al. paraiunclianal route for d apedesis of mflammatary cells. ireland falbology royal viclona hospital, bcl/asl hi bl lrrlnrld a sewice for the blochemtcal dlagnosts of lysosamd torpge diseases has now been o n operalaon m betlast forslx y n a r~ it currently lids assays available for the measurement lysasamal acid hydrolases in plasma. serum. lkwcocvtes. cultured sk nfibroblasts. amnioticfluld and cultured amniatlccellstordlagnos~s of lysosomalstorage diaurders solar patients have been referred from throughout ireland wtth having a positive diagnosis of these. were diagnosed as being hamozygous for a specific lysosomal enzyme deficiency, were identified as having multiple enzyme acl~ciencies (mucolipidosis type -cell disease) and had heterozygote (carrier) enzyme ibvpis t t v latier. w~i e either parents (obligate hetemrygotes) or siblings of homozygotes and one was a heterozyquti' lor x~lirlhrll recessively inherited fabry's disease. in addttlon. prenatal diagnosis has been performed on motherswithafam,iy hi~toryofi-celldiseaseand/orhurler'ssyndmme.oneofthesepmvedto bepositivefor huller tht' resuiic the biochemical investigations of these cases are presented. high levels of circulating immunoglobulins are common ~n liver dlsbase. in alcohol c hver disease depos s of mmunaglobullna(lga) have been found in the liver and therenal mesanglum, and werepart acaseof a oyearoldfemale with a year history of cardiomyopathy and progressivemuscle weakness anerthe birth of her baby shewas subsequentlyflnedwith apacemaker. clin~cally, therewas sevweweaknessof neck flexors with proximodistal weakness tn both arms and mild weakness of htp flexors. the most stnking weaknesswasin herbreathmg muscles therewas no ptosisorfaaal weakness rellexeswere symmetrical and her plantarswere flexor herckwas normal. aquadriceps musclebiopsy revealed abnormal vanatcon o n fibre diameters affecting bothflbrelypes. occasional pink hyalme ~nclus~ons which stainedforacid phosphataseand wlth pas wwe seen i~i both fibre types electron microscopy showed these i n~l~s i o n~ to cwtsist of aggregates nm diameter filamentaenmeshedwithinacentral coreofdenseamorphousmatenal. inotherareastheamorphausmatsnal layas inegutar patches within !he sarcoplasrn mainly at the level of the "z" tine causing disintegration of the sacomere immunoelection microscopy wing collmdai gold showed that the denseamorphous material reacted slrongiyw<th desmiri antisera and calld therefore represent a phosphorylated form of the pratein. tubular aggrcgatesitas] hayebeendescr,bedinassociat,on witha widevarietyofdisorders wherethey most onen occurin type %fibres recentlytwolam~i~eshavebeenrepored with muscularweaknessandtasasthedom~nant biopsylinding wereporla thtrdfamilyol whatseemsla beadistinctcondition twopatients afalherandda-ohter presented with slowly progressive p.oxima weakness. limitation of eye movements and aciiilles t e o d a r.antractufes creatine kina-was s t times normal by light mcroscopy, basophllic accmulations were ~e e n in both fibre types clecson m!croscopy revealed that these conslsted tightly packed parallel tubular a m p (tas) these varied somewhat m theiiulliast,wct~ral appearance and were therefore clawfled accordingly thisreport lhrows furner bwdexe m support of a otstmct cllntcopathologicai enttry. the c-myconcaprotein (p ) is a dna-bmdmg protem. increased expression of which is assmated wth shartenmg of the gog, phaseof the cell cycle. quantitahon of p m breast cancers may have prognoshc and therapeutc implicatrons. flow cyiometnc quantitatton (fcmo) of p has been shown to correlate wxth certatn parameters m breast carcinoma. however, thsre are factors which we felt could potenttally confound this fcmq m foimalln flxed paraffinembeded(ffpe)tissues. bothnuclear(n)andcyt~plsmic(c)express~oncanoccur. dependlngonthetlssue fixative used. cytoplasmic stripping and exposure of nuclei to the digestwe enzyme, trypsin, occw dwng the preparation of the nuclear suspension from ffpe tissue. this study documents c-myc oncoprotein stainlog i" * tissue senion of p m a r y breast carcinomas: turnour cells, adlacent benign epithelium and stromal cells were assessed. the monccional antibody om- - (crb) was employed using the abc immunocytochemical technique thi~antibodyrecognisesp andacyiaplasm ~ kd protein the resultsoftrla trypsmsatm of tissue sbctionspriortostsiningwerealsonoted. positivbstainingwasseenin y~oftumaun. both nandcstainmg belng present in % benign epithelium, many endotheiial, fibroblast and lymphocyte nuclel showed posltlvlty trypsinisatwn ledto lossof staining ntensity.thusin ffpe breastcawnomas. ~, " g l e p~~~m = t =~f c m q~f om- - anti-c-mycantiobody isconfounded by facts((i) much extratumoural c-mycexpresslon cccurs, ( ) cytoplasmic stripping may iead to oncoprotrin loss and ( ) breast oancercells,iisinducedaver -fald by phorbolssten.amphiregulin bindstotheegfreceptotandcan be stimulatoryorinhibitorydependingan theceil line. ltal~oblndsto~tsown receptor, possiblyerbb- .weevaluated expression of amphiregulin in primary breast cancers using immunocyiochemistry. % of turnours showed staining using amonoclonal antibody toamphireguiin which wasdlffuseorfocal in tumourcells.amphiregulin was not expressed in stroma and much less often in normal breast ep!thellum than m tumours. immunohistochemistry waspositiveincases withthe highest mrnaexprsssion(concordance %)asmeasuredusingacdnaprobeand qualitativenortherblotsanddat blotsanabplatecounter all caseswereassayedforegfraod er. er'egfr-. er* egfr*. er-egfr-. er-egfr'. there was no association of amphtregulln expresston wlth other receptors. these results suggest amphiregulm may be an independant factor regulating growth of a substantla proportion of breast cancers. in h a s t cancer, overexpression of the c-erbb- oncogene is associated with poorer prognosis, and in a prwious study we found it to be associated with lack of response to endocrine therapy bolus doxorubicin with infmons of ifosfamiddmesna appears to be a very active chemotherapy combination for advanced breast cancer in young women. thirty-nine women (median age = yrs) with rapid recurrence of breast cancer (median disease free interval = mth) were treated with doxarubicin and ifosfamlde/mesna. and c-erbb- expression in their pnmary tumours (determined immunohistochsmically) related to treatment response. the tumours of patlents strongly expressed c-erbb- protein and of these patients had objective responses to chemotherapy in patlents with turnourseitherweakly expressingc-erbb- (n = )otshowingnostaining(n = )therewereobject,veresponses,n . these data indicate that c-erbb- expression ~n primary breast carclnoma, while associated with resistance to hormonetherapy. daesnot preclude responsetosystemic chemotherapy. and sugge~taposs~blerolefarc-erbb- status in directing treatment strategies for individual breast cancer patients. pmicularly adpvant therapies ~n early stage disease. transforming growth factor is a muitifuncyional regulatory protein which can either stimulate or inhibit cell proliferation. can inhibit immune responses and can enhance both angiogenesis and the formation of connective tlssue.tgfpmrnahas beendetectedin breastcancercelliines, andtheprotein hasbe~nfoundinthemediafrom several such lines. in view of the prominent stromal reaction seen in many breast cancen. tgfp may have a srgnificant role in tumour development and subsequent behawour. tgfb, protein expression has been examined ~mm~noh~stdchemically using a specific polyclonal antiserum in formalin fixed. paraffin embedded invaswe and in s,fu breast carcinomas occasional staining of normal acinar cells was seen. % of invawe cancers had prominent staining of cells for tgfb. often with associated stromal staining. % showed occasional cellular and stromal staining. and staining of stroma only wasobserved in %. theremainder werenegative staining of ins it^ carcinomas was less with only % having prominent staining and % being negative. there was no conelatkon with type or grade of tumour. or oestrogen receptor status but all carcinomas with prominent reactivity had metastasised to nodes. this along with the differences between lnvasive and m srtu carcinomas suggests that tgfp may be a determining factor for invasion and metastasis. depanment ofpathoiwy, univers,ty ofshemeld, poboxsq , shefiela s ul chromatin changes ~n neoplasticcells are well recagnised quantitation of nuclear chromatin distcibuhon is dcfficult becauseaf thevanetyof parameterswhich couldpossibly bemeasured in thisstmiyamethodof quantttatmg the distribution of dna was developed for a seescan solitaire plus image analysts system. the parameters homogeneity, condensation and clumping were calculated by segmenting the nucleus grey scale intensity into three levels, black, grey and white, byamethod of adaptivethresholding.theseleveis represent the darkwand lighter regions of chromatin distribution. the relative pr~portlons and positions of each of these regions were calculated by viewing the nucleus through a pixel wide computer generated "mesh" the system was used to compare benign and malignant feulgen stained breast fnac specimens. the homogeneily and clumping parameters were significantly different between the two groups (p < ). but complete discrimination was not possible in order to test the valtdity of the system. spicimens were graded subp wely ( to ) and compared with the image analysis results. there was % correlation for homogeneity and % lor clumping. indicating the difference in chromatin distribution s real and not a result of system error the role of nuclear dna analysis. oestrogen receptor and thymidine kinase (tk) activity as prognostic indicators in human breast cancer was assessed. these parameten were investigated in relation to traditional pmgnostlcators. theoveralloblectivewastodeveiopaprognosticindexthat canpredlctforsunlval.tumourmatenalfmm breast cancer patients was anaiysed the nuclear dna content and oestrogen receptor status were determined by static cylophotometry and a multipoint titration assay respectively thymldlne klnase actlvlty was assessed using atp or ctp as a phosphate donor. patients were followed-up for a median of months. the cox proprtlonal hazards model wasused todetermine which parameterscould predict survival.pathologicalgrade, tumours e. totaltkand ctpjatpratiowerefo~ndto beindependent predictonof survival.aprognosticscore wasderivedforeachpatlent and these were assigned to one of three prognostic groups. using these prognostic groups the rlsk of reduced sunwpi could be predicted in . % of patients. inconcluslon, the assesment of pathological grade, turnow s m and thymidine kinase activity provides a reliable means of predicting prognosis year periodarereviewed.the median follow-up was months. on the basiso margln contour, degreeofstmmal overgrowth and atypla, mitotic activity. nuclear pleomorphism and the presence of speclallsed stroma, benlgn and malignant phyllodestumounwereidentified turnoursoccurredin womenof msdlanage years whomost often presented with a palpable, occasionally painful mass with a medlan diameter of cm exclson ( ) or smple mastectomy(l ) werethemorefrequentformsof therapy. localrecurrenceswereexperlenced by gpatlentswhose pnmary tumours although classified as benign contained areas of stromal overgrowth and specnaltsed stroma: all had been primarily treated by a histologically inadequate local e~~i~i~n~r~~b c~t a n e o~~ mastectomy (l).these local recunenceswere successfully controlled by local surgery ( )and mastectomy( ) mf~vemal~gnant tumours treated by mastectomy, none has recurred locally or developed metastases. flve mcompletely emsed turnours whlch showed neither evidence of stromal overgrowth nor speciallsed stroma remaln disease free at years. it s concluded that histologically malignant phyllodes tumoun are unllkely to develop distant dlsease i treated appropriately andthatstromal overgrowth may indicatethe possibilityof recurrence ~n incompietelyexcisedbenign lesions. several recent studies have evaluated the incidence in primary breast carcinoma of "micrornetastases" ~n multiple sections of axillary lymph nodes. howbyb~, the significance of these findings ~n terms of prognosis and sunw remainsunclear. inanattempt toelaborateon this, wereviewedthecasesof patlentsdlagnosedas havlng'bodenegative'' breast carcinomaon routine histologyand in whom therewasafollow-upperladof at least fwe years. the anginal diagnostic h e slides were reviewed in conjunction with eptthellal immunohistochemical pr-aratlons usmgcea,ema. hmfg, andkeratin, andappropriateclinicalfollow-updatawasaccumulated.thestudycasesfell into two categories, those which retained a 'node-negatlve' status after revew, including immunohistachemical appraisal ( %). and those which demonstrated individual or grouped malignant epithelial cells ( %) ~n the peripheral or deeperainuses of the lymph node. of the former group. all pattents but one werealive with noevidence of recurrent breast carcinoma five yean after mastectomy. of the second cohort. posnttve far "micrometastases". % showed nodiseaserecurrence. while % had gross metatatic d i s e a s e o r h a d w c c~m b t o thecarcmoma within hefiveyearpenod.thefindingsdescnbed.aithough basedon low patient numbenln thisprelimmarysludy. indicate the appropriateness of a large multicentre sunw to evaluate completely the prognostic significance of these '"msrometastases". sadhna bhatnagar. j. mcclure. d a. kalbhen the injection of sodium iodoacetate ( . mg) into the avian knee joint on two consecutive days induces changes which macmscopically and radiologically resemble osteoarthrosis. knee-pnts from groups of six hens were studied atregularinterval~upt weeksalterinjection by histological and histochemlcel methods. characteristlcles~ons were identified and assessadon asemi-quantiative basisand indwdual ision profilesacrossthetime course of the expenment were constructed. during the first five weeksthe obvious changes wwe chondrocyte loss and depleted matrix staining. chondrone formation was also noted. fmm six weeks there was also tibravascular proliferation at the chondro-asseousiunction wim modelling activity and new bone fwmation. in addition near the insenion of ligaments there was chondrocyte differentiation and proliferation. the amount of cartilage fibrillation and flsswng increase during the expenment aithough there were so areas of apparent resurfacing. the decreased matrlx staining noted early in the expenmen stabilised and many lacunar spaces are occupied by chondmcytes towards the end. subchondral bone hyperplasia and osteaphyte formation are prominent persisting features. such sequentialcharacterisation may be usefulin a-ssinglhee(fectsofput=~~vetherapeuticcompounds onthe model. rodentachilles tendonsweiesubiected to midpointtenotomy and allowed to recover for various timesin sllu before the operaled tissue was mmved, placed into a millipore dinusion chamber and insened inhaprntoneally into syngeneic hosts. diffusion chambers were removed at weekly intervals such that the tom time post-operation :i.e. time sru plus time wnhin the diffusion chamber) was up to weeks. histological examination demonstrated that ectopiccartilage wasprodwed withinthediffusion chamber byatotal of weeks but only if thefirst weeks were recovery in situ. wnh increasing time. calcified cartilage, mtteoid and pnmary spongmsa bone was obseived evtdence suggests that the camlage forms via direct tendon metaplasia and that the bone may form as a result of dinerentialive changes within hypertrophic chondrocytes. tlbla and fibula appearto be directly exposed to tha surface of the medial femoral condyle and inner ridge of the lateral femoral condyle. the exposed load-bearing area of the femur and tibia contain demonstrable amyloid around chondrocytes and in the matrix below the surface. these areas are also covered with the densest hyalmd fibro-cartilage. amyloid p r e e u~r s from h e synovlum may penehatethe surface ofthe cartilage under pressure or precursm from cartilage matrix or chondrocytes may be converted into amyloid and are napped below the surface. the inpction of sodium todoacetate into avian knee iolnts is followed by the development of an osteoarthrotic pmess to studytheeftectal sodium lodoacetateon chondrocytemetabalism m wire, chickstmal chondrocytes grown i~th~ee-dimensionalcollagen gels wereexpmedtothe compound. sterna from chick embryos(l - days in om) were digested with collagenase releasing the chondrocytes which were then cultured in collagen gels. w i u m iodoacetate was added to -day old cultures at concentrations of . . and wg/rnl. ( , . and .o y lodm)tor hours. theeftectswere assessed lor up to days by: ) staining wnhfluorescein diacetate which pmducesfiuorescenceiniive. metabolisingceilsonly. )thelevelofproteoglycansinthemedium wasestimated by complexing with dimethylmethylene blue and measuring the increase in absorbance at nm. ) histologycultures were fixed in glutaraldehyde, embedded in paraffin, sectioned. and starned wm alcoholic toluidine blue. alcaan blueandpicmsinusred.treatmentwlthiodoacetateproducedadoserelateddecreaseincellnumbersand intheamount of proteoglycmsreleased into themedium (lessthan % at pg/ml).the histolagyshawed thatthe treated cells were smaller and produced less matrix. these results show that sadium iodoacetate reduces cell number and interferes wqth the manufacture of matrix components. instftute of pathology, ro i vcfona hosprtal, belfast. l. irelend theoblectivesof this study were tocorrelatecertain clmcal features of ependymoma. (i e. age, sex, anatomcai slte. turnour size. meningeal dissemination and raised intracranial pressure with certain pathological features. . e dna content, mnotic rate. immunocytochsmistry and ultrastwctural features) with prognoss a total cases was available for clinical pathological assessment univewty of liverpool, p box , liverpooi bx and 'sari andres unrvemty it is not surprising that wmal exposure to high altitude causes increased activity of the hypothalamic-pltultaryadrenocortical axis. but fflidence suggests that continued exposure to hypoxla leads it to perstst long after homeostas sis restored and acclimatization achieved their pltuatary glands were not sgnlflcantly different insizefromthoseof thesea-levelsubpcts, but c~ntainedlargerpopulat~onsofcort~cotrophs~n termsof the total population of their anterior lobes ( . vs . %: p < ) these fmdlngs are in keeping with those of previous studies of the hypothalamic-pituitary-=d~=~~cottical axis in man and animais exposed to prolonged hypoxia at natural high altitude or in the laboratory. they suggest that greater amounts of acth might be necessary to sus ain normal adrenocoltid function under such circumstances and that adrenocortical hyperplasla bone marrow wnsists of a haamopolstic system whch is nn intimate association with aftbrous stramal network.adun mammalian bonemanowstromais knownto have both chondmgenicand ostecgeniccapabilitiesinvlvoand stromal tissue has been shown to tom fibroblastic wlonies capable of giving nse to bone in vitro. however, the mqbility of manow stroma to form cartilage in who has not been addressed when grown in identical conditions to mammalian stroma. mechanically dissociated single cell suspensions of chick embryo bane manow hom > days in ovo and from day hatchlings readily lorm bath fibroblastic and cartilage colonies in vitro. cells within the cartilage colonies are polygonai in morphology, are separated by a relradile exhaceiiuiar matrix and svnthesise catilage specific pmeogiycans and collagens. as shown histochemicelly, biochemically and immunocytochemically. in contrast, adult chicken bone manow does not form cartilage. instead, the cells appear osteoblast-like and synthesise coilagens typical of bone. a. m. fianagan t. j. chambers &wtmment of h~slopatholosy. sl george's hosptal medlcel sch-i, london. sw ore osteaclastshavebeensuccessfullygeneratedinculturesofmurinehaemopoisticcells. itwouldbeuseful ifasmila, model were available to analyse the mechanisms of regulatlm of human mteaclast formaim ir normal and pathological states. although the osteoclast is present in reverai neoplastic conditions. it is not known whether it forms part of other haemowietic malignancies, lor example, polycythaemia rubra "era or chrmic lymphatic leuhemia. we used strategies based on our experience with murine osteoclastogenesis. however, we have been unabletogeneratefunctional human osteoclastscapableoiresorbingbone m vrtro. large numbersofmultinucleate cells developed in these cultures mese cells did not show a typical panem of reactivity with asteociast-specific manoclonal antibodies, nor did they bind ' sct but rath@r possessed an antigenic profile characteristic of macmphage polykaryons. it is pecullarthat human tissue fails to support osteoclast generation stnce cells of the other haemopoietic lineages were consistently generated in our cuitures. in murine cunuras it is known that a particular shomal cell type is requtred for osteoclastagen@sis; it is possible therefore that this cell population is spamin adult humantissue.miswouldreflecttheiownumberofosteoc asts presentinhuman adults comparedto mice elucidation of conditionssuitableforthe generation mthehuman osleoclastm wtrow~ll heldus understand the mechanisms by which it is regulated in health and disease spaceof one year. the other case s b middie-agedwoman who &=being affected bythe disease far sevaral years developed separate sarcomas in each lower limb dunng a nine month pwiod. each tumour was treated bv pamal amputation but she died from widespread metastases within one year of the first amputationthe distribution of proline- -hydroxylase in a range of human tissues shown by a monoclonal antibody, fib s. smlth, p. revell aepariment of mobd anatomy and bone and h m f research unrt, the london hospw medcal cdl€ge, london. e l fib . a commercially available monoclonal antibady to the b subunit at the enzyme proiine- -hydroxyla~ invalved~ntheproductionofcallagen, wasappl'edtaacetonebxedcryostat sect~onsofawiderangeoftissues. in hver, hspatocytesshowedvarying degrsesof labelling with the antibody, along with spindle shapedcells(sscs) in associated connective tissue in both tonsil and lymph node. sscs in the connective tissue were melled with the antibody along with a number of other cells (lymphocytes) within the germinal centres. in addition to this. perivascularcellsand cells intheconnectivetissue iayerimmediatelybelowtheepithelium also labeliedin sections of tonsil. in skin, very few cells in the dermis were positive for pm ne- -hydroxylase. as were also only a small numbetof epidermal cells. afew chondrocyteswere marked bythisantibody in artlcularcartilageand intervertebral disc,along withswneostwcytesin bone.manycellsinthepleuraandtheepimysiumof normal~keletalmusclew~e posotive. there was no staining at all in specimens of kidney. in addition to these 'normar tissues, examples of a seminoma, a breast carcinoma and a thymoma were examined. each of the turnours showed fib labeliiw of ssc~withinthestromalt~ssue.theseresultsshowthat fib b sele~tivelylabelssscs.whlcharapresumedto be f brobiasts. in a wide ranged both normal and pathological tissues. which produce and maintaln the collagen matnx. proime- -hydoxylase is an enzyme involved in the pmduction of collagen and demonshahle in the rer of fibroblasts. it may therefore be cmsldered as a possible matker for fibroblasts in tissue sections. we have applied the mouse moncclonal antlbdy fib , raised against the $ subunn of prol ne- -hydroxylase. to alcohol fixed paramn embeddedsections and acetonefixedcryostat sect~onsolnormal (n = ) and meumatoid (n = ) synovia. synoviocytes labelled very strongly, but the distribution vaned between samples. insome, mostsynoviocytes weremahed, whilein others ~nlythedeepiayerofcells wasmitive. it isnot known whether thts dillerence ~n prdine- -hydroxylase expression is due to the severity and duration of disease. drug treatment or other factors. it is of interest, however, that fib labelling was not wnflned to the type b (fibroblast-llke) synoviocytes and that the more supficlal type a synoviocytes also contained proline- hydroxylase. spindleshapsdeells i" thesublntlmaleonnectiva tissue were labelledma vanablemanner. inaddltlm to these findings for fibroblastic cells. a small cap of fib posnive cells was seen around lymphoidfollicles. sometimes polansed towards the synovial surface. this enzyme expression by lymphocytes is under further invsstlgatlo". vitronectin s an adhesive glycoprotein which shares several functional similarities with fibronectin. it is a major component of extracellular matnx and plays a role in cell-matrix mteradians, monocyte function. and the coagulation and wmplement systems. we have employed a monoclonal antibody to assess the distribution of vironectin in frozen synovial biopsies from patients with rheumatoid arthntis, ostwnhntis. ankylosing spmdyiitis andtraumatic non-inflammato~ control^ ( cases). lmmunoreactive vltronectin was identified in the synovium. similarto the panem of immunoreactiyefibronectin, itwas located in adensefibrillarpanem surrounding cellsof the synovial lining layer. vitronectin was also associated with fibres throughoutthe sub-intimal connective tissues. being most prolific in fibrotic areas. vltronectin was identified in the sub-endothellal layen of blood vessels. but unlike fibronecttn was not associated with basement membranes. similar distributlon patterns wme observed in all biopsies studied thelocalisation ofvitronectitin in synovial tissues suggestsapossibleroie inanachmmtofcellsto the extracellular matrix and that may be important in the pathophysiology of inflammation and repair manolayercultured articularchondrocytesare known to rapidly losethelrexpressionof collagen typeil.the purpose of this study was to compare the expression of various collagen types in twoand three-dimensional cultures articular chandracytes. in addition. the expression of s- w protein and its alpha and beta subunits was studied in monolayer cui ures. bavine articular chondrocytes were isolated by collagenase digestion from ankle joints and cuhured in monolayerandspheroid culturesin dmemwim % fcs lmmunocytochemical studieswere performed using the indirect peroxidase technique an monolayers affer methanollethanol ( vlv) fixation and on frozen sections of spheroids. the reaction was scored semi-quantitatively as negative (-), weakly (+) moderately (++) ontha basisofthenumbersafcasesrefsiredtoustottheidentificalionofjointcry~talsintissuesectians, webelieve that calcium pyraphosphatedihydrate(cppd) deposnion disease isbeing underdiagnosed byhistopathologists. a crltical light microscopic reviewof cases. all with thediagnosisconfimed bymicroanalysis(energydispersivexrayspectroscopyln thescanning electron microscope, infrared spectroscapywboth) revealed adistinctwefeathery or br"shlikeappearanceinal suchdeposits.thisfeaturewasapparentat lowpower, whileconvincingvisualisation of crystalswithinthedepositswasdiff~cuneven withanoil immersionobiective.thesignof birehingeneeof cppd crystals is more dificult to demonnrate i" tissue sections than synoviai fluids. due to iactois such as stain. fragmentation and heaping up of crystals, buf it can be more readily assessed in unstained sections or following microincineration of the section. in six of our c a m the deposits were exclusively within bone: demonstration depended on relatiyeunderdecalcification: deposits in this position have not previously been recognised. this study thus provides new information an the histological identdication of cppd deposns in tisues and implies heterogeneity in the pathogenesis of such deposits. in human knee osteoarthrosis (oa) overt unicornpartmental disease is frequently accompanied by a macroscopically normal second cornpartmsm. however. there are a number of light micmscopical changes within the latter which might amount to an "early osteoarthrosis". these are chondrocyte pmliferation and chondrone formation. decreased proteoglycan staining and disruption of the chandra-osseous interface with duplication of the tidemark and resorption ofthe cartilage by chondmclasts. tidemark duplication is also a feature of established oa re~resenti~gadistu~ancedfcabif~cat~oninrone ofarticularcartilage.slnceslwp~~t~i~~~~ knowncalciumion transponmoleculs.altsrationm~~sstainingpanernand~ntens~tym~grn beanlndexotearlyo~. sl~~protemstamng was studied in the tiblai plateau cartdage of cases: with unicornpartmental oa. with bicompartmental oa and controls. lntheianerall chondrocytesgavepositivemembrana and cytoplasmic staining (especially in zones e n d ) , d~u s e w e a k m a t~~c~l s t~~~~~g~~~~~e l , s t~o~g p a r i c e l l~i a~a~d~~t~~-t~~t o~~l s t~i~~~g~~~o~~s a~d . in overt and early oa the orderly malrlcal panem was disrupted with prominent patchy staining around chondrocyte clusters. the significance of the change in the matncal distribution ~n oa is unknown and unlikely lo be related to a disturbance of calcification in zone . road, london. wcl m e histogenesis at alveolar son part sarcoma (asps) is still unsenled: nonchromaffin paraganglioma. malignant granular cell myoblastoma, neuml tumour, myogenic tumour. habdomyosarcoma and renin-producing tumoui theories have been proposed lmmunohistochemical studies have yielded discrepant results we recentlyobsewed that the diastase resistant crystalline material in asps was strikingly reactive for vimentin by the immunoperoxidase method on paraffh sections one case. we then studied paraffin sections of seven other cases from our files between and ~ by routine light microscopy, immunohistochemistry and electron microscopy all eight cases were reactlve for vimentin. which highlighted the crystalline materlal as in the first case. vanabie numbers of immunoreactlve cells for desmin were found in three. and smooth muscle specific actin in four. all cases showed some reactivity for neuron specific enolase. and seven of the eight cases reacted for s- protein. the clinical and pathological lea lure^ of cases of synoviai sarcoma have been reviewed. these tumours are aggressive with a poor prognosis. typically affecting young aduns with a long history before presentation and detinltive diagnosis. a high index of suspicion is required if the diagnosis is not to be missed several features, including age, size. site. histological type (monophasicibiphasic), mitotic actlvity and necms~s have been investigated withaview toestablishing possible prognosticindicators. the bestguideto prognosisis assessment mitotic actlvity. size and histological type dld not affen the outcome. in this study the effecl of subcapsular orchidectomy on skeletal metastases from prostatic carcinoma was studied using bone histomorphomatnc paramsten. twenty-eight patients with bone metastases were studied immediately before and for seven months after orchidectomy. tetracycline labelled bone biopsies were taken from metastases and turnour free areas at the beginning and end of study. sixteen of the patients also underwent o~teocla~t inhibition tor six months using disodium pamidronate ( mg i.v. weekly for weeks then anemale weekly for five months) to enable differentiation of the skeletal response to castration. histamarphametnc anslysi~ tumour frse bonerevealed adrapin overall bonevolume. histological analysisofmetastasesshawedadecrease m osteoblastic activity but widespread osteoclast mediated ostealysis. tumour regression and manow recolonisation were present in most c~s b s but malignant foci remained in % of repeat metastatic biopsies, inducing a typical. lacalised disruption of bone metabolism. it is concluded that orchidectomy causes ostmblastic regression blrt induces increased ostboclast mediated bone destruction, which is most pronounced within metastases. although tumour regression and marrow recolonisation usually occur within metastases, active turnour foci anen perstsf. ( ) chairman s. g. silverberg, washington theeffectsafoncogeneson thedeveloping nelvoussystem havebeenstudiedinaneuraltransplant system ~ntats, taking advantage of the extraordinary capacity of fetal cns to differentiate in and fully integrate with, the adult host brain. gene transfer tnto tetal brain cells was mediated by in viiro infection with replication-defsctwe retroviral vectors. fetal rat brain suspensions were then stermtaxically injected into the caudoputamen of adult f rats.animals carrying transplants exposed in vim lo the polyoma medium tantigen developed endothellal hemangiomas in the graft which often led to fatal cerebral hemorrhage within - days alter transplantatm lntroductm of the viral sic gene caused astrocytic and mesenchymai tumors affer latency periods of months.following infection of fetal donor cells with a vector encoding the v-myc oncogene led to the development of only a single embryonal cns tumor whereas exposure to v-ha-ras and v-myc resulted in the rapbd induction of multiple malignant neoplasms. when injected intracerebrallyinto newborn ratsin vivo, complementation of theseongogenes led the development of malignant hemangioendotheliomas, undinerentiated neural tumors andlor leukmia.oncogene transferthus constitutes a challenging new model to assess the effects of translorm~ng genes on the developing nervous system. since the presentahon of molecular genetic evidence supporting the knudson hypothesis m the eariy s there hasbeen increasing interestinthe ideathatasimilartwo-hit mechanism mayaperateln sporadadlccancers therens now evidencbthatlassofonealleleandretentionottheother~nmutated/wildfarmaccuninsparad~ccalono. lung. renal and breast cancers in breast cancer lossof heterorygoslty(l h) has been demanstratedfarseveral alleleson chromosomes l p q and an the short arm of chromosome . loh has also been demonstrated on other chromosomes thegeneral viewisthat loh indicatesthatasuppressorgene may bepresentattheseloct. hawevet in interpreting lohthere sdifficulty indetermining when loh becomessignificant because itsincidencevariesfrom % / depending on the locus examined. in this presentation, knowledge about loh on chromosome p (and q where a new deletion has been recently discovered), and p will be presented and the pathqlenetic significanceand ciinicsl relevanceexamined. lnthe lattercontext anewrapid methodfordetemlnmg alleljc dosage will a l x be described which does not requlre rflp analysis. expelt systems - .e. computer software that can function as cansuhant, decision support system, or process contr~llerhas undergone a rapid development durlng the past decade. applications to histopathology have gnaw some ,ocqdiffuse maiignantmesotheliomas( mm) occurannuailymn. americaat thepresenttime.cumulat~~ely, substantial numbersot lesser-knownfarms of mesothelia turnourare also seen, including serous paptllary tumoun of the peritoneum, well differentiatedpapillarymesothellomas and benign cystic mesotheliomas, but incidencedata are not available.the relativeiyfrequent atypical reactive hyperplmasof w o s a membrane add further vanstytothe range of mesothellai lesions which may present diagnostic problems. the expenence of a u.s.-canadian mesotheliomapanel suggests that dmm vs. metastatic carcinomacontinues to bethe commonest mesatheliamarelateddiagnostieehaliengeandthatthedifficunyandalwayssolved bytheappiicationofspecialstains almostas common are le~ions in which the ditferential diagnosiscenters on dmm us. a reactive process (atypicai mesotheliai hyperplasia, fibrous pleurisy) within the laner group it is particulady difflcun lo obtain a strong consensus opinion, andfoilaw-uphasconfirmedthemaiorityopinioninonly %ofcases. sarcomatousdmmvs.sarcomanosisaiso a notable area of difficuny. most mesothelial lesions tn north amenca. including dmm. are reviewed within a short time of biopsy by a pathologist in a major teaching centre, only a small number ( - %) being subpct to further scrutiny by a panel or ~n the coune of epidemiological or clinical studies however, many cases resurface later ~n a legal sening when the material and clinl~al information s often available. the original diagnosis of the hosoital pathologist s usually endaned by the courts. sharon w. weiss llposarcoma is one of the most common forms of son tissue sarcoma and may be divided into several subwes well-differentiated. myxoid. round cali, phmwpha, and dedifferentiated. this presentation will discuss the ) diagnosticcnteriaof lipblasts ) d agnosisand behaviorof myxoidround cell iiposarcoma andthe ) behavior and incidence of "dedifferentiation" dwell-differentiated ihposarcoma. the diagnosis of lipsarcoma depends in part on the identdication of lipoblasts or pnmitive fat ceils. since iipoblast-l!ke cdls may be seen m a variety of conditions apart from iiposarcoma, strict diagnostic c!i tma must be applied in identlfving these ceiis. these cells contain a hyperchromatic. indented or scalloped, ecmtnc nucleus set in a cytoplasm containing one or more lipid-nch vacudes. these cells must also occur in an appropriate histaiqic background. vanous lesions which may contain ihpoblast-like cells and which may. therefore, mimic liposarcoma include fat necrosis, fat atrophy, silicone granuloma, signet nng carcinomas or melanomas, and a variety of malignant tumors with fixation artifact. myxold androundcell lipsarcomarepresentthemost commanfarmofsarcomaaccuningmearlytamidadunlifeandare commoniy located #n the region of the mlgh and popitteal fossa. although the designation of "myxold and "raund cely suggest two separateturnortypes. they represnt ends d a common h~stologlcspbctnm. myxaid liposeicoma represents the well differentiated end of the spenrum. whereas round cell represents the pcarly differentiated end.however, transitional or mixed forms ex~st. accounting for confusion as to how such tumors should be classlfled mymd liposarcomas are characterized by nodules of bland stellate or rounded cells set n hyaiuronic aod-rich strama. an intricate plexiform vasculature and numerous lipblasts are easily vdentaed. wlth progression to round celliiposarcomathecellsbecomelarger,moreatypicalandthestromalessmyxaid. lipoblastsaremoredlfticultto find and a plexiform vasculature s less apparent. recent work by evans suggests that evaluatlon of myxoidlfound cell ihpasarcomashould includethe percentage of round cell component wdhin atumorsincethisdirectclh/ mtluences prognosis. our policy is to carefully sampk such tmors, submining t section for each centimeter in greatest diameter of the tumor. a rough estimate of the percentage of a round cell component s made. we w a r d tumors havinglessthan faroundcellcomponentasgradei.thosehav,ngbetween & % roundcelicomdonent are considered grade . whereas those with more than % are considered grade . well dmerentiated liposarcoma is one of the most common sarcomas accuning m late adult life. characteristically affecting the deep musclesaftheextremities, theretropentonealspace. and the groin, this tumor ischaractenzed by varying amounts of mature fat interspersed with fibrous bands, atypical hyperchromaric spmdledceiis, and lipoblasts. these lesions are considered low grade sarcomas having a high rate of local recurrence but no abilny to metastaslze. recently evans and ammi eial suggested that well-differentiated liposarcomas occurring m the wbcutaneous tissue and muxles of the extremity cause so hnle morbidity that the use of the term "atypical lipma" should be used rather than ihposarcoma. in contrast. well-differentiated liposarcomas in the retropentoneum cause significant morbidihl and pose a significant risk of death from local disease. thus. nearly all pathologists agree that the term "weii differentiated lipasarcoma" should be retained for these tumors ~n the retroperitoneum. however. none of these recent studies have followed a large number of these tumors for a proianged period at time m order to assess the long term behavior and specihcalty risk that such es ons may progresswith time to a higher grade lesions ( . dedifferentiate). we have recently completed a follow-up study of cases of well ditferentiated iiposarcoma accurringmthemusc~oftheextremity,retropntoneum,andgroin. inalllmatlonsthenskof local recurrence was high. however,dedifferentiationoccurred~n % of casesandwasnotrestnnedtotumors~nanyparticularlacatlon. butcouldbe bestconelatedwiththedurationofthetumor. withmostcasesoccun~ngaflerl mmoreyean thus. dedifferentiation is not a site-dependent phenomenon, as has previously been suggested. but rather a time dependentphenomenon.anhough thesedatado notneee~~arily indicatethatwe should abandon theterm"atwca itpoma" they do indicate the need tor proianged foilow-up of patients wlth wei&-dlfferent,ated ddosarcoma and the small but deflnne risk of dedifferentiation as a long term complication of the disease. key: cord- - uanhe p authors: burke, rachel m.; balter, sharon; barnes, emily; barry, vaughn; bartlett, karri; beer, karlyn d.; benowitz, isaac; biggs, holly m.; bruce, hollianne; bryant-genevier, jonathan; cates, jordan; chatham-stephens, kevin; chea, nora; chiou, howard; christiansen, demian; chu, victoria t.; clark, shauna; cody, sara h.; cohen, max; conners, erin e.; dasari, vishal; dawson, patrick; desalvo, traci; donahue, matthew; dratch, alissa; duca, lindsey; duchin, jeffrey; dyal, jonathan w.; feldstein, leora r.; fenstersheib, marty; fischer, marc; fisher, rebecca; foo, chelsea; freeman-ponder, brandi; fry, alicia m.; gant, jessica; gautom, romesh; ghinai, isaac; gounder, prabhu; grigg, cheri t.; gunzenhauser, jeffrey; hall, aron j.; han, george s.; haupt, thomas; holshue, michelle; hunter, jennifer; ibrahim, mireille b.; jacobs, max w.; jarashow, m. claire; joshi, kiran; kamali, talar; kawakami, vance; kim, moon; kirking, hannah l.; kita-yarbro, amanda; klos, rachel; kobayashi, miwako; kocharian, anna; lang, misty; layden, jennifer; leidman, eva; lindquist, scott; lindstrom, stephen; link-gelles, ruth; marlow, mariel; mattison, claire p.; mcclung, nancy; mcpherson, tristan d.; mello, lynn; midgley, claire m.; novosad, shannon; patel, megan t.; pettrone, kristen; pillai, satish k.; pray, ian w.; reese, heather e.; rhodes, heather; robinson, susan; rolfes, melissa; routh, janell; rubin, rachel; rudman, sarah l.; russell, denny; scott, sarah; shetty, varun; smith-jeffcoat, sarah e.; soda, elizabeth a.; spitters, christopher; stierman, bryan; sunenshine, rebecca; terashita, dawn; traub, elizabeth; vahey, grace m.; verani, jennifer r.; wallace, megan; westercamp, matthew; wortham, jonathan; xie, amy; yousaf, anna; zahn, matthew title: enhanced contact investigations for nine early travel-related cases of sars-cov- in the united states date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: uanhe p coronavirus disease (covid- ), the respiratory disease caused by severe acute respiratory syndrome coronavirus (sars-cov- ), was first identified in wuhan, china and has since become pandemic. in response to the first cases identified in the united states, close contacts of confirmed covid- cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. close contacts of nine early travel-related cases in the united states were identified and monitored daily for development of symptoms (active monitoring). selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. respiratory samples were tested for sars-cov- by real-time reverse transcription polymerase chain reaction at the centers for disease control and prevention. four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. three hundred thirty-eight of the close contacts provided at least basic exposure information, of whom close contacts had ≥ set of respiratory samples collected and tested. across all actively monitored close contacts, two additional symptomatic covid- cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. when considering only household members, all of whom had ≥ respiratory sample tested for sars-cov- , the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was % ( % ci: – %). the results from these contact tracing investigations suggest that household members, especially significant others, of covid- cases are at highest risk of becoming infected. the importance of personal protective equipment for healthcare workers is also underlined. isolation of persons with covid- , in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of covid- . in late december , a cluster of patients with pneumonia of unknown etiology was identified in wuhan, china [ ] . this disease, now termed coronavirus disease (covid- ) , spread rapidly within china and quickly became pandemic [ ] . phylogenetic analyses of severe acute respiratory syndrome coronavirus (sars-cov- ), the causative agent of covid- , suggest zoonotic origin [ ] , with subsequent rapid spread indicative of person-to-person transmission [ , ] . on january , , the first case of covid- was confirmed in the united states [ ] ; through the end of january, nine more travel-related cases were identified. to interrupt transmission and facilitate early identification of secondary cases (i.e., transmissions of sars-cov- from the original travel-related case patient to a close contact), public health authorities at the state, county, and local levels, in consultation with subject-matter experts from the u.s. centers for disease control and prevention (cdc), mobilized rapidly to place the patients under appropriate isolation and identify contacts exposed to these patients. some of the information from the contact investigations of the first travel-associated case patients was briefly and rapidly reported through a morbidity and mortality weekly report [ ] . enhanced contact investigations were conducted centered on nine of these first patients, and included in-depth interviews to better characterize exposure type, exposure duration, and contact medical history, in addition to collection of respiratory specimens to identify asymptomatic or pre-symptomatic infections. the present manuscript details the results from these nine enhanced contact investigations, including information on exposures, active monitoring, laboratory testing, and secondary attack rates among close contacts. these investigations included the close contacts of nine travel-related covid- patients (hereafter referred to as "travel-associated case patients") first identified as suspected covid- patients between january and january , , and represent collaboration among state and local health department staff, cdc personnel, and healthcare facility staff (hereafter referred to as "covid- outbreak response teams"). the aims of these investigations were to interrupt transmission, investigate risk factors for transmission, and identify both symptomatic and asymptomatic infections among contacts of travel-associated case patients. after diagnosis confirmation, these nine travel-associated case patients were interviewed to determine the date of symptom onset and to collect information on movements and interactions with other individuals during the presumed infectious period of the travel-associated case patient. individuals with potential exposure to a travel-associated case patient were contacted by covid- outbreak response teams to determine their exposure risk level, whether they met the definition of a close contact, and whether they met criteria for active monitoring (terms defined below in "classification of contacts and exposures"). individuals not meeting the definition of a close contact are not included in this report. to better understand sars-cov- transmission, covid- outbreak response teams selected a convenience sample of the close contacts who met active monitoring criteria to target for collection of additional, detailed exposure and demographic information using standardized forms; some sites were able to collect information on all close contacts, while others collected information only on those close contacts they classified as having had high-or medium-risk exposures. to understand the prevalence of asymptomatic or pre-symptomatic infection, a convenience sample of actively monitored close contacts was selected from whom to request respiratory (nasopharyngeal [np] and oropharyngeal [op]) samples outside of diagnostic specimen collection procedures (i.e., while contacts were asymptomatic or, in some cases, symptomatic with � previous negative sars-cov- result); some sites were able to request at least one set of samples from all close contacts, but most sites targeted sample collection mainly to close contacts determined to have had high-risk exposures, such as household members and some healthcare personnel. definitions of the infectious period, close contact, and exposure risk, as well as decisions regarding which types of contacts to monitor and how to manage their movement, were made at the site level by the covid- outbreak response teams. in one site, the presumed infectious period began on the date of symptom onset in the travel-associated case patient; however, in other sites, investigators also considered between one and three days before symptom onset in the travel-associated case patient. in all sites, the presumed infectious period ended when the travel-associated case patient was released from isolation. travel-associated case patients were released from isolation after consultation with subject matter experts and following the cdc test-based criteria that were in use at that time (requiring two consecutive negative rt-pcr tests from samples collected at least hours apart). generally, close contacts were defined as persons having frequent or more than brief contact (> - minutes within ft) with a travel-associated case patient during the travel-associated case patient's presumed infectious period. most sites also considered persons sharing the same airspace as the travel-associated case patient for more than minutes to be close contacts. for persons whose exposure occurred in the healthcare setting, the definition of close contact also depended on usage of personal protective equipment (ppe) by the exposed person during their interaction with the travel-associated case patient. close contacts were grouped by type. close contacts were classified as "household contacts" if they were family members or friends of a travel-associated case patient who spent at least one night in the same residence as the travel-associated case patient during the presumed infectious period. close contacts were classified as "healthcare personnel" (hcp) if they were healthcare or public health personnel working in healthcare settings who had the potential for exposure to a travel-associated case patient or to infectious materials from a travel-associated case patient. close contacts who were defined as neither household contacts nor hcp were classified as "community contacts"; this category was broken down into contact occurring in a healthcare setting (e.g., waiting room close contacts) and contact occurring outside a healthcare setting (e.g., coworkers). "community contacts" also included flight-related close contacts of travel-associated case patients whose infectious periods included plane travel; these were defined as passengers seated in the same row as the travel-associated case patient, or in the two rows in front of or behind the travel-associated case patient. for the purposes of analyses of hcp ppe data, "all recommended ppe for airborne and contact precautions" is defined as gloves, gown, eye protection (goggles or a disposable face shield that covers the front and sides of the face), and a powered air-purifying respirator (papr) or n filtering facepiece respirator (ffr) with fit-testing in the past year"; "all recommended ppe for droplet and contact precautions" is defined as gloves, gown, eye protection, and a face mask [ ] . any encounter during which an hcp was wearing any combination of ppe not meeting either of the above definitions was considered to be "less protected." risk stratification varied by site, but all sites considered household contacts as well as hcp who provided patient care without all recommended ppe to have had high-risk exposures. community contacts less frequently met the criteria for having high-risk exposure, given that their interactions with the travel-associated case patient tended to be shorter and less frequent. however, there were some community contacts (including workplace and social contacts) across sites that did meet the high-risk exposure criteria and were treated accordingly. close contacts meeting criteria for active monitoring were contacted daily via phone, text message, email, or in person, and were asked to report temperature and any symptoms. close contacts selected for collection of detailed exposure information were interviewed using forms that were standardized within but not across jurisdictions. information collected included dates of exposure to the travel-associated case patient; basic demographics; duration and types of exposure (e.g., face-to-face contact, direct physical contact); and, among hcp close contacts, use of ppe and interactions with or procedures performed on travel-associated case patients. information was entered into standardized forms, spreadsheets, or databases maintained by the covid- outbreak response teams. close contacts selected for biological sample collection agreed to provide np and op samples for sars-cov- testing. samples were collected by trained personnel. most sites aimed to collect samples from close contacts with high-risk exposures every - days through days following last exposure to the travel-associated case patient. close contacts living outside the response jurisdictions were forwarded to their respective health jurisdictions for assessment and monitoring. some flight-related close contacts were forwarded to cdc's division of migration and quarantine for follow-up. close contacts meeting criteria for active monitoring were monitored through days following their last exposure to a travel-associated case patient. close contacts not meeting criteria for active monitoring were asked to self-monitor and to contact the local health department if they developed any symptoms. close contacts who developed new or worsening symptoms that covid- outbreak response teams deemed possibly consistent with covid- (e.g., fever, cough) were considered to be suspect covid- patients and had respiratory samples (and serum samples, when possible) collected and sent for testing at the time that determination was made, regardless of whether previous samples had been collected. household contacts of some non-hospitalized travel-associated case patients were quarantined in the same home with their respective travel-associated case patient following the travelassociated case patient's diagnosis; this quarantine lasted through the period of case isolation. this situation is hereafter referred to as "co-habitation during case isolation." to prevent household transmission, the travel-associated case patients were instructed to stay in a separate bedroom, use a separate bathroom if possible, and to wear a face mask if they had to be in the same room as cohabitants [ ] . all specimen samples were collected according to cdc guidance then packaged and shipped to cdc [ ] . specimens were refrigerated at - ˚c before shipping on icepacks. cdc performed real-time reverse transcriptase-polymerase chain reaction (rrt-pcr) to detect three separate genetic markers of sars-cov- in the n , n , and n regions [ ] . respiratory specimens were considered positive if all three genetic markers were positive by rrt-pcr, negative if all three genetic markers were negative, and inconclusive otherwise. demographic, clinical, exposure, and testing results for contacts are summarized and described. because the exact information that was collected varied by site, denominators are presented throughout. collection of respiratory specimens is described by sample type and days since last exposure to the travel-associated case patient. the secondary attack rate by close contact type was calculated as the percent of close contacts with at least one positive sars--cov- test result among close contacts for whom � set of respiratory samples was tested; % confidence intervals were calculated using the wilson score interval. differences in continuous variables were tested by the mann-whitney u test given non-parametric distributions. data were entered into access, excel, or redcap databases. data were merged and analyzed using the r environment for statistical computing. these activities were reviewed by cdc's human research protection office and determined to be exempt from human participants' research regulations as the activities involved identification, control or prevention of disease in response to an immediate public health threat. patient consent was waived. a total of (range to close contacts per case) individuals were identified as close contacts of the first nine patients with travel-related covid- in the united states (fig ) . four hundred and four ( %; range: to per confirmed case) met criteria and participated in local active monitoring. most of the close contacts who did not participate in local active monitoring were determined to have had low-risk exposures that did not require active monitoring. other close contacts who did not participate in local active monitoring were either unable to be reached or were managed by other jurisdictions. among those close contacts actively monitored, ( %) had either limited demographic and exposure type information (hereafter referred to as "at least basic exposure data") or demographic plus detailed exposure information collected; the type and amount of information for different types of close contacts varied by study site depending on their protocol. of these close contacts, ( %) were household contacts, ( %) were hcp, ( %) were community contacts exposed in a healthcare setting, and ( %) were community contacts exposed in another setting ( table and fig ) . among the actively monitored close contacts with demographic information, the majority were female (n = / ; %) and aged - years (n = / ; %). of these close contacts, only nine ( %) were exposed prior to symptom onset in the travel-associated case patient, including seven household members who were also exposed while the travel-associated case patient was symptomatic. a total of actively monitored close contacts with at least basic exposure data ( %) developed new or worsening respiratory symptoms and had a set of diagnostic respiratory samples table . demographic, clinical, exposure, and investigation characteristics among actively monitored close contacts with at least basic data on exposures to confirmed covid- patients, united states, january-february . private collected; of these ( %) had additional respiratory samples taken as part of enhanced contact investigations or case follow-up. there were ( %) actively monitored close contacts with at least basic exposure data who remained without new or worsening symptoms, of whom ( %) had at least one set of respiratory samples collected and had more than one set of respiratory samples collected (fig ) . a histogram of samples collected by type, contact category, and days since last exposure is shown in s and s figs. household contacts. the nine travel-related travel-associated case patients had a total of household contacts, of whom all were actively monitored. two household contacts, both spouses of travel-associated case patients, became symptomatic and tested positive for sars--cov- ( table ). all others repeatedly tested negative. the secondary attack rate among all household members of travel-associated case patients was % ( % ci: - %). the secondary attack rate among significant others of travel-associated case patients was % ( % ci: - %). travel-associated case patients who transmitted sars-cov- to their household contacts had an older average age (mean age vs. years; p = . ), and both were hospitalized for clinical management (as compared to of the travel-associated case patients who did not transmit to their household contacts; p = . ). there were two couples ("a" and "b") in which secondary transmission occurred (i.e., transmission of sars-cov- from the travel-associated case patient to their spouse); neither spouse shared a travel history with their respective travel-associated case patient. in couple a, the travel-associated case patient developed symptoms one day after returning from travel and enrolled in active monitoring with the local health department; the spouse, who had no reported comorbidities, developed symptoms three days after the travel-associated case patient's symptom onset. couple a reported the use of some isolation precautions during the period of exposure: the travel-associated case patient wore a face mask and used a separate bedroom and bathroom even prior to developing symptoms, although the couple did share a meal and spent extended time in the car together. both persons in couple a were diagnosed with covid- at the same time and were instructed to co-isolate at home until released by public health officials; however, eight days after symptom onset in the travel-associated case patient, couple a had to be hospitalized due to worsening conditions in both patients. in couple b, as in couple a, the travel-associated case patient's symptoms began the day after returning from travel. six days after symptom onset, the travel-associated case patient was hospitalized; the next day, the travel-associated case patient was identified as having suspect covid- , and the spouse entered active monitoring. symptom onset in the couple b spouse could not be precisely determined, as this person has underlying conditions, but could have been as early as three days after the travel-associated case patient's symptom onset. couple b did not report any isolation precautions prior to the diagnosis of the travel-associated case patient (which occurred days after symptom onset) and had frequent unmasked face-to-face and direct contact. in both couples, the spouse tested positive in the first respiratory samples collected. in general, the length of exposure to the travel-associated case patient was lower among the household contacts who did not develop covid- . among these , eight (including significant others) were completely separated from the travel-associated case patient once the patient was diagnosed and isolated; these persons maintained separate living space throughout the period of case isolation. two ( %) had < hours of exposure to the symptomatic travelassociated case patient before isolation, five ( %) had - days of household exposure to the symptomatic travel-associated case patient before isolation, and one ( %) had eight days of household exposure to the symptomatic travel-associated case patient before isolation. among these eight, three household members of two travel-associated case patients shared a travel history with the travel-associated case patient. all eight household members who were separated from the travel-associated case patients following diagnosis had serial specimens collected (median: . sets; range: - ), and all persistently tested negative; the date of last specimen collection ranged from five to days following last exposure. five household members (including significant others) across four households co-habited with the travel-associated case patient during the period of case isolation; none shared a travel history with the travel-associated case patient. none of these travel-associated case patients were hospitalized at any time. when following up with these four co-habiting households via phone and in-person visits, the covid- outbreak response teams noted moderate to very high adherence to recommended home isolation procedures: in two out of four households, the travel-associated case patient was able to use a separate bathroom, and in only one of four households did the covid- outbreak response team ever directly observe or learn of the travel-associated case patient spending time in the same room as their household member(s). all five household members undergoing co-habitation had multiple respiratory samples collected for testing (median: sets; range: - ) and remained sars-cov- -negative throughout the period of cohabitation, with the last samples collected within seven days of the end of case isolation or the end of co-habitation. these samples are shown in s fig. healthcare personnel (hcp) . the nine travel-related travel-associated case patients made a total of visits to healthcare facilities ( outpatient clinics, one urgent care clinic, hospital visits), resulting in hcp contacts who met criteria for active monitoring. there were hcp ( %) for whom data were available to describe patient contact and ppe usage in more detail. among hcp who provided care to or came into contact with the infectious fluids of travel-associated case patients and who had at least one set of respiratory samples collected and tested for sars-cov- , the secondary attack rate was % ( % ci: - %). two hcp (< %) reported performing a possibly aerosol-generating procedure on a travelassociated case patient (nebulizer therapy: ; spirometry: ); both reported using all recommended ppe during the procedure. laboratory personnel reported using recommended ppe when processing samples from travel-associated case patients. fourteen hcp ( %) reported collecting diagnostic respiratory specimens, of whom six ( %) reported always using all recommended ppe for airborne and contact precautions, one ( %) reported always using all recommended ppe for droplet and contact precautions, and seven ( %) reported using less ppe than recommended on at least one occasion (i.e., ppe meeting neither airborne/contact nor droplet/contact precautions; table ). among the seven hcp using less ppe than recommended, five reported the details of their ppe use: all five wore gloves, one wore a gown, one wore eye protection, and one wore only a face mask; one wore an ill-fitting n ffr. all occasions during which "less-protected" hcp collected respiratory specimens from a travel-associated case patient were at the travel-associated case patient's first presentation to care-before covid- was confirmed. there were ( %) hcp who reported providing patient care, touching the patient, or coming into contact with the patient's infectious fluids ( table ) . of these hcp, ( %) reported always using all recommended ppe for airborne and contact precautions, two ( %) reported always using all recommended ppe for droplet and contact precautions, and ( %) reported using less ppe than recommended on at least one occasion. among hcp using less ppe than recommended, described ppe usage in detail. eye protection was most frequently missing ( ; %), followed by gown ( ; %), and less commonly ffr or mask ( ; %). all but three of these less-protected encounters occurred before covid- was suspected in the travel-associated case patient. during all but seven of these less-protected encounters, the patient wore a mask for source control and removed it only for specimen collection and temperature measurement. community contacts. there were community contacts ( exposed in a healthcare setting and exposed in another setting) for whom information was sufficiently detailed to classify at least one specific type of exposure ( table ). the secondary attack rate for community contacts of travel-associated case patients was % ( % ci: - %) among the contacts with some detailed exposure information and at least one set of respiratory samples tested. for community contacts exposed in the healthcare setting, some exposure information was missing as the patient was not always identified to these persons. out of who provided information, only one ( %) recalled having face-to-face contact with the travel-associated case patient. as compared to community contacts in the healthcare setting, community contacts exposed outside the healthcare setting had more interaction with the travel-associated case patient, and included airport quarantine station screeners, workplace contacts, flight contacts, four rideshare drivers, and three friends. of those with data, many reported having face-to-face contact ( / ; %) with the travel-associated case patient or spending time within feet of the patient ( / ; %), and nearly all ( / ; %) could remember being in the same room as the travel-associated case patient. fewer ( / ; %) reported being within feet of the patient while the patient was coughing. airborne & contact precautions � a total of community contacts exposed in the health care setting and exposed in other settings had information sufficiently detailed to classify at least one specific type of exposure. sample sizes within each exposure do not sum to these totals because data was either not collected by the covid- outbreak response team or was not reported by the participant. �� zero samples tested positive for sars-cov- . the enhanced contact tracing investigations undertaken by the covid- outbreak response teams around nine early travel-related covid- cases in the united states resulted in identification of two transmissions from two travel-associated case patients to their spouses. we did not find evidence of secondary transmission of sars-cov- among the other actively monitored close contacts who developed symptoms suspicious for covid- nor among the close contacts who submitted respiratory specimens for virologic testing and who did not develop new symptoms during the -day active monitoring period. no clear patterns of differences were noted between travel-associated case patients who transmitted the virus as compared to those for whom no evidence of secondary transmission was observed. the results of these investigations suggest that the risk of becoming infected with sars--cov- is high among close household contacts of confirmed covid- patients, especially significant others. additional detail on one of these transmissions has been previously published [ ] , and a brief summary of key findings from the overall contact investigations of the first travel-associated patients in the u.s. was previously published as an mmwr [ ] . overall, the average exposure durations among household contacts were longer among those who developed covid- compared with those who did not. the higher transmission risk observed for household contacts is consistent with published research on other coronaviruses as well as sars-cov- [ , , ] . interestingly, we did not detect any sars-cov- infections among household members who were co-habiting with their confirmed sars-cov- -positive household members during the period of case isolation. since the majority of these co-habiting case patients and close contacts adhered very well to home isolation precautions, it is possible that careful adherence to isolation protocols mitigated the transmission risk to household members co-habiting with travel-associated case patients during the period of case isolation. we did not detect any symptomatic secondary cases of covid- among the nonhousehold contacts who completed active monitoring, including hcp contacts and community contacts from whom respiratory samples were tested for sars-cov- . this finding is similar to findings from early contact investigations in europe and asia [ ] [ ] [ ] [ ] , but in contrast to other data suggesting a much higher secondary attack rate [ ] . it is possible that asymptomatic secondary cases could have developed in persons from whom respiratory samples were not collected [ , ] , or that secondary cases could have developed without being detected in respiratory samples (for instance, if the timing of shedding did not align with the timing of sample collection) [ ] ; follow-up serology could help to rule out some of these possibilities [ ] . the low number of secondary cases could also be related to the quick isolation of most of these travel-associated case patients, as found in studies of mers-cov [ , ] . out of hcp with higher-risk exposures to a travel-associated case patient, all but three reported these exposures to have occurred prior to confirmation of the patient's diagnosis. once the patients were classified as suspected covid- cases, contact and transmission-based precautions were begun and maintained by the majority of hcp throughout the patient's care. in contrast to the first community-acquired cases identified in the united states, it is also important to consider that most if not all of these first travel-related cases were likely cognizant of the possibility that they were infected, and engaged in practices such as wearing face masks, practicing social distancing in some cases, and seeking care [ , , ] ; these practices have the potential to have reduced secondary transmission from these cases. further, these investigations were taking place at a very early stage in the u.s. outbreak, and many sites employed a low threshold for defining close contacts, potentially inflating our denominator. this report is subject to several limitations. because individual covid- outbreak response teams were operating out of distinct locations with unique considerations, the procedures of the investigation were heterogeneous across sites: different teams made different decisions regarding how to define close contacts, how to categorize exposure risk, which close contacts to actively monitor, which types of exposure information to collect, and how often (and from whom) to attempt collection of respiratory samples. although available information was standardized across sites for the purposes of analysis, this heterogeneity led to missing data, limiting our ability to assess certain types of exposure in this population. relatedly, only % of actively monitored close contacts provided any respiratory specimens, and fewer provided serial respiratory specimens. incomplete sample collection could have biased secondary attack rates, and also raises the possibility of a missed asymptomatic infection. symptomatic infections occurring after the end of the -day monitoring period also could have been missed. although some sites attempted to reach individuals with close contact prior to symptom onset in the travel-associated case patient, many of these exposures occurred during the travel of the travel-associated case patient and therefore were managed by other jurisdictions. as a result, only nine such persons are included in the present analysis (of whom seven were household members with continued exposure). thus, secondary transmissions occurring prior to symptom onset in the travel-associated case patient may have been missed. missed transmissions (either asymptomatic infections, transmissions occurring outside the presumed infectious period, or transmissions with an incubation period outside the -day active monitoring period) may have contributed to community spread, as suggested by some genetic analysis of sars-cov- circulating in washington [ ] . lastly, although all sites endeavored to interview and sample the close contacts with the highest-risk exposures, the selection of the sample for interview and respiratory specimen collection was not systematic or consistent across sites. this may have introduced bias in the characteristics of the close contacts described as well as in the secondary attack rates. further, the relatively small sample of primary cases (travel-associated case patients) and the low observed incidence of secondary transmission makes it difficult to identify any characteristics of the travel-associated case patients that might have been associated with an increased risk of secondary transmission. the findings of these enhanced contact investigations, consistent with other research, suggest that household members of covid- patients, particularly significant others, who are likely to have prolonged close contact with the patients, are at excess risk of developing covid- [ , ] . further, the lack of observed transmission to hcp underlines the importance and effectiveness of rapid identification and isolation of suspected cases of covid- and appropriate use of ppe in caring for these patients [ , ] . careful adherence to infection prevention procedures within the home and the healthcare setting may help to reduce the risk of transmission of covid- , while monitoring and quarantine of household contacts may help interrupt transmission. close contacts with high-risk exposures (such as household contacts or hcp providing patient care without ppe) should continue to be quarantined and actively monitored, as data from covid- clusters have raised the concern of transmission from asymptomatic or pre-symptomatic individuals infected with sars-cov- [ , , , ] , which may be contributing to the widespread community transmission that is currently occurring in the united states [ ] . it is important for hcp and public health professionals to remain vigilant to the possibility of sars-cov- transmission from confirmed cases to household, community, and hcp contacts, and continue to emphasize isolation and other precautions [ , ] . further, individuals exposed to sars-cov- should self-quarantine, and all persons should practice everyday behaviors to limit the spread of covid- such as proper hand hygiene, covering coughs and sneezes, wearing cloth face coverings, and social distancing [ , ] . supporting information s fig. histogram of specimens collected by day since last exposure, grouped by type of contact and days per person. specimens (n = ) collected from contacts with known exposure periods are shown by the days following last exposure to the confirmed covid- patient on the x axis. excludes specimens from five household contacts with ongoing household exposure after the diagnosis of the travel-associated case patient, one household member diagnosed concurrently as the travel-associated case patient, and four community contacts without a known exposure period or date of collection. specimens from contacts submitting only a single set of respiratory specimens are shown in navy, while specimens from those submitting multiple sets of respiratory specimens are shown in lighter blue. household contacts (hh) are shown in the first row (excluding who were co-habiting with the case patient following diagnosis and who was concurrently diagnosed), healthcare personnel (hcp) contacts are shown in the second row, and community contacts are shown in the bottom row. the first column shows the number of nasopharyngeal (np) swabs collected and tested, and the second column shows the number of oropharyngeal (op) swabs collected and tested. some hh members and hcp have specimens collected at negative days from last exposure-these represent specimens collected during a period of ongoing exposure to the covid- patient. samples collected relative to the first day of exposure are shown in s fig patient on the x axis. excludes specimens from five household contacts with ongoing household exposure after the diagnosis of the travel-associated case patient, one household member diagnosed concurrently as the travel-associated case patient, and four community contacts without a known exposure period or date of collection. specimens from contacts submitting only a single set of respiratory specimens are shown in navy, while specimens from those submitting multiple sets of respiratory specimens are shown in lighter blue. household contacts (hh) are shown in the first row, healthcare personnel (hcp) contacts are shown in the second row, and community contacts are shown in the bottom row. the first column shows the number of nasopharyngeal (np) swabs collected and tested, and the second column shows the number of oropharyngeal (op) swabs collected and tested. only the initial specimens are shown for the secondary cases, as these specimens tested positive. (tiff) s fig. histogram of specimens collected by day since first exposure, among household contacts who were co-habiting with travel-associated covid- case patients during the period of case isolation. specimens (n = ) collected from contacts who were co-habiting with a covid- patient following the travel-associated case patient's diagnosis are shown by the days following first exposure to the confirmed covid- patient on the x axis. the first column shows the number of nasopharyngeal (np) swabs collected and tested, and the second column shows the number of oropharyngeal (op) swabs collected and tested. a pneumonia outbreak associated with a new coronavirus of probable bat origin a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster. the lancet early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia first case of novel coronavirus in the united states active monitoring of persons exposed to patients with confirmed covid- -united states interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid- ) in healthcare settings phylogenetic analysis of sars-cov analysis of the epidemic growth of the early -ncov outbreak using internationally confirmed cases longitudinal characteristics of lymphocyte responses and cytokine profiles in the peripheral blood of sars-cov- infected patients first known person-toperson transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) in the usa middle east respiratory syndrome coronavirus transmission in extended family, saudi arabia case management team kcfdc, prevention. early epidemiological and clinical characteristics of cases of coronavirus disease in south korea case management team kcfdc, prevention. coronavirus disease- : summary of , contact investigations of the first cases in the republic of korea investigation of three clusters of covid- in singapore: implications for surveillance and response measures first cases of coronavirus disease (covid- ) in france: surveillance, investigations and control measures, january serological and molecular findings during sars-cov- infection: the first case study in finland secondary attack rate and superspreading events for sars-cov- presumed asymptomatic carrier transmission of covid- asymptomatic and presymptomatic sars-cov- infections in residents of a long-term care skilled nursing facility investigation and serologic follow-up of contacts of an early confirmed case-patient with covid- clinical and epidemiologic characteristics of spreaders of middle east respiratory syndrome coronavirus during the outbreak in korea transmission of middle east respiratory syndrome coronavirus infections in healthcare settings initial public health response and interim clinical guidance for the novel coronavirus outbreak-united states cryptic transmission of sars-cov- in washington state escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease (covid- ) due to sars-cov- in hong kong risk of nosocomial transmission of coronavirus disease : an experience in a general ward setting in hong kong public health responses to covid- outbreaks on cruise ships-worldwide presymptomatic transmission of sars-cov- -singapore epidemiological and clinical features of the novel coronavirus outbreak in china estimation of the time-varying reproduction number of -ncov outbreak in china the authors would first like to acknowledge the covid- patients and close contacts described in this manuscript. we also gratefully acknowledge the assistance and contributions of glen key: cord- -wawui fd authors: tulchinsky, theodore h.; varavikova, elena a. title: communicable diseases date: - - journal: the new public health doi: . /b - - / - sha: doc_id: cord_uid: wawui fd publisher summary in a world of rapid international transport and contact between populations, systems are needed to monitor the potential explosive spread of pathogens that may be transferred from their normal habitat. the potential for the international spread of new or reinvigorated infectious diseases constitute threat to mankind akin to ecological and other man-made disasters. public health has addressed the issues of communicable disease as one of its key issues in protecting individual and population health. methods of intervention include classic public health through sanitation, immunization, and well beyond that into nutrition, education, case finding, and treatment, and changing human behavior. the knowledge, attitudes, beliefs, and practices of policy makers, health care providers, and parents is as important in the success of communicable disease control as are the technology available and methods of financing health systems. together, these encompass the broad programmatic approach of the new public health to control of communicable diseases. important for all health providers and public health personnel so as to be able to cope with the scale of these problems and to absorb new technologies as they emerge from scientific advances and experience, and their successful application. lived. it was to be observed, indeed, that it did not come straight on toward us; for the city, that is to say within the walls, was indifferently healthy still; nor was it got over the water into southwark; for though there died that week , of all distempers, whereof it might be supposed above died of the plague, yet there was but in southwark, lambeth parish included; whereas in the parishes of st. giles the agent-host-environment triad, discussed in chapter , is fundamental to the success of understanding transmission of infectious diseases and their control, including those well known, those changing their patterns, and those newly emerging or escaping current methods of control. infection occurs when the organism successfully invades the host body, where it multiplies and produces an illness. a host is a person or other living animal, including birds and arthropods, who provides a place for growth and sustenance to an infectious agent under natural, as opposed to experimental, conditions. some organisms, such as protozoa or helminths, may pass successive stages of their life cycle in different hosts, but the primary or definitive host is the one in which the organism passes its sexual stage. the secondary or intermediate host is where the parasite passes the larval or asexual stage. a transport host is a carrier in which the organism remains alive, but does not develop. an agent of an infectious disease is necessary, but not always sufficient to cause a disease or disorder. the infective dose is the quantity of the organism needed to cause clinical disease. a disease may have a single agent as a cause, or it may occur as a result of the agent in company with contributory factors, whose presence is also essential for the development of the disease. a disease may be present in an infected person in a dormant form such as tuberculosis, or a subclinical form, such as poliomyelitis or hiv. the virulence or pathogenicity of an infective agent is the capacity of an infectious agent to enter the host, replicate, damage tissue, and cause disease in an exposed and susceptible host. virulence is indicated by the severity of clinical disease and case fatality rates. the environment provides a reservoir for the organism, and the mode of transmission, by which the organism reaches a new host. the reservoir is the natural habitat where an infectious agent lives and multiplies, from which it can be transmitted directly or indirectly to a new host. the reservoir refers to the natural habitat of the organism, which may be in people, animals, arthropods, plants, soil, or substances in which an organism normally lives and multiplies, and on which it depends for survival or in which it survives in a dormant form. contacts are persons or animals who have been in association with an infected person, animal, or contaminated inanimate object, or environment that might provide an opportunity for acquiring the infective agent. persons or animals that harbor a specific infectious agent, often in the absence of discernible clinical disease, and who serve as a source of infection or contamination of food, water, or other materials, are carriers. a carrier may have an inapparent infection (a healthy cartier) or may be in the incubation or convalescent stage of the infection. communicable diseases may be classified by a variety of methods: by organism, by mode of transmission, by methods of prevention (e.g., vaccine preventable, vector controllable), or by major organism classification, that is, viral, bacterial, and parasitic disease. a virus is a nucleic acid molecule (rna or dna) encapsulated in a protein coat or capsid. the virus is not a complete cell and can only replicate inside a complete cell. the capsid may have a protective envelope of a lipid containing membrane. the capsid and membrane facilitate attachment and penetration of a host cell. inside the host cell, the nucleic molecule may cause the cell's chromosomes to be changed in its own genetic material or so that there is cellular manufacture and virus replication. viroids are smaller rna structures without capsids which can cause plant disease. prions are recently discovered (stanley prusiner, nobel prize, ) variants of viruses or viroids which are the infective agents cause of scrapie in sheep, and similar degenerative central nervous system diseases in cattle and in man (mad cow disease or creutzfeld-jakob disease in humans). bacteria are unicellular organisms that reproduce sexually or asexually, grow on cell-free media, and can exist in an environment with oxygen (aerobic) or in one lacking oxygen (anaerobic). some may enter a dormant state and form spores where they are protected from the environment and may remain viable for years. bacteria include a nucleus of chromosomal dna material within a membrane surrounded by cytoplasm, itself enclosed by the cellular membrane. bacteria are often characterized by their coloration under gram's stain, as gram-negative or gram-positive, as well as by their microscopic morphology, colony patterns on growth media, by the diseases they may cause, as well as by antibody and molecular (dna) marking techniques. bacteria include both indigenous flora (normal resident) bacteria and pathogenic (disease causing) bacteria. pathogenic bacteria cause disease by invading, overcoming natural or acquired resistance, and multiplying in the body. bacteria may produce a toxin or poison that can affect a body site distant from where the bacterial replication occurs, such as in tetanus. bacteria may also initiate an excessive immune response, producing damage to other body tissues away from the site of infection, e.g;, acute rheumatic fever and glomerulonephritis. parasitology studies protozoa, helminths, and arthropods that live within, on, or at the expense of a host. these include oxygen-producing, flagellate, unicellular organisms such as giardia and trichomonas, and amoebas such as entamoeba important in enteric and gynecologic disorders. sporozoa are parasites with complex life cycles in different hosts, such as cryptosporidium or malarial parasites. parasitic disease usually refers to infestation, with fungi, molds, and yeasts that can affect humans. helminths are worms that infest humans especially in poor sanitation and tropical areas. transmission of diseases is by the spread of an infectious agent from a source or reservoir to a person (table . ). direct transmission from one host to another occurs during touching, biting, kissing, sexual intercourse, and projection via droplets, as in sneezing, coughing, or spitting, or by entry through the skin. indirect transmission includes via aerosols of long-lasting suspended particles in air, fecal-oral transmission such as food and waterborne as well as by poor hygenic conditions with inanimate materials, such as soiled clothes, handkerchiefs, toys, or other objects. vector-borne diseases are transmitted via crawling or flying insects, in some cases with multiplication, and development of the organism in the vector, as in malaria. the subsequent transmission to humans is by injection of salivary gland fluid during biting, e.g., congenital syphilis, or by deposition of feces, urine or other material capable of penetrating the skin through a bite wound or other trauma. transmission may occur with insects as a transport mechanism, as in salmonella on the legs of a housefly. airborne transmission occurs inderectly via infective organisms in small aerosols that may remain suspended for long periods of time and which easily enter the respiratory tract. small particles of dust may spread organisms from soil, clothing, or bedding. vertical transmission occurs from one generation to another, or from one stage of the insect life cycle to another stage. maternal-infant transmission occurs during pregnancy (transplacental), delivery, as in gonorrhoea, breast-feeding, e.g., hiv, with transfer of infectious agents from mother to fetus or newborn. resistance to infectious diseases is related to many host and environmental factors, including age, sex, pregnancy, nutrition, trauma, fatigue, living and socioeconomic conditions, and emotional status. good nutritional status has a protective effect against the results of an infection. vitamin a supplements reduce complication rates of measles and enteric infections. tuberculosis may be present in an individual whose resistance is sufficient to prevent clinical disease, but the infected person is a cartier of an organism which can be transmitted to another or cause clinical disease if the person's susceptibility is reduced. immunity is resistance to infection resulting from presence of antibodies or cells that specifically act on the microorganism associated with a specific disease or toxin. immunity to a specific organism can be acquired by having the disease, that is, natural immunity, or by immunization, active or passive, or by protection box . vaccines and prevention "the greeks had two gods of health, aesculapius and hygeia, therapy and prevention, respectively. medicine in the twentieth century retains those two concepts, and vaccination is a powerful means of prevention. what follows is information on the vaccines that together with sanitation, make modem society possible, and that if wisely used will continue to bestow on mankind the gift of prevention, which according to proverb is worth far more than cure." source: plotkin, s. a., mortimer, e. a. . vaccines. second edition. philadelphia: wb saunders (with permission). infectious agent: a pathogenic organism (e.g., virus, bacteria, rickettsia, fungus, protozoa, or helminth) capable of producing infection or an infectious disease. infection: the process of entry, development, and proliferation of an infectious agent in the body tissue of a living organism (human, animal, or plant) overcoming body defense mechanisms, resulting in an inapparent or clinically manifest disease. antigen: a substance (e.g., protein, polysaccharide) capable of inducing specific response mechanisms in the body. an antigen may be introduced into the body by invasion of an infectious agent, by immunization, inhalation, ingestion, or through the skin, wounds, or via transplantation. antibody: a protein molecule formed by the body in response to a foreign substance (an antigen) or acquired by passive transfer. antibodies bind to the specific antigen that elicits its production, causing the infective agent to be susceptible to immune defense mechanisms against infections e.g., humoral and cellular. immunoglobulins: antibodies that meet different types of antigenic challenges. they are present in blood or other body fluids, and can cross from a mother to fetus in utero, providing protection during part of the first year of life. there are five major classes (igg, igm, iga, igd, and ige) and subclasses based on molecular weight. anfisera or antitoxin: materials prepared in animals for use in passive immunization against infection or toxins. source: jawetz, melrick, and adelberg, medical microbiology, . through elimination of circulation of the organism in the community. immunity may be by antibodies produced by the host body or transferred from externally produced antibodies. the body also reacts to infective antigens by cellular responses, including those that directly defend against invading organisms and other cells which produce antibodies. the immune response is the resistance of a body to specific infectious organisms or their toxins provided by a complex interaction of antibodies and cells including a. b cells (bone marrow and spleen) produce antibodies which circulate in the blood, i.e., humoral immunity; b. t cell-mediated immunity is provided by sensitization of lymphocytes of thymus origin to mature into cytotoxic cells capable of destroying virusinfected or foreign cells; c. complement, a humoral response which causes lysis of foreign cells; d. phagocytosis, a cellular mechanism which ingests foreign microorganisms (macrophages and leukocytes). surveillance of disease is the continuous scrutiny of all aspects of occurrence and spread of disease pertinent to effective control of that disease. maintaining ongoing surveillance is one of the basic duties of a public health system, and is vital to the control of communicable disease, providing the essential data for tracking of disease, planning interventions, and responding to future disease challenges. surveillance of infectious disease incidence relies on reports of notifiable diseases by physicians, supplemented by individual and summary reports of public health laboratories. such a system must concern itself with the completeness and quality of reporting and potential errors and artifacts. quality is maintained by seeking clinical and laboratory support to confirm first reports. completeness, rapidity, and quality of reporting by physicians and laboratories should be emphasized in undergraduate and postgraduate medical education. enforcement of legal sanctions may be needed where standards are not met. surveillance of infectious diseases includes the following: . morbidity reports from clinics to public health offices; . mortality reports from attending doctors to vital records; . reports from selected sentinel centers; . special field investigations of epidemics or individual cases; . laboratory monitoring of infectious agents in population samples; . data on supply, use, and side effects of vaccines, toxoids, immune globulins; . data on vector control activities such as insecticides use; . immunity levels in samples of the population at risk; . review of current literature on the disease; . epidemiologic and clinical reports from other jurisdictions. epidemiologic monitoring based on individual and aggregated reports of infectious diseases provide data vital to planning interventions at the community level or for the individually exposed patient and his contacts, along with other information sources such as hospital discharge data and monitoring of sentinel centers. these may be specific medical or community sites that are representative of the population and are able to provide good levels of reporting to monitor an area or population group. a sentinel center can be a pediatric practice site, a hospital emergency room, or other location which will provide a "finger on the pulse" to assess the degree and kind of morbidity occurring in the community. it can also include monitoring in a location previously known for disease transmission, such as hong kong in relation to influenza. epidemiologic analysis provided by government public health agencies should be published weekly, monthly, and annually and distributed to a wide audience of public health and health-related professionals throughout the country. feedback to those in the field on whose initial reports the data are based is vital in order to promote involvement and improved quality of data, as well as to allow evaluation of the local situation in comparison to other areas. in a federal system of government, national agencies report regularly on all state or provincial health patterns. state or provincial health authorities provide data to the counties and cities in their jurisdictions. such data should also be readily available to researchers in other government agencies, universities, and other academic settings for further research and analysis both on internet and hard-copy publications. notifiable diseases are those which a physician is legally required to report to state or local public health officials, by reason of their contagiousness, severity, frequency, or other public health importance (table . ). public health laboratory services provide validation of clinical and epidemiologic reports. they also pro- vide day-to-day supervision of public health conditions, and can monitor communicable disease and vaccine efficacy and coverage. in addition, they support standards of clinical laboratories in biochemistry, microbiology, and genetic screening. nosocomial or hospital-acquired infections constitute a major health hazard associated with care in institutions. in the united states, they occur in - % of hospital admissions and are the cause of lengthening of hospital stay and an estimated , deaths per year. in developing countries, nosocomial infection rates may occur in up to % of hospitalizations. this category of infectious disease most commonly includes infections of the urinary tract, surgical wounds, lower respiratory tract (pneumonias), and blood poisoning or septicemias. in the united states, up to % of hospital-acquired infections are caused by multidrug resistant organisms. staphylococcus infections resistant to many current antibiotics, for example, methicillin and vancomycin, are a notable cause of prolongation of hospitalization or even death. the increasing number of immunodeficient patients has increased the importance of prevention of nosocomial infections. where standards of infection control are lacking, in both developed and developing countries, hospital staff are vulnerable to serious infection. in developing countries, deadly new viruses, such as ebola and marburg viruses mainly affect nursing, medical, and other staff as secondary cases. surveillance and control measures are important elements of hospital management. hospital epidemiologists and infection control staff are part of modem hospital staffing. the cost to the health system of nosocomial infections is a major consideration in planning health budgets. reducing the risk of acquiring such infections in hospital justifies substantial expenditures for hospital epidemiology and infection control activities. with diagnostic related group payment for hospital care (by diagnosis rather than by days of stay) the good manager has a major incentive to ensure that the risk of nosocomial infections is minimized, since they can greatly prolong hospital stays, raising patient dissatisfaction and health care costs. an endemic disease is the constant usual presence of a disease or infectious agent in a given geographic area or population group. hyperendemic is a state of persistence of high levels of incidence of the disease. holoendemic means that the disease appears early in life and affects most of the population, as in malaria or hepatitis a and b in some regions. an epidemic is the occurrence in a community or region of a number of cases of an illness in excess of the usual or expected number of cases. the number of cases constituting an epidemic varies with the disease, and factors such as previous epidemiological patterns of the disease, time and place of the occurrence, and the population involved must be taken into account. a single case of a disease long absent from an area, such as polio, constitutes an epidemic, and therefore a public health emergency because a clinical case may represent a hundred carriers with nonparalytic or subclinical poliomyelitis. in the s, two to three or more cases of measles linked in time and place may be considered sufficient evidence of transmission and presumed to be an epidemic. a pandemic is occurrence of a disease over a very wide area, crossing international boundaries, affecting a large proportion of the population. each epidemic should be regarded as a unique natural experiment. the investigation of an epidemic requires preparation and field investigation in conjunction with local health and other relevant authorities. verification of cases and the scope of the epidemic will require case definition and laboratory confirmation. tabulation of known cases according to time, place, and person are important for immediate control measures and formulation of the hypothesis as to the nature of the epidemic. an epidemic curve is a graphic plotting of the distribution of cases by the time of onset or reporting, which gives a picture of the timing, spread, and extent of the disease from the time of the initial index cases and the secondary spread. epidemic investigation requires a series of steps. this starts with confirmation of the initial report and preliminary investigation, defining who is affected, determining the nature of the illness and confirming the clinical diagnosis, and recording when and where the first (index) and follow-up (secondary) cases occurred, and how the disease was transmitted. samples are taken from index case patients (e.g., blood, feces, throat swabs) as well as from possible vectors (e.g., food, water, sewage, environment). a working hypothesis is established based on the first findings, taking into account all plausible explanations. the epidemic pattern is studied, establishing common source or risk factors, such as food, water, contact, environment, and drawing a time line of cases to define the epidemic curve. how many are ill (the numerator) and what is the population at risk (the denominator) establish the attack rate, namely, the percentage of sick among those exposed to the common factor. what is a reasonable explanation of the occurrence; is there a previous pattern, with the present episode a recurrence or new event? consultation with colleagues and the literature helps to establish both a biological and epidemiologic plausibility. what steps are needed to prevent spread and recurrence of the disease? coordination with relevant health and other officials and providers is required to establish surveillance and control systems, document and distribute reports, and respond to the public's fight to know. the first reports of excess cases may come from a medical clinic or hospital. the initial (sentinel or index) cases provide the first clues that may point to a common source. investigation of an epidemic is designed to quickly elucidate the cause and points of potential intervention to stop its continuation. this requires skilled investigation and interpretation. epidemiologic investigations have defined many public health problems. rubella syndrome, legionnaire's disease, aids, and lyme and hantavirus diseases were first identified clinically when unusually large numbers of cases appeared with common features. the suspicions that were raised led to a search for causes and the identification of control methods. a working hypothesis of the nature of an epidemic is developed based on the initial assessment, the type of presentation, the condition involved, and previous local, regional, national, and international experience. the hypothesis provides the basis for further investigation, control measures, and planning additional clinical and laboratory studies. surveillance will then monitor the effectiveness of control measures. communication of findings to local, regional, national, and international health reporting systems is important for sharing the knowledge with other potential support groups or other areas where similar epidemics may occur. the centers for disease control and prevention (cdc), originally organized in as the office for malaria control in war areas, is part of the u.s. public health service. as of , the cdc had a budget of $ . billion, and employees include epidemiologists, microbiologists, and many other professionals. the cdc includes national centers for environmental health and injury control, chronic disease prevention and health promotion, infectious diseases, prevention services, health statistics, occupational safety and health, and international health. the epidemic intelligence service (eis) of the cdc in the united states is an excellent model for the organization of the national control of communicable diseases. young clinicians are trained to carry out epidemiologic investigations as part of training to become public health professionals. eis officers are assigned to state health departments, other public health units, and research centers as part of their training, carrying out epidemic investigation and special tasks in disease control. the cdc, in cooperation with the who, has developed and offers free of charge, a personal computer program to support field epidemiology, including epidemic investigations (epi-info), which can be accessed and down-loaded from the worldwide web. this program should be adopted widely in order to improve field investigations, to encourage reporting in real time, and to develop high standards in this discipline. cdc's morbidity and mortality weekly report (mmwr) is a weekly publication of the cdc's epidemiologic data, also available free on the internet. it includes special summaries of reportable infectious diseases as well as noncom- although an infectious disease is an event affecting an individual, it is communicable to others, and therefore its control requires both individual and community measures of protection. control of the disease is a reduction in its incidence, prevalence, morbidity, and mortality. elimination of a disease in a specified geographic area may be achieved as a result of intervention programs such as individual protection against tetanus; elimination of infections such as measles requires stoppage of circulation of the organism. eradication is success in reduction to zero of incidence of the disease and presence in nature of the organism, such as with smallpox. extinction means that a specific organism no longer exists in nature or in laboratories. public health applies a wide variety of tools for the prevention of infectious diseases and their transmission. it includes activities ranging from filtration and disinfection of community drinking water to environmental vector control, pasteurization of milk, and immunization programs (see table . ). no less important are organized programs to promote self protection, case finding, and effective treatment of infections to stop their spread to other susceptible persons (e.g., hiv, sexually transmitted diseases, tuberculosis, malaria). planning measures to control and eradicate specific communicable diseases is one of the principal activities of public health and remains so for the twenty-first century. treating an infection once it has occurred is vital to the control of a communicable disease. each person infected may become a vector and continue the chain of transmission. successful treatment of the infected person reduces the potential for an uninfected contact person to acquire the infection. bacteriostatic agents or drugs such as sulfonamides inhibit growth or stop replication of the organism, allowing normal body defenses to overcome the organism. bacteriocidal drugs such as penicillin act to kill pathogenic organisms. traditional medical emphasis on single antibiotics has changed to use of multiple drug combinations for tuberculosis and more recently for hospital-acquired infections. antibiotics have made enormous contributions to clinical medicine and public health. however, pathogenic organisms are able to adapt or mutate and develop resistance to antibiotics, resulting in drug resistance. wide-scale use of antibiotics has led to increasing incidence of resistant organisms. multidrug resistance constitutes one of the major public health challenges at the end of the twentieth century. antiviral agents (e.g., ribovarin) are important additions to medical treatment potential, as are "cocktails" of antiviral agents for management of hiv infection. antibiotic use is a health problem requiting attention of clinicians and their teachers as well as the public health community and health care managers, representing the interaction of health issues across the entire spectrum of services. organized public health services are responsible for advocating legislation and for regulating and monitoring programs to prevent infectious disease occurrence and/or spread. they function to educate the population in measures to reduce or prevent the spread of disease. health promotion is one of the most essential instruments of infectious disease control. it promotes compliance and community support of preventive measures. these include personal hygiene and safe handling of water, milk, and food supplies. in sexually transmitted diseases, health education is the major method of prevention. each of the infectious diseases or groups of infectious diseases have one or more preventive or control approaches (table . ). these may involve the coordinated intervention of different disciplines and modalities, including epidemiologic monitoring, laboratory confirmation, environmental measures, immunization, and health education. this requires teamwork and organized collaboration. very great progress has been made in infectious disease control by clinical, public health, and societal means since in the industrialized countries and since the s in the developing world. this is attributable to a variety of factors, including organized public health services; the rapid development and wide use of new and improved vaccines and antibiotics; better access to health care; and improved sanitation, living conditions, and nutrition. triumphs have been achieved in the eradication of smallpox and in the increasing control of other vaccine-preventable diseases. however, there remain serious problems with tb, stds, malaria, and new infections such as hiv, and an increase in multiple drug-resistant organisms. vaccines are one of the most important tools of public health in the control of infectious diseases, especially for child health. vaccine-preventable diseases ta b l e . annual incidence of selected vaccine-preventable infectious diseases in rates per , population selected years, united states, - disease the body responds to invasion of disease-causing organisms by antigenantibody reactions and cellular responses. together, these act to restrain or destroy the disease-causing potential. strengthening this defense mechanism through im-box . definitions of immunizing agents and processes vaccines: a suspension of live or killed microorganisms or antigenic portion of those agents presented to a potential host to induce immunity to prevent the specific disease caused by that organism. preparation of vaccines may be from: a. live attenuated organisms which have been passed repeatedly in tissue culture or chick embryos so that they have lost their capacity to cause disease but retain an ability to induce antibody response, such as polio-sabin, measles, rubella, mumps, yellow fever, bcg, typhoid, and plague. b. inactivated or killed organisms which have been killed by heat or chemicals but retain an ability to induce antibody response; they are generally safe but less efficacious than live vaccines and require multiple doses, such as polio-salk, influenza, rabies, and japanese encephalitis. c. cellular fractions usually of a polysaccharide fraction of the cell wall of a disease-causing organisms, such as pneumococcal pneumonia or meningococcal meningitis. d. recombinant vaccines produced by recombinant dna methods in which specific dna sequences are inserted by molecular engineering techniques, such as dna sequences spliced to vaccinia virus grown in cell culture to produce influenza and hepatitis b vaccines. toxoids or antisera: modified toxins are made nontoxic to stimulate formation of an antitoxin, such as tetanus, diphtheria, botulism, gas gangrene, and snake and scorpion venom. immune globulin: an antibody-containing solution derived from immunized animals or human blood plasma, used primarily for short-term passive immunization, e.g., rabies, for immunocompromised persons. antitoxin: an antibody derived from serum of animals after stimulation with specific antigens and used to provide passive immunity, e.g., tetanus. munization is one of the outstanding achievements of public health, as treatment of infectious diseases by antimicrobials is a major element of clinical medicine. immunization (vaccination) is a process used to increase host resistance to specific microorganisms to prevent them from causing disease. it induces primary and secondary responses in the human or animal body: a. primary response occurs on first exposure to an antigen. after a lag or latent period of - days (depending on the antigen) specific antibodies appear in the blood. antibody production ceases after several weeks but memory cells that can recognize the antigen and respond to it remain ready to respond to a further challenge by the same antigen. b. secondary (booster) response is the response to a second and subsequent exposure to an antigen. the lag period is shorter than the primary response, the peak is higher and lasts longer. the antibodies produced have a higher affinity for the antigen, and a much smaller dose of the antigen is required to initiate a response. c. immunologic memory exists even when circulating antibodies are insufficient to protect against the antigen. when the body is exposed to the same antigen again, it responds by rapidly producing high levels of antibody to destroy the antigen before it can replicate and cause disease. immunization protects susceptible individuals from communicable disease by administration of a living modified agent, or subunit of the agent, a suspension of killed organisms or an inactivated toxin (see table . ) to stimulate development of antibodies to that agent. in disease control, individual immunity may also protect another individual. herd immunity occurs when sufficient persons are protected (naturally or by immunization) against a specific infectious disease reducing circulation of the organism, thereby lowering the chance of an unprotected person to become infected. each pathogen has different characteristics of infectivity, and therefore different levels of herd immunity are required to protect the nonimmune individual. the critical proportion of a population that must be immunized in order to interrupt local circulation of the organism varies from disease to disease. eradication of smallpox was achieved with approximately % world coverage, followed by concentration on new case findings and immunization of contacts and surrounding communities. for highly infectious diseases, such as measles, immunization coverage of over % is needed to achieve local eradication. immunization coverage in a community must be monitored in order to gauge the extent of protection and need for program modification to achieve targets of disease control. immunization coverage is expressed as a proportion in which the numerator is the number of persons in the target group immunized at a specific age, and the denominator is the number of persons in the target cohort who should have been immunized according to the accepted standard: vaccine coverage = no. persons immunized in specific age group • no. persons in the age group during that year immunization coverage in the united states is regularly monitered by the national immunization survey by a household survey in all states, as well as selected urban areas considered to be at high risk for undervaccination. an initial telephone survey is followed by confirmation, where possible, from documentation from the parents or health care providers. the survey for july -june examined children born between august and november (i.e., aged - months, median age months). the results show improving coverage, with % having received three or more doses of dpt (diphtheria, pertussis, and tetanus), % with three or more doses of opv (oral polio vaccine), % with three or more doses of haemophilus influenzae, type b (hib), but only % with three or more doses of hepatitis b. however, only % had received all recommended vaccines at the recommended ages. eases that still cause millions of deaths globally each year. other important infectious diseases are still not subject to vaccine control because of difficulties in their development. in some cases, a microorganism can mutate with changes. viruses can undergo antigenic shifts in the molecular structure in the organism, producing completely new subtypes of the organism. hosts previously exposed to other strains may have little or no immunity to the new strains. antigenic drift refers to relatively minor antigenic changes which occur in viruses. this is responsible for frequent epidemics. antigenic shift is believed to explain the occurrence of new strains of influenza virus necessitating, for example, annual reformulation of the influenza vaccine associated with large scale epidemics and pandemics. new variants of poliovirus strains are similar enough to the three main types so that immunity to one strain is carded over to the new strain. molecular epidemiology is a powerful new technique used to specify the geographic origin of organisms such as poliomyelitis and measles viruses, permiting tracking of the source of the virus and epidemic. combinations of more than one vaccine is now common practice with a trend to enlarging the cocktail of vaccines in order to minimize the number of injections, and visits required. this reduces the number of visits to carry out routine immunization saving staff time and costs, as well as increasing compliance. there are virtually no contraindications to use of multiple antigens simultaneously. examples of vaccine cocktails include dpt (diphtheria, pertussis, and tetanus) in combination with haemophilus influenzae b, poliomyelitis, and varicella, or mmr (measles, mumps, and rubella) vaccines. interventions in the form of effective vaccines save millions of lives each year and contribute to improved health of countless children and adults throughout the world. vaccination is now accepted as one of the most cost-effective health interventions currently available. continuous policy review is needed regarding allocation of adequate resources, logistical organization, and continued scientific effort to seek effective, safe, and inexpensive vaccines for other important diseases such as malaria and hiv. new technology of recombinant vaccines, such as that of hepatitis b, holds promise for important vaccine breakthroughs in the decades ahead. internationally, much progress was made in the s in the control of vaccinepreventable diseases. at the end of the s, fewer than % of the world's children were being immunized. who, unicef, and other international organizations mobilized to promote an expanded programme on immunization (epi) with a target of reaching % coverage by . immunization coverage increased in the developing countries, preventing some million child deaths annually. bacillus calmette-gu rin (bcg) coverage rose from to %; poliomyelitis with opv (three doses) from to %, and tetanus toxoid for pregnant women from to %. since , there has been a decline in coverage in some parts of the world, mainly in sub-saharan africa. the challenge remains to achieve control or eradication of vaccine-preventable diseases, thus saving millions of more lives. part of the hfa stresses the epi approach, which includes immunization against diphtheria, pertussis, tetanus, po-liomyelitis, measles, and tuberculosis. an extended form of this is the epi plus program which combines epi with immunization against hepatitis b and yellow fever and, where appropriate, supplementation with vitamin a and iodine. the success in international eradication of smallpox is now being followed by a campaign to eradicate poliomyelitis and other important infectious diseases. diphtheria. diphtheria is an acute bacterial disease of the tonsils, nasopharynx, and larynx caused by the organism corynebacterium diphtheriae. it occurs in colder months in temperate climates where the organism is present in human hosts and is spread by contact with patients or carriers. it has an incubation period of - days. in the past, this was primarily an infection of children and was a major contributor to child mortality in the prevaccine and preantibiotic eras. diphtheria has been virtually eliminated in countries with well-established immunization programs. in the s, an outbreak of diphtheria occurred in the countries of the former soviet union among people over age . it reached epidemic proportions in the s, with , cases ( - ) with deaths in in russia alone. this indicates a failure of the vaccination program in several respects: it used only three doses of dpt in infancy; no boosters were given at school age or subsequently; the efficacy of diphtheria vaccine may have been low, and coverage was below %. efforts to control the present epidemic include mass vaccination campaigns for persons over years of age with a single dose of dt (diphtheria and tetanus) and increasing coverage of routine dpt vaccines to four doses by age years. the epidemic and its control measures have led to improved coverage with dt for those over years, and % coverage among children aged - months. who recommends three doses of dpt in the first year of life and a booster at school entry. this is considered by many to be insufficient to produce long-lasting immunity. the united states and other industrialized countries use a four-dose schedule and recommend periodic boosters for adults with dt. pertussis. pertussis is an acute bacterial disease of the respiratory tract caused by the bacillus bordetella pertussis. after an initial coldlike (catarrhal) stage, the patient develops a severe cough which comes in spasms (paroxysms). the disease can last - months. the paroxysms can become violent and may be followed by a characteristic crowing or high pitched inspiratory whooping sound, followed by expulsion of a tenacious clear sputum, often followed by vomiting. in poorly immunized populations and those with malnutrition, pneumonia often follows and death is common. pertussis declined dramatically in the industrialized countries as a result of widespread coverage with dpt. however, because the pertussis component of the vaccine caused some reactions, many physicians avoided its use, using dt alone. during the s in the united kingdom, many physicians recommended against vaccination with dpt. as a result, pertussis incidence increased with substantial mortality rates. this led to a reappraisal of the immunization program, with insti-tution of incentive payments to general practitioners for completion of vaccination schedules. as a result of these measures, vaccination coverage, with resulting pertussis control, improved dramatically in the united kingdom. pertussis continues to be a public health threat and recurs wherever there is inadequate immunization in infancy. a new acellular vaccine is ready for widespread use and will be safer with fewer and less severe reactions in infants, increasing the potential for improved confidence and support for routine vaccination. use of the new vaccine is spreading in the united states and forms part of the u.s. recommended vaccination schedule. tetanus. tetanus is an acute disease caused by an exotoxin of the tetanus bacillus (clostridium tetani) which grows anaerobically at the site of an injury. the bacillus is universally present in the environment and enters the human body via penetrating injuries. following an incubation period of - days, it causes an acute condition of painful muscular contractions. unless there is modem medical care available, patients are at risk of high case fatality rates of - % (highest in infants and the elderly). antitetanus serum (ats) was discovered in and during world war i, ats contributed to saving the lives of many thousands of wounded soldiers. tetanus toxoid was developed in . the organism, because of its universal presence in the environment, cannot be eradicated. however, the disease can be controlled by effective immunization of every child during infancy and school age. adults should receive routine boosters of tetanus toxoid once very decade. newborns are infected by tetanus spores (tetanus neonatorum) where unsanitary conditions or practices are present. it can occur when traditional birth attendants at home deliveries use unclean instruments to sever the umbilical cord, or dress the severed cord with contaminated material. tetanus neonatorum remains a serious public health problem in developing countries. immunization of pregnant women and women of childbearing age is reducing the problem by conferring passive immunity to the newborn. the training of traditional birth attendants in hygienic practice and the use of medically supervised birth centers for delivery also decreases the incidence of tetanus neonastorum. elimination of tetanus neonatorum by the year was made a health target by the world summit of children in . in that year, the number of deaths from neonatal tetanus was reported by unicef as , infants worldwide, declining to , in . immunization of pregnant women increased from under % in to % in - . despite progress, coverage is still too low to achieve the target of elimination. poliomyelitis. polio virus infection may be asymptomatic or cause an acute nonspecific febrile illness. it may reach more severe forms of aseptic meningitis and acute flaccid paralysis with long-term residual paralysis or death during the acute phase. poliomyelitis is transmitted mainly by direct person-to-person contact, but also via sewage contamination. large-scale epidemics of disease, with attendant paralysis and death, occurred in industrialized countries in the s and s, engendering widespread fear and panic and thousands of clinical cases of "infantile paralysis". growth of the poliovirus by john enders and colleagues in tissue culture in led to development of the first inactivated polio vaccine by jonas salk in the mid- s and gave hope and considerable success in the control of the disease. the development of the live attenuated oral poliomyelitis vaccine by albert sabin, licensed in , added a new dimension to its control because of the effectiveness, low cost, and ease of administration of the vaccine. the two vaccines in their more modern forms, enhanced strength inactivated polio vaccine (eipv), and triple oral polio vaccine (topv), have been used in different settings with great success. oral polio vaccine (opv) induces both humoral and cellular, including intestinal, immunity. the presence of opv in the environment by contact with immunized infants and via excreta of immunized persons in the sewage gives a booster effect in the community. immunization using opv, in both routine and national immunization days (nids) has proven effective in dramatically reducing poliomyelitis and circulation of the wild virus in many parts of the world. use of the enhanced strength ipv (eipv) produces early and high levels of circulating antibodies, as well as protecting against the vaccine-associated disease. in rare cases opv can cause vaccine-associated paralytic poliomyelitis (vapp), with a risk of case per , with initial doses, and case per over million with subsequent doses. approximately eight to ten cases of vapp occur annually in the united states, with clinical, ethical, and legal implications. use of ipv as initial protection eliminates this problem. experience in gaza and the west bank in the s and s, and later in israel, showed that a combination of ipv and opv is effective in overcoming endemic and imported poliovirus. opv requires multiple doses to achieve protective antibody levels. where there are many enteroviruses in the environment, as is the case in most developing countries, interference in the uptake of opv may result in cases of paralytic poliomeylitis among persons who have received or even doses of adequate opv. controversy as to the relative advantages of each vaccine continues. the opv program of mass repeated vaccination in control of poliomyelitis in the americas established the primacy of opv in practical public health, and the momentum to eradicate poliomyelitis is building. a combined schedule of ipv and opv would eliminate the wild virus and protect against vaccine-associated disease. the sequential use of ipv and opv was adopted as part of the routine infant immunization program in the united states in , but ipv alone was adopted in . there are concerns that exclusive use of either vaccine alone will not lead to the desired goal of eradication of polyomyelitis. progress in global eradication of polio has been impressive. global coverage of infants with three doses of opv reached % in as compared to % in . the african region of who had an increase in opv coverage from % in to % in . national immunization days (nids) were conducted in countries in and in , covering million children in . mopping up operations to reinforce coverage of children in still endemic areas is proceeding along with increased emphasis on acute flaccid paralysis (afp) monitoring. confirmed polio cases reported continued at - , per year in - . with continued national and international emphasis, and support of who, rotary international, unicef, donor countries, and others, there is a real prospect of a world without polio, if not by the year , then or shortly thereafter. measles is an acute disease caused by a virus of the paramyxovirus family. it is highly infectious with a very high ratio of clinical to subclinical case ratio ( / ). measles has a characteristic clinical presentation with fever, white spots (koplik spots) on the membranes of the mouth, and a red blotchy rash appearing on the rd- th day lasting - days. mortality rates are high in young children with compromised nutritional status, especially vitamin a deficiency. the measles virus evolved from a virus disease of cattle (rinderpest) some - years ago, becoming an important disease of humans with high mortality rates in debilitated, poorly nourished children, and significant mortality and morbidity even in industrialized countries. in the prevaccine era, measles was endemic worldwide, and even in the late s it remains one of the major childhood infectious diseases. it is one of the commonest causes of death for school age children worldwide. despite earlier predictions that measles deaths would be halved to , by , who reported . million measles deaths in that year and over million in . eradication in the first decade of the next century is a feasible goal, provided that there is an adequate international effort. measles immunization increased from under % worldwide in to % in - , but % in sub-saharan africa. single-dose immunization failed to meet control or eradication requirements even in the most developed parts of the world. a live vaccine, licensed in , was later replace by a more effective and heat stable vaccine, but still with a primary vaccination failure rate (i.e., fails to produce protective antibodies) of - %, and secondary failure rate (i.e., produces antibodies but protection is lost over time) of %. a two-dose policy incorporates a booster dose, usually at school-age, in addition to maximum feasible infant coverage of children in the - month period (timing varies in different countries). catch-up campaigns among schoolage children should be carried out until the routine two-dose policy has time to take full effect. nearly universal primary education in developing countries, offers an opportunity for mass coverage of school age children with a second dose of measles and a resulting increase of herd immunity to reduce the transmission of the virus. the two-dose policy adopted in many countries, should be supplemented with catch-up campaigns in schools to provide the booster effect for those previously immunized and to cover those previously unimmunized, especially in developing countries. the cdc considers that domestic transmission in the united states has been interrupted and that most localized outbreaks were traceable to imported cases. south america and the caribbean countries are now considered free of indigenous measles, based on their successful use of nids, although a large epidemic occurred in in brazil. it now appears that eradication has become a feasible target during the early part of the next century, with a strategy of levels of coverage in in-fancy with a two-dose policy, supplemented by catch-up campaigns to older children and young adults, and outbreak control. mumps. mumps is an acute viral disease characterized by fever, swelling, and tenderness usually of the parotid glands, but also other glands. the incubation period ranges between and days. orchitis, or inflammation of the testicles, occurs in - % of postpubertal males and oophoritis, or inflammation of the ovaries, in % of postpubertal females. sterility is an extremely rare result of mumps. central nervous system involvement can occur in the form of aseptic meningitis, almost always without sequelae. encephalitis is reported in - per , cases with an overall case fatality rate of . %. pancreatitis, neuritis, nerve deafness, mastiffs, nephritis, thyroiditis, and pericarditis, although rare, may occur. most persons born before are immune to the disease, because of the nearly universal exposure to the disease before that time. the live attenuated vaccine introduced in the united states in is available as a single vaccine or in combination with measles and rubella as the measlesmumps-rubella (mmr) vaccine. it provides long-lasting immunity in % of cases. mumps vaccine is now recommended in a two-dose policy with the first dose of mmr given between and months of age and a second dose given either at school entry or in early adolescence. mmr in two doses is now standard policy in the united sates, sweden, canada, israel, the united kingdom, and other countries. the incidence of mumps has consequently declined rapidly. local eradication of this disease is worthwhile and should be part of a basic international immunization program. rubella. rubella (german measles) is generally a mild viral disease with lymphadenopathy and a diffuse, raised red rash. low grade fever, malaise, coryza, and lymphadenopathy characterize the prodromal period. the incubation period is usually - days. differentiation from scarlet fever, measles, or other febrile diseases with rash may require laboratory testing and recovery of the virus from nasopharyngeal, blood, stool, and urine specimens. in , norman gregg, an australian ophthalmologist, noted an epidemic of cases of congenital cataract in newborns associated with a history of rubella in the mother during the first trimester. subsequent investigation demonstrated that intrauterine death, spontaneous abortion, and congenital anomalies occur commonly when rubella occurs early in pregnancy. congenital rubella syndrome (crs) occurs with single or multiple congenital anomalies including deafness, cataracts, microophthalmia, congenital glaucoma, microcephaly, meningoencephalitis, congenital heart defects, and others. moderate and severe cases are recognizable at birth, but mild cases may not be detected for months or years after birth. insulin-dependent diabetes is suspected as a late sequela of congenital rubella. each case of crs is estimated to cost some $ , in health care costs during the patient's lifetime. prior to availability of the attenuated live rubella vaccine in , the disease was universally endemic, with epidemics or peak incidence every - years. in unvaccinated populations, rubella is primarily a disease of childhood. in areas where children are well vaccinated, adolescent and young adult infection is more apparent, with epidemics in institutions, colleges, and among military personnel. a sharp reduction of rubella cases was seen in the united states following introduction of the vaccine in , but increased in , following rubella epidemics in - . a further reduction in cases was followed by a sharp upswing of rubella and crs in [ ] [ ] [ ] . an outbreak of rubella among the amish in the united states, who refuse immunization on religious grounds, resulted in cases of crs in . it is now thought that vaccination of sufficient numbers in the united states reduced circulation of the virus and protected most vulnerable groups in the population. in the past, immunization policy in some countries was to vaccinate school girls aged to protect them for the period of fertility. the current approach is to give a routine dose of mmr in early childhood, followed by a second dose in early school age to reduce the pool of susceptible persons. women of reproductive age should be tested to confirm immunity before pregnancy and immunized if not already immune. should a woman become infected during pregnancy, termination of pregnancy previously recommended is now managed with hyperimmune globulin. the infection of pregnant women during their first trimester of pregnancy is the primary public health implication of rubella. the emotional and financial burden of crs, including the cost of treatment of its congenital defects, makes this vaccination program cost-effective. its inclusion in a modem immunization program is fully justified. elimination of crs syndrome should be one of the primary goals of a program for prevention of vaccine-preventable disease in developed and developing countries. adoption of mmr and the two-dose policy will gradually lead to eradication of rubella and rubella syndrome. viral hepatitis. viral hepatitis is a group of diseases of increasing public health importance due to their large scale worldwide prevalence, their serious consequences, and our increasing ability to take preventive action. viral hepatic infectious diseases each have specific etiologic, clinical, epidemiologic, serologic, and pathologic characteristics. they have important short-and long-term sequelae. vaccine development is of high priority for control and ultimate eradication. hepatitis a. hepatitis a (hav) was previously known as infectious hepatitis or epidemic jaundice. hav is mainly transmitted by the fecal-oral route. clinical severity varies from a mild illness of - weeks to a debilitating illness lasting several months. the norm is complete recovery within weeks, but a fulminating or even fatal hepatitis can occur. severity of the disease worsens with increasing age. hav is sporadic/endemic worldwide. improving sanitation raises the age of exposure, with accompanying complications. it now occurs particularly in persons from industrialized countries when exposed to situations of poor hygiene, or among young adults when traveling to areas where the disease is en-demic. common source outbreaks occur in school-aged children and young adults from case contact, or from food contaminated by infected handlers. hepatitis a may be a serious public health problem in a disaster situation. prevention involves improving personal and community hygiene, with safe chlorinated water and proper food handling. hepatitis a vaccine has been recently licensed for use in the united states, and will probably soon be recommended for routine vaccination programs, as well as for persons traveling to endemic areas. hepatitis b. hepatitis b (hbv) once called serum jaundice, was thought to be transmitted only by injections of blood or blood products. it is now known to be present in all body fluids and easily transmissible by household and sexual contact, perinatal spread from mother to newborn, and between toddlers. however, it is not spread by the oral-fecal route. hepatitis b virus is endemic worldwide and is especially prevalent in developing countries. carrier status with persistent viremia varies from < % of adults in north america to % in some parts of the world. carders have detectable levels of hbsag, the surface antigen (i.e., australian antigen), in their blood. high risk groups in developed countries include intravenous drug users, homosexual men, persons with high numbers of sexual partners, those receiving tattoos, body piercing or acupuncture treatments, and residents or staff of institutions such as group homes and prisons. immunocompromised and hemodialysis patients are commonly carders of hbv. hbv may also be spread in a health system by use of inadequately sterilized reusable syringes, as in china and the former soviet union. transmission is reduced by screening blood and blood products for hbsag and strict technique for handling blood and body fluids in health settings. hbv is clinically recognizable in less than % of infected children but is apparent in - % of infected adults. clinically hbv has an insidious onset with anorexia, abdominal discomfort, nausea, vomiting, and jaundice. the disease can vary in severity from subclinical, very mild to fulminating liver necrosis, and death. it is a major cause of primary liver cancer, chronic liver disease, and liver failure, all devastating to health and expensive to treat. hepatitis b virus is considered to be the cause of % of primary cancer of the liver in the world and the most common carcinogen after cigarette smoking. the who estimates that more than billion people alive today have been infected with hbv. it is also estimated that million persons are chronic carriers of hbv, with an estimated - . million deaths per year from cirrhosis or primary liver cancer. this makes hepatitis b control a vital issue in the revision of health priorities in many countries. strict discipline in blood banks and testing of all blood donations for hbv, as well as hiv, and hepatitis c, is mandatory, with destruction of those with positive tests. contacts should be immunized following exposure with hbv immunoglobulin and hbv vaccine. the inexpensive recombinant hbv vaccine should be adopted by all countries and included in routine vaccination of infants. catch-up immunization for older children is also desirable. immunization programs should include those exposed at work, such as health, prison, or sex workers and adults in group settings. hbv immunization has been included in who's epi-plus expanded program of immunization. hepatitis c. first identified in , and previously known as non-a, non-b hepatitis, hepatitis c (hcv) has an insidious onset with jaundice, fatigue, abdominal pain, nausea, and vomiting. it may cause mild to moderate illness, but chronicity is common going on to cirrhosis and liver failure. the cdc estimates that million americans are chronically infected with hcv, with - , resulting deaths per annum, and the main cause of liver transplants. hcv is transmitted most commonly in blood products, but also among injecting drug users ( % of intravenous drug users were hcv positive in a vancouver study in ), and is also a risk for health workers. the disease may also occur in dialysis centers and other medical situations. person-to-person spread is unclear. prevention of transmission includes routine testing of blood donations, antiviral treatment of blood products, needle exchange programs, and hygiene. the who in has declared hepatitis prevention as a major public health crisis, with an estimated million persons infected worldwide ( ) , stressing that this "silent epidemic" is being neglected and that screening of blood products is vital to reduce transmission of this disease as for hiu hcv is a major cause of chronic cirrhosis and liver cancer. no vaccine is available at present, but an experimental vaccine is undergoing field trials. interferon and ribavirin treatment is reportedly effective in % of cases. hepatitis d. hepatitis d virus (hdv) also known as delta hepatitis, may be self-limiting or progress to chronic hepatitis. it is caused by a viruslike particle which infects cells along with hbv as a coinfection or in chronic carriers of hbv. hdv occurs worldwide in the same groups at risk for hbv. it also occurs in epidemics and is endemic in south america, africa, and among drug users. prevention is by measures similar to those for hbv. management for hdv is by passive immunity with immunoglobulin for contacts and high risk groups, and should include hbv vaccination as the diseases often coincide. there is currently no vaccine for hdv. hepatitis e. hepatitis e virus has an epidemiological and clinical course similar to that of hav. there is no evidence of a chronic form of hev. one striking characteristic of hev is its high mortality rate among pregnant women. the disease is caused by a viruslike particle with an incubation period of - days and is most common in young adults. sporadic cases as well as epidemics have been identified in india, pakistan, burma, china, russia, mexico, and north africa. hev results from waterborne epidemics or as sporadic cases in areas with poor hygiene, spread via the oral-fecal route. it is a hazard in disaster situations with crowding and poor sanitary conditions. prevention is by safe management of water supplies and sanitation. disease management is supportive care; passive immunization is not helpful and no vaccine is currently available. teria which causes meningitis and other serious infections in children under months of age. before the introduction of effective vaccines, as many as in children developed invasive hib infection. two-thirds of these had hib meningitis, with a case fatality rate of - %. long-term sequelae such as hearing impairment and neurological deficits occurred in - % of survivors. the first hib vaccine was licensed in , based on capsular material from the bacteria. extensive clinical trials in finland demonstrated a high degree of efficacy, but less impressive results were in seen in postmarketing efficacy studies. by , a conjugate vaccine based on an additional protein cell capsular factor capable of enhancing the immunologic response was introduced. several conjugate vaccines are now available. the conjugate vaccines are now combined with dpt as their schedule is simultaneous with that of the dpt. although the hib vaccine has been found to be cost-effective, despite initially being as costly as all the basic vaccines combined (i.e., dpt, opv, mmr, and hbv). for this reason, its use thus far has been limited to industrialized countries. the vaccine is a valuable addition to the immunologic armamentarium. it showed dramatic results in local eradication of this serious early childhood infection in a number of european countries and a sharp reduction in the united states. impressive field trials in the gambia showed a sharp reduction in mortality from invasive streptococcal diseases. the price of the vaccine has also fallen dramatically since the mid s. as a result, in , the world health organization recommended inclusion of hib vaccine in routine immunization programs in developing countries. influenza. influenza is an acute viral respiratory illness characterized by fever, headache, myalgia, prostration, and cough. transmission is rapid by close contact with infected individuals and by airborne particles with an incubation period of - days. it is generally mild and self-limited with recovery in - days. however, in certain population groups, such as the elderly and chronically ill, infection can lead to severe sequelae. gastrointestinal symptoms commonly occur in children. during epidemics, mortality rates from respiratory diseases increase because of the large numbers of persons affected, although the case fatality rates are generally low. over the past century, influenza pandemics have occurred in , , , and , while epidemics are annual events. the influenza pandemic of caused millions of deaths among young adults, by some estimates killing more than had died in world war i. it was the fear of recurrence of this pandemic which led the cdc to launch a massive immunization program in the united states in to prevent swine flu (the virus was a strain antigenically similar to that of the pandemic influenza) from spreading from an isolated outbreak in an army camp. the effort was stopped after millions of persons were immunized with an urgently produced vaccine when serious reactions occurred (guillain-barre syndrome, (i.e., a type of paralysis), and when no further cases of swine flu were seen. this demonstrated the difficulty of extrapolating scenarios from a historical experience. each year, epidemiologic services of the who and collaborating centers such as the cdc recommend which strains should be used in vaccine preparation for use among susceptible population groups. these vaccines are prepared with the current anticipated epidemic strains. the three main types of influenza (a, b, and c) have different epidemiological characteristics. type a and its subtypes, which are subject to antigenic shift, are associated with widespread epidemics and pandemics. type b undergoes antigenic drift and is associated with less widespread epidemics. influenza type c is even more localized. active immunization against the prevailing wild strain of influenza virus produces a - % level of protection in high risk groups. the benefits of annual immunization outweigh the costs, and it has proven to be effective in reducing cases of influenza and its secondary complications such as pneumonia and death from respiratory complications in high-risk groups. pneumococcal disease. pneumococcal diseases, which are caused by streptococcus pneumoniae, include pneumonia, meningitis, and otitis media. the capsular types of pneumococci selected out of known types of the organism for the vaccine are those responsible for % of pneumococcal pneumonia cases and - % of all pneumonia cases in the united states, and are responsible for some , deaths per year. this vaccine has been found to be cost-effective for high risk groups, including persons with chronic disease, hiv carriers, patients whose spleens were removed, the elderly, and those with immunosuppressive conditions. it should be included in preventive-oriented health programs, especially for long-term care of the chronically ill. because pneumococci cause bacterial meningitis, pneumococcal vaccine may be a future candidate for use in routine immunization programs for children (over age ). varicella is an acute, generalized virus disease caused by the varicella zoster virus (vzv). despite its reputation as an innocuous disease of childhood, varicella patients can be quite ill. a mild fever and characteristic generalized red rash lasts for a few hours, followed by vesicles occurring in successive crops over various areas of the body. affected areas may include the membranes of the eyes, mouth, and respiratory tract. the disease may be so mild as to escape observation or may be quite severe, especially in adults. death can occur from viral pneumonia in adults and sepsis or encephalitis in children. neonates whose mothers develop the disease within days of delivery are at increased risk with a case fatality rate of up to %. long-term sequelae include herpes zoster or shingles with a severely painful, vesicular rash along the distribution of sensory nerves, which can last for months. its occurrence increases with age and it is primarily seen in the elderly. it can, however, occur in immunocompromised children (especially those on cancer chemotherapy), aids patients, and others. some % of a population will experience herpes zoster during their lifetimes. reye's syndrome is an increasingly rare but serious complication from varicella or influenza b. it occurs in children and affects the liver and central nervous system. congenital varicella syndrome with birth defects similar to congenital rubella syndrome has been identified recently. varicella vaccine is now recommended for routine immunization at age - months in the united states, with catch-up for children up to age years and for occupationally exposed persons in health or child care settings. varicella vaccine is also recommended for nonpregnant women of child bearing years. cost-benefit studies indicate a : ratio if both direct and indirect costs are included (see chapter ). varicella vaccine is likely to be added to a "cocktail vaccine" containing dpt, polio (ipv), and hib. meningococcal meningitis. meningococcal meningitis, caused by the bacterium neisseria meningitides, is characterized by headache, fever, neck stiffness, delirium, coma, and/or convulsions. the incubation period is - days. it has a case fatality rate of - % if treated early and adequately, but rises up to % in the absence of treatment. there are several important strains (a, b, c, x, y, and z). serogroups a and c are the main causes of epidemics, with b causing sporadic cases and local outbreaks. transmission is by direct contact and droplet spread. meningitis (group a) is common in sub-saharan african countries, but epidemics have occurred worldwide. during epidemics, children, teenagers, and young adults are the most severely affected. in developed countries, outbreaks occur most frequently in military and student populations. in , meningococcal meningitis spread widely in the "meningitis belt" in central africa. epidemic control is achieved by mass chemoprophylaxis with antibiotics (e.g., rifampin or sulfa drugs) among case contacts, although the emergence of resistant strains is a concern. vaccines against serotypes a and c (bivalent) or a, c, w, and y are available. their use is effective in epidemic control and prevention institutions and military recruits, especially for a and c serogroups. vaccination is one of the key modalities of primary prevention. immunization is cost-effective and prevents wide-scale disease and death, with high levels of safety. despite the general consensus in public health regarding the central role of vaccination, there are many areas of controversy and unfulfilled expectations. a vaccination program should aim at % coverage at appropriate times, including infants, school children, and adults. immunization policy should be adapted from current international standards applying the best available program to national circumstances and financial capacities (table . ). public health personnel with expertise in vaccine-preventable disease control are needed to advise ministries of health and the practicing pediatric community on current issues in vaccination and to monitor implementation and evolution of control programs. controversies and changing views are common to immunization policy, so that discussions must be conducted on a continuing basis. policy should be under continuing review by a ministerially appointed national immunization advisory committee, including professionals from public health, academia, immunology, laboratory sciences, economics, and relevant clinical fields. bduring , the recommendation for polio virus was changed to doses of ipv in infancy. vaccine supply should be adequate and continuous. supplies should be ordered from known manufacturers meeting international standards of good manufacturing practice. all batches should be tested for safety and efficacy prior to release for use. there should be an adequate and continuously monitored cold chain to protect against high temperatures for heat labile vaccines, sera, and other active biological preparations. the cold chain should include all stages of storage, transport, and maintenance at the site of usage. only disposable syringes should be used in vaccination programs to prevent any possible transmission of blood-borne infection. a vaccination program depends on a readily available service with no barriers or unnecessary prerequisites, free to parents or with a minimum fee, to administer vaccines in disposable syringes by properly trained individuals using patientoriented and community-oriented approaches. ongoing education and training on current immunization practices are needed. incentive payments by insuring agency or managed care systems promote complete, on-time coverage. all clinical encounters should be used to screen, immunize, and educate parents/guardians. contraindications to vaccination are very few; vaccines may be given even during mild illness with or without fever, during antibiotic therapy, during convalescence from illness, following recent exposure to an infectious disease, and to persons having a history of mild/moderate local reactions, convulsions, or family history of sudden infant death syndrome (sids). simultaneous administration of vaccines and vaccine "cocktails" reduces the number of visits and thereby improves coverage; there are no known interferences between vaccine antigens. accurate and complete recording with computerization of records with automatic reminders helps promote compliance, as does co-scheduling of immunization appointments with other services. adverse events should be reported promptly, accurately, and completely. a tracking system should operate with reminders of upcoming or overdue immunizations; use mail, telephone, and home visits, especially for high risk families, with semiannual audits to assess coverage and review patient records in the population served to determine the percentage of children covered by second birthday. tracking should identify children needing completion of the immunization schedule and assess the quality of documentation. it is important to maintain up-to-date, easily retrievable medical protocols where vaccines are administered, noting vaccine dosage, contraindications, and management of adverse events. all health care providers and managers should be trained in education, promotion, and management of immunization policy. health education should target parents as well as the general public. monitoring of vaccines used and children immunized, individually and by category of vaccination can be facilitated by computerization of immunization records, or regular manual review of child care records. where immunization is done by physicians in private practice, as in the united states, determination of coverage is by periodic surveys. inspection of vaccines for safety, purity, potency, and standards is part of the regulatory function. vaccines are defined as biological products and are therefore subject to regulation by national health authorities. in the united states, this comes under the legislative authority of the public health service act, as well as the food, drug and cosmetics act, with applicable regulations in the code of federal regulations. the federal agency empowered to carry out this regulatory function is the center for drugs and biologics of the federal food and drug administration. litigation regarding adverse effects of vaccines led to inflation of legal costs and efforts to limit court settlements. the u.s. federal government enacted the child vaccine injury act of . this legislation requires providers to document vaccines given and to report on complications or reactions. it was intended to pay benefits to persons injured by vaccines faster and by means of a less expensive procedure than a civil suit for resolving claims. using this no-fault system, petitioners do not need to prove that manufacturers or vaccine givers were at fault. they must only prove that the vaccine is related to the injury in order to receive compensation. the vaccines covered by this legislation include dtp, mmr, opv, and ipv. development of vaccines from jenner in eighteenth century to the advent of recombinant hepatitis b vaccine in , and of vaccines for acellular pertussis, varicella, hepatitis a, and rotavirus in the s, has provided one of the pillars of public health and led to enormous savings of human life. vaccines for viral in-fections in humans for hiv, respiratory syncytial virus, papilloma, epstein-barr virus, dengue fever, and hantavirus are under intense research with genetic approaches using recombinant techniques. the potential for the future of vaccines will be greatly influenced by scientific advances in genetic engineering, with potential for development of vaccines attached to bacteria or protein in plants, which may be given in combination for an increasing range of organisms or their harmful products. recombinant dna technology has revolutionized basic and biomedical research since the s. the industry of biotechnology has produced important diagnostic tests, such as for hiv, with great potential for vaccine development. traditional whole organism vaccines, alive or killed, may contain toxic products that may cause mild to severe reactions. subunit vaccines are prepared from components of a whole organism. this avoids the use of live organisms that can cause the disease or create toxic products which cause reactions. subunit vaccines traditionally prepared by inactivation of partially purified toxins are costly, difficult to prepare, and weakly immunogenic. recombinant techniques are an important development for production of new whole cell or subunit vaccines that are safe, inexpensive, and more productive of antibodies than other approaches. their potential contribution to the future of immunology is enormous. molecular biology and genetic engineering have made it feasible to create new, improved, and less costly vaccines. new vaccines should be inexpensive, easily administered, capable of being stored and transported without refrigeration, and given orally. the search for inexpensive and effective vaccines for groups of viruses causing diarrheal diseases led to development of the rotavirus vaccine. some "edible" research focuses on the genetic programming of plants to produce vaccines and dna. vaccine manufacturers, who spend huge sums of money and years of research on new products, tend to work on those which will bring great financial rewards for the company and are critical to the local health care community. this has led to less effort being made in developing vaccines for diseases such as malaria. yet industry plays a crucial role for continued progress in the field. since the eradication of smallpox, much attention has focused on the possibility of similarly eradicating other diseases, and a list of potential candidates has emerged. some of these have been abandoned because of practical difficulties with current technology. diseases that have been under discussion for eradication have included measles, tb, and some tropical diseases, such as malaria and dracunculiasis. eradication is defined as the achievement of a situation whereby no further cases of a disease occur anywhere and continued control measures are unnecessary. reducing epidemics of infectious diseases, through control and eradication in selected areas or target groups, can in certain instances achieve eradication of the disease. local eradication can be achieved where domestic circulation of an organism is interrupted with cases occurring from importation only. this requires a strong, sustained immunization program with adaptation to meet needs of importation of carriers and changing epidemiologic patterns. smallpox was one of the major pandemic diseases of the middle ages and its recorded history goes back to antiquity. prevention of smallpox was discussed in ancient china by ho kung (circe ao ), and inoculation against the disease was practiced there from the eleventh century ad. prevention was carried out by nasal inhalation of powdered dried smallpox scabs. exposure of children to smallpox when the mortality rate was lowest assumed a weakened form of the disease, and it was observed that a person could only have smallpox once in a lifetime. isolation and quarantine were widely practiced in europe during the sixteenth and seventeenth centuries. variolation was the practice of inoculating youngsters with material from scabs of pustules from mild cases of smallpox in the hope that they would develop a mild form of the disease. although this practice was associated with substantial mortality, it was widely adopted because mortality from variolation was well below that of smallpox acquired during epidemics. introduced into england in (see chapter ) it was commonly practiced as a lucrative medical specialty during the eighteenth century. in the s, variolation was also introduced into the american colonies, russia, and subsequently into sweden and denmark. despite all efforts, in the early eighteenth century smallpox was a leading cause of death in all age groups. toward the end of the eighteenth century an estimated , persons died annually from smallpox in europe. vaccination, or the use of cowpox vaccinia virus to protect against smallpox, was initiated late in the eighteenth century. in , a cattle breeder in yorkshire, england, inoculated his wife and two children with cowpox to protect them during a smallpox epidemic. in , edward jenner, an english country general practitioner, experimented with inoculation from a milkmaid's cowpox pustule to a healthy youngster, who subsequently proved resistant to smallpox by variolation (see chapter ). vaccination, the deliberate inoculation of cowpox material, was slow to be adopted universally, but by , over , persons in england were vaccinated. vaccination gathered support in the nineteenth century in military establishments, and in some countries which adopted it universally. opposition to vaccination remained strong for nearly a century based on religious grounds, observed failures of vaccination to give lifelong immunity, and because it was seen as an infringement of the state on the rights of the individual. often the protest was led by medical variolationists whose medical practice and large incomes were threatened by the mass movement to vaccination. resistance was also offered by "sanitarians" who opposed the germ theory and thought cleanliness was the best method of prevention. universal vaccination was increasingly adopted in europe and america in the early nineteenth century and eradication of smallpox in developed countries was achieved by the mid twentieth century. in , the soviet union proposed to the world health assembly a program to eradicate smallpox internationally and subsequently donated million doses of vaccine per year as part of the million needed to promote vaccination of at least % of the world population. in , who adopted a target for the eradication of smallpox. a program was developed which included a massive increase in coverage to reduce the circulation of the virus through person-to-person contact. where smallpox was endemic, with a substantial number of unvaccinated persons, the aim of the mass vaccination phase was % coverage. increasing vaccination coverage in developing countries reduced the disease to periodic and increasingly localized outbreaks. in , countries were considered endemic for smallpox, and another experienced importation of cases. by , the number of endemic countries was down to , and by only countries were still endemic, including india, pakistan, bangladesh, and nepal. in these countries, a new strategy was needed, based on a search for cases and vaccination of all contacts, working with a case incidence below per , . the program then moved into the consolidation phase, with emphasis on vaccination of newborns and new arrivals. surveillance and case detection were improved with case contact or risk group vaccination. the maintenance phase began when surveillance and reporting were switched to the national or regional health service with intensive follow-up of any suspect case. the mass epidemic era had been controlled by mass vaccination, reducing the total burden of the disease, but eradication required the isolation of individual cases with vaccination of potential contacts. technical innovations greatly eased the problems associated with mass vaccination worldwide. during the s, there was wide variation in sources of smallpox vaccine. in the s, efforts to standardize and further attenuate the strains used reduced complication rates from vaccinations. the development of lyophilization (freeze-drying) of the vaccine in england in the s made a heat-stable vaccine that could be effective in tropical field conditions in developing countries. the invention of the bifurcated needle (bernard rubin ) allowed for easier and more widespread vaccination by lesser trained personnel in remote areas. the net result of these innovations was increased world coverage and a reduction in the spread of the disease. smallpox became more and more confined by increasing herd immunity, thus allowing transition to the phase of monitoring and isolation of individual cases. in the last case of smallpox was identified in somalia, and in the who declared the disease eradicated. no subsequent cases have been found except for several associated with a laboratory accident in the united kingdom in . the who recommends that the last stores of smallpox virus should be destroyed in . the cost of the eradication program was $ million or $ million per year. worldwide savings are estimated at $ billion annually. this monumental public health achievement set the precedent for eradication of other infectious diseases. the world health assembly decided to destroy the last two remaining stocks of the smallpox virus in atlanta and moscow in . destruction of the remaining stock was delayed in to because of concern that illegal stocks may be held by some states or potential bioterrorists for potential use in weapons of mass destruction, concern regarding the appearance of monkeypox and a wish to use the virus for further research. in , the who established a target of eradication of poliomyelitis by the year . global immunization coverage with three doses of opv increased from some % in to over % in , with a slight decline in the period - . support from member countries and international agencies such as unicef and rotary international has led to widescale increases in immunization coverage throughout many parts of the world. the world health organization promotes use of opv only as part of routine infant immunization or national immunization days (nids). this strategy has been successful in the americas and in china, but india and the middle east remain problematic. eradication of wild poliomyelitis by the year will require flexibility in vaccination strategies and may require the combined approach, using opv and ipv, as adopted in the united states in to prevent vaccine-associated clinical cases. the combination of opv and ipv may be needed where enteric disease is common and leads to interference in opv uptake, especially in tropical areas where endemic poliovirus and diarrheal diseases are still found. the world bank estimated that achievement of global eradication would save $ million annually in the united states alone. since the eradication of smallpox, discussion has focused on the possibility of similarly eradicating other diseases, and a list of potential candidates has emerged. some of these have been abandoned because of practical difficulties with current technology. diseases that have been under discussion for eradication have included measles, tb, and tropical diseases such as malaria and dracunculiasis. eradication of malaria was thought to be possible in the s when major gains were seen in malaria control by aggressive case environmental control, case finding, and management. however, lack of sustained vector control and an effective vaccine has prevented global eradication. malaria control suffered serious setbacks because of failure in political resolve and capacity to continue support needed for necessary programs. in the s and s, control efforts were not sustained in many countries, and a dreadful comeback of the disease occurred in africa and asia in the s. the emergence of mosquitoes resistant to insecticides, and malarial strains resistant to antimalarial drugs, have made malaria control even more difficult and expensive. renewed effort in malaria control may require new approaches. use of community health workers (chws) in small villages in highly endemic regions of colombia resulted in a major drop in malaria mortality during the s. the chws investigate suspect cases by taking clinical histories and blood smears. . scientific feasibility a. epidemiologic vulnerability; lack of nonhuman reservoir, ease of spread, no natural immunity, relapse potential; b. effective practical intervention available; vaccine or other primary preventive or curative treatment, or vectoricide that is safe, inexpensive, long lasting, and easily used in the field; c. demonstrated feasibility of elimination in specific locations, such as an island or other geographic unit. . political will/popular support a. they examine smears for malaria parasites and a diagnosis is made. therapy is instituted and the patient is followed. quality control monitoring shows high levels of accuracy in reading of slides compared to professional laboratories. in the late s, there was widespread discussion in the literature of the potential for eradication of measles and tb. measles eradication was set back as breakthrough epidemics occurred in the united states, canada, and many other countries during the s and early s, but regional eradication was achieved combining the two-dose policy with catch-up campaigns for older children or in national immunization days, as in the caribbean countries. tuberculosis has also increased in the united states and several european countries for the first time in many decades. unrealistic expectations can lead to inappropriate assessments and policy when confounding factors alter the epidemiologic course of events. such is the case with tb, where control and eradication have receded from the picture. this deadly disease has returned to developed countries, partly in association with the hiv infection and multiple-drug-resistant strains, as well as homelessness, rising prison populations, poverty, and other deleterious social conditions. directly observed therapy is an important recent breakthrough, more effective in use of available technology and will play a major role in tb control in the twenty-first century. a decade after the eradication of smallpox was achieved, the international task force for disease eradication (itfde) was established to systematically evaluate the potential for global eradicability of candidate diseases. its goals were to identify specific barriers to the eradication of these diseases that might be surmountable and to promote eradication efforts. the subject of eradication versus control of infectious diseases if of central public health importance as technology expands the armamentarium of immunization and vector control into the twenty-first century. the control of epidemics, followed by interruption of transmission and ultimately eradication, will save countless lives and prevent serious damage to children throughout the world. the smallpox achievement, momentous in itself, points to the potential for the eradication of other deadly diseases. the skillful use of existing and new technology is an important priority in the new public health. flexibility and adaptability are as vital as resources and personnel. selecting diseases for eradication is not purely a professional issue of resources such as vaccines and manpower, organization and financing. it is also a matter of political will and perception of the burden of disease. there will be many controversies. the selection of polio for eradication while deferring measles when polio kills few and measles kills many may be questioned. the cdc published criteria for selection of disease for eradication are shown in box . . the who, in a review of health targets in the field of infectious disease control for the twenty-first century, selected the following targets: eradication of chagas' disease by ; eradication of neonatal tetanus by ; eradication of leprosy by ; eradication of measles by ; eradication of trachoma by ; reversing the current trend of increasing tuberculosis and hiv/aids. in , a conference in atlanta, georgia, reviewed the subject, which is still very much in a state of flux. table . summarizes the selection of diseases which are presently seen as controllable and those considered to be potentially eradicable. the subject will be under review in the years ahead. mycobacterium tuberculosis in humans and m. bovis in cattle. the disease is primarily found in humans, but it is also a disease of cattle and occasionally other primates in certain regions of the world. it is transmitted via airborne droplet nuclei from persons with pulmonary or laryngeal tb during coughing, sneezing, talking, or singing. the initial infection may go unnoticed, but tuberculin sensitivity appears within a few weeks. about % of those infected enter a latent phase with a lifelong risk of reactivation. approximately % go from initial infection to pulmonary tb. less commonly, the infection develops as extrapulmonary tb, involving meninges, lymph nodes, pleura, pericardium, bones, kidneys, or other organs. untreated, about half of the patients with active tb will die of the disease within years, but modern chemotherapy almost always results in a cure. pulmonary tb symptoms include cough and weight loss, with clinical findings on chest examination and confirmation by findings of tubercle bacilli in stained smears of sputum and, if possible, growth of the organism on culture media, and changes in the chest x-ray. tuberculosis affects people in their adult working years, with - % of cases in persons between the ages of and . its devastating effects on the work force and economic development contribute to a high cost-effectiveness for tb control. the tubercle bacillus infects approximately . billion people in the world today, causing over million cases and nearly million deaths in . during , new cases of tb included . million ( %) in southeast asia and the western pacific regions of who, with . million cases in india, and . million in indonesia. by , the incidence of tb may increase to . million new cases per year, a % increase over . between and , who estimates there were million new cases of tb, of which million cases were in association with hiv infection. during the s, an estimated million persons died of tb, including . million with hiv infection. a new and dangerous period for tb resurgence has resulted from parallel epidemiologic events: first, the advent of hiv infection and second, the occurrence of multiple drug resistant tb (mdrtb), that is, organisms resistant at least to both isoniazid (inh) and rifampicin, two mainstays of tb treatment. mdrtb can have a case fatality rate as high as %. hiv reduces cellular immunity so that people with latent tb have a high risk of activation of the disease. it is estimated that hiv negative persons have a - % lifetime risk of tb; hiv positive people have a risk of % per year of developing clinical tuberculosis. drug resistance, the long period of treatment, and the socioeconomic profile of most tb patients combine to require a new approach to therapy. directly observed treatment, short-course (dots), has shown itself to be highly effective with patients in poor self-care settings, such as the homeless, drug users, and those with aids. the strategy of dots uses community health workers to visit the patient and observes him or her taking the various medications, providing both incentive, support, and moral coercion to complete the needed to month therapy. dots has been shown to cure up to % of cases, at a cost of as little as $ per patient. it is one of the few hopes of containing the tb pandemic. in , who released a new strategy for control of tuberculosis over the next decade. the plan calls for new guidelines for control, new aid funds for developing countries, and enlistment of ngos to assist in the fight. the new guidelines stress short-term chemotherapy in well-managed programs of dots, stressing strict compliance with therapy for infectious cases with a goal of an % cure rate. even under adverse conditions, dots produces excellent results. it is one of the most cost-effective health interventions combining public health and clinical medical approaches. tuberculosis incidence in the united states decreased steadily until , increased in , and has declined again since. from to , there was an excess of , cases over the expected rate if the previous decline in case incidence had continued. this rise was largely due to the hiv/aids epidemic and the emergence of mdrtb, but also greater incidence among immigrants from areas of higher tb incidence, drug abusers, the homeless, and those with limited access to health care. this is particularly true in new york city, where mdrtb has appeared in outbreaks among prison inmates and hospital staff. from to , tb incidence in the united states declined by % and in some states, including new york, by % or more. this turnaround was due to stronger tb control programs that promptly identified persons with tb and initiated and ensured completion of appropriate therapy. aggressive staff training, outreach, and case management approaches were vital to this success. concern over rising rates among recent immigrants and the continued challenge of hiv/aids and coincidental transmission of hepatitis a, b, and c among drug users and marginal population groups show that continued support for tb control is needed. bacillus calmette-gurrin (bcg) is an attenuated strain of the tubercle bacillus used widely as a vaccination to prevent tb, especially in high incidence areas. it induces tuberculin sensitivity or an antigen-antibody reaction in which antibodies produced may be somewhat protective against the tubercle bacillus in % of vaccinees. although the support for its general use is contradictory, there is evidence from case-control and contact studies of positive protection against tb meningitis and disseminated tb in children under the age of . in some developed, low-incidence countries, it is not used routinely but selectively. it may also be used in asymptomatic hiv-positive persons or other high risk groups. the bcg vaccine for tuberculosis remains controversial. while used widely internationally, in the united states and other industrialized countries, it is thought to hinder rather than help in the fight against tb. this concern is based on the usefulness of tuberculin testing for diagnosis of the disease. where bcg has been administered, the diagnostic value of tuberculin testing is reduced, especially in the period soon after the bcg is used. studies showing equivocal benefit of bcg in preventing tuberculosis have added to the controversy. while those in the field in the united states continue to oppose the use of bcg, internationally it is still felt to be of benefit in preventing tb, primarily in children. a metaanalysis of the literature of bcg carried out by the technology assessment group at harvard school of public health concluded: on average, bcg vaccine significantly reduces the risk of tb by %. protection is observed across many populations, study designs, and forms of tb. age at vaccination did not enhance predictiveness of bcg efficacy. protection against tuberculous death, meningitis, and disseminated disease is higher than for total tb cases, although this result may reflect reduced error in disease classification rather than greater bcg efficacy. [colditz et al., jama, .] box . control of tuberculosis . identifying persons with clinically active tb; . diagnostic methods--clinical suspicion, sputum smear for bacteriologic examination, tuberculin skin testing, chest radiograph; . case finding and investigation programs in high risk groups; . contact investigation; . isolation techniques during initial therapy; . treatment, mainly ambulatory, of persons with clinically active tb; . treatment of contacts; . directly observed treatment, short-course (dots), where compliance suspect; . environmental control in treatment settings to reduce droplet infection; . educate health care providers on suspicion of tb and investigation of suspects. currently, the who recommends use of bcg as close to birth as possible as part of the expanded programme of immunization (epi). tuberculosis control remains feasible with current medical and public health methods. deterioration in its control should not lead to despair and passivity. the recent trend to successful control by dots despite the growing problem of mdrtb suggest that control and gradual reduction can be achieved by an activist, community outreach approach. the who in made tb control one of its major priorities, expressing grave concern that the mdr organism, now widely spread in countries of asia, eastern europe, and the former soviet union, may spread the disease much more widely. the disease constitutes one of the great challenges to public health at the start of the new century. acute infectious diseases caused by group a streptococci include streptococcal sore throat, scarlet fever, puerperal fever, septicemia, ersypelas, cellulitis, mastoiditis, otitis media, pneumonia, peritonsillitis (quinsy), wound infections, toxic shock syndrome, and fasciitis, the "flesh eating bacteria." streptococcus pyogenes group a include some serologically distinct types which vary in geographic location and clinical significance. transmission is by droplet, person-to-person direct contact, or by food infected by carriers. important complications from a public health point of view include acute rheumatic fever and acute glomerulonephritis, but also skin infections and pneumonia. acute rheumatic fever is a complication of strep a infection that has virtually disappeared from industrialized countries as a result of improved standards of living and antibiotic therapy. however, outbreaks were recorded in the united states in , and an increasing number of cases have been seen since . in developing countries, rheumatic fever remains a serious public health problem affecting school age children, particularly those in crowded living arrangements. longterm sequelae include disease of the mitral and aortic heart valves, which require cardiac care and surgery for repair or replacement with artificial valves. acute glomerulonephritis is a reaction to toxins of the streptococcal infection in the kidney tissue. this can result in long-term kidney failure and the need for dialysis or kidney transplantation. this disease has become far less common in the industrialized countries, but remains a public health problem in developing countries. the streptococcal diseases are controllable by early diagnosis and treatment with antibiotics. this is a major function of primary care systems. recent increases in rheumatic fever may herald a return of the problem, perhaps due to inadequate access to primary care in the united states for large sectors of the population, along with increased social hygiene problems. where access to primary care services is limited, infections with streptococci can result in a heavy burden of chronic heart and kidney disease with substantial health, emotional, and financial tolls. measures to improve access to care and pub-lic information are needed to assure rapid and effective care to prevent chronic and costly conditions. zoonoses are infectious diseases transmissible from vetebrate animals to humans. common examples of zoonoses of public health importance in nonindustrialized countries include brucellosis and rabies. in industrialized countries, salmonellosis, "mad cow disease" and influenza have reinforced the importance of relationships of animal and human health. strong cooperation between public health and veterinary public health authorities are required to monitor and to prevent such diseases. brucellosis is a disease occurring in cattle (brucella abortus), in dogs (br. cahis), in goats and sheep (br. melitensis), and in pigs (br. suis). humans are affected mainly through ingestion of contaminated milk products, by contact, or inhalation. brucellosis (also known as relapsing, undulant, malta, or mediterranean fever) is a systemic bacterial disease of acute or insidious onset characterized by fever, headache, weakness, sweating, chills, arthralgia, depression, weight loss, and generalized malaise. spread is by contact with tissues, blood, urine, vaginal discharges, but mainly by ingestion of raw milk and dairy products from infected animals. the disease may last from a few days to a year or more. complications include osteoarthritis and relapses. case fatality is under %, but disability is common and can be pronounced. the disease is primarily seen in mediterranean countries, the middle east, india, central asia, and in central and south america. brucellosis occurs primarily as an occupational disease of persons working with and in contact with tissues, blood, and urine of infected animals, especially goats and sheep. it is an occupational hazard for veterinarians, packinghouse workers, butchers, tanners, and laboratory workers. it is also transmitted to consumers of unpasteurized milk from infected animals. animal vectors include wild animals, so that eradication is virtually impossible. diagnosis is confirmed by laboratory findings of the organism in blood or other tissue samples, or with rising antibody titers in the blood, with confirmation by blood cultures. clinical cases are treated with antibiotics. epidemiologic investigation may help track down contaminated animal flocks. routine immunization of animals, monitoring of animals in high risk areas, quarantining sick animals, destroying infected animals, and pasteurizing milk and milk products prevents spread of the disease. control measures include educating farmers and the public not to use unpasteurized milk. individuals who work with animals (cattle, swine, goats, sheep, dogs, coyotes) should take special precautions when handling animal carcasses and materials. testing animals, destroying carriers, and enforcing mandatory pasteurization will restrict the spread of the disease. this is an economic as well as public health problem, requiring full cooperation between ministries of health and of agriculture. rabies is primarily a disease of animals, with a variety of wild animals serving as a reservoir for this disease, including foxes, wolves, bats, skunks, and raccoons, who may infect domestic animals such as dogs, cats, and farm animals. animal bites break the skin or mucous membrane, allowing entry of the virus from the infected saliva into the bloodstream. the incubation period of the virus is - weeks; it can be as long as several years or as short as days, so that postexposure preventive treatment is a public health emergency. the clinical disease often begins with a feeling of apprehension, headache, pyrexia, followed by muscle spasms, acute encephalitis, and death. fear of water ("hydrophobia") or fear of swallowing is a characteristic of the disease. rabies is almost always fatal within a week of onset of symptoms. the disease is estimated to cause , deaths annually, primarily in developing countries. it is uncommon in developed countries. rabies control focuses on prevention in humans, domestic animals, and wildlife. prevention in humans is based on preexposure prophylaxis for groups at risk (e.g., veterinarians, zoo workers) and postexposure immunization for persons bitten by potentially rabid animals. because reducing exposure of pets to wild animals is difficult, immunization of domestic animals is one of the most important preventive measures. prevention in domestic animals is by mandatory immunization of household pets. all domestic animals should be immunized at age months and revaccinated according to veterinary instructions. prevention in wild animals to reduce the reservoir is successful in achieving local eradication in settings where reentry from neighboring settings is limited. since , the use of oral rabies immunization has been successful in reducing the population of wild animals infected by the rabies virus. rabies eradication efforts, using aerial distribution of baits containing fox rabies vaccine in affected areas of belgium, france, germany, italy, and luxembourg, have been underway since . the number of rabies cases in these affected areas has declined by some %. switzerland is now virtually rabies-free because of this vaccination program. the potential exists for focal eradication, especially on islands or in partially restricted areas with limited possibilities of wild animal entry. livestock need not be routinely immunized against rabies, except in high risk areas. where bats are major reservoirs of the disease, as in the united states, eradication is not presently feasible. salmonella, discussed later in this chapter under diarrheal diseases, is one of the commonest of all infectious diseases among animals and is easily spread to humans via poultry, meat, eggs, and dairy products. specific antigenic types are associated with food-borne transmission to humans, causing generalized illness and gastroenteritis. severity of the disease varies widely, but the diseases can be devastating among vulnerable population groups, such as young children, the elderly, and the immunocompromised. epidemiologic investigation of common food source outbreaks may uncover hazardous food handling practices. laboratory confirmation or serotypes helps in monitoring the disease. prevention is by maintaining high standards of food hygiene in processing, inspection and regulation, food handling practices, and hygiene education. bacillus anthracis causes a bacterial infection in herbivore animals. its spores contaminate soil, worldwide. it affects humans exposed in occupational settings. transmission is cutaneous by contact, gastrointestinal by ingestion, or respiratory by inhalation. it has gained recent attention (iraq, ) as a highly potent agent for germ warfare or terrorism. limited supplies of vaccine are available. creutzfeld-jakob disease is a degenerative disease of the central nervous system linked to consumption of beef from cattle infected with bovine spongiform encephalopathy. it is transmitted by prions in animal feed prepared from contaminated animal material and in transplanted organs. this disease was identified in the united kingdom linked to infected cattle leading to a ban on british beef in many parts of the world and slaughter of large numbers of potentially contaminated animals. the tapeworm causing diphyllobothriasis (diphyllobothrium latum) is widespread in north american freshwater fish, passing from crustacean to fish to humans by eating raw freshwater fish. it is especially common among inuit peoples and may be asymptomatic or cause severe general and abdominal disorder. food hygiene (freezing and cooking of meat) is recommended; treatment is by anthelminthics. leptospiroses are a group of zoonotic bacterial diseases found worldwide in rats, raccoons, and domestic animals. it affects farmers, sewer workers, dairy and abattoir workers, veterinarians, military personnel, and miners with transmission by exposure to or ingestion of urine-contaminated water or tissues of infected animals. it is often asymptomatic or mild, but may cause generalized illness like influenza, meningitis, or encephalitis. prevention requires education of the public in self protection and immunization of workers in hazardous occupations, along with immunization and segregation of domestic animals and control of wild animals. vector-borne diseases are a group of diseases in which the infectious agent is transmitted to humans by crawling or flying insects. the vector is the intermediary between the reservoir and the host. both the vector and the host may be affected by climatic condition; mosquitoes thrive in warm, wet weather and are suppressed by cold weather; humans may wear less protective clothing in warm weather. the only important reservoir of malaria is humans. its mode of transmission is from person to person via the bite of an infected female anopheles mosquito (ronald ross, nobel prize, ) . the causative organism is a single cell parasite with four species: plasmodium vivax, p malariae, p falciparum, and p ovale. clinical symptoms are produced by the parasite invading and destroying red blood cells. the incubation period of approximately - days, depending on the specific plasmodium involved. some strains of p vivax may have a protracted incubation period of - months and even longer for p ovale. the disease can also be transmitted through infected blood transfusions. confirmation of diagnosis is by demonstrating malaria parasites on blood smears. falciparum malaria, the most serious form, presents with fever, chills, sweats, and headache. it may progress to jaundice, bleeding disorders, shock, renal or liver failure, encephalopathy, coma, and death. prompt treatment is essential. case fatality rates in untreated children and adults are above %. an untreated attack may last months. other forms of malaria may present as a nonspecific fever. relapse of the p ovale may occur up to years after initial infection; malaria may persist in chronic form for up to years. malaria control advanced during the s- s through improved chlovaquine treatment and use of ddt for vector control with optimism for eradication of the disease. however, control regressed in many developing countries as allocations for environmental control and case findings/treatment were reduced. there has also been an increase in drug resistance, so that this disease is now an extremely serious public health problem in many parts of the world. the need for a vaccine for malaria control is now more apparent than ever. the world health organization estimated that, in , sub-saharan africa (ssa) had million new malaria cases, with % of children up to age . over million deaths occur annually from malaria more than two-thirds of them in ssa. large areas, particularly in forest or savannah regions with high rainfall, are holoendemic. in higher altitudes, endemicity is lower, but epidemics do occur. chloroquine-resistant p. falciparum has spread throughout africa, accompanied by an increasing incidence of severe clinical forms of the disease. the world bank estimates that % of all disability-adjusted life years (dalys) lost per year in ssa are from malaria, which places a heavy economic burden on the health systems. in the americas, the number of cases detected has risen every year since , and the who estimates there to have been . - . million cases in . the nine most endemic countries in the americas achieved a % reduction in malaria mortality between and . southeast asian region reports some . million cases of malaria in and deaths from tb. this accounts for more than one-third of all non-african malaria cases. there is an increase in resistant strains to the major available drugs and of the mosquitoes to insecticides in use. vector control, case finding, and treatment remain the mainstay of control. use of insecticide-impregnated bed nets and curtains, and residual house spraying, and strengthened vector control activities are important, as are early diagnosis and carefully monitored treatment with monitoring for resistance. control of malaria will ultimately depend on a safe, effective, and inexpensive vaccine. attempts to develop a malaria vaccine have been unsuccessful to date due to the large number of genetic types of p. falciparum even in localized areas. a colombian-developed vaccine is being field-tested with partial effectiveness. research in vaccines for malaria has also been hampered by the fact that it is a relatively low priority for vaccine manufacturers because of the minimal potential for financial benefit. research on malaria concentrates on the pharmacological aspects of the disease because of increasing drug resistance. in , who has initiated a new campaign to "roll back malaria" and maintain the dream of eradication in the future. effective low technology interventions include community-based case finding, early treatment of good quality, insecticide use, and vector control. the use of community health workers in endemic areas, has shown promising results. local control and even eradication can be achieved with currently available technology. this requires an integration of public health and clinical approaches with strong political commitment. the rickettsia are obligate parasites, i.e., they can only replicate in living cells, but otherwise they have characteristics of bacteria. this is a group of clinically similar diseases, usually characterized by severe headache, fever, myalgia, rash, and capillary bleeding causing damage to brain, lungs, kidneys, and heart. identification is by serological testing for antibodies, but the organisms can also be cultured in laboratory animals, embryonic eggs, or in cell cultures. the organisms are transmitted by arthropod vectors such as lice, fleas, ticks, and mites. the diseases caused millions of deaths during war and famine periods prior to the advent of antibiotics. these diseases appear in nature in ways that make them impossible to eradicate, but clinical diagnosis, host protection, and vector control can help reduce the burden of disease and deal with outbreaks that may occur. public education regarding self-protection, appropriate clothing, tick removal, and localized control measures such as spraying and habitat modification are useful. epidemic typhus, first identified in , is due to rickettsia prowazekii. spread primarily by the body louse, typhus was the cause of an estimated million deaths, i.e., during war and famine, in poland and the soviet union from - . untreated, the fatality rate is - %. typhus responds well to antibiotics. it is currently largely confined to endemic foci in central africa, central asia, eastern europe, and south america. it is preventable by hygiene and pediculicides such as ddt and lindane. a vaccine is available for exposed laboratory personnel. murine typhus is a mild form of typhus due to rickettsia typhi, which is found worldwide and spread in rodent reservoirs. scrub typhus, also known as tsutsugamushi or japanese river fever, is located throughout the far east and the pacific islands, and was a serious health problem for u.s. armed forces in the pacific during world war ii. it is spread by the rickettsia tsutsugamushi and has a wide variation in case fatality according to region, organism, and age of patient. rocky mountain spotted fever is a well-known and severe form of tick-borne typhus due to rickettsia rickettsii, occurring in western north america, europe, and asia. q. fever is a tick-borne disease caused by coxiella burnetii and is worldwide in distribution, usually associated with farm workers, in both acute and chronic forms. regular anti-tick spraying of sheep, cows, and goats helps protect exposed workers. protective clothing and regular removal of body ticks help protect exposed persons. arthropod-borne viral diseases are caused by a diverse group of viruses which are transmitted between vertebrate animals (often farm animals or small rodents) and people by the bite of blood-feeding vectors such as mosquitoes, ticks, and sandflies and by direct contact with infected animal carcasses. usually the viruses have the capacity to multiply in the salivary glands of the vector, but some are carried mechanically in their mouthparts. these viruses cause acute central nervous system infections (meningoencephalitis), myocarditis, or undifferentiated viral illnesses with polyarthritis and rashes, or severe hemorrhagic febrile illnesses. arbovirus diseases are often asymptomatic in vertebrates but may be severe in humans. over antigenetically distinct arboviruses are associated with disease in humans, varying from benign fevers of short duration to severe hemmorhagic fevers. each has a specific geographic location, vector, clinical, and virologic characteristics. they are of international public health importance because of the potential for spread via natural phenomena and modem rapid transportation of vectors and persons incubating the disease or ill with it, with potential for further spreading at the point of destination. arboviruses are responsible for a large number of encephalitic diseases characterized by mode of transmission and geographic area. mosquito-borne arboviruses causing encephalitis include eastern and western equine, venezuelan, japanese, and murray hill encephalitides. japanese encephalitis is caused by a mosquito-borne arbovirus found in asia and is associated with rice-growing areas. it is characterized by headache, fever, convulsions, and paralysis, with fatality rates in severe cases as high as %. a currently available vaccine is used routinely in endemic areas (japan, korea, thailand, india, and taiwan) and for persons traveling to infected areas. tick-borne arboviruses causing encephalitis include the powassan virus, which occurs sporadically in the united states and canada. tickborne encephalitis is endemic in eastern europe, scandinavia, and the former soviet union. an epidemic of mosquito-borne encephalitis in new york city in included cases and deaths, due to the west nile fever virus, never before found in the united states. other insect vectors. it affects animals and humans who are in direct contact with the meat or blood of affected animals. the virus causes a generalized illness in humans with encephalitis, hemorrhages, retinitis and retinal hemorrhage leading to partial or total blindness, and death ( - %). it also causes universal abortion in ewes and a high percentage of death in lambs. the normal habitat is in the rift valley of eastern africa (the great syrian-african rift), often spreading to southern africa, depending on climactic conditions. the primary reservoir and vector is the aedes mosquito, and affected animals serve to multiply the virus which is transmitted by other vectors and direct contact with animal fluids to humans. an unusual spread of rvf northward to the sudan and along the aswan dam reservoir to egypt in - caused hundreds of thousands of animal deaths, with , human cases and deaths. rvf appeared again in egypt in . this disease is suspected to be one of the ten plagues of egypt leading to the exodus of the children of israel from egypt during pharaonic-biblical times. in , an outbreak of rvf in kenya, initially thought to be anthrax, with hundreds of cases and dozens of deaths, was related to abnormal rainy season and vector conditions. satellite monitoring of rainfall and vegetation is being used to predict epidemics in kenya and surrounding countries. animal immunization, monitoring, vector control, and reduced contact with infected animals can limit the spread of this disease. arboviruses can also cause hemorrhagic fevers. these are acute febrile illnesses, with extensive hemorrhagic phenomena (internal and external), liver damage, shock, and often high mortality rates. the potential for international transmission is high. yellow fever. yellow fever is an acute viral disease of short duration and varying severity with jaundice. it can progress to liver disease and severe intestinal bleeding. the case fatality rate is < % in endemic areas, but may be as high as % in nonendemic areas and in epidemics. it caused major epidemics in the americas in the past, but was controlled by elimination of the vector, aedes aegypti. a live attenuated vaccine is used in routine immunization endemic areas and recommended for travelers to infected areas. determining the mode of transmission and vector control of yellow fever played a major role in the development of public health (see chapter ). in , the who reported , cases and , deaths from yellow fever globally. dengue hemorrhagic fever. dengue hemorrhagic fever is an acute sudden onset viral disease, with - days of fever, intense headache, myalgia, arthralgia, box . dengue fever and dengue hemorrhagic fever, dengue fever, a severe influenza-like illness, and dengue hemorrhagic fever are closely related conditions caused by four distinct viruses transmitted by aedes aegypti mosquitos. dengue is the world's most important mosquito-borne virus disease. a total of , million people worldwide are at risk of infection. an estimated million cases occur each year, of whom , need to be hospitalized. this is a spreading problem, especially in cities in tropical and subtropical areas. major outbreaks were reported in colombia, cuba, and many other locations in . source: world health organization. . world health report gastrointestinal disturbance, and rash. hemorrhagic phenomena can cause case fatality rates of up to %. epidemics can be explosive, but adequate treatment can greatly reduce the number of deaths. dengue occurs in southeast asia, the pacific islands, australia, west africa, the caribbean, and central and south america. an epidemic in cuba in included more than , cases, and deaths. vector control of the a. aegypti mosquito resulted in control of the disease during the s- s, but reinfestation of mosquitoes led to incresased transmission and epidemics in the pacific islands, caribbean, central and south america in the s and s. outbreaks in vietnam included , cases in , another , cases in , and a similar sized outbreak in . indonesia had over , cases in with deaths, and in over , cases (january-may) with at least deaths. in , epidemics of dengue were reported in fiji, the cook islands, new caledonia, and northern australia. the who estimates , deaths and . million cases worldwide in . monkeys are the main reservoir, and the vector is the a. aegypti mosquito. no vaccine is currently available, and management is by vector control. lassa fever. lassa fever was first isolated in lassa, nigeria, in and is widely distributed in west africa, with , - , cases and deaths annually. it is spread by direct contact with blood, urine, or secretions of infected rodents and by direct person-to-person contact in hospital settings. the disease is characterized by a persistent or spiking fever for - weeks, and may include severe hypotension, shock, and hemorrhaging. the case fatality rate is %. marburg disease. marburg disease is a viral disease with sudden onset of generalized illness, malaise, fever, myalgia, headache, diarrhea, vomiting, rash, and hemorrhages. it was first seen in marburg, germany, in , following ex-posure to green monkeys. person-to-person spread occurs via blood, secretions, organs, and semen. case fatality rates can be over %. ebola fever. ebola fever is a viral disease with sudden onset of generalized illness, malaise, fever, myalgia, headache, diarrhea, vomiting, rash, and hemorrhages. it was first found in zaire and sudan in in outbreaks which killed more than persons. it is spread from person to person by the blood, vomitus, urine, stools, and other secretions of sick patients, with a short incubation period. the disease has case fatality rates of up to %. an outbreak of ebola among laboratory monkeys in a medical laboratory near washington, d.c., was contained with no human cases. the reservoir for the virus is thought to be rodents. an outbreak of ebola in may in the town of kikwit, zaire, killed persons out of cases ( % case fatality rate). this outbreak caused international concern that the disease could spread, but it remained localized. another outbreak of ebola virus occurred in gabon in early , with cases, of whom had direct exposure to an infected monkey, the remainder by human-to-human contact, or not established; of the cases died ( %). this disease is considered highly dangerous unless outbreaks are effectively controlled. in zaire, lack of basic sanitary supplies, such as surgical gloves for hospitals, almost ensures that this disease will spread when it recurs. lyme disease is characterized by the presence of a rash, musculoskeletal, neurologic, and cardiovascular symptoms. confirmation is by laboratory investigation. it is the most common vector-borne disease in the united states, with , cases reported between and . it primarily affects children in the - age group and adults aged - . lyme disease is preventable by avoiding contact with ticks, by applying insect repellant, wearing long pants and long sleeves in infected areas, and by the early removal of attached ticks. several u.s. manufacturers produced vaccines which are approved for animal and human use. in the mid s, a mother of two young boys who were recently diagnosed with arthritis in the town of lyme, connecticut, conducted a private investigation among other town residents. she mapped each of the six arthritis cases in the town, cases which had occurred in a short time span among boys living in close proximity. this suggested that this syndrome of "juvenile rheumatoid arthritis" was perhaps connected with the boys playing in the woods. she presented her data to the head of rheumatology at yale medical school in new haven, who investigated this "cluster of a new disease entity." some parents reported that their sons had experienced tick bites and a rash before onset of the arthritis. a tick-borne, spiral shaped bacterium, a spirochete, borrelia burgdorferi, was identified as the organism, and ticks shown to be the vector. cases repond well to antibiotic therapy. in over , cases ( . per , ) were reported from states, an increase from , in and , in . cases were mainly located in the northeast, north central, and mid-atlantic regions. the disease accounts for over % of vector-borne disease in the united states and was the ninth leading reported infection in . lyme disease has been identified in many parts of north america, europe, the former soviet union, china, and japan. a newly licensed vaccine is effective for people exposed to ticks but not general usage. personal hygiene for protection from ticks and environmental modification are important to limit spread of the disease. source: cdc, , mmwr, : - ; and cdc, , mmwr, , no. . lyme disease website http://www.cdc.gov/ncidad/disease/lyme/lyme.htm medically important parasites are animals that live, take nourishment, and thrive in the body of a host, which may or may not harm the host, but never brings benefit. they include those caused by unicellular organisms such as protozoa, which include amoebas (malaria, schistosomiasis, amebiasis, and cryptosporidium), and helminths (worms), which are categorized as nematodes, cestodes, and trematodes. public health continues to face the problems of parasitic diseases in the developing world. increasingly, parasitic diseases are being recognized in industrialized countries. giardiasis and cryptosporidium infections in waterborne and other outbreaks have occurred in the united states. parasitic diseases are among the most common causes of illness and death in the world, e.g., malaria. milder illnesses such as giardiasis and trichomoniasis cause widespread morbidity. intestinal infestations with worms may cause of severe complications, although they commonly cause chronic low-grade symptomatology and iron deficiency anemia. echinococcosis (hydatid cyst disease) is infection with echinococcus granulosus, a small dog tapeworm. the tapeworm forms unilocular (single, noncompartmental) cysts in the host, primarily in the liver and lungs, but they can also grow in the kidney, spleen, central nervous system, or in bones. cysts, which may grow up to cm in size, may be asymptomatic or, if untreated, may cause severe symptoms and even death. this parasite is common where dogs are used with herd grazing animals and also have intimate contact with humans. the middle east, greece, sardinia, north africa, and south america are endemic areas, as are a few areas in the united states and canada. the human dis-ease has been eliminated in cyprus and australia. while the dog is the major host, intermediate hosts include sheep, cattle, pigs, horses, moose, and wolves. preventive measures include education in food and animal contact hygiene, destroying wild and stray dogs, and keeping dogs from the viscera of slaughtered animals. a similar, but multilocular, cystic hydatid disease is widely found in wild animal hosts in areas of the northern hemisphere, including central europe, the former soviet union, japan, alaska, canada, and the north-central united states. another echinococcal disease (echinococcus vogeli) is found in south america, where its natural host is the bush dog and its intermediate host is the rat. the domestic dog also serves as a source of human infection. surgical resection is not always successful, and long-term medical treatment may be required. control is through awareness and hygiene as well as the control of wild animals that come in contact with humans and domestic animals. control may require cooperation between neighboring countries. tapeworm infestation (taeniasis) is common in tropical countries where hygienic standards are low. beef (taenia saginata) and pork (t. solium) tapeworms are common where animals are fed with water or food exposed to human feces. freezing or cooking meat will destroy the tapeworm. fish tapeworm (diphyllobothrium latum) is common in populations living primarily on uncooked fish, such as inuit people. these tapeworms are usually associated with northern climates. toddlers are especially susceptible to dog tapeworm (dipylidium caninum), which is present worldwide, and domestic pets are often the source of oral-fecal transmission of the eggs. the disease is usually asymptomatic. similarly, dwarf tapeworm (hymenolepis nana) is transmitted through oral-fecal contamination from person to person, or via contaminated food or water. rat tapeworm (hymenolepis diminuta) also mostly affects young children. onchocerciasis (fiver blindness) is a disease caused by a parasitic worm, which produces millions of larvae that move through the body causing intense itching, debilitation, and eventually blindness. the disease is spread by a blackfly that transmits the larva from infected to uninfected people. it is primarily located in sub-saharan africa and in latin america, with over million persons at risk. control is by a combination of activities including environmental control by larvicidal sprays to reduce the vector population, protection of potential hosts by protective clothing and insect repellents, and case treatment. a who-initiated program for onchocerciasis control started in is sponsored by four international agencies: the food and agriculture organization (fao), the united nations development program (undp), the world bank, and who. it covers countries in sub-saharan africa, focusing on control of the blackfly by destoying its larvae, mainly via insecticides sprayed from the air. prevalence in was reported by who as over million persons. the program has been successful in protecting some million persons and helping . million infected persons to recover from this disease. who estimates that the program will have prevented , cases of blindness by the year and has freed million hectares of land for resettlement and cultivation. the program cost $ million. this investment is considered by the world bank to have a return of - % in terms of large scale land reuse and improved output of the population. a who program, the african program for onchocerciasis control (apoc), started in , uses a new drug (ivermectin) and selective vector control efforts by spraying. this involves countries in africa, and in a similar program in south america. see website http://www/who.int/ocp and is financed by many donor countries, internation organizations, merck & company, and ngos. dracunculiasis (guinea worm disease) is a parasitic disease of great public health importance in india, pakistan, and central and west africa. it is an infection of the subcutaneous and deeper tissues caused by a large ( cm) nematode, usually affecting the lower extremities and causing pain and disability. the nematode causes a burning blister on the skin when it is ready to release its eggs. after the blister ruptures, the worm discharges larvae whenever the extremity is in water. the eggs are ingested in contaminated water and the larva released migrate through the viscera to locate as adults in the subcutaneous tissue of the leg. incubation is about months. the larva released in water are ingested by minute crustaceans and remain infective for as long as a month. prevention is based on improving the safety of water supplies and by preventing contamination by infected persons. education of persons in endemic areas to stay out of water sources and to filter drinking water reduces transmission. insecticides remove the crustaceans. chlorine also kills the larvae and the crustaceans which prologue larval infectivity. there is no vaccine. treatment is helpful, but not definitive. dracunculiasis was traditionally endemic in a belt from west africa through the middle east to india and central asia. it was successfully eliminated from central asia and iran and has disappeared from the middle east and from some african countries (gambia and guinea). the world health organization has promoted the eradication of dracunculiasis. major progress has been made in this direction. worldwide prevalence is reported to have been reduced from million cases in to million in , , in , and , cases in . eradication was anticipated for the year , and in the who established a commission to monitor and certify eradication in formerly endemic areas. india's reported cases fell from , in to in , and the country was free of transmission in . in , formerly high prevalence countries such as kenya reported no cases in , while chad, senegal, cameroons, yemen, and the central african republic less than cases each. eradication of this disease appears to be imminent. the who eradication program was developed successfully as an independent program with its own direction and field staff, but further progress will require the integration of this program with other basic primary care programs in order to be self-sustaining as an integral part of community health. community-based surveillance systems for this disease are being converted to work for monitoring of other health conditions in the community. schistosomiasis (snail fever or bilharziasis) is a parasitic infection caused by the trematode (blood fluke) and transmitted from person to person via an intermediate host, the snail. it is endemic in countries in africa, south america, the caribbean, and asia. there are an estimated million persons infected worldwide and more than million at risk for the disease. the clinical symptoms include fever, nausea, vomiting, abdominal pain, diarrhea, and hematuria. the organisms schistosoma mansoni and s. japonicum cause intestinal and hepatic symptoms, including diarrhea and abdominal pain. schistosoma haematobium affects the genitourinary tract, causing chronic cystitis, pyelonephritis, with high risk for bladder cancer the ninth most common cause of cancer deaths globally. infection is acquired by skin contact with freshwater containing contaminated snails. the cercariae of the organism penetrate the skin, and in the human host it matures into an adult worm that mates and produces eggs. the eggs are disseminated to other parts of the body from the worm's location in the veins surrounding the bladder or the intestines, and may result in neurological symptoms. eggs may be detected under microscopic examination of urine and stools. sensitive serologic tests are also available. treatment is effective against all three major species of schistosomiasis. eradication of the disease can be achieved with the use of irrigation canals, prevention of contamination of water sources by urine and feces of infected persons, treatment of infected persons, destruction of snails, and health education in affected areas. persons exposed to freshwater lakes, streams, and rivers in endemic areas should be warned of the danger of infection. mass chemotherapy in communities at risk and improved water and sanitation facilities are resulting in improved control of this disease. leishmaniasis causes both cutaneous and visceral disease. the cutaneous form is a chronic ulcer of the skin, called by various names, e.g., rose of jericho, oriental sore, and aleppo boil. it is caused by leishmania tropica, l. brasiliensis, l. mexicana, or the l. donovani complex. this chronic ulcer may last from weeks to more than a year. diagnosis is by biopsy, culture, and serologic tests. the organism multiplies in the gut of sandflies (phlebotomus and lutzomi) and is transmitted to humans, dogs, and rodents through bites. the parasites may remain in the untreated lesion for - months, and the lesion does not heal until the parasites are eliminated. prevention is through limiting exposure to the phlebotomines and reducing the sandfly population by environmental control measures. insecticide use near breeding places and homes has been successful in destroying the vector sandflies in their breeding places. case detection and treatment reduce the incidence of new cases. there is no vaccine, and treatment is with specific antimonials and antibiotics. visceral leishmaniasis (kala azar) is a chronic systemic disease in which the parasite multiplies in the cells of the host's visceral organs. the disease is characterized by fever, the enlargement of the liver and spleen, lymphadenopathy, anemia, leukopenia, and progressive weakness and emaciation. diagnosis is by culture of the organism from biopsy or aspirated material, or by demonstration of intracellular (leishman-donovan) bodies in stained smears from bone marrow, spleen, liver, or blood. kala azar is a rural disease occurring in the indian subcontinent, china, the southern republics of the former u.s.s.r., the middle east, latin america, and sub-saharan africa. it usually occurs as scattered cases among infants, children, and adolescents. transmission is by the bite of the infected sandfly with an incubation period of - months. there is no vaccine, but specific treatment is effective and environmental control measures reduce the disease prevalence. this includes the use of antimalarial insecticides. in localities where the dog population has been reduced, the disease is less prevalent. sleeping sickness. sleeping sickness a disease caused by trypanosoma brucei, transmitted but the tsetse fly, primarily in the african savannahs, affecting cattle and humans. some million persons are at risk in sub-saharan africa. who reported , new cases, a total prevalence of , cases, and , deaths from this disease in . prevention depends on vector control, and effective treatment of human cases. chagas disease is a chronic and incurable vector and blood transfusion borne parasitic disease (trypanosoma cruzi) which causes disability and death. it affects some million persons mainly in latin america, with some , new cases and , deaths occurring annually. about % of affected persons develop severe heart disease. brazil, which accounts for % of the cases prevalent in latin america, achieved elimination of transmission in , after uruguay ( ) and venezuela ( ) and followed by argentina ( ) . elimination of transmission is projected by who by the year . control is difficult, but control measures include reducing the animal host and vector insect population in its habitat by ecological and insectiside measures, education of the population in prevention by clothing, bednets, and repellents, and with chemotherapy for case management. amebiasis. amebiasis is an infection with a protozoan parasite (entamoeba histolytica) which exists as an infective cyst. infestation may be asymptomatic or cause acute, severe diarrhea with blood and mucus, alternating with constipation. amebic colitis can be confused with ulcerative colitis. diagnosis is by microscopic examination of fresh fecal specimens showing trophozoites or cysts. transmission is generally via ingestion of fecal-contaminated food or water containing cysts, or by oral-anal sexual practices. amebiasis is found worldwide. sand filtration of community water supplies removes nearly all cysts. suspect water should be boiled. education regarding hygienic practices with safe food and water handling and disposal of human feces are the basis for control. ascariasis. ascariasis is infestation of the small intestine with the roundworm ascaris lumbricoides, which may appear in the stool, occasionally the nose or mouth, or may be coughed up from lung infestation. the roundworm is very common in tropical countries, where infestation may reach or exceed % of the population. children aged - years are especially susceptible. infestation can cause pulmonary symptoms and frequently contributes to malnutrition, especially iron deficiency anemia. transmission is by ingestion of infective eggs, common among children playing in contaminated areas, or via the ingestion of uncooked products of infected soil. eggs may remain viable in the soil for years. vermox and other treatments are effective. prevention is through education, adequate sanitary facilities for excretion, and improved hygienic practices, especially with food. use of human feces for fertilizer, even after partial treatment, may spread the infestation. mass treatment is indicated in high prevalence communities. pinworm disease or enterobiasis. pinworm disease (oxyuriasis) is common worldwide in all socioeconomic classes; however, it is more widespread when crowded and unsanitary living conditions exist. the enterobius vermicularis infestation of the intestine may be symptomless or may cause severe perianal itching or vulvovaginitis. it primarily affects schoolchildren and preschoolers. more severe complications may occur. adult worms may be seen visually or identified by microscopic examination of stool specimens or perianal swabs. transmission is by the oral-fecal ingestion of eggs. the larvae grow in the small intestine and upper colon. prevention is by educating the public regarding hygiene and adequate sanitary facilities, as well as by treating cases and investigating contacts. treatment is the same as for ascariasis. mass treatment is indicated in high prevalence communities. ectoparasites. ectoparasites include scabies (sarcoptes scabiei), the common bed bug (cimex lectularius), fleas, and lice, including the body louse (pediculus humanis), pubic louse (phthirius pubis), and the head louse (pediculus humanus capitis). their severity ranges from nuisance value to serious public health hazard. head lice are common in schoolchildren worldwide and are mainly a distressing nuisance. the body louse serves as a vector for epidemic typhus, trench fever, and louse-borne relapsing fever. in disaster situations, disinfection and hygienic practices may be essential to prevent epidemic typhus. the flea plays an important role in the spread of the plague by transmitting the organism from the rat to humans. control of rats has reduced the flea population, but during war and disasters, rat and flea populations may thrive. scabies, which is caused by a mite, is common worldwide and is transmitted from person to person. the mite burrows under the skin and causes intense itching. all of these ectoparasites are preventable by proper hygiene and the treatment of cases. the spread of these diseases is rapid and therefore warrants attention in school health and public health policy. legionnelae, a gram-negative group of bacilli, with species and many serogroups. the first documented case was reported in the united states in , and the first disease outbreak was reported in the united states in among participants of a war veterans convention. general malaise, anorexia, myalgia, and headache are followed by fever, cough, abdominal pain, and diarrhea. pneumonia followed by respiratory failure may follow. the case fatality rate can be as high as % of hospitalized cases. a milder, nonpneumonic form of the disease (pontiac fever) is associated with virtually no mortality. the organism is found in water reservoirs and is transmitted through heating, cooling, and air conditioning systems, as well as from tap water, showers, saunas, and jaccuzzi baths. the disease has been reported in australia, canada, south america, europe, israel, and on cruise ships. prevention requires the cleaning of water towers and cooling systems, including whirlpool spas. hyperchlorination of water systems and the replacement of filters is required where cases and/or organisms have been identified. antibiotic treatment with erythromycin is effective. leprosy (hansen's disease) was widely prevalent in europe and mediterranean countries for many centuries, with some , leprosaria in the year . leprosy was largely wiped out during the black death in the fourteenth century, but continued in endemic form until the twentieth century. leprosy is a chronic bacterial infection of the skin, peripheral nerves, and upper airway. in the lepromatous form, there is diffuse infiltration of the skin nodules and macules, usually bilateral and extensive. the tuberculoid form of the disease is characterized by clearly demarcated skin lesions with peripheral nerve involvement. diagnosis is based on clinical examination of the skin and signs of peripheral nerve damage, skin scrapings, and skin biopsy. transmission of the mycobacterium leprae organism is by close contact from person to person, with incubation periods of between months and years (average of - years). rifampicin and other medications make the patient noninfectious in a short time, so that ambulatory treatment is possible. multidrug therapy (mdt) has been shown to be highly effective in combating the disease, with a very low relapse rate. treatment with mdt ensures that the bacillus does not develop drug resistance. mdt is covering % of known cases in , according to who reports, as compared to only % in . the increase has been associated with improved case finding. bcg may be useful in reducing tuberculoid leprosy among contacts. investigation of contacts over years is recommended. the disease is still highly endemic primarily in five countries, india, brazil, indonesia, myanmar, and bangladesh, and is still present in some countries in southeast asia, including the philippines and burma, sub-saharan africa, the middle east (sudan, egypt, iran), and in some parts of latin america (mexico, colombia) with isolated cases in the united states. world prevalence has declined from . million cases in , . million in , to less than million cases in . the world health organization expects to eliminate leprosy as a public health problem by the year , defined as prevalence of less than per , population, or less than , cases. trachoma is currently responsible for million blind persons or % of total blindness in the world. the causative organism, chlamydia trachomatis, is a bacteria which can survive only within a cell. it is spread through contact with eye discharges, usually by flies, or household items (e.g., handkerchiefs, washcloths). trachoma is common in poor rural areas of central america, brazil, africa, parts of asia, and some countries in the eastern mediterranean. the resulting infection leads to conjuncfival scarring and if untreated, to blindness. who estimates there are million cases of active disease in endemic countries. hygiene, vector control, and treatment with antibiotic eye ointments or simple surgery for scarring of eyelids and inturned eyelashes prevent the blindness. a new drug, azithromycin, is effective in curing the disease. the who is promoting a program for the global elimination of trachoma using azithromycin and hygiene education in endemic areas. chlamydia (chlamydia pneumonia) is suspected of playing a role in coronary artery disease by intraarterial infection, with plaque formation and occlusion of the artery by thrombi consisting mainly of platelets. if borne out, this will provide potential for low cost intervention to reduce the burden of the leading worldwide cause of death. sexually transmitted diseases (stds) are widespread internationally with an estimated million new cases per year, with . million new cases, over million total cases, and . million deaths ( ), aids has captured world attention over the past decade. the global burden of stds is enormous (table . ), and the public health and social consequences are devastating in many countries. sexually transmitted diseases, especially in women, may be asymptomatic, so that severe sequelae may occur before patients seek care. infection by one std increases risk of infection by other diseases in this group. syphilis is caused by the spirochete treponema pallidum. after an incubation period of - days (mean - ), primary syphilis develops as a painless ulcer or chancre on the penis, cervix, nose, mouth, or anus, lasting - weeks. the patient may first present with secondary syphilis - weeks (up to weeks) after infection with a general rash and malaise, fever, hair loss, arthritis, and jaundice. these symptoms spontaneously disappear within weeks or up to months later. tertiary syphilis may appear - years after initial infection. complications of tertiary syphilis include catastrophic cardiovascular and central nervous system conditions. early antibiotic treatment is highly effective when given in a large initial dose, but longer term therapy may be needed if treatment is delayed. gonorrhea (gc) is caused by the bacterium neisseria gonorrhoeae. the incubation period is - days. gonorrhea is often associated with concurrent chlamydia infection. in women, gc may be asymptomatic or it may cause vaginal discharge, pain on urination, bleeding on intercourse, or lower abdominal pain. untreated, it can lead to sterility. in men, gc causes urethral discharge and painful urination. treatment with antibiotics ends infectivity, but untreated cases can be infectious for months. drug resistance to penicillin and tetracycline has increased in many countries so that more expensive and often unavailable drugs are necessary for treatment. prevention of gonococcal eye infection in newborns is based on routine use of antibiotic ointments in the eyes of newborns. chancroid. chancroid is caused by haemophilus ducreyi. in women chancroids may cause a painful, irregular ulcer near the vagina, resulting in pain on in-tercourse, urination, and defection, but it may be asymptomatic. in men it causes a painful, irregular ulcer on the penis. the incubation period is usually - days, but may be up to days. an individual is infectious as long as there are ulcers, usually - months. treatment is by erythromycin or azithromycin. herpes simplex. herpes simplex is caused by herpes simplex virus types and and has an incubation period of - days. genital herpes causes painful blisters around the mouth, vagina, penis, or anus. the genital lesions are infectious for - days. herpes may lead to central nervous system meningoencephalitis infection. it can be transmitted to newborns during vaginal delivery, causing infection, encephalitis, and death. cesarian delivery is therefore necessary when a mother is infected. anti-viral drugs are used in treatment, orally, topically, or intravenously. chlamydia. chlamydia is caused by chlamydia trachomatis. in women, it is usually asymptomatic but may cause vaginal discharge, spotting, pain on urination, lower abdominal pain, and pelvic inflammatory disease (pid). in newborns, chlamydia may cause eye and respiratory infections. in men, chlamydia causes urethral discharge and pain on urination. the incubation period is - days and the infectious period is unknown. treatment for chlamydia is doxycycline, azithromycin, or erythromycin. chlamydia infection, not necessarily venereal in transmission, may be transmitted to newborns of infected mothers. chlamydia pneumoniae, presently under investigation as a possible cause or contributor to coronary heart disease, and is widespread in poor hygenic conditions. trichomoniasis. trichomoniasis is caused by trichomonas vaginalis. the incubation period is - days (mean = ). in women, trichomoniasis may be asymptomatic or may cause a frothy vaginal discharge with foul odor, and painful urination and intercourse. in men, the disease is usually mild, causing pain on urination. treatment is by metronidazole taken orally. without treatment, the disease may persist and remain infectious for years. (hpv). it is a sporadic disease which may be associated with cervical neoplasia and cancer of the cervix. hpv includes many types associated with a variety of conditons. the search for a hpv vaccine to prevent cancer of the cervix looks promising. in areas where a full range of diagnostic services is lacking, a "syndromic approach" is recommended for the control of stds. the diagnosis is based on a group of symptoms and treatment on a protocol addressing all the diseases that could possibly cause those symptoms, without expensive laboratory tests and repeated visits. early treatment without laboratory confirmation helps to cure persons who might not return for follow-up, or may place them in a noninfective stage so that even without follow-up they will not transmit the disease. std incidence between and is shown in table . , with decline overall except around , with subsequent further fall in incidence. screening in prenatal and family planning clinics, prison medical services, and selected years - disease syphilis ( [ ] [ ] [ ] [ ] [ ] [ ] and subsequent decline by more than % in reported cases includes all three stages of the disease as well as congential syphilis. rates are cases per , population, rounded. in clinics serving prostitutes, homosexuals, or other potential risk groups will detect subclinical cases of various stds. treatment can be carried out cheaply and immediately. for instance, the screening test for syphilis costs $ . and the treatment with benzathine penicillin injection costs about $ . in . partner notification is a controversial issue, but may be needed to identify contacts who may be the source of transmission to others. control of stds through a syndrome approaach based on primary care providers is being promoted by who. health education directed at high risk target groups is essential. providing easy and cost-free access to acceptable, nonthreatening treatment is vital in promoting the early treatment of cases and thereby reducing the risk of transmission. promoting prevention through the use of condoms and/or monogamy requires long-term educational efforts that are now fostered by the hiv/aids pandemic. increased use of condoms for hiv prevention is associated with reduced risk of other stds. training medical care providers in std awareness should be stressed in undergraduate and continuing educational efforts including personal protection as care givers. human immunodeficiency virus (hiv) is a retrovirus that infects various cells of the immune system, and also affects the central nervous system. two types have been identified: hiv , worldwide in distribution, and the less pathogenic hiv , found mainly in west africa. hiv is transmitted by sexual contact, exposure to blood and blood products, perinatally, and via breast milk. the period of communicability is unknown, but studies indicate that infectiousness is high, both during the initial period after infection and later in the disease. antibodies to hiv usually appear within - months. within several weeks to months of the infection, many persons develop an acute self-limited flulike syndrome. they may then be free of any signs or symptoms for months to more than years. onset of illness is usually insidious with nonspecific symptoms, including sweats, diarrhea, weight loss, and fatigue. aids represents the later clinical stage of hiv infection. according to the revised cdc case definition ( ), aids involves any one or more of the following: low cd count, severe systematic symptoms, opportunistic infections such as pneumocystis pneumonia or tb, aggressive cancers such as kaposi's sarcoma or lymphoma, and/or neurological manifestations, including dementia and neuropathy. the who case definition is more clinically oriented, relying less on often unavailable laboratory diagnoses for indicator diseases. aids was first recognized clinically in in los angeles and new york. by mid- it was considered an epidemic in those and other u.s. cities. it was primarily seen among homosexual men and recipients of blood products. after initial errors, testing of blood and blood products became standard and has subsequently closed off this method of transmission. transmission has changed markedly since the initial onslaught of the disease, with needle sharing among intravenous drug users, heterosexual, and maternal-fetal transmission becoming major factors. comorbidity with other stds apparently increases hiv infectivity and may have helped to convert the epidemiology to a greater degree of heterosexual transmission. the disease grew exponentially in the united states (table . ), but incidence of new cases nas declined since . aids has become a major public health problem in most developed and developing countries, reaching catastrophic proportions in some sub-saharan african countries affecting up to % of the population. hiv-related deaths were the eighth leading cause of all deaths in in the u.s., the leading cause among men aged - years of age, and the fourth leading cause for women in this age group. by , aids had been diagnosed in , persons and , had died. it is estimated that up to million persons are hiv infected in the united states. globally, deaths from aids totalled . million in , with an estimated . million person having died from this pandemic up to . in , an estimated . million person were hiv infected with . million new infection in . the declining incidence of new cases in the industrialized countries may be the result of greater awareness of the disease and methods of prevention of transmission. improving early diagnosis and access to care, especially the combined therapy programs that are very effective in delaying onset of symptoms, are important parts of public health management of the aids crisis. until an effective vaccine is available, preventive reliance will continue to be on behavior risk-reduction and other prevention strategies such as needle and condom distribution among high risk population groups. throughout the world, hiv continues to spread rapidly, especially in poor countries in africa, asia, and south and central america. the united nations reports that million persons are living with hiv/aids, % of them in developing countries, where transmission is % by heterosexual contact. every day, more than persons are infected, including children. in thailand, person in is now infected. in sub-saharan africa person in is infected, and in some cities as many as person in carries the virus. estimations of new infections per year in sub-saharan africa range from to million persons, while in asia the range is from . to . million new infected persons per year. lessons are still being learned from the aids pandemic. the explosive spread of this infection, from an estimated , people in to an anticipated million persons hiv infected, shows that the world is still vulnerable to pandemics of "new" infectious diseases. enormous movements of tourists, business people, truck drivers, migrants, soldiers, and refugees promote the spread of such diseases. widespread sexual exchange, traffic in blood products, and illicit drug use all promote the international potential for pandemics. war and massive refugee situations promote rape and prostitution, worsening the aids situation in some settings in africa. hiv has arrived in almost every country. however, there is the somewhat hopeful indication that the rate of increase, has slowed in the united states. this may be an indication either of higher levels of self-protective behavior, or that the most susceptible population groups have already been affected and the spread into the general population is at a slower rate. it is also possible that this may yet prove to be only a lull in the storm, as heterosexual contact becomes a more important mode of transmission. the eleventh international conference on aids, held in vancouver, canada, in july , reported signs that combinations of several drugs from among a number of antiretroviral medications are showing promise to suppress the aids virus in infected people. at a current annual price of $ , - , per patient, these sums well beyond the capacity of most developing countries. development of methods of measuring the hiv viral load have allowed for better evaluation of potential therapies and monitoring of patients receiving therapy. in developed countries, transmission by blood products has been largely controlled by screening tests; transmission among homosexuals has been reduced by safe sex practices; transmission to newborns has been reduced by recent therapeutic advances. safe sex practices and condom use may have helped in reducing heterosexual transmission. further advances in therapy and prevention with a vaccine are expected over the next decade. the hiv/aids pandemic is one of the great challenges to public health for the st century due to its complexity, its international spread, its sexual and other modes of transmission, its devastating and costly clinical effects, and its impact on parallel diseases such as tuberculosis, respiratory infections, and cancer. the cost of care for the aids patient can be very high. needed programs include home care and community health workers to improve nutrition and self-care, and mutual help among hiv carriers and aids patients. the ethical issues associated with aids are also complex regarding screening of pregnant women, newborns, partner notification, reporting, and contact tracing, as well as financing the cost of care. diarrheal diseases are caused by a wide variety of bacteria, parasites, and viruses (table . ) infecting the intestinal tract and causing secretion of fluids and dis- solved salts into the gut with mild to severe or fatal complications. in developing countries, diarrheal diseases account for half of all morbidity and a quarter of all mortality. diarrhea itself does not cause death, but the dehydration resulting from fluid and electrolyte loss is one of the most common causes of death in children worldwide. deaths from dehydration can be prevented by use of oral rehydration therapy (ort), an inexpensive and simple method of intervention easily used by a nonmedical primary care worker and by the mother of the child as a home intervention. in , diarrheal diseases were the cause of almost million child deaths, but by this had declined to . million, largely under the impact of increased use of ort. diarrheal diseases are transmitted by water, food, and directly from person to person via oral-fecal contamination. diarrheal diseases occur in epidemics in situations of food poisoning or contaminated water sources, but can also be present at high levels when common source contamination is not found. contamination of drinking water by sewage and poor management of water supplies are also major causes of diarrheal disease. the use of sewage for the irrigation of vegetables is a common cause of diarrheal disease in many areas. salmonella are a group of bacterial organisms causing acute gastroenteritis, associated with generalized illness including headache, fever, abdominal pains, and dehydration. there are over serotypes of salmonella, many of which are pathogenic in humans, the most common of which are salmonella typhimurium, s. enteritidis, and s. typhi. transmission is by ingestion of the organisms in food, derived from fecal material from animal or human contamination. common sources include raw or uncooked eggs, raw milk, meat, poultry and its products, as well as pet turtles or chicks. fecal-oral transmission from person to person is common. prevention is in safe animal and food handling, refrigeration, sanitary preparation and storage, protection against rodent and insect contamination, and the use of sterile techniques during patient care. antibiotics may not eliminate the carrier state and may produce resistant strains. shigella are a group of bacteria that are pathogenic in man, with four groups: type a = shigella dysenteriae, type b = s. flexneri, type c = s. boydii, and type d = s. sonnei. types a, b, and c are each further divided into a total of serotypes. shigella are transmitted by direct or indirect fecal-oral methods from a patient or carrier, and illness follows ingestion of even a few organisms. water and milk transmission occurs as a result of contamination. flies can transmit the organism, and in nonrefrigerated foods the organism may multiply to an infectious dose. control is in hygienic practices and in the safe handling of water and food. escheria eoli e. coli are common fecal contaminants of inadequately prepared and cooked food. particularly virulent strains such as o :h can cause explosive outbreaks of severe (enterohemmorhagic) diarrhoeal disease with a hemolytic-uremic syndrome and death, as occurred in japan in with cases and deaths due to a foodborne epidemic. other milder strains cause travellers diarrhoea and nursery infections. inadequately cooked hamburger, unpasturized milk, and other food vectors are discussed under food safety in chapter . cholera is an acute bacterial enteric disease caused by vibrio cholerae, with sudden onset, profuse painless watery stools, occasional vomiting, and, if untreated, rapid dehydration, and circulatory collapse, and death. asymptomatic infection or carrier status, and mild cases are common. in severe, untreated cases, mortality is over %, but with adequate treatment, mortality is under %. diagnosis is based on clinical signs, epidemiologic, serologic and bacteriologic confirmation by culture. the two types of cholera are the classic and el tor (with inaba and ogawa serotypes). in , a large scale epidemic of cholera spread through much of south america. it was imported via a chinese freighter, whose sewage contaminated shellfish in lima harbor in peru (box . ). the south american cholera epidemic has caused hundreds of thousands of cases and thousands of deaths since . prevention requires sanitation, particularly the chlorination of drinking water, prohibiting the use of raw sewage for the irrigation of vegetable crops, and high standards of community, food, and personal hygiene. treatment is prompt fluid therapy with electrolytes in large volume to replace all fluid loss. oral rehydration should be accomplished using standard ort. tetracycline shortens the duration of the disease, and chemoprophylaxis for contacts following stool samples may help in reducing its spread. a vaccine is available but is of no value in the prevention of outbreaks. viral gastroenteritis can occur in sporadic or epidemic forms, in infants, children, or adults. some viruses, such as the rotaviruses and enteric adenoviruses, af- in the s, peruvian officials stopped the chlorination of community water supplies because of concern over possible carcinogenic effects of trihalomethanes, a view encouraged by officials of the u.s. environmental protection agency (epa) and the u.s. public health service. in january , a chinese freighter arrived in lima, peru, and dumped bilge (sewage) in the harbor, apparently contaminating local shellfish. consumption of raw shellfish is a popular local delicacy (ceviche) and associated with cases of cholera seen in local hospitals. contamination of local water supplies from sewage resulted in the geometric increase in cases, and by the end of the pan american health organization (paho) reported an epidemic of , cases and deaths. the epidemic spread to countries, and in there were a further , cases and deaths spreading over much of south america, continuing in . in the united states, cases of cholera were reported in ; of these, cases and death were among passengers of an airplane flying from south america to los angeles in which contaminated seafood was served. in , cases of cholera were reported in the united states which were unrelated to international travel. these occurred mostly among persons consuming shellfish from the gulf coast with a strain of cholera similar to the south american strain, also possibly introduced in ship ballast. cholera organisms are reported in harbor waters in other parts of the united states (promed, , promed, . fect mainly infants and young children, and may be severe enough to cause hospitalization for dehydration. others such as norwalk and norwalk-like viruses affect older children and adults in self-limited acute gastroenteritis in family, institution, or community outbreaks. rotaviruses cause acute gastroenteritis in infants and young children, with fever and vomiting, followed by watery diarrhea and occasionally severe dehydration and death if not adequately treated. diagnosis is by examination of stool or rectal swabs with commercial immunologic kits. in both developed and developing countries, rotavirus is the cause of about one-third of all hospitalized cases for diarrheal diseases in infants and children up to age . most children in developing countries experience this disease by the age of years, with the majority of cases between and months. in developing countries, rotaviruses are estimated to cause over , deaths per year. the virus is found in temperate climates in the cooler months and in tropical countries throughout the year. breastfeeding does not prevent the disease but may reduce its severity. oral rehydration therapy is the key treatment. a live attenuated vaccine was approved by the fda in and adopted in the u.s. recommended routine vaccination programs for infants. adenoviruses. adenoviruses, norwalk, and a variety of other viruses (including astrovirus, calcivirus, and other groups) cause sporadic acute gastroenteritis worldwide, mostly in outbreaks. spread is by the oral-fecal route, often in hospital or other communal settings, with secondary spread among family contacts. food-borne and waterborne transmission are both likely. these can be a serious problem in disaster situations. no vaccines are available. management is with fluid replacement and hygienic measures to prevent secondary spread. giardiasis. giardiasis (caused by giardia lamblia) is a protozoan parasitic infection of the upper small intestine, usually asymptomatic, but sometimes associated with chronic diarrhea, abdominal cramps, bloating, frequent loose greasy stools, fatigue, and weight loss. malabsorption of fats and vitamins may lead to malnutrition. diagnosis is by the presence of cysts or other forms of the organism in stools, duodenal fluid, or in intestinal mucosa from a biopsy. this disease is prevalent worldwide and affects mostly children. it is spread in areas of poor sanitation and in preschool settings and swimming pools, and is of increasing importance as a secondary infection among immunocompromised patients, especially those with aids. waterborne giardia was recognized as a serious problem in the united states in the s and s, since the protozoa is not readily inactivated by chlorine, but requires adequate filtration before chlorination. person-to-person transmission in day-care centers is common, as is transmission by unfiltered stream or lake water where contamination by human or animal feces is to be expected. an asymptomatic carrier state is common. prevention relies on careful hygiene in settings such as day-care centers, filtration of public water supplies and the boiling of water in emergency situations. cryptosporidium. cryptosporidium parvum is a parasitic infection of the gastrointestinal tract in man, small and large mammals and vertebrates. infection may be asymptomatic or cause a profuse, watery diarrhea, abdominal cramps, general malaise, fever, anorexia, nausea, and vomiting. in immunosuppressed patients, such as persons with aids, it can be a serious problem. the disease is most common in children under years of age and those in close contact with them, as well as in homosexual men. diagnosis is by identification of the cryptosporidium or-ganism cysts in stools. the disease is present worldwide. in europe and the united states, the organism has been found in < to . % of individuals sampled. spread is common by person-to-person contact by fecal-oral contamination, especially in such settings as day-care centers. raw milk and waterborne outbreaks have also been identified in recent years. a large waterborne disease outbreak due to cryptosporidium occurred in milwaukee in described in chapter . management is by rehydration and prevention is by careful hygiene in food and water safety. helicobacter pylori. helicobacter pylori, first identified in , is a bacterium causally linked to duodenal ulcers and gastritis, contributing to high rates of gastric cancer (chapter ). it is an important example of the link between infection and chronic disease. this has enormous implications for prevention of cancer of the stomach, chronic peptic ulcers and large-scale use of hospitals and other medical resources (see chapter ). the control of diarrheal diseases requires a comprehensive program involving a wide range of activities, including good management of food and water supplies, education in hygiene, and, particularly where morbidity and mortality are high, education in the use of oral rehydration therapy (ort). oral rehydration therapy (ort) is considered by unicef and who to have resulted in the saving of million lives each year in the s. proper management of an episode of diarrhea by ort (table . ), along with continued feeding, not only saves the child from dehydration and immediate death, but also contributes to early restoration of nutritional adequacy, sparing the child the prolonged effects of malnutrition. the world summit for children (wsc) in called for a reduction in child deaths from diarrheal diseases by one-third and malnutrition by one-half, with em- phasis on the widest possible availability, education for, and use of ort. this requires a programmatic approach. public health leadership must train primary care doctors, pediatricians, pharmacists, drug manufacturers, and primary care health workers of all kinds in ort principles and usage. they must be backed by the widest possible publicity to raise awareness among parents. oral rehydration therapy is an important public health modality in developed countries as well as in developing countries. diarrhoeal disease may not cause death as frequently in developed countries, but it is still a significant factor in infant and child health and, even under the most optimal conditions, can cause setbacks in the nutritional state and physical development of a child. use of ort does not prevent the disease (i.e., it is not a primary prevention), but it is excellent in secondary prevention, by preventing complications from diarrhoea, and should be available in every home for symptomatic treatment of diarrheal diseases. an adaptation of ort has found its place in popular culture in the united states. a form of ort, marketed as "sports drinks," is used in sports where athletes lose large quantifies of water and salts in sweat and insensible loss from the respiratory tract. the wider application of the principles of ort for use in adults in dry hot climates and in adults under severe physical exertion with inadequate fluid/salt intake situations requires further exploration. management of diarrheal diseases should be part of a wider approach to child nutrition. the child who goes through an episode of diarrheal disease may have a faltering in growth and development. supportive measures may be needed following the episode as well as during it. this involves providing primary care services that are attuned to monitoring individual infant and child growth. growth monitoring surveillance is important to assess the health status of the individual child and the child population. supplementation of infant feeding with vitamins a and d, and iron to prevent anemia are important for routine infant and child care, and more so for conditions affecting total nutrition such as a diarrheal disease. in the developing world, respiratory infections account for over one-quarter of all deaths and illnesses in children. as diarrheal disease deaths are reduced, the major cause of death among infants in developing countries is becoming acute respiratory infections (aris). in industrialized countries, aris are important for their potentially devastating effects on the elderly and chronically ill. they are also the major cause of morbidity in infants in developed countries, causing much anxiety to parents even in areas with good living conditions. cigarette smoking, chronic bronchitis, poorly controlled diabetes or congestive heart failure, and chronic liver and kidney disease increase susceptibility to aris. aris place a heavy burden on health care systems and individual families. improved methods of management of such chronic diseases are needed to reduce the associated toll of morbidity, mortality, and the considerable expenses of health care. acute respiratory infections are due to a broad range of viral and, to a lesser extent, bacterial infections. it is the latter which can progress to pneumonia with mortality rates of - %. acute viral respiratory diseases include those affecting the upper respiratory tract, such as acute viral rhinitis, pharyngitis, and laryngitis, as well as those affecting the lower respiratory tract, tracheobronchitis, bronchitis, bronchiolitis, and pneumonia. aris are frequently associated with vaccine-preventable diseases, including measles, varicella, and influenza. they are caused by a large number of viruses, producing a wide spectrum of acute respiratory illness. some organisms affect any part of the respiratory tract, while others affect specific parts and all predispose to bacterial secondary infection. while children and the elderly are especially susceptible to morbidity and mortality from acute respiratory disease, the vast numbers of respiratory illnesses among adults cause large-scale economic loss from work absence. bacterial agents causing upper respiratory tract infection include group a streptococcus, mycoplasma pneumonia, pertussis, and parapertussis. pneumonia or acute bacterial infection of the lower respiratory tract and lung tissue may be due to pneumococcal infection with streptococcus pneumoniae. there are known types of this organism, distinguished by capsule characteristics; account for % of pneumococcal infections in the united states. an excellent polyvalent vaccine based on these types is available for high risk groups such as the elderly, immunodeficient patients, and persons with chronic heart, lung, liver, blood disorders, or diabetes. opportunistic infections attack the chronically ill, especially those with compromised immune suystems, often with life-threatening aris. mycoplasma (primary atypical pneumonia) is a lower respiratory tract infection which sometimes progresses to pneumonia. tb and pneumonocytis carynia are especially problematic for aids patients. other organisms causing pneumonias include chlamydia pneumoniae, h. influenza, klebsiella pneumonia, escherichia coli, staphylococcus, rickettsia (q fever), and legionella. parasitic infestation of lungs may occur with nematodes (e.g., ascariasis). fungal infections of the lung may be caused by aspergillosis, histoplasmosis, and coccidiomycosis, often as a complication of antibiotic therapy. access to primary care and early institution of treatment are vital to control excess mortality from aris. in developed countries, aris as contributors to infant deaths are largely a problem in minority and deprived population groups. because these groups contribute disproportionately to childhood mortality, infant mortality reduction has been slower in countries such as the united states and russia than in other industrialized countries. the continuing gap in mortality rates between white and black children in the united states can, to a large extent, be attributed to aris and less access to organized primary care. children are brought to emergency rooms for care when the disease process is already advanced and more dangerous than had it been attended to professionally earlier in the process. many field trials of ari prevention programs have been proved successful involving parent education and training of primary care workers in early assessment and, if necessary, initiation of treatment. this needs field testing in multiple settings. reliance on vaccines to prevent respiratory infectious diseases is not currently feasible. aris are caused by a very wide spectrum of viruses, and the development of vaccines in this field has been slow and limited. the vaccine for pneumococcal pneumonia has been an important breakthrough, but it is still inadequately utilized by the chronically ill because of its limitations, costs, and lack of sufficient awareness, and it is too expensive for developing countries. improvements in bacterial and viral vaccine development will potentially help to reduce the burden of aris. a programmatic approach with clinical guidelines and education of family and care givers is currently the only feasible way to reduce the still enormous morbidity and mortality from aris on the young and the elderly. the success of sanitation vaccines and antibiotics led many to assume that all infectious diseases would sooner or later succumb to public health and medical technology. unfortunately, this is a premature and even dangerous assumption. despite the longstanding availability of an effective and inexpensive vaccine, the persistence of measles as a major killer of million children per year represents a failure in effective use of both the vaccine and the health system. the resurgence of tb and malaria have led to new strategies, such as managed or directly observed care, with community health workers to assure compliance needed to render the patient noninfectious to others and to reduce the pool of carriers of the disease. current successes in reducing poliomyelitis, dracunculiasis, onchocerciasis, and other diseases to the point of eradication has raised hopes for similar success in other fields. but there are many infectious diseases of importance in developed and developing countries where existing technologies are not fully utilized. oral rehydration therapy (ort) is one of the most cost-effective methods of preventing excess mortality from ordinary diarrheal diseases, and yet is not used on sufficient scale. biases in the financing and management of medical insurance programs can result in underutilization of available effective vaccines. hospital-based infections cause large-scale increases in lengths of stay and expenditures, although application of epidemiologic investigation and improved quality in hospital practices could reduce this burden. control of the spread of aids using combined medical therapies is not financially or logistically possible in many countries, but education for "safe sex" is effective. community health worker programs can greatly enhance tuberculosis, malaria, and std control, or in aids care, promote prevention and appropriate treatment. in the industrialized and mid-level developing countries, epidemiologic and demographic shifts have created new challenges in infectious disease control. prevention and early treatment of infectious disease among the chronically ill and the elderly is not only a medical issue, it is also an economic one. patients with chronic obstructive lung disease (copd), chronic liver or kidney disease, or congestive heart failure are at high risk of developing an infectious disease followed by prolonged hospitalization. public health has addressed, and will continue to stress the issues of communicable disease as one of its key issues in protecting individual and population health. methods of intervention include classic public health through sanitation, immunization, and well beyond that into nutrition, education, case finding, and treatment, and changing human behavior. the knowledge, attitudes, beliefs, and practices of policy makers, health care providers, and parents is as important in the success of communicable disease control as are the technology available and methods of financing health systems. together, these encompass the broad programmatic approach of the new public health to control of communicable diseases. in a world of rapid international transport and contact between populations, systems are needed to monitor the potential explosive spread of pathogens that may be transferred from their normal habitat. the potential for the international spread of new or reinvigorated infectious diseases constitute threat to mankind akin to ecological and other man-made disasters. the eradication of smallpox paved the way for the eradication of poliomyelitis, and perhaps measles, in the foreseeable future. new vaccines are showing the capacity to reduce important morbidity from rubella syndrome, mumps, meningitis, and hepatitis. other new vaccines on the horizon will continue the immunologic revolution into the twenty-first century. as the triumphs of control or elimination of infectious diseases of children continue, the scourge of hiv infection continues with distressingly slow progess an effective vaccine or cure for the disease it engenders. partly as a result of the hiv/ aids, tb staged a comeback in many countries where it was thought to be merely a residual problem. at the same time an old/new method of intervention using directly observed short-term therapy has shown great success in controlling the tb epidemic. the resurgence of tb is more dangerous in that mdrtb has become a widespread problem. this issue highlights the difficulty of keeping ahead of drug resistance in the search for new generations of antibiotics, posing a difficult challenge for the pharmaceutical industry, basic scientists as well as public health workers. the burden of infectious diseases has receded as the predominant public health problem in the developed countries but remains large in the developing countries. with increases in longevity and increased importance of chronic disease in the health status of the industrial and mid-level developing nations, the effects of infectious disease on the care of the elderly and chronically ill is of great importance in the new public health. long-term management of chronic disease needs to address the care of vulnerable groups, promoting the use of existing vaccines and antibiotics. most important is the development of health systems that provide close monitoring of groups at special risk for infectious disease, especially patients with chronic diseases, the immunocompromised, and the elderly. the combination of traditional public health with direct medical care needed for effective control and eradication of communicable diseases is an essential element of the new public health. the challenge is to apply a comprehensive approach and management of resources to define and reach achievable targets in communicable disease control. access to e-mail and the internet are vital to current practice of public health and nowhere is this more important than in communicable diseases. there are many such information sites and these will undoubtedly expand in the coming years. several sites are given as examples. the internet has great practical implications for keeping up to date with rapidly occurring events in this field. outstanding encyclopedia database on infectious diseases (available via mdcassoc@ix.netcom.com at reduced price for promed users, and free to sub-saharan african sites) promed is an excellent, free report on current events in communicable diseases internationally; join via owner-promed @usa recommended readings centers for disease control. . update: international task force for disease eradication addressing emerging infectious disease threats: a prevention strategy for the united states. executive summary update: trends in aids incidence--united states one thousand days until the target date for global poliomyelitis eradication tuberculosis morbidity--united states measles--united states, . morbidity and mortality weekly report national adult immunization awareness week--october - , recommended readings ; and influenza and pneumococcal vaccination levels among adults aged --- years impact of the sequential ipv/opv schedule on vaccination cover-agemunited states advances in global measles control and elimination: summary of the international meeting recommended childhood immunization schedulemunited states impact of vaccines universally recommended for childrenmunited states progress toward global poliomyelitis eradication global disease elimination and eradication as public health strategies childhood immunizations rotavirus vaccines: who position paper. weekly epidemiologic record infectious diseases of humans: dynamic and control vaccines and world health: science, policy, and practice control of communicable diseases manual jawetz, melnick and adelberg's medical microbiology, twenty-first edition preventive medicine and public health, second edition efficacy of bcg vaccine in the prevention of tuberculosis. meta-analysis of the published literature manson's tropical diseases vaccination and world health principles and practice oflnfectious diseases immunization of adolescents: recommendations of the advisory committee on immunization practices, the american academy of pediatrics, the american academy of family physicians and the combination vaccines for childhood immunization: recommendations of the advisory committee on immunization practices, the american academy of pediatrics, the american academy of family physicians and the poliomyelitis prevention: revised recommendations for use of inactivated and live oral poliovirus vaccines diphtheria outbreakmrussian federation rubella and congenital rubella syndrome~united states compendium of animal rabies control, : national association of state public health veterinarians progress toward elimination of haemophilus influenzae type b disease among infants and children in the united states tetanus surveillance~united states, - recommendations and reports--vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of measles: recommendations of the advisory committee on immunization practices national, state and urban area vaccination coverage levels among children aged - months~united sates varicella related deaths among children--united states progress toward global poliomyelitis eradication ten great public health achievements--united states a ten-year experience in control of poliomyelitis through a combination of live and killed vaccines in two developing areas measles control in developing and developed countries: the case for a two-dose policy integration of vitamin a supplementation with immunization. weekly epidemiological record update cholera--western hemisphere, . morbidity and mortality weekly report isolation of vibrio cholerae o from oystersmmobile bay, - estimates of future global tuberculosis morbidity and mortality arbovirus disease--united states ~:~ other communicable diseases update: outbreak of legionnaire's disease associated with a cruise ship rift valley fever--egypt the role of bcg vaccine in the prevention and control of tuberculosis in the united states: a joint statement by the advisory council for the elimination of tuberculosis and the advisory committee on immunization practices update: trends in aids incidence--united states case definition for infectious conditions under public health surveillance guidelines for treatment of sexually transmitted diseases primary and secondary syphilis--united states global tuberculosis incidence and mortality during the th century pandemic: need for surveillance and research escherichia coli o :h diarrhoea in the united states: clinical and epidemiologic features the state of the world's children the rational use of drugs in the management of acute diarrhoea in children world health organization. . the malaria situation in aids: images of the epidemic. geneva: who. world health organization progress toward the elimination of leprosy as a public health problem the world health report : fighting disease, fostering development the world health report health for all in the twenty-first century. eb / . geneva: who. world health organization. . the world health report : life in the twenty-first century: a vision for all world health organization. . the world health report : making a difference key: cord- -m tapjp authors: peng, liangrong; yang, wuyue; zhang, dongyan; zhuge, changjing; hong, liu title: epidemic analysis of covid- in china by dynamical modeling date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: m tapjp the outbreak of the novel coronavirus ( -ncov) epidemic has attracted world- wide attention. herein, we propose a mathematical model to analyzes this epidemic, based on a dynamic mechanism that incorporating the intrinsic impact of hidden la- tent and infectious cases on the entire process of transmission. meanwhile, this model is validated by data correlation analysis, predicting the recent public data, and back- tracking, as well as sensitivity analysis. the dynamical model reveals the impact of various measures on the key parameters of the epidemic. according to the public data of nhcs from / to / , we predict the epidemic peak and possible end time for different regions. the epidemic in beijing and shanghai, mainland/hubei and hubei/wuhan, are expected to end before the end of february, and before mid- march respectively. the model indicates that, the outbreak in wuhan is predicted to be ended in the early april. as a result, more effective policies and more efforts on clinical research are demanded. moreover, through the backtracking simulation, we infer that the outbreak of the epidemic in mainland/hubei, hubei/wuhan, and wuhan can be dated back to the end of december or the beginning of january . a novel coronavirus, formerly called -ncov, or sars-cov- by ictv (severe acute respiratory syndrome coronavirus , by the international committee on taxonomy of viruses) caused an outbreak of atypical pneumonia, now officially called covid- by who (coronavirus disease , by world health organization) first in wuhan, hubei province in dec., and then rapidly spread out in the whole china . as of : feb. th, (beijing time), there are over , reported cases (including more than , death report) in china, among which, over % are from hubei province and over % from wuhan city, the capital of hubei province , . the central government of china as well as all local governments, including hubei, has tightened preventive measures to curb the spreading of covid- since jan. . many cities in hubei province have been locked down and many measures, such as tracing close contacts, quarantining infected cases, promoting social consensus on self-protection like wearing face mask in public area, etc. however, until the finishing of this manuscript, the epidemic is still ongoing and the daily confirmed cases maintain at a high level. during this anti-epidemic battle, besides medical and biological research, theoretical studies based on either statistics or mathematical modeling may also play a non-negligible role in understanding the epidemic characteristics of the outbreak, in forecasting the inflection point and ending time, and in deciding the measures to curb the spreading. for this purpose, in the early stage many efforts have been devoted to estimate key epidemic parameters, such as the basic reproduction number, doubling time and serial interval, in which the statistics models are mainly used [ ] [ ] [ ] [ ] [ ] [ ] . due to the limitation of detection methods and restricted diagnostic criteria, asymptomatic or mild patients are possibly excluded from the confirmed cases. to this end, some methods have been proposed to estimate untraced contacts , undetected international cases , or the actual infected cases in wuhan and hubei province based on statistics models , or the epidemic outside hubei province and overseas , [ ] [ ] [ ] . with the improvement of clinic treatment of patients as well as more strict methods stepped up for containing the spread, many researchers investigate the effect of such changes by statistical reasoning , and stochastic simulation , . compared with statistics methods , , mathematical modeling based on dynamical equations , - receive relatively less attention, though they can provide more detailed all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint mechanism for the epidemic dynamics. among them, the classical susceptible exposed infectious recovered model (seir) is the most widely adopted one for characterizing the epidemic of covid- outbreak in both china and other countries . based on seir model, one can also assess the effectiveness of various measures since the outbreak , , [ ] [ ] [ ] , which seems to be a difficult task for general statistics methods. seir model was also utilized to compare the effects of lock-down of hubei province on the transmission dynamics in wuhan and beijing . as the dynamical model can reach interpretable conclusions on the outbreak, a cascade of seir models are developed to simulate the processes of transmission from infection source, hosts, reservoir to human . there are also notable generalizations of seir model for evaluation of the transmission risk and prediction of patient number, in which model, each group is divided into two subpopulations, the quarantined and unquarantined , . the extension of classical seir model with delays , is another routine to simulate the incubation period and the period before recovery. however, due to the lack of official data and the change of diagnostic caliber in the early stage of the outbreak, most early published models were either too complicated to avoid the overfitting problem, or the parameters were estimated based on limited and less accurate data, resulting in questionable predictions. in this work, we carefully collect the epidemic data from the authoritative sources: the such a design aims to minimize the influence of hubei province and wuhan city on the data set due to their extremely large infected populations compared to other regions. without further specific mention, these conventions will be adopted thorough the whole paper. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint in progress. a. generalized seir model {s(t), p (t), e(t), i(t), q(t), r(t), d(t)} denoting at time t the respective number of the susceptible cases, insusceptible cases, exposed cases (infected but not yet be infectious, in a latent period), infectious cases (with infectious capacity and not yet be quarantined), quarantined cases (confirmed and infected), recovered cases and closed cases (or death). the adding of a new quarantined sate is driven by data, which together with the recovery state takes replace of the original r state in the classical seir model. their relations are given in fig. and characterized by a group of ordinary differential equations (or difference equations if we consider discrete time, see si). constant n = s + p + e + i + q + r + d is the total population in a certain region. the coefficients {α, β, γ − , δ − , λ(t), κ(t)} represent the protection rate, infection rate, average latent time, average quarantine time, cure rate, and mortality rate, separately. especially, to take the improvement of public health into account, such as promoting wearing face masks, more effective contact tracing and more strict locking-down all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint of communities, we assume that the susceptible population is stably decreasing and thus introduce a positive protection rate α into the model. in this case, the basic reproduction it is noted that here we assume the cure rate λ and the mortality rate κ are both time dependent. as confirmed in fig. a -d, the cure rate λ(t) is gradually increasing with the time, while the mortality rate κ(t) quickly decreases to less than % and becomes stabilized after jan. th. this phenomenon is likely raised by the assistance of other emergency medical teams, the application of new drugs, etc. furthermore, the average contact number of an infectious person is calculated in fig. e-f and could provide some clue on the infection rate. it is clearly seen that the average contact number is basically stable over time, but shows a remarkable difference among various regions, which could be attributed to different quarantine policies and implements inside and outside hubei (or wuhan), since a less severe region is more likely to inquiry the close contacts of a confirmed case. a similar regional difference is observed for the severe condition rate too. in fig. g -h, hubei and wuhan overall show a much higher severe condition rate than shanghai. although it is generally expected that the patients need a period of time to become infectious, to be quarantined, or to be recovered from illness, but we do not find a strong evidence for the necessity of including time delay (see si for more details). as a result, the time-delayed equations are not considered in the current work for simplicity. according to the daily official reports of nhc of china, the cumulative numbers of quarantined cases, recovered cases and closed cases are available in public. however, since the latter two are directly related to the first one through the time dependent recovery rate and mortality rate, the numbers of quarantined cases q(t) plays a key role in our modeling. a similar argument applies to the number of insusceptible cases too. furthermore, as the accurate numbers of exposed cases and infectious cases are very hard to determine, they will be treated as hidden variables during the study. leaving alone the time dependent parameters λ(t) and κ(t), there are four unknown coefficients {α, β, γ − , δ − } and two initial conditions {e , i } about the hidden variables (other initial conditions are known from the data) have to be extracted from the time series all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . data {q(t)}. such an optimization problem could be solved automatically by using the simulating annealing algorithm (see si for details). a major difficulty is how to overcome the overfitting problem. to this end, we firstly prefix the latent time γ − , which is generally estimated within several days , , . and then for each fixed γ − , we explore its influence on other parameters (β = nearly unchanged), initial values, as well as the population dynamics of quarantined cases and infected cases during best fitting. from fig. a -b, to produce the same outcome, the protection rate α and the reciprocal of the quarantine time δ − are both decreasing with the latent time γ − , which is consistent with the fact that longer latent time requires longer quarantine time. meanwhile, the initial values of exposed cases and infectious cases are increasing with the latent time. since e and i include asymptomatic patients, they both should be larger than the number of quarantined cases. furthermore, as the time period between the starting date of our simulation (jan. th) and the initial outbreak of covid- (generally believed to be earlier than jan. st) is much longer than the latent time ( - days), e and i have to be close to each other, which makes only their sum e +i all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint matters during the fitting. an additional important finding is that in all cases β is always very close to , which agrees with the observation that covid- has an extremely strong infectious ability. nearly every unprotected person will be infected after a direct contact with the covid- patients , , . as a summary, we conclude that once the latent time γ − is fixed, the fitting accuracy on the time series data {q(t)} basically depends on the values of α, δ − and e + i . and based on a reasonable estimation on the total number of infected cases (see fig. c-d) , the latent time is finally determined as days. in order to further evaluate the influence of other fitting parameters on the long-term forecast, we perform sensitivity analysis on the data of wuhan (results for other regions are similar and not shown) by systematically varying the values of unknown coefficients , . as shown in fig. e-f , the predicted total infected cases at the end of epidemic, as well as the the inflection point, at which the basic reproduction number is less than , both show a positive correlation with the infection rate β and the quarantined time δ − and a negative correlation with the protection rate α. these facts agree with the common sense and highlight the necessity of self-protection (increase α and decrease β), timely disinfection (increase α and decrease β), early quarantine (decrease δ − ), etc. an exception is found for the initial total infected cases. although a larger value of e + i could substantially increase the final total infected cases, it shows no impact on the inflection point, which could be learnt from the formula of basic reproduction number. we apply our pre-described generalized seir model to interpret the public data on the cumulative numbers of quarantined cases, recovered cases and closed cases from jan. th to feb. th, which are published daily by nhc of china since jan. th. our preliminary study includes five different regions, i.e. the mainland * , hubei * , wuhan, beijing and shanghai. through extensive simulations, the optimal values for unknown model parameters and all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . initial conditions, which best explain the observed cumulative numbers of quarantined cases, recovered cases and closed cases (see fig. ), are determined and summarized in table . there are several remarkable facts could be immediately learnt from table . firstly, the protection rate of wuhan is significantly lower than other regions, showing many infected cases may not yet be well quarantined until feb. th (the smaller α for wuhan does not necessarily mean people in wuhan pay less attention to self-protection, but more likely due to the higher mixing ratio of susceptible cases with infectious cases). similarly, although the average protection rate for hubei * is higher than that of wuhan, it is still significantly lower than other regions. secondly, the quarantine time for beijing and shanghai are the all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint shortest, that for mainland * is in between. again, the quarantine time for wuhan and hubei * are the longest. finally, the estimated number of total infected cases on jan. th in five regions are all significantly larger than one, suggesting the covid- has already spread out nationwide at that moment. we will come back to this point in the next part. the initial values for exposed cases and infectious cases separately. the time-dependent cure rate λ(t) and mortality rate κ(t) can be read out from fig. and are given in si. most importantly, with the model and parameters in hand, we can carry out simulations for a longer time and forecast the potential tendency of the covid- epidemic. in fig. and fig. a -b, the predicted cumulative number of quarantined cases and the current number of exposed cases plus infectious cases are plotted for next days as well as for a shorter period of next days. official published data by nhc of china from feb. th to th are marked in red spots and taken as a direct validation. overall, except wuhan, the validation data show a well agreement with our forecast and all fall into the % confidence interval (shaded area). and we are delighted to see most of them are lower than our predictions, showing the nationwide anti-epidemic measures in china come into play. while for wuhan city (and also hubei province), due to the inclusion of suspected cases with clinical diagnosis into confirmed cases ( cases for wuhan and cases for hubei * on feb. th) announced by nhc of china since feb. th during the preparation of our manuscript, there is a sudden jump in the quarantined cases. although it to some all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint extent offsets our original overestimates, it also reveals the current severe situation in wuhan city, which requires much closer attention in the future. towards the epidemic of covid- , our basic predictions are summarized as follows: . based on optimistic estimation, the epidemic of covid- in beijing and shanghai would soon be ended within two weeks (since feb. th). while for most parts of mainland, the success of anti-epidemic will be no later than the middle of march. the situation in wuhan is still very severe, at least based on public data until feb. th. we expect it will end up at the beginning of april. are not included into parameter estimation). by coincidence, on the same day, we witnessed a sudden jump in the number of confirmed cases due to a relaxed diagnosis caliber, meaning more suspected cases will receive better medical care and have much lower chances to spread virus. besides, wuhan local government announced the completion of community survey on all confirmed cases, suspected cases and close contacts in the whole city. besides the forecast, the early trajectory of the covid- outbreak is also critical for our understanding on its epidemic as well as future prevention. to this end, by adopting the shooting method, we carry out inverse inference to explore the early epidemic dynamics all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint of covid- since its onset in mainland * , hubei * , and wuhan (beijing and shanghai are not considered due to their too small numbers of infected cases on jan. th). with respect to the parameters and initial conditions listed in table , we make an astonishing finding that, for all three cases, the outbreaks of covid- all point to - days before jan. th (the starting date for public data and our modeling). it means the epidemic of covid- in these regions is no later than jan. st (see fig. d ), in agreement with reports by li et al. , , . and in this stage (from jan. st to jan. th), the number of total infected cases follows a nice exponential curve with the doubling time around days. this in some way explains why statistics studies with either exponential functions or logistic models could work very well on early limited data points. furthermore, we notice the number of infected cases based on inverse inference is much larger than the reported confirmed cases in wuhan city before jan. th. in this study, we propose a generalized seir model to analyze the epidemic of covid- , which was firstly reported in wuhan last december and then quickly spread out nationwide in china. our model properly incorporates the intrinsic impact of hidden exposed and infectious cases on the entire procedure of epidemic, which is difficult for traditional statistics analysis. a new quarantined state, together with the recovery state, takes replace of the original r state in the classical seir model and correctly accounts for the daily reported confirmed infected cases and recovered cases. based on detailed analysis of the public data of nhc of china from jan. th to feb. th, we estimate several key parameters for covid- , like the latent time, the quarantine time and the basic reproduction number in a relatively reliable way, and predict the inflection point, possible ending time and final total infected cases for hubei, wuhan, beijing, shanghai, etc. overall, the epidemic situations for beijing and shanghai are optimistic, which are expected to end up within two weeks (from feb. th, ). meanwhile, for most parts of mainland including the majority of cities in hubei province, it will be no later than the middle of march. we should also point out that the situation in wuhan city is still very severe. more effective policies and more efforts on medical care and clinical research are eagerly needed. we expect the final success of anti-epidemic will be reached at the beginning all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint of this april. furthermore, by inverse inference, we find that the outbreak of this epidemic in mainland, hubei, and wuhan can all be dated back to - days ago with respect to jan. th, in other words the end of dec. , which is consistent with public reports. although we lack the knowledge on the first infected case, our inverse inference may still be helpful for understanding the epidemic of covid- and preventing similar virus in the future. the authors declare no conflict of interest. epidemic doubling time of the novel coronavirus outbreak by province in mainland china. medrxiv epidemiological and clinical features of the novel coronavirus outbreak in china preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china the novel coronavirus, -ncov, is highly contagious and more infectious than initially estimated. medrxiv serial interval of novel coronavirus ( -ncov) infections. medrxiv assessing spread risk of wuhan novel coronavirus within and beyond china all rights reserved. no reuse allowed without permission author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the using predicted imports of -ncov cases to determine locations that may not be identifying all imported cases. medrxiv epidemic size of novel coronavirusinfected pneumonia in the epicenter wuhan: using data of five-countries' evacuation action. medrxiv estimating the daily trend in the size of covid- infected population in wuhan. medrxiv estimation of the asymptomatic ratio of novel coronavirus ( -ncov) infections among passengers on evacuation flights early dynamics of transmission and control of -ncov: a mathematical modelling study. medrxiv the effect of travel restrictions on the spread of the novel coronavirus ( -ncov) outbreak. medrxiv the impact of traffic isolation in wuhan on the spread of -ncov. medrxiv feasibility of controlling -ncov outbreaks by isolation of cases and contacts effectiveness of airport screening at detecting travellers infected with -ncov. medrxiv predictions of -ncov transmission ending via comprehensive methods all rights reserved. no reuse allowed without permission author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the a data driven time-dependent transmission rate for tracking an epidemic: a case study of -ncov novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions. medrxiv estimation of the transmission risk of the -ncov and its implication for public health interventions an updated estimation of the risk of transmission of the novel coronavirus ( -ncov). infectious disease modelling transmission dynamics of -ncov in malaysia. medrxiv lockdown may partially halt the spread of novel coronavirus in hubei province interventions targeting air travellers early in the pandemic may delay local outbreaks of sars-cov- . medrxiv simulating the infected population and spread trend of -ncov under different policy by eir model. medrxiv the lockdown of hubei province causing different transmission dynamics of the novel coronavirus ( -ncov) in wuhan and beijing. medrxiv jing-an cui, and ling yin. a mathematical model for simulating the transmission of wuhan novel coronavirus. biorxiv a time delay dynamical model for outbreak of -ncov and the parameter identification modeling and prediction for the trend of outbreak of ncp based on a time-delay dynamic system all rights reserved. no reuse allowed without permission author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the partial equilibrium approximations in apoptosis. ii. the death-inducing signaling complex subsystem chiu fan lee, and ya jing huang. statistical mechanics and kinetics of amyloid fibrillation we acknowledged the financial supports from the national natural science foundation all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity.the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . author/funder, who has granted medrxiv a license to display the preprint in perpetuity.the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . all rights reserved. no reuse allowed without permission.author/funder, who has granted medrxiv a license to display the preprint in perpetuity.the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity.the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint key: cord- -a cjx authors: zhang, zhibin; sheng, chengfa; ma, zufei; li, dianmo title: the outbreak pattern of the sars cases in asia date: journal: chin sci bull doi: . /bf sha: doc_id: cord_uid: a cjx the severe acute respiratory syndrome (sars) caused tremendous damage to many asia countries, especially china. the transmission process and outbreak pattern of sars is still not well understood. this study aims to find a simple model to describe the outbreak pattern of sars cases by using sars case data commonly released by governments. the outbreak pattern of cumulative sars cases is expected to be a logistic type because the infection will be slowed down due to the increasing control effort by people and/or due to depletion of susceptible individuals. the increase rate of sars cases is expected to decrease with the cumulative sars cases, as described by the traditional logistical model, which is widely used in population dynamic studies. the instantaneous rate of increases were significantly and negatively correlated with the cumulative sars cases in mainland of china (including beijing, hebei, tianjin, shanxi, the autonomous region of inner mongolia) and singapore. the basic reproduction numberr ( ) in asia ranged from . to . (except for taiwan, china). ther ( ) of hebei and tianjin were much higher than that of singapore, hongkong, beijing, shanxi, inner mongolia, indicating sars virus might have originated differently or new mutations occurred during transmission. we demonstrated that the outbreaks of sars in many regions of asia were well described by the logistic model, and the control measures implemented by governments are effective. the maximum instantaneous rate of increase, basic reproductive number, and maximum cumulative sars cases were also calculated by using the logistic model. ported the transmission epidemic of sars in singapore and hong kong. both teams made use of mathematical models based on a system of four subpopulations: susceptible, exposed, infectious, and recovered (immune) individual, also called a seir model [ j . they estimated that the basic reproduction number r o at the early stage without control is of order to . the basic reproductive number is a good indicator of the severity of epidemic diseases and effectiveness of contrd - j . if ro<l, it means articles that the disease will eventually disappear, while r o > implies that the disease will persist[ j . estimation of r o from disease outbreak data is not an easy job because the actual process of infection is not observable, data are often incomplete and the rate of infection is often nonlinear [ - j . in most situations, detailed epidemical data are lacking. it is time consuming and labor consuming to trace the secondary infection cases from a single sars case. it is necessary to find an alternative model to describe the outbreak pattern of sars cases by using simple data of number of sars cases commonly released by governments. in population ecology, the continuous exponential model of population growth is described by where n is the population size, and r is the instantaneous rate of increase. the discrete model is written as where nt is the population size at time t, a is the finite rate of increase, and a=e r • because resources are limited, the instantaneous rate of increase usually decreases with the increase in population size, which is called the effect of density dependency. the logistic model has been widely used to describe the population growth under limited resources. the continuous logistic model is written as: where rm is the maximum r, k is the carrying capacity of a population in specific environment. with eq. ( ), we can dn prove that when n=k/ , will reach the maximum. dt according to eq. ( ), the maximum of cumulative sars cases (k h ) can be roughly estimated if the outbreak pattern follows the logistic model. fig. shows how the popula- , h ' tlon size an mcrease rate --;jt vary wit time t, and how r varies with n, as described by eq. ( ). when . . cumulative sars cases mu ative sars cases in a region correspond to the carrying capacity (k) in the logistic model. the "density dependency effect" in this study refers to the fact that the numbers of new sars cases become smaller over time as the result of the efforts of both control and natural immunization in the whole population. in this paper, the outbreak patterns of cumulative cases of sars in the regions of hong kong, taiwan and the mainland of china, and singapore were investigated by using the logistic model. the original data of the cumulative cases of sars are collected from the related governmental websites (e.g. http://www.who .inticsr/don/archiveldisease/severe_acute_ respiratory_syndrome/en/; http://www.moh.gov.cn/). .+ ij. the discrete logistic model of eq. ( ) is written as: k from eq. ( ), r m and k can be estimated. the equation is also widely used to testify if the population growth is density-dependent or not, depending on whether n(nt+/nt) is negatively correlated to np j • in fact, except for population growth, many other biological processes, e.g. the growth of body size of organisms, can be well described by using the logistic model. the outbreak pattern of cumulative sars cases is likely of a logistic type because at the initial stage, it grows exponentially, later due to the increasing control effort by people and/or due to depletion of susceptible individuals, the infection will be slowed down. the increase rate of sars cases is expected to decrease with the cumulative sars cases, which corresponds to the density-dependent effect in the logistic model. the total cu- dn reach to the peak at time t p , k can be estimated from dt the n at time t p , i.e. k= n (fig. l(a) ). there is a negative linear relationship between rand n ( fig. (b) ). significant and negative linear "density dependency" of the instantaneous rate of increase on the cumulative cases of sars indicates that the outbreak pattern of sars can be well described by the logistic model( fig. (a) and (b) ). in table , according to eq. ( ), b o is the estimation of r m and k l =rm/bj, k l is the estimation of the maximum sars cases k ( table ). according to eq. ( ), k h is also an estimation of k ( table ). the accuracies of estimation of k by using both methods are very high, further sup porting the conclusion that the growth pattern of sars cases is generally a logistic curve. the variation of r is larger at the early stage with smaller cumulative sars cases, probably due to smaller number of cumulative cases. mathematical models have been widely used to calculate and describe the dynamic evolution of epidemic threshold values and severity [ , [ ] . these models are relatively complex, and we often need to consider the susceptible people, exposed people, removed people, etc. when establishing such kind of models. data collection for estimating model parameters is not only time consuming but also labor consuming. in most situations, it is hard to estimate the basic reproduction number (r o ), and it is often impossible to predict the maximum cumulative cases in the early stage of disease outbreak, which limited its application. we do not consider the different populations when establishing a logistic model; only the number of infectious patients is sufficent. the logistic model is also tolerable to the variation of survey interval. though simple, the logistic model enables us to easily estimate the maximum relative increase rate (rm) and maximum cumulative sars cases (k). from rm, r o can be estimated if only the infection period from a single case to the secondary case is given. according to the epidemic studies on sars in hong kong, china and singapore[i, , the mean serial interval, defined as the sum of incubation period and the duration of infectiveness of sars person, is estimated as - d with an average of . ± . din singapore, and r o is estimated to be from . to . . since the incubation period is about or . d[ , the duration of infectiveness (d ) is about d. hospitalized sars persons would also infect front-line doctor staff in hospital, and the average duration of sars person in hospital (d ) is about d [ ] . as shown in table rate of increase against the cumulative sars cases in china and in singapore. this is also a good indication that the control measures, mostly strict isolation of sars persons and persons with experience of close contact to the maximum cumulative sars cases in many provinces or cities in the mainland of china were fitted very well byusing eq. ( ) based on the peak values of new sars cases or by using eq. ( ) ( table ). the maximum cumulative sars cases in beijing were estimated to be and respectively by using the two methods, very close to the observed value ; the maximum cumulative sars cases in whole mainland of china were estimated to be and respectively, very close to the observed cases ( table ). the prediction accuracy was very high. therefore, the model could play an important role in prediction of outbreak of sars accumulative cases. however, prediction using both ways would become difficult if the variation of increase rate is large for a small number of cumulative sars cases. our study clearly indicates that the outbreak pattern of the sars virus in china is of a logistic type, and there is strong negative "density dependency" of the instantaneous sars persons, implemented by government, are effective, and these measures were also causative factors in the negative correlation between rate of increase and total cumulative sars cases. transmission dynamics and control of severe acute respiratory syndrome transmission dynamics of the etiological agent of sars in hong kong: impact of public health interventions modeling the sars epidemic perspective: human contact patterns and the spread of airborne infection disease on the definition and computation of the basic reproductive ratio r o in the models for infectious diseases in the heterogeneous populations an sis epidemic model with variable population size and a delay analysis of infectious disease data parametric inference for epidemic models britton, t, statistical studies of infectious disease incidence accurately simulating the growth in the size of the hiv infected population in aids epidemic country: computing the usa hiv infection curve estimating the initial relative infection rate for a stochastic epidemic model some properties of an estimator for the basic reproductive number of a general epidemic model a tutorial introduction to bayesian inference for stochastic epidemic models using markov chain monte carlo methods extrinsic and intrinsic factors determine the eruptive dynamics of brandt's voles microtus brandti in inner mongolia the mathematical theory of diseases infectious diseases of humans: dynamics and control a generalization of the kermack-mckendrick deterministic epidemic model epidemic models: their structure and relation to data correlation models for childhood epidemics a general model for stochastic sir epidemics with two level of mixing subcritical endemic steady states in mathematical models for animal infectious with incomplete immunity dynamical evolution of discrete epidemic models global stability of two-stage epidemic model with generalized non-linear incidence global dynamics of an epidemic model with time delay dynamical behavior of an epidemic model with a nonlinear incidence rate sars control manual (in chinese) simulating the sars outbreak in beijing with limited data acknowledgements we would like to thank dr. s. davis and dr. r. . moorhouse for their valuable comments to this manuscript. this work was supported by the innovation program of the chinese academy of sciences. key: cord- -vr eqsbq authors: sawalha, khalid; abozenah, mohammed; kadado, anis john; battisha, ayman; al-akchar, mohammad; salerno, colby; hernandez-montfort, jaime; islam, ashequl m. title: systematic review of covid- related myocarditis: insights on management and outcome date: - - journal: cardiovasc revasc med doi: . /j.carrev. . . sha: doc_id: cord_uid: vr eqsbq abstract introduction severe acute respiratory syndrome coronavirus (sars-cov- ), also referred to as covid- , was declared a pandemic by the world health organization in march . the manifestations of covid- are widely variable and range from asymptomatic infection to multi-organ failure and death. like other viral illnesses, acute myocarditis has been reported to be associated with covid- infection. however, guidelines for the diagnosis of covid- myocarditis have not been established. methods using a combination of search terms in the pubmed/medline, ovid medline and the cochrane library databases and manual searches on google scholar and the bibliographies of articles identified, we reviewed all cases reported in the english language citing myocarditis associated with covid- infection. results fourteen records comprising a total of fourteen cases that report myocarditis/myopericarditis secondary to covid- infection were identified. there was a male predominance ( %), with the median age of the cases described being . years. the majority of patients did not have a previously identified comorbid condition ( %), but of those with a past medical history, hypertension was most prevalent ( %). electrocardiogram findings were variable, and troponin was elevated in % of cases. echocardiography was performed in % of cases reduced function was identified in %. endotracheal intubation was performed in the majority of cases. glucocorticoids were most commonly used in treatment of myocarditis ( %). majority of patients survived to discharge ( %) and % of those that received steroids survived to discharge. conclusion guidelines for diagnosis and management of covid- myocarditis have not been established and our knowledge on management is rapidly changing. the use of glucocorticoids and other agents including il- inhibitors, ivig and colchicine in covid- myocarditis is debatable. in our review, there appears to be favorable outcomes related to myocarditis treated with steroid therapy. however, until larger scale studies are conducted, treatment approaches have to be made on an individualized case-by-case basis. infection with the novel pathogen severe acute respiratory syndrome coronavirus (sars-cov- ), also referred to as covid- , was first reported in wuhan, china in december and declared a pandemic by the world health organization (who) in march ( ). sars-cov- is one of the zoonotic coronaviruses similar to severe acute respiratory syndrome coronavirus (sars-cov) and the middle east respiratory syndrome coronavirus (mers-cov) and believed to have resulted from a zoonotic transmission to humans from bats ( ). the manifestations of covid- are widely variable and range from asymptomatic infection to multi-organ failure and death. pulmonary involvement is the most dominant clinical manifestation of covid- including acute respiratory distress syndrome (ards) which is associated with higher mortality, up to . % in one series ( ). with rapidly evolving research on covid- , cardiovascular manifestations were found to occur in - % of hospitalized patients and associated with worse outcomes ( ). covid- related viral myocarditis has been reported in multiple case reports and review articles. the mechanism of cardiac injury remains poorly understood which makes management challenging. multiple institutions have established guidelines for the management of covid- however focus on respiratory distress and ards management. no guidelines for the management of myocarditis currently exist. current practice is limited to case reports and our understanding of the pathophysiology of the disease is still to be determined. investigate the most common presenting features, workup and outcomes in the reported cases to identify a common pattern to aid in the diagnosis and management. we conducted a systematic search of the medical literature of online databases including pubmed/medline , ovid medline and the cochrane library from december st to june th th . we searched for the following medical subjects heading (mesh) terms: (((covid- or coronavirus or novel coronavirus or sars-cov- or sars cov ))) in combination with terms "myocarditis", "pericarditis", and "myopericarditis". we also screened all primary articles bibliography for addition cases. we limited our search to articles written in the english language. we limited our search to case reports only. our search was in line with prisma guidelines and the flowchart in figure portrays the search and screening process. a total of records were identified through our literature search. two reviewers (k.s and m.a) reviewed all retrieved titles, abstracts and manuscripts and identified eight relevant manuscripts. another four eligible cases were identified by a manual search on google scholar, google search engine, and the bibliographies of the primary articles which resulted in a total of cases. one of the identified manuscripts reported two cases however only one of them reported a case of myocarditis and the second discussed a case of stress cardiomyopathy which was excluded. for each case identified, we collected patient demographics including age and gender and clinical information such as presentation, laboratory results, electrocardiogram, echocardiography and advanced cardiac imaging results. described being . years. a third ( %) of all cases were younger than years of age. the majority of patients did not have a previously identified comorbid condition ( %), but of those with a past medical history, hypertension was most prevalent ( %). shortness of breath and/or dyspnea were the commonest presenting features ( %) along with fever ( %).comorbidities and presenting symptoms were summarized in table- . of the cases with documented hemodynamic status, the majority were in shock ( %), with cardiogenic shock being the most commonly identified cause ( % cardiogenic and % mixed cardiogenic and septic shock). examination findings beyond vital signs were rarely reported and so their findings were not included. around % of all patients either presented in acute respiratory distress syndrome (ards), or developed it during their hospitalization (table ) . electrocardiogram findings were variable and included diffuse st-segment elevation, stsegment depression, and t-wave inversion occurring equally at % each. troponin was elevated in % of cases, whereas ck-mb and pro-brain natriuretic peptide (pro-bnp) were checked less frequently endomyocardial biopsy was performed in one case which showed virus-negative lymphocytic myocarditis. echocardiography was performed in most cases ( %) and % had reduced ejection fraction. cardiac tamponade physiology was reported in % of all echocardiograms, with diffuse hypokinesis occurring % of the time. advanced cardiac imaging with mri was performed in % of cases which showed diffuse gadolinium enhancement. coronary artery diagnostic work-up included ct angiography ( %) and invasive coronary angiography ( %). no patients were found to have any obstructive coronary disease. (table ). around % of the patients required vasopressor support and % of them requiring inotropic support. mechanical support was also utilized ( %), with the commonest modality being extracorporeal membrane oxygenation. medical management included therapies targeted at covid- , therapies for management of myocarditis/myopericarditis, and therapies targeted cytokine storm. many j o u r n a l p r e -p r o o f treatment modalities were also utilized to manage myocarditis/myopericarditis specifically, with glucocorticoids being the most commonly used ( %), followed by immunoglobulin therapy ( %) and colchicine ( %). of the cases in which glucocorticoid therapy was used, % started therapy on day of admission. additional therapy targeting the cytokine storm were used such as tocilizumab ( %) and interferon ( %) ( table- ). there was no report of outcomes whatsoever in cases ( %). at the time of submission of the case reports, the majority had survived to discharge ( % of those with reported outcomes) with only a minority of cases not surviving ( % of those with reported outcomes). all of the patients that reportedly passed away were noted to have both ards and myocarditis (table ). our study shows several trends across all cited cases. hypertension was the most common comorbidity noted amongst cases ( %).. steroids were used in % of cases and multiple second-line agents including tocilizumab ( %), immunoglobulins ( %) and interferon ( %) were used in addition to steroids. echocardiography showed reduced ejection fraction in the majority of cases. the overall survival rate was % and survival rate in those who received steroids was %. sars-cov- is a beta coronavirus comprised of an enveloped positive single-stranded ribonucleic acid (rna) structure that belongs to the coronavirinae subfamily ( ) . the virus can invade the human host cell by binding to angiotensin-converting enzyme (ace ). the ace is a membranebound protein that is expressed in many organ tissues, including cardiovascular epithelium, renal and lung tissues. after penetration, viral rna enters the cell nucleus for replication and apoptosis ( ) . the human immune response to the virus is variable which explains the variable clinical presentation. higher plasma level of cytokines has been found in severe cases such as ards ( ). to date, no definitive cure is j o u r n a l p r e -p r o o f available for covid- and most of the medications used or currently being studied are targeting the activation of inflammatory cells and proinflammatory cytokines. cardiovascular involvement has been prominent in covid- cases. however, despite rapidly developing data and information, little is known about the incidence and outcomes of cardiovascular manifestations in covid- . there are several cardiac presentations that have been noted, including acute myocardial infarction, acute heart failure, cardiogenic shock, myocarditis, and malignant arrhythmia ( ). patients with underlying cardiovascular disease (cvd) have a higher risk of developing cardiac injury. in a single-center retrospective study from wuhan including patients, the mortality rate was higher in patients with underlying cvd compared to patients without cvd ( . % vs . %). it also showed that . % of patients who died had cardiac injury with elevated troponin and mortality was . % in those with a history of cvd ( ) . in most studies, cardiac injury was evident by elevated troponin and pro-bnp. the levels of these markers were higher in critically ill patients admitted to the icu ( ) . given that the exact mechanism of cardiac involvement is not well understood, management of this entity is more challenging. like other viral illnesses, acute myocarditis has been reported to be associated with covid- infection. guidelines for the diagnosis of covid- myocarditis have not been established. current literature on this manifestation is limited to case reports and a small number of patients in cohort studies. however, a workup including cardiac biomarkers and electrocardiogram are initially recommended ( ). our results revealed that ecg changes were non-specific and highly variable. this is consistent with non-specific ecg findings in myocarditis cited in the literature ( ). serial ecgs may be a tool to provide a relatively quick, cost-effective, and non-invasive means at outlining and intervening in early stages of the disease process. echocardiography is an important tool in evaluating structural and functional changes secondary to myocarditis ( , ). however, no specific echocardiographic features of myocarditis exist, but it allows the physician to exclude other causes of heart failure, pericardial effusion, and intracavitary j o u r n a l p r e -p r o o f journal pre-proof thrombi ( ). patterns consistent with dilated, hypertrophic, and ischemic cardiomyopathies have all described in biopsy-proven myocarditis ( ). in our study, no trend was appreciated with regards to echocardiogram findings on presentation, with % showing reduced ejection fraction and % showing evidence of pericardial effusion. diffuse hypokinesis was also seen in % of cases. cardiac mri is the noninvasive gold standard test for myocarditis. it was done in six of the reported cases of which all showed gadolinium enhancement and two showed evidence of myocarditis as fulfilled by the lake louis criteria for mri based diagnosis of myocarditis. the current data on the use of glucocorticoids in covid- infection remains controversial and to our knowledge, no current studies have been conducted to assess the efficacy of corticosteroid therapy on covid- myocarditis. corticosteroid therapy was ineffective in treating viral myocarditis according to a cochrane systematic review published in ( ). furthermore, it has been reported that corticosteroid therapy might delay the clearance of the virus . in a study that was recently done on covid- patients, the duration of viral rna detection for oropharyngeal swabs and feces was longer in patients who were treated with corticosteroids ( ). moreover, there is concern for increasing secondary infection and adrenal insufficiency as a result of steroid therapy. two studies from china showed that iv methylprednisone has no significant benefit in covid- patients ( ) and was associated with higher icu admissions ( ). however, these findings might be cofounded given that steroids were used on sicker patients and likely for separate treatment purposes. on the contrary, a study from wuhan involving -patients with ards secondary to covid- , administration of corticosteroids decreased the risk of mortality ( ). additionally, a recent press release from a large clinical trial on covid- patients, the recovery (randomized evaluation of covid- therapy), dexamethasone was shown to reduce mortality in one third of the ventilated patients ( rate ratio . [ % ci . to . ]; p= . ). in our review, five out of seven patients who were treated with corticosteroid recovered; one passed away and the other case did not report outcomes. we cannot j o u r n a l p r e -p r o o f confirm if it is due to a true treatment effect or by chance only, yet based on recent data, steroid might be associated with favorable outcomes in critically ill covid patients ( ). intravenous immunoglobulin was used in three reported cases with variable outcomes. there is strong evidence on the efficacy of ivig in the treatment of acute myocarditis. a meta-analysis published in comparing ivig to corticosteroid for acute myocarditis showed that ivig therapy improved mortality and recovery of left ventricular function ( ). it was difficult to notice a specific trend on ivig in our review because it was used only in three patients and more studies are needed to prove its efficacy on covid- myocarditis. tocilizumab is an il- receptor antagonist that is used more commonly in rheumatoid arthritis treatment. it is also approved to be used for cytokine release syndrome based on multiple studies that proved its efficacy ( ). in a single center case series including patients, patients improved or stabilized after starting tocilizumab however, the study included a small number of patients and reported the outcomes after days post treatment only ( ). in the reported cases, four report high il- levels, and % of those with high il- levels received tocilizumab with variable outcomes resulting. trial results, remdesivir, was found to be superior to placebo in shortening the time to recovery in adults hospitalized with covid- ( ). it was also found to prevent and reduce disease severity in mers coronavirus in primates ( ). until prospective studies and trials establish guidelines for the management of covid- myocarditis, treatment has to be catered to individual case presentations. the limitations of this study are characteristic to studies based on case reports. first, our study is limited to cases reports which imparts potential selection bias since reported cases are usually unique cases in presentation and management. since the covid- pandemic impacted routine clinical practice and diagnostic approaches, many cases did not undergo further diagnostic workup done such as cardiac mri and endomyocardial biopsy. in addition, publication bias on the part of authors reporting these cases is another factor to account for. despite these limitations, we believe the use of case reports in our review is fundamental in detecting trends and generating hypotheses. our knowledge on the complications and management of covid- is exponentially growing. myocardial injury and myocarditis have been shown to be associated with higher morbidity and mortality. despite the rapidly growing research on management of covid- and its complications, there are many unanswered questions and areas to explore. currently, most of the ongoing research is focusing on the respiratory complications of covid- and little is known about myocarditis management. the use of glucocorticoids in covid- myocarditis is debatable. in our review, there appears to be favorable outcomes related to myocarditis treated with steroid therapy. however, until larger scale studies are conducted, treatment approaches have to be made on an individualized case-bycase basis. infection with fulminant myocarditis complication: case report and insights coronavirus genome structure and replication atypical manifestation of covid- -induced myocarditis acute myocarditis presenting as a reverse tako-tsubo syndrome in a patient with sars-cov- respiratory infection covid- pathophysiology: a review t cell-mediated immune response to respiratory coronaviruses clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study cardiovascular implications of fatal outcomes of patients with coronavirus disease (covid- ) mechanical support ( ) corticosteroid only ( ); % survival amongst those who received corticosteroids only corticosteroid + ivig ( ); % survival amongst those who received corticosteroids + ivig therapy corticosteroid + tocilizumab ( ); patient survived to discharge tocilizumab alone ( ); patient ultimately died key: cord- -hiylqqie authors: namasivayam, abirami; soe, than; palman, jason title: atypical case of covid- in a critically unwell -week old infant date: - - journal: bmj case rep doi: . /bcr- - sha: doc_id: cord_uid: hiylqqie the effect of covid- by sars-cov- on the paediatric population remains an evolving mystery. early reports from china stated that children seem to be unharmed by its dangerous effects, yet more recently there has been evidence of a systemic inflammatory response in a small number of children who are affected. we discuss a -week-old male infant who presented atypically with severe covid- infection. to our knowledge, he is the youngest reported case in the uk to require mechanical ventilation and intensive care treatment as a direct result of covid- following horizontal transmission. this case has generated several learning points with regard to atypical presentations of covid- and identifying a potential cohort of ‘at risk’ infants. we also highlight a number of new challenges that have arisen for paediatricians and anaesthetists providing airway management for infants with sars-cov- . the world has unfortunately entered into a new challenge by facing the global pandemic of covid- . at the time of writing, more than countries have been affected with over million confirmed cases and over deaths. even months from the first reported case there remain vast uncertainties surrounding the virus. there has been extensive evidence which highlights the discriminatory nature of covid- . while the elderly, immunocompromised and black asian and minority ethnic community remain its prime victims; children seem to be largely spared by its effects. why and how children have this tolerance are crucial unanswered questions. between december and february , china reported a total of cases of confirmed covid- . only nine of these cases were infants (aged days to year), none of whom required intensive care, mechanical ventilation or had severe complications. choi et al reviewed the epidemiology and clinical presentation of coronavirus in children as of march , reporting . % ( - years) in china, . % ( months to years) in singapore, . % ( - years) in italy, % ( - years) in republic of korea and . % ( - years) in australia. a larger nationwide study investigating paediatric cases across china reported that % cases had fever, . % cases presented as acute upper respiratory tract infection, . % as mild pneumonia and . % cases were critical; unfortunately, the specific age groups and comorbidities were not reported. the royal college of paediatric child health has recently released evidence of children responding to covid- with a systemic inflammatory response. however, greater awareness and investigation for children with suspected infection is needed. we report the case of a -week-old male infant who presented atypically to the commonly described features and deteriorated rapidly in our district general hospital (dgh). we explore the learning points from this case. a -day-old . kg ex-premature male infant was brought to the paediatric emergency department (ped) with reduced feeding and lethargy; he was + weeks corrected gestation at the time. he was born at + weeks gestation via caesarean section due to maternal type diabetes mellitus and was admitted to the neonatal unit for support of prematurity and respiratory distress. the antenatal history was unremarkable. he was the first child born to parents, both white caucasian. although maternal steroids were given, he required surfactant at hours of age and mechanical ventilation for hours before weaning to continuous positive airway pressure (cpap) for days, and later high flow nasal cannula (hfnc). chest x-ray at day of life is seen in figure . he was off all respiratory support by day of life and quickly established breastfeeding. he was treated with antibiotics for hours with suspected sepsis. he was discharged home at day of life. since being discharged from the neonatal intensive care unit (nicu), he had been breastfeeding and thriving well with no other concerns. his mother brought him to ped because he had not fed well over the last hours and his activity levels were reduced. he had no fever, no increased work of breathing and no cough. on initial assessment, he was alert but quiet. his heart rate was bpm, his respiratory rate was /min, his saturations were % and despite being fully dressed, he was hypothermic with an unrecordable axillary temperature. high flow facial oxygen was given which improved his oxygen saturations to above %. although his respiratory rate was reduced, there were no other clinical signs of respiratory distress-no grunting, no recessions and his chest was clear with good air entry. he was haemodynamically stable with capillary refill time under s. intravenous access was obtained to deliver ceftriaxone and amoxicillin for suspected sepsis; his blood gas at this time showed a partially compensated respiratory acidosis (table ) . during this period he remained alert but was particularly quiet with minimal response to the interventions being performed. shortly after achieving intravenous access, the infant unexpectedly became unresponsive and bradycardic with heart rate reducing to - bpm with minimal respiratory effort. effective bag valve mask (bvm) ventilation was established and an intravenous fluid bolus was given. the heart rate rapidly improved on warming with a bair hugger and warmed intravenous fluids. during rewarming he became increasingly alert and responsive, however, his respiratory effort gradually deteriorated with tachypnoea, grunting, nasal flaring and intercostal recession. chest auscultation remained clear, heart sounds were normal with palpable femoral pulses and no hepatomegaly. the decision for cpap escalated to mechanical ventilation as he then developed frequent apnoeas. his rapid clinical decline within a short time frame and a suspicious chest x-ray raised the likely possibility that this was all attributed to covid- (figure ). as per national and local resuscitation guidelines, minimal staff all wearing full personal protective equipment (ppe), were present during intubation. a size cm endotracheal tube was used; however, ventilation was more difficult than anticipated reflecting a rapidly evolving acute respiratory distress syndrome (ards). to improve ventilation, the infant was mechanically ventilated using a bvm which maintained stable observations. haematological markers revealed thrombocytopenia; platelets × /l while the haemoglobin concentration was g/l, white cell count . × /l, neutrophils . × /l and lymphocytes . × /l. his renal function and electrolytes were normal; his albumin was low at g/l with a raised alanine aminotransferase of iu/l and raised c reactive protein (crp) of mg/l. his clotting studies were normal. table demonstrates his progressive blood gases. his initial chest x-ray showed bilateral consolidation of the lung parenchyma and the subsequent x-ray performed after intubation showed bilateral 'ground-glass infiltration'. the worsening radiological findings correlate to the clinical deterioration of the patient and illustrate evidence of evolving ards. his nose and throat swabs for coronavirus pcr returned after hours as strongly positive for sars-cov- rna. the patient was transferred to a tertiary unit where he required high frequency oscillation ventilation for hours with a trial of inhaled nitric oxide and intermittently kept in prone position. he was conventionally ventilated for a further days before weaning to cpap and later hfnc; he was off respiratory support by day . he was given a -day course of remdesivir along with cefotaxime, clarithromycin and acyclovir and had been on ionotropic support via a peripherally inserted central catheter line. his echocardiogram was structurally normal with normal ventricular function. he unfortunately developed a femoral thrombus for which he remains on dalteparin. he has been discharged from hospital, is developing well and being regularly monitored by the local dgh. at present there are few reports of paediatric patients requiring intensive care support with confirmed covid- . to the best of our knowledge, this is the youngest reported case of sars-cov- following horizontal transmission in the uk. on presentation to ped the patient had no cough or fever symptoms which have been extensively reported as common clinical manifestations of covid- . similarly, the distinguishing biochemical abnormalities associated with covid- positive patients, specifically leucopenia and significantly elevated crp, were not observed in our case. as noted in table , the initial blood gas of the infant demonstrates a mixed acidosis and metabolic alkalosis. a plausible explanation for this could be that the infant had been in respiratory distress prior to presentation. this may also account for his hypothermia, lethargy and subsequent apnoeas; all of which suggest some neurological involvement. this case demonstrates the need for vigilance in considering covid- infection in infants presenting with less discriminatory symptoms such as lethargy or reduced feeding. in adults, comorbidities such as cardiovascular disease, diabetes and hypertension are associated with significant morbidity when infected with covid- . it remains a challenge to identify the most vulnerable groups among children. dong et al report a case series of paediatric patients with confirmed and suspected coronavirus; infants (< year) were noted to be particularly vulnerable. thirteen cases were 'critical'-quickly progressing to ards±shock, encephalopathy, myocardial injury, heart failure, coagulation dysfunction and acute kidney injury-seven of whom were less than year of age. the authors did not report the patient's comorbidities. there is evidence that the respiratory tract of premature babies has an immature mucosal barrier with a reduced mucociliary clearance, increasing their vulnerability to pulmonary infections. although our patient was corrected to weeks at presentation, his prematurity may have contributed to the increased risk of contracting the virus and the cascading response that followed. hong et al hypothesised that the reason for the small number of infants affected by the virus was because of their low risk of unusual presentation of more common disease/injury exposure to the virus. since the infant was discharged from the neonatal unit days before presenting to the emergency department he was within the - day incubation period for covid- . we must therefore consider the possibility of exposure before discharge from the neonatal unit, especially since he had remained at home isolating with his parents following his discharge. however, it is also important to note that there is no substantive evidence for vertical transmission from covid- positive mothers to their baby, and therefore neonatal units are considered a low risk area to covid- . it would have been valuable to have identified sources of potential exposure with contact testing and tracing. it is unfortunate that at the time of presentation, the 'nhs test and trace' service had not been implemented in the uk and therefore the route of transmission and acquisition of covid- remains unsolved. covid- is highly contagious and there is a large concern for healthcare staff involved in airway management for patients with the virus. guidance released by the resuscitation council uk and cook et al is being used to maintain the safety of staff while performing high risk aerosol generating procedures including intubation ; however, the guidance remains quite limited for infants. there are also challenging non-technical factors to consider when providing advanced airway management for an infant with suspected covid- . these factors included designating the most appropriate person to carry out intubation, use of cuffed endotracheal tubes, the number and selection of health professions involved during intubation, and communication barriers with full ppe and designated contained areas for managing the patient. understanding the clinical course of covid- in the paediatric population is continually evolving. although cases of critically unwell infants remain uncommon, this particular group may be more vulnerable. an appreciation for early identification of subtle symptoms, such as reduced feeding, lethargy and hypoxia in the absence of respiratory distress, will enable prompt escalation of care and appropriate stabilisation. although there is no specific guidance on airway management for infants with suspected covid- , it is important to keep up-to-date with local and national guidance to ensure patient and staff safety. further epidemiological reports will hopefully uncover the vast expanse of symptomology of the heterogenic covid- positive paediatric cohort and the optimal management of the virus. contributors an contributed to the concept, write up and literature search of the case as well has being involved in the patient's initial care. ts was the consultant involved in the patient's care. jp reviewed, revised and edited the manuscript. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. chest x-rays of the patient pre and post intubation . hours apart, showing the transition from bilateral consolidation to bilateral ground glass infiltration due to evolving ards. ards, acute respiratory distress syndrome. ► covid- may present as subtly as lethargy and poor feeding in infants. ► infants may present with hypoxia in the absence of respiratory distress. ► more understanding on the effects of covid- in infants, especially premature infants is required. world health organization. coronavirus disease (covid- ) situation report covid- virus and children: what do we know? novel coronavirus infection in hospitalized infants under year of age in china epidemiology and clinical features of coronavirus disease in children royal college of paediatrics and child health. guidance-paediatric multisystem inflammatory syndrome temporally associated with covid resuscitation council uk statement on covid- in relation to cpr and resuscitation in paediatrics consensus guidelines for managing the airway in patients with covid - clinical, laboratory and imaging features of covid- : a systematic review and meta-analysis hyperinflammatory shock in children during covid- pandemic covid- in children: an epidemiology study from china why are preterm newborns at increased risk of infection? clinical characteristics of novel coronavirus disease (covid- ) in newborns, infants and children the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records coronavirus disease (covid- ) and neonate: what neonatologist need to know patient consent for publication parental/guardian consent obtained.provenance and peer review not commissioned; externally peer reviewed.copyright bmj publishing group. all rights reserved. for permission to reuse any of this content visit https://www.bmj.com/company/products-services/rights-and-licensing/permissions/ bmj case report fellows may re-use this article for personal use and teaching without any further permission.become a fellow of bmj case reports today and you can: ► submit as many cases as you like ► enjoy fast sympathetic peer review and rapid publication of accepted articles ► access all the published articles ► re-use any of the published material for personal use and teaching without further permission if you have any further queries about your subscription, please contact our customer services team on + ( ) or via email at support@bmj.com.visit casereports.bmj.com for more articles like this and to become a fellow key: cord- -wm xho o authors: hanna, fikry title: multiple myelomas in cats date: - - journal: j feline med surg doi: . /j.jfms. . . sha: doc_id: cord_uid: wm xho o multiple myelomas are uncommon neoplasms of the bone marrow of cats [weber na, tebeau cs ( ) an unusual presentation of multiple myeloma in two cats. journal of the american animal hospital association ( ), – ]. nine cats diagnosed with multiple myelomas were retrospectively identified over a -year period ( – ). cats with multiple myelomas were older than years (mean age . years); six males and three females were affected ( . ), but no breed predisposition was evident. treatment of multiple myelomas consisted of supportive management in the nine cats and anti-neoplastic therapy in eight cats. supportive treatment consisted of maintaining hydration, renal function and antimicrobial therapy even when there was no sign of infection. anti-neoplastic therapy with melphalan and prednisolone was carried out in eight cats. three failed to respond to treatment and five responded to treatment, but the response was only partial and temporary in one cat. the five cats that responded were improved clinically and had reduced serum protein levels. five out of eight cats ( %) responded to chemotherapy, and it appeared to be complete in four cats and partial in one cat. survival time in those cats was , , and months. multiple myelomas are uncommon neoplasms of the bone marrow of cats [weber na, tebeau cs ( ) an unusual presentation of multiple myeloma in two cats. journal of the american animal hospital association ( ), e ]. nine cats diagnosed with multiple myelomas were retrospectively identified over a -year period ( e ) . cats with multiple myelomas were older than years (mean age . years); six males and three females were affected ( . ), but no breed predisposition was evident. treatment of multiple myelomas consisted of supportive management in the nine cats and anti-neoplastic therapy in eight cats. supportive treatment consisted of maintaining hydration, renal function and antimicrobial therapy even when there was no sign of infection. anti-neoplastic therapy with melphalan and prednisolone was carried out in eight cats. three failed to respond to treatment and five responded to treatment, but the response was only partial and temporary in one cat. the five cats that responded were improved clinically and had reduced serum protein levels. five out of eight cats ( %) responded to chemotherapy, and it appeared to be complete in four cats and partial in one cat. survival time in those cats was , , and months. m ultiple myelomas are plasma cell neoplasms of the bone marrow (osborne et al ) . reports of multiple myeloma in cats are infrequent; there are reported cases with no series describing more than six cats (macewen and hurvitz ) . multiple myeloma accounts for less than % of feline haematopoietic neoplasm and plasmacytomas are rarer than multiple myelomas (eastman , jacobs . plasma cell tumours originating in the bone marrow and involving other organs are multiple myelomas, while solitary plasma cell tumours in organs other than bone marrow are plasmacytomas. they usually occur in aged cats, with no breed or sex predisposition (jacobs , eastman , vail . neoplastic plasma cells secrete large amounts of paraproteins that appear as a monoclonal spike in serum protein electrophoresis commonly in the gamma globulin region (weber and tebeau ). there appears to be no relationship with feline leukaemia virus (felv) or feline immunodeficiency virus (fiv) (jacobs , weber and tebeau , vail . presenting signs tend to be insidious in onset and non-specific, including depression, anorexia and weight loss. there have also been isolated cases with hindlimb paresis, ataxia or lameness (mills et al , jacobs , weber and tebeau , bienzle et al . there is little information on the responsiveness of multiple myeloma to chemotherapy; these patients are severely immunocompromised (vail ) . this, combined with administration of immunosuppressive drugs, indicates the need for concurrent administration of antibiotics at the beginning of therapy to prevent opportunistic bacterial infection (eastman , weber and tebeau ) . the disease is usually progressive and fatal (eastman ) . complications of multiple myelomas seen in this cat study were similar to those seen by hammer and couto ( ) in the dog. they included renal failure, haemostatic abnormalities, infection and spinal cord compression. diagnosis of multiple myelomas requires meeting at least two of the following criteria: . greater than % neoplastic plasma cells in the bone marrow. these criteria were originally developed for use in the dog by macewen and hurvitz ( ) , although they have also been applied to the cat. the purpose of this study was to describe nine cases of multiple myelomas in the cat, to show that multiple myelomas can co-exist with other conditions, and with polyclonal gammopathy, and to classify multiple myelomas to establish prognostic criteria. a retrospective medical records search based on the diagnosis of myelomas was performed for nine cats between and ; all nine cats were referred and treated by the author. parameters abstracted from each cat's medical record: age, breed, sex, complete blood haematological and biochemical analysis results, feline leukaemia, feline immune deficiency and coronavirus (fip) antibody titre test results, relative serum viscosity readings, serum protein electrophoresis and agar gel immunoelectrophoresis results, radiological findings, bone marrow aspiration cytologies or biopsy findings, routine urinalysis, urine electrophoresis and urine heat precipitation test results. the owners were questioned about the medical history of the animal. each cat underwent a full clinical, orthopaedic and neurological examination. haemoglobin and total white cell count were measured on a sysmex impedance counter (vet lab), packed cell volume (pcv) was measured by microhaematocrit, and mcv and mchc derived arithmetically. differential white cell counting was performed by microscopy. all biochemistry analyses were performed by standard methods on a i lab clinical chemistry system (instrumentation laboratories, vet lab). this included creatinine, and blood urea nitrogen calcium values (including ionised calcium). serum electrophoresis was performed in all cats using the technique described by kerr ( ) : protein fractions were separated on a polyacrylamide gel at ph . . the dried and stained gel was then scanned by a densitometer to produce the typical electrophoretic trace. this was compared to the normal patterns for the species. immunoelectrophoresis to determine the class of paraprotein using the technique by schultz and adams ( ) was performed in three cats. following electrophoretic separation of serum proteins, troughs were cut into the agarose gel parallel to the separated serum proteins. antisera specific for each of the major ig classes were loaded into the troughs and the gel was incubated for h. the antiserum diffused from the trough and formed an arc of precipitation where it encountered specific antigen. urine was analysed in all cats using nephur- test chemical strips (roche-vet lab), specific gravity was measured by refractometry. bacteriology was carried out by standard bacteriological culture methods. urine was also evaluated for the presence of light chains of myeloma proteins (bence jones) by heat precipitation methods described by terry et al ( ) . urine was heated to e (c. if bence jones proteins are present a protein precipitation is observed which redissolves on boiling at (c and reprecipitates on cooling again from to (c. light chains appear electrophoretically as homogeneous band. relative serum viscosity was determined by the rbc pipette method as described by wright and jenkins ( ) . the red cell pipette was filled by suction of ml of plasma from a standard tube. the time flow between the lines immediately above and below the bulb reservoir was recorded, the flow time of the plasma in seconds was divided by the flow time for water in seconds, this gave the relative viscosity of the plasma carried at room temperature. the normal flow of water is s, e min for normal plasma. thoracic and abdominal radiography was performed in all cats and survey bone radiography was performed in all cats to evaluate the presence of osteolytic bone lesions. contrast myelography was performed in two cats. ante-mortem surgical bone marrow aspirates were collected in eight cats (cases , , , , , , and ) with a jamshidi bone marrow biopsy needle. the anatomical sites that were aspirated differed in different cats were: case (l /l ), case (l /l ), case (c /c /c ), case (left proximal tibia), case (l and left and right stifles). the anatomical site of aspiration was based on the suspected sites of multiple myelomas noted on the radiographs (as in the five cases described above) or the most accessible site for bone aspiration as in cases , and where the proximal humerus was aspirated. a post-mortem section of the affected bone was sampled for histopathology in cases , , , and . they were fixed in % neutral buffered formalin, decalcified in % formic acid, embedded in paraffin wax and sections were stained with haematoxylin and eosin. initial treatment included intravenous administration of sodium chloride . % or lactated ringer's solution, to correct dehydration if present and improve renal perfusion. supportive treatments including antibiotics, diuretics and vasodilators were prescribed in individual cases as follows. nitroglycerine ointment ( cm topically every h) to help heart conditions if present. methylprednisolone sodium succinate ( mg/kg body weight, iv) initially, followed by two treatments of mg/kg body weight, iv every h. therapy was used to relieve spinal cord compression if present. therapy for hypercalcaemia, if present, consisted of rehydration with intravenous saline. cage immobilisation to induce rest was employed if pathological fractures were present. therapy included melphalan (alkeran; wellcome) at a dose of ( . mg/kg) . mg (¼ tablet) melphalan mg, once daily for days, then every other day until clinical improvement or leukopenia developed. this was followed by a continuous maintenance therapy of ( . mg/ kg) . mg (¼ tablet) melphalan mg once every days. melphalan therapy was combined with prednisolone (prednicare; animalcare) given at a dose of . mg/kg of body weight orally once daily. to cats which presented with leukopenia in addition to anaemia, melphalan was given at a dose of . mg/kg of body weight orally (¼ tablet) melphalan mg, every days. if severe leukopenia developed melphalan was discontinued, but prednisolone continued. when wbc counts returned to normal the cats recommenced melphalan at a maintenance dose ¼ of a tablet weekly. patients were seen initially at weekly intervals for weeks, and monthly thereafter, when no more improvement could be achieved the frequency of assessment was usually reduced to every e months. owners were questioned at each consultation on the degree and duration of the clinical signs after starting the treatment (eg, anorexia, lameness, weakness, lethargy). an initial complete blood cell count and serum protein were repeated at weekly intervals for weeks, then monthly for months and monthly thereafter. liver enzymes were measured in order to evaluate hepatotoxicity before starting the treatment, then at the same time as testing for cell count and serum protein. a good response to therapy was based on: (a) clinical reduction in the presenting signs (ie, lameness, weakness, anorexia, dyspnoea, melena, haematuria and bone pain). (b) laboratory evidence of response to therapy (ie, reduction in serum total protein). (c) radiographic evidence of response to therapy (ie, reduction or complete absence of lucent lesions). cats were classified into those with more aggressive disease and those with less aggressive disease on the basis of the system proposed by matus et al . these criteria were originally developed for use in the dog. prognostic criteria were based on: . clinical stage of multiple myeloma (ie, pcv value, serum calcium level, extent of radiographic evidence of boneless, light chains of myeloma protein (bence jones) in the urine, changes in the serum protein level and renal abnormalities). . response to therapy (ie, marked improvement, temporary or little improvement and no improvement). our criteria for complete remission are transient or absence of clinical signs, insignificant or complete absence of lucency on the radiographs of the effected bone and return of serum protein level to normal when re-measured weeks after treatment and partial when the above mentioned criteria were not achieved. in the nine cats, clinical signs included lethargy and anorexia ( / , %); polyuria and polydypsia ( / , %); lameness ( / , %); paresis/ paralysis and/or pain ( / , %). cns deficits (dementia with concurrent deficiency in mid brain or brainstem) were documented in three out of nine cats ( %) ( table ) . common metabolic abnormalities included hyperglobulinaemia (globulin o g/l) in all cats, renal azotaemia (creatinine o mmol/l) in four out of nine ( %) cats, hypercalcaemia (calcium o . mmol/l) in three out of nine ( %) cats. ionised calcium (o . mg/dl) in three out of nine ( %) cats and hypoalbuminaemia (albumin ! g/l) in six out of nine ( %) cats (table ) . initial pretreatment leukocyte counts were variable ranging from . to . (! /l) (mean, ! /l; range e ! /l). leukopenia was noted in cases , , and . the leukocyte count was within normal range in cases , and . leukocytosis was noted in cases and ( table ) . non-regenerative anaemia was found in cases , , , and . routine urinalysis revealed proteinuria (protein o mg/dl) in ( / , %) cases and recorded and mg/dl protein in the urine, respectively (reference range, ). abnormalities in urinalysis included changes in specific gravity and deposition of urine sediment (see table ). electrophoresis of blood samples revealed monoclonal gammopathy in seven out of nine cats (fig ) and polyclonal gammopathy in two out of nine cats (cases and ). electrophoresis of urine samples revealed polyclonal gammopathy in case , while blood electrophoresis revealed monoclonal gammopathy. light-chain protein (bence jones protein) was found in five out of nine ( %) cats. serum immunoelectrophoresis to determine the immunoglobulin class was performed in three cats and found to be associated with igg (cases and ) and iga (case ). attempts to identify this protein were not made in other cases (table ) . plain radiography of the thorax and abdomen performed in all cats revealed no soft tissue organ abnormalities in eight cats, but in case , thoracic radiography showed blurring of the pulmonary vasculature, linear and nodular densities in the lungs and general loss of contrast, typical of interstitial pulmonary pattern and cardiomegally. abdominal radiograph showed a distended bladder. routine thoracic and abdominal radiograph were not sufficiently diagnostic of the lytic bone lesions, therefore, close-up bone surveys are essential to detect the bone lesions. radiographically, skeletal lesions characterised by well-circumscribed osteolytic bone lesions were seen in the cervical spine, (case ), the lumbar spine, (cases , , and ), the left stifle, (case ) (fig ) and the left and right stifles (case ) (fig ) . contrast myelography was performed in two of the cats and revealed extradural compressive lesion caused by tissue expansion from the bone marrow in cases and (fig ) . all eight cats that had ante-mortem surgical bone biopsies exhibited plasma cell infiltration (o % plasma cell population in bone marrow aspirate) (table ) . post-mortem microscopic examination of sections of neoplasms exhibited abundant (o %) plasma cells in the bone marrow. these cells were larger, pleomorphic and contain two or more nuclei (fig ) . in case , post-mortem histopathology of the bone biopsy exhibited abundant (o %) plasma cells in the bone marrow, with many features of malignancy (multinucleated cells and immature nuclear features). no neoplasia was found within organs of the abdomen and/or the thorax, instead granulomatous lesions, which appeared as white foci on cut surfaces, were found in the liver, kidney, abdominal lymph nodes and spleen ( table ). the cat also had pulmonary haemorrhage/oedema, myocardial necrosis and blood filled bladder. bleeding or haemorrhagic disease was observed in four cats in this study. in case retinal vessels were dilated and tortuous, and intraocular haemorrhage was detected on ophthalmoscopic examination. in case , on clinical examination there was melena and haematuria, and on postmortem examination there was approximately ml of serosanguinous fluid, mixed with clots of blood in the thoracic cavity, pulmonary haemorrhage and bladder haemorrhage. in case , focal areas of perivascular haemorrhage were detected in the retinas of both eyes on ophthalmoscopic examination. in case , melena was detected on clinical examination. relative serum viscosity which was determined by the rbc pipette method was in case , . ; case , . ; case , . ; and case , . . relative serum viscosity in clinically normal cats is reported to be ! . . an estimate of overall improvement was made based on all the data collected from the owners, related to clinical improvement or deterioration (eg, degree and duration of morning stiffness and stiffness related to activity, increased appetite, resolution of melena and haematuria) and our own assessment related to disease severity (eg, the degree of clinical signs (neurological, cardiac or ocular abnormalities), the degree of lucency seen on the radiographs, haematological parameters (serum protein level, liver enzymes measurement) and functional activity, eg, ability of the animal to move). little or no improvement was noted in cases , , and . temporary improvement was noted in case and marked improvement in cases , , , and . cases , , and were judged to be in complete remission. in those cats with complete remission, transient or absence of the clinical signs were seen in cases , , and , insignificant or complete absence of lucency on radiographs of the affected bone in cases and , and return of serum protein level to normal in cases , , and when serum proteins were re-measured weeks after treatment. at the onset of therapy alt, alp and bile acids were found to be within normal limits. a mild elevation of alt (average iu/l) and alp (average iu/l) occurred in five cats (cases , , , and ) weeks after treatment, but returned to normal when liver enzymes were re-measured weeks later (cases , , and ) and weeks later (case ). during that time cats were fed a balanced diet with moderate to high levels of high biological value protein and vitamin supplementation. lethargy after starting treatment increased in all cats, but returned to normal weeks later. all animals presented in this study with the exception of case have definite classic antemortem multiple myelomas by following the criteria described originally by macewen and hurvitz ( ) in dogs. case also satisfied these criteria but only after a post-mortem examination was performed. haematological and radiological signs that were repeatedly noted in cases which had less favourable outcome were listed in the aggressive group, and other haematological and radiological signs which had favourable outcomes were listed in the less aggressive group (table ). the survival time of the four cats in the aggressive group (cases , , and ) was , , and days, with a median survival time of days. the survival time of the five cats in the less aggressive group (cases , , , and ) was , , , and days, with a median survival time of days. there was significant difference between survival time and mean survival time in the aggressive and less aggressive groups. this may be helpful to assess the tumour burden and outcome of treatment in the future. cats in this study manifested clinical signs associated with the proliferation of plasma cells in the bone marrow and other soft tissues; these findings agree with other investigators' findings (osborne et al , martinson et al , matus et al , and the production of immunoglobulin (ig) a or igg. immunoglobulins have been identified as iga, igd, igm, or ige by binta et al ( ) and iga or igg by bienzle et al ( ) . myeloma light-chain protein (bence jones proteins) in this study developed in five cats ( %) and was associated with the development of renal insufficiency in four cats ( %). the relationship between the development of renal disease and the presence of bence jones proteins may be related to the fact that bence jones proteins are nephrotoxic (hurvitz et al ) or the production of light-chain protein metabolic degradation by renal tubular cells causing direct tubular damage and kidney dysfunction (levi et al , fer et al . cases , and had increased total calcium and ionised calcium concentrations. measurement of ionised concentration is essential as increased serum protein concentration may result in 'falsely' increased total serum calcium concentrations as more calcium is bound to the proteins in the blood. two of these cats (cases and ) had evidence of renal disease. possible causes of renal insufficiency that occurs with multiple myelomas are first, hypercalcaemia can cause renal mineralisation (kruger and osborne ) ; second, myeloma cells can infiltrate the kidney (osserman et al ) ; third, paraproteins can infiltrate the kidney (osserman et al , alexanian and dimopouls ) . hypercalcaemia may develop as a result of direct osteolysis by the infiltrative plasma cells (sheofor et al ) or the production of parathyroid hormone (pth) like substances, parathyroid hormone related peptide (pthrp) (rosol and capen ) . in cases , and , increased total and ionised calcium concentration may be consistent with pth-like effect from the tumour. explanation of how hypercalcaemia develops in these cats would require quantification of pth related protein. renal failure in multiple myelomas is rarely reversible and a poor prognostic sign. management is directed primarily towards control of the myelomas with anti-neoplastic therapy (fer et al ) . immunophenotyping was performed in three cats in this study. of these three cats only one cat with igg is still in remission months after treatment. this may highlight the potential prognostic value of immunophenotyping and support the findings of bienzle et al ( ) . the prognosis of cats with igg myeloma may be better than that of cats with iga myeloma. survey radiographs showed osteolytic bone lesions in six cats and myeloma light-chain protein was found in five cats. the frequent findings of bony lesions and bence jones proteins in this study have not been observed by other investigators, this may be because other studies have not performed the required investigations or because the diagnosis requires high quality radiographs. bleeding or haemorrhagic disease was observed in four cats in this study (cases , , and ). although various mechanisms that might cause prolonged bleeding in patients with multiple myelomas have been proposed, the exact mechanism is unknown. in our study cases , , and all had adequate platelet number. bleeding could have resulted from decreased platelet adhesiveness after being coated by the myeloma proteins, overloading of the blood vessels with thickened blood causing it to table . summary of response to treatment, follow-up and necroscopy findings in nine cats with multiple myeloma response to treatment neuropsy findings cat died days post diagnosis greater than % immature nucleated and multinucleated plasma cells were present in the bone marrow of l /l l vertebra euthanasia was advised days post presentation because of the rapid deterioration greater than % of the bone marrow was replaced with medium sized oval cells with eccentric oval nuclei having the appearance of neoplastic plasma cells at l . granulomatous tissue was found in the liver, kidneys, abdominal lymph nodes and spleen, and the bladder was distended, with blood in the abdomen. intrapulmonary haemorrhage/oedema and myocardial necrosis in the chest. in remission months post diagnosis not applicable euthanasia was elected months post diagnosis greater than % of the bone marrow was replaced by multineucleated plasma cells in remission ½ months post diagnosis not applicable in remission months post diagnosis not applicable in remission months post diagnosis not applicable euthanasia was elected on humane grounds weeks post diagnosis. % replacement of bone marrow with multinucleated plasma cells. euthanasia was elected week post treatment the whole bone marrow was replaced with immature plasma cells rupture or precipitation of plasma cells in the blood vessel wall causing its weakening and rupture (hendrix et al ) . although serum hvs is diagnosed infrequently in cats, it should be considered in cats with monoclonal gammopathy, especially if the cat has cns neurological deficits, cardiac and ocular abnormalities (eg, perivascular haemorrhage, vessels tortuosity, retinal detachment or intraocular haemorrhage). although plasmapheresis has not been used in this study, its use may have been beneficial in reducing plasma protein concentration and serum viscosity and render neoplastic cells more susceptible to chemotherapy. not all cases of multiple myelomas revealed monoclonal gammopathy on serum electrophoresis. in case , abnormalities in the blood analysis included elevated serum total proteins, globulin and urea. the cat had hypochromic non-regenerative anaemia (pcv . or %, hb, g/ ml, rbc . / l). the cat was leukothrophic (total wbc . / l) with neutrophilia (neutrophils . / l). the cat tested negative for feline leukaemia and feline immune deficiency but coronavirus (fip) antibody titre was / . the cat had a polyclonal gammopathy with elevated gamma globulin that is consistent with chronic inflammation. urine protein electrophoresis and bence jones protein test could not be run as an inadequate amount of protein was present in the urine ( mg/dl), the laboratory needed at least mg/dl. although osteolytic lesions in the lumbar spine and pathological fracture at the fourth lumbar (l ) vertebra were seen on the radiographs, no permission was given for needle aspiration of the osteolytic lesions. blood samples were suggestive of feline infectious peritonitis and the only evidence that multiple myeloma might be present was the presence of osteolytic bone lesions on radiographs of the lumbar spine and relative serum viscosity was . which may suggest hyperviscosity syndrome. in this cat final confirmation of the diagnosis was only made on post-mortem histopathology of the bone biopsy where abundant (o %) plasma cells were present in the bone marrow, most with features of malignancy (ie, multinu-cleated cells with eccentric nuclei and immature nuclear features), compatible with the diagnosis of multiple myelomas. no neoplasia was found within organs of the abdomen and/ or the thorax. instead granulomatous lesions, which appeared as white foci on cut surfaces were found in the liver, kidneys, abdominal lymph nodes and spleen, confirming feline infectious peritonitis. the cat also had pulmonary haemorrhage, oedema, myocardial necrosis and blood filled bladder indicating that this cat is likely to have had hyperviscosity syndrome secondary to its elevated globulins, which probably led to cardiac hypoxia, pulmonary haemorrhage, oedema and bladder haemorrhage. the cat did not have classic monoclonal gammopathy; rather, it had a polyclonal gammopathy. a possible explanation for the absence of monoclonal gammopathy is the presence of feline infectious peritonitis. the virus could have been present subclinically before the development of the plasma cell neoplasia, and feline infectious peritonitis became clinically apparent when normal immunoglobulin levels became severely depressed. decreased immunoglobulin synthesis may be caused by proliferating b-cells that release an inhibitory factor which may block proliferation of normal b-cells. this cat was initially treated for spinal cord compression because of the history, clinical signs, results of the neurological examination and results of the radiological examination. however, the intravenous steroids were not sufficient to reduce the neurological signs. effort to alleviate respiratory distress using frusemide (lasilaction: lasix mg/kg iv every e h) while maintaining hydration status and electrolyte balance with lactated ringer solution was unsuccessful. the cat was given anabolic steroid nandrolone (laurabolin; intervet at a dose of mg/kg sc every days) to stimulate appetite and prophylactic amoxicillin clavulanic acid (synulux; pfizer mg/kg body weight, po every h) but the haematuria did not resolve within the days. this may be because the cause of haematuria was hyperviscosity syndrome rather than infection. in our experience one of the main differential diagnoses of multiple myelomas in cats is feline infectious peritonitis. both may be presented with a similar clinical and haematological picture. the main differences were the identification of high levels of coronavirus titre; absence of bence jones protein in the urine and electrophoresis consistently produced polyclonal gammopathy in both blood and urine in feline infectious peritonitis. to the author's knowledge this is the first reported case where multiple myeloma existed at the same time as feline infectious peritonitis, and illustrates the need for caution when interpreting the results of serological tests for fip and multiple myelomas and the danger of relying on serology alone for making a diagnosis. polyclonal gammopathy, which is rare in multiple myeloma, was also found in case in the present study. possible explanations for the absence of monoclonal gammopathy in case are the presence of a secondary infection the tumour was non-secretory, the paraprotein had broken before electrophoresis was performed, or multiple plasma cell types involved in the neoplasm that secreted different paraproteins (kato et al ) . this finding shows that other pathological changes can be present at the same time as multiple myeloma and great care should be taken when reading the radiographs and interpreting haematological and urinalysis; the presence of feline infectious peritonitis in case had a great effect on treatment and prognosis. this can confirm that multiple myelomas can be associated with polyclonal gammopathy. in case monoclonal gammopathy was present in the blood, but polyclonal gammopathy was present in the urine. this may confirm that monoclonal gammopathy can be present in the blood and polyclonal gammopathy in the urine or vice versa in the same cat. in this study neutropenia developed after starting the treatment in cases , , , and at , , , and week after treatment, respectively. in these cats melphalan treatment was discontinued but prednisolone treatment continued. wbc counts were repeated weekly until returned to normal. once wbc counts returned to normal, melphalan was recom-menced ( mg) at a maintenance dose of x of a tablet weekly. initial melphalan therapy can cause profound neutropenia, this may be related to: (a) overdosing, because the pill size ( mg) is inconvenient to divide in cats. (b) individual sensitivity in different cats. (c) profound neutropenia was present initially. infections are a common cause of death in animals with multiple myeloma and must be treated promptly. antibiotic therapy is highly recommended, even if there is no obvious sign of infection, especially during the diagnostic work up (macewen and hurvitz ) . one reason for an increased infection rate may be that normal immunoglobulin levels are usually severely depressed. proposed mechanisms that might cause infection are: decreased immunoglobulin synthesis seems to be caused by proliferating b-cells which release an inhibitory factor which may block the proliferation of normal b-cells and another reason is that severe bone marrow infiltration and replacement by neoplastic cells results in granulocytopenia (macewen and hurvitz ) . although radio responsiveness of multiple myeloma has not been evaluated in the nine cats in this study, one cat had an exceptional response to a combination of surgery, radiation and alkylating therapy and survived nearly years (bienzle et al ) . therefore, radiotherapy may have been beneficial in the treatment of the nine cats in the study. radiotherapy can be used in the treatment of focal myeloma lesions (bienzle et al ) . genetic predisposition may have been a possible aetiological factor in cases and as they were siblings. genetic predisposition was an important factor in the development of plasmacytomas in mice as these neoplasms occur only in a few mice strains (dunn , potter and robertson ) . further studies are requested to support this hypothesis. relapse of the clinical signs and therefore the tumour in case , could be due to the presence of multiple cell types in the tumour and the response of one type but not the other or due to the development of resistance of the neoplasm to the chemotherapy drugs, or a combination of the two (weber and tebeau ) . finally, although multiple myelomas may progress to fatal termination it has been classified into aggressive and less aggressive to help decide the prognosis. characteristic clinical, radiological and laboratory findings were associated with the four cats in the aggressive group; they may be considered a poor prognostic indicator because they were associated by short survival and mean survival time. multiple myeloma should be suspected when the total protein and globulins are shown to be elevated, early diagnosis and treatment is paramount for a rapid early response, all coming together in a strategy of total therapy for the disease. what has become apparent is that patients can now be put into complete remission, a state where using ordinary laboratory methods and radiography, the disease can be detected and the patient treated early. it is in this state that the patients are able to come back to a normal quality of life. be vigilant for any additional conditions that may co-exist with multiple myeloma because this will have a direct effect on treatment and prognosis, and in multiple myelomas can be associated with polyclonal gammopathy. the treatment of multiple myeloma multiple myeloma in cats: variable presentation with different immunoglobulin isotypes in two cats multiple myeloma associated with paraproteinuria and hyperviscosity syndrome: a case report plasma cell neoplasms beginning in the ileocecal area in strain c mice plasma cell tumours in a cat cancer and the kidney: renal complications of neoplasms complications of multiple myeloma ophthalmic disease as the presenting complaint in five dogs with multiple myeloma bence-jones proteinemia and proteinuria in a dog multiple myeloma in a cat with paraparesis gammopathy with two m components in a dog with iga e type multiple myeloma veterinary laboratory medicine: clinical biochemistry and haematology canine and feline hypercalcemic nephropathy: causes and consequences. compendium of continuing education for the practicing veterinarian immunofluorescent studies of the myeloma kidney with special reference to light chain disease diagnosis and management of monoclonal gammopathies multiple myeloma of iga type in a dog plasmapheresis and chemotherapy of hyperviscosity syndrome associated with monoclonal gammopathy in the dog prognostic factors for multiple myloma in the dog a case of multiple myeloma in a cat multiple myeloma in the dog multiple myeloma and related plasma cell dyscrasias development of plasma cell neoplasms in balb/c mice after intraperitoneal injection of paraffin oil adjuvant, heat-killed staphylococcus mixtures biology of disease mechanisms of cancer-induced hypercalcaemia immunologic methods for the detection of humoral and cellular immunity hypercalcaemia in two cats with multiple myeloma structural identity of bence jones and amyloid fibril proteins in a patient with plasma cell dyscrasia and amyloidosis textbook of veterinary internal medicine an unusual presentation of multiple myeloma in two cats simplified method for estimation of serum and plasma viscosity in multiple myeloma and related disorders the author is grateful to mr hamish denny for reading the manuscript and to those veterinary surgeons who referred cases, which have been included in this study. key: cord- -hnn byf authors: dolgikh, s. title: identifying explosive cases with unsupervised machine learning date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: hnn byf an analysis of a combined dataset of wave and cases, aligned at approximately local time zero + months with unsupervised machine learning methods such as pca and deep autoencoder dimensionality reduction allows to clearly separate milder background cases from those with more rapid and aggressive onset of the epidemics. the analysis and findings of the study can be used in evaluation of possible epidemiological scenarios and as an effective modeling tool to design corrective and preventative measures to avoid developments with potentially heavy impact. a possible link between the effects of covid- pandemics and a number of epidemiological factors including universal immunization program against tuberculosis with bcg vaccine was proposed and investigated in [ ] [ ] [ ] . here we provide an analysis of the combined dataset of wave and wave cases adjusted and aligned at the time period of approximately months after the first local exposure. the intent of this work is to analyze the distribution of case data points in the most informative parameter spaces identified by unsupervised machine learning methods and to attempt identification of the cases with the heaviest impact. evaluating the combination of the parameters that can identify such cases would allow to evaluate and predict the potential risks of heavy impacts in the population proactively with the potential to make necessary corrections before the explosive onset that may result in a heavy cost to the society. the methodology is based on processing the input data expressed as a set of observable parameters that were identified and described in the study with unsupervised machine learning methods to identify and extract a smaller set of the most informative components. in many cases, evaluating distributions of data in the representations of informative components such as principal components in pca or dimensionality reduction with neural network autoencoder models allows to identify and separate classes in the data by essential characteristics that can be linked to the outcome. the zero time of the start of the global covid- pandemics was defined in [ ] as: clearly, the time of local exposure to the epidemics is one of the defining parameters of the impact, so the case data was adjusted and aligned at a similar phase in the development, chosen based on the availability of data at approximately ltz + months, i.e. months after the first local exposure to the infection. that translates to the beginning of april, for wave cases (ltz in january, ) and beginning of may for wave (ltz end of february to early march, ). a combined dataset of cases was thus constructed based on the conditions outlined in [ ] , essentially, certain level of reliability of the reported data and exposure to the epidemics. the dataset was constructed from the current data on the epidemics impact per case, i.e., reporting jurisdiction as described in [ ] . in addition to the current measure of impact, several initial or observable parameters were recorded as described further in this section with the hypothesis of a certain level of correlation between the parameter set and the severity of the outcome, measured by a combination of perceived severity and the actual reported impact in mortality per capita (m.p.c.), per million of population. on the relative scale of m.p.c. by jurisdiction, the "explosive" cases were normally identified as those with relative m.p.c. (relative to the maximum among all reporting jurisdictions worldwide, new york city in both groups of cases) of around and above . . this subgroup of cases included all commonly reported cases of high epidemics impact. in evaluation of distribution in the coordinates of principal components two higher impact clusters of cases were identified by relative impact: explosive cases with relative m.p.c. above . group included the widely commented first wave cases: italy; spain and new york with the highest impact worldwide observed to date. in the second group were six somewhat milder-impact cases, namely: united kingdom; france; belgium; netherlands; ireland and quebec (canada), with relative m.p.c. in the range from . to . . the examples of extra factors can include, among others: genetic differences; population density, social traditions and cultural practices, past widespread public policy such as immunization; smoking habits and of course the epidemiological policy of the jurisdiction aimed at controlling the spread of the disease. in addition to the factors of population density, smoking level and bcg immunization practice described in [ , ] a number of other factors with potential impact on the severity of the epidemics pattern were considered in this study as described in this section. a common comment for several of them is that due to limitation of time and resources, a rating scale approach was chosen for those factors that cannot or would be challenging to measure directly. granted, such an approach can be influenced by subjective perceptions; however, we believe that more robust and objective techniques can be developed over time improving the quality of the analysis and the resulting conclusions. connections hub: this band parameter defined in the range - . , was intended to measure the intensity of communications related to the case, on multiples levels for example, international, inter and intra-continental, regional and so on; clearly more intensive connection hubs could be expected to have higher exposure to the pandemics increasing the probability of a heavier impact. social proximity: a band parameter, range - . , intended to reflect the closeness of inter-personal connections in the case, again in multiple spheres and domains, for example: family connections; socializing practices and traditions; the intensity of business connections; lifestyle practices; social events and others. again, as was commented previously [ ] modeling such a complex factor as a single value parameter may open the analysis to the vulnerability of subjectiveness; yet we believed that it could be important for the analysis and improvements to make its evaluation, by case more objective and accurate are possible in the future studies. we also used three rating parameters intended to measure the policy of the jurisdiction as relates to the response to the pandemics. they are: ) epidemiological preparedness of the health case system to an intensive and rapid development of an epidemics; ) the effectiveness of the policy response; and ) the timeliness of the response. epidemiological preparedness: a band parameter, range - . , intended to measure the preparedness of the health care system to handle a rapid onset of a large-scale epidemics (specifically, not the general state of the health care system, its technological level, funding and so on). policy response: range - . , intended to indicate both the effectiveness of the policy in controlling the epidemics based on available scientific data at the time; as well as its clarity to the general population and its preparedness to participate. while some concerns can be expressed that this factor can be influenced by post-impact considerations with potential post-factum correlated with the outcome, we believe that with the accurate approach these risks can be minimized. for example, it is clear that an unclear or misleading policy message could be highly detrimental to the intended effect of the policy and one doesn't need the outcome to judge such policy parameters objectively at the time the decision is taken and before the outcome is recorded. policy timeliness: measures the relative timing of introduction of the control policy to the local exposure to the epidemics. range - . . the resulting dataset of identified cases with observable parameters and the "explosiveness" label, proportional to the relative impact of the epidemics is presented in table , appendix. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint to evaluate the hypothesis of the correlation between the identified parameters and the epidemiological outcome in the case, several well-known machine learning methods were used: . linear regression . principal component analysis and identification of principal informative factors . unsupervised deep neural network-based dimensionality reduction and selection of principal informative factors the first method produces a best fit linear approximation of the resulting effect series with a total deviation (error) from the trend [ ] . pca [ ] produces a linear transformation of the dataset to the coordinates with the highest variation and does not use the resulting effect labels. a deep neural network autoencoder (method ) produces a non-linear compression (i.e., dimensionality reduction) of the observable data to the lower-dimensional representation with the most informative features [ ] . the structure of the deep neural network model used in this work is described in detail in [ ] . the diagram of the model is given in fig. . in the unsupervised training phase, the model is trained to reproduce the input data with a good accuracy and thus does not require labels marked with the outcome, same as pca. achieving an improvement in the accuracy of reproduction, that can be measured by a number of training metrics indicates that the model has learned some essential characteristics of the initial distribution. once trained, the unsupervised model can perform two essential transformations: the encoding one, from the observable data creating a representation image; and the generative one, from the representation to the observable data space. the aim of unsupervised learning is thus to minimize the deviation of the original training sample from its regeneration created by the model. the models were implemented in python, keras, tensorflow with a number of common machine learning and data processing packages . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint results linear regression with identified input parameters produces a trend with a strong match score to the label of . of out . maximum. the most influential factors in the regression trend are shown in table . policy factors were expected to have a strong influence on the outcome of the case that is confirmed by the results of the linear regression analysis. as well, the importance of other factors such as connection intensity, social proximity culture, bcg immunization and smoking were also observed. pca identified three principal components with overall influence of % as described in table . the highest influence factors in the pca analysis are mostly aligned with the earlier results: policy-time, connection hub, social proximity, bcg and the smoking rate. pca transformation is inherently unsupervised method of learning, meaning that the prior known outcome labels are not required to learn the principal components as well as representation of the input data in the coordinates of identified principal component eigenvectors. by plotting thus transformed dataset in the coordinates of the principal component vectors, interesting result can be observed by identifying the highest impact cases . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . shown in fig. are the visualizations of the distribution of the dataset in the coordinates of principal components identified by pca analysis. the cases and the resulting region of the highest-impact cluster is shown in blue; whereas the milder cluster of cases, in magenta. in the visualizations of the case clusters in the principal component representation one can observe a clear separation of the higher-impact case clusters from the general background cases. such a clear separation allows to identify the region where the cases with potentially higher impact including the "explosive" pattern can be located, in the coordinates of principal component representation as well as in the initial, observable parameter space, with the possibility to identify the combinations of the observable parameters that can be linked to higher impact outcomes. a similar approach and results can be demonstrated with an unsupervised neural network autoencoder model that reduces the number of parameters by compressing the observable date into a lower dimensional representation while unsupervised training process is aimed at improving the accuracy of regeneration form the compressed representation to the observable space. the dimensionality of the unsupervised representation for the models in the study that is defined by the size of its central encoding layer was chosen as based on the results of the principal component analysis in the previous section, indicating three most informative dimensions. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . presented in fig. are direct visualizations of the distributions of data in the unsupervised representation created by a trained autoencoder model. the highest impact cluster ( cases) is shown in fig. in green whereas the milder one ( cases), in orange. again, a similar pattern of clear separation of higher-impact cases from general background can be observed with these models as well. it is worth noting that as with pca, though essentially non-linear, autoencoder models also allow to identify the higher-impact regions in the coordinates of the unsupervised representation as well as in the observable parameters, by forward-propagating through the model the identified set of points defining the region of interest in the representation coordinates to the observable space. the methods of unsupervised machine learning often allow to identify and separate the most informative components in complex general data. in this case, two different methods unsupervised learning methods applied independently demonstrated good separation of cases with higher impact from general background. further studies can lead to more precise and confident measurement of the observable parameters resulting in higher confidence in the results. the analysis and the findings of the study can be used in evaluation of possible epidemiological scenarios and as an effective modeling tool to identify the areas of potential risk and design corrective and / or preventative measures to avoid the developments with potentially heavy impact. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint p-tme: response timing, band conn: connection intensity, band bcg: bcg immunization record smo: smoking rate den: population density, band soc: social proximity, band label: relative mortality per million capita, band r.mpc: mortality per million capita, relative to world's highest . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint correlation between universal bcg vaccination policy and reduced morbidity and mortality for covid- : an epidemiological study further evidence of a possible correlation between the severity of covid- and bcg immunization possible covid- /bcg correlation: factor analysis statistical models: theory and practice principal component analysis learning deep architectures for ai, foundations and trends in machine learning categorized representations and general learning the bcg world atlas: a database of global bcg vaccination policies and practices plos medicine • key: cord- -vjyad p authors: hao, yan; xu, ting; hu, hongping; wang, peng; bai, yanping title: prediction and analysis of corona virus disease date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: vjyad p the outbreak of corona virus disease (covid- ) in wuhan has significantly impacted the economy and society globally. countries are in a strict state of prevention and control of this pandemic. in this study, the development trend analysis of the cumulative confirmed cases, cumulative deaths, and cumulative cured cases was conducted based on data from wuhan, hubei province, china from january , to april , using an elman neural network, long short-term memory (lstm), and support vector machine (svm). a svm with fuzzy granulation was used to predict the growth range of confirmed new cases, new deaths, and new cured cases. the experimental results showed that the elman neural network and svm used in this study can predict the development trend of cumulative confirmed cases, deaths, and cured cases, whereas lstm is more suitable for the prediction of the cumulative confirmed cases. the svm with fuzzy granulation can successfully predict the growth range of confirmed new cases and new cured cases, although the average predicted values are slightly large. currently, the united states is the epicenter of the covid- pandemic. we also used data modeling from the united states to further verify the validity of the proposed models. infectious diseases are caused by various pathogens that can be transmitted from person to person, animal to animal, or person to animal. they can be transmitted in various ways, and the speed of transmission is fast. early diagnosis of infectious diseases is crucial, and prevention and control are paramount. in people infected with the -ncov will experience varying symptoms, including fever, mild cough, or pneumonia, occasionally leading to death. the mortality rate of covid- is approximately % to %, although this is an extremely early percentage and may change as more information becomes available. meanwhile, this does not mean that the virus is not serious, it simply means that not everyone infected with it will face the worst outcome. we are currently in a tense state of prevention and control, and are concerned about a global pandemic. -ncov is an intractable and unexpected virus with the following characteristics. first, it has a strong ability to camouflage itself. the virus can be present asymptomatically, making an infected person appear healthy, or can manifest with various other symptoms in which an infected person seems to be suffering from a common respiratory disease. it also has a long latency period. according to a report from lancet, the median latency time of the new coronavirus is approximately days, reaching up to days for some patients. in addition, it is transmitted in various ways. the transmission method of the -ncov is similar to that of various other infectious diseases. in addition to a traditional droplet transmission, it also includes contact, air, fecal-oral, and blood transmissions. a high relapse rate has also been seen. since the initial outbreak of covid- , there have been many cases of recovered patients testing positive again after a reexamination, even leading to death after a relapse. the virus has also shown variability. as a foreboding aspect of the future development of novel coronaviruses, their rapid genetic recombination results in a mutation into new strains. each recombination can increase the toxicity and infectivity, invalidating original treatment methods and drugs. forty variants of novel coronaviruses have been discovered by scientists in iceland. finally, it is highly infectious. scientific data have shown that the affinity between the sprotein of -ncov and angiotensin converting enzyme (ace ) is to times that of sars, which means that the infectivity of covid- is significantly higher than that of sars. there are currently no specific treatments for covid- . however, many symptoms can be treated, and treatment must be given according to the clinical status of the patient. in addition, supplementary care for those infected may be effective. self-protection includes maintaining basic hand and respiratory hygiene, adhering to safe eating habits, and avoiding close contact with anyone who shows symptoms of a respiratory disease (such as coughing or sneezing). at present, owing to the widespread nature of covid- , factories are being shut down, schools are being suspended, and people are isolating in their own homes, significantly disrupting daily life. it is therefore extremely important to reasonably predict and analyze the development trend of this pandemic. in previous studies, the prediction methods for the occurrence, spread, and change in infectious diseases mainly included regression prediction models [ , ] , markov chain models [ ] , bayesian networks [ ] [ ] [ ] , and other machine learning methods [ ] [ ] [ ] . most of the previous studies have been based on research related to influenza, with a few studies conducted on human immunodeficiency virus (hiv) infection [ , ] and sars [ , ] . for example, ray [ ] used ensemble methods with three component models to predict the seasonal timing of influenza and severity in the united states. xue et al. [ ] established five models for predicting and assessing influenza outbreaks across regions of the united states. experiments on google flu trends (gft) and centers for disease control (cdc) data have shown that gft and historical influenza data are partially complementary and that gft +cdc regression is a preferable model. in addition, alkouz et al. [ ] proposed a system called tweetluenza, which can predict the spread of influenza in real time. many scholars have published reports on covid- . for example, in [ ] [ ] [ ] [ ] , its clinical features are described, and in [ ] and [ ] , the authors demonstrated that covid- has a high comorbidity with hypertension, diabetes, and cardiovascular diseases. anastassopoulou et al. [ ] estimated the case fatality and case recovery ratios based on a susceptible infectious- recovered-dead (sidr) model, along with their % confidence intervals as the outbreak evolves. in [ ] [ ] [ ] [ ] [ ] [ ] , the authors use machine learning methods to diagnose covid- based on x-ray and ct images. randhawa et al. [ ] also used machine learning-based methods to achieve ultra-fast, scalable, and highly accurate classification of whole covid- virus genomes based on the covid- intrinsic virus genomic signature. in [ ] [ ] [ ] , other characteristics related to covid- were studied. to date, few studies related to the use of quantitative prediction methods to predict the development trend and growth range of covid- have been conducted. in the present study, three methods, namely, an elman neural network, lstm, and svm are applied to predict and analyze covid- data from january , to april , in wuhan, hubei province, china, including cumulative confirmed cases, confirmed new cases, cumulative deaths, new deaths, and cumulative cured cases and new cured cases. first, the elman neural network, lstm, and svm were used to predict the development trend of cumulative confirmed cases, cumulative deaths, and cumulative cured cases. next, the svm with fuzzy granulation was used to predict the growth range of confirmed new cases, new deaths, and new cured cases. experimental results showed that the elman neural network and svm adopted in this study can accurately predict the development trend of covid- , whereas lstm is more suitable for the prediction of cumulative confirmed cases. the svm with fuzzy granulation is effective for the growth range prediction of confirmed new cases, new deaths, and new cured cases, despite the larger averages. the same models were also used on data in the united states to verify the robustness of the models. the rest of this paper is organized as follows. section introduces the methods applied. section describes the experiments and analysis results. finally, some concluding remarks and areas of future research are provided in section . there are two main research topics in this paper. the first is the development trend prediction and analysis of the cumulative confirmed cases, deaths, and cured cases. the second is the growth range prediction of the confirmed new cases, new deaths, and new cured cases. because the present state of cumulative confirmed cases, deaths, and cured cases is related to the state of the previous day, and shows a non-linear growth, recurrent neural networks (rnns) are applicable. in this study, we mainly apply the elman neural network and lstm. in addition, the svm has a better prediction effect on non-linear data, therefore, the svm model is also introduced for development trend prediction. because there are many factors affecting the growth of new cases, the growth trend fluctuates significantly. here, only the growth range of the new cases is predicted. to predict the change space of the three datasets more accurately, this paper introduces a svm model with fuzzy granulation. the elman neural network is generally divided into four layers: input, hidden, receiving, and output layers. the receiving layer is also called the context layer or state layer, and is used to memorize the output value of the hidden layer unit at the previous moment and return it to the network input. it can be considered a one-step delay operator. as the characteristic of the elman neural network, the output of the hidden layer is self-connected to the input of the hidden layer through the delay and storage of the receiving layer. this self-connected method makes it sensitive to historical data. the addition of an internal feedback network enhances the ability of the network to process dynamic information, thereby achieving the purpose of dynamic modeling. the network structure of the elman neural network is shown in fig . the connections of the input layer, hidden layer, and output layer are similar to those of a feedforward network. unlike a feedforward network, the elman neural network contains a receiving layer, which takes the hidden layer state of the previous moment together with the network input of the current moment as the input of the hidden layer. here, x c (k) = x(k − ) indicates that the feedback state vector is equal to the hidden layer state at the previous moment. the hidden layer state is expressed as follows: the output layer state is expressed as where u is the input vector, x c is the feedback state vector, w is the weight of the receiving layer to the hidden layer, w is the weight of the input layer to the hidden layer, w is the weight of the hidden layer to the output layer, f( � ) is the activation function of the hidden layer, and g( � ) is the activation function of the output layer. lstm networks are variants of rnns. general rnns only have short-term memory owing to a disappearance of the gradients. lstm networks combine short-term and long-term memory through a subtle gate control and solve the problem of disappearing gradients to a certain extent. lstm was proposed by hochreiter and schmidhuber [ ] in . it has three special structures: a forget gate, an input gate, and an output gate. lstm networks can delete or add information to a cell state through a structure called a gate. fig shows a diagram of the lstm network. the diagram shows the details of the forget gate, input gate, and output gate. the first step is to decide what information to discard from the cell state, which is done through a layer called the forget gate. the forget gate reads the hidden state of the previous moment h t− and the current input data x t , and then outputs a vector between zero and . the value between zero and in this vector indicates how much information is retained or discarded in the cell state c t . a value of zero means all information is discarded, and means all information is retained. the next step is to decide how much new information is added to the cell state. two steps are needed to achieve this. first, we use h t− and x t to decide which information to update through an input gate operation. we then use h t− and x t to obtain a new candidate cell state z through a tanh layer. next, the cell state is updated as follows: finally, we need to determine the output value. after updating the cell state, we need to determine which part of the cell state will be output according to the input h t− and x t . here, we need to pass the input through a sigmoid layer called the output gate to obtain the judgment conditions. we then need to pass the cell state through the tanh layer to obtain a vector between - and , which is multiplied by the judgment conditions obtained by the output gate to obtain the output. where z i , z f , and z o are the gate control state of the forget gate, input gate, and output gate, respectively. in addition, z is the input through a tanh layer, which is a so-called candidate cell state. finally, � represents a multiply operation of the corresponding elements of the matrix. svm is a classic model that can be used not only for classification but also for regression. we do not delve into its theoretical derivation here, however. unlike with a classification problem, the output of the regression problem is no longer a discrete value, but a continuous value. in reality, it is often impossible to accurately predict the value of the covid- , and to this end, it is particularly important to predict the development trend and change space for the important parameters of this disease. without considering other factors, time is clearly an important independent variable affecting covid- . to more accurately predict the change space of each group of data on this disease, in this paper, a fuzzy granulation model is introduced. first, we divide the original data into multiple granulation windows and then apply fuzziness to each window. the so-called fuzzy granulation means that the information granulation adopted is based on the model of fuzzy set theory. the key to fuzzy granulation is fuzzification, here, we use the pedrycz's granulation method [ ] . for a given time series, we consider the entire time series x as a window and then apply fuzziness to it. fuzzification is a task used to establish a fuzzy particle p on x, that is, a fuzzy concept g that can reasonably describe x. fuzzy particles can reasonably represent the original data and have certain specialties. a fuzzy particle p can be described simply as p = a(x), where a is a membership function of the fuzzy concept g. commonly used fuzzy particles include triangular, ladder, gaussian, and parabolic particles. in this study, we choose triangular fuzzy particles, the membership function of which is as follows: here, m is the kernel of triangular fuzzy particles, and a and b are the lower and upper bounds of the support, respectively. we studied covid- data from january , to april , , which were published by the wuhan municipal health commission (http://wjw.wh.gov.cn/) [ ] . we used the elman neural network, lstm, and svm to predict and analyze the development trend of cumulative confirmed cases, cumulative deaths, and cumulative cured cases. as an additional study, we also used the svm with fuzzy granulation to predict and analyze the growth range of confirmed new cases, new deaths, and new cured cases. to further demonstrate the robustness of the models, we used the same models on data from the united states from march , to june , . the data were obtained from the world health organization (who) [ ] . the data from the united states contains confirmed cases, deaths while without cured cases. all experiments were conducted in matlab (r a) . fig (a) shows a line chart of the confirmed new cases. from fig (a) , it can be seen that, from january , to february , , the number of confirmed new cases showed a fluctuating upward trend. confirmed new cases fluctuated sharply on february , showing a peak, the reason for which was the announcement of , clinically confirmed cases for the first time on that day, with a sharp increase in confirmed new cases. fig (b) shows a line chart of the new deaths and cured cases. the number of new cured cases showed an increasing trend before february , after which the growth trend of the cured cases slowed. moreover, the number of new deaths showed a significant downward trend after february , demonstrating a promising future recovery. in this section, the elman neural network, lstm, and svm were used to predict and analyze the development trends of the cumulative confirmed cases, deaths, and cured cases. in the elman neural network and lstm, the experimental datas are in the form of the first three days to the fourth (i.e., using data from the first three days to predict the data on day four). thus, the original groups of data are converted into groups, and the last group of data are used as the test sample. according to the data, both the elman neural network and the lstm in this paper contain only one hidden layer. because the initial weights of the elman neural network and lstm were randomly initialized, the average of experimental results is given here as the final outcome. in addition, the number of hidden layer neurons is an important factor. we chose , , , and hidden layer neurons according to experience. fig shows the error in the elman neural network based on these different numbers of hidden layer neurons. fig shows that the effect of the number of hidden neurons on the error is not too obvious. by comparison, with hidden neurons, the prediction result is slightly better. in addition, the prediction error of the cumulative confirmed cases is larger than that of the cumulative deaths and cumulative cured cases because the number of confirmed cases increased dramatically owing to the clinically confirmed cases announced on february , which has had a significant impact on the prediction results. fig shows the error rates of the elman neural network and lstm when the number of hidden layer neurons is . the prediction errors of the two methods are listed in table . as can be seen from fig and table , the prediction results of the lstm are worse than those of the elman neural network, particularly for cumulative cured cases. as is well-known, lstm is a powerful model for time-series prediction. however, the novel coronavirus pneumonia data have no obvious periodicity, and lstm has a relatively poor prediction effect on data with a weak periodicity. regarding the poor result of the cumulative cured cases, no effective treatment has been found, and fewer people were cured during the initial stage of the pandemic. in addition, it takes time between treatment and recovery. the treatment period varies from person to person. with continuous research, the number of cured cases continues to increase nonlinearly. for irregular growth, neural networks tend to fall into the local optimum, making it difficult to achieve an accurate prediction, which is also a major drawback of a neural network. in the svm experiment, we used a one-day-to-the-next approach, that is, we used the data from the previous day to predict data for the next day. in this study, data of days from january to march were used as training samples, and data from march to april were used as test samples. the radial basis function was used in the experiments. fig shows the prediction results of the cumulative confirmed cases, deaths, and cured cases. the prediction mean square error and square correlation coefficient of the cumulative confirmed cases, deaths, and cured cases are shown in table . it can be seen from the results that the svm can predict the three sets of data well, and the square correlation coefficients of the cumulative deaths and cumulative cured cases between the predicted output and the actual output are all above %. although the mean square error of the cumulative confirmed cases is relatively large and the square correlation coefficient is relatively small, it can be seen from fig (a) that the fluctuation range of the cumulative confirmed cases from march to april is extremely small, and only two of the -day prediction results are incorrect. similar to the aforedescribed experiments, herein we predict and analyze the development trend of cumulative confirmed cases and deaths from the data in the united states. here, hidden layer neurons of the elman neural network and lstm are applied. table shows the prediction error of the two methods on data from the united states. in the svm experiment, data of days from march to may were used as training samples, and data from may to june were used as test samples. the prediction results of the cumulative confirmed cases and deaths are shown in fig . the mean square error and square correlation coefficient of the cumulative confirmed cases and deaths are shown in table . comparing the experimental results of wuhan and the united states, the elman neural network and svm can well predict the development trend of wuhan and the united states, whereas the prediction result of lstm for the united states is clearly worse than that of wuhan. this occurs because the data from the united states used in this study are national data, not data from a certain city, and the data growth is more irregular and without any periodicity. in addition to predicting the development trend of covid- , we also used a svm with fuzzy granulation to predict the growth range of the confirmed new cases, new deaths, and new cured cases. taking days as a granulation window, the data from january , to april , were used as the training samples, and the growth range of the next days was predicted, that is, the growth range of the confirmed new cases, new deaths, and new cured cases from april to april . to reduce the impact of the peak value on the experimental results, we first smoothed the data of confirmed new cases and new cured cases. table shows the predicted growth range of confirmed new cases, new deaths, and new cured cases. table shows that the growth ranges predicted in this paper are basically reasonable, although the growth range of new deaths is slightly large. however, the average predicted values are larger than actual average values. this is because the algorithm depends on the data, regardless of the actual situation. owing to continuous medical research and strict control, there are increasingly fewer confirmed new cases and existing confirmed cases in wuhan, resulting in increasingly fewer new deaths and cured cases. in the middle of the epidemic, the numbers of confirmed new cases and new cured cases increased rapidly, leading to a higher predicted average value. in addition, the number of confirmed cases had steadily increased from january to february . however, on february , , clinically confirmed cases were announced for the first time and included in the confirmed new cases. the subsequent growth trends were completely inconsistent, which severely affected the prediction results. the data from march , to may , were used as the training samples, and the growth range of the confirmed new cases and new deaths from june to june were predicted. table shows the results. the predicted growth range of confirmed new cases and new deaths is smaller than the actual growth. the predicted average for confirmed new cases is larger than the actual average of , . , whereas the predicted average for new deaths is smaller than the actual average of . the negative value in the public data has a significant influence on the prediction results (the number of confirmed new cases on may is − , and the number of new deaths on may is − ). there is no obvious downward trend in confirmed new cases and new deaths, and strict control is still required. individuals should therefore strengthen their awareness of prevention and control and be responsible for themselves and others. the emergence of covid- has been a heavy burden. during the past months, however, significant progress has been made in the diagnosis and treatment of this disease. in this study, machine learning was used to predict and analyze the development trend and growth range of covid- . the results using data from wuhan showed that the elman neural network and svm can better predict the development trend of cumulative deaths and cumulative cured cases, whereas the prediction error of cumulative confirmed cases is relatively large. in comparison, the lstm model has a worse predictive effect on cumulative confirmed cases, deaths, and cured cases owing to the aperiodic data. moreover, the prediction results of the two recurrent neural network models used in this study are unstable because neural networks tend to fall into a local optimum for data with irregular growth. this is a major drawback of neural networks, and needs to be improved in the future. for the prediction of the growth range of confirmed new cases, new deaths, and new cured cases, the svm with fuzzy granulation introduced in this paper was shown to be effective. however, the predicted average values are larger than the actual average values, which indicates that the model is less robust to data with large fluctuations and still needs to be improved. the experimental results on data from the united states verified the robustness of the models, although the prediction result of lstm was worse than that of wuhan. in future research, we will improve the models based on the aforementioned problems and continue to improve the generalizability of the models. data curation: ting xu, hongping hu. prediction of infectious disease spread using twitter: a case of influenza. international symposium on parallel architectures the utility of lasso-based models for real time forecasts of endemic infectious diseases: a cross country comparison a novel approach to real-time risk prediction for emerging infectious diseases: a case study in avian influenza h n a personalized infectious disease risk prediction system personalization of infectious disease risk prediction: towards automatic generation of a bayesian network a bayesian monte carlo approach for predicting the spread of infectious diseases an unsupervised machine learning model for discovering latent infectious diseases using social media data prediction model of bp neural network based on improved genetic algorithm optimization for infectious diseases predicting local inversions using rectangle clustering and representative rectangle prediction a self-learning fuzzy discrete event system for hiv/aids treatment regimen selection fuzzy artmap prediction of biological activities for potential hiv- protease inhibitors using a small molecular data set a network integration approach to predict conserved regulators related to pathogenicity of influenza and sars-cov respiratory viruses prediction of sars epidemic by bp neural networks with online prediction strategy prediction of infectious disease epidemics via weighted density ensembles influenza activity surveillance based on multiple regression model and artificial neural network predicting flu trends from twitter data. big data mining and analytics clinical presentation and virological assessment of hospitalized cases of coronavirus disease in a travel-associated transmission cluster clinical features of patients infected with novel coronavirus in wuhan clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan clinical characteristics of novel coronavirus infection in china data-based analysis, modelling and forecasting of the covid- outbreak iteratively pruned deep learning ensembles for covid- detection in chest x-rays covid- : automatic detection from x-ray images utilizing transfer learning with convolutional neural networks deep learning system to screen coronavirus disease pneumonia a framework of deep learning classifiers to diagnose covid- in x-ray images covidiagnosis-net: deep bayes-squeezenet based diagnosis of the coronavirus disease (covid- ) from x-ray images covid- ) classification using ct images by machine learning using intrinsic genomic signatures for rapid classification of novel pathogens: covid- case study a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster the epidemic of -novel-coronavirus ( -ncov) pneumonia and insights for emerging infectious diseases in the future clinical and computed tomographic imaging features of novel coronavirus pneumonia caused by sars-cov- long short-term memory a granulation of linguistic information in ahp decision-making problems. information fusion coronavirus disease (covid- ) situation reports from the world health organization(who) key: cord- -ttjja r authors: kahambing, jan gresil s.; edilo, shienazile r. title: stigma, exclusion, and mental health during covid : cases from the philippines date: - - journal: asian j psychiatr doi: . /j.ajp. . sha: doc_id: cord_uid: ttjja r nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. amid the coronavirus disease pandemic, the world health organization (who) called for considerations that might include stigma and social exclusion as mental health and psychological concerns. the editor of the journal has thus justly linked the relevance of the crisis to psychiatry as it has effects on mental health (tandon, ) . psychiatry is vital in the crisis since it exposes psychosocial problems that, in the case of mental health, feed on the response of the people and society at large (tandon, ) . mackolil & mackolil ( ) then lists anxiety and stigma and their proliferation as contextual effects of misinformation, uncertainty, hesitation to 'disclose or seek help,' fear, and 'unawareness about [sic] health promoting strategies.' in the philippines, some provinces have a lesser number of covid cases due to quarantine measures and distance from the metropolises with a densely larger population. for the first five months (january to may), the province of southern leytepart of the eastern visayas region of central philippinesenjoyed zero positive cases. as of the th of june, however, there are already with total cases in the region (department of health, region viii, ). but the following cases were before the announcement of those who got positive results. one of the crucial aspects that may stem from this is the fact that stigmatization and exclusion may not necessarily be tied to empirical evidence but only in the criterion of whether or not the cases fit the contextual 'shared belief.' there is informed consent from the case persons for the publication of the study. this is a young priest of the iglesia filipina independiente (philippine independent church) in padre burgos, southern leyte. he was objectively well and healthy and actively serving his church. but he was allegedly discriminated by his parishioners due to misconceptions. exploration of the history revealed that while driving home, he mentioned that he passed by a man he recognized and let him in the car since they were heading to the same destination. the man was said to be in contact with a suspected covid case and was therefore thought to be exposed. the news spread around their church that immediately caused ruckus and fear to their community. the people in their church discriminated him including his altar boys to the point that harsh words were hurled at them. almost everyone deliberately avoided them. the priest was very upset and hurt after learning this. this resulted in anxiety around his parishioners. he felt specially excluded and shied away because these people were no strangers to him. the manner of exclusion derails some of his relationships, even to his close friends. he was very worried that his case was not an ordinary incident of prejudice leading to stigma because he represents the church as its pastor and he provides service to those who need spiritual support. "how can i work efficiently if the people are getting rid of me?" he said. a conference held with his fellow clergy and their bishop days after the incident showed the pandemic's effect on him and their churches. his instance of discrimination became a tool for social exclusion and this sadly includes his fellow churchmen. this is a -year-old institutional worker of a privately owned hospital in sogod, southern leyte. he was discriminated by his workmates after learning that he suffered from flu-like symptoms. he was advised by the attending physician to self-isolate for days at home as per the covid prevention protocol. luckily, it was just ordinary flu and he came back at work after the advised length of time. however, upon returning, his colleagues regarded him indifferently. some of his close friends at the hospital, for instance, advised him to just go home and leave. though in a form of jest, some said they would sign a petition to let him be suspended for several days. these kinds of remarks created psychological inputs for him since the jokes resemble a certain degree of seriousness and truth in them. additionally, the bantering that borders on bullying becomes physical when he was intentionally avoided by some. openness seemed to be blocked especially when he tries to start a conversation with them. due to the degrees of 'hostility' that he claims to have experienced when he got back to work, he developed resentment against his colleagues due to the incident. he was unable to work properly and was therefore unable to finish his job efficiently. this has caused many absences. with the drive to work and social interaction impeded, self-doubt, lowered self-esteem, and feelings of vulnerability from being excluded prevailed in his disposition. the impact of this situation has a certain traumatic element as this was for him the first time that he experienced such treatment. health care workers in the philippines often suffer from the abuse that comes from stigma (reuters, ) and this was shown even among themselves in the second case. in the first case, there is the denial of access to the benefits of the group, as the priest can no longer enjoy the j o u r n a l p r e -p r o o f company of his parishioners. this denial forms part of the negative effect on the health of those socially excluded (samers, ) . without comfort from contemporaries, the situation may not be effectively handled. having a good and empathetic support group and confidence in one's belief are potential factors for recovery. on the other hand, what the second case shows is a kind of disempowerment that is a negative result of stigma and exclusion (kai & crosland, ) . the disempowered perform less in their functions and lose motivation in the workplace, which can jeopardize the outcome of the workforce. emphatic interventions at home or providing safe places for openness with friends can help ease the effects of exclusion. good management support from hospitals must also assure employees that evidence-based results must prevail over false beliefs. moreover, both case persons were young. this has to be taken seriously since "mental health problems early in life can be associated with a trajectory of exclusion and disadvantage" for example through "reduced participation" or "exclusion from civil society" (evans-lacko et.al, ) . one critical problem in the philippines is not xenophobic as in multiracial societies but the misinformation or the hesitance to confer with verified information that provokes discrimination. the authors certify that they have each made a substantial contribution so as to qualify for authorship. none. j o u r n a l p r e -p r o o f the state of the art in european research on reducing social exclusion and stigma related to mental health: a systematic mapping of the literature lockdowns case of mass hysteria perspectives of people with enduring mental ill health from a community-based qualitative study addressing psychosocial problems associated with the covid- lockdown covid- : philippines health care workers suffer abuse, stigma imigration, 'ethnic minorities', and 'social exclusion' in the european union: a critical perspective the covid- pandemic, personal reflections on editorial responsibility world health organization, . world health organisation. mental health and psychosocial considerations during the covid- outbreak the authors would like to thank the case persons for their openness. jan kahambing would like to thank april cabezada and leo omamalin for their constant updates on the cases.j o u r n a l p r e -p r o o f none.. key: cord- - eko htz authors: li, yang; cao, jianghui; zhang, xiaolong; liu, guangzhi; wu, xiaxia; wu, baolin title: chest ct imaging characteristics of covid- pneumonia in preschool children: a retrospective study date: - - journal: bmc pediatr doi: . /s - - - sha: doc_id: cord_uid: eko htz background: recently, the world health organization has declared the coronavirus disease (covid- ) outbreak a public health emergency of international concern. so far, however, limited data are available for children. therefore, we aimed to investigate the clinical and chest ct imaging characteristics of covid- in preschool children. methods: from january , to february , , the clinical and initial chest ct imaging data of eight preschool children with laboratory-confirmed covid- from two hospitals were retrospectively collected. the chest ct imaging characteristics, including the distribution, shape, and density of lesions, and the pleural effusion, pleural changes, and enlarged lymph nodes were evaluated. results: two cases ( %) were classified as mild type, and they showed no obvious abnormal ct findings or minimal pleural thickening on the right side. five cases ( . %) were classified as moderate type. among these patients, one case showed consolidation located in the subpleural region of the right upper lobe, with thickening in the adjacent pleura; one case showed multiple consolidation and ground-glass opacities with blurry margins; one case displayed bronchial pneumonia-like changes in the left upper lobe; and two cases displayed asthmatic bronchitis-like changes. one case ( . %) was classified as critical type and showed bronchial pneumonia-like changes in the bilateral lungs, presenting blurred and messy bilateral lung markings and multiple patchy shadows scattered along the lung markings with blurry margins. conclusions: the chest ct findings of covid- in preschool children are atypical and various. accurate diagnosis requires a comprehensive evaluation of epidemiological, clinical, laboratory and ct imaging data. as a novel coronavirus disease, the coronavirus disease (covid- ) emerged in wuhan, hubei, china in late december . it is a highly infective disease caused by the severe acute respiratory syndrome coronavirus virus (sars-cov- ; previously provisionally named novel coronavirus or -ncov). then, the disease spread rapidly in the other regions of china and even abroad, and has become global health emergency as declared by the world health organization [ ] . as of march , , the total number of covid- confirmed cases in the world is close to , . the outbreak of covid- has seriously affected people's daily life, physical and mental health, and economic activities. at present, researches on covid- suggest that patients of all ages are susceptible to the disease, and individuals with comorbid conditions are more susceptible and tend to have poor outcomes [ ] . previous studies on clinical and chest ct imaging characteristics of covid- are mainly focused on adults [ ] [ ] [ ] [ ] [ ] . a recent report based on patients with laboratory-confirmed covid- indicates that the most common symptom in adult patients is fever ( . %) on admission, the percentage of which is more higher during hospitalization ( . %) [ ] . the typical ct imaging manifestation of covid- pneumonia is multifocal bilateral ground-glass opacities (ggo) with patchy consolidation that tends to develop in the outer zones of the lung and particularly in the subpleural regions [ , [ ] [ ] [ ] . due to the immaturity of immune systems in children, more attention should be paid to those subjects in the prevention and control of covid- . however, limited data are available for children with covid- pneumonia. as a simple and quick imaging tool, ct can accurately detect and assess the lung lesions pediatric patients with covid- pneumonia. to date, ct findings have been recommended as major evidence for clinical diagnosis of covid- in hubei, china. in the present study, we aimed to conduct a retrospective study to investigate the clinical and chest ct imaging characteristics of covid- in preschool children. the institutional ethics committees of the xiangyang no. people's hospital and taihe hospital approved this retrospective study and waived the requirement for patient informed consent. from january , to february , , eight preschool children with laboratory-confirmed covid- from the xiangyang no. people's hospital, hubei university of medicine, xiangyang, hubei, china and taihe hospital, hubei university of medicine, shiyan, hubei, china were enrolled in the present study. these patients have not been included in any other reports, and the datasets used in the current study are available from the corresponding author on reasonable request. the inclusion criteria were ) patients aged less than years; ) patients with complete clinical history information and ct image data; and ) patients with good chest ct image quality. the diagnosis of covid- was based on the guidelines for the diagnosis and treatment of novel coronavirus pneumonia ( th trial edition) proposed by the national health commission of the people's republic of china [ ] . all patients were positive for covid- after detection of sars-cov- from nasal swabs or aspirates via laboratory testing with real-time reverse transcriptase polymerase chain reaction (rt-pcr). the ct images and clinical data of all patients were collected. all patients were administered with anti-viral and supportive treatment, and prevention of complications based on their clinical condition. plain ct scans were performed for all patients using multi-detector ct scanner (toshiba, tokyo, japan; emotion , siemens, erlangen, germany) at the time of admission. patients were placed in a supine position with their breath held at the end of inspiration, and the scanning range was from the chest entrance to the bottom of the lungs. the parameters used were as follows: thickness of the slices mm, interslice gap mm, matrix mm × mm; and tube voltage kv, current ma, pitch . /hp . , and dose-length product - mgy•cm. the ct scan was performed by technicians with over years of experience. comprehensive protective measures for technicians included wearing isolation gowns, caps, masks, protective goggles, gloves, and shoe covers. scanning rooms were regularly disinfected. children under the age of years were examined after sedation to reduce artifacts. all patients wore masks for protection. initial ct images of the eight patients were viewed at the picture archiving and communication systems (pacs) workstation, with window settings optimized for the assessment of the lung parenchyma (width hu; level − hu) and of the mediastinum and pleura (width hu; level hu). two senior radiologists independently carefully observed and recorded the lung markings, the distribution, shape, density and number of the lung lesions, and other features that included the presence of hilar or mediastinal lymphadenopathy, and presence of pleural thickening or pleural effusion, based on the transverse view, combined with multi-planar reformation and other methods. a final determination was reached through consultation between the two radiologists. when the opinions were inconsistent, a third chest ct specialist with over years of experience was brought in for discussion to make an agreement. clinical typing of patients with covid- was evaluated according to the guidelines for the diagnosis and treatment of novel coronavirus pneumonia ( th trial edition) [ ] . the severity of covid- was classified into categories: ① mild type: patients with mild clinical symptoms and no pulmonary changes on ct imaging; ② moderate type: patients with symptoms of fever and signs of respiratory infection, and having pneumonia changes on ct imaging; ③ severe type: patients presenting with any one item of the following: a. respiratory distress, respiratory rate ≥ /min; b. oxygen saturation of finger ≤ % in resting condition; c. arterial partial pressure of oxygen (pao )/oxygen concentration (fio ) ≤ mmhg ( mmhg = . kpa); ④ critical type: patients meeting any one of the following criteria: a. respiratory failure requiring mechanical ventilation; b. shock; c. requiring icu admission requirement due to multiple organ failure [ ] . statistical analysis was performed using software spss version . . continuous variables were expressed as medians and interquartile ranges, or simple ranges, as appropriate. categorical variables were summarized as counts and percentages. showed runny nose. regarding the severity classification of covid- , two cases ( %) were classified as mild type, five cases ( . %) were classified as moderate type, and one case ( . %) was classified as critical type and had a coinfection of sars-cov- and mycoplasma. in addition, one case had a past medical history of surgery for nephroblastoma, and one case had a previous history of surgery for congenital heart disease. routine peripheral blood testing was performed for all cases. one case ( . %) had increased white blood cell counts, with normal counts in the remaining cases. four cases ( %) exhibited decreased neutrophil percentages and increased lymphocyte counts and/or percentages. in one case ( . %), the neutrophil percentage was increased and lymphocyte percentage was decreased. one case ( . %) exhibited normal neutrophil and increased lymphocyte percentage. one case ( . %) showed increased c-reactive protein level (table ) . of the two mild cases, one case did not show positive lung ct findings, and one case only showed minimal pleural thickening on the right side. among the five moderate cases, one case displayed consolidation located in the subpleural region of the right upper lobe, with thickening in the adjacent pleura (fig. ) . one case presented multiple consolidation and ggo, with blurry margins; the patchy/nodular consolidation was mostly located in the mid and inner zones of the both lower lung lobe, with high density inside the lesions and relatively low density in the periphery, presenting a "halo sign" appearance; the ggo was located in the outer zone of the left upper lobe (fig. ) . one case displayed bronchial pneumonia-like changes in the left upper lobe, with multiple high-density nodular shadows and ggo along the bronchovascular bundles (fig. ) . two cases displayed asthmatic bronchitis-like changes. one of the two cases showed increased lucency shadows in the right upper lobe, and another case exhibited multiple saccular lucency shadows in the bilateral lower lobes with unclear margins (fig. ). in addition, the chest ct examination of the one case who was classified as critical type revealed bronchial pneumonia-like changes in the bilateral lungs, presenting blurred and messy bilateral lung markings and multiple patchy shadows scattered along the lung markings with blurry margins (fig. ). there were no pleural effusions, hilar lymphadenopathy, or other signs in this group of patients. except for the one severe case, the remaining seven mild and moderate cases were routinely administered symptomatic medications. lian hua qing wen capsules, oseltamivir, and other medications were commonly used. the patient with the shortest disease course had a negative nucleic acid test after days. all patients were followed up for month. after - days, most of the nucleic acid tests were negative. most of the patients displayed mild symptoms and favorable outcomes. one case was discharged after treatment according to the discharge criteria outlined in the guidelines for the diagnosis and treatment of novel coronavirus pneumonia [ ] . by the end of follow-up, six patients had entered the clinical isolation stage, while the severe case was still being treated with ventilator. different age group are generally susceptible to sars-cov- . du et al. estimated that the basic reproduction [ ] , suggesting that the sars-cov- has a strong transmission capacity in the special population (i.e., neonate and children). the present study indicates that infected preschool children have different clinical symptoms and ct imaging findings from those of adults. symptoms may not be apparent in young children. under the current epidemic conditions, cluster outbreaks in families have occurred. if children, especially preschool children, are not paid attention to, they may contribute to the spread of infection and may not be treated in a timely manner. the incubation period of the novel coronavirus infection in children can be as short as day or as long as days, with an estimated mean of . day s [ ] . of the eight cases in this study, two subjects had a travel history to wuhan for surgery; however, these two cases were in wuhan prior to the outbreak of the covid- . based on the history of exposure, their incubation periods were greater than days. thus, it is reasonable to think that the covid- already existed in wuhan before january , or that the two cases were all postoperative cases with low immunity who were infected with the sars-cov- after they returned home. findings from a recent study also indicate that sars-cov- infections in children were occurring early in the epidemic [ ] . of the six remaining cases, two mild cases had a history of family members (mothers) infected, and thus were familial outbreaks. in four cases, the parents denied or were uncertain concerning the history of contact with the epidemic area. epidemiologically, viral pneumonia is an inhalation infection that is directly transmitted from human-tohuman through sputum and droplets. the infection is mainly caused by pulmonary lesions due to the downward spread of upper respiratory virus. since preschool children tend not to actively enter high-traffic places, the possibility of transmission through droplets is markedly lower than that in adults. the infection may be "second-generation" or "third-generation". therefore, epidemiology is important in the diagnosis of covid- in preschool children, although the final diagnosis remains dependent on the nucleic acid test. our study revealed that the clinical manifestations of covid- in preschool children are different from those in adults. the main clinical manifestations of covid- in adults are fever and cough [ ] . of the eight cases in our study, only one exhibited high fever. clinical symptoms of covid- in preschool children are relatively mild, and most are diagnosed as mild or moderate. this may be related to the non-susceptible physiological basis of children. the prevalence of severe acute respiratory syndrome in children is also lower than that in adults. considering the common characteristics of coronaviruses, children may be relatively less susceptible based on their cellular structure or immunity. the present findings indicate that the chest ct features of covid- pneumonia in preschool children differ from those in adults. the early-stage imaging features of preschool children are not typical, mainly presenting consolidations, while the most common early-stage ct feature in adult patients with covid- pneumonia is the ggo distributed along the bronchovascular bundle or the dorsolateral and subpleural part of the lungs [ ] . pulmonary consolidations were smaller in the present cases and showed changes that included small patches or nodules with unclear margins. there were no pure ggo, or "crazy paving sign", or other imaging features that are typical findings in adult patients at the early stage [ ] [ ] [ ] . the chest ct manifestations of the eight cases were mostly mild or moderate, with better outcomes after treatment. the lesions were significantly absorbed in - days. this is different from changes in adult that pulmonary interstitial fibrosis is common after treatment. in our study, there was one critical case who was only months old and had a previous history of surgery and combined with mycoplasma infection, suggesting that infants can also be infected with the sars-cov- , and that a previous surgical history and comorbidity may aggravate the progression of covid- . asthmatic bronchitis-and bronchial pneumonia-like changes are also characteristics of covid- pneumonia in preschool children, which were found in four cases in our study. in addition, the covid- pneumonia in preschool children can manifest as small airway lesions, with uneven lucency of the regional lung lobe or multiple small cystic lucency shadows in the bilateral lower lungs. the epidemic of covid- began during the winter season in china. common diseases seen in young children in winter are mycoplasma pneumonia, influenza a (h n ) with pneumonia, and adenovirus pneumonia. therefore, the ct features of covid- pneumonia need to be differentiated from those infectious diseases. the most common ct manifestations of mycoplasma pneumonia are bilateral peribronchial perivascular interstitial infiltrations in central and middle lung zones [ ] . one case in our study was confirmed to have mycoplasma and sars-cov- infection at the same time. adenoviral pneumonia mostly occurs in children, mainly involving the middle and inner zones of bilateral lungs and presenting hilar enlargement, pleural effusion, pneumothorax, mediastinal emphysema, subcutaneous emphysema, while involvement of subpleural areas is rare [ ] . the most common imaging features of h n pneumonia are unilateral or bilateral ggo with or without associated focal or multifocal areas of consolidation, and the ggo and areas of consolidation had a predominant peribronchovascular and subpleural distribution [ , ] , which is difficult to distinguish from ct findings of covid- pneumonia. we acknowledge several limitations in this study. first, it was a retrospective study with a small sample size. second, a co-infectious case (sars-cov- and mycoplasma pneumoniae) was included in this study, which might give confusion for the ct findings of covid- pneumonia. in summary, the chest ct imaging features and clinical manifestations of covid- in preschool children are atypical and various, and are relatively mild or moderate compared with adult patients. familial aggregation infection may be the main cause of covid- in preschool children. it is difficult to distinguish the ct manifestations of covid- pneumonia from those of other common pneumonia occurring in winter. finding of the present study may help accelerate our understanding of the ct manifestations of covid- pneumonia, thus can make up for the false negative results of rt-pcr testing and be helpful for early isolation and intervention of sars-cov- infected children. accurate diagnosis of covid- still needs a comprehensive evaluation of epidemiological, clinical, laboratory and ct imaging data for the special population. coronavirus disease clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan ct imaging features of novel coronavirus ( -ncov) ct imaging of the novel coronavirus ( -ncov) pneumonia. radiology. covid- ): role of chest ct in diagnosis and management ct features of coronavirus disease (covid- ) pneumonia in patients in wuhan, china clinical characteristics of coronavirus disease in china chest ct findings in novel coronavirus ( -ncov) infections from wuhan, china: key points for the radiologist outbreak of novel coronavirus (covid- ): what is the role of radiologists? eur radiol pneumonia associated with novel coronavirus: can computed tomographic findings help predict the prognosis of the disease? national health commission of the people's republic of china: diagnosis and treatment protocols of coronavirus disease ct manifestations of coronavirus disease- : a retrospective analysis of cases by disease severity risk of novel coronavirus importations throughout china prior to the wuhan quarantine coronavirus disease (covid- ) and neonate: what neonatologist need to know the incubation period of -ncov from publicly reported confirmed cases: estimation and application detection of covid- in children in early chest ct findings in coronavirus disease- (covid- ): relationship to duration of infection ct imaging and differential diagnosis of covid- coronavirus disease (covid- ): a perspective from china mycoplasma pneumonia: clinical and radiographic features in children severe communityacquired pneumonia caused by human adenovirus in immunocompetent adults: a multicenter case series swine-origin influenza a (h n ) viral infection: radiographic and ct findings high-resolution ct findings in a patient with influenza a (h n ) virus-associated pneumonia publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. huaxi mr research center (hmrrc), functional and molecular imaging key laboratory of sichuan province, department of radiology, west china hospital of sichuan university, no. guo xue xiang, chengdu , sichuan, pr china. abbreviations ggo: ground-glass opacity; ct: computed tomography; covid- : coronavirus disease ; sars-cov- : severe acute respiratory syndrome coronavirus ; rt-pcr: reverse transcription polymerase chain reaction; who: world health organization authors' contributions bw, yl and jc conceived and designed the study. bw supervised the conduct of the study. yl and jc were responsible for data acquisition. bw, yl and jc analyzed the data. xz, gl and xw assisted with literature review. bw and yl drafted the initial manuscript, and bw reviewed and revised the manuscript. bw takes responsibility for the paper. all authors read and approved the final manuscript. not applicable. the datasets used and analyzed during the current study are available from the corresponding author on reasonable request. the institutional ethics committees of the xiangyang no. people's hospital and taihe hospital approved this retrospective study and waived the requirement for patient informed consent. not applicable. the authors declare that they have no competing interests. key: cord- -nukv fh authors: bartoszek, krzysztof; guidotti, emanuele; iacus, stefano maria; okrój, marcin title: are official confirmed cases and fatalities counts good enough to study the covid- pandemic dynamics? a critical assessment through the case of italy date: - - journal: nonlinear dyn doi: . /s - - -w sha: doc_id: cord_uid: nukv fh as the covid- outbreak is developing the two most frequently reported statistics seem to be the raw confirmed case and case fatalities counts. focusing on italy, one of the hardest hit countries, we look at how these two values could be put in perspective to reflect the dynamics of the virus spread. in particular, we find that merely considering the confirmed case counts would be very misleading. the number of daily tests grows, while the daily fraction of confirmed cases to total tests has a change point. it (depending on region) generally increases with strong fluctuations till (around, depending on region) – march and then decreases linearly after. combined with the increasing trend of daily performed tests, the raw confirmed case counts are not representative of the situation and are confounded with the sampling effort. this we observe when regressing on time the logged fraction of positive tests and for comparison the logged raw confirmed count. hence, calibrating model parameters for this virus’s dynamics should not be done based only on confirmed case counts (without rescaling by the number of tests), but take also fatalities and hospitalization count under consideration as variables not prone to be distorted by testing efforts. furthermore, reporting statistics on the national level does not say much about the dynamics of the disease, which are taking place at the regional level. these findings are based on the official data of total death counts up to april released by istat and up to may for the number of cases. in this work, we do not fit models but we rather investigate whether this task is possible at all. this work also informs about a new tool to collect and harmonize official statistics coming from different sources in the form of a package for the r statistical environment and presents the “covid- data hub.” abstract as the covid- outbreak is developing the two most frequently reported statistics seem to be the raw confirmed case and case fatalities counts. focusing on italy, one of the hardest hit countries, we look at how these two values could be put in perspective to reflect the dynamics of the virus spread. in particular, we find that merely considering the confirmed case counts would be very misleading. the number of daily tests grows, while the daily fraction of confirmed cases to total tests has a change point. it (depending on region) generally increases with strong fluctuations till (around, depending on region) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] march and then decreases linearly after. combined with the increasing trend of daily performed tests, the raw confirmed case counts are not representative of the situation and are confounded with the sampling effort. this we observe when regressing on time the logged fraction of positive tests and for comparison the logged raw confirmed count. hence, calibrating model parameters for this virus's dynamics should not be done based only on confirmed case counts (without rescaling by the number of tests), but take also fatalities and hospitalization count under consideration as variables not prone to be distorted by testing efforts. furthermore, reporting statistics on the national level does not say much about the dynamics of the disease, which are taking place at the regional level. these findings are based on the official data of total death counts up to april released by istat and up to may for the number of cases. in this work, we do not fit models but we rather investigate whether this task is possible at all. this work also informs about a new tool to collect and harmonize official statistics coming from different sources in the form of a package for the r statistical environment and presents the ''covid- data hub.'' keywords covid- Á coronavirus Á r language Á data mathematics subject classification - Á n in december , the first cases of pneumonia of unknown etiology were reported in wuhan city, people's republic of china. analyses of patients' samples collected from their respiratory tract revealed that a novel coronavirus, later named as ''severe acute respiratory syndrome coronavirus '' (sars-cov- ) is the pathogen responsible for infection [ ] . the disease, officially called covid- by world health organization (who), is characterized by higher transmissibility and infectivity but lower mortality than middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars) caused by other coronaviruses [ ] . apart from the source of infection, the spread of the virus depends on the transmission route and general susceptibility of the population. sars-cov- is believed to be transmitted mostly by close contact (and further carry-over to the mucous surfaces of the body) and inhalation of aerosol produced by an infected person. the presence of the virus was also reported in samples from the gastrointestinal tract [ ] , but the potential role of the oral-fecal route of infection is unknown. the evidence of asymptomatic carriers who may unintentionally transmit the virus together with relatively long incubation period up to days [ ] increase the risk of viral spread worldwide and make prevention measures difficult. on the other hand, separation of identified cases, prior immunity to sars-cov- or cross-reactivity of human antibodies naturally risen against other viruses would act as a barrier for virus transmission. the latter is probable as rna sequences of sars-cov- are in % identical to the sequences of sars-cov responsible for the previous pandemic in far east countries in and % identical to mers-cov [ ] . all above- fig. cumulative confirmed cases and case fatalities for all the regions of italy. right: cumulative case fatalities divided by confirmed cases, left: cumulative confirmed cases divided by the cumulative number of tests mentioned issues would act as confounding factors for any modeling of pandemic progression. except of the city of wuhan where the first reports of covid- were announced in december , there was another outbreak of disease, which took place in january-february on the diamond princess cruise ship with more than people onboard. as such a great number of people were locked in a confined space using common facilities, air-condition systems, restaurants, etc., and once the chronology of infections, symptoms and undertaken health measures are known [ , , ] , one can consider this as a unique, naturally occurring epidemiological study useful for prediction of mortality, disease spread and other parameters of the covid- pandemic. since the virus has spread across the world appeared, especially on the arxiv preprint server. they are usually concerned with connecting the pandemic with various epidemiological models (e.g., [ , , , ] following a brief survey of arxiv at the start of april ). however, such models of course require data concerning the infected individuals. furthermore, the media are bombarding today with two basic numbers (for each country)-the number of confirmed cases and the number of case fatalities. given that supposedly the vast majority of people are asymptomatic and testing is not done as random sampling of the population but due to particular protocols these values by themselves might be misleading. we can only second [ ] in despite millions of tests having been performed, there are still no results from statistically well founded samplingbased testing programmes to establish basic epidemic quantities such as infection fatality rate and infection rates. in the absence of such direct data, epidemic management has to proceed on the basis of data produced largely as a side effect of the clinical response to the disease. as a motivating example, we present fig. from which we can see that in italy the case fatality to confirmed ratio is constant, while the confirmed cases to number of tests has been decreasing since around march . indeed, the time period since march is longer than the median time of . days of infection till death [ ] , so one should already start observing some drop in the case fatality to confirmed ratio. through the case of italy, this paper tries to investigate the following issues: -with each country having their own reporting standard and testing strategy are these raw numbers comparable across countries? -do these data actually mean what they are being said to be and are they appropriate for model fitting at all? clearly, the curves presented in fig. suggest that a more in-depth look at the raw numbers is required and that there is a need to put the data in a correct perspective before trying to fit any epidemiological model to them, especially because the viral dynamics are starting to be inferred from reported case fatalities [ , , ] . in this work, we approach these issues by looking in detail at the available infection data for individual italian regions (sect. ) and present the r [ ] acquisition process and the subsequent analysis. section contains a discussion on what other data would be useful (if of course possible to collect for the already overworked public services), in understanding the dynamics of the pandemic. most regional analyses are contained in the appendices. italy is a country which is being very extremely hardhit with the covid- pandemic. it is currently (as of may ) as a whole in lockdown and the medical services are extremely strained. however, due to this situation it has also very detailed epidemiological data that has been made publicly available. its constantly increasing infected and case fatality count has lead us looking in greater detail into this data, especially as it is used for curve-fitting of epidemiological models (e.g., [ , , , ] following brief survey of arxiv) and presented in public media. the first hurdle that one comes across is what do the presented counts actually represent. this seems to be region dependent. furthermore, any deceased whose test result is found positive is classified as a covid- case fatality, regardless of any past or underlying diseases, and this methodology has been consistently applied in italy since the beginning [ ] . it is important to point out that different countries seem to have different testing strategies and classification systems of deaths-hence, raw counts between countries might not be comparable. given the huge amount of tests performed in italy , , (as of th may , [ ] ) an important question is: ''what fraction of them were serological tests?'' as there is no official data on this. a serological test may not distinguish between a person actively infected with the virus and a person that was exposed to the virus in the past. alternatively, serological test may not detect person actively infected with still low viral titer of anti-virus antibodies. on the other hand, if the protocol is to test only people exhibiting symptoms and medical personnel, then given that it is hypothesized that the vast majority of cases are asymptomatic, such a raw count might not be representative of the scale of the epidemic. given the above uncertainties, we set out to see how the italian regional data could be presented in a standardized manner. furthermore, we see how the data of each region compares to the diamond princess' data. we focus on the two values that are being presented everywhere-the confirmed case count and the case fatalities count. however, these should be scaled. we scale the confirmed case count by the total number of tests performed. scaling the case fatalities is more problematic. a common way is to present them as the case fatality ratio, but these may be misleading when estimated during an epidemic [ ] . furthermore, assuming that the vast majority of cases are asymptomatic-hence, not tested and not inside given the lack of hard data, another objective approach would be to compare the daily count of case fatalities to the total deceased count for the day. to the best of our knowledge, such statistics are not centrally reported in italy in real time. daily deceased counts (from nearly all of the italian municipalities-see discussion) are available though for the period january- april . hence, for this time period we are able to plot the weakly ''nearly''-desired ratios (see sect. ). we aggregate per week to remove daily fluctuations, which obscure the picture. furthermore, the same data source provides deceased counts for the years - (for the same time period). this allows us to also visualize the excess mortality (with respect to the per week average from the past five years). beyond this time interval, it is impossible to provide such curves. however, having daily case fatalities counts and past mortality (this is taken as a constant value equaling the average number of deceased for th april) we are able to plot the (per week) ratio of case fatalities to previous average mortality. this provides some indication of the magnitude of excess mortality. however, it is worth noticing that when looking at the current excess mortality it could be appropriate to compare with past mortality peak (e.g., for uk death toll, the / and / peaks, , , , , in appendix b'' we compare the current deceased peak with the seasonal start of the january one. we should remark that perhaps more focus should be on the cumulative positive test fraction instead of the daily positive test fraction. this is because the daily fraction is extremely noisy and furthermore, it sometimes happens that this fraction, in the official data source for italy, exceeds . for similar reasons, we plot the weekly scaled deaths and cumulative scaled deaths. the daily counts are extremely noisy as well. we plot the scaled daily and cumulative positive test count and scaled case fatalities next to the cumulative positive tested fraction of passengers on the diamond princess. here, we present the graphs from two special regions in italy: lombardy and veneto. the remaining regions are presented in ''appendix a.'' lombardia is the center of the epidemic, where the cases and deaths counts are the highest. veneto seems to be a region where the pandemic's dynamics are special. it was a region that very early on undertook population-wide testing and drastic lockdown measures. on all of the graphs, the curve labels have the following meaning. veneto) on the log-scale graphs, the cumulative case to tests ratio curve seems the peak around or below the diamond princess' cumulative case curve and then start dropping. the scaled death curves exceed this curve. when looking at the graphs of the number of tests per day, two things can be seen. firstly, the number of positive cases closely follows the number of tests (this is clearly visible on the log-scale graphs and supported by the regression study). we look at this issue in detail and present for each region and italy the confirmed cases with respect to the total tests carried out. we also regress the logð(daily confirmed cases)/ (daily total tests)) on time (in days) and logð(cumulative confirmed cases)/(cumulative total tests)) on time (in days). the slope of such a regression can be presented in terms of the half-lives, if it is negative. such a presentation in terms of effect sizes is important; otherwise, it is difficult to assess if the raw slope is big or small. the linear model approach means that the proportion of infected behaves exponentially dailyðcumulativeÞtotaltests then to get the half-life (for a negative, t [ t ) one takes for a [ , one will obtain the doubling time in the same way as ðt À t Þ ¼ logð Þ=a. it is important to point out that this is a rather rule-of-thumb approach-our aim is not to model the dynamics of infections, but rather to visualize and understand what the data in front of us are. these regressions were not performed from the first day, as initially there seems to be a lot of noise in the tests, the starting time considered is visible in each graph-where the fitted line with prediction confidence band is fitted. we performed a regression for both the daily and cumulative counts. for some regions (molise, valle d'aosta), no regression is performed as the daily counts seem to noisy. secondly, one can very clearly identify days when something must have changed due to the testing methodology in the emilia romagna region-there are huge dips in the numbers of tests performed. hence, for this region the dates - march were removed for the regression estimation. in the basilicata and calabria regions, spikes to can also be observed (these are also removed, as on the log scale would result in infinite values which cannot be handled by the regression procedure in lm(). however, such dips require careful investigation. the directly plotted death toll in figs. , , , , , and shows that in the regions emilia-romagna, lombardia and valle d'aosta, p.a. bolzano combined with p.a. trento, there is a larger current (spring ) mortality peak than the past december/january ( - are plotted separately) maximum one. in the regions liguria, marche and piemonte, such a larger current peak is present for men only. in the other regions for all age groups and both men and women, the current ''covid- peak'' seems to be approximately of the same height, or lower, than past december/january ( - ) maximum ones. looking at italy for men and both sexes combined, it is higher, but women seem to have the same peak height. however, it must be stressed that this is only considering the peak's height, not the total amount of deceased during the current peak and the december/january ones. we used the, available on cran, covid r package for the purpose of obtaining the data. the package unifies covid- datasets across different sources in order to simplify the data acquisition process and the subsequent analysis. covid- data are pulled in real time and merged with demographic indicators from several trusted sources including but not limited to: johns hopkins university center for systems science and engineering (jhu csse); world bank open data; world factbook by cia; ministero della salute, dipartimento della protezione civile; istat -istituto nazionale di statistica; swiss federal statistical office; open government data zurich. besides worldwide data, the dataset includes fine-grained data for the diamond princess, switzerland and italy. at the time of writing, these include the number of confirmed cases, deaths and tests, total population, population ages - , - and þ (% of total population), median age of population, population density per km , population mortality rate. depending on the data provider, the data are available at the country level, state level, or city level. for non-r users, the combined datasets are available in csv format. discussion or should we use these data to calibrate epidemiological models? in this work, we analyzed in depth the two statistics that are commonly reported for the currently ongoing covid- pandemic-the number of confirmed cases and the number of case fatalities for the different regions of italy. we found significant variability between regions but also some common insights. in particular, the number of confirmed cases is clearly related to the number of tests and their ratio seems to be decaying for some time now in all regions. this is confirmed when looking at the log-scale plot. the difference between the logarithm of the cumulative number of tests and the logarithm of the cumulative number of confirmed seems to be (visually) dropping linearly (apart from the below, extremely noisy ones) regions and italy as a whole. furthermore, for a number of regions (molise, valle d'aosta), on the log scale, the tests, total, positive and difference behave very chaotically, suggesting rather various test handling situations, than any pattern. such oscillations can be visible in all regions at the initial stages, but they settle down (apart from the previously mentioned three regions). however, in regions with seemingly well-behaved curves individual huge dips can be observed (emilia-romagna, marche). therefore, reports claiming the growth of the epidemic based only on the increasing number of confirmed individuals will not be catching its dynamics. furthermore, studying only daily positively tested counts could be misleading. on a number of days, we found (for some regions) that this count was greater than the number of tests performed. this can certainly be understood, as the result of reporting procedures, in a crisis situation. however, this also implies that any statistical analysis or modeling of such data has to be done very carefully. we find that the cumulative positively tested fraction behaves much more stably, even though in the official cumulative counts decreases can be observed. more importantly, using the raw confirmed case counts one could risk combining the sampling effort with the actual disease spread. in our regressions, for the logarithm of the ratio confirmed cases to total tests on time the fitted slopes are all negative (indicating that the virus is receding and this was observed also by [ ] ). furthermore, these slopes are steeper than the slopes of the logarithm of the raw confirmed case counts on time. with the exceptions of lazio, p. a. bolzano the % confidence intervals for these two slopes do not overlap, or overlap very slightly. the ratios of the two slopes lie between . (p. a. bolzano) and . (piemonte). we report these ratios alongside the slope estimates in the captions of figs. , , , , , , , , , , , , , , , , , , , and . this means that the number of confirmed cases will be confounded by the number of performed tests and cannot be analyzed without them as a point of reference. hence, the raw confirmed case counts are not representative of the virus' infection dynamics. the logarithm of the fraction of confirmed cases to total tests is modeled well by a linear function with an increasing number of daily tests being performed and has a steeper slope than the logarithm of the confirmed case counts. drawing conclusions from raw confirmed case data would seem to be mixing-in the study of the sampling effort (it is important to stress that we do not make any statements here concerning the interpretation of the confirmed cases to tests fraction). therefore, calibrating model parameters for this virus's dynamics should not be done based solely on confirmed case counts, but maybe rather also on case fatalities or hospitalization data (given that classification protocols are taken into account) as, e.g., [ , , ] do. in fact, already [ ] , critised (as [ ] later also did following them) looking at case counts and postulated a focus on the ''observed deaths'' while [ ] writes that ''the cumulative number of deaths can be regarded as a master variable.'' [ ] developed an estimation methods based on the cumulative reported number of case fatalities. on the other hand, we also looked at the ratio of case fatalities to the number of deceased per day. this has the analytical advantage, of referring to something certain and well measured, and detailed records are collected (sooner or later) on the exact number of deceased in a given time period. here, there is hardly any chance of missing asymptomatic (of being dead) people. if the assumption, mentioned in the introduction, that a significant proportion of the tests is serological is true, then the ratio of case fatalities to all deceased should be telling us something about the cumulative proportion of infected individuals. our graphs (especially on the log-scale) do not contradict this, while the cumulative proportion of confirmed cases changes very slowly, the ratio of case fatalities to total deceased per day seems to look like an epidemic growth curve. since italy has very high-quality data on the case fatalities, this data could be further studied to assess the dynamics of the pandemic (e.g., [ ] uses the raw death counts for assessing the dynamics of the pandemic, albeit at the country level). this seems to be supported by that if one compares the curves to a potential ''gold standard''-the cumulative fraction of confirmed cases on the diamond princess, then the case fatalities ratio seems to shadow this curve (on the initial part when the epidemic was taking place on the cruise ship and for some regions like emilia-romagna or lombardia) but exceeds it. one could hope that once all curves would flatten at the same level, then the epidemic will reach the plateau. unfortunately, at the level of some (e.g., emilia-romagna or lombardia) of the regions, the scaled case fatalities grew and exceeded both the diamond princess and cumulative fraction of confirmed cases. we also compared the regional results to the same curves for the whole of italy, fig. . on the one hand, the same patterns are visible-the number of confirmed cases are related to the testing effort, the case fatalities exceeding the diamond princess' cumulative confirmed cases and the confirmed cases fraction seems to be stabilizing around the diamond princess' and then dropping. however, these graphs completely miss the regional variation. this is particularly visible when looking at the total death tolls directly figs. , , , , and . combined italy shows a visible increase in the death toll during the march-april period compared to previous years and the seasonal december/january peak. however, this peak is driven by particular regions emilia romagna, lombardia and piemonte (liguria, marche, valle d'aosta, p.a. bolzano combined with p.a. trento also shows a big increase, but in raw numbers are much lesser than the other three). all the other regions' peak is on the same level or lower than the december/january one and for some the death toll is on similar levels to the march-april one from previous years. furthermore, looking just at epidemiological country level data would be especially misleading for italy as lombardy acted differently from veneto in terms of their testing strategies. we believe that our presented view on the italian regional data gives some insights how the pandemic data reporting can be improved (if of course given the difficult situation, it would be possible in practise). for the confirmed cases count, a breakdown should be provided, how many of these were medical personnel, how many had symptoms, how many were seriously hospitalized before, how many were tested for other reasons (e.g., after contact). similarly for the number of tests carried out and their type (serological or not). the case fatalities counts should also be put in perspective with a report of how many people died in total on the given day and how many deceased were tested negatively. this would allow for estimating excess mortality (crudely compared to previous years' average or more exactly if number of deaths for the given time period are available) and for correct scaling to compare to other ratios. in fact, in the time period january- april, we are able to visualize the excess mortality directly-the number of deceased (in each week) in to the average from the past five years. the dataset is based on the , italian municipalities. to the best of our knowledge, the presented here counts are at the moment the best available data that can be used for scaling and putting the deceased counts in italy in perspective. the death counts seem to be collected in a consistent manner, both the number of case fatalities and the (used here) population death counts. this means that such counts could be used as a proxy for monitoring the dynamics of the virus. it is also a question whether the diamond princess can be considered as a gold-standard. certainly at the beginning it seems to behave like the other presented here curves. however, the data very quickly end, when the passengers were disembarked. we do not know if it reached the plateau or would have still grown. the confirmed case ratio seems to usually stay below/ around this curve, slightly go above and then drop. scaled case fatality curves exceed the curve. finally, the counting methodology should be made readily available for easy comparison between different countries. while of course each country is free to follow their own protocol, without putting numbers into context one can analyze data in an overpessimistic or over-optimistic way. the effect of different counting methods is pointed out by [ , , ] , when fitting parameters to the confirmed case counts (in lombardy, bergamo and brescia), one has a change of coefficients following march and march, and the latter can be possibly due to containment measures, but the former the authors are convinced is due to a change in the counting methodology. we have also abstained here from fitting any models to the data (the regression performed does not have as an aim modeling but formally testing what the respective curve could be telling us). it is known that due to different protocols between regions and changes in the protocols with time, the data are not homogeneous. in order to fit any model, one would have to obtain documentation what were the measurement strategies for each region in the time periods. in fact, when [ ] modeled the cumulative number of infections in italy through time (obtained using the covid r package), they performed fits to date separately in different time intervals which corresponded to various government introduced confinement measures. the covid r data package is available from https://cran.r-project.org/web/packages/covid / . the r script used to generate the graphics is available from https://github.com/krzbar/covid . responsibility for the content of this document lies with the authors. conflict of interest the authors declare that they have no conflict of interest. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. on the uncertainty of real-time predictions of epidemic growths: a covid- case study for china and italy presumed asymptomatic carrier transmission of covid- what we know, and what we don't, about the true coronavirus death toll why estimating populationbased case fatality rates during epidemics may be misleading. medrxiv basic estimation-prediction techniques for covid- , and a prediction for stockholm basic prediction methodology for covid- : estimation and sensitivity considerations. medrxiv la prima foto del virus a milano: la mappa dei contagi in città e nell'hinterland editor: tracking covid- excess deaths across countries: official covid- death tolls still under-count the true number of fatalities report -estimating the number of infections and the impact of non-pharmaceutical interventions on covid- in european countries coronavirus death toll in uk twice as high as official figure covid- data hub. datahub clinical features of patients infected with novel coronavirus in epidemiological study of novel coronavirus (covid- ). arxiv e-prints genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding logistic approximations used to describe new outbreaks in the covid- pandemic chronology of covid- cases on the diamond princess cruise ship and ethical considerations: a report from japan covid- : data analysis of the lombardy region and the provinces of bergamo and brescia inferring the covid- infection curve in italy r: a language and environment for statistical computing. r foundation for statistical computing covid- outbreak on the diamond princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures short-term predictions of country-specific covid- infection rates based on power law scaling exponents coronavirus deaths: how does britain compare with other countries? the guardian excess registered deaths in england and wales during the covid- pandemic forecasting the outcome and estimating the epidemic model parameters from the fatality time series in covid- outbreaks a review of the novel coronavirus (covid- ) based on current evidence simple models for covid- death and fatal infection profiles , missing deaths:tracking the true toll of the coronavirus crisis evidence for gastrointestinal infection of sars-cov- . gastroenterology estimation of the reproductive number of novel coronavirus (covid- ) and the probable outbreak size on the diamond princess cruise ship: a data-driven analysis clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study some numerical observations about the covid- epidemic in italy publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements we would like to thank marco picariello (miur-iiss) and paola aliani (cognizant) for sharing their preliminary work on data analysis of the veneto region with us. we would like to thank pierpaolo malinverni (jrc) for his critical reading of an earlier version of the manuscript. all key: cord- -pwkxgbxk authors: cai, xiaofang; jiang, hanlan; zhang, simin; xia, shengying; du, wenhui; ma, yaoling; yu, tao; li, wenbin title: clinical manifestations and pathogen characteristics in children admitted for suspected covid- date: - - journal: front med doi: . /s - - - sha: doc_id: cord_uid: pwkxgbxk coronavirus disease (covid- ), which is caused by severe acute respiratory syndrome coronavirus- (sars-cov- ), has spread around the world. however, approaches to distinguish covid- from pneumonia caused by other pathogens have not yet been reported. we retrospectively analyzed the clinical data of children with probable covid- . a total of ( . %) patients were confirmed positive for sars-cov- infection by nucleic acid rt-pcr testing, and ( . %) patients were found to be infected with other pathogens. notably, no pathogen was detected in ( . %) patients. among all patients, ( . %) had familial cluster exposure history, and ( . %) had one or more coexisting conditions. fifteen ( . %) patients were admitted or transferred to the picu. in the confirmed covid- cases, ( . %) and ( . %) were positive for igm and igg against sars-cov- , respectively. in patients with suspected covid- , ( . %) was positive for igg but negative for igm. the most frequently detected pathogen was mycoplasma pneumonia ( , . %). one patient with confirmed covid- died. our results strongly indicated that the detection of asymptomatic covid- or coexisting conditions must be strengthened in pediatric patients. these cases may be difficult to diagnose as covid- unless etiologic analysis is conducted. a serologic test can be a useful adjunctive diagnostic tool in cases where sars-cov- infection is highly suspected but the nucleic acid test is negative. electronic supplementary material: supplementary material is available in the online version of this article at . /s - - - and is accessible for authorized users. coronavirus disease (covid- ) , which is caused by severe acute respiratory syndrome coronavirus (sars-cov- ), has spread around the world, constituting a public health emergency of international concern [ ] . sars-cov- is the seventh coronavirus that has been identified to date that is known to cause human disease. compared with sars and middle east respiratory syndrome (mers) viruses that were responsible for pandemics in and , respectively, sars-cov- is associated with a lower mortality rate but a higher transmission speed [ ] [ ] [ ] [ ] . most people, including children, are susceptible to sars-cov- . however, data on pediatric patients with covid- are lacking. similar to sars and mers, most children infected with covid- have mild clinical presentation unless they have underlying comorbidities or coexisting conditions [ ] . as the largest children's hospital in central china, wuhan children's hospital affiliated to tongji medical college of huazhong university of science and technology, was the first hospital assigned by the chinese government to treat children with covid- in hubei province, china. during the outbreak, only the fever clinic and emergency department remained open to tend to outpatients, all of whom were required to undergo two preexaminations and triage. all febrile or suspected covid- cases were referred to the fever clinic, and the others-including critically ill children-were received by the emergency department after pediatric -level triage. the majority of children with confirmed covid- were admitted to the hospital through the fever clinic, whereas some with probable covid- were admitted from the emergency department. we retrospectively analyzed the clinical data of these children admitted from the emergency department to characterize thoroughly the features of covid- that can be evaluated to distinguish this novel disease from pneumonia caused by other pathogens in pediatric patients. the study was approved by the institutional ethics board of wuhan children's hospital affiliated to tongji medical college of huazhong university of science and technology. oral consent was obtained from the legal guardians in this study. we retrospectively recruited a total of children (excluding newborn cases) with probable covid- who were admitted by the emergency department of wuhan children's hospital from january , to march , . the clinical diagnostic criteria for covid- were based on chinese experts' consensus statement [ ] . the patients' medical records were analyzed by the research team at the emergency department of wuhan children's hospital. epidemiological, clinical, laboratory, and radiological characteristics, as well as treatment and outcome data, were obtained by two trained staff using standardized data collection forms from electronic medical records. after admission, all cases in the study underwent testing for a common set of pathogens, including influenza, parainfluenza virus, respiratory syncytial virus, adenovirus, enterovirus, mycoplasma, chlamydia, and legionella. routine bacterial and fungal examinations were also performed as necessary. a confirmed covid- case was defined as positive for sars-cov- nucleic acid in nasopharyngeal swab and/or anal swabs by real-time rt-pcr according to who guidance. clinical specimens were collected from patients with probable covid- . real-time rt-pcr was performed using a nucleic acid test kit (bgi biotechnology co., ltd., wuhan, china) according to the manufacturer's instructions. serological test for detection of specific igm and igg antibodies against sars-cov- in the early phase of the covid- pandemic, no suitable assay for sars-cov- specific igm and igg detection was available. some children with probable covid- underwent serological testing in the hospital starting on march , . serum samples were analyzed for igm and igg against sars-cov- by using chemiluminescence test kits (shenzhen yhlo biotech co., ltd., shenzhen, china) following the manufacturer's instructions. treatment, release from isolation, and follow-up no effective antiviral treatments for covid- have been developed to date [ , , ] . we chose interferon α- b aerosol inhalation, ribavirin intravenous infusion, oseltamivir, arbidol, and traditional chinese medicine oral administration as antiviral therapies for some patients following the recommendations of the pediatrics society of chinese medical association [ , ] . appropriate oxygen support (nasal cannula and noninvasive or mechanical ventilation) was administered to patients according to the severity of hypoxaemia. glucocorticoid and immunoglobulin were used in severe cases. if the patient's body temperature (if febrile) returned to normal for more than days, respiratory symptoms remarkably improved, pulmonary images clearly showed that the focus was evidently absorbed, and the nucleic acid test results were negative two consecutive times (the sampling interval was at least day), then the patient was released from isolation or discharged. constant health monitoring and medical observation for days at the patient's home was recommended. after weeks post discharge, two trained staff followed up the patients via telephone. continuous variables were expressed as median and interquartile range (iqr) values and compared with mann-whitney u test or kruskal-wallis test. categorical variables were expressed as number (%) and compared with χ test or fisher's exact test. a two-sided α value < . was considered statistically significant. data were analyzed using spss version . software (spss inc., chicago, il, usa), unless otherwise indicated. owing to the outbreak of covid- , wuhan was put under lockdown starting on january , , and nearly all citizens were required to remain at home. children with probable covid- were admitted to wuhan children's hospital starting on january , . the majority of these admissions occurred between january and march . during this period, out of the outpatients received by the emergency department, ( . %) with probable covid- were admitted to the hospital. out of the patients, ( . %) cases were confirmed (classified as children with confirmed covid- ) , and cases were found to be infected with other pathogens (classified as children with non-covid- ). however, no pathogen was detected in cases (classified as children with suspected covid- ) (fig. ). at the same time, between january and march , a total of children with probable covid- were admitted to the hospital, of which were confirmed as covid- cases, that is, . % ( / ) probable covid- and . % ( / ) confirmed covid- cases were admitted from the emergency department. all patients lived in wuhan within days before the onset of symptoms; ( . %) children had documented exposure to one or more adult family members with confirmed or suspected covid- . compared with the ( . %) patients with suspected covid- and ( . %) patients with non-covid- causes, the exposure incidence of the ( . %) confirmed covid- cases was significantly higher (p < . ) ( table ). out of the patients, ( . %) had one or more comorbidities or coexisting conditions, including ( . %) confirmed covid- cases, ( . %) suspected covid- cases, and ( . %) non-covid- cases. epilepsy and encephalopathy ( , . %), acute abdomen ( , . %), and immunodeficiency ( , . %) were the most common coexisting conditions (table ) . the median time from symptom onset to hospital admission for the patients cases ( ( . %) and ( . %), respectively) and the non-covid- cases ( ( . %) and ( . %), respectively) (p = . and . , respectively). the incidence of fever was higher in non-covid- cases ( , . %) than that in confirmed covid- cases ( , . %) and suspected covid- cases ( , . %) (p = . ). a total of patients with shortness of breath received oxygen, of which ( . %) were confirmed covid- cases, ( . %) were suspected covid- cases, and ( . %) were non-covid- cases. out of the patients, ( . %) were admitted or transferred to pediatric intensive care unit because of organ dysfunction (table ) . white blood cell (wbc) count was normal in ( . %) out of the patients; ( . %) of the confirmed covid- cases, ( . %) of the suspected covid- cases, and ( . %) of the non-covid- cases showed leucopenia (wbc count < .  /l). most patients had slightly elevated c-reactive protein ( . mg/l; iqr, . - . mg/l) ( out of cases ( . %)) and procalcitonin ( . ng/ml; iqr, . - . ng/ml) ( out of cases ( . %)) ( table ) . out of the patients, alanine aminotransferase and aspartate aminotransferase were elevated in ( . %) and ( . %) cases, respectively. out of patients, increased lactate dehydrogenase, creatine kinase (ck), and ck isoenzyme levels were observed in ( . %), ( . %), and ( . %) cases, respectively. out of patients, blood urea nitrogen and creatinine were elevated in ( . %) and ( . %) cases, respectively ( table ) . out of patients, plasma concentrations of interleukin (il)- and il- increased in ( . %) and ( . %) cases (mostly severe), respectively. however, il- , il- , and tumor necrosis factor (tnf)-α levels were normal. no differences were found in il- and il- levels among confirmed, suspected, and non-covid- cases (p > . ). out of patients, counts of cd + t cells, cd + t cells, and cd + cd + natural killer (nk) cells were below normal in ( . %), ( . %), and ( . %) cases, respectively ( table ). counts of helper t cells (cd + ), suppressor t cells (cd + ), and nk cells (cd + cd + ) were reduced mainly in critically ill patients. no differences were observed in the numbers of cd + t cells, cd + t cells, and cd + cd + nk cells among confirmed, suspected, and non-covid- cases (p > . ). all patients underwent rt-pcr testing for sars-cov- nucleic acid upon admission. the median number of tests was (range, - ) in patients with confirmed covid- , (range, - ) in those with suspected covid- , and (range, - ) in those with non-covid- causes. out of the patients, ( . %) patients underwent serum anti-sars-cov- igm and igg testing starting on march , , including ( . %) confirmed covid- cases, ( . %) suspected covid- cases, and ( . %) non-covid- cases. out of the confirmed covid- cases, ( . %) and ( . %) were positive for igm and igg, respectively. out of the suspected covid- cases, ( . %) was positive for igg but negative for igm (table , fig. (table s ) . upon admission, chest imaging abnormalities were observed in all patients. typical findings in chest computed tomography (ct) images were bilateral distribution of patchy shadows or ground-glass opacity, and/or infiltrating shadows in the confirmed covid- cases (fig. s ) . the most commonly used antiviral therapy was interferon α- b aerosol inhalation, which was administered to ( %) confirmed covid- cases, ( . %) suspected covid- cases, and ( . %) non-covid- cases. four ( . %) confirmed covid- cases, ( . %) suspected covid- cases, and non-covid- cases received intravenous ribavirin. oseltamivir was orally administered to ( . %) confirmed covid- cases, ( . %) suspected covid- cases, and ( . %) non-covid- cases. three ( . %) non-covid- cases were given oral arbidol. azithromycin was the most commonly used antibiotic (for mycoplasma infection) in to date, ( . %) out of the confirmed covid- cases and all suspected covid- cases and non-covid- cases have been cured and discharged. one ( . %) confirmed covid- case had intussusceptions and multiorgan failure and eventually died [ ] . at weeks after discharge, all patients were followed up by telephone. only one patient was readmitted because of diarrhea, but nucleic acid retesting by rt-pcr remained negative. the other patients were in good condition with no symptoms related to covid- . the most striking feature of this cohort was that the early symptoms in these children with probable covid- were apparently nonspecific or covered by other diseases. although we strictly adhered to two pre-examinations and triage for all outpatients, most of the probable and confirmed covid- cases were admitted from the fever clinic, and . % ( / ) of the probable covid- cases (including . % ( / ) of confirmed covid- cases) with atypical symptoms or critical illness were admitted from the emergency department. the initial symptoms of these patients did not always include fever or cough. some pediatric patients were brought to the emergency department because of digestive tract symptoms (vomiting, diarrhea, and abdominal pain), nervous system symptoms (convulsion), or even trauma. only when chest ct showed signs of pneumonia, they were hospitalized as probable or confirmed covid- cases. therefore, this approach was different from that of lu et al. [ ] . owing to the parents' fear that their children were infected with sars-cov- , the median time from symptom onset to hospital admission was shorter for confirmed covid- cases ( . days) than that for suspected covid- cases ( . days) and non-covid- cases ( . days) (p < . ). however, because of the mandatory isolation period, the median length of hospital stay was longer for confirmed covid- cases ( . days) than that for suspected covid- cases ( . days) and non-covid- cases ( . days) (p = . ). the clinical symptoms of covid- in children differ from those in adults [ ] . most children with covid- had mild symptoms or were asymptomatic. in our study, the main symptoms in confirmed covid- cases during hospitalization were fever ( . %), diarrhea ( . %), vomiting ( . %), shortness of breath ( . %), cough ( . %), and abdominal pain ( . %). compared with suspected covid- and non-covid- cases, the incidence of gastrointestinal symptoms (diarrhea and abdominal pain) was higher in confirmed covid- cases (p < . ) ( table ) . sars-cov- infection in children is mainly the result of family aggregation [ , ] . our study showed that ( . %) out of the confirmed covid- cases had documented exposure to one or more other adult family members with confirmed or suspected covid- . thus, aggregative onset is an important feature in pediatric cases, and it also underscores the highly contagious nature of the virus [ ] . children with covid- who are asymptomatic or have coexisting conditions can be misdiagnosed and may become potential vectors for virus transmission. similar to adult patients with covid- , most children have normal or only slightly reduced leukocyte count without evident organ dysfunction [ , ] . severely ill adult patients often have coexisting medical conditions [ , ] . although severe cases are less frequent among children, they can progress to death when they have coexisting conditions [ ] . we analyzed cytokine (il- , il- , il- , il- , and tnf-α) levels and cellular immune functions (cd + t cells, cd + t cells, cd + t cells, and cd + cd + nk cells) in some patients and found that the increase in il- and il- levels and the decrease in numbers of helper t cells (cd + ), suppressor t cells (cd + ), and nk cells (cd + cd + ) mainly occurred in severe cases with no difference between confirmed, suspected, and non-covid- cases (p > . ) ( table ). this result suggested that the virus causes direct damage to organs and that further impairment of organ function related to cytokine storm induced by the viral invasion in critical cases is not unique to sars-cov- infection because it was also found in children that were severely infected with other pathogens. as with sars and mers, children with sars-cov- infection have low morbidity [ ] [ ] [ ] [ ] [ ] . the reason for this phenomenon is unknown, but it has been attributed to the fact that children have a more active innate immune response, healthier respiratory tracts, and fewer underlying disorders than adults. a more vigorous immune response in adults may also explain the detrimental immune response in acute respiratory distress syndrome [ ] . sars-cov- , a newly emerged virus, binds with high affinity to human angiotensin converting enzyme (ace ) and employs it as an entry receptor to invade target cells [ ] . the ace protein is abundantly expressed in lung alveolar epithelial cells and enterocytes of the small intestines and is present in arterial and venous endothelial cells and arterial smooth muscle cells of all organs [ , ] . therefore, sars-cov- may infect patients not only through the respiratory tract in the form of air droplets but also through the digestive tract by contact or fecal-oral transmission. we previously described chest imaging features in five covid- cases with nonrespiratory symptoms as the first manifestation in children [ ] . in the early phase of the disease, chest x-rays showed no abnormalities, potentially leading to missed diagnosis. as in adults, chest ct images in children with cocid- revealed the presence of viral pneumonia, with early lesions frequently detected in the lung periphery and showing ground-glass opacity and/or infiltrating shadows. with disease progression, the lesions increased in number and expanded to involve multiple lung lobes. in the serious cases, the ct images showed diffuse consolidation in the lungs, as well as so-called white lung and air bronchogram. rt-pcr was one of the first laboratory diagnostic methods to be established in this pandemic and can yield results within h. in our study, out of the children were confirmed to be positive for sars-cov- infection by this method. owing to the sudden outbreak of covid- , detection kits varying in sensitivity and specificity were used for testing, and cases that were highly suspected of sars-cov- infection were sometimes found to be negative although they could not be completely ruled out [ ] . in fact, nucleic acid testing of nasal and pharyngeal swabs has a detection time window [ ] . dynamic monitoring of sars-cov- nucleic acid profiles by rt-pcr showed that the positive rate of oral swabs gradually decreases, whereas that of anal swabs increases with the duration of hospitalization [ ] . at the same time, serum igm positivity increased from % ( / ) upon admission to % ( / ) after days of hospitalization, whereas igg positivity rate increased from % ( / ) to % ( / ) [ ] . therefore, to improve the reliability of diagnosis and avoid false-negative results, different biological specimens (nasal and pharyngeal swabs, anal swab, and blood) should be used for nucleic acid testing, and serum igm and igg levels should be monitored. serological tests can serve as an important supplementary tool for covid- diagnosis. therefore, serologic testing must be conducted in children who are highly suspected of having covid- but who have tested negative via rt-pcr. notably, in the children with probable covid- who were initially admitted from the emergency department, the most frequently detected pathogen was m. pneumonia in ( . %) out of the non-covid cases and ( . %) out of the confirmed covid- cases. additionally, out of the non-covid- cases, we detected other viral infections in cases, bacterial infections in cases, and fungal infection in case. four cases had coinfection with two pathogens, and two cases had coinfection with three pathogens. therefore, clinical manifestations, laboratory test results, and findings from chest imaging of children with covid- can be nonspecific, and these cases cannot be definitively diagnosed as covid- unless etiological analysis is performed. in particular, coinfection with another pathogen-especially m. pneumonia-could mask the symptoms of the primary infection. our study had some limitations. first, it was a retrospective, single-center study with a small sample of patients admitted by the emergency department. standardized data from a larger prospective cohort study could provide more information on the features of covid- in children. second, we only conducted serologic testing in a subset of our patients and found just one case that was positive for sars-cov- specific igg in suspected covid- cases. detection of nucleic acid in different biological specimens of suspected covid- cases and dynamic monitoring of serum antibodies could reveal additional cases and thus reduce the risk of missed diagnosis. finally, according to the standards of experts' consensus statement [ ] , suspected cases may be considered as confirmed based on supportive evidence from nucleic acid or serologic testing. however, serologic testing was not initiated until march , and was only performed in some children ( cases) . to ensure the consistent application of diagnostic criteria to all patients, we used nucleic acid test results as the basis for diagnosis, and this approach may have resulted in some cases being overlooked. to address this potential omission, we are currently following up these children and advising them to undergo serologic testing. in summary, our findings highlighted the characteristics of covid- in pediatric patients admitted from the emergency department, which differ from those admitted from the fever clinic [ ] . in children with similar clinical manifestations and even chest ct images, distinguishing covid- from pneumonia caused by other pathogens (e.g., m. pneumoniae) before etiologic analysis (nucleic acid and serological testing) is impossible. moreover, serologic testing can serve as an important adjunctive method for covid- diagnosis, especially when the patient is highly suspected of sars-cov- infection but is found to be negative by nucleic acid testing. with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of , as revised in ( ) . oral consent was obtained from the legal guardians in this study. supplementary material is available in the online version of this article at https://doi.org/ . /s - - - and is accessible for authorized users. coronavirus disease (covid- ): a clinical update novel coronavirus outbreak: a quiz or final exam unique epidemiological and clinical features of the emerging novel coronavirus pneumonia (covid- ) implicate special control measures severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges protecting healthcare personnel from -ncov infection risks: lessons and suggestions chinese pediatric novel coronavirus study team. sars-cov- infection in children chinese medical association; chinese medical doctor association committee on respirology pediatrics; china medicine education association committee on pediatrics; chinese research hospital association committee on pediatrics; chinese non-government medical institutions association committee on pediatrics; china association of traditional chinese medicine, committee on children's health and medicine research global pediatric pulmonology alliance. diagnosis, treatment and prevention of novel coronavirus infection in children: experts' consensus statement washington state -ncov case investigation team. first case of novel coronavirus in the united states recommendations for the diagnosis, prevention and control of the novel coronavirus infection on children (first interim edition) covid- patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis novel coronavirus infection in hospitalized infants under year of age in china -novel coronavirus infection in a threemonth-old baby sars-cov- infection in children: transmission dynamics and clinical characteristics clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china dysregulation of immune response in patients with covid- in wuhan, china first case of neonate infected with novel coronavirus pneumonia in china first case of severe childhood novel coronavirus pneumonia in china middle east respiratory syndrome coronavirus disease in children other members of the hospital for sick children sars investigation team. children hospitalized with severe acute respiratory syndrome-related illness in toronto characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention are children less susceptible to covid- ? structure, function, and antigenicity of the sars-cov- spike glycoprotein tissue distribution of ace protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis pulmonary angiotensin-converting enzyme (ace ) and inflammatory lung disease clinical characteristics of covid- cases with non-respiratory symptoms as the first manifestation in children improved molecular diagnosis of covid- by the novel, highly sensitive and specific rdrp/hel real-time reverse transcription-polymerase chain reaction assay validated in vitro and with clinical specimens positive rate of rt-pcr detection of sars-cov- infection in cases from one hospital in molecular and serological investigation of -ncov infected patients: implication of multiple shedding routes we acknowledge all healthcare workers involved in the diagnosis and treatment of patients in wuhan children's hospital. this study was supported by the national natural science foundation of china (no. ). key: cord- -sa eyzq authors: ramos-fresnedo, andres; domingo, ricardo a.; refaey, karim; gassie, kelly; clifton, william; grewal, sanjeet s.; chen, selby g.; chaichana, kaisorn l.; quiñones-hinojosa, alfredo title: neurosurgical interactive teaching series: a multidisciplinary educational approach date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: sa eyzq objective the goal of this manuscript is to investigate the effects of a multidisciplinary multinational web-based teaching conference on trainee education, research and patient care. methods we present the structure, case selection and presentation of our educational lectures. we retrospectively reviewed our database to gather data on the number of presentations, type of presentation, and the pathology diagnosis from november , until february , . to investigate attendee satisfaction, we analyzed our yearly cme evaluation survey results to report the impact that this series may have had on our attendees. we assigned a numeric value to the answers and the mean overall scores where compared through an anova. further analysis on specific questions was performed with a fisher’s exact test. results we have hosted lectures, in which we have presented neurosurgical cases corresponding to general session, pituitary, and spine cases, as well as distinct lectures by guest speakers from institutions across the globe. we received responses to our yearly cme evaluations over the course of three years. on these evaluations, we have maintained an excellent overall rating from - (two-sided p> . ) and received significantly less suggestions to improve the series comparing with (two-sided, p= . ). conclusion as the world of medicine is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based lectures as presented in this manuscript. the impact that this series may have had on our attendees. we assigned a numeric value to the answers and the mean overall scores where compared through an anova. further analysis on specific questions was performed with a fisher's exact test. results: we have hosted lectures, in which we have presented neurosurgical cases corresponding to general session, pituitary, and spine cases, as well as distinct lectures by guest speakers from institutions across the globe. we received responses to our yearly cme evaluations over the course of three years. on these evaluations, we have maintained an excellent overall rating from - (two-sided p> . ) and received significantly less suggestions to improve the series comparing with (two-sided, p= . ). conclusion: as the world of medicine is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based lectures as presented in this manuscript. in , alfred w. adson founded the neurosurgery department at the mayo clinic. however, his expertise was mostly related to general surgery. despite being appointed to treat neurosurgical patients, he is noted to describe neurosurgery as a "hopeless field" due to the high mortality and morbidity associated with these procedures at that time. just a few years prior to the work of dr. adson, ( ) , harvey cushing was establishing neurosurgery as its own separate discipline. - neurosurgery has since evolved from general surgeons taking care of neurosurgical patients, to a completely separate entity with multiple sub-specializations; including vascular, functional, spine, pediatrics, and skull-base. as we advance medical knowledge, we strive towards the need to process an impressive amount of information limited to a single topic, leading to a sub-specialization across all medical fields, including neurosurgery. - furthermore, certain pathological entities require multiple medical sub-specialties to achieve the best patient care possible. it has been repeatedly shown that multidisciplinary approach to patient care maximizes patient outcomes in multiple disciplines, and this holds true for neuro- oncology as well. [ ] [ ] [ ] similarly, in skull-base surgery, resection of these tumors is an essential component of treatment, but a multispecialty team, including neurosurgery, radiation oncology, neuro-oncology, neuro-pathology and neuro-radiology is needed to appropriately manage these patients. institutions have established weekly multidisciplinary meetings where complex cases are discussed to reach a consensus on how that specific case should be approached. , based on the multidisciplinary approach, we created a separate weekly lecture format, that is broadcast internationally, where trainees are encouraged to critically prepare (with the help of multiple experts) and review surgical cases for educational purposes. in this multimedia format, the trainee is encouraged to use intraoperative videos to be able to tell a story where multiple groups get to comment and learn from, including the junior and senior colleagues. technological advances over the recent years has had an impact on the way physicians are trained, shifting from practicing directly on the patient towards the use of indirect and simulated experiences to avoid harming the patient during their learning. [ ] [ ] [ ] in this manuscript we present the structure of a new integrative, interactive, international, and multidisciplinary educational approach to neurosurgical cases (accredited by the accreditation council for continuing medical education (accme)) of patients who underwent care in our institution, as well as data from our experience since the series was established in november of . the neurosurgical teaching series lecture is held on a weekly basis. it is scheduled to last one hour, where two interactive cases are presented. the cases are led by our neurosurgery resident physicians, fellows, and trainees, who present at least once a month. the lecture is structured in a way that the presenter talks about the case as if he was the lead physician, promoting third order thinking skills. the physicians and surgeons who are involved in the care of the case are present for guidance and surgical rationale. the physicians who were not involved in the care of the presented case are also in the audience for questions and discussions. to develop a multidisciplinary approach, members from the following specialties are present to enrich our discussion from different perspectives: neurosurgery, neurology, medical neuro- oncology, radiation-oncology, neuroradiology, neuropathology, otorhinolaryngology, neuropsychology, and endocrinology. after the cases are presented, the audience engages in a discussion on the rationale that will be beneficial in the education of trainees. this is a real-time peer-reviewed discussion using scientific evidence from the literature, as well as experience from our institution. the structure of the case presentations is based on recommendations by the american board of neurological surgery (abns) for case studies. cases are selected with two weeks in advance, so the presenter can properly prepare the case, have a thorough understanding, and review the presentation with the corresponding neurosurgery supervisor, and all other physicians involved in care. additionally, the neuro-pathology team prepares representative images of the histology studies performed on the tissue, and the neuro-radiology team selects representative images from the diagnostic workup to make a comment on how the diagnosis was guided. these cases are selected to either have a high complexity or include surgical pearls and nuances to maintain our trainees up to date. the presentations begin with the history of present illness and chief complaint, including the evolution of the disease and symptomatology. initial workup is then presented including laboratory values, imaging studies (e.g. magnetic resonance imaging (mri), computerized j o u r n a l p r e -p r o o f tomography (ct) scans, and conventional angiography) that are representative of the decision- making process during surgical assessment based on case-specific characteristics. presenters are encouraged to recognize important anatomical landmarks in these images. after the history, symptomatology, and diagnostic workup is presented, differential diagnoses are discussed with the audience, enlisting the most probable to the least probable. the final diagnosis is not disclosed with the audience to encourage third order thinking. to enhance surgical education, a brief operative procedural video is presented. this video is three to five minutes long, and includes: positioning, surgical approach, surgical pearls, reconstruction, and closure. post- operative hospital care and evolution is presented to evaluate acute complications related to the procedure. post-operative follow-up with relevant laboratory values and imaging studies is also presented. this is followed by conclusions, where the presenter is encouraged to engage in critical thinking and comment on the obstacles that had to be overcome during patient care. to finalize the case, a brief review of the literature with the latest data is presented. the audience and the presenter are then encouraged to engage in an active discussion about the nuances of the case ( fig. ) . every four weeks our multidisciplinary neuro-oncology team holds a special pituitary section where the endocrinology team leads the discussion about complex pituitary cases. these are co- presented by both endocrinology and neurosurgery to provide a more thorough understanding of the hypothalamic-pituitary-end organ axes disrupted by these lesions. j o u r n a l p r e -p r o o f although rare, spinal and medullary tumors arise and also need a multidisciplinary approach to their care. , every eight weeks, we hold a special spine section to discuss two challenging cases on spinal oncology. we retrospectively analyzed our records of the multidisciplinary teaching series, including the yearly report done to comply with the regulations for continuing medical education (cme). we analyzed previous presentations to review their diagnosis, which are presented in this paper. presentations that were not available for retrospective review were not included in the analysis. to ensure patient confidentiality, the presentations are stored in a password protected and encrypted drive for educational and research purposes, within the mayo clinic server. informed consent for research and education was obtained for each case prior to presentation. no patient information, identity or identifiers are disclosed during the presentations. after the end of every calendar year, our group surveys our audience members from the different disciplines to provide feedback about this academic activity. to obtain objective suggestions these responses are anonymized. we reviewed the feedback reports for the years , , and . to assess whether there has been a change overall in the survey results over the course of our series, a one-way anova with tukey's multiple comparisons was performed. to obtain the mean score of the survey we assigned a numerical value to the answers of every question as follows: answers to questions , , and included: very deficient, deficient, good, very good, and excellent; and values from - were assigned, respectively. answers to questions , , and included: unmet, partially met, and met; and values from - were signed, respectively. answers to questions , , , and included: no or yes; and values from - were assigned, respectively. for question , we assigned a value of for the answer "no changes needed" and no score for any other answer. to evaluate the changes for each specific question, a fisher's exact test was performed. only questions and were analyzed as they were the only questions with variation of the responses. statistical analysis was carried our using graphpad prism (version for mac, graphpad software, san diego, california usa, www.graphpad.com). the questions and answers to the close-end questions are summarized in table . results we analyzed our records from november , to february , . over this period, we have hosted a total of meetings. there has been a total of cases presented; out of which were general session cases, were pituitary cases, and were spine cases. we have also over . % of the total survey answers for question rated the lectures overall as "excellent" (maximum rating) while the rest . % rated it as "very good"; no answers were recorded for the rest of the categories (good, bad, very bad). objectives and were recorded as "met" on the % of the survey results; while % recorded objective as "met" with only one response as j o u r n a l p r e -p r o o f "partially met"; no responses were recorded as "unmet". for presenter skills in , . % of the responses recorded them as "excellent" while the rest classified them as "very good"; in we saw an increase in this ratings to a recorded . % rating them as "excellent"; we had no year (two-sided, . % and . % vs. . % and . %, p= . ) or year to year (two-sided, . % and . % vs. . % and . %, p= . ) (fig. ) . even though the topics discussed in the lectures are focused on neurosurgical topics, the format of the presentations allows for any healthcare professional, ranging from technicians to fully trained faculty. this is due to the recurring specific structure that can be applied to any medical field or specialty, allowing any-level health professional to develop an ordered rationale and third order thinking. by directing to any type of health worker, we allow the lectures to have a larger audience. there have been results on the variability of attention span in humans, and its relationship with different types of stimulus. our group has tried to account for these factors by including multimedia elements, such as imaging and short surgical videos into the presentations; as well as frequent interaction between attendees. in this manuscript we present a cme accredited, recurring and international lecture series for medical trainees from all levels of education that has been shown to have a direct impact in patientcare. a multidisciplinary approach towards patient care is essential to achieve optimal outcomes in neuro-oncologic patients. , , [ ] [ ] [ ] [ ] many institutions, including our own, have implement a weekly multidisciplinary conference, commonly known as a multidisciplinary tumor board (mtb), where complex cases from the practice are discussed to reach an integrative approach towards treatment. , , recent studies have surged about the importance and benefits of these multidisciplinary meetings, further highlighting the importance of this approach to patient care. [ ] [ ] [ ] due to the growing evidence, our group decided to establish a weekly educational series for our young surgeons. we believe that a multidisciplinary form of care must be integrated to the education of every surgical trainee, as early understanding of its benefits will be beneficial to the care delivered by them. to the best of our knowledge, this is the first manuscript to describe an established multidisciplinary interactive lecture series, organized and presented by medical trainees that is held on a weekly basis. we present how a structured meeting can be effectively held in the benefit of residents and attendings. we also present data on the type of lesions that are chosen for presentation, which are mostly skull base tumors. this is probably due to the tenacity of the cases that are chosen for presentation as they require a multispecialty team. [ ] [ ] [ ] we believe that this educational tool will have a positive impact in the career of our young residents, and as such we are enthusiastic to share our methods with other training programs. the overall satisfaction level has been maintained as "excellent" throughout the past three years as reflected in our analysis. even though in the year we obtained less "excellent" responses than the previous two years, the difference was non-significant. we believe that this is possibly due to the responses consistently falling within the maximal values throughout the study period, therefore any small variation within the responses will not affect the significance. the decrease in these responses may be due to the variability of the attendees answering the survey as they may be different between the years, as well as a minimal difference in the definition between "very good" and excellent". moreover, on analysis of question we see a significant improvement in the feedback, with a significant increasing number of answers recommending no further changes to the format, suggesting that our attendees are satisfied with how the meeting is carried out. by creating a case review within a multidisciplinary setting, like the one we present in this paper, we take medical education one step further by allowing our trainees to develop a framework of how to critically think through complex cases, and receive real time feedback from international experts as they present. this is a study representing the data that we have collected from our weekly multidisciplinary lecture series. it was done at a single institution with a single multidisciplinary team within a single residency program. studies within our institution, as well as multicenter studies are needed to validate our data, as well as the efficacy and impact that these meetings have in the education of young physicians. there are inherited limitations in this study as it is retrospective and survey-based in nature. these include sampling error and recall bias. as the survey results are anonymous and blinded, it gives us the opportunity for future feedback. even though this study has its strengths and limitations, it can provide a baseline for future manuscripts in order to improve medical education. as the world of neurosurgery is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based lectures as presented in this manuscript. we encourage the community to share their experience institution. this process is based on the recommendations by the abns for case studies. following these steps allows for a structured format that can be replicated on a weekly basis. n/a -data was unavailable for this section. the answers that were not recorded in the survey results were not included in the summarized table. answers to questions , , and included: excellent, very good, good, bad, very bad. answers to questions , , and included: met, multidisciplinary management of brain metastases communication in and clinician satisfaction with multidisciplinary team meetings in neuro-oncology the role of tumor board conferences in neuro-oncology: a nationwide provider survey new requirements for resident duty hours simulation-based surgical education effectiveness of continuing medical education: updated synthesis of systematic reviews pituitary hormonal loss and recovery after transsphenoidal adenoma removal an integrated multidisciplinary algorithm for the management of spinal metastases: an international spine oncology consortium report multidisciplinary management of primary tumors of the vertebral column outbreak of a novel coronavirus letter: the impact of the coronavirus (covid- ) pandemic on neurosurgeons worldwide letter: approaches to mitigate impact of covid- pandemic on neurosurgical residency application cycle impact of covid- on neurosurgery resident research training the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study. acta neurochir (wien) impact of covid- on neurosurgery resident training and education on pandemics: the impact of covid- on the practice of neurosurgery path to reopening surgery in the covid- pandemic: neurosurgery experience ensuring an adequate neurosurgical workforce for the st century follow-up on a national survey: american neurosurgery resident opinions on the accreditation council for graduate medical education-implemented duty hours. world neurosurg impact of the accreditation council for graduate medical education work-hour regulations on neurosurgical resident education and productivity understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery more learning in less time: optimizing the resident educational experience with limited clinical and educational work hours. world neurosurg the importance of teaching clinical anatomy in surgical skills education: spare the patient, use a sim! clin anat the future of biomechanical spine research: conception and design of a dynamic d printed cervical myelography phantom. cureus development of a novel d printed phantom for teaching neurosurgical trainees the freehand technique of c laminar screw placement biomimetic -dimensional- printed posterior cervical laminectomy and fusion simulation: advancements in education tools for trainee instruction. world neurosurg attention span during lectures: seconds, minutes, or more? multidisciplinary management of colorectal brain metastases: a retrospective study the management of pineal tumors as a model for a multidisciplinary approach in neuro-oncology improvements in quality of care resulting from a formal multidisciplinary tumour clinic in the management of high-grade glioma neuro-oncology: continuing multidisciplinary progress tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer practice and impact of multidisciplinary tumor boards on patient management: a prospective study a single-institution prospective evaluation of a neuro-oncology multidisciplinary team meeting a prospective study of the clinical impact of a multidisciplinary head and neck tumor board. otolaryngol head neck surg case-based learning and its application in medical and health-care fields: a review of worldwide literature key: cord- -boq pci authors: lee, jia‐jung; hwang, shang‐jyh; huang, jee‐fu title: review of the present features and the infection control challenges of covid‐ pandemic in dialysis facilities date: - - journal: kaohsiung j med sci doi: . /kjm . sha: doc_id: cord_uid: boq pci the covid‐ has swept the world causing suffering, death, loss, and massive economy damage. the dialysis population is vulnerable and the dialysis facility is critical in maintaining operations and avoiding disease transmission. the present information regarding the clinical features of covid‐ infection in the dialysis population was collected, and the useful measures of covid‐ infection prevention and infection control in the dialysis facilities were summarized. leadership, education, preparedness, management, and recovery phase were determined to be the critical procedures. it is hoped this updated interim review might provide information for medical professionals to take proactive action to best prepare and mitigate damage when facing the covid‐ pandemic challenge. the world is now in the middle of the covid- pandemic. since a cluster of severe pneumonia cases was first noted in wuhan, hubei transmission. , today, on april , there were covid- -infected cases globally, causing deaths, and affecting countries. taiwan has covid- confirmed cases with clinical presentation including ( . %) cases of mild disease, ( . %) cases of pneumonia, ( . %) cases of acute respiratory distress syndrome, and six deaths ( . %). the first mortality case in taiwan was a case of end-stage renal disease (esrd) with peritoneal dialysis. the first two mortality cases in the united states were esrd cases under regular hemodialysis (hd). a recent article and news also suggested increasing dialysis indication in severe covid- patients. [ ] [ ] [ ] at this moment, physicians and scientists continue fighting at the front lines, swiftly collecting data, studying, and constantly learning about this novel contagious disease. accordingly, this interim summary is not a comprehensive review but aims to update present clinical information and infection control strategies currently focusing on covid- control in dialysis facilities. till mid-april, most of the other published articles have not focused on dialysis populations, and only some related information can therefore be highlighted. in the first case series reported in the united states, in the presentation and outcome of critically ill patients, the majority was linked to exposure at a skilled nursing facility. fifteen of the cases ( %) needed mechanical ventilation, deaths occurred ( . %), and eight cases ( . %) remained critically ill with ventilator support at the time of reporting. among the patients, two ( . %) cases had baseline esrd and four cases developed acute kidney injury (aki) ( . %). moreover, seven cases ( . %) showed cardiomyopathy and one case developed seizure. whether these acute multiple organ injuries reflected a direct organ complication induced by the virus or resulted from overwhelming critical illness remains to be determined. one large, retrospective case series of covid- -positive cases who were admitted to the intensive care unit (icu) in the lombardy region of italy showed similar presentation and patient outcomes. in total, of the cases needed respiratory support, and among these, ( %) needed invasive mechanical ventilation, and five cases needed extracorporeal membrane oxygenation (ecmo) support, with ( %) dying in the icu and ( %) still in icu care at the time of report. the most common comorbidity was hypertension ( , %) and the second was cardiovascular disease ( , %). thirty-six cases ( %) were identified as having chronic kidney disease (ckd). an early case series of critically ill covid- patients of the seattle region included cases from nine hospitals. sixteen cases ( %) came from home and six ( %) cases were from skilled nursing homes, with a mean age of years; five cases ( %) had history of ckd, but there were no esrd cases; cases needed invasive mechanical ventilation ( %), no case needed ecmo; and cases ( %) died in the hospital. on the other hand, reports from china showed more diverse information. one large case series including cases from china had the median age of years, where cases ( . %) had coexisting disease including ( . %) with diabetes mellitus, ( %) with hypertension, and only eight cases ( . %) had ckd. six cases ( . %) developed aki during the course. twenty-five ( . %) cases needed invasive mechanical ventilation, five cases ( . %) needed ecmo, and deaths ( . %) occurred. professor ikizler has emphasized the importance of patient and health care worker education. professor ikizler has also suggested advising patients to call ahead and report any fever or respiratory symptoms. in general, early recognition of symptomatic patient signs including fever, cough, upper airway involvement, or conjunctivitis and avoiding entrance to the waiting and treatment area is suggested. in taiwan, all clinics and hospitals perform at-the-gate body temperature measurement and infectious risk assessment recording any recent travel, occupation, contact, and clustering (tocc) history. , the tocc at present concerns every traveler from abroad who must abide by home quarantine for days, health-care workers and staff related to transportation or travel business, those ever attending large-scale public or private activities, and recent health problems simultaneously occurring in family members, friends, or coworkers, while also considering any alerting symptoms including fever, respiratory symptoms, newly noticed loss of taste and smell, and diarrhea. any symptomatic patient will be triaged and examined for covid- at a separate area. we allocate patients according to their covid- infection status and the risk status. [ ] [ ] [ ] symptom-free, tocc free patients with no symptoms and no exposure history or cluster history receive regular dialysis at the clean zone. caring medical staff comply with dialysis standard precautions, while the patient and health-care workers wear facemasks in the treatment area. in the updated cdc guidelines, to address asymptomatic and presymptomatic transmission, implementation of source control for everyone entering the health facilities is suggested. symptom-free, with tocc risk patients having history of exposure are closely monitored for their health condition for days after exposure. they may dialyze in the transition zone and the caring team is equipped with higher-level ppe, including shields or goggles for eye protection, n masks, waterproof isolation gowns, hair caps, and gloves. , , the confirmed case patients are allocated to the patient zone, ideally, the negative pressure isolation room. if the medical capacity is exceeded, the covid- the air conditioner should be operated full-time to maintain good indoor ventilation, while stringent cleaning and disinfecting of surfaces of the environment and equipment are mandatory as is the terminal station. the cleaning worker should be equipped with adequate ppe. , before the herd immunity and promising therapies available in the longer future, we may plan for a step-down strategy step-by-step. source control with adequate masking, keeping social distance, cleaning, and disinfecting surfaces of the regular environment, and hand hygiene could become a normal part of life. the early report from china showed that covid- was not associated with aki or had relatively low incidence around % to % of aki. , updated and accumulated data have now shown the incidence of aki is higher, up to % of the severe covid- cases and is associated with high mortality. (table ) . the authors thank the teamwork of the contingency team and the dialysis committee of the taiwan society of nephrology. covid- and dialysis units: what do we know now and what should we do? on the frontline of the covid- outbreak: keeping patients on long-term dialysis safe taiwan centers for disease control and prevention: taiwan cecc report on covid- and kidney failure in the acute care setting: our experience from seattle how does coronavirus kill? clinicians trace a ferocious rampage through the body, from brain to toes new covid- crisis hits icus as more patients need dialysis. cnn novel coronavirus disease in hemodialysis (hd) patients: report from one hd center in wuhan, china. medrxiv preprint covid- in hemodialysis patients: a report of cases a case of novel coronavirus disease in a chronic hemodialysis patient presenting with gastroenteritis and developing severe pulmonary disease characteristics and outcomes of critically ill patients with covid- in washington state baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region covid- in critically ill patients in the seattle region-case series clinical characteristics of coronavirus disease in china clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study the novel coronavirus epidemic and kidneys recommendations for the prevention, mitigation and containment of the emerging sars-cov- (covid- ) pandemic in haemodialysis centres mitigating risk of covid- in dialysis facilities take proactive measures for the pandemic covid- infection in the dialysis facilities centers for disease control and prevention: interim additional guidance for infection prevention and control recommendations for patients with suspected or confirmed covid- in outpatient hemodialysis facilities recommendations on the care of hospitalized patients with covid- and kidney failure requiring renal replacement therapy taiwan society of nephrology: guidance of covid- infection prevention in dialysis facilities % %e %bd%ae%e %a % f%e %af% (%e % %ac%e % % a%e % % %e %ac%ac%e %b % %e % % )-tsnpdf taiwan's traffic control bundle and the elimination of nosocomial severe acute respiratory syndrome among healthcare workers taiwan centers for disease control and prevention: guidelines for infection control in medical institutions responding to covid- infection coronavirus disease infection does not result in acute kidney injury: an analysis of hospitalized patients from wuhan, china clinical features of patients infected with novel coronavirus in wuhan, china. lancet kidney disease is associated with in-hospital death of patients with covid- identification of a potential mechanism of acute kidney injury during the covid- outbreak: a study based on single-cell transcriptome analysis. intensive care med renal histopathological analysis of postmortem findings of patients with covid- in china kidney involvement in covid- and rationale for extracorporeal therapies compassionate use of remdesivir for patients with severe covid- prophylactic and therapeutic remdesivir (gs- ) treatment in the rhesus macaque model of mers-cov infection comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against mers-cov response to covid- in taiwan: big data analytics, new technology, and proactive testing the authors declare no potential conflict of interest. https://orcid.org/ - - - shang-jyh hwang https://orcid.org/ - - - jee-fu huang https://orcid.org/ - - - key: cord- -a ig t authors: hellewell, joel; abbott, sam; gimma, amy; bosse, nikos i; jarvis, christopher i; russell, timothy w; munday, james d; kucharski, adam j; edmunds, w john; working group, cmmid ncov; funk, sebastian; eggo, rosalind m title: feasibility of controlling -ncov outbreaks by isolation of cases and contacts date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: a ig t background: to assess the viability of isolation and contact tracing to control onwards transmission from imported cases of -ncov. methods: we developed a stochastic transmission model, parameterised to the -ncov outbreak. we used the model to quantify the potential effectiveness of contact tracing and isolation of cases at controlling a ncov-like pathogen. we considered scenarios that varied in: the number of initial cases; the basic reproduction number r ; the delay from symptom onset to isolation; the probability contacts were traced; the proportion of transmission that occurred before symptom onset, and the proportion of subclinical infections. we assumed isolation prevented all further transmission in the model. outbreaks were deemed controlled if transmission ended within weeks or before cases in total. we measured the success of controlling outbreaks using isolation and contact tracing, and quantified the weekly maximum number of cases traced to measure feasibility of public health effort. findings: while simulated outbreaks starting with only initial cases, r of . and little transmission before symptom onset could be controlled even with low contact tracing probability, the prospects of controlling an outbreak dramatically dropped with the number of initial cases, with higher r , and with more transmission before symptom onset. across different initial numbers of cases, the majority of scenarios with an r of . were controllable with under % of contacts successfully traced. for r of . and . , more than % and % of contacts respectively had to be traced to control the majority of outbreaks. the delay between symptom onset and isolation played the largest role in determining whether an outbreak was controllable for lower values of r . for higher values of r and a large initial number of cases, contact tracing and isolation was only potentially feasible when less than % of transmission occurred before symptom onset. interpretation: we found that in most scenarios contact tracing and case isolation alone is unlikely to control a new outbreak of -ncov within three months. the probability of control decreases with longer delays from symptom onset to isolation, fewer cases ascertained by contact tracing, and increasing transmission before symptoms. this model can be modified to reflect updated transmission characteristics and more specific definitions of outbreak control to assess the potential success of local response efforts. evidence before this study contact tracing and isolation of cases is a commonly used intervention for controlling infectious disease outbreaks. this intervention can be effective, but may require intensive public health effort and cooperation to effectively reach and monitor all contacts. when the pathogen has infectiousness before symptom onset, control of outbreaks using contact tracing and isolation is more challenging. this study uses a mathematical model to assess the feasibility of contact tracing and case isolation to control outbreaks of -ncov, a newly emerged pathogen. we used disease transmission characteristics specific to the pathogen and therefore give the best available evidence if contact tracing and isolation can achieve control of outbreaks. contact tracing and isolation may not contain outbreaks of -ncov unless very high levels of contact tracing are achieved. even in this case, if there is asymptomatic transmission, or a high fraction of transmission before onset of symptoms, this strategy may not achieve control within three months. as of th february , there have been over , confirmed cases of a novel coronavirus infection ( -ncov), including over international cases, and over reported deaths . control measures have been instigated within china to try to contain the outbreak . as infectious people arrive in countries or areas without ongoing transmission, efforts are being made to halt transmission, and prevent potential outbreaks , . isolation of confirmed and suspected cases, and identification of contacts are a critical part of these control efforts. it is not yet clear if these efforts will achieve control of transmission of -ncov. isolation of cases and contact tracing becomes less effective if infectiousness begins before the onset of symptoms , . for example, the severe acute respiratory syndrome (sars) outbreak that began in southern china in was amenable to eventual control through tracing contacts of suspected cases and isolating confirmed cases because the majority of transmission occurred after symptom onset . these interventions also play a major role in response to outbreaks where onset of symptoms and infectiousness are concurrent , for example ebola virus disease , and mers , , and for many other infections , . the effectiveness of isolation and contact tracing methods hinges on two key epidemiological parameters: the number of secondary infections generated by each new infection and the proportion of transmission that occurs prior to symptom onset . in addition, the probability of successful contact tracing and the delay between symptom onset and isolation are critical, since cases remain in the community where they can infect others until isolation , . transmission prior to symptom onset could only be prevented by tracing contacts of confirmed cases and testing (and quarantining) those contacts. cases that do not seek care, potentially due to subclinical or asymptomatic transmission represent a further challenge to control. if -ncov can be controlled by isolation and contact tracing, then public health efforts should be focussed on this strategy. however, if this is not enough to control outbreaks, then additional resources may be needed for additional interventions. there are currently key unknown characteristics of the transmissibility and natural history of -ncov; for example, whether transmission can occur before symptom onset. therefore we explored a range of epidemiological scenarios that represent potential transmission properties based on current information about -ncov transmission. we assessed the ability of isolation and contact tracing to control disease outbreaks using a mathematical model , [ ] [ ] [ ] [ ] . by varying . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the efficacy of contact tracing efforts, the size of the outbreak when detected, and the promptness of isolation after symptom onset, we show how viable it is for countries at risk of imported cases to use contact tracing and isolation as a containment strategy. we implemented a branching process model in which the number of potential secondary cases produced by each individual (the 'infector') is drawn from a negative binomial distribution with a mean equal to the reproduction number, and heterogeneity in the number of new infections produced by each individual , , [ ] [ ] [ ] . each potential new infection was assigned a time of infection drawn from the serial interval distribution. secondary cases were only created if the infector had not been isolated by the time of infection. in the example in figure , person a can potentially produce three secondary infections (because three is drawn from the negative binomial distribution), but only two transmissions occur before the case was isolated. thus, a reduced delay from onset to isolation reduced the average number of secondary cases in the model. figure : example of the simulated process that starts with person a being infected. after an incubation period (blue) person a shows symptoms and is isolated at a time drawn from the delay distribution (green) ( table ) . a draw from the negative binomial distribution with mean r and distribution parameter determines how many people person a potentially infects. for each of those, a serial interval is drawn (orange). two of these exposures occur before the time that person a is isolated. with probability ρ, each contact is traced, with probability -ρ they are missed by contact tracing. person b is successfully traced, which means that they will be isolated without a delay when they develop symptoms. hey could, however, still infect others before they are isolated. person c is missed by contact tracing. this means that they are only detected if and when symptomatic, and are isolated after a delay from symptom onset. because person c was not traced they infected two more people (e and f) in addition to person d than if they had been isolated at symptom onset. a version with asymptomatic transmission is given in figure s . we initialised the branching process with , , or cases to represent a newly detected outbreak of varying size. initial symptomatic cases were then isolated after symptom onset with a delay drawn from the onset-to-isolation distribution (table ) . isolation was assumed to be % effective at preventing further transmission; therefore, in the model, failure to control the outbreak resulted from the lack of complete contact tracing and the delays in isolating cases rather than the inability of isolation to prevent further transmission. either % or % of cases became symptomatic, and all symptomatic cases were eventually reported. each newly infected case was identified through contact tracing with probability ρ. secondary cases that had been traced were isolated immediately upon becoming symptomatic. cases that were missed by contact tracing (probability -ρ) were isolated when they became symptomatic with a delay drawn from the onset-to-isolation distribution. in addition, each case had an independent probability of being subclinical (asymptomatic), and were therefore not detected either by self report or if traced by contact tracing. new secondary cases caused by an asymptomatic case were missed by contact tracing and could only be isolated based on symptoms. the model includes isolation of symptomatic individuals only, i.e. no quarantine, so isolation cannot prevent transmission before symptom onset. quarantining contacts of cases requires a considerable investment in public health resources, and has not been widely implemented for all contacts of cases , . we ran , simulations of each combination of the proportion of transmission before symptom onset, r , onset-to-isolation delay, the number of initial cases, and the probability that a contact was traced (table ) . we explored two scenarios of delay between symptom onset and isolation: "short" and "long" . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the incubation period for each case was drawn from a weibull distribution. a corresponding serial interval for each case was then drawn from a skewed normal distribution with the mean parameter of the distribution set to the incubation period for that case, a standard deviation of , and a skew parameter chosen such that a set proportion of serial intervals were shorter than the incubation period (meaning that a set proportion of transmission happened before symptom onset) ( figure ). this sampling approach ensured that the serial interval and incubation period for each case was correlated, and prevents biologically implausible scenarios where a case can develop symptoms very soon after exposure but not become infectious until very late after exposure and vice versa. there are many estimates of the reproduction number for the early phase of the -ncov outbreak in wuhan, china , , , , , [ ] [ ] [ ] [ ] [ ] , and therefore we used the values . , . , and . , which span most of the range of current estimates (table ) . we used the secondary case is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint short delay to isolation, % of transmission before symptom onset, and % subclinical infection. table . b) the incubation distribution estimate fitted to data from the wuhan outbreak by backer et al. . c) an example of the method used to sample the serial interval for a case that has an incubation period of days. each case has an incubation period drawn from the distribution in b, their serial interval is then drawn from a skewed normal distribution with the mean set to the incubation period of the case. in c, the incubation period was days. the skew parameter of the skewed normal distribution controls the proportion of transmission that occurs before symptom onset, the three scenarios explored are < % of transmission before onset (grey), % of transmission before onset (gold), and % of transmission before onset (pink). outbreak control was defined as no new infections between and weeks after the initial cases. outbreaks that reached , cumulative cases were assumed to be too large to control within - weeks, and were categorised as uncontrolled outbreaks. based on this definition, we reported the probability that an outbreak of a -ncov-like pathogen would be controlled within weeks for each scenario, assuming that the basic reproduction number remained constant and no other interventions were implemented. the probability that an outbreak is controlled gives a one-dimensional understanding of the difficulty involved in achieving control, because the model places no constraints on the number of cases and contacts that can be traced and isolated. in reality, the feasibility of contact tracing and isolation is likely to be determined both by the probability of achieving control, and the resources needed to trace and isolate infected cases . we therefore reported the weekly maximum number of cases undergoing contact tracing and isolation for each scenario that results in outbreak control. once the weekly number of cases reaches a . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint certain point, it can overwhelm the contact tracing system and affect the quality of the contact tracing effort . all code is available as an r package (https://github.com/epiforecasts/ringbp). the funders of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit for publication. all authors had full access to all the data in the study and were responsible for the decision to submit the manuscript for publication. to achieve % of outbreaks controlled required % of contacts to be traced and isolated for scenarios with a reproduction number of . (figure a) . the probability of control was . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint higher at all levels of contact tracing when the reproduction number was lower, and fell rapidly for a reproduction number of . . at a reproduction number of . , the effect of isolation is coupled with the chance of stochastic extinction resulting from overdispersion , which is why some outbreaks were controlled even at % contacts traced. isolation and contact tracing decreased transmission, as shown by a decrease in the effective reproduction number (figure b ). for the scenario where the basic reproduction number was . , the median estimate rapidly fell below , which indicates that control is likely. for the higher transmission scenarios a higher level of contact tracing was needed to bring the median effective reproduction number below . figure : the percentage of outbreaks controlled for the baseline scenario (black), and varied number of initial cases (a), time from onset to isolation (b), percentage of transmission before symptoms (c), and proportion of subclinical (asymptomatic) cases (d). the baseline scenario is r of . , initial cases, a short delay to isolation, % of transmission before symptom onset, and % subclinical infection. results for r = . and . are given in the supplement. a simulated outbreak is defined as controlled if there are no cases between weeks and after the initial cases. the number of initial cases had a large impact on the probability of achieving control. with five initial cases, there was a greater than % chance of achieving control in months, . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint even at modest contact tracing levels (figure a ). more than % of these outbreaks were controlled with no contact tracing due to the combined effects of isolation of symptomatic cases and stochastic extinction. the probability of control dropped as the number of initial cases increased, and for initial cases, even % contact tracing did not lead to % of simulations controlled within months. the delay from symptom onset to isolation played a major role in achieving control of outbreaks (figure b ). at % of contacts traced, the probability of achieving control falls from % to % when there is a longer delay from onset to isolation. if there is no transmission before symptom onset then the probability of achieving control is higher for all values of contacts traced (figure c) . the difference between % and % of transmission before symptoms had a marked effect on probability to control. we found this effect in all scenarios tested (supplementary figure s ). including only % of cases being asymptomatic resulted in a decreased probability that simulations were controlled by isolation and contact tracing for all values of contact tracing (figure d ). for % of contacts traced, only % of outbreaks were controlled, compared with % without subclinical infection. in many scenarios there were between and symptomatic cases within a week ( figure ), all of whom would need isolation and would require contact tracing. the maximum number of weekly cases may appear counterintuitive because a lower maximum number of weekly cases is not associated with higher outbreak control. this occurs because with better contact tracing it becomes possible to control outbreaks with higher numbers of weekly cases. the maximum number of weekly cases is lower if the initial number of cases is and higher if it is (see supplement). in the ebola epidemic in liberia, each case reported between and contacts , and the number of contacts may be higher, as seen in mers outbreaks . tracing contacts per case could mean up to , contacts in the week of peak incidence. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure : the maximum weekly cases requiring contact tracing and isolation in scenarios with index cases that achieved control within months. scenarios vary by reproduction number and the mean delay from onset to isolation. % of transmission occurred before symptom onset, and % subclinical infection. the percentage of simulations that achieved control is shown in the boxplot. this illustrates the potential size of the eventually controlled simulated outbreaks, which would need to be managed through contact tracing and isolation. * indicates that the % interval extends out of the plotting region. we determined conditions where case isolation, contact tracing, and preventing transmission by infected contacts would be sufficient to control a new -ncov outbreak in the absence of other control measures. we found that in many plausible scenarios, case isolation alone would be unlikely to control transmission within three months. case isolation was more effective when there was little transmission before symptom onset and when the delay from symptom onset to isolation was shorter. preventing transmission by tracing and isolating a larger proportion of contacts, thereby decreasing the effective reproduction number, improved the number of scenarios where control was likely to be achieved. however, these outbreaks required a large number of cases to be contact traced and isolated each week, which is of crucial concern when assessing the feasibility of this strategy. subclinical infection markedly decreased the probability of controlling outbreaks within months. in scenarios where the reproduction number was . , % of transmission occurred before symptom onset, and there was a short delay to isolation, at least % of infected contacts . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint needed to be traced and isolated to give a probability of control of % or more. this echoes other suggestions that highly effective contact tracing will be necessary to control outbreaks in other countries . in scenarios where the delay from onset to isolation was larger, similar to the delays seen in the early phase of the outbreak in wuhan, the same contact tracing success rate of % achieved less than % probability of containing an outbreak. higher pre-symptomatic transmission decreases the probability that the outbreaks were controlled, under all reproduction numbers and isolation delay distributions tested. our model does not include other control measures that may decrease the reproduction number and therefore also increase the probability of achieving control of an outbreak. at the same time, it assumes that isolation of cases and contacts is completely effective, and that all symptomatic cases are eventually reported. relaxing these assumptions would decrease the probability that control is achieved. we also make the assumption that contact is required for transmission between two individuals, whereas transmission via fomites may be possible. this would make effective contact tracing challenging, and good respiratory and hand hygiene would be critical to reduce this route of transmission, coupled with environmental decontamination in healthcare settings. we intentionally simplified our model to determine the effect of contact tracing and isolation on the control of outbreaks under different scenarios of transmission. however, as more data becomes available, the model can be updated, or tailored to particular public health contexts. it is likely that the robustness of control measures is affected both by differences in transmission between countries but also by the concurrent number of cases that require contact tracing in each scenario. practically, there is likely to be an upper bound on the number of cases that can be traced, and case isolation is likely to be imperfect . we reported the maximum number of weekly cases during controlled outbreaks but the capacity of response efforts may vary. we explored a range of scenarios informed by the latest evidence on transmission of -ncov. similar analyses using branching models have already been used to analyse the wuhan outbreak to find plausible ranges for the initial exposure event size and the basic reproduction number , . our analysis expands on this by including infectiousness before the onset of symptoms, case isolation, explicit modelling of case incubation periods and time to infectiousness. a key area of uncertainty is if and for how long individuals are infectious before symptom onset, and if asymptomatic or subclinical infection occurs. both are likely to make the outbreak harder to control . the model could be modified to include some transmission after isolation (such as in hospitals) which would decrease the probability of achieving control. in addition, we define an outbreak as controlled if it reaches extinction by months, regardless of outbreak size or number of weekly cases. this definition may be narrowed where the goal is to keep the overall caseload of the outbreak low. this may be of concern to both local authorities for reducing the healthcare surges, and may provide a way to limit geographic spread. our study indicates that in most plausible outbreak scenarios case isolation and contact tracing alone is insufficient to control outbreaks, and that in certain scenarios even near perfect contact tracing will still be insufficient, and therefore further interventions would be required to achieve control. however, rapid and effective contact tracing can also reduce the initial number of cases, which would make the outbreak easier to control overall. effective contact tracing and isolation could contribute to reducing the overall size of an outbreak or bringing it under control over a longer time period. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the authors have no interests to declare. no data were used in this study. the r code for the work is available at https://github.com/epiforecasts/ringbp. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint world health organization world health organization. novel coronavirus ( -ncov) situation report public health management of persons having had contact with novel coronavirus cases in the european union effectiveness of airport screening at detecting travellers infected with -ncov factors that make an infectious disease outbreak controllable comparing nonpharmaceutical interventions for containing emerging epidemics modeling and public health emergency responses: lessons from sars contact tracing performance during the ebola epidemic in liberia implementation and management of contact tracing for ebola virus disease contact tracing for imported case of middle east respiratory syndrome mers-cov close contact algorithm: public health investigation and management of close contacts of middle east respiratory coronavirus (mers-cov) cases (v european centre for disease prevention and control. risk assessment guidelines for diseases transmitted on aircraft. part : operational guidelines for assisting in the evaluation of risk for transmission by disease active contact tracing beyond the household in multidrug resistant tuberculosis in vietnam: a cohort study the effectiveness of contact tracing in emerging epidemics the transmissibility of novel coronavirus in the early stages of the - outbreak in wuhan: exploring initial point-source exposure sizes and durations using scenario analysis the transmissibility of novel coronavirus in the early stages of the - outbreak in wuhan: exploring initial point-source exposure sizes and durations using scenario analysis report : transmissibility of -ncov effectiveness of ring vaccination as control strategy for ebola virus disease estimating the potential total number of novel coronavirus cases in wuhan city, china superspreading and the effect of individual variation on disease emergence coronavirus: uk patient is university of york student epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong. the lancet early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china influenza forecasting with google flu trends pattern of early human-to-human transmission of wuhan early transmissibility assessment of a novel coronavirus social science research network novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions. medrxiv preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak. biorxiv when is contact tracing not enough to stop an outbreak? contact tracing during an outbreak of ebola virus disease in the western area districts of sierra leone: lessons for future ebola outbreak response. front public health clinical features of patients infected with novel coronavirus in wuhan, china. the lancet key: cord- -io f kn authors: killeen, g.; kiware, s. title: why lockdown? simplified arithmetic tools for decision-makers, health professionals, journalists and the general public to explore containment options for the novel coronavirus date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: io f kn half the world's population is already under lock-down and the remainder will have to follow if the ongoing novel coronavirus (covid- ) virus pandemic is to be contained. faced with such brutally difficult decisions, it is essential that as many people as possible understand ( ) why lock-down interventions represent the only realistic way for individual countries to contain their national-level epidemics before they turn into public health catastrophes, ( ) why these need to be implemented so early, so aggressively and for such extended periods, and ( ) why international co-operation to conditionally re-open trade and travel between countries that have successfully eliminated local transmission represents the only way to contain the pandemic at global level. here we present simplified arithmetic models of covid- transmission, control and elimination in user-friendly shiny and excel formats that allow non-specialists to explore, query, critique and understand the containment decisions facing their country and the world at large. based on parameter values representative of the united republic of tanzania, which is still early enough in its epidemic cycle and response to avert a national catastrophe, national containment and elimination with less than deaths is predicted for highly rigorous lock down within weeks of the first confirmed cases and maintained for weeks. however, elimination may only be sustained if case importation from outside the country is comprehensively contained by isolating for three weeks all incoming travellers, except those from countries certified as covid-free in the future. any substantive relaxation of these assumptions, specifically shortening the lock-down period, less rigorous lock-down or imperfect importation containment, may facilitate epidemic re-initiation, resulting in over half a million deaths unless rigorously contained a second time. removing contact tracing and isolation has minimal impact on successful containment trajectories because high incidence of similar mild symptoms caused by other common pathogens attenuates detection success of covid- testing. nevertheless, contact tracing is recommended as an invaluable epidemiological surveillance platform for monitoring and characterizing the epidemic, and for understanding the influence of interventions on transmission dynamics. for all but the most expert specialists, the silent early phase of an epidemic, when there is still time to contain it, is often imperceptible and difficult to grasp the significance of. this is especially true for pathogens like novel coronavirus- (covid- ) that largely exhibit only mild symptoms, if any, - that are non-specific and difficult to distinguish from other, more common illnesses. currently, half the world's population is already under lock-down of some kind, meaning vertically enforced and severe restrictions of movement, and the remainder will have to follow if the ongoing covid- virus pandemic is to be contained. faced with such brutally difficult decisions, it is essential for policy-makers, health professionals, journalists and the general public that as many people as possible understand ( ) why lock-down interventions represent the only realistic way for individual countries to contain their national-level epidemics before they turn into public health catastrophes, ( ) why these need to be implemented so early, so aggressively and for such extended periods, and ( ) why international co-operation to conditionally re-open trade and travel between countries that have successfully eliminated local transmission represents the only way to contain the pandemic at global level. here we introduce a simplified arithmetic modelling tool for predicting covid- transmission dynamics and how it is likely to respond to different containment, delay or mitigation strategies. we coin the term arithmetic modelling, as distinct from the ubiquitously used term mathematical modelling, to convey the fact that it uses only addition, subtraction, multiplication, division, rounding off, a few conditional statements (eg. if, less than/greater than, and/or), and two unavoidable power terms, to make the necessary calculations. this tool includes no differential equations, calculus, limits, distributions, stochastic simulations or agent-based approaches that would render it opaque to most non-specialist readers, such as medical and public health practitioners, decision-makers, journalists and the general public. the model is presented in userfriendly excel® and shiny® formats that allow non-specialists to explore, query, critique and understand the containment decisions facing their country and the world at large. for those who wish to satisfy themselves that the calculations make intuitive sense, the excel® version provides a complementary spreadsheet format in which the formula for each cell can be critically examined. for those content to accept the underlying arithmetic, the shiny® format provides a convenient interactive web application that can be used on any device. while a formal mathematical description of this model has been critically reviewed by specialist experts, it is provided only as an online supplement because none of the principles, assumptions or predictions are entirely new, and because in our experience nothing deters non-specialists from reading an article faster than equations do. we caution readers not to expect too much from any predictive model in terms of exact numerical reliability, [ ] [ ] [ ] and note that this one is no different. we specifically advise against interpreting the exact numbers this tool generates at face value: any predictive model is, by definition, a deliberately simplified representation of complex real-world processes, the usefulness of which is largely subjective. [ ] [ ] [ ] the exact numerical predictions should therefore not be used to confidently define precise operational timelines for introducing and sustaining interventions, or set effectiveness thresholds required of specific containment measures. instead, the purpose of this tool is to help users broadly understand the inevitable consequences of an uncontained epidemic, explore the likely outcomes a wide range of different possible containment strategies, identify those which could plausibly succeed and understand the failures of those which seem unlikely to do so. prospectively and will be too late to quantify retrospectively. they should therefore factor such unknown levels of uncertainty into their response plans by allowing for wide margins for error when planning the timing, intensity and duration of new interventions, always being more ambitious and cautious whenever in any doubt. assumed input parameters values were chosen to be representative of the united republic of tanzania (table ) , because it has experienced relatively modest inbound air traffic from china , and is still early enough in its epidemic cycle and response for a national catastrophe to be averted. tanzania has also had more opportunity to learn from ongoing experiences in asia, europe and north america, and prepare by establishing testing capacity at the outset of the national epidemic, more consistent with that simplifying assumption of the model than asian and european countries affected earlier in the pandemic would be. tanzania is also a typically vulnerable, low-income african country, - which had only icu beds in all four national referral hospitals combined in , and is representative of the pandemic that is now imminent all across africa. , the simplified model predicts that national containment and elimination may be achieved and sustained, without ever exceeding national icu capacity, by using a full, timely package of interventions. the national epidemic may be contained with only cases and deaths by highly rigorous -week lockdown ( % effective exposure prevention behaviours by % of the population) as soon the first cases are confirmed, weeks into the epidemic, complemented by % effective tracing and isolation of all contacts for confirmed cases (figure ). in this simulation, a rigorous -week lock down was initiated from week onwards and complemented by complete containment of imported cases, as well as contact tracing and isolation of confirmed cases. rigorous lock down was assumed to achieve % reduction of exposure behaviours by % of the population. complete % containment of imported cases assumes that all inbound international visitors are fully isolated for three weeks, , , , , , , except those coming from countries that may be certified as free of local transmission by who in the future. contact tracing and isolation follow up from confirmed cases was assumed to be % effective at preventing onward transmission from entire contact clusters. as points of reference against which ongoing national containment campaigns may benchmark themselves, the epidemic was predicted to grow % bigger each week at the outset and shrink by % each week once rigorous lock down had been in place for several weeks. note, however, that even these alarming projections for the rate of expansion of the epidemic and the rate of contraction required to contain it may under-represent the scale of the challenge in real epidemics. for example, at the outset of the epidemic in china, numbers of confirmed cases doubled every week. , furthermore, subsequent analyses allowing for frequent carriage without overt symptoms indicate much higher viral reproduction rates than assumed in table , and suggest true doubling time for all cases may be less than days. , interesting, almost exactly the same containment trajectory is predicted even if contact tracing and isolation is completely removed from the intervention package (supplementary figure ) , resulting in only more cases and one more death. the explanation for this becomes apparent when one examines the trajectories of confirmed versus all cases: even though the number of real cases never approaches an optimistically-assumed full testing capacity of , patients per week, half of all cases are never tested because they are asymptomatic and most of the remainder are only mildly symptomatic, so they get lost in the mass of other people who appear equally sick for unrelated to is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint covid- . as illustrated in figure d , the background noise of similar mild symptoms caused by other common pathogens dwarfs the mild coid- cases, so almost all of them go untested and undetected. less than one in every tests is conducted on a mildly symptomatic case of covid- , so even though we assume all severe cases are tested, only % of cases predicted to occur were confirmed. with contact tracing and isolation only being possible for this very small fraction of cases, there are obvious limits to how much it can achieve as a containment intervention in its own right. however, successful containment ( figure ) does requires that the lock down intervention is maintained for the full weeks (figure a and b) to eliminate the virus. delaying a -week lockdown by only weeks, the duration of one generation of viral infection, also allows the virus to persist and the epidemic resumes soon afterwards ( figure c and d). a slightly less rigorous lock down of the same duration, which nevertheless achieves % coverage with % reductions of personal exposure behaviours, also fails to eliminate the epidemic with tragic consequences ( figure e and f). furthermore, elimination may only be sustained by comprehensively containing case importation from outside the country ( figure g and h). preventing reintroduction requires isolation of all incoming travellers, except those coming from countries that may be certified as free of local transmission by who in the future, to achieve % prevention of onward local transmission ( figure ). even % containment of imported cases seems unlikely to protect the country against reintroduction of the virus and re-initiation of the epidemic ( figure g and h). tanzania therefore did the right thing by isolating all inbound travelers since march rd (over so far) for two weeks following their arrival). however, for such importation containment measures to effectively exclude new cases from a covid-free tanzania in the future, isolation periods may need to be extended to three weeks. , , , , , , however, it is also notable that all the scenarios in figure two, except for panels g and h, assume % effective containment of imported cases. it is therefore clear that local transmission must be eliminated before such rigorous control of inbound travellers can usefully protect the country against reintroduction. all these delays, truncations or inadequacies of lock down, or imperfections of importation containment, result in failure to eliminate local transmission that then rebounds and rapidly spirals out of control without a second full containment campaign ( figure ). the implications of such an uncontained rebound scenario are essentially identical to doing nothing in the first place: in all cases, % of the population is expected to become infected over about a year, resulting in approximately , deaths and icu demand exceeding capacity about times over. it is also worth noting that total national hospital inpatient capacity of approximately , beds would be overwhelmed by cases of severe coid- disease peaking at . million over a three-week period. under such conditions of a full-blown public health catastrophe, the mitigating effect of stronger health systems in high income countries are largely negated, so our predictions of over half a million deaths in tanzania compare well with those of others for the united kingdom, which has a similar population size. considering also the travel distances and household costs of hospital attendance in tanzania [ ] [ ] [ ] [ ] , it also raises the question as to whether severe covid patients should be cared for in hospitals and other health facilities [ ] [ ] [ ] [ ] which are already % understaffed or at home [ ] [ ] [ ] [ ] with support from a rapidly mobilized cadre of community health workers, for which well-characterized curricula and training platforms already exist. [ ] [ ] [ ] . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . ( ) shortening the lock down period by weeks, from to weeks (panels a and b), ( ) reducing importation containment from % to %, ( ) delaying the lock down by weeks (panels c and d), starting on week rather than week (panels e and f), and ( ) reducing the coverage and protective effectiveness of exposure behaviour reduction from % to % (panels g and h). is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint the mirage of flattening the curve to steadily acquire population-wide herd immunity the best-case scenario we could identify for "flattening the curve", as advocated by many national and international authorities, required removing all importation controls to ensure steady reseeding of the epidemic with a small number of cases and relaxing lock down assumptions to exactly % effective reduction of exposure behaviours among % of the population ( figure c and d) . under such precisely assumed conditions, the epidemic proceeds steadily with between and icu cases per week over a decade, at the end of which national icu capacity has never been exceeded and only deaths will have occurred. however, at the end of such a -year campaign, with no end in sight for at least several decades, only . % of the population would have acquired hard-won immunity through prior infection, so the remainder of the population would remain just as vulnerable to a resurgent epidemic. , intended to flatten the curve enough for national health system capacity to cope while herd immunity is acquired over the long term. all these simulations have identical input parameters to figure except that no importation containment is assumed and the coverage and protective effectiveness of exposure behaviour reduction is assumed to be lower, at % (panels a and b), % (panels c and d) or % (panels e and f). is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint however, such precise control over real epidemics with such sensitive and extremely curved trajectories, will be unachievable in practice. even lowering the assumed lock down coverage and effectiveness parameters for a simulated epidemic by only % to % results in a long drawn out peak that completely overwhelms icu capacity within years and continues to do so after a decade ( figure a and b) , nevertheless leaving % of the population lacking acquired immunity. on the other hand, raising assumed lock down coverage and effectiveness by only % to % results in a long-drawn out containment trajectory that never reaches the elimination end-game ( figure e and f) because the steady trickle of imported cases sustains transmission. re-introducing complete containment of imported cases merely results in a more extended version of figure e and f, with elimination taking over years to achieve (supplementary figure ) . perhaps more to the point, simply expressing icu capacity as a proportion of overall population size pragmatically puts suggestions that countries should aim to merely slow and mitigate their covid- epidemics into stark perspective. even if tanzania can build its icu capacity from to beds in the coming weeks, and even if the whole population could be somehow perfectly queued up for covid- exposure to make full sequential use of that capacity, assuming each patient needs only week in the icu and all regular causes of icu admission magically disappeared, it would take almost two centuries to care for the . million covid- cases expected. readjusting such hypothetical calculations to represent higher capacity countries like ireland or the uk shortens these timeline to decades rather than years, so "flattening the curve" to achieve population-wide "herd immunity" is clearly an infeasible and unwise choice. if a lock down is delayed by three weeks, approximately the duration of one viral infection, the epidemic may still be contained be extending it by the same length of time, from weeks to weeks ( figure a and b) . note, however, that the epidemic peaks at an almost four-fold higher incidence of cases, resulting in , cases and deaths overall. although icu capacity is not expected to be overwhelmed, timely access will clearly represent a challenge for many patients in country with a surface area of almost a million square kilometres and only four national referral hospitals. longer delays of , and weeks necessitate prolonged lock downs ( weeks for the latter) to contain epidemics of rapidly expanding scale: , and then cases, exceeding icu capacity by , and patients, and resulting in , and fatalities, respectively. note, however, that none of this will be obvious during the silent early phase of the epidemic, during which time the number of undetected cases snowballs: even if the lock down response is initiated after only weeks post-initiation, immediately after the first cases are confirmed in this simulation, the epidemic has already quietly progressed much further than most members of the public would guess. indeed, far enough that another people are already actively infected and almost new cases are predicted to occur in the subsequent -week period, out of which only ( %) will be detected. infectious carriers who exhibit little or no symptoms at the time - clearly contribute to the cryptic nature of an early-stage covid- epidemic: in this case we assumed this accounts for % of cases lacking symptoms overt enough to consider self-reporting and seeking a test (table ) . however, a much more important factor is the sheer volume of background noise arising from similar symptoms caused by more common pathogens, such as the common cold and malaria. even though these simulations assume that capacity for conducting , covid- tests per week would have been established in tanzania before the outbreak began, total confirmed cases are only expected to exceed about weeks after the lock down is introduced. most of these confirmed cases are . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint accounted by the clinically severe fraction we assume will all be tested. only % ( / ) of predicted mild or asymptomatic cases are expected to be confirmed because the relatively small number of covid- cases are so easy to miss in a population of million people, out of whom we assume % or , will experience a fever, cough or stomach pains in any given week for unrelated reasons ( figure b and d) . note, however, that that even this is a very conservative assumption about background rates of illness with similar symptoms to covid- : in the first contact-tracing study in the usa, over % of all carefully-followed contacts became symptomatic within weeks, even though none of them became infected with covid- . events . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint these simulations are nevertheless useful in that they illustrate how no perceptible increase in the incidence of such common symptoms may be obvious to the general population unless containment efforts fail and a full-scale, resurgent epidemic sweeps through the country (figure ). tanzania therefore did exactly the right thing by reacting fast during the silent earliest phase of the epidemic, announcing school closures within a day of the first confirmed case report and introducing additional restrictions immediately afterwards. note, however, that the quiet tail of a fading epidemic may be just as dangerous as the it's silent onset. three of the four scenarios in figure include periods of two month or more when few if any confirmed cases are expected, but some mild cases persist that can re-seed the whole epidemic afresh. the predicted persistence of the epidemic despite total predicted cases dropping below zero is an artefact of the simplified deterministic form of the model, which calculates case numbers as a continuous decimal outcome until it drops below . , at which point it is set to because the probability of elimination is % or better. the take-home message is nevertheless clear: persist with rigorous lock-down until one can be sure that elimination has been achieved, drawing on statistical approaches used by veterinary epidemiologists to certify elimination with imperfect surveillance systems. [ ] [ ] [ ] [ ] [ ] [ ] the vital importance of ambition and rigour to lockdown outcome: who dares loses least! as illustrated by figure c and d, it is now crucial that tanzania urgently builds on that early momentum to ramp up lock down efforts to the most rigorous level practically attainable. the implications of even a slightly less rigorous lock down appear less daunting in epidemiological terms but far more severe in practical and economic terms, because it greatly prolongs the lockdown period required: even reducing coverage and effectiveness of personal protection measures by only %, from % to % requires that the lock down period is extended by more than %, from weeks to weeks ( figure c and d) . the practical social and economic sustainability of such a protracted lock down period is very questionable, but much can be learned from the predicted benefits of getting such an imperfect lock down started in good time: the , cases and deaths predicted over the course of such a "slow burn" containment campaign are only marginally higher than for the best case scenario illustrated in figure . it is therefore important to get some form of reasonably rigorous lock down in place as early as possible, and then intensify it as rapidly as possible. like any race, it is critical to get an early head-start by any means possible, but then build up speed towards a strong finish. while compliance and enforcement is of great importance to lock down effectiveness, so is acceptability and socio-economic feasibility. while high income countries move to facilitate population-wide compliance with direct financial support and augmented social services, different tactics will be required in low income countries like tanzania. although tanzania is urbanizing very rapidly, most of the population still resides in rural areas where propagation of directly-transmitted diseases like covid- is always less intense. fortunately, tanzania is currently in the midst of this year's farming season, during which many rural families are out in the fields where social distancing is relatively easy. while farming season also conveniently brings a lull in trading activity at commercial hubs in rural towns and villages, it also represents a seasonal low point in the domestic food reserves of many rural households, so selective food support may be invaluable for enabling the most vulnerable families to comply effectively with self-quarantine and self-isolation directives. however, the growing urban population represents a much larger challenge, because far fewer people rely on farming for their livelihoods. many live in crowded informal settlements where lack of shelter, water, sanitation and space, relying on unreliable, informal sources of income to survive on a day-to-day basis. informal livelihoods and settlements in the busiest urban centres of the country will therefore require particularly urgent attention and creativity, to support daily food, water and hygiene needs. it may also be useful to consider providing safe transport with managed social distancing (to be followed by self-isolation) for those with options to sit out the epidemic with family and friends in rural areas. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint as is the case for elimination of other diseases, such as malaria for example , it may be more useful to think about gaps in coverage and effectiveness to understand how such apparently minor deficiencies can make all the difference between success and failure: while a shift from % to % lock down coverage and effectiveness might seems small in relative terms, a % shortfall relative to perfect containment is twice as big as %. and the difference between % prevention of onward local transmission from imported cases contrasts starkly with even such high targets as %: when you need to achieve zero new cases in a country, any other number simply isn't good enough. in practical terms, we should first think of most the vulnerable, such those lacking homes, shelter, security, citizenship or family support, [ ] [ ] [ ] especially those in the low income countries at greatest risk. , , , , beyond these long-neglected population groups, the most important lock down coverage and effectiveness gaps will be accounted for by the most important exceptions to restrictions and those exceptional individuals most determined to evade them. unfortunately, the most obvious exceptions to lock down restrictions who will facilitate continued transmission will be health service personnel, [ ] [ ] [ ] [ ] notably those caring for those most vulnerable to the disease. however, all other essential workers in shops, markets, kitchens, food processing facilities, factories, banks, post offices, transport services and law enforcement agencies will also inevitably mediate more transmission than they would if they stayed at home. indeed, it the crew that enabled self-sustaining levels of covid- transmission to persist aboard the quarantined diamond princess cruise ship. it is also worth remembering that the anti-hero of infectious disease epidemiology, the infamous typhoid mary (real name mary mallon) was a cook by profession who infected at least people, three of whom died. like many covid- cases, - mary was a silent carrier of the disease: she herself lived to a ripe old age and died of a stroke rather than typhoid. this is not to say that such essential services should necessarily be suspended, but rather that the roles and working practices of these personnel should be scrutinized particularly carefully. how essential is essential? what is the minimum level of service needed to facilitate extended lock down while mitigating indirect effects on health, well-being and economic welfare that are even worse than covid- ? what procedures, behaviours and protective equipment could most effectively minimize persistent workplace transmission? and with so many people's livelihoods on the lines, we may be asking too much of human nature by expecting everyone to do the right thing voluntarily. many of the greatest public health campaigns in history have necessitated an authoritarian style, and it may be necessary for people all over the world to temporarily embrace and accept new restriction measures they would otherwise justifiably describe as draconian. perhaps the single most important take-home message of the widelyaccepted - rule of epidemiology (less than % of people cause more than % of transmission) is that the extremes of human circumstances and behaviour, especially during mass gatherings and population movements, are more important to the survival of pathogens than the average. it inevitably follows that such exceptions are vitally important to target if one wishes to eliminate covid- . [ ] [ ] [ ] [ ] again, it is worth remembering typhoid mary , who resisted repeated efforts to get her out of the kitchen and did nothing to disprove stereotypes about the stubborn irish. she repeatedly returned to working as a cook because it paid better and frequently changed jobs as people fell ill around her, even changing her name to evade more than years of quarantines imposed on her. it took policemen over three hours to apprehend her despite a stealthy approach and forced entry to her home. eventually mary was found hiding in an outside closet at the rear of a neighbour's house, and things remained spicy following her arrest: "she fought and struggled and cursed. i tried to explain to her that i only wanted the specimens and that then she could go back home. she again refused and i told the policemen to pick her up and put her in the ambulance. this we did and the ride down to the hospital was quite a wild one." . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint when we read about the ongoing "coronavirus challenge" game mediated through social media, we are inclined to think the spirit of mary mallon is alive and well and needs to be curbed. the experiences of those who knew mary mallon seem extreme but are difficult to disregard completely in the context of a pandemic threatening a global population of over billion people with more eccentric characters, miscreants and outright criminals than we would wish in the circumstances: "mary was now about forty-eight years of age and a good deal heavier than she was when she slipped through a kitchen full of servants, jumped the back fence and put up a fight with strong young policemen. she was as strong as ever, but she had lost something of that remarkable energy and activity which had characterized her young days and urged her forward to meet undaunted whatever situation the world presented to her. in these eight years since she was first arrested, she had learned what it was to yield to other wills than her own and to know pain." as for the full the full, timely intervention package simulated in figure (compare with figure s ), removing contact tracing from the less rigorous but extended lock down intervention package has only a modest effect on the overall containment trajectory ( figure e and f), with only more cases and additional fatalities. under a the far more extreme conditions of a failed containment campaign, followed by a resurgent, full-blown epidemic, contact tracing becomes a rather pointless exercise, even for targeting clinical disease management. at the peak of the epidemic, when over million new symptomatic cases may occur per week and even mortality rate may outstrip testing capacity (figure ), so case confirmation success rates may plummet to below . %. however, such spectacular containment failures are to be avoided at all costs and this simplified model only accounts for the direct preventative effects of follow up on subsequent transmission, so none of these simulations should be used to in any way imply that contact tracing and isolation should be de-prioritized. in particular, it does not account for the invaluable functions of contact tracing for monitoring and characterizing an epidemic, , , , , , and for understanding the influence of interventions on transmission dynamics. for example, the tracing of transmission to a relatively small number of clusters in korea, and especially the incrimination of venues like the shincheonji church provide invaluable insights that guide more rigorous, effective follow up on lock down measures. in ireland, early observations that mean size of close contact clusters had shrunk from to were reported to the public as an encouraging early sign that behavioural interventions were impacting risks of onward transmission. without such essential detailed information about how transmission persists, as well as the strengths and weakness of ongoing intervention efforts, national containment programmes would be flying blind. it should be noted, however, that testing, contact tracing and isolation of known contacts is only useful as part of a deliberate containment strategy that keeps an epidemic manageably small, and may be particularly useful for extinguishing the remaining embers of an effectivley-contained epidemic. while testing is always useful for clinical management of severe cases, once % or more of the population has been infected even this important subset of cases alone overwhelms testing capacity ( figure b , d, e and f) and the fraction of non-severe cases confirmed plummets to negligible levels. in any case, population-wide testing of mildly symptomatic cases becomes unhelpful as a guide to targeting containment measures: how does one selectively target those at immediate risk when that means everyone? and how would we attempt contract tracing if we allowed the epidemic to grow to tens or hundreds of thousands of new cases each week? note, however, that the expected failure of contact tracing, and indeed testing generally, is just one more good reason to contain national covid- epidemics before they progress from emergencies (figures and ) into outright catastrophes (figure ). . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . like other recent models of covid- , our simplified formulation does not attempt to predict complex indirect effects of the pandemic upon morbidity and mortality from other causes that will be exacerbated by the expected pressures on a health system that is already overstretched. nor does it attempt to anticipate the extent of economic and social damage that will arise from different epidemic containment scenarios, partly because doing so would defeat the purpose of developing a simplified arithmetic formulation. despite its limitations as a relatively simple and untested model, the predictions described above are consistent with those of most other process-explicit models using more sophisticated mathematical formulations and specialist software, as well as recent reports of heroic , success from china. , , , , in fact, perhaps the most useful new lessons to be learned come from a few studies that reach substantively different conclusions based on markedly different underlying assumptions. our predictions that contact tracing and isolation will play only a minor role in successful containment contrast with those of others which assumed asymptomatic carriage by only % of cases or less, and which do not account for the detection dilution effect of similar mild symptoms caused by other common pathogens ( figure b , d, f, h). on the other hand, the predictions presented here appear relatively optimistic when compared with recent reports suggesting viral reproduction rates are higher than generally thought , because previous analyses failed to consider the likelihood that large fractions of cases may go undetected [ ] [ ] [ ] [ ] [ ] [ ] because they exhibit only mild, non-specific symptoms, if any - , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] as underlined right at the outset of the global response, , the most important remaining question that needs to be answered to reduce the uncertainties of model predictions is the extent of asymptomatic carriage and infectiousness. learning lessons from other diseases like endemic malaria, which is primarily a chronic illness transmitted by semi-immune adult carriers, the term asymptomatic may well be a misnomer not only because some individuals become infectious before exhibiting symptoms, , , , , , , , but also because it is often applied to those who shrug off mild symptoms to get on with their daily lives. , , a particularly important caveat arising from current uncertainty about the role of cryptic carriers is that it also has a major influence on estimation of fatality rate for infections rather than clinical cases. the latest analyses allowing for this phenomenon suggest that fatality rates are may be to times lower per infection than per confirmed case, , consistent with our conclusion that the vast majority of cases are never confirmed. while fatality rates are difficult to estimate directly, , these modelling analyses support the conclusions of the most controlled empirical epidemiological studies, indicating that the covid- fatality rates may be comfortably below %. the surge of severe cases and fatalities in an uncontained epidemic may therefore peak at a far lower level than those predicted in figure . however, much of the variation between fatality rate estimates appears related to geographic differences in health system capacity and burden, , so low income countries will be much more vulnerable. even if the best worst-case scenario proves to be less catastrophic than previously projected, , it will nevertheless overwhelm critical care capacity several times over and should be avoided if at all possible. the current global health emergency demands immediate, bold, pre-emptive decisions in the absence of unambiguous evidence, , based on our best understanding of covid- epidemiology as it stands today. , , the three key sequential actions every country needs to embrace as early and emphatically as possible are contain, eliminate and exclude. even when faced with the prospect of lock downs lasting months or more, there is no place for more timid terms like slow, flatten or mitigate when faced with an epidemic capable of overwhelming icu capacity hundreds of times over . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint or taking several years of restrictions to slowly burn through an entire population at rates that icus can cope with. and tackling this pandemic will rely overwhelmingly upon widespread understanding and mass participation by the entire global public, rather than just the health professionals and high-level decision makers who will lead the response. currently, half the world's population is already under lock down of some kind, meaning vertically enforced and severe restrictions of movement and physical interaction, and the remainder will have to follow if the ongoing covid- virus pandemic is to be contained. faced with such brutally difficult decisions, it is essential to policy-makers, health professionals and the general public that as many people as possible understand why lock down interventions represent the only realistic way for individual countries to contain their national-level epidemics before they turn into public health catastrophes. it also vital for as many people as possible to understand why these need to be implemented so early, so aggressively and for such extended periods. over the medium-to-long term, it will also be vital for us all to understand why widespread national action and international co-operation , will be required to conditionally re-open trade and travel between countries that have successfully eliminated local transmission. as explained by the simplified simulations presented here, this appears to be the only means by which national elimination efforts can be sustained, following which pandemic eradication may be pursued at global level. supplementary figure . the predicted trajectory of a successfully contained national covid- epidemic in the united republic of tanzania, achieved without any contact tracing and isolation. in this simulation, a rigorous -week lock down was initiated from week onwards and complemented by complete containment of imported cases, as well as contact tracing and isolation of confirmed cases. rigorous lock down was assumed to achieve % reduction of exposure behaviours by % of the population. complete % containment of imported cases assumes that all inbound international visitors are fully isolated for three weeks, , , , , , , except those coming from countries that may be certified as free of local transmission by who in the future. however, these simulations differ from figure in that absolutely no contact tracing and isolation was assumed. predicted successful national containment and elimination though prompt, rigorous lockdown, and then sustained with complete containment of imported cases, despite lack of contact tracing and isolation . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint a familial cluster of infection associated with the novel coronavirus indicating potential person-to-person transmission during the incubation period a well infant with coronavirus disease (covid- ) with high viral load clinical characteristics of asymptomatic infections with covid- screened among close contacts in nanjing alert for non-respiratory symptoms of coronavirus disease (covid- ) patients in epidemic period: a case report of familial cluster with three asymptomatic covid- patients transmission of -ncov infection from an asymptomatic contact in germany asymptomatic and human-to-human transmission of sars-cov- in a -family cluster electronic pubication ahead of print sars-cov- viral load in upper respiratory specimens of infected patients evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease the different clinical characteristics of corona virus disease cases eleven faces of coronavirus disease electronic pubication ahead of print asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus (sars-cov- ): facts and myths detection of novel coronavirus by rt-pcr in stool specimen from asymptomatic child case management team kcfdc, prevention. early epidemiological and clinical characteristics of cases of coronavirus disease in south korea electronic pubication ahead of print characteristics of covid- infection in beijing radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study evidence of sars-cov- infection in returning travelers from wuhan, china epidemiologic characteristics of early cases with novel coronavirus ( -ncov) disease in korea the rate of underascertainment of novel coronavirus ( -ncov) infection: estimation using japanese passengers data on evacuation flights transmission of covid- in the terminal stage of incubation period: a familial cluster serial interval of covid- among publicly reported confirmed cases electronic pubication ahead of print first known person-to-person transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) in the usa substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study electronic pubication ahead of print modeling the epidemic dynamics and control of covid- outbreak in china prudent public health intervention strategies to control the coronavirus disease transmission in india: a mathematical model-based approach impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand: who collaborating centre for infectious disease modelling, mrc centre for global infectious disease analysis interventions to mitigate early spread of sars-cov- in singapore: a modelling study nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study real-time forecasts of the covid- epidemic in china from short-term forecasts of the covid- epidemic in guangdong and zhejiang electronic pubication ahead of print real-time monitoring the transmission potential of covid- in singapore how will country-based mitigation measures influence the course of the covid- epidemic? the global impact of covid- and strategies for mitigation and suppression: who collaborating centre for infectious disease modelling, mrc centre for global infectious disease analysis identifying locations with possible undetected imported severe acute respiratory syndrome coronavirus cases by using importation predictions analysis of covid- infection spread in japan based on stochastic transition model prediction of the epidemic peak of coronavirus disease in japan, potential impact of seasonal forcing on a sars-cov- pandemic the effectiveness of quarantine and isolation determine the trend of the covid- epidemics in the final phase of the current outbreak in china early dynamics of transmission and control of covid- : a mathematical modelling study estimating the reproductive number and the outbreak size of novel coronavirus disease (covid- ) using mathematical model in republic of korea a conceptual model for the coronavirus disease (covid- ) outbreak in wuhan, china with individual reaction and governmental action transmission dynamics of the covid- outbreak and effectiveness of government interventions: a data-driven analysis phase-adjusted estimation of the number of coronavirus disease risk assessment of novel coronavirus covid- outbreaks outside china electronic pubication ahead of print an updated estimation of the risk of transmission of the novel coronavirus ( -ncov) estimation of the transmission risk of the -ncov and its implication for public health interventions electronic pubication ahead of print uncertainty in epidemiology and health risk and impact assessment wrong, but useful": negotiating uncertainty in infectious disease modelling with covid- , modeling takes on life and death importance passengers' destinations from china: low risk of novel coronavirus ( -ncov) transmission into africa and south america preparedness and vulnerability of african countries against importations of covid- : a modelling study will covid- be a litmus test for post-ebola sub-saharan africa africa prepares for coronavirus bearing the brunt of covid- : older people in low and middle income countries preparedness is essential for malaria-endemic regions during the covid- pandemic referral and admission to intensive care: a qualitative study of doctors' practices in a tanzanian university hospital projection of early spread of covid in africa as of data-based analysis, modelling and forecasting of the covid- outbreak transmission potential and severity of covid- in south korea early epidemiological assessment of the transmission potential and virulence of coronavirus disease (covid- ) in wuhan city: china novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions the novel coronavirus, -ncov, is highly contagious and more infectious than initially estimated a mathematical model for simulating the phase-based transmissibility of a novel coronavirus incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data electronic pubication ahead of print electronic pubication ahead of print. . national bureau of statistics & ministry of finance and planning dar es salaam and the office of the chief government statistician & ministry of finance and planning zanzibar. national population projections: united republic of tanzania estimated effectiveness of symptom and risk screening to prevent the spread of covid- . elife ; serial interval of novel coronavirus (covid- ) infections clinical characteristics of coronavirus disease in china early estimation of the case fatality rate of covid- in mainland china: a data-driven analysis investigation of three clusters of covid- in singapore: implications for surveillance and response measures persistence and clearance of viral rna in novel coronavirus disease rehabilitation patients electronic pubication ahead of print. . ministry of health, community development, gender, elderly and children. health statistical tables and figures for women's determinant factors for preferred place of delivery in dodoma region tanzania: a cross sectional study reasons for delay in seeking treatment among women with obstetric fistula in tanzania: a qualitative study costs of dental care and its financial impacts on patients in a population with low availability of services pathways and associated costs of care in patients with confirmed and presumptive tuberculosis in tanzania: a cross-sectional study a novel approach for a novel pathogen: using a home assessment team to evaluate patients for novel coronavirus (sars-cov- ) proposed protocol to keep covid- out of hospitals coronavirus: home testing pilot launched in london to cut hospital visits and ambulance use ministry of health, community development, gender, elderly and children. mid-term review of the health sector strategic plan iv for an exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in tanzania quality of sick child-care delivered by community health workers in tanzania factors associated with retention of community health workers in maternal, newborn and child health programme in simiyu region freedom from infection: confirming interruption of malaria transmission two-stage sampling in surveys to substantiate freedom from disease a new probability formula for surveys to substantiate freedom from disease demonstrating freedom from disease using multiple complex data sources : case study--classical swine fever in denmark demonstrating freedom from disease using multiple complex data sources : a new methodology based on scenario trees risk-based disease surveillance: a manual for veterinarians on the design and analysis of surveillance for demonstration of freedom from disease: food and agriculture organization of the united nations eliminating malaria vectors why inequality could spread covid- responding to the covid- pandemic in complex humanitarian crises the neglected health of international migrant workers in the covid- epidemic protecting healthcare personnel from -ncov infection risks: lessons and suggestions am i part of the cure or am i part of the disease? keeping coronavirus out when a doctor comes home covid- : towards controlling of a pandemic coronavirus: hospitals must learn from past pandemics transmission potential of the novel coronavirus (covid- ) onboard the diamond princess cruises ship the curious career of typhoid mary heterogeneities in the transmission of infectious agents: implications for the design of control programs covid- control in china during mass population movements at new year identifying and interrupting superspreading events-implications for control of severe acute respiratory syndrome coronavirus electronic pubication ahead of print covid- : preparing for superspreader potential among umrah pilgrims to saudi arabia secondary attack rate and superspreading events for sars-cov- statement in support of the scientists, public health professionals, and medical professionals of china combatting covid- covid- containment: china provides important lessons for global response china's local governments are combating covid- with unprecedented responses -from a wenzhou governance perspective feasibility of controlling covid- outbreaks by isolation of cases and contacts a novel coronavirus emerging in china -key questions for impact assessment relationships of host infectivity to mosquitoes and asexual parasite density in plasmodium falciparum asymptomatic" malaria: a chronic and debilitating infection that should be treated asymptomatic only at first sight: malaria infection among schoolchildren in highland rwanda communicating the risk of death from novel coronavirus disease (covid- ) electronic pubication ahead of print -novel coronavirus ( -ncov): estimating the case fatality rate -a word of caution potential association between covid- mortality and health-care resource availability parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials offline: apostasy against the public health elites covid- -navigating the uncharted offline: covid- and the nhs-"a national scandal key: cord- -trwggffp authors: hoz, samer s.; al-sharshahi, zahraa f.; albanaa, saja a. title: neurosurgery in iraq at the time of corona date: - - journal: surg neurol int doi: . /sni_ _ sha: doc_id: cord_uid: trwggffp nan quick response code: on december , , the world health organization (who) country office in wuhan city, china, was informed of a "case of unknown pneumonia. " [ ] on january , , the chinese authorities identified a novel strain of the coronavirus family (covid- ). [ ] despite strict containment measures to stem the spread of the virus, the situation has escalated rapidly; the virus has now swept across nations, with a total of deaths and confirmed cases worldwide (data as of the who's situation report on march , ). [ ] on march , , the who director -tedros adhanom ghebreyesus -officially announced the disease as a global pandemic. [ ] e trajectory of cases in china and italy, along with the current exposure graphs, predicts that the numbers will skyrocket and reach a peak at the end of april/may/june. [ ] the situation in iraq e first confirmed case of covid- in iraq was reported on february , . soon after, case reporting was coming from all the governorates, with a total death toll of and confirmed cases, as of march , data. [ ] importantly, due to the scarcity of testing kits and poor case reporting, it is very likely that these numbers represent the tip of the iceberg of a larger cohort of covid-positive patients. e government has taken several steps in an attempt to contain the spread of the virus; a nation-wide curfew was imposed since march , , a complete lockdown ordered, schools suspended, religious gatherings banned, airports closed, and flight operations ceased. however, adherence to the governmental orders has been sub-optimal throughout the country and the number of cases is multiplying. several factors may have contributed to the public defiance of governmental orders including the recent anti-political turmoil, collapsing central government systems, and lack of public awareness of infection control principles. e health-care systems across the globe are struggling to meet the new challenges imposed by the new pandemic. even the most efficient of systems are stricken by the urgent need to re-allocate and mobilize human and technical resources. case-triaging recommendations are being constantly updated by professional societies to lessen the unprecedented decision-making burden on health-care providers. [ ] as in all public health emergencies, there has been a paradigm shift toward a utilitarian model of healthcare; community rather than patient-centered approach is now the basis of treatment decisions meaning that the principles of patient autonomy and beneficence are being sacrificed for the greater good. predictably, such a shift has opened the door to significant moral and ethical dilemmas. in iraq, the set of challenges is rather unique; while the medical personnel are accustomed to working under conditions of extreme resource scarcity, our already collapsing, war-strained, cash-starved health-care system is unlikely to withstand the pressure brought on by the pandemic and, should the number of cases continues to escalate, the system is very likely to disintegrate, with deleterious short-and long-term consequences. despite having no direct pathological effects from a neurosurgical point of view, the covid- pandemic is significantly impacting the neurosurgical practice worldwide. in anticipation of the next exponential phase of the pandemic, many neurosurgical centers have curtailed the performance of non-emergency surgeries in an attempt to limit the spread of the virus and conserve vital resources. [ ] e neurosurgery teaching hospital (nth) in baghdad/ iraq provides neurosurgical care for . million peopleapproximately % of the population in baghdad -with a total capacity of beds, neurosurgical intensive care unit beds, and operating rooms. e hospital hosts neurosurgeons and residents. on january , , the nth declared a delay in all elective and semi-elective cases until further notice to curb the spread of the virus. from january to april , operations performed, as compared to cases over this same period in ; a net decrease of %. elective spinal and peripheral nerve surgeries were mostly affected with a total decrease of % (from to cases). e number of elective cranial operations went from to ; a total decrease of %. trauma and other emergency operations were reduced to a lesser extent, from to ; a decrease of %. at present, only operating rooms are available for trauma and emergency cases. while not yet a covid-burdened area, cases are getting imported into the hospital and in-patient cross-contamination will be inevitable, especially in the absence of basic hygiene and infection-control measures and the lack of terminal cleaning supplies. as of march , , a total of hospital personnel (four doctors and four paramedics) have been home-quarantined due to possible contact with two covidpositive cases that were accidentally identified in the hospital. is trend is alarming for multiple reasons: first, with the lack of sufficient testing kits, the hospital will quickly become a covid-hub. second, the hospital is already limping with the minimum number of trained personnel and is unlikely to survive the challenges posed by further staff shortages. ird, there is a serious supply deficit in terms of personal protective equipment (ppe). indeed, only % of hospital needs of standard ppes are currently being met and hospital staff is working exposed under minimum protection. fifth, the hospital provides care to a critically-ill patient group who is extremely vulnerable to the fatal complications of the infection. it is inevitable that health-care resources and infrastructure will be strained over the forthcoming months. however, to survive this public health crisis, a strategic, inter-sectorial action plan that involves international experience sharing is urgently called for. patient's consent not required as there are no patients in this study. nil. ere are no conflicts of interest. american college of surgeons novel coronavirus ( -ncov) situation reports neurosurgery in iraq at the time of corona key: cord- - fuuqbyq authors: machery, edouard title: responses to herman cappelen and jennifer nado date: - - journal: philos stud doi: . /s - - -z sha: doc_id: cord_uid: fuuqbyq nan since the very early days of experimental philosophy proponents of the so-called negative program in experimental philosophy have claimed that their experimental findings-the influence of demographic variables and of trivial changes to the cases (which i call, respectively, ''demographic and presentation effects'') on the judgments elicited by philosophical cases (henceforth, ''case judgments'')-raise troubles for the argumentative use of cases in particular areas of philosophy (epistemology: e.g., weinberg et al. ; philosophy of language: e.g., machery et al. ) or more generally in philosophy (e.g., weinberg ; machery ) . it has however always been difficult for this philosophical tradition to determine precisely and in a principled manner what class of judgments was supposed to be undermined by experimental philosophers' demographic and presentation effects, and some have used this difficulty against the negative program, arguing that any argument based on demographic and presentation effects would impugn judgment in general (williamson ) . the difficulty under consideration does not result from idiosyncratic features of the arguments against the method of cases; it is rather an instance of a general problem related to induction: specifying the reference class for which some generalization is meant to hold on the basis of a subset of this class (e.g., hempel ) . for this reason, i will call this problem ''the reference class problem.'' in some scientific contexts, the reference class problem is solved by formal sampling (as noted by alexander and weinberg, forthcoming) : either by creating a sufficiently large random sample or by some form of matched sampling from some predetermined population. but this solution is not available here since the selection of cases examined by experimental philosophers is not the result of formal sampling from a given population. philosophy within its proper bounds (machery ) addresses the reference class problem by identifying the causes of the demographic and presentation effects-the disturbing characteristics-and by generalizing to all the cases that have the same characteristics. i take this argumentative strategy to be one of the original ideas of the book, and i am delighted to see nado agreeing. for short, i often refer in the book and elsewhere to philosophical cases generically and i claim to target the method of cases, but, as is the case of generics in general, the claim that philosophical cases elicit unreliable judgments allows for exceptions. indeed, i repeatedly exclude from the skeptical conclusions of my three main arguments (unreliability, dogmatism, and parochialism) the cases that are known not to elicit demographic and presentation effects (e.g., p. , p. , p. ) , and i call them ''good cases'' (p. ). the gettier case may be a good case (machery et al. a, b ; but see machery et al. ; for a recent discussion, see hawke and shoonen, in press) . in her penetrating commentary, nado expresses doubts about whether it is possible to treat the class of judgments elicited by cases with disturbing characteristics (which, following my habit, i will simply call ''philosophical cases'') uniformly and thus to accept the same skeptical attitude toward all case judgments. as nado puts it, ''suppose i come to have a view on a 'disturbing' philosophical case based on an inference from further theoretical commitments, or on some other chain of argumentation. are such judgments to be dismissed along with the more intuitive snap judgments that x-phi originally aimed to target?'' she illustrates this concern by referring to a judgment about the gettier case formulated on the basis of theoretical virtues like simplicity: gettier cases describe an instance of knowledge because the identification of knowledge with true justified belief is much more general and simpler than any other proposal denying knowledge in gettier cases (weatherson ) . the question, then, is whether this judgment is included in the class of judgments impugned by unreliability, and why. i will assume that nado does not take weatherson's proposal to be a normative proposal about how to use ''knowledge'' (i.e., it is not a piece of conceptual engineering or a metalinguistic negotiation) nor is it a case of precisifying an antecedently indeterminate question; it is rather a truth-evaluable claim about the fact of the matter in the situation described in gettier cases, and it takes theoretical virtues to be truth-conducive. this judgment and similar ones are clearly a challenge for the approach proposed in philosophy within its proper bounds. at least initially, it is not clear whether my skeptical conclusions extend to them, and if they do not, on what grounds the arguments i proposed can be properly circumscribed. i will have more to say about this question below, but as a preamble it is important to state that it is wrong to focus on these unclear cases (see my discussion of williamson's points in machery , ) : whether or not we know where to draw the border of the reference class is irrelevant for how we should treat prototypical cases. still, what about weatherson's case judgment and its ilk? on second thought it should clearly be excluded from the class of case judgments threatened by the arguments of unreliability, dogmatism, and parochialism, for the process by which weatherson forms a judgment about whether the character in a gettier case genuinely has knowledge differs markedly from the process by which we ordinarily ascribe or deny propositional knowledge. indeed, weatherson must override, so to speak, the judgment he would otherwise make to conclude that the agent does know the relevant proposition. it would be a mistake to say that weatherson reaches his conclusion by a process that is altogether different from the process underlying everyday judgments about knowledge: after all, he must take into account various cues about the epistemic situation of the agent in a gettier case, as we do when we ascribe and deny knowledge in everyday situations and when we make a judgment about the gettier case, and he must have started with, or at least considered or relied on at some point, the ordinary understanding of knowledge in order to modify it. but the conclusion is ultimately driven by a theory about knowledge reached on the basis of, among other things, theoretical virtues. the ordinary understanding of knowledge features in a different manner from when we decide on the basis of a new york times article that trump does not know what he is talking about when he blabbers about covid- . and this judgment is thus more similar to the kind of judgment lewis called ''spoils to the victor'' (lewis , ) : once we have a theory, reached on some ground or other (by considering cases and using theoryconstruction tools like theoretical virtues), we can apply it to unclear cases. additionally, while the skeptical conclusions reached as a result of unreliability, dogmatism, and parochialism do not apply to the theory-driven case judgments, i have also argued that theoretical virtues cannot be in general assumed to be truthconducive (machery , chapter ). if they are, it is only locally, for reasons that can be explained, and there is no reason whatsoever to think that they are generally truth-conducive in philosophy. while nado might agree with this diagnostic, she is likely to be unsatisfied until a more general characterization of the reference class to which the skeptical conclusions of unreliability, dogmatism, and parochialism are meant to apply. i am not confident i can settle all possibilities in advance, but i can at least exclude the following class of case judgments: judgments that are formed on the basis of an explicitly developed theory that differs from philosophers' antecedent understanding of the theory's topic. such case judgments have to be assessed on other grounds, perhaps because they have been reached by means of other case judgments and theoretical virtues (as is the case for lewis). this discussion, however, addresses only part of nado's broader concerns: reliability is likely to vary among case judgments, even among those that are not theory-driven. as she puts it (emphasis in the original): ''[w]e have prima facie reason to assume that some such cognitive process types will substantially differ in their vulnerability to the disturbing characteristics'' (see also alexander and weinberg, forthcoming for a similar concern). it would not bet against the existence of some differences in reliability among partitions of the class of case judgments, even at good odds, but there are differences and differences. first, some differences in reliability are probably too small to be of interest: we can group partitions into equivalence classes based on the size of the variation in reliability. second, nado is fully aware that differences would only matter if case judgments in some partitions were ''sufficiently reliable to permit their use,'' and that we have no evidence at this point that there are such partitions. in his insightful commentary, cappelen too raises concerns about the homogeneity of the cases used in philosophy. he doubts that they have any characteristic in common, and as a result that they can impugned as a class: ''metaphilosophers should give up the idea that there's a small set of features that characterize all philosophical cases. i would go further: the term 'method of case' doesn't describe a theoretically useful class. it encourages the thought that there's uniformity where there isn't. the thing we call 'cases' come in too many varieties.'' nado and cappelen are right to press this point: this is a crucial issue, one that would weaken experimental philosophers' critic of the methods of analytic philosophy. however, even if experimental philosophers' generalization failed, their criticisms would not be fully invalidated: they would still apply to the cases they have focused on, which happen to be central to important literatures in philosophy, such as the gettier case, the gödel case, or the trolley cases, and to the probably many other cases that are like them (machery , ) . in any case, i have tried to meet this concern halfway. i distinguish various uses of cases in philosophy in chapter of philosophy within its proper bounds, many of which i deem to be uncontroversial: for instance, using cases to elicit puzzlement or to illustrate a definition or a theory. what's more, some famous cases in philosophy such as davidson's original swampman case are just used in such uncontroversial ways. so, i limit my concerns to the use of cases for argumentative purposes. the discussion of nado's objection has also led me to exclude another type of case judgment. finally i grant that there might be good cases, and i only generalize to those cases that have some of the disturbing characteristics-what philosophers should stop using are those disturbing cases-although i believe philosophers are extremely likely to rely, for non-accidental reasons, on such cases (more on this in the next section). i suspect that cappelen will not be willing to meet me halfway, insisting either that the disturbing characteristics i have identified do not undermine the reliability of case judgments or that many cases in philosophy can be used argumentatively without having any disturbing characteristic. i turn to these two issues in the next section. as noted in sect. , i call ''disturbing characteristics'' the properties of cases that explain why the philosophical cases examined by experimental philosophers elicit demographic and presentation effects. i acknowledge in chapter of philosophy within its proper bounds that little empirical evidence bears on what these disturbing characteristics are, but i speculate that three features of the philosophical cases examined by experimental philosophers are disturbing: • unusualness: the cases used by philosophers describe unusual situations. • separating what goes together in everyday life: the properties that are possessed by instances of a concept in everyday concept applications are separated in philosophical cases. • the entanglement of target and superficial content: the features of cases that are relevant to philosophical cases and the philosophically irrelevant narrative settings of these cases both influence judgment. i am explicit that not all philosophical cases possess these disturbing characteristics: ''some philosophical cases may well be free of all these characteristics, and the judgments these elicit are not vulnerable to the influence of demographic and presentation variables' ' ( , ) . those that don't are likely to be good cases, but i argue that to fulfill some of their argumentative functions cases must have some of these disturbing characteristics (others are accidental): ''some disturbing characteristics are accidental, and cases without them could be developed; others are non-accidental: to bear on some central material-mode issues, cases must have these properties' ' ( , ) . i also explicitly reject the idea that these three disturbing effects are always found in all the cases known to give rise to demographic and presentation effects: ''some philosophical cases may possess all these characteristics, while others only a few' ' ( , ) . i do not exclude the existence of other disturbing characteristics. finally, the disturbing characteristics do not necessitate unreliability; they just increase the likelihood that judgments are going to be unreliable ( , ): ''these characteristics do not necessitate that demographic and presentation variables influence judgment rather, they merely make it likely.' ' cappelen takes issues with various aspects of the discussion of the disturbing characteristics, which he rightly identifies as one of the pivots of the book. he focuses on unusualness, claiming that the points generalize to the two other disturbing characteristics: ''what i will say will generalize, and if so, it has wide reaching implications for the overall project in the book.'' his focus is cappelen wonders whether this modal claim is consistent with the claim in chapter that many modal propositions are beyond our epistemic reach. the answer is, clearly yes: the modal skepticism is limited to metaphysical necessities (and not even to all of them), while the necessity expressed by the claim that cases must have some disturbing properties isn't. i need not make any claim about what holds in every possible situation to claim that for us philosophers cases must have these characteristics to fulfill their argumentative functions. understandable since i discuss cappelen's ( ) take on the unusualness of philosophical cases, but he does not explain how his objections would generalize to the two other disturbing characteristics, and it is not straightforward how they would since they depend on some specific points of my discussion of unusualness. so, even if cappelen were right about unusualness, more would need to be said to defang the discussion of the disturbing characteristics in chapter . more important, cappelen loses track of the dialectical situation. the disturbing characteristics are hypothesized to explain the unreliability of the judgments elicited by the philosophical cases examined by experimental philosophers. demographic and presentation effects are meant to establish that these philosophical cases elicit unreliable judgments. even if cappelen were right about unusualness and even if his arguments somehow extended to the two other disturbing characteristics, this would only show that i have failed at identifying the features of the cases examined by experimental philosophers that produce unreliable judgments, not that there are no such features. indeed, there must be some if i am right about demographic and presentation effects, something that cappelen does not discuss. ultimately, then, it does not matter much if cappelen is right about unusualness: the disturbing characteristics, whatever they are, explain why the judgments elicited by the philosophical cases examined by philosophers are unreliable, and we should suspend judgment about any case that possesses them. perhaps this response is too quick: cappelen might respond that how threatening the disturbing characteristics are depends on what they are. if they are idiosyncratic features of the cases examined by experimental philosophers, then the threat for the method of cases is limited, although not null as we saw in the previous section. some cases would be problematic-the ones examined by experimental philosophers and perhaps a few others-not the bulk of philosophical cases. what makes the three candidate disturbing characteristics threatening is that they are plausibly shared by many other cases. while this response has merit, its significance is limited: experimental philosophers have examined a limited, but reasonably diverse group of cases, and it would be very surprising, although of course not impossible, if whatever explains why those cases elicit unreliable judgment was only found in them, and not in a much broader group of philosophical cases. in any case, it is worth looking at cappelen's two objections to the metaphilosophical significance of unusualness. cappelen ( ) proposed a counterexample (adding two and three pink elephants) to the claim that unusualness makes judgment unreliable. i responded in philosophy within its proper bounds that whether a situation is unusual for the purpose at hand depends on what is ''germane'' to the judgment it is meant to elicit: ''the fact that harm involves causing death in the trolley cases is germane to getting it right when one is making a permissibility judgment, while whether one is adding chairs or pink elephants is not when one is adding'' ( , ). cappelen responds in two ways: first, he gives another counterexample, where the color and identity of what one is adding seems germane (although he doesn't explain why): ''there are two pink, one orange, and one grey elephant in the room. then seven orange elephants walk in (and none leave). question: 'how many of the elephants in the room are orange?' the answer to this is easy and we're reliable in making the judgment, but surely the color of the elephant is germane.'' second, and more important, he presses me to explain what ''germane'' means here: how does one determine whether some aspect of a situation is ''germane'' to the judgment at hand and as a result bears on its usualness: ''it's super important that we're given an account of germaneness, but machery has nothing to say about this.' ' cappelen rightly presses me to give an account of germaneness: in philosophy within its proper bounds, i failed to make explicit what this means. to address this shortcoming, let's first introduce the notion of the topical concept: the topical concept is the concept whose application a philosophical case is meant to elicit. the topical concept of a gettier case is the concept of knowledge; the topical concept of a trolley case is the concept of permissibility. we can then define the notion of replaceability as follows: an aspect of a case (e.g., the identity of its main character) is replaceable if and only if what a reader views as evidence for or as constitutive of the application of the topical concept is not affected by its replacement by something else. color is replaceable in cappelen's two examples: in his first example, the elephants' color can be replaced with another property (e.g., their size: dwarf elephants) or even eliminated without this change affecting what the reader takes to bear evidentially or constitutively on the result of the addition; in his second example, the elephants' color can similarly be replaced with another property (e.g., their size: dwarf, normal, and giant elephants). in the first example, color is utterly otiose; in the second example, it distinguishes several sets of elephants, which must be tracked in order to complete the addition, but other properties can distinguish the relevant sets of elephants. (incidentally, being an elephant is also replaceable.) what is not replaceable is information about set membership. in the first example, what is not replaceable is the fact that there is a set of two items as well as a singleton; in the second example, the fact that there is a set of two items as well as a singleton, another singleton, and a set of seven items, and the fact that one of the two singletons and the set of seven items belong to a superset. change any of this, and what the reader takes to be evidentially and constitutively relevant to the addition changes. i can now give an account of germaneness-the facts that are germane are those that are not replaceable-and distinguish unusual situations from usual ones: in unusual situations, some germane facts are missing or somehow altered. ned stark's lie in the game of thrones is not unusual because the situation includes all the non-replaceable facts: ned starks intends to mislead his wife, jon, and robert baratheon by asserting something (that jon is his son) he believes (indeed, knows) to be false. the teletransporter in startrek is an unusual vehicle (the topical concept) because some of the facts that readers take to be evidentially or constitutively relevant for judging whether something is a vehicle (e.g., that the candidate vehicle moves) are absent. cappelen's second argument goes as follows: if judgments about unusual situations are unreliable, how can i reliably identify a situation as unusual since that judgment itself should be unreliable by virtue of being about an unusual situation? briefly, we are reliable at recognizing usual situations as such, and we judge those that aren't recognized as usual to be unreliable. bracketing the previous concerns about the boundaries of the reference class discussed in sect. above, the weight of evidence entitles me to assert that case judgments are unreliable, but it is also the case that new findings could lead us to withdraw this assertion (see, e.g., knobe, forthcoming; but see stich and machery, forthcoming) , and some have wondered whether this possibility should lead experimental philosophers to qualify the skeptical conclusions they want to draw (sosa ; discussed in machery , - ) . in this spirit, nado asks: ''is it really better to refrain from theorizing entirely rather than run a moderate risk of getting things wrong? legions of weathermen would likely protest otherwise.'' nado discusses different types of costs that could result from banning case judgments, ranging from the possibility that this ban might be challenged by new data to its consequences for everyday judgments that seem to share some features with case judgments. i will explore these alleged costs in turn. when you think it through, the analogy between experimental philosophers and weather scientists does not support nado's tolerant use of case judgments. weather scientists make predictions about the next few days-five to six days ahead in , one or two when i was a kid-but suspend judgment when it comes to the weather two or three weeks ahead. it isn't that their models are silent about the weather weeks ahead; rather, weather scientists have reasons to believe their models are unreliable when it comes to predicting weather weeks ahead while being reasonably reliable for the days ahead, despite being obviously (and sadly) fallible. as i insist in philosophy within its proper bounds, the evidence shows that case judgments are unreliable, not just fallible (p. - ), and nothing nado has said challenges this claim. nado probably thinks that the evidence for the unreliability of case judgments is suggestive, but not compelling, and that weather scientists' evidence about the unreliability of their predictions is just much (much much perhaps) better than the evidence for the unreliability of case judgments. no doubt weather scientists have more evidence than experimental philosophers (among other things, they can compare their predictions to reality), but their advantage does not mean that experimental philosophers' evidence is just suggestive. what nado must establish, then, is that the evidence doesn't show that judgments are unreliable, but at best suggestive. it is also important to conceive of the costs of maintaining the status quo in philosophy properly. opportunity costs should be taken into consideration: instead of worrying merely about the possibility of jettisoning traditional philosophy erroneously and of the small costs of letting it bloom, we should take into account what else philosophers could be doing: research topics selection is a zero sum game, and maintaining the status quo in philosophy in effect means not engaging in more productive ways of doing philosophy (see the discussion in machery , pp. - ; chapter ) . perhaps nado disagrees about the values of those, but she doesn't say. what about the other costs that result from suspending judgment whenever there is evidence of disturbing characteristics or whenever there is direct evidence of unreliability in the guise of presentation and demographic effects? nado refers to the consequences of suspending judgment for ''ordinary folk talk of ethics, of freedom, of knowledge, of beauty, of mental states, of causation''; she notes that ''practical matters hang on such variation-sensitive judgments'' and ''it's a risk we must take; the short of considered suspension of judgment that machery recommends isn't really an option here.'' nado, who acknowledges making a ''self-consciously williamsonian'' point here, is unconvincing for the same reasons that explain why williamson's attack on experimental philosophy failed: distinctions must, and can, be drawn, and it isn't helpful to paint everyday judgment with a broad brush. some of the assertions she refers to (talk about ethics and beauty) just aren't expressing judgments at all: they express preferences or perhaps commitments to particular norms. they are not truthevaluable in any robust sense, and thus are neither reliable nor unreliable. perhaps we can't avoid having moral and political opinions that are determined by who we are and a myriad of contingent factors, but this is not an issue for my views. naturally, nado might disagree with this metaethical view about moral and political assertions, and in any case not all assertions she refers to-such as assertions about causality and mental states-are plausibly understood as expressions of preferences. so what to do with those? again distinctions matter. many judgments about knowledge, causation, and responsibility are very difficult to frame (consider the judgment that stealing is wrong), and to the extent that they vary across demographic groups partitions are often easily justified, and the variation does not justify suspending judgment. epidemiologists are better placed to judge about the covid pandemic, and political disagreements about the matter raise no concern for the argument developed here: the judgments of trumpsters should be ignored, the judgments of epidemiologists taken seriously. but what about the other lay judgments, those that can be framed or those that vary across demographic groups when it is not clear whether we can partition the class of judgments into one that is reliable and one that isn't? what's good for the goose is good for the gander as the saying says: skepticism is not limited to the seminar room, and we should suspend judgment there too. while philosophy within its proper bounds targets the excess of philosophy, the intellectual humility it recommends in philosophy has a broader significance: we are just too confident in our judgments. nado is concerned about the status of the reliability condition for knowledge, on which unreliability relies: is it a metaphysically necessary truth? if so, how do i know it given my skepticism about knowing metaphysical necessities? and why would it be a nomologically necessary truth? what is the relevance of the laws of nature for this condition on knowledge? these are excellent questions, and i was not fully clear about the status of this principle in philosophy within its proper bounds, but there are a number of satisfying answers to them. first, one could go expressivist about the issue: i am merely proposing and recommending a particular norm for knowledge. on this view, the claim that reliability is necessary for knowledge is neither metaphysically nor nomologically true because it is no more true than other prescriptions. this proposal coheres with my inclination toward understanding normative discourse in the moral and political domain. a shortcoming of this proposal, however, is that if someone does not share this commitment, unreliability will be ineffectual. the impact of this shortcoming is somewhat blunted by the fact that unreliability is only one of the three arguments leading to skepticism about case judgments, and the further fact that the two other arguments do not rely on reliability. furthermore, most philosophers, internalists as well as externalists, do in fact agree about the significance of either reliability in itself or at least a belief in reliability. an alternative proposal is inspired by nado's own commentary: one could view this proposal as a piece of conceptual engineering. a shortcoming, discussed below, is that conceptual engineering requires substantial argumentation for its comparative superiority (see sect. below), and i did not offer any in philosophy within its proper bounds. finally, one could view this proposal as a piece of non-ideal theorizing: so understood, i am asserting that for us, reliability is necessary for knowledge, while suspending judgment about whether it is for creatures different from us and even about whether this question is meaningful. it might or might not be true in all possible situations that knowledge requires reliability, but that is totally irrelevant for the claim on which unreliability rests on. as pogge has described those who resist pressure to look for modally immodest normative principles ( , ) : those (…) are not typically lazily neglecting to unify their moral views about the various factual contexts by tracing them back to ultimate principles that cover all possible worlds. rather, most of them seem to be (…) reluctant to try to cover, with their moral principles, factual contexts substantially different from our own, like the described outlandish context of regressing fetuses. on this view, in contrast to the first proposal, it is true that unreliability requires knowledge, and necessarily true for many possible situations, provided the possible worlds are close enough to ours. in contrast to the second proposal, no reform of the concept of knowledge is proposed, and no need to argue for such a defense is needed. this proposal has the advantage and drawback of embracing non-ideal theorizing: if one remains unconvinced by this method and its defense, then one would not accept one of the crucial premises of unreliability. nado makes one of the most interesting proposals in recent metaphilosophy: the debate about the past and prospects of philosophy should not be formulated in traditional epistemological terms (do we know that the agent in the situation described by russell's clock case fails to know that it's : pm?), but in newly conceptually engineered terms: do we know* that the agent in the situation described by russell's clock case fails to know that it's : pm? we could then stipulate how much evidence, in a context-sensitive manner, would be required to know*. i am friendly to conceptual engineering or, as i call it in philosophy within its proper bounds, to prescriptive conceptual analysis (chapter ; see next section), and i thus welcome this original idea, which should be investigated further. full evaluation will however have to wait for the details since the superiority of any conceptual engineering depends on the details of the proposals: typically, there are several ways of reforming a given concept, and the assessment of their comparative merits depends on their exact similarities and differences (see schupbach on the notion of explanatory power). furthermore, the case for the superiority of the concept of knowledge* has to be clear. otherwise, the metaphilosophical discussion in terms of knowledge* would quickly run into an impasse: the traditional philosopher would concede whatever conclusion we might want to draw in terms of knowledge*, and ask, insistently, whether case judgments amount to knowledge. cappelen and i independently and at the same time defended the importance of conceptual engineering or as i call it prescriptive conceptual analysis (perhaps evidence that conceptual engineering really is important), but we have very different views about what conceptual engineering is about: cappelen ( ) takes conceptual engineering to be a semantic project and endorses semantic externalism (with the surprising result that conceptual engineering is not about concepts); i take it to be a psychological project focused on the tools we use to reason about the world. to establish the philosophical significance of prescriptive conceptual analysis, i have argued that the project of psychologized conceptual analysis is similar to a long tradition in philosophy, best illustrated by carnap and gramsci (machery , ) : ''many traditional philosophical projects are, in important respects, similar to the program described in the present chapter.'' i then referred to hume, whewhell, james, peirce, and carnap. cappelen raises two main objections. first, psychologized prescriptive conceptual analysis differs from other forms of conceptual engineering in philosophy, including carnap's explication, because the latter were explicitly semantic. as he puts it, ''the conceptual engineering tradition is focused on concepts as determinants of extensions and intensions. it is essential to carnapian explication that the semantic values changes (for example, there can be no precisification without such change).'' second, because of the notion of concept i rely on, the project of psychologized prescriptive conceptual analysis seems at odds with what philosophers do. following machery ( ) , i identify concepts as bodies of information that are retrieved by default from long-term memory, to engage in various cognitive tasks (reasoning, categorization, etc.) where a body of information is retrieved by default if it is retrieved in a context-independent manner, and as a result quickly and automatically. cappelen objects that so understood concepts don't seem to be what philosophical reflection with its slow, careful, controlled pace is about: ''if we constantly remind ourselves that what machery means by this [''concept'']: a subset of judgments that are made fast, by default, and in contextinsensitive way, the claims he makes start looking bizarre. this is because most philosophers think slowly, carefully and endlessly assess the judgments we come up with. they are not what machery calls 'default' judgments.' ' cappelen is right that my psychological, explicitly non-semantic take on conceptual engineering differs from some older and contemporary versions of conceptual engineering. similarity is however always a matter of respect, and while different from the latter in some respects, it is similar in other respects. one of the goals of conceptual engineering in philosophy and in the sciences is to avoid being caught in paradoxes and to avoid unreliable inferences, and my psychological approach is tailored to meet these goals: by engineering a concept, we determine what assertions people make and prevent them from asserting something and its negation; we also determine what conclusions they draw from which premises (see the example of the concept of innateness in chapter of philosophy within its proper bounds), ensuring that their inferences are tuned to the world we live in, as revealed by our best science, or the world we want to live in, as determined by our political preferences. what's more, we can do without the semantic detour: we can reformulate the outcomes of conceptual engineering that appear to require a semantic approach. consider precisification: instead of saying that a concept is engineered so as to turn indeterminate propositions into propositions that are determinately true or false, we now say that our goal is to be able to make determinate judgments (judgments we take to be determinately true or false) where we were unable to judge determinately beforehand (because we took the matter to be indeterminate). consider also a change in the truth value of propositions: instead of engineering the concept of a woman so as to make it true that there would be no women if sexist subordination disappeared, we engineered the concept of a woman such that if we were to believe that sexist subordination has disappeared, we would be disposed to believe and assert that there are no women. semantic outcomes are replaced by changes in our dispositions to infer, believe, or assert. comparing these two approaches is beyond the scope of this symposium, but i speculate that this psychologized reformulation of the semantic outcomes of traditional conceptual engineering gets us everything we should want. consider the precisification of the concept of a heap such that nine grains together do not make a heap but ten or more do. what does saying that ''these nine grains are not a heap'' has been rendered determinately true add to saying that we are now likely to ascent to ''these nine grains are not a heap'' as being determinately true? search me. finally, it is worth emphasizing the crucial advantage of a non-semantic approach: the conceptual engineer proposes to modify the conceptual role of a concept without having to worry whether this conceptual role is constitutive of the meaning of the concept. unending controversies about what constitutes the meaning of a concept are entirely bypassed, and we can focus on what matters: avoiding contradictions, inferring reliably, etc. cappelen's second argument fails in the context of conceptual engineering. (it would be a better argument in the context of descriptive conceptual analysis). there is no inconsistency, not even a tension, in holding that, on the one hand, the targets of conceptual engineering are bodies of information retrieved by default and that, on the other, the process of conceptual engineering requires much pondering: we need to decide and argue which revision of our practices is the best. what seems to underlie cappelen's second argument is the idea that it is strange for philosophers to care about concepts, as i characterize them: he speaks dismissively of ''fast and default judgments.'' this concern can be alleviated by seeing philosophy as concerned, at least in part, with describing and improving the cognitive tools people, not simply philosophers, use when they engage with the world. these tools should be concepts as i understand them: they should drive people's attention to the world, their understanding of what they perceive, their reactions and expectations. for instance, when gramsci proposed to conceptually engineer the concept of ideology, his goal was to offer a way of describing discourses about social reality (as ''ideologies'') that would give a task to political activists (viz. identify and criticize ideologies). this is also true of the concepts of consciousness that, following machery ( , - ) , cappelen discusses: block's distinction between phenomenal and access consciousness is meant to be a tool to prevent fallacies not only in philosophy, but also in neuroscience. it is meant to become a default way of understanding phenomena related to consciousness. it is only a useful conceptual distinction if the mechanisms that underlie the qualitative aspects of perceptions differ from those that underlie the use of information in action and reasoning. you just can't count on (un)reliability fixing language: an essay on conceptual engineering aspects of scientific explanation forthcoming). difference and robustness in the patterns of philosophical intuition across demographic groups causation doing without concepts thought experiments and philosophical knowledge philosophy within its proper bounds semantics, cross-cultural style gettier across cultures the gettier intuition from south america to asia cohen to the rescue! ratio comparing probabilistic measures of explanatory power experimental philosophy and philosophical intuition demographic differences in philosophical intuition: a reply to joshua knobe. review of philosophy and psychology what good are counterexamples? philosophical studies how to challenge intuitions empirically without risking skepticism. midwest studies in philosophy normativity and epistemic intuitions the philosophy of philosophy publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -o da x authors: wang, yuke; teunis, peter title: strongly heterogeneous transmission of covid- in mainland china: local and regional variation date: - - journal: front med (lausanne) doi: . /fmed. . sha: doc_id: cord_uid: o da x background: the outbreak of novel coronavirus disease (covid- ) started in the city of wuhan, china, with a period of rapid initial spread. transmission on a regional and then national scale was promoted by intense travel during the holiday period of the chinese new year. we studied the variation in transmission of covid- , locally in wuhan, as well as on a larger spatial scale, among different cities and even among provinces in mainland china. methods: in addition to reported numbers of new cases, we have been able to assemble detailed contact data for some of the initial clusters of covid- . this enabled estimation of the serial interval for clinical cases, as well as reproduction numbers for small and large regions. findings: we estimated the average serial interval was . days. for early transmission in wuhan, any infectious case produced as many as four new cases, transmission outside wuhan was less intense, with reproduction numbers below two. during the rapid growth phase of the outbreak the region of wuhan city acted as a hot spot, generating new cases upon contact, while locally, in other provinces, transmission was low. interpretation: covid- is capable of spreading very rapidly. the sizes of outbreak in provinces of mainland china mainly depended on the numbers of cases imported from wuhan as the local reproduction numbers were low. the covid- epidemic should be controllable with appropriate interventions (suspension of public transportation, cancellation of mass gatherings, implementation of surveillance and testing, and promotion of personal hygiene and face mask use). in december , several cases of severe pneumonia appeared in wuhan, the capital city of hubei province in china. the outbreak was caused by a novel coronavirus: severe acute respiratory syndrome coronavirus , or sars-cov- ( ) and the disease (covid- ) started to spread rapidly ( ) in wuhan. as of may , globally , , cases have been confirmed with , deaths in countries ( ) . in the early outbreak in china, by february , . % ( , / , ) of the confirmed cases were located in hubei province and . % ( , / , ) were located in the city of wuhan, where the outbreak originated ( , ) . the "pneumonia of unknown etiology" appeared in wuhan from december . many early cases have been reported to be linked to the huanan (southern china) seafood wholesale market (hereafter referred to as "the market") ( ) . by january , initial cases were confirmed as covid- ( ) . as the novel coronavirus epidemic was spreading within wuhan, the chinese new year/spring festival ( january ), the most important holiday in china, was approaching. in , . billion of people traveled by bus, train, and plane during days around chinese new year ( ) . wuhan, with a population size of million, is one of the four most important railway hubs in china. with billions of people traveling and lots of family and friends gathering, there was greatly increased risk of rapidly spreading this newly emerging infectious disease, nationally, and even globally. on january , the first confirmed covid- case outside of wuhan appeared in shenzhen, guangdong ( ) . as of january , confirmed covid- cases have been reported in provinces of mainland china and nine countries and areas outside of mainland china ( , ) . on the same day, the central government of the people's republic of china initiated a lockdown in wuhan and two nearby prefectural cities, huanggang and ezhou, in hubei province, to prevent spreading of the covid- outbreak ( , ) . however, as many cases had "escaped" from wuhan before the lockdown, covid- has spread to most provinces. the numbers of cases imported from wuhan for different provinces heavily depend on their connectivities with wuhan. at the same time, municipalities responded differently, regarding timeliness and adequacy of measures (including declarations of public health emergency, holiday extension, event cancelation, and surveillance using infrared thermometers in public spaces. in this study, we used a method for analysing transmission patterns based on the serial interval between clinical cases of covid- ( ) . based on dates of symptom onset and contact various data with different levels of detail were collected from different sources. first, detailed data for confirmed cases between january and february in tianjin province was obtained from the website of tianjin health commission, the website of tianjin centers for disease control and prevention, and the official weibo (china's twitter equivalent) of a local newspaper ( ) ( ) ( ) . collected information included demographic information, travel history to wuhan/hubei, date of symptom onset, and any contact information that could be found. see table for a summary. second, to evaluate the role of "the market" in wuhan and estimate the numbers of cases caused by contact with this source (its reproduction number) in early transmission, data for the first confirmed covid- cases with date of symptom onset and exposure information to "the market" was extracted from a recently published report ( ) . and in third place, we collected epidemic curve data: numbers of cases (total of ) by province and date of confirmation from the wikipedia page of covid- cases in mainland china ( ) and combined these data with detailed information, wherever available, about travel history and location (city and district) extracted from announcements of the health commissions of the provinces. these data were used to compare transmission of covid- in different provinces and cities. since the travel figure | the serial interval between linked cases. (a) when a subject is infected, there is a latency until they start shedding virus and become infectious to others, then they (may) become symptomatic and can be detected clinically. when subject j infects subject i the time between symptom onset in case j and symptom onset in their descendant case i is the serial interval for onset of clinical symptoms. (b) distribution of the serial interval for onset of clinical symptoms, estimated from covid- clusters with partially known links ( figure ). shown are the prior and the posterior mode distribution (the most probable), with % predictive interval. history to wuhan is currently not available for all cases outside of wuhan, the probability that any confirmed cases were linked with wuhan was estimated using the confirmed cases with known travel history between january to february in beijing. adopting terminology of teunis et al. ( ) a transmission probability matrix v can be defined where element v i,j is the probability that subject i was infected by another subject j; v i is a vector of transmission probabilities linking case i to any other case. the total number of observed subjects is n. all observed cases could appear twice: as a descendant (infected subject) i and an ancestor (infecting subject) j. since any case can only have one ancestor the corresponding network must be sparse. elements of v can be estimated by utilizing a distance kernel κ i,j (x i,j |i ← j), that defines a pairwise likelihood that subject i was infected by subject j. the distribution of the serial interval ( figure a) : the distance in time between pairs of cases defines a practical distance kernel, translating the time intervals between symptom onsets in any two cases into a likelihood that these cases were linked as a transmission pair ( ) . as outlined in teunis et al. ( ) , the elements of the transmission probability matrix v may be estimated in a markov chain monte carlo procedure. the elements of the transmission matrix are subject to constraints. diagonal elements must be zero (subjects cannot infect themselves) and rows must add to (unless the parent of the corresponding subject was not observed). additional constraints may be imposed, for instance by preventing links between subjects known to have not been in contact. a mask matrix m (n × n, like v) may be defined, with elements where links are admissible, and where they are not. this mask m may be applied to the matrix of kernels κ i,j () by elementwise multiplication. elements of v representing pairs of subjects with inadmissible links are thus excluded: the corresponding v i,j are set to zero, and they are not updated in mcmc estimation. the mask m can be used to define contacts: whenever subject i is known to have been in contact with another subject j element m i,j = . and perhaps more importantly: when subject i is known to not have had contact with subject k then m i,k = . when a sufficient number of infectious contacts is known, the serial interval distribution may be estimated from outbreak data. first, the elements of the transmission probability matrix v are estimated, using (plausible) starting values for the parameters of the serial interval distribution. then, v is fixed and the serial interval distribution parameters are estimated. then the serial interval distribution is fixed and v is estimated. this alternating procedure can be repeated until no more improvement (in posterior probability) is found ( ) . in the present analyses a special node ( ) was defined, that has a uniform kernel κ i, : any subject can be infected by node at any time, within a given time range. outside that time range κ i, = . such a node could represent environmental transmission, i.e., from "the market" to anyone in contact with that environment, or contact with a pool of infectious subjects, i.e., from any infectious subjects within wuhan/hubei to subjects outside of wuhan/hubei. as the outbreak progressed, travel to wuhan became increasingly less likely, especially after the lockdown of the city of wuhan on january . however, contacts did not cease abruptly: travel records from the confirmed cases in beijing showed a gradually decreasing probability of contact with wuhan. therefore the probability of linking any confirmed cases outside hubei province to wuhan was modeled as a logistic function of the date of confirmation where t is the number of days after january . the parameters were estimated using the travel history records from the confirmed cases in beijing ( figure a ). the fitted logistic relation was then used to impute contacts with wuhan sources for all cases outside hubei province with unknown travel history. once infection has been imported from wuhan, further transmission depends on local contacts: since these comprised relatively few cases it is unlikely that all local cases were equally connected. to simulate inhomogeneous transmission local contacts were imputed by distributing cases within a province or city into clusters. cases within a cluster were assumed fully connected while cases in different clusters were not connected, thus allowing only transmission within a cluster and not between clusters. cluster size was assumed random, with average size five people, and a high probability ( . %) of small clusters (average - people) and a low probability ( . %) of medium to large clusters (average - people). the transmission probability matrix may be used to estimate reproduction numbers by calculating the row sums that represent expected numbers of cases infected by infectious case j (its outdegree), or its reproduction number. reproduction numbers thus are calculated for individual subjects. therefore, they can be grouped in any way useful: by time, to illustrate the progression of transmission during the outbreak; by location, to illustrate spatial variation in transmission; or by other characteristics, like age or gender. in order to translate the transmission probability matrix into a transmission network a multinomial sample of size and probability vector row v i reduces the vector v i to a binary vector with exactly one element and the rest zero. this reduced matrix may be interpreted as an adjacency matrix, equivalent to a directed graph representing a transmission tree of the outbreak ( ). for confirmed cases in tianjin between january and february , the transmission network could be estimated based on the dates of symptom onset, augmented by contact information between cases. table shows some summary statistics of demographic and contact information for those cases in tianjin. as contacts between many of the cases could be identified, so that many elements of the transmission probability matrix were known, joint estimation of the remaining unknown contact probabilities and the serial interval distribution was feasible. with a prior for the serial interval distribution set as gamma( , ), , updates were performed, alternating between probability transmission matrix and serial interval distribution parameters, with iterations for each update and the best fit parameters were chosen as those with the highest posterior probability ( ) . figure shows an estimated (posterior mode) transmission network. using the available contact information, there appeared to be considerable variation in the sizes of clusters of cases. there were two major clusters: one among crew members of tianjin railway and another one among sales representatives and customers in baodi department store. figure b shows the posterior mode serial interval distribution as a gamma distribution (shape parameter . , scale parameter . ), with a mean of . days. this best fit serial interval distribution has been used in all following analyses. figure shows estimated reproduction numbers by day for the initial confirmed cases in wuhan. "the market" node as an infectious source was linked to as many as . cases, on average. for those initial cases, the mean reproduction number was . (until december ). the estimated numbers of imported cases from wuhan varied among provinces in mainland china. provinces bordering hubei province include henan, hunan, anhui, and jiangxi ( , , , ), and provinces with close economic ties with hubei province include zhejiang and guangdong ( and , respectively). these provinces all had high estimated numbers of cases imported from wuhan by february ( figure b) . outside hubei there was less transmission than within hubei province, with average reproduction numbers between and during the first days after the first confirmed local case. the provinces guizhou, hebei, shandong, and guangdong had higher average reproduction numbers: . , . , . , and . , respectively ( figure a) . though the average reproduction numbers were not very high, there existed large variations in reproduction numbers of individual cases, which indicated some individual cases could have spread the disease to many people (figure ) . within a province, there was also spatial variation in the amount of transmission. figure shows the disease transmission in cities within guangdong province. shenzhen and guangdong, the two largest and most affluent urban centers in guangdong, had the highest estimated numbers of cases imported from wuhan ( and , respectively) by february . guangzhou, zhaoqing, shaoguan, shenzhen, and zhuhai had reproduction numbers slightly larger than ( . , . , . , . , and . , respectively) for first days after the first confirmation of a local case in the city. figures a , a show boxplots of estimated reproduction numbers for provinces in china and cities in guandong province, respectively. figure a shows reproduction number estimates by gender and age for beijing and tianjin. spreading patterns of covid- at different spatial scales, from local (railway department and department store) to regional (cities within guangdong province) to nationwide (provinces within china), appear similar: new cases arise from contacts with a reservoir, spreading to remote locations through travel from the origin outbreak region. there likely is some secondary spread locally, from cases infected from the reservoir, but local reproduction numbers are low, often insufficient to support sustained transmission. knowledge of the serial interval, for symptomatic cases in the outbreak, is essential for analysis of the transmission probabilities ( ) . previous studies have estimated the distribution of serial intervals from a set of confirmed transmission pairs, where both the ancestor (who caused infection) and the descendant (who frontiers in medicine | www.frontiersin.org became infected) were known ( , ) . as such information is mostly lacking ( ) (and may be hard to obtain) in this covid- outbreak, we have estimated the serial interval distribution from a curated network, using whatever contact information was available. existing knowledge of contacts (and timing of those contacts) between cases was used to construct a matrix of prior probabilities, to restrict the transmission network to only those links that are possible. when all transmission links are known, the serial interval distribution can be easily estimated. however, at early stages of an outbreak, information on transmission links is usually incomplete. when a sufficiently large proportion of the transmission links is known, it is possible to estimate both the serial interval distribution, and the transmission probability matrix ( ) . starting from a plausible serial interval distribution, the transmission probability matrix v is updated until convergence; then v is frozen and the serial interval parameters are updated, again until obtaining a new optimum; then the serial interval distribution is frozen and the transmission probability matrix is updated again, and so on, until no further improvement can be found. the estimated serial interval distribution, gamma( . , . ), has a mean of . days and good spread out (i.e., large scale parameter) to long serial interval. the variation of serial interval could caused by highly varied incubation period ( ) . such a short serial interval, compared to sars (mean: . days) ( ) and mers (mean: . days) ( ), gives covid- ability to spread more rapidly. the rapid spread of covid- in south korea (from cases on february to , cases on february) and italy (from cases on february to cases on february), shows how missed infectious subjects may cause rapid transmission within a very short period, due to the combination of a short serial interval and an occasionally high reproduction number ( ) . as the incubation period seems to be highly variable, it may be possible that appearance of symptoms in any case precedes symptom onset in its ancestor. when that happens, the serial interval for symptom onset is negative. details of the negative serial interval can be found in the supplementary material. to check whether negative serial intervals would adversely affect analysis we used an alternative distribution, where the serial intervals were shifted leftward by a small amount. a shift of or days had no destructive effect on estimation of v, and the resulting estimates of the effective reproduction numbers did not change substantially. early transmission of a newly emerging infectious disease in a population lacking immunity could reveal the basic reproduction number as long as there is no intervention. currently, the source of covid- is still unclear but many of the early cases were reported to have had contact with the huanan seafood wholesale market. a recent announcement released by the chinese academy of sciences indicated that the source may not have come from this seafood market ( ) . any patient zero would have occurred before the initial confirmed cases, but lacking any specific information about early spread of covid- , it can be assumed that a reservoir of infectious subjects could function as a super-spreading node causing new infections upon contact at any time within the outbreak. assuming such a source for the initial cluster in wuhan ("the market") led to an estimated basic reproduction number . . it must be noted that this environmental "super-spreading node" is hypothetical, and represents the production of new cases by the joint presence of infectious subjects connected to the initial source. there was strong heterogeneity in disease transmission in different provinces of mainland china. the present analysis produces two relevant characteristics: the numbers of cases imported from wuhan, and the average reproduction number for the first days after any confirmed imported case in each province. when there are many imported cases from wuhan, these constitute a large base number of cases to start local spreading of the disease. provinces geographically close to hubei province are expected to experience mass migration from wuhan, especially near the holiday season. provinces with big tier- cities like zhejiang and guangdong both have very high estimated numbers of cases imported from wuhan due to their economic connection with hubei. when early transmission has a high reproduction number, local growth rate in a province will be high. provinces geographically distant from hubei, like hebei, guizhou, and shandong, appear to have relatively high reproduction numbers during early local transmission. in provinces distant from wuhan, the central hub of the outbreak, inhabitants and local governments may have been less cautious (with few public and personal prevention measures) considering high costs of interventions and perceived low risk. since guangdong province has both large numbers of imported cases and high reproduction numbers for early transmission, we further examined the transmission inside of guangdong by city. shenzhen and guangzhou, two of the biggest cities in china, had many imported cases. this is expected considering intense economic connectivity: transportation links, for goods and people including enormous numbers of migrant workers working in those two cities. the numbers of cases imported from wuhan into other cities in guangdong province was smaller. this pattern matches the flow of people in public transport (by train and airplane) converging onto the main transportation hubs (shenzen and guangzhou) and diverging from there toward other destinations in guangdong province. for early transmission following import from wuhan, the reproduction number in most cities in guangdong had an average reproduction number around , during the first days. with appropriate and sustained disease prevention and control measures (e.g., suspension of public transportation, cancellation of mass gatherings, implementation of surveillance and testing, and promotion of personal hygiene and face mask use), the outbreak is unlikely to spread out in those cities. among reported cases, gender differences seemed unimportant; most serious illnesses occurred among the elderly, in particular those with health problems prior to infection, while only a small proportion of cases were young of age ( ) . in the present study, when reproduction number estimates were grouped by gender, no differences were found. similarly, estimates of transmission from different age groups showed that small children and elderly people were equally likely to transmit infection as any other age group (figure a ) . we also examined the effect of the size of clusters imputed on the results and the difference was trivial between average cluster size three and five. an important issue in analyzing transmission of covid- is the amount of silent transmission. as mentioned earlier, some infectious subjects may transmit their infection before they become symptomatic. as long as their descendant cases also go on to develop symptoms their transmission link may still be established. however, when infected subjects who remain completely asymptomatic could be infectious to susceptible contacts, the appearance of such contacts, when symptomatic, could not be linked to their immediate ancestors. given the fact that symptoms seem to be milder in those who are young, such unobservable transmission cannot be excluded ( ) . silent transmission has been seen in other infectious diseases ( ) where, notably, asymptomatically infected subjects appeared to cause fewer transmission. as asymptomatic infections would lead to an antibody response, serology could be a valuable tool to assess the importance of asymptomatic transmission. the datasets analyzed for this study can be found at github (https://github.com/ywan /covid- -transmission). severe acute respiratory syndrome-related coronavirus: the species and its viruses a statement of the coronavirus study group national health commission of the people's republic of china ( ) available online at early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia clinical features of patients infected with novel coronavirus in wuhan available online at available online at national health commission of the people's republic of china ( ) available online at available online at infectious disease transmission as a forensic problem: who infected whom? available online at available online at available online at available online at different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures enhanced hygiene measures and norovirus transmission during an outbreak clinical characteristics of novel coronavirus infection in china transmission dynamics and control of severe acute respiratory syndrome unraveling the drivers of mers-cov transmission how generation intervals shape the relationship between growth rates and reproductive numbers decoding the evolution and transmissions of the novel pneumonia coronavirus (sars-cov- ) using whole genomic data molecular and serological investigation of -ncov infected patients: implication of multiple shedding routes nosocomial transmission of norovirus is mainly caused by symptomatic cases all authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. we were grateful to the alumni of cohort b ' at shijiazhuang no. middle school, including di an, jiayi liu, xun li, menghan hou, yunpeng zhang, fan huang, and hongxu li for gathering and sharing information form various sources about covid- . the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/ . /fmed. . /full#supplementary-material conflict of interest: the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © wang and teunis. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- - l rcfm authors: mamode khan, naushad; soobhug, ashwinee devi; heenaye-mamode khan, maleika title: studying the trend of the novel coronavirus series in mauritius and its implications date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: l rcfm mauritius stands as one of the few countries in the world to have controlled the current pandemic, the novel coronavirus (covid- ) to a significant extent in a relatively short lapse of time. owing to uncertainties and crisis amid the pandemic, as an emergency announcement, the world health organization (who) solicits the help of health authorities, especially, researchers to conduct in-depth research on the evolution and treatment of covid- . this paper proposes an integer-valued time series model to analyze the series of covid- cases in mauritius wherein the corresponding innovation term accommodates for covariate specification. in this set-up, sanitary curfew followed by sanitization and sensitization campaigns, time factor and safe shopping guidelines have been tested as the most significant variables, unlike climatic conditions. the over-dispersion estimates and the serial auto-correlation parameter are also statistically significant. this study also confirms the presence of some unobservable effects like the pathological genesis of the novel coronavirus and environmental factors which contribute to rapid propagation of the zoonotic virus in the community. based on the proposed com-poisson mixture models, we could predict the number of covid- cases in mauritius. the forecasting results provide satisfactory mean squared errors. such findings will subsequently encourage the policymakers to implement strict precautionary measures in terms of constant upgrading of the current health care and wellness system and re-enforcement of sanitary obligations. four months since the start of the covid- outbreak, most affected states have imposed strict confinement measures, largely disrupting the daily sequence of works in various spheres. most people are working from home with limited resources, online teaching instead of traditional classroom teaching are being conducted and strict sanitization measures in public places, especially in super, and hypermarkets have been imposed. overall, the world is in an unexpected turmoil. however, there is still a ray of hope, especially, when developing sub a a a a a saharan african countries with limited economic resources, like mauritius and seychelles, are combating the pandemic with full vigor. setting the focus on mauritius, this is one of the countries whose economy has made great strides and as of the end of april , the health authorities officially reported that more than percent of covid- patients have recovered ( recovered cases out of confirmed cases, with active cases). indeed the situation was alarming when the first cases of covid- was reported on the th march and within four weeks, the total number of confirmed cases climbed to , an exponential increase, and the total number of deaths was hovering at . considering the severity of the situation, policy makers announced a six-week national complete lockdown, effective from the th march , high-tech medical diagnostic apparatus, key protective hygiene and sanitation equipment and life saving medical drugs like hydroxychloroquine tablets, worth a colossal amount, were purchased and even obtained free of charge from sister countries like india, to upgrade the quality of health services and fight the pandemic. thorough covid- screening is being conducted on a daily basis. within one month, by the end of april , around , polymerase chain reaction (pcr) tests in addition to , rapid swab tests have been conducted among "frontliners" who are hospital health care workers and essential service workers, representing around per cent of the whole population. this measure is indeed applaudable as by early detection of the virus, some patients can be cured quickly. as pro-active measures, mauritius is better equipped with an average of . hospital beds per population, as compared to developed countries like the united kingdom (uk) and other sub saharan countries [ ] and with the collaboration with private stakeholders, an adequate number of quarantine centers have been instituted. all these measures, along with the positive changes in the population behaviour in regard to confinement, have altogether helped to contain the pandemic in mauritius. the measures adopted by mauritius have highly been praised by international organizations such as world health organization (who) and united nations (un). as a retrospective, it is important to retrieve, via inferential statistical methods, the factors that have contributed significantly in controlling the propagation of the novel coronavirus in mauritius. besides, since the covid- data is in the form of an integer-valued time series [ ] layout, it is of research importance to develop an integer-valued regression time series process that can provide insights on the significance of explanatory variables as well set a platform to forecast the possible number of covid- infected cases which is quite tedious as illustrated in [ , , ] . admittedly, research findings in [ ] indicate that the covid- data exhibits lots of dynamic and latent features and hence, to cater for such volatilities, we introduce random effects in our model specification. in this context, we propose gamma [ ] and normal [ ] random effects that, in addition to the covariate specifications, would render the model estimators less biased and improve the forecasts. in the same vein, such forecasts will aid policymakers in articulating post pandemic measures, since mauritius, which is highly dependent on the hospitality sector, is expected to face a drastic contraction in its economic growth. the research findings in this paper will evidently guide policy makers and add value to the limited research undertaken so far in the case of covid- in mauritius. it is important to understand the evolution of covid- in mauritius otherwise as an import-dependent country, mauritius may find itself engulfed in the darkness of covid- in terms of loss in economic wealth and deterioration in population health state. the paper therefore proposes an integer-valued auto-regressive model (inar( )) with conway-maxwell poisson (com-poisson) mixed innovation terms that can accommodate for covariate, random effect and serial auto-correlation specifications. the organization of the paper is as follows: in section , material in terms of time series of covid- in mauritius and proposed methods principally the inar( ) process and the com-poisson mixture innovations have been provided. estimation of parameters are in section as well. in section , the results have been interpreted followed by some discussions in section . finally, section concludes the study. the local data on covid- is publicly available in european union open data portal at s . as aforementioned, mauritius registered its first three cases on the th march and as at th april or after days, the health authorities of mauritius officially reported active cases of covid- and deaths. this signifies an overall average of . covid- cases per day with a variance of . . detailed statistics for the days are given at s . currently, three important peaks have been noted on day ( th march ), day ( th april ) and day ( th april ) where , and patients were tested positive for covid- respectively. based on these statistics, it is obvious that the data are exhibiting severe over-dispersion. this is confirmed by the qcc.overdispersion.test in r statistical software via the qcc package that yields a chi-squared p-value of . e − , showing a high level of significance. moreover, the rcorr and the adftest illustrate that the data exhibit some serial correlation and are non-stationary. this indicates that the number of infected cases in mauritius shows some fluctuations as well. the varselect routine in the library vars showed that the akaike information criterion (aic) yielded a lag order of , and hence we can conclude that the model proposed in section is suitable to model the above series. let y t indicates the number of infected or covid- positive case at the t th time point, t = , , , . . ., t and e y t ¼ y t jg, where γ describes the aforementioned latent effect. in the subsequent parts of this section, we show the different probability models for γ. thus, the vector of time series conditional count observations is represented by e y ¼ ½ e y ; e y ; . . . ; e y t ; . . . ; e y t � . it is important to assume that the observations e y t and g y ðtþhÞ are likely to be serially correlated, where the lag h z þ ; � h � t À . due to the latent effect γ, the covariance between the unconditional observation y t and y t + h is computed as: we further assume that the observation y t is subject to a p × vector of covariates, denoted by x t ¼ ½x t; ; x t; ; x t; ; . . . ; x t;k ; x t;ðkþ Þ ; . . . ; x t;p � that comprises of both time-variant and timeinvariant exogeneous variates. the regression vector β is denoted by β = [β , β , . . ., β k , β k+ , . . ., β p ]. as stated earlier, we assume that the conditional observation e y t follows the inar( ) process that satisfies the first-order auto-regressive equation [ ] e where r t is the random innovation component and ρ ( , ) independent of the observation e y t , covðg y tÀ k ; e r t Þ ¼ , for k z þ and � indicates the binomial thinning operator where r � g y tÀ jg y tÀ � binomialðg y tÀ ; rÞ [ ] . hence, the above auto-regressive equation can be re-written in terms of the error components r t [ ] as: and hence the moments of e y t are derived from the distributional properties of e r t and using the binomial thinning properties. we now introduce the com-poisson mixture model, wherein the innovation term e r t in eqn( ) follows the com-poisson mixture as: . hence, the com-poisson generalizes some important discrete models and for some substitutions, the com-poisson acts a bridge between the binomial, geometric and negative binomial. however, in practice, the exact evaluation of zð e l t ; nÞ is nearly impossible for a general ν > . the following approximation was suggested in [ ] zð e l t ; nÞ ¼ expðn and this proves to yield satisfactory results especially for very large λ, as illustrated in [ , ] . in fact, under this approximation, the moments of e r t can be expressed suitably in closed forms as follows: n ; whilst still, the above approximations satisfy the over-(under) dispersion assumptions for ν < (>) . in fact, e l t ¼ expðx t b þ gÞ. in the same vein, an alternative re-parameterization of the com-poisson was proposed in [ ] , by allowing e m t ¼ expðx t b þ gÞ. as for the model specification for γ, we let w = w(κ ) = exp(γ) follows the exponential of the respective probability function, assuming κ = σ + ν. the moments of the unconditional response, y t are given as below and the detailed proof is in s appendix: it is clear, from the above marginal moments that the ratio vðy t Þ eðy t Þ > and hence the above model is suitable to model over-dispersion, in particular, severe over-dispersion. we assume the following single-parameter models-gamma and normal distributions for the random effect w = exp(γ), given as: with where κ = σ + ν. by assuming e y t ¼ r � g y tÀ þ e r t , the conditional log-likelihood function for the set of observations (y , y , . . ., y t , . . ., y t ) is written as: where f ðe y t j g y ðtÀ Þ ; gÞ ¼ x min ðe y t ;g y ðtÀ Þ Þ s¼ g y ðtÀ Þ s � � r s ð À rÞ g y ðtÀ Þ À s � f e r t ðe y t À sÞ ð Þ from the above, the evaluation of the integrand in eq ( ) is performed using the numerical quadrature techniques using the integral, fastghquad packages in r and likelihood is thereon optimized using the optim function. further to the model construction and estimation procedures, in this section, some time-independent and time-variant covariates that could explain the fluctuations in the number of confirmed covid- active cases in mauritius have been considered. the following covariates are measured as from th march until th april . many songs of hope in local and international languages, with the aim to communicate the seriousness of the situation and encourage the population to stay home, have been playing on social media. slogans like "stayhomestaysafe" and "besafe-moris" have been trending on social media to draw attention on the importance of confinement. in some strategic areas, the police force even addressed the public on important confinement-related matters using loudspeakers. the results illustrate that the climatic conditions do not contribute quite significantly to the evolution of the covid- in mauritius, while the remaining variables do impact significantly on the number of covid- cases. it can be noticed that the sanitary curfew/lockdown, sanitization and sensitization campaigns and safe shopping guidelines have helped to curb down, by a large extent, the number of covid- cases in mauritius. hence, such preventive and pro-active measures, with the main focus on sanitization measures at grocery stores and in busy public places, should be maintained even after lifting lockdown orders. we can also note that the number of contravention fines and traffic offences tackled by the officers of the mauritius police force have also helped in containing the virus as due to road blockages, the mobility of people are minimised leading to no public gatherings. the treatment variable confirms availability of adequate hydroxychloroquine tablets to treat the number of covid- cases in mauritius. the number of quarantine centers have significantly helped in timely containment of the novel coronavirus, eliminating to a great extent the risk of spreading in the local community. as per the protocols set by the ministry of health and wellness, as soon as people were repatriated to mauritius, they were immediately self-isolated. based on the numerical evidence, the age composition, in the local context, shows that people below years of age has been more affected by covid- . the value of σ confirms the presence of some unobservable effects that are possibly contributing to the propagation of the virus. this could be linked to research findings in [ , ] which showed that the sars-cov- is an aerosolized virus, particularly found in patients' bathrooms, whilst others concluded that the small airborne particles could remain suspended in air and even flow up to six feet with the air current [ ] . the results in table were obtained assuming the training dataset from th march to th april . we use the above regression estimates or weights to forecast the number of infected covid cases in mauritius from th april to rd april . from table , the mean squared error (mse) based on the proposed com-poisson gamma mixture is computed as . with relatively lower corresponding aic, which can be viewed as satisfactorily adequate. in fact, the model slightly overstates the number of cases which is surely more beneficial and prudent to the policymakers. local authorities, through provision of sufficient ppes to "frontliners", re-enforcement of the sanitary obligations and by upgrading the sanitization campaigns, can help to contain the virus more rapidly. also, using these forecasts, the local health authorities can make reliable action plans, especially, regarding bed capacity in each covid- hospitals in case of sudden increase in the number of covid- cases in the future. note that a similar prediction exercise was reported in italy [ , ] using an alternative forecasting method, but since not all its regions were under confinement and, most importantly, due to delay in policy making, the scenario went uncontrollable. in line with confinement measure, new feasible approaches including broadcasting of educational content on television for primary and secondary grade levels, work from home schemes, setting up of online purchasing platforms, provision of urgent court services via technological communication and a more safe and hygienic lifestyle have been adopted to limit socio-economical shocks. however, many individuals, especially working people and children, are exposed to this unprecedented stressful situation of unknown duration. it is proven that changes in work schedule and requirements and home schooling affect the psychological behaviours of most individuals [ , ] . here, right parenting skills and sustainable programmes by local stakeholders become crucial. for the tertiary sector, academics used intensively interactive online teaching platforms for virtual lecturing, as well as open source learning platforms for assignment practices. for adequate food supply and a reasonable price mechanism on the local market, a controlled mark-up of percent on some basic commodities and restrictions on quantity of basic groceries purchased, have been implemented. local crop production is being encouraged through provision of diverse rebate schemes and reduction in the price of vegetable seeds. vulnerable families, where the head of the household are self-employed, or are informal sector workers or lead a small and medium enterprise, are financially being assisted based on the new social protection schemes. the aforementioned economic activities have recently faced a drastic fall in performance due to the prolonged movement restrictions. it is compulsory for any employee to be in possession of a work access permit, when travelling to work. misuse of the permit will lead to serious legal convictions. recently, the covid- (miscellaneous provisions) bill and the quarantine bill were implemented with foremost aim to drive the mauritian economy and to prevent any resurgence of the disease. through setting up of a comprehensive set of strict sanitary measures, improvement in surveillance control and in the level of preparedness in the health care system, mauritius remain on alert to stave off a second wave of sars-cov- in the country. the covid- (miscellaneous provisions) bill brought in amendments to safeguard the fundamental rights of mauritians and most importantly the public health. in this context, it is believed that the findings from this study will act as a yardstick for policy makers when planning for preparedness measures and response strategies. every stakeholders, be it the individuals, the governmental or non-governmental organisations and the principal actors of the private sector, should bring in their collective capacities to work towards a "covid- -free" mauritius. as of now, physical distancing is the new "norm" of the society. the results of this research revealed that several factors, the most significant being confinement measure, and least one being climatic conditions, affect the number of covid- cases in mauritius. it is worth mentioning that the proposed model adapts to the local data since the number of covid- cases in mauritius is mostly low integer-valued, hence, its usage is not generic as it depends on the nature and pattern of the covid- data. besides, some countries like, seychelles, faces a zero-inflated pattern which implies the present model needs to be modified to accommodate for zero-inflated cases. however, as for mauritius, this shall guide the policy makers to implement stricter preventive measures associated with legal obligations and economical tools to curb the pandemic on time and capitalise the mauritian economy. the state of mauritius should ensure that other jurisdictions like rodrigues, agalega and chagos archipelago, which lack high quality health care services are not affected by covid- . research on covid- should be ongoing due to pathological complexities of the novel coronavirus and unexplored area of research like seasonal effect on the spread of the virus [ ] . mauritius heads into coronavirus storm with strong social welfare buffers. the conversation autoregressive moving-average processes with negative binomial and geometric marginal distrbutions composite monte carlo decision making under high uncertainty of novel coronavirus epidemic using hybridized deep learning and fuzzy rule induction finding an accurate early forecasting model from small dataset: a case of -ncov novel coronavirus outbreak forecasting models for coronavirus disease (covid- ): a survey of the state-of-the-art investigating the cases of novel coronavirus disease (covid- ) in china using dynamic statistical techniques on familial longitudinal poisson mixed models with gamma random effects random effects models for longitudinal data discrete operator self-decomposability and queing networks. stochastic models first-order integer-valued autoregressive process a useful distribution for fitting discrete data the com-poisson model for count data: a survey of methods and applications approximating the conway-maxwell-poisson distribution normalizing constant reparametrization of com-poisson regression models with applications in the analysis of experimental data. statistical modelling eco-epidemiological assessment of the covid- epidemic in china temperature, humidity, and latitude analysis to predict potential spread and seasonality for covid- . ssrn preprint the coronavirus pandemic and aerosols: does covid- transmit via expiratory particles aerodynamic analysis of sars-cov- in two wuhan hospitals consideration of the aerosol transmission for covid- and public health modelling and predicting the spatio-temporal spread of coronavirus disease (covid- ) in italy. statistical modelling covid- and italy: what next dealing with sleep problems during home confinement due to the covid- outbreak: practical recommendations from a task force of the european cbt-i academy mitigate the effects of home confinement on children during the covid- outbreak seasonality and immunity to laboratory-confirmed seasonal coronaviruses (hcov-nl , hcov-oc , and hcov- e): results from the flu watch cohort study special thanks to ministry of health and wellness in mauritius and to world health organization (who) for disseminating covid- related information on a daily basis. conceptualization: maleika heenaye-mamode khan. key: cord- -h nrw authors: gong, xiaohuan; xiao, wenjia; cui, yan; wang, yuanping; kong, dechuan; mao, shenghua; zheng, yaxu; xiang, lunhui; lu, lu; jiang, chenyan; yu, xiao; zhu, yiyi; fang, qiwen; pan, hao; wu, huanyu title: three infection clusters related with potential pre-symptomatic transmission of coronavirus disease (covid- ), shanghai, china, january to february date: - - journal: euro surveill doi: . / - .es. . . . sha: doc_id: cord_uid: h nrw we report three clusters related with potential pre-symptomatic transmission of coronavirus disease (covid- ) between january and february in shanghai, china. investigators interviewed suspected covid- cases to collect epidemiological information, including demographic characteristics, illness onset, hospital visits, close contacts, activities’ trajectories between days before illness onset and isolation, and exposure histories. respiratory specimens of suspected cases were collected and tested for sars-cov- by real-time reverse-transcriptase polymerase chain reaction (rrt-pcr) assay. the interval between the onset of illness in the primary case and the last contact of the secondary case with the primary case in our report was to days. in cluster (five cases), illness onset in the five secondary cases was to days after the last contact with the primary case. in cluster (five cases) and cluster (four cases), the illness onset in secondary cases occurred prior to or on the same day as the onset in the primary cases. the study provides empirical evidence for transmission of covid- during the incubation period and indicates that pre-symptomatic person-to-person transmission can occur following sufficient exposure to confirmed covid- cases. the potential pre-symptomatic person-to-person transmission puts forward higher requirements for prevention and control measures. we report three clusters related with potential presymptomatic transmission of coronavirus disease (covid- ) between january and february in shanghai, china. investigators interviewed suspected covid- cases to collect epidemiological information, including demographic characteristics, illness onset, hospital visits, close contacts, activities' trajectories between days before illness onset and isolation, and exposure histories. respiratory specimens of suspected cases were collected and tested for sars-cov- by real-time reverse-transcriptase polymerase chain reaction (rrt-pcr) assay. the interval between the onset of illness in the primary case and the last contact of the secondary case with the primary case in our report was to days. in cluster (five cases), illness onset in the five secondary cases was to days after the last contact with the primary case. in cluster (five cases) and cluster (four cases), the illness onset in secondary cases occurred prior to or on the same day as the onset in the primary cases. the study provides empirical evidence for transmission of covid- during the incubation period and indicates that pre-symptomatic person-to-person transmission can occur following sufficient exposure to confirmed covid- cases. the potential pre-symptomatic person-to-person transmission puts forward higher requirements for prevention and control measures. an outbreak of pneumonia of unknown aetiology occurred in wuhan, hubei province, china, in december [ , ] . the first cases were linked to exposure at wuhan's huanan seafood wholesale market. a novel coronavirus, severe acute respiratory syndrome coronavirus (sars-cov- ), was identified as the causing infectious agent [ ] and the world health organization (who) declared a public health emergency of international concern on january and a pandemic on march [ , ] . as at march , there were , coronavirus disease (covid- ) confirmed cases in china and , confirmed cases globally [ ] . the covid- pandemic has since continued to progress rapidly worldwide [ , ] . as at january , hubei province reported confirmed cases and shanghai had reported nine confirmed cases [ ] . on january, the shanghai municipal government declared the first-level response for a major public health emergency to firmly curb the spread of the epidemic [ ] . stringent prevention and control measures were implemented, including strengthening health screening and quarantine, cancelling various large-scale public activities, encouraging people to stay at home and to wear a mask in unavoidable outside activities. there was early evidence for human-to-human transmission among close contacts, such as in hospital, family and community settings [ ] [ ] [ ] [ ] . although evidence of pre-symptomatic transmission accumulated [ ] [ ] [ ] , the infectivity and duration of transmission during the incubation period have been inconclusive. these key epidemiological parameters, however, are important for outbreak control and to reduce virus transmission. virus spread by pre-symptomatic cases poses great challenges to disease control and has an important impact on preventive strategies. between and january , three hospitals in two districts of shanghai city reported five suspected covid- cases to the local district centers for disease control and prevention (cdc). the five cases (cluster ) were laboratory-confirmed - days later by the shanghai municipal cdc laboratory; two were index cases and three were close contacts, i.e. friends and close family members. cases had histories of common activities, such as travelling and dining, or were living together. on february , another hospital in shanghai reported one suspected covid- case and six of their close contacts to the local district cdc; four of the close contacts tested positive for sars-cov- by realtime reverse-transcriptase polymerase chain-reaction (rrt-pcr), - days later (cluster ). the seven persons were from one family, including four grandparents plus a young couple and their infant. two grandparents had come to shanghai from wuhan on january. from - january , a further hospital in shanghai reported four suspected covid- cases to the local district cdc. these four cases (cluster ), two index cases and two close contacts, were laboratoryconfirmed day later. they were from two couples and two of the four individuals were siblings. one couple had come to shanghai from wuhan on january and had lived with the other couple since then. initial investigations revealed the epidemiological links in each of these thee clusters. further epidemiological investigations, control measures and specimen collection were conducted by a joint field epidemiology team from the respective days when reports were received. we report the key findings of the field epidemiological investigations of the three infection clusters related with potential pre-symptomatic transmission of covid- . a joint field epidemiology team, comprising public health physicians from shanghai municipal cdc and local district cdcs, was formed and conducted detailed field investigations from the day covid- case reports were received. investigators interviewed covid- cases, close contacts and healthcare workers directly (face-to-face or over the phone) to collect epidemiological information including demographic characteristics, date of illness onset, hospital visits, close contacts, activities' trajectories between days before illness onset and isolation and exposure histories (i.e. travel to or living in wuhan or hubei province, visiting any other area with local sustained transmission of sars-cov- , contact with persons with respiratory symptoms, contact with suspected or confirmed covid- cases). in addition to interviews, medical records and travel records were checked, security cameras' videos were retrieved, and on-site investigation of key public settings were performed. the epidemiological information of cases from multiple sources was cross-checked to ensure the reliability of information. once an infection cluster was identified, epidemiological links and transmission chains were analysed. timeline of exposure to pre-symptomatic case and illness onsets of cases in cluster of covid- outbreak, shanghai, china, january- february (n = ) upper respiratory specimens (nasopharyngeal swab, throat swab and/or nasopharyngeal-throat swab) and/ or lower respiratory specimens (sputum) of suspected cases were collected and tested for sars-cov- by rrt-pcr assay in the shanghai municipal cdc laboratory. the viral target included open reading frame ab (orf ab) and nucleocapsid protein (n). the specimen was positive for covid- only if both viral targets were positive [ , ] . we used the rd version of prevention and control guidelines for novel coronavirus pneumonia by the national health commission of the people's republic of china's case definition [ ] . a suspected case was defined as any person meeting clinical signs of covid- and/or with epidemiological histories. a confirmed case was any suspected case with respiratory samples testing rrt-pcr-positive for sars-cov- . epidemiological histories were defined as (i) history of travelling or residing in wuhan or any other areas where local sustained transmission of covid- existed within days before illness onset, (ii) history of contact with patients with fever or respiratory symptoms from wuhan or any other area where local sustained transmission of covid- existed within days before illness onset, and (iii) clustering of illness onsets, or having an epidemiological association with cases rrt-pcr-positive for sars-cov- . clinical and laboratory signs included were (i) fever, (ii) radiological evidence of pneumonia, (iii) normal or under normal white blood cell count in early stage, or under normal lymphocyte count. an infection cluster was identified if more than one sars-cov- rrt-pcr-positive case was found in a confined environment or group (such as a family, a company, etc.) within days, and there was a possibility of interpersonal transmission because of close contact or co-exposure. a close contact was anyone who was closely in contact with a suspected, confirmed and asymptomatic case without effective personal protection (classified protection according to the contact situation, including gloves, medical protective masks, protective face screens, isolation clothing, etc.) since onset of symptoms in the suspected case and confirmed case or the day asymptomatic case's specimens were collected. the close contact included: (i) living, working, or studying in one house or classroom, (ii) diagnosing, treating, or visiting cases in hospital ward, (iii) being within short distance in the same vehicle, (iv) other situations assessed by the field investigators. the epidemiological investigations were carried out according to the law of the people's republic of china on prevention and control of infectious diseases [ ] . ethical approval was not required because the cdcs are able to access and use personal identifiable information for infectious disease outbreak investigation according to the law of the people's republic of china on prevention and control of infectious diseases [ ] . all cases were informed about the related rights and obligations and oral consent was obtained from all cases. details were anonymised to protect the individual's privacy. timeline of exposure to pre-symptomatic case and illness onsets of cases in cluster of covid- outbreak, shanghai, china, january- february (n = ) case a became symptomatic with fever ( . °c) at night on january. they presented to hospital accompanied by a parent on january and were diagnosed with bronchitis. the examination showed: body temperature was . °c, white blood cell count was . x /l (norm . - . x /l). influenza a and b antigen tests were both negative. case a visited the hospital again, accompanied by their parent, on january because of persisting symptoms. chest computed tomography (ct) scan showed scattered patches and increased density in both lungs. they went back home that day. following case e's detection as suspected covid- case on january, case a returned to hospital alone and was suspected as covid- case one day later, when they were isolated and treated. the nasopharyngeal-throat swab was rrt-pcr positive for sars-cov- on february. case b developed fever ( . °c) at : on january. they developed headache, productive cough (bloodshot) and myalgia subsequently during and january. they presented to hospital accompanied by their parent on january and january, respectively. influenza b antigen test was positive and influenza a antigen test was negative. on january, they went to hospital again, accompanied by their parent, were suspected as covid- case, were isolated and received treatment at the hospital. the examination showed: white blood cell count was . x /l. chest ct scan showed multiple ground glass opacities in both lungs. the nasopharyngeal-throat swab and sputum specimen were both rrt-pcr positive for sars-cov- on january. case b died in february at the treating hospital. case c had a fever ( . °c) at : on january. they visited the hospital accompanied by their parent on january, got symptomatic treatment and went back home. as case b's close contact with symptoms, case c visited the hospital again, alone; they were suspected as covid- case, they were isolated and received treatment at hospital on january. the examination showed: body temperature was . °c, white blood cell count was . x /l. chest ct scan showed infection in the left lung. the sputum specimen was rrt-pcr positive for sars-cov- on january. cases d and e became symptomatic on january and january, respectively. case e was isolated and received treatment on january. as case e's close contact with symptoms, case d was isolated and timeline of exposure to pre-symptomatic case and illness onsets of cases in cluster of covid- outbreak, shanghai, china, january- january (n = ) case c became symptomatic with a light productive cough and diarrhoea around noon of january, hour after illness onset of case a. as case b's close contact with symptoms, they presented to hospital, were suspected as covid- case, were isolated and received treatment on february. the nasopharyngealthroat swabs were rrt-pcr negative for sars-cov- on february and positive on february. as case b's close contacts, cases a and b's spouses, as well as cases d and e had been asymptomatic and were admitted to hospital on february. the nasopharyngeal swabs of cases d and e were both rrt-pcr positive for sars-cov- on february. the nasopharyngeal swabs of cases a and b's spouses were both twice rrt-pcr negative for sars-cov- at an interval of hours (figure cluster involved four confirmed covid- cases, two males and two females, aged between and years. case a is case d's spouse. case c is case b's spouse. case a and case c are siblings. cases a and d lived in wuhan, hubei province. they stayed at home except for purchasing food items in the market. they had not been to wuhan's huanan seafood wholesale market or been in contact with wild animals in wuhan. cases b and c lived in shanghai. case b was a long-term bedridden patient with several comorbidities (hypertension, cardiac disease and chronic obstructive pulmonary disease). case c purchased food items, cooked meals and took care of case b at home. cases a and d arrived in shanghai by train on january and stayed in case b and c's apartment since : that day. on january and january, cases a, c and d went shopping at a nearby supermarket twice. apart from this, the four cases stayed at home and did not go outside. case a became symptomatic with chills and fever at : on january. they presented to hospital, were suspected as covid- case, and were admitted to hospital for isolation and treatment on january. the examination showed: body temperature was . °c, white blood cell count was . x /l. chest ct scan showed two patchy ground glass opacity high-density shadows in the right lung. the throat swab was rrt-pcr positive for sars-cov- on january. case a died in hospital in march. case b developed poor appetite and dry cough on the morning of january and fever ( . °c) on january. they presented to hospital, were suspected as covid- case, and admitted to hospital for isolation and treatment on january. the examination showed: white blood cell count was . x /l. influenza a and b antigen tests were both negative. chest ct scan showed interstitial hyperplasia and infection of both lungs. the nasopharyngeal swab and throat swab were both rrt-pcr positive for sars-cov- on january. case b died in hospital on january. as close contact of cases a and b, case c developed fever ( . °c); case d also developed fever ( . °c), both at : on january, and they were both admitted to hospital on the same day. the nasopharyngeal swabs and sputum specimens of cases c and d were both rrt-pcr positive for sars-cov- on january (figure ). in these three infection clusters, confirmed cases developed symptoms and visited hospitals when they were in shanghai and eight of these confirmed cases were related with potential pre-symptomatic transmission (table ) . cdcs' public health physicians conducted field epidemiological investigations and communicated with the cases directly; contact situations of three infection clusters are shown in table . in each of the clusters, the primary cases were identified (cases a, a, a) and in total five cases (case b, c, b, c, b) were secondary cases who got infected by being in close contact with the primary cases. the primary cases a, a and a, had no clinical symptoms or signs when they were in contact with these five secondary cases, and there were no contacts after the illness onset of the primary cases. in cluster , illness onset in the five secondary cases was to days after the last contact with the primary case. in cluster and cluster , illness onset in secondary cases occurred prior to or on the same day as the onset in the primary cases. the interval between the onset of illness in the primary case and the last contact of the secondary case with the primary case in our report was to days. no other relevant exposure histories of the secondary cases were found. multiple control measures were implemented immediately once these three clusters were detected. first, isolation and treatment was performed immediately when patients were suspected to have covid- according to doctors' judgment based on the existing guidelines [ ] . suspected cases were transferred by ambulance to a municipal-designated hospital once their respiratory specimens were rrt-pcr positive for sars-cov- . second, close contacts were put under centralised or home medical observation for days since the last day of contact with cases, under supervision of a team including clinical physicians, nurses, cdc physicians, and community workers. during observation, body temperature and respiratory symptoms or signs were recorded twice every day. third, disinfection measures were implemented in cases' homes, visited hospitals, work places and other places where cases had spent time, to prevent secondary infections. fourth, surveillance in fever clinics and health education for the population were strengthened especially in areas where the infection clusters occurred. fifth, people arriving to shanghai from other provinces or foreign countries were health quarantined for days in a centralised isolation location, and observed medically with body temperature and respiratory symptoms or signs being recorded twice every day. the study provides empirical evidence for transmission of covid- in the pre-symptomatic phase. it supports the th version of prevention and control guidelines for novel coronavirus pneumonia published by the national health commission of the people's republic of china on february [ ] which refers to close contacts as those in close contact with cases without effective protection from days before the onset of symptoms. in their research, zou et al. showed that the viral load detected in asymptomatic covid- cases was similar to that in symptomatic ones [ ] , which suggests the transmission potential of asymptomatic or minimally symptomatic patients. in april , who interim guidelines also suggested that individuals who had contact with a confirmed case from days before symptom onset should be identified and traced [ ] . these changes to the earlier who interim guidelines emphasised the importance of looking for contacts in their pre-symptomatic stage. the longest interval between the onset of illness in the primary case and the last contact of the secondary case with the primary case in our report was days, which was longer than days and within the ranges of published mean incubation period ( . - . days) according to recent research [ , , ]. an alternative explanation could be that the initial symptoms of the primary case of cluster were too mild to self-recognise. both explanations of this study provide clues for further research on pre-symptomatic transmission of covid- . unlike sars-cov- , where almost all onward transmissions occur after symptom onset [ ] , published evidence of pre-symptomatic transmission has been accumulating for sars-cov- [ ] [ ] [ ] , ] . transmission before symptom onset has a marked effect on control and prevention of infectious diseases. it increases the probability for the population to get infected, and weakens the power of isolation because contacts may have got infected already before isolation of the cases [ ] . in the study by mizumoto et al., the estimated asymptomatic proportion was . % ( % credible interval: . - . %) [ ] . the clinical spectrum and infection spectrum of covid- still need to be studied deeper to help public health decision making. among the three infection clusters, pre-symptomatic transmission appeared to take place when (i) the exposure time was sufficiently long i.e. equal to or more than hours, (ii) the exposure distance was short i.e. less than m, (iii) the exposure frequency was high and the distance was short i.e. living together in one house, dining or playing together at one table, and (iv) no masks were worn when in contact. this indicates that pre-symptomatic person-to-person transmission can happen when there is sufficient exposure with a confirmed covid- case. however, we do not know whether shorter or less intense exposures to pre-symptomatic cases might also lead to transmission. there are two main limitations that need to be acknowledged. first, the evidence case reports provide is less persuasive than results of well-designed studies where information is obtained following a specific protocol. second, even with detailed field investigation and information that was cross-checked from multiple sources, considering recall bias, there is still chance that not every possibility for transmission was recorded, such as whether there were alternative sources for cluster . this report also showed that covid- can be transmitted between families, friends and cities. transmission has taken place all over the world [ , ] . strict measures were adopted in the early stage of the covid- epidemic in shanghai, which resulted in decreasing numbers of reported confirmed and suspected cases. in the past months people have been returning to shanghai for work from all over china and people have been arriving in shanghai from all over the world; shanghai is facing great challenges in preventing imported cases. medical observation and centralised isolation of people from abroad was strengthened. health quarantine for days in centralised isolation location for every traveller returning from other countries is crucial in preventing imported covid- cases, which can lead to imported cases in this pandemic. the potential pre-symptomatic person-to-person transmission puts forward higher requirements for research and prevention and control measures. until the infectivity and duration of incubation period transmission are conclusive, more research is needed for optimising prevention and control strategies, including seroprevalence studies, natural history studies based on population in epidemic areas, and studies about efficiency of asymptomatic transmission. the incubation period should be taken into consideration in epidemiological investigations and the identification of close contacts. moreover, the importance of pre-symptomatic transmission in outbreak evolution needs to be in far wider and deeper consideration. the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) -china a novel coronavirus outbreak of global health concern a novel coronavirus from patients with pneumonia in china detail/ - - -statement-on-the-second-meeting-of-theinternational-health-regulations director-general's opening remarks at the media briefing on covid- - coronavirus disease (covid- ) situation report - . geneva: who rapidly increasing cumulative incidence of coronavirus disease (covid- ) in the european union/ european economic area and the united kingdom coronavirus disease (covid- ) situation report - national health commission of the people's republic of china (nhc) shanghai declared the first-level response for major public health emergency to firmly curb the spread of the epidemic. shanghai: shanghai municipal government of the people's republic of china early transmission dynamics in wuhan, china, of novel coronavirusinfected pneumonia a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster a family cluster of sars-cov- infection involving patients in nanjing, china coronavirus disease (covid- ) in a paucisymptomatic patient: epidemiological and clinical challenge in settings with limited community transmission transmission of -ncov infection from an asymptomatic contact in germany presumed asymptomatic carrier transmission of covid- transmission of covid- in the terminal stages of the incubation period: a familial cluster coronavirus disease (covid- ) technical guidance: laboratory testing for -ncov in humans law of the people's republic of china on prevention and control of infectious diseases. beijing: npcsc the th version of prevention and control guidelines for novel coronavirus pneumonia sars-cov- viral load in upper respiratory specimens of infected patients interim guidance: considerations in the investigation of cases and clusters of covid- incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application modeling and public health emergency responses: lessons from sars estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship clinical outcomes in patients with severe acute respiratory syndrome coronavirus who were asymptomatic at hospital admission in shenzhen feasibility of controlling covid- outbreaks by isolation of cases and contacts early transmission patterns of coronavirus disease (covid- ) in travellers from wuhan to thailand first case of novel coronavirus in the united states the authors of this study thank all the cases and the cases' relatives, the public health physicians from baoshan, huangpu, putuo, pudong district cdcs and shanghai municipal cdc, the nurses and the clinical physicians from hospitals for the strong support during the epidemiological investigations.funding: this work was supported by science and technology commission of shanghai municipality (study on the seroepidemiology and transmission risk of covid- , grant number jc ; shanghai sailing program, grant num-ber yf ; the epidemiological study on covid- in shanghai, grant number ). none declared. xiaohuan gong and wenjia xiao analysed the infection clusters, drafted the manuscript and acquired the funding. yan cui and yuanping wang participated in the manuscript revision and epidemiological investigation. xiaohuan gong, wenjia xiao, dechuan kong, shenghua mao, yaxu zheng, yan cui, yuanping wang, lunhui xiang and lu lu collected the information and participated in the epidemiological investigation. chenyan jiang, xiao yu, yiyi zhu and qiwen fang analysed the data. huanyu wu and hao pan conceived the study, gave valuable instruction and acquired the funding, in epidemiological investigation and in laboratory test and analysis, respectively. this is an open-access article distributed under the terms of the creative commons attribution (cc by . ) licence. you may share and adapt the material, but must give appropriate credit to the source, provide a link to the licence and indicate if changes were made.any supplementary material referenced in the article can be found in the online version. key: cord- -jqesw e authors: yu, xinhua title: modeling return of the epidemic: impact of population structure, asymptomatic infection, case importation and personal contacts date: - - journal: travel med infect dis doi: . /j.tmaid. . sha: doc_id: cord_uid: jqesw e background: proactive interventions have halted the pandemic of coronavirus infected disease in some regions. however, without reaching herd immunity, the return of epidemic is possible. we investigate the impact of population structure, case importation, asymptomatic cases, and the number of contacts on a possible second wave of epidemic through mathematical modelling. methods: we built a modified susceptible-exposed-infectious-removed (seir) model with parameters mirroring those of the covid- pandemic and reported simulated characteristics of epidemics for incidence, hospitalizations and deaths under different scenarios. results: a larger percent of elderly people leads to higher number of hospitalizations, while a large percent of prior infection will effectively curb the epidemic. the number of imported cases and the speed of importation have small impact on the epidemic progression. however, a higher percent of asymptomatic cases slows the epidemic down and reduces the number of hospitalizations and deaths at the epidemic peak. finally, reducing the number of contacts among young people alone has moderate effects on themselves, but little effects on the elderly population. however, reducing the number of contacts among elderly people alone can mitigate the epidemic significantly in both age groups, even though young people remain active within themselves. conclusion: reducing the number of contacts among high risk populations alone can mitigate the burden of epidemic in the whole society. interventions targeting high risk groups may be more effective in containing or mitigating the epidemic. : flowchart of the epidemic model the above flowchart is applied to both young (age < ) and old populations (age>= ). we assume there is cross infection between younger and older age groups. the combined flowcharts can be modeled in differential equations (with index t suppressed and subscript y for young people, s for old people) as follows: table : detailed parameter estimates and ranges. all rates are set as daily rates in a region with population size of , , . range and references f importing rate for susceptible population, proportional to the size of population people per day, only for young people arbitrary, net travel inflow of - people per day for a city of a million. f y , f s importing rate for exposed and infectious persons, proportional to the size of population note: ) the infecting rate per contact per day is based on the basic reproductive number and serial interval between case generations. early reports suggested a r of . (range . - ), and a serial interval range of - days. however, several recent studies found the r was greater than , one reported as high as . . in this study, we took a conservative estimate of . and a moderate serial interval: days for young people, days for old people. based on simple sir model, the reproductive number is k*b*t, where k is contact rate, b is infecting probability per contact, and t is serial interval. assuming k= contacts per person per day for young people, and the infecting probability is b = . for a symptomatic young people. for mild or asymptomatic cases, we assume % less infectious than symptomatic cases, thus b = . for young undiagnosed people. for older people, the parameters are set to higher than young people, with fewer contact and shorter serial interval. ) the base rate per day is based on disease duration such as incubation period, diagnosis delay, hospitalization delay, hospitalization stay and recovery duration. we assumed an exponential distribution of duration, i.e., daily rate is -exp(- /duration). j o u r n a l p r e -p r o o f we investigate the impact of population structure, case importation, asymptomatic cases, and the number of contacts on a possible second wave of epidemic through mathematical modelling. methods: we built a modified susceptible-exposed-infectious-removed (seir) model with parameters mirroring those of the covid- pandemic and reported simulated characteristics of epidemics for incidence, hospitalizations and deaths under different scenarios. have detected virus shedding in nasopharyngeal swap samples among asymptomatic cases [ ] . a few case reports have shown some cluster of cases initiated by asymptomatic cases [ , , ] . researchers have postulated that asymptomatic and pre-symptomatic cases may play a significant role in sustaining the community transmission [ ] . second, government leaders have been pressed to allow people to return to normal work and life to avoid economic recession. after social activities are restored, both international and domestic j o u r n a l p r e -p r o o f travel ban will be lifted. social and work-related gatherings are restored. imported symptomatic and asymptomatic cases may kindle a second wave of epidemic in the community [ ] . the us, the mortality rate for age or younger is below %, while the mortality rate increases to more than % among people aged or above [ ] . finally, as demonstrated in the h n flu pandemic [ ] , a pandemic with lower hospitalization and mortality rates has less impact on the society than those with higher hospitalization and mortality rates, though it may still have heavier impact on the economy. epidemic model simulation has been used extensively to estimate essential epidemic parameters, in this study, we will build a modified susceptible-exposed-infectious-removed (seir) model [ ] to simulate the covid- pandemic and investigate the impact of population structure, asymptomatic cases, case importation, and the number of contacts on the epidemic progression. we will explicitly evaluate the changes of hospitalizations and mortality under various scenarios for young and elderly people. our analysis will provide theoretical evidence for possible strategies to prepare for a second wave of epidemic. the covid- , like many other respiratory infectious diseases such as influenza, often has an incubation period during which the exposed persons cannot transmit the virus to others. after the incubation period, there is an infection period during which cases may or may not have symptoms but are able to infect other people. the infectivity may also vary at different time points of the infection period. as in the covid- pandemic, the highest infectious points are - days around the symptom onset [ ] . after the infection period, the patients are recovered or removed from the infectious pool. in addition, various controlling measures may be implemented j o u r n a l p r e -p r o o f during the epidemic, notably the case isolation, quarantine of high risk people through contact tracing, and also social distancing. all these measures will change the transmissibility of virus during a contact between an infectious person and a susceptible person. therefore, the modified seir model as shown in figure is appropriate (also see the modeling framework section in supplemental documents for details). the seir model and its variants have been used in many previous studies for modeling the covid- pandemic [ , ] . briefly, we divide the population into the susceptible population (s), self-quarantined susceptible people (q), exposed we also assume a dynamic population in which the numbers of imported susceptible persons and assumptions that will be discussed later and also in the supplemental document. to account for population heterogeneity, we also apply the basic framework (figure ) to both young (age < ) and elderly (age >= ) populations. the two flowcharts are connected through cross-infection due to mutual contacts. the combined flowcharts can be translated into a set of ordinary differential equations (see supplemental document). the key equations relevant to the drive of pandemic and cross-infection between two age groups are for the change of exposed people at time t (subscript y for young, and s for elderly people, with time indicator t suppressed): specifically, the first equation models the exposure dynamics among young people. it includes imported exposed people (f y n y ), newly exposed people through contacting within the young people ( + ) and contacting between young susceptible and infected elderly people ( + ). then some percent of exposed young people become symptomatic cases ( ), and some become asymptomatic cases ( ). a fixed percent of exposed people will die of other diseases ( ). the second equation for the exposure dynamics among elderly people can be interpreted similarly. the model involves many parameters. their definitions, default values, and ranges are listed in the supplemental document (supp. the default model is set on a region with million residents, consisting of % elderly people and % of total population with past infection (or immunized). there is no existing symptomatic or asymptomatic case, and no person in self-quarantine in the region. we assume only one imported young exposed case every two days for days (i.e., imported cases). analyses are performed based on the ranges of parameter estimates. we vary one parameter at a the r package epimodel is used for simulating the deterministic epidemic models [ ] . the r codes for simulating the modified seir epidemic models are available (http://github.com/xinhuayu/returnepidemic/). this study is deemed exempt from ethics approval as the research involves no human subjects and we use publicly available data. no informed consent is needed. under the default model setting, all epidemic measures reflect the model parameters satisfactorily (table , also refer to supplemental table ). that is, the resulting epidemic j o u r n a l p r e -p r o o f measures from the default model such as the disease incidence, epidemic peak, and duration of the epidemic are reasonable and mirror those reported in the literature. for example, starting with ten imported infectious persons and assuming % asymptomatic cases at the peak of epidemic, the epidemic reaches peak quickly within days and lasts days. it is ten days quicker among elderly people than among young people ( table ). the epidemic curves for incident cases (symptomatic and asymptomatic), hospitalizations and deaths by age groups are typical (supplemental figure ). the modeling results in an overall hospitalization rate of . %. the in-hospital mortality rate is . % for young and . % for elderly people, with an overall mortality rate of . %, similar to those empirical measures in the covid- pandemic in the early epidemic of the us. therefore, the default model represents the current covid- pandemic sufficiently well. as summarized in table , the size of region and a small percent change of self-quarantined susceptible people do not change the epidemic progression significantly except for the total number of cases. a smaller percent of elderly slows down the epidemic, while a much higher percent of elderly does not change the epidemic curve significantly. as expected, when over % people have prior infections, the epidemic takes very long to reach the peak and results in substantial fewer cases. the effects are similar in both young and elderly people (supplemental both the percent and infectivity of asymptomatic cases were investigated (table ). an increase of the percent of asymptomatic cases from % to % postpones the epidemic peak by days j o u r n a l p r e -p r o o f due to less infectivity of asymptomatic cases, and results in significantly fewer hospitalizations and deaths. on the other hand, a higher infectivity of asymptomatic cases (e.g., % of symptomatic cases) results in a fast developing and narrow epidemic curve which reaches the peak within days. there are more hospitalizations and deaths at the epidemic peak compared with the default model, both assumed % asymptomatic cases. in addition, a change of the percent of asymptomatic cases among elderly people leads to larger changes in hospitalizations and deaths than that of young people (supplemental table a & b) . for example, comparing % with % asymptomatic cases, the total hospitalizations are reduced only by half among elderly people, while it is a two third decrease among young people. furthermore, when the effects of the percent and infectivity of asymptomatic cases are combined, for example, in a low risk epidemic with % asymptomatic cases but with a lower ( %) infectivity, the epidemic reaches its peak slower for both young and elderly people with peak hospitalizations almost half of the default model (assuming % asymptomatic cases and % infectivity) (supplemental figure ) . this epidemic model is initiated by imported infectious persons (may be asymptomatic or presymptomatic cases). the number of imported cases is in absolute sense, regardless of the size of population. a daily arrival of two infectious people speeds up the epidemic by days compared with one case every two days in the default model ( table ). the magnitudes of epidemic are similar between different importation scenarios. in addition, a longer importing duration shifts the epidemic only slightly. finally, if we assume all the imported cases are asymptomatic cases, the epidemic curves are not significantly different from that of default model (supplemental figure ) . respectively, all significantly lower than those of default model ( table ). the times to the epidemic peaks are also postponed in both curves. when both young and elderly people reduce contacts to per day, such as under the stay-at-home rule, the epidemic curves on hospitalizations are significantly mitigated in both age groups (figure d ). finally, we consider two extreme scenarios: ) high risk scenario: assuming one imported case per day continuously throughout the epidemic, % asymptomatic cases at the epidemic peak, and the same infectivity between symptomatic and asymptomatic cases; ) low risk scenario: assuming one imported case every two days for twenty days, % asymptomatic cases, and asymptomatic cases have only % infectivity of symptomatic cases. in both scenarios, limiting contacts among elderly people alone still has significant impact on hospitalizations in both age j o u r n a l p r e -p r o o f groups, and a larger relative difference in the low risk scenario than high risk scenario ( figure and supplemental figure ). we with growing availability of detection kits during the covid- pandemic, more asymptomatic or mild symptomatic cases are identified. ultimately, an optimal view is asymptomatic cases may account for % of infections. however, recent research and case reports have confirmed that asymptomatic or pre-symptomatic cases can shed enough quantify of virus to be infectious [ ] [ ] [ ] [ ] ] . furthermore, if the infectivity of asymptomatic cases is similar to that of symptomatic cases, a faster epidemic will occur. despite more asymptomatic cases at the peak of epidemic, there are also significantly more hospitalizations and deaths, which may overwhelm the health care system. with a lower infectivity ( % infectivity) among asymptomatic cases, the epidemic reaches its peak later and results in half of hospitalizations at the peak compared with the default model (supplemental figure ) . in addition, a closely related issue is case importation [ ] . imported cases are often pre-symptomatic, asymptomatic or with mild symptoms. they seed of a second outbreak, even with just a few cases. therefore, proactively identifying asymptomatic j o u r n a l p r e -p r o o f cases, isolating them and tracing their contacts thereafter will prevent the occurrence of an epidemic [ ] . our study has some strengths. we have devised a modified seir model to incorporate both symptomatic and asymptomatic cases. we emphasize population heterogeneity such as age structure in the model. we include a self-quarantined group who will not infect other people if they are infected with the virus. naturally, these settings can be extended to represent other high risk or special groups with revised parameters. in addition, we separate hospitalization and death from other removed compartments to explicitly estimate the impact of an epidemic on hospitalizations and deaths. from the health impact point of view, severe cases that lead to hospitalizations and deaths are more important than mild cases, as demonstrated in the h n pandemic [ ] . furthermore, we explored a few key determinants of epidemic explicitly, leading to many insights on epidemic prevention strategies. there are a few limitations in our study. as inherent in all modeling studies, simulation interpretations are heavily dependent on model assumptions and parameter estimations. our epidemic model is a population model. although we take account of population heterogeneity such as age in the current model, our age group is overly broad. a more detailed age grouping scheme, including children, young adults, middle age group, and elderly, may reflect the agespecific epidemic more realistically. other factors may also be included, and additional compartments such as pre-symptomatic stage may be modeled. however, more sophisticated models require more assumptions and may not necessarily provide more insights about the epidemic process. instead, in this study, in addition to ensuring the mathematical correctness of the models, we prioritize the epidemiological concepts and clinical relevance in setting up the models rather than model complexity. nevertheless, our findings do not intend to provide j o u r n a l p r e -p r o o f definitive advice to design a new policy but rather gain insights of the epidemic process and provide theoretical support for a possibly more effective prevention strategy based on approaches targeting high risk populations. in addition, we assume random mixing within and between age groups. as a population model, we cannot assess the impact of individual behaviors such as the way of reducing contacts, social distancing and travelling. furthermore, it ignores clustering within the population such as senior group living, community gatherings (e.g., churches, community centers), worksites and schools. these clusters are hotbeds for superspreading events which may lead to a sudden increase of new cases and overwhelm the healthcare system unexpectedly. furthermore, the quarantine compartment in the model is not contact tracing based. modeling contact tracing based quarantine is more relevant to public health interventions [ ] . therefore, the goal of our future research is to exploring the effect of these factors with stochastic simulations of individual behavior [ , ] and network analysis [ ] . additionally, our model is set on a mid-size region with million residents. we do not intend to model an pandemic, as all prevention strategies are ultimately local. our study only examines a small subset of scenarios during the epidemic. multi-interventions and more stringent controlling measures are more effective in mitigating a pandemic but are likely less sustainable in the long run. after the initial epidemic ends, society will return to normal, and only one or two most effective interventions such as social distancing may be practiced, often partially. thus, one parameter analysis under various scenarios is important for evaluating the probability of a second epidemic. finally, one critical issue in preparing for and preventing a second wave of pandemic is vaccinating the susceptible people, which is the most effective way to protect people, especially j o u r n a l p r e -p r o o f early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a novel coronavirus from patients with pneumonia in china most americans say coronavirus outbreak has impacted their lives impact of mitigating interventions and temperature on the instantaneous reproduction number in the covid- epidemic among us metropolitan areas the severe acute respiratory syndrome asymptomatic and human-to-human transmission of sars-cov- in a -family cluster asymptomatic and presymptomatic infectors: hidden sources of covid- disease asymptomatic cases in a family cluster with sars-cov- infection observation and analysis of cases of asymptomatic sars-cov infection presumed asymptomatic carrier transmission of covid- severe acute respiratory syndrome coronavirus shedding by travelers, vietnam, . emerg infect dis clinical characteristics of coronavirus disease in china clinical features of patients infected with novel coronavirus in wuhan, china. lancet clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study covid- ) -united states estimating the burden of pandemic influenza a (h n ) in the united states centre for mathematical modelling of infectious diseases, early dynamics of transmission and control of covid- : a mathematical modelling study a mathematical model for simulating the phase-based transmissibility of a novel coronavirus serial interval of covid- among publicly reported confirmed cases serial interval of novel coronavirus (covid- ) infections real-time forecasts of the covid- epidemic in china from feasibility of controlling covid- outbreaks by isolation of cases and contacts the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak. science covid- impact on hospital bed-days, icu-days, ventilatordays and deaths by us state in the next months. ihme covid- health service utilization forecasting team transmission dynamics and control of severe acute respiratory syndrome temporal dynamics in viral shedding and transmissibility of covid- high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus . emerg infect dis the basic reproduction number of novel coronavirus ( -ncov) estimation based on exponential growth in the early outbreak in china from to : a reply to dhungana transmissibility of -ncov nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study social contacts and mixing patterns relevant to the spread of infectious diseases evolving epidemiology and transmission dynamics of coronavirus disease outside hubei province, china: a descriptive and modelling study serial interval in determining the estimation of reproduction number of the novel coronavirus disease (covid- ) during the early outbreak the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application estimating the infection and case fatality ratio for coronavirus disease (covid- ) using age-adjusted data from the outbreak on the diamond princess cruise ship estimates of the severity of coronavirus disease : a model-based analysis epimodel: an r package for mathematical modeling of infectious disease over networks association of public health interventions with the epidemiology of the covid- outbreak in wuhan when is quarantine a useful control strategy for emerging infectious diseases? comparing nonpharmaceutical interventions for containing emerging epidemics networks and epidemic models clinical characteristics of non-critically ill patients with novel coronavirus infection (covid- ) in a fangcang hospital the peak self-quarantined is % of the susceptible population but changes with the prevalence of disease. the hospitalization rate is % for young, and % for old symptomatic cases, respectively. the mortality rate is % for hospitalized young people and % for hospitalized elderly. there are no prior symptomatic or asymptomatic cases or quarantined people in the total population the x. yu is solely responsible for the conceptualization, data collection, analysis, report writing and reporting writing of this study. key: cord- -d v b j authors: cheong, chang heon; lee, seonhye title: case study of airborne pathogen dispersion patterns in emergency departments with different ventilation and partition conditions date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: d v b j the prevention of airborne infections in emergency departments is a very important issue. this study investigated the effects of architectural features on airborne pathogen dispersion in emergency departments by using a cfd (computational fluid dynamics) simulation tool. the study included three architectural features as the major variables: increased ventilation rate, inlet and outlet diffuser positions, and partitions between beds. the most effective method for preventing pathogen dispersion and reducing the pathogen concentration was found to be increasing the ventilation rate. installing partitions between the beds and changing the ventilation system’s inlet and outlet diffuser positions contributed only minimally to reducing the concentration of airborne pathogens. emergency departments (ed) are visited by patients with various diseases, and thus, are vulnerable to the dispersion of airborne pathogens [ ] [ ] [ ] . in particular, if the hospital does not have isolation rooms [ ] [ ] [ ] for the treatment of patients carrying airborne pathogens or has more respiratory patients visit the hospital than the number of beds available in the isolation rooms, it is possible that patients with respiratory problems will be assigned to normal beds in the ed. in this situation, it is anticipated that the possibility of airborne pathogen dispersion in the ed increases. airborne pathogens are particles that are µm or smaller (aerosol) [ ] . as they travel in the air, their dispersion to nearby areas is possible, depending on the indoor air conditions. controlling the indoor air patterns, installing partitions between units to prevent airborne pathogen dispersion, and installing uv lamps to sterilize the pathogens can be considered as alternatives to prevent the dispersion of airborne pathogens inside eds. partitions are used in target ed in hospitals as a means to control the dispersion of airborne pathogens [ ] . among these options, we focused on the effects of arrangement of diffusers, the installation of partitions between beds, and increased ventilation rate affect the airflow patterns in an ed. each of these factors was applied to the bed areas of an ed, and the evolution of airborne pathogen dispersion was analyzed through a cfd (computational fluid dynamics) simulation. as mentioned previously, the objectives of the research were to investigate the effects of the locations of ventilation system diffusers, the presence of partitions between beds, and increased ventilation rate on the dispersion of airborne pathogens. therefore, the following scenarios were analyzed. first, the ventilation around the beds in the ed was increased from the regulated ventilation level of three air change per hour (ach) to the ventilation level of six ach, which is required for a negative-pressure isolation chamber. isolation rooms for patients with airborne pathogens require a minimum ventilation rate of - ach [ , ] . then, the effect on the pathogen dispersion control was analyzed. second, the location of diffusers was changed around the beds in the ed, and the consequential changes observed in the pathogen dispersion patterns were analyzed. in this case, the conditions were largely in one of two categories: supplying and exhausting the air over the respiratory system of a patient. an alternative was designed by considering the general design of inlets and outlets for negative pressure chambers, in which the air is exhausted at the restroom side or around the respiratory system of the patient. last, an additional partition was installed between the ed beds, and the degree of change observed in the pathogen dispersion patterns was analyzed. this approach is thought to be an alternative that can prevent the dispersion of airborne pathogens to adjacent beds. in south korea, generally, ed is designed with an open plan and the airborne pathogen can freely migrate from infected patient to any place in ed. the conventional fabric partition or curtains between beds easily pass the airborne pathogens smaller than µm. the impermeable partitions that have benefits such as easy installation and cheap price are thought to be useful to prevent the air pathogen transfer from a bed to another. however, airflow pattern and ventilation rate can influence the effects of the partition regarding airborne pathogen dispersion. this study investigates the combined effects of ventilation rate, inlet/outlet location and existence of partition in ed on airborne pathogen dispersion and consequent infection risk. the results of this study are expected to provide an effective architectural design guide for ed to prevent airborne infections. the subject for analysis was an ed based in seoul. the ed was consisted of faculty area, nurse station, laboratory, family waiting area, acute treatment area and general treatment area. the general treatment area where the emergency beds were located in the ed was selected as the analysis model. figure illustrates target area with ten beds without partitions. in the actual conditions, the space was open to some other areas in the department. the conditions concerning the surrounding areas, which cannot be specified, were excluded and the subject space was independently modeled in the analysis. a cfd analysis program, star-ccm+ v , was used to achieve the research objectives. star-ccm+ is a cfd simulation tool to fluid dynamics, particle/gas flow and heat transfer in a controlled volume. this software provides lots of physics models and analysis tools for the investigation. the airflow dispersion patterns and the airborne pathogen density distribution were analyzed in the study to estimate airborne infection risk. the subjects of the cfd analysis were the airflow and ventilation conditions of the bed area in the ed, and variation in the pathogen dispersion trend with the installation of partitions between the beds. for the star-ccm modeling, only the indoor air area was modeled as a solid object in autocad (computer-aided design, autodesk, san rafael, ca, usa), and imported to star-ccm+. a polyhedral mesh was selected for the analysis model, and a prism layer mesh was applied. for the equations governing the flow field of the three-dimensional model, the continuity equation, momentum equation, and equations related to the degree of turbulence were applied. for the turbulence analysis, the realizable k-ε turbulence model was used. the segregated flow model was selected for the fluid model. the three-dimensional model, the continuity equation, momentum equation, and equations related to the degree of turbulence were applied. for the turbulence analysis, the realizable k-ε turbulence model was used. the segregated flow model was selected for the fluid model. in this research, two analysis models were established based on the installation of partitions. figure shows the image of each simulation model with and without partition. the images of meshing conditions are also depicted in figure . the mesh and number of cells for each condition, and the boundary conditions are listed in tables and , respectively. the air supply and exhaust were in the upper area shown in figure . all patients were lying in the beds with their heads near the wall. according to the literature by sung ( ) , the minimum ventilation requirements for hospitals in south korea, as defined by current regulations, is approximately . ach. based on this, the baseline ventilation condition without airborne pathogen control was set at ach in this study. the entire air supply was assumed to come from the outside [ ] . the ventilation condition for pathogen control was set at ach. this is the minimum value in the range of ach- ach, which is the required ventilation rate inside negative pressure units suggested by the "plan for extended installation of negative pressure units at nationally designated isolation hospitals" published by the korea centers for disease control & prevention in [ ] . in this research, two analysis models were established based on the installation of partitions. figure shows the image of each simulation model with and without partition. the images of meshing conditions are also depicted in figure . the mesh and number of cells for each condition, and the boundary conditions are listed in tables and , respectively. the air supply and exhaust were in the upper area shown in figure . all patients were lying in the beds with their heads near the wall. according to the literature by sung ( ) , the minimum ventilation requirements for hospitals in south korea, as defined by current regulations, is approximately . ach. based on this, the baseline ventilation condition without airborne pathogen control was set at ach in this study. the entire air supply was assumed to come from the outside [ ] . the ventilation condition for pathogen control was set at ach. this is the minimum value in the range of ach- ach, which is the required ventilation rate inside negative pressure units suggested by the "plan for extended installation of negative pressure units at nationally designated isolation hospitals" published by the korea centers for disease control & prevention in [ ] . in this research, two analysis models were established based on the installation of partitions. figure shows the image of each simulation model with and without partition. the images of meshing conditions are also depicted in figure . the mesh and number of cells for each condition, and the boundary conditions are listed in tables and , respectively. the air supply and exhaust were in the upper area shown in figure . all patients were lying in the beds with their heads near the wall. according to the literature by sung ( ) , the minimum ventilation requirements for hospitals in south korea, as defined by current regulations, is approximately . ach. based on this, the baseline ventilation condition without airborne pathogen control was set at ach in this study. the entire air supply was assumed to come from the outside [ ] . the ventilation condition for pathogen control was set at ach. this is the minimum value in the range of ach- ach, which is the required ventilation rate inside negative pressure units suggested by the "plan for extended installation of negative pressure units at nationally designated isolation hospitals" the numbers of inlets and outlets, as shown in figures and , were slightly different in the base model and the type model. this was because the diffusers were placed in the spaces between the beds in the base model so that the ventilation would not occur directly in the face of the patient. the type model applied walls between each bed, and the ventilator supply was placed at every bed. the inlet condition for the star-ccm+ simulation model was set to the velocity inlet, and the outlet condition was set as a split ratio outlet. the buoyancy effect was considered, and the detailed thermal conditions of the simulation models are shown in table . assuming that the patient breathed times/min, had a breathing capacity of ml (about l/min), and their mouth measured . m × . m, the average air velocity of exhalation was calculated to be approximately . m/s. based on this, therefore, the average exhalation velocity was set in the model to be . m/s (red arrow in figure .). patients were assumed to be lying in the center of their beds. the exhalation was emitted from one patient, and the analysis was conducted accordingly. a passive scalar was selected to represent the pathogen included in the exhalation, and the concentration was . . according to previous study [ ] , the passive scalar method is also a good approach of small particles bioaerosols. the airborne pathogen dispersion pattern resulting from the exhalation, mixing of airflows, and turbulence patterns was visualized for analysis. figure shows the data measuring points for the analysis of pathogen concentration. the points were set at a height of . m, in consideration of the location of the respiratory system of a patient lying in a bed. the meshing conditions of the base ( , , cells) and type ( , , cells) models are provided in table . the black boxes above the beds are inlets and outlets of the ventilator. the bulge of the bed is . m × . m × . m. human body is expressed in figure and mouth is modeled top of the human body( . m × . m, . m height). simulation cases for analysis were established, as shown in table , to conduct a case study that analyzed the range of airborne pathogen dispersion according to the location of diffusers in the bed area of the ed, the ventilation rate, and the installation of partitions between beds. case is the condition that best represents the usual bed conditions of existing eds. the ventilation rate was ach, per regulation, with no partitions between the beds. fabric curtains are usually installed between the beds, but it was assumed that the curtains were left open, as in situations where undressing or exposing the body was not necessary. the inlets were around the periphery of the ed (region a), and the outlets were in the central area (region b). the inlet was located near the side of the patient's respiratory system. the conditions of case were the same as in case , only with the locations of the inlet and outlet switched, so that the outlet was located over the patient's respiratory system. cases and were the same as cases and , respectively, with the ventilation rate increased to ach. cases - had the same conditions as cases - , except for having partitions in place between the beds. as in the previous explanation of the analysis model, the total number of inlets and outlets was increased, and the air velocity at the inlets decreased accordingly with the installation of a diffuser for every bed. simulation cases for analysis were established, as shown in table , to conduct a case study that analyzed the range of airborne pathogen dispersion according to the location of diffusers in the bed area of the ed, the ventilation rate, and the installation of partitions between beds. case is the condition that best represents the usual bed conditions of existing eds. the ventilation rate was ach, per regulation, with no partitions between the beds. fabric curtains are usually installed between the beds, but it was assumed that the curtains were left open, as in situations where undressing or exposing the body was not necessary. the inlets were around the periphery of the ed (region a), and the outlets were in the central area (region b). the inlet was located near the side of the patient's respiratory system. the conditions of case were the same as in case , only with the locations of the inlet and outlet switched, so that the outlet was located over the patient's respiratory system. cases and were the same as cases and , respectively, with the ventilation rate increased to ach. cases - had the same conditions as cases - , except for having partitions in place between the beds. as in the previous explanation of the analysis model, the total number of inlets and outlets was increased, and the air velocity at the inlets decreased accordingly with the installation of a diffuser for every bed. simulation cases for analysis were established, as shown in table , to conduct a case study that analyzed the range of airborne pathogen dispersion according to the location of diffusers in the bed area of the ed, the ventilation rate, and the installation of partitions between beds. case is the condition that best represents the usual bed conditions of existing eds. the ventilation rate was ach, per regulation, with no partitions between the beds. fabric curtains are usually installed between the beds, but it was assumed that the curtains were left open, as in situations where undressing or exposing the body was not necessary. the inlets were around the periphery of the ed (region a), and the outlets were in the central area (region b). the inlet was located near the side of the patient's respiratory system. the conditions of case were the same as in case , only with the locations of the inlet and outlet switched, so that the outlet was located over the patient's respiratory system. cases and were the same as cases and , respectively, with the ventilation rate increased to ach. cases - had the same conditions as cases - , except for having partitions in place between the beds. as in the previous explanation of the analysis model, the total number of inlets and outlets was increased, and the air velocity at the inlets decreased accordingly with the installation of a diffuser for every bed. the wells-riley model is a method of expressing the probability of air-borne infection using the concentration of a steady-state infection source and thread ventilation [ ] [ ] [ ] [ ] [ ] . equation ( ) shows the expression of the wells-riley model. equation ( ) shows the modified wells-riley model for infection risk by spatial area. where: p i : airborne infection probability of a susceptible person; c: number of infection cases; i: number of infectors; p: breathing rate of a susceptible person; and q: quantum generation rate by an infector. where n: expected number of quanta. the quanta generation rate of influenza was set to particles/h [ , ] . the existing literature suggests that the quanta generation rate of influenza is - particles/h [ ] . in south korea, after the middle east respiratory syndrome (mers) outbreak in , only one patient companion can stay in the ed and take care of the patient near their bedside. other patient companions must wait in the waiting room. the duration of a patient's stay in the emergency room depends on the patient's condition, but in the worst case, a patient may stay for two or three days. however, in this study, we assumed that the condition is treated for h: h for blood tests and h of other medical treatments by hospital members' interview. the quanta generation scenario is depicted in figure . airborne pathogen concentration of each monitoring point is used to calculate airborne infection risk of neighboring non-infected patient. airborne pathogen concentration at x -y is used to evaluate companions' airborne infection risk. figure . figure shows the average concentration at all measuring points together with the beds of the patient with a respiratory problem who generated the pathogen (x -y and x -y ), the beds opposite to the pathogen source patient (x -y and x -y ), and the average pathogen concentration at the rest of the beds. according to figure , there was a large difference between the pathogen concentrations at the pathogen source bed and that at the rest of beds. first, the reduction of pathogen concentration with increased ventilation rate is well demonstrated in all cases analyzed (cases and vs. cases and and cases and vs. cases and ). the effect of switching the ventilation outlet from region b to region a varied depending on the existence of partitions. in the condition without partitions, there was minimal effect on the average concentration at the periphery, and the pathogen concentration at the pathogen source bed showed a slight increase (x ). however, the change of outlet location (from region b to region a) reduced the dispersion of the pathogen to the adjacent beds (x , x , x , and x ). placing a partition between the beds when the outlet location was at region b did slightly decrease the concentration at the pathogen source beds (x -y ) as compared to the condition without partitions. in the case of the condition with the partitions, switching the outlet location from region b to region a increased the concentration at the pathogen source bed. in addition, comparing cases and , changing the outlet location from region b to region a when partitions were between the beds contributed to a significant increase in the pathogen concentration at the adjacent bed (x -x ). the pathogen concentration at x -y and x -y in case exceeded the corresponding values in case and . however, installing partitions between the beds (case vs. cases and ) was confirmed to slightly reduce the average concentration levels at the rest of the beds on the periphery. figure shows the expected infection risk at each measuring point. the infection risk reflects the tendencies of the pathogen concentrations in each case; a higher pathogen concentration means a higher infection risk. increasing the ventilation rate is always desirable for the reduction of infection risk. figure illustrates that installing partitions contributed to a reduced infection risk in the periphery (a) and a clear reduction in the average infection risk at the increased ventilation rate of ach. however, the increased infection risk at the bed adjacent to the airborne pathogen generation source should not be neglected in the cases with partitions between the beds. estimated number of airborne pathogens and airborne infection risk at each monitoring point is demonstrated in appendix a. figure . figure shows the average concentration at all measuring points together with the beds of the patient with a respiratory problem who generated the pathogen (x -y and x -y ), the beds opposite to the pathogen source patient (x -y and x -y ), and the average pathogen concentration at the rest of the beds. according to figure , there was a large difference between the pathogen concentrations at the pathogen source bed and that at the rest of beds. first, the reduction of pathogen concentration with increased ventilation rate is well demonstrated in all cases analyzed (cases and vs. cases and and cases and vs. cases and ). the effect of switching the ventilation outlet from region b to region a varied depending on the existence of partitions. in the condition without partitions, there was minimal effect on the average concentration at the periphery, and the pathogen concentration at the pathogen source bed showed a slight increase (x ). however, the change of outlet location (from region b to region a) reduced the dispersion of the pathogen to the adjacent beds (x , x , x , and x ). placing a partition between the beds when the outlet location was at region b did slightly decrease the concentration at the pathogen source beds (x -y ) as compared to the condition without partitions. in the case of the condition with the partitions, switching the outlet location from region b to region a increased the concentration at the pathogen source bed. in addition, comparing cases and , changing the outlet location from region b to region a when partitions were between the beds contributed to a significant increase in the pathogen concentration at the adjacent bed (x -x ). the pathogen concentration at x -y and x -y in case exceeded the corresponding values in case and . however, installing partitions between the beds (case vs. cases and ) was confirmed to slightly reduce the average concentration levels at the rest of the beds on the periphery. figure shows the expected infection risk at each measuring point. the infection risk reflects the tendencies of the pathogen concentrations in each case; a higher pathogen concentration means a higher infection risk. increasing the ventilation rate is always desirable for the reduction of infection risk. figure illustrates that installing partitions contributed to a reduced infection risk in the periphery (a) and a clear reduction in the average infection risk at the increased ventilation rate of ach. however, the increased infection risk at the bed adjacent to the airborne pathogen generation source should not be neglected in the cases with partitions between the beds. estimated number of airborne pathogens and airborne infection risk at each monitoring point is demonstrated in appendix a. case and had the same ventilation rate of ach, but the ventilation system inlet and outlet locations were switched to compare the consequent pathogen dispersion patterns. figure shows the analysis results for cases and in plan (at . m height) and sectional (x ) views. figure a ,b are the analysis results, in plan and sectional views, respectively, for case , in which the air was supplied from the periphery and exhausted at the center of the room. figure c ,d show the results of a central air supply and peripheral exhaust, in other words, exhaust over the respiratory systems of patients, as in the conditions of case . white parts of figure b ,d are the bed and human body section. in terms of the pathogen concentration distribution, the pathogen normally dispersed towards the adjacent beds, in both cases and . the concentration in the area near the bed of the patient who released the airborne pathogen was slightly higher in case , where the air was supplied from the periphery (region a) that was above the patients' respiratory systems. the same pattern can be observed in figure a ,c, which show the sectional views. these figures show that, in both cases and , the pathogen dispersed towards the beds on the opposite sides. the pathogen concentration at the hallway side was higher in case than in case . it is therefore anticipated that the probability of infection for the people in the hallway and the patient on the other side would be greater in case than in case . case and had the same ventilation rate of ach, but the ventilation system inlet and outlet locations were switched to compare the consequent pathogen dispersion patterns. figure shows the analysis results for cases and in plan (at . m height) and sectional (x ) views. figure a ,b are the analysis results, in plan and sectional views, respectively, for case , in which the air was supplied from the periphery and exhausted at the center of the room. figure c ,d show the results of a central air supply and peripheral exhaust, in other words, exhaust over the respiratory systems of patients, as in the conditions of case . white parts of figure b ,d are the bed and human body section. in terms of the pathogen concentration distribution, the pathogen normally dispersed towards the adjacent beds, in both cases and . the concentration in the area near the bed of the patient who released the airborne pathogen was slightly higher in case , where the air was supplied from the periphery (region a) that was above the patients' respiratory systems. the same pattern can be observed in figure a ,c, which show the sectional views. these figures show that, in both cases and , the pathogen dispersed towards the beds on the opposite sides. the pathogen concentration at the hallway side was higher in case than in case . it is therefore anticipated that the probability of infection for the people in the hallway and the patient on the other side would be greater in case than in case . cases and are the same as cases and , respectively, except for the ventilation rate. the ventilation rates for cases and were increased to ach. the analysis results for cases and are depicted in figure . the concentrations of airborne pathogens in cases and were clearly lowered when the ventilation rate was ach, as compared to ach. in other words, pathogen control by increasing the ventilation rate would have a greater effect on the pathogen concentration than changing the ventilation inlet and outlet locations would. cases and are the same as cases and , respectively, except for the ventilation rate. the ventilation rates for cases and were increased to ach. the analysis results for cases and are depicted in figure . the concentrations of airborne pathogens in cases and were clearly lowered when the ventilation rate was ach, as compared to ach. in other words, pathogen control by increasing the ventilation rate would have a greater effect on the pathogen concentration than changing the ventilation inlet and outlet locations would. cases and have the same ventilation conditions as cases and , respectively, with partitions added between the beds. the upper and lower parts of these partitioning walls were fixed to the ceiling and the floor, thus spatially separating the pathogen source bed from the adjacent beds. the front side remained open. this partitioning format not only controlled the dispersion of airborne pathogens from the source bed to the neighboring beds but also limited the visual field of the medical personnel. figure a ,c show, in plan view, the pathogen dispersion for the conditions of changing the inlet locations at the ventilation rate of ach. in case , the air was supplied over the patient's respiratory system (region a), and the air supply pattern in sectional view was as shown in figure b . the pathogen concentration for case in plan view is shown in figure a . in case , the air was supplied from the hallway side (region b), resulting in concentrations in sectional view as shown in figure d , and plan view as shown in figure c . considering figure , it is evident that the partition delayed the airborne pathogen dispersion to the adjacent beds. when the ventilation system inlets were installed over the patients' respiratory systems (region a), the airflow into the inlet acted like an air-curtain and prevented the airborne pathogen dispersion from the emitting source to other places, and the outlet at the hallway provided a secondary barrier (case ). interestingly, in case , with a ach ventilation rate, the airborne pathogens were not sufficiently exhausted at the outlet above the patients' respiratory organs. the rest of the airborne pathogen moved to the hallway, and the airflow from the inlet installed in the hallway accelerated the dispersion of the airborne pathogen to the adjacent beds. as a result of these dispersion patterns, installing partitions caused airborne pathogen concentration to increase at x and x . however, installing partitions contributed to a decrease in the airborne pathogen concentrations at x and x . in case , the pathogen concentration in the pathogen source bed greatly increased compared to the other cases, which could increase the infection risk for medical staff working in the source bed area. cases and have the same ventilation conditions as cases and , respectively, with partitions added between the beds. the upper and lower parts of these partitioning walls were fixed to the ceiling and the floor, thus spatially separating the pathogen source bed from the adjacent beds. the front side remained open. this partitioning format not only controlled the dispersion of airborne pathogens from the source bed to the neighboring beds but also limited the visual field of the medical personnel. figure a ,c show, in plan view, the pathogen dispersion for the conditions of changing the inlet locations at the ventilation rate of ach. in case , the air was supplied over the patient's respiratory system (region a), and the air supply pattern in sectional view was as shown in figure b . the pathogen concentration for case in plan view is shown in figure a . in case , the air was supplied from the hallway side (region b), resulting in concentrations in sectional view as shown in figure d , and plan view as shown in figure c . considering figure , it is evident that the partition delayed the airborne pathogen dispersion to the adjacent beds. when the ventilation system inlets were installed over the patients' respiratory systems (region a), the airflow into the inlet acted like an air-curtain and prevented the airborne pathogen dispersion from the emitting source to other places, and the outlet at the hallway provided a secondary barrier (case ). interestingly, in case , with a ach ventilation rate, the airborne pathogens were not sufficiently exhausted at the outlet above the patients' respiratory organs. the rest of the airborne pathogen moved to the hallway, and the airflow from the inlet installed in the hallway accelerated the dispersion of the airborne pathogen to the adjacent beds. as a result of these dispersion patterns, installing partitions caused airborne pathogen concentration to increase at x and x . however, installing partitions contributed to a decrease in the airborne pathogen concentrations at x and x . in case , the pathogen concentration in the pathogen source bed greatly increased compared to the other cases, which could increase the infection risk for medical staff working in the source bed area. figure shows the analysis result of the cases considering the conditions of installing partitions between the beds, changing the ventilation system inlet/outlet locations, and increasing the ventilation rate to ach. the simulated results of cases and demonstrate that the increase in airborne pathogen concentration occurred mainly at x . the increased ventilation ensures a solution for airborne infection prevention. the effects of installing partitions at a ventilation rate of ach varied depending on the ventilation system's inlet and outlet locations. locating the inlets above the patients' respiratory organs still generated turbulence and increased the airborne pathogen concentration at the adjacent beds. the simulation results of case clearly show that the increased ventilation rate of ach and partition installation effectively reduced the airborne pathogen figure shows the analysis result of the cases considering the conditions of installing partitions between the beds, changing the ventilation system inlet/outlet locations, and increasing the ventilation rate to ach. figure shows the analysis result of the cases considering the conditions of installing partitions between the beds, changing the ventilation system inlet/outlet locations, and increasing the ventilation rate to ach. the simulated results of cases and demonstrate that the increase in airborne pathogen concentration occurred mainly at x . the increased ventilation ensures a solution for airborne infection prevention. the effects of installing partitions at a ventilation rate of ach varied depending on the ventilation system's inlet and outlet locations. locating the inlets above the patients' respiratory organs still generated turbulence and increased the airborne pathogen concentration at the adjacent beds. the simulation results of case clearly show that the increased ventilation rate of ach and partition installation effectively reduced the airborne pathogen the simulated results of cases and demonstrate that the increase in airborne pathogen concentration occurred mainly at x . the increased ventilation ensures a solution for airborne infection prevention. the effects of installing partitions at a ventilation rate of ach varied depending on the ventilation system's inlet and outlet locations. locating the inlets above the patients' respiratory organs still generated turbulence and increased the airborne pathogen concentration at the adjacent beds. the simulation results of case clearly show that the increased ventilation rate of ach and partition installation effectively reduced the airborne pathogen dispersion. however, the large increase in the pathogen concentration at the pathogen generation bed must be mitigated. the study focused on the effects of some potential solutions for preventing the spread of airborne pathogens in eds: changing the ventilation inlet/outlet locations, installing partitions, and increasing the ventilation rate. in terms of ventilating the ed, supplying the air from the center (region b) and exhausting over the patients' respiratory systems (region a) helped prevent dispersion of the airborne pathogen when partitions were not present. changing the ventilation inlet and outlet locations in conditions of low ventilation rate and partition installation could cause the undesirable dispersion of the airborne pathogen (case ). installing the outlet of the ventilation system over the patients' respiratory systems was found to greatly increase the pathogen concentrations around the airborne pathogen source. yang et al. ( ) analyzed by cfd, it was said that setting the parallel bed layout and the exhaust port near the patient's head will lower the probability of air infection in the isolating room [ ] . hospital managers should be considered the placement of beds and the direction of airflow to reduce airborne infections. ordinary breathing generates lots of bio-aerosol ( µm or smaller) that can be transferred via air [ ] [ ] [ ] . thus, it is concluded that switching the ventilation inlet/outlet locations presents a high risk of increasing the probability of infection for medical staff providing medical treatments, such as endotracheal intubation [ , ] and nebulizing [ ] , to patients. installing partitions between the beds generally offered the advantage of reducing the average concentrations of pathogens in the ed (cases , , and ). however, it also had the shortcoming of increasing the pathogen concentration at the beds opposite and adjacent to the pathogen-source bed. these results suggest that patients who are at high risk of airborne infections may be able to provide appropriate patient placement in the ed. physical blocks primarily prevent the spread of airborne pathogen between the emergency beds [ ] . according to the cfd analysis, hospital curtains were presented in a simple and effective way for the spread of infection [ ] . thus, the airborne pathogens tend to accumulate around the source. increased ventilation should, therefore, accompany partition installation in the ed. it should be ach recommended by who rather than korean ventilation's criteria. increasing ventilation rate requires additional hvac system installation and surplus energy consumption. natural ventilation or hybrid ventilation method may be implemented to reduce energy consumption. however, natural ventilation has limitation or disadvantage regarding airflow control, heat recovery, outdoor contaminants incoming [ ] , difficulty in securing sufficient and consistent ventilation rate by season changing [ , ] . to reduce energy consumption, partial fan assisted natural ventilation with appropriate filtering system, dedicated outdoor air system (intermediate season) and heat recovery system (heating season) in hvac system can be good solutions. most hospitals use partitions, but each hospital has a different material. future research of the effect of airborne infection of the partition is also necessary. future research needs to investigate the influence of airborne infection depending on the material, installation structure and usage method of the partition. the south korean government tries to enhance the quality of ed facilities in major hospitals to prevent airborne pathogen infections. however, the korean building code still does not require the performance enhancement of small hospital and ed building equipment with respect to airborne infection prevention. this study provides the basis for design guidelines for airborne-infection prevention for small hospitals and eds. the limitation of this study did not take into account the various factors affecting the airflow, such as natural ventilations. future research needs to consider the airflow around the ceiling diffuser and approach the multidisciplinary research on hospital facilities and built environment will be conducted. our research investigated the effect of various architectural features in eds on indoor pathogen concentration distribution. the major variables considered were ventilation rate, installation of partition walls between beds, and changing ventilation inlet/outlet locations. the overall analysis is summarized as follows. ( ) the most effective method for controlling airborne pathogen dispersion is increasing the ventilation rate. ( ) changing the ventilation inlet/outlet locations generally results in good prevention of airborne pathogen dispersion. however, it can also cause undesirable airborne pathogen dispersion in conditions with low ventilation rates and partitions (case ). ( ) installing partitions could contribute to decreasing the average airborne pathogen concentration (cases , and ). however, it was also observed that the partitions could increase the pathogen concentrations in the beds opposite and adjacent to the pathogen source. increasing the ventilation rate can enhance the effect of installing partitions. ( ) in the analysis, the most effective method for pathogen control was to use all the methods studied: increasing the ventilation rate, installing partitions, and positioning the ventilation system outlets over the patients' respiratory organs (region a). further research will be conducted to improve architectural techniques for preventing the dispersion of airborne pathogens. our research only analyzed the concentrations of the airborne pathogen; therefore, it has the limitation of not indicating the real probability of infection. in our future research, an analysis of the probability of infection by the airborne pathogen will be included. author contributions: chang heon cheong designed the research plan, performed the cfd simulation and drafted the manuscript. seonhye lee reviewed the results of the study relating to the hospital environment, airborne infection, and public health. all authors read and approved the final version of the manuscript. the authors declare no conflict of interest. emergency nurses' perception and performance of tuberculosis infection control measures influencing factors on the compliance about standard precautions among icu and er nurses press release for th regular session of the national assembly of korea guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings american institute of architects (aia). - guidelines for design and construction of hospitals and health care facilities isolation rooms: design, assessment, and upgrade hvac system and contamination control in hospital relating mers natural ventilation for infection control in health-care settings improvement of airborne infection prevention methods in emergency room by design case study korea centers for disease control & prevention. plan for extended installation of negative pressure units at nationally designated isolation hospitals cfd simulation of airborne pathogen transport due to human activities an advanced numerical model for the assessment of airborne transmission of influenza in bus microenvironments modelling the risk of airborne infectious disease using exhaled air risk of indoor airborne infection transmission estimated from carbon dioxide concentration airborne contagion and air hygiene spatial distribution of infection risk of sars transmission in a hospital ward influenza outbreak related to air travel review and comparison between the wells-riley and dose-response approaches to risk assessment of infectious respiratory diseases hvac filtration for controlling infectious airborne disease transmission in indoor environments: predicting risk reductions and operational costs simulation of the aii-room for preventing spread of the air-borne infection in hospital inhaling to mitigate exhaled bioaerosols the size distribution of droplets in the exhaled breath of healthy human subjects airborne infectious disease and the suppression of pulmonary bioaerosols compliance with nosocomial infection control and related factors among emergency room nurses the relationship between empowerment and performance of infection control by emergency department nurses evaluation of droplet dispersion during non-invasive ventilation, oxygen therapy, nebulizer treatment and chest physiotherapy in clinical practice: implications for management of pandemic influenza and other airborne infections reducing risk of airborne transmitted infection in hospitals by use of hospital curtains quantifying the impact of traffic-related air pollution on the indoor air quality of a naturally ventilated building assessment of natural ventilation potential for residential buildings across different climate zones in australia the effect of the london urban heat island on building summer cooling demand and night ventilation strategies key: cord- - pshh ov authors: nan title: sars alert applicability date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: pshh ov nan to the editor: since its emergence early in , the epidemic of severe acute respiratory syndrome (sars) has been characterized by its rapid spread among healthcare workers. on august , , the world health organization (who) issued an alert concerning sars and recommended a staged approach to surveillance ( ) . because occupational transmission has been a feature of the sars outbreak, who recommends surveillance for clusters of alert cases among healthcare workers in low-risk areas (i.e., cases not reported, only imported cases reported, or local cases with limited transmission potential reported). a sars alert is identified when two or more healthcare workers in the same healthcare unit meet the clinical case definition of sars with onset of illness in the same -day period. to determine the value of routinely collecting worker absence data as part of this kind of surveillance and to assess a threshold level of possible alert cases, directors of six major italian hospitals were asked for the number of cases that fit the alert definition in . (in italy, the hospital director is a physician who is in charge of nosocomial and occupational infection control.) the facilities involved were three general hospitals, two university hospitals, and one research hospital; each has an infectious and respiratory tract diseases unit. three of four patients with imported cases of probable sars observed in italy during the epidemic ( ) were treated in two of these hospitals. no hospitals were able to immediately provide the requested data; in all hospitals in italy, information on sickness certificates is recorded only for administrative purposes, and certificates are not generally used for medical surveillance. the european union council directive / directs all participating countries to introduce measures to improve worker safety and health and to provide a designated service that will protect workers, prevent occupational risks, including hazards from biological agents, and conduct health surveillance. in the hospital, these activities are coordinated by the hospital director. when a worker has a transmissible disease, the attending physician for the infected patient recommends that the patient stay home from work for the duration of the infectivity period. if the illness is included in the list of notifiable infectious diseases, the case must be reported to the local public health authority so infection control measures can be implemented. however, neither the attending physician nor public health personnel usually supervise home isolation, and adherence to the recommendations relies on the patient. sickness certificates are generally provided by the physician and sent by the worker to the hospital administration within days of illness onset. the certificate indicates the prognosis (i.e., recommended number of days absent from work) but does not report the diagnosis because of privacy concerns. in case of hospital admission, the worker can send the hospital certificate (attesting to the duration of the hospital stay), followed by a physician's certificate for the recommended length of convalescence, if any. to determine how the sickness certification system in other european union countries operates and assesses the feasibility of the who alert surveillance, we interviewed specialists in infectious diseases or public health in france (seven imported cases of sars, two in healthcare workers), spain (one case), and denmark (no cases) ( ) by electronic mail. according to their answers, the situation in those countries is not substantially different from that in italy. in view of the increasing concern related to the emergence and reemergence of transmissible diseases, surveillance efforts focused on groups likely to be first affected by the reemergence of sars have been strongly encouraged ( , ) . possible alternatives similar to the sars alert system have been proposed, based on healthcare workers' sickness absenteeism, when other illnesses are concerned. for example, the effectiveness of enforced monitoring of pneumonia in healthcare workers requiring hospitalization should be evaluated in the context of a wider syndromic surveillance strategy ( ) . although the current healthcare worker sickness reporting system cannot be fully representative and generalizable, italy and several other european union countries (e.g., france, spain, and denmark) do not support initiating the who recommendation and do not have the capacity to detect and respond to sars, should it reemerge. to overcome barriers to early detection of cases and clusters of severe unexplained respiratory infections that might signal the reemergence of sars, regulatory changes are necessary, and efforts should be made to balance the need for protecting the privacy of persons with the need for an effective surveillance system. to identify clusters of occupational diseases among healthcare workers and provide prompt response to any alert, an expanded sickness information system should be implemented. for example, an active confidential assessment of diagnosis could be performed in selected circumstances when healthcare workers are absent. we plan to evaluate the feasibility of this kind of surveillance by focusing on workers with absences with longer than a week and on workers with onset of illness in the same -day period. to the editor: the article by hsieh et al. analyzed the daily casereport data for severe acute respiratory syndrome (sars) from may to june , , posted on the web site for the taiwan center for disease control, to show how this disease had rapidly spread in the outbreak ( ). hsieh et al. suggested that infection in hospitalized patients who were classified erroneously as suspected sars case-patients was a major factor in the rapid spread of the disease in hospitals. slow classification and delayed placement of these patients in negative-pressure isolation rooms contributed to the high percentage ( %) of nosocomial infection in taiwan ( ) . during the outbreak period (stage ii), three teams were responsible for classifying sars cases ( ) . the team included infectious disease specialists, respiratory specialists, and epidemiologists recruited from major teaching hospitals throughout taiwan and was organized by the taiwan center for disease control and the national health insurance bureau. the team met daily and reviewed the clinical data, travel and contact history, and chest radiographic scans of the reported case-patients obtained (by email or fax) from the patients' attending physicians. the same protocol (figure) was used by all team members to classify the case-patients as having suspected or probable sars. all hospitals that treated patients with suspected sars either had their own committee to classify patients according to world health organization guidelines or followed the protocol for classification or reclassification of reported cases by the team members ( ). although official reclassification might have taken . days as suggested by hsieh et al., the conclusion that inadequate isolation of infected patients during this period led to a higher rate of nosocomial transmission cannot be based on the data available to these authors. from the first day that suspected cases were reported to the taiwan center for disease control, the patients were placed in negative-pressure isolation rooms when available. suspected casepatients may have been less likely than probable case-patients to be placed in negative-pressure isolation rooms when these were in short supply; however, all other available isolation precautions were used to treat suspected case-patients before they were reclassified. the notion that increased infection transmission occurred despite these isolation precautions is not consistent with the literature suggesting the central role of gloves, gowns, and surgical masks in preventing transmission ( ) . thus, the process of reclassification was not associated with the timing of isolation measures shown to have the greatest impact in preventing infection transmission. the high proportion of patients with nosocomial sars infection in taiwan is consistent with the observations of lingappa et al. ( ) and others who have noted that the hospital setting was the primary amplifier of sars transmission, with significant community transmission occurring in only the largest outbreaks. the high in search of encephalitis etiologies: diagnostic challenges in the california encephalitis project agent of amebic meningoencephalitis in humans and other animals testing for balamuthia encephalitis by indirect immunofluorescence environmental isolation of balamuthia mandrillaris associated with a case of amebic encephalitis amebic encephalitis caused by balamuthia mandrillaris: a report of four cases successful treatment of balamuthia amoebic encephalitis: presentation of two cases epidemiology of human rabies in the united states world health organization. alert, verification and public health management of sars in the post-outbreak period world health organization. summary of probable sars cases with onset of illness from innovative surveillance methods for rapid detection of disease outbreaks and bioterrorism: results of an interagency workshop on health indicator surveillance this study was performed within ricerca finalizzata and ricerca corrente istituti ricovero e cura a carattere scientifico. i thank all the colleagues who responded to the questionnaire.vincenzo puro* *istituto nazionale per le malattie infettive lazzaro spallanzani, rome, italy key: cord- -wkb sq authors: saez, marc; tobias, aurelio; barceló, maria a. title: effects of long-term exposure to air pollutants on the spatial spread of covid- in catalonia, spain date: - - journal: environ res doi: . /j.envres. . sha: doc_id: cord_uid: wkb sq background: the risk of infection and death by covid- could be associated with a heterogeneous distribution at a small area level of environmental, socioeconomic and demographic factors. our objective was to investigate, at a small area level, whether long-term exposure to air pollutants increased the risk of covid- incidence and death in catalonia, spain, controlling for socioeconomic and demographic factors. methods: we used a mixed longitudinal ecological design with the study population consisting of small areas in catalonia for the period february to may , . we estimated generalized linear mixed models in which we controlled for a wide range of observed and unobserved confounders as well as spatial and temporal dependence. results: we have found that long-term exposure to nitrogen dioxide (no( )) and, to a lesser extent, to coarse particles (pm( )) have been independent predictors of the spatial spread of covid- . for every μm/m( ) above the mean the risk of a positive test case increased by . % ( % credibility interval, icr: . %, . %) for no( ) and . % ( % icr: - . %, . %) for pm( ). regions with levels of no( ) exposure in the third and fourth quartile had . % and . % greater risk of a death, respectively, than regions located in the first two quartiles. conclusion: although it is possible that there are biological mechanisms that explain, at least partially, the association between long-term exposure to air pollutants and covid- , we hypothesize that the spatial spread of covid- in catalonia is attributed to the different ease with which some people, the hosts of the virus, have infected others. that facility depends on the heterogeneous distribution at a small area level of variables such as population density, poor housing and the mobility of its residents, for which exposure to pollutants has been a surrogate. (i.e. chronic) exposure to air pollutants (measured as the spatial variation of air pollutants in a given geographic area over a relatively long period of time), fattorini and regoli ( ) (in italian provinces) and coccia ( ) (in the italian cities he studied) found that exposure to air pollutants was significantly associated with an increase in the number of cumulative cases of covid- . with regard to short-term (i.e. acute) exposure (measured as the temporal variation of air pollutants), xu et al. ( ) (in locations in china), zhu et al. ( ) (in cities in china), jiang et al. ( ) ( cities in china), li h et al. ( ) ( cities in china) and adhikari et al. ( ) (in queens, new york) found significantly positive associations between the short-term exposure to air pollutants with newly confirmed cases. furthermore, as domingo et al. ( ) point out, in a very recent review, the results of most of the studies suggest that the long-term exposure to air pollutants might lead to more severe and lethal forms of covid- . most of the studies evaluating socioeconomic and demographic variables (four of the six studies) considered population density (coccia, ; ahmadi et al., ; pequeno et al., ; and you et al. ) . three studies evaluated the influence of income (azar et al., ; you et al., ; and price-haywood et al., ) . you et al. ( ) considered the percentage of the population aged or over and the ratio of total floor area to the number of residential buildings. bontempi ( a) considered the role of commercial exchanges, as a proxy for social interactions. in spain, the region of catalonia has been the second most affected by the covid- pandemic (the madrid region being the most affected), both by number of cases ( , cases, % of all cases in spain, . cases per , inhabitants - . cases per , in spain), and by deaths ( , deaths, % of all deaths in spain, . deaths per , inhabitants - . deaths per , in spain) (secretaría general de sanidad, ; ine, a) . the geographical distribution of the spread of the pandemic has not been spatially homogeneous in the catalan territory either, and important differences at the small area level have been observed. catalonia is mainly an urban region. sixty percent of the population reside in cities with more than , inhabitants (comprising . % of the total catalan territory) and % in cities with more than , inhabitants (comprising . % of the territory) (idescat, ). among these include the secondlargest city in spain, barcelona, and the adjacent municipalities making up the barcelona metropolitan area, i.e. . % of the population of catalonia (representing only . % of the territory). all have a high population density and exhibit different levels of urban air pollution whose primary source of emission is from road traffic. our hypothesis is that the heterogeneity in the spatial distribution of the pandemic could be attributed to the fact that the risk of infection and death by covid- could be associated with, on the one hand, a heterogeneous distribution at a small area level of environmental factors and, on the other hand, to different socioeconomic and demographic factors in each of those small areas. our objective in this paper was to investigate, at a small area level and controlling for socioeconomic and demographic factors, whether long-term exposure to air pollutants, such as particulate matter (pm , coarse particles with a diameter of µm or less) and nitrogen dioxide (no ), increased the risk of covid- incidence and death in catalonia, spain. this work presents as novelties, the use of spatio-temporal models to evaluate the effects of long-term exposure to air pollutants on the spatial spread of covid- . in the models we control for a wide range of confounders, both observed and unobserved, and for spatial and temporal dependence. finally, we have exclusively used open data. we used a mixed longitudinal ecological design, in which the response variables were observed several times at different points in time for each small area involved in the study. the study population consisted of small areas of catalonia: for incidence, the basic health area (abs, for its acronym in catalan from here on) and for mortality the 'comarca', an administrative territorial division of catalonia (region, hereinafter). the study period was between february and may , . the design was unbalanced, since neither the abss nor the regions were observed the same number of times. catalan health planning defines an abs as the elementary territorial unit through which primary health care services are organized (atenció primària girona, ) . the abss are either made up of neighbourhoods or districts in urban areas or by one or more municipalities in rural areas. their delimitation is determined by geographical, demographic, social and epidemiological factors and, in particular, based on the accessibility the population has to services and the efficiency in the organization of health resources (atenció primària girona, ) . each abs has a primary care team, consisting of general practitioners, paediatricians, dentists, nurses and nursing assistants, social workers and administrative support staff. depending on the size of the abs, the number of municipalities and the dispersion of the population, the abs will have one primary care centre (cap) and may have more clinics that are organically dependent on the cap (atenció primària girona, ). specifically, we considered of the abss in catalonia (because in six of the abss no positive test was reported), with a population between and , inhabitants (mean , inhabitants, standard deviation , , median , inhabitants, first quartile -q - , , third quartile -q - , ). the population density was in the range of . - , . inhabitants/km (mean , . , standard deviation , . , median . , q . , q , . ) . of the municipalities considered, were divided into more than one abs, of them into a maximum of five abss, eight between six and abss and one, (the city of barcelona) into abss (idescat, ). to avoid the identification of the deceased and to guarantee their confidentiality, no cases of mortality are provided at the level of the abs but rather at the 'region' level (open government, ) . we had mortality data for all regions of catalonia, with a population between , and , , inhabitants (mean , inhabitants, standard deviation , , median , inhabitants, q , , q , ) . the population density was in the range . - , . inhabitants/km (mean . , standard deviation . , median . , q . , q . ) (idescat, ). to evaluate the incidence, we used daily incident positive cases, which were those that tested positive on some diagnostic test (pcr or fast test) (open government, ) , at the level of the abs. for mortality we used daily deaths obtained from the funeral homes' reports to the catalan health department (open government, ) . these reports declare positive cases as well as suspicious ones. suspicious cases corresponded to people who presented symptoms at some point and a health professional classified them as a possible case, but they did not have a diagnostic test with a positive result. all data were obtained from the rsacovid records from the catalan health department (open government, ) . we used long-term exposure to air pollutants, particulate matter (pm ) and nitrogen dioxide (no ) in each of small areas from to . it is important to note that we evaluated long-term exposure to these air pollutants. that is to say, a subject, by virtue of residing in a certain small area, has been exposed to an (average) level of various environmental variables in the small area where, in our case, they resided at least during the period - . we were interested in the effects that geographical variation of such exposure may have on the spatial spread of covid- . we obtained information on the levels of air pollution for - from the monitoring stations in the catalan network for pollution control and prevention (xvpca) located throughout catalonia (dades obertes catalunya, ). we predicted the levels of air pollutants to which the inhabitants of each abs and each region had been exposed to from to using a joint bayesian model. the dependent variables were pm and no . as explanatory variables we included air pollutants other than the dependent variable (fine particles with a diameter of . µm or less -pm . -nitrogen oxide -no-, sulphur dioxide -so -, carbon monoxide -co-, ozone -o -, benzene -c h -, benzopyrene -b-, lead, arsenic, nickel, cadmium; in addition to pm and no when the dependent variable was no and pm , respectively) and the surface of the abs or the region. in the model we controlled for spatial heterogeneity and both spatial and temporal dependence. this model allowed us to avoid the j o u r n a l p r e -p r o o f problems caused by spatial misalignment. if this problem is not corrected properly (as we did), there will be a complex form of measurement error leading to biased (i.e. asymptotically biased) and inconsistent estimates and erroneous standard errors in the estimates of the parameters. further details concerning this can be found in barceló et al. ( ) . in fact, although pm was observed at stations located at only of the abss and no at of them, the model fit was very good in both cases (figures a and a in supplementary material) . we controlled for socioeconomic and demographic variables in the last year (or period) available at the census tract level (the only small area below the municipality for which data are provided). in particular: with the exception of population density, all other variables were observed at the census tract level. using the population of each of the census tracts as weights (the source of the total population of the census tract and of the population of the census tract by sex was ine ( a) we calculated the weighted average of the values at the census tracts that composed the abs and the region to obtain their value at abs and region levels. j o u r n a l p r e -p r o o f we specified two generalized linear mixed models (glmm) with variable response from the poisson family; one for daily incident positive cases and the other for daily mortality. conditional to the true risk in the small area (abs or region) ݅ on day ‫,ݐ‬ ‫ݔ‬ ௧ , the cases of the response variable (ܻ ௧ ) occurring in each of the small areas on each day was distributed as a poisson. where ߠ ௧ , is the mathematical expectation of ܻ ௧ , ‫ܧ‬ሺܻ ௧ ሻ = ߠ ௧ ; ݅ = , … , ݊; ‫,…, , =ݐ‬ ; where t = corresponded to february and t = to may , ; and ‫݊݅ݐ݈ܽݑܲ‬ was the population at risk of being a case (positive case or death) in the small area ݅ and on day ‫.ݐ‬ the link functions of the glmms were as follows: -daily incident positive cases where the subindexes ݅ and ‫ݐ‬ indicated the abs, and the day, respectively; pollutant i denoted the predicted levels of air pollutant (pm and no ) in abs ݅; incomeq i the average income per person in abs ݅ (in quartiles, taking the fourth quartile as the reference category); unemploymentq i the unemployment rate (in quartiles, taking the first quartile as the reference category); aged population i the percentage of population aged and over; foreigners i the percentage of foreigners; poor housing i percentage of houses with less than m of living area in ; single person i the percentage of single person households; densityq i the population density (in quartiles, taking the first quartile as the reference category); population i the population of the abs ݅; dummy i a dummy variable that collected the abs where a possible outlier was located (explained below); ߟ , ܵ, ߬ ௧ , ߮ ௧_ denoted random effects (explained below); and ‫ݏߚ‬ were the coefficients of the explanatory and control variables (݁ ఉ was the relative risk associated with each of them). -daily mortality j o u r n a l p r e -p r o o f in addition to considering total deaths, the model for daily deaths was stratified by sex. where the subindexes ݅ and ‫ݐ‬ indicated the region, and the day, respectively; pollutant i the air pollutant (pm , included linearly in the model, and no , included in quartiles, considering the first two as the reference category); income i the average income per person in the region ݅ (included linearly in the model); population i the population of the region (in the stratified models, the total number of men and the total number of women, both in (ine, a)); dummy i a dummy variable that collected the region where a possible outlier was located (explained below). the definition of the rest of the parameters, variables, and the random effects is the same as described previously. in order to assess whether the effect of the exposure to pollutants was different along the epidemic curve, the models for daily incident cases and daily deaths (total, men and women) were re-estimated including the interaction between the pollutant variable and the week of the year (from week , that of february , until week , that of may , ). when we represented both the number of positive cases and the number of deaths per , inhabitants by abs and region, respectively, we observed the existence of an outlier (see figure a in supplementary material). this outlier corresponded to an abs in the city of barcelona in which the largest hospital in catalonia is located. we chose to control this outlier, including dummy variables in the models. these variables took the value when the abs, or the region, coincided where the outlier was located and otherwise. the number of positive cases did not correspond to the number of subjects. the problem being that the government of catalonia, although it provides the daily data of diagnosed subjects, only publishes them at the level of the whole of catalonia, without disaggregating. therefore, the number of positive cases can only be considered as an estimator of the incidence. the measurement error of this estimator, however, was not random. if this error were not controlled, the estimators would be inconsistent. we constructed a new variable, daily number of tests per confirmed case, t_c, dividing the daily total number of tests (for all of catalonia) by the daily number of subjects with a confirmed diagnosis (these data were obtained from open government, ) . this variable indicated the daily number of tests that were performed to detect a subject with a confirmed diagnosis of covid- (at the level of catalonia). during the study period, an average of . tests per person were performed each day in catalonia (standard deviation: . ; median . , q . , q . ). note, however, that as of mid-april the behaviour of this variable ceased to be stationary in mean. that is, the number of tests grew faster than the number of diagnosed subjects. furthermore, the difference in the growth of both variables increased over time ( figure a in supplementary material). to control the measurement error resulting from using an estimator of the incidence and not the incidence by itself, in the model we included for daily incident positive cases a random effect indexed in the daily number of tests per confirmed case, t_c, ߮ ௧_ . to control the non-stationarity in mean explained above, we interacted this effect with ߬ ௧ , another random effect indexed on time (see the model for daily incident positive cases). we included four random effects in the models. first, ߟ , a random effect indexed on the small area (abs in the model for daily incident positive cases, and region in the model for daily mortality). this random effect was unstructured (independent and identically distributed random effects, (iid), and captured individual heterogeneity, that is to say, unobserved confounders specific to the small area and invariant in time. second, in the model we included ߮ ௧_ , a structured random effect (random walk of order one, rw ). following the integrated nested laplace approximations (inla) approach (rue et al., and when, as in our case, the random effects are indexed on a continuous variable, they can be used as smoothers to model non-linear dependency on covariates in the linear predictor. we also included ߬ ௧ , a structured random effect (rw ) indexed on time, in order to control the temporal dependency (that is, the shape of the curve itself). finally, we included the structured random effect s(small area) to control spatial dependency. that is to say, the fact that small areas that are close in space show more similar incidence and mortality than areas that are not close. following the inla approach, random effects were defined using a multivariate gaussian distribution with a zero mean and precision matrix kΣ, where k was a constant and Σ was a matrix that defined the dependence structure of the random effects [ , ] . in unstructured random effects (iid) Σ was a diagonal matrix of s; and in random walk random effects Σ was defined assuming that increments (in rw , Δ‫ݑ‬ = ‫ݑ‬ ௧ − ‫ݑ‬ ௧ିଵ ) followed a gaussian distribution with zero mean and a constant precision k (gómez-rubio, ). the spatially structured random effect s was normally distributed with zero mean and a matérn covariance function: where Κ ఔ is the modified bessel function of the second type and order ߥ > . ߥ is a smoother parameter, ߪ ଶ is the variance and ߢ > is related to the range (ߩ = √ ߥ ߢ ⁄ ), the distance to which the spatial correlation is close to . (lindgren et al., ) . we carried out various sensitivity analyses in which we included explanatory and control variables linearly and non-linearly (quartiles). when we included the variables non-linearly, we tried different reference categories. we tested the interaction between air pollutants and the average income per person. in the model for daily incident positive cases we included, as an additional control variable, an indicator of the number of inhabitants of the city to which the abs belonged. we estimated the models with or without the dummy variables that controlled the outlier. we estimated the model both without controlling and controlling the measurement error due to the use of the daily number of tests per confirmed case. in the latter case, we tested without interacting and interacting with the random effect that controlled temporal dependence. also, in this last case, we tried different smoothers (specifically autoregressive of order and random walk of order , with curves smoother than that of a rw ). we compared the models using their predictive accuracy and evaluated them using the watanabe-akaike information criterion (waic) (watanabe, ) and the deviance information criterion (dic) (spiegelhalteer et al., ) . to evaluate the existence of a geographical pattern in the incidence of and mortality from covid- , we represented the relative risks (rrs), estimated in the glmm for daily incident positive cases and for daily mortality, on a map of the region under study (i.e. catalonia). we represented the maps at two points in time: before and after the peak of the pandemic (which occurred in the first week of april). maps at the abs and at the region levels were obtained from the department of health, government of catalonia ( ) and from the institut geogràfic i geològic de catalunya ( ), respectively. we also computed exceedance probabilities which are the probability that the smoothed relative risks were above (richardson et al., ) . richardson et al. recommend using, as a specific interpretation rule, the cut-off % (and %). in this sense, when the exceedance probability is greater than % (less than %), a reasonable sensitivity will be achieved. that is, a large proportion of areas in which an excess (or a defect) of risk has been estimated correspond to areas that actually have an excess (or a defect) of risk (richardson et al., ) . this cut-off can be used as a measure of the statistical significance of the smoothed risk and, furthermore, to help assess the existence of agglomerations of excess cases (i.e. clusters). the exceedance probabilities were also represented on a map of the study area. inferences were made following a bayesian perspective, using the inla approach (rue et al., and . we used priors that penalize complexity (called pc priors). these priors are robust in the sense that they do not have an impact on the results and, in addition, they have an epidemiological interpretation . all analyses were carried out using the free software r (version . . ) (r core team, ), through the inla package (rue et al., and r inla project, ) . the maps were represented using the leaflet package (cheng et al., ) . descriptive results are shown in tables (bivariate analyses) and a (univariate analyses) (in supplementary material). all variables have fairly asymmetric distributions. for this reason, only robust summary statistics (median and quartiles) should be interpreted. the results of the bivariate analyses show that, in general, the most polluted abss and regions were those that presented the highest number of positive cases and deaths per , inhabitants, respectively. however, note that they grew more or less monotonically as pm levels did, only when deaths per , inhabitants were considered (table b ). in the rest of the cases, the possible relationships between air pollutants and the number of positive cases and deaths (both per , inhabitants) did not appear to be monotonous. in this sense, the highest number of positive cases per , inhabitants occurred in the third quartile of pm and no (table a) . note, in particular, the possible relationship between no and deaths per , inhabitants at the region level, with an imperfect v-shape where the right wing is longer than the left (table b) . the higher the average income per person in the abs and in the region, the greater the number of positives and deaths per , inhabitants, respectively. the greater the population density of the abs or the region, the greater the number of positive cases and deaths per , inhabitants. the possible relationship between the unemployment rate and the number of positive cases and deaths (both per , inhabitants) was nonlinear, with a maximum in the second (number of positive cases per , inhabitants, table a ) and in the third quartile (deaths per , inhabitants, table b ). note that, after the maximum, the highest number of positive cases was in the first and third quartiles (table a ) and the highest number of deaths in the second quartile (table b) . in the sensitivity analysis, regarding the functional form of the explanatory variables (linear or nonlinear, the latter represented parametrically, including the variable in quartiles) and the reference categories when the variable was entered non-linearly, the models with a better fit (lower waic and dic) corresponded to those specified above. the interaction between air pollutants and the average income per person was not statistically significant in the two models. in the model for daily incident positive cases, the indicator of the number of inhabitants of the city to which the abs belonged was not statistically significant either. furthermore, both in the interaction and in the indicator, the models that included them did not show a better fit. however, the models that included the dummy variables to control the outlier, as well as those that controlled the measurement error due to the use of the daily number of positive cases (in interaction with the random effect that controlled temporal dependency) provided a much better adjustment (lower waic and dic). finally, the best smoother for the random effect indexed by the number of tests per day (in catalonia) was the random walk of order (rw ). in tables and we show the estimation results of the glmm models with which we specified the association between air pollutants and the daily incident positive cases and daily deaths, controlling, in both cases, for socioeconomic and demographic variables, unobserved confounders and the spatial and the temporal dependency. to facilitate the interpretation of the relative risks (rr) in the case of the variables introduced in the models linearly, we centred these variables, subtracting the mean. furthermore, in tables and , in addition to the rr and their credibility intervals at % ( % icr, from now on), the probability of the parameter estimator (the log (rr)) as an absolute value being more than is also shown. unlike the p-value in a usual environment (i.e. frequentist), this probability allows us to make inferences about possible associations. for no , for every µm/m above the mean, the risk of a positive result increased by . % (relative risk . , % icr: . - . ). in the case of pm , for every µm/m above the mean, the risk of a positive result increased by . % ( % icr: . - . ) (table ) . however, in the latter case, the association was found only marginally significant (i.e. the % credibility interval contained the unit, but not the % credibility interval). associations between the levels of air pollution and the risk of dying were found for no (total deaths and deaths of men) and for pm (only in deaths of men), although in all cases they were only marginally significant (table ) . regions with levels of no exposure in the third quartile had . % ( % icr: . - . ) (total deaths) and . % ( % icr: . - . ) (deaths in men) greater risk than the regions located in the first two quartiles. the relative risk was even higher in the regions located in the fourth quartile, with a . % ( % icr: . - . ) greater risk in total deaths and . % ( % icr: . - . ) in male deaths. for every µm/m above the mean for pm , the risk of death in men increased by . % ( % icr: . - . ). with regard to the socioeconomic and demographic control variables, with the exception of average income per person and poor housing, both in mortality (table ) , associations were found for both the risk of a positive case and of death, although many of them were only marginally significant. the higher the population density, the greater the percentage of population aged years old and the higher the percentage of poor housing in the small area (abs for the three variables, region only in the first two), the greater the risk of a positive result and death. conversely, the higher the unemployment rate and the percentage of foreigners in the small area (both in abs and in the region), the lower the risk of a positive result and death. note that with respect to the most economically favoured abs (quartile ), those abss located in the third and in the second quartiles (in this order) had the highest risk of a positive result (table ) (the average income per person was not associated with the risk of death). the higher the percentage of single person households, the lower the risk of a positive result (table ), but the higher the risk of death (table ) . at least in terms of risk of death (data on small areas segregated by sex are only provided for mortality), sex could be a confounding variable of the association of the risk with air pollutants, single person households, and poor housing, since in these cases, the credibility intervals of % and % in the stratum of women contained the unit (table ) . the association between the air pollutants and the risk of a positive case and of a death throughout the evolution of the pandemic are shown in figures and , respectively. we observed that rrs increased up to a few weeks after the lockdown and then decreased (albeit oscillating). for mortality this week was from march to (third week after lockdown) (figure right) and for positive results it was somewhat earlier, the week from march to (second week after lockdown) for pm and the week from march to (the week after lockdown) for no (figure left) . it should be noted, however, that the credibility intervals of the rrs overlapped (that is, we could not reject the null hypothesis that the rrs were the same) and that there were few statistically significant rrs (especially for pm both in daily incident positive cases and in deaths) and most of them were only marginally significant (especially in no in deaths) (figures ). the maps of the smoothed relative risks of the study area and of the exceedance probabilities are shown in figures (positive result) and (death). the smoothed relative risks should be interpreted in relation to the smoothed rr average throughout catalonia in the period considered (before and after the peak of the pandemic). both the maps of smoothed relative risk of a positive result ( figure ) and those of a death (figure ) , closely resemble the maps of the exceedance probabilities (figures a a and figure a b in supplementary material, respectively). most of the small areas (abss or regions), in which we estimated either an excess (rr> , exceedance probability> %) or a risk defect (rr< , exceedance probability< %) corresponded, effectively, with areas with an excess or a defect of risk, respectively. in the maps of the smoothed relative risks of a positive result, the same geographic pattern was observed both before and after the peak of the pandemic (figure ). it is observed how the largest smoothed rrs were concentrated in three parallel j o u r n a l p r e -p r o o f axes from north-south direction, one on the coast, another in the interior and a third on the western limit of catalonia. the first two coincided with densely populated abss and large road and rail infrastructures. the third, however, was made up of abss with very little population, suggesting that smoothed rrs could be very unstable. in the maps of the smoothed relative risks of death ( figure and figure a b in supplementary material), the highest (and statistically significant, i.e. exceedance probabilities> % or < %) smoothed rrs are observed in an area in the center of catalonia, with the lower limit in the city of barcelona ( figure a b in supplemental material). in figure a (in supplementary material) we show those abss and regions with statistically significant variation in the smoothed relative risks before and after the peak of the pandemic (first week of april ). very few abss, and even fewer regions, varied their smoothed rr. specifically, abs (out of a total of ) went from having a smoothed rr of a positive result greater than unity to a rr less than unity, and most of them were abs from the city of barcelona ( of ). only five went from having a smoothed rr less than unity to one greater than unity and only four regions out of a total of went from having a smoothed rr of death greater than one to another less than one. all of these regions had very low population densities (alt camp, noguera, urgell and vall d'aran). no region was found in the opposite case. we have found that long-term exposure to nitrogen dioxide (no ) and, to a lesser extent, to coarse particles (pm ), have been independent predictors of the spatial spread of covid- in catalonia, from late february to mid-may . as we have found, significantly positive associations between air pollutants and covid- cases were found by all studies that, in the systematic review we carried out, evaluated the association with air pollutants. the problem is that not all of them are totally comparable. only coccia ( ) and fattorini and regoli ( ) evaluated, as we did, long-term exposure to air pollutants. however, the dependent variable used by both studies (number of cumulative cases) differed from ours. in addition, as a difference with respect to our study, fattorini and regoli ( ) allowed, as in our case, non-linear relationships (approximated in a non-parametric way through gam models) between the pollutants and the new daily cases of covid- . secondarily, part of the discrepancy could also be due to the probability family used for the response variable (gaussian in zhu et al., ; and in li h et al., ; poisson in jiang et al., ) . adhikari et al. ( ) , who evaluated the influence between meteorological variables and air pollutants on the incidence and mortality from covid- , found that, among pollutants, daily maximum eight-hour ozone concentrations were significantly and positively associated with new confirmed cases related to covid- (although not so pm . ). however, neither meteorological variables nor air pollutants showed significant associations with deaths related to covid- . all studies evaluating the association between population density and covid- , found, as we did, that increases in population density were associated with increased covid- morbidity and mortality. although they differ in the study population ( italian cities in coccia, ; iran in ahmadi et al., ; the state capital cities of brazil in pequeno et al., ; and the districts of wuhan, china in you et al., ) , in the response variable (number of cumulative cases (coccia, ; pequeno et al., ; you et al., -; infection rate -ahmadi et al., -: and deaths -coccia, -) , in the variables they controlled for (meteorological - coccia, ; ahmadi et al., ; pequeno et al., -; air pollutants -coccia, -; and socioeconomic variables -pequeno et al., ; you et al., -) only three studies evaluated the influence of income. unlike us, azar et al. ( ) and you et al. ( ) , found that the most economically favored areas show less morbidity from covid- . you et al. ( ) found that increasing gdp per unit of land area ( districts of the city of wuhan, china) was associated with a decreased covid- morbidity rate. azar et al. ( ) , whose study population consisted of a cohort of individual patients residing in counties from northern california, usa (ten of them in san francisco bay), found that covid- positive patients residing in zip codes within the third and fourth quartiles of income were less likely to be admitted to hospital than those residing in the bottom zip code quartile. however, price-haywood et al. ( ) , who also used an individual data cohort from the ochsner medical centre, new orleans, louisiana, usa, found that black race was not associated with higher in-hospital mortality than white race, after adjustment for differences in sociodemographic and clinical characteristics on admission. however, we have important differences with respect to azar et al. ( ) and you et al. ( ) . firstly, the dependent variable differed from ours, the covid- morbidity rate (number of cumulative cases divided by the population of the district) in you et al. ( ) azar et al.) . you et al. ( ) , as in our case, found that both the percentage of the population aged or over and the ratio of total floor area to the number of residential buildings (indicator of poor housing) were risk factors of morbidity due to covid- . none of the studies reviewed considered the unemployment rate, the percentage of foreigners or of single person households in the area. the instituto de salud carlos iii (ministry of health, government of spain) ( ) has already carried out two rounds of the national study of sero-epidemiology of sars-cov- infection in spain (ene-covid). ene-covid is a large population-based sero-epidemiological longitudinal study, whose objectives are to estimate the prevalence of sars-cov infection in spain by determining antibodies against the virus and evaluating its temporal evolution. the estimated prevalence of igg antibodies against sars-cov- in spain is . % ( % ci: . %- . %) ( . %; % ci: . %- . %, in the first round). when stratified by employment situation, the highest prevalence is presented by retirees ( . %, % ci: . %- . %), followed by active workers ( . %, % ci: . . %- . %). the lowest prevalence, after those who are dedicated to charitable activities ( . %, % ci: . %- . %), is presented by the unemployed ( . %, % ci: . %- . %; men . %, % ci: . %- . %; women . %, % ci: . %- . %). these results are in line with ours. the higher the percentage of unemployment the small area (abs or region) has, the less positive results and fewer deaths from covid- it presented. although it is true that the information on the unemployment rate referred to (the worst year of the great recession in spain) and that, today, the percentages are much lower, the spatial distribution of the rate is practically identical (that is, those areas with lower rates continue to have lower rates and vice versa). none of the studies reviewed evaluated the influence of the percentage of foreigners. our results, however, are in line with those we found for the average income. the higher the percentage in a certain small area, the lower the income of that area and, therefore, the lower incidence and mortality from covid- . nor did any study evaluate the percentage of single person households in the small area. our findings, although contrary in positive results and deaths, could be explained by figure a (in supplementary material) . when considering abss (positive results), that is the general population, single person households are inhabited by high-income people. however, when the region (deaths), that is the elderly population, is used as a small area, single person households are inhabited by low-income people. thus, the rrs for this variable were in line with the rr for income. it has been argued that there could be potential biological mechanisms that may explain the association between air pollutants and respiratory viral infections, including influenza, pneumonia, and sars (ciencewicki and jaspers, ) . wu et al. ( ) , in a very recent study evaluating the effects of long-term average exposure to fine particulate matter (pm . ) on the risk of covid- death in the united states at the small area level ( , counties), point out that exposure to pm . adversely affects the respiratory and cardiovascular systems, increasing mortality risk. furthermore, exposure exacerbates the severity of covid- infection symptoms and worsens the prognosis of covid- patients . although we do not rule out that these mechanisms could partially explain our findings, we are more inclined to suppose that, in our work, air pollutants have actually been surrogates of another variable, the mobility of residents in the small area (abs or region). there are several pieces of evidence that support this. first, that no was the pollutant that we found statistically significantly associated in the two small areas (that is, for a positive case result and for death). pm was not found statistically significant when we considered the region (that is, deaths) and, in addition, in this case no was found only marginally significant. this suggests that the effects of exposure to air pollutants that we found were related to urban traffic. in fact, in the city of barcelona, while % of no originates from traffic, this origin is only % for pm (barcelona city council, ). conversely, while % of pm is generated outside the municipality, only % of no is generated outside (barcelona city council, ). it is not unreasonable to suppose that these figures can be extrapolated to the entire barcelona metropolitan area, which comprises . % of the total population of catalonia. residing in an area with significant urban traffic (i.e. with high long-term exposure to the pollutants generated by it, especially no ) means residing in an area with greater mobility and, therefore, a higher risk of contagion. on the other hand, the fact that we found that sex has been a confounding variable of the association between exposure to air pollutants and the risk of dying from covid- , contributes to this first evidence. deaths, in both men and women, occurred mainly in the elderly population. however, elderly women in this age group are much less mobile than men (for whom statistically significant relationships were found). this evidence can also be confirmed by the fact that, after an increase in rrs up to one to three weeks after the lockdown (the incubation time, first, and worsening for the seriously ill and eventual death, later) the rrs associated with exposure to air pollutants barely varied (credibility intervals overlapped), even though exposure to air pollutants was substantially reduced. the same phenomenon could be behind the finding that the smoothed rrs were very similar before and after the peak of the pandemic (the first week of april). the second piece of evidence is provided by the effects the socioeconomic variables have on the risk of a positive outcome and death. in the most economically favored areas (with more average income per person, lower percentage of foreigners from low-and middle-income countries, and a lower j o u r n a l p r e -p r o o f unemployment rate) mainly people with middle-high incomes reside there. in the period that we have analyzed, these people have been mobile very little. during the confinement, they have stayed at home, teleworked, and those who had to go anywhere have done so with their own vehicles. residents in the most economically disadvantaged areas have also been mobile very little. most of those who were working have lost their jobs due to the lockdown and the subsequent closure of economic activity. however, residents in the intermediate areas (those located in quartiles and of average income per person) have been the most mobile. they had to go to work (at least since the restrictions on work in non-essential activities were lifted after easter in the second week of april) and they commuted, mainly, by public transport. high mobility, and therefore a greater possibility of contact, has been found to be associated with a higher spread of the disease (ahmadi et al., ; pequeño et al., ) . another argument in favor of our hypothesis could be drawn from the discussion about the route of transmission of the virus. some authors have suggested that the rapid spread of the sars-cov- could be explained not only by person-toperson transmission, but also by air pollution-to-human transmission (ie airborne transmission) (frontera et al., ; hadei et al., ; morawska and cao, ) . coccia ( ) , even, has suggested that the transmission dynamics of covid- could be due to air pollution-to-human transmission, rather than the direct human-to-human transmission (domingo et al., ) . bontempi ( b) , however, argues that it is not possible to conclude that covid- diffusion mechanism also occurs through the air, by using pm as a carrier. in particular, she showed that piedmont cities, presenting lower detected infections cases in comparison to brescia and bergamo in the investigated period, had most sever pm pollution events in comparison to lombardy cities. in fact, bontempi et al. ( ) argue that the current pandemic's diffusion patterns are caused by a multiplicity of environmental, economic and social factors and that the spread of the infection is more nonlinear and depends on measures, health care system's efficiency and other factors, which could even explain different trajectories. for example, bontempi ( a) found a strong correlation (even higher than with air pollutants) between commercial exchanges (that exemplify the social interactions) and covid- diffusion in italy. thus, it could happen that the contagion was greater in those areas that, in addition to greater mobility, had high economic/commercial exchanges. our study might have some limitations. first of all, we used an ecological design. the potential ecological fallacy should be taken into account and, when interpreting the results, no inferences should be made at the individual level. also, there might still be unmeasured confounding bias inherent in this type of design. however, we have tried to control for bias, including in the models both observed variables, demographic and socioeconomic variables, as well as, unstructured and structured confounders, random effects, that captured unobserved confounders at the small area level, and spatial and temporal dependence, respectively. on the other hand, although data are not yet available at the individual level, we are sure that when we have the data, we will be able to contrast the findings of our study with them. second, all the variables we had were measured with error. as we explained, we control for non-random measurement errors, both those associated with using an estimator of the incidence of covid- , and those associated with estimating long-term exposure to air pollutants. however, we were unable to control other measurement errors. governments and agencies do not use the same covid- death definition. for example, according to the ministry of health (government of spain) in catalonia, until june , , there were , deaths (secretaría general de sanidad, ). however, according to the government of catalonia there were , deaths (open government, ) . for the government of catalonia, one death by covid- is both the one who had a positive result on some test (pcr or fast test) and the one who presented symptoms at some point and a sanitary professional classified them as a possible case, but they did not have a diagnostic test with a positive result (open government, ) . for the government of spain, until may , one death by covid- was someone who presented a positive result by pcr. from then on, it uses the same definition as in catalonia, although it has not yet updated the information prior to that date. as we said, with the exception of population density, all other socieconomic and demographic variables were observed at the census tract level and then they were averaged, weighted by population, to obtain their value in the small area. however, not all residents in the small area actually had these mean values of the variables, leading to a measurement error, most likely random. if the explanatory variables are measured with error, the estimators will be inconsistent (greene, ) . nevertheless, if the between-area variability of the variable measured with error is much greater than the within-area variability of such variable then the effect of measurement error on the estimator consistency may be negligible (elliott and savitz, ) . in our case, this occurred with the abss but not with the regions. as we pointed out, the boundaries of the abss are determined based on geographical, demographic, social and epidemiological factors, as well as on the accessibility the population has to services. a region is an administrative unit that, in most cases, is quite heterogeneous. in any case, when, as in the region, this criterion is not met, the presence of measurement errors tends to underestimate the effect of the variable measured with error (greene, ) . third, we were unable to distinguish whether the effects of the variables that we found associated with the spread of covid- were more related to initial contagion or subsequent diffusion mechanisms (bontempi et al., ) . our hypothesis is that we have provided evidence of the different starting conditions with which they found the small areas (through both observed and unobserved confounders, such, in particular, individual heterogeneity) for, in the words of bontempi et al. ( ) , the development of the different contagion trajectories in each of those small areas. fourth, there are a number of limitations inherent in spatio-temporal ecological designs. in them it is essential to minimize within-area exposure variability and maximize between-area exposure variability [ ] . as we have mentioned, this is true when we used abss. on the other hand, these designs assume that the exposure that a person has suffered is the same in that of the area in which their residence has been identified. in our case, that person's residence was identified from their health card (open government, ) . however, the person does not have to have always resided in the same area and/or could have been exposed in different areas. fortunately, this measurement error, although unavoidable in any spatio-temporal ecological design, is also random. another problem is known as the 'modifiable areal unit problem' (maup). the maup, which refers to data aggregation in units for analysis, is a potential source of bias that affects spatial studies using aggregated data. wang and di ( ) found that the association between no and covid- deaths varies when the data is aggregated at different levels. thus, they found that no was a protective factor on mortality in the hubei province, however, it was a risk factor when considering an aggregation of wuhan districts (from to four districts). similar differences were discovered in the henan province, where the positive city-level association became negative when the aggregation strategy was employed (wang and di, ) . in our case, perhaps part of the nonsignificance of pm in daily mortality could be attributed to maup. finally, from a methodological point of view, in the models we have assumed that space and time were independent. in other words, the spatial variability of the pandemic did not vary over time. although the results seem to confirm our assumption, we estimated another glmm for daily incident positive cases, with the same specification, but assuming that, although space and time were not independent, they were separable. the estimators of the rrs were very similar to those shown in this work. however, we believe that these could vary with a dependent and non-separable time and space specification. in any case, this aspect deserves further research. we believe that these limitations are offset by the strengths of our study. in particular, we highlight four. first, although we are not the only ones to consider small areas below the municipality (you et al., , analyzed the districts of wuhan, china), we are in using a spatio-temporal model to evaluate the effects of long-term exposure to air pollutants on the spatial spread of covid- . second, we used models in which we control for a wide range of confounders, observed and unobserved, and for spatial and temporal dependence, that is, for the spread of the disease in the territory and over time. third, we have shown the robustness of our results to a different specification errors (i.e. outliers, nonrandom measurement errors). finally, we have exclusively used open data. although it is possible that there are biological mechanisms that explain, at least partially, the association between long-term exposure to air pollutants and covid- , we hypothesize that the spatial spread of covid- in catalonia is attributed to the different ease with which some people, the hosts of the virus, have infected others. that facility depends on the heterogeneous distribution at a small area level of variables such as population density, poor housing and the mobility of its residents, for which exposure to pollutants has been surrogate. adjusted by the dummy variable to control the outlier, by the number of tests per day, by individual heterogeneity (at the basic health area level), by spatial dependence and by temporal dependence. reference category in square brackets. prob(abs(log(rr))> ) higher than . . prob(abs(log(rr))> ) higher than . . j o u r n a l p r e -p r o o f adjusted by the dummy variable to control the outlier, by individual heterogeneity (at the region level), by spatial dependence and by temporal dependence. %crint %: credibility interval. reference category in square brackets. prob(abs(log(rr))> ) higher than . . prob(abs(log(rr))> ) higher than . . j o u r n a l p r e -p r o o f short-term effects of ambient ozone, pm . and meteorological factors on covid- confirmed cases and deaths in queens investigation of effective climatology parameters on covid- outbreak in iran the coronavirus pandemic and aerosols: does covid- transmit via expiratory particles? institut català de la salut disparities in outcomes among covid- patients in a large health care system in california long term effects of traffic noise on mortality in the city of barcelona barcelona air quality improvement plan commercial exchanges instead of air pollution as possible origin of covid- initial diffusion phase in italy: more efforts are necessary to address interdisciplinary research first data analysis about possible covid- virus airborne diffusion due to air particulate matter (pm): the case of lombardy understanding covid- diffusion requires an interdisciplinary, multi-dimensional approach centers for disease control and prevention (cdc). coronavirus disease (covid . symtoms of coronavirus epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study leaflet: create interactive web maps with the javascript 'leaflet' library air pollution and respiratory viral infection factors determining the diffusion of covid- and suggested strategy to prevent future accelerated viral infectivity similar to covid- immission data from the measurement points of the air pollution monitoring and forecasting network layer with the basic areas of health, health sectors, areas of care management, and health regions influence of airborne transmission of sars-cov- on covid- pandemic. a review design issues in small-area studies of environment and health european centre for disease prevention and control (ecdc) role of the chronic air pollution levels in the covid- outbreak risk in italy regional air pollution persistence links to covid- infection zoning bayesian inference with inla econometric analysis, th edition a letter about the airborne transmission of sars-cov- based on the current evidence nacional de estadística. indicators for census tracks spanish census of population and housing &menu=resultados&secc= &idp= #!t abs- ine. instituto nacional de estadística. household income distribution atlas b enterprises/downloads/geoinformation-layers/administration-boundaries, last accessed on ministry of health. government of spain. national study of sero-epidemiology of sars-cov- infection in spain (ene-covid) effect of ambient air pollutants and meteorological variables on covid- incidence air pollution and temperature are associated with increased covid- incidence: a time series study clinical characteristics of death cases with covid- : a retrospective review of medical records in a single medical center an explicit link between gaussian fields and gaussian markov random fields: the stochastic partial differential equation approach airborne transmission of sars-cov- : the world should face the reality case-fatality rate and characteristics of patients dying in relation to covid- in italy generalitat de catalunya. open data and covid- air transportation, population density and temperature predict the spread of covid- in brazil hospitalization and mortality among black patients and white patients with covid- r: a language and environment for statistical computing. r foundation for statistical computing interpreting posterior relative risk estimates in disease-mapping studies approximate bayesian inference for latent gaussian models using integrated nested laplace approximations (with discussion) bayesian computing with inla: a review update . coronavirus disease (covid- ) penalising model component complexity: a principled, practical approach to constructing priors (with discussion) bayesian measures of model complexity and fit (with discussion) united nations development program modifiable areal unit problem and environmental factors of covid- outbreak asymptotic equivalence of bayes cross validation and widely applicable information criterion in singular learning theory who virtual press conference on covid- exposure to air pollution and covid- mortality in the united states: a nationwide cross-sectional study possible environmental effects on the spread of covid- in china distribution of covid- morbidity rate in association with social, and economic factors in wuhan, china: implications for urban development association between short-term exposure to air pollution and covid- infection: evidence from china this study was carried out within the 'cohort-real world data' subprogram of ciber of epidemiology and public health (ciberesp). we appreciate the comments of two anonymous reviewers of a previous version of this work who, without doubt, helped us to improve our work. the usual disclaimer applies.j o u r n a l p r e -p r o o f the manuscript is an original contribution that has not been published before, whole or in part, in any format, including electronically. all authors will disclose any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations, that could inappropriately influence or be perceived to influence their work, within three years of beginning the submitted work. data and code are available upon request to marc saez (marc.saez@udg.edu). not applicable. ms had the original idea for the paper. ms designed the study. the bibliographic search and the writing of the introduction were carried out by all the authors. the methods and statistical analysis were chosen and performed by ms. mab created the tables and figures. all authors wrote the results and the discussion. the writing and final editing was done by all authors. all authors reviewed and approved the manuscript. key: cord- -ba we o authors: boelle, pierre-yves title: excess cases of influenza like illnesses in france synchronous with covid invasion. date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ba we o several french regions where covid has been reported currently show a renewed increase in ili cases in the general practice based sentinelles network. here we computed the number of excess cases by region and found correlation with the number of reported covid cases so far. these data suggest larger circulation of sars-cov- in the french population than apparent from confirmed cases. influenza like illnesses cases are defined as cases with fever of sudden onset (> °c) with respiratory signs (cough, running nose) and myalgia of any age. acute respiratory infection (air) include diseases with respiratory signs and are only monitored in the > y.o. cases are reported in real time by participating gps (approx. gps) all over france. additionally, sentinelles gps may swab ili case and up to ira cases per week for viral characterization ( ) . influenza virus, respiratory syncytial virus, human rhinovirus and human metapneumovirus are routinely looked for, and sars-cov- has been added since february . we computed the expected number of ili consultations using the superposition of a seasonal ( ) and an influenza epidemic component ( ) , as detailed in the appendix. excess cases were computed as the difference between observed cases and expected numbers. the rate of increase in excess cases was determined, assuming exponential growth. confirmed covid cases were obtained from the santé publique france website, march bulletin( ). in week of , swabs were collected in ili patients and in ari patients. two ( ) swabs in each category were positive for sars-cov- . the positive swabs in ari patients had been collected in in bourgogne-franche comté (bfc) and grand est (gre) regions, out of a total of swabs in these regions. assuming a positivity rate for sars-cov- of / in these regions, we estimated that (ci % [ , ]) ari consultations in the > y.o. could have been caused by covid during week ( / of ari visits). one of the positive ili case was linked to an existing cluster in the east of france. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march , . . the modelling approach allowed computing excess cases in out of regions. the model did not provide a good fit in the remaining regions (see appendix). the overall ili incidence showed renewed increase with [- , ] consultations/ in excess during week and [ , ] consultations/ in excess in week . this changed with regions: / regions displayed positive excess (credible interval excluding ) in week and / regions in week . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint several processes may be at play in this observation, including at least characteristics of the influenza season, change in population behaviour or increase in covid incidence. h n pdm and b influenza viruses co-circulated in - in france. seasons with the type b virus can lead to prolonged periods for decrease in incidence but a renewed increase has never occurred before ( ). the school holidays occurred gradually in france during the end of february and early march. while this may change the dynamics of influenza ( ), the effect is generally notable in the ascending phase of the epidemic rather than after the peak. the current situation with covid may change the health-seeking behaviour of patients and, to some extent, of the contributing general practitioners although they conform to a case definition. preliminary assessment of behavioural data in crowdsourced surveillance system is under way (grippenet.fr( )) but, as of today, no massive trend towards more consultations has been observed. as information regarding the coronavirus risk is widespread, a uniform increase over all regions could have been expected in this scenario, but we acknowledge that it may have led to increased consultation rates in regions where covid is the most reported. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march , . . https://doi.org/ . / . . . doi: medrxiv preprint the overlap between covid and flu symptoms makes it possible that the excess of ili cases is due to covid cases, and the presence of sars-cov- positive swabs in the patients demonstrate this possibility. the correlation between the number of confirmed cases and the computed excess is also consistent with this scenario. in this case, the excess in cases is compatible with an exponential growth with rate estimated at approximately . /week. interestingly, this estimate is very similar from one region to the next in the four most affected regions (gre, idf, occ, hdf). this estimate may prove useful to help calibrate models for studying the impact of the covid pandemic. estimating the true number of covid cases remains difficult in the presence of these uncertainties. we note that the extrapolated number of covid presenting as ari was in the > y.o. in the eastern regions (gre and bfc), which was at least twice more than the number of reported cases at the time ( + ), all ages confounded. as we enter a period of generalized circulation of the sars-cov- virus, surveillance based on clinical description and swabbing by gps will prove essential to help us assess the situation. the number of expected ili consultations reported to the sentinelles network was modelled as the superposition of components: an "epidemic" component due to influenza infections and a background seasonal signal not due to influenza ( ) . more precisely, we fitted the influenza epidemic part using richard's model ( ) . richard's model is a parameters equation describing the cumulated number of cases at time t as follows : the seasonal part was modelled as in a second step, we fitted excess cases by an exponential increase ( ) = exp ( ), and assumed that number of ili cases for weeks to was poisson distributed with mean ( ) + ( ) + ( ). we tied the number of excess cases at in week of for this estimation. estimations were performed with stan. code is available upon request. example data used for estimating excess cases in a french region. the orange points were used to estimate the seasonal part; the first peak in the black part was fit using richard's model plus the seasonal part, and excess was computed over the last weeks as indicated in figure s . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march , . . https://doi.org/ . / . . . doi: medrxiv preprint influenza epidemics observed in primary care from to in france: a decrease in epidemic size over time. influenza other respir viruses first cases of coronavirus disease (covid- ) in france: surveillance, investigations and control measures baseline characteristics and clinical symptoms related to respiratory viruses identified among patients presenting with influenza-like illness in primary care a routine tool for detection and assessment of epidemics of influenza-like syndromes in france early outbreak of influenza a (h n ) in mexico prior to identification of ph n virus covid- : point épidémiologique du mars estimating the impact of school closure on influenza transmission from sentinel data participatory syndromic surveillance of influenza in europe the sentinelles syndromic and viral and surveillance group" including (but not limited to) cécile souty , titouan launay , clément turbelin , caroline guerrisi , chiara poletto , vittoria colizza , sylvie van der werf -institut pasteur, centre coordonnateur du centre national de référence des virus des infections respiratoires (dont la grippe) sorbonne paris cité, unité de génétique moléculaire des virus à arn key: cord- -zjpi up authors: pennisi, m.g.; venza, m.; reale, s.; vitale, f.; lo giudice, s. title: case report of leishmaniasis in four cats date: journal: vet res commun doi: . /b:verc. . .be sha: doc_id: cord_uid: zjpi up nan the cat is an unusual host of l eishmania spp. and only a few cases of leishmaniasis have been reported for this species, mostly in areas where the microorganism and several species of phlebotomine sandflies are endemic (pennisi, ) . about twenty clinical cases have been reported in the literature, sometimes described only briefly with regard to both the clinical course and the therapy employed. because of this, we wish to describe the clinical findings of four cases of feline leishmaniasis observed between december and may . four domestic cats were involved (three short-haired, one long-haired); two males (cases and ) and two females (cases and ). the cats were six (case ), (case ) and (case ) years of age, in case the age was unknown but the subject was an adult cat. all cats came from the messina district and they were free-roaming. diagnosis was achieved by microscopic (smears from cutaneous ulcers and cysts, and from lymph node needle-aspiration) and serological investigations (ifat) with anti-l eishmania antibody titres ranging from (cases , , and ) to (case ). further confirmation came from pcr and isolation of l eishmania spp. in cases , and . the cats were tested for fiv and felv (duospeed, bvt, la seyne sur mer, france), t oxoplasma gondii (ifat), bartonella henselae (ifat) and given blood tests (complete blood cell count, biochemistry profile, serum protein electrophoresis, urinalysis). two cats did not undergo specific treatment (cases and ) because the owner was not compliant with the drug regimen. cases and were treated by oral administration. case was given three different oral treatments without any success: fluconazole ( mg/kg sid for months), metronidazole ( mg/kg) and spiramycin ( , ui/kg) sid for days and itraconazole ( mg sid) for months. seven months later the owner decided to suspend all treatment drugs. case was given allopurinol ( mg/kg sid) for months. case was a fiv+ cat also suffering from pancytopenia. on this occasion erythropoietin ( ui/kg/ h sc) and ferrous sulphate were administered ( mg sid po) for ten weeks and rhuifna- a ( ui sid topically on the oral mucosa) for months. the clinical course of three cases was recorded until the death of the subjects. cases and were euthanised; case is still alive. at the time of diagnosis the following clinical signs were observed: depression and anorexia (cases and ), severe weight loss (cases and ), pale mucous membranes (cases and ), dehydration (case ), solitary (case ) or systemic lymph node enlargement (cases and ), presence of a small crusty ulcer (case ), cutaneous bloody cyst (cases and ), alopecia (case ), dyspnea (case ) and hepatomegaly (case ). ophthalmologic examination highlighted signs of a previous uveitis (cases and ), inactive chorioretinitis (case ) and acute uveitis (case ). hematological abnormalities were: non-regenerative anaemia (cases and ), leukopenia (cases and ), thrombocytopenia (cases and ), increased bun (case ) and increased creatinine (case ). all cats showed hyperproteinemia and hyperglobulinemia with monoclonal hypergammaglobulinemia. cases , and were fiv+; case was positive for coronavirus (titre ). cases (titre ), (titre ) and (titre ) were igg positive for t oxoplasma, while cases (titre ) and (titre ) were igg positive for b. henselae. case (fiv+) was also affected with crf complicated by non-regenerative anaemia, bronchopneumonia and pyothorax and died days after diagnosis. in cases (unsuccessful treatment) and (no treatment), development of the disease led to the progressive development of crf with severe non-regenerative anaemia. euthanasia was performed months (case ) and years (case ) after diagnosis. in case crf was evident months after diagnosis with consequent cachexia and severe anaemia. at the time of euthanasia lymph node enlargement was no longer evident, the specific antibody titre was and serum protein electrophoresis had changed in the preceding month with reduction of hypergammaglobulinemia and development of hyperalfaglobulinemia. case (no therapy), which developed urinary signs of renal failure three years later, was healthy for about two more years, when the onset of a proliferative stomatitis led to anorexia; at the same time there was the onset of seizures and an irregular bradycardia ( beats/minute) associated with a th degree heart murmur. the owner opposed any further investigation and asked for euthanasia. the cutaneous lesions, lymph node enlargement, serum protein electrophoresis and antibody titre did not change over the course of the disease, and when the cat was put down the anti-l eishmania titre was , with positive lymph node needle-aspiration (pcr and microscopy). case (treated with allopurinol, erythropoietin, ferrous sulphate and rhuifna- a) showed a rapid improvement with recovery in appetite and vitality within the first two weeks, while a dramatic improvement of the severe haematological data was seen after three weeks. five months later a weight gain ( kg) was observed, along with the regrowth of hair, the liver and lymph nodes enlargements disappeared, and the hypergammaglobulinemia and anti-l eishmania antibody titre were reduced. the drug regimen was modified and the cat was given allopurinol for ten further months. at the end of the treatment ( months in all) l eishmania serology and pcr were negative, while neutropenia and hypergammaglobulinemia were still present. two months later the cat exhibited anaemia, leucopenia, hypergammaglobulinemia and positive antibody (titre ) once again. in the following months the uveitis recurred, anaemia worsened and the ifa titre rose to . parasites were isolated once again from the submandibular lymph node. at this time allopurinol ( mg/kg sid) was recommenced, and the treatment remains ongoing. for the first time feline leishmaniasis has been reported in fiv+ cats (three cases out of four) and treated with oral drugs, which generally meet with greater compliance from the owners, especially for long-term therapy. clinical signs of feline leishmaniasis are quite similar to those observed for dogs: lymph node enlargement, cutaneous ulcers, alopecia, weight loss, pale mucous membranes, hypergammaglobulinemia and crf. on the contrary, cutaneous bloody cysts (with evidence of amastigotes inside) have not been reported for canine leishmaniasis. the ocular lesions cannot be considered specific because of the concurrent fiv infection (cases , and ) and a high anti-t oxoplasma titre (case ). despite the fact that the literature reports the efficacy of fluconazole (gangneux et al., ), itraconazole (gangneux et al., and spiramycin+metronidazole (gangneux et al., ; pennisi et al., ) , these drugs did not work for the fiv− cat (case ) which developed crf. the same happened in case which, in spite of the fiv infection and the lack of therapy, lived for five more years after diagnosis. allopurinol was given to cats for the first time and it was well tolerated in case which had a symptomatic (stage iv) fiv infection. the allopurinol treatment was clinically efficient but, as reported for dogs (baneth, ) , did not succeed in eradicating the infection. a review of the treatment of canine leishmaniasis a high prevalence of feline leishmaniasis in southern italy efficacy of metronidazole-spiramycin combined therapy in the treatment of canine leishmanisis the authors wish to thank ms. angela burrascano and ms. giuseppa di giovine for their technical assistance. key: cord- -puhm w authors: juan, j.; gil, m. m.; rong, z.; zhang, y.; yang, h.; poon, l. c. y. title: effects of coronavirus disease (covid- ) on maternal, perinatal and neonatal outcomes: a systematic review of pregnancies date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: puhm w objective: to perform a systematic review of available published literature on pregnancies affected by covid- to evaluate the effects of covid- on maternal, perinatal and neonatal outcomes. methods: we performed a systematic review to evaluate the effects of covid- on pregnancy, perinatal and neonatal outcomes. we conducted a comprehensive literature search using pubmed, embase, cochrane library, china national knowledge infrastructure database and wan fang data until april , (studies were identified through pubmed alert after april , ). for the research strategy, combinations of the following keywords and mesh terms were used: sars-cov- , covid- , coronavirus disease , pregnancy, gestation, maternal, mothers, vertical transmission, maternal-fetal transmission, intrauterine transmission, neonates, infant, delivery. eligibility criteria included laboratory-confirmed and/or clinically diagnosed covid- , patient was pregnant on admission, availability of clinical characteristics, including maternal, perinatal or neonatal outcomes. exclusion criteria were unpublished reports, unspecified date and location of the study or suspicion of duplicate reporting, and unreported maternal or perinatal outcomes. no language restrictions were applied. results: we identified several case-reports and case-series but only studies, including a total of pregnant women with covid- , met eligibility criteria and were finally included in the review. in the combined data from seven case-series, the maternal age ranged from to years and the gestational age on admission ranged from to weeks. the most common symptoms at presentation were fever, cough, dyspnea/shortness of breath and fatigue. the rate of severe pneumonia was relatively low, with the majority of the cases requiring intensive care unit admission. almost all cases from the case-series had positive computer tomography chest findings. there were six and cases that had nucleic-acid testing in vaginal mucus and breast milk samples, respectively, which were negative for sars-cov- . only a few cases had spontaneous miscarriage or abortion. cases had delivered, of which the majority by cesarean section. the gestational age at delivery ranged from to weeks. apgar scores at and minutes ranged from to and to , respectively. a few neonates had birthweight less than grams and over one-third of cases were transferred to neonatal intensive care unit. there was one case each of neonatal asphyxia and neonatal death. there were neonates that had nucleic-acid testing in throat swab, which was negative for sars-cov- . from the case-reports, two maternal deaths among pregnant women with covid- were reported. conclusions: the clinical characteristics of pregnant women with covid- are similar to those of nonpregnant adults with covid- . currently, there is no evidence that pregnant women with covid- are more prone to develop severe pneumonia, in comparison to nonpregnant patients. the subject of vertical transmission of sars-cov- remains controversial and more data is needed to investigate this possibility. most importantly, in order to collect meaningful pregnancy and perinatal outcome data, we urge researchers and investigators to reference previously published cases in their publications and to record such reporting when the data of a case is being entered into a registry or several registries. with over three million individuals infected, the global pandemic caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), the coronavirus disease (covid- ) is a global public health crisis. , most cohort studies have focused on evaluating the effects of covid- on the general population, [ ] [ ] [ ] and there is insufficient data on vulnerable populations, such as pregnant women. it is recognized that pregnant women are at an increased risk of acquiring viral respiratory infection and developing severe pneumonia due to the physiologic changes in the immune and cardiopulmonary systems. , lessons learned from the two notable coronavirus outbreaks, the severe acute respiratory syndrome coronavirus (sars-cov) and the middle east respiratory syndrome coronavirus (mers-cov), suggest that pregnant women are particularly susceptible to adverse outcomes, including the need for endotracheal intubation, admission to an intensive care unit (icu), renal failure and death. - the first study describing the clinical characteristics and investigating the possibility of vertical transmission of sars-cov- in nine pregnant women with laboratory-confirmed covid- , demonstrated that the impact of covid- on pregnant women was similar to that of non-pregnant adults and that there was no evidence of vertical transmission as sars-cov- was not detected in amniotic fluid, cord blood and neonatal throat swab of six cases. to date, the largest series reporting on both pregnancy and neonatal outcomes, with a total of covid- -infected pregnant women, demonstrated that covid- during pregnancy was not associated with an increased risk of adverse outcomes such as spontaneous preterm birth. amongst the neonates born to these women, none was infected with sars-cov- . based on very scarce data to-date, conflicting evidence from nuclei acid-based testing and antibodies testing in neonates born to mothers with covid- has raised further controversy in relation to the risk of vertical transmission during pregnancy. , the objective of this study was to perform a systematic review of available published all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint literature on pregnancies affected by covid- to evaluate the effects of covid- on maternal, perinatal and neonatal outcomes. we conducted a comprehensive literature search using pubmed, embase, cochrane titles were selected from first screening and abstracts of citations were reviewed by two reviewers independently (j.j. and m.m.g.) to identify all potentially relevant articles. we identified several case-reports and case-series. after the first screening of titles and abstracts, we decided to repeat the screening procedure and exclude case-reports or case-series that include less than cases from china in order to avoid duplication of cases as there have since been several cohort series published. the potentially relevant articles were fully evaluated by the same reviewers. reference lists of relevant original and review articles were searched for additional reports. full-text articles were retrieved for further consideration for inclusion. disagreements were resolved by the opinion of a third party (l.c.p.), who also independently reviewed the final included articles to confirm they met the inclusion criteria. the review was registered in all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the following information was extracted from the articles: author names, institution and country, study design, sample size, maternal age, gestational age on admission, symptoms on admission, pregnancy complications, gestational age at delivery, mode of delivery, disease severity, laboratory and radiological findings, maternal and neonatal outcomes, samples collection (amniotic fluid, cord blood, placenta, vaginal secretion, urine, feces, breast milk, neonatal pharyngeal swab, neonatal blood, neonatal urine, neonatal feces, neonatal gastric juice). any evidence of maternal to fetal transmission of sars-cov- was also recorded. we contacted the authors directly when further clarification on their data was needed, such as overlapping cases in different studies published by the same group or to complete outcome data. details on correspondence are provided in supplementary table . due to the lack of studies with designs that allow for meta-analysis, we opted to perform a narrative synthesis using the synthesis without meta-analysis (swim) reporting guideline (intended to complement the prisma guidelines in these cases). summary statistics (numbers and ranges) were calculated to show sample distribution, where all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint appropriate. figure summarizes the selection of articles for review. initial database searches identified records which, after exclusion of duplicates, were screened for the eligibility criteria and included in the current systematic review. finally, studies, including a total of pregnant women with covid- , met the eligibility criteria and were included in the review. there were seven case-series, including pregnant patients, published from march , to april , (tables - ). there were case-reports, including pregnant patients, published from march , to april , (tables - ). from the case-series, all seven studies reported all cases diagnosed during the study period. we recorded data related to maternal and perinatal characteristics, the clinical manifestations of covid- at admission including laboratory testing, treatment received and maternal, perinatal and neonatal outcomes. the majority of the studies originated from china, but cases from australia, canada, france, korea, iran, peru, spain, sweden, turkey and united states were also included. we differentiated cases that were laboratory-confirmed from those that were clinically diagnosed but data from the two types of diagnosis were combined for presentation. a laboratory-confirmed case of covid- was defined as a positive result on quantitative reverse-transcriptase-polymerase-chain-reaction (qrt-pcr) assay of maternal pharyngeal swab specimens. it is important to note that at the peak of the covid- outbreak within hubei province, china, cases with relevant symptoms, significant epidemiological history and typical chest computer tomography (ct) findings were clinically diagnosed as covid- , as the viral nucleic acid test was reported to have a false-negative rate of %. reasons for exclusion are provided in supplementary table . quality assessment of the included studies is reported in supplementary tables and . clinical characteristics all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. in the combined data from consecutive case-series, the maternal age ranged from to years and the gestational age on admission ranged from to weeks. two-thirds of the data derived from laboratory-confirmed covid- cases. the most common symptoms at presentation were fever, cough, dyspnea/shortness of breath and fatigue. -year-old weeks pregnant woman who complained of fever, cough, and myalgia for days. her admission laboratory tests showed leukopenia and thrombocytopenia, accompanied with elevated crp and lactate dehydrogenase levels [r] . soon after admission, her temperature was noted at °c and her respiratory rate was per minute, accompanied by suprasternal and intercostal retraction. immediate blood tests showed metabolic alkalosis while the patient was under non-invasive ventilation. she was eventually intubated for mechanical ventilation due to worsening acute respiratory distress syndrome (ards) based on clinical and radiological findings. on day of admission, the patient had spontaneous onset of labor and delivered a cyanotic neonate vaginally with no signs of life that did not respond to neonatal cardiopulmonary resuscitation. one day after birth, the mother developed multi-organ failure (ards, all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint acute kidney injury, and septic shock) and died. the second case was a -year-old weeks pregnant woman with dyspnea, myalgia, anorexia, nausea, non-productive cough and fever for days. on admission, she was treated with azithromycin, ceftriaxone, kaletra, tamiflu and hydroxychloroquine. based on the ct chest findings, lymphopenia, worsening pneumonia symptoms, and an unfavorable cervix for induction, a cesarean delivery was indicated to terminate the pregnancy at weeks' gestation. a preterm female infant, weighing grams, was delivered uneventfully; with apgar scores of and at and minutes, respectively. the amniotic fluid tested positive for sars-cov- by qrt-pcr. the immediate post-delivery nasal and throat swabs of the newborn tested negative for sars-cov- , however, repeat testing hours later became positive. such results raised the possibility of vertical transmission. the mother underwent peritoneal dialysis due to ards on day and postpartum, and required intubation and mechanical ventilation due to sudden oxygen desaturation to % on day postpartum. she developed emphysema after intubation that resolved spontaneously on day postpartum, however, her condition deteriorated dramatically and she died on day postpartum. from the case-series, the rates of gestational diabetes, hypertensive disorders of pregnancy and preeclampsia did not appear to be higher than in pregnant women without covid- . there were only a few cases with hypothyroidism and placenta previa/acreta. nearly one-third of the cases ( / ) were not delivered at the time of reporting. a few cases had spontaneous miscarriage or abortion. in the remaining cases, including two with twin pregnancy, the majority had a cesarean delivery. the gestational age at delivery ranged from to weeks. the apgar scores at and minutes ranged from to and to , respectively. a few neonates had birthweight less than grams and over one-third of cases were transferred to neonatal intensive care unit (nicu). there was one case each of neonatal asphyxia and neonatal death. for the neonates, a few cases had increased white blood cells and crp. no cases had lymphocytopenia and thrombocytopenia. of note, there were , , , , and cases that had nucleic-acid testing in amniotic fluid, cord blood, neonatal throat swab, all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint neonatal feces, neonatal urine and neonatal gastric juice samples, respectively, which were negative for sars-cov- . there was a case-report demonstrating that the neonate throat swab tested positive for sars-cov- . the mother was a -year-old woman with pre-existing diabetes mellitus and significant covid- exposure from immediate family members. she presented at weeks' gestation with a -day history of malaise, fatigue, low-grade fever, and progressive shortness of breath. the nasopharyngeal swab of the patient was positive for sars-cov- . the patient developed severe respiratory failure requiring mechanical ventilation on day of disease onset. she was started on azithromycin, hydroxychloroquine, meropenem, vancomycin, and oseltamivir. the patient underwent a preterm cesarean delivery due to compromised respiratory status. neonatal isolation was implemented immediately after birth, without delayed cord clamping or skin-to-skin contact. the neonate weighed grams, with apgar's scores of and at and minutes, respectively. the neonate was not exposed to family members. breastfeeding was not initiated. the neonate was placed in the nicu with no other covid- cases, as this was the first pediatric case at the institution. this systematic review has demonstrated that, first, the clinical characteristics of these patients with covid- pneumonia during pregnancy are similar to those of nonpregnant adults with covid- ; , second, the most common symptoms reported all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint are fever, cough, dyspnea/shortness of breath and fatigue; third, on admission, most cases have patchy shadowing or ground-glass opacity on ct of the chest, and that normal or low leukocyte, lymphocytopenia and raised crp are the most common laboratory findings observed in covid- -infected pregnant patients; fourth, the rate of severe covid- pneumonia is relatively low but there are two reported maternal deaths, as of april , ; fifth, covid- does not appear to increase the risk of adverse pregnancy outcomes such as preeclampsia; sixth, only a few pregnancies have resulted in a spontaneous miscarriage or abortion; seventh, of those who have delivered, the gestational age at delivery ranged from to weeks and the majority of cases have had cesarean delivery; and eighth, in the case-series there have been no reported cases of neonates tested positive for sars-cov- , however, in the case-reports there has been one case each with positive sars-cov- in amniotic fluid and neonatal throat swab. at present, there is much controversy relating to the possibility of vertical mother-to-baby transmission of sars-cov- . in the two earlier studies, with a combined total of ten pregnant women with covid- in the third trimester, amniotic fluid, cord blood and neonatal throat-swab samples tested negative for sars-cov- , suggesting there was no evidence of vertical transmission in women who developed covid- pneumonia in late pregnancy. , in another series, a neonate born to a pregnant woman with covid- that tested positive for sars-cov- in the pharyngeal swab sample hours after birth, it was subsequently confirmed that qrt-pcr testing of the placenta and cord blood was negative for sars-cov- , suggesting that intrauterine vertical transmission might not have occurred. , two research letters , have suggested the possibility of vertical transmission of sars-cov- based on the presence of igm antibodies in blood drawn from three neonates born to covid- -infected mothers. however, for all three, the respiratory samples tested negative for sars-cov- . furthermore, one neonate had repeated testing for sars-cov- igg and igm antibodies, and the observed rapid decline of igg levels within days, along with a decline in igm antibodies, strongly suggested that all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint multinucleation and nuclear atypia and a mild increase in alveolar wall thickness). these findings are comparable to what have been observed in nonpregnant cases. a recent case-series reported on maternal death of seven pregnant women presenting with severe covid- during the latter second and third trimester over a -day interval in iran. all cases received a three-drug regimen, which included oseltamivir mg po every hours for days, hydroxychloroquine sulfate mg po daily or chloroquine sulfate mg tablet po as a single dose and lopinavir/ritonavir / mg po every hours for days. there were two key distinguishing features from these cases. first, the average maternal age of this series ( . + . years versus . + . years) was higher than others. second, none of the pregnant patients had pre-existing co-morbidities, such as hypertension, cardiovascular disease and asthma. the authors believed that the covid- -infected pregnant patients did not receive suboptimal care and raised concern regarding the potential for maternal death among pregnant women diagnosed with covid- in the latter trimester. notably, the authors did not provide details of cause(s) of death. this systematic review had several strengths. we undertook a meticulous process in identifying duplicate reporting: (i) case reports from china were excluded, (ii) when a hospital had published their cases more than once, only the paper with the biggest data or published on the later date was included, (iii) we were able to identify the duplicates from our own publication, which is the biggest cohort series with available pregnancy outcome data from china and (iv) when necessary we contacted the corresponding authors using their native language, i.e. chinese and spanish, thus increasing the chance of receiving a response from them. we did not apply any language restrictions in order to capture a global picture of the impact of covid- on pregnancy and perinatal outcomes and most importantly we had the capability to ensure that data from china could be accurately interpreted and recorded. there were several major limitations. we were unable to include the second biggest cohort series with available pregnancy outcome data from china because the data were pooled from a national registry. despite contacting the corresponding author directly, it was not possible to identify the actual sources of cases. all pregnant patients with pregnancy outcome all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint data were cases from wuhan, and the authors did not make reference to previously published cases. in our publication we included cases from wuhan and we had strong reasons to believe that there was significant overlap between the two series, and therefore we regrettably had to exclude the data from chen et al in order to avoid inflating the number of covid- -infected pregnant cases in china. we also learned that covid- -infected pregnant cases could have been transferred to other hospitals, which made it difficult to determine duplicate reporting as cases could have been reported by both the admitting and receiving hospitals. we decided to combine laboratory-confirmed and clinically diagnosed covid- cases in our analysis because both groups had similar outcomes. we believed it was important to include the clinically diagnosed cases in this review as clinically diagnosed cases had typical covid- chest ct findings and significant epidemiological exposure. only two cases of maternal death had been reported, as of april , , in the literature. traditionally any maternal death requires an extensive process of investigation and therefore it is not immediately reported and made public. it is highly probable that covid- -related maternal case fatality rate is higher but such data will only come to light at the end of the pandemic. in conclusion, the clinical characteristics of pregnant women with covid- pneumonia are similar to those of nonpregnant adults with covid- pneumonia. currently, there is no evidence that pregnant women with covid- are more prone to develop severe pneumonia, in comparison to nonpregnant patients. the subject of vertical transmission of sars-cov- remains controversial and more data is needed to investigate this possibility. lastly, in order to collect meaningful pregnancy and perinatal outcome data, we urge researchers and investigators to reference previously published cases in their publications and to record such reporting when the data of a case is being entered into a registry or several registries. we wish to thank marisa maquedano from imaterna foundation for assisting with the literature search. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . available from https://reviewersmanual.joannabriggs.org/ (accessed on january ). all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . /s - - -x. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint this search is continuously updated with new terms and conditions and freely available at: https://bvcsmaquedano.wordpress.com/ / / /covid- -pregnancy/ all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia clinical features of patients infected with novel coronavirus in wuhan clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china novel influenza a (h n ) pregnancy working group. h n influenza virus infection during pregnancy in the usa phenotypic and metabolic characteristics of monocytes and granulocytes in normal pregnancy and maternal infection maternal death due to covid- disease clinical characteristics of pregnant women with covid- in wuhan, china clinical and ct imaging features of the covid- pneumonia: focus on pregnant women and children clinical manifestations and outcome of sars-cov- infection during pregnancy pregnancy and perinatal outcomes of women with coronavirus disease (covid- ) pneumonia: a preliminary analysis clinical characteristics of neonates born to mothers with covid- radiological findings and clinical characteristics of pregnant women with covid- pneumonia primer caso de infección neonatal por sars-cov- en españa covid- in pregnancy with comorbidities: more liberal testing strategy is needed pronóstico perinatal y de la paciente embarazada con infección por covid- [pregnancy and perinatal all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint doi: medrxiv preprint outcome of a woman with covid- infection an uncomplicated delivery in a patient with covid- in the united states lung ultrasound and computed tomographic findings in pregnant woman with covid- emergency cesarean section on severe acute respiratory syndrome coronavirus (sars-cov- ) confirmed patient covid- vaginal delivery -a case report covid and acute coagulopathy in pregnancy key: cord- - uvta authors: singh, brijesh p. title: modeling and forecasting the spread of covid- pandemic in india and significance of lockdown: a mathematical outlook date: - - journal: nan doi: . /bs.host. . . sha: doc_id: cord_uid: uvta a very special type of pneumonic disease that generated the covid- was first identified in wuhan, china in december and is spreading all over the world. the ongoing outbreak presents a challenge for data scientists to model covid- , when the epidemiological characteristics of the covid- are yet to be fully explained. the uncertainty around the covid- with no vaccine and effective medicine available till today create additional pressure on the epidemiologists and policy makers. in such a crucial situation, it is very important to predict infected cases to support prevention of the disease and aid in the preparation of healthcare service. india is fighting efficiently against covid- and facing greater challenges because of its large population and high population density. though the government of india is taking all needful steps to prevent its spread but it is not enough to control and stop spread of the disease so far, perhaps due to defiant nature of people living in india. effective measure to control this disease, medical professionals needs to know the estimated size of this pandemic and pace. in this study, an attempt has been made to understand the spreading capability of covid- in india through some simple models. findings suggest that the lockdown strategies implemented in india are not successfully reducing the pace of the pandemic significantly after first lockdown. a novel corona virus is responsible for epidemic popularly known as covid- is a new strain that has not been identified previously in humans. world health organization (who) declared covid- a pandemic on march , . the virus that caused the incidence of severe acute respiratory syndrome (sars) in in china, middle east respiratory syndrome (mers) in in saudi arabia and the virus that causes covid- are genetically related to each other, but the diseases they caused are quite different (who). these viruses, in general, are a family of viruses that target and affect mammal's respiratory systems. the sars corona virus spread to humans via civet cats, while the mers virus spread via dromedaries. in case of the novel corona virus, typically happens via contact with an infected animal, perhaps the common carriers are bats initial reports from seafood market in central wuhan, china. the novel corona virus (covid- ) started from wuhan, china and thus, initially known as the wuhan virus, expanded its circle in south korea, japan, italy, iran, usa, france, spain and finally spreading in india. it is named as novel because it is never seen before mutation of animal corona virus but certain source of this pandemic is still unidentified. it is said that the virus might be connected with a wet market (with seafood and live animals) from wuhan that was not complying with health and safety rules and regulations. as of july , , with the continuously increasing global risk more than million confirm positive cases and more than . million of deaths have occurred in the world. as number of cases growing day by day, in most of the countries of the world, some most populous countries like china, india, brazil, usa, etc., are badly affected by it. in this context, the crucial role of modeling, transmission dynamics and estimating development of covid- are expected. the population based mathematical model especially growth model in this scenario are the most preferable techniques to understand the epidemic future trajectory. epidemiological characteristics like propagating dynamics, severity, susceptibility, and the effects of control measures, for covid- has produced a greater concern for researchers (cowling and leung, ; lipsitch et al., ) . since preventive measures like lockdown and social distancing have immense pressure on economy of the country, quantitative estimates and predictions are necessary to learn the impact of spread that will help in plan the strategies against covid- . given the paucity of such quantitative measures, the predictions on the basis of different idea given in this paper become critical and to know when the covid- stops. in recent past a number of studies with various technique and tools have been carry out to understand the dynamics of propagation of disease and future course of action. for covid- , various models which are capable of providing worth insights for health care policy making are being continuously developed and used to explain this pandemic retrospectively as well as to project the events (batista, ; koo et al., ; kucharski et al., ; tuite and fisman, ; wu et al., ) . wu et al. ( ) has been done to analyzing the pace of virus transmissibility through estimating the value of r with the help of stochastic markov chain monte carlo method. another analysis with mathematical incidence decay and exponential adjustment is performed. further to explain growth behavior of covid- a statistical exponential growth model adopting the serial interval from severe acute respiratory syndrome is applied by zhao et al. ( ) . a three-parameter logistic growth function is applied and predicted for china as well as some other countries is found very satisfying (shen, ) . in the context of india, an early study of covid- (when it started spreading in india) done by singh and adhikari ( ) rightly believed that countrywide lockdown on march for days may be insufficient for controlling the covid- pandemic. malhotra and kashyap ( ) tried to forecast the endpoints to explain the progression of covid- in indian states, using sir and logistic growth models and found the endpoint of covid- in india is in july , . india with a huge population about . billion, among majority of the people are living in poor hygienic condition and the medical facilities like number of doctors and hospitals are less in india as compared to developed countries indicates that the situation of india will become very critical but comparatively better public health system and political control in india than the above developed countries. the picture of india is not so good and has more than million confirm positive cases and more than thousand of deaths. although the death rate of this pandemic is low in comparison of other pandemics and diseases but its high rate of spread and no proper cure available so far is the major concern in the present time. right now in india only districts out of districts have covid- case more than . these districts are mainly metropolitans; if we implement preventive measures properly then spread can be under control at desired level, but due to defiant nature of people living in india, political desire and rivalry, still we india society are facing problem made by covid- . the first case of covid- is reported in india on january , when a student returned from wuhan, china (covid india.org). the government of india was quick to launch various levels of travel advisories beginning from february , , with restrictions on travel to china and nonessential travel restrictions to singapore, south korea, iran and italy. the efforts to control by the hon'ble prime minister narendra modi ji through janata curfew (public curfew) on march , , can be seen as the beginning of wide-scale public preventive measures. india has launched several social distancing measures and personal hygiene measures during the second week of march. symptoms of covid- are reported as cough, acute onset of fever and difficulty in breathing. out of all the cases that have been confirmed, up to % have been deemed to be severe. cases vary from mild forms to severe ones that can lead to serious medical conditions or even death. it is believed that symptoms may appear in - days, as the incubation period for the has not yet been confirmed. however, in india days minimum quarantine period is declared by government for suspected cases. since it is a new type of virus, there is a lot of research being carried out across the world to understand the nature of the virus, origins of its spreads to humans, the structure of it, possible cure/vaccine to treat covid- . india also became a part of these research efforts after the first two confirmed cases were reported here on january , . then in india screening of traveler at airport migrant was started, immediate chinese visas was canceled, and who was found affected from covid- kept in quarantine centers (ministry of home affaires government of india, advisory). for the spread of covid- , when disease dynamics are still unclear, mathematical modeling helps us to estimate the cumulative number of positive cases in the present scenarios. now india is interring in the mid stages of the epidemic. it is important to predict how the virus is likely to grow among the population. the covid- pandemic presents a challenge for data scientists to model it; however, the epidemiological characteristics of the covid- are yet to be fully explained. the uncertainty around the covid- with no vaccine and effective medicine available until today create additional pressure on the epidemiologists and policy makers. in such a crucial situation, it is very important to predict infected cases to support prevention of the disease and support in the preparation of healthcare service. a mathematical modeling approach is a suitable tool to understand the dynamics of epidemic. in the study some mathematical approach to understand the dynamics of novel covid- in india has been discuss. in absence of a definite treatment modality like vaccine, physical distancing has been accepted globally as the most efficient strategy for reducing the severity of disease and gaining control over it (ferguson et al., ) . also in india it is reported that the country is well short of the who's recommendations of minimum threshold of . skilled health professionals per population (anand and fan, ) . therefore, on march , , the government of india under prime minister narendra modi ji ordered a nationwide lockdown for days, limiting movement of the entire . billion population of india as a preventive measure against the covid- pandemic in india. it was ordered after a -h voluntary public curfew on march. the lockdown was placed when the number of confirmed covid- cases in india was approximately . on april, prime minister of india extended the nationwide lockdown until may, with a conditional relaxation after april for some regions. on may, the government of india again extended the nationwide lockdown further by weeks until may. also, the government has divided the entire nation into three zones viz. green, red and orange with relaxations applied accordingly. there are already various measures such as social distancing, lockdown masking and washing hand regularly has been implemented to prevent the spread of covid- , but in absence of particular medicine and vaccine it is very important to predict how the infection is likely to develop among the population that support prevention of the disease and aid in the preparation of healthcare service. this will also be helpful in estimating the health care requirements and sanction a measured allocation of resources. it is well known fact that covid- has spread differently in different countries, any planning for increasing a fresh response has to be adaptable and situationspecific. data obtained on covid- outbreak have been studied by various researchers using different mathematical models srinivasa rao arni et al., ) . many other studies (anastassopoulou et al., ; corman et al., ; gamero et al., ; huang et al., ; hui et al., ; rothe et al., ) on this recent epidemic have been reported so many meaningful modeling results based on the different principles of mathematics. most of pandemics follow an exponential curve during the initial spread and eventually flatten out ( junling et al., ) . sir model is one of the best suited models for projecting the spread of infectious diseases like covid- where a person once recovered is not likely to become susceptible to the infection again (kermack and mckendrick, ) . susceptible-infectious-recovered (sir) compartment model (herbert, ) is used to include considerations for susceptible, infectious, and recovered or deceased individuals. these models have shown a significant predictive ability for the growth of covid- in india on a day to day basis so far. a time dependent sir models have been defined to observe the undetectable infected persons with covid- (chen et al., ) . a recent study by mandal et al. ( ) has shown that social distancing can reduce cases by up to %. further, time series models have been employed for predicting the incidence of covid- disease. as compared to other prediction models, for instance support vector machine (svm) and wavelet neural network (wnn), arima model is more capable in the prediction of natural adversities (zhang et al., ) . chatterjee et al. ( ) studied a stochastic mathematical model of the covid- epidemic in india. the logistic growth regression model is used for the estimation of the final size and its peak time of the covid- pandemic in many countries of the world and found similar result obtained by sir model (batista, ) . it is well known that the effects of social distancing become visible only after a few days from the lockdown. this is because the symptoms of the covid- normally take some time to come out after getting infected from the covid- . an estimates indicates that, with hard lockdown and continued social distancing, the peak total infections in india will be million and the number of infective by september is likely to be over million (schueller et al., ) . the study of infectious diseases is called epidemiology. a disease is called endemic if it persists in a population and pandemic when it occurs worldwide. the spread of an infectious disease involves not only disease related factors such as the infectious agent, mode of transmission, latent period, infectious period, susceptibility and resistance, but also social, cultural, demographic, economic and geographic factors. mainly there are three types of models for infectious diseases that are spreading directly through person to person contact in a population. some simple models are formulated and analyzed mathematically considering differential equations. parameters are estimated for infectious diseases and also used to compare the vaccination levels necessary for herd immunity. the three models considered here are the simple epidemiological models and suitable for diseases which are transmitted directly from person to person. more complicated models must be used when there is transmission by insects called vectors or a reservoir of nonhuman infective. epidemiological models are widely used to understand the pattern and policy development. even though vaccines are available for many infectious diseases, these diseases still cause suffering and mortality in the world, especially in developing countries. in developed countries chronic diseases such as cancer and heart disease have received more attention than infectious diseases, but infectious diseases are still a more common cause of death in the world. the transmission mechanism from an infective to susceptible is understood or nearly all infectious diseases and the spread of diseases through a chain of infections is known. however, the transmission interactions in a population are very complex so that it is difficult to comprehend the large scale dynamics of disease spread without the formal structure of a mathematical model. an epidemiological model uses a microscopic description (the role of an infectious individual) to predict the macroscopic behavior of disease spread through a population. in many sciences it is possible to conduct experiments to obtain information and test hypotheses. experiments with infectious disease spread in human populations are often impossible, unethical or expensive. data is sometimes available from naturally occurring epidemics or from the natural incidence of endemic; however, the data is often incomplete due to underreporting. this lack of reliable data makes accurate parameter estimation difficult so that it may only be possible to estimate a range of values for some parameters. since repeatable experiments and accurate data are usually not available in epidemiology, mathematical models and computer simulations can be used to perform needed theoretical experiments. mathematical models have both limitations and capabilities that must recognized. sometimes questions cannot be answered by using epidemiological models, but sometimes the modeler is able to find the right combination of available data, an interesting question and a mathematical model which can lead to the answer. comparisons can lead to a better understanding of the processes of disease spread. modeling can often be used to compare different diseases in the same population, the same disease in different populations, or the same disease at different times. comparisons of diseases such as measles, rubella, mumps, chickenpox, whooping cough, poliomyelitis and others are made (hethcote, ; yorke and london, ; yorke et al., ) and in the article on rubella in this volume by hethcote ( ) . quantitative predictions of epidemiological models are always subject to some uncertainty since the models are idealized and the parameter values can only be estimated. however, predictions of the relative merits of several control methods are often robust in the sense that the same conclusions hold over a broad range of parameter values and a variety of models. optimal strategies for vaccination can be found theoretically by using modeling. longini et al. ( ) use an epidemic model to decide which age groups should be vaccinated first to minimize cost or deaths in an influenza epidemic. hethcote ( ) uses a modeling approach to estimate the optimal age of vaccination for measles. within a short period of time, covid- has traumatized the world with a greater magnitude and coercion than older pandemics. its eventuality is grabbed by the fact that it has infected millions and killed thousands across the globe. global markets, accessible transportation, large scale production have largely contributed to make this pandemic spread faster. this has drastically affected the social life and health mental as well as physical of human beings worldwide. the already burdened health infrastructure across the globe is virtually exposed up to an irreparable point. the who declared - corona virus outbreak a public health emergency of international concern (pheic) on january th, and a pandemic days later on february th, . with its outbreak in wuhan, china, the pandemic seems to occupy and include all the vitals of the world thereby affecting the mechanistic processes of any nation. the countries are trying hard to combat and contain this outbreak by following suitable set of protocols that tend to alter the transmission rate effectively. in the initial phase of spread of covid- ; italy, spain, france and some other european countries are one of the worst sufferers of the pandemic and the coercive measures have resulted in the disruption of all the necessary services. on the other hand, the case is virtually less severe in south asia. india is less affected by the covid- , however, china is its neighboring country having border through buffer states like nepal and bhutan. being the second most populous country of the world, india is fighting hard to minimize the damage of covid- . as on th april, the total number of infected cases in india was , with deaths and most recoveries (covid india.org). india reported its first case on th january and entered the countrywide lockdown on march th, with constantly increase in number of covid- cases. indian government as well as states government has issued early guidelines and travel advisories to limit the further damage of disease. also, the timely precautions taken by the government have contributed greatly toward combating this pandemic. the paper attempts to devise a model that would conveniently help in assessing the predictability of pandemic covid- in future time period. this can be achieved by evaluating the different parameters that directly or indirectly affect the ongoing rate of pandemic. moreover, theoretical explanation, quantitative analysis and other parameters are highly required to predict the peak and size of any pandemic. we obtained information on cumulative number of covid- confirmed cases in india from covid india.org. all cases are laboratory confirmed following the case definition by the government of india. some studies modeled the epidemic curve obeying the exponential growth (de silva et al., ). the nonlinear least square framework is adopted for data fitting and parameter estimation for covid- at this early stage. first exponential and then logistic growth curve is used to model the covid- pandemic, since epidemics grow exponentially not linearly. but it is surprising that exponential growth curve always provide increasing number of daily new cases. there is no saturation point. another deterministic model used for understanding the dynamics of epidemic is the susceptible-infectious-recovered (sir) model, which has been used to accurately predict incidence like sars. in the sir model, we need to know the input parameters first the stats we feed into the model (chatterjee et al., ; mandal et al., ; singh and adhikari, ) . the first one is r called the basic reproduction number. it is essentially the number of new cases a single infected person will cause during their infectious period. it is one of the most important parameters for assessing any epidemic. corona virus has an r $ . . in contrast, the swine flu virus had an r $ . in the swine flu epidemic (gupta, ) . the r will inform us about how many people will get infected with one infected person. other one is the case fatality rate (cfr), which is the percentage of infected people that will die due to the infection. the cfr for corona virus has been reported between . % and %. the lower values are more appropriate in resource better settings of medical facility. but sir model assumes that every person is moving and has equal chance of contact with each and every other person among the population irrespective of the space or distance between different people. it is assumed that the transmission rate remains constant throughout the period of pandemic. also this model considered to have the same transmission rate for who have been diagnosed and are in quarantine or those who have not been quarantined. the harmonic analysis methods and dynamic model (rao srinivasa arni et al., ) estimates show that the number of covid- infected would be (if there were infected individuals as of march , , who was not taking any precautions to spread), , (if there were ) and , (if there were ). sir model is a theoretical epidemiological model, in which, the population is categories into three component such as: susceptible (s), which is the group of people who are vulnerable to exposure with infectious people, infected (i), are those with the disease and can transmit it to the susceptible and the third component is the individuals who have recovered from the infectious disease and developed immunity and not susceptible to the same illness anymore (r). this framework enables us to understand the dynamics of any epidemic. thus sir model is a compartmental model in which individuals are separated into different compartments based on their status and follow the corresponding population sizes over the time. the diagrammatical representation of threecompartment model (kermack and mckendrick, ) is given as where, s(t) ¼ proportion of individual susceptible to covid- at time t, i(t) ¼ proportion of individual who have been infected by covid- and are capable of infecting others at time t, and r(t) ¼ proportion of individual who have been infected by covid- and recovered at time t, such that s(t) + i(t) + r(t) ¼ . hereβ is the transmission parameter controlling how much the disease can be transmitted. this is the average number of individuals that one infected individual will infect per unit time. it is determined by the chance of contact and the probability of disease transmission. while γ is the parameter representing the rate of recovery in a particular period. the model allows us to describe the number or proportions of persons in each compartment by solving the following ordinary differential equations, several assumptions have been discussed with respect to the sir model (brauer and castillo-chavez, ; daley and gani, ) . based on the sir model, the basic reproduction number is defined as, here, r is the average number of new covid- cases produced by a single covid- infected case over the time. in order to fit a sir model, the parameters were obtained by minimizing the residual sum of squares between the observed active cases and the predicted active cases. the utilization of the seir model lies in the fact that it focuses on the basic processes that are directly related to this growing pandemic. in the preparation of this model, there is a need that the population is to be divided into some subdivisions which are susceptible subdivision s(t), that denotes the population which is susceptible to catch the virus; exposed subdivision e(t), that denotes the population which is infected but the symptoms are not visible yet; infected subdivision i(t), that denotes the population which has been infected by the virus and are showing the symptoms; recovered subdivision r(t), that denotes the population which has immunity to the infection. the basic assumption to formulate this model is that the recovered patients acquired permanent active immunity. it can be justified by the strong reason that none of the patients were re-infected by the covid- . there have been numerous cases where patients died after being discharged from the hospital but it was found that the patients were either discharged for having mild symptoms or the testing machine reported wrongly. now we have normalized these components as s + e + i + r ¼ . furthermore, suppose that there are equal birth and death rates, i.e., μ and α is the mean latent period for the disease. γ is the mean infectious period and recovered individuals are permanently immune. the contact rate β may or may not be a function of time. thus the seir model is defined as the variable r is determined from the other variables according to equation s + e + i + r ¼ . a growth curve is an empirical model of the evolution of a quantity over time. growth curves are widely used in biology for quantities such as population size in population ecology and demography for population growth analysis, individual body height in physiology for growth analysis of individuals. growth is also a key property of many systems such as an economic expansion, spread of an epidemic, the formation of a crystal, an adolescent's growth and the condensation of a stellar mass. this is the simplest growth model, in which population grows at a constant rate over time. linear growth is described by the equation where p t represents the numbers or size of the system at time t, p t+ represents the system's numbers or size of the system one time unit later, and a is the system's (linear) growth rate. many times this model fails to explain natural phenomenon. another simple model describes exponential growth, in which population grows at a constant proportional rate over time. the relation may be expressed in either of two forms, depending on whether reproduction is assumed to be continuous or periodic (shryock and siegel, ) . exponential growth results in a continuous curve of increase or decrease, whose slope varies in direct relation to the size of the population. where r is the constant rate of growth, p o is the initial population size, and the variables t and p t respectively represent time and the population at time t (method ). another form of exponential curve is as follows where k ¼ p n p = n and that therefore the growth rate in eq. ( ) with the current incidence of the covid- going on, we hear about exponential growth. in this study, an attempt has been made to understand and analyze the data through exponential growth curve. the reason for using exponential growth curve for studying the pattern of covid- incidence is that epidemiologists have studied these types of happenings and it is well known that the first period of an epidemic follows exponential growth. the exponential growth function is not necessarily the perfect representation of the epidemic. i have tried to fit exponential curve first, and at the next point to study the logistic growth curve because exponential curve is only fit the epidemic at the beginning. at some point, recovered people will not spread the virus anymore and when someone is or has been infected, the growth will stop. logistic growth is characterized by increasing growth in the beginning period, but a decreasing growth after point of inflection. for example, in the corona virus case, the maximum limit would be the total number of exposed people in india because when everybody is infected, the growth will be stopped. after that the increasing rate of curve starts to decline and reach to the minimum. the logistic model reveals that the growth rate of the population is determined by its biotic potential and the size of the population as modified by the natural resistance, or, in other words, by all the various effects of inherent characteristics, that are density dependence pearl and reed, . natural resistance increases as population size gets closer to the carrying capacity. logistic growth is similar to exponential growth except that it assumes an essential sustainable maximum point. in exponential growth curve, the rate of growth of y per unit of time is directly proportional to y but in practice the rate of growth cannot be in the same proportion always. the logistic curve will continue up to certain level, called the level of saturation, sometimes called the carrying capacity, after reaching carrying capacity it starts declining. a system far below its carrying capacity will at first grow almost exponentially, however, this growth gradually slows as the system expands, finally bringing it to a halt specifically at the carrying capacity (pearl and reed, ; shryock and siegel, ) . the logistic relationship can be expressed as where a, b and k are constant and y t is that value of the time series at the time t. the reciprocal of y t follows modified exponential law. hence, the given time series observation y t will follow logistic law if their reciprocal /y t follows modified exponential law. thus in general, we may take the factor y is called the momentum factor which increases with time t and the factor (k À y) is known as the retarding factor which decreases with time. when the process of growth approaches the saturation levelk, the rate of growth tends to zero. now we have dy y kÀy ð integrating, we get log y kÀy ¼ αkt + γ, where γ is the constant of integration. k y ¼ + e Àαkt :e Àγ ) y ¼ k + e À γ+αkt ð Þ , this equation is same as eq. ( ) where a ¼ Àγ and b ¼ Àαk. logistic curve has a point of inflection at half of the carrying capacity k. this point is the critical point from where the increasing rate of curve starts to decline. the time of point of inflection can be estimate as Àa b . for the estimation of parameter of logistic curve, method of three selected point given by pearl and reed ( ) has been used. the estimate of the parameters can be obtained with equation given as: k ¼ y y + y ð ÞÀ y y y y À y y where y , y and y are the cumulative number of covid- cases at a given time t , t and t respectively provided that t À t ¼ t À t . you may also estimate the parameter a and b by method of least square after fixing k. to predict confirmed corona cases on different day, logistic growth curve has been also used and found very exciting results. the truncated information (means not from the beginning to the present date) on confirmed cases in india has been taken from march to april , . the estimated value of the parameters are as follows k ¼ , . , a ¼ . and b ¼ À . , with these estimates predicted values has been obtained and found considerably lower values than what we observed. on april and , the number of confirmed corona cases are drastically increasing in some part of india due to some unavoidable circumstances thus there is an earnest need to increase carrying capacity of the model, thus it is increased and considered as , and the other parameters a and b are estimated again which are a ¼ . and b ¼ À . . the predicted cumulative number of cases is very close to the observed cumulative number of cases till date. the time of point of inflection is obtained as . , i.e., days after beginning. we have taken data from march , so that the time of point of inflection should be april , and by may , there will be no new cases found in the country. exponential growth model and model given swanson provided natural estimate of the total infected cases by june , is all most all people in india. this estimate is obtained when no preventive measure would be taken by the government of india. the testing rate is lower in india than many western countries in the month of march and april, so our absolute numbers was low, when government initiate faster testing process then we have observed more number of cases and found this logistic model fail to provide cumulative number of corona confirm cases after april , thus there is a need to modify this model (fig. ) . in order to the modification, i have taken natural log of cumulative number of corona confirm cases instead of cumulative number of corona confirm cases as taken in the previous model. this model provides the carrying capacity is about , cases and time of point of inflection is april , . the present model provides reasonable estimate of the cumulative number of confirmed cases and by the end of july there will be no new cases found in the country. further, the number of covid- cases increases and the model estimate does not match to the observed number of case, therefore we need to change the data period, since the logistic curve is data-driven model that provide new estimate of point of inflection and maximum number of corona positive cases by date when disease will disappear, that helps us to plan our strategies. finally in this study we changed the data period, i.e., we have taken data from april th to july th . this provides the carrying capacity is about lakh cases and time of point of inflection is august th, with a maximum number of new cases on a day is about , per day. the model based on this data (from april th to july th ) provides reasonable estimate of the cumulative number of confirmed cases, and predicted value along with % confidence interval provided up to august th, (see table ) and by the end of march we expect there will be no new cases in the country in absence of any effective medicine of vaccine (fig. ) . to know the significance of lockdown we define the covid- case transmission is as , where x t is the number of confirm cases on t th day. we have calculated c t and the doubling time of the corona case transmission in india. the doubling time is calculate as ln c t ¼ : c t . we have calculated covid- case transmission c t on the basis of days moving average of daily confirm cases (in the beginning the data in india is very fluctuating) and it is found gradually decreasing in india. this indicates the good sign of government attempts to combat this pandemic through implementing lockdown. these findings indicate that in future the burden of corona will be expectedly lowering down if the current status remains same. in table given below, an attempt has been made to show the summary statistics of corona case transmission c t during various lockdown periods in india. it is observed that average covid- case transmission was maximum ( . with standard deviation . ) in the period prior to the lockdown. during the first lockdown period the average covid- case transmission was . with standard deviation . , however, in lockdown it was . with standard deviation . and in lockdown covid- case transmission was . with standard deviation . , however, in the period of fourth lockdown the average case transmission was . with standard deviation . , thus it is clear that both average transmission load and standard deviation are decreasing. table reveals the result of anova for average c t during various lockdown periods which is significant means that the average corona case transmission is significantly different is various lockdown periods considered. a group wise comparison of the average covid- case transmission c t during various lockdown periods is shown in table which reveals that first lockdown is significantly affects the spread of corona case transmission than others but second lockdown period is not significantly different than third and fourth. same result is observed for third and fourth lockdown period. this indicates that the covid- transmission is not under control now. fig. shows corona case transmission and doubling time in india. the corona case propagation in decreasing and doubling time is increasing day by day. let us define a function called tempo of disease that is the first differences in natural logarithms of the cumulative corona positive cases on a day, which is as: where p t and p tÀ are the number of cumulative corona positive cases for period t and t À , respectively. when p t and p tÀ are equal then r t will become zero. if this value of r t , i.e., zero will continue a week then we can assume no new corona cases will appear further. in the initial face of the disease spread, the tempo of disease increases but after sometime when some preventive measures is being taken then it decreases. since r t is a function of time then the first differential is defined as where r t denotes the tempo that is the first differences in natural logarithms of the cumulative corona positive cases on a day, r t is the desired level of tempo, i.e., zero in this study, t denotes the time and k is a constant of proportionality. eq. ( ) is an example of an ordinary differential equation that can be solved by the method of separating variables. the eq. ( ) can be written as dr t r t ¼ kdt integrating eq. ( ), we get where c is an arbitrary constant. taking the antilogarithms of both sides of eq. ( ) we have r t ¼ e kt+c ) e kt e c ) r t ¼ ae kt where a ¼ e c . this eq. ( ) is the general solution of eq. ( ). if k is less than zero, eq. ( ) tells us how the covid- cases will decreases over the time until it reaches zero. value of a and k is estimated by least square estimation procedure using the data sets. the government of india implemented lockdown on march th, and expected that the tempo of disease is decreasing. government suggested and implemented social distancing and lockdown to control the spread of covid- in the society. in table , the predicted value of covid- cases obtained with this method is given along with % confidence interval. about . lakh cases are expected by august th, . with this model it is expected that about lakh peoples will be infected in india by the end of october and after that no cases will happen since the tempo of disease r t will become zero (fig. ) . in table an attempt has been made to show the summary statistics of tempo of covid- r t during various lockdown periods in india. it is observed that average tempo is maximum ( . with standard deviation . ) in the period prior to the lockdown. during the first lockdown period the average tempo is . with standard deviation . and after that it is found decreasing in the various lockdowns. table various lockdown periods is shown in table which reveals that first lockdown is significantly different than others. consecutive mean difference shows that the decrease in disease spread has been observed but insignificant, means there is no impact of lockdown on controlling the disease spread. to analyze the temporal trends and to identify important changes in the trends of the covid- outbreak joinpoint regression is used in china (al hasan et al., ) ; here in this study we performed a joinpoint regression analysis in india to understand the pattern of covid- . joinpoint regression analysis, enable us to identify time at a meaningful change in the slope of a trend is observed over the study period. the best fitting points known as joinpoints, that are chosen when the slope changes significantly in the models. to tackle the above problem joinpoint regression analysis (kim et al., ) has been employed in this study to present trend analysis. the goal of the joinpoint regression analysis is not only to provide the statistical model that best fits the time series data but also, the purpose is to provide that model which best summarizes the trend in the data (marrot, ) . let y i denotes the reported covid- positive cases on day t i such that t < t < … < t n . then the joinpoint regression model is defined as ln y i ¼ α + β t + δ u + δ u + :…+ δ j u j + ε i ( ) & and k < k … < k j are joinpoints. the details of joinpoint regression analysis are given elsewhere (kim et al., ) . joinpoint regression analysis is used when the temporal trend of an amount, like incidence, prevalence and mortality is of interest (doucet et al., ) . however, this method has generally been applied with the calendar year as the time scale (akinyede and soyemi, ; chatenoud et al., ; missikpode et al., ; mogos et al., ) . the joinpoint regression analysis can also be applied in epidemiological studies in which the starting date can be easily established such as the day when the disease is detected for the first time as is the case in the present analysis (rea et al., ) . estimated regression coefficients (β) were calculated for the trends extracted from the joinpoint regression. additionally, the average daily percent change (adpc), calculated as a geometric weighted average of the daily percent changes (clegg et al., ) . the joinpoints are selected based on the data-driven bayesian information criterion (bic) method (zhang and siegmund, ) . the equation for computing the bic for a k-joinpoints regression is: where sse is the sum of squared errors of the k-joinpoints regression model and n is the number of observations. the model which has the minimum value of bic(k) is selected as the final model. there are other methods also for identifying the joinpoints such as permutation test method and the weighted bic methods. relative merits and demerits of different methods of identifying the joinpoints are discussed elsewhere (national institute cancer, ) . the permutation test method is regarded as the best method but it is computationally very intensive. it controls the error probability of selecting the wrong model at a certain level (i.e., . ). the bic method, on the other hand, is less complex computationally. in the present case, data on the reported confirmed cases of covid- are available on a daily, thus the daily percent change (dpc) from day t to day (t + ) is defined as if the trend in the daily reported confirmed cases of covid- is modeled as then, it can be shown that the dpc is equal to it is worthwhile to discuss here is that the positive value of dpc indicates an increasing trend while the negative value of dpc suggests a declining trend. the dpc reflects the trend in the reported covid- positive cases in different time segments of the reference period observed through joinpoint regression techniques. for the entire study period, it is possible to estimate average daily percent change (adpc) that is the weighted average of dpc of different time segments of the study period with weights equal to the length of different time segments. however, when the trend changes frequently, adpc has little meaning. it assumes that the random errors are heteroscedastic (have nonconstant variance). heteroscedasticity is handled by joinpoint regression using weighted least squares (wls). the weights in wls are the reciprocal of the variance and can be specified in several ways. thus standard error is used to control heteroscedastic in the analysis during the entire period. to observe the trend of reported cases, the moving average method has been used in this study. the daily percent change (dpc) in the daily reported confirmed cases of covid- during the period march th, through july th, is used for forecasting the daily reported confirmed cases of covid- in the immediate future under the assumption that the trend in the daily reported confirmed cases of covid- remains unchanged. the number of cases increased by the rate of . % per day in india; however, the rate is different in the different segment. also table reveals that the growth rate is positive and significant (about %) from th march to rd april and after that the growth rate is decreasing in comparison of first segment, i.e., for days (from rd april to th april). the possible reason may be lockdown imposed in india. in the third segment, i.e., from th april to th may a high increase has been observed but it is insignificant. from th april to th may the rate is although the positive but dramatically lower than the previous segments growth rate. in the next segment, i.e., th segment which is of days, we observe a significant increase of . % in covid- cases. in the last and th segment from th may to th july, i.e., for days, the growth rate is found again positive and significant ( . % per day) in the covid- cases. fig. shows that the trend increases in india still sharply and there is no hope of decline in covid- cases. fig. shows the forecasted value of covid- daily cases in india. the covid- cases will increase further if the same trend prevailing. table presents the forecast of the predicted cases of covid- in india along with % confidence intervals. this exercise suggests that by august th, , the confirmed cases of covid- in india is likely to be , , with a % confidence interval of , , - , , and daily reported cases will be , with % confidence interval of , - , . this daily reported covid- positive cases may change only when an appropriate set of new interventions are introduced to fight covid- pandemic. it is observed that analysis indicates that in the month of august, india faces more than thousand cases per day (fig. ). india is in the comfortable zone with a lower growth rate than other countries. logistic model shows that, the epidemic is likely to stabilize with lakh cases by the end of march and peak will come in middle of the august, however, propagation model provide estimate of maximum covid- case as lakh but the timing is different (by end october) than the logistic model. logistic model need to monitor the data time to time for good long term prediction. the projections produced by the model and after their validation can be used to determine the scope and scale of measures that government need to initiate. joinpoint regression is based on the daily reported confirmed cases of covid- , asserts that there has virtually been little impact of the nationwide lockdown as well as relaxations in restrictions on the progress of the covid- pandemic in india. the joinpoint regression analysis provides better estimate up to th august for the confirmed covid- cases than the other two methods. to know the better understanding of the progress of the epidemic in the country may be obtained by analyzing the progress of the epidemic at the regional level. in conclusion, if the current mathematical model results can be validated within the range provided here, then the social distancing and other prevention, treatment policies that the central and various state governments and people are currently implementing should continue until new cases are not seen. the spread from urban to rural and rich to poor populations should be monitor and control is an important point of consideration. mathematical models have certain limitations that there are many assumptions about homogeneity of population in terms of urban/rural or rich/poor that does not capture variations in population density. if several protective measures will not be taken effectively, then this rate may be changed. however, the government of india under the leadership of modi ji has already taken various protective measures such as lockdown in several areas, make possible quarantine facility to reduce the rate of increase of covid- , thus we may hopefully conclude that, country will be successful to reduce the rate of this pandemic. joinpoint regression analysis of pertussis crude incidence rates the novel coronavirus disease (covid- ) outbreak trends in mainland china: a joinpoint regression analysis of the outbreak data from the health workforce in india. who; human resources for health observer data-based analysis, modelling and forecasting of the covid- outbreak estimation of the final size of the second phase of the coronavirus covid epidemic by the logistic model mathematical models in population biology and epidemiology modelling transmission and control of the covid- pandemic in australia laryngeal cancer mortality trends in european countries healthcare impact of covid- epidemic in india: a stochastic mathematical model a time-dependent sir model for covid- with undetectable infected persons estimating average annual per cent change in trend analysis detection of novel coronavirus ( -ncov) by realtime rt-pcr epidemiological research priorities for public health control of the ongoing global novel coronavirus ( -ncov) outbreak epidemic modelling: an introduction a preliminary analysis of the epidemiology of influenza a (h n ) v virus infection in thailand from early outbreak data prevalence and mortality trends in chronic obstructive pulmonary disease over impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand forecast of the evolution of the contagious disease caused by novel corona virus ( -ncov) in china corona virus in india: make or break the mathematics of infectious diseases measles and rubella in the united states optimal ages or vaccination for measles rubella clinical features of patients infected with novel coronavirus in wuhan the continuing -ncov epidemic threat of novel coronaviruses to global health-the latest novel coronavirus outbreak in wuhan estimating initial epidemic growth rates a contribution to the mathematical theory of epidemics permutation tests for joinpoint regression with applications to cancer rates comparability of segmented line regression models interventions to mitigate early spread of sars-cov- in singapore: a modelling study early dynamics of transmission and control of covid- : a mathematical modelling study defining the epidemiology of covid- -studies needed an optimization model for influenza a epidemics progression of covid- in indian states-forecasting endpoints using sir and logistic growth models prudent public health intervention strategies to control the corona virus disease transmission in india: a mathematical model-based approach colorectal cancer network (crcnet) user documentation for surveillance analytic software: joinpoint. cancer care ontario trends in non-fatal agricultural injuries requiring trauma care differences in mortality between pregnant and nonpregnant women after cardiopulmonary resuscitation joinpoint regression program. national institutes of health, united states department of health and human services on the rate of growth of the population of the united states since and its mathematical representation joinpoint regression analysis with time-on-study as time-scale. application to three italian population-based cohort studies transmission of -ncov infection from an asymptomatic contact in germany covid- in india: potential impact of the lockdown and other longer term policies a logistic growth model for covid- proliferation: experiences from china and international implications in infectious diseases age-structured impact of social distancing on the covid- epidemic in india model-based retrospective estimates for covid- or coronavirus in india: continued efforts required to contain the virus spread reporting, epidemic growth, and reproduction numbers for the novel coronavirus ( -ncov) epidemic nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study recurrent outbreaks of measles, chickenpox and mumps ii seasonality and the requirements for perpetuation and eradication of viruses in populations a modified bayes information criterion with applications to the analysis of comparative genomic hybridization data comparison of the ability of arima, wnn and svm models for drought forecasting in the sanjiang plain preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak further reading covid- key: cord- -pabaoiqs authors: oprinca, george-călin; muja, lilioara-alexandra title: postmortem examination of three sars-cov- -positive autopsies including histopathologic and immunohistochemical analysis date: - - journal: int j legal med doi: . /s - - -w sha: doc_id: cord_uid: pabaoiqs this paper describes three autopsy cases with postmortem diagnosis of sars-cov- infection, with detailed macroscopic examination as well as advanced microscopic studies of organ tissues collected using hematoxylin-eosin stains and immunohistochemical markers. two of the cases were admitted briefly in the county clinical emergency hospital of sibiu, and one was found deceased at his home address. all three autopsies were completed at the county morgue, in the covid- restricted area, using complete protective equipment. the lungs of the patients seemed to be the center organ of invasion and pathogenesis of the novel coronavirus with diffuse areas of condensation, subpleural retraction zones but with different aspect of the classic bacterial bronchopneumonia. microscopic evaluation revealed viral cytopathic effect of type ii pneumocytes with a couple of cells that presented cytoplasmic and nuclear inclusions and who tend to form clusters mimicking multinucleated giant cells. hyaline membranes and destruction of the alveolar wall as well as microthrombi formation within the small blood vessels were constantly found in almost all our three cases. the spleen had sustained white pulp atrophy with absence of lymphoid follicles. there were no microscopic signs of viral infection on the myocardium or the other organs. infections with coronaviruses are widespread in humans and animals. human pathogens include causative agents of rhinitis-like infections but also the virus of the "severe acute respiratory syndrome" (sars), which first erupted in china in and the novel coronavirus sars-cov- with the outbreak starting in december in china [ ] . the genome of covs is a single-stranded positive-sense rna (+ ssrna) (~ kb) with ′-cap structure and ′-poly-a tail. the genomic rna is used as template to directly translate polyprotein a/ ab (pp a/pp ab), which encodes nonstructural proteins (nsps) to form the replication-transcription complex (rtc) in double-membrane vesicles (dmvs) [ ] . the covid- global pandemic has put to the test not only governments worldwide but also healthcare professionals from many countries, in trying to find a way to stop the spread of the disease, to find a cure for those infected, and most of all, in finding a vaccine. all these developments can be accomplished only with the help of intense medical research. a great number of clinical studies have been published so far, but only few autopsy reports have been published. only few histopathological and immunohistochemical studies have been released despite the length of time, more than months, passed since the outbreak in wuhan, hubei province of china. in order to fully understand the pathogenesis and physio-pathological manifestations of sars-cov- infections, we must first break through the unknown morphological aspects of every tissue and organ that has succumbed to the novel coronavirus, find specific or non-specific modifications within the cells and tissues, and clearly define the response of the organism on a microscopic level. after that, we can draw a map of how exactly the virus interacts with the human organism, a george-călin oprinca and lilioara-alexandra muja contributed equally to this work. particularly important step in finding a definitive treatment for individuals affected by the virus. we feel it is particularly important for the future management of covid- patients that more autopsy reports like this one should be published with no hesitations. this paper describes three autopsy cases with unknown cause of death, with full macroscopic examination as well as histopathologic and immunohistochemical analysis of collected organ tissues, including the lung from which reverse transcription polymerase chain reaction (rt-pcr) tests were made to determine sars-cov- infection. all three cases were found positive postmortem. we ran one full autopsy on a -yearold male found dead at his home and other two thoracoabdominopelvic autopsies. the first one was a -year-old woman admitted briefly to the clinical emergency hospital of sibiu county, under the suspicion of covid- infection but with death occurring before a pcr test could be performed. the second thoraco-abdominopelvic autopsy of a -year-old male was admitted at the same hospital. he presented with superior digestive hemorrhage but with no suspicion of infection at that time, since no respiratory symptoms or fever were present and there was no known history of contact with covid- -positive individuals. we performed a background check of admissions to hospital on all three cases, with detailed research of their medical records and with a thorough analysis of their complete laboratory and radiological findings. we prepared a total of approximately microscopic hematoxylin-eosin slides; immunohistochemical slides including cd , cd , cd , and cd as well as cytokeratins (ck-ae -ae , ck-mnf , and ck ) with a total of microscopic pictures from different pathological sites of tissue and cellular changes for research purpose. all three autopsies were done in sibiu county morgue, in the covid- restricted area, using complete protective equipment. the first case presented is of a -year-old female patient with a history of hypertension, ischemic cardiomyopathy, and atrial fibrillation, who was hospitalized months prior to death for choledochal preampular intraluminal obstruction, which was managed through endoscopic retrograde cholangiopancreatography (ercp). thirteen days after discharge, she presented to the emergency department with symptoms such as vomiting, abdominal pain, fatigue, loss of appetite, and productive cough. her chest radiography showed bilateral perihilar congestive processes. she was diagnosed with acute pneumopathy and discharged from hospital with prescribed medication. after other days, the patient was readmitted with a new range of symptoms such as fatigue, difficulty in breathing, and fever. a repeated chest x-ray pointed out that the congestive processes had an aggravated evolutionary aspect. notable laboratory findings are relative clotting disorder, acute renal failure, increased white blood cell count with neutrophilia, and lymphocytopenia (table ) . despite comprehensive treatment, including antibiotics, corticosteroids, and assisted oxygenation, the patient's condition deteriorated, and she presented asystole without response to resuscitation, so death was declared. subsequent clinical information confirmed that her husband, who was as well hospitalized, was found to be infected with sars-cov- . no specific pathological findings were observed upon external examination of the body. the cranial cavity was not opened. the thoracic cavity was clean, and the pleura was soft, smooth, and glassy. multiple dark grey lymphadenopathies were discovered in the mediastinum as well as in the hilum of both the lungs, between and mm in diameter. the external aspect of the lungs was of purple dark coloration with signs of diffuse congestion. the surface had small subpleural retraction zones, and by palpation, the lungs had a more elastic consistency with lack of crepitations. immediately after dissection of the lung, massive dark deoxygenated blood leaked from the small blood vessels, and a frothy pink fluid was discharged upon compression. the pulmonary parenchyma had a dark brown appearance with diffuse areas of condensation. the heart was increased in size, the right atrium and ventricle were dilated, and the left ventricle suffered moderate to severe eccentric hypertrophy. the myocardium had a relatively normal aspect only with loosely focal fibrotic striations. coronary atherosclerosis was present but with preserved luminal permeability. hepatomegaly with a "nutmeg" appearance of the liver was found, suggesting chronic passive congestion. (table ) lung architecture was modified with diffuse alveolar damage consistent with acute lung injury. the intra-alveolar septa were ruptured, with scattered lymphocytes; there was destruction of the alveolar wall with desquamation of the pneumocytes and formation of hyaline membranes, and fibrin deposits were present in the alveolar spaces. there was type ii pneumocyte hyperplasia. the most important aspect we discovered was the focal type ii pneumocytes that underwent cytopathic changes. there was marked enlargement (cytomegaly) of these cells with enlarged irregular nucleus with single-centered, prominent, nucleolus, and round to oval inclusions situated at the periphery of the nucleus and surrounded by clear halo. the cytoplasm was rich, eosinophilic, and lacked viral inclusions. in some areas, these cells tend to form clusters and imitate multinucleated giant cells and are defined as multinucleated giant cell-like pneumocyte aggregates. upon further examination of the lung parenchyma, we came across focal areas of rich polymorphonuclear infiltration, composed of mainly neutrophils, which translates as focal areas of bacterial superposition. also, we must mention that there were areas of intra-alveolar proteinaceous exudate, capillary congestion, and amylaceous bodies present in examined sections ( fig. and table ). upon microscopic examination of the heart, we concluded that there were no specific pathological changes indicating viral myocarditis. there was a mild to moderate perivascular edema and vascular congestion. areas of small contraction band-like lesions were seen, and there were only a few scattered lymphocytes between the myocardial fibers. microscopic examination of the liver revealed a preserved lobular architecture with some degree of centrilobular vascular congestion. the hepatocytes had intracellular large clear droplets defined as macrovesicular steatosis. there was periportal fibrosis with focal porto-portal and porto-central bridging fibrosis and a mild to moderate lymphocytic infiltrate contained within the portal tract, most probably secondary to obstructive biliary disease. the biliary ducts were of a normal architecture. the renal parenchyma studied had relatively unspecific changes. there were some glomeruli loss in the renal cortex most probably due to age, and we identified the presence of focal microthrombi formation within the glomerular capillary lumen, but no other specific morphologic abnormality was evident upon studying the glomeruli architecture. the proximal convoluted tubules had suffered loss of cytoplasmic and nuclear detail (rarefaction) and retraction of tubule epithelial cells from basement membranes, most probably due to the autopsy being performed h later after death. we identified only small areas of acute tubular injury with coagulative necrosis of focal tubular epithelial cells. there was passive congestion within the medullary blood vessels. no inflammatory cells could be identified in the sampled specimen that was examined, and there were no viral cytopathic changes within the renal cells. microscopy of the spleen showed autolytic changes but also disorganization of spleen compartments translated by marked congestion with white pulp atrophy and with the absence of lymphoid follicles. the remaining lymphoid tissue was found around the central arteries. the capsule was intact (fig. ) . on the lung samples from this case, we managed to perform immunohistochemistry studies, to be able to understand exactly which type of cells was involved in the pathogenesis of sars-cov- . pancytokeratin panels (ck-ae -ae ; ck-mnf ) most importantly found positivity within hyaline membranes, corroborating the fact that these membranes formed by destruction of the epithelial lining, and they had no fibrin origin. cytokeratin (ck ) was reactive in pneumocytes that underwent viral cytopathic effect, including in clusters of giant celllike pneumocytes aggregates. we also found that ck fig. microscopic aspect of lung (case )-hematoxylin-eosin (× , × ). a (arrow) (× ); b (arrow head) (× ) type ii pneumocyte hyperplasia with viral cytopathic effect forming clusters and imitating multinucleated giant cells. c (× ) hyaline membranes (black triangle) and scattered lymphocytes within the alveolar septum (red triangle). d (× ) focal area of neutrophilic inflammatory infiltrate immunostain was forming cytoplasmic halos of nonreactivity in a small number of cytopathic cells revealing possible cytoplasmic viral inclusions. focal areas of lymphocytic infiltrates described earlier were reactive to cd and cd , and only scattered lymphocytes were found positive to cd in the examined lung tissue. cd and cd were found negative in every sample examined (fig. ) . the second case was a male patient, years of age who was found dead in his house. before the autopsy was performed, we checked his medical history, and we found out that he requested an ambulance days before his death. on that occasion, he was examined in the hospital's emergency department for dry cough and shortness of breath. however, there was no history of recent travel or known exposure to sick contacts; thus he was not tested at that time for sars-cov- . he was discharged from the emergency unit with recommendation of further evaluation at the pulmonary disease department; however, he was found dead days later. searching further through his medical history, we found out that year ago, he had two hospitalizations for bronchopneumonia, acute respiratory failure, hypercapnic respiratory acidosis, septal deviation, ethmoidal sinusitis, and sleep apnea syndrome (which remained in observation). both times he was admitted to hospital in the past, he was in a coma. two months prior to his death, he had another admission with influenza virus infection. he underwent treatment, and he gradually recovered. it is important to mention that he suffered from class obesity and he was a smoker. external examination of the body revealed the absence of trauma and no specific signs that could have indicated a violent cause of death. mild edema and vascular congestion and no ischemic or hemorrhagic lesions were found upon cross section of the cerebral hemispheres. the thoracic cavity lacked any fluid accumulations. the visceral pleura was clean, smooth, and glassy with the presence of groups of small brown to red papule-like lesions on the subpleural surface of both the lungs accompanied by small to medium foci of subpleural retraction zones of the pulmonary parenchyma. the lungs were heavy and congested with lack of crepitations upon palpation. cross section revealed a fleshy dark red parenchyma of elastic consistency with dirty dark deoxygenated liquid blood that leaked from the blood vessels, and a moderate frothy pink fluid was discharged upon compression (fig. ) . there was a mild dilatation of the right atrial and ventricular cavity. no other pathological findings were observed upon macroscopic examination of the other organs (tables ). microscopic examination of the pulmonary tissue revealed large areas of alveolar damage with destruction of the alveolar wall lining and intra-alveolar septa, marked vascular congestion, accompanied by intra-alveolar hemorrhage. in the alveolar space, we found large numbers of hemosiderin-laden macrophages, detached pneumocytes, and a rich intra-alveolar eosinophilic homogenous material suggesting marked pulmonary edema. the detached type ii pneumocytes within the alveolar space were enlarged with a round to oval structure, a big irregular nucleus with prominent nucleolus, and coarse clumped chromatin at the edge of the nucleus. sometimes binucleation was present. all these changes suggest viral cytopathic effect. these cytopathic cells tend to form groups like in the other case, mimicking multinucleated giant cells. focal areas of mild pneumocyte hyperplasia were observed. there was only focal presence of hyaline membranes. foci of lymphocytic inflammatory infiltration could be seen with an affinity for the perivascular spaces and around the small to medium size bronchi. in some areas, the lymphocytes tend to invade the vascular wall but with no fibrinoid necrosis formation, suggesting a mild vasculitic reaction. the epithelium of the bronchi was detached and eroded, and there was mild glandular hyperplasia within the bronchus walls. the blood vessels were markedly dilated with hematic content, the walls of these vessels were fibrotic as well as the perivascular space with fibrotic trabecula extending from the spaces to the intra-alveolar septum. in some areas of the affected lung, there was a presence of necrosis, with cellular debris and neutrophilic inflammatory response. small blood vessels in these areas are microthrombotic but with no signs of leukocytoclastic vasculitis upon the small, medium, or large blood vessels of the examined lung tissues (table and fig. ). microscopic examination of the myocardium revealed areas of small vessel thrombosis but with no histological signs of ischemia. there was marked vascular congestion, mild edema between the muscle fibers, and no inflammatory infiltrate in the examined specimens. the myocardial architecture was normal beside scattered areas of myocardial fibers that tended to form contraction bands, most likely due to acute circulatory disorders originated immediately before death. the thickness of the arteries was normal with preserved luminal permeability and no sign of atherosclerosis or myocarditis (fig. ). the deceased was a -year-old man with a complex medical history of hypertension, ischemic cardiomyopathy, chronic heart failure (nyha iii), mitral insufficiency, tricuspid insufficiency, atrial fibrillation, aortocoronary bypass (in ), chronic renal failure, generalized atherosclerosis, chronic rhinitis, and chronic pharyngitis. two months prior to his death, he was prescribed with anticoagulant drugs for his cardiovascular diseases. one day prior to death, he was admitted to hospital for melena and hematochezia, having blood pressure / mmhg, and sao = %. laboratory specimens drawn on that day detected a hypocoagulatory state, acute renal failure, increased level of c-reactive protein, increased white blood cell count with neutrophilia, severe hemorrhagic anemia translated by decreased red blood cell count, and extremely low level of hemoglobin ( . g/dl) ( table ). due to his condition, he presented cardiac arrest without response to resuscitation, so death was declared. there was no history of recent travel or known exposure to sars-cov- -positive contacts. no specific pathological findings were observed upon external examination of the body. the cranial cavity was not opened. the examination of the thoracic cavity revealed about ml of clear serous fluid in the pleural space, on each side. the inferior lobes of each lung and part of the middle lobe of the right lung had a fleshy appearance, but with no increase in volume, the surface of the lobes was smooth and glassy. upon palpation, the consistency was more elastic with areas that lack crepitations. there was compensatory emphysema at the level of the bilateral superior lobes. dark deoxygenated liquid blood leaked upon dissection of the lung parenchyma, and a mild frothy pink fluid was discharged upon compression. the sectioned surface had small areas of a more intense reddish color between stretched areas of dark purple color. dilatation of the right atrium and right ventricle and left ventricular hypertrophy was observed. the coronary arteries suffered extreme atherosclerosis, with marked narrowing of the arterial lumen. upon dissection we found areas of myocardial fibrosis secondary to an old myocardial infarction. the gastric mucosa was hyperemic with small areas of diffuse hemorrhage. moderate amount of hematic content was found within fig. macroscopic aspect of lung (case ). a (arrows) subpleural parenchymal retraction zones. b (arrow heads) groups of small brown to red papule-like lesions on the subpleural surface of both lungs. c fleshy dark red parenchyma of elastic consistency with dirty dark deoxygenated liquid blood that leaks from the blood vessels the intestinal lumen, but upon examination of the mucosa, there were no signs of ulcers or hemorrhagic tumors. the liver was increased in volume with diffuse fibrosis and regenerative nodules. the spleen was mildly decreased in volume (table ) . in this case, the pulmonary architecture was relatively preserved, with lack of diffuse lung injury and hyaline membrane formation. there was marked vascular congestion with the presence of numerous dilated blood vessels with hematic content, focal areas where the intra-alveolar walls were ruptured and focal areas of pulmonary edema. detachment of the alveolar lining with scattered pneumocytes throughout the alveolar space and mild to moderate type ii pneumocyte hyperplasia were also a constant finding. these pneumocytes had an increased volume with rich eosinophilic cytoplasm, a round to oval sometimes irregular nucleus with round prominent nucleolus and course, clumped chromatin, mainly at the edge of the nucleus. sometimes binucleation was present. these type ii pneumocytes had suffered viral cytopathic effect, similar with the other two cases. there was a mild to moderate lymphocytic inflammatory reaction, more evident in the perivascular region, with some lymphocytes invading the vascular wall but without fibrinoid necrosis. there were areas of fibrosis within the intra-alveolar septum and atelectasis zones. some small blood vessels had clumped red blood cells in the lumen, forming microthrombi (table and fig. ) . the architecture of the renal parenchyma was preserved. the glomeruli were shrunken, and the bowman space was widened. there was focal vacuolar degeneration in the cytoplasm of some proximal convoluted tubule cells and cellular debris in the luminal space, consistent with a degree of acute tubular necrosis, most probably by renal hypoperfusion. there is also marked peritubular congestion more accentuated in the medullary parenchyma. there is diffuse disruption of the normal hepatic architecture with regenerative nodules of hepatocytes, fig. microscopic aspect of myocardium (case )-hematoxylin eosin (× ). small vessel thrombosis (star) fig. microscopic aspect of lung (case )-hematoxylin-eosin (× , × ). a (× ) destruction of alveolar walls with marked congestion, intra-alveolar hemorrhage, and diffuse desquamation of pneumocytes. b (arrows) (× ) moderate perivascular lymphocytic inflammatory response with invasion of vascular walls. c (× ) groups of hemosiderinladen macrophages (arrow heads) with microthrombi formation within a small blood vessel (star). d (× ) numerous pneumocytes who underwent viral cytopathic effect, one binucleated (triangle) surrounded by fibrous connective tissue that bridges between portal tracts, consistent with chronic liver disease. within this collagenous tissue, there were scattered lymphocytes and a proliferation of bile ducts. microscopy of the spleen like in our first case showed an abnormal architecture with marked congestion, red pulp necrosis and white pulp atrophy, with absence of lymphoid follicles. the residual lymphoid tissue was found around the central arteries. the capsule was intact. in out of cases, there was no known positive covid- contact and no recent travel history to or from countries with high number of infections in that period of time. in case , it was known that the husband was found positive during his one admission, but the chronological order of the infections could not be determined. in two out of these three cases, the cause of death was a result of direct lung injury due to viral pneumonia, in contrast to our third case where the cause of death was due to a massive diffuse intestinal hemorrhage after an anticoagulant drug overdose in a patient with undiagnosed hepatic cirrhosis. for the two cases with hospital admissions prior to their death, the laboratory findings were consistent with an inflammatory response due to infection. complete blood count showed leukocytosis with mild neutrophilia and mild lymphocytopenia, with a c-reactive protein of . mg/l in our first case and a c-reactive protein of . mg/l in our last case. the lungs were heavy, congested with an elastic consistency, and lack of crepitations upon palpation in cases and , the same cases in which the direct cause of death was due to acute lung injury from sars-cov- infection. in case number , the inferior lobes of each lung and part of the middle lobe of the right lung had a fleshy appearance, but with no increase in volume. upon cross section, the lung tissues examined had a fleshy dark red or dark brown appearance, with patchy consolidations and with focal areas of normal parenchyma, more or less depending on the severity of pulmonary damage. pulmonary congestion and edema were also a constant finding. in our first case, we found multiple dark grey lymphadenopathies up to mm in diameter, at the level of the bilateral pulmonary hilum and mediastinum. we found several important microscopic lesions of the lungs, which helped us draw a clearer picture of the pathology of covid and help us better understand the pathogenesis and pathophysiology of the new viral disease. the presence of alveolar wall destruction with detachment of the surface epithelial lining with various degree of type ii pneumocyte hyperplasia confirms that impaired gas exchange by loss of alveolar-capillary membrane can still be considered an important pathophysiological mechanism, in which sars-cov- produces acute respiratory distress syndrome (ards). these findings were backed up by previews studies [ ] [ ] [ ] [ ] [ ] [ ] . the consistent presence of pneumocytes increased in volume, with big round to oval, sometimes irregular nucleus, prominent central or peripheral nucleolus and clumped, course chromatin, with some cells that present binucleation or small, pyknotic, intense basophilic nuclear inclusions situated to the periphery of the nucleus, can be interpreted as a viral cytopathic effect, thus confirming the viral origin of the pulmonary infection. pernazza a. et al. described similar findings of reactive hyperplasia and focal pneumocytes with nuclear inclusions [ ] , as well as suess c. et al. who found patchy and severe type ii pneumocyte hyperplasia with atypically enlarged pneumocytes with large nuclei, amphophilic granular cytoplasm, and prominent nucleoli showing viral cytopathiclike changes [ ] . in all three cases investigated, we discovered areas where these cells tend to form clusters and cohere one to another, fig. microscopic aspect of lung (case )-hematoxylin-eosin (× , × ). a (arrow) (× ) mild to moderate perivascular lymphocytic infiltrate with some lymphocytes with tendency of invading the vascular wall. b (× ) viral cytopathic changes within type ii pneumocytes, one with binucleation (arrow head). c (stars) (× ) microthrombi formation within the small blood vessels of the lung forming giant cell-like syncytial aggregates, which can be mistaken with multinucleated giant cells of histiocytic origin. like in our study, zhe xu*, lei shi* et al. described these cells as multinucleated syncytial cells with atypical enlarged pneumocytes characterized by large nuclei, amphophilic granular cytoplasm, and prominent nucleoli that were identified in the intra-alveolar spaces, showing viral cytopathic-like changes and no obvious intracytoplasmic or intra-nuclear viral inclusions [ ] , as well as previews studies in the literature [ ] . after immunohistochemical studies, we confirmed that indeed these cells are of pneumocytic origin with cytokeratin positivity. hyaline membranes, specific of diffuse alveolar damage, were found more prominent in our first case and only focally on our second case. the presence of microthrombi in the lung parenchyma was found constantly, and in our -year-old who died at home (case ), we found these microthrombi even in some areas of the myocardium. the presence of microthrombi was described in many other case reports suggesting an important pattern of sars-cov- pathogenesis [ , , ] . we have put the problem that our pulmonary pathological findings were, in some degree, caused by ventilator-induced lung injury, but we concluded that this was not the case of our three patients because, to our knowledge, only our first patient was put on a ventilator but for a short period of time right before death. mild vasculitic reaction consistent with invasion of pulmonary vascular wall by lymphocytes but with no presence of fibrinoid necrosis was found upon two out of three cases (case and case ). this finding is consistent with a form of endotheliitis, discussed in detail by varga z. et al. who found viral inclusion structures upon studying under an electron microscope endothelial cells of a patient's kidney who was confirmed with sars-cov- infection. histopathology described accumulation of inflammatory cells associated with endothelium, as well as apoptotic bodies, in the heart, small bowel, and lung [ ] . other studies confirmed the same findings as lymphocytic capillaritis within the lung and viral endotheliitis of myocardial vessels [ ] . beside the lungs, we could not find specific signs of vasculitis, perivasculitis, and capillaritis, and we concluded that our inflammatory response around the vessels of the other organs was a perivascular inflammatory infiltrate. the first two cases presented focal neutrophil infiltrate in the lung tissues examined. other publications described more or less the same microscopic lesions [ , , , ] . the myocardium tissues presented small areas of contraction bands and scattered lymphocytes; no signs of myocarditis were present. the same conclusion was expressed by sharon e. fox et al. [ ] . dettmeyer et al. confirmed the presence of lymphocytic myocarditis in the right ventricle of a sars-cov- -positive case. microscopy of the kidney revealed focal areas of acute tubular necrosis upon the proximal convoluted tubules overlaying postmortem changes. other studies revealed the same injury upon the proximal tubules with loss of brush border and nonisometric vacuolization, which partially may be caused by direct virulence of sars-cov- [ ] . some authors described microscopic alterations consistent with collapsing glomerulonephritis [ , ] ; however, this was not present in our specimens. in case , small focal microthrombosis of the glomerular capillaries was found upon microscopic examination. immunohistochemical studies done to define our type of lymphocytic inflammatory infiltrate in our lung cut sections established that mostly cd , cd -positive t lymphocytes, and only scattered cd -positive b lymphocytes were found during examination, consistent with recent literature [ , ] . conflict of interest the authors declare that they have no conflict of interest. human rights statements and informed consent all procedures performed in studies involving human participants were in accordance with the ethical standards and with the helsinki declaration and its later amendments or comparable ethical standards. all personal data were anonymized in order to protect the identity of our patients. autopsy results including histology may be used anonymously for scientific purpose. animal rights this article does not contain any studies with animal subjects performed by any of the authors. pathological study of the novel coronavirus disease (covid- ) through postmortem core biopsies histopathologic changes and sars-cov- immunostaining in the lung of a patient with covid- püschel k ( ) evidence for systematic autopsies in covid- positive deceased: case report of the first german investigated covid- death autopsy in suspected covid- cases gross and histopathological pulmonary findings in a covid- associated death during self-isolation early histologic findings of pulmonary sars-cov- infection detected in surgical specimen pathological findings of covid- associated with acute respiratory distress syndrome moch h ( ) endothelial cell infection and endotheliitis in covid- histopathological findings following sars-cov- infection with and without therapy -report of autopsies. rechtsmedizin dying with sars-cov- infection-an autopsy study of the first consecutive inside the lungs of covid- disease vander heide rs ( ) pulmonary and cardiac pathology in covid- : the first autopsy series from new orleans renal histopathological analysis of postmortem findings of patients with covid- in china covid- -associated collapsing glomerulopathy: an emerging entity acute kidney injury due to collapsing glomerulopathy following covid- infection publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -ll pnl authors: saberi, m.; hamedmoghadam, h.; madani, k.; dolk, h. d.; morgan, a.; morris, j. k.; khoshnood, k.; khoshnood, b. title: accounting for underreporting in mathematical modelling of transmission and control of covid- in iran date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ll pnl background: iran has been the hardest hit country by the outbreak of sars-cov- in the middle east with , confirmed cases and , deaths as of april . with a relatively high case fatality ratio and limited testing capacity, the number of confirmed cases reported is suspected to suffer from significant under-reporting. therefore, understanding the transmission dynamics of covid- and assessing the effectiveness of the interventions that have taken place in iran while accounting for the uncertain level of underreporting is of critical importance. we use a mathematical epidemic model utilizing official confirmed data and estimates of underreporting to understand how transmission in iran has been changing between february and april . methods: we developed a compartmental transmission model to estimate the effective reproduction number and its fluctuations since the beginning of the outbreak in iran. we associate the variations in the effective reproduction number with a timeline of interventions and national events. the estimation method also accounts for the underreporting due to low case ascertainment by estimating the percentage of symptomatic cases using delay adjusted case fatality ratio based on the distribution of the delay from hospitalization to death. findings: our estimates of the effective reproduction number ranged from . to . between february and april , with a median of . . we estimate a reduction in the effective reproduction number during this period, from . ( % ci . - . ) on march to . ( % ci . - . ) on april , due to various non-pharmaceutical interventions including school closures, a ban on public gatherings including sports and religious events, and full or partial closure of non-essential businesses. based on these estimates and given that a near complete containment is no longer feasible, it is likely that the outbreak may continue until the end of the if the current level of physical distancing and interventions continue and no effective vaccination or therapeutic are developed and made widely available. interpretation: the series of non-pharmaceutical interventions and the public compliance that took place in iran are found to be effective in slowing down the speed of the spread of covid- within the studied time period. however, we argue that if the impact of underreporting is overlooked, the estimated transmission and control dynamics could mislead the public health decisions, policy makers, and general public especially in the earlier stages of the outbreak. funding: nil. evidence before this study since the outbreak of sars-cov- in late , several studies have attempted to understand its transmission and control dynamics. the majority of the existing studies reported the dynamics and initial estimates of the effective reproduction number from china followed by a few other studies using data from other countries including italy, spain, south korea, germany, france and iran among others. however, none of the previous work has taken into account the impact of possible underreporting of cases in estimation of the effective reproduction number. also, no other study reported the time-dependent association between the interventions and variations in the effective reproduction number for iran as the hardest hit country in the middle east. we use a mathematical model to estimate the transmission and control dynamics of covid- in iran, taking into account the significant underreporting of cases. we estimated the time-dependent effective reproduction number in association with a timeline of events and interventions that took place. we showed that if underreporting is overlooked, the estimated dynamics could mislead the public health decisions and general public. the impact of control measures on the effective reproduction number could also significantly be overestimated unless under-reporting is taken into account. the estimation of transmission and control dynamics of covid- in any country highly depends on the quality of the reported data. however, in the presence of high uncertainty in the number of confirmed cases, it is of crucial importance to take into account the impact of underreporting when interventions are to be introduced or lifted. the outbreak of sars-cov- in iran was first officially announced in february , two months after the initial outbreak in wuhan, china. iran's patient zero is believed to have been a merchant from qom who had travel history to china. despite the initial signs of a spread in qom, the government declined to place the city under quarantine to contain the epidemic at an early stage for various technical, socio-economic, religious, and security reasons. the first local non-pharmaceutical interventions such as schools and universities closure were put in place a few days after the official acknowledgement of the first cases in qom and tehran. since then, various public health control measures at the local and national levels were taken that are believed to have altered the course of the outbreak. see figure for a spatial illustration of the spread throughout the country by province in the first week since the official announcement of the first case (appendix p ). the relatively high case fatality ratio (cfr), defined as the total number of deaths over the total number of infected cases, in iran's official reports after the first week since the official declaration of the first case ( . %) has raised questions on the true number of cases in the country. , the testing protocol in iran at the early stages of the outbreak was limited to hospital admissions of the patients with severe symptoms. while iran has extended the covid- diagnostic testing capacity later on to patients with milder symptoms, it is believed that under-ascertainment of cases still remains high. this study aims to understand the transmission dynamics of covid- in iran and to assess the effectiveness of the control measures that were put in place over time through estimation of the effective reproduction number ܴ ሺ ‫ݐ‬ ሻ defined as the average number of susceptible persons infected by an infected person during its infectious period at a given time in the course of the epidemic. we assessed ܴ ሺ ‫ݐ‬ ሻ in relation to a timeline of national events and non-pharmaceutical interventions. in the absence of timely and reliable data, modelling can provide helpful answers, including the degree of plausible uncertainty in different estimates and the effectiveness of non-pharmaceutical interventions. by providing explicit and clear information about model assumptions and parameters, modelling can also foster scientific discussion of data gaps and what can be done to improve outbreak-related estimates by borrowing information available elsewhere. finally, models can be developed and presented using both average estimates and measures of their uncertainty or, alternatively, as scenarios that can illustrate possible developments of the epidemic under various conditions. we use official time-series reports of the number of confirmed cases, recovered, and deaths from the world health organization (who) and iran's ministry of health and medical education . the first confirmed case was reported on february which is assumed as the beginning of the outbreak of covid- in iran. we describe the dynamics of spread using a variation of the susceptible-exposed-infected-recovered (seir) model, distinguishing between fatality and recovered cases combined with an estimate of the percentage of symptomatic cases using delay-adjusted cfr (appendix p ). see figure . the model . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint accounts for the time between exposure-to-onset of symptoms (or confirmation), also known as incubation period, assuming a gamma distribution with an average of . days and a standard deviation of . days. we also assume the time from symptoms onset-to-death and -to-recovery both follow a gamma distribution with an average of . days and a standard deviation of . days and an average of . days and a standard deviation of days, respectively. the size of the initial susceptible population is assumed to be million. to estimate the parameters of the developed seir model, we formulate an ordinary least squares (ols) minimization. we use pattern search as a derivative-free global optimization algorithm to find the model parameters that minimizes the sum of the normalized root mean squared error (rmse) of the number of infected ߝ , recovered ߝ and removed cases ߝ . the basic reproduction number, ܴ , a fundamental measure in infectious disease epidemiology and public health, is defined as the average number of susceptible persons infected by an infected person during its infectious period in a fully susceptible population. ܴ ௧ is defined similarly to ܴ but is not limited to the assumption of a completely susceptible population. here, we use empirical data from iran to trace changes in ܴ ௧ over a rolling day period since the beginning of the covid- outbreak and describe its association with various interventions (e.g. school closures, social distancing, and bans on public gatherings) that took place by the public and government. various methods exist to estimate ܴ (and ܴ ௧ ). , here, we use the same framework described in figure in which the parameters of the formulated seir model are inferred through an optimization problem. ܴ ௧ is calculated using a rolling time window of days to capture the evolving trend of the spread over time due to various changes in the social network contact rate. the calculated ܴ ௧ may be overestimated during the early stage of an outbreak due to different reasons including the impact of imported cases and heterogeneity in subpopulations (e.g. older than years old) with higher transmission rates. we account for the under-reporting of the number of infected cases in the official confirmed data using delay-adjusted case fatality ratio (cfr) approach. this approach assumes that the time from hospitalization-to-death has a known statistical distribution and uses this distribution to estimate when the people who died from covid- would have been reported as being infected. the case fatality ratio is the ratio of the numbers of deaths over the numbers of reported infections calculated at the time of reporting not the time of death. this is extremely important for rapidly evolving epidemics. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . the method, however, does not account for underreporting in fatality cases. the distribution of the time from confirmation-to-death is assumed to follow the same distribution as of the time from hospitalization-to-death, following a lognormal distribution with a mean of days and a standard deviation of . days. here, we assume that the estimate for percentage of symptomatic covid- cases reported for iran follows a lognormal distribution (same distribution type as of the time from hospitalization-to-death) with a mean of . % and a standard deviation of % based on the latest estimates in the literature. this is based on the assumption of a baseline cfr of . %. we assume the underreporting level remains constant over time. we estimated that the cfr on february , before adjusting for the time from diagnosis-to-death, was . %. with more data emerging after the second week, the cfr dropped to . % on the th day since the declared beginning of the outbreak on february , . later, between march and april , the cfr stabilized between . % and . % with a mean of . %. see figure (c). with the wider spread of covid- across the country, the cfr increased to . % on march . however, the cfr declined and plateaued around . % between and april . the relatively high cfr could correspond to a significant level of under-reporting of the infected cases and an overwhelmed health system. given the wide distribution of the time from confirmation-to-death of covid- , we also explore the delay-adjusted cfr with -and -day delay period, as examples. the dynamics of the delay-adjusted cfr with -day delay suggests that the cfr has been gradually reducing in iran from . % on march to . % on april . when underreporting of infected cases is overlooked, the estimated effective reproduction number began from . ( % ci . - . ) on march and reduced to . ( % ci . - . ) on april suggesting the outbreak peak has already occurred on april when ܴ ௧ goes below , about days from the confirmation of the first case. the outbreak is also likely to continue until the end of . see figure . the estimates of the effective reproduction number were consistently larger during the early stage of the outbreak when underreporting is overlooked compared to when underreporting is taken into account. however, the estimated effective reproduction numbers converged as the number of infected cases approached the peak. the convergence of the estimates can be partly explained by the fact that the effective reproduction number is more dependent on the rate of change in the infected and recovered cases rather than their absolute numbers. results also suggest that the impact of control measures on the effective reproduction number is significantly overestimated when under-reporting is taken into account. with the gradual reduction of the effective reproduction number to below one and the increasing pressure on an already fragile economy because of the implemented control measures, the government is seeking an exit strategy and is considering easing some of the restrictions. here, we conduct a scenario analysis to understand how three different scenarios could change the projected outlook of the outbreak in iran: i) maintaining the same level of control measures as of april , ii) intensifying the measures to increase physical distancing represented by a % reduction in the reproduction number, and iii) partially lifting the restrictions to ease physical distancing represented by a % increase in the reproduction number. to estimate the number of icu beds needed, we assume % of the confirmed cases require intensive care. we found that in all scenarios the projection of patients requiring icu admission exceeds the original icu capacity. note that no official information is available on the expanded icu capacity. as of april , both projected curves start above the icu capacity. easing the restrictions can quickly push the peak to a level that is five times higher than the scenario where the current level of control measures is maintained and puts additional pressure on the health system. results clearly suggest that with further restrictions . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint (scenario ii), the projected curve quickly goes back under the icu capacity while it takes more than days for the curve to go back under the icu capacity in scenario i and iii. with % ci over a -day rolling window when underreporting is taken into account. (c) estimated cfr with and without delay adjustment over the same time period in a semi-log scale. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . the projected number of icu beds needed under the three scenarios. the original icu capacity is assumed between to beds. in this study, we used a mathematical epidemic model to provide the first estimates of the changing transmission of sars-cov- infection in iran when underreporting of cases are considered. we used official data and adjusted our estimates for underreporting based on delay-adjusted cfr. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . we used a variation of the seir model combined with an estimate of the percentage of symptomatic cases using delay-adjusted cfr based on the distribution of the time from confirmation-to-death . in contrast to previous models of the epidemic , we did not assume any prior information on the distribution of the effective reproduction number. this combined with the use of a series of distributions allowed us to take into account more appropriately the uncertainty and the random variation in both input data and model outcomes. the outbreak of covid- in iran is claimed to have been started in qom province with the first case officially reported on february . as shown earlier in figure (a) , according to the official data, it only took two days, for four more provinces, including tehran, markazi, mazandaran, and gilan (guilan) to report their first cases. the first non-pharmaceutical intervention took place on february with the closure of schools and universities in qom followed by the capital city of tehran after a day. with the school closures in the capital and yet low level of social awareness about the potential risks of covid- , a surge in the number of holiday trips from tehran to northern provinces of mazandaran and gilan was observed. soon after, with no restriction on the inter-city travels the number of identified cases in gilan and mazandaran grew rapidly, and the infection spread throughout the rest of the country. the second major non-pharmaceutical intervention occurred on february with a wide campaign to disinfect public spaces and closure of all schools and universities across all provinces. on march , the government announced an increase in the covid- testing capacity. on march , sporadic closure or reduction of working hours in government offices and banks across the country was reported. on march , two often crowded religious shrines in qom and mashhad were closed to visitors. the increased physical distancing as the result of interventions and increase in public awareness of the crisis through major official and unofficial information campaigns, especially on social media, gradually showed its impact by slowing down the speed of the spread as shown earlier in figure (b) . the estimated effective reproduction number increased from . on march to . on march , perhaps due to the increase in case ascertainment and delay in early interventions to show their impact. the effective reproduction number decreased consistently to . on march . on march , only a few days before the persian new year (nowruz, march ), in the absence of strict travel restrictions, millions of iranians began making road trips to various destinations across the country despite the warnings from the government and many hotels, restaurants and the general hospitality industry's refrainment to provide services to any traveller. this is believed to have increased the speed of the spread of covid- in iran, increasing the effective reproduction number to . on march . on march , government announced more restrictive non-pharmaceutical interventions leading to closure of all non-essential businesses for at least two weeks, followed by further intensified interventions on march , including restrictions on entry and exit to affected provinces and cities, closure of parks, pools and all recreational places, and a ban on public gatherings including sport, cultural, and religious events. these restrictions pushed the effective reproduction number further down to . on april and . on april . iran has had one of the highest case fatality rates (cfr) among the affected countries in the world. while the cfr is known to vary significantly between countries due to various reasons including testing frequency and population age distribution , the cfr is still higher in iran despite having a younger population with the median age of . years old compared to china with % cfr and the median population age of . and south korea with % cfr and the median population age of . . perhaps a comparable country in the middle east region with similar population characteristics (median age of . ) is turkey. the cfr in turkey as of april was %, three times lower than that of iran. while the evidence is indirect, it suggests that the official number of cases reported by iran may has been significantly under-reported, possibly due to relatively low case-ascertainment and under-reporting of identified cases. the continuous reduction in the delay-adjusted cfr shows a different trend compared to the cfr with no consideration of the time from confirmation-to-death. the continuous reduction could be explained by the improving case identification practice in iran over time with various initiatives including a national coronavirus helpline (the " " service), established in late february to self-report symptoms and identify suspected cases. our results confirmed the significant impact of underreporting in describing the story of the covid- outbreak in iran, especially in the early stages. we showed how overlooking underreporting can drastically affect estimation of ܴ ሺ ‫ݐ‬ ሻ and overestimate the impact of control measures. our results also showed the reduction in effective reproduction number, a measure of infection transmission, during this period. this decrease was most likely due to the increased physical distancing as the result of multiple non-pharmaceutical public health interventions, including school closures, ban on public gatherings, travel restrictions, full/partial closure of non-essential businesses, as well as major awareness campaigns over social media. based on the latest trends, while the first peak of covid- in iran occurred on april , the post-peak period may continue to the end of . however, these projections assume the continuation of the current level of control measures and the absence of effective therapeutic treatment or vaccination programs. hence, they can be subject to important shifts depending, in particular, on the public's willingness to continue and the government's success in implementing social distancing measures or easing the restrictions. our model provides tangible evidence of the association between the different non-pharmaceutical interventions and their impact on the course of the outbreak. the results showed how the acceptance and hence effectiveness of the interventions endorsed by the iranian government aimed at "flattening the curve" depended in part on the public's level of awareness of the principles behind governmental policies and their trust in the government and its control measures. for example, closure of schools and businesses in the capital city of tehran near the time of the persian new year was followed by a surge of holiday trips to gilan and mazandaran and a subsequent increase in the number of cases in these provinces and in other parts of the country. this observation shows how interventions may be associated with unintended and at times counterproductive consequences. these negative consequences can be prevented when there is open and credible communications by competent officials and mutual trust between public and government. moreover, intervention measures need to be developed, implemented and enforced as a whole, for example by strict reinforcement of travel restrictions in conjunction with school and workplace closings. there is no substitute for high quality data -complete, accurate, and timely -as a basis for public policy. however, in the absence of such data, modelling of the type presented here can help provide reasonable estimates as well as realistic bounds of their uncertainty. the range of uncertainty can be viewed as the margin of error in the model's predictions of the number of cases, icu admissions or deaths. modeling can also illustrate different scenarios --pessimistic vs. optimistic vs. realistic --of how the epidemic may evolve in relation to current and future public health measures and the possible compliance of the public over time. in conclusion, using a stochastic model of the sars-cov- epidemic in iran, we assessed the dynamic of the epidemic in relation to public health measures to increase social distancing. we took into account both the inherent uncertainty in the data and the possible impact of under-reporting of true cases due to low case ascertainment and reporting. in the absence of consistently reliable data, the modelling approach as presented here can help generated reasonable estimates of key public health metrics such as the number of cases and case fatality ratio. in turn, these metrics and scenarios can help serve the dual purpose of informing public policy and the public and fostering discussions and improvements of epidemic modelling. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint coronavirus disease (covid- ) world economic forum. finding 'patient zero': the challenges of tracing the origins of coronavirus coronavirus could break iranian society iran takes emergency measures after two coronavirus deaths in qom cross-country comparison of case fatality rates of covid- /sars-cov- why is iran's reported mortality rate for coronavirus higher than in other countries? iran's ministry of health and medical education. daily covid- epidemic reports the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application report : severity of -novel coronavirus (ncov) inverse problem for coefficient identification in sir epidemic models analysis of generalized pattern searches complexity of the basic reproduction number (r ) effective reproduction numbers are commonly overestimated early in a disease outbreak the effective reproduction number as a prelude to statistical estimation of time-dependent epidemic trends the estimation of the basic reproduction number for infectious diseases on the exact measure of disease spread in stochastic epidemic models incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data centre for mathematical modelling of infectious disease, london school of hygiene & tropical medicine the centre for evidence-based medicine characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention centre for mathematical modelling of infectious disease, london school of hygiene & tropical medicine key: cord- -f imrltt authors: weimer, louis h. title: neuromuscular disorders in pregnancy date: - - journal: handb clin neurol doi: . /b - - - - . -x sha: doc_id: cord_uid: f imrltt many neuromuscular disorders preexist or occur during pregnancy. in some cases, pregnancy unmasks a latent hereditary disorder. most available information is based on case reports or series or retrospective clinical experience or patient surveys. of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. anesthesia for cesarean section surgery requires special precautions in many disorders. the types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. disorders include carpal tunnel syndrome and other focal neuropathies, bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions. numerous neuromuscular conditions develop or preexist in women of childbearing age. some are immune or inflammatory disorders that may be influenced by pregnancy; processes can be incited, improved, or unaffected. some of the most common and most important conditions are reviewed (sax and rosenbaum, ; guidon and massey, ; massey and guidon, ; edmundson and guidon, ) . categories include focal and generalized neuropathy, neuromuscular junction disorders, acquired and hereditary muscle disorders, channelopathies, motor neuronopathies, and autonomic disorders. there are no rigorous studies to rely on with regard to most conditions; treatment advice is also often based on anecdotal case series or on retrospective chart data or patient survey. many conditions cause difficulty because of skeletal muscle but not uterine smooth muscle weakness that impacts labor and delivery. decisions to wean or continue medication treatments are important considerations-most commonly used treatments have animal but no reliable human information on pregnancy safety. the fda class for some examples is listed in table . . however, the fda removed this alphabet system effective mid- in favor of a narrative summary of drug risks during pregnancy and lactation and discussion of the evidence. however, the category system is still referenced and useful to many physicians and patients. the new system was intended to be phased in by , but that review process continues. therefore, a combination of details is presented in this section. some conditions, such as orthostatic intolerance or postural orthostatic tachycardia syndrome (pots), are often paradoxically lessened during pregnancy. episodic, recurrent numbness and tingling in the fingertips of the first three digits, characteristically more at night. nocturnal awakening that triggers hand shaking is highly characteristic. thenar muscle weakness or atrophy occurs only in severe or untreated cases. incidence varies considerably in published reports based on ascertainment methods. hand symptoms are relatively common, affecting up to % of pregnant women, but some older estimates are much lower. the italian cts study group surveyed women in their last trimester: % had a clinical diagnosis of cts, but only % had a positive electrophysiologic diagnosis (padua et al., (padua et al., , a . a common belief is that cts exclusively occurs in the third trimester; however, symptoms and findings can occur at any stage including the postpartum period. other risk factors include multiple births and age over (ekman-ordeberg et al., ; wand, ) . gestational diabetes was not a risk factor in one study (turgut et al., ) . also, contrary to common belief, symptoms often improve but do not resolve after delivery but can develop or persist postpartum. symptoms starting earlier in pregnancy are more likely to persist after delivery. one study noted frequent postpartum symptoms, but only % remained symptomatic at months and % at year (turgut et al., ) . however, a multicenter prospective italian study found % remained symptomatic at the same timepoint (pazzaglia et al., ) . in some cases, lactation can trigger cts symptoms that improve after weaning (wand, ) . conservative nonsurgical treatments including neutral angle or degrees cock-up wrist splinting or local steroid injections are often sufficient. one case of us fda category designations were removed june in favor of description and narrative discussion. however, the replacement system is incomplete, and these designations retain usefulness: (a) adequate and well-controlled studies found no increased risk; (b) no risk found in animal studies but insufficient human studies; (c) adverse fetal animal studies but no adequate human studies; treatment benefits may warrant use despite potential risk; (d) evidence of human fetal risk based on studies or marketing experience but benefit may outweigh risk; and (x) animal or human studies or other experience find fetal abnormalities so that potential benefit in pregnancy is outweighed by risk. na, not assigned. prospective and multiple sequential nerve conduction studies during pregnancy found early onset and symptom resolution with conservative measures during pregnancy, but responses took between and months postpartum to return to baseline values (weimer et al., ) . neuropathic pain medication is generally avoided during pregnancy. severe or refractory cases can be considered for carpal tunnel release surgery, done under local anesthesia, especially earlier in the pregnancy or after delivery. back pain is quite common during pregnancy and can be severe; about % of women are affected. sciatica is much less common, occurring in approximately % (ostgaard et al., ; padua et al., b) . in one patient-reported symptom-based study, a male fetus and prior back pain were positive risk factors but prior pregnancy was not. symptomatic root injury, producing sensory loss or weakness, however, is very uncommon-one older study estimated the incidence to be in , pregnancies (laban et al., ) . pregnancy-related pelvic pain and sacroiliac-induced pain can mimic a radicular pattern. exaggerated lumbar lordosis, direct uterine pressure, and hormonally induced ligamentous laxity are possible factors. pain often improves after delivery but can persist postpartum. treatment is generally conservative unless overt root injury develops. mri scans are feasible in more severe cases. successful and uncomplicated lumbar laminectomy is reported in refractory, severe cases (ostgaard et al., ; garmel et al., ; ng and kitchen, ) . neuropathic pain medications are generally avoided. the risk of idiopathic or a rare hereditary form of brachial neuritis increases mostly in the postpartum period (lederman and wilbourn, ) . typically, severe shoulder or neck pain occurs without provocation. as the pain subsides, muscle weakness is noted; certain patterns are typical, including scapular winging and anterior interosseous neuropathy. weakness is expected to slowly improve but recovery is sometimes incomplete. a rare hereditary cause of recurrent brachial neuritis, known as hereditary neuralgic amyotrophy, can be unmasked. a mutation in the septin (formerly sept ) gene is causative. one case of in the cleveland clinic series suggested that pattern (lederman and wilbourn, ) . entrapment or injury to the lateral femoral cutaneous nerve produces sensory loss or paresthesia in the lateral thigh known as meralgia paresthetica-the neuropathy produces purely sensory symptoms and no objective weakness. weight change, compressive bands, low belts or constrictive garments are recognized risk factors. hip hugger jeans are an example. the nerve is also vulnerable during hip flexion during delivery and by retractors during cesarean section surgery. identification and behavior or garment changes can help. neuropathic pain medications are avoided while pregnant. femoral neuropathy rarely occurs during pregnancy. rates of nerve injury have declined over time with refinements in obstetric care, such as better attention to prolonged lithotomy positioning (al hakim and katirji, ) . one retrospective study found femoral neuropathy affected . % of live births. nerve injury causes isolated thigh and medial lower leg numbness (saphenous nerve), quadriceps weakness, and reduced or absent knee deep tendon reflex (wong et al., ; guidon and massey, ) . the iliopsoas muscle that controls hip flexion variably arises from the proximal femoral or distal lumbar plexus and may be affected. if hip adduction is also affected, a more proximal plexus or root injury is supported. risk factors include primiparous women and prolonged labor. recovery time depends on the severity of axonal injury but often takes weeks to months to improve (rowland et al., ) . obturator neuropathy is rare and primarily occurs during delivery. the nerve travels very deeply in the pelvis and innervates most of the hip adductors and a sensory patch on the medial thigh and occasionally in the upper medial calf. obturator neuropathy can cause medial thigh numbness and pain and hip adductor weakness. because of the deep position, injury is otherwise quite rare, except in severe trauma or infiltrative processes. during labor and delivery, the fetal head can compress the nerve against the pelvic wall; forceps can also cause injury. prognosis is related to the degree of injury and nerve axonal loss. electrodiagnostic studies can distinguish this neuropathy from radiculopathy, plexopathy or femoral neuropathy. however, obturator nerve studies are more challenging because of the deep location. bell palsy is an acute unilateral peripheral facial neuropathy that is typically idiopathic. reduced lacrimation, hyperacusis, or loss of taste sensation may accompany facial muscle weakness. involvement of the forehead muscle (frontalis) can help distinguish from central causes of facial asymmetry. the course may progress to maximum weakness over days, followed by recovery of some, if not all, functions over several months. more severe cases develop complete paralysis. most studies support an increased incidence in pregnancy, especially in the third trimester and immediate postpartum periods. the condition must be separated from central conditions that occur in late pregnancy or immediately afterwards; examples include ischemic or hemorrhagic stroke and venous sinus thrombosis. bell palsy rates range from to times that of nonpregnant women of childbearing age. hilsinger in reported rates of and . per , in pregnant and nonpregnant women, respectively (hilsinger et al., ) . a more recent prospective italian series found pregnancy to have an increased odds ratio of . , compared to the general population, but only two pregnancy-related cases were included (monini et al., ) . some reports suggest that pregnancy-associated facial neuropathy is more severe and more likely to be complete, leading to a worse prognosis. one retrospective study found about half of pregnant women with severe or complete facial paralysis significantly improved, compared to % of others (gillman et al., ) . in contrast, a very large and recent retrospective korean study found no association with bell palsy and pregnancy or postpartum periods (choi et al., ) . that study compared over , pregnancies to over , controls employing the national korean health insurance review and assessment service. the extrapolated annual incidence of bell's palsy per , women during pregnancy was . %, and in the control group, it was . %; postpartum rates were . % in the patient group and . % in the control group. pathogenic mechanisms that may differ in pregnancyrelated bell palsy include altered immune tolerance, hormonal effects on fluid shifts, increased herpes simplex or varicella viral susceptibility, and vasa nervorum thrombosis (hilsinger et al., ; falco and eriksson, ; shmorgun et al., ) . risk factors include essential or gestational hypertension, preeclampsia, and obesity (falco and eriksson, ; shmorgun et al., ) . not surprisingly, treatment considerations are more complicated. the american academy of neurology treatment guidelines concluded that corticosteroids are highly likely to be effective and should be offered in the acute setting (level a); antiviral agents may provide modest benefit (level c) (gronseth et al., ) . however, understandably, pregnant women were excluded from all studies considered for this consensus recommendation. corticosteroids, including prednisone, are prescribed to pregnant women with bell palsy and other conditions despite some concerns of fetal toxicity, especially at high dose. prognosis is dependent on the degree of nerve injury; however, the facial nerve typically recovers better than most other peripheral nerves. one study found further evidence that facial neuropathy is more severe in pregnancy-associated cases despite corticosteroid treatment (phillips et al., ) . antiviral treatments are more controversial given the unproven benefit. one danish study found no increase in birth defects in a large cohort of women exposed to acyclovir, valacyclovir, and famciclovir, compared to other pregnant women in the first trimester (pasternak and hviid, ) . eye patching or lubricating drops and nocturnal ointment should be used in cases of severe eye closure weakness to prevent ocular dehydration injury. fibular (peroneal) neuropathy causing acute foot drop must be distinguished from acute l radiculopathy or lumbosacral plexopathy. nerve stretch can occur due to several factors, including prolonged squatting during childbirth, external compression by inappropriate stirrup leg positioning, or hyperflexion of the mother's knees (babayev et al., ; wong et al., ) . prognosis for recovery is generally good unless the nerve injury is severe. a rare condition, hereditary neuropathy with tendency for pressure palsy caused by a deletion of the pmp gene-the same gene that causes charcot-marie-tooth (cmt) type a discussed later-is particularly vulnerable to fibular neuropathy and related foot drop. radial neuropathy was reported in two unusual situations. one case was attributed to compression from prolonged use of a birthing bar (roubal et al., ) ; another case was caused by a compressive synovial cyst that required surgical intervention (hsiao et al., ) . intercostal neuropathy causing isolated pain and numbness in a thoracic dermatome is described sometimes as thoraconeuralgia gravidarum or intercostal neuralgia (pleet and massey, ; skeen and eggleston, ) . the condition is said to spontaneously improve or resolve-autoimmune or inflammatory causes similar to brachial neuritis are suspected. pregnancy does not specifically cause generalized or polyneuropathy. most forms of polyneuropathy affect the longest nerves exclusively or more severely, leading to the stocking-glove distribution. most neuropathy cases affect sensory more than motor fibers. there are many exceptions that include disproportionate sensory ataxia, weakness, or asymmetry. the exceptions are often caused by inflammatory or immune mechanisms. glucose intolerance and gestational diabetes can signal the start of longstanding blood sugar issues and later diabetic neuropathy. autoimmune or inflammatory conditions in general may change during pregnancy-both acute inflammatory demyelinating polyneuropathy or gbs is an acute or subacute onset of ascending weakness, sensory loss, and areflexia-a nadir by definition occurs within weeks after onset. incidence is about . - cases per , population. patients may progress to severe weakness or paralysis. facial, cranial, and autonomic nerve involvement occur in severe cases that can progress to respiratory insufficiency, autonomic instability, and protracted recovery. there is no evidence that the condition is more common during pregnancy, but many pregnant women develop gbs by coincidence, usually in the second and third trimesters. however, incidence seems to be about three times higher in the days postpartum (chan et al., ) . before the advent of immune treatments, such as intravenous immunoglobulin and plasmapheresis, significant morbidity and mortality occurred in pregnant women with gbs (chan et al., ) . typical infectious triggers such as campylobacter jejuni gastroenteritis occur but may be less common in pregnant women (rees et al., ) . cytomegalovirus (cmv), a known gbs trigger, seems to more problematic. pregnant women have a similar underlying seropositivity to the general population, roughly %; however, mothers with cmv and gbs may have more severe respiratory involvement and worse neonatal outcomes (araki et al., ; lupo et al., ) . some advocate testing all pregnant women with gbs for cmv. zika virus is associated with increased gbs risk (krauer et al., ; muñoz et al., ) . a systematic review of zika-related complications during pregnancy found one report of a pregnant woman with confirmed zika infection who developed gbs at weeks gestation; she recovered and delivered a healthy infant (chibueze et al., ). an association of gbs to the novel coronavirus covid- is suspected but not yet established. standard treatment using either plasmapheresis or intravenous immune globulin (ivig) is generally safe; significant treatment-related complications are rare. both are effective. some prefer to avoid plasmapheresis because of fluid shifts that can trigger hypotension and potentially endanger the fetus. a large italian series reviewed plasmapheresis complications of procedures during pregnancies; treatment indications were various and included some for myasthenia gravis (mg). they found only % had significant adverse events; none required hospitalization or extended ongoing hospitalization (colpo et al., ) . fewer risks and complications are present for ivig during pregnancy but concerns include volume overload, hyperviscosity, and hypercoagulability. termination of pregnancy does not shorten gbs disease duration or improve maternal outcome (chan et al., ) . interestingly, cases that progress to complete paralysis continue to demonstrate normal fetal movements, supporting a lack of placental transmission of the causative factors in most cases. one notable exception reported hypotonia and respiratory distress in a newborn that received successful treatment of both mother and child (luijckx et al., ) . gbs does not significantly affect uterine contractility so that vaginal delivery remains the preferred route. epidural anesthesia is considered to be generally safe in this setting, though one case of acute worsening was reported (brooks et al., ; wiertlewski et al., ) . succinylcholine should be avoided for cesarean section induction (brooks et al., ) . induced preterm delivery is common- % in one large series-mostly because of maternal neurologic decline (chan et al., ) . the need for cesarean section surgery should be based on obstetric indications. prevention of complications from infection and venous thromboembolism is critical, especially in the postpartum period. chronic inflammatory demyelinating neuropathy (cidp) of various subtypes causes proximal and distal weakness, sensory loss, and reduced deep tendon reflexes; most forms are relatively symmetric but an asymmetric form is well known. the syndrome is distinct from gbs but many features overlap. the course may be relapsing or progressive; immune treatments are typically highly effective. onset is most common between and years, but onset also occurs in younger ages, including in childhood and teenage. cidp in pregnancy is uncommon but described. one study reviewed women of childbearing age with cidp; became pregnant. of these , developed cidp during pregnancy, and the disease flared in the other with-the authors concluded that cidp risk increases during pregnancy (mccombe et al., ) . a tendency for symptoms to worsen during the third trimester or during the immediate postpartum period was noted. corticosteroids can be used in cidp but are often not necessary. steroid-sparing therapies such as azathioprine (category d) are generally avoided during pregnancy. plasmapheresis can be used for refractory cases. multifocal motor neuropathy (mmn) is a separate and distinct syndrome that causes chronic and multifocal, typically distal weakness in specific nerve territories. a minority of cases are associated with gm ganglioside igm antibodies. conduction block is demonstrated on electrodiagnostic testing in many. intravenous immunoglobulin is the preferred and fda-approved therapy. exacerbation of existing weakness or new weakness is known to occur during pregnancy despite treatment; findings generally return to baseline after delivery (chaudhry et al., ) . ivig is generally continued during and after pregnancy. corticosteroids and plasmapheresis are contraindicated in this disease. one case of suspected transplacental transfer of pathogenic gm ganglioside antibodies was reported (attarian et al., ) . the mother had mmn and underlying iggl monoclonal gammopathy. the fetus had decreased movement; the infant had distal weakness and hyporeflexia; and weakness and atrophy persisted at age years. hereditary motor and sensory neuropathy also known as cmt is a prevalent condition affecting roughly in individuals. many subtypes and specific genetic forms are known but cmt a, caused by a duplication of the pmp gene is by far most common. that condition causes progressive distal weakness, areflexia, pes cavus, and associated orthopedic issues. onset is generally in the teens or soon afterwards so that the condition is often known prior to pregnancy. penetrance is variable. autosomal dominant inheritance is most common, though x-linked and recessive forms are known. data on pregnancy effects are sparse. in general, cmt patients demonstrate no increased risk of miscarriage, fetal malformations, or hypertensive complications. about % of patients self-report worsened weakness while pregnant that tends to improve in about a third and not improve or worsen in others afterwards (rudnik-sch€ oneborn et al., ; awater et al., ) . women with cmt have a higher occurrence of presentation anomalies and postpartum bleeding (hoff et al., ) . the rate of operative delivery or forceps requirement was - times more frequent than for others. the majority of cmt cesarean sections were emergencies. epidural anesthesia is employed when needed. succinylcholine should be avoided if intubation is needed because of concerns that it may induce hyperkalemia. most other forms of hereditary neuropathy are too rare or severe to have sufficient pregnancy data. myasthenia gravis (mg) the autoimmune condition mg causes fluctuating and fatigable muscular weakness-bulbar muscles are particularly vulnerable. ptosis, diplopia, dysarthria, and dysphagia are common manifestations. ocular myasthenia is the term used for isolated ptosis and diplopia but without any other impairment. more severe cases demonstrate muscle weakness, notably proximal. myasthenic crisis is characterized by severe weakness, severe dysphagia, aspiration, and respiratory insufficiency that requires urgent or emergent intervention. the majority of cases, up to %, demonstrate antibodies to the alpha subunit of the nicotinic acetylcholine receptor (binding antibodies). additional cases are associated with muscle-specific kinase (musk), agrin, or lipoprotein receptor-related igg (lrp ) antibodies. the remainder of cases supported by clinical and electrodiagnostic features are seronegative, roughly %. the overall incidence estimates range from about to per , (macdonald et al., ) ; an estimated excess of , people worldwide are affected (sanders et al., ) . a bimodal age distribution is well documented but is, overall, more common in women. women of childbearing age constitute one large spike peaking in the second and third decades; older men make up the other group, who more often have an underlying thymoma. as a result, pregnancy and mg are a relatively common cooccurrence. congenital myasthenic syndromes are rare genetic defects affecting components of the neuromuscular junction, nerve terminal, or muscle. these conditions are quite rare and distinct from autoimmune mg. transient neonatal mg is a relevant topic discussed later. pregnancy-induced disease severity alterations and treatment adjustments are important clinical considerations; a multidisciplinary medical approach that includes an obstetrician and neurologist is best (norwood et al., % of mildly affected patients became relatively severe. about % paradoxically improved, and the remainder did not change. exacerbations tended to be early or late in the course, though one review found the second trimester most critical (ducci et al., ) ; alterations within months postpartum were also noted. in the same review, transient neonatal mg occurred in . % of live-born infants-no predictors were found. mg associated with musk antibodies demonstrates some clinical and treatment differences. the entity represents about %- % of mg cases overall. african americans and women overrepresent with musk, compared to other mg forms. onset in women tends to be slightly later than achr seropositive patients, peaking in the s but still overlapping with childbearing age. patients tend to demonstrate more proximal limb, bulbar, and ocular weakness but typically do not have purely ocular disease; tongue atrophy, muscle cramping, and twitching can occur. respiratory involvement and disease crises are a risk. one portuguese series retrospectively examined the pregnancy course in musk positive women, of which had more than one pregnancy ( total pregnancies studied) (santos et al., ) . all were on steroids at the time of conception, one on azathioprine and another on ivig maintenance infusions. only mild pregnancyinduced changes were noted, but some required medication titration. no changes were considered to be relapses. mg onset during pregnancy is also well described. seropositive patients with typical symptoms and signs are straightforward to diagnose, but treatment options are narrowed. seronegative patients may require additional testing such as repetitive nerve stimulation or single fiber electromyography to confirm the diagnosis, in part to consider treatment and to guide delivery management. to assess for thymoma, an increased risk in mg patients, a chest ct is typically the care standard. during pregnancy, a chest mri may be indicated depending on the pregnancy stage; if late in pregnancy, the study is often deferred until after delivery. the treatment of mg is more complex than other neuromuscular disorders, in part because so many effective therapeutic options are available. family planning in known mg patients should be proactive so that treatments can be optimized or tapered prior to conception. counseling in advance is prudent, including the risks for individual ongoing and potential therapies. thyroid status should be addressed and optimized prior to pregnancy. some options are strictly contraindicated, but many have limited available medical evidence for pregnancy risks. pyridostigmine (mestinon) is an initial and effective treatment for all mg stages. it has been used for decades. because of pregnancy-induced changes in intestinal absorption and renal clearance, the pyridostigmine dose may need titration. no fetal risk is known despite longstanding use in pregnancy. prednisone or prednisolone is typically continued during pregnancy. corticosteroid risks are discussed earlier, but an optimized dose prior to pregnancy is prudent. some early studies suggested steroids increased cleft palate risk, but later case-controlled studies did not replicate the findings. treatment can also suppress normal adrenal output so that stress steroids may be needed during labor and delivery to avoid acute adrenal insufficiency. in general, initiating a new steroid-sparing agent is avoided, if possible, by most practitioners. azathioprine (imuran) is the most common steroid-sparing agent. the agent, previously rated category d by the us fda, is generally avoided in the united states primarily because of teratogenic effects in laboratory animals and reported hematologic effects in some newborns. because of this concern, use during pregnancy is rare in the united states. however, azathioprine remains a recommended option in europe (norwood et al., ) , mostly based on experience treating various rheumatologic conditions (ostensen et al., ) and using similar agents such as -mercaptopurine to treat inflammatory bowel disease (francella et al., ) . no detectable drug was found in neonates of breastfeeding mothers who had been treated (sau et al., ) . because of some ongoing use during pregnancy, this drug and others discussed are part of a national transplantation pregnancy registry to track effects. a recent meta-analysis including a large cohort of contributors concluded that available human studies are lacking to answer the question of azathioprine exposure risk during pregnancy (belizna et al., ) . mycophenolate mofetil (cellcept) was initially classified as category c but was downgraded to category d in prior to elimination from the fda rating system in ; birth defects and serious teratogenic concerns during pregnancy were recognized. a typical clinical syndrome includes hypoplastic nails, shortened fifth fingers, diaphragmatic hernia, microtia, micrognathia, cleft lip and palate, and congenital heart defects-quoted risk is as high as % (sifontis et al., ; ostensen et al., ; norwood et al., ; perez-aytes et al., ) . in general, treatment is tapered off prior to pregnancy. calcineurin inhibitors such as cyclosporin or tacrolimus are occasionally used to treat mg and show no known teratogenic effects, but there is some concern for spontaneous abortions, prematurity, and low birth weight; the agent may also aggravate gestational diabetes. methotrexate is strictly contraindicated during pregnancy (former category x). thymectomy is demonstrated to benefit mg course, reduce steroid dosage, and increase remission likelihood; the benefit persists for multiple years (wolfe et al., , . thymectomy during pregnancy is rarely indicated unless a benign or malignant thymoma is discovered. because of the long-term potential benefit, surgery prior to a planned pregnancy is a consideration in generalized seropositive mg patients. mg crisis or inadequate steroid control may require rescue or more aggressive treatment. for mg crisis both plasmapheresis and ivig are indicated. the risks for each were reviewed earlier with reference to gbs treatment. clinical use for maintenance therapy with ivig has steadily increased, but mg is not an indication recognized by the us fda, so that use is technically off-label. rituximab (rituxan) is an option in refractory seropositive mg, especially for musk positive cases. treatment is generally considered to be safe despite some animal toxicity concerns. the newest and most expensive treatment option is the humanized anti-c antibody, eculizumab (soliris). treatment is reserved for refractory seropositive mg patients that are uncontrolled despite all other options, including ivig and plasmapheresis. pregnancy risk information is limited. however, usage is currently generally regarded to be safe (sarno et al., ) . experience from use in various hematologic conditions is available, mostly hemolytic uremic syndrome. vaccination for meningococcal meningitis is required prior to treatment. some differences are evident in musk mg patients. pyridostigmine is less often helpful. the course tends to be less responsive to ivig, but that treatment is still used. patients often respond to plasmapheresis. musk positive patients were specifically excluded from thymectomy trials. in addition, a lack of benefit is generally accepted, so surgery is not indicated for these patients. agrin and lpr seropositive patients seem to respond to treatment similar to achr positive patients. ongoing prenatal care, including fetal monitoring is expected. spontaneous delivery at term is the goal, provided there is no deterioration in the mother's myasthenic control (norwood et al., ) . of all potential labor and delivery difficulties, only premature membrane rupture is more common. infection-induced disease flares are a concern, notably urinary tract infections, especially in women on immune suppression. infections should be treated; however, aminoglycosides, fluoroquinolones, and macrolides can aggravate the condition. for delivery, conventional epidural or spinal is accepted and preferable to general anesthesia, including women that need cesarean section (c-section). opiates should be avoided because of potential respiratory depression in mother or fetus. calcium channel blockers and b-blockers are also generally avoided. stress steroids for women on ongoing steroid therapy were previously discussed. mg affects skeletal muscle and not smooth muscle uterine contractions, so that impairment in early labor stages is not expected. mothers can fatigue in later stages so that assisted delivery may be needed. in one study c-sections were more common in mg patients, but assisted vacuum or forceps deliveries were no more common (hoff et al., ) ; another taiwanese study found no difference in c-section rates between mg patients and others (wen et al., ). magnesium sulfate is generally avoided for eclampsia prevention because of potential interference with calcium influx in the nerve terminal and aggravating acetylcholine release. one case of severe magnesium-induced muscular weakness in a previously minimally affected patient was reported (bashuk and krendel, ) . if eclampsia-induced seizures develop, magnesium sulfate can be given with extreme caution but intubation is expected. appropriate anticonvulsants can be used instead. if a c-section is required, general anesthesia presents potential concerns. typical intubation utilizes a muscle relaxer, such as succinylcholine. mg patients are particularly sensitive to these agents; so they should be used at low dose or not at all. if needed, a peripheral nerve stimulator must be used to monitor the effect. other agents to initiate or maintain anesthesia, such as propofol and volatile anesthetics, are used. despite these delivery concerns, there is no evidence of increased rates of premature birth, reduced birth weight, congenital malformations, or infant mortality (hoff et al., ; wen et al., ; guidon and massey, ) . breast feeding is not contraindicated, including for women on active immune therapies. transmission of antibodies to newborns is well recognized; this can transiently complicate functions. hypotonia, dysphagia, and respiratory difficulties are most concerning-other findings include ptosis, eye muscle weakness, and other bulbar weaknesses. the incidence of transient neonatal mg ranges from % to %, depending on the series, though most infants demonstrate transient antibodies in seropositive mothers. because the mother's mg disease severity seems to bear no predictive value for this entity, neonatologists must screen newborns carefully. in some cases, transplacental passage of antibodies occurs, resulting in reduced fetal movement and postnatal weakness. there are some exceptional cases of antibodies to the fetal achr g subunit that can result in severe or sometimes fatal fetal arthrogryposis (vincent et al., ; oskoui et al., (lee et al., ) . she delivered a normal infant who quickly developed hypotonia and respiratory failure requiring mechanical ventilation for weeks. the mother later worsened, and musk antibodies were uncovered on further evaluation. anti-musk-mediated transient neonatal mg was presumed. this form appears to be less common but more severe (niks et al., ) . autoimmune lambert-eaton myasthenic syndrome (lems), not from a lung cancer associated paraneoplastic syndrome, can occur in women of childbearing age. three notable cases have been reported. one patient had an uncomplicated, successful delivery; another had a child with a week of severe neonatal weakness and infant voltage gated calcium channel antibody seropositivity reuner et al., ) . another previously asymptomatic woman developed third trimester weakness that led to a new lems diagnosis (bayrak et al., ) . the only fda-approved therapy amifampridine (firdapse), previously known as , -diaminopyridine, is highly effective and, often, transformative for affected patients. the drug is associated with fetal animal toxicity but no documented human pregnancy-related concerns. autoimmune forms of myositis are uncommon, representing about . - cases per , population (munira and christopher-stine, ) . the most common forms, polymyositis and dermatomyositis cause symmetric proximal limb weakness, variably increased creatine kinase, and sometimes dysphagia, head drop, or respiratory compromise. the pathophysiology differs between the two. polymyositis is almost always a component of a generalized rheumatologic or systemic condition, such as mixed connective tissue disease, systemic lupus erythematosus, or rheumatoid arthritis; some have antisynthetase syndrome. dermatomyositis is distinct and manifests as variably impacted muscular and characteristic skin manifestations. muscle pathology shows differing and distinctive features. both occur during childbearing ages. in general polymyositis tends to have more severe weakness, but most pregnancy-related literature lumps the two conditions. sporadic inclusion body myositis is often classified in this group but is not a simple autoimmune condition and almost always occurs after age ; so that entity will not be discussed further. necrotizing myositis is a more aggressive and severe form that requires aggressive immune treatment. fortunately, the combination of necrotizing myositis and pregnancy is rare. pregnancy does not appear to affect disease activity for the mother. however, disease activity and general health of the mother greatly impacts fetal risk. patients with controlled disease or remission have low risk of complications and generally good outcomes for both mother and child. in contrast, active disease is associated with increased fetal mortality, low birth weight, and prematurity (silva et al., ; váncsa et al., ; nagy-vincze et al., ; zhong et al., ; che et al., ) . a large and recent retrospective series from india reviewed pregnancies resulting in only live births, though some were voluntarily terminated (gupta et al., ) . mothers also have longer hospital stays, more hypertensive complications, and higher c-section rates but no other labor or delivery complications (kolstad et al., ) . neither condition is transmitted to the newborn but interestingly, two asymptomatic newborns were noted to have elevated creatine kinase levels for a few months (messina et al., ) . initial disease onset during pregnancy is rare, but that group may have the highest infant mortality, nearing % (silva et al., ; munira and christopher-stine, ) . similar to mg patients, uterine smooth muscle is unaffected but voluntary muscles necessary for labor can fatigue, requiring c-section in some cases. transient spikes in creatine kinase can indicate muscle breakdown after excessive muscular activity. treatment considerations during pregnancy are similar to mg. corticosteroids are the mainstay of treatment. ivig can be used in refractory patients (williams et al., ; nozaki et al., ; linardaki et al., ) . other usual immune therapies or steroid-sparing agents are highly problematic and discussed earlier, such as azathioprine (category d), methotrexate (category x), mycophenolate (category d), and cyclophosphamide (category d). in refractory cases, severe disease may require aggressive treatment. one was a case of a -year-old woman with myositis associated with antisignal recognition particle antibody. she was in remission on a combination of oral prednisolone and rituximab every months that was stopped prior to a planned pregnancy. treatment was restarted at weeks gestation without complication, despite concerns for rituximab treatment later in pregnancy increasing the risk of neonatal b-cell depletion and cytopenia (mehta et al., ) . similar to other autoimmune diseases, patients on prednisone at the time of delivery should be treated with stress steroids to prevent acute adrenal insufficiency (briemberg, ) . hereditary and genetic entities represent a higher percentage of muscle disorders than most other areas of neurology. a variety of types of conditions that impact pregnancy are considered in this chapter. there are too many individual conditions to address all, but some groups are detailed. dystrophinopathies caused by multiple different mutations or deletions in the dystrophin gene are the most common form of muscular dystrophy. both duchenne and becker muscular dystrophy are x-linked disorders that overwhelmingly affect males. however, female carriers can manifest symptoms and signs (ishizaki et al., ) . information on pregnancy and delivery of these symptomatic patients, however, is very limited. myotonic muscular dystrophy is the second most common muscular dystrophy and most common starting in adulthood. prevalence is - per , (guidon and massey, ) . myotonic dystrophy type i (dm ) is a multisystem disease caused by an excess of ctg repeats in the dystrophia myotonica protein kinase (dmpk) gene. the number of repeats correlates with disease severity and onset age. typical symptoms include muscle weakness, cramps and stiffness (myotonia), cardiac conduction delay, endocrine dysfunction, and early cataracts. of note, mothers with this condition often have children with more severe disease and expanded repeats that can present in infancy (anticipation). in that instance, the term congenital myotonic dystrophy is employedthe risk for affected mothers is approximately one-third (rudnik-sch€ oneborn and zerres, ; johnson et al., ) . congenital dm is quite severe and includes respiratory insufficiency, hypotonia, generalized weakness, poor feeding, and mental retardation. only % live to months, and % reach adulthood. congenital arthrogryposis can occur because of severe prenatal weakness. one study of women found % were unaware of the diagnosis prior to discovery of the affected infant, and fewer were aware of their diagnosis prior to pregnancy (rudnik-sch€ oneborn and zerres, ). obstetric complications of various types were increased. a registry-based review of pregnancies of women with dm found a % miscarriage rate and various delivery complications, including preterm labor ( %), preeclampsia ( %), and peripartum hemorrhage ( %) (johnson et al., ) . polyhydramnios due to reduced fetal swallowing is a prime cause attributed to the premature labor and delivery. many women reported disease progression that did not return to the prior baseline during pregnancy. despite the overt clinical myotonia, that phenomenon often needs no specific treatment. in contrast to other discussed muscular conditions, smooth muscle including uterine contractions are affected, so that assisted delivery may be needed and hemorrhage risks increased (sax and rosenbaum, ) . the tocolytic ritodrine used to arrest labor is reported to cause rhabdomyolysis, but that agent is no longer available in the united states but is used in japan (ogoyama et al., ) . depolarizing muscle relaxants are avoided because of the risk of triggering severe and dangerous myotonic spasms. spinal block and epidural anesthesia have been successfully used; general anesthesia should be avoided if possible (hopkins et al., ) . despite these concerns a series of dm patients that underwent general anesthesia for other surgeries found no instances of malignant hyperthermia (mh) or problematic spasms (mathieu et al., ) . however, case reports of both complications are known (edmundson and guidon, ) . myotonic dystrophy type (dm ), previously known as proximal myotonic myopathy (promm), is an autosomal dominant multisystem disorder whose clinical manifestations resemble dm but often starts at later ages. proximal weakness, early cataracts, and myotonia are present but as lesser systemic features. a different repeat sequence (cctg) of the zinc finger protein (znf ) gene is causative. anticipation is not prominent. a congenital form is not described. retrospective data from pregnancies in women with dm found that previously pregnant women had symptom onset at an earlier age than the general population of men and other women (rudnik-sch€ oneborn et al., ) . of pregnancies, % ended early and % as late miscarriages. roughly % had initial symptoms during pregnancy and symptomatically worsened in later pregnancies. although not muscular dystrophies, there are several hereditary conditions that have prominent myotonia and some similar delivery recommendations. autosomal dominant (thomsen disease) and autosomal recessive (becker disease) are forms of myotonia congenita caused by mutations in a muscle chloride channel (clcn ). both have prominent and symptomatic myotonia and abundant myotonic discharges on electromyography. mild weakness may be present more commonly in the more severe and recessive becker disease. paramyotonia congenita is another related condition characterized by either paralysis spells or myotonia, most commonly caused by a sodium channel defect (scn a). labor and delivery concerns are much less than for myotonic dystrophy (lacomis et al., ) . myotonic symptoms l.h. weimer can worsen during pregnancy (gorthi et al., ) . cold is a prominent myotonia trigger; one case of cold inducing a spontaneous abortion was reported in a mother with paramyotonia congenita (chitayat et al., ) . similar precautions as for myotonic dystrophy are important for medications and anesthesia concerns. mexiletine, a common medication used to treat symptomatic myotonia, may be stopped during pregnancy if possible. the third most common muscular dystrophy is the autosomal dominant condition, facioscapulohumeral muscular dystrophy (fshd). prevalence is approximately - per , ; however, many patients are minimally symptomatic or asymptomatic. unlike many hereditary conditions, weakness is often asymmetric or selective. facial, shoulder girdle, and proximal arm and foot dorsiflexion weakness are common. weak abdominal muscles can impact labor. contraction of d z repeats in the double homeobox protein (dux ) on chromosome is causative and represents % of cases. a second form accounting for the remainder of cases is linked to a similar process on chromosome (type fshd). males are more symptomatic; so some women of childbearing age are unaware of their diagnosis. a survey of women with fshd reported pregnancies and live births (ciafaloni et al., ) . only about half knew their diagnosis prior to pregnancy. records found that outcomes were generally favorable, but birth weight was lower, instrument delivery rates higher, and c-section rates higher than the general population. one quarter noted increased weakness during pregnancy that did not resolve postpartum. miscarriage, preterm labor, and adverse neonatal outcome rates were not increased. another series included fshd patients; reported symptom aggravation that resolved after delivery (rudnik-sch€ oneborn et al., ) . rapid prenatal diagnosis of d z repeat numbers was reported (zheng et al., ) . a multitude of additional inherited muscular diseases are known resulting from mutations of several dozen different genes. in general, muscular dystrophy is used for progressive conditions. congenital myopathy is employed for conditions that have distinctive neuropathology and static or very slowly progressive weakness. most have proximal arm and leg weakness but few other distinctive features. autosomal recessive forms are most common (lgmd type ). type lgmd is autosomal dominant and often associated with allelic disorders. one series included lgmd patients and live births (rudnik-sch€ oneborn et al., ) . no miscarriages or preterm births were noted. five had prolonged labor that required assisted vaginal delivery or c-section. all infants were normal except one that had a likely unrelated neural tube defect. over half noted increased weakness during pregnancy that did not recover but many attributed that change to expected disease progression. the majority needed more family assistance for child care but retained a positive attitude for the pregnancy. the same series included women and pregnancies in patients with congenital myopathy of various forms. the small numbers make conclusions problematic, but findings were similar to the lgmd patients (rudnik-sch€ oneborn et al., ) . additionally, some forms of congenital myopathies, such as multiminicore myopathy and central core disease, have an increased risk of anesthesia-induced mh. during delivery, halogenated inhaled anesthetics and succinylcholine must be avoided, and monitoring must be more detailed. dantrolene can be used to treat mh associated with c-section. if the diagnosis is known, additional information about individual genetic conditions or even the specific mutation should be sought prior to delivery. additional conditions related to lipid, carbohydrate, or mitochondrial metabolism can produce specific muscle disorders. either fixed or exercise-induced weakness depends on the disorder. fixed or exercise-induced weakness can occur depending on the specific disorder. myophosphorylase deficiency (mcardle disease) characterized by autosomal recessive inherited bouts of myoglobinuria, is one of the most common conditions. two case reports noted no specific pregnancy or delivery issues other than one exercise-induced bout of myoglobinuria during the first trimester; both deliveries were successful (cochrane and alderman, ; giles and maher, ) . acid maltase disease (pompe disease) is caused by a-glucosidase deficiency; enzyme replacement therapy is well established for this disease. fixed weakness starting at variable ages, ranging from early childhood to the old age, is characteristic. there are a growing number of reports detailing successful pregnancies during ongoing enzyme replacement (kłos et al., ; santos et al., ; van houtte and de bleecker, ) . no specific complications were noted. treatment was interrupted during the first trimester in one case because of organogenesis toxicity concerns, but the mother's weakness progressed and treatment resumed (zagnoli et al., ) . a european consensus panel recommended that treatment should be continued during pregnancy (van der ploeg et al., ). mitochondrial encephalomyopathies are relatively rare, but some published experience during pregnancy in some syndromes is available. multiple syndromes are known and caused by various underlying genetic defects, including mitochondrial genome mutations or deletions or somatic mutations-overall prevalence is about in . mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (melas) is a discrete but rare multisystem disorder caused by various mitochondrial gene mutations. onset of myopathy and neuropathy symptoms during pregnancy led to the initial diagnosis in one case (yanagawa et al., ) . severe worsening in one case included severe pulmonary edema, intensive care needs, and fetal demise at weeks (sánchez and romero, ) . a european survey of women with the most common m. a > g melas mutation reported on pregnancies (de laat et al., ) . results listed % preterm delivery ( % prior to weeks), % preeclampsia, and % gestational diabetes. deficiency of cytochrome oxidase can cause myopathy and weakness; severely reduced maternal strength to the point of immobility was noted in one patient. despite this risk others advocate to attempt vaginal delivery (blake and shaw, ; soccio et al., ) . a survey of women with various mitochondrial disorders included women who were pregnant at least once ( pregnancies and live births) (karaa et al., ) . one-third had myopathy. overall, some increases in common obstetric complications occurred as expected but there was no notable worsening of fetal outcomes, other than various congenital anomalies. several forms of channelopathies causing intermittent bouts of paralysis are known. hypokalemic periodic paralysis bouts can be severe-triggers include carbohydrate load, glucose and insulin infusion, cold, stress, b-agonists, and potassium-lowering medications. a calcium channel mutation is most common. specific reports noted attacks during pregnancy triggered by betamethasone, new onset grave disease, glucose tolerance testing, and excessive caffeine (damallie et al., ; appel and myles, ; donovan et al., ; teagarden and picardo, ) . of note, the patient with new onset thyrotoxic form of the disease responded well to thyroid treatment. asians are highly overrepresented in this subtype including the case described (donovan et al., ) . spinal muscular atrophy (sma) sma is the most common fatal autosomal recessive disorder and results in severe progressive weakness. subtypes - are based on onset age and motor milestones. weakness onset ranges from prenatal to adulthood. prevalence is approximately - per , persons and incidence is around in , live births. the condition is caused by a mutation in the survival motor neuron (smn ) gene; copy numbers of the smn gene affect the phenotype severity. two current fda-approved treatments altered the expectations of future prognosis of this condition; additional agents are in the pipeline. nusinersen (spinraza) is an intrathecal infusion approved for all ages but is mostly given to infants and children; onasemnogene abeparvovec-xioi (zolgensma) is a single dose adenovirus vector gene therapy approved for patients under years. the expectation is that the most severe type i patients that previously expired prior to child bearing ages will have a much better prognosis. there is current limited information on pregnancy mainly for later onset types ii and iii that will hopefully change as children currently treated reach adulthood. a number of successful pregnancy reports have been published (carter et al., ; pugh et al., ; yim et al., ) . a recent literature review found that the incidence of maternal and fetal complications was not higher than the general population, but not surprisingly, premature labor and c-section rates were higher (abati and corti, ) . similar to conditions already discussed, regional anesthesia is preferred, and depolarizing muscle blockers avoided. weakness exacerbation was reported in a notable percentage of women. respiratory muscle weakness can hamper delivery and anesthesia management; spinal deformities and surgical hardware can complicate epidural or spinal anesthesia and respiratory management during c-section (carter et al., ) . als is typically a late-onset sporadic progressive fatal disorder-mean age of onset is years. about %- % are inherited conditions that start at younger ages. however, onset during pregnancy occurs (chiò et al., ; lunetta et al., ) . successful pregnancies are also reported (chiò et al., ; sarafov et al., ; kawamichi et al., ; pathiraja and ranaraja, ). an italian group reviewed all registered als patients of childbearing age and found examples of disease onset during or soon after five pregnancies (lunetta et al., ) . two had genetic forms, namely, superoxide dismutase one mutations. the authors noted a vascular endothelial growth factor promoter genotype that they theorize might impair oxidative stress mechanisms and promote als onset. the original fda-approved treatment is riluzole; several reports note no recognized negative fetal effects (kawamichi et al., ) . the most recently approved infusion, edaravone (radicava) is l.h. weimer associated with some adverse animal effects. both vaginal and c-section deliveries are reported, mainly based on the degree of impairment, especially muscular weakness and respiratory capacity. delivery and anesthesia concerns are similar to other discussed conditions. autonomic neuropathy, orthostatic intolerance, and postural orthostatic tachycardia syndrome (pots) pregnancy affects autonomic responses in multiple ways. various studies have documented various differences, which are further altered by preeclampsia (chaswal et al., ; da corrêa et al., ; garg et al., ) . autonomic neuropathy is uncommon but can occur in young women. significant autonomic neuropathy can create challenges, such as vomiting from gastroparesisdiabetes is the most common cause (macleod et al., ) . much more common is general dysautonomia, often termed orthostatic intolerance or pots. about . - million cases in the united states, predominantly affecting women, are estimated (garland et al., ) . common symptoms include orthostatic lightheadedness and tachycardia, syncope or presyncope, gastrointestinal disturbance, cognitive dysfunction, nausea, exercise or heat intolerance, and fatigue. symptoms can be disabling. onset can occur after an acute infection or other monophasic event or progress gradually; a minority of patients have signs of mild but painful small fiber neuropathy, suggesting underlying sensory and autonomic neuropathy following a viral syndrome. the condition must be distinguished from chronic fatigue syndrome, anxiety disorders, simple deconditioning, and cardiac-induced tachycardia. a variety of risk factors are known but most common are various forms of ehlers danlos syndrome. that condition can create additional pregnancy and delivery challenges, predominantly from joint hyperextensibility concerns (karthikeyan and venkat-raman, ) . contrary to many of the neuromuscular conditions already discussed, these patients often paradoxically improve during pregnancy, most commonly in the second trimester. however, given the heterogeneous nature of this syndrome, no consistent or reliable patterns are present. a review of available reports of pregnancy publications, mostly case reports, highlighted this variability (morgan et al., ) . volume expansion and weight gain during pregnancy can help and reduce the need for supplemental fluids and salt loading. even significant neurogenic orthostatic hypotension from diabetic autonomic neuropathy can improve in this setting (scott et al., ) . weaning helpful medications, such as fludrocortisone, midodrine, pyridostigmine, b-blockers, and others prior to pregnancy can be problematic in some patients. most are category c, but no examples of deleterious fetal medication events in this population are published. special considerations during delivery can include excess responses to epinephrine and stimulants and inappropriate tachycardia. some patients improve postpartum, but most return to baseline symptoms after delivery. pregnancy outcomes in women with spinal muscular atrophy: a review femoral mononeuropathy induced by the lithotomy position: a report of cases with a review of literature caffeine-induced hypokalemic paralysis in pregnancy two cases of guillain-barr e syndrome in late pregnancy neonatal lower motor neuron syndrome associated with maternal neuropathy with anti-gm igg pregnancy course and outcome in women with hereditary neuromuscular disorders: comparison of obstetric risks in patients common peroneal neuropathy secondary to squatting during childbirth myasthenia gravis presenting as weakness after magnesium administration course and treatment of myasthenia gravis during pregnancy manifestation of lambert-eaton myasthenic syndrome during last trimester of pregnancy in utero exposure to azathioprine in autoimmune disease. where do we stand? mitochondrial myopathy in a primigravid pregnancy myasthenia gravis in pregnancy: experience of a portuguese center neuromuscular diseases in pregnancy pregnancy, anaesthesia and guillain barr e syndrome successful pregnancies in the presence of spinal muscular atrophy: two case reports guillain-barr e syndrome in pregnancy heart rate variability and cardiovascular reflex tests for assessment of autonomic functions in preeclampsia worsening of multifocal motor neuropathy during pregnancy pregnancy outcomes in women with idiopathic inflammatory myopathy, before and after diagnosis-a population-based study zika virus infection in pregnancy: a systematic review of disease course and complications amyotrophic lateral sclerosis associated with pregnancy: report of four new cases and review of the literature cold-induced abortion in paramyotonia congenita pregnancy does not increase the risk of bell's palsy: a national cohort study pregnancy and birth outcomes in women with facioscapulohumeral muscular dystrophy normal pregnancy and successful delivery in myophosphorylase deficiency (mcardle's disease) therapeutic apheresis during pregnancy: a single center experience fetal acetylcholine receptor inactivation syndrome and maternal myasthenia gravis: a case report cardiovascular autonomic modulation and baroreflex control in the second trimester of pregnancy: a cross sectional study hypokalemic periodic paralysis in pregnancy after -hour glucose screen obstetric complications in carriers of the m. a> g mutation, a retrospective cohort study on maternal and fetal outcome myasthenia gravis in pregnancy: report on cases thyrotoxic periodic paralysis in pregnancy with impaired glucose tolerance: a case report and discussion of management issues clinical follow-up of pregnancy in myasthenia gravis patients neuromuscular disorders in pregnancy carpal tunnel syndrome in pregnancy. a prospective study idiopathic facial palsy in pregnancy and the puerperium the safety of -mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study sequential analysis of heart rate variability, blood pressure variability and baroreflex sensitivity in healthy pregnancy postural tachycardia syndrome: beyond orthostatic intolerance lumbar disk disease in pregnancy myophosphorylase deficiency (mcardle disease) in a patient with normal pregnancy and normal pregnancy outcome bell's palsy in pregnancy: a study of recovery outcomes management of pregnancy with thomsen's disease evidence-based guideline update: steroids and antivirals for bell palsy: report of the guideline development subcommittee of the american academy of neurology neuromuscular disorders in pregnancy outcomes of pregnancy in women with inflammatory myositis: a retrospective cohort from india idiopathic facial paralysis, pregnancy, and the menstrual cycle myasthenia gravis: consequences for pregnancy, delivery, and the newborn pregnancies and deliveries in patients with charcot-marie-tooth disease neurologic disease with pregnancy and considerations for the obstetric anesthesiologist compressive radial neuropathy by a synovial cyst during pregnancy: a clinical case report. medicine (baltimore) : e female dystrophinopathy: review of current literature the impact of pregnancy on myotonic dystrophy: a registry-based study effects of mitochondrial disease/dysfunction on pregnancy: a retrospective study hypermobile ehlers-danlos syndrome and pregnancy riluzole use during pregnancy in a patient with amyotrophic lateral sclerosis: a case report alglucosidase alfa therapy for pompe disease in pregnancy-case report pregnancy outcomes in adult patients with dermatomyositis and polymyositis zika virus infection as a cause of congenital brain abnormalities and guillain-barr e syndrome: systematic review pregnancy and the herniated lumbar disc fluctuating clinical myotonia and weakness from thomsen's disease occurring only during pregnancies postpartum neuralgic amyotrophy transient neonatal myasthenia gravis due to a mother with ocular onset of anti-muscle specific kinase myasthenia gravis intravenous immunoglobulin treatment for pregnancy-associated dermatomyositis guillain-barr e syndrome in mother and newborn child amyotrophic lateral sclerosis in pregnancy is associated with a vascular endothelial growth factor promoter genotype guillain-barr e syndrome and cytomegalovirus infection during pregnancy the incidence and lifetime prevalence of neurological disorders in a prospective community-based study in the uk the problem of autonomic neuropathy in diabetic pregnancy peripheral neuropathies in pregnancy anesthetic and surgical complications in cases of myotonic dystrophy chronic inflammatory demyelinating polyradiculoneuropathy associated with pregnancy difficult case: rituximab in anti-srp antibody myositis in pregnancy women with pregnancy-related polymyositis and high serum ck levels in the newborn epidemiology of bell's palsy in an italian health district: incidence and case-control study postural orthostatic tachycardia syndrome during pregnancy: a systematic review of the literature pregnancy in myositis and scleroderma pregnancy outcome in idiopathic inflammatory myopathy patients in a multicenter study neurosurgery and pregnancy a transient neonatal myasthenic syndrome with anti-musk antibodies myasthenia in pregnancy: best practice guidelines from a u.k. multispecialty working group respiratory muscle weakness with dermatomyositis during pregnancy: successful treatment with intravenous immunoglobulin therapy ritodrine-induced rhabdomyolysis, infantile myotonic dystrophy, and maternal myotonic dystrophy unveiled fetal acetylcholine receptor inactivation syndrome and maternal myasthenia gravis pregnancy and reproduction in autoimmune rheumatic diseases prevalence of back pain in pregnancy symptoms and neurophysiological picture of carpal tunnel syndrome in pregnancy carpal tunnel syndrome in pregnancy: multiperspective follow-up of untreated cases patient-oriented assessment of back pain in pregnancy use of acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy and the risk of birth defects a successful pregnancy with amyotrophic lateral sclerosis multicenter study on carpal tunnel syndrome and pregnancy incidence and natural course mycophenolate mofetil embryopathy: a newly recognized teratogenic syndrome onset of bell's palsy in late pregnancy and early puerperium is associated with worse long-term outcomes intercostal neuralgia of pregnancy successful pregnancy and spinal muscular atrophy campylobacter jejuni infection and guillain-barr e syndrome transient neonatal lambert-eaton syndrome bilateral radial nerve palsies from use of the standard birthing bar postpartum femoral neuropathy: managing the next pregnancy outcome in pregnancies complicated by myotonic dystrophy: a study of patients and review of the literature pregnancy and delivery in charcot-marie-tooth disease type obstetric aspects in women with facioscapulohumeral muscular dystrophy, limb-girdle muscular dystrophy, and congenital myopathies outcome and effect of pregnancy in myotonic dystrophy type acute pulmonary edema secondary to pregnancy in a patient with the mitochondrial disease melas international consensus guidance for management of myasthenia gravis: executive summary musk myasthenia gravis and pregnancy two consecutive pregnancies in early and late stage of amyotrophic lateral sclerosis eculizumab in pregnancy: a narrative overview azathioprine and breastfeeding: is it safe? neuromuscular disorders in pregnancy pregnancy and delivery of a healthy baby in autoimmune lambert-eaton myasthenic syndrome improvement of postural hypotension and severe diabetic autonomic neuropathy during pregnancy association between bell's palsy in pregnancy and pre-eclampsia pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus pregnancy outcome in adult-onset idiopathic inflammatory myopathy thoraconeuralgia gravidarum pregnancy with cytochrome oxidase-deficient mitochondrial myopathy betamethasone-induced hypokalemic periodic paralysis in pregnancy the management of carpal tunnel syndrome in pregnancy european consensus for starting and stopping enzyme replacement therapy in adult patients with pompe disease: a -year experience two successfully completed pregnancies in adult onset pompe disease, under continued treatment with alglucosidase alfa pregnancy outcome in idiopathic inflammatory myopathy arthrogryposis multiplex congenita with maternal autoantibodies specific for a fetal antigen carpal tunnel syndrome in pregnancy and lactation serial studies of carpal tunnel syndrome during and after pregnancy no increased risk of adverse pregnancy outcomes for women with myasthenia gravis: a nationwide population-based study worsening of neurologic symptoms after epidural anesthesia for labor in a guillain-barr e patient successful treatment of dermatomyositis during pregnancy with intravenous immunoglobulin monotherapy randomized trial of thymectomy in myasthenia gravis long-term effect of thymectomy plus prednisone versus prednisone alone in patients with non-thymomatous myasthenia gravis: -year extension of the mgtx randomised trial incidence of postpartum lumbosacral spine and lower extremity nerve injuries mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes with deterioration during pregnancy successful pregnancy in a patient with spinal muscular atrophy and severe kyphoscoliosis pregnancy during enzyme replacement therapy for late-onset acid maltase deficiency rapid prenatal diagnosis of facioscapulohumeral muscular dystrophy by combined bionano optical mapping and karyomapping pregnancy in polymyositis or dermatomyositis: retrospective results from a tertiary centre in china key: cord- -ddulfe authors: ismael, julia; losco, federico; quildrian, sergio; sanchez, pablo; pincemin, isabel; lastiri, jose; bella, santiago; chinellato, alejandro; dellamea, guillermo; ahualli, alejandro; rompato, silvana; velez, julio; escobar, rafael; zwenger, ariel; rosales, cristina; bagnes, claudia; puyol, jorge; niewiadomski, dario; smecuol, edgardo; nachman, fabio; gonzalez, eduardo; ferraris, gustavo; suppicich, juan ramos; price, paola; medina, luis; o’connor, juan title: multidisciplinary approach to covid- and cancer: consensus from scientific societies in argentina date: - - journal: ecancermedicalscience doi: . /ecancer. . sha: doc_id: cord_uid: ddulfe introduction: the world is living through an outbreak of an acute respiratory syndrome caused by a new betacoronavirus known as coronavirus (sars cov- ), which has been declared an international public health emergency by the world health organisation. cancer patients are a very special population in this setting since they are more susceptible to viral infections than the general population. several recommendations have been made on this issue, most of them based on expert opinion and institutional experience. it is essential to gather the evidence available for decision making. objective: to review the evidence available in order to create a multi-institutional position from the perspective of scientific societies in argentina involved in the management of cancer patients. methodology: the review included two phases: ) search and systematic revision of the medical literature; ) consensus and revision of the document drafted by national scientific societies involved in the management and care of cancer patients using the modified delphi method. the final results were presented at a videoconference with all the participants. also, additional comment and recommendations were discussed. the final document was revised and approved for publication by the members of the panel. results: the consensus panel included representatives from scientific societies from argentina who assessed the evidence and then made recommendations for the management of cancer patients in our country. international guidelines (cdc; asco, nccn and esmo) were considered as a background for analysis, as well as institutional guidelines and an open ad hoc survey administered to healthcare professionals from the scientific societies involved in this study. the recommendations are grouped as follows: ) general care interventions—training of the personnel, cleaning and disinfection of the hospital premises and patient scheduling; ) treatment decisions—patient care, surgeries, immunosuppressive therapy, radiotherapy and screening; ) ethical considerations—optimisation of resources, end-of-life care for critically-ill patients; ) management of hospitalised patients; and ) wellbeing of the healthcare team. the general recommendation arising from the study is that the management of cancer patients must adapt to the exceptional pandemic status quo without disregarding treatment or cure options. moreover, healthcare professional accompaniment of all patients should not be neglected. all healthcare professionals must make a significant joint effort to create multidisciplinary teams to discuss the most appropriate measures for each particular situation. conclusions: the scientific evidence available on this topic worldwide is in progress. this together with the epidemiologically shifting scenario poses unprecedented challenges in the management of cancer amidst this global pandemic. furthermore, the key role of the healthcare structural organisation appears evident, such as the drafting of clear guidelines for all the stakeholders, adaptability to constant change and an interdisciplinary shared vision through consensus to provide adequate care to our cancer patients in the light of uncertainty and fast-paced change. the world is experiencing an outbreak of acute respiratory syndrome caused by a new betacoronavirus known as coronavirus (sars-cov- ) [ ] by march, , the rapid spread of the virus had resulted in , confirmed cases and , deaths. cases have been reported in countries. the world health organisation (who) has declared the new coronavirus disease , caused by sars-cov- , is a public health emergency of international concern. in contrast to the severe acute respiratory system, coronavirus and the middle east respiratory syndrome-related coronavirus, covid- has caused more deaths from multiple organ dysfunction syndrome than from respiratory failure [ ] , which could be attributable to the widespread distribution of angiotensin-converting enzyme -the functional receptor for sars-cov- -in multiple organs [ , ] . the authorities from national scientific societies were convened in order to appoint a participating member. his/her function will be to represent the institutional position with a single vote when developing the questionnaire. societies were invited and accepted the invitation to participate. the list of participating societies, representative and conflicts of interest are detailed in appendix i. once the pertinent and relevant evidence was identified, the points or questions of controversy to be developed in relation to the proposed theme were extracted. a list was generated following asco and nccn guidelines. the questionnaire was subsequently distributed among the members of the panel to validate the different aspects of the topic to address, and to modify or add relevant questions not covered in the initial proposal. the final questionnaire set out in this document was eventually agreed upon (appendix ii). consensus methodology: the modified delphi method was used. this is an iterative process, whereby participants must give their opinions or answers anonymously on more than one occasion, via rounds that result in opinion stability. it is characterised by feedback controlled by the coordinating group at each stage, through which a statistical response for the group is reached. a first round of questions was conducted using the survey monkey® tool, outlining a percentage of agreement of greater than %. by decision of the elaboration group, the same survey was carried out with an open and non-nominalised format by the members of the intervening societies, with the aim of finding out the general perception of the subject in different areas of focus. there were participants. the final results were presented in a video conference with all of the participants, where additional comments and recommendations were brought up. the results of the open survey were also shared, for the purpose of enriching the discussion space. in cases where the established percentage was not reached, a second vote was taken in order to come to an agreement during the video conference meeting. a draft document was prepared, which was sent by email for the members of the panel to review and conclude, in order to arrive at a final version of the document. recommendations from asco [ ] , nccn [ ] and esmo [ ] have charted them on six axes, which respond to these questions of healthcare practice for oncology patients, through evidence and the agreement of experts. we have supplemented this with local recommendations in the same order. what are the recommendations for the general care of cancer patients? points of practice may be considered to guide the clinic's preparation and planning: clinic or hospital staff may need additional training to assess patients for possible covid- / other infections [ ] . the procedures for isolating potentially infected patients may need to be reviewed and updated. clinic staff may need additional training on the use of personal protective equipment (ppe). it may be necessary to obtain additional ppe, as staff who do not usually use it may be required to perform tasks where it is appropriate. clinic or hospital staff may need additional training on how to obtain sars-cov- testing for patients according to the current testing guidelines. the recommendation for this is to follow the inter-institutional recommendations to prevent covid- -version / / of the argentine society of infectious diseases (sadi) / argentine intensive care society (sati) / infection control nurses association (adeci) / institute of epidemiology-dr juan h hara [ ] . it may be reasonable to postpone routine follow-up visits for patients who are not undergoing active cancer treatment, or make those appointments by telemedicine. consider calling all scheduled patients day before they visit the clinic in order to detect covid- exposure/symptoms. routine collection of laboratory samples from the patient's home may be considered, instead of having them come into the clinic. treatment planning: ) for patients with a fever or other symptoms of infection, an in-depth evaluation must be carried out according to usual medical practice. ) patientswith covid- currently receiving treatment against cancer must follow standard clinical management plans to delay or modify cancer treatment in a patient with an active infection. current information suggests that patients with cancer are at a greater risk of infection and severe complications from covid- than other patients. for the majority of cases where there is no known covid- infection, it is likely to be more important to start or continue systematic treatment, than delay or interrupt it over concerns about possible covid- infection. however, decisions should be made on an individual basis after considering the age of the patient, the general objectives of the treatment, the present oncological state of the patient and tolerance to treatment, as well as their general medical condition. consider if domiciliary infusion of chemotherapy medication is feasible from a medical and logistical point of view for the patient, medical staff and caregivers. in our country, legal aspects must also be taken into account. given that oncology patients are also at a high risk of serious complications from influenza, they should be vaccinated before starting chemotherapy (at least weeks before if possible), and in cases where chemotherapy has already started, it should be done immediately before the next cycle of treatment [ ] . initially, there was no formal recommendation regarding the use of masks with cancer patients [ ] . in the recommendations for health workers from the department of health in our country, they mention the use of masks by staff who care directly for isolated patients. for example, patients with influenza, coronavirus (including covid- ), respiratory syncytial virus, meningococcus, mumps, rubella and patients with respiratory infections walking around the hospital [ ] . in an update of the guidelines, the cdc recommends the use of masks for healthy people who are going to be exposed to the public, or for patients who must attend health centres; even more so for cancer patients, due to the risk posed by their illness. protection with masks/face coverings is complementary to maintaining distance and isolation as part of preventative measures [ ] . before symptoms are present, the usual early clinical evaluation is recommended [ ] . with respect to systematic covid- testing, there is no conclusive evidence. even though no conclusive increase has been established in the number of infections by covid- in people with an oncological diagnosis, there is evidence that they are more at risk of developing severe forms of the illness, with a higher death rate [ ] . at the moment, only one detailed published report has been identified that compares the spread of the covid- virus in the patients with and without cancer [ ] . this report outlines a prospective cohort of , patients with covid- , of which had a history of cancer. they observed that patients with a history of cancer had more severe complications. this was defined as the percentage of patients admitted to one of the intensive care units who required invasive ventilation or died, in comparison with other patients. according to correspondence from the report, xia et al [ ] , these patients represent a heterogeneous group and are not an ideal representation of the entire population of cancer patients. another recent publication, based on cases of cancer and covid- from three hospitals in wuhan, reports outcomes from patients. in these cases, . % developed severe forms of the illness and . % were related deaths [ ] . the cdc suggests 'elective surgeries' are rescheduled if possible. the american college of surgeons has also given a recommendation. however, doctors and patients should discuss individual cases, evaluating the potential harm of delaying cancer related surgeries; without which they risk missing the window of opportunity for surgical treatment of the patient. in many cases, these surgeries cannot be considered as 'elective [ ] . can immunosuppressive therapy be cancelled, delayed or interrupted? for patients with covid- who are currently receiving treatment for cancer, consider delaying or changing the cancer treatment for patients with active infection. the current information suggests that cancer patients are at a higher risk of infection and complications from covid- than other patients. for patients with no known covid- infection, in the majority of cases, it is likely to be more important to start or continue systematic cancer treatment, than delay or interrupt it over concerns about possible covid- infection. however, decisions should be made on an individual basis after considering the overall objectives of treatment, the current oncological state of the patient and their tolerance to treatment, as well as their general medical condition. at the moment, there is no direct evidence to support the change or suspension of chemotherapy or immunotherapy in cancer patients. therefore, suspending routine anticancer or immunosuppressive therapy is not recommended. the balance of possible harm that could result from delaying or interrupting treatment versus the possible benefits of preventing or delaying covid- infection is very unclear. clinical decisions should be individual considering factors such as the risk of the illness recurring if adjuvant chemotherapy is delayed, modified or interrupted, as well as the number of adjuvant chemotherapy cycles already done and the tolerance of the patient to treatment. however, the following practices should be considered: ) forpatientslargelyinremissionundergoingmaintenancetherapy,stoppingchemotherapymaybeanoption. ) somepatientsmaychangefromintravenoustooralchemotherapy,whichwoulddecreasethefrequencyofvisitstotheclinic,but would require greater care from medical teams to ensure the correct prescription is met. ) decisionsaboutmodifyingorsuspendingchemotherapyshouldconsiderchemotherapyadviceandtreatmentobjectives,aswellas the clinical characteristics of the patient and their tolerance to treatment. for example, the risk/benefit evaluation of continuing with chemotherapy in untreated small cell lung cancer patients is different to patients being maintained with pemetrexed for non-small cell metastatic lung tumours. ) iflocaltransmissionaffectsoneoncologycentreinparticular,reasonableoptionsmayincludeofferingachemotherapybreakfor weeks, organising infusion at a remote unaffected unit, or coordinating treatment with another unaffected centre. ) considerhomeinfusionifitismedicallyandlogisticallyfeasibleforthepatient,medicalteamandcaregivers.insomeenvironments, the delay or change of adjuvant treatment may mean putting infection control at risk, compromising long-term survival. prophylactic growth factors that would be used in high-risk neutropenia chemotherapy regimes, as well as prophylactic antibiotics, can have potential value in maintaining the general health of the patient and make them less vulnerable to possible complications from covid- . in cases where the overall benefit from adjuvant chemotherapy may be small, and where there are no immunosuppressive options available (for example, hormonal therapy in early-stage hormone-dependant breast cancer), the risk of infection from covid- can be considered as an additional factor to evaluate before the different options available to the patient. immunotherapy: it is important in the context of active treatment in cancer patients. it includes the use of agents such as pd- inhibitors, for example, nivolumab and pembrolizumab and anti ctla- therapy such as ipilimumab. on this point, consider aspects [ ]: ) itispossiblethattreatmentrestorestheimmunesystem,creatingasimilarpicturetothatdevelopedinsevereformsofcovid- (caused by a massive release of cytokines). ) considerthesubtypeofthetumourandtheobjectiveofthetreatmenttodecidewhethertocontinueorstarttreatmentwithpd- inhibitors (e.g. melanoma, kidney cancer). ) evenifthealveolitiswasgeneratedwithtoxicitybythepd- inhibitorsisnotafrequentoccurrence,itcanbethecauseofdeathinup to % of cases. in patients with comorbidity or a respiratory disease, it is necessary to consider the increased risk when using pd- inhibitors, mainly when combining pd- inhibitors with anti ctla therapy. in summary, here are recommendations [ ] : ) onlythepatientshouldenterthecentre,wearingamaskandkeepingasafedistancefromothers. ) first-timeandpost-treatmentconsultationsshouldtakeplaceviavideocallortelephone. ) deferstartingtreatmentinearly-stagecasesoftheillness.thesecasesshouldhavebeenpreviouslydiscussedbythetumourcommittee. confirmed cases of covid- : treatment will be limited to urgent cases, such as patients with spinal cord compression, superior vena cava syndrome or bleeding identified by a specialist. in this situation, it is vital to give priority to hypofractionated treatments, especially with a single dose ( gy or gy in fx). for non-urgent cases, treatment will be paused depending on the individualised decision for each patient. individual and group protection is defined accordingly by the rules established by the ministry of health. the last shift of each day will be dedicated to treating patients with suspected or confirmed cases of covid- . diagnoses in which it is feasible to omit starting radiotherapy treatment in breast cancer patients are: hormone receptor-positive ductal carcinoma (dcis, rh+); patients over years who are receiving hormonal treatment after carrying out an individualised evaluation of the risks and benefits of adjuvancy treatment alongside radiotherapy; dcis in patients under years who meet the low-risk criteria (clinically hidden tumour, detected by mammogram, screening or incidental findings during surgery amounting to a mm with a nuclear grade or ). in these hormone receptor-positive cases, endocrine therapy needs to be completed. in cases of stage ia (ct n ) luminal a invasive ductal carcinoma for those over years who receive hormone therapy and palliative cases with a luminal illness with an indication of hormone therapy. prostate cancer: depending on the clinical characteristics and the risk subgroup, the use of neoadjuvant androgen deprivation therapy should be evaluated. in case of low-risk or very low-risk illnesses, it is recommended to continue active surveillance. for intermediate-risk diseases, defer starting treatment during the contingency period. for localised high-risk and very high-risk diseases with positive ganglions, it is not advisable to start treatment during the contingency period when neoadjuvant androgen deprivation therapy is the proposed method of treatment. for advanced illnesses, delay starting treatment within this period. such illnesses are based on the stampede protocol or ablative therapies of metastatic diseases or m . all patients must continue androgen deprivation therapy. for patients with a biochemical recurrence and without a distant disease, it is recommended to begin hormone therapy. consider postponing radiotherapy in treatments with palliative intent in asymptomatic or oligosymptomatic patients, or in response to medical management. brachytherapy: palliative brachytherapy is recommended for skin tumours. should members of the community continue with recommended activities for detecting cancer (e.g., mammograms)? to conserve resources in the health system and limit contact with patients at healthcare facilities, asco recommends that procedures requiring visits to clinics and centres, such as mammograms and colonoscopies, should be postponed for the time being. it is recommended that healthcare teams carefully consider the risks and benefits of continuing elective procedures, such as screening procedures, at this moment. digestive endoscopy generates aerosols [ , ] . the viral load of sars-cov- in the pharyngeal saliva is similar to that in stool, where it can linger for days after respiratory sample results indicate they are negative [ ] . up to % of infections with sars-cov- occur during the presymptomatic phase [ ] . the core recommendations of the spanish association of digestive endoscopy (seed) during the covid- pandemic consist in: endoscopist responsibilities: • under the oath to do no harm that doctors have taken, the seed reminds us that all endoscopic doctors must currently: • suspend all scheduled endoscopic outpatient activity. • without delay, be available to carry out urgent endoscopies. • limit digestive endoscopy to vital hospital activity, such as in: a) p atients with upper gastrointestinal bleeding who suffer from haemodynamic instability, when it is possible to carry out endoscopic treatment. b) patients with oesophageal impaction from foreign bodies. c) patients with obstructive cholangitis who require an ercp. d) cancer patients who require endoscopic treatment. e) specific colonoscopies, where diagnostic yield is urgent. • protect themselves and all personnel by properly using ppe [ , ] . beyond the care of each individual patient, medical oncologists will have to face the reality of limiting care. as the pandemic advances, a point will arrive at which channelling a large number of resources for an individual patient will directly conflict with the greater social good. if a cancer patient at an advanced stage of the illness or with comorbidities, such as cardiac or pulmonary dysfunction, becomes infected with covid- and requires mechanical ventilation, it's possible that it's a bleak prognosis. based on a recent retrospective study from wuhan, china, only one patient survived from the who were all gravely ill with confirmed cases of covid- and required mechanical ventilation [ a large number of sars-related coronaviruses (sarsr-covs]. therefore, it is imperative to have proactive discussions about end of life arrangements and palliative care with cancer patients at risk of infection by covid- . the proactive discussions surrounding these challenging decisions should occur among specific groups of illnesses, between specialists in medical ethics and palliative care teams. in triage procedures, where patients with a shorter life expectancy should not be treated, palliative care teams insist that these patients should not be abandoned, but still provided with the adequate health care needed. in this regard, it is convenient to adapt spaces for patients with a shorter life expectancy. such will avoid overburdening healthcare workers on the front line who will suffer extreme stress seeing patients pass from untreated symptoms and who will at times be unable to exercise their necessary skill and expertise. from an ethical perspective, we can assume the following criteria: ) protection from harm. a flu pandemic and classification system can cause significant physical and emotional distress. it is our obligation to protect those who suffer from the effects of the pandemic and classification system. ) proportionality. the administration of resources in palliative care must reflect the needs of the community and high-quality palliative care must be provided to those who need it. medication, equipment, beds and specialists must not 'accumulate' when they are needed by others in the community. ) obligation to provide access to care. palliative care is a critical component of any pandemic classification plan and the professionals working within palliative care have an obligation to provide care and alleviate suffering. this must be balanced by the obligation to protect the health of oneself and that of their families. reciprocity. palliative resources should be directed more to patients who have greater burden on the classification system, such as critical patients who will not receive life support treatment. these patients (and their families) run a greater risk of feeling abandoned by the healthcare system and should receive care based on the therapeutic objective for comfort by an interdisciplinary palliative care team. we must ensure that high-quality palliative care is available for all patients who may need it, regardless of their ranking on the scale. the argentine association of medicine and palliative care (aamycp) have made the recommendations outlined in this document (see appendix iii), https://aamycp.com.ar/covid /. the priority for oncology units for hospitalised patients has been to prepare for the upcoming bed and resources shortage caused by the expected increase in covid- patients who require beds and acute care in intensive care units (icu). even though some centres have beds or facilities that are allocated for cancer care, the rapid increase in cases may require the reassignment of units, hospital wards or even entire systems for patient care during the pandemic. shortage of blood products due to the drop in blood donors within the community calls for stricter usage guidelines both for clinics and hospitals [ ] . transfer of potentially infected patients from one centre to another requires careful logistics planning in order to reduce both public and staff exposure. due to shortage of supply and increased demand, creative solutions must be developed to preserve ppe, including favouring hand-washing with soap and water over using hand gel in standard precaution wards, limiting the number of team members entering patient rooms and reducing nursing procedures that require ppe, such as measuring urine output. to protect staff, ppe training sessions must be updated and available to all the users. it is recommended to adopt a policy limiting the number of visitors in hospitalised patient departments in order to protect both the public and patients from exposure and reduce the use of ppe, with rare exceptions, such as end-of-life circumstances. these decisions, taken together with patients, are difficult both for patients and families as well as medical personnel, who acknowledge the significant contribution of friend and family support for hospitalised cancer patients. finally, the emotional and physical well-being of our staff requires proactive attention. provider burnout is expected; therefore, priority must be given to protecting the health of frontline staff and ensuring a safe workplace environment. furthermore, human resources should be attended to by developing policies and compensation for leaves of absence and mandatory isolation and creating work support groups. reassignment from clinical tasks to administrative functions must be considered for immunocompromised staff or those having significant comorbidities that put them at higher risk of covid . guidelines for healthcare staff [ , ] • schedule and take short breaks from work to de-stress and attend to your basic needs. a few minutes of rest during your shift can be enough. even a -minute walk can improve your energy and mental focus. • take time each day to do something that brings you joy, even if it is for a brief moment. • maintain a healthy diet; bring your own food to work. • keep your daily activities schedule as regular as you can. • take some sunlight. • try to practice chair yoga or stretch at work. • exercise regularly. try to walk or bike to work if you can. • avoid or limit alcohol and caffeine consumption. • manage excessive fatigue, irritability, lack of concentration or anxiety. • take a moment to breathe slowly before entering a work area or entering or exiting a patient room. this can be difficult while you are wearing personal protective equipment, such as a mask, but breathing is relaxing and helps your body ease the physical symptoms of stress. if you consult regularly with a mental health professional, schedule video appointments or a telephone call. if you do not consult regularly with a mental health professional but do feel that it could be useful at this moment, schedule an appointment or call. • if a spiritual practice is or has been important to you in the past, resume it. the covid- pandemic has posed unique challenges and learning opportunities for oncology centres. the future trajectory of this pandemic is uncertain and we must continue to prepare for its widespread impact. the situation is dynamic and policies and recommendations may change at any point. while we write this document, the health crisis surrounding covid- continues to evolve, and circumstances may change some of our current recommendations. we hope to overcome these uncertain times, even though the long-term economic and emotional impact will be two great future challenges. however, the overall objective is to continue to provide compassionate and safe care to cancer patients. we hope to continue to support our patients and the cancer community while this pandemic continues to spread globally. the the questions were presented to the panel and then distributed to the associates of the different scientific societies, whose responses were anonymous and not identified by name. this constituted a component for the face-to-face discussion, where results of the literature review were presented (sent in due course along with the first delphi round), the survey open to medical professionals who treat oncology patients and the first round of the delphi panel. it is to be noted that the professionals, when responding to the open survey, did not have the document with the analysis and synthesis of the literature review prepared by the revising group, which reflected their usual practice. the analysis of responses concluded that: regarding the question on triage or patient selection for first-time consultations or face-to-face consultations at their centres, there was a satisfactory implementation in % of cases. when asked about an established algorithm at their centres for patients with fever and suspicion of covid- , there was an affirmative response in % of cases. for the question about when cancer patients who had finished their specific treatments would be considered at risk of developing severe forms of covid- , little over half ( %) responded only in those cases less than months from completion of onco-specific treatment. however, % did not take this variable into account and considered all those who had received treatment to be at risk. in relation to the question about adjuvant treatment in patients at risk of developing severe forms of covid- , % revealed inconsistent practices. for example, % decided to delay adjuvant treatment, while the remaining % decided to conduct curative treatment regardless of the covid- situation. on the other hand, % decided to delay treatment in all cases. different comments about this subject were sent, the majority of which agreed on the decision or individualisation of treatment by taking into consideration the risk-benefit ratio, consensus with the patient and also discussions within the interdisciplinary framework. for those deciding to delay treatment, a -day cut-off point was mentioned (two comments). one comment refers to the extreme situation, that is to say the catastrophe, under which it would also depend on the resources of the healthcare system and prioritisation of care. when asked about the use of radiation therapy and prioritising cases, % responded by referring to symptomatic advanced illness or oncological emergencies, preferably with hypofractionated schedules. almost one third of cases ( %) included invasive cancer with curative intent, provided there was no neoadjuvant treatment option. % took no position in relation to radiation therapy. regarding performing elective operations for cancer and the practice adopted in their medical society or care centre, % would not consider delaying surgery, since it would not be elective as it pertained to a serious disease such as cancer. however, one third of cases ( %) envisage postponing all surgical operations, and % consider that postponement should only occur in the context of containment and mitigation due to sars-cov- . responses to this question mention discussing postponement of certain types of surgery on a case-by-case basis, highlighting the importance of not missing the therapeutic window of opportunity-such as in the case of patients receiving neoadjuvant therapy. as a follow-up to the previous question, respondents were asked about the resection of metastases for remedial purposes: % answered that the decision was to proceed with surgery anyway to avoid missing the window of opportunity. nearly half of the cases ( %) favour maintaining systemic treatment and rescheduling surgery. as regards elective surgeries and the health centre's adoption of covid- screening measures for patients in the at-risk category, in % of cases these are conducted through anamnesis and historical exposure records. in % of instances, it is mentioned that all preoperative cases undergo pharyngeal swabbing. in considering the treatment and strategy for cancer patients, % agree that treatment be decided in all cases following discussion by the multidisciplinary team, whereas % are of the opinion that a discussion should only be held in cases where this is warranted at the discretion of the treating physician. concerning the highly sensitive and important matter of ppe, or personal protective equipment, on this subject % of respondents agree or strongly agree with measures taken by their centre. approximately, one third disagree or strongly disagree with measures taken or implemented by their centre. a panel comprising the scientific organisations met to discuss via video conference on april, . global and national epidemiological data were presented, and the definition of risk groups was shared, along with what has been published by the ministry of health on the handling of chronic noncommunicable diseases. review of the document's structure: based on evidence arising from three clinical practice guides (nccn, asco and esmo). an account was made of the methodology used: search, modified delphi consensus. the result of the open-ended and non-standardised survey submitted to the participating organisations' professionals was presented in statistical format. the panel's composition was outlined. question : implementation of a triage system for oncological consultations: % agreement in the open survey, in agreement with the panel. question : organisational algorithm in response to the admissions circuit for patients with suspected or confirmed covid- symptoms: agreement in both surveys. discussion: chemotherapy clinics or oncology day units at hospitals are high-transit areas presenting a higher risk of contagion in the context of the covid- pandemic. patients (actively undergoing treatment and at greater risk of immunosuppression), accompanying persons and health care team members all transit through these areas. implementing safety measures is a priority: implement social distancing in waiting rooms: restrict the number of accompanying persons to one per patient, adhere strictly to the schedule of appointments, establish spacious waiting areas or allow patients to walk around until their treatment begins (e.g., suggest that they leave the waiting room and call them on their phone once it is their turn for treatment). reduce daily patient admissions capacity: to avoid overcrowding in the waiting room and treatment room, assess the feasibility of increasing available days and extending time slots for treatment in order to curb the daily volume of patient admissions. implement a pre-entry triage: looking for symptoms indicative of a covid- infection, carry out or reinforce its implementation if conducted prior to admission to the facility. respect social distancing in the treatment room: configure seats to ensure appropriate distance between patients and accompanying persons, and provide health care practitioners with sufficient room for manoeuvre. conduct methodical cleaning between patients: to this end we rely on the inter-institutional recommendations for preventing covid- , version / / sadi/sati/adeci/ine [ ] . question : in relation to the time interval following the end of treatment taken as a risk variable: open survey: the majority of respondents indicated less than six months. panel: % indicated less than six months. not time-dependent %. discussion: consideration given to assessing patients in line with prescribed monitoring controls. three months and six months following the completion of treatment. even within the month time interval, a stricter approach should be adopted towards the oncological monitoring plan. there is uncertainty regarding immunological recovery, which in some patients can be lengthy (up to months), and should therefore be monitored. the wuhan case study report reveals that oncology patients stand a higher risk of suffering serious complications ( % compared to % in cancer-free patients, p = . ) regardless of the treatment-or illness-free time interval. after adjusting to account for other variables such as age, smoking habits or other comorbidities, the risk was markedly higher (or . ic % . - . ) in the subgroup where chemotherapy treatment had been completed or an operation performed in the preceding month. consequently, the panel recommends that risk be discussed on a case-by-case basis in order to establish monitoring needs. in an open survey, the majority chose to delay the start of treatment, contrasting with the panel's strongly supported choice to follow standard procedure. discussion: possibility of case-by-case discussion linked to the current phase of the pandemic in the country. decisions need to be taken in the context of the pandemic's evolving epidemiological landscape, with a particular focus on rationalising resources. in light of the existing impact of the pandemic on comorbidity-free patients, the panel agrees to recommend that standard oncological treatment may be continued. for patients that are elderly and/or have comorbidities, assessments will be performed using the same criteria as under non-pandemic conditions. the treatment's absolute benefit and potential risks need to be weighed up for each pathology, targeting prioritisation and decision making within a multidisciplinary team context. in an open survey, % pointed to limiting radiation therapy to urgent cases only, preferably through hypofractionation schemes. the panel is in agreement. % have not adopted a formal position on the matter. discussion: certain definitive treatment modalities should be incorporated such as treatment for cancer of the cervix, lung, anus and adjuvant treatment of breast, head and neck cancer. hypofractionated treatment modalities can be envisaged whenever feasible. the timely and proper delivery of radiation therapy is a priority where some of the pathologies mentioned are concerned, in instances where hypofractionation (anal, cervical, and head and neck cancers) and concurrent radiotherapy and chemotherapy treatment modalities are not an option. for such pathologies priority should be given to standard fractionation treatments, following prior multidisciplinary committee discussion. in the open survey referring to non-postponement because of the non-elective nature of surgeries, the panel's view is to delay only in the containment stage and not to postpone. discussion: it must be considered within the context of the current phase of the pandemic, assessing the risk for complications on a caseby-case basis and the need for icu. this extends to human resources, in terms of health care teams and treatment centre resources that are faced with the pandemic's potential to evolve into a catastrophic situation. the natural progression of the illness also needs to be considered (e.g., pancreatic cancer where delaying would not be feasible), provided surgical interventions are curative in scope. prioritising surgeries in pathologies with curative criteria, otherwise refer the patient to concurrent therapies or chemotherapy. multidisciplinary teams should discuss each case individually. furthermore, considering context: the progression of the pandemic compared to available resources in each centre. the aim is to prioritise surgeries for patients who risk missing a therapeutic window (i.e., colorectal cancer patients with metastases after conversion treatment) based on an epidemiological assessment of covid- question : elective surgery and screening patients to detect covid- : open survey, the panel agreed on only screening using clinical criteria. what happens with asymptomatic patients in this community transmission phase? experience and studies from wuhan show that major surgery for covid- -positive patients increases mortality. studies by shaoqing et al. [ ] and other authors [ ] found that patients having major surgery should be swabbed as sars-cov- infection increases mortality. infection also negatively impacts patients at high risk due to age and/or comorbidity as well as underlying oncological disease. these patients need chemotherapy, radiotherapy, or therapies with a high risk of neutropenia or immunosuppression. question : multidisciplinary team discussion: the panel agreed to recommend multidisciplinary team discussion of all cases. question : ppe: there is a consensus that the measures adopted are adequate for institutions. please consider that these recommendations may change. protecting patients must be a priority. advance decisions and support at the end of life. palliative care association document (aamycp). decisions amid scarce resources, such as ventilation criteria. there are algorithms for setting clinical and ethical decision making criteria. isolation at the end of life, crafting communication strategies to promote support. there are common elements in all multidisciplinary discussions that have addressed distinct questions. decisions and recommendations should consider the national epidemiological situation (if it is not catastrophic). measures and their implementation must be considered based on resources, available medical equipment, and care centres in which each professional works. the ideal framework for supporting medical decisions is a multidisciplinary discussion including all involved specialists and relies on the recommendations of scientific organisations. a general recommendation is to provide adequate care to oncology patients in exceptional pandemic circumstances without missing opportunities to treat or cure them. clinicians must also continue to provide professional support for all patients. this recommendation requires health professionals to strive to create multidisciplinary teams that can discuss the best, most timely measures for each situation. discussions continue about how to classify patients at greatest risk of developing severe forms of covid- , for example, patients who will have major surgery, chemotherapy or radiotherapy. is swabbing all patients before these therapies to detect asymptomatic infection adequate? if swabbing is feasible and is implemented systematically, how will it impact patients whom testing identifies as presymptomatic? another unresolved response issue is what some authors call the third wave: measuring the medium-term impact the pandemic has on response measures. for example, the consequences of delaying or interrupting care for chronic, non-communicable diseases, including cancer. the relevant international scientific evidence is still under investigation. incomplete evidence combined with constantly changing epidemiological circumstances poses unique challenges for treating cancer during a global pandemic. it is clear that health systems need organisational frameworks, such as preparation guidelines for all staff. the flexibility to adapt to change and a shared, multidisciplinary vision based on consensus are also vital. institutions need these elements to continue treating cancer patients adequately amid uncertainty and rapid change. cancer patients in sars-cov- infection: a nationwide analysis in china epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study a pneumonia outbreak associated with a new coronavirus of probable bat origin tissue distribution of ace protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis centers for disease control and prevention information for healthcare professionals: covid- and underlying conditions nosocomial infections in patients with cancer selective depletion of regulatory t cell subsets by docetaxel treatment in patients with nonsmall cell lung cancer features of postoperative immune suppression are reversible with interferon gamma and independent of interleukin- pathways myeloid suppressor cells in cancer and autoimmunity ministerio de salud estadísticas -incidencia managing cancer care during the covid- pandemic: agility and collaboration oward a common goal esmo covid- : supporting oncology professionals sadi recomendaciones inter-institucional para la prevención de covid- sadi / sati / adeci / ine vacunación en huéspedes especiales ministerio de salud recomendaciones para el uso de los epp centers for disease control and prevention how to protect yourself & others clinical characteristics of covid- -infected cancer patients: a retrospective case study in three hospitals within wuhan american college of surgeons covid- : elective case triage guidelines for surgical care controversies about covid- and anticancer treatment with immune checkpoint inhibitors immunotherapy recomendaciones generales de actuacion ante la situación de pandemia por covid- paraservicios de radioterapia de adultos considerations in performing endoscopy during the c- pandemic. ge m coronavirus can persist in stool after its clearance in respiratory tract. faculty of medicine cpra m estimating the generation interval for c- based on symptom onset data medrxiv seed recomendaciones de la seed: protección en unidades de endoscopia frente al covid- endoscopistas digestivos de buenos aires coronavirus: recomendaciones para unidades de endoscopia endoscopistas digestivos de buenos aires recomendaciones para unidades de endoscopia parte ii covid- response tools: seattle cancer care alliance stress management and self-care during covid- : nccn publishes guidelines clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid- infection eclinicalmedicine intercollegiate general surgery guidance on covid- update arethemeasuresyourcentrehastakentomanagepersonalprotectiveequipment(ppe)appropriate?indicatetheoptionthatmatches your opinion best national scientific organisation guidelines included in the document • sociedad argentina de terapia radiante dr maría celeste diaz contributed to the methodology of this report. dr federico esteso provided technical support for and participated in the virtual meeting.we would also like to thank the professionals who answered the open survey, providing perspectives of their daily practices. the declaration of conflicts of interest was made by all members of the development group and participants in this consensus. the group of experts states that no sponsorship was received for the development of the document. this document represents the position of the participating scientific societies in the development of this recommendation. the recommendations are the product of a careful evaluation of the available evidence. in no case does it replace the clinical judgment of the treating physician, nor does it substitute for medical judgment in making appropriate decisions for each individual case, the consultation of the patient, the family or the caregivers. key: cord- - kbz c authors: kesteman, thomas; ghassani, ali; hajjar, crystel; picot, valentina; osman, marwan; alnajjar, zahraa; komurian-pradel, florence; messaoudi, melina; pouzol, stéphane; soulaiman, hicham ghazi; vanhems, philippe; ramilo, octavio; karam-sarkis, dolla; najjar-pellet, josette; hamze, monzer; endtz, hubert title: investigating pneumonia etiology among refugees and the lebanese population (pearl): a study protocol date: - - journal: gates open res doi: . /gatesopenres. . sha: doc_id: cord_uid: kbz c background: community-acquired pneumonia (cap), a leading cause of mortality, mainly affects children in developing countries. the harsh circumstances experienced by refugees include various factors associated with respiratory pathogen transmission, and clinical progression of cap. consequently, the etiology of cap in humanitarian crisis situations may differ to that of settled populations, which would impact appropriate case management. therefore, the pneumonia etiology among refugees and the lebanese population (pearl) study was initiated with the objective of identifying the causal pathogenic microorganisms in the respiratory tract of children and adults from both the refugee and host country population presenting with signs of cap during a humanitarian crisis. methods: pearl, a prospective, multicentric, case-control study, will be conducted at four primary healthcare facilities in tripoli and the bekaa valley over months (including two high-transmission seasons/winters). sociodemographic and medical data, and biological samples will be collected from at least cap cases and controls. nasopharyngeal swabs, sputum, urine and blood samples will be analyzed at five clinical pathology laboratories in lebanon to identify the bacterial and viral etiological agents of cap. transcriptomic profiling of host leukocytes will be performed. conclusions: pearl is an original observational study that will provide important new information on the etiology of pneumonia among refugees, which may improve case management, help design antimicrobial stewardship interventions, and reduce morbidity and mortality due to cap in a humanitarian crisis. lower respiratory tract infections (lrti) are the second leading cause of mortality worldwide, accounting for an estimated . million deaths annually, and mainly affect children in developing countries . community-acquired pneumonia (cap) is caused by a variety of bacteria and viruses and is mainly characterized by lobar or broncho-pneumonic changes. however, identification of the etiology of pneumonia is often difficult, and optimal prevention and treatment strategies for cap critically depend on a full understanding of its etiology. for example, intracellular ("atypical") bacteria (chlamydophila, mycoplasma, etc.) require treatment with specific antibiotics, while purely viral infections do not. furthermore, clinical exams, chest radiology and biological tests lack specificity, and blood cultures yield positive results in only to % of cases. current interventions for cap are primarily based on etiological studies conducted in the early s - , which indicated bacteria are responsible for almost half of all cases of cap , ; streptococcus pneumoniae, haemophilus influenzae and staphylococcus aureus were the most commonly identified bacteria. in children < -years-old, bacteria were responsible for severe forms of cap: s. pneumoniae and h. influenzae accounted for approximately % of cases of severe and fatal pneumonia , and s. pneumoniae alone accounted for % of mortalities overall in children < -years-old . however, other bacteria (e.g. mycoplasma pneumoniae, chlamydophila pneumoniae, legionella pneumophila, bordetella pertussis, etc.) may be responsible for a significant proportion of cap . moreover, respiratory viruses such as influenza viruses, respiratory syncytial virus (rsv) and human metapneumovirus (hmpv) are known to make significant, often seasonal, contributions to cap. finally, superinfections, although poorly understood, are widely accepted to contribute to severe cap. a clear picture of the etiology of cap would help to estimate the potential impact of novel public health interventions, such as antiviral therapies in case management or influenza vaccination for prevention in vulnerable populations. in order to provide up-to-date data on the etiology of cap, several studies were recently conducted, in particular two large studies in the usa in - , targeting children and adults , , and two studies that targeted under-fives in low and middle income countries, the gabriel pneumonia study in - , and the pneumonia etiology research for child health (perch) study in - . these studies pointed to the importance of viruses in the etiology of cap. lrti are a major cause of morbidity and mortality in the acute phase of humanitarian crises. case management (diagnoses, treatment choice and delivery) and public health interventions (immunization strategies) for cap in humanitarian crisis settings are conducted blindly or based on the assumption that evidence gathered in non-crisis settings applies to displaced populations. however, large knowledge gaps remain in many areas, including the etiology of these infections , . no studies have been specifically designed to assess the etiology of cap in populations facing humanitarian crisis. the reference method for identifying the pathogen responsible for an infection is to sample the infected tissues, i.e., the lung, in patients with pneumonia, and screen for pathogenic agents by culture or molecular tools. such invasive procedures are difficult to set up, even in hospital settings, and virtually impossible in primary health care. to circumvent this issue, the causative agent can be identified using samples from the upper respiratory tract using non-invasive techniques, e.g. nasopharyngeal swabs , . due to the existence of healthy carriers of several potential pathogens (e.g. streptococcus pneumoniae) in the population, there is a need to adjust for carriage: the higher the proportion of asymptomatic carriers of a given pathogen, the lesser the chances that this agent is the etiology of cap when found in the upper respiratory tract. in the last decade, transcriptomic analyses of the blood of patients infected with different pathogens have revealed gene expression patterns that correlate strongly with individual etiologic agents , . white blood cells express different genes in response to infection with different agents, and these patterns can be used to distinguish viral and bacterial infections with high accuracy . these transcriptomic patterns can even distinguish between different viral (or bacterial) infections, and also enable evaluation of the severity of infection. rna sequencing analysis of the gene expression profiles of white blood cells during infection enables differentiation of viral and bacterial infections with higher specificity than white blood cell counts . therefore, transcriptomics represents an innovative tool that reduces the need to identify pathogens by culturing respiratory tract samples and does not need to be adjusted for asymptomatic carriage. the ideal control samples for transcriptomic analysis are samples from healthy patients, i.e. those attending for vaccination or other routine healthcare visits. lebanon is severely affected by a complex, chronic and protracted refugee crisis due to the ongoing war in syria that began in march . the bekaa valley is the main entry point for syrian refugees, followed by the north lebanon region and beirut, with refugees settling all over the country. the crisis not only affects syrian refugees, but also the local lebanese population and palestinian refugees who settled decades ago. as compared with version , and thanks to the accurate remarks of the two reviewers, the version of this manuscript has been stripped of imprecisions, clarified, and complemented with additional details (inclusion criteria, molecular methods, procedures for transcriptomics, conventional microbiology methods), as well as a more comprehensive and nuanced discussion. changes included the addition of the complete methodology of a triplex pcr that had not been disclosed in a previous scientific article. this prompted us to add m stéphane pouzol, who designed and developed that technique, as an author of the second version of the manuscript. 'erasmus medical center, rotterdam, the netherlands' has been added as affiliation for co-author hubert endtz. the majority of syrian refugees reside in approximately informal tented settlements and mobile centers, garages and unfinished buildings, with no officially established access to food, water, sanitary means, health or education. respiratory tract infections (rti) are among the leading causes of morbidity and mortality in children and adults affected by the current humanitarian crisis in lebanon. according to médecins sans frontières (msf), rti accounted for at least % of ambulatory or in-patient health care visits in the first six months of , and up to % of visits among children under -years-old in the healthcare facilities attended mainly by refugees in the bekaa valley (msf, personal communication). unpublished data from primary healthcare facilities in lebanon suggests that - % of these cases of rti are cap (ali ghassani, personal communication), though data on the etiology and severity of these cases of cap cases is lacking. in lebanon, cap peaks between october and april. specifically, % of the primary consultations for children during winter are related to rti, compared to % in the summer (ali ghassani, personal communication). the lebanese surveillance program for pulmonary infections due to s. pneumoniae considers the general population, and therefore current data on the incidence, predominant serotypes, and antimicrobial susceptibility of cap among the refugee population is not available . unicef and the lebanese ministry of health started the introduction of a -valent pneumococcal vaccine (pcv) as part of a national program in , among children of syrian, palestinian and lebanese origin. in order to fill the knowledge gaps described above, the pneumonia etiology among refugees and the lebanese population (pearl) study was initiated in to identify the causal pathogenic microorganisms in the respiratory tract of children and adults presenting with signs of cap to health facilities run by medical associations in the context of a humanitarian crisis. the first inclusions took place in november , and the study is expected to last until march . the primary objective of the pearl study is to estimate the population attributable fractions (pafs) of specific viral and bacterial pathogens, i.e. the proportion of cap attributable to each pathogen, in both the refugee population and lebanese population. the goals behind this objective are (i) to enable local healthcare staff to provide more accurate diagnoses and improved case management and care, (ii) to help designing antimicrobial stewardship interventions, and (iii) to help assessing the impact of pcv, as it will generate baseline data on the burden of cap caused by streptococcus pneumoniae at the introduction phase of pcv in the national vaccination program. the secondary objectives of the pearl study are to: identify s. pneumoniae serotypes in nasopharyngeal and blood samples; identify the antimicrobial susceptibility profiles of the pathogenic bacteria isolated from nasopharyngeal and blood samples and compare these profiles with antibiotic prescriptions; examine the association between respiratory viral infections and invasive pneumococcal infections; identify risk factors for cap in this population, especially those that may be modifiable (crowding, tobacco smoking, domestic sources of smoke produced by cooking or heating, etc.), and thus provide data for prevention programs; provide current data on the incidence and severity of cap in vulnerable populations in lebanon; provide a unique transcriptomics dataset as regards the sociodemographic profile of the patients and spectrum of diseases; compare microbiological and transcriptomic methods in estimating viral vs bacterial attributable fractions of lrti; and assess the operational capacity of rapid, nuclear acid-based point-of-care diagnostic tests in a humanitarian crisis. study setting and design based on refugee density, two main regions were selected for this multicentric prospective case-control study: the bekaa valley and the city of tripoli ( figure ). both regions have similar demographic composition, dynamics and climate. the population eligible for the study consists of any child (> -months-old) or adult attending one of four primary healthcare facilities (no hospital facilities) that provide routine health care and immunization: one site located in tripoli and three sites in the bekaa valley (kamed el loz, machghara, and baalbeck el ain). in addition to refugees, local and vulnerable lebanese individuals who also attend these health centers (although to a lower extent) will be included for ethical and practical reasons. nasopharyngeal, urine and blood samples will be collected from patients with cap (cases). adults with cap able to produce sputum will be asked to provide a sputum sample. as cap-related pathogens can also be carried by healthy individuals, control individuals will be recruited from the same health facilities; cases and controls will be matched in a : ratio by age, season and site. nasopharyngeal swabs and urine will be collected from all controls; a subset of controls ( %) will also be asked to provide a small blood sample ( - µl) for transcriptomic analysis. controls will not be asked to provide sputum samples. after enrolment in the study, patients will be managed as per local guidelines and doctors' recommendations; in particular, the study won't alter procedures for referral for complementary examinations or hospitalization. cases. physicians will evaluate case definitions on the basis of a clinical examination and patient history. the case definition was based on who's imci . cases should meet all of the following inclusion criteria: (i) patient aged > months, (ii) with cough or dyspnea, (iii) lower chest wall indrawing (in children ≤ years only) or tachypnea, (iv) no wheezing suggestive of asthma at auscultation, (v) onset of symptoms within the last days, (vi) and informed consent statement signed by the patient, parent, or legal guardian (supplementary file ). tachypnea is defined as > breaths per minute in patients between -months and < -year-old; > breaths per minute, between and < -years-old; breaths per minute, between ≥ and < -years-old and > breaths per minute, if ≥ years-old. characteristics of wheezing suggestive of asthma included: expiratory wheezing, high pitched wheezing, wheezing with history of asthma and without fever nor history of fever, and any clinical picture such as the clinician would exclude lrti and retain asthma as final diagnostic. exclusion criteria are (i) any characteristic of healthcareassociated pneumonia, (including hospitalization at an acute care hospital for or more days within days of infection, residence in a nursing home or long-term care facility, recent intravenous antibiotic therapy, or wound care from medical staff within the days prior to the current infection); or (ii) increased risk of lower airway disease, such as immunocompromised status due to underlying disease, including hemodialysis, or immunosuppressant treatment; or (iii) treatment with inhaled corticosteroids or other asthma medications. the study nurse will check inclusion criteria, and ask the patient or their parent/guardian to provide signed informed consent and fill in the case report form (crf), which includes a medical history (e.g. hiv infection, tuberculosis, respiratory infections), risk factors for pneumonia, prior medical treatment and immunizations, description of clinical signs that warrant enrolment in the study, current and recent treatment (antibiotic therapy), disease progression, and socio-economic characteristics (supplementary file ). pulse oximetry is used to assess the severity of cap ; pulse oximeters will be made available to all four healthcare facilities for the present study and pulse oximetry will be reported in the crf. data will be anonymized by attributing a unique patient identification code number issued at enrolment of each patient. physicians may request other tests such as chest radiography without interfering with the study protocol. antimicrobial treatment may begin immediately after blood sampling, if required. cases and controls may also undergo clinical and lab tests as required. chest x-ray is not required as this examination is not available at all health care facilities, especially the three remote healthcare facilities in bekaa valley; if available, results from chest x-rays will be reported in the crf. severity of pneumonia will be classified according to the imci/ who guidelines . moreover, in children under five years of age, we will assess the breathing rate twice, since it has been shown that the cut-off of > breaths per minute, assessed twice, is more specific for pneumonia than the standard imci recommendations for children - years old ( breaths/min) , and was successfully adopted in the almanach protocol , . controls. an aged-matched control will be recruited for each case by age group (± year for children aged months to years, ± years for children - years, and ± years for patients aged - years old and adults aged ≥ years old). controls will be matched to cases attending the same site in the same calendar month (some flexibility is allowed since controls for cases included at the end of one month may be recruited in the next calendar month). the study nurse will identify next patient consulting for reasons other than respiratory (upper or lower respiratory tract) or gastrointestinal infection, check eligibility, obtain written informed consent from the participant, and fill in the crf. controls should meet all of the following inclusion criteria: (i) patients aged > months attending one of the four sites participating in the study for symptomatic disease or immunization; and (ii) informed consent signed by patient or parent/guardian. patients will be excluded as controls if they (i) exhibited any symptom of rti (cough, dyspnea, chest wall indrawing, tachypnea, fever, coryzal symptoms/"cold") or (ii) intestinal infection (watery/bloody diarrhea, abdominal cramps) in the last days. individuals with gastro-intestinal symptoms were excluded as some viruses (adenovirus, enterovirus, and coronavirus) are proven or suspected to cause either respiratory or gastro-intestinal symptoms - , and including such patients as controls would result in an underestimation of the attributable fraction of these pathogens. as pathogen distributions can vary according to patient age, the univariate and multivariate analyses will be stratified by age group. we calculated the total sample size required for each age group to detect a difference in pathogen prevalence between cases and controls (assuming an equal distribution of samples between the age groups) based on a power of % (α = . ). pearson's χ test indicated cases and controls were required in each of the four age strata ( months to years, - years, - years, > years) to detect a % difference in pathogen frequency between cases and controls (with a carriage prevalence < % in controls) or detect a difference in pathogen frequency of % (with a carriage prevalence of up to % in controls). if no differences between age groups is observed, pooling the data from age groups will increase statistical power. thus, the final sample size will be a minimum cases and controls with the aim of including a maximum of cases and controls. biological samples will be collected and stored using standard protocols and transported together with the sample log to the laboratories in a multicentric manner ( table ). all analytical tests will be performed according to good clinical laboratory practice (gclp) following standard operating procedures defined for the study. sample processing for cases and controls are illustrated in figure and figure , respectively. the total volume of blood taken is . - . ml in controls of all ages and, in cases, . - . ml in infants (< year old), . - . ml in children aged one to four, . - . and ml in children aged five or above, and . - . ml in adults (≥ years old), with a flexibility in the age cut-off depending on the individual's weight and overall health status. clinically relevant results will be communicated to the clinicians in a timely manner. such results include: (i) identification of pathogen bacteria in blood, by conventional microbiology or molecular tools, (ii) identification of clinically relevant bacteria in nasopharyngeal swab or sputum of cases, e.g. detection of atypical bacteria; (iii) identification of rsv in infants (cases or controls) aged ≤ months, and (iv) positive binax® test in urine of case. whenever the lab identifies a pathogen or sensitivity profile of importance for the clinical management of pneumonia, they will provide their etiological diagnosis to the clinical team to ensure appropriate case management. all laboratory data will also be transmitted to the local fondation mérieux office in beirut. a trained nurse or lab technician-in-charge will collect two nasopharyngeal samples from all cases and controls : one will be discharged in virus transport medium (vtm) and the other in skim milktryptone-glucose-glycerol (stgg) medium. nasopharyngeal swabs will be processed and analyzed as shown in table and figure and figure . nucleic acids extracted from µl of vtm using qiaamp® dna mini kit (qiagen, hilden, germany) will be subjected to a real-time triplex pcr assay targeting streptococcus pneumoniae, staphylococcus aureus and haemophilus influenzae b, the three most common bacteria detected in cap. this triplex pcr has been used in previous studies , . briefly, µl extracted nucleic acids are added to µl takyon no rox probe x mastermix dttp (eurogentec, seraing, belgium) and µl of a solution containing µm of each primer and probe. each pcr ccc gag t, using cy as a fluorophore. amplification curves will be examined individually by two independent technicians, at the local laboratory and at the laboratoire des pathogènes emergents (lyon, france). cycle thresholds (ct) value will be manually set so that it intersects the exponential curve at its inflexion point. any exponential signal observed between and ct value will be considered as positive. sputum samples and stgg media will be inoculated onto different selective agar plates according to standard laboratory procedures (at least one blood culture medium, one chocolate agar, and one medium selective for gram-negative bacilli) and incubated under specific conditions ( °c, aerobic atmosphere supplemented with co ) to determine the presence of respiratory pathogens and assess antibiotic susceptibility . quality of sputum and absence of contamination by saliva will be assessed by standard laboratory procedures . positive cultures will be subjected to gram staining and examined by light microscopy, and sub-cultured for identification and antimicrobial susceptibility testing if the strain is confirmed to be clinically relevant. duplicate aerobic haemoculture assays will be performed for all cases using bact/alert (biomérieux, marcy l'etoile, france) or bactec (becton dickinson, franklin lakes, nj, usa) automated blood culture systems. the target blood volume for blood culture is - ml in under-fives and ml in children aged five or above and in adults, following manufacturers' recommendations. if the volume of blood recovered is insufficient to inoculate two bottles, a single culture will be performed. positive cultures will be examined by light microscopy (gram staining) and subcultured on agar culture media for identification. antimicrobial susceptibility testing will be performed for all clinically relevant strains. whole blood ( µl edta) samples from all cases will be extracted using qiaamp dna blood mini kit (qiagen, hilden, germany), and the same semi-quantitative multiplex real-time pcr assay as for respiratory samples will be conducted on µl of extracted dna to identify streptococcus pneumoniae, staphylococcus aureus and haemophilus influenzae b. transcriptomics. blood samples ( . - ml) for transcriptomics from all cases and % of controls will be collected in tempus tubes containing stabilizing agents for conservation of mrna, and shipped to the nationwide children's hospital research institute, in columbus, ohio, usa. sampling for transcriptomics was initiated in may . total rna will be isolated from whole blood collected in tempus tube and analyzed for quality using the rna nano kit (agilent technologies). globin mrnas will be further removed with gobinclean kit (thermo fisher scientific). poly(a)-enriched next-generation sequencing library construction will be performed using the kapa mrna hyper prep kit (kapa biosystems) with ng of input total rna and amplification cycles according to the manufacturer's protocol. individual libraries will be quantitated via quantitative pcr using the kapa library quantification kit, universal (kapa biosystems) and equimolar pooled. final pooled libraries will be sequenced on an illumina hiseq with singleend -base-pair (bp) read lengths. the presence of antibiotics in urine samples from all cases and controls will be assessed using the disk diffusion method , and the rapid immunochromatographic binax® assay (alere, orlando, fl, usa) will be used for qualitative detection of s. pneumoniae c polysaccharide antigen in urine . other data collected all involved healthcare facilities will be required to provide monthly report of the total number of consultations and, whenever available, the number of lrtis. this will help weighting the monthly results from the study to reflect the actual incidence of cap. a subgroup of patients or parents/legal guardians, randomly selected, was called back at least one month after inclusion to re-evaluate the outcome of included cases (hospitalization, death). the primary outcome of the pearl study is the etiological distribution of cap, expressed as pafs for individual pathogenic agents. pafs will be calculated for each three-month period of the -month study, and by patient age group ( to -months-old and to , to , to , and ≥ -years-old), by site location (tripoli vs. bekaa valley), subpopulation (syrian refugees versus lebanese population), and severity of pneumonia. additional indicators will be examined to assist data interpretation and for public health and clinical care purposes, including the incidence of rti and other diseases in the populations consulting the four healthcare facilities involved in the study, agent-specific hospitalization and fatality rates, the sociodemographic characteristics of the patients, clinical signs of cap (e.g. severity criteria), epidemic features if appropriate (e.g. types of influenza viruses circulating during epidemic periods), and care provided (e.g. antimicrobial use). all data (crf, informed consent forms, data logs) will be transmitted to the local fondation mérieux office in beirut for data entry using epiinfo version . (cdc, atlanta, ga, usa). the data will be anonymized by attributing a unique patient identification code number issued at patient enrolment. access to the names of participants and their corresponding identification codes will be restricted and forms will be secured in locked cupboards. data analyses will include (i) descriptive comparisons of the sociodemographic, clinical, and lab data of cases and controls; (ii) univariate/multivariate logistic regression of the relationship between case/control status and pathogens, adjusted for age, season, site, and pneumonia risk factors; and (iii) computation of pafs for every pathogen, specified by age group, period, study site, subpopulation (syrian refugees, or general lebanese population), and pneumonia severity, as described previously . ninety-five-percent confidence intervals will be calculated, with regards to the outcomes linked to the primary and secondary objectives. analyses will be performed using r version . . (r core team, vienna, austria ) and/or stata version . (stata-corp lp, college station, tx, usa) software. rna sequencing data from transcriptomics will be analyzed at the nationwide children's hospital, oh, usa. quality control of raw reads will be performed with fastqc. reads will be aligned to the reference human genome (grch ) using hisat after quality and adapter trimming by cutadapt. featurecounts program will be used to quantify total number of read counts for each gene. the rna sequencing data analysis will be performed in the r programming language, using deseq r package for size factor, dispersion estimation calculation and differential gene expression analysis. a number of supervised and unsupervised analytical approaches, and modular analyses will be used to identify the pathogen-associated transcriptome profiles as previously described [ ] [ ] [ ] . etiologic fractions will be also computed from transcriptomics data, independently from calculations from microbiological data, and compared with each other. the results of the study (microbiological and transcriptomics results) will be published as scientific publications in international peer-reviewed journals. the designation of co-authors will conform to international guidelines governing publications. the findings of the project, when completed, will be presented to the ministry of health of lebanon, and to the medical and scientific community, such as united nations agencies and non-governmental organizations, involved in medical care of vulnerable populations in lebanon. the results will also be communicated via the gabriel website (https://www.gabrielnetwork.org/). the study data relevant to a publication authored by the investigators will be available for review in a public data repository this study will be conducted in accordance with the declaration of helsinki , the recommendations for good ethical practices in epidemiology of the association of french-language epidemiologists , the good clinical practice recommendations from the international conference on harmonization of technical requirements for registration of pharmaceuticals for human use (ich) relevant to observational studies , and the gclp guidelines of the who . the informed consent statement has been translated into arabic and was validated during the pilot phase of the study. all adult patients and the parents or legal guardians of children (i.e. ≤ years) will be asked to sign an informed consent statement prior to enrolment in the study. the pneumonia etiology among refugees and lebanese population (pearl) study will yield unique data on the etiology of cap in the context of a humanitarian crisis. this study is not only original in terms of target population (refugees), but also as it will assess patients of all ages and adopt a primary health care approach while previous major studies only targeted hospitalized cases - , , . therefore, this study may provide a unique and valuable perspective on the etiology of cap in the context of a humanitarian crisis. however, assessment of the etiology of cap in low resource primary health care settings relies on clinical signs for case definition, as chest x-rays are not available at most of the centers in this study. inclusion criteria for cases of pneumonia are a controversial issue. several case definitions, based on different clinical, radiological, or biological criteria, have been used in different studies. opting for a single case definition imposes restrictions on the anatomical and histological levels of the respiratory tract involved, on the severity of disease, and therefore may introduce a bias towards the relative prevalence or contribution of specific pathogens. this makes it difficult to compare results between studies using different case definitions; the present study does not avoid this limitation. we also anticipate other limitations. for example, the imperfect sensitivity of the diagnostic tests used to identify certain pathogens may result in an underestimation of certain etiological fractions . moreover, with regards to surveillance of pneumonia, given that the population covered by the healthcare facilities participating in this study is hard to define, estimation of the precise incidence of cap in this population might not be possible. additionally, certain aspects of cap will not be explored in this study, especially aids-associated pneumonia and tuberculosis. we expect individuals with hiv will be excluded from the present study as hiv infection is one type of immunosuppression, which is an exclusion criterion. as the prevalence of hiv is very low (< . %) in both the general lebanese and syrian populations , inclusion of cases hiv/aids-associated cap would only have a small effect on the results. patients with tuberculosis are also expected to be excluded, since duration of symptoms > days is an exclusion criterion. the incidence rate of tuberculosis among syrian refugees did not increase in the last couple of years and remains relatively low at close to pre-war levels, i.e. - / . population . therefore, we consider it unlikely that tuberculosis is a major cause of acute lrti in our population . finally, the external validity of our study is limited in time ( months) and space (four health facilities). a case-control study cannot replace longitudinal surveillance systems, as are currently being set up in lebanon, e.g. the lebanese inter-hospital pneumococcal surveillance program . therefore, although the situation of syrian refugees in lebanon shares a lot of characteristics with other crises, one should be cautious about applying the results of pearl to other humanitarian crises, because of the variations of the epidemiology of lrti. despite these limitations, the pearl study is expected to provide healthcare planners with an empirical basis for the management of cap in the context of a refugee crisis. such information may help to guide population-based health interventions, such as immunization strategies for pneumococci, h. influenzae and influenza. in particular, analysis of s. pneumoniae serotypes in vaccinated and non-vaccinated individuals will provide information on the herd effect following introduction of the pcv in lebanon and will provide proxy baseline data for evaluation of the success of this vaccination program. this study will also provide practical experience and a methodology for determination of the etiology and involvement of viral and bacterial agents in cap in other similar humanitarian crisis settings. no data is associated with this article. stephen r. howie department of paediatrics: child and youth health, university of auckland, auckland, new zealand thank you for the opportunity to review this study protocol. this protocol describes a multicentre case control study of pneumonia etiology in refugee populations in lebanon. this is a population at high risk of pneumonia and data on etiology in this group will be welcome. the study has already completed recruitment, and is undergoing analysis. it is no simple task undertaking such a study, and i look forward to seeing its findings. i have a number of comments and suggestions. the protocol is clear in some of its aspects and unclear in others: i commend the authors for the former and i will focus my comments on the latter, which are points to be addressed. the authors rightly stress the limitations of 'blindly' applying etiology data from other studies to this population. they should be similarly cautious about applying their findings to those suffering in the midst of humanitarian crisis elsewhere, and even to those in the study settings at other times. fifteen months is relatively short, and refugee contexts are unstable and prone to epidemics. what happens in that month period may not be what is happening the next year. a case-control study such as this certainly has value, and longitudinal surveillance would add more value. the relationship between existing pneumococcal surveillance systems in lebanon and this study is not clear from the protocol; adding broader pathogen surveillance to those systems has much to recommend it. i note too the lack of any data about tb in the study protocol, a gap it would be good to fill. are there plans to address this in the future? the protocol makes much of the benefits of transcriptomic analysis (including that it 'reduces the need to identify pathogens by culturing respiratory tract samples') but is relatively silent on how this will be undertaken and how data will be used to achieve the primary aims. biomarkers for pneumonia etiology (whether they be transcriptomic or other), while attractive conceptually, have many limitations, and their practical applicability at this point need careful scrutiny. i wonder whether the transcriptomic aspect of this study is an exploratory add-on (not in itself an invalid thing to do). i see no mention of power calculations with respect to the transcriptomic element, for instance, or how it will be integrated into the analysis as a whole. the power calculation description is restricted to the primary objective. it would be helpful to show that there is adequate power for all objectives. the analytic methods planned for the primary objective are fairly restricted. i would encourage the authors to learn from the approaches taken in studies such as perch and get the most they can out of the data. this can still be done even though recruitment has been completed. there is no mention of using a point-of-care testing approach except at the end of the objectives and i wonder what was meant by that. the case definition used was not explicitly linked to the who definition, but reference was made to using who categorisation of severity. clarifying the relationship between study and who definitions would be helpful. what does the protocol mean when it says that inclusion requires "no wheezing suggestive of asthma at auscultation"? what sort of wheezing is that? does 'suggestive' mean age, history, trial of bronchodilator, or something else? what does the protocol mean when it specifies "particular attention to pneumonia with a breathing rate > breaths per minute'? was this a de facto entry criterion? what does the protocol mean when it says that 'relevant' results will be communicated to clinicians. which are these? did you share np or sputum pcr results and if so how did you suggest that clinicians interpret them? the protocol appears to state that ml of blood will be taken for blood culture. even in infants? the sample collection protocols requires clarification here. are the datasets clearly presented in a useable and accessible format? not applicable carefully reviewed his report and we changed the manuscript according to his propositions. our answers to his questions and comments are listed in the text below. the authors rightly stress the limitations of 'blindly' applying etiology data from other studies to this population. they should be similarly cautious about applying their findings to those suffering in the midst of humanitarian crisis elsewhere, and even to those in the study settings at other times. action/answer: we added a sentence in the paragraph regarding the limitations of the study (discussion chapter): "although the situation of syrian refugees in lebanon shares a lot of characteristics with other crises, one should be cautious about applying the results of pearl to other humanitarian crises, because of the variations of the epidemiology of lrti." comment: fifteen months is relatively short, and refugee contexts are unstable and prone to epidemics. what happens in that month period may not be what is happening the next year. a case-control study such as this certainly has value, and longitudinal surveillance would add more value. the relationship between existing pneumococcal surveillance systems in lebanon and this study is not clear from the protocol; adding broader pathogen surveillance to those systems has much to recommend it. action/answer: we added a sentence in the discussion, just before the one above: "finally, the external validity of our study is limited in time ( months) and space (four health facilities). a case-control study cannot replace longitudinal surveillance systems, as are currently being set up in lebanon, e.g. the lebanese inter-hospital pneumococcal surveillance program.". comment: i note too the lack of any data about tb in the study protocol, a gap it would be good to fill. are there plans to address this in the future? action/answer: this was acknowledged as a limitation of our study in the first version of the manuscript: "certain aspects of cap will not be explored in this study […] . patients with tuberculosis are expected to be excluded, since duration of symptoms > days is an exclusion criterion." nevertheless, we added the following sentence: "the incidence rate of tuberculosis among syrian refugees did not increase in the last couple of years and remains relatively low at close to pre-war levels, i.e. - / . population. therefore, we consider it unlikely that tuberculosis is a major cause of acute lrti in our population." and we provided references for this assertion. the protocol makes much of the benefits of transcriptomic analysis (including that it 'reduces the need to identify pathogens by culturing respiratory tract samples') but is relatively silent on how this will be undertaken and how data will be used to achieve the primary aims. biomarkers for pneumonia etiology (whether they be transcriptomic or other), while attractive conceptually, have many limitations, and their practical applicability at this point need careful scrutiny. i wonder whether the transcriptomic aspect of this study is an exploratory add-on (not in itself an invalid thing to do). i see no mention of power calculations with respect to the transcriptomic element, for instance, or how it will be integrated into the analysis as a whole. action/answer: the reviewer is right: transcriptomics is an add-on, as we have clearly stated that "patient enrollment began in november " and that "sampling for transcriptomics was initiated in may " (i.e. months after the initiation of the study). therefore, the overall study has not been powered to meet this secondary objective. in order to clarify these points, we added the following sentence in the chapter related to data management and analysis: "etiologic fractions will be also computed from transcriptomics data, independently from calculations from microbiological data, and compared with each other." the power calculation description is restricted to the primary objective. it would be helpful to show that there is adequate power for all objectives. action/answer: the study has been powered for the primary objective only, and the uncertainty around the values corresponding to secondary objectives will be provided by % confidence intervals. we added the following sentence in data management and analysis: "ninety-five-percent confidence intervals will be calculated, with regards to the outcomes linked to the primary and secondary objectives." the analytic methods planned for the primary objective are fairly restricted. i would encourage the authors to learn from the approaches taken in studies such as perch and get the most they can out of the data. this can still be done even though recruitment has been completed. action/answer: methodologies such as partially latent class models (if this is what dr howie refers to) have been considered for pearl study. nevertheless, they can poorly be applied to our dataset given the restricted range of samples in our study: nasopharyngeal swab mainly, some sputum, and blood cultures -that are expected to have a low yield in primary health care and will therefore be poorly informative. in comparison with perch, where information from a much wider range of biological samples taken from severe cases was used, our dataset would be poorly suitable for complex models. another drawback of plc models is that they appear as a 'blackbox' while population attributable fraction, resulting from generalized linear models, are much more straightforward and comprehensible. there is no mention of using a point-of-care testing approach except at the end of the objectives and i wonder what was meant by that. action/answer: actually, the poc tests will be performed in laboratories located nearby but not in the institution where the patients will be included. the results are therefore not become available real time and cannot be considered true poc tests. the case definition used was not explicitly linked to the who definition, but reference was made to using who categorisation of severity. clarifying the relationship between study and who definitions would be helpful. action/answer: exact. we added the following sentence in inclusion criteria: "the case definition of cap was based on the who's imci. " comment: what does the protocol mean when it says that inclusion requires "no wheezing suggestive of asthma at auscultation"? what sort of wheezing is that? does 'suggestive' mean age, history, trial of bronchodilator, or something else? action/answer: the reviewer is correct. this is indeed not clear. we added the following sentence in inclusion criteria: "characteristics of wheezing suggestive of asthma included: expiratory wheezing, high pitched wheezing, wheezing with history of asthma and without fever nor history of fever, and any clinical picture such as the clinician would exclude lrti and retain asthma as final diagnostic." comment: what does the protocol mean when it specifies "particular attention to pneumonia with a breathing rate > breaths per minute'? was this a de facto entry criterion? action/answer: no, it just means that we measured the breathing rate twice in children, in order to evaluate its pertinence in our own dataset. in the manuscript, we therefore changed the sentence as follows: "moreover, in children under five years of age, we will assess the breathing rate twice, since it has been shown that the cut-off of > breaths per minute, assessed twice, is more specific for pneumonia than the standard imci recommendations for children - years old ( breaths/min), and was successfully adopted in the almanach protocol." comment: what does the protocol mean when it says that 'relevant' results will be communicated to clinicians. which are these? did you share np or sputum pcr results and if so how did you suggest that clinicians interpret them? action/answer: the criteria for feedback of individual lab data, as specified in the protocol shared with laboratories, included: identification of clinically relevant bacteria in blood (e.g. no bacteria associated to skin contamination, like coagulase-negative staphylococci), by conventional microbiology or molecular tools. information of identification and ast results will both be reported to the clinician by phone as soon as they will become available. identification of clinically relevant bacteria in nasopharyngeal swab or sputum of cap cases, by conventional microbiology or molecular tools. this includes detection of atypical bacteria (chlamydia pneumoniae or mycoplasma pneumoniae) by biofire. information related to the identification and ast results will be reported by phone to the clinician as soon as they become available. the protocol appears to state that ml of blood will be taken for blood culture. even in infants? the sample collection protocols requires clarification here. action/answer: no, in infants and small children, the volume of blood taken was lower. the following sentence has been added to clarify this: "the target blood volume for blood culture is - ml in under-fives and ml in children aged five or above and in adults, following manufacturers' recommendations." © page a. this is an open access peer review report distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. epicentre, paris, france this manuscript describes the study protocol for a study on the etiology of pneumonia among refugees and local population in lebanon. the study, which has already completed all inclusions, was designed to investigate the population-attributable fractions (paf) of specific viral and bacterial pathogens by comparing the proportion of pathogens detected by culture, pcr and rapid tests among pneumonia cases and age-matched controls. in addition, it aims at describing the pathogens isolates (antimicrobial susceptibility and serotypes if applicable), identifying risk factors for pneumonia and providing transcriptomics data to identify expression patterns associated with specific pathogens. the manuscript is clear and well written and describes the study adequately, except for some areas, which would require additional information: describe the recommended volumes of blood collection for blood culture according to the age . the study sites are primary healthcare facility (no hospital facility), but some of the inclusion criteria (in particular chest indrawing in children < years of age) would require immediate referral to hospital. please describe how inclusions are performed for these patients. describe the rationale for having gastrointestinal infections as exclusion criteria for controls. the sample size calculation is stratified by age group ( patients for each of four age groups), leading to a final sample size of minimum cases and maximum cases. it would be helpful to know what were the expected proportions of patients in each age group to understand the final sample size calculation. the authors could comment on the fact that finally patients were included, which is not consistent with the initial sample size calculated. more information could be provided on the culture of bacterial from respiratory samples (sputum samples and nasopharyngeal swabs). is quality of the sputum and absence of saliva contamination assessed? which selective media are used? . please provide more information about transcriptomics analysis (at least a reference). . the references cited for the semi-quantitative multiplex real-time pcr assay to detect s. pneumoniae, s. aureus and h. influenzae b do not provide sufficient information on the method. authors should also describe more in details how this assay is performed on edta whole blood (volume of blood used for extraction and in the pcr assay). interpretation of the pcr results from blood, sputum and nasopharyngeal swabs should also be described, in particular if there is a threshold (in ct or copies/ml) used to consider the result as positive. it is unclear whether the additional indicators described in the study outcomes would come from the study results or from other sources. some, like clinical signs of cap, can be analysed from the study data, whereas others, while for others, like agent-specific hospitalization and fatality rates, the corresponding data is not collected in the crf. the primary objective states that the pafs will be estimated "using a combination of conventional methods and transcriptomics", but it is unclear in the analysis plan if or how the transcriptomics data will be used to determine the pafs and how these transcriptomics data will be analysed. is the rationale for, and objectives of, the study clearly described? yes are sufficient details of the methods provided to allow replication by others? partly are the datasets clearly presented in a useable and accessible format? not applicable global and regional mortality from causes of death for age groups in and : a systematic analysis for the global burden of disease study we would like to thank all of the participants in this study, who provided their time and biological samples. we are very grateful to all health care workers, nurses, medical doctors and laboratory technicians at the participating health facilities, in particular: ahmad al hallak, anas altabaa, ali rida, asma are the datasets clearly presented in a useable and accessible format? not applicable competing interests: no competing interests were disclosed.reviewer expertise: infectious epidemiology, paediatric pneumonia i confirm that i have read this submission and believe that i have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.reviewer report january https://doi.org/ . /gatesopenres. .r © page a. this is an open access peer review report distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. epicentre, paris, france i have reviewed the response from the authors and believe that the revisions are appropriate.is the rationale for, and objectives of, the study clearly described? not applicable are sufficient details of the methods provided to allow replication by others? are the datasets clearly presented in a useable and accessible format? not applicable competing interests: no competing interests were disclosed. i confirm that i have read this submission and believe that i have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. competing interests: dr. howie has a patent 'lipocalin- as a biomarker for pneumococcal infection status' pending, which is not of specific relevance to this article but of broad relevance to the subject of pneumonia aetiology. no other competing interests were disclosed.i confirm that i have read this submission and believe that i have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however i have significant reservations, as outlined above. we would like to express thanks the reviewer for her useful comments and suggestions. we carefully reviewed her report and we changed the manuscript according to her propositions. these changes included adding the complete methodology of a triplex pcr that had not been disclosed in a previous scientific article. therefore, we added m stéphane pouzol, who designed and developed that technique, as an author of the present manuscript. our answers to her questions and comments are listed in the text below.comment: describe the recommended volumes of blood collection for blood culture according to the age. action/answer: the following sentence has been added to clarify this: "the total volume of blood taken is . - . ml in controls of all ages and, in cases, . - . ml in infants (< year old), . - . ml in children aged one to four, . - . and ml in children aged five or above, and . - . ml in adults (≥ years old), with a flexibility in the age cut-off depending on the individual's weight and overall health status." the study sites are primary healthcare facility (no hospital facility), but some of the inclusion criteria (in particular chest indrawing in children < years of age) would require immediate referral to hospital. please describe how inclusions are performed for these patients. action/answer: we added the following in study setting and design: "after enrolment in the study, patients will be managed as per local guidelines and doctors' recommendations; in particular, the study won't alter procedures for referral for complementary examinations or hospitalization." comment: describe the rationale for having gastrointestinal infections as exclusion criteria for controls. action/answer: we added the following in inclusion criteria -controls and provided a reference: "individuals with gastro-intestinal symptoms were excluded as some viruses (adenovirus, enterovirus, and coronavirus) are proven or suspected to cause either respiratory or gastro-intestinal symptoms, and including such patients as controls would result in an underestimation of the attributable fraction of these pathogens." the sample size calculation is stratified by age group ( patients for each of four age groups), leading to a final sample size of minimum cases and maximum cases. it would be helpful to know what were the expected proportions of patients in each age group to understand the final sample size calculation. action/answer: at the moment of protocol design, there were no data available regarding incidence of lower respiratory tract infection in the different age groups. we assume that will would include an approximately equal number of cases in each of the four age groups. hence, * = . the authors could comment on the fact that finally patients were included, which is not consistent with the initial sample size calculated. action/answer: actually, this is a result of the study, and that should not have appeared in the protocol. therefore, we removed that sentence. it will be discussed in the manuscript presenting the results of the study.comment: more information could be provided on the culture of bacterial from respiratory samples (sputum samples and nasopharyngeal swabs). is quality of the sputum and absence of saliva contamination assessed? which selective media are used? action/answer: we agree with the reviewer's comment. we modified the manuscript as follows: "sputum samples and stgg media will be inoculated onto different selective agar plates according to standard laboratory procedures (at least one blood culture medium, one chocolate agar, and one medium selective for gram-negative bacilli) and incubated under specific conditions ( °c, aerobic atmosphere supplemented with co ) to determine the presence of respiratory pathogens and assess antibiotic susceptibility. quality of sputum and absence of contamination by saliva will be assessed by standard laboratory procedures."comment: please provide more information about transcriptomics analysis (at least a reference). action/answer: done. the transcriptomics paragraph of analysis of biological samples chapter and the data management and analysis chapter have been substantially supplemented to include all procedures related to transcriptomics, and we added references to articles where those methods have been used. the references cited for the semi-quantitative multiplex real-time pcr assay to detect s. pneumoniae, s. aureus and h. influenzae b do not provide sufficient information on the method. action/answer: we amended references and added the information required for performing the pcr in the molecular biology testing of respiratory samples paragraph of analysis of biological samples chapter: sequences of primers, probes, reagents, and temperature cycle. authors should also describe more in details how this assay is performed on edta whole blood (volume of blood used for extraction and in the pcr assay). action/answer: done. the detection of bacteria in blood paragraph of analysis of biological samples chapter has been modified as follows: "whole blood ( μl edta) samples from all cases will be extracted using qiaamp dna blood mini kit (qiagen, hilden, germany), and the same semi-quantitative multiplex real-time pcr assay as for respiratory samples will be conducted on μl of extracted dna to identify streptococcus pneumoniae, staphylococcus aureus and haemophilus influenzae b." comment: interpretation of the pcr results from blood, sputum and nasopharyngeal swabs should also be described, in particular if there is a threshold (in ct or copies/ml) used to consider the result as positive. action/answer: done. the following sentence has been added in molecular biology testing of respiratory samples paragraph of analysis of biological samples chapter: "amplification curves will be examined individually by two independent technicians, at the local laboratory and at the laboratoire des pathogènes emergents (lyon, france). cycle thresholds (ct) value will be manually set so that it intersects the exponential curve at its inflexion point. any exponential signal observed between and ct value will be considered as positive." comment: it is unclear whether the additional indicators described in the study outcomes would come from the study results or from other sources. some, like clinical signs of cap, can be analysed from the study data, whereas others, while for others, like agent-specific hospitalization and fatality rates, the corresponding data is not collected in the crf. action/answer: agree. the following sentence has been added in other data collected: "a subgroup of patients or parents/legal guardians, randomly selected, was called back at least one month after inclusion to re-evaluate the outcome of included cases (hospitalization, death)." the primary objective states that the pafs will be estimated "using a combination of conventional methods and transcriptomics", but it is unclear in the analysis plan if or how the transcriptomics data will be used to determine the pafs and how these transcriptomics data will be analysed. action/answer: agree. this is indeed misleading. we removed this part of the sentence in the primary objective and added the following secondary objective: "compare microbiological and transcriptomic methods in estimating viral vs bacterial attributable fractions of lrti". no competing interests were disclosed. key: cord- -yx ucrb authors: ali, kamran; raja, mahwish title: coronavirus disease (covid- ): challenges and management of aerosol-generating procedures in dentistry date: - - journal: evid based dent doi: . /s - - - sha: doc_id: cord_uid: yx ucrb data sources experimental investigation. study design a retrospective review to evaluate the use of a negative-pressure otolaryngology viral isolation drape (novid) system to reduce cross-infection through aerosol. the apparatus consists of a plastic drape suspended over the surgical field in the head and neck region with a smoke evacuator suction placed inside the chamber with an ultra-low penetrating air (ulpa) efficiency rating and a fluid suction high-efficiency particulate air (hepa) filter compartment. spread of patient secretions and droplet formation was evaluated using % fluorescein dye in ml of normal saline and ultraviolet light. the dye was applied topically in the nasal cavity and nasopharynx preoperatively and intraoperatively prior to the use of instruments such as micro-debrider, electrocautery and high-speed drilling. following completion of the surgical procedure, an ultraviolet wood's lamp was used to evaluate the presence of droplets on the surgical drapes and surgical gowns of the operating team. results the study sample consisted of four patients who underwent endonasal endoscopic surgical procedures; two of these patients required concurrent endoscopic sinus surgery. a micro-debrider was used in three cases; electrocautery in three cases, while a high-speed drilling was employed in two cases. presence of fluorescein was identified around the patients' nares; on the chest wipe and instrument tray in all four patients. dye contamination was noted on the gauze placed over the smoke evacuator (two cases of skull base surgery); no fluid droplets were identified beyond the nares or the smoke evacuator (two cases of sinus surgery). however, fluid contamination was identified underneath barrier several centimetres away from the nares (one case of trans-sphenoidal surgery). droplets were also identified on the surgeon's gown in the abdominal region in all cases and on the arm region in one case. in one case, droplets were also identified on the abdominal region of the nurse, but this was attributed to cross contamination from surgical gauze and instruments. conclusions this retrospective study provides preliminary data on aerosol and droplet contamination during endonasal and transoral surgery performed under a negative pressure isolation drape system. although the authors did not screen patients for sars-cov- , they propose smoke evacuator ulpa filter attachment is appropriate to capture particles down to . microns including sars-cov- which is . microns. it would be helpful to see direct evidence to support this claim in future studies. the authors have not provided details regarding set-up time and training requirements for effective application of the isolation drape apparatus or the associated costs etc. it would have also been helpful if the authors could comment on any potential difficulties in undertaking the surgical procedure with the isolation system in place. the sample size is limited to four patients and variations in the magnitude and extent of aerosol contamination needs to be investigated further before drawing any conclusions. although unlikely, this study design did not capture the presence of aerosol/droplets in the air within the operating room which may follow removal of the isolation drape system or from exposed surgical instruments. notwithstanding the limitations of the design, negative-pressure aspiration of air under a chamber barrier is likely to minimise the contamination from aerosol and droplet during endonasal and transoral surgery. the study sample consisted of four patients who underwent endonasal endoscopic surgical procedures; two of these patients required concurrent endoscopic sinus surgery. a micro-debrider was used in three cases; electrocautery in three cases, while a high-speed drilling was employed in two cases. presence of fluorescein was identified around the patients' nares; on the chest wipe and instrument tray in all four patients. dye contamination was noted on the gauze placed over the smoke evacuator (two cases of skull base surgery); no fluid droplets were identified beyond the nares or the smoke evacuator (two cases of sinus surgery). however, fluid contamination was identified underneath barrier several centimetres away from the nares (one case of trans-sphenoidal surgery). droplets were also identified on the surgeon's gown in the abdominal region in all cases and on the arm region in one case. in one case, droplets were also identified on the abdominal region of the nurse, but this was attributed to cross contamination from surgical gauze and instruments. this retrospective study provides preliminary data on aerosol and droplet contamination during endonasal and transoral surgery performed under a negative pressure isolation drape system. although the authors did not screen patients for sars-cov- , they propose smoke evacuator ulpa filter attachment is appropriate to capture particles down to . microns including sars-cov- which is . microns. it would be helpful to see direct evidence to support this claim in future studies. the authors have not provided details regarding set-up time and training requirements for effective application of the isolation drape apparatus or the associated costs etc. it would have also been helpful if the authors could comment on any potential difficulties in undertaking the surgical procedure with the isolation system in place. the sample size is limited to four patients and variations in the magnitude and extent of aerosol contamination needs to be investigated further before drawing any conclusions. although unlikely, this study design did not capture the presence of aerosol/droplets in the air within the operating room which may follow removal of the isolation drape system or from exposed surgical instruments. notwithstanding the limitations of the design, negative-pressure aspiration of air under a chamber barrier is likely to minimise the contamination from aerosol and droplet during endonasal and transoral surgery. the coronavirus disease (covid- ) caused by the novel coronavirus (sars-cov- ) has had an unprecedented impact on people across the globe. even the most advanced healthcare systems in the world are still battling to deal with the challenges of covid- and no single strategy to limit the spread of this pandemic appears to be sustainable. covid- has posed serious tests for the political leadership across the globe due to the financial and social fallout and also exposed the vulnerabilities of modern healthcare infrastructures. the death rate from covid- in the western world including the usa, uk, france, italy, and spain etc, has been alarming and has raised questions regarding our preparedness for managing pandemics. kamran ali and mahwish raja • for now practitioners should focus on emergency and preventive dental care as evidence-based clinical protocols are needed prior to commencing invasive dental procedures • dental surgeries represent a potentially high-risk clinical environment and dental professionals must follow the most updated national and international guidelines in letter and spirit to protect themselves as well as their staff, patients, and the general public from further spread of covid- • additional costs related to ppe, staff training, and the investment to improve clinical environment coupled with low rates of patient turn-over will have a knock-on effect on the financial resources of dental businesses. therefore, governments and healthcare bodies must be urged to come up with concrete strategies to support the dental profession and keep dental practices financially viable • finally, dental professionals should not remain at the receiving end of cross infection control guidelines and should explore appropriate platforms to actively participate in research aimed at informing evidence-based protocols to limit the spread of covid- in dental environments. unsurprisingly povidone-iodine or . - % hydrogen peroxide may also be utilised preoperatively to reduce the viral load in the oral cavity. , the use of novid system offers promise to limit contamination from aerosol during surgical procedures performed under general anaesthesia in operating theatre environments. although use of this device on conscious patients in dental practice settings is unlikely in its current form, it opens doors to innovation in the development of barrier systems. in any case, dentists may benefit from evaluating the spread on aerosol during operative dentistry by using fluorescein dye and ultraviolet (uv) light as identified in this study. given our current understanding, covid- may be around for the coming months or even years, and is likely to influence the provision of dental care in more ways than one. the best-case scenario is development of an effective vaccine and coupled with universal precautions, life in dentistry may return to normal. until then, we are likely to be presented with a plethora of strategies and measures aimed at minimising the spread of covid- in clinical dental settings. these may include innovations in ppe; barrier devices to minimise aerosol contamination; air purification systems; anti-viral adjuncts; chairside screening for covid- in saliva; and modifications in clinical techniques, to name a few. undoubtedly, commercial players in the dental market will be interested to exploit these business opportunities as dentistry attempts to resume. therefore, dental professionals must make informed choices supported by scientific evidence. on the plus side, covid- presents an opportunity for dental professionals to diversify their career interests and explore their research potential through engagement with relevant research forums and platforms. cross infection protocols in dentistry are likely to undergo rapid evolution and dental professionals must contribute to this process rather than wait to be told what to do! who. coronavirus disease (covid- ) situation reports. available at virtual screening, and repurposing of fda approved drugs against covid- main protease remdesivir for covid- : challenges of underpowered studies evidence of increasing diversification of emerging sars-cov- strains what policy makers need to know about covid- protective immunity transmission of coronavirus disease (covid ) transmission routes of -ncov and controls in dental practice the oral surgery response to coronavirus disease (covid- ) inactivation of sars coronavirus by means of povidoneiodine, physical conditions, and chemical reagents persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents key: cord- - w qsld authors: valev, d. title: relationships of total covid- cases and deaths with ten demographic, economic and social indicators date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: w qsld we have used data for countries with a population of over millions in which . % of the world's population lives. the statistical relationships of total covid- cases and deaths per million populations in these countries with demographic, economic and social indicators (indices) were studied. these indicators are life expectancy, median age, growth rate, population density, gdp ppp per capita, human development index (hdi), gini index of income equality, intelligence quotient (iq), corruption perceptions index (cpi) and democracy index. statistically significant relationships were found with all indicators excluding gini index and population density. we have found that the closest is the relationship of deaths per million population and total cases per million population with correlation coefficient r = . . therefore, it is clear statistically that the more are cases per million in a country the more are deaths per million. this confirms the correctness of the timely and effective introduction of the necessary pandemic restrictions in the countries. it is interesting that the close correlations were found of cases and deaths per million with a purely economic index like gdp ppp per capita, where r = . and r = . , respectively. even more close correlations were found of cases and deaths per million with a composite index hdi, where the correlation coefficients reach . and . , respectively. this paradoxical results show that the richest and well-being countries are most seriously affected by the covid- pandemic. the most probable reason for this is the large percentage of aging population, comorbidity of population with severe chronic diseases and obesity in countries with high gdp and hdi. no less important reason appears the delayed and/or insufficiently effective pandemic restrictions in these countries, which have underestimated the danger of a pandemic in early stage. other indicators (excluding gini index and population density) also show statistically significant correlations with cases and deaths per million with correlation coefficients from . to . . the countries that deviates the most from the regression lines were shown. surprisingly, there was no statistically significant correlation between cases and deaths with population density. the statistical significance of the found correlations determined using student's t-test was p < . . the countries that deviate the most from both sides of the regression line were shown. it has been shown that the correlations of covid- cases and deaths with the studied indicators decrease with time. key words: covid- pandemic; statistics; cases and deaths per million; demographic, economic and social indicators coronavirus disease (covid- ) is an infectious disease caused by severe acute respiratory syndrome coronavirus (sars-cov- ) [ ] . it was first identified in december in wuhan, china, and has resulted in an ongoing pandemic [ ] . as of september , more than . million cases have been reported across countries and territories, resulting in more than thousand deaths. more than . million people have recovered [ ] . common symptoms include fever, cough, fatigue, shortness of breath, and loss of smell and taste. while the majority of cases result in mild symptoms, some progress to acute respiratory distress syndrome (ards) possibly precipitated by cytokine storm, multi-organ failure, septic shock, and blood clots. the virus is primarily spread between people during close contact, most often via small droplets produced by coughing, sneezing, and talking. according to the world health organization (who), there are neither vaccines nor specific antiviral treatments for covid- [ ] . management involves the treatment of symptoms, supportive care, isolation, and experimental measures. the who recommends - meters of social distance. severe acute respiratory syndrome coronavirus (sars-cov- ) is a novel severe acute respiratory syndrome coronavirus closely related to the original sars-cov [ ] . it is thought to have an animal (zoonotic) origin. it is % identical at the whole genome level to other bat coronavirus samples (batcov ratg ) [ ] . it is the seventh known coronavirus to infect people [ ] . the coronaviruses are capable of causing illnesses ranging from the common cold to more severe diseases such as middle east respiratory syndrome (mers, fatality rate ~ %). the standard method of testing is polymerase chain reaction (pcr) [ ] . the test is typically done on respiratory samples obtained by a nasopharyngeal swab, however, a nasal swab may also be used. based on johns hopkins university statistics, the global case fatality rate (cfr) is . % as of june . [ ] the number strongly varies by regionfrom less than % in saudi arabia, ethiopia, and uzbekistan to - % in italy, united kingdom and france [ ] . several factors have been found statistically that increase severe course and mortality of covid- : . one of the most important factors in covid- mortality is the age of infected. the case fatality rate (cfr) is the number of deaths divided by the number of diagnosed cases. according to data for china, cfr remains within . % for children and young people in the age groups - , - , - and - years. with age, cfr increases rapidly and reaches . % for the age group + years [ ] . dependence of cfr from age of infected is shown on fig. . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint the exponential type of cfr dependence on the age of the infected is similar in other countries, but in some countries with increasing age the cfr increases more sharp. for example, in the netherlands, sweden, finland, israel, canada, mexico, and the philippines, the cfr for the - age group exceeds %. in these countries, the cfr is significantly higher in the age groups over years too. [ ] . . the next crucial factor of mortality from covid- appears comorbidity of patients with severe diseases. most of those who die of covid- have pre-existing (underlying) conditions, including hypertension, diabetes mellitus, and cardiovascular disease [ , ] . . vitamin d deficiency in populations. strong correlation between prevalence of severe vitamin d deficiency and population mortality rate from covid- in europe has been found in [ ] . very high body mass index (obesity). johns hopkins cardiologist david kass discusses a recent study he co-led that links higher body mass index to more severe cases of covid- and points to obesity as a significant pre-existing condition in younger patients in particular [ ] . . the role of the bcg vaccine for the prevention of covid remains controversial yet [ , ] . the infection fatality rate (ifr) reflects the percent of infected individuals (diagnosed and undiagnosed) who die from a disease. ifr at least is several times less than cfr because of many asymptomatic and mild symptoms infected persons. it is hardly be accurately calculated yet the global value is of the order of . % [ ] . ifr strongly varies across regions and countriesfrom . % in sub-saharan africa to slightly above % in western europe and high-income asia pacific [ ] . the basic reproduction number (r ) of the virus has been estimated to be . [ ] . therefore each infection from the virus is expected to result in . new infections when no members of the community are immune and no preventive measures are taken. this shows that covid- is much more contagious than seasonal flu, which has r between and . preventive measures to reduce the chances of infection include staying at home, avoiding crowded places, keeping distance from others, washing hands with soap and water often and for at least seconds, avoiding touching the eyes, nose, or mouth with unwashed hands, and monitoring and self-isolation for people who suspect they are infected. authorities worldwide have responded by implementing travel restrictions, lockdowns, workplace hazard controls, and facility closures. many places have also worked to increase testing capacity and trace contacts of infected persons. many countries have recommended that healthy individuals wear face masks at least in certain public settings. this recommendation is meant to reduce the spread of the disease by asymptomatic and pre-symptomatic individuals and is a complementary measure to established preventive measures such as social distancing. the severity of covid- varies. the disease may take a mild course with few or no symptoms. social distancing includes infection control actions intended to slow the spread of disease by minimizing close contact between individuals. methods include quarantines; travel restrictions; and the closing of schools, workplaces, stadiums, theatres, or shopping centers. self-isolation at home has been recommended for those diagnosed with covid- and those who suspect they have been infected. many governments have mandated or recommended self-quarantine for entire populations. those who may have been exposed to someone with covid- and those who have recently traveled to a country or region with the widespread transmission have been advised to self-quarantine for days from the time of last possible exposure [ ] . containment is undertaken in the early stages of the outbreak and aims to trace is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint and isolate those infected as well as introduce other measures to stop the disease from spreading. suppression requires more extreme measures so as to reverse the pandemic by reducing the basic reproduction number to less than [ ] . more drastic actions aimed at containing the outbreak were taken in china once the severity of the outbreak became apparent, such as quarantining entire cities and imposing strict travel bans [ ] . contact tracing is an important method for health authorities to determine the source of infection and to prevent further transmission [ is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint we used data for countries with a population of over million. there are countries from china with million inhabitants to angola with . million inhabitants [ ] . in our work, we have used the limit of more than million populations, because these countries are less than a quarter of the countries in the world, and . % of the world's population lives in them. moreover, the difference in population of the countries used for statistical analysis does not exceed times. if all countries were used in the study, taking into account that the difference in the population between the largest country and smallest one (china and the vatican, respectively) is over a million times, an unacceptably large difference in the statistical weight of the countries would be obtained. data for total covid- cases per million population (cases/ m) and deaths per million populations (deaths/ m) were used for all countries studied. the data were taken from [ ] . data for may were used in the main calculations. to check whether there is a change in the correlations with the development of the pandemic, a statistical analysis was made for three different dates roughly two months apart - april, may and august . the following demographic, economic and social indicators (indices) for the surveyed countries were used, namely: is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . in addition to linear regression, power, logarithmic and exponential functions were used for statistical data processing. the statistical significance of the found correlations was assessed using student's t-test. the statistical package statistica has been used for calculations. below the results of statistical studies on the relationship of total covid- cases per million population and deaths per million populations at may with demographic, economic and social indicators (indices) are shown. we have found that the log deaths per million is the most closely connected with log cases per million and the coefficient of correlation reaches r = . . the dependence of log deaths per million from log cases per million is shown in fig. . the names of the most deviated countries from the regression line are shown in the figure. therefore, it is statistically clear that how the more are cases per million in a country, the more are deaths per million. from fig. it is seen that saudi arabia, russia, vietnam and uganda lie below the regression line, i.e. mortality in these countries is lower. a case fatality rate (cfr) from cases per million was then sought and it was found that cfr increased logarithmically with increasing of cases. the relationship is statistically significant with a correlation coefficient r = . and is shown in fig. . this confirms that the higher the cases per million, the higher the case fatality rate. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . a statistical analysis of the relationship of total covid- cases and deaths with demographic, economic and social indices has been implemented below. a statistical link between total cases and deaths with life expectancy was first sought. a positive correlation was found with correlation coefficients r = . and r = . , respectively. as total cases and deaths per million differ by several orders of magnitude in different countries, we hypothesized that they increase exponentially with life expectancy. indeed, the correlation coefficients of the exponential relationship increased and reached . and . , respectively. the dependence of log cases/ m from life expectancy is shown in fig . the most deviating countries from exponential relationship were shown. vietnam, japan, south korea, thailand, myanmar and angola lie below the regression line, whereas spain, usa, peru, russia, south africa, nigeria and dr congo lie above the regression line. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . the statistical significance of the found correlations determined using student's t-test was p < . . the trend of exponential growth of total cases and deaths with life expectancy is unambiguous. this is not a surprising result as it is well known that covid- disease affects people over the age of much more severely [ ] . due to the high proportion of adults over the age of living in countries with a high life expectancy, their cases and deaths are significantly higher than those with low life expectancy. the median age of a population is the point at which half the population is older than that age and half is younger. the median age closely correlated with life expectancy (r = . ). by reason of that the correlations of log cases and log deaths with median age were similar to log cases and log deaths with the life expectancy, respectively r = . and r = . . the relationship of log deaths per million from median age is shown in fig. . the countries that deviate significantly from the exponential curve are also shown in the figure. the most of them coincide with the countries that deviate extremely from the relationship between log cases per million from life expectancy presented in fig. . this is result from the close relationship of median age and life expectancy. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . the last studied demographic indicator is the population density. the usual expectations are that the countries with higher population density will have higher total cases and deaths per million. the statistical analysis has shown a surprising result -absence of significant correlation of cases and deaths with population density. the found negative coefficients of correlation of cases and deaths are: r = - . and r = - . , respectively. these correlations are low and not statistically significant, therefore cases and deaths don't depend from the population density. the correlations of cases and deaths per million was then sought with a purely economic index, namely gross domestic product at purchasing power parity per capita (gdp). close correlation of log cases and log deaths with log gdp was established having correlation coefficients r = . and r = . , respectively. the results for cases are presented in fig. . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . therefore, the total cases and deaths per million increase by degree law with gross domestic product per capita. this result is astounding because it shows that the higher the gross domestic product per capita, the higher the rate of infection and mortality from covid- , i.e. the richer the countries, the harder they are hit by the covid- pandemic! the next index included in statistical calculations is human development index (hdi). the hdi is a statistic composite index of life expectancy, education, and per capita income indicators, which are used to rank countries by tiers of human development. it is accepted that hdi evaluates development not only by economic advances but also improvements in human well-being. the dependence of log cases and deaths per million from hdi is shown in fig. . the cases per million are shown in blue and the deaths per million are in red. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . the correlation coefficients reach high values of r = . and r = . , respectively. this result confirms above mention observation that the richest and well-being countries are most severe affected from the covid- pandemic. this paradoxical result cannot be simply explained, because countries with high per capita incomes, well-developed health systems and a high level of education should be expected to be better protected from a pandemic. apparently, in the case of the covid- pandemic, part of the population of these countries is significantly more vulnerable than countries with a lower human development index. several factors can be suggested that are probably the cause of this paradox: . the countries with high hdi have a significant part of older population (high life expectancy and median age), that is highly vulnerable to covid- . our statistical calculations have shown that hdi is closely correlated with life expectancy (r = . ), and as we have seen above cases and deaths are closely correlated with life expectancy (r = . and r = . , respectively). . the health systems in these countries support the lives of a significant number of people with severe chronic diseases such as diabetes, cancer, cardiovascular disease and others. infection of such patients with coronavirus overloads their weakened body and they become seriously and often fatally ill. . a significant percentage of people in countries with high hdi suffer from overweight and obesity due to immobilization and consumption of high-calorie foods, and obesity is known to be a risk factor for severe course and death from covid- . . the population in countries with high hdi is not inclined to enough strictly pandemic restrictions, excluding some east asian countries. . other factors -the population in countries with high hdi is exposed to higher stress, uses more drugs and canned foods that weaken the immune system and more. fig. . it can be seen that this distribution is very similar to the distribution of countries by covid- deaths per million people presented in fig. . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint it has been found that the total cases and deaths per million showed no correlations with gini index of income equality. therefore, cases and deaths don't depend from income equality. the statistical relationship of log cases and deaths per million with corruption perceptions index (cpi) has been analyzed, too. the found correlation coefficients are r = . and r = . , respectively. the corruption perceptions index is closely related with hdi (r = . ) and the last index could explain the above correlation. the situation is similar with the connection of log cases and deaths per million with intelligence quotient (iq) of countries. the respective correlation coefficients are r = . and r = . , respectively. the iq of countries is also closely correlated with hdi (r = . ). therefore, the defining parameter is again the human development index. finally, we found correlation of log cases and deaths per million with democracy index r = . and r = . , respectively. the democracy index is also well correlated with hdi (r = . ). the found statistically significant relationships of covid- cases and deaths with most of studied demographic, economic and social indicators are the result of their connections with log gdp ppp. the correlation coefficients r and significance levels p of the connection of log gdp ppp with the rest indicators is presented in table . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint gini index of income equality -. n. s. population density - . n. s. table shows that the studied indicators excluding density of population and gini index have statistically significant correlations with log gdp ppp. to check whether there is a change in the correlations with the development of the pandemic, a statistical analysis was made for three different dates roughly two months apart. the results of this analysis are presented in table . table shows that the correlation of deaths per million from covid- cases per million slow increase during the pandemic and reach r = . . the correlation coefficients of covid- cases and deaths with the rest indicators decrease during the pandemic. furthermore, at the beginning of august the relationships of covid- cases and deaths with iq index ceases to be statistically significant, and the relationships of covid- cases with cpi and growth rate has significance level p < . . a probable reason for this time course of correlation coefficients is that most west european countries with high gdp, hdi, and life expectancy (italy, spain, uk, france) introduced significantly stricter pandemic restrictions than at the beginning of the pandemic and they succeeded significantly slow the spread of the infection. on the other hand, in recent months, the pandemic has spread rapidly to a number of countries with medium or low gdp, hdi, and life expectancy in the latin america (mexico, brazil, argentina, peru, colombia), india and south africa. in these countries, the pandemic began later, and when the number of covid- cases and deaths in western europe and the united states increased alarmingly, the cases and deaths in the indicated countries remained low. this created illusions among the people and institutions in these countries that the pandemic would not affect them severely, and therefore . cc-by-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint pandemic restrictions were significantly weakened. as a result, covid- cases and deaths have risen sharply in these countries. we have used data for countries with a population of over millions in which . % of the world's population lives. the statistical relationships of total covid- cases and deaths per million populations in these countries with demographic, economic and social indicators (indices) were studied. these indicators are life expectancy, median age, growth rate, population density, gdp ppp per capita, human development index (hdi), gini index of income equality, intelligence quotient (iq), corruption perceptions index (cpi) and democracy index. statistically significant relationships were found with all indicators excluding gini index and population density. we have found that the closest is the relationship of deaths per million population and total cases per million population with correlation coefficient r = . . therefore, it is clear statistically that the more are cases per million in a country the more are deaths per million. this confirms the correctness of the timely and effective introduction of the necessary pandemic restrictions in the countries. it is interesting that the close correlations were found of cases and deaths per million with a purely economic index like gdp ppp per capita, where r = . and r = . , respectively. even more close correlations were found of cases and deaths per million with a composite index hdi, where the correlation coefficients reach . and . , respectively. this paradoxical results show that the richest and well-being countries are most seriously affected by the covid- pandemic. the most probable reason for this is the large percentage of aging population, comorbidity of population with severe chronic diseases and obesity in countries with high gdp and hdi. no less important reason appears the delayed and/or insufficiently effective pandemic restrictions in these countries, which have underestimated the danger of a pandemic in early stage. other indicators (excluding gini index and population density) also show statistically significant correlations with cases and deaths per million with correlation coefficients from . to . . the countries that deviates the most from the regression lines were shown. surprisingly, there was no statistically significant correlation between cases and deaths with population density. the statistical significance of the found correlations determined using student's t-test was p < . . the countries that deviate the most from both sides of the regression line were shown. it has been shown that the correlations of covid- cases and deaths with the studied indicators decrease with time. the established close positive correlation between cases and deaths per million with gdp (ppp) per capita and hdi seems paradoxical at first glance. because countries with high gdp (ppp) per capita and hdi have well-developed health systems that are provided with sufficient high-tech medical equipment and highly qualified specialists. what, then, is the reason why most of these countries allow the highest rates of covid- infection and mortality? these countries do have well-off and well-functioning health systems in a normal health situation. in this case, however, the situation is not normal, but a crisis one, because we have a pandemic due to a new coronavirus sars-cov- against which there is no vaccine or specific drug. this virus causes airborne infection and has a reproductive number r ~ . , which is significantly higher than that of seasonal flu (r ~ . ), i.e. coronavirus is significantly more contagious than the flu. in addition, mortality from covid- is of the order of a few percent, therefore many times greater than that of seasonal influenza, in which the mortality rate is about . %. the situation is further complicated by the fact that the latency period of covid- is much longer than that of seasonal flu and reaches - weeks, compared to - days for seasonal flu. in addition, most cases of covid- infection have mild flu-like . cc-by-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint symptoms or asymptomatic. therefore, it is not possible to distinguish well between the sick and to isolate or quarantine them, and for the healthy to continue to work and live unrestricted by quarantine measures. in case of dangerous infectious diseases against which there is no vaccine, the only effective means of limiting the percentage of infected is quarantine, which has been known and applied since the middle ages. for this reason, the precautionary and quarantine measures of the entire population play a crucial role in limiting the infection rate and the associated mortality of the population. developing countries generally have lower rates of relevant comorbidities compared to high-income countries (where the best measures of infection fatality rates come from). therefore, the material wellbeing of the citizens and the provision of the health systems of the countries with equipment, consumables and qualified specialists play a secondary role. the main thing is the discipline and self-discipline of the population, its readiness to comply with pandemic restrictions at a distance, isolation and disinfection and especially the timely and decisive introduction and implementation of pandemic restrictions by the executive authorities -government, police, health services and others. this is why many countries with relatively low gdp per capita and hdi (vietnam, philippines, ethiopia, nigeria) have been able to achieve much lower covid- infection and mortality than countries with high gdp per capita and hdi (italy, spain, usa, united kingdom, france). most countries with high gdp per capita and hdi are developed democracies with high individual freedom from the state and its organs, and their governments hesitated too long before introducing pandemic restrictions restricting the freedom of movement, assembly and life of citizens. too much time was wasted (of the order of - weeks) during which the epidemic spread uncontrollably and the number of infected reached high values that made it very difficult to limit the pandemic, despite the strict restrictive pandemic restrictions. of course, there are countries with high gdp per capita and hdi, such as japan, south korea and malaysia, which have managed to effectively limit the spread of covid- and prevent high mortality. this is due to the traditional culture of these countries, in which the trust of the citizens in the ruling elite and their tendency to obey the reasonably justified decisions of these elite is deeply rooted. the continuing -ncov epidemic threat of novel coronaviruses to global health-the latest novel coronavirus outbreak in wuhan covid- dashboard by the center for systems science and engineering quarantine alone or in combination with other public health measures to control covid- : a rapid review mystery deepens over animal source of coronavirus real-time rt-pcr panel for detection -ncov age comparison of covid- fatality rate in china hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease -covid-net predicted covid- fatality rates based on age, sex, comorbidities, and health system capacity more evidence on vitamin d deficiency and death rates from covid- obesity could shift severe covid- disease to younger ages a shred of evidence that bcg vaccine may protect against covid- : comparing cohorts in spain and italy systematic review and meta-analysis of published research data on covid- infection-fatality rates the potential effects of widespread community transmission of sarscov- infection in the world health organization african region: a predictive model impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand. imperial college covid- response team china may be beating the coronavirus nick phin, coronavirus (covid- ) expert interview: what is contact tracing? blog: public health matters. public health england, government of the united kingdom coronavirus: first two cases in italy. corriere della sera who says europe is new epicenter of coronavirus pandemic coronavirus cases have dropped sharply in south korea. what's the secret to its success? science the who ignores taiwan. the world pays the price. the nation total confirmed deaths due to covid- per million people the authors have declared no competing interest. no funding. i confirm all relevant ethical guidelines have been followed. no human subjects research as i accessed only publicly available data from the web. key: cord- -wcoch b authors: file, thomas m.; tsang, kenneth w. t. title: severe acute respiratory syndrome: pertinent clinical characteristics and therapy date: - - journal: treat respir med doi: . / - - sha: doc_id: cord_uid: wcoch b severe acute respiratory syndrome (sars) is a newly emerged infection that is caused by a previously unrecognized virus–a novel coronavirus designated as sars-associated coronavirus (sars-cov). from november to july the cumulative number of worldwide cases was > , with a mortality rate of close to %. the mortality has been higher in older patients and those with co-morbidities. sars has been defined using clinical and epidemiological criteria and cases are considered laboratory-confirmed if sars coronavirus is isolated, if antibody to sars coronavirus is detected, or a polymerase chain reaction test by appropriate criteria is positive. at the time of writing ( may ), no specific therapy has been recommended. a variety of treatments have been attempted, but there are no controlled data. most patients have been treated throughout the illness with broad-spectrum antimicrobials, supplemental oxygen, intravenous fluids, and other supportive measures. transmission of sars is facilitated by close contact with patients with symptomatic infection. the majority of cases have been reported among healthcare providers and family members of sars patients. since sars-cov is contagious, measures for prevention center on avoidance of exposure, and infection control strategies for suspected cases and contacts. this includes standard precautions (hand hygiene), contact precautions (gowns, goggles, gloves) and airborne precautions (negative pressure rooms and high efficiency masks). in light of reports of new cases identified during the winter of – in china, it seems possible that sars will be an important cause of pneumonia in the future, and the screening of outpatients at risk for sars may become part of the pneumonia evaluation. severe acute respiratory syndrome (sars) was first recog- . definition nized in the guangdong province in southeast china in late , for surveillance purposes and before the availability of laboraand it subsequently spread globally rapidly during the early tory tests to detect the causative agent, sars was originally months of . [ , ] sars captured worldwide attention as a defined using clinical and epidemiologic criteria from suspect or highly infectious disease with high mortality and as an occupationprobable cases. [ , ] a suspect case included a respiratory illness of al hazard among healthcare providers. the impact of sars was unknown etiology and with the following criteria: extensive from both a sociological and economical consequence -• measured temperature > . ºf (> . ºc) particularly in asia. because the causative agent of sars is • one or more clinical findings of respiratory illness (e.g. cough, contagious, preventative measures focus on avoidance of exposhortness of breath, difficulty in breathing, or hypoxia) sure, and infection control strategies for suspected patients and • travel within days of onset of symptoms to an area with contacts. the emergence of sars illustrates the need for global suspected or documented community transmission of sars cooperation of healthcare systems to ensure the public health of (excluding areas with secondary cases limited to healthcare local regions, and the need to be prepared to rapidly institute workers or direct household contacts and close contact within policies to respond to newly emerging infectious threats. days of onset of symptoms with either a person with a respiratory illness or a person under investigation or suspected recombination event between mammalian-like and avian-like parof having sars). ent viruses which may have been responsible for the switch of host of the sars-cov from animals to humans. a probable case was defined as a suspect case with either radiographic evidence of pneumonia or respiratory distress syndrome, or autopsy findings consistent with respiratory distress . epidemiology syndrome without an identifiable cause. [ ] once the virus was identified and laboratory tests became as of july the cumulative number of worldwide sars available for detection, the surveillance case definition for sars cases was , with a mortality of . %. [ ] of the reported cases was updated to include laboratory criteria for evidence of infection % were from china, % from hong kong, % from taiwan, with the sars-associated coronavirus (sars-cov). initially, % from canada, and % from singapore. the us has been since it was unclear whether sars infection could be present in relatively spared from the clinical impact of sars. at july , people who were asymptomatic, the definition included the possi- probable cases had been reported, of which only eight had bility of asymptomatic ('subclinical') infection. however, subselaboratory confirmation of acute coronavirus infection. [ ] quent investigations suggest that asymptomatic infection is very the initial cases reported in hong kong were linked to an index uncommon. [ ] as a consequence, the latest surveillance case defipatient, a medical doctor from the guangdong province of china nition for sars by the us center for disease control and who traveled to hong kong to attend a wedding in late february prevention (cdc) has been updated to include clinical criteria for . [ ] he had previously treated patients with 'atypical' pneuearly illness, mild-to-moderate illness, and severe respiratory illmonia in guangdong. subsequently several guests who had stayed ness, which are then characterized by epidemiological and laboraat the same hotel became ill with sars. these patients subsetory criteria (table i) . [ ] quently infected numerous healthcare workers and family members or became index cases in other countries (canada, vietnam, singapore, etc.) [ figure ]. the mortality has been higher in older patients and those with co-morbidities. the syndrome has been observed primarily in soon after the recognition of the clinical syndrome of sars, adults aged - years, and children have been relatively spared. several different laboratories identified a novel coronavirus, desig-there appears to be no significant underlying predisposing condinated sars-cov, in vero e cell cultures inoculated with respirtion for the development of sars, however the elderly and atory secretions and lung tissue of infected patients. [ , ] other patients with underlying conditions are at greater risk for mortalitechniques, including electron microscopy, reverse transcriptionty. in one study from hong kong the mortality for those > years polymerase chain reaction (rt-pcr), and serovonversion, have of age was %. [ ] in another study, multivariate analysis showed also pointed to this as the causative agent. sero-epidemiological that age > years, presence of diabetes mellitus or heart disease, data indicate the sars-cov was not previously found in and the presence of other co-morbid conditions were independenthumans. [ ] preliminary reports of detection of the sars ly associated with mortality. [ ] early in the evaluation of this coronavirus in himalayan palm civet cats and a number of other syndrome, most of the descriptions were of patients who required species are suggestive of interspecies transmission of this new hospitalization. however, as more cases were identified, particuvirus. investigators from hong kong reported a coronavirus relarly in the western countries, the majority of patients have not sembling sars virus isolated from several himalayan palm civet required hospitalization. cats and a raccoon dog obtained in a market in the guangdong province (such animals are considered as food delicacies in that sars appears to be transmitted by close contact with patients region. [ ] ) they also reported that several of the handlers at the who have illness due to sars virus. [ , ] the greatest risk of market had antibody to the sars virus. studies of the genetic transmission is most probably via direct contact with respiratory sequence of the two viruses show a similar pattern, suggesting a secretions. there is no evidence of spread from patients before species jump from wild animals to humans. furthermore, experi-they develop symptoms. the majority of cases have been reported mental infection of macaques with sars-cov produced a pneu-among healthcare workers and family members of affected permonia that was pathologically similar to sars in humans. [ ] sons. however, evidence of community spread of the disease is stavrinides and guttman compared the sars-cov genome with emerging, suggesting that other modes of transmission, such as related coronaviruses and found about half the dna resembled airborne or direct contact, may also have a role. [ ] clusters of cases coronavirus sequences from mammals, while the other half looked in community settings such as hotels and apartment buildings like virus found in birds. [ ] these data suggest a possible past demonstrate that transmission can be efficient. many household [ ] clinical criteria presence of two or more of the following features: fever (might be subjective), chills, rigors, myalgia, headache, diarrhea, sore throat, or rhinorrhea temperature > . °f (> °c), and one or more clinical findings of lower respiratory illness (e.g. cough, shortness of breath, or difficulty breathing) meets clinical criteria of mild-to-moderate respiratory illness, and one of more of the following findings: radiographic evidence of pneumonia, or acute respiratory distress syndrome, or autopsy findings consistent with pneumonia or acute respiratory distress syndrome without an identifiable cause one or more of the following exposures in the days before onset of symptoms: travel to a foreign or domestic location with documented or suspected recent transmission of sars-cov, or close contact with a person with mild-to-moderate or severe respiratory illness and history of travel in the days before onset of symptoms to a foreign or domestic location with documented or suspected recent transmission of sars-cov one or more of the following exposures in the days before onset of symptoms: close contact with a person with confirmed sars-cov disease, or close contact with a person with mild-to-moderate or severe respiratory illness for whom a chain of transmission can be linked to a confirmed case of sars-cov disease in the days before onset of symptoms detection of serum antibody to sars-cov by a test validated by cdc (e.g. enzyme immunoassay), or isolation in cell culture of sars-cov from a clinical specimen, or detection of sars-cov rna by a rt-pcr test validated by cdc and with subsequent confirmation in a reference laboratory (e.g. cdc) case classification b probable case of sars-cov disease: meets the clinical criteria for severe respiratory illness and the epidemiologic criteria for likely exposure to sars-cov confirmed case of sars-cov disease: clinically compatible illness (i.e. early, mild-to-moderate, or severe) that is laboratory confirmed a tests to detect sars-cov are being refined and, therefore, criteria for laboratory diagnosis of sars-cov are changing. b asymptomatic infection or clinical manifestations other than respiratory illness may be identified in future as more is learned about sars-cov. cdc = center for disease control; rt-pcr = reverse transcription polymerase chain reaction; sars-cov = sars-associated coronavirus. contacts have become ill. epidemiologic evidence indicates that quired sars via contact with a fomite. of still unexplained significance, a few patients have been involved in the transmission the transmission of sars is facilitated by face-to-face contact, of an unusually large number of secondary cases -so-called superand this still appears to be the most common mode of spread in the spreading events. form of droplet transmission. [ ] however, airborne or fecal transmission may have a role in some settings, and it could account for peiris et al. [ ] studied the viral load of sars-cov over time in the extensive spread within buildings and other confined areas that respiratory secretions from sars patients and found the load in has been observed in some places in asia. transmission via casual nasopharyngeal aspirates increased to a peak on the tenth day after contact is uncommon, but has been documented on an airplane or onset of symptoms, then decreased gradually. notwithstanding the in a taxi. [ ] some healthcare workers also appeared to have ac-small sample size and the effects of concomitant administration of ribavirin and corticosteroid, this suggests that sars patients of virology in beijing. the virus was apparently transmitted to the student's mother and a nurse caring for the student (all three had might be most contagious in the second week of illness. laboratory-confirmed cases). at the time of writing, a total of nine after the termination of the initial outbreak of sars in july possible cases of sars have been identified and the health author- , there were two further cases of sars-cov infection which ities were involved in active surveillance to identify other possible were likely acquired in a laboratory setting, one case in late august cases. [ ] and the other in december. [ ] this reinforces the necessity for careful laboratory practices when working with this virus. it . clinical manifestations appears there was no evidence of secondary transmission associated with either case, despite the active social activities undertaken the initial descriptions of the clinical manifestations of sars by these two scientists after their exposure to sars-cov. an have come from reports of patients who have required hospitalizaadditional four community-acquired cases from the guangdong tion. [ , [ ] [ ] [ ] [ ] in such patients the disease is often reported as a bi-province of china were subsequently diagnosed from december phasic or tri-phasic illness with an initial acute febrile phase through january . of interest, no close contacts of these followed by a lower respiratory illness phase then progression in cases was found to have fever or respiratory symptoms after home approximately - % of patients to a phase characterized by quarantine to date. [ ] more recently, in april , the chinese acute respiratory distress syndrome (ards) necessitating ventilator support. ministry of health reported additional cases of sars which seemed to be initially associated with an index case of a -year-it is imperative to appreciate that individual patients do not old female graduate student who worked at the national institute necessarily display these 'phases', which could be highly individ- peiris et al. [ ] (n = ) lee et al. [ ] (n = ) poutanen et al. [ ] (n = ) tsang et al. [ ] (n = ) ualized, from hyperacute to indolent presentation in time course. festations as the patients described above (figure ). although the at the time of writing, the mortality of probable sars cases was majority of patients developed symptoms of respiratory tract inapproximately %, but was much higher in older individuals and fection during admission, only a minority of patients had sympthose with significant co-morbidities. toms at the time of admission to the hospital. diarrhea was present the mean incubation period of sars is estimated to be days, in only % at the time of admission, but % developed this with a usual range up to approximately days after exposymptom while in the hospital. these investigators also observed sure. [ , , , ] the illness generally begins with a prodrome of fever, the duration of time from the onset of illness until the evolution of often associated with chills, rigors and myalgia. headache and various endpoints of their disease: fever, . days; admission to the severe malaise may accompany this phase; rash has been absent in most cases. in one outbreak within an apartment complex in hong kong, diarrhea was found in % of cases. [ ] after a typical period of - days, a lower respiratory phase may begin with the onset of non-productive cough and progressive pneumonia. in the initial reports of cases, - % of patients required intensive care unit management and mechanical ventilation. the presenting symptoms of patients admitted to the hospital from four published series are listed in table ii. [ , [ ] [ ] [ ] most patients were admitted to the hospital several days after the onset of symptoms. the most common complaints were fever and chills or rigors. upper respiratory tract symptoms such as rhinorrhea and sore throat were less common. at the time of examination, abnormal auscultatory findings were present in about one-third of patients. although fever and progressive respiratory manifestations are a hallmark of most cases of sars, patients with more indolent characteristics (including absence of fever) have been describedespecially in elderly or immunocompromised patients. [ , ] the first report of a complete outbreak of sars (from beginning of the outbreak until declaration of containment) was recently published by vu et al. [ ] they report a cohort of patients, all of whom required hospitalization, who presented with similar mani- hospital, . days; onset of radiographic change, . days; onset of multivariate analysis, the only factors that were predictive of an respiratory symptoms, . days; onset to maximal radiographic adverse outcome were advanced age, a high peak lactate change, days; onset to intubation, . days; onset to end of dehydrogenase level, and a higher absolute neutrophil count. fever, . days; and onset to death, . days. [ ] . diagnosis chest x-ray abnormalities are usually absent during the initial phase of illness but become progressively abnormal during the the initial manifestations of sars are not specific and cannot phase of lower respiratory illness. initially this is characterized by easily be distinguished from those of other respiratory infections. early focal interstitial infiltrates, usually seen as ground glass the first clinical definition developed by the who (see section ) opacity, and progressing to bilateral disease (figure ). a typical was found to be only % sensitive and approximately % ards picture has emerged in many very seriously ill patients. in specific for identifying laboratory documented cases. [ ] clinicians these patients, high-resolution computed tomography (hrct) is should conduct thorough diagnostic testing to rule out other etiolomore sensitive in early disease when the chest x-ray could be gies in patients suspected of having sars. initial recommended normal or only showing inconclusive consolidation. characteristidiagnostic testing procedures include chest radiograph and pulse cally, hrct shows peripheral and, most commonly, lower lobe oximetry. since sars often progresses rapidly, repeated chest xconsolidation. [ , ] although non-diagnostic and closely mimickrays within the first or second day, sometimes twice daily, may be ing the appearance of bronchiolitis obliterans with organizing helpful in documenting the course of disease. indiscriminate use of pneumonia, hrct is also helpful for showing no evidence of hrct to detect 'radiographically occult disease' is to be discourpleural effusion or intrathoracic lymphadenopathy, which are very aged in view of infection control issues, and the rapidly progresrarely seen in sars. [ , , , ] spontaneous pneumomediastinum sive nature of sars, thus making it likely that radiographic also occurs as a rare complication with sars. [ ] abnormalities would be more apparent within a few days after laboratory abnormalities most often associated with sars hospitalization. [ ] tests for evaluation of specific organisms assoinclude absolute lymphopenia, mild neutropenia, and thrombociated with pneumonia should be performed, and include: blood cytopenia. mild to moderately elevated plasma levels of creatine cultures, sputum gram stain and culture, and testing for viral phosphokinase, lactate dehydrogenase, and transaminases were respiratory pathogens -especially influenza and respiratory synseen in - % of cases (table ii) . cytial virus. urinary antigen for both pneumococcus spp. and lee et al. [ ] found that advanced age, male sex, and high levels legionella spp. should also be considered. acute and convalescent of serum creatine phosphokinase, serum lactate dehydrogenase, a serum (preferably days after onset of symptoms) should be relatively high initial neutrophil count (i.e. mean . vs . × collected from each patient who meets the sars clinical case - l), and a low levels of serum sodium were significant predic-definition. however, if acute and convalescent phase sera are tive factors for intensive care unit admission, and death. on collected at least - days apart, a -fold or greater rise in different rt-pcr assays performed on different specimen aliquots identify the coronavirus rna. [ ] because of the possibility of false-negative cultures and rt-pcr assays, only the absence of antibody in a serum specimen obtained > days after symptom onset is considered by the cdc to be a negative laboratory test for sars coronavirus. the likelihood of detecting sars-cov is increased if multiple specimens (e.g. stool, serum, respiratory tract specimens) are collected during the course of illness. clinicians should consult with their local laboratory personnel and health department about obtaining such tests. the priority of specimens for sars-cov testing and optimal timing for collection are presented in table iii. of the patients with clinical sars described by peiris et al., [ ] had serological or pcr evidence of sars-associated coronavirus infection; and of the who were unconfirmed, had serological testing prior to days of onset of illness (possibly prior to the time of seroconversion). another series of cases in hong kong showed that despite significantly high dosages of corticosteroid therapy, a seroconversion of . % occurred on day after onset of illness. [ ] this differs from the us experience where of the probable cases of sars reported by july , only had been confirmed by laboratory diagnosis (all by serology); were negative and had no result. b antibody testing should also be carried out on a serum sample collected > days after symptom onset. antibody titer when tested in parallel should be considered indicative of a confirmed case. a variety of methods for detection of coronavirus infection are now available. these include culture methods, pcr-based methods, and serological tests. [ ] culture of the sars coronavirus is considered solid evidence of infection, but there have been problems with the various generations of rt-pcr assays, both with false-positive results and with inconsistent detection of viral genome in the first days of illness as well as later in the convalescent phase. it is therefore recommended that detection of sars-cov rna by rt-pcr be validated by a second reference laboratory. [ ] because antibodies to sars coronavirus have not been found in the general population, background sars coronavirus antibodies do not appear to be a substantial concern. however, the current serologic assays (both elisa and ifa [indirect fluorescent antibody] formats) do not reliably detect antibodies until the titers rise substantially after the second week of illness. according to the uscdc, suspect or probable cases are considered laboratory-confirmed if sars coronavirus is isolated, if antibody to sars coronavirus is detected and confirmed by a second reference laboratory, or if two table iv . a summary of infection control precautions for patients hospitalized with suspected/probable severe acute respiratory syndrome (sars) [reproduced from sampathkumar et al., [ ] with permission] place patient in a negative pressure, specially vented, room a number of other agents have been suggested for therapy of sars-cov, including interferon-α, glycyrrhizin, and protease inhibitors. [ ] in one preliminary, uncontrolled study by loutfy et al. [ ] from toronto, use of interferon μg/day for a minimum of days and increased to μg/day for a total of days, plus corticosteroids (oral prednisone mg twice a day, or intravenous methylprednisolone mg every hours) was associated with reduced disease-associated impaired oxygen saturation and more rapid resolution of radiographic lung abnormalities. the authors acknowledge, however, that these findings need to be interpreted cautiously in view of lack of randomization, the retrospective dosing, and the limited sample size (a total of patients). table v . a summary of protective measures taken by severe acute respiratory syndrome (sars)-infected and non-infected staff in hong kong hospitals (reproduced from seto et al., [ ] c comparing proportion of infected (n = ) over non-infected staff (n = ), with those without mask. since the causative agent of sars is contagious, in the absence of effective drugs or vaccines the only currently effective strategy . treatment for limiting the impact of sars is implementation of preventive at the time of writing ( may ), no specific therapy is recommended. a variety of treatments have been attempted, but there are no controlled data. most patients have been treated throughout the illness with broad-spectrum antimicrobials, supplemental oxygen, intravenous fluids, and other supportive measures. some clinicians have advocated a combination of ribavirin and corticosteroids, but the efficacy of these drugs has not been established. the use of systemic corticosteroids in sars is controversial, and the efficacy based on controlled studies is unavailable. [ ] one study found initial use of pulse-dosed methyl prednisolone (≥ mg/day) to be more efficacious and equally well tolerated as a lower dose of methyl prednisolone, but this was based on retrospective observational evaluation. [ ] the use of corticosteroids in patients with viral infections can be hazardous when not accompanied by an effective anti-viral agent. [ ] early testing of ribavirin and other antiviral compounds against the novel coronavirus have not produced evidence of in vitro activity. [ ] an evaluation of the use of ribavirin was published by knowles et al., [ ] who reported adverse events in patients with suspected or probable sars treated with ribavirin. of those patients % had evidence of hemolytic anemia; hypocalcemia and hypomagnesemia were detected in % and % of patients, respectively. [ ] the authors felt the benefits of ribavirin may not outweigh the risk of adverse events. there was a potential for ribavirin to have negative clinical and economic consequences because of the adverse events. it is now considered among the table vi . recommendations for the evaluation of patients with communityacquired respiratory illness in the presence or absence of severe acute respiratory syndrome-associated coronavirus (sars-cov) transmission in the world [ ] in the absence of sars-cov transmission anywhere in the world, the diagnosis of sars-cov disease should be considered only in patients who require hospitalization for radiographically confirmed pneumonia and who have an epidemiologic history that raises the suspicion of sars-cov disease. in the absence of sars-cov transmission anywhere in the world, suspicion of sars infection is raised if, within days of symptom onset: the patient had a history of recent travel to mainland china, hong kong, or taiwan; was in close contact with ill people with a history of recent travel to such areas; is employed in an occupation at particular risk for sars-cov exposure, including a healthcare worker with direct contact or a worker in a laboratory that contains live sars-cov; or is part of a cluster of cases of atypical pneumonia without an alternative diagnosis once sars-cov transmission has been documented in the world, a diagnosis of sars should still be considered in patients who require hospitalization for pneumonia and who have an epidemiologic history described above. in addition, all patients with fever or respiratory symptoms should be questioned about whether within days of symptom onset they have had: close contact with someone suspected of having sars-cov disease; a history of foreign travel (or close contact with an ill person with a history of travel) to a location with documented or suspected sars-cov infection; exposure to a domestic location with documented suspected sars-cov (including a laboratory that contains live sars-cov); or close contact with an ill person with such an exposure history fig. . algorithm for evaluating and managing patients requiring hospitalization for radiographically confirmed pneumonia, in the absence of person-toperson transmission of severe acute respiratory syndrome-associated coronavirus (sars-cov) anywhere in the world. [ ] measures centered on avoidance of exposure and infection. such hospitalized patients with suspected sars should be isolated measures include global and regional surveillance, early detection in negative pressure rooms; healthcare workers should wear masks of new cases, identification of patient contacts, and strict adher-(a high efficiency mask such as the n- respirator used for ence to infection control policies. guidelines for infection control tuberculosis) to prevent air-droplet and airborne acquisition. behave been published and should be consulted for updated recom-cause coronaviruses can survive on environmental surfaces, good mendations. [ , ] healthcare workers encountering a possible case hand-washing with soap and water or use of an alcohol-based hand of sars (suspected or probable) should take meticulous safety rub is highly recommended as well. environmental surfaces that precautions and seek advice from an expert in sars infection are frequently touched by the patient or are soiled with body fluids control. should be cleaned and disinfected with a household disinfectant. the early symptoms of sars-cov disease usually include fever, chills, rigors, myalgia, and headache. respiratory symptoms often do not appear until - days after the onset of illness. in settings with more extensive transmission, all patients with fever or respiratory symptoms should be evaluated for possible sars-cov disease. depending on symptoms and exposure history, initial diagnostic testing for patients may include complete blood count, chest x-ray (cxr), pulse oximetry, blood cultures, sputum gram stain and culture, testing for viral respiratory pathogens (notably influenza and respiratory syncytial virus), legionella sp. and pneumococcal urinary antigen. an alternative diagnosis should be based on laboratory tests with high-predictive value (e.g. blood culture, urinary antigen). chest computed tomography (ct) may show evidence of an inflitrate before a cxr. therefore, a chest ct should be considered in patients with a strong epidemiologic link to a known case of sars and a negative cxr days after onset of symptoms. sars isolation precautions should be discontinued after consultation with local public health authorities and the evaluating physician. an important characteristic of the recent sars outbreaks has been infection transmission. table iv lists precautions for patients hospitalized with sars. the predilection for transmission to healthcare providers after patient care. for the most part this has occurred after close, patients with sars-cov disease who do not otherwise need to unprotected contact with symptomatic individuals. healthcare be hospitalized can be managed appropriately as outpatients. workers who have had unprotected exposure and who develop these patients should limit interactions outside the home. they fever or respiratory symptoms should not come to work, and should be instructed to wear surgical masks in the presence of should report their symptoms to the infection control/employee household contacts, contain respiratory secretions in facial tissues, health service and their physician immediately. healthcare workand wash hands frequently. they should stay away from work, ers who have had unprotected exposure during procedures with school, or other public places for days after resolution of fever. high risk of aerosolization (e.g. intubations, bronchoscopy) should household members or other close contacts of these patients should wear gloves and practice good hand hygiene. in the abbe quarantined for a -day period, since there is a high risk of sence of fever or respiratory symptoms, they need not limit their sars. [ ] this policy has been running since the middle of march at queen mary hospital of the university of hong kong, activities. despite the disappearance of sars in hong kong since june the importance of sars precautions was demonstrated in a . only authorized and minimum number of staff working in case-control study in five hong kong hospitals, with nonthese wards may enter the premises. all staff entering these infected and infected healthcare providers who had documentrestricted areas follow strict and stepwise 'gowning' and 'degowned contacts with sars patients (table v) . [ ] all of the healthcare ing' procedures, and use standard personal protection equipment providers were surveyed concerning the use of masks, gloves, (disposable surgical paper cap, n- mask, and reusable eye gowns, and hand-washing, as recommended under droplet precaugoggles and cotton surgical gown). patients are treated with potent tions. no staff member who reported use of all four measures was antibiotics, usually in the form of a combination of cephalosporin infected. in contrast, all infected staff members had omitted at and macrolide, or in the event of allergy to these antibiotics with least one of the measures (p = . ). the authors observed that levofloxacin. patients who improve clinically and radiologically both surgical and high efficiency masks (n- masks) were proare unlikely to have sars, and are moved to wards that don't tective against infection, whereas paper masks did not significantrequire the level of intensive care and/or isolation as would be ly reduce the transmission (such masks are easily wet with saliva required for those patients who have sars, for observation for and are not recommended for precautions against droplets). - days before discharge. in the event of confirmed or suspected in order to be prepared for the recurrence of sars and the need sars, a patient will be diverted to the appropriate wards to for early implementation of control measures, the us cdc reminimize exposure of fellow patients, if no single-room accomleased clinical guidelines for the identification and evaluation of modation could be provided. possible sars-cov disease among patients presenting with community-acquired illness. [ ] the key principles upon which control . conclusion measures are based have taken into consideration the fact that in the year a vast majority of patients with sars-cov disease because a new virus causes sars, it is very difficult to predict had a clear history of exposure either to a sars patient or to a the eventual significance of this infection. however, the resetting in which srs-cov transmission occurred (i.e. hospital); emergence of sporadic cases in china, has caused great concern as and developed pneumonia. recommendations for the evaluation to its future impact. it has had enormous economic and political of patients with community-acquired respiratory illness were deimpact on the affected areas of the world. although important veloped for two primary circumstances: firstly in the absence of progress has been made concerning the etiology, epidemiology, sars-cov transmission anywhere in the world, and secondly and prevention of this virus, many important questions remain. once transmission had been documented (these were released prior without answers to some of these questions, the eventual province in china (or close contact with an ill person with a outcome of sars remains unclear. history of recent travel to the area) in the days before onset of symptoms. [ ] when such patients are identified, appropriate isola- a major outbreak of severe acute respiratory syndrome references in hong kong outcomes of patients with sars in the greater toronto area management of severe acute respiratory syndrome: the center for disease control and prevention. outbreak of severe acute respiratory - syndrome: worldwide case definitions for surveillance of severe acute respiratory syndrome sars clinical description of a completed outbreak sever acute respiratory syndrome (sars) [online]. available from url: of sars in vietnam severe acute respiratory syndrome: radiographic high-resolution ct findings of severe acute cases: united states and worldwide a novel coronavirus associated with severe acute respiratory syndrome evaluation of who criteria for identifying patients with severe respiratory syndrome out of hospital: prospective observa identification of a novel coronavirus in patients with severe acute respiratory syndrome coronavirus as a possible cause of severe (sars) and coronavirus testing: united states center for disease control and prevention. interpreting sars-cov test results the sars coronavirus from animals in southern china koch's postulates fulfilled for sars ] virus detection of sars coronavirus in plasma by mosaic evolution of the severe acute respiratory real-time rt-pcr available level preparedness and response to severe acute respiratory syndrome (sars) from url high-dose pulse versus nonpulse corticosteroid regimens in severe acute respiratory syndrome the use of corticosteroids in sars severe acute respiratory syndrome common adverse events associated with the use of ribavirin for severe acute respiratory syndrome in canada short term outcome and risk factors for adverse clinical outcomes in adults with severe acute respiratory syndrome clinical progression and viral load in a roids in severe acute respiratory syndrome: a preliminary study sars: epidemiology, clinical . center for disease control and prevention / presentation, management, and infection control measures center for disease control and prevention. recent sars cases in china accessed and contact in prevention of nosocomial transmission of severe acute respirato-may ] ry syndrome (sars) center for disease control and prevention. china reports ninth recent possible sars case correspondence and offprints: professor thomas m. file, jr, infectious a cluster of cases of severe acute respiratory disease service identification of severe acute respiratory syndrome in canada key: cord- - scdvu d authors: ge, yang; sun, shengzhi title: estimation of coronavirus disease case-fatality risk in real time date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: scdvu d we ran a simulation comparing methods to calculate case-fatality risk for coronavirus disease using parameters described in previous studies. case-fatality risk calculated from these methods all are biased at the early stage of the epidemic. when comparing real-time case-fatality risk, the current trajectory of the epidemic should be considered. yang ge, shengzhi sun ( ) . in their analyses, the authors estimated the case-fatality risk adjusted to a fixed lag time to death. they acknowledged that the calculated adjusted case-fatality risk (acfr) might be influenced by residual uncertainties from undiagnosed mild covid- cases and a shortage of medical resources. however, we believe the time-varying number of cumulative cases and deaths also should be considered in the epidemic profile. because of the exponential growth curve of the covid- outbreak, the numbers of cumulative cases and cumulative deaths have been relatively close to each other in the early stages of the outbreak, leading to a much higher acfr. as the outbreak progresses, the ratio of the cumulative cases and deaths declines, which reduces the acfr. thus, a higher acfr does not necessarily indicate increased disease severity. to test our hypothesis, we performed a simulation study by using a susceptible-infectious-recovered-death model and parameters set according to prior studies. we set the infectious period as days ( ); case-fatality risk as % ( ); basic reproductive ratio (r ) as . ( ); recovery rate as / day ( ) , that is, days from illness onset to recovery; and the population size as million. we compared crude casefatality risk, acfr per wilson et al.'s method, and acfr per mizumoto et al.'s method ( ) . although the case-fatality risk calculated from these methods all are biased at the early stage of the epidemic, case-we ran a simulation comparing methods to calculate case-fatality risk for coronavirus disease using parameters described in previous studies. case-fatality risk calculated from these methods all are biased at the early stage of the epidemic. when comparing real-time casefatality risk, the current trajectory of the epidemic should be considered. progression of coronavirus disease outbreak and changes in the case-fatality risk by crude and adjusted rates. crude case-fatality risk is the cumulative number of deaths on a given day divided by the cumulative number of cases on the same day. we set the infectious period as days ( ); case-fatality risk as % ( ); basic reproductive ratio (r ) as . ( ); recovery rate as / day ( ) , that is, days from illness onset to recovery; and the population size figure) . in conclusion, we recommend the mizumoto et al. method ( ) to calculate acfr in real time. when comparing real-time estimation of the case-fatality risk across countries and regions, our results indicate that the current trajectory of the epidemic should be considered, particularly if the epidemic is still in its early growth phase. mr. ge is a phd candidate in the department of epidemiology and biostatistics at the university of georgia, athens, georgia, usa. his research interests include infectious disease modeling and vaccine design. dr. sun is a research scientist at the boston university school of public health. his research focuses on estimating the impact of air pollution and climate change on human health. viral load of sars-cov- in clinical samples prolonged presence of sars-cov- viral rna in faecal samples detection of sars-cov- in different types of clinical specimens viral load dynamics and disease severity in patients infected with sars-cov- in zhejiang province, china isolation of infectious sars-cov- from urine of a covid- patient evidence for gastrointestinal infection of sars-cov- evidence of airborne transmission of the severe acute respiratory syndrome virus case-fatality risk estimates for covid- calculated by using a lag time for fatality. emerg infect dis clinical characteristics of coronavirus disease in china novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia report of the who-china joint mission on coronavirus disease (covid- ) estimating risk for death from novel coronavirus disease, china key: cord- - zgolyqf authors: zhang, lan; huang, songming title: clinical features of cases in children infected with sars-cov- in anhui province, china–a multi-center retrospective cohort study date: - - journal: front public health doi: . /fpubh. . sha: doc_id: cord_uid: zgolyqf background: as of rd february , china had , patients with confirmed sars-cov- infections, and only . % of patients were under the age of years. morbidity among children was much lower, with milder or absent signs and symptoms; chest ct scans showed milder symptoms, if at all, compared to adults. objective: report the epidemiological, clinical features, laboratory, radiological characteristics, and treatment of sars-cov- infections. compare additional signs and symptoms, investigate familial clustering, compare laboratory results, and find out relevance between age and typical chest ct scans in patients. methods: we studied young patients with laboratory-confirmed sars-cov- infection in anhui province of china by th february . their signs, symptoms, and familial clustering were analyzed. we compared the laboratory test results, age, and gender among three parts based on their chest ct scans. results: familial clustering was seen in ( / ; . %) patients; three families had seven confirmed members infected with the disease. eight ( / ; . %) patients had no symptoms, ( / ; . %) patients had only fever, nine ( / ; . %) patients had fever and additional symptoms, and ( / ; . %) patients had no fever. dry cough was the most common additional symptom. in ( / ; . %) patients, the percent of lymphocytes decreased; ( / ; . %) patients were older than years. more male than female patients and patients older than years showed typical abnormalities in the chest ct scans (p = . ). only two years old patients had hepatic injury. conclusion: children's infection is mild and familial clustering was the most common channel. the older patients had more typical ground glass opacity (ggo) or consolidation in chest ct scans. cases without fever strongly suggested that non-symptomatic children should not be assumed to be free of infection when their family members have confirmed infection. most children showed clinical features distinguishable from adults and with increased susceptibility within family members. since december , the epidemic of coronavirus− (sars-cov- ) has spread throughout the world, rapidly resulting in , , confirmed cases and , deaths as of th may . anhui province was the third region to be affected by coronavirus- in china, with hubei and guangdong provinces being the first two. among the patients, only . % were under the age of years. not only was their morbidity less than adults, their clinical features were also milder. and a few of them showed no signs and symptoms of the infection. however, every child with a confirmed sars-cov- infection is being diagnosed as having novel coronavirus pneumonia ("ncp"), even though some of them had no fever, cough, fatigue, or typical radiological characteristics in a chest ct. here, we report patients under the age of years with confirmed covid- infection from anhui province, china, and describe the clinical features, laboratory, and radiological characteristics of a chest ct, treatment, and clinical outcome. we also report the patients' history of contact with infected person/s (direct or indirect), and (familial clustering). these cases highlight the importance of familial clustering clinical features, chest ct characteristics, and age. we aim to share our findings and recommend that pediatricians reconsider the diagnoses of children with confirmed infection. a total of patients were enrolled in this study who were admitted to one of the hospitals in anhui province in china between december and february . the inclulsion criteris was: being under years of age having respiratory specimens that were analyzed twice by real-time rt-pcr, and being diagnosed according to the world health organization's interim guidance ( ) . all the cases were discharged with twice negative real-time rt-pcr up to th may . all case data can be provided on request. the medical data were analyzed by the medical team from the pediatric department at the first affiliated hospital of ustc. information recorded included demographic data, medical history, familial clustering, details of the confirmed patients, if any, in the family, whether they were residents of wuhan, or traveled to wuhan, whether they came in contact with confirmed patients, signs, and symptoms, including pharyngodynia, fever, cough, vomiting and diarrhea, fatigue, tightness in the chest, total wbc and lymphocyte percentages, levels of c-reactive protein (crp), il- , liver function, ckmb, a marker of myocardial injury, chest ct, administration of inf a, lopinavir and ritonavir, ribavirin, or arbidol, and titers of mp-igm, anti-parainfluenza virus igm, anti-influenza virus igm, and anti-adenovirus igm. the laboratory test results and statistical analyses were the first ones carried out since the symptoms were noticed. as lymphocyte population vary according to age a lymphocyte content of < % in patients below years of age and < % in patients over years of age is considered as "lymphocyte percentage decrease." we divided the chest ct images into three classes: ( ) typical abnormalities, with bilateral multiple lobular and subsegmental areas of consolidation or bilateral ground-glass opacity (ggo) and subsegmental areas of consolidation or ggo; ( ) non-typical abnormalities, showing nodal and patchy shadow of bilateral median and extrapulmonary zone; and ( ) normal. we divided the cases under study based on various aspects. when the incidence of fever was considered, they were classified into two groups: with fever ( ) and without fever, and the baseline characteristics and differences in other signs and symptoms between the two groups were analyzed. from these data, the percentage of confirmed familial cluster among the cases, and the predominance of different signs and symptoms in the cases were estimated. based on the laboratory results, we divided the cases into three phases: total wbc≤ x /l, - x /l, and > x /l, and counted the cases in different phases. we also divided the cases into two categories: decreased and nondecreased, based on the percentage of lymphocytes, and scored the number of cases in each of these categories. when the radiological characteristics of chest ct were considered, the cases were divided into three parts: typical, non-typical, and normal. we also considered differences based on age and gender, details of the treatment, including the drugs administered in all cases, and identified the most widely used ones among these cases. a retrospective cohort study was used to analyze the epidemiological data, clinical symptoms, and signs, changes in wbc and total lymphocyte counts, chest ct, and the different treatments in children infected with sars-cov- . a comparison of the baseline characteristics of the data and signs and symptoms revealed that in both the groups fever was a common symptom. the data were analyzed using cases number (n) and percentage (%), except for the age of the patients, which was calculated as the mean. cases were divided into three categories, according to the severity of chest ct (typical, non-typical, and normal), and compared the differences in age and sex between the three categories. variables between these were presented as numbers and percentages, and continuous variables were presented as mean ± standard deviation. chisquare test or fisher's exact test was used to compare categorical variables, and student's t-test was used for continuous variables. a two-sided p < . was considered statistically significant. data were analyzed using spss statistics version . (spss inc., chicago, il, usa). the studies involving human participants were reviewed and approved by anhui provincial hospital (the first affiliated hospital of ustc) medical research ethics committee. written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. in particular, written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. among the cases, the fever group (n = ) had more patients than the non-fever group (n = ). baseline characteristics, including demographic data, familial clusters, wuhan residence, travel to wuhan, and contact with confirmed patients were not significantly different between the two groups ( table ) . among the cases under study, ( / ; . %) had only fever, six ( / ; . %) had a dry cough, two ( / ; . %) had vomiting and diarrhea, and ( / ; . %) were placed in the "others" group, showing symptoms like rhinorrhea, sneezing, sore throat, fatigue, and herpes ( table ) . thirty cases ( / ; . %) exhibited familial clustering. there were three families, each of whom had seven members with confirmed sars-cov- . fourteen families ( / ; . %) had two confirmed members (figure ) . overall, eight ( / ; . %) cases had no symptoms, ( / ; . %) had only fever, nine ( / ; . %) had both fever and additional symptoms, while ( / ; . %) were without fever. dry cough was the most common symptom in addition to fever, and additional symptoms included vomiting, diarrhea, and fatigue (figure ) . total wbc count was < * /l in cases, between x /l and x /l in cases, and more than x /l is six cases. twenty-five cases presented with a decreased lymphocyte population, while eight cases did not (figure ) . among the patients under study, seven were under years, were school-age children, and were older than the school-age children. in the three classes based on chest ct images, typical abnormalities occurred in children older than years (figure ) . we divided chest ct images into typical abnormalities (n = ), non-typical abnormalities (n = ), and normal (n = ). the mean age of the group showing typical abnormalities was higher ( . ± . years) than that of the other two groups ( . ± . years and . ± . years, respectively), but the differences were not statistically significant. the number of female patients in the normal group was higher than in the other groups and the differences were significant (p = . ) ( table ) . most of the typical abnormalities showed ggo with patchy consolidations at subpleural focal changes on ct image ( figure a ) and non-typical abnormalities ct image mostly showed increased lung marking or dense hilar shadows ( figure b) . among various treatment categories, nine cases were administered with only inf-a, cases had inf-a combined with other antiviral drugs, including lopinavir and ritonavir, ribavirin, and arbido, while four cases used only chinese patent medicine as an antiviral drug. we did not find any difference in the curative effects of these drugs. we present here a descriptive study on the clinical and epidemiological characteristics of the covid- infection. we collected data on young patients (< years of age) who were as of february , , among the patients included in this study, no dyspnea or similar complications were reported, and none of them were critically ill. covid- infection is associated with clustering onset ( ) . the data in this cohort study showed that only three patients had no familial clustering history, including two patients who were residents of wuhan. a majority of these patients ( , or / ; . %) cases showed familial clustering. three families had seven members each, and five families had four patients each with confirmed infection. among all cases, two were twins, two were sisters, and four were cousins. this suggests rapid personto-person transmission of covid- , similar to what happens in adults. covid- is mainly transmitted through respiratory droplets or through contact ( ) . in addition, current research shows that it may also be transmitted through the fecal-oral route ( ) , inhalation through aerosols produced through coughing by the infected family members, relatives, and healthcare workers, or though other sources in the environment ( ) . a recent study also suggested that infection in the womb or during birth could not be denied completely ( ) . nevertheless, in children, familial clustering is an important factor in rapid human-tohuman transmission of covid- through close family contacts. therefore, vigilant control measures should be taken at an early stage of the infection in a family ( ) . as other studies reported, we noticed that sars-cov- less commonly affects children ( ) , and that they have much fewer symptoms and less severe cases ( ) compared with adults, and also much lower case-fatality rates ( ) . in our study, none of the cases had difficulty breathing or needed oxygen support; this is different to adult cases. the common symptoms at the onset of illness were fever and dry cough. huang ( ) reported fever [ of patients [ %]], cough ( %), myalgia or fatigue ( %), headache ( %), hemoptysis ( %), and diarrhea ( %). wang et al. ( ) reported common symptoms, including fever ( . %), fatigue ( . %), dry cough ( . %), myalgia ( . %), and diarrhea and nausea ( . %). however, ( / ; . %) cases in the present study were without fever and a small proportion of patients presented initially with atypical symptoms, like fatigue, sore throat, rhinorrhea, sneezing, vomiting, diarrhea, and herpes. one of them had a sore throat at the onset of symptoms and one had fatigue; the status was the same as that of adults. a -year-old man ( ) was reported with vomiting and loose stools before admission. michelle et al. ( ) reported the first case in the united states which was that of a year-old man, with a "subjective fever" of . • c. this patient presented with a persistent dry cough, nausea, and vomiting. in a report ( ) of cases, % had no fever or cough at the onset. this suggests that measuring the body temperature cannot be considered as a decisive screening method. furthermore, in our report, there were eight ( / ; . %) cases without any early signs or symptoms. when present, the signs and symptoms were from the respiratory system (upper and lower) to the digestive system. we speculate that this observation probably indicates that the target cells might be located in different tissues, and this may change with age. in most of the cases enrolled in this study, the total wbc count was normal or decreased. the percentage of lymphocytes decreased in ( / ; . %) cases. many reports ( , , , ) of adults showed the routine blood test was useful as a diagnostic tool. a decrease in lymphocyte count indicates that sars-cov- affects immune cells and inhibits cellular immune function ( ) . t lymphocyte damage ( ) might be an important factor in exacerbating the condition of patients. the decreasing percentage of lymphocytes could prompt sars-cov- infections in the clinic. in addition, huang et al. ( ) reported that % of the cases they studied showed hepatic injury, five cases had myocardial injury, and injuries were more severe in critical patients. in our study, none of the patients showed myocardial injury, only two -year-old patients showed hepatic involvement. this difference may be attributed to better liver regeneration capacity and better ability to recover from myocardial injury. six ( / ; . %) cases had typical ggo or consolidation ( ) of the lungs as the primary findings on ct scans. all the patients were more than years old. the infants and preschool-age children had atypical chest ct scans or normal ct. a familial clustering report suggested that the symptoms of covid- were non-specific, but the three oldest patients in that family had more critical symptoms ( ) . it may be because the trachea, bronchi, and capillaries are relatively thin in childhood, and children's lungs are rich in connective tissue, poorly developed elastic tissue, abundant blood vessels, capable of holding less air, have fewer alveoli, and a less well-developed pulmonary interstitium. more research focused on the function of ace as the sars-cov- receptor and proved the binding of sars-cov- to ace lead to driving the systemic manifestations of covid- , including respiratory clinical feature and cardiovascular complication ( ) . most elderly patients routinely take ace receptor antagonists to treat high blood pressure, which increases the expression of ace and helps covid- enter the cells. on the contrary, the level of ace expression in children is low and therefore the symptoms are mild. in both healthy and diabetic individuals, ace /ace is negatively correlated with age ( ) . many reports have shown that older males ( ) ( ) ( ) ( ) are more likely to be infected by covid- . the atypical and normal chest ct scans suggest that more attention needs to be paid to young children. we also observed a greater number of males than females with typical ct scans. in adults ( ), the proportion of confirmed infection in men is higher than in women. however, wei et al. ( ) reported nine infected infants from to months, and seven of them were females. thus, covid- is more likely to infect adult and older males ( ) ( ) ( ) ( ) . on january , , chinese scientists identified the cause of a new illness as a novel coronavirus, and as of january , confirmed cases of coronavirus pneumonia had been reported in wuhan city. this is the first time this disease was called "ncp." this new virus was designated as wh-human coronavirus (whcv) ( ) and has also been referred to as " -ncov." huang et al. ( ) reported that all patients had pneumonia. the virus was given the official name of covid- by the who on february , ( ) , and this name is more scientific and suitable. in this retrospective study, we report cases without fever and eight cases without any signs and symptoms, and all cases were mild. only six cases had typical ggo or consolidation on ct scans. we divided the patients into those with typical signs and symptoms such as fever, dry cough, and atypical sore throat, fatigue, vomiting, and diarrhea. we also divided the chest ct scans into typical, atypical, and normal. we suggest more attention should be paid on the children without syndrome but with family member infected by covid- . this is a small case report of patients admitted to different hospitals, and the test results and chest ct scan results were not homogenous. it is necessary to follow up the cases enrolled in this study until all of them are discharged from the hospital, and also to test the respiratory specimens weeks after discharge to re-confirm that all of them are cured of sars-cov- infection. children's infection is mild and familial clustering was the most common channel of infection. the older patients had more typical ground glass opacity (ggo) or consolidation in chest ct scans. cases without fever strongly suggested that nonsymptomatic children should not be assumed to be free of infection when their family members have confirmed infection. children were highly susceptible to covid- and they showed clinical features distinguishbale from adults. all datasets generated for this study are included in the article/supplementary material. the studies involving human participants were reviewed and approved by anhui provincial hospital medical research ethics committee. written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance axillary temperature compared to tympanic membrane temperature in children the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study chinese expert consensus on the perinatal and neonatal management for the prevention and control of the novel coronavirus infection covid- faecal-oral transmission: are we asking the right questions? potential maternal and infant outcomes from (wuhan) coronavirus -ncov infecting pregnant women: lessons from sars, mers, and other human coronavirus infections expert reaction to newborn baby testing positive for coronavirus in wuhan coronavirus infections in children including covid- : an overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children covid- in children, pregnancy and neonates: a review of epidemiologic and clinical features clinical features of patients infected with novel coronavirus in wuhan clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan importation and human-to-human transmission of a novel coronavirus in vietnam first case of novel coronavirus in the united states the first case of novel coronavirus pneumonia imported into korea from wuhan, china: implication for infection prevention and control measures t-cell immunity of sars-cov: implications for vaccine development against mers-cov ct imaging features of novel coronavirus ( -ncov) angiotensin-converting enzyme : sars-cov- receptor and regulator of the renin-angiotensin system: celebrating the th anniversary of the discovery of ace aging healthy, or with diabetes, is associated with ace /ace this imbalance in the hematopoietic stem progenitor cells prevalence of comorbidities in the middle east respiratory syndrome coronavirus (mers-cov): a systematic review and meta-analysis sex-based differences in susceptibility to severe acute respiratory syndrome coronavirus infection sexual dimorphism in innate immunity pathophysiology and burden of infection in patients with diabetes mellitus and peripheral vascular disease: focus on skin and soft-tissue infections novel coronavirus infection in hospitalized infants under year of age in china a new coronavirus associated with human respiratory disease in china three emerging coronaviruses in two decades the story of sars, mers, and now covid- lz and sh contributed to the conception and design of research. lz gathered the medical data, updated the literature search, made independent quality assessments, and extracted data before comparing results and resolving differences. the nicu team of the first hospital affiliated to ustc analyzed the data. lz edited and revised the manuscript. sh and lz approved the final version of manuscript. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © zhang and huang. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- - vojgu authors: boddington, n. l.; charlett, a.; elgohari, s.; walker, j. l.; mcdonald, h.; byers, c.; coughlan, l.; garcia vilaplana, t.; whillock, r.; sinnathamby, m.; panagiotopoulos, n.; letley, l.; macdonald, p.; vivancos, r.; edeghere, o.; shingleton, j.; bennett, e.; grint, d. j.; strongman, h.; mansfield, k. e.; rentsch, c.; minassian, c.; douglas, i. j.; mathur, r.; peppa, m.; cottrell, s.; mcmenamin, j.; zambon, m.; ramsay, m.; dabrera, g.; saliba, v.; lopez bernal, j. title: covid- in great britain: epidemiological and clinical characteristics of the first few hundred (ff ) cases: a descriptive case series and case control analysis date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: vojgu objectives: following detection of the first virologically-confirmed cases of covid- in great britain, an enhanced surveillance study was initiated by public health england to describe the clinical presentation, course of disease and identify risk factors for infection of the first few hundred cases. methods: information was collected on the first covid- cases according to the first few x who protocol. case-control analyses of the sensitivity, specificity and predictive value of symptoms and risk factors for infection were conducted. point prevalences of underlying health conditions among the uk general population were presented. findings: the majority of ff cases were imported ( . %), of which the majority had recent travel to italy ( . %). . % were secondary cases acquired mainly through household contact ( . %). children had lower odds of covid- infection compared with the general population. the clinical presentation of cases was dominated by cough, fever and fatigue. non-linear relationships with age were observed for fever, and sensitivity and specificity of symptoms varied by age. conditions associated with higher odds of covid- infection (after adjusting for age and sex) were chronic heart disease, immunosuppression and multimorbidity. conclusion: this study presents the first epidemiological and clinical summary of covid- cases in great britain. the ffx study design enabled systematic data collection. the study was able to characterize the risk factors for infection with population prevalence estimates setting these relative risks into a public health context. it also provides important evidence for generating case definitions to support public health risk assessment, clinical triage and diagnostic algorithms. in december , the world health organisation (who) was notified of a cluster of unexplained pneumonia cases detected in wuhan city, china. this was subsequently identified and designated as covid- , caused by the novel severe acute respiratory syndrome coronavirus (sars-cov- ), a strain previously unseen in humans. the uk was one of the first countries affected in europe, with its first two confirmed cases of covid- detected on january ( ) . the epidemiology and clinical features of early covid- cases identified in china and elsewhere have been reported ( ) ( ) ( ) ( ) ( ) ( ) . in a pre-print article, ma et al., present a pooled analysis of , cases from seven countries with estimates of key epidemiological parameters ( ) and the first identified cases in the who european region have been described ( ) . the most commonly reported symptoms have been fever, fatigue, dry cough, myalgia and dyspnoea ( - , , ) . these studies did not report on the sensitivity, specificity or positive predictive values of symptoms. reported estimates of proportions of cases with underlying health conditions vary between % and % ( ) ( ) ( ) ( ) ) . a range of underlying health conditions have been found to be associated with poor outcomes from covid- ( ) ( ) ( ) . however, there are few controlled studies of underlying health conditions as risk factors for infection. in a pre-print from the united states, a test-negative design study of veterans tested for covid- found that the only comorbidity associated with testing positive after multivariable adjustment was chronic obstructive pulmonary disease, which was associated with decreased risk of testing positive for covid- ( ) . studies in other settings and with general population controls (not selected by testing) are needed to understand the role of underlying health conditions in infection itself, rather than severity of illness. the first few x (ffx) is an established enhanced surveillance system designed to investigate the clinical and epidemiological characteristics of at least the first confirmed cases of an emerging infectious disease and their close contacts ( ) . the design has previously been used in the influenza h n pandemic ( ) and the who has recommended that countries adopt this protocol for investigation of covid- ( ) . following the detection of the first gb cases at the end of january , the ff surveillance system for covid- was initiated by public health england (phe). the primary objectives were to describe the clinical presentation and course of disease and underlying health conditions associated with for infection. this paper describes the epidemiological and clinical characteristics of the first few hundred cases of covid- identified in gb, including estimates of sensitivity and specificity of selected symptoms, associations of underlying health conditions with infection and estimates of the prevalence of these conditions in the uk population. after detection of covid- in china, the ff protocol, data collection questionnaires and electronic data capture system were modified for the covid- outbreak. initially enhanced surveillance forms were collected for all virologically-confirmed cases of covid- in gb. due to the large predominance of imported cases during february , this was later restricted to sporadic cases only. case definitions for testing and the time periods that they applied are outlined in table . • requiring admission to hospital (a hospital practitioner has decided that admission to hospital is required with an expectation that the patient will need to stay at least one night) and • have either clinical or radiological evidence of pneumonia or • acute respiratory distress syndrome or • influenza like illness (fever ≥ . °c and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing imported cases were defined as cases with travel to countries with known covid- circulation at the time or with contact with a confirmed case whilst abroad within a maximum incubation period of their onset of symptoms. secondary cases were defined as cases that had contact with a confirmed or probable/suspected case in the uk and did not fit the definition of an imported case. sporadic cases were defined as cases with no travel history to countries with known covid- circulation, and no known contact with a confirmed case. data collection was coordinated by the phe surveillance cell, national infection service. on identification of a positive case, the local health protection teams, field service teams and the equivalents in the devolved administrations of great britain, were asked to complete an initial enhanced surveillance questionnaire (form a) providing information on demographic details, medical history and travel history. this information was collected as soon as possible after a positive laboratory result was reported and was collected through interview with the cases and/or healthcare workers or family members. cases were followed up after days from initial report (form b). follow-up information on cases was collected to determine the occurrence of any medical complications and clinical outcome. to improve completeness of the initial questionnaires and to achieve a high rate of follow-up, a team of phe health protection practitioners, nurses, doctors and field epidemiologists proactively followed up the ff cases in england using telephone interviews. data from completed forms were entered into a dedicated ff web-tool. data were extracted, cleaned and quality checked. o control data possible cases who tested negative during the early stages of the epidemic more limited data on patient demographics, presenting illness, clinical course/complications after onset and exposures in the days before onset of first symptoms, were collected on all possible cases using a minimum data set (mds) form. those suspected cases testing negative were used as a control group for the analyses of symptoms. general population data were obtained from an anonymised dataset of primary care electronic health records, clinical practice research datalink (cprd) gold. in the uk, almost % of the population is registered at a general practice and healthcare is free at the point of delivery. cprd is broadly representative of the population in terms of age and sex ( ) . primary care prescriptions and laboratory test results are automatically recorded electronically. diagnoses are recorded using read codes, and generally have good positive predictive value ( ) . approximately % of cprd practices in england have consented to data linkage, and for patients at these practices anonymised secondary care data (hospital episode statistics (hes)) is linked to primary care records. descriptive analyses of the ff cases were undertaken in relation to patient characteristics, clinical symptoms and complications, healthcare interactions and outcomes. for the analysis of symptoms, missing data was assumed to indicate absence of that symptom. ethnicity was assigned to cases by linking, using nhs number and date of birth, to the latest recording of ethnicity in the outpatient hes database. if no record of ethnicity was found in the outpatient record, then the hes admitted patient care recording of ethnicity was used. underlying health conditions among the uk general population were ascertained from diagnoses, prescriptions and test results in cprd primary care records, with hospital diagnoses supplementing ascertainment for a secondary analysis limited to england (due to availability of hes-linkage). detailed definitions of risk groups were tailored to respiratory infection risk using established methods described more fully in supplementary analysis of associations of underlying health conditions with infection used a case-control design, with controls from the uk general population in cprd (details in supplementary table a) . cases with any data recorded for any underlying health condition (whether 'yes' or 'no') or any medical history recorded in free text were included, with missing data assumed to indicate absence of that comorbidity. cases for whom there was no evidence of any data collection for underlying health conditions were excluded (n= ). cancer in controls was defined as any history of malignant cancer, as questionnaire free-text suggested this would be most comparable to cases. single variable and multivariable logistic regression were used to calculate odds ratios of each underlying health condition in covid- cases compared to the uk general population, adjusted for sex and age (in categories < , - , - , - and ≥ years) as a priori confounders. consideration of other potential confounders (such as comorbid health conditions) was limited by data sparsity. age (over and under years) and infection source (imported or sporadic/secondary) were considered as potential effect modifiers. point prevalence estimates for underlying health conditions were calculated per , for the uk general population on march . prevalence of cancer was estimated for malignant cancer incident within the previous year rather than ever, for greater clinical relevance. estimates of the sensitivity and specificity of symptoms were obtained from the proportion of covid- cases, and those testing negative respectively. predictive values were estimated for the observed prevalence of positive patients. the functional relationships between the presence of a symptom and age were explored using locally weighted scatter plot smoothing. fractional polynomial logistic regression models were used to obtain parametric functions of these relationships with age. interaction terms between the fractional polynomial age terms and case type (imported, sporadic or secondary) were used to assess if there was evidence of different age relationships. logistic regression analyses were performed to assess which symptoms were independently associated with covid- , accounting for sex and age. multinomial regression models were used with case type as the outcome variable to assess whether the associations with symptoms differed for each case type. analyses were undertaken in microsoft excel , r and stata mp. this was an observational surveillance system carried out under the permissions granted under regulation of the health service (control of patient information) regulations , and without explicit patient permission under section of the nhs act . analysis involving cprd data was approved by the independent scientific advisory group of the cprd (isac, reference _ a) and the london school of hygiene and tropical medicine ethics committee (reference ). the isac protocol was made available to reviewers. confirmed cases of covid- in gb were included in this analysis (up to april ) ( from england, from scotland and three from wales). . % of cases were resident in london. figure shows the distribution of cases included in the ff study by date of symptom onset and covid- case types. approximately half of the ff cases were imported ( . %) with the remainder being secondary ( . %) or sporadic ( . %) cases. of the ff cases, . % reported travel to italy in the days prior to symptom onset ( . % of imported cases) and hence europe was the most commonly visited continent by the imported cases ( figure ). where occupation was recorded (n= ), cases were healthcare workers ( . %), although the majority of these were imported cases (n= ). of the secondary cases, almost all reported close contact with a confirmed case ( / , . %), of these . % had close contact within a household setting, . % in a healthcare setting, . % in other settings (for example work setting, social gatherings) and . % unknown setting. there were slightly more male cases ( . %) compared with female cases ( . %). the ff cases ranged between year and years of age with a mean age of . years (standard deviation (sd) . ) ( figure ). country of birth was available on . % of the cases, of which the majority were born in the uk ( . %), followed by italy ( . %), iran ( . %) and the united states ( . %). the ethnicity breakdown of the ff cases (available for . % of cases) was comparable to the general population (england and wales, ons census) ( table ). all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest) logistic regression analysis of associations of age and sex with covid- included cases with data on underlying health conditions (to allow adjustment for immunosuppression), and , , uk general population controls. when stratified by infection source and sex, women had lower odds of imported covid- than men (aor . , % ci . - . ), but there was no evidence of an association of sex with secondary/sporadic cases (table ) . when stratified by infection source and age, children aged under years had considerably lower odds of imported and secondary/sporadic covid- than the general population ( table ). adults aged - years had higher odds of imported covid- than adults aged - years, but otherwise there was no evidence of any association between infection and age for adults aged under years. adults aged years or over had lower odds of imported covid- than younger adults, but this association was not observed among secondary/sporadic cases (table ) . o analysis of associations of underlying health conditions with covid- infection included cases with comorbidity data, and , , uk general population controls (table ). approximately one third of the cases had an underlying health condition ( / , . %), and . % of cases had multimorbidity. the most frequent conditions were asthma, diabetes, and chronic heart disease. after adjustment for age and sex, cases had higher odds of chronic heart disease (adjusted odds ratio (aor) . , % ci . - . ), immunosuppression (aor . , . - . ), and multimorbidity (aor . , . - . ), and lower odds of chronic kidney disease (aor . , . - . ) compared to the general population. there was weak evidence suggesting that cases had higher odds of chronic liver disease (aor . , . - . ) and lower odds of asthma (aor . , . - . ) than the general population. when stratified by infection source, associations between underlying health conditions and covid- infection appeared generally smaller for imported cases than for sporadic or secondary cases, but confidence intervals overlapped for all conditions other than multimorbidity. there was no evidence of any association of covid- infection with diabetes, chronic respiratory disease (excluding asthma), chronic neurological disease, organ transplant or a history of malignant cancer, although confidence intervals were particularly wide for organ transplant. in england, age-and sex-adjusted odds of liver disease (aor . , % ci . - . ) and organ transplant ( . , . - . ) were higher among cases than the general population, but no evidence of these associations remained in analysis using linked hospital data among patients eligible for data linkage (supplementary table b ). when secondary care data were used to enhance ascertainment of underlying health conditions in england, the increased ascertainment of underlying health conditions among controls resulted in a general decrease in odds ratios for associations of those conditions with covid- infection -this was most pronounced for chronic liver disease, immunosuppression and chronic heart disease. nevertheless, odds of chronic heart disease and immunosuppression remained consistently higher among cases than the general population in all analyses. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. or, odds ratio; aor, odds ratio adjusted for age and sex; % ci, % confidence interval. * individuals with no data recorded for any underlying health conditions were excluded from logistic regression analysis adjusted odds ratios were adjusted for age (under years, - years, - years, - years, and ≥ years) and sex. multimorbidity was defined as two or more of the following: chronic liver disease; chronic heart disease; chronic respiratory disease (including asthma); chronic neurological disease; immunosuppression (including organ transplant recipient), or chronic kidney disease. a previous history of cancer was not included in estimates of multimorbidity in case-control analysis. as a post hoc analysis considering the possibility of over ascertainment of multimorbidity among controls by including all individuals with a history of asthma, the multimorbidity analysis was repeated additionally excluding asthma. the prevalence of any underlying health condition was . % in england, . % in scotland, . % in northern ireland, and . % in wales (supplementary table c) . among those conditions associated with covid- , point prevalence of chronic heart disease ranged from . % (england) to . % (scotland), immunosuppression from . % (wales) to . % (scotland), chronic liver disease from . % (england) to . % (scotland) and multimorbidity from . % (england) to . % (wales and northern ireland). prevalence of any underlying health condition increased to . % in england when ascertainment was supplemented with secondary care data; the greatest increases in prevalence estimates were for chronic liver disease and chronic heart disease. the symptoms during illness reported by all ff cases are summarised in figure . the most frequent symptoms were cough ( . %), fatigue ( . %), fever ( . %), headache ( . %), muscle ache ( . %), appetite loss ( . %). just over three quarters of the cases experiencing a cough reported whether they experienced a dry or productive cough: the majority of whom reported a dry cough ( . %). anosmia was added to the follow-up questionnaire part way through the ff study. of the cases who were asked this question reported anosmia during their illness ( . %). one case reported anosmia as their only symptom. cough was the most common presenting symptom for all age groups. a lower proportion of cases in the + year old age group reported headache, sore throat, runny nose and sneezing compared with other age groups (supplementary table d table d) . table shows common groups (pairs/trios) of presenting symptoms. there were four symptoms; fever, cough, shortness of breath and sore throat, that were collected on symptomatic covid- cases in the ff , and contemporaneous confirmed non-covid- respiratory infections. the relationship between the presence of a symptom and age for those with covid- and those with non-covid- respiratory illness is shown in figures and . these show non-linear relationships with age. for fever, there is an increase in occurrence with increasing age for covid- , while for those with other respiratory infections the occurrence decreases with increasing age. for cough, a similar relationship is observed with covid- and other respiratory infections. shortness of breath exhibits an increasing occurrence with increasing age for both, although in those with covid- there is a higher proportion of elderly cases with this symptom compared to those with other respiratory infections. the age relationship for sore throat was similar for both covid- and other respiratory infections. the shape of the age relationship with each symptom were similar in each of the different types of covid- cases (imported, sporadic and secondary). o sensitivity and specificity estimates of sensitivity and specificity for symptoms are presented in table . broad age categories; < , - , +, have been used to provide estimates within these age strata. fever had both good sensitivity and specificity ( . % and . %), cough had high sensitivity but poor specificity ( . % and . %), shortness of breath was the most specific symptom but had low sensitivity, while sore throat had relatively low sensitivity and specificity. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. estimates of the positive predictive value (ppv) and negative predictive value (npv) for the observed proportions of cases are presented in table . the ppv and npv were similar for fever and shortness of breath. these were . % and . %, respectively, for fever and . % and . % for shortness of breath, respectively. the estimated ppv increased with increasing age groups, with the npv decreasing. the association between covid- and symptoms has been assessed using logistic regression modelling. the estimated odds ratios (or) and adjusted odds ratios (aor) results are presented in table . *adjusted for other symptoms, age and sex all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. after adjusting for the other symptoms, age and sex; fever and shortness of breath were significantly associated with a diagnosis of covid- (aor . ( % ci . - . ) and (aor . ( % ci . - . ), respectively. cough and sore throat exhibited no association with covid- . age was positively associated which may reflect how the early cases were identified rather than what may have be occurring in the general population. as the occurrence of symptoms change with age, interaction terms between a symptom and the broad age groups used previously have been explored. this provided strong evidence that the association with fever differed in these age groups (interaction term p value . ). in the under -year olds the aor was . ( % ci . - . ), in the to -year old the aor was . ( % ci . - . ), while in those years of age or older the aor was . ( % ci . - . ). no other symptom exhibited any strong evidence of an interaction with age. finally, a multinomial regression model was used to assess associations with the different covid- case types. as with the logistic regression models, there was strong evidence of an interaction with age group and fever (table ). sporadic cases exhibit a stronger association with both fever and shortness of breath, and have a higher proportion aged or older. for all case types the association with fever is strongest in those aged or older. cough and sore throat are not strongly associated with any case type. overall follow-up information was obtained on . % of ff cases ( / ) ( . % of the ff cases in england ( / )). duration of illness, in those cases which had sufficient information recorded (n= ), ranged from to days (median days, iqr - days, mean . days). the use of nhs , a telephone and online service was the most common healthcare interaction amongst the ff cases in england with just over three quarters of cases accessing nhs at least once ( this study presents an early assessment of the epidemiological and clinical characteristics of covid- patients in gb. the covid- ff system was rapidly established with data collected and analysed from the first virologically-confirmed cases. in this early phase, patients were only eligible for testing if they fitted the case definition at the time, which was based on a combination of clinical symptoms, travel history or contact with a confirmed case and later admission to hospital. this is the first epidemiological and clinical summary of severe and non-severe confirmed covid- cases in gb and is also the first controlled analysis that we are aware of outside the united states that investigates associations of underlying health conditions with covid- infection, rather than severe outcomes. the study is also the first to estimate sensitivity and specificity of different symptoms for covid- in the gb population. just over half of the cases included in our study were imported with the majority imported from italy, highlighting the importance of the italian outbreak in facilitating spread to other european countries ( ) . sporadic cases were detected within a month of the first confirmed case in gb. where known exposure to a confirmed case was documented, the most common setting for exposure was the household, confirming the household as a high risk setting for transmission. only a small proportion of the cases were healthcare workers and most of these acquired their infection abroad suggesting that, in the containment phase of the epidemic, healthcare acquired infection did not play a significant role. there were slightly more males amongst the ff cases than females; a gender distribution that has been described elsewhere ( ) ( ) ( ) ( ) . however, there was no evidence of an association of sex with secondary/sporadic cases. the median age was . years, again similar to other case series ( - , , ) . children had lower odds of infection compared to the general population for all case types. the proportion of cases with any underlying health condition was . %, slightly lower than the . % of , cases reported to cdc in the us ( ). chronic heart disease, immunosuppression and multimorbidity were associated with higher odds of covid- infection, for sporadic and imported cases. there was also weak evidence suggesting that chronic liver disease might be associated with higher odds of covid- infection. these conditions may be risk factors for infection, although the associations could alternatively be explained by a greater likelihood of symptomatic or severe presentations in these patients which in turn increased the probability of testing for covid- . the prevalence of any specified underlying health condition among the general population on march ranged from . % in england to . % in wales, similar to the proportion seen in the ff cases ( . %). chronic kidney disease and a history of asthma were associated with lower odds of covid- infection for imported and sporadic cases, suggesting this is not explained by reduced likelihood of travel. this could be explained if ascertainment of these conditions is higher using electronic primary care records for general population controls than case questionnaires. for asthma this is plausible since the case questionnaires only asked about asthma requiring medication -although free text responses include mild or childhood asthma. it is also possible that asthma is not a risk factor for covid- infection: asthma has been under-represented in case series of hospitalised patients, and there are mixed findings on the association of asthma with severe outcomes of covid- ( , ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the clinical presentation in ff cases was dominated by cough, fatigue and fever, consistent with other studies ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the proportion of ff cases reporting fever was slightly lower than case series descriptions from china ( ) ( ) ( ) ( ) , although similar to the first cases of covid- described in europe ( ). this may be due to the inclusion of non-hospitalised cases in this study as well as the european study. almost half of cases reported anosmia during the course of their illness, an unexpected symptom that has been observed by others, with some suggestion that it might precede the onset of more common symptoms or be present in those with mild or asymptomatic infection ( ) ( ) ( ) ( ) . further work is required to understand anosmia as a distinctive clinical feature of covid- ( , ) . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. symptoms were relatively consistent by sex. we noted differences in symptom presentation by age, with a lower proportion of cases in the youngest (< years) and oldest age groups ( + years) reporting symptoms when compared to the other age groups. in particular, a non-linear relationship with age was observed for fever which increased with age for the covid- cases. although this study included only a small number of children, our findings are congruent with other studies suggesting that children may experience milder illness with different symptoms ( - ). the different sensitivity and specificity of symptoms by age highlights the need to consider this when setting up case definitions to support public health risk assessment, clinical triage and diagnostic algorithms. fever is clearly an important symptom, exhibiting good sensitivity and specificity. it was also significantly associated with a diagnosis of covid- , as was shortness of breath, and there was evidence of an interaction between fever and age, including for the different case types. in particular, sporadic cases exhibited a stronger association with fever and shortness of breath. the model used broad age groups, so differences due to age may have been concealed by this. as expected, the non-urgent medical telephone and online service, nhs , was the most common healthcare interaction of the ff cases, in keeping with key government messaging during the study period which emphasised that those experiencing covid- symptoms should stay home and contact nhs . this highlights the importance of public messaging about using online and telephone services to avoid propagating transmission of covid- in healthcare settings. forty-three percent of cases included in our study were hospitalised however this is certainly an overestimate of the case hospitalisation rate since at the beginning of the uk covid- incident response all confirmed cases were hospitalised for isolation rather than clinical management purposes, and from march , testing was restricted to hospitalised cases only. the fact that only a small proportion of those hospitalised required mechanical ventilation in comparison with other studies supports this ( , ) . one of the key strengths of this study is the detailed epidemiological and clinical data it was able to obtain. use of the ffx study design allowed for systematic data collection on cases using ready to use infrastructure. the study achieved high rates of follow up on the ff cases and also benefits from having followed the majority of cases up past the intended days. this has enabled capture of totality of symptoms over the course of illness which in many cases has been longer than days. this study included detailed ascertainment of underlying health conditions in controls from the general population to describe age and sex adjusted associations of health conditions with infection. there were a number of limitations to this study. firstly, the ff cases are a small subset of cases that were identified at the beginning of the covid- epidemic in the great britain. they are unlikely to be representative of all gb cases of covid- or of the general population, with different exposure and risk profiles. as such, the case-control study is vulnerable to selection bias. the ff cases are likely to be biased towards more severe cases who presented to healthcare, therefore they will underrepresent those with mild illness in the population, which may overestimate the associations between underlying health conditions and infection. the clinical presentation of ff cases may also differ to that of all gb cases since the imported cases (accounting for more than half of all cases) are more likely to have been of working age and may have been 'healthier' than the general population. this could conversely bias our estimates of associations between health conditions and infection downwards. the severity estimates are likely to be overestimates due to policy changes over the course of the study period, with hospitalisation of cases for isolation purposes initially and latterly restricting testing to hospitalised cases only. despite having a high follow-up rate, clinical outcome was not available on some cases due to sensitivities and difficulties around ascertaining the required information, particularly for the most severe cases. also, for some cases the timing of follow-up, during which the initial questionnaire was revisited, may have been some time after onset of illness leading to possible recall bias. the power and precision of estimates of associations between underlying health conditions and covid- is limited by the number of cases in the ff . this also limits the scope to adjust for potential confounders other than age and sex in the study. it is important to note that the predictive values do not necessarily reflect the prevalence of covid- in the population at any particular time. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. future pandemic planning, should note the importance of maintaining ffx studies into the community transmission phase, as we have shown differences between imported and gb-acquired cases. furthermore, achieving high quality and complete data capture and follow-up of cases, depends on the ability to rapidly mobilise a cadre of trained public health professionals. this can pose a challenge when capacity is already overwhelmed by the incident response. consideration should also be given to case ascertainment through ffx investigations and how this may differ as a pandemic progresses due to changing contact tracing and testing policies over time. in summary, this paper presents the first epidemiological and clinical summary of covid- cases in great britain. this study has informed modelling of likely disease burden and healthcare demand, as well as priority groups for preventive measures such as physical distancing. this study also provides important evidence for generating case definitions to support public health risk assessment, clinical triage and diagnostic algorithms. the analysis using cprd data was funded by the national institute for health research (nihr) health protection research unit (hpru) in immunisation at the london school of hygiene and tropical medicine in partnership with public health england (phe). the views expressed are those of the authors and not necessarily those of the nhs, the nihr, the department of health and social care, or phe. first cases of coronavirus disease (covid- ) in the who european region clinical features of patients infected with novel coronavirus in wuhan epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical characteristics of coronavirus disease in china covid- ) outbreak in the republic of korea from characteristics and outcomes of critically ill patients with covid- in washington state epidemiological parameters of coronavirus disease : a pooled analysis of publicly reported individual data of cases from seven countries clinical findings in a group of patients infected with the novel coronavirus (sars-cov- ) outside of wuhan, china: retrospective case series clinical determinants for fatality of , patients with covid- uk patients with covid- using the isaric who clinical characterisation protocol opensafely: factors associated with covid- -related hospital death in the linked electronic health records of million adult nhs patients global surveillance during an influenza pandemic pandemic (h n ) influenza in the uk: clinical and epidemiological findings from the first few hundred (ff ) cases. epidemiology and infection data resource profile: clinical practice research datalink (cprd) validation and validity of diagnoses in the general practice research database: a systematic review safety of inadvertent administration of live zoster vaccine to immunosuppressed individuals in a uk-based observational cohort analysis validation of asthma recording in the clinical practice research datalink (cprd) medium and long-term risks of specific cardiovascular diseases in survivors of adult cancers: a population-based cohort study using multiple linked uk electronic health records databases accessed on what can research primary care datasets contribute to routine monitoring of vaccine coverage and uptake centers for disease control. preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease -united states covid- : pandemic contingency planning for the allergy and immunology clinic do chronic respiratory diseases or their treatment affect the risk of sars-cov- infection? self-reported olfactory and taste disorders in sars-cov- patients: a cross-sectional study neurologic manifestations of hospitalized patients with coronavirus disease utility of hyposmia and hypogeusia for the diagnosis of covid- olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid- ): a multicenter european study epidemiology of covid- among children in china sars-cov- infection in children we also acknowledge the contributions of richard pebody, katie owens, hongxin zhao and chinelo obi from the phe immunisation department for their work on developing the protocols, study design, data collection and data entry, and the phe software development unit for their work on developing the ff web-platform.we would like to acknowledge the contribution of a number of teams to this study including the phe health protection teams, phe field services, phe centres, the phe centres and regions operational cell, and the team of phe health protection and immunisation specialist nurses and public health registrars who assisted with the case follow ups. also the contribution of the teams in health protection scotland, and malorie perry, clare sawyer and the staff of public health communicable disease surveillance centre and covid- response cells in public health wales.we would also like to acknowledge the contributions of nick andrews, anthony scott, julia stowe, liam smeeth from the nihr health protection research unit in immunisation at phe and lshtm, and angel wong from lshtm, towards study design, data extraction and cleaning, and interpretation of results for the analysis of underlying health conditions in cases and cprd controls. all authors have completed the icmje conflicts of interest form and declare: no support from any organisation for the submitted work; jmcm reports grant funding from imove covid- , no other relationships or activities that could appear to have influenced the submitted work. jlb is the corresponding author and guarantor. nlb, ac, himcd, vs and jlb drafted the manuscript. applications for relevant anonymised data should be submitted to the public health england office for data release: https://www.gov.uk/government/publications/accessing-public-health-england-data/about-the-phe-odrand-accessing-data. the data used for this study were obtained from the clinical practice research datalink (cprd). all cprd data are available via an application to the independent scientific advisory committee (see https://www.cprd.com/data-access). data acquisition is associated with a fee. key: cord- -qcghtkk authors: russo, lucia; anastassopoulou, cleo; tsakris, athanasios; bifulco, gennaro nicola; campana, emilio fortunato; toraldo, gerardo; siettos, constantinos title: tracing day-zero and forecasting the covid- outbreak in lombardy, italy: a compartmental modelling and numerical optimization approach date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: qcghtkk introduction: italy became the second epicenter of the novel coronavirus disease (covid- ) pandemic after china, surpassing by far china’s death toll. the disease swept through lombardy, which remained in lockdown for about two months, starting from the th of march. as of that day, the isolation measures taken in lombardy were extended to the entire country. here, assuming that effectively there was one case “zero” that introduced the virus to the region, we provide estimates for: (a) the day-zero of the outbreak in lombardy, italy; (b) the actual number of asymptomatic infected cases in the total population until march ; (c) the basic (r( ))and the effective reproduction number (r(e)) based on the estimation of the actual number of infected cases. to demonstrate the efficiency of the model and approach, we also provide a tentative forecast two months ahead of time, i.e. until may , the date on which relaxation of the measures commenced, on the basis of the covid- community mobility reports released by google on march . methods: to deal with the uncertainty in the number of the actual asymptomatic infected cases in the total population volpert et al. ( ), we address a modified compartmental susceptible/ exposed/ infectious asymptomatic/ infected symptomatic/ recovered/ dead (seiird) model with two compartments of infectious persons: one modelling the cases in the population that are asymptomatic or experience very mild symptoms and another modelling the infected cases with mild to severe symptoms. the parameters of the model corresponding to the recovery period, the time from the onset of symptoms to death and the time from exposure to the time that an individual starts to be infectious, have been set as reported from clinical studies on covid- . for the estimation of the day-zero of the outbreak in lombardy, as well as of the “effective” per-day transmission rate for which no clinical data are available, we have used the proposed seiird simulator to fit the numbers of new daily cases from february to the th of march. this was accomplished by solving a mixed-integer optimization problem. based on the computed parameters, we also provide an estimation of the basic reproduction number r( ) and the evolution of the effective reproduction number r(e). to examine the efficiency of the model and approach, we ran the simulator to “forecast” the epidemic two months ahead of time, i.e. from march to may . for this purpose, we considered the reduction in mobility in lombardy as released on march by google covid- community mobility reports, and the effects of social distancing and of the very strict measures taken by the government on march and march , . results: based on the proposed methodological procedure, we estimated that the expected day-zero was january (min-max rage: january to january , interquartile range: january to january ). the actual cumulative number of asymptomatic infected cases in the total population in lombardy on march was of the order of times the confirmed cumulative number of infected cases, while the expected value of the basic reproduction number r( ) was found to be . (min-max range: . - . ). on may , the date on which relaxation of the measures commenced the effective reproduction number was found to be . (interquartiles: . , . ). the model approximated adequately two months ahead of time the evolution of reported cases of infected until may , the day on which the phase i of the relaxation of measures was implemented over all of italy. furthermore the model predicted that until may , around % of the population in lombardy has recovered (interquartile range: ∼ % to ∼ %). italy became the second epicenter of the novel coronavirus disease (covid- ) pandemic after china, surpassing by far china's death toll. the disease swept through lombardy, which remained in lockdown for about two months, starting from the th of march. as of that day, the isolation measures taken in lombardy were extended to the entire country. here, assuming that effectively there was one case "zero" that introduced the virus to the region, we provide estimates for: (a) the day-zero of the outbreak in lombardy, italy; (b) the actual number of asymptomatic infected cases in the total population until march ; (c) the basic (r )and the effective reproduction number (r e ) based on the estimation of the actual number of infected cases. to demonstrate the efficiency of the model and approach, we also provide a tentative forecast two months ahead of time, i.e. until may , the date on which relaxation of the measures commenced, on the basis of the covid- community mobility reports released by google on march . to deal with the uncertainty in the number of the actual asymptomatic infected cases in the total population volpert et al. ( ), we address a modified compartmental susceptible/ exposed/ infectious asymptomatic/ infected symptomatic/ recovered/ dead (seiird) model with two compartments of infectious persons: one modelling the cases in the population that are asymptomatic or experience very mild symptoms and another modelling the infected cases with mild to severe symptoms. the parameters of the model corresponding to the recovery period, the time from the onset of symptoms to death and the time from a a a a a exposure to the time that an individual starts to be infectious, have been set as reported from clinical studies on covid- . for the estimation of the day-zero of the outbreak in lombardy, as well as of the "effective" per-day transmission rate for which no clinical data are available, we have used the proposed seiird simulator to fit the numbers of new daily cases from february to the th of march. this was accomplished by solving a mixed-integer optimization problem. based on the computed parameters, we also provide an estimation of the basic reproduction number r and the evolution of the effective reproduction number r e . to examine the efficiency of the model and approach, we ran the simulator to "forecast" the epidemic two months ahead of time, i.e. from march to may . for this purpose, we considered the reduction in mobility in lombardy as released on march by google covid- community mobility reports, and the effects of social distancing and of the very strict measures taken by the government on march and march , . based on the proposed methodological procedure, we estimated that the expected dayzero was january (min-max rage: january to january , interquartile range: january to january ). the actual cumulative number of asymptomatic infected cases in the total population in lombardy on march was of the order of times the confirmed cumulative number of infected cases, while the expected value of the basic reproduction number r was found to be . (min-max range: . - . ). on may , the date on which relaxation of the measures commenced the effective reproduction number was found to be . (interquartiles: . , . ). the model approximated adequately two months ahead of time the evolution of reported cases of infected until may , the day on which the phase i of the relaxation of measures was implemented over all of italy. furthermore the model predicted that until may , around % of the population in lombardy has recovered (interquartile range: * % to * %). the butterfly effect in chaos theory underscores the sensitive dependence on initial conditions, highlighting the importance of even a small change in the initial state of a nonlinear system. the emergence of a novel coronavirus, sars-cov- , that caused a viral pneumonia outbreak in wuhan, hubei province, china in early december has evolved into the covid- acute respiratory disease pandemic due to its alarming levels of spread and severity, with more than . million cases and , deaths globally, as of may , ( [ , ] ). the seemingly far from the epicenter, old continent became the second-most impacted region after asia pacific, mostly as a result of a dramatic divergence of the epidemic trajectory in italy first, where there have been , total confirmed infected cases and , deaths, and then in spain where there have been , total confirmed infected cases and , deaths, as of may , ( [ , ] ). the second largest outbreak outside of mainland china officially started on january , , after two chinese visitors staying at a central hotel in rome tested positive for sars-cov- ; the couple remained in isolation and was declared recovered on february [ ] . a -year-old man repatriated back to italy from wuhan who was admitted to the hospital in codogno, lombardy on february was the first secondary infection case ("patient "). "patient " was never identified by tracing the first italian citizen's movements and contacts. in less than a week, the explosive increase in the number of cases in several bordering regions and in the two autonomous provinces of trento and bolzano (the northerner in italy) placed enormous strain on the decentralized health system. following a dramatic spike in deaths from covid- , italy transformed into a "red zone", and the movement restrictions were expanded to the entire country on the th of march. all public gatherings were cancelled and school and university closures were extended through at least the next month. in an attempt to assess the dynamics of the outbreak for forecasting purposes, it is important to estimate epidemiological parameters that cannot be computed directly based on clinical data, such as the transmission rate (or as otherwise called "effective contact rate" of the disease and the basic reproduction number, r . the transmission rate is defined as the product of the probability of transmitting the virus given a contact between a susceptible and an infected individual and the average rate of contacts between susceptibles and infected. r is defined as the expected number of exposed cases generated by one infected case in a population where all individuals are susceptible [ ] . since the first confirmed covid- case many mathematical modelling studies have already appeared. the first models mainly focused on the estimation of the basic reproduction number r using dynamic mechanistic mathematical models ( [ ] [ ] [ ] [ ] ), but also simple exponential growth models (see e.g. [ , ] ). compartmental epidemiological models like sir, sird, seir and seird have been proposed to estimate other important epidemiological parameters, such as the transmission rate and for forecasting purposes (see e.g. [ , ] ). other studies have used metapopulation models, which include data of human mobility between cities and/or regions to forecast the evolution of the outbreak in other regions/countries far from the original epicenter in china [ , , , ] , including the modelling of the influence of travel restrictions and other control measures in reducing the spread [ ] . among the perplexing problems that mathematical models face when they are used to estimate epidemiological parameters and to forecast the evolution of the outbreak, two stand out: (a) the uncertainty regarding the day-zero of the outbreak, the knowledge of which is crucial to assess the stage and dynamics of the epidemic, especially during the first growth period, and (b) the uncertainty that characterizes the actual number of the asymptomatic infected cases in the total population (see e.g. [ , ] ). at this point we should note that what is done until now with dynamical epidemiological models is the investigation of several scenarios including different "days-zero" or just fixing the day-zero and run different levels of asymptomatic cases e.t.c. to cope with the above problems, we herein address a methodological framework that provides estimates for the day-zero of the outbreak and the number of the asymptomatic cases in the total population in a systematic way. towards this goal, and for our demonstrations, we address a conceptually simple seird model with a total of five compartments, with one of them modelling the asymptomatic infected cases in the population and another one modelling the part of the infected cases that will experience mild to severe symptoms, a significant share of which will be hospitalized, admitted to intensive care units (icus) or die from the disease. the proposed approach is applied to lombardy, the epicenter of the outbreak in italy. furthermore, we provide a twomonths ahead of time forecast from march (the day of lockdown of all italy) to may (the first day of the relaxation of the strict isolation measures). the above tasks were accomplished by the numerical solution of a mixed-integer optimization problem using the publicly available data of daily new cases for the period february -march , and the covid- community mobility reports released by google on march . we address a compartmental seiird model that includes two categories of infected cases, namely the asymptomatic (unknown) cases in the total population and the cases that develop mild to more severe symptoms, a significant share of which are hospitalized, admitted to icus and a part of them dies. in agreement with other studies and observations, our modelling hypothesis is that the confirmed cases of infected are only a (small) subset of the actual number of asymptomatic infected cases in the total population [ , , ] . regarding the confirmed cases of infected as of february , a study conducted by the chinese cdc which was based on a total of , cases in china, found that about . % of the cases were mild and could recover at home, . % severe and . % critical [ ] . on the basis of the above findings, in our modelling approach, it is assumed that the asymptomatic or very mildly symptomatic cases recover from the disease relatively soon and without medical care, while for the other category of infected, on average their recovery lasts longer than the non-confirmed, they may also be hospitalized, admitted to icus or die from the disease. based on the above, let us consider a well-mixed population of size n. the state of the system at time t, is described by (see also fig for a schematic) s(t) representing the number of susceptible persons, e(t) the number of exposed, i(t) the number of asymptomatic infected persons in the total population who experience very mild or no symptoms and recover relatively soon without any other complications, i c (t) the number of infected cases who may develop mild to more severe symptoms and a significant part of them is hospitalized, admitted to icus or dies, r(t) the number of asymptomatic cases in the total population that recover, r c (t) the number of the recovered cases that come from the compartment of i c and d(t) the reported number of deaths. for our analysis, and for such a short period, we assume that the total number of the population remains constant. based on demographic data, the total population of lombardy is n = m; its surface area is , . kmq and the population density is * (inhabitants/kmq). the rate at which a susceptible (s) becomes exposed (e) to the virus is proportional to the density of infectious persons i. the proportionality constant is the "effective" disease transmission rate, say b ¼ � cp, where � c is the average number of contacts per day and p is the probability of infection upon a contact between a susceptible and an infected. our main assumption here is that only a fraction, say � of the actual number of exposed cases e will experience mild to tracing day-zero and forecasting the covid- outbreak in lombardy more severe symptoms denoted as i c (t) and a significant part of them will be hospitalized, admitted to icus or die. thus, we assume that the infected persons that belong to the compartment i c go into quarantine at home or they are hospitalized, and, thus, it is assumed that for any practical means they don't transmit further the disease. here, it should be noted that a wide testing policy may also result in the identification of asymptomatic cases belonging to the compartment i that would then be assigned to compartment i c . however, as a generally reported rule in italy, tests were conducted only for those who presented for treatment with symptoms like fever and coughing. thus, people who did not seek medical attention were tested very scarcely [ ] [ ] [ ] . thus, for any practical means the compartment i c reflects the reported confirmed infected cases. a fraction of the i c cases that is given by the fatality ratio f = d(t)/(i c (t) + r c (t) + d(t)) dies with a mortality rate δ the inverse of which is the average time from the onset of symptoms to death, while the remaining part (( − f)) of the i c compartment recovers with a rate γ c , the inverse of which corresponds to the average time from the onset of symptoms to full recovery. we note that while more compartments could conceptually be included, we aimed at keeping a low level of complexity in order to avoid the introduction of more parameters, and thus a model that would suffer from the "curse of dimensionality". at this point we should note that on march , the date of the general lockdown, the number of confirmed infected cases was , , the number of cases in icus was and the number of hospitalized persons was , [ ] . that is, until march , the number of confirmed cases was approximately equal to the number of hospitalized cases and the cases that were admitted to icus. therefore, until march , any difference between the asymptomatic cases as represented by our model by the compartment i and the compartment i c would approximately reflect a level of under-reporting of the actual asymptomatic cases in the total population. we should also note that in the available data of reported cases [ ] there is no distinction between cases that recovered at home and those that recovered at and were dismissed from hospitals. thus, in the absence of such information, if one were to consider as a separate category the cases that are hospitalized, an extra parameter would have to be introduced (the fraction of recovered cases dismissed from hospitals). on one hand, such a piece of information is not available, and, on the other, such an attempt would add an extra degree of freedom that would need calibration or to be fixed at a certain value; however, due to the small size of the data and the "curse of dimensionality", this would also introduce unnecessary computational burden and further modelling uncertainty. thus, our discrete mean field compartmental seiird model reads: sðt À Þiðt À Þ À seðt À Þ ð Þ the above system is defined in discrete time points t = , , . . ., with the corresponding initial condition at the very start of the outbreak (day-zero): the the term fδi c (t − ) in eq represents the fraction f of the i c cases that dies with a mortality rate γ and the term ( − f)γ c i c (t − ) represents the complementary part (( − f)) of the i c cases that recovers with a rate γ c . the parameters of the model are: is the average per-day "effective" rate at which an exposed person becomes infectious, is the average per-day "effective" recovery rate within the group of asymptomatic cases in the total population, is the average per-day "effective" recovery rate within the subset of the i c infected cases that finally recover, • δ(d − ) is the average per-day "effective" mortality rate within the subset of i c infected cases that finally die, • f is the probability that a i c case will die. here, this, is given by the "emergent" case fatality ratio, computed as f is the fraction of the actual (all) cases of exposed in the total population that enter to the compartment i c . here, we should note the following: as new cases of recovered and dead at each time t appear with a time delay (which is generally unknown but an estimate can be obtained by clinical studies) with respect to the corresponding infected cases, the above per-day rates are not the actual ones; thus, they are denoted as "effective/apparent" rates. the values of the epidemiological parameters σ, γ, γ c , δ that were fixed in the proposed model were chosen based on clinical studies. in particular, in many studies that use seird models, the parameter σ is set equal to the inverse of the mean incubation period (time from exposure to the development of symptoms) of a virus. however, the incubation period does not generally coincide with the time from exposure to the time that someone starts to be infectious. regarding covid- , it has been suggested that an exposed person can be infectious well before the development of symptoms [ ] . with respect to the incubation period for sars-cov- , a study in china [ ] suggests that it may range from - days, with a median of . days. another study in china, using data from , patients with laboratory-confirmed -ncov ard from hospitals in provinces/provincial municipalities suggested that the median incubation period is days (interquartile range: to ). in our model, as explained above, /σ represents the period from exposure to the onset of the contagious period. thus, based on the above clinical studies, for our simulations, we have set /σ = . regarding the recovery period, in a study that is based on , laboratory-confirmed cases, the who-china joint mission has reported a median time of weeks from onset to clinical recovery for mild cases, and - weeks for severe or critical cases [ ] . based on the above, and on the fact that within the subset of confirmed cases the mild cases are the % [ ] , we have set the recovery period for the confirmed cases' compartment to be δ c = / in order to balance the recovery period with the corresponding characterization of the cases (mild, severe/critical). the average recovery period of the unreported/non-confirmed part of the infected population, which in our assumptions experiences the disease like the flu or a common cold, is set equal to one week [ ], i.e. we have set δ = / . this choice is based also on reports on the serial interval of covid- . the serial interval of covid- is defined as the time duration between a primary case-patient (infector) having symptoms and a secondary case-patient having again symptoms. for example, it has been reported that the serial interval for covid is estimated at . - . days [ ] ; for the case of lombardy, the average serial number has been estimated to be . days [ ] . in our model, the /σ = period refers to the period from exposure to the onset of the contagiousness. in this period, obviously there are no symptoms. thus, the serial interval in our model is days (this is the average number of days in which an infectious becomes recovered and no longer transmits the disease). importantly, there are studies (see e.g. nushiura et al. [ ] ) suggesting that a substantial proportion of secondary transmission may occur prior to illness onset. thus, the days period that we have taken as the average period that an infectious person can transmit the disease before he/she recovers, reflects exactly this period; it refers to the serial interval for the cases that are asymptomatic and for cases with mild symptoms. finally, the median time from the onset of symptoms until death for italy has been reported to be eight days [ ] , thus in our model we have set γ = / . we have set f = % for the optimization. for the forecasting (i.e. for the period march to may ), the value of f was not fixed but it was computed dynamically each day t through the model simulations as the transmission rate β, as it cannot be obtained in general by clinical studies, but only by mathematical models, was estimated through the optimization process. regarding day-zero in lombardy, that is also unknown and estimated by the optimization process, what has been officially reported is just the date on which the first infected person was confirmed to be positive for sars-cov- . that day was february , , which is the starting date of public data release of confirmed cases. the day-zero of the outbreak, the per-day "effective" transmission rate β, and the ratio � were computed by the numerical solution of a mixed-integer optimization problem with the aid of genetic algorithms to fit the reported data of daily new cases (see the discussion in [ ] ) from february to march , the day of the lockdown of lombardy. as already mentioned, on march , the number of confirmed infected cases in the population was , , the number of cases in icus was and the number of hospitalized persons was , [ ] . that is, until march the number of mild and severe cases that were hospitalized and admitted to icus was approximately equal to the number of confirmed infected cases. thus, for the period of calibration, it is reasonable to assume that for any practical means the number of confirmed cases was approximately the same as for those that experienced mild to more severe symptoms and were admitted for medical care. thus, until march , the parameter � reflects also the level of under-reporting of the asymptomatic cases in the total population. here, for our computations, we have used the genetic algorithm "ga" provided by the global optimization toolbox of matlab [ ] to minimize the following objective function: where, Δx seird (t), (x = i, r, d) are the new cases resulting from the seird simulator at time t. the weights w , w , w correspond to scalars serving in the general case as weights to the relevant functions for balancing the different scales between the number of infected, recovered cases and deaths. the convergence tolerance was set to .e − , the population size (distributed between the lower and upper bounds) was selected as resulting from min(max ( � nvars, ), ) for mixed-integer problems (here nvars = ), ceil( . � populationsize) individuals are guaranteed to survive to the next generation, the migration fraction was set to . , while the number of generations that take place between migrations of individuals between subpopulations was set to [ ] . at this point we should note that the above optimization problem may in principle have multiple nearby optimal solutions (mnos). finding and assessing the information contained from mnos (known also as niching) is a particular challenging problem [ ] . here, we created a grid of initial guesses within the intervals in which the optimal estimates were sought: for the day-zero (t ) we used a step of days within the interval december , until the th of february, i.e. ± days around the th of january, for β we used a step of . within the interval ( . , . ) and for � we used a step of . within the interval ( . , . ). the numerical optimization procedure was repeated times for each combination of initial guesses. for our computations, we kept the best fitting outcome for each combination of initial guesses. next, in order to reveal structured patterns of distributions vs. uniformly random distributions, we fitted the resulting probability distributions of the optimal values using several functions, including the normal, log-normal, weibull, beta, gamma, burr [ ] , exponential and birnbaum-saunders [ ] distributions and kept the one resulting in the maximum log-likelihood (see in the supporting information for more details). for the computed parameters of the corresponding best distributions, we also provide the corresponding % confidence intervals. such fitting can demonstrate that the obtained values are not uniformly distributed. finally, we have run simulations based on all obtained values to assess the efficiency of the model and obtained results and the forecasting uncertainty until may . for our computations, we used the parallel computing toolbox of matlab a [ ] utilizing intel xeon cpu x cores at . ghz. estimation of the basic reproduction number. here, we note that we provide an estimation of the basic reproduction number r based on the estimation of the total number of (asymptomatic) infected cases in the population. thus, it is expected that the estimated r will be larger than the ones reported using just the confirmed number of cases; the latter may underestimate the actual r . initially, when the spread of the epidemic starts, all the population is considered to be susceptible, i.e. s � n. on the basis of this assumption, we computed the basic reproduction number based on the estimates of the epidemiological parameters computed using the data from the st of february to the th of march with the aid of the seiird model given by eqs ( )-( ) as follows. note that there are three infected compartments, namely e, i, i c and two of them (e,i) determine the outbreak. thus, considering the corresponding equations given by eqs ( ), ( ) and ( ) , and that at the very first days of the epidemic s � n and d � , the jacobian of the system as evaluated at the disease-free state reads: the eigenvalues (that is the roots of the characteristic polynomial of the jacobian matrix) dictate if the disease-free equilibrium is stable or not, that is if an emerging infectious disease can spread in the population. in particular, the disease-free state is stable, meaning that an infectious disease will not result in an outbreak, if and only if all the norms of the eigenvalues of the jacobian j of the discrete time system are bounded by one. jury's stability criterion [ ] (the analogue of routh-hurwitz criterion for discrete-time systems) can be used to determine the stability of the linearized discrete time system by analysis of the coefficients of its characteristic polynomial. the characteristic polynomial of the jacobian matrix reads: where a ¼ the necessary conditions for stability read: the sufficient conditions for stability are given by the following two inequalities: the first inequality ( ) results in the necessary condition bð À �Þ g < : it can be shown that the second necessary condition ( ) and the sufficient condition ( ) are always satisfied for the range of values of the epidemiological parameters considered here. thus, the necessary condition ( ) is also a sufficient condition for stability. hence, the disease-free state is stable, if and only if, condition ( ) is satisfied. note that in this necessary and sufficient condition ( ) , the fraction ( − �)/δ is the average infection time of the compartment i. thus, the above expression reflects the basic reproduction number r which is qualitatively defined by r = β � /infection time. hence, our model results in the following expression for the basic reproduction number: note that for � = , the above expression simplifies to r for the simple sir model. estimation of effective reproduction number. for the estimation of the effective reproduction number r e , representing the average number of secondary infections from an infectious individual when in the population exist already non-susceptible individuals. for the calculation of r e , we now use the next generation matrix approach [ ] . the next generation matrix g with elements = g ij is formed by the average number of secondary infections of type i from an infected individual of type j. formally, it is constructed by: where f is the vector containing the transmission rates from the model, and v is the vector containing the transition rates between the infected compartments. in our model: the effective reproduction number r e is the spectral radius, i.e. the dominant eigenvalue of g. thus, r e ðtÞ ¼ bð À �Þ g sðt À Þ n À dðt À Þ À r c ðt À Þ À i c ðt À Þ : ð Þ as discussed, we used the proposed approach to forecast the evolution of the pandemic in lombardy from march to may , i.e. from the first day of lockdown to the first day of the relaxation of the social isolation. our estimation regarding the as of march reduction of the "effective" transmission rate was based on the combined effects of prevention efforts and behavioral changes. in particular, our estimation was based on (a) the covid- community mobility reports released by google on march [ ] , and, (b) an assessment of the synergistic effects of such control measures as the implementation of preventive containment in workplaces, stringent "social distancing", and the ban on social gatherings, as well as the public awareness campaign prompting people to adopt cautious behaviors to reduce the risk of disease transmission (see also [ ] [ ] [ ] [ ] ). the effect of the distribution of contacts at home, work, when travelling, and during leisure activities can be also assessed. for example, based on an analysis for the social contacts and mixing patterns relevant to the spread of infectious diseases that was conducted in various countries, it has been found that for italy, around - % of all physical social contacts during a day are attributed to workplaces, around - % to schools, - % to transportation, % to leisure activities, - % to home, % to other activities (contacts made at locations other than home, work, school, travel, or leisure) and a - % to contacts made at multiple other locations during the day, not just at a single location [ ] . on the basis of the google covid- community mobility report released on march [ ] , the average reduction in the mobility in lombardy during the period february -march , compared to the period before february , was * % in retail & recreation activities, * % in transit stations, * % in workplaces, while it was increased in parks by * % and was almost the same in groceries and pharmacies. in the period march to march , the mobility was reduced by an average of * % in retail & recreation activities, by * % in transit stations, by * % in workplaces, by * % in parks and by * % in groceries and pharmacies. thus, taking into account the coarse effect of different activities in the physical contact [ ] , the average reduction was of the order of * % in mobility when compared to the period february -march . in fact, on march , based on the release of mobile phone data, the vice-president of lombardy, announced that the average mobility in the region (for distances more than meters) had been reduced by a * % with respect to the period before february [ ] . on march , the government announced the implementation of even stricter measures that included the closure of all public and private offices, closing all parks, walking only around the residency and not even in pairs, and the prohibition of mobility to second houses [ , ] . according to the google covid- community mobility reports [ ] , from march - until april , activities were reduced by an average of * % in retail & recreation activities, by * % in transit stations, by * % in workplaces, by * % in parks and by * % in groceries and pharmacies. thus, taking into account the coarse effect of different activities in the physical contact [ ] , the average reduction was of the order of * % in the mobility when compared to the period of february -march . a further reduction may be attributed to behavioral changes [ ] . for example, it has been shown that social distancing and cautiousness reduce the disease transmission rate by about % [ ] . thus, based on the above, it is reasonable to consider a ( - . as discussed, for our computations we ran times the numerical optimization procedure for each combination of initial guesses based on the daily reported new cases from february to for all the near-optimal points obtained using the genetic algorithm optimization, the residuals were of the order of * , , . regarding the values of the optimal parameters, we fitted their cumulative probability distributions using several functions, including the normal, log-normal, weibull, beta, gamma, burr, exponential and birnbaum-saunders functions, and kept the one yielding the maximum log-likelihood (see in the s file). table summarizes the mean values of the optimal parameters and their interquartiles, for the day-zero, the transmission rate (β) and the fraction (�) of the actual cases of exposed in the total population that enter to the compartment i c , and also the information on the values of the parameters of the best fitting distributions. note that the optimal values of day-zero were between january -january (interquartile range: january to january ) (see s fig in s file) , the optimal values of β were between . and . (interquartile range: . to . ) (see s fig in s file) , and the optimal values of � were between . and . (interquartile range: . to . ) (see s fig in s file) . the best fit to the distribution of optimal values of the day-zero was obtained using a normal cdf with mean . (i.e. sim days before the th of january) ( % ci: . , . ) and variance . ( % ci: . , . ); thus taking the round value at days, the expected day-zero corresponds to january (interquartile range: january to january ). the best fit to the distribution of the optimal values of β, was given by fitting a burr cdf with α = . ( % ci: . , . ), c = . ( % ci: . , . ), k = . ( % ci: . , . ) having a mean value of . (interquartile range: . to . ). finally, the best fit to the distribution of the optimal values of � was given by fitting a birnbaum-saunders cdf with parameters μ = . ( % ci: . , . ) (scale parameter) and α = . ( % ci: . , . ) (shape parameter), resulting in an expected value . (interquartile range: . to . ) (see in s file). thus, based on the derived values of the "effective" per-day disease transmission rate, the basic reproduction number r is . (min-max range: . - . ). finally, we ran the simulator for all values of the optimal triplets from the corresponding distributions as found by the solution of the optimization problem using the data from february until march , then from march to march for validation purposes and from march to may for forecasting purposes. figs ( )-( ) depict the simulation results based on the optimal estimates, until the th of march. to validate the model with respect to the reported data of confirmed cases from march to march , we have considered an ( - . )( - . ) reduction in the "effective" transmission rate and as initial conditions the values resulting from the simulation on march as described table . optimal parameter values and interquartiles for day-zero, transmission rate (β) and fraction (�) of the cases of exposed individuals in the total population that enter to the compartment i c . the resulting value of r along with the minimum and maximum value is also given. tracing day-zero and forecasting the covid- outbreak in lombardy in the methodology. thus, the model approximated fairly well the dynamics of the pandemic in the period from february to march . as discussed in the methodology, we also attempted based on our methodology and modelling approach to forecast the evolution of the outbreak until may , the first day of the relaxation of the measures. to do so, as described in the methodology, we have considered a ( - . ) ( - . ) reduction in the "effective" transmission rate starting on march (compared to the period february -march ), the day of announcement of even stricter measures in the region of lombardy (see in methodology). the result of our forecast is depicted in fig . as shown, the model predicts fairly the evolution of the epidemic two months ahead of march (the model parameters and the day-zero were estimated using the reported data from february to march ). note that, regarding the confirmed cases, the mean values of i c (t) from over all simulations almost coincide with the reported values of the confirmed cases (see top panel of fig ) . the reported recovered cases are in the lower part of the model predictions (r c (t)) (see medium panel of fig ) . also, the model predicts fairly the total number of deaths until may (see bottom panel of fig . however, at may there is a significant difference between the mean value of deaths as obtained from simulations and the actual number of deaths. this is due to the following reasons. first, the difference that is observed with respect to the reported number of deaths and model forecasts in the period from march to april can be attributed to facts that the model did not take into account, such as the saturation of icus in that period, which could potentially lead to a larger number of deaths. indeed, on march , new deaths were reported. however, we note that the model was calibrated with the data reported until march . until march , the case fatality ratio was of the order of * - % and the number of cases admitted to icus was relatively small. after march when there were many cases admitted to icus, the death toll increased significantly, it almost doubled, thus reaching the * - % of the confirmed cases. second, regarding the difference that is observed between the model predictions and actual number of deaths at may , this is due to the fact that we did not calibrate the model parameters to take into account the changes in the death and recovery rates. it is expected that when the evolution of the epidemic is abrupt, as it was in lombardy in the period march until the early of april, due to the saturation of the tracing day-zero and forecasting the covid- outbreak in lombardy health system and icus the mortality rates would be higher and the recovery rates longer. indeed, during this period, it has been reported, that the median time from the onset of symptoms until death in lombardy was eight days [ ] which a very short period. for example, in other studies it has been reported that the time between symptom onset and death ranged from about weeks to weeks which from two to seven times longer than the one reported in lombardy [ , ] . so, this difference explains the difference between simulations and reported number of deaths at may . here, for our demonstrations we have used the information about the epidemiological parameters, that was available at the early phase of the epidemic. thus, we must underline the very good agreement of the model predictions with the actual number of confirmed infected cases for the entire period march -may . this number, in contrast to the number of recovered and number of deaths is not shaped/biased by the capacity of icus and this is the number on which policy makers should focus in order to decide ahead of time of the necessary resources (e.g. necessary number of beds and icus) needed to keep the fatality ratio as low as possible. the model predicts that until may , an average of % of the population in lombardy has already recovered (interquartile range: * % to * %) (see fig ) . finally, in fig , we report the evolution of the effective reproduction number r e until may . on may the estimated mean value of r e was . (interquartile range: . to . ), thus marking the onset of a critical date for the post-lockdown period. tracing day-zero and forecasting the covid- outbreak in lombardy the crucial questions about an outbreak is how, when (day-zero), why it started, and if and when it will end. answers to these important questions would add critical knowledge to our arsenal to combat the pandemic. the tracing of day-zero, in particular, is of outmost importance. it is well known, that minor perturbations in the initial conditions of a complex system, such as the ones of an outbreak, may result in major changes in the observed dynamics. undoubtedly, a high level of uncertainty for day-zero, as well as the uncertainty in the actual numbers of exposed people in the total population, raise several barriers to our ability to correctly assess the state and dynamics of the outbreak and to forecast its evolution and its end. such pieces of information would lower the barriers and help public health authorities respond fast and efficiently to the emergency. for example, an over-or under-estimation of day-zero would result in an under-or over-estimation of the the transmission rate β and therefore of the basic reproduction number r and consequently the effective reproduction number r e . furthermore, the correct estimation of day-zero is important for the assessment of the number of asymptomatic and actual recovered cases in the total population. this is turn will bias the assessment and ultimately the design of efficient control policies in real time. this study aimed exactly at shedding more light into this problem. to achieve this goal, we addressed a conceptually simple compartmental seiird model with two infectious compartments in order to bridge the gap between the number of asymptomatic cases in the total population and the cases that will experience mild to more severe symptoms. what is done until now with mathematical epidemiological models is the investigation of several scenarios, by changing e.g. the (or assuming a fixed) initial day (day-zero), the level of asymptomatic cases etc. our work, is the first that introduces a methodological framework, to estimate the day-zero as well as the level of asymptomatic cases in the total population in a tracing day-zero and forecasting the covid- outbreak in lombardy systematic way. following the proposed methodological framework, we found that the dayzero in lombardy was around the middle of january, a period that precedes by one month the fate of the first confirmed case in the hardest-hit northern italian region of lombardy. interestingly enough, when we submitted a preprint of the work at medrxiv on march ( [ ] , another study that was also submitted at the same day at medrxiv, that was based on genomic and phylogenetic data analysis, reports the same time period, between the second half of january and early february, , as the time when the novel coronavirus sars-cov- entered northern italy [ ] . our analysis further revealed that the actual number of asymptomatic infected cases in the total population in the period until march was around times the number of confirmed infected cases, which until march was also approximately equal to the number of cases that were hospitalized and admitted to icus. our model and methodological approach assume that there was one effective "zero" infected case that introduced the virus to the region; one could certainly argue that there were more than one cases that introduced the virus to the region on the same day; such scenarios can be investigated in a straightforward manner based on our proposed methodological approach. furthermore, the proposed approach could be used for the quantification of the uncertainty of the evolving dynamics, taking into account the reported, from clinical studies, distributions of the epidemiological parameters rather than their expected values. a critical point that is connected with the above is that with such a small number of infectious at the initial stage of the simulations, a stochastic model or a hybrid stochastic model could be more realistic in which uncertainty could be modelled in the form of realistic perturbations (see for example [ ] ). furthermore, we did not consider the effect of an ongoing sampling strategy in the total population for the estimation of the level of under-reporting (represented in our model with the variable �). as mentioned in the methodology, within the first period of the outbreak the number of confirmed cases was approximately equal to the number of hospitalized cases, i.e. there was no sampling strategy. furthermore, as also reported for the later period, tests were conducted only for those who seeked medical care and had symptoms like fever and coughing. thus, people who did not seek for medical attention were tested very scarcely [ ] [ ] [ ] . we will consider such type of modelling and analysis in a future work. regarding the forecasting in lombardy from march until may (the first day of relaxation of the measures), we have taken into account the very latest facts on the drop of human mobility, as released by google [ ] until april for the region of lombardy; these were shaped by the very strict measures announced on march - that included the closure of all parks, public and private offices and the prohibition of any pedestrian activity, even individually [ ] . our modelling approach approximated fairly well the reported number of infected cases in lombardy two months ahead of time. the mean value of the evolution of the compartment that in our model reflects the confirmed cases, almost coincides with the reported cases for the entire period from march to may . the differences that are observed between the reported number of deaths and simulations as discussed in the results should be attributed to the very short times from the onset of symptoms to death that have been reported in lombardy at the early phases of the pandemic in the region ( days instead of to weeks that have been reported in other studies for china that is linked with the saturation of the icus [ , ] . furthermore another important factor that is missing from the data used is that the number of deaths is largely affected by the criteria of death notification. indeed as it has been reported, the global coronavirus death toll could be % higher than the confirmed [ ] . however, this fact did not affect the model predictions with respect to the confirmed cases, but the rate with which the confirmed cases die; the later is also dependent on the rate of the outbreak and the relevant capacity of the icus. to this end, we would like to make a final comment with respect to the basic reproduction number r , the significance and meaning of which are very often misinterpreted and misused, thereby leading to erroneous conclusions. here, we found a r * . , which is higher compared to the values reported by many studies in china, and also in italy, and in lombardy in particular. for example, zhao et al. estimated r to range between . ( % ci: . , . ) and . ( % ci: . , . ) in the early phase of the outbreak [ ] . similar estimates were obtained for r by imai et al., . ( % ci: . , . ) [ [ ] . regarding italy, d'arienzo and coniglio [ ] used a sir model to fit the reported data in nine italian cities and found that r ranged from . to . . in another study, the authors provided an estimate of the basic reproduction number by analyzing the first , laboratoryconfirmed cases. by doing so they estimated the basic reproduction number at . [ ] . first, we would like to stress that r is not a biological constant for a disease as it is affected not only by the pathogen, but also by many other factors, such as environmental conditions, demographics, as well as, importantly, by the social behavior of the population (see for example the discussion in [ ] ). thus, a value for r that is found in one part of the world (e.g. in china), and even in a region of the same country, e.g. in tuscany, italy, cannot be generalized as a global biological constant for other parts of the world, or even for other regions of the same country. obviously, the environmental factors and social behavior of the population in lombardy are different from the ones, for example, prevailing in hubei. second, most of the studies that provide estimates of the basic reproduction number are based solely on the reported cases, thus the actual number of infected cases in the total population, that may be asymptomatic but transmit the disease, is not considered; this fact may lead to an underestimation of the basic reproduction number. moreover, in our approach as compared to clinical studies, the computation of r comes out as the necessary and sufficient condition of the stability as derived from the proposed model whose parameters are computed based on the available reported data, thus with a delay between the first actual case (see also the discussion in [ ] . our relatively simple conceptually model and approach do not aspire to accurately describe the complexity of the emergent dynamics, which in any case is an overwhelmingly difficult, if not impossible, task in the long run, even with the use of detailed agent-based models. we tried to keep the structure of the model as simple as possible in order to be able to model (in a coarse way) the uncertainty in both the "day-zero" and the number of asymptomatic actual cases in the total population using as few parameters as possible. the results of our analysis have indeed proved that the modelling approach succeeded in providing fair predictions of the evolution of the epidemic two months ahead of time. such an early assessment would help authorities to evaluate the required measures to control the epidemic, such as the scale of diagnostic tests that have to be performed and the number of icu beds required. while more complicated models can, in principle, be constructed to take into account more detailed information, such as the number of hospitalized patients and patients in icus, for any practical means such an approach would suffer from the "curse of dimensionality" as it would introduce many more parameters that would need calibration based on a relatively small size of data especially at the beginning of an outbreak. an attempt to compute the values of some of these additional parameters, which can only be roughly estimated by clinical studies at the early stages of an emerging novel infectious disease, would introduce additional uncertainty, thereby further complicating matters rather than solving the problem. to this end, we hope that our conceptually simple, but pragmatic, modelling approach and methodological framework help to provide improved insights into the currently uncontrolled pandemic and to contribute to the mitigation of some of its severe consequences. author contributions coronavirus disease (covid- ). situation report coronavirus covid- global cases by covid- : preparedness, decentralisation, and the hunt for patient zero complexity of the basic reproduction number (r ) nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study transmissibility of -ncov estimating the scale of covid- epidemic in the united states: simulations based on air traffic directly from wuhan, china data-based analysis, modelling and forecasting of the covid- outbreak preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak covid- and italy: what next? breaking down of the healthcare system: mathematical modelling for controlling the novel coronavirus ( -ncov) outbreak in wuhan estimating the risk on outbreak spreading of -ncov in china using transportation data using predicted imports of -ncov cases to determine locations that may not be identifying all imported cases the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak coronavirus-scientific insights and societal aspects current us coronavirus cases are "just the tip of the iceberg,-former usaid director says the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china in one italian town, we showed mass testing could eradicate the coronavirus perch& x e ; non stiamo facendo pi& x f ; tamponi? covid- -situazione in italia prevention, how covid- spreads early transmission dynamics in wuhan, china, of novel coronavirus infected pneumonia report of the who-china joint mission on coronavirus disease how will country-based mitigation measures influence the course of the covid- epidemic? the early phase of the covid- outbreak in lombardy, italy ( ) serial interval of novel coronavirus (covid- ) infections superiore di sanit characteristics of covid- patients dying in italy report based on available data on avoidable errors in the modelling of outbreaks of emerging pathogens, with special reference to ebola niching methods and multimodal optimization performance cumulative frequency functions a new family of life distributions inners and stability of dynamic systems the construction of next-generation matrices for compartmental epidemic models advancing the right to health: the vital role of law, world health organization case investigations of infectious diseases occurring in workplaces, united states quantifying social distancing arising from pandemic influenza nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-social distancing measures, emerging infectious diseases social contacts and mixing patterns relevant to the spread of infectious diseases il % ancora si sposta a milano militari per le strade. posti di blocco a roma coronavirus, ordinanza lombardia con nuove limitazioni modeling the interplay between human behavior and the spread of infectious diseases real estimates of mortality following covid- infection tracing day-zero and forecasting the covid- outbreak in lombardy, italy: a compartmental modelling and numerical optimization approach genomic characterisation and phylogenetic analysis of sars-cov- in italy bounded noises in physics, biology, and engineering who statement regarding cluster of pneumonia cases in wuhan global coronavirus death toll could be % higher than reported | free to read early transmission dynamics in wuhan, china, of novel coronavirus infected pneumonia assessment of the sars-cov- basic reproduction number, r , based on the early phase of covid- outbreak in italy a new framework and software to estimate timevarying reproduction numbers during epidemics key: cord- -i zm bt authors: al-waleedi, ali ahmed; naiene, jeremias d.; thabet, ahmed a. k.; dandarawe, adham; salem, hanan; mohammed, nagat; al noban, maysa; bin-azoon, nasreen salem; shawqi, ammar; rajamanar, mohammed; al-jariri, riyadh; al hyubaishi, mansoor; khanbari, lina; thabit, najib; obaid, basel; baaees, manal; assaf, denise; senga, mikiko; bashir, ismail mahat; mahmoud, nuha; cosico, roy; smith, philip; musani, altaf title: the first months of the sars-cov- epidemic in yemen: analysis of the surveillance data date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: i zm bt introduction: yemen was one of the last countries in the world to declare the first case of the pandemic, on april . fear and concerns of catastrophic outcomes of the epidemic in yemen were immediately raised, as the country is facing a complex humanitarian crisis. the purpose of this report is to describe the epidemiological situation in yemen during the first months of the sars-cov- epidemic. methods: we analyzed the epidemiological data from february to june , including the months before the confirmation of the first case. we included in our analysis the data from out of governorates of yemen, located in southern and eastern part of the country. results: a total of laboratory confirmed, probable and suspected cases with onset of symptoms between february and june were reported through the surveillance system. the median age among confirmed cases was years (range: – years), and % of the confirmed cases were male. a total of deaths were reported among those with confirmed infection. the mean age among those who died was years (range: – years), with % of deaths (n = ) occurring in individuals under the age years. a total of individuals with confirmed sars-cov- infection were hospitalized ( %), among whom there were in-hospital deaths, conclusions: the surveillance strategy implemented in the first months of the sars cov in the southern and eastern governorates of yemen, captured mainly severe cases. the mild and moderate cases were not self-reported to the health facilities and surveillance system due to limited resources, stigma, and other barriers. the mortality appeared to be higher in individuals aged under years, and most fatalities occurred in individuals who were in critical condition when they reached the health facilities. it is unclear whether the presence of other acute comorbidities contributed to the high death rate among sars-cov- cases. the findings only include the southern and eastern part of the country, which is home to % of the total population of yemen, as the data from the northern part of the country was inaccessible for analysis. this makes our results not generalizable to the rest of the country. although pneumonia caused by a novel coronavirus was first described in china in december , it was officially named as coronavirus disease (covid- ) on february [ ] . the virus that causes the disease was named severe acute respiratory syndrome coronavirus- (sars-cov- ) due to its genetic similarities to the coronavirus responsible for the severe acute respiratory syndrome (sars) epidemic in [ ] . sars-cov- is transmitted through respiratory droplets and the case fatality rate ranges from . % to % among the confirmed cases, primarily due to pulmonary complications [ , ] . the incubation period is estimated to be from to days, with majority of the cases developing symptoms days after exposure to the virus. the signs and symptoms may include fever, cough, difficult breathing, fatigue, headache and others [ ] . the virus can also be transmitted by individuals who are asymptomatic carriers of the virus [ ] . the development of symptoms and fatality varies by age group, with older people being most at risk of becoming symptomatic and die [ ] . yemen was one of the last countries in the world to declare the first case of the pandemic, on april [ ] . fear and concerns of catastrophic outcomes of the epidemic in yemen were immediately raised, as the country is facing a complex humanitarian crisis [ ] . suppression measures were already being implemented by the government before the notification of the first case, including curfew, closure of schools, airports, markets, mosques, and prohibiting public gatherings [ ] . about % of the population of yemen is estimated to be in acute need of health care, with high rates of malnutrition, child and maternal mortality [ ] . in addition, the limited availability of safe drinking water, people living crowded houses, inadequate sanitation, and stigma constitute barriers for effective response and control of the epidemic in yemen [ ] . due to the ongoing armed conflict, less than % of the health facilities in yemen are fully functional [ ] and more that million children are malnourished [ ] . yemen has a population of million people, and the armed conflict which started in led to a fragmentation of the healthcare system [ , ] . for early detection of sars-cov- in yemen, as in other countries, a case definition, active surveillance, and contact tracing were required [ , ] . the purpose of this report is to describe the epidemiological situation in yemen during the first months of the sars-cov- epidemic, from april to june . the report also includes the months before the notification of the first confirmed case from february to april , as well as the challenges and information gaps. we analyzed the epidemiological data from february to june . we included in our analysis the data from out of governorates of yemen, namely abyan, aden, al-dhale'e, al-mahrah, hadramout, lahj, marib, shabwa, taizz and the island of socotra, located in southern and eastern part of the country controlled by the internationally recognized government. yemen has a total population of million according to projections from the census, with % of the population located in the southern and eastern governorates. the data from the northern governorates were not available for analysis. the cases and contacts were investigated by -member multidisciplinary rapid response teams (rrts) in each district, comprising a clinician, laboratory technician, surveillance officer, risk communication officer and an environmental health officer. a line list of cases and contacts was compiled daily in a microsoft excel spreadsheet using the data received from all the governorates. all the variables in the line list were extracted from the case-based form used in the country. these included demographic information, signs and symptoms, history of contact with other cases, history of travel, comorbidities, and hospitalization data. the comorbidities only included some specific non-communicable diseases, although information regarding communicable diseases and other health conditions was sometimes recorded in the comments section of the form. contact tracing data were available only from hadramout governorate. we constructed the chains of transmission of the other governorates using the information available in the line list. the contact tracing activities started with the reporting of the first confirmed case, who had onset of illness on april . we decided to limit the analysis of the chains of transmission to the first cases, with onset of illness from april to may , when the collection of the information was more consistent. the contacts were followed up daily by the rrts. each team was responsible to follow up a maximum of contacts to ensure quality and consistence of contact tracing data. there was no specialized software available for contact tracing and the daily analysis was done through microsoft excel. a temporary interruption followed by inconsistency of contact tracing data reporting was observed after may . when the number of contacts exceeded the recommended contacts per contact tracing team the daily information and analysis regarding the status of the contacts became irregular. we used the microsoft excel to perform univariate analysis of the cases and contacts data. yemen adopted the who case definition of suspected, probable, and confirmed cases in march [ ] (fig ) . the suspected cases had to present acute respiratory illness and were subdivided in the following components: a component "a" with history of travel to affected countries, a component "b" with history of contact with confirmed or probable cases and a the first months of the sars-cov- epidemic in yemen component "c" requiring hospitalization, without a clear diagnosis, regardless to history of travel of contact with sick people. due to limited laboratory supplies, component "c" of definition of a suspected case was given low priority for several weeks. probable cases were suspected cases either not tested or with inconclusive laboratory results. cases with positive laboratory results for covid- were classified as confirmed. real-time reverse transcriptase polymerase chain reaction (rt-pcr) performed to nasopharyngeal swabs specimens was used for laboratory confirmation of sars-cov- infection. the rrts transported the specimens to the laboratories in viral transport medium. only cases that were positive for sars-cov- using rt-pcr were classified as confirmed. a total of central public health laboratories (cphls) were available in different geographical areas of the country to perform rt-pcr, namely in aden, mukalla, sayoun, taizz, and sana'a. data for the cphl in sana'a were not provided by the local authorities from the north of yemen, and therefore were not included in our analysis. the aden cphl started sars-cov- testing on march , and confirmed the first case on april . mukalla cphl started sars-cov- testing on april , and confirmed the first case confirmed on april . this was the first confirmed case in yemen. the taizz cphl starting testing for sars-cov- on april, and confirmed the first case on may . sayoun was the last cphl to start testing for sars-cov- on may , and confirmed the first case on may . the analysis and publication of the data was authorized by the scientific committee of the ministry of public health and population in aden. no additional ethical approval was required because the data collection and analysis were part of an outbreak response and not a research. the requirement for informed consent was waived because the study is based on a retrospective analysis of routine surveillance data collected in an emergency. the patients and health workers details were kept confidential. a total of laboratory confirmed, probable and suspected cases with onset of symptoms between february and june were reported through the surveillance system (table ) . of the confirmed cases, had history of travel abroad within days before the the first months of the sars-cov- epidemic in yemen onset of symptoms, namely to saudi arabia (n = ) and egypt (n = ). the median age among confirmed cases was years (range: - years), and % of the confirmed cases were male ( table ) . three confirmed cases were reported in children under years old. a total of deaths were reported among those with confirmed infection, % of them (n = ) occurring in males. the mean age among those who died was years (range: - years), with % of deaths (n = ) occurring in individuals under the age years. hadramout governorate reported the highest number of deaths (n = ). among those with confirmed infection, diabetes ( %) was the most common comorbidity among those with confirmed infection, and the first months of the sars-cov- epidemic in yemen hypertension ( %), diabetes ( %), and chronic lung diseases ( %) were the most common comorbidities among those who died. one of the fatal cases from hadramout governorate was in an individual with hiv infection. a pregnant woman of approximately weeks gestation was reported in hadramout. her pregnancy ended in a spontaneous miscarriage after the onset of her covid- symptoms. no underlying conditions were reported in % of the cases. the most common symptoms were fever, cough, and difficulty breathing and sore throat ( table ). in addition to the symptoms shown in the table, individuals reported a headache and reported a loss of smell and taste. housewives were the most commonly affected occupational category, followed by healthcare workers and soldiers (table ). among the healthcare workers, medical doctors and laboratory technicians were the most frequently affected, with deaths of medical doctors and deaths of laboratory technicians reported. a marked increase occurred in number of cases reported according to the date of onset of symptoms from april , with a peak on may (fig ) . aden and hadramout were the governorates that reported the highest numbers of confirmed cases, followed by taizz. although the first case that was confirmed in aden tested on april , other cases in the governorate were subsequently confirmed that had earlier dates of onset of symptoms than the first case. a total of individuals with confirmed sars-cov- infection were hospitalized ( %), among whom there were in-hospital deaths, and were admitted to an intensive care unit (icu), including of those who died subsequently. of the patients admitted to an icu, were provided with mechanical ventilation, including of those who died (table ) . among the patients who died in hospital, had both the date of admission and the date of death the first months of the sars-cov- epidemic in yemen recorded in the line list. of these, % (n = ) died within hours after admission. the mean time from admission to death was . days. the mean time from admission to death and from onset of symptoms to death per district is described in the s table. the date of death was missing in cases (s table) . of all the fatal cases reported, individuals were reported to be dead on arrival ( from mukalla city in hadramout, from qairah district in taizz, and from salh district in taizz). al-mukalla city in hadramout governorate reported % (n = ) of all the deaths in the country (s table) (fig ) . (fig ) . all the chains of transmission had generation of cases, except one which had generations. the average number of cases generated by each index case was (range: - ). the average time between the onset of symptoms of the index case to onset of symptoms of the contacts was . days (range: - days). the source of infection and the cases generated by cases were not identified. the contact tracing activities were interrupted in aden governorate in the first week of the epidemic due to limited human resource capacity, community resistance, and security issues. the first months after confirmation of the sars-cov- epidemic in yemen was characterized by a % hospitalization rate in the southern and eastern parts of the country included in the first months of the sars-cov- epidemic in yemen our study, % of deaths occurring in individuals aged < years, confirmatory testing of < % of the suspected cases, and majority of cases were not related to a defined chain of transmission. therefore, the country satisfied the criteria to be classified as a community transmission setting [ ] . the percentage of severe cases requiring admission in yemen was more than the double that reported in several other countries including iran, where the percentage was reported to be approximately % [ , , , ] . however, the mean time from onset of symptoms to admission to the health facility was . days, which is comparable to the average of - days reported in other countries [ , [ ] [ ] [ ] [ ] . closure of some hospitals, and other hospitals refusing to receive and admit patients with acute respiratory illness may had led to notification of more serious cases, as cases of mild and moderate severity were not self-reported [ ] . the closure of health facilities was mainly due to a shortage of personal protective equipment and other supplies to manage sars-cov- [ ] . in addition, there was a shortage of trained rrts, who were responsible for investigation and collection of laboratory samples of each case reported in the community and in health facilities [ ] . this may also have led to underreporting, especially of mild cases that were not self- the first months of the sars-cov- epidemic in yemen reported due to limited resources, stigma, and other barriers. more than % of the cases were classified as probable due to a shortage of laboratory supplies to investigate all the cases reported [ ] . the case fatality rate was also overestimated in china (> %) at the beginning of the epidemic, when testing capacity was limited, but dramatically decreased once tests became widely available in the country [ ] . as yemen was one of the last countries in the world to notify the first case, the sensitivity of the case definition remained high for long time, capturing mainly individuals with history of travel, and those with severe disease. therefore, it can be inferred that most of the mild and moderate cases were not reported. the fact that the index case had no clear source of infection and was identified on the day after the laboratory start testing for sars-cov- suggests that the infection was probably circulating in the country for a period prior to confirmation of the first case. the low prioritization of the component "c" of the case definition may have led to misdiagnosis of severe cases admitted to the hospitals before the confirmation of the first case. the epidemiological curve shows confirmed cases reported in aden with date of onset of symptoms in the days before the confirmation of the first case and with no clear source of infection. however, it is possible that those who died of the infection may have had other acute and chronic comorbidities besides those captured in the line lists which may have contributed to their deaths [ ] . the mean age at death was years, which is much younger than that reported in iran, china and other countries where the mean age varies from to years [ , , ] . in addition, % of all deaths were in individuals aged under years, while other countries have reported less than % of deaths in this age group [ ] . considering that the older people are at high risk for severe illness [ ] , in yemen many of them likely died at home without reaching the health facilities. among the individuals who died in the hospitals, the mean time from admission to death was . days and % of deaths occurred within hours of hospital admission. in other countries, in-hospital deaths due to sars-cov- have generally been reported to occur several days after admission [ , , , ] . this indicates that individuals tended to reach health facilities late, with less chance of survival, especially among those who required mechanical ventilation [ ] . as in other countries, there was no deaths reported in children aged under years in yemen [ ] . yemen is experiencing outbreaks of other infectious diseases such as dengue fever, measles, diphtheria, cholera [ , ] , and the h n influenza virus has also been identified in yemen [ ] . therefore, co-existence of these diseases among sars-cov- infections should be considered. khat is a plant consumed in few countries, including yemen as stimulant of central nervous system with effects similar to amphetamines [ ] . the majority of adults in yemen consume khat, but the effect that this has among individuals with acute and chronic illnesses remains unclear [ , ] . it has been described in studies conducted in yemen that khat reduces the appetite, increases blood pressure and induces respiratory diseases [ ] [ ] [ ] . however, no study has been conducted to assess the magnitude of these respiratory diseases, and so the possible effect of khat among individuals with sars-cov- infection is unknown. malnutrition, especially among adults should also be considered among the comorbidities contributing to sars-cov- deaths in yemen [ ] . a higher number deaths was also observed in the areas with more limited resources iran and china in the early stages of sars-cov- epidemic [ , ] . the mean age among confirmed cases was years, with higher percentage of cases among males. this is similar that the demographics described in china in the early stage of the epidemic [ , ] . however, considering that population pyramid in poor countries is usually younger that in developed countries, we also consider underreporting of cases among young people with mild symptoms in yemen. the signs and symptoms of the cases in yemen were also similar to those described in china [ , , ] . in yemen, some patient reported a loss of the sense of taste and smell as described in other countries [ ] . the contact tracing was successful in the beginning of the epidemic, especially in hadramout governorate, where the index case was detected. however, it was more complex in aden, where the first cases detected had no clear source of infection, human resources were limited, there was community resistance, and limited supplies, especially ppes for the contact tracers. in addition, contact tracing in conflict settings may be also a challenge due to security and accessibility issues [ ] . however, household contacts, and healthcare workers were among the most affected people, which is similar to what was described in china [ ] . our study has several potential limitations. the findings only include the southern and eastern part of the country, which is home to % of the total population of yemen, as the data from the northern part of the country was inaccessible for analysis. this makes our results not generalizable to the rest of the country, because besides the higher population, the northern part of yemen has different characteristics including lower temperature and higher altitude. some studies suggest that different climatic conditions, including temperature and altitude may affect the transmission and mortality due to sars-cov- infections [ , ] . the case fatality rate is unclear, as most of the cases reported through the surveillance system were severe. therefore, we excluded this indicator from our analysis to avoid misinterpretations. the nutrition status of the cases among both adults and children was not reported in the line list, making it impossible to determine the prevalence of malnutrition among sars-cov- cases. the majority of sars-cov- articles published with detailed epidemiological analysis are from china and other developed countries. this makes comparisons challenging as yemen is a country with very different characteristics. the line list used for the analysis had a lot missing information, including key dates and key variables. however, this description of the findings and challenges may be useful for documentation and as a basis for assessing the improvement of the surveillance system in the later stages of the sars-cov- epidemic in yemen. the surveillance strategy implemented in the first months of the sars-cov- in yemen, where rrt members were responsible of investigation of each case in the communities and health facilities was shown to have limited effectiveness, especially in the areas when the available resources were the most limited. the surveillance system in the southern and eastern governorates included in our study captured mainly severe cases, making it difficult to interpret the mortality data. the mortality appeared to be higher in individuals aged under years, and most fatalities occurred in individuals who were in critical condition when they reached the health facilities. it is unclear whether the presence of other acute comorbidities contributed to the high death rate among sars-cov- cases in yemen. we recommend a revision of the surveillance strategy, to reduce the burden on the rrts and the investigation of additional acute comorbidities among sars-cov- patients in yemen, including h n , dengue fever, malnutrition, and the effects of khat. supporting information s table. time novel coronavirus covid- : current evidence and evolving strategies perspective sars-cov- vaccines: status report the many estimates of the covid- case fatality rate covid- and medical education the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak sars-cov- and coronavirus disease : what we know so far estimating clinical severity of covid- from the transmission dynamics in wuhan, china covid- and conflict: the devastating impact of withdrawing humanitarian support on universal health coverage in yemen yemen is free of covid- responding to the covid- pandemic in complex humanitarian crises the implementation of integrated disease surveillance and response in liberia after ebola virus disease outbreak - enhancing ebola virus disease surveillance and prevention in counties without confirmed cases in rural liberia: experiences from sinoe county during the flare-up in monrovia global surveillance for covid- caused by human infection with covid- virus: interim guidance characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention epidemiological characteristics of coronavirus disease (covid- ) patients in iran: a single center study case report: pathological findings of covid- associated with acute respiratory distress syndrome clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study. lancet risk factors for severity and mortality in adult covid- inpatients in wuhan clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china world report fears of "highly catastrophic" covid- spread in yemen comorbidity and its impact on patients with covid- in china: a nationwide analysis understanding of covid- based on current evidence clinical characteristics of death cases with covid- : a retrospective review of medical records in a single medical potential association between covid- mortality and healthcare resource availability presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the new york city area predictors of -h mortality after inter-hospital transfer to a tertiary medical intensive care unit epidemiology of fatal cases associated with pandemic influenza reported in yemen qat habit in yemen society: a causative factor for oral periodontal diseases the subjective effects of chewing qat leaves in human volunteers medical and social aspects of qat in yemen: a review a medical evaluation of the use of qat in north yemen coronavirus disease (covid- ) outbreak in iran: actions and problems review of the clinical characteristics of coronavirus disease (covid- ) epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study smell and taste dysfunction in patients corona virus infection in syria, libya and yemen; an alarming devastating threat significance of geographical factors to the covid - outbreak in india high-altitude populations need special considerations for covid- we thank all the rapid response teams' members across the country who conducted the investigations of the cases under difficult circumstances. we also thank the health workers and the partners who support the response activities in the country. key: cord- - jwbg bc authors: awasthi, amit; sharma, aditi; kaur, prabhjot; gugamsetty, balakrishnaiah; kumar, akshay title: statistical interpretation of environmental influencing parameters on covid- during the lockdown in delhi, india date: - - journal: environ dev sustain doi: . /s - - - sha: doc_id: cord_uid: jwbg bc the novel coronavirus disease is known as covid- , which is declared as a pandemic by the world health organization during march . in this study, the covid- connection with various weather parameters like temperature, wind speed, and relative humidity is investigated and the future scenario of covid- is predicted based on the gaussian model (gm). this study is conducted in delhi, the capital city of india, during the lowest mobility rate due to strict lockdown nationwide for about two months from march to may , . spearman correlation is applied to obtain the interconnection of covid- cases with weather parameters. based on statistical analysis, this has been observed that the temperature parameter shows a significant positive trend during the period of study. the number of confirmed cases of covid- is fitted with respect to the number of days by using the gaussian curve and it is estimated on the basis of the model that maximum cases will go up to , in number. the maximum number of cases will be observed during the range of ± days. it is also estimated by using the width of the fitted gm that it will take minimum of months for the complete recovery from covid- . additionally, the linear regression technique is used to find the trend of covid- cases with temperature and it is estimated that with an increase in temperature by °c, new covid- cases on daily basis will be expected to observe. this study is believed to be a preliminary study and to better understand the concrete relationship of coronavirus, at least one complete cycle is essential to investigate. the laboratory-based study is essential to be done to support the present field-based study. henceforth, based on preliminary studies, significant inputs are put forth to the research community and government to formulate thoughtful strategies like medical facilities such as ventilators, beds, testing centers, quarantine centers, etc., to curb the effects of covid- . electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. the world is facing a challenge on how to cope with the effects of coronavirus disease which is first identified in the chinese city named wuhan in late december (ahmadi et al. ) . world health organization (who) named this disease as covid- in february . covid- is named after coronavirus- sars-cov- which causes acute respiratory problems and the suffix denotes its triggering year (sohrabi et al. ) . it is important to understand that the discovery of coronaviruses in human and animals is made in the s (zhong et al. ) . among all coronaviruses, only seven types are responsible for causing diseases in humans. out of these, four viruses are responsible for symptoms of the common cold but the other three are responsible for severe lung infections like pneumonia, etc. these three viruses are severe acute respiratory syndrome (sars-cov), middle east respiratory syndrome (mers-cov- ), and sars-cov- , i.e., the current pandemic known as covid- triggered in years , , and , respectively (zheng et al. . coronaviruses are tiny in size having a diameter in the range between and nm that contains a single-stranded rna as a nucleic material. the alpha, beta, gamma, and delta are the subgroups of the coronaviruses family (shereen et al. ) . chinese researchers initially named this novel virus as the wuhan coronavirus and thereafter named as a novel coronavirus ( -ncov). the international committee on taxonomy of viruses (ictv) called the virus as sars-cov- and the illness associated with it as covid- (cui et al. ; lai et al. ; shereen et al. ). similar to the common flu, coronavirus transmits through droplets from person to person when a disease-ridden person coughs or sneezes near other people. it is also observed that covid- enters the body through mouth, nose, or eyes as and when touched by an infected hand which was in contact with the contagious surface. clinical signs of mers and sars are similar to those of covid- (chow ; lai et al. ; zhong et al. ) . the common symptoms include body ache, fever, lung infection, difficulty in breathing, tiredness, etc. it is observed that risk of casualty due to covid- increases among the elderly group and people having chronic health conditions. elder subjects and children, in general, are more sensitive to respiratory symptoms (agarwal et al. , awasthi et al. awasthi et al. , . covid- is a major concern these days in every country because there is no exact cure so far. precautions are sought to be the prevailing means to protect from this pandemic prone virus infection. people with mild illness/symptoms are treated by self-isolation (quarantine) and basic medication. the duration of self-isolation depends on the intensity of the symptoms which is observed from the testing results of patients. since many factors may trigger the covid- cases, in the present work, the aim is to study the interconnection of meteorological parameters and covid- cases. after the announcement of covid- as a pandemic by who in march , different types of investigations increased at a faster pace gautam and hens a, b; gautam and trivedi ; rajput et al. ) . along with other studies on covid- , researchers also focused to find the relationships between weather conditions and coronavirus jahangiri et al. ; menebo ; Şahin ; shi et al. ; tosepu et al. ) . a portion of the investigations even stated that a warm climate may reduce the vulnerability of the virus (gupta et al. ) . different countries around the world announced a lockdown to make some strategic plans, to reduce and to control the effects of covid- . besides, in india, the first lockdown was announced on march , with more consecutive lockdowns ahead. lockdown possessed a serious effect on the economy of countries but air quality and environment improved (gautam ; jain and sharma ; metya et al. ; nakada and urban ) , because most industries and transportation halted during the period of lockdown. in this work, the study period considered for the investigation is the lockdown period, so that the relationship of meteorological parameters with covid- cases is studied in a controlled manner that may help in better anticipation of the relationship between the virus and weather parameters. along with this, efforts have been carried out to predict the maximum number of covid- cases, peak time, and maximum duration of this pandemic. for this purpose, statistical approach is used and available data points are fitted based on the exponential and gaussian curve. the study area selected is delhi, capital city of india, which lies in the northern part of india located between . ° n, . ° e and has a land cover of km and a population of about million ( fig. ) ("delhi location map" ). in delhi, the first case of covid- is reported on march , , and up to june , , , infected people are reported and consisting of deaths ("delhi location map" ). the information with respect to the weather conditions is collected from wunderground, which fetches its data from the national weather service (nws), comprising of around , climate stations (wunderground ) . the information of the number of covid- patients for delhi state has been taken from covid india.org, a site that updates its information in real time from state press announcements, official (cm, health ministry) handles, pbi, press trust of india, ani reports, and ministry of health and family welfare ("covid delhi data" ). confirmed cases of covid- represent the sum of all active, recovered, and deceased number up to that particular day, while daily cases are the difference of two consecutive days of confirmed cases. the study period for this research is for two months from march , to may , . this duration is decided because it comprised the period of the first three phases of lockdown in india. during the lockdown, sources of harmful gases and particulate matters were reduced dramatically, because most of the industries and major movement of vehicles were halted due to which air quality is improved up to a remarkable extent throughout the world (broomandi et al. ; gautam and hens a; gautam and trivedi ; jain and sharma ; li et al. ; zhang et al. ). during the current study period, a major movement of people is restricted due to lockdown, and henceforth other transmission factors of covid- are targeted to nullify, reduce, or control up to a certain level. the statistical analysis is carried out using the statistical package for social sciences (spss) (windows version ). the standard method of linear regression is applied to calculate the association between different meteorological parameters and covid- cases. origin software is used for plotting different types of graphs and fitting the data for extrapolation. a nonlinear exponential curve is used to fit the two months data during a rigorous lockdown period. for the prediction of future scenarios of covid- cases, a gaussian model (gm) is developed. gm is used because epidemics like covid- are firstly exponential in nature and sooner or later saturation in number of cases will be observed and show a bell-shaped curve like the gaussian function. three independent parameters of fitted gm, a peak time, an amplitude, and a width of the gaussian curve (gc), are used to predict valuable information. using the gm, the forecast for further course of the covid- pandemic is possible statistically from the three independent descriptors. all statistical significance tests are two-tailed and with confidence index/level at %. a level of p value ≤ . is considered to be statistically significant. figure represents the daily variation in different weather parameters from march to may , . t max , t min , and t av represent the maximum, minimum, and average temperature, respectively. humidity av represents average humidity and ws av represents average wind speed on a particular day. average wind speed varies between ± , relative humidity varies between ± , maximum temperature varies between ± , minimum temperature varies between ± , and average temperature varies between ± . to check the trend in different weather parameters, the linear trend is drawn between weather parameters as a dependent variable and time, i.e., on different dates as an independent variable and shown in fig. . there is no clear trend observed in the cases of average wind speed, whereas a negative trend is observed in relative humidity. the minimum, maximum, and average value of temperature show a positive trend. the value of r indicates that the strength level is maximum in case of average temperature value. overall there is no significant decrease or increase with time in case of wind speed, whereas temperature value increases during the study period. for further clarity, the correlation table is drawn for weather parameters and the number of confirmed cases. it is observed from the table that the average temperature is significantly correlated with the number of covid- cases. table indicates that based on the correlation coefficient and p value, covid- cases show a nonsignificant relationship with wind speed. slope, correlation coefficients, and significance level indicate that average temperature is strongly connected with the covid- cases in comparison with other weather parameters. finally, it is calculated based on linear regression, by taking the number of daily covid- cases as dependent and daily average temperature as the independent variable and trend is shown in fig. . based on the linear trend and linear regression technique, it is observed that with the increase in the fig. , the daily variation in covid- cases (blue dot) is plotted from march to may , . these data points are then fitted to different types of curves, and the best fit curve is obtained for a nonlinear exponential equation and the equation is shown in fig. . the equation formulated for the initial set of data is as follows: the best fitted line (r = . ) in fig. on the basis of the nonlinear fitting, strongly indicates that the number of confirmed covid- cases increase exponentially during the study period. the exponential growth rate is the main concern of intellectuals like researchers, doctors, and strategists to think about possible solutions. to predict the future scenario of covid- , this is not appropriate to use an exponential equation, because an exponential growth represents a continuous increase, whereas in the pandemic scenario, the number of cases will indeed increase rapidly up to certain days or months, afterward the value will start to decrease after forming a peak. it is interesting to estimate the peak value and time coverage of covid- cases. for this purpose, a predicted model other than an exponential equation is required. keeping in view the expected behavior of covid- cases, the available data points are fitted and plotted based on the single gaussian curve as shown in fig. . the fitted gaussian model statistically predicts that the number of covid- cases initially increases continuously until a peak is formed at , number of cases. based on y = − . + . * exp x+ ;r = . fig. daily variation in confirmed covid- cases the fitted gm, it is predicted that the maximum number of cases is observed during the time range of . ± days. based on the number of days calculated from the peak value of the fitted model, it is estimated that the number of cases will increase maximum up to the second week of october , afterward a decrease in the number of cases may be observed. the fitted model also indicates that it may take about days to touch the minimum number of covid- cases yet again. this predicted observation or estimation is assumed to be true based on the fitted statistical gaussian equation when only one wave of covid- cases is considered. undoubtedly, the covid- pandemic has shown a lower mortality rate in comparison with previously observed viruses like sars, mers, etc. but its exponential growth is a serious concern all around the world. this concern among the people will be the maximum until the development and availability of vaccination of covid- . previous studies show that the strength of similar viruses like sars reduces at a higher temperature and relative humidity (lin et al. ) . but in the present study, the number of cases of covid- has increased with the increase in temperature. in fig. , the legend shape of a square, triangle, and circle denotes three weather parameters namely temperature, humidity, and wind speed, respectively. figure contains three quarters representing three types of variation of covid- , i.e., positive, negative, and neutral trend with different weather parameters as observed in the state-of-the-art studies. sahin ( ) and shi et al. ( ) relationship. the study conducted by shi et al. ( ) showed no significant relationship between humidity and covid- cases. the third weather parameter wind speed showed negative, positive, and no relation with covid- by menebo et al. ( ) , bashir et al. ( ) , and shi et al. ( ) , respectively. jahangiri, et al. ( ) provided a conclusive statement that no scientific evidence is found to confirm that warm ambient temperature reduces the number of covid cases. these studies along with the present preliminary study have certain limitations like population sensitivity, virus confrontation, and cleanliness of population and precaution taken by the population related to covid- . the study duration for the state-of-the-art studies shown in fig. is maximum for up to three months, thus categorize these under preliminary indicative studies. all these are indicated as field-based studies that provide conclusions based on statistical analysis which need to be supported by laboratory-based experiments. the first case of covid- in delhi is observed in march . as per the climate of delhi, november-january are the coldest months of the capital city, and afterward, the temperature increases, and march is supposed to be the initial month of the summer season. this may be a coincidence that covid- started to spread in northern india during the mid of march and similarly temperature also started to increase from march onward with the arrival of the summer season. the availability of testing kits increased with time leading to more testing, which is supposed to be one of the reasons for more diagnoses fig. relationship of covid- with respect to temperature, humidity, and wind speed for the number of covid- cases. the variation in covid- cases in winter or cold temperature is still needed to be observed. this is supposed to be one of the drawbacks of the study, i.e., if the study period could have been for at least six months including both winter and summer season, then better relational results with temperature could be drawn. so this is not confirmed that it is the temperature that is responsible for an increase in the number of cases with time or it is just coincidental due to the availability of a large number of the testing kit. besides, it is too early to provide a conclusion about the relationship of covid- with temperature. however, our results show that with the rise in temperature, the number of covid- cases has increased dramatically. although, this is also not confirmed that these cases have either been triggered by temperature or just coincidental. to achieve/obtain more reliable results, one complete cycle of covid- need to be observed as in india winter season was over just before the arrival of covid- in delhi. more strategic and rigorous studies of persistent data are required for a better conclusion. if the studies in which temperature has a negative relation with the covid cases are believed to be precise, then this is more challenging for delhi or all over the world where winter season is yet to come in the coming months. this indicates that upcoming months are tougher for those regions where winter season is commencing because in winter season usually due to cold weather conditions, respiratory diseases are easily triggered. therefore, more care and strategies are needed to be designed by government agencies to reduce the effect of covid- because gm extrapolates that it will take days to recover from covid- cases. the weather parameters are significant to consider the transmission of communicable diseases. this preliminary study shows a positive significant relationship of covid- with temperature and a negative relationship of covid- with relative humidity. based on the statistical approach of the linear regression technique, this is estimated that new cases of covid- are observed for every °c rise in temperature. however, this is not supported by the r value. moreover, there is no scientific evidence that these numbers are triggered by weather parameters like temperature or just coincidental. to understand the threshold of virus transmission and survival, more rigorous and robust studies are essential. for conclusive and concrete remarks, at least one complete cycle of covid- is required for investigation. however, the present study along with state-of-the-art studies clearly shows a significant exponential increase in covid- cases with time which is a serious concern for everyone. the exponential growth of covid- cases is observed only in the initial stage which shows peak value after a certain time, hence the exponential fitting of data for prediction is not an accurate approach. therefore, the gc is used to fit and extrapolate the data, which is used to estimate the number and date of the peak value. based on the fitted gm, number of cases increases up to , in number, which will go maximum up to the second week of october . based on the width of gm, covid- cases will be controlled in a minimum of days, starting from march , and extending up to january . hence, this study is considered as one of the inputs for the researchers and government agencies to formulate some thoughtful strategies to control and reduce the effects of covid- . this study proposed to the government that more planned and vigorous arrangements in terms of infrastructure, health facilities, and financial support are required as the predicted results of gm show an extended number of covid- cases in the near future. the extrapolated information from gm including maximum number, peak time, and maximum time will provide a basic idea to the government about the requirement of medical facilities such as ventilators, beds, testing centers, quarantine centers, etc. statistical model to study the effect of agriculture crop residue burning on healthy subjects effects of air pollution on respiratory parameters during the wheat-residue burning in patiala investigation of effective climatology parameters on covid- outbreak in iran current perspective of covid- spread across south korea: exploratory data analysis and containment of the pandemic. environment, development and sustainability elucidative analysis and sequencing of two respiratory health monitoring methods to study the impact of varying atmospheric composition on human health effects of agriculture crop residue burning on children and young on pfts in north west india correlation between climate indicators and covid- pandemic impact of covid- event on the air quality in iran a citizen's thoughts about covid- origin and evolution of pathogenic coronaviruses delhi location map the influence of covid- on air quality in india: a boon or inutile covid- : impact by and on the environment, health and economy. environment sars-cov- pandemic in india: what might we expect? environment global implications of bio-aerosol in pandemic effect of weather on covid- spread in the us: a prediction model for india in the sensitivity and specificity analyses of ambient temperature and population size on the transmission rate of the novel coronavirus (covid- ) in different provinces of iran social and travel lockdown impact considering coronavirus disease (covid- ) on air quality in megacities of india: present benefits, future challenges and way forward severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges impact of the covid- event on the characteristics of atmospheric single particle in the northern china environmental factors on the sars epidemic: air temperature, passage of time and multiplicative effect of hospital infection temperature and precipitation associate with covid- new daily cases: a correlation study between weather and covid- pandemic in oslo norway covid- lockdowns improve air quality in the south-east asian regions, as seen by the remote sensing satellites covid- pandemic: impacts on the air quality during the partial lockdown in são paulo state brazil a shock like no other: coronavirus rattles commodity markets. environment devlopment and sustainability, impact of weather on covid- pandemic in turkey covid- infection: origin, transmission, and characteristics of human coronaviruses the impact of temperature and absolute humidity on the coronavirus disease (covid- ) outbreak-evidence from china world health organization declares global emergency: a review of the novel coronavirus (covid- ) correlation between weather and covid- pandemic in jakarta indonesia new delhi, delhi, india weather history impact of the covid- event on air quality in central china covid- and the cardiovascular system epidemiology and cause of severe acute respiratory syndrome (sars) in guangdong, people's republic of china publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflict of interest the authors of this manuscript declare no conflict of interest. key: cord- -muon kuu authors: bellido-blasco, j. b.; arnedo-pena, a. title: epidemiology of infectious diarrhea date: - - journal: encyclopedia of environmental health doi: . /b - - - - . - sha: doc_id: cord_uid: muon kuu abstract diarrhea is a very frequent symptom. a great variety of chemical agents, microorganisms, and biotoxins can cause diarrhea, acute or persistent, slight or serious. from the epidemiological point of view, the cases can be sporadic or epidemic, and identification of the infection source and transmission mechanism is important for prevention and control. knowledge of the etiology is a great help. the entrance route to the human body is usually through the digestive system. from some source in an individual's surroundings, the causal agent somehow reaches the mouth of the susceptible person. the hands play a fundamental role in many situations. this article revises the most important epidemiological characteristics of the agents that produce diarrhea as a main symptom, placing an emphasis on epidemiological point of view and environmental transmission mechanisms. some aspects regarding individual susceptibility (genetic or other types) are also mentioned. because the long-term consequences of infectious gastroenteritis are less well known, a small section dedicated to the long-term consequences of infectious gastroenteritis has been included. with suitable prevention, not only the acute consequences but also the aftereffects of these diseases can be avoided. the consequent effects of diarrhea can be highly variable: from a slight and transitory condition that spontaneously resolves itself to its more severe incarnations where loss of water and electrolytes can be an important factor. the resulting hypovolemic shock can cause renal failure, disorders in other organs, and in the most vulnerable patients it can prove to be fatal. the appearance of diarrhea results from confrontation between aggressive external elements (a causal agent's toxicity or virulence, the quantity of the inoculant dose) and the body's own defense mechanisms. among the defense mechanisms combating infectious agents, the following can be highlighted: gastric acid, gastrointestinal mucus, intestinal motility, bile salts, regular intestinal bacteria, macrophage cells, lymphocyte cells, and type iga immunoglobulin in the mucus. additionally, there are genetic factors that can affect resistance to particular infections; for example, blood group 'o' individuals are at greater risk of suffering from cholera, whereas the so-called nonsecretory individuals, with certain fut gene mutations, are partially resistant to norovirus infection. other specific external circumstances such as the ingestion of alcohol or (nonvolatile) red wine could act as protective factors against infection by salmonella when the ingestion of the microorganism and those kind of drinks is almost simultaneous. there are few vaccines effective against diarrheal diseases. recently, a vaccine against rotavirus has been authorized, which is expected to show positive results. occasionally, diarrhea presents itself as an accompanying symptom of chronic conditions, such as the collateral effect of some medicines or a sign of malnutrition. however, this article discusses diarrhea as the principal effect of infections and poisoning by microorganisms, ingestion of animals, plants, or compound chemical toxins. in this context, it is very common to associate diarrhea with the ingestion of food that is either contaminated or well past its best. but infections and food poisonings do not always present themselves as the clinical profile in which diarrhea is predominant. for example, in botulism or some marine biotoxins the essential factors are the neurological signsdiarrhea may or may not be present. infant mortality from acute diarrhea has reduced throughout the last years of the twentieth century, essentially due to improvements in sanitation and the implementation of oral rehydration therapy programs by the who. even so, in the year , it caused approximately million deaths. the vast majority was related to avoidable causes. in the distribution of diarrhea cases there are geographic and age-related differences. with as much respect to etiology as to the seriousness of the cases, somewhat different patterns have been found, according to whether the countries are industrialized or not. certain parasites and cholera, for example (of whom the who is continuously in international pursuit), are still frequent in some underdeveloped regions where favorable conditions for their propagation exist. bad conditions of individual hygiene, nutrition, and existing public sanitation in many poor countries favor the presence of diarrhea. even when incidences of the infection do not display such great geographic differences, in the case of some viruses, the indicators in terms of its lethality are noticeably different; for example, rotavirus is very frequent in all types of countries, but its severity (mortality rate) is greater in poor countries. in england and wales, the microorganisms that most frequently cause diarrhea are campylobacter, rotavirus, norovirus, salmonella, giardia, and cryptosporidium. since means have been available for the virological diagnosis of gastroenteritis, it has been seen that viruses are the most common cause of diarrhea in western countries. generally they do not cause very serious illnesses at the individual level, but they are responsible for a considerable social burden in the form of hospital admissions and scholastic and employee absenteeism. the age of patients, the seriousness of the illness, and the capabilities of laboratories are factors that determine the scope of the etiological diagnosis. age also relates to the etiology of diarrhea ( figure ) and to the probability of fecal analyses. faced with a similar clinical profile, a child does not have the same probability as an adult of receiving an etiological diagnosis: in the child's case it is more likely. the same happens with serious conditions in comparison to slight ones. the slight diarrheas often go without etiological diagnosis. this is also the case with conditions caused by agents that are not detected by the laboratory participating in the analysis. age bias, age, and technical ability need to be considered when analyzing epidemiological statistics. however, epidemiological studies were performed in england and holland at the end of s and in the united states in and , in which a thorough fecal examination of all patients was undertaken, independent of their age and the seriousness of their condition, including those patients who no longer showed symptoms of diarrhea. in these studies, fecal examination was also carried out in healthy control subjects, so that the frequency in which specific microorganisms appeared could be compared with asymptomatic subjects. usually the etiological diagnosis of acute infectious (or toxic) diarrhea is obtained by fecal analysis: wet mount, coproculture, antigen detection, toxin detection, or other analyses. specialized laboratories can use more complex techniques that, generally, prove to be more sensitive and specific, but are also more expensive and difficult. nevertheless, many of the coprocultures a standard laboratory requests and examines are negative. a negative result can be the consequence of the following reasons: diarrhea is not actually infectious, it is caused by an agent for which the laboratory has no data, there is a failure in the test sensitivity, the patient may have taken antibiotics, or there may have been problems in fecal transport. cases that have returned negative results are a mixture of etiologies, and for that reason further investigation makes little sense. in the edics study (study of infectious diarrhea in castellón) of risk factors in infantile diarrhea, no risk factors were found associated to the cases with a negative fecal analysis result. on the contrary, risk factors were found in cases of campylobacteriosis, salmonelosis, or rotavirus. this indeed suggests that the group of negatives is a mixture of different etiological cases without common origin and with few shared risk factors. the appearance of vomit as an initial symptom, the absence of fecal blood (macro-or microscopic,) and low pcr (reactive c protein) are signs suggestive of viral etiology, especially in children. faced with an epidemiological case of diarrhea two questions arise: one, if the etiology is already known; two, if there are more cases related to the original. these two elements are represented in table , where each cell signifies a distinct epidemic concern. there are noticeable differences in modes of approaching the epidemiological study of diarrhea cases according to their sporadicity or pertinence to an outbreak. certain microorganisms have a preference to appear fundamentally as one of these forms. as such, campylobacter or rotavirus constitutes the majority of sporadic cases, not excluding the possibility of producing outbreaks. on the contrary, salmonella and, especially, norovirus more characteristically present themselves in the form of outbreaks. from the epidemiological point of view, it could be said that epidemic cases 'come' to the investigator as one, whereas the investigator 'goes' in search of the sporadic cases and reunites them for their studies. among the sporadic cases there is a group, which in fact belongs to small clusters, that escapes common systems of epidemiological monitoring and needs special investigations. this group of apparently sporadic cases (but which, in fact, are not sporadic) can only be detected by the existence of an exceptionally good monitoring system or by performing specific studies. steen ettenberg and other collaborators performed a specific study on cases registered throughout denmark in the s and found that . % of salmonella enteritidis, . % of shigella sonnei, . % of salmonella serotype typhimurium, . % of campylobacter, and . % of yersinia enterocolitica cases belonged to this type of clusters, which is a large majority unknown to epidemiological monitoring systems. in absolute terms, the cases of campylobacteriosis were the most numerous due to the large amount of patients diagnosed with the infection in the last years of the study. in a much smaller study in castellón (spain), clusters of this type were identified after systematic investigation of coprocultures in an area of inhabitants. small family clusters of campylobacter, s. enteritidis, rotavirus, and intestinal adenovirus were found. in addition to the etiology and level of aggregation, a third question arises: the source of infection and its mechanism of transmission. when the etiology is well known, the epidemiology of the agent involved is generally known. table summarizes some epidemiological characteristics of five infection sources and significant mechanisms of transmission. figures and represent two outbreaks of diarrhea by norovirus in residential homes for the elderly; these charts clearly demonstrate two mechanisms of transmission. figure shows a specific outbreak transmitted by foods (foodborne point source outbreak), and figure shows an outbreak, beginning gradually and progressively exacerbating, in which the transmission mechanism was predominantly 'person to person' and environmental (surfaces, fomites). figure represents a simple theoretical diagram for the investigation of transmissible disease cases by using the armigo system (agent, reservoir, mechanism of transmission, individual, groups, other people). following an outline inspired by the epidemic cases of table , three situations can be distinguished according to the characteristics of the affected population. first, a defined, open population with a specific exposure, which refers to people who only momentarily shared an exposure factor, for example, attending a shared dinner or banquet. second, a defined, closed population with lasting exposure factors, for example, permanent residents within a closed institution, who continually share meals, places, and activities. and third, an indefinite population, with or without specific exposure, which occurs when there is no obvious relationship between people and they are implicated in an outbreak, solely by sharing an exposure factor distributed throughout the population. in the case of laboratory analysis, an epidemic is identified where some rare microorganism in unusually large numbers of people is detected in a fairly prolonged time frame. for example, an outbreak that occurred in the united states in the first half of was table epidemiologic first approach to a case of diarrhea produced by salmonella saintpaul with the same genetic fingerprint that affected more than people in states. the epidemic was related to the consumption of tomatoes distributed throughout the country. table shows the agents that most frequently cause diarrhea, and table summarizes the more relevant epidemiological features of the diarrhea caused by these agents. some of these microorganisms are discussed below. this was identified by ruth bishop in and was named as such because of its 'wheel-like' form. there are various groups of rotavirus capable of producing infections in humans. the vast majority of cases are children infected by group a rotavirus. group b is related to diarrheas in adults and group c to slight diarrheas at any age. other serogroups are zoonotic and are possibly transmitted by some animals. rotavirus is the main etiological agent for serious diarrheas in children all over the world. at a very young age, a large number of children have already been infected or reinfected. rotavirus has limited capabilities for producing outbreaks. the most important problems it constitutes are sporadic and hospital cases. many cases are relatively serious infections that require hospitalization. according to a study of common rotaviral diarrhea in children under years of age, carried out in and again in in castellón, almost half of the patients were hospitalized. in nonindustrialized countries, hospitalizations are fewer because welfare services are less accessible; mortality rates, however, are greater. year saw the authorization of two new oral vaccines that promise to be effective: rotateq Ò and rotarix Ò . previously known as 'agent norwalk,' this virus was identified by albert kapikian in . it is related to the caliciviridae family, of which only norovirus and sapovirus cause diarrhea in humansthe former preferentially causing epidemic cases (outbreaks) and the latter causing sporadic ones. norovirus, especially genogroups i and ii, actually constitutes the most frequent cause of viral diarrhea epidemics in industrialized countries. if rotavirus is characterized by producing sporadic cases, norovirus characteristically produces outbreaks; especially in semienclosed spaces such as residential homes for the elderly. the infection originates from diverse sources: foods, water, patients, a schematic theoretical diagram of a communicable transmissible disease, for example, diarrhea, obtained by using armigo system. agent: bacterial, viral, other (biotoxin, chemical); reservoir and exposure source: animal, soil, surfaces, water, food, ill person, carriers; mechanism of transmission: food, water, hands, aerosol, or dust swallowed via mouth; individual at risk: age, earlier health status, genetic susceptibility; group at risk: same opportunity to exposure; other related people: contact with primary ill or asymptomatic person. and environment. the fingers are easily contaminated. a small dose of inoculant is sufficient to produce symptoms in susceptible people. on wood, metal, or plastic surfaces, the virus can survive for hours or even days. it has been proven that transmission is possible through typical hand-to-surface contact, such as door handles, telephone receivers, or taps. an experimental study found that contaminated fingers could transfer the virus to the clean surfaces they touch by up to seven times, and at least people could be contaminated by touching the same surface. alternatively, it is known that certain subjects are genetically resistant to infection by norovirus. the polymorphism of gene fut divides into secretory and nonsecretory individuals, who are susceptible and resistant, respectively. approximately % of caucasian subjects are nonsecretory. however, recently it has been seen that nonsecretory subjects are not totally resistant, suggesting some norovirus strains use alternative routes of infection. the characteristics of norovirus make it difficult to produce a vaccine against it. this belongs to the adenoviridae family. within the adenovirus genus, serotypes and are responsible for cases of diarrhea. it is possible to identify them in feces by elisa techniques or latex agglutination, but serologic determinations useful for the diagnosis of respiratory infections by adenovirus do not have the same use in gastroenteritis profiles. these serotypes generally cause cases of infantile diarrhea throughout the year. the only demonstrated mechanism of infectious transmission is direct contact between people. perhaps they have a limited epidemic potential. the infectious capacity of this virus is not accurately known. this was first identified in in a fecal examination among children with diarrhea. the astroviridae family, to which it belongs, was established in , and was named after its star-shaped appearance. it causes diarrhea in children and adults, with a slight seasonal pattern of predominance in cold months in regions with a temperate climate. the infectious capacity is high, perhaps very few viral particles can produce disease. epidemiological data suggest that immunity does not last and is serotype specific. few laboratories can diagnose the routine of this infection. it is believed that the virus can be an important factor in hospital diarrheas as much as in external cases. these belong to the coronaviridae family. among the viruses that cause diarrhea in humans, they are the only ones that possess envelopes. it is believed that the torovirus produces acute diarrhea in children and can also be an important factor in nosocomial diarrhea. coronavirus occasionally produces diarrhea, but it gained importance as a result of severe acute respiratory syndrome (sars) outbreaks, originated by coronavirus with a great capacity for environmental and person-to-person dissemination. the elimination of the virus in feces is less at the beginning of the illness. however, viral particles have been found several months after the symptoms first started. campylobacter, especially campylobacter jejuni, is responsible for the majority of bacterial gastroenteritis cases in the industrialized countries. it is a germ that grows little or nothing in foods. this is the probable cause of its limited epidemic potential and the scarcity of known outbreaks. some relationships to the ingestion of milk or public drinking water have been described. however, the majority of diagnosed cases are sporadic, essentially occurring in very small children and with little evidence of any seasonal pattern. it is possibleas happens with other microorganismsthat this predominance of diagnosed cases in children may be the consequence of a diagnostical age bias. studies on intestinal infection where adult participants were asked to provide fecal cultures revealed that campylobacter is also frequent in adolescents, adults, and the elderly. the majority of diagnosed intestinal infections do not require hospital admission. according to the authors of this article, only % of cases resulted in patients being hospitalized. reservoirs of campylobacter are not only found in farm animals, essentially avian, but also found in bovine livestock. companion animals, if they have diarrhea when very young, can pose an infection risk to their owners. the study of risk factors in campylobacter infection presents difficulties given that the majority of cases are sporadic and in children under the age of years. exposure to avian or bovine meat products has been related to infection. exposure is not necessarily by direct consumption; the presence of these products in home kitchens presents a risk factor, probably by cross-contamination due to poor hygienic practices. the existence of other diarrhea cases in the patient's nearby surroundings implies that there are small groupings, small outbreaks not identified by conventional systems of epidemiological monitoring. salmonella owes its name to the north american veterinarian daniel elmer salmon, who was one of the pioneers of microbiology toward the end of the nineteenth century. diarrhea by salmonella is a very common zoonosis all over the world. the clinical profile in many patients consists of diarrhea with fever and an exaggerated variable state of health. in the nontyphoidal salmonella group, there are more than serotypes that can cause gastroenteritis in humans, most common are s. enteritidis and s. typhimurium, although many others have been identified on numerous occasions. when available, the serotype and fagotype are laboratory data that aid in the investigation of epidemiological factors and the infection source (eggs, birds, and other animals). some serotypes have a preference to form reservoirs in specific animals. chickens and hens are principal reservoirs of s. enteritidis; however, pigs and cattle transmit s. typhimurium. other serotypes such as s. hadar, s. virchow, and s. heidelberg are also present in chickens and hens. reptiles are transmitters of some less frequent serotypes. hen eggshells can also be contaminated. but a remarkable fact is the vertical transmission of salmonella in hens, laying eggs that are internally contaminated. adequate data about the prevalence of contaminated eggs do not exist. at the beginning of the s, random sampling was carried out for a study in castellón, the estimation was little more than in a . also, common vegetables (tomatoes, watermelon) and foods with little water activity such as chocolate or powdered milk have been implicated in outbreaks. an outbreak was even transmitted by marijuana consumption. in , an outbreak in the united states transmitted by tomatoes affected more than people in some states. when investigating outbreaks, the possibility of secondary cases has to be taken into account. it is not believed that there are chronic carriers as with s. typhi, but the feces of some patients can remain contagious for months, especially in children. these situations and the cases with few symptoms are particularly important when they occur in food handlers. the infectious dose, the conditions surrounding its ingestion (accompanying food, antacid medication, etc.) and some characteristics of the host can act as factors that greatly modify the incubation period and the severity of the clinical profile. symptoms can start from h up to days after the ingestion of contaminated produce. some greasy foods facilitate salmonella's crossing the stomach without being eliminated by the extreme acidity of the gastric juices. it has been suggested, when faced with infection by s. ohio, that the simultaneous ingestion of alcohol (or red wine) has a protective effect. several serotypes of shigella exist. of them, s. dysenteriae type is responsible for the most serious cases, bacillary dysentery, due to the shiga toxin. other serotypes are s. sonnei, s. flexneri, and s. boydii, which in general produce less severe profiles, accompanied by watery diarrhea. the geographic distribution of each serotype is different. in industrialized countries the impact is diminished. in asia, it seems that incidents of shigellosis maintain a presence but tend to be less serious. little is known about incidents in africa. the infectious dose is very low (from to bacilli); therefore, secondary cases are very frequent due to easily contaminated hands. shigella produces outbreaks and sporadic cases. the incubation period of s. dysenteriae is longer, up to a week. carriers can be asymptomatic for weeks, and with antibiotic treatment they could reduce the time needed for elimination of shigella in the feces. however, the appearance of antibiotic resistance has been observed. the protection from natural infection it offers is type specific. within the yersinia genus there are numerous nonvirulent environmental strains. those that most frequently cause intestinal infection are y. enterocolitica and y. pseudotuberculosis. the former (whose taxonomic classification has undergone important changes from its initial description in as flavobacterium pseudomallei to the denomination yersinia at the beginning of the s) produces a diarrhea profile that includes abdominal pain and, sometimes, fever; the latter (whose first identification dates from many years earlier, in ) produces a clinical profile in which it is worth mentioning the symptoms of mesenteric adenitis, which can sometimes simulate an appendicitis. not all strains of y. enterocolitica are pathogenic in humans; furthermore, different pathogenic serotypes and biotypes are unequally distributed among the population. specific culture media are required for the identification of yersinia from human fecal samples; standard culture mediums are not usually sufficient. changes in laboratory practice have been considered an explanation for observed increases in the s and some geographical differences. the large majority of y. enterocolitica cases are sporadic. in many countries with temperate climates, the patients are usually small children diagnosed in winter months. the percentage of total diagnosed cases of diarrhea is small. the y. pseudotuberculosis species is less frequent and little knowledge exists regarding its mechanisms of transmission. there have been cases grouped in spatiotemporal clusters without a commonly identified nexus. in these clusters no secondary cases were observed, suggesting the source was most probably environmental. y. enterocolitica is frequently found in pig's tonsils. in the case of y. pseudotuberculosis, the reservoirs are wild rodents and birds. there is a possibility that some humans may be carriers of y. enterocolitica. also, yersinia, from these reservoirs, may contaminate foods or water, which will then infect those who consume them. in the case of y. pseudotuberculosis, there are recorded outbreaks transmitted by 'iceberg' lettuce and radishes. it is postulated that initially the infection is caused by waters contaminated by animal reservoirs, which indicates that the washing of fresh vegetables is a method to prevent infection. but an outbreak that occurred in finland in experimentally demonstrated the possibility of internal contamination of the lettuces, with the result that in such an eventuality external washing would have little effect. escherichia coli is a bacterium that forms part of the normal intestinal flora in humans and other warm-blooded animals. nevertheless, in the s, it was discovered that certain strains of e. coli had a pathogenic capacity in humans. there are many serotypes. their capacity to produce different clinical syndromes and affect different age groups is a factor unique to each serotype, ranging from 'traveler's diarrhea' to a serious profile of hemorrhagic colitis. the serotypes able to cause diarrhea are enterotoxigenic e. coli (etec), enteropathogenic e. coli (epec), enteroinvasive e. coli (eiec), enteroaggregative e. coli (eaec), and most virulent of all enterohemorrhagic e. coli, also named verocytotoxic e. coli (ehec or vcec) of the serotype o :h . the geographic distribution and transmission channels vary between serotypes. among the clinical characteristics of these infections, it is worth mentioning a serious complication of serotype o :h , hemolytic-uremic syndrome (hus), which appears mainly in children, and can be exacerbated by taking antidiarrheal or antibiotic medicines. this virulent stock of e. coli is transmitted mainly through ingestion of contaminated meat from bovine livestock, but it is also possible that there are other environmental routes of contagion by contact with surfaces or dust and sawdust in farms and zoological parks. recent studies suggest that eaec can cause both traveler and chronic diarrhea. furthermore, the inflammatory response to this infection depends on human genetic factors linked to interleukin- . this is a microorganism that can cause serious diarrhea, occasionally as pseudomembranous colitis, especially in hospitalized and debilitated patients. usually, it is triggered by taking antibiotics for therapeutic or preventive purposes. nevertheless, slight cases exist that are not diagnosed and are only detected in specific studies. the asymptomatic carrying and elimination of bacterial spores is relatively frequent in small children, but it is only patients with established diarrhea who are contagious. the origin of diarrhea from microorganisms previously present in the same individual can be endogenous. these microorganisms are stimulated when intestinal flora is altered as a result of taking antibiotics; this can happen for - days at the beginning of an antibiotic course and even later, up to or weeks after starting. in these cases, it is difficult to speak of an incubation period in the classic sense. there may also be exogenous contagion from environmental spores or c. difficile excreted by another patient. in some countries improvement in diagnostical methods has contributed to the increased number of diagnoses, especially in hospitalized patients. it is rare that it produces communal outbreaks. when it appears in an epidemic form it usually does so in hospitals. according to what is known of its clinical and epidemiological characteristics, cholera only produces the v. cholerae serogroups o and o , the latter confined to southeast asia. other serogroups, denominated 'non-o ' and 'non-o ,' usually present themselves as sporadic cases or small outbreaks with an incubation period of - h. as per epidemiological characteristics of cholera, it is easily spread through water or foods but not from person to person. in countries where there is overcrowding, poor nutrition, and poor environmental hygiene, cholera remains a very serious problem. people with blood group o are generally more susceptible to severe diseases. clostridium perfringens, bacillus cereus, and vibrio parahaemolyticus all these cause diarrhea through the consumption of contaminated food. the first two have the capacity to form spores and are found in terrestrial environments (the ground, for example). v. parahaemolyticus is halophilic and is found in marine environments and seafood products. person-to-person transmission, if it exists, would be rare. diarrheas caused by parasites usually have a more prolonged and insidious course. relapses and chronic forms are frequent and cause weight loss. they are usually resistant to the levels of chlorination in drinking water. entamoeba histolytica is frequent in tropical and subtropical countries. patients with diarrhea dispose of the parasite in trophozoit form, a form with little infectious potential due to its environmental fragility. in contrast, a significant number of infected people remain asymptomatic for months or years, eliminating cysts that have a greater infectious capacity than trophozoit. giardia lamblia is distributed by people all over the world. outbreaks caused by giardia are relatively common in day-care centers, especially when there are poor hygienic conditions that facilitate person-to-person transmission. foods and water can also provide vehicles of transmission. the reservoir is human and, perhaps, some animals such as beavers. people can remain carriers for months. cryptosporidium parvum produces diarrhea in humans and can also affect systems other than the digestive system. they are parasites resistive to the levels of chlorination used to disinfect drinking water; therefore, hydric transmission outbreaks occur without requiring failures in chlorination. water filtration is a preventive method to avoid propagation. it has a good survival capacity in the aquatic environment of continental waters. it is responsible for % of gastroenteritis outbreaks related to swimming venues in the eu, although hyperchlorination can inactivate cysts present in the water. it has been diagnosed with relative frequency throughout and in ireland, england, and belgium, and with less frequency in germany. there have been outbreaks from tap water contamination. parasites such as cyclospora cayetanensis, balantidium coli, and isospora belli have less importance than the ones mentioned earlier. there are even doubts about their capacity to produce symptomatic infection in humans. there is a very diverse range of agents that cause, or can cause, diarrhea ( table ) . they are characterized by short incubation periods following ingestion (minutes or hours). they have a very broad clinical spectrum. notable among the biotoxins is scombroid fish poisoning, which can take place after ingestion of certain scombroid fish (such as tuna and herring) in certain circumstances. the symptomology simulates an allergic reaction that presents itself in an epidemic form. ciguatoxin, tetrodotoxin, and gempilotoxin are marine biotoxins that can produce very serious digestive and neurological symptoms. especially striking is gempilotoxin poisoning, in which diarrhea with orange colored feces has been observed. among vegetables, mushroom poisoning can cause serious consequences. less well known is the diarrhea from robinia pseudoacacia poisoning, which can be observed after chewing the bark of common trees. as consequences of the intestinal infections, complications and long-term aftereffects are distinguishable. the former occurs in the acute phase and the latter appears weeks or year after resolving the clinical profile, sometimes even later. studies used by epidemiologists to investigate aftereffects are: • point source outbreaks studies • prospective cohort studies of sporadic cases • retrospective cohort studies. the etiology of inflammatory bowel disease (ibd) is not known, but cohort studies carried out in the united kingdom and sweden indicate that previous bacterial intestinal infections by salmonella, campylobacter, or diarrheagenic e. coli and other agents of acute gastroenteritis double or triple the risk of suffering from some ibd variants, with incidences reaching almost per personyears. irritable bowel syndrome (ibs) can develop after infectious gastroenteritis by campylobacter, shigella, salmonella, or e. coli o :h . by case-control studies, a statistically significant odds ratio of . has been estimated. it is believed that age (young), sex (feminine), psychological profile, severity, and duration of gastroenteritis are all risk factors in contracting ibs. the leirisalo-repo definition of reactive arthritis (rea) is "joint inflammation that develops soon after or during infection elsewhere in the body but in which the microorganism cannot be recovered from the joint." it usually occurs in the first weeks after infection, is self-limiting, and affects a single joint. incidence varies according to the germ and its serotype, as well as the patient characteristics and case definition in each different study. although the frequency of bacterial musculoskeletal symptoms after foodborne infection can reach up to % of affected patients, the incidences of rea are positioned between % and %. microorganisms related to rea are enteric salmonella, shigella, campylobacter, yersinia, e. coli o :h , and c. difficile. perhaps there may be more. apparently women, adults (above years), and those who have suffered more serious illnesses are at greater risk. the genetic marker hla b would be associated more with severity than incidence. the effect of taking antibiotics during the acute phase of intestinal infection is an object of discussion relating to the appearance of rea. guillain-barré syndrome (gbs) is an acute neuropathy of immune origin, which is associated with infections from campylobacter and cytomegalovirus. studies from the united kingdom give an incidence of gbs, which takes place - weeks after infection, in out of every inhabitants, especially for some serotypes of campylobacter such as o and o . males are at greater risk of suffering from gbs. after years of monitoring, a greater risk of hypertension and problematic kidney function after exposure to c. jejuni and e. coli o :h has been observed in hydric outbreaks of gastroenteritis. autoimmune diseases (graves' disease, autoimmune tiroiditis, kawasiki disease, sjogren syndrome, and psoriasis) have been related to previous intestinal infections by staphylococcus and yersinia. the aftereffects of viral intestinal processes are less well known due to limitations of diagnosis in conventional laboratories. some of them are fibromyalgia or chronic fatigue syndrome (cfs), and chronic inflammatory muscle disease (cimd). studies of stomach biopsies and the presence of enterovirus in skeletal muscles suggest the persistence of infection with viral replication in these patients. some cohort studies carried out in the united states suggest that children between and months of age infected by norovirus, sapovirus, or rotavirus are at greater risk of displaying persistent diarrhea in the months following viral infection. cross-sectional epidemiological studies and prospective studies in children have suggested the importance of enteric viral infections in the development of autoimmune celiac disease (acd). according to a cohort study carried out in finland in , enteric viruses (rotavirus, adenovirus, and others) could increase the risk of type diabetes in children with a genetic predisposition to that disorder. it will be necessary to incorporate knowledge of medium and long-term effects to what is already known about the acute effects of intestinal infections. epidemiological investigation has a prominence in this investigation. possibly intestinal infections will gain even greater importance in public health. effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces the protective effect of alcoholic beverages on the occurrence of a salmonella food-borne outbreak outbreaks of acute viral gastroenteritis in geriatric homes: threshold detection system for prevalence (sidup) incidencia de artritis reactiva y otras secuelas osteoarticulares después de un brote de salmonella enteritidis fagotipo fecal-oral transmisión an outbreak of escherichia coli o :h among visitors to a dairy farm direct exposure to animal enteric pathogens household outbreaks among culture-confirmed cases of bacterial gastrointestinal disease risk factors for acquiring sporadic campylobacter infection in france: results from a national case-control study infectious diarrhea short and long term mortality with foodborne bacterial gastrointestinal infection: registry based study chronic sequelae of foodborne disease a widespread outbreak of yersinia pseudotuberculosis o: infection from iceberg lettuce microbicides and the environmental control of nosocomial viral infections salad and pseudoappendicitis: yersinia pseudotuberculosis as a foodborne pathogen short and long-term effects of bacterial gastrointestinal infections mr. richard nightingale translated the text from spanish to english. also we thank you for the review dr. juan b. bellido-blasco, unit of epidemiology, public health center of castellón, ciber-esp. key: cord- - mue eiv authors: bertozzi, giuseppe; maglietta, francesca; baldari, benedetta; besi, livia; torsello, alessandra; di gioia, cira rosaria tiziana; sessa, francesco; aromatario, mariarosaria; cipolloni, luigi title: mistrial or misdiagnosis: the importance of autopsy and histopathological examination in cases of sudden infant bronchiolitis-related death date: - - journal: front pediatr doi: . /fped. . sha: doc_id: cord_uid: mue eiv pediatrics, among all the branches of medicine, is a sector not particularly affected by a high number of claims. nevertheless, the economic value of the compensation is significantly high, for example, in cases of children who suffered multiple disabilities following perinatal lesions with a long life expectancy. in italy, most of the claims for compensation concern surgical pathologies and infections. among these latter, the dominant role is taken by respiratory tract infections. in this context, the purpose of this manuscript is to present a case series of infant deaths in different emergency-related facilities (ambulances, emergency rooms) denounced by relatives. following these complaints, the autopsy was performed, and subsequent histological examinations revealed the presence of typical and pathognomonic histological findings of acute viral bronchiolitis, whose morphological appearance is poorly reported in the literature. the analysis of these cases made it possible to highlight the following conclusions: the main problems in diagnosing sudden death causes, especially in childhood, are the rapidity of death and the scarce correlation between the preexistent diseases and of the cause of death itself. for all these reasons, the autopsy, either clinical or medicolegal, is mandatory in cases of sudden unexpected infant death to manage claim requests because only the histological examinations performed on samples collected during the autopsy can reveal the real cause of death. pediatrics, among the branches of medicine, is not particularly affected by a high number of claims. nevertheless, the economic value of compensation is significantly high, for example, in cases of children who suffered multiple disabilities following perinatal lesions with a long life expectancy. according to carroll and buddenbaum ( ) and moriani et al. ( ) , examining the data collected by an association of several american insurance companies (physician insurers association of america), it was found that only % of the cases resulted in compensation; among these, in cases where no damages had been paid, the average cost per the only defense was $ , , while it results in $ , for paid claims ( ) . the medical diagnoses, most commonly involved in civilian pediatric trials in the united states, were brain damage (average damages $ , ) and meningitis ($ , ) . respiratory problems in newborns account for $ , . in italy, data from the insurance company carige spa, in the period - , excluding neonatology, highlighted how the main pathologies for which legal action was referred to surgery (gastrointestinal and testicular) and infections (more respiratory ones). moreover, the data on litigation have also shown a different stratification of the number of requests for compensation, which were greater in the north and minors in central italy, mostly involving the public health system ( ) . according to the italian study performed during the - period, neonatology has also shown an overlapping geographical stratification, with the greatest interest for the public sector. the claims for damages following death, concerning the neonatal intensive care unit (nicu), mainly concern respiratory diseases ( . % of cases) ( , ) . both in the pediatric population in general, but especially in the neonatological one, the dominant role is taken by the respiratory tract infections. in this context, the purpose of these case series is to demonstrate how the identification of the correct cause of death in the sudden unexpected infant deaths (suids) allowed evaluating the absence of medical liability. particularly, the definition of gold standard methods in similar cases could be considered very important to avoid the compensation in unjustified claim requests. all procedures performed in the study were in accordance with the ethical standards of the institution and with the helsinki declaration and its later amendments or comparable ethical standards. written informed consent was obtained from the first-degree relatives. a -month-old male infant died during emergency medical services (ems) transport to the hospital. when parents had been asked for any modification in their child habits, a mild "rhinitis" for a few days was told. for this reason, they went to their trusted pediatrician days earlier, who suggested saline nasal rinses and a short turn check. the medical examiner documented no relevant external sign to explain death. therefore, the parents sued the pediatrician for both penal and civil liability. during the forensic autopsy, the macroscopic examination was unremarkable except for mild edema affecting both lungs. on the contrary, histological examination showed in both lungs a diffuse transmural inflammation in the bronchiolar wall. other tissue sections showed chronic inflammation, and bronchiolar wall fibrosis primarily restricted to bronchioles (figure ). an ambulance was called for a -month-old female infant, who lived in a nomad camp; her parents referred that suddenly she did not respond to external stimuli. relatives did not refer to any symptoms neither clinical signs in the previous days. during the resuscitation maneuvers in place, the infant died. thus, the prosecutor ordered the autopsy for alleged medical liability; her parents demanded the civil compensation to the local health insurance, thinking that during the ambulance transportation, there was medical responsibility. the macroscopic examination, both at the external corpse and internal organs, only showed severe pulmonary edema. the histology was characterized by lymphocytic infiltration of the bronchioles (figure ). an -month-old female infant was admitted to the emergency room of a pediatric hospital for severe cough and pharyngitis; she died after a few hours. symptoms onset occurred the day before hospitalization. she was a preterm infant ( . weeks, birth weight , g) who suffered from severe respiratory distress at birth (apgar score ′ = ) and needed a long period of hospitalization. after discharge, she showed neurodevelopmental impairment; moreover, a month before death, she suffered from many viral infective pathologies such as influenza and mononucleosis: all pathologies were successfully treated with standard pharmacological therapies. in this case, the judicial authority disposed of the forensic examination, suspecting medical liability to clarify penal and civil aspects: indeed, at the time of death, a claim for damages has been made to the hospital by the family of the patient. the autopsy showed congestion of tracheal and bronchial mucosa. at histological examination, focal edema and diffuse congestion of both lungs, acute emphysema, and peribronchial and intrabronchial wall leukocyte infiltrates were found; the same results involved nearby septal vessels (figure ). the method used in these cases, as in all cases of sudden death, consists of a rigorous and multidisciplinary methodological approach ( , ) : -anamnestic collection and clinical findings: the clinical symptomatology presented by the subject before his death or in close chronological concurrence, clinical history of the case, and previous medical records; -anatomical evidence: a macroscopic examination of all organs, their weight, consistency, and color at the autopsy, such as the appearance of fluids (blood, urine, vitreous humor). -histomorphological examination h&e of the organ samples to study any alteration due to pathological condition; -immunohistochemistry: to evaluate, in particular, the presence and the location of the main white blood cells via antibody anti-leukocyte common antigen (cd ). the adherence to this diagnostic procedure not only allows you to check and evaluate a larger quantity of data but allows a complete evaluation on all fronts, from the study of which can confirm the suspicion and/or an unexpected result but crucial for investigations. in the discussed cases, following both the autoptic and especially the microscopic examination, the cause of death was identified in all investigated cases: a rapidly progressive acute bronchiolitis was ascertained. these findings allowed exonerating doctors from any penal liability. the bronchiolitis was defined in , from a collaboration between the american academy of pediatrics (aap) and the european respiratory society (ers), as "a constellation of clinical symptoms and signs including a viral upper respiratory prodrome followed by increased respiratory effort and wheezing in children < years of age" ( ) . acute viral bronchiolitis (avb) is a lower respiratory tract infective disorder, typically affecting infants < years old ( % of cases). respiratory syncytial virus (rsv) is involved in up to % of cases, followed by rhinovirus (up to %); the remaining cases are related to coronavirus, adenovirus, influenza, and parainfluenza virus, and human metapneumovirus. coinfections are common ( ) . however, the seasonality of bronchiolitis, generally more frequently found during the winter months, coincides with the seasonal pattern of rsv diffusion ( ) . the infection starts in the upper respiratory tract, spreading to the lower airways in a few days. the bronchiolar damage is determined by the direct action of the virus on the epithelium of the same tract; alternatively, it was indirectly immunemediated, and it was characterized by a peribronchial infiltration of white blood cell types, mainly mononuclear cells, with edema of the submucosa and adventitia ( ) . the pathophysiological continuation is caused by a mixture of edema, increased production of mucus, and progressive damage of the epithelium even to necrosis, which determines obstruction of the airflow, entrapment of distal air, atelectasis, and alteration of the ventilation/perfusion. the results are hypoxemia and increased respiratory work, which in turn worsens hypoxemia ( ) . the most important extrapulmonary symptoms involve the brain (apnea, epileptic status) and heart (ventricular tachycardia, ventricular fibrillation, cardiogenic shock, complete heart block, and pericardial tamponade) and are common in children with severe infections ( ) . the most dreadful complications of bronchiolitis are central apnea, a respiratory pause with bradycardia, cyanosis, pallor, and hypotonia that often requires hospitalization ( ) . bronchiolitis represents a disease with high morbidity but low mortality. death from respiratory failure in bronchiolitis is rare and varies from deaths from . : , in the uk to . : , in the us, for children under months, with a relationship that goes hand in hand, reducing itself to the improvement of good intensive practices ( , ( ) ( ) ( ) . in all these cases, in the absence of the clinical-anamnestic data that can guide the clinical diagnosis, the external examination data and the autopsy macroscopic data could point toward a diagnosis of suid. in the case of Özdemir et al. ( ) , in fact, on the totality of the cases of malpractice claims, . % of the children had died and . % were subjected to autopsy. in these cases, the causes of death reported before and after the autopsies were different in %, and the medical staff was found to be responsible for . % of the claims. therefore, the determination of the exact cause of death assumes fundamental importance to ascertain the causal link of any conduct of both health facilities and individual professionals in determining death ( ) ( ) ( ) . this allows not only a measurement of the quality of care provided by promoting public trust for the health system but also as a measure of clinical governance; moreover, it is possible to better manage the medicolegal disputes as a guarantee of ascertaining the truth. indeed, in italy, the data on the frequency of adverse events (aes), preventable adverse events (paes), and negligent adverse events (naes) are available; nevertheless, data about malpractice claims are not available both under the penal and civil points of view. furthermore, the epidemiological purposes cannot be forgotten, considering that it is the only reliable method of data collection. indeed, a complete methodological approach, integrating clinical data, autopsy, and histological findings could be considered the best way to solve similar cases. in fact, in the reported case studies, histopathologic diagnostics identified pathognomonic signs of acute bronchiolitis characterized by edema, congestion, leukocytic infiltration in the bronchiolar wall, leukocytes in the peribronchial interstitial pulmonary space, allowing the identification of the exact cause of death. therefore, these pieces of evidence have allowed excluding the medical responsibility in the reported cases, demonstrating that there are events not related to the supplied health care. the analysis of the presented cases shows that the autopsy is mandatory in suid occurrence, in which the absence of anamnestic data and/or acute clinical signs does not allow to identify the cause of death. hypothesizing medical negligence in each case, the autopsy was performed following the judicial appointment after the relative's complaint. the subsequent histological examinations revealed the presence of typical and pathognomonic histological findings of avb, whose morphological appearance is poorly described in the literature. only the postmortem examinations have allowed excluding medical liability and therefore the compensation for damage. in light of these findings, it could be considered essential an accurate evaluation of similar cases, collecting all data to avoid compensation in unjustified claims made against the hospital. in this way, it is possible to contain the hospital costs related to this kind of accident. for all these reasons, the autopsy combined with the subsequent examination represents a gold standard method to identify the absence of the hospital's responsibility in suid cases. all datasets generated for this study are included in the article/supplementary material. written informed consent was obtained from the first-degree relatives for the publication of this case report. gb, fm, ma, and lc contributed to the conception of the study and wrote the manuscript. fs, bb, lb, at, and cd contributed significantly to literature review and manuscript preparation. gb, fm, fs, bb, lb, at, cd, ma, and lc helped perform the analysis with constructive discussions and approved the final version. malpractice claims involving pediatricians: epidemiology and etiology suicide by sharp instruments: a case of harakiri medical diagnoses commonly associated with pediatric malpractice lawsuits in the united states pediatric claims in italy during a -years survey neonatal malpractice claims in italy: how big is the problem and which are the causes? post-mortem magnetic resonance foetal imaging: a study of morphological correlation with conventional autopsy and histopathological findings a multidisciplinary approach is mandatory to solve complex crimes: a case report italian mafia: a focus on apulia mafia with a literature review acute bronchiolitis in infants, a review prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis effect of prematurity on respiratory syncytial virus hospital resource use and outcomes extrapulmonary manifestations of severe respiratory syncytial virus infection -a systematic review frequency of apnea and respiratory viruses in infants with bronchiolitis clinical predictors of radiographic abnormalities among infants with bronchiolitis in a paediatric emergency department variation in the management of infants hospitalized for bronchiolitis persists after the american academy of pediatrics bronchiolitis guidelines risk factors for bronchiolitis-associated deaths among infants in the united states medical malpractice claims involving children medical records quality as prevention tool for healthcare-associated infections (hais) related litigation: a case series personalised healthcare: the dima clinical model healthcare-associated infections: not only a clinical burden, but a forensic point of view key: cord- - qn authors: chen, zhi-min; fu, jun-fen; shu, qiang; chen, ying-hu; hua, chun-zhen; li, fu-bang; lin, ru; tang, lan-fang; wang, tian-lin; wang, wei; wang, ying-shuo; xu, wei-ze; yang, zi-hao; ye, sheng; yuan, tian-ming; zhang, chen-mei; zhang, yuan-yuan title: diagnosis and treatment recommendations for pediatric respiratory infection caused by the novel coronavirus date: - - journal: world j pediatr doi: . /s - - - sha: doc_id: cord_uid: qn since december , an epidemic caused by novel coronavirus ( -ncov) infection has occurred unexpectedly in china. as of pm, january , more than pediatric cases have been reported in china. of these cases, ten patients were identified in zhejiang province, with an age of onset ranging from days to years. following the latest national recommendations for diagnosis and treatment of pneumonia caused by -ncov (the th edition) and current status of clinical practice in zhejiang province, recommendations for the diagnosis and treatment of respiratory infection caused by -ncov for children were drafted by the national clinical research center for child health, the national children’s regional medical center, children’s hospital, zhejiang university school of medicine to further standardize the protocol for diagnosis and treatment of respiratory infection in children caused by -ncov. since december , an epidemic caused by novel coronavirus ( -ncov) infection has occurred unexpectedly in china. at present, -ncov infection has been a legal class b infectious disease of the law of the people's republic of china on the prevention and treatment of infectious diseases, and managed as a class a infectious disease for infection prevention and control practices. as of pm, january, more than pediatric cases have been reported in china. of these cases, ten were identified in zhejiang province, with an age of onset ranging from days to years. following latest national recommendations for diagnosis and treatment of respiratory infections caused by -ncov (the th edition) and current status of clinical practice in zhejiang province, recommendations for the diagnosis and treatment of respiratory infection caused by -ncov for children were drafted out by the national clinical research center for child health, national children's regional medical center, children's hospital, zhejiang university school of medicine to further standardize the protocol of respiratory infection in children caused by -ncov. etiology -ncov is a novel human coronavirus in addition to coronavirus e, nl , oc , hku , middle east respiratory syndrome-related coronavirus (mersr-cov) and severe acute respiratory syndrome-related coronavirus (sars-cov). -ncov is enveloped single-stranded plus stranded rna virus with a diameter of - nm, spherical or elliptical in shape and pleomorphic [ ] . it has been reported that the consistency of whole genome-wide nucleotide sequences of -ncov with sars-like coronavirus in bats (bat-sl-covzc ) ranges from . [ ] to % [ ] . the nucleotide sequence of spines protein on the envelope of the virus is also highly consistent with that of bat-sl-covzc ( %) and sars-cov ( %). the physicochemical property of -ncov has not been clarified clearly yet. it is thought that -ncov is sensitive to ultraviolet radiation and heating. for example, according to researches on sars-cov and mers-cov, the virus can be inactivated by heating at °c for minutes and by using lipid solvents such as % ethanol, chlorinecontaining disinfectant, peroxyacetic acid and chloroform, but not by chlorhexidine, according to the researches on sars-cov and mers-cov. the main sources of the infection are patients infected by -ncov with or without clinical symptoms [ ] . in addition, patients in the incubation period may also have potency to transmit the virus based on the case evidence. the novel virus is spread through respiratory droplets when patients cough, talk loudly or sneeze. close contact is also a source of transmission (e.g., contact with the mouth, nose or eye conjunctiva through contaminated hand). whether transmission can occur through mother-infant vertically or breast milk has not been established yet. there are general susceptibilities in all groups, with the elderly and people with basic diseases more likely to become severe cases. children may have mild clinical symptoms after infection [ ] . the incubation period of -ncov infections ranges from to days, though most often rangs from to days [ ] . at the onset of the disease, infected children mainly present with fever, fatigue and cough, which may be accompanied by nasal congestion, runny nose, expectoration, diarrhea, headache, etc. most of the children had low to moderate fever, even no fever. dyspnea, cyanosis and other symptoms can occur as the condition progresses usually after week of the disease, accompanied by systemic toxic symptoms, such as malaise or restlessness, poor feeding, bad appetite and less activity. the condition of some children may progress rapidly and may develop into respiratory failure that cannot be corrected by conventional oxygen (nasal catheter, mask) within - days. in these severe cases, even septic shock, metabolic acidosis and irreversible bleeding and coagulation dysfunction may occur. rapid respiration rate and moist rales on auscultation usually indicate pneumonia. the criteria for rapid respiratory rate are as follows: ≥ times/min for less than months old; ≥ times/min for - months old, ≥ times/min for - years old, ≥ times/min for > years old (after ruling out the effects of fever and crying). with the aggravation of the disease, respiratory distress, nasal flaring, suprasternal, intercostal and subcostal retractions, grunting and cyanosis may occur. maternal hypoxemia caused by severe infection can lead to intrauterine asphyxia, premature delivery and other risks. neonates, especially preterm infants, who are more likely to present with insidious and non-specific symptoms need more close observation. according to the current conditions of the reported cases, the children mainly belong to family cluster cases. most of them have good prognosis, and in mild cases recover - weeks after disease onset. no deaths in children have been reported up to now. routine blood test white blood cell count is usually normal or reduced, with decreased lymphocyte count; progressive lymphocytopenia in severe cases. c-reactive protein (crp) normal or increased. procalcitonin (pct) normal in most cases. the level of pct > . ng/ml indicates the co-infection with bacteria. others elevation of liver enzymes, muscle enzymes and myoglobin, and increased level of d-dimer might be seen in severe cases. nucleic acid testing is the main method of laboratory diagnosis. -ncov nucleic acid can be detected by rt-pcr or by viral gene sequencing of throat swabs, sputum, stool or blood samples. other methods -ncov particles can be isolated from human respiratory epithelial cells through virus culture [ , ] , but this experiment cannot be carried out in general laboratories. virus antigen or serological antibody testing kits are not available at present. chest x-ray examination in the early stage of pneumonia cases, chest images show multiple small patchy shadows and interstitial changes [ ] , remarkable in the lung periphery [ ] . severe cases can further develop to bilateral multiple ground-glass opacity, infiltrating shadows, and pulmonary consolidation, with infrequent pleural effusion. chest ct scan pulmonary lesions are shown more clearly by ct, including ground-glass opacity and segmental consolidation in bilateral lungs, especially in the lung periphery. in children with severe infection, multiple lobar lesions may be present in both lungs. patients should be suspected of -ncov infection who if they meet any one of the criteria in the epidemiological history and any two of the criteria in clinical manifestations. city and neighboring areas, or other areas with persistent local transmission within days prior to disease onset. . children with a history of contacting patients with fever or respiratory symptoms who have a travel or residence history in wuhan city and neighboring areas, or in other areas with persistent local transmission within days prior to disease onset. . children with a history of contacting confirmed or suspected cases infected with -ncov within days prior to disease onset. . children who are related with a cluster outbreak: in addition to this patient, there are other patients with fever or respiratory symptoms, including suspected or confirmed cases infected with -ncov. . newborns delivered by suspected or confirmed -ncov-infected mothers. . fever, fatigue, dry cough; some pediatric patients may have no fever. . patients with the above-mentioned chest imaging findings (refer to the section of imaging features); . in the early phase of the disease, white blood cell counts are normal or decreased, or with decreased lymphocyte count. suspected cases who meet any one of the following criteria: . throat swab, sputum, stool, or blood samples tested positive for -ncov nucleic acid using rt-pcr; . genetic sequencing of throat swab, sputum, stool, or blood samples being highly homologous with the known -ncov; . -ncov granules being isolated by culture from throat swab, sputum, stool, or blood samples. it is necessary to strengthen the awareness of the early identification of the disease. in clinic, screening was conducted mainly according to the epidemiological history and fever or respiratory symptoms, and pathogen examination should be carried out on time. furthermore, effective isolation measures and appropriate treatment need to be provided promptly. even if the common respiratory pathogen tests are positive, children who have a history of close contact with -ncov-infected cases also are recommended for timely -ncov pathogen testing. this type of patient includes those with asymptomatic infection, upper respiratory infection (uri) and mild pneumonia. symptoms include fever, cough, sore throat, fatigue, headache or myalgia. some patients show pneumonia signs on chest imaging. these patients do not have any of the severe or critical symptoms and complications described below. disease progresses to meet any of the following conditions [ ]: . significantly increased respiration rate: rr ≥ /min (≤ year), rr ≥ /min (> year). . hypoxia: spo ≤ % (< % in premature infants) or nasal flaring, suprasternal, intercostal and subcostal retractions, grunting and cyanosis, apnea, etc. . b l o o d g a s a n a ly s i s : p a o < m m h g , paco > mmhg. . consciousness disorders: restlessness, lethargy, coma, convulsion, etc. . poor feeding, bad appetite, and even dehydration. . other manifestations: coagulation disorders (prolonged prothrombin time and elevated level of d-dimer), myocardial damage (increased level of myocardial enzyme, electrocardiogram st-t changes, cardiomegaly and cardiac insufficiency in severe cases), gastrointestinal dysfunction, raised level of liver enzyme and rhabdomyolysis. disease progresses rapidly along with organ failure with any of the following conditions: . respiratory failure which requires mechanical ventilation patients present with acute respiratory distress syndrome (ards) and are featured by refractory hypoxemia, which cannot be alleviated by conventional oxygen therapy, such as nasal catheter or mask oxygen supplement. . septic shock in addition to severe pulmonary infection, -ncov can cause damage and dysfunction of other organs. when dysfunction of extrapulmonary system such as circulation, blood and digestive system occurs, the possibility of sepsis and septic shock should be considered and the mortality rate increases significantly. . accompanied by other organ failure that needs icu monitoring and treatment. viruses such as sars virus, influenza virus, parainfluenza virus, adenovirus, respiratory syncytial virus and metapneumovirus can cause viral respiratory infections. patients commonly present with fever, cough and dyspnea, and interstitial pneumonia in some cases. most of the cases have normal or decreased white blood cell counts, while severely infected children show reduced level of lymphocyte count. similar to -ncov, all of these viruses can transmit through respiratory tract or direct contact, which is characterized by clustering onset. epidemiological exposure history plays an important role in differential diagnosis, which is mainly confirmed by laboratory examinations. patients with bacterial pneumonia mostly display high fever and toxic appearance. in the early stage of the disease, cough is not obvious but moist rale can be heard. chest image may show small patchy shadows, or segmental or even lobar consolidation. blood routine examination shows increased white blood cell count with neutrophil predominating, as well as elevated crp. noninvasive pneumonia is usually accompanied by obvious cough. antibiotics are effective. blood or deep sputum culture is helpful for diagnosis of bacterial pneumonia. mycoplasmal pneumonia may occur in any season and in schools and child-care institutions with small epidemic. patients are predominantly school-age children, but the number of younger children is increasing. they usually start with high fever and cough. chest images may reveal manifestations including reticular shadows and small patchy or large consolidation. blood routine examination shows that the white blood cell count is normal or increased and crp is slightly elevated. nucleic acid detection of airway secretion and serum mycoplasma-specific igm determination are helpful for differential diagnosis. it should be noted that patients with -ncov infection can have co-infection or superimposed infection with other viruses or bacteria simultaneously. the four principles of "early identification", "early isolation", "early diagnosis", and "early treatment" should be emphasized. medical isolation is supposed to be carried out once the suspected cases are identified. the confirmed cases should be admitted to the designated hospitals. avoid using broad-spectrum antibiotics and corticosteroids. antibiotics, corticosteroids, bronchoalveolar lavage, mechanical ventilation, and other more invasive intervention, such as blood purification and extracorporeal membrane oxygenation (emco) should be applied cautiously, based on cost-benefit evaluation. monitoring patient's conditions closely and adjusting the therapeutic protocols timely through multidisciplinary cooperation are of great significance. suspected case should be isolated in a single room, while confirmed cases can be arranged in the same room. during the course of treatment, pay close attention to the changes in children's conditions, regularly monitor vital signs, spo , etc., and identify the severe and critical cases as early as possible. the general strategies include bed rest and supportive treatments; ensuring sufficient calorie and water intake; maintaining water electrolyte balance and homeostasis, and strengthening psychotherapy for elder children when necessary. there are no effective antiviral drugs for children at present. interferon-α b nebulization can be applied, and the recommended usage is as follows: irrational use of antibiotics should be avoided. bacteriological monitoring should be strengthened. if there is evidence of secondary bacterial infection, appropriate antibiotics should be used timely. corticosteroids should be avoided in common type of infection. however, it can be considered in the following situations: intravenous methylprednisolone ( - mg/kg/day) is recommended for - days, but not for long-term use [ , , [ ] [ ] [ ] . intravenous immunoglobulin can be used in severe cases when indicated, but its efficacy needs further evaluation. the recommended dose is . g/kg/day for days, or mg/kg/ day for days [ , , , ] . bal is not suitable for most patients, and there is an increased risk of cross-infection. the indications should be strictly controlled. bal can be considered if patients have obvious symptoms of airway obstruction, refractory massive atelectasis indicated by imaging, a significant increase in peak pressure during ventilator therapy, decrease of tidal volume, or poor oxygenation which cannot be reversed by conservative treatments. in case of circulation dysfunction, vasoactive drugs should be used to improve microcirculation on the basis of adequate liquid support [ ] . patients with acute renal injury should be given continuous blood purification on time. in the meantime, paying attention to the brain function monitoring if neccessary. if intracranial hypertension and convulsion occurs in children, it is necessary to reduce the intracranial pressure and control convulsion timely [ , , ] . in the case of respiratory distress that occurs despite nasal catheter or mask oxygenation, heated humidified high-flow nasal cannula (hhhfnc), non-invasive ventilation such as continuous positive airway pressure (cpap), or non-invasive high-frequency ventilation can be used. if improvement is not possible, mechanical ventilation with endotracheal intubation and a protective lung ventilation strategy should be adopted. continuous blood purification should be considered in cases of multiple organ failure (especially acute kidney injury), or capacity overload and life-threatening imbalance of water, electrolyte, and acid-base. the therapeutic model may include continuous veno-venous hemofiltration (cvvh), continuous veno-venous hemodiafiltration (cvvhdf), or heterozygosis. if combined with liver failure, plasma exchange is feasible. coronavirus investigating, and research team. a novel coronavirus from patients with pneumonia in china a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster national recommendations for diagnosis and treatment of pneumonia caused by -ncov (the th edition). national health commission and national administrative office of chinese tradition medicine / ed b b bd e /files / a a d c bf .pdf. access clinical features of patients infected with novel coronavirus in wuhan another decade, another coronavirus diangosis and treatment guideline of community acquired pneumonia in children role of lopinavir/ritonavir in the treatment of sars: initial virological and clinical findings treatment of middle east respiratory syndrome with a combination of lopinavir-ritonavir and interferon-β b (miracle trial): study protocol for a randomized controlled trial expert consensus on the diagnosis and treatment of viral pneumonia in children corticosteroid therapy for critically ill patients with middle east respiratory syndrome clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected the editorial board, chinese journal of pediatrics. diagnosis and treatment guideline of community acquired pneumonia in children ( the first part) guidelines for the diagnosis and treatment of adenovirus pneumonia in children ( edition) pediatric branch, chinese medical association thoracic vascular anesthesiology society, extracorporeal life support committee, pediatric surgery branch, chinese medical association. consensus of extracorporeal membrane oxygenation support for acute fulminant myocarditis in children publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations ecmo therapy should be considered when mechanical ventilation, blood purification, and other means are ineffective, and cardiopulmonary failure occurs which is difficult to correct. . ecmo indications [ ] . . pao /fio < mmhg or oxygen index (oi) > for more than h, or severe respiratory acidosis (ph < . ). . high mean airway pressure (map) during mechanical ventilation, or severe air leakage and other severe complications. . circulation function cannot be improved with conventional treatment, or large amounts of vasoactive drugs are required to maintain basal blood pressure, or lactic acid levels continuously rise.contraindication [ ] ecmo should be contraindicated or used with caution if the duration of mechanical ventilation is more than weeks, or if serious brain failure or bleeding tendency occurs. children with body temperature back to normal for at least days, significant improvement in respiratory symptoms,and completion of two consecutive negative tests of respiratory pathogenic nucleic acid (sampling interval of at least day) can be discharged. if necessary, home isolation for days is suggested after discharge. special vehicles should be used to transfer infected patients. strict protection for staff of transportation and disinfection for the vehicle are of vital importance. enforcing close to the lines of notification of the project for transportation of pneumonia cases infected with novel coronavirus (trial version) published by the national health commission of people's republic of china is required. medical personnel are supposed to have good personal protection, hand hygiene, ward management, environmental ventilation, object surface cleaning and disinfection, medical waste management and other hospital infection control work, based on the standard prevention protocol, to minimize nosocomial infection. infectious diseases department, and isolation ward: equipped with medical overalls, caps, disposable isolation clothing, surgical masks, and goggles or face shield for daily medical activities and ward rounds; fit with goggles or face shield is stressed when collecting respiratory samples; using latex gloves in addition when contacting with blood, body fluid, secreta, or excreta; wearing surgical masks, goggles or face shield, latex gloves, medical protective clothing (disposable impermeable isolation clothing can be added), and respiratory hood when necessary, to prevent aerosol or splash during operations of endotracheal intubation, bronchoscopy, airway nursing, and sputum suction. . medical personnel should wear and remove personal protective equipment in strict accordance with the onoff procedure, rather than leaving ward with the contaminated equipment, so as to avoid cross-contamination in different zones. . patients and their accompanying family members are required to wear surgical masks. . channels for medical personnel and patients in the isolation ward should be separated and equipped with medical personnel channel buffer zone. . wearing gloves cannot replace hand hygiene. . perform strict visiting regulations for pediatric patients admitted in isolation, and ask visitors to have personal protection according to relevant regulations when necessary. . optimize medical procedures to reduce the frequency of medical personnel's contact with patients. . attention should be paid to the strict elimination and disinfection of the patient's secretions and excretions.author contributions all authors drafted part of the manuscript and approved the final version.funding none. ethical approval none. all authors declared no conflict of interest related to this paper. key: cord- - w x g authors: wu, joseph t.; leung, kathy; bushman, mary; kishore, nishant; niehus, rene; de salazar, pablo m.; cowling, benjamin j.; lipsitch, marc; leung, gabriel m. title: estimating clinical severity of covid- from the transmission dynamics in wuhan, china date: - - journal: nat med doi: . /s - - - sha: doc_id: cord_uid: w x g as of february there were , confirmed cases and , deaths from covid- in mainland china. of these, , cases and , deaths occurred in the epicenter, wuhan. a key public health priority during the emergence of a novel pathogen is estimating clinical severity, which requires properly adjusting for the case ascertainment rate and the delay between symptoms onset and death. using public and published information, we estimate that the overall symptomatic case fatality risk (the probability of dying after developing symptoms) of covid- in wuhan was . % ( . – . %), which is substantially lower than both the corresponding crude or naïve confirmed case fatality risk ( , / , = . %) and the approximator( ) of deaths/deaths + recoveries ( , / , + , = %) as of february . compared to those aged – years, those aged below and above years were . ( . – . ) and . ( . – . ) times more likely to die after developing symptoms. the risk of symptomatic infection increased with age (for example, at ~ % per year among adults aged – years). of case fatality risk warrants these interventions, which seriously disrupt social and economic stability. for a completely novel pathogen, especially one with a high (say, > ) basic reproductive number (the expected number of secondary cases generated by a primary case in a completely susceptible population) relative to other recently emergent and seasonal directly transmissible respiratory pathogens , assuming homogeneous mixing and mass action dynamics, the majority of the population will be infected eventually unless drastic public health interventions are applied over prolonged periods and/or vaccines become available sufficiently quickly. even under more realistic assumptions about mixing informed by observed clustering of infections within households and the increasingly apparent role of superspreading events (for example, the diamond princess cruise ship, chinese prisons and the church in daegu, south korea) , , at least one-quarter to onehalf of the population will very likely become infected, absent drastic control measures or a vaccine. therefore, the number of severe outcomes or deaths in the population is most strongly dependent on how ill an infected person is likely to become, and this question should be the focus of attention. we therefore extended our previously published transmission dynamics model , updated with real-time input data and enriched with additional new data sources, to infer a preliminary set of clinical severity estimates that could guide clinical and public health decision-making as the epidemic continues to spread globally. estimation of true case numbers-necessary to determine the severity per case-is challenging in the setting of an overwhelmed healthcare system that cannot ascertain cases effectively. therefore, as in our prior work , our approach has been to use a range of publicly available and recently published data sources (numbered to below) to build a picture of the full number of cases and deaths by age group. briefly, because the healthcare structure has been overwhelmed in wuhan and milder cases were unlikely to have been tested, we used the prevalence of infection in travelers (both on commercial flights before january and on charter flights from january to february) to estimate the true prevalence of infection in wuhan; we also used the wuhan case numbers from only the first cases to estimate the growth rate of the epidemic (assuming that the ascertainment proportion was constant between december and january ) (fig. ) . specifically, we inferred the epidemiologic parameters listed in extended data fig. by fitting an age-structured transmission model to the following data: . the epidemic curve of confirmed cases of covid- in wu- han with no epidemiologic links to huanan seafood wholesale market (which was postulated to be the index zoonotic source of the covid- epidemic) between december and january ( fig. table ). . the time between onset and death or the time between admission and death for death cases of covid- in wuhan [ ] [ ] [ ] (supplementary table ). . the time between the onset dates (that is, serial intervals) of infector-infectee pairs (supplementary table ). the clinical severity of infectious diseases is typically measured in terms of infection fatality risk (ifr), symptomatic case fatality risk (scfr) and hospitalization fatality risk (hfr). the case definitions underlying these severity measures are as follows: . ifr defines a case as a person who would, if tested, be counted as infected and rendered (at least temporarily) immune, as usually demonstrated by seroconversion or other immune response . such cases may or may not be symptomatic. . scfr defines a case as someone who is infected and shows certain symptoms. . hfr defines a case as someone who is infected and hospitalized. it is typically assumed in such estimates that the hospitalization is for treatment rather than isolation purposes. figure summarizes our estimates of age-specific scfrs and susceptibility to symptomatic infection. both parameters increase substantially with age. if the probability of developing symptoms after infection, p sym , is . , the scfr values are . % ( . - . %), . % ( . - . %) and . % ( . - . %) for those aged < years, - years and > years, respectively. the overall scfr is . % ( . - . %). compared to those aged - years, those aged < years and > years are . ( . - . ) and . ( . - . ) times more susceptible to symptomatic infection. our estimates of scfrs would be lower if p sym were higher than the baseline value of . ; for example, the overall scfr is . % ( . - . %) and . % ( . - . %) if p sym is . and . , respectively. our estimates of age-specific susceptibility are not sensitive to p sym . figure summarizes our estimates of the key epidemiologic parameters of covid- in wuhan. in the baseline scenario i.e., cases due to human-to-human (h h) transmission) between december and january (blue), the daily number of cases exported from wuhan to cities outside mainland china via air travel between december and january (orange) and the proportion of expatriates on charter flights between january and february who were laboratory-confirmed to be infected (green). the numbers of passengers and confirmed cases who returned to their countries from wuhan on chartered flights are provided in supplementary table . bars indicate the % confidence intervals (cis) of the proportion. b, the daily number of deaths in wuhan reported between december and february . (p sym = . ), the basic reproductive number is . ( . - . ). the mean serial interval is . ( . - . ) days, with a standard deviation of . ( . - . ) days. the mean time from onset to death is ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days, with a standard deviation of ( - ) days. the epidemic doubling time (the time it takes for daily incidence to double) was . ( . - . ) days before wuhan was quarantined and public health interventions implemented within wuhan reduced transmissibility by % ( - %). we estimate that only . % ( . - . %) of symptomatic cases that occurred between december and january were ascertained. figure suggests that our estimates of the basic reproductive number, mean generation time and intervention effectiveness would be slightly lower if p sym were higher than the baseline value of . , whereas our estimates of the other parameters are largely insensitive to p sym . there is a clear and considerable age dependency in symptomatic infection (susceptibility) and outcome (fatality) risks, by multiple folds in each case. given that we have parameterized the model using death rates inferred from projected case numbers (from traveler data) and observed death numbers in wuhan, the precise fatality risk estimates may not be generalizable to those outside the original epicenter, especially during subsequent phases of the epidemic. the experience gained from managing those initial patients and the increasing availability of newer, and potentially better, treatment modalities to more patients would presumably lead to fewer deaths, all else being equal. public health control measures widely imposed in china since the wuhan alert have also kept case numbers down elsewhere, so that their health systems are not nearly as overwhelmed beyond surge capacity, thus again perhaps leading to better outcomes , . indeed, so far, the death-to-case ratio in wuhan has been consistently much higher than that among all the other mainland chinese cities (extended data fig. ). given the intensive efforts of case finding and the sharp drop in community transmission of covid- in chinese cities outside hubei over the past few weeks, the ascertainment rates in these cities were probably very high. as such, we postulate that confirmed case fatality risk in these cities should be in some ways comparable to our scfr estimates for wuhan, which attempt to account for under-ascertainment of cases in wuhan. nonetheless, crude case fatality risks estimated from cities outside wuhan should be, and are, lower than our scfr estimates for wuhan, because the former do not account for the delay between onset and death (thus being artefactually lower) and because healthcare outside hubei is less overwhelmed (thus allowing a truly lower cfr). indeed, as of february , the crude case fatality risk in areas outside hubei was . %, which is ~ - % lower than our scfr estimates of . - . % for wuhan . considering the risk estimates in context, extended data fig. compares infection, case and hospitalization fatality risks for pandemic influenza in and , sars and mers. sars causes moderate to severe disease requiring hospitalization, so the infection fatality risk and case fatality risk are essentially the same as the hospitalization fatality risk. the hospitalization fatality risk for mers is well documented, although the shape and depth of the clinical iceberg remains less well defined. in contrast, because ( ) the majority of covid- infections do not cause severe disease and ( ) hospitals in wuhan have been overwhelmed, presumably having led to prioritized admission of more serious cases, the scfr will be substantially lower than the hfr. however, despite a lower scfr, covid- is likely to infect many more (given emerging evidence of presymptomatic transmission , and growing evidence of extensive community spread in numerous countries ), thus ultimately causing many more deaths than sars and mers. compared with the and influenza pandemics, our estimates are intermediate but substantially higher than , which was generally regarded as a low-severity pandemic. we find that scfr is highest in the oldest age group. unlike any previously reported pandemic or seasonal influenza, we find that risk of symptomatic infection also increases with age, although this may be in part due to preferential ascertainment of older and thus more severe cases. one largely unknown factor at present is the number of asymptomatic, undiagnosed infections. these do not enter our estimates of scfr, but if such asymptomatic or clinically very mild cases existed and were not detected, the infection fatality risk would be lower than scfr. further clarifying this requires new data sources that are not yet available, specifically including agestratified serologic studies. our inferences were based on a variety of sources, and have a number of caveats that are highlighted below, but considering the totality of the findings they nevertheless indicate that covid- transmission is difficult to control. with a basic reproductive number of around two, we might expect at least half of the population to be infected, even with aggressive use of community mitigation measures. perhaps the most important target of mitigation measures would be to 'flatten out' the epidemic curve, reducing the peak demand on healthcare services and buying time for better treatment pathways to be developed. in due course, but almost certainly after the first global wave of infections, vaccines may also be available to protect against infection or severe disease. although our estimates of scfr are concerning, these could be reduced if effective antivirals were identified and widely adopted for the treatment of severe cases. timely data from clinical trials of remdesivir, lopinavir/ritonavir and other potential chemotherapies, as well as supportive care modalities, would be extremely informative. several important caveats are worth mentioning, as follows. first, and most importantly, our modeled estimates have necessarily relied on numerous strong assumptions, given the paucity of definitive data elements such as serosurveys, serial viral shedding studies, robust ascertainment of sufficient transmission chains and incomplete testing of travelers and returnees from wuhan, all of which need to be underpinned by systematic unbiased sampling of the underlying population and by important age and other sub-groups. our estimates of scfr are inevitably affected by under-ascertainment of cases and deaths of covid- . on the one hand, overstretched and overwhelmed healthcare surge capacity in wuhan could result in scfrs that are higher than they would be in a less stressed healthcare setting, as presumably the sicker patients would have been prioritized for admission while leaving the milder cases untested and thus unconfirmed. our prevalence estimates relying on travelers are based on those well enough to travel, so may slightly underestimate prevalence in wuhan by not including those who are already in a serious condition and perhaps hospitalized. we have accounted for the possibility that travelers may underestimate the prevalence of infection in wuhan by using our best estimate, from a separate analysis, of the probability of detection for international travelers ( % ( - %)) . on the other hand, the numerator of the number of deaths could also have been undercounted, although much less likely compared to enumerating the denominator, for the same surge capacity reason or due to imperfect test sensitivity, especially during the first month of the outbreak . if deaths in wuhan were under-ascertained, this would bias our severity estimates downward. another caveat concerns one of our key inputs-the infection prevalence among returnees airlifted out of wuhan on charter flights. their point prevalence might well be lower than that among local residents, because of a generally more advantaged socioeconomic background, and the sensitivity for detecting infected individuals among them might not be %, as assumed. as such, this would be a lower bound of the cross-sectional disease prevalence. if this were the case, then we would have overestimated the reduction in transmissibility conferred by public health interventions in wuhan and overestimated the severity. based on only publicly available data, there is necessarily substantial uncertainty in our estimates of the effectiveness of intra-wuhan public health interventions in reducing transmissibility. calculating the instantaneous reproductive number from a set of line lists that are updated daily would be the most reliable method for detecting changes in transmissibility associated with interventions. there has been refinement of case definitions at both national and provincial levels, such as excluding rt-pcr-test-positive asymptomatics (perhaps, in fact, very mildly symptomatics) from being labeled an officially 'confirmed' case or including test-naïve clinically diagnosed cases with clear epidemiologic links as 'confirmed' . although these should not affect our estimation given our data sources from the earlier phase of the epidemic, such changes in the reporting criteria may influence the interpretation of future data. finally, given that wuhan is no longer the only (albeit the first) location with sustained local spread, it would be important to assess and take into account the experience from elsewhere, both domestically in mainland china and overseas. these secondary epicenters, having learned from the early phase of the wuhan epidemic, might have had a systematically different epidemiology and response that could impact the parameters estimated here - . any methods, additional references, nature research reporting summaries, source data, extended data, supplementary information, acknowledgements, peer review information; details of author contributions and competing interests; and statements of data and estimates of basic reproductive number, mean serial interval, initial doubling time, intervention effectiveness, ascertainment rate and the mean time from onset to death, assuming p sym is . (red), . (green) and . (blue). the markers show the posterior means and the bars show % cris. we made the following assumptions in the model: . the population of wuhan is stratified into m = age groups: - , - , - , - , - , - , - , - and > . the relative susceptibility to infection of age group i is α i with respect to those aged - years (that is, α = ). the scfr of age group i is scfr i . . the probability density function (pdf) of the incubation period, f incubation , is gamma, with a mean of . days and standard deviation of . days . . the pdf of the time between onset and death, f onset-to-death , is gamma. we inferred the values of the mean and standard deviation of f onset-to-death (extended data fig. ). . the pdf of the generation time, f gt , is gamma and the same as that of the serial interval. we inferred the values of the mean and standard deviation of f gt (extended data fig. ). . the infection-symptomatic probability (p sym ; the proportion of infections that progress to develop symptoms) is the same for all age groups. we assume p sym = . in the baseline scenario and . and . in alternate scenarios. . the sensitivity of detecting symptomatic cases exported from mainland china is p det = % ( %- %) for cities that reported case importation between december and january (supplementary table . as such, we assume that the epidemic in wuhan was seeded by a single zoonotic event that generated z infections on november . we inferred the value of z (extended data fig. ). . public health interventions in wuhan reduced local transmissibility by φ . we inferred the value of φ (extended data fig. ). . given that the epidemic curve in wuhan was weeks ahead of that in other mainland chinese cities, we ignored the effect of case importation at wuhan. these assumptions were reflected in the following susceptible-infectedrecovered (sir) model for simulating the covid- epidemic in wuhan, where s i (t), and r i (t) are the number of susceptible and recovered individuals in age group i at time t, and i(t, τ) is the number of infected individuals in age group i at time t who were infected at time t − τ: the next-generation matrix for this sir model is where t g is the mean generation time. the basic reproductive number r is the largest eigenvalue of this matrix, which is βtg n p m i¼ α i n i i . the incidence rates of infection, onset and death for age group i at time t are calculated as follows: the number of new cases (onset) and the cumulative number of cases in age group i on day d are be the summation of the number of new cases, the cumulative number of cases and the cumulative number of deaths across all age groups up to time t, respectively. similarly, is the total number of infected individuals at time t. we inferred the parameters listed in extended data fig. assuming that the remaining parameters are fixed at the values shown in extended data fig. . we use θ to denote the set of parameters that are subject to inference (extended data fig. ). the likelihood function is a product of several components associated with the data in supplementary tables - : the formulation of each component was as follows: . the number of observed international case exportations on each day is assumed to be an imperfect poisson observation of the number of infected travelers leaving wuhan on that day who had or would develop symptoms. let x d be the observed number of such international case exportations on day d between december (d s , ) and january (d e , ) based on the data in supplementary table . we assume that travel behavior is not affected by disease and hence such case exportation occurs according to a non-homogeneous process with rate λ t ð Þ ¼ p sym lw;i t ð Þ n t ð Þ iðtÞ: i let p det be the probability that an infected traveler who has or will develop symptoms is detected in the destination country. the expected number of detected case exportations on day d is and hence x d ≈ poisson(λ d ). as such, the likelihood function associated with the data in supplementary table is where g is the posterior distribution of p det from a separate study that had a mean of % and a % credible interval of - % . . let y d be the observed number of confirmed cases of covid- in wuhan with no epidemiologic links to huanan seafood wholesale market (which is presumed to be the index zoonotic source of the covid- epidemic) on day d between december (d s , ) and january (d e, ) based on the data in supplementary table . these cases are assumed to be a poisson observation of the true number of newly symptomatic cases on that day, with ascertainment rate ε, which remained fixed over this time period. as such, assuming y d ≈ poisson(εω d ), the likelihood function for the data in supplementary table is table . the prevalence of infection and symptoms among travelers are assumed to reflect a representative binomial sample of the same quantities in the wuhan population on their day of departure. the likelihood function associated with the data in supplementary table is is the proportion of individuals who were infected on day d. . we assume that all deaths from covid- infection in wuhan were confirmed. let g be the cumulative number of death cases in wuhan as of february (time t). we assume g ≈ poisson(d(t)) and hence the likelihood function associated with this data is l θ ð Þ ¼ e �dðtÞ dðtÞ g g! . we assume that the age distribution of confirmed cases is a multinomial sampling process from the age distribution of true cases. let c i be the observed number of confirmed cases in age group i in wuhan based on the data in supplementary table . the likelihood function for the data in supplementary table is . we assume that the age distribution of confirmed deaths is a multinomial sampling process from the age distribution of true deaths. given that most covid- deaths were wuhan-related, we assume that the age distribution of confirmed deaths for wuhan is the same as that for mainland china . let b i be the observed number of death cases in age group i in wuhan based on the data in supplementary table . the likelihood function for the data in supplementary table is with regard to the data in supplementary table , let a be the set of death cases whose onset dates are known, and b the set comprising the remaining cases. let v j be the observed time delay between onset and death for the jth case in a and let v l j i be the observed time between hospital admission and death (which serves as a lower bound for the delay between onset and death) for the jth case in b. the likelihood function for the data in supplementary table is where f onset-death and f onset-death are the pdf and cumulative density function (cdf) of the time between onset and death (assumed to be gamma-distributed with mean μ d and standard deviation σ d ). . with regard to the data in supplementary table , let a be the set of infectorinfectee pairs for whom the serial interval (time elapsed between their onset dates) is known and b the set comprising the remaining pairs for whom only the ranges of their serial intervals are known. let s j be the observed value of the serial interval for the jth pair in a, and s l j ; s u j i be the observed range of the serial interval for the jth pair in b. for some infector-infectee pairs, the travel history and onset dates of the infector impose a lower bound on the serial interval (supplementary table ). let s * j be such a lower bound for the jth pair. the likelihood function for the data in supplementary table is where f si and f si are the pdf and cdf of the serial interval. we assume that the serial interval and the generation time have the same pdf. we estimated the model parameters θ using markov chain monte carlo methods with gibbs sampling and non-informative flat priors. point estimates and statistical uncertainty are presented using posterior means and % cris, respectively. reporting summary. further information on research design is available in the nature research reporting summary linked to this article. we collated epidemiological data from publicly available data sources (news articles, press releases and published reports from public health agencies). all the epidemiological information that we used is documented in the main text, the extended data and supplementary tables. the codes are available upon request to the corresponding author. last updated by author(s): mar , reporting summary nature research wishes to improve the reproducibility of the work that we publish. this form provides structure for consistency and transparency in reporting. for further information on nature research policies, see authors & referees and the editorial policy checklist. for all statistical analyses, confirm that the following items are present in the figure legend, table legend, main text, or methods section. the exact sample size (n) for each experimental group/condition, given as a discrete number and unit of measurement a statement on whether measurements were taken from 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influenza a h n virus: an assessment of clinical severity nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study secondary attack rate and superspreading events for sars-cov- report of the who-china joint mission on coronavirus disease (covid- ) early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- )-china chinese center for disease control and prevention. dashboard of reported -ncov cases data platform of shanghai observer. line list of -ncov confirmed fatal cases (from publicly available information wuhan municipal health commission. wuhan municipal health commission's briefing on the current pneumonia epidemic in the city hubei municipal health commission's briefing on the current pneumonia epidemic in the province infection fatality risk of the pandemic a(h n ) virus in hong kong sars-cov- viral load in upper respiratory specimens of infected patients viral load of sars-cov- in clinical samples time to use the p-word? coronavirus enters dangerous new phase quantifying bias of covid- prevalence and severity estimates in wuhan, china that depend on reported cases in international travelers the state council of the people's republic of china national health commission of people's republic of china. notice of the general office of the national health commission on the distribution of the plan of prevention and control of the pneumonia caused by the novel coronavirus situation of the epidemic of pneumonia caused by the novel coronavirus in hubei case fatality of sars in mainland china and associated risk factors epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong the epidemiology of severe acute respiratory syndrome in the hong kong epidemic: an analysis of all patients a comparative epidemiologic analysis of sars in hong kong, beijing and taiwan influenza: the mother of all pandemics age and sex incidence of influenza in the epidemic of - , with comparative data for preceding outbreaks: based on surveys in baltimore and other communities in the eastern states epidemiologic characterization of the influenza pandemic summer wave in copenhagen: implications for pandemic control strategies mortality from pandemic a/h n influenza in england: public health surveillance study middle east respiratory syndrome: what we learned from the outbreak in the republic of korea hospitalization fatality risk of influenza a (h n )pdm : a systematic review and meta-analysis middle east respiratory syndrome coronavirus (mers-cov) neutralising antibodies in a high-risk human population incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china extended data fig. | a summary of severity estimates among pandemic influenza strains and coronaviruses with pandemic potential in the past the study is a mathematical modeling study. we have provided the full information of data in figures data exclusions not applicable. the study is a mathematical modeling study. we have provided the full information of data in figures replication all the data have been provided in figures, extended data and supplementary tables randomization not applicable. the study is a mathematical modeling study. we have provided the full information of data in figures blinding not applicable.not applicable. the study is a mathematical modeling study. we have provided the full information of data in figures reporting for specific materials, systems and methods we require information from authors about some types of materials, experimental systems and methods used in many studies. here, indicate whether each material, system or method listed is relevant to your study the authors declare no competing interests. extended data is available for this paper at https://doi.org/ . /s - - - .supplementary information is available for this paper at https://doi.org/ . / s - - - .correspondence and requests for materials should be addressed to j.t.w.peer review information joao monteiro was the primary editor on this article and managed its editorial process and peer review in collaboration with the rest of the editorial team. key: cord- - t bn authors: cori, anne; donnelly, christl a.; dorigatti, ilaria; ferguson, neil m.; fraser, christophe; garske, tini; jombart, thibaut; nedjati-gilani, gemma; nouvellet, pierre; riley, steven; van kerkhove, maria d.; mills, harriet l.; blake, isobel m. title: key data for outbreak evaluation: building on the ebola experience date: - - journal: philos trans r soc lond b biol sci doi: . /rstb. . sha: doc_id: cord_uid: t bn following the detection of an infectious disease outbreak, rapid epidemiological assessment is critical for guiding an effective public health response. to understand the transmission dynamics and potential impact of an outbreak, several types of data are necessary. here we build on experience gained in the west african ebola epidemic and prior emerging infectious disease outbreaks to set out a checklist of data needed to: ( ) quantify severity and transmissibility; ( ) characterize heterogeneities in transmission and their determinants; and ( ) assess the effectiveness of different interventions. we differentiate data needs into individual-level data (e.g. a detailed list of reported cases), exposure data (e.g. identifying where/how cases may have been infected) and population-level data (e.g. size/demographics of the population(s) affected and when/where interventions were implemented). a remarkable amount of individual-level and exposure data was collected during the west african ebola epidemic, which allowed the assessment of ( ) and ( ). however, gaps in population-level data (particularly around which interventions were applied when and where) posed challenges to the assessment of ( ). here we highlight recurrent data issues, give practical suggestions for addressing these issues and discuss priorities for improvements in data collection in future outbreaks. this article is part of the themed issue ‘the – west african ebola epidemic: data, decision-making and disease control’. detection of a new infectious disease outbreak requires rapid assessment of both the clinical severity and the pattern of transmission to plan appropriate response activities. following the subsequent roll-out of interventions, continued evaluation is necessary to detect reductions in transmission and assess the relative impact of different interventions. surveillance data are crucial for informing these analyses, and directly determine the extent to which they can be performed. despite the unprecedented scale of the - west african ebola epidemic [ , ] , detailed data were collected during the outbreak, which proved invaluable in guiding the response [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . multiple studies have already considered the lessons to be learned from the ebola experience with respect to coordinating international responses to health crises, strengthening local health systems and improving clinical care and surveillance tools [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . here we discuss what can be learned to improve real-time epidemiological assessment in future outbreaks via improved data collection and analyses, building on similar contributions after other epidemics [ - ] . we focus on efforts to reduce and interrupt transmission. first, we outline analyses that are essential to inform response activities during different stages of an epidemic. second, we detail the various types of data needed to perform these analyses, with examples from the ebola experience. third, we summarize the successes and challenges of data collection experienced during this outbreak, and the implications this had for answering key public health questions. fourth, we suggest improvements that could be implemented in future outbreaks, again drawing from the ebola experience. finally, we discuss issues related to availability of data and analyses (box ). key public health questions for any emerging infectious disease outbreak are the following: (i) what is the likely public health impact of the outbreak? (ii) how feasible is controlling the outbreak and what interventions would be appropriate? (iii) are current interventions effective and could they be improved? here, we describe statistical and mathematical analyses that facilitate epidemic response planning, focusing on these questions (figure ). in this section, we take a general view, as these questions are recurring during most, if not all, outbreaks. we provide examples from the west african ebola epidemic in subsequent sections. (a) what is the likely public health impact of the outbreak? a key issue in the early phase of an epidemic is to determine the potential impact of the outbreak in terms of clinical severity and the likely total number of cases over different time periods. the severity of a pathogen is often characterized by the case fatality ratio (cfr), the proportion of cases who die as a result of their infection. estimating the cfr during an outbreak can be challenging due to inconsistent case definitions, incomplete case reporting and right-censoring of data [ ] [ ] [ ] . in particular, it is critical to know the proportion of cases for whom clinical outcome is unknown or has not been recorded, which is typically easier to assess using detailed case data rather than aggregated case counts [ ] . the cfr may differ across populations (e.g. age, space, treatment); quantifying box . recommendations for collecting and using data for outbreak response. data need to be collected at each of the three levels: individual level: detailed information about cases exposure level: information about exposure events that may have led to transmission population level: characteristics of the population(s) in which the outbreak is spreading and the interventions carried out in the population(s) although some data will be context-specific, others, in particular at the population level, will be useful for a wide range of epidemics, and should be routinely and centrally collected in preparation for the next outbreak. . optimizing data quality having a general framework ready in advance of the next outbreak will facilitate: quality and timeliness of data centralization and harmonization of data at all three levels preparedness to deploy training material, personnel and logistical resources there is substantial room for improvement in the quality of data collected in an epidemic context, particularly for emerging pathogens. . ensuring adequate data availability data need to be shared ensuring a balance between the following considerations: ethical: protecting anonymity while ensuring data are sufficiently detailed to be useful scientific: wide data access is desirable to promote independent analyses; however, mechanisms must be in place for systematic comparison of results practical: deciding on a data format for sharing, on who will be responsible for data cleaning and on how various roles will be acknowledged discussions and decisions relating to data sharing remain ongoing and guidelines should be agreed on in advance of the next outbreak. . analysing data and reporting results in an appropriate manner the scientific community should agree on guidelines for epidemic modelling and analyses (such as those in place for reporting experimental studies), such as: assumptions underlying analyses should be clearly stated sensitivity to these assumptions should be tested uncertainty in results should be adequately explored and reported these are particularly relevant for reporting epidemic projections. these heterogeneities can help target resources appropriately and compare different care regimens. for less severe emerging pathogens, the case definition typically only encompasses a small fraction of all infected individuals, and hence the infection fatality rate (i.e. the proportion of infected individuals who die, rather than the proportion of cases who die-as per the case definition, which may not be equivalent to infection) may be a more useful measure of severity [ ] . (ii) short-and long-term incidence projections short-term impact of an outbreak can be assessed by predicting the number of cases that will arise in the next few days or weeks. this is particularly relevant for evaluation of immediate health-care capacity needs. projections of future incidence and estimates of the doubling time (the time taken for the incidence to double) can be obtained by extrapolating the early time series of reported cases either obtained from aggregated surveillance data or calculated from individual records [ ] . these projections typically rely on the assumption that incidence initially grows exponentially [ ] . they are subject to uncertainty, which increases the further one looks into the future. quantifying and appropriately reporting such uncertainty and underlying assumptions are crucial [ , , , ] . overstating uncertainty can lead to inappropriately pessimistic projections, which may in turn be detrimental to the control of the outbreak [ ] . on the other hand, understating uncertainty prevents policymakers from making decisions based on the whole spectrum of possible impacts. some studies have already discussed how to find the balance between these two extremes [ - ] . here, we propose two simple rules of thumb for projecting case numbers. first, projections should not be made for more than two or three generations of cases into the future. second, central projections should be shown together with lower and upper bounds. in the future, the modelling community should agree on guidelines for reporting epidemic projections, as are already in place for reporting experimental studies [ ] . a number of factors can lead to incidence not growing exponentially. in particular, this happens once herd immunity accumulates, if population behaviour changes or as a result of the implementation of interventions. dynamic transmission models, which account for saturation effects, can be used to assess the long-term impact of the outbreak such as predicting the timing and magnitude of the epidemic peak or the attack rate (final proportion of population infected) [ , ] . however, these models are hard to parametrize as they require information on population size and immunity, interventions (if any) and potential behavioural changes over time, all of which may be subject to uncertainty [ , ] . we discuss these issues in more detail in § . projecting longer term is likely to be associated with a large degree of uncertainty and these projections may be more useful for evaluating qualitative trends and evaluating intervention choices rather than predicting exact case numbers. interventions would be appropriate? interventions to reduce transmission can include community mobilization, quarantine, isolation, treatment or vaccination. the potential success of these interventions is determined by general characteristics of the disease such as overall transmissibility and how this varies across populations [ ] . furthermore, certain types of interventions may be more or less appropriate depending on the natural history of the disease and the context of the epidemic. the transmissibility of a pathogen determines the intensity of interventions needed to achieve epidemic control [ ] . the parameter most often used to quantify transmissibility is the reproduction number (r), the mean number of secondary cases infected by a single individual. this parameter has an intuitive interpretation: if r . , then the epidemic is likely to grow, whereas if r , , the epidemic will decline [ , ] . the final attack rate ( proportion of the population infected) of an epidemic also depends on the value of r at the start of an epidemic (termed r if the population has no immunity). r can be estimated from the incidence of reported cases, given knowledge of the serial interval distribution (i.e. distribution of time between symptom onset in a case and symptom onset in his/her infector; see § b(iii)) [ ] [ ] [ ] [ ] . heterogeneity in the number of secondary cases generated by each infected individual affects epidemic establishment and the ease of control. greater heterogeneity reduces the chance of an outbreak emerging from a single case [ ] . however, this heterogeneity can make an established outbreak hard to control using mass interventions, as a single uncontrolled case can generate a large number of secondary cases [ ] . conversely, heterogeneity in transmission may provide opportunities for targeting interventions if the individuals who contribute more to transmission (because of environmental, behavioural and/or biological factors [ ] [ ] [ ] ) share socio-demographic or geographical characteristics that can be identified [ , ] . reconstruction of transmission trees (who infects whom) can provide an understanding of who contributes more to transmission. this can be done using detailed case investigations and/or using genetic data [ ] [ ] [ ] [ ] . environmental, behavioural and biological factors may also lead to groups of individuals being disproportionately more likely to acquire infection (e.g. children during influenza outbreaks [ , ] or health-care workers (hcws) during ebola outbreaks [ , ] ). to identify whether such groups exist and target them appropriately, the proportion infected in each group must be estimated. this requires population size estimates for the different groups, which may be difficult to obtain, as we highlight § c. spatial heterogeneity in transmission is particularly interesting to assess as it can inform the targeting of surveillance and interventions to the geographical areas most at risk. phylo-geographical studies based on genetic data can improve understanding of the geographical origins of the outbreak, identify and characterize sub-outbreaks and quantify whether transmission is very local or travels large distances [ , , ] . results of such analyses can be used to determine the appropriate spatial scale of control measures. spatially explicit epidemic models can also be used to quantify the risk of exportation of the infection from one place to another. this can help public health officials to tailor prevention and control resources to the level of risk likely to be experienced by a given area. such models typically require detailed data on mobility patterns and immunity levels of the populations in the areas of interest [ ] [ ] [ ] . disease natural history fundamentally affects outbreak dynamics. the generation time distribution (i.e. distribution of time between infection of an index case and infection of its secondary cases) determines-with the reproduction number-the growth rate of an epidemic [ ] . most commonly, the generation time distribution is estimated from data on the serial interval distribution of an infection-the delay between symptom onset in a case and symptom onset in his/her infector. other delays between events in the natural history of infection (e.g. exposure, onset of symptoms, hospitalization and recovery or death) also affect disease transmission or have implications for control [ , ] . delays from symptom onset to recovery (or death) will determine the required duration of health-care and case isolation. the incubation period (the delay between infection and symptom onset of a case) and the extent to which infectiousness precedes symptom onset will determine the feasibility and effectiveness of contact tracing or prophylaxis [ ] . estimating these delay distributions requires detailed data on individual cases and their exposure, e.g. through transmission pairs identified in household studies [ ] . other analyses can also help refine the type of interventions that should be considered. ecological associations between transmissibility (measured by r) at a fine spatio-temporal scale and any covariate measured at the same scale, may be rstb.royalsocietypublishing.org phil. trans. r. soc. b : of interest. for instance, analyses of the west african ebola epidemic showed that districts with lower reported funeral attendance and faster hospitalization experienced lower transmissibility, highlighting the effectiveness of promoting safe burials and early hospitalization [ ] . however, interpreting the results of such analyses can be challenging, as they might be prone to bias and confounding. efficacy (which measures the impact of an intervention under ideal and controlled circumstances) and effectiveness (which measures the impact of an intervention under real-world conditions) of an intervention (e.g. vaccine) are best measured in a trial setting (either individual-or cluster-randomized [ - ] ). however, performing trials to evaluate the comparative impact of different multi-intervention packages is impractical. dynamic epidemic models, where the interventions of interest can be explicitly incorporated, allow the impact of such intervention packages to be predicted [ ] . however, outputs of such models are strongly determined by the underlying assumptions and parameter values. hence they require careful parametrization, supported by data such as intervention efficacy and the size, infectivity, susceptibility and mixing of different groups [ , ] . these parameters may not be straightforward to estimate, as we discuss in § using examples from the west african ebola epidemic. another factor determining the appropriate choice of interventions is their cost, combinations of interventions with higher effectiveness at lower cost (i.e. higher cost-effectiveness) being preferable. economic analyses combined with mathematical models can help to evaluate the optimal resource allocation among both current available interventions and potential new interventions, accounting for development and testing costs for the latter. indirect costs, e.g. those associated with a restricted workforce following school closures [ ] , or trade limitations from air-travel restrictions [ ] , also need to be considered. while economic analyses have played an important role in designing optimal intervention packages for endemic diseases such as hiv and malaria [ , ] , such analyses are more difficult to perform during an epidemic, when cost data might be unavailable and uncertain, costs may vary rapidly over time and ethical considerations suggest interventions should be implemented immediately. (c) are current interventions effective and could they be improved? tracking changes in estimates of key epidemiological parameters over the course of an outbreak enhances situational awareness. it also allows the impact of interventions to be assessed as they are implemented, although disentangling the effects of different interventions carried out simultaneously may be challenging. obtaining reliable estimates of the epidemiological parameters detailed above requires a wide range of data, such as incidence time series and detailed case information (figure ). here, we explain how these can be obtained from various sources, with the objective to help improve data collection systems in preparation for future outbreaks. we use ebola as a specific example throughout this section, commenting on the strengths and limitations of the data collected during the west african epidemic. we distinguish data needs at the individual level, the exposure level and the population level. simple analyses can be performed solely using incidence time series, from surveillance designed to capture aggregate case counts. however, individual case reports provide much richer information, essential to estimate many of the key parameters outlined above (e.g. characterization of delay distributions). such data are typically stored in a case database or 'line-list'a table with one line containing individual data for each case. the more data recorded on each case, the more detailed the analyses can be. in the ebola epidemic, demographic characteristics, spatial location, laboratory results and clinical details such as symptoms, hospitalization status, treatment and outcome, and dates associated with these were reported for at least a subset of cases. the appropriate information to collect may vary depending on the disease: for ebola, dates of isolation and funeral were relevant. comprehensive demographic information can be used to determine risk factors for transmission or severity of infection and to project case numbers stratified by demographic characteristics. detailed information also helps to identify and merge any duplicate entries in a line-list, which may occur when the same person visits multiple health centres over the course of illness, for instance. finally, information on how each case was detected-for example, through hospitalization, or via contact tracing-can aid assessment of how representative the data are and allow subsequent adjustment for bias [ ] ; however, this was not available for ebola. cases in the line-list should be classified using standardized case definitions, which is sometimes difficult for outbreaks of new pathogens, or where different case definitions are provided by different organizations (e.g. world health organization (who) and us centers for disease control and prevention (cdc)) [ ] . for the ebola response, although the who released official case definitions of confirmed, probable and suspected ebola cases [ ] , different countries adopted different testing strategies, thereby limiting the opportunity for inter-country comparison. for example, in guinea deceased individuals were not tested for ebola, meaning these individuals were never classified as confirmed cases, unlike in liberia and sierra leone. encouraging use of a consistent testing protocol and case definition, and ensuring transparency in what is used where and when, would improve the validity of subsequent analyses. laboratory testing of clinical specimens is key for confirming cases and test results should be linked to the line-list. understanding diagnostic test performance in field conditions is important; cross-validation of diagnostic sensitivity and specificity between laboratories is useful to assess the extent to which observed differences in case incidence may be explained by variations in laboratory conditions and practices. in addition, recording raw test results with the case classification may help evaluation of diagnostic performance. ebola cases were defined as confirmed cases once ebola virus rna was isolated from clinical specimens using reverse transcription polymerase chain reaction (rt-pcr [ ] temperature and humidity to which these laboratories were subjected reduced the test performance compared with manufacturer evaluation reports [ ] . during the west african ebola epidemic, the case line-list contained a large quantity of data collected from reported cases. the information allowed estimation of the cfr, the incubation period distribution (and evaluation of differences in these by age and gender) and the reproduction number [ , , ] . projections of the likely scale of the outbreak were also made, either from the line-list or from aggregated case counts [ , , , ] . there were regular data updates [ ] , with a total of over confirmed and probable cases reported, which allowed analyses to be updated as more data became available. data on exposures allow cases to be linked to their potential sources of infection, and hence provide a better understanding of transmission characteristics. the relevant modes (e.g. airborne, foodborne) and pathways (e.g. animal-human, human-human) of transmission may be identified using information on exposure reported by cases. cases can report contact both with sick individuals (their potential source of infection) and healthy individuals they have contacted since becoming ill (who may need to be traced and monitored as potential new cases). these data will be more informative if the majority of infections are symptomatic (and hence easily identifiable), if individuals are mostly infectious after the onset of symptoms [ ] and if the time window over which exposures and contacts are monitored is as long as the upper bound of the incubation period distribution. if exposure information is collected with enough demographic information to allow record linkage, these backward and forward contacts can be identified in the case line-list, defining transmission pairs. depending on the mutation rate of the pathogen, genetic data can also be used to identify or confirm these epidemiological links [ , ] . the increasing availability of full genome pathogen sequences offers exciting prospects in that respect. some genetic sequence information was available during the ebola epidemic, but most sequences could not be linked to case records, limiting the use of sequence data in this context. on the other hand, individuals who were named as potential sources of infection could often be identified in the case linelist, although this process was hindered by non-unique names and limited demographic information collected on the potential sources [ ] . these exposure data were used to characterize variation in transmission over the course of infection [ ] , and to estimate the serial interval and the incubation period [ ] . the upper bound of the incubation period distribution was estimated to be days [ ] , which supported monitoring contacts for up to three weeks. studies of transmission in well-defined, small settings such as households are useful to quantify asymptomatic transmission, infectivity over time and the serial interval as they capture explicitly the number and timing of secondary cases. additionally, these studies can estimate the secondary attack rate (the proportion of contacts of a case who become infected within one incubation period), which can be used to characterize heterogeneities in transmission of different groups [ ] . estimates of the secondary attack rate have been obtained for the west african ebola epidemic by reconstructing household data based on information reported by cases, in particular, as part of contact-tracing activities [ , ] . although they might not immediately appear as useful as individual-or exposure-level data, metadata are crucial for answering many public health questions. knowing the sizes of affected populations is important for quantifying the attack rate and informing dynamic transmission models. census data are likely to be the most reliable source, but may be infrequently collected. methods based on interpreting satellite imagery [ , ] can inform population size and structure, although demographic stratifications are not always available. for the west african ebola epidemic, the most recently available age-and genderstratified population census data were from in guinea [ ] , in sierra leone [ ] and in liberia [ ] . a particular population of interest is hcws who, due to their contact with patients, are often at high risk of infection and may also be high-risk transmitters. large numbers of hcws were infected during the west african ebola epidemic [ , ] . however, the proportion of hcws affected at different stages of the outbreak and the relative risk of acquisition for the hcws compared with the general population could not be estimated since the total number of hcws was not systematically reported and changed during the course of the outbreak with the scale-up of interventions. note that, depending on the transmission route, the definition of hcws may need to include anyone working in a health-care setting who could be at risk (e.g. cleaners may be exposed to bodily fluids). characterizing population movement is crucial to assessing the risk of exportation of the infection from one place to another. air-travel data are the most reliable, consistently available and commonly used data source to inform models of long-distance spread [ ] . such data were widely used during the west african ebola epidemic to quantify the risk of international spread of the disease, and to assess the potential impact of airport screening and travel restrictions on the outbreak [ , - ] . however, air travel does not cover other population movements that may play an important role in disease spread, e.g. travel by road or on foot in guinea, liberia and sierra leone and across the porous country borders during the west african ebola epidemic [ ] . usually, little data are available to directly characterize these typically smaller-scale movements. gravity models, which assume that connectivity between two places depends on their population sizes and the distance between them, can be used to quantify spatial connectivity between different regions [ ] [ ] [ ] [ ] , and have proved useful to predict local epidemic spread, e.g. for chikungunya [ ] . such models require data on population sizes and geographical distances. recently, mobile phone data have been explored as an alternative source of data on mobility patterns, which could be used to predict spatial epidemic spread [ ] [ ] [ ] . however, a number of challenges (in particular related to privacy issues) meant that such data were unavailable to rstb.royalsocietypublishing.org phil. trans. r. soc. b : understand the regional and local spread of the west african ebola epidemic [ ] . in addition, inter-country movement is not captured from these data. at a national level, the utility of mobile phone data may depend on whether mobile phone users are representative of the population contributing to transmission, the level of mobile phone coverage in the affected population and whether population movement is likely to remain the same during an epidemic compared to the time period of the data. assessing seroprevalence in a population affected by an outbreak can provide valuable information on the underlying scale of population exposure and insight into how interventions might be targeted. for instance, if there is pre-existing population immunity prior to an outbreak that varies with age (as was the case in the h n influenza pandemic), vaccination could be targeted at those with lower pre-existing immunity. dynamic transmission models incorporating such differences in susceptibility can be used to explore different targeting strategies [ ] . ideally, serological surveys would be undertaken to quantify seroprevalence [ ] ; however, they are expensive and not performed on a regular basis. in the absence of such data, information on historical outbreaks and vaccine use can sometimes be used to infer seroprevalence [ ] . serological studies performed before and after an epidemic can also be useful to measure the attack rate and the scale of the outbreak, and hence provide information on the level of underreporting during the outbreak [ ] . it was widely assumed that the population in west africa was entirely susceptible to ebola at the start of this outbreak, with no known previous outbreaks in the area. however, some studies have suggested that there might have been low levels of prior immunity [ ] . during an outbreak, multiple interventions are often implemented by different groups and organizations. evaluating the role of interventions in interrupting transmission is important for revising and improving efforts, but it is challenging without detailed quantitative information of what has been implemented where and when [ , ] . maintaining a systematic real-time record of the different interventions at a fine spatio-temporal scale would help, e.g. the number and location of health-care facilities and their personnel, number of beds, vaccine or treatment coverage and details of local community mobilization. developing centralized platforms to routinely record such data once a large-scale outbreak is underway is probably unfeasible. however, developing such tools in advance of outbreaks (such as those developed for the global polio eradication initiative [ ] and those recently developed to collect health-care facility data [ ] ) should be a priority since better information to evaluate intervention policies in real time will allow for more optimal resource allocation. during the west african ebola epidemic, many data on interventions were recorded at a local level by some of the numerous partners (e.g. non-governmental organizations (ngos) and other organizations) involved in the response. for example, some data were collected on the number and capacity of hospitals over time [ ] and these were used in a study modelling community transmission to assess the impact of increasing hospital bed capacity [ ] . however, the decentralization of the response meant that intervention data were not systematically reported or collated and these data were not shared widely with the research community. a failure to report interventions centrally and systematically can make it difficult to disentangle a lack of intervention effect from a lack of intervention implementation. this can particularly be a problem when numerous groups coordinate their own efforts, making it impossible to draw firm conclusions about interventions. in the absence of detailed data on intervention efforts in west africa, multiple studies have assessed the combined impact of all interventions in place, by comparing transmissibility in the early phase (with no intervention) to that in the later phases [ , ] . however, this approach provides less compelling evidence of a causal effect and does not disentangle the impact of different interventions performed at the same time, and hence is less informative for future response planning. vaccine or treatment trials together with case-control and cohort studies can be useful in assessing the impact of an intervention. for example, during the west african ebola epidemic there was an urgent need to estimate the efficacy of newly developed vaccines. trials such as the guinea ebola ça suffit vaccine trial [ ] provided key data on the effectiveness of the rvsv-zebov ebola vaccine [ , ] . these trials occurred at the tail end of the epidemic and results will be useful in future outbreaks. statistical power from trials will be maximized by implementing such studies as early as possible in future outbreaks. this will be facilitated if research on diagnostics, drugs and vaccines is promoted between, and not only during, outbreaks, e.g. through new initiatives such as the coalition for epidemic preparedness innovation [ ] . all of the data sources mentioned above are inevitably imperfect; what they are trying to measure is different from what they measure in practice. quantifying the mismatch between the two is vital to appropriately account for these imperfections. for instance, case line-lists are likely to contain information on only a proportion of all infected individuals: typically those with symptoms, or those who sought care. the level of reporting may also be influenced by the capacity of the local health systems, which can vary over time and space. during the west african ebola epidemic, less than a third of cases were estimated to be reported [ ] and severe cases were probably over-represented compared to mild cases. at the end of , health-care capacity was exceeded in many parts of guinea, liberia and sierra leone [ ] , but new health-care facilities were subsequently built; hence the line-list of cases is likely to be more complete towards the end of the outbreak. underreporting might also have been higher in this compared to previous ebola outbreaks, during which the health-care systems were less overburdened. systematic evaluation of the surveillance system [ ] over different spatial units and time periods could help inform the level of underreporting. in addition, joint analysis of genetic sequence and surveillance data can provide insight into the degree of underreporting [ ] . quantifying completeness of, and potential biases in the line-list is important, e.g. to adequately quantify the cfr [ ] . although differences in the cfr were observed across rstb.royalsocietypublishing.org phil. trans. r. soc. b : different health-care facilities in the west african ebola epidemic, it was not possible to determine whether these were due to reporting differences or underlying differences between settings [ ] . similarly, exposure-level data can be incomplete, depending on the available capacity (personnel and resources) to perform contact tracing and the willingness of people to share information on their contacts. complete data can be used to assess the route of transmission-animal to human or human to human-and the number of cases imported from other locations. if data are incomplete, these estimates may be incorrect. population-level data may suffer the same issues. for instance, the recording of intervention efforts (e.g. the number of personal protection equipment (ppe) kits distributed) can differ from the reality of the intervention (e.g. the number of people who used ppe in practice). quantifying this mismatch is crucial to evaluating the impact of various interventions, and requires dedicated studies, with both qualitative and quantitative components, on the acceptability of and the adherence to given interventions. such studies have been carried out in the past, e.g. to assess the potential impact of face masks on the risk of influenza transmission in households, or of condom use on the risk of hiv transmission [ ] [ ] [ ] . it is also important to quantify delays encountered in the reporting of cases [ ] . during the west african ebola epidemic, there were delays in all databases and disparities between different data sources. in particular, comparison between the line-list of cases and aggregated daily case counts reported by the affected countries highlighted reporting delays in the line-list. as a result, at any point in the outbreak, naive time series of case counts derived from the line-list suggested that the epidemic was declining, due to right-censoring. comparison between the line-list and reported aggregated case counts (which were more up-todate) and between successive versions of the line-list allowed the reporting delays to be quantified. analyses such as the projected incidence could then be adjusted accordingly [ ] . in summary, the enormous quantity of detailed data collected during the west african ebola epidemic played an invaluable role in guiding response efforts. however, several analyses could not be performed. early on, severity, transmissibility and delay distributions were quantified and short-term projections were made, based on the case line-list and/or contact tracing data [ , , ] . some heterogeneity in severity and transmissibility could be identified (e.g. by age and viraemia [ , , , , [ ] [ ] [ ] ), but other types of heterogeneity could not be assessed. for example, it was not possible to compare the cfr between hospitalized and non-hospitalized cases, because of biases in the way cases were recorded in the line-list [ ] . long-term projections were extremely challenging due to large uncertainty in population sizes, behaviour changes and changing intervention efforts. in addition, the relative risk of ebola acquisition for hcws was difficult to estimate due to the absence of reliable spatio-temporal data on the number of hcws. finally, systematic evaluation of interventions was not feasible due to multiple control measures being carried out at the same time, with little central recording of details of each intervention. data collection during the west african ebola epidemic was possible, in part, due to a pre-existing case investigation form and data management system (epi info viral haemorrhagic fever (vhf) application [ , ] ). for outbreaks of new pathogens, such systems are not usually in place. the list of data needs we have outlined above, based on our experience during the ebola epidemic, could serve as a basis for data collection in future outbreaks. here we outline improvements that could be made to streamline data collection, minimize delays between data collection and data dissemination, and improve data quality during future outbreaks. all of these are necessary for timely analysis to inform the response in real time. we consider this particularly for line-list and exposure data. data need to be digitized before they can be analysed; streamlining this process reduces the potential for delays and errors. using electronic data capture on tablets or phones may reduce delays and errors compared with using paper forms that then require manual digitization, with its contingent issues [ ] [ ] [ ] [ ] . electronic questionnaires may not be available at the start of the epidemic, but could be quickly adopted using available tools (e.g. epicollect [ ] or epibasket [ ] ). interpretation problems (e.g. abbreviations) and spelling errors could also be minimized at the data collection level by using multiple choice questions rather than free text and at the data entry level by using drop-down menus. for example, for spatial information the choices could be the standard administrative levels used in the country-such as district or county. as response efforts evolve over time, such as the building of new treatment centres, the lists would be updated as required. similarly, using pop-out calendars to select dates would limit typing errors. additionally, internal consistency checks could flag problems such as the recorded date of death being before that of symptom onset, and the system could force a manual check before the record is saved. in the west african ebola epidemic, data were collected using paper forms (electronic supplementary material, figures s -s ) and manually entered into an electronic system at local operation centres. data entry problems were particularly noticeable in clinical dates and free text variables, such as district locations and hospital names, and required considerable cleaning (e.g. to correct spelling errors) [ , , ] . with any data system there is potential for delays in data entry and dissemination due to limitations in personnel and hardware, and logistical constraints in data delivery (e.g. reliable electricity, internet access and transport). although the latter limitations are arguably outside the scope of outbreak control, delays from data collection to dissemination could be reduced by increasing training in data entry and providing more data entry facilities where possible. delays in data entry and release during the ebola epidemic meant that real-time analyses of the line-list data could not be performed on fully up-to-date data. in the world today, an epidemic emerging anywhere is a global threat due to high population connectivity [ , ] and, as such, a response will have to operate across multiple languages. ideally, the same data entry system would be used in every affected country to allow easy collation into a single case line-list. however, a global response requires careful translation of the questions and the system to ensure they make sense and are identical in every language. additionally, different languages, dialects or alphabets could be challenging due to differing pronunciations, accents, alternate names or spellings, and these should be acknowledged in the form design. the language barrier was not a major problem during the ebola response: guinea had a form in french, while in sierra leone and liberia the form was in english, though there were some minor differences in formulations between the two (for example the english version of the form asked 'in the past one month prior to symptom onset: did the patient have contact with (. . .) any sick person before becoming ill' (see § in the form in electronic supplementary material, figure s ), while the french form did not specify 'before becoming ill'). analysis of laboratory results and sequence data can be much more powerful if they can be dated and linked to the epidemiological data recorded for each case. in the early stages of the ebola response, there were reports that laboratory results could not always be linked to case records as labels were incorrectly written or damaged in transit [ ] . later in the epidemic, case report forms came with pre-printed unique id barcode stickers to label all records and samples for each case (electronic supplementary material, form s ). this would be useful if implemented early in future outbreaks, particularly if laboratory tests are not performed at the point of care. rapid diagnostic tests were developed during the west african ebola epidemic but not used widely [ , ] ; similarly, mobile sequence tests were introduced later in the epidemic [ ] : both of these would reduce delays and maximize the potential to link patient data. we have described a set of data needed to perform analyses to inform the public health response during an outbreak. we have proposed strategies to ensure fast and high-quality data collection, to enable robust and timely analyses. however, such analyses can only be performed if the data are accessible to data analysts and modellers. the west african ebola epidemic has prompted an ongoing public debate about the ethical, practical and scientific implications of wide data access [ , [ ] [ ] [ ] . ethical considerations require removal of data that might compromise anonymity, but such detailed information might be required to answer important public health questions. mechanisms also need to be found to appropriately acknowledge those who collected and digitalized the data. from a scientific perspective, having several groups analysing the data is desirable, as independent analyses leading to similar results will reinforce their utility for policymaking [ , ] . such parallelized efforts have been formalized through consortiums of highly experienced groups, e.g. for modelling of hiv [ ] , influenza [ , ] and malaria [ ] . however, if results differ, understanding what assumptions drive these differences may confuse and delay the process of decision-making. a consequence of data sharing, therefore, needs to be an increased emphasis on evidence synthesis, such as systematic reviews of the different analyses. to enable this process, groups should explicitly state all assumptions underlying their analyses and which data they are based on. like the original analyses, reviews need to be timely to be useful. these issues have partly been addressed through new data availability policies [ ] . furthermore, this process would ideally be performed by a group independent of those performing the primary analyses. identifying an effective system, appropriate personnel and appropriate recognition for this important role needs to be planned in advance of future outbreaks. data from the west african ebola epidemic required significant cleaning before it could be analysed, and this was necessary for every updated dataset, i.e. every few days during the peak. were outbreak data to be shared more widely, collaborative or centralized cleaning would be optimal, to avoid repetition and ensure consistency across different groups. if a centralized effort was not possible, regular sharing of the cleaning code and cleaned datasets between groups would facilitate comparison of results. even better, code could be shared on a collaborative platform such as github (https://github.com/), leading to a common clean dataset being actively maintained by the scientific community. however, for this process to be effective, a set of best practices would need to be established in advance, such as designing a transparent workflow, establishing a fair distribution of tasks and clarifying how credit will be given for this (often lengthy) task. this is important to avoid duplication of effort and allow effective collaboration. as the process of data sharing is debated further, it is critical that the practicalities of data cleaning are discussed in parallel. based on our experience, a centralized cleaning platform would be the most effective method. finally, analyses will be most useful if they are shared widely across policymakers, local health teams and other research groups. the format for dissemination could be anything from a report to a scientific publication. reports can be made available faster and regularly updated but do not undergo the peer review process of publications. peer review can delay publication, though there are now new platforms for fast-tracking this process [ , ] . at the time of writing, as interest in zika virus is gaining momentum, there seems to be an encouraging trend to the use of pre-print servers [ , ]. by the very nature of emerging infectious diseases, we do not know which pathogen will emerge next, when or where. there have been many suggestions about how to be rstb.royalsocietypublishing.org phil. trans. r. soc. b : better prepared [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , ] ; here, we argue that preparedness should include development of a broad-use data collection system that can be easily and quickly adapted to any disease (in agreement with [ ] ) as well as the regular collection of population health data in centralized systems. different infectious diseases may require different types of data [ ] : a single approach is not applicable to all diseases. in particular, different interventions may need to be recorded for different diseases. data collection and management may need to evolve as the outbreak progresses and/or as more is learnt about the pathogen: the ebola data collection forms changed late in to streamline collection and entry when the response effort was almost overwhelmed with cases (electronic supplementary material, figures s and s ). similarly, both for ebola and the recent zika outbreak, reports of sexual transmission have led to a broadening of the contact tracing and exposure information collected. the data collected during the ebola epidemic allowed many analyses to be performed, which informed the response. however, as in many outbreak situations, it has not been possible to systematically quantify the relative contribution of different interventions (such as safe burials, hospitalization, contact tracing and community mobilization) in reducing transmission. this is because data on where and when these interventions took place were not centrally recorded and released in a timely fashion. efforts have been made to collate some information from sierra leone, liberia and guinea [ ] ; however, this commenced late in the epidemic. as this effort relies on different organizations to contribute data, the submissions are in different formats and are unlikely to provide comprehensive information. in the midst of a global public health crisis resources are often deployed favouring implementation rather than documentation of interventions. however, we would argue that securing some resources to monitor interventions-especially during the early stages-is critical to optimally prioritizing future control efforts. some of the data we have suggested to be collected during outbreaks may not be obviously useful at the field or case management level, e.g. detailed demographic characteristics of cases and contacts. collecting such data costs money and time as well as trained personnel. these three 'resources' are limited and, during an epidemic, should be prioritized where their need is greatest. however, from a population perspective, collecting these data may help quantify epidemic impact, assist in the design and evaluation of interventions, and help prevent new infections. further studies might examine how to appropriately balance these two considerations. we have built on the ebola experience to draw up a list of the data needed to assist the response throughout an epidemic, which should help to collect relevant data in a standardized effort in future epidemics. to make the most of these data, epidemiologists and modellers should work now to develop tools to automatically clean, analyse and report on the data in a more timely and robust manner [ ] . based on critical review of past outbreak analyses, future studies could flag common methodological mistakes and propose good practice [ ] . this includes clearly stating all assumptions underlying a model or analysis and ensuring that parametrization is either directly informed by relevant data or has appropriate sensitivity analyses, with corresponding uncertainty clearly reported [ , ] . improving our ability to respond effectively to the next outbreak will require collaboration between all parties involved in outbreak response: those in the field, epidemiologists, modellers and policymakers as well as the populations affected. here we have given the data analyst perspective on what data are required to answer important policy questions. it is equally important that other perspectives should be heard to be better prepared for and improve interactions during crises, thereby minimizing the impact of future outbreaks. a review of epidemiological parameters from ebola outbreaks to inform early public health decision-making after ebola in west africa: unpredictable risks, preventable epidemics ebola virus disease in west africa-the first months of the epidemic and forward projections ebola virus disease among male and female persons in west africa west african ebola epidemic after one year-slowing but not yet under control ebola virus disease among children in west africa chains of transmission and control of ebola virus disease in conakry, guinea, in : an observational study estimating the future number of cases in the ebola epidemic-liberia and sierra leone effectiveness of screening for ebola at airports exposure patterns driving ebola transmission in west africa, a retrospective observational study are we learning the lessons of the ebola outbreak? the next epidemic-lessons from ebola global health security: the wider lessons from the west african ebola virus disease epidemic will ebola change the game? ten essential reforms before the next pandemic. the report of the harvard-lshtm independent panel on the global response to ebola clinical research during the ebola virus disease outbreak in guinea: lessons learned and ways forward the emergence of ebola as a global health security threat: from 'lessons learned' to coordinated multilateral containment efforts ebola in west africa: lessons we may have learned lessons learned from hospital ebola preparation ebola in west africa: learning the lessons strengthening the detection of and early response to public health emergencies: lessons from the west african ebola epidemic ebola clinical trials: five lessons learned and a way forward lessons from ebola: improving infectious disease surveillance to inform outbreak management epidemiological data management during an outbreak of ebola virus disease: key issues and observations from improving the evidence base for decision making during a pandemic: the example of influenza a/h n epidemic and intervention modelling-a scientific rationale for policy decisions? lessons from the influenza pandemic emerging infections: what have we learned from sars? assessing the severity of the novel influenza a/h n pandemic potential biases in estimating absolute and relative case-fatality risks during outbreaks optimizing the precision of case fatality ratio estimates under the surveillance pyramid approach influenza-related deathsavailable methods for estimating numbers and detecting patterns for seasonal and pandemic influenza in europe an introduction to infectious disease modelling six challenges in modelling for public health policy uses and abuses of mathematics in biology national center for infectious diseases sars community outreach team decisions under uncertainty: a computational framework for quantification of policies addressing infectious disease epidemics development and consideration of global policies for managing the future risks of poliovirus outbreaks: insights and lessons learned through modeling quantifying uncertainty in epidemiological models the orion statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection generality of the final size formula for an epidemic of a newly invading infectious disease modeling to inform infectious disease control nine challenges in incorporating the dynamics of behaviour in infectious diseases models nine challenges in modelling the emergence of novel pathogens factors that make an infectious disease outbreak controllable infectious diseases of humans: dynamics and control a brief history of r and a recipe for its calculation epiestim: a package to estimate time varying reproduction numbers from epidemic curves (r package a new framework and software to estimate timevarying reproduction numbers during epidemics how generation intervals shape the relationship between growth rates and reproductive numbers different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures superspreading and the effect of individual variation on disease emergence mathematical models of infectious disease transmission a bayesian mcmc approach to study transmission of influenza: application to household longitudinal data risk factors of influenza transmission in households heterogeneities in the transmission of infectious agents: implications for the design of control programs bayesian inference of infectious disease transmission from wholegenome sequence data bayesian reconstruction of disease outbreaks by combining epidemiologic and genomic data unravelling transmission trees of infectious diseases by combining genetic and epidemiological data relating phylogenetic trees to transmission trees of infectious disease outbreaks household transmission of pandemic influenza a (h n ) virus in the united states ebola virus disease in health care workers-sierra leone ebola virus disease cases among health care workers not working in ebola treatment units-liberia temporal and spatial analysis of the - ebola virus outbreak in west africa evolution and spread of ebola virus in liberia modeling the spatial spread of infectious diseases: the global epidemic and mobility computational model the foot-and-mouth epidemic in great britain: pattern of spread and impact of interventions large-scale spatial-transmission models of infectious disease the interval between successive cases of an infectious disease standards of evidence: criteria for efficacy, effectiveness and dissemination criteria for distinguishing effectiveness from efficacy trials in systematic reviews agency for healthcare research and quality vaccine epidemiology: efficacy, effectiveness, and the translational research roadmap modeling infectious diseases in humans and animals social contacts and mixing patterns relevant to the spread of infectious diseases modeling infectious disease parameters based on serological and social contact data: a modern statistical perspective (statistics for biology and health closure of schools during an influenza pandemic the international response to the outbreak of sars in health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of mathematical models costs and cost-effectiveness of malaria control interventions-a systematic review performance of case definitions for influenza surveillance case definition recommendations for ebola or marburg virus diseases mobile diagnostics in outbreak response, not only for ebola: a blueprint for a modular and robust field laboratory reebov antigen rapid test kit for point-of-care and laboratory-based testing for ebola virus disease: a field validation study temporal variations in the effective reproduction number of the west africa ebola outbreak inference and forecast of the current west african ebola outbreak in guinea, sierra leone and liberia epidemiological and viral genomic sequence analysis of the ebola outbreak reveals clustered transmission transmissibility and pathogenicity of ebola virus: a systematic review and meta-analysis of household secondary attack rate and asymptomatic infection transmission dynamics of ebola virus disease and intervention effectiveness in sierra leone landscan tm about worldpop population statistics of guinea population and housing census national population and housing census final results the role of the airline transportation network in the prediction and predictability of global epidemics assessment of the potential for international dissemination of ebola virus via commercial air travel during the west african outbreak assessing the international spreading risk associated with the west african ebola outbreak assessing the impact of travel restrictions on international spread of the west african ebola epidemic mali case, ebola imported from guinea local and regional rstb.royalsocietypublishing.org phil gravity models for airline passenger volume estimation five challenges for spatial epidemic models dynamic population mapping using mobile phone data mapping population and pathogen movements impact of human mobility on the emergence of dengue epidemics in pakistan commentary: containing the ebola outbreak -the potential and challenge of mobile network data assessing optimal target populations for influenza vaccination programmes: an evidence synthesis and modelling study use of serological surveys to generate key insights into the changing global landscape of infectious disease key issues in the persistence of poliomyelitis in nigeria: a casecontrol study increased transmissibility explains the third wave of infection by the h n pandemic virus in england undiagnosed acute viral febrile illnesses how to make predictions about future infectious disease risks new approaches to quantifying the spread of infection polio information system about healthsites the humanitarian data exchange measuring the impact of ebola control measures in sierra leone retrospective analysis of the - ebola epidemic in liberia the ring vaccination trial: a novel cluster randomised controlled trial design to evaluate vaccine efficacy and effectiveness during outbreaks, with special reference to ebola efficacy and effectiveness of an rvsv-vectored vaccine expressing ebola surface glycoprotein: interim results from the guinea ring vaccination cluster-randomised trial efficacy and effectiveness of an rvsv-vectored vaccine in preventing ebola virus disease: final results from the guinea ring vaccination, open-label, cluster-randomised trial (ebola Ça suffit!) an r&d blueprint or action to prevent epidemics plan of action use of capturerecapture to estimate underreporting of ebola virus disease updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group inference for nonlinear epidemiological models using genealogies and time series heterogeneities in the case fatality ratio in the west african ebola outbreak - face mask use and control of respiratory virus transmission in households barriers to mask wearing for influenza-like illnesses among urban hispanic households efficacy of structural-level condom distribution interventions: a meta-analysis of us and international studies quantifying reporting timeliness to improve outbreak control clinical features of and risk factors for fatal ebola virus disease assessment of the severity of ebola virus disease in sierra leone use of viremia to evaluate the baseline case fatality ratio of ebola virus disease and inform treatment studies: a retrospective cohort study the epi info viral hemorrhagic fever application the epi info viral hemorrhagic fever (vhf) application: a resource for outbreak data management and contact tracing in the - west africa ebola epidemic e-health technologies show promise in developing countries a comparison of the completeness and timeliness of automated electronic laboratory reporting and spontaneous reporting of notifiable conditions replacing paper data collection forms with electronic data entry in the field: findings from a study of communityacquired bloodstream infections in pemba, rstb.royalsocietypublishing.org phil comparison of electronic data capture (edc) with the standard data capture method for clinical trial data epibasket: how e-commerce tools can improve epidemiological preparedness. emerg who report on global surveillance of epidemic-prone infectious diseases address to the sixty-ninth world health assembly notes from the field: baseline assessment of the use of ebola rapid diagnostic tests-forecariah, guinea essential medicines and health products: diagnostics real-time, portable genome sequencing for ebola surveillance sharing data for global infectious disease surveillance and outbreak detection data sharing: make outbreak research open access providing incentives to share data early in health emergencies: the role of journal editors mathematical modelling of the pandemic h n studies needed to address public health challenges of the h n influenza pandemic: insights from modeling public health impact and cost-effectiveness of the rts,s/as malaria vaccine: a systematic comparison of predictions from four mathematical models developing global norms for sharing data and results during public health emergencies outbreaktools: a new platform for disease outbreak analysis using the r software avoidable errors in the modelling of outbreaks of emerging pathogens, with special reference to ebola seven challenges for model-driven data collection in experimental and observational studies acknowledgements. the authors give credit to and thank the many individuals who were involved in data collection, entry and management during the west african ebola epidemic. key: cord- -iwkuwnun authors: schweitzer, wolf; ruder, thomas; baumeister, rilana; bolliger, stephan; thali, michael; meixner, eva; ampanozi, garyfalia title: implications for forensic death investigations from first swiss post-mortem ct in a case of non-hospital treatment with covid- date: - - journal: forensic imaging doi: . /j.fri. . sha: doc_id: cord_uid: iwkuwnun abstract case details: a case of a -year old hiv-positive man is presented, with focus on visualization of post-mortem computed tomography (pmct) of the lungs, in comparison to a forensic control case. he had been found dead at home, a day after his nasopharyngeal swab had returned positive for sars-cov- , three days after the sample had been taken as an outpatient, over five weeks after first exhibiting possible symptoms. d-visualization was performed by visually discriminating correlates for aerated, poorly aerated and non-aerated lung regions. the visual side-by-side comparison with a control case shows the deterioration beyond any ”normal” post-mortem finding, however. the pmct findings in the lungs resemble those of patients with acute respiratory distress syndrome (ards), while histologically identified inflammation also shows, in part binuclear, lymphocytes. in addition, acute liver dystrophy and acute tubular necrosis in the kidneys were found. except coronary artery atherosclerosis, there appeared to be no remarkable pathology of the heart. comment: with the pandemic impact of sars-cov- , a range of issues unfolds, also for medicolegal investigations into deaths, as we report the first swiss case with post-mortem ct where death had occurred due to a sars-cov- infection, with features of a severe acute respiratory distress syndrome, as an outpatient. as this pandemic from the view of risk assessment does constitute a black swan, underestimated fat tails as technical reason should be addressed by also analyzing apparent extreme single observations. this case of an outpatient (without hospital or intensive-care treatment) shows a pulmonary progression beyond the typical findings of covid- , to a non-specific picture of ards, where histologically, in part binuclear lymphocytes were remarked. what appeared to be an initially slow progression with final rapid escalation raises the question whether nasopharyngeal swabs alone or added pulmonary ct might be better for screening high-risk patients. the reported symptoms and relatively late medical consultation in this case appeared to contrast with the extensive pathology, raising the question whether any search for super-spreaders should not just focus on asymptomatic but under-reported symptomatic patients, and whether their prolonged circulation in everyday life would justify measures such as for example more extensive face mask policies. as post-mortem testing for sars-cov- may not be available for every case, pmct may provide sensitive testing for lung changes related to covid- . in order to allow for more precise medicolegal investigations in the context of covid- , however, any more specific extra tests may have to be financed by stakeholders in epidemiology, infectious disease or policy. same day, he called the clinic again, now complaining of a racing heart [ ] , and was told to consult with the hospital at once. he never made it there, but was found dead at home on the following day. to clarify manner and cause of death, a medicolegal investigation into his death was opened. before autopsy, pmct was obtained ( fig. and ) that also showed absence of gas as indirect sign of probable absence of concurrent septicemia or bacterial infection [ ] [ ] [ ] . the pmct shows what appears to be a fatal case of a severe acute respiratory distress syndrome. the pmct correlates for normally aerated lungs were identified between - and - hounsfield units (hu), against which over-inflated (below - hu), poorly aerated (- to - hu) and nonaerated (above - hu) regions were differentiated on basis of density [ ] . the visualizations in figures and show a marked difference in the lung appearance compared to a control case. the details of the axial slice images are denoted in figure ; no reverse halo sign was identified. there appeared to be fluid in the maxillary and sphenoid sinuses. bronchi and trachea appeared to be filled with fluid, whose pmct surface characteristic was uneven, matching the autopsy finding of frothy fluid in the airways (see also fig. ). at autopsy, the heart of g presented coronary artery atherosclerosis with pre-existing narrowing to % of the lumen of both the left anterior descending and right coronary arteries [ ] , no macroscopic signs of myocardial ischemia, and no relevant histological findings (such as contraction band necroses, infarction, or inflammation) were noted. the lungs with g weight showed extensive tardieu spots and an increased consistency, with haemorrhagic foam or frothy fluid, in bronchi and trachea (fig. ) . microscopic features included congested blood vessels, some hyaline membranes, and patchy inflammation with lymphocytes (in part biand trinuclear). histology of the liver that exhibited reduced consistency at autopsy was, other than macro-and microvesicular steatosis [ , ] , a peracute liver dystrophy without inflammation; the kidney showed acute tubular necroses (fig. ) . no signs of postmortem decomposition were noted on pmct or at autopsy. control: case of a year old woman who had no acute respiratory distress syndrome related findings at all; there was post-mortem hypostasis dorsally at the right lung. the case allows for a comparison, as it may be seen as a "normal" lung pmct in a forensic caseload ( fig. and ). pmct: lung pmct was reconstructed from dedicated thorax/abdomen scans using a hard reconstruction kernel (siemens, b s). the data had been acquired on a dual-source ct (computed tomography) scanner (somatom definition flash, siemens, erlangen, germany). standard protocols were employed [ ] : for each case, whole body scans, thorax/abdomen scans as well as separate head scans were obtained. all scans used kv and x . mm collimation with automated dose modulation (care dose d, siemens, erlangen, germany). thorax/abdomen scans were obtained at reference mas and for these, slice thickness was mm with an increment of , mm. d-visualisation ( fig. ) was performed after manual segmentation (mevislab, fraunhofer institute, germany). the current sars-cov- /covid- pandemia constitutes a crisis in a number of ways [ , ] . here, we argue that medicolegal specialists are privileged to a wider view, also on first-order and secondorder effects, of sars-cov- , and, how even single extreme or rare observations should be relevant for policy-making. primarily, covid- appears to concern clinical rather than forensic medicine: the direct impact of sars-cov- is that it infects people where it may cause an illness with pneumonia in pandemic proportions that currently lacks specific treatment or vaccination. then, it affects governments in that recommendations and emergency laws may be . correlates for non-aerated (~red), poorly aerated (~green) and aerated (~blue) lung regions (density ranges see text) were visualised three-dimensionally. issued, suspected patients may be recommended to report early symptoms, in order to follow procedures, in part also to medically observe and treat symptoms of covid- . medicolegal complications of sars-cov- , however, mainly appear to derive from subsequent first-order and second-order effects. there, the fear-based "social distancing" as a government-imposed practice to lower risk of infection seems to provide a conceptual epicenter [ ] : in combination with dramatic media reports [ ] , a current variety of "social distancing" seems to also push irrational or aggressive behavior [ ] while effectively exploiting fear to control the pandemic [ , ] . in considering its history, "social distancing" had always been a well-established tradition, exerted upon various minorities, once even attributed with an individual fear-based graded -item scale of various levels (including items such as "would keep away from", "would keep in an institution", "would send out of my country" and "would put to death") [ ] : according to that paper, infectious disease outranked deafness, blindness or amputation, but not alcoholism or mental illness, as people to preferably stay away from. apparent consequences of fear, leveraged through the tool of "social distancing", thus seem to surface, as fear will predispose to a whole range of individual reactions, rather than just the government-intended single reaction ("would keep away from" [ ] ). medical personnel are now being evicted from their own housing, because landlords fear sars-cov- infection (reports from india, switzerland, great britain [ ] [ ] [ ] [ ] [ ] ). domestic violence has escalated world-wide [ , ] , in one instance, a man allegedly killed his partner out of fear of getting infected (with both later testing negative [ ] ), and there seems to be a new sars-cov- related road rage [ , ] . intentional murder charges were introduced [ ] , against infected people that are not respecting quarantine rules. with that, sars-cov- -related issues are being pushed far into the domain of medicolegal investigation: particularly by leveraging fear in the public also through what is called "social distancing:, a whole range of relevant meta-level consequences ensue despite good intentions [ , ] . from there, even single and extreme observations can and should influence statistical methods in order to improve policies. with regard to statistics, one may consider black swans as an ultimate consequence of underestimated fat tails [ , ] . the statistical models that are used for risk assessment [ ] risk to be wrong if assumptions, as those about normal distributions, are met with differing realities [ , ] . with that, statisticians particularly outside medicine already now routinely consider single extreme observations to better characterize fat tails [ ] . medicolegal observations that seem to exceed a clinical view in significant ways may thus be well suited also to at least be considered in informing policies. some existing policies are already reasonably well-informed. as forensic medical doctors covering both clinical forensic medicine and forensic pathology, we may mostly not get funding for microbiological sars-cov- testing. identifying possibly critical cases can be performed differently though. forensic post-mortem ct (pmct) imaging has become an increasingly valuable asset [ ] whereas we perform pmct traction bronchiectasis ( , ) , crazy-paving with ground-glass opacities and septal thickening (for example, ) and multifocal consolidations (e.g., in the right lung, ) as well as small pleural effusions ( ) . these findings resemble those of patients with acute respiratory distress syndrome (ards). there appears to be no additionally visible post-mortem hypostasis. the control case shows dorsal location of post-mortem hypostasis (b: arrows). scanning and data reporting on all bodies [ , ] before further steps, including autopsy, are done. one application of pmct-based triage is to identify possible infectious disease prior to autopsy [ ] and another one is to examine forensically relevant aspects of the lungs [ ] [ ] [ ] . to the best of our knowledge, this report shares the first postmortem computed tomography (pmct) of a fatal course in a covid- non-hospital patient. while one might interprete these to be extreme findings only because of their post-mortem nature, one should consider how a "normal" pmct may look like ( fig. and ) . while this single sars-cov- fatality with what appear to be extreme findings should be seen within a wide forensic scope, we also stress the preliminary, early nature and necessarily incomplete nature of such communications as these. while this man's subjective report apparently did not include dyspnea, even less than a day prior to his death, the pulmonary pathology of this outpatient, as evidenced by pmct, appears to extend beyond the severity shown in descriptions of currently published sars-cov- -related fatalities, all of which apparently had obtained prior hospital and intensive-care treatment [ ] [ ] [ ] . the extent of pulmonary affection in this case, both radiologically (see fig. and ) and at autopsy, seems extensive in context of sars-cov- cases reported so far [ ] but lies in the range of fatal sars cases [ ] . the findings appeared to be that of a per-acute respiratory distress syndrome, whereas no fibrosis and only some hyaline membranes were noted. acute liver dystrophy and acute renal tubular necroses may be interpreted as consequences of acute right heart failure [ , ] , which seems relevant in the context of possible covid- related liver damage [ , ] . hiv-infection reportedly correlates with more frequent and more severe viral pneumonia [ , ] . the presence of binuclear lymphocytes as identified here may be considered as possibly enigmatic [ ] , whereas such cells had previously been reported in conjunction with polyclonal b-cell activation [ ] , also in mhv-a infections (mouse hepatitis virus, also named murine coronavirus (mcov) [ ] ) or ebv (epstein-barr-virus [ ] ), whereas ebv also was reported to correlate with a more severe course of covid- [ ] . a first relevant policy aspect to consider is that of infectiousness in the light of covid- [ ] . here, an individual appeared to have reported only relatively mild symptoms, and was advised to stay home only for the three days preceding death. post-mortem examination however showed large amounts of frothy fluid in trachea, bronchi and paranasal sinuses, which also may indicate a wet cough [ , ] rather than a dry cough [ ] in what appears to be a history with at least some symptoms stretching over around five weeks. most of that time, this man can be assumed to have traveled and interacted freely with others. while over % in one series of covid- patients [ ] showed chest ct abnormalities, the frequencies of absent symptoms (no fever in , %, no dyspnea in , %, no cough in %) may also signify that there are those that under-report their illness and stay outside hospitals [ ] . the reported symptoms and relatively late clinic consultation appeared to contrast with the extensive pathology, raising the question whether any search for super-spreaders should not just focus on socalled asymptomatic [ , ] but also on under-reported symptomatic patients (already suspected in those suffering from chronic cough [ ] ), and whether their prolonged circulation in everyday life would justify any measure of physical distancing, including the consideration of face masks [ , ] . at our institute [ ] , this has been taken into consideration for the latest recommendations regarding examination of deceased or live people in a forensic context. thereby, in addition to usual protective gloves, surgical masks are recommended for all examinations for all people attending, whereas high-grade masks and a protective suit are required to protect the examiner in cases of known or strongly suspected covid- . a second policy aspect to consider is that of diagnostic effort to screen for covid- . what appeared to be an initially slow progression with final rapid escalation in this case raises the question whether nasopharyngeal swabs are sufficient or if pulmonary ct might be a sensible addition for screening high-risk patients early into the course of suspected covid- . in this case, disease progression appears to be w. schweitzer, et al. forensic imaging ( ) characterized by a particularly fast deterioration, in comparison to at least one other fatal sars-cov- case with a known detailed timeline [ ] : whereas it seems to be typical that shortness of breath may precede death by a few days, here, the cardinal symptom preceding imminent death reportedly was that of a "racing heart" [ ] . one has to consider that naso-pharyngeal swabs and ensuing rt-pcr evaluation may delay the diagnosis, while also turning out significant portions of false negatives [ ] . if available, additional early pulmonary ct appears to offer both a relatively high speed and sensitivity [ ] , albeit at lower specificity [ ] . for forensic post-mortem examinations, we had already previously identified triage pmct as valuable, particularly and also in the context of screening for correlates of possible infections [ ] . as post-mortem rt-pcr testing for sars-cov- in a forensic setting may not be available or too slow, pmct may identify lung changes possibly related to covid- . with that, it is also relevant to note that forensic pmct may show correlates of pathology that differ from a clinical setting [ ] . this case was exceptional also in the way it was handled as "reportable death", because forensic work typically focuses on whether a crime was committed, without spending extra cost or effort. a conservative handling of swiss procedures with regard to "reportable deaths" [ ] risks to list most probable natural deaths as a result of assumed or possible acute cardiac failure. as relevant as that may appear to forensic investigations, this seems rather uninformative otherwise, and may definitely entail under-reporting of covid- cases [ ] when in fact, death with covid- (as in: fall from great height, intoxication, road traffic accident, etc.), death caused by covid- (as in: death of sars-cov- related ards, etc.), and death with or of covid- under medical treatment (as in: experimental or cross-label medication was administered), might become a relevant distinction. differentiating virus strains may be important, from view of epidemiology, rather than simple binary testing, seeing as if the clinical picture of covid- and illness severity may differ across different viral strains (or subtype, or genetic variant) [ ] , with a majority of fatal covid- cases possibly including additional microbial agents, whose pathophysiological role may yet have to be clarified; there, elevated serum procalcitonin as possible indicator of bacterial (rather than viral) infection [ ] had already been identified to correlate with clinical severity [ ] . so, more research, also with regard to aspects of previously unreported cases with covid- , may be needed, in order to identify where policies may require adaptation or extensions. in order to allow for more precise medico-legal investigations in the context of covid- , more specific testing may have to be financed by stakeholders in epidemiology, infectious disease or policy. cardiovascular complications of severe acute respiratory syndrome post-mortem diagnosis of air embolism by radiography portal venous gas in the pediatric age group: review of the literature and report of twelve new cases small-but fatal: postmortem computed tomography indicated acute tonsillitis non-invasive imaging of regional lung function using x-ray computed tomography risk factors for primary middle east respiratory syndrome coronavirus illness in humans sars-associated viral hepatitis caused by a novel coronavirus: report of three cases pathological findings of covid- associated with acute respiratory distress syndrome imaging in forensic radiology: an illustrated guide for postmortem computed tomography technique and protocols critical care crisis and some recommendations during the covid- epidemic in china covid- outbreak: is it a health crisis or economic crisis or both? case of african counties, case of african counties facing up to the uncertainties of covid- creating fear: transforming terrorist attacks into control and consumption emotional contagion, studies in emotion and social interaction coupled contagion dynamics of fear and disease: mathematical and computational explorations the hierarchy of preference toward disability groups as covid- fears grow, some medical personnel face eviction from their home -the kathmandu post wagholi hospital staff evicted from nearby society amid covid- scare -pune mirror weil ich rztin bin- minuten coronavirus: nhs doctor 'evicted from home due to landlady's fears over covid- '-sky news coronavirus: doctor evicted by frightened landlady-the times women are using code words at pharmacies to escape domestic violence during lockdown-cnn global rise in domestic violence cases since coronavirus lockdown-vatican news italy coronavirus nurse, , strangled his doctor girlfriend, , to death after claiming she gave him killer bug-the sun monsters in metal cocoons:road rage and cyborg bodies road rage and cyclists injuries are sadly up in these tense cornavirus times-ny daily news coronavirus patients who refuse to self-isolate face murder charges in italy-metro news network structure and the biology of populations the black swan: the impact of the highly improbable, random house mathematical and statistical estimation approaches in epidemiology extreme value theory and fat tails in equity markets the rise of forensic and post-mortem radiologyâanalysis of the literature between the year format preferences of district attorneys for post-mortem medical imaging reports: understandability, cost effectiveness, and suitability for the courtroom: a questionnaire based study virtopsy approach: structured reporting versus free reporting for pmct findings role of pmct as a triage tool between external inspection and full autopsy-case series and review visualization and quantification of air embolism structure by processing postmortem msct data postmortem pulmonary ct in hypothermia fatal obstructive asphyxia: trans-pulmonary density gradient characteristic as relevant identifier in postmortem ct imaging and clinical features of patients with novel coronavirus sars-cov- radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study imaging profile of the covid- infection: radiologic findings and literature review radiology of severe acute respiratory syndrome (sars): the emerging pathologic-radiologic correlates of an emerging disease analysis of deaths during the severe acute respiratory syndrome (sars) epidemic in singapore: challenges in determining a sars diagnosis fatal fat embolism in acute hepatic necrosis with associated fatty liver when the heart kills the liver: acute liver failure in congestive heart failure acute liver failure liver injury in covid- : management and challenges severe influenza-associated respiratory infection in high hiv prevalence setting first cases of covid- in heart transplantation from china persistent polyclonal lymphocytosis of b lymphocytes b-cell signaling in persistent polyclonal b lymphocytosis (ppbl) role of mouse hepatitis virus-a receptor bgp a expression in virus-induced pathogenesis lymphocytose polyclonale à lymphocytes binuclées: une série monocentrique de patient(e)s, faculté de médecine de positive epstein-barr virus detection in corona virus disease (covid- ) patients cough quality in children: a comparison of subjective vs. bronchoscopic findings flow dynamics and characterization of a cough clinical characteristics of patients infected by sars-cov- in internationally lost covid- cases covid- outbreak on the diamond princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures presumed asymptomatic carrier transmission of covid- -novel coronavirus outbreak: a new challenge high infectivity and pathogenicity of influenza a virus via aerosol and droplet transmission rational use of personal protective equipment for coronavirus disease (covid- ): interim guidance coronavirus: handlungsanweisungen für ausrückfälle -v . acute heart failure negative nasopharyngeal and oropharyngeal swab does not rule out covid- correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases performance of radiologists in differentiating covid- from viral pneumonia on chest ct clinical radiology and postmortem imaging (virtopsy) are not the same: specific and unspecific postmortem signs der aussergewöhnliche todesfall: erste feststellungen am ort des geschehens virus strain of a mild covid- patient in hangzhou representing a new trend in sars-cov- evolution related to furin cleavage site procalcitonin as a biomarker in respiratory tract infection correlation analysis between disease severity and inflammationrelated parameters in patients with covid- pneumonia the authors express their gratitude to emma louise kessler, md for her generous donation to the zurich institute of forensic medicine, university of zurich, switzerland. data was published after having obtained a waiver by the ethics committee of the canton of zurich and with explicit permission of the investigating state attorney. the authors declare that they have no competing interests. key: cord- -ndzgxk k authors: kassa, semu m.; njagarah, john b.h.; terefe, yibeltal a. title: analysis of the mitigation strategies for covid- : from mathematical modelling perspective date: - - journal: chaos solitons fractals doi: . /j.chaos. . sha: doc_id: cord_uid: ndzgxk k in this article, a mathematical model for the transmission of covid- disease is formulated and analysed. it is shown that the model exhibits a backward bifurcation at [formula: see text] when recovered individuals do not develop a permanent immunity for the disease. in the absence of reinfection, it is proved that the model is without backward bifurcation and the disease free equilibrium is globally asymptotically stable for [formula: see text]. by using available data, the model is validated and parameter values are estimated. the sensitivity of the value of [formula: see text] to changes in any of the parameter values involved in its formula is analysed. moreover, various mitigation strategies are investigated using the proposed model and it is observed that the asymptomatic infectious group of individuals may play the major role in the re-emergence of the disease in the future. therefore, it is recommended that in the absence of vaccination, countries need to develop capacities to detect and isolate at least % of the asymptomatic infectious group of individuals while treating in isolation at least % of symptomatic patients to control the disease. a novel coronavirus, named a severe acute respiratory syndrome coronavirus (sars-cov- ; previously known as -ncov), was identified as the infectious agent causing an outbreak of viral pneumonia in wuhan, china, in december [ ] . the world health organization (who) medical team codenamed the new outbreak caused by sars-cov- as "coronavirus disease (covid- ) ". the infection is in the same category as the severe acute respiratory syndrome (sars) which emerged in southern china in , spreading to up to countries, with a total of , cases and claiming lives [ ] . covid- is also in the same category as the middle east respiratory syndrome (mers) which was first identified in saudi arabia in , and ended up spreading to countries around the world, reaching a total of , cases confirmed and claiming up to lives [ ] . since january , an increasing number of cases confirmed to be infected with covid- have been detected outside wuhan, and currently the infection has spread all over the world. as of may , , ( : gmt), covid- had affected all continents including island nations ( countries and territories as well as international conveyances), with the total number of cumulative infections globally standing at , , cases and , deaths [ ] , and the numbers still increasing. the major portal of entry of the virus into the body is the tissue lining the t-zones of the face (including the nose, eyes and mouth). the infection is characterised by loss of the sense of smell (a condition referred to as hyposmia/anosmia), taste and poor appetite. although, such conditions have been observed in covid- patients, many carriers of the infection may not show any severe symptoms like fever and cough but have hyposmia, loss of taste and loss of appetite. whereas knowledge of the virus dynamics and host response are essential for formulating strategies for antiviral treatment, vaccination, and epidemiological control of covid- , estimation of changes in transmission over time can provide insights into the epidemiological situation and help to identify whether public health control measures are having a measurable effect [ , ] . the analysis from mathematical models may assist decision makers to estimate the risk and forecast the potential spread of the disease in the population. understanding the transmission dynamics of the infection is crucial in designing alternative intervention strategies [ ] . in general, by approaching infectious kassa) mechanisms and adherence to the advice given by public health agencies. in particular, the people in some parts of asia have fully embraced the measures while many in other parts of the world were very much hesitant to use them. for example, wearing a face mask everyday in public appearances is like a ritual in most of the countries in southeast asia, while the same is considered as a bad gesture in many of the other parts of the world [ ] (even if it is now becoming a "new normal" also everywhere in the globe). one key difference between these societies and the people in the west is that, the communities in the southeast asia have experienced similar disease outbreaks before and the memories are still fresh and painful [ ] . that means, recent history of a similar event plays a role in behavioural change of the population especially at the beginning of the outbreak in addition to the perceived threat from the disease. therefore, in this paper, we consider a mathematical model that takes into account . the transmission dynamics of covid- similar to the sirs model, . the contribution of the asymptomatic infectious individuals in the transmission dynamics of the disease in the population, . the effect of indirect transmission of the disease through the environment, . behavioural change of individuals in the society to apply self-protective measures, and . the intensity of historical events from recent similar outbreaks. by analysing the proposed basic mathematical model, the effect of each of these factors is investigated in terms of their contribution to the control strategies of the disease. moreover, the use of isolation or quarantining and strict social distancing measures are also considered as mitigation strategies, and a comparative study is made for different scenarios. the layout of this paper is as follows: the model is described and formulated in the next section. its qualitative analysis is presented in section . estimation of the parameters and the sensitivity analysis of the reproduction number of the model with respect to involved parameters are discussed in section . numerical simulations of the model with some assumed intervention scenarios are also presented and analysed in this same section. concluding remarks of the study are given in sections . in this section, we present a mathematical model for the transmission dynamics of covid- which spreads in a population. the susceptible individuals can be infected through either direct contact with infectious individuals or indirect contact with the novel coronavirus infected environment. the population under consideration is grouped into disjoint compartments. individuals who are susceptible to the disease and without formal awareness about the prevention mechanisms or who did not decide to use any protective mechanisms are grouped in the class. individuals who are susceptible but are aware of and decide to apply any of the existing protective mechanisms after receiving public health information on how to protect themselves from the novel coronavirus infection are placed in the class. covid- infected individuals who are asymptomatic and symptomatic are grouped in classes and , respectively. some studies consider the asymptomatic class as the "exposed" class (see for instance [ ] ). but since the individuals in this group are known to be infectious and some of them also recover from the disease without going through the group [ ] , we used a name "carrier" to avoid confusion. the class contains the recovered individuals from covid- . finally, denotes the amount of the novel coronavirus pathogen that contaminates the environment due to shedding by covid- infectious individuals. in the analysis of the model, we intentionally excluded the actual exposed class for mathematical simplicity. however, a days incubation period is taken into consideration in the numerical simulation part of this paper. by combining the direct and indirect ways of transmission, the force of infection will have the form where = + + + + and is the concentration of the novel coronavirus in the environment which increases % chance of triggering the disease transmission. the proposed flow diagram for the transmission dynamics of covid- is depicted in figure while the description of each of the state variables is given in table . pathogen concentration on contaminated surfaces or objects in the environment. table description of the model variables the dynamics of the pandemic is described by using the following system of differential equations (see table for the description of the involved parameters): where with is the value of the force of infection corresponding to the threshold infectivity in which individuals start reacting swiftly (that means, the point at which the behaviour change function changes its concavity). we append the following nonnegative initial conditions to the system ( ): ( ) = , ( ) = , ( ) = , ( ) = , ( ) = , and ( ) = . rate of disease transmission from the environment the pathogen concentration in the environment that yields % of chance for a susceptible individual to catch the viral infection from the environment modification parameter (transmission of relative to ) rate of loosing immunity after recovery natural death rate fraction of recovered individuals moving into the class after loosing immunity table description of the model parameters in this section, we study the quantitative and qualitative analysis of the model system eq. ( ). we begin by determining the biologically feasible set for the model ( ) . the following theorem implies that the solutions of ( ) are nonnegative and bounded from above, provided that the initial conditions are nonnegative. proof: the proof of this theorem is outlined in appendix a. to determine the equilibrium solutions, we set the right-hand-side of eq. ( ) equal to zero and obtain then, the disease-free equilibrium (dfe) is found to be the basic reproduction number, which is very important for the qualitative analysis of the model, is determined here below by using the method of the next generation matrix used in [ , ] . for the model under consideration, using the notation = ( , , ), we have the vector functions with = + + and = + + represent the rates at which the disease compartments increase and decrease in size due to the infection, respectively. then the next generation matrix is where the basic reproduction number denoted by  is defined as the average number of secondary cases produced in a completely susceptible population by a typical infected individual during its entire period of being infectious [ , ] . mathematically,  is the spectral radius of in eq. ( ) and after further simplification, we obtain the next result is a direct application of theorem in [ ] . ( ) is locally asymptotically stable whenever  < and unstable if  > . the epidemiological implication of theorem . is that the transmission of covid- can be controlled by forcing the dynamics through its parameter values so that  < if the initial total numbers in each of the subpopulation involved in eq.( ) are in the basin of attraction of  . to ensure that elimination of the disease is independent of the initial size of the subpopulation, the disease-free equilibrium must be globally asymptotically stable when  < . this is what we present here below. where = the proof of theorem . is carried out using the center manifold theory in [ ] and is given in appendix b. in the above theorem (theorem . ), if the parameter describing the waning of immunity, , is zero, we can observe that both and are negative. hence, eq. ( ) fails to be true. in this case, we give below a theorem which asserts the global stability of the dfe of the model. the disease-free equilibrium of system ( ) in the case when = is globally asymptotically stable for  < . to prove the theorem for the case = , we use kamgang-sallet stability theorem stated in [ ] . let = ( , ) with = ( , , ) ∈ r and = ( , , ) ∈ r . then the system ( ) can be written aṡ and analysis of the mitigation strategies for covid- we show that the five sufficient conditions of kamgang-sallet theorem (in [ ] ) are satisfied as follows. . the system ( ) is a dynamical system on Ω. this is proved in theorem . . . the equilibrium * is gas for the subsysteṁ = ( , )( − * ). this is obvious from the structure of the involved matrix. . the matrix ( ) is metzler (i.e., all the off-diagonal elements are nonnegative) and irreducible for any given ∈ Ω. again this is straight forward from the formulation of matrix ( ). . there exists an upper-bound matrix̄ for the set this can also be verified by checking the eigenvalues of̄ under the condition of  < . hence, by the kamgang-sallet stability theorem [ ] , the disease-free equilibrium is globally asymptotically stable for  < . □ the reality behind theorem . is that, if immunity is permanent ( = ), coronavirus will be effectively controlled in the community by reducing  effectively to a value less than unity. the novel coronavirus being a new strain of coronaviruses, information about the dynamics of the infection is still evolving. biological studies of parameter values describing the vital dynamics of the infection are still ongoing as more laboratory tests become available. although some studies have been done on the early dynamics of the disease most especially on data from wuhan, extensive reading reveals that some of the disease dynamics parameters are highly variable and some processes are not fully explored. in this work, we use new cases data from hubei province of china extracted from who situation reports - [ ] , i.e. for the period january , to march , . we ought to fit the proposed model to the extracted data and estimate the unknown parameters. the total population of hubei province was estimated as . million. the life expectancy of hubei province varies depending on the area of dwelling (i.e urban or rural) as well as gender [ ] . for urban dwellers, the average life expectancy is estimated to be . years (with an average being . years for men and . years for women). the life expectancy of china of the year was estimated to be . years whereas that for the year is estimated as . years [ ] . owing to the negligible difference in the provincial and countrywide value, we use the country life expectancy for the year which gives an average mortality rate of = . × − per day. the recruitment rate is thus given as = × , where is taken to be the total population size, . million. the average time period taken for symptoms to appear after exposure is observed to vary considerably, with ranges between - days [ ] , - days [ ] , and some outliers going to up to days. the observed median incubation period was nearly days [ ] . the time to recovery from the onset of symptoms varies depending on the seriousness of the infection. individuals presenting mild illness were observed to recover in an average period of weeks while those presenting serious/critical illness recovering in about to weeks. for our parameter estimation and simulations, we consider a nominal value of . day − (corresponding to weeks) estimated from an interval ( . , . ). we note that a patient is considered recovered: ( ) if two swab tests taken in a time interval of at least hours both test negative, ( ) if the time taken after the end of respiratory symptoms and fever is at least hours. the waning of the immunity after recovery is estimated to range between months to year, which gives an interval for as ( . , . ) day − . for our simulation, we consider a nominal value of = . day − (approximately one year). we propose that at the end of the epidemic, at least − % of the recovering population will learn from the experiences during the infection and even when the acquired immunity wanes, such individuals will become susceptible individuals with past history/knowledge of the disease. the rate of recovery for the symptomatic individuals ( ) in wuhan varied considerably but majority of individuals who recovered from the virus were discharged from hospital after weeks [ ] . however, the patients in wenzhou-china stayed in hospital for days ( . per day) on average. in the model fitted on the early trends data from wuhan-china [ ] , the recovery rate obtained for symptomatic cases was . per day (accounting for days to recovery). the rate of recovery ( ) for carrier individuals is expected to be higher [ ] . according to the who situation report [ ] , it is estimated that up to % of covid- cases are asymptomatic or show mild symptoms, % show severe symptoms and up-to % end up with critical infection and require oxygen or a ventilator. the proportion of individuals who do not show symptoms or have mild symptoms can be as high as % [ ] . for our model fitting, we use a range of ( . , . ) for both and with selected initial values within the prescribed interval. although hubei province was put on a lockdown on january , , the first major decline in the number of new confirmed cases was only observed on february , (situation report [ ] ), approximately month after the lockdown was imposed. from february , , the method of identification of new cases was revised to include both cases confirmed through laboratory tests and clinical observations. as such, there was an observed spike in the number of new cases on february , to compared to cases (reported on february , ) and cases (reported february , ). applying the above described set of assumptions in the bounds for some of the parameters, we optimized the model output to fit the daily new cases data reported from the hubei province, china. the parameter values for which the model best fits to the incidence data are given in table . figure shows the plot of the reported new-cases data together with the incidence of the disease obtained from the model. as we can observe from the graph, the model analysis of the mitigation strategies for covid- slightly overestimates the reported data except for the two highest points. in addition, since our model does not assume any control measure at this stage while the reported data after the st day may represent the effect of the strict lockdown measure taken by the authorities, the parameters estimated give a good result. we note however that, in some recent work [ , ] , the use of fractional-order calculus is recommended to get better data fit. when we calculate the value of  from eq. ( ) using the estimated parameters given in table , we obtain  ≈ . , which is within the range of values reported in [ , ] . we examine the sensitivity of  to variations in parameter values and establish the significance of the sensitivity indices. we used the latin hypercube sampling (lhs) scheme, which is an efficient stratified monte carlo sampling that allows for simultaneous sampling of the multi-dimensional parameter space [ ] . for each run, simulations were done and partial rank correlation coefficients (prccs) [ ] calculated between each of the selected input parameters and the disease threshold. the prccs indicate the degree of effect each parameter has on the outcome, which in this case is the disease threshold. the sign of the prcc identifies the specific qualitative relationship between the input parameter and the output variable. the positive value of the prcc of the variables implies that when the value of the input parameter increases, the future number of cases will also increase. on the other hand, processes underlying the parameters with negative prccs have a potential to contain of the number of cases when enhanced. the results of sensitivity analysis are indicated in figure (a) and the box plot (figure (b) ) gives the five-number summary for the computed disease threshold value from the sampled parameter space. the processes described by parameters , , and with the greatest positive prccs have the greatest potential of worsening pandemic when increased. on the other hand, parameters (ℎ and ) with negative prccs have the greatest potential in helping contain the infection when maximised. in this respect, we note that increasing social/physical distancing directly reduces as this lowers the likelihood of a susceptible individual getting in contact with a potentially infected individual. in addition, practising good hygiene (such as regularly washing hands, using sanitisers to disinfect the infected environment and avoiding touching the t-zones of the face) is associated with lowering the likelihood of contracting the virus from infected surfaces. anything contrary to the above increases the likelihood of getting the infection through the two aforementioned routes. we further note that practising good hygiene also involves the infected individuals reducing the shedding of the virus into the environment. it is evident from the results in figure table . the processes underlying the parameters , , and have the greatest potential of making the epidemic worse if increased, whereas processes described by and ℎ have the greatest potential of containing the epidemic when enhanced. table that reducing the rate at which the virus is shed into the environment is significant in reducing the severity of the problem. from the five number summary of the results in figure (b), the lower quartile of the computed values of  is about , the median around . and the upper quartile of about . the obtained value of  is within the range of . ( % , . − . ) obtained in the early studies in [ ] . we note that for a selected combination of underlying processes much higher values of  can be obtained, which is an indication of possible worsening of the situation. in a similar way, we observe that for particular underlying processes (a selected combination of parameters) the value of  can be reduced to values below one. as indicated in [ ] , we note that although some parameters in the model may have very small magnitudes of prccs (non-monotonically related to the disease threshold output), they may still produce sizeable changes in the disease burden. to identify the most important parameters in containing or aggravating the epidemic, we computed p-values for the simulated parameters using fisher's transformation [ ] . we note that the computed prccs are bounded between the interval [− , ]. for this matter, some sampling distribution of variables that are highly correlated is skewed. the fisher's transformation ( ) = . log + − is used to transform the skew distribution to a normal distribution and then compute p-values for each of the parameters based on the prccs [ ] . the prccs for the parameters together with their corresponding p-values are indicated in table . we carry out pairwise comparison of the significant parameters (whose p-values are less than . , see table ) to ascertain whether the processes described by the compared parameters are different. we computed the p-values for the different pairs of significant parameters while accounting for the false discovery rate (fdr) adjustment and the results are given in table . the major question posed at this point is: are the different pairs of significant parameters different after fdr adjustment? based on the fdr adjusted p-values in table , the compared pair of parameters are rendered to be different if their p-value is less than . and not different otherwise. we summarise our results in table , where "true" indicates that the compared parameters are significantly different and "false" indicating otherwise. table are the parameters different after fdr adjustment? we observe that the more sensitive parameters are also significantly different (see table ) except for the − pair which may not necessarily be related. we examine effect of variation of the sensitive parameters on the reproduction number ( ). the results of the variation of parameters with more negative prccs are indicated in the bar graphs in figure ( ) . from figure , it is evident that the decay of the virus from the environment (figure (b) ) which can be accelerated by disinfecting surfaces reduces the value of  and consequently the disease burden. in addition, we observe that an increased proportion of individuals with knowledge of similar infections from the past that are practising selfprotection and preventive measures (see figure (a)) is important in slowing down the infection at the initial stage. such proportions of individuals would normally have knowledge about prevention and control mechanisms of the infection just at the onset of the disease. we observe in figure that the increase in person-to-person contact, (figure (a) ), poor personal hygiene, ( figure (b) ), and the rate of shedding of the virus into the environment by both carriers (figure (c) ) and symptomatic individuals ( figure (d) ) increase the value of  and therefore the disease burden. it is evident that the most effective way of containing the infection is by minimizing contact, which is why in most cases imposing a lockdown becomes an effective way of slowing the spread of the infection. in addition, good hygiene practices by all individuals are twofold: ( ) avoiding touching surfaces, always washing hands with soap and water, or using alcohol based hand sanitizer, which reduced the likelihood of contracting the pathogen from the environment; ( ) those who are sick with symptoms like cough and flu, ought to use masks, when they cough or sneeze, must do so in a sanitary tissue which must then be properly disposed off. we also note that hygienic practices without social/physical distancing may not significantly slow down the infection. in summary, we observe that it is possible to reduce the value of  to a value less than unity by reducing only the value of below . (see figure (a) ). this observation is in direct agreement with mitigation approaches that are aimed at minimising human-to-human contact (such as social distancing and imposing a lockdown). therefore, the table paremeter is more influential in the model and can also play a significant role in eradication of the disease. the other parameters (see figures , (b) , (c) and (d)) may reduce the value of  significantly when applied in combination but not as independent mitigation processes. there are various intervention mechanisms for covid- that are being implemented in different parts of the world. the strategies differ from country to country depending on the scientific information available to decision makers. to investigate the outcomes of the mitigation strategies, we include the isolated and/or quarantined classes to the model system ( ) . we assume that the individuals in the asymptomatic class ( ) are detected at a rate of and placed in isolation class, while the individuals in the symptomatic class ( ) are identified at a rate of and quarantined in class. moreover, the system is formulated as a mixed-delay system of differential equations, where the time delay is assumed to account for the incubation period of the disease. then the system becomes where the force of infection is now modified to with representing the average percentage of contacts reduced due to the social distancing measures and representing the total average rate (or percentage) of disinfecting the environment. in the modified model system ( ) , the parameters analysis of the mitigation strategies for covid- table . for the simulation purpose of this study, we considered five different cases or scenarios of how to apply the interventions. the strategies described in each of the cases below are in addition to the awareness creation for voluntary self-protective mechanisms which are widely communicated through various media outlets. here, we assume that the average effectiveness of the self-protective measures is % (as estimated from the data and reported in table ) , and the individuals who decided to use any one of them are strict in following the appropriate rules. here below, we consider each of the scenarios for mitigation strategies case by case. in this case, we assume that about % of the symptomatic infectious individuals and only % of the asymptomatic infectious individuals are detected and quarantined. this scenario is based on the assumption that among the people in the class only about % show "above mild" symptoms and hence visit health care facilities, while the remaining individuals in this class (nearly % of them) remain at home or at large in the society. then, through contact tracing mechanisms corresponding the hospitalized individuals, some people will be traced and tested, thereby about % of the total asymptomatic individuals can be detected. a similar scenario is being applied currently in some sub-saharan african countries. the time profile in figure shows the situation described in case . from this graph we can observe that the infection stabilizes around its endemic equilibrium, which is nearly at cases. (this number depends on the initial conditions and the demographic variables of the population under study.) this shows that the disease persists in the population. analysis of the mitigation strategies for covid- figure : dynamics of the disease with no additional intervention is applied. in this case, we assume that strict and longer time ( weeks) of social distancing rules are enforced by the government nearly weeks after the first positive case of covid- is reported in the community. we assume for simulation purpose that the implementation of the intervention strategy is divided into the following time phases. phase : the first phase in this case, is days long (measured starting from the time the first positive case of covid- is reported). during this phase, because of lack of information and the nature of the infection, we assume (as in case ) that only % of symptomatic infectious individuals and % of the asymptomatic infectious individuals are detected and quarantined. phase : the second phase is assumed to last for weeks ( days). during this period, it is also presumed that; * % of the symptomatic class and % of the asymptomatic class are detected and quarantined, * a mandatory strict social distancing rule is imposed, which is assumed to have a % reduction of effective contacts of individuals in the society, * environmental disinfection is widely carried out, which is assumed to result in a % reduction in the rate of infection from the environment, and to contribute about the same percent impact in increasing the rate of decay of the pathogen from the environment. phase : the third phase is assumed to be weeks ( days) long, and is characterised by the partial lifting of the 'lockdown' imposed in phase . during this period, it is assumed further that; * % of the symptomatic class and % of the asymptomatic class are detected and quarantined, * a relaxed social distancing rule is exercised, which is assumed to have a % reduction of effective contacts of individuals in the society, * environmental disinfection is partially carried out, which is assumed to have an impact of reducing the rate of infection from the environment by % and increasing the rate of decay of the pathogen from the environment by the same %. phase : the last and fourth phase is the time when the social distancing rule is fully lifted. due to the lesson learnt from the previous phases, we assume that the following interventions will continue during this period as well; * % of the class and % of the class are detected and quarantined, analysis of the mitigation strategies for covid- possible to significantly reduce the infection to a level where it cannot be a public threat. otherwise, any lower proportion of this effort will imply the resurgence of a second wave of the infection in the community. therefore, to contain covid- in every given community, public health authorities need to work more on the detection and quarantining of the asymptomatic infectious individuals. in this case, we assume that there is no lockdown imposed but only a large number of testing is applied to detect and quarantine a larger proportion of infected cases. if it is possible to intensify the effort of tracing the asymptomatic infectious individuals and be able to quarantine at least % of them continuously and effectively, our simulation shows that there is a possibility for the disease to be contained without imposing the strict lockdown rule on the total population. the plot in figure shows the time profile of the count of the infected groups while about % of the individuals from class are effectively quarantined (for example inside appropriate health facilities). we can observe that this intervention strategy can also produce the required result in containing the outbreak as some countries (like south korea) are currently following this pattern. in this case, we assume that the length of the lockdown period is nearly twice to the scenario in case . however, the effort in detecting the asymptomatic infectious individuals is kept at the minimum level. this scenario is more applicable in highly resource constrained countries as the current cost of testing is high. in this case, it is assumed that the length of the duration of each phase (except for phase ) is the same as that given in case . more still, it is supposed that; . the conditions in phase remain the same, . phase lasts weeks with % of the symptomatic individuals and % of the asymptomatic individuals detected and quarantined. moreover, strict social distancing rules are still in place with an effect of reducing % of human contacts and % of environmental variables, . phase lasts weeks (the same as in case ), but with % of individuals in the class and % of individuals in the class detected and quarantined, while partial social distancing rules are in place with an effect of reducing % of human contacts and % of environmental variables, . phase continues with detecting and quarantining % of members in the class and % of members in the class, while the other mandatory intervention are lifted. the time profile of the infection following the scenario in case is plotted in figure . the simulation for this scenario shows that even if we increase the length of lockdown period to weeks (like it was practised in the hubei province, china) the disease may re-emerge after some period of time. however, the heights of the peaks in the subsequent waves of the disease are much lower than the first peaks. therefore, once again, unless the authorities apply some kind of strict contact tracing mechanism and conduct enough testing to detect and isolate up to % of the asymptomatic infectious individuals, the disease persists in the community with multiple subsequent waves. in general, from the simulations, we can observe that in all of the above scenarios a transition from one phase to the other intervention phase is characterised by a surge in new cases. however, the number will eventually go down if the intervention in the immediate next phase is effective, or else the disease re-emerges in the population. analysis of the mitigation strategies for covid- figure : dynamics of the disease with at most % of the population in the class and at least % of the class are detected and quarantined just after phase period, with strict social distancing rule imposed for weeks. we presented a mathematical model for the dynamics of covid- whose first cases were reported in december in wuhan-china. the model incorporates a behaviour change function to account for the proportion of individuals who decided to use any of the self-protective measures and adhered to them. in addition, it also considers a proportion of individuals with a history/knowledge of similar infections from the past and practice necessary protective measures right from the onset of the epidemic. the model also accounts for asymptomatic carriers of the infection as well as the concentration of the pathogen within the environment. the basic properties of the model including well-posedness, the disease free equilibrium and its stability, model basic reproduction number as well as the existence of backward bifurcation were examined. to estimate the parameter values, the model was fitted to the data on daily new cases reported in who situation reports - [ ] , which accounts for the period from january , to march , . from the nominal values from the data fitting, we obtained a reproduction number,  ≈ . ( . - ) which compares well with the values of  obtained in other researches, for instance, ( . − . ) [ ] and . ( %ci, . − . ) [ ] . from our sensitivity analysis simulations, we observed that for some given parameter combinations, the value of  can be reduced to below , and similarly for values much higher than . we observed that if the recovering individuals do so with permanent immunity ( = ), then reducing the reproduction number to a value below unity is enough to contain the infection. on the other hand, if recovering individuals do so with temporary immunity ( ≠ ), the proposed model exhibits backward bifurcation, which implies that reducing the value of  below is not enough to contain the infection. by applying the latin hypercube sampling scheme, we observed that if the disease is to be easily contained, measures such as; physical/social distancing (which reduces the rate of disease transmission directly from human to human), improved personal hygiene (which reduces the rate of disease transmission from the environment to humans), and minimal shedding of the pathogen into the environment by both asymptomatic and symptomatic individuals, have the greatest potential of slowing the epidemic when enhanced. we further observed that increased decay of the pathogen from the environment (achieved by disinfecting surfaces) alone is less significant in reducing/curbing the number of cases. we further observed that having high numbers of people with knowledge from previous similar infections, that are practising the prescribed self-protective measures can delay/slow down the otherwise potentially explosive outbreak. consequently, the daily number of cases is kept at low manageable levels. in addition, increasing the average effectiveness of the self-protective measures and adherence to such measures is vital in realising low peaks of the number of cases. furthermore, due to the absence of vaccination or any approved medication, developing capacity to detect carrier groups is very important. from our results, it is recommended that countries should develop capacities to identify and quarantine at least % of carriers as well as at least % of symptomatic cases if the infection is to be controlled. our model predicts a possible resurgence of the number of cases, if the asymptomatic cases are still many by the time disease spread curbs/lockdown measures are lifted. in addition, we observe from simulations that although disease spread curbs (such as a lockdown measure) may be imposed, their real impact on the number of new cases may only be realised after approximately days, and the reduction (when it appears) could be sharp in the case of a strict lockdown measure with high impact in reducing effective contact between individuals in the population. when providing the mitigation strategies, we did not account for the delay between the actual incidence and the point when cases have been confirmed since the actual parameters describing such a delay are not known. in health systems where testing of suspected cases is done after individuals show symptoms or on demand, it is likely to have a big gap between the actual incidence and confirmation of new cases. the impact of the delay between actual incidence and confirmation of case can be explored in future work. in addition, we assumed that all individuals who recover, do so with the same level of immunity. however, this may not necessarily be the case since immunity of individuals is affected by a number of factors, including age, cortisol levels and nutrition among others. the impact of differentiated levels of immunity on the disease dynamics and potential resurgence of the epidemic can be explored in the future when relevant data becomes available. our model did not include the possibility of vaccination or treatment. we, however acknowledge their importance in controlling the infection. therefore, optimal control of the infection in the presence of these mitigation strategies can be explored in future works when relevant data becomes available. since the disease has been observed to affect age groups differently, it is plausible to consider age-structured models to better understand the effect of the disease in the respective age groups. likewise, from the fourth equation of ( ), we obtain ′ = ( − ) + ( − )( − ) + − ( + + ) ≥ −( + + ) . solving ( ) similarly, using the last two equations of eq. ( ), we have and because ( ), ( ), ( ), and ( ) are nonnegative for ≥ . solving eqs. ( ) and ( ) gives and respectively. thus, any solution of eq. ( ) is nonnegative for ≥ and any initial condition in Ω. finally, the total number of the population ( ) at time is governed by thus, for the initial data ≤ ( ) ≤ , by gronwall inequality, we obtain moreover, for the environmental variable , we have because ( ) and ( ) are less than for all ≥ . applying again the gronwall inequality, for ≤ ( ) ≤ ( + ) , leads into combining the above two steps and theorem . . in [ ] for the existence of unique bounded solution, we infer that any solution of eq. ( ) is nonnegative and bounded. hence, eq. ( ) defines a dynamical system on Ω. □ sensitivity and uncertainty analysis of complex models of disease transmission: an hiv model as an example effects of information-dependent vaccination behavior on coronavirus outbreak: insights from a siri model vertically transmitted disease: models and dynamics a day-by-day breakdown of coronavirus symptoms shows how the disease covid- goes from bad to worse temporal changes in ebola transmission in sierra leone and implications for control requirements: a real-time modelling study dynamical models of tuberculosis and their application symptoms of coronavirus a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster a mathematical model for simulating the phase-based transmissibility of a novel coronavirus vital surveillances: the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- )-china mathematical epidemiology of infectious diseases optimal covid- epidemic control until vaccine deployment. medr iv: preprint vaccinating behaviour, information, and the dynamics of sir vaccine preventable diseases endemic disease, awareness, and local behavioural response modelling the influence of human behaviour on the spread of infectious diseases: a review clinical characteristics of novel coronavirus infection in china multiple sources and routes of information transmission: implications for epidemic dynamics covid- : what proportion are asymptomatic? sampling and statistical analyses tools (sasat) for computational modelling clinical features of patients infected with novel coronavirus in wuhan epidemiology of coronavirus respiratory infections mathematical modeling of the spread of the coronavirus disease (covid- ) taking into account the undetected infections. the case of china analysis of an epidemic model with awareness decay on regular random networks computation of threshold conditions for epidemiological models and global stability of the disease-free equilibrium (dfe) epidemiological models with prevalence dependent endogenous self-protection measure the impact of self-protective measures in the optimal interventions for controlling infectious diseases of human population effect of negligence and length of time delay in spontaneous behavioural changes for the response to epidemics modeling the dynamics of novel coronavirus ( -ncov) with fractional derivative early dynamics of transmission and control of covid- : a mathematical modelling study modeling the role of information and limited optimal treatment on disease prevalence new coronavirus outbreak: framing questions for pandemic prevention china life expectancy modeling the interplay between human behavior and the spread of infectious diseases mathematical modeling of covid- transmission dynamics with a case study of wuhan sars (severe acute respiratory syndrome) fractional derivatives applied to mseir problems: comparative study with real world data modeling chickenpox disease with fractional derivatives: from caputo to atangana-baleanu novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions transmission dynamics of the etiological agent of sars in hong kong: impact of public health interventions mathematical modeling of epidemic diseases: a case study of the covid- coronavirus. ar ive dynamical systems and numerical analysis reproduction numbers and sub-threshold endemic equilibria for compartmental models of disease transmission aerosol and surface stability of sars-cov- as compared with sars-cov- statistical physics of vaccination middle east respiratory syndrome: mers situation update coronavirus disease (covid- ): situation report- coronavirus disease (covid- ) situation reports total population, life expectancy and ethicity of hubei virological assessment of hospitalized cases of coronavirus disease coronavirus: why some countries wear face masks and others don't coronavirus incubation period covid- coronavirus pandemic nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study duration of antibody responses after severe acute respiratory syndrome preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak the analysis of the mitigation strategies for covid- figure : dynamics of the disease with a mandatory -weeks lockdown and a -weeks of partial social distancing is imposed as described in case * environmental disinfection is partially carried out, which is assumed to have an impact of reducing the rate of infection from the environment by % and increasing the rate of decay of the pathogen from the environment by the same %.the time profile of the disease dynamics after implementing the above described interventions strategy is plotted in figure . the figure shows that the count of the infected individuals decreases down to nearly zero in phases and , but the disease resurges back into the society soon after. however, the peak of the second wave looks to be much smaller than the first one. that means, the intervention mechanisms described in the above phases of this case are not enough to contain the disease, and unless some additional intervention mechanisms are developed the disease persists in the society. in this case, we assume that early action with shorter time social distancing rule is applied. in this scenario, it is assumed that the interventions described in case started half way through the time that phase was implemented in case . that means, the implementation of the interventions described in the four phases of case is assumed to be followed, but the length of the time in phases and is reduced as described below. otherwise, all the details of the interventions in case are kept the same. the time profile for this set of interventions is given in figure . the general behaviour of the graph in figure is the same as that of figure . however, this strategy has an advantage in significantly reducing the height of the first peak. the height of the subsequent peaks are found to be the same unless some additional measures are taken after phase .unfortunately, the strategies in both of the above two scenarios (case and case ) do not help to fully contain the disease once it spreads in the population. as it can be seen from figures and , another wave of outbreaks of the disease emerge at a later stage. here, we can see that the asymptomatic infectious individuals play the greater role in becoming the major source for the second wave. therefore, if there is a possibility to track and detect people with asymptomatic infection, and if they can be effectively quarantined for the required period of time, then there is a possibility for the disease to be contained. as it can be observed from figure , if we can increase the rate of detecting and quarantining the asymptomatic individuals to a proportion of about %, it is appendix a. proof of theorem . the proof of theorem . is outlined here below based on the following two steps. first, we show that all solutions of eq.( ) are nonnegative as required in [ , ] . to show that the state variables and of the model are positive for all ≥ , we use proof by contradiction. we suppose that a trajectory crosses one of the positive cones at times or such that:using the first equation of eq. ( ), the first assumption leads towhich contradicts the first assumption that ′ ( ) < . thus, ( ) remains positive for all ≥ . here, is chosen so that our point to be on the positive axis of ( ) so that ( ) is positive.using the second equation of eq. ( ), ′ ( ) = ℎ + + > , which also contradicts the assumption ′ ( ) < . hence, ( ) remains positive for all ≥ . based on the third equation of eq. ( ),analysis of the mitigation strategies for covid- proof: the theorem is the direct application of theorem . in [ ] . to check the existence of backward bifurcation of the model eq. ( ) at  = , we use the center manifold theorem [ ] . for this purpose, we introduce the following change of variables.so that = + + + + , = ( + ) + + , and ( ) = + .moreover, by using the vector notation = ( , , , , , ) , the model eq.( ) can be written in the form ′ ( ) = = ( , , , , , ) as follows: where, = + + , = + + , and = + . when  = and is considered as a bifurcation parameter, from ( ) we get further more, < * if and only if  < and > * whenever  > . the jacobian of the system ( ) at the associated ( ) isthe transformed system eq. ( ), with = * , has a non-hyperbolic equilibrium point such that the linear system has a simple eigenvalue with zero real part and all other eigenvalues have negative real parts. hence, the centre manifold theory [ ] can be used to analyse the dynamics of the model eq. ( ) near = * . by using the notation in [ ] , the following computations are carried out.the right-eigenvectoranalysis of the mitigation strategies for covid- associated with the zero eigenvalue of ( ) such that ( ). = at = * is given byof ( * ) such that the right-eigenvector and the left-eigenvector need to satisfy the condition . = .the bifurcation coefficient at the dfe ( ) is given by analysis of the mitigation strategies for covid- thus, the bifurcation coefficient , can be positive for the right choice of the parametric values that satisfy the condition in eq. ( ) .the second bifurcation coefficient is given by clearly, > because and are positive. when = , and in ( ) are negative and in ( ) is negative as well. hence, by theorem . in [ ] , the model will not exhibit a backward bifurcation at  = . ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: semu mitiku kassa, hatson j. b. njagarah, yibeltal a. terefe. key: cord- -yrq n k authors: teles, pedro title: predicting the evolution of covid- in portugal using an adapted sir model previously used in south korea for the mers outbreak date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: yrq n k since original reports in wuhan, china, the new coronavirus covid- has spread very quickly worldwide, leading the world health organization (who) to declare a state of pandemic. moreover, as of the th of march , the who has announced that the european continent is now the main centre of the pandemic. many european governments have already implemented harsh measures to attempt to contain the spread of the virus. in portugal, there are, as of the th of march , confirmed cases. one of the questions many policy makers, and governments are asking themselves is how the spread is going to evolve in time. a timely idea of the amount of cases that will exist in a near future can allow governments and policy makers to act accordingly. in this study, i applied an adapted sir model previously used in south korea to model the mers outbreak, which is also caused by a coronavirus, to estimate the evolution of the curve of active cases in the case of the portuguese situation. as some of the parameters were unknown, and the data for portugal is still scarce, given that the outbreak started later (first case on the nd of march) i used italian data (first reported case in italy on the st of january) to predict them. i then construct two or three different scenarios for the evolution of covid- in portugal, considering both the effectiveness of the mitigation measurements implemented by the government, and the self-protective measures taken by the population, as explained in the south korean model. in the out of control scenario, the number of active cases could reach as much as ~ , people by the beginning of april. if measures are appropriately taken this number can be reduced to about cases. in case that some measures are taken, but their implementation is not done appropriately, the active cases could reach circa , people. the actual figures probably lie between the interval (~ - , ) and the peak will be reached between th and the nd of april . without control and self-protective measures, this model predicts that the figures of active cases of sars-covid- would reach a staggering ~ , people it shows the importance of control and self-protecting measure to bring down the number of affected people by following the recommendations of the who and health authorities. with the appropriate measures, this number can be brought down to ~ - , people. hopefully that will be the case not just in portugal, but in the rest of the world. there is already abundant information on the new coronavirus and its spread worldwide [ ] [ ] [ ] , as well as the risks it poses to the population. the person infected with the severe acute respiratory syndrome coronavirus (sars-cov- ) [ ] may develop the disease called covid- , which manifests with mild to severe symptoms of fever, cough, shortness of breath and other signs [ ] . in the most severe cases, the infection can lead to the development of acute respiratory distress syndrome (ards) causing respiratory failure, septic shock, or multiorgan failure, and even death [ ] . there is yet a lot about this new coronavirus that is still unknown. studies suggest that the case fatality rate of the virus is of about . % in mainland china, but the authors suggest considering the range . - . % [ ] . however, this value seems to be much higher in italy [ ] , suggesting its strong dependence on demographics. in fact, the chinese center for disease control, released an analysis that showed that the case fatality rate ranged from % in children aged - years old to . % in those over [ ] , which implies that countries with a high number of elderly citizens, as is the case of italy and portugal, are more prone to having higher death rates. the quick spread of the virus in europe has led the who to declare europe as the new epicentre of the disease on the th of march of [ ] . the rapid growth of the number of active cases presenting severe symptoms has saturated the health services in most countries in the continent, especially in italy [ ] . it is yet unknown when the epidemic will reach an end, but governments throughout europe have implemented harsh measures to prevent and mitigate the spread of the virus. yet, as of today there are as many as , confirmed cases on the european continent, in territories, resulting in , deaths, and rising [ ] [ ] . in portugal, the two first confirmed cases in the portuguese territory were announced on the nd of march, which puts the country slightly behind the curve in the outbreak in the european continent. as of today, there are confirmed cases, deaths, and recovered [ ] . also, the country is on lockdown since the th of march , and the portuguese parliament declared a state of emergency today ( th of march ). one of the questions many policy makers, and governments are asking themselves is how the spread is going to evolve in time. a timely idea of the amount of cases that will exist in a near future can allow governments and policy makers to act accordingly. in this study, i adapted a model of the sir type used in south-korea to model the evolution of the active cases of the mers outbreak in the country back in [ ] . although there are other models being used [ ] [ ] , this model seemed most appropriate given that the mers and the sars-cov- are related illnesses, both provoked by a coronavirus strand, and with similar symptoms, although mers was much deadlier. in order to fit the parameters and given that there is still very little data in the case of portugal, i used the data of italy instead. this allowed me to fit the curve of current active cases in portugal with a model, which i then use, by implementing the control measure parameters predicted in the model to predict the future number of cases, in three different scenarios (the outof-control scenario, a scenario in which the government is successful in applying control measures and citizens mildly adhere to self-protection measures, and a scenario in which the government fails to completely apply control measures, yet citizens still adhere to some measure of self-protection). the model used is the model described in xia et al [ ] , which can be understood by the flow diagram shown in figure (which was taken from the paper, page ). in this model, s corresponds to the number of susceptible individuals; e, the number of exposed individuals; a, the number of asymptomatic infected cases; i, the total number of mild-to-severe infected patients. h, the number of hospitalized cases; r, the number of removed cases, and finally n, the total population of portugal. β is the transmission coefficient of the asymptomatic infected cases, β is the transmission coefficient of the symptomatic infected cases (mild infected person and severe patients) to the susceptible, β is the transmission coefficient of the hospitalized cases to the susceptible, / is the mean incubation period, / is the mean time between symptom onset to hospitalization, /k is the mean infectious period of asymptomatic infected person for survivors, /k is the mean duration for hospitalized cases for survivors, / is the mean time from hospitalization to death, γ is the clinical outbreak rate in all the infected cases. the time unit is day. figure . flow chart of the sir-type model used in this work, taken from [ ] the set of differential equations can then be written as: ( ) given that the available data for covid- is still very preliminary, the model was further adapted. the only parameters that were considered "known" were the mean incubation time, which was taken as / = . days from the literature (here using the median as equal to the mean) [ ] , and the mean infectious period of asymptomatic people, where a conservative estimate of /k = days was used. all other parameters were taken to be "unknown". furthermore, and because the fitting of the model was difficult to achieve, i took β = β = β as a first approximation, meaning that the mean transmission coefficient is the same independently of type and setting of the transmission. finally, unlike xia et al [ ] , i consider that the epidemic starts with only one person infected (i = ), being the rest of the values , except for s which is simply n- . see table for a breakdown of the different parameters of this model. the solving of the system of differential equations was performed using the mathematica code [ ] , which also allows for the use of fittable parameters, using the function "nonlinearmodelfit" [ ] . given that there is still very little data for portugal, the data for italy was used as proxy. this seems like the most reasonable approach (instead of using data from china or another asian country), given the cultural and health system proximity between the two countries. in order to determine the parameters   i used the number of deaths, as reported by the italian ministry of health and available online [ ] . for the estimation of the value of k , the number of recovered was used. after determining the values for these parameters, they were used to fit the curve of infected cases for portugal, where the values of === and  were fitted to obtain a model. this model was then used to estimate the future evolution of future cases in portugal, according to three different scenarios: • out-of-control scenario (nothing done, the virus is free to spread); • scenario in which the government takes severe mitigating measures and the population mildly adheres to self-protecting measures; • scenario in which the government fails to implement mitigating measures, yet still implements some, and the population mildly adheres to selfprotecting measures. . . fitting of parameters  and  (italy). the number of deaths in italy was taken from [ ], and the set of differential equations described in eq. fitted to obtain the best possible fit for parameters  and  an r value of . was obtain with the fit. the rest of the parameters are presented in table . results are shown in figure . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint as can be seen, in the case of recovered cases, the fit has not the same quality as the fit in . . this is further evidenced by figure , where a graphical representation of the fit is shown. after the two previous procedures, we now have all the parameters we need to fit eq. to the number of portuguese active cases, in order to determine the value of  and  the number of portuguese active cases was taken from [ ], which is updated daily. the values previously obtained of parameters   and k were used. as explained previously, because the fitting was difficult to obtain, as a first approximation, we considered β = β = β . the obtained values for  and  are given in table . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . a graphical depiction of the fitted model is given in figure . in this scenario, the out-of-control scenario, in which the corona virus would be "free" to spread within the country would lead to a pic of ~ , infected around the th of april . a scenario that will very likely be avoided given the strong containment measures implemented by the government. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the fitting of these parameters was difficult to obtain. there is enough systematic error and lack of statistics to make the present results very unreliable. in order to obtain the parameters for  and k , an ersatz value for  had to be given. in this model,  is originally defined as "the clinical outbreak rate in all the infected cases", which is in itself difficult to understand what it means. in the cases of the fits of  and k , the ersatz value used for  had a very strong impact in the results of the other parameters. in fact, as it comes multiplied with  in the transfer from compartment e(t) to compartments a(t) and s(t), i think the high variation in this value could very well be due to the huge uncertainty there is at the moment for the appropriate incubation time of this virus, which some authors claim can be of up to days [ ] , although this number is probably an outlier. finally, a case of an incubation period of days seems to have been confirmed by a recent study [ ] . the other parameters are somewhat less elusive. the obtained value for = . is % the value obtained by xia et al [ ] of . , which shows the difference in case fatality rates between the sars-covid- ( . % currently for italy), and mers (estimated at %), but then again the value should be % of this value and not %, further implying that the case fatality rate of the sarscovid- is still difficult to determine, and could be higher than previously thought. finally, from the obtained values it is also possible to determine a value for the basic reproduction number r , which here i take as being simply the value r == . which demonstrates how strong the capacity for spreading of this particular virus is. in table , the final values of the obtained parameters are given. the paper by xia et al [ ] further presents an extra parameters to take into account control measures in time evolution of the epidemic. these parameters are meant to take into account two things: -isolation and monitoring measures taken by the government (parameters d , d , d , and d ); -self-protection measures taken by the population (parameters l , l , and l ). . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. ( ) the l , l , and l parameters are basically multiplication factors for the transmission parameter , so in our model we only consider one value for it as we did for . the d , d , d , and d parameters are summed to the parameters of spread between the infected, asymptomatic and hospitalized cases, further stressing their connection to implemented government measures. the values provided by xia et al [ ] , when applied to the portuguese case, seem to provide a very unrealistic scenario, in which the values would immediately start to diminish. perhaps this made sense in the case of the mers epidemic, given that it was much more localised that the one provoked by this virus. as such, and for the lack of a better model, i devised two different scenarios in addition to the "outof-control" scenario described in the previous section: • scenario in which the government takes severe mitigating measures and the population mildly adheres to self-protecting measures (scenario ); • scenario in which the government fails to implement mitigating measures, yet still implements some, and the population mildly adheres to selfprotecting measures (scenario ). the values for these scenarios are given in table . [ ] . in the second scenario i keep the % reduction in the transmission rate but diminish the efforts of the government by half. results are shown in figure . results show that measures can be effective in "flattening the curve", as it has come to be called this effect in recent times. in the first scenario the effectiveness of the control measures seems to be at a maximum, and a maximum of just about cases would be reached. this seems unlikely as of today, there are active cases in the country. in scenario , the maximum is shifted to the th of april, reaching a maximum number of ~ , active cases in the country. in this scenario, the transmission rate has been cut to a half, but the government has not been effective in implementing control measures. as said previously, in the out-of-control scenario, the peak would be reached at about ~ , people. given the huge uncertainties concerning these numbers, and the current lack of knowledge of the ongoing epidemic, it is very hard to make sense of its evolution, even using well-established sir methods. the current work makes a series of assumptions which may or may not be proven correct in the future, including the incubation period of the virus, which is still not well-known. this proved to be a major source of uncertainty to fit the results, because it had a great influence in the other parameters, especially parameter , which seems to describe a probability of the person being exposed to the virus being symptomatic or not. instead this parameter seems to behave in this study as an indicator of the huge uncertainty of the value for the incubation period. finally, epidemiologists and pathologists will tell you that these parameters, unlike what is considered in this study, are not only not constant, but dependent on time, location, culture, and other factors. it is therefore particularly hard to model the current epidemic of covid- . also, this study takes into account the particular situation for one country (portugal), and we know that in globalised times, the likelihood that new foci of infections arise from outside visitors is also very high. although currently most government have implemented serious travel restrictions, it is now well-known exactly how this parameter could affect this model, which does not take that into account. in fact, one of the major issues with the sars-covid- virus is that, unlike the other sars, it seems to be much less contained locally, as is evident by the amount of countries afflicted. the amount of actual active cases is another clear source of uncertainty. this model takes the values of active cases and compares them with official confirmed numbers, which not only may be smaller than the actual cases, as are released at an administratively defined time, which probably does not correspond to something realistic. the author believes that the values obtained in this study should be taken qualitatively rather than quantitatively. one can think of the scenarios as defining two limits of a likelihood interval, and as such, the actual figure of maximum number of active cases in portugal will likely be in the interval ~ - , between the th- th of april. this can perhaps serve to advise the competent authorities in taking the appropriate measures. it also serves to show the importance of control and self-protecting measures. it is possible to bring down the number of affected people by following the recommendations of the who and health authorities. without them, this model predicts that the figures of active cases would reach a staggering ~ , people. it also shows that with the appropriate measures this can be indeed brought down. hopefully that will be the case not just in portugal, but in the rest of the world. novel coronavirus ( -ncov) situation reports -world health organization coronavirus disease (covid- ) -research and statistics the species severe acute respiratory syndrome-related coronavirus: classifying -ncov and naming it sars-cov- epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study covid- : what is next for public health case-fatality estimates for covid- calculated by using a lag time for fatality emerg infect dis why deaths from coronavirus are so high in italy, rachael rettner, livescience on march novel coronavirus pneumonia emergency response epidemiology teamexternal icon. [the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china who director-general's opening remarks at the media briefing on covid- - the atlantic modeling the transmission of middle east respirator syndrome corona virus in the republic of korea xia a time-dependent sir model for covid- risk assessment of novel coronavirus covid- outbreaks outside china the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application mathematica, version dipartimento della protezione civile covid- italia -monitoraggio della situazione coronavirus incubation could be as long as days, chinese provincial government says -reuters presumed asymptomatic carrier transmission of covid- key: cord- -ps f jq authors: levallois, p.; chevalier, p.; gingras, s.; déry, p.; payment, p.; michel, p.; rodriguez, m. title: risk of infectious gastroenteritis in young children living in québec rural areas with intensive animal farming: results of a case–control study ( – ) date: - - journal: zoonoses public health doi: . /zph. sha: doc_id: cord_uid: ps f jq this study was designed to evaluate the epidemiology of severe gastroenteritis in children living in québec rural areas with intensive livestock activities. from september through june , cases of gastroenteritis in children aged from months to years, hospitalized or notified to the public health department were enrolled, and eligible controls participated. the parents of cases and controls were asked questions about different gastroenteritis risk factors. the quality of the drinking water used by the participants was investigated for microbial indicators as well as for four zoonotic bacterial pathogens (campylobacter spp, escherichia coli, salmonella spp and yersinia spp) and two enteric parasites (cryptosporidium spp and giardia spp). from stool specimen analysed, viruses were detected in cases ( %), while ( %) were found with at least one of the bacteria investigated, and five cases were infected by parasites. campylobacteriosis was the main bacterial infection (n = ), followed by salmonella sp (n = ) and e. coli o :h (n = ) among cases with bacterial gastroenteritis. no significant difference was found between cases and controls regarding the quality of water consumed; the frequency of faecal contamination of private wells was also similar between cases and controls. considering the total cases (including those with a virus), no link was found between severe gastroenteritis and either being in contact with animals or living in a municipality with the highest animal density ( th quartile). however, when considering only cases with a bacterial or parasite infection (n = ), there was a weak association with pig density that was not statistically significant after adjusting for potential confounders. contact with domestic, zoo or farm animals were the only environmental factor associated with the disease. intensive livestock activities generate manure run-off, which can be an important source of microbial water contamination (thurston-enriquez et al., ) . this could be a significant source of pathogenic microorganisms, if improper manure handling contaminates the water supply (guan and holley, ) . as a consequence, drinking water in regions with intensive agricultural activities may be responsible for increasing the risk of acute enteric infections, especially from non-disinfected groundwater (kapperud et al., ; kuusi et al., ) . agro-environmental activities represent a potential pressure on water quality and may lead to the presence of waterborne pathogenic microorganisms from animal sources (zoonotic agents) (bigras-poulin et al., ) . this situation has been described in several studies in the province of ontario (canada), and cattle density was positively associated with notified gastrointestinal diseases caused by escherichia coli o :h (michel et al., ) or shiga toxin-producing e. coli (valcour et al., ) . in a review of waterborne outbreaks in canada during the - period, schuster et al. ( ) found eight outbreaks (of ) attributed to livestock, and as reported by guan and holley ( ) , several waterborne outbreaks in north america for the - period could have involved improper manure handling. children have been identified as a sensitive population for gastroenteritis morbidity (balbus and lang, ; kosek et al., ; olesen et al., ) . most studies have demonstrated that children are more prone to become ill from enteric pathogens than adults (peterson and calderon, ; sinclair et al., ) with a disproportionate disease burden for those younger than years (koehler et al., ) . payment et al. ( ) reported that children - years old were the most affected by gastrointestinal illnesses during a prospective study. a recent survey also indicated a higher prevalence of gastroenteritis for children aged less than years living in rural municipalities with an 'excess' of animal manure in the province of qu ebec (febriani et al., ) . we conducted a population-based case-control survey of all children aged less than years and living in a large rural area, with intensive animal farming, admitted to hospitals or notified to the public health department (as reportable diseases), with symptoms of acute diarrhoea during a period of months. the specific objective of the study was to verify whether drinking water from private wells or public waterworks in rural or intensive animal farming was a risk factor for water contamination and gastroenteritis in a sensitive subpopulation. we also intended to evaluate more proximal factors such as contact with farming or domestic animals. the study was conducted from november through june in the administrative area of chaudi ere-appalaches (province of qu ebec, canada), which had a population of approximately inhabitants ( . % of qu ebec's population) among municipalities. this region was selected due to its importance in livestock agricultural production; the area includes % of the farms in qu ebec and is responsible for % and % of porcine and avian production, respectively (mapaq, ) . the study was conducted with the collaboration of the paediatric departments of the five hospitals covering the entire area and where hospitalized cases were identified: three general care community hospitals and two tertiary university hospitals. non-hospitalized cases (diagnosed in private clinics or at a doctor's office) notified to the region's public health department were reported to the research team. because the notified cases were recruited only after august and the recruitment of the hospitalized patients was fully operating only after that date, the analysis only included data from september - june . we defined a case as a child who was (i) a resident of the study area; (ii) aged from months to years; (iii) either (a) hospitalized for diarrhoea in the absence of a diagnosed chronic gastrointestinal disease; or (b) notified to the public health department with a laboratory diagnosis of gastroenteritis for one of the microbial enteric pathogens of interest. within hospitals, medical staff approached the parents or caretakers of eligible children to obtain consent to provide epidemiological and clinical information. notified community cases (not hospitalized) were investigated by nurses from the public health department. for each case, two controls in the same age category (table ) , living in the study area, were selected at random from the qu ebec public health insurance plan (r egie de l'assurance-maladie du qu ebec) and contacted the following day after the case was discovered. before being phoned, parents of potential controls had received a letter of information about the investigation. criteria for exclusion of potential controls were (i) a history of diarrhoea during the preceding months and (ii) being a sibling of a case. shortly after the children were discharged from the hospitals, data were gathered by asking parents or caretakers to complete a standardized questionnaire by telephone. the same protocol was applied to non-hospitalized children after the nurse from the public health department enrolled the case. enrolled children were further excluded if the parent(s) refused to complete the telephone follow-up. parents or caretakers of controls were also contacted by telephone to be interviewed with a similar standardized questionnaire. there was a mean delay of days between interviewing the parents of cases and those of controls. the interviewers were not blinded to the case/control status of the study subjects; however, they were given training so that they interviewed parents of cases and controls in the same systematic manner. the questionnaire covered personal, demographic and socio-economic data, as well as specific exposures occurring in the previous weeks of the reference date (the beginning of symptoms for the cases and the time of the interview for controls). among the included exposures were travel abroad (previous month), eating outside of the home, eating meat products or milk products (previous week), drinking water not from waterworks or from bottles and contact with domestic, zoo or farm animals (previous weeks). information describing the quality and supply of the household's drinking water was also collected. all study subjects were also asked about chronic gastrointestinal illness. for hospitalized cases three faecal samples were collected from the cases within h of admission to hospital. samples for bacteriological culture were placed in an enteric pathogen transport medium (quelab laboratories, qu ebec, canada), preserved at °c and transported to the hospital laboratory. samples for protozoan evaluation were collected in a parasitology medium (sodium acetate, acetic acid and formalin -saf) and stored at room temperature. samples for virus detection were collected in a transport tube, frozen at À to À °c (depending on hospital facilities). stools of non-hospitalized cases were collected wether at home or at clinics or in doctors' offices and sent to hospitals where they were analysed for bacteria in the same way as specimens from hospitalized cases. however, protozoa and virus detection was not systematically carried out for these cases because it is not a usual practice for family doctors to request those tests for a child having gastroenteritis. bacteriology fresh faecal samples were checked for campylobacter sp, e. coli o :h , salmonella sp and yersinia sp according to general methods described in murray et al. ( ) and gilligan et al. ( ) . campylobacter species were identify using agar plates (skirrow medium) incubated microaerophilically at °c. isolated colonies were sent to laboratoire de sant e publique du qu ebec (lspq) for species identification according to barrett et al. ( ) and morris and patton ( ) . escherichia coli o was identified by plating specimens on sorbitol-macconkey selective medium, followed by latex agglutination test, according to sowers et al. ( ) . selected colonies were sent to lspq for flagellar antigen h identification by monoclonal antibodies techniques (he et al., ) . salmonella-shigella, macconkey or xylose-lysine media, followed by biochemical test (kliger slant culture, onpg-pam test, tsa plates) were used salmonella sp and yersinia sp identification. serovars of salmonella sp. were determined by lspq using anti-sera agglutination tests according to kauffmann-white classification scheme. parasites were first detected with combined giardia/cryptosporidium antigen detection eia assay (ivd research inc., carlsbad, ca, usa). a positive detection led to a second eia assay with individual antigen detection assays for both protozoa (ivd research inc.). a positive result was further submitted to microscopy with iron-haematoxylin stain to detect cysts or oocysts in the concentrated specimens; analyses were carried out at the mcgill university centre for tropical diseases (montr eal, qu ebec). specimens were investigated for the presence of enteric viruses (adenovirus, calicivirus-like, coronavirus, parvovirus, picornavirus, reovirus, rotavirus and norwalk virus) by negative-staining electron microscopy (em) (berthiaume et al., ; palmer and martin, ) at the electron microscopy laboratory of inrs-institut armand-frappier (institut national de la recherche scientifique, laval, quebec, canada). water samples from each household were collected from the kitchen tap in sterile bacteriological containers. samples were preserved at °c and processed within h of collection at the laboratory of the quebec ministry of agriculture (pathogenic bacteria) and at the laboratory of the ministry of environment (indicator microorganisms). escherichia coli was detected in a two-step procedure, the first being part of standard method d (fecal coliform membrane filter procedure) (apha-awwa-wef, ) adapted by the quebec ministry of environment laboratory. enterococci were identified by a two-step procedure, based on method c (apha-awwa-wef, ). f-specific (male specific, f + ) coliphages virus (bacteriophages) was detected using the usepa presence/absence method (epa -r- - ). campylobacter species were identified according to the method of giesendorf et al. ( ) , based on gene amplification coding for s rrna. identification of e. coli o : h was carried out by a two-step procedure: identification of verotoxin type and , then identification of the o : h serotype (tyler et al., ) . salmonella spp detection was carried out according to trkov et al. ( ) , using non-selective and selective enrichment media. pcr primers st and st , which have previously been shown to be highly specific for salmonella spp (aabo et al., ; trkov et al., ) , were used. yersinia enterocolitica detection was carried out according to the method developed by wannet et al. ( ) , based on targeting the chromosomal factor ail, an attachment invasion gene present in pathogenic serotypes. all water distribution networks that served the residences of participants were assessed to evaluate their vulnerability to microbiological contamination. this was carried out using a systematic evaluation based on the following criteria: (i) source susceptibility, (ii) water treatment efficiency, (iii) distribution system management and (iv) overall management (cool et al., ). an index of vulnerability to microbiological contamination was then calculated for each participating network. livestock density data of each municipality were obtained from the minist ere de l'agriculture du qu ebec (mapaq); data available as of january . livestock density was defined as the number of animal units relative to total cultivated area (a.u./ha) within a municipality. collected data were analysed using the sas software, version . (sas. user's guide. sas institute inc., cary, nc, usa). distribution of possible confounding factors (demographic factors, medical history, gi risk factors and water exposure) between cases and controls was compared with odds ratios (ors), their % confidence intervals (cis) and p value. the animal exposure was evaluated by contact with domestic or farm or zoo animal in the previous weeks and by livestock density in the residence area. the categorization of livestock density exposure was first based on quartiles of exposure of the control groups; however, the fourth quartile was further considered the exposed category and the pooling of the other quartiles, the unexposed category. odds ratios and their % cis for association with the various exposures were determined using unconditional logistic regression models while controlling for possible covariates and matching variables. no collinearity was observed between independent variables retained. all variables associated in univariable analysis with gastrointestinal illness (with a higher proportion among cases than controls and p value < . ) were included in the multivariable analyses. to take into account the municipality level of the livestock density variables, all ors were obtained by the generalized estimating equation (gee) approach, with link logit and binomial distribution, and the municipality was entered as a repeated effect. the statistical significance level was %. the study received approval from standing committees on ethics in research within each of the participating hospitals and from a provincial ethics committee (comit e central d' ethique du minist ere de la sant e et des services sociaux du qu ebec). informed written consent was obtained in the hospitals from the caretakers of the children enrolled in the study, before collecting stool specimens. a total of cases were included in this study: hospitalized and non-hospitalized and recruited by the regional public health department. for each case, two controls were found; controls were enrolled, but four of them were excluded a posteriori (because they were retrospectively found to be ineligible). participation among eligible hospitalized was about % and % among notified cases. participation among eligible controls was about %. characteristics of cases and controls are presented in table . due to the matching design, cases and controls had a similar age distribution. however, males were more represented in cases than in controls (p = . ), and parents of cases had a lower education than parents of controls (p = . ). a history of chronic disease was also more frequent in cases (p = . ). risk factors for gastrointestinal disease did not appear more frequent statistically in cases than in controls. moreover, swimming outdoors was more frequent in controls. one hundred and thirty-four cases ( . %) had a microbiological analysis of their stools ( for bacteriological analysis, for parasites and for viruses). bacteria were found in . % of cases, parasites in . % and viruses in . %, with these percentages calculated on the basis of analysed samples for each group of microorganisms. only one child had a concomitant infection: parasitic and bacterial infections. the list for each bacterial species detected is presented in table . campylobacter spp was detected in cases, salmonella spp in nine cases and e. coli in six cases. rotavirus was detected in cases. other species were rarely detected. no major difference was found between cases and controls regarding the type of water consumed (table ). in particular, the microbiological vulnerability indicator of the consumed water serving residences from public waterworks was similar between cases and controls (p = . ). moreover, children living in houses supplied by community surface or groundwater waterworks were distributed equally between the two groups (p = . ). frequency of private wells as the source of drinking water was similar between cases and controls, but drilled wells were more frequent in cases than surface wells. however, the frequency of faecal contamination of private wells (presence of e. coli or enterococci) was similar for cases and controls: . % versus . %, respectively (p = . ) (data not shown). no coliphage virus was found in these wells. the logistic regression analysis estimated the odds ratios associated with animal exposure for univariable and multivariable models (tables and ). when all the cases (mostly viral cases) were considered globally, no link was found between severe gastroenteritis and either contact with animals or living in a municipality with animal density in the th quartile. however, when considering only the cases with a bacterial or a parasitic infection (the so-called 'potential zoonotic pathogens'), the crude analysis revealed an association between hog density and disease occurrence (p = . ). however, when adjustment was carried out for important co-variates, this increase was reduced and became statistically non-significant. however, bacterial or parasitical infection was found significantly associated with contact with domestic, farm or zoo animals (adjusted or = . ; % ci: . - . ). a sensitivity analysis demonstrated that, when adjustment was not provided for contact with animals, the association with swine density was slightly stronger but remains not statistically significant (table ) . this study confirms the importance of viral aetiology in severe gastroenteritis among children living in rural areas and the lower rate of bacterial and parasitical infections ( table ). the results do not support an impact of animal farming activities on the incidence of viral as well as bacterial or parasitical infections. however, a link with contact with either domestic, zoo or farm animals was found for gastroenteritis cases. in hospital settings, most diagnosed infectious gastroenteritis is caused by viruses, with bacteria and protozoan parasites usually accounting for less than % (barnes et al., ; friesema et al., ; wiegering et al., ) , while some studies report a higher rate (denno et al., ) . in our study, cases ( . %) were infected by a virus, mainly rotavirus, a reported leading cause of gastroenteritis among children (bettinger et al., ; fischer et al., ) , including those living in rural areas (bessell et al., ) . twenty-eight cases ( . % of analysed samples) had a bacterial aetiology, which is a higher percentage *models obtained using generalized linear models by taking into account the possible correlation between individuals in the same municipality. than the one reported by a retrospective study conducted in a parisian hospital ( . %) (lorrot et al., ) , but lower than the incidence of % reported by friesema et al. ( ) in children requiring hospitalization in the netherlands. however, given that our bacterial cases are a mix of hospitalized and not hospitalized patients, comparison with hospital data might be difficult. in this study, the main bacterial genus involved was campylobacter sp ( % of bacterial infections). several studies have suggested that farm animals might be a source of zoonotic gastroenteritis associated with campylobacter bacteria. green et al. ( ) showed that the incidence of campylobacter infections was significantly higher in populations living in rural and agricultural areas, with the highest rates occurring in people living in proximity of high-density animal farming. in a retrospective ecological study using reported cases in the province of qu ebec, arsenault et al. ( ) demonstrated a higher incidence of campylobacteriosis in areas with high ruminant density. campylobacter species are carried by dairy cows (gilpin et al., ) but are also present in swine (varela et al., ; gu evremont et al., ) ; however, as reported by these authors and others (boes et al., ; nielsen et al., ) , the dominant species in swine is c. coli, accounting for more than - % of campylobacter species, while species like c. jejuni is almost absent. in our study, campylobacter sp was the most frequent bacterium found in faeces of cases ( cases), but the most often identified strain was c. jejuni ( cases), while c. coli was never recovered from stools samples. escherichia coli o :h was identified in five children (table ). this serotype is usually reported in bovine herds (oporto et al., ) , and contamination is usually through food consumption (karmali et al., ) , but drinking water contaminated by cattle farm operations has also been involved (krewski et al., ) . outbreaks associated with petting zoo have been described, but food or water exposures were not involved (centers for disease control and *models obtained using generalized linear models by taking into account the possible correlation between individuals in the same municipality. †density by cultivated area for the municipality. prevention, ; goode et al., ) . cases infected by e. coli o :h could have been contaminated from cattle strains (by drinking water, food or following direct contact with animals on a farm), but this scenario has not been verified. jackson et al. ( ) identified an e. coli o :h infection in a young child resulting from well water contamination by infected cattle on an ontario farm. however, in the present study, no e. coli o :h was recovered from cases' drinking water. among the seven cases infected by salmonella species, four were by the choleraesuis serotype, the most frequently isolated from swine. it is an infrequent serotype isolated from human sources in north america, but the epidemiological pattern differed greatly in asian countries (chiu et al., ) where it can be of particular concern (chiu et al., ) . jones et al. ( ) identified only human cases of choleraesuis serotype during the - time frame in the united states (about five cases/year). one study suggested that groundwater consumption could be an independent risk factor of salmonella choleraesuis infection in taiwan (li et al., ) . the origin of these infections may be the environmental impact of swine herds (three of six cases infected with this serotype lived in areas with a swine density ! . au); however, it could result from food or direct contact with animals. in our study, there was an association of children having a bacterial gastroenteritis resulting from contact with animals; however, most of the contacts ( %) were related to domestic animals, and when contact with animals was not considered in the model, the association was not significantly modified. therefore, we do not consider that contact with farm animals and particularly pigs was a credible explanation for cases illness in this study. no link was found between occurrence of these infections and the microbiological quality of the drinking water served in the participants' residences. based on what is known about rotavirus, it is not possible at this time to implicate this virus as a source of zoonotic transmission. however, it is worthwhile to mention that despite the fact that rotavirus infects particular species, heterologous infections may occur under natural and experimental conditions. it has been shown that human and animal strains of rotavirus may share a high degree of genetic similarities. reassortants between heterologous strains of porcine and human origin may have occurred and spread among populations (martella et al., ) . however, rotavirus transmission through water consumption has not been demonstrated. taken globally, our study does not support the potential environmental impact of farming activities on the occurrence of severe gastroenteritis. several studies have reported associations between livestock farming activities and acute gastroenteritis incidence. drinking water from private wells is usually considered as a risk factor (kuusi et al., ; denno et al., ), but a study in vancouver area revealed that private well water was not associated with an increase risk of intestinal infectious diseases (teschke et al., ) . in qu ebec, an ecological study found an increasing risk of children's hospitalization associated with higher animal farming activities, especially poultry (febriani et al., ) . studying the notified cases of gastroenteritis in qu ebec's children - years of age living in small municipalities, kabor e et al. ( ) found an association with cattle density, but no association with poultry or swine density. however, a cross-sectional survey, also carried out in qu ebec, resulted in a negative association between intensive farming activities and acute gastrointestinal illness (febriani et al., ) . in alberta, pearl et al. ( ) in a multilevel analysis reported that cattle density was not associated with acute gastroenteritis. our study has some important strength that should be underlined. in particular, it is a population-based study, with all cases and controls derived from the same population base. given the accessibility of all the population to hospital and medical consultation in all the areas of the study, we do consider that all severe cases of gastroenteritis in young children were gathered within the study area, the collaboration of all hospitals in the sector was very effective, and we are confident that few cases could have been missed by our recruitment procedures. the evaluation of bacteria, viruses and parasites at the same time for most of the cases should be underlined, as well as the important characterization of the quality of the water serving the participants' residences. finally, our rather extensive questionnaire permitted us to consider in the analysis most of the factors commonly associated with gastroenteritis. some limitations should be considered when interpreting the results. unexpectedly, very few cases of bacterial and parasitical infection occurred, reducing the power to detect some statistically meaningful results. this limits our ability to answer to the research question. also, the evaluation of viral and parasitical infection for community cases was frequently lacking, but it did not have any impact on the bacterial findings that were the most preeminent infection among potential zoonotic cases. we nevertheless acknowledge that community cases were only a selection of incident cases (that consulted a physician and had faecal sample). our measure of animal farming intensity was quite crude, which may reduce our ability to detect an association with animal farming activity. finally, this study was conducted only in rural areas, which have precluded a formal evaluation between rural and urban settings. however, the variety of environmental exposure, especially to animal burden, was important across the study areas, which makes it very adequate to study the potential effect of over exposure to animal farming activities. in conclusion, despite an important number of cases of infantile gastroenteritis in this rural population, no environmental factors, except contact with different animals, could be linked to the occurrence of the disease. in particular, no link was found between the microbiological quality of drinking water and illness. however, the low rate of potentially zoonotic diseases (bacterial and parasitic) limits the statistical power of the study. salmonella identification by the polymerase chain reaction environmental characteristics associated with campylobacteriosis: accounting for the effect of age and season is the water safe for my baby? etiology of acute gastroenteritis in hospitalized children in melbourne differentiation of campylobacter species using phenotypic characterization geographic determinants of reported human campylobacter infections in scotland rapid dectection of human viruses in faeces by a simple and routine immune electron microscopy technique heterogeneity of rotavirus testing and admitting practices for gastroenteritis among tertiary care pediatric hospitals: implications for surveillance. can development of agroenvironmental indicators to evaluate the hygienic pressure of livestock production on human health prevalence and diversity of campylobacter jejuni in pig herds on farms with and without cattle or poultry outbreaks of escherichia coli o :h associated with petting zoos-north salmonella enterica serotype choleraesuis: epidemiology, pathogenesis, clinical disease, and treatment salmonella enterica serotype choleraesuis infections in pediatric patients evaluation of the vulnerability to contamination of drinking water systems for rural regions in qu ebec tri-county comprehensive assessment of risk factors for sporadic reportable bacterial enteric infection in children : diarrhea etiology in a pediatric emergency department: a case control study association between indicators of livestock farming intensity and hospitalization rate for acute gastroenteritis the association between farming activities, precipitation, and the risk of acute gastrointestinal illness in rural municipalities of quebec, canada: a cross-sectional study etiology of acute gastroenteritis in children requiring hospitalization in the netherlands laboratory diagnosis of bacterial diarrhea. cumitech a the transmission of thermotolerant campylobacter spp to people living or working on dairy farms in new zealand niesters, : rapid and sensitive detection of campylobacter spp. in chicken products by using the polymerase chain reaction outbreak of escherichia coli o : h infections after petting zoo visits, north carolina state fair spatial analysis of campylobacter infection in the canadian province of manitoba pathogen survival in swine manure environments and transmission of human enteric illness -a review characterization of campylobacter isolates recovered from clinically healthy pigs and from sporadic cases of campylobacteriosis in humans monoclonal antibodies for detection of the h antigen of escherichia coli escherichia coli o :h diarrhoea associated with well water and infected cattle on an ontario farm salmonellosis outcomes differ substantially by serotype association between potential zoonotic enteric infections in children and environmental risk factors in quebec factors associated with increase and decrease risk of campylobacter infection: a prospective case-control study in norway verocytotoxin-producing escherichia coli (vtec) population-based incidence of infection with selected bacterial enteric pathogens in children younger than five years of age the global burden of diarrhoeal disease managing health risks from drinking water-a report to the walkerton inquiry : incidence of gastroenteritis in norway -a population-based survey consumption of groundwater as an independent risk factor of salmonella choleraesuis infection: a case-control study in taiwan epidemiology and clinical features of gastroenteritis in hospitalised children: prospective survey during a -year period in a parisian hospital l'industrie bioalimentaire de chaudi ere-appalaches; estimations pour zoonotic aspects of rotaviruses temporal and geographical distributions of reported cases of escherichia coli o :h infection in ontario campylobacter manual of clinical microbiology distribution of serotypes of campylobacter jejuni and c. coli from danish patients, poultry, cattle and swine etiology of diarrhea in young children in denmark: a case-control study escherichia coli o :h and non-o shiga toxinproducing e. coli in healthy cattle, sheep and swine herds in northern spain a prospective epidemiological study of gastrointestinal health effects due to the consumption of drinking water a multi-level approach for investigating socio-economic and agricultural risk factors associated with rates of reported cases of escherichia coli o in humans in alberta trends in enteric diseases as a cause of death in the united states, - infectious disease outbreaks related to drinking water in canada pathogens causing community gastroenteritis in australia evaluation of commercial latex reagents for identification of o and h antigens of escherichia coli water and sewage systems, socio-demographics, and duration of residence associated with endemic intestinal infectious diseases: a cohort study microbial quality of runoff following land application of cattle manure and swine slurry detection of salmonella in food over h using enrichment and polymerase chain reaction identification of verotoxin type variant b subunit genes in escherichia coli by the polymerase chain reaction and restriction fragment length polymorphism analysis associations between indicators of livestock farming intensity and incidence of human shiga toxin-producing escherichia coli infection prevalence of campylobacter spp isolated from grower-finisher pigs in ontario detection of pathogenic yersinia enterocolitica by a rapid and sensitive duplex pcr assay gastroenteritis in childhood: a retrospective study of hospitalized pediatric patients this work was supported by the fonds qu eb ecois de la recherche sur la nature et les technologies (fqrnt) and the minist ere de la sant e et des services sociaux du qu ebec (msss). we thank the doctors, nurses and laboratory technicians in the five hospitals involved, and we are indebted to children's parents for their participation in this study. we thank christine barthe, from the ministére de l'agriculture, des pêcheries et de l'alimentation (mapaq), marc gignac and michel patoine, from the ministére du développement durable, de l'environnement et des parcs (mddep), for their help and suggestions. the authors also acknowledge the important contribution of benoît gingras and other health professionals from the direction r egionale de la sant e publique chaudi ere-appalaches. key: cord- - trr d u authors: ventura, francesco; bonsignore, alessandro; gentile, raffaella; de stefano, francesco title: two fatal cases of hidden pneumonia in young people date: - - journal: j forensic sci doi: . /j. - . . .x sha: doc_id: cord_uid: trr d u abstract: acute respiratory distress syndrome (ards) is a severe lung disease characterized by inflammation of the lung parenchyma leading to impaired gas exchange. this condition is often lethal, usually requiring mechanical ventilation and admission to an intensive care unit. we present two fatal cases of hidden pneumonia in young people and discuss the pathophysiological mechanism of ards with reference to the histological pattern. a complete forensic approach by means of autopsy and histological, immunohistochemical, and microbiological, examination was carried out. in both cases the cause of death was cardio‐respiratory failure following an acute bilateral pneumonia with diffuse alveolar damage and ards associated with sepsis and disseminated intravascular coagulation. our cases suggest on one side the importance of an early diagnosis to avoid unexpected death while on the other that the diagnosis of ards has to be confirmed on the basis of a careful postmortem examination and a complete microscopy and microbiological study. acute respiratory distress syndrome (ards) is a severe lung disease characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators by local epithelial and endothelial cells, causing inflammation, hypoxemia resulting often in multiple organ failure (mof), and disseminate intravascular coagulation (dic) ( ) . this condition is often lethal, usually requiring mechanical ventilation and admission to an intensive care unit ( ) . physiopathologically when the endothelium of lung capillaries and the alveolar epithelium are damaged, plasma and blood flood the interstitial and intra-alveolar spaces. such a change implies decreased lung compliance, pulmonary hypertension, reduced functional capacity, compromised ventilation ⁄ perfusion ratio, and hypoxemia ( ) . acute respiratory distress syndrome can occur within - h of an injury or attack of acute illness. in such a case the patient usually presents with shortness of breath and tachypnea, usually associated with hypoxemia, petechiae in the axillae, and neurologic abnormalities such as mental confusion ( ) . typical histological presentation involves diffuse alveolar damage (dad) and hyaline membrane formation in alveolar walls ( ) . hyaline membranes, especially, as a result of the acute inflammatory processes in the alveolar compartment ( ) is the histological hallmark of ards. if the underlying disease or injurious factor is not removed, the amount of inflammatory mediators released by the lungs in ards may result in a systemic inflammatory response syndrome (or sepsis if there is lung infection) ( ) . the evolution toward shock and ⁄ or mof follows the same pathophysiological path of sepsis ( ) . it is estimated that ards is caused by septic shock-characterized by leukocytosis or leukopenia, fever, hypotension, and the identification of a potential source of systemic infection with positive blood cultures for pathogenous agents-in more than % of cases ( ) . pneumonia is thought to be the most common lung disease leading to ards as it determines a direct lung injury in the immunocompetent host ( ) . in cases of severe ards the survival rate is % with appropriate and early treatment, but if the ards-induced severe hypoxemia is not recognized and treated or if the disease reaches medical attention only in the terminal phase then cardio-respiratory arrest occurs in more than % of patients ( ) . we present two fatal cases of hidden pneumonia in young people who died within a few hours. the clinical presentation, the radiological and laboratory findings in one case, and the postmortem examination with histological, immunohistochemical, and microbiological exams in both cases, led us to conclude for an acute cardio-respiratory failure secondary to bilateral pneumonia with dad and consequently ards associated with sepsis and dic. the features of the disease are discussed with reference to the histological and immunohistochemical evaluation. a -year-old man was found dead at home by his girlfriend who was sleeping with him. the night before he went out with his friends and came back home late. his friends reported that nothing ''strange'' happened during the evening he spent with them. the day after, in the afternoon, when he should wake up his girlfriend saw the presence of foam around his mouth and nose and when she tried to wake him up he did not respond. so she called the emergency services who could do nothing but declare him dead. he took psychodrugs and was known to be a drug addict and a heavy drinker. family history was reported negative for sudden death. death scene investigation was unremarkable. a complete postmortem examination was performed days after death. external examination did not show any visible sign of injury. the internal examination revealed polyvisceral stasis, diffuse microthrombosis, cerebral and pulmonary edema. free citrine liquid was found on both sides of the pleural cavities. a marked lung congestion and the release of foamy material were bilaterally observed. ''hydrostatic docimasia'' for large and small fragments was bilaterally positive in all fields. also known as ''the flotation test,'' or ''the lung test,'' this old test is still in use to check if there are areas of increased density within the adult lung parenchyma. in these cases lung specimens, being not inflated with air, do not float. such is the case of pneumonia ( ) . the microscopic histological study, performed using formalinfixed paraffin-embedded tissue sectioned at lm and stained with hematoxylin-eosin (h&e), revealed the typical findings of dad: alveolar septa mildly thickened by edema and capillary congestion, alveolar edema, hyaline membranes lining the denuded alveolar walls, hyperplastic type ii pneumocytes, alveolar infiltrates of polymorphonuclear neutrophilic leukocytes, pigmented macrophages, monocytes and plasma cells (fig. a) , fibrin thrombi in small arteries. in some fields, numerous endoalveolar erythrocytes were also observed. bronchial walls presented epithelial denudation, inside the lumen there were infiltrates of leukocytes, mostly neutrophils, and a moderate quote of eosinophilic amorphous material. all these findings were suggestive for a typical dad in the early exudative phase, confirmed by the positive results to immunohistochemical dye for surfactant apoprotein (pe- ) that outlines hyperplastic type ii pneumocytes ( ) . fungal infections were not found on slides by grocott staining. gram staining did not give evidence for bacterial colonies. the examination of other histological samples was unremarkable. the lung samples were also examined under a confocal laser scanning microscope ( ) , and a three-dimensional reconstruction was performed (fig. ) . additional microbiological tests ( ) to identify possible pathogenous agents were carried out through isolation of nucleic acids from formalin-fixed paraffin-embedded tissue sections. to control the course of extraction and check for pcr inhibitors, a fragment of the homo sapiens beta-globin gene was amplified. the purified dna sample was negative for all bacterial cultures. the positive result for beta-globin demonstrated that the dna extraction procedure was efficient in extracting amplifiable dna from the sample. toxicology was negative for drugs and alcohol. thus, viral infection was a diagnosis of exclusion, according with recent literature which reports a prevalence of viral etiologies in communityacquired pneumonia up to % ( ) and an extremely high incidence of lung injury and ards arising from coronavirus and avian influenza virus infection ( , ) . a -year-old previously healthy man presented to the hospital with a -h history of sore throat, fever, and cough. the clinical prodromes were followed by the acute onset of increasing shortness of breath quickly progressing in acute respiratory failure with hemoptysis. chest x-ray demonstrated bilateral diffuse airspace opacification; the high-resolution ct (hrct) confirmed the presence of bilateral, symmetric diffuse ground-glass attenuation associated with liquid in pleural cavities. the patient was admitted to the intensive care unit with severe leukopenia, but he got worse and after few hours died. two postmortem blood cultures were positive for group a beta-hemolytic streptococcus which is well known for causing invasive disease leading to death even though diagnosis is not always made in life, as in this case ( ) . no other pathogenous agents were present. an autopsy was performed within h after death. external examination was irrelevant. internal examination revealed an increased consistency and weight of the lungs ( g the left and g the right respectively) with positive hydrostatic docimasia in all fields and intense congestion which was ascribed to a bilateral pneumonia. the examination of other organs was unremarkable except for intense polyvisceral stasis. the histological examination of lung specimens (one sample per lobe and more samples in increased thickening pulmonary areas as common practice), performed by using the same method described earlier for the previous case, showed alveolar septa that mildly thickened by edema and capillary congestion, alveolar edema, hyaline membranes coating alveolar septal surfaces, flattened pneumocytes, alveolar infiltrates of polymorphonuclear neutrophilic leukocytes, pigmented macrophages, monocytes and plasma cells, fibrin thrombi in small arteries (fig. b) . all these findings suggested a typical dad, confirmed by positive results to immunohistochemical dye for surfactant apoprotein (pe- ) (data not shown) ( ) . in the kidneys was found a thrombotic microangiopathy compatible with dic. the lung samples were examined under a confocal laser scanning microscope, and a three-dimensional reconstruction was performed ( ) . the silent (case ) and the paucisymptomatic (case ) presentations, and the histological and immunohistochemical findings led us to the diagnosis of ards supporting the conclusion that both were affected by a quite rare type of pulmonitis definable as hidden pneumonia. acute respiratory distress syndrome is a pathological entity arising from multiple pulmonary or extrapulmonary causes ( ) . generally, patients with ards report a short prodromal illness characterized by few symptoms like fever and cough, followed by the acute onset of progressive shortness of breath which rapidly evolves to respiratory failure ( ) . chest radiographs typically show bilateral diffuse airspaces opacifications ( ) . chest hrtc scans are significative for bilateral ground-glass attenuation ( ) . the histological features of ards, investigated from open lung biopsies or autopsies, are those of dad, a nonspecific pattern of acute lung injury ( ) . acute respiratory distress syndrome has a poor prognosis, with reported mortality rates still appearing to be higher than % ( ) . the first case concerns a -year-old man found lifeless at home by his girlfriend. at autopsy polyvisceral stasis, diffuse microthrombosis, free citrine liquid on both sides of the pleural cavities, a marked lung congestion, and the release of foamy material were found. hydrostatic docimasia for large and small fragments was bilaterally positive in all fields. the histological evaluation of lungs samples stained with h&e, also examined under a confocal laser scanning microscope, gave evidence of a pattern of dad. the presence of hyperplastic type ii pneumocytes and hyaline membranes was confirmed by the positive reaction of the immunohistochemical dye for surfactant apoprotein (pe- ). additional tests were carried out to identify possible pathogenous agents through microbiological studies but all the cultures showed no bacterial growth. toxicology was negative for drugs and alcohol. the second case involves a -year-old previously healthy man who presented, after a -h history of sore throat, fever, and cough, an acute onset of increasing shortness of breath rapidly progressing in acute respiratory failure with hemoptysis. chest x-ray and hrct showed the typical pattern of ards, with bilateral, symmetric, diffuse ground-glass attenuation. despite admittance to the intensive care unit, the patient died after few hours. two blood cultures were positive for group a beta-hemolytic streptococcus. the macroscopical and histological patterns were similar to that of case . in both cases the cause of death was attributed to an acute cardio-respiratory failure secondary to acute bilateral pneumonia and consequently ards, sepsis, and dic. these cases demonstrate how ards can rapidly lead to death in young patients that can generally be successfully treated in case of pneumonia. in the first case the postmortem diagnosis of ards and sepsis with dic ( ) was made exclusively on the basis of a careful postmortem examination and a complete histological study. therefore, the authors underline that forensic pathological procedures should be applied in all cases of sudden death using systematic practical investigations to find the cause of death, more so in fatal cases involving young people. just in this way it is possible to perform an adequate differential diagnosis when sudden cardiac death is more likely to be expected because of the young age of the patient. the second case, which has attracted the medicolegal interest because of medical liability profiles that were assumed as fault for doctors, suggests that clinicians should be suspicious of all community-acquired pneumonia ( ) , especially in young people, because rigorous diagnosis as well as early and appropriate therapy is mandatory to avoid unexpected death ( ) . particularly, from a forensic point of view, in such cases the authors suggest the importance of taking postmortem bacterial and viral cultures. last, the forensic community should not forget the role played by ards as a potential cause of sudden and unexpected death in previously healthy young people. a shock toxin that produces disseminated intravascular coagulation and multiple organ failure low-tidal-volume ventilation in the acute respiratory distress syndrome the american-european consensus conference on ards. definitions, mechanisms, relevant outcomes, and clinical trial coordination irwin and rippe's intensive care medicine, th edn abbas ak robbins and cotran pathologic basis of disease nonhomogeneous immunostaining of hyaline membranes in different manifestations of diffuse alveolar damage the acute respiratory distress syndrome mechanisms of sepsis-induced organ dysfunction sepsis definitions conference a multicenter registry of patients with acute respiratory distress syndrome. physiology and outcome effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome in: chapman hc, editor. a manual of medical jurisprudence, insanity and toxicology an immunohistochemical study in a fatal case of acute interstitial pneumonitis (hamman-rich syndrome) in a -year-old boy presenting as sudden death using new technology to answer old questions in forensic investigations the microbiology of the autopsy viral community-acquired pneumonia in nonimmunocompromised adults writing committee of the world health organization (who) consultation on human influenza a ⁄ h . avian influenza a (h n ) infection in humans acute respiratory distress syndrome and pneumonia: a comprehensive review of clinical data acute deaths in nonpregnant adults due to invasive streptococcal infections pulmonary and extrapulmonary forms of acute respiratory distress syndrome comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings diagnostic imaging of idiopathic adult respiratory distress syndrome (ards) ⁄ diffuse alveolar damage (dad) adult respiratory distress syndrome due to pulmonary and extrapulmonary causes: ct, clinical, and functional correlations pulmonary pathology of acute respiratory distress syndrome epidemiology and outcome of acute lung injury in european intensive care units. results from the alive study post-mortem diagnosis of sepsis update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults incidence, clinical course, and outcome in patients with acute respiratory distress syndrome the authors thank prof. vittorio fineschi for his help in histological and immunohistochemical studies. they also thank margherita neri, m.d. and irene riezzo, m.d. for their excellent technical assistance in confocal microscopy. finally the authors thank claudio giacomazzi, m.d. for his help in microbiological studies. key: cord- -fgtatt authors: ghaffarzadegan, navid; rahmandad, hazhir title: simulation‐based estimation of the early spread of covid‐ in iran: actual versus confirmed cases date: - - journal: syst dyn rev doi: . /sdr. sha: doc_id: cord_uid: fgtatt understanding the state of the covid‐ pandemic relies on infection and mortality data. yet official data may underestimate the actual cases due to limited symptoms and testing capacity. we offer a simulation‐based approach which combines various sources of data to estimate the magnitude of outbreak. early in the epidemic we applied the method to iran's case, an epicenter of the pandemic in winter . estimates using data up to march th, , point to , ( % ui: k, . m) cumulative cases and , ( % ui: . k, . k) total deaths, numbers an order of magnitude higher than official statistics. our projections suggest that absent strong sustaining of contact reductions the epidemic may resurface. we also use data and studies from the succeeding months to reflect on the quality of original estimates. our proposed approach can be used for similar cases elsewhere to provide a more accurate, early, estimate of outbreak state. © system dynamics society the novel coronavirus (sars-cov- ), the pathogen that causes covid- infection, is exposing the world to one of its largest global health challenges of recent decades. from public understanding to policy choices, much depends on the data about the epidemics spread and models that integrate such data into actionable policies (kaplan et al., ; thompson et al., ) . yet the official data are highly uncertain, with large variations in quality depending on the country reporting it, and regularly offering lower bounds that have unknown error bounds compared to the reality on the ground. other sources of data, often based on smaller samples, travel screening, and anecdotal evidence may offer relevant hints, but they are not easily generalized or combined with official data. the current paper focuses on using a standard dynamic epidemiological model as a tool for incorporating various sources of data into a unified estimation of the actual trajectory of disease, applying the method to covid- outbreak in iran. our focus is on how well one can realistically estimate the magnitude of the epidemic in early stages when disease parameters are uncertain, data are limited, and projections are highly volatile. current information (as of may , ) point to the spread of covid- starting from a food market in wuhan china in mid-november . the epidemic initially spread mostly in china but has become a global pandemic by may with over million official cases and thousand deaths (worldmeters, ) . the situation may also be worse than official statistics portray. for example, despite a massive screening and response campaign in china, li and colleagues estimate that % of early cases in china were undocumented . the situation in iran, another early epicenter, is instructive. the first official cases were reported on february th, , in the city of qom (wikipedia, ). yet, later reports suggested the disease was likely circulating in iran as early as january (iran international, ) . thus from february th on the spread of disease was very rapid according to official statistics. by march th some , cases and , deaths were recorded. the question in the minds of policy makers and public was: how far will this epidemic go and what policies should be put in place to control and mitigate the risks? the answers heavily depend on understanding the true magnitude of the epidemic. any under-estimation is worrisome, but early in the exponential growth phase of an epidemic such errors could be extremely costly as those estimates drive the mobilization of public health resources and government responses. the risk of under-estimation is partly driven by the characteristics of the disease such as a potentially large population of unrecognized patients with mild symptoms (at least % of the cases have symptoms not very different from common cold or flu) (novel coronavirus pneumonia emergency response epidemiology, ). as a result no consensus also exists on other parameters of the disease, such as fatality rate (fauci et al., ; wu and mcgoogan, ) . moreover, the country-specific variations in measurement and reporting may exceed those due to the nature of the disease. to illustrate, in the next section we provide a quick survey of various early clues related to the magnitude of epidemic in iran, which we then build on in our analysis. there have been a few clues from iran which may inform efforts to estimate the true cases. first is the number of cases identified among travelers arriving in other countries from iran. screening of passengers from high-risk countries in airports is more reliable than most country-level screening statistics. one study in pre-print estimated , total cases of infected individuals in iran by february (tuite et al., ) . the method relied on estimation of cases in the whole country based on three diagnosed cases of infection upon individuals' arrival from iran in various international airports and the likelihood of such an incident given approximately daily outbound passengers from iran during those early days (fraser et al., ). this number was two orders of magnitude larger than official statistics at the time. later reports on the number of infected travelers from iran rose rapidly, to cases by february (radiofarda, ). an article in the atlantic, offered a series of back-of-the-envelope calculations which, with strong simplifying assumptions, estimated million accumulated cases of infected individuals by march th (wood, ) . one may expect the death statistics to be more reliable. but test kits for identifying have been in short supply, and post-mortem testing may not have been a priority of officials in iran. on february th a member of iran's parliament reported deaths only in qom, a city of . million (wikipedia, ) . several reports of government officials contracting the disease have also been released, including reports on infection of member of the iranian parliament (a body of members), as well as several deaths among officials (bbcpersian, b) . a bbc persian report on february th used interviews with an unspecified number of hospitals in iran to put the death from the disease at , an order of magnitude larger than official numbers at the time (bbcpersian, a). another news agency quoted similar sources for a total of deaths by march st (iran international, ) and by march th. we develop a dynamic simulation model of the spread of the disease in iran to estimate the likely trajectory of the disease that is consistent with the evidence summarized above. we start with the traditional seir (for susceptible, exposed, infectious, and recovered stocks representing population groups) model and incorporate feedbacks regulating endogenous changes in contact rate, screening, diagnosis, and reporting in response to risk perception and other relevant factors. thus not only reported statistics, but also the effective reproduction number (r e ), are endogenously generated and can change as people respond to the epidemic. we use this model, along with various strands of data, to weave together an estimate of disease trajectory early on, simulation-based estimation of the early spread of covid- in iran and offer projections for medium term future. keeping in mind the various uncertainties involved in this analysis, reflected in our wide uncertainty intervals (ui), we estimate over , ( % ui: k, . m) cumulative cases of the disease in iran as of march th, with over , ( % ui: . k, . k) deaths. we thus estimate that only . % of cases and . % of deaths are officially attributed to covid- , with the rest going undetected. these results point to extreme gaps between official data and actual trajectory of disease, which may lead to slow response and under-appreciation of risks of the diseases. the rest of the paper is largely focused on documenting the original estimates developed on march th. as a secondary goal we also consider their accuracy in light of the data and findings in the two months following original estimates. this latter exercise provides a window into the actual challenges and promises of conducting policy-relevant projections early in a crisis. figure offers a simple representation of the model's structure. model equations, and parameter values are documented in appendix a. the model builds on the well-known seir (susceptible, exposed, infectious, and recovered) framework. the model includes the 'infection' reinforcing loop (r ) which creates the initial exponential growth in the number of cases. we divide the population of infected to early infected and late infected, and assume that early infected, while largely asymptomatic, might also be infective though at a lower rate (bai et al., ) . the infected population will follow two different paths of recovery or death. a fraction of late infected are symptomatic (in the figure, the variable "symptomatic late infected"). to avoid proliferation of free parameters we use general population averages rather than disaggregating into population groups. to this basic epidemiological model we add two endogenous mechanisms. first, we formulate contact rate to be endogenously changing in response to perceived risk of infection (a function of death statistics). this feedback captures changes in social interactions, gatherings, self-isolation of suspected cases, and hygiene as well as government-mandated closure of events, schools, and businesses in response to perceived risk. we assume public risk perception depends on the number of recent reported cases of death. this balancing feedback (loop b) can bring down contact rate, potentially enough to slow down the epidemic. second, we explicitly model the endogenous changes in screening and reporting of cases over time. here, the increased understanding of risks leads to mobilization of screening resources that expand the fraction of cases that are tested and thus will show up in the official statistics. we note that even with good screening many mild cases will go undiagnosed and will not be in official statistics. this analysis is focused on understanding the spread of the disease in its early phases, about one month after first diagnosed cases, and the core estimations in this paper are based on data only from that early period, until march th, . we use time series data for official reports of death, recovered, and cumulative number of infection over time. we also use unofficial data points including four observations about the number of iranian passengers diagnosed with covid- upon arrival in international airports, and three estimates aggregated by healthcare providers in iran and reported by bbc and iran international news agencies about total cases of death from covid- . the model includes three biological parameters (early-stage exposed period, average duration of illness, and fractional infectivity of early-stage exposed group) which we specify based on prior literature novel coronavirus pneumonia emergency response epidemiology, ; wu and mcgoogan, ) . population size and travel scope are also input using existing data. nine uncertain parameters remain that are estimated using the above data. three of the parameters are used to specify how official measurement and reporting relates to "true" values of infection and death, three parameters estimate public reaction to the reports, and two parameters are for mortality rate among two different groups of patients. finally, the arrival time of first cases of the virus is estimated as a separate parameter. simulation-based estimation of the early spread of covid- in iran our calibration method is based on forming a likelihood function for observing the actual time series data conditional on model parameters. we then conduct a markov chain monte carlo (mcmc) simulation to estimate the joint posterior distribution of the model parameters subject to observed data. we define a likelihood function for change over time (net-inflow) of official reports on cumulative death, recovered and infection assuming they are count events drawn from model-predicted rates (poisson distribution). we use a similar poisson distribution assumption for number of infected passengers and unofficial reports of death as well, since they both fit well into a count measure framework. the mcmc method searches over the feasible ranges for the uncertain parameters and accepts combinations that are consistent with the observed data. similar methods are used frequently in estimating dynamic models in this domain . our prior experience with the use of mcmc methods in nonlinear dynamic models highlights the risk that uncertainty intervals do not capture model mis-specifications and thus may be too tight. we therefore downscale the likelihood function to expand the uncertainty intervals (details and sensitivity in the online supplement) to err on the side of caution in assessing uncertainties and structural nuances not explicitly modeled. more details are reported in appendix a. we follow the procedure described in the modeling section and calibrate our model using multiple data sources and find uncertainty ranges using mcmc. figure a compares best-fitting simulation results for official confirmed death, recovered, and cumulative cases of infection against data. root mean squared percentage error values of reported recovered, death, and cumulative infected are %, %, and %, and root mean squared error values are , , and . simulation runs almost perfectly correlate with data. table a in the appendix a reports estimated parameters along with those adopted from the literature. figure b shows how simulation runs replicate unofficial statistics including the number of infected travelers diagnosed before air travel patterns changed substantially, and medical community's counts of cumulative death reported by media sources. we use the calibrated simulation model to estimate cumulative number of infected (panel c in figure ), cumulative number of death (panel d), and current number of infected (panel e) until march , , starting from december st, (day in simulation). we find that total infected cases may have been closer to , , than the reported , on march th. cumulative deaths, over , , may also be an order of magnitude higher than official statistics and might have almost tripled in the last days of the analysis. there is also much uncertainty in these numbers: our baseline estimate for cumulative infected may be as low as , and as high as . million ( % uncertainty interval). similarly cumulative deaths is between and , ( % confidence interval). the wide uncertainty intervals are partly due to the nature of the data: absent data on testing coverage in iran it is very hard to fully know the underlying diffusion patterns based only on the formal statistics. the travel and informal estimates of death partially address these limitations, but much uncertainty remains. our conservative assumption on downscaling the likelihood function may also have contributed to this wide interval. nevertheless, even our lower bound are times the official statistics for total infections and times larger than the death statistics. there are some glimmers of hope in our estimates as well. the drop in contact rate in response to perceived risk, which we have captured in our model, might have reduced r e significantly, to just below as of late march (panel f). that reduction (which was confirmed by later data), if sustained, would help bring down the number of new cases. thus, figure e shows the number of currently infected cases may well be reaching its peak at the end of the simulation. the epidemic seems to have raged with a reproduction number close to . ( % ui: . - . ui) for more than six weeks before the behavioral and policy interventions have slowed down the diffusion rate starting in late february. some of this drop may also be attributed to weather, but current research is mixed on the impact of weather wang et al., ; xu et al. , ) so we did not include it in our estimation (but would explore it in the forward projection in the next sections). those factors, we estimate, brought down the aggregate contact rate to % ( % ui: %- %) of pre-epidemic levels by the date of analysis. this number may just succeed in bringing down the reproduction number below , which is the necessary condition for containment of the epidemic. whereas the case fatality rate in iran, based on official statistics until march th, is . %, our estimated infection fatality rate is . ( . )% (standard errors for estimates are in parentheses). this estimate is consistent with, and somewhat higher than, the . % reported by wu and mcgoogan ( ) based on tracing confirmed cases in china. if correct, the toll of epidemic in iran would have been larger than that in most other countries by the estimation date, and limits to healthcare services may explain the increased death rate. this finding is reinforced by the limited coverage of testing in iran that is indicated in our estimation. many cases go un-confirmed, and at its maximum, formal testing is covering only . ( . )% of infections. these estimates are consistent with qualitative media reports from iran on very limited availability of testing, the doctors' need for getting authorization before conducting tests, and the multi-day delays in receiving test results that render them ineffective in the clinical decision making processes. we estimate that hospital sources of news organizations who have offered alternative versions of actual death statistics in iran have had a much wider coverage of true death statistics ( ( )% of estimated true values). their count offers a lower bound for true deaths, is also close to our lower confidence bound, and suggests that the true number of cumulative cases, even with an infection fatality rate as high as . %, would not be lower than , . nevertheless, we estimate that even those medical community reports offer coverage significantly below %, consistent with the lessthan-perfect coverage of hospital reports by media sources, and anecdotal evidence that hospital system has been overwhelmed in many hot spots of the disease and many patients have died at home and been buried with no testing or proper association of cause of death to covid- . the model used prior estimates from the literature for three important parameters: the total duration of illness (d = days), the exposure (early infection) period (τ = days), and the fractional infectivity of the exposure period (θ = . ). noting significant uncertainty in such estimates early in an epidemic, we assess our projections' sensitivity to these structural assumptions by re-estimating the model for different values of each parameter. in this analysis we find a new set of best-fitting parameters and estimates for true cases given each different assumption on disease parameters. in table results are summarized as percentage changes in key estimates (cumulative infections and cumulative death until march th, ) compared to baseline best-fitting projections. results suggest these structural parameters are important in identifying the true magnitude of the epidemic and may propagate additional uncertainty in our projections due to limited early data on their exact values. specifically, a smaller fractional infectivity during exposure period (θ), a longer exposure period (τ), or a shorter duration of illness all significantly increase the projections for total cases and deaths. reductions in the estimates are less significant when parameters move in the opposite direction, though a very high level of θ would bring down the estimated cumulative cases notably. in lower values of θ, model calibration suggests earlier arrival of first cases of infection, which, in a few days, can make a difference in the number of late-infected, and increase exposure rate. current evidence for transmission during early infection (exposure) period is rather limited, and thus our baseline projections for total cases may be somewhat conservative. nevertheless, given our conservative treatment of the uncertainty intervals all the best-fitting projections with different disease parameters remain within the % bounds of our baseline projections. we run the model until july st of under six scenarios (three alternative assumptions about the impact of seasonality times two policy measures). specifically, our scenarios about seasonality include no effect (status quo), moderate effect (infectivity of the virus decreases linearly from may st and halves by june st, then stays the same for the rest of the simulation), and very strong mitigating effect (infectivity of the virus decreases from may st to a quarter of its base value by june st, then stays the same for the rest of the simulation). for policy, our focus is on contact rate, and we include two conditions of status quo (i.e. only behavioral responses) and aggressive efforts to decrease contact rate by half what it would be otherwise. these six conditions provide intuitions for a potentially wide range of cases. both intervention and weather impacts are assumed to include rather strong options to inform the range of possibilities, and should not be interpreted as predictions. moreover, we also note that the wide cone of uncertainty in the baseline simulations will continue and expand in future projections. keeping the uncertainty considerations in mind (but not graphed due to clutter), figure shows results based on best-fit parameters. if our best case scenario on the reduction of contacts and benefits of seasonality for containment materialize, the number of infected cases would be expected to peak soon after the analysis date at approximately , ( % ui: k- k), and will go down later on. this optimistic scenario will still lead to over a million infections and some , deaths ( % ui: k- k) by the end of june. the less aggressive scenarios point to continued spread of the epidemic at large rates. a reduction in contagion is realized only when reproduction number remains below one as a result of reduced physical contact, government interventions, and seasonality. among these three, the first (behavioral response) is endogenous to recent death rate. when death rate comes under control (due to the combination of all three factors), our model assumes the contract rate rebounds, weakening the first channel and increasing the transmission. economic pressures, normalization of death, and behavioral modeling after those not practicing distancing (or those already recovered and thus presumably immune) could all weaken the behavioral response when the perceived risks fade. the increased transmission would then, with a delay, bring up the death rate close to levels sustaining a reproduction number around one. this creates a strong attractor in the dynamics where in steady state contact rate is high enough to sustain the contagion but not so high to lead to the rapid infection of all the population. it may also lead to oscillations in peak transmission. therefore it is only with strong weather and/or government interventions that reduced reproduction number brings the epidemic under control. this dynamic offers a cautionary tale against declaring victory early in the fight against the epidemic. however the actual magnitude of such rebound effect is not known in this setting and our data offers no guidance on the relevant parameters. therefore these results are only qualitatively suggestive but not quantitatively reliable. this research was conducted under extreme urgency to inform decisions amidst crisis. the primary objective of the analysis was to understand the magnitude of the outbreak during early stages of infection when uncertainties are large and major decisions at stake. the main analysis of this paper was completed on march th and first reported publicly on march th on medrxiv pre-print server. thus we intentionally leave those projections untouched to avoid post-hoc justification and corrections that would cover the true uncertainties involved in real world modeling projects targeting fast evolving situations. furthermore, given that march th marks the end of the winter and beginning of persian new year, emerging annual reports can be used to assess some of our findings. in this section we summarize a few such tests and observations made based on findings post initial analysis. first, our estimates can be partially tested against official all-cause mortality data which are reported seasonally by the iranian government. the data for winter were released on may th, during the final preparations of this manuscript. based on a regression analysis on the all-cause mortality data we find that covid- related deaths are likely . ( % ci: . , . ) times more than official death counts for the disease (see appendix c). our simulation-based estimates, suggesting . ( % ci: . , . ) times more deaths than official data, are consistent with this new information. a second study informed the true magnitude of epidemic in one of the provinces of iran using anti-body testing. specifically, testing for covid- antibodies informs whether a person has been previously infected by the disease, offering estimates for cumulative infection when randomly conducted on a population. we have found one such study conducted on a random population of iran's guilan province (population of . million) (shakiba et al., ) . these researchers estimate that - % of guilan residents were infected by late april. we did not simulate our model at the province level, but our march th estimate of times undercounting, combined with confirmed cases in guilan ( . % of the residents), gives an estimate of % prevalence at the end of winter. our model estimates about %- % growth in cases over the following month (see figure b ), so our estimate of cumulative infections in guilan, at %- % for late april, are still five to ten times lower than this new study. these findings would suggest that a rather high fraction of cases were asymptomatic and/or not included in any of the data sources for infection that we used (official data and infected traveler counts). incidentally, if we assume that our estimates for infection were times below true numbers, the infection fatality rate for covid- in iran goes down to close to . %, a number much closer to some recent estimates for this key parameter (basu, ) . third, we can test model's capability in projecting confirmed cases. although prediction of official cases was not the purpose of the model, we present this out-of-sample test as an indirect way of assessing the model's predictive power. the model was calibrated with days of data, and since the pre-print, days of more data on confirmed cases and deaths have become available, which we use to compare the model's predictive performance for official, reported cases. these results are provided in appendix b, and show that while qualitative trends are consistent, the model misses a major increase in the number of cases right after the first days. confirmed death projections are closer to data. two mechanisms may explain this gap. first, our simple formulation for testing only tracks the fraction of cases tested, saturating that fraction at a maximum. that formulation is fine in capturing growth in test capacity during the rise of epidemic, but would underestimate cases when the growth slows down and milder cases can be found with the already enhanced test capacity. indeed since estimation we have found that initial test capacity in iran grew to about tests per day, stayed at that level for the later part of our estimates, and then jumped to , tests per day; similar increasing patterns of tests are seen across nations globally. thus, the testing formulation likely introduces under-counting in simulating official cases later in the epidemic, but this does not mean the model is under-predicting the actual infections and deaths. a second factor may explain why our model predicted an earlier peak, by about two weeks. iran's new year holiday season, nowruz, which starts on march th, is a major time of travel, family visits, and social interaction. those activities may well have increased contact rates in later march, but we decided against post hoc introduction of a nowruz parameter in the model. finally, we note that our model predicted a resurgence of the epidemic in early may due to reduced risk perception, which is consistent with a rise in cases in the real world in may. it is harder to fully assess the impact of these discrepancies on future estimation of true cases, had we decided to extend those estimates beyond the original timeline. nevertheless, it seems our model is somewhat conservative in predicting the 'reported' infections and deaths after the estimation period, and a more explicit account of physical test capacity would add value in longer term projections. finally, upon the release of the first draft of the paper we have received reports from a few hospitals and officials in iran that confirm: a) unofficial death counts by hospital sources that continue to be about five times the official death statistics, and in some states of iran are close to our estimates; and b) the low sensitivity (false negative risk) of tests, at about %, when conducted by hospital staff. moreover, availability of tests even in major hospitals is limited, covering about % of those clinically diagnosed using other methods (often ct scans). it is important to note that some evidence from random testing in other countries (including iceland and germany) point to a very high asymptomatic fraction of patients, which would not be captured in any of our data sources and is consistent with our comparisons with the guilan study. furthermore, new evidence suggests we might have used under-estimates for the delay between exposure to onset of symptoms (about days), from onset to testing (another days), and from testing to resolution (about days) (lauer et al., ; linton et al., ) . adjusting for these parametric assumptions would increase our estimated case count as discussed in the sensitivity analysis and may bring our overall estimates closer to the new evidence on the cumulative infections. in this paper we provide a more sobering picture of the covid- outbreak in iran using a dynamic model that goes beyond official statistics. integrating data from various sources we suggest that the official statistics are at least an order of magnitude below actual spread of the epidemic, and even in optimistic scenarios the burden of disease will be large and lasting for many months. implementing and sustaining strong policies that target physical distancing offers the main hope for containing the epidemic until a vaccine becomes available. the gap between official statistics and our estimates may be due to various complications in measurement as well as policy choices. the availability of testing infrastructure has been a major bottleneck for detecting cases in iran. citizens with suspicious symptoms have had no easy way for getting tested; most tests are conducted on hospitalized patients, require specific authorization, and are processed in a few centralized labs adding significant delays to the process. not only mild cases are missed, but also many critical patients have been unable to access the care they need due to hospital congestion. the fact that majority of cases have mild symptoms similar to flu (wu and mcgoogan, ) adds to the risk of under-counting even if the testing capacity was ample. in fact many mild or moderately sick patients may have preferred to stay home than risk being infected upon visiting a congested hospital, further reducing demand for testing. finally, false negative test results seem to be common among covid- patients in iran, with healthcare providers indicating sensitivity levels as low as % due to challenges in sample extraction and varying concentration of viral load over the course of disease. the problem of undercounting cases of infection and death is not limited to iran. due to the relatively long period of incubation, a considerable proportion of asymptomatic cases, significant fraction of false negatives in existing tests, and especially the limits on test capacity, the undercounting problem is common, but its magnitude would vary across different countries. even with ample test capacity, the undercounting of infection is likely large due to both the asymptomatic patients (estimated to be more than % (mizumoto et al., ; nishiura et al., ) ) and those cases with false negative results (about % of positives in case of pcr based covid- tests (fang et al., ) ). for example a pre-print paper estimates that in the us less than % of cases of infection were diagnosed until march (pei and shaman, ). others have made similar claims about official data of china . the undercounting of deaths may be less in magnitude, but still very common. under significant strain, limited testing capacity may not be allocated to post-mortem testing of suspected cases, and thus country-specific routines for categorizing death in those cases may lead to large variations. we suspect this is a major reason why iran's official death counts may be significantly below the actual numbers. but other countries may have similar issues. for example a recent article estimates much higher number of deaths in italy than official numbers (stancati and sylvers, ) . moreover, recent investigative reporting by financial times, new york times, wall street journal, and economist has used all-cause death data of different countries and cities and estimated that globally, as much as % of covid- death cases are missed (burn-murdoch et al., ) . for example italy's excess death in march is , , out of which only , is attributed to covid. jakarta (indonesia) had excess deaths in march and april, with only attributed to covid. absent extended testing capacity, expanded post-mortem testing, and random testing in the population, policymakers may face a significant undercount of existing cases and thus miscalculate their response. we hope that our proposed approach can be used for similar cases elsewhere to de-bias such estimates. methodologically, we faced important challenges to estimation and projection of s-shaped behavior based on early data that are worth highlighting here. first, estimating s-shaped curves before observing their inflection point can be unreliable. minor changes in the slope of the cumulative curve can significantly change the estimated future trajectory when simple curve-fitting is pursued. overcoming this risk requires a more mechanistic model that is fitted to the flow (infections in this case) rather than cumulative stock, so that the slope is constrained by physical mechanisms determining the flow variable (e.g. the size of the susceptible population). the calibration should also properly weigh different data points so that the larger numbers during peak period do not overwhelm the signal from other periods. in our case we achieved this using poisson log-likelihood error. other promising alternatives may include negative binomial log-likelihood, among others. a second challenge is teasing out the various potential reasons for reduction in new infections. for example those may include a reduction in susceptible population, a change in contact rate due to social distancing, or exogenous changes such as weather. while mechanistically proper model specification can partially address this challenge, one needs to be cognizant of the uncertainty in estimated parameters, e.g. by using mcmc methods to identify the various combinations of those effects that are broadly consistent with the data. the problem is rapidly changing, and timely estimation is critical. therefore we have made several simplifying assumptions that readers should be aware of in interpreting our results. first, consistent with prior findings (rahmandad and sterman, ) we have focused on capturing behavioral feedbacks in contacts and testing and have adopted a formal estimation process, but have done so at the cost of abstracting away from much detail complexity and heterogeneity in populations and risks. we converged on the current model structure in an iterative process, attempting to keep the model simple and feasible to estimate, but not missing components that would qualitatively change the results. for example we tested the inclusion of healthcare capacity, test accuracy, and physical test capacity (rather than as a percentage of cases) and decided against including them explicitly because they did not change the conclusions qualitatively and our data did not offer reliable ways to estimate those effects beyond what is informed by our current structures. generally, a more detailed model may be appealing, but if the purpose is to offer quantitative estimates and projections, constraining additional model parameters during calibration would be a major constraint that should be weighed against the value of additional structure. second, during the early periods of infection, there is considerable uncertainty in most data sources. for example, infected passenger data, while useful, is a not a perfect data source for modeling. it can be argued that exposed to more travel, this population may be exposed earlier than a random sample. on the other hand, this is typically a higher income and more educated population that may be more aware of, and responsive to, infection risks. similar issues can be raised for informal death reports in the media, which are based on potentially limited samples of hospitals and may include subjective assessments of medical cases. such uncertainties are part of any emerging, fastmoving situation, and one should be cognizant of these factors in interpreting modeling results. third the model is scoped only around iran --we ignore potential effects of global spread of the disease on iran, including the risk of reintroduction of cases in future. forth, we assumed that the recovered population are immune during our simulation horizon. fifth, we ignore mutations in the virus which may change its contagiousness and case fatality rate. despite these limits we hope the paper offers an accurate assessment of the risks and scope of the epidemic for iran and beyond. we also hope other researchers build on this work using the publicly available data, models, and replication instructions provided in the online supplement. finally, we hope that the study contributes to the system dynamics modeling literature. there are a wide range of epidemic models with different levels of dynamic and detailed complexity (darabi and hosseinichimeh, ) and a large number of models have been built in response to covid- . while epidemic models with interesting and relevant feedback mechanisms could be built rather quickly, their results depend heavily on the parameters regulating the strength of contagion, behavioral response, testing, and other mechanisms. for example reputable research groups have offered models with forecasted cumulative deaths that vary significantly (ferguson et al., ; murray and ihme, ) . without quantitative estimation methods, different models may point to starkly different conclusions, with little guidance on how to select the appropriate analysis. our contribution is to offer a model-based estimation approach during an on-going pandemic where data are uncertain and limited. this requires combining all sources of available data with different levels of uncertainty, each one, potentially an imperfect indicator of the reality, yet collectively providing a better picture. our data-driven approach is consistent with recent calls for detailed data-informed modeling approaches (sterman, ) , and combining different methods and techniques to enrich dynamic modeling (duintjer tebbens and thompson, ; ghaffarzadegan and larson, ) . we hope the methods used in this paper can be extended to a variety of other system dynamics applications where actionable insights rely on rigorous combination of feedback rich models and quantitative data. data sources to study dynamic problems in organizational and health domains. as the number of infected cases increase, the probability of infection increases given the increased number of contacts between infected and susceptible populations. some of these contacts lead to new cases of infection (loops r and r ). infections may be due to a fraction of early infected cases who can infect others (bai et al., ) , and the late infected population. exposure rate (i e ) is formulated as following: we set e at (no seasonal effect) for historical calibration, and later for scenario analysis, check different functions that give lower values during summer. the equation has two degrees of freedom, and since the actual value of c and i are not independently knowable, we assume i = . and vary c to fit the model output against data (details below). death and recovery rates are estimated using fractional death rate. we have, where the disease duration is assumed to be total of τ e (early-stage asymp- contact rate can change in response to the progression of the disease and consequently change infection rate (see figure a ). the impact of perceived risk on contact rate captures not only the endogenous changes in social interactions, gatherings, self-isolation of suspected cases, and hygiene, but also government mandated closure of events, schools, and businesses to name a few. we assume public risk perception depends on reported cases of death. finding infected cases is challenging given that many cases remain mild and unknown, yet potentially infectious. furthermore, especially early on, many cases were misdiagnosed as healthcare providers were unaware of the existence of the virus in the country. as the first cases are revealed and reported, a higher fraction of cases are found (loop r ). there are three death-rate-related variables: actual death rate ( c is inversely related to o d . we bound c between and c max , and use the following sigmoid function to represent c: ρ represents the impact of other policy measures beyond the perception of death that may impact c (e.g. various government interventions) and is set to for base run simulations but experimented with for policy analysis. o à d and s represent the relation between o d and c. conceptually o à d is a threshold for public report of death, at which contact rate endogenously declines to half of c max and s is the sensitivity of public behavior to the reported death rate. the free parameters, o à d ,s, and c max , are estimated. we assume only symptomatic cases of patients can be diagnosed. let f symp < be the fraction of late-infected individuals that develop symptoms. let α be the fraction of symptomatic who are tested, then αf symp is the fraction of i l who will be tested. more severe cases are more likely to be diagnosed, so mortality rate of diagnosed cases(f ), is likely to be higher than average fatality rate (f). death rate of diagnosed individuals is f (αf symp i l )/τ l , with the constraint αf symp f ≤ f. we assume no post-mortem diagnosis. including first cases of death discovery diagnosed early on (x): where d is the cumulative reported cases of death. x is equal to on t =february th and for the rest of the simulation it is zero. we set α = min ad, À Á Á α max , and let the model estimate α max , and a through calibration (explained below). for reported cases of recovered (r), we use the following equations: is reported cases of recovery per day. this formulation assumes the reporting of recovered cases happens with the same rate (α) as the reporting of infections and death. while iran's data are supportive of this assumption, exploration of statistics from other countries suggests many do not track the recovered cases. for total infected (i), cumulative cases (i cum ) and reported cumulative cases of infection (i cum ) we have: we set f symp = . , but the model is not sensitive to the value of f symp , as any change in f symp will be compensated by α to match the simulation with simulation-based estimation of the early spread of covid- in iran the data, and calculate total fraction of infected who are diagnosed. the reproduction number is estimated asr = ( τ e + τ l )(i e /i). besides the official data, we use a few unofficial data points: four observations about number of iranian passengers diagnosed with covid- upon arrival in international airports (p ), and three unofficial estimations from bbc and iran international news sources about cumulative death from covid- (d u ) early in the epidemic. in our model, we estimate them as following: where d u, = , and μ is the ratio of number of passengers going from iran abroad in early days of the outbreak. the term (t + − t ) represents days since the first cases of infection were diagnosed. it is assumed that the daily number of passengers is fixed and death is minimum, thus this estimation only works during the first few days of the outbreak. for d u , we assume γ represents the fraction of actual deaths identified by these sources. note that the unofficial reports for death cases in media are based on unofficial reports from the medical community with limited samples, thus γ is likely below one. γ will be estimated through model calibration. we initialize the model as i e, = i l, = r = d = , and s = million people. we set r = d = . new infected cases are injected to the model through i f , at time t , to be estimated through model calibration. although we are not aware of number of foreign patients entering iran, since t is also unknown, we have two degrees of freedom, and one can be assumed and the other estimated through model calibration. we set i f equal to patients per day at t , and throughout the rest of the simulation. we run the model from t = , december , , and our time unit is a day. t , the time first cases are diagnosed, is february , . we have time series data for d, r, i cum , and a few data points for p and d u . our method is mainly based on forming a likelihood function for observing the actual time series data conditional on model parameters. we then conduct a markov chain monte carlo (mcmc) simulation to estimate the joint posterior distribution of the model parameters subject to observed data. we define a likelihood function for change over time (net-flow) of d , r , i cum assuming they are count events drawn from model-predicted rates (poisson distribution). we use a similar poisson distribution assumption for p and d u as well, since they both fit well into a count measure framework. the mcmc method searches over the feasible ranges for nine uncertain parameters in our model. these include: three data-related parameters of α max , a, and γ; three public-behavior-related parameters of c max , o à d , and s; and three disease-related parameters of fractional death rate (f and f ) and time for the injection of first cases of infection into the population (t ). prior experience and this exercise point to rather tight confidence intervals coming from mcmc methods directly applied to large nonlinear models. the problem could be addressed using filtering (e.g. extended kalman filtering or particle filter) methods or heuristics that scale the likelihood function in mcmc method to be consistent with model's predictive performance. in light of the computational costs of the former and time sensitivity of the research topic, we chose the latter option. to be conservative, we therefore downgrade our confidence in the data, scaling the likelihood function by a factor of . , which allows the algorithm to explore the parameter space much more freely. this approach is a heuristic we use to avoid putting too much confidence in our estimation results; however, without strong theoretical reasons to support the specific scaling factor, we caution against a strong interpretation of these results. with this caveat in mind, the mcmc method offers % confidence intervals for joint-distribution of the parameters. we conducted additional sensitivity analysis to this downscaling parameter choice. the rest of the parameters are specified based on the literature. the counter factual of "what is expected absent covid- " is. a simple counter-factual would compare deaths in previous winters with that in winter . yet, depending on which previous years one includes in such counter-factual, excess deaths between to thousands could be estimated. however, the released death data is disaggregate at the province level ( provinces). this provides a unique opportunity to more accurately estimate the excess deaths in iran by comparing the variations in death in different provinces and how those variations could be explained by the official death toll in each providence. formally, we run the following regression to estimate the undercounting of covid- related deaths: excessdeath i = β + β :pastdeath i + β :confcoviddeath i: where excessdeath i is the difference between death in winter and winter in province i, and pastdeath i is a vector of death in past seasons (e.g., winter , , etc.) in province i. confcoviddeath i is an estimation for confirmed death cases based on confirmed total cases for each province which were available for the analysis (iran does not provide province level death statistics for covid, but did provide province level cumulative infection statistics; scaling total death based on province level infections we calculate "confcoviddeath"). β will represent death undercounting factor. our estimate of , ( % ui: . k, . k) death implies that this ratio should be around . ( % ci: . , . ). our regression models are reported in table a . based on the best regression model (in terms of adjusted r-squared), we find that β = . ( % ci: . , . ). this ***p < . , **p < . , *p < . . presumed asymptomatic carrier transmission of covid- estimating the infection fatality rate among symptomatic covid- cases in the united states: study estimates the covid- infection fatality rate at the us county level corona virus has at least claimed lives in iran who, among political and government figures, have contracted the corona virus? global coronavirus death toll could be % higher than reported. financial times system dynamics modeling in health and medicine: a systematic literature review using integrated modeling to support the global eradication of vaccine-preventable diseases sensitivity of chest ct for covid- : comparison to rt-pcr covid- -navigating the uncharted impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand pandemic potential of a strain of influenza a (h n ): early findings sd meets or: a new synergy to address policy problems the number of deaths from corona virus in iran reach db% c%d %b %d %a %d % -%d %a %db% c%d % %d %aa% d %b %d % %d %b %d % %d %a %d % -%d %b %d % % d %a %d %b -%d %ac%d %a %d % %e % % c%d %a %d % a %d %ae%d %aa%da%af%d %a %d % -%da%a %d %b %d % %d % %d %a -%d %af%d %b -%d %a %db% c%d %b %d % a %d % -%d %a %d % -%db%b %db%b %db%b -%d % %d % %d %b -%d %b %d %b %db% c%d %af emergency response to a smallpox attack: the case for mass vaccination the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov- ) incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data the role of absolute humidity on transmission rates of the covid- outbreak estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship forecasting covid- impact on hospital bed-days, icudays, ventilator-days and deaths by us state in the next months novel coronavirus pneumonia emergency response epidemiology team. . the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china initial simulation of sars-cov spread and intervention effects in the continental us who chief says cases of coronavirus in countries originated from iran heterogeneity and network structure in the dynamics of diffusion: comparing agent-based and differential equation models seroprevalence of covid- virus infection in guilan province italy's coronavirus death toll is far higher than reported system dynamics at sixty: the path forward the risks, costs, and benefits of possible future global policies for managing polioviruses estimation of covid- burden and potential for international dissemination of infection from iran temperature significant change covid- transmission in cities wikipedia. . coronavirus outbreak in iran iran has far more coronavirus cases than it is letting on. the atlantics nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention weather conditions and covid- transmission: estimates and projections. medrxiv we are thankful to mohammad akbarpour, narges doratoltaj, babak heydari, hamed ghoddusi, and tse yang lim for their thoughtful feedback on various drafts of this paper. navid ghaffarzadegan is an associate professor in the department of industrial and systems engineering at virginia tech. he develops system dynamics simulation models to study complex social systems and policy problems. the main application areas of his research include science policy and health policy.hazhir rahmandad is an associate professor of system dynamics at mit sloan school of management. he combines simulation models and various simulation-based estimation of the early spread of covid- in iran basic model architecturethe model uses a country-level system of differential equations to capture the dynamics of contagion ( figure a ). the infected population is first asymptomatic and is represented as "early infected" and later becomes "late infected" with the majority being symptomatic.the following equations represent the aging chain:appendix b: out of sample prediction testour main analysis in this paper is done based on data up to march th, (total of days). since then days of new data have become available which we use to conduct an out-of-sample test of our model's projection for confirmed cases. figure a shows the results. the model is better at replicating reported cases of death (panels c and d) than reported infection (panels a and b) and recovery (panels e and f). it appears that by increased testing, milder cases of infection are diagnosed in iran than we predicted, while confirmed death rate is still in the same range as our model's prediction. in recovery data we see a peak on a specific day (panel f) that might relate to some follow-up or closing active cases. the data for all-cause death, which in iran is reported seasonally, were released on may th, , during the final preparation of this manuscript. winter ends on march th, thus seasonal reports on all-cause number is lower than our estimate for death, but of comparable magnitude, and falls within our confidence intervals. it is worth noting that the covid-related excess death may not be all attributed to covid- alone. for example social distancing policies in response to covid may reduce traffic-accidents and death due to air pollution (both major causes of mortality in iran), leading to an under-estimate of covid- deaths in this approach. on the other hand hospital congestion may increase death due to other conditions, leading to over-estimation of covid- deaths using this method. we do not have data to correct for these potential biases, but overall we suspect that they are a second order effect and the true magnitude of covid- death is captured by the excess mortality data. additional supporting information may be found in the online version of this article at the publisher's website.appendix s : supporting information appendix s : supporting information simulation-based estimation of the early spread of covid- in iran key: cord- -h kc w authors: liang, donghai; shi, liuhua; zhao, jingxuan; liu, pengfei; sarnat, jeremy a.; gao, song; schwartz, joel; liu, yang; ebelt, stefanie t.; scovronick, noah; chang, howard h. title: urban air pollution may enhance covid- case-fatality and mortality rates in the united states date: - - journal: innovation (n y) doi: . /j.xinn. . sha: doc_id: cord_uid: h kc w background the novel human coronavirus disease (covid- ) pandemic has claimed more than , lives worldwide, causing tremendous public health, social, and economic damages. while the risk factors of covid- are still under investigation, environmental factors, such as urban air pollution, may play an important role in increasing population susceptibility to covid- pathogenesis. methods we conducted a cross-sectional nationwide study using zero-inflated negative binomial models to estimate the association between long-term ( - ) county-level exposures to no , pm . and o and county-level covid- case-fatality and mortality rates in the us. we used both single and multipollutant models and controlled for spatial trends and a comprehensive set of potential confounders, including state-level test positive rate, county-level healthcare capacity, phase-of-epidemic, population mobility, population density, sociodemographics, socioeconomic status, race and ethnicity, behavioral risk factors, and meteorology. results , , covid- cases and , deaths were reported in , us counties from january , to july , , with an overall observed case-fatality rate of . %. county-level average no concentrations were positively associated with both covid- case-fatality rate and mortality rate in single-, bi-, and tri-pollutant models. when adjusted for co-pollutants, per inter-quartile range (iqr) increase in no ( . ppb), covid- case-fatality rate and mortality rate were associated with an increase of . % ( % ci . % to . %) and . % ( % ci . % to . %), respectively. we did not observe significant associations between covid- case-fatality rate and long-term exposure to pm . or o , although per iqr increase in pm . ( . ug/m ) was marginally associated with . % ( % ci: . % to . %) increase in covid- mortality rate when adjusted for co-pollutants. discussion long-term exposure to no , which largely arises from urban combustion sources such as traffic, may enhance susceptibility to severe covid- outcomes, independent of long-term pm . and o exposure. the results support targeted public health actions to protect residents from covid- in heavily polluted regions with historically high no levels. continuation of current efforts to lower traffic emissions and ambient air pollution may be an important component of reducing population-level risk of covid- case-fatality and mortality. the novel human coronavirus disease (covid- ) is an emerging infectious disease caused by severe acute respiratory syndrome coronavirus (sars-cov- ) . first identified in in wuhan, the capital of hubei province, china, the covid- pandemic has since rapidly spread throughout the world. as of july , , there have been , , cases and , deaths confirmed in the united states [ ] [ ] [ ] . despite substantial public health efforts, the observed covid- case-fatality rate (i.e. the ratio of the number of covid- deaths over the number of cases) in the us is estimated to be . % [ ] [ ] [ ] . although knowledge concerning the etiology of covid- -related disease has grown since the outbreak was first identified, there is still considerable uncertainty concerning its pathogenesis, as well as factors contributing to heterogeneity in disease severity around the globe. environmental factors [ ] [ ] [ ] [ ] , such as urban air pollution, may play an important role in increasing susceptibility to severe outcomes of covid- . the impact of ambient air pollution on excess morbidity and mortality has been well-established over several decades [ ] [ ] [ ] . in particular, major ubiquitous ambient air pollutants, including fine particulate matter (pm . ), nitrogen dioxide (no ), and ozone (o ), may have both a direct and indirect systemic impact on the human body by enhancing oxidative stress, inflammation, and respiratory infection risk, eventually leading to respiratory, cardiovascular, and immune system dysfunction and deterioration [ ] [ ] [ ] [ ] [ ] . while the epidemiologic evidence is limited, previous findings on the outbreak of severe acute respiratory syndrome (sars), the most closely related human coronavirus disease to covid- , revealed a crude positive correlation between air pollution and the sars case-fatality rate in the chinese population without adjustment for confounders . an analysis of cities in china recently demonstrated that temporal increases in covid- cases were associated with short-term variations in ambient air pollution . hence, it is plausible that prolonged exposure to air pollution may have a detrimental effect on the prognosis of patients affected by covid- . as is usual in the early literature on emerging hazards, questions remain concerning the generalizability and reproducibility of these finding, due to the lack of control for the epidemic stage-of-disease, population mobility, residual spatial correlation, and potential confounding by co-pollutants. to address these analytical gaps and contribute towards a more complete understanding of the impact of long-term exposures to ambient air pollution on covid- -related health consequences, we conducted a nationwide study in the usa ( , counties) examining associations between multiple key ambient air pollutants, no , pm . , and o , and covid- case-fatality and mortality rates in both single and multi-pollutant models, with j o u r n a l p r e -p r o o f comprehensive covariate adjustment. we hypothesized that residents living in counties with higher long-term ambient air pollution levels may be more susceptible to covid- severe outcomes, thus resulting in higher covid- case-fatality rates and mortality rates. we obtained the number of daily county-level covid- confirmed cases and deaths that occurred from january , , the day of first confirmed case in the us, through july , in the us from three databases: the new york times , usafacts , and point acres.com . briefly, data on county-level covid- cases and deaths data was confirmed by referencing state and local health agencies directly. covid- confirmed case counts include both laboratory confirmed cases and presumptive positive cases (i.e. cases diagnosed by doctors based on signs and symptoms without a test), which is in line with how the us center for disease control (cdc) reports data. in these databases, cases were assigned to where the person was diagnosed as that information became available. if a state reports both location of death and the location of residency, the case was attributed to the location of residency . covid- death counts include both confirmed (i.e. by meeting confirmatory laboratory evidence for covid - ) and probable deaths (i.e. meeting clinical criteria and epidemiologic evidence with no confirmatory laboratory testing performed for covid- ; meeting presumptive laboratory evidence and either clinical criteria or epidemiologic evidence; meeting vital records criteria with no confirmatory laboratory testing performed for covid ). after data acquisition from these sources, we compared the number of confirmed covid- cases and deaths in each us county (identified by the federal information processing standards, fips code) across all databases for accuracy and consistency. in case of discrepancy, county-level case and death number were corrected by manually checking the data reported from the corresponding state and local health department websites. in this analysis, the main covid- death outcomes included two measures, the county-level covid- case-fatality rate and mortality rate. the covid- case-fatality rate was calculated by dividing the number of deaths over the number of people diagnosed in each us county with at least confirmed case, which can imply the biological susceptibility towards severe covid- outcomes (i.e. death). the covid- mortality rate was the number of covid- deaths per million population, and can reflect the severity of the covid- outcomes in the general population. j o u r n a l p r e -p r o o f three major criteria ambient air pollutants were included in the analysis, including no , a traffic-related air pollutant and a major component of urban smog, pm . , a heterogeneous mixture of fine particles in the air, and o , a common secondary air pollutant . we recently estimated daily ambient no , pm . , and o levels at km spatial resolution across the contiguous us using an ensemble machine learning model - . we calculated the daily average for each county based on all covered km grid cells (i.e., we calculated the arithmetic mean of daily air pollutant concentrations at km grid cells whose centroids fall within the boundary of that county). we then further calculated the annual mean ( - ) for no and pm . , and the warm-season mean ( - ) for o , defined as may to october , which is a standard time window to examine the association between ozone and mortality . although more recent exposure data were not available, county-specific mean concentrations of air pollutants across years are highly correlated . we fit zero-inflated negative binomial mixed models (zinb) to estimate the associations between long-term exposure to no , pm . , and o and covid- case-fatality rates and mortality rates. the zinb model comprises a negative binomial log-linear count model and a logit model for predicting excess zeros . the former was used to describe the associations between air pollutants and covid- case-fatality rate among counties with at least one reported covid- case. the latter can account for excess zeros in counties that have not observed a covid- death as of july , . we fit single-pollutant, bi-pollutant, and tri-pollutant models, in order to estimate the effects of each pollutant without and with control for co-pollutants. all analyses were conducted at the county level. for the negative binomial count component, results are presented as percent change in case-fatality rate or mortality rate per interquartile range (iqr) increase in each air pollutant concentration. iqrs were calculated based on mean air pollutant levels across all , counties. similar results are presented as odds ratios for the excess zero component. we included a random intercept for each state because observations within the same state tended to be correlated, potentially due to similar covid- responses, quarantine and testing policies, healthcare capacity, sociodemographic, and meteorological conditions. as different testing practices may bias outcome ascertainment, we adjusted for state-level covid- test positive rate (i.e. a high positive rate could imply that the confirmed case numbers were limited by the ability of testing, thus upward-biasing the case-fatality). to model how different counties may be at different time points of j o u r n a l p r e -p r o o f the epidemic curve (i.e., phase-of-epidemic), we adjusted for days both since the first case and since the th case within a county through july . in addition, we adjusted for potential confounders and covariates that may also contribute to heterogeneity in the observed covid- rates and thus may confound associations with long-term air pollution exposure. these include county-level healthcare capacity, population mobility, population density, sociodemographics, socioeconomic status (ses), race and ethnicity, behavior risk factors, and meteorological factors. specifically, healthcare capacity was measured by the number of intensive care unit (icu) beds, hospital beds, and active medical doctors per people . population travel mobility index, based on anonymized location data from smartphones, was used to account for changes in travel distance in reaction to the covid- pandemic . socioeconomic status was measured by social deprivation index , a commonly used measure of area-level ses, composed of income, education, employment, housing, household characteristics, transportation, and demographics. sociodemographic covariates included population density, percentage of elderly (age ≥ ), and percentage of male. race and ethnicity included percentage of black and percentage of hispanic in each county. we also obtained behavioral risk factors including population mean body mass index (bmi) and smoking rate, and meteorological variables including air temperature and relative humidity. additional information about these covariates, including data sources, are given in the technical appendix. to control for potential residual spatial trends and confounding, we included spatial smoothers within the model using natural cubic splines with degrees freedom for both county centroid latitude and longitude. to examine the presence of spatial autocorrelation in the residuals, we calculated moran's i of the standardized residuals of tri-pollutant main models among counties within each state. statistical tests were -sided and statistical significance and confidence intervals were calculated with an alpha of . . all statistical analyses were conducted in r version . . we conducted a series of sets of sensitivity analyses to test the robustness of our results to outliers, confounding adjustment, and epidemic timing (figures and ) . given that new york city has far higher covid- cases and deaths than any other region, we excluded all five counties within new york city in one sensitivity analysis. in another, we restricted the study to the most recent weeks (june to july ), when the case count and death count may be more reliable and accurate compared to earlier periods. we also conducted sensitivity analysis by using air j o u r n a l p r e -p r o o f pollution data averaged between to . to assess the importance of individual confounders or covariates, we fit models by omitting a different set of covariates for each model iteration and compared effect estimates. a total of , us counties were considered in the current analysis, with confirmed cases reported in , ( . %) and deaths in , ( . %). by july , , , , covid- cases and , deaths were reported nationwide ( table ) . among the counties with at least one reported covid- case, the average county-level casefatality rate was . ± . % (mean ± standard deviation), and the average mortality rate was . we observed significant positive associations between no levels and both county-level covid- casefatality rate and mortality rate ( table and figure ), when controlling for covariates. in tri-pollutant models, covid- case-fatality and mortality rates were associated with increases of . % ( % ci . % to . %) and . % ( % ci . % to . %), respectively, per iqr (~ . ppb) increases in no ( table ). these results imply that one iqr reduction in long-term exposure to no level would have avoided , deaths ( % ci: , to , ) among those who tested positive for the virus and . deaths ( % ci: . to . ) per million people in the general population, as of july , . the strength and magnitude of the associations between no and both covid- case-fatality rate and mortality rate persisted across single, bi-, and tri-pollutant models ( figure ). in contrast, pm . was not associated with covid- case-fatality rate ( % ci: - . % to . %) but was marginally associated with higher covid- mortality rate in tri-pollutant models, where one iqr ( . ug/m ) j o u r n a l p r e -p r o o f increase in pm . was associated with . % ( % ci: . % to . %) increase in covid- mortality rate (table ). null associations were found between long-term exposure to o and both covid- case-fatality and mortality rates ( % ci: - . % to . % and - . % to . %, respectively). similar trends persisted across single, bi-, and tripollutant models ( figure ). the moran's i and p-values (appendix table s ) from these models suggested that most spatial correlation in the data has been accounted for. results remained robust and consistent across sets of sensitivity analyses (figures and ). when we restricted the analyses to data reported between june to july , when covid- tests were more readily available, significant associations remained between no and covid- case-fatality and mortality rates, and no consistent associations were found with pm . or o . we also observed similar trends pointing to associations with no when excluding new york city. in addition, we found similar results when omitting the counties ( . %) with missing behavioral risk data. in this nationwide study, we used county-level information on long-term air pollution and corresponding health, behavioral, and demographic data to examine associations between long-term exposures to key ambient air pollutants and covid- death outcomes in both single and multi-pollutant models. we observed significant positive associations between no levels and both county-level covid- case-fatality rate and mortality rate, a marginal association between long-term pm . exposure and covid- mortality rate, and null associations for long-term o exposures in multipollutant models. these results provide additional initial support for the interpretation that long-term exposure to air pollution, especially no -a component of urban air pollution related to traffic -may enhance susceptibility to severe covid- outcomes. these findings may help identify susceptible and high-risk populations, especially those living in areas with historically high no pollution, including the metropolitan areas in new york, new jersey, california, and arizona. given the rapid escalation of covid- spread and associated mortality in the us, swift and coordinated public health actions, including strengthened enforcement on social distancing and expanding healthcare capacity, are needed to protect these and other vulnerable populations. although average no concentrations have decreased gradually over the past decades, it is critical to continue enforcing air pollution regulations to protect public health, given that health effects occur even at very low concentrations . currently, there are few existing studies investigating the link between air pollution and covid- , the majority of which are correlation-only studies without adjustment for confounders. among these sparse studies, our findings are consistent with a recent european study that reported % of the covid- deaths across administrative regions in italy, spain, france and germany, occurred in the five most polluted regions with the highest no levels . another recent paper reported correlations between high levels of air pollution and high death rates seen in northern italy . however, major questions remain concerning the robustness and generalizability of these early findings, due to the lack of control for population mobility, multipollutant exposures, and most importantly, potential residual spatial autocorrelation. the current analysis addresses several of these limitations. we examined two major covid- death outcomes, the county-level case-fatality rate and the mortality rate. the case-fatality rate can indicate biological susceptibility to severe covid- outcomes (i.e. death), while the mortality rate can offer information on the severity of covid- deaths in the general population. our study also included an assessment of three major air pollutants using high spatial resolution maps, uses recent county-level data, considers both single and multipollutant models, and controls for county-level mobility. given that the stage of the covid- epidemic might depend on the size and urbanicity of the county, we included the time of the first and th case for each county in the models as covariates to minimize the possibility that the observed associations are confounded by epidemic timing due to unmeasured location and population-level characteristics. due to the cross-sectional design, we controlled for potential spatial trends by including flexible spatial trends in the main analysis, and evaluated residual autocorrelation using moran's i statistic. our analyses indicated that the presence of spatial confounding was substantial, necessitating the use of spatial smoothing (figures and ) . we performed both stratified analyses and effect modification analyses by adding interaction terms in the model to examine the effects of potential confounders including socioeconomic status. none of these potential modifying effects were significant and were not included in the final analytical modeling approach. finally, we conducted a total of sets of sensitivity analyses and observed robust and consistent results. although social distancing measures around the us have reduced vehicle traffic and urban air pollution in the short-term, it is plausible that long-term exposure to urban air pollutants like no may have sustained direct and indirect effects within the human body, making people more biologically susceptible to severe covid- outcomes. j o u r n a l p r e -p r o o f no can be emitted directly from combustion sources or produced from the titration of no with o . no and nitric oxide (no) have relatively short atmospheric lifetime, thus having larger spatial heterogeneity compared to more regionally distributed pollutants such as pm . and o . as a result, the spatial distribution of no represents the intensity of anthropogenic activity, especially emissions from traffic and power plants. as a reactive free radical, no plays a key role in photochemical reactions that produce other secondary pollutants, including ozone and secondary particulate matter. in our analysis of three major air pollutants, however, no showed strong and independent effects with covid- case-fatality rate and mortality, meaning that the effects of no may not be mediated by pm . and o . even so, we cannot rule out the possibility that no is serving as a proxy for other traffic-related air pollutants, such as soot, trace metals, or ultrafine particles. long-term exposures to no have been associated with acute and chronic respiratory diseases, including increased bronchial hyperresponsiveness, decreased lung function, and increased risk of respiratory infection and mortality - . in addition, as a highly reactive exogeneous oxidant, no can induce inflammation and enhance oxidative stress, generating reactive oxygen and nitrogen species, which may eventually deteriorate the cardiovascular and immune systems , . the impact of long-term exposure to pm . on excess morbidity and mortality has also been well-established [ ] [ ] [ ] . an early unpublished report that explored the impacts of air pollution on mortality found that μg/m pm . was associated with % increase in covid- mortality rates in the usa . the study was conducted in a single pollutant model and did not investigate on covid- case-fatality rates. similarly, we found marginally significant associations between covid- mortality rates and pm . , when controlling for co-pollutants and covariates, although the magnitude and strength of this association observed in the current analysis were weaker, mainly due to our control of the spatial trends, co-pollutants, and residual autocorrelation, which may have confounded the previous study findings. in addition, pm . was not associated with covid- case-fatality rate across all single and multipollutant models, indicating that it may have less impact on biological susceptibility to severe covid- outcomes compared to no . we acknowledge that our study is limited in several key areas. first, the cross-sectional study design reduced our ability to exploit temporal variation and trends in covid- deaths, an important determinant in establishing causal inference. however, an ecological (area-level) analysis may offer valuable information as part of initial public health investigations for hypothesis generation, particularly where individual-level studies may not be possible for some time until fine-scale exposure data become available. towards this end, future time-series j o u r n a l p r e -p r o o f analyses of air pollution and covid- case-fatality rates and corresponding mortality rates will be important. second, there may be complex case ascertainment biases in the county-level covid- data, particularly during the early stages of the outbreak due to lack of reliable testing, which may greatly underestimate the actual covid- case number. while the case data quality gradually improved over the past two months due to enhanced testing capacity, we repeated the analysis using the covid data reported at several time points (by april , by may , by june , and by july ), and the results still hold. third, actual death counts are likely biased, with highly dynamic reported fatality rates, increasing from . % to . %, then decreasing to . % in the past three months - . however, results using data from only the most recent four weeks were largely unchanged, suggesting that differential errors in reporting or testing for covid- may not have exerted much influence on these findings. in this analysis, the air pollution levels were modelled between - , which may introduce bias in the exposure assessment. specifically, given that the average air pollution levels in us have gradually decreased over the years, when using the exposure data between - rather than more recent data, we may have over-estimated the exposure levels, leading to under-estimated health effects. although more recent exposure data were not available, county-specific mean concentrations of air pollutants across years are highly correlated . moreover, we have conducted a sensitivity analysis by using the exposure data between - and the results remained robust and consistent. in addition, although we controlled for many potential confounders such as population density, we cannot rule out the possibility that no might be a proxy of urbanicity. the exclusion of climate meteorological variables and ses -two factors that have received substantial attention regarding the outbreak -did not alter the main results. due to the lack of county-level data, we could not account for the percentage of hospitalized cases or icu use among cases or deaths, the number of available ventilators, and the underlying health conditions of cases likely to increase death risk (e.g., chronic obstructive pulmonary disease). also, as a classic traffic related air pollutant, no can exhibit spatial variation within a county , which may not be captured in our analysis. identification of no pollution hotspots within a county may be warranted. we found statistically significant, positive associations between long-term exposure to no and covid- casefatality rate and mortality rate, independent of pm . as different testing practices may bias outcome ascertainment, we adjusted for state-level covid- test positive rate (i.e. high positive rate might imply that the confirmed case numbers were limited by the ability of testing, and the case-fatality can be biased high). to model how different counties may be at different time points of the epidemic curve (i.e., phase-of-epidemic), we adjusted for days both since the first case and since the th case (i.e., case counts reaching ) within a county through july as a measure of epidemic timing. in addition, we considered potential confounding by county-level healthcare capacity, population travel mobility index, sociodemographic, ses, behavior risk factors, and meteorological factors. because county-specific population densities span orders of magnitude, we adjusted for density using a logarithmic transformation. to control for potential residual spatial trends and confounding, we included spatial smoothers within the model using natural cubic splines with degrees freedom for both county centroid latitude and longitude. we further calculated moran's i of the standardized residuals of tri-pollutant main models for each state, to examine the presence of spatial autocorrelation in the residuals. we also conducted a series of sensitivity analyses to test the robustness of our results to outliers, confounding adjustment, and epidemic timing (figures and ) . given that new york city has far higher covid- cases and deaths than any other regions in the us, which can be a very influential observation, we excluded all five counties within new york city and repeated the analysis. in another set of sensitivity analyses, we restricted the study only to the most recent weeks (june to july ), when the case count and death count may be more reliable and accurate than earlier periods and when covid- tests were more available. we also conducted sensitivity analysis by using air pollution data averaged between to . to assess the impact of potential bias of individual covariates, we fit models by omitting a different set of covariates for each model iteration while comparing effect estimates. statistical tests were -sidedand statistical significance was determined with an alpha of . . all statistical analyses were conducted used r version . . • long-term exposures to urban air pollutants, especially no , may enhance population susceptibility to severe covid- death outcomes. • reduction in urban air pollution exposures would have avoided over , deaths among those who tested positive for the virus as of july , . • public health actions to protect populations from covid- should include considerations for areas with historically high no exposures along with other behavioral and clinical risk factors. the novel human coronavirus disease (covid- ) pandemic has claimed more than , lives worldwide, causing tremendous public health, social, and economic damages. while the risk factors of covid- are still under investigation, environmental factors, such as urban air pollution, may play an important role in increasing population susceptibility to covid- pathogenesis. major ubiquitous ambient air pollutants, including fine particulate matter (pm . ), nitrogen dioxide (no ), and ozone (o ), may have both a direct and indirect systemic impact on the human body by enhancing oxidative stress, inflammation, and respiratory infection risk, eventually leading to respiratory, cardiovascular, and immune system dysfunction and deterioration. although the epidemiologic evidence is limited, a few early crude correlation analyses conducted in china and europe suggest a potential link between air pollution and covid- outcomes. however, questions remain concerning the generalizability and validity of these finding, due to their lack of control for the epidemic timing, population mobility, residual spatial correlation, and potential confounding by co-pollutants. to address these analytical gaps, we conducted a nationwide study in the usa ( , counties) examining associations between multiple key ambient air pollutants, including no , pm . , and o , and covid- case-fatality and mortality rates in both single and multi-pollutant models, with comprehensive covariate adjustment. we hypothesized that residents living in counties with higher long-term ambient air pollution levels may be more susceptible to covid- severe outcomes, thus resulting in higher covid- case-fatality rates and mortality rates. to start this analysis, we obtained the number of daily county-level covid- confirmed cases and deaths that occurred from january , through july , in the contiguous us from three independent databases. the main covid- death outcomes included two measures, the case-fatality rate, which was calculated by dividing the number of deaths over the number of people diagnosed, and the other outcome is the mortality rate, which was calculated as the number of covid- deaths per million population. we include three major criteria pollutants in the analysis, including no , pm . , and o . the high-resolution exposure datasets (daily, km resolution) were generated by our collaborators at harvard using an ensemble-learning method, which integrated three machine learners and a variety of predictor variables. based on these daily predictions from - , we then further calculated the annual mean for no and pm . , and the warm-season mean for o between may to october. case-fatality rate and characteristics of patients dying in relation to covid- in italy the new york times social and environmental risk factors in the emergence of infectious diseases. nature medicine environmental factors on the sars epidemic: air temperature, passage of time and multiplicative effect of hospital infection social, behavioural and environmental factors and their impact on infectious disease outbreaks an imperative need for research on the role of environmental factors in transmission of novel coronavirus (covid- ) ambient particulate air pollution and daily mortality in cities estimates of the global burden of ambient pm . , ozone, and no on asthma incidence and emergency room visits ambient air pollution and emergency department visits for asthma: a multi-city assessment of effect modification by age air pollution and respiratory viral infection. inhalation toxicology effects of nitrogen dioxide on the expression of intercellular adhesion molecule- , neutrophil adhesion, and cytotoxicity: studies in human bronchial epithelial cells use of high-resolution metabolomics for the identification of metabolic signals associated with traffic-related air pollution perturbations of the arginine metabolome following exposures to traffic-related air pollution in a panel of commuters with and without asthma acute pulmonary and inflammatory response in young adults following a scripted car commute air pollution and case fatality of sars in the people's republic of china: an ecologic study association between short-term exposure to air pollution and covid- infection: evidence from china does air pollution influence covid- outbreaks? in: multidisciplinary digital publishing institute health effect institute panel on the health effects of traffic-related air pollution. traffic-related air pollution: a critical review of the literature on emissions, exposure, and health effects. health effects institute the new york times an ensemble-based model of pm . concentration across the contiguous united states with high spatiotemporal resolution assessing no concentration and model uncertainty with high spatiotemporal resolution across the contiguous united states using ensemble model averaging. environmental science & technology area health resources files mobility changes in response to covid- mapping county-level mobility pattern changes in the united states in response to covid- social deprivation index continental-scale water and energy flux analysis and validation for the north american land data assimilation system project phase (nldas- ): . intercomparison and application of model products when adjusted for co-pollutants and confounding factors, per inter-quartile range (iqr) increase in no ( . ppb), covid- case-fatality rate and mortality rate were associated with an increase of . % ( % ci: . % to . %) and . % ( % ci: . % to . %), respectively. in other words, per iqr reduction in long-term exposure to no level ( . ppb) would have avoided , deaths ( % ci: , to , ) among those who tested positive for the virus and . deaths ( % ci: . to . ) per million people in the us general population, as of which largely arises from urban combustion sources such as traffic, may enhance susceptibility to severe covid- death outcomes, independent of long-term pm . and o exposure. public health actions to protect populations from covid- should include considerations for areas with historically high no exposures along with other behavioral and clinical risk factors. continuation and expansion of current efforts to lower traffic emissions and ambient air pollution may be an important component of reducing population-level risk of covid- case-fatality and mortality * descriptive statistics was conducted on , us counties using data reported as of july , **covid- case fatality rate was calculated by the number of deaths divided by the number of cases, reported as of july , key: cord- -lmgn authors: howe, james r.; bartlett, david l.; tyler, douglas s.; wong, sandra l.; hunt, kelly k.; dematteo, ronald p. title: covid- guideline modifications as cms announces “opening up america again”: comments from the society of surgical oncology date: - - journal: ann surg oncol doi: . /s - - - sha: doc_id: cord_uid: lmgn nan illness or covid-like symptoms within days . a downward trajectory of documented cases or positive tests (as a percentage of total tests) within days . hospitals are treating patients without crisis care . robust testing programs are in place for at-risk health care workers. phase of re-opening would allow resumption of elective surgeries as clinically appropriate on an outpatient basis at facilities that adhere to cms guidelines. if a region shows no rebound in the number of cases and satisfies the -day gating criteria a second time, it can move to phase , in which ''elective surgery can resume, as clinically appropriate, on an out-or inpatient basis at facilities that adhere to cms guidelines.'' if a region then shows no rebound in the number of cases and satisfies the -day gating criteria a third time, it can move to phase , in which surgery can fully resume, and other social restrictions can be relaxed (e.g., unrestricted staffing of worksites, limited physical distancing in large venues). the cms document suggests that ''providers should prioritize surgical/procedural care and high/complexity chronic disease management.'' this would require testing capacity, a healthy workforce, adequate personal protective equipment (ppe), and post-acute care that would not jeopardize the facility's capacity to respond to another surge in covid- cases. facilities also should continue taking steps to reduce transmission (distancing, separation of covid- -free spaces, prohibition of visitors, increased sanitation protocols), and all patients should be screened for symptoms and by laboratory testing ''before care'' (presumably including surgery). health care workers also should be regularly screened by laboratory testing when ''adequate testing capability is established.'' to summarize, the white house and cms documents , suggest that facilities with down-trending numbers of covid- cases, adequate testing abilities, and no shortages of ppe, intensive care unit (icu) beds, ventilators, or health care workers may be able to resume elective surgeries, which would reasonably include all cancer cases. phase of recovery, as described by the white house document, would allow outpatient procedures for cancer patients, which had been deferred as lower-priority operations during the pandemic phase of care. phase then would allow for cases requiring inpatient care and for outpatient procedures. in their document, ''local resumption of elective surgery guidance,'' the american college of surgeons (acs) also has given detailed suggestions about what facilities should do to prepare for the ramping up needed for initiation of elective surgeries. the acs recently updated their cancer-triaging suggestions during covid- to include a recovery phase in a document entitled ''acs guidelines for triage and management of elective cancer surgery cases during the acute and recovery phases of coronavirus disease (covid- ) pandemic.'' this document breaks down the covid- outbreak into the pandemic phases for which the society of surgical oncology (sso) and the acs had already posted guidelines (on march ) for triaging of cancer cases, and these new guidelines now include two recovery phases. the early recovery phase is characterized by fewer covid- cases each day and greater availability of limited resources such as ppe, health care workers, ventilators, icu beds, and testing. in the late recovery phase, the facility is more than days beyond its peak, and resources are at near normal levels. the acs document gives specific suggestions for prioritizing cancer cases in the acute and late recovery phases for patients with breast cancer, colorectal cancer, thoracic malignancies, pancreatic and periampullary cancers, soft tissue sarcoma, and melanoma. although the release of these documents from the white house and the cms , are encouraging for surgeons, inspiring hope that they may be able to resume elective surgeries soon, all regions of the country and even specific hospitals within the same region will have unique challenges in meeting these proposed criteria. some confusion may result from the fact that phase of recovery mentions only performance of outpatient procedures, and that individual states may have different criteria mandated by their governors. therefore, surgeons must work closely with their hospital leadership and local authorities to determine whether they fall within the pandemic or recovery phases, and whether they meet gating criteria as well as cms and state guidelines. if these standards are met, then it would be reasonable for hospitals to resume elective surgeries for cancer patients, which could include both in-or outpatient procedures because few cancer cases would be considered as truly elective. the updated acs guidelines for triage give detailed suggestions on how to prioritize cancer cases that have been deferred at these six disease sites. a general principle emerging from these suggestions is that clinicians must review the priority of cancer cases suggested in the pandemic phases, and begin by performing the more urgent cases that were delayed, followed by the semi-urgent cases. afterward, other cancer cases can follow based on prioritization as to which patients are most likely to have compromised outcomes with further delays. it is important for health care workers to be aware that there could be a resurgence of covid- cases related to seasonal changes (in the fall or winter), as social distancing practices are relaxed, or as a result of other currently unforeseen factors. should this happen, these events could again lead to severe restrictions in cancer care delivery and a return to these triage guidelines for cancer patients. all guidelines will also need to be updated periodically as both covid- polymerase chain reaction and antibody testing become more universally available, effective drugs are identified, and/or a successful vaccine is developed. readers might also be interested in how the covid- pandemic is affecting the academic mission in surgical oncology, and a detailed example of how one medical center has navigated the issues surrounding covid- . opening up america again: centers for medicare & medicaid services (cms) recommendations for re-opening facilities to provide nonemergent non-covid- healthcare: phase i. retrieved local resumption of elective surgery guidance acs guidelines for triage and management of elective cancer surgery cases during the acute and recovery phases of coronavirus disease (covid- ) pandemic. updated management of cancer surgery cases during the covid- pandemic: considerations american college of surgeons. covid- guidelines for triage of cancer surgery patients executive committee at memorial sloan kettering. cancer surgery and covid covid- pandemic and surgical oncology: preserving the academic mission resuming elective surgery at utmb predicated on patient and staff well-being publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations covid- guideline modifications as cms announces ''opening up america again disclosures dr. kelly k. hunt reports medical advisory board support from armada health and merck & co.; research funding to her institution from endomagnetics, lumicell, and onconano. all other authors report no conflicts. key: cord- -zklwovba authors: jombart, thibaut; van zandvoort, kevin; russell, timothy w.; jarvis, christopher i.; gimma, amy; abbott, sam; clifford, sam; funk, sebastian; gibbs, hamish; liu, yang; pearson, carl a. b.; bosse, nikos i.; eggo, rosalind m.; kucharski, adam j.; edmunds, w. john title: inferring the number of covid- cases from recently reported deaths date: - - journal: wellcome open res doi: . /wellcomeopenres. . sha: doc_id: cord_uid: zklwovba we estimate the number of covid- cases from newly reported deaths in a population without previous reports. our results suggest that by the time a single death occurs, hundreds to thousands of cases are likely to be present in that population. this suggests containment via contact tracing will be challenging at this point, and other response strategies should be considered. our approach is implemented in a publicly available, user-friendly, online tool. as the coronavirus- (covid- , ) epidemic continues to spread worldwide, there is mounting pressure to assess the scale of epidemics in newly affected countries as rapidly as possible. we introduce a method for estimating cases from recently reported covid- deaths. results suggest that by the time the first deaths have been reported, there may be hundreds to thousands of cases in the affected population. we provide epidemic size estimates for several countries, and a user-friendly, web-based tool that implements our model . using deaths to infer cases covid- deaths start to be notified in countries where few or no cases had previously been reported . given the nonspecific symptoms , and the high rate of mild disease , a covid- epidemic may go unnoticed in a new location until the first severe cases or deaths are reported . available estimates of the case fatality ratio, i.e. the proportion of cases that are fatal (cfr, , ), can be used to estimate the number of cases who would have shown symptoms at the same time as the fatal cases. we developed a model to use cfr alongside other epidemiological factors underpinning disease transmission to infer the likely number of cases in a population from newly reported deaths. our approach involves two steps: first, reconstructing historic cases by assuming non-fatal cases are all undetected, and, second, model epidemic growth from these cases until the present day to estimate the likely number of current cases. we account for uncertainty in the epidemiological processes by using stochastic simulations for estimation of relevant quantities. two pieces of information are needed to reconstruct past cases: the number of cases for each reported death, and their dates of symptom onset. intuitively, the cfr provides some information on the number of cases, as it represents the expected number of deaths per case, so that cfr - corresponds to the expected number of cases per death. in practice, the number of cases until the first reported death can be drawn from a geometric distribution with an event probability equal to the cfr. note that while our approach could in theory use different cfr for each case (to account for different risk groups), our current implementation uses the same cfr for all cases in a simulation. dates of symptom onset are simulated from the distribution of the time from onset to death, modelled as a discretised gamma distribution with a mean of days and a standard deviation of . days . once past cases are reconstructed, we use a branching process model for forecasting new cases , . this model combines data on the reproduction number (r) and serial interval distribution to simulate new cases 'y t ' on day 't' from a poisson distribution: where w(.) is the probability mass function of the serial interval distribution. more details on this simulation model can be found in jombart et al. . optionally, this model can also incorporate heterogeneity in transmissibility using a negative binomial distribution instead of poisson. the serial interval distribution was characterized as a discretized lognormal distribution with mean . days and standard deviation . days . we assume that past cases caused secondary transmissions independently (i.e. are not ancestral to each other), so that simulated cases for each death can be added. this assumption is most likely to be met when reported deaths are close in time. as the time between reported deaths increases, past cases may come from the same epidemic trajectory rather than separate, additive ones, in which case our method would overpredict epidemic size. further details on model design and parameters values are provided in supplementary material. our approach is implemented in the r software and publicly available as r scripts (see extended data) , as well as in a user-friendly, interactive web-interface available at: https://cmmid.github.io/visualisations/ inferring-covid -cases-from-deaths . we first used our model to assess likely epidemic sizes when an initial covid- death is reported in a new location. we ran simulations for a range of plausible values of r ( . , and ) and cfr ( %, %, % and %), assuming a single death on the st march . , epidemic trajectories were simulated for each parameter combination. simulations for an 'average severity' scenario with r = and cfr = % show that by the time a death has occurred, hundreds to thousands of cases may have been generated in the affected population ( figure ) . results vary widely across other parameter settings, and amongst simulations from a given setting (table ) , with higher r and lower cfr leading to higher estimates of the numbers of cases. however, a majority of settings give similar results to our 'average' scenario, suggesting that a single death is likely to reflect several hundreds of cases. results were qualitatively unchanged when incorporating heterogeneity in the model using recent estimates , but prediction intervals were wider (extended data). we applied our approach to three countries which recently reported their first covid- deaths (spain, italy, and france), using the same range of parameters as in the single-death analysis. in order to compare predictions to cases actually reported in these countries, projections were run until th march. overall, predictions from the model using the baseline scenario (r = , crf = %) were in line with reported epidemic sizes ( several limitations need to be considered when applying our method. first, our approach only applies to the deaths of patients who have become symptomatic in the location considered, which should usually be the case in places where traveler screening is in place. we also assume constant transmissibility (r) over time, which implies that behavior changes and control measures have not taken place yet, and that there is no depletion of susceptible individuals. consequently, our method should only be used in the early stages of a new epidemic, where these assumptions are reasonable. similarly, the assumption that each death reflects independent, additive epidemic trajectories is most likely to hold true early on, when reported deaths are close in time (e.g. no more than a week apart). used on deaths spanning longer time periods, our approach is likely to overestimate epidemic sizes. contact tracing has been shown to be an efficient control measure when imported cases can be detected early on , in addition to permitting the estimation of key epidemiological parameters . when the first cases reported in a new location are mostly deaths, however, our results suggest that theunderlying size of the epidemic would make control via contact tracing extremely challenging. in such situations, efforts focusing on social distancing measures such as schoolclosures and self-isolation may be more likely to mitigate epidemic spread. underlying data all data underlying the results are available as part of the article and no additional source data are required. this project contains the file 'extended_data' (pdf), which contains supplemental information and methodological details regarding the model described in this article. extended data are available under the terms of the creative commons attribution . international license (cc-by . ). the shiny app using the model is available at: https://cmmid. github.io/visualisations/inferring-covid -cases-from-deaths. source code and r scripts available at: https://github.com/thibautjombart/covid _cases_from_deaths. cmmid covid- working group gave input on the method, contributed data and provided elements of discussion. all authors read and approved the final version of the manuscript. the following authors were part of the centre for mathematical modelling of infectious disease -ncov working group: mark jit, charlie diamond, fiona sun, billy j quilty, kiesha prem, nicholas davies, stefan flasche, alicia rosello, james d munday, petra klepac, joel hellewell. each contributed in processing, cleaning and interpretation of data, interpreted findings, contributed to the manuscript, and approved the work for publication. all authors read and approved the final version of the manuscript. to reconstruct the past history to know how much trouble one is currently in? what would the effect of a heterogeneous cfr be? (i believe this would correspond e.g. to a 'beta-geometric distribution', unless one instead wanted to treat it as a finite mixture of probabilities for discrete risk categories). it would be nice to have a little more detail (i.e. a few sentences) on the simulation procedure. i see how to get from cfr and deaths to a total number of preceding cases, and how to simulate times of symptom onset for the observed deaths. it's not completely obvious to me how to get from there to 'history of past cases' (i.e. incidence over time); does one run the renewal process backward in time? or use branching-process theory to find the time distribution of symptom onset of the index case given the current size of the epidemic? please clarify "we assume that past cases caused secondary transmissions independently (i.e. are not ancestral to each other), so that simulated cases for each death can be added." does this mean that you assume that all observed deaths are from separate lineages/transmission chains? (the last sentence of the paragraph suggests that, but the initial statement could probably be clearer.) (does this assumption even matter if we are in the branching-process regime?). i appreciate that the authors are trying to keep things simple, and thus the scenario-based approach (try the model for a range of cfr/r values and see what is implied) is useful. i note that the confidence intervals are already very wide (that's part of the point), but there are several quantities that are treated as known (delay distribution, serial interval distribution); i wonder how sensitive the results are to these assumptions (probably not much -i'm guessing that with r specified they might only change the timing, not the numbers). given that the authors are already basing the answers on , solutions, it might not be too hard to construct point estimates and intervals based on a prior/uncertainty distribution of r and cfr (rather than constructing separate scenarios), and allowing for uncertainty in the delay and serial distributions. minor comments/typos: intro, line ; methods, l. : extra comma inside parens before superscript refs?) "use [a] different cfr for each case" "parameters" values "theunderlying" "schoolclosures" in tables and consider stating " . % quantile, % quantile, % quantile, . % quantile" (rather than lower/upper x %/ %) ? is the description of the method technically sound? yes who: novel coronavirus -china reference source inferring covid- cases from recent death world health organization: coronavirus disease (covid- ) world health organization: pneumonia of unknown cause--china the incubation period of -ncov from publicly reported confirmed cases: estimation and application. medrxiv estimating underdetection of internationally imported covid- cases. medrxiv. . reference source estimating the case fatality risk of covid- using cases from outside china. medrxiv. . publisher full text . midas-network: covid- parameter estimates reference source incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data pubmed abstract | publisher full text | free full text a simple approach to measure transmissibility and forecast incidence pubmed abstract | publisher full text | free full text the cost of insecurity: from flare-up to control of a major ebola virus disease hotspot during the outbreak in the democratic republic of the congo serial interval of novel coronavirus ( -ncov) infections. medrxiv. . publisher full text r foundation for statistical computing extended data for: inferring the number of covid- cases from recently reported deaths pattern of early human-to-human transmission of wuhan novel coronavirus ( -ncov) this article describes a statistical modeling method for estimating the number of covid- cases from the first reported deaths in a defined location. the described methodology can provide useful information for decision making, especially as a shiny app has been developed for facilitating quick application of the method by public health practitioners, and the r code has been made available. i would be interested to see in the text a few words about how many (and which) countries found themselves in the situation of observing no covid- case before the first deaths were reported. the reference provided (number ) is not really specific about this point. the statistical method is well described and seems sound.i have a minor comment: in practice, published estimates of the cfr and r will be used as input parameters for the model. these estimates are derived from samples and are usually published with a certain measure of uncertainty, typically the standard deviation or a confidence interval. my understanding is that this estimation uncertainty on these input parameters is not taken into account in the prediction model: instead, the cfr and r are held constant for all simulations drawn with a set of parameter.taking into account the uncertainty on these input parameters may lead to even greater prediction intervals, but may reflect more completely the uncertainty about the total number of cases given the current knowledge about the disease at a certain point in time. this could be done, for example, by drawing the cfr in a beta distribution with a and b derived from the published mean and sd instead of holding it constant. in the shiny app, the user could provide the confidence interval. this is a useful, technically correct, and clearly written contribution. could the authors comment on how much extra mileage one gets/advantages of this approach relative to simply saying that the current number of cases is approximately equal to /cfr? that is, does one have to reconstruct the past history to know how much trouble one is currently in? if any results are presented, are all the source data underlying the results available to ensure full reproducibility? yesare the conclusions about the method and its performance adequately supported by the findings presented in the article? yesno competing interests were disclosed. competing interests:reviewer expertise: ecology, evolution, epidemiological modeling i confirm that i have read this submission and believe that i have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. key: cord- -vpih wvs authors: petropoulos, fotios; makridakis, spyros title: forecasting the novel coronavirus covid- date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: vpih wvs what will be the global impact of the novel coronavirus (covid- )? answering this question requires accurate forecasting the spread of confirmed cases as well as analysis of the number of deaths and recoveries. forecasting, however, requires ample historical data. at the same time, no prediction is certain as the future rarely repeats itself in the same way as the past. moreover, forecasts are influenced by the reliability of the data, vested interests, and what variables are being predicted. also, psychological factors play a significant role in how people perceive and react to the danger from the disease and the fear that it may affect them personally. this paper introduces an objective approach to predicting the continuation of the covid- using a simple, but powerful method to do so. assuming that the data used is reliable and that the future will continue to follow the past pattern of the disease, our forecasts suggest a continuing increase in the confirmed covid- cases with sizable associated uncertainty. the risks are far from symmetric as underestimating its spread like a pandemic and not doing enough to contain it is much more severe than overspending and being over careful when it will not be needed. this paper describes the timeline of a live forecasting exercise with massive potential implications for planning and decision making and provides objective forecasts for the confirmed cases of covid- . the accuracy of traditional forecasting largely depends on the availability of data to base its predictions and estimates of uncertainty. in outbreaks of epidemics there is no data at all in the beginning and then limited as time passes, making predictions widely uncertain. on february , , a new york times article [ ] cautioned against excessive optimism about the crisis peaking, even though there were close to days since the virus had been identified. besides, there are concerns that the data may not be reliable, as was the case of bird flu and sars when the number of affected people and deaths were misreported to hide the extent of the epidemic. similarly, in the case of covid- , the reporting did not reflect the correct numbers as well when on the february a new category of "clinically diagnosed" was added to "lab-confirmed" ones [ ] . such problems decrease forecasting accuracy and increase uncertainty, making the drawing of definite conclusions more difficult. related to forecasting accuracy and uncertainty, there is a more severe problem that has to do the perception of epidemics and pandemics. politicians are concerned with regards to the a a a a a measures to be taken while the general population fears about the impact on the epidemic on their health/lives. furthermore, the pharmaceutical firms are working on vaccinations for the new virus with considerable commercial interest. this was the case with sars when governments persuaded on the severity of the virus bought large numbers of vaccines that were never used as its spread stopped without the need to vaccinate people. of course, the big problem is the asymmetry of risks and the irrational fear of a pandemic with its possible catastrophic consequences, as happened with the spanish flu that killed an estimated million worldwide. in contrast, the sars killed a total of in and the bird flu around in . covid- has resulted in an estimated . thousand deaths until now ( / / ). at the same time, there is much less concern over the seasonal flu that kills about , people worldwide each year [ ] . medical predictions are often not accurate while their uncertainty is seriously underestimated [ ] . predicting the future of epidemics and pandemics is much more difficult as the number of cases to be studied can be measured in one hand. at one end of the scale is the case of sars where the fear of becoming a pandemic was overblown, resulting in overspending and the application of restrictive measures to be contained that it turned out to be unnecessary. at the other end is the spanish flu that turned out to be a serious pandemic with catastrophic consequences, arguably in a different era when communication and the ability to raise public awareness (and possibly exaggerated fear) were limited. despite the inaccuracies associated with medical predictions, still forecasting is invaluable in allowing us to better understand the current situation and plan for the future. in this paper, we provide statistical forecasts for the confirmed cases of covid- using robust time series models, and we analyse the trajectory of recovered cases. we focus on the cumulative daily figures aggregated globally of the three main variables of interest: confirmed cases, deaths and recoveries. these were retrieved by the center for systems science and engineering (csse) at johns hopkins university (https://github.com/ cssegisanddata/covid- accessed on / / ) and are presented in fig . the data refer to daily cumulative cases and cover the period from january , until march , . we include both "lab-confirmed" and "clinically diagnosed" cases. we emphasise the importance of the recovered cases, which is not covered in media as widely as the confirmed cases or the deaths. while all three data patterns show an exponential increase, the trends of both the confirmed cases and the deaths were reduced in the mid of february; a second exponential increase is observed in late february and march as a result of the increased number of cases in south korea, iran, and europe. at the same time, the number of recovered cases is steadily increasing. to forecast confirmed cases of covid- , we adopt simple time series forecasting approaches. we produce forecasts using models from the exponential smoothing family [ , ] . this family has shown good forecast accuracy over several forecasting competitions [ ] [ ] [ ] and is especially suitable for short series. exponential smoothing models can capture a variety of trend and seasonal forecasting patterns (such as additive or multiplicative) and combinations of those. we limit our attention to trended and non-seasonal models, given the patterns observed in fig . note that we follow a pragmatic approach in that we assume that the trend will continue indefinitely in the future. this approach contradicts other modelling approaches to covid- using an s-curve model (logistics curve) that assumes convergence. while statistical approaches to model selection (such as information criteria, which measure the maximum likelihood of a model while penalising for its complexity) could be used, we judgmentally select a model [ ] to better reflect the nature of the data. we opt for an exponential smoothing model with multiplicative error and multiplicative trend components. even if in some cases an additive trend model gave lower information criteria values, we opted for the multiplicative trend model given the asymmetric risks involved as we believe that it is better to err to the positive direction. we produce ten-days-ahead point forecasts and prediction intervals and update our forecasts every ten days. please note that this is not an ex-post analysis, but a real, live forecasting exercise. we have been posting and evaluating our forecasts publicly in social media (please, refer to the twitter accounts of the authors, @fotpetr and @spyrosmakrid). we first started at the end of january , and only had ten actual data points in hand. we decided to use a multiplicative trend exponential smoothing model. the forecasts (and % prediction intervals) produced at the end of / / are presented in fig with red (and pink) colour. note that the vertical axis is log-scaled. the mean estimate (point forecast) for the confirmed cases ten-days-ahead was thousand with the % prediction intervals ranging from about to thousand cases. the actual confirmed cases on / / were just under thousand. we observe a considerable forecast error from the mean estimate equal to thousand cases (an absolute percentage error of %), with the forecasts being extremely positively biased. still, the actual cases lie within the prediction intervals. then, we increased the historical number of our data to include cases up to the end of february , ( data points). we once again produced ten-days-ahead predictions. the forecasts and prediction intervals are depicted in fig with blue colour. we observe that the actual values for the period / / until / / closely follow the mean estimate. the forecast error on / / was . thousand cases (an absolute percentage error of . %). this was despite the change that was made on / / with regards to how confirmed cases are recorded to now include "clinically diagnosed" instances as opposed to exclusively lab-confirmed. one crucial observation is that this more accurate forecast came with a significant decrease in the steepness of the slope compared to the forecast for the previous ten-days period. another observation is that at the end of / / , we were still over-forecasting the number of confirmed cases. finally, all actual values lied well inside the prediction intervals range. we produced a third set of forecasts and prediction intervals using the data up until / / . the forecasts are presented in fig with green colour. the mean estimate for ten-daysahead ( / / ) was thousand cases. the slope of the forecasts was, once again, lower compared to the previous two sets of forecasts, confirming the fact that the observed confirmed cases (up until / / ) show a steady decrease. we also observed a significant decrease in the associated forecast uncertainty, with the prediction intervals being much tighter compared to our past forecasts. the % prediction intervals worst-case scenario was about thousand cases, which is halved compared to that of the last round of forecasts ( . million cases). the actual confirmed cases at the end of / / were thousand. at the end of this third round of forecasts, we recorded an error of . thousand cases ( . %). while this error was lower than the previous round (in both absolute and percentage terms), it was the first time that our -days ahead forecast were below the actual values (under-forecasting). this was because the virus had been spreading in three countries outside mainland china (south korea, iran, and italy). our fourth round of forecasts is shown in fig with purple colour. the mean estimate for / / was thousand confirmed cases, with the uncertainty levels being similar to the previous round: there was a % chance that they would exceed thousand by the end of / / . the observed actual confirmed cases at the end of this period were almost thousand. the absolute forecast error at the end of the last period ( / / ) was . k ( . %), higher compared to the previous set of forecasts but still well within the prediction intervals. for the second round in a row, we were consistently under-forecasting the actual cases. this was due to the exponential increase of the confirmed cases mostly in europe, iran and the us, with south korea managing to decrease the number of new daily cases significantly. we produced a final set of forecasts and prediction intervals using the most recent data, up until / / . these are presented in fig with yellow/gold colour. note that we estimated three levels of uncertainty ( , and %). the trend of our forecasts is much increased compared to the last two rounds: we predict thousand new cases for this round (a total of thousand cases). the associated levels of uncertainty are also increased: there is a % chance that the total confirmed cases will exceed thousand by the end of / / ; and a % chance that they will exceed . m. we also attempted to produce forecasts by splitting the recorded confirmed cases into two groups: cases within mainland china and cases anywhere else, as the trends into these two groups are different. we fitted independent exponential smoothing models, and then we summed up the forecasts (bottom-up hierarchical forecasting). we notice that using this approach, the mean estimate is close to that if all data are considered together ( versus thousand cases). however, the estimated uncertainty by splitting the data is considerably lower, possibly since the confirmed cases outside mainland china have significantly increased only recently. we next turn our attention to the recovered cases that have received little attention until now. we focus on the number of the recovered cases as a percentage of the total confirmed cases as well as the ratio of recovered cases versus deaths. we are particularly interested in the trajectory of these two ratios. fig presents this analysis. first, we observe the solid relationship between the two curves. second, we notice that despite the very small percentages of recovered cases until the end of january (less than %), currently, about out of confirmed cases have recovered ( . % of the total confirmed cases). moreover, the ratio of recovered cases versus deaths is currently above : . despite this, we observe a reverse of both curves since / / , which is associated with the increasing number of cases outside mainland china. the uncertainty surrounding an unknown, novel coronavirus can spark a global alarm, leading a harvard professor stating that - % of the global population might be infected in the coming year [ ] which matches chancellor angela merkel's warning regarding the effects of the novel coronavirus in germany [ ] . norman, bar-yam and taleb [ ] discuss the systemic risk of pandemics, the existence of fat-tailed processes due to global interconnectivity and the negatively biased estimates of spread, reproduction and mortality rates. on the opposite side, others are arguing about people overly panicking [ ] and neglecting the probabilities [ , ] with the new virus being the first "infodemic" as a result of the hyper-connectivity offered by today's social media [ , ] . the polarisation of the opinions globally can be summarised by the quotes of three renowned personalities: • elon musk: "the coronavirus panic is dumb" [ ] . • nassim nicholas taleb: "saying the coronavirus panic is dumb is dumb" [ ] . • bill gates: "i hope it's not that bad, but we should assume it will be until we know otherwise." [ ] . regardless of what one's beliefs are, we believe that forecasts and their associated uncertainty can and should be an integral part of the decision-making process, especially in highrisk cases. apart from the significant public health concerns, the dangers imposed on global supply chains and the economy as a whole are also considerable [ , ] . risk-averse people can focus on the worst-case-scenarios and act accordingly. deciding to discard any formal, statistical forecasts and acting conservatively, still implies an underlying forecasting process, even if this process is not formalised (personal judgment/belief). in this exercise, we used univariate time series models, which assume that the data is accurate and past patterns (including precautionary measures) will continue to apply. significant, consistent forecast errors (potentially spanning outside the prediction intervals) should be associated with changes in the observed patterns and the need for additional actions and measures in the case of negatively biased forecasts. we believe that the significant forecast error at the end of the first forecast period (from / / to / / ) as depicted in fig could be the result of two factors: • while the forecasts that we produced using the data up until / / would be a good estimate in the scenario of "business-as-usual" (nothing changes), they disregard the fact that the world will act to get the virus under control. the chinese authorities managed to rapidly construct two new hospitals, in huoshenshan and leishenshan areas in wuhan, that opened on / / and / / respectively. multiple commuting restrictions were applied both within china and internationally. the world health organisation helped in creating awareness of the novel virus. so, the decline in the spread of the covid- during this first round could well be linked with these attempts from local and global authorities. • there may be a "garbage-in, garbage-out" situation. as mentioned above, our analysis and forecasts assumed that the data are accurate. it could be the case that the positive bias of the first-period forecasts is not as significant as it seems dues to potential inaccuracies in the actual data and the under-accounting of confirmed cases. this is especially true given the delay effects in diagnosing covid- cases [ ] . our second and third sets of forecasts that cover the period / / to / / were very close to the recorded confirmed cases (the forecast error was lower than thousand cases at the end of each -day period). the slowing down of the trend during this period suggested that covid- would not cause any serious problems, particularly outside of mainland china. unfortunately, that was not the case. the last two sets of forecasts that cover the period / / to / / show a significant increase in the trend of cases globally coupled with an increase in the associated uncertainty. we hope that our forecasts will be a useful tool for governments and individuals towards making decisions and taking the appropriate actions to contain the spreading of the virus to the degree possible. conceptualization: fotios petropoulos, spyros makridakis. formal analysis: fotios petropoulos. coronavirus epidemic keeps growing, but spread in china slows sharp increase in deaths and cases in hubei flu kills , people worldwide each year: study finds predicting medical risks and appreciating uncertainty a state space framework for automatic forecasting using exponential smoothing methods exponential smoothing with a damped multiplicative trend the accuracy of extrapolation (time series) methods: results of a forecasting competition the m -competition: results, conclusions and implications the m competition: , time series and forecasting methods judgmental selection of forecasting models harvard professor sounds alarm on 'likely' coronavirus pandemic: % to % of world could be infected this year up to % of germany could become infected-merkel systemic risk of pandemic via novel pathogens-coronavirus: a note coronavirus: there are better things to do than panic the cognitive bias that makes us panic about coronavirus coronavirus and its global sweep stokes fear over facts. experts say it's unlikely to produce 'apocalyptic scenario coronavirus in europe: epidemic or 'infodemic'? mit technology review. the coronavirus is the first true social-media "infodemic bill gates and elon musk just issued very different responses to the coronavirus. it's a lesson in emotional intelligence the black swan' author to elon musk:'saying the coronavirus panic is dumb is dumb responding to covid- -a once-in-a-century pandemic? how coronavirus could impact the global supply chain by mid-march jpmorgan officially forecasts a coronavirus-driven recession will rock the us and europe by july characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china visualization: fotios petropoulos. writing -review & editing: fotios petropoulos, spyros makridakis. key: cord- -nr fwc q authors: porten, klaudia; rissland, jürgen; tigges, almira; broll, susanne; hopp, wilfried; lunemann, mechthild; van treeck, ulrich; kimmig, peter; brockmann, stefan o; wagner-wiening, christiane; hellenbrand, wiebke; buchholz, udo title: a super-spreading ewe infects hundreds with q fever at a farmers' market in germany date: - - journal: bmc infect dis doi: . / - - - sha: doc_id: cord_uid: nr fwc q background: in may the soest county health department was informed of an unusually large number of patients hospitalized with atypical pneumonia. methods: in exploratory interviews patients mentioned having visited a farmers' market where a sheep had lambed. serologic testing confirmed the diagnosis of q fever. we asked local health departments in germany to identiy notified q fever patients who had visited the farmers market. to investigate risk factors for infection we conducted a case control study (cases were q fever patients, controls were randomly selected soest citizens) and a cohort study among vendors at the market. the sheep exhibited at the market, the herd from which it originated as well as sheep from herds held in the vicinity of soest were tested for coxiella burnetii (c. burnetii). results: a total of reported q fever cases was linked to this outbreak. the mean incubation period was days, with an interquartile range of – days. the case control study identified close proximity to and stopping for at least a few seconds at the sheep's pen as significant risk factors. vendors within approximately meters of the sheep's pen were at increased risk for disease compared to those located farther away. wind played no significant role. the clinical attack rate of adults and children was estimated as % and %, respectively, % of cases were hospitalized. the ewe that had lambed as well as % of its herd tested positive for c. burnetii antibodies. conclusion: due to its size and point source nature this outbreak permitted assessment of fundamental, but seldom studied epidemiological parameters. as a consequence of this outbreak, it was recommended that pregnant sheep not be displayed in public during the (rd )trimester and to test animals in petting zoos regularly for c. burnetii. q fever is a worldwide zoonosis caused by coxiella burnetii (c. burnetii), a small, gram-negative obligate intracellular bacterium. c. burnetii displays antigenic variation with an infectious phase i and less infectious phase ii. the primary reservoir from which human infection occurs consists of sheep, goat and cattle. although c. burnetii infections in animals are usually asymptomatic, they may cause abortions in sheep and goats [ ] . high concentrations of c. burnetii can be found in birth products of infected mammals [ ] . humans frequently acquire infection through inhalation of contaminated aerosols from parturient fluids, placenta or wool [ ] . because the infectious dose is very low [ ] and c. burnetii is able to survive in a spore-like state for months to years, outbreaks among humans have also occurred through contaminated dust carried by wind over large distances [ ] [ ] [ ] . c. burnetii infection in humans is asymptomatic in approximately % of cases. approximately % of cases are hospitalized, and fatal cases are rare [ ] . the clinical presentation of acute q fever is variable and can resemble many other infectious diseases [ ] . however, the most frequent clinical manifestation of acute q fever is a self-limited febrile illness associated with severe headache. atypical pneumonia and hepatitis are the major clinical manifestations of more severe disease. acute q fever may be complicated by meningoencephalitis or myocarditis. rarely a chronic form of q fever develops months after the acute illness, most commonly in the form of endocarditis [ ] . children develop clinical disease less frequently [ , ] . because of its non-specific presentation q fever can only be suspected on clinical grounds and requires serologic confirmation. while the indirect immunofluorescence assay (ifa) is considered to be the reference method, complement fixation (cf), elisa and microagglutination (ma) can also be used [ ] . acute infections are diagnosed by elevated igg and/or igm anti-phase ii antibodies, while raised anti-phase i igg antibodies are characteristic for chronic infections [ ] . in germany, acute q fever is a notifiable disease. between and the annual number of cases varied from to cases per year [ ] . in and , and cases were notified, respectively [ , ] . on may , the health department of soest was informed by a local hospital of an unusually large number of patients with atypical pneumonia. some patients reported having visited a farmers' market that took place on may and , in a spa town near soest. since the etiology was unclear, pathogens such as sars coronavirus were considered and strict infection control measures implemented until the diagnosis of q fever was confirmed. an outbreak investigation team was formed and included public health professionals from the local health department, the local veterinary health department, the state health department, the national consulting laboratory (ncl) for coxiellae and the robert koch-institute (rki), the federal public health institute. because of the size and point source appearance of the outbreak the objective of the investigation was to identify etiologic factors relevant to the prevention and control of q fever as well as to assess epidemiological parameters that can be rarely studied otherwise. on may and , we conducted exploratory interviews with patients in soest hospitalized due to atypical pneumonia. attending physicians were requested to test serum of patients with atypical pneumonia for mycoplasma pneumoniae, chlamydia pneumoniae, legionella pneumophila, coxiella burnetii, influenza a and b, parainfluenza - , adenovirus and enterovirus. throat swabs were tested for influenza virus, adenovirus and sars-coronavirus. laboratory confirmation of an acute q fever infection was defined as the presence of igm antibodies against phase ii c. burnetii antigens (elisa or ifa), a -fold increase in anti-phase ii igg antibody titer (elisa or ifa) or in anti phase ii antibody titer by cf between acute and convalescent sera. a chronic infection was confirmed when both anti-phase i igg and anti-phase ii igg antibody titers were raised. because patients with valvular heart defects and pregnant women are at high risk of developing chronic infection [ , ] we alerted internists and gynaecologists through the journal of the german medical association and asked them to send serum samples to the ncl if they identified patients from these risk groups who had been at the farmers' market during the outbreak. the objective of the first case control study was to establish whether there was a link between the farmers' market and the outbreak and to identify other potential risk factors. we conducted telephone interviews using a standardised questionnaire that asked about attendance at the farmers' market, having been within km distance of one of sheep flocks in the area, tick bites and consumption of unpasteurized milk, sheep or goat cheese. for the purpose of ccs we defined a case (ccs case) as an adult resident of the town of soest notified to the statutory sur-veillance system with q fever, having symptom onset between may and june , . exclusion criterion was a negative igm-titer against phase ii antigens. two controls per case were recruited from soest inhabitants by random digit dialing. we calculated the attributable fraction of cases exposed to the farmers' market on may (afe) as (or- )/or and the attributable fraction for all cases due to this exposure as: the farmers' market was held in a spa town near soest with many visitors from other areas of the state and even the entire country. to determine the outbreak size we therefore asked local public health departments in germany to ascertain a possible link to the farmers' market in soest for all patients notified with q-fever. a case in this context ("notified case") was defined as any person with a clinical diagnosis compatible with q fever with or without laboratory confirmation and history of exposure to the farmers' market. local health departments also reported whether a notified case was hospitalized. to obtain an independent, second estimate of the proportion of hospitalizations among symptomatic patients beyond that reported through the statutory surveillance system we calculated the proportion of hospitalized patients among those persons fulfilling the clinical case definition (as used in the vendors' study (s.b.)) identified through random sampling of the soest population (within ccs (s.b.)) as well as in two cohorts (vendors' study and the sailor friends (see below)). the objective of ccs was to identify risk factors associated with attendance of the farmers' market on the second day. we used the same case definition as in ccs , but included only persons that had visited the farmers' market on may , the second day of the market. we selected controls again randomly from the telephone registry of soest and included only those persons who had visited the farmers' market on may and had not been ill with fever afterwards. potential controls who became ill were excluded for analysis in ccs , but were still fully interviewed. this permitted calculation of the attack rate among visitors to the market (see below "estimation of the overall attack rate") and gave an estimate of the proportion of clinically ill cases that were hospitalized (s.a.). in the vendors' study we investigated whether the distance of the vendor stands from the sheep pen or dispersion of c. burnetii by wind were relevant risk factors for acquiring q fever. we obtained a list of all vendors including the approximate location of the stands from the organizer. in addition we asked the local weather station for the predominant wind direction on may , . telephone interviews were performed using standardized questionnaires. a case was defined as a person with onset of fever between may and june , and at least three of the following symptoms: headache, cough, dyspnea, joint pain, muscle pain, weight loss of more than kg, fatigue, nausea or vomiting. the relative distance of the stands to the sheep pen was estimated by counting the stands between the sheep pen and the stand in question. each stand was considered to be one stand unit (approximately meters). larger stands were counted as units. the direction of the wind in relation to the sheep pen was defined by dividing the wind rose ( °) in equal parts of °. the predominant wind direction during the market was south-south-east ( figure ). for the purpose of the analysis we divided the market area into sections with the sheep pen at its center. in section the wind was blowing towards the sheep pen (plus minus °). section was on the opposite side, i.e. where the wind blew from the sheep pen towards the stands, and sections and were east and west with respect to the wind direction, respectively. location of the stands in reference to the sheep pen was thus defined in two ways: as the absolute distance to the sheep pen (in stand units or meters) and in reference to the wind direction. we identified a small cohort of sailor friends who visited the farmers' market on may , . all of these were serologically tested independently of symptoms. we could therefore calculate the proportion of laboratory confirmed persons who met the clinical case definition (as defined in the cohort study on vendors). the overall attack rate among adults was estimated based on the following sources: ( ) interviews undertaken for recruitment of controls for ccs allowed the proportion of adults that acquired symptomatic q fever among those who visited the farmers' market on the second day; attributable fraction afe number of cases exposed all cases = * ( ) interviews of cases and controls in ccs yielded information about accompanying adults and how many of these became later "ill with fever"; ( ) results of the small cohort of sailor friends (s.a.); ( ) results from the cohort study on vendors. local health departments that identified outbreak cases of q fever (s.a. "determination of outbreak size and descriptive epidemiology") interviewed patients about the number of persons that had accompanied them to the farmers' market and whether any of these had become ill with fever afterwards. however, as there was no differentiation between adults and children, calculations to estimate the attack rate among adults were performed both with and without this source. to count cases in ( ), ( ) and ( ) we used the clinical case definition as defined in the cohort study on vendors. for the calculation of the attack rate among children elicited in ccs was the same for all visitors. the number of children that visited the market could then be estimated from the total number of visitors as estimated by the organizers. we then estimated the number of symptomatic children (numerator). for this we assumed that the proportion of children with q fever that were seen by physicians and were consequently notified was the same as that of adults. it was calculated as: thus the true number of children with q fever was estimated by the number of reported children divided by the estimated proportion reported. then the attack rate among children could be estimated as follows: because this calculation was based on several assumptions (number of visitors, proportion of adult visitors and clinical attack rate among adults) we performed a sensitivity analysis where the values of these variables varied. serum was collected from all sheep and cows displayed in the farmers' market as well as from all sheep of the respective home flocks ( animals). samples of sheep from five other flocks in the soest area were also tested for c. burnetii. tests were performed by elisa with a phase i and phase ii antigen mixture. we conducted statistical analysis with epi info, version . (cdc, atlanta, usa). dichotomous variables in the case control and cohort studies were compared using the chi-square test and numerical variables using the kruskal-wallis test. p-values smaller than . were considered statistically significant. the outbreak investigation was conducted within the framework of the communicable diseases law reform act of germany. mandatory regulations were observed. patients at the local hospital in soest reported that a farmers' market had taken place on may and , in a spa town close to the town of soest. it was located in a park along the main promenade, spanning a distance of approximately meters. the market attracted mainly three groups of people: locals, inhabitants of the greater soest region, patients from the spa sanatoria and their visiting family or friends. initial interviewees mentioned also that they had spent time at the sheep pen watching new-born lambs that had been born in the early morning hours of may , . the ewe had eaten the placenta but the parturient fluid on the ground had merely been covered with fresh straw. overall ( %) of serum samples submitted to the ncl were positive for igm anti-phase ii antibodies by elisa. results of throat swabs and serum were negative for other infectious agents. (figure ). if we assume that symptom onset in cases was normally distributed with a mean of days, % of cases (mean +/- standard deviations) had their onset between day and . the two notified cases with early onset on may and , respectively, were laboratory confirmed and additional interviews did not reveal any additional risk factors. of the cases with known gender, ( %) were male and ( %) were female. of the notified cases, ( %) were from the county of soest, ( %) were porportion reported number of notified adults number of vis = i iting adults attack rate among adults * attack rate among children estimated true number of childr = e en with q fever estimated number of children at the market from other counties in the same federal state (northrhine westphalia) and ( %) were from five other federal states in germany (figure ). only eight ( %) cases were less than years of age, the mean and median age was and years, respectively ( figure ). ( %) of notified cases were hospitalized, none died. calculation of the proportion of cases hospitalized through other information sources revealed that of ( %; % ci = - %; ( / (ccs ), / (vendors study) and / (sailor friends)) clinically ill cases were hospitalized. laboratory confirmation was reported in ( %) outbreak cases; ( %) were confirmed by an increase in anti-phase ii antibody titer (cf), ( %) had igm antibodies against phase ii antigens, ( %) were positive in both tests and one was confirmed by culture. no information was available as to whether the ( %) cases without laboratory confirmation were laboratory tested. patients with valvular heart defects and eleven pregnant women were examined. none of them had clinical signs of q fever. two ( %) of cardiological patients and four ( %) of pregnant women had an acute q fever infection. during childbirth strict hygienic measures were implemented. lochia and colostrum of all infected women were tested by polymerase chain reaction and were positive in only one woman (case ; table ). serological follow-up of the mothers detected chronic infection in the same woman (case ) weeks after delivery. one year follow-up of two newborn children (of cases and ) identified neither acute nor chronic q fever infections. we recruited cases and controls who visited the farmers' market on may for the second case control study. they did not differ significantly in age and gender (or for male sex = . ; %ci = . - . ; p = . ; p-value for age = . ). seventeen ( %) of cases indicated that they had seen the cow (that also was on display at the market next to the sheep) compared to ( %) of geographical location of q fever outbreak cases notified to the statutory surveillance system figure geographical location of q fever outbreak cases notified to the statutory surveillance system. or directly at the gate of the sheep pen compared to ( %) of controls (or = . ; %ci = . - . ; p = . ). touching the sheep was also significantly more common among cases ( / ( %) ccs cases vs. / ( %) controls; or undefined; lower % ci = . ; p = . ). ( %) of ccs cases, but only ( %) of controls stopped for at least a few seconds at or in the sheep pen, the reference for this variable was "having passed by the pen without stopping" (or = . ; %ci = . - . ; p < . ). among ccs cases, self-reported proximity to or time spent with/close to the sheep was not associated with a shorter incubation period. we were able to contact and interview ( %) of vendors, and received second hand information about more (overall response rate: %). fourty-five ( %) were male and ( %) were female. ( %) met the clinical case definition. of the vendors who worked within two stand units of the sheep pen, ( %) became cases compared to only ( %) of persons who worked in a stand at a greater distance (relative risk (rr) = . ( %ci = . - . ; p = . ); figure ). of these vendors, had spent time within meters of the pen on may , one had been near the pen, but at a distance of more than meters, and no information on this variable was available for the remaining . in the section of the market facing the wind coming from the pen (section , figure ), ( %) of vendors became cases, compared to ( %) of persons who worked in section (p = . ). among persons who worked in stands that were perpendicular to the wind direction, ( %) became cases. (table ). in all scenarios the ar among adults was significantly higher than that among children ( figure ). in total, lambs and ewes were displayed on the market, one of them was pregnant and gave birth to twin lambs at : a.m. on may , . of these, ewes including the one that had lambed tested positive for c. burnetii. the animals came from a flock of ewes, of which had given birth between february and june. the majority of the births ( ( %)) had occurred in february and march, usually inside a stable or on a meadow located away from the town. six ewes aborted, had stillbirths or abnormally weak lambs. among all ewes, / ( %) tested positive for c. burnetii. the percentage of sheep that tested positive in the other sheep flocks in the region ranged from % to % ( %; %; %; %; %). we have described one of the largest q fever outbreaks in germany which, due to its point-source nature, provided the opportunity to assess many epidemiological features of the disease that can be rarely studied otherwise. in , more than cases of q fever were, similar to this outbreak, linked to the abortion of an infected cow at a farmers' market [ ] . more recently a large outbreak occurred in jena (thuringia) in with reported cases [ ] associated with exposure to a herd of sheep kept on a meadow close to the housing area in which the cases occurred. the first case control study served to confirm the hypothesis of an association between the outbreak and the farmers' market. the fact that only attendance on the second, but not the first day was strongly associated with illness pointed towards the role of the ewe that had given birth persons accompanying notified cases (source ) were a mixture of adults and children and are therefore listed separately. in the early morning hours of may , . this strong association and the very high attributable fraction among all cases suggested a point source and justified defining cases notified through the reporting system as outbreak cases if they were clinically compatible with q fever and gave a history of having visited the farmers' market. the point-source nature of the outbreak permitted calculation of the incubation period of cases which averaged days and ranged from to days with an interquartile range of to days. this is compatible with the literature [ ] . an additional interview with the two cases with early onset ( and days after attending the market on may , attack rates among adults and children in a most likely scenario and other scenarios figure attack rates among adults and children in a most likely scenario and other scenarios. most likely scenario: visitors, % adult visitors and % clinical attack rate among adults. scenarios - varied in the assumptions made for "number of visitors", "proportion of adult visitors" and "attack rate among adults" (see table ). displayed are attack rates and % confidence intervals. respectively) could not identify any other source of infection. a short incubation period was recently observed in another q fever outbreak in which the infectious dose was likely very high [ ] . the second case control study among persons who visited the market on may demonstrated that both close proximity to the ewe and duration of exposure were important risk factors. this finding was confirmed by the cohort study on vendors which showed that those who worked in a stand close to (within meters) the sheep pen were at significantly higher risk of acquiring q fever. the study failed to show a significant role of the location of the stand in reference to the wind direction, although we must take into account that the wind was likely not always and exactly as reported by the weather station. however, if the wind had been important at all more cases might have been expected to have occurred among vendors situated at a greater distance to the sheep. according to statutory surveillance system data, the proportion of clinical cases hospitalized was %, similar to the proportion of % found in persons pooled from the other studies conducted. several publications report lower proportions than that found in this investigation: % ( / ) [ ] , % [ ] and % ( / ) [ ] ), and there was at least one study with a much higher proportion ( % ( / )) [ ] . it is unlikely that hospitals reported cases with q fever more frequently than private physicians because the proportion hospitalized among q fever patients identified through random telephone calls in the soest population or those in the two cohorts was similar to that of notified cases. thus reporting bias is an unlikely explanation for the relatively high proportion of cases hospitalized. alternative explanations include overly cautious referral practices on the part of attending physicians or the presumably high infectious dose of the organism in this outbreak, e.g. in those cases that spent time in the sheep pen. the estimated attack rate among adults in the four studies varied between % and %. the estimate of % based on the random sample of persons visiting the market on the second day would seem most immune to recall bias, even if this cannot be entirely ruled out. the estimation based on information about persons accompanying the cases may be subject to an overestimation because these individuals presumably had a higher probability of being close to the sheep pen, similar to the cases. on the other hand the estimate from the cohort study on vendors might be an underestimate, since the vendors obviously had a different purpose for being at the market and may have been less interested in having a look at the sheep. nevertheless, all estimates were independent from each other and considering the various possible biases, they were remarkably similar. in comparison, in a different outbreak in germany, in which inhabitants of a village were exposed to a large herd of sheep (n = - ) [ , ] the attack rate was estimated as %. in a similar outbreak in switzerland several villages were exposed to approximately sheep [ ] . in the most severely affected village, the clinical attack rate was % (estimated from the data provided) [ ] . it is remarkable that in the outbreak described here, the infectious potential of one pregnant ewe -upon lambing -was comparable to that of entire herds, albeit in different settings. our estimate of the proportion of serologically confirmed cases that became symptomatic ( % ( / )) is based on a very small sample, but consistent with the international literature. in the above mentioned swiss outbreak, % of serologically positive patients developed clinical disease [ ] . only approximately half of all symptomatic cases were reported to the statutory surveillance system. patients who did not seek health care due to mild disease as well as underdiagnosis or underreporting may have contributed to the missing other half. our estimated % attack rate among children is based on a number of successive assumptions and must therefore be interpreted with caution. nevertheless, sensitivity analysis confirmed that adults had a significantly elevated attack rate compared to children. while it has been suggested that children are at lower risk than adults for developing symptomatic illness [ , ] few data have been published regarding attack rates of children in comparison to adults. the estimated c. burnetii seroprevalence in the sheep flocks in the area varied from % to %. the % seroprevalence in the flock of the exhibited animals together with a positive polymerase chain reaction in an afterbirth in june suggested a recent infection of the flock [ ] . seroprevalence among sheep flocks related to human outbreaks tend to be substantially higher than those in flocks not related to human outbreaks. the median seroprevalence in a number of relevant studies performed in the context of human outbreaks [ , , ] , was % compared to % in sheep flocks not linked to human outbreaks [ ] . this outbreak shows the dramatic consequences of putting a large number of susceptible individuals in close contact to a single infected ewe that (in such a setting) can turn into a super-spreader upon lambing. there is always a cultural component in the interaction between people and animals, and these may contribute to outbreaks or changing patterns of incidence. during the past decades urbanization of rural areas and changes in animal husbandry have occurred [ ] , with more recent attempts to put a "deprived" urban population "in touch" with farm animals. petting zoos, family farm vacations or the display of (farm) animals at a market such as this may lead to new avenues for the transmission of zoonotic infectious agents [ , [ ] [ ] [ ] . while not all eventualities can be foreseen, it is important to raise awareness in pet and livestock owners as well as to strengthen recommendations where necessary. this outbreak led to the amendment and extension of existing recommendations [ ] which now forbid the display of sheep in the latter third of their pregnancy and require regular testing of animals for c. burnetii in petting zoos, where there is close contact between humans and animals. due to the size and point source nature this outbreak permitted reassessment of fundamental, but seldom studied epidemiological parameters of q fever. it also served to revise public health recommendations to account for the changing type and frequency of contact of susceptible humans with potentially infectious animals. abbreviations afe = attributable fraction of cases exposed the author(s) declare that they have no competing interests. q fever: current concepts a large outbreak of q fever in the west midlands: windborne spread into a metropolitan area? an outbreak of sheep-associated q fever in a rural hyperendemic focus of q fever related to sheep and wind q fever in children diagnosis of q fever rki: meldepflichtige zoonosen annual summary for infectious diseases rki: infektionsepidemiologisches jahrbuch für [annual summary for infectious diseases risks factors and prevention of q fever endocarditis q fever during pregnancy: diagnosis, treatment, and follow-up archiv für hygiene und bakteriologie ausbruch in jena rki: aufklärung eines q-fieber ausbruchs durch erkrankung eines film-teams investigation of a slaughterhouse-related outbreak of q fever in the french alps an important outbreak of human q fever in a swiss alpine valley changing epidemiology of q fever in germany q fever outbreak in cdc: outbreaks of escherichia coli o :h associated with petting zoos -north carolina, florida, and arizona salmonella typhimurium infection in domesticated fowl in a children's zoo ratgeber infektionskrankheiten -merkblätter für Ärzte: q-fieber [physicians' advisor for infectious diseases: q fever we would like to thank the veterinary state laboratory arnsberg (head: franz holling), katharina alpers, andrea ammon and walter haas from the robert koch institute, brunhilde schweiger at the nrl for influenza, colleagues in the institute of public health, state of northrhine westfalia, münster, and local health departments in germany for their assistance in this investigation. kp headed the investigation, analysed data and wrote the first version of the manuscript. jr and uvt assisted in the design of the study and co-ordinated reporting of cases. at co-ordinated activities on the local level and conducted exploratory interviews. sb assisted in the design of the study and co-ordinated collection of veterinary data. wh collected veterinary data and assisted with advice on veterinary issues. ml collected data from reporting health departments. pk, sb and cw co-ordinated laboratory confirmatory testing and followed up patients with valvular heart defects and pregnant women. wh assisted with the study design, literature review and writing of the manuscript. ub conceived of the study, analysed data and wrote later versions of the manuscript. all authors read and approved the final manuscript.publish with bio med central and every scientist can read your work free of charge the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -qfvm x authors: maponga, brian a; chirundu, daniel; gombe, notion t; tshimanga, mufuta; shambira, gerald; takundwa, lucia title: risk factors for contracting watery diarrhoea in kadoma city, zimbabwe, : a case control study date: - - journal: bmc infect dis doi: . / - - - sha: doc_id: cord_uid: qfvm x background: kadoma city experienced an increase in watery diarrhoea from cases during week beginning (th) september, to cases during week beginning (th) september . the weekly diarrhoea cases crossed the threshold action line during week beginning (th) september at the children’s clinic in rimuka township, and the remaining four clinics reported cases crossing threshold action lines between week beginning (th) september and week beginning (th) september. eighty-two percent of the cases were children less than years old. we conducted a case controlstudy to determine risk factorsfor contracting watery diarrhoea in children less than years in kadoma city. methods: an unmatched : case control study was conducted in ngezi and rimuka townships in kadoma city, zimbabwe. a case was a child less than years old, who developed acute watery diarrhoea between (th) september and (st) october . a control was a child less than years old who stayed in the same township and did not suffer from diarrhoea. a structured questionnaire was administered to caregivers of cases and controls.laboratory water quality tests and stool test results were reviewed.epi info™ statistical software was used to analyse data. results: a total of cases and controls were enrolled. independent protective factors were: having been exclusively breastfed for six months [aor = . ; % ci ( . - . )]; using municipal water [aor = . ; % ci ( . - . )]; using aqua tablets, [aor = . ; % ci ( . – . )] and; storing water in closed containers, [aor = . ; % ci ( . – . . ). the only independent risk factor for contracting watery diarrhoea was hand washing in a single bowl, [aor = . ; % ci ( . – . )]. salmonella, shigella, rotavirus, and enteropathogenic escherichia coli were isolated in the stool specimens. none of the municipal water samples tested showed contamination with escherichia coli, whilst of ( %) shallow well water samples and of ( %) borehole water samples tested were positive for escherichia coli. conclusions: the outbreak resulted from inadequate clean water and use of contaminated water. evidence from this study was used to guide public health response to the outbreak. acute diarrhoea is defined as the passage of three or more loose or liquid stools per day, in a period not exceeding days. other types of diarrhoea include dysentery; and persistent diarrhoea which lasts days or longer. patients presenting with diarrhoea can also present with other symptoms such as vomiting, fever, and body weakness. diarrhoea causes loss of body fluid and electrolytes, which can result in dehydration. if dehydration is not corrected, death can result [ ] . the causes of diarrhoea can be bacterial, viral or parasitic. bacteria causes of diarrhoea include vibrio cholerae, escherichia coli, campylobacter jejuni, salmonellae and shigella species. viral causes of diarrhoea include rotavirus, adenovirus, and corona viruses. parasitic causes of diarrhoea include giardia, entamoeba, cryptosporidium and the helminthes (strongyloides, schistosoma) [ ] . diarrheal disease is a leading cause of child mortality and morbidity in the world, and mostly results from contaminated food and water sources.in developing countries, children below years experience on average episodes of diarrhoea every year. globally, there are about billion cases of diarrhoeal disease every year [ ] . fifteen percent of child deaths are directly attributable to diarrhoeal diseases [ ] . according to the world health organization (who), key measures to prevent diarrhoea include access to safe drinking-water, improved sanitation, exclusive breastfeeding for the first six months of life, good personal and food hygiene and health education about how infections are spread [ ] . in , kadoma city had an estimated , inhabitants. of these , were children less than years old based on the census projections [ ] . more than half the population resides in the city's rimuka township. nearly the whole population in kadoma city has access to piped water. however, demand for water is very high, reaching as high as mega litres per day, yet the city can only pump at best mega litres per day [ ] . the quantity of water pumped is further compromised by recurrent power cuts to the water treatment plants. in the absence of municipal water, residents use shallow wells and boreholes among others as water sources [ ] . kadoma city has had recurrent problems with watery diarrhoeal outbreaks since . in , a rotavirus outbreak killed children [ ] . a cholera outbreak in and affected , people, with deaths [ ] . another cholera outbreak in affected people and caused deaths [ ] . most of the problems, such as shortage of water, and recurrent sewer blockages have not had permanent solution due to lack of financial resources. in , kadoma city experienced an upsurge of watery diarrhoeal cases during week (week beginning th september), in ( figure ). the total cases reported by the city's five clinics doubled from to cases between week and . the cases further doubled from to between week and week . the weekly watery diarrhoeal cases at the under clinic crossed the action threshold line during week ( figure ). the action threshold was defined using the c cusum method (defined as the sum of the mean plus three standard deviations for preceding weekly diarrhea recordings, skipping two most recent weeks) [ ] . the diarrhoeal cases at the children's clinic increased fold, from to cases, between weeks and . the remaining four clinics (for all age groups) also experienced more than doubling of cases between week and week . initial analysis showed that about % of the cases were children less than five years old. the study was conducted to determine factors associated with contracting watery diarrhoea in children less than five years old. an unmatched : case-control study was conducted in kadoma city's rimuka and ngezi townships. the study was conducted among children less than years old. a case was defined as a child less than five years old who presented to a health facility with acute watery diarrhoea, with or without vomiting and other symptoms, between th september and st october , who had been resident in kadoma city for one week prior to onset of symptoms. a control was defined asa child less than five years old, who did not develop diarrhoeabetween th september and st october , and had been resident in kadoma city, one week prior to the interview. children whose caregivers agreed to participate were recruited into the study. children who had passed diarrhoea for more than days were excluded from participating in the study. epi info™ statistical software was used to calculate sample size. assuming % exposure in controls and % exposure in cases, using unchlorinated water, odds ratio of . [ ] , % confidence level, % power, and % refusal rate, we calculated a minimum sample size of ( cases and controls). multistage sampling of cases was done. rimuka and ngezi townships were selected because they were the most affected. using proportionate sampling, rimuka was to provide ( %) cases whilst ngezi was to provide ( %) cases. cases were selected from clinic line lists; using random numbers generated using microsoft™ excel . a control was selected from a household houses away from a case. where there was more than one child less than years old at the household, a child whose age was closest to the age of the case was selected. if there was no child less than years old, or if the caregiver declined to participate, the next house was selected till a less than years old was obtained. a pre-tested, interviewer administered questionnaire, was used to collect data from caregivers of cases and controls. the information collected included caregiver and case/control demographic information, symptoms, knowledge of caregiver on diarrhoea illness and treatment, duration of exclusive breast feeding, immunization status, the source of water, water treatment and storage, and sanitation facilities at the family home. the questions were in english and local shona languages. record review of water surveillance reports was done. the water quality parameters tested were bacteriological and chemical (chlorine content for municipal water, and ph). bacteriological water quality tests had been done using a delagua field testing machine. water samples that were found with zero colonies after incubation for hours were considered satisfactory. residual chlorine content was tested using the lovibond comparator using dpd tablets (n,n diethyl- . phenylenediamine sulphate) to check colour changes. specimens within the range . to . parts per million (ppm) were considered satisfactory. the ph was measured with the same equipment using phenol red tablets. specimens with ph ranging between . and . were considered satisfactory. the results were reported as proportions. data were analyzed using epi info™. means, proportions, frequencies, odds ratios and chi square tests at % significant levels were generated using the software. stratified analysis and forward step-wise logistic regression analysis was used to control for confounding and effect modification. permission to conduct the study was obtained from the local health authorities. ethical review was done at the health studies office, university of zimbabwe. written informed consent was obtained from all study participants caregivers. children or relative with diarrhoea found during interviews were referred to the nearest health facility for free treatment. a total of , cases of watery diarrhoea were attended to between th september and nd november . of these, ( %) were residents of kadoma city. the crude attack rate was per , people. five hundred and fifty two cases ( %) were females. six hundred and ninety three ( %) cases were children less than years old. the attack rate among children less than years old was per , people, whilst for those above years old, the attack rate was per , people. five cases, all children less than five years old died of diarrhoea. the crude case fatality rate was . %. one child died in hospital, and four children died at home after having sought treatment at health facilities. all the residential areas in kadoma city were affected. the highest risk of developing diarrhoea was in ngezi township, with an attack rate of per , people, followed by rimuka township, with an attack rate of per , people. however, during the early part of the outbreak, the highest risk of contracting diarrhoea was in rimuka township. figure shows the epidemic curve for kadoma city for the period st september to rd november . the outbreak commenced during the week beginning th september. the epidemic curve shows multiple waves with progressively taller peaks that are - days apart up to the st of october. the peaks became progressively shorter, until less than cases were attended to per day from rd october . a total of stool specimens were submitted to the local laboratory. thirty specimens yielded e.coli, yielded shigella species, yielded salmonella species and one yielded rotavirus. one out of the sixteen specimens submitted to the national virology reference laboratory tested positive for rotavirus. two of the specimens/isolates submitted to the national microbiology reference laboratory (nmrl) were confirmed as enteropathogenic escherichia coli. no cholera or cryptosporidium was isolated. all municipal water samples tested were below the threshold limit for contamination with escherichia coli. three of the ( %) borehole water samples and of the ( %) shallow well samples were above the threshold for contamination with escherichia coli. thirty-two ( %) of the municipal water samples tested for chlorine had chlorine levels within normal range. all the samples had ph levels within normal range. the samples were collected and analyzed between st september and nd october . a total of cases and controls were recruited into the study. there were no significant differences in the demographic characteristics of cases and controls as shown in table . less than % of cases and controls caregivers had received health education on diarrhoea six months prior to the outbreak. the knowledge on prevention and home treatment of diarrhoea was fair, and did not differ significantly between cases and controls as shown in table . table . statistically significant protective factors against contracting diarrhoea were: using municipal water source table . hand washing in a single bowl [aor = . , % ci ( . - . )] was an independent risk factor for contracting diarrhoea. independent protective factors against contracting diarrhoea were: using municipal water [aor = . , % ci ( . table . this study sought to establish risk factors for contracting watery diarrhoea among children less than five years old in kadoma city. the epidemic curve is typical of a propagated outbreak, highly suggestive of person-toperson transmission. the multiple peaks, to days apart, suggest the incubation period of the causative organisms to be between to days. the causative organisms that were isolated, (rotavirus, salmonella, shigella and escherichia coli) fit into the average incubation period of to days which is typical of faecal contamination [ ] . the importance of hand washing practices in preventing diarrheal illness is highlighted in this study. hand washing in a single bowl was found to be a risk factor for contracting watery diarrhoea. it is biologically plausible for infection to be spread from one person into the water, then to the next person. having a hand washing facility at home was found to be protective as the facility encourages run to waste method of hand washing, especially after using the toilet. these findings are supported by several studies. a systematic review of several studies, estimated that appropriate hand washing with soap, could reduce the risks of severe intestinal infections and of shigellosis by up to % and %, respectively [ ] . the water could have been contaminated by blocked sewer. the problem of blocked sewer had earlier been highlighted by mangizvo r.v et al., [ ] . this could explain the contamination of shallow wells and boreholes in kadoma city, most probably through seepage. in karachi, pakistan, khan et al. demonstrated that % of sewer influent samples were positive for rotavirus, which was also identified in one of the cases in the outbreak in kadoma city [ ] . contamination of water can occur at any stage from the source, to the point of use. the biological plausibility of storing water in a closed container, boiling and use of aqua tablets was demonstrated in this study. the use of chlorine containing materials have been made use of in situations of acute water shortage, where people tend to use unsafe sources of water, as reported by lantagne d s, et al., in [ ] . in kadoma city, in this epidemic, the use of municipal water was protective, compared to water from other sources (aor = . , p = . ). similar findings were obtained in harare by gonese g, et al., in . (risk factors associated with salmonella outbreak in budiriro suburb, harare city, zimbabwe, -unpublished). the laboratory tests on municipal water which was of satisfactory bacteriological and residual chlorine levels support the findings. at the same time, families who accessed water from municipal supply are more likely to access water in the family home. this study demonstrated that distance of the water source from home increased risk of developing diarrhoea. this results in families accessing less than the required amount of water per day, compromising personal hygiene practices such as hand washing. exclusive breast feeding for months was protective against developing diarrhoea. exclusively breastfed children were protected as they were unlikely to take any other foods or fluids likely to be contaminated. this protective effect was less for children on mixed breastfeeding and weaned from their mother's milk.the protective effect of exclusive breastfeeding had been demonstrated using different study designs, in different settings. in belarus, kramer m.s. et al., , reported that exclusive breast feeding reduced risk of diarrhoea by % [ ] . in guinea bissau, mølbalk k, et al., , reported that partial breast feeding, rr = . ( . - . ), and no breast feeding rr = . ( . - . ) increased risk of diarrhoea [ ] . in zimbabwe, a nutritional survey in reported that . % of children were [ ] . thus, efforts to increase the prevalence of exclusive breast feeding could reduce the impact of diarrhoea on child morbidity and mortality, in zimbabwe. limitations of this study included the following: controls might have contracted the disease but not developed clinical symptoms leading to case ascertainment bias. this could have under estimated the strength of some associations. the observed protective effect of the water treatment tablets is self reported, thus may lead to bias. some of the caregivers were interviewed more than two weeks after treatment, which could have resulted in recall bias. the study was conducted in children less than five years old, thus the results may not be generalizable to residents older than five years. some agents isolated in the local laboratory, salmonella and shigella could not be confirmed by the national microbiology reference laboratory. the outbreak was propagated and affected all the residential areas in kadoma city. mixed etiological agents were responsible for the outbreak. knowledge on prevention and home treatment of diarrhoea was fair and did not differ between caregivers of cases and controls. the importance of providing adequate safe water, appropriate hand washing, exclusive breast feeding and good environmental hygiene were demonstrated to be protective against contractingdiarrhoea. the results of the study provided guidance for policy makers in responding to the outbreak, and formulating strategies to improve child health. based on the evidence from this study water purification tablets, municipal water trucking to residential areas, disinfection and repair of boreholes, and sewer unblocking was conducted in the affected communities. health education on importance of practicing good personal hygiene, boiling and treating water with water purification tablets before drinking and long term benefits of exclusive breast feeding was conducted, and is ongoing. all municipal clinics now have weekly updated diarrhoea reports. the national electricity distribution company installed dedicated electricity power lines to the municipal water pumping stations to maintain continuous water pumping. world health organization: diarrhea, factsheet number world gastroenterology organization practice guideline: acute diarrhoea where and why are million children dying every year? lancet zimbabwe government printers (now renamed printflow) kadoma city council offices kadoma city health department: cholera outbreak report kadoma city health department: cholera outbreak report assessing the performance of the early aberration reporting system (ears) syndromic surveillance algorithms. united states of america: naval postgraduate school a nationwide case-control study of escherichia coli o : h infection in the united states water: monitoring and assessment. available on url effect of washing hands with soap on diarrhoea risk in the community: a systematic review the problem of burst sewage pipes and sewerage outflows in east view suburb in kadoma city diarrhea due to rotavirus and probability of sewage contamination household water treatment and safe storage options in developing countries: a review of current implementation practices promotion of breastfeeding intervention trial (probit): a randomized trial in the republic of belarus risk factors for diarrheal disease incidence in early childhood: a community cohort study from guinea-bissau zimbabwe launches nutritional survey report. health harare risk factors for contracting watery diarrhoea in kadoma city i would like to express my sincere gratitude to my field supervisor, mr. d chirundu for his guidance and support, and to the staff and management at kadoma city council, and sanyati district for their support. special thanks go to the staff in the department of community medicine and mph field office for all the help they rendered. we would also like to express our profound gratitude to centres for disease control (cdc) zimbabwe for funding and technical input.many thanks go to all the caregivers for their consent to allow me to interview them. last, but not least, i would like to thank my family for social support throughout the project. the authors declare that they have no competing interests.authors' contributions bam: conception, design, acquisition, analysis and interpretation of data and drafting the manuscript. dc: conception, design, acquisition, analysis and interpretation of data and drafting the manuscript. ntg: conception, design, data collection, analysis, interpretation and reviewing of several drafts of the manuscript for important intellectual content. gs and lt :conception, design, key: cord- -oj v x authors: catala, m.; pino, d.; marchena, m.; palacios, p.; urdiales, t.; cardona, p.-j.; alonso, s.; lopez-codina, d.; prats, c.; alvarez lacalle, e. title: robust estimation of diagnostic rate and real incidence of covid- for european policymakers date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: oj v x policymakers need a clear and fast assessment of the real spread of the epidemic of covid- in each of their respective countries. standard measures of the situation provided by the governments include reported positive cases and total deaths. while total deaths immediately indicate that countries like italy and spain have the worst situation as of mid april , on its own, reported cases do not provide a correct picture of the situation. the reason is that different countries diagnose diversely and present very distinctive reported case fatality rate (cfr). the same levels of reported incidence and mortality might hide a very different underlying picture. here we present a straightforward and robust estimation of the diagnostic rate in each european country. from that estimation we obtain an uniform unbiased incidence of the epidemic. the method to obtain the diagnostic rate is transparent and empiric. the key assumption of the method is that the real cfr in europe of covid- is not strongly country-dependent. we show that this number is not expected to be biased due to demography nor the way total deaths are reported. the estimation protocol has a dynamic nature, and it has been giving converging numbers for diagnostic rates in all european countries as of mid april . from this diagnostic rate, policy makers can obtain an effective potential growth (epg) updated everyday providing an unbiased assessment of the countries with more potential to have an uncontrolled situation. the method developed will be used to track possible improvements on the diagnostic rate in european countries as the epidemic evolves. the evolution of the epidemic in europe has affected spain and italy more strongly than in other countries so far. this is clear from reported cases and fatalities in these however, they lack the recipe-type nature needed sometimes to direct a policy response. the focus of this paper is, thus, to introduce a method to compute the real diagnostic rate and the real incidence of covid- in each european country, testing that the key hypothesis of the method is fulfilled and that, if they were to be slightly off, they would affect all countries in the same direction. in other words, we provide a recipe for policymakers that we have tested to be correct, unbiased across countries and useful to make cross-country comparison provided the evolution and prognosis of the disease in a patient is not strongly dependent on socio-economic factors and only on age, sex and previous clinical history. we must recall here that the ability to determine the diagnostic ratio is essential to evaluate what the real number of infected people is. knowledge of this number is not only useful to visualize the full scope of the epidemic but also to properly estimate the number of people with probable short-term immunity. in this sense, our method can be added as an empirical take of other assessments about the real incidence of the disease and to study the possibility of developing herd immunity. a large number of real infected people would be a positive scenario for policymakers while a low number will be negative. it is thus very important to err on the side of caution in all our estimates giving always the less optimistic take. the basic structure of the paper is the following. first, we give a general overview of our framework in the methods section. then we discuss our key assumption: the real case fatality rate (cfr) in european countries experiencing a significative incidence will be roughly the same, given the similar structure of the population. if the real cfr were to be lower, or higher, it would affect all countries in the same way and would not affect most policy decision-making since it will move all countries in the same direction. we take this real cfr to be % and proceed to test that, effectively, there is a strong correlation between the day of reported deaths with the number of cases taken - days before. once a given value for the real cfr is taken, one must consider that people do not die immediately from the disease, as it takes roughly days after infection [ ] [ ] [ ] . in other words, the present values of the death toll can provide an estimation of the number of infected people days ago. knowing the number of infected people at present, not days in the past, is crucial. we attack this problem considering that people who become infected are usually diagnosed a few days after the onset of the symptoms, which can be to days after infection occurs. by comparing the number of people diagnosed on a certain date with our estimation of the real number of infected people, we can estimate what percentage of the cases are being diagnosed. we can calculate this for different countries and regions and test how this ratio has changed dynamically as the epidemic advanced. in the results section, we provide a full detailed description of how this fraction has become steady in the last weeks. we demonstrate that the percentage of diagnosis throughout the development of the epidemic has taken values that gradually converge for most countries. this gives a final clear picture showing the rate of diagnosis for each country. using this rate is straightforward to give a present-day estimate of the incidence given the number of reported infected people in each country as long as we can observe that the rate of diagnosis remains fairly constant. for policymakers, we have constructed an index named effective potential growth (epg) that combines this information with the growth rate of the epidemic to provide insight regarding which countries are, comparatively and in the short-term, in the most potentially complicated situation [ ] . framework of our methodology our analysis will be applied to european countries with a minimum of deaths on april so that we can guarantee a minimum statistical significance. the analyzed countries are: belgium, france, germany, italy, netherlands, portugal, spain, sweden, switzerlands and united kingdom. our two core assumptions are that the real cfr in all european countries is roughly the same and that reported data of death due covid- is uniform in all european countries under consideration. we will address these two hypothesis in the following sections. with these assumptions we need to carry out four steps, as indicated in fig. , to obtain the percentage of diagnosis. first, using a common reference cfr = % and, given the reported reported death count, we estimate the number of cases days ago. according to medical reports people die between and days after the development of the first symptoms [ ] . this time to death, ttd, after the development of the first symptoms will not be country-specific for demographic reasons. the estimated number of infected people with the disease at time t (see process in fig. this allows us to know to estimate the number of cases days ago. this value can be compared with the number of cases detected days ago, obtaining a diagnostic depending on the availability of tests, saturation of the health system and other external factors, countries have a great variability in the time of diagnosis delay. countries accumulate some delay that may arrive to days in the case that a country detected people as late as they were detected on death. this delay to detection (dd) due to lags in diagnosis corresponds to the time between the patient having the first symptoms and being reported by the health system. in fact, this time in some countries may vary throughout the course of the infection. therefore we cannot assume that the estimated and the reported are comparable and we need to know what the diagnostic time was for each of the countries studied. we can compare the reported deaths with the reported cases to find the maximal correlation, see process in fig. (a) , to estimate the dd, see process in fig. (a) . finally the ratio between reported cases at dd with the estimated cases, see below, provides an estimation for the percentage of diagnosis, see process in fig. (a) . note that the usual development of the reporting of a new case/death, see fig. (b), depends on the particular country under consideration, which determines dd. in fact, dd also includes a delay in reporting the diagnostic to death to official information systems. the cornerstone of our analysis is that the real cfr in all european countries will not be biased against any country in particular. we should point out immediately that we are not arguing that there are not important uncertainties in the real cfr, what we do claim and check in this methodology is that these uncertainties will not generate any biased against particular countries and should not affect policy decision. we take the cfr in of covid- in europe to be between . - % and we assume % to be the benchmark scenario. this value ( %) is the cfr observed in the initial stages of the south korea pandemic and the diamond princess cruise. in both cases, it was found to be around - . % and, in both, error margins came from different sources [ , ] . in south korea, the ability to test all the population in contact with infected people and the tracking of contagious chains was thorough, despite that, the reported cfr increased from initial values around . - . % to higher values around %. in the diamond princess cruise, cfr for confirmed cases was % but estimation of false negatives and the possibility that a fraction of the passengers never developed symptoms and was never tested put the cfr again around %. both south korea and the diamond princess cruise provide complementary evidence, one coming from a natural experiment and another from a country with the ability to perform half a million tests/day from the very beginning of the transmission chain [ ] . if we accept the two measurements of the cfr independent, the most likely interval of real cfr is between . and %. recent experimental results from random testing in the german city of gangelt [ ] and preliminary results from iceland [ , ] indicate the presence of a layer of people fully asymptomatic that are normally not detected. this group of people have passed the disease without any knowledge seems to be larger than previously thought. these preliminary studies point to a cfr of around . % in zones where the epidemics was not fully spread. we cannot disregard the possibility that, just as cfr inceased with time even in south korea, similar studies in countries with more cases, could have a real higher cfr. it is thus reasonable to consider cfr at % as an easy policy guiding principle and not to use the more positive scenario of . %. unbiased nature of cfr in europe there are three sources of possible biased cfr across countries. the disease affects more strongly elder people with comorbidity problems than healthy younger ones, and more men than women. in all european countries the male/female ratio is unbiased except for older people. this is precisely the group with higher mortality rate. it is thus very important to asses how the different demographic structure of european countries could affect our central benchmark [ ] . the same must be said about the relative prevalence of other comorbidity factors. we proceed to show that, with the data we have today: the demographic and comorbidity structure, none of these possible sources of bias can have anything but a small effect. to do so, we will do a comparison with the cfr of south korea on april , . %. table shows the demographic structure of south korea and the corresponding cfr for each analyzed age group reported on april . the first row shows the demographic structure according to eurostat, but the analysis has be performed by using only the three age groups shown in the second row: ≤ , − and ≥ years. this was done because for many countries reported cases and fatalities consider different age groups, and some countries even report this two figures using different age groups. the three age groups considered in the analysis were the only ones that includes all the analyzed countries. as can be observed in the to analyze what is the role played by the differences in demography in europe in the covid- cases and fatalities we have downloaded from eurostat the demographic distribution by age (see table ). we can readily asses that, when comparing with south korea, all the countries have a larger percentage of population above years ( % larger for italy) and larger median age except sweden and united kingdom, but the relative differences in each of the cohorts in between the european countries shown in the table is small. only italy presents a relevant larger than average ratio of people over . using this demographic data and assuming each european country presents the same cfr by age group as south korea on april , we have computed the cfr for each country. table shows the results of this analysis and the officially reported cfr by the different european countries on the same date. both values are presented relative to the cfr reported by south korea on april , . %. as can be observed in the first column, when demography is the only difference between countries, between the worst and best case of the relative cfr the differences april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . having previously a very bad prognosis. we know this group is strongly affected by the virus [ ] . in blunt terms, we must examine the possibility that different countries are counting the raw number of dead people differently. before entering in the detail of the analysis, let us point out that two indications go against this possibility. first, health care systems in europe can have different april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . resources in different countries with different focus and priorities, but they attend there is a single exception that we know of: belgium [ ] . belgium seems to be reporting unconfirmed cases from nursing homes without tests as due to covid- . it is quite clear that this includes a good number of people who, either, did not die from covid- or that covid- was not an important factor in the prognosis. therefore, we will include a reminder that belgium data is biased compared with other countries, being anywhere from % to % lower given the number of reported deaths from nursing homes compared with hospitals. there is a second argument regarding the treatment of the elder population in other countries. if large undercounting woul be the case, it should be noted in the mortality rate for people years and older, which is not observed in the countries where we have data. in this framework, spain becomes a key country. if spain were not to have an important undercounting is highly implausible to think that other countries would. we proceed to analyze the data of the national epidemiology center (instituto de salud march to april for the whole of spain, they see that, as expected, mortality is much higher than in previous years. an increase of % is observed. however, it is interesting to compare this with the data reported for covid- deaths. the reported deaths by covid- are roughly , depending on how you attribute deaths to a particular day in the calendar. on the other hand, the reported excess of deaths by the momo surveillance system is . we think that the assessment of around % underreporting can be taken indeed as a worst-case scenario for a highly impacted country. it seems reasonable to expect other countries to have underreported way below or slightly below this level. all the data point out right now, that the undercounting due to a different treatment of the very fragile population is highly unlikely across europe, and at most introduces changes in cfr around ± %. having shown that the real cfr should not present bias in european countries larger than %, we address now how to deal with the real sources of bias in the diagnostic rate for each country. to estimate dd we look for a correlation between the number of reported cases (see fig. a ) and the number of reported deaths (see fig. b ) [ , ] . to deal with noise effects we put a weighted moving average filter on the data of both cases and deaths. the correlation time between reported cases and reported deaths will be named as time from diagnosis to death (dtd), and: ttd = dd + dtd. ( ) correlation between reported cumulative cases and reported cumulative deaths exploring different delays between diagnose (reported) and death for germany (red), spain (green) and switzerland (green). (d) maximum correlation is marked with a red square for each country. % correlation interval can be seen with black bars. april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . in fig. c we can see the correlation [ ] between reported cases and reported deaths assuming different dtd for germany, spain and switzerland. as you might expect, correlations have values close to . in most cases the correlation has a concave parabolic shape with a clearly defined maximum. we assume this maximum represents dtd for each country. the correlation interval is estimated as the points where the correlation is greater than % of the observed maximum. we decided to set a lower limit of days and a higher limit of days [ ] because we believe that time outside diagnostic rate by country as discussed in the methods, we use the same cfr = % in all european countries instead of making small corrections for demography. the bias due to demography was shown to be around - %, precisely the same order of magnitude we obtain for the possible bias in the counting of reported mortal cases. given that our aim is to provide a clear method for policymakers and that there is no data on how, or even if, both correlate, a common cfr allows us to homogenize the results with the clear limitation that we will obtain reasonable estimations and not exact results. the resulting picture is expected to be closer to reality than using purely reported data, but worse than correcting properly for age and diagnosis if the data of cfr for all age brackets and locations (nursery homes, hospitals, individual homes) were available, which is not the case. the estimation of the diagnostic rate is straightforward. from the cumulative number of deceased each day, and multiplying by ( % cfr) we get the cumulative number of people with symptoms days ago [ ] [ ] [ ] simply by rescaling and displacing backward in time the cumulated death curve of any country. to give an initial realistic and homogenous diagnostic rate we must establish how many days are needed as a bare minimum to be able to detect a patient from the onset of symptoms. first, the patient has to feel sufficiently sick and then contact the health service. from this contact, the doctor needs to be suspicious that the person has the disease and request a test. then, this test must be available, performed and the result received and annotated. it is clear that a bare minimum of one week is needed for this process. we use the name -days . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . symptoms and then days forward to be detectable/diagnosable. from this curve, we can obtain the rate between the cumulated number of people who had symptoms for or more days and the cumulated number of people detected days ago. it is thus clear that this homogenous analysis across countries could be performed assuming d-dr or d-dr and different cfr. it gives a proper first estimation of the situation. we argue, however, that there is indeed bias in the way people deal with the health care system in normal situations and, especially, under an epidemic. different countries and populations are in fact behaving very differently. we have observed that this is the case in the methods section checking the delay between diagnostic and death using time-displaced correlation analysis. this is the reason why we also define the delay to detection diagnostic rate (dd-dr) as the diagnostic rate computed using a time delay between the appearance of symptoms and detectability different for each country. we proceed to use fig. , with spain as an example, to explain the concept behind dd-dr. for spain, the maximum correlation between cumulated death curves and cumulated reported cases appears when cumulated deaths are displaced days backward. this suggests a dd of around two weeks ( − = days). this makes sense in a situation like the one in spain during march . the population receiving news that the health care system is under stress may decide to delay reporting of symptoms unless they are very serious. additionally, there is the possibility that tests are not available to people who report with symptoms to primary health care centers, and that the delay between the test, its positive result, and its record to official information systems is not negligible as well. it is thus important to correct for this bias in the estimation of the diagnostic rate. it is clearly not the same to have a time delay from symptom to the detection of days than . dd-dr can be computed from spain just like we did before for the d-dr using the same rescaling of the cumulated dead curve as before but using a displacement backward of days instead of days. fig. shows how the dd-dr is obtained in different countries depending on the delay between symptoms and detectability. countries with a lower dd, such as germany, have the same d-dr than dd precisely because they diagnose as early as realistically possible. we notice now that both d-dr and dd-dr can be tracked along time, as the epidemic advances we can check how these diagnostic rates changes. each new day we can look days back for the d-dr and compute the diagnostic rate. dd-dr can be tracked similarly. in fig. we show the evolution for both as a function of time for three selected countries. we observe that the dd-dr reaches a steady state after the initial stages of the disease while d-dr seems more affected by trends. this can be expected since dd-dr uses, precisely, the maximum of the correlation delay so it is expected to fluctuate less. the dd-dr is not only more stable but it also allows as to produce a proper assessment of the errors involved. the main one is the fact that the april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . april as above million in spain and close to half million in germany. the table in fig. shows a list of the d-dr as of the beginning of mid-april of , and the dd-dr, which seems stable, together with the associated error. to interpret estimated cumulative cases and estimated attack rate we must take into account detection delay, because they are computed using the reported data. data updated on april . belgium data is biased due to reporting of unconfirmed death cases [ ] . best estimations might shift - % once the diagnostic rate is known, it is straightforward to establish a real incidence no longer affected by the presence of important differences in the time delays to diagnostic in different countries (see the table in fig. ). the level of diagnosis and the real incidence is indeed useful for policymakers since it gives a clear general picture. however, the policy response needed to improve the diagnostic rate is limited, in the short-term, by the ability to increase the production of pcr kits and other diagnostic tools. policymakers have more ability to affect immediately mobility patterns and social contact. in this sense, a key number for policymakers would be to have a reliable and robust estimation of the number of infected people in each country that can propagate the disease. providing an exact number is, right now, impossible. we can, however, produce an index of the effective potential growth using the dd-dr and the guidelines used by the ecdc to track the epidemic. even if the precise number of people with the disease were known, and the distribution of symptoms by sex and age was reported, there is no clear knowledge regarding the level of infectivity of the different type of person and symptoms. for instance, it is not known the days a person with mild symptoms can transmit the disease. the same can be said for people with serious symptoms. virus loads in the throat seem to be rather high across the board [ ] , but data on how this influence contagion is unclear. the only way to assess the situation is to use a general unbiased broad measure, which is indicative of the potential for infection. the ecdc uses the number of newly infected people in the last days [ ] . we use this same criterion. this number can only be obtained properly some days in the past, on the day we have a typical diagnosis. after that, we would need input from new data to properly compute how many people are diagnosed. so the number i is strictly a measure of the recent past, but good enough to give the proper picture that the system will face the following days. april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . fig . schematics of the procedure to obtain incidence a , recovered and estimated cases using germany as an example. incidence of estimated cases (blue), contagious incidence (red) and total estimated recovered cases (green). blue shaded part is the number of cases used to compute the estimated contagious incidence. to interpret final number of total cumulative cases, recovered cumulative cases and estimated attack rate we must take into account detection delay, because they are computed using the reported data. similar figures for all countries are shown in si fig. we also consider those undetected cases which appear earlier than days as recovered r i . notice that here we use the word recovered lousily. it does not mean literally that all of them are fully recovered since most of them never fell ill to begin with, and some of them could not have neutralized tests yet, but that those infected and undetected for more than two weeks ago do not seem to pose a serious risk. a alone, however, does not give a full picture of the situation. it is not the same to have contagious per inhabitants when the number of contacts is high that when the number of contacts is low. it is important to take into account the level of spreading velocity of the epidemic related to the effective reproductive number (r t ). the effective reproductive number depends on multiple factors, from the properties of the virus itself to the number and type of contacts. those, again, depend on different social behavior and structure such as mobility, density or the typical size of the family unit sharing a house, to name a few. the only feasible way to estimate r t is using fits from seir models. complex seir models which include spatial and contact-processes have a large number of parameters which, due to the present lack of knowledge, are ( ) and epg.ρ ( ) is computed using the mean value for the last three days. epg: effective potential growth described in the text. to interpret table data we must take into account detection delay, because they are computed using the reported data. data updated on april . * belgium data is biased due to reporting of unconfirmed death cases [ ] . best estimations might shift - %. given the partial empiric nature of present r t , we prefer to take a fully empiric surrogate as a quantitative evaluation of the level of infections. we define an alternative reproductive number as the number of new cases detected today divided with the number of new cases detected five days ago as n t /n t− . however, the high fluctuations on this quantities imposes the use of averaged values over three days [ ] : where n t stand for new cases reported at day t. this rate is one if the number of new cases is constant. it will be below if new cases are decreasing and larger than if the april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint number of cases is increasing. we take days as the key delay unit since this is roughly the time since infected people develop symptoms if they do develop them. there are still clear fluctuations on a day-to-day basis of this measure ρ t due to common delay and irregularities in reporting. most fluctuations can be eliminated by taking the average of ρ t during three daysρ ( ) which is normally enough to get a rather smooth measure. it is not uncommon to find still some fluctuations and one-week averages can be done if required. we propose the following day-to-day index epg: epg is just the multiplication of the growth rate of the diseaseρ ( cases is biased by diagnosis protocols and ratios in each country, as well as by the pool of asymptomatic cases. moreover, any attempt to improve diagnosis percentage requires an economic, infrastructural and logistical effort that is not always possible. in addition, this health system structure is a strong conditioning that limits the possible actions to carry out in this direction. the reported number of deaths, if uniformly and properly recorded, provides very relevant information as a first general overview. even in countries where there is a bias on death reporting, the effort that should be made to improve these data collection is much lower than the necessary effort to increase data about cases. the assumption of a common lethality, which has been situated around %, allows for using the cfr as an indicator of real incidence. current information on cfr is still not complete, since many countries do not report distribution of deaths by age or sex, neither provide covid- mortality outside hospitals. however, we argue that the kingdom ( , ), france ( , ) and belgium ( , ). if we estimate the cases that should have been diagnosed by that time, the ranking is lead by italy ( , , ) and followed by france ( , , ), spain ( , , ), united kingdom ( , , ), belgium* [ ] ( , ) and germany ( , ). thus, differences in diagnostic rate are absolutely significant when analyzing global situation in europe. countries like germany, portugal and switzerland would be diagnosing around % of cases, while belgium, france, sweden and united kingdom would be in the level of %. assessing the risk of countries to enter or remain in the epidemic growth phase is essential. in this sense, the epg index is a valuable tool for policy makers. a high epg in the situation where there is a high growth rate of the epidemic and large number of active cases is a clear situation of danger, while a very low epg because both the reported epg vs estimated real epg. different european countries in terms of the epg computed using the reported data on the attack rate vs the epg using our estimation of the real attach rate. the order of the different countries should be done from right to left (for the reported state of the index) and from top to bottom (for the estimated value of the index). we observe how the comparative situation of the different countries changes as of april . * belgium data is biased due to reporting of unconfirmed death cases [ ] . best estimations might shift - %. despiteρ ( ) is quite independent of the diagnostic rate, reported i directly depends on the level of diagnosis. thus, if epg is evaluated with reported data, it can provide a wrong picture of the situation. based on reported epg, the worst situation in europe at april would be for belgium, followed by spain, united kingdom, netherlands and portugal. if risk is evaluated with estimated epg, highest value would still correspond to belgium as well, but followed by sweden, united kingdom, spain, netherlands and italy. portugal is in much better position that its reported data suggest. actually, countries with similar reported epg like portugal, and netherlands have, in fact, totally different estimated epg, being the last country at significantly higher risk than the former . we have shown in the methods section that the basis for obtaining estimated i and a is not biased due to demographic differences and, right now, there is no indication that it is biased due to a different way of accounting for the cumulative dead toll of the epidemic. there is also no indication that comorbidity factors are largely different in different countries or that cfr is higher on some countries given that icu units and hospitals are not available for people that would need it, at least so far. if this were the case, under any scenario where the situation occurs, the epidemic in that country will have such a larger number of cases, attack rate and growth that the epg will be extremely high. the only real limitation is that the social and environmental issues could affect the prognosis of the infected. if living in a small house with other people infected could lead to worse prognosis than staying in a large house alone, a new analysis regarding the unbiased nature of the cfr would need to be done. it is important to indicate that not only i is unbiased, as analysed in previous sections, but thatρ ( ) is not biased as well. even though absolute reported cases is biased, as we have shown, ρ t deals with ratios and its evolution. as long as the diagnosis and recording of the people with disease follows roughly the same criteria along time in each country, ρ t is a good measure of the growth the epidemic. indeed, if evaluated diagnosis percentage is more or less constant in time, we can assume that ρ t correctly reveals tendencies in contagiousness. if a change in criteria in reporting the cases occurs (i. e., a large increase in the number of tests per day leading to an increase of cases due to more testing), ρ t will be temporally affected but will go back to be a good measure once the new criteria is established. in this case, epg will provide a wrong picture for a while as well, until stationary conditions in diagnosing and reporting are achieved again. there is another important point to address in order to guarantee that ρ t is a robust measure. as soon as we are estimating real number of cases, we can determine the associated ρ t . it is expected that both ρ t behave similarly but with a certain delay. this delay can be determined by translating both ρ t in time until error between both is minimized. we show this detailed analysis in the supplement material si file where we evaluate that both the reported ρ t and the inferred ρ t are indeed different but that follow the same type of evolution once the proper delay is accounted for si fig. . the third important outcome of this analysis is the estimation of recovered people. this is an important number to assess the possibility of herd immunity discussed as a possible exit strategy. the idea is that those that recover might have immunity and act as barrier in the transmission of the disease. a recent study from the fudan university at shangai [ ] has analyzed antibody titters of adult covid- recovered patients. the study is based in the detection in plasma of spike-binding antibody using rbd, s , and s proteins of sars-cov- using an elisa technique. it is also the first study that looks after neutralizing antibodies (nabs) specific for sars-cov- using a gold standard to evaluate the efficacy of vaccines against smallpox, polio and influenza viruses. the study highlights the correlation between the nab titters and spike-binding antibodies that were detected in patients from day - after the onset of the disease, remaining afterwards. middle and elderly age patients had higher titters compared with young age patients, in which in cases the titters were under the limit of detection. nab titters had a positive and negative correlation with c-reactive protein (crp) levels and lymphocyte counts, respectively. this indicates that the severity of the disease, in terms of inflammatory response (crp levels), usually worse in middle and elderly age, favors the increase of antibody titters. equally, the negative correlation with lymphocyte counts suggests an association between cellular and humoral response. therefore, it is possible that the immunity reached by young people, which were mostly asymptomatic, is residual. in that case, this sub-population would keep being carriers of covid- . serological studies that many countries are designing and carrying out should provide further information on post-infection immunity. even if the entire recovered population acquires middle-term immunity, current incidence situates european countries far from herd immunity. nevertheless, it is feasible that regions with highest affectation were closer to use herd immunity as a strategy for de-confinement. governments might wish to explore the possibility of local deconfinement. there are two possible limitations of this present study. it could be possible, in theory, that some countries present an intrinsically different cfr if they are able to isolate completely and significantly its elder population more than others. the epidemics real cfr is a measure of the case fatalities if all the population, or a representative sample of it, has become infected. if one country would effectively prevent all infections among all its elder population from contagious forever, it will certainly have a different cfr. right now, it is impossible to assess if this is indeed the case in different countries given the lack of reported cases and mortality rates by age and sex. we should notice however that, if this disaggregation were to be provided, we could proceed with exactly the same methodology but instead of using the whole country as a whole we would divide it into different age brackets and treat them separately. the second limitation is related to the first one but coming from a more structural perspective. a clear possibility is that countries under stress could be failing in providing the same medical support changing the cfr. we must notice that health care in european countries, even under stress, has been able to increase dramatically its number of health personnel, of beds and hospitalization in short notice [ , ] . italy and spain present some regions under stress but not the whole country [ ] . finally, one cannot disregard the possibility that complex mechanisms of mutations and repetitive exposure to the virus may change the prognosis depends on the type of residence and, hence on socio-economic factors, which are clearly different across countries. if any proof that a close environment not only increases the level of infections, which they obviously do, but also changes the disease evolution in the patient, one should again test that the uniform/unbiased cfr hypothesis holds with the proper knowledge at hand. to obtain dtd for each country and the corresponding evolution of the diagnostic rate. we also provide fore each country the evolution of recovered and the attack rate in the last days a . we also provide the demonstration thatρ ( ) is also unbiased showing the correlations between real and estimated growth rates. fig. series of figures showing the evolution of the estimated cases for different european countries. in blue, incidence of estimated cumulative cases. in green, estimated incidence of cumulative recovered cases. in red, estimated incidence of attack rate lasts days (a ). day is considered the first day where cumulative cases was over cases, it is different for each country. data extended till april . . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . growth rate and, in blue, reported cases growth rate. (b) the gorwth rate of estimated cases is displaced to find better match with the growth rate of reported cases. (c) error between estimated and reported growth rates using differents delays. minimum delay is marked and is the one used in (b). european centre for disease prevention and control. download today's data on the geographic distribution of covid- cases worldwide situación actual covid- ministerio della salute republica italiana. covid- , i casi in italia coronavirus testing: how are the hardest-hit countries responding? suppression of covid- outbreak in the municipality of vo transmission potential and severity of covid- in south korea correcting under-reported covid- case numbers: estimating the true scale of the pandemic using a delay-adjusted case fatality ratio to estimate under-reporting. centre for mathematical modelling of infectious diseases. london school for hygiene and tropical medicine analysis and prediction of covid- for eu-efta-uk and other countries. dpt. of physics. universitat politècnica de catalunya estimating clinical severity of covid- from the transmission dynamics in wuhan, china real estimates of mortality following covid- infection case-fatality estimates for covid- calculated by using a lag time for fatality clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study. the lancet estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship estimating the infection and case fatality ratio for coronavirus disease (covid- ) using age-adjusted data from the outbreak on the diamond princess cruise ship central disease control headquarters. coronavirus disease- , republic of korea vorläufiges ergebnis und schlussfolgerungen der covid- case-cluster-study large scale testing of general population in iceland underway spread of sars-cov- in the icelandic population demographic science aids in understanding the spread and fatality rates of covid- neutralizing antibody responses to sars-cov- in a covid- recovered patient cohort and their implications chain safety and environment belgium government. the covid- figures: collection, verification and publication vigilancia de los excesos de mortalidad por todas las causas. momo world health organization. coronavirus disease (covid- ) situation reports correlation (in statistics virological assessment of hospitalized patients with covid- european centre for disease prevention and control. coronavirus disease (covid- ) in the eu/eea and the uk -eighthupdate el ministerio de sanidad amplía las medidas para el refuerzo de personal sanitario hospital fira salut ja està a disposició del sistema sanitari per si calen llits addicionals incidencia de la covid- en las camas uci en españa key: cord- - ykwwq authors: ippolito, g.; puro, v.; heptonstall, j. title: biological weapons: hospital preparedness to bioterrorism and other infectious disease emergencies date: - - journal: cell mol life sci doi: . /s - - -y sha: doc_id: cord_uid: ykwwq in the last decades, successive outbreaks caused by new, newly recognised and resurgent pathogens, and the risk that high-consequence pathogens might be used as bioterrorism agents amply demonstrated the need to enhance capacity in clinical and public health management of highly infectious diseases. in this article we review these recent and current threats to public health, whether naturally occurring or caused by accidental or intentional release. moreover, we discuss some components of hospital preparedness for, and response to, infectious disease of the emergencies in developed countries. the issues of clinical awareness and education, initial investigation and management, surge capacity, communication, and caring for staff and others affected by the emergency are discussed. we also emphasise the importance of improving the everyday practice of infection control by healthcare professionals. the global eradication of smallpox, arguably the greatest international public health achievement of the twentieth century, was certified in at a time of almost untrammelled optimism that the fight against infectious diseases had been won. in the following decades, successive outbreaks of infectious diseases caused by new, newly recognised and resurgent pathogens -which have been described as a series of 'perfect microbial storms' -amply demonstrated that such optimism was misplaced, and that, far from winding down capacity in clinical and public health management of highly infectious diseases, it was necessary to enhance it [ , ] . the risk that highconsequence pathogens, including smallpox (variola) virus, might be used as biological weapons or bioterrorism agents had been recognised, and policy makers and planners were encouraged to ensure that that health and other services were adequately prepared to deal with the threat, even before the attacks on the world trade center and the pentagon in september [ , ] . these attacks, coupled with the deliberate release of letters containing anthrax spores via the us postal service a month later [ ] , showed that the threat was real, and that work to improve preparedness and response was urgently needed at local, national, and international levels. in this article we review recent and current threats to public health in developed countries from bioterrorism and other highly infectious diseases, and discuss some of the components of hospital preparedness for, and response to, infectious disease emergencies. we also emphasise the importance of improving the every-day practice of infection control by healthcare professionals and of taking a generic, 'all-hazards' approach to hospital preparedness, integrating planning for response to infectious disease emergencies, whether naturally occurring or caused by accidental or intentional release, with planning for major incidents and natural disasters. the concepts used in developing laboratory biosafety guidelines forms the basis for categorisation of biological agents by risk group and the designation of appropriate biosafety levels. these concepts rely on expert risk assessment of the severity of human infection, the potential for transmission to exposed individuals and to the wider community or environment, and the availability of effective prophylaxis or treatment. additional assessments include likely ease of dissemination by terrorists and the estimated overall impact of any dissemination to generate lists of 'critical agents' [ , ] . the lists then rank the biological agents that might be used in deliberate release by priority, and identify measures needed to ensure public health preparedness. critical agent lists are also being used to set priorities in biodefence research, including basic research on biology and pathogenesis, and development and evaluation of molecular diagnostic assays, vaccines, antivirals, and other preventive or therapeutic interventions [ ] . although critical agent lists generally make provision for inclusion of newly recognised or recently emergent pathogens, they were developed specifically to improve preparedness for bioterror events. so though all categorise smallpox virus as a high-priority, 'category a pathogen', none accords high-priority to highly pathogenic influenza viruses, or severe acute respiratory syndrome (sars) coronavirus, despite the fact that these viruses are epidemic prone, and capable of rapid global spread and enormous public health impact. the term 'highly infectious diseases' describes infections caused by pathogens that are transmissible from person to person, cause severe or life-threatening illness; present a serious hazard in healthcare settings and in the community; and require specific control measures, which may include management of cases in a highly secure isolation unit. it thus includes some, but not all, of the infections caused by category a critical agents (including smallpox, lassa, marburg, ebola and congo crimean haemorrhagic fevers, and pneumonic plague, but excluding anthrax, bubonic plague, tularaemia and botulism because these are not transmissible from person to person), and also includes sars, influenza caused by avian influenza virus h n or other highly pathogenic influenza virus, and unusual illness of unknown, but possibly infectious, aetiology. incidents caused by the intentional release of pathogens are rare: in the last years, five such incidents have been recognised and reported. three of the first four incidents involved gastrointestinal pathogens (salmonella typhi, salmonella enteritidis, shigella dysenteriae); in the fourth a group of students developed asthma and pulmonary eosinophilia after being fed ascaris suum [ ] [ ] [ ] [ ] . in the largest of the outbreaks of gastrointestinal infection, over people developed symptoms after eating from salad bars in two restaurants in dalles, oregon, in . this was a 'covert' deliberate release: unannounced, without any warning or indication of the organism involved, or of the population affected, and it was not until late in that it was discovered that followers of baghwan shree rajneesh had deliberately contaminated the salad bars with cultures of s. enteritidis, nicely illustrating that intentional and naturally occurring outbreaks may be indistinguishable. in the united states, the intentional dissemination of anthrax through the postal service in led to cases of anthrax ( pulmonary, cutaneous) among residents of seven states along the eastern seaboard. five of the pulmonary infections were fatal [ ] [ ] [ ] [ ] [ ] [ ] [ ] . this was an example of an 'overt deliberate release', insofar as explicitly threatening notes were enclosed in the envelopes containing the anthrax spores, although the diagnosis of the first cases preceded recognition of the risk. most ( ) cases occurred in postal service employees or employees of the media companies targeted in the attacks; environmental sampling detected widespread anthrax contamination of the postal system. anthrax, along with all other infections caused by category a pathogens, is uncommon in developed countries, and lack of familiarity with the disease, coupled with failure to include it in the differential diagnosis of an unusual skin lesion or of sudden onset of serious sepsis and respiratory failure led to delays in diagnosis: the median time from onset to diagnosis of the cases of cutaneous anthrax in the first cluster was days [ ] . many of these had already occurred by the time that the index case of pulmonary anthrax was diagnosed in florida by an alert clinician who had recently undergone bioterrorism preparedness training. although the number of cases was small, the overall impact of the incident on an already stretched public health system was considerable. in new york alone, over 'suspect' cases, identified as a result of intensive case finding in hospitals and through clinician networks, or by self-referral by calls to telephone hotlines, required clinical assessment. all those who had potentially been exposed to anthrax required assessment for prophylaxis; completion of a -day course of post-exposure antibiotics was recommended for over , persons [ ] . laboratories within the laboratory response network tested over , clinical specimens. the incident highlighted the need for coordination and clear command structures at local and national levels; for stronger linkages between clinicians, clinical microbiologists, hospitals and public health departments; for information, communications and laboratory systems with inbuilt 'redundancy', readily capable of expansion to meet surges in requirements, and for coordinated and effective communication with clinicians, the media and the public [ ] . in the oregon outbreak, the organism had been obtained from a commercial source; in two of the three other outbreaks caused by gastrointestinal pathogens, the per-cell. mol. life sci. vol. , multi-author review article petrators, a bacteriologist and a laboratory worker, had access to organisms from their laboratories. the source of the b. anthracis used in the united states in remains uncertain. recent changes intended to strengthen containment of critical agents within laboratories include more stringent regulation of work on, and transfer of, high-consequence pathogens, and updated guidance that recommends that all clinical, diagnostic and research laboratories develop threat and risk assessment based site-specific biosecurity plans covering personnel selection, access and inventory control, specimen accountability, reporting of incidents, injuries and breaches, and response to an emergency [ ] [ ] [ ] . the epidemic of sars in - , with over cases in countries, illustrated how a new infection can, given the speed and reach of international air travel, spread globally within weeks [ ] . transmission was amplified within hospitals, as early cases were cared for without effective infection control measures; % of sars cases in hong kong and nearly half ( %) of sars cases in toronto and singapore ( %) occurred in healthcare workers. overall, % of hospitalised patients required mechanical ventilation, and % of hospitalised cases died. sars coronavirus, although a newly emergent virus, was transmitted in the same way as more common respiratory infections, mainly by respiratory droplet spread, and the sars epidemic was controlled by the efficient application of long-recognised public health control measures: rapid identification and early isolation of cases, and stringent adherence to infection control precautions. in canada, where sars 'paralysed the greater toronto area healthcare system for weeks' [ ] , and the toronto public health department investigated potential cases of sars, identified over , contacts as requiring quarantine and logged more than , calls on its sars hotline [ ] , a national review commission identified systemic deficiencies in response capacity, including 'inadequacies in institutional outbreak management protocols, infection control and infectious disease surveillance', and found that these deficiencies resulted at least in part from failure to implement lessons learned from earlier public health emergencies [ ] . global travel and global trade expose industrialised countries to other infectious disease threats. human monkeypox is a zoonosis, normally geographically confined to west and central africa, which is clinically similar to smallpox in that a vesiculopustular rash follows a febrile prodromal illness. the illness tends to be milder than smallpox; in contrast with smallpox, lymphadenopathy is often a prominent feature, and person-toperson transmission is uncommon. in , the first clus-ter of human cases ( confirmed, suspected) of community-acquired monkeypox in the western hemisphere occurred in the united states [ , ] . infection followed exposure to infected pet prairie dogs that had been housed or transported with african rodents imported from ghana. although pox virions were seen on electron microscopy of clinical samples from the index case, the diagnosis of smallpox was excluded because the development of pocks in the case followed, and was localised to, the site of a bite by a sick pet prairie dog. the diagnosis of monkeypox was made by specialist testing of referred samples in the national laboratory. this incident again highlighted the role of the astute clinician in outbreak recognition; the value of maintaining close working relationships between clinicians working in healthcare facilities and in public health departments, and the need for multi-level, multi-agency cooperation, including collaboration between animal and human health experts, in outbreak management. in , an outbreak of marburg haemorrhagic fever in angola, and the potential for exported cases prompted the rapid development of national guidelines for risk assessment and case management in countries that had not previously published such guidelines [ , ] . marburg viral haemorrhagic fever, and ebola, congo-crimean, and lassa haemorrhagic fevers are of particular concern in healthcare settings because there is a high risk of person-to-person transmission through percutaneous or mucocutaneous exposure to blood. lassa fever is endemic in west africa, where estimates suggest that around , cases occur each year [ ] ; congo-crimean haemorrhagic fever has a wide geographic range that includes greece, albania and pakistan; and outbreaks of the more geographically restricted ebola and marburg haemorrhagic fevers have recently occurred with apparently increasing frequency [ , ] . despite this, imported cases of viral haemorrhagic fever are uncommon: laboratory confirmed cases of lassa fever (likely to be the most frequent importation) have been reported from the united states, and fewer than from other industrialised countries since the disease was recognised in [ ] [ ] [ ] [ ] . this is perhaps because transmission and outbreaks of haemorrhagic fever viruses occur mostly in rural areas, which thus limits the opportunities of most business travellers or tourists for exposure. nevertheless, and because there have been reports of weaponisation of marburg, ebola and lassa viruses [ ] , all of which are category a pathogens, clinicians should remain alert to the possibility of these infections, maintain an awareness of current outbreaks, and should know how to conduct a risk assessment of febrile illness compatible with a diagnosis of viral haemorrhagic fever, how to safely undertake initial management and apply appropriate infection control measures, and, most important, know whom to contact for further advice on diagnosis and further management [ , , ] . infections emergencies and hospital preparedness one of the consequences of the resurgence in biodefence-related research is that more laboratories, and more laboratory workers, are now working with category a pathogens, which increases the potential for occupational exposure, for occupationally acquired infection and, for some pathogens, for onward transmission to others. laboratory workers may also be exposed to high-consequence or newly emerging pathogens whilst working on diagnostic or surveillance-related samples. since , cases of laboratory acquired glanders ( case, us military research laboratory, the first case reported in the united states since ) [ ] ; the wr strain of vaccinia ( case, research laboratory, brazil) [ ] ; recombinant vaccinia virus ( cases, research laboratories in germany, united kingdom, canada, and united states) [ ] [ ] [ ] [ ] , tularaemia ( cases, us research laboratory) [ ] ; sars ( cases, in research laboratories in taiwan, singapore, and china; all occurred after the end of the sars epidemic, infection spread from the laboratory workers in china to a further people, of whom died) [ ] [ ] [ ] ; ebola viral haemorrhagic fever ( fatal case, russia, research laboratory) [ ]; anthrax ( cutaneous case, us laboratory) [ ] ; brucellosis ( linked cases, us clinical microbiology laboratory) [ ] ; and west nile virus ( cases, us laboratories) [ ] have been reported. in several of these cases, diagnosis was delayed because the possibility of occupationally acquired infection was not considered, and/or because of difficulties in identifying the organism in the clinical microbiology laboratory. in only of these cases was the exposure that led to infection identifiable. guidelines on laboratory biosafety advise that laboratory workers should have access to expert occupational health advice, including, where appropriate, pre-exposure prophylaxis, and that those working in bsl or bsl facilities should carry 'medical contact cards' [ ] . clinicians should take an occupational history as a routine, and, if a laboratory or animal house worker presents with an unexplained febrile illness, a senior clinician should obtain further information from the laboratory director about the agents to which the patient may have been exposed, regardless of whether the worker can recall a specific exposure. since , a new, highly pathogenic strain of avian influenza virus, a/h n , has emerged, initially in se asia, but with more recent spread to countries in europe, the middle east, central asia, and africa. the first human cases were reported from vietnam in ; to date (may ), laboratory-confirmed cases, including deaths (case fatality rate %) have been reported to the world health organisation from countries (azerbaijan, cambodia, china, djibouti, egypt, indonesia, iraq, thailand and turkey) [ ] . there is limited evidence of human-to-human transmission of the virus [ ] ; most cases have followed close contact with infected birds (of-ten from household or 'backyard' flocks) or their faeces, other body fluids or carcasses. it is not known whether, and if so, when, how or where, influenza virus a/h n will evolve to become more easily transmissible between humans. nor is it known whether an increase in transmissibility would be accompanied by a change in lethality. however, the world health organisation believes that the threat of pandemic human influenza is now greater than at any time since , when the last influenza pandemic occurred [ ] . the world health organisation uses a series of six alert levels to inform the world of the seriousness of the threat, and to recommend progressively more intense preparedness activities. at present (pre-pandemic threat level ) [ ] , clinicians need to be aware of the potential for infection in travellers returning from affected countries, and in those who may have had occupational (e.g. poultry farmers, veterinarians, animal cullers) or other contact with infected domestic, commercially farmed or wild birds, a human case or virus in the laboratory. advice, algorithms and response protocols for investigation and management of possible cases or case clusters have been published, and give details of reporting mechanisms, diagnostic specimens, infection control measures and other containment responses [ ] [ ] [ ] . assessments of preparedness plans in europe and the united states suggest that, at best, most countries remain only moderately prepared for pandemic influenza; furthermore, the degree to which planning at the national level has been translated into increased preparedness at the local level within healthcare facilities remains unknown [ ] [ ] [ ] . it would be prudent, however, for planners within hospitals to review existing influenza pandemic contingency plans in conjunction with the relevant national preparedness plan, with the aim of ensuring preparedness to provide supportive medical care for influenza cases, prevent transmission of infection and at the same time continue to provide essential medical services to their community. where concerns arise about issues (e.g. criteria for hospital admission; prioritisation of antiviral use; prioritisation of admission to intensive care units; responsibility for decisions to defer elective surgical admissions; sourcing of additional supplies e.g. of personal protective equipment; use of volunteer personnel) that are not clearly dealt with within the national plan, urgent clarification should be sought from the relevant national authority. the overall aim of hospital preparedness for an infectious disease emergency is to be able to provide adequate medical care to those affected whilst at the same time continuing to provide essential medical services to the community. cell. mol. life sci. vol. , multi-author review article the phases of the traditional disaster management cycle (preparation, response, recovery and mitigation) are paralleled in infectious disease emergency management by preparedness (activities undertaken before an event, including planning, training, and undertaking practice drills and exercises to test the plans); surveillance and detection (recognising that an infectious disease emergency is occurring); and response, control and containment (the clinical, public health and other measures that minimise the health, social and economic consequences of the incident). effective preparedness planning requires a multidisciplinary approach, involving emergency planners, clinical practitioners, laboratorians, managers and administrators, emergency responders, pharmacists, voluntary agencies, mental health and occupational health services, religious and spiritual advisors, support staff including catering, housekeeping, portering and security, medical records, communications, information technology and transport/ courier services; with clear, pre-event designation of roles and responsibilities and clear chains of command, control and communication, and regular testing and evaluation of 'major incident' or emergency operations' plans by drills and exercises. hospital preparedness for infectious disease emergencies needs to be sufficiently versatile to encompass response to incidents that range from those of high/moderate probability-low/moderate consequence (e.g. a local, but severe point-source outbreak of norovirus infection), through low probability-moderate consequence (e.g. managing a single imported case of viral haemorrhagic fever or a hospital-associated outbreak of legionellosis), to low probability-high consequence (e.g. pandemic influenza; bioterrorist attack). early diagnosis and prompt institution of effective control measures are critical determinants of the eventual impact of any infectious disease emergency [ ] . nine of the cases of pulmonary anthrax in the us outbreak in presented direct to hospitals or emergency rooms. these clinicians are also likely to be the first to see cases of newly emergent highly pathogenic influenza, re-emergent sars or imported viral haemorrhagic fever. clinicians need, therefore, to maintain their awareness of current infectious disease threats by daily review of national, regional and international web-based alerting systems, or by ensuring that their department receives national cascade alerts, and to incorporate relevant epidemiological information into their daily practice (e.g. by using knowledge of areas currently affected by avian influenza h n coupled with travel and occupational histories to exclude the diagnosis in patients with febrile respiratory illness). useful and reliable open-access sources of medical intelligence include the web sites developed by the infectious diseases society of america (promed; http://www. promedmail.org) [ ] , the world health organization (http://www.who.int/csr/don/en/) [ ] ; further links to additional sources can be found at http://www.ecdc.eu.int/. all clinicians must remain open to the possibility that they may be the first person to recognise a deliberate release or other infectious disease emergency; must be prepared to consult urgently with their local infectious disease specialist, clinical microbiologist and public health department on suspicion alone, without waiting for a definitive diagnosis, and must remain alert to the unusual, the unexpected and the case that 'just doesn't fit'. examples of the unusual include unusual illness (e.g. a sudden, unexplained febrile death, critical illness or pneumonia in a previously healthy adult); an unusual number of patients with the same symptoms presenting within a short time frame; illness unusual for the time of year (e.g. 'flu in summer'); an illness unusual for the patient's age group (e.g. chicken pox in a middle-aged adult); illness in an unusual patient (e.g. cutaneous anthrax in a patient with no history of contact with animals, animal hides or products); an illness acquired in an unusual place (e.g. tularaemia acquired in the united kingdom); unusual clinical signs (e.g. mediastinal widening on chest x-ray; symmetrical flaccid paralysis of sudden onset; 'chickenpox' rash predominantly on the extremities); and unusual progression of illness (e.g. lack of response to usually effective antibiotics) [ ] . most of the illnesses caused by high-consequence pathogens are uncommon in industrialised countries (though some e.g. plague, anthrax remain endemic elsewhere) so few clinicians have direct experience of them; similarly, few of those now practising have ever seen a case of smallpox. considerable resources have therefore been invested since in training clinicians and emergency responders to recognise illnesses caused by these pathogens, and in developing web-based and other training materials, guidelines, fact sheets, and incident response check lists for health care and emergency response professionals. these can be found on, or through, national authorities' web sites (e.g. http://www.bt.cdc.gov; http://www.hpa. org.uk) and used, where formal face-to-face training programmes are not accessible, as the basis for self-directed learning. decision-based algorithms for diagnosis and clinical management pathways have also been developed, and can be used to guide initial responses to suspected cases of smallpox, sars, viral haemorrhagic fever or avian influenza [ , [ ] [ ] [ ] [ ] . effective infection control saves lives. all healthcare workers have a responsibility to ensure that their clinical infections emergencies and hospital preparedness practice prevents transmission of infection, and puts neither their own health, nor that of their patients, coworkers or others at risk. all healthcare workers should be trained in standard and transmission-based infection control precautions at induction [ ] . overall standards might be improved if an annual demonstration of competence was made a requirement for re-accreditation, and if a more stringent approach was taken to any recognised breach of infection control practice. infection control guidelines, updated after the sars epidemic, now stress the importance of incorporating 'respiratory hygiene' or 'cough etiquette' -simple measures designed to prevent transmission of respiratory infections -into standard infection control precautions [ , ] . this is particularly applicable to emergency departments, outpatient clinics and day-care centres -and includes training staff to identify and segregate or spatially separate patients with signs and symptoms of respiratory tract infection from others; offering a surgical mask to symptomatic patients; instructing all patients to cover their nose and mouth with tissues when coughing or sneezing, to dispose of used tissues safely and to clean their hands frequently, and providing tissues and tissue-disposal and hand-cleaning facilities for patients [ , ] . emergency departments should review their existing infection control practices and consider whether these are adequate to prevent intra-hospital transmission of infection, from the moment that a patient with an unrecognised but highly infectious disease arrives in the department, through the initial evaluation and investigation, to the point when the patient is admitted or transferred elsewhere. this should include identifying a space (ideally a negative pressure room) suitable for airborne infection and respiratory isolation and ensuring that staff understand when and how it should be used; review of available personal protective equipment (ppe: gloves, gowns, face and eye protection, surgical masks or other respiratory protection e.g. n -type respirators), hand-cleaning facilities, and sharps safety and disposal arrangements; assessment of staff competency in choosing, and safely using, removing and disposing of the ppe available, ensuring that, if n -type respirators are to be used, staff have been fit-tested and know how and when to perform fit checks; reinforcement of the importance of hand hygiene; arrangements for cleaning and ensuring environmental hygiene; and setting triggers for notifying the infection control team and public health department, and for seeking further expert advice. departmental competency can and should be tested by regular drills and simulation exercises. infection control planning for infectious disease emergencies should also consider the number of isolation or single rooms available, and determine when, where and how cases posing a risk of transmission to others could be cohort-nursed once the supply of single rooms is exhausted. the aim of the initial investigation and management of a patient suspected of having a highly infectious disease, or a patient who presents with an unusual, and possibly highly transmissible, illness is to provide life-sustaining medical care to the patient whilst ensuring staff safety. this implies placing the patient in a side room, limiting the number of staff exposed to the patient to the minimum necessary, evaluation of the patient by a senior clinician, using appropriate personal protective equipment during the evaluation (gloves, gown, face and eye protection, surgical mask or n -type respirator for staff, surgical mask for patient), and urgently seeking expert advice about management and diagnostic testing before taking diagnostic samples. expert advice should also be sought on the desirability and mechanism of transfer of the patient to a highly secure infectious disease unit. detailed, disease-specific national guidance on the management and investigation of highly infectious diseases has been produced by many countries, and can usually be found on the website of the relevant national authority [ ] ; planners should download this guidance, incorporate relevant points (e.g. contact details for national or regional laboratories that will undertake specialised laboratory diagnostic testing; smallpox response team) into emergency plans, and designate the task of ensuring that the locally available version is up-to-date to a specific jobholder. laboratorians should be involved in planning, and protocols for the safe collection, transport and external referral of clinical specimens should be available, and should comply with international transport regulations and international and national guidance on biosafety and biocontainment. robust systems for information management and specimen tracking should also be in place pre-event. if the event is linked to deliberate release or criminal action, or there are other forensic considerations, chain of custody (sometimes called 'chain of evidence') documentation of samples, and close liaison with the police or security forces will be required. surge capacity is the ability to expand healthcare provisions to respond to an increased number of patients that exceeds usual capacity, including the provision of specialised or unusual medical care (e.g. paediatric care; intensive care requiring mechanical ventilation; haemodialysis or haemofiltration). this is sometimes split into 'surge' capacity -the expansion of healthcare provision whilst retaining near-normal care standards, and 'supersurge' capacity -further expansion, requiring the use of alternative care facilities (e.g. schools, church halls) and/ cell. mol. life sci. vol. , multi-author review article or significant changes in standards of care, sometimes referred to as 'planned degradation of care' [ ] . infectious disease emergencies may range from providing care to a single, seriously ill, highly infectious patient, to providing care to a community affected by a bioterror event or pandemic influenza. surge requirements might include not only the ability to increase bed and personnel capacity to cope with an increased number of acute admissions, but also, for example, the ability to manage an increased number of laboratory samples, increased clinical waste for disposal, increased communication and information technology requirements (e.g. networked computers, cell phones, telephone lines connected to automatic routing systems), and increased requirements for supplies of ppe. planners need also to consider, and formalise, with nearby healthcare providers, arrangements for collaborative working and mutual aid, and to consider also how essential functions (e.g. providing ventilatory support; communications) might be maintained if utility supplies (e.g. electricity, fuel) were compromised [ , ] . modelling estimates for pandemic influenza in the united states suggest that, although many patients could be cared for at home, if the pandemic was severe, and numbers affected paralleled those of the pandemic, at the peak, hospitals would need % of available non-intensive care beds; % of available intensive care beds; and % of available ventilators for influenza alone [ , ] . thus, for influenza, the ability to provide intensive care might well be the rate-limiting step in surge capacity, and criteria for admission to intensive care and for continuation of intensive support might need to be different from those that would normally be used. this raises complex ethical and legal questions, which are best thought through, preferably at the national level, in advance of, rather than during, the event. effective communication is essential to management of infectious disease emergencies, and a communication plan is an integral part of any emergency management plan. 'communication' is a broad term that encompasses provision of accurate, timely, complete, easily understood information to the community about what the emergency is, what is being done to control it and what people can do to make themselves safer; provision of information to healthcare professionals about diagnosis, investigation, and pre-or post-exposure interventions; communication with families and others close to those affected by the emergency; communication with the media; and communication within and between all levels of all those involved in managing the emergency. recent international guidelines on risk communication, and on communicating with the media and the public during an infectious disease emergency provide greater detail, and highlight the importance of communicating in ways that build or maintain trust, of planning and testing outbreak communications strategies, and of providing media communications training for all public officials as part of professional development [ , ] . occupational health services should be involved in hospital preparedness planning. this involvement will help to ensure that staff are as well protected before the event as is possible (e.g. by ensuring uptake of seasonal influenza vaccine, pneumococcal vaccine and hepatitis b vaccine by all those who are eligible under existing national policies, and of vaccines specifically relevant to laboratory staff). occupational health services should also participate in development of systems for surveillance of infection in health care workers, which are needed both pre-event, as a means of detecting that an infectious disease emergency is occurring [ ] , and during an event, to monitor the outcome for potentially exposed workers, and of infection specific protocols for post-exposure management [ , ] . any traumatic incident, emergency or disaster, whether natural or man-made, has a psychological impact on those involved -survivors, the bereaved, witnesses, rescuers, responders and health professionals, and their families, relatives, friends and workmates. planning should ensure that, whatever the emergency, staffing levels will be sufficient for time on duty to be limited to no more than h a day, and should make provision for staff rotation from highly taxing to less taxing functions. staff will need somewhere quiet, safe and private 'off-scene' to eat, drink and rest without interruption, and facilities will also need to be such that staff are able to stay in touch with friends and family. staff should also be made aware of other sources of support (e.g. their family doctor, hospital chaplain, and other religious and spiritual advisors), and should be provided with details of how to contact confidential listening or counselling services [ , ] . it is impossible to predict when, where or how another deliberate release of a biological agent will occur, and equally impossible to predict which emergent infection will next threaten global public health, or whether the influenza pandemic will occur this year, next or in some years time. it is, however, possible to predict that infectious disease emergencies will continue to occur g. ippolito, v. puro and j. heptonstall infections emergencies and hospital preparedness with regularity, and it is possible, with appropriate planning, to be prepared to meet them in a way that ensures that they cause as little social disruption as possible. the greatest danger is complacency -the belief that 'it cannot happen', or that ' it could happen, but it will happen somewhere else'. it is not clear to what extent the efforts made at the international and national level and the long lists of lessons learned have translated into improved and sustainable hospital preparedness at the local level; we hope this article will provoke you to prepare, plan and practice, now. microbial threats to health: emergence, detection, and response the challenge of emerging and re-emerging infectious diseases smallpox as a biological weapon; medical and public health management anthrax as a biological weapon: medical and public health management update: investigation of anthrax associated with intentional exposure and interim public health guidelines biological and chemical terrorism: strategic plan for preparedness and response. recommendations of the cdc strategic planning workgroup world health organisation deliberate spreading of typhoid in japan a large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars an outbreak of shigella dysenteriae type among laboratory workers due to intentional food contamination pulmonary infiltrates, asthma and eosinophilia due to ascaris suum infestation in man bioterrorism-related inhalational anthrax: the first cases reported in the united states death due to bioterrorism-related anthrax clinical presentation of inhalational anthrax following bioterrorism exposure: report of surviving patients index case of fatal inhalational anthrax due to bioterrorism in the united states fatal inhalational anthrax with unknown source of exposure in a -year old woman cutaneous anthrax associated with microangiopathic hemolytic anemia and coagulopathy in a -month old infant fatal inhalational anthrax in a -year old connecticut woman investigation of bioterrorism-related anthrax update: investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy anthrax bioterrorism: lessons learned and future directions laboratory biosafety manual cfr part . possession, use, and transfer of select agents and toxins laboratory security and emergency response guidance for laboratories working with select agents summary of probable sars cases with onset of illness from public health measures to control the spread of severe acute respiratory syndrome during the outbreak in toronto learning from sars: renewal of public health in canada. health canada multistate outbreak of monkeypox -illinois the detection of monkeypox in humans in the western hemisphere multi-author review article outbreak of marburg virus hemorrhagic fever-angola eunid archive of national guidelines on management of highly infectious diseases advisory committee on dangerous pathogens ( ) management and control of viral haemorrhagic fevers. the stationery office the natural history of ebola virus in africa. microbes infection marburg and ebola-arming ourselves against the deadly filoviruses management of lassa fever in european countries viral haemorrhagic fevers (article in japanese historical lassa fever reports and -year clinical update viral haemorrhagic fever hazards for travelers in africa hemorrhagic fever viruses as biological weapons: medical and public health management management of patients with suspected viral hemorrhagic fever -united states hospital preparedness and management of patients affected by viral haemorrhagic fever or smallpox at the lazzaro spallanzani institute laboratoryacquired human glanders -maryland accidental infection of laboratory worker with vaccinia laboratory acquired infection with recombinant vaccinia virus containing an immunomodulating construct laboratory-acquired vaccinia infection laboratory-acquired vaccinia infection accidental infection with vaccinia virus report of pneumonic tularemia in three boston university researchers laboratory-acquired severe acute respiratory syndrome severe acute respiratory syndrome (sars) in taiwan, china china's latest sars outbreak has been contained, but biosafety concerns remain -update update: cutaneous anthrax in a laboratory worker -texas laboratoryacquired brucellosis laboratory-acquired west nile virus infections -united states cumulative number of confirmed human cases of avian influenza a/(h n ) reported to who - probable personto-person transmission of avian influenza a (h n ) world health organisation. current who phase of pandemic alert world health organisation. who global influenza preparedness plan. the role of who and recommendations for national measures before and during pandemics influenza pandemic planning and guidance how prepared is europe for pandemic influenza? analysis of national plans limitations of recently published review of national influenza pandemic plans in europe meeting report: hospital preparedness for pandemic influenza the initial hospital response to an epidemic the internet and the global monitoring of emerging diseases: lessons from the first years of promed-mail who operational support team to the global outbreak alert and response network ( ) hot spots in a wired world: who surveillance of g. ippolito, v. puro and j. heptonstall infections emergencies and hospital preparedness emerging and re-emerging infectious diseases cbrn incidents: clinical management and health protection. health protection agency development and experience with an algorithm to evaluate suspected smallpox cases in the united states algorithm for the management of returning travellers from countries affected by sars, presenting with febrile respiratory illness clinical pathway: viral haemorrhagic fever guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee respiratory hygiene/cough etiquette in healthcare settings avian influenza, including influenza a (h n ), in humans: who interim infection control guideline for health care facilities blackout : preparedness and lessons learned from the perspectives of four hospitals surge capacity for response to bioterrorism in hospital clinical microbiology laboratories centers for disease control and prevention. flusurge . software. available at outbreak communication guidelines. who/cds/ effective media communication during public health emergencies. who handbook and field guide. who, geneva who guidelines for the global surveillance of severe acute respiratory syndrome (sars) management guidelines for laboratory exposures to agents of bioterrorism emergency preparedness and response. disaster mental health resources acknowledgement. this work was performed within european commission project eunid, and within ricerca finalizzata and ricerca corrente irccs projects, italian ministry of health. key: cord- -x wpp authors: long, rachel b.; krumlauf, kristi; young, anna m. title: characterizing trends in human-wildlife conflicts in the american midwest using wildlife rehabilitation records date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: x wpp human-wildlife conflict is difficult to measure, but the analysis of records from wildlife rehabilitation facilities has shown potential as a technique for characterizing human impacts on wildlife. to examine the value of wildlife rehabilitation records for characterizing local human-wildlife conflicts and prevalence of select wildlife diseases, we reviewed , records representing over species admitted to a wildlife rehabilitation facility over a -year period ( – ). we identified the most frequently recorded causes of admission for commonly admitted species, and evaluated how causes of admission may vary across taxa throughout the year. our analyses support the value of wildlife rehabilitation facility data for characterizing some pressures from human-wildlife conflict and select disease trends for certain taxa, as well as utility for informing topics to emphasize in local conservation education efforts. for example, orphaned neonatal wildlife accounted for the largest proportion of admissions to this facility, and highlights a opportunity for conservation education regarding when wildlife is truly orphaned and requires professional intervention. additionally, domestic dog attack cases accounted for a proportion of admissions comparable to that of domestic cat attacks, demonstrating a need for the conversation surrounding the impact of domestic pets on local wildlife to expand to include dogs in addition to cats. interactions between humans and wildlife have become more frequent as a consequence of encroachment, resulting in an increase in the likelihood of human-wildlife conflict events and zoonotic disease transmission [ , ] . human-wildlife conflicts-negative interactions between humans and wildlife that pose a real or perceived threat to either party [ ] -are substantial causes of wildlife mortality and population decline, and manifest differently across taxa and anthropogenic contexts [ , ] . examples of conflicts demonstrated to significantly impact wildlife populations include vehicle strikes [ , ] , mid-flight collisions with windows [ ] , domestic cat predation [ ] , and anthropogenic sources of ecological contamination [ , ] . quantifying causes of morbidity and mortality in wildlife populations is often difficult, as there are significant logistical challenges associated with in situ studies of wildlife health [ , ] . it can also be challenging to navigate the behavioral biology of wild populations in a minimally invasive manner; high stress events and capture myopathy can be significant welfare risks to surveys of live individuals [ ] . continued innovation of methods that can be used to identify threats to wildlife health with fewer logistical and welfare challenges is necessary [ ] . the analysis of records from admissions to wildlife rehabilitation facilities has potential to be a useful technique for characterizing human-wildlife conflicts and disease trends that may be impacting local wildlife, as this method would not be as subject to the challenges of assessing wildlife health in the field as described by ryser-degiorgis [ ] and spalding and forrester [ ] . additionally, there is an impressive number of wildlife rehabilitation facilities located around the world-for example, there are currently over wildlife rehabilitation organizations located in the state of ohio [ ] , over wildlife rehabilitation carers in australia as of [ ] , and over wildlife rehabilitation facilities in the united kingdom [ ] . these facilities each frequently admit hundreds to thousands of animals annually-uniquely positioning them to assess pressures faced by their respective local species [ ] . the studies to date from wildlife rehabilitation institutions have focused primarily on identifying common causes of morbidity and mortality for specific taxa, including raptors [ ] [ ] [ ] , reptiles [ ] , and black cockatoos [ ] , as well as comparing rehabilitation outcomes [ , ] , causes for admission across taxa, and causes for admission across ecological niches [ ] . a broader analysis of wildlife rehabilitation records could be ideal for identifying human-wildlife conflicts of particular significance for conservation, such as the recent study that used these records to demonstrate the impact of domestic cat predation on a variety of native species [ ] . analyses that span longer time periods could also provide insight regarding how causes of morbidity and mortality may fluctuate seasonally-valuable information for epidemiological studies of disease and human-wildlife conflicts [ , ] , as well as conservation education efforts. one such study on australian wildlife found that admissions peaked in the spring and summer during breeding seasons [ ] . the purpose of this study was to examine the value of wildlife rehabilitation facility admissions records for informing understanding of local human-wildlife conflicts and wildlife disease trends by ) identifying the top reasons for admission to this facility, ) examining how occurrences as measured by admitted cases may fluctuate monthly and across taxa, and ) analyzing trends in commonly admitted disease cases. this information could have direct implications for wildlife rehabilitators and conservation educators, as well as offer information relevant to human and domestic animal health [ , , ] . this study utilized records from admissions to a wildlife rehabilitation facility, but did not involve direct interaction with or experimental manipulation of live animals. as such, iacuc approval was not required. however, the permission of the wildlife rehabilitation facility to utilize these records for the purposes of this study was sought and granted. we utilized records from admissions to a wildlife rehabilitation facility veterinary hospital in central ohio, united states of america. this facility was located in a suburban context, with urban and rural areas in near proximity. animals were regularly admitted from all three contexts, though most frequently from urban and suburban areas. most admissions (> %) originated from the county in which this facility was located and the six immediately surrounding counties (franklin, licking, delaware, union, madison, fairfield, pickaway). animals were also admitted from more distant regions of ohio; at least one animal was admitted to this facility from of the counties in ohio during the span of this study. we reviewed records spanning a -year period ( - ), which included , individuals from over species, including rabies vector species. each individual admitted to this facility had been assigned a unique record entry, regardless of life stage or being admitted with conspecifics at the same intake event. the records included both animals that were alive on presentation to the hospital as well as animals that were dead on arrival. admissions records had been recorded in a microsoft access database from - , and in the wildlife incident log/ database and online network (http://www.wild-one.org) database from - . the two databases differed in how information was recorded, so consolidation of all records in the time span of this study necessitated standardization to facilitate analysis across the -year period. we assigned each case to one of eight taxonomic groups: mammals, reptiles, amphibians, waterfowl, water/shorebirds, raptors, gallinaceous birds, and songbirds+. we assigned all mammalian, reptilian, and amphibian species to their respective taxonomic categories. we assigned orders anseriformes, podicipediformes, and gaviiformes to the waterfowl taxonomic group, orders pelecaniformes, gruiformes, ciconiiformes (excluding vultures), and charadriiformes to the taxonomic group of water/shorebirds, the orders falconiformes, accipitriformes, strigiformes, and vulturine ciconiiformes to raptors, and the order galliformes to gallinaceous birds. we categorized all passerines and other small bodied terrestrial birds, namely the orders piciformes, caprimulgiformes, apodiformes, and columbiformes, into the songbirds+ taxonomic group. we classified records where species was not identified as unknown. information in the records regarding the circumstances that led to an animal being admitted to this wildlife rehabilitation facility was documented according to what was stated by the individuals admitting the animal to the facility and/or derived from physical examinations by a veterinarian upon admission. causes for admission were numerous and there was variation in how the causes were documented in the records, so to facilitate analysis we created a categorization system that involved assigning each case a broad cause of admission category and a specific subcategory. the broad cause of admission categories we created for the purposes of this study were modelled after the "circumstance" categories utilized by the wild-one database system. we divided some of these categories into multiple categories (ex: we divided wild--one's "collision" category into the broad categories of "collision with non-moving object" and "collision with moving object") to enable us to analyse groups of similar specific causes for admission with more precision. our list of specific cause of admission categories was formulated based on the more detailed information contained in records related to the circumstances that led to an animal being admitted. these lists of broad cause of admission categories and specific cause of admission subcategories were then applied to all records across both the microsoft access and wild-one databases resulting in broad categories and subcategories (s table) . if an animal was admitted with multiple injuries, we assigned its cause of admission based on the primary reason the animal was brought to the wildlife hospital. if an animal was admitted with both a disease and an injury-for example, a raccoon (procyon lotor) that had been struck by a vehicle but also exhibited signs of canine distemper virus-we categorized the animal with the cause of admission categories corresponding to both the source of its injury and its disease to ensure that disease occurrences were represented appropriately. this dual categorization was only necessary for cases. while most records explicitly stated the reasons that individuals were admitted to the hospital and cause for admission categories were assigned accordingly, there were records where the circumstances that resulted in an animal's injury were either unknown by the individual who admitted the animal, or were not recorded. in unknown cases, it was possible in many instances to reasonably assign a cause for admission based on corroborating information and/ or findings from physical examinations-an approach also utilized by other facilities [ ] . a frequently encountered example of this involved animals that had been found by the side of a road, but had not been observed or recorded being hit by a vehicle. if a record in this instance contained at least two other items of information (fractures, abrasions, contextual information, etc.) that would implicate a car strike, we assigned the individual the broad category of "collision with moving object" and specific subcategory of "hit by vehicle." if a record stated an individual was "found by road" but there was not sufficient information to implicate a car strike, we assigned the broad category of either "unknown" if no other relevant information was included, or "injury unspecified cause" and the appropriate subcategory if at least one injury was noted. for the purposes of this study, causes of admission considered to be human-wildlife conflicts involved animals being admitted due to an adverse direct interaction with a human (ex: vehicle strikes, lawn mowing equipment strikes, or intentionally inflicted trauma) or an adverse indirect interaction with a human or a human-associated phenomenon (ex: window strikes or domestic pet attacks). there are many reasons that wildlife may become orphaned, ranging from misinformed human interferences, the caregiving parent(s) becoming deceased due to a human-wildlife conflict, predation, etc.; the reason neonates become orphaned is rarely known unless the event was directly observed. we have chosen to include animals with the "orphaned" cause of admission designation to be part of the conversation regarding local human-wildlife conflict as it is postulated by wildlife rehabilitators that a noteworthy portion of neonate and juvenile animals admitted as orphans were likely not truly orphaned. while the prevalence of some diseases can be exacerbated by human influence, such as how close contact with infected individuals at bird feeders or contact with contaminated bird feeders contributes to the spread of mycoplasmal conjunctivis in finches [ ] , diseases are considered separately from human-wildlife conflicts. as this wildlife rehabilitation facility is a non-profit organization that relies largely on donations/grants to operate, and as such has limited resources to dedicate to diagnostic testing, some disease cases were identified based on a syndromic approach, where a presumed diagnosis is made based on clinical signs, relevant history, and/or response to treatment. mycoplasmal conjunctivitis and avian botulism are two examples of diseases in this study where cases were typically identified using this approach, as they have very characteristic clinical signs. suspected west nile virus cases were at times presumed based on a syndromic approach, but were typically also supported via serum antibody blood tests as resources allowed. however, it was not indicated in this data set which cases were confirmed and which were not. while this approach is certainly not without limitation and possibility for error, it is common in wildlife rehabilitation facilities across the united states due to similar resource constraints, and does have some merit; syndromic surveillance for wnv was recently described as still potentially conferring value to wnv surveillance efforts [ ] . suspected canine distemper virus cases in mesopredator species such as raccoons were typically confirmed via serum antibody tests. rabies testing was pursued in mentally inappropriate mesopredators when there was a known situation where another animal or a human may have been exposed. to examine how human-wildlife conflict as measured by admissions to this facility may vary seasonally and across taxonomic groups, we assessed changes in mean cases admitted per month via chi-squared tests. we also described the total number of each taxonomic group admitted, the top species admitted, the top five broad causes for admission, the top five specific causes for admission, and the top three specific causes for admission for each taxonomic group. to characterize the most common causes for admission to this wildlife rehabilitation facility, we first identified the top four specific causes for admission. for each of the top four specific causes, we assessed the number of cases admitted, the percentage that those cases constituted of all cases admitted to the facility, the taxonomic groups affected, and how mean cases per month fluctuated with chi-squared tests. for one of the top four specific causes for admission, vehicle strikes, we utilized average daily traffic volume data [ ] for the county where this facility was located to evaluate the contribution of monthly and annual changes in traffic volume to trends in vehicle strike cases with linear regression tests. to examine the potential of wildlife rehabilitation records to contribute to disease monitoring, we assessed the number of cases admitted for five diseases of particular importance to the wildlife rehabilitation facility-canine distemper virus, west nile virus, avian botulism, mycoplasmal conjunctivitis, and rabies. we identified the species that were affected by each of these five diseases, as well as the percentage of all cases admitted that these diseases constituted. for the most represented of the five diseases, canine distemper virus, we also analyzed fluctuations in mean cases per month and in total cases per year via chi-squared tests as it was the only disease with a degree of representation in the records that facilitated meaningful analysis (n> cases across years). a total of , cases were admitted to this wildlife rehabilitation facility from - , with a mean of , . ± . cases admitted annually. of these records, % contained sufficient information to be included in some level of analysis and % contained sufficient information to be assigned a broad and specific cause of admission category. total admissions varied across all years (w ¼ : , p < . ), ranging from , to , . the mean cases admitted each month fluctuated throughout the year (w ¼ : , p < . ). more cases were admitted from may through august than october through march, with may being the peak month for total cases admitted ( , . ± . ). the month with the fewest mean cases admitted was december ( . ± . ); (fig ) . of the eight defined taxonomic categories, mammals were the most frequently admitted, representing over half of all cases (table ). of the species most frequently admitted, seven were mammals, with the eastern cottontail rabbit (sylvilagus floridanus) accounting for nearly one-fourth of all admitted cases. songbirds+ also accounted for a notable percentage of cases admitted, followed by waterfowl, raptors, and reptiles. water/shorebirds, amphibians, and gallinaceous birds accounted for only a small portion of all cases admitted, . % collectively. the top five most frequently assigned broad causes for admission categories account for . % of all cases admitted, and the top five most frequently assigned specific causes for admission subcategories account for . % of all admitted cases ( table ). the most assigned broad category and specific subcategory was "orphaned", encompassing just over half of all cases admitted. domestic animal interactions were the second most frequent cause of admission at nearly one in five of all cases admitted; within this broad category, both cat and dog attacks each accounted for close to a tenth of all cases admitted. collisions with moving objects constituted nearly a tenth of all cases admitted, with vehicle strikes accounting for most of these incidents. the most frequently observed specific causes for admission varied across taxonomic groups (table ) . being orphaned was the most frequent reason for admission for mammals, song-birds+, waterfowl, water/shorebirds, and gallinaceous birds, and the second most common reason for raptors and reptiles. vehicle strikes were the top cause of admission for raptors, reptiles, and amphibians. domestic animal attacks were either the second or third top cause for admission of mammals, songbirds+, reptiles, and gallinaceous birds. collisions with buildings/ windows were the third most recorded cause of admission for songbirds+ and raptors. amphibians were most frequently admitted due to lawn mower strikes. we further examined the top four identified specific causes of admission to the wildlife rehabilitation facility: orphaned, dog attacks, cat attacks, and vehicle strikes. orphaned a total of , neonate and juvenile individuals were admitted as having been orphaned, constituting . % of all cases admitted during the study period, a large proportion of admissions during the spring and summer months (figs and ) , and one of the top three specific causes for admission for seven of the eight taxonomic groups ( table ). the mean orphan cases varied significantly across months (w ¼ : , p < . ), with the peak month being may and the month with the fewest cases being january (fig ) . the total orphan cases also varied annually (w ¼ : , p < . ), with the most admitted in and the fewest admitted in . a total of , individuals were admitted due to being attacked by a cat, and , individuals were admitted due to a dog attack. cat attacks and dog attacks account for comparable percentages of all cases admitted to the wildlife rehabilitation facility ( . % and . % respectively). the three taxonomic groups most impacted by cat attacks were mammals ( , cases), song-birds+ ( , cases), and waterfowl ( cases), collectively representing species. mammals ( , cases), songbirds+ ( cases), and reptiles ( cases) were most impacted by dog attacks. cat attacks impacted , more songbirds+ individuals than dog attacks, and dog attacks impacted more mammals than cat attacks. the mean cases of cat attacks (w ¼ : , p < . ) and dog attacks (w ¼ : , p < . ) varied across months. the peak month for mammal cases admitted due to either cat or dog attacks was may, and the peak month for songbirds+ cases admitted due to either cat or dog attacks was june. the months with the fewest dog attack or cat attack cases admitted were december and january (fig ) . the total cases of dog attacks (w ¼ : , p < . ) and cat attacks (w ¼ : , p < . ) also differed annually, with peak admissions for dog attacks occurring in , peak admissions for cat attacks occurring in , and the fewest cases of either cat or dog attacks being admitted in . vehicle strikes represented % of all cases admitted to the wildlife hospital. diverse taxa were admitted due to vehicle strike cases, with canada geese (branta canadensis), virginia opossums (didelphis virginiana), eastern cottontail rabbits, mallards (anas platyrhynchos), and eastern gray squirrels (sciurus carolinensis) being the five most admitted species. the mean vehicle strike case admissions varied significantly across months (w ¼ : , p < . ), and the total cases differed annually (w ¼ : , p < . ). the peak month for cases admitted due to vehicle strikes occurred in june, and the month with the fewest vehicle strike cases was january (fig ) . the peak month for mean daily traffic volume in franklin county, ohio, usa was june, and the month with the lowest mean daily traffic volume was january (fig ) . a strong linear relationship was found between mean daily traffic volume per month and mean monthly vehicle strike cases admitted (f , = . , p = . , r = . ), but not between mean annual traffic volume and total annual vehicle strike cases admitted (f , = . , p = . , r = . ). raccoons (procyon lotor) and ( . %) cases observed in striped skunks (mephitis mephitis). the mean cases of canine distemper per month exhibited some fluctuation (fig ) , but not to a statistically significant degree (w ¼ : , df = , p = . ). however, across all years there was a fluctuation in total cases admitted annually for both raccoons (w ¼ : , df = , p < . ) and skunks (w ¼ , df = , p = . ) with peak years in for raccoons and for skunks. mycoplasmal conjunctivitis (mycoplasma spp.) accounted for % of all disease cases admitted, and largely impacted house finches and goldfinches ( % collectively). west nile virus (family flaviviridae, genus flavivirus) was recorded for % of all disease cases, avian botulism (clostridium spp.) accounted for %, and other miscellaneous disease states accounted for %. a total of three individuals, all big brown bats (eptesicus fuscustested), tested positive for rabies (family rhabdoviridae, genus lyssavirus), accounting for . % of disease cases admitted, and . % of all cases admitted to the wildlife rehabilitation facility during the examined time period. our study demonstrates the value of wildlife rehabilitation records for characterizing local human-wildlife conflicts and potentially select disease trends, as well as how occurrences may fluctuate seasonally and impact taxa differently. while our analysis is most directly applicable to the region where this wildlife rehabilitation facility is located, we believe this technique can be applied in other regions as well. a similar study in australia found that car strikes, dog and cat attacks, and orphans were also top reasons for admissions, although they additionally found entanglement and disease to be highly prevalent [ ] . using the records, we were able to identify what are likely some of the predominant types of human-wildlife conflicts in the central ohio region, including domestic animal attacks, vehicle strikes, lawn mower strikes, and collisions with buildings, and how they impact taxa differently. it is likely that wildlife rehabilitation facilities have a greater monitoring capacity for some taxa more than others; mammals, songbirds+, and waterfowl constituted the majority of admissions to this facility. it should be noted that distinctive species or subgroups within the taxonomic categories utilized in this study may experience human-wildlife conflict differently; here we focused on broad trends, future studies are needed to tease apart which threats may apply more to specific species or taxonomic subgroupings. additionally, this facility primarily depends on the public to bring in animals they find, which results in the predominantly admitted species being those that are more frequently seen by people, and those that non-professional individuals are willing to attempt to handle. however, meaningful trends were still able to be discerned for some of the taxa that were admitted, such as mammals being more likely to be admitted due to domestic dog attacks than cat attacks. these findings also suggest utility for future studies that examine how human-wildlife conflicts may vary or be experienced differently by taxonomic groups more specific than those examined in this study. it was also found that other forms of human-wildlife conflict, such as vehicle strikes, impacted a larger assortment of taxonomic groups. vehicle strikes were one of the top three specific causes of admission for five of the eight taxonomic groups utilized in this study (table ) . this suggests that ongoing study and education is needed regarding vehicle strike deterrents such as wildlife-friendly driving practices. orphaned. orphaned neonates and juveniles were a primary cause of admission for seven of the eight taxonomic groups admitted, accounting for the largest source of admissions to this facility ( table ) and highlighting the ongoing need for public education regarding legitimately orphaned wildlife. orphaned wildlife admissions have constituted a predominant cause for admission in other wildlife rehabilitation facilities as well [ , ] . this facility has protocols to help screen for neonatal wildlife that may not actually be orphaned, but they mostly entail conversational questioning, and are dependent on the honesty and existing knowledge of the members of the public presenting the animals to the hospital. thus, increasing the rigor and/or consistency of these screenings may be useful to some degree, but increasing public understanding of topics such as the biology of local neonatal wildlife, how to discern whether found neonates are legitimately orphaned, and local resources that can be contacted for assistance would likely be the more ultimate solution. domestic animal attacks. domestic animal attacks demonstrated significant month-tomonth fluctuations, likely corresponding with seasonal changes in the biology of local wildlife related to habitat use [ , ] , breeding seasons [ ] , migration [ , ] , and range size [ , ] . domestic animal attack cases may also exhibit this seasonality as during the months of april-august in the northern hemisphere, domestic animals maintained as household pets may be more likely to spend more time outside and thus have a greater likelihood of encountering wildlife. the seasonal influx and thus increased density of migratory songbird species may also be a contributing factor. a similar trend in seasonal rates of domestic cat attacks on wildlife was also reported for another u.s. wildlife rehabilitation facility's records [ ] . this highlights a time of year where it is particularly important to emphasize supervising pets outdoors to decrease the frequency of domestic animal attacks on wildlife. a similar study that was broader in region, including all north america wild-one data but focusing on cat-wildlife conflicts over a shorter period of time, also determined domestic pet attacks to be a top reason for admission at %, comparable to our finding of % for this ohio facility. unlike our study, they found that birds presented to the facility due to a cat attack more than other taxa, but similarly the species most commonly admitted for cat attacks were the eastern cottontail rabbit, american robin, and eastern gray squirrel [ ] . this suggests that our findings are representative of national trends for at least domestic felid attacks. our study also suggests that the current conversation regarding the impact of domestic animal attacks on wildlife needs to expand. we found evidence for the previously demonstrated magnitude with which domestic cat predation impacts songbird and mammalian taxa [ , , ] , but our findings also illuminate that in terms of total cases admitted, dog attacks exert pressure comparable to cats. it should be noted that cats are primarily predating taxa that are typically considered of higher conservation concern, namely songbirds. although none of the species in this study were threatened or endangered, many admitted songbird species are protected under the migratory bird treaty act. however, dogs are impacting small mammals to an extent that is of notable concern from an animal welfare standpoint, and they could pose a conservation threat in regions where endangered small mammals are more prevalent than in central ohio. while it has been previously suggested that dog attacks may have a noteworthy impact on wildlife populations [ , ] , we provide evidence that dog attacks are another source of anthropogenic pressure on wildlife that should be addressed in wildlife education efforts and accounted for in conservation decision-making for songbird and mammalian taxa. vehicle strikes. our findings suggest that changes in traffic volume throughout the year are not the primary driver of the fluctuations observed in vehicle strike cases. while a relationship was found between traffic volume and vehicle strikes across months within a mean year, this was not the case across years. it is likely that seasonal changes in wildlife dispersal, migration, and behavioral biology contribute more significantly to vehicle strikes than the fluctuations in traffic volume recorded in this area. these findings support the relevance of vehicle strikes as a significant source of morbidity and/or mortality in wildlife [ , ] , as well as the need for additional study regarding effective wildlife/vehicle strike prevention measures such as wildlife crossing structures or warning signage for motorists [ ] . additionally, these findings lend support to the value of incorporating mitigation techniques such as wildlife crossing structures into roadway preconstruction planning [ ] , as well as heightened education efforts during times of the year where changes in wildlife behavioral biology may contribute to increased likelihood of vehicle strikes. disease. while the mean canine distemper virus cases admitted per month were not found to fluctuate to a statistically significant degree, there was fluctuation in total raccoon and skunk canine distemper cases admitted annually from - . these species are known reservoirs of canine distemper virus in this region [ ] [ ] [ ] . an increase in admissions of both species due to canine distemper may suggest an increase in overall prevalence of canine distemper cases during those years. this facility also admitted a noteworthy number of cases of mycoplasma conjunctivitis, an ocular infectious disease primarily affecting finch species that was first observed in ohio in [ , ] , throughout the examined time period, these findings, in conjunction with other recent work that has observed annual fluctuations in west nile virus cases admitted to a minnesota wildlife rehabilitation facility [ ] and characterized european hedgehogs as a natural reservoir for some coronaviruses via surveillance testing of admissions to a facility in northern italy [ ] , may implicate value for wildlife rehabilitation admissions for disease monitoring. however, additional research is needed which compares wildlife records and monitored wildlife population disease prevalence before conclusions can be drawn. it should be noted that resources available for diagnostic testing and relatively low rates of diseased individuals being admitted may limit the ability of wildlife rehabilitators to discern small fluctuations in disease occurrences locally [ ] , and diseases that do not show obvious clinical signs will be underrepresented in this dataset. however, in the event of significant spikes in disease prevalence in local populations, wildlife rehabilitation facilities would be among the first to detect it via abnormal increases in cases admitted, potentially such as those observed in canine distemper cases admitted in and . this would corroborate speculation in other literature regarding the potential value of wildlife rehabilitation records for wildlife disease monitoring [ , , ] . while rabies is one of the diseases of greatest public health concern, it was only confirmed in three cases out of over , admitted across years. this could be due to the public being less likely to approach animals exhibiting signs that can be associated with rabies, but is also likely a reflection of the low prevalence observed in this region [ ]. while wildlife management challenges are multifaceted, wildlife rehabilitation facilities could feasibly serve as one piece of the puzzle by contributing information regarding human-wildlife conflict and some disease trends in urban and suburban areas broadly, or more specifically by taxon. a standardized system of record keeping would optimize the potential effectiveness of rehabilitators as a resource in this way. progress has been made with the creation of standardized national databases such as wild-one (http://www.wild-one.org/), wildlife rehabilitation md (http://wrmd.org/), and state-specific online databases, but there is a need for cohesiveness between organizations and public health agencies regarding data collection [ ] . some of the most significant challenges for wildlife health surveillance are related to the lack of confirmed cases, underreporting of confirmed cases, and lack of infrastructure to facilitate assembling records for surveillance [ ] . an increase in federal financial support of wildlife rehabilitation facilities could enable increased staff power, resources for disease-related diagnostics, and a cohesive nationwide database. this infrastructure would facilitate more uniform, cohesive monitoring of human-wildlife conflicts and disease occurrences nationally and internationally, and potentially enable wildlife rehabilitation facilities to contribute to monitoring of these trends on both local and global scales. additionally, our findings highlighted several needs for public education outreach efforts-namely, the impacts of both domestic cat and dog predation on wildlife, how to recognize when neonatal wildlife is truly orphaned and resources to contact for professional intervention, time periods throughout the year when different human-wildlife conflicts are most likely to occur, and affected wildlife taxa. the identification of such trends and subsequent development of relevant public outreach campaigns has been shown to contribute to wildlife population recovery and maintenance [ ] , and our findings suggest that wildlife rehabilitation facilities are uniquely positioned to contribute to these efforts. supporting information s table. all broad and specific causes for admission. a complete list of the broad specific causes for admission and the corresponding specific causes for admission that were used to categorize the admissions records from a wildlife rehabilitation facility in the midwest, usa. (docx) morbidity and mortality of urban wildlife in the midwestern united states. proceedings of the th international wildlife symposium experimental studies of microbial populations and incidence of zoonotic pathogens in the faeces of red deer (cervus elaphus) the emergence of human-wildlife conflict management: turning challenges into opportunities causes of mortality in north american populations of large and medium-sized mammals who's in conflict with whom? human dimensions of the conflicts involving wildlife review of ecological effects of roads on terrestrial and aquatic communities spatial patterns and factors influencing small vertebrate fauna road-kill aggregations architectural and landscape risk factors associated with bird-glass collisions in an urban environment the impact of free-ranging domestic cats on wildlife of the united states red-backed salamander (plethodon cinereus) as a bioindicator of mercury in terrestrial forests of the northeastern united states spatiotemporal patterns and risk factors for lead exposure in endangered california condors during years of reintroduction disease monitoring of free-ranging and released wildlife wildlife health investigations: needs, challenges and recommendations evaluating ungulate mortality associated with helicopter net-gun captures in the northern great plains ohio division of wildlife. - permitted wildlife rehabilitators the role of wildlife rescue groups in the care and rehabilitation of australian fauna british wildlife rehabilitation council. find a rehabilitator [internet]. rehabilitators by county a retrospective study of morbidity and mortality of raptors in florida: - causes of morbidity in wild raptor populations admitted at a wildlife rehabilitation centre in spain from - : a long term retrospective study morbidity, outcomes and costbenefit analysis of wildlife rehabilitation in catalonia (spain) morbidity and mortality of reptiles admitted to the wildlife center of virginia presentation and prognostic indicators for free-living black cockatoos (calyptorhynchus spp.) admitted to an australian zoo veterinary hospital over years final disposition and quality auditing of the rehabilitation process in wild raptors admitted to a wildlife rehabilitation centre in catalonia, spain, during a twelve year period annual intake trends of a large urban animal rehabilitation centre in south africa: a case study free-roaming cat interactions with wildlife admitted to a wildlife hospital marine ecology-emerging marine diseases-climate links and anthropogenic factors efficacy of wildlife rehabilitation centers in surveillance and monitoring of pathogen activity: a case study with west nile virus the impact of human activities on australian wildlife wildlife, exotic pets, and emerging zoonoses a review of rspca research into wildlife rehabilitation feeder density enhances house finch disease transmission in experimental epidemics syndromic surveillance for west nile virus using raptors in rehabilitation traffic monitoring: annual comparisons by functional classification veterinary treatment and rehabilitation of indigenous wildlife veterinary treatment and rehabilitation of indigenous wildlife eastern box turtle, terrapene carolina, neonate overwintering ecology on long island ecology of spring-migrating anatidae: a review spatial and temporal distribution of atlantic population canada geese home range and survival of cottontail rabbits in southwestern wisconsin movements and home range dynamics of cottontail rabbits in mississippi the role of domestic cats in the admission of injured wildlife at rehabilitation and rescue centers urban bird declines and the fear of cats is wildlife going to the dogs? impacts of feral and free-roaming dogs on wildlife populations a review of the interactions between free-roaming domestic dogs and wildlife mitigation measures to reduce highway mortality of turtles and other herpetofauna at a north florida lake vertebrate road mortality predominately impacts amphibians a review of mitigation measures for reducing wildlife mortality on roadways genetically distant american canine distemper virus lineages have recently caused epizootics with somewhat different characteristics in raccoons living around a large suburban zoo in the usa genetic characteristics of canine distemper viruses circulating in wildlife in the united states j zoo wild med canine distemper in terrestrial carnivores: a review ohio division of wildlife. diseases in wildlife-conjunctivitis (birds) eco-virological preliminary study of potentially emerging pathogens in hedgehogs (erinaceus europaeus) recovered at a wildlife treatment and rehabilitation center in northern italy opportunities and obstacles to collecting wildlife disease data for public health purposes: results of a pilot study on vancouver island, british columbia impediments to wildlife disease surveillance, research, and diagnostics. current topics in microbiology and immunology we would like to thank dusty lombardi and the other staff and volunteers of ohio wildlife center for their enthusiastic partnership in this study and remarkable work on behalf of wildlife. we would also like to specifically acknowledge the late dr. donald burton, founder of ohio wildlife center and revered wildlife veterinarian. thank you also to barbara ray for support in the early stages of this project, the young lab at otterbein university for their feedback on multiple manuscript drafts, and dr. michelle willette for her feedback on a later draft of this manuscript. key: cord- - ucemm authors: sazzad, hossain m.s.; hossain, m. jahangir; gurley, emily s.; ameen, kazi m.h.; parveen, shahana; islam, m. saiful; faruque, labib i.; podder, goutam; banu, sultana s.; lo, michael k.; rollin, pierre e.; rota, paul a.; daszak, peter; rahman, mahmudur; luby, stephen p. title: nipah virus infection outbreak with nosocomial and corpse-to-human transmission, bangladesh date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: ucemm active nipah virus encephalitis surveillance identified an encephalitis cluster and sporadic cases in faridpur, bangladesh, in january . we identified case-patients; of these patients died. for case-patient, the only known exposure was hugging a deceased patient with a probable case, while another case-patient’s exposure involved preparing the same corpse for burial by removing oral secretions and anogenital excreta with a cloth and bare hands. among persons with confirmed sporadic cases, died, including a physician who had physically examined encephalitis patients without gloves or a mask. nipah virus–infected patients were more likely than community-based controls to report drinking raw date palm sap and to have had physical contact with an encephalitis patient ( % vs. %, matched odds ratio undefined). efforts to prevent transmission should focus on reducing caregivers’ exposure to infected patients’ bodily secretions during care and traditional burial practices. in bangladesh, probable or confirmed cases of nipah virus (niv) infection in humans were identified from through ; ( %) were fatal ( ) . drinking raw date palm sap, contaminated by niv from urine or saliva of pteropus spp. fruit bats, has been identified as a vehicle for transmission of niv to humans in bangladesh ( , ) . niv, an rna paramyxovirus ( ), was isolated from human respiratory secretions, saliva, and urine during the outbreaks ( , ) . outbreak investigations in bangladesh and india have repeatedly implicated person-to-person transmission of niv, including health care-associated transmission in the siliguri, india, outbreak in ( ) ( ) ( ) ( ) . however, to our knowledge, no evidence of niv transmission to health care workers had been confirmed in bangladesh ( ) . in the area where niv outbreaks have been repeatedly identified (figure ), the institute for epidemiology, disease control and research (iedcr) of the government of bangladesh, in collaboration with icddr,b (formerly the international centre for diarrhoeal disease research in bangladesh) is conducting hospital-based encephalitis surveillance. to detect outbreaks of niv infection, the surveillance system identifies sporadic niv cases during january-march and clusters of encephalitis patients throughout the year. on january , , two cousins living in the faridpur district in bangladesh ( figure ) were admitted to faridpur medical college hospital (fmch) with fever and altered mental status. a team from iedcr and icddr,b initiated an investigation on january , . the objectives of the investigation were to identify the cause of the outbreak and to detect sporadic cases of niv infection. surveillance physicians maintained a registry of patients who sought treatment with fever or with history of fever with axillary temperature > . °c ( . °f), altered mental status, new onset of seizures, or a new neurologic deficit, either diffuse or localized to the brain ( ) . the physicians collected whole blood, cerebrospinal fluid, a throat swab specimen, and urine samples from patients admitted during january-march in of the active surveillance hospitals (faridpur, rajshahi, and rangpur medical college hospitals) and during january-april at faridpur medical college hospital. these samples were stored in liquid nitrogen in local hospitals and transported biweekly to the iedcr laboratory. we defined possible case-patients as persons with acute onset of fever living in the outbreak area with onset of illness from january through january , . we identified possible case-patients by conducting door-todoor visits of all homes and contacting local physicians in the affected villages. we defined probable case-patients as persons who met the possible case definition and who had new onset of altered mental status or new onset of breathing difficulty. we defined case-patients with laboratoryconfirmed niv infection as those with detectable serum igm against niv. to assess asymptomatic niv infection in the outbreak community, we asked community members who had close physical contact or had shared date palm sap from the same pot with probable or confirmed case-patients within the preceding month, to provide a blood specimen for serologic testing. we obtained a clinical history and information about exposures during the month before illness from each probable and confirmed case-patient. friends, relatives, and neighbors of deceased or unconscious case-patients served as proxy informants for interviews. the investigation team collected acute-phase and subsequent whole blood specimens from possible casepatients. samples were centrifuged in the local government community clinic, and the separated serum was stored and transported to the iedcr laboratory in liquid nitrogen. samples were stored at - °c. we tested serum samples at iedcr with an igm capture enzyme immunoassay that detects niv igm ( ) . we shipped an aliquot of serum, cerebrospinal fluid, throat swab specimens, and urine from patients with probable and confirmed cases of niv infection and from those with igm against niv to the centers for disease control and prevention (cdc), atlanta, georgia, usa, for confirmatory testing. we conducted in-depth interviews with families of casepatients to explore history of illness and exposures of casepatients. we also had informal discussions with neighbors of case-patients to explore possible modes of transmission. we conducted a matched case-control study to identify risk factors for transmission of niv. persons with probable and confirmed cases from the outbreak and with sporadic cases identified from surveillance were considered to be case-patients. the field team selected neighborhood controls for each case-patient, starting from the fourth closest courtyard to the case-patient's residence. the courtyards where other case-patients resided were excluded. in each courtyard, only the household closest to the main entry was selected. the age of every person in the selected household was recorded. then a control (only from each courtyard), whose age was closest to the case-patient's age, was selected. if that control was absent during the first visit, the team tried times to reach the control. if the team was unsuccessful, no control was selected from that household. this process was repeated at the next closest courtyard household until we had selected the required number of controls. all case-patients, except , were either too sick or too confused to respond or had died, so the field team selected multiple appropriate proxy respondents for interview. we used standardized, structured questionnaires in the bengali language. to estimate the association between each exposure and niv infection, we calculated the matched odds ratio (mor). we used conditional logistic regression and considered any association to be statistically significant if the p value was < . . we analyzed data in stata (stata corp., college station, tx, usa). legal guardians of study participants and healthy adult participants provided informed verbal consent for participation in this investigation. the ethical review committee of icddr,b reviewed and approved the protocol for niv surveillance and outbreak investigation. during january-april , surveillance physicians from the hospitals reported meningoencephalitis casepatients. of these, ( %) were reported by surveillance physicians in faridpur, including outbreak case-patients. ninety-seven ( %) serum samples were collected at the faridpur surveillance site. of these, had igm against niv ( %), including from the outbreak area. the outbreak investigation team identified possible niv-infected persons with febrile illness in the outbreak area during january - , . of these, persons gave a blood sample for niv laboratory diagnosis. one person's sample was positive for igm against niv and that person was classified as a confirmed niv-infected casepatient. we collected blood samples positive for igm against niv from probable case-patients. the remaining case-patients died before blood samples were collected. we defined these persons as probable niv-infected casepatients. all but case-patient had altered mental status, and two thirds of case-patients had breathing difficulty (table ) . seven ( %) of persons who met the case definition for probable or confirmed niv infection died. the onset of illness for all of case-patients occurred within days of exposure. four cases constituted an initial peak, and a second-generation outbreak of cases appeared after contact with the initial case-patients ( figure ). sporadic case-patients among patients with sporadic cases of niv infection, of whom died, had a history of drinking raw date palm sap in the month preceding illness onset, and of these were harvesters of date palm sap. one case-patient attended to a family member who was hospitalized at fmch with an illness unrelated to encephalitis for days, days before the onset of illness. while staying in the hospital, he spent the days talking with and caring for other patients and slept alongside them. another case-patient was a physician in training at fmch. from january through february , , he worked in the adult medicine and pediatric wards and clinically managed cases of meningoencephalitis in patients, including with confirmed niv infection and other severely ill febrile patients who had not been enrolled in niv surveillance. he performed physical examination, intravenous canalization, and nasogastric intubation for confirmed case-patient in the adult medicine unit > month before the onset of his illness. he also similarly treated the condition of confirmed niv case-patients in the pediatric unit days before his onset of illness. a handwashing station for physicians did not exist in either the adult medicine or pediatric wards, and his colleagues reported that he did not use gloves or a mask during patient care or wash his hands after patient care. his illness began on february , , with fever and myalgia. subsequently, he experienced coughing, respiratory distress, convulsions, altered mental status, and loss of consciousness. he died on march , . the duration between onset of illness of the physician and his contact with known niv-infected casepatients in the adult medicine ward was days, and the time from his contact with the children with niv infection to illness was - days. two niv genomic sequences, obtained from of meningoencephalitis patients that the physician had been in contact with, did not match the niv genomic sequence of the physician's isolates ( ) . case-patient a, a -year-old man with a probable case of niv infection, lived under a pteropus bat roost. he drank raw date palm sap from his own date palm tree during the last week of december , week before the onset of illness on january , . he had fever, headache, and myalgia, which progressed over days to drowsiness, convulsions, confusion, unconsciousness, and death. on january , three neighbors of case-patient a, from a single family (case-patients b, c, and d), bought and drank raw date palm sap from the village date palm sap harvester. all became ill on january , within hours of each other. none had any history of contact with any person who had symptoms similar to encephalitis. probable case-patients a and b died on january ; confirmed case-patients c and d died on january and ( figure ). among those with second-generation cases, casepatient e (confirmed case) was the wife of case-patient a and was involved in feeding, comforting, and transporting her husband to fmch and in bringing his dead body back home on january . she cleaned saliva from her husband using her bare hands and did not wash her hands afterwards. she also drank raw date palm sap with case-patient a in last week of december and did not get ill. on january , , a fever developed, but she did not have altered mental status. she recovered on the fourth day of illness and was a confirmed case-patient who survived. casepatient f (confirmed case) was a friend of case-patient a, who frequently visited case-patient a during case-patient a's illness. when case-patient a's condition deteriorated, case-patients e and f took him to the hospital. case-patient a had to be supported by case-patient f, and the distance between the faces of case-patients a and f was < foot while case-patient a was coughing, salivating, and having difficulty breathing. while bringing the dead body back from hospital by bus, case-patient a's head rested on the thigh of case-patient f. case-patient g (confirmed case) was the uncle of case-patient a who lived in the same village, and he never visited case-patient a during his illness. he had no contact with any other encephalitis case-patient. he arrived only after case-patient a died and had caressed the head of the corpse before the ritual corpse bathing. case-patient h (probable case), was a neighbor of casepatient a, who did not come into contact with case-patient a during his illness. he carried out the muslim practice of ritual purification by cleaning the body and washing it. he used pieces of cloth to clean the body orifices (anus, urethra, oral and nasal secretions) with an ungloved hand. he then washed the entire corpse with water. he took a bath hour after the ritual cleansing. case-patient g came in contact with the corpse of case-patient a hours after case-patient a's death, and case-patient h came in contact with the corpse of case-patient a hours after case-patient a's death. none of these case-patients (f, g, and h), who cared for case-patient a before or after his death, had drunk raw date palm sap in the preceding month. their illnesses began - days after contact with case-patient a, they had symptoms similar to those of case-patient a, and they died on january or january , , after - days of illness. the field team enrolled case-patients and controls ( table ). the mean age of the case-patients and controls was similar (mean age [±sd] ± years for casepatients vs. ± years for controls, t = - . , p = . ). among case-patients with niv infection and neighborhood controls, niv case-patients were more likely than controls to have consumed raw date palm sap during the month before the case-patient's illness ( % in case-patients vs. % in controls, matched odds ratio [mor] . , p = . ) and were more likely than controls to have been in the same room as case-patients ( % vs. %, mor undefined, p< . ) or to have touched ( % vs. %, mor undefined, p value undefined) case-patients. during , we identified an outbreak and several sporadic cases of encephalitis caused by niv infection. two case-patients from the outbreak and patients with sporadic cases had igm against niv in serum and niv rna in oropharyngeal swab samples by conventional and real-time reverse transcription pcr ( ) . we could not collect biological specimens from probable outbreak case-patients, including the source case-patient; however, the onsets of illness of patients with confirmed and probable cases were within weeks of each other in an area where niv outbreaks have been repeatedly confirmed over the past decade ( , , ( ) ( ) ( ) ( ) , ) . clinical features of fever, evidence of brain involvement, and rapid progression to death were also consistent with previous niv outbreaks ( , , - , ). the first case-patients of the initial phase of the outbreak, and of of the patients with sporadic cases, apparently contracted niv infection by drinking raw date ( , ) . the remaining case-patients from the outbreak probably acquired niv infection from physical contact with the source case-patient. such person-to-person transmission has been observed in prior niv outbreaks in bangladesh ( - ). the generations of transmission are reflected in the peaks in the epidemiologic curve ( figure ). among the second-generation cases, a novel finding was the transmission of niv from the corpse of the source case-patient to persons who had contact with the corpse before burial. this is the most plausible transmission pathway, because they did not have known exposures to living persons with encephalitis and had no history of drinking raw date palm sap. because niv is found in the respiratory secretions of niv case-patients ( ) , casepatient g may have had intimate hand and facial contact with the corpse's respiratory secretions while performing ritual purification. consistent with the culturally prescribed method of ritual bathing of a corpse, case-patient h did not wear a mask or gloves during cleansing of the corpse's orifices. he only used pieces of cloth and his bare hands, which then were almost certainly contaminated with niv. case-patient h also likely touched his face or nose during or after the ritual purification. persons commonly touch their own faces subconsciously, and videotaped observational study found that persons touched their own eyes, nostrils, and lips times per hour during normal activities ( ) . during muslim ritual bathing, water is poured on the body ( ) . thus, the water may have become contaminated with niv and came in contact with case-patient h's clothes and body. similar to other infectious diseases, including severe acute respiratory syndrome and measles, the transmission efficiency of individual niv case-patients varies ( , , ) . case-patient a was an unusually efficient spreader of niv, perhaps because of an unusually high concentration of niv in his oral secretions. the dead bodies of all niv-infected patients who are muslim in bangladesh have undergone the same process of ritual bathing, but to our knowledge, corpse-to-human transmission has not been previously recognized. in other niv outbreaks when niv infection developed in family members, many persons had contact with the source casepatient during illness and when preparing the corpse, so we were unable to separately assess corpse-to-person transmission. this investigation suggests that occasional niv transmission could occur during the muslim ritual purification of a corpse before burial. this study also documents the death of a physician in bangladesh from niv encephalitis after he cared for niv-infected patients with encephalitis in the surveillance hospital. the physician's colleagues and roommates did not report any history of his drinking raw date palm sap during the month preceding onset of illness. although the physician had contact with oral secretions of several meningoencephalitis patients during the outbreak, the genetic sequence of niv found in the physician was distinct from those of hospitalized niv-infected casepatients who were positive for niv by reverse transcription pcr ( ) . indeed, none of the hospitalized patients with confirmed niv infection was likely to have been the source of the physician's infection. the duration between onset of illness of the physician and his contact with confirmed niv case-patients was beyond the range of the -to day incubation period for niv ( , ) . during the assumed time of exposure to niv, he cared for patients in the adult medicine ward; some of them may have had niv infections that were missed by hospital surveillance. however, we did not identify any patient who met the case definition for meningoencephalitis in that ward - days before onset of the physician's illness. the clinical spectrum of human niv infection in bangladesh also includes patients who sought treatment with respiratory disease as the primary manifestation ( ) , and surveillance may have missed any niv-infected persons on the ward with this clinical manifestation. another line of evidence suggests that an unidentified niv-infected patient was hospitalized on that adult medicine ward at that time. one patient with a sporadic case, who visited fmch as a family caregiver, also provided care for several patients in the men's medicine ward during the same days that the physician attended to patients on that ward. this case-patient may have come in close physical contact with the same unidentified nivinfected case-patient as the physician. during , health care workers were infected by niv in siliguri, india. among infected persons, case-patients were hospital staff or family caregivers attending to the patients, and patients were infected from an unidentified, hospitalized index case-patient ( ) . however, during an niv outbreak in bangladesh in , health care providers (using minimal personal protective equipment [ppe] and with substantial exposure to niv case-patients) had no evidence of having acquired niv infection ( ) . during in faridpur, niv was transmitted from person to person in community and hospital settings. the observed differences in risk for person-to-person transmission between outbreaks suggest that niv strains may differ in their proclivity for personto-person transmission. because niv infection is not the major cause of acute meningoencephalitis in bangladesh, and because most persons who contract niv infection have died by the time a diagnosis is made, it is difficult to identify a strategy to prevent person-to-person transmission that could be consistently applied to niv-infected casepatients. strategies to reduce care providers' exposure to respiratory secretions could prevent a broad array of saliva-transmitted infections, including niv encephalitis. prevention approaches to reduce corpse-to-person transmission of niv and other potentially fatal respiratory secretion-transmitted viruses should focus on minimizing exposure to saliva and other bodily fluids from the body of a person who died of severe febrile illness. wearing gloves and a mask during the handling and washing of a dead body before burial would not be feasible in lowincome communities, where the annual total per capita spending on health is us $ per person per year ( ) . research to identify culturally acceptable cost-effective approaches that can be consistently implemented in lowincome settings, for example, washing hands thoroughly with soap and water immediately after corpse contact, could save lives. this report of nosocomial transmission of niv to a health care worker in bangladesh after caring for nivinfected patients highlights the risk of working without ppe. barriers to developing an appropriate prevention strategy for nosocomial transmission of niv in hospitals in bangladesh include the following: inadequate supplies of ppe for hospital staff, absence of isolation wards, absence of handwashing facilities in hospital wards and physicians' rooms, and inadequate training and monitoring for infection control ( ) . because saliva is the most likely vehicle for transmission of niv among care providers, implementation of standard and contact precautions ( ) that have been culturally and economically customized to fit this setting could reduce niv transmission. as a first step, we recommend that handwashing stations be established and consistently supplied with soap and water in every ward of the hospital for health care workers and patient attendants. second, because laboratory diagnosis for niv infection is not available during the initial evaluation of patients with meningoencephalitis syndrome, during niv season all hospitals in niv infection-prone areas should admit patients with meningoencephalitis syndrome into an isolation room or ward and routinely provide gloves and masks for health care workers when they are caring for meningoencephalitis patients. patient attendants could reduce their exposure to patient saliva and respiratory secretions by frequent handwashing and by avoiding sharing food and beds with patients. transmission of human infection with nipah virus foodborne transmission of nipah virus date palm sap linked to nipah virus outbreak in bangladesh molecular biology of hendra and nipah viruses the presence of nipah virus in respiratory secretions and urine of patients during an outbreak of nipah virus encephalitis in malaysia genetic characterization of nipah virus person-to-person transmission of nipah virus in a bangladeshi community nipah virus outbreak with person-to-person transmission in a district of bangladesh cluster of nipah virus infection nipah virus encephalitis reemergence risk of nosocomial transmission of nipah virus in a bangladesh hospital clinical presentation of nipah virus infection in bangladesh laboratory diagnosis of nipah and hendra virus infections characterization of nipah virus from outbreaks in bangladesh risk factors for nipah virus encephalitis in bangladesh date palm sap collection: exploring opportunities to prevent nipah transmission recurrent zoonotic transmission of nipah virus into humans a study quantifying the hand-to-face contact rate and its potential application to predicting respiratory tract infection the terminally ill muslim: death and dying from the muslim perspective superspreading sars events the effect of superspreading on epidemic outbreak size distributions nipah virus-associated encephalitis outbreak, siliguri, india health economics unit, ministry of health and family welfare policy making in bangladesh: a study of the health policy process guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. atlanta: centers for disease control and prevention we thank the family members of study participants for their constant support and the volunteers from the outbreak village for their participation in the investigation. we are grateful as well to md yusuf ali, barun k. biswas, and muzahidul islam for their extensive cooperation in the surveillance and investigation. in addition, we acknowledge dorothy southern's helpful review of this manuscript.the study was funded by cdc, atlanta, ga, usa, cooperative agreement no. u ci - , the us national institutes of health (nih), grant no. - - - (bangladesh-nih/emerging infectious disease), and national science foundation/nih ecology and evolution of infectious diseases grant no. r -tw from the fogarty international center. icddr,b also acknowledges with gratitude the commitment of cdc, nih, and the government of bangladesh to its research efforts.dr sazzad is a physician working with the centre for communicable diseases at icddr,b. his research area of interest is emerging and reemerging disease epidemiology, including prevention and control in low-income countries. key: cord- -t ru authors: hermanowicz, slav w title: simple model for covid- epidemics - back-casting in china and forecasting in the us date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: t ru in our previous work, we analyze, in near-real time, evolution of covid- epidemic in china for the first days of reliable data (up to february , ). in this work, we used the data for the whole days (up to march , ) in china and the us data available till march (day ) for systematic evaluation of the logistic model to predict epidemic growth. we sequentially estimated sets of model parameters (maximum number of cases k, growth rate r, and half-time t ) and the epidemic "end time" t (defined as the time when the number of cases, predicted or actual, reached % of the maximum). the estimates of these parameters were done for sequences of reported cases growing daily (back-casting for china and forecasting for the us). in both countries, the estimates of k grew very much in time during the exponential and nearly exponential phases making longer term forecasting not reliable. for the us, the current estimate of the maximum number of cases k is about , but it is very likely that it will grow in the future. however, running estimates of the "end time" t were in a much smaller interval for china ( - days vs. the actual value of ). for the us, the values estimated from the data sequences going back two weeks from now range from to days. if the behavior of the us epidemic is similar to the previous chinese development, the number of reported cases could reach a maximum around april to . in our previous recent work (hermanowicz ) , we used a simple logistic model to analyze the evolution of data on covid- cases as reported in mainland china by the national health commission of the people's republic of china (nhc ) . this initial analysis was done in three phases in near-real time (up to jan. , feb. , and feb ) . the analysis resulted in a sequence of continually updated forecasts of the epidemic dynamics. although the predicted maximum numbers of cases increased as new data became available, they systematically underestimated final reported numbers (even without accounting for a major change in reporting criteria in china on february resulting in a large surge of new reported cases). however, the successive predicted dynamics of the epidemic were remarkably close to the final real-world outcome. we explore this issue further in this work where we use the full reported dataset for mainland china for systematic back-casting of the epidemic. at the same time, when this work is being conducted, in the us we are experiencing a fast developing covid- epidemic that in some aspects is similar to china but with a delay. we use the experience from our analysis of the situation in china to forecast further evolution of coronavirus cases in the united states. obviously, our predictions are based on the data currently available. these predictions do not account for any possible other secondary sources of infection, changes of diagnostics or reporting, or virus mutation. modelling the epidemics and infection dynamics is very important and numerous results have been recently reported for worldwide covid- outbreak (chen, rui et al. , chen, cheng et al. , hui, azhar et al. , li, guan et al. , liu, hu et al. , liu, hewings et al. , roosa, lee et al. , shen, peng et al. , zhao, lin et al. , zhou, hong et al. , ziff and ziff . many reported models are complicated, incorporate tentative assumptions and need parameters estimates that are not reliable as underscored by fong and coworkers (fong, li et al. ) . in this work, we present the results of fitting a very simple logistic model to the available data and a forecast of new infections. in contrast to other models, the logistic model does not include any external assumptions and is derived completely from available data. the logistic model is one of the simplest used in population dynamics and has been used specifically for epidemics for a long time (bailey , cockburn , mansfield and hensley , jowett, browning et al. , waggoner and aylor , koopman , bangert, molyneux et al. . in our earlier analysis of the developing epidemic in china, we used a discrete version of the model due to its uncomplicated structure and easy calculations. in discrete time, more appropriate to daily reported infection cases, the logistic model becomes where p(t) and p(t+ ) are populations (cases) on consecutive days, r * is the growth rate (basic reproduction number in epidemiology) at the beginning of the logistic growth, and k is the limiting population (maximum cases). however, expressing the growth of population p in continuous time t allows to formulate the model as an ordinary first-order differential equation describing dynamic evolution of the population p (in our case the number of infected individuals) being controlled by the growth rate r and maximum cases k due to limited growth. in continuous time t, the change of p is initially, the growth of p is close to exponential since the term ( − ⁄ ) is almost one. when p becomes larger (commensurate with k) the growth rate slows down with becoming an effective instantaneous growth rate. the solution to eq. ( ) is the well-known sigmoidal function (logistic function) where t is the time when the population reaches one-half of the maximum value p(t ) = ½ k. using a differential version of the model is more convenient since a closed-form solution exists and allows for direct estimation of three model parameters: k, r, and t . the logistic model may be adequate for the analysis of mainland china and the us as a whole since at this time each country can be treated as a unit where a vast majority of cases occurred without any significant "import" or "export" of cases. for china, we used data reported daily by the national health commission of the people's republic of china (nhc ) up to march , (day from the outbreak) when only new cases were reportedless than  - of total case number, effectively ending the epidemic on the national level. there is a considerable controversy as to the exact date of the outbreak with most reports pointing to mid-december (li, guan et al. , wang, horby et al. while one analysis suggest multiple sources of original infection ). initially, the outbreak was not recognized and number of confirmed cases is not fully known (wu, hao et al. ) . in our analysis, we adopted december , as the best estimate of the outbreak following the work of zhang and co-workers . in addition, in the initial stages of the epidemic the reported numbers of cases may severely underestimate the actual numbers due to asymptomatic carriers (zhao, musa et al. ). more accurate numbers can be only estimated after the epidemic (wu and mcgoogan ) . the data from china are show in figure and in the appendix. as seen in this figure, the cumulative number of cases grew in a sigmoidal fashion. on february , (day ) the reporting criteria were changed resulting in a one-day increase of about , cases. we analyzed the subsequent data with this jump and also ignoring it. the logistic model turned out to be quite robust. while the numerical estimates of the maximum number of cases k was significantly affected by the inclusion or exclusion the jump, the dynamics of the model was much less impacted (see further discussion). in this work, we decided to report the results with the jump as parsing data of new and cumulative cases past day is very unreliable. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . in the us, there are numerous agencies tracking the covid- cases at different administrative levels in accordance with multi-tiered structure of the us government. for this reason, we relied on web-based data aggregators (mostly at state level) following daily updates (covid- ). we used january , as the start of the epidemic in the us (day ) since on that day the first non-repatriated covid- case was reported. it should be noted that like in china the number of cases in the initial stages is underreported due to the same factors (asymptomatic carriers, initial administrative confusion, limited testing). despite these problems, the data used in this work are the best currently available. the current evolution of the epidemic in the us is presented in figure and in the appendix. despite smaller population, the number of cases in the us at the time of writing already exceeds that of china. reasons for such higher numbers are outside the scope of this analysis. both, china and the us data are also plotted in the semi-log format (??) to underscore exponential growth of the epidemic in the initial stagesstraight line on these plots. in china, exponential growth occurred from day till day as shown in ?? and ?? by the dashed lines. after day (january ), the number of cases still increased but the rate of growth was . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . becoming lower and the line representing the cumulative cases deviated from the exponential curve. this feature was also clearly recognized in a previous report (zhao, lin et al. ). in the us, exponential growth occurred for a longer period and only very recently (march - ) perhaps starts to deviate from the exponential curve. for each dataset of reported cumulative case numbers (china and the us), we estimated three parameters of the logistic model (maximum case number k, growth rate r, half-time t ) fitting model predictions to the data. we use a custom nonlinear curve fitting procedure employing the levenberg-marquardt method for minimization of the residual sum of squares. similarly to our previous work (hermanowicz ), we estimated model parameters sequentially from datasets growing day after day. for china, the first dataset contained days from day through . the next estimate used days from day through . this process was repeated until day when the entire china dataset was used. for the us, the first dataset contained also days from day through . the last day of the available sequence for the us was day (march , ). all resulting estimates are show in the appendix. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . in case of china, where the epidemic growth has essentially ended, the sequential estimation process (back-casting) simulated near-real time analysis of the dynamics. in the us, where we are still in the substantial growth phase, the sequential estimates are indeed performed in nearreal time. in addition to three model parameters, for each day we also estimated predicted time for the epidemic to end. for this purpose. we chose arbitrarily time when the predicted number of cases reach % of the predicted maximum k. this time, t was calculated from eq. ( ) by setting p(t) = . k and is also shown in the appendix. figure shows the development of sequential estimates of the maximum predicted cases k for china and figure presents the corresponding "ending times" t . as reported earlier (hermanowicz ) for actual near-real time analysis, estimates of predicted maximum cases k depended very heavily on the length of the dataset used for estimation. as examples, figure shows a few logistic curves corresponding to selected model parameter estimates on specific days for china. as seen in this figure, the initial estimates (close to the exponential phase) were below , but they grew to about , as more data became available and was used for estimate refinement. obviously, the estimate of k obtained from the full dataset (up to day ) matches closely the actual reported number of cases ( , vs. , ) but it should be noted that the estimates of k from day (more than days in advance) converged very closely to the actual maximum. figure for china and figure for the us) . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https: //doi.org/ . //doi.org/ . / due to a change in reporting criteria in china on day (february ), there was a major increase in the number of reported cases that could not be incorporated in the model. as mentioned before, we decided to use all data (with the jump) in any subsequent analysis. the immediate result was a very large increase in the estimated maximum cases k (figure ), approximately doubling it from about , on day to about , on day . this big increase underscores again the sensitivity of the logistic model to data quality. however, the model is also robust in a longer term as the k estimates quickly converged toward their ultimate values. similarly, there was also a significant jump in the estimates of t (see figure ) due to the jump in the case numbers. however, it is remarkable that the estimates of the "end time" t were much more constrained and much closer to the actual value. even as early as three weeks before the end of the epidemic the estimates of the "end time" were between and days, very close to the final value of days. unlike china, the epidemic in the us is still at the growth phase, perhaps deviating slightly from the exponential growth. thus, the available dataset is much smaller and the logistic model estimates are burdened with much larger uncertainty. currently available estimates of the . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https: //doi.org/ . //doi.org/ . / maximum cases k are also shown in figure . they exhibit very large variations increasing from approximately , on day to approximately , on day without any sign of leveling off. this large variation is not unexpected since the nearly exponential growth does not contain sufficient information on the actual maximum. in other words, the derivative dp/dt in eq. ( ) is dominated by the term r p while ( -p/k)  . this behavior is also seen in the examples of predicted logistic curves for selected sets of estimated parameters k, r, t ( figure ). the sequential estimates of the "end time" t are plotted in figure . they also tend to increase in time with the increasing number of reported cases but unlike the estimates of k (and similarly to the chinese case) it varies in a much smaller interval - to days in the past two weeks, if the behavior of the us epidemic is similar to the chinese case, we could expect further leveling off of t at slightly above days. if this bold prediction will hold, we could see the end of the epidemic growth around - days after its origin, around april to . of course, the end here is defined as the cessation of new cases and not the complete recovery of the infected patients. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . note: each row contains estimates of the logistic model k, r, t and the % end time t estimated from recorded number of cases for the period starting on day and ending on the day in column . . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . forecasting the wuhan coronavirus ( -ncov) epidemics using a simple (simplistic) model -update evaluating the secondary transmission pattern and epidemic prediction of the covid- in metropolitan areas of china the continuing -ncov epidemic threat of novel coronaviruses to global health &#x ; the latest novel coronavirus outbreak in wuhan, china transmissibility of -ncov london report : estimating the potential total number of novel coronavirus cases in wuhan city nonlinear disease progress curves modeling infection transmission epidemiological characteristics of novel coronavirus infection: a statistical analysis of publicly available case data transmission dynamics of novel coronavirus ( -ncov) modeling the situation of covid- and effects of different containment strategies in china with dynamic differential equations and parameters estimation the logistic process -tables of the stochastic epidemic curve and applications national health commission of the people's republic of china the extent of transmission of novel coronavirus in wuhan, china, short-term forecasts of the covid- epidemic in guangdong and zhejiang modelling the epidemic trend of the novel coronavirus outbreak in china epidemiology: a science of patterns a novel coronavirus outbreak of global health concern nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study real-time tentative assessment of the epidemiological characteristics of novel coronavirus infections in wuhan, china, as at characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention mrca time and epidemic dynamics of the novel coronavirus origin time and epidemic dynamics of the novel coronavirus preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak estimating the unreported number of novel coronavirus ( -ncov) cases in china in the first half of forecasting the worldwide spread of covid- based on logistic model and seir model fractal kinetics of covid- pandemic key: cord- -mx dbm authors: bajunirwe, francis; izudi, jonathan; asiimwe, stephen title: long distance truck drivers and the increasing risk of covid- spread in uganda date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: mx dbm abstract objectives to examine the patterns of covid- transmission in uganda. methods we reviewed press releases from the uganda ministry of health from when the first case was announced on march up to may , a -week period. we obtained the press releases from the moh website and the twitter handle (@minofhealthug). data include number of persons tested and the categories classified as international arrivals, community members and long distance truck drivers. results the first cases were international arrivals from asia and europe and thereafter community cases emerged. however, in the middle of april , covid- cases were detected among long distance truck drivers. by may , , a total of , persons had been tested and overall tested positive. of those that tested positive, majority or ( . %) were truck drivers, ( . %) were community cases and ( . %) were international arrivals. majority of community cases have been linked to contact with truck drivers. conclusions the truck drivers are the most frequently diagnosed category, and have become a core group for covid- in uganda. they have generated significant local transmission which now threatens a full blown epidemic in the country unless strict controls are put in place. subgroups of the population with a higher prevalence or incidence of an infectious disease are often called core groups and can serve as a source of infection to the general population. the term has commonly been applied to sexually transmitted infections such as hiv, syphilis and gonorrhea (watts et al. , gesink et al. , lewis but can apply to non-sexually transmitted infections (lietman et al. ) . core groups may spread infection to the general population directly or through bridge populations, and will sustain infection levels at endemic or even epidemic levels unless control measures are instituted to lower prevalence of disease among them or restrict their contact with the general population. in december , cases of a rare pneumonia, connected to a sea food market were reported in wuhan, china and the causative agent was identified as a viral agent that was named severe acute respiratory syndrome coronavirus (sars-cov- ) (zhu et al. ) , the cause of what we now know as corona virus disease (covid- ). starting in china, the infection spread very rapidly and has now nearly reached all continents. given the scale and rate of spread, it is clear that the sars-cov- is a highly infectious agent, with a relatively large basic reproductive rate estimated to be at least three j o u r n a l p r e -p r o o f (d'arienzo and coniglio , liu et al. , zhuang et al. . also, given its origin from a single country, all new cases in other countries were introduced by travellers from china and eventually to the new hotspots in asia and europe. in africa, the first case was reported in egypt in mid-february and in uganda, the first case was reported by the ministry of health (moh) on march , , of a traveler arriving from dubai. the ministry initiated steps to screen travelers from hotspot countries and presidential directives were issued to close international borders. however, long distance trucks were allowed access to bring essential goods into the country or as transit to neighboring countries of rwanda, democratic republic of congo and south sudan. in this paper, we track the reports of new covid- cases reported by the moh and trace the emerging patterns of the new cases reported and identify the categories of persons at high risk for covid- in uganda. we reviewed moh reports and press releases for new covid- cases detected in uganda as they were made public on a regular basis. the reports are regularly posted on the twitter page for the ministry of health (@minofhealthug) and all entries were verified based on posts at this handle. data were entered into excel and analyzed using stata version . we plotted an epidemic curve using a -day interval as the unit on the time scale. we classify the cases into three categories namely: international traveller, local/ community cases, and long-distance truck drivers. international travellers are those passengers who arrived from a foreign country regardless of their citizenship. local cases are those that were diagnosed among local residents and had no evidence of recent foreign travel, and these were assumed to be a result of local transmission, or what the moh refers to as community cases. long distance truck drivers are those who arrived at uganda's borders as drivers of trucks carrying merchandise or goods, regardless of their nationality. we report a combination of both ugandan and foreign national cases detected in uganda and do not specify the nationalities of the cases. we tracked new cases of covid- detected between march , and may , a period of weeks. the first case was reported on march , . a total of , persons were tested and overall tested positive. of those that tested positive, majority or ( . %) are truck drivers, ( . %) were community cases and ( . %) were international arrivals as shown in table below. table the data are also shown in the figure below and indicate that at the beginning of the ugandan epidemic, the cases were all international arrivals. these quickly shifted to community cases but have since mid-april been dominated by truck drivers, followed by a surge in community cases starting in mid-may. the steady rise in covid- cases among truck drivers has been has been accompanied by a rise in the community cases. at the beginning of the epidemic, the first community cases identified were all linked to contact with international travelers. however, the subsequent community cases have all been linked to most probable contact with truck drivers. we present novel data to describe the dynamics of covid transmission in a setting where local transmission has been largely contained, but current data suggest the number of new cases could escalate. the first cases were all international travelers as described before (olum and bongomin ) , then community cases arising from contact with the international travelers were detected, and currently long distance truck drivers and their local contacts now dominate the epidemic, and threatening an escalation in the epidemic. these events take place in the midst of a national lockdown that was announced on march , and only eased on may , . long distance truck drivers have established themselves as the highest risk group for covid- currently in uganda. this population has historically been at risk and formed a core group for other infectious diseases such as hiv and other stds (pickering et al. , gysels et al. ). the reasons why long distance truck drivers are likely to test positive for covid are not clear. there are some possible explanations. first, is that they drive long distances, and this exposes them to a larger social network, in most urban and likely crowded places such as trading centers, ports of goods shed where probability of mixing with infected persons may be increased. the second is that they may represent the general prevalence of the communities where they come from, signifying high prevalence in the neighboring countries. there is limited screening data from the neighboring countries to corroborate this hypothesis. the data suggest that interventions for drivers to limit social contact along their journey are urgently required. transport companies will need to test their drivers and ensure those who are positive do not proceed with the journey. uganda embarked on testing the truck drivers in mid-april and initially allowed them to continue their journey before results were available. samples were then transported to a hub in entebbe, near the capital kampala. this may have cost the country an increase in community transmission as evidenced by the growth in cases in week and . with evidence of this increased community transmission, the moh has changed the approach to now test the drivers at border points, and truck drivers who test positive are not allowed to continue their journey. the strength of this report is that we present novel data, comprehensive to include all confirmed cases to-date as reported by moh and collected using innovative means. the limitation of this analysis is that new data are added daily and the epidemic is dynamic. data analysis should be done on a continuous basis to obtain a more complete and up-to-date picture of the epidemic trajectory. in conclusion, the covid- epidemic in uganda was sparked by travellers from europe and asia. the country is now facing threats of new transmission from regional long distance truck drivers arriving from neighboring countries. the epidemic is now literally being driven by the truck drivers who have emerged as a core group for covid in uganda. public health prevention measures that take into account regional integration of efforts are required to ensure success for the covid programs in uganda and its neighbors. j o u r n a l p r e -p r o o f assessment of the sars-cov- basic reproduction number, r , based on the early phase of covid- outbreak in italy sexually transmitted disease core theory: roles of person, place, and time truck drivers, middlemen and commercial sex workers: aids and the mediation of sex in south west uganda the role of core groups in the emergence and dissemination of antimicrobial-resistant n gonorrhoeae identifying a sufficient core group for trachoma transmission the reproductive number of covid- is higher compared to sars coronavirus uganda's first covid- cases: trends and lessons sexual networks in uganda: casual and commercial sex in a trading town remodelling core group theory: the role of sustaining populations in hiv transmission a novel coronavirus from patients with pneumonia in china preliminary estimating the reproduction number of the coronavirus disease (covid- ) outbreak in republic of korea and italy by mar key: cord- -t x gknd authors: nan title: abstract presentations from the aabb annual meeting san diego, ca ctober ‐ , date: - - journal: transfusion doi: . /trf. sha: doc_id: cord_uid: t x gknd nan background/case studies: zika virus (zikv) is associated with severe neurological consequences in fetuses and adults and potential for transfusion transmission (tt). rna persistence has been reported in whole blood (wb) long after clearance of viremia in plasma, raising concerns over the risk of tt with plasma based nucleic-acid amplification testing (nat). the dynamics of zikv persistence in asymptomatic infection are not well understood and are needed for understanding of the natural history of zikv infection. we sought to characterize the dynamics of infection through prospective enrollment of zikv rna blood donors. study design/method: donors identified through investigational zikv nat screening were enrolled into longitudinal follow up and assessed for viral and serological persistence and clinical outcomes. plasma and rbc were obtained from index donations and blood, urine, saliva and semen samples were collected prospectively at weeks , , , and following index donations from donors and detailed symptom questionnaires were administered at each study visit. blood compartments and body fluids were tested for zika rna by real time rt-pcr. plasma samples were tested for zika specific igm and igg antibodies results/finding: the percent of zikv rna samples, followed by the number of samples tested in parenthesis, for each sample type during each sampling interval is summarized in the table. plasma viremia declined rapidly after index donations whereas rbc-and wb-associated viral rna persisted for up to months and peripheral blood mononuclear cell (pbmc) associated virus was detected intermittently at low levels and waning by months. urine and saliva detection decreased significantly after weeks and was undetectable by months. of donors who were enrolled in the acute pre-seroconversion stage of infection % ( / ) developed multiple zikv related symptoms week post index donation, compared to only % ( / ) for donors detected post-seroconversion. conclusion: zikv rna persists in cellular blood compartments for several months following clearance from plasma and body fluids, with higher rates of symptoms than previously reported. the persistence of zika rna in rbcs has unknown implications for blood screening, which currently relies on plasma testing; infectivity studies are in progress. wb testing may be of value to extend detection of acute infection and for diagnostics and monitoring of pregnant women. iron status and novel risk factors for iron depletion in a diverse donor population bryan r. spencer* , yuelong guo , ritchard g. cable , joseph e. kiss , michael paul busch , grier page , stacy endres-dighe , steve kleinman , simone glynn , alan mast and for the nhlbi recipient epidemiology and donor evaluation study-iii (reds-iii) . american red cross, rti international, american red cross blood services, blood systems inc., blood systems research institute, university of british columbia, nih/ nhlbi, blood research institute, nhlbi background/case studies: blood centers and regulators in the united states (us) are evaluating strategies for minimizing iron depletion in blood donors. the logistics of donor management might differ across blood centers, but the optimal approach may also vary according to biological or behavioral differences across sub-populations of donors. studies donors have been conducted in predominantly caucasian populations, which may differ from racial/ethnic minority donors in iron metabolism and capacity to undergo repeat phlebotomy. study design/method: over , donors were enrolled from us blood centers for ferritin testing. the study population was enriched for racial minorities [ african-american (aa), asian (as), hispanic (hisp)] and for "super donors" ( , who had completed donations in two years without low hemoglobin deferral). the minority donors and the remaining non-hispanic white (nhw) donors were an unselected population with no specific eligibility criteria. subjects completed questionnaires on risk factors for iron depletion. logistic regression was used to identify demographic and behavioral predictors of absent iron stores (ais, ferritin < ng/ml) and low ferritin (lf, ferritin < ng/ml). results/findings: across all subjects, % had ais and % had lf, with a high degree of variability based on demographic factors and donation behavior. in models stratified by race, expected patterns common to all groups included a sharp increase in risk with increasing donation intensity, and a large decrement in risk for females > years old. in models including all subjects, race was an independent predictor of both ais and lf controlling for age, sex, body weight, donation frequency, and other factors (table) . aa and as donors showed % % decreased risk for ais compared to nhw, while hisp donors had % higher risk. daily use of exogenous iron reduced risk for lf and ais by to %, respectively, while the estimated benefit from less-than-daily use was lower ( to % protection). regular use of antacids was associated with a % or greater increment to risk. reported use of hormone supplements showed opposing effects in males and females. use of oral contraceptives or estrogen in females reduced risk by % - %, while males who reported current use of supplemental testosterone had twice the estimated risk for ais. conclusion: this large study confirms the high prevalence of lf and ais in us donors and the principal risk factors of age, sex, and donation frequency. the diverse population studied and the questionnaire data from donors identify additional demographic and behavioral risk factors of secondary importance. in developing iron mitigation strategies, practices based on age and gender could be further refined depending on a given blood center's operational context and donor population. data are reported as mean ( sd) *p < . compared to batf / , ul hod rbcs mfi, median fluorescence intensity background/case studies: during storage, red blood cells (rbcs) undergo multiple morphological, biochemical and molecular modifications, collectively called the storage lesion. the proportion of cleared rbcs is correlated with storage duration, which may be responsible for the rapid clearance of up to % of transfused rbcs, reducing transfusion yield. it has been shown, using imaging flow cytometry that a subpopulation of morphologically altered rbcs accumulates during storage. the reduced surface area of these small rbcs (srbcs) suggests their rapid elimination by the spleen in the hours following transfusion. this hypothesis remains to be clarified, since the physiological mechanisms of rbc clearance remain to be precisely identified. study design/method: murine "young" and "old" rbcs (respectively on d and d of storage) were transfused into different models including splenectomized or macrophage-depleted mice. flow cytometry was used to determine the kinetics of clearance, the transfusion yield and to quantify rbcs retention in organs. the accumulation, during storage, and the posttransfusion disappearance of srbcs were analyzed by imaging flow cytometry. results/finding: using a murine model of transfusion, we confirmed that the post-transfusion yield decreases with storage duration ( % on d vs % on d of storage). a clearance of the storage-damaged rbcs mediated by spleen and macrophages is shown by significant improvements in post-transfusion yield observed in the splenectomized ( %) and macrophage-depleted ( %) groups. as in humans, we observed the accumulation of a subpopulation of small rbcs (mouse small rbc: msrbc) of reduced projected surface area with altered morphology. these msrbcs disappear rapidly from the circulation in control or splenectomized mice with a decrease of more than % at h post-transfusion. in contrast, in macrophage-depleted mice, msrbcs are kept in circulation at h posttransfusion. at h, these msrbcs completely disappear in all models, suggesting the importance of their elimination and the presence of compensation clearance mechanisms. in control mice, storage-damaged rbcs are mostly retained in the spleen but also in the bone marrow (bm) . no retention is observed in the liver, kidney or lung. in macrophage-depleted mice, retention is decreased in the spleen and bm. conversely, elevated retention is observed in the bm of splenectomized mice, associated with a transient retention in the kidney and liver. conclusion: during storage of murine rbcs, damaged rbcs accumulate, and are eliminated following transfusion via spleen/macrophage-mediated mechanisms. they include, as observed in humans, a subpopulation of small rbcs which undergoes a rapid macrophage-mediated clearance. the increase in transfusion yield in the absence of spleen or macrophages suggests that the recipient's functional state is one of its determining factors. age dependent relapsing and remitting autoimmune hemolytic anemia in a murine model andrea sut ling wong* , amanda l richards and krystalyn e hudson . background/case studies: breakdown of tolerance to rbc antigens may result in development of pathogenic autoantibodies (autoab) and lead to autoimmune hemolytic anemia (aiha), a severe and sometimes fatal disease. aiha in humans has a number of known features, including increased frequency with age, and tendency to relapse and remit. however, the mechanisms behind such observations are not understood. to gain insight into tolerance (or loss thereof) to an rbc autoantigen, we utilized the hod mouse, which expresses an rbc-specific triple fusion protein consisting of hen egg lysosyme (hel), ovalbumin (ova), and, duffy (hod). hod mice were bred to a transgenic mouse that expresses a t cell receptor specific for an ova peptide in hod presented by mhcii (otii mice). thus, hod otii mice are predisposed to have autoreactive cd t cells. study design/method: four cohorts of hodxotii f mice ( - mice/ cohort) were bled monthly for months to assess for autoab production. peripheral rbcs were stained with anti-complement (c ) and mouse immunoglobulin ab. spleens were weighed and splenocytes were stained with anti-cd and ter to assess for the presence of rbc progenitors. statistical analysis between hod otii autoab vs. hod otii autoabvs. hod -otii was performed using kruskal-wallis test and corrected for multiple testing with dunn's test. results/finding: otii cd t cells were not deleted in the thymus of hod otii mice; rather, they matured to the periphery. despite these peripheral autoreactive t cells, no detectable autoab were observed in hod otii . however, as they aged, - % of hod otii were positive for rbc autoab by months. thereafter, $ % of the autoab mice stopped producing autoab within two months after onset and remained autoab free throughout the study. in of the cohorts, - % of autoab mice were female. hod otii autoab mice also had enlarged spleens compared to hod otii autoaband hod -otii mice ( . g vs. . g and . g, resp., p< . ). this may due to rbc consumption, extramedullary erythropoiesis, or both. consistent with increased erythropoiesis, elevated numbers of rbc progenitors (cd hi ter inter ) were observed in the spleens of hod otii autoab mice but not in hod otii autoaband hod -otii ( . % vs. . % and . % resp., p< . ). moreover, autoab and c deposition were found ( . - % and - %, resp.) on ter rbcs in all of the hod otii autoab mice analyzed. conclusion: several features known to exist in human aiha were observed, including age-dependant autoab production, relapsing of autoimmunity after onset, and an increased frequency in females. this model may serve as an experimental system to investigate the mechanisms of aiha. b -a a reduction in neutrophil numbers is a risk factor for rbc alloimmunization amanda l richards , christopher a tormey and krystalyn e hudson* . background/case studies: red blood cell (rbc) alloimmunization occurs in up to % of transfusion recipients (excluding abo and rhd). the underlying factors that influence alloimmunization are poorly understood; thus, there is currently no reliable way to predict who will make an alloantibody and who will not. patients who receive multiple rbc units or several separate transfusions are at higher risk of alloimmunization; likewise, certain disease states have higher rates of alloimmunization, such as myelodysplasctic syndrome (mds) and sickle cell disease patients. however, despite chronic transfusions, some patients never develop rbc alloantibodies. it has been recently reported that poly (i:c)-elicited inflammation leads to enhanced alloimmunization rates and is correlated with increased splenic neutrophil (pmn) numbers. additionally, rbc transfusion into an inflamed recipient leads to enhanced erythrophagocytosis by pmns. here, we test the hypothesis that pmns regulate rbc alloantibody generation. study design/method: mice: c bl/ (b ) mice were treated with pbs, or anti-ly g to deplete pmns, followed by poly (i:c) to elicit inflammation, and finally a transfusion of allogeneic dio-labeled rbcs expressing a synthetic antigen, hod (hel-ova-duffy). multiple splenic cellular subsets were evaluated for dio fluorescence, an indirect measure of rbc consumption, at - hours post-transfusion. anti-hod alloantibody generation was assessed days post-transfusion by flow cytometry. humans:retrospectively, mean white blood cell (wbc) and pmn counts were collected on chronically transfused mds patients at va connecticut healthcare. for alloimmunized patients (n ), wbc and pmn counts were assessed on the day of exposure to the alloimmunizing rbc unit, whereas counts were averaged for the entirety of rbc therapy for non-alloimmunized patients (n ). patients were matched for numbers of rbc transfusions. results/finding: mice: the mfi of anti-hod antibodies was significantly increased in pmn-depleted mice, compared to controls ( / experiments, p< . ). while many control mice made no alloantibody (non-responders), all pmn-depleted mice made detectable anti-hod. pmn depletion also led to a significant reduction in dio leukocytes, suggesting a lack of compensatory mechanism(s) for rbc consumption. absence of pmns also shifted rbc consumption from macrophages to immune-stimulating dendritic cell subsets. flow cytometric analysis revealed that pmns with internalized rbcs upregulated expression of co-inhibitory molecules (e.g. pd-l ), compared to pmns (without internalized rbcs) from the same mouse; thus, pmns may regulate alloimmunization through antigen presentation and/or inhibitory signals. humans:. alloimmunized mds patients had a significant decrease in pmns, compared to non-alloimmunized (p< . ); no significant differences were detected in mean wbc counts between the two arms. conclusion: these data demonstrate that in both murine and human settings, pmns may play a significant role in regulating rbc alloimmunization and may provide key insights into predicting which patients will become alloimmunized. b -a b cxcr pd and ccr expressions characterize responders to rbc immunization benoît vingert* , , , marie tamagne , , , sadaf pakdaman , , , anoosha habibi , , , philippe bierling , , , , , rachid djoudi and france pirenne , , , . efs ile de france, laboratory of excellence gr-ex, imrb u -eq , ap-hp, universit e paris est background/case studies: post-transfusion alloimmunization can induce life-threatening hemolytic transfusion reaction. in human, mechanisms responsible of rbc alloimmunization are not fully defined. cd t cells are major for antibodies production. we have already shown in responder patients that the majority of anti-rbc cd t cells have a th profile. in contrast, in whole blood of non-responder patients, there is an unexpected expression of circulating cd t cells with a cxcr pd phenotype. this phenotype is usually associated with the presence of tfh cells, specialized in the production of antibodies. it has been suggested that some of the activated circulating tfh could have a cxcr pd hi profile, with a differentiated expression of ccr . ccr is essential for t cells domiciliation in lymph nodes where the encounter t and b cells is major for b cell differentiation and antibody production. others chemokines receptor like ccr and cxcr can also differentiate circulating tfh subpopulations. in this study, we were interested in the phenotype and function of these cxcr pd lymphocytes which were paradoxically highly represented in non-responder patients. study design/method: the membrane and functional phenotype of the circulating cxcr pd cells were compared in groups of transfused sickle cell patients : alloimmunized (n ) and non-alloimmunized patients (n ). the analysis was also performed in non-transfused healthy controls (n ). all assays were performed on whole blood without separation procedures that are known to alter the expression of chemokine receptors results/finding: the cxcr pd hi subpopulation expression was identical between transfused groups and controls. ccr and cxcr expressions show no difference between the transfused groups or the controls. however, in non-responder patients, ccr expression was very strong independently of the expression of pd . in the aim to determine the help of the circulating cxcr pd cells in the production of antibodies, these cells were purified by flow cytometry and co-cultured for days with b cells, and in the presence of seb protein. the levels of antibodies after seb stimulation were identical with the cxcr pd subpopulations from transfused groups or controls. conclusion: the paradoxical presence of circulating cxcr pd cells in non-responder transfused patients do not appear to have any particular functions that can promote the absence of a humoral response. however, in responder patients, the high expression of ccr on circulating cxcr pd cells suggests remarkable migratory properties towards secondary lymphoid organs, and could facilitate allo-immune responses. in conclusion, the study of the cxcr pd profile and the ccr expression in these cells could help to differentiate responder and non-responder patients to rbc immunization. primed cd t cells to one rbc alloantigen can enhance subsequent alloimmunization seema r patel* , ashley bennett , kathryn girard-pierce , connie arthur , amanda mener , patty zerra , christopher a tormey , jeanne hendrickson and sean stowell . emory university, yale-new haven hospital, yale university, emory university school of medicine background/case studies: while red blood cell (rbc) alloantibodies can increase the probability of transfusion-related complications, not all patients become alloimmunized following transfusion. however, individuals that do generate alloantibodies appear to experience an increased rate of additional alloantibody formation following subsequent transfusion. however, how immunity to one rbc alloantigen primes immunization to a completely distinct alloantigen remains unknown. though cd t cell help classically occurs through direct recognition of a peptide that resides within a target b cell antigen, individuals who develop antibodies toward one rbc alloantigen experience increased rates of antibody formation against completely distinct rbc alloantigens. these observations suggest that cd t cells that respond to one alloantigen may directly facilitate immunity to a completely distinct rbc alloantigen. study design/method: b recipients were transfused with kel rbcs in the presence or absence of poly i:c (pic), followed by transfusion of hod rbcs, kel rbcs, rbcs expressing hod and kel (hod x kel), or a mixture of hod and kel rbcs (hod kel). to examine the role of cd t cells, pic/kel primed b recipients were cd t cell depleted prior to transfusion. in addition, b recipients were adoptively transferred with cd t cells from na€ ıve or pic/kel primed donors, followed by transfusion of hod rbcs or (hod x kel) rbcs. anti-hod and anti-kel alloantibody formation was evaluated using indirect immunofluorescence staining. results/findings: kel rbc transfusion in the presence of pic (pic/kel) not only enhanced anti-kel antibody production through a cd t celldependent process, but this same priming event directly facilitated anti-hod antibody formation following subsequent (hod x kel) rbc transfusion (p < . ); pic/kel primed recipients transfused with (hod kel) rbcs or hod rbcs alone failed to impact anti-hod antibody formation. the ability of immunity to kel to boost a humoral response to the hod antigen following (hod x kel) rbc transfusion required kel priming in the presence of pic. cd t cell depletion prevented pic/kel primed recipients from boosting an anti-hod antibody response (p < . ) and transfer of cd t cells from pic/kel primed recipients likewise directly facilitated anti-hod antibody formation following a (hod x kel) rbc transfusion (p < . ). conclusion: these results demonstrate that cd t cells primed to one rbc alloantigen can directly enhance the immune response to a completely distinct rbc alloantigen, suggesting a mechanism whereby alloantibody responders may exhibit an increased rate of additional alloantibody background/case studies: platelet refractoriness remains a significant clinical problem, yet the mechanisms by which it occurs are incompletely understood. immune-mediated platelet clearance by anti-platelet alloantibodies plays a significant role, and patients with detectable alloantibodies can be managed with transfusion of hla-matched platelets. still, many patients are refractory even after receiving hla-matched platelets. it was shown previously that cd t cells can play a direct role in platelet clearance, as allogeneic platelets are cleared within hours post transfusion in b celldeficient mmt recipient mice (ie in the absence of anti-platelet alloantibodies) and depletion of cd t cells prevents such clearance. since minor antigenic differences still exist between donor hla-matched platelets and a recipient, we hypothesized that minor antigens alone may mediate clearance of otherwise hla-matched platelets. study design/method: to test whether minor antigens can stimulate cd t cell-dependent platelet clearance we examined platelet refractoriness using mova and oti transgenic mice. leukoreduced donor platelets from mova mice, which express a membrane-bound form of chicken ovalbumin and thus present ovalbumin peptides complexed with murine mhc class i h kb, were labelled in vivowith the fluorescent dye cfse and transfused into wildtype (wt, c bl/ ) mice or oti mice, whose cd t cell receptors recognize a specific ovalbumin peptide in the context of mhc class i h kb. in some experiments oti mice were primed with mova or wt splenocytes one week prior to mova platelet transfusion, and in others wt mice were adoptively transferred with oti splenocytes hours before mova platelet transfusion. platelet recovery was measured immediately after transfusion as well as after , , , , and hours and on days - . results/finding: transfusion of mova platelets into oti mice results in significant platelet clearance as compared to transfusion with wt platelets. clearance kinetics demonstrate platelet loss starting after hours and peaking at hours, and are similar whether oti mice are na€ ıve or previously primed with mova splenocytes. specifically, mova platelet recovery in oti recipients is - % versus > % in wt recipients at hours (p< . ), whereas transfusion of wt platelets into either oti or wt recipients is approximately % at hours after transfusion. adoptive transfer of oti cd t cells into wt mice recapitulates the effect, with significant mova platelet clearance at hours compared to wt platelet clearance (p< . ). conclusion: this work extends the ability of cd t cells to mediate platelet clearance to a minor antigen, providing insight into the potential etiology of platelet refractoriness in patients receiving hla-matched products. this study also holds implications for the clinical management of any nonantibody-mediated platelet refractory patient, as therapies directed toward immunomodulation of t cell responses may prove beneficial. background/case studies: alloimmunization against major histocompatibility (mhc) antigens is a common complication of transfusion, and can negatively impact subsequent transfusions and transplants. we have previously demonstrated that pathogen reduction with riboflavin and uv light (uv r) is effective both at rapidly killing donor white blood cells (wbcs) and at blocking their ability to stimulate an allogeneic response in vitro. furthermore, uv r treatment of allogeneic platelet rich plasma (prp) prevents alloimmunization in mice, and provides partial antigen-specific tolerance to subsequent transfusions. as cells that die through different pathways can be either tolerizing or inflammatory, we sought to determine which cell death pathways are triggered by uv r, as well as evaluate the immunogenicity of prp containing wbcs killed by other methods. study design/method: wbc-rich prp was prepared from c bl/ mouse blood and treated with uv r, and wbcs prepared in parallel from the same blood were treated with known inducers of either apoptosis or necrosis. membrane integrity, phosphatidylserine exposure, caspase activity, and chromatin condensation were evaluated by flow cytometry. balb/c recipients were transfused with either uv r treated wbc-rich prp, or uv r treated wbc-poor prp either alone or with added untreated, apoptotic, or necrotic wbcs, all generated from allogeneic c bl/ donor blood. a second transfusion of untreated wbc-rich c bl/ prp was given weeks later, and alloresponses were compared against mice given no transfusion or only the second untreated transfusion. results/finding: uv r treated wbcs have a pattern of phosphatidylserine exposure and loss of membrane integrity consistent with early apoptosis, but fail to demonstrate significant caspase activity or clear chromatin condensation. alloantibody responses to transfusion were significantly higher in mice previously exposed to untreated (p< . ) or necrotic (p< . ) wbcs, but not those given uv r treated or apoptotic wbcs. ex vivo cytokine responses to stimulation with c bl/ wbcs were reduced in recipients of either uv r or apoptotic wbcs, and enhanced in recipients of untreated or necrotic wbcs. conclusion: the mechanism of wbc death following uv r treatment shares some membrane characteristics of early apoptosis, but is distinct from classic apoptosis. however, both uv r treated and apoptotic wbcs fail to trigger an alloresponse, and offer some protection against subsequent alloexposures. background/case studies: in mitochondria-less red blood cells (rbcs), oxygen is the main substrate for oxidative reactions and resulting oxidative damage is considered as one of the major causative factors in the development of rbc storage lesion. oxygen saturation (so ) of venous blood is generally assumed to be around - % as measured from a central venous line. however, a recent investigation of so levels in freshly prepared leukocyte-reduced red cell concentrates (lr-rccs) revealed unexpectedly wide so distribution (mean . % . % [yoshida et al. ; blood transfusion , ] . the present study was undertaken to determine the distribution of so in lr-rcc produced at a medium-size blood center using a novel non-invasive so probe. additionally, quantitative metabolomics were carried out to examine the redox status of the stored rbc under various so levels. study design/method: the so from units of lr-rcc were examined on five consecutive days representing % of the collected units during the period at a regional blood center where all the units were processed at room temperature within hours of blood collection. so was measured noninvasively through the pvc bag immediately prior to refrigeration by employing a resonance raman spectrometry (pendar microvascular oximeter a u ; pendar technologies, cambridge ma). in addition to so , process methods, rcc volumes, blood types, gender and process times were recorded for analyses. in a separate study, lr-rcc (n ) from human volunteers were stored in as- under normoxic, hyperoxic, or hypoxic conditions for up to days (so ranging from < to > %) prior to uhplc-ms metabolomics analyses in presence of c, n or deuterated internal stable-isotope labeled standards for absolute quantitation. results/finding: measurements of so carried out non-invasively at a blood center yielded a similar wide distribution as previous study from units of lr-rcc procured and sampled invasively within hours after blood collection [yoshida ibid]. the shape of the so distribution appeared near normal with the mean of . % . %, median . %, range < % to > % and inter-quartile range (iqr) of . %- . %. male donors showed higher so compared to female donors (p< . ). no correlations were observed between so levels and processing time, donor age or blood types. metabolomics workflow indicated that lower so levels ameliorate the energy and oxidative metabolic lesion. lower so levels yielded higher rate of gsh synthesis, higher nadph concentration, higher gsh / gssg and nadph/nadp ratios, lower supernatant urate consumption and lower purine oxidation. the surprisingly wide distribution of starting %so levels was observed from lr-rcc manufactured at a blood center using -hour room background/case studies: cellular prion protein (prp c ) is a gpi-anchored cell surface glycoprotein that is expressed mainly in the brain but also in peripheral organs including blood, bone marrow (bm), and lymphoid tissue. prp c can be converted post-translationally into scrapie-prp (prp sc ), which is involved in the pathogenesis of neurodegenerative diseases including creutzfeldt-jakob disease, kuru in humans, and scrapie and bovine spongiform encephalopathy in animals. however, biological functions of prp c have yet to be conclusively elucidated. study design/method: in this study, prp c knockout mice (ko) are utilized to investigate the role of prp c in the hematopoietic system with controls of age and sex-matched prp c transgenic mice harboring a slightly augmented prp c expression. peripheral blood was examined by hematology analyzer to establish counts. bone marrow, thymus, spleen, lymph nodes, and peripheral blood were harvested and analyzed by flow cytometry using a comprehensive panel of fluorochrome-conjugated antibodies specific for all hematologic cell precursors/ lineages. histology of bone marrow, spleen, thymus and lymph nodes were evaluated by light microscopy. results/finding: complete blood count (cbc) showed a significant increase of wbc in ko mice. closer analysis of wbc differential revealed that the elevated number of wbc in ko mice was due to lymphocytosis. specifically, ko mice had a -fold increase in the absolute lymphocyte count (ko . . x /l vs. wt . . x /l, p . ), as well as a higher lymphocyte percentage compared to controls. ko mice also had a trend toward higher hemoglobin, rbc, and hematocrit compared to wt mice. additionally, platelet count in ko mice was higher than control mice. of interest, the mean platelet volume indicating platelet size was significantly increased in ko mice compared to controls (ko . . fl vs. wt . . fl, p . ). a comprehensive flow cytometric analysis of all cell lineages revealed no significant differences in the numbers of rbc and megakaryocyte in bm, and of lymphocytes in the thymus, spleen and lymph nodes. histological analysis of bm, thymus, spleen and lymph node tissue from ko and wt animals failed to show morphological differences between the two groups. conclusion: absence of prp c resulted in significant leukocytosis and specifically higher absolute count and percentage of lymphocytes, as well as larger platelets in peripheral blood, but does not appear to affect hematopoiesis and lymphopoiesis. our findings indicate that prp c might be critical in the survival and trafficking of lymphocytes in peripheral blood. the molecular mechanisms underlying the observed changes in lymphocytes and platelets, and whether these involve functional changes in these cells will be subject of future studies. potential role of cd foxp regulatory t cells derived exosomes in their immune modulation yiming yang*, rufeng xie and jie yang. blood engineering laboratory, shanghai blood center background/case studies: exosomes are defined as one type of membrane vesicles secreted into extracellular space by most types of cells and are reported to involve in intercellular communications, mediate biological process. human periphery blood cd foxp tregs cells are reported as more stable regulatory cells with greater inhibition effects. however, cd foxp tregs derived exosomes and their functions involved in cd tregs mediated immune-modulation were seldom reported. study design/method: cd t cells were freshly purified from pbmcs, cultured with anti-cd /cd antibody packaged beads and il- , and then polarized with tgf-b and rapamycin into cd foxp treg cells. the harvest cells were co-cultured with cd /cd beads stimulating cd cd effector cells in the transwell plate. the supernatant derived from cd tregs was collected and ultrafiltrated by centrifugation and the remaining solution was precipitated with peg. the harvest precipitation was resuspended in pbs and exosomes were analyzed by sem and nta. exosome surface marker cd , cd , tsg and other proteins expression were evaluated by flow cytometry and western blot. microrna was isolated with mircute mirna kit and mir- , let- b, let- d were measured by qpcr. the precipitated exosomes were further purified by cd immunoaffinity capture and co-cultured with effector cells to investigate their function in immune modulation. results/finding: as compared with direct contact co-culture, separated cd treg cells could suppress the proliferation of effector cells with a small decline (p> . ), which means some non-contact factors involved in the cd treg mediated immune modulation. a total number of . . / cells exosomes were harvest. electron microscope analysis demonstrated a kind of round-shaped membrane vesicle - nm in diameter ( . . nm by nta). cd and cd were expressed on these background/case studies: regulatory t cells (tregs), containing cd and cd subtypes, play an essential role in immune regulation and autoimmune disease prevention which makes it a potential candidate for cell therapy on autoimmune disease (aids). unfortunately, due to the instability of natural cd foxp regulatory t cells (ntregs) in inflammation conditions (including instability of foxp , conversion to pro-inflammatory effector cells and was unable to modify established disease), thus, it is needed to investigate cd regulatory t cells stability both in vitro and in vivo. in our previous works, we found that cd treg has an effective therapeutic function on cia mice. in this study we aim to investigate the stability of induced polyclonal human cd regulatory t cells in inflammation and transfusion. study design/method: human cd tregs were induced with tgf-b and rapamycin from cd t lymphocytes in vitro. collagen-induced arthritis (cia) mice were induced with type-two collagen as an autoimmune disease model. in vitro the stability of cd tregs when encountering with inflammation were test by foxp expression, th and th cells conversion in inflammations conditions (il tgf-b il il and il tgf-b il b il ) on day , day and day . in vivo, cd tregs were transfused into cia mice and then their survival in mice and foxp express were evaluated to reveal the stability of cd tregs in an inflammation condition model. additionally, we also investigate the stability maintenance of cd tregs when induced factor tgf-b and rapamycin were removed by testing the foxp expression on day , day and day . results/finding: ex vivo induced human cd treg were foxp ( . . %) and did not secret il a (both in supernatant and % of cells). foxp express in cd tregs were maintained after induced factor tgf-b and rapamycin were removed on day , day and day . in vitro, foxp , il and ifn-c expression has no significant difference when compared with controlled tregs on day , day and day and did not secret il a when encounter with inflammation conditions (il tgf-b il il and il tgf-b il b il ). in vivo, cd treg cells were transfused into cia mice on the peak of disease onset ( days after the first collagen immunization, has inflammation condition in vivo) to test cd tregs survival. cd tregs were found in cia mice foot ( . . %), blood ( . . %) and spleen cells ( . . %) hours after transfusion and their % of foxp were remained. conclusion: the results revealed that ex-vivo induced and expanded human cd tregs are stable in inflammation and transfusion and can maintain foxp expression when induced factor were removed, these make cd treg a novel and stable cell for potential cell therapy on aids. this research can provide some instructive reference and improve the utilization of blood components. tolerogenic dendritic cells induced by mtor suppression and control inflammation in chs model through s k related proteins translation inhibition. li gao*. shanghai blood center background/case studies: tolerogenic dendritic cells (tdcs) adoptive cellular immunotherapy is a cutting edge strategy for treating hypersensitivity response disease, in which immune responses are directed against selfantigens, such as atopic dermatitis, systemic lupus erythematosus (sle), rheumatoid arthritis (ra),et al. however, the traditional strategy base on the tdcs was usually unstable and inconspicuous through cytokines inducing processing so that might be the limitations on tdc adaptive cell therapy in future clinical use. study design/method: human tdcs were derived from fresh purified monocytes from pbmncs isolated from buffy coat and induced by mtor inhibitors (rapamycin and temsirolimus) in safe concentrations confirmed by apoptosis assay when the cells were completely differentiated. the mature markers and endocytisis were detected by flow cytometry. the production of cytokines and chemokines was measured using elisa. mechanism investigation was analysis by real-time pcr and western blotting. contact hypersensitivity (chs) model, an atopic dermatitis animal model, was treated with tdcs induced via mtor suppression and analyzed by ear thickness and tissue leukocytes number calculating. results/finding: human tdcs treated with mtor inhibitors had a lower mature marker cd /cd /cd expression after tlr signaling activation, accompanied with a set of cytokines and chemokines remarkably downregulated in a concentration dependent manner but not the lps absent group. moreover, mtor suppression extremely reduced the capacity of lps treated human dcs to stimulate autogenic na€ ıve t cell proliferation, which is one of the most important characteristics of tdc. beyond expectation, the common signal transduction pathway, mapk and nf-jb pathway, were not the signal target so that it could hardly be the explanation for the tolerogenic performance of tdc when exposure to lps stimulation. however, the p s k and its downstreanm proteins, especially the protein s , which controls the protein translation, were shown in charge of the tolerogenic induction mechanism. the data were also supporting the suggestion that rare difference on mrna transcription of the related functional proteins in tdcs induced by mtor inhibitors when exposure to lps stimulation from the non-induced cells, although there was more transcription of ido induced by mtor inhibitors. more important, edema responses of ears were clearly weakened in the chs model and recruited less leukocytes to the tissue when co-sensitized with mtor inhibitors or with tdcs induced by mtor inhibitors suggested that the tdc induced by mtor suppression were able to control hypersensitivity inflammation response in vivo. conclusion: accordingly, tdc induced by mtor suppression is a potent adoptive cellular immunotherapy strategy for treating hypersensitivity response disease and the induction mechanism of it might be through suppressing systematically effective function proteins by mtor-s related protein translation inhibition. xiaoyun fu* , , mikayla anderson and james c zimring , . bloodworksnw research institute, university of washington school of medicine background/case studies: red blood cells (rbcs) undergo many changes when stored under blood banking conditions, collectively known as the storage lesion. bioactive lipids generated during rbc storage have been implicated in certain adverse outcomes. recently, we reported that bioactive lipids, especially polyunsaturated fatty acids (pufas) and their oxidized products (oxylipins) accumulate during rbc storage despite leukoreduction. to evaluate the extent of membrane lipid degradation and oxidation in stored rbc units among the donor population with different blood groups, we quantified pufas and lysophospholipids (lpls) in leukoreduced rbc units. study design/method: rbc units from different donors were acquired and processed on day (one day past their expiration). bioactive lipids including common fatty acids, oxylipins, and lpls were analyzed by liquid chromatography-tandem mass spectrometry with multiple reaction monitoring (lc-ms/ms-mrm). total fatty acid concentrations of selected units were also analyzed. a one-way anova test was used to determine significant difference of analytes amongst the different blood groups. results/finding: we observed a wide distribution in concentration of major pufas in stored rbc units. for example, arachidonic acid (aa) ranges from . - . mm, linoleic acid (la) ( . - mm), dihomo-c-linolenic acid (dgla) ( . - . mm), eicosapentaenoic acid (epa) ( . - . mm), docosahexaenoic acid (dha) ( . - . mm), and alpha-linolenic acid (ala) ( . - . mm). ten oxylipins including hetes, hodes, and dihomes, and lpls including lpcs, lpss, and lpes all showed a large variation in concentration among donors. of analytes quantified, showed a significant difference in concentration among different blood types by one-way anova testing (fdr< . ). the ab rh blood group consistently exhibited the lowest concentration of major pufas, while the o rh-blood group showed the highest, averaging a two-fold difference in concentration (o rh-/ab rh ). the fold increase of o rh-/o rh among pufas ranges from . to . , suggesting the rh blood group, independent of the abo blood group, correlates with donor to donor variation in lipid metabolism. conclusion: the wide distribution in the concentration of bioactive lipids among stored rbc units suggests that lipid degradation is highly donor-background/case studies: to ensure availability of biological products to hospitals, blood banks have developed and validated multiple storage conditions for each of their products to maximize shelf life and quality. in the case of labile products, their metabolism is known to remain active during storage, leading to storage lesions. micrornas (mirnas) levels are modulated by these storage-related damages, which makes mirnas ideal candidates as potential biomarkers of quality monitoring. lately, nanoparticles have been widely studied and used for biosensing applications. the objective of this work is to develop biocompatible gold nanosensors for sensitive, selective and direct detection of biomarkers to characterize and assess the quality of blood products delivered to hospitals. study design/method: gold nanoparticles (gnps) surrounded by a fluorescent silica shell were prepared using a wet chemistry method. mirna- was chosen as a potential target, since it is strongly expressed in platelet concentrates and its concentration fluctuates according to storage lesions. custom rna and dna molecular beacons were designed and used as a probe for the specific detection of mirna- targets in pbs and human plasma. these fluorescent transducer probes were conjugated at the surface of fluorescent silica shell-gnps using an edc/nhs cross-linking reaction. the hybridization reaction between the target and the probe initiates an energy transfer mechanism which can be recorded by fluorescence. results/finding: gnps ( nm) surrounded by a thick fluorescent silica shell ( nm) were prepared and used as nanosensors because of their optimal luminescence properties and long-term stability. conjugation of the probe onto the nanoparticles was confirmed by fluorescence spectroscopy and microscopy, as well as nanoparticle tracking analysis. the fluorescent response of the molecular beacons was studied and showed a reproducible and linear relationship (r rnaprobe . and r dnaprobe . ) with mirna- concentration, down to a -nm limit of detection. hybridization assays in % human plasma appear to demonstrate denaturation of rna probes and targets. conclusion: biocompatible fluorescent gnps were prepared and used as tools for blood product characterization. the conjugation of a molecular beacon at the surface of nanoparticles was achieved and characterized using spectroscopic and microscopic techniques. the functionalization of the probe is still being optimized. the fluorescence response of the molecular beacon was characterized for the detection of a model mirna target in pbs and in % human plasma. energy metabolism profile of erythrocytes during storage suping ren*, qun yu, yanbing wang, changlan li and yu wang. background/case studies: the moment the mature red blood cells (rbcs) leave the bone marrow, it is optimally adapted to perform the binding and transport of oxygen and its delivery to all tissues. red blood cells modulate oxygen transport, protect hemoglobin from oxidant-induced damage, and maintain the osmotic environment of the cell. glycolysis is the only energetic metabolic pathway for mature rbcs to obtain atp which is the energy for rbcs to maintain a number of vital cell functions. generally, the current methods used to measure rbcs glycolysis are not in living state in realtime, or are destructive to cells or require radioactivity.xf technology can be applied to different types of cells, in which the red blood cells are suspended and the cell shape and size are different from other cells, and more importantly, rbcs have no nucleus, mitochondria and other organelles, so application of the xf technology in erythrocytes and exploration of the assay conditions are necessary. . . a . . . . a . . . . a . . total atp,lm/ghb . . a . . . . a . . . . a . . extracellular lactate,mm a extracellular glucose,mm a a a extracellular na ,mm a extracellular k ,mm a a a a p< . , paired t-test b intercept blood system for red blood cells is not approved for commercial use. c this project has been funded in whole or in part with federal funds from the dhhs; aspr; barda; contract no. hhso c. background/case studies: pathogen inactivation methods for platelet concentrates are increasingly being used in blood banks worldwide to make transfusion safer. in vitro studies have demonstrated the effects of pathogen inactivation on storage lesion, but little routine quality control data on blood banking outcomes have been reported. study design/method: swirling of distributed products was monitored one year before and one year after implementation of intercept pathogen inactivation. metabolic parameters like ph, glucose and lactic acid were determined in a random sample of expired pathogen inactivated products. furthermore, indicators of platelet storage lesion were measured in apheresis concentrates with premature low swirling and compared to controls with normal swirling. results/finding: in an experimental phase on a limited number of products (n ) to validate the intercept pathogen inactivation method, ph and glucose levels decreased faster in apheresis platelet concentrates with high platelet content than with low platelet content or than in pooled buffy coat derived products. once pathogen inactivation was implemented, routine products showed glucose exhaustion more often when prepared by apheresis compared to buffy coat derived platelet concentrates despite more plasma carryover in the former. furthermore, the number of apheresis products with premature low swirling increased by % ( / , ) compared to the previous year without pathogen inactivation ( / , , p . , chisquare) . in contrast, the incidence of premature low swirling in platelet concentrates prepared by the buffy coat method decreased ( / , vs / , ). of note, apheresis concentrates with premature low swirling had a significantly higher median platelet count ( . x ) than unaffected controls ( . x ) and showed signs of increased storage lesion compared to controls expiring on day five without swirling defects. these signs included lower ph, higher lactic acid concentration, increased mean platelet volume, phosphatidylserine exposure and alpha-degranulation. conclusion: the risk of increased storage lesion rates following intercept pathogen inactivation is higher for apheresis than for buffy coat derived platelet concentrates, especially when platelet content is above . x . in vitro quality of single dose amotosalen/uva treated platelets in % plasma/ % pas- after days of storage crystal stanley , marguerite kelher , nero evero , melissa vongoetz , betsy donnelly and anna erickson* . belle bonfils memorial blood center, university of colorado, cerus corporation background/case studies: the interceptv r blood system for platelets is fda approved for the ex vivo preparation of pathogen-reduced amicus o apheresis platelet components (pc) in pas- to reduce the risk of tti, including sepsis, and to potentially reduce the risk of transfusion-associated gvhd. registration studies (clinicaltrials.gov nct ) are in progress to support approval of the trima o apheresis platform for collection of platelets components (pc) suspended in pas- and plasma. the objective of this study was to evaluate in vitro function of platelets suspended in % plasma/ % pas- , collected using the trima platform, after treatment with the intercept blood system for platelets. study design/method: double dose apheresis pc, . . platelets in ml, were collected on the trima apheresis platform in % plasma/ % pas- . a sample was taken from each donation prior to dividing the donation to produce intercept treated apheresis pc (t), using the small volume (sv) set, and an untreated control pc (c). input volumes for replicates, n , were ml (t) and ml (c) with doses of . . (t) and . . (c). all pc were stored under the same conditions and evaluated on day and day for physical/metabolic characteristics. results/finding: on days and all t and c pc had ph c ! . . the dose recovery for t was % %. on day , t had lower count, volume, dose, bicarbonate and glucose compared to c pc; however, parameters predictive of in vivo function (atp, morphology score, hsr, and esc) were equivalent between t and c (table ) . conclusion: trima pc in % plasma/ % pas- treated with the inter-cept blood system for platelets using the sv set and stored for days retained in vitro metabolic and functional properties consistent with in vivo functionality. induction of pluripotent stem cell-derived cardiomyocyte toxicity by supernatant of long term-stored red blood cells in vitro feng-yan fan , , yang yu , li-ping sun , shu-fang wang , rui wang , lei-ying zhang and deqing wang* . the department of blood transfusion, the pla general hospital, the department of blood transfusion, air force general hospital, pla background/case studies: recently, multi researches have reported that longer term-stored red blood cells(rbcs) units were associated with increased risks of clinically adverse events, especially in critically ill patients. however, other studies have concluded the negative results. whether rbcs storage duration was associated with increased risks of clinically adverse events is uncertain and had become a popular topic. to study the adverse effects of longer term-stored rbcs directly, we aim to look at the pluripotent stem cell-derived cardiomyocyte toxicity induced by supernatant of suspended red blood cells(ssrbcs), and study the possible mechanism. study design/methods: five doses of leuko-reduced rbcs were prepared, and supernatant was isolated by centrifugation on d , d and d . we looked at the cardiotoxicity of ssrbcs on human-induced pluripotent stem cell-derived cardiomyocytes (hips-cms). hips-cms were treated with ssrbcs in % final volume simulating the large volume blood transfusion. using real-time cellular analysis (rtca) technology the beating of hips-cms was recorded in real time in detail. levels of k and lactic acid (la) were tested using automatic biochemical analyzer. k and la solution with concentrations being consistent with ssrbcs were prepared and cocultured with hips-cms. we analyzed the cardiotoxicity of k and la solution on hips-cms. treated hips-cms with d ssrbcs, d k and cell culture media for h. the nuclear shape and integrity of filament and sarcomere was examined by immunofluorescence. total rna of hips-cms was isolated and mrna analysis microarray was implemented. screened for toxic effects related signaling pathways through bioinformatics analysis. results/findings: d ssrbcs had no obvious influence on beating state of hips-cms-hips-cms treated with d ssrbcs stop beating, but beating patterns restored at h. hips-cms treated with d ssrbcs stop beating, and beating patterns did not restored at h. levels of k and la in ssrbcs changed most obviously. only d k solution made hips-cms stop beating and can restore in h; d k, d k and la solution did not influence the beating pattern in at the end of the treatment for h, hips-cms treated with d ssrbcs show obvious shrinkage. at the end of the treatments for h, cells treated with d k and d ssrbcs both show obvious shrinkage, the shrinkage in d ssrbcs group was more serious. the immunofluorescence results show the integrity of filament and sarcomere was complete and no nuclear pyknosis was detected. gene expression array results show a total of genes were differentially expressed in d ssrbcs group compared with naive group. there was no consistent separation within the d k and naive group. fifteen differently expressed genes were selected with bioinformatics method which were likely to play an important role in the cytotoxic effect. under the condition of simulating the large volume blood transfusion, ssrbcs of long term-stored rbcs have toxic effect on myocardial cells. in addition to high potassium that induced cardiotoxicity, there must be other elements are involved in the toxic effects. further study should be applied to signal pathways on ssrbcs induced cytotoxicity. large volume transfusion of long term-stored rbcs may be a risk factor for adverse clinical outcomes, and clinical should pay attention to it. background/case studies: processing thawed, deglycerolized red cell concentrates (rcc) in a functionally closed system allows for a prolonged storage after thawing. thawed cells are better maintained in as- as compared to sagm. the presence of citrate in as- seems to be necessary to prevent hemolysis of thawed cells. during storage in as- , atp and , -dpg levels rapidly decline. recently developed additive solutions like pag m and as- have shown to better maintain , -dpg and atp levels during storage of normal, unfrozen, rcc. however, most probably due to the absence of citrate, these solutions are not suitable for storage of thawed cells. we therefore designed pag c in which the mannitol of pag m was replaced by citrate. the aim of this study was to investigate the in vitroquality of thawed, deglycerolized rbc during storage at - c in pag c. study design/method: leukoreduced rcc (n ) in pag c (phosphate, adenine, glucose, guanosine, gluconate, citrate) were stored at - c. on day , rccs were glycerolized using acp (haemonetics v r , braintree, ma) to a final concentration of % (w/v), frozen and stored for at least two weeks at - c. after thawing and deglycerolization using acp , rcc were resuspended in pag c. during storage at - c, stability (hemolysis), atp and , -dpg levels were determined. results were compared with thawed rcc (prefreeze storage in sagm, n ) resuspended in or sagm (n ). results/finding: pre-freeze storage in pag c resulted in increased , -dpg levels at day as compared to storage in sagm, resp. . . mmol/g hb and . . mmol/g hb. hemolysis during post-thaw storage in pag c remained below . % for days and was comparable with storage in as- . in sagm, hemolysis remained below . % for days. during the first weeks of post-thaw storage in pag c, both atp and , -dpg levels increased, followed by a gradual decline during prolonged storage. during the whole postthaw storage period, rccs in pag c showed significantly higher atp and , -dpg levels compared to as- or sagm. while in sagm and as- , , -dpg levels were undetectable after days post-thaw storage, in pag c, , -dpg levels only decreased to . lmol/g hb after days of storage. conclusion: pre-freeze storage in pag c resulted in increased , -dpg levels. as compared to as- , post-thaw storage in pag c showed comparable hemolysis while atp and , -dpg levels were much better maintained. based on a maximum allowed hemolysis of . % and an atp content of > . mmol/g hb, thawed rcc can be stored at - c for days in pag c. background/case studies: platelets (plts) are vital for effective treatment of hemorrhage. cold ( c, c) storage of plts in platelet additive solution (pas) is a promising alternative to conventional storage at room temperature (rt) due to a lower risk of bacterial concerns, preservation of plt function, and mitigation of plt activation. currently only apheresis (ap) and pas systems are fda-approved for use in the us: trima and isoplate-pas (iso; terumo) and amicus and intersol (int; fenwal) . the goal of this study was to assess the adhesive function of long-term cold-stored plts collected by fda-approved ap/pas methods. study design/method: plts were collected (n - ) in % iso using a trima or in % int using an amicus and stored for days at rt and c. samples were tested on day (baseline, bl), , , and of storage to assess plt adhesion under shear flow (bioflux). acd vacutainer tubes were collected from donors and centrifuged to obtain red blood cells (rbcs) for all bioflux runs. simulated whole blood was created by combining plts labeled with calcein-am with rbcs at % hct. labeled blood was perfused through microfluidic channels (fluxion) coated with ug/ml type- collagen at s - shear rate. images were acquired every sec for min using a fluorescent microscope and % surface coverage was reported. data were analyzed using two-way anova and posthoc tukey test with significance at p< . . results/finding: both rt-int and rt-iso plts showed significantly decreased adhesion by day of storage compared to bl (bl: . . %, rt: . . %; p< . ). c-int samples showed no difference in adhesion at any timepoint compared to bl-int but significantly enhanced adhesion compared to both rt-int and rt-iso. in contrast, c-iso plts showed significant enhancement of surface coverage compared to bl-iso by day (p . ) and compared to c-int by day (p< . ). conclusion: our work suggests that c storage of plts collected with a trima ap system in iso for up to days offers a significant enhancement in adhesive function compared to plts collected with an amicus system in int and stored at c. these results are surprising since both c-int and c-iso have been shown to express similar levels of cd p, pac- , and phosphatidylserine and may suggest differences in pas plt intracellular signaling. as expected, storage at c of plts collected on either platform demonstrated superior function to rt storage. a plt product with superior hemostatic function and a shelf-life x longer than the current standard-ofcare provides the potential for shipment of products to underserved areas and may bolster plt availability for trauma care in the us. table . comparisons of white blood cell counts and percentages of apoptotic cells in whole blood components after -week storage between unirradiated and irradiated groups (n ) tang, is an anti-inflammatory agents and has a good safety records in clinic. it could reduce the severity of experimental autoimmune encephalomyelitis (eae), asthma, colitis, systemic lupus erythematosus(sle) and other immune diseases.however,its potential in inducing transfusion tolerance remains to be explored.the aims of our study are to find if baicalin could inhibit red blood cell (rbc) immunization and to elucidate the possible mechanism of yin-chen-tang in preventing hdn. study design/method: we used human red blood cells with adjuvant lipopolysaccharide (lps) and transfused mice to induce antibodies, as an experimental system to study the effect of baicalin on rbc immunization. mice were divided into a normal control group, a human rbc transfused positive control group receiving human rbc and lps intravenously weekly for five weeks, a control group receiveing dexamethasone ( mg/kg/day) intraperitonealy daily for five weeks,a treatment group receiving baicalin ( mg/kg/day) intraperitonealy daily for five weeks. assessment of human rbc immunization was performed by measuring serum immunoglobulin g (igg) and immunoglobulin m (igm) against human rbc weekly. and the lymphocyte changes in spleen are also monitored by flow cytometry. results/finding: we found that baicalin treatment decreased serum igg but not igm production significantly since the second week, with a concomitant reduction in th cells and increase in cd regulatory t cells in both spleen and mesenteric lymph nodes. and there are no significant differences in the percentage of th ,th ,tfh and tfr cd subpopulation among all groups.in addition, baicalin treatment didn't decrease the size of spleen and the percentage of cd positive cells in spleen in baicalin treatment mouse but in dexamethasone treated mouse. our results indicate that baicalin could inhibit rbc immunization especially igg production without the damage to the function of spleen,while dexamethasone as a wildly used immune-suppressive drug in blood transfusion could damage the function of spleen.considering its good safety records in clinic, it may be exploited for suppressing transfusion immunization events. in addition, our results elucidate the inhibitory effect in antibody production of baicalin may be a possible mechanism for yin-chen-tang as a widely used chinese herbal medicines in preventing hdn. comparison of immucor's pak plus and pak lx assays for the detection of human platelet alloantibodies randy m schuller* , sarah kloss , sara crew and sandra j nance . american red cross, american red cross and american rare donor program background/case studies: alloantibodies directed against human platelet membrane glycoproteins (gp) ia, iia, iib, iiia, ib, ix, iv, and cd have been implicated in several clinically significant disorders such as fetal and neonatal alloimmune thrombocytopenia (fnait), post-transfusion purpura (ptp), refractoriness to platelet transfusions, and passive transfer of antibodies in donor plasma. polymorphic epitopes on these gps give rise to unique human platelet antigens (hpa). identification of the specific platelet alloantibody is crucial in diagnosing and treating these bleeding disorders. currently the only k fda approved test permits the identification of these hpa antibodies to the glycoprotein level. immucor has recently released pak lx, a research use only (ruo) assay in the united states that has the ability to identify hpa antibodies to a single nucleotide polymophism (snp). we compared the performance of pak lx to the fda approved immucor pakplus. study design/method: we compared pakplus and pak lx results from plasma and serum clinical specimens. group contained a single hpa alloantibody specificity with or without hla antibodies (n ). group included specimens with hla antibodies alone and group consisted of patient samples that were negative for both hpa and hla antibodies. pak lx utilizes a luminex bead based assay which allows the user to report antibodies to the platelet specific antigen (hpa- , hpa- , hpa- , hpa- , hpa- , gpiv) and hla class i. pakplus uses an elisa method and results can only be reported to the glycoprotein location (gpiib/iiia, gpia/ iia, gpib/ix, gpiv) along with hla class i. however, based upon the pattern of reactivity observed in the pakplus and pak lx assays it is possible to determine the most probable hpa antibody specificity to the hpa snp. results/finding: conclusion: when analyzing hpa antibody specificity, there is % concordance observed for hpa- a, hpa- b and hpa- b antibodies. the pak-plus assay had difficulty discriminating hpa- b from hpa- a antibody when hpa- a antibody was present ( false positive samples) although the pak-plus signal od to cutoff od ratio was significantly higher for hpa- a when compared to hpa- b in these samples. the discordant hla class i antibody results between the assays was isolated to very weakly positive antibody (within % of the cut-off for pakplus and < . adjusted ratio for pak lx). we conclude that pak lx is an easy to use platelet alloantibody screening method that has the ability to differentiate hpa antibodies to the allele level. histo-blood group antigen lewis y promotes cell migration via regulation of microtubule acetylation huijun zhu* and ping lu. shanghai blood center background/case studies: blood group antigens are critical for transfusion practices as antibodies raised against them can cause severe transfusion reaction. beside this, blood group antigens themselves are composed of sugar chains, proteins, lipids, etc, which may be involved in various biological processes. lewis y is a histo-blood group antigen belonging to abh family. ley consists of carbohydrate chains which may play important roles in cell recognition, adhesion as well as migration, which are all critical steps in tumor progression and thus attracts wide researches focusing on its relevance in tumor biology. ley is demonstrated to affect cell mirgration via various mechanisms. however. although changes in cytoskeleton organization is the basis for cell motility, little is known about the association between cytoskeleton and ley. as microtubule and its construction unit tubulin participate in various steps of cell migration, we aim to explore the role of ley in microtubule and cell migration using breast cancer cells, which may provide reference to clinical study of other histo-blood group antigens and change the way of thinking in transfusion practice. study design/methods: we first manipulate ley expression in breast cancer cells by overexpression or sirna knockdown of fucosyltransferases, and block ley activity in mda-mb cells using anti-ley antibody, to verify the effect of ley on cell migration. then, we detect acetyl-a-tubulin level change as microtubule acetylation is a sign for stability. to establish the role of ley in cell migration via microtubule modification, we use hdac specific (tubacin) and nonspecific (tsa) inhibitors to minimize deacetylation of acetyl-atubulin and test again the effect of fut overexpression on cell motility. results/findings: fut overexpression increases both ley expression and cell migration, while fut knockdown leads to the opposite. ley activity blockade by anti-ley antibody also significantly inhibits cell migration. western blot and immunostaining results show a-tubulin acetylation level is negatively related with ley expression. tubacin or tsa treatment increases the acetyl-a-tubulin level while inhibits cell migration; in the meantime, the significance of fut overexpression in promoting cell migration is eliminated. conclusion: it can be concluded from the results above that ley can promote cell migration via regulation of a-tubulin acetylation, wherein ley may have interaction with deacetylase hdac . as tumor promoter, hdac becomes the target of many anti-cancer drugs. we demonstrated the potential association of ley and hdac function in this study. many blood group antigens are also carbohydrate chains, which are not only critical in blood group determination, compatible transfusion and immunological reaction, but may also have an effect in the initiation and development of diseases as tumor, similar to ley; they can even be components in a network with other important molecules and contribute to the destiny of diseases. transfusion of blood products is frequently needed by tumor patients. most attention is focused on the search of compatible blood for reducing transfusion reaction. however, it may lower the chance for the disease to advance to take account background/case studies: reducing the risk of bacterial contamination in platelet (plt) products is of great concern since plt storage occurs at room temperature (rt). pathogen reduction technologies (prt) were developed to inactivate pathogens prior to transfusion; however, studies have shown that prt may damage plts over the course of extended storage at rt resulting in a greater loss of function than what is normally concomitant with platelet storage lesion. storage of plts in platelet additive solution (pas) at c helps to preserve plt function and reduces the risk of contamination. in this study, we established the impact of prt performed after long-term coldstorage of plts in pas, instead of before storage, on plt function, mitochondrial respiration, and cell death parameters. study design/method: plt units were collected in pas (n ) and stored at c for up to days. after this time period, the bag was treated using mirasol prt (riboflavin and uv). samples were obtained and tested on the day of collection (baseline, bl), pre-mirasol (pre), post-mirasol (post), and minutes post-mirasol . aggregometry (adp, collagen, trap), rotem, flow cytometry (cd p [p-selectin] , lactadherin [ps] , , and gpib), high-resolution respirometry (oroboros), and imaging flow cytometry (amnis) were used for analysis. data are reported as means sem, and paired student's t-tests were used to determine statistical significance (p< . ). results/finding: on day , p-selectin levels were significantly higher in pre than bl (p . ). mirasol treatment caused a significant increase in pac- expression compared to pre (pre: . . %, post: . . %; p . ), which remained after incubation. a significant drop in both collagen and trap aggregation was observed in post samples compared to pre, but adp aggregation response was preserved. no differences in p-selectin, gpib expression, and mitochondrial respiration were observed between pre and post samples. post- samples displayed significantly less function, higher activation levels, and lower mitochondrial respiration compared to pre and post. conclusion: prt treatment of plt units in pas after day storage at c presents a unique alternative to prt treatment of plts prior to rt storage. in addition to providing a lower risk of bacterial contamination, c-stored pas plts may provide better preservation of hemostatic function than standard-of-care rt plts, even after mirasol prt treatment. however, we show here that mirasol prt of day c-stored pas plts followed by incubation ( minutes or more) results in widespread cell damage and should be avoided. safety evaluation of lyophilized canine platelets in a model of coronary artery bypass graft (cabg) todd m. getz* , arthur p. bode , anne s hale , michael stanton , mark johnson and g. michael fitzpatrick . cellphire, bodevet, inc, cellphire, background/case studies: cellphire has completed a micro dose clinical safety trial using lyophilized human platelets. cellphire also evaluated the safety of lyophilized canine platelets (lcp) in comparison to liquid stored canine platelets, following intravenous administration in a model of on-pump coronary artery bypass graft (cabg) in the canine. this safety study was in support of a future phase ii human clinical trial in cardiac patients. study design/method: three groups of eight mixed breed hounds underwent cabg to create an anastomosis and were administered lcps equal to , , and . % of the total circulating platelet count (tcpc). one group of four animals served as the vehicle group which received lyophilization platelet-formulation buffer, and another group of four animals received control ( -day old liquid-stored platelets). safety was assessed through the collection of blood loss data, evaluation of blood flow through the bypass graft, evaluation of the development of acute thrombosis, and maintenance of patency through the graft over the hr evaluation period. full necropsies with complete tissue analysis were also performed. efficacy signals were evaluated through the collection of blood loss data and coagulation endpoints (pt, aptt, fibrinogen, and teg). the results demonstrated that administration of the test article at doses up to % of the tcpc was not associated with any unexpected mortality, adverse changes in hematology or coagulation parameters, development of thrombosis at the anastomosis sites, or evidence of adverse thrombosis formation either clinically or microscopically regardless of group. the mortality noted on study was considered to be related to the surgical model and not a result of test article administration. the results also demonstrated that administration of doses of % and % of the tcpc produced a significant decrease in blood loss. the lcps at % and % tcpc were as effective in mitigating blood loss as -day old liquid-stored platelets and trended towards being more effective. no appreciable differences in coagulation parameters were observed between groups. conclusion: the results of the study demonstrate that administration of lcp up to % of the tcpc was safe in a canine cabg model. the data also demonstrate that administration of lcp at doses of % and % of the tcpc reduced blood loss. these results suggest a starting dose above . % tcpc may be required to achieve an effective dose in future human phase ii trials in cardiac patients. although the study was not powered for efficacy, these data indicate a level of safety, as % tcpc had similar efficacy signals as % tcpc with no observable severe adverse events. the starting effective dose may vary depending on the clinical indication. future studies will be required. this study was funded under barda contract hhso c. the study on pcr-ssp technique for the genotyping of cd - del.ac mutation and the genetic polymorphism of cd - del.ac in chinese population lilan li* and guoguang wu. nan-ning institute of transfusion medicine background/case studies: cd (platelet glycoprotein iv, scarb ) is an important and characteristic platelet antigen implicated in immune-mediated thrombocytopenia in chinese population. except anti-hla, anti-cd is the most common antibody of clinically relevant platelet antibodies in chinese population, which is associated with the high frequency of cd deficiency in china. cd gene mutation is the main reason that leads to cd deficiency. cd - del.ac (frameshift at aa ) mutation is one of the cd mutations that causes cd deficiency. have had natural mumps, measles and rubella infections, resulting in lower antibody levels in their blood. the recommendations may thus be unfounded and outdated, and prevent valuable vaccination opportunities for children with frequent blood transfusions. this places an already highly vulnerable pediatric population at risk for acquiring preventable infections. the primary aim of this project was to determine mmr vaccination immunogenicity in patients chronically transfused with rbc. study design/method: medical charts were reviewed for vaccination and transfusion histories. mmr-specific antibodies were quantified in pediatric patients who received both doses of the mmr vaccine at and months of age while they were on a chronic rbc transfusion program for sickle cell disease, b-thalassemia major, diamond-blackfan anemia or pyruvate kinase deficiency. there was no formal control group; long-term immunity rates in the literature are ! % for all mmr components. results/finding: table shows immunogenicity to vaccine components. delays between vaccination and serology testing averaged . years ( . to . years). thirteen patients ( %) were chronically transfused at the time of serology. twenty-three patients ( %) seroconverted to at least one of the vaccine components. conclusion: to the best of our knowledge, this is the first study designed to measure the effect of rbc transfusions on mmr vaccine immunogenicity. although lower than the rates reported in the literature, the results suggest a high rate of immunogenicity to each component of the mmr vaccine in chronically transfused patients immunized prior to months posttransfusion. weighing the risks and benefits of disease prevention in a highly vulnerable population, and taking into account the aforementioned results, a reevaluation of immunization delays post rbc transfusions is called for in chronically transfused infants. post-vaccination serology should be considered. cold stored uncrossmatched whole blood can be safely administered to pediatric trauma patients christine m leeper , , franklyn cladis , richard saladino , darrell triulzi , barbara a gaines and mark yazer* . university of pittsburgh, children's hospital of pittsburgh of upmc, institute for transfusion medicine background/case studies: the use of uncrossmatched cold stored whole blood (wb) is becoming increasingly popular in the initial resuscitation of trauma patients without a current abo group. wb has advantages over conventional component therapy including greater platelet and factor concentrations, as well as less saline and additive solution compared to an equivalent volume of reconstituted whole blood. this report details the initial use of wb in pediatric trauma patients. study design/method: pediatric trauma patients ! years old and ! kg with evidence of hemorrhagic shock were eligible to receive up to cc/kg of cold stored, leukoreduced group o negative wb during their initial resuscitation. all wb units had a low titer of anti-a and -b (< ) to reduce the likelihood of hemolysis in non-group o recipients. biochemical markers of hemolysis were measured on the day of wb transfusion and the following two days. admission thromboelastograms were obtained and repeated as necessary during the resuscitation. after receipt of the maximum quantity of wb, conventional components were utilized. results/finding: in approximately months, trauma patients received wb: group o and group a recipients, % male, median (iqr) age was ( . - ) and % blunt trauma mechanism. patients were severelyinjured with a median (iqr) injury severity score of ( - ) and % mortality rate. the median (iqr) quantity of wb transfused to group o recipients was . ( . - . ) ml/kg versus . ( - ) ml/kg to non-group o recipients. no transfusion reactions were reported. the mean standard deviation haptoglobin concentrations for non-group o recipients was . . mg/dl on day , . . mg/dl on day , and . . mg/dl on day ; the corresponding haptoglobin concentrations for group o recipients were . . mg/dl, . . mg/dl, and . . mg/dl, respectively (p> . for all comparisons). similarly there were no significant differences in total bilirubin, ldh, creatinine, and potassium at any time point. regarding evaluation of cold platelet function, we compared the subset of patients who received wb but no warm platelets (n ) to a historical group of pediatric trauma patients who received conventional components including warm platelets (n ). the mean standard deviation platelet volume administered was cc for whole blood recipients versus cc for warm platelet recipients. when pre-and posttransfusion teg and platelet counts were analyzed, there was no difference in median platelet count or teg maximum amplitude (ma) between cold and warm platelet groups. conclusion: use of cold-stored uncrossmatched whole blood for the resuscitation of pediatric trauma patients is feasible, acceptable, and appears to be safe. receipt of low titer group o wb did not lead to detectable hemolysis amongst the non-group o recipients. given this finding, the maximum quantity of wb per patients will be increased to ml/kg. identification of red blood cell antibodies in human breast milk by novel adaptation of serological method philippe p pary*, alexis leonard, lauren hittson, naomi lc luban, deepika s darbari, yunchuan delores mo, cyril jacquot, valli criss and jennifer webb. children's national medical center background/case studies: human breast milk contains immunoglobulins that are present in maternal serum and secretions. data in mice has demonstrated the potential for kell antibodies to be absorbed enterally from breast milk and impact the survival of transfused kell positive cells; however, methods to test and titer human breast milk for red cell antibodies are lacking. a two week old infant with a history of rh-d hemolytic disease of the fetus and newborn (hdfn), previously treated with intravenous immunoglobulin and phototherapy, was referred for anemia and reticulocytosis. patient was o positive, positive direct antiglobulin test (dat) with anti-human igg only, and a positive antibody screen by gel method. antibody identification showed anti-d in both the plasma and eluate. patient was transfused o negative red cells and discharged. over several weeks, the patient returned twice for persistent anemia requiring additional transfusions. at eight weeks of age, evaluation showed a persistent dat igg reactivity concerning for continued antibody exposure. maternal breast milk was evaluated as a potential source. study design/method: based on similar properties of human breast milk and plasma, testing to identify igg antibodies using a stantard tube saline method was performed with a minute c incubation, followed by automated washes prior to the addition of anti-human igg reagent. as a control, breast milk from an o positive, antibody screen negative mother was used to assess for interference by milk proteins. antibody screens were performed on the plasma of the patient, the patient's mother and the control concurrently using the same method. antibody identification and titers were also performed when indicated. only freshly collected breast milk stored at room temperature for less than days was found suitable for this technique. results/finding: the patient's mother showed plasma anti-d with a titer and the breast milk showed anti-d with a titer between and . the patient had a consistent plasma anti-d titer of . the patient's mother chose to stop breast feeding after weeks, and the patient's hemoglobin was improved at and weeks of age. using this method, we identified two additional cases of breast milk induced hemolysis: another anti-d and an anti-jka. conclusion: testing showed that it is possible to identify red cell igg antibodies in human breast milk using a standard tube saline method. we identified implicated antibodies in the breast milk received by infants with persistent anemia due to hdfn. breast milk titers were generally lower than maternal serum titers, but titers varied depending upon the timing and frequency of breast feeding. cessation of breast feeding correlated with improved hemoglobin in affected infants. background/case studies: red blood cell (rbc) transfusion is lifesaving for patients with sickle cell disease (scd), but is commonly complicated by rbc alloimmunization. despite transfusion protocols serologically matching for c,e, and kell antigens, alloimmunization to rh antigens continues. scd patients often exhibit a hybrid rhd-ce-d gene which is often characterized by the production of a partial c antigen. it has been previously documented that % of c scd patients from the west indies and west and central africa are partial c and at ( %) risk for alloimmunization to the c antigen through transfusion of c rbcs. this study sought to determine the prevalence within a cohort of children with scd at a u.s comprehensive scd center. study design/method: rbc genotyping results performed on all scd patients using precisetype hea array (immucor, norcross, ga) at children's healthcare of atlanta were reviewed and compared to the serologic type for rh (c/c, e/e) antigens. the prevalence of c-antigen positive patients (serologically) was determined overall, and compared to the prevalence partial c antigen based on the detection of the rhce*ce( g, t) allele in the absence of an rhce gene encoding a conventional c antigen in trans, since this allele is commonly linked to the hybrid rhd*diiia-ce( - )-d gene which encodes the partial c antigen. review of the blood bank information system was performed to identify the number of c-antigen positive transfusion exposures and frequency of alloimmunization to the c antigen. results/finding: out of a total of patients with genotype/rh phenotype data available, ( . %) were c antigen positive serologically. the allele frequency of rhce*ce( g, t) was . . in total, ( . %) patients possessed rhce*ce( g, t) in the absence of conventional c gene in trans. of the c antigen positive patients, individuals ( . %) were predicted to be partial c based on four molecular profiles [rhce*ce( g, t)/rhce*ce: ; rhce*ce( g, t)/rh*ce: ; rhce*ce( g, t)/rh*ce( g): ; rhce*ce( g, t)/rh*ce( g, t): ]. in these partial c patients, no anti-c alloantibodies (or other rh antibodies) were detected after transfusion exposures ( c-antigen negative units; mean: , range: - ), likely from placement of a c-negative rbc restriction upon detection of the rhce*ce( g, t) allele. conclusion: this report confirms previous data of a high prevalence of the partial c antigen in scd patients historically typed as c-positive serologically, and demonstrates the benefits of rbc genotyping to prevent alloimmunization to a highly immunogenic rh antigen by identifying individuals who should receive c-negative blood. all patients with scd should have rbc genotyping performed for determination of their rbc phenotype, preferably prior to receiving transfusions. investigational detection of zika virus rna in us blood donors paula p sa a* , megan l nguyen , melanie c proctor , david e krysztof , gregory a foster , erin k sash , sandy s dickson , joua yang , jeffrey m linnen , kui gao , jaye p brodsky and susan l stramer . american red cross, grifols diagnostic solutions inc., grifols diagnostic solutions, inc, quality analytics, inc background/case studies: zika virus (zikv), an emerging flavivirus, is primarily transmitted by infected aedes aegypti mosquitoes, but recent outbreaks have revealed non-vector transmission routes including the unprecedented sexual transmission of an arbovirus. acute zikv infection is mainly asymptomatic or presents as a self-limited disease but also includes severe congenital defects and neurologic disorders. the large proportion of asymptomatic cases, high numbers of returning travelers from zikv-active areas, severe clinical consequences to developing fetuses, the detection of rna in asymptomatic donors during the french polynesia epidemic, and suspected cases of transfusion transmission in brazil led fda to release guidance documents to minimize the risk of zikv transmission via blood/ blood components. study design/method: investigational testing by mini-pool (mp)-nat using the procleix zika virus assay (tma) was implemented on collections from five presumed high-risk us states on / / (fl, ga, sc, ms, al). following revised guidance on / / , testing was extended to all blood donations; conversion from mp-nat to individual donation (id)-nat was implemented in phases and completed on / / . travel history questions were discontinued on / / . confirmatory testing included repeat tma; in addition, rt-pcr, serology and red cell (rbc) tma were performed. estimates of viral loads were performed by end-point tma on plasma and rbcs. results/finding: as of / / , , , donations were tested including , ( %) in , mps. no reactive donations were identified by mp-nat. of the , , id-nat donations, were initial reactive (ir) of which ( %) confirmed positive (cp) by subsequent testing (cp rate of : , ; positive predictive value of %; specificity of . %). five ( %) cp donations were id-nat repeat reactive (rr); ( %) donations were id-nat ir only, igm positive and rna positive in rbcs. cp donors resided in ma, tx, ca, ny, wv and in fl, of which were local transmissions. six donors had traveled to a zikv-active area returning to the us from to days prior to donation. two donors with a travel risk reported clinical symptoms; cp donors ( %) remained asymptomatic. zikv rna was detected in rbcs from all cp index donations with estimated levels varying from less than copies (c)/ml to about Ê c/ml. at the time of writing, the longest period of detection in rbcs was days vs. days in plasma from the same tma-rr donor. zikv rna levels in plasma were obtained from ir and all rr donors, ranging from to c/ml. study design/method: plasma from blood donors were screened by individual donation (id-nat) for the presence of zikv rna with the cobasv r zika test. id-nat samples were repeated in duplicate and further tested by a second nat to confirm infection and estimate vl, and for anti-zikv igm. simulated mps of were prepared by diluting nat plasma : and tested to discriminate id-nat only detectable donations. nat yield samples for which simulated mp and conclusive igm results were available (n ) were sorted into categories corresponding to sequential stages of acute zikv infection: igm-/low vl; igm-/high vl; igm /high vl; igm /low vl. results/finding: of , donations collected april -december , were reactive for zikv rna. igm-index donations had higher vls (mean . x vs . x iu/ml) and higher proportions of simulated mp-detectable results ( % vs %) than igm donations. the distribution by stage of infection was evaluated as the epidemic evolved. over the course of the epidemic, the rates of id-nat only detectible and igm donations increased (table ) . conclusion: this study demonstrates how the viral and immunological profiles of zikv infection in the index donations shifted through the course of the pr epidemic. categorization of index samples into stages of infection is important for blood safety considerations, since infectivity and utility of mp vs id-nat screening likely correlate with vl and serological stages of infection. staging of infections also has implications for diagnostic testing and understanding the durations of zikv viral and immunological markers in blood and persistence of zikv in body fluids and tissues. cobasv r zika is not commercially available for blood screening. data generated under the cobasv r zika ind is preliminary and has not been reviewed by fda. this project has been funded in whole or in part with federal funds detection of zika virus rna in united states blood donations using cobas v r zika on the cobas v r / systems lisa lee pate* , phillip c williamson , michael paul busch , susan rossmann , scott jones , ann butcher , john duncan , jean stanley and susan a galel . roche molecular systems, inc., creative testing solutions, blood systems research institute, gulf coast regional blood center -sugar land, qualtex laboratories background/case studies: in february , the us fda recommended that all blood donations in areas with active zika virus (zikv) transmission be tested with an fda approved nucleic acid test (nat) for zikv rna or treated with an fda approved pathogen reduction technology. the cobasv r zika test was approved under an investigational new drug application on march , and testing of puerto rico donations began on april , . as a precautionary measure some blood centers in the us states also began nat testing for zikv. in august , the fda recommended universal screening of all blood donations. the aim of this study is to describe the detection of zikv rna in blood donations collected in us states between april , -february , using the investigational cobasv r zika for use on the cobas v r / systems. study design/methods: donations were screened with cobasv r zika by individual donation testing. all initial reactive (ir) results were repeated in duplicate. supplemental testing included an alternative nat (altnat) assay which is less sensitive than cobasv r zika and serology testing for anti-zika igm and igg. reactive donors were invited to enroll in follow-up, which included cobasv r zika and serology testing. a donor was considered to be zika confirmed positive if at least one replicate of the repeat testing by cobasv r zika was reactive on index donation or follow-up, reactive by altnat on the index donation, or positive for anti-zika igm on index or follow-up. all ir donations were also retested at a : dilution to simulate mini-pool testing. results/findings: a total of , , blood donations were screened using cobasv r zika. of ir donations, were repeat reactive (rr), non-rr and had no repeat testing. of the rr donations, were positive by altnat; of these were igm positive. all altnat negative donors were igm positive. one donor was alt-nat equivocal and igm negative. of the rr donors that were not igm positive on index, enrolled in follow-up and all seroconverted. of non-rr donations, were altnat negative and is pending supplemental testing. / donors were igm positive on index. donors were igm negative on index; / enrolled in follow-up; remained igm negative and was gm inconclusive. of donations without repeat testing results, met criteria for positive ( was altnat positive, igm negative and altnat negative, igm positive). donation is pending additional testing. altogether, / ir donations met the criteria for true positive on the index donation. / ( %) true positive donations were reactive when retested in a simulated minipool. / were igm positive. conclusion: . % of the , , donations in us states screened for zikv rna were confirmed as true positives. cobas v r zika is not commercially available for blood screening use. using monte carlo simulation luiz amorim* , marc germain , gilles delage , maria esther lopes and yves gr egoire . hemorio, hemaquebec, h ema-qu ebec background/case studies: zika virus was implicated in very large and recent outbreaks, in french polynesia ( ) , and in brazil ( / ), which was followed by outbreaks in south america, central america and caribbean. four probable transfusion transmitted cases were reported in brazil; since % of zika cases are asymptomatic, the actual transfusion rates can be much higher than reported. in this study, we used a monte carlo simulation for risk estimation during the brazilian outbreak. study design/method: the data feeding the monte carlo simulation were collected from january st , through november, th , , from brazil (the whole country) and for rio de janeiro state, one of the outbreak epicenters. the data came from brazilian epidemiologic bulletins and from brazilian blood donation figures. the risk assessment was performed separately for whole blood (wb) donation and for apheresis platelets (ap). the model took into account the following parameters: zika incidence in brazil and in rio; lognormal distribution symptomatic viremia (period: days, with % of the values lower than days); % of infected donors with symptoms lasting days; . donation/donor/year for wb and . for ap. the formula for transfusion risk calculation was: incidence x infectious period x average donation number per donor per year (wb, x/y; aph, z/y) x ( -proportion of refused donors) x ( proportion of discarded donations due to post donation -pd -information). results/finding: the table below shows the results. the estimated risk of transfusion transmitted zika is very important in brazil and in rio de janeiro, where it can attain : , , for apheresis platelets. the severe consequences of zika in vulnerable populations -pregnant women and newborn -indicate that interventions to reduce this unfavorable outcome, such as donor testing and pathogen inactivation, should be considered in brazil dengue (denv) arboviruses in the population are not available in brazil. the objective of this study was to assess the contemporaneous incidence of these agents in donors at large geographically dispersed blood centers located in the southeast and northeast of brazil. study design/method: in the brazil public blood bank system, nat screening for hiv, hcv and hbv is performed on minipools (mp from donations). the residual volume of mp plasma, . - . ml, is routinely discarded. beginning in april each blood center saved $ mps/week for retrospective testing using the triplex zikv, chikv, denv transcription mediated amplification (tma) assay developed by grifols/hologic. mps were shipped to the usa and batch tested at grifols. in the first two weeks (april - ) mp were combined into pools of donations; thereafter mp were tested without additional pooling. to estimate the percent positive donors, the denominator was adjusted to account for the number of donations included in each pool each month and % confidence intervals (ci) calculated using the method developed by biggerstaff. results/finding: the triplex assay performance was shown to have very high sensitivity ( % limit of detection < copies/ml for zikv/chikv/ denvs) and to accurately discriminate each of the arboviruses. testing of the first months of samples is complete for , mp, comprised of , donations collected from april to october , . a total of pools were positive, with detected between april-june . the table summarizes the highest monthly estimated percent positive donors for each virus in each city. months with highest percent postive donors were april or may. at the peak over . % of donors in belo horizonte and rio were viremic for zikv, whereas zika was not evident in donors in recife, but over . % of donors in that city were viremic for chivk during the peak. conclusion: during the latter part of the arbovirus outbreak season in brazil in , zikv, chikv, and denv were being transmitted by mosquitoes to donors with asymptomatic donors donating, indicating that blood recipients in brazil were extensively exposed to viremic blood components. the use of donor mps for surveillance may be one of the most efficient approaches for public health monitoring of the onset and magnitude of arbovirus infections. universal zika screening for blood donors in singapore sally lam* , sze sze chua , mars stone , michael paul busch and ai leen ang . health sciences authority, blood services group, blood systems research institute background/case studies: singapore reported its first locally transmitted zika case on august . the numbers rose rapidly to cases by the end september, with eight clusters (hotspots) of cases island-wide. zika virus (zikv) shares the same mosquito vector, aedes aegypti, as the dengue viruses and can caused microcephaly in unborn fetuses of infected pregnant women and guillan-barr e syndrome, which hastened singapore's blood services group (bsg) to look into securing the safety of blood supply from the zika threat. we aimed to assess the assay performance of usa-fda investigational (ind) procleix zikv nucleic acid technology (nat) assay for universal blood donation screening in singapore to prevent transfusion-transmitted zika infection. study design/method: all blood donations were screened for zika with the procleix zikv nat assay since october . zika nat reactive samples were tested at blood system research institute (bsri) for zika rna in plasma and red cells by pcr and for zika and dengue igm and igg antibodies. a zika confirmed case was defined by the presence of zika rna by pcr and/or zika antibodies. the analytical sensitivity was evaluated using blinded frozen samples consisting of replicates of half log dilutions of the who international standard for zikv and replicates of negative controls prepared by bsri. probit analysis was performed to determine the % and % limits of detection (lod) . clinical performance of the procleix zikv assay was also assessed with local patient samples obtained from institute of infectious disease and epidemiology, singapore and a member blinded zikv reference panel from the usa-fda. results/finding: a total of , donations were screened from october to march , with false positive case and zika confirmed donation detected. alternative zikv pcr tested positive in both the plasma and red cells with an estimated plasma viral load of . x copies/ml. zika igm was negative in the index donation sample but present in the -day post-donation follow up sample.. the donor reported no clinical symptoms. the analytical sensitivity for the procleix zikv assay was determined to be . copies/ml at % lod and . copies/ml at % lod. the procleix zikv assay detected rna in out of patient samples and provided . % agreement to the results of the usa-fda zikv reference material. conclusion: the investigational procleix zikv assay showed good analytical sensitivity and clinical performance, suitable for blood screening of zika infection especially in asymptomatic donor populations. bsg commenced universal zika nat screening by individual donation testing following the zika outbreak with confirmed zika donation (high-titer and seronegative) interdicted, which translates to a risk incidence of in , donations in singapore. background/case studies: a cap/aabb work group suggested that steps be taken to phase in rhdgenotyping for patients with a serologic weak d phenotype. weak d types , and express all the major rhd epitopes and these patients can be managed as rhd-positive, which may lead to a reduction in unnecessary rh immunoglobulin (rhig) administration and conservation of rhd-negative rbcs. study design/method: rhd genotyping was performed on all patient samples with weaker than expected or discrepant rhd typing results, utilizing a commercially available genotyping kit manufactured by immucor (rhd beadchip). initially, testing was performed at a reference lab while the rhd beadchip was validated and implemented at this institution. a serologic weak d phenotype is defined as weak to reactivity on initial gel testing. if genotyping demonstrated weak d types , or , the intent was to manage the patient as rhd-positive. if weak d types , or were not detected, the patient is considered at risk for alloimmunization and treated as rhdnegative. while rhd genotyping results were pending, rhd-negative rbcs were used and if pregnant, the patient was eligible for rhig. results were generally available in to weeks. results/finding: rhdgenotyping was performed on patient samples over months. of these patient samples, ( %) were weak d types or . the remaining samples demonstrated a variety of alleles including known partial d variants (see table) . one patient identified as weak d type required multiple transfusions over the study period, and refused rhd-positive rbcs. the remaining weak d types and patients have not received transfusions at this institution since they were genotyped. four of obstetric weak d types and patients received rhig while genotyping was pending. conclusion: testing and management of patients with serologic weak d phenotypes is not standardized. rhd genotyping may lead to more consistent, personalized patient care and appropriate management of resources. in this month study period serologic weak d patients were identified who could be managed as rhd-positive, however this did not result in withholding any doses of rhig nor conservation of rhd-negative rbcs. genotyping results pertaining to the management of an obstetric patient were discussed with each obstetrician and it is possible this information may impact management of future pregnancies. these outcomes highlight the limitations of current genotyping processes, including long turn-around-time background/case studies: the rh blood group is highly immunogenic and the most clinically significant blood group secondary only to abo. currently, in the united states, blood donors who type rhd-negative by serology undergo weak-d testing to identify some weak and partial states of rhd expression. however, not all rhd expression can be detected serologically. it has been suggested that investigation of serologic rhd-negative blood donors using genotyping methods can more accurately identify units that may lead to alloimmunization in rhd-negative recipients. study design/method: rhd genotyping of all serologic rhd-negative blood donors presenting to our blood donor center was implemented to identify units with altered rhd alleles that should be characterized as rhdpositive. repeat donations were not tested. initial serologic testing of blood donors was performed using fda approved anti-d reagents. when reactivity with all reagents was negative, rhd genotyping was performed using a commercially available genotyping kit manufactured by immucor (rhd beadchip). this assay detects over rhd variant alleles and additional dna sequencing was performed in selected cases. to maximize efficiency samples were batched for testing; testing was generally performed once a month. if an rhd variant known or suspected to be associated with an increased risk of alloimmunization was detected, recipients of previous donations were investigated for evidence of alloimmunization, and all future donations were restricted to rhd-positive recipients. results/finding: over a period of months we tested rhd-negative blood donors. there were ( . %) partial-d, weak d ( . %), and ( . %) del donors. in one donor sample a novel rhd allele was identified through dna sequencing (rhd*ivs - _ deltctc). the phenotype associated with this allele variant is unknown. investigation of previous donations from these donors showed that rhd-negative recipients received rbcs from of these donors. five of these recipients underwent antibody screening after an average follow-up period of months; anti-d was not detected in any sample (see table) . conclusion: serologic testing occasionally fails to identify some rhdpositive donor units, which could place rhd-negative recipients at risk for alloimmunization. dna-based testing can be used to identify donors who have the potential to sensitize rhd-negative individuals. in this limited study period a small number of serologic rhd-negative donors, whose genotype indicated potential to sensitize recipients, were found. however, review of recipient transfusion records indicated that prior exposure to these donors' rbcs did not lead to detectable immunization to date. future potential sensitizing events will be avoided by restricting these units to rhd-positive recipients. grifols diagnostic solutions labs, grifols immunohematology center background/case studies: pregnant women with rhd variants may be candidates for rhig prophylaxis if molecular analysis reveals a genotype associated with possible anti-d formation. proposed testing algorithms advocate molecular characterization of weak d types but if a patient types as rhd-positive, no further action is proposed. women with partial d variants who may also be at risk of anti-d formation have not been included in algorithms proposed to date yet molecular testing may unmask this hidden subpopulation of women who type as d-positive but who may be candidates for rhig prophylaxis. our hospital is in an urban setting in which % of deliveries are to african-american patients. we initiated routine, full-gene rhdsequencing for obstetric patients whose serology demonstrated not only weak d, but also those who were categorized as "d " with reactivity to determine the prevalence of partial d patients in an ethnically-mixed population who may be at risk of anti-d formation. study design/methods: from october to march , we performed routine d typing (neo, immucor) on obstetric specimens followed by rhd sequencing on samples with either a serologic weak d phenotype or anti-d testing strength of using at least antibody. solid phase and manual testing used the series and series reagents. four additional anti-d reagents manufactured by grifols (dg gel anti-d), quotient (anti-d blend), biorad (anti-d (rh ) blend), and ortho (bioclone anti-d) were also used for supplemental testing. rhd sequencing was performed by sanger methodology using routine clinical protocols. results/findings: rhd polymorphisms or variations were identified in all samples. two of ( . %) were d with an rhd gene with only common, known intronic variants that is predicted to produce the "reference" rhd protein (ivs - c, rs ; ivs c, rs ; and ivs a, rs ). two ( . %) were d and heterozygous for two apparently new rhd coding variations which we are confirming by further testing. four ( . %) patients had rhd alleles with known potential to make anti-d (rhd*dol , rhd*dar . , and with weak d type . ). one had weak d type , which has uncertain susceptibility to alloimmunization and one was weak d type , which has not yet been associated with anti-d. interestingly, two ( . %) had variable d expression associated with apparently new alleles, pending ongoing confirmatory testing and cloning. one patient background/case studies: a weak d type is a variant of the rhd protein that comprises an amino acid substitution located in the th transmembrane segment and expresses a reduced amount of the d antigen. this variant is known to be associated with the missense mutation c. g>c which is the first nucleotide of the exon of the rhd gene and thus could be implicated in exon skipping when it is mutated. when performing ngs (next generation sequencing) analysis to fully genotype known patients, we identified an additional variant. study design/method: dna samples were studied by beadchip technology (immucor/bioarray solutions) and ngs using the sureselect human all exon v (agilent) and the nextseq platform. in silico analysis with different bioinformatic tools was used to predict splicing events. furthermore, a functional splicing assay was performed to determine the impact of the nucleotide variations on exon skipping of rhd gene. this study was completed by the comparative modeling between the wild type and the weak type rhd proteins. results/finding: by a targeted analysis of full exome sequencing, we have confirmed the blood group genotype of patients previously characterized by beadchip technology. interestingly, out of carry the c. - c>t intronic variation on the rhd gene, already described and associated with a del allele. among these last patients, one has been previously characterized as rhd weak type carrying the c. g>c (p.gly ala). independently, sanger sequencing on unrelated rhd weak type samples pinpoint to a linkage disequilibrium between c. g>c (exac, maf . ) and the c. - c>t (exac, maf . ). in silico analysis of both mutation located close to the splice acceptor site of the exon does not predict a significant reduction of its strength score. with minigene vectors harboring rhd wildtype exon , mutant rhd c. g>c, mutant rhd c. - c>t and double rhd mutants c. g>c plus c. - c>t, we showed no influence on skipping of exon due to these mutations. comparative modeling of rhd proteins pointed out an additional hydrophobic interaction on the rhd weak type between ala (transmembrane helix ) and val (transmembrane helix ) hampering membrane insertion. conclusion: the c. - c>t variation is always associated in cis with the missense mutation c. g>c on the allele rhd weak type . the c. - c>t can be found alone on the rhd gene as a neutral polymorphism. we assess that these two mutations isolated or combined do not lead to abnormal rhd transcripts. our results clearly demonstrate that the weak d antigen reactivity observed with rhd type red blood cells is due to the substitution of alanine at amino acid position to glycine. topology of jk-weak or jk-negative single-nucleotide missense variants in the kidd protein glenn ramsey*. northwestern university background/case studies: the human urea transporter-b (hut-b) protein carrying the kidd blood group has transmembrane (tm) and tilted ureapore a-helices, a long extracellular connector segment, and cytoplasmic segments at each end. numerous single-nucleotide missense variants (snmvs) weaken or abolish expression of jk a/b antigens determined at p. . we mapped all reported jk-weak or jk-negative (jk-neg) snmvs onto the hut-b structure to explore topological correlates of jk antigen expression. study design/methods: jk*a and jk*b snmvs affecting jk expression were compiled from dbrbc and isbt registries, literature searches and - aabb, isbt and british blood transfusion society meeting abstracts. snmv locations were correlated with the human homolog of the x-ray-crystallographic structure of mammalian ut-b derived for analysis of ut function (levin ej, ) . results/finding: seven snmvs located within amino acid (aa) from the exofacial or internal end of a tm helix are mostly weak variants (table) . all at the exofacial ends (p.a t, p.w r, p.v d) are jk-weak; the two jkneg exceptions p.g e and p.g e are at the internal end of the tm helix bearing jk a/b . four snmvs in the cytoplasmic n-terminal segment are mostly weak variants. in contrast, snmvs within membrane helices are mostly jk-neg variants. three jk-weak snmvs (p.v m, p.e k, p.v i) have been associated with allo-anti-jk a/b to the antigen on their alleles ("weak partial"). six of the jk-neg variants are within aa (p. -p. ) of jk a/b at p. . none of these snmvs are in the long extracellular connector region or the cytoplasmic c-terminal segment. jk-neg variants p.n s and p.s p are adjacent to p. f and p. l which line part of the urea transporter pore. conclusion: in the transporter-structured rhd and rhce proteins, snmvs with weak d, c, c, e or e expression are mostly within the rbc membrane, and non-canonical antigen-negative snmvs are unusual. in the structurally similar kidd hut-b, most jk-weak snmvs are at the ends of the tm helices or in the n-terminal cytoplasmic segment. among jk-neg snmvs, most are in membrane helices. however, whether a variant appears jk-weak or jk-neg may depend on the extent of testing. next-generation sequencing may provide more complete structure-antigen correlations. background/case studies: the kidd-null blood group is most often inherited as a recessive genetic trait due to biallelic mutations in the slc a gene, which encodes the urea transporter ut-b . the kidd-null phenotype is associated with transfusion risk and also is associated with abnormalities in the ability to concentrate urine. the cause of the identical kidd-null phenotype with dominant inheritance [in(jk)] has not yet been defined, though it was first described in . in contrast to recessively inherited kidd-null phenotype, this is not associated with mutations in the slc a gene. the aims of the studies was to identify and characterize the causative gene for dominant kidd-null red blood cell phenotype (injk). jk-weak (bold)/ jk-neg expression n within aa from tm a-helix end v i, a t, w r, w r, g e, g e, v d* cytoplasmic n-terminal v m, g s, e k, l p in membrane tm and urea-pore a-helices r w, r q, g d, i t, a v, l r, a t ‡, a a §, l f, n s, s p, t m / * second nucleotide variant in this allele is synonymous (p.p p). ‡reported as jk-neg but considered jk-weak by isbt. §near splice point. study design/method: we identified several families with dominant inheritance of the kidd-null phenotype in multiple kindreds in spain. we performed whole-genome linkage analysis, exome sequencing, expression (rt-pcr and western) analyses, and urea lysis using patients' cells. in addition, two probands underwent urine concentration tests. results/finding: using molecular approaches, we mapped the affected locus to a mbp region in q . - . with an lod score of . . using deep sequencing, we identified a potential deleterious mutation in the znf gene, which deletes bp resulting in loss of an entire zing finger domain. the identical del -znf mutation is present in all affected individuals, and is absent from all controls tested (n> ). in addition, two adult individuals who are homozygous for the entire haplotype including the deletion within the znf locus, thus completely lacking the common allele, were identified. we also obtained dna from an unrelated injk individual reported from japan. in this individual, there was a similar, though not identical, znf del . none of the other potential genetic variants identified in the spanish kindreds was present in the dna from the injk individual from japan. consistent with the fact that the kidd antigen, encoded by the slc a gene, is a urea transporter that has been associated with renal function, we found that people with the znf del in spain had an inability to concentrate their urine. conclusion: a predicted zinc finger deletion at znf , prevalent in southern spain due to a founder mutation, leads to ut-b dysfunction and underlies the dominantly inherited kidd-null blood phenotype. the phenotype associates subnormal urine concentrating ability. in background/case studies: di-( -ethylhexyl) phthalate (dehp) makes pvc film flexible and useful for blood products. during storage, dehp can leach from the bag film into solution and be metabolized. studies in rodents have suggested that exposure to dehp may be associated with adverse health effects, albeit at high dosages. attempts to find dehp alternatives for blood bags have been difficult due to the rbc membrane-stabilizing effect of dehp. bis( -ethylhexyl) terephthalate (deht) a non-ortho-phthalate is structurally and functionally similar to dehp, but distinct from a metabolic and toxicological standpoint. deht can undergo complete hydrolysis and has an excellent safety profile; it is not classified as a carcinogen, mutagen, reproductive toxicant or endocrine disruptor. the study objective was to evaluate the quality of fresh frozen plasma (ffp) stored in deht containers versus ffp stored in dehp containers at days and year. study design/methods: thirty-six wb units were collected into cpd solution, leukoreduced, centrifuged, and separated into rbc and plasma. abo identical plasma units were pooled together in groups of three. the pools included group a, group o and group ab. each plasma pool was weighed, mixed, sampled, divided into dehp and deht pairs, and frozen at less than - c within hours of collection. in vitro plasma testing (pt, aptt, factor v, factor viii, fibrinogen, protein c, and protein s) was done on day (pool), day , and year of storage. dehp and deht paired plasmas were thawed and tested at the same time. plasticizer concentrations were determined on day , day , and year of ffp storage. dehp and deht and their monoesters were analyzed by liquid chromatography-mass spectrometry. internal standards were deuterated-dehp, mehp, deht and meht. the lower limits of quantification (lloq) were: dehp . ppm; mehp . ppm; deht . ppm; and meht . ppm. results/findings: mean and standard deviation (sd) for key clotting factors and plasticizer results are summarized in the table. there was no statistical difference in any plasma parameter between dehp and deht bags at the same time period. factor viii retained greater than % of its initial value. plasma stored in deht bags had an average plasticizer content % lower than that of the dehp bags. background/case studies: plasma prevents dilutional coagulopathy in trauma victims by replacing coagulation factors and substrates during resuscitation with red blood cells (rbcs) and/or crystalloid solutions. spray-dried plasma (spdp) is lightweight and can be reconstituted in minutes making it ideal for use in combat and pre-hospital settings to rapidly provide plasma in situations where it is impractical to administer fresh frozen plasma (ffp). the spray-drying process preserves coagulation proteins, but high molecular weight multimers (hmwm) of von willebrand factor (vwf) are decreased. the objective of this study was to compare spdp and ffp in reconstituted whole blood (rwb) to test the hypothesis that spdp is not inferior to ffp in facilitating platelet adhesion and thrombus formation. study design/method: under an irb-approved protocol, whole blood from healthy volunteers was collected into sodium citrate and centrifuged at g to separate rbcs from platelet-rich plasma (prp). prp was diluted -fold in pipes-saline with . mm pge and centrifuged at g. the platelet pellet was resuspended in either spdp or ffp and recombined with the packed rbcs to create rwb with hematocrit of - % and , - , platelets/ml. in addition, two rwb pairs were reconstituted with spdp diluted : (spdp %) with plasma from a patient with type vw disease (t vwd). samples were fluorescently labeled with a gpiibiiia-specific antibody and the sample was flowed through a type i collagen-coated microchannel at a shear rate of s - for seconds. still images of adherent platelets and thrombi were captured in order to calculate surface area coverage (sa) along the length of the channel. ratio paired t-test was used to compare sa in samples reconstituted with spdp vs. ffp. the margin of noninferiority was % (spdp/ffp > . ). results/finding: six batches of spdp/ffp were evaluated using subjects. there was no statistical difference between the spdp/ffp pairs (p . ). the mean ratio of spdp/ffp was . with a % ci of . - . . comparing spdp vs. spdp %, there was no difference (median ratio . , range: . - . ) in sa. two-way anova demonstrated that batch did not significantly affect ratio of sa in spdp vs. ffp. conclusion: spdp, despite a decrease of vwf hmwm, was not inferior to ffp in ability to support platelet adhesion and thrombus formation. on average, sa in samples reconstituted with spdp was % greater than in samples reconstituted with ffp. the lower limit of the th % ci is a difference of %, which is less than the a priori determined margin of noninferiority of %. even with % dilution with t vwd plasma, there was no reduction in platelet adhesion and thrombus formation in the spdp rwb samples. these data support the development of in-human studies to evaluate the efficacy and safety of spdp in preventing and reversing trauma-related coagulopathy. spray-dried plasma deficient in high molecular weight multimers of von willebrand factor retains hemostatic properties michael a. meledeo* , qiyong peter liu , grantham c. peltier , ryan c. carney , ashley s. taylor , colby s. mcintosh , james a. bynum and andrew p cap . u.s. army institute of surgical research, velico medical inc background/case studies: restoring coagulation factors is key in acute resuscitation after traumatic hemorrhage, but blood products are frequently unavailable in emergency response due to shelf-life restrictions and storage needs. a single unit spray dried plasma (spdp) process has been developed that produces a long-lived and readily stored product that has a reduction in high molecular weight multimers of von willebrand factor (vwf) and an increase in low molecular weight multimers. vwf is critical in platelet adhesion and thrombus formation. following work demonstrating enhanced function with use of glycine-based reconstitution solutions for spdp, this study examines two different spdp pretreatment conditions. study design/method: the samples were: ( ) ffp; ( ) ffp with mm glycine; ( ) regular spdp without pretreatment (rspdp), rehydrated with glycine-hcl:glycine; ( ) spdp pretreated with glycine-hcl ( mm); and ( ) spdp pretreated with glycine-hcl:glycine ( mm: mm; both pretreated were rehydrated in water). six donor-matched plasmas of each type were tested. vwf activity was measured by ristocetin cofactor assay. fibrin polymerization kinetics were analyzed by turbidimetry. thrombin generation (tg) was observed by thrombogram. chemistry was evaluated by i-stat. residual cell material was quantified by flow cytometry. coagulation properties were measured by thromboelastography (teg) in plasma and reconstructed whole blood ( % hct with platelets/nl from typematched donors). platelet adhesion to collagen under shear was measured by bioflux. results/finding: pretreated spdp showed enhanced vwf activity over rspdp (p < . ). fibrin polymerization density was slightly diminished in rspdp vs. ffp ( . vs. . o.d., p < . ), but tg was unchanged. bicarbonate/base excess were lower in spdp samples vs. ffp (p < . ). residual cellular material (especially platelet-derived) was reduced threefold in rspdp vs. ffp (p < . ) and an additional twofold in pretreated spdps vs. rspdp (p < . ). teg results were unchanged in plasma-only samples; in reconstructed wb there was a reduction in amplitude (clot strength) in all spdp samples vs. ; p < . ). platelet adhesion was equivalent in pretreated spdps and ffp, while rspdp was improved vs. all other samples ( . % surface coverage vs. . - . %, p < . ). conclusion: spdp has a longer shelf life and easier storage requirements than ffp and was equivalent or superior to ffp in most of these in vitro assays. spdp pretreated with glycine solutions was similar to ffp in most assays and showed superior vwf activity and fewer residual cellular materials but inferior support for platelet adhesion to collagen while under flow compared with untreated spdp. clinical significance of these findings is unclear, but overall in vitro outcomes suggest clinical studies are warranted. the interaction between red blood cell transfusion and lung injury: the influence of blood component manufacturing methods mathijs wirtz* , anita tuip-de boer , ruqayyah almizraq , jason p. acker , philip j. norris , jennifer a muszynski and nicole juffermans . academic medical center, university of alberta, canadian blood services, blood systems research institute, nationwide children's hospital background/case studies: red blood cell (rbc) transfusion is associated with acute lung injury, in particular in patients on mechanical ventilation. the causative factor is not known but may include residual cells or extracellular vesicles (evs) . in this study we investigated the functional effect of different manufacturing methods of rbc products on the response of pulmonary cells in an in vitro model of mechanical ventilation. study design/methods: groups of rbc products (whole blood filtered [wbf] , red cell filtered [rcf] , apheresis derived [ad] and whole blood derived [wbd]) were manufactured from donors (blood type a or b). supernatants were prepared after - (fresh) and - days of storage (stored) for measurement of thrombin generation and ev analysis. a type ii alveolar cells were seeded onto flexible membranes and incubated with rbc supernatant. cells were subjected to % stretch using a cellstretcher. control cells were not stretched. after hours, il- and il- production were measured. results/findings: both fresh and stored supernatants from ad products significantly increased pulmonary cell il- and il- production compared to incubation with other rbc products and non-incubated controls, which was further exacerbated by cell stretching. ad products also had significantly increased thrombin generating ability compared to other rbc products, as well as a significantly increased number of rbc-derived evs compared to rcf and wbd products (p< . ) . incubation of stretched cells with stored wbf products resulted in higher il- production compared to other blood products and stretched controls. rcf products did not activate pulmonary cells, had an absence of tg and had low levels of evs compared to other products. conclusion: manufacturing methods markedly influence the interaction of rbc products with lung cells. ad products activate lung cells, which is further aggravated by cell stretching. this may in part be mediated by rbc-background/case studies: investigators previously demonstrated immunosuppressive effects of rbc supernatant on monocytes in vitro, with greater effects seen in response to older units. recent clinical data suggest that rbc manufacturing method may influence immunomodulatory potential, but this has not been directly measured. we used in vitro models to test the hypothesis that rbc supernatants obtained by different manufacturing methods will have differential effects on monocyte function. study design/method: rbc products were manufactured by different methods from individual donors, each: (whole blood filtration [wbf] , red cell filtration [rcf] , apheresis, and whole blood derived [wbd] ). rbc products were stored in sagm (wbf and rcf) or adsol-containing preservative solution (apheresis and wbd). supernatants were obtained after - days (fresh) and - days (expiry). monocytes were co-cultured in media plus % rbc supernatant or media only (control) followed by lps stimulation. experiments were performed in replicates, each with a distinct monocyte donor. comparisons between groups by anova with dunnett's post-test for multiple comparisons. data are mean sd of % of control values. results/finding: exposure to apheresis or wbd rbc supernatants suppressed monocyte lps-induced tnfa production capacity compared to controls (table ) . this was true for fresh units and those at expiry. for monocytes exposed to rbc supernatant alone without lps, interleukin- production was higher after exposure to fresh wbf ( % control, p . ) or wbd at expiry ( % control, p . ). conclusion: manufacturing method and/or storage solution significantly alters immunomodulatory effects of rbc supernatant on monocytes in vitro and may confound analyses of clinical effects of rbc storage duration, particularly within international multi-center studies. a magnetic levitation system to study the impact of donor gender, age and blood storage conditions on red blood cell density profile gozde durmus* , alessandro tocchio , anita howell , kaushik sridhar , jason p. acker and utkan demirci . stanford university, canadian blood services, centre for innovation, background/case studies: the amount of hemolysis in red blood cell units increases as the product ages and has been shown to be lower in female blood donors than in males. it is hypothesized that female donors possess, on average, a younger population of red cells, which results in the lower hemolysis that is observed in the pre-menopausal population. it is also hypothesized that the differences between donor populations are mitigated by lysis of older cells when whole blood units undergo processing steps to produce red cell concentrate (rcc) units. as red blood cells (rbcs) age in circulation, they undergo characteristic changes in density and membrane composition that allows for them to be separated from younger cells. study design/method: our aim is to study the effect of donor factors and method of manufacturing and storing conditions on the average rbc age and density of red cell units. we have recently developed a powerful yet simple and inexpensive magnetic levitation-based platform, which allows realtime, high-resolution imaging and monitoring of various cell populations. this label-free system allows density profiling for individual red blood cells, with an unprecedented resolution of - g/ml. first, to determine the effect of rcc storage on the density profile of rbcs, levitation and single-cell density profiles were measured at , , , , and days. in addition, to determine the effect of donor age and sex on the rbc density profile, blood samples from volunteers with four different age and sex categories (male, - years; male, > years; female, - years; female, > years) were profiled. results/finding: first, we observed that the levitation and density profiles as well as morphology of rbcs within rcc units change significantly during storage. in addition, rbc density was significantly different between young ( . g/ml) and older female donors ( . g/ml) (p < . ). moreover, rbcs from young males ( . g/ml) were significantly less dense compared to rbcs profiled from older female donors ( . g/ml) (p < . ). conclusion: we have developed a magnetic levitation system for the point-of-care, real-time evaluation of rbc and red cell concentrate (rcc) quality. we envision our results might inform decision makers about impact that donor deferral criteria may be having on the quality of red cell concentrates available in the blood banks, for the optimal clinical outcomes. cytokine production of pulmonary cells il- (pg/ml) il- (pg/ml) background/case studies: oxidation reduction potential (orp) or redox is the ratio of activity between oxidizers and reducers. redox imbalance caused by a higher production of reactive oxygen species (ros) and reactive nitrogen species or a decrease in endogenous protective antioxidants results in oxidative stress (os). while os can cause cellular injury and death, it is also important in the regulation of a healthy immune response to injury or disease. in the present study we investigated changes in hemoglobin, free heme, and orp as red blood cells (rbc) age and the effects of red blood cell age on icu patient morbidity and mortality. study design/method: icu patients were enrolled in this prospective observational trial investigating the effect of transfused rbc age on icu patient morbidity and mortality. all rbcs were pre-storage leukoreduced and abo identical. citrated blood samples were collected from each rbc unit prior to issue. the rbc supernatants were tested for free hemoglobin/ heme and orp. the patients were followed prospectively. results/finding: a total of rbc units were transfused. patients and rbc characteristics are shown in the table. significant reductions were detected in orp values over storage duration (p< . ). substantial correlations were also found between orp and free hemoglobin (p< . ) and orp and free heme (p< . ). interestingly, there was a statistically significant difference between the average orp values of the transfused rbc in patients who developed infection with higher orp values measured in rbc units given to patients who developed post-transfusion infections vs (p< . ). no significant differences were observed between orp and patient mortality, hospital/icu days, or thrombosis. also, no correlations were detected between free heme/hemoglobin or rbc age and infection development. conclusion: these data demonstrate that older blood has lower orp values as well as increased free heme/hemoglobin. there were no differences in orp values between the different blood groups once rbc age was controlled for and there were no statistically significant differences in patient mortality associated with orp, free heme/hemoglobin, or rbc age. the decreased orp values observed in the older blood are likely attributable to the "storage lesion". higher transfused rbc orp values were associated with subsequent development of infection, and younger rbcs were found to have higher orp values. thus, this data supports that young/fresher blood may predispose to subsequent development of infection in critically ill patients. further studies are needed. background/case studies: no randomized trials in humans have addressed whether only exposure to red blood cells (rbcs) that have been stored for a long time is associated with harm. we explore the effect on inhospital mortality of transfusing rbcs stored for more than days compared to rbcs stored for days or less. study design/method: data from a multi-national randomized controlled trial were used for this exploratory analysis. the patients were hospitalized adults who required transfusions and were randomly allocated to receive the freshest rbcs in inventory or the oldest (standard issue) rbcs providing a large cohort of patients receiving rbcs with storage durations along the entire rbc storage continuum of to days. using a time dependent variable patient exposure was defined by the maximum storage duration of rbcs received. this was then used to classify individuals on each day of hospitalization into one of three mutually exclusive exposure categories: freshest (exclusively exposed to rbcs less than or equal to days storage duration -reference group), medium age (at least rbc of - days storage), and oldest (at least rbc greater than days storage). the primary outcome was all-cause in-hospital mortality. cause-specific cox regression models of in-hospital death assessed the effect of exposure of rbcs in each category to exclusive exposure to rbcs stored for days or less. the effects of fixed and time-dependent confounders were dealt with through stratification and regression. sensitivity analyses were conducted with a) weekly partition with cut-points every days, and b) a finer partition using cut-points every days. results/finding: , patients receiving , rbcs were included in the analysis. exposure to rbcs stored for more than days was not associated with increased risk of in-hospital death compared with exposure exclusively to the freshest rbc units (stored for days or less) after adjusting for several fixed and time-dependent potential confounders (hr . ; % ci: . , . ; p . ). exposure to blood stored for at most - days yielded a similar hazard ratio (hr . ; % ci: . , . ; p . ). in the sensitivity analyses using weekly partitions, exposure to rbcs stored for greater than days compared to exclusive exposure to rbcs stored days or less was not significant (hr . ; % ci . , . ; p . ). the confidence intervals around the hazard ratios for the other -day intervals all include . similar findings were obtained with partitioning exposure data into day intervals where exposure to rbcs stored for - days was not associated with increased risk of death compared with exclusive exposure to rbcs stored for - days (hr . ; % ci . , . ; p . ). the confidence intervals around the hazard ratios for the other -day intervals all include . conclusion: individuals exposed to rbcs stored for more than days were not at increased risk of in-hospital death compared to individuals exposed exclusively to rbcs stored for days or less. transfusion of anaerobically stored red blood cells improves recovery in experimental rat hemorrhagic shock model alexander williams* , cynthia walser , tatsuro yoshida , andrew dunham and pedro cabrales . university of california san diego, new health sciences inc. background/case studies: hemorrhagic shock (hs) severely decreases oxygen (o ) delivery and induces cardiovascular collapse. in parallel to controlling the hemorrhage, clinicians respond by infusing large volumes of red blood cells (rbcs) to restore blood volume, o carrying capacity, and hemodynamic stability. the quality of the transfused rbcs determines the recovery from hs, and extent of clinical sequelae prompted by the hs. this study compares the ability to recover from hs with conventionally stored rbcs, anaerobically (o saturation < %) stored rbcs, or anaerobic/hypercapnic (o saturation < % and pco (@ c) $ mmhg) stored rbcs. study design/method: packed red blood cells (prbcs) stored in as- after leukorfiltration were created from donor sprague-dawley rats. prbc units were randomly stored under either ) conventional; ) anaerobic; or ) anaerobic/hypercapnic conditions. rats ( - g) were hemorrhaged to % of blood volume, held in hypovolemia for minutes, and resuscitated to recover blood pressure to % pre-hemorrhage with prbc stored for either or weeks. systemic hemodynamics, cardiac function, and blood gas parameters were monitored during shock and resuscitation; and vital organ inflammation, oxygenation, and function were evaluated post resuscitation. data were analyzed using two-way anova, followed by the appropriate post hoc analyses. ( %) neg patient showed short term response and ( %) patients showed progressive disease. at the neg group standard eval ( %) patient showed response and ( %) had progressive disease. ( %) neg patient had long term response compared to ( %) pos patients. at the pos short term eval ( %) patients showed response and ( %) patients had progressive disease. at the pos group standard eval, ( %) patients showed response and ( %) patients had progressive disease. overall, ( %) pos patients responded compared to ( %) neg. conclusion: there is a trend in lower response rate in patients with negative antibody screens compared to positive controls. these findings suggest that an anti-cd neutralizing substance could play a role in treatment response. alternatively, reduced cd expression may also contribute. the low response rates seen in both groups may result from biased selection. the need for repeat t&s and presumed repeat transfusions may be preselecting patients with more aggressive disease. also, only a small number of patients were suitable for review. a larger prospective study that controls for such variables is needed. a review of blood utilized during provider-activated and critical administration threshold-triggered massive transfusion events patrick ramos* and john hess. division of transfusion medicine, harborview medical center background/case studies: traditional definitions of massive transfusions -e.g., the transfusion of ten or more units of red blood cells (rbcs) in a -hour period -are limited in prospectively identifying patients requiring massive transfusions, excluded patients who may not survive long enough to meet criteria, or ignored the acuity of the event. to address these issues, a level i trauma center adopted the critical administration threshold (cat) as an additional indication for activating its massive transfusion protocol (mtp). this study reviewed blood utilized during massive transfusion events based upon whether the mtp was provider-activated versus cat-triggered. study design/method: all massive transfusion events between january and april were reviewed to identify the start time, termination time, number of components transfused, and the start time of each component transfused. the transfusion of three or more blood components in an hour defined cat. a massive transfusion was any event in which the concern for hemorrhagic shock either necessitated a provider to activate the mtp or blood components were transfused at a rate that met cat criteria. the massive transfusion start time is based on either the time the provider activated the mtp or the time the first blood component was transfused, whichever came first. unless the patient expired first, the termination of the massive transfusion event was determined by identifying the point in time in which the patient went three or more hours without the transfusion of any additional blood components. this information was tabulated to determine the monthly number of provider-activated mtps, cat-triggered mtps, and average blood component transfused per massive transfusion. conclusion: blood utilization is lower within the cat-triggered mtps even though it outnumbered provider-activated mtps. however, the mode for both groups suggests that most massive transfusion require less blood components than the average rate. using the mode provides an approximate % replacement of blood volume. this should be enough to counter the early signs and symptoms of hemorrhagic shock. though this study did not review the appropriateness of provider-activated mtps, using cat as an indicator ensures clinicians are prepared for a potential massive transfusion. further investigation is needed to determine the factors contributing to the downward trend of the average blood components transfused. the mode would suggest optimistically that patients are being stabilized faster and resuscitated more efficiently. if this is the case, defining massive transfusion should include the rate of components transfused in addition to the total volume transfused. the long term storage effect of . m dithiothreitol on red cell antigen integrity in reagent red blood cells heike carrel* , laurie sutor , , germ an leparc , marjorie doty and william crews . carter bloodcare, ut southwestern medical center, oneblood background/case studies: anti-cd drugs, such as daratumumab, pose a problem for the transfusion service. they may cause a number of false positives, including positive direct antiglobulin tests (dat), indirect antiglobulin tests (iat), and panreactivity in eluates. such results can prolong compatibility testing and delay delivery of blood products for patients. treating reagent red cells (rrbcs) with . m dithiothreitol (dtt) removes drug interference due to daratumumab and allows for the detection of underlying alloantibodies. this study aimed to investigate the effect of dtt-treatment on rrbc antigen integrity over a day period. study design/method: twelve aliquots of human plasma, each containing an antibody of a single, known specificity (anti-d, -c, -e, -c, -e, -m, -s, -s, -fy a , -fy b , -jk a , and -jk b ), were tested against untreated and . m dtttreated rrbcs (immucor panoscreen i, ii, iii; dtt from acros organics). dtt treatment of rrbcs was performed using the methodology described in the aabb technical manual ( th edition). each of the plasma aliquots was further separated into aliquots and stored at - c until day of use. fresh aliquots were thawed each day to avoid unintended antibody integrity degradation. a polyethylene glycol (immucor) enhancement technique was used and reactions were read at the iat phase. hemolysis, if present, was observed in the diluent each day prior to mixing the cell suspension and given a grade based on the haemonetics color comparator chart. serological antibody reaction strengths were observed and documented each day. ( ) a monthly breakdown for both groups also displayed a downward trend in the average use of blood components. results/finding: there was noticeably more hemolysis with the dtttreated cells over time compared to the untreated cells. red cell antigens remained serologically detectable on the dtt-treated cells throughout the study, despite a greater degree of observed hemolysis. there was minimal difference in reactivity strength between untreated and dtt-treated cells for antigens not affected by dtt. in most instances, the dtt-treated cells reacted slightly more strongly. none of the antibodies produced reactivity strengths of less than with the untreated or dtt-treated cells during the study. conclusion: long term storage of . m dtt-treated rrbcs does not compromise antigen integrity. advance dtt-treatment and storage of a large aliquot of rrbcs may serve to increase efficiency in the transfusion service. background/case studies: monocyte monolayer assay (mma) is a cellular bioassay used to evaluate the hemolytic significance of blood group antibodies and aid in the selection of rbcs for alloimmunized patients. the requirement for fresh auto/allogenic monocytes for mma is highly restrictive due to tedious processing of fresh peripheral blood (pb). our previous study described processing and cryopreservation of buffy-coat (bc) derived and fresh pb-monocytes for mma assay. the aim was to evaluate the functional properties of cryopreserved bc-monocytes as substitute for fresh pbmonocytes in mma in evaluation of previously reported clinically significant rbc alloantibodies. study design/methods: peripheral blood mononuclear cells (pbmcs) were isolated from buffy-coats (histopaque- ), pooled, suspended in cryopreservation media ( % dmso; : ) and stored in liquid nitrogen. pbmc membrane integrity post-thaw was determined by trypan blue exclusion. pbmcs were cultured on poly-l-lysine-treated coverslips ( c, % co , h) and monocyte monolayers incubated with fresh or cryopreserved antigen positive (o ) rbcs sensitized with either anti-d (positive control), anti-scianna- (sc ) or anti-anwj or lipopolysaccharide stimulated for h. aliquots of the sensitized rbcs were tested for opsonization by indirect antiglobulin test (iat). phagocytosis index (pi) was determined microscopically as the number of fully phagocytosed rbcs/ monocytes. supernatants were analyzed for cytokines using luminex technique. results/findings: cryopreserved pbmcs showed . % viability postthaw. we report no significant difference in phagocytosis of anti-d sensitized rbcs by cryopreserved monocytes vs fresh monocytes. we show a significant increase in tnf-a, il- b, il- , il- , mip-a (p < . ), mip-b and gro (p < . ) secretion from cryopreserved bc monocytes vs both fresh bc and pb-monocytes. sc -and anwj-sensitised rbcs resulted in a pi of . % and . . % respectively vs anti-d sensitized rbcs (pi: . %). a weak ( ) reactivity by iat was observed for anti-anwj sensitized rbcs while anti-d sensitized rbcs resulted in iat reactivity. these results correlated with previously reported results for clinical significance and mma when using freshly obtained autologous or healthy donor monocytes. conclusion: this study shows that cryopreservation preserved monocyte viability and phagocytosis function for mma. as previously reported with fresh monocytes mma assay, the two alloantibodies tested with cryopreserved bc monocytes were shown to have a phagocytic index of clinical significance (pi> %). the use of cryopreserved bc-monocytes has the ability we describe antigen typing discrepancies in patients, involving antigens (c, jk a , s), revealed when serologic results differed from the phenotype predicted by dna testing. all patients had - positive dat with anti-igg and warm autoantibodies identified in the plasma. investigation of the antigen typing discrepancies showed both false negative and false positive results using monoclonal reagents. study design/method: standard tube hemagglutination methods were used for antigen typing. rbcs were treated with edta glycine-acid (ega) using gamma ega kit. genomic dna was isolated from wbcs and hea precisetype performed. results/finding: the rbcs of patients and typed c-on initial testing with immucor gamma-clone anti-c, but were predicted c by hea precise-type. ega-treated rbcs gave reactions with the same anti-c reagent. patient rbcs gave variable reactivity (vw- ) with bio-rad seraclone and ortho bioclone anti-c. patient rbcs gave reactivity with all anti-c reagents when incubated for the maximum incubation time allowed. patient rbcs were jk(a ) with immucor gammaclone anti-jk a , which the manufacturer states is suitable for testing dat rbcs, but predicted jk(a-) by hea. ega-treated rbcs tested jk(a-) with the same reagent. rbcs from patients and tested s with bio-rad seraclone anti-s ( - ), but predicted s-by hea. further testing with immucor gammaclone anti-s showed rbcs from both patients were s-. ega-treated rbcs from both were non-reactive with both anti-s reagents. conclusion: commercial monoclonal reagents are valuable resources, especially when phenotyping dat rbcs but not all manufacturers include reagent limitations regarding testing of dat rbcs. we describe cases of false negative tests with monoclonal anti-c due to antigen blocking by igg, and cases with false positive tests with anti-s (n ) and anti-jk a (n ) typing. false positive tests would potentially be anticipated, but false negative results due to antigen blocking are unexpected. extended incubation as indicated in the reagent insert may reveal weak reactivity when antigen blocking is involved. results concordant with dna testing were obtained with ega-treated rbcs, but it is generally accepted that this is not necessary when using a direct-agglutinating monoclonal reagent. these cases caution the potential for both false negative and false positive results for samples with - positive dat and supports testing to dissociate igg from rbcs strongly dat before antigen typing. in addition, this report highlights the benefits of dna testing as part of the routine reference laboratory workup. background/case studies: sensitization to antigens expressed on transfused cells, by triggering premature antibody-mediated clearance, diminishes the therapeutic effectiveness of transfusion and may also lead to serious delayed hemolytic transfusion reactions. accepted us clinical practice, while providing that sensitized patients receive only cells lacking "offending" antigens, nevertheless ensures continued alloexposure, and thus possible sensitization, to additional antigens, thereby complicating patient management. to mitigate sensitization risk, especially in an era of increasingly cost-conscious procurement, a quantitative assessment of the immunogenicity of specific antigens will be desirable. giblett, long ago, introduced a relative scale relating the rbc antigen immunogenicities to (an assumed) immunogenicity of "k" (http://bit.ly/ opqfew ). here, we show that an absolute estimate of immunogenicities may be extracted directly from observed antibody counts provided these are properly normalized to the fraction of recipients at risk (namely those lacking a specific antigen) and the expected fraction of donors expressing that antigen. study design/method: we define immunogenicity, or sensitization risk, r, for any antigen ("ag") of interest, as the conditional probability of alloantibody ("ab") formation, given allo-exposure to ag, i.e. r : prob(ab|al-loexp), so that prob(ab) prob(ab|alloexp)*prob(alloexp) and r ; rewriting prob(alloexp) prob(recipient, "r", lacks ag)*prob(donor , "d" has ag); and estimating prob(ab) nab/nr, nab denoting the number of ab in nr recipients, we obtain: nab/(nr*prob(r lacks ag)) r * prob(d has ag), the left-hand side representing the observed sensitized fraction, u, i.e. the number of observed ab in relation to the number of recipients at risk. conclusion: several antigens, though corresponding antibodies may be rare (e.g. "jsa", "e", "u"), nevertheless are highly immunogenic, requiring only a single exposure (on average) for sensitization; in contrast, others (on average) will require many exposures and thus pose a relatively low risk. in conjunction with patient genotypes, our r -scale will facilitate the selection of patient-specific cells so as to minimize the risk of (proliferating) alloimmunization even when perfectly matched cells are not available. our approach may be readily extended to additional rbc antigens and other antigen systems. background/case studies: aabb and fda require a month deferral of donors with a tattoo applied using non-sterile needles or reusable ink. we review state regulations to ascertain if tattoo establishments are licensed and required to use sterile or single-use needles and single-use ink. we recently added two large states in which we collect blood to the acceptable states list (asl). we compared the rates of donors deferred before and after the addition of these states to determine potential donor gain with changes in state tattoo licensing regulations. study design/method: we analyzed allogeneic interview responses to the screening question, "in the past months have you had a tattoo?" and if 'yes', whether the tattoo was applied by a state regulated entity. blood centers in states were selected for the analysis before and after state tattoo regulation. in state a, a comparison period of similar months before ( / - / ) and months after ( / - / ) was selected; for state b, a similar months before ( / - / ) and months after ( / - / ) was selected. frequency and rate of responses were compared in before and after periods. among those who responded to having a tattoo in a regulated state, donations were reviewed for presence of infectious disease markers including hiv, hbv and hcv. results/finding: a higher proportion of donors presenting to give blood admitted to having a recent (< months) tattoo in the post period in both states. this increase occurred immediately following the addition of states a and b to the asl (data not shown). among those who responded yes to having a tattoo, in states a and b respectively, there was a -and -fold increase in accepted donors (table) . the absolute number of accepted donors with tattoos increased from to (state a) and to , (state b), which annualized, represents a potential gain of , (state a) and , (state b) additional donations. all donors who had a tattoo in regulated states (asl) tested negative for hiv, hbv and hcv. conclusion: to counter rising numbers of ineligible donors resulting from recently added deferrals, we considered recovery of donors deferred for tattoos as a way to enhance our donor base. the immediate rise in the number of donors reporting a tattoo following the addition of the states may reflect a decline in self-deferrals based on having had a recent tattoo. we demonstrated an increase in the potential number of donations without compromising safety. background/case studies: transgender donors represent a small fraction of blood donors. determining their eligibility to donate has been challenging for blood centers. to assess behavioral risk, the donor is required to answer gender specific questions. the same is true when assessing trali risk where the donor is asked about a history of prior pregnancies. prior to the implementation of the fda's final rule, blood centers asked donors for their birth gender and determined eligibility based on that gender. if the donor changed their gender they were asked to answer both the male and female questions. the final rule now allows blood centers to accept the donor's stated gender and to determine eligibility based on that gender. in order to assess the risk of failing to ask a transgender male donor (birth gender female) the pregnancy question, a review was done to determine the number of transgender males who were actively donating with a large blood center. and tracked. donors were contacted to resolve any descrepancies. donors who had changed their gender from female to male and who had answered yes to prior pregnancies were identified. hla antibody test results were reviewed for these donors to see if they had been tested and whether they had tested positive or negative. results/finding: from - , there were donors identified who had changed their gender from their birth gender; female donors changed their gender to male and male donors changed their gender to female. there were ( %) transgender male donors, birth gender female, who had answered yes to the pregnancy question at one of their donations. three of these donors were apheresis donors who had been tested for hla antibodies. one tested positive and the other two tested negative for hla antibodies. the four other donors were whole blood donors and had not been tested. an hla test was added to these donors' records so that the test could be performed the next time they presented to donate. conclusion: transgender male donors may have had prior pregnancies and are also choosing to become pregnant after having transitioned from female to male. six percent of transgender males that we identified reported a prior history of pregnancy. at our center, when a donor requests a gender change from female to male, an hla test is requested for the next donation. first time donors are qualified based on their stated gender so transgender donors with a history of pregnancy will not be identified unless they volunteer this information. consideration should be given to using educational materials to prompt the donor to reveal a history of pregnancy at the time of donation so that hla antibody testing can be performed. effect of variable volume scale introduction in a large multi-site blood center ralph r vassallo*, marjorie d bravo and hany kamel. blood systems, inc. background/case studies: regulations allow whole blood donation [wbd] of up to . ml/kg or % of estimated blood volume [ebv] . traditional measuring/mixing devices are set to halt blood flow at fixed volumes which, with testing samples, are consistently below the % limit. variable volume scales [vvs] can be programmed to vary unit volume (up to ml) by donor ebv. this maximizes transfusable rbcs and plasma and recovered plasma [rp] volume. rp from wbds is a small but important source of derivatives and blood center cost recovery. we report the effect of introducing the hemoflow vvs on donor reaction rates and rp volume in a large blood center. compared to previous fixed settings, variable collection volumes were expected to decrease by ml at ebvs < . l in donors ! yo, but increase by - ml for all others. study design/method: donor vasovagal reaction [vvr] rates (prefaints, prolonged/offsite reactions, and loss of consciousness [loc]) for successful wbds were obtained from the center's hemovigilance database for the mos. before a mo. phased implementation of the vvs, and the subsequent mos. multivariable analysis [mva] by -mo. periods was performed in a model incorporating donor sex, age, first-time [ftd] vs. repeat status, ebv and donation site. both the volume and number of units of plasma sent for fractionation were available for the same time periods from the blood center's data warehouse. results/finding: compared to the baseline period, a significant increase in prefaint reaction rates were noted in pre-implementation (impl) periods & , continued during impl and post-impl periods & , returning to the baseline rate in post-impl periods & (table) . more severe reactions showed an increasing trend that only became significant in post-impl periods & . the mva showed the vvs as independent factor contributing to the increased prefaint and more severe reactions. however, its contribution, as measured by odds ratios, was consistently lower than those exerted by known donor determinants of reaction rates: young age, low ebv, ftd status and collection site (not shown). plasma unit volume increased an average of . ml during post-impl periods & from the temporally matched baseline & pre-impl period . conclusion: following an initial increase in mild vvrs during and immediately after implementation of the vvs, vvr rates fell back to baseline, suggestive of transient staff distraction from usual donor care, or a minor effect of increased blood loss with a superimposed improvement trend. the subsequent increase in prolonged/offsite reactions and loc after prefaint reactions had already returned to baseline suggests that staff training, work load, donor compliance with mitigation strategies and other determinants of donor reactions have a far greater effect than the small additional blood loss due to the vvs. small but significant increments in rp volume improve derivative availability and offset the cost of the vvs. comparison of vasovagal and citrate reaction rates in donors according to type of apheresis procedure pierre robillard* and yves gr egoire . hema-quebec, h ema-qu ebec background/case studies: apheresis procedures expose donors to various volumes of citrate depending upon type and length of procedure and type of machine used. citrate reaction (cr) results from various degrees of hypocalcemia in donors. blood volumes taken from donors vary according to type of procedure and use of volume replacement. loss of blood volume is in part responsible for the occurrence of vasovagal reactions (vvr). this analysis was conducted to estimate the incidence of cr and vvr according to various types of apheresis procedures performed at our blood center. (yfv) were reported in some brazilian states -rio de janeiro, sao paulo, minas gerais and espírito santo, mainly. the vectors of those cases were mosquitoes from the haemagogus and sabethes genders, whose habitat is the tropical forests. since many brazilian urban areas are very close to rain forests, there is an outbreak risk in those areas, where the infection is transmitted by the aedes mosquitoes. in order to minimize this risk, rio de janeiro health authorities decided to promote a mass vaccination in late march, . the vaccine is produced with live and attenuated yfv, which can circulate for at least weeks after vaccination. in some individuals, the vaccine can elicit viscerotropic effects and sometimes severe diseases. due to that, brazilian blood regulation authority established a week deferral period after yfv vaccination. this action could dramatically affect the availability of blood donors. this study shows the measures taken by rio de janeiro blood center to circumvent this risk and attract more donors. study design/method: the strategy consisted in offering the population, at a single place -the blood center -the possibility to donate blood and, immediately after donation, to get vaccinated against yfv. there were no financial advantages to the donors, since yfv vaccine is completely free of charge for any brazilian citizen. the vaccine was administrated by trained nurses, in an office close to the donors session. if, for any reason, the prospective donors were not able to donate, the vaccine was also offered to them, provide there were no contraindications. the blood center annnounced just before the mass vacination campaign launching that it would vaccinate people who came to the blood center to donate blood. if, for any reason, the prospective donors were not able to donate, the vaccine was also offered to them, provide there were no contraindications. results/finding: during the five days of campaign, we received , blood donors candidates; from those, , were accepted as a blood donor, after medical interview. the deferral rate was . %. at the same period of the year , there were , prospective donors, and blood donations. the deferral rate was . %. the "get vaccinated against yfv . . .but give blood before" campaign was able to attract, in a five day period, , additional donors, compared to same dates. that represents a . % increase in the number of blood donations, without deferral rate increment. there was a slight increase in the proportion of first-time donors, from . % in to . % in . conclusion: the strategy was more than successful, and it allowed the blood center to build a blood inventory large enough to avoid risks of shortage due to mass vaccination against yfv. dose loss which must be accommodated when collecting plt donations to ensure the us plt dose of ! . x is met. currently, triple set kits for pr are only approved in europe. plt loss, and adjusted apheresis targeting parameters may impact split rate (sr) or products per apheresis procedure. inventory suitable for pr without impacting us blood center srs warrants evaluation and optimization. study design/method: , apheresis collections from centers with different srs were analyzed. a baseline sr for conventional pc was calculated assuming i) a minimum dose (allowing for production loss) of . x for single (s), . x for double (d), and . x for triple (t) conventional pcs, ii) concentration and volume requirements from apheresis device manufacturer were used. for each collection, dose, volume, and concentration were assessed for pr kit compatibility, based on storage medium (pas or % plasma) assuming i) a minimum dose (allowing for production loss) of . x for s and . x for d for pr units, ii) removing small quantities from units with excess volume or dose to meet pr specs., iii) if all or part of an out of parameter d or t collection could be divided into one or more kits for pr, eligible parts undergo pr, and the remainder treated conventionally, iv) collections unsuitable for pr specs. or would decrease sr if treated would be counted as conventional pcs. results/finding: conclusion: blood centers today can adopt pr for a significant percent of their current supply (as high as %) without affecting their sr. compatibly increases further by dividing t and large d donations. percent achievable depends on their current s, d, t proportion of collections and practices. changes to d and t collection parameters, optimized donation and counting accuracy, and volume reduction will improve pr compatibility further. individual analysis is warranted for each blood center. rbc rbc plt/p plt plt/rbc/p plt/rbc plt plt/rbc plt/p #donations citrate exposure (mls) - study design/method: a randomized ( : ), placebo-controlled, single blind, subject, single-site study of ascending microdoses of autologous (apheresis-derived) thrombosomes was conducted. subjects were divided into cohorts, receiving increasing doses, ranging from / , - / of the lowest effective dose found in the above rabbit model. cohorts and received the / th dose, but cohort received two / th doses one hour apart. the primary end points were safety and tolerability. subjects were monitored in-hospital for hrs post infusion and followed for up to days for adverse events, global neurological assessments, abbreviated physical exams, and laboratory tests. results/findings: there were no serious adverse events (saes) or subject discontinuation post-infusion due to a significant decrease in platelet count from baseline. there were a total of aes: were treatment emergent (teae), of which were treatment-related ( thrombosomes and control). all teaes were mild or moderate in severity. in cohorts and , / thrombosomes subjects had treatment related adverse events. one cohort subject developed an upper respiratory infection and elevated wbcs within hours post infusion, which resolved by hours, and an elevated d-dimer at hours post infusion, which resolved by day . this subject also had an elevation of prothrombin fragment at baseline, which increased post transfusion and peaked at hours with resolution by day . one cohort subject developed non-specific t-wave changes at and hours following her nd infusion that resolved by day without clinical symptoms. troponin levels and echo stress tests were normal. ekgs were considered possibly a normal variant or related to placement of the ekg leads. another cohort subject developed an igg platelet autoantibody on days - , which was undetectable on days - ; there was no change in platelet counts. the thrombosomes autoantibody assay was positive at baseline, days - , and negative on days - . background/case studies: cryopreservation of platelets (plts) could extend the shelf life from - days to over two years. cryopreserved plts (cryoplts) appear to have a greater in vivo hemostatic effect than liquidstored plts. plts have been shown to require protein synthesis capabilities for certain functions such as clot signaling and immune responses. this study was designed to assess whether reconstituted cryo-plts carry out protein synthesis upon thawing and short term storage. study design/methods: apheresis plts were cryopreserved with % dmso and stored at c. after thawing, the unit was reconstituted in thawed ffp spiked with either lm puromycin (pm) or nm biotinlabeled pm. plts were stored at room-temperature with agitation. samples were drawn immediately after reconstitution as well as after , and hours to assess pm incorporation as a measure of protein synthesis, and for in vitro assays to determine platelet activation by cd p binding, phosphatidylserine exposure by annexin-v binding and microvesicle count in the supernatant. plt microvesicles (pmv) were prepared from the supernatant by ultracentrifugation. plts and pmv were lysed in a triton x- containing buffer and qualitative proteomics was performed on samples following affinity-purification with streptavidin beads. results/findings: in vitro parameters of reconstituted and subsequently stored platelets were in line with previously published results, with high surface levels of cd p and phosphatidylserine. pmvs were generated during cryopreservation and the count increased by -fold during hour storage. immunoblot analyses of the plts showed a -and -fold increase in pm incorporation after and hours of storage, respectively. massspectrometry revealed unique proteins that were synthesized after hours of storage, which was confirmed for gtpase and gtpase-regulatory proteins rac , rap and rhogdi by immunoblot analyses. analyses of the pmv translatome also revealed the presence of synthesized proteins; however, these did not change throughout storage. this finding suggests that a defined panel of proteins is packaged into pmvs upon freezing and thawing. additionally, the pmv translatome profile comprised a smaller subset of synthesized proteins compared to the cryo-plt translatome, including the proteins rac , rap and rhogdi. conclusion: this study has demonstrated that cryo-plts can synthesize proteins upon reconstitution in ffp and subsequent storage. discovery of a subset of these proteins in the pmv suggests their encapsulation, possibly in a selective manner. this observation provides novel insights into the capacity for protein synthesis in cryo-plts and the potential regulation of protein packaging into pmv. background/case studies: in , the authors' hospital-based blood bank received variances from the fda and aabb for the use of cold stored platelets (csps) with a shelf life of days. these group a csps, stored in a refrigerator in the emergency department, were used to support the trauma program for use in massively bleeding patients. the placement of the csps on the air ambulances, stored in coolers, was the next logical step in providing platelet therapy sooner to these patients. study design/methods: eight double unit csps were collected using the trima accelv r . two double csps were pathogen reduced using the inter-ceptv r pathogen reduction system. half of the csp pairs were subjected to flat storage in a refrigerator; the other half were loaded into a credov r - cooler with units of ffp, units of rbcs, and unit of whole blood. three to ml of platelets were collected via syringe from each unit at min (before storage in cooler or refrigerator) and after . , , , , and hours of storage for functional validation of platelets. the platelet count, agonists (thrombin receptor agonist peptide (trap), adenosine diphosphate (adp) and collagen stimulated platelets aggregation), non-activated and agonists activated platelet surface expression of phosphatidylserine (ps, annexin-v binding), p-selectin, fibrinogen receptor (pac- binding) were measured by coulter counter, channel aggregometer, and digital flow cytometer. paired wilcoxon rank sum tests were used to analyze differences in degradation rates with p< . deemed significant. conclusion: platelets, including pathogen reduced, stored in an oxygendeprived environment, (cooler), do not lose functional capabilities when compared to those platelets stored in a refrigerator with adequate oxygen for hours. therefore, cold stored platelets transported in a cooler are a viable option for providing timelier platelet intervention for severely injured patients prior to hospital arrival. c -a h molecular sieving: beyond genotyping ghazala hashmi , reinhard klemm and michael seul* , . biomolecular analytics, immunoinformatica background/case studies: more than a decade after its commercial introduction (hashmi http://bit.ly/ ohlehe), blood group genotyping, though available in several formats, has remained a tool for special tasks, e.g. the profiling of difficult patient samples or the identification of rare antigen combinations, while serology has remained the tool of choice for routine antigen typing. here, we introduce molecular sieving as an alternative to the current approach of managing special donor unit inventories. this novel process for dna analysis combines the "multiplexing" of markers offered by existing genotyping methods with the pooling of multiple samples in manner permitting the step -wise refinement of candidate sets by molecular attribute patterns. study design/method: molecular sieving is a special format of leansequencing, a proprietary process that permits the simultaneous analysis of up to four samples for alleles encoding rbc antigens in mns,rhce, lu,kel,fy,jk, di,yt,do and co, including the identification of rhce alleles. molecular sieving extends these capabilities to the analysis of pools to attain large scale. thus, in one format of the process, * * samples are accommodated in a single run. following the completion of the sieving step, candidates may be directly assigned to requests, or may be selected to enrich a subsequent profiling step for samples with rare or otherwise desirable attributes. here, molecularsieving was used to identify suitable donor units for sensitized sickle cell anemia ("sca") patients (tb in cas-tro , http://bit.ly/ oplxhr, excluding le and e(variant) and assuming request per patient), presenting with up to allo-antibodies ("ab") in multiple combinations. proprietary "greedy" algorithms were invoked to optimally pair candidate units with requests. results/finding: sieving of only = plate holding * candidate units from actual black donors, followed by profiling of samples selected to enrich for "e neg" and "c neg" and "c-e-k-fya neg", produced assignments for of requests ( . %), as indicated by colors, and shown in the row "assigned" below: thus, the number of assignments substantially exceeded the number of wells processed. moreover, the remaining pooled samples produced additional assignments to a second set of requests, for a total of assignments from only wells. in another scenario, sieving of a full plate of * samples, produced $ assignments for two successive batches of requests from sca patients, a yield exceeding . x. sieving alone typically fills - % of requests of moderate complexity ( ab). conclusion: molecularsieving, by widening the "funnel" while focusing the search for candidate donor units, attains a new level of efficiency in procuring suitable units for patients with hemoglobinopathies. molecular sieving for identifying red blood cells with special phenotype attributes kristopher fernandez , monica kalvelage , ghazala hashmi* and michael seul . biomolecular analytics, lifeshare blood centers background/case studies: providing transfusion support to patients with sickle cell anemia and other hemoglobinopathies remains a challenging logistical task that must accommodate pre-existing allo-antibodies in multiple combinations preferably while minimizing the risk of (continued) transfusion-related sensitization. the allelic diversity of the predominantly black patient population, especially at the rh locus which encodes a variety of "partial" phenotypes further complicates the problem (chou http://bit. ly/ ppvfeq ). study design/method: molecular sieving is a proprietary new process that, in order to rapidly probe candidate donor units in large numbers for multiple phenotype patterns, permits the analysis of pools and pools of pools of samples for a multiplicity of alleles (including at the rhce locus) that encode mns, rh, lu, kel, fy, jk, di, yt, do and co antigens. based on sieving, samples may be grouped by molecular attribute patterns ranging from single "ag " (e.g. e ,c ,e ,c ) to specific combinations of "ag " (e.g. c e k fya and c e jsa ) or combinations of alleles such as those encoding partial rh phenotypes. sieving, optionally, may be followed by profiling of samples selected for desirable attribute patterns. genomic dna from (predominantly) black donors, independently genotyped by one of two commercial methods were provided by lbc. at bmx, pools were prepared prior to amplification, and analyzed by a novel leansequencing method. results/finding: all pool genotypes were consistent with available individual sample genotypes. antigen patterns of particular interest included two groups, namely: several for which pools were homozygous and certain others t for which pools were heterozygous. illustrative of the former pattern type are these: appropriate pool queries revealed that sieving alone identified, among the c samples, that were also v and vs and, among the e samples, that were also negative for any partial_e phenotype. illustrative of the latter pattern type are pools identified as heterozygous ("het") for alleles encoding antigens of high or low prevalence. by segregating het pools into subpopulations, we were able to select specific "ee" pools of which were demonstrated (in subsequent profiling) to contain an e-sample. we also identified pools "het" for alleles indicating the possible presence of a rare donor, for example yta|b ( pools), co a|b ( ) and others. conclusion: molecularsieving of a single -well plate identified many desirable "antigen-negative" phenotypes and permitted selection of pools for combinations of "ag-neg" patterns including "partial:" rh phenotypes and combinations of c , e and jsa . these samples are thus confirmed "ag neg" and available for assignment. sieving also facilitated the enrichment of subsequent refinement of molecular attribute profiles in accordance with pending or anticipated demand. "antigen-neg" pattern partial_c partial _c, _e samples available after sieving background/case studies: sequence information generated from next generation sequencing (ngs) is often computationally phased using haplotype-phasing algorithms. utilizing experimentally derived haplotype information improves this prediction, as routinely used in hla typing. among the blood group systems, however, experimentally derived haplotypes are known for short genes only, such as icam (landsteiner-wiener) and ackr (duffy). for longer genes, such as abo of > kb, most haplotypes are only statistically derived. we recently established a large dataset of long ermap haplotypes, which code for the scianna blood group system. study design/methods: the nucleotide sequence of > kb each was used for all physically confirmed ermap alleles that we previously published. full-length sequences were aligned and variant sites were extracted manually. the bayesian coalescent algorithm implemented in beast v . . was used to estimate a coalescent phylogeny for these variants and the allelic ancestral states at the internal nodes of the phylogeny. results/findings: we found at least clades representing clusters of to alleles. for each clade, one observed allele was identified as the ancestral allele for its cluster of alleles. using the alleles, we were able to predict alleles with high posterior probability, which were ancestral to the observed alleles and, while not yet observed, may be extant. conclusion: we explored the phylogenetic structure and evolutionary events underlying the origin of different ermap alleles and predict ancestral alleles. in the present study, we show means to predict alleles and to calculate the distinct probabilities of correctness for such predicted alleles. the probabilities can be instrumental in defining a cut-off value to determine which computationally predicted alleles are worth confirming by physical evidence. the alleles identified by studies like ours may be utilized in designing of microarray technologies, imputing of genotypes and mapping of ngs data. the new alleles with nucleotide insertions would be predicted to cause complete loss of expression of the corresponding antigen from a bioinformatics perspective and to encode group o. rather very weak expression of the respective antigen and lack of the corresponding antibody in the plasma was found, confirming these represent subgroups of a and b and suggesting that transcriptional slippage, which has been observed before, is responsible for low level antigen expression. abo genotyping is powerful when both serology and molecular results are evaluated together, and these studies are needed to inform development of bioinformatics tools to accurately associate abo genotypes with phenotypes. background/case studies: evolutionarily related abo and gbgt genes encode a and b glycosyltransferases (at and bt) and forssman glycolipid synthase (fs), which catalyze the biosynthesis of a and b, and forssman (fors ) oligosaccharide antigens responsible for the abo and fors blood group systems, respectively. human at and bt possess leuglygly and metglyala, respectively, at codons - , and these tripeptides are important in determining the sugar specificity of enzymes, n-acetyl-d-galactosamine (galnac) for at and galactose for bt. functional fss possess gly-glyala at the corresponding codons, and exhibit galnac specificity. it has been recently shown that human at gained weak fs activity when the leu-glygly was substituted by glyglyala, suggesting that the tripeptide is involved in the recognition/binding of acceptor substrates, in addition to donor nucleotide-sugar substrates. study design/methods: we have searched for additional mechanisms that might enable human at to express fors . a variety of amino acid substitution constructs of human at were prepared. additionally, exon deletion constructs of at mrna transcripts were also prepared. dna from those expression constructs was transfected into cos (b galnt ) cells, and cell-surface expression of fors antigen was immunologically monitored with a monoclonal anti-fors antibody. results/findings: we found that met thr/ser substitutions also conferred human at with weak fs activity. we also found that the deletion of exon or of human at transcripts bestowed weak fs activity. because altered rna splicing is frequent in cancer, this mechanism may explain, at least partially, the appearance of fors antigen on certain cancer cells and tumors in forssman antigen-negative human species. furthermore, the co-introduction of one of those changes together with the glyglyala substitution synergistically conferred strong fs activity, in addition to strong at and bt activities. conclusion: the substitution of the glyglyala tripeptide codon in the catalytic domain may modify the acceptor specificity of the enzyme. met thr/ ser or exon / deletion may alter the intra-glogi localization of the enzyme. and those mechanisms function in synergy. the overlapping usage of acceptors by glycosyltransferases encoded by abo and gbgt genes is reminiscent of common ancestral origin of alpha , -gal(nac) transferase genes. the finding that at can synthesize fors implicates that the boundary between abo and fors systems may not be as strict as was previously delineated due to the crosstalk in-between. rh typing is required by the fda and fact/aabb for identity testing. since most antibodies in cb plasma are maternal in origin, the abo/rh phenotype relies only on the red cell typing. a and b antigens are not fully developed at birth, presenting about one third of a or b antigen expression levels compared to adult cells. this can result in indeterminate abo results for some cb products. we evaluated the use of dna-based methods for abo typing to aid the resolution of inconclusive ("indeterminate") or discrepant serologic typing results. study design/methods: a total of , cb units (cbu) were typed for abo/rh (beckman coulter pk system blood grouping and phenotyping) during the period / / - / / . abo genotyping targeting specific snps for groups a, a , b, o , and o and, if needed, gene sequencing was conducted in cases with indeterminate results, and in cbu that were provided for transplantation with abo discrepancy found at the transplant center. results/findings: sixty-two ( . %) cb samples had no reportable abo/ rh phenotype on initial testing, and therefore the cbu could not be used clinically. molecular abo/rh typing resolved all but one. all cases were heterozygous (a/o, b/o, or a/b); in % the predicted abo phenotype was a rh neg (table a ). the predominant donor race was caucasian ( %). four cbu with abo discrepancy were also evaluated by genotyping (table b) . in of those, abo typing performed at the hospital on the day of transplant differed from that reported by the cb bank; the fourth was identified by posttransplant abo typing of the recipient. molecular genotyping resolved the discrepancies. cbu identity was always verified by confirmatory hla typing. conclusion: there is currently no fda approved dna-based abo assay. however, abo genotyping is a useful method for samples where antibody tests alone cannot be conclusive, and can "rescue" cbu that could not be used otherwise. further, genotyping can help resolve abo discrepancies. abstract cobas v r hev for use on the cobasv r / systems is a qualitative pcr test for the detection of hev rna in human plasma. the purpose of this study was to evaluate the prevalence of hev rna among us blood donations collected in the midwest, a region reported to have a higher prevalence of hev infection, and the eastern us. study design/methods: , fresh and , frozen edta plasma samples from american red cross donors, collected from february - , were de-identified and screened by individual donation testing (id-nat) using cobasv r hev for use on the cobasv r system under a research protocol. samples were primarily from midwestern and eastern regions of the us. samples reactive on cobasv r hev were further tested by an alternate hev nat, hev rna quantitation, hev genotyping, and for hev antibodies. results/findings: of , valid results, a total of donations were reactive on cobasv r hev and all were confirmed positive. the confirmed donations were from a -year old male in indiana, a -year old male in california, and a -year old female in kentucky. all donations were positive by hemi-nested pcr and alternative hev nat; however, only the kentucky donation had a high level of hev rna ( iu/ml), and was strongly positive for both igm and igg hev antibodies. the indiana donation was genotyped as a, the california donation genotype b, and no genotype determined for the kentucky donation (see table) . the clinical specificity for the cobasv r hev test in id-nat was % ( % exact ci: . % to %). conclusion: based on the confirmed-positive donations of , tested, the hev prevalence was . % ( % exact ci: . % to . %) with a detection rate of : , ( % ci, : - : , ). to date, no cases of tt-hev have been documented in the us. however, based on the prevalence observed, immunosuppressed transfusion recipients may be at increased risk for transfusion-transmitted hev. background/case studies: monitoring the epidemiology of ttis within the donor population is critical to provide an ongoing assessment of infection risks associated with fda policy changes such as the msm deferral criteria. ttims is a multi-center, federally-funded program intended to derive hbv, hcv and hiv prevalence, incidence, viral genotypes, and donor risk factors for greater than % of blood collected in the us. ttims is supported by two distinct coordinating centers (laboratory and risk factor, lrcc, and donation database, ddcc). here we report months of prevalence along with demographic trends from the ddcc. study design/methods: four blood providers and their respective testing laboratories participated. standardized consensus-positive (cp) monitoring definitions were established for donor test results for hbv, hcv and hiv. these results, along with demographics for each donor and donation status (first-time vs repeat) were assembled into a single data set. rates of nucleic acid test (nat) yield (seronegative) and concordant positives (serologic plus nat positives) were combined to comprise cps, were computed overall for donors and donations and by demographic, geographic and temporal characteristics. where appropriate, rates were compared for differences using % confidence intervals. this analysis contains data from / / - / / . results/findings: among , , donations reported ( . % from firsttime and . % from repeat donors), there were respectively , and cp results for hbv, hcv and hiv with corresponding rates of . , . and . per , (pht) donations. prevalence among firsttime donors was, as expected, higher than among donations from repeat donors with ratios of : , : and . : for hbv, hcv and hiv. rates (pht) among males were higher than among females for all markers (hbv . vs . ; hcv . vs . ; hiv . vs . ). in general, higher rates for all markers were seen among minority donors, those in the - -year age group (also - year for hiv), and those from the southeast (and south central for hiv and hcv, and southwest for hbv). no trends were noted over time when -month periods were compared. conclusion: data from major us blood systems were successfully combined and are a baseline for monitoring purposes. demographic trends are similar to those observed in other donor studies and generally agree with community trends. changes in rates will require analyses in the context of potential changes in the demographic structure of the donor population. screening donated blood from babesia endemic regions of the united states using a transcription-mediated amplification assay on a fully automated system vanessa bres* , melanie c proctor , deanna self , monique portugal , adrian gurrola , laura tonnetti , sonia bakkour , cheryl lobo , michael paul busch , susan l stramer and jeffrey m linnen . grifols diagnostic solutions inc., american red cross, blood systems research institute, new york blood center background/case studies: the procleix v r babesia assay on the procleix panther v r system is a qualitative in vitro nucleic acid test currently under development. the assay, which is based on transcription-mediated amplification (tma), detects four clinically relevant babesia species (b. microti, b. divergens, b. duncani, and b. venatorum) in human whole blood specimens. this test is intended to screen blood donations individually and in pools of up to donations. whole blood samples are lysed and then pooled on the automated procleix xpress v r system prior to testing on the procleix panther system. these studies evaluated the preliminary analytical and clinical performance of the procleix babesia assay on the panther system. study design/method: analytical sensitivity was determined by diluting in vitro synthesized rna transcripts for the four babesia species. fresh b. microti-infected hamster whole blood, cryopreserved b. duncani-infected hamster whole blood and fresh b. divergens-infected human erythrocytes were tested to determine the limit of detection (lod) of parasites/ml (p/ml) by probit analysis. clinical sensitivity and specificity were determined by screening , unlinked whole blood donations collected from august th to april th in the northeastern united states. initial reactive donations were confirmed by repeat testing, pcr, and/or igg immunofluorescence assay (ifa). reactive individual donor lysates were tested in pools of . results/finding: the procleix babesia assay detected all four babesia species with a % lod ranging from . - . copies/ml. the preliminary % lod in parasites/ml ranged from . - . p/ml for b. microti (n ), from . - . p/ml for b. duncani (n ), and from . - . p/ml for b. divergens (n ). of the , donations screened, initial reactive and confirmed positive donations were identified for specificity of . % ( %ci: . - . %). of the confirmed positive specimens, were reactive by both ifa and pcr, by ifa only and by pcr only. all confirmed positive samples were reactive in lysate pools of . donors of reactive donations resided in ct ( ), nj ( ), nh ( ) and me ( ) for an overall incidence of : , , and : , in ct. conclusion: the procleix babesia assay on the procleix panther system demonstrated high clinical specificity and sensitivity and detected all four babesia species with similar sensitivity. all confirmed positive donations were also detected in pools of thus demonstrating the effectiveness of pooled lysate screening. conclusion: use of the lag avidity assay shows that in both first-time and repeat hiv-positive us blood donors, newly-acquired (i.e., incident) hiv infections are more frequent in younger donors. the use of this approach provides an additional monitoring tool to assess changes in characteristics of donors whose risk exposure was proximate to the date of donation and will also complement traditional incidence methods by allowing derivation of incidence by donor type. epidemiology of hepatitis b virus, hepatitis c virus and human immunodeficiency virus in united states blood donors lauren a crowder* , whitney r steele , ed p notari , james haynes , roger y dodd and susan l stramer . american red cross, american red cross (retired) background/case studies: from - , the prevalence of hbv and hcv in us blood donors decreased, while hiv rates remained constant. however, incidence has not been recently calculated. here we report the prevalence, incidence and residual risk (rr) of hbv, hcv, and hiv in a large us blood system from - . study design/methods: prevalence was calculated in -year intervals. incidence was measured as the number of positives among repeat donors divided by the total time at risk, in person-years (py). rr was calculated using the window periods of . , . and . days for hbv, hcv and hiv, respectively. linear regressions were calculated with p< . (*) as significant. results/findings: from / / - / / , there were more than million donations from , , donors ( . % female, % first-time (ft), . % caucasian). there were significant decreases in donation prevalence for hbv and hcv (p . and . ), but no significant decrease in hiv during the years (see table for f and r values). a significant decrease was seen in ft donor prevalence for hbv and hcv (p . and . ). prevalent ft donors were significantly more likely to be male ( . % -hbv, . % -hcv, . % -hiv; p< . ). incidence for all agents declined (significant only for hbv; p . ). the decrease in hcv incidence was not significant, but there were fewer incident donors in the last -year period ( in - vs. in - ) . hcv incident donors in - were more likely to be male ( . % vs . % in - , p< . ) and were younger ( . % vs. . % in - < years, p . ). overall, incident donors were more likely to be caucasian males (p< . ). rrs for all agents decreased over time with rrs in - of in , , ; in , , ; and in , , for hbv, hcv and hiv, respectively. conclusion: prevalence, incidence and rr of hbv, hcv and hiv have generally decreased within this blood system over the -year time frame. as donor screening and deferral regulations evolve, it is important to monitor these risks. it is critical to note that even in a large population, small changes to the number of positives can have a significant impact on prevalence and incidence rates. furthermore, in , mayv was isolated from a patient in haiti, suggesting the virus is already circulating in the caribbean. the extent of mayv transmission could be underestimated due to limited surveillance and diagnostic capabilities; therefore, it is necessary to be prepared for mayv emergence and the potential risk for the blood supply in case it can be transmitted through blood transfusion. study design/method: platelet components (pc) prepared in pas were spiked with mayv and treated with amotosalen and uva illumination. samples were collected pre-uva and post-uva illumination for infectious titer determination. as- rbcs were spiked with mayv, mixed with glutathione (gsh)/processing solution, dosed with lm amustaline, and incubated for hrs at room temperature. samples were collected prior to the addition of amustaline (pre-treatment) and following the hr incubation (post-treatment) to determine infectious titers. infectious titers for all samples were determined by plaque assay on vero cells. the extent of inactivation was determined by comparing the infectious titers (plaque forming units (pfu)/ml) in pre-vs. post-treatment samples. results/finding: mayv was inactivated to the limit of detection in both pc and rbcs. in platelets, > . log , or > . log pfu/ml, inactivation of mayv was achieved. in rbcs, inactivation of mayv was > . log , or > . log pfu/ml. conclusion: this study demonstrates robust inactivation of mayv by both amotosalen/uva treatment in pc and amustaline/gsh treatment in rbcs. these systems are efficient at inactivating alphaviruses that have demonstrated or have the potential for transfusion-transmission, including mayv, chikv and rrv. prt offers potential as a mitigation strategy for maintaining blood component availability in areas where multiple alphaviruses are epidemic or endemic, and testing is not feasible. (data have not been submitted for fda review and intercept for red blood cell is not approved for commercial use). thrombotic thrombocytopenic purpura with high adamts- inhibitor may represent a distinct disease subset in response to therapy based on immature platelet count (a-ipc) dynamics hamza n gokozan* , , hollie m reeves , and robert w maitta , . case western reserve university school of medicine, university hospitals cleveland medical center background/case studies: thrombotic thrombocytopenic purpura is a lifethreating consumptive thrombocytopenia and microangiopathic hemolytic anemia causing diffuse ischemic damage to tissues. early therapeutic plasma exchange (tpe) initiation has improved survival. absolute immature platelet count (a-ipc) has been found to aid in diagnosis and follow-up of ttp patients. a-ipc changes in response to therapy in patients with low adamts activity and high inhibitor have not been analyzed in a patient cohort. we analyzed a-ipc response to therapy in five patients with adamts deficiency and high inhibitor at a large tertiary academic medical center. study design/method: patients had adamts activity of < % and high inhibitor ( . - ). mean age of cohort . years (range - ). four patients were female and one was male. patients presented with microangiopathic hemolytic anemia, thrombocytopenia (mean . x /l, range - x /l) and low a-ipc (mean . x /l, range . - . x /l). patients were initiated on daily tpe and prednisone; additional immunosuppression during hospital stay for cohort consisted of rituximab mg/m ( patients) and cyclophosphamide mg/m (one patient). tpe continued until platelet count reached x /l for at least two consecutive days. immature platelet fraction (%-ipf) and a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. results/finding: patients responded rapidly to daily tpe (mean of . days [range - days]) when they achieved a three-fold increase in a-ipc from baseline (mean . x /l, range . - . x /l) and a rapid improvement in platelet count. however, this improvement in platelet count was not accompanied by expected decreases in a-ipc, suggestive of recovery from disease. all patients experienced platelet (mean . x /l, range - x /l) and a-ipc (mean . x /l, range - . x /l) decreases that occurred concurrently while receiving daily tpe so that after a mean of . days (range - days) mean platelet count was . x /l (range x /l) and mean a-ipc . x /l (range . - . x /l). patients were initiated in either rituximab or cyclophosphamide therapy in conjunction with tpe after a mean of . days of a-ipc and platelet count instability. a-ipc trended to levels indicative of restoration of a negative feedback after this time. conclusion: rapid decreases in platelet counts after a good response in ttp patients may raise suspicion for presence of high adamts inhibitor. patients with a high inhibitor have similar a-ipc dynamics during which initial high a-ipc production is followed by unexpected decreases in a-ipc concurrent with platelet counts. recovery occurs once negative feedback between platelet and a-ipc production is re-established. patients with a high inhibitor may represent a distinct subset of ttp as suggested by a-ipc responses. benchmarking the centralized urgent plasma exchange service for patients admitted with a diagnosis of thrombotic thrombocytopenic purpura at a multi-hospital healthcare system jansen n seheult* , michelle n stram , joan sevcik , alesia kaplan , and joseph e. kiss , . department of pathology, university of pittsburgh medical center, blood systems inc., university of pittsburgh background/case studies: consensus guidelines recommend that therapeutic plasma exchange (tpe) must be started as early as possible and within - hours after the diagnosis of thrombotic thrombocytopenic purpura (ttp) has been made; however, there are limited data documenting actual practice. there are several operational facets of delivering a centralized urgent tpe program in a multi-hospital healthcare system, including: central venous (cv) access, ordering, release and delivery of thawed plasma, and transportation of personnel and equipment to perform the procedure. this study analyzes the time elapsed between major steps from diagnosis to initiation of tpe in patients admitted with ttp. study design/method: a retrospective review of the electronic medical record and laboratory information systems from january , to november , was conducted to identify all ttp patients undergoing urgent tpe. demographics, comorbidities, and other pertinent laboratory tests (such as adamts- activity levels, complete blood count, biochemical markers of hemolysis and coagulation studies) were reviewed on all identified patients. temporal data for tpe request, cv access placement, plasma product release (which usually happens after cv access), arrival of tpe team and initiation of the procedure were extracted from procedure notes and the blood bank information system. descriptive and summary statistics were generated using stata version (statacorp, tx). group comparisons were made based on hospital location, level of care and history of ttp using a wilcoxon rank-sum test. results/finding: of the ttp patients identified, were excluded due to missing temporal data for important variables. the majority ( %) of patients were treated at central academic centers, with the remainder being treated at peripheral sites. fifteen patients ( %) had a prior history of ttp and % had severe adamts deficiency on admission. the median time from tpe request to initiation was . hours (interquartile range: . - . hours). there were non-significant trends to shorter time intervals from request to cv access and request to tpe initiation in patients admitted to the intensive care unit (icu) versus non-icu patients (table ) . treatment was not started within an -hour window in patients; the median time to cv access was significantly longer in these patients ( . vs . hours, p< . ). two of these patients had a prior history of ttp and only four patients had severe adamts- deficiency. the majority (more than %) of the time interval between tpe request and tpe initiation was spent obtaining cv access and plasma products. there were no significant differences in time intervals comparing patients with a new diagnosis of ttp versus patients with recurrent/ relapsed disease (table ) or between patients treated at a central academic center versus a peripheral hospital. conclusion: the consensus - hour target window from tpe request to initiation appears feasible for a centralized tpe program servicing a multi- a transfusion vol. supplement s hospital healthcare system. addressing limitations in availability of cv access would likely yield the greatest improvement in timeliness of urgent tpe. cytoreductive therapy for cellular hyperviscosity: utility of cytapheresis treatment for chronic myelogenous leukemia and essential thrombocythemia. jan c hofmann* and dobri d kiprov. california pacific medical center background/case studies: several retrospective, case series have suggested that cytoreductive therapy to treat cellular hyperviscosity and prevent thrombotic events in patients (pts) with chronic myelogenous leukemia with accelerated transformation (cml-at) or essential thrombocythemia (et) may improve short-term outcomes. however, no randomized controlled trial (rct) assessing the efficacy of cytapheresis treatment in this group of pts has been performed. study design/method: from january, through january, , we performed cytapheresis (cy) treatments (txs) for pts with either cml-at or et, and clinical and/or laboratory evidence of cellular hyperviscosity. pts ( %) had cml-at and received leukapheresis (lp) txs; pts ( %) had et and received thrombocytapheresis (tc) txs. cml-at pts presented with median wbc x /l (range - x /l), of which % had blast percent > % or blast count > x /l. median age was years ( - years); % were male. cns symptoms (sxs) of leukostasis (lks) were defined as: headache, cognitive decline, confusion, somnolence, visual abnormalities, or seizure; pulmonary (pulm) sxs of lks were defined as: dyspnea, hypoxia, or bilateral chest infiltrates. % of cml-at pts had no sxs of lks; % pts had sxs of either cns or pulm lks ( sxs), and % pts had sxs of both cns and pulm lks ( sxs). et pts presented with median platelet (plt) count of: x /l ( - x /l)and % pts had sxs of thrombosis (evidence of cva or tia, mi, or dvt). median age was years ( - years); % pts were male. results/finding: all pts received a course of cy tx with following objectives: ) decreasing the risk of thrombotic/ hemorrhagic complications related to hyperviscosity, and ) stabilizing cml-at pts for induction chemotherapy (ind chemo). wbc (or plt ct) tx goals were: wbc count (ct) < x /l for cml-at pts, and plt ct < x /l for symptomatic et pts and < x /l for asymptomatic et pts. cml-at pts received median of lp txs (mean . txs/pt; range - txs). et pts underwent median of tc txs (mean . txs/pt; - txs). outcomes were evaluated by percentage of pts who: ) reached wbc (or plt ct) tx goal, and ) received ind chemo. "improved" outcome was defined as pts who reached their wbc (or plt ct) tx goal during cy tx; "stabilized" were pts who achieved > % reduction in wbc (or plt ct) without reaching goal; and "unchanged" were pts who achieved neither. in cml-at cohort, % pts improved, % pts stabilized; and % pts worsened. in et cohort, % improved, % stabilized, and % were unchanged. for cml-at pts, median final wbc ct x /l (range - x /l); % pts received ind chemo. for et pts, median final plt ct x /l ( - x /l); % pts had resolution of thrombotic a transfusion vol. supplement s symptoms. % of cml-at pts and % of et pts expired within - days after course of cy tx. of expired pts, pts had both blast crisis and sxs of cns/ pulm lks; pt had intracranial hemorrhage or cva; and pts were hypotensive, intubated, or unable to tolerate ind chemo. conclusion: pts with cml-at or et and evidence of impending thrombosis may benefit from cytoreductive therapy. a limited number of cytapheresis treatments (median - txs) can enable a high percentage of pts to receive definitive treatment and may improve short-term clinical outcomes. a rct to assess efficacy of cytapheresis treatment versus induction chemotherapy (or platelet inhibitor tx) alone in this subset of pts would be very useful. background/case studies: partial normal saline replacement during plasma exchange procedures is common practice. benefits of using normal saline as a replacement fluid include reduced procedure costs and possible reduction of the hypothetical hyper-oncotic effects of standard albumin formulations. however, the use of normal saline may increase the risk of undesired, and potentially costly, adverse events, such as hypotension and citrate reactions. the goal of this study was to compare the frequency of reported adverse outcomes for patients that received all albumin versus albumin/ saline as replacement fluid for plasma exchange at our institution. study design/method: a four year retrospective chart review was done of all therapeutic apheresis procedures performed by our apheresis service that used % albumin or % albumin- % normal saline ( / ) as replacement. patients who received plasma entirely or partially as replacement were excluded. the procedure type ordered ( % albumin vs / ), the percent of normal saline actually used during the procedure, age, gender, and any noted adverse events during the procedure were recorded in all cases. repeated procedures were modeled using a generalized linear mixed model to examine the risk of having hypotension and/or citrate toxicity where % albumin was used versus those that used / . covariates included were fluid types, age and gender. odds ratios (or) and % confidence intervals (ci) were used as a measure of risk. we used the term significant for a two-sided p-value < . . results/finding: during the study period, procedures were documented for subjects ( % female), age range - years, of which , ( . %) received / . the type of fluid used as replacement had a significant effect on the risk of having either hypotension or citrate toxicity. replacement with % albumin had a significantly lower risk of having either event than by using / , [p . , or (ci): . ( . , . )] , and also had a significantly lower risk of causing hypotension [p . , or (ci): . ( . , . )] in addition to a lower risk of causing citrate toxicity [p . , or (ci): . ( . , . )]. age had a significant effect on having a hypotensive event [p . , or (ci): . ( . , . )] but no effect on citrate toxicity or the combined outcome. gender had no effect on frequency of any event. conclusion: partial saline use as a replacement fluid with albumin during plasma exchange significantly increases the risk of hypotension and citrate toxicity during the procedure. age also increases the risk of hypotension. use of saline as replacement fluid during plasma exchanges should be minimized to maximize patient safety especially in older patients. background/case studies: therapeutic apheresis (ta) is a complex procedure that is mostly well-tolerated and rarely associated with adverse events (aes). there are few studies published on aes associated with ta but they lack uniformity of data. moreover, there is no common database in the united states (us) to report ta-associated aes. we evaluated the annual incidence rates of aes associated with ta at a large tertiary academic medical center over a year period and compared it to published literature. study design/method: we conducted a -year retrospective study of ta procedures performed and aes were classified according to criteria described in table . during the study period, ta were performed using cobe spectra (software versions . and . ) and since the spectra optia apheresis system (version . ). literature search was conducted for data published on aes associated with ta. four studies from us and non-us studies (canada, europe and japan) were analyzed. trend for ae rates from - was also analyzed. statistical analysis was performed using chi square and spearman rho tests. results/finding: the overall ae incidence was . % ( of , procedures) during year period. frequency of aes associated with therapeutic plasma exchange (tpe) was significantly higher ( . %, p< . ) compared to other ta procedures. we found significant correlation between number of tpe and aes (spearman rho . , p . ) over the years and significant down trend of moderate and severe aes with a spearman rho of - . (p . ) and - . (p . ) respectively. there were no fatalities during the study period. majority of aes were grade i ( %) and grade ii ( %): / ( . %) procedures were not completed due to aes. comparison of aes [ . % ( / , )] to both european [ . % (n , , / , ) ] and other us studies [ . % (n , / , )] showed a statistically significant difference (p< . ). conclusion: overall incidence of aes was significantly lower than current published literature. incidence of aes published in other countries is significantly lower than rates published in us. differences in incidence of aes in literature emphasizes need for uniform reporting and stratification of aes and development of a common database to report ta-associated aes. we propose a grading rationale in order to standardize reporting of ae (table ) . variations in biochemical markers of bone metabolism during plateletpheresis: impact of socio-demographic and lifestyle factors? markus dettke*. akh vienna university hospital background/case studies: plateletpheresis is associated with short-term variations in biochemical markers of bone turnover. socio-demographic factors and lifestyle behaviors are recognized factors which influence mineral metabolism and bone health. in the present study we analyzed the influence of demographic and lifestyle factors on the observed changes in bone markers in a large cohort of routine platelet donors. study design/method: altogether platelet donors with a donation activity of up to platelet donations participated in the study. after a detailed anamnesis all participants underwent a standardized questioner asking for several lifestyle factors known to affect bone metabolism. blood was sampled before and after plateletpheresis and was analyzed for the bone formation marker osteocalcin (oc) and the bone resorption marker cross-linked telopeptides of type i collagen (ctx), among other parameters. the effect of calcium supplementation on bone metabolism was tested in a placebocontrolled crossover study involving ten donors. results/finding: plateletpheresis resulted in an increase in the serum levels of the bone resorption marker ctx and the bone formation marker oc. both parameters returned to base levels within hours after the end of the collection. multiple regression analysis including the parameters sex, age , positive family history of bone disease, but also individual factors like hormonal contraception, smoking, regular alcohol consumption or sportive activity revealed no influence of socio-demographic or lifestyle factors on the observed variation in ctx or oc. there was no association between individual donor career or the number of previous donation and the observed increase in bone turnover. the only predictive parameter we could identify was the amount of citrate exposure during plateletpheresis. increase in serum ctx, showed an inverse correlation to changes of serum ionized calcium. continuous iv supplementation of calcium-gluconate throughout plateletpheresis reduced the variations in bone markers, although this effect was more pronounced for ctx compared to oc. conclusion: the amount of citrate infused during routine plateletpheresis is a predictive parameter for the transient increase in serum markers of bone metabolism. known risk factors for bone diseases, including sex, age, smoking or alcohol consumption, seems to have a low impact on the observed citrate-related variations in serological biomarkers of bone turnover. transfusion with optimized blood products versus transfusion with standard products in a trauma-transfusion rat model mathijs wirtz* , jordy jurgens , jacoline buchner-doeven , joris roelofs , philip spinella , jennifer a muszynski , carel goslings and nicole juffermans . academic medical center, washington university school of medicine, nationwide children's hospital background/case studies: transfusion is associated with nosocomial infection and organ dysfunction in trauma patients, which may be mediated by soluble bioactive substances in blood products. we hypothesized that removing these bioactive substances improves host immune response and reduces organ dysfunction. study design/methods: blood products were prepared from syngeneic rat blood according to blood bank standards. soluble mediators were removed from red blood cells ( days old) and platelets ( days old) by washing. plasma was filtered through a . um filter. rats ($ grams) were poly-traumatized by crush injury to the small intestines, the liver lobes, and by fracture of the right femur and hemorrhaged $ % of their estimated blood volume, which was calculated to be ml/kg. hemorrhage continued until a mean arterial pressure of mmhg was reached. rats were randomized to resuscitation with standard blood products, washed/filtered blood products or sham. blood samples were taken up to h after trauma to assess biochemistry and coagulation status. ex vivo whole blood stimulation tests with lps were performed after sacrifice, and organ damage was assessed by histopathology. blood products were sampled to assess for biochemical changes. comparisons between groups was done by anova and dunnett's post-test for multiple comparisons. results/findings: filtering or washing of blood products significantly stabilized ph, sodium and potassium concentrations and decreased lactate levels in the products compared to standard products. both resuscitation groups received an average of ml/kg of blood products in a : : ratio. however, use of washed/filtered products did not improve organ failure, as assessed by histopathologic score and levels of creatinine, asat and alat. the coagulation status as assessed by thromboelastometry was deranged in all groups and normalized during transfusion, showing no significant differences between washed/filtered products and standard care. immune response to lps was decreased following trauma compared to healthy controls but did not differ between groups. conclusion: filtering or washing of blood products reduces some aspects of storage lesion of blood products, without affecting the hemostatic capacity of the products, but does not improve organ injury in a rat trauma and transfusion model, nor does it improve the immunosuppressive host response. these results suggest that washing or filtering of blood products may have no relevant clinical effects in a rat polytrauma model. safety and efficacy of tranexamic acid during cardiovascular surgery: a single center before-and-after study takuma maeda* and shigeki miyata. national cerebral and cardiovascular center background/case studies: tranexamic acid (txa), an antifibrinolytic agent, has been widely used in cardiovascular surgery, since several studies have shown that prophylactic use of txa is effective in reducing blood loss after cardiovascular surgery. however, there is concern about the risk of thromboembolic events and adverse neurological effects such as seizures, which might worsen patient outcomes. consequently, we stopped using txa in april , which enabled us to conduct a before-and-after study. the present study aimed to examine the association between txa and adverse effects (seizures, thromboembolism, and renal dysfunction) in patients undergoing cardiovascular surgery using a propensity score matching model. we also assessed the association between txa and other clinical outcomes (reoperation for bleeding, transfusion volume, blood loss, ventilation time, intensive care unit stay, and -day mortality). study design/method: this single center retrospective cohort study involved patients who underwent cardiovascular surgery with cardiopulmonary bypass or offpump coronary artery bypass grafting between january and july (n ). because of missing data on patient characteristics, patients were excluded. the incidence of adverse effects associated with txa and other clinical outcomes were evaluated before (january to march , n ) and after (april to july , n ) using a propensity score model. we estimated propensity scores using a logistic regression model for txa use as a function of baseline variable, generating pairs of patients who received or did not receive txa. we also evaluated the adverse effects of txa using segmental regression analysis. results/finding: propensity-matched analysis showed that seizures were more common ( . % vs . %, p< . ) and ventilation time was longer ( h vs h, p . ) significantly in the txa group than in the non-txa group. in contrast, transfusion volume and blood loss were significantly lower in the txa group than in the non-txa group ( ml vs ml, p . ; and ml vs ml, p< . , respectively). however, -day mortality was not statistically different between the groups ( . % vs . %, p . ). none of the other outcomes were significantly different. segmental regression analysis yielded similar results. conclusion: even though txa may be associated with an increased rate of seizures and longer ventilator time, it does not increase mortality. the use of txa is significantly associated with decreased blood loss and transfusion volume, providing social benefit by reducing the need for blood transfusion because the supply of blood components will be limited with the aging of japanese society. it seems to be advantageous to use txa because decreased blood loss and transfusion volume and the associated social benefit outweigh the disadvantages of an increased rate of seizures and longer ventilator time. sustained impact of blood management strategies in orthopedics: continuous quality improvement linda levinus* and michele deeney. new england baptist hospital background/case studies: transfusions are one of the most over-utilized treatments performed in any hospital setting (choosing wisely campaign, april , www.choosingwisely.org/societies/american-association-of-bloodbanks). costs and risks associated with transfusions are high and may have a significant impact on patient safety. in our institution we perform over , joint replacements and spine surgeries per year, making transfusion-associated costs very high. since our last formal evaluation of the metrics used post implementation of patient blood management (pbm) strategies, questions regarding the feasibility of continued transfusion reduction and sustainability of the program were raised by administration and key stakeholder physicians. the objective of this study is to determine what, if any, sustainable improvement to our blood utilization dashboard table ). the data collected show that there has continued to be a reduction in transfusion rate, and blood expenditures through fy . length of stay has also shown a continued reduction, which is an indicator that the pbm strategies implemented have not compromised quality outcomes. further, continued review and monitoring of the chosen metrics, evaluating changes to policy and practice related to transfusion medicine, and communication of findings to providers/administration upon immediate restrospective analysis, are integral to the continued success and sustainability of our pbm program. going forward, these practices, along with investigating use of additional pbm strategies, will provide the basis for an effective continuous quality improvement program in transfusion medicine for orthopedics. safety and efficacy of -factor prothrombin complex concentrate: a retrospective review of outcomes at an academic hospital stephanie jalaba*, hollie benson, nan zhang, jill adamski and theresa kinard. mayo clinic arizona background/case studies: -factor prothrombin complex concentrate (pcc) contains factors ii, vii, ix, x, proteins c and s and is used for reversal of vitamin k antagonists in acute major bleeding or urgent, invasive procedures. occasionally, it is used off-label when plasma is not optimal for achieving hemostasis. this study compares the efficacy of on-label and off-label use of pcc in correcting coagulation parameters and reducing allogeneic blood transfusion. study design/methods: a retrospective chart review was performed for pcc use at our institution in . marginal modeling (gee method) was used to account for within patient correlation and assess changes in lab values and products transfused. logistic regression (gee method) was used to evaluate potential risk factors for unsuccessful hemostasis (uh rate of transfusion after pcc ! rate before pcc) or thrombotic complications. results/findings: the reduction in pt (p . ) and ptt (p . ) was significantly greater in on-label than off-label use. interestingly, transfusion reduction in rbc (p . ) and plasma (p . ) after off-label use was significantly greater than on-label use. cases, both on-label and off-label, with uh were associated with cell saver, acute normovolemic hemodilution (anh), or cardiopulmonary bypass (cpb). the odds of having uh were . times (p . ) more with cell saver or anh, and . (p . ) times more with cpb. post-pcc thromboses were identified in cases, but no association was found with potential risk factors: use of antifibrinolytics, vitamin k, factor viia, or extracorporeal support. background/case studies: when a pregnant woman with high risk pregnancy (diagnoses such as abnormal placentation, multiple gestation) is admitted to inpatient bedrest the obstetrical team would like to assure ability to crossmatch red blood cells (rbc) at all times by always having an in-date type and screen specimen. per current aabb standards, this necessitates a new sample every days. this can lead to excessive iatrogenic blood loss and increasing difficulty with obtaining intravenous access in the patient, to the point that an invasive catheter such as a picc line may be placed. in order to mitigate these issues, we chose to extend the type and screen specimen to expire after days in patients without rbc alloantibodies other than passively acquired anti-d due to rh immune globulin administration. study design/method: patients expected to have an antenatal hospitalization of at least days with high risk for transfusion need are identified by the obstetrical service, which submits a request to the transfusion service for extension of pre-transfusion specimens to days. the transfusion service medical director reviews the case and gives final approval. we observed only patient did not have an in-date specimen when the extended out-dating was requested. thirty-eight ( ) patients were in-patients continuously until delivery. five patients were discharged prior to delivery- moved to another state, was admitted later at another local hospital, and three were readmitted for later deliveries. the mean interval from approval to delivery was days (range - ). six ( ) patients delivered within days of approval. after approval, the mean number of additional specimens per patient was . (range, - ). no patient required transfusion prior to delivery. five patients received transfusion of at least rbc at the time of delivery, and none had evidence of transfusion reaction. conclusion: since no new antibodies were identified prior to discharge or delivery and no transfusion reactions were observed, the process appears safe. with only patients delivering within days of approval for extended specimens, patients avoided collection of at least specimen each, and patients avoided at least collections each. since new antibodies are not detectable for at least days after immunization, even longer extension of pre-transfusion specimen out-date may be considered. although this requires further study, we believe our practice of extending the pre-transfusion testing sample expiration date to days is safe and is justified, when weighed against the risk of excess iatrogenic blood loss and placing an invasive line for blood sampling in a pregnant patient. iron metabolism in critically ill patients developing anemia of inflammation margit boshuizen* , , jan m. binnekade , benjamin nota , pieter r tuinman , kirsten van de groep , olaf l cremer , janneke horn , marcus j schultz , robin van bruggen and nicole p juffermans . academic medical center, sanquin research and landsteiner laboratory, vu university medical center, university medical center utrecht background/case studies: anemia due to inflammatory processes (anemia of inflammation, ai) frequently occurs in critically ill patients. in ai, inflammation-induced hepcidin decreases iron availability, a process that is thought to be regulated by erythroferrone, which impact erythropoiesis. knowledge on changes in iron metabolism during the course of ai is limited, hampering the development of strategies to counteract ai. this study aimed to investigate the dynamics of parameters of iron metabolism during the development of ai in critically ill patients. study design/methods: a case control study was performed in tertiary icus in the netherlands comparing patients who developed ai during icu stay with control groups: non-anemic patients with sepsis, non-anemic patients without sepsis, and patients with anemia due to acute blood loss. patients were matched on age and sex. a linear mixed model was used to assess differences in parameters of iron metabolism between groups and over time. results/findings: in patients with ai, levels of iron, transferrin and transferrin saturation decreased already prior to the development of anemia, with lower levels compared to controls (table) . ferritin and hepcidin were increased in ai compared to controls. in the course of ai development, erythroferrone decreased. differences in iron metabolism between groups were not influenced by disease severity. patients with ai differed from patients with anemia due to acute blood loss, the latter was characterized by high iron ( . vs. . mmol/l, p< . ) and transferrin saturation ( vs. %, p< . ), and low ferritin ( vs. mg/l, p< . ). conclusion: in critically ill patients with ai, iron metabolism is already altered prior to the development of anemia, suggesting a potential window of opportunity for therapy. iron metabolism in ai is more disturbed than in non-anemic septic controls, irrespective of disease severity, indicating that ai is not solely determined by severity of inflammation. iron metabolism in ai patients differs from patients with acute blood loss, suggesting that efforts to modulate iron metabolism in anemic icu patients should take the cause of anemia into account. clinical oral abstract session: novel approaches to processing and assessing cell therapy products a paradigm shift in stem cell isolation and storage jeffrey drew*. cells life group llp background/case studies: widespread use of umbilical cord blood is limited by processing yield and post-thaw recovery of viable nucleated cells. the recommended therapeutic cell dose is approximately . x cells per kg body weight indicating that a single cord unit may be insufficent to treat larger individuals. cell isolation methods were developed to remove erythrocytes whilst recovering the white cell fraction (wcf). however, all current methods result in significant loss of the wcf, some up to %, whilst leaving % of the starting volume of erythrocytes. additionally, there is an almost total loss of potentially important, low abundance cellular subsets. the use of cord blood for hematopoietic reconsititution and in regenerative medicine would be widened if processing methods improved postprocessing and post-thaw viable cell recovery. study design/methods: we have developed a solution consisting of a defined concentration of reagents routinely used in blood therapy. on combination with blood, this solution results in the selective sedimentation of erythrocytes by gravity within minutes. the wcf remains in solution and can be easily separated from the erythrocyte sediment. the wcf can then be concentrated by gentle centrifugation into a small volume containing less than % of the original erythrocyte content. the addition of dmso for cryogenic storage and controlled freezing using standard procedures then completes this simple process. results/findings: we have clearly demonstrated that this method allows almost the entire wcf to be isolated and/or concentrated with only modest loss of any of the cellular sub-sets thus far examined. in addition to improving pre-freeze yields, post-thaw recoveries of viable cells are markedly increased, with a yield of approximately % of the cd fraction post separation and freeze thaw (table ) . possibly more important, the cfu assay results reproducibly yield higher counts of cfu-gm, cfu-gemm and bfu colonies (table ) which is a strong indicator that this method will improve patient outcomes. in addition, our separation method isolates and preserves the megakaryocyte-like cells (cd cd ) and early projenitor cells expressing oct and nanog (markers for vsels) which are two examples of cellular subsets usually lost using current separation techniques. conclusion: these results demonstrate that our method achieves: . routine recovery of the wcf at levels higher than current methods, independent of volume. . higher percentage recoveries of all cell types tested than can be achieved with existing methods. . markedly higher post-thaw recovery of viable nucleated cells than any current methodology. . almost complete removal of hematocrit. as a result units of cord blood separated using this new method will contain cell yields that could only otherwise be achieved through pooling multiple separate units. therefore, this new method has the potential to increase the demand for cord blood in therapy, expanding to larger individuals and adults, where up until now, it has been suppressed due to limited cell yields delivered by existing methods. effects of implementation of an absolute lymphocyte count target, in addition to cd target, for hematopoietic progenitor cell collection edwin a burgstaler*, luis f porrata, dennis a gastineau, eapen k jacob and jeffrey l winters. mayo clinic background/case studies: lymphoma patients receiving > . x lymphocytes(lymph)/kg during peripheral blood stem cell transplant have superior survival. in addition to a cd cell target of . x /kg, a lymph target was also implemented. fifty patients before (no alc) and after (alc) implementation were retrospectively evaluated. study design/method: lymph and cd yields, number of collections, lymph target reached, and days to engraftment were examined. mobilization was g-csf (g) or g-csf plerixafor (g pl). consecutive no alc and alc procedures were examined. the mann-whitney and chi square tests were used for statistical comparison, p< . considered significant. results/finding: no alc and alc collections occurred among the patients. fenwal amicus was used for % of the no alc and % of the alc collections (terumobct spectra optia cmnc used for remaining). diagnosis was hodgkin's and non-hodgkin's lymphoma (no alc); hodgkin's and non-hodgkin's lymphoma (alc). pre procedure wbc and lymph counts were significantly higher for no alc (wbc . , lymph . x /l) than alc (wbc . , lymph . x /l). equivalent whole blood (corrected for ac) was processed for no alc ( . l) and alc ( . l). for alc group, extra collections beyond cd target were: days: %, day: %, days: %, days: %, and days: %. significantly more patients were mobilized with g pl in no alc group (n ) than alc group (n ) and collections in alc group had mobilization discontinued after cd cell target reached. there was no significant difference in g ( . x lymph) compared to g pl mobilized collections ( . x lymph); both were significantly higher than the collections where mobilization had been discontinued ( . x lymph). days to wbc engraftment ( . no alc vs . alc) and platelet engraftment ( . no alc vs . alc) were not significantly different. median number of collections for no alc ( ) and alc ( ) were not significantly different. data (medians) in the table. conclusion: not all patients achieved the . x lymph/kg or even the . x lymph/kg targets. implementation of a lymph target increased patients obtaining . x lymph/kg from % to %. only % had < . x lymph/ kg. discontinuation of mobilization once cd cell target was reached significantly reduced lymph yield. the median increase of one collection per patient following implementation was less than had been expected. extended preprocessing storage impairs cord blood hematopoietic stem cell activity suria jahan* , and nicolas pineault , . canadian blood services, university ottawa, canadian blood services, centre for innovation background/case studies: large distances between collection and processing sites combined with staff availability can result in long processing delays of umbilical cord blood (ucb) unit. current net-cord-fact standards specify that units can be stored for almost hours at room temperature (rt) as long as units are cryopreserved by -hours post-collection. the impact of such delay on hematopoietic stem cell (hsc) function is unclear since most studies have not used transplantation assays that measure hsc key properties and activities. we hypothesized that such processing delay reduces the engraftment activities of ucb units. we set out to measure the loss in engraftment activities associated with preprocessing storage. study design/method: ucb units (n ) were split with one half processed immediately (baseline - hours) and the second after hours storage at rt. ucb were then processed with hetastarch and buffy coat maintained cryopreserved in liquid nitrogen until use. viability was assessed post-thaw, and thawed ucb buffy coat cells were transplanted into nsg mice. serial transplantation was used to test the self-renewal and differentiation activities of hsc, while limiting dilution (ld) assay and poisson statistic were used to estimate the frequency of scid repopulating cells (src) in thawed units. results/finding: storage before processing had no significant impact on the recovery of viable post-thaw cd cells and cd cell (n ). primary nsg mice were transplanted with a ucb cell dose that contained a total of , annexinv neg viable cd cells. the latter was done to avoid any bias towards one group or another. short term platelets ( vs. hplt/ml, p . ) and leucocytes ( . % vs. . % hcd , p< . ) engraftment at -weeks were significantly reduced in stored mice vs. baseline (n ), and similar results were observed long-term at -weeks. long-term human bone marrow (bm) engraftment was also reduced in primary transplants from stored samples ( myeloid engraftment was however confirmed in both groups. bm cells from primary mice were transplanted into secondary recipients and human engraftment investigated months post-transplant. strikingly, the frequency of human cd bm cells was -fold greater in baseline vs. stored mice (p< . , n ). hence, storage at rt of ucb units is associated with a deficit in engraftment activity likely due to a loss in hsc activity and/or numbers. to distinct between both possibilities, the net number of src in baseline and stored samples for two units were calculated by ld transplantation assay. the net number of src measured -weeks post-transplants were reduced by % in unit , and by % in unit . conclusion: prolonged preprocessing rt storage significantly impairs the engraftment activities of ucb units. the reduced engraftment in secondary transplants coupled with the results from the ld assays suggest that this engraftment deficit origins from loss of hsc numbers. our results stress the importance of rapid ucb processing to avoid loss of engraftment activity. acoustic microfluidic separation of blood components charles lissandrello, ryan dubay, kenneth kotz and jason fiering*. draper background/case studies: new cell therapies require efficient and automated methods for purification of target cells prior to subsequent processing. while apheresis, density gradient centrifugation, and magnetic separation achieve some of the requirements, no method is currently available that fully meets clinical needs for a closed, automated, and scalable process. continuous acoustic separation in microchannels is emerging as a versatile method for sorting, separating, and concentrating cells from blood. it has advantages over centrifugation because it is scalable to small or large quantities and can discriminate cells by size as well as density. meanwhile, unlike magnetic methods, acoustophoresis is "label free" and adds no reagents to the therapeutic cells. it has been shown previously that acoustic separation can separate blood components including purification of lymphocytes. however, these studies used devices that were constructed from silicon or glass and have limited potential for scale-up or production as disposable cartridges. in contrast, we report the first ever demonstration of acoustic lymphocyte enrichment along with rbc and platelet depletion in a disposable plastic chip, and we present a cartridge concept that enables clinical scale throughput by linking microchannels in parallel. study design/method: acoustophoresis uses ultrasonic waves to oscillate a rectangular microchannel having a cross section on the scale of the ultrasonic wavelength ($ mm). this results in an acoustic force across the channel that drives cells toward the axial center stream. because the force increases with a cell's size and density, lymphocytes experience a weaker force than rbcs and other classes of wbcs. thus, as blood product flows through the device, the lymphocyte population is enriched at the sides of the channel and can be captured in a branching outlet. likewise, platelets can by separated from lymphocytes. initial and output cell counts are measured by a standard hematology analyzer. results/finding: in our acoustic system, lymphocyte purity (% of total wbcs) was enriched up to %, using leukapheresis product as the starting material. this enrichment was achieved in a single pass through the device (residence time of sec). total lymphocyte recovery was % and monocyte concentration was reduced %. furthermore, in a two-pass process platelets were reduced by %. in a -fold parallel system we tested rbc separation from plasma and achieved % separation at ml/hr. conclusion: acoustic lymphocyte enrichment along with platelet depletion from standard blood product was demonstrated for the first time in plastic microchannels. such disposable devices are suitable for scale up to clinical bioprocessing systems. lymphocyte purity is comparable to existing methods with the advantage of monocyte and platelet depletion and potential for an automated instrument. background/case studies: the use of natural killer (nk) cells as a cellular immunotherapy has increased over the past several years, specifically their use in patients with hematologic malignancies. nk cells have been used at our institution for the past years. most patients have a reaction with nk cell infusion with some reactions being quite severe. we retrospectively analyzed the reactions associated with nk cell infusions to help address why some patients have more severe reactions than others. study design/method: retrospective chart review of nk cell infusions performed at our institution from clinical protocols from - . an infusion reaction was defined as any symptom from the time of nk cell infusion up to hours afterwards. a severe reaction was defined as any symptom with grade or higher severity (graded on common terminology criteria for adverse events-ctcae). preliminary data was analyzed using r . . . two major endpoints of interest were: ) infusion reaction with any symptom and ) severe infusion reaction. to numerically summarize the association of continuous variables with our endpoints, the median, (range) and interquartile range (iqr) were used. a wilcoxon test was performed to test the association between the continuous variables and our end points. a chi-square test was used to test the association between categorical variables and our endpoints of interest. results/finding: there were a total of nk cell infusions. there were ( %) patients with an infusion reaction of any symptom and there were ( %) patients with a severe reaction. infusion rate (ml/min) was similar among those with any reaction (median . , p . ) and those with severe reaction (median . , p . ). infusion rate (ml/min/kg) was also similar among those with any reaction (median . , p . ) and those with severe reaction (median . , p . respectively). incubation of nk cell product overnight in il- vs il- had similar reaction rates for those with any symptom ( % had reaction with il- , % had reaction with il- , p . ) and those with severe reaction ( % had severe reaction with il- , % had severe reaction with il- , p . ). patients with severe reaction had a higher calculated monocyte dose (monocytes/kg) in the nk cell product (median . x ) versus those without (median . x , p . ). conclusion: our preliminary data analysis reveals that a higher number of monocytes in the nk cell product may contribute to severe infusion reactions, causing patients to have a grade or higher symptom. limitations to this study include this was a retrospective review at a single institution. a streamlined mixed lymphocyte reaction (mlr) assay for evaluation of human mesenchymal stem cell immunomodulation activity christopher p delavan , maryanne c herzig* , barbara a christy , james a. bynum and andrew p cap . us army institute of surgical research, u.s. army institute of surgical research background/case studies: mesenchymal stem cells (msc) have been investigated for treatment of acute respiratory distress syndrome (ards), graft versus host disease (gvhd), wound healing and trauma. a consensus is building that the immunomodulation by mscs is key to their therapeutic potential. mscs suppress peripheral blood mononuclear cells (pbmc) proliferation in vitro, suggesting a correlation for suppressing pbmc inflammatory responses in vivo. current mixed lymphocyte reaction (mlr) assays generally rely on either direct co-culture or indirect culture using transwell systems for monitoring the proliferation of isolated pbmcs in the presence of mitotically inactive mscs. in the study detailed here, mscs are analyzed in a direct co-culture with pbmcs using a luminescent atp assay. study design/method: blood was obtained from an in house blood bank and pbmcs were separated by centrifugation over ficoll-paque in leuco-sep tubes as specified by the manufacturer. the pooled donor pbmcs were stored at - . mscs derived from bone marrow, adipose tissue or umbilical cord (bm-msc, ad-msc, uc-msc, respectively) or human umbilical cord endothelial cells (huvec) were serially diluted starting at - , cells/ well and cultured in well plates for - h in their respective medias. on day , mscs were washed, resuspended in pbmc media and incubated with or without , freshly thawed pbmcs/well, in the presence or absence of phytohemagglutinin a (pha, - lg/ml). proliferation of both mscs and pbmcs was assessed in triplicate wells by quantitation of atp levels using the bioluminescent reagent cell titer-glo (promega). results/finding: pbmc proliferation in response to pha gave a robust atp signal by h, with > fold increase over control pbmcs. no increase in atp response or proliferation was seen in the absence of pha. co-culture with mscs inhibited pbmc proliferation dependent upon msc passage, source, msc media additive. intra-assay variance of triplicate samples was . %. inter-assay variation of msc preps run under identical conditions was . %. inhibition of pbmc proliferation was graded from - % over the range msc concentrations therefore an ec of msc cell number resulting in % suppression of pbmc could be determined for each msc prep. this ec however was dependent upon pbmc donor pool. conclusion: direct co-culture of live mscs with freshly thawed pbmcs give a robust determination of immunosuppression by mscs. graded responses can be determined, allowing comparison of potency between msc preparations. this streamlined assay can be performed within h, without irradiating cells and with minimal equipment outlay. background/case studies: a high prevalence of iron depletion (id) in blood donors has been documented by recent studies, but none targeted high school aged donors, who consistently contribute % or more of the us blood supply. differences between donors - years old (yo) and adults in baseline and donation-altered iron status are important to understand because teenagers need increased iron for physiological growth and development and may be more susceptible to harm from iron depletion. study design/method: donors aged - were eligible for ferritin testing if they donated at a high school (hs) blood drive at the start of the / academic year at two blood centers. samples from return donations over the remainder of the school year were also tested. the prevalence of absent iron stores (ais, ferritin < ng/ml) and low ferritin (lf, ferritin < ng/ml) were estimated for , , and - yo groups separately for both genders. linkage to operational databases established first-time (ft) vs repeat (rpt) donor status. linear regression analysis tested for differences in natural log of enrollment ferritin values by age. multiple logistic regression assessed whether young age independently predicts iron depletion controlling for donation frequency and other factors. results/finding: a total of donors contributed donations. donors were evenly split by gender, % were ft donors, and % were - yo. ft and rpt - yo donors had on average lower ferritin values at enrollment (p<. ), and a greater percentage were iron-depleted than donors - yo (table) . in repeated measures logistic regression analysis using data from all visits, female sex, greater number of previous donations, shorter interval since last donation, and lower body weight were risk factors for both ais and lf. controlling for these covariates, donors aged - have sharply higher risk for iron depletion than donors - yo. odds for lf were to times greater in the younger donors, and for ais were -to fold higher. preliminary statistical models indicate yo donors may have greater risk for lf than or yo by to percentage points, controlling for other factors (p . ). conclusion: the prevalence of iron depletion varies markedly by age, sex, and donation frequency, but was considerably higher in - yo donors than in adult controls. logistic regression analysis confirms lower age as an independent risk factor for iron depletion. blood centers should implement measures to mitigate higher risk for iron depletion and the potential adverse consequences for this population of vulnerable donors. mitigation of iron deficiency in young donors -a preliminary report ralph r vassallo*, marjorie d bravo, mary townsend and hany kamel. blood systems, inc. background/case studies: iron deficiency is observed in blood donors who meet regulatory hemoglobin (hb) requirements for blood donation. frequent donations result in negative iron balance and eventually lead to anemia. young donors may be at risk for adverse health consequences (cognitive dysfunction, pregnancy-related complications, fatigue, decreased exercise endurance and pica) even before anemia occurs. study design/method: serum ferritin testing was implemented on / / by a large blood collector. testing was performed on successful - y/o whole blood and apheresis donations. low ferritin (lf) was defined as a value < ng/ml in females (f) and < ng/ml in males (m). donors with low ferritin were notified of deferral from red blood cell (rbc) donations ( months for f and months for m) and counseled to take - mg of elemental iron daily for days. for m and f, a ferritin < ng/ml indicated absent iron stores (ais) and < ng/ml indicated iron deficient erythropoiesis (ide). ferritin levels ! ng/ml in f and ! ng/ml in m were considered as indicating an iron-replete state. conclusion: ferritin testing of young donors identified individuals with lf who would benefit from risk mitigation, e.g., delaying subsequent rbc donations and/or taking iron supplements. lf is more common in f than in m donors. lf is more prevalent in m and f donors with any rbc donations in the prior months. an appreciable number of donors with no rbc donations in the prior months presented with lf. these data may be useful in conducting a riskbased decision making exercise to establish recommendations for risk mitigation which could be different for m than for f, e.g., universal iron replacement in teen male donors may not be warranted above a certain hb value. ferritin blood screening in minor or young adult donors jennifer l ritter* , joan williams , michelle humphries , nancy haubert , ben reynolds , michael phillips , randall spizman , ralph r vassallo , hany kamel , sally caglioti , german leparc , and phillip c williamson . abstract completely investigated. the adolescent growth spurt, poor nutrition and onset of menses increase the risks of iron depletion in young donors. new studies show that teenage donors who give blood frequently may be more susceptible to becoming iron deficient than older repeat donors. study design/methods: over , serum samples from donors aged , and years were analyzed for ferritin levels using the beckman coulter au instrument and reagent kit. the anti-ferritin reagent is a suspension of polystyrene latex particles, of uniform size, coated with polyclonal rabbit anti-ferritin antibody. immune complexes formed in solution scatter light in proportion to their size, shape and concentration. the decrease in light intensity is measured spectrophotometrically. results/findings: background/case studies: the risk of cardiovascular (cv) disease in adults can often be identified during adolescent years. the presence of even borderline levels of multiple risk factors increases the likelihood of a cv event. our blood program routinely provides a total non-fasting cholesterol (tc) and blood pressure (bp) measurement for all blood donors. we added glycated hemoglobin (hba c) determination and performed analyses of the prevalence of abnormal (borderline or elevated) levels of multiple risk factors among , adolescents (ages - ; . % female) who donated blood from to . study design/method: abnormal risk factor levels were defined as hba c ! . %, sbp/dbp ! / mm hg and tc ! mg/dl, as suggested by the american heart association for adolescents. the presence of isolated risk factors was defined as one single abnormal risk factor per individual. clustering of risk factors was defined as the presence of or more abnormal risk factors in the same individual. donor sex was recorded at the time of donation. results/finding: table shows the prevalence of isolated abnormal risk factors and the prevalence of abnormal risk factor clustering in the study cohort. overall, , ( . %) adolescents had at least one abnormal risk factor ( . % of males, . % of females). of these, , adolescents had isolated abnormal risk factors, and , adolescents had clustering risk factors. higher proportions of males were in the abnormal bp alone, background/case studies: pre-donation determination of hemoglobin (hb) level in candidate blood donors is a pre-requisite in the majority of blood services and is used to ensure donor safety and blood product quality. however, a variety of hb testing strategies are used across blood services to satisfy this selection criterion. this study aimed to identify how hb screening practices vary across blood donation services and to what extent they influence deferral rates for low hb. study design/method: an online survey was performed among members of the biomedical excellence for safer transfusion (best) collaborative. additionally, data from literature were used to extend the dataset. the survey involved a detailed assessment of hb screening practices, numbers of donations and low hb deferrals for male and female donors separately. multivariable negative-binomial regression models were built to estimate the adjusted effects of minimum donation intervals, hb cutoffs (high/low with high defined as ! . g/dl for men and ! . g/dl for women), iron monitoring (y/n), iron supplements (y/n providing or prescribing), and geographical location on deferral rates due to low hb. results/finding: data were included from blood services worldwide and complete data were available for blood services. deferral percentages for low hb varied from . % to . % among male donors and . % to . % among female donors. hb deferral rates were notably higher in asian blood services. overall, iron monitoring was associated with % lower hb deferral rates in men ( % confidence interval [ci] % to %) and % lower rates in women ( %ci % to %). iron supplementation was associated to % lower hb deferral rates among women ( %ci % to %) but there was no evidence of such an effect among men (p . ). each one-week increase in minimum donation intervals resulted in % lower hb deferral rates among women ( %ci % to %) but not among men (p . ). at the % level of significance, higher hb cutoffs do not appear to have an effect among men or women. conclusion: the variation in hb deferral rates across blood donation services can be, particularly in female donors, explained by differences in hb screening and deferral practices. mitigation strategies should consider the variable response among men and women. these insights can help improve both blood service efficiency and donor care. were: characteristics of donors (age, sex, size, weight, region); hb levels, date and volume of donation for index application and previous donation; and number of previous donations (in the previous years and the lifetime). data were analyzed using logistic regression stratified by sex. results/finding: . % of all candidates for wb donation were deferred in continental france in . deferral was significantly more frequent in women ( . %) than in men ( . %), due to anemia in . % of deferred women and . % of deferred men. plotting mean hb recovery against time showed mean recovery times ranging from to weeks. analysis (table) identified main factors associated with a higher likelihood of hb recovery: higher logarithm of time since previous donation, lower levels of hb at previous donation, higher number of blood donations in the previous years. conclusion: the main factors associated with higher likelihood of hb recovery after wb donation are probably linked with hematopoiesis stimulation and selection bias among high-frequency donors. mean times required for hb recovery were long enough to require further studies to assess interdonation intervals in france. background/case studies: red blood cell (rbc) transfusion has been related to thrombo-embolic events. microvesicles in the rbc product may support coagulation, which in part may depend on storage time because microvesicles have procoagulant effects in vitro and the amount of microvesicles increase with storage duration. study design/method: we investigated whether transfusion of rbcs containing microvesicles promotes coagulation in human recipients. as transfusion is mostly administered to ill patients, we used a model of mild endotoxemia. eighteen healthy volunteers were randomized to receive either saline, days stored or days stored autologous rbc transfusion two hours after infusion of lipopolysaccharide (lps, from e.coli, ng/kg). blood was sampled every hours up to hours after lps infusion. results/finding: lps resulted in a mild increase in thrombin generation. during storage, the total number of microvesicles increased from . e (iqr . e - . e ) /ml in the fresh product to . e (iqr . e - . e /ml; p< . ) in the stored product (p < . ), which were mostly rbc derived vesicles. after transfusion, microvesicles from stored rbc products, but not from fresh products, could be detected in the circulation of healthy volunteers and were cleared within hours. however, infusion of stored rbc microvesicles did not augment thrombin generation. levels of d-dimer and thrombin-antithrombin complex were also unaffected. conclusion: transfusion of autologous rbcs containing high levels of microvesicles does not enhance coagulation in human volunteers with mild endotoxemia. background/case studies: transfusion-associated circulatory overload (taco) is characterized by hydrostatic pulmonary edema related to blood transfusion. we sought to examine contemporary risk factors and outcomes for taco during a period where patient blood manaement has led to declines in blood utilization. study design/methods: at four academic hospitals, cases of taco were detected by active surveillance of all adult hospitalized patients who received a blood transfusion, and transfused controls were matched to cases by transfusion intensity. taco incidence was calculated, and clinical characteristics were compared with control patients. odds ratios (or) were calculated using multivariable logistic regression. hospital mortality and length of stay were modeled using cumulative incidence functions in proportional hazards regression. results/findings: cases of taco and matched controls were enrolled from , transfused patients who received , blood components from may until july . taco incidence was case per patients transfused. in addition to well described cardiac and renal comorbidities, multivariable analysis identified the following independent predictors of taco: number of plasma units, emergency surgery, pre-transfusion diuretic use, and higher post-transfusion hemoglobin levels (see table) . compared to controls, taco cases were more likely to require mechanical ventilation ( % vs. %; p < . ), experienced longer intensive care ( vs. days; p . ) and hospital length of stay following transfusion ( vs. days; p< . ), and had higher mortality ( % vs. %; p . ). conclusion: the incidence of taco was lower than what has been reported by prior active surveillance studies. despite declines in its incidence and the number of blood components transfused per case, taco remains a complication of transfusion with significant associated morbidity and mortality. in addition to risk factors for cardiovascular and kidney disease, plasma transfusion and higher post-transfusion hemoglobin levels were associated with taco after controlling for other covariates in the model. additional research is needed to examine the utility of these risk factors in the development of real-time predictive algorithms and the benefit of reduced erythrocyte or plasma exposure in patients at high risk for taco. background/case studies: the residual risk of bacterial contamination of single-donor apheresis platelets (ap) was recently addressed by the march fda draft guidance to enhance the safety of platelet transfusion. this document also describes an existing pathway for ap outdate extension from to days using an fda cleared rapid test (rt). our hospital based transfusion service has used this rt to enhance the safety of ap transfusion since july and to routinely extend ap outdate to day since february . this study reports a month experience of secondary screening of ap using a rt. study design/methods: all ap were obtained from our hospital-based donor center or one of four external suppliers. ap were screened by culture based methods post-collection and prior to entry into our inventory. from july -january , ap underwent rt on day . day and units were transfused with physician approval when deemed medically necessary. any units remaining in inventory on day had a second rt performed. from february -january , ap underwent rt on day with routine outdate extension to days by performing a second rt on day and a third rt on day , as per manufacturer instructions. any positive rts were repeated in triplicate. repeat rt positive units were quarantined and cultured to identify true positives. false positives (fp) were defined as repeat rt negative (type ) or repeat rt positive with negative confirmatory culture (type ). all rt results were reviewed during both study periods. ap transfusion and outdate rates were also summarized. results/findings: since july , , ap were entered into inventory. of these, , ( %) were transfused prior to rt testing. the remaining ( %) underwent rt on day or day . of these ( . %) were rt positive ( type fp, returned to inventory; type fp, discarded), leaving a total available inventory of units tested by rt. of these, ( % of original inventory) were transfused before the end of day and the remaining ( % of original inventory) reached a day outdate. a total of ( % of original inventory) were transfused on day or day . of these, underwent a second rt on day ( rt positives; fp type one and fp type ) and underwent a third rt on day (no positive results). a total of ( % of original inventory) outdated on day . of these, underwent a second rt on day (no positive results). conclusion: to date we have performed rts on ap at our hospital. no true positives have been identified. use of rt over the study period decreased our outdate rate from a predicted % to only %. a total of ap have been tested twice by rt ( on day and ; on day and ) with ( . %) positive results, both of which were deemed fp by repeat testing or culture. a total of units have been tested times (day , day and day ) with no additional positives identified. we have not yet identified any units with an initial negative rt result that subsequently converted to a true positive. there is a low fp rate which should also be expected when performing repeat testing on the same unit. these data suggest that the yield for repeating the rt every hours, as currently specified by the manufacturer instructions, is quite low. additional studies are needed to clarify how rt can optimally be used to enhance detection of ap bacterial contamination. survival of trypanosoma cruzi in human blood components laura tonnetti*, aaron thorp and susan l stramer. american red cross background/case studies: trypanosoma cruzi, the agent of chagas disease, is associated with to million infections worldwide, mostly in latin america. despite the extensive immigration from endemic areas, only cases of transfusion-transmission (tt) t. cruzi have been reported in the us, before blood donor screening was implemented in . contributing factors to the low number of tt cases are a possible association between parasite lineage and tt, and high numbers of unreported cases. platelets are almost exclusively involved in t. cruzi tt cases; however, during preparation of components a large fraction of the parasites can be found in red blood cells (rbcs). we investigated if blood component preparation and storage time affect the survival of the parasite and thus play a role in tt of t. cruzi. study design/method: whole blood (wb) units were spiked with t. cruzi trypomastigotes to a final concentration between - , parasites/ml. each parasite concentration in wb was tested x . an aliquot of contaminated wb was used to prepare hemocultures to detect live parasites before preparation of components. rbcs were separated and half of the components leukoreduced (lr) by filtration. platelets and plasma were separated, along with one aliquot of plasma collected before lr. rbcs were stored at c for up to days; platelets were stored at c (rt) under agitation for days and plasma was frozen at - c. aliquots for culture were removed weekly from rbcs, daily from platelets and after days from frozen plasma. all samples were cultured in liver infusion tryptose (lit) media at c for detection of live parasites for up to weeks. results/finding: hemocultures from spiked-wb were positive at all concentration of parasites. lr'd and non-lr'd rbcs cultured before storage were positive at all concentrations. after storage at c, rbcs from all units spiked with , parasites/ml were positive for up to days; all further times yielded negative results. at lower concentrations, only non-lr'd rbcs spiked with parasites/ml were positive for up to days. plasma samples cultured before freezing were positive at the highest concentration in one non-lr'd sample, while all others were negative. platelets obtained from wb spiked with , and parasites/ml were positive up to days at rt. no parasites were observed in plasma or platelets prior to storage at lower concentrations. molecular analysis to determine the presence of parasite dna in each component is on-going. conclusion: platelet storage conditions offer a suitable environment for t. cruzi survival; however, high concentrations of parasites also survived in rbcs at c for up to weeks. leukoreduction offers partial protection, while freezing conditions appears unsuitable for t. cruzi survival. hemovigilance monitoring of platelet septic transfusion reactions (str) after treatment with intercept tm pathogen reduction or large volume, delayed bact/alert tm bacterial culture screening richard benjamin* , marion lanteri and larry corash . cerus corporation, scientific affairs department, cerus corporation background/case studies: amotosalen/ultraviolet a (uva) light (inter-cept tm blood system, cerus corporation) pathogen reduction (pr) and delayed, large volume, bacterial culture with the bact/alert tm system (dlvbc) (biomerieux, inc) represent respective best-in-class systems to reduce the risk of str associated with platelet concentrates (pc). where implemented, hemoviligance (hv) programs continue to receive reports of suspected str, most of which have low imputability as other causes are more likely or insufficient information is available to impute system failure. study design/methods: united kingdom ( - ), french ( - , swiss ( - ), and belgium( - hv reports, and cerus corporation's adverse event records were reviewed to assess the residual risk and imputability of str with amotosalen/uva-treated or dlvbc-screened pc. results/findings: approximately . million dlvbc-screened were issued with a day outdate after release into inventory days after collection, and $ . million amotosalen/uva-treated pc were released into inventory on day or , with a to day shelf-life. no septic fatalities were reported with either technology. the french, belgium and swiss hv programs monitored > . million conventional, non-dlvbc-screened pc and recorded str and fatalities. concurrently, zero definite and possible str were reported with , amotosalen/uva-treated pc, significantly fewer than with conventional pc (table ) ( . str per million vs. . per million, p< . ). one definite, possible, undetermined/indeterminate non-fatal str and contaminated "near miss" pc were reported with . million dlvbc-screened pc between and , for a reduced falsenegative rate compared with the prior five years ( . str per million vs. . per million, p < . ). hv programs highlight a major weakness when reporting str. stringent criteria are used to determine definite imputability, including evidence of patient infection, pc contamination and irrefutable evidence of a donor source, with confirmation of strain identity. reports with incomplete investigations are considered undetermined or indeterminate, or possible sepsis. some of these cases are almost certainly due to bacterial contamination of pc, suggesting that the actual rates of sepsis are considerably higher than that reported by hv programs. conclusion: best-in-class pathogen reduction and bacterial culture systems reduce str risk, although underreporting and inadequate clinical data may result in underestimation of the true rates. pathogen reduction of background/case studies: despite extant mitigation measures (e.g. diversion pouches and primary platelet culture at the collection facility), bacterial contamination of platelets and associated septic transfusion reactions remains a leading cause of transfusion-associated fatalities in the united states (us). consequently, the us food and drug administration has recommended adoption of additional measures such as point of release testing (port) and/or pathogen reduction to safeguard against transfusionassociated sepsis. however, port poses logistical challenges, particularly in institutions with high-volume platelet utilization, while pathogen reduction is a high cost intervention. we evaluated a second bacterial culture to contend with residual risk. study design/method: phased implementation of secondary bacterial culture testing (bact/alert tm ,biomerieux, inc., durham, nc) was initiated in october for all platelets received at our institution. at time of receipt at the blood bank (day post collection), products were sampled using a sterile connection device (tscd tm , terumo, elkton, md) and a sampling kit (sam-plok tm sampling kit, ml, itl biomedical, malaysia). five mls of product was transferred aseptically to bact/alert bpa (aerobic) culture bottles using the same sampling device. inoculated culture bottles were loaded into the bact/alert incubator modules and incubated at c for three days. results/finding: a total of / , ( . %) platelet products were successfully cultured ( / [ . %] and / [ . %] in october and march respectively). over the -month period, two true positive cultures were obtained (incidence of in platelet products). the cultures grew acinetobacter species (case a) and coagulase negative staphylococcus species (case b); both positive results were obtained four days following collection. repeat testing of cases a and b grew the same organisms identified in the initial cultures. there was a co-component in our inventory (case a) with negative initial and repeat cultures. none of the products were released for transfusion. the initial post-collection product cultures remained negative at the collection facility. over the same time period, no false positives were detected. implementation required hiring one additional dedicated fte; the total cost (technologist time, equipment and related supplies) was calculated to be $us . per product tested. the cost per averted case was $us , . conclusion: we demonstrate the feasibility of implementation of a secondary bacterial culture test of apheresis platelets to interdict bacterially contaminated units and prevent septic transfusion reactions. this presents a low-cost strategy (as compared to pathogen reduction) to mitigate risk of septic transfusion reactions. importantly, it offers a viable alternative to port in high volume institutions where logistic (e.g. time and personnel) constraints impede practical adoption of port. an increase in cases of blood culture positive transfusion reactions (bcptr) was noted at our hospital; bcptr was defined as bacterial culture positivity in the transfusion recipient and/or associated transfused blood product during investigation of a transfusion reaction. we sought to characterize the risk and clinical presentation of bcptr at our institution. study design/method: an analysis was conducted of all reported transfusion reactions at johns hopkins hospital (jhh) between january and december . the data, extracted from hemovigilance records, were evaluated to determine the incidence of bcptr; the severity and symptoms were evaluated in concordance with recipient data, including patient diagnosis, medications and clinical manifestations of the reaction. bacterial culture results were evaluated for both patients and associated blood products (i.e. partially transfused or residual product in blood bag). results/finding: in the -year study period, a total of transfusions reactions were reported, of which were bcptr ( . % of transfusion reactions). of the bcptr, ( %) were associated with apheresis platelets, ( %) with red blood cells, and ( %) with plasma. recipient diagnoses spanned hematologic/oncology (n ), renal (n ), cardiac (n ), autoimmune (n ), and obstetrics (n ). an organism was identified in both the blood product and recipient in ( %) cases; in ( %) cases an organism was grown in the blood product but not the recipient; and in ( %) cases an organism was isolated from the recipient only, due to inability to culture the product. the transfusion recipients in of the cases that did not isolate organisms in the recipients were on broad-spectrum antibiotics at the time of transfusion. symptoms of bcptrs included fever ( %), chills ( %), nausea and vomiting ( %), pain ( %) and dyspnea ( %). blood pressure (bp) decreased in %, increased in %; % of reported bcptrs had no change in bp. conclusion: the signs and symptoms of bcptrs are not specific and overlap both with underlying disease as well as other types of adverse transfusion associated events, thus contributing to delayed diagnosis and under-reporting. furthermore, high rates of antibiotic use in transfusion recipients can mask symptoms of true septic transfusion reactions. hospitals should consider expanding the clinical indications for culturing blood components that are implicated in transfusion reactions. furthermore, excessively stringent criteria (cdc/nhsn blood safety surveillance) for transfusion-transmitted infection, may contribute to misclassification of septic events in some recipients, particularly if on antibiotics. clinical oral abstract session: immonohematology and genetics --sickle cell disease and beyond blindspots and cross-reactivities of anti-human globulin specific for igg subtypes heather howie , jenna lebedev , linda kapp , xiaohong wang , meghan delaney , lay see er and james c zimring* . bloodworksnw research institute, bloodworks nw, university of washington school of medicine background/case studies: there are four different subclasses of human igg (igg -igg ), each with different effector function. essentially all existing data on the effect of igg subclass on hemolytic transfusion reactions and hdfn, were generated using ahg specific for igg subclasses. in recent decades, it has become appreciated that there are at least natural human variants of igg. in this study, the reactivity of igg specific ahg was tested against all known variants. study design/methods: the heavy and light chain variable regions of an anti-k monoclonal antibody were sequenced and cloned into expression plasmids that fused variable regions (in frame) with each of the known igg variants. plasmids were expressed by co-transfection into cho cells. the resulting panel of antibodies were pre-incubated with k rbcs and were then subjected to testing with currently available igg subtype specific ahg (monoclonal ahgs from southern biotech and sanquin, polyclonal ahgs from sanquin and the bindingsite). all testing was carried out by flow cytometry. results/findings: polyclonal reagents against igg , igg , and igg had cross-reactivity with variants found in other igg subclasses, and specific amino acids responsible were identified by site directed mutagenesis (table ). titrations of the ahgs did not identify a dilution at which crossreactivities were lost, but authentic targets were still detected. however, cross-reactivity could be neutralized by pre-incubating ahg with the crossrecognized igg forms (against a third party antigen); the remaining reactivity recognized the intended igg subtype without detectable cross-reactivity. no cross-reactivity was detected for polyclonal anti-igg or for any of the monoclonal ahgs tested. monoclonal anti-igg had a blindspot for igg - , due to the shorter hinge region on igg - . no blindspots were detected in other monoclonal or polyclonal ahg. conclusion: the relative quantitation of different igg subtypes has been studied in multiple immune settings, and plays important roles in diagnosis and research of human disease, including immunohematology. herein, we demonstrate that the reagents used to generate this body of knowledge suffer problems of cross-reactivities and blindspots. as such, the existing data regarding igg subtype biology may have some inaccuracies as a result of these defects in igg specific ahg. genotype matching for pediatric sickle cell disease patients nancy robitaille* , yves dominique pastore and maryse st-louis . chu sainte-justine, hema-quebec background/case studies: among the different treatment modalities available for sickle cell disease (scd), blood transfusion is frequently used. however, alloimmunisation remains a significant problem, even if prophylactic antigen matching is performed for c, e and kell antigens. this is partly explained by different antigen frequency among caucasian blood donors and african-american recipients, and by variants in the rh blood group of people of african-descent. blood group genotyping has been proposed as a potential way to alleviate this problem. the scd cohort of a pediatric academic hospital was genotyped for rhd, rhce and fy genes. the primary objective of our study was to evaluate whether compatible genotyped blood donors presenting similar rh variants could be identified. study design/methods: since , our local blood provider intensified recruitment of african-descent blood donors. these donors were phenotyped and genotyped for clinically relevant antigens by different means: genomelab snp stream, laboratory-developped assays and idcorext. as of , scd children were genotyped by sequencing rhd, rhce and fy cdnas after obtaining informed consent. extended red blood cell phenotypes were done at diagnosis at the hospital. patients' genotypes were compared to h ema-qu ebec's donor database to attribute blood donors to specific patients. results/findings: from diagnosis until september , ( %) patients had been transfused and had antibodies with known blood group antigen specificity: anti-c, anti-e ( ), anti-hrb, anti-fya, anti-jka, anti-jkb ( ), anti-s, anti-m, anti-sc , anti-leb ( ). seventeen patients ( . %) were either d or partial d. rhce results showed that patients expressed a normal c antigen and expressed partial c. as for e antigen, had a normal antigen, bore a partial antigen and were weakly expressed. fy(a b ) phenotype was found in ( %) patients. a total of genotyped blood donors of african-descent were available. the table below indicates the compatibility with these donors. conclusion: this study shows that several patients have rhce variants difficult to match, even with available genotyped blood donors from their community. although this measure is probably beneficial to decrease alloimmunisation, a larger donor pool is still needed to fulfill the patients' needs. the continued effort put towards recruitment and pheno/genotyping should improve the situation. using genetic markers to select responders and non-responders sickle cell disease (scd) patients for transfusion with rh haplotype matching red blood cell (rbc) units tamires delfino dos santos , emilia sippert , mayra dorigan de macedo , sheila fatima perecin menegati and lilian castilho* , . hemocentro unicamp, university of campinas background/case studies: rbc alloimmunization has been associated with several factors and with individual characteristics of each patient. we recently found that tnfa- a, il b- t cytokine polymorphisms, rhag g>a and hla-drb * alleles may predict a good responder phenotype (sippert et al, transfusion ) and that rhag a and hla-drb* alleles are closely linked to rh alloimmunization. based on this and considering the challenge to fulfill the transfusion needs of the patients with rh variants, we used these genetic markers to select responders and nonresponders scd patients for transfusion with rh haplotype matching rbc units and evaluated the risk of alloimmunization. study design/method: our study included non-alloimmunized patients with scd, homozygous for hbs, receiving a range of - rbc units. rbc antigen phenotypes of each patient and history of rbc antibodies were obtained from the medical records and transfusion service computerized database. rbc genotyping was performed using whea, wrhd and wrhce beadchip arrays (bioarray solutions, immucor) in accordance with the manufacturer's instructions. cytokine gene polymorphisms (tnfa- g>a, il b- c>t) and the rhag g>a gene polymorphism were analysed by pcr-rflp and taqman assays. hla class ii genotyping was performed using pcr-sso. results/finding: among non-alloimmunized patients, were homozygous or compound heterozygous for rh variant alleles. from those, had rhag a and/or hla-drb* alleles and at least one cytokine polymorphism (tnfa- a or ilb - t) associated with risk of alloimmunization and were transfused with extended and rh haplotype matching rbc units. the other patients with no risk factors associated with rbc alloimmunization were considered non-responders and were not transfused with extended and rh matching units. all patients were followed for one year and did not develop rbc antibodies. conclusion: these findings contributed to the development of a transfusion strategy for non-alloimmunized scd patients as typing for these polymorphisms could potentially help in the classification of responder and nonresponder scd patients, allowing blood with high level of compatibility to be five discrepant samples required sequencing. id core xt identified three rhce*cear samples encoding a partial c, and a partial e (predicted phenotype: vweak, vs-) and were confirmed by sequencing. the third sample was found to be rhce*cevs. ,rhce*cebi on sequencing (predicted phenotype v ,vs ). the samples were typed as v (or ce s ) and vs (or e s ) by hea. in addition, id core xt accurately identified rhce*ce[ g]in samples. this snp has been linked to various allelic variants affecting c and e antigenic expression. both samples were predicted to be c by hea. conclusion: blood group genotyping platforms vary depending on the specific snps that are included in each assay. such variations may be clinically significant when genotyping is used as a tool for providing matched blood. discrepancies leading to differences in the predicted phenotype could affect unit selection. despite the discrepancies between the methods, the high concordance rate and the limitations of serology warrant further reconsideration for the need for serologic confirmation of extended phenotypes. background/case studies: over three decades ago, two independent groups published work suggesting a novel categorization of warm autoimmune hemolytic anemia (waiha) on the basis of dat scores of agefractionated rbcs: type i waiha, comprising % of patients, showed increased binding of autoantibodies to aged rbc, whereas type ii waiha autoantibodies ( % of patients) bound young and old rbcs with no apparent prejudice. band- is a ubiquitously expressed rbc transmembrane protein which plays a vital role in maintenance of rbc structural integrity, cellular hemostasis, and regulation of senescence; and, has been suggested to be targeted by autoantibodies from patients with waiha. band- is regulated through phosphorylation of key residues; its hyperphosphorylation is a hallmark of normal rbc senescence, which causes band- to disengage from the cytoskeleton, increasing its lateral diffusion, thereby permitting the formation of band- aggregates forming new epitopes which are recognized by natural igg autoantibodies causing phagocytosis and destruction of senescent rbcs. type i waiha has been postulated to be caused by an exacerbation of normal rbc senescence. study design/methods: in an effort to confirm and characterize the two waiha subtypes we age-fractionated whole blood samples from patients with waiha on discontinuous percollv r gradients and looked for differences in dat results between less (young rbcs) and more dense (aged rbcs) fractions, fractionation patterns and band- tyrosine phosphorylation. results/findings: we confirm that two distinct types of waiha can be identified based on autoantibody reactivity with the youngest and oldest autologous rbcs. further, comparing type i and type ii patients, we found that type i is characterized by percollv r fractions (similar to healthy storage-matched controls) but increased band- tyrosine phosphorylation compared to healthy storage-matched controls, with phosphorylation occurring during younger stages of rbc development. type ii patients were characterized by - percollv r fractions, lacking the fraction containing the oldest rbcs, and showed a complete lack of, or dramatic decrease in, band- tyrosine phosphorylation compared to healthy storage-matched controls. conclusion: these results confirm the two distinct types of waiha. in type i waiha, the increased binding of autoantibodies to older rbcs coupled with increased tyrosine phosphorylation of band- suggests that rbcs from type i patients are aging faster than rbcs from normal healthy controls; this may represent an accelerated and pathogenic form of normal rbc senescence. in contrast, type ii waiha where autoantibodies bind strongly to either young or old rbcs coupled with a lack of fractionated bands that represent the oldest rbcs and a dramatic diminution in tyrosine phosphorylation of band suggests faster destruction of rbcs, consistent with the early published data, and metabolic changes that could affect rbc function. microbial pathogen primary sequence correlates with blood group antigen immunogenicity ian baine* , burak bahar , jeanne hendrickson , krystalyn e hudson and christopher a tormey . yale-new haven hospital, yale university, background/case studies: it is known that specific groups of patients immunologically respond more readily than others to rbc antigens. while rbc antigenic differences between donors and recipients are required for humoral immune responsiveness, other variables are also involved. studies have shown that there is significant primary sequence identity between common rbc antigens and microbes, and that cross-reactivity is possible between antigens in experimental models. we hypothesize that responder populations may be immunologically primed to form rbc alloantibodies via environmental exposure to cross-reactive microbial antigens, and that such a correlation may be linked to observed blood group antigen immunogenicity. study design/method: we performed peptide homology searches of the most immunogenic rbc antigens, based on previously published antigenicity findings. thirteen amino acid peptides containing the polymorphic residues of k, jk a , lu a , e, c, m, c, fy a , and s antigens were queried for identity with microbial peptides using the blast database (blastp, pam abstract algorithm, e value x - , word size , gap costs: existence exten-sion ). search results were restricted to bacteria and fungi, with a selective threshold of > % identity set for inclusion criteria. to corroborate with observed patient data, we also examined preceding cultures from alloimmunized patients to explore agreement between specific pathogens and rbc alloantibodies. results/finding: significant peptide identity was found between rbc antigens and pathogenic organisms including b. fragilis, p. aeruginosa, candida spp. among others. linear regression analysis of the number of genuses in microbial kingdoms meeting inclusion criteria showed a statistically significant inverse trend in predicting the degree of immunogenicity when fy a (an outlier) was removed (b - . , r . & p . ); that is, lower immunogenicity antigens were associated with larger number of kingdoms. k-medoids cluster analysis comparing immunogenicity and kingdoms showed that antigens clustered to low (c), moderate (e, c, s, m) and high (k, jk a , lu a , fy a ) immunogenicity groups, suggesting that an antibody response is inversely associated with environmental antigenic prevalence. of alloimmunized patients reviewed, were culture-positive. of these, % of the anti-c/c group ( of patients) and % of the anti-k group ( of patients) had microbe-antibody agreement. remaining microbe-rbc antibody agreements ranged from - . %. overall, . % ( of patients) demonstrated agreement. interestingly, we observed a particularly strong agreement between infection with klebsiella species and anti-k, despite the lack of > % sequence identity. while . % ( of ) patients reviewed had positive cultures for klebsiella species, . % of these ( of patients) demonstrated an anti-k. conclusion: our study highlights the potential connection between microbial infection and rbc alloimmunization, based on shared epitopes. we speculate that low-level antigenic exposure to highly prevalent microbial antigens such as commensals may promote immunotolerance, providing a model for the inverse relationship between rbc antigen immunogenicity and prevalence of microorganisms. longitudinal studies of microbial carriage (or acute microbial infection) and rbc alloimmune responses in larger patient cohorts may be informative. background/case studies: thromboelastogram (teg) has been incorporated into many hospital armories to manage transfusions during cardiovascular (cv) surgeries. some institutions use well-defined protocols for teg utilization at different stages of surgery (baseline, rewarming, postprotamine, and post-operative). on the other hand, at some institutions teg utilization is driven mainly by clinical judgment. when teg is ordered based on clinical judgment (clinical bleeding in most cases), some patients receive blood transfusions before teg is performed. there is no published literature on how pre-teg transfusions impact teg results and guide further transfusion requirements during cv surgeries. in this study, we have tried to address this issue. study design/method: we retrospectively reviewed tegs performed on patients undergoing cv surgeries at our institution from jan to dec , . no specific teg protocol was used to direct transfusions (plasma, platelets, and cryoprecipitate) during that period. only the first teg performed during surgery was included in the analysis. we excluded the patients that received only red blood cell (rbc) transfusions during the surgery because rbc transfusions are usually not based on teg results. for the tegs analyzed, teg results were divided into three categories: "normal" (reaction time (r), kinetics (k), angle (a), maximum amplitude (ma), and lysis at minutes (min) all within reference range), "hypocoagulable" (r> min, k> min, a< degrees, ma< mm) and "hypercoagulable" (r< min, k< min, a> degrees, ma> mm). fisher's exact tests and z-scores for two population proportions were used to identify statistically significant differences in teg results and blood product utilization. results/finding: out of tegs analyzed, patients ( %) received pre-teg transfusions. we found significantly fewer hypocoagulable teg results in pre-teg transfused patients than nontransfused patients ( % vs. %, p . ). the data also reflected a trend suggesting that there may be more normal teg results in pre-teg transfused patients compared with nontransfused ( % vs. %, p . ). there was no statistically significant difference in transfusions after obtaining teg results in both groups. however, there was a trend suggesting that hypocoagulable state was more likely to be corrected by transfusion in patients who were already transfused pre-teg compared to nontransfused ( % versus %, p . ). conclusion: pre-teg transfusions impact teg results (transfusions correct/normalize coagulopathy) but do not significantly impact further blood product utilization during cv surgeries. the decreased threshold (more transfusions) for correcting hypocoagulable state in patients who already received pre-teg transfusions may be due to more clinical significant bleeding in these patients to begin with. background/case studies: orthotopic liver transplantation (olt) is associated with significant blood loss, due to the complexity of the procedure and extensive liver vascularity, demanding blood transfusion. in this setting, cell salvage autotransfusion (cs) is been used as an alternative to decrease allogeneic red blood cell transfusion. however, as long as some studies have shown that cs in olt decreases allogeneic blood transfusion, others reported that cs presented little benefit or might have been associated with increased blood loss through fibrinolysis. in this study, we evaluate cs efficacy in reducing allogeneic blood transfusion in the intraoperative period. study design/method: we retrospectively evaluated data from liver transplants, performed from to in a single-center. patients were divided in two groups: one with cell salvage (cs) and another without cs (ncs). study endpoint included the requirement of allogeneic blood components transfusion during intraoperative period in both groups. cs was used in all liver transplant recipients but patients with malignancy and sepsis. blood transfusions were indicated based on clinical and hemodynamic criteria. clinical data included age, gender, diagnosis, body weight, height, warm and cold ischemic time and model for end-stage liver disease (meld) score. statistical analyses were performed using t-test, chi-square test, mann whitney test. results/finding: in this study period, olts were performed. a total of patients was submitted to cs. the median age was years (range - yo). cirrhosis caused by chronic hepatitis c virus infection was the main etiology of liver disease. hepatocellular carcinoma (hcc) was found in , % of the patients. the average meld score was , , and it was slightly higher in the cs group ( , vs , , p< , ) . there was no statistically significant difference in other variables such as body weight, height and cold ischemic time. the mean salvaged blood volume was ml and mean reinfused blood volume was ml. allogeneic blood transfusion was required in , % patients in the cs group, compared to , % patients in the ncs group. however, average red blood cells (rbc) and fresh frozen plasma (ffp) units transfused were lower in the cs group. the threshold for rbc transfusion was significantly lower in the cs group ( , units vs , units, p< , background/case studies: hemorrhage is a leading cause of mortality in trauma patients and morbidity in non-trauma patientsaddin en.cite.data. massive transfusion protocols (mtp) reduce mortality in trauma and nontrauma settings; however, this may be at the cost of blood product wasta-geaddin en.cite.data. blood product wastage benchmarks are loosely established, and data on wastage associated with mtps especially sparse. with a redesign of mtp and obstetric massive transfusion protocols (obp) which have different blood product preparation schedules, we assessed wastage, delivery method, and product utilization to identify differences in wastage during these protocols. study design/method: following institutional review board approval, a retrospective study on blood product wastage associated with the mtp and obp between july -december was performed. data on numbers of products dispensed and wasted were manually collected from transfusion service paper and electronic records and an automated data report from the electronic medical record. results/finding: the mtp resulted in higher total number of wasted products than the obp ( and products, respectively) however, obp wastage occurred more frequently in the month period. this reflects automatic thawing of cryoprecipitate in the first round of deployed products in the opb. mtp-trauma activations contributed higher wastage than non-trauma activations ( versus products). this is skewed by one month when products were wasted due to expiration of product on the floor. cooler-related issues ( ) and products dwelling too long out of a controlled environment ( ) were common reasons reported for wastage. the overall product wastage rates for mtp: trauma, mtp: nontrauma, and obp were . %, . %, and . %, respectively, with a total exsanguination protocol waste rate of . %. the difference between the overall proportion of waste between the mtp and obp protocols was insignificant (p . ). conclusion: wastage associated with both protocols was low and there is no statistical difference between mtp versus obp wastage. coolerrelated issues accounted for most product wastage, allowing for targeted waste reduction strategies including educational outreach and improved product delivery methods. better documentation of waste events identifies wastage trends for further product utilization optimization during these protocols. a year old female with multiple gun shots was admitted to a level one trauma center and received uncrossmatched group o, rh negative (d-) red blood cells (rbcs) through a rapid infuser during resuscitation. transfusion of uncrossmatched products before sample collection can lead to errors and confusion in blood typing, as can the venipuncture site used for collecting the patient's blood sample. the current fda guidance and aabb standard of two samples for determination of blood type to prevent cases wrong blood in tube (wbit) or electronic identification systems do not always catch or clarify these errors. study design/methods: patient was tested by manual tube method. two different technologists using two different reagent racks performed initial testing with matching results. results/findings: two samples were collected during resuscitation from the patient and typed as o d-. patient was transfused with units of o d-rbcs before stabilizing. two days later another sample was collected and typed as o rh positive (d ) with mixed field being seen on the anti-d. a weak d testing was performed to see if the negative result with anti-d could be strengthened through incubation. both original samples still resulted as d- (table a) . after consulting the patient care team it was discovered the samples were collected above the iv site after one unit had been completed and while the second unit was being transfused. it was also discovered all other clinical laboratory samples were rejected due to possible line contamination when results for the sodium, potassium, and glucose appeared inaccurate. the transfusion service laboratory is in a different area of the hospital and was unaware those samples had been rejected. conclusion: the initial samples were collected above the iv site and were contaminated with the d-blood product being rapidly transfused during resuscitation. the samples collected during the initial trauma response should have been rejected and a request made for samples drawn below the iv site. because both samples were collected while the unit was being transfused, contamination was in both. use of a handheld barcode system would not have caught this error because the patient had been correctly identified. future prevention of the above anomaly would be the education of transfusion testing staff to recognize an abnormal high hematocrit: secondly reminding the staff collecting samples to be aware of the proper collection procedures for laboratory testing, which would include type and screen. facilities also should strive to perform collection of the confirmatory sample from a completely different venipuncture site. impact of cell saver usage during solid organ transplants at a major institution holly ross* , edward smith , thomas brown , foeks jeremy , metcalf suzanne , james johnson , peter davis , karafa sw badjie and abba zubair . department of laboratory medicine and pathology, transfusion medicine, mayo clinic, department of anesthesia, mayo clinic background/case studies: our institution performs an average of solid organ transplants (sots) yearly. transfusion support for transplants can be tremendous, accounting for a large percentage of red blood cell (rbc) transfusions annually. even the best practices for allogeneic transfusion are not without risk. transmission of pathogens is possible with even the strictest screening methods, and each transfusion increases the risk of alloimmunization. the advent of intraoperative blood recovery has reduced the need for allogeneic donor rbcs during surgeries expected to bleed heavily. with the cell saverv r (haemoneticsv r , braintree, ma), patients' own blood shed during surgery is collected, washed, concentrated, and reinfused, lessening the need for transfusion support. this study sought to examine the amount of allogeneic donor rbc units saved during sots through the use of the cell saver for intraoperative blood recovery. study design/methods: data was collected for sots which utilized the cell saver. these included liver, liver/kidney combination, lung, and heart transplants. data a y.o. female was admitted to the trauma department after a motor vehicle collision (mvc) and transfused o( ) rbc units from the kiosk. her blood type was determined as o(-) with a negative rbc antibody screen (as). she was transfused more units of o(-) rbc. two months later, a repeat as identified two new rbc alloantibodies, anti-d and anti-e. the anti-d formation resulted from the o( ) rbc transfused from the kiosk, but the source of the anti-e was undetermined since e antigen is expressed in % of rh(-) individuals. the trauma department staff was notified of delayed serologic transfusion reaction and asked to investigate further since a y.o. female patient should not have received o( ) rbcs. study design/method: an investigative plan was developed by the trauma staff involving a patient census, review of the chart and kiosk inventory, obtaining feedback from clinical providers, and review of information provided by emergency services (ems). results/finding: the trauma unit was busy with admissions during the hours preceding the patient's arrival. the chart review found the following physical attributes; patient was overweight ( kg) with obvious facial deformities from the mvc, that compromised age assessment. it was determined that the kiosk was fully stocked with both o(-) and o( ) rbc units. one clinical provider recalls that the patient identification (id) might have been unknown. review of the ems communication states "patient is a y.o. female." conclusion: use of visual examination to determine age was significant in the selection of o( ) rbc for this patient. the trauma staff proposed and implemented a change in policy to prevent future incidents. any female patient that arrives without id or written confirmation of age will be transfused o(-) uncrossmatched rbc until a blood type can be determined. after being notified of the incident, the trauma staff took the lead in investigating and providing a process improvement resolution. this is credited to the excellent collaborative relationship between the transfusion service and trauma department on ensuring patient safety during emergent, uncrossmatched rbc transfusions. rate of abo/rh confirmation in outpatient pelvic organ prolapse surgery alexis r peedin*, taylor brueseke, yara park and jay s raval. university of north carolina background/case studies: approximately , surgeries for urinary incontinence or pelvic organ prolapse (pop) are performed annually. for abdominal pelvic floor disorder (pfd) surgeries, transfusion rates historically range from - %, whereas transfusion rates for vaginal and robotic pfd surgeries range from . - . % and . - . %, respectively. since the implementation of college of american pathologists (cap) requirements for abo/ rh confirmation, approximately % of patients who receive a transfusion in our hospital required a second abo/rh specimen to be drawn; however, limited data are available regarding the impact of this new requirement on patients preparing to undergo outpatient surgery that currently require preoperative type & screen (t&s). the primary objective of our study was to assess the rate of abo/rh confirmation in women who underwent outpatient pop surgery. study design/method: this was a planned secondary analysis of a retrospective cohort study of consecutive patients undergoing pop surgical repair from may -may in our academic tertiary care institution. among this sample, patients were excluded if their first t&s was drawn before our institution implemented the abo/rh confirmation requirement. fisher's exact test was used, and statistical significance was defined as p< . . results/finding: we identified patients for analysis, of whom ( . %) had a preoperative t&s ordered. two ( . %) of these patients had positive antibody screens; one patient had an anti-k and one had a warm-reacting autoantibody. fifty-nine ( . %) of the patients required a second abo/rh specimen per hospital protocol; ( . %) of these actually had a second specimen drawn. in patients for whom abo/rh confirmation was indicated, there were no differences between those who did and did not have abo/rh confirmed when comparing age, body mass index (bmi), pre-operative hemoglobin (hgb), or surgical approach (table ) . no abo/rh discrepancies were identified. one patient received unit of red cells after abdominal pop surgery. conclusion: the rate of requiring abo/rh confirmation before pop surgery was markedly higher than that seen in all patients receiving transfusions at our institution ( . % vs. %, respectively). because the vast majority of women undergoing vaginal or robotic pop surgery are not transfused perioperatively, hospital transfusion services should consider eliminating routine pre-operative t&s for this low-risk population in the maximum surgical blood ordering schedule, avoiding this unneeded test and subsequent abo/rh confirmation. volume reduction of red cells to reduce transfusion-associated adverse events related to hyperkalemia maressa t pollen*, laura knicks, linda van tol and c. michael knudson. background/case studies: one attribute of older blood is an increase in supernatant potassium level which can contribute to transient hyperkalemia. this problem is exacerbated in conditions of massive transfusion and in patients with renal failure. washing rbcs can effectively remove free potassium but is time consuming and can often only be performed on one unit at a time. here, we estimate the amount of potassium that is removed by volume reduction of red cell units. we also examined whether this technique would be feasible in the setting of massive transfusion in a patient with hyperkalemia. study design/method: expired or over temperature units (n ) that had been removed from inventory were utilized for these studies. each unit was weighed and a volume reduction procedure was performed. the supernatant was weighed and the potassium of the supernatant was measured using routine laboratory assays. for all formulas, weight was converted to volume using a specific gravity of . g/ml. the hematocrit (hct) of the volume reduced rbc was measured using a sysmex xs- i instrument. the percentage of supernatant removed was calculated by dividing the residual supernatant in the volume reduced unit (rbc hct x rbc volume) by the total supernatant prior to the procedure (residual supernatant removed supernatant). the remaining free potassium (meq) was calculated as the (concentration of potassium in the supernatant (mmol/l) x the estimated red blood cell residual supernatant volume. to simulate the process that would occur in the setting of a massive transfusion protocol (mtp), units were subjected to the volume reduction while recording the time needed to process all units. this was performed twice for a total of units processed in this manner. results/finding: the volume reduction procedure reduced the supernatant volume by an average of % (range %- %). in units between and days (n ), the estimated mean residual k was . meq (range . to . ). in the two mock mtp trials, the time to complete the procedure was approximately minutes and we estimate an additional - minutes would be required to modify and issue the units in our lis/emr. conclusion: a manual volume reduction protocol in red cell units significantly reduces the amount of potassium administered in a unit of red cells. this procedure may be useful when only older red cell units are available for a patient at risk for hyperkalemia. the procedure can be performed in less than one hour and may be useful under the conditions of massive transfusion. processing, cryopreservation, and non-specialized hospital collection. preliminary studies of three shipping conditions after collection were tested using sterile containers with sterile normal saline (ns) alone, ns plus antibiotic/antimycotic (ab/am) and a dry container. prolonged exposure to ab/am solution retarded outgrowth of mscs, but control of microbial growth in cultured tissue samples was needed. these findings were used to construct a validation study. study design/methods: a validation study designed to test procedures to collect, transport, process, and store umbilical cord tissue was measured by post-thaw outgrowth. collected uc tissue from consenting mothers was transported to the distant lab in validated shipping containers in a dry, sterile cup from vaginal ( ) and caesarian ( ) births. uc collections were divided into segments to test conditions. segment explants were placed on . % gelatin-coated gridded tissue culture plates ( explants per plate) in enriched medium specified for msc outgrowth containing antibiotic only with an endpoint of days. growth was scored as the number of squares with explants exhibiting outgrowth compared to the total planted explants. one segment (fresh control) was dissected and planted without further processing. the remaining tissue segments were soaked in (ab/am) saline solution for hr and hrs at c, respectively. tissue segments were frozen in cryo bags with a proprietary % dmso/large molecular weight sugar solution. background/case studies: it has been the practice in our institution to process or times the total blood volume (bv) of the patient, up to a maximum of liters (l) per procedure, to obtain peripheral blood cd stem cells. as a consequence, a patient often would need to spend hours or more on the machine. it would be desirable to be able to specify the exact volume of blood to process to achieve the desired cd cell yield, thus minimizing the patient's time on the machine, the nurse's time performing the procedure, and the number of bags that have to be submitted for cryopreservation and storage. study design/methods: our institution recently implemented the new spectra optia cmnc collection protocol, a continuous flow and continuous collection procedure that uses the automated interface management (aim) system to precisely manage the separation interface. an analysis of our collection data suggested a highly reliable collection process, so a prediction algorithm (pa) based on the linear regression between the patient's cd pre-count and cd yield, normalized per liter of blood processed, was derived utilizing the patient's cd pre-count, the patient's weight in kilograms (kg), and the target cd dose/kg. this pa calculated the exact volume of whole blood to be processed to achieve the requested dose of peripheral cd stem cells. the initial equation was modified to add an additional % to the predicted volume, to account for the natural variability of the process. this pa was then tested prospectively in the clinical setting. results/findings: in patients, representing both allogeneic and autologous donors, the average blood volume processed was . l. the range was . l - . l. the target dose was achieved in all patients. our previous practice for these patients would have required, assuming a standard bv procedure, processing an average of up to l per patient, with a range of - l. to quantify how well the new pa works, it was decided to evaluate the ratio between actual and predicted volume vs. the ratio between the actual and expected cd yield. the result was a high correlation between these two ratios (r . ), indicating that the algorithm produces very consistent results. conclusion: the predictability of our collection process during the time period analyzed was a robust r . , confirming the findings in the first data analysis. the blood volumes processed and patient time on the machine decreased substantially, with some patients only needing hours or less to achieve their target dose. nurses and lab medical technologists have seen a dramatic change in their workflow. the number of bags to process has dropped for the lab, with the consequent freezer space savings and the shorter collection times allowing the lab medical technologists to finish with their work earlier in the day. all in all, implementation of this pa has produced huge increases in patient and provider satisfaction. important factors that likely contributed to the success of the protocol included the precision and consistency of the aim system of the apheresis device, as well as the small number of nurses ( - ) who performed the procedures, resulting in less variability. the economic impact of this pa has not been quantified, but might be an interesting area for future studies. background/case studies: zarziov r , a biosimilar granulocyte colonystimulating factor (g-csf) has recently been introduced into clinical practice. its use has stimulated a certain debate regarding their possible less efficacy and security on cd mobilization. the aim of this study is to evaluate if there are differences between good and bad mobilizers and assess the need for plerixafor when a biosimilar as g-csf is used. study design/method: we retrospectively evaluated autologous mobilization processes performed between june and march . patients (n ) evaluated were diagnosed with malignant lymphoma (n ), multiple myeloma (n ) and primary amyloidosis (n ) and were mobilized according to standard protocols. collection cd cellularity target was established ! x e /kg. two groups, good and bad mobilizers, have been determined. predictors of unsuccessful mobilization were defined by > years old, previous fludarabine, lenalidomide, or bendamustine treatments or ! previous regimens, present peripheral cytopenias, active disease and previous mobilization failure. mann-whitney u test was used to compare means and comparisons of medians were performed by the median test. cd count was performed according ishage protocol. adverse events (ae) were analysed according to ctcae v . . results/finding: the media (range) general collection parameters were: cd (day ) . /ml ( . - . /ml), blood volume processed ml ( - ml) and . ( - . ) exchanged volemias. seventeen patients were considered bad mobilizers, needed plerixafor and had to undergone a collection procedure twice. there were statistically significant differences between both groups on mobilization characteristics and product cellularity [mean (sd) ); p . ]. there were no significant differences on mobilization characteristics and product cellularity between both groups. five mobilization ae were observed [muscle pain (n ), fever (n ) and flu syndrome; all grade ]. two patients could not undergo hematopoietic stem cell transplantation due low cd cellularity. conclusion: there are differences between products collected from the good mobilizer (rich in gm and cd ) versus poor mobilizer (with plerixafor) rich in cn and cmn. the mobilization with zarziov r could be smaller than expected since there are no significant differences if we compare the good mobilizers versus the bad mobilizers although the number of cases studied can be limiting. background/case studies: mesenchymal stem cells (mscs) have been widely studied and have shown beneficial effects on tissue regeneration, immunomodulation, and improvement of multiple organ failure caused by infection, sepsis, and trauma. however, mscs express tissue factor, which may be a risk factor for thrombosis especially if administrated systemically following trauma when coagulopathies are common. before applying mscs in a preclinical animal model, we sought to determine the procoagulant properties of rat mscs in vitro. study design/methods: bone marrow and adipose derived mscs (bmsc and amsc) were isolated from bones (femur and tibia) and visceral fat tissue in normal young sprague dawley rats respectively. both bmscs and amscs were cultured and passaged using dmem medium with % fetal bovine serum. bmsc and amsc at passage - were used in this study. the tissue factor expression of mscs was determined by immunohistochemistry. citrated whole blood collected from normal rats was treated with rat bmscs and amscs at low, medium and high doses ( . /ml, /ml and . /ml respectively). the prothrombin time (pt), coagulation properties and platelet aggregation (response to adp, collagen and par ) were measured by hemostasis analyzer, rotational thromboelastometry (rotem) and impedance aggregometry (multiplate) respectively within min and hr after incubation. results/finding: tissue factor was significantly expressed among both bmsc and amsc at all passages in vitro. bmsc and amsc at any dose and time of treatment neither shortened nor elongated pt in whole blood. however, both bmsc and amsc significantly shortened the clotting time (ct) (none: seconds, versus low, medium and high doses of amsc ( , , and seconds), and bmsc ( , , . seconds), p< . ), clot formation time (cft, p< . ) and increased alpha angle (p< . ) by natem measurement, but did not significantly affect the ct, cft and alpha angle by extem. maximum clot firmness (mcf) and fibrinolytic index were not affected by mscs. there was no significant impact of both bmsc and amsc on platelet aggregation simulated by adp, collagen and par . no significant differences of hemostatic and platelet function were found between the treatments of bmsc and amsc. conclusion: consistent with reports from human derived msc, both rat bmsc and amsc significantly expressed tissue factor in both early and late passages, which led to a significant decrease in clotting time at various dose and time of treatment. however, mscs had no direct impact on platelet aggregation in vitro. as considering the procoagulant capability of mscs, future study will be necessary to determine the optimal dose and safety of using mscs for systemic application in vivo. comparison of the terumo bct mnc and cmnc protocols for peripheral blood stem cell collections lindsey westbrook* , neil bagamasbad , reynold dilag , melissa nasser , nicole bauer , jennifer wheeler and mary berg . department of pathology, university of colorado -anschutz medical campus, department of medicine, division of hematology, university of colorado hospital, scientific support, terumo bct background/case studies: terumo bct recently offered a new method of peripheral blood stem cell (pbsc) collection using the spectra optia, an apheresis instrument. the new protocol, continuous mononuclear cell collection (cmnc) collects cells continuously as opposed to the older protocol, the mononuclear cell collection (mnc) protocol, which is batch collection or dual stage collection, involving an additional step where platelets are separated from mnc within a cell separation chamber. our institution has used both protocols and the purpose of this study was to compare pbsc product characteristics and run times between the cmnc and the mnc protocols. study design/method: a retrospective review and comparison of parameters from collection procedures using the mnc protocol and collection procedures using the cmnc protocol was done using the t-test. data from patients/donors (including allogeneic donors) as well as procedure details including run time, flow cytometry marker for stem cells (cd )-positive (cd ) throughput, cd collection efficiency (ce%), platelet loss a transfusion per total blood volume processed (plt loss/tbv), and collection product characteristics were included in the analysis. results/finding: numerical results are summarized in the table. the mnc and cmnc donor groups included and allogeneic donors, respectively. donor weight was not significantly different between the two groups. pre-procedure wbc values were also similar between the two groups. run time was found to be significantly shorter using the cmnc protocol compared to the mnc protocol. product volume was also significantly lower in the cmnc group compared to the mnc group. although the volume was lower, the cmnc product had significantly higher percentages of mononuclear cells (mono%) and lymphocytes (lymph%) collected when compared to the mnc product. the cd throughput was significantly higher in the cmnc group than the mnc group. the cd ce% was found to be slightly increased in the cmnc group, though not significantly. the platelet loss was not significantly different between the protocols when normalized for total blood volume. product hematocrit (hct%) was significantly higher using the cmnc protocol; however, the red blood cell volume never exceeded ml due to the lower product volume with the cmnc protocol. the cmnc protocol collects a smaller volume of a purer product when compared to the mnc protocol with comparable platelet and red blood cell loss. staff members who perform apheresis procedures are pleased by the shorter run time. background/case studies: hematopoietic stem cell (hsc) donors and their recipients need not have a matching blood type. eventually, the hsc recipient will become the blood type of the hsc donor. this scenario can become quite a conundrum if the hsc recipient becomes a patient in need of an organ transplant. in order for a patient to receive a donor organ, the patient and donor's blood type and hla typing must be compatible. study design/methods: blood type was determined using gel test cards. hla typing was determined by using sequence-specific oligonucleotide (sso), sequence-specific primer (ssp), and sequence based typing (sbt) technologies. hsc sources were bone marrow and umbilical cord blood. results/findings: patient # , originally typed as an a , had bone marrow donor and cord blood transplants. one of the cord blood transplants successfully engrafted. the engrafted unit was from a type o donor. patient # is now typing as type o. patient # was originally typed as a and received a bone marrow transplant from a type b donor. patient # is now front-typing as a b and backtyping as an ab. since the patient's abo front and back-type do not match, a note must be made, that when confirming abo during crossmatch, the abo will not match. the patient now has an hla and abo identical kidney match (his father who is a type b). previously, the patient and his father were abo incompatible. the abo and hla results on both patient # and patient # indicate that the hsc transplants have engrafted. results also indicate that the abo and hla now match that of the donor and differ from the recipient's original abo and hla type. due to various reasons, for example, a side effect of the immunosuppression, both patients now need a kidney transplant. both patients will be entered into the unet system according to their "new" abo and hla types, as unos regulations require patients to be listed as per the results of two separate abo typing tests. the patients' antibodies will be monitored as per lab policy and communication with the transplant centers and blood banks is crucial. background/case studies: mesenchymal stem cells (msc) are beneficial for tissue regeneration, immunomodulation and improvement of multiple organ failure caused by infection, sepsis, and trauma. mscs express tissue factor (tf) that activate the clotting cascade and interfere hemostasis. hypoxia is a condition that occurs after trauma globally during shock or at the site of injury, and is known to change or influence the phenotypes of cells, including mscs. in this study, we want to determine if hypoxia changes the expression of tissue factor and the pro-coagulant properties of rat msc in vitro. study design/method: bone marrow and adipose derived mscs (bmsc and amsc) were isolated from bones (femur and tibia) and visceral fat tissue in normal young sprague dawley rats respectively. both bmscs and amscs were cultured using dmem medium with % fetal bovine serum under either normoxia ( % o ) or hypoxia ( . % o ). msc growth curves were measured by cell counter. the tf expression was determined by immunohistochemistry. cd /cd and cd were measured as positive and negative markers of msc respectively by flow cytometry. the citrated rat whole blood was treated with msc ( . /ml) either from normoxia or hypoxia. the coagulation properties were measured by hemostasis analyzer and rotational thromboelastometry (rotem). results/finding: hypoxia potentiated the growth of bmsc by %, but depressed the growth of amsc by % at day in comparison to normoxia. both bmsc and amsc equally expressed cd and cd but not cd under any culture condition. tissue factor was significantly expressed among bmscs and amscs from both normoxia and hypoxia. whole blood treated with bmscs and amscs from normoxia significantly shortened the clotting time (ct: (control), versus (bmsc), and (amsc) seconds) by natem. hypoxia also significantly shortened ct ( (bmsc), (amsc) seconds, p< . as compared to control), but the changes in ct were not significantly different between bmscs and amscs. maximum clot firmness (mcf) and fibrinolytic index did not change after treatment with bmsc and amsc regardless of the normoxia or hypoxia conditions. conclusion: tissue factor is constitutively expressed in rat bmscs and amscs. adjustment of the msc culture condition to hypoxia did not affect tissue factor expression or the procoagulant properties of msc (bmsc and amsc). this study also suggests that the procoagulant properties will not be affected if mscs are recruited into injured tissues with hypoxic environments. future study will be necessary to determine the optimal dose msc and whether it is safe to use mscs for systemic application in trauma. effect of double-end cryopreservation on gene-transduced human hematopoietic stem and progenitor cells sandeep k srivastava*, jiaqiang ren, steven highfill, narda theobald, suksee deravin, andre larochelle, david f stroncek and sandhya r panch. national institutes of health background/case studies: current early-phase clinical gene therapy trials use freshly collected or cryopreserved cd cells as the starting fraction prior to gene manipulation. following gene-transduction and culture, the end product is infused fresh into recipients. for wider applicability and scale-up, gene therapy manufacturing protocols would benefit from double-end cryopreservation (dec) of cd cells during manufacture (i.e. immediately post-collection and again, post-gene modification). dec helps delink patients' preparative conditioning phase from cell manufacture, eases logistics of inter-facility cell transportation, and ensures fulfillment of regulatory product release criteria before infusion. our objective was to study the effects of dec on gene transduced mobilized peripheral blood (mpb) cd cells. study design/method: cryopreserved cd cells from healthy adult donors were thawed and transduced (tr) in retronectin coated tissue culture bags with an ef -alpha-yfp lentivirus ( . % concentration) and media (x-vivo- , human serum albumin(hsa), ng/ml each of cytokines (scf, tpo and flt -l) over days. untransduced (utr) cells were cultured as controls. tr and utr fractions were re-cryopreserved. a standard freeze-mix of % dmso, % pentastarch, hsa, plasma-lyte a was used for cryopreservation. viability, hematopoietic stem cell (hsc) (cd cd -cd ra -cd cd f cells) phenotyping and cfu assays were done following first thaw (pt ), post-transduction (ptxn) and second cryopreservation-thaw (pt ). results/finding: tnc recovery decreased gradually in the donor samples at each step. transduction efficiency, cd %, cfus were similar before and after pt . hscs ranged from to cells/ cd cells in the pt -tr arm compared to a range of to / cd cells after pt . viability, % cd and cfus were lower in the tr compared to the utr arm. this difference was not altered after pt (table) . conclusion: dec of mpb human cd cells decreases tnc recovery, but has minimal effects on cd cell phenotype, transduction efficiency and cell function. hsc numbers were within acceptable range after recryopreservation. lower viability and cd % in the tr arm compared to the utr arm is likely due to vector toxicity. this was unaffected by recryopreservation. additional studies to assess dec mediated changes on cd cell early apoptotic markers, telomere lengths, gene expression and engraftment potential in nod/scid mice will inform clinical trials. background/case studies: autologous peripheral blood stem cell (pbsc) transplantation has been used as a powerful resource during the treatment of some hematological malignancies. cryopreservation of these cells is routinely performed to allow for patient adequate conditioning and chemotherapy. in some cases, pbsc are harvested as a backup option and remain stored for several years, although effect of storage lesion in this product is still controversial. our work presents retrospective data on pbsc infusion after long-term storage. study design/method: all products were harvested after patient mobilization with g-csf by apheresis with cobe spectra v r . flow cytometry analysis of cd cells was performed prior to cryopreservation. the cryoprotective solution was freshly prepared by addition of % hydroxyethyl starch, % human serum albumin and % dmso at final concentration. pbsc were cryopreserved by direct immersion on - c mechanical freezer (dump freeze) and stored until transplantation. post-thaw viability was determined from stored cryotube samples by trypan blue exclusion minutes prior to infusion. cells were thawed and infused on bedside. engraftment was defined as the first day of consecutive days of neutrophil count > . x /l and platelet count > x /l after days. with g-csf for four days and patients with g-csf for five days with use of mozobil when cd was below x cells/l on the fourth day. hpc collection was performed on the fourth day of mobilization for healthy donors and on the fifth day for patients. all procedures were realized based on a prediction algorithm using pre-cd on the day of the collection and estimating wbc liters to be processed to obtain sufficient stem cells for the transplant. this algorithm was designed using linear regression of peripheral blood cd on the day of the collection versus collected cd per liter of blood processed. there was no distinction between patients and donors, once the efficiency coefficient was used for both. collected material was sent to analysis and total cd was calculated. final laboratory count of cd per kilogram was compared with the number predicted by the algorithm with spearman's correlation to evaluate whether the formula is effective. calculations were made using ibm spss software. results/findings: among patients collecting hpc for autologous transplantation, , % needed only one day of hpc harvesting, while , % needed two days and , % needed three or more days. our collection efficiency (ce) and standard error of the mean (sem) was - , %. after comparing predicted values with cd collected in the final product, we found a very strong correlation of . (p< . ) for patients and a strong correlation . for healthy donors (p< . ). conclusion: the use of a mathematical model with a prediction algorithm is safe, has low cost and provides a good tool to estimate wb liters to process and avoid unnecessary procedures in both patients and healthy donors. this study evaluated the phenotypic characteristics of uc-mscs derived from fresh and cryopreserved cord tissues (ct), as described in isct's position paper on minimal characteristics of mesenchymal stem cells (plastic adherent; ! % cd , cd , cd and % cd , cd , cd , cd , hla-dr) study design/method: umbilical cord tissue (n ) was washed, blood vessels removed, cut into . - mm pieces, and washed twice in saline. fresh tissue was immersed in . % saline for same day culture, while frozen tissue was cryopreserved for at least hours prior to culture. for colony forming unit (cfu) testing tissue was plated directly in a cm tissue culture flask following a wash in pbs with antibiotic/antimycotic. the tissue was allowed to adhere for minutes prior to the addition of cell culture media. media was changed several times a week. cells were passed when robust colony growth was observed and in subsequent cultures > % confluence. all cells were tested on an msc flow panel at passage just prior to confluence. results/finding: both fresh and cryopreserved tissue showed excellent colony forming capabilities. average time for cellular emergence of days (fresh . , frozen . ), and days (total) for the msc's to reach passage (fresh . , frozen . ). all cells were ready for flow analysis in approximately weeks time. there was no statistical difference between fresh and frozen tissue in their colony emergence (p . ), or their growth rates (p > . for all). flow cytometry showed average ! % for positive markers and % negative markers. there was no statistical difference between fresh and frozen flow result (p > . ). conclusion: uc-msc's show excellent adherence to plastic in both fresh and frozen explant cultures, with a consistent fibroblast-like morphology. flow cytometry analysis showed strong msc phenotype in both fresh and frozen samples. the data show that the cryogenic process does not appear to have any detrimental effects on the ability to obtain msc colonies. studies have shown that hsct improves survival and disease-free survival rates when compared to conventional chemotherapy treatments. the increase in the number of hscts over the last years has demanded quality and safety improvements of cell processing and cryopreservation services. cell recovery and viability are crucial parameters to assess ucb quality as a viable hsct graft source. study design/method: twenty-five ucb units cryopreserved for periods of up to years ( to ) were analyzed. units underwent red cell and plasma depletion and then subjected to controlled rate freezing and subsequent cryopreservation using dmso (dimethylsulfoxide) cryoprotectant with % concentration. informed consent and the unit discard terms for all units were obtained. units were thawed in a c water bath and . ml aliquots were diluted at a : proportion with % human albumin solution and plasmin were prepared, enabling dmso stabilization and concentration reduction. the following analysis were performed: nucleated cell count (tnc) in an automated hematologic counter and cell viability using flow citometry. post-processing (pre-cryopreservation) cell viability was tested using trypan blue as exclusion dye, while post-thaw cell viability was assessed using -aad marker through flow cytometric analysis. results/finding: ucb storage period was . years (mean) and cell recovery was . % (mean). there was no statistically significant correlation between storage period and post-processing cell recovery (p . ). post-thaw cell viability of . % (mean) showed no statistically significant correlation with unit storage period (p . ). post thaw cell viability results are within parameters defined in other studies. background/case studies: umbilical cord (uc) tissue is a rich source of mesenchymal stem cells (mscs) that can be collected noninvasively at birth and stored for potential future use. as such, a growing number of stem cell banks have established uc storage programs based on mounting preclinical evidence of its therapeutic potential. however, little has been reported on the ability to isolate msc-like cells from uc tissue after extended periods of cryopreservation. this work describes and characterizes the isolation of mscs from uc tissue cryopreserved as a composite material at a family stem cell bank for years. study design/method: donated uc units from consenting mothers were evaluated. units had been cryopreserved as composite tissue pieces in ln vapor in a dmso-based cryoprotectant for yrs. ( . . ; n ). units were rapidly thawed and rinsed in dpbs, then pieces were excised from each using a biopsy punch. pieces from each unit were explanted in a x grid pattern in msc-supportive medium and incubated for days, after which the tissue was discarded and media exchanged. cells were isolated on the th day, counted, and subcultured for two passages. at the end of each passage, cells were collected, counted and population doubling time was calculated. isolated cells from each unit were also evaluated for msc immunomarkers. results/finding: small, proliferative cells with fibroblastic morphology were obtained from all explants, yielding a % success rate. cells were positive for the msc markers cd , cd , and cd ( . . %, . . %, and . . %, respectively) and negative for the hematopoietic markers cd / ( . . %). passage and passage doubling times were . . days and . . days, respectively, which are in line with values reported for mscs isolated from fresh uc tissue. conclusion: due to their immature status, ease of collection, and potential therapeutic value, uc mscs are an appealing candidate for future clinical a transfusion vol. supplement s research and treatment. the present work demonstrates that the long-term cryopreservation of uc tissue does not disrupt the ability to isolate functional mscs from the tissue at a later date. importantly, growth characteristics of isolated mscs appear to be comparable to those reported for mscs from fresh uc tissue. based on the consistent isolation and lack of apparent impact on proliferation kinetics, it is reasonable to expect cell yields in the range anticipated for therapeutic requirements and more than sufficient for moving to clinical grade bioreactors for expansion. these results support the feasibility of storage of uc as a composite material for future potential cell isolation and expansion to clinically relevant doses. large volume leukapheresis with spectra optia cmnc protocol in adult and pediatric patients: performance and determination of cd yield prediction algorithm ines bojanic* , nelly besson , ivana vidovic and branka golubic cepulic . department of transfusion medicine and transplantation biology, university hospital centre zagreb, terumo bct background/case studies: large volume leukapheresis (lvl) have shown to enhance cd cell yield collected. this study evaluated performance and safety of the spectra optia cmnc protocol (version ) in adult and pediatric lvl. a prediction algorithm for cd cell yield was also tested. study design/method: we evaluated retrospectively lvl performed in adult patients, and lvl in pediatric patients treated in uhc zagreb from march till september . mobilization regimen combined chemotherapy and filgrastim; poor mobilizes received plerixafor additionally. a combination of acd-a and heparin was used as anticoagulant (acd-a:whole blood ratio : ). in patients weighting kg (n ), a rbc prime was performed. cd , lymphocyte(ly) and monocyte(mo) collection efficiencies (ces) were calculated. a customized prediction algorithm was determined on linear regression between pre-cd cell count and cd cells collected / blood volume processed. prediction accuracy was evaluated by comparing predicted cd values to real cd yield. results are presented as median (iqr). results/finding: in both groups, cd , ly and mo ces were high. target cd dose was successfully reached in procedure in ( , %)adults and in ( . %) children. all procedures were well tolerated: adverse reactions were restricted to mild citrate toxicity symptoms in ( . %) adults, while all pediatric apheresis went uneventful. no bleeding episodes occurred, and no transfusion was needed. product and procedure characteristics* a high correlation between precd cells and cd cells collected/ blood volume was observed in both groups (r . and . in adults and children respectively, p< . ) suggesting cd yield could be predicted based on precd cells and blood volume to process. linear regression equations served as prediction algorithm. the high correlation between predicted cd yield and observed cd yield (r . and . in adults and children respectively, p< . ) showed accuracy of the algorithm. implementation of the algorithm could have allowed sparing a median of . ( . - . )l of blood in adult procedures, and . ( . - . )l in pediatric procedures. conclusion: lvl performed using spectra optia cmnc protocol is safe and efficient in adults and in low body weight children. high cd , ly and mo ce were observed in both groups. implementation of a predictive algorithm can reliably minimize blood volume processed, shorten procedure duration, reduce anticoagulant volumes infused, and improve patient comfort. mesenchymal stem cell therapy in steroid refractory graft-versus-host disease (gvhd) emese molnar* , aniko barta , arpad batai , zoltan csukly , zita farkas , laszlo gopcsa , gabor tatai background/case studies: steroid refractory acute graft-versus-host disease (gvhd) is a serious complication of allogeneic hematopoietic stem cell transplantation (hsct). more experience accumulates in the immunomodulatory effect of mesenchymal stem cell (msc) infusion in numerous immunopathological disorders -such as gvhd -and signals. mscs have a hlarestrictive and non-immunogenic nature. study design/method: we have evaluated the efficacy of msc transfusions in cases of acute gvhd refractory to conventional immunosuppressive treatment. the patients with steroid-resistant gvhd had received third-party mscs (derived from wharton's jelly and bone marrow) times per case weekly at a dose of million cells/kg. clinical response was assessed days after administering the first dose. complete remission was defined as the complete disappearance of symptoms. partial remission was assessed by the significant relief of symptomsand by the general improvement of the patient's condition. results/finding: in all patients had received cycles of msctreatment ( dose per cycle). the median age was years old ( - ) with a male/female ratio of : . distribution of the original malignancies (n): acute myeloid leukemia: ; acute lymphoblastic leukemia: ; myelofibrosis: ; myelodysplastic syndrome: ; multiple myeloma: ; t-cell lymphoma: . nine patients had undergone allogeneic hsct with matched unrelated donors, the other three had stem cells derived from hla-identic relatives. the first episode of gvhd after hsct was started on the median rd day ( - ). the involved organs were skin ( ), gut ( ), skin and gut combined ( ) and even lung in cases. the median time of msc's first infusion was days after the stem cell transplantation (hsct) and ( - ) days after the first episode of gvhd. of the cycles of msc-treatment led to complete remission ( . %) and resulted inpartial remission ( . %). conclusion: we have evaluated msc-therapy as an effective treatment of gvhd in the majority of the observed cases with % overall cumulative response rate. the application of third-party mscs offers a promising alternative in the therapy of gvhd and other gvhd-associated complications after hsct. further research is needed to determine the optimal start of the treatment, along with the issue of long-term safety. background/case studies: stem cell collection by leukapheresis for transplantation is a significant endeavor for the patient and the clinical team. whether the collection is allogenic or autologous, the patient undergoing the collection and the physicians caring for the patient are always concerned whether they will be able to harvest enough cells for transplantation and engraftment. a typical goal for most adult procedures is million cd cells/kg. if a patient does not reach this goal on the day of the procedure, they will likely have to return the following day to undergo a second procedure to reach the desired goal. given the logistical challenges in planning transplantation, it is reasonable to attempt to optimize the number of cells collected while minimizing the number of collections. measuring a patient's cd cells/ml in their peripheral blood before the leukapheresis procedure has been used to predict if the collection will successfully reach the million cells/kg goal. the ideal minimum cd cells/ml that will lead to successful harvest has not been conclusively identified. study design/methods: we analyzed the collection data from patients to evaluate the predictive value of the cd cells/ml level. data was collected over months from every patient who underwent a stem cell collection. four patients were allogenic donors and were autologous donors. the patients' weight, diagnosis, and pre-procedure cd cells/ml level were all collected. the run time, amount of volume processed, and the absolute viable cd cells collected were recorded. the collection efficiency and the cd cells/kg were calculated for each patient. results/findings: our data showed a strong linear correlation between pre-procedure cd cells/ml and post-procedure cd cells/kg (r . ). any patient who had a pre-procedure cd cells/ml count of or greater had a collection of at least million cells/kg. any patient who had a pre-procedure cd cells/ml count of or less collected less than conclusion: the pre-procedure cd cells/ml level in the peripheral blood has a very strong predictive value for the post-procedure cd cells/kg level. to confidently know that a patient will be able to produce the desired million cells/kg, a pre-procedure cd cells/ml count of at least should be obtained. for any patient with a count below , they should be counseled that their collection is likely to take at least a second day and a second procedure. further studies, including potentially lengthening the run time and the volume processed, to evaluate how to handle the patients who fall between and cd cells/ml should be conducted. heidi elmoazzen , antonio giulivi , michael halpenny* , lisa martin , donna perron , chris bredeson , lin yang , locksley mcgann , paul birch and jason p. acker . canadian blood services, ottawa hospital background/case studies: a critical aspect of hematopoietic progenitor cell processing is the cryopreservation method. our program uses a "dump" freeze method consisting of product placement directly into liquid nitrogen vapour after addition of a cryopreservation solution containing dmso ( % final concentration) and hes (hydroxyethyl starch). pentastarch (hes source) a critical component of the cryoprotectant formulation was discontinued by the commercial vendor. this required that an alternative cryoprotectant formulation be validated to minimize the risk to patient safety without compromising engraftment quality. study design/method: the validation study consisted of phases; firstevaluation of the efficacy of four different cryoprotectant formulations, second -evaluation of full scale production and crypreservation and third -a concurrent validation for clinical transplant. phase i -samples from four different cryoprotectant formulations were tested for tnc, cd , viability and cfu at three points during manufacturing (fresh, post processing and post thaw). phase ii -mock hpc, apheresis units were used for a side-by-side comparison of freezing curves for the control and replacement formulations. phase iii -five clinical transplants were performed with hpc, apheresis products cryopreserved using the recommended replacement (hetastarch). results/finding: phase i -results indicate that aliquots cryopreserved in % dmso and . % hes (hetastarch) did not behave significantly different than cells cryopreserved in the control in terms of cell recovery, viability or cell proliferation assay (cfu). phase ii -the majority of freezing profiles displayed typical or expected bulk freezing profiles for both formulations. phase iii -transplants performed resulted in a mean engraftment time of . days for anc with no adverse patient reactions observed. engraftment times using the new hetastarch formula were compared to the previous engraftment times with no significant difference. conclusion: a change in the formulation of a cryoprotectant solution represents a major change that could have a significant impact on quality. in addition, maintaining the current % dmso final concentration was critical as post thaw washing is not performed at the clinical site, history demonstrating a very low toxicity rate with the existing formulation. this study demonstrated the acceptability of the hetastarch formulation using % dmso and . % hetastarch to replace pentastarch in the cryoprotectant formulation used for cryopreservation of hpc, apheresis products. background/case studies: autologous stem cell transplantation is usually performed with mobilized peripheral blood stem cells (pbscs). traditional mobilization regimens include granulocyte colony stimulating factor (g-csf) with or without chemotherapy, but have failure rates ranging from % to %. plerixafor is an adjunct agent used to improve mobilization in many clinical settings. however, its high cost is a significant concern. the manufacturer-recommended dose is . mg/kg, therefore patients weighing > kg would require a second vial, thus doubling the drug cost. in we implemented a policy of capping plerixafor at mg for patients weighing > kg. this retrospective study compares the mobilization of patients > kg who received capped doses ( ) ( ) ( ) ( ) , with historical control patients ( - ) who received full or uncapped doses. study design/method: patients weighing > kg with crcl > ml/min who received capped and full doses of plerixafor were identified in the pharmacy database. electronic medical records were used to collect baseline characteristics and cell collection data. results/findings: a total of and consecutive patients were included in the capped and full dosing groups, respectively. they showed comparable baseline distributions of age, weight, gender and diagnoses. plerixafor was given upfront, or as a rescue agent due to suboptimal mobilization in both groups. in the capped dosing group, fewer patients received chemomobilization or plerixafor upfront. when compared to historical controls, they used half of the number of vials of plerixafor, but collected similar numbers of cd /cells kg and achieved a comparable collection success rate. the strategy dose capping plerixafor at mg for patients > kg is cost-effective and achieves comparable mobilization outcomes while decreasing the drug cost by half. mean and range of %cd in peripheral blood were calculated. the data show that in the non-hispanic group, the youngest donors (< yrs) have a higher pre-apheresis %cd level than any of the other groups, reaching statistical significance when comparing the %cd pre-apheresis between the youngest group (< yrs) and the oldest group (> yrs). hispanic donors show statistically similar %cd pre-apheresis levels over all age groups. moreover, the hispanic older age group (> yrs) had a statistically higher %cd pre-apheresis level than the non-hispanic older age group. conclusion: in this analysis of sequential unrelated pbsc donors, hispanic donors maintain a similar pre-apheresis %cd level even as the donor ages, while non-hispanic donors show a decreasing pre-apheresis %cd level as they age. if proven, this data would suggest there are genetic factors that modulate a person's ability to mobilize stem cells as they age and that these genetic factors differ between ethnic groups. this small data set would suggest that people of hispanic ethnicity maintain a more robust and quickly responsive stem cell pool, even as they age. further studies of larger cohorts are needed to validate this observation. if proven, this has far reaching implications within the stem cell research and therapy arena. background/case studies: an update in hpc apheresis collection software led to higher collection volume in the organization's human progenitor cell (hpc) products without a corresponding increase in total cellular counts. incorporation of a volume reduction step was therefore warranted as larger product volumes require additional time to transfuse and lead to a larger dmso load to the recipient, often resulting in the need to transfuse over several days. the objectives of this study were to develop suitable mock hpc (mhpc) products and evaluate the effectiveness of the biosafe pericell volume reduction technology on white blood cell (wbc) recovery and viability. study design/method: hpc products are not readily available for development. mhpc were created from whole blood buffy coats (bcs). fresh abo compatible bcs were pooled and concentrated using centrifugation and manual extraction of supernatant and red cells. the mhpc products were then diluted in plasma to produce an appropriate concentration and volume. hpc collection data from last years was analyzed to determine the th percentile, median and th percentile values for both hpc volume and wbc concentration. six mhpc products were tested; three high wbc ( x cell / ml) and three low wbc ( x cells / ml) concentrations, each at high ( ml), low ( ml) and median ( ml) volumes. each unit was processed sequentially from high, median and low volumes. hence, the highest mhpc volume was processed for volume reduction first with a sepax (pericell protocol, cs. . kits), analyzed and then reconstituted and volume adjusted to the next volume target before being volume reduced again, and so forth. one additional mock product was prepared for a reproducibility study and was volume reduced three times. wbc concentration and -aad viability was determined before and after each volume reduction. a control sample was removed from the product prior to processing and sat on the bench top until the end of the protocol to assess the change in cell concentration and viability over time. results/finding: mock hpc products had a mean starting -aad viability of % [range - ]% and a hematocrit of % [ - ] which is well below the maximum allowable limit of the pericell. no significant differences in wbc recovery or change in viability were seen between the mhpc products. aggregate data showed that the mean wbc recovery of the volume reduction process was % [ - ] with a % [- - ] change in viability. the recovery protocol used to salvage product after each volume reduction gave a recovery of [ , ] % and a change in -aad viability of [ , ] % from the input product. the method was found to have a cv of . %. the change in wbc concentration and wbc viability of the test products was not significantly different from the unprocessed control samples. conclusion: mock bc products are a suitable alternative where hpc products are not available for development and are a good use of product otherwise directed for rejection and disposal. the volume reduction protocol evaluated had minimal impact on the wbc concentration and wbc viability in the mock products and was found to be highly reproducible, giving confidence that it will be a valuable processing step with hpcs and will facilitate transfusion of hpc products into the recipient. the protocol is now in use with patient hpc products and engraftment kinetics will be tracked in a postimplementation study. validating a transfusion clinical assessment. in the first phase, cryopreserved pbsc products were tested. two aliquots were thawed simultaneously for each product: one was passed through a pre-set infusion pump and a second control aliquot was drained by gravity. each aliquot was tested for baseline total nucleated cell (tnc) count and viability, and for final tnc recovery, trypan blue (tb) viability, cd -aad viability, and potency (cfu). the effect of longterm exposure to dmso was assessed by visually inspecting the product for aggregates and measuring viability up to hours post thaw. the second in vivo phase included use of an infusion pump for consecutive autologous patients, with comparison of infusion and transplant outcomes to previous infusions by gravity drip. comparison variables included infusion rate, adverse events (ae), and engraftment time. results/finding: no significant differences were observed between infusion pump and drip for the products tested in vitro, including tnc recovery, cell viabilities, and potency. for both methods tnc tb viability decreased by more than % within hour, while cd cell viability remained stable up to hours post thaw. small aggregates appeared after hour for both methods and increased by a similar rate over time. comparison of infusion and transplant outcomes between drip and infusion pump patients showed no significant differences for all measured variables. engraftment time was similar for both groups. anc days to engraftment for pump and drip were . . and . . , respectively (p-value . ). platelet days to engraftment for pump and drip were . . and . . , respectively (p-value . ). infusion rates were slightly higher for the pump group. for control patients, required transfer of products to syringes due to slow infusion rate and others experienced allergic and hypotension infusion adverse events. conclusion: no significant in vitro or clinical differences were observed between thawed pbscs infused by gravity or an infusion pump. these results demonstrate that the use of a pump for pbsc infusion is safe, provides consistent infusion rates, eliminates the need to transfer products to syringes, and results in comparable engraftment times. donor racial distribution among the zikv ineligible cbus was: caucasian %, asian %, black/aa %, and multi-race %. racial distribution of all clinical cbu donors was caucasian %, asian %, black/aa %, and multi-race %, suggesting there is no race correlation for this risk factor driven by cultural habits such as family travel. there were no cases in which onlythe sexual partner's potential exposure determined donor's ineligibility. conclusion: our study indicates that currently the leading risk factor for ineligible cb donors is potential exposure to zikv: % of all ineligible cbus and % of all banked cbus in the study period. we anticipate the number of cases to decrease following maternal education and travel warnings. recognizing the importance of zikv in public health, and its potential transmission via hct/p products, an fda approved screening test for hct/ p donors becomes a timely necessity. acknowledgments: funded by zimmer biomet, a zimmer biomet company, ibgrl red cell reference and nhsbt reagents background/case studies: during storage, red blood cells (rbcs) become less deformable, deplete , -diphosphoglycerate ( , -dpg) and adenosine triphosphate (atp), release pro-coagulation phospholipids, accumulate pro-inflammatory molecules, free iron and haemoglobin and increase their potential for adhesion to a recipient's vascular endothelium. longer rbc storage may impair transfusion outcome due to impaired oxygen delivery, promotion of oxidative stress, increased pro-inflammatory state and coagulation. a sterile, non-pyrogenic rejuvenation solution, containing pyruvate, inosine, phosphate, and adenine (citra labs, llc, braintree, ma), is approved by the u.s. food and drug administration for the rejuvenation of stored rbcs. the solution acts by restoring , -dpg and atp in stored rbcs to levels equivalent to those in the circulation. the aim of the study was to investigate the effect treatment with this rejuvenation solution had on the crossmatch reaction profile and phenotypic state of stored rbcs. study design/method: a ml aliquot was removed from abo/rh grouped, leucocyte depleted rbc units (n ), which were stored in sagm for days, to act as untreated controls. the remainder of each unit ($ ml) underwent treatment with the rejuvenation solution ( ml, minutes at o c), followed by cell washing twice in sagm ('manual' centrifuge-based process). to represent current transfusion laboratory practice, units were crossmatched against plasma from random donors, using both diamed gel column and glass tube technique. phenotype investigation with commercial antisera was performed to identify the effect the rejuvenation solution treatment exerted on rbc surface antigens (a, b, d, c, c, e, e, k, m, n, s, s, p , lu a , k, kp a , kp b , le a , le b , fy a , fy b , jk a , and jk b ), including whether it exposed crypt antigens (t, tn, tk*, th, tx*, and cad). crossmatch and phenotype agglutination scores observed for the untreated and treated rbcs were then compared. results/finding: crossmatch findings were defined as compatible, suitable, and incompatible. the study identified no difference between the crossmatch reaction profiles of untreated and treated rbcs. furthermore, no difference was observed in the phenotypic state between untreated and treated rbcs. conclusion: treatment of day old stored rbcs with the rejuvenation solution had no effect on crossmatch reaction profiles or phenotypic state when compared to matched untreated samples. background/case studies: cryopreserved platelet production is burgeoning worldwide. currently, there are no automated platelet cryopreservation methods. by contrast, red blood cell cryopreservation using the acp (haemonetics corp., baintree, ma) has automated the processing within a closed system, increased labour productivity and provided high quality blood components. purpose: to automate platelet cryopreservation procedure. study design/method: apheresis platelet concentrates (pc) were collected on the trima accel system. platelet counts were performed using an abx micros . pc were centrifuged at g in a sorvall rc c centrifuge (sorvall, usa) for min. the combination cryoprotectant dmso dextran (cryosure dex , germany) was used for pc cryopreservation. cryopreserved pc (cpc) were frozen and stored in a kelvinator chest freezer. cpc were thawed at degrees c (barkey plasmatherm) for min. cpc osmolality was measured with an osmomat osmometer. results/finding: staged platelet cryopreservation technology has been developed. platelets were cryopreserved in a closed system (patent no.: ru u ). during the first stage, cpc were spun to separate a plateletrich plasma (prp) fraction from platelet-poor plasma (ppp). the second step was to resuspend the prp by adding a combination of dmso dextran (cryosure dex ) , as a cryoprotectant, to obtain a final concentration of % dmso in the platelet suspension. the injectomat mc agilia and npbi compomixer m were instrumental in automating that phase. pc to be frozen had an osmolality of no less than mosm/l. prp and ppp were frozen at a cooling rate of - c/min and stored at - in the chest freezer for up to months. pre-transfusion defrosted platelets were also processed in a closed system (patent no.: ru u ). our transfer set made it possible to automate platelet resuspension in plasma through the agency of the exadrop v r . post-thaw prp was resuspended in plasma, which lowered the osmolality to mosm/l. freeze-thaw recovery of platelets was % or more of the original population. defrosted pc were stored at - with continuous gentle stirring from a helmer platelet agitator for no longer than hours before transfusion. it took no more than min to cryopreserve pc and process pre-transfusion thawed platelets. the automated processing accounted for the bulk of the time (over min). conclusion: the automated technique developed reduced the workload while offering reproducibility of the procedure and high cpc quality. the use of closed systems ruled out bacterial contamination. employing the infusion pump, platelet stirrer and precision flow regulator enabled adequate osmolality monitoring. bacterial detection in leukoreduced apheresis platelets on day and day evelyn c. oyler*. suncoast blood bank background/case studies: the recently published fda draft guidance describing bacterial testing to enhance the safety and availability of platelets outlined the steps for blood collection establishments and transfusion services to extend apheresis platelets dating for up to days. this evaluation will compare culture based and rapid based test methods for detecting bacterial contamination in apheresis platelets. study design/method: a large community blood center and transfusion service collects leukoreduced apheresis platelets (lrap) using amicus separator system (fenwal, lake zurich, il) and trima accel system (terumo bct, lakewood, co). previously-cultured lrap units were sampled on day for secondary culture using bact/alert (biomerieux, durham, nc) and rapid bacterial tests using bactx (immunetics, boston, ma) and pgd (verax, marlborough, ma). if lrap unit is still available, it is also sampled and tested for rapid testing on day . a total of lrap units were tested over a -month period: were cultured and rapid tested on day ; were rapid tested on day . the rapid test methods were also evaluated based on cost, ease of use, incubation time and indication for use. results/finding: of the lrap units evaluated for this study, there were true negatives (tn) and false positive (fp) on day when tested by bact/alert, with tns on day . bactx testing results showed tns on day and tns on day . testing using the pgd kit showed tns on day ; and tns and fps on day . fp results were confirmed by performing a secondary culture, which were found to be negative. bactx requires a specific analyzer and minutes are required for result interpretation. there is no instrument requirement for pgd and reactions can be read within minutes. conclusion: the results of this evaluation makes pgd the best fit for this blood center based transfusion service. pgd offers a shorter time for reading of results, does not need an initial investment for an analyzer and is indicated for lrap in % plasma and lrap in pas/plasma. its ease of use allows for testing of lrap on day and day during the night shift to be accomplished without additional staffing and allows to extend outdate to day storage of lrap. change in growth factor content of human serum for use as eye drops during frozen storage for year jos lorinser , pieter f van der meer , hans van der heiden and dirk de korte* . department of product and process development, sanquin blood bank, mu-drop background/case studies: growth factors are thought to be among the active components in serum used for treatment of dry-eye syndrome. stability of growth factors during frozen storage in mini containers ( ml) is unknown. if these products can be stored at - c it will be feasible to store this product in -star household freezers, making the product available for patients in need of serum eye drops. the purpose of this study is to demonstrate stability of growth factor content in human serum during longtime storage at - c or <- to - c packed in a new micro dose device for single use as eye drops. study design/method: serum produced from ml whole blood donations from non-remunerated healthy donors was quickly frozen. after frozen storage at <- c for - months and controlled thawing, six different sera were used to fill a large number of mini ( ll) containers, which were refrozen and stored at either - c or <- c. during storage at months intervals, samples were tested for several growth factors, using magpixv r luminex multiplex assays and compared to control samples stored at <- c. growth factors tested were pdgf-aa&ab/bb, tgf-ß / / , vegf, a transfusion vol. supplement s egf, fgf . the study was a fact-finding study, without preset acceptance criteria. results/finding: pdgf-ab/bb and tgf-ß were the most abundant growth factors, on average , resp. ng/ml. also pdgf-aa was detected at relatively high concentration in human serum, on average ng/ml. tgf-ß , egf and vegf were detected at relatively low values, resp. ng/ml, . ng/ml and . ng/ml. average levels of fgf and tgf-ß were close to detection limit (< . ng/ml). the controls stored at <- c showed for all growth factors close to % of the initial values in samples at t (moment of filling mini containers). for serum stored at <- c for up to months, most factors showed less than % decrease, except for pdgf-aa and tgf-ß , showing % resp. % lower values. for serum stored at - c the values for tgf-ß , egf and vegf were stable, whereas pdgf-ab/bb, pdgf-aa and tgf-ß showed a decrease of resp. , and %. conclusion: human serum eye drops can be stored in the new micro dose device at - c ( -star household freezers) or <- c (professional freezers) for at least one year after preparation without large decreases in growth factor content. the maximum decrease was found for pdgf-aa in serum stored at - c. it is yet unknown if the tested components add to the in vivo effectiveness of serum eye drops and what the minimal concentration is to ensure in vivo effectiveness. further stability testing in combination with in vitro and in vivo application is required to extend the shelf-life beyond year. ruqayyah almizraq* , heather inglis , phillip norris , , jennifer a muszynski , nicole juffermans , jelena holovati and jason p. acker , . university of alberta, blood systems research institute, university of california, san francisco, nationwide children's hospital, academic medical center, canadian blood services background/case studies: different blood manufacturing methods can influence residual cell numbers and membrane vesiculation, which may affect quality and safety of blood components. the aim was to identify, quantify and characterize residual cells and extracellular vesicles (evs) in stored rbc products produced by different blood manufacturing methods. study design/methods: thirty-two rbc units produced using whole blood filtration (wbf), red cell filtration (rcf), apheresis, and whole blood derived (wbd) methods were examined (n per method). residual platelets and white blood cells (wbcs) were measured on day using flow cytometer (fc). on storage day and , number and cell of origin/surface markers of evs were assessed with fc, and concentration and size-profile of evs were examined using tunable resistive plus sensing (trps). results/findings: on day , apheresis and wbd units had significantly greater residual platelets in comparisons to rcf (vs: apheresis p< . , wbd p< . ) and wbf (vs: apheresis p< . , wbd p< . ) methods. while rcf units yielded the lowest count of platelet-evs (cd a ) on day and , the highest number of platelet-evs were in apheresis (day ) and in wbd (day ). similarly, there was significant difference among methods in the number of wbc-evs (cd , cd , cd , cd , cd b ) and rcf contained the smallest concentration. moreover, both trps and fc showed an increase in the total number of evs on day vs day in all of the processing methods. noteworthy, trps showed that the number of small evs/exosomes (< nm) was greater than large evs (! nm) in all of the products on day and , and the highest level of evs < nm were in apheresis units. trps results also showed a significant difference in the evs size-profile amongst all rbc products (p< . ). conclusion: this study shows that the method of manufacturing significantly affects rbc and non-rbcs evs characteristics throughout storage, which has the potential to impact quality and safety of rbc products. the differences in the evs cell-of-origin, concentration, and size-profile observed between manufacturing methods, warrants further examination of their potential immunomodulatory effects and clinical consequences. coagulation and complement assays in whole blood stored at centigrade maryanne c herzig* , crystal lafleur , chriselda g fedyk , sherrill j. slichter and andrew p cap . us army institute of surgical research, u.s. army institute of surgical research, university of washington background/case studies: whole blood has been demonstrated to retain hemostatic activity, including platelet aggregation function, over at least weeks of storage at c without agitation. it may be possible to extend the preservation of platelet function by agitating wb. in order to more fully characterize the quality of wb stored at c with or without agitation, we evaluated complement activation as a marker of inflammatory potential. study design/method: subjects donated one unit of wb collected in cpd-a (citrate phosphate dextrose anticoagulant with adenine). the wb was not leukoreduced nor was it separated into components. units were stored under refrigerated conditions for , , , or days after collection. units were stored for days without agitation. units stored for , or days were agitated during storage with a model hybridization incubator at c set for end over end rotation at - rpms. at the appropriate time point, platelet free plasma was obtained from the wb sample and stored at - c. the frozen plasma was analyzed by elisa assays to determine: thrombinantithrombin complex (tat) as a marker of coagulation; soluble cd l as a measure of platelet activation and granule release; plasmin anti-plasmin complex (pap) as a marker of fibrinolysis; plasminogen activator inhibitor (pai- ) as another fibrinolytic measure; and complement activation markers c a, c d, c a and c b- . data was analyzed by one way repeated measure anova. results/finding: only % of the platelets were recovered in units stored for days without agitation. these levels did not meet fda requirements of . x platelets per wb unit. subsequently, wb was agitated and platelet recovery was - %. no difference was seen in elisa analysis for agitated or non-agitated samples. no change was seen in tat or pap levels between t (day of collection) and t , , , or measurements. significant elevations of pai- and scd l indicate activation of platelets and inhibition of fibrinolysis (p< . ). activated complement peptides c a, c a, and c d were all elevated over time (p< . ) while sc d- was not. however, only c a and c d levels at t were above normal reference ranges at . and . times maximum reference, respectively. conclusion: whole blood agitation appeared necessary to recover platelets at or above fda requirements. whole blood stored at c for - days did show some activation of complement proteins. in contrast to studies in stored red blood cells with elevations of sc d- reported, wb showed elevation of c a, a and c d and not sc d- . complement was gradually and modestly activated with most levels remaining within reference ranges over whole blood shelf life. meredith lummer* and christian todd . cerus corporation, community blood serivces background/case studies: the interceptv r blood system for platelets (cerus, concord ca) is used for the pathogen reduction (pr) of platelet collections, and replaces irradiation, cmv testing, bacterial culture and point of issue bacterial testing. to better understand pr compatibility and impact to split rate, data were analyzed from a mid-size blood center with roughly . x . x . x . x rcf . x . x . x . x apheresis . x . x . x . x wbd . x . x . x . x platelet collections must meet specific volume, concentration, and dose ranges to qualify for intercept pr. changes made to apheresis devices included adding the following collection targets: . x in ml, . x in ml, . x in ml, and . x in ml. study design/methods: four months of collections were retrospectively analyzed. platelet collections were evaluated to determine eligibility for pr treatment, and all products meeting pr processing specifications (unless intended for an hla matched recipient at a hospital not able to accept pr products) underwent pr treatment regardless of potential impact to split rate. a minimum post-treatment dose of . x or . x was required to classify collections as singles or doubles respectively. volume/dose mitigation (removal of volume to increase the number of products eligible for pr) was not utilized during this study. thus units were treated conventionally if volume, dose, and/or concentration did not meet pr specifications without further manipulation. results/findings: % of all single and double collections were eligible for and underwent pr treatment. split rate for single and double collections was . . conclusion: it is possible to treat % of single and double platelet donations with intercept pr at the blood center's current state with only a slight impact to split rate if centers are willing to make alterations to their targeting practices. platelet collections that fall outside of the specifications for pr are processed and distributed as conventional products. strategies to increase eligibility toward % while minimizing impact to split rate are being investigated, including incorporating new collection settings, splitting triples, and volume/dose mitigation. further evaluation is needed to determine the additional quantity of pr eligible products resulting from such changes. monique p gelderman* , andrey skripchenko , fei xu , ying li , stephen j wagner , pamela h whitley and jaroslav g vostal . fda/cber/ obrr/dbcd/lch, american red cross holland laboratory, american red cross mid-atlantic research facility background/case studies: platelets (plts) stored at room temperature (rt) can support bacterial proliferation in contaminated units and therefore septic transfusion reactions may occur. storing plts at cold temperature ( - o c [ct]) limits bacterial growth but results in rapid clearance upon transfusion. the development of alternate storage conditions usually involves costly radiolabeling human studies but success in these studies is difficult to predict based on in vitro studies. thus, an animal model of plt circulation that could predict performance of human plts in human volunteers would positively impact the development of alternate storage conditions. study design/method: we designed an immunodeficient (scid) mouse model to evaluate recovery of human plts and compared this side by side to a radiolabeling study in human volunteers that was conducted for evaluating a new plt storage condition: thermocycling plts ( hrs ct: hr o c [tc]). autologous apheresis plts stored for -days at rt, tc and ct were radiolabeled and infused into healthy human volunteers (n ) and the same non-labeled plts were also infused into mice (n ). blood samples from humans and mice were collected over time to generate survival and clearance curves of the plts in circulation. flow cytometry was used to detect and analyze the human plts in the mouse samples to generate such curves; counts < % were considered background. results/finding: the mean recoveries of infused plts were . . % for rt, . . % for tc and . . % for ct in humans. in mice, mean recoveries of the same plts were . . % for rt, . . % for ct and . . for ct (mean sd). to compare performance of the plts in humans and mice we expressed all recoveries as a percentage of the rt recoveries. in humans tc was $ % and ct was $ % of rt. in mice tc was $ % and ct was $ % of rt. the area under the survival curve (auc) was calculated for the individual mouse study and human trial data sets. the results of both auc were normalized to % for rt plts. human tc plts had % auc while ct plts had % auc compared to rt plts in humans. in comparison, the same tc plts had % auc and ct plts had % auc of the rt auc in the mice. the calculated ratios of the auc between the tc plts and ct plts of the human data set and mouse model data set are . and . , respectively. conclusion: the scid mouse model differentiates between rt plts and ct plts similar to humans based on auc and plt recovery data. however, the mouse model cannot differentiate between ct plts and tc plts as occurs in humans. even though the mouse model cannot differentiate between ct plts and tc plts, it may still be a useful tool to screen other novel storage conditions for human plts. converting the component manufacturing from a manual process to automation nicole peters* and geeta paranjape , . coastal bend blood center, carter blood care background/case studies: initiatives focused on improvements to donor collection processes drove us to investigate opportunities in our component manufacturing processes. our goal was to maintain blood quality while streamlining manufacturing and automating the in-process documentation. the compomat g was evaluated using a multi-team approach including component manufacturing staff, equipment management, qa, regulatory affairs and it. study design/method: after a comprehensive evaluation, the team decided to purchase the compomat g with the compomaster net software for data management. implementation was planned for a november go-live. . to centralize processing, new work counters were installed. fresenius kabi installed the compomat g s and compomaster in june . training and validations were successfully completed and a full launch occurred mid-march . device and sop training was performed. training qualification checklists were completed for each technician with a required number of successful units processed and completed december . validation was completed and signed off in march of . manufacturing data was collected using the compomaster net data management system and our quality control software for platelet (plt) parameters, including plt count, plt weight, and plt yield from before implementation (bi) and after implementing (ai) of the compomat g system. data points were collected from units bi and units ai. results/finding: upon initial implementation, staff training and use, the compomat g was found to be easy. plt weight spread was reduced from an average of gm to an average of gm. actual plt weights were reduced from an average of gm to gm, resulting in an average increase in recovered plasma of . ml per unit. plt count on average increased from a count of to ( /mm ) with a negligible change in plt yield. conclusion: plt weight spread was reduced by . % after implementation of the compomat g and our plt concentrations increased on average by %. we were able to consistently produce a smaller volume plt (average gm), which gave us . ml more plasma per unit for recovered plasma. the team intends to review a dryer cryo as a next step for potential additional plasma yields for recovered plasma. deglycerolization of manually glycerolized, frozen rccs using a closed system cell processor anita howell , angela hill , brandie dennis and jason p. acker* , . canadian blood services, centre for innovation, canadian blood services, university of alberta background/case studies: upon implementation of a closed system cell processor for glycerolization and deglycerolization of red cell concentrates (rccs), many rare rccs frozen using the current manual, open system glycerolization method will remain in the organization's frozen inventory. a study was undertaken to assess the feasibility of deglycerolizing this existing inventory on the closed cell processor and to evaluate how the change may impact post-thaw red blood cell (rbc) in vitro quality. as the closed cell processor uses a fixed centrifuge bowl for deglycerolization and rbc resuspension, both large and small units were assessed to determine the impact of cellular loss and variability in hematocrit on the post-thaw product. study design/methods: abo/rh matched lr sagm rccs were pooled and split to produce large ( ml) and small ( ml) rccs. the rccs were stored to d and glycerolized manually by mixing ml of glycerol with the rcc in a ml freezing bag. units were frozen at - c for ! h before being removed from frozen storage and thawed in a c water bath. large rccs and small rccs were deglycerolized using the organization's current procedure on the cobe cell processor prior to re-suspension in . % saline, . % dextrose. the remaining rccs were transferred into a l bag, spun to allow removal of excess glycerol by manual extraction to achieve a hematocrit of %, and deglycerolized in a ml centrifuge bowl on the acp- with re-suspension in as- . rbc quality was tested at h post-deglycerolization. results/findings: large rccs had significantly higher hemoglobin per unit (cobe: p . , acp : p . ) and lower cell recovery (cobe: p . , acp : p< . ) post-deglycerolization than smaller rccs on both cell processors. large rccs deglycerolized on the cobe had higher hemolysis (p< . ) and supernatant potassium (p . ) than did small volume rccs. large cobe rccs had higher hematocrits (p . ), hemoglobin (p . ), and recovery (p . ) than did large acp- rccs. however, all cobe rccs had higher (p< . ) hemolysis ( . . %) levels than did acp- rccs ( . . %). cobe rccs failed to meet regulatory hemolysis standards of . %. conclusion: addition of a ml bolus dose of glycerol to rccs of different volumes results in different concentrations of glycerol in the frozen rcc product and may lead to differences in frozen rcc quality. additionally, the size of the rcc impacts quality for rccs processed on the closed cell processor due to centrifuge bowl volume limitations which result in lower recovery, hemoglobin, and hematocrits. use of the closed cell processor with resuspension in as- and storage for h, met in vitro quality standards for recovery, hemoglobin, and hematocrit, and drastically reduced hemolysis levels in rccs glycerolized manually. the acp- cell processor can therefore be used to deglycerolize rccs glycerolized using a manual, open system glycerolization method. background/case studies: washed platelets may be indicated for thrombocytopenic patients who experience severe allergic/anaphylactic or febrile reactions to conventional platelet transfusions. platelet washing process is time-consuming which may delay transfusion. this study was conducted to evaluate the manual platelet washing method (mm) using . % saline and centrifugation and the semi-automated washing method (sam) using the cobe blood cell processor. study design/method: in this study, units of single donor platelets were evaluated ( washed using the mm and washed using the sam. the collected data included product weights (pre-and post-wash), platelet counts (pre-and post-wash), total plasma protein (pre-and post-wash), presence/absence of platelet clumps, calculated % protein removal, and calculated % platelet recovery rate. the platelet counts were measured on the sysmex exn and the total plasma protein samples were measured on the roche cobas . results/finding: table shows that the average platelet recovery for the sam ( %) was significantly higher compared to the mm ( %). the mm had a slightly higher average protein removal compared to the sam. no platelet clumps were observed in either the mm or the sam. it was observed that the hands-on time for the mm took - minutes longer than the sam. background/case studies: the interceptv r blood system for platelets is currently licensed for pathogen reduction (pr) of amicus platelets in inter-sol (pas- ) for input platelet doses of . to . platelets in to ml of to % plasma and - % pas. a new platelet processing set was designed with three storage containers (ts) to process apheresis platelet components in pas- containing doses of . to . platelets in a volume of to ml. study design/methods: apheresis pcs (amicus v r ) were collected in % plasma and % pas- . one study was performed at the nominal dose ( . - . x platelets), volume ( - ml) in % pas/ % plasma using single donor apheresis collections. two studies were performed to evaluate the high dose and high volume condition ( . - . x platelets in - ml) using either single or pooled donations. input pcs (n ) were treated with the intercept ts set by the end of day post collection; the incubation time in the compound adsorption device (cad) container ranged from to hours and the intercept treated pcs were stored in containers (n ). day and post-donation pcs were evaluated using a panel of in vitro platelet function assays results/findings: in vitro function data for apheresis pcs in pas- treated in the intercept ts set demonstrated acceptable in vitro function (table ). all intercept treated pcs had ph( c) ! . . platelet dose and volume recovery post-treatment ranged from % to % and % to %, respectively. conclusion: pathogen reduced platelet components processed using the intercept ts set from either single or pooled apheresis donations maintained acceptable in vitro quality through days of storage. intercept blood system for platelets ts set is currently not approved for use in the us. background/case studies: the possibility of transmitting infectious organisms via blood products, plasma and their derivatives is a major public health concern. while current screening measures have considerably improved transfusion safety by reducing the risks associated with known pathogens, they cannot protect from emerging infectious threats. the pathogen reduction technology (prt) represents a proactive strategy to further reduce transfusion-transmitted infectious risk. however, the scientific community broadly agrees over the fact that prt has negative impacts on the product's quality markers. this study aims at evaluating the impacts of the mirasol prt on platelet (plt) quality and plt processing. study design/method: two abo-compatible platelet concentrates (pcs) containing % plasma obtained from either apheresis or sagm whole blood (wb)-derived processing were paired, pooled and then split into two equal units. one unit was used as a non-treated control (ctrl) (n ). riboflavin was added to the other pc unit and then exposed to uv light according to the manufacturer's instructions for the mirasol prt (teru-mobct) (test) (n ). numerous in-vitro quality markers (plt concentration, atp, po , pco , ph, glucose, lactate, sodium, and potassium) were measured for both mirasol-treated and non-treated pcs on days , , and for apheresis pcs, and on days , , and for wb-derived pcs. two flow cytometry assays were used to evaluate cd p expression with and without thrombin activation, and to measure the percent annexin vpositive plt. transfusion vol. supplement s results/finding: platelet recovery was % and % for apheresis and wb-derived pcs, respectively. mirasol-treated pcs showed higher levels of annexin v-positive cells ( % (test), vs. . % . (ctl) on day ) and a higher rate of cd p expression than control pc units ( % (test), vs. % (ctl)) on day ). the mirasol treatment generates changes in ph, glucose and lactate for pcs during storage. conclusion: the mirasol treatment induces a loss in the net number of plts/unit and elevated platelet activation. changes in ph, glucose and lactate suggest that prt affects plt metabolism. finally, prt has numerous impacts on logistic, storage and processing time constraints of blood bank operations. nevertheless, the mirasol prt is routinely used in europe with acceptable clinical outcomes. evaluation of a test method to detect bacterial contamination in platelets; bactx tm assay ji hye park sexton* , lorraine blagg , christi e marshall , herman woodson , sean erony , krishna patel and eric gehrie . the johns hopkins hospital, johns hopkins hospital transfusion medicine dept, johns hopkins university school of medicine background/case studies: bacterial contamination of platelets (plts) is the leading infectious risk of platelet transfusion therapy and it is the most significant infectious cause of transmission-associated morbidity and mortality. therefore, detecting various potential bacterial contaminants in platelets in a timely manner is critical. the bactx assay is a rapid colorimetric assay that detects peptidoglycan, a cell wall component of both gram-positive and gram-negative bacteria. here, we report an analysis of the bactx assay at our hospital. study design/method: we aimed to determine the sensitivity and specificity of the bactx assay. intact leukoreduced apheresis plt (lrap) units were tested by bactx at storage day . as a control, each intact lrap was also cultured by an automated bacterial detection system (bact culture) on storage day . the results of the bactx test were compared to the results of the bact culture system. results/finding: a total of lrap were tested. lraps initially tested negative by bactx, while lraps initially tested positive by bactx. all initial positive bactx tests were negative when subjected to repeat testing. in contrast, all lraps tested negative with the bact culture system. the specificity of the bactx test was . %. we did not have any true positive test results; therefore, the sensitivity of the bactx could not be determined. conclusion: this is a small study of only platelet units. the expected rate of bacterial contamination of platelets is less than per units. the . % initial positive rate was therefore higher than expected, but given the small sample size, it is clear that further study is needed to more rigorously assess the true sensitivity and specificity of the bactx assay. in vitro quality of rejuvenated and washed cpd/as- and cp d/as- rbc alan d. gray* , matt landrigan , pamela whitley , michael wellington , sherrie sawyer , shalene hanley , emily rondeau , louise herschel , neeta rugg , patricia a.r. brunker , shawnagay nestheide , jose cancelas-perez , larry dumont and zbigniew m. szczepiorkowski . and , -dpg to fresh levels. the objective was to demonstrate that in vitro quality measures are maintained for rbc when stored for > hours after treatment with an fda approved rejuvenation solution. study design/method: whole blood ( - ml) was collected and processed at sites into leukocyte-reduced rbc (a total of n cpd/ as- and n cp d/as- ). ml of rejuvenation solution (citra labs) was added to each rbc on day (d- ), incubated for minutes with agitation at c water bath (helmer dh ), washed (haemonetics acp ), and stored in as- at - oc for days (d- through d- ). in vitro recovery (%) was calculated and hemolysis, atp, and , -dpg were determined on day , d- , d- after rejuvenation and washing (postrjv), d- , d- , d- , and d- . all units were cultured on d- postrjv and on d- , and then concentrated by centrifugation on d- . results/finding: in vitro rbc recoveries were . % and . % (as- and as- , respectively) and no bacterial growth was observed. hemolysis on d- was maintained < % in / ( %) as- units and / ( . %) as- units. all as- and as- units ( %) had hemolysis < % following concentration by centrifugation. morphology score was reduced to % (as- ) and % (as- ) by d- , restored after rejuvenation ( %, %, respectively) and maintained through d- (> %). atp was restored and maintained above fresh levels after rejuvenation. , -dpg was restored above fresh levels and was maintained ! % of fresh levels through d- . all values were significantly different compared to d- except as noted (p< . , paired ttest) ( table ) . conclusion: rejuvenation of stored rbc restores atp and , -dpg above fresh values and morphology to near fresh levels while maintaining improved in vitro rbc quality measures through d- when compared to nonrejuvenated rbc on d- . this study is funded by zimmer biomet. storage > hours is not fda approved for use at the time of this publication. liposomes and rejuvenation: new approach for improving quality of stored red blood cells luciana da silveira cavalcante , jason p. acker* , and jelena holovati . background/case studies: liposomes have been shown to minimize rbc membrane damage occurring during -day hypothermic storage (hs), while rejuvenation solutions have been shown to restore rbc metabolism by maintaining atp and , -dpg levels. this study aimed to evaluate the effect of combining liposomes and rejuvenation on the quality of stored rbcs. study design/methods: five leukoreduced packed rbc units obtained were pooled and split. the units produced were segregated into four experimental groups: sham control (s), liposome-treated (l), rejuvesol-treated (r) and liposome rejuvesol-treated (l r). the prbcs were incubated for h at c with hepes-nacl (sham), liposomes (dopc:chol, : mol%, mm lipid), rejuvesol or liposomes plus rejuvesol. the in vitro quality was accessed by hemolysis, deformability, aggregation, atp and , -dpg at day hs. results/findings: hemolysis was significantly decreased in all treatments compared to sham control ( . . %): l ( . . %, p . ), r ( . . %, p . ), l r ( . . %, p . ). ektacytometry analysis showed an increase in maximum elongation (ei max ) in r ( . . , p . ) and l r ( . . , p . ) treatments compared to s ( . . ) but not l ( . . , p . ). rbc rigidity (kei) increased in all treatments compared to sham ( . . ): l ( . . , p . ), r ( . . , p . ) and r l ( . . , p . ). aggregation amplitude was significantly increased by r treatment only ( . . au vs. . . au, p . ). atp levels were significantly higher in all treatments compared to sham ( . . mmol/g hb): l ( . . mmol/g hb, p . ), r ( . . mmol/g hb, p . ), l r ( . . mmol/g hb, p . ). the levels of , -dpg were no longer detectable in s and l treatments at day . the combined treatment was comparable to r ( . . mmol/g hb vs. . . mmol/g hb, p . ). conclusion: both rejuvenation and liposome treatments improved the quality of stored rbcs compared to sham control. the combined treatment (l r) did not have a greater impact in improving in vitro quality of stored rbcs compared to rejuvenation alone. step toward a unique and adaptable thermoregulation system lucie boyer , eric ducas , patricia landry , nathalie dussault , jacques bernier , danny brouard* and anne maltais . h ema-qu ebec, institut de technologie des emballages et du g enie alimentaire background/case studies: h ema-quebec (hq) is facing major logistic challenges in the transportation and distribution of blood components over a large geographic area. in collaboration with the institut de technologie des emballages et du genie alimentaire, our applied research group is working on the development and optimization of a transport packaging for the -ml whole blood leukotrap rc system (haemonetics corp.). the objective is to design a packaging system for the rapid cooling (t < c) of one to six -ml whole blood units (wbu) within h from collection. moreover, the insulating and thermoregulation system must maintain the internal temperature of wbu between c and c for h under extreme external conditions (- c to c), including the initial blood cooling period. study design/method: the proposed packaging design is based on an external coroplast box containing six vacuum insulated panels (vip) for increased insulating efficiency. preservation of the initial cooling period and extended thermoregulation properties were ensured by an assembly of preconditioned c phase change material (pcm). the number of pcm, their position and conditioning were optimized and tested in order to meet the expected performance criteria. preconditioned pcm were stored into vip boxes for h at - c before each test to mimic a worst-case scenario for remote blood drives. for the experimental testing, -ml wb bags were filled with ml saline . % at t c to mimic freshly collected wb. probes were positioned inside the saline-filled bags to monitor temperature profiles of wbu under extreme winter (- c) and summer ( c) conditions. shipping boxes were filled with either one or six bags (n ). results/finding: the results showed that the thermoregulation box prototype is able to cool wbu bags under c in . . h and maintain their internal temperature between c and c for h with final values ranging between . c and . c for the extreme summer scenario. similar results were obtained for the extreme winter scenario; units reached the c threshold value in . . h and the bags' internal temperatures were within the acceptable range for h. conclusion: the insulating and thermoregulation system met hq performance criteria. preliminary results showed that pcm could be conditioned at temperatures higher than - c without any significant impact on the system performances. hq is currently validating the shipping box prototype performances. additionally, we are working on reducing the pcm conditioning time to optimize logistic operations. as this packaging has many advantages in terms of durability, price and convenience, hq intends to evaluate this system for the packaging and transport of other lines of blood products. stuart weisberg* , christopher c. c silliman , beth shaz , marguerite kelher and claudia s. cohn . new york blood center, bonfils blood center, department of laboratory medicine and pathology, university of minnesota background/case studies: platelets collected and stored in platelet additive solution (pas) reduce recipient exposure to donor plasma components. to better define the effects of pas on platelet supernatant composition, we compared total protein, isohemagglutinin titers, hla antibodies and in vitro neutrophil (pmn) priming activity in supernatants of pas-c platelets to plasma platelets. study design/methods: apheresis platelets from group o blood donors were collected into either % donor plasma (n ) or % pas- / % donor plasma (n ). within hours of collection, samples of the product supernatant were frozen, assayed for total protein concentration, anti-a and anti-b titer, and pmn priming activity within the total and lipid extractable fractions. all samples were screened for hla antibodies. screen-positive samples were tested using luminex single bead assays for antibody strength and specificity. soluble cd ligand (scd l) was measured using solid-phase elisa. results/findings: supernatants of pas-c platelets had significantly lower total protein concentration, anti-a and anti-b titers compared to plasma platelets. there was no significant difference in the number of hla-antibody screen positive pas-c ( / products) compared to plasma platelets ( / products); however, the hla-antibody screen-positive supernatants of pas- a transfusion vol. supplement s abstract c platelets had fewer hla specificities ( specificities) compared to those of the plasma platelets ( specificities). pmn priming activity was significantly increased in the supernatant of pas-c platelets. the lipid extractable fraction was not affected; however scd l levels were increased in the supernatant of pas-c compared to plasma platelets (table ) . conclusion: decreased plasma proteins likely underlie lower rates of allergic and febrile non-hemolytic transfusion reactions seen with use of pas-c platelets. decreased anti-a and anti-b titers may prevent hemolysis from minor abo mismatch. lower hla-antibody specificities may mitigate transfusion related acute lung injury (trali). increased pmn priming by pas-c platelets is likely due to platelet membrane release of scd l and not bioactive lipids. although scd l has been associated with trali, only pmn priming with lipid -not cytokine -agents has been causally linked with trali. the mechanism and clinical impact of increased scd l in pas-c platelets remain to be elucidated. background/case studies: current guidelines require a reduction of residual white blood cells (rwbc) below x wbc in us and x wbc in europe, per unit. the established reference method for testing rwbc in platelet (plt) and red blood cell (rbc) products is flow cytometry. alternative technologies have been developed including hemocytometry and microfluorometry. study design/methods: this study compared performance and workflow efficiency of the facsvia, a flow cytometer with a simplified workflow and automated loader to the adam automatic microscopic cell counter based on imaging technology. nonfiltered whole blood (wb) samples, apheresis platelet units (n ) and leukoreduced (lr) rbc units (n ) were used to generate spiked samples. apheresis platelets and lr rbc were filtered to deplete wbcs and were used as a diluent. nonfiltered wb samples were the source of wbcs to prepare a sample of wbc/ul. the spiked samples of , . , , , and wbc/ul were prepared from the source sample of wbc/ul and filtered platelet and rbc units. to evaluate linearity, wbc concentrations ( , . , , , , wbc/ul) were measured using adam and facsvia. samples were stained and run in triplicate on each analyzer. data was analyzed using linear regression. the results were proportional to the wbc concentration in the spiked samples. reproducibility of the two systems was measured by running spiked samples ( , , , wbc/ul). tubes of each sample were stained and run per system. the %cv and %diff were calculated. a batch of samples (plt and rbc) were run on both analyzers, repeated for days. workflow efficiency was assessed observationally by measuring the time of tasks performed. tasks recorded were instrument qc, assay controls and sample testing and analysis. results/findings: the wbc concentration results for plt and rbc samples on facsvia correlated well with adam (r-plt . , slope . ), (r-rbc . , slope . ). the %diff-plt at , , wbc/ul were . , . and , respectively. the %diff-rbc at , , wbc/ul were . , . and . , respectively. the average total testing time was similar on both instruments; min for the facsvia and min for the adam. of the total testing time, adam required continuous hands-on time, while facsvia demonstrated % ( of min) hands-off time. conclusion: both instruments showed comparable precision, linearity and accuracy. while the average total testing time was similar on both instruments, facsvia offered a significant workflow efficiency advantage. users saved an average hands-on time of minutes that could be used on other tasks. platelet rich plasma and quality control: is there a role for the blood bank? claudia s. cohn* and mickey koh . department of laboratory medicine and pathology, university of minnesota, st george's hospital and medical school background/case studies: autologous platelet-rich plasma (aprp) is a poorly regulated blood component often produced at the patient's bedside and used for indications such as chronic and acute orthopedic injuries, wound and incision-healing and rheumatologic diseases. prp isolation can be done by apheresis, which yields a consistent, platelet-rich fraction; however, most aprp is made using small bench-top centrifuges with cartridges that deliver uneven platelet enrichment. thus, the consistency and quality of aprp is questionable and the lower yielding prp may have decreased efficacy. study design/methods: a survey was designed to assess aprp manufacture, usage and quality control (qc) measures taken prior to its use. a survey was developed with input from content experts. the survey was sent to members of best and isbt. survey respondents were encouraged to forward the survey to colleagues, thus a true denominator is unknown. a total of completed and partially completed surveys were received. results/findings: responses came from countries, but the majority of responses came from the united states (us). of the respondents, % reported aprp use in their hospital. aprp was used predominantly for outpatients, though > % of hospitals also used aprp in the in-patient setting. in most hospitals, aprp was used by - mds; however, hospitals had > mds using aprp. the aprp was used for orthopedics, wound/incision repair, rheumatology and other indications. in the us the aprp was manufactured outside of the blood bank, while outside the us aprp was isolated by blood bank personnel. nearly all the aprp manufacturing was done with no quality control (qc) measures ( %); however, respondents assessed the final product prior to release. these qc measures included a platelet count to measure the enrichment of the platelet fraction, culturing the product and infectious serology testing. in some cases, if the aprp failed qc it could still be used, pending an md's approval. in the hospitals conducting qc on the final aprp, the testing was done by the blood bank. a subset of respondents from african nations also used allogeneic prp (allprp). in contrast to the patterns of use with aprp, allprp was used primarily for inpatients for indications including orthopedics, wound/incision repair and 'other'. the allprp was manufactured in the blood bank or the donor center with no qc other than a regular check of the centrifuge used to isolate the prp fraction. conclusion: prp is used in hospitals throughout the world for a wide variety of indications. the blood bank is involved in its manufacture in some countries, but in the us aprp is made outside of the blood bank. quality control of aprp production and the final product is not done in most hospitals. to improve the consistency and efficacy of prp, more stringent qc measures need to be in place. background/case studies: the morphology of donated red blood cells (rbc) change with storage, along with a loss of deformability, increased surface exposure of phosphatidylserine (ps), and decreased intracellular atp. these changes have been associated with increased rbc clearance within hours of transfusion. analysis of morphological alterations of stored rbc with imaging flow cytometry (ifc) has identified a subpopulation of small rbc that accumulates upon storage. this rbc subpopulation has a reduced projected surface area and undergoes a spherocytic shift which is expected to induce their retention in the spleen (roussel, dussiot et al, ) . some of the storage alterations are reversible when the rbc metabolism is reestablished. as such, treatment with a rejuvenation solution (citra labs) before transfusion is expected to restore some of the rbc properties and thus potentially increase their capacity to stay in circulation and operate effective tissue oxygenation following transfusion. study design/methods: a multi-parametric analysis of rbc alterations was performed to evaluate the effect of rejuvenation on rbcs stored in sagm (n ) under blood bank conditions at day (d ), at day (d ), after rejuvenation (r), and after rejuvenation and washing (rw). morphological alterations of stored rbcs were evaluated with ifc (imagestream x mark ii, amnis v r ). results/finding: rejuvenation increased the level of intracellular atp, confirming the metabolic effect of this process. population distribution as per rbc projected surface area measured by ifc depicted a well-demarcated subpopulation of small rbc that increased with storage from . - . % at d to . - . % at d . rejuvenation markedly reduced this storage-induced spherocytic shift ( . - . %) and partially restored rbc morphology, an effect confirmed by differential interference contrast microscopy. the restoration effect of the rejuvenation process did not correct the storage-related loss of rbc elongation but was associated with a decrease in ps exposure (table) . conclusion: our multi-parametric analysis shows that some but not all storage-related alterations are therefore corrected by metabolic rejuvenation. the impact of these effects while generally positive at the cellular scale requires further analysis by specific clinical studies assessing transfusion yield and tissue oxygenation. red cell concentrate volume and manufacturing method impact post-thaw quality in cryopreserved products processed using a closed cell processor anita howell , angela hill , tracey turner , april xu , brandie dennis and jason p. acker* , . canadian blood services, centre for innovation, canadian blood services, university of alberta background/case studies: the blood service uses both top/top with whole blood filtration (wbf) and top/bottom with red cell filtration (rcf) methods to prepare cpd/sagm lr red cell concentrates (rccs). mean volume (ml) is higher in wbf units ( ) than in rcf units ( ), with similar hematocrits. a closed system cell processor is currently being implemented for cryopreservation of rccs. post-deglycerolization re-suspension in as- additive solution is performed on-instrument to a defined total end volume, as dictated by the centrifuge bowl size. the impact of the resulting variation in hematocrit on post-thaw in vitrorbc quality was evaluated to ensure that regulatory standards can still be met for rccs at the extreme edge of the input volume range. study design/methods: small rcf ( - ml) and large wbf ( - ml) rccs were stored for d before being glycerolized and frozen at - c for ! h. large rccs whose red cell mass exceeded the capacity of the ml deglycerolization centrifuge bowl were volume reduced prior to glycerolization. rccs were thawed in a c water bath, deglycerolized and re-suspended in as- . rccs were stored d and then tested for in vitrorbc quality. results/finding: small rcf rccs had lower (p< . ) hematocrit, specific gravity, hemoglobin per unit, supernatant k and na concentration, deformability (ei max ), and higher (p< . ) recovery than did large wbf units. no significant differences in hemolysis, atp, , -dpg, p , rbc indices, rbc morphology, or residual glycerol were seen between groups. the majority of units met acceptance criteria (table ) , however of large wbf units had rbc recoveries < % due to pre-glycerolization volume reduction, and of the small rcf units had hemoglobin values < g per unit. when the recovery and hemoglobin failure rates are analyzed against the organization's rcc production volume distribution, the mean recovery is projected to be well above % and the hemoglobin failure rate would be below % of units tested; compliant with regulatory standards. conclusion: the differences between groups in the cryopreserved rcc physical characteristics were expected due to the re-suspension method and differences in the input product red cell mass. the lack of significant metabolic differences between groups indicates that the differences in postdeglycerolization hematocrits are not adversely affecting product quality. . . . . . . . . elongation index ( pa) . . . . . . . . this study is funded by zimmer biomet. (hasan ) . the objective was to determine the effect of rbc rejuvenation on rbc oxygen release capacity (orc) and estimated oxygen consumption (vo ) after simulating a single unit transfusion of either standard or rejuvenated rbc stored for days. study design/method: oxygen dissociation curves (odc) (hemox analyzer, tcs scientific) were generated from fifty-two ( ) rbc units (leukocyte-reduced), cpd/as- or cp d/as- , on day , day , and after rejuvenation and washing (pw). the odc for each sample was used to determine orc (ml o /g hb) and total releasable oxygen (tro) of the unit (ml o ). orc was determined by assessing the change in % o saturation from mm hg po (e.g., lung) to mm hg po (e.g., venous blood) multiplied by . ml o /g hb (li ). a simulated baseline pretransfusion vo of ml o /min was estimated using the day orc and assuming a g/dl transfusion trigger with a cardiac output of l/min and l blood volume. paired student's t tests were used for comparative statistical analyses. results/finding: rbc rejuvenation on day restored orc and tro to levels greater than day ( table ) . orc of the rejuvenated unit was . . times and . . times greater than rbc on day and day , respectively (p< . ). vo increased after a simulated single unit transfusion of rbc (day , day , and pw) by . %, . %, and . % over the pre transfusion vo , respectively (p< . ). conclusion: these results suggest a transfusion with rejuvenated rbcs has the potential to release . times the volume of o compared to standard, untreated rbcs stored for days. inferior oxygen delivery to tissues (vo max) has been observed during exercise in healthy human volunteers after transfusion of two autologous rbc units stored for days vs days which seem dependent on genetic variability and storage time (bennett-guerrero ). therefore, transfusion practices to correct anemia may be less effective than intended due to the variable orc of standard stored rbc units. transfusion strategies should consider whether the use of rbc with increased orc may be physiologically advantageous. disclosure: this study was funded by zimmer biomet. rejuvenation solution as an adjunct storage solution maintains physiological hemoglobin oxygen affinity during rbc unit storage andrea ansari* , jay srinivasan , gustaaf de ridder , alan d. gray , matt landrigan , keaton charles stoner , angela crabtree , jessica poisson and ian welsby . duke university school of medicine, duke health pathology, citra labs, a zimmer biomet company, zimmer biomet, duke university, department of pathology, durham veterans affairs medical center, duke university hospital, duke university medical center background/case studies: deleterious changes develop during the storage of packed red blood cells (rbcs) collectively called the "storage lesion". these include altered membrane composition and decreased deformability, increased in-bag and post-transfusion hemolysis, loss of atp, snitrosohemoglobin, vasodilatory capacity, and cell surface ps expression, and depleted , -diphosphoglycerate ( , -dpg). the loss of , -dpg increases the oxygen affinity of hemoglobin, resulting in lower p (partial pressure of oxygen at % hemoglobin saturation). decreased p may negatively impact the ability for transfused rbcs to release oxygen to peripheral tissues. an fda-approved rejuvenation solution (citra labs) can restore normal levels of atp and , -dpg, normalizing membrane function and oxygen affinity, respectively. this process requires incubation at c for an hour, an impractical step in time-sensitive situations, followed by washing of the rbcs. we tested the hypothesis that rejuvenation without the incubation step ("cold rejuvenation") could prevent or reverse changes in oxygen affinity, deformability, and susceptibility to hemolysis of rbcs. study design/method: eight units of group a , leukoreduced prbc stored in as- were obtained from our local blood center. after days of storage, units were divided into separate aliquots: control (ctl), wash (w), standard rejuvenation (sr), and cold rejuvenation (cr). the rejuvenation solution ( ml) was added to the cr group, and all groups were then stored for another days at - c. on day of storage, the sr group was incubated for hour at c with rejuvenation solution, after which the w, sr, and cr groups were separately washed on a c.a.t.s v r (fresenius kabi) using the high quality wash setting. hemoglobin p was measured by tonometry using a hemox analyzer (tcs scientific). deformability (elongation index or ei) was measured by ektacytometry (lorrca mechatronics). supernatant plasma free hemoglobin (pfhb) was measured using visiblelight spectrophotometry. cell surface ps expression (ps ) was measured by annexin v flow cytometry. all group results were compared using nonparametric wilcoxon signed-rank tests with a . . results/finding: significant differences in p were noticed between all groups (table ) . ei, ps , and pfhb did not differ between groups. conclusion: cold rejuvenation prevents the increased oxygen affinity (lower p ) seen over days of rbc storage without adverse effects on deformability or hemolysis. this offers an alternative to incubated rejuvenation to provide clinicians with ready access to rbcs with a high/normal p that may better release oxygen to the tissues. cause transient and potentially fatal cardiac arrhythmias upon transfusion, particularly in infants, and massively-transfused patients, and those with compromised renal function. reactive antibodies and other inflammatory agents in rbcs can also elicit life-threatening reactions, potentially causing high fever, transfusion-related acute lung injury (trali), anaphylaxis, and even death. in this study, a multifunctional bead-based filter was evaluated for removal of k , along with free hemoglobin (hb) and other prbc contaminants that can contribute to transfusion related adverse events. study design/method: ten leukocyte-reduced prbc ( ml) units stored in as- , obtained from a regional blood donor center at expiration ( days), were passed by gravity through sorbent-devices containing ml of multifunctional polymer bead, at a flow rate of ml/min. supernatants were analyzed for k removal as well as free hb, antibodies and cytokines ( -plex, biorad). rbcs were analyzed for viability and integrity via flow cytometry and osmotic fragility assay, respectively. results/finding: filtration of the aged prbc units through the sorbent device reduced [k ] from . . to . . meq/l; equivalent to an . % reduction. free hb was reduced by . % from . . to . . mg/ml. antibodies, specifically igg, iga, and igm decreased from . . to . . mg/ml ( . %), . . to . . mg/ml ( . %), and . . to . . mg/ml ( . %), respectively. inflammatory cytokines were significantly reduced, specifically: ip- from . . to . . pg/ml ( . %), mip- b from . . to . . pg/ml ( . %), and pdgf from . . to . pg/ml ( . %). filtration had no significant impact on cell surface markers of rbc viability (< . % decrease) or sensitivity to osmotic changes. values listed represent mean sem (p < . for all analytes tested). a paired ttest was used to assess significance. conclusion: the sorbent filter was highly effective in reducing the levels of extracellular k as well as free hb, antibodies, and cytokines from prbcs without impact on rbc viability or integrity. this study demonstrates the viability of a multifunctional sorbent filter for removal of k along with other detrimental components from stored prbcs that can readily be incorporated into transfusion practices to minimize adverse effects. background/case studies: platelets carry no rh antigens, but residual red blood cell (rbc) in platelet products can immunize d negative recipients if the donor is d positive. current recommendation is to give rh immunoglobulin (rhig) to rh negative patient if they receive rh positive platelet unit to avoid potential alloimmunization to d antigen. a recent study has shown a very low frequency ( . %) of d alloimmunization when a rh mismatch platelet is transfused. restricting d negative patients to receive only d negative platelets could create shortage and cause inventory challenges. higher yields of platelets with minimum to none residual rbcs are obtained with new generations of apheresis machines. as a consequence, the need for prophylactic rh immunoglobulin (rhig) may be unnecessary with the use of apheresis derived platelets. the accurate determination of residual rbc in a platelet unit is important for patient safety to prevent rh alloimmunization. hemocytometer is considered the gold standard for cell counting. however, the rapidity and convenience offered by automated methods resulted in widespread use of automated hematology analyzers. currently there are no standardization and/or guidelines to advise what system to use for rbc quantification in platelet products. study design/method: we designed this study to quantify the residual rbc in apheresis platelets and whole blood derived platelets comparing hemocytometer and automated methods. we measured the amount of red blood cells per microliter in apheresis and whole blood derived platelet units using hemocytometer and two different automated hematology analyzers, namely, sysmex (sysmex america, lincolnshire, il) and advia (siemens healthcare diagnostics, tarrytown ny). the whole blood derived platelet units were produced using acrodose tm system technology. we conducted non-parametric permutation test based on permutations to compare sysmex and advia between apheresis and whole blood derived groups. abstract collection) rbcs to rbcs stored for days and after treatment with an fda approved rejuvenation solution. study design/method: the addition of a rejuvenation solution to stored red blood cells (rbcs) has been shown to increase atp and , -dpg profiles to fresh levels. the objective was to compare % hemoglobin-oxygen saturation (p ) and morphology profiles of fresh(day of collection) rbcs to rbcs stored for days and after treatment with an fda approved rejuvenation solution. results/finding: in vitro rbc recovery (overall) was . . %. hemolysis (%) was similar on day before and after dry-air incubation with the rejuvenation solution ( . . % vs . . %). percent hemolysis (%) decreased after washing ( . . %) and was maintained below < % for all units during storage for hr ( . . %). average atp and , -dpg were restored above the average fresh values. the morphology score decreased $ % by day , which was restored to near fresh values following rejuvenation and washing and storage hr ( . % and . %, respectively). rbc oxygen affinity, as assessed by p , was restored above fresh values. all values were significantly different compared to day (p< . , paired t-test) ( table ) . conclusion: rbc morphology was restored to near fresh and average atp, , -dpg, and p were restored above fresh values when incubated with a rejuvenation solution using the dry-air incubation process. rbc morphology, atp and , -dpg were maintained during storage hr. rejuvenation of refrigerated rbcs may offer avenues to improve rbc quality prior to transfusion. vandi ly*, dimath alyemni, warren r korn, matthew j brune and julie katz karp. thomas jefferson university hospital background/case studies: blood donors are screened with a donor history questionnaire that includes questions regarding behavioral risk factors, but none that specifically screen for the use of marijuana. therefore, there is the theoretical possibility of transfer of active cannabis metabolites through transfusion. donor plasma collected at an urban, hospital-based blood donor center was examined for the presence of active cannabis metabolites, d tetrahydrocannabinol (thc) and -oh-d -tetrahydrocannabinol ( -oh-thc). study design/method: de-identified donor plasma segments were sequestered and stored frozen until time of testing. testing for thc and -oh-thc was performed by liquid chromatography-tandem mass spectrometry (lc-ms/ms) based on a method modified from lacroix and saussereau. in summary, this method used dabsyl chloride derivatization of thc and -oh-thc to produce samples for lc-ms/ms analysis. lc used a c column. post-column detection by ms/ms used positive ion electrospray with q :q ion pairs of m/z . : . (internal standard (is), d -thc), m/ z . : . (thc), and m/z . : . ( -oh-thc). quantitative results for thc and -oh-thc were obtained from a standard curve (ratio of analyte integrals to integrals of internal standard) ranging from - ng/ ml for both thc and -oh-thc. limits of quantitation, defined as standard deviations above background, were . ng/ml for thc and ng/ml for -oh-thc. results/finding: a total of donor plasma samples were tested for thc and -oh-thc. no samples tested positive for either thc or -oh-thc. theoretical calculations according to statistics of a poisson distribution indicated that there would be a % probability of one or more positives at a prevalence of . % positive samples, and a % probability of one or more positives at a prevalence of . % positive samples. results thus indicated a boundary of prevalence of the presence of active thc-metabolites in plasma samples to be less than % among this donor population. standard pharmacokinetics of cannabis metabolism in previous studies indicate a likely time window of less than hours for post-exposure detection of thc and/or -oh-thc in plasma. conclusion: testing of donor plasma samples for active metabolites of cannabis at one urban, hospital-based blood donor center produced no testpositives. statistically, results indicated that prevalence of positivity, if greater than zero, is at most less than %. probability of occurrence of cannabis metabolites in blood donor samples is likely to be highly variable across donor centers and is largely dependent on blood donor demographics. elisabeth maurer-spurej* , ruqayyah almizraq , daniel millar and jason p. acker . university of british columbia, university of alberta, lightintegra technology inc., canadian blood services background/case studies: the controversy around the quality and clinical impact of aged red blood cell concentrates (rcc) is ongoing. current studies are limited by the lack of quality measures suitable for routine screening of rcc. based on evidence that fragments called microparticles (mp) or extracellular vesicles are markers of cellular activation or degradation, this study investigated the utility of mp screening to characterize the effect of rcc production methods and storage. study design/method: red blood cell concentrates were prepared by whole blood filtration (wbf; top/top) or red cell filtration (rcf; top/bottom) methods, centrifuged to prepare a supernatant and tested for mp content (as measured with dynamic light scattering or a tunable resistive pulse sensing technique), hemolysis, atp and red cell deformability on days , , and of storage. one rcf rcc was tested on days , , , , and and six ml aliquots were stored in parallel and tested on days , , and . all samples were tested for mp content and compared to the other quality indicators. results/finding: mp content showed a linear increase with storage time with statistically significant differences between days , and (p< . ) and correlated with supernatant hemoglobin, and inversely with atp or rbc elasticity. both mp testing methods agreed with respect to total mp content. starting levels of the quality indicators varied between donations, preparation methods (wbf rcc contained much higher levels of mp), and storage time. mp content in the aliquots were consistent at each time point but statistically higher than in the original rcc on and after day of storage. conclusion: mp content correlates with measures of hemolysis and other rbc quality indicators and could be implemented as a routine screening tool. differences in mp content between donors, processes and age could be monitored and used to inform component production decisions. measuring mp content would allow % screening of rcc products in studies and pragmatic qc initiatives which are needed to settle the controversy about the clinical effect of rcc age. single donor spray-dried plasma: the future of plasma therapy? qiyong peter liu*, jihae sohn, ryan c. carney, sruthi sundaram and mark a popovsky. velico medical inc background/case studies: frozen plasma is integral to hemostasis management in many situations but logistically cumbersome because of frozen storage and long thawing time. spray-dried plasma (odp, on demand plasma) is potentially superior because it may be stored under refrigeration near the patient and reconstituted in minutes at the point-of-care. the objective of this study is to determine if odp can be consistently manufactured at a blood center with key proteins and coagulation function comparable to ffp. study design/methods: units of never frozen plasma collected at a blood center were processed on-site at a fixed volume into odp using velico's spray dryer. odp (n ) and paired ffp aliquots were stored for - days at - c and - c, respectively, reconstituted with a fixed volume of rehydration fluid (sterile water for injection), and extensively characterized with respect to the levels of hemostatic proteins, coagulation and complement activation markers, and clotting performance. the volumes of processed plasma and rehydration fluid were pre-determined ensuring similar total protein concentration in reconstituted odp and ffp for direct comparison. results/findings: compared to ffp, odp had ! % levels of functional clotting factors (fibrinogen, factors ii, v, vii, viii, ix, x, xi and xii), plasminogen, and protease inhibitors (antithrombin iii, protein c, protein s; plasmin, c esterase and alpha -proteniase inhibitors). the level of factor xiii in odp was slightly lower, about % of ffp by both activity and antigen assays. odp was identical to ffp in the levels of albumin, immunoglobulins (iga, igg and igm), lipoproteins, calcium, citrate, and coagulation proteins evaluated by antigen assays except for factor xiii. the levels of the markers for coagulation (thrombin-antithrombin, prothrombin fragments i ii and ddimer) and complement (c a and c a) activation in odp remained similar to ffp. odp was equivalent to ffp when assessed by aptt, pt and thrombelastography. transfusion vol. supplement s abstract spray-drying fragmented a substantial number of high molecular weight von willebrand factor (vwf) multimers into smaller ones, leading to a net increase of vwf multimers in odp. the size re-distribution reduced the vwf ristocetin cofactor activity (vwf:rco) to % in odp relative to ffp, but had no impact on vwf antigen and factor viii function (stabilized by vwf). vwf-specific studies have shown that odp retains hemostatic function in supporting platelet adhesion and aggregation (see abstracts by meledeo et al/us army institute of surgical research and bercovitz et al/blood center of wisconsin). conclusion: odp can be manufactured at a blood center with a quality comparable to that of ffp. future studies will determine if the product is bioequivalent to ffp and comparable in safety and efficacy. background/case studies: the collection time of whole blood is, according to european guidelines, limited to minutes. in addition, donations with collection times between and minutes should not be used for preparation of platelet (plt) concentrates (pc) because of the chance of too much activation of plt. it seems justified to re-evaluate the quality of plt from these donations because new generations collection systems and mixers were introduced, including a more efficient needle. the aim of this study was to investigate the in vitro quality of pc prepared from - minutes buffy coats (bc) with the aim to prevent unnecessary discarding of bc and to simplify the total blood bank process. study design/method: single-donor pc (spc, n ) were prepared from one - minutes bc and ml of autologous plasma in a ml pvc-dehp container. as a reference, spc from donations with collection times of < minutes were prepared (n ). in addition, pc were prepared from bc, of which at least bc were from - minutes donations (n ). after pooling of the bc, ml of pas-e was added and a standard pooling set with a pvc-bthc storage container was used for storage of pc. all pc were stored for days at c and sampled at regular intervals for determination of the in vitro quality. aggregation tests were performed with chronolog (adp or collagen) and multiplate (arachidonic acid) aggregometers. thromboelastography (teg), using kaolin as an activator, was applied for assessment of the overall clotting capacity. values are expressed as mean sd. a non-paired t-test or a mann-whitney u test was applied for statistical analyses of normal or non-normal distributed data respectively. results/finding: volume ( vs. ml) and platelet content ( vs. x ) were similar in both groups. at the end of storage, both groups showed comparable in vitro quality (day , ph( c): . . vs . . , other data not shown). no differences in aggregation response after stimulation with arachidonic acid, adp or collagen were measured. teg parameters in both groups were also comparable. the five-donor pc fulfilled all requirements of european guidelines, aside from occurrence of small aggregates at day and/or in / pc (possibly because sometimes ab incompatibility was accepted). on day , plt showed low cd p expression ( . . %) and phosphatidylserine exposure (annexin v binding, . . %). hypotonic shock response of platelets was comparable with historical data. conclusion: single-pc in plasma as well as five-donor pc in pas-e, prepared from - minutes whole blood donations had a normal composition and showed good in vitro quality during day storage. to substantiate that the exclusion of - minutes donations for pc preparation could be stopped, further studies will be performed. the effects of a pneumatic tube system on red blood cell units amy mata* , jessie miller , ranee marie wannarka-farlinger , sandra bryant , scott a hammel , sherry stern and camille van buskirk . mayo clinic, mayo clinic rochester background/case studies: the use of pneumatic tube systems (pts) has become commonplace in many healthcare facilities throughout the world. the purpose of these systems is to transport products and specimens, resulting in reduced turnaround time for laboratory testing and to aid in the timely delivery of patient care. a downfall of ptss is that they have the potential to play a role in increased hemolysis. while several studies have been published on the effects of ptss on blood specimens, there are very few that address the effects on blood products, specifically red blood cells (rbc). the objective of this study was twofold: to determine if the pts that is in use at our facility contributes to an increase in hemolysis of rbc units and to evaluate how the pts system affects red cell microparticle (rmp) levels. study design/method: forty-one units of as- rbcs, irradiated and non-irradiated, were selected for the study. the units varied in age, ranging from to days old. specimens were obtained from each unit both prior to and after being transported through the pts, which runs underground and spans the length of a mile and a half. specimens were spun down and the plasma supernatant was removed. all specimens were evaluated for plasma hemoglobin (hgb), potassium (k), hemolysis index (hi), and rmps. the wilcoxon signed-rank test and p value were used to compare the pre and post values. additional statistical analysis was performed to compare the values after adjusting for age and irradiation. results/finding: after sending the rbc units through the pts, hgb, hi, and rmps were statistically (p< . ) higher than before. when adjusted for irradiation, the same analytes remained statistically higher, however when adjusted for age, the p-value was only significant for hgb and hi. the k values did not significantly change. rmps significantly increased, but only if the units were irradiated (p . ). (table) conclusion: the use of a pts provides an effective means to transport blood products; however, it can contribute to biological changes within rbc units. it is uncertain at this time how those changes can affect the outcome of patients who receive these products. each pts system is different in its specifications and should be validated prior to being used to transport blood products. validation of factor viii levels of thawed fresh frozen plasma after days of storage pei lun karen lim* , erma sofia sumardi , isamar eduardo ancheta , susan lim , christina yip , lip kun tan and shir ying lee . national university hospital singapore, national university hospital, national university hospital, singapore background/case studies: plasma transfusion is indicated in patients with coagulation factor deficiencies and active bleeding, or who are about to undergo an invasive procedure. fresh frozen plasma (ffp) has to be placed in the freezer within hours of processing and stored at - c or colder in order to preserve its coagulation factors. thawed ffp has an expiration period of hours hence to reduce wastage, this study aims to investigate factor viii (fviii) activity in thawed plasma stored for days and kept at to c. fviii was chosen as it is an important coagulation factor in correcting coagulopathies. arbitrary fviii level acceptance limit was set as not less than iu/dl. study design/method: randomly selected units of ffp (n ) were measured for fviii concentration based on clotting assay (stav r -deficient a transfusion vol. supplement s viii diagnostica stago). fviii levels were measured at five time points: prefreezing, , , and hours post-thawing. ffp were thawed using helmer plasma thawer (helmer scientific) at to c for minutes. an aliquot of thawed ffp from each unit was removed and measured for fviii before refrigeration ( hours post-thaw). thawed plasma (tp) units were kept in a refrigerator at to c for days for subsequent testing. results/finding: results obtained were listed in table . units to were not tested for fviii at post thaw- hour due to operational issues. the overall fviii concentration decreased at an average of % from pre-freezing to post thaw hour. after further storage of tp post thaw- hour and - hour, residual fviii level remain to be above iu/dl except unit which had a lower initial fviii concentration. at post thaw- hour, out of units tested had residual fviii activity within the pre-set standard of iu/ dl. the average decline from -hour post-thaw to -hour, -hour and hour post-thaw was . %, . % and . % respectively. there was no observed trend of any blood group having higher or lower pre-freezing fviii and this is likely due to small sample size. conclusion: decrease of coagulation factor such as fviii in ffp is expected due to its diminishing stability. nevertheless, our data showed that majority of the tp retained at least iu/dl of fviii. typically patients with factor levels below iu/dl may start to show abnormal coagulation profile. while tp is not used for specific factor replacement therapy, it may be indicated for patients with general coagulopathies and active bleeding. further study extending to measurement of other labile factor such as fv may add value to the validation study. validation of the pathogen reduction method using amotosalen/ uva: comparing pathogen-reduced pooled prp-platelets and conventional single prp platelets for quality and bacterial inactivation efficacy lubna ahmed almenawi , ayman mohamad sabri , ali abdullah alajeafi , ashwaq hasan alhekri , saleem bin mahfouz , ali hasan alkhodari , rawya saeed shealy , marcus picard-maureau* and hussain bana almalki . king abdulaziz hospital and oncology center, cerus europe bv background/case studies: the growing number of transfusiontransmitted infectious (tti) risks, including emerging and endemic pathogens, is a constant challenge for blood centers in saudi arabia. while for a limited number of these pathogens tti risk can be reduced using blood screening assays, alternative solutions are anticipated. pathogen reduction (pr) technology was identified as a potential solution. validation of amotosalen/uva photochemical treatment in our blood center was performed by comparing the platelet component (pc) quality of the standard "control" single-donor prp-concentrate in % plasma over a day storage period and the new "test" pathogen-reduced, pooled (pools of ) prp pc in % plasma over a day storage period. the efficacy of the bacterial inactivation was also assessed in our setting. study design/method: the quality parameters of leucoreduced test pcs were assessed at day of storage and compared to leucoreduced control pc at day of storage. the test pcs were pathogen-reduced with the intercept blood system (cerus corporation, concord, u.s.a.) at day ; the process was completed by day post-collection. samples were taken daily for quality analysis from test and control pc until day and day , respectively. for bacterial spiking, additional pc were spiked with each receiving ml of mcfarland ($ . x cfu) s. aureus, s. epidermidis, e. coli, p. aeruginosa or s. viridans, respectively, to challenge pr efficacy. results/finding: the average platelet loss in the test pc post pr treatment was . % . , the total average platelet loss at day was . % . . the average platelet loss in the control units at day was . % . . the average ph of the test units at day was . . and in the same range as the control pc, ph . . . glucose concentration in test pc at day ( . . mmol/l) was lower than in the day control units ( . . mmol/l). lactate levels increased during the course of storage; lactate levels at days and were outside the range of the assay (> mmol/l). cultures inoculated with pathogen reduced, bacterially spiked units were negative after days of incubation, in contrast to those inoculated with nonpathogen reduced samples from the control units, which were positive for bacterial growth. conclusion: the quality parameters of the pathogen reduced test pc were within specifications and comparable to the conventional control pc. the high efficacy of bacterial inactivation together with comparable quality parameter values suggests the use of amotosalen/uva pathogen reduction is safe and efficient to enhance pc transfusion safety. keaton charles stoner* , jay srinivasan , jessica poisson and ian welsby . duke university, duke university school of medicine, duke university hospital, duke university medical center background/case studies: the coagulation cascade relies on a complex interaction between proteins known as clotting factors. cryoprecipitate (cryo) is a plasma-derived blood product that contains several of the proteins central to the clotting cascade and is typically used as a fibrinogen replacement in bleeding patients. however, cryo contents tend to be variable, and little quantitative evidence exists regarding the exact therapeutic effect of cryo on coagulation. my study aimed to better characterize cryo for consistency across and within sources in terms of its functional effect on in vitroclot formation. study design/method: the duke proteomics core conducted a semiquantitative liquid chromatography-mass spectrometry/mass spectrometry transfusion developed an in vitromodel for a coagulopathic patient using serial dilutions of pooled normal plasma with saline and then added the equivalent of one, two, and three cryoprecipitate doses. a tissue factor-activated test on the rotemv r delta hemostasis analyzer (extem) was performed on each condition. for each source, dose-response curves for clotting time (ct), alpha angle, and maximum clot formation (mcf) were generated using linear regression models. inter-source unit variability was determined by anova and tukey's hsd post-hoc analysis (rstudio inc.). results/finding: lc-ms/ms identified proteins in cryo; of the most abundant, only fibrinogen was relevant to coagulation. notably, the american red cross (arc) single donor source had the steepest slope for mcf ( . mm/dose), indicating a greater per dose potency than the other sources. the arc single donor source had the highest mean mcf across all dosing levels, but also the highest standard deviations and response variability. the arc single donor source was significantly more potent than the australian source. conclusion: paired with our estimates regarding the variability of clot formation responses to cryo, the quantitative dose-response curves provided in this study for ct, mcf, and alpha angle can provide physicians with more information regarding cryo dosing. future studies that evaluate the therapeutic effect of cryoprecipitate versus fresh frozen plasma or fibrinogen concentrate would be of clinical importance and give us further insight into the relative utility of and dose requirements for cryo to correct dilutional coagulopathy. viral inactivation and enrichment of factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers from fresh frozen plasma (ffp)using, "vips plasma, virus inactivation treatment system". background/case studies: the solvent/detergent (sd) process used for plasma can safely inactivate all lipid-enveloped viruses. the method proved effective in the processing of coagulation factor concentrates by disrupting the membranes of lipid-enveloped viruses, cells and most protozoa, while leaving the labile coagulation factors intact. this study is done to assess viral inactivation and, factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers enrichment capacity of, "vips plasma, virus inactivation treatment system". study design/method: "vips plasma, virus inactivation treatment system" comprise of interconnected bag system where the s/d reagents are removed by filtration and the final products subjected to bacterial ( Á lm) filtration. cryoprecipitate mini-pools ( ml) were subjected to doublestage s/d viral inactivation, followed by one oil extraction and a filtration on a s/d and phthalate [di( -ethylhexyl) phthalate (dehp)] adsorption device and a Á lm filter. the initial and the final products were compared for visual appearance, blood cell count, factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers. initial and final products were also checked for hiv, hbv, hcv, dengue, malaria and bacterial contaminations. results/finding: our analysis showed that the treated cryoprecipitate were very clear, with negative blood count and the protein content of factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers were well conserved (table ) . kit ensured bacterial sterility (table ) and most importantly, final product was free of hbv, hcv and hiv (table ) . conclusion: it's the first time, "vips plasma, virus inactivation treatment system", is used in south asia for product enrichment and viral inactivation. results showed effective product enrichment and viral inactivation in our conditions. but further investigation is needed to characterize functional activity of the enrich component. irrespective of that the process may offer one additional option to blood establishments for the production of virally inactivated plasma components especially in low income countries. background/case studies: buffy coats (bc) from donors who used pain medication like aspirin and ibuprofen up to days prior to the donation are discarded, because a known side effect of these non-steroidal anti-inflammatory drugs (nsaids) is inhibition of platelet (plt) aggregation. these nsaids inhibit the enzyme cyclooxygenase- , thereby blocking synthesis of thromboxane a from arachidonic acid. however, the quality of platelet concentrates (pc), prepared from this bc is not known. the aim of the study was to investigate the in vitro quality of pc prepared from nsaid-bc and autologous plasma during storage. study design/method: single-donor pc (spc, n ) were prepared from a nsaid-bc and ml of autologous plasma. information about the type of pain medication was extracted from the anamneses form. the spc were stored for days at c and sampled at regular intervals. aggregation tests were performed with chronolog (adp or collagen) and multiplate (arachidonic acid) aggregometers. thromboelastography (teg, kaolin) was applied for assessment of the overall clotting capacity. spc in plasma from normal controls (n ) were investigated as a reference. values are expressed as mean sd or as median & iqr. a non-paired t-test or a mann-whitney u test was applied for statistical analyses of normal or nonnormal distributed data respectively. results/finding: volume ( vs. ml) and plt content ( vs. x ) were similar in both groups. on day , both groups showed comparable ph and changes in plt content (data not shown). phosphatidylserine exposure on day was significant higher in a subset of donors who had used ibuprofen (n ). aggregation tests with arachidonic acid revealed in general a low or absent response for spc with aspirin ( , - , p< . ), diclofenac ( , - ) and naproxen ( , - , p< . ), compared to normal controls ( , . no differences were detected in aggregation with adp or collagen. with teg, slightly longer r-times (initiation phase) were measured on day in spc with aspirin, diclofenac and naproxen, compared to the normal controls (only significant for naproxen). these differences disappeared during storage. conclusion: storage properties of spc prepared from nsaid-bc were comparable with spc from normal controls. main differences were observed in aggregation and coagulation properties for donors who used aspirin, diclofenac or naproxen. plt from donors who used ibuprofen showed little or no deviations. this is most likely caused by the fast (< hour) disappearance of ibuprofen from the blood circulation and the reversible binding to plt. the use of bc from donors who used ibuprofen will be further investigated in a 'worst case' (pc in plasma) and 'best case' (pc in additive solution) scenario. the effects of ibuprofen on aggregation and coagulation properties will be further investigated in a dose-response study design adding different levels of ibuprofen to plt. background/case studies: previously it was shown that donors could be classified as having platelets (plt) with good, average or poor storage properties [bontekoe, transfusion, ] . a main difference between 'good' and 'poor' storage properties involved metabolic activity, resulting in a faster decline of ph during storage of 'poor' plt concentrates (pc). this might be caused by a different functionality of the plt mitochondria and there are indications that donors with a history of 'poor' pcs are more likely to have health issues, pointing towards metabolic syndrome and type diabetes (t d). because of the strong rise of people with t d in the dutch population, the aim of this study was to characterize plt from whole blood donors diagnosed for t d, but accepted as donor. study design/method: twelve whole blood donors with t d, not using insulin, were selected and buffy coat (bc) and plasma were, after overnight hold, used for preparation of a single-donor pc (spc). an equivalent number of spc was prepared from age and sex matched control donors, derived from the same collection sessions. spc were stored for days at c and sampled on day , or and . the diabetic marker hba c was determined in red cells and cholesterol and triglyceride levels in plasma. from both groups 'good' (ph day > . ) and 'poor' (ph day < . ) storing spc were selected and analysed in more detail. results/finding: donors were of age year and primarily men ( %). donors with t d had a higher mean bmi ( . . vs. . . kg/m ) and higher hba c than controls. the spc of both groups had the same volume ( vs ml) and plt content ( vs x ) but on day glucose concentration was higher in the diabetic group ( . . vs . . mm, p< . ). on day , the average in vitro quality was comparable in both groups (data not shown). when combining a transfusion vol. supplement s the selected 'good' and 'poor' storing plt from both groups, a large difference in lactate production was observed ( . . vs . . mmol/ day/ plt). the 'poor' plt showed a faster decline of the mitochondrial membrane potential (as measured with jc- ) during storage than 'good' plt. remarkably, a difference in triglyceride levels was detected on day ('poor': . . vs 'good': . . , p< . ). conclusion: bc from donors with t d who did not use insulin and fulfilled all donor criteria, were comparable with bc from age and sex matched controls, and seem suitable for preparation of pc. when selecting the 'good' and 'poor' storing plt from the combined groups, the results of our previous study were confirmed, with significant differences in glycolysis rate and functionality of mitochondria. metabolic syndrome and t d are still suspected as health issues involved in 'poor' storage of plt because donors were of high mean age and because of the observed differences in triglyceride levels between 'good' and 'poor' stored pcs. whole blood leukoreduction failures --following manufacturer's instructions may not be enough karen klinker*, nancy m. dunbar and zbigniew m. szczepiorkowski. background/case studies: our hospital based blood donor program uses a blood collection system which leukoreduces the unit at room temperature prior to centrifugation. the manufacturer recommends minimum wait time of minutes prior to filtration. anecdotally, the vendor states waiting an hour improves the leukoreduction. we experienced leukoreduction failures in january and february of detected by our routine qc. we initiated an investigation as to the cause of these unexpected failures. study design/method: for each of the leukoreduction failures, the following factors were analyzed: collection time, length of filtration, length of wait time prior to filtration, platelet count, staff performing the process, the lot number of the collection system bag, and whether or not units collected from the same donor failed leukoreduction in the past. hemoglobin s determinations were not sought out as no repeat donor failures were noted and our donor population would suggest a minimal number of donors would be found to be hemoglobin s positive. results/finding: a relationship was established between the length of time the product rested or waited prior to filtration and leukoreduction failure. we found that shorter wait times increased the percentage of leukoreduction failures (see table ). all units that failed had wait times less than one hour. a similar trend was noticed for the previous year. the investigation showed no relationship between length of collection time, or the length of filtration time and leukoreduction failure. staff performing the filtration was ruled out as possible cause as the failures were spread out among numerous personnel and observation of their technique displayed no sample collection issues. platelet counts on the donors involved were available and none were outside of the normal range. various lot numbers of the collection sets were involved, and no donors were repeat failures. conclusion: in our small study, we found that following manufacturer's recommendations for the resting or wait time prior to filtration was insufficient to avoid excessive leukoreduction failures. we extended our minimum wait time to minutes based on our data. we have not experienced any leukoreduction failures after this change. absolute immature platelet count in diagnostic algorithm and management of pediatric thrombotic microangiopathy hamza n gokozan* , , katharine a downes , , hollie m reeves , and robert w maitta , . case western reserve university school of medicine, university hospitals cleveland medical center background/case studies: prior studies highlighted the utility of absolute immature platelet count (a-ipc) and a-ipc ratio once therapeutic plasma exchange (tpe) is initiated to differentiate thrombotic thrombocytopenic purpura (ttp) from other thrombotic microangiopathies. this can be helpful to determine those who may benefit from prompt initiation of tpe when tests such as adamts are not readily available. we report a young pediatric patient presenting with diarrhea in the setting of laboratory results suggestive of a microangiopathic thrombocytopenia suspicious for ttp in which a-ipc measurement was clinically useful. study design/methods: previously healthy month old unvaccinated girl presented with history of diarrhea for days which was bloody at onset, accompanied by fever and dehydration. laboratory results showed: white blood cell count: x /l, platelets: x /l, bun: mg/dl, creatinine: . mg/dl, lactate dehydrogenase u/l. hospital course was complicated by tonicclonic seizure episodes that stopped with anti-convulsants and acute kidney injury requiring hemodialysis. peripheral blood smear revealed schistocytes. on third day of hospitalization, platelet count decreased to x /l, adamts sample was sent out and tpe was initiated for clinical suspicion of ttp versus hemolytic uremic syndrome, atypical versus shiga-toxin mediated. immature platelet fraction (%-ipf) and calculated a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. results/findings: platelet count began to increase prior to tpe initiation ( x /l and a-ipc of . x /l). two consecutive tpe were completed which resulted in a platelet count decrease to x /l and a-ipc of . x /l. a-ipc ratio was . below the ratio of which has been reported for ttp patients. similarly a-ipc count was not below x /l threshold reported in setting of ttp with severe adamts deficiency. at this time stool culture obtained prior to start of tpe came back positive for e. coli o :h toxin. testing of c , c , factor h, factor h autoantibody, factor i and factor b were normal. adamts activity was %. patient was treated for the infection and platelet count improved within days to x /l, with resolution of her renal failure: bun: mg/dl, creatinine: . mg/dl. no additional seizures were observed during follow-up. conclusion: measurement of a-ipc can be used to aid clinical decisions in pediatric patients suspected of ttp especially when adamts testing and those for other etiologies are still pending. tpe did not seem to have a significant effect in a-ipc but decreased platelet counts in this patient. a-ipc is rapid to obtain and can provide helpful information in the setting of potentially overlapping etiologies in the setting of other testing with longer turnaround time. background/case studies: thrombotic thrombocytopenic purpura (ttp) is a thrombotic microangiopathy characterized by low adamts activity. many patients with severe autoantibody-mediated adamts deficiency at initial disease presentation may suffer from one or more recurrent episodes over the following months or years. it is unclear if disease course and characteristics of recurrent/relapsed ttp may be different from that seen at initial presentation. since absolute immature platelet counts (a-ipc) have been shown to be useful in the diagnosis and to follow response to therapy of ttp patients, we proceeded to evaluate if a-ipc pattern was different in relapsed verse initial presentation. study design/methods: our study cohort consisted of three patients (two female and one male) with acquired ttp (adamts activity < %) who underwent daily therapeutic plasma exchange (tpe). clinical course and laboratory values were reviewed. platelet count (plt), immature platelet fraction (%-ipf) and a-ipc (%-ipf x platelet count) were analyzed during treatment course. a-ipc values at presentation and peak, a-ipc peak time (days), and plt count recovery time (days) were compared between initial onset and relapse episode for each patient. a-ipc percent change in relapse episodes compared to initial presentation was calculated. results/findings: all patients had an increased %-ipf, and decreased a-ipc and plt count at presentation in both initial and recurrent episodes. once tpe treatment was initiated, a-ipc rapidly increased and reached a peak value - days prior to plt count recovery, consistent with that previously described in ttp patients. however, compared to first onset, recurrent episodes featured lower a-ipc at presentation (results shown as percent decrease, column ), increased peak a-ipc value (results shown as percent increase, column ), delayed a-ipc peak, and delayed plt recovery (table ) . moreover, recurrent episodes required more procedures compared to initial presentation (table ) . conclusion: recurrent/relapsed ttp demonstrate lower a-ipc at presentation and a delayed and increased a-ipc peak value in response to tpe compared to initial presentation. a longer treatment course was observed in recurrent patients. future studies of more relapsed ttp patients are needed. donors undergoing frequent plateletpheresis and its effect on the hematological parameters sweta nayak*, poonam coshic and r.m pandey. all india institute of medical sciences background/case studies: frequent plateletpheresis donors are assets for the blood banks. the well-being of these donors has been a matter of concern. in our study we intend to analyze the effect of plateletpheresis on the hematological parameters of these donors assessed prior to each subsequent procedure. we also try to compare the effect cell separators used for plateletpheresis on the post donation hematological parameters. study design/method: the study was conducted during february to march on all the repeat plateletpheresis donors coming to the department of transfusion medicine for the nd time within a month of the first plateletpheresis. the values of the hematological parameters including red cell and platelet indices tested prior to each plateletpheresis were entered into the excel sheet and gap between each donations were calculated. the plateletpheresis were done either on hemonetics mcs separator (hemonetics corporation, braintree, massachusetts, usa), fresinius separator (com.tec), dn (fresinius hemocare gmbh, bad homburg v.d.h, germany) and gambro trima accel, software version . after taking consent from the donors. the target collection of each procedure was a dose of x platelets in - ml of plasma. to compare the effect of the cell separators on the hematological parameters due to the plateletpheresis, parameters at consecutive donations within days were considered. data was analyzed by stata . within change in the continuous variables were assessed by paired t-test and between two groups comparison was done by independent t-test or wilcoxon rank sum test. the comparison among the cell separators was done by kruskal-wallis test or one way anova. results/finding: of the donors, repeated the plateletpheresis within a week (group i) and underwent nd plateletpheresis within - days (group ii). no significant alteration was found in the red cell or the platelet indices within either group but a significant difference in the variation of platelet counts of the groups (p . ). though above the eligibility cutoff of . lakhs/ml, platelet counts were lower than baseline in group i donors whereas it was higher at nd plateletpheresis in group ii donors. there were donors who presented to us for the rd time for plateletpheresis with a mean gap between st and rd plateletpheresis being days. no significant difference in the parameters assessed prior to any of the plateletpheresis was found except the platelet distribution width (p . ). plateletpheresis through all the cell separators had similar effects on the hematological parameters. conclusion: there was no significant change in the hematological parameters in the plateletpheresis donors who underwent frequent plateletpheresis. post donation follow-up hematological parameters were not affected by the cell separators used for plateletpheresis. efficacy of therapeutic plasma exchange on angiotensin ii type receptor antibodies in two kidney transplant recipients chisa yamada*, silas p. norman, milagros samaniego and laura cooling. background/case studies: some kidney transplant recipients develop antibody mediated rejection (amr) without detected hla donor specific antibodies (dsas) in sera. in recent years, angiotensin ii type- receptor antibody (at rab) has been reported to cause amr, especially refractory amr, possibly by contraction of renal arteries. at our institution, therapeutic plasma exchange (tpe) followed by ivig every other day has been applied to reduce at rabs in kidney transplant recipients, and we here report efficacy of tpe treatments in two cases. study design/methods: two kidney transplant recipients who received tpe treatment followed by ivig to decreased at r ab are reviewed. results/findings: case : the patient is a currently -year-old female with focal segmental glomerulosclerosis who received her first kidney transplant from a living related donor at age , and a second deceased donor transplant due to a rejection of the transplanted kidney at age . three years post-transplant, her creatinine (cr) started to rise from . to . mg/dl and a biopsy showed banff criteria grade amr, grade a t-cell mediated rejection (tcmr) and grade interstitial fibrosis and tubular atrophy. hla dsa had been negative in serum, but high level at rab was identified at > u/ ml (high: > u/ml, intermediate: - u/ml, negative: < u/ml). she received tpe treatments every other day and started losartan. after a course of tpe, at rab decreased to u/ml and histology showed improvement of amr and tcmr, however, cr kept increasing slowly to . ml/dl. in one month, her at rab increased again to > u/ml, therefore, she received more tpe treatments with a decrease in her at rab to u/ml. although at rab level increased slightly to u/ml after months, her cr has been stable at . - . ml/dl. case : the patient is a -year-old mean /-se - . /- . % * . % /- . %* * p< . a female with malignant hypertension who received a deceased donor kidney transplant at age . her cr started to rise weeks post-transplant from . to . mg/dl without detectable hla dsa. although biopsy showed no amr or tcmr, there was focally severe arteriopathy. she was found to have high at rab level at u/ml. she received tpe procedures every other day and at rab decreased to u/ml with a decrease of cr to . mg/dl and improved arteriopathy in histology. because her at rab level slightly increased to u/ml over the next weeks, she started weekly tpe treatment. after weekly tpe, tpe treatment was stopped because her at rab level remained relatively unchanged. her cr has been stable at around . ml/dl to date. conclusion: we present kidney transplant recipients who received tpe treatments for high at rab levels. a course of tpe procedures followed by ivig every other day was effective to decrease at rab levels; however, weekly tpe had no effect on reducing at rabs. tpe treatment may be also beneficial to improve histological amr and clinical kidney function. experience in management of thyroid storm by plasmapheresis tatiana belousova*, vanya jaitly, brian castillo, hlaing tint, kimberly klein and yu bai. university of texas health sciences center at houston background/case studies: thyroid storm (ts) is an extreme manifestation of thyrotoxicosis that is a serious complication occurring primarily in patients with graves' disease. clinically they may present with a wide range of hypermetabolic symptoms which may be fatal if not managed appropriately. we report two cases where ts with severe cardiac complications was managed by plasmapheresis (plex) with excellent effect. study design/method: a year old man (patient a) with a medical history of hyperthyroidism present with ts complicated with cardiogenic shock [ejection fraction (ef) < %], renal and hepatic dysfunction as well as coagulopathy. patient was persistent tachycardic while being intubated, sedated and requiring tandem heart support. a year old man (patient b) with a medical history of hypothyroidism (on synthroid for years), end stage renal disease and non-ischemic cardiomyopathy (ef of - %) presented for evaluation of dual kidney-heart transplant. he subsequently developed ts with multiorgan failure. standard steroid medication treatment showed little response. results/finding: both patients underwent urgent plex along with standard medication administration as soon as the clinical suspicion of thyroid storm was raised. a - . plasma volume, iso-volumic procedure using fresh frozen plasma as replacement was performed in the intensive care unit where the procedure associated hemodynamic impact could be easily managed. both patients showed significant clinical improvement within hours of the procedure completion. their total t , t and free t levels trended to normal or near normal range within hours (table) . in addition, the plex effect on hormone and the associated antibody removal seemed remained and no "rebound" phenomenon was observed in both cases, making repeated plex unnecessary. both patients had total thyroidectomy - weeks after the event with great clinical outcome. conclusion: our cases demonstrate that plex is a safe, effective treatment option in managing ts patient with severe cardiac dysfunction. the procedure can not only lead rapid decrease in thyroid hormone and its associated antibody levels, but also lessen the severity of tissue injury by moderating the inflammatory process and correcting complications. extracorporeal photopheresis in s ezary syndrome treatment: hospital-based blood bank experience sandra ortega s anchez* , laura martínez molina , cristina muniesa montserrat , octavio servitje bedate , silvia cosano navarro and maria isabel gonz alez medina . banc de sang i teixits, dermatology service. background/case studies: extracorporeal photopheresis (ecp) is an immunomodulatory therapy widely used since years in cutaneous t cell lymphoma, several autoimmune diseases and organ transplant rejection, and in the last years, also used in graft versus host disease treatment. the use of ecp in cutaneous t cell lymphoma (ctcl), mycosis fungoides (mf) and s ezary syndrome (ss) in their erytrodermic form are recently categorized by the american society for a pheresis (asfa) , as first line treatment alone or in combination with other therapies, with a strong recommendation: grade ib, category . since mf and ss are incurable diseases current therapies are focus in controlling skin symptoms and minimizing immunosuppression. the objective of this observational study is to assess outcomes of patients diagnosed with ss and compare them in their first evaluation once the th procedure is been performed. study design/method: ecp is a leukapheresis-based therapy, ex vivo exposition to a photosensitizer drug ( -methoxypsoralen, -mop) and uva light, and subsequent reinfusion of the treated cells which are now induced to apoptosis. volume treated varies from . to total body volume (tbv) and the schedule for ss disease is one cycle (two daily ecp procedures) twice per month. the venous access was peripheral in all cases except in where central catheter was needed. the procedures were performed with optia or amicus devices for the aphaeresis and external uva irradiation for off-line system (in / patients) and with online system (therakos) just in . main parameters for evaluation were cutaneous response rate, number of s ezary cells, previous treatments, duration of the response and possible complications during ecp treatment. results/finding: global response rate is ' % (partial remission . % and complete remission . % with maintained response). no severe side effects related with the procedure were found. the patient outcomes analyzed are similar to results in published literature. conclusion: cases treated in our hospital confirm the efficacy of ecp in ss treatment, with a good safety profile. another great advantage of ecp is the relative lack of immune suppression. many questions remain still unanswered about ecp: which schedule is the most suitable one, how we must continue or stop when partial or complete remission is achieved; and the number of leukocytes to be treated, as techniques as mini-photopheresis are also getting good results. all these questions and more make prospective studies necessary to be performed. : u/l) requiring transfusions, mild thrombocytopenia ( x /l), acute kidney injury (bun mg/dl, creatinine . mg/dl). by the third hospitalization day hgb improved to g/dl, however with worsening thrombocytopenia ( x /l) that led to clinical concern for ttp. peripheral smear showed many red cell fragments. patient was transfused with platelets day prior to first tpe. immature platelet fraction (%-ipf) and a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. results/finding: four tpe in five days were performed (hospital days - ). platelet count and a-ipc improved to x /l and . x /l respectively just prior to first tpe. response to four tpe led to a decrease in both platelet count ( x /l) and a-ipc . x /l. these dynamics did not resemble those which had been described for ttp patients with adamts deficiency. adamts obtained prior to tpe initiation was resulted at this time and was %. no causative organism or toxin was identified after urine, blood, and stool examination and culture. based on these results, tpe was discontinued which led to an immediate increase in a-ipc ( . x /l) that preceded platelet count increase to x /l three days later when patient was discharged. other laboratory values at this time were ldh of u/l, hgb: . g/dl in the setting of recovery of renal function. conclusion: timely diagnosis of ttp is essential to start of tpe. a-ipc dynamics differ in ttp compared to other thrombotic microangiopathies. in our patient a-ipc failed to improve despite tpe and improved once procedures were discontinued and were followed by increases in platelet counts three days later. when ttp is not the causative etiology, a-ipc can help adjust therapy and lead to clinical improvement. further research is needed to characterize immature platelet dynamics in non-ttp microangiopathies. infection and its role in the clinical course of idiopathic thrombotic thrombocytopenic purpura associated with severe adamts deficiency eiman hussein* and jun teruya . department of clinical pathology, cairo university, texas children's hospital background/case studies: ttp is a life threatening disease, defined by microangiopathic hemolytic anemia, thrombocytopenia and severely deficient adamts . since the introduction of therapeutic plasma exchange (tpe) as a treatment modality for ttp, its prognosis has improved dramatically. nonetheless, some patients may develop relapse or refractoriness, with potentially fatal outcomes. despite the notable progress that has been made with studies that emphasized the pivotal role of adamts , the epidemiology of ttp remains uncertain. previous studies have suggested that many factors appear to influence its pathogenesis. some studies point toward infection as a possible trigger which may contribute to the development and can ultimately influence its clinical course. one of the theories to explain this association is the possible cross reactivity between antibodies targeting infectious pathogens and those directed against adamts . the aim of this study was to prospectively examine the potential association between infection and the clinical outcome in a cohort of patients with idiopathic ttp. study design/method: patients with idiopathic ttp who underwent tpe from january through march were studied. sessions were performed daily until platelets and reticulocytes had been normal, then sessions were gradually tapered. we only included patients with adamts activity of less than %. data on infections that occurred at or within a week prior to the development of ttp were analyzed. results/finding: thirty-two patients were categorized as idiopathic ttp with severe adamts deficiency. eight patients ( %) were associated with suspected bacterial infection. four of the patients ( %) showed acute relapse coincident with bacterial infections. central line associated staphylococcus aureus infections occurred in three patients and acinetobacter urinary tract infection was reported in one patient. one patient had symptoms of respiratory infection before the development of ttp, on his initial as well as his relapsing episode. refractoriness to treatment was demonstrated in patients. it was associated with dental abscess in one patient. the other two were associated with mycoplasma pneumonia. tpe sessions were continued in all refractory patients until their death. conclusion: in patients with idiopathic ttp refractory to conventional treatment, a serious consideration should be given to non-idiopathic causes, particularly the presence of a remote source of infection, which can be an additional triggering factor for their initial and / or recurrent episodes. sandra satoe kayano*, marcos paulo colella, rafaela guerra maciel, ingrid priscila ribeiro paes ferraz and rafael colella. a c camargo cancer center background/case studies: therapeutic leukapheresis (tl) has become an ordinary procedure in low body weight children with cancer, and its use over the time has been replacing exchange transfusion. leukodepletion preceding chemotherapy helps preventing leukostasis and hiperviscosity, and aims to reduce metabolic and renal complications associated with cell lysis. the objective of this study is to evaluate the efficacy and safety of leukapheresis procedure in pediatric patients with less than kilograms using a single apheresis procedure. study design/method: in october and june , two children with possible leukemia were submitted to tl procedure. they were and months old, and weighted , and , kilograms. central venous catheters were placed, and apheresis were performed using a continuous flow apheresis system. the device was primed with ml of abo, rh and kell compatible, leukocyte-reduced, irradiated, % hematocrit packed rbcs, and the anticoagulant used was acd-a plus heparin ( ml of acd-a and , units of heparin), at a blood to anticoagulant ratio of : . a complete blood count was determined before and after apheresis. the room was heated to avoid hypothermia, and ionized calcium was measured every minutes to prevent hypocalcemia. during the collection, changes in blood pressure, oxygen saturation and heart rate were observed. net fluid balance was calculated as the sum of the volume of anticoagulant, cation and nondiverted apheresis prime solutions minus the product volume. when the procedure was completed, the blood that filled the apheresis tubing was discarded. the patients were in the intensive care unit (icu) under the supervision of a pediatric physician and icu nurse who were aware of potential adverse events, and the procedure were performed by two hematology physicians and the nurse practitioner. results/finding: the white blood cell (wbc) in blood was counted immediately before apheresis in both subjects, and were . and . / mm . the formula "collection pump flow , x inlet flow x preapheresis wbc count" was used with the goal of removing up to x leukocytes/ml. a single leukapheresis procedure was performed with total blood volume processed per patient. immediately after the -hour procedures, wbc count were . and . wbc/mm , and -hour post tl, wbc count were respectively . and . /mm . net fluid balance was zero in both procedures, and the patients required no transfusion. conclusion: tl was safe and efficient. experience with leukodepletion in infants is limited, and a procedure in children weighing kg or less needs forethought and a multidisciplinary effort, hence operators need to customize procedures for safe collection. however, despite the potential complications that may occur (placement of adequate vascular access, management of low extracorporeal blood volume, anticoagulant-related toxicity with metabolic and hematologic issues), remains an excellent source for leukoreduction in hematologic malignant diseases. background/case studies: nationwide apheresis registry can give us information on the current status and trend regarding apheresis procedures. data can be compared with other regions to find and understand differences in perspectives, indications, technology, and clinical practice. the korean society for apheresis (ksfa) has launched an online web based registry system for apheresis procedures since . we report the data from the year . study design/method: the registry is consisted of two sub-registries. one addresses the overall aspects of apheresis procedures performed at each institute, and the other is focused on therapeutic plasmapheresis procedures. data is registered by voluntarily participating hospitals in korea. results/finding: a total of , apheresis procedures were performed at hospitals. therapeutic plasmapheresis was the most frequent procedure ( . %) followed by autologous peripheral blood stem cell (pbsc) collection ( . %), allogeneic pbsc collection ( . %), donor leukapheresis ( . %), and therapeutic leukapheresis ( . %). cobe spectra ( . %) and amicus ( . %) were the most widely distributed instruments. centrifugation was the dominant technique ( . %) for therapeutic plasmapheresis. detailed information was given for , therapeutic plasmapheresis procedures performed on patients (some items were not completely filled out). spectra optia ( . %) and cobe spectra ( . %) were the most frequently used instruments for therapeutic plasmapheresis. fresh frozen plasma (ffp) was used most frequently ( . %) as the replacement fluid followed by % albumin ( . %), % albumin ( . %), and % albumin ffp ( . %). most of the procedures were performed for plasma volume ( . %). acd ( . %) and heparin ( . %) were used for anticoagulation. central venous catheter ( . %) was the dominant type of vascular access. major clinical indications were desensitization for abo incompatible renal transplantation ( . %), antibody mediated rejection in renal transplantation ( . %), thrombotic microangiopathy ( . %), desensitization for abo compatible renal transplantation ( . %), neuromyelitis optica spectrum disorders ( . %), and hyperviscosity in monoclonal gammopathies ( . %). adverse reactions were observed in . % of the procedures. allergic reaction ( . %), hypocalcemic symptom ( . %), and hypotension ( . %) were frequently reported. therapeutic effect was achieved in . % of the patients. our apheresis registry has been well run for years. recent data reflects the increase of abo incompatible transplantation in korea. revision and update of the registry planned this year will help us achieve better understanding on the apheresis status of our region. plasma exchange may not always be necessary in patients with severe hypertriglyceridemia and acute pancreatitis. jan c hofmann* and dobri d kiprov. california pacific medical center background/case studies: hypertriglyceridemic pancreatitis (hp) is characterized by severe hypertriglyceridemia (shtg: triglyceride > - mg/dl), acute pancreatitis (ap), and absence of other causes. hp is a potentially fatal complication of acute pancreatitis with an incidence of $ deaths/ , cases/year. complications of shtg include: abdominal pain (nausea/vomiting), acute pancreatitis, hepatosplenomegaly, eruptive xanthomas, lipemia retinalis, memory loss, dementia, and peripheral neuropathy. we report on the effective use of plasma exchange (pe) to treat patients (pts) with hp refractory to conventional medical therapy (lipid-free diet plus pharmaceutical interventions). study design/method: we reviewed the medical records of pts who were diagnosed with hp from january, through january, , and referred for immunotherapy evaluation. / ( %) pts received conventional therapy (ct) and pe (pe group), and / ( %) pts received ct alone (ct group). mean age was years (range - ), and % were female. baseline mean triglyceride level (normal < mg/dl) for pe group was , mg/dl ( , - , ) versus , mg/dl ( , - , ) for ct group. baseline mean lipase level (normal < u/l) for pe group was , u/l ( - , ) versus u/l ( - , ) for ct group. results/finding: all pts were treated with dietary restriction (lipid-free diet, or nothing by mouth) and aggressive lipid lowering protocols involving - medications. / ( %) of pe group and / ( %) of ct group received insulin therapy to manage symptoms (sxs) of hyperglycemia and/or diabetic ketoacidosis. / ( %) of pe group and / ( %) of ct group received heparin therapy to stimulate lipoprotein lipase release. the pe group underwent an average of . pe treatments (txs) (median of , range - daily txs) using % albumin; / ( %) required ffp to treat dilutional coagulopathy. in most cases, we did not perform pe txs when baseline triglyceride levels were < - mg/dl and lipase < - u/l ( . - . x upper limit of normal). mean triglyceride levels after pe txs were , mg/dl ( - , ) for pe group (mean decrease %); mean triglyceride levels after additional hours of ongoing ct were , mg/dl ( - , ) for ct group (mean decrease %). while the pe group achieved a greater mean decrease in triglyceride levels after pe txs (compared to the ct group after hours of ct), both groups experienced marked improvement in clinical sxs of pancreatitis and hyperglycemia (p> . ). limitations of the retrospective cohort study include lack of long-term follow-up. conclusion: this small study adds to the literature which demonstrates that plasma exchange is very effective in rapidly lowering triglyceride levels in pts with acute pancreatitis and hypertriglyceridemia. it suggests that there may be a threshold (or range) of triglyceride and lipase levels below which conventional therapy may be nearly as effective in achieving clinical resolution of symptoms. randomized controlled trials would further elucidate the appropriate use of adjunctive plasma exchange in the setting of hypertriglyceridemic pancreatitis. role of plasma replacement in therapeutic plasma exchange for hypertriglyceridemia: a single patient study geoffrey wool* and angela treml. university of chicago background/case studies: our apheresis service performs chronic therapeutic plasma exchanges (tpe) for a -year-old man with a chronic history of hypertriglyceridemia > mg/dl, diabetes mellitus type ii, and chronic abdominal pain. his abdominal pain is severe and persistent, but there is not overt evidence of chronic pancreatitis on imaging or fecal elastase testing. targeted sequencing has not revealed a pathogenic mutation to explain the patient's hypertriglyceridemia. hypertriglyceridemic pancreatitis is a category iii indication for tpe by asfa guidelines, in a patient unresponsive to optimal medical management. asfa guidelines for this disorder state that "some have used plasma as it contains lipoprotein lipase and could enhance triglyceride (tg) removal. no direct comparisons of replacement fluids have been reported". there are three apheresis physicians on our service and use of partial plasma replacement has been variable. we undertook a retrospective study of the efficacy of partial plasma replacement in this patient. study design/method: we have performed tpe on this patient. we performed a chart review to capture replacement fluid use and pre-and post-tg levels, if drawn. tpe was performed using spectra optia (terumo, lakewood, co) exchanging approximately one plasma volume, using entirely % albumin for exchange fluid ( % albumin procedures) or partial plasma replacement ( - units of thawed plasma). twenty-six tpe had pre-and post-procedure tg values available. we determined the percent tg reduction achieved by the tpe. we also determined the daily rate of tg increase until the next tpe appointment (to assess any long-term effects of plasma preventing tg rebound). significance was assessed by student's t-test (one-tailed, heteroscedastic). results/finding: twelve tpe were performed with partial plasma replacement, while were performed with % albumin replacement. table shows that partial plasma replacement was associated with significantly greater % tg reduction. the rate of subsequent daily tg increase was also lower with partial plasma replacement, but this did not meet significance. one mild allergic reaction has occurred during partial plasma replacement which responded quickly to additional iv diphenhydramine. conclusion: we have performed an ad hoc cross-over study on the efficacy of partial plasma replacement in tpe for hypertriglyceridemia. in this patient without lipoprotein lipase mutations, plasma was significantly associated with improved % tg reduction, but not with prevention of post-tpe tg rebound. safety and efficacy of local albumin replacement for therapeutic plasma exchange phandee watanaboonyongcharoen* , , metha apiwattanakul , sompis santipong , jutaluk jaipian , jettawan siriaksorn and ponlapat rojnuckarin . chulalongkorn university, king chulalongkorn memorial hospital, prasat neurological institute background/case studies: therapeutic plasma exchange (tpe) with albumin replacement has been used to treat a variety of diseases. however, there had been rising cost and supply shortage of imported albumin in our country. to solve the problem, our national blood centre had established a plasma fractionation plant to manufacture plasma derivatives including albumin. the objective of the study was to evaluate the safety and efficacy of local albumin as a replacement for tpe. study design/method: all tpes using local albumin as a replacement from two tertiary care hospitals performed from june through february were included. complete blood count and serum calcium were tested before tpe. serum albumin was tested before and after tpe. local albumin is available as a % solution. before using, it was diluted to a % albumin concentration with normal saline. all the patients were hospitalized and received oral calcium before tpe to prevent hypocalcemia. the adverse effects were recorded. results/finding: the total of tpes in patients were included as shown in the table. neurologic disorders were the most common indication for tpe, followed by autoimmune diseases. the median total plasma volume was , (range , - , ) ml. although the corrected calcium level was low (< mg/dl) in . % ( / ) before the procedure, no clinical manifestation of hypocalcemia was detected. adverse effects were observed during the tpe procedure in patients. the first patient had events of mild symptomatic hypotension. he previously took angiotensin converting enzyme inhibitor. the second patient complained nausea after finishing tpe. all reactions were mild. the incidence of adverse effects was . % ( / ). in , the incidence of tpe adverse effects was . % ( / ) when commercial albumin was used. the difference was not statistically different (p . ). median serum albumin levels pre-tpe and post-tpe were . ( . - . ) and . ( . - . ) g/dl. the increase in serum albumin after tpe was statistically significant (p< . ). eighty-two percent of pre-tpe serum albumin levels were lower than . g/dl explaining the rises of albumin after the procedures. we demonstrated that local albumin was safe and effective in maintaining albumin levels in patients undergoing tpes. safety, efficancy and cost-effectiveness of mononuclear cell collections for autologous immunotherapies: experience from a private outpatient collection facility within the eu markus dettke*. akh vienna university hospital, cyto-care.eu background/case studies: within the eu the collection of mononuclear cells (mnc) as starting source for the manufacturing of autologous cell therapies are mainly performed in hospitals or hospital-associated apheresis centers. we report about the challenges to perform the leukapheresis procedure (la) at a private held medical practice, with specific emphases on safety, cell collection efficiency, and cost-effectiveness. study design/method: we reviewed the records of altogether outpatients who underwent a total of la procedure at cyto-care, a private held medical practice/ certified cell collection facility located in vienna, austria. all patients participated in various industry-sponsored clinical p i-iii trials; the study sponsors were responsible for the manufacturing of the active cell product. disease entities were mainly prostatic cancer ( %) and ovarian cancer ( %). based on differences in the study protocols la was performed either one-time ( %), two-times ( %) or three-times ( %), with an interval of at least weeks between repeated collections. results/finding: all patients successfully completed the apheresis course. because of poor venous access, out of patients ( %) required a shortterm femoral catheter insertion. there were no serious side effects in patients who required a femoral catheter, or in patients with repeated la procedures. side effects of the la procedure mainly consisted on mild hypocalcaemia-related symptoms in % of patients. a follow-up survey one week after completion of the la revealed no infectious complications, and no patient required hospitalization. median cell yield collected per single apheresis was . x wbc consisting of . x mnc. mnc cell yields remained stable even in repeated la collections. all cell products were successful transformed into an active cellular product. analysis of the cost structure showed that the total cost of care was % lower in the setting of a private collection center compared to hospital-based apheresis centers. conclusion: leukapheresis performed in a private medical practice/ certified cell collection facility is safe and effective, with low rates of complications and high levels of patient satisfaction. this service model is costeffective and can help to reduce the cost of manufactured goods in the production of innovative cellular products. although typically associated with monoclonal gammopathies (e.g. waldenstrom's macroglobulinemia and multiple myeloma), hvs has rarely been reported in patients with disorders of immune system such as rheumatoid disease, sjogren's syndrome, hiv and igg -related diseases. therapeutic plasma exchange (tpe) is indicated in hvs due to monoclonal gammopathy (asfa category indication). however, there are limited data for the utility of tpe in hvs due to polyclonal gammopathy. study design/methods: a year old female patient with a medical history significant for seropositive erosive rheumatoid arthritis, hypertension, diabetes mellitus, cutaneous lupus and diffuse parenchymal lung disease, presented to our institution with complaints of progressive fatigue, muscle weakness, poor appetite, headache and epistaxis for a few months. fundoscopic examination showed dilated and tortuous vasculature as well as bilateral retinal hemorrhages (mixed flame-shaped and dot-blot patterns). pertinent laboratory findings included a positive anti-nuclear antibody screen with anti-histone antibodies and anti-ro antibodies. serum rheumatoid factor was markedly elevated to , iu/mls (ref. range < ) and anti-cyclic citrulline peptide antibody was elevated to , units (ref. range < ) . serum protein electrophoresis and immunofixation demonstrated a polyclonal hypergammaglobulinemia; protein precipitates were noted at the point of application, suggestive of circulating immune complexes. serum igg, igm and iga were , and mg/dl respectively. a cryoglobulin screen was negative. serum free kappa to lambda ratio was . . peripheral blood flow cytometry did not identify any monoclonal bcell population. plasma viscosity was noted to be . centipoise (cp) at admission (ref. range . - . ). pet-ct imaging was negative. the patient was treated with high dose steroids; a single tpe procedure was performed using the following parameters: volume treated - total plasma volume; replacement fluid - % albumin and normal saline in a : ratio; replacement fluid volume: % of the total volume processed. the procedure was tolerated without complication. results/findings: immediately post-tpe her plasma viscosity level dropped to . cp. serum igg, igm and iga levels decreased to , and mg/dl respectively. her rf had decreased to , iu/ml. the patient reported subjective improvement in strength. she subsequently received two infusions of rituximab separated by two weeks. her plasma viscosity has remained less than cp since tpe. conclusion: polycolonal gammomathy (e.g. secondary to ra) is a rare cause of hvs. tpe can provide transient relief of symptoms in unusual cases of hvs and may facilitate therapy to prevent recurrent hvs episodes. therapeutic plasma exchange in neuromyelitis optica spectrum disorders -experience from tertiary care centre in north india ratti ram sharma*, rekha hans, satya prakash, naveen sankhyan and neelam marwaha. postgraduate institute of medical education and research background/case studies: neuromyelitis optica spectrum disorder (nmosd) is an idiopathic inflammatory demyelinating disorder of central nervous system preferentially involving optic nerve and upper segments of the spinal cord leading to optic neuritis and myelitis. tpe is indicated in acute phase or as a maintenance therapy to treat or prevent relapses in chronic phase. study design/method: to assess the efficacy of plasma exchange in patients of nmosd not responding to high dose intravenous steroids. we did a retrospective review of tpe records for patients with nmosd over a period of three years (jan -dec ). tpe was done using, cobe spectra (terumo bct, lakewood co. usa), replacing one to one and half patient plasma volume with % human serum albumin or fresh frozen plasma on alternate days. the improvement in clinical signs and symptoms was recorded after each tpe procedure and at the end of the therapy. adverse reactions if any were also recorded results/finding: eleven patients of nmosd between to years age (m: f; : ) underwent tpe procedures with an average of . per patient. all the patients were on high dose immunosuppressant therapy without much clinical improvement. three ( %) patients had only visual symptoms, ( %) had both visual as well as muscular symptoms whereas ( %) patients had muscular symptoms only. three ( %) out of the seven tested, were positive for aqp -igg. all the patients showed significant improvement in their visual symptoms post exchange, from no vision/light perception to finger counting in two patients, recovery of colour vision and diplopia in six patients. post exchange recovery in the muscle power was observed in patients with grade- , in patient, and by grade- , in seven. adverse events were observed in % ( / ) of the procedures with allergic reactions to replacement fluid as most common event (n- ) followed by hypotension (n- ). follow up was available in % ( / ) of patients and are doing well on immunosuppressive therapy. one patient died due to respiratory failure after months and another had relapse for which he underwent second tpe cycle and continue to do well. conclusion: tpe is a safe and effective adjunct therapy to high dose immunosuppression in nmosd. trima accel software upgrade from . to . for platelet collections rachel m beck*, kimberly j duffy, sandra bryant, audrey e traun, mary m benike, james r stubbs and justin d kreuter. mayo clinic background/case studies: terumobct released trima accel software version . as an enhancement to allow for the collection of platelets (plt) with platelet additive solution (pas) and provide additional improvements to increase overall reliability. additionally, the manufacturer identified a slower centrifuge speed at low draw flow rates. this software was expected to function similarly to version . . the objective of this retrospective study is to identify any variances with the software upgrade influenced the plt products collection process or products collected. study design/methods: prior to / / , plt collections were performed on nine trima accel machines operating with version . . upgrading and validating all nine machines to version . occurred from / / to / / . the trimas were programmed with the same plt configurations both before and after software update. platelet collection data from version . ( / / to / / ) was compared to version . ( / / to / / ). incomplete collections, runs identified as having possible leukocyte contamination, duration of collection, and plt split rate were evaluated for each time period. generalized estimating equations (gee) were used to assess differences between plt collections with version . and . , adjusting for multiple visits per donor, with significance defined as p-value < . . results/findings: following the upgrade to version . , staff observed a number of changes including an increased centrifuge recovery time on a donor with a low flow and a notable increase in possible leukocyte contamination products. version . of the trima accel showed a statistically significant increase in possible leukocyte contamination from % to % of collections as compared with version . . both the duration of collections and the plt split rate remained constant even with centrifuge speed adjustments in version . . conclusion: due to fda limitations not allowing for the implementation of trima accel pas plts with the currently available pathogen reduction system, the institution decided to implement only the pathogen reduction system at this time. subsequently, the version . software is no longer required. with the noted slight increase in possible leukocyte contamination as well as the lack of enhancements for plt collection, the upgrade to version . currently does not provide added value over version . for plt collection. pulmonary and neurologic symptoms due to leukostasis. therapeutic leukocytaphersis (tl) is used as an adjuvant therapeutic modality in these patients with symptoms suggestive of leukostasis. tl procedures are performed using cell separators where anticoagulated blood is subjected to centrifugal force resulting in separate layers of cells and plasma depending on their density. there are two programs in the cell separator, a mononuclear (mnc)program which has greater centrifuge speed and efficiency for the collection of mncs and a polymorphonuclear (pmn)cell program with lower centrifuge speed for the collection of pmns. hydroxyethyl starch(hes) is preferred for the collections of granulocytes for transfusion from healthy donors. use of hes facilitates the sedimentation of the granulocyte layer and increases the efficiency of collection. though use of hes in tl was not associated with adverse events with its use as a volume expander (pagano) its use in tl varies and no reports are available on the efficiency of leukodepletion using hes for tl. study design/method: we received a request for leukoreduction in yearold lady with chronic myelogenous leukemia (cml) who had a good response to imatinib. she is weeks pregnant with an increased wbc count due to the discontinuation of imatinib. we performed tl with the cobe spectra using a replacement fluid of ml % albumin. wbc counts were monitored pre and post tl in the patient and in the collected product. we modified the collection based on these results using the mnc program with acd-a or the pmn program with acd-a . as leukodepetion was not adequate with these programs we elected to use hes after discussion with the patient and her physician. tl was performed using ml of hes with citrate and the pmn program. wbc pre procedure, immediate post procedure and the product was obtained and the efficiency of leukodepletion with the different programs was calculated. results/finding: the efficiency of % wbc depletion was calculated by product wbc to patient wbc based on blood volume and also pre to post wbc the patient tolerated the procedures well and there were no adverse reactions in the patient and in fetal monitoring during the procedures conclusion: therapeutic leukocytapheresis in cml patients is safe and more effective in reducing the wbc count with the use of ml of hydroxyethyl starch with anticoagulant. post procedure patient wbc counts sometimes may not provide the data on the efficiency of leucodepletion. background/case studies: early recognition of hypertriglyceridemia (htg) in the setting of acute pancreatitis (ap) is critical to initiate effective therapy. the role of plasmapheresis as an early/adjuvant approach in acute htg-induced pancreatitis is controversial. currently, there are no consensus guidelines in optimal therapy and is asfa category iii. reported here is a case where the tg level as well as clinical symptoms improved after one therapeutic plasma exchange (tpe). study design/method: a years old male with history of hypertension, htg, and diabetes mellitus (dm) presented to our emergency department with excruciating abdominal pain. the patient was diagnosed with htg at years old. he was treated initially with diet and lifestyle modification. however, his clinical course has been compromised after developing pancreatitis with acute episodes requiring prolong hospital admission of approximately months each which were successfully treated medically. however, the recurrent episodes resulted in chronic pancreatitis which was complicated with pancreatic pseudocyst and pancreatic insufficiency. since the first episode of pancreatitis, he was then medically managed with fenofibrate, lovaza, lisinopril, levemir and novolog. during evaluation on current admission, he was found to have a tg level of mg/dl, lipase u/l, glucose mg/dl, bicarbonate mmol/l, anion gap . ct findings were consistent with ap without evidence of necrosis and stable pancreatic pseudocyst. medical therapy was started with omega fatty acid, fibrate, statin, hydration as well as pain control. statin therapy was suspended on day of hospitalization, because he was noted to have elevated liver function tests (lft) and tpe was requested and started on day after admission. results/finding: the patient tg decreased by % ( mg/dl) with medical therapy, followed by additional % ( mg/dl) after one volume of tpe. his symptoms significantly improved and was discharged with medical treatment on day after admission. compared to previous episodes, his hospital stay was significantly decreased. tg levels remained below mg/dl at days follow up after discharge. conclusion: early tpe may be of value in treating patients with elevated tg associated with recurrent pancreatitis. plasmapheresis might be an effective early adjuvant therapy to mitigate length of hospital stay, improve cost-effectiveness and patient safety. background/case studies: from to , a national blood donor center in southeast asia conducted a program to monitor the ferritin levels of platelet blood donors. the aim of this study was to explore the trend of changes in ferritin. study design/method: in this study, we collected , cases whose ferritin levels have been monitored more than twice with an interval of detection in - days. the collected plasma samples were tested for ferritin by chemiluminescence using a commercial assay. inclusion criteria included apheresis platelet blood donors with over two results of ferritin, and first time ferritin test result was over lg/l. and the upper limit was set to be lg/ l in male and lg/l in female as described in manufactures insert. the impact on ferritin from gender, age, and the blood donation frequency were examined with anova test. the blood donations frequency was categorized into five groups: times, to times, to times, to times and more than times. the high frequency (more than times group) blood donors were analyzed ferritin changes in longitudinal data. results/finding: there were , donors included in the study, of which , were male ( . %) and were female ( . %). the mean ferritin was . lg/l in male ( % ci: . - . lg/l) and . lg/l in female ( % ci: . - . lg/l). the result of anova indicates that the group with the highest frequency (more than times) has the significant lowest ferritin level (p< . ). the average change of ferritin if donation over times would up to . and . lg/l in younger and elder y/o male and and lg/l in female. and then for high frequency (half a year more than times the group of blood donors) for longitudinal analysis and found that the long-term sustained high frequency of blood donation caused a significant decline in ferritin. the average change about ferritin in high frequencies donors (over times in $ days) was reduced from . lg/l in the first period to . lg/l in the third period ( period $ days). along with the more and more period, the decline of ferritin decreased. conclusion: this analysis revealed that frequent apheresis platelet donation would decrease ferritin of donors. but the high frequency of platelet blood donors who continue to donate after a year, the decline of ferritin slowed down. a rare case of blood donation precipitating acute delirium joseph griggs* , mary townsend and lizabeth rosenbaum . university of new mexico hospital, blood systems, inc., blood systems inc. background/case studies: we report a case of whole blood (wb) donation that precipitated a transient agitated delirium. a year-old first time male donor presented to the local blood center, completed the donor health questionnaire, mini-physical exam, and hemoglobin check, and was deemed eligible for blood donation. approximately minutes after an uncomplicated wb donation, the donor had an observed, brief loss of consciousness in the post-donation area. no fall or injury was seen. shortly after regaining consciousness, the donor became agitated, confused, and was not oriented to month or year; was unable to remember the names of friends and family members; was unable to read an analog clock; and had difficulty with word finding. the donor was transported to the local university hospital where he was noted to be combatively delirious and had altered mental status; he had to be forcibly restrained. he ultimately was sedated and intubated, and transferred to the intensive care unit. study design/method: an extensive laboratory investigation was performed including standard hematologic and chemistry panels; serologic and pcr-based studies for multiple organisms including west nile, herpes, hiv, varicella zoster, and syphilis; aerobic and anaerobic blood cultures; and a urine drug screen for multiple drugs of abuse. radiographic imaging was performed including a chest x-ray, and a ct and mri of head and spine. in addition, an eeg was performed. the inpatient neurology and psychiatry services were consulted for this patient. results/finding: after the sedation was discontinued, the patient was successfully extubated and rapidly improved. he completely returned to baseline within hours of onset of the event. laboratory investigation revealed no signs of infectious organisms or evidence of drugs of abuse. radiographic imaging and eeg studies showed no abnormalities. in addition, infectious disease marker testing performed by the blood center laboratory was negative. investigation revealed that the donor was experiencing high levels of stress at school, had an aversion to the sight of blood, and was coerced into donating by his girlfriend and peers. a week following hospital discharge, the blood center medical director contacted the donor by phone; the donor had resumed his normal routine and was attending his graduate level classes. conclusion: to our knowledge, this is the first report of blood donation precipitating a transient acute delirium. at the time of donation, the health status of all potential blood donors is assessed to help ensure the safety of the donor and the recipient. the health questionnaire, physical exam, vital signs, hemoglobin level, and infectious disease testing help to identify overt signs of medical illness that may disqualify a donor. however, routine donor screening does not explicitly evaluate mental health issues, both diagnosed and undiagnosed. although exceedingly rare, this case highlights the limitations of donor screening to identify donors who may be at risk for mental health adverse reactions when donating blood. a targeted approach to increasing the african american blood donor pool arnethea sutton* , william korzun , teresa nadder , susan roseff and elizabeth ripley . virginia commonwealth university, virginia commonwealth university medical center background/case studies: a continuous need for blood products for those who require frequent transfusions, such as individuals with sickle cell disease who could benefit from products collected from african american donors, warrants the need for targeted interventions to increase blood donations from underrepresented populations. one population in particular, african americans, only account for % of blood donors in the united states. literature indicates numerous reasons why this population is underrepresented amongst donors, including fear, lack of knowledge about the blood donation, and specific to this population, lack of trust in the medical community. study design/method: african americans in richmond and norfolk, virginia were recruited through churches and local universities. the study's aims were to develop, implement, and assess a targeted educational approach incorporating the theory of planned behavior and various teaching methods, to develop and implement a survey to evaluate participants' feelings, attitudes, and intent to donate, and to motivate african americans non-donors to attempt to donate blood. participants attended a -hour educational session where they were educated on the importance of red blood cell donations from african americans. participants completed three surveys -one before the session, one directly after the session and one, two months after the session. a two-proportion z-test was used to compare the known proportion of african americans who present to donate in the study areas to those who presented to donate in this study, while regression analysis was used to estimate the relationships among survey variables. results/finding: a total of subjects were included in the data analysis. sixteen percent of the study participants presented to donate as a result of attending the educational session. this resulted in a statistically significantly higher proportion of african americans presenting to donate than the current proportion in the areas of the state where this study was conducted. results from the first two surveys indicated that subjective norm and attitude were significant predictors of one's intent to donate blood, while perceived behavioral control was not a factor. the educational session increased survey scores related to intent to donate in comparison to scores obtained prior to the session. conclusion: this study shows that a targeted educational program can change attitudes toward blood donations in african americans resulting in an increase in new blood donors. additional studies are needed to see if this behavior will continue and whether african americans can influence their community to increase awareness and motivation for life-long blood donation. were from female basic trainees conclusion: the significant increase in hemoglobin deferrals at basic training site a from to could be a result of a change in the blood drive timing of the training schedule of that location. in , basic trainees at site a were scheduled at day of . in january , the blood drive date changed to day of . the extra three days in the basic training atmosphere, and its associated diet changes and increased physical activity may have had an effect on the hemoglobin levels in that population. at basic training site b, the significant increase from to of hemoglobin deferrals can be attributed to a larger male population presenting at this site for basic training. additionally, the percentage of female recruits donating at the blood drives decreased in . these observations support the hypothesis that the increase in hemoglobin deferrals in resulted from the implementation of the male hemoglobin standard change from . to . g/dl at basic training site b. when planning for blood drives at basic training site b, screening of an additional % of recruits must be considered when performing these blood drives, in order to meet the same collection goals set prior the implementation of the change in the male hemoglobin standard. blood donation in the donor with spinal cord injury joan-ramon grífols* , eva alonso , oscar bascuñana , monica romero , teresa vich , elena castaño , laura carbonell , eva palomas , saray almerge , francesc carpio and xavier curia . banc de sang i teixits, institut guttmann background/case studies: donation of blood components (bc) in donors with spinal cord injuries (sci) is poorly studied. paralysis is a state, not a disease, after a reasonable time since its acquisition these people should not be differentiated from the rest of the non-paralytic population in terms of bc donation. the literature reviews of blood donation suitability criteria among these people are scarce and the vegetative lability that they may present depending on the type of their sci it's obvious. in daily practice these potential donors are often rejected for donation with no specific criteria related to their sci. the objectives of this study are to establish the selection criteria for bc donation in people with sci based on medical criteria. to evaluate the rate of adverse donation blood reactions of these donors against a donor control group without sci. study design/method: our organization regularly organizes a donation campaign at a rehabilitation center for patients with sci. in this campaign some donors with sci as donors without (professionals of the center, relatives, etc.) donate blood. from january to december we analyzed the number of donors who came to give blood, the number and reasons for exclusion of those who could not make the donation, whether or not they had sci and number and typology of adverse reactions to the donation detected in both groups. donors with sci higher than t due to the high risk of autonomic dysreflexia were excluded for donation. donors with sci below t and less than one year of evolution were set as temporary exclusion criteria. the presence of neurogenic bladder was not considered a reason for exclusion. results/finding: in the analyzed period, donors came to give blood, of these, ( %) were excluded for donation for various reasons. two of the donors excluded suffered sci higher than t excluding them due their high risk of dysreflexia. another one donor excluded suffered sci lower than t but his hemoglobin levels were lower than our selection criteria. of the donors selected for donation ( . %) had sci lower than t and t . adverse reactions to donation ( . %) were recorded in our haemovigilance program, none of them in donors with sci. conclusion: according to our experience donors with sci lower than t have not had any type of adverse reaction to the blood donation. there should be selection / exclusion criteria based on the donor's paralytic conditions. the vagal syndrome that could appear as a complication to the donation in these sci donors should be approached differently to the usual protocols that we use. blood donor center's experience with changing from manual to automated blood pressures kimberly j duffy*, sandra bryant, audrey e traun, kristine i borth, mary m benike, james r stubbs and justin d kreuter. mayo clinic background/case studies: blood pressure (bp) is important for determining the health and suitability of blood donors. the manual method of reading bp can result in variability due to minor variances in the way staff perform the manual procedure. automated bp devices are able to reduce the variability in bp determination. in december of , automated bp devices were validated and replaced the manual bp method in our blood donor center. the objective of this retrospective study is to determine if the change from a manual to an automated bp process has impacted the average systolic and diastolic pressures and, additionally, if a differences in the deferral and reaction rate can be observed. study design/methods: data for the manual bp process was accumulated for an month period from january to november . the same information was assembled for the automated bp process for the month period of january to november . the automated bp process implemented in mid-december ; so the december data for both and has been excluded from the study. bp, bp deferrals, reactions, donor weights and demographics were evaluated for each time period. a donor may be included multiple times in each year and could be in both sets of data. generalized estimating equations were used to assess differences between automated and manual bp with significance defined as p < . . results/findings: significantly more people were deferred using automated bp compared to manual bp readings (p . ). both systolic and diastolic bp measured significantly higher by automated bp method than by manual method. although donors in the automated bp group experienced fewer reactions than those in the manual bp group, the reduction was not large enough to reach statistical significance. even after adjusting for gender, weight and age at donation, bp deferrals, systolic and diastolic bps all remained significantly higher (all p < . ) with the automated bp while and reactions remained non-significantly lower (p . ). conclusion: automated bp devices have improved convenience for both staff and donors. with a statistically significant increase in deferrals and marginal decrease in reactions, the use of automated bp devices may play a minor role in the safety of blood donors. for the purpose of this study, only the hemoglobin values that were below . g/dl will be compared as a surrogate for deferral. to adjust for multiple visits per donor, generalized estimating equations were used to assess significance between lancet a and lancet b, using the appropriate distribution for the data type, defining statistical significance as p-value < . . results/findings: the average hgb was slightly lower with lancet b but there was a larger change with the number of donors under . . statistically more visits with hgb less than . g/dl used lancet b than lancet a. additionally, fewer first time donors were seen during the lancet b time than during the lancet a time. after adjusting for the effects of both gender and first-time donation by using logistic regression, the risk of hgb under . was . % higher with lancet b than with lancet a. conclusion: donor's hgb was slightly lower with lancet b than lancet a, but not clinically different. slightly more lancet bs were used per visit than lancet as. in addition, more hgb deferrals were obtained using lancet b than lancet a. even after adjusting for the effects of gender and repeat donors, we saw more potential deferrals with lancet b than lancet a. the slight difference in the gauge of the lancet may have some association to free-flowing amount of blood and may affect hgb levels. prior to implementing materials at a lower cost, an evaluation of downstream consequences would be recommended. blood donors' acceptance and response towards implementation of automatic appointment booking yi lin ang*, ching lian toh and william choon hong sim. health science authority background/case studies: with surges in demand for blood due to an aging population and more hospitals being built, it is becoming increasingly important to be able to ensure that donors return on a regular basis to improve blood supply and blood stock management. disliking the obligation imposed by appointments, singaporean donors generally prefer "walk-ins" as opposed to appointment bookings. blood services group (bsg) singapore, has made a move to change donors' mindset by introducing automatic appointment scheduling. this paper aims to study donors' level of acceptance towards this initiative. study design/method: to determine the donors' acceptance rate, data was collected from january to march . after completing their donation, donors were automatically given the next earliest eligible date for their next donation. those who do not wish to accept the recommended appointment can either decline this arrangement or log into the blood bank's donor appointment booking system (donor-care) to make changes to the appointment offered. a reminder will be sent to their phone via sms and/or email to their account three days before the appointment date. data was collected from donor-care and was used to measure the number of appointments made and declined over the three months period. donors who declined appointment scheduling were verbally interviewed for their reasons. results/finding: a total of donors who has donated blood in the blood bank's main branch were used as the baseline for this study. % of donors (n ) accepted automatic appointment booking, whereas some donors (n ) were not comfortable with it. % of those who declined still preferred walk-ins (n ) based on their own time schedule, the rest decided that variable situations (n ), donation frequency (n ) and choice of preferred donation locations (n ) were reasons for declining automatic appointment booking. prior implementation of appointment booking at other blood bank branches showed that donors who booked appointment through donor-care was %. a comparison was made and found that this study shown a significant increase of acceptance rate by %. conclusion: generally, the results were positive and the automatic appointment booking system enabled bsg to predict donor attendance, ensure better manpower management to reduce donor turnaround time and thus hopefully improve donor retention. bsg is still monitoring this automatic appointment system and future study are still required to determine the effectiveness of automatic appointment booking, donor return and retention rate. currently bsg has collection centers, each managing its own appointment system. the eventual aim is to be able to have a centralized appointment booking system whereby donors can book appointments and still be able to donate at any collection site. ) , . . poisson distribution, normal distribution, logistic distribution, lognormal distribution a transfusion (p> . ) in donor and reference populations except in younger ( - yrs) male donors (p< . ; donor . %, reference . %). mean donor sbp, dbp, and pulse were . mmhg, . . mmhg, and . . bpm, respectively. screening blood pressure levels consistent with hypertension ( . % male; . % female) in the - year donor group, significantly (p< . ) higher than the reference population ( . % male; . % female). no differences were observed in the - year groups. conclusion: normal source donor demographic and physiologic characteristics often paralleled those of the reference usa populations. however there were differences including lower cholesterol levels and a higher rate of high blood pressure in younger donors and higher weights in - year old females. developing blood donor educational materials gay wehrli* , susan rossmann , louis m. katz and dan a waxman . university of virginia health system, gulf coast regional blood center -sugar land, americas blood centers, indiana blood center background/case studies: donors must have sufficient information to make a decision, time to consider options before making a decision and an opportunity to make a choice of whether to proceed with or decline donating. donor education (de) materials must address mandates set forth by regulatory agencies. these materials must be accessible and understandable by the general population. the goal of this non-experimental, qualitative design study was to evaluate knowledge acquired through standardized de materials. this study was irb approved as an exempt protocol. study design/method: we developed a de document written at an th grade comprehension level. a convenience sample of volunteers was identified for this two-part study. a focus group (fg) incorporated a pre-and post-quiz for knowledge acquisition from reading the four-page de document. the quiz was followed by a group discussion for feedback. the preand post-quiz contained the same multiple choice questions with single best answers including the option to answer, "i don't know." the de document was revised based upon the fg feedback and quiz results. the revised, . page, de document was then tested using the same pre-and post-quiz during individual interviews (ii). results/finding: demographics and quiz results are summarized in table . results from the fg and ii revealed a lack of knowledge in four areas: a donor might be asked not to donate at any time during the donation process, the need for photo identification to donate, iron helps increase a low red blood cell level, and not to donate for the sole purpose to obtain hiv testing. post-quizzes from the ii group revealed an improvement in knowledge acquisition for all four areas. feedback from both groups reiterated that the document was too long. conclusion: developing de materials requires a complicated balance of providing critical information, concisely and at an appropriate comprehension level ( th grade). testing de materials is an essential step in the development process to ensure the intended knowledge is acquired by the end user population. the next steps for this group will be to pilot the further revised, two-page de document at donation sites. effect analysis of the 'rh(-) blood supply program' establishment hyesung han*, deokja oh, buja hur and chulyong kim. korean red cross blood services background/case studies: the rh(-) blood supply program was developed in for the purpose of prompt and stable blood supply. based on the computerized system, the program operates the emergency contact/ communication. this program has major functions such as the request of the emergency blood, the recruitment and management of the rh(-) blood donors for the emergency blood donation, real-time blood supply status monitoring program and statistics program. the aim of the research is to validate the effect of rh(-) blood supply program operations and the responsiveness of the emergency blood supply under the rh(-) blood supply program. study design/method: researchers investigated the database from to after the rh(-) blood supply program was developed. investigators analyzed and compared the recruitment and blood donation of the rh(-) blood donors for the emergency blood donation and securing the blood supply upon request. results/finding: the data shows that the number of voluntary blood donors who pledge to give blood for the emergency blood donation has increased from . % to . % in and , respectively. also, the actual participation rate of rh(-) blood donations among the group who pledge to give blood for the emergency blood donation has increased from . % in to % in . moreover, the data has indicated that the blood supply has fully met the demand for the emergency blood request. conclusion: the result showed that the rh(-) blood supply program was effective for the recruitment/management of the rh(-) blood donors for the emergency blood donation. this system contributes to recruiting and managing rh(-) blood donors who pledge to donate blood and securing rh(-) blood in emergency situation . the institution that needs to meet the demand of rare blood type could possibly use the rh(-) blood supply program which leads to securing special type blood. hanwei chen*. wuhan blood center background/case studies: in china, volunteer blood donors can donate platelets by apheresis (ap) up to times per year. however, the awareness and knowledge of ap donation is much lower than whole blood donation among the chinese population. there are approximately . million doses of ap transfused within . billion people each year in china; it is one challenge to recruit new ap donors and retention them as frequency ap donors in china. study design/method: one stratified recruitment and retention strategy established and applicate at wuhan blood center since . firstly, "one-to-one" telephoning model for whole blood donors instead to donate platelet; secondly, group message for permanent ap donors and had not donated with an interval of more than days in low inventory. thirdly, specific recruiter telephone for those ap donors who had donated aps for more than times and had not donated for more than days or less than times with an interval of more than days from the last donation; the last one is preparing one letter of thanks for those ap donors who gave more than times annually which advise them to voluntarily come to the blood center for ap donation when they were available. results/finding: over the past decade, the overall donation time of ap donors increased by . times from to and the doses of ap increased by . times from to within years. the aps collected fulfilled the clinical needs. according to the donation frequency, ap donors were divided into groups: those who donated ap once, those who donated - times, - times, - times, and those who donated more than times, respectively. it was found that the number of permanent ap donors who donated ap more than times was only ( . %), but they denoted a total of doses of ap ( . %) from to . conclusion: aps increased at a rapid and steady pace in wuhan blood center from to , which not only met the clinical needs but also were supplied to other region outside wuhan. and in addition, the permanent ap donors who gained more attention donated the greatest percentage of platelets. in conclusion, stratified recruitment is one effective approaches to meet clinical needs for platelets and worth to popularize to other region. years were evaluated at sites on consecutive donations for finger stick (fs) hemoglobin (hb) per site policy. venous (ven) and capillary (cap) zpp and ven ferritin (fer) were performed per manufacturers' direction. donors were assessed for subclinical iron deficiency using ranges (fer < ng/ml and zpp levels > umol/mol heme) at hb levels. participants completed an online survey between donations to collect data on symptoms of anemia. univariate linear regression analysis was used to determine relationship between tests. results/finding: subclinical iron deficiency was present among first-time and repeat blood donors at all hb levels with both genders and all age groups. (table) there was a highly significant correlation between fs zpp and ven zpp . % (r . ) at first and . % (r . ) at second donations. at first donation when compared to fs hb, only . % (r . ) of variation could be explained by variation in fs zpp, . % (r . ) by ven zpp and . % (r . ) by ven fer. at second donation, when compared to fs hb, only % (r . ) of variation could be explained by variation in fs zpp, . % (r . ) by ven zpp and . % (r . ) by ven fer. for each donation, variation among tests (fs hb, ven fer, ven zpp and fs zpp) was significant (p< . ) suggesting strong evidence against correlation. % ( ) responded to the survey of which % ( ) reported not feeling well after donation. it should be noted that noted that % ( ) female study participants reported feeling unwell after the first donation and had ferritin levels below ng/ml but the zpp levels were less than umol/mol heme. of the % ( ) male participants that reported not feeling well none had ferritin levels below ng/ml nor ven or fs zpp levels above umol/mol heme. conclusion: subclinical iron deficiency was present at all hemoglobin levels. there was insufficient correlation with fs hb and ven fer to support use of fs or ven zpp analysis as measurement of iron stores for blood donors. symptoms reported by study participants were not consistent with laboratory results. the minimum male hb was raised from . to . gm/dl. fda imposed specific vs ranges for acceptable pulse (p) and blood pressure (bp), removing center-by-center discretion. a survey of members of america's blood centers (abc) was performed to assess the impact on donor deferrals resulting from these changes. study design/method: online survey software (surveygizmo, boulder, co) was used to solicit collections and deferral information from blood centers over two intervals, july-dec. and july-dec. (i.e., before and after the implementation deadline for the final rule respectively). information on deferral at presentations for whole blood (wb) donations and apheresis platelet (ap) donations was requested for hb thresholds and vs. the information was stratified by gender (male m, female f), and abo type. statistical analysis included t-tests for numerical and chi-square for categorical data (minitab . , chicago il). p <. was considered significant. results/findings: data were provided by of centers invited, representing , , and , , wb donations and , and , ap donations in aggregate during the two intervals respectively. gender and abo distributions appeared representative of the us donor base. among m wb donors the rate of deferral rose from . % to . % in the two intervals among aggregated donation attempts (p<. ), and for m ap from . to . % (p<. ). the mean "by center" deferral rates (table) were similar to that and significant (p<. ). mean by center hb deferral rates among f donations during the two intervals were . and . % (p . ) for wb, . and . % (p . ) for ap, respectively, absent any change in their acceptable hb thresholds. data on vs deferrals were much sparser. for p deferrals, only centers could provide specific high vs. low vs. irregular pulse deferrals; provided only a summary (i.e total pulse deferrals), and could provide none. for bp, provided detail (high vs. low), summary and none. p deferrals increased in the successive intervals among f wb donors from a center mean of . to . % (p . ) and for m wb donors from . to . % (p . ). where details were available, high and irregular pulses were responsible for most of the changes for both genders. bp deferrals were not significantly increased among wb donors, regardless of gender. the data sets and deferral rates re: vs in ap donors were quite small, possibly reflecting culling during their prior donation experience. conclusion: substantial additional donor deferrals attended the increased hb thresholds for m in the final rule, for both wb and ap. changes were more modest among female donors, consistent with the absence of changes in allowable hb levels. modest but significant changes attended more stringent requirements for vs, though data limitations restrict this aspect of the analysis. background/case studies: diabetes mellitus is reaching potentially epidemic proportions in india. given the disease is now highly visible across all sections of society within india, there is now the demand for screening of diabetes and urgent research and intervention -at regional and national levels -to try to mitigate the potentially catastrophic increase in diabetes that is predicted for the upcoming years. due to its ease of use, several studies have found that hba c testing can identify patients in the community who might otherwise go undiagnosed. we took an initiative to find out the incidence of diabetes by random blood sugar (rbs) measurement among indian blood donors and measure the hba c levels among those with rbs > mg/dl study design/methods: a prospective study was done at department of transfusion medicine and department of biochemistry from st march to st march . total of , blood donors were tested for rbs. those with rbs > mg/dl were further tested for hba c by gold standard hplc method using variant ii biorad. blood donors with > mg/dl rbs and hba c > . % were advised to consult a physician for further evaluation. results/findings: of the , donors tested, ( . %) donors showed a rbs of > mg/dl. forty two ( . %) were males and ( . %) females with a mean age of . years ( - years). of these, ( . %) were known case of type-ii diabetes mellitus (dm) on oral medications and were excluded. of the remaining , ( . %) of them had a family history of dm. of these donors, donors did not give a consent for testing for hba c. among the donors tested for hba c levels, ( . %) had hba c > . %. all the donors were counselled and referred to a physician for further management. the overall incidence of donors having dm in the population is . % ( of donors). conclusion: screening for blood glucose level by targeting the blood donors can go a long way in curbing the diabetes burden on the society. incidence of low ferritin levels in regular male blood donors with acceptable hemoglobin levels in singapore ramir alcantara* , hwee huang tan and ai leen ang . health sciences authority blood services group, health sciences authority, blood services group background/case studies: iron deficiency is a known complication of regular blood donation. in order to protect the donor's health and prevent iron deficiency, aabb increased the minimum acceptable hemoglobin level for male whole blood and apheresis donors from . to . g/dl last may . the current minimum acceptable hemoglobin for male donors in singapore is . g/dl. the aim of the study is to determine the incidence of low ferritin levels in regular whole blood and apheresis male blood donors with acceptable borderline hemoglobin levels ( . - . ) and in donors with hemoglobin g/dl and above. study design/method: during a month period, serum ferritin testing was performed on regular male whole blood and regular male apheresis donors who made at least donations in the last two years with an acceptable hemoglobin level. the donors were divided into groups according to donation type and hemoglobin range; group a (whole blood with hemoglobin . - . ) group b (whole blood with hemoglobin ! , group c (apheresis with hemoglobin . - . ) and group d (apheresis with hemoglobin ! ). the serum ferritin levels of the four donor groups were compared and analyzed. a ferritin level below ug/l is considered low and levels below < ug/l are considered having absent iron stores. results/findings: . % of donors in the study have ferritin levels below ug/l. there were more donors with low ferritin in group a compared to group b, % and % respectively (p< . ). in apheresis donors, low ferritin rates were higher in group c donors compared with group d, % and % respectively (p . ). ferritin results for the groups can be seen in table . conclusion: more than half of the donors in the study have low ferritin and of the donors with low ferritin, more than half or . % have absent iron stores. donors with low ferritin were immediately informed of their result, given iron supplements and advised to come back for donation after months or more. since donor health and safety is of paramount importance, measures to limit and prevent iron deficiency in blood donors must be implemented. due to the high incidence of low ferritin levels in whole blood and apheresis donors with hemoglobin . - . g/dl, it is recommended that the minimum hemoglobin level cut off for male blood donors in singapore be increased to . g/dl. other measures to be implemented includes better donor education on the risk of iron deficiency and the need for iron supplementation using our website and social media. background/case studies: safe blood is a crucial and irreplaceable component in the medical management of many diseases. the voluntary nonremunerated blood donation is the ideal sources of quality blood, which forms less than % of the demand of the blood in pakistan. motivation among the youth, particularly students, is essential to make voluntary blood movement more successful. to assess the knowledge, attitude and practice regarding the voluntary blood donation among the young student population of karachi so that an effective approach can be made regarding motivation enrolment of voluntary non remunerated blood donors in future in pakistan study design/method: a cross sectional prospective study was conducted among students from different universities and colleges of karachi. a well-structured and pre-tested questionnaire, in english, was used to access the knowledge, attitudes and practices about voluntary blood donation. a scoring mechanism was used to understand overall knowledge level. obtained data was analyzed. results/finding: the sample population consisted of % male and % female students in the age group of - years. only % of the students have heard about voluntary blood donation and % of the students have given blood once in their lifetime and among them % are blood donors at the moment. % of the participants believed that there is a specific reason why they don't donate blood and % believed that there is a risk involved for the donors, when donating blood. % students wanted to promote voluntary blood donation. fear and lack of awareness on blood donation are the reasons for not donating blood. students gather information about voluntary blood donation from several sources mostly schools, colleges, family and friends. ( ); miscellaneous effects were reported in courses. side effects led to interruption of supplementation in instances. ferritin levels (mgt sd) at entry into the program and at the last visit were . and . . mg/l in participants, vs . . and . . mg/l in controls. the positive impact of iron supplementation on ferritin levels was observed only in those who took ! % of the tablets. ferritin levels< mg/l were found in , % of participants and . % of controls. deferral for low hemoglobin was below % in both groups. conclusion: an iron supplementation program in a drbcd program is feasible.however, when taking into account acceptance to participate and compliance with supplementation, only % of donors obtain full benefit from such a program. using an iron preparation which is better tolerated may increase compliance. background/case studies: hereditary hemochromatosis (hh) patients are permitted to donate blood for the allogeneic blood supply as long as they are eligible for donation under cfr . and the collection is a physician-ordered therapeutic phlebotomy. blood collections establishments do not need an exception or alternative under § . to make a collection under this provision if the requirements set forth in § . (a)( ) are met. the objective is to describe current hh donors and long-term contributions of to our hospital-based donor center and hospital blood supply. study design/method: in , an irb protocol was approved for the enrollment and therapeutic phlebotomy of hh patients/subjects. this required filing an fda variance to permit hh donor blood for use in our allogeneic supply without disease labeling. the frequency of therapeutic bleeds are guided by routine clinical assessment, mcv/hemoglobin, serum ferritin, and transferrin % saturation monitoring. serum ferritin levels of - ng/ ml are targeted for maintenance phlebotomy. operationally, a custom, computerized database application is employed to ease phlebotomy management. results/finding: since inception, the cumulative number of hh subjects enrolled in the hemochromatosis protocol reached , of whom ( %) are c y homozygotes. without active recruitment, accrual rate is about per quarter, with % of subjects qualifying as allogeneic donors. the mean current age is . years, % male, % caucasian. the majority of hh donors ( of an active cohort of ) are in the maintenance phase of therapy with an average of . donations/year and a % deferral rate. over the last years, hh donors contributed approximately - % of the hospital's allogeneic blood supply, averaging whole blood units for transfusion per year. moreover, hh donor's whole blood (wb) donations provided - % of blood for in vitro research at our institution with an average of wb research donations/year. there have been no hh donor-derived transfusion-transmitted infections over years. since / / , with an increase in male hgb deferral threshold to g/dl, there has been only hh male deferral from blood donation. conclusion: a simple, safe system for donor evaluation, phlebotomy management, and transfusion of blood drawn from hh subjects was established. blood donated by hh donors remains an important resource at our hospital. hh donors benefit from careful medical follow-up of their iron status. this mutually beneficial relationship is feasible and sustainable. testing for accuracy of non-invasive blood hemoglobin methodology in a blood donor setting michele walker*, sharon garcia and mythili ram. gulf coast regional blood center background/case studies: the objective of the study was to assess the accuracy of hemoglobin (hb) levels measured on the orsense nbm- non-invasive occlusion spectroscopy device by comparing them to hb levels measured on venous samples with a laboratory hematology analyzer. in addition, the study examined operator ease of use and donor satisfaction with a finger stick-free method. study design/method: study procedures and protocol, including acceptance criteria, were defined in conjunction with the device manufacturer to determine the standard deviation (sd) of the difference between the nbm- non-invasive sample results and the sysmex hematology analyzer venous sample results. staff were provided training on the use of the nbm- non-invasive occlusion spectroscopy device. over a span of days, eligible blood donors, both male and female, were first screened by the nbm- non-invasive occlusion spectroscopy device followed by performance testing utilizing a capillary blood screening method. a venous sample was collected from each of the blood donors for the performance of hb measurement on the sysmex hematology analyzer within - hours of collecting the venous samples. results/finding: the sd of the difference between the nbm- non-invasive sample results and the sysmex hematology analyzer venous sample results was not to exceed . g/dl. the hb measurements obtained from the nbm- and the sysmex hematology analyzer were analyzed using the statistical software minitab and the sd of the difference was reported to be . g/dl. the precision of the nbm- yielded a co-efficient of variation of . g/dl and a standard deviation of . g/dl. conclusion: the operators found the nbm- easy to install, maintain, and operate with minimal training. the nbm- non-invasive occlusion spectroscopy technology showed accurate performance compared with the venous sample results. it was comparable to the capillary finger stick method and deemed suitable for screening donors. donors were satisfied with the process and appreciated the safe, painless methodology. ronel swanevelder , ravi reddy , dhuly chowdhury , don brambilla and edward l. murphy* . sanbs, rti international, ucsf/bsri background/case studies: to maintain an adequate blood supply, south african blood centers need to collect more blood from their majority black african population. success in recruiting first-time black blood donors has been tempered by lower suboptimal return rates. study design/method: we performed a prospective cohort study of firsttime, black blood donors donating during a four-month period in and followed them for one year. within days post donation, a questionnaire including questions on blood donation motivators and deterrents was administered by telephone. questions used -point likert scales to assess agreement with statements relating to domains of altruism, collectivism, selfesteem and marketing derived from local focus groups (muthivhi et al. ) . linking questionnaires to a blood donation database allowed logistic regression analysis to predict return for a second donation within one year. results/finding: we included , first-time black donors with median age and female predominance ( %). within one year, , donors ( %) attempted at least one additional donation. when likert scales were analyzed as an ordinal variable ( strongly agree to strongly disagree), donor return was associated with the following motivators "blood donation is an easy way to make a difference" (odds ratio for each likert increment (or) . , % ci . - . ), "i donated in response to adverts/campaigns on the radio, tv or newspapers" (or . , % ci . - . ). responses to altruism-associated statements were not associated with return. among deterrents, donors were less likely to donate if they agreed with the statement "i am afraid of the sight of blood" (or . , % ci . - . ) and "i wasn't treated well by the <blood center> staff" (or . , % ci . - . ). surprisingly, donors were more likely to return if they agreed with the statement "i was afraid of finding out about my hiv status" (or . , % ci . - . ). a secondary analysis treating the likert scales as -level categorical variables revealed generally similar results, with the additional finding that donors who disagreed with the statements "if i give blood then blood will be available when i need it" and "i don't know where the nearest blood collection point is" were more likely to return. conclusion: this novel design allowed us to study the link between donation motivators and deterrents and actual rather than intended return for donation. it is interesting that self-esteem and marketing predicted return better than altruism. fear and poor customer experience are recognized deterrents which could be addressed. we plan to use these data to construct black donor recruitment interventions which may be tested using randomized trial designs. willingness to donate blood during the summer christopher d bernard , ramya ghantasala , obhijit d hazarika , nicole leonard , cori a polonski , zachary b wunrow , michelle heleba , jan k carney and mark k fung* . university of vermont larner college of medicine, american red cross blood services background/case studies: each year donation rates fall in the summer months straining blood banks' capacities to meet local demands. in hopes of identifying factors to increase summer donations, our study investigated donor reported barriers which influence summer donations habits. study design/method: an anonymous question survey investigating various donation factors was administered across multiple blood donor centers in a state-wide region. questions addressed donor demographics, frequency of blood donation, preference in appointment making modalities including smartphone app use, summer travel habits, willingness to donate during vacation, and factors that deter donors from donating on vacation. results/finding: a total of surveys were received. survey respondents across multiple demographic groups cited similar barriers to summer donation, namely "too busy" ( . %) and "traveling is a time for me to relax." ( . %). of the respondents who travel in the summer, very few reported donating while traveling ( . %). summer donation rates between summertime travelers ( . %) and non-travelers ( . %) were essentially equivalent. the most preferred methods of scheduling appointments were via the regional blood donor center website ( . %) and phone ( . %). willingness to use a regional blood donation smartphone app was highest among respondents ages of to ( - %) and lowest among ages and older ( - %). of respondents with no prior knowledge of summer seasonal shortages ( %), / rds indicated newfound motivation to donate. background/case studies: viral infections (adenovirus, ebv, cmv, bk, hhv , and rsv etc.) have been implicated as major contributors to posttransplant morbidity and mortality in hematopoietic stem cell transplantation (hsct) from unrelated donors. investigators have shown that in-vitro expanded virus specific cytotoxic t lymphocytes (ctls) generated from donors with specificity for one or more viruses are safe and effectively treat viral infections in the hsct setting in recent clinical trials. present clinical trials have shown that ctls can be rapidly produced by a single stimulation of donor peripheral blood mononuclear cells (pbmcs) with a peptide-mixture spanning the target antigens in the presence of potent prosurvival cytokines interleukin- (il- ) and il . others have used banked third party epstein barr virus (ebv)-specific ctls generated from third party ebv-seropositive blood donors with encouraging results. study design/methods: eligible and consented blood donors were tested for cmv antibodies by serology. cmv-seropositive whole blood (wb) units underwent buffy coats processing from non-leucocyte reduced wb units collected in fenwal triple blood-packs tm that underwent hard spins at rpm for minutes with separation after each spin on a compomatev r g . plasma and buffy coat was separated from red cells after the first spin. the second spin lead to the separation of the buffy coat from plasma. the buffy coats were submitted to the gmp stem cell lab for processing of cytomegalovirus-specific ctls. hla typing at high resolution for hla-a/-b/-drb loci was obtained for all donors. results/findings: forty five eligible healthy blood volunteers ( m [ %]: [ %] f); median age years (range - ) donated a unit ( ml) blood from which buffy coats (average volume ml) were processed. the buffy coat process was previously validated on wb units. the mononuclear cells (lymphocytes and monocytes) recovered from the buffy coats are listed in figures and . all of the buffy coats received by the gmp stem cell lab were adequate in cell numbers to be processed. the processing of buffy coats from whole blood is a viable option for the concentration of pbmcs specifically for production of viral specific ctls as third party off the shelf products as well as use in other research projects that require pbmcs from healthy adults. background/case studies: the goal of this presentation is to describe the journey and challenges towards tjc, patient blood management (pbm) certification. transfusion-related health risks and increasing economic pressures have driven hospitals to recognize evidence-based blood management as an important cost-saving strategy. providence holy cross medical center (phcmc), as the providence california region alpha site, has embarked on this journey. our goals are pbm certification and reduction of the number of unnecessary transfusions by % within months of the program launch while improving patient outcomes. this paper will discuss our journey toward certification and the various hurdles being overcome. study design/method: tjc, aabb, and the society for the advancement of blood management have served as our primary resources for identifying current evidence-based transfusion practices and management methods. we needed to identify our organizational gaps in data gathering and analysis. then we could determine baseline performance and set improvement targets. from our internal assessment, we learned we had to start from scratch as we had no easily accessible data metrics and gaps in education to our staff. we took the following steps to develop our pbm program: formed an interdisciplinary pbm team consisting of physicians, nurses, blood bank staff, and data analysts constructed a report on rbc transfusions to help identify outliers and opportunities background/case studies: the maximum surgical blood ordering schedule (msbos) is a list of surgical procedures performed at a hospital along with a recommendation for pre-transfusion testing and rbc allocation before each surgery. the extent to which hospitals have an msbos and its design was explored in this survey. study design/methods: the survey was designed, piloted and refined by members of the best collaborative and invited colleagues. it was then encoded in online survey software and the link distributed to best members and colleagues who were encouraged to respond and to further distribute it. the survey was open for days. results/findings: there were completed responses, of which ( %) indicated that their hospital had an msbos and ( %) did not. the majority of hospitals without an msbos were academic centers ( / , %) from oceania ( / , %) or europe ( / , %), had between - beds ( / , %); the majority of these hospitals transfused between , - , rbcs ( / , %) per year. / ( %) are going to implement an msbos in . of those with an msbos, the majority / ( %) were from north america. the majority were academic hospitals ( / , %) with - beds ( / , %) that transfused ! , rbc units per year ( / , %) offering a wide range of surgical services. on average there were procedures listed in the msbos'. the msbos recommended no pre-transfusion testing for a mean of % of the procedures listed, a pre-operative type and screen for %, crossmatching rbc units for %, and for % of procedures a different recommendation was made. most ( / , %) of the msbos' were created by a combination of obtaining consensus between the surgical services and blood bank and use of procedure-specific transfusion data; only / ( %) of msbos' were created solely by using procedure-specific data, and most ( / , %) do not use patient-specific data in making a testing recommendation. most msbos' are updated less frequently than annually ( / , %), and the hospital transfusion committee is often ( / , %) involved in updating it. the msbos' are generally available electronically in both the operating rooms and in the blood banks. it was the opinion of the majority of respondents ( %) that the msbos was used regularly by only a limited number of surgeons and anesthesiologists, % of respondents felt that it was regularly used by all surgeons and anesthesiologists; % felt that it was not used at all at their hospital, % did not respond. conclusion: an msbos was available in only about half of the respondent's hospitals and in only the minority of cases was it felt to be regularly used. however, % of the hospitals currently without one indicated that it would be implemented in suggesting that these hospitals perceive the value of having one in place. implementing and following an msbos can be an important step in peri-operative patient blood management and in streamlining the operations of the blood bank vis-a-vis pre-operative testing. blood management -one hospital system experience leana serrano rahman*, mallika gupta, susan solometo, ronald walsh and joan uehlinger. montefiore medical center background/case studies: our system, a pioneer aco, is a -bed tertiary-care referral center dedicated to serving patients from across the new york city area and beyond. the comprising four hospitals see , hospital admissions and nearly , emergency department visits annually. we have active programs in high risk ob, stem cell transplant, solid organ transplant (heart, liver, and kidney), ct surgery, ecmo, oncology and critical care. transfusion medicine plays a key role in the support of these services. blood product spending in was approximately $ . m. in nov. , an interdisciplinary committee was created in an effort to improve patient care (by reducing blood product exposure) and reduce blood product expenditures. the vice president-sponsored multidisciplinary committee was composed of representatives of: surgery, anesthesia, blood bank, pediatrics, perfusion, cardiothoracic surgery, critical care, medicine, and emergency department. study design/method: first important step: "know your numbers"-although the committee had multiple sources of data, there was no "one report" that could display all of the pertinent information. baseline numbers were imperative to the committee's ability to effect change. a home grown one time only report revealed which services and clinicians were the highest volume users. the initial plan was to target their use with education. an initial goal was set to reduce expenditure by $ . m. the journey continued with regular bimonthly meetingsto brainstorm strategies and monitor utilization. utilization was analyzed using a home grown crystal report "transfused patients by location". this report was further compared to utilization patterns ( and ), by "dollars spent" and "total units per patient" by the project manager using excel. key initiatives developed by the committee . development of evidence based transfusion triggers. . education on evidence based transfusion triggers across multiple campuses, specialties and resident programs . clinical information system (cis) "soft stops" when ordering blood products outside guidelines. rbc order set defaulting to " " unit instead of " " units. . updated guidelines posted to easy to find internal intranet spots results/finding: despite higher patient volumes and a more complicated patient mix in , we were still able to reduced blood product expenditures by $ , when compared to . conclusion: in spite of limited resources, the committee was able to effect change by capitalizing on current stakeholders fully supported by leadership and project management. cord blood pathway to reduce iatrogenic blood loss in neonatal intensive care patients tracy shachner* , anna w rains and christopher t clark . university of tennessee graduate school of medicine, univeristy of tennessee medical center, univeristy of tennessee graduate school of medicine background/case studies: anemia due to iatrogenic blood loss in preterm and low birth weight infants is a major contributory factor leading to red blood cell transfusion in this patient population. methods to reduce phlebotomy for laboratory testing can reduce iatrogenic anemia. at a universitybased teaching hospital, a pathway to collect cord blood samples on all newborn deliveries was established. the cord blood sample is used for initial blood bank laboratory testing on newborn patients transferred to the neonatal intensive care unit (nicu), preventing need for additional blood draw. the blood tubes are saved for week post-delivery, with cost of $ . per delivery tray for sterile tubes. with an initial negative antibody screen on cord blood sample, no additional phlebotomy is required for blood product selection or compatibility testing in this population until four months of age. study design/method: labor and delivery data from our facility in was analyzed, and the gestational age and birth weight of all infants transferred to the nicu was collected. from this data, we were able to calculate the total blood volume of these infants using medcalc system. by using the blood volume values, and assigning a value of . ml as the minimum amount of blood that would be drawn to perform an antibody screen, we calculated the percent of an infant's blood that would have to be drawn if the cord blood pathway was not established. transfusion results/finding: in , there was a total of , infants delivered at our facility. out of all the deliveries, ( %) infants were transferred to the nicu. of those infants, % received at least one red blood cell transfusion and % received at least one platelet transfusion. of the infants transferred to the nicu, ( %) had a percentage of blood volume that would have had to be drawn for blood bank testing greater than or equal to % (which we considered to be significant), had the cord blood pathway not been in effect. the percentage of blood volume preserved in these infants ranged from . % all the way up to . %. in those infants, the birth weight ranged from - grams, and the gestational age ranged from weeks to weeks and days. conclusion: the established cord blood pathway has proven to be a relatively cost-effective method to prevent iatrogenic blood loss secondary to blood bank testing in a population of nicu infants who are most susceptible to iatrogenic anemia. the infants that were most likely to benefit from this policy are premature infants who are low birth weight (less than grams). development of a standardized response team for massive hemorrhage events outside of an operating room setting james burner* , shannon davis , suzan new , vaishali patel and oren guttman . university of texas southwestern medical center, ut southwestern medical center background/case studies: managing a massive transfusion protocol (mtp) in an operating room (or) is a relatively frequent occurrence with team members well trained in their specific roles. however, in the event of mtp activation outside of an or, sufficient and/or appropriately trained individuals may not be present. this can lead to a scene of confusion and chaos with potential for patient harm. study design/method: a failure mode effects analysis was performed to develop a standardized process for managing mtp outside of an or setting. with participation from anesthesia, surgery, transfusion medicine, patient safety and quality and nursing, every step of the hospital's mtp was analyzed for potential errors. the results were used to create a "code hemorrhage" team trained to respond to any massively hemorrhaging non-or patient. results/finding: code hemorrhage represents a multi-system team critical event requiring coordination of different sub-teams (primary resuscitation, surgical/interventional, transfusion services, blood preparation, equipment management, medication management, and lab requisition/monitoring). our code hemorrhage protocol utilizes critical care trained nurses from the hospital's rapid response team who play two key new coordination roles: hemorrhage coordinator and electronic medical record (emr) coordinator. their combined roles serve to reduce the cognitive load of the various teams, prevent duplication of resources/efforts during mtp and enable enhanced closed loop task performance. the hemorrhage coordinator establishes reliable : communication between the primary resuscitation team and transfusion services, and aids in multi-team on-site coordination. the emr coordinator enters all orders into the emr, sends/communicates laboratory results and ensures blood products are available to the resuscitation team. the primary resuscitation team includes a team leader (medical decision making and cardiac life-support management); a proceduralist (establishing venous and/or arterial access), event documenter (real-time documentation of actions, medications, events, etc.), medication manager (registered nurse who prepares and administers medications) and equipment technologist (managing rapid blood product infusion devices). additional secondary roles will also be assigned, such as blood product checker(s) (verifies blood product prior to transfusion) and blood bank runner (courier sent to retrieves blood product shipments). conclusion: the code hemorrhage protocol is designed to ensure timely, efficient delivery of blood products to massively bleeding patients outside of an or setting. future work will assess its overall effectiveness by comparing blood product utilization/wastage and patient outcomes before and after implementation. background/case studies: preoperative anemia affects up to % of surgical patients and increases the risk of red blood cell (rbc) transfusion. both preoperative anemia and perioperative rbc transfusion are associated with increased risk of adverse outcomes following surgery. preoperative treatment of anemia includes oral and intravenous (i.v.) iron and erythroid stimulating agents (esa) such as erythropoietin (epo); however, the optimal treatment strategy for preoperative anemia remains to be established. our objectives were to evaluate the efficacy and safety of esa and iron therapy based on their effects on the prevalence of rbc transfusions and adverse thrombotic events. study design/method: we searched the cochrane central register of controlled trials, medline and embase from inception to july ; reference lists of published guidelines, reviews and associated papers, as well as conference proceedings. no language restrictions were applied. we included randomized controlled trials in which adult patients undergoing surgery received either an esa and/or iron before surgery, versus iron or no intervention. three authors independently reviewed the studies and extracted data from included trials. risk of bias was assessed for all included studies. where applicable, we pooled risk ratios of dichotomous outcomes and mean differences of continuous outcomes across trials using randomeffects models. our primary outcome was the number of patients transfused with red blood cells. secondary outcomes included risk of mortality and other thrombovascular events (stroke, myocardial infarction, deep vein thrombosis, and pulmonary embolism). results/finding: a total of randomized controlled trials ( , conclusion: amongst patients undergoing surgery, the administration of an esa in addition to oral or i.v. iron was associated with a reduction in patients requiring rbc transfusion. intravenous iron was less effective at reducing rbc transfusion. neither treatment was associated with any clear increase in risk of adverse thrombotic events. additional large prospective randomized controlled trials are required to determine the optimal management strategy for patients undergoing surgery with iron restricted anemia. evidence based blood therapeutics scott neeley* and stephanie rogers . dignity health st joseph's medical center, dignity health background/case studies: over million units of packed red blood cells (prbc) are transfused annually in the united states and there is no clinical basis for as many as half of these transfusions. no randomized prospective trial has ever demonstrated a clinical benefit for transfusion in mild to moderately anemic patients and yet there is a large body of evidence which has shown that due to a variety of reasons including an immunomodulatory effect and the storage lesion, blood transfusions can cause considerable harm, including higher risk of hospital acquired bacterial infections, transfusion related acute lung injury/acute pulmonary edema, acute myocardial infarction, higher recurrence of rebleeding and higher cancer recurrence. study design/methods: a system wide goal was launched across hospitals to decrease the number of prbc transfusions given to clinically stable patients with hemoglobin (hgb) levels > . g/dl. the numerator consisted of all prbc units transfused to patients with a hgb of . g/dl or greater prior to transfusion and the denominator consisted of all prbc units transfused. exclusions included cardiac surgery, nursery, nicu, pregnancy, post-partum hemorrhage, massive transfusion protocol and transfusions in which or more prbc units were transfused in one episode. data was extracted directly from the electronic medical record and hospitals received patient level detail every month for all prbc units transfused to patients with a hgb of . g/dl or higher prior to transfusion. an extensive educational campaign re: evidence-based transfusion practice was launched for physicians and nurses, including the development of a blood therapeutics toolkit, development of standardized dignity health blood therapeutics guidelines, a one day blood therapeutics advanced training symposium, on-site visits to hospitals including cme presentations, online physician and nursing educational videos, communication tools including infographics and " is the new " buttons, development of a patient education resource and bi-monthly webinars with various educational topics and speakers. additionally, the ehr powerplans were revised to ensure available selections for "transfusion indication" (required field) were aligned with evidence based guidelines. facilties were encouraged to develop multi-disciplinary blood therapeutics committees to review all transfusions given to patients with pre-transfusion hgb > . g/dl on a routine basis, providing feedback to providers whose transfusions were deemed not in accordance with current evidence-based guidelines. results/findings: from fy to fytd , there was a % reduction in prbc units transfused to patients with hgb > . g/dl, starting at a baseline of % down to %. this represents an fy annualized savings of $ . m, from a baseline of units per , patients days down to an average units and approximately , fewer units transfused per month. conclusion: blood transfusions, while life saving, should be regarded as an organ transplant and as such they carry considerable risk. transfusions to stable, non-bleeding patients with hgb levels > . g/dl are not in accordance with evidence-based guidelines and should be avoided due to the associated potential harm. furthermore, this potential harm is dose dependent, so if the decision to transfuse is made, one unit of prbc should be transfused rather than two. three af studies (sdm - . ) reduced rbc units and two studies decreased the percentage of patients transfused (or . ). forty-three studies showed that intravenous tranexamic acid reduced the percentage of patients (or . ) and rbc units transfused (sdm - . ). qualitative/meta-analyses were translated into recommendations by an expert panel and approved by the lmbp workgroup for reducing rbc transfusion. recommendations are: early assessment and effective am; rt, hb alerts in cpoe/cds; reduction of blood loss and af assessing the percentage of patients and rbc units transfused across cases, physicians and service areas over discrete periods of time with feedback to physicians for continuous quality improvement. conclusion: conclusion: the lmbp a- method led to evidence-based recommendations for reducing transfusion. critical laboratory support is needed to achieve continuous quality and patient safety. background/case studies: reducing the inappropriate use of blood products via the implementation of evidence based guidelines is a main tenet of patient blood management. the use of electronic decision support tools such as best practice alerts (bpas) to enforce red blood cell (rbc) transfusion thresholds have been shown to reduce use by informing ordering providers when or when not to transfuse. the tools in use to date have not provided a dose of rbcs to transfuse, so in fact providers can continue to over-transfusion based on the number of units of rbc given. a therapeutic hemoglobin/hematocrit (hgb/hct) targeted approach to rbc indications/ orders allows for the calculation of a dose of rbcs to achieve the desired target and could further reduce the use of rbc units. our group has developed a computer algorithm to calculate rbc dose based on patient specific data drawn from the electronic medical record (emr) that has been used in select patient populations but has not been prospectively applied to hospital wide clinical practice. this study describes our initial experience with the use of this algorithm in non-surgical rbc transfusion. study design/method: the blood utilization calculator (buc) is a mathematical formula that draws patient specific information including index hgb/ hct and calculates a dose in number of units of rbcs to transfuse in order to achieve a selected target hgb/hct. hgb/hct target based indications for rbc transfusion were designed and used as the basis for rbc order set with in the ethe buc was embedded within the emrs rbc order set to provide a recommended transfusion dose in number of units when any nonsurgical rbc indication was selected. the target hgb/hct for these indications was g/dl/ % or g/dl/ %. the number of rbc units ordered and transfused were tracked prospectively for each of the orderable indications. comparison of units transfused per month before and after the buc implementation was performed using student's t-test. results/finding: historically, the three non-surgical rbc indications represented approximately % of the total rbc transfused. prior to the buc the mean number of non-surgical rbc units transfused was units/ month. after the first months of buc activation the mean number of units was units/month a reduction of units/month or % of nonsurgical blood use (p . by t-test). non-surgical rbc use now represents approximately % of the total rbc use hospital wide a % reduction. this change represents a significant cost savings in rbcs over time. conclusion: the use of target based transfusion indications and an electronic decision support algorithm to calculate a recommended transfusion dose can significantly reduce the non-surgical rbc transfusion rate providing enhanced patient blood management and potential cost savings. implementation of patient blood management at a community hospital - month report card richard gammon*. oneblood, inc. background/case studies: a collaboration between blood center between (bc) as consultant and three hospital ( beds) healthcare system (hcs) to implement a patient blood management (pbm) program was undertaken. this is a review of the first months. study design/method: during year one pbm working group was established. achievements included physician engagement programs, creation of transfusion committee and providing nursing education. auditing processes were implemented with nonconformance letters sent to physicians and nurses when compliance with informed consent, transfusion tags and thresholds and discharge instructions was not achieved. in year two, it created best practice alerts (bpa) when an order did not meet transfusion threshold criteria. bpa showed first line of associated procedure, link to the full procedure, three most recent lab results (e.g., hemoglobin & hematocrit for red blood cells (rbc)) and allowed ordering physician to cancel order after review. a blood administration video was created. it was mandatory that all physicians granted privileges complete within six months. low vital sign compliance required action that included reducing requirement from five to three during transfusion and formation of working group (wg) to address knowledge and practice gaps. in year three, as historically at this hcs very few jehovah's witness patients (jwp) presented, pbm wg was involved with implementation of a bloodless medicine program. all steps of care were addressed including identifying jwp at registration, creating a transfusion special arm bands, forming a bloodless medicine physician group, implementing nursing bpa in the electronic medical record, creating advanced directives and marketing to the public. results/finding: the following were monitored for compliance ( q vs. q ): present and completed consents ( vs. %), present and completed nursing flow sheets ( vs. %), transfusion thresholds supported ( vs. %), discharge instructions provided ( vs. %); ( q vs. q ) vital sign compliance ( % vs. %). jwp increased from to ( / - / ). cost savings were realized by decreased utilization and implementation of bpa. (table - q ) conclusion: pbm implementation at a hcs is a continuous and multiyear process. even with a robust program challenges such as vital sign compliance remain. improving patient outcomes in the golden-hour beatrice lebeuf*. medical city plano background/case studies: in emergency medicine, "the golden hour" refers to the critical one-hour time period following traumatic injury in which the patient has a higher likelihood of survival. nearly half of all trauma related deaths occur in the first hour after injury -half of those deaths are the result of major hemorrhaging. rapid administration of blood products is vital to the survival of these patients. we implemented bloodtrack emerge (haemonetics, braintree, ma) in our trauma emergency department (ed) as part of a quality improvement initiative to more efficiently provide group o rbcs and thawed/liquid plasma for incoming trauma patients to support ratio-based transfusions and ensure the proper handling and traceability of this regulated resource. study design/methods: we treat approximately - trauma patients monthly. an assessment of our current blood supply chain revealed a multistep, manual process that took about minutes to prepare and physically transport a cooler from the blood bank to the ed. coolers of blood were provided for incoming trauma patients, whether they ended up needing transfusions or not. this practice worked to ensure available blood supplies during critical moments, but resulted in inefficiencies and unnecessary inventory tie-ups, with only percent of coolers fully used. it also consumed valuable staff time as technologists typically made - trips per month from the blood bank to the ed. plus, there was no effective way to maintain traceability, control access to coolers or monitor usage. results/findings: since our november implementation, bloodtrack emerge has freed up technologists to perform important tasks, tightened traceability and inventory control procedures and contributed to the medical city plano's verification as a level trauma center. rather than preparing coolers of blood in case they may be needed in emergency situations, bloodtrack emerge provides ed staff ready access to emergency units whenever they're actually needed -and frees up an estimated - hours of tech time per month during which they can perform other tasks. audio and visual alerts notify the blood bank when emergency units are removed, allowing a quick response. plus, by stocking emergency blood supplies in the ed, the blood bank isn't unnecessarily tying up group o rbc units. today, the blood bank stocks and maintains - units of group o rhd negative, units of o rhd positive, and units of group a thawed plasma/ liquid plasma in bloodtrack emerge. conclusion: implementing bloodtrack emerge has enabled us to more effectively provide blood products for incoming trauma patients to support ratio-based transfusions, improve staff efficiencies and proactively respond to emergency situations. background/case studies: platelets are a limited resource for which the benefits of transfusion must be weighed against the risks. in , the aabb published platelet transfusion guidelines to assist providers. at our academic medical center, a computer provider order entry (cpoe) system combines institutional transfusion guidelines with a patient's most recent lab results to guide transfusion decisions. discordant information activates an "override" system, in which providers are prompted to select a prefixed indication for transfusion (e.g. count < k/ml [prophylaxis]) with the option to add a free-text comment. the order is placed and data is stored for later review. study design/method: override platelet orders placed from june -october were reviewed using the following data: prefixed indication, most recent platelet count, free-text comment, and ordering service/department. one of five "codes" was assigned to each order: i-indicated or ni-not indicated (based on institutional/aabb guidelines); nmi-need more information; p-protocol (e.g. liver transplant), and nic-non-indication comments (e.g. reserve for or). free-text comments were categorized and assigned one or more keywords in order to determine the common reasons for overrides. results/finding: over a -month period, , cpoe override platelet orders occurred. the percentages of code assignments by month are provided in table below. overall, ( %) were assigned as not indicated (ni). the top keywords assigned to free-text comments were "platelet count less than. . ." ( ), "active bleeding" ( ), "platelet count of . . ." ( ), and "downtrend" ( ), many with specified platelet count goals. certain platelet count goals and reasons for transfusion (e.g. "downtrend," "anticipate drop," or "per service,") are not included in institutional or aabb guidelines. of note, ( %) of overrides were placed by hematology-oncology providers. conclusion: a majority of override platelet orders were determined to not be indicated based on institutional and aabb guidelines. of concern were keywords such as "downtrend" and "anticipate drop," as these are not indications for transfusion and expose patients to unnecessary transfusions. it is unclear whether trainee progression throughout the year had any effects on ordering practices and associated override patterns. this review suggests the potential benefits of provider education initiatives at all levels of experience (with particular emphasis on hematology-oncology) in order to improve blood product utilization practices. background/case studies: early diagnosis of iron deficiency anemia (ida) by clinical laboratories (cl), with effective prevention and treatment in primary care may have an impact on packed red blood cell (prbc) transfusion, as well as intravenous iron therapy and, most importantly, applying lower transfusion triggers. they all help to avoid not essential transfusions, but also promote health and wellbeing by improving iron status in the population. results are described after implementing a process to prevent ida, its early detection and treatment for years - . study design/methods: performance measure after educational and organizational intervention. setting: public integrated healthcare system located in north africa bordering morocco, isolated by km sea distance to nearest continental spain airport, with a general hospital blood transfusion service and a establishment for blood donation and component production. cl involved in anemia detection and diagnosis receives four primary care centers and hospital based samples, and shares common leadership with both blood establishments. process: guidelines for first step cl diagnosis of ida and call for attention, primary oral iron prevention and treatment in first level care, and early intravenous iron complex for inpatients (sucrose) and outpatients (carboxymaltose). transfusion was avoided for stable ida patients without active bleeding or coronary heart disease, with a safety hemoglobin (hb) threshold of , g/dl. severely anemic patients were closely followed to asses hb increase and referred for etiology studies when hb> g/dl. background/case studies: bedside nurses are critical in safeguarding the delivery of appropriate patient care. more recently, nurses have also begun to play an important role in patient blood management (pbm) programs at the administrative level, although to our knowledge little has been published on the influence nurses may have on transfusion practice at the bedside. the goal of this study was to evaluate the impact nurses have on patient expectations and physician ordering practice. study design/method: a short electronic survey ( questions) was prepared to assess how often bedside nurses discussed transfusion necessity and the persons (patient or physician) with whom they discussed it with, as well as what was discussed, and what they felt were appropriate lab thresholds for transfusion. the survey was distributed to all registered nurses via email from floor leaders. responses were also solicited by hospital volunteers and lab staff with electronic tablets and included coverage of the night shift. results/finding: there were a total of complete responses ( %). the nurses had a range of experience from less than one year to forty years. ninety percent stated they discussed transfusion necessity with patients, % with physicians, and of these, % reported doing so proactively before an order was placed. ninety-six percent said they would discuss transfusion to suggest their patient required a blood product; only % responded that they would suggest product was not needed. nursing perception of acceptable transfusion thresholds had a wider distribution, with the most commonly reported values being hemoglobin of - g/dl ( %), platelet count of - , ( %), and inr of greater than . ( %). conclusion: this study demonstrates that nurses are willing to discuss transfusions with both patients and providers, although they appear to be most comfortable doing so in the setting of perceived transfusion necessity. the limited number of survey responses suggests a discomfort with their level of education in transfusion practice. this, along with the distribution of perceived thresholds and the reluctance to recommend against transfusions, presents an opportunity for education to further empower nurses in providing appropriate patient care within the guidelines of pbm programs. background/case studies: the use of red blood cell per , inhabitants may vary folds between european countries, revealing that there may be substantial room for blood optimization strategies. patient blood management (pbm) is an evidence-based, multidisciplinary approach aiming to preserve and optimise patients' own blood in order to improve clinical outcomes. the objective of our study was to assess the effect of a nationwide pbm program on public health in portugal. study design/method: the first phase of this research project involved a group of key opinion leaders (kol) in a stated preference inquiry to assess the relative value of specific pbm strategies, grouped in pbm pillars, to highlight the need for strategy prioritization in the implementation of a nationwide pbm policy. adaptive conjoint analysis techniques were used to elicit kol preferences. in the second phase a decision analysis model was used to estimate the impact of pbm implementation in the following therapeutic areas: surgery (orthopaedic, cardiac and urologic), cardiology, oncology, gastrointestinal bleeding, abnormal uterine bleeding, haemodialysis, inflammatory bowel disease and pregnancy. model inputs included effectiveness data regarding transfusion utilization, health resource consumption and mortality obtained from portuguese national health databases and literature review. the public health value of pbm implementation in portugal derives from the comparison of two scenarios: "current clinical practice" and "with pbm implementation". results/finding: kol elicited iron administration followed by restrictive transfusion of red blood cell as the most preferred pbm strategies ( . % and . %), for the remaining strategies weights varied between . % and . %. we estimate that , patients would be eligible for pbm strategies in one year time horizon, resulting in premature death avoided ( . % reduction) corresponding to a gain of approximately , life years and a reduction of , ( . %) disability adjusted life years (daly) relative to the current clinical practice. a decrease of , in-hospital days is expected mainly due to a . % reduction in hospital length of stay and a . % reduction in -day readmission rate. in this population the overall transfusion rate could decrease to . % from the current . % ( . % reduction) implying , blood transfusion avoided and , red blood cells units spared. conclusion: we anticipate that the implementation of a nationwide patient blood management program will represent a paramount improvement in clinical outcomes in terms of morbidity and mortality and may have a substantial public health impact while contributing a more efficient use health resources. results/finding: adult liver transplants were performed during the evaluation period. preoperative hemoglobin, creatinine, meld score, spontaneous bacterial peritonitis (sbp), preoperative hemodialysis, gender, and portal vein thrombosis (pvt) gave the strongest model predicting rbc usage. if the model predicted < ml of rbcs, all cases with ml transfused were captured and only . % of the time > ml were used. if - ml rbcs were predicted to be transfused, > ml were used % of the time. if predicted usage was > ml, % of the time it exceeded ml. conclusion: a model using specific preoperative factors can be used to predict intraoperative rbc usage. patients at risk for > ml of rbc transfusion can be identified with reasonable accuracy using this model at our institution. use of this model might help improve preparation and utilization of the blood bank. review of blood ordering practice for elective surgeries in a maternity hospital qi raymond fu*. kk women's and children's hospital background/case studies: pre-operative over-ordering of blood is common, resulting in waste of blood bank resources. blood units are withdrawn from the pool, leading to constraints in allocating the limited blood resources to meet the needs of other patients. the cross-match to transfusion (ct) ratio is often used in benchmarking efficient blood utilization within the hospital blood transfusion service. according to the american association of blood banks (aabb), a ct ratio of less than . is favorable, and anything above indicates over-ordering and cross-matching of blood. to achieve this, it is necessary to review pre-surgical blood ordering practice in a maternity hospital. study design/methods: data on elective surgeries requiring blood for standby was collected retrospectively over a month period (jan to mar ). details of total blood cross-matched, issued, transfused and returned were analyzed along with the ct ratio. results/findings: during the month period, there were patients undergoing obstetrics and gynecology procedures requiring blood on standby. a total of units of blood were requested. units were crossmatched, of which units were sent to the operating theatre (ot). only . % of blood issued to ot were transfused (n ) while the rest were unutilized. the observed ct ratio was . . conclusion: although only % of total blood requested was crossmatched, the ct ratio remains above the recommended guideline of ! . , with almost % of cross-matched blood unutilized. there is a need to improve and standardize the blood ordering practice to achieve costeffectiveness and reduce unnecessary workload. establishing and adhering to a maximum surgical blood order schedule (msbos) could help in conserving blood and prevent over-ordering of blood. background/case studies: total knee arthroplasty (tka) is a major orthopaedic procedure with increased perioperative blood loss. this perioperative blood loss could be more significant in patients undergoing bilateral tka in a single stage. the increased blood loss in bilateral tka often requires blood transfusion which results in high post-operative morbidities. study design/methods: in this retrospective study patients who received tranexamic acid (txa) (study group) and patients who did not receive txa during surgery (control) were evaluated for blood loss and transfusion requirement. the study group received a single bolus dose of txa gm iv before tourniquet deflation on first side knee. statistical background/case studies: blood product utilization is an increasing concern for hospital systems attempting to reduce transfusion-associated risks. one strategy to optimize utilization is to employ clinical decision support in the form of alerts to clinicians ordering blood products. we investigated whether an alert targeted to a patient's transfusion indication could alter provider ordering behavior. study design/method: this retrospective, observational study over the course of seven months included the inpatient adult medicine floors and intensive care units at a large academic hospital. each time a crossmatch for packed red blood cells (prbcs) was ordered via the hospital's electronic ordering system, an indication (e.g. "hemodynamically stable with hemoglobin < . g/dl") must be selected. if the indication selected contains a threshold hemoglobin concentration, and the patient's most recent hemoglobin on record was greater than this threshold, an interruptive alert displaying the patient's hemoglobin was activated. ordering providers were then given three options: cancel the order, select a more appropriate indication from a list, or provide an explanation via free text as to why transfusion was being requested outside of approved indications. an alert encounter was defined as all activations on a patient within a six hour period without an intervening transfusion results/finding: over seven months, there were unique alert encounters. of these, ( . %) led to a crossmatch being ordered while ( . %) led to the order being canceled. providers were more likely to cancel transfusions in response to alerts for hemodynamically stable patients with lower hemoglobin thresholds ( . g/dl) than for more complicated patients (bleeding, cardiovascular disease, or preoperative) with higher hemoglobin thresholds ( . or . g/dl background/case studies: the maximum surgical blood ordering schedule (msbos) is a list of surgical procedures performed along with a recommendation for the extent of pre-transfusion testing to be completed before the surgery begins. with improved patient data management systems it is now possible to create an msbos based on actual red blood cell (rbc) utilization data on a per-patient basis. this study investigated the transfusion patterns at academic hospitals with data-derived msbos. study design/method: the hospitals were in groups, with one shared msbos for each group. three of these hospitals were large academic centers while one was a children's hospital. at each center the msbos recommended no pre-transfusion testing if % of patients had been transfused for a specific procedure in the previous year, a pre-operative type and screen (t&s) if - % of the patients had been transfused, and a crossmatch of the median number of rbcs transfused if ! % of the patients had been transfused. data were collected at each center over a month period between january to march and included a maximum of cases per hospital during that one month to ensure equal representation between centers results/finding: between these centers there were a total of cases analyzed. some of the more frequently performed surgeries included orthopedics ( % of cases), general surgery ( %) and cardiac surgery ( %). there were t&s ordered for these cases, of which were positive for antibodies on the day of surgery. of all the t&s ordered, % were ordered in accord with the msbos recommendation, % were ordered when the msbos did not recommend one, and in . % a t&s was not ordered when the msbos recommended one. background/case studies: peripartum blood transfusion is more common in south africa than in the usa and recent studies have demonstrated that antenatal anemia is a strong risk factor for such transfusion (odds ratio . for prenatal hemoglobin (hgb) - . ). we therefore analyzed the etiology and characteristics of antenatal anemia according to hiv status at a large hospital with a hiv prevalence of % among obstetric patients. study design/method: we studied a sample of anemic (hgb< . g/dl) pregnant women who were referred to an antenatal anemia clinic at a large hospital in south africa. clinical information was abstracted and blood was sent for laboratory studies. t-tests were used to compare continuous variables between groups. results/findings: a total of women were enrolled, with median age (interquartile range - ) years, median gravida / para and median gestational age weeks. mean hgb before referral was . g/dl and most were already taking oral iron therapy. a total of women were hiv positive with mean cd lymphocytes counts of cells/ul; ( %) of hiv positive subjects were on anti-retroviral therapy (art) prior to the pregnancy and ( %) were on art during the current pregnancy. iron deficiency anemia was the overwhelmingly prevalent diagnosis, present in ( %) of women. there was concurrent chronic disease (n ), infection (n ), vitamin b deficiency (n ) and antenatal hemorrhage (n ); had other/unknown/missing causes of anemia. there were few pregnancy related complications. hiv positive women had higher levels of c-reactive protein but slightly lower levels of transferrin, soluble transferrin receptor and rbc folate than hiv negative women (table) . conclusion: iron deficiency is the overwhelming cause of antenatal anemia among south african pregnant women. compared to hiv-negative women, hiv-positive women had evidence of increased inflammation, relatively little differences in iron studies after early treatment with iron and lower red cell folate. a high proportion of hiv positive women were receiving art, consistent with national guidelines. future studies will examine longer-term responses to iron therapy to assess its potential in decreasing the incidence of peripartum blood transfusion. background/case studies: a month old boy presented to our institution after a month hospitalization in japan. he was admitted there, several weeks after his unremarkable term birth to an ab rh positive woman, with lethargy, failure to thrive, bloody mucoid stools with eosinophilia, and an elevated serum white count. he was found to be anemic and thrombocytopenic and required multiple transfusions. also, he had a diffuse, scaling, erythematous rash over his inner thighs. study design/method: initial workup was suspicous for an allergic/necrotizing enterocolitis. the patient had an elevated ldh and potassium, and concern was raised for leukemia with possible tumor lysis syndrome. a sample sent to our blood bank showed an anti-e, with a positive dat (igg and complement), and was positive for e, e, and c antigens. concern for a maternally-induced antibody was raised, as was the possibility of a red cell antigen passively transfused from blood products administered at the japanese hospital; both possibilities were excluded. further workup revealed no infection or hematologic proliferation. biopsy of his rash showed spongiotic dermatitis. his clinical course deteriorated, and he developed hepatomegaly and jaundice. a concern for wiskott-aldrich syndrome was raised, and workup showed normal immunoglobulin levels, but with elevated ige ( ku/l; rr: - . ). anti-platelet antibodies were identified. three days after admission, testing was sent for genetic alterations of foxp , while a japanese-speaking physician at our institution read a prior flow cytometry study showing a deficiency of foxp cd lymphocytes. the majority of these indications are seen in adults and for which a reported plasma wastage is $ . %. fortunately in pediatrics the incidence of these indications is low despite the heterogeneity of the patient population. during the utilization review process at our primary pediatric institution, we noted a mean wastage of . % over the last years. with recent changes in clinical practice (liver transplants and increased trauma) and recent evidence that faster plasma improves massive transfusion protocol (mtp) outcomes, our facility decided to implement the use of thawed plasma and benchmark mtp plasma wastage. study design/method: blood utilization review revealed an increase in the overall percentage of plasma wastage from to , with a peak of . % (range . %- . %). a single cause could not be readily identified prompting us to query children's hospital association (cha), as our initial external pediatric benchmarking, to determine if our wastage was comparable to other children's hospitals in addition to reviewing our "time of plasma availability" for mtps. results/finding: in , mtp was activated times. in cases the patient did not receive any blood product and in cases plasma was already available at the time of rbc allocation/issue. this left cases to evaluate. the median time to plasma availability was minutes (range minutes - minutes). the mean plasma wastage for mtp activations was % (range - %). of the cha replies, were using thawed plasma and their wastage was </ %. conclusion: increasing clinical evidence supports the prompt transfusion of plasma in the setting of mtp to decrease morbidity and mortality. our brief review suggests that implementing thawed plasma will allow a potential decrease in plasma availability of minutes. our implementation began with thawing a single unit of plasma for "level neuro trauma" alerts, and we are now keeping a single unit of ab plasma thawed at all times. plasma is now available at the same time as rbcs thus providing more effective and balanced blood product support while reducing wastage (preliminary estimates are . %) to a level consistent with external benchmarking. prospective evaluation of this practice is ongoing at our institution and includes collaborative clinical assessment with the trauma team. ultimately prospective, multi-institutional studies in pediatric institutions are necessary to define best clinical practice and effectively benchmark blood bank practice. background/case studies: bacterial and fungal infections remain a significant cause of morbidity and mortality in severely neutropenic patients with hematological disease receiving high-dose chemotherapy and hematopoietic stem cell transplantation (hsct). granulocyte transfusions (gtx) have been used for over years, although effectiveness, indications, and both patient and donor safety remain debated, particularly in children. to contribute to this discussion we demonstrated cases of gtx in pediatric patients with age from months to years old, neutropenic, with severe infection resistant to antibiotics and/or antifungal therapy, undergoing hsct and chemotherapy. study design/method: donors: data concerning a total of granulocytes donations from to were collected from health donors ( male/ female). donors had matched blood type and serology status for cytomegalovirus when the patient was negative. granulocytes were mobilized with a single dose of rhu-g-csf (filgrastim) subcutaneously, mcg/kg/dose (donors up to kg, maximum of mcg) and oral dexamethasone ( mg), h prior to apheresis. apheresis was performed using cobe spectra v r or spectra optia v r with citrate as anticoagulant. all products were irradiated with gy. results/finding s: granulocytes number increased times from basal levels and the median of cells collected were . x (range . - . ). in general donors reported no significant adverse reactions. from donations, only in was reported light paresthesia during the procedure. patients: all patients were medicated prior to transfusions with diphenhydramine and acetaminophen. the product was transfused within hours after collection, with efforts to transfuse as soon as possible. details about the transfusions are described on table . adverse reactions for patients were minor and not frequent ( in gtx) including vomiting, hypotension and headache, which resolved without serious or lasting complications, assuming that gtx is well tolerated. conclusion: our study provides further evidence that gtx transfusions can be safely performed on pediatric patients. irina kumukova* , elena kurnikova and pavel trakhtman . russian institute for paediatric haematology, oncology and immunology, instituteffor pediatric hematology, oncology and immunology background/case studies: infections cause major mortality among persons with prolonged neutropenia related to hsct and chemotherapy and among patients with granulocyte disorder. the granulocyte transfusion therapy, a logical approach in treating patients with infections, who are refractory to antibiotics. we want to demonstrate our granulocyte transfusions experience in children who have neutropenia or defects of the immune system, with severe infections study design/method: we analyzed the retrospective data for the period / - / . donors underwent granulocyte mobilization with g-csf in a dose - mg/kg s.c. - hrs prior to donation; granulocytes were collected with cobe spectra, caridianbct. the analysis was performed through microsoft excel, nonparametric mann-whitney's and spearman tests results/finding: was performed granulocytes collections in donors ( f, m), ages to . the mean increment of wbc after stimulation was , x /l ( , - , x /l; f- , x /l; m- . x /l); in the age groups - years (n ) and over years (n ), the mean increment of wbc was respectively , x /l ( , - , x /l) and , x /l ( , - x /l). the mean volume of treated blood was , a , ) . the mean number of total wbc in the product was , x /l ( . - x / l; f- , x /l, m- , x /l). only three donors ( , %) had apheresisrelated adverse effects the analysis included granulocyte transfusions in cases of infectious complications in patients. the mean number of transfusions was . ( - ). each patient received transfusions from mean donors ( - ); the granulocyte transfusions started at the mean days ( - ) after infection; the mean dose of wbc on the transfusion was . x /kg ( - . x /kg). wbc increment was able to estimate after transfusions. wbc increment was recorded after transfusions ( . %); the mean increment was , x /l ( , - , x /l). efficacy was determined by the number of patients who survived an infection episode and amounted to . %. in the cases of severe sepsis, the efficacy of transfusions was . %. the frequency of post-transfusion reactions was %, (n ): febrile nonhemolytic reactions , % (n ); pulmonary complications , % (n ); the anti-hla antibodies formation , % (n ) conclusion: no significant differences in the mobilization of granulocytes and products' volume, between men and women, or between age groups and we did not find significant relationship between baseline wbc and their increment after stimulation. the mean total wbc in the collected product and the mean volume of treated blood from men and women were significantly different. perhaps the reason for lower cell products from women is to treat smaller blood volume. the lack of increment wbc after transfusion is not equivalent to lack of its efficacy. we found a significant association between transfused dose and increment of wbc. we deliberately did not estimate our data on the treatment of patients with sepsis and other severe infections between patients receiving and not receiving granulocyte transfusions because the need for transfusions of granulocytes indicates more severe patients, when they have infections in a neutropenia or dysfunction of the immune system, and refractory to antibiotics cp hemolytic disease of the newborn due to anti-rh keegan barry-holson* and jennifer andrews . stanford university, dept of pathology, stanford university, dept of pathology & pediatrics background/case studies: anti-rh is a rare antibody against a high incidence red blood cell (rbc) antigen (ag) present in people with common rh phenotypes. this ag is missing in individuals who are rh null or have rh deletion phenotypes, including d--/d--. d--individuals strongly express d and lack c, c, e, and e ags. the clinical relevance of anti-rh has primarily been reported in pregnant women, causing mild to fatal hemolytic disease of the newborn (hdn). we present a rare case of hdn due to anti-rh alloimmunization during pregnancy in a d--mother. study design/methods: an o-positive full term infant was born to an opositive g p > mother with a negative st trimester antibody screen and no prior transfusions. she had two prior pregnancies, the first resulted in a normal term singleton, and the second resulted in a spontaneous miscarriage during the st trimester. father's blood type is unknown but presumably he has rh antigens. the infant was transferred to our institution at hours of life because he was found to have anemia (hemoglobin . g/dl), severe hyperbilirubinemia (total bilirubin (t bili) . mg/dl), reticulocytosis ( %) and a positive direct antiglobulin test (igg ). he was admitted to our neonatal intensive care unit for potential need for exchange transfusion given concern for hdn. he was treated with intravenous immunoglobulin and triple phototherapy on the day of admission, temporarily blunting his hemolysis. t bili rose to a maximum of . mg/dl on day of life and phototherapy was restarted. his t bili subsequently stabilized and he was discharged home and followed in clinic. meanwhile, his mother donated blood given there were no compatible red blood cells available in the united states via rare donor query. nine days after discharge, he was readmitted for worsening anemia (hemoglobin . g/dl) and was given steroids and washed maternal red blood cells. he was discharged and followed in clinic for several months with ultimate resolution of his anemia and hyperbilirubinemia. results/findings: at delivery, the mother's antibody screen was positive and anti-rh was identified; no other alloantibodies were detected. antibody identification was performed using polyethylene glycol, low ionic strength solution and ficin enhancement. maternal serum was pan reactive against panel cells and non-reactive against d--cells. anti-rh sera did not react against maternal rbcs. phenotyping of the mother revealed that she was d c-e-c-e-. molecular testing confirmed her d--genotype; molecular beadchip test yielded no type due to low signal for e, e, v and vs ags. genotyping for rh variant and targeted genomic rhce testing failed to detect several rhce exons. father was unavailable for further testing. conclusion: we report a rare case of hdn due to anti-rh antibody in a d --mother. we hope to obtain further laboratory studies in maternal relatives given the rarity of this phenotype in the general population. these studies have important implications for genetic counseling for mother's sisters. management of severe autoimmune hemolytic anemia: a case report of an infant treated with manual whole blood exchange with rapid clinical improvement yunchuan delores mo* , cyril jacquot , valli criss , philippe p pary , jay greenberg , naomi lc luban and edward cc wong . children's national medical center, quest diagnostics background/case studies: management of severe autoimmune hemolytic anemia (aiha) presenting with life-threatening anemia is challenging, particularly in the pediatric population. mortality rates in aiha are typically low; however, in children, the rate may be as high as - %. although corticosteroids and immunomodulatory therapies are first line modalities, several case reports describe the use of manual whole blood exchange (wbex) to successfully treat aiha in older children and adults refractory to first line treatment. to our knowledge, this is the first case report in which an infant with severe aiha has been successfully treated with manual wbex in an acute care setting. study design/methods: case report format. results/findings: a month-old previously healthy female patient presented to the emergency department with hemodynamic instability and a nadir hemoglobin (hb)/hematocrit (hct) of . g/dl/ . %. wbc counts ( x /l) were mildly elevated and platelet counts ( x /l) were within normal limits. her history was notable for upper respiratory tract infection days prior to the onset of anemia. laboratory studies on admission showed hyperbilirubinemia (total . mg/dl, direct . mg/dl), normal ldh ( u/l), and undetectable haptoglobin (< mg/dl) indicative of ongoing hemolysis. clinical symptoms included diffuse jaundice, hemoglobinuria, lethargy, and emesis. she was admitted to the pediatric intensive care unit for further management, including right internal jugular central venous catheter placement due to poor peripheral vascular access. the patient's blood group was o, rh (d)-negative with a positive antibody screen and panel demonstrating a strong panagglutinin ( - reactivity) with positive autocontrol. dat was positive for anti-igg and negative for c despite a positive cold antibody screen. the patient weighed . kg with an estimated total blood volume of ml. she initially received simple transfusions totaling ml/kg of least incompatible group o rh(d)-negative rbcs with no incremental response. manual wbex was then performed with ml of reconstituted whole blood consisting of o, rh(d)-negative rbcs and ab fresh frozen plasma (ffp) to an hct of %, utilizing the central venous catheter. no adverse events took place over the course of the hour exchange. her one hour post-exchange hb was . g/ dl and a subsequent antibody screen demonstrated reduced intensity of the panagglutinin ( ). after initiation of steroid therapy (methylprednisolone, mg/kg/day), she continued to improve clinically. one week later, the patient was discharged home with a hb of g/dl. one month later, she experienced recurrent hemolysis requiring re-hospitalization, at which time she had normal igm and iga levels with markedly elevated igg levels ( mg/dl). at a subsequent follow-up visit months after her initial presentation, her anemia had resolved and she had been completely weaned off steroids. conclusion: we demonstrate a case of severe neonatal aiha successfully treated with manual wbex. the main advantages of wbex include removal of both autologous rbcs and plasma as well as infusion of allogeneic rbcs. in this case, manual exchange transfusion avoided the need for an automated apheresis procedure requiring citrate anticoagulation. in summary, manual wbex is a potentially safe procedure that may be performed in young children with severe aiha. abstract operating room, each experienced blood-colored urine, laboratory evidence of hemolysis, and acute kidney injury. clerical and serologic investigations revealed no cause for hemolysis. mechanical hemolysis from transfusion rate, catheter gauge, or a recently introduced one-way valve was considered. study design/methods: in vitro simulated transfusions were performed via syringe. measurements included hematocrit (hct), free hemoglobin, and visual hemolysis index. washed and unwashed red blood cells (rbcs) were tested with or without a one-way valve, using a or gauge (g) intravenous (iv) catheter. each one-way valve was used to test three identical samples. constant pressure was applied manually (rapidly, . /- . ml/ second) or with a mechanical syringe pump (slowly, ml/min). a subset of the manual transfusions was timed. control samples for baseline measurements were collected by gravity drip, without passing through the one-way valve or catheter. results/findings: the one-way valve increased hemolysis markedly during rapid transfusion using both catheters as well as both washed and unwashed rbcs (see table) . with the g catheter, the mean change in hct was - . /- . % with the one-way valve and . /- . % without (p< . ). comparing the one-way valves tested, differences in hemolysis were observed (change in hct; p< . ). during rapid manual transfusion with a g catheter and unwashed rbcs, hemolysis was greater for samples that took longer to transfuse . ml when using a one-way valve (change in hct versus time: r - . , p< . ) compared to a significantly different (p . ) slight increase in hemolysis for samples that took less time to transfuse . ml when not using a one-way valve (change in hct versus time: r . , p . ). correlations between time and hemolysis were similar, but insignificant using g with washed rbcs and the g iv catheter. conclusion: mechanical hemolysis should be considered when investigating possible hemolytic transfusion reactions, especially with high rates of transfusion and use of a one-way valve. during rapid manual transfusion with the one-way valve, greater resistance was associated with increased hemolysis. background/case studies: gerbich (ge) antigens expressed on glycophorin c are present in . % of the population. ge antibodies cause delayed hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (hdfn). ge antibodies also suppress erythropoiesis resulting in late-onset anemia. we report a case of hdfn due to anti-ge . study design/methods: a woman of paraguayan origin with prior terminated pregnancies presented at weeks gestation with passive anti-d and an anti-ge titer of . she was d-and ge:- ,- , by antigen typing. her obstetrician scheduled maternal blood collection near her due date for possible neonatal transfusion, but the woman went into labor at weeks. cord blood was dat positive for igg; the eluate confirmed anti-d and anti-ge . the birth hemoglobin (hgb) was . g/dl, reticulocyte (retic) was . %, bilirubin (bili) was . mg/dl; the infant was discharged. on day of life, the infant was referred to pediatric hematology for lethargy and poor feeding, with hgb . g/dl, retic . %, and bili . mg/dl. ge -blood was not available from the blood center or rare donor registry. the mother was b rh-and baby was b rh . obstetrics had to authorize maternal blood donation due to her hgb of . g/dl. maternal blood collection and rbc washing was expedited and the infant received ml of maternal rbcs within hours, at which time his hgb was . g/dl. post-transfusion hgb was . g/dl. one week later, the infant was symptomatic with hgb . g/dl, retic . %, bili . mg/dl. a nd aliquot of ml washed maternal cells was transfused. two weeks thereafter, the infant had hgb . g/dl, retic . %, anti-ge titer , and needed another transfusion. the maternal blood stored for just weeks had hemolyzed necessitating a nd maternal donation for baby's rd transfusion. at weeks, the infant's anti-ge titer was , hgb . g/dl, retic . %; no transfusion was necessary. at weeks of life, hgb was . g/dl, retic was . %, and the baby was thriving. results/findings: serologic studies at the hospital and reference blood center confirmed the antibodies and risk of anti-ge hdfn. molecular analysis revealed that the mother was homozygous ge -negative ge* .- , the father had homozygous wild type ge* , and the infant was heterozygous ge* /ge* .- . conclusion: the infant had hdfn due to antibodies to the high prevalence ge antigen. the continued need for transfusion was consistent with hemolysis and suppression of erythrocyte production caused by anti-ge . hemolysis of stored maternal blood was consistent with the absence of glycophorin c. this case demonstrates that cooperative multidisciplinary care among the blood bank, donor center, obstetrics, and hematology in a rare case of hdfn resulted in a successful neonatal outcome. background/case studies: patient blood management is a collaborative approach to optimize transfusion therapies to improve patient outcomes. in pediatrics, blood management is not 'one size fits all' given the paucity of clinical trials to guide evidence-based practice. in addition, pediatric care encompasses a very heterogeneous patient population such that applying one set of guidelines is difficult. because there are no standard, evidence-based clinical best practices regarding blood product usage in all children, unnecessary variation is occurring at our institution. we designed a robust analytics process to study baseline clinical practice and examine blood product usage, and plan to target the three pediatric sub-specialties with highest usage to establish standards in order to decrease variation/unnecessary transfusions. study design/methods: a data base encompassing all admissions and outpatient visits to a large, tertiary care academic children's and women's hospital was established, and included all relevant patient demographics, diagnostic and procedural codes, attending physician and specialty for each visit/admission, relevant hematology/coagulation laboratory results and blood product orders. we focused on rbc orders given the tripicu randomized clinical trial results ( ) supporting a hemoglobin trigger of g/dl in stable critically ill children and ffp since anecdotally we noted many children receiving this product for only minimally elevated international normalized ratio (inr) values without bleeding. results/findings: in , , rbc orders occurred and the top three patient groups were: % in congenital heart disease patients, % in hematology/oncology patients and % in neonates in the neonatal intensive care unit (nicu). average hemoglobin of every patient was . g/dl as measured in the hours prior to rbc order placement. in , ffp orders occurred and the top three patient groups were: % in neonates in the nicu, % in congenital heart disease patients and % in pediatric intensive care patients. average inr of every patient was . as measured in the hours prior to ffp order placement. conclusion: we have designed a robust data base that is continually updated for children in a large, tertiary care academic children's hospital. this serves as an important benchmark in pediatric blood utilization, and we plan to leverage usage patterns to make relevant practice changes in the care of children with a heterogeneous set of illnesses. background/case studies: bacterial contamination of plts remains an ongoing threat to transfusion recipients. recently, a psoralen-based pr technology that reduces the replication potential of pathogens in stored plts was fda approved. we describe our approach to phasing pr-plts into our inventory, including preliminary results of an ongoing qa study of neonatal and pediatric (peds) recipients of pr-plts. study design/methods: before the arrival of pr-plt, we undertook an educational campaign for hospital administrators, it staff, laboratory staff, clerical/clinical aides, nurses, and physicians. we also contacted risk management and the hospital ethics committee. phototherapy devices used at our hospital were confirmed to be compatible with the psoralen-based pr-plt product. shortly following the arrival of pr-plt, we introduced day bacterial "safety measure" testing of our conventional (c-plt) supply. a peds qa study monitored plt utilization and adverse transfusion event reporting relating to both pr-and c-plt transfusions. this study evaluated neonates ( - months of age), infants (> - months of age) and children (> months- years of age) who received at least one transfusion of pr-plts. results/findings: risk management and the ethics committee agreed that both pr-plts and bacteria tested c-plts would be the hospital standard of care. pr-plts were phased in and transfused to patients based on abo compatibility and expiration date, per routine, without regard for patient age or medical condition. after months, pr-plt represented % of our platelet inventory (average daily plt inventory: units). we encountered no complications with the pr platelet phase-in, either from a clinical, informatics or logistical perspective. due to the dual inventory, many peds patients in all age groups were transfused with both pr-and c-plts (table) . two potential transfusion reactions (trs) were reported over the study period in teenage recipients, one associated with a c-plt and the other with a pr-plt. in both cases, the symptoms were ultimately attributed to an underlying medical condition. no rashes were observed among transfused neonates ( - m) who received any pr-plts and phototherapy. background/case studies: packed red blood cell (prbc) transfusions are believed to improve oxygen delivery particularly in vulnerable patients such as neonates and children. however, evidence shows that hemoglobin (hgb) in prbcs has increased oxygen affinity and thus reduced oxygen delivery to tissues due to decreased , dpg levels. standardization of prbc transfusion practices in this population and the scientific evidence on which current practice is based is limited. additionally, due to small transfusion volumes, infants may be exposed to multiple blood donors, increasing their potential for adverse events. study design/method: medical records of pediatric patients receiving prbc transfusion over a month period were retrospectively reviewed. a total of patients were identified as receiving allogeneic prbc transfusion. patients who received autologous blood (cell salvage) were excluded. patient characteristics, length of stay, prbc transfusion volume, pre-and post-transfusion hgb, and adverse events were collected. results/finding: the average pre-transfusion hgb was . g/dl with post-transfusion hgb rising to . g/dl. the mean prbc volume transfused was . ml using a dose of ml/kg for all patients. complications noted were; volume overload, thrombosis, fever/infection, hemolysis, necrotizing enterocolitis (nec), and death (table) . conclusion: evidence based transfusion guidelines are lacking in neonates and infants. a typical dose of - ml/kg in a kg patient, for instance, would translate into full prbc units (about ml) in an average size adult. the current standard dose of - ml/kg yields very high increases in hgb and may put these patients at risk of adverse outcomes, especially thrombosis due to increased blood viscosity. additionally, many of these patients received volume reduced products which delivers a higher hgb concentration per transfusion. dosing should be based on goal hgb and patient condition rather than weight based, though the hematocrit level at which the benefits outweigh the risks remains unclear. pneumoniae has rarely been associated with warm autoimmune hemolytic anemia, with only case reports suggesting this association. however, each of these cases is confounded by other findings in addition to a mycoplasma infection. we describe a unique case in which a pediatric patient has clear evidence of severe hemolysis, a very strongly reactive warm autoantibody, and clinical and laboratory evidence of a mycoplasma infection without a detectable cold agglutinin. study design/methods: the patient is a month-old, previously healthy female infant who presented to the hospital with a -week history of fever, fatigue, decreased appetite, and pallor. she was only treated with acetaminophen. she also developed clear rhinorrhea the day before hospital admission. at the time of her admission, laboratory testing (outside hospital) revealed a hemoglobin and hematocrit of . g/dl and . %, respectively, platelets of , , and a reticulocyte count of . %. all other elements of the complete blood count were within the normal reference range for age. a complete metabolic panel revealed no abnormalities except for a total bilirubin of . mg/dl with a direct fraction of . mg/dl. a filmarray respiratory panel (biofire diagnostics; salt lake city, ut) detected mycoplasma pneumoniae, while all other pathogens ( total) were non-detectable. the patient was started on a -day course of azithromycin (zithromax). results/findings: prior to rbc transfusion, blood bank evaluation revealed that the patient was o-positive and had a stronglyreactive antibody screen. further testing demonstrated an antibody reactive with all reagent red blood cells. the dat was strongly reactive for igg but very weakly reactive for c . an eluate was reactive with all reagent red cells tested. finally, a cold agglutinin study was negative with undiluted serum. in addition to starting azithromycin, the patient was given iv methylprednisolone. during her -day hospital course, the patient received rbc transfusions on the day of admission and several rbc transfusions thereafter (see table ). despite transfusion, her hemolytic process persisted, so she was infused with a dose of iv immunoglobulin on hospital day . her hemoglobin rose to . g/dl on hospital day and increased to . g/dl on hospital day . at that time, the patient was discharged from the hospital with instructions to wean her oral steroid dose over the next weeks. she was followed closely by the hematology clinic and was found to have a stable hemoglobin (up to . g/dl on day after her hospital admission) with no recurrence of her hemolytic process. conclusion: m. pneumoniae infection is a typical cause of cad and has only rarely been associated with warm autoimmune hemolytic anemia. our case demonstrates clear evidence of severe warm autoimmune hemolysis in a previously healthy infant. with the increasing use of multiplex respiratory viral and bacterial pathogen detection systems, the once rare phenomenon of a m. pneumoniae infection associated with warm autoimmune hemolytic anemia may become a more recognized entity. ) and may serve to more reliably reflect when the neonates at risk for hyperbilirubinemia. the difficulty in eliminating the cord blood testing is the neonatologists' reliance of using abo incompatibility as part of the neonates risk assessment rather than using the point of care bilirubin testing. currently the ts requires all positive dat tests to be communicated to the nursing staff immediately. given that the dat strength positively correlates with the percentage of neonates diagnosed with hyperbilirubinemia, the ts staff may also consider notifying nursing staff only for those patients whose dat is or . platelet and leukocyte immunohematology, testing and genetics table . of pairs, pairs were complete match ( / ), pairs were partial match ( / ), pairs were complete mismatch ( / ). the matching rate of hla-dpb in our study is %. conclusion: the matching rate of hla-dpb in / hla matched unrelated hematopoietic stem cell transplantation is low and the gene frequency of hla-dpb in unrelated hematopoietic stem cell transplantation was obtained ,which will help to study on the relationship between hla-dpb and unrelated hematopoietic stem cell transplantation. this work was sponsored by national science foundation of china ( ) background/case studies: thrombotic thrombocytopenic purpura (ttp) is caused by severely reduced activity of the von willebrand factor-cleaving protease adamts . therapeutic plasma exchange (tpe) as well as immunosuppression minimize the morbidity and potential mortality of this presentation. absolute immature platelet counts (a-ipc) have been shown to help diagnose and follow ttp patients' responses to therapy. we report the case of a man with relapsing ttp, low adamts with high inhibitor, treated with mycophenolate mofetil in which a-ipc-indicated an unexpected response to therapy. study design/method: a year old male with a -year history of ttp, presented with status epilepticus complicated by acute respiratory failure admitted with suspicion for relapsing ttp. patient had been treated in prior admissions with tpe, prednisolone, rituximab, and cyclophosphamide with clinical improvement. he was on mycophenolate mofetil maintenance therapy which he last received just prior to day of admission due to consistently low platelet counts, adamts < % and inhibitor of . . on day of admission platelet count was x /l which decreased within five days to x /l leading to initiation of daily tpe along with mycophenolate mofetil discontinuation just prior to tpe start. immature platelet fraction (%-ipf) and calculated a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. abstract results/finding: a-ipc and platelet count were x /l and x /l respectively. counts improved rapidly post-tpe initiation and after one tpe his a-ipc tripled to . x /l achieving the ratio of previously shown to be diagnostic of ttp. on day his a-ipc and platelet counts had improved to . x /l and x /l respectively. absence of anti-pf antibodies ruled out heparin-induced thrombocytopenia at this time. on day he had an unexpected decrease in both a-ipc and platelet count to . x /l and x /l respectively, worsening by day to . x /l and x /l respectively despite daily tpe. patient received additional tpes that failed to improve a-ipc or platelets which on day were . x /l and x /l respectively. a-ipc had remained at this level for days suggesting that the observed decrease was irreversible. adamts activity remained < % low with a high inhibitor. patient's clinical condition continued to deteriorate and family placed patient on comfort care. conclusion: ttp patients have low a-ipc and plt counts at presentation, with the former improving first post-tpe initiation. despite appropriate therapy leading to early improvement of platelet count, patient's counts declined rapidly leading to suspicion for platelet production suppression as indicated by the sustained very low a-ipc. in the setting of ttp, or relapsing ttp use of immunosuppression should be closely followed and a-ipc may aid in establishing early if therapy is affecting platelet production. application of luminex bead technology to detect hpa- a, hpa- a, and hpa- a antibodies su-dan tao*, ying liu, yan-min he, ji he and fa-ming zhu. blood center of zhejiang province, key laboratory of blood safety research, ministry of health background/case studies: detection of antibodies against human platelet antigens (hpas) is crucial for patients' refractory to platelet transfusion therapy. in the text, luminex bead coupled with anti-gpiib/iiia and anti-gpia/iia monoclonal antibody was implied to detect hpa- a, hpa- a, and hpa- a antibodies, and the sensitivity of luminex bead technology was compared with monoclonal antibody immobilization of platelet antigens (maipa) assay. study design/method: monoclonal antibodies p and gi , specific for platelet glycoproteins gpiib/iiia and gpia/iia, were separately coupled to luminex xmap beads. four standard sera, containing anti-hpa- a, anti-hpa- a, anti-hpa- a and anti-hpa- b respectively, were bought from nibsc; three negative sera without hpa antibodies were prepared from ab type blood donors. platelets (containing hpa- aa, hpa- ab and hpa- aa) were collected and reacted with anti-hpa- a, anti-hpa- a, anti-hpa- a and anti-hpa- b standard sera respectively, then the antigen-antibody reaction complexes were lysed and the lysates were incubated with luminex beads to specifically capture antigen-antibody complexes via the epitopes on platelet glycoproteins. the beads-antigen-antibody complexes were then subjected to flow cytometric analysis on a luminex . the hpa- a serum was diluted to serial dilutions (from neat to / ) to test the sensitivities of maipa and luminex beads assay. the two methods were then used to test five blinded samples which were collected from fmait patients. results/finding: luminex bead technology showed that the mfi values of hpa- a, hpa- a, hpa- a standard sera samples reacted with the coupled beads were significantly higher than the negative controls ( . vs . ), which implied that the luminex bead technology could specifically identify negative and positive sera of anti-hpa- a, anti-hpa- a, anti-hpa- a. furthermore, because the platelet was hpa- aa, the hpa- b serum did not react with the coupled beads with mfi was comparable to negative control ( . vs . ). the sera were re-tested by maipa and the results of which were comparable to luminex bead technology, illustrating that detecting hpa antibodies by luminex beads technology was successful. the sensitivity of luminex bead assay and maipa to detect anti-hpa- a was / ( . iu/ml) and / ( . iu/ml), respectively. no cross-reactivity was observed with the samples containing hla, abo or other platelet antibodies. all results of five blinded samples tested by luminex assay showed that four sera were positive for gpiib/iiia antibodies which were consistent with maipa results. conclusion: the luminex beads coupled with gpiib/iiia and gpia/iia monoclonal antibodies could be successfully used to detect hpa- a, hpa- a and hpa- a antibodies via the epitopes on platelet glycoproteins. the sensitivity of luminex technology was higher than maipa technology. (ahus) is a thrombotic microangiopathy (tma) characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia and renal failure in the absence of infectious toxin. the literature suggests the presence of pathogenic mutations in complement proteins in % of cases of ahus. there is a lack of well-defined recommendations regarding testing for genetic ahus. complement pathway mutation analysis is an expensive test so appropriate utilization is crucial to prevent undue health care costs. we reviewed the indications for genetic testing to understand physician ordering practice and determine the frequency of pathogenic mutations in the population. study design/method: we performed a retrospective review of all cases referred for complement pathway mutation analysis to a national reference laboratory from january to december . clinical history was solicited by genetic counselors. cases were classified by the authors as primary ahus (tma and renal failure without identifiable cause), secondary tma (tma and renal failure with identifiable cause previously associated with tma) or non-tma. the test panel identified variants in complement proteins (cfh, cfi, mcp, factor b, c , c bp, thbd, dgke, cfhr , cfhr , cfhr and cfhr ) that were classified as vus (variances of uncertain significance), pathogenic or benign by the american college of medical genetics. chi square analysis/fishers' exact test was used to determine differences in proportion of patients with pathogenic mutations and primary ahus versus secondary tma. independent sample t-test was used to compare differences in continuous variables between primary ahus and secondary tma. results/finding: of patients tested, pathogenic mutations were detected in % ( / ) and vus in % ( / ). % ( / ) of patients did not fulfill criteria for tma; no pathogenic mutations were found in this group and ( %) had vus. % ( / ) of patients had primary ahus; of these, % ( / ) had pathogenic mutations and % ( / ) had vus. % ( / ) of patients had secondary tma; of these, % ( / ) had pathogenic mutations and % ( / ) had vus. in patients with pathogenic mutations, % ( / ) were children, . % ( / ) had a positive family history of ahus and % ( / ) had recurrent disease. patients with primary ahus had a significantly lower age at presentation ( vs. yrs; p-value: . ) and a higher proportion of pathogenic mutations ( % vs. % p-value: . ) compared to patients with secondary tma. gender distribution, hemoglobin nadir and serum creatinine levels were similar between the two groups. conclusion: we found a lower frequency of patients with pathogenic mutations compared to reported literature. our data suggests that patients with secondary tma should be carefully evaluated prior to ordering genetic testing and those without tma should not undergo this test. counting of platelets in platelet concentrates on hematology analyzers pentraxl and sysmex xn compared with a flow cytometric method farshid ezligini , kjersti roen eriksen , annette vetlesen , thomas larsen titze and geir hetland* , . oslo university hospital, university of oslo background/case studies: hematology analyzers are made for counting of whole blood samples but are often used for quality control of blood components such as platelet (plt) concentrates (pcs). a flow cytometric method for counting of plt in pcs has been developed as validation tool (van der meer et al, transfusion ). therefore, it is pertinent to evaluate plt counting in bcs on hematology analyzers with this validation method in a flow cytometer. study design/methods: samples from ten apheresis pcs and buffy coat-derived pcs were subjected to plt counting on hematology analyzers pentraxl (horiba abx, montpelier, france) and xn sysmex toa (kobe, japan) (both impedance score), and additionally, diluted and stained with anti-cd a fitc in truecount tubes (bd biosciences)(internal bead standard) for measuring in a gallios flow cytometer (beckman coulter, indianapolis in, usa). results were analyzed by paired samples test and shown in bland-altmann plots. results/findings: mean plt values x /l sd were , (<) , (<) and for counting by sysmex toa, pentraxl , and the gallios flow cytometer, respectively. sysmex count was the very lowest a transfusion vol. supplement s abstract ( . % less than for flow cytometry), but all plt counts were significantly different (p< . ), although least so ( . %) between pentra and flow cytometry. conclusion: as validated by the flow cytometric method, pentraxl seems suitable for routine quality control of pcs both because of the small difference and lower counts compared with flow cytometric method, which is too cumbersome in a routine setting. the much lower plt count on sysmex may reflect its optimization for plt counting in whole blood rather than in pcs. fast, precise & easy hpa typing with real-time pcr jonathan downing , arishma lata , roland russnak , zachary antovich , heather dunckley and thierry viard* . new zealand blood service, linkage biosciences background/case studies: the interaction of membrane-bound plateletspecific glycoproteins with the extracellular matrix plays a significant role in hemostasis. human platelet antigens (hpa) found within these glycoproteins can stimulate production of antibodies in recipients of transfused platelets or in fetus of mothers with incompatible hpa. thus, platelet incompatibility is associated with various forms of thrombocytopenia, posttransfusion purpura and other blood disorders. the new zealand blood service performs hpa typing on a pool of platelet donors to provide compatible transfusions where the need arises. the molecular basis of most hpas has been characterized as generally caused by a single-nucleotide polymorphism (snp). hpa typing has typically been performed using pcr-ssp, a method that utilizes time-consuming post pcr analysis steps. the aim of this study was to evaluate the use of real-time pcr-based techniques in a transfusion laboratory setting. study design/method: we evaluated a commercially available solution which consists of reactions that identify both variants of relevant snps located within hpa genes (hpa- through hpa- , and hpa ). genomic dna purified from blood samples, previously genotyped for hpa- ,- ,- ,- ,- and - by our in house pcr-ssp method were used in this study as validation samples. results/finding: results of the validation samples were % concordant with typing obtained by pcr-ssp. the real-time pcr approach overcomes the major challenges of hpa molecular typing by providing an automated solution resulting in increased laboratory productivity and decreased turn-around time. the analysis is facilitated by a software which generates the results. with less than minutes of hands-on set-up and no further operator intervention with the reagents, complete molecular genotyping results are provided in approximately minutes. further, since amplified products are never handled, the risk of laboratory contamination is significantly reduced. the real-time pcr approach with automated analysis was implemented by the new zealand blood service tissue typing laboratory in late and to date has tested dna samples from blood donors ( donors were tested in duplicate). concordance between the sample replicates was %. there were occasions where the assay had to be repeated, giving a repeat rate of . %. occasionally a reaction peak was insufficient to trigger the software automatic allele call and a manual interpretation was required. this occurred most commonly with the hpa- ( . %) and hpa- ( . %) assays. conclusion: real-time pcr with automated analysis provides an effective, robust an accurate method for molecular hpa genotyping. with its minimal hands-on time workflow, it is also very easy to implement and offers a cost effective alternative to classical methods used in a transfusion laboratory setting. genetic variation of cd antigen deficiency expression in jiangsu chinese han population qing chen* , jianyu xiao and chengyin huang . jiangsu province blood center, jiangsu province blood center background/case studies: cd has been implicated in the platelet refractoriness, neonatal alloimmune thrombocytopenia, and posttransfusion purpura, especially in the non-caucasian. cd deficiency varies widely among different ethnic populations, with the frequency of - % in asians and . % of african americans, respectively. however, there is little information on the molecular basis of individuals with cd deficiency in jiangsu chinese han population. study design/method: to investigate platelet cd expression levels and to determine the molecular basis of cd deficiency on the platelet surface of the han population in jiangsu region. cd expression levels on platelets were detected by flow cytometry among blood donors in jiangsu region. donors without cd antigen expression on their platelet surface were further to be determined the expression of cd antigen on their peripheral blood monocyte cells. the coding exons of cd gene and adjacent introns were amplified and sequenced in cd deficient individuals. results/finding: among these blood donors, cd -deficient and cd -expression individuals were . % ( / ) and . % ( / ), respectively. the frequencies of type i and type ii cd deficiency among the study population were . % ( / ) and . % ( / ), respectively. among individual with platelet cd expression, according to mean fluorescence intensity (mfi) value, , and individuals showed low, moderate and high expression levels of cd , respectively, and their mfis were . . , . . and . . (p< . ), respectively. the type i cd deficiency individual were heterozygous for - a>g and - c>g, respectively. among type ii cd deficiency individuals, two harbored a t insertion at position in exon which caused frameshift at codon ; one has a t>c exchange at position in exon which resulted in a tryptophan to arginine substitution at codon ; one has a a insertion before the th bp of the start codon atg in the promoter region; one were heterozygous for t>c and t>g, respectively. conclusion: platelet cd surface expression levels were diversified in the jiangsu chinese han population. the frequency of the type ii cd deficiency was higher than that in type i. the study findings indicated that the frequency of cd deficiency in the chinese population is slightly lower than that in other asian countries. background/case studies: cd -deficient phenotype can be immunized by pregnancy or transfusion, and involved in neonatal alloimmune thrombocytopenia, platelet transfusion refractoriness and other disorders. the frequency of platelet cd -deficient individuals widely varies among ethnic groups, with % to % in japanese, % in sub-saharan africans, . % in african americans, and . % in caucasians. although some studies of cd deficiency are focused on the asian populations, relatively little information has been reported in the chinese population. here we investigated the cd expression on platelets in large samples of the eastern chinese donors. study design/methods: peripheral blood samples were collected from unrelated platelet-apheresis donors in the eastern china. the expression of cd antigen on platelets was determined by flow cytometry using fluorescein conjugated monoclonal antibodies (fitc-anti-cd and peanti-cd ). the isotype control (fitc-mouse igg) was also analyzed to calculate a reference range of cd -nagtive phenotype. for those donors with cd -negative platelets, cd antigen expression on monocytes was analyzed further to distinguish between cd type i and type ii deficiency. flow cytometric parameters were statistically analyzed by mann-whitney test. the work was supported by national natural science foundation of china ( ) and zhejiang high-level innovative health talents. results/findings: the mfi (mean fluorescence intensity) of platelet cd in all samples showed a continuous distribution profile, and no obvious fluorescence-gap could be utilized to distinguish negative from positive phenotype. on account of this limitation, we classified the cd phenotypes using the (mean sd) of the background mfi observed in isotype controls. forty-three samples were detected as cd deficiency on platelet, in which one sample was cd negative both on platelet and monocyte. the frequency of cd type i and type ii deficiency in the eastern chinese donors was . % and . %, respectively. the average mfi of cd deficiency samples was significantly lower than cd positive samples ( . . vs . . , p< . ). conclusion: the frequency of platelet cd deficiency in the eastern chinese donors was close to japanese and african americans. it means that the possibility of cd antibody occurred by pregnancy and transfusion in this population is existed. it is useful to find and register cd -deficient donors by large-samples screening for potential immune thrombocytopenia patients with cd antibody. background/case studies: cd (gpiv, chromosome q . ) is an kda glycoprotein expressed on multiple cell types including platelets (plts), monocytes (mono), & erythroblasts. although rare among whites, cd deficiency (cd -n) is observed in - % of africans (t g) & is classified as either type i (cd -n plt, cd -n mono) or type ii (cd -n plt, cd mono). an acquired type ii cd -n phenotype can also be observed in the setting of myelodysplastic syndrome (mds). type cd -n individuals can develop anti-cd alloantibodies with plt refractoriness & neonatal alloimmune thrombocytopenia. we report a case of profound plt refractoriness caused by anti-cd in a patient with newly diagnosed mds. study design/method: hla antibody testing was performed with a commercial bead-based fluorescent assay. cd phenotyping (plt, mono) of patient & family members was performed by flow cytometry (fc). cd staining of bone marrow was performed by immunohistochemistry. plt crossmatching (plt-xm) was performed by the american red cross. pltspecific alloantibody testing & cd dna sequencing were performed at a commercial reference laboratory. results/finding: the patient was an year-old, group o african-american male who presented with blurry vision & lightheadedness. complete blood count findings were significant for hemoglobin . g/dl & plt count k/ml. bone marrow biopsy & cytogenetic analysis revealed multilineage dysplasia, - % blasts & a complex karyotype with del( )(q q ) consistent with mds. plt refractory work-up was initiated after repeated plt transfusion failures with corrected count increments (ccis) < . hla antibody testing was negative (class i panel reactive antibody (pra) %). the patient was plt-xm-incompatible with most donors ( / ). a trial of group o, plt-xm-compatible plts was unsuccessful (cci ). subsequent testing for plt-specific alloantibodies identified anti-cd . fc-phenotyping showed no cd on patient's mono or plt, consistent with type i cd -n. preliminary dna results show that the patient is heterozygous for t g. because cd -n apheresis plt were unavailable from blood suppliers, the patient's children & grandson were screened as possible donors: all showed normal cd expression on plts. trial of eltrombopag & romiplostim was attempted with no improvement in plt count. repeat hla antibody testing (day ) demonstrated new class i alloantibodies (pra %) in response to transfusion ( apheresis plts, rbcs). given his plt refractoriness & poor prognosis, the patient opted for hospice. conclusion: we describe a patient with cd -n & severe plt refractoriness in the setting of new mds, and q-chromosomal abnormalities. the absence of cd on plt & mono support congenital type cd -n although a contribution by the patient's underlying mds cannot be excluded. rapid platelet donor classification: hla & hpa profiles by "leansequencing" without dna purification dipika patel , kristopher fernandez* , eric senaldi , pascal george , michael seul and ghazala hashmi . biomolecular analytics, central jersey blood center background/case studies: prophylactic platelet transfusion is the standard of care for managing thrombocytopenia. in the emerging paradigm of personalized medicine, the selection of cellular products in accordance with patient immunomolecular signatures has the potential to reduce the rate of antibody-mediated platelet clearance and thus to improve treatment efficacy. while the benefits of customizing transfusion therapy have long been recognized (gmur http://bit.ly/ q heq), the routine, real-time selection of platelets by immunogenetic profile has remained impractical by current methods of dna analysis. to address this issue, we evaluated a process of platelet donor classification using buccal swab samples from apheresis platelet donors for determining the combined hla class i and hpa signature without dna purification using a novel "leansequencing" process. study design/method: under a study protocol and informed consent, we evaluated a process for collecting and classifying buccal swab samples from $ adult donors who had made ! donations in the previous months. samples (labeled with study barcodes) were shipped weekly to biomolecular analytics ("bmx") for preparation of "crude extracts" for leansequencing: this novel process combines a proprietary sample pooling strategy with a protocol that eliminates many traditional sample "clean-up" steps. briefly, after preparation of crude extracts, samples were amplified, pooled and analyzed (in separate runs) for , , , , , , , , , and for hla class (a,b,c) , the latter using a proprietary design that limits analysis to informative alleles in the hla sequence; this "information-theoretic" design permits direct allele and haplotype reconstruction using bmx-proprietary software. a subset of crude extracts was purified and analyzed side by side with positive and negative controls. results/finding: crude extracts from buccal swabs produced viable profiles for hpa as well as hla class i with significant savings in time-to-result. as an illustration, the table reports allele frequencies for platelet-antigens ("hpa") that are consistent with a predominantly caucasian or hispanic platelet donor population (http://bit.ly/ pdplf ) in hw equilibrium. similarly, hla-class i haplotype frequencies were determined. conclusion: leansequencing lends itself to the rapid determination of hla-class i and hpa signatures of platelets; the process with its streamlined lean protocol achieves additional time (and cost) savings by accommodating crude extracts produced from buccal swab samples collected and handled in accordance with the process validated in this project. the process could be readily implemented to another site using the elements and process developed. the "pool & plex" process and the early donor recruitment enables economies of scale for matched donor procurement. the serological characteristics and heritage background of a novel hla allele, hla-a * : chuan-fu zhu*, yong-hong song, xiang-min nie and wen-ben qiao. blood center of shandong province background/case studies: there are , hla alleles documented according to the imgt / hla sequence database in janury , and more than % of them were identified in the last years. besides sequences many of the novel hla alleles have not been analyzed their serological reactivities. hla-a * : allele was fist detected in our laboratory during our hla typing for china bone marrow donor program(cmdp). for further study, the serological characteristics and heritage investigation were performed. study design/methods: the routine hla tying for the potential donors from cmdp were performed by bi-allelic sequence-based typing method,using a commercial kit (rose europe gmbh, frankfurt, germany). in the case of no full matched hla typing results, group specific hlassure-se sbt typing kit (texas biogene inc., taipei, taiwan) was employed to identify the nucleotide sequences of the novel allele. fresh blood samples were collected of the proband and his family members with the consent, in order to nanalysis the serological reactivities and the possible haplotype associations to the novel allele. the hla serological specificity was indicated by one lambda(asn d)hla kit. results/findings: no full matched result was obtained at hla-a locus in hla typing for a donor,which suggested the possible existence of a novel allele. the latter nanalysis indicated that the proband have a nove nucleotide sequences at hla-a locus, the new sequences was most close to those of hla-a * : : : , but nucleotide substitution in exon , by nt c-a (codon acc-aac), which resulted in one aminoacid substitution ,thr-asn. the novel hla-a allele was officially named as hla-a background/case studies: anti-d is a frequent cause of hemolytic disease of the fetus and newborn (hdfn). as a rule, immunization occurs in d negative pregnant women, but occasionally anti-d is also observed in carriers of d variants. currently, maternal plasma analysis for determination of the fetal rhd status became an exciting new tool for the management of d-negative pregnant women, but one of the challenges in non invasive fetal rhdgenotyping is the presence of d variants in the pregnant women. we present a case of a year-old pregnant woman typed as ab , who delivered a baby affected by severe hdfn. the newborn was typed as b and presented a positive direct antiglobulin test (dat) with an anti-d identified in the eluate. the baby was treated by exchange transfusion and the mother's sample was investigated. study design/method: serologic testing was done by hemagglutination in gel cards. genomic dna was extracted from whole blood by spin column and all rhd exons were sequenced by sanger sequence method. results/finding: the mother's rbcs reacted with the four monoclonal anti-d used (igm clones p x and rum and the blends clones th ms and d d ) and were typed as c-c e-e . an anti-d was identified in her serum. molecular analysis showed the c>t and a>c in exon , the snp t>c changes in exon and the t>g nucleotide change in exon . the set of snps found is similar to the molecular background of dol , except for a>c change. conclusion: this novel set of snps found in this mother is related to a novel rhd allele leading to a partial d antigen involved in the production of an anti-d that can cause severe hdfn. this finding shows the need to elucidate the clinical significance of different rhd genotypes in various ethnic backgrounds. the and erytra v r (the routine reference platform) was performed. a total of immuno hematological tests ( abo/d grouping (including newborn samples), extended erythrocytic phenotype, antibody screening, antibody identification, dat) and crossmatches were performed on patient's whole blood samples. the erytra eflexis v r performance was evaluated according to a protocol that was designed to simulate the routine workload using the system in its two different configurations. concordance between systems was assessed and discrepancies were analyzed. the following performance metrics were assessed: time to first result (ttfr), turn-around time (tat) for the total workload from first result to last result (throughput, results/h), and manual "handson" time required as well as walk-away time, considering the two different configurations of the system. for the ease of use evaluation, different usability features were ranked and the number of steps and timing of the following activities were tracked: sample sort and loading, routine testing, post-run procedures, consumables used, and space requirements. a threshold for in vitrodetection of anti-d gamma globulin was also determined. v r analyzer and the reference method were obtained in . % of the abo/d tests (n ), , % of the antibody screening tests (n ), , % of the antibody identification tests (n ) and % of the dat tests (n ). there were discrepancies ( abo/d for the same patient, for antibody screening and antibody identification: in both cases, the erytra eflexis v r could conclude whereas erytra could not due to a poor reaction. use of the stat mode (incubator is reserved for urgent tests) proved its usefulness when testing several samples (time saving was more than min). detection threshold of the d antibody was assessed at . ng/ml ( . ui/ml) whereas the french recommendations are ng/ml. the possibility of interchanging the trays (reagents/sample) makes also possible to optimize the analyzer operation. the impressions of the technical staff were positive regarding esthetic and functional design, intuitive and easy use, as well as flexibility. v r results demonstrated velocity, sensitivity, as well as the ability to easily perform the routine workload of a medical analysis laboratory. erytra eflexis v r meets both the requirements for french regulatory in immunohematology and for iso accreditation. background/case studies: kell system antibodies inhibit erythropoiesis causing severe anemia in hemolytic disease of the fetus and newborn (hdfn). we report a case of hdfn secondary to anti-kpb that resulted in multiple intrauterine transfusions of kp (b-) donor cells and hemolytic anemia upon birth. case: a year old g p presented during her fifth pregnancy with anti-kpb with an initial titer measured of . by history, the anti-kpb developed during her third pregnancy which ended in a spontaneous abortion before antibody titers could be initiated. the patient's antibody titers peaked at during the fourth pregnancy which resulted in a healthy male without anemia or jaundice. . in the latest pregnancy, ultrasound was initiated with elevated middle cerebral artery doppler exams ( . moms) peaking at weeks. this resulted in three intrauterine transfusions. due to potential labor and the finding of reversed diastolic flow on middle cerebral artery doppler studies, a finding that has been associated with impending intrauterine fetal demise, caesarean delivery was performed at weeks gestation. the baby boy required phototherapy for hyperbilirubinemia. the indirect bilirubin at birth was . mg/dl with . g/dl hemoglobin. the baby typed as o positive, kp (b ) with a micro positive dat. the antibody workup revealed an anti-kpb. continued hemolysis required one more transfusion at weeks of age. the positive dat and passively acquired anti-kpb were no longer detected by weeks of age. his hemoglobin recovered to . g/dl with an indirect bilirubin of . mg/dl at weeks of age. all clinical signs of hemolytic anemia were resolved. study design/method: serologic testing included peg iat by tube methods. acid elution was performed using immucor gamma elu-kit ii. molecular testing was performed using immucor bio-array hea platform. results/finding: antibody identification on the mother was performed as well as alloadsorption studies to rule out other underlying alloantibodies. a new weakly reacting anti-s was detected on the day of the delivery. the baby typed as s positive however the anti-s was not detected in an eluate prepared from the baby's red cells. all of the intrauterine transfusion units were s negative. conclusion: to our knowledge only five case reports have been described for anti-kpb which resulted in moderate to severe hdfn. pregnant mothers with anti-kpb detected should be monitored closely. background/case studies: in some clinical cases, the c d-specific dat may be too insensitive to detect low, but significant levels of c d, or it may be inconclusive due to spontaneous red cell (rbc) aggregation. further, the dat is not well suited to quantify the number of immunoprotein molecules on rbcs, since a " " reaction corresponds to about molecules/ cell. a number of flow cytometric methods for the detection of rbc-bound c d have been published. however, these are mainly designed to quantify the fraction of rbcs with c d-sensitization. the aim of this study is to present a flow cytometric method for the quantification of the level of rbcbound c d. study design/method: ten microliters (ul) of : (after documenting experimentally that this amount ensured maximum binding of anti-c d) mouse monoclonal anti-human anti-c d (abcam, clone c ) were added to ul of a . % rbc suspension. after incubation for minutes at c, samples were washed x , and ul of : diluted anti-mouse-f(ab) -pe (ro , dako) were added. after incubation at c, samples were washed and resuspended before being acquired on a flow cytometer (becton dickinson facscanto ii). to enable calibration of fluorescence signals in antibody binding capacity (abc), a calibration standard (dako qifikit) stained with ro was run in parallel with all experiments. background fluorescence (in abc) was subtracted to yield net abc values corresponding to specific staining with anti-c d. the assay, in parallel with our routine dat (dc-screening i, id-card, gel card, biorad) was applied to a series of a rbcs stained with levels ( fold dilution, : - : ) of o serum with high titer anti-a. to estimate the normal range of rbc-bound c d, edta-stabilized samples from healthy donors were tested. finally, the assay was applied to a sample from a patient with clinical aiha with an inconclusive dat due to unspecific dat polyreactivity. results/finding: the correlation of the net level of rbc-bound c d (values ranging from to , abc) with level of -serum dilution (used to sensitize a rbcs) proved to be highly linear (logarithmic vs. logarithmic plot; r . , p < . ). compared with dc-screening , the sensitivity of the flow cytometric assay was superior. it detected c d sensitization at least dilution steps further. the median normal level of rbc-bound c d was abc (range - abc, n ). the assay enabled demonstration of specific c d-sensitization in the patient; the level of rbc-bound c d in the sample was significantly elevated ( , abc). conclusion: the presented flow cytometric assay is capable of quantifying the level of rbc-bound with a high degree of linearity and analytical sensitivity. further, it is capable of quantifying the level of rbc-bound c d in dat polyreactive samples. background/case studies: abo blood group system of red blood cells (rbcs) consists of a and b oligosaccharide antigens and anti-a and anti-b antibodies against these antigens, which are present in the sera of individuals who do not express the antigen(s)(landsteiner's law). because of the expression of those antigens on some epithelial and endothelial cells in the body, the abo matching is critical not only in blood transfusion, but also in cell/tissue/organ transplantation. in spite of the fact that both antigens and antibodies are involved, these genetic traits are specified by a single genetic locus of abo. forssman (fors) system is another rbc blood group system which consists in a glycosylation polymorphism specified by the gbgt gene. in humans, the abo and gbgt genetic loci are located on chromosome q , and the functional alleles encode a and b glycosyltransferases (at and bt) and forssman glycolipid synthase (fs), which catalyze the last biosynthetic steps of a and b, and forssman (fors ) oligosaccharide antigens. the molecular genetic bases for allelism of those two systems in humans have been well-elucidated. the abo and gbgt genes are also present in some other species in addition to humans. however, the presence/absence and functionality/non-functionality are species-dependent. molecular mechanisms/forces that created this species divergence, including human polymorphism, were unknown. study design/methods: utilizing genomic information available from gen-bank and ensembl databases, the gene maps of the chromosomal region surrounding the abo and gbgt genes have been constructed of vertebrate species. results/findings: extensive similarities were observed in the kinds, numbers, and orders of genes, as well as their chromosomal locations. however, numerous differences were also identified. these include chromosomal rearrangements, as well as the insertions and amplifications of specific genes. interestingly, the abo and gbgt genes were found located at the boundaries of chromosomal fragments that seem to have undergone frequent inversions/translocations during species evolution. conclusion: genetic alterations, such as deletions and duplications, are known to be prevalent at the ends of rearranged chromosomal fragments. therefore, the species-dependent divergence and polymorphism within species of those clinically important glycosyltransferase genes may have been resulted, at least partially, from unstable chromosomal structures neighboring those genes. alloimmunization despite phenotype matching in a patient with sickle cell disease and a complex rhce genotype jessica kneib* and emily coberly. university of missouri health care background/case studies: red blood cell transfusion plays an important role in the treatment of patients with sickle cell disease. sickle cell patients have a significantly increased risk of alloimmunization compared to the general population, and the standard of care is to provide phenotypically matched units for at least c, e, and k antigens to reduce this risk. unfortunately, the genotype and true alloimmunization risk may not always be accurately represented by the red blood cell phenotype, particularly in patients with complex partial rhce variants. study design/method: a year old female with a history of sickle cell disease, stroke, and iron overload presented for routine exchange transfusion. transfusion vol. supplement s the patient's blood type was o positive and her red cells had been previously phenotyped as c-, c , e-, e and k -. an antibody screen was positive, and antibodies against c and e antigens were identified in the plasma. the patient had only received phenotypically matched units negative for c and e antigens for all previous transfusions at our institution, based on her known red blood cell phenotype. blood samples were sent to a reference laboratory for molecular testing to look for partial rhce variants that might explain the antibody development. results/finding: molecular testing was performed to reveal the presence of two different partial rhce alleles, resulting in a predicted phenotype of d , c-, e-, partial c , partial e . the probable rhce genotype, rhce*ce-jal/rhce*ce g, results in partial expression of both c and e antigens. in addition to the known risk of alloimmunization against the absent c and e antigens, this result indicates that the patient is also capable of forming alloantibodies against the absent portions of both c and e antigens. based on these results, the patient's anti-e was determined to be an alloantibody and not an autoantibody. conclusion: although phenotypically matched units are standard of care for patients with sickle cell disease, the red blood cell phenotype may not accurately represent the alloimmunization risk in patients with complex partial rhce genotypes. in this case, molecular testing confirmed that the patient is at risk of developing alloantibodies against c, c, e, and e antigens. as the patient had already made alloantibodies against c and e antigens, it was determined that she would require units that were molecularly matched to her rhce variants for all future transfusions. this case demonstrates that phenotype matching for sickle cell disease patients may not be adequate to prevent alloimmunization in individuals with partial rhce variants. altered splicing in the rhd*weak d type allele associated with the skipping of exon in a pregnant woman and her newborn carolina bonet bub* , maria giselda aravechia , thiago costa , marilia sirianni , eduardo bastos , leandro santos , lilian castilho and jos e kutner . hospital israelita albert einstein, hemocentro unicamp background/case studies: rhd*weak d type is a variant commonly found in caucasians associated with a weak d phenotype. as previously reported (vege et al, transfusion ) the c. g>c change (p.g a), which characterizes the rhd*weak d type allele is a splicing variant that induces skipping of the whole rhd exon . we report an altered splicing in the rhd*weak d type allele associated with the skipping of exon in a pregnant women and her newborn with weak d expression. study design/method: the d antigen expression was evaluated with commercially available monoclonal anti-d reagents: blended igm/igg (clones th- /ms- ), igm (clones ms and p x ) and igg (ms ) in tube and on gel cards. c, c, e and e phenotyping were performed in gel. rhd genotyping was performed with the rhd beadchip platform from immucor. direct automated sequencing of the rhd exons and flanking intron regions was performed by the sanger dideoxy method. results/finding: both pregnant women and newborn samples were phenotyped as d w c-c e e . the samples showed weak hemagglutination reactions ( / ) with all anti-d clones used. rhd beadchip results showed the ls* signal indicating a possible deletion of exon in both dna samples. sequencing showed the c. g>c change and the intronic c. - t>a and c. - t>c substitutions, which are associated to the rhd*weak d type allele. conclusion: our results showed that c. g>c associated with c. - t>a and c. - t>c variations had probably a functional impact on splicing inducing exclusion of exon in both dna from mother and newborn. this finding is important to develop assays and interpret genotyping results, as current guidelines do not recommend anti-d igg prophylaxis for women with weak d type . background/case studies: sickle cell disease (scd) patients require red blood cell (rbc) transfusions to minimize disease-specific symptomatology. previous studies have shown that more than % of children with scd receive at least one rbc transfusion in their lifetime. both simple transfusions and erythrocytapheresis are associated with increased risk of rbc alloimmunization. published literature is lacking on the frequency of alloimmunization and geographical associations in pediatric populations, which is made difficult to compare due to lack of standardized categorization of what represents a pediatric patient population across studies. therefore, we looked at the alloimmunization rates of pediatric patients with scd in the unites states (us) and other countries. study design/method: a literature search was performed for studies published on alloimmunization rates of scd pediatric patients including hbss, sickle beta-thalassemia and hbsc. we evaluated the overall alloimmunization rates as number of alloantibodies per transfused patient and alloantibodies per transfused units across world literature and compared them using chi-square analysis. results/finding: fourteen studies reporting data to derive alloimmunization rates of pediatric scd patients were found. these included eleven us studies with , patients and studies from other regions (brazil, egypt and france) with patients. majority of patients included in the studies had hbss disease. patients received either episodic, chronic simple transfusions or erythrocytapheresis. age range for the us studies was to years and for the other countries to years. available data from us studies included a total of alloantibodies, the most frequent of which were antibodies to c, e, kell, m, s and kidd antigens ( . %, . %, . %, . %, . % and . % respectively). alloimmunization rates were calculated as antibodies per patient in some studies and antibodies per transfused units in other studies. we evaluated rates using both approaches as per available data. us had an alloimmunization rate of . % ( . to . , % ci) vs. . % for non-us studies ( . - . , % ci) (p . ) and a transfusion vol. supplement s more alloantibodies per transfused patient ( . vs. . , p . ). similarly, the number of alloantibodies per transfused units in the us, evaluated from five studies, was higher compared to a large french patient cohort ( Á vs. . , p Á ). average number of rbc units transfused per patient in the us was also higher compared to data from france ( vs. , p . ). conclusion: despite limited studies available to compare alloimmunization rates in pediatric scd patients in the us and other countries, the overall rates are higher in the us. though no definitive reasons could be concluded from the available data, limiting the number of rbc exposures, i.e. units transfused in non-critical conditions could lead to lower alloimmunization rates. results/findings: a post-transfusion sample was referred to the irl for a trxn investigation. there were no clerical errors; however, hemolysis was present in the post-transfusion plasma/serum. abo/rh and crossmatches using lo-ion tm were repeated on the pre-and post-transfusion samples with no discrepancies. the post-transfusion dat was positive with a negative eluate. the hospital requested another unit before the investigation was complete. antibody identification on the post transfusion sample with lo-ion tm was negative. suspecting a weak antibody, additional investigation using peg tm on both samples revealed an anti-c. no additional clinically significant alloantibodies detected in the pre-or post-transfusion samples using peg tm . conclusion: the patient experienced an acute hemolytic transfusion reaction due to anamnestic interaction of anti-c in the patient's plasma/serum against c antigen on the transfused cells. anti-c was not detected by our routine antibody identification techniques. the mma confirmed anti-e, -m and -c were clinically significant. laura bailey* , melissa grohotolsky , lisa deblass , bala carver and kip kuttner . health network laboratories, miller keystone blood center background/case studies: the en a antigen is a high prevalence antigen in the mns blood group system. the antigens of the mns system are carried on glycophorin a (gpa) and glycophorin b (gpb). anti-en a is a rare immune igm/igg antibody made by individuals who lack all or part of the gpa protein. anti-en a has been implicated in fatal htr and hdfn. the en(a-)phenotype can result from either a rare deletion of the gpa protein or the even rarer m k phenotype. because individuals with the m k phenotype lack both the gpa and gpb protein their red blood cells type as m-, n-, s-, s-, u-, en(a-), wr(b-) and have reduced sialic acid. study design/method: year old white mennonite female g ,p presented to her midwife for prenatal care with the intent of home delivery. she had a positive antibody screen by solid phase at the hospital transfusion service. an antibody identification panel was done in gel. testing for antibodies against selected cells (u-and u var ) in tube with peg enhancement and phenotyping was done. based on mns phenotype, anti-en a was suspected. the specimen was referred to an immunohematology reference laboratory (irl). the testing included phenotyping with unlicensed antisera, ficin treated panels by tube technique, allogeneic adsorptions for antibody exclusion and identification and antibody titration. following identification of anti-en a by the irl the midwife was advised to refer the patient to a maternal fetal medicine specialist at an academic center close to the patients' home. the midwife was also advised to consider autologous blood donation and /or testing of siblings. results/finding: testing by the hospital blood bank demonstrated positive reactivity in the antibody screen. the gel antibody panel ahg phase resulted in panagglutination and a negative autocontrol, suggesting a high prevalence antibody. the phenotype was performed and determined to be m-, n-, s-, s-, u -. outdated u variant reagent cells reacted in peg igg phase ruling out anti-u. anti-en a was suspected and the sample was referred to the irl. allogeneic adsorptions were performed to rule out antibodies to common red cell antigens. lack of reactivity on a ficin panel eliminated the presence of anti-u,-wr b . phenotyping with unlicensed anti-u was negative and unlicensed glycine soja demonstrated reactivity, suggesting that the patient is en(a-). the patient's phenotype is consistent with the m k phenotype. based on the lack of reactivity on the ficin panel, the antibody was identified as anti-en a fs. since anti-en a is extremely rare, this specificity could not be confirmed due to the lack of en(a-) cells and appropriate antisera. the baseline antibody titer was at igg phase without enhancement. conclusion: this case study describes the workup of a rare antibody in a prenatal patient at a tertiary care hospital. studies performed after the patient was transferred closer to home confirmed the anti-en a (fs) and genotyping was performed. three titers were performed for the remainder of the pregnancy and held at . although anti-en a has been implicated in hdfn, a healthy infant was delivered without complications. this patient should be monitored closely through future pregnancies. autologous donation and/or sibling testing should be considered in order to provide compatible blood for intrauterine transfusion or transfusions at or after delivery. background/case studies: a year old caucasian male diagnosed with hemolytic anemia and no previous transfusions was referred to the immunohematology reference laboratory (irl) for antibody identification and rbc genotyping. initial serologic testing by the referring facility and the irl demonstrated anti-d, anti-c and/or anti-g specificity with a positive auto control and igg dat. anti-g has an anti-d, -c specificity and is most frequently found in rr individuals exposed to r'r cells. the g antigen is present on rbcs expressing either rhd and/or c and very rarely on d-c-g (r g r) cells. both rhce*c and rhd genes encode ser which determines g expression. rare rhd variant antigens lacking ser are g-. study design/methods: serologic evaluation included tube testing using gamma lo-ion tm (immucor, inc., norcross, ga) enhancement, elution studies (gamma elu-kitv r ii (immucor, inc.)), edta glycine acid treatment (gamma ega tm kit (immucor, inc.)), allogeneic adsorptions with papain treated intact rbcs, reagent and patient-derived rbcs and antisera. molecular testing was performed with bioarray precise type ivd hea assay (immucor, inc.). results/findings: molecular testing revealed an rhce*ce genotype (with a c-e c e-predicted phenotype) and an otherwise unremarkable rbc typing report. serologically, the antibody(ies) demonstrated an anti-d, -c, -g specificity in the serum and eluate using r o r, r r , r'r, r g r and rr cells. this patient is predicted to be r r (dce/dce) therefore, anti-c is possible but an allogeneic anti-d or -g is exceptionally unlikely. allogenic adsorptions using papain treated r o r and r'r cells excluded anti-c and anti-d, leaving anti-g as the only explanation of the initial findings. reactivity with the patient's ega treated (dat negative) cells against the "neat" serum, eluate and anti-g antisera confirmed auto anti-g. conclusion: warm autoantibodies are common findings and often have an rh specificity; however, these antibodies usually demonstrate a broad but weaker specificity in the eluate or in the serum when enhancements are used. this anti-g had no reactivity with g-cells. the differentiation of anti-g from anti-d and anti-c is generally academic as transfusion recommendations are the same: provide rhd-, c-units. it is relevant and clinically important to determine the presence or absence of anti-d in rhd negative women of childbearing age who present with an anti-g specificity. if anti-d is a transfusion vol. supplement s excluded these women should receive rhig as part of their prenatal care. in this case differentiating anti-d, -c from an auto anti-g was necessary to provide transfusion recommendations. providing rhd-and c-units to give serologically compatible rbcs could result in formation of an allogeneic anti-e. automated eluates: comparison of solid-phase red cell adherence and gel automated eluate testing jayanna slayten* , christa voliva , kathy fletcher , heather vaught and tracie ingle . indiana university health, indiana university health (iu health) background/case studies: acid eluates (elu kit ii. immucor. norcross, ga) are to be tested via tube iat method in parallel with the recovered last wash per the manufacturer's package insert. finck et al (immunohematology ; : - ) demonstrated acid eluates may be tested in other platforms such as manual gel microcolumn assay (id-mts.igg card. ortho clinical diagnostics. raritan, nj) and automated solid-phase red cell adherence systems (echo. immucor. norcross, ga). our study looked to compare the use of the automated gel microcolumn analyzer (vision, ortho clinical diagnostics. raritan, nj) to the solid-phase red cell adherence analyzer (echo, immucor. norcross, ga) for the testing of acid eluates in a regional midwestern transfusion service. study design/methods: twenty patient samples, less than days from collection and drawn in edta, were used to prepare acid eluates (elu-kit ii. immucor. norcross, ga) while retaining the last wash to be tested in parallel. two samples were > dat positive, were weakly dat positive and were dat negative. the prepared eluates were observed for color (bluegreen/bg, blue-brown/bb, blue-purple/bp), and the ph was documented for the prepared eluate (whatman . - . ph. whatman international. maidstone, england). the prepared eluates and last washes were tested on the vision and echo against an antibody screen. if the antibody screen was positive, the sample was tested against an antibody panel to determine specificity/pan-reactivity. prior to the eluates being tested on the automated platforms, they were spun for minutes twice to remove any rbc debris which could cause false positive reactions. results/findings: the eluates prepared ranged in color: bb, bg and bp. the ph of all eluates ranged from . - . with the highest percentage of eluates at a ph of . ( %). sixteen of the eluates tested yielded the same results in both automation platforms (concordance of %). four eluates with different results are summarized in table . conclusion: the study demonstrated that both analyzers may be used for eluate investigations. both methods yielded apparent false positive results on samples which were initially dat negative. the echo was more sensitive, yielding false positive results ( ) when the vision was negative, while the vision was false positive with one eluate with echo negative. there was no apparent association in the non-correlating eluate results in relation to color of eluate, age of sample when eluate was prepared, or ph of the eluate. a larger study may be able to better elucidate the apparent false positive results noted in this study between echo and vision eluate study. background/case studies: blood agglutination observed by landsteiner in led to the discovery of human blood groups. in the abo system > alleles have been described. the glycosyltransferase encoded by most results in weakened expression of a or b or the null (group o) phenotype. as testing methods and reagents improve, donors may appear to change their abo type. here we describe a frequent group o blood donor ( units over years) who is actually a w . study design/methods: donations were tested with the pk instrument (beckman coulter inc.). routine forward and reverse abo testing was used to investigate the discrepancy. molecular studies were performed by dna sequencing of abo introns , and and exons and . specific primers located in the flanking intron regions of the blood group gene were used to amplify relevant exons by pcr. the template used is genomic dna extracted from whole blood collected in edta. pcr-amplified exons are subjected to bidirectional dna sequence analysis using standard sanger dideoxy chemistry. seqscape software (abi) was used to analyze sequence data by comparing the obtained sequence to a reference sequence from ncbi. results/findings: serologic results are shown in table . tests with anti-a, -a , -b anti-a,b were negative as were the a cells in reverse testing. the results of dna sequencing of abo introns/exons are shown in table . the significant changes were found in exons and . in exon there was a nucleotide (nt) deletion of g which resulted in a shortened transcript due to a stop codon, and another nt substitution lead to the amino acid change gly ala. mutations in exon included a nt substitution causing a pro -leu change and a nt deletion c resulting in shortened transcript. conclusion: serologic testing of the donor plasma with a cells was nonreactive revealing the abo discrepancy. molecular testing confirmed the donor genotype is heterozygote a/o [abo*o. . /abo*aw. ] which predicts a w phenotype. normally, donor rbcs are tested with anti-a and -b and the reverse type confirmed by testing the with a and b cells. this abo discrepancy was caused by the presence of anti-a in the plasma causing the forward and reverse type to be interpreted as group o. according to fda guidelines, the donor is technically group a, and as such all donations need to be labeled as group a. the donor was contacted and instructed to cease donating blood for transfusion. if donations continue, the unit labeled group a would likely test as group o at the transfusion facility resulting in an fda reportable error. there are numerous reports in the literature of the relative insusceptibility of a cells to destruction by anti-a, however, there is one hemolytic transfusion reaction to a x blood transfused to a patient with a potent anti-a titer > : . (schmidt, nacarrow et al. ) . a review of transfusion recipients of the donor reported here did not reveal any untoward reaction after transfusion. a transfusion vol. supplement s extraction of gdna from edta-anticoagulated whole blood from pilot tubes derived from the unit. dna extraction from whole blood is performed on up to blood tubes using the biorobot universal system (qiagen). there is no information on the maximum acceptable age of the blood for this purpose, either from the vendor or in peer-reviewed literature. we set out to assess if blood up to days post collection yielded suitable gdna for downstream rbc genotyping. study design/method: edta blood tubes collected from random blood donors were used to extract dna from microliters of whole blood on day , and days post collection. blood samples were stored at - c before and after extraction. tubes were brought to room temperature and rocked before loading on the biorobot. extraction was performed using the mdx blood minikit (qiagen). resulting dna samples were assessed for gdna yield and absorbance a /a using a nanodrop (thermo scientific). the extracted gdna was tested using precisetype hea molecular beadchip ("hea", immucor) and failure rates on both the biorobot and the hea were assessed. results/finding: all three extractions were successful with no invalids (result ) on the biorobot universal report. no evidence of visible clots or splatter during extraction was noted by the technologist. out of the samples, samples were chosen at random and concentrations were measured using nanodrop for each of the extracted plates. dna concentrations ranged from . to . ng/ul. all readings with the exception of ( . ng/ ul) had concentrations > ng/ul. interestingly, the one that was < ng/ ul on day , yielded > ng/ul on day and post collection. over the next months, sets of samples were extracted and tested by hea. eighty-three ( . %) failed extraction and ( . %) failed hea. none of the samples that failed extraction were or days post collection; none of those that failed hea were days post collection; . % were > < days post collection. conclusion: based on these results it can be concluded that edta blood tubes up to days post collection can be used as a source of gdna for rbc genotyping without negatively effecting the concentration of the resulting dna samples and the validity of the resulting genotyping. case study: investigation of persistent negative antibody screens on patients receiving daratumumab raeann thomas , carlos villa , rachel davis-rauser* , helen carpenter and vrunda patel . university of pennsylvania, hospital of the university of pennsylvania background/case studies: daratumumab is an anti-cd monoclonal antibody therapy that received fda approval for treatment of multiple myeloma in . communications suggest all patients receiving therapy would have a positive antibody screen because cd is a common antigen expressed on red blood cells. currently, patients have been treated with daratumumab at a large academic medical center. a wide variation of reactivity was observed, including patients who were found to have consistently negative antibody screens. while there are several potential causes, neutralization of anti-cd antibodies could easily be tested by applying established techniques used for neutralizing antibody reactivity. study design/method: samples received were drawn as a standard of care. indirect antiglobulin testing was performed using solid phase red cell adherence and gel. neutralization was performed by adding equal volumes of negative daratumumab treated patients' plasma with positive daratumumab treated patients' plasma. a dilution control was made by adding saline to each positive patient's plasma. samples were incubated for hour at room temperature and antibody screens were repeated. serial two-fold dilutions were also tested to determine if the neutralization could be titered. testing was repeated using various positive patient samples to determine if negative/positive combinations resulted in different reactivity. results/finding: all control samples remained positive. positive/negative samples were negative in solid phase testing across all patient combinations at : dilutions. variable reactivity was observed in gel. serial dilutions showed that neutralization for negative patients was observed up to a : dilution. conclusion: results suggest that patients' plasma may have a substance that neutralizes the antibodies. there is a possible correlation with patients who have persistent negative antibody screens and patient response to daratumumab. additional studies are necessary to uncover how this correlates to patient outcomes. further studies using a standardized daratumumabspiked sample will be conducted. background/case studies: the mns blood group is a red cell antigen system located on glycophorin a (gypa) and glycophorin b (gypb). individuals lacking gypa or both gypa and gypb on their red blood cells may develop a rare antibody against the en (a) antigen. the en (a) antigen is a highprevalence antigen, located on gypa. we present a case with a rare red cell phenotype and alloimmunization to the en (a) antigen. a y/o g p at approximately weeks gestation was discovered to have an anti-en (a) antibody in her plasma on a prenatal type and screen. this was worrisome for both mother and fetus, as the en (a) antibody is of igg isotype and has been implicated in both acute and delayed hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (hdfn) [ , ] . further testing with red cell antisera revealed that the patient lacked m, n, s, s, and u antigens. a multiplex, allele-specific, pcr platform we commonly use to detect the presence or absence of red cell gene sequences failed to amplify genes specific for the m, n, s, s, and u antigens. these findings were consistent with a null phenotype for both gypa and gypb antigens, i.e. m (k) m (k) phenotype. the patient's husband and father of her unborn baby demonstrated a m n-s s phenotype by the same serological and molecular means. given the exceedingly rare incidence of en (a-) individuals (positive frequency > . ), clinical encounters with alloantibodies to this antigen are limited in our experience and in the literature [ , ] . however, the existing data gives credence to its association with transfusion reactions and hemolytic disease of the fetus and newborn (hdfn). the consensus in this case was to work her up as a high-risk pregnancy with frequent intensive monitoring which involved frequent monitoring of antibody titers. if transfusions were required for the mother or fetus, our options were to either search for rare units lacking the en(a) antigen via rare blood donor registries or directed donations from family members who match the patient's phenotype. at term, the patient underwent induction of labor and successfully delivered a health baby boy by vaginal route. the delivery was without event. no transfusions were necessary antepartum or postpartum. study design/methods: n/a results/findings: n/a conclusion: anti-en(a) is a rare antibody and there is limited data about its potential clinical sequelae, which is concerning in a pregnant woman. providing this patient with rare en(a) negative red cells via national or international blood donor registries would have been an arduous task if needed. this patient had many compatible family members available and willing to donate blood. the m(k) null allele (s) within this family is likely due to a genetic recombination among the gypa and gype genes rather than a mutation in both the gypa and gypb genes [ ] . this results in the absence of glycophorins a and b and the constitutive antigens of the mns blood group system. our patient was exposed to the en(a) present on glycophorin a on her unborn baby's red cells (inherited from father) in utero with subsequent alloimmunization. in conclusion, this case report demonstrates a clinical approach in identifying a rare anti-en(a) antibody in a prenatal sample. the clinical finding of a rare antibody in which there is limited data requires leveraging every resource available in order to predict its behavior and provide safe blood products to patients who may require it. background/case studies: transfusions are essential for patients with scd and thalassemia to maintain growth and development during childhood and to sustain good quality of life during adulthood; however, the development of red blood cell (rbc) alloantibodies and autoantibodies complicates transfusion therapy in such patients. routine phenotyping of blood recipients and the use of phenotype-matched blood units for transfusion has been useful to lower the occurrence of red cell alloantibodies in chronically transfused patients with thalassemia and scd. nevertheless, extensive phenotyping is expensive, laborious and cannot be performed in certain situations. the molecular understanding of blood groups has enabled the design of assays a transfusion vol. supplement s that are being used to better guide matched red blood cell transfusions and to maintain an inventory of units dna typed. based on this, our aim was to evaluate the clinical outcomes of molecular matching performed at different levels during years for patients with scd and thalassemia. study design/method: blood group genotypes were determined in dna samples from chronically transfused patients with scd, in patients with thalassemia and in dna samples from blood donors. laboratory developed tests (ldts), hea beadchip tm , rhd beadchip tm , rhce bead-chip tm , and sequencing were used to determine the genotypes among patients and donors. molecular matching was performed in levels: ( ) rh and k matching; ( ) extended matching and ( ) extended matching including rh variants. we considered the total of red blood cell units requested for each patient and a number of donations per year for the compatible donors. results/finding: according to the patients needs we performed molecular matching for % of our thalassemic and scd patients at level , % for scd patients and % for patients with thalassemia at level and % for patients with scd and % for patients with thalassemia at level . the patients were transfused with a median of . rbc units. after three years of molecular matching, we observed that this transfusion strategy avoided new alloantibodies development and hemolytic transfusion reactions in all studied patients. conclusion: molecular matching has shown clinical benefits to the patients with scd and thalassemia, contributing significantly to reduce the rates of alloimmunization to - % with c e k matching and < % with extended matching. improvements in the clinical outcomes of the patients have also been observed as shown by an increase in their hb levels and reduction in the % of hbs in scd patients, better in vivo rbc survival and diminished frequency of transfusions. allahna lilly elahie* and sandra fazari. hamilton regional laboratory medicine program background/case studies: the ideal manual backup method for an automated antibody detection system is an important choice. currently, our backup method is saline tube ( drops plasma, minutes incubation). the change to either a low ionic strength solution (liss) or polyethylene glycol (peg) method would reduce incubation time to minutes and specimen volume to drops, both important laboratory considerations. objectives of this study were to compare the relative sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of peg and liss, and to determine the most appropriate manual backup method for the existing automated solid phase system. study design/method: a total of specimens were compared utilizing: automated solid phase red cell adherence assay (sprca) with manual tube peg and liss, some samples were not sufficient quantity to test in liss. identification panels were used to determine: clinically significant antibodies, warm autoantibodies, and nonspecific reactions. calculations were based upon comparison to sprca. results/findings: a total of clinically significant antibodies were detected using sprca technique, as well as warm autoantibodies and nonspecific reactions. peg demonstrated the highest sensitivity and lowest specificity while liss was least sensitive and most specific for clinically significant antibodies. for warm autoantibodies, liss was more sensitive than peg with both being % specific. both reduced the detection of nonspecific reactions. while peg had more nonspecific reactions ( versus ), it identified more clinically significant antibodies ( ) than liss ( ). (table) conclusion: ultimately, the decision to choose a manual backup method must be based upon the highest sensitivity for clinical significant antibodies so as to minimize failure to detect one. peg was selected as the backup manual method even though peg has a higher sensitivity to nonspecific reactions. this study clearly demonstrates the interplay and tradeoffs between methods, which are important to understand and consider when making method choice decisions. comparison of thiol reagents in denaturing cd on rbcs patricia a arndt* , anthony salazar and regina m. leger . american red cross blood services, long beach memorial medical center background/case studies: monoclonal anti-cd , e.g., daratumumab (dara), which is used to treat patients with multiple myeloma, causes positive indirect antiglobulin tests (iats) due to expression of cd on red blood cells (rbcs). this serologic reactivity cannot be removed by adsorption so other methods have been developed to detect/identify underlying alloantibodies. one popular method is to denature the cd antigen by treatment of rbcs with thiol reagents, e.g., dithiothreitol (dtt) or aminoethylisothiouronium bromide (aet). chapuy et al described ( ) and validated ( ) ), and % aet (ph . ) as per the aabb technical manual, th ed. these treated and untreated rbcs were stored in alsevers at c and tested on days , , , and by two methods: ) polyethylene glycol (peg) iat using plasma from two myeloma patients who had received dara (plasmas from total dara patients were tested with reactivity - ), and ) flow cytometry using phycoerythrin (pe)labeled anti-cd . rbcs were also tested on days and or with a serum containing anti-k by peg iat. results/findings: the . m dtt in ph . pbs had a final ph of . and the ph of the commercial . m dtt was . . results are in table ; flow cytometry results from days , and (data not shown) were similar to those from days and . rbcs treated with . m dtt (both sources) or aet were nonreactive with anti-k and plasma from all dara patients and gave very low results (% positive events) with pe anti-cd by flow cytometry for up to days after treatment. rbcs treated with . m dtt reacted similarly to untreated rbcs with anti-k and dara plasmas, and showed only some weakening ( - %) of reactivity with pe anti-cd . background/case studies: clinically significant hemolytic disease of the fetus and the newborn (hdn) is often caused by feto-maternal rhd incompatibility. with the discovery of cell-free fetal dna (ccfdna) in maternal plasma, it became possible to determine the rhd genotype of the fetus using non-invasive techniques. however, the reliability of the non-invasive prenatal rhd test (nip rhd) is dependent on sufficient amounts of cffdna in the maternal plasma sample. recent studies show that the fraction of ccfdna in maternal plasma varies significantly between pregnant women and is inversely related to maternal body mass index (bmi). thus, high maternal bmi, may impair the validity of nip rhd. the aim of this study was to examine the effect of maternal bmi on the correctness of nip rhd and the correlation of maternal bmi with fraction of ccfdna to total free dna in the sample. study design/method: measurements of body height and weight of pregnant rhd negative women in gestational week were obtained from patient records and used for the calculation of maternal bmi. data on bmi were combined with the results from nip rhd (real-time pcr targeting rhd exon and ) and sample fraction of ccfdna (measured as threshold cycle [ct] value of rhd) to total free dna (measured as ct of ccr ) in gestational week . the correctness of nip rhd was determined by correlation with postnatal serological rhd determination. results/finding: a total of pregnant women were included. nip rhd was positive in / ( %), negative in / ( %) and inconclusive in / ( . %). compared to the postnatal rhd type, / ( . %) of nip rhd results were false positive (fp) and / ( . %) were false negative. in / ( %) of inconclusive nip rhd, the postnatal rhd type was positive. mean bmi (n ) at gestational week was . ( -and -percentiles: . - . ). there was no difference in mean bmi between individuals who tested inconclusive or false negative by nip rhd compared to the remainder (p , ). the fraction of ccfdna was calculated for randomly selected nip rhd true positive cases. median ccfdna ratio was . (the distribution had a highly positive skew, -and -percentiles: . - . ). there was no statistical correlation between bmi and fraction of ccfdna to total free dna (r , ; p . ). conclusion: neither the correctness of nip rhd test result nor the fraction of cffdna to total free dna appear to be correlated to maternal bmi with regard to maternal plasma samples drawn in the th gestational week. delayed hemolytic transfusion reaction due to anti-lan antibody: a case report. adla dh angelina*, suneeti sapatnekar and suzanne bakdash. cleveland clinic background/case studies: lan is a high-prevalence antigen and the sole member of the lan blood group system. anti-lan is a very rare igg antibody, with conflicting information regarding its clinical significance and potential for hemolysis. we report a case of delayed hemolysis in a patient with anti-lan antibody. study design/method: the patient's medical record and available literature were reviewed. results/finding: an year old man, o-positive, with a history of heart disease and bladder cancer was admitted for radical cystectomy. the antibody screen and panel were panreactive by multiple test methods (gel, liss, peg) with negative autocontrols and dat and a saline antibody titer of , suggestive of an antibody to a high-frequency antigen. anti-lan antibody was identified by a reference laboratory. only in , donors are lan-, but two frozen rbc units were locally available and transfused postoperatively. the patient's siblings were tested; one o-positive, lan-sibling was identified. nine months later, the patient was admitted for surgical management of metastases. at this time, the antibody screen was weakly reactive with cell and new antibodies were ruled out. blood conservation measures were instituted, including limited blood draws and cell salvage for surgery. due to bleeding during and after surgery, lan-rbc units were transfused over days, including rare donor units and units from the sibling donor. another surgical procedure was then performed; by post-operative day , the patient had symptomatic anemia with hemoglobin (hb) . g/dl and serially increasing troponin. no lan-rbc units were available. four rbc units untested for lan were transfused without adverse event; the units were presumed lan but crossmatch compatible and phenotypically matched for the patient's other antigens. a post-transfusion hb of . g/dl was maintained for days. the antibody screen was negative on day post-transfusion, but strongly panreactive on day , with a positive dat (igg , c ) and anti-lan antibody identified in the plasma and eluate. there was also evidence of extra-vascular hemolysis, including a progressive decrease in hb from . g/dl on day to . g/dl by day with no bleeding identified, and increase in total bilirubin and ldh (peak . mg/dl and u/l on day ) with normal haptoglobin. the patient was febrile with leukocytosis, but had negative cultures and no other evidence of infection. a lan-rbc unit was transfused on day with good response (hb . g/dl). the patient remained stable and was discharged to a skilled nursing facility days later. conclusion: transfusion of lan rbcs caused a resurgence of anti-lan antibody and a delayed hemolytic transfusion reaction days after transfusion. the rarity of lan-units may require a patient with anti-lan to be transfused with lan units, but close monitoring for delayed hemolysis is necessary even if the antibody is not demonstrable at the time of transfusion. delayed serologic transfusion reaction caused by auto-anti-f. karen yunker* , andrea gerner , lynne stewart , carol sostok , mollie bell and gregory r halverson . st. elizabeth healthcare, hoxworth blood center background/case studies: anti-f was first described in by rosenfield and coworkers in the serum of a hemophiliac who had been multiply transfused. the f antigen is comprised of the c and e antigens alligned in cis on the same chromosome, and is the th antigen assigned to the rh blood group system (isbt rh ). it is capable of causing significant transfusion reactions and mild hdfn. we report in this case a year old caucasian male, admitted for evaluation of suspected t-cell lymphoma, who appears to have had a delayed serologic transfusion reaction (dstr) due to auto anti-f. abstract study design/method: antibody screen and compatibility testing was performed by automated solid phase (echo and neo, lmmucor, inc). red cell phenotyping was done by standard tube testing with commercial reagents following the manufacturers instructions. molecular genotyping was performed using the bloodchip assay (grifols, san marcos tx). elution studies were performed using the elu-kit ii (lmmucor, inc.) results/finding: the initial antibody screen (as) was negative and the patient was transfused unit o-rbcs. two weeks later the patient received an additional o-rbc. within days the hgb had decreased from . to . g/dl, the as and direct antiglobulin test (dat) were now positive, and ounits were incompatible. anti-f was identified in the patient's plasma and eluate. three additional units were requested for transfusion. due to the rarity of o-f-rbcs, the patient was transfused r r (dce/dce) rbcs with no reported complications. the patient was discharged to follow up in clinic. molecular genotyping showed the patient was rhd deleted (rho* del) and had normal rhce (rhce*ce/rhce*ce) genes which predict a d-c-e-c e f phenotype. the rh phenotype and as was repeated on a sample collected days later. the c typing was micro positive, mixed field only after minute incubation. the other rh antigens were not mixed filed, and the as was non reactive. however, the dat was weakly positive with anti-lgg. no elution study was performed. conclusion: the expected post hour hgb increment from the receipt of a standard unit of blood should be near g/dl (or % hct.) throughout this patients hospitalization, the post-transfusion increments did not fully achieve this expectation. the first transfuion resulted in a . g/dl increase, and the second unit was only . g/dl. the last transfusion of units increased by only . g/dl. less than three weeks later, the rhc antigen typing was microscopic/mixed field only after extended incubation, indicating the removal of r r units was nearly complete. in a case from , ohto and kariyone (transf. ; vol , no. ) reported a cr Ásurvival study of f rbcs in a patient with anti-f. they showed that the initital survival of f cells was fairly normal, however, after days, there was a sudden increase of red cell destruction, and by day all f cells were cleared from the circulation. it is not unusual to find auto-anti-f as many have been reported, however, it is unusual to find the auto-antibody has caused the clearance of three units of f-negative blood. this patient will be monitored to see if the autoantibody recurs and determine if it still has anti-f specificity. background/case studies: use of dithiothreitol (dtt) treated reagent red cells (rrbc) is increasing in blood banks as an effective way to negate the interfering panreactivity caused by daratumumab, an anti-cd drug for treatment of multiple myeloma. daily preparation of dtt-treated rrbc for testing of individual patients is burdensome for the laboratory and may delay patient care. we evaluated the effectiveness of batch-prepared dtt-treated rrbc, stored up to days after treatment, in antibody detection tests. study design/methods: in-date rrbc (ortho clinical diagnostics, raritan nj) were selected based on phenotype to match the antisera to be tested. rrbc were treated with . m dtt (sigma-aldrich, st. louis mo) and stored in reagent red cell diluent. rrbc were tested with commercial antisera (ortho clinical diagnostics, raritan nj and immucor, norcross ga) per the manufacturer's instructions for specificities from the rh, duffy, kidd and mns blood groups (see table ). patient source antibodies (anti-d, anti-c) were also tested. testing was performed before dtt treatment, on the day of dtt treatment and up to days following the dtt treatment of rrbc. reactions were graded using standard serological grading of (negative) to (positive) reaction strength. stored dtt-treated rrbc were also observed for hemolysis during the storage period. results/findings: see table for a summary of results. commercial monoclonal and human source antisera, and patient source antibody, were reactive with the dtt-treated rrbc throughout the storage period. reactivity decreased by less than one reaction grade for all antisera and patient source antibodies tested. mild to moderate hemolysis was noted in the dtttreated rrbc's during the storage period. conclusion: dtt-treated rrbc showed adequate reactivity with various red cell antisera after storage for up to days. this suggests that dtttreated reagent red cells can be stored for at least days and used for the detection of alloantibodies with minimal effect on detection ability. batch preparation and storage of dtt-treated rrbc can increase testing efficiency and decrease turn-around-time when performing pre-transfusion testing for patients receiving anti-cd therapy. interference: more than just kell? marilyn stewart*, angela treml and geoffrey wool. university of chicago background/case studies: daratumumab (dara) is an anti-myeloma and anti-lymphoma agent that is known to interfere with routine blood bank antibody screening tests. dara is an igg monoclonal antibody that binds cd that is present on the red cell surface. at the university of chicago blood bank, we have seen many patients treated with dara and were showing this interfering reactivity. it has been well described that cd is a disulfidelinked molecule and its immune epitopes are disrupted by reducing agents such as dtt. we performed a validation of dtt-treatment of reagent rbc to abrogate dara interference. study design/methods: the validation was done to prove that dtt treated red cells could be used to screen patients receiving dara and still detect clinically significant allo-antibodies. screening cells and panel cells selected for dtt treatment were those rbc homozygous for clinically significant antigens, therefore allowing rule-outs of clinically significant antibodies in patient plasma. several patients that had received the dara drug protocol were selected for testing as well as many patients that had allo-and auto-antibodies (but not dara treatment). reagent screening cells and panel cells were treated with . m dtt prepared using the sop from judd's methods in immunohematology and the aabb technical manual. the treated cells were preserved between testing episodes using alsever's solution, stored at abstract - c, and observed for hemolysis (none was seen) for up to days. all immunohematology testing using dtt-treated cells was performed using gel methodology. untreated and dtt treated cells were tested with anti k before any patient testing was done. the untreated cells reacted - with the anti k, and the treated cells were negative. these controls were run and tested each time dtt treatment was done. thirty eight patient samples, including six dara patient samples were tested. results/finding: of the six patients who had dara interference in their untreated antibody screens, all samples had negative reactions with the dtt treated cells except one patient, which had weak reactions in one cell. this specimen was repeated three times and all repeats had weak positive reactions in the same cell. this sample was sent to the arc reference lab for dtt treatment and all clinically significant antibodies were ruled out. patients with allo-antibodies present in their plasma did react with the dtt treated cells as would be expected based on the underlying alloantibody, with the exception of newly formed anti-e antibodies in patients. plasma from these four patients with a nascent anti -e all showed no reactivity with dtt treated cells. plasma from fourteen patients with a long history of anti-e (greater than months) did react with the dtt treated cells. conclusion: dtt treatment eliminates dara interference as previously described, but also unexpectedly lessens the ability of treated cells to react with nascent anti-e. because of the negative testing with some of the alloanti e antibodies, dara-treated patients at ucm will be given both kell and e negative blood if they have immunohematology testing performed using dtt reagent cells. mahboubeh rahmani* , monique scott , garcia curtis , ellice wong , alexa j siddon and christopher a tormey . yale-new haven hospital, va connecticut healthcare background/case studies: benign ethnic neutropenia (ben) seen in approximately % to % of persons of african descent is characterized by neutrophil count of < . x /l with no obvious cause and no increased susceptibility to infection or any other adverse effect. at present, there is no laboratory assay used to identify this condition and it is generally diagnosed on a clinical basis. in this study, we investigated whether duffy (fy) blood group phenotyping would be a potentially useful modality to help identify patients with ben; such testing could potentially be used as a surrogate test to prevent unnecessary further work up including bone marrow biopsy in the correct ethnic and clinical setting. study design/method: cases included patients clinically diagnosed with ben; and controls were chosen randomly from the pools of patients from whom a cbc and type and screen were checked for any other reason. cases and controls were tested for the rbc antigens fy a and fy b phenotype using serologic methods. the fy phenotype, absolute neutrophil count (anc), white blood cell (wbc), hemoglobin level, platelet count, and medical diagnoses were extracted from the medical record. where appropriate, data were compared statistically using the mann-whitney u test with significance set at p< . . results/finding: subjects who were clinically identified as having probable ben included patients (mean age . ; all self-identified as african-american; / were male) and controls included patients (mean age . ; self-identified as african american; ( / male). all of the cases ( %) diagnosed with ben had fy(a-b-) phenotype. mean anc ( . x /ul) and wbc counts ( . x /ul) were significantly lower in the cases with ben and fy(a-b-) phenotype (p . and . , respectively) compared with controls (mean anc . x /ul ; mean wbc count . x /ul). there was no significant difference in mean platelet counts ( x /ul vs x /ul; p . ) or mean hemoglobin levels ( . g/dl vs . g/dl; p . ) between the two groups. none of the patients with ben had an accompanying marrow-suppressive hematologic disorder based on record review; however, subjects in the control group had accompanying conditions that were potentially marrow-suppressive including hepatocellular carcinoma, acute myeloid leukemia, and myelodysplastic syndrome. conclusion: testing for fy phenotype could potentially be used as a surrogate test in patients with chronic neutropenia in a correct ethnic and clinical setting for the diagnosis of ben. further studies regarding fy phenotyping comparing controls with neutropenia for any reason to our ben population are in progress to better determine the positive predictive value. these tests were compared to the provue for concordance. additional samples tested with anti-igg,-c d were correlated against tube testing for the dat and antigen typing for: c, c, e, e, and k. results/findings: the ih- had % concordance for all blood grouping assays. for ahg assays, the ih- detected an anti-jka e, anti-fya warm antibody, antibody to a high incidence antigen and a warm antibody that were missed by the provue. the ih- identified one additional anti-e not identified on the provue. discrepancies were also noted with the non-cord dat results. five samples were positive on the ih- with anti-igg,-c d vs. tube testing; reflecting the increased sensitivity of gel methodology over tube. the table below summarizes the results. conclusion: this study demonstrated that the ih- analyzer and associated ih-system tm gel cards are equivalent to the ortho provue. with random access capability, minimal operator touchpoints, broad test menu and excellent assay performance, the ih- is an ideal immunohematology system for the hospital transfusion service environment. chris elliott*, susan barnes, fiona lisle, debra smith and whitehouse natalie. background/case studies: the erytra eflexisv r (grifols) is a new fully automated, mid-size analyzer that performs pre-transfusion compatibility testing using dg gelv r technology. erytra eflexisv r analyzer performance, usability and adaptability to different workflows was evaluated in the routine environment of a large uk acute hospital transfusion laboratory. study design/methods: a comparison study was performed between the erytra eflexisv r and erytra (our routine system providing the reference platform). a total of tests were performed on , adult patient samples and donor red cell units. erytrav r eflexis performance was evaluated according to a series of scenarios designed to simulate routine workload using the system in different configurations. concordance between systems was assessed and discrepancies analyzed. time to first result (ttfr), overall turn-around time (tat) total workload from first result to last result (throughput, results/h), manual "hands-on" time and walk-away time were all recorded. for ease of use evaluation, we ranked usability features with number of steps and timing of activities including sample sort and loading, routine testing, post-run procedures, consumables used, and space requirements. fault recognition and messaging was assessed by simulating failures e.g. reagent absence. results/findings: blood grouping, antibody screening, antibody identification (using panels), direct antiglobulin test, red cell phenotyping and serological crossmatching were successfully tested. concordant results between the erytra eflexisv r analyzer and reference method were obtained in . % of samples tested. there were discrepancies, all antibody screening ( false positives, failure to detect a very weak prophylactic anti d and positive reaction not detected on the erytra but panels on both systems suggested a genuine anti cw). ttfr and tat depended significantly on a number of factors including; number and variety of tests requested and whether the stat functions were activated. the analyser seemed to prioritise antibody screening prioritization of the group, especially for stat samples, was considered preferable the laboratory team found the software easy to use with some improvements over existing ertyra software. physical design of the analyser was considered good with easy access to almost all areas. probe changing was quick and simple. while the analyser successfully flagged all error scenarios some messages were considered misleading and could be better phrased. conclusion: results showed the erytra eflexisv r offered a robust automated solution for routine transfusion testing. the device could comfortably deal with a medium laboratory (processing - group and screens per day). it is very flexible being able to deliver grouping, antibody screening and identification, dat, phenotyping and serological crossmatching ,compensating for its' single probe and wash station by clever use of incubators, centrifuges and design features. this allows a compact design with maximum flexibility without compromising on turnaround times cp evaluation of two monoclonal anti-e as reagents for the detection of the rh e antigen and its variants gregory a. denomme* , kathleen bensing , michael schanen , cindy piefer , randall w. velliquette , christine lomas-francis and connie m. westhoff . immunohematology reference laboratory, versiti/bloodcenter of wisconsin, immunohematology and genomics laboratory, new york blood center background/case studies: monoclonal antibodies are used as reagents for automated and manual phenotyping. false negative phenotypings have implications for variant antigens; e.g. altered c antigen mistyped as a cblood unit stimulating anti-c in a c-recipient. the development of new / / / cecf / / / rhce*ce or rhce*ce compound heterozygotes ce g ce g or ce c, g or ces or ceti / / / ce g ce c, g or c, g / / / ce g ces or cemo or ceek or ceek(var) or cern / / / ce c, g ce c, g or cemo or ceti / / / ce c, g/ce g/ g; ces/ceti; cear/ceek; ceek/cejal; cemo/cebi / / / total / / / a transfusion vol. supplement s reagents should include an evaluation of antigen variants to confirm fidelity. we evaluated two monoclonal anti-e reagents with comparator reagent using a large panel of molecular confirmed rh e variants. study design/method: two monoclonal anti-e clones, rd / and rd / , and a licensed comparator anti-e (p gd ms ), all from diagast (loos, france), were evaluated. rbc samples were either recovered from frozen storage (n ) or edta blood from donors (n ) and were tested using a manual tube method or on a pk automated platform. a score ( ) or greater was deemed acceptable for manual tube and a positive call for automated testing. results were tabulated by complexity of rhce*ce alleles (table ) . results/finding: the specificity of the monoclonal anti-e were confirmed using common rhce haplotypes: r r , r r , r r, and rr. twenty-one different rhce*ce alleles were included in the extensive panel: were rhce*ce that were in trans to rhce*ce; were various rhce*ce plus rhce*ce c compound heterozygotes; were rhce*ce or rhce*ce homozygotes; were various rhce*ce and rhce*ce compound heterozygotes. the comparator reagent was negative or unacceptably weak for rhce*ce alleles in trans to rhce*ce (rhce*cear, rhce*cemo, rhce*-cejal, rhce*cehar), with rhce*cear/rhce*ce c compound heterozygote, and with rhce*cecf homozygote. rhce*cear, rhce*cemo, rhce*cejal, and of rhce*cecf homozygotes were detected using the comparator reagent. rd / and rd / failed with and e variants, respectively (table ) . failure to detect the e variants was observed using both manual tube and automated methods for the comparator and the rd / clone. none of the reagents detected e antigen variant expressed on example of rhce*cehar/rhce*ce. conclusion: rd / and rd / anti-e reacted with more e variants than the comparator reagent. the e antigen encoded by rhce*jal and rhce*ar is not always detected when in trans to rhce*ce. however, double-dose expression was detected suggesting that the monoclonal reagents bind weakly to the respective altered e antigen epitopes. the e antigen encoded by rhce*cehar continues to be a challenge to detect. meihong liu*, teresita mercado, orieji illoh, maria rios and zhugong liu. obrr, cber, fda background/case studies: extended molecular typing of a large number of blood donors can increase the likelihood of identifying donor red blood cells (rbcs) that match those of the recipient. this is especially important in the management of chronically-transfused patients and patients with rbc alloantibodies. several high-throughput multiplex blood group molecular typing platforms have been developed to determine blood group antigen phenotypes. targeted next-generation sequencing (ngs) provides comprehensive sequence information focusing on specified genomic regions, and allows the simultaneous detection of genetic variants from multiple genes in a large number of samples. we developed and evaluated targeted ngs assays using two different target enrichment platforms for extended blood group genotyping. study design/method: two custom design platforms sureselect and halo-plex were used independently for preparation of probes that target the entire genes of blood group genes associated with the expression of blood group antigens from blood group systems. we used the illumina's hiseq / system to perform next generation sequencing first on sureselect-enriched genes from dna reference samples with average target design coverage of . %, and then on haloplex-enriched genes from dna reference samples with average target design coverage above . %. twelve samples were enriched and sequenced in both methods to allow a direct comparison. all reference samples were previously characterized for blood group genetic variants in these genes using taqman snp assay and sanger sequencing assay. serological data were also available for these samples. the ngs data were analyzed by clc genomic workbench. sequencing variants were detected and annotated using dbsnp database. blood group genotype calls by the two targeted ngs methods were compared with the reference results. results/finding: for the two targeted ngs methods, we evaluated and compared the target enrichment efficiency, off-target enrichment, quality of ngs, sequencing coverage, and genotype concordance. a higher percentage of the haloplex reads ( . %) were mapped to the target regions relative to the sureselect reads ( . %). the mean sequence coverage depth of the targeted bases was around x for sureselect method and x for haloplex method. some exons, such as rhd exons and , , rhce exon , ermap exons and , cd exons and , cr gene (most exons) and gypb exon , are consistently covered with less than x coverage by both sureselect and haloplex targeted ngs methods. both methods detected rhd gene deletion in a few representative samples. the genotype call concordance on blood group genetic variants was assessed by comparing ngs results to taqman genotyping and sanger sequencing results, and more than % concordance was obtained for both targeted ngs methods. incorrect calls were restricted to four complex blood group genes: mns, rhd, rhce and abo, and involved mainly heterozygous variants and indels. conclusion: using two targeted ngs methods, we have correctly detected more than % blood group genetic variants in selected genes. evidence rhce*cehar does not encode for rh (hr b ) antigen debra j bailey* , trina horn , paul mansfield , najmi qazi , pamela nickle , jessica keller , margaret a keller and jan r hamilton . background/case studies: the rhce gene has many variant forms, yet for many, the phenotypes encoded by these variant alleles is unknown or incomplete. new information can be elucidated when two altered alleles or haplotypes are expressed in an individual with subsequent alloantibody formation. the rhce*cehar allele was first described in and has a phenotype of c e c e w f w , g , hr w , hr , hr s , rh: , rh: with a partial d antigen expression. we describe new information regarding an rh haplotype that includes an rhce*cehar allele and its apparent rh: (hr b ) expression. study design/method: rbc typing was performed by standard tube methods with polyclonal and monoclonal antisera. antibody identification studies were performed by standard tube hemagglutination methods by published techniques. molecular immunohematology testing was performed on genomic dna extracted from whole blood and included hea, rhd and rhce beadchips (immucor) and pcr-rflp analysis for rhce c. c>g and rhd c. c>t. results/finding: a sample from an african american female with a history of an anti-e and anti-k was evaluated for unexpected antibodies. her red cell serologic rh phenotype on an untransfused sample was d c e c e . her plasma contained an alloanti-s and an antibody that reacted strongly with all random e k s reagent red cells except her own. the unidentified reactivity persisted following ficin and dtt pretreatment of reagent red cells. only d and dc red cells were non-reactive in initial tests. differential adsorption studies excluded antibodies to all other common antigens and hr b except e, s and k. when subsequent examples of e s k red cells homozygous for the rhd*diiia-ce( - )-d, rhce*-ce c, g, t haplotype (i.e., r' s /r' s ) and rhd*diiia, rhce*-ce c, g, t/ rhd*diiia-ce( - )-d, rhce*ce c, g, t (i.e., bastiaan genotype) were found to be non-reactive with the patient's plasma, the antibody specificity was determined to be anti-hr b . the patient's red cell antigen genotype identified the following probable rh haplotypes: rhd* , rhce*cehar and rhd*diiia-ce( - )-d, rhce*ce c, g, t. additional antigen typing of the patient's red cells with unlicensed antisera indicated an hr ( of sources) and hr b ( of sources) phenotype. conclusion: the rhd*diiia-ce( - )-d, rhce*ce c, g, t haplotype is one of the rh haplotypes expressed by the original hr b individual bastiaan. the hr b antigen status of red cells of individuals with the rhce*-cehar allele has not been described. we report an individual with the probable rhd* , rhce*cehar and rhd*diiia-ce( - )-d, rhce*ce c, g, t rh haplotypes and production of alloanti-hr b . the specificity of the alloantibody produced and the red cell hr b serologic antigen type supports the conclusion the variant allele rhce*cehar does not encode for the hr b antigen. excluding clinically significant alloantibodies in the presence of interfering antibodies with high-titer, low-avidity characteristics. background/case studies: high-titer, low-avidity antibodies (htla) are a group of clinically insignificant antibodies (ab) directed against highprevalence red cell antigens. they interfere with the exclusion of clinically significant red cell ab and crossmatch testing, leading to long work-ups and potential transfusion delays. we often use automated solid phase red cell adherence assay antibody panels (sp) when htla interference is seen by other methods, and undertook this study to determine its efficacy. study design/methods: a search of the laboratory information system database was conducted for patients with htla between / / and / / . all patient samples with available records of the full serological investigation were reviewed for testing method and results, with specific attention to the value of a given test method in permitting exclusion of clinically significant ab (rule out). results/findings: over approximately years, patients had htla established at least once by titration studies. serological investigations on a total of samples using a combination of gel, sp, and peg and liss tube methods, and occasional dtt and ficin panels, found that htla interference noted most frequently in gel (primary method) was, indeed, less often seen with sp. however, the proportion of cases achieving rule out on sp was no greater than that with peg testing (table) . for samples where rule out could not be performed with a combination of methods, patients were assigned to phenotype-matched transfusions, or testing was referred to a reference laboratory. reference testing on samples was successful in rule out in % of cases. in an additional patient samples, with negative antibody screens, htla were identified upon work-up for incompatible crossmatches. conclusion: sp is useful in avoiding interference from htla, but this conclusion is limited because sp was performed in only % of samples, and the inability to use select cell panels with sp made it difficult to complete rule out on samples containing multiple ab. peg testing was available for % of samples, and was at least as effective. further, manual testing allowed flexibility in selecting test cells when other ab were present. both sp and peg testing may be used alone or in combination to avoid interference due to htla, and can potentially decrease the number of patients requiring phenotype-matched units due to incomplete serological evaluations. background/case studies: the dau family of rhd alleles is characterized by c. c>t (p.thr met). the dau allele harbors only this change, is not associated with depressed or altered d antigen expression, and is the ancestral allele from which other dau alleles are purported to have evolved. srivastava et al (transfusion , : ) recently summarized serologic characteristics and associated anti-d alloimmunization for dau family alleles. we investigated two samples with the c. c>t change referred with weak d antigen expression. study design/method: serologic testing was performed by standard tube methods using licensed anti-d reagents and the albaclone partial rhd typing kit. genomic dna was isolated from wbcs and used in manual and array assays and for amplification and sequencing rhd. results/finding: sample was from a yo multiracial female. her rbcs reacted s at immediate spin (is) and in iat with immucor gammaclone and series and , and mi at is and in iat with ortho bioclone anti-d. rbcs did not react with of (lhm / & / ) anti-d in the partial d typing kit. this pattern did not match any of the defined partial d epitope patterns. rhd beadchip found no changes but rflp detected c. c>t characteristic of dau. rhd sequencing confirmed c. c>t and identified two adjacent changes, c. g>t and c. g>t (c. _ delinstt), in exon encoding p.gly leu. sample rbcs reacted w at iat with both ortho bioclone and quotient albaclone delta, but were non-reactive with immucor gamma-clone, series and , and quotient albaclone blend and alpha anti-d. papain treated rbcs were s in iat with ortho bioclone. these results suggested a d el like phenotype. rhd beadchip found no changes but rflp detected c. c>t. sequencing confirmed c. c>t and found a new c. c>t change (p.ser -leu) in exon . the c. t has not been reported, but c. g encodes a stop codon (p.ser stop) in japanese (vox sang , : ). conclusion: we report two new alleles: rhd with c. _ delinstt (p.gly leu) and rhd with c. c>t (p.ser leu), both also carrying the c. c>t (p.thr met) characteristic of the african dau cluster. d antigen associated with p. leu is a partial d antigen with a novel epitope pattern. the p. leu change is associated with a del-like phenotype, the first observed to our knowledge for a dau allele, and d antigen on the rbcs is not detected in iat by / commercial anti-d. the rhd nucleotide changes reported here are not in dbsnp database. this study brings the dau family of alleles to . the number and diversity of alleles in the dau cluster supports that the c. c>t change is a major ancestral african background allele (wagner et al, blood , : ). tae eun kim*. krc btri background/case studies: there have been the cases of anti-d alloimmunization caused by the transfusion of serologically d negative blood component. by analysis of genotype of the blood component, all of them were confirmed as asian type del. for that reason, the application of genetic analysis for the blood donor has been required in addition to serological assay. we established the algorithm for the genetic analysis of rhdin blood donors. in this study, we would introduce the experience of the application of the algorithm and the results in the preliminary test. study design/method: from september to present day we got samples of repeated blood donors who are known to be d negative, c positive and/or e negative from blood centers. we obtained the consent for the test from all of the donors who provided samples. as a genetic analysis, we accomplished polymerase chain reaction with sequence-specific primers (pcr-ssp) for the region of promoter, exon , exon and exon in rhd gene. based on the results of pcr-ssp, we discriminated the results into total rhd deletion, rhd-ce-d hybrid and rhd variant. when the results were discriminated to be rhd variant, we additionally analyzed the sequence of exon to confirm the existence of c. g>a and c. t>a variations. for the sample with indeterminate results, we performed sequencing for the full region of exon. when the result was confirmed to be rhd deletion or rhd-ce-d hybrid, the blood components were regarded as rhd negative. when the result was confirmed to be rhdvariant, the blood components were regarded as rhd positive. blood components were not supplied until the final results were obtained. results/finding: for the sample, we identified cases ( . %) of total rhd deletion, cases ( . %) of rhd-ce-d hybrid, and cases ( . %) of rhd variant. of rhd variant were determined to be asian type del with c. g>a variation. cases of rhdvariant were regarded to be unknown variation. conclusion: the frequency of rhd variant in this study was % higher than that of the general d negative donors not considering rhce phenotype in a previous study. for that reason, we considered that the genetic analysis of rhd targeting the donors of d negative, c positive and/or e negative is more efficient approach to identify rhd variant and better way to improve blood safety in the transfusion medicine related with rhd negative blood donors. lei fang tsai*, ping chun wu, shu hui feng, yi wen tsai, ming hung chen and shun chung pai. taipei blood center, taiwan blood services foundation background/case studies: certain abo subgroups or physiologic conditions may lead to mixed-field agglutination on abo typing among blood donors. the b phenotype was found to be the most common subgroup in taiwanese. however, it is hard to distinguish the b phenotype from other b subtypes also with mixed-field agglutination using routine serology without the genotype. this study aimed to evaluate if flow cytometric method could alternatively differentiate different b subtypes with mixed-field agglutination rather than using molecular genotyping. study design/method: blood samples from taiwanese blood donors exhibiting known common abo phenotypes were included to establish normal flow cytometric patterns and genotyped. blood samples (n ) from b subtype donors with mixed-field agglutination by routine serology (tube method and gel card) were further analyzed by flow cytometry and genotyping. flow cytometric method was performed by facscalibur flow cytometry using the gamma-clone anti-a and -b. for genotyping, exon and exon of the abo gene were amplified and sequenced. the abo*b . allele was confirmed by pcr-rflp analysis. results/finding: among subjects with b or ab phenotypes, were genotyped as abo*b . . the abo*b . group performed similar characteristic flow cytometric pattern and the profile was reproducible over time. the pattern showed the main population of cells expressed no b antigen, while a percentage ( . . ) of the rbcs exhibited b antigen levels diminishing with increasing of fluorescence. other subjects with b or ab subjects, genotyped as abo*b . (n ), abo*bw. (n ), abo*bw. (n ), abo*bw. (n ) and abo*bw. (n ), displayed flow patterns differed from the abo*b . group. the abo*bw. , abo*bw. and abo*b . subjects also showed a main population of cells expressed no b antigen and, however, less percentage of rbcs exhibited b antigen levels (< % in abo*bw. and abo*bw. subjects and < % in abo*b . subject). both abo*bw. and abo*bw. displayed a wedge-shaped pattern. conclusion: the flow cytometric method for the detection of b antigens on rbc might be useful in discriminating between b subtypes with mixed-field agglutination, especially abo*b . genotype. this approach could assist the serological abo subgrouping in clinical reference laboratory. frequencies and specificities of "solid-phase only" detected erythrocyte antibodies: is solid phase testing worth the headache? karen finegan*, karen gray, jill adamski, theresa kinard and qun lu. background/case studies: an effort to re-evaluate automated testing platforms (automated solid-phase red blood cell adherence vs automated gel column agglutination) was recently initiated due to the perception of excessive equivocal reactions from the solid-phase resulting in "unnecessary" workup at one site of a hospital system. the data available from parallel testing on solid-phase, gel, and peg performed at another cite of the same hospital system was collected and evaluated to determine the frequencies and specificities of "solid-phase only" detected erythrocyte antibodies and to see if solid-phase only antibody workup is necessary for patient care. study design/methods: throughout , the transfusion service used automated solid-phase red blood cell (rbc) adherence as the primary method for antibody screening and identification. all solid-phase antibody screen positive samples were re-tested using both gel column agglutination and peg method manually in order to determine which method should be used for antiglobulin phase crossmatch of rbc products. all antibody screen results on three methods and final antibody identification results were transcribed into a spread sheet and analyzed. results/findings: a total of patients were positive on solid-phase antibody screen and re-tested on gel and peg antibody screen. in % (n ) patients antibody reactivity observed in solid phase only and the concurrent gel and peg testing were completely negative. of them clinically significant rbc alloantibodies, warm autoantibodies, clinically insignificant antibodies were identified in % (n ), % (n ), and % (n ) of the cases, respectively. rbc alloantibodies identified in solid-phase only included anti-e (n ), anti-jka (n ), anti-k (n ), anti-jkb (n ), both anti-e and anti-c (n ) (see table ). conclusion: solid-phase only rbc antibodies are clinically important in a significant portion of cases (roughly in cases). workup for solid-phase only antibodies is not "unnecessary" workload. transfusion of corresponding antigen negative rbcs to these patients prevented possible hemolytic transfusion reactions. full-length nucleotide sequence of ackr alleles encoding duffy (fy) antigens in africans of ethiopia qinan yin*, kshitij srivastava, addisalem taye-makuria and willy a flegel. background/case studies: the human ackr gene (previously known as darc), comprising two exons and a single intron, encodes a multi-pass trans-membrane glycoprotein expressing the duffy blood group antigens (fy). the duffy protein acts as a chemokine receptor for various proinflammatory cytokines and for the malaria parasites plasmodium vivax and p. knowlesi. the study of fy variants in the low altitude and tropical gambela region is important, as malaria is endemic and the endogenous population is living in this region for a long time. in the present study, we determined the full length nucleotide sequence of the ackr gene encoding fy antigens in donors from ethiopia's southwestern gambela region. study design/method: edta-anticoagulated whole blood was collected from study volunteers in the gambela region (nct ). the whole ackr gene was amplified in one reaction covering , base pairs (bp). this primary amplicon was re-amplified using nested primers covering nucleotides. nucleotide sequence was obtained by sequencing reactions and manually annotated using ncbi refseq ng_ . . the sequencing covered bp of both exons, bp of intron, bp of '-flanking region, bp of '-utr, bp of '-utr and bp of '-flanking region and encompassed all the variations present in dbsnp and nhlbi esp databases. results/finding: among the samples, a total of snps, including one novel snp in '-utr were observed. snps occurred in the exons, in 'and 'flanking region, in '-utr and in the intron. all individuals carried the snp indicative of the common fy: phenotype; while individuals were homozygous and was heterozygous for the gata box mutation. no splice site mutation was detected. as individuals were observed as being homozygous or heterozygous for snp, we could unambiguously assign distinct alleles. in the remaining individuals with or more heterozygous snps, allele specific pcr is required to identify the alleles. conclusion: we sequenced more than . kb of the ackr gene and identified at least different alleles. the present study found that the vast majority of alleles ( / ) in the gambela population as defined by snps, were similar to the clinically relevant fy* n. allele, which in turn is defined by only snps at positions c. - t>c and c. g>a. out of the remaining alleles, were similar to fy* with the fy(b ) phenotype and was similar to fy* w. with the fy x phenotype. the high frequency of fy* n. ( %) in this study is similar to other studies conducted in western, central and south-eastern regions from gambia to mozambique ( %- %). a more detailed analysis, including other regions of ethiopia, will be useful to support transfusion care in the us for ethiopian-americans, the majority of whom may be of mixed ethiopian ethnical background. judith aeschlimann*, sunitha vege, christine lomas-francis and connie m. westhoff. immunohematology and genomics laboratory, new york blood center background/case studies: the homology, proximity, and inverted orientation of rhd and rhce on the chromosome favor gene conversion events. regions of rhd are transferred into rhce and conversely, resulting in hybrid alleles that encode novel or the absence of high prevalence antigens. rhd*diiia-ce( - )-d is the most common hybrid and is found in african blacks. it arose by conversion of exons - of rhce*ces into rhd*diiia and no longer encodes d antigen, rather (somewhat confusingly) encodes partial c antigen from the rhd locus. this hybrid allele is in cis to rhce*-ces, together known as the r's haplotype. we investigated atypical rh genotyping results in three samples; two associated with weak d typing and one patient with sickle cell disease (scd). study design/method: serologic testing was by standard methods. genomic dna was isolated from wbcs. all samples were investigated by hea precisetype, rhd and rhce beadchip, rflp, and rh-cdna sequencing. snp-specific sequencing was used to establish linkage/phasing. results/finding: sample (male) and sample (multiracial female), both c c e e (presumed r r ), presented with weaker than expected d typing; is and / at iat. rhd beadchip identified the common african rhd*diiia-ce( - )-d hybrid encoding partial c antigen with apparent conventional rhd in trans. these results did not provide an explanation for weak d antigen. hea indicated rhce*ce /ce, concordant with the rh phenotype, but c. c>g and c. g>t (heterozygous) was also detected. as rhce*ce with g and t has not been reported, rh-cdna analysis was done. transcripts from the rhce locus included one conventional rhce*ce in trans to rhce*ces with exons and replaced with rhd*diiia, and from the rhd locus, one conventional rhd and the hybrid rhd* diiia-ce( - )-d were found in both samples. sample (scd male), d c e c e , by rh beadchip had one conventional rhd and rhd*diii type , and rhce*ce g/ces. as rhd*diiia type has never been found with either of these rhce alleles, rh-cdna analysis was performed. transcripts representing a unique conversion event at the rhd locus, specifically rhce*ce( c) exons and had replaced those exons in the common hybrid rhd*diiia-ce( - )-d and expression of partial c antigen was lost these unique hybrid alleles have been deposited as genbank#: ky and ky . we report two different and novel complex rh rearrangements: two samples thought to be r r had a unique rhce locus representing a gene conversion into rhce*ces, designated rhce*ces-diiia( - )-ce. in kind, a sample genotyped as diii type rather had a novel rhd locus representing a gene conversion into the common hybrid, designated as rhd*ce c( - )-diiia( )-ces( - )-d . these represent novel events on the r's haplotype that can confound rh genotyping interpretations. interestingly, samples and have weaker than expected d antigen typing, despite the presence of a conventional rhd with rhce*ce [r haplotype (dce)]. it is important to further investigate samples with unconventional results when interpreting rh genotypes. high-frequency antibodies anti-lu(b-) and anti-yt(a-) in a multi-transfused patient: a case study nadia baillargeon*, carole ethier, cynthia parent, jessica constanzo-yanez, maryse st-louis, marie-claire chevrier and andre lebrun. hema-quebec background/case studies: a -year-old caucasian female was referred to our immunohematology reference laboratory (irl) for serological investigation. she was diagnosed with anemia, renal failure and cardiac history. her hemoglobin level was recorded at g/l. her pregnancy history was not provided. she had received units of packed red blood cells (rbcs) in the past including unit within the last months. none of the transfused unit was phenotypically-matched. the referring hospital obtained panreactivity in gel with liss-suspended rbcs and ficin-treated rbcs and negative direct antiglobulin test (dat) and autocontrol (at). study design/methods: abo/rh, dat and antibody identification were performed by h ema-qu ebec's irl according to approved techniques. in addition to liss-suspended rbcs and papain-treated rbcs, trypsin-treated and chemical-treated reagent rbcs such as dithiothreitol (dtt) were tested. alloadsorption were done using papain-treated allogeneic rbcs (r r , r r , rr). id core xt platform (progenika biopharm / grifols, vizcaya, spain) was used to analyse polymorphisms which determine antigens including carthright and lutheran blood groups. pcr-ssp (sequence specific primer) and pcr-rflp (restriction fragment length polymorphism) were also performed to verify the absence of the high frequency antigens yt a and lu b . sibling samples were also requested to conduct a family study. results/findings: initial serologic testing showed strongly reactive panels in gel with liss suspended rbcs, papain-treated rbcs as well as trypsintreated rbcs and dtt-treated rbcs but negative at in each media leading to a probable antibody directed against high-frequency antigen. alloadsorption procedure allowed the identification of an anti-jk a . a select panel of high frequency antigens absent in caucasian population was tested. the patient's sera react weakly with one jk(a-), lu(a-b-) reagent cell. in the meantime, genotyping results confirm the probable phenotype of the patient as jk(a-) lu(b-) yt(a-). additional testing in gel using trypsin and dtt differential effects on antigens lu(b) and yt(a) were performed to confirm antibody specificities. no rbcs unit jk(a-) lu(b-) yt(a-) were available for transfusion. selected units were jk(a-) and lu(b-) as alloanti-yt a are known to cause none to moderate transfusion reactions. her daughter' sample were types as yt(a ) and lu(b ). conclusion: serological study showed the presence of an anti-jk a in addition to two antibodies directed against high prevalence antigen namely anti-lu b and anti-yt a . the association of various selected serologic procedures combined with ethnic clues and genotyping results serves to solve this uncommon antibody combination. background/case studies: the kel blood group system, consisting of antigens encoded by the kel gene, is organized into exons. there are approximately kel alleles associated with a kell null phenotype (k ) in which no kell antigens are expressed, and alleles associated with a kell mod phenotype (k mod ). individuals with the k mod phenotype express very weak amounts of antigen on the surface of the rbc, and expression levels vary based on the allele present. here we describe the molecular and serologic testing that was performed in the case of a year-old hispanic male blood donor whose rbcs phenotyped k-k-js(b-) kp(b-). study design/method: the blood donor was phenotyped for k, k, kp b and js b antigens using standard tube agglutination methods. adsorption and elution studies of the donor red cells were performed using commercial anti-k antisera (american national red cross). genomic dna (gdna) was isolated from an edta blood tube using standard techniques. dna was genotyped for human erythrocyte antigens using the precisetype tm hea molecular beadchip (immucor). exons , , , and and flanking intron sequences were amplified and sequenced. total rna was extracted using rneasy lipid tissue mini kit (qiagen) and kel cdna was amplified and the resulting pcr product was subjected to sanger sequence analysis and aligned using sequencher (genecodes). results/finding: precisetype tm hea molecular beadchip testing predicted the sample to be k-k kp(a-b ) js(a-b ). kel-cdna sequence analysis was performed and detected a single transcript species with c. c, c. c, t, and missing the sequences corresponding to exons , and . amplification of the exons from gdna did not identify any nucleotide changes when compared to the reference sequence and the splice sites were intact. cdna analysis was repeated and the same aberrant transcript was detected. adsorption and elution studies of the k antigen demonstrated weak anti-k reactive after c incubation at the peg-igg-agt phase. conclusion: here we describe a donor homozygous for a novel kel* allele. this donor was presumed to have a k phenotype based on serology, but after molecular testing, has been reclassified as a k mod phenotype with extremely weak expression of k. the discovery of the aberrant transcript led to adsorption and elution studies to confirm the presence of weakly expressed k antigen on the red cells. the variant alleles reported to date (http://www.isbtweb.org/working-parties/red-cell-immunogenetics-and-bloodgroup-terminology/) are associated with missense mutations. in contrast, the allele reported here is associated aberrant mrna transcript. we propose that this allele be named kel* m. . here we report a case of a possible novel b subgroup observed in a pregnant black female. the patient specimen was referred to our reference laboratory to investigate a possible abo discrepancy. the referring facility reported the patient's red blood cells were nonreactive with reagent anti-a and anti-b and the patient's plasma was reactive with a cells, but nonreactive with b cells using automated gel methodology. study design/methods: serological testing of the patient's red blood cells was performed using routine and enhancement methods. molecular testing by pcr-rflp was performed to determine the patient's genetic abo typing and predicted abo phenotype. results/findings: serological testing of the patient's red blood cells is summarized in table ; similar results were obtained with multiple sources of antisera. enzyme treatment failed to enhance reactivity. patient sera strongly agglutinated a and a cells, but failed to agglutinate multiple sources of b cells at all phases of testing. molecular testing by pcr-rflp resulted in an uncommon banding pattern and indicated the presence of c. deleted g, characteristic of o alleles, c. t, characteristic of a and some uncommon o alleles, and c. a and c. a, characteristic of b alleles. genomic sequencing of exons and confirmed the presence of an o allele, abo*o del g, t, t), and the presence of a b allele ( g, g, t, a, a, c, and a), but did not reveal any changes associated with previously reported weak subgroups of b. conclusion: while serologic abnormalities in pregnancy have been reported due to decreased antigen expression, the unusually weak reactions observed when testing this patient are unlikely due to pregnancy alone. additional abo gene sequencing is required to determine the specific allele mutation responsible for this weakened antigen expression. carine arnoni* , tatiane vendrame , janaína muniz , diana gazito , afonso cortez , lilian castilho and flavia latini . associa, associac¸ão beneficente de coleta de sangue, hemocentro de são jos e do rio preto, hemocentro unicamp background/case studies: after the elucidation of the molecular basis of vel, molecular tools have been used to explain the reduced expression of vel antigen in different populations. negative or weak reactions are generally related to the -bp deletion in smim in homozygous or heterozygous status. however, other nucleotide changes have been described to reduce the vel expression, as for example, the major a allele of the snp rs located in the second intron of the gene, a regulatory region in erythroblasts. this study aimed to characterize the genetic changes related to atypical vel expression in a brazilian population. study design/method: a total of blood donor samples from the southeast region of brazil were typed for vel with an anti-vel serum from our inventory in gel-iat. samples typed as vel-negative were further analyzed by adsorption-elution. molecular study was performed in samples with negative results, in samples reacting and in samples with reactivity of . dna was isolated from peripheral blood and smim was sequenced. results/finding: from donor samples studied, were serologically vel negative by gel-iat but positive by adsorption-elution, presented a reaction and the remained samples showed a reactivity of . genotyping results showed that the samples with negative results and of samples that presented reaction were heterozygous for the bp deletion and presented the a allele rs in homozygous status. from the of remaining samples with reactivity of , ( %) had the a allele of rs and ( . %) had the a allele of rs . in contrast, in the samples with stronger reactions we found the a allele of rs in ( . %) samples and the a allele of rs in ( . %) samples. conclusion: the molecular changes rs and rs are located in intron distancing nucleotides. this study reinforces the association of the a allele of rs with reduction of vel expression and suggests the involvement of a new rs change in vel expression. in conclusion, the several patterns of vel expression found in different populations can be influenced by different molecular changes. background/case studies: the d antigen is the most immunogenic antigen after abo. consequences of misclassification of the d-antigen in patients or donors can be severe. some persons inherit mutations resulting in quantitative reductions of d antigen on the cell surface (weak d), some inherit rh haplotypes that result in biochemical effects that reduce the availability of the d antigens to reagent anti-sera (ceppellini effect), and others inherit d genes which are qualitatively different than wild type d. these latter individuals are often not identified until after they have formed anti-d. we hypothesize that some of these persons at risk of forming anti-d might be uncovered if they have weak and/or disparate d typing results with reagents that recognize different epitopes of the d antigen. study design/methods: all testing was performed using microtiter-well direct agglutination on the galileoneo or galileoecho (immucor, norcross,ga). any specimen that did not react as (rh negative), or ! on the neo or ! on the echo (rh positive) for both series and series anti-d antisera were included. patients with discrepant historical types also were evaluated. any specimens meeting the inclusion criteria were tested on the neo, echo, and by saline tube method using series and series anti-d antisera. genotyping was performed from whole blood samples sent to immucor genotyping laboratory in warren, nj using an algorithm of: rhd beadchip, rhdxp (prototype assay), rhd zygosity, and rhce beadchip. results/findings: patients met inclusion criteria for molecular testing for the d antigen. weak or rhd variants were identified in of ( . %) of the samples. ceppellini effect (i.e. c in trans to rhd) resulting in weak d reactivity was seen in of ( %) of samples. of ( . %) of the samples that resulted in weak or discrepant reactivity had some type of genetic cause that was resolved by using our algorithm. of ( %) of tested samples had results indicating weak/variant d proteins with the potential to cause alloimmunization to the d antigen. the remaining of ( . %) samples did not have identified genetic cause for the weak and/or discrepant d test results and were presumptively classified as wild type d. conclusion: transfusion services that use the galileoneo or galileoecho to perform rh typing should consider molecular testing of patients whose rh typing results are discrepant, or positive but < on the galileoneo or positive but < on the galileoecho, as about half of these patients can develop anti-d. this is particularly relevant for females of child-bearing potential where avoidance of d-positive transfusions and administration of rhig during pregnancy is prudent until their d typing can be confirmed by molecular testing. carine arnoni* , tatiane vendrame , janaína muniz , rosangela person , lilian castilho , afonso cortez and flavia latini . associa, associac¸ão beneficente de coleta de sangue, hemocentro de são jos e do rio preto, hemocentro unicamp background/case studies: rhd and rhce, are major protein constituents of red blood cell membrane, composing a complex together with rhag. many variant rh proteins have been described and most of them affect the integration of rh proteins in the membrane. d antigen expression can be affected by several molecular changes and also by the rhcehaplotypes. the present study investigated the score of reactivity of samples presenting a strong reduction in d expression. study design/method: a total of samples were included in the study, being previously genotyped as rhd*dar . , rhd*dar . and rhd*dau . the samples were phenotyped in neov r (immucor) to d, c/c and e/e antigens by direct agglutinationin microplate. results obtained in neov r were expressed in a score from - corresponding to the reaction intensity. zygosity assay was performed by a multiplex real-time quantitative pcr using a set of rhd-specific primers in rhd exon . rhce genotyping was performed by pcr-rflp and ssp-pcr. the presence of a d-cehybridexon was identified by amultiplex pcr. sequencing and identification of rhce variants were also performed when necessary. results/finding: zygosity results showed that of samples ( dar . , dar . and dau ) had rhd genes, were phenotyped as c e-c e and genotyped as rhce*ce/rhcece. rhd and rhce genotyping in these samples showed the presence of the d-ce-d s hybrid gene. rhce variants investigated in dar . samples showed the rhce*-cear/ce s genotype, in dar . samples the rhce*cevs. /ce s genotype and in the dau sample the rhce*ce s /ce genotype. table describes the differences found in the reactivity of d among the samples carrying the (c)ce s allele and in the samples homozygous for rhce*ce. the results showed that the presence of rhce*(c)ce s significantly reduces the expression of d antigen, probably due to the expression of the partial c partial antigen in trans to rhd. additionally, the samples with reduction on d expression carrying rhce variant alelles phenotype can be useful to provide compatible blood to some patients with rarerh variant alleles. background/case studies: drugs are known to interfere with routine blood bank testing. a novel monoclonal humanized f antibody (hu f -g ) that binds human cd has been entered into clinical trials for patients with acute myeloid leukemia, non-hodgkin lymphoma and solid tumors. we describe two cases of patients treated with hu f -g (anti-cd ) who had abo discrepancy with extra-reactivity in the reverse typing and a panaggutinin in the plasma. study design/method: this is a retrospective review of two cases with immunohematology work-up showing abo discrepancy and plasma panagglutinin. the first case is of a year old female with progressive follicular lymphoma who was enrolled in phase b/ trial of hu f g in combination with rituximab designed for patients with relapsed/refractory b cell nhl. she had no prior transfusion history and her historical blood type was not known. two rbc units were requested in anticipation for a surgical procedure. the second case is of a year old male with refractory diffuse large b cell lymphoma enrolled in hu f -g clinical trial. his historical blood type was a rh d positive with a negative antibody screen. he received three rbc units within the past month prior to testing and receiving the anti-cd therapy. results/finding: the abo typing in the first case showed a discrepancy between the forward typing ( with anti-a, non-reactive with anti-b) and the reverse typing ( with both a cells and b cells). rhd typing was positive. the extended reagent rbc panel tested with the patient's serum reacted with all cells tested at the immediate spin (is) phase ( to ), at liss- c ( to ), at liss-polyspecific ahg (m ), and at peg-anti-igg (m to ). plasma reactivity at is persisted with dtt or ficin treated red cells and was not removed by cold autoadsorption, cold alloadsorption, or rest adsorption. repeat testing, which avoided the is and c readings, was non-reactive in the antihuman globulin (ahg) phase using both liss and peg enhancements, ruling out clinically significant alloantibodies directed toward common red blood cell antigens. the direct antiglobulin test (dat) and autocontrol were negative. the rbc units issued to the patient were crossmatch compatible at o c ahg phase. the abo typing of the second case performed after anti-cd administration showed a discrepancy between the forward ( with anti-a) and the reverse ( with both a and b cells). rhd typing was positive. the antibody screen performed in solid phase technology was positive with all reagent red cells. his plasma reacted with all reagent red cells at is ( ), at c in liss ( ), and liss-polyspecific ahg (m ). the dat and autocontrol were negative. his genotype was determined to be a /o and full rbc phenotype by dna analysis was obtained. repeat testing which avoided the is phase did not show reactivity at peg-ahg excluding all alloantibodies directed toward common red blood cell antigens. conclusion: anti-cd therapy interferes with blood bank testing by causing abo discrepancies and panagglutinin reactivity in the plasma at is, c liss, but not at ahg phase using gamma-clone anti-igg, unlike the anti-cd interference. knowledge of patient's blood type and phenotype before starting this therapy is critical for providing safe blood. background/case studies: a middle-aged male with discrepant abo typing results was investigated. initial forward typing was group o but no anti-b was seen in the reverse typing. an unexpected reaction was noted with an anti-a,b reagent. genotyping surprisingly showed abo*o. . / o. . , consistent with group o. after initial testing at the referring center, samples were sent for extended analysis. study design/method: standard serological methods and flow cytometry were used. a panel of abo reagents (n ) and lectins were tested with both native and papain-treated red blood cells (rbcs). lewis phenotyping was performed, as was genetic testing for abo, gbgt and a galt. papain-treated patient rbcs were used to screen donor plasmas (n ) and two reactive plasmas were dtt-treated. results/finding: positive reactions were obtained with polyclonal anti-a,b and a monoclonal anti-b (clone g / ) when tested with the patient's papain-treated rbcs. a panel of lectins gave negative results. genetic testing confirmed the predicted group o and ruled out the presence of fors or nor antigens. the patient was le(a-b ) and thus a secretor. a positive crossmatch was seen with % of group o plasmas, while no reactivity was obtained with a or b plasmas. dtt treatment of crossmatchpositive plasmas indicated the antibody to be mainly of igg type. this was confirmed by positive flow cytometry cross match using anti-human igg secondary antibodies. reactivity remained after b-zyme treatment, thus excluding the normal (type or ) b antigen to be the underlying reason. inhibition with lewis substance significantly decreased reactivity. enzyme activity assay showed the patient's plasma to contain a fully functional b glycosyltransferase. on the suspicion that the patient had non-erythroid cells producing breactive type chains, a sample from a hematopoietic stem cell transplant (hsct) patient (group b secretor receiving group o donor cells) was included as a control and gave the same type of reactions. conclusion: the medical history of the patient was queried and he had indeed undergone an hsct $ years earlier. the reactions are likely due to uptake of recipient-derived ble b (type ) antigen (isbt no. ), which is the dominant lewis antigen in the recipient's original blood group, b le(a-b ). interestingly, b-zyme did not affect ble b . anti-ble b is not simply anti-b plus anti-le b but an inseparable and rarely reported specificity, which appears to be common among group o donors. the phenomenon reported here has unknown clinical implications but highlights the complexities of carbohydrate blood groups. background/case studies: the provuev r and visionv r (ortho scientific, raritan new jersey) automated analyzer use mts-gel tm card technology to perform immunohematology testing. benefits of automated testing include improved efficiency and enhanced reliability. after eight years of using the provuev r our transfusion medicine service switched to the ortho visionv r analyzer in january of . shortly after implementation, technologists reported increased time spent performing manual resolution of indeterminate (designated as "?") results. additionally, some test columns were noted to be visually negative but called positive ( ) by the analyzer. the objective of this study was to investigate the cause of "?" and apparent false positive results on visionv r three-cell antibody screens. study design/methods: with assistance from ortho diagnostics, analyzer archives were queried to identify the number of gel card columns used for screens, the number of columns with "?" results, and the gel card lot numbers used for testing from / / to / / . reactivity was determined to be false positive based on supervisory review of digital images and antibody panel results. investigation also included review of daily qc records, instrument maintenance, instrument diagnostics, and camera calibration. results/findings: of , columns run as part of antibody screens, , ( . %) columns generated "?" results. assuming seconds of technologist time per "?", we estimate that . hours were needed to resolve and update these results. among all potential causes investigated, only the gel card lot number was associated with the number of "?" generated (table ) . in cases, all three columns were visually negative but the analyzer reported reactivity with of cells. all cases had mts-gel tm antibody identification panels performed, of also had a mts-gel tm ficin panel. the yield for the panels performed was two routine panels with weak reactivity against hla cells, and four ficin panels with weak reactivity with no apparent specificity. fourteen patients coincidentally had a subsequent type and screen; were negative. one patient newly demonstrated anti-jka. fifty percent ( / ) of visually negative but analyzer positive samples were tested with gel card lot number , % ( / ) with lot , and % ( / ) with lot . conclusion: the incidence of "?" and visually negative analyzer positive results is dependent on the specific lot of mts-gel tm cards used. the difference between the lots is being investigated by ortho diagnostics, and remains to be explained. to avoid unnecessary waste of technologist time and other resources, with assistance from ortho diagnostics, we have results/finding: of the methods evaluated, the dtt method proved the most useful for mitigating dara interference. cord cells were effective but in limited supply and alloadsorption was ineffective. of the three different dtt methods evaluated, the tube method initially failed which led to re-evaluation with the addition of liss (passed). the gc method was the most sensitive method. following release of dara, samples from patients ( cross-match samples, units issued) were tested using both liss tube and gc iat methods. despite dtt treatment, the gc method remained positive by iat in / patients. further testing was performed in / . eight were tested for the presence of antibodies at c and confirmed in / . rouleaux formation was observed in / patients, / had reactivity detectable at c. no transfusion reactions have been reported to date nor has alloantibody formation been observed to date. conclusion: as previously reported, the dtt method was the most useful for mitigating dara interference. the observed interference seems to be due to rouleaux and/or cold reactive antibodies -seen least in the liss tube iat. this may be due to the washing phase in this technique which dissipates rouleaux formation. reactivity due to cold reactive antibodies can be eliminated by performance at strict c. our practice is now to use both dtt iat methods on initial patient referral, if residual reactivity in gc is observed use liss tube in preference thereafter in these patients. a further observation is that investigation of pan-agglutination could include the use of cord cells to confirm/exclude dara use if suspected. wendy beres* , sandra nance , david moolten and p. dayand borge . ( ): - ). our laboratory tested random allogeneic blood donors, and autologous donors (which were intended to represent a hospitalized patient population), to determine a mean and range of "normal" levels. this . year retrospective study was performed to assess levels of rbc-bound igg, iga and igm in normal donors. study design/method: residual edta-anticoagulated aliquots from random allogeneic and autologous blood donors were sequestered and tested per institutional review board approved protocol. the samples were tested by fc with fluorescein isothiocyanate (fitc)-labeled anti-human igg and iga (jackson immunoresearch lab, west grove, pa) or fitc-labeled anti-human igm (life technologies, carlsbad, ca) at optimized dilutions in dulbecco's pbs containing . % bsa. the becton dickinson facscalibur tm or facscan tm (san jose, ca) fc analyzed k rbcs from each sample. edta-anticoagulated samples and ig coated control rbcs were tested to determine fc settings and control for validity and cross-reactivity. controls reacted as expected. there were less autologous donors tested and with a mean age of these donors could have been older than the allogeneic donors, but the mean age of the allogeneic donors was not captured. despite the relatively small number of samples tested there was a higher than expected instance of allogeneic donors having elevated rbc-bound iga, igg, and igm levels. this emphasizes the need to include testing of normal donor populations in establishing expected reactivity, thus normal and abnormal ranges for flow cytometric testing. long range pcr reveals the genetic basis of an antibody in pregnancy to a high prevalence mns antigen judith aeschlimann* , anna burgos , virginia lew , sunitha vege , susan veneman , christopher j gresens , jonathan hughes and connie m. westhoff . immunohematology and genomics laboratory, new york blood center, blood centers of the pacific, bloodsource background/case studies: recombination events have generated many gypa and gypb hybrids giving rise to glycophorin (gp) variants that express low-prevalence antigens (e.g. mia, miny, mur). in rare individuals who are homozygous these alleles are associated with lack of highprevalence antigens (e.g. enkt, eneh, enav). complex hybrid recombination events can make it challenging to elucidate specific alleles present in samples, particularly heterozygotes. we investigated samples from a pregnant asian (hmong) woman with an antibody to an unidentified highprevalence mns antigen, and samples from her sister. study design/method: standard methods were used for rbc typing with licensed and unlicensed reagents and for antibody identification. dna was isolated from wbcs, and hea precisetype, exon-specific amplification and sequencing gypb exons - , and long range sequencing of exon - ( . kb amplicon) were performed. snp-specific primers were used to associate changes (phasing) to specific alleles. results/finding: rbcs of the pregnant proband typed s-s-(gammaclone anti-s), and the plasma reactivity was consistent with an antibody to a high background/case studies: the rhd antigen is clinically significant and immunogenic and therefore individuals who develop anti-d are at risk of haemolytic transfusion reaction. rhd polymorphism shows substantial ethnic variability and at least rhd variants associated with weak d alleles have been reported. in this study, we report two new rhd alleles in brazilian blood donors associated with weak d antigen expression. study design/method: the d status was evaluated with commercially available monoclonal anti-d reagents: blended igm/igg (clones th- / ms- ), igm (clones ms and p x ) and igg (ms ) in tube and on gel cards. c, c, e and e phenotyping were performed in gel. most common weak d and partial d alleles were investigated by allele specific (as) pcr and with the rhd beadchip platform from immucor. direct automated sequencing of the rhd exons and flanking intron regions was performed by the sanger dideoxy method. in order to determine rhd allelic combinations, we also performed rh-cdna cloning and sequencing. background/case studies: donors negative for multiple common antigens or lacking a high prevalence antigen are efficiently identified using a red blood cell (rbc) genotyping panel. when serology is used to confirm antigen negative status, discrepancies are identified, albeit rarely. investigation of the discrepancy often leads to identification of variant antigens. it is known that the set of gyp variants associated with expression of the st a antigen can also be associated with n typing discrepancies in m n-individuals (meyer et al. br j haematol. ; : - ) . the st a allele, also described as gyp* , is a hybrid gypb-gypatranscript with the crossover in intron . we sought to investigate five n typing discrepancies for which alternative genotyping methodology was performed and found to be concordant with the initial panel. background/case studies: a sample from a years old pregnant, african american female g p was sent to the blood bank for abo/rh and antibody screen. the sample was analyzed using the provue analyzer (ortho diagnostics). the patient was typed as o pos with no reverse type discrepancy. a retype of the same sample was performed using tube method with biorad reagents per hospital policy due to no previous abo/rh history on file. the retype showed that the patient was a subgroup with anti-a antibody present in the plasma. the sample was referred for genotyping, with the suspicion of a like phenotype. genetic testing did not support the serological findings of a subgroup and a new abo allele, abo* c that has never been reported in correlation with an a like subgroup was detected study design/method: the patient rbcs were typed with anti-a (immucor) and anti-a,b (biorad and grifols dg gel). an anti-a antibody work up was performed using three different lots of a cells and three lots of a cells, as well as a type o screening cell and auto control . the tubes were read at is and also incubated at rt and c for min. the patient 's initial antibody screen using ortho gel was negative. conclusion: the patient delivered a healthy baby boy at weeks of gestation. the baby cord was sent to the laboratory. the baby serological type showed an a b phenotype and it was referred for genetic testing. the baby rbcs showed the same abo* c found in the mother. the previously reported abo* a allele encoded an aspartic acid to asparagine change at position p. consistent with an a weak phenotype. also, at least five other alleles encoding an a phenoytpe consisted of polymorphisms at positions c. through c. , giving special characteristics to this new and unreported abo allele. from the data collected, it can be concluded that this a / aweak phenotype is encoded by the variant allele abo* c. this highlights the clinical relevance of confirming the serology of abo subgroups by molecular methods. philip berardi*, jacqueline cote, gwen clarke, vito scalia, robert liwski and mindy goldman. canadian blood services background/case studies: elucidation of the molecular basis of blood group expression has led to the development of high throughput molecular methods for predicting blood group antigens. the commonly used single nucleotide polymorphism (snp) arrays require nucleic acid isolation which is typically achieved by extracting genomic dna from whole blood. this method requires venipuncture and may not be an ideal approach for severely anemic patients or potential donors that are unable to provide a sample of whole blood due to their remote location. dna extracted from buccal swab samples offers a noninvasive alternative to venipuncture and may provide a safe and efficient means of transporting samples from remote locations to reference laboratories for extended blood type prediction. canadian blood services (cbs) has performed large scale dna extraction and hla genotyping for the onematch stem cell and marrow registry using buccal swabs since ; buccal swabs are also used by other unrelated donor stem cell registries, such as the us nmpd. we sought to assess the accuracy and reliability of using dna extracted from buccal swabs in predicting blood group antigen expression. study design/method: we performed parallel red cell genotyping on an automated typing platform, the progenika/grifols idcorext assay (progenika biopharma-grifols, bizkaia, spain) using dna extracted from blood and buccal tissue from volunteers. for antigen systems with available serologic reagents, we also compared results with serologic typing. we evaluated three different methods of dna extraction and performed testing regardless of dna yield or purity. two buccal swabs (puritan medical products, guilford, maine) were used for each test. swabs were stored at room temperature, and dna extraction was performed within six days of collection. in the initial phase of the study, buccal swab samples (n ) were processed with the automated biorobot m robot using the magattract dna mini m extraction method (qiagen, venlo, the netherlands). extracted dna had a mean concentration and purity of . ng/ml and . respectively. in the second phase of the study (n ), dna extractions from buccal swabs were performed using methods available in our national red cell immunohematology reference laboratory: the qiaamp dna mini kit, using either manual or an automated qiacube robotic workstation (qiagen, venlo, the netherlands). results/finding: the manufacturer's recommended analytical range for dna concentration was - ng/ll and the recommended purity was an absorbance ratio of . - . (a / ) for use of the id corext platform. dna extraction from buccal swab samples did not meet these specifications in several cases. however, in most cases, a lower concentration of dna was adequate for prediction of phenotype. the dombrock system was the most susceptible to failure of interpretation in the samples with a low dna concentration, with "no call" results reported. there was % concordance in genotyping results when source dna was extracted from whole blood or buccal tissue; there was also % concordance between predicted phenotype and serologic testing results. conclusion: this study supports the use of genomic dna extracted from buccal tissue on the id corext for predicting rbc phenotype with high accuracy. extraction methods may require optimization to achieve dna yields within the recommended analytical range of the assay. performance evaluation of id rhd xt, a genotyping assay for the detection of high-prevalence rhd negative and weak d types araitz molano , izaskun apraiz , maría azcarate , miguel angel vesga , montserrat rubia , mercedes piedrabuena , fernando puente , barbera veldhuisen , ellen van der schoot and m onica l opez* . progenika biopharma, a grifols company, centro vasco de transfusi on y tejidos humanos, banco de sangre y tejidos de arag on, sanquin blood supply research background/case studies: it is well established that weak d , and phenotypes are not at risk for forming allo-anti-d, whereas a few weak d and all partial d and negative phenotypes are. routine serologic d typing does not distinguish among them, consequently rhd genotyping is recommended, especially in patients. id rhd xt (progenika, grifols) is a qualitative, pcr/luminex v r xmap hybridization-based genotyping test for the identification of the following rhd gene allelic variants: rhd*weak d type , rhd*weak d type , rhd*weak d type , rhd deletion, rhd*pseudogene and rhd*diiia-ce( - )-d and itgb gene: hpa a and hpa b, in genomic dna extracted from whole blood specimens. in this study the performance of id rhd xt genotyping assay was evaluated in terms of whole system failure rate, call rate and accuracy for rh and hpa- blood group typing. study design/method: a cohort of previously serotyped samples for d antigen obtained from three european blood centers were analyzed with id rhd xt at progenika. samples were distributed as recommended by the annex of the common technical specifications / /ce for a ivd product of list a (! % clinical samples, > % neonatal specimens and ! % weak d donors). for the intended use of the product, weak d serotyped donors were enriched (n , %). commercial serology tests for d antigen predicted phenotype and bi-directional-sequencing (bds) for weak d type confirmation and hpa- predicted phenotype were used for comparison. transfusion results/finding: no system failure, % call rate and no inconclusive results were obtained. discrepancies were found for d antigen between serology and id rhd xt predicted phenotype results, although a % concordance was obtained when analyzed by bds, considering id rhd xt result correct. concordance between id rhd xt and bds results for the weak d type was %. the following id rhd xt predicted phenotype results were obtained: d negative (n ), no amplification variant (n ), weak d type (n ), weak d type heterozygous (n ), weak d type (n ), weak d type heterozygous (n ), weak d type (n ), weak d type heterozygous (n ), weak d types , or not detected (n ). regarding hpa- blood group, the predicted phenotype results obtained by id rhd xt were % concordant with bds results: hpa- a positive (n ) and hpa- a negative (n ), hpa- b positive (n ) and hpa- b negative (n ). conclusion: id rhd xt genotyping assay performed as a reliable and accurate method for predicting the genotype and phenotype of high prevalence rhd negative and weak d types ( % specificity and % sensitivity for d antigen, hpa- a and hpa- b antigens). that makes it a useful tool for the implementation of the rhdgenotyping recommendation on patient blood transfusion and anti-d prophylaxis. background/case studies: scd patients form red blood cell (rbc) antibodies at higher rates than other transfused populations. multiple predictors of alloimmunization have been reported but not well replicated in large scd cohorts. we investigated the clinical, laboratory and genetic predictors of alloimmunization. study design/method: a large scd cohort was established in brazil to investigate disease outcomes. at participating sites, patients are currently transfused with abo/d/cc/ee/kell matched rbcs prophylactically and extended phenotypically matched rbc after first antibody forms. policies for matching are center-specific and evolved to increased levels of matching over the exposure period included in this study. transfused subjects with rbc alloantibody of defined specificity within the cohort were compared to transfused antibody negative subjects using chi squared to compare categorical variables and t-test or wilcoxon rank-sum tests as appropriate to compare continuous variables. backward elimination multivariable logistic modeling was used to generate odds ratios (or) and identify independent predictors of alloimmunization using results of univariate analyses. all subjects had peripheral blood whole genome snp typing performed using an affymetrix array, which included enhanced content for blood related snps. genome wide association (gwa) analyses were conducted using a logistic model to identify additive genetic effects associated with alloimmunization. a p value < . (clinical analysis) or < x - (gwa) was considered statistically significant. results/finding: of the cohort patients, ( . %) transfused subjects were included with alloimmunized children < years ( . % of ) and alloimmunized adults ( . % of ). in multivariable logistic regression models, age (or . , p . , for age compared to - ), gender (or . , p . , for female compared to male), transfusion history (or . , p< . , for transfusions compared to - ), site, hemolysis (or . , p . , for log transformed lactate dehydrogenase) and presence of autoimmune disorders (or . , p< . ) were independent predictors of alloimmunization. gwa identified a single snp of unclear biologic significance associated with alloimmunization (eefsec gene responsible for incorporation of selenocysteine into proteins). conclusion: rbc alloimmunization is primarily driven by transfusion burden in this scd cohort. hemolysis remained significantly associated with alloimmunization after controlling for transfusions. presence of an autoimmune disease was also associated with rbc alloimmunization, indicating more systemic immune dysregulation may be present in scd patients who develop rbc alloantibodies. however, the gwa did not identify snps in immunoregulatory genes significantly associated with rbc antibody formation in the study population. background/case studies: physiologic anemia is more severe in preterm infants and worsened by the blood loss required for laboratory tests. to reduce iatrogenic anemia, placental blood, which otherwise would be discarded, can be used for laboratory testing. mother and infant blood are mixed in the placenta during delivery and pre-transfusion test results potentially can be altered due to fetal-maternal hemorrhage. there has been no published study to show if pre-transfusion test results of placental blood give the same result as the heel stick samples, which is the standard of practice. study design/methods: transfusion service tested sample pairs from newborns less than , gr birth weight. one of the samples was collected from the newborn as a heel stick sample, the other from the placenta. the following tests were performed on the sample pairs: abo, rh, antibody screen and direct antiglobulin test with igg (dat). results/findings: abo, rh and dat tests were performed on sample pairs. dat test was negative on sample pairs and two were positive. there was % concordance with the abo, rh and dat tests performed on these sample pairs. antibody screen was performed on placental blood samples and heel stick samples. twenty eight sample pairs were negative with the antibody screening test. there was one positive heel stick sample, which was also positive using the placental sample. one heel stick sample was negative for the presence of an antibody but found to be positive with the placental blood sample. this antibody which was detected only in the placental sample was a passive anti-d mother received during pregnancy. this discrepant result indicates that the placental blood sample was more sensitive to detect a weak antibody. conclusion: this study shows that placental blood sample is not inferior to heel stick sample regarding abo, rh and dat testing. based on this comparison study placental blood can be used for pre-transfusion testing for < , g birth weight newborns. o-( . %), ab ( . %), b-( . %), and a-( . %). among the tested donors, . % were d positive with r r being the most common rh phenotype. in the kell blood group system, . % of the donors were k positive, while the k antigen was found to be . %. the most common phenotype in the duffy blood group system was fy(a-b-), while the fy(a b ) was found at a higher frequency compared to what has been reported in the black population. (table) the commonest phenotypes for the kidd and mns blood group systems were jk(a b ) and m n-s s at % and . % respectively. the le a and le b alleles were seen in . % and . % of donors respectively, while lu b -phenotype was found in . % of the donors. the frequencies of the rare phenotypes jk(a-b-), le(a b ) and lu(a-b-) were . % , . % and . % respectively, while the m n-s-s-and m-n s-s-phenotypes were not found. the frequency of the p antigen was found to be at . % similar to what has been reported in caucasians. conclusion: this is the first study to examine the frequencies of rbc blood group phenotypes among the omani blood donors. the results show higher frequencies of the rare null phenotypes fy(a-b-), jk(a-b-) and lu(a-b-) compared to what has been reported in caucasians. the frequencies of the duffy blood group system resemble what has been reported in the black population. this data is helpful in understanding the influence of the arab ethnic background on the rbc blood group systems and warrants large genotype-phenotype studies in the region. quantitation of anti-d in serum using flow cytometry amanda whitelonis*, izekial butler, karen leighton, scott jones and anand srinivasan. qualtex laboratories background/case studies: rh(d) antibodies (anti-d) are developed in rhnegative individuals when exposed to d antigens. this scenario is commonly observed in alloimmunized antenatal and volunteer immunized patients. quantitation of anti-d in serum is important in the clinical setting to predict the risk of hemolytic disease of the newborn. quantitation of anti-d is also performed in quality control operations of organ procurement organizations and plasma fractionators. it is a common practice to report the strength of anti-d in serum as antibody titer values but quality control operations require a quantitative value. we have developed a screening assay using flow cytometry to quantitate anti-d in serum. study design/method: we have developed a method to quantitate anti-d in serum using flow cytometry, by modifying the protocols of christensson et al., and hilden et al.. red blood cells from rh-positive blood samples were washed three times in phosphate-buffered saline (pbs) at ph . and the supernatant was discharged. a dilution buffer containing % human serum albumin (v/v) in phosphate buffered saline was prepared. serum samples or who anti-d standards, suspended in dilution buffer were mixed with ll of washed red cells. the cell suspensions were incubated for min at c. following incubation, fitc-labeled anti-igg diluted in buffer was added and the mixture was incubated for an additional min at c. the samples were then analyzed by flow cytometry using gates for a typical red cell based on the forward and side-scatter signals. green fluorescence was collected using a band-pass filter set for - nm. events were recorded at a frequency of cells. results/finding: multiple dilutions of who anti-d reference standard were tested against rh-positive red blood cells from five different donors. the reproducibility of the assay was determined by measuring the change in coefficient of variance due to dilution procedure, machine variation and sample storage condition. after optimizing these factors, a linear regression was calculated to establish the standard curve. the fluorescent intensity emitted by probes demonstrated a linear correlation with the concentration of rh(d) antigens in reference standard. serum from thirty rh(d)-immunized volunteers were analyzed for concentration of anti-d and the results were benchmarked with antibody titer values. conclusion: based on our study, we conclude that the quantitation of rh antigens by flow cytometry can be used as a reliable assay to measure the concentration of anti-d antibodies in serum. the method is reproducible and advantageous over reporting antibody titer values. the operations of this platform can be translated to a well-plate based high-throughput flow cytometry. sarah k harm* , mark yazer , nancy m. dunbar and biomedical excellence for safer transfusion (best) collaborative . university of vermont medical center, university of pittsburgh, dartmouth-hitchcock medical center background/case studies: the use of emergency issued group a plasma and uncrossmatched group o whole blood (wb) in patients without a valid abo group is becoming increasingly common in the usa. it is unclear if low titer products should be provided in this situation and indeed a universally agreed upon threshold that would qualify as "low titer" has not been established. this study was designed to determine the rate of high titer donors using a titer threshold of . study design/methods: three academic hospitals that routinely issue group a plasma units for emergency issue participated in this study. before issuing this plasma to patients, a : dilution of the donor's plasma in saline was produced and added to group b reagent red blood cells (rbc). if any degree of macroscopic agglutination after immediate spin was observed, the unit was considered high titer and it would only have been issued to group a or o recipients. at these three centers no temperature, plasma volume or time enhancements were performed in the titer procedure, and anti-human globulin was not added. at one center samples were taken from the plasma of group o wb units and the same procedure was followed using a and b reagent rbcs; if at least one antibody demonstrated macroscopic agglutination after immediate spin, the wb unit was considered high titer and it was then centrifuged into an rbc unit for transfusion while the plasma and platelet components were discarded. two centers provided plasma testing data for a -year and -year period, respectively. one center provided plasma and wb testing data for a -year period. results/findings: in total there were group a plasma units tested and ( . %) had a high titer anti-b. the range of high titer group a plasma units between these three centers was . %- . %. of the wb units tested, ( . %) units had a high titer; / ( . %) of the units had a high titer anti-a, / ( . %) had a high titer anti-b, and / ( %) had high titers of both anti-a and anti-b. background/case studies: dithiothreiol (dtt) is a sulfhydryl reagent that denatures selective blood group antigens. reagent red blood cells (rbcs) treated with . m dtt is used as a tool in identifying antibodies to high frequency antigens. recently, dtt has become widely used in destroying cd on reagent rbcs and render them free from plasma anti-cd drug interference. procedures for the preparation of . m dtt has been published advocating the use of buffered saline at different ph levels. in this study, an effect of ph on . m dtt treatment time is investigated. study design/methods: non-buffered saline (nbs, thermo fischer scientific inc, middletown, va), used in the preparation of . m dtt, was adjusted to ph . , ph . , ph . using sodium phosphate dibasis (sigma aldrich, saint louis, mo). reagent rbcs (immucor, norcross, ga)(n ) were treated with the . m dtt solutions in parallel by mixing : ratio of packed rbcs to . m dtt solution followed by incubation at c. for up to minutes during treatment, the expression of k antigens was measured every minutes by tube method using different sources of anti-k. to assure uniformity, all reactions were graded by the same investigator. each reaction grade (in each rbc and each antiserum) is converted into a semiquantitive score and an average score was calculated every minutes for each ph level. the reduction in average scores between different phs were also calculated at every minutes to measure the impact of . m dtt reagent ph on the rate of k antigen destruction. results/findings: the expression of k antigen, measured by agglutination grades with two different k antisera, is significantly weakened (by ! ) after minutes of dtt treatment at ph . ; minutes at ph . and minutes at ph . . complete loss of k expression was seen after minutes of dtt treatment at ph . ; minutes at ph . and minutes at ph . . the reactivity patterns of k antigen tested with sources of anti-k correlate with each other. the reductions in average scores were seen between to minutes range of dtt treatment time when ph . was raised to ph . ; to minutes range when ph . was raised to ph . ; and to minutes range when ph . was raised to ph . . conclusion: the use of higher ph buffered saline may shorten the treatment time it takes to weaken or destroy k antigen. based on the comparison of reaction scores between different ph levels, the ph levels did not have an impact on dtt treatment up to minutes and/or beyond minutes of incubation. the ph of the . m dtt reagent relative to the treatment time is a factor to consider during the validation of dtt-treatment process and qualification of . m dtt reagent in a laboratory. background/case studies: data on the characteristics and frequencies of clinically significant red cell antibodies within the prenatal population have not been well established in the united states. the aim of this study was to determine if frequencies of red cell antibodies differed between geographically distinct regions within the continental united states. study design/ method: the aim of this retrospective study was to evaluate a cohort of prenatal patients (n , ) drawn between july , and june , . these patients were divided into united states census bureau regional and divisional categories according to their place of residence. prenatal blood work was collected which included an abo, rh(d) and a screen for unexpected alloantibodies. samples found to be positive for red cell antibodies were sent to one of nine regional laboratories for identification. results/ finding: in total, , patients were found to possess clinically significant red cell antibodies for an overall incidence of . percent. the three most commonly encountered antibodies were anti-d (n ) . %, anti-m (n ) . %, and anti-e (n ) with a frequency of . %. a total of ( . %) prenatal women were found to possess two or more antibodies. in general, the combination of anti-d and anti-c proved to be the most common, with instances ( . %) followed by anti-e and anti-c with ( . %), and anti-c, anti-e with ( . %). of the multiple antibodies identified, ( . %) included at least one antibody from the rh blood group. the south region had the largest number of antibodies identified with or . % of the total. the west had ( . %), the midwest ( . %) and the northeast with ( . %). a contingency table, using the two-sided fisher's exact test, was performed comparing the northeast, south, midwest and west regions. the p value of anti-d was calculated to determine nonrandom associations and values of . and below was deemed significant from a region-to-region perspective. with regard to anti-d, the pacific division comprised of california, oregon, washington, and alaska, had p values below the . thresholds when compared against seven of the eight other divisions. the west south central division (texas, oklahoma, arkansas, and louisiana) did not show statistically significant results when compared against the pacific division (p . ). conclusion: depending upon the antibody, statistically significant variations between geographical regions and divisions within the united states were observed. this relationship between antibody and locality requires further investigation but may be attributed to the presence or absence of red cell antigens among different racial and ethical populations. reduction in repeat testing using gel technology amy mata* , lindsy rich , sherry stern , sharon wangen and camille van buskirk . mayo clinic, mayo clinic rochester background/case studies: our institution currently uses the immucor neo (immucor, inc., norcross, georgia) to perform abo/rh and antibody screen (absc) testing utilizing solid phase technology. when results are unable to be obtained from the immucor neo, testing is repeated on the manual testing bench using tube agglutination. this repeat testing can lead to significant expenses including reagents, supplies, and technologist time. it was decided by leadership in our laboratory that it would be beneficial to observe how other methodologies perform in this regard. a side-by-side evaluation was performed between the immucor neo and the ortho vision (ortho clinical diagnostics, rochester ny) to determine if there was a significant difference in the amount of repeat manual tube testing that needed to be performed. the evaluation looked at abo/rh and absc testing as those are the only tests that are currently automated in our laboratory. study design/method: thirty specimens that were processed on the immucor neo and resulted in no type determined (ntd) for abo/rh testing were selected to be tested on the ortho vision. twenty-three specimens that were processed on the immucor neo and produced positive results for absc testing were selected to be tested on the ortho vision. all specimens were edta tubes and were collected within the previous days. the timeframe between when the specimen was tested on the immucor neo and the ortho vision was to days. results/finding: of the ntd specimens from the immucor neo, resulted in valid abo/rh typings on the ortho vision. three results were flagged indicating possible extra reactivity. upon performing a visual review of all results, it was determined that there was no reactivity and a valid result was present. the other samples required manual tube testing to interpret the abo/rh and were due to mixed field, weak isoagglutinins, unexplained extra reactivity, and hemolysis. of the absc specimens that were resulted out as positive on the immucor neo, specimens produced a negative result on the ortho vision and were confirmed to be negative with manual tube testing using peg as the enhancement media. one specimen was flagged for fibrin, but upon performing a visual review, was determined to be negative. nine specimens that were positive on the immucor neo were also positive on the ortho vision. one specimen proved to be an anti-m that was seen in gel but not in tube and one specimen displayed unexplained reactivity in gel as it was negative in tube and all clinically significant antibodies were ruled out. all showed discrepant results with monoclonal anti-c reagents, with a similar pattern of reactivity: - with ms (n ), - s with ms (n ), no reaction with ms , dgc , p x (n ). samples tested with a polyclonal anti-c showed a - reactivity. d c e c e cases tested with a polyclonal and monoclonal anti-e (ms , ms , ms , ms ) showed no weakened reactivity. rhce sequencing (genomic dna or cdna) showed a c. g>a mutation in exon , predicted to encode the p.gly ser substitution. for apparent r r donors, a f-negative type allowed the prediction of a rhce*ce a/rhce*ce genotype. altogether, our results are consistent with the presence of a very likely rhce*ce a allele (c and e in cis) in all samples. d c e c e individuals were reactive s with the original source of anti-rh , slightly weaker when compared to rhce*ce a/rhce*ce rbc samples available from our cryobank ( ). conclusion: our results confirm that the c. g>a mutation alters the conformational properties of the rhce protein, either on a ce or ce background, and encodes the low-prevalence locr antigen (rh ). the locr reactivity appears to be rather similar when coded by rhce*ce a or rhce*ce a alleles. this was quite an unexpected finding, since the p.gly ser substitution is close to the critical amino-acid for c/c expression (p.pro ser). none of our cases made anti-c and/or anti-e but few were subject to a potential alloimmunization background. however, as rhce*-ce a was reported to code for a partial c (rh:- ), we consider that rhce*ce a likely encodes partial c and e, this being also supported by the predicted localization of the p.gly ser change on the second extracellular loop of the rhce protein. background/case studies: weak d genotyping is recommended for transfusion recipients, pregnant women, and newborns who had a rhd typing discrepancy, or a serological weak d phenotype, to determine if they carried the weak d genotypes , or . the purpose of this study was to analyze the underlying rhd genotypes of the patient samples received for weak d genotyping since published recommendations, in particular those found to not carry the weak d , , or genotypes. study design/methods: between / and / samples were received for weak d genotyping. testing was performed using pcr-rflp targeting the sequence variants in the rhd gene that have been previously defined. samples that did not have weak d types , , or genotypes, but a transfusion vol. supplement s had evidence of rhd genetic sequences in exon and/or intron in preliminary testing were evaluated by sanger sequencing for rhd and rhce exons - to determine the underlying rh genotype. when provided, the patient's ethnicity and presence of anti-d was recorded. results/findings: the majority of the samples were from obstetrical patients ( %) followed by transfusion patients ( %); % had no clinical indication provided. samples ( %) were found to be weak d type , , or ( , , and samples, respectively). samples ( %) appear to be genetically rhd negative. genetic sequencing was performed on samples; had rhd genetic variants that were not weak d types , , or (table) . all of these variant rhd samples also showed some variation in the rhce gene. two samples ( %) had wild type rhd alleles; further evaluation is ongoing. conclusion: most samples tested by weak d genotyping were found to be weak d types - . of the samples that had evidence of an rhd gene and did not carry the known weak d types - polymorphisms, ( %) of were found to have other rhd variants, and ( %) did not have underlying genetic variation detected in the rhd gene. the majority of the non weak d types - variants were dar alleles, which are often associated with anti-d production. background/case studies: rhd genotyping has been recommended to guide transfusion of d-negative rbcs and administration of rh immunoglobulin to patients with discordant or weaker than expected d typing, particularly for females and ob patients . the recommendation is based on observational evidence, primarily from europe (flegel , curr opin hematol : ) , that individuals with weak d types , , and are not at risk for clinically significant anti-d. the implications and utility of this approach for the diverse u.s. population are not yet clear. here we report months experience with rhd genotyping on samples referred with discrepant or weak d typing investigated from january to april . study design/method: serologic testing was performed by standard tube agglutination with licensed reagents. dna isolated from wbcs was used in manual rflp and rhd beadchip assays and rhd sequencing for some. ethnicity was known for samples ( . % caucasian, . % african american/african, . % multiracial, . % hispanic, % asian, and . % other). results/finding: rhd genotyping identified weak d types , , and in / ( %) and alleles known to encode partial d phenotypes in / ( . %) (table) . uncommon or rare weak d alleles including types , , , , , , (n ), , , , , and were found in ( . %). the partial d alleles found were diverse, but the largest number included partial rhd*d . (n ) and *dar ( conclusion: in a multiracial cohort of individuals with weaker than expected d typing % were due to weak d types , , or and would not be considered at risk of clinical significant anti-d, but for % there is potential or unknown risk. these studies are important to gain insight into the prevalence of specific alleles in the u.s. multiethnic population and to continue to evaluate and refine rhd genotyping for clinical practice. cp rhd* . allele causes discrepant genotyping results for rhce small c sabine scholz* , sandra schneider , sabrina k€ onig , susanne helmig and vicky van sandt . inno-train diagnostik gmbh, rode kruis vlaanderen background/case studies: in the human rh blood group system the c, c, e, e and d antigens are expressed by the two highly homologous genes rhce and rhd. after d, c is the most immunogenic rh antigen. the difference between c ( c) and c ( t) is caused by the snp on position on the rhce gene. the rhd* . allele (also known as rhd cat vii type ) carries the snp t>c on the rhd gene and additionally the snp t>c. this rhd* . allele has been described to partially express rhc on the d polypeptide (faas, transfusion, ) . aims: genotyping was performed to clarify the cause of the weak c expression. serology of a patient sample (male, ) indicated a partial c phenotype with a cde. study design/method: rhd and rhce phenotyping was done by accredited routine protocols (monoclonal ab id card: diaclon rh subgroups, seraclone anti-c). genotyping was performed with a taqman probe assay (rbc-fluogene veryfy, inno-train diagnostik gmbh), sso (rbc-lifecodes, gen-probe inc.), in-house ssp-pcr (hila, rode kruis-vlaanderen) and commercial ssp-pcr (rbc-ready gene cde, inno-train diagnostik gmbh). sanger sequencing of the rhd gene was performed using an inhouse method (inno-train diagnostik gmbh). results/finding: discrepant genotyping results were generated by different test systems: the taqman probe based assay showed in repetition a ccee genotype, while the sso system rbc-lifecodes predicted in repetition a ccee phenotype. in ssp-pcr the sample showed a weak c band with the in-house method, while there was no band visible with the commercial test kit. the parallel analysis of the rhd gene with rbc-ready gene cde test system revealed a variant d cat vii rhd allele. sequencing of the dna sample identified two snps on one of the rhd alleles ( t>c, t>c) confirming a rhd* . and one rhd* allele. hispanic female in preparation for surgery resulted in variable reactivity and weakly positive d reactions when using microtiter-well agglutination versus tube testing. determination of whether the d antigen expression represented a weak d or a variant d could not be resolved by serologic testing alone. here we report the characterization of a novel rhd gene mutation identified by rhd gene sequencing. study design/method: serologic typing was initially performed by microtiter-well agglutination by automated analyzer platforms galileo neo and galileo echo (immucor, norcross,ga) and by standard tube testing using the immucor series and anti-d reagents. further immunohematologic evaluation was performed by standard tube testing (immediate spin -is, and indirect antiglobulin -iat) using orthobioclone, immucor gammaclone, immucor series and series , and albaclone anti-d reagents. dna isolated from wbcs was used in manual rflp and rhd beadchip assay (immucor, bioarray) and rhd sequencing. results/finding: rbc reactivity is summarized in the table. dna testing detected a hybrid rhesus box associated with the rhd gene deletion, indicating the patient was hemizygous for rhd. rflp assay and rhd beadchip did not identify any changes. rhd gene sequencing identified a new c. a>g change in exon encoding an amino acid change p.met val. the predicted location of this change is within the fourth transmembrane segment of the rhd protein. conclusion: we identified a novel rhd allele with c. a>g (p.met val) change in exon . several snps, deletions, and insertions have been reported with changes in exon . phenotypes of these genetic variations result in rh negative, weak d types, and variant d. since this change has not been previously identified, we are unable to determine if this confers a risk of anti-d alloimmunization, but the rhd c. a>g snp results in serologically weak phenotypic expression of d antigen when tested by microtiterwell agglutination on the neo/echo platforms. in this case the combination of microtiter-well agglutination and dna sequencing helped identify a new allele which would be missed by standard tube serologic testing and the current commercially available array assays. serologic and molecular detection of an antibody to a high incidence antigen in patient with history of chronic transfusions georgia spanos* , juan merayo-rodriguez , christopher lough and nancy eckert . lifesouth community blood centers, life south community blood centers, lifesouth community blood center-headquarters background/case studies: the jo a antigen is one of three high incidence antigens in the dombrock system. the prevalence of this antigen is % in most populations and greater than % in the black population. the jo a antigen can be resistant or enhanced with enzyme treatment (ficin/papain) and typically variable with dithiothreitol (dtt), w.a.r.m. tm (immucor) and zzap treatment. anti-jo a is an igg antibody that demonstrates at ahg phase. hemolytic transfusion reactions to the jo a antigen vary from none to moderate/severe. hemolytic disease of the fetus and newborn (hdfn) has not been observed with any antibody associated in the dombrock system. there are two common phenotypes present in the black population:hy negative/ jo a negative and hy weakly expressed/jo a negative. study design/methods: an antibody identification and red blood cell (rbc) units were requested for an o positive, year old, african-american female with a history of sickle cell disease and no history of pregnancy. the patient was not recently transfused, however, had a history of chronic transfusions. last reported transfusion was three years prior to the current specimen. there were no known rbc antibodies at the time of the request. facility reports that the patient's hemoglobin(g/dl)/hematocrit(%) (hgb/hct) is . / . and does not appear to be in sickle cell crisis. a request for phenotypically matched units, as per hospital policy, for c, e, k and s was received by our immunohematology reference laboratory (irl). results/findings: anti-jo a was detected in patient plasma reacting with liss and peg (tube method) and manual gel-iat. the antibody was resistant when tested with dtt treated red cells. in-house frozen reagent rbcs negative for the jo a antigen (positive for hy) were used to serologically prove the presence of the antibody to this high incidence antigen. an allogenic peg adsorption was performed to rule out other common clinically significant antibodies. anti-kp a was identified using this adsorbed plasma. further testing with molecular genotyping (grifols idcore xt ) confirmed the patient's genotyping as antigen negative for the jo a , kp a and positive for hy. conclusion: molecular testing is frequently performed on patients and retained donor samples from our local community donor pool throughout florida, georgia and alabama. staff is able to search our database for any combination of antigen negative phenotypes using the internal (k) blood establishment computer software (becs) integrated blood bank information system (ibbis). this enabled us to locate one refrigerated and three cryogenically preserved jo a negative rbc units. we found eligible blood donors that could be recruited via an automatically generated call list. the request for rbcs was cancelled. patient's clinical symptoms improved without transfusion and repeat hgb/hct increased to . / . the patient's sibling is historically negative for the jo a antigen and should future transfusions be required, it was recommended that a directed donation be made on the patient's behalf. in order to continue having blood components available to meet all our patient's needs, irl staff is consistently screening and searching our inventory for blood components that are negative for rare antigens to retain for patients needing antigen negative units in a timely fashion. rbcs of two females whose samples were referred for rhd genotyping with previously reported alleles for which serologic reactivity had never been investigated. study design/method: serologic testing was performed by automated analyzer, galileo echo and neo (immucor, norcross, ga), and by standard tube testing with licensed anti-d reagents and the albaclone advanced partial rhd typing kit. genomic dna isolated from wbcs was used for immucor rhd beadchip assay, pcr-rflp, and rhd sequencing. results/finding: patient was a yo female, c e c e , whose rbcs reacted by echo and by neo with anti-d , and '?' with anti-d . testing with d and d by tube gave and w on initial spin (is) respectively and by indirect antiglobulin test (iat). rbcs were non-reactive at is with ortho bioclone and biorad seraclone, and w with immucor gammaclone anti-d, and all were at iat. rbcs did not react with two (lhm / & / ) of anti-d in the alba partial d kit. this pattern did not match any partial d identified by these clones. rhd beadchip detected an inactive rhd pseudogene in trans to rhd. gene sequencing confirmed the presence of the pseudogene, but rhd had a c. c>a change encoding p.his gln. patient was a yo pregnant female, c e c e , whose rbc were w at is and at iat with immucor series and and gammaclone, and moderately reactive, is and iat, with alba alpha, alba blend and delta anti-d. rbcs did not react with two (lhm / & / ) anti-d in the partial d kit with no known partial d pattern. dna testing predicted she was rhd hemizygous and rhd beadchip detected markers for rhd*dar but exon gave low signal (ls). sequencing found a hybrid dar with ce-specific nucleotides in exon from c. to c. encoding amino acid changes p.ile leu and ser asn. conclusion: we found two previously reported rare alleles: rhd with a c. c>a (p.his gln), previously found in france (lefloch et al. genbank ku ), and rhd*dar with part of exon replaced by rhce, reported in sub-sahara africa (granier et al. transfusion : ) designated rhd*dar(ce :v v-s n) with an allele frequency of . to . . blood samples were not available to test for alterations in d expression for either allele. we provide serologic evidence that these alleles, found in two females evaluated by rhd genotyping, inform transfusion and rh immune globulin prophylaxis, as they encode partial d phenotypes with novel epitope expression patterns, meaning these patients are at risk of forming allo anti-d. background/case studies: hu f -g is a human monoclonal igg antibody recognizing cd that is in clinical trials to treat hematologic or solid malignancies. cd is a transmembrane glycoprotein that binds to signalregulatory protein a (sirpa) on macrophages and functions to regulate phagocytosis. blocking cd is thought to enhance phagocytosis and promote anti-tumor responses. cd is also highly expressed on rbcs, and the purpose of this study was to evaluate anti-cd drug interference in blood bank testing. study design/method: serologic testing was performed by standard methods. serial samples (n ) from patients were tested over the course of month treatment. plasma was tested at immediate spin (is) and by iat with r r , rr, d--, rh mod and rh null rbcs, as cd expression levels vary depending on rh phenotype. dtt and enzyme treated rbcs were also tested. both immucor gamma-clone anti-igg (does not detect igg ) and ortho bioclone anti-igg (total igg) were used. for titration plasma was diluted in pbs. allo-adsorptions were performed with papain treated rr rbcs and eluates were made using gamma elu-kit ii. results/finding: anti-cd was observed in plasma as soon as hour post infusion. plasma reacted to at is and with all panel cells in peg iat using ortho anti-igg. d--, rh mod and rh null rbcs were nonreactive at is and weaker ( and ) in peg iat with ortho reagent. reactivity with all panel cells by ortho igg gel card was . in contrast, iat reactivity using gamma-clone anti-igg was only w to , and this reactivity was confirmed to be carry-over agglutination. d--, rh mod and rh null were non-reactive in peg iat using gamma-clone anti-igg . the anti-cd titer was at is and peg iat with gamma-clone anti-igg, but was ! with ortho anti-igg. plasma reacted with dtt, trypsin, papain, a-chymotrypsin or w.a.r.m. treated rbcs. somewhat unexpected, autocontrols were negative and dats were non-reactive or microscopic only. acid eluates (n ) were reactive with ortho, and non-reactive with gamma-clone anti-igg. plasma reactivity was removed after x allo-adsorption with papain treated rr cells, but in some samples low level (micro- ) reactivity remained. peg adsorption was invalid due to precipitation/complexing of antibody. robust plasma reactivity interferring in abo reverse typing was observed, and weak spontaneous agglutination of the rbcs in the abo forward and rh typing. conclusion: hu f -g anti-cd therapy interferes with routine pretransfusion testing, not only antibody screening and crossmatch, but abo and rh typing. high levels of cd expression on rbcs results in plasma agglutination at is, mimicking reactivity observed with igm antibodies although hu f -g is igg . reactivity was observed in all phases and with all test methods. cd is not cleaved from rbcs by dtt, trypsin, papain/ ficin, dtt with ficin (w.a.r.m.) or a-chymotrypsin, and treatment of rbcs with these does not mitigate interference. numerous adsorptions with papain treated rr rbcs were required to remove anti-cd reactivity from plasma. use of immucor gamma-clone anti-igg, which does not detect igg , can mitigate interference in iat although carryover reactivity may be observed. due to blocking by anti-cd on the patient rbcs, dat and autocontrols were weak or non-reactive; however eluates prepared from the dat rbcs were strong and pan-reactive using ortho anti-igg. background/case studies: a caucasian woman with history of a caesarean section and a rbc tx in . in august , she was admitted to hospital for trauma surgery, ab screening was negative and two units were transfused without transfusion reactions. five days later she was referred to a tertiary care trauma center due to a severe postop infection and need for a reoperation. ab screening was now positive, with an antibody reacting with all panel cells detected. because of the urgent need for rbc tx, two weakly cross-match positive rh k matched units were transfused with a warning of possible alloantibodies. the patient got acute hemolysis. study design/method: a gel technique was used in the hospital transfusion laboratory. in addition, various antibody identification panels and special serological and genotyping methods were used in the reference laboratory. kel sequencing was done by the international immunohematology center. results/finding: the hospital transfusion laboratory results were o rhd neg, dat neg, and the ab identification was with untreated and with enzyme-treated cells, with weakly positive autocontrols. a sample was submitted to the reference laboratory for additional investigation. dat was weakly positive, while ab identification results were similar to the hospital results. different pheno-and genotyping methods were used in addition to several identification panels to exclude rare blood groups. after pk, vel neg, jk:- etc. had been excluded, k-phenotyping revealed a k -phenotype. a total of silencing mutations are known for the kel gene and the genotyping kits used did not recognize these. the anti-ku antibody reacts with all cells apart from the k -phenotype. the presence of dtt-sensitive anti-ku was confirmed with dtt-treated panel cells. anti-ku may cause immediate and delayed hemolytic transfusion reactions. samples were taken from the patient's two siblings and daughter. kel sequencing revealed kel* n. with c. t encoding p. ter (reported in an individual from austria in ). there are two known k -patients in our country, both homozygous for c. t. the daughter was a c. t heterozygote, while the siblings did not have this variant. a new operation is necessary but no k -donors are available in our country. with the help of the isbt rare donor working party, a k o rhd neg donor was found in japan and one unit was delivered to us for use in the next operation. conclusion: an alloantibody should always be suspected when autocontrol is weaker than panel cell reactions, even if the direct coombs is positive. a combined serological and genotyping approach offers the best solution for problematic antibody cases. compatible blood is not always available in rare blood group cases, but international co-operation may be of help in finding a suitable donor. transfusion strategy for the serologic weak d phenotype in tunisia based on rhd alleles and rh haplotypes mouna ouchari* , kshitij srivastava , houda romdhane , saloua jemni yacoub and willy albert flegel . nih, dtm/cc/nih, regional blood transfusion center sousse, regional blood transfusion center sousse, tunisia background/case studies: d antigen variants have been studied molecularly in many arab populations, including gaza, tunisia, egypt and libya, a transfusion vol. supplement s since . the tunisian population has the largest known prevalence of weak d type . alleles, occurring in of rh haplotypes, compared to in , or less in europe. a systematic study was missing for samples with the serologic weak d phenotype routinely found in blood donor and patient testing in tunisia. the study was designed to obtain data on weak d type . in a population known to harbor the greatest prevalence of such allele worldwide. study design/methods: a total of , random blood donors were serologically screened for the d antigen using routine techniques. samples with weak reactivity were tested with a panel of monoclonal anti-d (partial rhd-typing set) to identify partial d phenotypes. the rhd gene was sequenced in all samples with serologic weak d phenotype. the rhce gene was also tested molecularly by either direct sequencing or using the rhce beadchip kit to ascertain the rhce allele linked to the rhd allele. results/findings: a total of discrepant samples ( . %) were observed and expressed the serologic weak d phenotype. among them, carried an allele of the weak d type cluster ( . %), of which samples ( . %) showed the weak d type . allele. only sample each was found for the weak d types , and and the dvii, while samples showed the consensus rhd sequence. no mutation in any of the rhd exons was detected in another samples. the molecular analysis of the rhce gene showed that out of samples with serologic weak d phenotype ( . %) had a variant rhce allele and the most common associations were: weak d type . linked to rhce*cevs. . ; weak d type . . with cear; and weak d type . to rhce*cevs. , while the other rhd alleles were linked to one of the common rhce alleles. conclusion: almost % of the weak d phenotypes in tunisia were caused by alleles of the weak d type cluster, of which % represented the weak d type . allele. based on established rh haplotypes for variant rhd and rhce alleles and the lack of adverse clinical reports in tunisia, we recommend d positive transfusions for patients and no rhig administration for pregnant women with weak d type . in tunisia. we propose this strategy as a pragmatic clinical decision, even if eventually a rare allo-anti-d immunization would occur in tunisia associated with weak d type . phenotype. there is a possibility that the rhce*cevs. . allele, typically associated in tunisian individuals, may protect from allo-anti-d immunizaton and other rhce alleles, such as rhce*ce more often associated in individuals of other ethnic groups, may not. however, we conclude that this conjecture has not much evidence in support at this time and would need corroboration by experimental and clinical data, before used to guide clinical recommendations. martha rae combs* , heather simmons , christine lomas-francis , gayane shakarian , sunitha vege , lauren hutelmyer , sandra nance , jessica poisson , nicholas bandarenko and connie m. westhoff . duke university hospital, immunohematology and genomics laboratory, new york blood center, arc pennjersey, american red cross, immunohematology reference laboratory, biomedical services background/case studies: plasma from a transfused, a , year old white female, post liver transplant with rbc aplasia, reacted at rt and in peg iat with all rbc samples tested except her own. study design/method: standard hemagglutination methods were used for antibody id and antigen typing. acid eluates were prepared using gamma elu-kit ii (immucor). genomic dna was isolated from wbcs and used for hea precisetype array and kel and sc gene sequencing. samples from the proband and her mother were tested, as applicable. results/finding: the patient's dat was negative. her plasma reacted with . m dtt-treated and papain-treated rbcs, all available rbc samples lacking high-prevalence antigens, and with phenotypically similar rbc samples [c , k , fy(a ),s ]. reactivity was detected to a titer of ; it was not removed by prewarm technique or by x peg alloadsorption. the adsorbed plasma reacted with . m dtt-treated rbcs. extensive rbc phenotype results were unremarkable except for the following: k , k , js(b ), kp(a b ) and sc: , . her plasma reacted with k o , mcleod, sc: , rbc samples and dtt-treated sc: rbcs at rt and peg iat but her diluted plasma and pretransfusion eluate showed relative kp b specificity. the patient was transfused aliquots of crossmatch incompatible kp(b ), s rbcs. her post-transfusion dat was with anti-igg, with anti-c d. the eluate reacted with all rbc samples except kp(b ) sample. she tolerated additional aliquots from phenotypically similar rbcs untested for high-prevalence kell or scianna antigens. the hea precise-type predicted k , k , kp(a b ), js(a b ) and sc: , , discordant with her rbc phenotype. kel gene sequencing identified a homozygous change, c. a>t (p.glu val) (kel* . ) encoding the low prevalence antigen, ul a , but no changes associated with lack of kell system antigens; however, her rbcs typed ul(a ). sc sequencing found heterozygosity for a '- g>a change (rs , to % prevalence) and conventional sc* , predicting sc: , , . kel and sc results on the mother were kel* /kel* . , heterozygous for the sc change '- g>a, and her rbcs typed k k kp(a b ), sc , ula , consistent with dna predictions. plasma collected months later was nonreactive at rt and in peg iat. her rbcs were dat and now typed k , kp(a b ), ul(a ) sc and sc ,concordant with predicted kell and sc phenotypes. conclusion: we report an example of kell and scianna antigen suppression or blocking in the presence of autoantibody or an alloantibody in the kel system. to our knowledge, this is the first report of a ul a kel* . homozygote. the rbcs may lack a high-prevalence antigen antithetical to ul a . without dna testing and gene sequencing, the patient would be presumed to have kell null and sc null phenotypes, a search for k o , and/or sc: , rbc units would be performed and we would not have been prompted to re-type her rbcs when the dat was negative. background/case studies: anti-jka is a common antibody identified in the blood bank and providing phenotypically characterized red cells lacking this antigen is important in avoiding an acute or delayed hemolytic transfusion reaction. in nearly all cases, this antibody is identified in the context of a phenotypically homozygous jkb patient, jk(a-b ). other scenarios are quite rare. we present two cases of anti-jka in which this phenotype was not observed. study design/method: patient a is a -year-old multiparous female with no known transfusion history. her blood typed as o positive with a positive antibody screen, negative dat, and a clearly identified anti-jka in plasma. the patient phenotyped as jk(a-b-). genotyping revealed the presence of the jk*b allele, but not the jk*a allele. complete sequencing of the jk gene showed an intron polymorphism in homozygosity. specifically, the patient showed a jk*b(ivs - a)genotype, associated with a jkb null phenotype. anti jk was not identified. the conclusion was an allo-anti-jka in a jk null patient. the patient did not receive any transfusions. patient b is a multiply transfused old female. her blood typed as a positive with a positive dat and antibody screen. both the plasma and eluate revealed an anti-jka. despite the recent transfusion, the patient phenotyped as jk(a ) and jk(b ) . genotyping showed the presence of both jk*a and jk*balleles. whole gene sequencing was not performed. there was no hematologic or biochemical evidence of hemolysis. the patient was considered to have an auto-anti-jka and jka negative cells used for transfusion. results/findings: patients a and b both developed anti-jka while having uncommon phenotypes/genotypes. conclusion: it is common for jk null patients to develop anti-jk . however, we speculate that expression of the kidd glycoprotein with the jkb epitope was below the threshold of serological detection, but enough to prevent the formation of anti-jk or anti-jkb. auto-anti-jka is usually reported in the context of an active hemolytic process, but patient b illustrates an auto-anti-jka without hemolysis which is more commonly observed with autoantibodies exhibiting specificity for rh epitopes. these rare cases of anti-jka require phenotypic and genetic analysis for the jkb epitope and jk*b allele respectively, and in more complex cases whole gene sequencing. background/case studies: donor genotyping for red blood cell antigens has become common practice in many blood bank laboratories. package inserts for commercial assays indicate false negative results may be generated when unexpected rare mutations affect primer or probe binding and cause allele dropout or failed amplification. these outcomes may go unrecognized unless serological results are available for comparison. study design/method: a routine blood donor, self-identified as african american, was selected for red blood cell genotyping. dna was extracted and genotyping was performed using two commercial platforms a transfusion vol. supplement s (precisetype, bioarray, warren nj; idcore xt , grifols, emeryville, ca). genotype results were compared to historical serological results. discrepancies were resolved by sanger sequencing (grifols ih, san marcos, tx). results/finding: genotyping results showed variants in both the duffy (fy) and kell (kel) blood group systems. the donor's genotype was concordant on both platforms, fy*a/fy*b_gata, kp*a/kp*a, for a predicted phenotype: fy(a b-); kp(a b-). when genotype results were compared to historical serology, it was noted that the donor previously typed fy(a-) on separate donations. no previous kpa or kpb serotyping was available. sequencing of fy exon revealed a g>a mutation, fy *n. , known to silence fya. sequencing of kel exons - exposed a silent polymorphism in exon , g>c. this polymorphism causes a dropout artifact yielding a false negative kpb interpretation. conclusion: the discrepant fy*a result, as well as the unlikely kp(b-) type prompted the request for sequencing. the rare fy *n. mutation has been reported in people of caucasian descent. this is the first example of this fy mutation identified in this regional population. the kpb antigen is present in nearly % of all populations. however, kp(b-) is most frequently seen in people of caucasian descent. to date, self-identified african american donors have been genotyped as kp*a/kp*b at this blood center. given the diversity of regional heterogeneity, it is feasible to identify a kp(b-) donor, self-reporting as african american. red blood cell genotyping offers an abundance of information, but cannot replace serology as the sole means of red cell antigen characterization. donor ethnicity continues to play a key role in selection for genotyping and the search for rare and unusual red cell types. in this case, a donor selected for genotyping based on ethnicity was initially thought to have genetic variants not previously reported in those of african descent. only was proven to be present. this case acts as a reminder that genotype limitations must be considered even when using licensed methodologies. this case report presents two group o pediatric patients who had been on enteral feeds and had absent/weak anti-b that became strong over time in patient . study design/methods: patient was a year-old male born prematurely with short gut syndrome who underwent a small bowel and liver transplant at years of age. anti-b changed from undetectable/weak to strong at the age of years. patient was a month-old female with a metabolic urea cycle disorder who underwent a liver transplant. anti-b was / . both patients were on total parenteral nutrition (tpn) since birth and had strong anti-a and normal immunoglobulin testing. abo typing with enhancing techniques is presented in table . results/findings: both patients typed as group o on forward typing. anti-a was strong in both patients. anti-b varied in strength in patient with - reactions up to years of age. thereafter, abo typing showed mainly strong anti-b. patient had / anti-b. conclusion: intestinal bacteria stimulates production of anti-a and -b. unexpected changes in anti-b that caused abo discrepancies are reported here for children on long-term tpn. patient had absent/weak anti-b since birth up to years of age, then developed strong anti-b with no change in feeding regiment and medications. patient had consistently strong anti-a and absent/weak anti-b. these findings support the notion that normal colonization of the gut is important in the development of anti-a and -b and suggests that microflora of the gut in patients on prolonged tpn is different leading to the delayed formation of these antibodies compared to individuals on normal enteral diet. difference in strength of anti-a and-b could be due to stronger a than b antigen expression on gut bacteria. results/finding: a daratumumab protocol was established that incorporated use of the cord panel. multiple myeloma patients selected as candidates for daratumumab treatment were baseline tested for blood type and antibody screen, dat and genotype. after daratumumab infusion, a two unit crossmatch was order as a precaution in the event the patient developed a reaction to the medication. repeat of the antibody screen demonstrated panagglutination which served as a positive control for the medication. the cord panel ruled out underlying alloantibodies. selected red cell units were crossmatched at immediate spin phase to avoid expected indirect antiglobulin reactivity. conclusion: the cord panel was used times over a five month period to rule out underlying alloantibodies. tests for the daratumumab protocol consisted of a routing antibody screen followed by a cord panel for resolution. the daratumumab protocol significantly reduced testing time and allowed for the provision of compatible blood products in an efficient and cost effective manner. teresa gorey* and elizabeth hart . brigham and women's faulkner hospital, university of massachusetts-dartmouth background/case studies: the purpose of performing a pre-transfusion antibody screen is to detect clinically significant unexpected antibodies and to decrease the probability of detecting clinically insignificant antibodies. several antibody detection methods (polyethylene glycol (peg), liss, and albumin) are routinely used in small transfusion services. the utility of peg is to enhance the sensitivity of detecting clinically significant antibodies by the indirect antiglobulin procedure. the code of federal regulations, title , cfr part . (a), states the manufacturer's instructions are followed when testing for unexpected antibodies. the package insert for gamma peg tm (immucor inc., norcross, ga), states that negative reactions may be examined with an optical aid. based on these directions, our institutional policy is to confirm all negative reactions using the microscope. study design/method: a one-year retrospective document review was performed on all patient samples in which a positive antibody screen (absc) triggered the antibody identification (abid) to be performed in . a total of samples were evaluated. each abid was subcategorized; ( ) as being a new antibody for our facility or in the patient's shared electronic health record within the partnersv r healthcare system and ( ) whether a microscopic absc result triggered the abid. also, patients with known antibodies were grouped according to a microscopic absc result. a comparison of the new patients and the previously known antibody patients with microscopic results were reviewed to determine if the antibodies were clinically significant. results/finding: a total of abids were performed on new patient samples. of the new abid samples, ( %) had microscopic absc results. for the previously known antibody patients, there were which accounted for % of the total abids performed. when reviewing the total abid workups, a total of ( %) of the abscs had microscopic results which resulted in an abid being performed. the antibodies identified in the new antibody samples were: conclusion: a total of % of the new antibodies identified based on a microscopic absc were clinically insignificant. the manufacturer's directions were followed but they do not state that an optical aid is required to confirm all negative results. due to the results of this study, a decision will be made to: ( ) discontinue the use of the microscope, ( ) switch to a peg manufacturer whose directions indicate to observe macroscopically for agglutination, or ( ) define the use of the agglutination viewer as the optical aid. decreasing the number of abids will save time and money while providing potential rbcs for transfusion in a timely and efficient manner. anton") has a prevalence greater than % in all populations. hereditary absence of anwj has only been described once (in a single family). however, red cell expression of anwj may be markedly decreased to near undetectable levels in blood donors of the in(lu) (or "dominant lutheran inhibitor") phenotype. similarly, anti-anwj antibody formation is rare, with only cases reported in the literature. the antibody developed in the context of hereditary absence of anwj (i.e., a true alloantibody) in only one of the cases. in the other nine cases, the antibody occurred in the context of autoimmune or lymphoproliferative disease, where, in this context, it is believed to have developed secondary to transient anwj antigen suppression. most of the reported cases lacked clinical or laboratory evidence of hemolysis. however, in the most recently reported case, involving a -yearold woman with aplastic anemia, the antibody was associated with acute hemolytic reactions after rbc transfusions, necessitating transfusion support with anwj-negative and in(lu) rbcs. the case was also unique in that the anti-anwj resulted in a direct antiglobulin test (dat) that was positive for complement only, rather than igg like all previous cases in which the dat was performed and was positive. study design/method: a -year-old woman with severe aplastic anemia experienced acute hemolytic transfusion reactions (ahtr) with development of a panagglutinin on indirect antiglobulin test (iat) screens. prior to identifying the specificity of the panreactive antibody, the patient received rbc transfusions and showed signs of hemolysis with six of them. the first three transfusions were prior to her positive iat and were electronically crossmatched. the next seven transfusions were incompatible by antihuman globulin (ahg) phase crossmatch, but were extended phenomatched for clinically significant antigens. the patient's ahtr signs and symptoms included fever, rigors, nausea, vomiting, dark urine, flank pain and "impending doom" anxiety; while her laboratory findings included hemoglobin decreasing below pre-transfusion levels, and increased total bilirubin and ldh. the dat, while initially negative during the immediate posttransfusion workup of the transfusion reactions, eventually became positive for igg only ( - ), and negative with anti-c b, c d reagent. the antibody showed a peak gel-igg iat titer of . results/finding: the antibody was identified as having anwj specificity. the patient's pre-transfusion sample showed weak anwj expression (w ), altogether suggesting an auto-anti-anwj. monocyte monolayer assay testing using the patient's plasma and rbcs from the ahtr-implicated units yielded monocyte indices ranging from to %, consistent with the clinical hemolysis observed. given the patient's group o, rh d negative blood type and continuing transfusion dependence, in order to avoid further ahtrs, international collaboration was necessary in order to procure and provision group o, rh d negative rbcs that were also serologically negative for anwj. the patient was successfully transfused three such units without further incident. conclusion: this is the second documented case of anti-anwj in a patient with aplastic anemia and, overall, the third anti-anwj case associated with ahtr. this case also underscores the importance of international collaboration. cold auto-antibody anti-p anti-m anti-sd a anti-le b anti-jk a anti-k anti-e anti-c results/finding: three hundred and ninety weak d genotypes have been determined to this day with frequencies of % (type ), % (type ), % (type ), % (type ) and % other than , , or . further investigation was conducted to determine the molecular identity of the «others». out of samples, ( %) were confirmed to be legitimate serological weak or partial d, mainly deletions of exon or both exons and . a surprising amount of samples were discovered to be normal rhd. conclusion: along with sandler et al. ( ) data, our findings highlight the difficulties hospitals face in interpreting serological weak d. trend analysis was conducted regarding the reagents and technologies used by each hospital, the origin of the request and the ethnicity of the concerned patient, but no significant correlation could be identified at this point. altogether, our findings allow to share the frequency of weak d types , , and obtained in serological weak d, years old quebec's women, and also highlight the need for further investigation of standard practices amongst hospitals regarding the management and interpretation of atypical d typing. were classified as fnhtr. taco incidence was , %. no trali happened in the period. prophylaxis were used in % of patients. conclusion: fnhtr is described as the most common adverse event related to transfusion, but our data showed a higher incidence of allergic reactions. fnhtr occurred times less than allergic reactions. this might be explained by universal leukoreduction and universal prophylaxis adopted at our institution. further studies are necessary to evaluated the benefit of this approach. that cannot be associated with a specific rbc unit or were deemed unrelated to transfusion, rbc transfusion aes were analyzed. chi-square test and logistic regression were used to compare the ae incidences among transfusion groups. results/finding: univariate and multivariate logistic analyses showed that irradiated rbcs were associated with a significantly increased incidence of transfusion-related aes (p < . ). there was a significant difference in febrile non-hemolytic transfusion reaction (fnhtr) ( . % vs . %, p < . ) or aes with a non-allergic type inflammation etiology ( . % vs . %, p < . ) including transfusion-related acute lung injury, transfusion-associated dyspnea, but not transfusion-associated circulatory overload, infections or hemolytic transfusion reactions, between irradiated rbcs and non-irradiated rbcs. in contrast, the incidences of allergic aes ( . % vs . %, p . ) were similar between these two groups. the incidences of inflammation aes after transfusion of irradiated rbcs that were stored for , , , and weeks were . %, . %, . % and . %, respectively (p . , logistic regression) but there was a significant difference in the incidence of inflammation aes caused by irradiated rbcs stored for a week ( . %) and longer than a week ( . %) (p < . ). conclusion: irradiated rbcs associated with a higher incidence of transfusion inflammation aes compared to non-irradiated rbcs and this risk increased when rbcs were stored longer than week after irradiation. while it is likely the patient population is a factor in ae caused by irradiated rbcs, it is also possible that rbc radiation damage, as shown in previous studies, contributed to this increased ae incidence. a list of patients with one of these icd codes was generated. the emr was searched to find the clinical scenario in which trali was mentioned. these patients' records were then searched within our laboratory information system (copath), to determine if they had a transfusion reaction reported to our transfusion medicine service. results/finding: the search of our electronic medical record found patients from - , who had trali mentioned in their chart as a diagnosis or possible/likely diagnosis. one patient was excluded from our study because trali was mentioned as a past medical history from an outside hospital. only the patients who had trali listed as a diagnosis or possible diagnosis were included in this study. these patients had clinical scenarios in which a transfusion of a blood product occurred which was followed by various forms of respiratory distress. the clinical teams caring for these patients were either giving a diagnosis of trali or considering trali as a possible diagnosis. of these cases, only of them were reported to our transfusion medicine service as transfusion reactions. of the reported cases, one was determined to be trali and the other one was consistent with taco. eight out of those cases were never reported. background/case studies: despite diligent efforts to transfuse the safest product available to patients, undetected alloantibodies may cause delayed hemolytic transfusion reactions (dhtr). this transfusion reaction is seen in as many as out of transfused products. therapeutic plasma exchange (tpe) may be employed to mitigate ongoing immune mediated hemolysis, but few reports in the literature describe tpe for clinical management after profound hemolysis. study design/method: case review of a patient was performed after diagnosis and treatment of severe dhtr. results/finding: a man with a history of gastrointestinal bleeding presented to the emergency room with shortness of breath and "hematuria". he had a known history of anti-d and anti-c, and was transfused two units of crossmatch compatible rbcs seven days prior during a previous admission. readmission hemoglobin (hb) was . g/dl but declined to . g/dl the next day. an antibody screen was consistent with anti-d, anti-c, and direct antiglobulin test (dat) was negative. he received three units of crossmatch compatible rbcs over days and with poor responses. on day , routine labs could not be reported due to marked hemolysis, he had "worsening hematuria", creatinine rose from . mg/dl to . mg/dl (reference . - . mg/dl), and lactate dehydrogenase was above reportable linearity, > u/l (reference - u/l). testing revealed additional anti-e, anti-jkb, dat c , plasma free hb . mg/dl (reference - . mg/dl), and hemoglobinuria. four of five transfused rbc units were jk(b ), one of which was also e . one volume tpe was performed to remove free hb on days , , and using fresh frozen plasma as replacement fluid for haptoglobin supplementation. creatinine peaked at . mg/dl on day , decreased to . mg/dl before discharge on day results/findings: twenty three cases were identified, of which had medical records available for analysis. ten ( %) patients were male, the mean age was . years (range - years), ( %) had an underlying hematologic malignancy or bone marrow disorder, and ( %) had a history of coronary artery disease (cad). the implicated units included ( %) red blood cells and ( %) platelets; ( %) patients received a single unit, and ( %) received two or more within the previous hours; the mean volume transfused was . ml (range - ml). the mean time to onset of chest pain was . minutes (sd minutes), with % of patients presenting within . hours and % within hours of starting the transfusion. chest pain was present as the only symptom in % of the cases, and for the other cases the accompanying symptoms included dyspnea ( %), fever ( %), back pain ( %), and hypo-and hypertension ( %). a post-transfusion chest x-ray was performed in % of cases, and all showed no evidence of pulmonary edema to suggest possible volume overload/transfusion associated circulatory overload (taco). electrocardiogram was performed in % of cases and showed no findings to suggest acute ischemia. three ( %) patients had a minimal increase in their troponin levels, although had a history of chronically elevated troponin due to stress cardiomyopathy. fourteen ( %) patients received some form of treatment, including increased oxygen supplementation, metoprolol, acetaminophen, morphine, and oral calcium carbonate; the pain resolved after more than minutes in the majority of patients ( %). no cases resulted in new admission to the icu or procedure cancelation. conclusion: chest pain associated with transfusion was infrequent, but several such cases were identified during the review period. this symptom is not a diagnostic criterion for any of the other hemovigilance categories and merits further characterization to determine whether blood product transfusion could be the cause of the chest pain. larger observational studies to power clinical characterization could help to further inform hypotheses regarding a transfusion-related mechanism, which could be interrogated by translational research studies. background/case studies: thrombotic microangiopathy (tma) in children is most commonly seen in the form of hemolytic uremic syndrome (hus). however, tma may be seen in the presence of streptococcus pneumoniae (spn). the action of bacterial neuraminidase of spn results in exposure of the normally "hidden" thomsen-freidenreich antigen (t-antigen) found on erythrocytes and other tissues. ultimately, this may lead to spn induced hemolytic uremic syndrome (phus) with subsequent hemolysis and end organ damage by naturally occurring anti-t antibodies against the exposed t antigen. specific lectins or anti-sera can confirm exposure of the t antigens in phus. alternatively, phus can be identified by minor crossmatch incompatibility resulting from agglutination of exposed t antigens on recipient's erythrocytes to anti-t antibodies in the plasma portion of blood products. we present a case of suspected phus that resulted in a compatible minor crossmatch leading to concern and eventually diagnosis of atypical hus (ahus). study design/method: a months old boy presented with respiratory failure. he was found to have blood cultures positive for spn as well as hemolytic anemia, thrombocytopenia, and acute renal failure. he was shiga toxin negative and had normal levels of adamts . based on the findings, the clinical team was concerned for phus. therefore, he received washed erythrocytes. for his thrombocytopenia, our institution does not routinely provide washed platelets due to decrease quality of the platelet product. as a result, a minor crossmatching was suggested and performed to determine if t activation was present. results/finding: minor crossmatch was performed with patient's erythrocytes and plasma of abo-identical platelets to be transfused. no agglutination was seen at immediate spin, degree, or anti-human globulin phase. check cells were found to be . these findings were conveyed to the clinical team and platelets were issued without washing. due to the lack of identification of t activation by minor crossmatching and poor clinical response despite appropriate antibiotic treatment, additional studies were performed by the primary team for complement mutations and found to be consistent with ahus. the patient was then treated with eculizumab with clinical and laboratory improvement. we present a case clinically consistent with phus. confirmation of this diagnosis is done with lectins or anti-sera that are not readily available. an alternative means of identifying phus is by minor crossmatch incompatibility. by demonstrating minor crossmatch compatibility, we further elucidated a definitive diagnosis of ahus with appropriate management. background/case studies: orthotopic liver transplantation (olt) is a complex and technically challenging procedure that can be complicated by severe intraoperative bleeding. we report a case of massive transfusion in an olt patient necessitating an abo blood group switch (from o to a ) to sustain transfusion support and minimum group o rbc inventories. study design/methods: type & screen (ts, gel) and anti-a titers (tube) were performed using routine methods. a chart review was performed for pertinent medical and laboratory findings. results/findings: the patient was a -year-old o man with cirrhosis secondary to nonalcoholic steatohepatitis and alpha- antitrypsin deficiency who presented for olt (donor o ). during olt, the patient endured substantial bleeding from retroperitoneal collateral vessels complicated by post-transplant coagulopathy. he required rapid high volume rbc and plasma support, which strained hospital inventories. after receiving units of o rbcs and units of o plasma with ongoing severe hemorrhage, he was switched to group a products. ten units of a plasma were transfused to wash out anti-a antibody prior to transfusion of a rbcs. due to difficulty controlling the bleeding, biliary reconstruction and fascial closure were delayed for hours post-transplant. the patient's total estimated blood loss was > l. he received a total of units of rbcs (including a ), units of plasma (including a ), units of cryoprecipitate, and units of platelets. towards the end of the second procedure, the patient's hemorrhage was stabilized and the final two rbc units he received were o . on postoperative day (pod) , a ts showed predominantly a rbcs with trace o rbcs, as well as very low anti-a igm and igg titers (table ) . he received two additional o rbc units ( each on pod and pod ) with increasing o rbcs on ts and rising anti-a titers. his blood type was unequivocally o by pod . the patient showed recovery of liver synthetic function on pod (factor activity %) complicated by cholestasis. conclusion: this study shows successful switching of a group o patient to group a in the setting of rapid hemorrhage and massive transfusion. by pod , the patient had reverted to o with recovery of anti-a titers. at months post-olt, the patient is alive with signs of improving biliary graft function. a new rfid transfusion safety system anna millan* , alfred mingo , maria isabel gonzalez , antoni mena and juan pedro benitez . bst, at-biotech background/case studies: a new transfusion safety system (tss), based on processes and technologies, especially, identification by radio frequency (rfid), is currently implemented in two hospitals, a general one (h ) and an oncology center (h ). the tss is fully effective in protecting against incidents, and specifically offers mechanisms to detect near misses (nm) by using procedural and physical barriers, assuring that the pretransfusional sample extraction (pse) and the blood components administration (bca) only take place at bed side, using a location control and interacting with the clinical and transfusion information systems (tis). the tss allows to analyze the transfusional activity information in real time to project organizational changes in both transfusion services and hospital units, and to create a new classification of nm. study design/method: retrospective analysis of transfusion activity in both h and h shows pse and bca, out of and respectively, since the tss deployment in . retrospective analysis and classification of security events has been done. results/finding: activity results for both hospitals are shown in the table below. the safety events have been classified in pretransfusion sample extraction (pse), blood component assignment (bcas) in the transfusion service and blood component administration (bca) near misses (nm). for h , nm related to pse accounted for . % of all, being the mistake in concordance between patient identification and prescription order the most frequent ( . %). the nm detected in bcas were . % of all and mostly ( . %) occur when the patient information in the tis does not match the one registered in the tss. the nm detected in bca are . % of all and mostly ( %) the systems detects a not assigned bracelet. for h , nm related to pse accounted for the . % of all, being the error in concordance between the transfusion security number in the bracelet and in pretransfusion sample the most frequent ( . %). the nm detected in bcas accounts for . % of all and in . % occurs when the patient information in the tis does not match with the one registered in the tss. the nm detected in bca are . % of all and in . % of them the blood components were assigned to another patient. ( , , , , , , , , , , , , , ) were analyzed via a commercially available elisa. comparison of adequate response to ppv , defined as ! mcg/ml for > serotypes, was perform based on alloimmunization status. statistical significance was determined by comparing means of subgroups using paired and non-paired t-tests. results/findings: pre-vaccine sp titers were available in patients (alloimmunized, ); pre-and post-vaccine titers were available for patients (alloimmunized, ). of the patients, were on chronic transfusions, were on hydroxyurea, were surgical splenectomized, patients had no history of surgical splenectomy or status was unknown. forty-four patients had a previous history of ppv in the previous years; / also reported previous history -valent sp conjugate vaccine within the last years. baseline pre-vaccination titers (n ) showed no difference between alloimmunized and non-alloimmunized patients (all p-values > . ). in the group with pre-and post-vaccination (n ) titers available, out of ( %) non alloimmunized patients had an adequate response versus out of in the alloimmunized group ( %, p ns background/case studies: blood transfusion is the most common procedure performed in the hospital setting and the transfusion process is monitored to ensure regulatory compliance. to safeguard safety, efficacy and regulatory compliance, transfusion services actively benchmark transfusionrelated errors (tres) as they occur from "vein-to-vein", i.e. from collection of pre-transfusion sample to final infusion of product -with the goal of ensuring that the right product/dose goes to the right patient at the right time. multiple over-lapping error documentation processes are needed to capture and report tres from within and outside of blood bank (bb). we present a comprehensive error management program along with data on five years of benchmarking tres at a large academic medical center. study design/method: tres were detected by capturing and reporting of sample suitability, testing variances and biologic product deviations. in addition, tres as observed and reported by providers and clinical staff (i.e. blood delays/undertransfusions, transfusions without consent, infusions with wrong fluids) were reported to the bb and hospital quality through the veritas system, a hospital based reporting system that enables reporting any occurrence with potential for causing patient harm. all serious errors were reviewed daily and summation of tres was discussed on a monthly basis. mapping tres within the "vein-to-vein" was performed by reviewing the fiveyear of transfusion medicine quality records (from to ). patient harm events recorded within the veritas system from january to july were investigated in depth. transfusion reactions were excluded in this analysis. results/finding: an average of tres per month and per year were found over five years. % of tres are associated with pre-bb activities, % occur within bb, and % are post-bb events. sample collection and handling represent % of total tres. most tres ( %) were reported by bb staff, % were reported by non-bb staff. patient harm analysis revealed an average of four level (near miss), three level (no known harm), and . level (patient harm) per month. no deaths related to tre were detected over the seven month january to july period. patient harm was associated with tres occurring in the bb ( %) and post-bb ( %). these events were reported externally ( %) and by bb staff ( %). conclusion: although most tres were detected in the pre-bb phase, no patient harm was associated with these events indicating an efficient capture prior to causing patient harm. the tres causing patient harm, including near miss events, were mostly reported externally and they occurred entirely in the post-bb and bb phases. these results suggest that significant opportunities for quality improvement may be achieved in two areas: the pre-bb phase aimed at reduction of waste associated with sample collection and handling, and the post-bb and bb phases aimed at improving tre detection and decreasing patient harm. background/case studies: uncrossmatched red blood cells (rbc) and emergency issued platelets (plt), plasma and cryoprecipitate (cryo) are lifesaving in a bleeding patient without a valid type and screen. collectively termed "emergently issued products" they are issued as a bridge until pretransfusion testing is completed. this study evaluated the utilization and wastage rates of blood products during pregnancy-related hemorrhage where the first products issued were emergently issued. study design/methods: a list of patients on whom blood products had been emergently issued between january , and march , was obtained from the blood bank at a regional maternity care hospital. patients who were not experiencing a pregnancy-related bleed (e.g., postpartum hemorrhage or bleeding relating to a complication of pregnancy such as a ruptured ectopic pregnancy or bleeding post spontaneous or therapeutic abortion) were excluded. the total number of products (emergently issued plus crossmatched or non-emergently issued products) that were transfused, returned back into the blood bank's inventory, and wasted within hours of the first emergently issued products were enumerated. apheresis plt units were multiplied by and added to the number of individual whole blood plts; apheresis plasma units were multiplied by and added to the number of whole blood plasma units. results/findings: seventy women who received emergently issued blood products during a pregnancy-related hemorrhage were identified. average age was . the majority of these patients with pregnancy-related hemorrhage who received at least one unit of emergently issued blood products received at least one unit of the product that was issued to them and few units were wasted. that plt wastage was higher than the other products was likely due to the -hour post-pooling room temperature shelf life. keeping wastage rates low while meeting the clinical needs of these patients is the ideal situation for the blood bank. . patient blood platelets were higher before prophylactic than therapeutic transfusions ( [ /l vs. [ /l, p . ). there were no significant differences in the frequency of effective therapeutic ( % vs. %, p . ) and prophylactic ( % vs. %, p . ) transfusions between the prcs and gypcs. we did not find significant differences between prcs and gypcs in cci after prophylactic ( . . vs. . . ) and therapeutic ( . . vs. . . ) transfusions, in cc after prophylactic ( . . vs. . . ) and therapeutic ( . . vs. . .) transfusions. there were no significant differences between prcs and gypcs also in ma after prophylactic ( . . vs. . , p . ) and therapeutic ( . . vs. . . , p . ) pc transfusions. reduction of the severity of bleeds was obtained in ( %) of the cases after prpc transfusions and in ( %) of cases after gypc transfusions. there were no significant differences in the frequency of adverse post-transfusion reactions between the groups (respectively, and cases). background/case studies: an 'end-to-end' electronic transfusion management process including a bedside administration system was developed and implemented in this large multi-site academic center in . it enables the safe administration of blood components at the patient bedside and provides an audit trail for all blood components. an error was identified in the electronic bedside transfusion process which was reported to our national hemovigilance scheme in under the category 'errors relating to information technology'. this error was the incorrect use of the emergency transfusion process for non-emergency transfusions. the standard (non-emergency) process requires a scan of the barcode on the patient's wristband containing their identification details which is verified against the same details from the barcode on the compatibility label attached to the blood bag. the emergency transfusion option is only intended for use with 'emergency group o rhd negative blood units' which, unlike non-emergency units allocated to specific patients, do not have a compatibility label. the emergency transfusion option skips the compatibility label barcode scan as the emergency units can be transfused to any patient needing urgent transfusion. it was found that the emergency blood option was being misused for non-emergency transfusions, leading to blood units not being checked to ensure they were for the correct patient. study design/method: this center worked with the software supplier to develop a solution which corrects the weakness in the process. the revised process involves providing a universal compatibility label for emergency units so that all units (emergency and non-emergency) require a scan of the compatibility label on the blood bag and the patient's wristband at the bedside before transfusion. the use of the emergency process was audited pre and post implementation of the new process to determine whether it was being used correctly or not. results/finding: there were units administered using the emergency transfusion process in the months before the change was implemented. it was found that / ( %) units were non-emergency units administered incorrectly without a bedside compatibility check. following the implementation of the change there were no instances of incorrect administration of non-emergency units in the next month ( components administered), / ( %) were emergency units which were administered correctly. users of the system reported the revised process was quicker, safer and unified with other functions on the device. conclusion: the improved process for the administration of blood in an emergency now prevents users from following the incorrect procedure for non-emergency transfusions and missing the essential final bedside electronic check. this report indicates the need for continued vigilance of the functionality of electronic transfusion processes, and the correction of any weaknesses compromising patient safety. background/case studies: recent recommendations indicate one red blood cell (rbc) unit should be transfused at a time with reassessment after each transfusion to determine the need for more. however, the practices of canadian transfusion medicine (tm) experts and what constitutes a reassessment are unknown. therefore, we conducted a survey of tm experts across canada to gather information on their practices and criteria for reassessment. study design/method: tm experts were identified and contact information obtained from the canadian national advisory committee (nac) and from contacting least one tm expert per province. each respondent was assigned a unique study id after consenting to the survey, allowing for anonymity on analysis. the survey contained demographics, general practice questions, and questions regarding transfusion in: ) a stable anemic inpatient, ) a stable anemic inpatient to be discharged, and ) an asymptomatic post-operative inpatient. results/finding: we identified canadian tm experts: ( . %) provided a response and most had a primary place of practice in a laboratory setting ( / ; . %). for a stable, non-bleeding, anemic inpatient, . % of respondents recommended transfusing one rbc unit, then reassessing. recommendations were more variable in outpatient settings, with . % generally recommending transfusing two rbc units then reassessing. recommendations for reassessment were mainly functional status/symptoms and vitals within a short time period ( - hours), a repeat hemoglobin > hours later dependent on the clinical scenario, and a search for an underlying cause of anemia in outpatient settings. lab practitioners emphasized volume status, cardiac examination, and transfusion at lower hemoglobin thresholds. with an asymptomatic patient to be discharged, fewer respondents chose to transfuse ( . %) compared to an inpatient potentially symptomatic due to anemia ( . %). none of the respondents suggested transfusion in an asymptomatic post-operative patient who had a hemoglobin trending down. conclusion: tm experts generally recommend transfusing one unit at a time in stable inpatients. assessment for transfusion should focus on patient symptoms, pertinent physical exam, hemoglobin levels, and an underlying cause. "top-up" transfusions were not recommended. these recommendations may help guide clinicians, but further research is needed to generate higher quality evidence around the clinical benefits and cost effectiveness of these practices. background/case studies: current evaluation of red blood cell (rbc) post transfusion recovery is based on ex vivo labeling of stored rbcs with radioactive chromium- ( cr). this method has several limitations including the risks associated with radioactivity, and the inability to evaluate multiple rbc populations in the recipient. rbc labeling with s-nhs-biotin (bio-rbcs) overcomes many of these limitations and offers safe and longitudinal tracking of multiple transfused rbcs in vivo. the purpose of this study was to scale up and optimize the biotinylation procedures to the current good manufacturing practice (gmp) environment. study design/method: packed rbc units (n ) were divided into two ml aliquots, which were labeled with selected concentrations of s-nhsbiotin ( and lg/ml) in a cgmp closed system (average bio-rbcs hematocrit of . . %). optimization of labeling efficacy was determined by flow cytometric analysis of bio-rbcs using fluorochrome-conjugated streptavidin (sa). approximately million rbcs were measured in triplicate. quantum simply cellular beads were used to quantify fluorochrome (molecules of equivalent soluble fluorescence, mesf) and infer number of biotin molecules per rbc. the lower limit of detection was determined for rbc labeled with varying amounts of biotin. product quality and safety were evaluated by endotoxin and sterility testing, and by determining the levels of spontaneous hemolysis before and after rbc biotin labeling. results/finding: investigation of different fluorochromes, laser excitation wavelengths and laser power to maximize the signal to noise ratio of labeled and unlabeled rbcs revealed that nm excitation of phycoerythrin (pe)-sa and high laser power ( mw) provided the best separation between the two bio-rbc populations, and between labeled and unlabeled rbcs. labeling with lg/ml of biotin resulted in $ , mesf/rbc, and were detectable among unlabeled rbc at a lower limit of detection (lld, % ci) of in , ( . %). the lld for rbc labeled with biotin at lg/ ml was $ in million ( . %). biotinylation was not associated with increased levels of hemolysis ( . . % before labeling versus . . % after labeling; p . ) or bacterial contamination. conclusion: the resulting manufacturing process produces large volumes ( ml/transfusion) of bio-rbcs with low risk of contamination or hemolysis. the flow cytometry assay can detect bio-rbc in unlabeled blood at very low frequency. we plan to use this technology to study the impact of donor characteristic on rbc storage stability and post-transfusion survival. background/case studies: blood products offer resuscitation benefits in trauma over crystalloid/colloid volume expanders (which provide no hemostatic benefit or oxygen delivery), but usage is often hampered by supply or storage needs. hemoglobin-based oxygen carriers (hbocs) are not red cell replacements but may supplement oxygen delivery and expand volume during transport until blood is available. since hemostasis is critical in resuscitation, this study evaluated bovine hemoglobin glutamer- (hboc- ) effects on coagulation parameters alongside freeze-dried plasma (fdp) in an in vitro model of hemorrhage/resuscitation. study design/method: whole blood (wb) was collected from healthy donors under an approved institutional standard operating procedure. in the first study (limited resuscitation), samples were: ( ) wb, ( ) wb % hboc volume (model of two units in an adult), ( ) wb % fdp, and ( ) wb % hboc % fdp. samples ( )-( ) simulated autoresuscitation by adding % plasmalyte to - . susceptibility to lysis was tested with ng/ml tissue plasminogen activator (tpa). follow-up studies were performed with severe resuscitation simulations of %, %, %, and % volume replacement with hboc and/or fdp, with or without prior % plasmalyte dilution. coagulation parameters were obtained with a coagulation analyzer and thromboelastography (teg). rbcs/hemoglobin were measured on a hematology analyzer. thrombin generation was quantified by thrombogram. platelet aggregation was measured in multiplate and adhesion to collagen under shear in bioflux. viscosity was evaluated by rheology. results/finding: a limited resuscitation model with hboc and/or fdp had no effects on fibrinogen, pt, aptt, ph, hct, or hemoglobin. in teg, wb, wb hboc, and wb hboc fdp had reduced clot strength with dilution and tpa. there was increased susceptibility to tpa-induced lysis between wb and wb hboc in autodilution simulation (mean lysis . % vs. . %; p<. ). hboc and fdp had no statistically significant impact on thrombin generation. no effects on platelet aggregation were observed; no significant differences within diluted v. undiluted groups were seen in platelet adhesion under flow. hboc ( %) did not significantly change viscosity. severe resuscitation simulations had increased pt/ptt and reduced clot strength, particularly in hboc-only resuscitation; however, even % hboc volume replacement produced clots with acceptable teg parameters. conclusion: in a limited resuscitation model with hboc- , there were no significant in vitro effects on hemostatic parameters (except increased susceptibility to lysis); more severe resuscitations impacted coagulation parameters but did not prevent clotting. considering the large impact healthy platelets have on coagulation function, further in vitro studies with impaired platelets are warranted alongside in vivo studies of hboc plasma as initial resuscitation of hemorrhagic shock. therapy in patients with acute major bleeding. while published literature has largely focused on the efficacy and safety of pcc, actual usage practices are less characterized. our aim was to describe the pcc usage practices within a tertiary care center. study design/method: we conducted a retrospective review of the electronic medical records of patients who received pcc between its addition to our institution's formulary in / and / . we compiled information about the usage of pcc in these patients. descriptive statistics were generated with microsoft excel. results/finding: of patients, were on warfarin. pcc was most frequently prescribed for hemorrhage due to surgery ( %). pcc was given for warfarin reversal in % of cases. a subset of patients received plasma within hours prior to pcc ( %) or hours after ( %). pcc was most frequently ordered in the or/perioperative service ( %). conclusion: the majority of pcc usage was "off-label" in terms of being prescribed for indications other than warfarin reversal. the most frequent indication was hemorrhage due to surgery, and pcc was most often ordered in the or/perioperative service. although guidelines recommend the use of pcc as a plasma alternative, plasma was administered within hours of pcc in a notable subset of patients. background/case studies: in emergent situations, when a patient's life may be jeopardized by delaying transfusion, a physician may decide to transfuse blood emergently. however, in some cases, poor communication and lack of clear expectations between the blood bank and patient care areas can lead to frustration and delays in the timely provision of blood products. an incident prompted an appraisal of our emergency release protocol (erp), which revealed gaps in communications and expectations by both the blood bank and nursing personnel. thus, it is imperative that there is a standardized er protocol with clear communications for both the blood bank and nursing personnel. reported here is the outcome of a process improvement that resulted in improved communication, expectations, and turnaround (tat) for our er protocol. study design/method: in , several meetings were conducted with stakeholders (critical care units (icu), emergency department (ed), internal medicine, interventional radiology (ir) etc.) in an effort to identify process gaps, improve communications, and expectations for er episodes. the goals was to design a process for emergent blood product request and release in life threatening situations that will; ) simplify and expedite the process; ) improve communication and expectations to decrease tat; ) improve patient safety and meet compliance. in order to achieve these goals, a series of activities were conducted. these included meetings with all stakeholders to ensure process improvement meet the needs intended. a series of training sessions with nurse educators in icu, ed, ir and surgery managers were conducted. during the meetings, communication goals, and expectations were defined and agreed upon. training sessions included powerpoint presentations to educate staff members and performance of dry runs, to identify weaknesses and strengths with the process flow. the impact on the current process was analyzed and, as a result, led to the revision of the current sop, addition of pre-labeled emergency pack blood ( units of o neg rbc's) and implementation of an electronic emergency blood order set. results/finding: in the ten months post implementation of our improved, standardized er pack protocol, a total of er episodes were received. the average tat from order to delivery at the bedside was reduced by % ( . minutes compared to minutes previously), while the compliance rate for er orders and physician documentation was % ( / ), with no current wastage of blood products. conclusion: the implementation of the improved standardized er protocol significantly improved communications and expectations, decreased tat and delays in transfusions while ensuring patient safety and compliance to regulatory requirements. background/case studies: massive transfusion (mt) in the trauma setting has been extensively studied. yet, the literature in non-trauma areas, especially oncology is rather sparse. the following study was conducted to understand the background and outcomes of mt in cancer patients. study design/methods: this was a single center retrospective study performed at a large cancer center between february -february . mt was defined as the transfusion of ! rbc units in a -hour period. the following data were collected included: age, gender, primary diagnosis, surgery or acute care type, amount and type of blood components transfused, whether or not a massive transfusion protocol (mtp) was activated, and survival at days. results/findings: thirty mts occurred during a one year period. a total of , blood products were transfused during that time period. gender distribution was / ( %) males, and the average age of all patients was with a range of to years of age. surgical patients accounted for / ( . %) mts, and / ( . %) were critical care patients. tumor categories included carcinomas ( / ), sarcomas ( / ), leukemias ( / ) and lymphoma ( / ). resection of tumor followed by complex reconstruction was the cause of the majority of mts. metastatic renal cancer ( / ) was the most common disease seen followed by sacral chordoma ( / ). mtps were activated in only / ( . %) cases. thirty-day survival was seen in / ( . %) patients. only of mortalities was a surgical case (peritoneal mesothelioma), and the remainder were caused by gi hemorrhage ( / ) or perisplenic hematoma ( / ). the overall ratio of rbc:ffp in the entire patients ( background/case studies: plasma is a straw-colored supernatant of blood that is used for type and screen (t&s) and crossmatch. in the analytic phase of testing, plasma is examined prior to processing. plasma occasionally becomes discolored, interfering with crossmatch procedures. timely identification of the etiology allows for corrective actions and minimizes delay in transfusion. study design/method: during the analytic phase of blood bank testing, samples were evaluated for t&s and crossmatch; this identified three samples with discolored plasma. we present a series of cases that illustrate the testing process. results/finding: a -year-old woman diagnosed with breast cancer presented for mastectomy with sentinel lymph node biopsy. a preoperative t&s specimen contained bright green plasma. review of her preoperative case revealed exposure to intravenous methylene blue. this dye is known to alter the color of urine, tears, and blood with no known pharmacologic effects. alternative causes of green plasma include other dyes used to locate sentinel nodes and oral contraceptive use. although not ideal, this sample could be used for crossmatch by tube method, but not automated gel technique. a specimen drawn one week later contained clear plasma. a -year-old woman diagnosed with a warm autoimmune hemolytic anemia was refractory to blood transfusions secondary to alloantibodies. administration of a synthetic blood product resulted in dark maroon colored plasma. the most common cause of a dark red color is hemolysis of the sample, which is usually discarded. in this instance, the hemoglobin color was due to the infused product, an experimental bovine pegylated carboxyhemoglobin that affects colorimetric evaluation of blood samples. with this in mind, the sample was not discarded and testing was completed by tube method. a -year-old woman admitted with acute stroke was treated with a thrombolytic. her t&s revealed cloudy white plasma that could not be used for the crossmatch procedure. common causes of white plasma include purulence, hypertriglyceridemia, and sampling of blood drawn proximal to administration of radiopaque agents such as propofol. although an etiology could not be identified a repeat specimen drawn several hours later was clear. conclusion: these cases highlight the importance of an appropriate evaluation of discolored plasma. once a discolored sample is identified, a repeat sample is required to confirm the change in color. in the first two cases, the discoloration persisted, prompting further clinical investigation. once the etiology was identified, need for further testing and eligibility for further transfusion was determined. testing by tube method could be performed in two cases. in the third case, repeated sampling revealed a clear sample and the transfusion process continued without delay. decisions regarding the analytic phase of testing must include reevaluation of the sample, identification of the etiology, and comprehension regarding how to proceed when discoloration persists. caleb wei-shin cheng* , , rebecca ross , christopher a tormey , , and amit gokhale , . yale university school of medicine, yale-new haven hospital, va connecticut healthcare background/case studies: daratumumab (dara) is a igg monoclonal antibody therapy that specifically targets cd , a glycoprotein highly expressed on plasma cells, where it has been successfully used in patients with refractory or relapsed multiple myeloma. dara interferes with blood bank testing as it binds to cd expressed on red blood cells, causing pan reactivity. the dara interference can be overcome with the use of dithiothreitol (dtt) treated reagent red blood cells. to minimize alloimmunization and to provide crossmatch compatible blood to treated patients, we instituted a dara protocol in our blood bank. the purpose of this retrospective study was to identify the outcomes of our protocol, with a particular focus on the development of de novo alloantibodies during dara treatment at our institution. study design/method: all dara patients' antibody workups were completed using dtt pre-treated reagent red blood cells. if the antibody screen was negative, k antigen negative rbc products are provided. if an antibody is identified, k negative along with that particular antigen negative blood is provided. our electronic medical record (emr) was searched for patients who received dara over the past eight months. study subjects were examined to see if they had pre-existing alloantibodies before dara treatment and whether they formed new alloantibodies during dara treatment. the age, gender, type and screen pre-dara treatment, type and screen post-dara, intervening blood transfusions, and the date of first dara treatment was recorded. results/finding: overall, subjects were identified for analysis. their mean age was . years, with male and female subjects; all were diagnosed with multiple myeloma. we found an alloimmunization rate of % ( / ) prior to administration of dara. of these patients, were transfused with red blood cells (rbcs) after initiation of dara therapy. following our testing/matching protocol, none of these ( %; / ) patients formed a confirmed, new alloantibody during dara treatment; each of these patients underwent at least one follow-up screen after their first rbc unit. we also found no complications in providing crossmatch compatible units to any of the patients. conclusion: to our knowledge, this is the largest case series reporting on results of overcoming dara interference with blood bank type and screen testing. the protocol implemented in our laboratory appears to be successful in providing compatible units and preventing alloimmunization in patients receiving dara therapy. it is possible that the drug, targeting antibody forming cells, may have an immunosuppressive effect on the humoral response; further studies of this effect may be warranted. background/case studies:a multi-facility transfusion service began stocking liquid plasma in september of for use in massive transfusion and trauma situations. due to the infrequent occurrence of these incidents, the liquid plasma would outdate before use. a policy to use liquid plasma in nonemergent situations when the units were nearing their expiration dates was implemented. this study evaluated the effects of that policy on inr values of plasma recipients. study design/methods:a retrospective analysis was developed to compare the effectiveness of fresh frozen plasma (ffp) and liquid plasma (lqp) in changing inr values of recipients. all plasma units transfused within the facility from september , through april , were identified. the following data was obtained from the hospital and laboratory information systems for each unit: the recipient, primary reason for transfusion of plasma, number of plasma units transfused, type of plasma transfused, preand post-transfusion inr values, and whether or not vitamin k was administered. patients were divided into groups based on the type of plasma units transfused and were evaluated based on primary reason for transfusion, number of units transfused, and administration of vitamin k. the change in inr for each recipient was calculated, along with the average change in inr for each group. background/case studies: in gynaecological settings, most but not all relatively young anaemic women are iron deficient due to blood loss associated with menstruation. transfusion could generally be avoided in those without haemodynamic instability. the oral antifibrinolytic drug tranexamic acid is an effective and well tolerated treatment for menorrhagia. besides, iron replacement is often necessary for a prolonged period of time after normalization of haemoglobin (hb). the present study attempted to look into transfusion appropriateness and the use of iron and tranexamic acid in transfused women in hong kong. study design/methods: anonymous data of gynaeological patients age was retrieved from a central database of public hospitals which included age, number of units of red cell transfused, pre-and posttransfusion hb, the use of iron and/or tranexamic acid during hospitalization and upon discharge. all transfusion episodes associated with surgical operations during same admission are excluded. results/findings: in , , unique women receiving a total of , units of red cells (rc) in , transfusion episodes were identified. their median age was (range - ). the distribution of pre-and post-transfusion hb and units of rc transfused were summarized below: in this cohort, pre-and post-transfusion hb were absent in ( . %) and ( . %). ( . %) transfusion episodes were associated with the use of units or more rc. as a result, ( . %) episodes resulted in a post transfusion hb ! g/dl. parenteral iron or tranexamic acid was uncommon during hospitalization and was given (< . %) and ( . %) women respectively. upon discharge, ( . %), ( . %) and , ( . %) women were prescribed with oral iron alone, oral tranexamic acid alone or both respectively. however, neither were given to ( . %) women. conclusion: in the present study, it is observed that . % transfusion episodes were given at hb ! g/dl. a substantial number of episodes ( . %) were transfused with multiple units and resulted in almost half having a post transfusion hb level (! g/dl). for iron replenishment and bleeding control, up to . % transfused women were not given iron or tranexamic acid at discharge. the results indicate that awareness of both transfusion appropriateness and iron deficiency anaemia management have to be improved. it is recommended that in-depth education and training should be provided for a better gynaecological patient blood management. background/case studies: granulocyte transfusions may be utilized to boost the immune response in patients with life-threatening neutropenia or neutrophil dysfunction and evidence of treatment-refractory bacterial or fungal infection. however, granulocytes are rarely administered due to uncertainty regarding efficacy, difficulty in collection, and increased propensity for adverse reactions. we report a case of granulocyte transfusion therapy following chimeric antigen receptor t-cell (car-t) therapy in a patient with severe neutropenia and multiple infections in the context of relapsed b-cell acute lymphoblastic leukemia (b-all). study design/method: granulocytes ( . - . x per unit) were collected from abo-identical unstimulated donors at a regional blood center. each unit was irradiated with gy and transfused over - hours within hours after the time of collection. the patient's response and laboratory data were reviewed in the medical record. conclusion: this data suggests that a diagnosis of aml is associated with anti-hla antibodies. an increased frequency of blood group a in patients with aml has been reported, but here no statistically significant difference between abo blood group frequencies was found in any category except the patient's with hla antibodies. blood group b has a significant association with hla alloimmunization in the studied patients. it has been reported in a large study of female blood donors that no difference in hla antibody frequency was observed based on abo blood group at centers using the flow-based assay. although the reasons for the higher rate of group b blood type among patients with anti-hla antibodies and hematologic malignancies is unknown, this could be due to variation in immunizing events (pregnancy vs transfusion) or immune dysregulation related to the hematologic malignancy, especially aml. females with aml who are blood group b appear to be most likely to have hla alloimmunization among patients with hematologic malignancies. implementation of electronic solution to reduce risk of mistransfusion in a regional transfusion service debra lane* , lee grabner , brenda herdman , robert fallis , amin kabani and charles musuka . canadian blood services, kenora rainy-river regional laboratory program, diagnostic services manitoba background/case studies: patient misidentification and improper sample labeling has been an ongoing risk for the safety of blood transfusion. the rate of mistransfusion has remained unchanged in over years. attempts have been made to reduce mistransfusion including barrier devices, barcoding and rfid. within a regional background/case studies: the role of donor age and sex on hemoglobin content and susceptibility to hemolysis during storage of red blood cell (rbc) units is receiving increased attention. however, the impact of donor characteristics on efficacy of rbc transfusion has not been studied in largescale donor-recipient outcomes databases. study design/methods: we conducted an analysis using blood donor data routinely collected by a blood center and transfusion recipient data from a large community hospital network between and before patient blood management initiatives. linkage was performed between blood donor characteristics and hospitalized rbc transfusion recipients who received a single rbc unit. studied exposures for this analysis were blood donor sex and age in addition to rbc storage age. the wilcoxon test was used to examine changes in hemoglobin level following rbc transfusion, and , and % were male. recipients of rbc's from male and female donors had similar pre-transfusion hemoglobin levels ( . g/dl; p . ); however, transfusion recipients of male donor rbc units had higher post-transfusion hemoglobin levels and larger increments in hemoglobin compared to those of female rbc units ( . vs . g/dl; . vs. . g/dl; both p . ). female recipients had a larger rise in hemoglobin per rbc unit compared to male recipients ( . g/dl vs. . g/dl; p< . ). female sex of the recipient remained a significant predictor of change in hemoglobin after accounting for recipient age and estimated circulating blood volume in multivariable analysis (p . ). rbc storage age and the age of the donor were not significant factors in changes in hemoglobin levels in multivariable analysis, p . and p . , respectively. conclusion: rbc units from male donors resulted in a larger rise in hemoglobin levels compared to those from female donors, and these changes were more apparent in female recipients even after accounting for effective circulating blood volumes. this suggests that the dose of hemoglobin is lower in female than male rbc units. this analysis demonstrates the feasibility of using this approach to study the association between donor characteristics and rbc efficacy, hemolysis and other donor-component-recipient interactions. background/case studies: people who identify as jehovah's witnesses (jw) comprise less than % of the population of the united states. however, as a group they can present a special challenge in medicine due to a religious aversion to blood products, based on biblical readings. the degree of this religious refusal can vary from individual to individual, but as institutional policy, a conservative approach is warranted. however, in large institutions where multiple teams manage a single patient, blood refusal information can be lost or poorly communicated from provider to provider. as such, a system to alert providers of patient blood refusal was recently implemented through the electronic medical record in a large west-coast institution. study design/method: the electronic medical record (emr) utilized in this study in an institutionally modified version of epic ea best practices alert (bpa) was designed to trigger each time an end user attempted to place orders related to blood transfusion, transfusion-related lab testing, or human-derived pharmacy items on patients with blood refusal codes in their history, problem list, or religion (jehovah's witness) discrete data fields. the alert constitutes a "soft-stop" in which the ordering provided is prompted to either cancel the triggering orders or acknowledge the blood refusal/religious history and override the warning with an option to select a reason for the override. data on the triggers are automatically collected through the emr systems and generated into a report by informatics personnel. results/finding: the available data covers triggers in the two month postimplementation of the bpa. the bpa triggered times in total, affecting patients and users. stratified by location, the majority of triggers occurred in the perioperative areas ( times) and the liver icu ( times) with a minority occurring on the regular hospital floors and emergency department. nurses, attendings, residents, pharmacists, and nurse anesthesiologists were the users affected. orders that triggered the bpa included type & screens, human albumin % iv solution, human albumin % iv solution, immune globulin (human) solution. conclusion: despite the limited and very preliminary data, the user action findings seem to indicate that the bpa is effective in halting up to half of the contraindicated orders for blood-derived products and type & screens orders. given the limited types of orders that the bpa is triggering on, the pattern suggests that the bpa is potentially alerting some previously unaware providers of the patient's religious status and/or the fact that certain pharmacy items are blood-derived, and therefore unacceptable to many jw patients. despite these positive initial findings, this is an ongoing study to track the efficacy of the bpa and more data needs to be collected for better metrics of the institutional sensitivity to patient blood refusal. intervention to address inappropriate cryoprecipitate-ahf orders at a tertiary medical center sirisha kundrapu* , , mahmut akgul , , hollie m reeves , , robert w maitta , , marcie pokorny , anne capetillo and katharine a downes , . background/case studies: although introduced for the management of hemophilia a, now cryoprecipitate is primarily indicated for low fibrinogen levels. at our institution the transfusion medicine service (tms) reviews and makes recommendations to clinicians for all inappropriate cryoprecipitate orders. we aimed at analyzing the effectiveness of this intervention in reaching target fibrinogen levels in under-estimated and over-estimated orders. study design/method: we conducted a -month retrospective study (january-july ) of adult cryoprecipitate order quality assurance forms. the reference range for fibrinogen was - mg/dl with critical value of mg/dl. cryoprecipitate orders for massive transfusion protocol, from operating rooms and for extracorporeal membrane oxygenation were not reviewed by the tms. during the study period, tms evaluated orders for appropriateness of dosing and agreement with estimated required doses. post-transfusion fibrinogen levels due to intervention were compared with hypothesized no intervention levels. statistical analysis was performed using chi-square and t-tests. results/finding: there were adult (> years) orders reviewed by tms out of which were approved. of the approved orders, ( . %) were in agreement with tms's estimated dose. of ( . %) orders that were not in agreement with the tms's estimate, ( %) were underestimated and ( %) were overestimated. seventeen of orders had no post-transfusion fibrinogen levels. without intervention, there would have been a median deficit of . mg/dl (range . to mg/dl) and a median excess of . mg/dl (range . to mg/dl) of fibrinogen from the target. median difference between target and actual post-transfusion fibrinogen level was mg/dl above target, which is significantly higher with intervention than without (which could have been mg/dl below the target; p< . ). median differences between target and post-transfusion fibrinogen levels for the group with agreement between approved and requested units was not significantly different from possible differences without intervention ( vs. . mg/dl, p . ). median differences between target and post-transfusion fibrinogen levels for the group with non-agreement between approved and requested units was significantly different from possible difference without intervention ( vs. - . mg/dl, p< . ). seven of ( ) ( ) orders were for critically low fibrinogen (< mg/dl) and of these were under-estimated requests and reached target fibrinogen with tms's estimate and approval of required units to be transfused. overall most frequent orders were and units ( . % and %) i.e. and pools and the most frequent orders in the disagreement group were , , and units ( %, %, % and %). there is a significant difference between agreement and disagreement groups based on clinical service ordering the units (table) . conclusion: intervention by tms to review and approve cryoprecipitate orders was associated with increased accuracy of orders and achievement of desired target fibrinogen levels. further studies are needed to develop multidisciplinary strategies for accurate cryoprecipitate dosage. patient characteristics, medical records, vitamin k administration, and adverse events, were collected (table) . results/finding: the average pre-transfusion inr was . and posttransfusion was . . only % of patients had their inr corrected to . , while % had no change, or had increased inr. (table) . the majority ( %) of patients received units of plasma. the mean plasma dose was ml/kg. there were transfusion reactions reported, non-hemolytic and transfusion associated circulatory overload reactions in which required admission to the icu. two patients experienced bleeding during ir procedures (tips) and developed a hematoma (tunneled central line). the median of inr correction in this study was . with no relationship to the number of units of plasma transfused and/or if vitamin k was administered. this study suggests it may not be beneficial and may be harmful to transfuse plasma for correction when inr is . . randomized trials are needed to assess whether the inr is a rational tool to measure bleeding risk, and whether prophylactic treatment with plasma yields any benefit. of the patients experienced bleeding complications indicating that inr of . may be considered safe in some lower risk procedures. current practices may provide little or no benefit, with substantial risk of life threatening complications. background/case studies: group ab plasma, which lacks anti-a and anti-b antibodies, is considered to be the universal plasma donor and is used in the emergency setting before the patient's blood group is available. approximately % of the population is group ab, which limits the available inventory of group ab plasma. of group ab population, only plasma from male donors are considered suitable for transfusion since females, especially multiparous female donors, have a greater propensity to develop antibodies that can cause transfusion related acute lung injury (trali). this makes type ab plasma a limited resource. our hospital is a level one trauma center, where a significant amount of plasma transfusion is required for severely bleeding patients before their blood type is known. group o individuals make up % of the population and have no a or b antigens on their cells. group a is the second most prevalent blood group in the us population ( %) and has no b antigen on their cells. so, group a plasma is compatible with both group o and a patients, approximately % of the patient population. before patient's blood type is known, type o red cell units are transfused with a plasma, which decreases the chance of hemolysis. to conserve ab plasma, we instituted a policy effective july , as follows: units of group a plasma and units of group ab plasma is provided for the massive transfusion protocol (mtp) along with units of o negative rbc until patient blood type is known. study design/method: this prospective study is designed to monitor the use of group a plasma in mtps at our institution and to evaluate the risk and severity of hemolysis in patients transfused with incompatible plasma. direct antiglobulin test (dat) is performed if patient received incompatible plasma. if dat is positive, lactate dehydrogenase (ldh), haptoglobin and bilirubin levels are obtained to detect possible hemolytic transfusion reaction. results/finding: we reviewed mtps at our institution between july and march . twenty patients ( . %) were transfused with incompatible group a plasma ( group ab and group b patients). five patients died due to severe injury, and follow-up testing of these patients could not be performed. the remaining patients had negative dat, indicating the lack of significant amount of antibody coating their red cells, which could lead to hemolysis. none of these patients developed acute hemolytic reaction, or any other adverse effects of incompatible plasma transfusion. conclusion: our study adds more evidence of the safety of group a plasma transfusion in trauma patients requiring emergent massive transfusion before the patient blood type is known. based on this and other recently published studies, starting in april , our institute will provide only group a plasma for emergency release and mtp cases before the patient blood type is known. average ( background/case studies: in , bonfils immunohematology reference lab (irl) sent out approximately special platelets for patients with hla antibodies. by , hla platelet orders increased dramatically and the irl sent out over special platelet products. the purpose of this abstract is to illuminate the methods used to fulfill increased client need that occurred in a short period of time. study design/methods: bonfils blood center has over , donors in the database with historical hla typing. however, only approximately of those donors actively donate. in the denver area, one of the most common hla types is a a b b . only of the , donors have this type ( . %). therefore, to fill an hla platelet order request for a common hla type, only donors in the system would be a perfect hla match. with that low number of donors, it is not likely that there would be a platelet on the shelf ready to fill the order. after a donor is recruited and donates, it takes at least two days to fill an order. for a less uncommon hla type like a a b b , there is only out of , donors ( . %) that match perfectly. in those cases, there are no donors to recruit to fill such an order. in some complicated cases, the irl was provided with an hla antibody list or panel reactive antibody test (pra). in order to find product for these patients, lists of platelets in inventory with corresponding hla types were printed. if a patient had an antibody to a for example, all of the a positive platelets were crossed off the list. this cross-out process would continue manually until the only platelets on the list were the ones positive for hla antigens to which the patient did not have antibodies. these platelets are pra matched to the patient. in order to automate this process a report linked to the donor database was created to find both pra platelets in inventory and donors for recruitment. the blood center medical director began suggesting that hospital clients order a pra for each patient with platelet refractoriness. the pra test is fast and it is a definitive method to discern hla antibody mediated refractoriness from platelet refractoriness due to other causes. results/findings: in all but the most complicated cases with rare hla patient phenotypes, it was much easier to find a pra patient matched platelet on the shelf than an hla match donor. in , approximately % of these special order platelets were pra matched and the remaining % were hla matched by donor recruitment. by , approximately % of special platelets sent are pra matched. this change resulted in a . fold increase of finding product in inventory to fill orders quickly. conclusion: developing a system to provide pra matched platelets is a faster alternative to finding hla matched platelets thus contributing to better patient care. background/case studies: in urgent cases where large amounts of blood products are needed quickly, maintaining a standard massive transfusion protocol (mtp) is critical to the timely delivery of these products. each mtp pack at ucm contains packed red blood cells (prbcs), fresh frozen plasma (ffp) units, and plateletpheresis pack; a unit of prepooled cryoprecipitate is also given if the patient is in labor and delivery (l&d) or if one is requested. at ucm, blood products are generally transported through the pneumatic tube system (pts). we undertook a review of our mtp issuing practices and efficiency patterns over the last three and half years. study design/method: the electronic archives of the blood bank laboratory information system and electronic medical record at our institution were queried for patients who had mtp activations. the archives were correlated to paper copies of these activations to collect data pertaining to the relevant information such as where the order originated from, how quickly the first product was sent out, how many products were transfused, and so on. results/finding: between august to march mtps were activated at ucm, of which orders could be traced to the origin: on inpatient floor (including icus), in the operating rooms, in the emergency department, in labor and delivery, and in other procedure rooms. of the prbcs that were issued, were transfused ( % utilized); of the units of ffp that were issued, were transfused ( % utilized); of the platelet packs that were issued, were transfused ( % utilized); of the units of cryoprecipitate that were issued, were transfused ( % utilized). since march , the time of first product issue after the initiation of an mtp has also been tracked. of the events that fall within this time period, ( %), had the first product issued in minutes or less. another ( %) were issued between - minutes, resulting in over % of patients being issued their first blood product within the first minutes. only of ( %) events had an initial time greater than minutes and none were greater than minutes. conclusion: the majority of our activations currently come from inpatient floors (primarily icus). as our institution anticipates the introduction of an adult level trauma center, we anticipate this balance will shift. in addition, the data shows that (with the exception of cryoprecipitate) the utilization rate is nearly identical among the blood products sent during mtp activations ($ - %). again, we anticipate utilization rate of issued mtp products to increase with the introduction of a new adult trauma center. we have recently begun tracking time to last product issued during an mtp, but cannot report on that variable at this time. overall, our data show that our transfusion service is generally performing adequately to issue the first product within minutes of mtp protocol activation. this data only reflects time to issue in the pts; patient care areas can experience additional minutes delay in pts delivery and arrival of product at bedside. we must continue to collaborate with our clinical colleagues to collect accurate data to provide the best and most efficient mtp care. mehreen yasin* , shailesh macwan , arline stein , jane fischman , nancy nikolis , matthew bank , lennart logdberg , alexander indrikovs , sherry shariatmadar and vishesh chhibber . north shore university hospital, northwell health background/case studies: massive bleeding is generally defined as any patient who requires blood volume replacement within hours and/or receives transfusion of greater than or equal to units in one hour with a transfusion vol. supplement s ongoing bleeding. our mtp was officially implemented in in preparation for an initial verification as a level trauma center by acs. our mtp has the following packages: st pack has a ratio of : : (rbcs, plasma & platelets) and subsequent packs a ratio of : : . our mtp also includes prothrombin time (pt), activated partial thromboplastin time (aptt) and fibrinogen testing after each pack is transfused. this data is used to assess the patient and allows the transfusion service and clinical team to identify coagulopathies. however, attempts to supplement mtp packs with cryoprecipitate (cryo) and prothrombin complex concentrate (pcc) were challenging to accomplish in a timely manner. study design/methods: due to challenges in timely supplementation of mtp packages with cryo and pcc, the protocol was modified in march to add cryo and pcc at a defined point in the mtp (cryo is included in the rd pack and pcc in the th pack). in order to validate this modification of adding these products at defined intervals regardless of laboratory data, we decided to review all patients that received > rbc at our institution as these massively hemorrhaging patients would receive pcc based on our current protocol. we reviewed the blood products received by these patients and their available laboratory data. results/findings: we had patients who received > rbc in and . mtp had been activated for all patients and all patients received between . to unit of plasma for each rbc unit transfused. despite receiving these ratios of blood products, all patients had elevations of their pt > seconds and many had elevations of the aptt and fibrinogen levels less than our institution's target of mg/dl (table ) . as anticipated, improvement in the coagulation parameters was noted with cryo and pcc supplementation. conclusion: our data on massively hemorrhaging patients supports a role for supplementation of our mtp with cryo and pcc in patients who require transfusion of > rbc. our current protocol with the addition of cryo and pcc at defined intervals has streamlined the process and improved timely provision of these products in bleeding coagulopathic patients. background/case studies: red blood cell hemolysis is a key finding for a diagnosis of transplant-associated passenger lymphocyte syndrome (ta-pls). however, whether a hematopoietic stem cell or organ transplant recipient experiences hemolysis when a transplant contains unintended antibody-forming passenger lymphocytes depends, by chance, on the recipient's blood group phenotype. a living donor liver segment transplant resulted in a case of ta-pls with donor-derived anti-d that had the potential for causing a clinically significant hemolytic event. the donor's plasma contained anti-d. anti-d was absent in the recipient's pre-transplant plasma, but present in the recipient's -day and -day post-transplant plasma. although these findings established a diagnosis of ta-pls, hemolysis did not occur because the recipient's blood group phenotype was d-. the conventional focus on hemolysis, rather than on the transfer of antibody-forming lymphocytes, is a diversion from the primary pathophysiology of pls and limits capturing the true scope of the syndrome. study design/method: to determine the standard of practice for detecting and diagnosing ta-pls, a retrospective -year pubmed search for peerreviewed english-language journal articles was conducted using key words "passenger lymphocyte syndrome." cases were categorized according to the presence or absence of hemolysis and whether there was a routine antibody screen to detect donor-derived, passenger lymphocyte-formed blood group antibodies. results/finding: of published cases ( reports) of ta-pls, ( reports) were stem cell and ( reports) were organ transplants. all ( %) stem cell transplants and ( %) organ transplants were associated with hemolysis, reflecting an overwhelming bias for identifying ta-pls associated with hemolysis. of the reports of stem cell ta-pls, actively screened for antibodies in the immediate post-transplant period, and of the reports of organ ta-pls, actively screened for antibodies. these screens detected cases of stem cell ta-pls before hemolysis became apparent and cases of organ ta-pls with antibodies without hemolysis. it can be inferred that ta-pls is currently under-diagnosed, because hemolysis is not consistently present and/or antibody screens are not performed routinely. conclusion: a new category of "non-hemolytic ta-pls" is recommended to capture otherwise undiagnosed cases where ta-passenger lymphocytes form blood group antibodies in the recipient, but hemolysis does not occur, as in our aforementioned case. to ensure including the full scope of ta-pls, an antibody screen should be performed routinely one week after transplant and repeated as clinically indicated. occult hemolytic anemia due to anti-mur in a patient receiving blood from a region with a prominent asian donor population jean oak* , rosario mallari , marc de asis , elaine shu , jonathan hughes and tho pham , . stanford university, stanford health care, stanford blood center, bloodsource background/case studies: mur antigen is present in - % of individuals in southeast asia, taiwan, and parts of southeastern china, but is rare elsewhere. antibodies against mur antigens are clinically significant, hence many countries in asia routinely screen for it while other countries, including the us, does not include mur in the standard screen. we describe a case of an occult anti-mur antibody causing anemia and donor ethnicity distribution in a regional blood center with a large asian donor population. year old hispanic male with chronic myelomonocytic leukemia and plasma cell dyscrasia developed anemia. initial antibody screen and dat were negative, and the patient received - rbc units every - weeks to maintain a hemoglobin (hb) level of g/dl. the patient remained stable for months when his hb level acutely dropped to . g/dl. the antibody screen remained negative for an additional months when it became positive for anti-jka and anti-mur. donor ethnicity data was available for of the rbc units he received. units were from an asian donor, and a unit transfused days prior to the hb drop was from a caucasian/chinese donor. study design/method: we reviewed the ethnicity data of , donors at a hospital-associated blood center located in a region where asians comprise approximately % of the population. results/finding: . % of donors identified as chinese, vietnamese, filipino, or other southeastern asian. these donors account for of ( . %) rbc collections. conclusion: identification of anti-mur in this patient was triggered by the presence of a concurrent anti-jka alloantibody. since over % of the rbc supply in the local blood center was collected from chinese or southeast asian donors, chronically transfused patients are at risk of developing anti-mur-mediated hemolysis that could be missed on a standard screen. this finding raises a possible need for blood banks located in regions with a prominent asian population to implement screening for anti-mur. brian adkins* , princess maynie , carol chandler , shelia garret and pampee young . vanderbilt, vanderbilt university medical center, department of pathology, microbiology and immunology background/case studies: antibody titration is a testing modality vital to both obstetric and transplant services. manual direct tube testing is associated with variability in results (poor reproducibility/precision) and is also time and resource intensive. in fact, studies have shown a three-to eightfold inter-institutional difference between the antibody titers from the same samples using manual tube method. the orthovision automated analyzers offers automated titering of patient plasma using gel technology. although there is intense interest in adopting automated testing technology for titering, it is well-appreciated that titers obtained in manual gel testing are much higher than those obtained by manual/direct tube testing. the higher titer results lack clinical fetal anemia and outcome correlations, which is a barrier to their implementation. moreover, despite the increased sensitivity of gel testing, prior studies have found variable results with regard to reproducibility and precision. [ ] [ ] [ ] there is minimal information on the comparisons of tube titers to orthovision automated titers or assessment of the reproducibility of this automated method. study design/method: rh and non rh minor rbc antibody titrations were performed by manual direct tube method on clinical samples and the same samples were analyzed on three different ortho vision analyzers to assess precision and inter-instrument reproducibility. results/finding: a total of samples have been analyzed (table) , rh and non-rh antigens. titers via automated testing on orthovision resulted in a mean titration being . (range - ) times higher. the average fold change for rhd/c/e antibody titers were . , whereas the average fold change for non rh titers was . (range - ). the range for anti d titers was particularly variable, - , whereas for c/e, it was - . the overall reproducibility/precision of the automated analyzer was $ %. to correlate the a transfusion vol. supplement s increased titers observed with some classes of antibodies, particularly anti d, we will be performing parallel testing of obstetric samples and correlating with pregnancy outcome/fetal testing the obtained values. conclusion: automated titration of antibodies using the orthovision analyzers resulted in highly reproducible results between different instruments using the same sample. however, the automated analyzers consistently yielded higher values, particularly with rh d, with results $ times higher than in manual tube testing. interestingly, the difference in titers of non rh antibodies between manual tube and automated testing was not statistically significant, although our n thus far is small. in order to leverage the efficiency and reproducibility benefits of automated titering we will need to establish "critical titer ranges" which require active monitoring of the fetus. platelet additive solution reduces the isoagglutinin titer in apheresis platelet units maxim tynuv*, elizabeth j furlong and willy a flegel. dtm/cc/nih background/case studies: isoagglutinins in the plasma of apheresis platelets are a concern during transfusion, as high titer anti-a and/or anti-b may cause a hemolytic transfusion reaction (htr) in a recipient with cognate antigen. apheresis platelet collections are usually reconstituted with donor plasma, however most facilities do not test for high titer of isoagglutinins, exposing recipients to the risk of htr due to plasma incompatibility if given based on short outdate and not abo type. at our facility testing is performed on all apheresis platelets with a cutoff titer of . units above the cutoff are marked as "high titer" and only given to abo plasma-compatible recipients or washed with saline to reduce plasma. however, washing platelets is a time consuming process that results in a loss of up to % of the platelets. platelet additive solution (pas) is used as an alternative collection and storage solution, replacing approximately % of donor plasma in the final product. the goal of this study was to determine what affect pas has on isoagglutinin titers and whether using pas could lead to a revision of one facility's procedure for management out of group platelet transfusions. study design/method: isoagglutinin titers of whole blood edta samples were compared to the final apheresis platelet unit collected in pas (intersol, fresenius kabi, lake zurich, il). using two-fold dilution steps, plasma was tested with pooled red cells (equal mix . % suspension of a and b cells, ortho, raritan, nj) in a gel matrix test (mts buffered card, ortho, raritan, nj) with min incubation (room temperature) prior to centrifugation (mts ortho workstation). fifty two donors were group o, group a, and group b. results/finding: of the whole blood edta samples tested, ( group o and group b) exceeded a high titer threshold of . when the pas samples of these donors were tested, only one (group o) exceeded the same threshold. pas specimens showed a consistent two-fold decrease in titer compared with whole blood specimens. nearly half of the group o donors exceeded a titer of when whole blood specimens were tested. conclusion: only one sample from apheresis platelets collected in pas exceeded our clinically applied titer threshold of , a % decrease from the number of whole blood specimens exceeding the threshold. testing the platelet bag collected in pas instead of plasma from whole blood specimens would lower the number of units exceeding the high titer threshold, and reduce products needing to be washed. furthermore, facilities not collecting platelets on site or without access to whole blood specimens from donors could implement the process described here and screen platelet apheresis collections for potentially clinically adverse isoagglutinin titers, whether collected using pas or not. other components. the majority of blood components in israel are collected and distributed by magen david adom (mda), from main locations. several hospitals in israel also collect platelets in-house. as part of an effort to understand plt utilization, a nationwide survey of plt transfusion and expiration was conducted. study design/methods: data on the disposition of all plt units, acquired from mda and collected in-house, during the calendar year was requested from all hospitals in israel. the number of plt distributed to hospitals by mda was also collected. plt wastage was defined as the sum of plt that were returned and not reissued from the hospital blood banks and plt that expired on blood bank shelves. results/findings: sixteen of the ( %) hospitals in israel, along with mda, participated in the survey, listed as a to p. the results are presented in the table along with each hospital's distance from the mda facilities. for some hospitals, the sum of transfused and wasted plt was slightly less than the number of plt supplied by mda; this is likely due to the small number of plt that had not either been transfused or expired by the time the data collection period ended. three of the largest hospitals (c, b and a) collected plt in-house in addition to acquiring units from mda. these hospitals had a lower overall rate of wastage including their own donations than the other hospitals that did not collect in-house plt. the other hospitals had wastage rates ranging between - %. no correlation was apparent between the hospital's distance from the mda facility or its number of beds and the plt wastage rate. conclusion: there is considerable platelet wastage in israel. large hospitals in israel with in-house donations had the lowest overall wastage rates in comparison to the other hospitals. factors known to affect plt utilization and wastage such as patient diagnosis mix, policies about how plt are issued and accepted back into hospital inventory, plt inventory size and the time of pooling of whole blood platelets relative to the time they are issued and returned to the blood bank need to be investigated and optimized in order to reduce wastage rates. possible immune-mediated hemolysis due to platelet transfusion masked by underlying hemolysis in a patient with blast crisis sirisha kundrapu* , , christopher j gresens , anne capetillo , hollie m reeves , and katharine a downes , . case western reserve university school of medicine, university hospitals cleveland medical center, bloodsource background/case studies: transfusion-related hemolysis with abomismatched platelets is rare with a reported incidence of < . %. most commonly in such cases group o platelets having high titer anti-a result in clinically significant hemolysis when transfused to a group a or ab recipient. we present a patient with a possible hemolytic reaction following transfusion of abo mismatched platelets presenting in the setting of underlying disease associated hemolysis. study design/method: a -year-old male with chronic myelogenous leukemia in blast crisis was evaluated for possible transfusion reaction to a single donor platelet (sdp). two hours post transfusion he developed chills, rigors, and increased blood pressure ( / mm hg to / mm hg) followed by hematuria ( ml). chills and rigors resolved; blood pressure stabilized after min with diphenhydramine, solumedrol, and acetaminophen. negative. patient abo group, rh (d) type and antibody screen on pre-and post-transfusion specimens showed no discrepancies. laboratory indicators of hemolysis are summarized in table. notably, while total/ indirect bilirubin increased and hemoglobin decreased after transfusion other tests were indeterminate for hemolytic transfusion reaction with abnormal pretransfusion levels. despite underlying disease associated hemolysis, the blood supplier of the unit was contacted to investigate into the possibility of high titer donor anti-a. this revealed donor anti-a titer results of (igm) and , (igg); donor was deferred from future platelet donations. conclusion: while the post-transfusion sample had no visible hemolysis and a negative dat, increased total/ indirect bilirubin after transfusion and high titer donor anti-a are supportive of immune mediated hemolytic transfusion reaction. the key unique aspect in this case is baseline underlying hemolysis, which may mask needs for further investigation of donor for high titer anti-a. ana paula hitomi yokoyama* , leila patricia de sousa fontenele , isabel nagle reis , carolina bonet bub , araci sakashita , raffael zamper , cristiane nakazawa , tatiane almeida omura paula , patricia silva batista , marcio dias almeida , fernanda loureiro de andrade orsi and jose mauro kutner . hospital israelita albert einstein, hemocentro unicamp-universidade estadual de campinas background/case studies: orthotopic liver transplantation (olt) is a high complex procedure, fundamental to therapeutic approach for end-stage liver disease. despite improvements in hemostatic , surgical, and anaesthetic techniques, liver transplantation is still associated with massive blood loss and high rates of transfusion requirements. peri and intraoperative transfusion of red blood cells (rbc) have been previously reported as major predictors of post -operative mortality . identifying predictive factors for transfusion requirements may help optimise patient blood management strategies in olt. we conducted a single center retrospective analysis of cases of olt performed between and in brazil in order to identify predictive factors for red blood cell transfusion study design/method: a retrospective analysis in a single institution was performed, and charts of consecutive patients submitted to liver transplantation between and were reviewed. the following variables were collected for each patient: gender, race, primary diagnosis, presence of hepatocellular carcinoma, age, body mass index, corrected model for end-stage liver disease (meld), duration of warm and cold ischemia. categorical variables were analysed using pearson chi-square test. continuous variables were analysed using t-student test. a forward logistic regression model was used to analyse data in a multivariate fashion, to identify independent contribution of variables previously found to be significant. results/finding: in univariate analysis, female patients, absence of hepatocellular carcinoma (hcc), primary diagnosis, corrected meld and warm ischemia time were significantly associated with consumption of rbc use in the intraoperative period. multivariate logistic regression of these factors showed that female patients (or , - % ci: , - , , p: , ), absence of hcc (or , - % ci: , - , , p: , ), cirrhosis of any cause (or , - % ci , - , -p: , ), miscellaneous diagnosis (auto-immune, metabolic diseases, familial amyloid polyneuropathy, vascular complications) (or , %ic , - , ) and retransplantation due to primary non function of the graft (or , %ci , - , , , p: , ) were independently associated with rbc transfusion requirements. conclusion: in this study, female patients, absence of hcc, specific primary diagnosis and retransplantation due to primary non function of the graft were significantly associated with rbc consumption in intraoperative period. determination of rbc transfusion predictors before surgery might provide important information regarding management of blood components and help optimise utilisation of resources for blood conservation strategies. prevalence of high-titer anti-a /b in group o platelet products. charles k. childers* , mark destree , ashley rose and theresa nester , . madigan army medical center, bloodworks northwest, bloodworks nw, dept of laboratory medicine, university of washington background/case studies: with platelet substitution policies, minor aboincompatible platelets (where donor's plasma may contain antibodies to recipient's red blood cells) are often issued in an effort to best utilize the community supply. however, rare reports of acute intravascular hemolysis have been reported from such transfusions, and can be attributed to high anti-a or anti-b titers, typically in a group o donor. one method to reduce the risk of hemolysis is to identify high titer platelet units prior to transfusion with a subsequent intervention. the percentage of high titer anti-a /b in group o platelet products is presented from a large regional blood center collected over - months. data from both pre-storage pooled platelet units (pspp) and apheresis derived platelet units (aplt) is shown. study design/method: platelet component samples were collected in ml edta sample tubes. a single : dilution of plasma was prepared using a hamilton microlab series dilutor using . ml saline diluent and . ml platelet component sample. using a standard transfer pipette, two drops of diluted sample were transferred to each reaction tube along with one drop of a or b red blood cell reagent. reaction tubes were centrifuged immediately in a serological centrifuge at rpm for seconds. reactions were read using a lighted agglutination reader. the presence of macroscopic agglutination (weak or greater) with either the a cells or b cells was recorded as a positive reaction, indicative of a high titer anti-a or anti-b. retesting of samples was performed to confirm high titers. results/finding: the above results indicate that, when a titer cut-off of is used, approximately % of group o apheresis platelets will have a high titer, most commonly with anti-a . less than half of a percent of pspp units will have a high titer. testing units for the titer can help to change abo out-of-group platelet substitution policies. in our example, the bloodworks transfusion service was able to change from a policy of volume reducing any group o apheresis platelets being issued to a group a or ab patient, to giving high titer products to only group o patients. the subsequent decrease in episodes of volume reduction helped to improve overall availability of apheresis platelets, by maintaining their day outdate. after months of testing pspp units and verifying that the products rarely had a high titer ( . %), the blood center stopped performing this testing for pspp units. rh ) ] started complaining of worsening back pain two and half hours after receiving one unit of rbc for a drop in hematocrit to % (from % on the previous day). his hematocrit did not increase ( %), and over the ensuing hours, he became anuric and jaundiced. clerical checks confirmed that his forward type was a positive, which was also the type of the rbc unit transfused, but revealed anti-a at a titer of in his plasma. furthermore, the direct antiglobulin tests (dat) were positive for c in the pre-and post-transfusion blood samples. anti-a was not detected in his plasma collected three days earlier, however. although his plasma color was amber, he had signs of intravascular hemolysis: undetectable haptoglobin, increased lactate dehydrogenase (ldh) and total and indirect bilirubin results/finding: the positive dat in the pre-transfusion sample pointed to ongoing hemolysis prior to the transfusion of the a rbc unit. in the setting of recent abo-mismatched transplant, his picture was consistent with hemolysis from newly formed anti-a by proliferation of donor lymphocytes, or pls. we performed an emergent rbc exchange using o rbcs with a goal hematocrit of % while reducing the number of a rbcs in his circulation by approximately %. his pain improved rapidly thereafter, and he had complete recovery of renal function. conclusion: pls should be in the differential diagnosis when suspecting/ investigating clinically significant hemolysis in abo-mismatched hpc transplant recipients, especially when the hpc source is from peripheral blood. as in our patient, it usually takes - days for antibodies to develop and they are short-lived ( - weeks). due to the severity of his manifestations, we performed an emergent rbc exchange successfully. furthermore, this patient's event exposed a vulnerability in our system of issuing the proper blood type for abo-mismatched transplant recipients, which has since been remediated electronically background/case studies: group o rhd negative (oneg) red blood cells (rbcs) are a precious resource. to conserve the oneg inventory while minimizing the risk of rhd alloimmunization in oneg females of childbearing age, transfusion services may automatically provide group o rhd positive (opos) rbcs to rhd negative males and/or rhd negative postmenopausal females during bleeding emergencies. despite these conservation strategies, shortages of oneg rbcs occur. the goal of this study was to determine how the utilization of oneg rbcs can be optimized using agebased opos switching for routine transfusions in oneg patients. study design/methods: recipient age and abo/rhd group were obtained for all allogeneic rbc transfusions during the calendar year from hospitals. an additional hospital* provided data for august-december . rbc transfusions in patients < year of age, and in patients whose age and/ or abo group were unknown, were excluded from analysis. the abo/rhd group of each rbc unit was compared to that of the recipient to determine the number of oneg rbcs transfused to all patients, the number of rbcs transfused to oneg patients and the number of oneg rbcs transfused to oneg patients. the number of oneg rbcs transfused specifically to oneg patients >/ years was also determined. results/findings: see table . the fraction of all transfused rbcs that were oneg ranged from - % (row f). the percentage of oneg rbcs transfused to oneg patients ranged from - % (row g); thus, non-oneg patients received - % of the oneg units transfused (row h). hospitals differed widely in the practice of issuing oneg rbcs to oneg patients ( %- %; row i). overall use of oneg rbcs could have been reduced by %- % if opos units had been given to all oneg patients >/ years old (row j). conclusion: during times of oneg shortage, age based opos switching rules may be applied for routine transfusions. this would help to ensure the availability of oneg rbc units for oneg females of childbearing age. rasha eldeeb mohammed* , nehad mohammed , marwa aly and nashwa fahmy . national blood transfusion services, nbts background/case studies: sensitization to the transfused red cell may complicate further transfusion& make it increasingly difficult to find compatible blood components for those patients. splenectomy has been shown to increase human leucocyte antigen immunization. the aim of the study is to evaluated the effect of splenectomy on the occurrence of red cell alloimmunization in humans. study design/method: this study was conducted on multitransfused patients who received blood transfusion chronically at our central blood center. they were thalassemia patients ( bthalassemia patients, one patients with a thalassemia), sickle cell anemia patients and immune hemolytic anemia patients ( auto immune hemolytic anemia patients, one paroxysmal nocturnal hemoglobinemia patient, one immune thrombocytopenic purpra patients). oncology patients, chronic diseases patients. history and demographic data were documented. all the patients who received blood are examined for the presence of the spleen.our patients were subjected to direct & reverse blood grouping (abo& rh) tests, alloantibody screening and detection. results/finding: statistical study is done to determine what is the effect of splenectomy in increasing the rate of red cell sensitization in chronically transfused hemolytic patients. the study revealed that: out of ( %) alloimmunized patients and out of ( %) non alloimunized patients(p< . ) . statistical analysis show that there is high statistical significant difference between patients who performed splectomy& who did not perform splenectomy as regard form conclusion: patients who had splenectomy had a higher alloimmunization rate removal of the spleen is not recommended in those patients who are periodically in need of blood and blood components. restrictive transfusion triggers rather than specific evidence. therefore, two systematic reviews of a) rbc transfusion guidelines and review articles to determine if single or multiple unit transfusion strategies are recommended and b) to identify studies comparing strategies were performed. study design/method: methods medline, embase, cinahl, web of science, national guideline clearinghouse, and the trip database were searched from inception to june . screening and data abstraction were done independently by two assessors. for review a, the proportion of articles with recommendations and articles recommending single unit strategies were assessed; stratified by guidelines, systematic reviews, and other review articles. for review b, the primary outcome was rbc utilization. secondary outcomes included proportion of units transfused using a single unit strategy, length of stay, and mortality. meta-analysis was done using the mantel haenszel random effects model. results/finding: review a identified articles for data abstraction, where articles were transfusion guidelines. there were guidelines ( %) that made a recommendation, for a single unit and for multiple unit transfusion strategy (table ) . review b identified retrospective cohort studies that were eligible and data abstraction was performed. all utilized a policy encouraging single unit transfusion strategies and compared a pre-implementation period to a post-implementation period. meta-analysis could only be performed on the secondary outcome of the proportion of units transfused using a single unit strategy, which was higher after the policy intervention (or . , % ci . - . ), although heterogeneity was high (i %). conclusion: our systematic reviews demonstrated a lack of recommendations amongst guidelines pertaining to transfusing single units of rbcs and only a few retrospective cohort studies to support benefits of the use of single unit transfusion strategies. additional high quality studies are needed to identify the benefits of a single unit transfusion strategy and when it should be used. guidelines groups should review research in this area to determine if a recommendation can be made. background/case studies: platelets made with platelet additive solution c (pas c) and treated for pathogen reduction (pr) have been shown to have decreased post transfusion platelet counts from platelets stored in all plasma. with the advent of multiple types of platelets, we are evaluating whether a mixed platelet inventory has had an effect on component use. the literature from europe has shown that platelet and red cell use does not increase when pr and pas products are used. evaluation of rbc use at our institution has shown no change in the number of products transfused per patient per month. we are evaluating whether the mixed inventory has led to more platelet transfusions. study design/method: we looked at occasions when patients received all of their platelet transfusions on a single day. by doing this we were able to exclude refractory patients from the analysis. the information obtained from routine quality management audits of transfusions between december and february was used for this analysis. the information included the ordering service, product release time, product code, pre and post counts. statistical analysis was performed using minitab. results/finding: during the months, units of platelets were transfused to recipients. over the months, a median of units was given to each patient with a range of to . the overall distribution of products used was % plasma, % pr, % pas f and % pas c. thirty percent of patients (n ) received all of their products on a single day. single units were given to patients while , and received , , and units respectively. the distribution by product type was % plasma, % pr, % pas c and % pas f. this same percentage was present for single and multiple products and was not statistically significantly different from the overall distribution of the products given during the month period (p . ). the distribution by service was different for the groups receiving multiple units. for single units the distribution was % hematologic malignancy, % infusion clinic (nos), % solid tumor medicine, % surgery, and % pediatrics. for those receiving multiple units the distribution was % surgery and % each for solid tumor, hematology and infusion (nos). the chi-square test for associations showed the increase in multiple units to surgical patients to be significant with a p value of . . conclusion: the distribution of the type of platelets given during a single event of transfusion was not significantly different from the overall distribution of platelets given during the month period. the patient's clinical service was a better predictor of the use of multiple products than the type of product given. this suggests that surgical losses or the need to have a higher platelet count during a procedure was the leading factor in the use of multiple products in this transfusion scenario. the effect of red blood cell transfusion on iron metabolism in critically ill patients margit boshuizen* , , yvemarie b.o. somsen , maike e. van hezel , marleen straat , robin van bruggen and nicole p juffermans . sanquin research and landsteiner laboratory, academic medical center background/case studies: anemia of inflammation (ai) has a high prevalence in critically ill patients. in ai, iron metabolism is altered, as high levels of inflammation-induced hepcidin reduces the amount of iron that is available for erythropoiesis. ai is treated by red blood cell (rbc) transfusions. it is known that rbc transfusions increase iron level in neonates and thalassemia patients, but the effect of rbc transfusion on iron metabolism during inflammatory processes is unknown. since one unit of rbcs contains mg of iron and % of the rbcs are cleared by macrophages within hour following transfusion, rbc transfusion could increase iron levels and iron availability for erythropoiesis. we investigated the effect of rbc transfusion on iron metabolism in icu patients, and additionally compared the effect in septic patients to non-septic patients. study design/method: in a prospective cohort study in icu patients who received one rbc transfusion, different iron parameters were measured before and hours after transfusion, to determine the effect of a rbc transfusion over a period of time. next, the impact of a rbc transfusion on plasma iron parameters in septic patients compared to that in non-septic patients was analyzed. plasma iron concentration, transferrin (saturation), ferritin, haptoglobin, hepcidin and il- levels were determined. results/finding: in this cohort, serum iron levels were low and did not change following transfusion ( . vs. . mmol/l, p . ). also, the transfusion had no effect on transferrin saturation ( vs. %, p . ), ferritin ( . vs. . mg/l, p . ) and il- levels ( . vs. . pg/ml, p . ). hepcidin levels increased in these icu patients after rbc transfusion ( vs ng/ml, p . ). in septic patients, rbc transfusion induced a decrease in haptoglobin levels compared to baseline, which did not occur in non-septic patients (- . vs. . % change, p . ). other iron parameters did not differ between septic and non-septic patients. conclusion: transfusion of one unit of rbcs does not increase iron levels in icu patients. the increase of hepcidin suggests rbc transfusion induced upregulation of hepcidin, despite the absence of a significant increase in il- or plasma iron levels. this increase in hepcidin levels after transfusion can potentially further hamper iron availability for erythropoiesis. in sepsis, rbc transfusion decreases haptoglobin levels, suggestive of hemolysis. in conclusion, rbc transfusion might have a negative effect on erythropoiesis, due to the increase in hepcidin levels that are observed after transfusion. the effects of pas and pr on platelet use barbara mendez, judith delmonte, elizabeth mccabe and joanne becker*. roswell park cancer institute background/case studies: with the anticipated release of the fda guidance: bacterial risk control strategies for blood collection establishments and transfusion services to enhance the safety and availability of platelets for transfusion, the use of pathogen reduced platelets (pr) which are often produced from products made with platelet additive solution (pas) may become more common. our institution has been transfusing platelets made with additive solutions since and pathogen reduced platelets have been available since . in our data validating pas and pr, the post counts from transfusion of pas-c and pr products have been statistically lower than platelets in all plasma (pp) or pas f products. our study looks at whether this difference has led to a corresponding increase in the number of units of platelets transfused. study design/method: the data was obtained from the routine quality reports produced for the blood utilization committee at our facility between and . during this time pas c, pas f and pr went from % to % of all platelet products given. all recipients had an oncology diagnosis. the data collected included the service, unit number and product code. the number of unique recipients was determined monthly. the data was converted to plt/month/recipient for analysis. statistical analysis was performed using the two sample t-test results/finding: the data was normalized to plt/recipient/month. in patients received an average of . units/recipient/month and in the average was . units/recipient/month. the intervening data points for , , and were . , . , and . respectively. the year average was . . the slope of the graph for all points was y - . . . the two sample t-test showed that the plt/recipient/month from to was not statistically different with a p value of . . conclusion: the implementation of pas and pr platelets in the oncology environment has not increased in the number of platelet transfusions given. in additional analysis, the red cell use has decreased (data not shown). this can be interpreted as indicating that patients have not had increased episodes of bleeding. although the post platelet count from pas/pr platelets may be lower, we do not have evidence from our platelet transfusion data that this is leading to clinical outcomes necessitating additional products to be given. background/case studies: it is reported that the incidence of alloimmunization in aml patients is unrelated to the number of transfusions the patient receives and most patients who have hla antibodies do not exhibit platelet refractoriness. many cases are also found not to have any anti-platelet antibodies detectable by standard laboratory tests. recent data in leukemia and hematopoietic stem cell (hsct) recipients transfused exclusively with leukoreduced products show that % to % develop alloimmune platelet refractoriness. objective: to determine an improvement in platelet count with the match grade and/or the abo blood group of the hla matched platelets in highly alloimmunized patients with concomitant non-immune causes for platelet destruction. study design/method: clinically documented platelet refractory patients, who received hla matched irradiated sda platelets with their hla typings for hla-a/-b and hla antibody identification were reviewed. there were two strategies utilized, the hla strategy (matching recipient and donor hla-a/ -b types) and the antibody specificity prediction (patient provided with platelets from donors lacking only those hlas to which the patient had antibodies) strategy. statistical analysis: a one sample t-test using minitab statistical software was performed comparing the mean against a platelet increment of a hypothetical difference of at least k/ul. the analysis revealed that the mean of . k/ul (n ) had a percent lower bound confidence interval platelet increment of k/ul (p< . ) results/findings: (median range [ - ]) hla matched leucoreduced irradiated sda platelets were transfused to ( m/ f) patients, median age years (range - ). / ( %) patients showing broad alloimmunization to hla class i/class ii antigens. / ( %) patients had anti-hpa antibodies (gp iib/iiia and gp iib/iiia and gp ia/iia). the majority / ( %) had a diagnosis of hematologic malignancy (aml/mds/mpn/ cmml/mm); / ( %) female patients had prior exposure via pregnancy and / ( %) had a history of hsct. ( %) platelets were abo identical-platelet increment median k/ul (range - to ), ( %) were abo compatible -platelet increment median of k/ul (range - to ) and ( %) were abo incompatible with platelet increments median k/ul ( range - to ). platelet counts were performed within hours in ( %) transfusions. the hla match grade of the transfused platelets were as follows: the use of massive transfusion protocol (mtp) in a community hospital rohini patel* , renee leblanc , dongfu xie , alice cabe and yanyun wu . overlake hospital, bloodworks northwest the use of massive transfusion protocol (mtp) in a community hospital background/case studies: the establishment and use of massive transfusion protocol (mtp) have become common practice, especially in trauma centers and tertiary hospitals due to significant number of patients with massive bleeding. however, it is not well established if the use of mtp also has value in small hospitals and community hospitals, and how mtp is used in fig. these settings, such as indication for mtp, blood products used, and the outcomes of these patients. study design/method: retrospective review of transfusion data from a community hospital with a bed size of about for years (from to ) was performed. patients with mtp requested are included in this study. results/finding: please see the table below for the summary of data. notably, patients with gi bleed and ob bleed are the two most common indications for mtp, and % of patients survived with the support of mtp. in one case, no blood product was used. the establishment and readiness of mtp can be very important in supporting patients who experience massive bleed in small hospitals and community hospitals. in these settings, mtp is most commonly used for patients with massive gi bleed and ob bleed. if the patient develops antibodies to a high incidence antigen, finding compatible units may become impossible. included in the mns system, and residing on glycophorin b (gpb), the u antigen is absent in less than . % of the black population. those with altered forms of gpb, known as u variants, can produce a diverse group of antibodies capable of causing mild to severe hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (hdfn). this case illustrates the balance between the need to transfuse and avoiding complications thereof. a -year-old ghanaian woman with scd and history of chronic transfusion presented with diffuse pain and a hemoglobin value of . g/dl (baseline - g/dl). she is known to be e, c, k, fya, jkb, s, s negative, u variant, and has anti-e, c and u antibodies. there were no eligible family donors and a nationwide search for compatible blood yielded four crossmatch compatible u variant units. the decision to transfuse was made. the patient had no change in symptoms or vital signs during transfusion but post-transfusion hemoglobin was . g/dl. a transfusion reaction work-up was ordered. post-transfusion serum sample was negative for hemolysis and no new antibodies were identified. the post-transfusion dat was weakly positive only with complement and laboratory data revealed a decrease in total bilirubin ( . to . mg/dl). two additional u variant, crossmatch compatible units were transfused over the next two days restoring her hemoglobin to . g/dl. the patient was discharged to home in stable condition and follow-up hemoglobin levels continued to rise back to baseline. study design/methods: molecular genotyping was used in donor unit selection prior to compatibility testing by transfusion services. conventional methods were used to monitor the patient's condition pre and posttransfusion. results/findings: each donor unit came from a different donor but all were the same gpb genotype as the patient. the patient did not experience an acute or delayed hemolytic transfusion reaction and genotype matching successfully facilitated donor unit selection in this case. conclusion: transfusion of u variant red cells to a u variant patient should be undertaken with great caution due to epitope and antibody heterogeneity. this case highlights the importance of genotype compatibility in selecting donor units for a chronically transfused, scd patient with anti-u. sound transfusion management of such patients requires planning and good communication on the part of clinicians and the laboratory staff. background/case studies: patients with decompensated waiha may require transfusion with red blood cell (rbc) products that are cross-match incompatible due free autoantibodies. the feasibility of blood transfusions in waiha patients is controversial because of difficulty in cross-matching and increased risk of transfusion reactions, since transfused rbcs may be destroyed more rapidly in patients with active hemolysis. to study the actual vs. theoretical risk of increased hemolysis in waiha patients, we investigated the post-transfusion (post-tfn) hematocrit (hct) change in waiha patients who were transfused compatible rbcs compared to those who received li blood. we further hypothesized that a post-tfn hct would be inversely related to the degree of ahg-phase incompatibility. study design/method: we reviewed all transfusions to patients in our quaternary-care hospital with a history of waiha from october to march . patient hcts were ordered by prescribing physicians for clinical purposes. a transfusion episode was defined as all units released in the interval before a post-tfn cbc. ahg-phase crossmatch was tube tested in saline per clinical procedure. transfusion medicine physicians determined the release of least-incompatible units. statistical tests were performed with statcalc (epiinfo, cdc) and www.socscistatistics.com. results/finding: there were rbc products transfused to waiha patients. twenty-three ( . %) patients received at least incompatible unit. the mean age was . years (range - yrs) with % women. ethnic composition was % african-american, % caucasian, and % patients of mixed/other ethnicity. one hundred fourteen ( %) of these products were released as li products and ( %) were compatible. ninetythree ( . %) of the li product transfusions had a post-tfn hct change of < % whereas only ( %) of the compatible product transfusions resulted in a post-tfn hct change of < % (p . , v ( ), exact methods). the mean hct increase in the compatible group was . % per unit vs. a slightly lesser per-unit increase of . % in the li group (p . , t-test, -tailed) within the li group, there was no difference in the per-unit hct change according to strength of incompatibility (table) . strength of ahg incompatibility was not available for units. units that were incompatible had a lower mean post-tfn hct rise compared to all other li units ( . % vs. . %); however, this difference was not statistically significant (p . ). conclusion: the post-tfn hct change for transfusions of li units to patients with waiha was less than the expected % per unit more frequently than it was for waiha patients who received compatible products ( . % vs. %). however, likely due to our small sample size, the mean differences were not statistically significant. interestingly, there was no difference in the per-unit post-tfn hct according to differing strengths of incompatibility in our sample, although the mean increase for the li products was less than all other li products combined. the increase was unexpectedly low for weaklyincompatible units, which we are further studying. future work includes consideration of inpatient vs. outpatient clinical status, effect of co-incident alloantibodies, comorbidities, and medications. transfusion management was summarised by individual hospital, type and total cases. in-hospital mortality (adjusted for age, sex, comorbidity, bleeding context and number of rbcs in the first -hours from mt onset) was calculated with % and . % control limits to indicate potential outliers. data were analyzed using statistical software (stata). results/finding: there were mt cases from hospitals ( tertiarylevel, smaller/medium sized acute-care and specialist women's). number of mt cases per hospital ranged from to . patient median age was years (iqr , ), % were male and % required admission to intensive care. the most common clinical groups were cardiac surgery ( % cases), trauma ( %) and gastrointestinal hemorrhage ( %); however there was marked variation between hospitals. ratios of transfused products, analyzed according to bleeding context, varied between hospital types. the pooled average adjusted in-hospital mortality for the tertiary-level hospitals was % (range % to %) and / ( %) were within the % control limit. cb that required ! rbcs within -hours of mt onset occurred in % of cases. comparison of transfusion management for this subset of mt cases showed that patients treated in smaller/medium sized acute-care were less likely to receive cryoprecipitate than patients treated in tertiary-level hospitals ( % versus %; p . ). conclusion: patient characteristics and transfusion practice varied between hospitals and hospital types, however in-hospital mortality outcomes were comparable. results are made available to participating hospitals in the anz-mtr to initiate discussion, practice review, and examination of compliance with national standards, patient blood management guidelines and to highlight areas for further investigation. data are also available for review by governance and policy bodies at state and national level to support practice improvement activities and highlight priority areas for future research. background/case studies: in hospitals and medical centers, in case of big traumas often an intraosseous entrance via a bone needle is combined with a fast flow fluid warmer. with this, infusion fluids, including blood products, are administered under pressure. this is done because veins of trauma patients are often not suitable for infusion of fluids. suppliers of pump and needles describe the possible transfusion of blood products, but this is mainly limited to plasma and erythrocytes. there is no information available concerning transfusion of platelets under pressure via a bone needle. the aim of the study was to investigate the effects of warming and administration of a platelet concentrate (pc) under pressure via a bone needle on the in vitro quality of platelets. study design/method: pools of bcs and ml of platelet additive solution iii (pasiii) were used to produce pcs (n ). pcs were stored on a flatbed agitator ( cycles/min) in a temperature-controlled cabinet at c for - days. to mimic hospital conditions, pcs were warmed using a blood warmer and transfused via a bone needle to a transfer bag. on the pcs a pressure of mm hg was applied. using clamps, a flow velocity of - ml/minute was realized. platelet quality before and after pressurized simulated transfusion was determined by means of various in vitro parameters. results/finding: due to priming of the transfusion disposable with saline, the pcs were diluted - %, resulting in a significantly increased pc volume and decreased platelet concentration after simulated transfusion. because of loss of platelets in the disposable set, also the total number of platelets was decreased after simulated transfusion. after simulated transfusion, the pcs still fulfilled the requirements for platelet concentration ( . - . x /l) and number (> x /unit). simulated transfusion had no effect on the percentages of cd p and annexin v positive cells, indicating no activation or induction of apoptosis. ph was not influenced by simulated transfusion. due to the dilution effect, glucose and lactate concentrations were slightly lower after simulated transfusion. conclusion: warming and simulated transfusion of pcs under high pressure via a bone needle has no negative effect on the in vitro quality parameters of platelets. transfusion of warmed pcs via an intraosseous entrance via a bone needle is not expected to have a negative effect on the in vivo functionality of platelets. it is recommended to study the in vivo effects in a limited clinical study. alesia kaplan* , , joan sevcik and joseph e. kiss , . university of pittsburgh, blood systems inc. background/case studies: low titer a plasma has been safely used as a substitute for ab plasma in trauma patients. low inventories of ab plasma can cause a delay in life saving therapeutic plasma exchange (tpe) procedures in ab patients needing plasma replacement. here, ab non-bleeding patients are presented who safely received ab and low titer a plasma for tpe. one ab patient who received ab plasma only was used as control to compare hemolysis laboratory data over tpe course. study design/method: a retrospective review of tpe procedures for patients was conducted from medical records. number of procedures, volume replaced, total number of plasma units, number of a plasma units, quantity of a plasma and hemolysis laboratory data were recorded. average quantity (ml) for a plasma and % of a plasma out of total volume of plasma used were calculated. all a plasma units were low anti-b titer units. in the laboratory, plasma dilution : is prepared and tested with reagent b cells. if agglutination is not observed, the unit is labeled as "low titer anti-b". hemolysis laboratory data was traced with linear graphs and trends were compared between patient and and (control). results/finding: all patients were ab blood type. patient , a year old female with recurrent adamts deficient ttp, received courses of tpe (total tpe procedures) for relapse and exacerbation. ten out of procedures were performed with ab and a plasma (average ml of a plasma or % of total plasma volume for tpe procedures). patient , a year old female with thrombocytopenia, schistocytes and presumed ttp, received a total of tpe procedures. four out of procedures were performed with ab and a plasma (average . ml of a plasma or % of total plasma volume for tpe procedures). patient , a year old female with adamts deficient ttp who served as a control, received a total of procedures with ab plasma only. haptoglobin, ldh, hemoglobin and total bilirubin were graphed and compared between patients. the trends of hemolysis laboratory data for patient and were comparable with patient . all patients had negative dat. only patient received rbc transfusions. all patients had a favorable clinical outcome with tpe treatments and adequate platelet recovery. conclusion: in this study, tpe was effectively performed without evidence of increased hemolysis using up to % of low titer a plasma. this approach can reduce strains on limited supplies of ab plasma while providing a vital treatment alternative for ab patients undergoing tpe who require plasma replacement. when cd negative platelet unit is not available for a patient with anti-cd antibodies sameer khatri* , charles harmon , brian r curtis and chisa yamada . background/case studies: refractoriness to platelet (plt) transfusion can be caused by antibodies (abs) against human leukocyte antigen (hla) class i antigens (ags) or less frequently against plt specific ags (psas). glycoprotein iv (cd ) is one of the identified plt surface ags and deficiency is rare, but found in asians ( - %), sub-saharan africans ( - %) and also in some people from mediterranean descent. two types of cd deficiency have been described. type deficiency is the complete lack of cd on both plts and monocyte-macrophages whereas type deficiency lacks cd on plts with variable expression ( - %) on monocytemacrophages. transfusing plts in a patient with cd deficiency is challenging given the rarity of cd negative phenotype and risk of further immunization when giving ag non-matched platelets. study design/method: a patient with cd negative phenotype who received multiple plt units was reviewed in the electronic medical record. results/finding: a year old man developed aplastic anemia following liver injury possibly due to a supplement for body building and required multiple plt and rbc transfusions. he received more than units of apheresis plt units over a week period without any significant increase in plt count. cross-match compatible plt unit found in of units and hla matched units were tried without success. at that point, a cd ab was identified in the serum and the patient's type cd deficiency was confirmed by flow cytometry. his hla class i panel reactive ab (pra) was % due to multiple plt transfusions, although all abs were low levels. the patient initially received high-dose prednisone and thymocyte immune globulin infusions without significant improvement in plt increase. following three doses of ivig, he received a cd- negative (but blood type different and hla a transfusion vol. supplement s unmatched) plt unit from his relative with only a slight increase in plt count. however, he started to respond to cd non-tested apheresis plts after receiving a fourth ivig and two rituximab infusions. since then, he has received ivig every weeks. other medications include filgrastim, eltrombopag, and cyclosporine for treatment of aplastic anemia. the mean corrected count increments (cci) when post-transfusion plt count was available are shown in table. with desensitization therapy, his cd antibody positive reactivity in serial dilutions has reduced from : to : dilutions and his hla class i pra has decreased to %. he is currently receiving apheresis plt units twice a week and rbc units periodically. his bone marrow (bm) has been slowly recovering evidenced by increased wbc count from zero to up to . k/ml and slow increase of reticulocyte counts. current plan is rbc/plt transfusion support until bm recovers or a haplo-identical transplant if bm recovery fails. conclusion: we report a case with anti-cd abs that received multiple plt transfusions. this case demonstrates that decreasing ab level with immunomodulation can be an alternative option for successful plt transfusion when compatible plts are not available for patients with rare or multiple abs to plts. table: mean available cci for plt transfusions a blood center's experience screening donations for babesia microti using enzyme-linked immunoassay methodology nancy van buren*, jed gorlin, vanessa reynolds and deborah anderson. background/case studies: our blood center, located in an area considered to be moderately endemic for babesia microti, implemented universal screening of red cell collections from minnesota and wisconsin under an investigation new drug (ind) study in oct utilizing the immunetics investigational enzyme-linked immunoassay (elisa) performed by creative testing solutions (cts). this test was selected as the most cost-effective approach for universal screening of blood donors, as opposed to the investigational ifa/pcr test combination. study design/methods: we performed a retrospective analysis of our screening test results and deferral rates for to evaluate for seasonality, donor abo bias, deferral rates, and outcomes of lookback investigations. since an opt-out of this research test was originally offered, we report donor opt-out rates. results/findings: from jan through dec , , blood donations were screened for b microti by immunetics elisa. of those, ( . %) were positive. the percent of positive donations was evaluated monthly revealing a variable reaction rate between . % and . %. no patient babesia transmission has been reported since implementing this test, but we only had documented babesia ttd cases from - . donors who previously tested negative demonstrated an increased seroconversion rate during the summer months, consistent with historical seasonal variation corresponding with tick season in minnesota and wisconsin. test performance characteristics were analyzed by abo group with no demonstrable differences in positive rates. the opt-out rate of donors who chose not to be tested significantly decreased over time, reflecting an increased acceptance of this test. of positive test results, lookback investigations were initiated representing % of positive donations. lookbacks were only performed when there was a donation within months of the new positive screening test, according to ind protocol. no confirmatory testing was performed per ind protocol or for donor counseling, so the true positive rate is unknown. in the prior ind trial, up to % were unlikely to transmit infection in our region, i.e. were pcr and blood smear negative. although a small number of antibody positive, pcr negative donors may be actively infected, no transfusion-transmitted babesia infections were identified by lookback investigations. notification of blood donors with positive screening results was also performed and information provided for healthcare provider followup. overall, donor deferral represented . % loss of eligible donors during this follow-up period. deferred donors were invited to participate in other research collections not requiring volunteer donor eligibility. conclusion: testing for b microti may help improve blood safety, particularly in endemic regions. although only . % of donors have a positive reaction, this represents a significant loss of eligible donors over time, most of whom are unlikely to transmit infection. a direct test capable of detecting babesia in individuals with very low levels of organisms without the need for concurrent antibody testing would be ideal. a reinstatement protocol for donors who test positive should also be considered. nonetheless, the current method of screening is inexpensive compared to pcr-based methods. background/case studies: human anelloviruses are the smallest in particle size, smallest in genome size, and least complex in genetic organization of all human pathogens. they establish a chronic persistent infection in infancy or early childhood and produce a constantly detectable load in plasma thereafter. some studies suggest they are ubiquitous, present in > % of the human population, and that immune surveillance is required to control the level of the virus load. study design/methods: we have developed a quantitative dna pcr assay for the most conserved region of the anellovirus genome that detects all known genotypes of the virus. we used this assay to examine viral loads in the plasma of us blood donors and transplant recipients pre-transplant and three months post-transplant. results/findings: for blood donors, were positive with an average load of . x copies/ml of plasma, a median value of . copies/ml of plasma, ranging from to . x copies/ml. pre-transplant viral loads were similar. for transplant candidates, were positive with an average of . x copies/ml of plasma, a median value of copies/ml of plasma, ranging from to . x copies/ml. post-transplant viral loads were remarkably different. for transplant recipients, all were positive with an average of . x copies/ml of plasma, a median value of . x copies/ml of plasma, ranging from to . x copies/ml. conclusion: these results validate the pcr assay that was developed and confirm that detectable viral loads of around - copies were present in > % of the blood donors surveyed. in addition, the effect of post-transplant immunosuppressive therapy has caused an increase in the viral load of at least orders of magnitude above that of non-immunosuppressed individuals. background/case studies: the screening of blood donors and travelers returning from endemic/epidemic areas has highlighted the importance of multiplex diagnostic approaches for the simultaneous analysis of various pathogens. furthermore, in the context of similar clinical signs, the differential diagnosis of arboviruses during acute infection is essential to discriminate the causative agent for patient management and epidemiological surveillance. the development of a flexible diagnostic approach is a key challenge to face the continuing emergence of arboviruses, belonging to flavivirus and alphavirus, such as dengue virus (denv), west nile virus (wnv), zika virus (zikv), yellow fever virus (yfv), usutu virus (usuv) and chikungunya virus (chikv). study design/method: an innovative diagnostic approach combining generic rt-pcr amplification and identification on low cost microarrays has been developed. we have patented original polythiolated probes grafted on maleimide-activated microplates for the robust, sensitive and specific mean cci pre-ivig: all plt ( ) . post-ivig: all plt ( ) . post-ivig: cd -negative plt from relative ( ) . post-ivig: single donor apheresis ( ) . post-ivig: cross-match compatible ( ) . post-ivig: flow cross-match compatible plt ( ) . a transfusion vol. supplement s detection of the viral genomes. analytical performances of the test were evaluated on viral standards and on clinical samples: denv ( / / / ), wnv, zikv and chikv. forty human plasmas from blood donors with no history of contact with arboviruses were used as negative controls. we have designed two sets of degenerated primers for the generic rt-pcr amplification of all flaviviruses and for chikv. biotinylated amplicons were captured on complementary grafted polythiolated probes on microplate. after addition of streptavidin-europium label, the molecular hybridization events were detected by time-resolved fluorescence using a microplate reader. results/finding: one original generic probe for denv and specific probes designed for each of the four denv serotype, wnv, the two zikv lineages and for chikv, were validated. the use of our methodology combining the amplification of the viral genomes and their identification using polythiolated probes shows % of specificity, with no false positive results on the control samples, and no cross reactions. using viral reference standards, we have observed sensitivities of tcid /ml for denv- , denv- and chikv and of tcid /ml for denv- , denv- and zikv. finally, the first results obtained on denv( ), zikv( ) and chikv( ) clinical samples show %, % and % correlation respectively between our approach and commercial or in house real time rt-pcr methods. conclusion: this innovative strategy allows the development of flexible, highly sensitive and easy to handle platforms dedicated to the multiplex screening and identification of emerging viruses. this methodology is adapted for the easy inclusion of additional molecular targets to improve the surveillance and the prevention of arboviral infections. babesia microti serological testing with pooled samples: a feasibility study laura tonnetti*, aaron thorp, letitia dixon and susan l stramer. background/case studies: blood donation screening for babesia microti, a tick-borne intraerythrocytic parasite endemic in the northeast and upper midwest us, is performed under an investigational study using nucleic acid and immunofluorescence assays (ifa). however, ifa is a time consuming and labor intensive procedure. with the possibility of an fda licensed screening assay(s) in the near future, we investigated if b. microti testing by ifa in pools of plasma or serum could be a feasible screening approach. study design/method: to test if the increased amount of plasma or serum interferes with background fluorescence, pools of , , and were prepared from plasma or serum samples determined to b. microti-negative by individual ifa screening. the pools were tested by ifa with or without a blocking step using bovine serum albumin (bsa) and goat serum to minimize background fluorescence. potential interference from multiple pooled plasma or serum samples on the endpoint titer of positive samples was investigated by including positive samples with endpoint titers from : to : ( -fold dilutions) in the pools. results/finding: non-specific fluorescence was visible in pools of or higher and was not eliminated by the addition of a blocking step. pools of or samples did not show significant increased background. there was no difference between testing of pooled serum or plasma samples. when one single positive sample was included in the pools of or samples, the pool tested positive and the final titer was the same as the positive sample tested individually. when two or more positive samples were included in the pools, the final titer of the pools was equal to the sample with the highest titer. conclusion: this study represents a proof of concept that serological testing for b. microti by ifa in pools of up to plasma or serum samples does not increase false positivity while maintaining the sensitivity of the test. background/case studies: the rapid detection of bacterial contamination in platelets is key to reducing the risk of infection in transfusion of blood components. the bact/alert virtuo* is an advanced, next generation system with improved automation, connectivity and with data management systems. the virtuo's new algorithm significantly reduces the time to detection (ttd) of microorganisms during quality control testing of platelet preparations using bact/alert (bta) bpa (aerobic) and bpn (anaerobic) bottles. as plasma is known to be bactericidal, a study was completed to evaluate plasma susceptibility/resistance for organisms considered for virtuo studies. study design/method: human plasma (thawed and pooled) and saline controls were seeded with $ cfu/ml of organisms associated with platelet contamination and incubated at room temperature for - hours. colony counts were performed initially and after incubation. plasma resistance was determined if the colony count of the seeded plasma was equivalent or higher ( log) than the colony count of the seeded saline after incubation. results/finding: the serially diluted strains and all bioball tm strains except p. aeruginosa, nctc , were determined to be plasma resistant. the bioball tm p. aeruginosa was susceptible to the antimicrobial effects of human plasma, but when spiked into ml of leukocyte reduced apheresis platelets (lrap) and inoculated into bta bpa bottles and loaded into the bta d and virtuo the organism was recovered % . conclusion: results confirm that previously tested organisms and additional strains are plasma resistant with the exception of p. aeruginosa, nctc . however, the bpa bottles still recover p. aeruginosa in the presence of lrap. bpa/bpn bottles inoculated with select organisms from this panel in the presence of ml lrap demonstrated % recovery when loaded onto the virtuo and d ( table ) . further studies may be required to determine if higher test volumes of lrap could affect the recovery of plasma sensitive strains. * virtuo is not fda cleared for platelet testing a. notoscriptus, identified as a major urban vector of rrv, is also capable of transmitting dengue virus - , and has recently been found in los angeles, illustrating an expansion in range. with the growing geographical distribution of aedes species mosquitoes, the potential for rrv to enter local transmission cycles outside of australia is significant. in , a probable transfusiontransmission (tt) was confirmed as the cause for an rrv infection in australia, validating the reality that rrv tt can occur. rrv morbidity leads to clinical manifestations that are similar to chikv infection, with varying degrees of arthralgia, which can become debilitating. various asymptomatic to symptomatic infection ratios have been reported, but this further increases the risk of additional tt in endemic areas and could mask the spread of the disease globally. study design/method: platelet concentrates (pc) prepared in pas were inoculated with rrv, amotosalen was added to final concentration of mm and the units were treated with uva light. pre-and post-treatment illumination samples were collected for titration. as- rbc units were contaminated with rrv, mixed with processing solution/glutathione (gsh) and treated with amustaline at a final mm concentration. pre-and post-treatment samples were removed prior to amustaline treatment and hrs after amustaline addition, respectively, for titration by plaque assay on vero cells. log reduction was calculated as the difference between the mean infectious titer in pre-vs. post-treatment samples. results/finding: inactivation of rrv was achieved to the limit of detection in pc and rbc. in pc, > . log or log /ml of rrv was achieved, with > . log or > . log /ml of rrv inactivated in rbc. conclusion: these studies illustrate that amotosalen/uva and amustaline/ gsh treatments are effective at inactivating rrv in pc and rbc, respectively. these data corroborate previous results achieved with other alphaviruses, including chikv and mayaro virus which are inactivated at high titers in pc and rbc, demonstrating the ability for these systems to mitigate tt potential and maintain safe blood component availability in endemic areas. (data have not been submitted for fda review and intercept for red blood cell is not approved for commercial use). background/case studies: the interceptv r blood system for platelets is designed to inactivate pathogens and contaminating leukocytes. this photochemical treatment process utilizes amotosalen and low energy ultraviolet a (uva) light. the current available sets include small volume (sv; - ml), large volume (lv; - ml) and dual storage containers (ds; - ml) designed to treat platelet doses between . and . x . the new triple storage (ts) set was designed to expand the dose range to . x and the maximum volume to ml, generating either or doses of pathogen reduced platelet components (pc). the objective of this study was to evaluate the effectiveness of the system by performing log reduction assays using representative gram positive and negative bacteria and enveloped and non-enveloped viruses in platelets suspended in pas, or % plasma using ts set. study design/methods: for each experiment, a platelet pool was prepared either in % plasma/ % pas or % plasma with a final volume of $ ml and a dose of - platelets. these conditions represent inactivation using the lowest amotosalen concentration ( mm) and highest concentration of platelets. platelet units were inoculated with high titers of viruses, or bacteria and treated. control (pre-uva) and test (post-uva) samples were serially diluted and cultured. plates with suitable media were used for bacteria, whereas viral titers were determined using plaque assays. log reduction was calculated as the difference between the log titers in control (pre-uva) and test (post-uva) samples. conclusion dromedary camels were identified to be the reservoir of mers cov, transmission to humans occurs through direct and indirect contact. mers cov has been detected with high genomic titers of - logs in respiratory secretions of mers patients, and with lower genomic titers of - logs in blood. the presence viral particles in the blood of acute patients gives rise to concerns, especially in endemic areas. the high mortality rate, especially for critically ill patients, which often require blood transfusion, raises the need for a method to safely exclude mers cov contamination of blood products. pathogen reduction with amotosalen/uva technology is a widely established technology with a broad range of data supporting clinical efficacy and safety of amotosalen/uva treated blood products. the aim of the study is the assessment of the mers cov inactivation efficacy in human plasma with amotosalen/uva pathogen inactivation technology to safely exclude the presence of infectious virus in human plasma units. pre-uva titer post-uva titer log reduction/ml (log /ml) %plasma/ % pas e .coli . <- . > . e. cloacae . <- . > . k. pneumoniae . < . > . s. aureus . <- . > . blue tongue virus . <- . > . bovine viral diarrhea virus . <- . > . adenovirus- . <- . > . %plasma k. pneumoniae . - . > . s. aureus . <- . > . adenovirus- . <- . > . n a transfusion vol. supplement s abstract study design/method: four therapeutic human plasma units were spiked with a fully characterized mers cov clinical isolate followed by pathogen inactivation with amotosalen/uva (intercept blood system, cerus corporation) at four different days. pathogen reduced samples were taken preand post-pathogen reduction after various processing steps to assess the infectious titer by plaque assay titration and the genomic titer by real-time-pcr. samples post pathogen reduction have been passaged times up to days, assessing the infectious titer and genomic titer every rd day to exclude the presence of low-titer infectious particles. results/finding: all viral particles in the plasma units were completely inactivated with an average efficacy of ! . log infectious titer. no viral replication was observed after days of passaging post inactivation. the genomic titer was only slightly affected by pathogen inactivation, which is designed to target the infectious titer, but not the physical titer. conclusion: amotosalen alone had a slight effect on the infectious titer while amotosalen/uva effectively inactivated all infectious mers cov viral particles in the plasma units with an inactivation efficacy above logs infectious titer, giving evidence for improved blood safety of amotosalen/uva treated plasma in mers cov endemic regions. estimating the prevalence and incidence in a national blood service in taiwan for hcv eradication program yun-yuan chen* , jen-wei chen , chi-ling chen , sheng-nan lu and pei-jer chen . department of research, head office, taiwan blood services foundation, graduate institute of clinical medicine, college of medicine, national taiwan university, division of hepatogastroenterology, department of internal medicine, kaohsiung chang gung memorial hospital background/case studies: world health organization (who) has set a goal to eliminate hcv by , and the epidemiological indicators generated from a national blood service is useful to monitor the effectiveness. this study aimed to evaluate the prevalence and incidence of hcv infection in taiwan. study design/method: in taiwan, anti-hcv (since ) and -sample mini-pools triplex nucleic acid test of hcv, hbv and hiv (since ) have been used in the routine blood screening. prevalence of anti-hcv and hcv rna were estimated in the first-time donors during - and - , respectively. age-standardized prevalence and its % confidence interval ( % ci) were calculated with adjustment of who world standard population - . for the incidence study, donors who have donated blood two or more times during - and who were without a history of anti-hcv positive before the follow-up period were included. the incidence and its % confidence interval was estimated from the number of new hcv rna positive cases divided by the person-years of follow-up. results/finding: the crude prevalence of anti-hcv in the first-time donors was dramatically decreased from . per , donors ( % ci: . - . ) to . per , ( % ci: . - . ) during - , and the agestandardized prevalence was also decreased from . per , donors ( % ci: . - . ) to . per , ( % ci: . - . ). the agestandardized prevalence of anti-hcv was generally higher in female donors before , but it was significantly higher in male donors at (p-value . ). a total of , hcv rna positive cases, . % of them were anti-hcv negative, identified from , first-time donors during - , and the crude and age-standardized prevalence of hcv rna was . per , ( % ci: . - . ) and . per , ( % ci: . - . ), respectively. crude prevalence of hcv rna was significantly higher in female donors (p value < . ), but no significant difference was found after age standardization (p value . ). both the prevalence of anti-hcv and hcv rna were increased with age (p for trend< . ). in the incidence study, a total of new hcv rna positive cases, . % of them were anti-hcv negative, found from , , donors followed for , , person-years. the incidence of hcv rna was . per , person-years ( % ci: . - . ), and no significant difference was observed between both genders (p-value . ) and between age groups (p for trend . ). conclusion: the prevalence of hcv infection has been dramatically decreased by . % during - . it becomes significantly higher in male donors and that needs to monitor in the future. incidence of hcv rna is low in repeat blood donors and it needs to identify more incident cases to observe the epidemiological characteristics. dalia ashour* , sahar muhmmad and dalia el dewi . national blood transfusion services, azhar university background/case studies: blood safety is a challenge in egypt because of the high prevalence of hcv and hbv. nucleic acid amplification test (nat) technologies have the potential to detect viremia earlier than current screening methods, which are based on seroconversion. the primary benefit of nat is the ability to reduce residual risk of infectious wp donations. the estimated reduction of the wp utilizing nat for hcv is - days, hiv from to days, and hbv from - days. study design/method: this cross sectional study was conducted in national blood transfusion center (giza, egypt) from to , the total number of donor samples to be screened is , the age of the donors ranged from to years, and they were of both sexes (m: f : ).screening by nat ulterio assay (grifols diagnostics; formerly novartis diagnostics) was done in parallel with eia testing for hbsag, hcv-ab and hiv ag/ ab. using individual donation nat (id-nat). multiplex nat yield samples are further tested using the discriminatory assay in order to ascertain which viral nucleic acid is present in the donor sample. statistical analysis chi-square (v ) test was used to measure the association between two qualitative variables. results/finding: nat screening detected a total of nat yield donations among ( . %) seronegative donors. among these nat yields cases, ( . %) were reactive for hbv, ( . %) were reactive for hcv and ( . %) were reactive for hiv- . we stratified the age of the donors into groups; group a ( - years), group b ( - years) and group c ( - years). the prevalence of nat yield to the three viruses was significantly higher in either group b or c, compared to group a (p . ; with % confidence interval (ci) . - . & p . ; with % ci . - . respectively). prevalence of nat-hbv; was significantly higher in age group b, as compared with group a (p . ; with % ci . - . ). on the other hand, there was no statistically significant difference between groups c and a and between groups b and c. comparing groups b and c combined with group a found a significantly higher prevalence of hbv in the former (p . ; with % ci . - . ). nat-hcv; did not differ significantly between the three groups (p . ; with % ci - . to . between groups a and b & p . ; with % ci - . to . between groups a and c & p . ; with % ci - . to . between groups b and c). nat-hiv; did not also differ significantly between the three groups (p . ; with % ci - . to . between groups a and b & p . ; with % ci - . to . between groups b and c). in either group a and c, no nat-hiv detected. nat yield to the three viruses was significantly higher in males than in females (p . ; with % ci . to . ). nat hbv was significantly higher in males (p . ; with % ci . - . ), but the prevalence of either hcv or hiv did not differ significantly between males and females (p . ; with % ci - . - . & p . ; with % ci - . - . ; respectively). conclusion: in this study the nat yield of in assumes more significance when one considers the fact that single donation is used for generating components that can be used by recipients. hence, in effect the nat yield becomes times that is, in . saving recipients from tti out of ( . %) is indeed very significant. results/finding: of the , donors who were tested by our donor center, , ( . %) were repeat reactive. a seasonal pattern in the prevalence was observed with the highest number of donors being positive in summer, and then progressively declining during the fall and winter months and increasing again in spring. there was a single case of transfusion transmitted babesiosis reported from our center during this period. a patient who was transfused with two units of packed red blood cells (rbcs) from two donors in the beginning of july presented in august for further transfusion and was found to have parasitemia in the peripheral blood smear and was subsequently diagnosed with babesiosis. the donors were called back, however one of them could not be tracked. samples were sent to the state for further testing: an immunofluoresence assay was performed (combination of igg, igm and iga). the test was positive at : titer. the screening elia s/co of this donor was . . both donors were indefinitely deferred as blood donors. conclusion: our data confirm a decreased risk in transfusion transmission with the use of a screening assay. prior to implementation of the screening there were - transfusion transmitted babesia cases per year from - (table ). in the months after implementation of pre-transfusion babesia screening, one break through case of transfusion transmitted babesia was observed ( in , donors tested). thus the babesia eia screening test effectively prevents ttb. however, there was a substantial loss of donors due to being screen positive. four years of experience with id-nat at a tertiary care centre in north india: implications for transfusion transmission and donor screening. jasmeet singh*, amarjit kaur, gurpreet kaur, rajesh kumar and sonia gupta. dayanand medical college and hospital background/case studies: transfusion transmitted diseases are a challenge for transfusion medicine specialists and patient care providers around the globe. blood safety is a formidable task especially in a high population country like india. newer technologies like id-nat equip us to screen and prevent transfusion transmitted viral infections and prevent their transmission by improving over the sensitivity and specificity of conventional methods. this study aims at examining the effect of id-nat as an additional test on the safety of blood supply. study design/method: a retrospective observational study was conducted to analyze the data of years of additional nat testing at blood bank, dmch, ludhiana from september to december . results/finding: results . % ( of ) units were initially nat reactive. these units were further tested, of which . % were discriminated ( hiv, hcv, hbv and co-infections). the remaining . % ( ) were repeat non-reactive and . % ( ) could not be discriminated. overall, nat yield rate was one in , whereas virus-specific nat yield rates were one in , for hiv, one in for hcv, one in for hbv and one in , for hbv/hcv coinfections, respectively. conclusion: id-nat screening of all blood donations at our institution over past years has increased the screening sensitivities to check viral load and prevented transmission of probable transfusion transmitted viral infections. assuming % component preparation it saved transfusion recipients from harm. implementation of nat along with routine serological tests for screening of the blood donations definitely improves the transfusion safety and should be mandated across all transfusion centers. min xu , , wei mao , tao he , yashan yang , , zhan gao , , chunhong zhang , hongmei liao , jingxing wang , and miao he* , . institute of blood transfusion, chinese academy of medical sciences & peking union medical college, sichuan blood safety and blood substitute international science and technology cooperation base, chongqing blood center background/case studies: many emerging infectious pathogens are known to be existed in heathy blood donations, and could be transmitted via transfusion with potential hazardous consequences against recipients. with more convenient application of high through put sequencing, it becomes much easier to investigate uncultured microbiome in qualified blood donations. therefore, metagenomics analyses were used to reveal emerging and re-emerging infectious diseases in healthy donations which might potentially threat the blood safety. study design/method: pooled plasma sample were collected from , voluntary blood donors from chongqing, china. total dna and rna were extracted and amplified with random primers pcr respectively in order to construct a pe library to peform deep sequencing by illumina miseq. all reads were trimmed to remove low quality bases and adapter sequences. the fully overlapping paired-end reads passing the quality filter were concatenated using pear. we classified the final reads using kraken and a kraken database made from complete refseq bacterial, archaeal and viral genomes, along with the grch human genome. the unclassified reads by kraken were aligned to ncbi nt database using blastn with cut-off evalue as e - . the best alignment hits were used to classify the reads. krona was used to generate all taxonomic distribution plots. finally, the potential emerging and re-emerging infectious pathogens were identified out of the classified microbiome by experience. abstract results/finding: . gb raw data with , , reads were generated in the dna library. meanwhile, . gb raw data with , , reads were generated in the rna library. after cleaning the human background, reads from bacteria, reads from viruses, and reads from parasites were identified (table ) . no hazardous viruses were identified as potential threats to blood safety. except for viruses and bacterias which would do limited hazards to blood safety, plenty of parasites were identified in which some were already considered as threats to blood safety in some developed countries were also discovered such as plasmodium sp. and leishmania infantum (table ) . conclusion: the investigation has revealed the metagenomics of the qualified blood donations in chongqing, china. the results showed a thoughprovoking discovery of genomic fragments of some microbes which might threat the blood safety. the displayed serious results let us have to think about regulating some reasonable screening methods as well as donor recruitment strategy in certain epidemic areas or seasons to ensure the blood safety. however, on the contrary, the results should be considered more cautiously because the existing of genomic fragments could not represent the existing of infectious pathogens. the validity of the metagenomics hints were suggested to go through epidemiological investigations and specifically tested under laboratory ways such as bacteria or virus culturing to ensure the vitality of those pathogens. background/case studies: the caribbean has become an endemic region for several emerging viruses in the last decade. after a chikungunya outbreak in most recently zika was shown to be endemic on the caribbean island of curacao. to effectively provide safe blood products in an endemic region the conventional international recommendations of donor exclusion and testing do not seem a viable option and could severely affect the local blood supply. pathogen reduction (pr) is considered an important new approach with potential benefits. the introduction and experience of use of pr platelets in the dutch caribbean over a period of one year is presented. study design/method: pathogen reduction of thrombocyte concentrates by use of riboflavin and ultraviolet treatment (mirasol prt, terumo, belgium) was introduced. all thrombocyte concentrates provided to the general hospitals on the dutch caribbean islands of curaçao, bonaire and sint maarten were pr and data collected over the period of february to february . thrombocyte concentrates are prepared out of single donation units by the buffycoat method. results/finding: over the period platelet concentrates were provided to adult and pediatric patients. these included patients on the intensive care and neonatal intensive care departments. no adverse events were reported and the cci for each transfusion was within the expected outcome. introduction of pr had minimal impact on the logistics of thrombocyte concentrate preparation and availability. furthermore no transfusion related bacterial contaminations were reported. conclusion: pr of platelet concentrates seems viable and safe for use in a small scale caribbean setting with endemicity for emerging viruses like chikungunya and zika. it offers a realistic alternative for conventional recommendations of donor exclusion and testing, thereby helping to maintain sufficient labile blood product availability. michael phillips* , germ an leparc , phillip c williamson , lani palmer , ben reynolds , maria noedel and lindsey houghton . creative testing solutions, oneblood background/case studies: due to the risk of travel and sexually transmitted zika infections, the food and drug administration issued a guidance document on february , recommending that blood centers in puerto rico cease distribution of locally collected blood products unless donors are tested or products are pathogen reduced by march , . with the high incidence of zika virus (zikv) in puerto rico and uncertainty of the impact to the continental u.s. blood supply, there was intense pressure to implement a donor screening test for zikv. the project was initiated on february , and included clinical trial requirements, client onboarding and laboratory operations. stakeholders consisted of clients, the manufacturer, institutional review boards (irb), informational technology (client and lab based), the food and drug administration (fda), the centers for disease control cdc, and the florida department of health. clinical trial requirements included development of instrument and assay validations, sop creation, result reporting, assay and clinical trial training, deviation management, donor notification, and follow up sample handling. client onboarding began with confidentiality agreements between the client and the sponsor. a zika based webinar was created to provide an overview of the sponsor protocol, lab test system and client responsibilities. the complexity of the project increased when mosquito borne zika transmission was identified in two counties in florida. this required zikv testing to be performed on collections in both florida and puerto rico. the zikv-nat is performed in singlet, unlike the mpx and wnv assays which are run in minipools. this had a significant impact on instrument capacity. despite these obstacles and the changing regulatory requirements, the zikv screening test was implemented within six weeks. study design/method: one metric used to measure client service levels is our ability to meet established upload time goals for individual clients. the percentage of samples released on time is evaluated daily with a running monthly total. our upload time goals were negatively impacted from july through september due to the unexpected increase in zikv testing, the requirement to perform testing in singlets and the resulting instrument capacity issues. additional instruments were sourced in october and operations stabilized. conclusion: on february , , the project to implement a zikv ind test was initiated. six weeks later, testing was performed on the first batch of samples. despite the changing regulatory requirements over time, the implementation was extremely successful. initiating a new ind testing within weeks is unprecedented and required exceptional collaboration between all participants and stakeholders. background/case studies: plasmodium falciparum (pf), an intraerythrocytic protozoan parasite, is accountable for nearly all malaria mortality in africa. in , who reported $ million new cases worldwide, resulting in > , deaths. malaria prevalence is highest in sub-saharan africa, home to % of all infections accounting for % of mortalities. both the incidence and prevalence of malaria in africa significantly increase the potential for transfusion-transmission (tt), with little to no screening of products in developing countries. the objective of this study was to evaluate the inactivation of pf in whole blood (wb) using a system specifically developed for the realities of the developing world and in support of the swiss red cross humanitarian foundation for whole blood pathogen inactivation for africa. the inability to consistently supply blood components leads to routine wb transfusion, and as transfusion-transmitted diseases are prevalent in the developing world, the establishment of a robust wb pathogen inactivation system is desirable. the approach uses the small molecule amustaline to form covalent adducts and crosslinks within nucleic acids of leukocytes and contaminating pathogens to prevent replication. the process includes addition of . mm amustaline and mm glutathione (gsh) and a h at room temperature (rt) incubation after which the treated wb unit is suitable for storage up to days at rt. study design/method: for each experiment, a wb unit was spiked with ring-stage pf-infected red blood cells (irbc). a pre-treatment sample was removed prior to addition of amustaline and a post-treatment sample was removed h after amustaline addition to determine the pre-and posttreatment titers to calculate the level of inactivation. these samples were serially diluted in flasks containing medium with % fresh rbcs. the diluted samples were used to inoculate flasks in quadruplicate and monitored for parasitemia by counting irbc in blood smears and by flow cytometry. pretreatment cultures were terminated after reaching > % parasitemia, while no residual pf was detected in post-treatment cultures. log reduction was calculated as the difference between the mean titer in pre-and posttreatment samples. results/finding: robust inactivation of pf in wb was achieved to the limit of detection, at > . log or > . log /ml. conclusion: pf was inactivated to the limit of detection in wb after treatment with amustaline/gsh, illustrating that the system has potential to mitigate the risk for pf transfusion transmission in endemic regions that lack testing capacity and operate under the constraint of a very limited blood component supply and rely on wb transfusion. (this system for wb is not approved for commercial use). increased patient safety and improved inventory management with day apheresis platelets nancy m. dunbar* and zbigniew m. szczepiorkowski. background/case studies: a pathway currently exists for apheresis platelet (ap) outdate extension from to days using an fda cleared rapid test (rt). in february , our hospital based transfusion service implemented the use of rt on day , and to routinely extend ap shelf life to days. prior to this, we tested aps by rt on day and transfused day or day units with physician approval when deemed medically necessary. this report describes changes observed in transfusion practice and platelet inventory management one year following routine use of day platelets. study design/methods: data were obtained for two -month study periods: october -september (pre-implementation) and february -january (post-implementation). the interval transition period was intentionally excluded. for each study period, we determined the total number of aps transfused, rt status on the day of transfusion, total number of rts performed, expired ap units, and aps obtained from suppliers using ad-hoc ordering. we also obtained hospital data including inpatient admissions, surgical volumes, average length of stay and case mix index. results/findings: data are shown in table . the number of ap transfusions increased by % post-implementation, comparable to a % increase in inpatient admissions and an % increase in surgical volumes. the hospital length of stay and case mix index were similar for both periods. the average number of platelet transfusions per patient was not statistically different ( . pre; . post, p . ). the number of rts performed increased by %. the percentage of transfused units tested at least once by rt prior to transfusion increased by % (p< . ). the outdate rate decreased from % to % (p< . ). ad-hoc ordering decreased from % to % (p< . ). conclusion: use of an approved rt for routine ap outdate extension to day was associated with increased patient safety as more transfused units underwent secondary testing prior to transfusion. increased cost of rt was offset by reduced ap waste and less frequent need for ad-hoc ordering. sheila o'brien* , vito scalia , carla osiowy , michael carpenter , anton andonov and margaret fearon . canadian blood services, public health agency of canada background/case studies: the rates of hepatitis b (hbv) and hepatitis c virus (hcv) positive donations are low ( . and . per , donations, respectively) and most are among first time donors. we aimed to determine the frequency of various genotypes of hbv and hcv in canadian blood donors confirmed positive for hbv and hcv. study design/methods: in the roche multiplex assay (hcv/hiv/ hbv) was implemented in minipools of units. hcv nat was in place since (using minipools of ) but this is the first time donors have been screened by hbv nat. hbsag, anti-hbc and anti-hcv were tested using the abbott prism assay. confirmatory testing for hbsag was by the prism neutralization assay. anti-hcv repeat reactivity was confirmed by the inno-lia hcv score line immunoassay. since march all samples testing hbv nat positive, or confirmed positive for hbsag and all hcv nat positive or anti-hcv confirmed positive samples were considered positive and samples were sent to phac for sequencing. a sample from each positive donation was aliquoted and frozen at - o c. genotyping was carried out by sequence and phylogenetic analysis of the hbv surface antigen coding region. hcv viral rna was extracted and subjected to reverse transcription and pcr amplification in the ' ntr-e and ns b regions. sanger sequencing of these regions represents approximately % of the genome. results/findings: all confirmed positive donations were whole blood donations. there were hbv positive donations. of these, had tested hbv nat positive. genotypes were type a, b, c, d and e. there were samples hbv nat negative but hbsag positive ( were anti-hbc reactive). of these, could not be sequenced and one was genotype a (also anti-hbc reactive). there were samples considered hcv positive. of these, samples were hcv nat positive. genotypes were type a, b, c, b and a. there were also samples hcv nat negative but anti-hcv positive. none of these could be sequenced. conclusion: the first months of molecular surveillance show a range of genotypes for hbv and hcv for samples identified as nat positive. to date no samples that were nat negative anti-hcv reactive could be sequenced, however one nat negative sample that was positive for hbsag and anti-hbc reactive was hbv genotype a. surveillance over a longer period is background/case studies: the bact/alert d microbial detection system (bta d) is currently fda cleared for the quality control testing of leukocyte reduced apheresis platelets (lraps). the bact/alert virtuo microbial detection system (virtuo) (biom erieux, st. louis, mo) is a new generation of bact/alert instrumentation. the underlying colorimetric technology used in previous generations of bact/alert is used in the vir-tuo and incorporates new instrument architecture to improve temperature stability, workflow improvement via automation of processes that are currently performed manually, an improved user interface and an enhanced algorithm to shorten time to detection. the objective of this study was to compare the performance of the virtuo and bact/alert d (bta d) instruments, using bact/alert bpa (aerobic) and bact/alert bpn (anaerobic) bottles, for the detection of a range of typical bacterial contaminants seeded into leukocyte reduced apheresis platelets (lraps).* study design/method: the study was performed at two institutions, one in the us and the other in the uk. aliquots of lraps were seeded with low levels ( - cfu/ml) of bacterial species commonly associated with platelet contamination, and replicates ( per instrument) of ml aliquots per bottle were inoculated into bpa and bpn bottles. one set of bottles was loaded into bta d and the other into virtuo and incubated until signaled positive by the instruments or for up to days. overall detection rates and time to detection of bacterial contaminants between instruments were compared. additionally bottles were tested in each instrument (lraps only, no organism) to evaluate differences in the overall negative agreement rates (detection of false positives) between instruments and to serve as sterility controls for the platelet preparations. background/case studies: the implementation of nucleic acid testing (nat) blood screening is still a challenge in resource-limited countries. at the same time, in these countries, higher to similar proportions of replacement to voluntary blood donors are recruited. a higher prevalence of infections is observed in relation to developed countries. as a consequence, more incident cases of infections can be expected. in our country, some hospital blood banks could not afford nat due to high costs, but belong to a net that centralizes nat in a reference blood center. the process to consolidate small blood banks in regional blood centers, which will be able to implement nat, is not yet complete. although efforts to reduce replacement /familiar blood donations are in progress, these goals have not been completely achieved. the aims were to compare the prevalence of hiv, hcv and hbv by nat screening in a blood center recruiting only voluntary blood donors with the prevalence in centers recruiting replacement and voluntary blood donors, and describe the nat yield rates for hiv, hcv and hbv in a period of three and a half year experience. study design/method: a regional blood donor center (rbdc) has centralized nat screening from centers in different regions of the country due to since august . this process required to achieve adequate laboratory conditions and staff qualification and a development of software to assure sample traceability and interface for transmission of results. when a window period was suspected, the nat screening was repeated from the plasma unit and a second sample of the blood donor was required to confirm nat results. this rbdc have also been developed a % voluntary donor program since and is the only center in the country that has achieved this goal. results/findings: a total of , blood donations were studied from august to december . in the rbdc, where only voluntary blood donations are recruited, the prevalence was per , donations for hiv (ic % - : , ); per , for hbv (ic % - : , ) and per , for hcv (ic % - : , ). in all other centers together, where voluntary and replacement blood donations are recruited, the prevalence was per , donations for hiv (ic % - : , ); per , for hbv (ic % - : , ) and per , for hcv (ic % - : , ). window period infections were detected only in centers recruiting voluntary and replacement blood donations, giving nat yield rates of : , for hbv; : , for hiv and : , for hcv. conclusion: the hiv, hbv and hcv prevalence was lower in a center where the tasks to sustain a voluntary blood donor program were developed. nat yield rates could be reduced in the region if this program could completely be applied in all centers. mechanisms leading to obi include various factors such as imperfect host's immune response and viral variation factors. this study was to determine the viral loads of obi under currently recruitment and screening among blood donors in five blood services of zhejiang province, china. study design/method: before donation, the donors were screened and precluded with hbsag preliminary test positive and alt level abnormal. following, the samples were detected for hbsag twice using different elisa reagents and hbv dna using tma or qt-pcr techniques. then, the samples with hbv dna positive and elisa negative were tested for the viral loads using taqman technique in cobas s system. hbv s region was also sequenced. results/finding: obi were found in the , donations. in the viral loads assay, samples were negative and samples' viral loads were lower iu/ml. the mean viral loads was . . (log ) iu/ml in other samples,while the mean viral loads with hbsag /hbv dna samples was . . (log ) iu/ml. samples of obis have analyzed the hbv genotype, which b was the most prevalent subtype ( . %) and the other was hbv c genotype( . %). compared the samples with hbsag /hbv dna ,we found two obi samples carrying with t>c mutation, which could cause an amino acid s f. conclusion: in this study, the viral loads of obi infection in donors was much low than hbsag /hbv dna , and some unique variation was identified in the obi individuals. a transfusion in general population. screening of blood donors for hbv in india is primarily based upon detection of hepatitis b surface antigen (hbsag) in donor's sera. the current study was undertaken to determine the prevalence of occult hbv infection (obi) in voluntary blood donors and to analyze the burden of hbv window period donations. study design/method: this is a prospective, observational, mono-centric study performed in a national accreditation board for hospitals (nabh) accredited apex blood bank, located in maharashtra state, india. monolisa hbsag ultra (bio-rad, france)sandwich type elisa using monoclonal and polyclonal antibodies was used for hbsag detection in donor's sera. all the elisa non-reactive samples were also tested by an additional real time multiplex polymerase chain reaction (mpx-pcr) by cobasv r taqscreen mpx test. the donors which were found to be positive for hbv dna were followed upat th days, month, months& months by monolisa hbsag ultra (bio-rad, france) to analyze interval of window period and to delineate the window period donations (wpd) & true obi. background/case studies: occult hepatitis b infection (obi) is characterized by hepatitis b virus (hbv) dna-positive, but hbv surface antigen (hbsag) -negative. since may , we have been testing apheresis donors for hbv nucleic acids and improvements in laboratory testing have reduced the risk of transfusion-transmitted infection. the number of apheresis collections increased significantly year by year, however, data on hepatitis b virus marker rates among these donors continue to be lacking. the aim of this study is to evaluate the epidemic characteristics, incidence and estimate the risk factors of obi among apheresis donors in a region of central china. study design/method: apheresis donors' data from may to dec was retrospectively analyzed. all samples were tested for hbsag, hbv dna, and other markers. nucleic acids testing (nat) was performed on the roche cobas s platform using pools of serologically negative samples and any pools positive would undergo nat again individually. hbsag negative, but hbv dna positive were further tested for hbv dna quantitative pcr, antibody to hepatitis b surface antigen (hbsab), antibody to hepatitis b core antigen (hbcab), hepatitis b e antigen (hbeag) and antibody to hepatitis b e (hbeab). results/finding: in the evaluation, seronegative donations were screened by nat and a total of hbv dna-reactive/hbsag-negative donors were detected. no hiv rna -reactive or hcv rna -reactive sample was detected. complete serologic screening of the index donations indicated that the majority of these donors had an occult hbv infection and the majority of which were married men and the fixed donors with many whole blood or apheresis donations. age distribution of the age group - years old showed a large proportion, who accounted for % of reported infections. most of the hbv dna cases (about . %) reached senior high school education. the average hbsag dna positive rate was . % ( / ). incidence among apheresis donors in this period for hbsag dna were . / . these estimates were comparable to those among repeat whole blood donors. we developed pathogen reduced (pr) cryo derived from ffp and pf with day stability at c. study design/method: six replicates of type-matched pools of whole blood derived (wbd) and apheresis (aph) plasma were split to produce conventional control ( ml) and test components ( ml ml). test components were pr with amotosalen and uva light. aph and wbd ffp were produced by freezing plasma within hr and wbd pf within hr. cryo was manufactured according to site sops and frozen at - c (test ml, control ml ). test and control cryos were thawed at c, and characterized immediately post thaw (t ), and after d storage at c and tested for fb and fviii function, thromboelastography (rotem) and thrombin generation (cat). results/finding: pr cryo retained sufficient fb and fviii activity post thaw and over d at c (table) for hemostatic capacity. rotem (extem) showed retention of fibrin formation (a angle) and clot quality (mcf) (table) . thrombin generation was robust as demonstrated by multiple parameters (lag time, peak thrombin, endogenous total thrombin potential (etp), and time to peak (tt) despite lower fviii levels. these parameters were maintained through d storage at c. conclusion: pr cryo can be processed from plasma sources, including pf , and stored at rt for days. pr plasma provides adequate levels of fb with hemostatic capacity equivalent to control as demonstrated by rotem and cat. use of pf with stability over days can increase the availability of cryo with a reduced risk of transfusion-transmitted infection. cryo produced with psoralen-treated (pr) plasma is not approved for use in the us. performance of a new automated alinity s assay for antibodies to t. cruzi darwin smith* , ed bakker , anton van weert , jane bryant , mark paradowski , lynne fleischmann , mirjana sarac , george chen , george schlauder and gregg williams . abbott diagnostics, sanquin diagnostics, abbott gmbh & co. kg background/case studies: the parasite, trypanosoma cruzi (t. cruzi), is the cause of chagas disease which is endemic to the americas and infects - million people. in order to prevent transfusion mediated transmission of this parasite in endemic countries, blood collection centers require high throughput anti-t. cruzi assays with good specificity and sensitivity. in nonendemic countries, selective testing of at risk donors is a strategy to avoid temporary donor deferrals. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. study design/method: the performance of the new automated chemiluminescence immunoassay for the detection of antibodies to t. cruzi was evaluated on the alinity s automated platform and compared to another onmarket chemiluminescent immunoassay. precision was assessed over days using a panel of positive and negative samples. sensitivity was evaluated on presumed antibody positive specimens and specificity was evaluated on random blood donor samples. results/finding: precision was % cv or less for positive samples over days. the overall specificity in a blood donor population was . % ( / ). sensitivity was . % for presumed antibody positive samples. conclusion: these results indicated that the new automated alinity s chagas assay provided very good performance in sensitivity and specificity, comparable to the current on-market anti-t. cruzi assay, and is equally suitable for use of universal screening in endemic and selective donor screening in non-endemic countries. performance of a new automated alinity s assay for hepatitis b surface antigen and hepatitis b surface antigen confirmatory randal makela* , anton vanweert , ed bakker , jane bryant , mark paradowski , lynn martin , daniela kaleve , george chen , gregg williams and george schlauder . abbott laboratories, sanguin diagnostics, abbott gmbh & co. kg, abbott diagnostics background/case studies: despite the development of sensitive nat methods, blood transfusion in many parts of the world relies on serologic screening for hepatitis b surface antigen (hbsag) to prevent transfusion transmitted hbv infection. sensitive hbsag assays must be capable of coping with a wide range of mutants while exhibiting an uncompromised specificity. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. study design/method: the performance of a new automated chemiluminescence immunoassay for the detection and confirmation of hbsag was evaluated on a next generation automated platform, abbott alinity s. precision was assessed over days. sensitivity was evaluated using known positive samples, commercially available seroconversion panels, the who standard, hbsag mutants, and hbsag genotyped specimens (a through h). specificity was evaluated on random blood and plasmapheresis donors. results/finding: precision was less than % cv for positive samples over days. the blood donor specificity was . % ( / ). sensitivity was % for presumed positive samples. sensitivity was % for all genotypes. % of the mutants were detected vs % for the comparator assay. seroconversion detection was equivalent to the comparator assay with reactive samples detected with the alinity s assay and reactive samples detected by the comparator assay. analytical sensitivity ranged from . to . iu/ml. the alinity s hbsag confirmatory assay confirmed all known positive hbsag specimens, including hbsag mutant samples that were not confirmed by the comparator hbsag confirmatory assay. conclusion: the new automated alinity s hbsag assay provided precision, specificity, and seroconversion sensitivity comparable to the current onmarket comparator assay. however, the alinity s hbsag assay demonstrated a gain in sensitivity over the comparator assay through the detection and confirmation of a wider range of mutants. performance of a new automated alinity s immunoassay assay for hiv darwin smith* , ed bakker , anton van weert , jane bryant , mark paradowski , kevin callear , susan sullivan , george chen , george schlauder and gregg williams . abbott diagnostics, sanquin diagnostics background/case studies: blood donations are commonly screened to detect the presence of antibodies (or antibody and antigen) to human immunodeficiency virus types and (anti-hiv- / ). blood centers require very high throughput anti-hiv- / assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining a safe blood supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in the response for the need for such screening assays, we have evaluated an improved automated assay for the detection of anti-hiv- / antibodies and hiv- p antigen. study design/method: the performance of the new chemiluminescence combination immunoassay for the detection of anti-hiv- / antibodies and hiv- p antigen was evaluated on the abbott alinity s system. precision was assessed over days evaluating positive samples. specificity was evaluated on samples obtained from random blood donors and plasmapheresis donors. sensitivity was evaluated using presumed positive samples for hiv- , hiv- and hiv group o antibodies and hiv- p antigen. seroconversion sensitivity was evaluated with commercial seroconversion panels. results/finding: precision was less than % cv for positive samples over days. the blood donor specificity was . % ( / ). sensitivity was % for presumed antibody positive samples comprised of hiv- , hiv- and hiv- groups o, n, p, crf and urf samples. also, sensitivity was % for antigen positive viral isolate samples comprised of hiv- , hiv- and hiv- groups o, n, p, crf and urf samples. seroconversion detection was equivalent to the comparator assay with reactive samples detected with the alinity s assay and reactive samples detected by the comparator assay. conclusion: these results indicate that the new automated alinity s hiv ag/ab combo assay provided acceptable performance in specificity, sensitivity and precision, while providing similar seroconversion sensitivity as the comparator assay. performance of a new automated alinity s immunoassay for the detection of anti-hbc antibodies randal makela* , anton vanweert , ed bakker , jane bryant , mark paradowski , joyce siregar , angela vockel , george chen , gregg williams and george schlauder . abbott laboratories, sanguin diagnostics, abbott gmbh & co. kg, abbott diagnostics background/case studies: in countries with a low prevalence of hepatitis b, blood donations are commonly screened to detect the presence of antibodies to hepatitis b core antigen (anti-hbc) alongside hbsag and hbv nat to detect donors with occult hepatitis b infections (obi). blood centers require anti-hbc assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining a safe blood supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in the response for the need for such screening assays, we have developed an improved automated assay for the detection of anti-hbc on the alinity s system. study design/method: the performance of a new chemiluminescence anti-hbc assay for the detection of anti-hbc antibodies was evaluated on the next generation automated abbott alinity s system. precision was assessed over days evaluating positive samples. specificity was evaluated on samples obtained from random blood donors. sensitivity was evaluated using specimens characterized as anti-hbc positive by means of serologic methods. analytical sensitivity was assessed using the who st international standard. seroconversion sensitivity was evaluated using commercial seroconversion panels. results/finding: precision was less than % cv for positive samples over days. the blood donor specificity was . % ( / ). sensitivity was % for samples presumed to be anti-hbc positive. analytical sensitivity results on the alinity s anti-hbc assay ranged from . to . iu/ml. seroconversion detection was equivalent to the comparator assay with reactive samples detected with the alinity s assay and reactive samples detected by the comparator assay. conclusion: these results indicate that the new automated alinity s anti-hbc assay provided good performance in specificity, sensitivity and precision versus the comparator assay. performance of a new automated alinity s immunoassay for the detection of htlv i and htlv ii antibodies melanie anderson* , anton vanweert , ed bakker , mark paradowski , jane bryant , tuan bui , joyce siregar , george chen , george schlauder and gregg williams . abbott laboratories, sanguin diagnostics, abbott diagnostics background/case studies: in endemic countries, universal blood screening is necessary to prevent transfusion transmitted htlv infections (anti-htlv i/htlv ii). in non-endemic countries, selective testing may avoid unnecessary temporal deferrals for donors at high risk, such as returning travelers from or donors born in countries with a high htlv prevalence. blood centers require high throughput anti-htlv i/htlv ii assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining a safe blood supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in response for the need of an assay with high specificity on a high throughput instrument we have developed a new assay for the detection of antibodies against htlv-i/ii antibodies for the alinity s system. study design/method: precision was assessed over days using htlv i and htlv ii positive samples. specificity was evaluated using , blood donor specimens from europe and diagnostic samples obtained from the united states. sensitivity was evaluated using preselected htlv i and htlv ii positive samples. sensitivity and specificity samples were split across reagent lots during testing. confirmation of repeatedly reactive samples was done using the mp diagnostic htlv blot . . results/finding: imprecision was less than . % for positive samples over days. clinical sensitivity was . % ( / ) on preselected htlv i and htlv ii positive samples. the specificity was . % ( , / , ) on a blood donor population and . % ( / ) on diagnostic samples. conclusion: these results indicate that the new alinity s automated htlv i/ ii assay provided very good performance in specificity, sensitivity, and precision. sensitivity and specificity were comparable to the comparator assay. claudia ramirez , michel garcia* , fernando palomino and guillermo orjuela-falla . national blood bank colombian red cross, universidad del rosario, fuats background/case studies: current hepatitis c virus (hcv) supplemental testing algorithm for blood donations in colombia, requires that an immunoblot assay be performed on every hcv enzyme immunoassay (eia) repeatreactive sample. a higher proportion of indeterminate (ind) results by immunoblot assays has been documented for non-us donor samples, affecting donor counseling and eventually increasing costs and opportunity for the notification of infected donors. this work aimed to establish the distribution of immunoblot results in colombian repeat-reactive samples, as well as the frequency of band detection in both positive and indeterminate blots. study design/method: in total, anti-hcv-reactive donor samples (signal-to-cutoff (s/co) ratio greater than . ; abbott architect i sr) underwent supplemental testing by immunoblot (either chiron riba hcv . sia or hcv blot . test, mp diagnostics). negative (neg), indeterminate (ind) and positive (pos) blot results were grouped by s/co ranges as follows: - . , - . , > . band detection and intensity were independently analyzed for indeterminate and positive results. results/finding: immunoblot results were negative in . % ( / ) of samples, indeterminate in . % ( / ) and were positive in . % ( / ). a direct relationship was observed between positive immunoblot and increased s/co. the proportion of ind results were higher in the s/co group - . ( . %) compared with the - . ( . %). in samples with indeterminate results, ns _ was the most frequent band detected ( , %). in contrast, the most frequent band in the group of positive results was core ( , %). only one sample from the indeterminate group ( . %) had a strong band intensity ( ), compared with samples from the positive group ( . %). conclusion: the proportion of indeterminate immunoblot results in this sample of colombian donors is one of the highest ever reported, being twice as much as the proportion found in larger samples of us donors. the high proportion of ind results found in the s/co group ( - . ) suggests that the optimal s/co ratio for predicting a confirmed anti-hcv result in this population should be higher than the one recommended by the cdc for us population (> ). overall, these results suggest that the supplemental testing algorithm for blood donations in colombia could be improved not only by using high s/co ratios as an alternative to immunoblot, but also by introducing hcv genomic assays instead of immunoblots, at least for samples with intermediate s/co ratios. ns _ and ns _ cross-reactivity in colombian population warrants further investigation. performance of the alinity s immunoassay for the detection of syphilis antibodies melanie anderson* , ivanka mihaljevic , manuela miletic , miljana stojic vidovic , irena jukic , jane bryant , mark paradowski , angela vockel , george chen , gregg williams and george schlauder . abbott laboratories, croatian institute of transfusion medicine, abbott gmbh & co. kg, abbott diagnostics background/case studies: blood donations are commonly screened for syphilis in order to detect the presence of antibodies to the bacterium treponema pallidum. in addition, continued pressures on laboratory operations demand that the full panel of ttid assays perform on a single platform capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in response to those needs, we have evaluated a new automated immunoassay for the detection of antibodies to t. pallidum. study design/method: performance of the new automated chemiluminescence immunoassay for the detection of antibodies to treponema pallidum was evaluated on the alinity s system. precision was assessed over days using positive samples. specificity was evaluated on samples obtained from , blood and plasmapheresis donors from the united states and europe and diagnostic samples obtained from the united states. sensitivity was evaluated using preselected positive samples. sensitivity and specificity samples were split across reagent lots during testing. confirmation of repeatedly reactive samples was done using a testing algorithm with confirmatory assays, inno-lia tm syphilis score, and mikrogen recomline treponema igg and igm blots. results/finding: imprecision was less than . % cv for positive samples over days. clinical sensitivity was . % ( / ) on preselected syphilis positive samples. the specificity was . % ( , / , ) for blood donor specimens and . % ( / ) on diagnostic samples. conclusion: these results indicate that the new automated alinity s syphilis assay provided good performance in precision, specificity and sensitivity in line with data found for the comparator assay. performance of the new automated alinity s assay for anti-hcv melanie anderson* , ed bakker , anton vanweert , jane bryant , mark paradowski , tuan bui , lynn martin , george chen , gregg williams and george schlauder . abbott laboratories, sanguin diagnostics, background/case studies: serological screening for antibodies to hepatitis c virus (hcv) often in conjunction with nucleic acid testing (nat) is used worldwide to prevent transfusion transmitted hcv infections. while nat provides improved sensitivity and detection of hcv in the pre-seroconversion window, serological testing provides continued detection of hcv in infected individuals and individuals with resolved infections with no detectable hcv rna. blood and plasma centers require very high throughput anti-hcv assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining the safety of the blood and plasma supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. study design/method: the performance of a new automated chemiluminescence immunoassay for the detection of antibodies to hcv was evaluated on the alinity s system. precision was assessed over days evaluating positive samples. sensitivity was evaluated using preselected positive samples and seroconversion panels. specificity was evaluated on samples obtained from , blood and plasmapheresis donors from the united states and europe and diagnostic samples obtained from the united states. sensitivity and specificity samples were split across reagent lots during testing. confirmation of repeatedly reactive samples was done using a testing algorithm consisting of the inno-lia tm hcv score and nat/hcv discriminatory nat assays. results/finding: imprecision was less than . % cv for positive samples over days. overall clinical sensitivity was % on preselected anti-hcv positive samples. seroconversion sensitivity was better than the comparator as evidenced by the new anti-hcv assay identifying more bleeds than the comparator assay. the specificity was . % ( , / , ) for blood donor specimens and . % ( / ) background/case studies: zika virus (zikv), which has been outbroken in south america and the united states since middle of , was declared as the public health emergency of international concern by who in feb . in addition to mosquito, zikv can be transmitted via maternalneonatal relationship, sexual intercourse or blood transfusion. the potential for transfusion-transmitted zika virus was shown in french polynesia where . % of asymptomatic blood donors tested were positive for zika virus rna using nucleic acid test (nat). several case reports have confirmed that zikv can be transmitted by transfusion. it has been shown that among blood donors, . % of the zikv infections were asymptomatic and the ratio of symptomatic to asymptomatic patients observed in micronesia was approximately : to : . thus zikv has raised a great challenge to transfusion safety. measures should be taken to prevent transfusion-transmitted zikv, including temporary deferral of blood donors in epidemic locations, donor self-reporting of zikv symptoms after donation with or without quarantine of blood components, supply by blood collected from non-endemic areas to epidemic regions, nat of blood donations, and pathogen inactivation of blood products. in this study, we evaluated zikv inactivation in plasma by using methylene blue photochemical treatment (mbpt). study design/methods: plasma units from randomly selected healthy donors were collected and spiked with zikv. samples were added by mb at a final concentration of lm and assayed after illumination with visible light from both sides for , , and min. viral infectivity and zikv rna loads (reverse transcription pcr) were measured in spiked plasma before and after mbpt and confirmed using repetitive passages in cell culture. control was zikv spiked plasma without photochemical treatment. results/findings: zikv titer of control sample was . log % tissue culture infectious dose (tcid )/ml. no viral infectivity was detected after mb photochemical inactivation treatment for min, min or min and the losses of the infectivity were further demonstrated by repetitive passages of cell culture. meanwhile, zikv rna loads decreased significantly during the initial min of treatment whereby ct-value jumped from . (control) to . (mbpt for min) (table ) . conclusion: it showed that mb photochemical treatment could effectively inactivate zikv in plasma. rna lesions were induced during mbpt process so that nucleic acid reverse transcription and amplification were inhibited. mbpt is proved to be an efficient method to prevent plasma transfusiontransmitted zikv infections. gilles delage* , margaret fearon , susan l stramer , megan l nguyen , france bernier , sheila o'brien , vito scalia , sakina smith , yves gr egoire and boris hogema . h ema-qu ebec, canadian blood services, american red cross, sanquin background/case studies: hepatitis e virus (hev) is known to be transfusion-transmissible. as part of the risk assessment for this infection, a study was carried out in , canadian blood donors in . in a subset of , donor samples the seroprevalence was . %. however, no donor samples were positive for hev by an in-house nucleic acid test (hev-nat). since that study suggested exposure to hev in canada but used an hev-nat with a limit of detection of iu/ml, a larger study was performed using a more sensitive hev-nat assay. study design/method: donors were informed about the study in the predonation reading materials. linked samples from approximately , canadian whole blood donors including , from canadian blood services (cbs) and , from h ema-qu ebec (hq) were collected. clinics were selected to ensure representative sampling of the donor population. all a transfusion vol. supplement s donations with available plasma samples were tested by individual donation nat at the american red cross laboratory in gaithersburg, md, using the cobas v r hev test ( % lod . iu/ml, % ci . - . ) for use on the cobas v r / system. this test is not currently approved in canada or the usa, but is available as a ce marked test. all nat-reactive donors are questioned concerning risk factors for recent hev infection (travel, animal contact, food and water exposure), undergo confirmatory testing (alternate nat, viral load, genotyping and igm/igg serology), are notified by letter, and deferred from donating for months; in-date products collected from the donor, and any frozen red blood cells or plasma from the previous months are destroyed. recipients will be traced in the event of any products transfused in the previous months. results/finding: as of april , , of , ( , cbs, , hq) tested samples with valid results have been found hev-nat reactive: donors have been confirmed by further testing to date. confirmation is pending in donor. of the donors, were from quebec, and one each from nova scotia and alberta ( male, female). ages ranged from to years. only two donors reported non-specific symptoms (fatigue). in terms of risk factors: ate pork (including who ate pork liver), ate shellfish, ate venison, and drank well water. one donor had no identifiable risk factor. viral loads ranged from to iu/ml, of which were < , were - , and were > iu/ml; were anti-hev igm positive and anti-hev igg positive at index (wantai assay). conclusion: the prevalence rate of acute hev infection in this donor population appears to be around / . the data from this study will contribute to the ongoing risk assessment of transfusion-transmitted hev infection in canada. prevalence of malaria parasite in donated blood at nakasero blood bank, uganda gerald nsubuga* and musiisi ezra. uganda blood transfusion service background/case studies: introduction infectivity of donated blood with malaria is a significant health problem facing humanity. in uganda, screening for malaria parasite is neither routinely done in blood banks, nor stipulated in the current uganda national blood transfusion service (ubts) guidelines by the ministry of health. as a result, the proportion of donated blood that is infected with malaria is largely unknown. malaria infection places more than half of the world's population at risk and in majority of the tropical and sub-tropical regions of the world and about to million cases and to million death occur per year. however the study aimed at determining the prevalence of malaria parasites in donated blood at nakasero blood bank, kampala, uganda study design/method: a cross sectional study was carried out in nakasero blood bank, kampala, uganda in four hundred and seventy randomly selected donor samples at the blood bank between june and august . both thin and thick glass stained blood smears of blood samples with giemsa was examined using microscope. results/finding: of the donated blood samples, ( . %) tested positive for malaria parasite (p. falciparum), although there was no significant difference in occurrence of plasmodium in relation to sex, age and blood group (p> . ), majority of the blood donors that tested positive belonged to blood group o ( . %). the prevalence of malaria parasite in the study was . %. regardless of the prevalence, the presence of malaria parasite (plasmodium falciparum) in donated blood from donors that were presumed to be healthy raises a serious concern on the safety of donated blood in uganda. the ministry of health should review the existing guidelines for screening malaria and mandatory universal blood donor screening policy for malaria, for exclusion of blood donors with plasmodia parasitaemia. using methods like pathogen inactivation compared to tedious microscopic procedure to screen donated blood to be introduced to further enhance blood safety in our communities. components. the bact/alert virtuo* (virtuo) is an advanced, next generation system with improved automation, connectivity, and with data management systems. most importantly, the virtuo's new algorithm significantly reduces the time to detection (ttd) of microorganisms during quality control testing of platelet preparations using bact/alert bpa (aerobic) and bpn (anaerobic) bottles. bpa and bpn bottles were tested on virtuo and bact/ alert d (bta d) to evaluate repeatability to detect growth in seeded leukocyte reduced apheresis platelets (lrap) without platelet additive solution (pas), throughout platelet shelf life ( , and days after collection). study design/method: pooled lrap were seeded with low levels of organisms commonly associated with platelet contamination at , and days post collection. the seeded lrap were inoculated into bpa and bpn bottles on different days (not consecutive) alternating between teams of people each. seeded bottles were loaded into a virtuo and a bta d and incubated until declared positive or negative (up to days). additionally, bpa and bpn bottles inoculated with ml of unseeded lrap were tested on the virtuo and the bta d ( and bottles respectively), to serve as negative controls, sterility controls, and to evaluate the risk of false positives caused by lrap results/finding: the repeatability of the virtuo to detect organisms in lrap was demonstrated by a recovery rate of seeded bottles of . % for the virtuo and . % for the bta d. the virtuo demonstrated an average improved ttd of . hours, when compared to the bta d in the presence of ml lrap platelets. the lrap did not cause false positives. additionally, the age of the lrap units (within day expiry),did not impact the ttd when seeded with organism background/case studies: zika virus (zikv) is an emerging flavivirus that is transmitted by the aedes aegypti mosquito and sometimes a. albopictus mosquito. most infections are asymptomatic. zikv nucleic acid testing (nat) became a required test for blood donors per the fda guidance entitled, "revised recommendations for reducing the risk of zika virus transmission by blood and blood components". based on our geographical location, implementation of this testing began weeks after this guidance was issued. we performed zikv nat for donors of whole blood and blood components under an investigational new drug (ind) study (sponsored by hologic, inc.). we performed a retrospective analysis on all nat results as there is a potential to defer donation due to false positive screening results. study design/method: donors that consented to donate blood and be tested for the zikv were obtained from three blood banks in colorado and nebraska. nat was performed using the procleix virus assay which is a qualitative in vitro nucleic acid assay system that detects zikv rna in plasma specimens. the assay was performed on the automated procleix panther system. all testing was performed according to the manufacturer package insert. results/findings: in the event of a reactive result, donors would be retested by nat in addition to other testing (igm antibody testing, neutralization test). donors are deferred for days barring continued zikv testing and nonreactive results. a total of , donors were screened for zikv. all donors screened for zikv were nonreactive by nat. no invalid test results were obtained. in addition the number of failed test runs due to instrument or assay issues were experienced were quite low ( . %). this data indicates that both the assay and instrument are robust. there was a low frequency for additional testing which allows the laboratory to publish timely infectious disease results for our blood bank customers. conclusion: the reactive rate data presented here demonstrate that there is a low/zero incident rate in our region for whole blood and blood component discard due to reactive results. this screening is important to continue to ensure blood safety in the united states. robust inactivation of the yellow fever virus d strain can be achieved using amotosalen and uva light for pathogen reduction treatment (prt) of platelet components andrew laughhunn , felicia santa maria , yvette girard , peter bringmann , marion lanteri* and adonis stassinopoulos . microbiology department, cerus corporation, scientific affairs department, cerus corporation background/case studies: yellow fever virus (yfv) is known to cause explosive outbreaks, such as the one in angola in . the rapidly increasing number of infections in brazil, with hundreds of fatalities since december , is of concern. yfv is a flavivirus transmitted by aedes mosquitoes and could spread, like zika virus, to other parts of the americas where the vector is endemic. with no effective antivirals and only supportive therapy available, the best mitigation strategy is through vaccination with live attenuated vaccine strains, like the d-yfv strain. yfv vaccine is considered an effective and safe vaccine; however major adverse events have been reported including neurologic and visceral adverse effects. in addition, transfusion transmission (tt) of live attenuated yfv has been reported with severe clinical outcomes, especially in immunosuppressed patients. in order to prevent tt by yfv vaccine strain, the aabb recommends a weekperiod deferral after yfv vaccination. yfv outbreaks and vaccination campaigns may therefore reduce blood availability. this pilot study evaluated the ability to inactivate d-yfv using amotosalen (s- ) and uva light prt of platelet components (pc). study design/method: pc in %pas (n ) or % plasma (n ) were spiked with high titers of d-yfv and treated with s- /uva prt. samples were taken pre-and post-uva illumination and infectious titers were determined, by plaque assay using vero cells. the extent of inactivation was quantified by comparing titers before and after inactivation. results/finding: pre-prt infectious titers were . . log pfu/ml for pc in % plasma and . log pfu/ml for pc in % plasma while titers in post-prt samples were <- . . log pfu/ml for pc in % plasma and <- . log pfu/ml for pc in % plasma. inactivation to the limit of detection of > . . log or inactivation of > . . log pfu/ml was achieved for pc in % plasma. inactivation to the limit of background/case studies: the use of biotin as a supplement has increased in recent years and many health care professionals may not be aware of the high dosage intake by their patients. this high dosage has resulted in an increased prevalence of individuals being exposed to biotin levels much greater than the recommended daily dose and as a consequence, has led to inaccurate lab results for assays that utilize the free capture biotin-streptavidin methodology. although abbott's alinity s assays do not utilize this free capture biotin-streptavidin methodology, eight assays developed for blood screening on the alinity s system were evaluated for biotin interference to ensure there are no unknown consequences of high biotin levels. study design/methods: the purpose of this study was to determine if the eight developed abbott alinity s assays would be susceptible to biotin interference by evaluating their performance in the presence of a high concentration of biotin. for each of the alinity s assays evaluated (hiv ag/ab combo, htlv i/ii, anti-hcv, chagas, hbsag, anti-hbc, syphilis, and cmv igg), samples spiked with a concentration of biotin at approximately ng/ml were tested against a control (unspiked) sample preparation to determine if there was a difference between the control and biotin containing samples. two samples, one negative and one positive, were tested with all assays, except the hiv and htlv assays, which each tested two positive samples ( hiv- antibody and hiv- p antigen, and htlv-i antibody and htlv-ii antibody, respectively). results/findings: for the negative samples, the sample to cutoff (s/co) differences between the biotin spiked and control were . for hcv, hbc, syphilis, cmv igg, and chagas, . for hiv ag/ab and htlv i/ii, and . for hbsag. for the positive samples, the mean s/co % differences between the biotin spiked and control were . % (antibody sample) and . % (antigen sample) for hiv ag/ab combo; . % (htlv i antibody sample) and . % (htlv ii antibody sample); - . % for anti-hcv, - . % for chagas, - . % for hbsag, - . % for anti-hbc, - . % for syphilis, and - . % for cmv igg. conclusion: eight abbott alinity s assays were evaluated to determine if they were susceptible to biotin interference. these results indicate that the eight alinity s assays do not show susceptibility to biotin interference at an approximate concentration of ng/ml. robustness of the abbott prism methods to biotin interference c fischer , r schneider , w leonard , m cobb , g schlauder , g williams , m zuske m janulis* . transfusion medicine, abbott diagnostics, wiesbaden, germany, add diagnostics, transfusion medicine, abbott laboratories, chicago, united states background/case studies: the use of biotin as a dietary supplement has increased significantly in recent years and many health care professionals do not realize their patients are taking high doses. the increase has resulted in an increased prevalence of people being exposed to biotin levels much higher than the recommended daily dose and as a consequence, potentially inaccurate lab results for assays that utilize the free capture biotin-streptavidin methodology. the purpose of this study was to identify any abbott prism assays that may be susceptible to biotin interference based on assay design and then evaluate the performance of those assays with high concentrations of biotin. after a comprehensive review of abbott's current on market prism assays, no assays were identified that utilize biotin-streptavidin capture; however, assays were identified for subsequent testing as they contain biotin in their assay design. background/case studies: bacterial contamination of platelets is the highest residual infectious risk in transfusion despite the current preventive strategies. while bacterial contamination may affect any blood component, the ambient storage temperature conditions for platelets make them most likely to facilitate bacterial growth. based on all the precautionary measures, the final platelet concentrates include in the worst cases a very limited viable bacteria number estimated from to colony forming units (cfus)/bag (i.e. . to . cfu/ml). one major difference between viruses and bacteria is that bacteria have the ability to grow up to a concentration of - cfu/ml over the days product shelf-life. moreover, a large diversity of strains is found in contaminated platelets representing a key challenge for the development of a generic bacterial test. the aim of this study was to develop an economic and easy diagnostic approach for the early, rapid, sensitive and generic detection of bacteria in platelet concentrates. the adaptability of the process with the blood transfusion services requirements was of major concern. hence, attention was focused on an easy to automate technique able to deliver results on day after collection. study design/method: a large panel of bacteria involved in transfusion reactions including clinical isolates and reference strains was established and used for mouse immunizations, antibody screening and platelet spiking steps. an original approach was used to produce and select monoclonal antibodies directed against bacteria to develop our generic immunoassay. as recommended, hours (day ) after collection a sampling volume of spiked platelets ( . - cfu/ml) was tested after a short generic culture, lysis and capture of bacteria on magnetic microparticles in a microplate format. an immunoassay was performed for the detection of the captured bacteria. results/finding: this approach was tested on a panel of bacterial strains involved in transfusion reactions. the pre-analytical steps and the capture of bacteria on microparticles were improved to avoid false negative results and to enhance the sensitivity of detection. the full test developed in this study combining a pre-analytical culture step followed by an there are many stakeholders are involved in hcv eradication program, including government authority such as centers for disease control and prevention, national health insurance and health promotion administration, and private property like hospitals, medical societies, pharmaceutical and vaccine industries, npos and academia. results/finding: tbsf is a private nationwide single blood services program in taiwan, and performs anti-hcv screening test and nat confirmatory test on every collected blood, which is a large-scale population screening of hcv in taiwan because of its high blood donation rate ( . %). tbsf confirmed positive test result of repeated blood donors, and can identify hcv rna seroconversion cases as recently-infected hepatitis patients. those infected patients would be referred to physician for further medical care and deferred permanently by tbsf to secure blood safety. by interviewing the newly-infected cases, the risk factors of hcv patients can be studied and then help identifying and eliminating sources of hcv infection. tbsf also contribute to health education by teaching our donors being aware of potential risks of hcv infection and keep monitoring every parameters of hcv epidemiology to evaluate the efficacy of hcv eradication program. conclusion: in hcv eradication program, tbsf can not only secure blood safety but also participate in health education, disease screening, etiology finding and prevention, surveillance and evaluation. thus, among all stakeholders, tbsf is particularly important and can play a pivotal role in eradicating hcv by in taiwan. the theraflex uv-platelets technology efficiently inactivates transfusion-relevant bacteria species in contaminated platelet concentrates ute gravemann , frank tolksdorf , wiebke handke , thomas h. m€ uller and axel seltsam* . german red cross blood service nstob, maco pharma international, gmbh background/case studies: the theraflex uv-platelets system (macopharma) is a uvc-based pathogen inactivation system for platelet concentrates (pcs). inactivation efficiency has been shown for a broad range of viruses, bacteria, and protozoans. previous studies with the first set of bacteria species of the who international repository of platelet transfusion relevant bacterial reference strains revealed a high inactivation capacity for clinically relevant bacteria. aim of the current study was to investigate the bacteria inactivation efficacy of the theraflex uv-platelets system for enterobacter cloacae, pseudomonas fluorescens, staphylococcus aureus and streptococcus bovis which have recently been added to the who international repository. study design/method: pcs were produced from buffy coats using the additive solution ssp (macopharma) with a residual plasma content of %. for inactivation kinetics, pcs (n ) were spiked with bacteria to a final concentration of approx. colony forming units (cfu)/ml and irradiated with increasing doses until the full uvc dose was achieved. samples were taken for the bacterial titer determination after each irradiation step. for sterilization studies, two pcs were pooled and inoculated with bacteria to a final concentration of approximately . cfu/ml. bacteria were allowed to grow for h in the pcs at c under agitation. after splitting, one pc remained untreated (growth control) while the other one was uvc-treated. after storage for seven days, samples were taken from both bags for sterility testing by bactalert (biomerieux) and for determination of the bacterial titer in the untreated control units. results/finding: bacteria in pcs were inactivated in a dose-dependent manner by treatment using the theraflex uv-platelets system. mean log reduction factors ranged from to for enterobacter cloacae ( . . , pei-b-p- ), pseudomonas fluorescens ( . . , pei-b-p- ), staphylococcus aureus ( . . , pei-b-p- ), and streptococcus bovis ( . . , pei-b-p- ). pcs (n for each species) spiked with these different bacteria species were efficiently sterilized ( out of ). treated pcs remained sterile during storage for days, while bacteria in non-treated pcs grew to high titers of - cfu/ml. the theraflex uv-platelets system efficiently inactivates a broad range of different bacteria species, including the who reference strains. sterility is maintained over a storage period of days. these results suggest that the uvc-based pathogen inactivation technology will significantly improve the bacterial safety of platelet transfusions. transfusion transmissible infections among blood donors and strategy on direct laboratory testing cost of blood screening at national blood bank center, addis ababa, ethiopia abraham zewoldie*. national blood bank service background/case studies: blood and its components are life saving; however, they are also associated with life threatening hazards such as transfusion transmitted infections (ttis). hepatitis b virus (hbv), hepatitis c virus (hcv), human immunodeficiency virus (hiv) and syphilis are the most serious infections transmitted during blood transfusion. serious of blood shortages especially in developing countries and reliance on unsafe family replacement or paid donors also contribute to an increased risk of ttis. knowing the current prevalence of ttis among blood donors will be crucial in donor program strategy development and cost effective alternative strategies of blood screening are highly required especially in resource limited setup. study design/method: a retrospective analysis of blood donors' record covering the period from july , to july , was conducted. the data was collected from the nation al blood bank (nbb) center donor data base. in addition, direct laboratory costs of parallel versus sequential strategy of blood screening were compared using the current price of the laboratory costs. data was first exported to spss version software for analysis. data analysis was performed using scores and odds ratio using same software to look for an association between dependent and independent variables. p values less than . were considered significant. results/finding: a total of , consecutive blood donors were screened between and . the overall seroprevalence rate of hbv, hiv, hcv and syphilis of blood donors was . %, . %, . % and . % respectively. the hiv-hbv co-infection was higher among blood donors ( . %) followed by hbv-hcv co-infection whish accounts about ( . %). significantly increased sero-prevalence of ttis was observed in among family replacement donors, factory workers, daily labors and the age group of - . in this study the difference in cost between the current in use strategy (parallel) versus the newly proposed designed sequential testing algorism was , . ethiopian birr. conclusion: a significant percentage of the blood donors harbor ttis. the nbb center should work on voluntary blood donor mobilization and develop culture of voluntarism. the direct laboratory cost analysis using current in use strategy (parallel) was higher than the newly designed sequential testing algorithm. thus, the new strategy can be implemented to make screening of ttis cost effective in nbb center. transfusion transmitted malaria in a month old infant patricia davenport* , geeta paranjape and laurie sutor , . carter bloodcare, ut southwestern medical center background/case studies: in at a large pediatric hospital, a month old infant was supported for days by extracorporeal membrane oxygenation (ecmo). over this time blood products were transfused. about days after end of ecmo support, a routine blood smear examination revealed inclusions in some of the patient's red cells. the patient had also been having intermittent fever. malaria was confirmed by pcr as plasmodium ovale (p. ovale). because the patient had no other risks, the infection was suspected to be transfusion related and was reported to our blood center which had supplied all transfused products. study design/method: the investigation began by focusing on donors of red cell products, since the chance of an apheresis platelet product transmitting malaria is relatively small, and that of a frozen product is remote. we identified donors of red cell products. each donor was contacted and was asked four questions. additional questions were asked for clarification if needed. based on donor response, risk for active malaria infection was assessed. we also considered areas where p. ovale is, or is not found. donors identified as having possible risk were tested for antibodies and parasitic dna. results/finding: the five donors who had been ill all had common cold or bronchitis like symptoms. donors who traveled went only to non-risk areas. three donors were former residents of another country and may have risk because they lived in malaria endemic countries since birth and came to the u.s. as adults. it was discovered that one of these three did not meet all donor criteria. the donor had failed to disclose that he had not completed years stay in the u.s. after emigrating from cameroon, an area endemic for p. ovale. he had not travelled anywhere after coming to the united states in october and answered "no" to travel. antibody tests on this donor were positive for p. ovale and p. falciparum, but pcr tests were negative. another possible at-risk donor, a former resident of iran was tested and was pcr and antibody negative. the third donor has not yet been tested but the country of residence does not have p. ovale malaria. conclusion: while it could not be definitively proven that the donor with antibodies to p. ovale had active malaria at the time of donation, the donor was indefinitely deferred and referred to an outside physician for treatment. transfusion-transmitted babesiosis outside an endemic area: a case report german felix leparc*. oneblood background/case studies: an y.o. male patient was admitted to the emergency room for severe acute gastrointestinal bleeding, caused by an arterio-venous malformation later located in the proximal jejunum that was clipped endoscopically. during this admission, he received a total of units of red blood cells. approximately weeks later, he was re-admitted due to another episode of gi bleed manifested by melena. as part of his routine evaluation, a cbc was performed in which a blood smear revealed the presence of intraerythrocytic parasites consistent with babesia sp. study design/method: upon notification of a suspected case of transfusion-transmitted babesiosis, lookback of all donors involved in prior transfusion event was initiated. results/finding: to confirm the presumptive diagnosis of babesiosis, pcr was performed and babesia microti dna was detected. an evaluation of the patient's risk factors revealed that prior to the gi bleed episode for which he received transfusions, eight months earlier he was also transfused during open heart surgery. no travel history to the us midwest, and while he travelled to new england two years ago he did not spend time outdoors. he was splenectomized in his mid 's. donor lookback identified a donor who lived in new london county, connecticut but spent the winter season in central florida, where the blood donation (double rbc collected by apheresis) took place. he had never been diagnosed with babesiosis, but participated regularly in outdoor activities in connecticut that put him at risk for tick bites (although he never noticed being bitten or showing signs of it). upon testing, he was found to be negative for b. microti on pcr as well as igm antibodies, but had igg antibody titers of : . the recipient of the other rbc unit collected in the same donation was deceased within hours of transfusion, so no follow up could be performed. during phone interviews, none of the remaining donors had risk factors for babesiosis, and all but four were tested and found serologically negative. conclusion: while transmission of babesiosis through the zoonotic route is confined to regions were the appropriate hosts and vector coexist, people from areas where it is endemic may establish temporary residency and donate blood in non-endemic locations facilitating transmission through transfusion as illustrated in this case. once licensed assays for babesia microti become available, testing schemes will have to be formulated through policies that take this issue into consideration. transfusion-transmitted stenotrophomonas maltophilia from a red cell unit: a case report ashley c gamayo* , andrea j linscott and donny dumani . background/case studies: transfusion-transmitted bacterial infections (ttbi) are rare, but serious complications of blood product transfusions. from - , % of transfusion-associated fatalities reported to the fda were attributed to bacterial contamination. red cell units are rarely implicated in severe and fatal ttbi. when present, contaminants are often gram-negative rod (gnr) bacteria with psychrophilic properties. we present a case of a sickle cell patient who developed definitive sepsis after receiving a red cell unit contaminated with stenotrophomonas maltophilia (s. maltophilia). study design/methods: a -year-old female with sickle cell disease was admitted to the hospital for possible pain crises. pre-transfusion blood and urine cultures collected on day of hospitalization showed no growth after five days. on day , the patient required a blood transfusion for which she was issued a cmv-safe, irradiated, hbs-negative, crossmatched, o-negative red cell unit. the ml unit had been aliquoted via sterile connecting device days prior for a pediatric patient. all ml of the pediatric aliquot were transfused without adverse effects. the patient's pretransfusion temperature was . c. within minutes of starting the transfusion, the patient's temperature increased to . c and subsequently reached a maximum of . c. the transfusion was stopped and the blood bank notified immediately. gram stain of the remainder of the transfused component revealed gnr bacteria. blood was collected from the patient for culture and antibiotic treatment initiated. results/findings: initial transfusion reaction work-up revealed no evidence of clerical errors with negative post-transfusion antibody screen and direct antiglobulin test. blood cultures from both the patient post-transfusion and the implicated red cell unit grew gnr bacteria identified as s. maltophilia. further microbial testing revealed the cultured pathogen was able to proliferate at - c; a finding not characteristically observed in s. maltophilia. conclusion: this is the first definitive case of ttbi with s. maltophilia. this bacterium is a globally emerging gnr that is widely spread in the environment, causing both community-acquired and nosocomial infections in immunocompromised and debilitated patients. contamination was unlikely due to an asymptomatic donor. there was laboratory evidence of the pathogen in both the transfusion recipient and the transfused component. the patient was not infected with the pathogen prior to transfusion, and no other potential exposures could be identified. the patient recovered following appropriate antibiotic treatment, but endured prolonged hospitalization. the transfusion reaction was classified as definitive, severe tti of definite imputability. validation of commercial immunoassays for detecting hbsag and hiv antibodies in production pools karen leighton, izekial butler and scott jones*. qualtex laboratories background/case studies: plasma fractionators test plasma production pools for hbsag and hiv antibodies as a qualitative limit test for the control of impurities, to safeguard against errors in donation testing or pooling. the european medicines agency (ema) has published guidelines for the validation of immunoassays for the detection of hbsag and hiv antibodies in production pools. the aim was to validate commercial immunoassays for the testing of production pools for hbsag and hiv antibodies utilizing the ema guidelines. study design/method: a lower calculated cutoff value for the abbott prism hbsag and hiv o plus assays was determined by calculating the mean signal-to-cutoff ratio (s/co) plus standard deviations of four different types of plasma production pool samples. the calculated cutoff values were utilized for the rest of the validation. the detection limit was determined by testing in triplicate, serial dilutions of who hbsag and hiv antibody standards diluted in plasma. a normalized detection limit was calculated for the hbsag assay using production pools containing low, typical and high anti-hbsag titers. intra-assay variability was determined by testing a minimum of determinations of a low positive control in run. inter-assay variability was determined by testing at least representative negative production pool samples, at least low positive sample (about s/co) and a titration series of who standard spiked into plasma production samples. runs were performed on six separate days using two different instruments and two different lots of assay reagents. results/finding: the lower calculated cutoff values for the hbsag and anti-hiv assays were both below the manufacturer cutoffs of . and were . and . respectively. the hbsag assay detection limit was . iu/ ml for source plasma and . iu/ml for recovered plasma samples. the normalized detection limit study demonstrated that one and a half hours was the maximum amount of time the pool samples could sit at - c where all samples were still reactive for hbsag. the anti-hiv lowest positive dilution for all replicates varied between : , to : , , depending on subtype and group. the % cv of the s/co values of the replicates of the intra-assay variability validation were less than % for both assays. the %cv of the s/co values of the panel of samples of the inter-assay variability validation were less than %. conclusion: a lower calculated cutoff value could be determined for commercially available immunoassays for hbsag and anti-hiv. these immunoassays could meet all of the recommendations in ema validation guidelines. the abbott prism hbsag and hiv o plus assays can be utilized to test production pool samples. was performed on donors ( - days after the index donation) - donors in the follow up study and tested by the doh. no donors tested by the doh participated in the follow up study. follow up testing was negative for all donors. denv antibodies were negative in donations and equivocal in . our initial reactive rate is higher than that reported to date for the procleix zikv tma of per , [p. williamson, et al transfusion, in press] . conclusion: universal testing under ind was successfully implemented and incorporated into blood center operations. we have noted an initial reactive other demographics that should be analyzed for their potential to be used to predict cmv seroconversion rate include gender, age, race, ethnicity or a combination of these. background/case studies : growing the geographic footprint has been a priority for the organization since . over a four year period, the organization doubled the number of blood centers, with continued growth expected. with the current challenges in the blood industry, the audit program needed to be flexible, maximizing efficiency and capacity utilization, and without increasing compliance risk. the internal audit function was centralized in late , for which the program consisted of types of audits, an operational compliance audit and a support systems compliance audit. each type was performed twice per year at each main center. this model was no longer serving the changing organization. study design/methods: lean six sigma concepts were applied to this project. survey results and brainstorming aided in capturing the strengths of the current program, opportunities for improvement, and ideas for a redesigned program. this information was the primary input to the swot analysis (strengths, weaknesses, opportunities, and threats) for the purpose of understanding performance of the current program, as well as elements that could impact the future design. potential solutions were placed into a pugh matrix, which was used to facilitate a disciplined, team-based process for concept generation and selection. each potential solution was compared to criteria for evaluation and selection of the best solution. results/findings: the program was re-designed to perform internal audits annually as a single, team-based comprehensive audit. remote auditing was incorporated to require less on-site time, less disruption, improved auditor work/life balance, and cost savings. a formula was created to determine on-site audit time that included adjustable risk factors. the audit reporting process was also automated for simplification, efficiency, and to meet stakeholder needs. the team-based approach leverages auditor strengths, fosters a learning environment, and increases detectability of organization-wide concerns. conclusion: the comprehensive team-based approach, and other program improvements, has been effective in responding to organizational growth without sacrificing quality or increasing compliance risk. external inspection performance has achieved record performance levels the past year. diversity of auditor skills led to a stronger skill presence, which was consistently applied across system. auditing is more efficient and effective. stronger collaboration among audit team members provided stronger objectivity, fairness, and consistency across the system. auditors and auditees have increased in knowledge, and the internal quality audit program has improved. background/case studies: in many places, blood banking is using semiautomated systems to perform fractioning in different blood components (red blood cells, platelets and plasma). banc de sang i teixits (bst), adopted the fully automated reveos system (terumo bct inc, lakewood, co) few years ago to manufacture blood components. in june , bst started a validation of new blood bags manufactured by terumo bct with different variables on platelet volume after processing and a kit to perform platelets pools with a new filter. study design/method: to perform this validation, blood donations were used under different conditions (see table below ). the current filter evaluated for the platelet pool (lrf-xl, haemonetics corporation) was compared to a new filter (terumo bct inc.). the new blood bags were manufactured using a new vinyl supplier. a portion of these processed blood components (red blood cells, platelets and plasma) was used for different quality control (qc) tests (routine qc performed at bst following european directorate for quality of medicines & healthcare; cytokine analysis, such as p-selectin and platelets recovery through the filter). results/finding: the results are very similar between both bags, current and new one, as well as filters. all the analysis done to evaluate the quality of the blood components were similar in all conditions. also, it was shown a better performance on platelets pools, when they came from bags centrifuged with ml of plasma, vs. ml of plasma and additive solution. conclusion: these new bags and filter have shown a similar behavior when using them for manufacturing blood donations with reveos system in our blood bank. regarding the new platelets pooling kits, a better manipulation by the operator was observed; although the tubing is shorter and it meant being more difficult when manipulating the pools. no issues should be found if they are implemented in routine use. it's planned to start this implementation during this year, ; so then there will be larger results in order to have a proper procedure qualification. conclusion: patients requiring rare blood products are rare, and those lacking high prevalence antigens are the most challenging for whom to obtain antigen negative blood. it is clear that some requests for exquisitely rare types are not able to be filled with current donors. molecular testing of large numbers of donors has likely helped to identify more rare donors in recent years. it is recognized that commercial platforms do not include many of these making these rare types even more challenging to find. consideration should be given to testing more donors of all ethnicities to identify more rare donors. recommendation # : updating donor educational material to provide more comprehensive information on risks of iron deficiency and recommendations on iron supplementation. updating our educational materials will likely have a minor impact. recommendation # : implementing strategies such as iron supplementation, ferritin testing or increasing interdonation intervals for all donors or those groups most at risk for iron deficiency. initial implementation would likely be either iron supplementation or ferritin testing for at risk groups only and implementation of either one of these strategies would potentially affect over , donors. the recommendation to limit the number of donations would have a substantial impact. for this analysis, the focus was on - year olds and premenopausal women (ages - ) donors. on average, - year olds donate . times a year and premenopausal women donate . times a year. if both of these groups were limited to donating once a year, a total of , donations from - year olds and , donations from premenopausal donors would not be collected. conclusion: after analyzing the impact of the aabb association bulletin # - , the bulletin will have a significant impact on both donors and our local blood supply. more than half of donors would receive either ferritin testing or iron supplementation. if the only measure employed is limiting the number of times a donor could donate for - year olds and premenopausal women, this recommendation would have a substantial impact on our ability to provide blood products to local hospitals. background/case studies: transfusion medicine knowledge deficits are apparent among medical students, residents and practicing physicians. these deficiencies may be due to the frequency and type of education. the majority of medical students in the united states receive four or fewer hours of transfusion medicine education. the transfusion medicine academic award group published educational content guidelines for medical school, residency and fellowships. however, the frequency and educational methods remain poorly evaluated and with little guidance. we investigated the effects of different educational techniques on transfusion medicine knowledge acquisition in novice learners. study design/method: three educational pathways were developed to teach principles of transfusion medicine while allowing learners to recognize problems and develop solutions for transfusion medicine complications. the simulation group received all educational activities within a . hour inperson, high-fidelity live session. the hybrid group received some educational component online and also attended an in-person high-fidelity simulation session. the online only group received all educational materials online, including a pre-recorded-video simulation session. the learners were second year medical students enrolled at one institution. the same faculty members taught all live sessions and developed all online materials ensuring the content was the same. a pre-and post-test was created to address blood groups, blood donation, blood testing, blood component indications and transfusion complications. the educational session was evaluated by the likert scale survey which ranges from zero (poor/unsatisfactory) to five (outstanding). results/finding: % ( / ) of the simulation group students improved their post-test scores and had an average likert scale rating of . (very good). % ( / ) of hybrid group students improved their post-test scores and had an average likert scale rating of . (very good). % ( / ) of online only students improved their post-test scores and had an average likert scale rating of . (good). the average changes in scores were statistically significant within all training groups (p value < . ). additionally, the simulation group had a larger increase in average post-test scores when compared to the online only group (p< . ) and the hybrid group (p< . ). conclusion: our study demonstrated that a faculty taught high-fidelity transfusion medicine simulation curriculum consisting of an in-person didactic session and simulation session for second year medical students produces greater knowledge acquisition compared to an online only or hybrid curriculum. the high-fidelity simulation curriculum is also preferred over the online only education as indicated by the likert survey results. aaron j wyble*, yeon mi kim and barbara j bryant. university of texas medical branch background/case studies: diagnostic management teams (dmts) are an innovative way to bridge the communication gap between the laboratory and clinical services thereby facilitating the delivery of improved patient care. dmts employ a multidisciplinary approach which integrates clinical and laboratory data into succinct interpretations and recommendations. the interpretations must be of moderate to high complexity in order to be clinically valuable. recommendations are made regarding future testing, timing of testing prior to blood component needs, and other pertinent concerns to allow for improved coordination of patient care. the timeliness of the dmt reporting is vital to patient management. the inherent design of a dmt also provides an educational opportunity for trainees at academic centers. study design/method: the transfusion medicine service at a large university-based academic medical center implemented a dmt in . all cases involving complex antibody identification workups, transfusion reactions, deviations from standard operating procedures, consultations for blood component utilization, and massive transfusion protocols from july through january were evaluated by transfusion medicine residents. the electronic medical record (emr) of each patient was also reviewed to determine relevant clinical history. all significant findings were presented at the transfusion medicine dmt conferences. the dmt was comprised of physicians from transfusion medicine, hematology/oncology, anesthesiology, transfusion service technical staff as well as visiting clinical staff from surgery, obstetrics and gynecology, transplant services, and pediatrics. the dmt integrated the clinical and laboratory data to formulate relevant interpretations and recommendations. the final dmt reports were placed into the emr for access by health care providers. financial benefits of a transfusion medicine dmt were also evaluated. results/finding: in a -month period, cases of complex antibody identification workups ( %), transfusion reactions ( %), consultations for blood component utilization ( %), and deviations from standard operating procedures and massive transfusion protocols ( %) were presented at the transfusion medicine dmt conferences. the placement of dmt narratives in the emr as progress notes and laboratory reports provided informative and timely communications. residents participating in dmts demonstrated improved clinical and laboratory correlation skills. as a result, resident competency in transfusion medicine was enhanced. over $ , of revenue was generated utilizing the standard professional component cpt codes. conclusion: dmts encompassing multiple aspects of transfusion medicine improved patient care through enhanced communication between laboratory and clinical services. additional benefits of a dmt program include resident, clinician, and technical staff education and the generation of revenue for the institution. streamlining a blood center and hospital transfusion service supply-chain with an informatics vendor-managed inventory solution hamilton c. tsang* , david lancaster , dianne geary , robert scott , anh thu nguyen , adam garcia , raina shankar , leslie buchanan and tho pham . stanford health care, stanford blood center background/case studies: inventory management is both a major challenge and an integral part of hospital transfusion service (hts) and blood centers (bc) operations. the current process at our institution involves twice-per-day shipments from the bc to the hts, with each shipment predicated upon current stock levels at hts. manually obtaining inventory levels for each product is time-consuming. the manual determination is also errorprone. we aim to enhance inventory management operations by developing an informatics solution to ( ) streamline the ordering process to accurately reflect inventory status and transfusion practices and ( ) re-allocate valuable hts tech time. study design/method: at our hts, the general inventory accounts for over product categories broken down by component, blood type, irradiated status, and cmv-serology status. we therefore sought to establish an electronic method to reliably infer the general inventory level. since the raw electronic inventory report comprised both the general inventory and physically sequestered units (e.g. special antigen units, cross-matched units), over a -month calibration period we performed linear regression between electronic and the gold-standard manual count to impute from the electronic census the number of units of each product category in the general inventory. once we had a reliable electronic method to determine inventory levels, we implemented a -month pilot period. we analyzed various metrics pre and post pilot implementation to ensure non-inferiority of our electronic system: ( ) the ratio of units transfused per week to the number stocked (t:s), ( ) the number of products ordered as stat, and ( ) the number of expired products. we created in-house programs on visual basic for applications (microsoft, redmond, wa) for both the calibration and pilot periods. lines of code were written for both programs, including class modules and distinct subroutines. results/finding: during the pilot period, we investigated our system's noninferiority. the average weekly t:s ratio for cryoprecipitate, plasma, and rbc, respectively, were . , . , and . before the pilot period compared with . , . , and . during the pilot period. these differences did not reach statistical significance (p . ). we also monitored the number of stat ordered products before and during the pilot period, which were and stat units per week, respectively (p . ). lastly, we also monitored the number of monthly wasted products due to expiration as an indicator of inventory mismanagement before and during the pilot period, which were and units, respectively (p . ). an estimated hours per week of technologist time was reallocated to other tasks once the electronic census was adopted. this translates to . fte and $ , per year saved from labor costs per year if permanently adopted. conclusion: we created an in-house electronic ordering system to enhance information fidelity, re-allocate technologist time, and further standardize ordering. our system showed non-inferiority to the labor-intensive manual system, by not changing the number of stat orders, having the same t:s ratio, and not increasing the number of expired products. this is achieved while freeing up over hours of staff time per year. future directions include full automation with involvement from hts informatics department. transfusion practice improvement: gaining traction through the use of a provincial transfusion quality improvement plan denise evanovitch* , yulia lin , troy thompson , allison collins and sheena scheuermann . ontario regional blood coordinating network, sunnybrook health sciences centre background/case studies: a provincial regional blood coordinating network (prbcn) held a "quality focus day" (qfd) in to explore transfusion quality indicators to be included in a province wide quality improvement plan (qip). the plan's main goal is to reduce patient harm by improving transfusion practice in hospitals through the reduction of inappropriate use. the following recommendations were made: select a blood component that most hospitals could monitor display progress in a public forum so that hospitals could compare themselves to peers strike a province-wide transfusion qip committee to guide the development of the plan, supporting resources and ongoing improvement initiatives study design/method: a provincial transfusion quality improvement plan (ptqip) committee was formed and included broad representation: the provincial patient blood management coordinators, physicians, technologists, nurses, administrators, clinicians, quality/risk managers from all regions of the province and the provincial blood advisory committee, the blood supplier and a patient. there was further collaboration with other organizations such as the provincial health quality division, choosing wisely after the launch, an informal survey indicated that of the province's hospitals were interested or had already adopted portions of the ptqip. to further assist hospitals in advancing their qips, a technologist prospective screening educational module was developed in addition to an electronic tracking tool with which hospitals can enter their baseline data and subsequent audit data and track their success. both hospital and provincial reports can be generated from the tracking tool. a more formal survey conducted in indicated that % plan to implement or already have implemented the ptqip and % of the respondents already have put prospective order screening by technologists in place. conclusion: helping hospitals through the development of standardized templates, instructions, education and other tools for transfusion quality improvement increases the ability of hospitals to uptake quality improvement initiatives. taking a standardized approach across the province allows for both aggregate and hospital data comparison analyses. background/case studies: military and civilian trauma-based studies have demonstrated the advantages of transfusing blood products prior to a patient's hospital arrival, a process known as pre-hospital transfusion (pht). helicopter emergency medical services (hems) worldwide have implemented this protocol with great success, despite a current lack of guidance or advisory publications. there is a need for literature that addresses the regulatory requirements and logistical challenges associated with developing a pht program. herein, we report our experience as a large hospital system embarking on the development of a multi-state pht service. study design/method: in october a work group was formed to establish pht services for the hems providing care to over thirty regional hospitals. composed of flight care staff, emergency physicians and transfusion medicine specialists, the group identified the major tasks to be addressed: federal/state regulations; inventory structure/management; product storage/testing; tracking/traceability; emergency release protocol; and staff training. while there are no specific regulations governing pht, the regulations pertaining to blood product storage, validation, and monitoring apply. the fda, aabb, and state agencies were each consulted to ensure compliance with all directives. results/finding: the largest hospital within this system, already acting as a reference site, was designated to perform all confirmatory testing on products supplied to the multi-state hems. similarly, this hospital was tasked with remote monitoring of all blood refrigerators at the helipad sites. the system's fda licensed blood supplier was deemed responsible for product consignment and transport between the four hems sites. the blood inventory at each site was designed to contain: group o positive rbcs, group a low anti-b titer liquid plasma, and four-factor prothrombin complex concentrate. a military-tested in-flight medical record system will be used to transfer transfusion information to non-affiliated hospitals as needed. validated inflight coolers, protocol for product emergency release, inventory tracking system, and re-stocking schedule were also requisite to this plan. staff competencies regarding emergency release guidelines, transfusion reactions, and the handling/storage of products are maintained by the hems medical director with additional oversight provided by transfusion medicine physicians. conclusion: our work group successfully identified the challenges associated with a multi-state pht helicopter based service, which spans blood product management, adaptation of existing transfusion procedures and operating policies, licensing requirements, and personnel training. our pht service will go live in . publishing this experience may benefit future sites as they launch similar pht initiatives. blood transfusion during humanitarian emergencies yetmgeta e. abdella* , rana hajjeh and cees th. smit sibinga . world health organization regional office for the eastern mediterranean, international quality management (iqm) consulting background/case studies: more than million people are affected by humanitarian emergencies in the eastern mediterranean region of the world health organization (who), where some of the most affected countries in the world are located. in these countries, the health systems have been weakened or destroyed and health workers provide health services under difficult circumstances. humanitarian emergencies increase the demand for blood transfusion and make its delivery challenging and complex. despite these obvious needs, across the region, there is a lack of information on the emergency preparedness and response capacity of blood transfusion and on the challenges countries and health responder's face in meeting the needs of the patients during emergencies. study design/method: we searched pubmed and index medicus for the who eastern mediterranean region for data on availability and safety of blood transfusion in humanitarian emergencies. we conducted a structured survey of blood transfusion services (bts) in all countries in the region to identify the following: type of humanitarian emergencies between and ; current strategies to ensure availability and safety of blood transfusion during emergencies; coordination and collaboration between countries; and gaps and challenges. additional information was collected during a regional consultation (eastern mediterranean region) held in may in tunisia. results/finding: we found publications on disaster from five countries in the region and publications on disaster preparedness and blood transfusion in casualties and severe trauma outside the region. however, none dealt with the questions of availability and safety of blood transfusion during emergencies. twelve countries ( . %) responded to the survey. armed conflicts and terrorism are the commonest types of emergencies with estimated - % of the injured requiring blood transfusion. nine countries have emergency preparedness and response plans for bts. potential blood donors are mobilized through public calls, besides a direct appeal on regular and replacement donors. seven of the responding countries keep an emergency blood stock. collaboration between the different stakeholders exists in seven countries. lack of adequate and competent human resource, transport and cold chain deficits, shortages in supply of consumables and maintenance of equipment, lack of reliable power supply, and shortage in finances are the gaps identified. conclusion: there is a need to integrate bts in the overall national emergency preparedness and response, collect and disseminate updated information on factors affecting provision of blood transfusion in humanitarian emergencies, provide technical and financial assistance to affected countries, strengthen mechanisms for coordination and collaboration among different parties, and develop a regional emergency blood services system and management expertise. ( , , and for - ) . the number of collections per registered trt donor varied significantly, ranging from to therapeutic draws/donor per year. excluding those that didn't present for a therapeutic blood collection, the average number of trt collections/donor per year decreased from . to . between and . conclusion: our blood center has experienced an increasing number of therapeutic phlebotomies, as well as individuals on trt referred for therapeutic phlebotomy due to elevated hemoglobin values from through . it is not clear from information provided by the ordering physician whether this is intended as a temporary measure to decrease the hemoglobin while the patient is on trt, or whether the dose was being adjusted or discontinued due to the known risk factor of cardiovascular disease in patients with polycythemia; however, the average number of donations per trt donor decreased during this timeframe. the percentage of men on testosterone who present as regular blood donors at our blood center is not known, since this hormone is not reason for deferral. our findings raise the concern, however, that regular phlebotomy is necessary to reduce the risk of testosterone-associated polycythemia in this population. as it is our duty to provide a safe and adequate blood supply, our blood center also has concerns about perpetuating the misperception that repeat phlebotomy, particularly if required more frequently than days, is sufficient to mitigate the risks of testosterone therapy. hence, we have made the decision to discontinue offering phlebotomy services to this population of donors other than for those on testosterone that meet all donor eligibility requirements. approaches involving the use of a vein illumination device in a blood donor center sara matheson*, kimberly j duffy, audrey e traun, mary m benike, james r stubbs and justin d kreuter. mayo clinic background/case studies: venipuncture is a critical step in blood collection and locating a suitable vein for this procedure can be a challenge. unacceptable vein selection or incorrect needle placement can lead to incomplete collection or infiltration. in a blood donor center, the primary selection of a vein is done by palpation within the antecubital area. prior to needle insertion, the skin at the site must be prepared and contact avoided until after needle is placed. vein illuminator (vi) devices are available to aid in visual display of potentially suitable veins. such a device was made available to staff in march of . after an initial testing and instructional period, the vi has since not been used by staff. the objective of this study is to discover reasons why staff does not use the vi to identify potentially suitable veins. study design/method: a staff survey was developed and distributed to staff in march to inquire about usage of the vi and obtain feedback about the device. at the time that the survey was sent, the device had been available for several years. the survey included questions involving frequency of use, adequacy of training, comfort with using the device, knowledge of the device's storage location, willingness try the device, and general feedback. results/finding: the survey had a % response rate (n ). of these, . % have never or very rarely utilized the vi. self-reported reasons for low utilization focused on two dominant themes. first, that the device is not needed and second that it doesn't accurately show veins. . % of respondents are aware of where the vi is stored and a more accessible location to share the device was not identified. although . % of respondents have been provided training on using the vi, the group was mixed regarding their comfort level in using the device independently. only % of the group was willing to try vi. conclusion: infiltration and incomplete collection account for approximate % ( units/year) of qualified blood donors, yet vi does not appear to be a viable solution for our blood donor program. there seems to be both an opportunity and challenge with vi implementation. the opportunity is to create critical awareness of problems with vein cannulation. the challenge is to identify a device that is more effective at visualizing deeper veins necessary for blood donation. benefits of converting from mcs to alyx penny schroeder* and elizabeth parker. indiana blood center background/case studies: in , apheresis red cells (arc) represented . % of total red cell collections at our center. hae mcs ln was utilized to collect arc. due to the age of the instruments, challenges with collections on mobiles as well as the need to increase collection of right type products, the decision was made to change technologies. study design/method: fresenius kabi demonstrated the fenwal alyx technology as well as the business case to the primary stakeholders. all implicated departments were involved in the initial impact assessment. a multidepartment kick off meeting was held and project team formed. due to product demands, the decision was made to validate arc and plasma apheresis. the primary departments affected were blood collection and production. fresenius kabi provided sample validation plans, sops, training and training materials for use. four mobile-carts were purchased for easy transportation of alyx and quick-connect feet for installation on mobile buses. the lead trainer and the bc technical administrator traveled to an affiliate blood center to observe their alyx program and identify best practices. a team of blood collection trainers and preceptors were the initial group trained and validation performed. this team also served as the subject matter experts and field preceptors. fresenius kabi returned for advanced alyx operator training. the training plan targeted previous mcs operators first and then operators new to apheresis with a training goal of % of mobile staff. validation of the alyx began / / and took approximately days to complete. during this time, fresenius kabi conducted alyx education and apheresis recruitment training to all collection and recruitment staff. the mcs machines were removed from service / / . alyx go-live occurred / / . additional operator training continued through september . results/finding: due to ease of mobility and use of alyx, reduced procedure time compared to mcs and donor conversion training we increase components collected. alyx disposable kit includes pre-attached solution containers reducing ancillary items required to pack and carry to mobiles. this decreased kit cost by $ . each providing an estimated annual savings of $ , . conclusion: with the multiple alyx donation types we were able to increase our collection of right type procedures by approximately . % and decrease our kit costs by %. with alyx the collection plasma on mobile blood drives is now possible. due to ease of use, operators have embraced this technology and we have consistently met our monthly collection goals from october -march . background/case studies: high frequency of donation is a risk factor for iron deficiency. because females' iron stores are generally lower than males' before they start their donation career, females who donate frequently are particularly high risk. minimum hemoglobin (hb) has long been the same for males and females at g/l, but for males this falls below the normal limit. as a first step to mitigate iron deficiency, criteria for whole blood donors were modified for males (minimum hb increased to ! g/l) and for females (minimum interdonation interval increased from to days). the longer interdonation interval in females was gradually implemented, starting with donor messaging in october , changes in rebooking of donation appointments in december and culminating with eprogesa criteria changes on march , . both these changes are expected to initially result in donation loss, but may be partly counteracted by a decrease in hb deferral rates in female donors. we aimed to assess the impact of these changes on hb deferral rates. study design/method: percentages of hb deferrals were calculated as the number of donation attempts that resulted in hb deferral divided by the number of successful donations plus hb deferrals multiplied by . percentages were calculated for male and female donors before and after changes were made. results/finding: the percentage of hb deferrals increased in male donors from . % in the weeks pre-implementation to . % in the weeks post-implementation of the change in the hb criterion. hb deferral rates for female donors were . % in september, . % in october/november, and . % from december to march, . conclusion: hb deferral was more frequent in male donors after the minimum hb was increased to g/l. the gradual implementation of increased interdonation interval for females resulted in a reduction in deferrals, thus the initial donation loss associated with this change may be partly offset over time by decreased hb deferrals. a longer observation period is necessary to confirm these findings and assess impact on phenotyped blood and donor retention. in the past years, , blood products, derived from , procedures, were distributed to different investigators in over laboratories. whole blood was the most common product ( . %), followed by unmanipulated mononuclear cell collections ( . %), and elutriated monocytes or lymphocytes ( . %). less common requests included platelets ( . %), plasma ( . %) and granulocytes ( . %). adverse donor reactions were infrequent ( . % of procedures). conclusion: we report the feasibility of a program for collecting and distributing blood for investigators to obtain blood components for in vitro research use, utilizing the staff and resources of a hospital-based blood bank. research blood donation is essential to support laboratory research and to maintain positive relationships with donors who have been deferred from allogeneic transfusion. hospital-based blood donor center's experience with implementing platelet pathogen reduction system kimberly j duffy*, mary m benike, james r stubbs and justin d kreuter. background/case studies: the safety of platelet products has been continually improving due to testing despite the continued emergence of microbial threats. the recent fda approval of platelet pathogen reduction technology will protect transfusion recipients regardless of the new microbial dangers. in order for platelet products to use the pathogen reduction technology, the volume, platelet yield (dose), and concentration must be collected within tight specifications. the objective of this study was to determine the optimal collection settings to enable % collection of pathogen reduced platelets while limiting the loss of products. study design/methods: the collection instrument evaluated for this study has fda approval for platelets suspended in % plasma. the corresponding pathogen reduction system used for the study has kits with different collection specifications. all apheresis collections occurred at a fixed site and pre-platelet counts were performed on a hematology analyzer. the yield scale factor has been established for correlation between the hematology analyzer and apheresis collection device. in order to determine the optimal collection targets, the apheresis collection instrument had a variety of multiple yields and volumes established for collections. staff was instructed to collect the highest available yield per donor. after collection, volume, platelet yield, and concentration data was obtained. this data was used to determine if the product met the specifications for one of the available kits, and if the actual platelet yield was higher than . x , thus meeting the criteria for a double product. results/findings: a higher platelet concentration product is ideal to produce a double product, but targeting products with a platelet concentration greater than x /ml was more likely to be outside the specification of the pathogen reduction kit. the platelet concentration target of x / ml results in discarding products and was quickly removed from instrument settings. collections with a platelet yield as low as of . x and platelet concentration of x /ml were more likely to produce a product that was not within the specification of the pathogen reduction kit. abstract conclusion: the loss of both triple platelet products and lowered postprocessing platelet recovery requires the collection of platelets to be far more precise. the goal of platelet collection has shifted from simply maximizing each platelet collection to an approach that considers optimal collection within the limits of kit specifications. final collection instrument configurations are platelet yield of . x and . x at the volume of mls and platelet yield of . x , . x , and . x at the volume of mls. moving from subjective to objective donor eligibility screening platforms: a blood center's journey angela dirr* and steve cihura . bonfils blood center, bbc / bsi background/case studies: in , the device used by bonfils blood center to determine donor hemoglobin and donor eligibility was reaching its end of life, and bbc needed to define a path forward for a reliable replacement device. study design/method: bbc evaluated devices with the following criteria in mind: ) device disposable costs, ) reagents/controls/quality control, ) objective hgb/hct measurement, ) portability and durability for a mobile environment, ) ease of use, ) donor experience, ) battery life, ) validation requirements plans, ) blood center suitability, and ) ability to link to becs. multiple departments including donor care, equipment management and validation, quality, and regulatory affairs were involved in the evaluation and product selection. bbc tested donors per each device at both a fixed and a mobile site. bbc also considered donor feedback for the choice of replacement technology. the project started february with a targeted implementation date of july . after creating necessary sops and adopting existing sops, bbc successfully completed the validation of the devices, and chose the compolab technology from fresenius kabi as the new device for bbc blood bank. results/finding: the compolab was selected as it met project scope and selection criteria. it was important for bbc to reduce paperwork and daily tasks. the compolab eliminates daily qc reducing paperwork, time and improves error management. after converting to the new technology, bbc donor deferral rates increased by approximately %. as a consequence to this increase, bbc conducted reminder training with bbc staff to ensure proper sampling technique and higher sample quality. over time, bbc deferral rates stabilized to . % in and . % in . during this time period, bbc also successfully recruited new blood donors to bbc program, which may have contributed to an increase in deferral rates. in , the deferral rate increased again, probably due in part to the fda final rule "requirements for blood and blood components intended for transfusion or for further manufacturing use", which went into effect in may . conclusion: during the evaluation for new equipment, bbc learned that it is critical to understand the equipment's life cycle and the effect the equipment has on all aspects of the business. after comprehensive evaluation of multiple donor eligibility screening platforms, the compolab device was selected at bbc facility. it met the majority of all aspects of the project scope and qualifying criteria. bbc also learned that continuous refresher training of the staff ensured optimal device performance, and how external factors such as changes to the regulatory environment may impact deferral rates. flowmetry on platelet apheresis. tetsu yamamoto* , ayumi araki , hiromi sanyoshi , hiromi kanai , hiroya kikuchi , katsushi tsukada and kazuhide mure . hokkaido red cross blood center, japanese red cross hokkaido blood center background/case studies: vasovagal reaction (vvr) is known to be the most common adverse reaction to blood collection, but effective measures for preventing vvr have not yet been developed. effective timing of interventions during apheresis donations in particular should hold the key to predicting vvr, but no research has been done on the topic. study design/methods: this study investigated the potential to predict vvr from fluctuations in peripheral blood flow measured by laser doppler flowmetry in platelet apheresis donors, a population highly likely to experience vvr. data were collected from individuals who donated platelets during the -month period between february and august , and data from the donors who experienced vvr were analyzed. to calculate the level for issuing vvr alert, the percent decrease in blood flow (dbf) and the percent decrease in heart rate (dhr) were calculated, the time from alert to vvr was estimated for three dbf levels, and the detection performance of each alert level was calculated. results/findings: eight of the men ( . %) and of the women ( . %) experienced vvr. one donor did not experience vvr during blood collection, but had a delayed reaction while resting afterward. mean maximum dbf in the donors in the vvr group was . . %, which was significantly higher than the . . % in the non-vvr group. at a maximum dbf threshold of %, sensitivity for discriminating between vvr and non-vvr donors was . % and accuracy was . %. when % dbf was used as the alert level, alerts were issued for donors, including in the vvr group. therefore sensitivity for predicting vvr was . % and specificity was . %. mean time from alert to diagnosis in the vvr group was . . minutes, and accuracy of the alert was . %. some of the vvr could not be predicted even the value of maximum dbf exceeded %. the reason was supposed to be the difference of donor susceptibility on dbf. conclusion: we investigated whether vvr in platelet apheresis donors can be prevented by prediction and found that it is possible to predict vvr early enough before onset to intervene by monitoring dbf in real time during blood collection using laser doppler flowmetry. future research must also investigate whether the incidence of vvr can actually be reduced by interventions such as adjusting extracorporeal circulation. the risks of alloimmunization in sickle cell patients using c, e, k negative blood: experience of a hospital apheresis and transfusion service grace banez sese* , , salam abdus and shabrina shah . inova blood donor services, inova fairfax medical campus, inova fairfax medical campus transfusion services background/case studies: red blood cell (rbc) transfusion is often a lifesaving measure for patients with sickle cell disease (scd). it is critical in the management of scd complications such as splenic sequestration, stroke, priapism, iron overload and acute chest syndrome. a wellrecognized complication of chronic transfusion in scd patients is alloimmunization to rbc antigens. to prevent alloimmunization, transfusion with rbcs negative for c, e, and k antigens has been advocated. this has led to reports of reduction in the rate of alloimmunization and a decrease in hemolytic transfusion reactions. we report a summary of our three year experience with the prophylactic transfusion of rbc units negative for c, e, k antigens for scd patients during red blood cell exchange transfusions (rbcx). study design/method: retrospective review of scd patients with a history of stroke, refractory sickle pain crisis and priapism was done. rbcx was performed every to weeks from december to march . blood bank work-up used the mts gel method for antibody screen and identification. our hospital-based donor center proactively works with the hospital blood bank in preparing these units in a timely manner. results/finding: a total of patients, females and males, who underwent a total of rbcx from october to march , using an average number of rbc units per rbcx. rbc units negative for c, e, and k antigens were used during rbcx for patients. two patients positive for c antigen underwent rbcx, using e and k antigen negative rbc units. review of the antibody screen test results performed prior to each of the rce showed that no new clinically significant alloantibodies were formed after exposure to multiple rbc units. conclusion: although there is no consistent standard of care in transfusion practice related to the extent of antigen matching for scd patients, studies suggest that the standard of care for transfusion of all patients with scd is to provide rbc negative for c, e, and k antigens. this ability to find these rare units is also affected by the characteristics of one's institution and blood supplier. it is an advantage to have a hospital based donor center to work with, as we proactively collaborate with them to provide these rare units. the approach by our institution to transfuse rbc units negative for c, e, k or study design/method: venous blood specimens of healthy volunteers were collected before blood donation and after blood donation immediately, day, week, weeks, and weeks among men and weeks among women. immunoglobulin g (igg), immunoglobulin m ( igm) , immunoglobulin a ( iga)and complement component ( c ) , red blood cell (rbc), white blood cell count ( wbc) , hemoglobin (hb), hematocrit (hct), and serum iron (fe) , were measured to monitor he dynamic changes of these biomarkers and blood quality. results/finding: the level of igg slightly decreased after blood donated immediately, iga and c decreased significantly but still within their normal ranges, igm did not change after blood donation. the level of iga significantly decreased at weeks among men and weeks among women, while c significantly increased at the same time period. igg, rbc, hb, hct and fe started to recover week after blood donated and reached their levels before blood donated within weeks among men and weeks among women. conclusion: the biomarkers mutually changed over the course of weeks among men and weeks among women. donating ml blood will not significantly affect overall blood quality. utilizing amicus dxt relay data managment solution to increase platelet split rate and improve amicus productivity janelle wilhelm* and jennifer kaluza. memorial blood centers background/case studies: with the increase in platelet demand and the opportunity to export products we set an initiative to increase the platelet products collected form our existing donor base. we also faced the challenge of managing multiple collection sites in multiple states. the decision was made to implement amicus dxt relay data management solution to provide us insight into procedure details to make data driven decisions. day to day variability previously dipped as low % split forcing reactive planning. study design/method: incorporate dxt to strategically plan our day to day operations. dxt reports were monitored by management and with the fresenius kabi team for productivity by site, phlebotomist and device. reports measured target vs actual yield, donor parameters, and procedure events to perform a donation opportunity analysis. this allowed us to adjust configuration settings when appropriate to improve the accuracy of the yield prediction. reports by phlebotomist were utilized for training on how to optimize the donor's gift to donate an additional platelet or plasma product(s) and increase procedure success rate. results/finding: the monthly dxt report analysis resulted in device configuration improvements, phlebotomist and center manager accountability, effective training, and donation optimization we increased our overall platelet split rate percent and increased concurrent plasma collections by percent. with utilization of the dxt reports we are able to take a proactive approach allowing us to predict product availability, with day to day variability dropping no lower than percent split. phlebotomist qns rates were easily monitored regularly (daily, weekly monthly) resulting in a decrease in our overall qns rate to consistently below percent. conclusion: dxt was easy to implement, is very user friendly and will continue to help improve our platelet collection and process improvements between donor centers. dxt provides invaluable tools for the operational supervisors to monitor their staff and improve productivity at their multiple sites. next step is to develop the plan for implementation of paperless documentation with dxt and healthcare-id. the ability to immediately review data directly from amicus was key in the productivity improvements realized. evaluating the impact of a background/case studies: as blood and blood products are limited and expensive resources, they are prescribed, handled, stored and transfused according to hospital guidelines established to ensure that the best practice standards are maintained for patient safety. it is a prerequisite for all registered nurses (rns) involved in blood and blood product administration to possess fundamental knowledge of transfusion practice. aim: the aim of this study is to evaluate the impact of a hospital-based transfusion practice training program among registered nurses, through administration of a knowledge-based questionnaire before and after implementation of the program. the results gathered would identify gaps in assimilation of knowledge and suggest improvements to the design and implementation of specific content in the nurse-led transfusion training programme. study design/method: all rns from various units and departments were invited to participate in the blood transfusion knowledge questionnaire in october . after which, a formal transfusion practice training programme was introduced, consisting of an online learning platform and in-service training sessions. the same questionnaire was administered to the rns one year later in september for post-training programme evaluation. individual item scores and proportion of nurses with perfect scores was compared pre-and post-implementation. results/finding: in and , a total number , rns and rns completed the questionnaires, giving a response rate of . % and . % respectively. the overall mean score in was . points (range to ). the mean score in was . points (range to ). the percentage of rns having perfect scores of increased from . % in to . % in . table i below shows the results for each question item. the implementation of a hospital-based, nurse-led transfusion practice training programme has led to encouraging improvement in blood transfusion knowledge amongst rns. further training may be needed in the preparation of blood sets and management of fever. background/case studies: clinical use of blood has shown to be the least developed part in the vein-to-vein transfusion chain. this global survey was therefore carried out in order to investigate the level of awareness, accessibility and utilization of e-continuous learning and quality of blood use among blood prescribing clinicians and nurses. study design/methods: a descriptive 'ex-post facto' survey design was used; purposively selected blood prescribing clinicians and nurses from hospitals in countries of the human development index (hdi) groups (low, medium, high, and very high) participated. three research questions were answered, while seven null hypotheses were tested at . level of significance. descriptive statistical tools (frequency counts and percentage) were used to analyze the demographic backgrounds, while inferential statistics -pearson product-moment correlation coefficient (ppmc), analysis of variance (anova), were used to analyse the hypotheses. results/findings: quality of clinical use of blood was positively and significantly correlated with levels of awareness (r . ; p . ; df ) and accessibility (r . ; p . ; df ) to e-continuous learning among blood prescribing clinicians/nurses. there was significant difference in levels of awareness [f( , ) conclusion: today e-continuous learning has become a conditio sine qua non to effective and quality clinical use of blood. the higher the hdi level the better the awareness, accessibility and utilization of continuous education, both through e-learning and conventional programs. there is a better awareness among clinicians routinely prescribing blood as compared to others involved only incidentally in blood transfusion. accessibility of e-learning depends highly on the presence of a sustained societal infrastructure which is less guaranteed in the low and medium hdi countries; reliable power supply, maintenance of hardware tools and updated software programs, together with the necessary knowledge and skills of e-technology are prominent factors. the results are used for policy and strategy recommendations to improve knowledge and clinical practice through continuous e-learning programs eg, starting at undergraduate medical and nursing schools and continuing at postgraduate vocational medical specialization institutes, principles of clinical transfusion practice should be comprehensively included through appropriate and timely curricula; creation of a technical climate to guarantee access to e-learning courses and materials; stimulation of national and international exchange of e-learning programs focused on continuing education; creation of an e-learning mentoring network through professional societies, associations and education institutes. background/case studies: transfusion medicine (tm) didactic teaching materials for pathology residents are not widely available to share among residency training programs. the advancing blood knowledge (abo) leaders project is a novel approach wherein education materials are created collaboratively through a community of practice (cop). educational theorist etienne wenger defined cops as groups of people who share a concern or passion for something they do and learn how to do it better as they interact regularly. study design/method: as a pilot project, junior faculty co-investigators from west coast institutions each had months to create a minute powerpoint presentation on a fundamental tm topic, after which other members had months to review and edit. therefore, each member created and reviewed presentations (three total steps). during each step, members wrote multiple-choice questions for those particular topics. in the end, each topic would have quiz questions to assess learning. at completion, evidence-based, peer reviewed presentations would be available for all members to use for teaching pathology residents. three methods were planned to measure effectiveness of these materials: ) pre and postlecture abo leaders exam using the questions made for each topic to assess learning; ) pre and post-lecture question validated examination (best collaborative) to assess learning; ) resident in-service examination trends specific to tm. results/finding: six presentations were developed as of the abo leaders members continue to participate in this cop for tm education. abo leaders and best pre-test results are shown in tables and . abo leaders pre-test data could not be obtained for institution b, and trainees declined to participate in the examinations at institution a. challenges experienced by the cop have included heterogeneity between institutionsÕ resident schedules, balancing time dedicated to the group given busy schedules, and difficulty in giving all presentations during the defined institution-specific teaching period. post-test results will be included when assessments are complete. conclusion: despite logistical and organizational challenges, it is feasible to create a multicenter cop for tm education. the impact of such a group on resident learning will be assessed and plans for growth will be evaluated. background/case studies: the traditional educational curriculum for the pathology residency program is primarily based on didactic lectures, casebased presentations, and discussion of on-call cases. the use of dramatic vignettes has proven to be an effective educational tool to illustrate complex and multidisciplinary topics in medicine. our goal is to use and evaluate the relevance of this approach in resident education. study design/method: a clinical vignette based on a placenta accreta case was written by a pathology resident during the transfusion medicine rotation. during a two-week laboratory management course, residents prepared for the dramatic vignette performance with a focus on transfusion medicine and laboratory management topics. each resident completed a question preand post-test on topics related to the vignette. several meetings for review and adaptation of the script, topic discussion, and rehearsals were held. there were several commonly encountered problems and deviations from the standard operating procedures that the residents in the audience were asked to identify prior to the performance. during the skit, each resident presented at least one major transfusion management teaching point. results/finding: the educational activity, including the minute vignette performance and the minute discussion, was completed with a focus on: communication between the operating room and the blood bank during surgery, maximum surgical blood order schedule, pre-transfusion testing, transfusion safety, informed consent, massive transfusion protocol, emergency release blood products, thromboelastometry interpretation, patient safety, adverse events, and root cause analysis. all performers significantly improved their scores in the post-test (mean %) when compared to the pre-test scores (mean %) ttest p< . . during the vignette discussion, residents together identified all the intended non-conformances and answered related questions. residents in the audience actively participated in the post skit discussion and % reported a satisfactory learning experience. conclusion: dramatic clinical vignettes can illustrate multidisciplinary complex interactions that are of pivotal importance in the daily activities and professional development of pathology residents. with specific structured goals, clinical dramatic vignettes can be used as a complementary educational tool to illustrate challenging topics in an integrative way that is enjoyable and easy to understand and remember. the skit performers benefit from the activity further by preparing and extensively studying the topics to deliver a multifaceted and coherent presentation with emphasis on the integral role of the laboratory and transfusion medicine in patient care. hannele sareneva*, susanna sainio, inna sareneva, tiia kivipuro and taru jaske. finnish red cross blood service background/case studies: the finnish red cross blood service (frcbs) is the nationwide blood service provider in finland, responsible for collection, testing, processing and distribution of blood products to all hospitals and health care providers. the frcbs serves as the national blood group reference laboratory and provides a wide range of other laboratory services e.g. tests for hemostasis and tissue typing for possible donors as well as patients waiting for organ or stem cell transplantation. frcbs also performs antenatal blood group and rbc antibody tests covering whole country. as a sole national operator we are providing educational services to ensure the safe use of blood products as well as accurate use of our laboratory services. study design/methods: we have performed customer surveys to healthcare professionals to assemble the needs for education. based on these results and continuous feedback frcbs provides hospital customers in blood banks and clinics the following additional services: * regular education * e-learning application of transfusion medicine * handbook for blood products on the web site * reports to hospitals for their use of blood products * annual national blood safety reports regular elements of our educational program are the practical, problem solving course for blood bank personal and safe transfusion training day for clinicians. for every education we collect numerical feedback as following: "how did the education responded your expectations" and "can you utilize the knowledge in practice". we also inquire "how likely you would recommend the training for your colleges" indicating net promoter score (nps). results/findings: more than healthcare professionals participate training days at frcbs annually. in addition our experts give tens of lectures at hospitals across finland. feedback from educations has been very good, varying between . to . (in the range of - ). nps varies between and . according to customer surveys frcbs provides appropriate education to healthcare professionals. this score has increased - from . to . . conclusion: feedback, nps scores and surveys ensure that education and training program of frcbs responses to customer needs. hospitals can utilize annual courses of frcbs in their own initiation programs. together with clinical contact persons in hospitals our aim is to ensure patient blood management (pbm) and to optimize use of blood products. we also have plans to increase e-learning applications and the courses of transfusion medicine for nurses and medical students. educational outreach and effect on reporting septic transfusion reactions kathleen m grima* , anne eder , beth a. dy and mary o'neill . american red cross, georgetown university background/case studies: hemovigilance programs to monitor adverse events after transfusion depend on clinicians' ability to recognize and report reactions to the blood center. about in , apheresis platelet donations are implicated in septic transfusion reactions (strs), but this could underestimate the risk because of the difficulty in recognizing delayed or mild reactions. a large blood center designed an educational outreach program to increase awareness of strs and assessed its effect on the rate of str reporting to its national hemovigilance program. study design/method: in dec. , a large blood center developed a web based course on strs for cme/ceu credit. letters were sent to , hospital customers about recognizing and reporting strs, and alerting them to the availability of the course. blood center physicians and staff in sales and marketing also engaged hospital customers directly in discussions about recognizing and reporting strs, using the online educational content. the physicians tracked their interactions. the blood center's national hemovigilance program compared the number of strs reported in the months before and after launching the educational outreach. results/finding: the web based course was completed by more than participants; were physicians. based on a review of the evaluations, the course was highly valued with % of participants rating it excellent or very good. the blood center physicians gave over presentations to hospital customers. reporting of suspected strs in increased by % compared to the prior year. the increased reporting came from specific regions. the total number of strs that met the hemovigilance definitions for definite (culture-confirmed) and probable strs in the nationwide system increased but did not change significantly compared to the previous years. the educational initiative was designed to deliver a consistent message on the risks, recognition and reporting of strs. while the number of reports of suspected strs in two regions increased, there was no meaningful change in the overall reporting of suspected or confirmed strs across the national blood system. this finding could reflect that hospitals already recognize and report medically significant reactions or that the target audience was laboratory personnel and physicians in transfusion medicine, but not the clinicians closest to patient care at the bedside. more targeted educational efforts provided by personnel who interface with hospitals could be used to address identified professional practice gaps in transfusion medicine. implementation of subscription-based cgmp e-learning laurie mcgraw*, courtney saphier, helene belton, sallie bittner and ward scott. gulf coast regional blood center background/case studies: previous cgmp e-learning courses we developed required - minutes for learners to complete. while feedback was positive, manufacturing areas struggled to schedule time for staff to complete courses within their assigned schedules. at the same time, a shift in design trends suggest that subscription-based learning is more effective (thalheimer, .) subscription-based e-learning utilizes - minute modules, delivered at regular intervals. this changes the learning process from a singular event to a regular interaction that reinforces learning and keeps the content at the top of the learner's mind. study design/method: we began developing cgmp subscription-based elearning in by selecting our first five series topics: equipment, personnel, labeling, sops, and records. the first topic, equipment, was divided into modules on selection, validation, calibration, quality control, and maintenance. these modules, and pre-and post-quizzes for the equipment series, were developed and assigned to employees in manufacturing-related jobs using our learning management system. the pre-quiz was assigned to employees in june , with a new equipment module assigned each month for the following five months. the series concluded in december with the post-quiz. results/finding: using surveys, assessments and incident reports, we evaluated the training effectiveness using three of the four kirkpatrick levels. while our previous cgmp courses received good ratings from learners, the equipment series received the highest rating of . on a -point scale. of employees who completed all versions of our cgmp courses, the majority preferred the equipment series over all previous courses combined. comments clearly demonstrated that learners preferred the short, subscription format over the previous courses with positive and negative comment. level : learning the average score of users increased % from the pre-test to the posttest, with the greatest improvements noted in the scores from laboratory employees. a two-sample t-test determined the result to be statistically significant with a t-critical value of . and a t-stat value of . . level : results while equipment-related errors decreased by % after training, there is not enough data to demonstrate a statistical significance. conclusion: our level and evaluation data validated that the subscription approach was effective. knowledge increased from the pre-to postquiz, learners reported that they appreciated the shorter training, and they completed the modules without special scheduling requirements. as a result, we are continuing development of the remaining series. background/case studies: the interdisciplinary nature of transfusion medicine requires the collaboration of multiple work units for efficient patient care, but departmental "silos" impede collaboration between transfusionrelated care teams. we hypothesized that regular educational meetings would improve knowledge and awareness of each department's role, so in october , a multidisciplinary educational meeting called friday blood conference (fbc) began as a collaborative, interprofessional forum involving frontline staff of our transfusion practice. during these monthly meetings, which are also broadcast online for those unable to attend in person, presenters from different work units share background information and patient cases before opening the floor to constructive discussion. study design/method: a survey was sent to fbc participants (n ) to retrospectively capture the effect of fbc on interdepartmental collaboration. the survey was structured to obtain formative feedback using the published interprofessional collaborative practice competencies (icpc) as a guide. these core competencies target maintaining a climate of mutual respect, communicating within and between departments, fostering teamwork, and understanding everyone's role in patient care. results/finding: our survey response rate was %. of those, % endorse that fbc creates a climate of respect within our transfusion practice, % believe it has improved communication between work units, and % feel that fbc leads to increased understanding of interdepartmental processes. notably, laboratory scientists and transfusion nurses have the highest attendance rate. furthermore, those attending via the online broadcast report the lowest satisfaction, with only % responding positively. the main reasons individuals attend fbc are to increase knowledge about transfusion medicine, interact with and learn from other departments, hear about patient case studies, and understand the "big picture" of one's role in patient care. suggestions for improvement include preparing questions to help initiate discussion, increasing representation of other areas for broader perspectives during interdepartmental dialogue, and posting recordings of fbc for later viewing. conclusion: the application of icpc in transfusion medicine was an effective lens to assess the value of interprofessional collaboration. although there is room for improvement, the results support that fbc has contributed to better communication between transfusion-related care teams and has increased understanding of interdepartmental processes within our transfusion practice. novel approach to curriculum development: demystifying transfusion medicine ritcha saxena* and ananya saxena. all saints university school of medicine background/case studies: transfusion medicine is an essential element of education required for the future physicians in various disciplines like surgery, internal medicine and anesthesiologists to work effectively with the blood bank personnel. transfusion carries considerable advantages as well as risks. consequently, educational initiatives are required to identify the particular knowledge deficits in transfusion medicine and subsequently, bridge the gaps. and the challenge is to update the undergraduate medical curriculum to reflect the latest enhancements in transfusion medicine. study design/methods: students of undergraduate semester and students of semester participated in the study. self-directed learning resources combined with modules of interactive instruction were implemented in a tbl course design. five education modules focusing on quality management, blood collection, transfusion reactions, precise utilization of blood products and innovations in component safety were designed for the students. the students' reaction to tbl in transfusion medicine was evaluated using qualitative and quantitative assessment tools to analyze knowledge attainment and critical thinking development along with team continuity. the participants were first assessed with readiness assurance testing (rat) to guarantee that they understood the concepts and their application followed by case study based test questions. results/findings: students' reaction to tbl was primarily positive, with % of students giving a positive feedback. evaluation through readiness assurance testing (rat) illustrated improved team knowledge acquisition in implementation of effective quality management systems over knowledge acquired through individual study. students grasped a conceptual knowledge of principles of transfusion medicine and achieved confidence in dealing with transfusion-related complications. anecdotally, students significantly attained perception in blood component preparation, storage and their optimal utilization along with developments in safety techniques in blood donation. conclusion: our study suggests that reforming the medical curricula for undergraduate medical students, with specific educational modules designed to focus on blood banking and blood transfusion principles and latest advances in transfusion medicine, is much required in the interest of patient care and safety, by the future physicians. tbl is an interesting and efficient way to deliver the key aspects of transfusion medicine to the students. results/finding: open house attendees were given tours of the bb, led by a bb attending, bb residents, bb supervisor, or bb quality coordinator. the patient blood management nurse was also in attendance to answer attendee questions and educate about patient blood management. light refreshments were offered to the attendees in the bb break room. the first bb open house was held on wednesday, / / from - am. there were attendees, including a second-year medical student, four regular blood donors at the hospital blood donor center (who were also employees in facilities management and the university office of admissions, respectively), a hospital senior vice-president, six apheresis nurses, two clinical laboratory staff, two medical laboratory science students, and one additional staff member from the university office of admissions. the second bb open house was held on thursday, / / from - am. there were attendees, including regular blood donors (who were also employees in the office of international affairs and supply chain, respectively), a hematology/oncology fellow, and surgical residents. background/case studies: simple, partial, and exchange transfusions are routinely performed in patients with sickle-cell disease (scd) with the goal to increase the oxygen carrying capacity of the blood and reduce the relative percentage of sickled cells. it is essential for clinicians to be able to rapidly estimate the effects of the available therapeutic modalities using clinical information to minimize the risk of red blood cell exposure. given that the formulas for these calculations are complicated, we developed and validated an online calculator to assist physicians with such tasks. study design/method: a web application was generated (www.phamcalcs.com). the performance of the simple transfusion and partial manual exchange calculators were validated by comparing the predictions to clinical data. the performance of the automated and depletion rbcx calculators was validated using the terumo bct (lakewood, co) calculator up to a fraction cells remaining (fcr) % as patients with fcr % may benefit from delaying the procedure for performance in the future. validation process included ( ) a deming regression to globally assess the predicted vs. actual results and ( ) an individual comparison wherein validation was contingent on the (predicted-expected results)/(expected results) demonstrating |d| %. validation was performed for hematocrit (hct) and hemoglobin s (hgbs) level post-transfusion for simple and partial manual exchange and volume of replacement fluid for automated and depletion rbc exchange. results/finding: see table background/case studies: with the focus on new technologies the modern medicine requires more expenses. despite the increase in the target impact on patients there is still a risk of adverse reactions to medical treatment. the issues that are currently under discussion: the use of standardized or personalized approach, for doctors -being multidisciplinary or having a narrow specialization, integration of new technologies, the need for more trainings resulted from knowledge deficiency. in russia, the development of insurance medicine creates the demand for more intensive and cost-effective treatment programs. as a multidisciplinary approach, pbm optimizes the transfusion practice reducing the risk of adverse effects and improving the financial performance of a health care institution. however, the prosperous implementation of pbm also requires supplemental medical competencies that provide harmonization of dialogue logistics: administrator -clinician -transfusiologist. study design/method: at the medical simulation centre of hospital there has been a unique opportunity to launch an educational program for the medical specialists practicing blood components transfusion. the main innovative features of the training course are an interdisciplinary approach, intensive learning performance, comprehensiveness of learning methods. during days ( academic hours) the trainees can attend lectures, discuss the methodical materials, participate in seminars, interactive clinical discussions, a master class and a game that presents the modelling of working processes. since initiating the project in june, with the group capacity a transfusion vol. supplement s of up to people the number of medical specialists who have attended the training is nearly . results/finding: the medical competencies gained: knowledge of modern recommendations on the use of blood components the ability to interpret all parameters of the haemogram, coagulogram and tromboelastogram the ability to unveil the indications and contraindications for urgent and scheduled blood component transfusion personalization of the blood transfusion risks using a personalized approach on selecting the type and the dosing of transfusion habitat predicting the efficacy of transfusion the correction of anemia and hemostasis system malfunctions using the medicinal treatment performing the macroscopic assessment of blood component before the transfusion procedure performing the differentiated diagnostics and ability to prescribe the adverse effect treatment ability to carry out the auditorial check of health cards conclusion: the launch of the program "guidance for safe and effective blood use in adult patients of multi-field hospitals" is aimed to meet the educational and professional needs of medical specialists, develop the algorithmic thinking and a range of useful motivations in case of patient blood management and reach the compliance in practice. the effect of emergent situation drills on technologist teamwork and comfort levels abigail neils*, raeanne stensgard, rebecca wren, elisabeth greer, amy mata and camille van buskirk. mayo clinic rochester background/case studies: teamwork and composure are essential for technologists when dealing with emergent situations in a large hospitalbased blood bank where multiple situations can occur simultaneously. in an effort to reduce errors and improve emergency response, a group was formed to evaluate the effectiveness of emergency situation drills (esd). the esd were based on common emergent situations encountered in the lab and were run once per month per shift. the main goal of esd was to improve teamwork and comfort level during real emergent situations; therefore reducing the amount of unplanned standard operating procedure (sop) deviations. study design/method: prior to esd implementation, a survey was sent to all technologists to determine baseline comfort levels associated with various emergent situations. one year post esd implementation the same survey was sent to all technologists to reassess the comfort levels for the same situations. the surveys asked employees to rate satisfaction and comfort level on a grading scale of - ; being least satisfied/comfortable and being most satisfied/comfortable. the pre and post survey results were evaluated by calculating lab average comfort levels per situation and survey. in addition, unplanned sop deviations related to emergent situations were counted for one year before and one year after esd implementation. results/findings: out of total technologists, technologists took the pre esd survey and technologists took the one year post esd implementation survey. table shows the lab averages from the pre and post surveys as well as the percent difference. out of the employees who responded to the post survey, ( . %) answered "true" to the statement "esd have improved my comfort level with emergent situations." in the year prior to esd implementation there were unplanned sop deviations; in the year after esd implementation there were only deviations. conclusion: all but one area increased in comfort level post esd implementation. also most technologists agreed that the esd helped improve their overall comfort level with emergent situations. the goal of implementing esd has been met based on the unplanned sop deviation decrease and technologist satisfaction increase; therefore esd were deemed effective. monthly esd will continue to be run with the hope of continual improvement in teamwork, comfort levels and deviation levels. therapeutic background/case studies: category i indications for red blood cell exchange (rbc exchange) in children with sickle cell disease include following acute stroke and for stroke prophylaxis, as well as for iron overload prevention. as described in the first installment of this series about therapeutic plasma exchange (tpe), the challenges of access, volume management, and instrumentation persist, as along with the need to address the psychological and emotional well being of this population. rbc exchange is a complicated procedure to explain to adults and becomes an even more intimidating task when translating into the language of childhood. nevertheless, pre-treatment education is shown to decrease the anxiety associated with medical care. providing age appropriate specific treatment information to pediatric patients decreases negative behaviors, reduces stress and promotes faster recovery. a previous project explaining tpe to the pediatric population revealed the lack of age specific literature for apheresis procedures in general, including tpe and rbc exchange. study design/method: in collaboration with a child life specialist, an ageappropriate story-driven explanation of the rbc exchange procedure was adapted from a previously implemented project related to tpe. artwork was produced with the aid of a medical illustrator to complement the story-line. results/finding: the story board addresses why rbc exchange is performed, the steps involved in preparing for and performing the procedure, and strategies for coping before, during and after the procedure. the idea of long-term therapy is also briefly addressed, to prepare these children for the concept of ongoing therapy. the booklet is in production in concert with our hospital's medical illustrator and will be available on our hospital website for patient use. conclusion: using the previously illustrated story as a guide, an explanation of red cell exchange was created to provide education and reduce anxiety. this second installment continues the pediatric series helping to explain apheresis procedures to pediatric populations in the hopes of reducing patient stress and promoting age appropriate coping strategies. transfusion safety officer resource manual leonor de biasio*. it is also intended to be utilized by hospitals that do not have a formal tso position but which have delegated the responsibilities to other staff. the resource provides helpful information to assist with education in transfusion safety, adverse event investigation and reporting, product administration guidelines or monographs, and links to information about the equipment used for infusion of blood. the resource manual will serve as a useful reference tool to assist with a healthcare professional's transition into the tso role. turning on pathogen reduction: a case of flipping the switch kassandra poffenberger*, darla wendt, jennifer vrieze and james r stubbs. mayo clinic background/case studies: a critical aspect of implementing a new method in manufacturing blood products is to develop a training plan that adequately prepares staff but doesn't interfere with production or cause delays in patient care. with the implementation of pathogen reduction technology (prt) using interceptv r blood system for platelets it was understood that we would need more collections to make up for the loss of products, specifically our triple collections. our institution collects the majority of its blood products and supplements inventory from a major blood collection center. it was crucial for the component laboratory to maintain daily processing levels while learning the new method in order to sustain optimal platelet inventory levels without relying on purchasing additional platelets from external vendors. our approach in introducing prt for apheresis platelets was to "flip the switch" and process all products with the new method rather than a step wise roll out with a dual inventory. study design/method: it was essential to prioritize who would be trained first. collections occur monday through friday from to . the first group to be trained was those who would be performing training (a two person team) and product validation; they were trained by cerus deployment team. the second group was those who would process platelets on weekends and evening hours without direct management support. the last group was the technologists who would be working during normal hours with direct management support. prt processing for platelets in % plasma is broken up in to two days. on day platelets are treated with amotosalen and placed in a compound adsorption device to remove residual amotosalen for - hours. on day products are removed from the cad and modified into final product codes and labeled. each technologist was trained one on one, over a one week period. the trainers alternated training processing days for day and day . in the weeks following training it was important that each technologist rotated back thru prt processing to maintain proficiency. results/finding: of employees were trained in a two month time period. prior to "flipping the switch" the daily average of products collected was . for the two month training period the daily average rose to . conclusion: our "flip the switch" training plan for implementing prt platelets in % plasma has been highly successful for our laboratory; training while implementing the new technology did not create a bottle-neck in the process. it was imperative to prioritize who would be trained first to insure complete coverage during off hour shifts. technologists were able to become proficient with the new process while maintaining daily processing expectations and sustaining an optimal platelet inventory. accepted depending on each individual's conscience. due to these unique medical challenges, it is important for caretakers to have an understanding of their beliefs in order to provide optimal care. we describe the process of identifying jw in our hospital and communicating treatment needs to staff. study design/methods: proper treatment of jw requires the ability to identify the patient and his/her needs. when a jw is admitted to our hospital, our electronic medical record (emr) triggers several processes based on the patient's listed religion. one process creates an order that reminds caretakers to complete the declining blood consent (dbc) with the patient. the dbc contains language declining mabf and reviews the mibf with the patient to identify any that would be accepted. the emr order regarding the dbc provides educational links that include a bloodless policy, step-by-step instructions on obtaining the dbc, and information on alternatives to transfusion. a second emr process triggers a stop-gate to prevent the completion of any mabf order or mibf order for a product that the patient has declined. a third enrolls patients in the minimal blood volume labs protocol which uses microtainers, partial-fill vacutainers, and blood reservoir sets to reduce blood loss during draws. additionally, at registration, a bloodless packet is added to the patient's paper chart. this packet contains the dbc, a glossary of dbc terms, a bloodless sign to be placed over the patient's bed, a bloodless wristband to be worn by the patient, and two bloodless chart stickers that are added to the outside of the chart. these steps remind the caretakers of the patient's special requests. finally, the patient blood management (pbm) department receives emr developed reports which identify jw presenting to the hospital. these patients are followed by the pbm nurses and medical director during the duration of care. treatment plans to optimize hemoglobin, oxygen carrying capacity, and hemostasis are discussed with the bedside caretakers and implemented as needed. results/findings: nearly % of jw that enter our hospital have a dbc completed. this has resulted in increased education of the medical staff. in addition, patients have reported better communication with caretakers leading to a more inviting environment for the patients. conclusion: our hospital has found success by using an education-based team-oriented approach involving emr, pbm, and caretakers when caring for the jw patient. this approach has set up a foundation for treating other bloodless medicine patients. background/case studies: transfusion services should provide safe blood components from vein to vein with donors acting as suppliers and patients as final customers. this process involves labor-intensive activities, critical materials, human resources, facilities and highly coordinated processes. cost management has a great impact on technical processes guiding decisions upon supplies and technical staff. activity-based costing (abc) is a method to determine cost drivers within activities and determine process or product final cost allowing managers to take precise decisions. we demonstrate how an effective abc approach can result in financial savings without compromising process quality in a mid-size transfusion service. study design/method: materials costs can represent as far as % of an activity. in we had a central storage supplying satellite storages at each department and replacement was done independent of residual stock. purchases were performed on demand. at the end of we performed a supply inventory on all departments to plan future purchases and control residual stocks. in , we implemented annual purchases and satellite storages were supplied only to replenish programmed stock. cost drivers were defined upon activities on standard operational procedures (sops) resulting in a cost estimate. technical staff was involved in cost driver calculations to indicate possible changes to sops, supplier and deliveries. to minimize seasonal fluctuations we compared last quarter (q / ) with last quarter (q / ). in this work we present activity data from blood collections to illustrate abc method. results/finding: in q / blood bags were used compared to in q / , demonstrating an activity " . %. price negotiation resulted in . % readjustment. both indicated an estimated cost " . % with a possible impact of over us$ , . we have identified a real cost # . % in q / , representing an overall # . % and us$ , . (r$ , . ) savings. conclusion: economy had deteriorated in our country in with higher inflation and exchange rate variations, directly impacting imported materials, most of them critical. even with adverse economy, abc showed to be an effective tool that allowed cost decrease without significant changes in critical materials and processes. cost drivers calculations demanded review of sops and suppliers by technical staff resulting in optimization of activities. also, staff involvement reduced discharged materials since costs were wellknown to area supervisors and satellite stocks were reviewed briefly. automated verification of immunohematology results and the impact to donor testing barbara j bachman* , candace williams , carmen meyer , paul lamonby , anne cleverley and silke milbradt-pohan . bio-rad laboratories, diamed gmbh title: automated verification of immunohematology results and the impact to donor testing background/case studies: staffing challenges in today's blood banks require instrumentation with minimal operator intervention. technology advances have developed where every immunohematology result does not necessarily require operator visual review. this study evaluates the impact of automated result verification on the bio-rad ih- tm immunohematology system through the ih-com tm data management system (dms) for donor processing laboratories. study design/method: a multi-center study was performed on donor samples as shown in table a evaluating two of the most commonly used ih-system gel cards available in the us. workflow data was analyzed using process modellar app (ipad). this study focused on post-analytical steps of result verification, evaluating with and without automated result verification to determine the impact on quality (# operator touchpoints, visual result review occurrence), result accuracy, and speed (time from result interpretation to lis data transfer). operator touchpoints during the post-analytical phase are only required when doing visual result verification and are software defined. speed metrics were analyzed using minitab v , statistical the transfusion team collaborated with multiple user groups to educate them regarding the new processes. a gap analysis was performed to determine the optimal delivery process for blood products, with key stakeholders invited to review the options. the use of the pneumatic tube system to deliver blood throughout the entire campus was investigated to determine whether it would be a viable option given the expanded size of the new campus. results/finding: user groups requested additional training sessions as questions arose regarding use of the ehr for blood ordering. because the pneumatic tube system would be heavily used, and due to concerns that blood products could become "lost", it was decided this would not be the best route for delivery of blood. department educators requested support to create job aids specific to workflow changes impacting their departments, such as how to order rh immune globulin, a cord blood workup, etc. conclusion: leadership was challenged to provide a stable and positive environment during a complex set of changes. the simultaneous hospital move/merger and implementation of a new ehr constituted an arduous task that would not have been possible had substantial preparations not been initiated a year in advance. training is essential to the success for a scope of change this big and should not be minimized. while training was thorough prior to the move, gaps were nonetheless discovered following the move. abstract conclusion: strategic development partners funding and support based on newly developed government strategy on blood service with commitment of the government has brought a positive impact in establishing sustainable and safe national blood service program in ethiopia. even though the identified positive impacts mentioned are achieved, the bts remains with multiple challenges and needs continuity of funding and more partner support and government commitment. pilot implementation of a comprehensive hybrid performance management system at national blood service zimbabwe blessing mukwada*, judith j parirewa and tonderai mapako. national blood service zimbabwe background/case studies: the national blood service zimbabwe (nbsz) introduced its first performance management system (pms) in . in the - nbsz strategic plan it was noted that the current pms lacked objectivitety and there was no relationship between perfomance and remuneration. in order to revise the pms, the nbsz set up a three membered committee at the executive management level to spearhead the revamp of the nbsz pms. the aim of the new pms was to achieve a shared vision of the purpose and objectives of the organization, helping each staff member to understand and recognize the contribution to the strategic plan. in this paper, we share how nbsz revamped and implemented its new hybrid pms that derived its inputs from established pmss and nbsz monitoring and evaluation (m&e) process that have been linked together. one-selected departmental results for one quarter are shared to demonstrate how the system works. study design/method: pms committee developed and shared with executive management a pms conceptual and implementation framework. consultations including field visits were done on three established pms to assess suitability for nbsz adoption. a hybrid pms was adopted for nbsz and a pilot application for one quarter on selected department was done. review of policy, procedures to including hybrid pms templates and forms were done. pms committee trained all staff on how to implement an integrated scorecard, how to conduct appraisal, how to develop scorecards, how to measure performance using the new pms, how weighted performance reward systems based on all layers of performance for bonus payments works using standardised tools. throughout the process risk assessment were done. results/finding: the nbsz hybrid pms is based on five levels of planning namely strategic, departmental, branch, sectional and individual. the fourcoloured traffic light reporting system is central in uniformly assessing performance at all levels. the levels of accountability were properly defined for each level of planning. a weighted overall integrated individual scorecard (iis) is determined based on % individual and % for the other four levels ( % for each). the bonus (%) is calculated based on the iis as follows; category a: % (iis > %), category b: % (iis: -< %), category c: % (iis: -< %) and category d: % (iis < %). on the pilot implementation, the individual scores for staff ranged from % to %. the iis were % to %. the number of staff in each bonus categories were , % (category a) and , % (category b). conclusion: the new hybrid pms was generally accepted by all staff and it was easily implemented at various staff levels. this provides a basis for the full implementation of the new pms and this simplified pms can be easily be adapted in similar settings to ensure all staff contribute sufficiently and objectively to the realisation of the organisation strategic vision. rare donor engagement with american rare donor program (ardp) margaret c manigly* , deborah r fludd and sandra j nance . background/case studies: rare donors are defined as a blood type occurring in less than in people in a given population. these donors are discovered by testing new donors in a random or targeted way and require testing many donors to find one rare donor. once found, if the facility is a member of the american rare donor program (by being an aabb accredited or american red cross accredited irl), the donor is registered in the ardp database as a rare donor. in , there were , active rare donors in the ardp. with the mobility of the population in the usa, it is important that as donors relocate, that they are recognized as a rare donor when they donate and their unit can be identified and used for a patient with a rare blood need. in addition, when recruitment is needed for a patient need, correct contact information on the donor is required. study design/method: the ardp procedure for ardp members requires that donors be contacted every six months to ensure that ardp (or the facility) has their latest contact information. the timing is determined by the postal service time limit of six months to forward mail to a new address. this contact ensures that if recruitment is required to obtain blood for a patient with a rare blood need, the donor can be contacted by the collecting center to donate. this contact is achieved by ardp sending a contact card by postal mail twice yearly to all donors for whom the ardp has address demographics. results/finding: the ardp reports on the information obtained from the contact cards returned in the ardp annual activity report to the ardp members at the aabb annual meeting. of the ( . % of total active donors) returned contact cards alerting ardp of changes in calendar year , ( . %) were donors moving from one ardp facility to another, ( . %) were donors no longer eligible to donate, and an additional ( . %) were address changes. other changes were ( . %) reactivated donors and ( . %) donors who we were notified were deceased, or did not want to be listed in the ardp. in , new rare donors were submitted to ardp for registration. the number of donors that could potentially be lost to follow-up in was ( ), which would be . % of the new donors submitted. conclusion: with nearly a % response rate for donors receiving the mailed contact cards, it is clear that rare donors (and their families) are responsive to the ardp contact card, and inform ardp of address changes and changes in their health status that affects their ability to donate. this is evidence of the importance of the card in ensuring correct donor contact information. in , donors changed their addresses which often are not known to the collecting facility until the donors donates again, after their move. the ardp contact card is effective in retaining the relationship with the ardp registered donors and keeps the address information of rare donors current. workflow comparison of two gel analyzers in a large transfusion service j peter pelletier* , barbara j bachman , mike leamy , susan olson and candace williams . university of florida college of medicine, bio-rad laboratories background/case studies: vendor-assisted workflow studies are becoming more popular as analyzer choices and capabilities vary in the market. the purpose of this study was to evaluate the provue (ortho clinical diagnostics) against the ih- (bio-rad laboratories, inc.) in a large volume transfusion service using lean process flow. study design/method: twenty-two ( ) runs of one to six ( ) samples per run were observed for two ortho provues alternating testing at a large transfusion service performing , types, screens, type & screens (t&s) annually. the workflow patterns observed were then repeated on the ih- and compared. each process was mapped in detail by direct observation using process modellar app (ipad). the evaluation started at sample centrifugation completion and ended with results sent from analyzer to lis (lab information system). each was evaluated for quality (testing process steps, biohazardous exposure episodes, and maintenance tasks), speed (operator/analyzer time) and cost (testing/maintenance personnel hours recaptured). time studies were analyzed using minitab v , and statistical significance was assessed using the paired t-test, with p values of < . considered significant. regardless of quality or speed metrics evaluated, the ih- demonstrated a significant reduction (improvement) in process steps and associated times when compared against the ortho provue (p < . ). ih- process steps and time studies addressed in the table below did not account for the ih- reagent storage capacity. in reality, the improvements would be greater than what was displayed here in a real-life operation. evaluating the total number of maintenance tasks required annually, as well as the times associated with maintenance performance, there was a significant reduction on the ih- ( % reduction, a difference of hours/year). conclusion: this study verified the ih- provided significant efficiencies and cost avoidance over the ortho provue for a large volume transfusion service. workflow comparison of two high volume, high throughput analyzers aaron samson* , kimberly monnin , barbara j bachman , kyla warren , susan olson and candace williams . clinical pathology labs, bio-rad laboratories background/case studies: few workflow studies have been performed on high volume, high throughput blood bank analyzers in large volume testing facilities. the purpose of this study was to evaluate the galileo v r neo (immucor) against the ih- tm (bio-rad laboratories, inc.) using lean process flow. study design/method: a total of separate test runs of or samples per run were observed over a three day period on the galileo neo at a reference laboratory annually performing approximately , type & screens (t&s). the workflow patterns observed were then repeated on the ih- and compared. each process was mapped in detail by direct observation using process modellar app (ipad). the evaluation started at sample centrifugation completion and drop-off in testing area and ended with results sent from analyzer to lis (lab information system). each was evaluated for quality (process steps, biohazardous exposure), speed (operator/analyzer time) and cost (testing/maintenance personnel hours recaptured). time studies were analyzed using minitab v , and statistical significance was assessed using the paired t-test, with p values of < . considered significant. results/finding: detailed process steps, biohazardous exposures, and published analyzer maintenance tasks were evaluated/compared (table, part a) . time studies focused on operator time, analyzer time, and maintenance time (table, part b). regardless of quality or speed metrics evaluated, the ih- demonstrated significant reduction (improvement) in process steps and associated times when compared against the galileo neo (p < . ). evaluating the total number of maintenance tasks required annually, as well as the times associated with maintenance performance and downtime, was a significantly reduced on the ih- (difference of hours/year). conclusion: this study verified the ih- provided significant efficiencies and cost avoidance over the galileo neo for high volume/high throughput testing facilities. workflow impact of automated result verification for patient and donor blood typing barbara j bachman* , candace williams , carmen meyer , paul lamonby , anne cleverley and silke milbradt-pohan . bio-rad laboratories, diamed gmbh background/case studies: immunohematology facilities face many challenges including standardization, process control, productivity, staffing and patient safety. to alleviate these challenges, the ih- tm instrument and complementary ih-com tm data management system (dms) were designed to provide lean automation to enhance blood testing facility workflow. the purpose of this study was to focus on the lean functionality of automated result verification on the ih- and ih-com dms and determine its impact on workflow. study design/methods: internal and external studies using the ih- with the ih-com dms were performed with patient and donor samples. assays included abo/rh blood grouping and antibody screening (abs) as shown in table a . workflow data was analyzed using process modellar app (ipad). the evaluation focused on post-analytical steps of result verification, evaluating with and without automated result verification to determine the impact on quality (operator touchpoints, visual result review occurrence, result accuracy), and speed (time from result interpretation to lis data transfer). operator touchpoints during the post-analytical phase are only required when doing visual result verification and are software defined. speed metrics were analyzed using minitab v . statistical significance was assessed using the paired t-test, with p values of < . considered significant. results/findings: using automated result verification, only . % out of , samples evaluated for abo/rh testing would require visual verification, resulting in a % reduction in operator touchpoints (p < . ) and a labor saving of minutes ( : hh:mm) for abo/rh testing. for , antibody screens, automatic validation of results would result in . % reduction in operator touchpoints (p < . ) and a labor savings of minutes ( : hh:mm). no false positive or false negative typing results or false negative screenings occurred with results auto-verification. (rbc) has remained, and in fact is proportionally increasing while blood usage has notably declined in the era of patient blood management. over the past years a steady increase in demand for o neg rbc compared to other blood types has been observed at our blood center. utilization metrics for hospital customers are monitored monthly for overall trending and forecasting and the data shared with them during regular visits. despite heightening awareness, percent o neg rbc sales continued to rise by % annually and peaked at % in mid . to better understand this increased demand a survey was conducted to gather insight for improved utilization. we speculated that during the survey an observer effect, or change in the staff behavior, would result in reduction of o neg rbc sales. study design/methods: a tie tag was designed as a survey tool and attached to each o neg rbc distributed to hospital customers for an week period in late . hospital transfusion service staff were asked to record the final disposition of the o neg rbc (transfused, wasted, returned) on the tie tag. information on the survey objective and instructions for tie tag completion were communicated via customer meetings, emails and reminders sent by blood center drivers. completed tags were returned to the blood center. customers are allowed to return rbc units with greater than day shelf life remaining. units with tie tags attached were in hospital inventories for up to months due to the shelf life of rbc. return rates and percent of net sales (gross sales minus returns) by abo/rh type were tracked monthly before, during and after the survey. results/findings: participation was % of the hospitals surveyed. mean percent o neg rbc gross sales for a month period before, during, and after the survey was . %, . % and . %, respectively. mean percent o neg net sales during the -month survey fell to . % compared to an average of . % in the months prior. during the -month survey period o neg rbc monthly return rate increased to an average of . % compared to an average of . % in the months prior. for the months after the survey the average o neg rbc return rate further increased to . % while mean percent o neg rbc net sales trended slightly upward to . %. when customer hospitals were queried whether any process changes occurred, no major changes to policy or inventory levels were reported. conclusion: during and after the survey percent o neg rbc gross sales was fairly constant indicating that target inventory levels and transfusion service staff ordering practices remained unchanged. however, during the same period the increase in o neg rbc return rate and corresponding decline in percent net sales suggests improved o neg rbc utilization. increased awareness from participating in the survey and staff knowing they were being observed likely played a role in the lowering of percent o neg rbc net sales. tracking of monthly metrics will provide ongoing review to determine if the effect is transient or sustained and identify other opportunities for improving o neg rbc utilization. acoustophoretic separation of platelets from whole blood: a relevant and practical alternative to centrifugation pierre bohec* , jeremie gachelin , veronique ollivier , thibaut mutin , xavier telot , benoit ho tin noe and sandra sanfilippo . aenitis technologies, hôpital bichat, inserm u background/case studies: shear-induced platelet activation is an unwanted side effect of the centrifugation-based procedure currently used in blood banks to prepare platelet concentrates. transfusion of partly activated platelets could indeed increase the risk of adverse transfusion reactions. aims: here we evaluated the effectiveness of an innovative acoustic-based fractionation device by carrying out a qualitative and functional in vivo analysis of isolated human platelets. study design/method: whole blood was obtained from donors and fractionated using an acoustic-based device. platelet recovery and purity were determined by quantifying blood cell subpopulations in the microchannel outlet samples. quality of isolated platelets was evaluated using the surface expression of two activation markers (p-selectin, pac ) using flow cytometric methods while their procoagulant ability was investigated using in vivo experimentation. platelets isolated using a soft-spin protocol, were used as inactivated control. results/finding: fractionation using the acoustic-based device led to a red blood cell clearance ratio from whole blood greater than % (p< . ) and a purity of platelets close to . %. we did not find any difference in terms of quality and functionality of platelets from the same donors isolated using the acoustic device versus the soft-spin protocol. conclusion: this acoustic-based blood processing method led to excellent preservation of platelet quality and functionality providing a novel promising technique for whole blood fractionation in clinical settings. automation in blood bank processing: where we go? robert fernandez, lluis puig, pilar ortiz, joan ovejo, nuria martinez, elena valdivia and susana g gomez*. banc de sang i teixits background/case studies: nowadays, blood banking is requiring new strategies to manufacture blood components, due to the increase on their production. at banc de sang i teixits (bst), we have implemented during the last years automation manufacturing, including lean management methods, to be able to process our needs of over . blood donations for an area with more than million people. study design/method: the automation of blood donations process, bst has done different changes on the equipment. in , orbisac (terumo bct) was the equipment to obtain buffy coats and from this product, we got platelets concentrates. it was in , when we moved from this equipment to atreus c (terumo bct), to get red blood cells, buffy coat and fresh frozen plasma. then we did some updated on atreus; in we changed to atreus c (terumo bct) and finally in , we moved to reveos system (terumo bct). since the changes in , our blood components were red cell concentrate, plasma, platelets and a leukocyte residue. while all these changes in processing equipment, we added also some automation in our registration (donation id, weight and temperature) and labeling steps, implementing two homemade robots. and finally, to get better results and more efficacy in our production, in , bst incorporated an engineer to introduce lean manufacturing methods. these methods are based on the identification and analysis of problems, and then chose all these activates that add some value to the procedure. results/finding: once all these changes have been updated, we have evaluated the quality of blood components, such as red cells and platelets, also the number of donations that we were missing and working hours that were necessary to process our blood donations. this evaluation was done for processes during and . conclusion: with these results, it's obvious that automation in blood banking makes more efficient the manufacturing of blood components, getting better quality of them and also in a cheaper way. we encourage maintaining lean philosophy in order to keep improving our methods and identifying those activities that add value to our processes and get rid of those ones that are not necessary. in a globalized and industrialized world, where everything changes very fast, these improvements are necessary to be on top of the field and be a state of the art blood bank. background/case studies: the laboratory envisioned an automated blood product delivery system that extended blood access to the bedside through the use of remote blood allocation devices, or "smart blood refrigerators" to improve patient safety, provide timely access to blood products, and potentially reduce laboratory workload. as part of this initiative, bloodtrack haemobanks (hb) (haemonetics, braintree, ma) were installed and interfaced to the existing safetrace tx (haemonetics, braintree, ma) laboratory information system. one hb was installed in the methodist hospital (rmh) campus which includes a busy outpatient infusion therapy center (itc). study design/method: an assessment of the current blood supply chain revealed improvement opportunities for both nursing and blood bank staff. frequent daily trips to and from the blood bank take nurses away from the patient beside and can create congestion at the blood bank window during peak times. for the itc, with a daily outpatient volume of - patients and an average, round-trip travel time of approximately -minutes, even small delays waiting in line at the blood bank window would produce profound ripple effects. itc nurses faced the additional challenge of maintaining nurse-to-patient ratios and providing timely patient care. about % of patients in the itc have same-day transfusion orders, adding to the blood bank workload and creating unpredictability in workflow. often for patients in the itc, nurses had to repeat pre-transfusion vital signs because too much time had elapsed between gathering vitals and obtaining the blood. these inefficiencies resulted in longer patient wait times and, ultimately, a longer stay in the itc. results/finding: hb devices allow nursing staff to access red blood cells (rbc) for the majority of their patients at the point of care. since implementing in november , the hb has significantly improved the turnaround time of rbc issue -from -minutes to less than -seconds-and helped maintain nurse to patient ratios and reduced traffic at the blood bank issue window. prior to hb implementation, blood bank staff at rmh were issuing approximately rbc per month out of the window for non-surgical patients. this has been reduced to approximately rbc per month, a % average monthly reduction. conclusion: having the hb located in the itc has helped to expedite the care of patients and more easily manage blood products for patients with same-day orders. the use of hb devices has not resulted in a reduction in blood bank fte, but rather a shift in workload; from issuing products to monitoring inventory and restocking. consists of registered paramedics that are pararescue specialists and helicopter personnel. when in combat, the squadron conducts personnel recovery operations and rescues downed airmen. when stationed in the us, they mitigate in state emergencies and perform aeromedical evacuations. in , they supported a civilian medical emergency and the patient needed a transfusion in the field. they procured blood products from a distant air force base with adjacent medical facility. at the debriefing, members of the st rescue squadron ( rqs) decided to find a local civilian blood supplier. the master sergeant contacted our blood center and set up a contract for blood supply. study design/method: blood center representatives met with the rqs master sergeant in january . we asked what rqs's order and delivery expectations were. he said sporadic use and the blood order would be rbcs. we wrote a procedure for consignment and packaging, using standard blood transport boxes. we developed a communication template for staff to anticipate the rqs needs. staff was trained based on data from january meeting. we contacted the rqs in september to perform a trial run. at that time, we learned the master sergeant was shipped out to military theater. we invited his replacement to the blood center. this pararescue senior airman had just returned from syria and was assigned to civilian duty. he had no prior knowledge of the rqs association with a civilian blood center. based on his field experiences, he changed the blood order from to rbcs. he introduced blood transport containers, used in military operations, saying they were easier to carry during water and land pararescue missions. we rewrote the procedures, incorporated his transport containers, and made a pictorial job aid to assist staff on packaging blood using these containers. the blood center and rqs performed a mock run on october , and we felt prepared for any future events. results/finding: on november , , the rqs was deployed to a civilian aeromedical evacuation. we anticipated a rbc order. the actual order was rbcs and ffp. staff was preparing frozen ffp to ship, as was their norm for filling hospital orders. realizing that they could not thaw plasma in flight, we contacted the rqs and offered liquid plasma instead, which they accepted. product was consigned and picked up at : am by the rqs. the patient was transfused in the field and then taken to a nearby hospital. at our joint debriefing on november th , we established a maximum blood order of rbc and liquid plasma, noting future orders may request fewer products, yet meet the preferred rbc; plasma transfusion ratio. conclusion: military personnel are adapted to instantly adjust to an ever changing environment. regulated blood centers are not as adaptable. with clear and comprehensive communication and anticipation on the blood center's part, we now supply civilian blood products to the air national guard. (table ). the highest mean fib concentration was mg/donor unit; lowest mean fib concentration was mg/donor unit. all sites had a mean fib concentration at least mg/donor unit above the fda minimum requirement of mg/donor unit. fifteen of blood centers completed the manufacturing process survey. one used a leukocyte reduction filter with ahf destined plasma. all blood centers manufactured single donor cryoprecipitate; manufactured pooled donor cryoprecipitate. most froze plasma in a - c or colder blood bank freezer. one froze plasma using dry ice, and one used a blast freezer. two blood centers method of thawing frozen plasma took longer than hours. conclusion: blood centers consistently met the overall fib minimum requirement with a mean of mg/donor unit, over double the fda requirement. however there is variability in fib levels amongst blood centers. in general, manufacturing processes were similar with a few exceptions. blood centers should inform their hospital customers of their average fib level in cryoprecipitate in order to most appropriately care for patients receiving this product. compliance & productivity improvement via engineered-staffing/ scheduling calculator application (app) mary deck, mark angelelli and kevin lee*. american red cross background/case studies: the healthcare industry, particularly the blood banking industry continues to experience tremendous pressures not only with ensuring patient safety and quality daily, but managing and maintaining an efficient operation with a cost competitive structure. applications of basic industrial engineering tools, coupled with lean-six sigma techniques such as time study analysis, bottleneck elimination & process standardization to transfusion reduce variation has been transformed into an application (for short "app"), which can be utilized to determine process and staffing optimization and provide flexibility to the dynamic nature of changing needs in blood banking. study design/methods: a time study analysis offers valuable data about the process requirements. once this baseline has been established, translating the data into a user-friendly app would enable ease and practical use to facilitate business decision-making as well as effectively manage daily operations. important concepts such as lean-pull production system, bottleneck elimination, work-load balancing together with basic development of the app using ms excel software will be demonstrated. results/findings: successful rollouts and implementations of the staffing/ scheduling calculator app across pilot facilities, then onto facilities nationwide, has yielded improved productivity together with a sustainable compliance scorecard. the app interactive-based approach, programmed via a commonly used software, ms excel, was used to analyze how to optimize staffing requirements together with staff-scheduling (i.e. match incoming volume/work content to staffing availability). the staffing/scheduling calculator app has been utilized by executives to evaluate "what-if" scenarios (sensitivity analysis) as well as a planning toolkit to proactively manage the changing demands of blood banking. conclusion: besides providing a key mechanism for increased productivity and sustained compliance -a top priority for blood banks -the staffing/ scheduling calculator app will highlight continuous improvement opportunities and spring-board to system-wide acceptance and standardization. all coolers were prepared in a walk-in refrigerator. two scoops of wet ice or two ice packs were placed at the bottom of large/medium or small coolers, respectively, with rbc units on top of the ice. a quality-controlled thermometer was placed on top of the rbc units. a control thermometer was place at the interface between the ice and the rbc units in one large and one medium cooler. the start temperature was recorded and then the temperature was recorded every minutes for a hour period or until the temperature exceeded c. results/finding: the temperature recorded from the thermometer on top of the units in all five coolers reached > c in minutes as shown in table . the control thermometer recorded temperatures maintained at - c for the entire hour observation period in both the large and medium cooler. conclusion: when units are placed on top of the ice in a cooler, the temperature is not reliably maintained at - c for more than minutes. these data support a policy of wasting units that are returned to the blood bank with rbc units on top of the ice. background/case studies: an fda draft guidance has highlighted the need to reduce the risk of bacterial contamination of platelet components (pc) via pathogen reduction (pr) or secondary rapid testing (rt). hospitals must understand the cost implications that may result. our objective was to create an interactive model to analyze the budget impact for different pc types across the range of existing us hospitals. study design/methods: an excel model was built and populated with base case costs and probabilities identified through literature search as well as through a survey administered to us hospital transfusion service directors. the model was reviewed and refined by a panel of seven transfusion medicine physicians. the model allows base-case assumptions to be overwritten with values specific to the institution. three scenarios were generated to compare annual costs of plt acquisition, testing, wastage, dispensing /transfusion, adverse events (ae), shelflife, and reimbursement for a hospital that purchases all of its pcs: % conventional (c-pc), % pr-pc, and mix of % c-pc/ % pr-pc. the model predicts a modest ($ %) cost increase for pr-pc compared to c-pc depending on the degree of pr conversion; this takes into account cost offsets such as elimination of bd and irradiation, decreased waste due to increased shelf-life, and outpatient reimbursement. the effective pc shelf-life is potentially increased with pr due to elimination of bd, and is dependent on nat turnaround time. benefits not captured by the model include transfusion-transmitted infectious risk mitigation from emerging pathogens, which may impact cost/benefit analyses. future iterations of this model will also enable hospitals to consider scenarios in which rt is used. this model can serve as an important tool for hospitals considering pr adoption. in january . a report was created to identify donors previously classified as rare according to the american rare donor program (ardp) criteria. donors are classified as rare by meeting one of the following: highprevalence antigen negative, multiple common antigen negative, or iga deficient. the new process utilized the report and involved sending a letter to the donors notifying them of their rare donor status and encouraging them to continue to donate. a database was created to track the letters sent to rare donors. in august , inventory reduction efforts were implemented to gradually decrease the number of allogeneic red blood cells (rbc) collected to minimize unit age at transfusion. the inventory reduction occurred in phases and was completed by january . a study was performed to determine the impact of the inventory reduction on the number of rare donor donations. study design/methods: the total number of allogeneic rbc donations, rare donor donations, and number of rare donor letters sent was analyzed from to (see table) . the percentage of rare donor donations per year was calculated. background/case studies: blood centers (clients) often carry low inventory of blood and blood components. laboratories performing donor screening therefore, have limited time to determine the presence or absence of infectious disease within these products. in order to measure and ensure expedited donor screening we implemented a daily performance metric consisting of upload time goals for release of results to clients. in , zkv-nat testing was implement for travel deferral donors (july), followed by universal individual donor screening in september and november in response to the fda recommendations for "reducing the risk of zkv transmission by blood and blood components". per the fda guidance we implemented mandatory zkv testing for clients with proximity to areas with locally acquired mosquito-borne cases of zkv within weeks (sept. phase ) and nationwide within weeks (nov. phase ). zkv testing is performed on individual samples, unlike all other nat tests that are performed in minipools ( -donations). therefore zkv testing has a disproportionate impact on the turnaround times for testing, which we analyzed in this study. study design/method: within two regional testing labs, participating in the same clinical trial, lab had % and lab had % of clients requiring universal zkv testing. we evaluated a -month test result upload performance period to determine the impact of zkv test implementation. results/finding: during , lab upload time performance ranged from % to . % from january to july; upload time performance fell between august through november, returning to . % performance in december. lab upload time performance ranged from . % to . % january to august. performance fell september through december . % - . %. lab experienced a low of % upload time performance during phase when there was a rapid implementation; % clients required zkv nat. improved performance was observed during phase , with a % increase in zkv clients. for lab : phase experienced a modest decline of upload performance ranging from . % to . % with . % of clients implementing zkv nat. performance was . % in phase , when an additional . % of clients implemented zkv testing. conclusion: with an unprecedented rapid implementation of zkv testing our laboratories experienced a short period of reduced ability to maintain our upload time performance metric. enhanced platelet bacterial screening in an eight-hospital system robin larson* and colleen a. aronson . advocate lutheran general hospital, acl laboratories/ advocate hospitals background/case studies: in response to two platelet-related septic transfusion reactions and the draft fda guidance released in march regarding bacterial risk control strategies for transfusion services, an eight-hospital system implemented the verax pgd enhanced platelet bacterial screening test in of the hospital transfusion services. the sites that did not implement the test arranged for fresh platelets to be rotated in from the blood supplier. the sites which implemented the verax pgd test perform testing on all day and day platelets to be issued for transfusion. this abstract summarizes the data collected for the first weeks of testing. study design/methods: platelet bacterial testing logs were reviewed over the entire time period studied for platelets tested on day , day , and those that were tested twice. inventory reports were reviewed for platelets issued on day or day that did not require testing, and for the total number of platelets issued over the time period studied. results/findings: in the month of february ( week of performing the test), . % of all platelets issued by the participating transfusion services were day or day platelets. in march that number dropped to . %. it is expected that this number will level off at some percentage at or below . % with further data collection. in february . % of platelets were tested twice prior to final issue from the transfusion services. in march conclusion: the percent of platelets issued fresh (day or day ) will likely level off at some number at or below . % due to inventory management from both the blood supplier and the individual transfusion services. testing platelets twice is undesirable. ideally, no platelets would be tested twice as this represents a high cost for both the test reagents as well as the staff time to complete the testing. in addition, of the sites performing testing are level trauma centers and need to have tested platelets available at all times. this will require some amount of double testing, but the goal is to have this number be as low as possible, so that the percent of tested vs issued platelets does not exceed %. as the transfusion service staff becomes more comfortable with judging inventory levels and performing testing, it is expected that the amount of double testing will decrease. background/case studies: in order to make up for the deficiency of the apheresis platelets in clinical application, and also to improve the comprehensive utilization of blood, we investigate the feasibility of preparation of pooled platelet concentrates(pcs) for providing a reliable source for clinical application. to speed up the storage research of pooled pcs in china, we evaluate the changes in platelet function after filtering leukocytes with leukocytes filter for pcs and the quality changes during storage in pvc-bthc blood bags. study design/method: pcs were prepared from ml virus free whole blood by platelet-rich plasma (prp) method. five or six bags of abomatched pcs were pooled and filtered with leukocytes filter for pcs(n ). the swirling phenomenon, ph, automatic blood count, platelet aggregation, hypotonic shock response (hsr), the extent of shape change(esc), cd p expression, atp level in platelet, glucose and lactate concentration were detected before and after filtering, and on days , , and of storage, respectively. results/finding: the platelet recovery ratio of a therapeutic dose of pooled platelet concentrates after filtering leukocytes was ( . . )%, relative change rate of hsr was ( . . )%, the residual leukocytes were ( . . ) . the ph, hsr, and the cd p expression of pooled platelet concentrates before and after filtering were ( . . ) vs ( . . ), ( . . )% vs ( . . )% and ( . . ) % vs ( . . )%. there is significant change for wbc after filtering (p< . ). during storage in pvc-bthc blood bags, the biochemical parameters of pooled platelet concentrates changed with increasing storage time, as shown in table . conclusion: storage in pvc-bthc blood bags for five days, the quality of pooled pcs met the requirements of chinese standards (gb - ) . it can be a complementary source for apheresis platelets supplement in china. evaluation of samplokv r segment sampler to obtain and measure samples from blood component tubing segments abbejane blair*. ajblair laboratory consulting background/case studies: current methods used to obtain samples from blood component tubing segments are cumbersome and present a significant risk for exposure to biohazards, sharps injury and cross contamination. itl biomedical has developed samplokv r segment sampler (ss), a device for obtaining measured samples from sealed tubing segments that is less cumbersome and offers improved safety, eliminating the need to manually cut and squeeze tubing segments. ss was evaluated with the goals of reducing the number of steps required to obtain a measured sample, and, reduce biohazards and sharps exposure. study design/method: ss obtains fluid samples from sealed tubing segments into a needleless syringe. it consists of two chambers with recessed internal needles located at the top of the device and a female port located at the bottom of the device. a needleless syringe is attached to the female port, the sealed tubing ends are then aligned with the ss chambers and, gently pushed onto the needles to pierce each end of the segment. the sample from the segment is then withdrawn into the syringe. the study was performed at rhode island blood center (providence, ri) using tubing segments from three bag manufacturers to demonstrate ease of use on the following processes: segment alignment over needles and piercing, ability to draw sample into syringe, ability to expel air bubbles from syringe, fluid leaks, ease of transfer of sample from syringe to tube and to collect user feedback. two lengths of tubing segments were filled to contain sample volumes of ml and ml. two users then evaluated the ss tubing segment types with ml or ml samples for a total of data points. samples were collected into the attached ml or ml syringe then a measured sample was transferred from the syringe into a test tube or microcentrifuge tube. results were tabulated as pass or fail. results/finding: a total of ss were evaluated by two users. all samples were successfully collected and transferred into tubes. insertion of the segment edge requires observation to ensure placement onto the needles. any air bubbles collected into the syringe could easily be moved to the top by background/case studies: the management of platelet inventory is crucial due to a number of factors including the day product outdate, the allocation of staff due to the lengthy donation process, the increasingly small donor pool, and the high cost of production (e.g. platelet collection kits, testing, product processing). the use of a platelet inventory management tool has the potential to enhance the understanding of units transfused, optimize inventory, increase efficiency, and reduce waste. the objectives of this assessment were to decipher if the platelet inventory management tool has reduced the amount of outdated platelet products, total cost of platelet production, and full time equivalent (fte) allocation. study design/method: in january , a platelet inventory management process was implemented which uses a spreadsheet based tool to predict the amount of platelet collection procedures needed to be scheduled each day. the tool uses daily historical transfusion data from the last five weeks. additional calculations are included to account for deferrals, no shows, incomplete collections, and product split rate. the number generated from the calculations correlates to how many platelet collection procedures to schedule for the specific day of the week considering testing release and historical daily transfusion trends. the effectiveness of the tool was verified by comparing platelet collections, platelet products outdated, and fte information for a one year period prior to the implementation of platelet inventory management to one year period following implementation. results/finding: by implementing a platelet inventory management tool, collections have been lowered or shifted to accommodate the transfusion needs. the staffing adjustments and targeted collections have lowered fte and outdate cost by %. the platelet outdate rates dropped after implementing the platelet inventory tool from % ( units) to % ( units); a % decrease. fte was able to be monitored closely with the donor schedule and lowered from a yearly average of fte to . fte, lowering fte by %. conclusion: considering historical transfusion data for potential platelet demand has had a positive impact on scheduling platelet collections. staffing requirements and outdating products have decreased since implementation of the platelet management spreadsheet tool, leading to less waste both in terms of staffing and platelets. given these positive results, we are beginning to develop a similar tool for our whole blood collections. identifying opportunities to right-size hospital inventory using compotrace radio frequency id inventory management system nanci fredrich* , jaclyn mckay , jennifer curnes and rowena punzalan , . bloodcenter of wisconsin, children's hospital of wisconsin background/case studies: the ability to track inventory of blood components in real time is challenging for both hospital transfusion services (ts) and blood centers (bc) using current blood bank information systems (bbis). in addition, determining if established par levels of individual components meet or exceed daily transfusion needs is difficult to ascertain. a pilot was designed to track and monitor all blood components from distribution at the bc to issue in a hospital ts using fresenius kabi compotrace radio frequency id (rfid) enabled inventory management system. the objectives were to determine feasibility of the compotrace system and analyze compotrace data for real-time usage and optimal inventory levels. study design/method: a month pilot was conducted at a pediatric hospital and its bc using both bbis and compotrace systems to track all adult-size blood components. staff were trained on use of compotrace system. upon receipt of order from pilot hospital, bc staff applied rfid tags to all component bags and scanned components into the compotrace system. components were transported and delivered to ts following established procedures. upon receipt at the hospital, components were scanned into inventory using both the ts bbis and compotrace systems. dual scanning of components occurred upon issue to or return from floor, component modification or return to bc. products for emergency use or at time of high demand were not rfid-scanned. a priori, the pilot would stop if the compo-trace system hampered current workflow, component issue was delayed or if ts errors increased. no inventory changes were made during the pilot. results/findings: real-time data from compotrace system provided actual usage for all blood components including component disposal and shipment to and from bc. average daily rbc inventory levels and usage for selected blood types is shown in table. lessons learned related to equipment and workflow: ( ) use of smaller irradiation canister may damage rfid tag, which was resolved by relocating tag, ( ) ts workflow and stat orders challenged consistent use of dual processes to track component status. however no increase in ts errors or delay in issue of components occurred. conclusion: use of rfid to track blood components from bc to final disposition is feasible. real-time data from compotrace system identified optimal inventory levels for rbc at the pilot ts. use of real-time rfid to track inventory and adjust target levels based on actual daily usage over time may reveal seasonal influences that affect target inventory. background/case studies: physicians expect blood to be available at all times. following a national appeal in july for donors based on a predicted summer shortage with high likelihood of extending into the fall, our transfusion service (ts) recognized a potentially dire situation given the institution's patient acuity. our hospital-based ts supports a full range of services: a level i trauma service; stem cell and solid organ transplant services; a brisk cardiothoracic surgical program; a high risk obstetrical service; and high acuity medical/surgical services. a regional donor center supplies our blood products. to insure appropriate response to patient needs, the ts created a management plan, with input from multiple stakeholders, to assist with product management in times of extreme shortages. the approach is described herein. study design/method: at the direction of the transfusion committee (tc), ts directors presented the concern for impending shortages to the hospital quality directors (qd) committee. the qd committee consists of clinicians and non-clinicians trained in health care quality/regulatory affairs who are responsible for institutional health care quality (hcq) activities. the qd recommended creation of a multidisciplinary team: "the blood shortage task force (bstf)", analogous to an existing task force started for management of drug shortages. results/finding: with hcq and tc support, the ts created the bstf and blood shortage management algorithm (bsma). standing members of the bstf include ts medical director (chair), senior vice president (svp) of hcq, svps of clinical services director of regulatory affairs, legal counsel, and representatives from ethics, social work, pharmacy, patient referrals, and communications. ad hoc members include those whose patients would be most impacted by the specific shortage. the bsma designed by the bstf provides a framework for ts's to conduct operational and therapeutic assessments of potential impact and defines criteria for convening the bstf. trigger criteria include: marked ts concern; essential product; high likelihood of inventory depletion; broad patient impact. once convened, the bstf is responsible for situational assessment and formulation of a management plan, with a goal of maintaining quality patient care. conclusion: faced with the potential for limited blood supply, the ts reached beyond the laboratory and engaged the tc and members of hcq to assemble a robust, multidisciplinary task force. this resulted in an inclusive plan which can be activated at any time to address shortages, and assist in management of impacted patients. abstract background/case studies: cryoprecipitate (for short "cryo") plays a critical role in clotting and controlling hemorrhaging, and is often used in the treatment of massive trauma and major diseases, including metastasized cancers, cardiac diseases, hepatic failures, and organ transplants. the collection process of cryo is particularly challenging; due to fact to be processed into cryo units, the collected whole blood has to be shipped to the production facility and be processed within -hours after collection. this tight hour time constraint between collection and production can only be satisfied with precision collection planning and extra courier services; which makes the collection for cryo units more costly than other products. study design/methods: the american red cross (arc), in partnership with researchers from the georgia institute of technology (gt), has developed a blood collection model to increase the amount of whole blood that can be processed into cryoprecipitate. after reviewing blood collecting and processing schedules, collection locations, and other factors, arc-cryo subject matter experts together with gt researchers were able to analyze the problem structurally with several analytic/dynamic programming properties, and developed a near optimal solution algorithm or mathematical model. results/findings: to facilitate implementation, a decision support tool (dst) was developed to systematize the selection of the collection sites; determining when and from which mobile collection sites to collect blood for cryo production and how to schedule the courier services such that the collection targets are met and the total collection costs are minimized. the implementation of the dst led to an increase in the number of whole blood units satisfying the tight -hour completion time constraint for cryo production (capacity expansion). in particular, during the th -quarter of , a blood processing region was able to process about more cryo units/month (an increase of %) at a slightly lower collection cost (cost avoidance), resulting in an approximately % reduction in the per unit collection cost for cryo. conclusion: by utilizing operations research toolkits, a mathematical model or near-optimal algorithm could be developed to optimize the cryoprecipitate collection process, ensuring the time constraints and product consistency levels are achieved. this interdisciplinary improving cryoprecipitate collections collaborative project has been selected as a finalist on the -the franz edelman award, recognizing outstanding achievements and practices in operations research. inventory management and transfusion practice before and after -day apheresis platelets sarah k harm*. university of vermont medical center background/case studies: the shelf life of apheresis platelet (ap) units stored in plasma may be extended from to days in the usa using an fda cleared rapid test (rt). in august , our hospital based transfusion service began using a rt on day and to routinely extend ap shelf life to days. this report describes changes in platelet inventory management and transfusion practice six months following routine use of -day ap. study design/methods: data were obtained for two study periods: september -february (pre-implementation) and september -february (post-implementation). the study periods were intentionally made to span the same months of the year due to seasonal variability in platelet transfusion rates in our region. the transition period from -day to -day ap inventory was excluded. the following data was collected for each study period: the total number of ap transfusion recipients, ap units transfused, expired ap units, ap units ordered ad-hoc from suppliers, inpatient admissions, surgical volumes, and average length of stay. results/findings: data are shown in the table. the number of ap transfusions decreased by % post-implementation while inpatient admissions and surgical volume increased by % and %, respectively. the hospital length of stay was similar for both periods. ap inventory decreased by % post-implementation and the outdate rate decreased from % to % (p< . ). ad-hoc ordering was not statistically different between study periods (p . ). the average number of ap transfusions per patient between pre-and post-implementation periods was not statistically different ( . and . , respectively, p . ). furthermore, a new "rejection threshold" for lipaemic products will be implemented. this threshold represents the tg concentration above which viral marker testing for donor screening will be affected. in kcbb abbott's prism assays are used for: hbsag, anti-hcv ab, anti-hiv ab, anti-htlvi/ii . results/finding: using data management system and file records in kcbb as regard discarding blood components due to lipaemia during the last five years ( ) ( ) ( ) ( ) ( ) , it was demonstrated that number of discarded rbcs due to lipaemia during the whole period was units. number of discarded different plasma, platelets, and cryoprecipitate components during the last two years due to lipaemia was , , and units respectively. the mean number of discarded rbc units of the five years of the study exceeds % of the tested ones. literature about guidelines on the management of lipaemic donations were reviewed in order to minimize donation loss, and establish an accurate rejection threshold for lipaemic donations. by reviewing sample requirements for viral marker testing in kcbb, the accepted level for tg in blood samples is below mg/dl, and so the rejection threshold for lipaemia is level equal to or more than mg/dl. conclusion: many blood product units are discarded needlessly in kcbb due to lipaemia in the last five years (including rbcs, plasma products and apheresis platelet units). in an effort to reduce the waste of potentially lifesaving products, the rejection threshold for lipaemic products is recommended to be changed from mg/dl to mg/dl which does not affect blood safety. a follow up study is recommended after applying the new threshold to evaluate the new policy. logistical management of the incorporation of pathogen reduced single donor platelets (pr-sdp) into inventory at a u.s. tertiary care medical center eric gehrie* , , rebecca ross , debra mraz , anne baker , zenna neal , melanie champion and edward l. snyder , . johns hopkins university school of medicine, yale university, yale-new haven hospital background/case studies: the approval of pr-sdp by the fda provided an opportunity to improve the safety of our platelet inventory across all patient demographics. we outline our approach and address issues we faced during the first months of pr-sdp availability. study design/methods: our nursing education team provided presentations to the nursing and clinical unit support staff. a company-sponsored trainer staffed sessions for the evening/night shifts on the clinical wards. presentations to physicians were made by the blood bank medical staff. information technology personnel created a new product type in the blood bank computer system, tested the abo/rh truth tables, and ensured that billing codes were in place. the necessity for transiently supporting a dual inventory of pr-sdp and conventional platelets led to consultation with the ethics committee and risk management, to confirm that pr-sdp and conventional platelets (c-plts) tested for bacteria ("safety measure" testing) could both be considered the hospital standard of care. we chose to not gamma irradiate any unit of pr-sdp, consistent with the package insert. results/findings: the ethics committee and risk management confirmed that informed consent was not needed for transfusion of pr-sdp. pr-sdp available from our blood supplier incremented monthly. over the first four months of pr-sdp availability, pr-sdp were transfused at our hospital (out of a total of platelets transfused). after months of scale-up, pr-sdp were approximately % of inventory. questions received during the nursing and medical conferences related to: the risk of bacterial contamination with c-plts vs. pr-sdp; toxicology of the pr process; scanning pr-sdp labels into the electronic medical record; and the need to irradiate pr-sdp. our use of a "safety measure" addressed concern over bacterial contamination of c-plts. published pr-sdp toxicology data comparing the content of psoralens in food products such as grapefruit ($ mg per g) to the content in pr-sdp (< ng per ml) addressed toxicology concerns. nursing/it allayed concern over scanning issues with a simple demonstration. finally, we ensured that all parties were aware that fda did not require irradiation of pr-sdp. presentations at the medical conferences were also used as an opportunity to provide transfusion-transmitted disease training and information on platelet utilization. company personnel did not present at medical or nursing conferences per institutional policy. no background/case studies: ensuring platelet supply capability represents a challenge in terms of donor recruitment and inventory management operations. in september , the apheresis collection process (acp) was completely revised to increase the number of products per donation by maximizing the rate of double-platelet donations (dpd). the process review has led to several changes, including the substitution of the pre-donation platelet (plt) count measurement before donation type allocation, in favor of the use of the donor's past donation records. multiple processing steps were eliminated, and the evaluation of plt concentration as a function of time, deduced from complete blood count (cbc) measurements, allowed the centralization of the analysis at the qc department. finally, introducing the concept of non-optimal donations has led to an increase in the proportion of dpd. study design/method: at the donation centers, whole blood (wb) from donors was collected in k edta tubes. plt concentrations were determined at the qc department using the coulter act diff hematology analyzer (beckman coulter). sample tubes were stored at - c and measured at , and hours post-collection. single platelet donations (spd) or dpd were collected using the trima accel. units were pooled and split in elp (extended life platelet, terumo bct) storage bags to mimic spd ( ml; n ) or dpd units ( ml; n ). plt pools were stored at - c under mild agitation for seven days except for dpd, which were split in two -ml bags after h. samples were taken on days and . ph, po and pco , hypotonic shock response (hsr), extent of shape change (esc), cd p expression, atp content, lactate and glucose concentrations were used as in vitroquality markers. results/finding: plt concentration as a function of time, determined from wb cbc measurements, showed no significant difference at h ( pltx /l), h ( pltx /l) and h ( pltx /l) postdonation. dpd can be stored in the same collection bag for h after donation without any significant impact on plt quality markers. plt concentrations were within the manufacturer's acceptable limits ( - pltx / l) before splitting. on day , lactate and pco concentrations increased, and po decreased in dpd. however, these values normalize to those of control units at the expiration day. conclusion: this project was approved by health canada and implemented in our organization in march . there are numerous operational and cost benefits from this process optimization initiative, without significant impact on safety and quality. post-implantation efficiency data will be compared to the targeted % increase in the targeted number of plt units per donation ratio. phased implementation of pathogen-reduced platelets in a health system elizabeth s. allen* , colleen vincent and patricia kopko . university of california -san diego, american red cross background/case studies: pathogen reduced platelets (prp) provide improved safety compared to conventional apheresis platelets, but collection and manufacturing are complex. early evidence shows only - % of double platelet collections meet requirements for pathogen reduction treatment. blood centers need hospitals to implement prp to start manufacturing, but hospitals may not wish to use prp until they can provide the product to all patients. scaling up manufacturing at the blood center and phasing in prp across patient populations meets both parties' needs. we evaluated this strategy at our university health system (transfusion volume: , apheresis platelets annually), which includes two hospitals ( inpatient beds) and an outpatient cancer center. study design/method: before initiation, approval and funding were obtained from the hospital quality council and administration, and stakeholder groups such as hematology/oncology were educated and consensus gained. live training was provided for nurses in the outpatient cancer center (week ) and the bone marrow transplant (bmt) ward (week ). an e-mail communication explained the change to all physicians and nurses. in phase , we implemented prp in the outpatient cancer center. these patients are immunocompromised and do not have access to the immediate advanced critical care of the inpatient environment should a septic reaction occur. in phase , we expanded usage to include the inpatient bmt ward. in phase , we lifted all restrictions so prp could be used throughout the health system, with the goal to reach % prp within months. results/finding: in phase (weeks - ), we requested prp products weekly, based on typical usage in the outpatient cancer center. our blood supplier provided an average of prp weekly (range - ), and prp constituted % of platelet transfusions in the cancer center. in week , excess prp inventory required use of prp in the inpatient bmt ward ahead of schedule, a practice which continued throughout phase . in phase (weeks - ), we formally expanded issuing of prp to include the inpatient bmt ward and requested prp products weekly. our blood supplier provided an average of prp weekly (range - ), and prp constituted % of platelet transfusions in the phased-in areas. in phase (weeks - ), we began issuing prp throughout the health system. our supplier provided an average of prp weekly (range - ), and prp constituted % of all platelet transfusions. scaling-up is ongoing. conclusion: phased implementation of prp by patient group prioritizes patients who stand to benefit most from the product, and allows time for the blood center to scale up manufacturing. background/case studies: maintaining adequate inventory of platelets without significant outdating and waste of product is a constant challenge for many institutions, especially for smaller community hospitals. our health system comprises hospitals including smaller community hospitals (sch) and larger tertiary care medical centers (tcmc). for several years, we have been using a limited internal process of platelet sharing between some of our institutions to successfully reduce platelet wastage. this encouraged us to analyze platelet usage throughout our health system and devise an expanded novel concept of platelet distribution, in partnership with our blood supplier that would allow us to maintain an inventory of apheresis platelet (ap) units at our smaller community hospitals without significantly increasing platelet waste and the associated cost. study design/methods: a "round robin" (rr) transportation system for platelet delivery and pick up was strategically developed with the regional blood center to align with routine delivery of red blood cell (rbc) standing orders. an efficient delivery system was implemented so that the regional blood center would realize reduced supplemental and emergency deliveries of blood components to our hospitals. platelets are transferred at the time of rbc standing order delivery based on a predetermined route schedule. each day, ap are delivered to the sch and the previous day's platelets retrieved (if not transfused), packed in blood center transport boxes, and then picked up by the blood center driver. these platelets typically have a hour shelf life remaining. the same process occurs at the next sch on the route. all retrieved platelets from the sch are delivered to the tcmc which is the last stop on the route. thus, the sch has adequate number of units available for regular transfusion and massive transfusion protocol. results/findings: review of our rr process revealed a significant benefit to our smaller community hospitals as we were able to routinely maintain an ap inventory for patients requiring urgent platelet transfusion. an additional benefit was further decrease in ap waste (table ) resulting in a cost savings of $ k. an additional cost savings of approximately $ k was noted due to decreased cost of emergent platelet transportation. conclusion: our novel rr process of platelet distribution has resulted in improved platelet availability at our smaller community hospitals while maintaining the reduced level of ap waste at our health system from our previous platelet sharing process. we anticipate additional decreases in ap waste as a transfusion vol. supplement s we further streamline our process. with the trending merge of health delivery systems, we predict that other health systems will adopt similar processes to improve platelet availability and reduce waste. post implementation adjustments of our pathogen reduction process jacqueline carlson* , james r stubbs , scott a hammel and manish gandhi . mayo clinic, mayo clinic-rochester background/case studies: the implementation of pathogen reduction for apheresis platelets using cerusv r intercept system for apheresis platelets was a substantial endeavor encompassing many different areas. as with any process change, adjustments and modifications can occur along the way. after implementing % pathogen reduction technology (prt) for apheresis platelets, we made two additional adjustments to our sampling processes to ensure accurate labeling/categorization/branding of our final products. study design/method: our prt validation consisted of apheresis platelet products. each product was tested pre-processing for white blood cell (wbc) content and platelet yield, along with post processing platelet yield. this data was used to calculate our yield and volume retention during processing. we anticipated products with preprocessing yields of . , . , and . x may end up below a . in the final storage bag and would need a post-processing sample to ensure the product met criteria at ! . x platelets. results/finding: during the validation, we discovered one collection was not leukoreduced and two collections started at a . yield but ended with a yield below . . these two discoveries led to adjustments in our prt platelet process. with the wbc failure, we reviewed the wbc count on the sysmex xe- d preprocessing report to see if it would alert us to a potential wbc failure. the review discovered that of results were . or . x / mcl with the exception being the wbc failure with a count of . . further monitoring of the wbc counts discovered a result of . which was tested on the adam r-wbc for wbc count and determined to not be leukoreduced. we decided all sysmex wbc results from the pre-processing sysmex report would be reviewed prior to processing and a wbc result of . will be tested on the adam to confirm a leukoreduced product. we also discovered of ( %) of the . preprocessing yields products ended with a post processing yield < . . we decided to increase the yields requiring post processing samples to include the . . conclusion: we are continuing to sample all collections for a post processing yield so we can be confident that we are releasing products into inventory with a yield of ! . x platelets and to have enough data to accurately determine our volume and yield loss during processing background/case studies: the university of kentucky medical center (ukmc), a large academic hospital with level i trauma center, is supplied with blood products by the kentucky blood center (kbc) on a consignment agreement-based contract. ukmc is kbc's largest consumer of blood products. as platelet usage can vary widely day to day platelet usage projections are provided to kbc by the ukmc blood bank, thereby allowing kbc to act accordingly with a given day's stock (i.e. import vs export). daily platelet projections are based on phone calls asking clinicians working in high-demand locations to estimate their needs. this process can be easily confounded by multiple factors and has undergone multiple adjustments to improve its accuracy. study design/method: daily platelet projection forms from / - / were retrospectively reviewed and compared to actual usage data over that same time. the prediction system used in the ukmc bb up to that time (estimated clinical need ) was evaluated for effectiveness based on: total number of days under-predicted, number of days with large underprediction, average number of units under-predicted, and average difference between prediction and usage. the prediction system was subsequently changed based on this data in ; the revised prediction method (estimated clinical need ) was then evaluated retrospectively using the same data sources covering / - / and then compared to the prior method. results/finding: the average number of platelets transfused from / - / was . u/d with a standard deviation of . u/d; the predicted amount was . u/d. the difference between the predicted amount and the number of units used was - . u/d. % days ( d/month) were under-predicted (average: u/d). % of days ( ) were under-predicted by ! u (average: u; max: u ( x)). the average number of platelets used from / - / was . u/d with a standard deviation of . u/d; the predicted amount was . u/d. the difference between the predicted and units used was a . u/d. % days ( d/ month) were under-predicted (average: . u/d). one day ( %) over this period was under-predicted ! u ( u). conclusion: review of clinical platelet usage over this time identified a relatively stable average daily clinical demand. adjustment of our prediction system to ensure that no, or as few as possible, days were projected for less than that average has markedly reduced catastrophic shortages ( % a %), reduced the number of days under-predicted ( % a %), and decreased the discrepancy on those under-predicted days ( . u a . u). these improvements in estimating usage allow for an increased ability to handle unpredictable events without suddenly straining kbc's supply flexibility or severely limiting ukmc clinical settings. rapid implementation of zika virus (zkv) nat blood donor screening joan dunn williams* , maria noedel , nancy haubert , kenneth hudson , larry morgan , robert shaw , tracy fickett , jamie jue , valerie winkelman , sally caglioti , german leparc , and phillip c williamson . background/case studies: on / / , fda issued a guidance document for "reducing the risk of zkv transmission by blood and blood components". in response, a plan was implemented for mandatory zkv testing for all clients with locally acquired mosquito-borne cases of zkv within weeks; nationwide in weeks. this organization performs testing for clients (blood centers, hospitals) across the country. we report on of manufacturers' (sponsor) provided investigational new drug (ind) protocols. a single project management (pmo) system was used to control all required processes. study design/method: project focus included: clinical trial requirements, client onboarding, lab operations (labs). our objectives were to implement zkv testing for clients within weeks, and an additional clients within weeks. to minimize the impact to labs a staggered implementation was used with tracked/streamlined communications from stakeholders: vendors, institutional review board (irb), it (client and lab based), client services and labs. results/finding: clinical trial requirements increased the complexity of implementing an unlicensed test. documents included donor notification, informed consent, protocol training, staff certification, deviation management, and result reporting. multiple irb documents were required. to ensure accuracy in ind commitments a principle investigator was assigned to labs with client sub-investigators. deliverables were multiple including client requirements, vendor responsibilities and labs. client onboarding included confidentiality agreements between client and sponsor. an immediate zkv based webinar provided materials and understanding of sponsor protocol, lab test system, and client/donor based responsibilities. to facilitate and ensure effective communication, twice weekly conference calls were held. clients sent questions which were facilitated by labs and directed to sponsor. specific to clients were irb documents, it updates/validation for zkv test ordering and result receipt. labs were multifaceted: vendor instruments, assay materials, package inserts, staff training. assessments included: zkv sample volume, throughput, instrument capability/capacity. work requirements included vendor installation, equipment, assay and reagent qualifications, staff training, competency assessments, result reporting. all clients were provided with zkv testing within required timeframes. conclusion: the success in meeting a rapid implementation of zkv testing was largely due to a centralized pmo system which provided a controlled process for sponsor, client, vendor and labs. within lessons learned strength was found in a multi-client onboarding process. a weakness was in understanding instrument test volume capacity throughput which was exceeded during the -week period but overcome during the -week cycle. red blood cells baby units traceability and discard in kuwait central blood bank and five hospitals marwa moemen al deeb* , hala samuel boules , fatemah saleh al matroud , rabab hussien ali dashti , hanan alawadhi and reem al radwan . kuwait central blood bank, kuwait central blood bank, kuwait central blood bank background/case studies: ill children are more likely to receive red blood cells (rbcs) transfusion than any other patient age group. rbcs are the component most often transfused during neonatal period. small volume aliquots are used to limit donor exposure, prevent circulation overload and decrease donor related risk. traceability is the ability to trace each individual unit from donor to recipient or disposal. blood component should be fully traceable from collection to final disposition. the kuwait central blood bank (kcbb), is preparing baby units and distributing it to all hospitals all over the country. kcbb, being accredited by the american association of blood banks (aabb), is following the aabb's regulations in tracing every component. study design/method: this is a retrospective study to assess final deposition and the percentage of discard of prepared packed rbcs baby units in the kcbb and five hospital blood banks (hbb). also, to assess the levels of traceability as a reflection of the improvement in the efficient use of these blood products. methods: a total of rbcs baby units were randomly chosen to be traced to their final deposition from the year till . half of them ( units) were traced in kcbb. tables showing the numbers of the chosen units were distributed to the five governmental hbb ( units for each year of the study period). results/finding: preliminary results show that the tracing of rbcs baby units in the kcbb is % efficient. results from other hospitals are under process. statistical analysis of the traceability will be done as soon as the data is collected. the study will analyze the usage of the baby units in different departments and the percentage of discarded units. the traceability of rbcs baby units in the kcbb is excellent, this is due to good management and training of the working staff and the use of an electronic system in registration and issuing. most of the kuwait governmental hospitals are using electronic systems, so the traceability should be up to the recommended levels. the percentage of discard of the baby units in the hospitals is very high. this may be due to the practice of using fresh blood (< days of donation) and the reservation of the baby units of the same donor to the same baby to reduce the hazards of multiple donor exposure. the creation of a national policy for using rbcs baby units is highly recommended to reduce the discard of such units. we also calculated the number of false positive results. the study traced all products through mid-march . results/findings: a total of products were tested. fifteen units ( %) had a false positive result and could not have their life span extended. of the fifteen reactive units, two repeat donors were identified and their charts were marked to not test subsequent donations. cross-reactive antibodies were identified in all by the vendor and none were true positives by re-culture. of the units that were successfully tested, were tested again on day for use on day ( %). there were platelets transfused ( %) and expired after day ( %). the cost to test the products including controls was $ , and our calculated cost to produce products would be $ , . if we had needed to import products to meet needs, the cost would be roughly $ , without shipping costs which are estimated at $ , . . we averaged expired platelet products per month (range - ) before verax testing and (range - ) after implementation. conclusion: using verax point-of-care testing saved platelet products from discard. the cost savings were $ , . from importing and $ , from producing a replacement for those products. the average discard rate per month went from to after verax implementation. extending platelet shelf life to days more than paid for the cost of testing and ensured products were available for patients who needed them. secure text messaging in transfusion medicine: can texting decrease wastage? melanie estrella* and elsie lee. george washington university hospital background/case studies: secure text messaging in hospital settings allows for quick, easy, and hipaa compliant communication between members of patient care teams. it works on a mobile phone or computer, and provides read-receipt confirmation and a temporary record of team communications. secure texting has potential to be a useful management tool in transfusion medicine in reducing blood product wastage. for example, it provides a relatively low-burden means for busy clinicians to provide feedback to the transfusion service about scenarios of potential wastage. this information can be used to identify areas in which management strategies could be developed. it also allows for personalized educational opportunities between clinicians and the blood bank about usage guidelines and how to reduce future wastage. the goal of this study is to use secure texting to investigate wastage, evaluate the responses from clinicians, and evaluate the potential effects on reducing wastage. it is hoped that the results will identify secure texting as a useful management tool in transfusion medicine. study design/method: wastage records that were investigated without the assistance of secure texting from july to december were reviewed to identify the most common scenarios of preventable blood product wastage. wastage records from january to april were reviewed, and wasted products that were considered preventable were investigated using secure texting to communicate with the ordering physician. results/finding: for data, units were investigated without the use of secure texting. of these, units were identified as preventable wastage, and wasted units were considered beyond the control of the clinician. the categories for preventable wastage were defined as follows: ) product not released after procedure/ or when patient stabilized ( ) ) product returned outside of appropriate temperature range ( ) ) clinician unaware product was assigned ( ). thus far in , wastage records have identified units of preventable wastage. secure texting was used by a transfusion service physician to investigate. twelve responses provided useful feedback for future management strategies, responses thanked the transfusion service for the information, and in instances, the message was read with no reply. conclusion: secure text messaging has the potential to improve communication in transfusion medicine. it is easy to use, hipaa compliant, and helps identify strategies for reducing wastage by improving communication and allowing personalized educational opportunities between ordering physicians and the transfusion service. sequence of reagent adding for cryopreservation freezing solution guoling chen*, xu zhao, andrew tiss, sasha turner, devin emerson, manijeh shemirani, sharon novak, david garvin, john eng and wanxing cui. medstar georgetown university hospital background/case studies: dimethyl sulfoxide (dmso), plasmalyte-a (plas-a), human serum albumin (hsa) are widely used to prepare cryopreservation freezing solution. some use autologous plasma instead of plas-a and hsa. this study is to identify the choice of reagents and the optimal sequence of adding these reagents when making freezing solution. study design/methods: materials: . % dmso, plas-a, % hsa, autologous plasma extracted. containers: transfer pack (bag) and polystyrene tubes. the freezing solution recipe used in this study is (volume ratio) . %dmso: plas-a : %hsa : : . plas-a and hsa are kept at room temperature ( - c, rt) and refrigerated at c, plasma at rt (to simulate the end-of-centrifuge temperature), dmso at rt (due to high freezing point . c). different combinations of the reagents choice, storage temperature, adding sequence, are tested with photo taken. total tests. at least minutes cooling after dmso, before adding the next reagent. see table: ( ) after directly adding . % dmso alone to bag, the bag turned from transparent to white, so dmso should not add first. ( ) in tube, autologous plasma first, dmso next, powder-like precipitates. ( ) in tube, dmso first, hsa next, precipitated instantly, a layered appearance. ( ) & ( ) in tube, plas-a first, then hsa, dmso at last, precipitates formed; rt plas-a and hsa combination formed a thicker precipitate than those kept at c. ( )&( ) in tube, hsa first, dmso next: precipitation formed heavily, sculpture shape. precipitation in the c group is slightly milder/slower than rt group. so hsa should not be added first. ( )&( ) trace of hsa(< ml) was mixed into the plas-a bag ( ml). in tube, such "hsa-contaminated" plas-a was added first, then dmso, small fragments of precipitates formed, so dmso should not add last. background/case studies: maintaining a robust blood product supply is an essential requirement to guarantee optimal patient care for all major hospitals. however, daily blood product use is difficult to anticipate. platelet products are the most variable in daily usage, have short shelf lives, and are also one of the more expensive products to produce, test, and store. due to the combination of absolute need, uncertain daily demand, and short shelflife, platelet products are also frequently wasted due to expiration. sophisticated data analysis has the potential to accurately predict hospital wide platelet needs and therefor reduce wastage. study design/method: we have investigated platelet usage patterns at our institution, and specifically interrogated the relationship between platelet usage and aggregated hospital-wide patient data over a recent consecutive -month period. using a convex statistical formulation, we have found that platelet usage is highly dependent on several factors. these include day of week, number of abnormal cbc, location-specific hospital census data, and other less important factors. we exploited this relationship to develop a mathematical model to guide collection and ordering strategy. results/finding: this model minimizes waste due to expiration while never allowing for a shortage; the number of remaining platelet units at the end of any day never drops below in our model. compared with historical expiration rates during the same period, our model reduces the expiration rate from . % to . %. with an annual platelet usage of approximately , units, this reduction equates to approximately units saved from expiration annually. depending on platelet pricing in different regions, this accounts for annual savings between $ , to $ , , per institution. conclusion: to our knowledge our research is the first such use of hospital wide data to inform real-time donor recruitment strategies based on anticipated patient demand. thawed plasma implementation: signficant cost savings and decreased plasma wastage morvarid moayeri* , russell thorsen , rosaline ma , antonio g insigne , amy decourten , florence panganiban , patricia mckean , cyril jacquot , sara bakhtary and ashok nambiar . ucsf health, children's national medical center background/case studies: plasma (ffp, pf , pf rt ) stored at - c outdates hours after thawing. if collected in a functionally closed system, it may be relabeled as thawed plasma (tp), extending expiration to days from the thaw date. although coagulation factor levels decrease over this period, they remain above hemostatic levels. as tp can be safely used for the vast majority of patients requiring coagulation support, we implemented use of tp in our multi-site tertiary care system, with the aim of decreasing costs and minimizing wastage. study design/methods: the massive transfusion protocol at our instiution already allowed the use of group ab tp. following a review of literature and practice at other large centers, the transfusion committee extended the approval of tp to all patients. neonates (< months), patients undergoing plasmapheresis and those with factor deficiency or other disorders for which we also noted a significant decrease (not quantified) in technologist time and effort, as less time was expended on the following: thawing units, printing inventory reports and reporting/record-keeping for discarded units. conclusion: in many large facilities, providers frequently order more plasma units than are ultimately transfused, leading to high plasma wastage rates due to limited ( hr) shelf-life. tp has an extended shelf-life, and can be used interchangeably with ffp and pf for most patients. implementing tp in a multi-site tertiary health care system resulted in sustained decrease in plasma wastage, saving thousands of dollars and helping conserve a precious resource. the merging of immunohematology reference lab's (irl) inventories-using technology to create advanced search functions alexander delk and richard gammon* . oneblood, oneblood, inc. background/case studies: immunohematology reference labs (irls) must maintain diverse inventory of antisera to aid in antibody identification, antigen type rbc units, and meet regulatory requirements. when our current organization was established, two irl sites had independent inventory management systems. although the purpose of maintaining the antisera inventory was the same, organization, storage, & access to instructions for use (ifus) were not. our irl developed a synergistic method to organize and store antisera coupled with in-house designed custom excel spreadsheet to organize and search antisera and view ifus. study design/method: a list of similarities and differences was constructed. best practices of both methods were identified. we determined that our antisera could be broadly classified/organized into two main categories: rare and bulk for screening. sequential lab assigned numbers were given to antiserum for each category: s (rare sera) and b (bulk sera). a dynamic/static freezer box storage system that was inter-box static and intra-box dynamic was determined to be best option to combine two inventories while conserving elements of each allowing for library growth. antisera assigned to a box remained in that box, but may be moved within the box. the box itself may be moved among freezers. to track boxes, location and movement within the box, a custom excel spreadsheet was created. its location tracking feature allowed for two different storage methods to function in one spreadsheet. the spreadsheet had a tab for s and b antisera categories. abo group, desired and unwanted antibodies filters allowed quick search for appropriate antisera. the spreadsheet also had hyperlinks to scanned ifus. results/finding: sequential lab s and b numbers were assigned to new additions using a dynamic/static storage system. an excel spreadsheet with scanned ifus (hyperlinks) was used. pre-merger systems, it took on average - minutes to choose an antiserum and obtain the appropriate ifu. post-merger system was reduced to on average - minutes. (table) conclusion: the merging of two irl's antisera inventories resulted in a need for innovation to create an inventory management system with an advanced search function and hyperlinked ifus. this process saved valuable technologist time and organized the antisera more efficiently. abstract continue to flash until they are removed from shelf and their status updated in our database. 'units allocated' tab includes truncated patient name (to protect privacy), unit number, component type, allocation and expiration date/time, and time since allocation, with a flashing alert for units expiring in < hours. the xm/hla platelets tab provides patient names and status of units allocated. a 'trxn/xmplat' tab lists pending transfusion reactions and platelet cross match reports. dashboard eliminated the printing (several times/shift) of lengthy computer-generated reports, simplified thawed plasma inventory management and helped decrease plasma wastage (from % to %). conclusion: using in-house talent and minimal capital expenditure, we designed and implemented a dynamic web-based dashboard for managing blood product inventory across a multi-site transfusion service. the dashboard is stable, customizable and requires little maintenance. initially built to optimize inventory display for thawed plasma implementation, the dashboard was expanded to include all allogeneic blood products. over the past year, this tool has replaced manual processes for monitoring and rotating inventory and directly helped decrease plasma wastage. use of deglycerolized red blood cells for hospital transfusion service inventory management ronnie l. hill*, jason corley and lizabeth ostiguin. us army background/case studies: regional blood shortages have been documented across the united states during the winter holiday timeframe. deglycerolized red blood cells (drbcs) have been shown to be an effective alternative though more expensive to manufacture. this study looks into the fiscal and inventory efficacy of using drbcs to meet the needs of transfusion services during times of blood shortage. study design/method: on three separate occasions, a medium sized dod donor center used its frozen blood inventory to produce type o drbcs to meet the needs of two regional transfusion services. all frozen red cells were manufactured by an offsite facility with the haemonetics acp- using the low glycerol ( %) freezing method and frozen at - c within six days of collection. thawing occurred in a c water bath in the following order: o positive and o negative on january ; o positive and o negative on february ; and o negative on february . deglycerolization occurred on site using the acp- with all units passing internal qc requirements. drbcs were shipped the same day to a hospital transfusion service, allowing for days of shelf life prior to expiration. results/finding: during the three events, all supported transfusion services and the blood center were below minimum inventory requirements for standard type o red blood cells (rbcs). o positive rbcs were only available through nbe at $ - and had the limitation of arrival on the next business day. collection and processing time of liquid rbcs takes approximately two days including: donor screening, phlebotomy, component processing, testing, and labeling. drbcs cost the dod on average $ per unit to produce and distribute. drbcs have a shorter shelf life, days versus the days for other rbcs, but are washed during deglycerolization and thus produce fewer transfusion reactions. one tech can operate up to four acp- 's and deglycerolize four units at a time. in january and february , it took one tech four hours per iteration of eight units to include thawing, labeling, and packing for shipment. conclusion: while not as readily available as traditional rbcs, drbcs can be an effective product to bridge the inventory gap when small numbers of units are needed due to reduced inventory. collection and processing of whole blood into components takes approximately two days, but can produce greater numbers of units in that timeframe. based on this, drbcs can be ready faster than freshly collected units of blood. there is an increased cost associated with manufacturing frbcs which is compensated for by the longer available shelf life of years. having a small contingency supply of frozen red cells and deglycerolization equipment has been effective on three occasions in ensuring availability of type o red blood cells for hospital transfusion services. validation of a human anti-tetanus toxoid immunoglobulin assay performed on the abbott c izekial butler* , karen leighton , scott jones and rachel beddard . qualtex laboratories, biobridge global background/case studies: plasma fractionators require anti-tetanus quantitative testing to be performed on plasma samples collected from individual donors or plasma production pools. this testing serves as a quality control test and helps estimate the antibody potency of the product. the binding site, human anti-tetanus toxoid immunoglobulin liquid reagent kit is for use on a turbidimetric analyzer. the aim was to optimize and validate the human anti-tetanus toxoid immunoglobulin liquid reagent kit for use on a photometric analyzer. study design/method: experiments were performed in order to determine the optimal amount required of reagent buffer and latex reagent from the anti-tetanus toxoid immunoglobulin kit utilizing the abbott c instrument. precision of the new assay parameters was determined by testing replicates of a panel of samples at three concentrations of tetanus antibody in a single testing run. the panel samples were created by spiking appropriate amount of a who tetanus antibody standard into sodium citrate plasma. accuracy was determined by testing a series of samples ranging from iu/ml to iu/ml of tetanus antibody. the samples for the accuracy study were created by diluting an appropriate amount of a who tetanus antibody standard with sample diluent from the reagent kit. linearity regression was determined by using the accuracy study values within the range of . to . iu/ml. stability of samples was determined by testing samples stored at - c and - c in triplicate at various time intervals. results/finding: the %cv for the optimized anti-tetanus assay for all antibody levels determined in the precision study varied from . to . . so, precision was acceptable since the %cv for all samples tested was %. the mean values for the samples tested in the accuracy study were all % of the expected value which was much lower than the acceptance criteria which was % of the expected value. the linearity of the assay was acceptable with a r ! . %. the linearity study established that the known tetanus concentration was a statistically significant predictor of the observed concentration. the sample stability studies demonstrated the ability to quantitate tetanus antibody concentrations in samples stored up to days at - c and up to month at - c. conclusion: the data presented shows the successful optimization of the human anti-tetanus immunoglobulin reagent kit for use on a photometric analyzer. validation studies of this optimized assay demonstrate excellent accuracy, precision and linearity using samples stored for days at - c and stored up to one month at - c. a deep dive audit of intravenous immunoglobulin use for immune thrombocytopenia: is its use inappropriate? jiajia liu*. university of toronto background/case studies: intravenous immunoglobulin (ivig) is a generally safe and effective therapy for immune thrombocytopenia (itp) but is only suggested for scenarios when a rapid increase in platelet count is desired or as first line therapy if steroids are contraindicated. due to concerns regarding adverse effects, cost and resource availability, an ivig request form was implemented in our jurisdiction in to track utilization and appropriateness. a recent audit of these request forms from four academic institutions found a lack of compliance with form requirements and inadequate documentation of efficacy which led the authors to conclude that the use of ivig was broadly inappropriate (shih et al, ) . as such, we aimed to conduct an extensive chart review of patients who received ivig for itp at our institution to assess appropriateness of use. study design/method: we conducted a retrospective chart review of all patients with itp who received ivig in our institution from april , to march , . local research ethics board approval was obtained. results/finding: patients received ivig for itp at smh over the study period for a total of unique ivig infusions. the most common indications for ivig within currently accepted guidelines were: active bleeding ( , %), pre-operative or antepartum care ( , %), a platelet count of less than and contraindication to corticosteroids ( , %). additional indications that still fell within accepted guideline recommendations included: patients with arterial/venous thromboembolism or risk thereof requiring initiation of antithrombotic therapy; and patients requiring myelosuppressive chemotherapy. indications that fell outside of guidelines included: use of ivig as a diagnostic challenge where the etiology of thrombocytopenia was unclear and use prior to international travel for patients with difficult-to-treat chronic itp despite a platelet count between - x /l. patients received ivig for a likely diagnosis itp while a transfusion being investigated for alternative explanations for thrombocytopenia. three patients were refractory to all other therapy for itp and were dependent on regular ivig infusions. / ( %) of infusions consisted of g/kg over days; the remainder of infusions consisted of g/kg. of those who received g/kg, of patients ( %) had evidence of partial remission after a first g/kg dose. ivig was generally well tolerated and infusion reactions were mitigated with use of corticosteroids, antipyretics and/or antihistamines. conclusion: we found, at our institution, that use of ivig for itp was generally appropriate and carefully considered even in cases that did not meet current guideline recommendations. we believe that ivig remains an important treatment for itp particularly in the aging population where prevalence of conditions complicating bleeding risk is increasing. detailed utilization/ knowledge data inquiries are required to develop tools and policies to enhance appropriate ivig use in multiple settings. we believe that there is an opportunity to promote administration of a single g/kg dose to minimize unnecessary utilization of ivig amongst hematologists who manage itp. a process for improving crossmatch bench ergonomics janet dornfeld*, sheng-chung cheng, ann eggebrecht, beth greer, savannahsue rondeau, brian rognholt and beth taylor. mayo clinic background/case studies: a mission of our institution is to reduce the risk of work-related injuries. accordingly, each year an ergonomic survey is undertaken as a component of a general department of laboratory medicine and pathology safety audit. our survey identified potential musculoskeletal risks that suggested a redesign of our crossmatch benches. study design/methods: a seven item ergonomics survey of the working environment was sent to staff members in early february of . twenty-two technologists responded for a % response rate. the below table below reports the survey items and responses. results/findings: the most problematic area was the available workspace. of the respondents, % indicated that workspace size was insufficient and % that the chairs at the fixed height benches were problematic. problems noted were difficulty with climbing up into a chair and backing down and with the chairs holding the chosen height. our laboratory lean team operational support group was tasked to aid with the bench redesign and to choose products for improving the workspace. our goals were to design a layout to streamline testing workflow and better utilize lab space, including our plasma thawing and sink space, eliminating dead space. the configuration of the new workspace was guided by the survey findings. adjustable height workstations were recommended to replace our fixed height bench. we worked with our facilities design contactor to purchase adjustable benches and plan add-on cabinet shop work. the benches were assembled off site, which allowed a bench top layout to be determined and installation of cabinet shop add-ons of a drawer for supplies and a pull out breadboard as a writing surface. the opportunity to assemble off site streamlined the process of installation, resulting in minimal disruption of testing. conclusion: the survey was effective in identifying working areas for improvement. employee comments have been positive for the new workstations. an effectiveness assessment will follow, using the original survey, to assess the success of the project. a retrospective study of emergency department initiated type and screen testing: were patients transfused after testing? sandra lamm* , neil bangs and kimberly sanford . vcu health system, virginia commonwealth university background/case studies: type and screen (t&s) testing is often ordered on patients presenting in the emergency department (ed). if the patient does not have a historical type, a second sample is drawn with an additional phlebotomy for type confirmation. if the patient does not need a transfusion of red blood cells (rbcs), the testing and second phlebotomy is an inefficient use of resources and time. study design/method: as part of a performance improvement initiative in transfusion medicine, we performed a retrospective study of all t&s orders that were initiated in the ed from / / to / / to determine if testing was subsequently followed by transfusion of blood products. patients were stratified by ed department, time from t&s draw (tsd) to transfusion (< hours, > hours < hours), and if a second sample was required. results/finding: a total of t&s orders were initiated from the ed in this time period. ( . %) patients were not subsequently transfused any type of blood product within hours of tsd and ( . %) patients were not subsequently transfused any type of blood product within hours of tsd. a total of ( . %) patients required a second sample. of these patients requiring a second sample, ( . %) were not subsequently transfused any type of blood product within hours of tsd and ( %) were not subsequently transfused any type of blood product within hours of tsd. conclusion: routine ordering of t&s testing is not an efficient use of resources and time as many patients are not subsequently transfused. ultimately unnecessary t&s and second sample collection and testing for those patients not subsequently transfused within hours of tsd amounted to an estimated $ , in unnecessary patient charges and approximately . nursing hours for phlebotomies in a six month period. anti-d from alloimmunization versus rh immune globulin: detective work in the blood bank and transfusion medicine services (bbtms) margaret diguardo* , debra berry , yunchuan delores mo and gay wehrli . university of virginia health system, children's national medical center background/case studies: the institute for healthcare improvement triple aim incorporates enhancing patient satisfaction by providing high quality, safe care. towards these goals the bbtms is charged with communicating to obstetric physicians (obs) a patient's antibody specificity with associated hemolytic disease of the fetus/newborn risk. thus, when anti-d is detected in a female of childbearing age, it is critical to determine whether this represents rh immune globulin (rhig) or alloimmunization (alloanti-d). review of a patient's electronic health record (ehr) helps quickly identify rhig administration, but if this documentation is missing, then it is easy to assume presence of alloanti-d. rhd alloimmunization impacts mom, fetus, newborn and future pregnancies. therefore, without a national, comprehensive health information exchange (hie) system, it is imperative to investigate beyond the on-site ehr whether a patient received rhig at an outside hospital (oh). we report an irb approved (exempt) case series where detective work revealed rhig administration at ohs. study design/method: over a two month time period, anti-d was identified in four pregnant women. review of their ehrs did not reveal a history of abstract rhig administration; nor did subsequent direct communication with their obstetricians (ob) reveal a history of rhig. based on each patient's home address, the bbtms of any nearby ohs were contacted as was a primary care physician if listed in the ehr. results/finding: investigations beyond the ehr and obs revealed each of the four patients received discontinuous prenatal care with presentations at multiple sites. through phone calls to the bbtms of ohs, a history of one or more rhig administrations within the preceding three months was found for each patient. our bbtms records and ehr were amended to reflect the presence of a passive anti-d due to rhig, rather than alloanti-d. the changes were also directly communicated with the ob caring for each patient. conclusion: when a new anti-d is identified in a pregnant female, investigation is required to determine whether it is passive rhig versus alloanti-d. when neither the ehr patient history or ob reveal a rhig history, it remains in the patient's best interest to investigate further. through phone calls to oh we revealed a history of rhig administration in four patients. finding and communicating this critical information helps enhance the quality and safety of patient by ensuring subsequent rhig administrations when indicated, at our institution. future strategies for avoiding similar situations include expanding our national hie for critical information such as bbtm history and allergy history and expanding use of wallet-size patient identification cards with rhig and alloantibody histories. auditing massive transfusion protocol colleen a. aronson* , elizabeth halperin , sharon breining and mona papari . acl laboratories/ advocate hospitals, advocate health care, itxm background/case studies: a large midwest hospital system with level i trauma sites evaluated how to audit the massive transfusion protocol (mtp). the possibility of real time audits is impractical due to the unpredictability of these events. a search of the internet found an example from new zealand for post process evaluation. this was shared with a team as a starting point and then adjusted for system specific priorities. to start the audit, the initiation of the mtp needed to be determined as events are often started as a verbal request but then followed up with either downtime or computer orders. study design/method: the transfusion service (ts) was determined to be the source of truth for all of the mtp events. a tracking sheet was created to capture the patient demographics, start and stop time, number and type of products issued and wastage. this was then passed onto nursing quality staff that used the tracking form and the patient chart to enter an event into the error management data base as a focused event. the focused event was built to include patient demographics and other information from the tracking form as well as where the event was called (surgery (or), emergency (ed), labor and delivery (l&d), etc.), type of event, use of tranexamic acid (txa), calcium chloride (cacl), temperature monitoring and pre/ post lab results. a trial was started and months of data were evaluated that contained events. results/finding: there was an equal number of events that were initiated in the ed and the or ( ). male patients were involved % of the time and % of time the patients expired. trauma of some type was the majority of the cause but . % of the cases involved gi bleed and only . % were obstetric cases (see chart). the lowest hemoglobin (hgb) was found to average . with the post hgb average of . . ratios of : for red blood cells (rbc) to plasma as well as rbc to platelets (plt) and cryoprecipitate (cryo) were also determined with a target of : . it was found that the rbc: plasma was . : , rbc: plt was . : and rbc to cryo was . : . use of txa was only . % and cacl was utilized in . % of cases. conclusion: although this data is for a short period of time it has pointed out several opportunities for improvement. the use of mtp in gi cases was not previously understood but opens up a new group of people for which education and understanding of the mtp process is needed. the low use of txa needs to be evaluated and already has started conversations about how this drug should be stored and accessed for the mtp process. the product ratio numbers were suspected of being off but now that data is available, it is much easier to speak to this issue and look for improvement. the process will now be expanded to the level ii trauma sites in the system and routine evaluation will be shared with all sites. automated report significantly reduces turnaround time for rbc antibody alert jessica l dillon* , jody a barna , donald e ulinski and nancy m. dunbar . dartmouth hitchcock medical center, dartmouth-hitchcock medical center background/case studies: clinically significant antibodies should be promptly and clearly communicated to the patients' healthcare team to avoid potential transfusion delays in blood availability or complications of incompatible transfusion. at our institution, all newly identified clinically significant antibodies are immediately resulted in the electronic medical record (emr). an interpretative comment is also entered by the transfusion medicine service (tms) physician after the antibody work-up has been reviewed (this may be up to weeks after the antibody is identified). this comment describes the antibody(ies) identified, indicates the need for crossmatch compatible blood and alerts clinicians of possible delays in providing crossmatched units. since clinicians may not always review these results, the tms physician also simultaneously adds an "allergy to red blood cells" alert in the patient emr at the time the interpretive comment is entered. study design/methods: in july , we implemented an automated report to reduce the turnaround time (tat) for entry of the allergy alert. the report contains all detected red cell antibodies in the prior hours and is provided to the tms physician during daily morning rounds (monday through friday) for manual entry of allergy alerts. this study describes a three month comparison both before and after the automated report intervention, to evaluate the tat for allergy alert entry into the emr. age ( abstract results/findings: between august and november (pre-implementation) , newly identified clinically significant antibodies were resulted for patients compared to patients between the months of august and november (post-implementation). the tat for allergy alert entry for both periods is shown in table . we observed that % of allergy comments were performed within hours in the post-implementation period versus only % pre-intervention (p . ). using the new process, nearly all of the alerts were entered into the emr within hours of antibody resulting and none of the entries were missed. conclusion: there was a significant improvement in the tat for allergy comment entry following implementation of an automated report. this project illustrates how information technology can be leveraged to facilitate timely communication of antibody identification. blood bank verbal tool implementation for cardiovascular surgery rita louie* , shailesh macwan , nancy nikolis , arline stein , janelle richardson , manju bagu , lennart logdberg , alexander indrikovs , vishesh chhibber and sherry shariatmadar . north shore university hospital, northwell health background/case studies: our institution is a tertiary care facility performing over cardiovascular surgeries (cvs) in , an increase of % after the healthcare system cvs integration in . transfusion support of these patients includes preoperative preparation of prbcs according to a maximum surgical blood order schedule. additional blood components are issued as orders are placed. until december , the additional written orders were submitted to the blood bank via the pneumatic tube system without further communication. after reported events in q that resulted in delays in blood transfusion, we examined our process very closely and identified opportunities for improvements. in collaboration with cvs, the blood bank implemented a new workflow process to enhance communication with the cvs team, reduce turnaround time and improve patient safety. study design/method: . open discussions and collaboration between blood bank and cvs nursing teams . mapping the process using flowcharts for additional blood orders from cvs. . identify bottlenecks and brainstorm solutions. . a verbal cvs order process and form was implemented to improve communication between cvs and blood bank, which solidified communication by including the time of the order, patient identifiers, caller identification, ordering prescriber, staff receiving order, the quantity and kinds of products ordered, the mode of order delivery, and anticipated future orders. a read back was also documented for verification of the order. . the blood bank staff immediately processes this order while waiting for the written order to arrive. upon receipt of the written order the blood is issued to the or. . follow plan-do-check-act. the transfusion safety officer reviews each order for the following parameters: number/type of products, turn around times (tat), wastage/returned products and overall efficacy since implementation of this process. results/finding: a significant improvement was noted in communication and tat after implementation of the process described above. for the period / / - / / the blood bank has received verbal orders with varying product combinations. the table below represents average turn-around times to issue blood products: conclusion: the introduction of the verbal order tool for cvs has streamlined the blood ordering process leading to increased efficiency and lower tat. effective communication between the or team and transfusion service is the key to timely provision of blood products for these critical patients. challenge of blood type testing for multiply transfused sickle cell disease patients jayanna slayten* , tracie ingle and heather vaught . indiana university health, indiana university health (iu health) background/case studies: we report our midwestern, university transfusion service challenge of obtaining the correct blood types in rbc exchanged sickle cell disease (scd) patients tested by our primary testing method, solid-phase red cell adherence analyzer echo (immucor. norcross, ga). the echo operation manual in chapter - and appendix d it states: "warning: the galileo echo cannot reliably detect hemagglutination reactions that are graded as or less in tube methodology. the galileo echo does not generate as interpretation of mixed-field. such a mixed-field reaction will be interpreted as positive, negative, or equivocal." we report of a challenge with this analyzer limitation which impacts the assignment of the correct blood type for multiply transfused scd patients. study design/method: two scd when initially tested by the echo as o, d negative; however, each patient was historically o, d positive. both patients had received a rbc exchange transfusion with - o, d negative red blood cells over days previously. repeat testing of the samples was completed by the vision (ortho clinical diagnostics. raritan, nj), neo (immucor. norcross, ga), and by standard abo/rh manual testing (anti-a, anti-b, anti-d series , anti-d series , a cell and b cells. immucor. norcross, ga). the repeat testing was compared to verify the patient's abo/rh typing and the results were entered into the computer system to allow for assigning the patient's abo/rh typing and electronic crossmatch. results/finding: table summarizes the initial and repeat testing with the two patient samples. although the echo failed to interpret or flag the blood type as mixed-field, the other methods identified the transfusion of o, d negative blood with the detection of mixed-field in the d typing or by failing to interpret the abo/rh as not type determined (ntd). the vision and manual abo/rh typing yielded the easiest mixed-field to interpret macroscopically. conclusion: our results agree with the findings of summers et al (trans-fusion ; : - who reported the challenge detection of mixed-field with the use of the echo compared to improved detected with automated gel column agglutination. when the samples were tested by multiple automated and manual abo/rh methods, the expected mixed-field was detected. the failure of the echo to detect the mixed-field is acknowledged by manufacturer, but there is a risk that a facility may mistype the abo/rh when there is not a historical abo/rh to compare. to avoid this risk, it may be appropriate to re-type first time scd patients by other methods rather than the echo to avoid this challenge. consistent with summers do not account for regional distribution. many large hospitals acting as regional hubs for redistribution may appear to have optimized inventory based on odr and bsr, but we hypothesized that these are crude key performance indicators (kpis) requiring redevelopment. study design/method: kpi redevelopment occurred in a large tertiary care hospital blood bank in canada, responsible for % and % of transfusions in the region and province respectively. rbc supply, inventory, and disposition data were retrospectively assessed from february -june as the baseline period. a "demand-driven inventory planning policy" (ddip) was instituted to assess and implement the optimal rbc reorder quantity based on the difference between the historical maximum and minimum rbc inventories during weekdays; that would not lead to blood shortages. shelflife inventory (sli) was chosen as the main surrogate marker for the assessment of efficiency of the supply chain process, calculated by the differences between age of blood transfused (abt) and received (abr). iterative simulation modeling (r statistical software) was then performed to optimize sli in a post-implementation period from june -october . results/finding: modeling predicted observed rbc disposition. through simulation, optimization of sli was found to occur by optimizing a set of kpis for each abo blood group (table ) . this led to a reduction in observed overall sli ( . . days vs . . days, p< . ) and odr ( . % vs . %). the bsr was not significantly increased during the postimplementation period. conclusion: optimization using simulation modeling of multiple factors other than bsr and odr led to further efficiency gains in a large tertiary care hospital blood bank. hospital blood banks should use an integrative approach with a set of kpis to optimize the supply chain. this approach requires validation in other blood banks and jurisdictions. ( )) requires that the hospital make reasonable attempts to notify the patient (or the patient's physician), counsel the patient, and offer testing. the hospital must maintain records of this lookback notification as part of the patient's medical record. paper records of lookback notifications are less accessible than electronic records and are at greater risk of being damaged or lost. to facilitate the lookback process and reduce paper documentation we sought to use the electronic medical record (emr) to perform and document notifications. study design/method: representatives from transfusion medicine (tm) and information technology (it) worked together to define minimum and optimal emr solutions. minimally, a completed paper packet could be scanned into the emr. this solution had no advantages in terms of ease of use, process control, or transparency. desired optimal functionality includes the ability to send letters in the emr, document control so that original communications may not be altered, opportunity for patient's physician to electronically sign and return responses, letter and form templates that can be individualized, and the ability to track when and by whom notifications were sent and received. the emr system at our institution, epic (epic systems corp., verona, wi), has a function called "letters" with the capacity to do all these tasks. a series of five templates were developed: hiv and hcv letters to physicians, response forms for physicians to return to the transfusion service, and a blank letter template to be used for specially tailored letters. templates are opened within the patient's emr and demographic information is automatically populated by epic (eliminating many possibilities for clerical errors), the blood product transfused (e.g. rbcs or plasma) is selected from a drop-down menu, and the date of transfusion is manually entered by the sender. the completed letter is then routed to the patient's physician; it shows up automatically (and instantly) in their electronic in basket as well as in the patient's emr. physicians may electronically complete and return the response form within epic, or print it and return the form by fax. results/finding: between january and december thirty-five ( ) notifications were sent to physicians using epic letters and of those, fourteen ( ) responded to the epic notification and five ( ) used the provided electronic response form. for these cases the time to mail or handdeliver paper notifications was avoided. the remaining cases required follow-up paper notification, but the electronic letter remains as permanent, easily accessible documentation of when the transfusion service first notified the physician. conclusion: lookback notifications within the emr makes compliance with government requirements more transparent and records more accessible to caregivers, patients, and assessors. secondarily, efficiency may be improved by reducing the need to print and mail/deliver letters. evaluation of ordering practice in the operating rooms and its impact on product wastage alexandra budhai* , denden benabdessadek , annu george and alexandra jimenez . westchester medical center, new york blood center background/case studies: blood product wastage is an issue that many hospitals aim to address. the or was identified to have the highest rate of wastage within our hospital. in this study, we assessed the appropriateness of the product order and utilization by the or to understand its impact on wastage. study design/methods: data on product orders, issue, and return for two months were analyzed. the hospital cpoe and product requisition forms were used to collect this data. the surgical procedures and number of ordered units were compared to the hospital's maximum surgical blood order schedule (msbos). trends for inappropriate orders for products by physicians were evaluated. results/findings: a total of orders were reviewed. approximately, % of these products were issued to the or. we found that the physician orders were within the guidelines of the msbos for most cases ( %), but of the issued products, all were returned to the blood bank in % of cases. we observed that the percentage of products ordered and used compared with the products ordered and returned in cardiac surgeries are nearly equal. in addition, all of the products ordered for c-sections were not used; albeit ordering frequency being significantly lower than for cardiac cases. conclusion: the data analyzed demonstrates that the majority of surgeons are adhering to our institutional msbos guidelines. it was noted that surgeons are requesting products be issued for invasive procedures where rapid exsanguination is possible. our analysis revealed that the hospital's msbos does allow for an excess in blood ordering for some surgical procedures. the msbos should be updated to reduce the suggested maximum product order. in general, the data does not imply that the blood product wastage in the or is due to the ordering practices of the surgeons. a larger period of surgical blood ordering practices should be analyzed to detect blood product ordering, utilization and wastage trends in other subspecialties. background/case studies: the visionv r and visionv r max (ortho diagnostics, raritan new jersey) are id-mts tm gel card-based automated immunohematology analyzers marketed for small to medium, and high-volume [> type and screens (t&s) per day] blood banks , respectively. our laboratory which serves a large -bed multispecialty academic hospital and receives - t&s specimens per day needed to replace three provue analyzers prior to the availability of the visionv r max. we implemented three visionv r analyzers to work with our existing neov r and echov r (immucor inc, norcross georgia). a recent multicenter field application trial of the visionv r reported a mean turnaround time (tat) for t&s and abo, rh typing (abo/rh) of . . and . . minutes , respectively. the objective of this study was to determine visionv r tats under routine daily high-volume practice. study design/methods: one visionv r was in operation during a five-week period (phase i), and then two additional analyzers were brought into service (phase ii). tats are defined as the time when the order is received by the instrument to when the test is completed and available for review. three-cell screen and abo/rh tats, and number of visionv r antibody panels were collected for a nine-week period. the tat for the screen was used as the tat for the t&s because the screen is the rate determining step. all testing was performed using in-service analyzers on routine patient samples by trained technologists. samples were not deliberately batched but were placed on the analyzer based on the volume and flow of work at the time. results/findings: under the high volume conditions of our laboratory with three visionv r analyzers, the mean t&s tat was % longer and had a larger standard deviation (s.d.) than the published trial result of . . . transfusion vol. supplement s abstract during phase i visionv r performed panels. during phase ii visionv r performed of the visionv r panels. conclusion: our visionv r analyzers are used under high volume conditions more suitable for the visionv r max. when balanced with the testing menu, including ability to perform select cell panels, our tats using three analyzers were satisfactory. the large standard deviation indicates that opportunities remain for improving tats through workflow improvement. from west nile virus to the emergence of zika virus: a nationwide survey of how regulators are keeping the blood supply safe and available falisha atwell* , john roback , ronald arkin , michael bartlett , robert geiger and jaxk reeves . university of georgia, emory hospital background/case studies: with the emergence of zikv in the united states, it is important to assess the fda's response time in providing guidance to ensure the safety and availability of blood products in the face of newly emerging infectious diseases. this research compares the responsiveness of the fda during west nile virus (wnv) and zika virus (zikv) outbreaks to evaluate our current preparedness. study design/methods: the literature review was conducted to analyze fda's response time during the wnv crisis and determine if it was effective and efficient. the research survey was performed to determine if the donor history questionnaire (dhq) adequately screens donors for zikv as the sole preventive method (as per the february guidance for industry: recommendations for donor screening, deferral and product management to reduce the risk of transfusion-transmission of zika virus) and to determine if the current regulatory practices (including the august guidance for industry: revised recommendations for reducing the risk of zika virus transmission by blood and blood components) are perceived to be effective and efficient in the face of the current zikv outbreak. survey monkey was used and participation was anonymous. over , emails and web-links were sent to members of aabb, scabb, seabb, and personal network with a % target response rate. participants self-selected or deselected based on the inclusion and exclusion criteria listed in the consent letter. results/findings: the literature review revealed that the fda's response was slow during the wnv outbreak, while the zikv response is efficient thus far. a total of participants responded to the survey ( . % response rate). statistically, participant agreement with fda's decisions was performed by "t" test (with n- - df) of the null hypothesis that the mean vs. the alternative that the true mean is> . overall participants had favorable opinions of the fda's decisions. statistically, whether participants in different levels of the demographic variables (region, profession, and years of experience) answer significantly differently, one way anova models were used with likert-scale question responses as if they were continuous. the f-statistic and p-value are for the null hypothesis that all levels of the explanatory variable have the same mean for the response variable. there were no significant differences in the years of experience and profession variables for participants. region was determined to be unreliable due to undefined states for each region listed. conclusion: the research revealed that industry experts conclude that the current system of dhq and fda guidance documents, if issued timely, are adequate. background/case studies: when evaluating a new instrument solution for pre-transfusion testing, it is important to consider the operational impact of the system on the lab. there are a variety of operational, performance and system metrics that can be evaluated to determine this impact including: test workflow, hands on time, and automation time. study design/methods: the study involved a current state to a future state comparison of testing processes with an instrument ortho provuev r (pv) and manual testing vs. an instrument ortho visionv r (ov). data collection methods included direct observation, time studies, and interviews. the pv bench performs type & screens (ts) on the pv and manual abid/selected cell panels in the gel test. all other testing; cord blood(cb), dat, unit confirm(uc), patient type confirm(pc) and crossmatch(xm), etc. are done manually in tube. the future state incorporated the ov. ts, abid and uc were evaluated in both states. cycle time(ct) was averaged based on run cycles. ct was comprised of metrics; instrument time(it), standby time(st) and labor time(lt). st may be comprised of components, time that could be utilized as "walkaway" time or vigilant time (vt) which requires operator presence but not operator action. for automated instruments, vt for each cycle was measured as instrument access unavailable. instrument daily maintenance (dm) ct was evaluated as well. similarly, timing of manual tube test processes used these metrics. for repetitive activities within a process, such as uc or xm, a time per individual process was captured and then multiplied per unit. results/findings: table provides details about the metrics of current state and future state processes. tube based test timing is as follows: pc ( : ), xm ( : ), cb ( : ) and dat ( : ). by implementing the future state, an average $ . min. lt and vt is saved on each sample loaded for ts equating to a % labor reduction over the current state. a % improvement in tat on the ts was achieved in the future state. moving from manual abid to automated processing resulted in a % lt reduction. on average, a min. continuous walk-away time is achieved for each automated abid. uc had less impact on labor time with minimal difference however allowed for focus on consistency and quality metrics. conclusion: based on the metrics evaluated and compared between current state and future state, the ov has demonstrated improvement in lab operations to both the labor required and result tat delivery. opportunity exists to automate workflows on other tests that are still manually performed. background/case studies: high throughput and efficient automation of serologic tests is crucial in the workflow of a blood bank that tests $ type and screen samples per day. the erytrav r (grifols) is a fully-automated walkaway analyzer utilizing -column gel cards for pretransfusion testing. the blood bank validated and implemented the use of erytrav r for abo/d typing, antibody screening and identification of patient samples as a replacement for a solid phase testing platform. the blood bank also validated automation of donor unit retypes. the instrument has bidirectional interface to the blood bank lab information system (lis), hcll tm (hemocare life line, mediware). instrument validation and implementation were done in conjunction with the software version upgrade of hcll tm and an interface system change to maestro tm . study design/method: correlation testing of the erytrav r results with the manual tube testing (peg iat; reference method) was performed on patient samples for abo/d typing and antibody screening; of which at least had a positive antibody screen. out of the , had known antibody specificities. forty-two rbc units were also tested for abo/d confirmation; of which were d(-) and were d( ). calculations of concordance, sensitivity, and specificity were performed. precision studies were also done. interface testing of erytrav r , hcll and the hospital's information system using the maestro tm interface system was performed and validated. results/finding: concordant results between both methods were obtained in all of the patient and donor samples tested ( % concordance). all samples with positive antibody screens were obtained by both methods. all clinically significant antibodies were detected by both systems. erytrav r gave % sensitivity and specificity. the precision studies showed that both methods gave the same type and screen results for samples at different testing events. after validation of the lis upgrade and interface system change, a bidirectional interface with hcll tm was established. the instrument has been operational in our lab for over months. conclusion: erytrav r was found to be reliable and accurate and can handle the high workload of our lab. users found the instrument easy to use; hence training, proficiency, and competency of the users are achievable and manageable. the validation of the the instrument is straightforward. the major challenge and delay in the implementation experienced by this blood bank were attributed to the concurrently occurring lis upgrade and migration of the data integration system. a post-implementation workflow assessment would be ideal to perform to ensure that the instrument is being used at its full potential. implementation of a system-wide platelet inventory report optimizes platelet utilization and reduces unit wastage elly landolfi* , craig fletcher and peter millward . beaumont hospital, beaumont health system background/case studies: a sufficient number of blood components should be available to meet routine and emergent hospital needs. this must be assured while minimizing outdating of scarce and expensive blood components -an inherent challenge with platelet units which have a short -day shelf-life. we report the results of a quality improvement project implementing a custom computerized platelet inventory report designed to mitigate the most common cause for platelet wastage at our institution: high platelet outdate rates. the report includes blood type, product code, unit number, respective product attributes, supplier and availability status of all platelet units for each hospital location. all system blood banks receive a morning fax of the report which facilitates transfer of units prior to expiration and adjustments are more readily made for product orders to the supplier. study design/method: the study was conducted in the hospital-based blood bank and based on available platelet inventory and wastage quality data. the report went live october and quality data was reviewed from august to december . the collected data was then analyzed using descriptive statistical methods. results/finding: data from indicates platelet wastage comprised % of total received platelets and % of these wasted platelet units were due to expiration. other reasons included failed visual inspection, blood dispensed but not used and wasted on the floors, potential tube station problems or short-dated units transferred into our blood bank from another facility. the mean of monthly wasted platelet units months preimplementation of the report was units, compared to units months post-implementation and units months post-implementation. wastage rates improved from % (wasted yearly platelets/total received yearly platelet units) in , the year of report implementation, to post-implementation rates of % in and % in (see table) . importantly, this occurred despite a greater than % increase in platelet inventory between and and resulted in cost savings of over $ , in this period. conclusion: study limitations included restricting data collection to one campus. the option to transfer expiring platelet units to another blood bank was available to all participating sister hospitals. it would have been interesting to see the effect of the report on those hospitals which have lower transfusion rates and different ordering practices. aside from lowering platelet wastage within years of implementation, additional benefits to the report included facilitating ordering from the blood supplier. cornerstones of a successful inventory management plan include daily inventory monitoring and, ideally, coordinated system-wide efforts to share platelet units. we have shown achievement of this end is facilitated by a customized daily platelet inventory report -an efficacious and easily adaptable tool with demonstrable gains. valerie halling* , lisa marie button , lori scanlan-hanson , karen koch , janet finley , deepi goyal and camille van buskirk . mayo clinic-rochester, mayo clinic, mayo clinic rochester background/case studies: transfusions in the emergency department of a level i trauma center were ordered using a handwritten order form. the transfusion lab's (tl) management team and medical director met with emergency department (ed) leadership and it resources in to define the needs of a successful electronic blood transfusion system. the handwritten order forms had several potential error sources which could lead to a delay in filling the order pending correction (in the best of circumstances) or could lead to transfusing the wrong patient or the wrong product if the error was not detected. the potential error sources included clerical errors involving the patient's name or medical record number (mrn), writing two different names on the order form (because there were two locations to record patient name), two product types ordered on one form when the requirement is for one product type per order, no priority indicated (stat or routine), or not including the prescriber call-back information. the number of ed reported transfusion related events in and were / (events/ed transfusions - ). study design/method: electronic ordering for the ed was implemented march st . any transfusion orders generated from the ed are now electronic, unless in the case of electronic downtime. the system electronically fills in the patient's name and mrn, controls for the type of blood product being ordered, requires an order priority and provides service contact information. it was designed to accommodate transfusion ordering needs for adults, pediatric patients < kg and pediatric patients > kg. a transfusion orders had three critical fields identified that are required for the order to be processed including patient weight, product volume, and infusion rate. the electronic system was designed so that an order cannot be submitted unless all critical fields are completed. results/finding: the electronic ordering system has been in place for years (april -march ), and during that time there was instance of blood being ordered for an unintended patient . % ( / ). this was because a previous patient's medical record was accessed rather than the intended patient's medical record. there have been no instances of clerical errors (name misspelled or mrn transposition etc.), missing service contact information, missing order priority information, more than one product type ordered on a single order, or two patient names on one order. electronic ordering also provided a place for the transfusionist to chart against, leading to increased transfusion documentation compliance. prior to electronic order implementation, in , / ( . %) units were transfused in the ed but not charted in the patient's medical record. in , / ( . %) transfusions were not charted. however, in , the first full year of electronic transfusion order capability, only / ( . %) transfusions were not charted in the patient's medical record. conclusion: electronic ordering in the ed has essentially eliminated ordering errors in this area resulting in less rework for both technologists and physicians. it allowed the order to be processed more quickly by tl, resulting in a faster turnaround time. improvement in the overall quality of transfusion ordering through electronic ordering reduced the influence of human factors in order placement and provided an added benefit of having a specific order to chart against. implementation of blood bank automated attendant lok tse*, gerald motta and maria aguad. brigham and women's hospital background/case studies: the blood bank receives numerous nonemergent phone calls on a daily basis. these calls not only occupied valuable time but also made the lines unavailable when a real emergency occurred. the hospital is categorized as a level trauma center, with over inpatient beds and over operating rooms. a proposal to implement a blood bank automated attendant was recommended to decrease phone calls, minimize errors due to distraction from phone calls, free team members to perform other duties and have a direct line designated for requesting trauma coolers, massive transfusion protocol (mtp) and emergency release of blood products. study design/method: the first step was to categorize the types of phone calls received by the blood bank by creating a phone log. data were collected and analyzed for four weeks. the blood bank collaborated with nursing, hospital administrative staff and telecommunication team to evaluate the possibility of implementing an automated attendant to minimize phone calls. it was very important to maintain patient safety and quality of service at the same time. the automated attendant consist of: option (urgent) for trauma, emergency release, mtp and obstetric hemorrhage emergency release; option (verbal) for verbal orders and coolers set up; and option (staff) to speak with staff member. instructions were also given for specimen inquiry and product availability in the hospital information system. results/finding: the data in table showed that most of the incoming calls fall into three categories (specimen inquiries, product order inquiries, and other inquiries). most of the calls were from nursing staff inquiring about the length of wait time for blood products and specimen availability. there was an overall decrease in phone calls by % with the implementation of an automated attendant. conclusion: with the implementation of an automated attendant, the blood bank team was able to identify and respond accordingly and efficiently to urgent requests and verbal phone orders. the decrease in phone calls freed up team members to perform other critical tasks in the department. improved detection of wrong blood in tube errors: implementation of a two-sample blood type verification process ariana king* , steven zibrat , geoffrey wool and angela treml . university of chicago medicine, university of chicago background/case studies: our organization used a blood bank identification (bbid) band system for pre-transfusion testing and detection of wrong blood in tube errors (wbit). additionally, type & screen results were compared to patient's historical records; the specimen was retyped by a second technologist if historical results were not available. the bbid bands were prone to clerical errors and excessive specimen rejections, and believed to miss some wbit errors. in , blood bank accounted for % of all rejected clinical laboratory samples, yet comprised only % of total laboratory volume; % of rejected blood bank samples were due to bbid band issues. the wbit error rate detected by bbid-based system was . %. study design/method: a multidisciplinary workgroup was formed to review data and best practices. the decision was made to discontinue bbid bands and implement a two-sample verification process, in keeping with standards. a new laboratory test order was created in the emr system and embedded into the existing t&s order. providers are prompted to order the abo verification test only when no previous abo/rh typing results are found. education was provided to all clinical staff in the form of in-services, emails, and annual competencies completed electronically. the new process went live in september . results/finding: in the five months following implementation, four wbit errors were detected with the second sample. these may have been missed using the bbid band system. improved detection revealed a wbit error rate of . %, three times the national average of . %. under the new system, rejected blood bank samples decreased from an average of % to % of all rejected laboratory samples, a % decrease. implementation of the new process produced a net savings of $ . k. conclusion: replacing the bbid band system with two-sample verification successfully improved our ability to detect wbit errors among patients who lacked historical blood bank results. additionally, discontinuation of the bbid system decreased the incidence of clerical errors and unnecessary specimen rejections, and also saved money for the organization. next steps are for blood bank and laboratory quality leaders to partner with nursing leadership to drive down wbit error incidence. a addendum with the final culture results. we used a student's t test to determine whether there was a statistically significant difference in the mean tat for result addendum entry in the post-implementation period compared to the pre-implementation period. results/findings: in the pre-implementation period, we cultured residual products for suspected str. the tat for final culture result entry into the patient's emr was - days (mean days, sd ). in the postimplementation period, we cultured residual products for suspected str. the tat for final culture result entry into the patient's emr was - days (mean days, sd ; p . ). there were no positive cultures during either study period. conclusion: our study demonstrates that tat for documentation can improve with the use of information technology to notify the transfusion medicine physician when results are available for documentation in a patient's emr. improved turnaround time of type and screen samples michaelene hultman* , marcus holme , johnathan bakst , gunta musa and angela treml . university of chicago medicine, university of chicago background/case studies: the primary test performed in the blood bank with regard to pre-transfusion testing is the type and screen (tys). the current target for this institution's blood bank is an minute turnaround time (tat). in april of , the blood bank was forced to move to a temporary location due to building construction, which necessitated a switch from automated solid phase methodology to manual gel method. the average number of outliers increased %. tat analysis of a representative one week sampling per month showed an increase in outliers from per month to per month. average monthly tys samples performed is . these numbers did not improve even upon returning to the original facilities. study design/method: two ortho clinical diagnostics visionv r analyzers (raritan, n.j.) were purchased for the blood bank. the instruments were set up with a bi-directional interface allowing for samples to be continuously loaded without manually ordering the tests. batch testing was eliminated allowing samples to be run as received. the results were auto interpreted, and transmitted to the laboratory information system (lis) based on predetermined rules. only results in need of manual review or interpretation were held back. final verification of results was performed by the technologist within the lis. reagents and other needed consumables could be preloaded on the instruments eliminating the need to repeatedly load consumables with each sample run. key quality indicators including tat continued to be monitored throughout implementation. data was monitored for significant changes and improvements in patient care. the go-live date was / / . results/finding: the average number of outliers decreased % from per month to . further benefits include a reduction in the number of technologists needed to perform tys testing. additionally, reduced waste due to better utilization of supplies by the instruments along with less repeat testing has resulted in projected cost savings of $ , for fiscal year . conclusion: the use of gel technology, in combination with a two way interface and a continuous load instrument can result in a significant decrease in tat over manual gel method. improvements in the timely reporting of final product culture results in the patient's emr. barbara a. hewitt*. dartmouth hitchcock medical center background/case studies: in certain transfusion reactions it is required that a culture of the returned blood product be performed. these cultures are reported in our cerner operating system but those results do not cross over to the patient's emr . the finalized product culture results are entered into the patient's emr as an addendum to the transfusion reaction clinical note. a review of the transfusion reaction database revealed that there were occasions when the final product culture results were not entered into the patient's emr in a timely manner. it is important to the patient's care for the transfusion medicine service and the patient's primary provider to know if a transfusion reaction is related to a contaminated product or the patient's general overall health. this information is also crucial to the supplier of the product to determine if others have received components of the affected unit and to possibly determine if there are any quality control issues at the donor facility. study design/methods: a review of a specific month period revealed that the timeframe in which the finalized product culture results were entered into the patient's emr ranged from - days with a mean of . days. it was determined that this was not in the interest of improving patient care. in collaboration with laboratory information services a report was created in which once product culture results were finalized an email would be generated notifying the medical director and the transfusion safety officer that results were available. results/findings: data was collected for months following the implementation of this report and it was noted that timeliness of finalized product culture results being entered into the patient's emr improved to a range of - days with a mean of days. conclusion: improvements in patient care require diligence and timely reporting of finalized culture reports to determine potential causes of transfusion reactions. this process can be made easier when the correct tools are used. omer ilyas* and randy levine . northwell health, lenox hill hospital background/case studies: transfusion of non-irradiated blood in patients with hematologic malignancies and those receiving cytotoxic chemotherapy can result in life-threatening graft versus host disease (gvhd). after noting several instances where non-irradiated blood was transfused in patients requiring irradiated blood, we designed a quality improvement project with educational sessions involving the oncology unit and blood bank. study design/method: the project was separated into three parts. in the first part, data on transfusion practices was retrospectively collected over a four month period on the oncology unit. the variables collected included date and time of transfusion, pre-and post-transfusion hemoglobin, patient diagnoses, and whether or not blood was ordered to be irradiated and if so, whether or not irradiated blood was issued by the blood bank. all patients with hematological malignancies and all patients receiving cytotoxic chemotherapy were candidates for irradiated blood. the second part of this project was an educational intervention. residents, oncology floor nurses, and blood bank staff were given lectures on the importance of transfusing irradiated blood on the oncology floor. residents were also instructed to order irradiated blood for all patients on the oncology unit. in the third part of this project, repeat data was collected over a two month period to assess whether the intervention was successful. results/finding: pre-intervention, units were transfused on the oncology floor with units ( %) requiring irradiation and only of those units ( %) ordered as irradiated. since the blood bank occasionally issues irradiated blood without a specific order, additional irradiated units were issued ( / ; %). post-intervention, units were transfused on the oncology floor with units ( %) requiring irradiation and all of those units ( %) ordered irradiated specifically to prevent gvhd. eight additional irradiated units were ordered with no requirement for irradiation; thus of the ( %) total units were ordered as irradiated. again, additional irradiated units were issued ( / ; %) without a specific order by the blood bank. the results are summarized in the accompanying table. conclusion: this quality improvement project demonstrates that educational intervention can succeed in changing clinical practices. continued monitoring of ordering practices will ensure that compliance continues. we plan to expand the quality improvement project to other settings, including the emergency department and surgical floors. we expect that adherence to transfusion guidelines in this patient population will reduce the incidence of adverse events. samantha ngamsuntikul* , charlotte van dyke , dina garza van hoose and rachel beddard . biobridge global, south texas blood and tissue center background/case studies: at our blood center, apheresis platelets and red cells are collected on trima accels and double red cells on haemonetics s. in addition to routine quality control (qc), qc is performed for instrument flags on collection instruments. quality control for apheresis platelets includes: volume variance and rwbc; quality control for apheresis red cells includes: product volume, volume variance, hemoglobin and red blood cell mass. study design/methods: during the period of january , to april , , , total collections were flagged for additional qc by our trima accels and haemonetics instruments. quality control at our center is tracked by our quality control software management system, hematerra's hemacomply which allows the ability to track and retrieve this information. the majority of products flagged for instrument qc pass and are released for distribution. a small percentage, however do fail qc leading to loss of product. quality control data can be retrieved and monitored for trends using a quality control software management system. background/case studies: in , the centers for medicare & medicaid services (cms) rolled out a plan for implementing iqcp (individualized quality control plan) as a new quality control option based on a risk management plan for clia laboratories performing non-waived testing. this plan was meant for clia approved tests, but serves as a good tool for labs performing non-traditional and traditional tests on non-traditional samples. study design/method: clia clinical laboratories can either follow traditional clinical clia qc requirements according to the regulations or implement iqcp. while we perfrom traditional qc assessments on all the tests we perfrom on our cellular products we did decide to implement the iqcp program within in our quality control laboratory. we followed the iqcp process for assessing some of our qc tests used to assess the safety, purity and potency of our cell based products. one test in particular where we applied this tool was in the review of our qc sterility testing method and found it to be a very useful in improving the overall process. the tool walks you through three process requirements: ) risk assessment, ) quality control plan and ) quality assessment for the preanalytical, analytical and post analytical phases of testing. abstract conclusion: the integration of the iqcp into the quality control laboratory was determined to be a success. the iqcp tool was successful in identifying gaps within the sterility testing process. this tool will be used on additional quality control tests and manufacturing processes. the implementation of the iqcp program ensure regulatory qc requirements appropriate for testing performed. we were able to revise our procedures, reeducate those involved in the process and hopefully minimize potential sources of error. objective performance of massive transfusion protocols at a single institution gustaaf de ridder* , rachel jug , kimberly ingersoll , nicholas bandarenko , nicole guinn and jessica poisson . duke health pathology, duke university hospital, duke health anesthesiology background/case studies: hemorrhage is both a leading cause of mortality in trauma patients and morbidity in non-trauma patients. using a balanced : : transfusion ratio (tr) for massive resuscitation is recommended based on trauma data. objective performance during massive transfusion protocol (mtp) activations is poorly studied and there may be differences based on site or medical service of mtp initiation. with the impending release of a unified, redesigned exsanguination protocol (exp) at our institution, we established baseline performance characteristics for our existing mtp and obstetric massive transfusion protocol (obp). study design/method: following institutional review board approval, we performed a retrospective study on blood product utilization and outcomes of mtp and obp activations from july -december . data were manually collected from transfusion service paper records, electronic (safe-trace) records, and an automated data report from the electronic medical record (epic). conclusion: we observed considerable variability in transfusion practices during acute hemorrhage depending on the service and location of activation. trauma activations demonstrated the sharpest deficit in platelet transfusion, whereas all groups lagged somewhat in transfused plasma relative to packed red blood cells. los and mortality varied among groups, likely reflecting underlying medical conditions and indications for massive transfusion. we have identified an opportunity for improvement in mtp transfusion ratios observed in trauma cases, the specific environment from which the : : ratio was derived, and in which the impact of protocol-driven blood resuscitation is most efficacious. patient identification improvement strategy to help reduce unacceptable specimens arline stein* , nancy nikolis , linda benison , ruthmire thelusca , renee liberty , sherry shariatmadar , alexander indrikovs and vishesh chhibber . north shore university hospital, northwell health background/case studies: our blood bank (bb) processes approximately , specimens per year. bb specimens are unacceptable when they are unlabeled, unsigned or missing necessary documentation. in such cases, a new specimen is requested to be drawn as per protocol. our investigation of unacceptable specimens previously included generation of a report by the blood bank staff that was subsequently submitted to the bb supervisor for completion. following completion, the report was sent to the nurse manager of the patient care unit (pcu) for follow-up and investigation with the staff members involved. this process was cumbersome, taking a few days before the staff member of the pcu was alerted to the deviation in protocol. at times, residents or float staff involved were difficult to identify and it was often challenging to track down the staff and do the necessary investigations and in-services. study design/method: in june , a patient identification improvement strategy was implemented jointly by the department of nursing and the bb to address mislabeled, unlabeled and unsigned specimens as part of a patient safety initiative. currently, following this strategy, when an unacceptable specimen is received, the nurse manager (nm) of the pcu is immediately notified by bb staff. the nm promptly initiates a debrief process with the staff involved in drawing the specimen. a debrief form (tool) was created to guide the discussion. this process is followed / . the nm will also engage other available staff in a huddle to review the incident and reinforce the policy. the debrief form is then submitted to hospital qa and the bb with preventative actions included. we believe in using the just culture model to help us understand the reasons why the staff did not label the specimen according to policy. just culture helps promote shared accountability to ensure we have the proper systems and processes in place to deliver high quality care. results/finding: the table below represents the percentage of unacceptable specimens identified by the bb since the second quarter of . the implementation of this new process has led to a decrease in the number of unacceptable specimens up to % quarterly following its implementation. the opportunity for direct intervention by the nm with the staff involved has risen from % to %, due to the immediate debrief process. abstract conclusion: the patient identification improvement strategy allows for real time engagement of the bb and pcu staff to promptly investigate and institute corrective/preventive actions when there is a deviation from policies related to specimen collection. the heightened awareness of correcting patient specimen labeling errors can only improve patient safety and the patient experience. platelet transfusion practices among pediatric oncology patients: a single institutional experience nicole m crews* , , morgan rockwell , joseph hagan , jun teruya , and shiu-ki hui . texas children's hospital, baylor college of medicine background/case studies: despite advances in adult platelet transfusion (ptx) literature, questions persist regarding pediatric transfusion thresholds, dosage and responses. therefore, ptx are commonly guided by local institutional recommendations (ir). the aim of this study was to determine the degree of adherence of ptx practice to ir at a pediatric tertiary institution. study design/method: retrospective review of ptx practices including transfusion thresholds, responses and dosages were collected. platelet counts within hours pre and post transfusion were evaluated. patients ( - years) receiving prophylactic ptx from july to december admitted to the oncology acute care unit with diagnosis of leukemia or lymphoma were included. for prevention of volume overload, the ir for ptx were < ml/kg for patients < kg and one apheresis unit (au) for patients > kg; therefore, patients were separated into groups: < kg and > kg. a significant proportion of orders for both < kg and > kg did not meet patient platelet threshold criteria (p< . ). conclusion: ptx threshold above ir for both groups were ( kg) and % (> kg). most common reason for above ir threshold was an invasive procedure or low molecular weight heparin therapy. greater than % of ptx dosage in both groups were above ir, however the platelet response did not increase significantly (p> . ) with a higher dose vs. ir dose. this study demonstrated that there were still considerable deviations from ir in ptx practice among pediatric oncological patients. in addition, the false assumption that a higher dose will yield a better response can put patients at increased risk for transfusion related adverse events. each institution should conduct a quality assurance review to determine ptx practice. pre-surgical sample process improvement to enhance patient safety and compliance lisa marie button*, stephanie saathoff, jered luedke, benjamin colvin, umalkair amare and james r stubbs. mayo clinic background/case studies: our institution provides the option for presurgical samples (pss) to be drawn up to days prior to surgery as long as the patient reports not being transfused with a blood or blood component containing allogeneic red cells and they have not been pregnant in the preceding months from the date of pss collection. when pss patients returned for surgery, the patient's service was required to ask the patient again about their transfusion and pregnancy history to determine if there had been any new opportunities for allogeneic red cell exposure, however, there was no process to capture the information the patient reported for the time between the pss draw to the day of surgery/possible transfusion. study design/method: an electronic fix was designed that was applied to the surgical intake process. a new set of questions was added to the a.m. admit questionnaire that must be completed prior to the patient's surgical procedure. the questions ask the patient if they have been pregnant or transfused in the preceding three months and if the answer is affirmative, the computer system runs a blaze rule causing an alert in the blood bank. the blood bank techs review the alert and inactivate the patient's pss based on the new transfusion/pregnany information. one year post-implementation of the electronic fix, transfusion lab performed a retrospective review of all pss alerts generated during a three-month period. results/finding: the results of the review were analyzed and are displayed in the table. it was determined that only . % of patients with a pss alert had an active sample requiring inactivation. conclusion: implementing an electronic solution that requires documentation about pss eligibility upon return for surgery has resulted in an estimated ( x ) pss alerts in the blood bank each year. of these alerts, it is estimated that approximately patients ( x ) per year are identified as no longer eligible for pss status. once this retrospective review was performed, it was shared with the project stakeholders to determine if the electronic questionnaire could be further tailored to patient's based on age, gender, and pss status. while the benefit of having fewer false positive pss alerts ( . %) was recognized as an ideal future state, it was not compatible with the institution's current it project of implementing a new electronic medical record (emr) system. the safety enhancement provided by the current electronic fix will remain as is and the improvement suggestions were shared with the team creating the parameters for the new emr with the intention of targeting only patients with an active pss in the blood bank, rather than all surgical patients. weill cornell medicine, columbia university school of medicine background/case studies: blood ordering is a complex, high-risk process with multiple steps that have the potential for errors and delays. risks associated with this process, from ordering through pick-up, require evaluation and strategies for mitigation. given the complexity and high-risk nature of blood ordering a proactive risk assessment (pra) for blood product ordering using the fmea methodology was conducted. the goal of the project was to proactively assess the effect of a redesigned electronic order set on the quality and safety of blood ordering study design/method: to evaluate the electronic blood ordering redesign process, a pra was completed using the fmea methodology. the team identified each step and sub-step of the electronic blood ordering process, all failure modes and causes, and then scored each by severity occurrence and detectability to determine the risk priority number (rpn). all rpns with a score above the threshold were reviewed and rescored based on mitigation strategies designed to address the failure mode. results/finding: the group scored the identified failure modes by categories used in root cause analyses. the electronic blood order process has internal logic and alerts that improve communication and reduce the risk score. several mitigation strategies that will reduce the risk of the identified failure modes include type and screen status within the rbc order, streamlined alerts when the order does not meet the laboratory threshold, a nursing task list for transfusion, and a change to the pickup process that is linked to the product ready status in the laboratory information system. a transfusion history will be available to providers when ordering blood products to further reduce communication risks. categories for failure modes included clinical,communication,equipment people,process and system. the average overall failure mode rpn was reduced by % with the communication category average rpn having the greatest reduction of %. conclusion: an fmea of an electronic blood ordering process can proactively improve quality and patient safety by preventing transfusion delays and errors in blood product administration. accurate and timely information in the blood ordering process has the potential to reduce risks associated with ordering,preparing and dispensing blood. reducing turn around time for type and screens in the blood bank kimberly ouellette* , karen king and joseph sweeney . rhode island hospital, lifespan academic medical center background/case studies: expeditious turn-around times (tat) in the blood bank are critical to provide fully tested and crossmatch compatible blood in a timely manner. the blood bank at rhode island hospital, a level trauma center and teaching hospital associated with brown university, was originally designed to accommodate tube testing by all technologists. the original setup of the lab was split into three sections allowing for preparation and issuing of units in the first section, bench testing in the second, and the receipt of components in the third. as technology changed, the blood bank adopted first the manual gel station and then the automated gel system (ortho provuev r ) but did not adapt the space. the second section of the blood bank contained the manual and subsequently automated gel stations with no other changes. the process of sample receipt through completion of testing and issuing of units remained segmented and inefficient. the average tat for type and screens was minutes. study design/method: the blood bank design was remodeled to make for a more open concept to allow for collaboration amongst technologists as well as the best use of space and technology. the first section of tables were removed and replaced with a center console to allow for movement about the entire front of the laboratory. a wall was constructed to separate the main work flow, automated gel testing and issuing units, from the area for complicated workups and inventory receipt. the third section remained, but was repurposed for teaching medical technology students and residents. in addition to the remodel, the blood bank retired the ortho provuev r for the ortho visionv r , which is considered a true continuous feed machine. although the inter-device tat is not significantly different ( minutes for the provuev r and for the visionv r ) the visionv r is built with a scheduler that effectively handles the system and processes samples efficiently. the visionv r is also equipped with two centrifuges to process samples, which further reduces tat when multiple samples are onboard. a bi-directional interface was designed to allow for test orders (type and screens) to go to the visionv r and test results to go directly from the visionv r to the lis without the need to manually order the tests or transmit the results. data on tat were collected and analyzed using independent t tests and chi square. results/finding: the mean tat pre-and post-reconfiguration and implementation of the ortho visionv r and a fraction of samples with tat over minutes are shown in the table. the results show a reduction in tat by minutes with a % reduction of tat greater than minutes. conclusion: a combination of new technology and space remodeling can lead to a significant reduction of tat of testing in the blood bank. caleb wei-shin cheng* , , lorna orengo , monique scott and christopher a tormey , , . yale university school of medicine, yale-new haven hospital, va connecticut healthcare background/case studies: the type and screen (t&s) is a fundamental laboratory test that allows the blood bank to provide compatible blood for patients. despite this, erroneous blood product administration may occur as much as in , blood transfusions. to prevent errors, adequate specimens such as those lacking hemolysis and those with proper specimen labeling are necessary; otherwise the specimen is rejected, leading to a second blood draw and a delay in medical/surgical management. hemolysis rates for t&s specimens are reported to be as high as % prior to interventions, but may potentially be reduced to as little as . %. however, there is little published data on non-hemolysis-related type and screen rejections. an initiative was undertaken to reduce the rejection rate in the blood bank to a sustained rate of < %, with a particular emphasis on non-hemolysisassociated forms of rejection. study design/method: a root cause analysis (rca) was performed over the preceding months to obtain a baseline understanding of the errors involved. t&s submission at our facility involves standard completion of the specimen label plus completion of a unique witness form to confirm the identity of the patient from whom the specimen was collected; specimen and witness form must be submitted simultaneously. when a specimen was rejected, we recorded the patient name, medical record number, and the reason for rejection. following rca, an intervention was created to resolve the most common issues documented that resulted in rejection. approval for the intervention was granted by the department chair, transfusion committee, forms committee, and the medical executive committee. after implementation, prospective data will be collected for several months in the same manner as before to determine the effectiveness of the intervention. results/finding: over the study period, the t&s rejection rate averaged . %. reasons for specimen rejection were divided into groups: ) hemolysis, ) blood bank witness collection form errors, ) quantity not sufficient, abstract ) duplicate sample, and ) specimen tube labelling errors. the highest percentage of rejections was due to improperly-filled witness forms (table ) . after multiple form redesigns and approval by appropriate committees the new form was implemented. preliminary data collected thus far demonstrates a . % rejection rate with only rejection relating to witness form errors. conclusion: rejected t&s specimens are an impediment to safe clinical care as it may delay medical/surgical management. rejection rates could be reduced through simplification of blood bank specimen collection forms. care providers have multiple tasks that need to be performed in a short amount of time, therefore, simplification is often times necessary to reduce human error. future quality initiatives will aim to simplify complex healthcare processes without compromising patient care. reduction of failed whole blood donor testing runs on the roche cobas s system christopher shahan* , christina dejesus , mosi mccall , fallon hampton , tangi herring , judy davis , anjali patel , sonya gomillion and bonnie maltby . qualtex laboratories, qualtex laboratories background/case studies: as part of our quality control program, we track the number of technician related failed runs observed on the roche cobas s system. this system is used to test whole blood donor samples for human immunodeficiency virus (hiv) rna, hepatitis c virus (hcv) rna, hepatitis b virus (hbv) dna and west nile virus (wnv) rna. technician related failed testing runs can cause the laboratory to report results outside of the contractual - hour turnaround time. failed runs also cause retesting which increases reagent utilization for the system. currently % of whole blood donor testing turnaround time delays are due to issues and failed runs on the s system and we have technician related failures per week. a lean six sigma approach for process improvement was utilized to identify root causes and develop countermeasures in order to decrease the number of technician related failures on the s system. study design/method: the number of technician related failed runs on the s system were tracked from / / thru / / . a pareto chart was used to determine that technician related errors was the largest controllable factor causing run failures. the whys were performed to determine root causes of technician related failed runs. a gemba walk was performed on all of the lab testing processes to help identify areas for improvement. the process improvement team talked, met, observed, and worked directly with staff that operate the s system. roche was also contacted to provide guidance on how to help decrease technician related failures. results/finding: the main root cause determined was that there was no current process flow map for whole blood donor testing using the s system. counter measures implemented included creating a two phase process map. one phase was related to the processes related to start-up of the system and the second phase was related to the processes involved in processing of samples. roche provided a job aid for the technicians which provides clear steps technicians should take when handling and cleaning up crashes and failed runs on the s system. after counter measures were implemented, the number of technician related failed runs decreased from to . failures per week, which was a % decrease. conclusion: a lean six sigma approach for process improvement was utilized to identify root causes and develop countermeasures in order to decrease the number of technician related failed runs on the cobas s system. this lean six sigma approach and counter measures significantly decreased the number of technician related failed runs by %. patients who were transfused for pre-transfusion hgb > g/dl with resulting post-transfusion hgb > g/dl were reviewed. demographics, medical history, provider identity, indication and transfusion complications were abstracted & compiled individually by volunteer internal medicine residents. group discussion for each case ensued before determination of transfusion appropriateness occurred. principal investigator/attending physician then made final determination of appropriateness of rbc transfusion. results/finding: patient charts were reviewed. were excluded for bleeding and cardiovascular instability. / ( . %) were determined to be transfused inappropriately. there was no difference in appropriateness of transfusion with respect to age or sex. patients with solid tumors ( . % vs . %, p . ) and anemia of chronic disease ( . % vs . %, p . ) were more likely to be inappropriately transfused. patients who had higher pre-transfusion hemoglobin were more likely to be inappropriately transfused (median hgb . g/dl vs . g/dl, p< . ). inappropriately transfused patients also had higher median post-transfusion hemoglobin ( . g/dl vs . g/dl, p< . ). moreover, lab evalutions revealed association with lower folate levels (median . nmol/l vs . nmol/l, p . ). / ( . %) patients were inappropriately transfused at least in part because they received more than one unit without an interval hemoglobin check in between. / providers were responsible for . % of all inappropriate transfusions. / appropriately-transfused patients experienced an fnhtr. deaths unrelated to transfusion occurred ( in appropriate, in inappropriate group). conclusion: physicians in training are interested in promulgating optimal rbc transfusion practice. this study identified patient factors (such as solid tumors and anemia of chronic disease) that correlate with a higher likelihood of receiving an inappropriate transfusion. beyond cpoe, educational intervention at individual level should be designed for specific providers responsible for more inappropriate transfusions. successful implementation of a blood bank information system in a small-scale caribbean blood bank: a structured step-wise approach. luigi sille* , willem martin smid and ashley john duits . red cross blood bank foundation, sanquin consulting services background/case studies: an important tool for complying with gmp quality standards is the effective use of a blood bank information system (bis). validation and implementation of a bis is described for centralized large blood bank and literature and guidelines are lacking for the nonautomated small scale blood bank environment. . small-scale blood banks face specific challenges for computerization in relation to economies of scale and existing processes requiring special attention. for the introduction of a bis at the blood bank of the dutch caribbean island of curaçao a specific procedure was designed based on existing guidelines and adapted to the local setting. study design/method: the red cross blood bank foundation curaçao is the sole provider of labile blood components for the dutch caribbean islands of curaçao, bonaire and sint maarten. after selection of the bis provider for implementation isbt and bcsh guidelines for validation of information systems in blood establishments were carefully analyzed to prepare the design of local procedures. these procedures were meant to evaluate and validate the features of a bis (e-delphyn, hemasoft america, miami, usa) before introduction. the outcome of the approach was entered in worksheets that were evaluated by the implementation team and management. from this the implementation plan was designed and implemented. an external auditor (sanquin consulting services, amsterdam, netherlands) was invited to evaluate the implementation and validation plan and its practical implementation. the evaluation was performed according to risk assessment of critical process steps. results/finding: based on the isbt and bcsh guidelines a process flow chart describing the relevant phases and critical steps for introduction and validation of a bis was designed. comparison of the current processes and procedures were compared to the bis characteristics making use of worksheets. with these worksheets the existing gaps with the bis procedures were carefully described. these gaps and the appropriate procedural changes for bis or blood bank were effectuated. the worksheets also provided the basis for staff training in a separate training environment before bis introduction. during the early validation phase all procedures and processes were audited by an external auditor. with the feedback of the expert several improvements were added for the validation and subsequent implementation processes. conclusion: with the use of existing international guidelines a validation and implementation plan was designed to prepare for successful introduction of a bis in a small scale caribbean blood bank. the program as designed seems well suited for small scale blood banks contemplating introduction of a bis. time and cost savings through implementation of a remote blood fridge jessica peters* , dee dee cassidy , jed b gorlin , and nancy l van buren , . hennepin county medical center, innovative blood resources background/case studies: rapid delivery of emergency release group o red blood cells (rbc) are vital to patient care. commercial remote blood fridge packages are available but have large upfront and maintenance costs. we implemented a remote blood fridge directly in our emergency department (ed) using an under counter fridge requiring id access, and a selfdeveloped ios application that scans, tracks and real-time alerts transfusion service (ts) to products used and to whom they were dispensed. prior to ed fridge implementation, rbc units were verbally requested and an ed blood runner would pick up and return the cooler. given that our ed is located in a separate building from the ts, this meant or more minutes may be required for transit of units often released in less than minutes. the net effect was that providers would routinely order products to ensure they were at the bedside for patient arrival as a precaution, only to return them when not required. implementing a blood fridge at bedside resulted in the predicted outcome of delivering emergency release rbcs more quickly, with the observed benefit of decreasing wasted staff time. study design/method: the remote blood fridge was implemented in july . data for rbc requests in coolers, rbc returns and rbc transfusions from the ed was collected and compared. baseline data included january -june , and post change included august -december . july data was excluded as it included both the pre and post processes. results/finding: baseline data shows that the ed requested an average of rbc/month in coolers. post change this dropped to rbc/month, thus less blood was requested from the transfusion service in coolers as units were being used from the fridge. baseline data also shows that an average of rbc/month were returned ( %). post change, the average rbc/ month returned was ( %), this represents an absolute % reduction in number of returned products. each rbc dispensed and returned takes approximately minutes to complete paperwork and transport, therefore this change saved an average of minutes per month. it was also noted that the average rbc/month transfused was for baseline and post change. this confirms that the decreased requests and returns were not due to decreased patient volume or severity. the fridge was also successful at decreasing delivery time of blood to patient bedside, as baseline delivery time of - minutes (estimated) was reduced to - minutes. conclusion: implementing a remote blood fridge and moving blood access closer to patient bedside ensures a faster delivery of blood to the patient. this change has an additional benefit of decreasing wasted time, and hence cost, by decreasing unnecessary product requests and returns. implementing a blood fridge can also be done at a reduced cost through homegrown processes. transfusions are everyday procedures and over patent-applications have been filed related to "transfusion medicine" and over related to "transfusion alarm", during the last years, employing numerous technical settings, aiming to support automated supervision of the mentioned actions. the aim of this contribution is to present a developed low-cost real-time individual intravenous blood-transfusion monitoring system, based on the internet of things. study design/method: the designed system is based on a commercially available pan-tilt-zoom (ptz) camera, employing an / inch color cmos sensor, providing effectively . mp, a . mm lens, ir-cut, day/night minimum illumination . lux/f and viewing angle. the camera is focused on the droplets and acts as vis/ir detector with a hz sampling-rate. custom-developed software supports droplets' ratemonitoring, causing acoustic alarm-signals if necessary (e.g. clotting, blood a transfusion vol. supplement s abstract or other suspensions depletion etc.) and enables, if necessary, wide-angle image-capturing. the video image-audio settings provide for compression h. , video frame rate (fps) - /s, refresh rate hz and audio input, through bidirectional built-in microphone. the acquires an ip-address, the connection mode is wireless, the network interface is wi-fi/ . /b/g, the supported protocols include dhcp, tcp/ip, upnp, http, smtp and p p is provided. typical v power-supply, sized x x mm and weighing g. client software is required. the ir range is - m; ir-cut filters, remote access, dual stream, motion detection, day/night and ir night vision distance of m are offered. two-way radio-link is provided, as well as, trans-flash (tf) recording and storage on a gb sd-card. pan/tilt-horizontal o and pan/tilt-vertical o movements can be performed. the system facilitates, if needed, also patient's position monitoring and readings of other monitoring displays, such as nibp, ecg, and spo , if present. results/finding: the system and is being presently tested in a laboratory (non-clinical) environment, by simulating the virtual patient, with a custommade "phantom", combining flow-rate, negative pressure and viscosity resistance regulation. conclusion: the system can measure infusion-speed with a deviation lower than %. the developed iot-system takes advantage of the existing hospital wi-fi networked environment and offers a low-cost solution, under $ for each monitoring-set. it allows for even multi-platform (ios, android, windows) smart-phone, short-range connectivity, for up to participants, for example nurse, physician etc. two potential approaches for the quality control of bact/alertv r culture media using various bioball tm organism preparations patricia rule*, michelle keener and christine crawford. biomerieux inc. background/case studies: the bact/alertv r bpa and bpn culture bottles are used with the bact/alert microbial detection system for rapid screening and detection of microbial contamination in leukocyte reduced apheresis platelets (lrap). recent changes in the clia quality control guidelines and aabb accreditation program will require additional quality control of manufactures media that is both lot specific and shipment specific to ensure recovery of bacterial growth. a study was conducted using commercially prepared organisms evaluating both a comprehensive organism panel as well as a streamlined method utilizing only two organisms from the panel. study design/method: the general protocol consisted of three replicates each of each organism inoculated into two lots each of bpa and bpn by two different analyst. the study was two part in that aspergillus brasiliensis, candida albicans, bacillus subtilis subsp. spizizenii, pseudomonas aeruginosa, escherichia coli, clostridium sporogenes, staphylococcus aureus and streptococcus pyogenes were prepared from bioball singleshot ( cfu), multishot cfu or highdose k organism preparations at a low level (< cfu) and evaluated on the same day of preparation as method validation. the second part of the study utilized escherichia coli and staphylococcus aureus prepared and frozen at a higher level and then evaluted over a day study as a stream line approach to routine quality control testing of the bact/alert culture bottles. inoculation preparations were enumerated in duplicate to confirm the level at each inoculation time point. inoculated bpa and bpn bottles were loaded into the bact/alert microbial detection system at c for automatic monitoring of growth. negative bpa and bpn bottles were included in duplicate at each day of testing. results/finding: escherichia coli, staphylococcus aureus, streptoococcus pyogenes and bacillus subtilis subsp. spizizenii were positive in both the bpa and bpn culture bottles. the aerobic aspergillus brasiliensis, candida albicans, and pseudomonas aeruginosa grew and were reported positive in only the bpa aerobic culture bottle as expected. while the obligate anaerobe, clostridium sporogenes was positive only in the anaerobic bpn culture bottles. bacterial cultures were positive in the bact/alert bpa and bpn bottles < days and the fungal organisms in < days. the overall agreement was . % in bottles tested here. no significant differences were observed in the time to detection between the different lots or between the different analyst. conclusion: the bioball prepared organisms demonstrated a reproducible method as both a comprehensive and streamline approach for the quality control of bact/alert bpa and bpn culture media. the method was simple and did not require additional microbial preparations or storage of live organisms by the laboratory. use of an electronic patient identification system for blood banking specimen labeling found to be superior over historical armband approaches annie newton* , diane schafer , debra brown , jesse cox , scott koepsell and sara shunkwiler . nebraska medicine, the nebraska medical center, university of nebraska medical center background/case studies: anticipating the implementation of the new ( th addition) aabb standard concerning the confirmation of patient abo blood typing of type and screen (crossmatch) specimens performed prior to the issue of crossmatched blood products, laboratory and organizational leadership evaluated the practical application of an electronic patient identification system to label blood bank specimen collections versus the traditional use of blood bank armbands. continued use of the armbands would require a second sample for abo confirmation of patients that did not have a historical blood type on file. concern was raised regarding the amount of increased workload of staff and delayed results availability based on the number of increased specimens that would be generated, as well the potential for increased iatrogenic blood loss and patient dissatisfaction. moreover, nd sample collection alone would not improve the rate of mislabeled specimens observed, which is of supplementary concern. study design/method: current organization employment of an electronic patient identification system for the labeling of other laboratory specimen collections made it feasible for applying this technology to the blood bank as well. an in-depth evaluation, including a failure modes and effects analysis (fmea) spanning several days, was completed to ensure that the use of the electronic system would produce comparable or superior safety results to its armband counterpart. an alternate process for specimen labeling and abo confirmation (which would satisfy the new standard) was established to support care areas that did not have the capability of using the electronic system. extensive education was provided to all staff (physicians, advanced practice providers, phlebotomist and nurses) to ensure comprehension as well rational for the new process. alerts were congruently built into the electronic health record (ehr) to supplement any information regarding crossmatch testing expiration that may not be readily available by the elimination of the armband use. results/finding: within days of implementing the new process (september , ), there was a noticeable reduction in the amount of mislabeled blood bank specimens received, totaling in months post implementation compared to in the months prior. in addition, the vast majority of specimens received into the blood bank are henceforth collected and labeled using the electronic system and thus have reduced the amount of potential nd specimen collections needed for abo confirmation. conclusion: use of an electronic patient identification system for labeling blood bank specimen collections in lieu of traditional blood bank armbands has proven to improve patient safety and department efficiency by substantially reducing the occurrence of mislabeled specimens and negate the need for nd specimen collections, reducing potential iatrogenic blood loss and improving patient satisfaction. background/case studies: based on a few small randomised controlled trials (rcts) performed in the late ' s and in early , intravenous immunoglobulin (ivig) use has been suggested as a potential treatment to avoid exchange transfusion (et) for rh hemolytic disease of the newborn (hdn). this treatment modality is now routinely used for rh-hdn and has been extended to hdn caused by abo incompatibility or by other red blood cell antibodies. however, larger rcts performed since have shown that prophylactic ivig did not reduce the need for et, the duration of hyperbilirubinemia, the maximum bilirubin levels nor the need for top-up red blood cell transfusions. the primary objective of this study was to describe the usage of ivig for hdn at a tertiary academic referral hospital. study design/methods: a retrospective chart review was performed of all neonates who received ivig for hdn in the neonatal intensive care unit (nicu) from january , to june , . data collected included patient demographics features and diagnosis, indications for ivig, neonatal laboratory results, treatment details, adverse events and patient outcomes. results/findings: ninety-seven neonates received ivig during the study period: % were female and % were less than weeks of gestational age. none had co-existing g pd deficiency, pyruvate kinase deficiency or spherocytosis. all neonates received phototherapy prior to ivig treatment. indications for ivig were abo-hdn ( %) and rhesus-hdn ( %). antibodies most often implicated in rh-hdn were anti-d ( / ), anti-d and anti-c ( / ) and anti-c ( / ). sixteen infants with rh-hdn had received intrauterine transfusions. the mean cumulative dose of ivig was g/kg (range from , g/kg to , g/kg). neonates received one to four ivig administrations. table shows the number of patients receiving ivig during two time periods. three adverse reactions were noted during ivig administration: cutaneous rash, hypotension and fever. of all neonates, required an et for rh-hdn and for abo-hdn. forty-five ( %) patients needed top-up transfusions during hospitalisation and until three months of age: with abo-hdn and with rh-hdn. the mean number of transfusions was three (range: to ). conclusion: although initially described for rh-hdn, abo-hdn is now one of the most frequent indications for ivig in neonates. the optimal use of ivig in abo-hdn needs to be better characterized. our study shows a wide variation of ivig dosing and a significant proportion of neonates requiring top-up transfusions. further research is required to evaluate whether anemia in abo-hdn might be exacerbated by hemolysis from ivig isohemagglutinins and if it is dose-dependent. background/case studies: background: one of the most serious adverse reactions to transfusion is the development of graft versus host disease. symptoms include the development of a characteristic cutaneous rash, enteritis often resulting in watery diarrhea, elevated liver function tests and ultimately pancytopenia. the clinical course is rapid with an over % case fatality rate. the patient population at risk is reasonably well-defined including patients who are immunocompromised due to disease process or therapy, the fetus and low birth-weight neonates, recipients of hla-matched cellular blood products and the recipients of cellular blood products donated by blood relatives. the basic etiology of ta-gvhd is the inability of the transfusion recipient to mount an effective immune response against donor t-lymphocytes. treatment options for ta-gvhd are ineffective, making it imperative that cellular blood components be irradiated prior to transfusion which virtually eliminates the risk of the complication. study design/methods: most transfusion service information systems have mechanisms to alert transfusion service staff to patients who have been previously identified as needing irradiated blood components. however, if these patients are not identified to the transfusion service at the time of the initial hospital visit or the time at which the qualifying diagnosis, these patients can erroneously receive non-irradiated blood components. following a "near-miss" situation, our hospital information department developed a -part program to minimize the risk that the transfusion service is not notified of patients newly requiring irradiated blood components. results/findings: our blood products ordering system has been redesigned to include specific queries to identify those patients who required irradiated cellular blood products. first, physicians have been notified to include the need for blood product irradiation in the patient problems list. once this is included in the list, the transfusion service will be notified of the need for irradiation on all subsequent transfusion orders until the problem list is modified by the clinical staff. second, if irradiated blood components have ever been requested on a patient, an alert will be generated for the ordering physician even if the requirement for irradiated products has not been included in the problem list. finally our system will automatically default to request irradiation on all cellular products ordered for children less than months of age to comply with local irradiation policies. conclusion: we believe that our approach can be further enhanced by including a list of specific diagnoses typically requiring blood product irradiation within our computer algorithm. we believe that this list will provide an additional level of safety in insuring that patients receive irradiated blood components when appropriate. using lab information system and a dynamic dashboard for labeling and tracking coolers russell thorsen, rosaline ma, peter suslow, gina giannarelli, sara bakhtary, ashok nambiar and morvarid moayeri*. ucsf health background/case studies: our tertiary-care transfusion service routinely issues blood products in validated coolers to high acuity areas such as ors, icus, cath-lab, etc. coolers are also used for emergency release and massive transfusion protocols, and for shipping products between our different hospital sites. a robot that can hold one cooler delivers products to locations not served by the pneumatic tube. on average, coolers are issued every day. cooler set-up is a multi-step, labor-intensive process. transfusion service staff track cooler location and elapsed time-in-use and notify clinical teams to return/recharge coolers to avoid product wastage. we developed a lab information system (lis)-based solution to manage cooler labelling and tracking more efficiently. study design/method: nine cooler test batteries were built; the batteries for rbc, plasma, platelet and cryoprecipitate ( each) are identical, whereas the final battery designated for the cooler delivered by robot (containing plasma and rbcs with variable expiration times) is slightly different. the second battery in each pair was built to avoid duplicate test cancellation by lis when a second cooler (for same component type) is being set up for the same patient. each battery consists of tests capturing the following information: cooler location, cooler id, number of units issued, and expiration. custom barcodes representing each test battery and different locations can be scanned from a 'quick-pick list', avoiding need for manual entry. when coolers are returned, a final entry is made in the test battery, updating lis. a dynamic cooler tracking dashboard with live-feed from lis displays data captured in the test battery. elapsed time, starting from cooler set-up (which is identical to time cooler battery is ordered in lis) is captured automatically. color codes alert users to coolers that have less than hour before expiration. a flashing alert pops up for coolers that have expired. results/finding: we replaced our manual process (hand-write patient information and expiration time on separate tags; affix one tag to cooler and retain second one to track cooler location and expiration) with a novel lis-driven labeling and tracking system. each time a cooler is set up, a test battery is ordered and resulted in lis by scanning the related custom barcodes. a single lis-generated label is printed and attached to each cooler. cooler expiration is defaulted to hours (per our current cooler validation) from the time the test battery is ordered during cooler set up. techs pay attention to expiration of each product they place in a cooler. if an individual product outdates before the cooler expiration time, this information is entered in the test battery and gets displayed on the dashboard as a cooler expiration time, distinct from the system-driven countdown. color-coded visual display and alerts greatly simplify cooler monitoring, and the elimination of some manual steps has improved staff satisfaction. conclusion: using lis for cooler set-up and deploying a linked dynamic dashboard to display cooler locations and expiration time makes cooler management more efficient. these tools reduce manual steps and decrease likelihood of wastage by aiding cooler tracking. improving cryoprecipitate collection operations using operations research and analytics-based methods american red cross, georgia institute of technology ap reduction in unnecessary use of type o-negative rbcs in a level i bellevue hospital-nyulmc our hospital is a level i trauma center serving a diverse predominately non-caucasian population. historically we stocked our trauma blood bank monitored refrigerator with o-negative rbcs. trauma requested that we stock additional rbcs to be able to initiate a mtp for multiple patients at the same time. believing that most of our trauma patients are male, elderly, or rh-positive, we agreed add type o-positive rbcs to the stock. rules for determining which units to use were established. o-positive rbcs are to be given to a) all adult males (am), b) women of non-childbearing age (wncba), and c) if both o-negative rbcs were used but not yet restocked, and o-negative rbcs are to be given to a) women of childbearing age (wcba) and b) children until the patient's aborh type are determined. we sought to assess the impact of this change on our usage and purchases of o-negative rbcs. study design/method: all patients issued emergency release trauma rbcs following the addition of o-positive rbcs were assessed %) would have needed to be o-negative. the addition of o-positive rbcs to our trauma refrigerator will enable us to markedly reduce our purchases of o-negative rbcs. ap saving apheresis platelets through use of verax point of care testing jennifer rhamy* and rebecca wride . st. mary's regional blood donor center, st. mary's regional medical center background/case studies: our rural hospital-based blood center serves hospitals and a diverse patient population including acute trauma. because of the varying need for platelet products (varies between and per day in ), we investigated the use of the verax point-of-care test to better manage our valuable inventory barrett lawson and jun teruya , . texas children's hospital, baylor college of medicine ap vision titers --easier or problematic? (table ) . results/findings: post intercept, t had volumes of - ml, with % hemoglobin (hb) recovery. t had -fold less extracellular protein than c. after days of storage t had higher atp and na than c while lactate and hemolysis were lower. hct, ph, k and glucose were equivalent between t and c on d . d hemolysis for t was . - . %, while for c it was . - . %. t and c atp was > mmol/g hb, the level of atp associated with effective rbc viability, throughout storage (table ) . hematocrit (hct, %) . . * . . . . . . hemoglobin (g/unit) not measured hemolysis (%) . . * . . . . * . . ph ( c) . . * . . . . . . total atp (mmol/g hb) . . * . . . . * . . k (mm) . . * . . . total tested total plts issued feb mar totals table: . resident reports to the intranet "drop box" increased from . % to . % to %, each over month time spans. conclusion: safe transfusion ordering requires a team approach to ensure the right information is available to the ordering provider at the right time. safe ordering prevented recurrent allergic reactions in our patient population. the tso plays a pivotal role in ensuring the full circle of communication occurs. processes that integrated the pathology resident improved with pdsa cycles and impacted the quality and timeliness of hand off. finally, the data provided from the residents enabled efficient participation in hemovigilance. decreasing results/finding: the main root cause determined was that there was no standard work process. sops were being followed but there was no standard work process that included the details so testing was not following the most efficient work flow. counter measures implemented included implementing a standard work process, visual cues were added to the work process, and a samples awaiting testing report was created for the batch release department. specific locations were identified within the work cells in the lab to place samples based on their phase/stage of testing. after counter measures were implemented, the number of exceptions decreased from . per day or , dpmo to . per day or , dpmo. this is a statistically significant difference since the p-value calculated was . . conclusion: a lean six sigma approach for process improvement was utilized to identify root causes and develop countermeasures in order to decrease the number of exceptions related to the testing of whole blood samples in the laboratory. this approach and counter measures statistically significantly decreased the number of exceptions seen in the whole blood testing process. background/case studies: our blood bank processes approximately , specimens per month. since , the requirement of having a second blood type on record was met by: . utilizing the historical blood type and the current specimen, or . having second type performed on same specimen by different technologist, and . each type and screen specimen signed by staff, one being a licensed practitioner attesting the identification of the patient was done accurately at bedside.to comply with the aabb standards th edition, # . . . a decision was made to change our practices. we considered challenges encountered at other hospitals and collaborated with nursing and it to create a streamlined and safe process. in april , the second specimen procedure was implemented addressing the following: ii. extensive education was provided to all involved in the process prior to implementation including a learning module prepared by blood bank and nursing collaboratively. results/finding: . there was a minor adjustment period with more phone calls made to blood bank to explain the process. . there was minimal impact on turn around times for release of components. . aborh retype workload decreased from to ( % to % of t&s volume) per month. . unnecessary blood draws minimized, improving patient experience. . no emergency release requests due to absence of a second specimen. the second specimen process with the conditional order has been beneficial to our blood bank as well as patient care services. overall feedback from staff on the process has been positive. our workload has decreased which results in cost savings and increased efficiency allowing us to devote more resources to the growing services at our institution. background/case studies: the hazards of transfusion are well recognized and in certain cases restrictive transfusion strategies compared to liberal transfusion strategies may be associated with better clinical outcome. with this in mind, aabb and others published guidelines for transfusion, but even with guidelines in place, rate of inappropriate blood transfusions is reported to be as high as to %. computerized provider order entry (cpoe), is a process of electronic medical order entry for medical practitioners with instructions and guidelines for treatment. the objective of this study was determination of transfusion practice quality by thorough chart and electronic medical record review, with measures in place to avoid inappropriate transfusion. additionally, factors associated with inappropriate transfusion were examined. study design/method: in our bed hospital, a retrospective chart review was performed ( / / - / / ) on hospitalized internal medicine patients. cpoe with hospital guidelines for rbc transfusions were in place. transfusion thresholds in different clinical settings were determined by a thorough literature review of studies analyzing restrictive transfusion strategy, and transfusion guidelines by various medical societies. charts for background/case studies: our midwestern university-based transfusion service (ts) evaluated the appropriateness the automated platform vision (ortho clinical diagnostics. raritan, nj) for prenatal titration studies. it has been established from previous publications that the micro-column assay, of which the vision is based, may lead to higher titer results compared to standard tube titrations. this study sought to evaluate the transition from manual to automated titer studies from a sensitivity as well as cost perspective. study design/method: twenty-three prenatal retention plasma samples were tested as part of the evaluation of titration studies of the vision. the samples were manually tested with a standard two-fold serial dilution. the titer was reported as the last tube to demonstrate a reaction by macroscopic observation. the titer studies were then repeated using the vision. the results of the manual and automated processes were compared and categorized as "< grade" or "> grade" difference between endpoints. this analysis is similar to the acceptable ranges used for evaluating college of american pathologists (cap) proficiency survey challenges. a cost analysis was completed based on the direct and indirect cost for each method, excluding the cost of an analyzer. results/finding: table demonstrates a summary of the samples tested by manual titer study and vision titration method. the vision titer results (mean, median, and mode) were higher than the manual tube titer results. less than half of the samples ( %) were > titer results higher, while the majority was titer results different ( %). the cost analysis is summarized in table . the indirect cost (labor) was significantly lower with the use of the vision. the reduction in pre-analytical technical time for manual preparation of the titration is eliminated with the vision completing the titration as part of the profile of the titer study of the analyzer. conclusion: with an estimated % decrease in the cost of a vision titer compared to manual tube method, the change in practice would clearly be a cost and efficiency measure in the blood bank. however, the vision demonstrated the expected increase in titer results compared to manual tube titer results. this would impact the critical values currently utilized. an impact assessment for clinical staff would be necessary to adequately implement the change in method. consideration must be given to changes in the computer logic for critical values on titer studies and training of physician and nurse obstetric practitioners for changes in the critical values. in addition, as part of changing to the vision an implementation period will be necessary to ensure that manual titers are compared to previous manual titers and not to vision titer results which would be higher and may be interpreted as a significant change for clinical care of the patient. what is the best practice for testing residual white blood cells in blood components for monthly routine quality control? janja pajk*. general hospital celje background/case studies: we wanted to discover what is the best routine quality control practice for testing residual white blood cells in blood components. our aim was to validate the adam device for counting thne number of residual white blood cells (wbc) in leucocyte depleted and in non-leucocyte depleted blood components (bc) and to compare with standard counting method by microscopy in fuchs rosenthal chamber (frc) used in ghc and with flow cytometry (fc). study design/method: after samples of red blood cells (rbc), platelets (plt) and fresh frozen plasma (ffp) (leucocyte depleted in top and top (t/ t) bags and non-leucocyte depleted in top and bottom (t/b) bags) were stained with propidium iodide (pi) on r-slides; adam -rwbc device was messured fluorescent images of stained wbc nucleus. data were analised by image analysis software and later compared with results of testing samples in frc by microscopy and with fc. samples of bc were microscopic tested in frc at department of laboratory medicine in ghc; another samples were measured with fc in ucc maribor. results/finding: samples ( rbc, plt, ffp-all leucocyte depleted and non-leucocyte depleted ffp) were tested in triplicates on adam and with frc once.coefficient of variation of (kv%) of samples measured on adam for leucocyte depleted bc varied for: rbc from , - , ; plt from , - , ; ffp from , - , ; and for non-leucocyte depleted ffp from , - , (table ) . samples ( rbc, plt, ffp -all leucocyte depleted and nonleucocyte depleted ffp) were tested in triplicates on adam and with fc once.kv% of samples measured on adam for leucocyte depleted bc varied for: rbc from , ; plt from , , ffp from , ; and for non-leucocyte depleted ffp from , - , (table ) .high percentage of kv was noticed in samples with low numbers of wbc (in leucocyte depleted bc; low percentage of kv in non-leucocyte depleted ffp, with higher amount of wbc was observed. conclusion: all samples tested with adam met expected criteria for wbc in bc in european union (less than x /unit for leucocyte depleted or x / unit for non-leucocyte depleted) and were comparable with those tested with fc; the correlation with microscopy in frc was worse.with use of disposable r-slides, the risk of exposure to the potential hazardous blood samples is grately reduced, the method is more precise and not time consuming.from january we changed our protocol for testing residual wbc in bc with adam device and we advise it as the best practice for monthly routine quality control.